San Francisco Health Plan Healthy Kids HMO Formulary AS OF November 20, 2019

SAN FRANCISCO HEALTH PLAN Healthy Kids HMO Formulary

As of November 20, 2019

San Francisco Health Plan Healthy Kids HMO Formulary AS OF November 20, 2019

San Francisco Health Plan Healthy Kids HMO Formulary The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The P&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physicians from various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to review formulary changes based on quality of care considerations and sound pharmacoeconomic principles.

The formulary is a list of drug products designed to reflect the most appropriate, high quality and cost- effective drug therapies. The formulary is updated regularly and is subject to change without notice.

The formulary requires the continuous support of all our providers and pharmacists. Please contact us at (415) 547-7818 x 7085 option 3 or [email protected] if you have any questions regarding the formulary. The SFHP Formulary can be easily accessed online from our website at https://www.sfhp.org/providers/pharmacy-services/sfhp-formulary/.

Request for Addition or Deletion of a Drug to the Formulary SFHP providers may request evaluation of drugs for addition to or deletion from the Formulary by submitting the Formulary Modification Request Form available on our website at https://www.sfhp.org/providers/pharmacy-services/prior-authorization-requests/.

Request for Non-Preferred Medications Non-preferred or non-formulary medications may be authorized when there is clinical justification for doing so. Clinicians can submit a prior authorization (PA) request in one of three different ways:

1. Online: Submit using the Online Pharmacy Prior Authorization Request Form. 2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standard and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form. 3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbal request.

The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can be accessed from our website at https://www.sfhp.org/providers/pharmacy-services/prior-authorization- requests/.

San Francisco Health Plan Healthy Kids HMO Formulary AS OF November 20, 2019

Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent generic product is available. Dispensing of brand name medications when generic equivalent is available will be allowed only in the following cases: • Pharmacy is dispensing one of the following narrow therapeutic index drugs: Armour Thyroid, Coumadin, Dilantin, Synthroid

In all other cases, a prior authorization (PA) request should be submitted using the instructions above. Detailed PA criteria for brand name medication requests can be found at https://www.sfhp.org/providers/pharmacy-services/sfhp-formulary/ under “General Criteria” section.

Healthy Kids HMO Formulary Exclusions The following drug classes are excluded from the Healthy Kids HMO formulary: • Over-the-counter (OTC) medications except: o OTC insulin and diabetic testing supplies including test strips, lancets, insulin needles and syringes, urine ketone testing strips o OTC nicotine replacement products o OTC prenatal vitamins, folic acid and fluoride preparations • Erectile dysfunction medications • Fertility medications • Medications for cosmetic uses (e.g. hydroquinone for hyperpigmentation of the skin)

Day Supply Policy SFHP standard day supply policy is 30 day supply. Refills are allowed when 75% of the medication has been used, except for opiate pain medications where refills are allowed when 90% of the medication has been used.

Exceptions to the 30 day supply policy for brand medications are as follows: • Up to 100 day supply is allowed for test strips, lancets, insulin syringes and urine ketone testing strips • Up to 90 day supply is allowed for most generic and brand medications when they are used for treatment of chronic conditions. Examples of drug classes covered under this policy include but are not limited to antidiabetic medications including insulin, anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, and asthma medications. • Contraceptives are eligible for up to a 12 month supply at the prescriber’s discretion.

Exceptions to the 90 day supply policy for generic medications are as follows: • 30 day supply only is allowed for all opiate medications. • 30 day supply only for other controlled substances such as sedatives San Francisco Health Plan Healthy Kids HMO Formulary AS OF November 20, 2019

Formulary Restrictions (DUR edits) Standard formulary restrictions applicable to SFHP formulary are medication quantity and age limitations. All formulary restrictions are based on FDA approved indications, standards of practice and safety and abuse potential considerations.

Step Therapy (ST) Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescription claims for preferred medications. If there are no paid prescription claims, a prior authorization (PA) request must be submitted for consideration of coverage. Visit our website at https://www.sfhp.org/providers/pharmacy-services/sfhp-formulary/ for detailed information on all active step therapy rules.

Therapeutic Interchange Policy Per American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and will only employ therapeutic interchange with prescriber’s approval. Criteria for consideration in therapeutic interchange include availability of agents within a therapeutic class, therapeutic equivalence, safety data, and costs.

Diabetic Supplies The following diabetic supplies are covered: • Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days • Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits: o 400 per 100 days for all members o 800 per 100 days for members with gestational diabetes • Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply

Respiratory Supplies The following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days: • Inhalers and inhaler assist devices • Nebulizers • Peak flow meters

Formulary Document Details The SFHP formulary document is listed by drug class and the following information: drug name, dosage form, drug tier, quantity limit and prior authorization or step therapy requirements. Brand products are listed San Francisco Health Plan Healthy Kids HMO Formulary AS OF November 20, 2019

in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary and will pay at the point of sale, if quantity limits and age limitations are met (see “Formulary Restrictions” above). Tier 2 drugs may require a Prior Authorization (see “Request for Non-Preferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above).

**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary and another strength of the same medication requiring a prior authorization.

If you are hearing impaired, please call the TDD/TYY line at 1(415) 547-7830, toll-free at 1(888) 883-7347 or through the California Relay Service at 711. You may request this document in alternative formats like Braille, large size print, and audio. To request other formats, or for help with reading this document and other SFHP materials, please call Customer Service at 1(415) 547-7800 or toll-free at 1(800) 288-5555.

Tier Drug T1= Formulary, Generic Generic drugs = lowercase T2= Formulary, Brand Notes italics T3= Formulary, Prior AL= Age Limit Authorization or Step Therapy PA= Prior Authorization Brand name drugs = T4= Specialty Pharmacy, Prior QL= Quantity Limit UPPERCASE Authorization ST= Step Therapy

Drug Tier Notes Antihistamine Drugs First Gen. Antihist. Derivatives, Misc. cyproheptadine T1 First Generation Antihistamines cyproheptadine T1 Phenothiazine Derivatives PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years) promethazine oral T1 AL (Min 2 Years) promethazine rectal suppository 25 mg T1 AL (Min 2 Years) PROMETHAZINE VC T1 AL (Min 2 Years) promethazine-dm T1 AL (Min 2 Years) Piperazine Derivatives hydroxyzine hcl oral solution 10 mg/5 ml T1 hydroxyzine hcl oral tablet T1 hydroxyzine pamoate T1 meclizine oral tablet 12.5 mg, 25 mg T1 Second Generation Antihistamines desloratadine oral tablet T1 levocetirizine oral tablet T1 Anti-Infective Agents 1St Generation Cephalosporin Antibiotics cefadroxil oral capsule T1 cephalexin oral capsule 250 mg, 500 mg T1 cephalexin oral suspension for reconstitution T1 AL (Max 12 Years) 1 Drug Tier Notes 2Nd Generation Cephalosporin Antibiotics cefaclor oral capsule T1 cefaclor oral suspension for reconstitution 125 T1 AL (Max 12 Years) mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr T1 cefprozil oral suspension for reconstitution T1 AL (Max 12 Years) cefprozil oral tablet T1 CEFTIN ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION 250 MG/5 ML cefuroxime axetil oral suspension for T1 AL (Max 12 Years) reconstitution 125 mg/5 ml cefuroxime axetil oral tablet T1 3Rd Generation Cephalosporin Antibiotics cefdinir oral capsule T1 QL (60 EA per 30 days) cefdinir oral suspension for reconstitution T1 AL (Max 12 Years) cefixime oral capsule T1 QL (28 EA per 28 days) cefixime oral suspension for reconstitution T1 AL (Max 12 Years) cefpodoxime oral suspension for reconstitution T1 AL (Max 12 Years) cefpodoxime oral tablet 100 mg T1 QL (60 QY per 30 DYs) cefpodoxime oral tablet 200 mg T1 SUPRAX ORAL TABLET,CHEWABLE T2 AL (Max 12 Years) Allylamine Antifungals terbinafine hcl oral T1 QL (180 EA per 365 days) Amebicides metronidazole oral tablet T1 Aminoglycoside Antibiotics BETHKIS Tier 5 neomycin T1 paromomycin T1 TOBI PODHALER Tier 5 tobramycin in 0.225 % nacl T4 PA tobramycin with nebulizer Tier 5 Aminopenicillin Antibiotics

2 Drug Tier Notes amoxicillin oral capsule T1 amoxicillin oral suspension for reconstitution T1 AL (Max 12 Years) amoxicillin oral tablet T1 amoxicillin oral tablet,chewable 125 mg, 250 mg T1 AL (Max 12 Years) amoxicillin-pot clavulanate oral suspension for T1 AL (Max 12 Years) reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml amoxicillin-pot clavulanate oral suspension for T1 reconstitution 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet T1 amoxicillin-pot clavulanate oral tablet extended T1 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable T1 AL (Max 12 Years) ampicillin oral capsule T1 AUGMENTIN ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION 125-31.25 MG/5 ML Anthelmintics albendazole T1 QL (6 EA per 365 days) ivermectin oral T1 QL (30 EA per 365 days) praziquantel T1 QL (15 EA per 365 days) Antifungals, Miscellaneous griseofulvin microsize T1 griseofulvin ultramicrosize T1 Antimalarials atovaquone-proguanil T1 QL (180 EA per 365 days) chloroquine phosphate T1 DARAPRIM T4 PA hydroxychloroquine T1 mefloquine T1 primaquine T1 quinidine gluconate oral T1 quinidine sulfate oral tablet T1 Antimycobacterials, Miscellaneous dapsone oral T1

3 Drug Tier Notes Antiprotozoals, Miscellaneous ALINIA T2 QL (30 ML per 365 days) atovaquone T1 dapsone oral T1 metronidazole oral tablet T1 NEBUPENT T3 PA tinidazole T1 QL (30 EA per 365 days) Antituberculosis Agents ciprofloxacin T1 AL (Max 12 Years) ciprofloxacin (mixture) Tier 5 ciprofloxacin hcl oral T1 clarithromycin oral tablet T1 QL (60 EA per 30 days) cycloserine T1 ethambutol T1 isoniazid oral solution T1 AL (Max 12 Years) isoniazid oral tablet T1 levofloxacin oral tablet T1 moxifloxacin oral T3 PA PASER T2 PRIFTIN T2 pyrazinamide T1 rifabutin T1 RIFAMATE T2 rifampin oral T1 SIRTURO T3 PA TRECATOR T2 Azole Antifungals CRESEMBA ORAL Tier 5 fluconazole T1 itraconazole oral capsule T3 PA itraconazole oral solution Tier 5 ketoconazole oral T1 NOXAFIL ORAL SUSPENSION Tier 5 4 Drug Tier Notes ONMEL T3 PA posaconazole oral tablet,delayed release (dr/ec) Tier 5 voriconazole oral T3 PA Erythromycin Antibiotics ERYTHROCIN (AS STEARATE) ORAL T1 QL (120 EA per 30 days) TABLET 250 MG erythromycin ethylsuccinate oral suspension for T1 AL (Max 12 Years) reconstitution erythromycin ethylsuccinate oral tablet T1 erythromycin oral capsule,delayed release(dr/ec) T1 erythromycin oral tablet T1 QL (120 EA per 30 days) erythromycin oral tablet,delayed release (dr/ec) T1 PCE T2 Glycopeptide Antibiotics FIRVANQ ORAL RECON SOLN 25 MG/ML T2 QL (400 ML per 10 days) vancomycin in dextrose 5 % intravenous solution Tier 5 1.75 gram/500 ml vancomycin intravenous recon soln 1,000 mg, 5 T1 gram, 500 mg vancomycin oral capsule T1 QL (40 QY per 10 DYs) vancomycin oral recon soln T1 QL (400 ML per 10 days) Hcv Polymerase Inhibitor Antivirals ledipasvir-sofosbuvir T4 PA sofosbuvir-velpatasvir T4 PA SOVALDI ORAL TABLET 400 MG Tier 5 VIEKIRA PAK Tier 5 VOSEVI T4 PA Hcv Protease Inhibitor Antivirals MAVYRET T4 PA TECHNIVIE Tier 5 VIEKIRA PAK Tier 5 ZEPATIER Tier 5 Hcv Replication Complex Inhibitors DAKLINZA ORAL TABLET 30 MG, 60 MG Tier 5 5 Drug Tier Notes ledipasvir-sofosbuvir T4 PA MAVYRET T4 PA sofosbuvir-velpatasvir T4 PA TECHNIVIE Tier 5 VIEKIRA PAK Tier 5 VOSEVI T4 PA ZEPATIER Tier 5 Hiv Entry And Fusion Inhibitors FUZEON SUBCUTANEOUS RECON SOLN T3 PA SELZENTRY ORAL TABLET T3 PA Hiv Integrase Inhibitor Antiretrovirals GENVOYA T3 PA ISENTRESS T3 PA ISENTRESS HD T3 PA STRIBILD T3 PA TIVICAY T3 PA TRIUMEQ T3 PA Hiv Nonnucleoside Rev.Transcrip. Inhib. ATRIPLA T3 PA COMPLERA T3 PA EDURANT T3 PA efavirenz T3 PA INTELENCE T3 PA nevirapine oral tablet T3 PA nevirapine oral tablet extended release 24 hr T3 PA ODEFSEY T3 PA RESCRIPTOR T3 PA VIRAMUNE ORAL SUSPENSION T3 PA Hiv Nucleoside, Nucleotide Rt Inhibitors abacavir T3 PA abacavir-lamivudine-zidovudine T3 PA ATRIPLA T3 PA COMPLERA T3 PA 6 Drug Tier Notes DESCOVY T3 PA didanosine T1 EMTRIVA T3 PA EPZICOM T3 PA GENVOYA T3 PA lamivudine oral solution T1 lamivudine oral tablet 100 mg T1 lamivudine oral tablet 150 mg, 300 mg T3 PA lamivudine-zidovudine T3 PA ODEFSEY T3 PA stavudine T3 PA STRIBILD T3 PA tenofovir disoproxil fumarate T1 TRIUMEQ T3 PA TRUVADA T3 PA VIDEX 2 GRAM PEDIATRIC T2 VIDEX 4 GRAM PEDIATRIC T2 VIREAD ORAL POWDER T3 PA VIREAD ORAL TABLET 150 MG, 200 MG, 250 T3 PA MG zidovudine T1 Hiv Protease Inhibitor Antiretrovirals APTIVUS T3 PA atazanavir T3 PA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T3 PA fosamprenavir T3 PA INVIRASE T3 PA KALETRA T3 PA LEXIVA ORAL SUSPENSION T3 PA NORVIR ORAL CAPSULE T3 PA NORVIR ORAL SOLUTION T3 PA PREZISTA ORAL TABLET 150 MG, 600 MG, T3 PA 75 MG, 800 MG ritonavir T3 PA 7 Drug Tier Notes TECHNIVIE Tier 5 VIEKIRA PAK Tier 5 VIRACEPT ORAL TABLET T3 PA Lincomycin Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg T1 clindamycin palmitate hcl T1 AL (Max 12 Years) Macrolide Antibiotics ERYTHROCIN (AS STEARATE) ORAL T1 QL (120 EA per 30 days) TABLET 250 MG erythromycin ethylsuccinate oral suspension for T1 AL (Max 12 Years) reconstitution erythromycin ethylsuccinate oral tablet T1 erythromycin oral capsule,delayed release(dr/ec) T1 erythromycin oral tablet T1 QL (120 EA per 30 days) erythromycin oral tablet,delayed release (dr/ec) T1 PCE T2 Monobactam Antibiotics CAYSTON T4 PA Natural Penicillin Antibiotics penicillin v potassium oral recon soln T1 AL (Max 12 Years) penicillin v potassium oral tablet T1 Neuraminidase Inhibitor Antivirals oseltamivir oral capsule 30 mg, 75 mg T1 oseltamivir oral capsule 45 mg T1 AL (Max 12 Years) oseltamivir oral suspension for reconstitution T1 AL (Max 12 Years) RELENZA DISKHALER T2 QL (20 QY per 30 DYs) Nucleoside And Nucleotide Antivirals acyclovir oral capsule T1 QL (150 QY per 30 DYs) acyclovir oral suspension 200 mg/5 ml T1 AL (Max 12 Years) acyclovir oral tablet T1 QL (150 QY per 30 DYs) adefovir Tier 5 BARACLUDE ORAL SOLUTION T2 AL (Max 12 Years) entecavir T1 QL (30 EA per 30 days)

8 Drug Tier Notes famciclovir oral tablet 125 mg T1 QL (60 EA per 30 days) famciclovir oral tablet 250 mg T1 QL (90 EA per 30 days) famciclovir oral tablet 500 mg T1 QL (120 EA per 30 days) ribavirin oral capsule T1 ribavirin oral tablet 200 mg T1 valacyclovir oral tablet 1 gram T1 QL (120 QY per 30 DYs) valacyclovir oral tablet 500 mg T1 QL (90 QY per 30 DYs) valganciclovir T3 PA VEMLIDY T3 PA Other Macrolide Antibiotics azithromycin oral packet T1 QL (1 FL per 60 DYs) azithromycin oral suspension for reconstitution T1 AL (Max 12 Years) 100 mg/5 ml azithromycin oral suspension for reconstitution T1 QL (2 FL per 365 DYs); AL (Max 12 200 mg/5 ml Years) azithromycin oral tablet 250 mg, 600 mg T1 QL (30 QY per 30 DYs) azithromycin oral tablet 500 mg T1 QL (15 EA per 30 fills) clarithromycin oral tablet T1 QL (60 EA per 30 days) DIFICID T4 PA Oxazolidinone Antibiotics linezolid oral suspension for reconstitution T1 AL (Max 12 Years) linezolid oral tablet T1 Penicillinase-Resistant Penicillins dicloxacillin T1 Polyene Antifungals nystatin oral suspension T1 nystatin oral tablet T1 Quinolone Antibiotics ciprofloxacin T1 AL (Max 12 Years) ciprofloxacin (mixture) Tier 5 ciprofloxacin hcl oral T1 levofloxacin oral solution T1 AL (Max 12 Years) levofloxacin oral tablet T1

9 Drug Tier Notes moxifloxacin oral T3 PA ofloxacin oral tablet 300 mg, 400 mg Tier 5 Rifamycin Antibiotics PRIFTIN T2 rifabutin T1 RIFAMATE T2 rifampin oral T1 RIFATER T2 XIFAXAN ORAL TABLET 200 MG T3 ST; QL (90 QY per 30 DYs) XIFAXAN ORAL TABLET 550 MG T3 ST; QL (60 QY per 30 DYs) Sulfonamide Antibiotics (Systemic) sulfadiazine T1 sulfamethoxazole-trimethoprim oral suspension T1 AL (Max 12 Years) sulfamethoxazole-trimethoprim oral tablet T1 sulfasalazine T1 Tetracycline Antibiotics doxycycline hyclate oral capsule T1 QL (60 EA per 30 days) doxycycline hyclate oral tablet 100 mg T1 QL (60 QY per 30 DYs) doxycycline monohydrate oral capsule 100 mg, 50 T1 QL (60 EA per 30 days) mg doxycycline monohydrate oral tablet 100 mg T1 QL (60 EA per 30 days) minocycline oral capsule T1 QL (60 EA per 30 days) tetracycline T1 QL (120 QY per 30 DYs) Urinary Anti-Infectives nitrofurantoin T1 AL (Max 12 Years) nitrofurantoin macrocrystal T1 nitrofurantoin monohyd/m-cryst T1 trimethoprim T1 Antineoplastic Agents Antineoplastic Agents abiraterone T4 PA AFINITOR T4 PA AFINITOR DISPERZ T4 PA 10 Drug Tier Notes ALECENSA T3 PA ALKERAN T4 PA ALUNBRIG T3 PA anastrozole T1 QL (30 QY per 30 DYs) BALVERSA T4 PA bexarotene T4 PA bicalutamide T1 BOSULIF T4 PA BRAFTOVI T4 PA CABOMETYX T4 PA CALQUENCE T4 PA capecitabine T4 PA CAPRELSA T3 PA COMETRIQ T4 PA COPIKTRA T4 PA COTELLIC T3 PA cyclophosphamide oral capsule T3 PA DAURISMO T4 PA diclofenac sodium topical gel 3 % Tier 5 ELIGARD T4 PA ELIGARD (3 MONTH) T4 PA ELIGARD (4 MONTH) T4 PA ELIGARD (6 MONTH) T4 PA EMCYT T4 PA ERIVEDGE T4 PA ERLEADA T4 PA erlotinib T4 PA etoposide oral T4 PA exemestane T3 PA FARESTON T4 PA FARYDAK T4 PA FIRMAGON KIT W DILUENT SYRINGE T4 PA SUBCUTANEOUS RECON SOLN 80 MG

11 Drug Tier Notes fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs) flutamide T1 GILOTRIF T4 PA GLEOSTINE T3 PA HEXALEN T4 PA HYCAMTIN ORAL T3 PA hydroxyurea T1 IBRANCE T4 PA ICLUSIG T3 PA IDHIFA T4 PA imatinib T4 PA IMBRUVICA T4 PA INLYTA T4 PA INREBIC T4 PA IRESSA T4 PA JAKAFI T4 PA KISQALI T3 PA LENVIMA ORAL CAPSULE 10 MG/DAY (10 T4 PA MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole T1 LEUKERAN T3 PA leuprolide T3 PA LONSURF T4 PA LORBRENA T4 PA LUPANETA PACK (1 MONTH) Tier 5 LUPANETA PACK (3 MONTH) Tier 5 LUPRON DEPOT T4 PA LUPRON DEPOT (3 MONTH) T4 PA LUPRON DEPOT (4 MONTH) T4 PA LUPRON DEPOT-PED T4 PA LUPRON DEPOT-PED (3 MONTH) T4 PA

12 Drug Tier Notes LYNPARZA T4 PA LYSODREN T4 PA MATULANE T4 PA megestrol oral suspension 400 mg/10 ml (10 ml), T1 400 mg/10 ml (40 mg/ml) megestrol oral tablet T1 MEKINIST T3 PA MEKTOVI T4 PA mercaptopurine T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 DYs) methotrexate sodium injection T1 QL (16 ML per 28 DYs) methotrexate sodium oral T1 MYLERAN T3 PA NERLYNX T3 PA NEXAVAR T4 PA NINLARO T3 PA NUBEQA T4 PA ODOMZO T3 PA PIQRAY T4 PA POMALYST T4 PA PURIXAN T3 PA REVLIMID T4 PA ROZLYTREK T4 PA RUBRACA T4 PA RYDAPT T3 PA SOLTAMOX T3 PA SPRYCEL T3 PA STIVARGA T4 PA SUTENT T4 PA SYNRIBO T4 PA TABLOID T3 PA TAFINLAR T3 PA TAGRISSO T4 PA

13 Drug Tier Notes TALZENNA T4 PA tamoxifen T1 TASIGNA T4 PA temozolomide T3 PA TIBSOVO T4 PA tretinoin (chemotherapy) T3 PA TREXALL T3 PA TURALIO T4 PA TYKERB T4 PA VENCLEXTA T4 PA VENCLEXTA STARTING PACK T4 PA VERZENIO T4 PA VITRAKVI T4 PA VIZIMPRO T3 PA VOTRIENT T4 PA XALKORI T4 PA XOSPATA T4 PA XPOVIO T4 PA XTANDI T4 PA YONSA T4 PA ZEJULA T3 PA ZELBORAF T4 PA ZOLINZA T4 PA ZYDELIG T4 PA ZYKADIA T4 PA ZYTIGA ORAL TABLET 500 MG T4 PA Antitoxins,Immune Glob,Toxoids,Vaccines Allergenic Extracts (Therapeutic) GRASTEK Tier 5 ODACTRA Tier 5 ORALAIR SUBLINGUAL TABLET 300 INDX Tier 5 REACTIVITY RAGWITEK Tier 5

14 Drug Tier Notes Antitoxins And Immune Globulins VARIZIG INTRAMUSCULAR SOLUTION Tier 5 Vaccines VIVOTIF BERNA VACCINE T2 QL (4 EA per 1 fill) Autonomic Drugs Alpha- And Beta-Adrenergic Agonists epinephrine injection auto-injector T1 QL (6 EA per 365 DYs) Alpha-Adrenergic Agonists clonidine hcl T1 clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days) clonidine transdermal patch weekly 0.2 mg/24 hr, T1 QL (8 EA per 28 days) 0.3 mg/24 hr methyldopa T1 methyldopa-hydrochlorothiazide T1 midodrine T1 PROMETHAZINE VC T1 AL (Min 2 Years) Antimuscarinics/Antispasmodics ANORO ELLIPTA T3 ST ATROVENT HFA T2 QL (25.8 QY per 30 DYs) COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) dicyclomine oral capsule T1 dicyclomine oral tablet T1 diphenoxylate-atropine T1 glycopyrrolate oral tablet 1 mg, 2 mg T1 hyoscyamine sulfate oral tablet T1 hyoscyamine sulfate oral tablet extended release T1 12 hr hyoscyamine sulfate sublingual T1 ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs) ipratropium-albuterol T1 QL (570 QY per 30 DYs) phenobarb-hyoscy-atropine-scop oral elixir 16.2- Tier 5 0.1037 -0.0194 mg/5 ml phenobarb-hyoscy-atropine-scop oral tablet Tier 5

15 Drug Tier Notes PHENOHYTRO Tier 5 SPIRIVA RESPIMAT T2 QL (4 GM per 30 days) STIOLTO RESPIMAT T2 QL (4 GM per 30 days) TUDORZA PRESSAIR T2 QL (1 QY per 30 DYs) Antiparkinsonian Agents benztropine oral T1 trihexyphenidyl T1 Autonomic Drugs, Miscellaneous CHANTIX T2 QL (60 EA per 30 days) CHANTIX STARTING MONTH BOX T2 QL (159 EA per 365 days) nicotine (polacrilex) buccal gum T1 QL (360 QY per 30 DYs) nicotine (polacrilex) buccal lozenge T1 QL (600 EA per 30 days) nicotine transdermal patch 24 hour 14 mg/24 hr, T1 QL (30 QY per 30 DYs) 21 mg/24 hr, 7 mg/24 hr NICOTROL T3 PA NICOTROL NS T3 PA Centrally Acting Skeletal Muscle Relaxnt cyclobenzaprine oral tablet 10 mg, 5 mg T1 QL (90 QY per 30 DYs) methocarbamol oral T1 QL (120 EA per 30 days) tizanidine oral tablet T1 QL (90 QY per 30 DYs) Gaba-Derivative Skeletal Muscle Relaxant baclofen oral T1 Non-Sel. Beta-Adrenergic Blocking Agents carvedilol T1 carvedilol phosphate Tier 5 labetalol oral T1 nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Non-Sel.Alpha-1-Adrenergic Blocking Agts CARDURA XL Tier 5 doxazosin T1 16 Drug Tier Notes prazosin T1 terazosin T1 Non-Sel.Alpha-Adrenergic Blocking Agents phenoxybenzamine T3 PA Parasympathomimetic (Cholinergic Agents) bethanechol chloride T1 donepezil T1 galantamine T1 NAMZARIC ORAL CAPSULE,SPRINKLE,ER T2 24HR pilocarpine hcl oral tablet 5 mg T1 QL (180 QY per 30 DYs) pilocarpine hcl oral tablet 7.5 mg T1 QL (120 EA per 30 days) pyridostigmine bromide oral syrup T1 pyridostigmine bromide oral tablet 60 mg T1 pyridostigmine bromide oral tablet extended T1 release rivastigmine T1 rivastigmine tartrate T1 Selective Alpha-1-Adrenergic Block.Agent alfuzosin T1 carvedilol T1 carvedilol phosphate Tier 5 labetalol oral T1 tamsulosin T1 Selective Beta-2-Adrenergic Agonists ADVAIR HFA T3 PA albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days) albuterol sulfate inhalation solution for T1 nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml albuterol sulfate inhalation solution for T1 QL (525 QY per 30 DYs) nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for T1 QL (100 QY per 30 DYs) nebulization 5 mg/ml

17 Drug Tier Notes albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years) albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs) albuterol sulfate oral tablet extended release 12 hr Tier 5 ANORO ELLIPTA T3 ST ARCAPTA NEOHALER T2 QL (30 EA per 30 days) BREO ELLIPTA T3 PA BROVANA T3 PA COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) DULERA T2 QL (13 QY per 30 DYs) fluticasone propion-salmeterol inhalation aerosol T1 QL (1 EA per 30 days) powdr breath activated 113-14 mcg/actuation, 55- 14 mcg/actuation fluticasone propion-salmeterol inhalation aerosol T1 powdr breath activated 232-14 mcg/actuation fluticasone propion-salmeterol inhalation blister T1 QL (60 EA per 30 days) with device ipratropium-albuterol T1 QL (570 QY per 30 DYs) levalbuterol hcl inhalation solution for T3 ST; QL (240 QY per 30 DYs) nebulization 0.31 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (360 QY per 30 DYs) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (150 QY per 30 DYs) nebulization 1.25 mg/0.5 ml levalbuterol tartrate T3 ST; QL (30 GM per 30 days) PERFOROMIST Tier 5 PROAIR RESPICLICK T2 QL (2 EA per 30 days) SEREVENT DISKUS T3 PA STIOLTO RESPIMAT T2 QL (4 GM per 30 days) STRIVERDI RESPIMAT T2 QL (4 GM per 30 days) SYMBICORT T2 QL (10.2 QY per 30 DYs) terbutaline oral T1 WIXELA INHUB T1 QL (60 EA per 30 days) Selective Beta-Adrenergic Blocking Agent acebutolol T1

18 Drug Tier Notes atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg Blood Formation, Coagulation, Thrombosis Blood Form.,Coag,Thrombosis Agents Misc. TAVALISSE Tier 5 Coumarin Derivatives JANTOVEN ORAL TABLET 3 MG, 7.5 MG T1 warfarin T1 Direct Factor Xa Inhibitors ELIQUIS ORAL TABLET T2 QL (60 EA per 30 days) ELIQUIS ORAL TABLETS,DOSE PACK T2 QL (74 EA per 30 days) SAVAYSA T2 QL (30 EA per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG T2 QL (30 EA per 30 days) XARELTO ORAL TABLET 15 MG, 2.5 MG T2 QL (60 EA per 30 days) XARELTO ORAL TABLETS,DOSE PACK T2 QL (51 EA per 30 days) Direct Thrombin Inhibitors PRADAXA T3 PA Hematopoietic Agents ARANESP (IN POLYSORBATE) T3 PA DOPTELET (10 TAB PACK) Tier 5 DOPTELET (15 TAB PACK) Tier 5 EPOGEN INJECTION SOLUTION 10,000 T3 PA UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML FULPHILA Tier 5 GRANIX T4 PA MIRCERA INJECTION SYRINGE 150 MCG/0.3 Tier 5 ML, 30 MCG/0.3 ML MOZOBIL T4 PA 19 Drug Tier Notes MULPLETA Tier 5 NEULASTA SUBCUTANEOUS SYRINGE T3 PA NEUPOGEN Tier 5 NIVESTYM Tier 5 NPLATE Tier 5 PROCRIT INJECTION SOLUTION 4,000 T3 PA UNIT/ML, 40,000 UNIT/ML PROMACTA ORAL TABLET T3 PA RETACRIT T3 PA ZARXIO T3 PA Hemorrheologic Agents pentoxifylline T1 Hemostatics DDAVP NASAL SOLUTION Tier 5 desmopressin nasal spray,non-aerosol T1 desmopressin oral T1 STIMATE T3 PA tranexamic acid oral T1 QL (30 EA per 30 days) Heparins enoxaparin subcutaneous solution T1 QL (18 ML per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 T1 QL (60 ML per 30 days) mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, T1 QL (48 ML per 30 days) 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (18 ML per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml T1 QL (24 ML per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml T1 QL (36 ML per 30 days) heparin (porcine) injection solution 10,000 T1 unit/ml, 20,000 unit/ml Iron Preparations ATABEX EC T2 QL (30 QY per 30 DYs) BIOTECT PLUS T1 CLASSIC PRENATAL T2 ELITE-OB 400 T1 QL (30 QY per 30 DYs)

20 Drug Tier Notes FOLIVANE-OB T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T1 QL (30 QY per 30 DYs) NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NESTABS T1 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) O-CAL FA T2 QL (30 QY per 30 DYs) PRENATA T1 QL (30 QY per 30 DYs) PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN ORAL TABLET 27 MG T1 IRON- 0.8 MG PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRETAB T1 QL (30 EA per 30 days) PUREFE OB PLUS T1 QL (30 QY per 30 DYs) SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs) STROVITE FORTE T2 THERANATAL COMPLETE T1 QL (60 QY per 30 DYs) TRIADVANCE T1 TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VEMAVITE-PRX-2 T1 QL (30 QY per 30 DYs) VINATE M T1 QL (30 QY per 30 DYs) VINATE ONE T1 QL (30 QY per 30 DYs) VINATE ULTRA T1 QL (30 EA per 30 days) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VITAMED MD ONE RX T2 QL (30 EA per 30 days) VITAMED MD PLUS RX T1 QL (60 QY per 30 DYs) VOL-NATE T1 QL (30 EA per 30 days)

21 Drug Tier Notes VP-CH PLUS T1 QL (30 EA per 30 days) VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 Platelet-Aggregation Inhibitors aspirin-dipyridamole T1 QL (60 EA per 30 DYs) BRILINTA T2 QL (60 EA per 30 days) cilostazol T1 QL (60 QY per 30 DYs) clopidogrel oral tablet 75 mg T1 dipyridamole oral T1 prasugrel T1 QL (30 EA per 30 days) Platelet-Reducing Agents anagrelide T1 Cardiovascular Drugs Alpha-Adrenergic Blocking Agents CARDURA XL Tier 5 carvedilol T1 carvedilol phosphate Tier 5 doxazosin T1 labetalol oral T1 prazosin T1 terazosin T1 Alpha-Adrenergic Blocking Agt.(Hypoten) CARDURA XL Tier 5 doxazosin T1 labetalol oral T1 prazosin T1 terazosin T1 Angiotensin Ii Receptor Antagon.(Hypotn) amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 amlodipine-valsartan-hcthiazid Tier 5 candesartan T3 ST

22 Drug Tier Notes candesartan-hydrochlorothiazid T3 ST EDARBI Tier 5 EDARBYCLOR Tier 5 eprosartan Tier 5 irbesartan T1 irbesartan-hydrochlorothiazide T1 losartan T1 losartan-hydrochlorothiazide T1 olmesartan Tier 5 olmesartan-amlodipin-hcthiazid Tier 5 olmesartan-hydrochlorothiazide Tier 5 telmisartan T1 telmisartan-amlodipine Tier 5 telmisartan-hydrochlorothiazid Tier 5 valsartan T1 valsartan-hydrochlorothiazide T1 Angiotensin Ii Receptor Antagonists amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 amlodipine-valsartan-hcthiazid Tier 5 candesartan T3 ST candesartan-hydrochlorothiazid T3 ST EDARBI Tier 5 EDARBYCLOR Tier 5 ENTRESTO T3 ST eprosartan Tier 5 irbesartan T1 irbesartan-hydrochlorothiazide T1 losartan T1 losartan-hydrochlorothiazide T1 olmesartan Tier 5 olmesartan-amlodipin-hcthiazid Tier 5 olmesartan-hydrochlorothiazide Tier 5

23 Drug Tier Notes telmisartan T1 telmisartan-amlodipine Tier 5 telmisartan-hydrochlorothiazid Tier 5 valsartan T1 valsartan-hydrochlorothiazide T1 Angiotensin-Convert.Enzyme Inhib(Hypotn) amlodipine-benazepril T1 benazepril T1 benazepril-hydrochlorothiazide T1 captopril T1 enalapril maleate T1 enalapril-hydrochlorothiazide T1 fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 perindopril erbumine T1 quinapril T1 ramipril T1 trandolapril T1 Angiotensin-Converting Enzyme Inhibitors amlodipine-benazepril T1 benazepril T1 benazepril-hydrochlorothiazide T1 captopril T1 enalapril maleate T1 enalapril-hydrochlorothiazide T1 fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 perindopril erbumine T1 quinapril T1 ramipril T1 trandolapril T1 24 Drug Tier Notes Antiarrhythmics, Miscellaneous digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1 digoxin oral tablet T1 Antilipemic Agents, Miscellaneous niacin oral capsule, extended release 250 mg, 500 T1 mg NIACOR T1 omega-3 acid ethyl esters Tier 5 VASCEPA Tier 5 Beta-Adrenergic Blocking Agents acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 carvedilol T1 carvedilol phosphate Tier 5 labetalol oral T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Beta-Adrenergic Blocking Agt.(Hypoten) acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 labetalol oral T1 metoprolol succinate T1

25 Drug Tier Notes metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Bile Acid Sequestrants cholestyramine (with sugar) T1 CHOLESTYRAMINE LIGHT T1 colesevelam T3 PA colestipol oral granules T3 PA colestipol oral packet T3 PA colestipol oral tablet T1 PREVALITE ORAL POWDER T1 Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Calcium-Channel Blocking Agents amlodipine T1 amlodipine-benazepril T1 amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 amlodipine-valsartan-hcthiazid Tier 5 diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1

26 Drug Tier Notes diltiazem hcl oral tablet T1 felodipine T1 nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 olmesartan-amlodipin-hcthiazid Tier 5 telmisartan-amlodipine Tier 5 verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Calcium-Channel Blocking Agents(Hypoten) diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Calcium-Channel Blocking Agents, Misc. diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide T1 Cardiac Drugs, Miscellaneous ranolazine T3 ST Cardiotonic Agents

27 Drug Tier Notes digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1 digoxin oral tablet T1 Central Alpha-Agonists clonidine hcl T1 clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days) clonidine transdermal patch weekly 0.2 mg/24 hr, T1 QL (8 EA per 28 days) 0.3 mg/24 hr guanfacine T1 methyldopa T1 methyldopa-hydrochlorothiazide T1 Cholesterol Absorption Inhibitors ezetimibe T1 Class Ia Antiarrhythmics disopyramide phosphate oral capsule T1 NORPACE CR T2 quinidine gluconate oral T1 quinidine sulfate oral tablet T1 Class Ib Antiarrhythmics DILANTIN T2 mexiletine T1 phenytoin oral suspension T1 phenytoin oral tablet,chewable T1 AL (Max 16 Years) phenytoin sodium extended T1 Class Ic Antiarrhythmics flecainide T1 propafenone oral tablet T1 Class Ii Antiarrhythmics acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 carvedilol T1 28 Drug Tier Notes carvedilol phosphate Tier 5 labetalol oral T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Class Iii Antiarrhythmics amiodarone oral T1 dofetilide T1 MULTAQ T2 sotalol oral T1 Class Iv Antiarrhythmics diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Dihydropyridines amlodipine T1 amlodipine-benazepril T1 amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 amlodipine-valsartan-hcthiazid Tier 5 felodipine T1 nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 olmesartan-amlodipin-hcthiazid Tier 5

29 Drug Tier Notes telmisartan-amlodipine Tier 5 Dihydropyridines (Antihypertensive) amlodipine T1 amlodipine-benazepril T1 amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 amlodipine-valsartan-hcthiazid Tier 5 felodipine T1 nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 olmesartan-amlodipin-hcthiazid Tier 5 telmisartan-amlodipine Tier 5 Direct Vasodilators hydralazine oral T1 minoxidil oral T1 Diuretics, Miscellaneous (Hypotensive) theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Fibric Acid Derivatives fenofibrate micronized T1 fenofibrate nanocrystallized oral tablet 145 mg, 48 T1 mg fenofibrate oral tablet 160 mg, 54 mg T1 fenofibric acid T1 fenofibric acid (choline) T1 gemfibrozil T1 Hmg-Coa Reductase Inhibitors atorvastatin T1 lovastatin T1 pravastatin T1 rosuvastatin T1 simvastatin T1 30 Drug Tier Notes Hypotensive Agents, Miscellaneous acebutolol T1 amlodipine T1 amlodipine-benazepril T1 amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 CARDURA XL Tier 5 carvedilol T1 carvedilol phosphate Tier 5 doxazosin T1 felodipine T1 nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 phenoxybenzamine T3 PA pindolol T1 propranolol oral T1 sotalol oral T1 terazosin T1 Loop Diuretics (Hypotensive Agents) bumetanide oral T1 furosemide oral T1 torsemide oral T1 Mineralocorticoid (Aldosterone) Antagnts eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 Mineralocorticoid(Aldoster.)Antag(Hypot) eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 Nitrates And Nitrites DILATRATE-SR T2

31 Drug Tier Notes ISORDIL T2 isosorbide dinitrate oral T1 isosorbide mononitrate T1 NITRO-BID T2 nitroglycerin sublingual T1 Pcsk9 Inhibitors PRALUENT PEN T3 PA REPATHA PUSHTRONEX T4 PA REPATHA SURECLICK T4 PA REPATHA SYRINGE T4 PA Phosphodiesterase Type 5 Inhibitors cilostazol T1 QL (60 QY per 30 DYs) sildenafil (pulm.hypertension) intravenous Tier 5 sildenafil (pulm.hypertension) oral suspension for Tier 5 reconstitution sildenafil (pulm.hypertension) oral tablet T3 PA tadalafil (pulm. hypertension) T3 PA Potassium-Sparing Diuretics (Hypoten) amiloride T1 eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 Renin Inhibitors aliskiren Tier 5 TEKTURNA HCT Tier 5 Renin-Angioten.-Aldost. Sys. Inhib, Misc ENTRESTO T3 ST Thiazide Diuretics(Hypotensive Agents) amlodipine-valsartan-hcthiazid Tier 5 benazepril-hydrochlorothiazide T1

32 Drug Tier Notes bisoprolol-hydrochlorothiazide T1 candesartan-hydrochlorothiazid T3 ST chlorothiazide T1 DIURIL T2 AL (Max 12 Years) enalapril-hydrochlorothiazide T1 hydrochlorothiazide T1 irbesartan-hydrochlorothiazide T1 lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 methyldopa-hydrochlorothiazide T1 olmesartan-amlodipin-hcthiazid Tier 5 olmesartan-hydrochlorothiazide Tier 5 spironolacton-hydrochlorothiaz T1 TEKTURNA HCT Tier 5 telmisartan-hydrochlorothiazid Tier 5 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 valsartan-hydrochlorothiazide T1 Thiazide-Like Diuretics(Hypotensive Agt) atenolol-chlorthalidone T1 chlorthalidone oral tablet 25 mg, 50 mg T1 EDARBYCLOR Tier 5 indapamide T1 metolazone T1 Vasodilating Agents, Miscellaneous ADEMPAS T4 PA amlodipine T1 amlodipine-benazepril T1 amlodipine-olmesartan Tier 5 amlodipine-valsartan T1 aspirin-dipyridamole T1 QL (60 EA per 30 DYs) bosentan Tier 5

33 Drug Tier Notes diltiazem hcl oral capsule,ext.rel 24h degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 dipyridamole oral T1 felodipine T1 LETAIRIS T4 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 olmesartan-amlodipin-hcthiazid Tier 5 OPSUMIT Tier 5 ORENITRAM Tier 5 telmisartan-amlodipine Tier 5 treprostinil sodium T4 PA TYVASO T4 PA TYVASO INSTITUTIONAL START KIT T4 PA TYVASO REFILL KIT T4 PA TYVASO STARTER KIT T4 PA UPTRAVI T4 PA VENTAVIS T4 PA verapamil oral capsule,ext rel. pellets 24 hr T1 verapamil oral tablet T1 verapamil oral tablet extended release T1 Central Nervous System Agents Amphetamine Derivatives diethylpropion oral tablet Tier 5 LOMAIRA Tier 5 phendimetrazine tartrate oral tablet Tier 5 phentermine T3 PA QSYMIA Tier 5 Amphetamines ADZENYS ER Tier 5 34 Drug Tier Notes ADZENYS XR-ODT Tier 5 amphetamine sulfate Tier 5 benzphetamine Tier 5 dextroamphetamine oral capsule, extended release T1 QL (60 EA per 30 DYs); AL (Min 5 Years and Max 18 Years) dextroamphetamine oral solution Tier 5 dextroamphetamine oral tablet 10 mg T1 QL (120 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) dextroamphetamine oral tablet 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) dextroamphetamine-amphetamine T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) DYANAVEL XR Tier 5 methamphetamine Tier 5 VYVANSE Tier 5 ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 Tier 5 MG, 30 MG, 7.5 MG Analgesics And Antipyretics, Misc. acetaminophen-codeine oral solution 120-12 mg/5 T1 AL (Min 12 Years) ml acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) butalbital-acetaminophen-caff oral capsule Tier 5 butalbital-acetaminophen-caff oral tablet 50-325- T3 PA 40 mg FIORICET ORAL CAPSULE Tier 5 gabapentin oral capsule T1 gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years) gabapentin oral tablet 600 mg, 800 mg T1 hydrocodone-acetaminophen oral solution 7.5-325 Tier 5 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 Tier 5 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 T1 QL (120 QY per 30 DYs) mg, 5-325 mg, 7.5-325 mg hydrocodone-acetaminophen oral tablet 2.5-325 T1 QL (120 EA per 30 days) mg 35 Drug Tier Notes oxycodone-acetaminophen oral tablet 10-325 mg, T1 QL (120 EA per 30 days) 2.5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs) PHRENILIN FORTE(WITH CAFFEINE) Tier 5 pregabalin oral capsule T1 QL (2 EA per 1 day) PRIMLEV Tier 5 tramadol-acetaminophen T1 QL (120 EA per 30 days); AL (Min 18 Years) VICODIN ES Tier 5 VICODIN HP Tier 5 Anorexigenic Agents, Miscellaneous CONTRAVE T3 PA Anticholinergic Agents (Cns) benztropine oral T1 trihexyphenidyl T1 Anticonvulsants, Miscellaneous APTIOM T2 BANZEL ORAL TABLET T2 BRIVIACT ORAL TABLET T2 carbamazepine oral capsule, er multiphase 12 hr T1 carbamazepine oral suspension 100 mg/5 ml T1 carbamazepine oral tablet T1 carbamazepine oral tablet extended release 12 hr T1 carbamazepine oral tablet,chewable T1 AL (Max 16 Years) divalproex T1 EQUETRO Tier 5 felbamate oral tablet T1 gabapentin oral capsule T1 gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years) gabapentin oral tablet 600 mg, 800 mg T1 lamotrigine oral tablet T1 lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years) levetiracetam oral solution 100 mg/ml T1 AL (Max 16 Years)

36 Drug Tier Notes levetiracetam oral tablet T1 levetiracetam oral tablet extended release 24 hr T1 oxcarbazepine oral suspension T1 AL (Max 16 Years) oxcarbazepine oral tablet T1 POTIGA T2 pregabalin oral capsule T1 QL (2 EA per 1 day) QSYMIA Tier 5 tiagabine T1 topiramate oral capsule, sprinkle T1 topiramate oral tablet T1 valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 16 Years) mg/5 ml VIMPAT ORAL SOLUTION T2 AL (Max 16 Years) VIMPAT ORAL TABLET T2 zonisamide T1 Antidepressants, Miscellaneous bupropion hcl (smoking deter) T1 bupropion hcl oral tablet T1 bupropion hcl oral tablet extended release 24 hr T1 150 mg, 300 mg bupropion hcl oral tablet sustained-release 12 hr T1 mirtazapine T1 Antimanic Agents aripiprazole oral solution Tier 5 aripiprazole oral tablet T1 aripiprazole oral tablet,disintegrating Tier 5 carbamazepine oral capsule, er multiphase 12 hr T1 carbamazepine oral suspension 100 mg/5 ml T1 carbamazepine oral tablet T1 carbamazepine oral tablet extended release 12 hr T1 carbamazepine oral tablet,chewable T1 AL (Max 16 Years) divalproex T1

37 Drug Tier Notes EQUETRO Tier 5 lamotrigine oral tablet T1 lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years) lithium carbonate oral capsule T1 lithium carbonate oral tablet T1 lithium carbonate oral tablet extended release 450 T1 mg lithium citrate oral solution 8 meq/5 ml T1 LITHOBID T1 olanzapine oral tablet T1 olanzapine oral tablet,disintegrating Tier 5 quetiapine oral tablet T1 quetiapine oral tablet extended release 24 hr Tier 5 risperidone oral solution Tier 5 risperidone oral tablet T1 risperidone oral tablet,disintegrating Tier 5 SAPHRIS Tier 5 valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 16 Years) mg/5 ml ziprasidone hcl T1 Antimigraine Agents, Miscellaneous AIMOVIG AUTOINJECTOR Tier 5 AIMOVIG AUTOINJECTOR (2 PACK) Tier 5 AJOVY Tier 5 butalbital-acetaminophen-caff oral capsule Tier 5 butalbital-acetaminophen-caff oral tablet 50-325- T3 PA 40 mg divalproex T1 EMGALITY PEN T3 PA EMGALITY SYRINGE SUBCUTANEOUS T3 PA SYRINGE 120 MG/ML FIORICET ORAL CAPSULE Tier 5 PHRENILIN FORTE(WITH CAFFEINE) Tier 5

38 Drug Tier Notes propranolol oral T1 tramadol-acetaminophen T1 QL (120 EA per 30 days); AL (Min 18 Years) valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 16 Years) mg/5 ml Antipsychotics, Miscellaneous ADASUVE Tier 5 loxapine succinate T1 pimozide T1 Anxiolytics,Sedatives,And Hypnotics,Misc BELSOMRA Tier 5 buspirone T1 EDLUAR Tier 5 eszopiclone oral tablet 1 mg T1 QL (30 EA per 30 days); AL (Min 16 Years) eszopiclone oral tablet 2 mg, 3 mg T3 ST; QL (30 EA per 30 days); AL (Min 16 Years) HETLIOZ Tier 5 hydroxyzine hcl oral solution 10 mg/5 ml T1 hydroxyzine hcl oral tablet T1 hydroxyzine pamoate T1 PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years) promethazine oral T1 AL (Min 2 Years) promethazine rectal suppository 25 mg T1 AL (Min 2 Years) ramelteon T3 PA zaleplon T1 QL (30 EA per 30 days); AL (Min 16 Years) zolpidem oral tablet T1 QL (30 QY per 30 DYs); AL (Min 16 Years) zolpidem oral tablet,ext release multiphase T3 PA zolpidem sublingual Tier 5 ZOLPIMIST Tier 5 Atypical Antipsychotics aripiprazole oral solution Tier 5 39 Drug Tier Notes aripiprazole oral tablet T1 aripiprazole oral tablet,disintegrating Tier 5 clozapine oral tablet T1 clozapine oral tablet,disintegrating Tier 5 FANAPT Tier 5 LATUDA Tier 5 olanzapine oral tablet T1 olanzapine oral tablet,disintegrating Tier 5 paliperidone Tier 5 quetiapine oral tablet T1 quetiapine oral tablet extended release 24 hr Tier 5 REXULTI Tier 5 risperidone oral solution Tier 5 risperidone oral tablet T1 risperidone oral tablet,disintegrating Tier 5 SAPHRIS Tier 5 VERSACLOZ Tier 5 VRAYLAR Tier 5 ziprasidone hcl T1 Barbiturates (Anticonvulsants) phenobarb-hyoscy-atropine-scop oral elixir 16.2- Tier 5 0.1037 -0.0194 mg/5 ml phenobarb-hyoscy-atropine-scop oral tablet Tier 5 phenobarbital oral elixir T1 AL (Max 16 Years) phenobarbital oral tablet T1 PHENOHYTRO Tier 5 primidone T1 Barbiturates (Anxiolytic, Sedative/Hyp) butalbital-acetaminophen-caff oral capsule Tier 5 butalbital-acetaminophen-caff oral tablet 50-325- T3 PA 40 mg FIORICET ORAL CAPSULE Tier 5 phenobarb-hyoscy-atropine-scop oral elixir 16.2- Tier 5 0.1037 -0.0194 mg/5 ml 40 Drug Tier Notes phenobarb-hyoscy-atropine-scop oral tablet Tier 5 phenobarbital oral elixir T1 AL (Max 16 Years) phenobarbital oral tablet T1 PHENOHYTRO Tier 5 PHRENILIN FORTE(WITH CAFFEINE) Tier 5 Benzodiazepines (Anticonvulsants) clobazam oral suspension T1 AL (Max 12 Years) clobazam oral tablet T1 clonazepam oral tablet T1 QL (60 QY per 30 DYs) clonazepam oral tablet,disintegrating T1 QL (90 EA per 30 days); AL (Max 12 Years) diazepam oral tablet T1 QL (120 QY per 30 DYs) diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 T1 QL (3 EA per 365 days) mg diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs) lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs) lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs) Benzodiazepines (Anxiolytic,Sedativ/Hyp) chlordiazepoxide hcl T1 QL (120 QY per 30 DYs) clobazam oral suspension T1 AL (Max 12 Years) clobazam oral tablet T1 clonazepam oral tablet T1 QL (60 QY per 30 DYs) clonazepam oral tablet,disintegrating T1 QL (90 EA per 30 days); AL (Max 12 Years) diazepam oral tablet T1 QL (120 QY per 30 DYs) diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 T1 QL (3 EA per 365 days) mg diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs) estazolam Tier 5 flurazepam Tier 5 lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs) lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs) midazolam injection solution 5 mg/ml T1 QL (5 ML per 1 fill) quazepam Tier 5

41 Drug Tier Notes temazepam T1 QL (30 QY per 30 DYs); AL (Min 16 Years) triazolam Tier 5 Butyrophenones haloperidol T1 haloperidol lactate oral T1 Calcitonin Gene-Related Peptide Antag. AIMOVIG AUTOINJECTOR Tier 5 AIMOVIG AUTOINJECTOR (2 PACK) Tier 5 AJOVY Tier 5 EMGALITY PEN T3 PA EMGALITY SYRINGE T3 PA Catechol-O-Methyltransferase(Comt)Inhib. carbidopa-levodopa-entacapone T1 entacapone T1 tolcapone T3 PA Central Nervous System Agents, Misc. atomoxetine T1 QL (60 EA per 30 days) AUSTEDO T4 PA carbidopa T1 guanfacine T1 INGREZZA T4 PA memantine T1 NAMZARIC ORAL CAPSULE,SPRINKLE,ER T2 24HR NUEDEXTA T3 PA riluzole T1 tetrabenazine T4 PA XYREM Tier 5 Cyclooxygenase-2 (Cox-2) Inhibitors celecoxib T1 Dopamine Precursors carbidopa-levodopa T1

42 Drug Tier Notes carbidopa-levodopa-entacapone T1 Ergot-Deriv. Dopamine Receptor Agonists bromocriptine T1 cabergoline T1 Fibromyalgia Agents duloxetine T1 pregabalin oral capsule T1 QL (2 EA per 1 day) Hydantoins DILANTIN T2 phenytoin oral suspension T1 phenytoin oral tablet,chewable T1 AL (Max 16 Years) phenytoin sodium extended T1 Monoamine Oxidase B Inhibitors selegiline hcl T1 Monoamine Oxidase Inhibitors selegiline hcl T1 Nonergot-Deriv.Dopamine Receptor Agonist pramipexole oral tablet T1 ropinirole oral tablet T1 Opiate Agonists acetaminophen-codeine oral solution 120-12 mg/5 T1 AL (Min 12 Years) ml acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) ARYMO ER Tier 5 codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) fentanyl T3 PA hydrocodone-acetaminophen oral solution 7.5-325 Tier 5 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 Tier 5 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 T1 QL (120 QY per 30 DYs) mg, 5-325 mg, 7.5-325 mg

43 Drug Tier Notes hydrocodone-acetaminophen oral tablet 2.5-325 T1 QL (120 EA per 30 days) mg hydromorphone oral tablet T1 QL (120 QY per 30 DYs) hydromorphone oral tablet extended release 24 hr Tier 5 12 mg, 32 mg, 8 mg methadone oral concentrate Tier 5 methadone oral tablet Tier 5 methadone oral tablet,soluble Tier 5 MORPHABOND ER Tier 5 morphine concentrate oral solution T1 QL (360 ML per 30 days) morphine oral capsule, er multiphase 24 hr Tier 5 morphine oral capsule,extend.release pellets T3 PA morphine oral solution T1 QL (360 ML per 30 days) morphine oral tablet T1 QL (120 QY per 30 DYs) morphine oral tablet extended release T1 QL (90 EA per 30 days) NUCYNTA ER Tier 5 oxycodone oral concentrate T1 QL (360 ML per 30 days) oxycodone oral solution T1 QL (360 ML per 30 days) oxycodone oral tablet T1 QL (120 QY per 30 DYs) oxycodone oral tablet,oral only,ext.rel.12 hr T3 PA oxycodone-acetaminophen oral tablet 10-325 mg, T1 QL (120 EA per 30 days) 2.5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs) OXYCONTIN ORAL TABLET,ORAL T3 PA ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG oxymorphone oral tablet extended release 12 hr Tier 5 PRIMLEV Tier 5 tramadol oral tablet T1 QL (240 QY per 30 DYs); AL (Min 18 Years) tramadol-acetaminophen T1 QL (120 EA per 30 days); AL (Min 18 Years) VICODIN ES Tier 5 VICODIN HP Tier 5 XTAMPZA ER Tier 5

44 Drug Tier Notes Opiate Antagonists naloxone T1 NARCAN NASAL SPRAY,NON-AEROSOL 4 T2 MG/ACTUATION Opiate Partial Agonists BUNAVAIL T3 PA buprenorphine hcl sublingual T1 QL (120 EA per 30 days) buprenorphine-naloxone sublingual tablet T1 QL (120 EA per 30 days) SUBOXONE T3 PA ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 T3 PA MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6- 2.1 MG Other Nonsteroidal Anti-Inflam. Agents diclofenac potassium T1 diclofenac sodium oral T1 diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days) diclofenac-misoprostol T1 etodolac T1 FLECTOR Tier 5 flurbiprofen T1 ibuprofen oral suspension T1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 INDOCIN ORAL T2 AL (Max 12 Years) INDOCIN RECTAL T2 indomethacin oral T1 ketorolac oral T1 QL (20 EA per 30 days) meloxicam oral tablet T1 nabumetone T1 naproxen oral suspension T1 AL (Max 12 Years) naproxen oral tablet T1 naproxen oral tablet,delayed release (dr/ec) T1 naproxen sodium oral tablet 275 mg, 550 mg T1 oxaprozin T1

45 Drug Tier Notes PENNSAID TOPICAL SOLUTION IN Tier 5 METERED-DOSE PUMP piroxicam T1 sulindac T1 sumatriptan-naproxen Tier 5 Phenothiazines chlorpromazine oral Tier 5 fluphenazine hcl oral concentrate Tier 5 fluphenazine hcl oral elixir Tier 5 fluphenazine hcl oral tablet T1 perphenazine T1 prochlorperazine T1 prochlorperazine maleate T1 thioridazine T1 trifluoperazine T1 Respiratory And Cns Stimulants APTENSIO XR Tier 5 butalbital-acetaminophen-caff oral capsule Tier 5 butalbital-acetaminophen-caff oral tablet 50-325- T3 PA 40 mg COTEMPLA XR-ODT Tier 5 DAYTRANA Tier 5 dexmethylphenidate oral capsule,er biphasic 50- T1 QL (60 EA per 30 days); AL (Min 5 50 Years and Max 18 Years) dexmethylphenidate oral tablet T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) FIORICET ORAL CAPSULE Tier 5 methylphenidate hcl oral capsule, er biphasic 30- T1 QL (60 EA per 30 days); AL (Min 5 70 Years and Max 18 Years) methylphenidate hcl oral capsule,er biphasic 50- T1 QL (60 EA per 30 days); AL (Min 5 50 Years and Max 18 Years) methylphenidate hcl oral solution 10 mg/5 ml T1 QL (900 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) methylphenidate hcl oral solution 5 mg/5 ml T1 QL (300 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

46 Drug Tier Notes methylphenidate hcl oral tablet T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) methylphenidate hcl oral tablet extended release T1 QL (60 QY per 30 DYs); AL (Min 5 10 mg Years and Max 18 Years) methylphenidate hcl oral tablet extended release T1 QL (90 QY per 30 DYs); AL (Min 5 20 mg Years and Max 18 Years) methylphenidate hcl oral tablet extended release T1 QL (60 EA per 30 days); AL (Min 5 24hr 18 mg, 27 mg, 36 mg, 54 mg Years and Max 18 Years) methylphenidate hcl oral tablet extended release Tier 5 24hr 72 mg methylphenidate hcl oral tablet,chewable Tier 5 PHRENILIN FORTE(WITH CAFFEINE) Tier 5 QUILLICHEW ER Tier 5 QUILLIVANT XR Tier 5 RITALIN LA ORAL CAPSULE,ER BIPHASIC T2 QL (60 EA per 30 days); AL (Min 5 50-50 10 MG Years and Max 18 Years) Salicylates aspirin-dipyridamole T1 QL (60 EA per 30 DYs) choline,magnesium salicylate T1 salsalate T1 Sel.Serotonin,Norepi Reuptake Inhibitor desvenlafaxine Tier 5 desvenlafaxine fumarate Tier 5 desvenlafaxine succinate Tier 5 duloxetine T1 venlafaxine oral capsule,extended release 24hr T1 venlafaxine oral tablet T1 Selective Serotonin Agonists almotriptan malate Tier 5 eletriptan Tier 5 frovatriptan Tier 5 naratriptan T3 ST; QL (36 EA per 30 days) rizatriptan T1 QL (36 EA per 30 days); AL (Min 6 Years) sumatriptan T3 PA

47 Drug Tier Notes sumatriptan succinate oral T1 QL (36 EA per 30 days); AL (Min 12 Years) sumatriptan succinate subcutaneous cartridge Tier 5 sumatriptan succinate subcutaneous pen injector 4 Tier 5 mg/0.5 ml sumatriptan succinate subcutaneous solution Tier 5 sumatriptan-naproxen Tier 5 zolmitriptan Tier 5 ZOMIG NASAL Tier 5 Selective Serotonin Receptor Agonists BELVIQ T3 PA BELVIQ XR T3 PA Selective-Serotonin Reuptake Inhibitors citalopram T1 escitalopram oxalate oral solution T1 AL (Max 12 Years) escitalopram oxalate oral tablet T1 fluoxetine oral capsule T1 fluoxetine oral solution T1 AL (Max 12 Years) fluvoxamine oral tablet T1 paroxetine hcl oral tablet T1 sertraline oral concentrate T1 AL (Max 12 Years) sertraline oral tablet T1 Serotonin Modulators nefazodone T1 trazodone T1 TRINTELLIX Tier 5 VIIBRYD ORAL TABLET Tier 5 VIIBRYD ORAL TABLETS,DOSE PACK 10 Tier 5 MG (7)- 20 MG (23) Succinimides ethosuximide oral capsule T1 ethosuximide oral solution T1 AL (Max 16 Years) Thioxanthenes

48 Drug Tier Notes thiothixene T1 Tricyclics, Other Norepi-Ru Inhibitors amitriptyline T1 clomipramine T1 desipramine T1 doxepin oral T1 imipramine hcl T1 nortriptyline T1 SILENOR Tier 5 Vesicular Monoamine Transport2 Inhibitor AUSTEDO T4 PA INGREZZA T4 PA tetrabenazine T4 PA Wakefulness-Promoting Agents armodafinil T3 PA modafinil T3 PA Contraceptives (E.G. Foams, Devices) Contraceptives (E.G. Foams, Devices) ORTHO DIAPHRAGM ALL-FLEX 65 T1 ORTHO DIAPHRAGM ALL-FLEX 70 T1 ORTHO DIAPHRAGM ALL-FLEX 75 T1 ORTHO DIAPHRAGM ALL-FLEX 80 T1 WIDE-SEAL DIAPHRAGM 60 T1 Devices Devices ACCU-CHEK AVIVA CONTROL SOLN T1 ACCU-CHEK GUIDE GLUCOSE METER T1 QL (1 EA per 365 days) ACCU-CHEK GUIDE L1-L2 CTRL SOL T1 ACCU-CHEK GUIDE ME GLUCOSE MTR T1 QL (1 EA per 365 days) ACCU-CHEK MULTICLIX LANCET T1 ACCU-CHEK SMARTVIEW CONTRL SOL T1 ACCU-CHEK SOFT DEV LANCETS T1

49 Drug Tier Notes ACCU-CHEK SOFTCLIX LANCET DEV T1 ACCU-CHEK SOFTCLIX LANCETS T1 AEROCHAMBER PLUS FLOW-VU,S MSK T1 QL (2 FL per 365 DYs) AEROECLIPSE II NEBULIZER T1 QL (2 FL per 365 days) ASTHMAPACK CHILDREN'S T1 QL (2 EA per 365 days) BREATHERITE VALVED MDI SPACER T1 QL (2 EA per 365 days) COMPACT COMPRESSOR NEBULIZER T1 QL (2 FL per 365 days) FREESTYLE LIBRE 10 DAY READER T3 PA FREESTYLE LIBRE 10 DAY SENSOR T3 PA HUMAPEN LUXURA HD T1 NESSI SPACER T1 QL (2 FL per 365 days) SILICONE MASK - INFANT T1 QL (2 FL per 365 days) sodium chloride inhalation solution for T1 nebulization 0.9 %, 3 %, 7 % SOFT TOUCH LANCETS T1 TRUZONE PEAK FLOW METER T1 QL (2 FL per 365 days) Diagnostic Agents Adrenocortical Insufficiency ACTHAR H.P. T4 PA Diabetes Mellitus ACCU-CHEK AVIVA PLUS TEST STRP T1 QL (120 EA per 30 days) ACCU-CHEK GUIDE T1 QL (120 EA per 30 days) ACCU-CHEK SMARTVIEW TEST STRIP T1 QL (120 EA per 30 days) Drug Hypersensitivity PRE-PEN T1 Ketones KETOSTIX T1 QL (100 QY per 100 DYs) Ocular Disorders ALTAFLUOR T1 Electrolytic, Caloric, And Water Balance Alkalinizing Agents CYTRA K CRYSTALS T1 QL (120 EA per 30 days)

50 Drug Tier Notes potassium citrate T1 QL (120 QY per 30 DYs) Ammonia Detoxicants ENULOSE T1 lactulose oral solution 10 gram/15 ml T1 Caloric Agents CLINIMIX 4.25%/D5W SULFIT FREE Tier 5 dextrose 70 % in water (d70w) Tier 5 PKU TRIO T3 PA Carbonic Anhydrase Inhibitors acetazolamide T1 Diuretics, Miscellaneous theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Irrigating Solutions sodium chloride irrigation T1 Loop Diuretics bumetanide oral T1 furosemide oral T1 torsemide oral T1 Phosphate-Removing Agents AURYXIA T3 PA calcium acetate oral capsule T1 ELIPHOS T2 lanthanum T3 PA PHOSLYRA T2 AL (Max 12 Years) sevelamer carbonate oral powder in packet T3 PA sevelamer carbonate oral tablet T1 sevelamer hcl Tier 5 VELPHORO T3 PA Potassium-Removing Agents KIONEX (WITH SORBITOL) T1

51 Drug Tier Notes LOKELMA T2 QL (35 EA per 30 DYs) SODIUM POLYSTYRENE (SORB FREE) T1 QL (240 QY per 30 DYs) sodium polystyrene sulfonate oral powder T1 SPS (WITH SORBITOL) ORAL T2 VELTASSA T3 ST Potassium-Sparing Diuretics amiloride T1 spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 Replacement Preparations ATABEX EC T2 QL (30 QY per 30 DYs) calcium gluconate oral tablet 45 mg (500 mg) T1 KLOR-CON M15 T2 NESTABS T1 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) O-CAL FA T2 QL (30 QY per 30 DYs) potassium chloride oral capsule, extended release T1 potassium chloride oral liquid T1 AL (Max 12 Years) potassium chloride oral tablet extended release T1 potassium chloride oral tablet,er particles/crystals T1 PRENATAL VITAMIN ORAL TABLET 27 MG T1 IRON- 0.8 MG PRETAB T1 QL (30 EA per 30 days) sodium chloride inhalation solution for T1 nebulization 0.9 %, 3 %, 7 % TRIADVANCE T1 TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VEMAVITE-PRX-2 T1 QL (30 QY per 30 DYs) VINATE ONE T1 QL (30 QY per 30 DYs) 52 Drug Tier Notes VINATE ULTRA T1 QL (30 EA per 30 days) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 ZATEAN-CH T1 zinc sulfate oral capsule T1 ZINGIBER T1 QL (60 QY per 30 DYs) Salt And Sugar Substitutes sodium saccharin (bulk) oral powder T1 Thiazide Diuretics amlodipine-valsartan-hcthiazid Tier 5 benazepril-hydrochlorothiazide T1 bisoprolol-hydrochlorothiazide T1 candesartan-hydrochlorothiazid T3 ST chlorothiazide T1 DIURIL T2 AL (Max 12 Years) enalapril-hydrochlorothiazide T1 hydrochlorothiazide T1 irbesartan-hydrochlorothiazide T1 lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 methyldopa-hydrochlorothiazide T1 olmesartan-amlodipin-hcthiazid Tier 5 olmesartan-hydrochlorothiazide Tier 5 spironolacton-hydrochlorothiaz T1 TEKTURNA HCT Tier 5 telmisartan-hydrochlorothiazid Tier 5 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 valsartan-hydrochlorothiazide T1 Thiazide-Like Diuretics atenolol-chlorthalidone T1 chlorthalidone oral tablet 100 mg T1 QL (30 QY per 30 DYs)

53 Drug Tier Notes chlorthalidone oral tablet 25 mg, 50 mg T1 EDARBYCLOR Tier 5 indapamide T1 metolazone T1 Uricosuric Agents probenecid T1 Vasopressin Antagonists SAMSCA ORAL TABLET 15 MG Tier 5 Enzymes Enzymes PULMOZYME T4 PA Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) ALPHAGAN P OPHTHALMIC (EYE) DROPS T2 0.1 % brimonidine T1 COMBIGAN T2 Antiallergic Agents azelastine nasal aerosol,spray T1 QL (30 QY per 30 DYs) azelastine ophthalmic (eye) T1 BEPREVE Tier 5 cromolyn ophthalmic (eye) T1 EMADINE Tier 5 epinastine T3 ST LASTACAFT Tier 5 olopatadine ophthalmic (eye) T3 ST PAZEO Tier 5 Antibacterials (Eent) bacitracin ophthalmic (eye) T1 bacitracin-polymyxin b ophthalmic (eye) T1 BLEPHAMIDE T3 ST BLEPHAMIDE S.O.P. T3 ST

54 Drug Tier Notes CIPRODEX T2 QL (7.5 QY per 30 DYs) ciprofloxacin hcl ophthalmic (eye) T1 doxycycline hyclate oral tablet 20 mg T1 QL (60 EA per 30 days) erythromycin ophthalmic (eye) T1 gentamicin ophthalmic (eye) T1 neomycin-bacitracin-poly-hc T1 neomycin-polymyxin b-dexameth T1 neomycin-polymyxin-gramicidin T1 neomycin-polymyxin-hc T1 NEO-POLYCIN T1 ofloxacin ophthalmic (eye) T1 ofloxacin otic (ear) T1 polymyxin b sulf-trimethoprim T1 sulfacetamide sodium ophthalmic (eye) T1 sulfacetamide-prednisolone T1 TOBRADEX OPHTHALMIC (EYE) T2 OINTMENT tobramycin T1 tobramycin-dexamethasone T1 Antivirals (Eent) trifluridine T1 ZIRGAN T2 Beta-Adrenergic Blocking Agents (Eent) betaxolol ophthalmic (eye) T1 COMBIGAN T2 dorzolamide-timolol T1 levobunolol ophthalmic (eye) drops 0.5 % T1 timolol maleate ophthalmic (eye) drops T1 Carbonic Anhydrase Inhibitors (Eent) acetazolamide T1 dorzolamide T1 dorzolamide-timolol T1 Corticosteroids (Eent)

55 Drug Tier Notes budesonide nasal T1 QL (8.6 GM per 30 DYs) CIPRODEX T2 QL (7.5 QY per 30 DYs) dexamethasone sodium phosphate ophthalmic T1 (eye) DUREZOL T3 ST; QL (5 ML per 30 days) fluocinolone acetonide oil T1 fluorometholone T1 fluticasone propionate nasal T1 QL (16 QY per 30 DYs) hydrocortisone-acetic acid T1 neomycin-bacitracin-poly-hc T1 neomycin-polymyxin b-dexameth T1 neomycin-polymyxin-hc ophthalmic (eye) T1 PRED MILD T3 ST prednisolone acetate T1 prednisolone sodium phosphate ophthalmic (eye) T1 TOBRADEX OPHTHALMIC (EYE) T2 OINTMENT tobramycin-dexamethasone T1 Eent Anti-Infectives, Miscellaneous acetic acid otic (ear) T1 chlorhexidine gluconate mucous membrane T1 hydrocortisone-acetic acid T1 Eent Anti-Inflammatory Agents, Misc. RESTASIS T3 PA RESTASIS MULTIDOSE T3 PA XIIDRA T3 PA Eent Drugs, Miscellaneous ENUCLENE T2 MURO 128 OPHTHALMIC (EYE) DROPS 2 % T2 sodium chloride ophthalmic (eye) T1 Eent Nonsteroidal Anti-Inflam. Agents ACUVAIL (PF) Tier 5 bromfenac Tier 5

56 Drug Tier Notes BROMSITE Tier 5 diclofenac sodium ophthalmic (eye) T1 flurbiprofen sodium T1 ILEVRO Tier 5 ketorolac ophthalmic (eye) T1 NEVANAC Tier 5 PROLENSA Tier 5 Local Anesthetics (Eent) ALTAFLUOR T1 fluorescein-benoxinate T1 lidocaine hcl mucous membrane jelly T1 LIDOCAINE VISCOUS T1 proparacaine T1 Miotics pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, T1 4 % Mydriatics atropine ophthalmic (eye) drops T1 atropine ophthalmic (eye) ointment T1 cyclopentolate T1 HOMATROPAIRE T1 tropicamide T1 Prostaglandin Analogs bimatoprost ophthalmic (eye) T1 latanoprost T1 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 Tier 5 % TRAVATAN Z Tier 5 VYZULTA Tier 5 XELPROS Tier 5 ZIOPTAN (PF) Tier 5 Gastrointestinal Drugs 5-Ht3 Receptor Antagonists

57 Drug Tier Notes AKYNZEO (NETUPITANT) T3 PA granisetron hcl oral T3 PA ondansetron hcl oral solution T3 PA ondansetron hcl oral tablet 4 mg T1 QL (180 EA per 30 days) ondansetron hcl oral tablet 8 mg T1 QL (90 EA per 30 days) ondansetron oral tablet,disintegrating 4 mg T1 QL (180 EA per 30 days) ondansetron oral tablet,disintegrating 8 mg T1 QL (90 EA per 30 days) Antidiarrhea Agents diphenoxylate-atropine T1 loperamide oral capsule T1 QL (30 EA per 30 days) Antiemetics, Miscellaneous BONJESTA Tier 5 DICLEGIS Tier 5 dronabinol T3 PA scopolamine base T3 PA Antihistamines (Gi Drugs) BONJESTA Tier 5 DICLEGIS Tier 5 meclizine oral tablet 12.5 mg, 25 mg T1 prochlorperazine T1 prochlorperazine maleate T1 Anti-Inflammatory Agents (Gi Drugs) alosetron T3 PA balsalazide T1 mesalamine oral tablet,delayed release (dr/ec) 1.2 T1 gram mesalamine oral tablet,delayed release (dr/ec) 800 T3 ST mg mesalamine rectal T1 sulfasalazine T1 Cathartics And Laxatives AMITIZA T3 PA ATABEX EC T2 QL (30 QY per 30 DYs)

58 Drug Tier Notes MOVIPREP T2 OBSTETRIX EC T2 QL (60 QY per 30 DYs) peg 3350-electrolytes T1 PEG-3350 WITH FLAVOR PACKS T1 polyethylene glycol 3350 T1 PREPOPIK T2 SUPREP BOWEL PREP KIT T2 TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) VEMAVITE-PRX-2 T1 QL (30 QY per 30 DYs) VINATE ULTRA T1 QL (30 EA per 30 days) VIRT-SELECT T1 QL (30 QY per 30 DYs) VP-CH PLUS T1 QL (30 EA per 30 days) ZATEAN-CH T1 Cholelitholytic Agents ursodiol T1 Digestants CREON T2 ZENPEP ORAL CAPSULE,DELAYED T2 RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000-47,000 - 63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT Gi Drugs, Miscellaneous CIMZIA T4 PA CIMZIA POWDER FOR RECONST T4 PA CIMZIA STARTER KIT T4 PA ENDARI T4 PA HUMIRA PEDIATRIC CROHNS START T4 PA HUMIRA PEN T4 PA HUMIRA PEN CROHNS-UC-HS START T4 PA HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA 59 Drug Tier Notes HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T4 PA MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) T4 PA HUMIRA(CF) PEDI CROHNS STARTER T4 PA HUMIRA(CF) PEN SUBCUTANEOUS PEN T4 PA INJECTOR KIT 40 MG/0.4 ML LINZESS T2 MOVANTIK T3 PA OCALIVA T4 PA RELISTOR ORAL Tier 5 RELISTOR SUBCUTANEOUS SOLUTION Tier 5 RELISTOR SUBCUTANEOUS SYRINGE 12 Tier 5 MG/0.6 ML SIMPONI T4 PA SYMPROIC T3 PA XENICAL Tier 5 Histamine H2-Antagonists cimetidine T1 cimetidine hcl oral T1 famotidine oral suspension T1 AL (Max 12 Years) famotidine oral tablet 20 mg, 40 mg T1 ranitidine hcl oral syrup T1 AL (Max 12 Years) ranitidine hcl oral tablet 150 mg, 300 mg T1 Neurokinin-1 Receptor Antagonists AKYNZEO (NETUPITANT) T3 PA aprepitant T3 PA EMEND ORAL SUSPENSION FOR T3 PA RECONSTITUTION Prokinetic Agents metoclopramide hcl oral solution T1 metoclopramide hcl oral tablet T1 Prostaglandins diclofenac-misoprostol T1 misoprostol T1

60 Drug Tier Notes Protectants sucralfate oral suspension T1 AL (Max 12 Years) sucralfate oral tablet T1 Proton-Pump Inhibitors DEXILANT Tier 5 lansoprazole oral capsule,delayed release(dr/ec) T1 lansoprazole oral tablet,disintegrat, delay rel T1 AL (Max 12 Years) OMEPPI Tier 5 omeprazole oral capsule,delayed release(dr/ec) T1 omeprazole oral tablet,delayed release (dr/ec) Tier 5 omeprazole-sodium bicarbonate Tier 5 pantoprazole oral T1 PROTONIX ORAL GRANULES DR FOR SUSP Tier 5 IN PACKET rabeprazole oral tablet,delayed release (dr/ec) T3 ST Gold Compounds Gold Compounds RIDAURA T2 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET T3 PA deferasirox T4 PA JADENU T4 PA JADENU SPRINKLE T4 PA Hormones And Synthetic Substitutes Adrenals ADVAIR HFA T3 PA ARNUITY ELLIPTA T2 QL (60 EA per 30 days) ASMANEX HFA T2 QL (26 GM per 30 days) ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs) BREO ELLIPTA T3 PA budesonide inhalation suspension for nebulization T1 QL (120 QY per 30 DYs) 0.25 mg/2 ml 61 Drug Tier Notes budesonide inhalation suspension for nebulization T1 QL (240 QY per 30 DYs) 0.5 mg/2 ml budesonide inhalation suspension for nebulization T1 QL (120 ML per 30 days) 1 mg/2 ml budesonide oral capsule,delayed,extend.release T1 DEXAMETHASONE INTENSOL T1 dexamethasone oral elixir T1 dexamethasone oral solution T1 dexamethasone oral tablet T1 DULERA T2 QL (13 QY per 30 DYs) EMFLAZA T3 PA FLOVENT DISKUS T2 QL (120 QY per 30 DYs) FLOVENT HFA INHALATION HFA AEROSOL T2 QL (24 QY per 30 DYs) INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL T2 QL (21.2 QY per 30 DYs) INHALER 44 MCG/ACTUATION fludrocortisone T1 fluticasone propion-salmeterol inhalation aerosol T1 QL (1 EA per 30 days) powdr breath activated 113-14 mcg/actuation, 55- 14 mcg/actuation fluticasone propion-salmeterol inhalation aerosol T1 powdr breath activated 232-14 mcg/actuation fluticasone propion-salmeterol inhalation blister T1 QL (60 EA per 30 days) with device hydrocortisone oral T1 MEDROL ORAL TABLET 2 MG T2 methylprednisolone T1 prednisolone oral solution 15 mg/5 ml T1 prednisolone sodium phosphate oral solution 15 T1 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone T1 PREDNISONE INTENSOL T1 PULMICORT FLEXHALER T2 QL (2 EA per 30 days) PULMICORT INHALATION SUSPENSION T2 QL (120 QY per 30 DYs) FOR NEBULIZATION 1 MG/2 ML QVAR REDIHALER T2 QL (21.2 GM per 30 days) 62 Drug Tier Notes SYMBICORT T2 QL (10.2 QY per 30 DYs) WIXELA INHUB T1 QL (60 EA per 30 days) Alpha-Glucosidase Inhibitors acarbose T1 Androgens ANDRODERM T3 PA ANDROGEL TRANSDERMAL GEL IN T3 PA PACKET 1 % (50 MG/5 GRAM) COVARYX T2 COVARYX H.S. T2 danazol T1 NATESTO Tier 5 oxandrolone T3 PA testosterone cypionate intramuscular oil 100 T1 QL (5 QY per 30 DYs) mg/ml testosterone cypionate intramuscular oil 200 T1 QL (5 ML per 30 days) mg/ml testosterone enanthate T1 QL (5 ML per 30 days) testosterone transdermal gel T3 PA testosterone transdermal gel in metered-dose T3 PA pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in metered-dose Tier 5 pump 20.25 mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 T3 PA mg/2.5gram) testosterone transdermal gel in packet 1.62 % Tier 5 (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram) testosterone transdermal solution in metered pump Tier 5 w/app Antidiabetic Agents, Miscellaneous colesevelam T3 PA WELCHOL ORAL TABLET T3 PA Antiestrogens anastrozole T1 QL (30 QY per 30 DYs)

63 Drug Tier Notes exemestane T3 PA letrozole T1 Antigonadtropins FIRMAGON KIT W DILUENT SYRINGE T4 PA SUBCUTANEOUS RECON SOLN 80 MG ORILISSA T3 PA Antiparathyroid Agents calcitonin (salmon) T1 cinacalcet T3 PA Antithyroid Agents methimazole oral tablet 10 mg, 5 mg T1 propylthiouracil T1 Biguanides alogliptin-metformin T3 ST glipizide-metformin T1 glyburide-metformin T1 INVOKAMET T3 ST INVOKAMET XR T3 ST JANUMET Tier 5 JANUMET XR Tier 5 JENTADUETO Tier 5 KOMBIGLYZE XR Tier 5 metformin oral tablet T1 metformin oral tablet extended release 24 hr T1 SEGLUROMET Tier 5 SYNJARDY T3 ST SYNJARDY XR T3 ST XIGDUO XR Tier 5 Contraceptives AMETHIA T1 ANNOVERA T2 BALCOLTRA T2 CAMRESE LO T1 64 Drug Tier Notes CHATEAL (28) T1 CRYSELLE (28) T1 CYCLAFEM 1/35 (28) T1 drospirenone-e.estradiol-lm.fa T1 ELLA T2 FALMINA (28) T1 FAYOSIM T1 GIANVI (28) T1 JOLESSA T1 JUNEL FE 1.5/30 (28) T1 JUNEL FE 1/20 (28) T1 JUNEL FE 24 T1 KELNOR 1/35 (28) T1 LEENA 28 T1 levonorgestrel-ethinyl estrad oral tablet 90-20 T1 mcg (28) LO LOESTRIN FE T2 MIBELAS 24 FE T1 MICROGESTIN 1.5/30 (21) T1 MICROGESTIN 1/20 (21) T1 MONONESSA (28) T1 MY WAY T1 MYZILRA T1 NATAZIA T2 NORA-BE T1 noreth-ethinyl estradiol-iron T1 norethindrone-e.estradiol-iron oral T1 tablet,chewable norgestimate-ethinyl estradiol oral tablet T1 0.18/0.215/0.25 mg-25 mcg NORTREL 0.5/35 (28) T1 NORTREL 7/7/7 (28) T1 NUVARING T2 OGESTREL (28) T1

65 Drug Tier Notes PHILITH T1 RECLIPSEN (28) T1 RIVELSA T1 SLYND T2 SYEDA T1 QL (30 QY per 30 DYs) TAYTULLA T2 TRI-LEGEST FE T1 QL (30 QY per 30 DYs) TRI-SPRINTEC (28) T1 QL (30 QY per 30 DYs) VELIVET TRIPHASIC REGIMEN (28) T1 QL (30 QY per 30 DYs) VIORELE (28) T1 QL (30 QY per 30 DYs) XULANE T1 ZOVIA 1/50E (28) T1 QL (30 QY per 30 DYs) Dipeptidyl Peptidase-4(Dpp-4) Inhibitors alogliptin T3 ST alogliptin-metformin T3 ST alogliptin-pioglitazone T3 ST GLYXAMBI Tier 5 JANUMET Tier 5 JANUMET XR Tier 5 JANUVIA Tier 5 JENTADUETO Tier 5 KOMBIGLYZE XR Tier 5 ONGLYZA Tier 5 STEGLUJAN Tier 5 TRADJENTA Tier 5 Estrogen Agonist-Antagonists FARESTON T4 PA raloxifene T1 SOLTAMOX T3 PA tamoxifen T1 Estrogens CLIMARA PRO T2 QL (4 QY per 28 DYs) COMBIPATCH T2 QL (8 QY per 28 DYs) 66 Drug Tier Notes COVARYX T2 COVARYX H.S. T2 DEPO-ESTRADIOL T1 QL (10 QY per 90 DYs) ESTRACE VAGINAL T2 estradiol oral T1 estradiol transdermal patch semiweekly T1 QL (24 EA per 84 days) estradiol transdermal patch weekly T1 QL (4 QY per 28 DYs) estradiol valerate T1 QL (10 QY per 90 DYs) ESTRING T2 QL (1 EA per 90 days) ESTROGEL T2 QL (50 GM per 30 days) MENOSTAR T2 QL (4 QY per 28 DYs) norethindrone ac-eth estradiol oral tablet 1-5 mg- T1 mcg PREMARIN ORAL T2 PREMARIN VAGINAL T2 PREMPHASE T2 PREMPRO T2 YUVAFEM T1 Glycogenolytic Agents GLUCAGON EMERGENCY KIT (HUMAN) T2 Gonadotropins ELIGARD T4 PA ELIGARD (3 MONTH) T4 PA ELIGARD (4 MONTH) T4 PA ELIGARD (6 MONTH) T4 PA leuprolide T3 PA LUPANETA PACK (1 MONTH) Tier 5 LUPANETA PACK (3 MONTH) Tier 5 LUPRON DEPOT T4 PA LUPRON DEPOT (3 MONTH) T4 PA LUPRON DEPOT (4 MONTH) T4 PA LUPRON DEPOT-PED T4 PA LUPRON DEPOT-PED (3 MONTH) T4 PA

67 Drug Tier Notes SYNAREL Tier 5 Gonadotropins And Antigonadotropins ELIGARD T4 PA ELIGARD (3 MONTH) T4 PA ELIGARD (4 MONTH) T4 PA ELIGARD (6 MONTH) T4 PA leuprolide T3 PA LUPANETA PACK (1 MONTH) Tier 5 LUPANETA PACK (3 MONTH) Tier 5 LUPRON DEPOT T4 PA LUPRON DEPOT (3 MONTH) T4 PA LUPRON DEPOT (4 MONTH) T4 PA LUPRON DEPOT-PED T4 PA LUPRON DEPOT-PED (3 MONTH) T4 PA SYNAREL Tier 5 Incretin Mimetics BYDUREON BCISE Tier 5 BYDUREON SUBCUTANEOUS PEN Tier 5 INJECTOR BYETTA Tier 5 OZEMPIC T3 ST; QL (9 ML per 84 days) SAXENDA Tier 5 TRULICITY Tier 5 VICTOZA 2-PAK T3 ST; QL (27 ML per 90 days) VICTOZA 3-PAK T3 ST; QL (27 ML per 90 days) Insulins ADMELOG SOLOSTAR U-100 INSULIN T2 ADMELOG U-100 INSULIN LISPRO T2 BASAGLAR KWIKPEN U-100 INSULIN T1 HUMALOG JUNIOR KWIKPEN U-100 T2 HUMALOG MIX 50-50 INSULN U-100 T2 HUMALOG MIX 50-50 KWIKPEN T2 HUMALOG MIX 75-25 KWIKPEN T2

68 Drug Tier Notes HUMALOG MIX 75-25(U-100)INSULN T2 HUMULIN 70/30 U-100 INSULIN T2 HUMULIN 70/30 U-100 KWIKPEN T2 HUMULIN N NPH INSULIN KWIKPEN T2 HUMULIN N NPH U-100 INSULIN T2 HUMULIN R REGULAR U-100 INSULN T2 HUMULIN R U-500 (CONC) INSULIN T2 HUMULIN R U-500 (CONC) KWIKPEN T2 insulin lispro T1 LANTUS SOLOSTAR U-100 INSULIN Tier 5 LANTUS U-100 INSULIN Tier 5 LEVEMIR FLEXTOUCH U-100 INSULN T3 ST LEVEMIR U-100 INSULIN T3 ST NOVOLIN N NPH U-100 INSULIN T2 NOVOLIN R REGULAR U-100 INSULN T2 NOVOLOG MIX 70-30 U-100 INSULN T2 NOVOLOG MIX 70-30FLEXPEN U-100 T2 TOUJEO MAX U-300 SOLOSTAR Tier 5 TOUJEO SOLOSTAR U-300 INSULIN Tier 5 TRESIBA FLEXTOUCH U-100 T3 ST TRESIBA FLEXTOUCH U-200 T3 ST TRESIBA U-100 INSULIN T3 ST Intermediate-Acting Insulins HUMALOG MIX 50-50 INSULN U-100 T2 HUMALOG MIX 50-50 KWIKPEN T2 HUMALOG MIX 75-25 KWIKPEN T2 HUMALOG MIX 75-25(U-100)INSULN T2 HUMULIN 70/30 U-100 INSULIN T2 HUMULIN 70/30 U-100 KWIKPEN T2 HUMULIN N NPH INSULIN KWIKPEN T2 HUMULIN N NPH U-100 INSULIN T2 NOVOLIN N NPH U-100 INSULIN T2 NOVOLOG MIX 70-30 U-100 INSULN T2

69 Drug Tier Notes NOVOLOG MIX 70-30FLEXPEN U-100 T2 Long-Acting Insulins BASAGLAR KWIKPEN U-100 INSULIN T1 LANTUS SOLOSTAR U-100 INSULIN Tier 5 LANTUS U-100 INSULIN Tier 5 LEVEMIR FLEXTOUCH U-100 INSULN T3 ST LEVEMIR U-100 INSULIN T3 ST TOUJEO MAX U-300 SOLOSTAR Tier 5 TOUJEO SOLOSTAR U-300 INSULIN Tier 5 TRESIBA FLEXTOUCH U-100 T3 ST TRESIBA FLEXTOUCH U-200 T3 ST TRESIBA U-100 INSULIN T3 ST Meglitinides nateglinide T1 repaglinide T1 Parathyroid Agents FORTEO T3 PA TYMLOS T3 PA Parathyroid And Antiparathyroid Agents calcitonin (salmon) T1 FORTEO T3 PA TYMLOS T3 PA Pituitary ACTHAR H.P. T4 PA DDAVP NASAL SOLUTION Tier 5 desmopressin nasal spray,non-aerosol T1 desmopressin oral T1 GENOTROPIN Tier 5 GENOTROPIN MINIQUICK Tier 5 HUMATROPE Tier 5 NORDITROPIN FLEXPRO T4 PA NUTROPIN AQ NUSPIN T4 PA

70 Drug Tier Notes OMNITROPE Tier 5 SAIZEN SUBCUTANEOUS RECON SOLN 8.8 Tier 5 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 Tier 5 MG, 6 MG STIMATE T3 PA ZOMACTON T4 PA ZORBTIVE Tier 5 Progestins COMBIPATCH T2 QL (8 QY per 28 DYs) CRINONE T2 DEPO-SUBQ PROVERA 104 T2 ENDOMETRIN T3 PA hydroxyprogest(pf)(preg presv) T4 PA hydroxyprogesterone cap(ppres) T4 PA LUPANETA PACK (1 MONTH) Tier 5 LUPANETA PACK (3 MONTH) Tier 5 MAKENA (PF) T4 PA medroxyprogesterone T1 megestrol oral suspension 400 mg/10 ml (10 ml), T1 400 mg/10 ml (40 mg/ml) megestrol oral tablet T1 norethindrone acetate T1 norethindrone ac-eth estradiol oral tablet 1-5 mg- T1 mcg progesterone micronized T1 QL (30 QY per 30 DYs) SLYND T2 Rapid-Acting Insulins ADMELOG SOLOSTAR U-100 INSULIN T2 ADMELOG U-100 INSULIN LISPRO T2 HUMALOG JUNIOR KWIKPEN U-100 T2 HUMALOG MIX 50-50 INSULN U-100 T2 HUMALOG MIX 50-50 KWIKPEN T2 HUMALOG MIX 75-25 KWIKPEN T2

71 Drug Tier Notes HUMALOG MIX 75-25(U-100)INSULN T2 insulin lispro T1 NOVOLOG MIX 70-30 U-100 INSULN T2 NOVOLOG MIX 70-30FLEXPEN U-100 T2 Short-Acting Insulins HUMULIN 70/30 U-100 INSULIN T2 HUMULIN 70/30 U-100 KWIKPEN T2 HUMULIN R REGULAR U-100 INSULN T2 HUMULIN R U-500 (CONC) INSULIN T2 HUMULIN R U-500 (CONC) KWIKPEN T2 NOVOLIN R REGULAR U-100 INSULN T2 Sodium-Gluc Cotransport 2 (Sglt2) Inhib FARXIGA Tier 5 GLYXAMBI Tier 5 INVOKAMET T3 ST INVOKAMET XR T3 ST INVOKANA T3 ST JARDIANCE T3 ST SEGLUROMET Tier 5 STEGLATRO Tier 5 STEGLUJAN Tier 5 SYNJARDY T3 ST SYNJARDY XR T3 ST XIGDUO XR Tier 5 Somatostatin Agonists octreotide acetate injection solution T4 PA octreotide acetate injection syringe T3 PA Somatotropin Agonists EGRIFTA SUBCUTANEOUS RECON SOLN 1 Tier 5 MG Somatotropin Antagonists SOMAVERT T4 PA Sulfonylureas 72 Drug Tier Notes glimepiride T1 glipizide T1 glipizide-metformin T1 glyburide T1 glyburide-metformin T1 Thiazolidinediones alogliptin-pioglitazone T3 ST pioglitazone T1 Thyroid Agents ARMOUR THYROID ORAL TABLET 180 MG T1 ARMOUR THYROID ORAL TABLET 240 MG, T2 300 MG levothyroxine oral T1 liothyronine oral T1 NATURE-THROID T2 NP THYROID ORAL TABLET 15 MG, 30 MG, T1 60 MG, 90 MG thyroid (pork) oral tablet 120 mg T1 Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors dutasteride T1 finasteride oral tablet 5 mg T1 Alcohol Deterrents disulfiram T1 Antidotes CHEMET T3 PA GLUCAGON EMERGENCY KIT (HUMAN) T2 KIONEX (WITH SORBITOL) T1 lanthanum T3 PA leucovorin calcium oral T1 naloxone T1 NARCAN NASAL SPRAY,NON-AEROSOL 4 T2 MG/ACTUATION

73 Drug Tier Notes phytonadione (vitamin k1) oral tablet 5 mg T1 sevelamer carbonate oral powder in packet T3 PA sevelamer carbonate oral tablet T1 sevelamer hcl Tier 5 SODIUM POLYSTYRENE (SORB FREE) T1 QL (240 QY per 30 DYs) sodium polystyrene sulfonate oral powder T1 SPS (WITH SORBITOL) ORAL T2 Antigout Agents allopurinol T1 colchicine T1 QL (60 EA per 30 days) febuxostat T3 PA INDOCIN ORAL T2 AL (Max 12 Years) INDOCIN RECTAL T2 indomethacin oral T1 naproxen oral suspension T1 AL (Max 12 Years) naproxen oral tablet T1 naproxen oral tablet,delayed release (dr/ec) T1 naproxen sodium oral tablet 275 mg, 550 mg T1 probenecid T1 Bone Anabolic Agents FORTEO T3 PA TYMLOS T3 PA Bone Resorption Inhibitors alendronate oral solution Tier 5 alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1 alendronate oral tablet 40 mg Tier 5 BINOSTO Tier 5 calcitonin (salmon) T1 etidronate disodium Tier 5 FOSAMAX PLUS D Tier 5 ibandronate oral T1 raloxifene T1 risedronate Tier 5 74 Drug Tier Notes Cariostatic Agents DENTA 5000 PLUS T1 FLUOR-A-DAY T2 fluoride (sodium) oral drops T1 fluoride (sodium) oral tablet,chewable 0.5 mg (1.1 T1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride) FLUORIDEX DAILY DEFENSE DENTAL T1 PASTE FLUORITAB ORAL TABLET,CHEWABLE 1 T1 MG (2.2 MG SOD. FLUORIDE) FLURA-DROPS T1 LUDENT FLUORIDE ORAL T1 TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID) MULTI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) TABLET,CHEWABLE 0.5 MG, 1 MG PREVIDENT 5000 BOOSTER PLUS T2 PREVIDENT DENTAL GEL T1 PREVIDENT DENTAL SOLUTION T2 TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Complement Inhibitors HAEGARDA Tier 5 icatibant Tier 5 KALBITOR T4 PA TAKHZYRO T3 PA Disease-Modifying Antirheumatic Agents ACTEMRA SUBCUTANEOUS T4 PA azathioprine T1 CIMZIA T4 PA CIMZIA POWDER FOR RECONST T4 PA CIMZIA STARTER KIT T4 PA cyclosporine modified oral capsule T1 cyclosporine modified oral solution T1 AL (Max 12 Years)

75 Drug Tier Notes ENBREL T4 PA ENBREL MINI T4 PA ENBREL SURECLICK T4 PA HUMIRA PEDIATRIC CROHNS START T4 PA HUMIRA PEN T4 PA HUMIRA PEN CROHNS-UC-HS START T4 PA HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T4 PA MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) T4 PA HUMIRA(CF) PEDI CROHNS STARTER T4 PA SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN T4 PA INJECTOR KIT 40 MG/0.4 ML hydroxychloroquine T1 KEVZARA Tier 5 KINERET T4 PA leflunomide T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 DYs) methotrexate sodium injection T1 QL (16 ML per 28 DYs) methotrexate sodium oral T1 OLUMIANT T4 PA ORENCIA T4 PA ORENCIA CLICKJECT T4 PA OTEZLA T4 PA OTEZLA STARTER T4 PA RIDAURA T2 SANDIMMUNE ORAL SOLUTION Tier 5 SIMPONI T4 PA STELARA SUBCUTANEOUS T4 PA sulfasalazine T1 TREXALL T3 PA XELJANZ T4 PA

76 Drug Tier Notes XELJANZ XR T4 PA Gonadotropin-Releasing Hormone Antagnts FIRMAGON KIT W DILUENT SYRINGE T4 PA SUBCUTANEOUS RECON SOLN 80 MG Immunomodulatory Agents ACTEMRA SUBCUTANEOUS T4 PA AUBAGIO Tier 5 AVONEX (WITH ALBUMIN) T4 PA AVONEX INTRAMUSCULAR PEN INJECTOR T4 PA KIT AVONEX INTRAMUSCULAR SYRINGE KIT T4 PA azathioprine T1 CIMZIA T4 PA CIMZIA POWDER FOR RECONST T4 PA CIMZIA STARTER KIT T4 PA cyclosporine modified oral capsule T1 cyclosporine modified oral solution T1 AL (Max 12 Years) ENBREL T4 PA ENBREL MINI T4 PA ENBREL SURECLICK T4 PA EXTAVIA T4 PA GILENYA ORAL CAPSULE 0.5 MG T4 PA glatiramer T4 PA GLATOPA SUBCUTANEOUS SYRINGE 20 T4 PA MG/ML HUMIRA PEDIATRIC CROHNS START T4 PA HUMIRA PEN T4 PA HUMIRA PEN CROHNS-UC-HS START T4 PA HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T4 PA MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) T4 PA HUMIRA(CF) PEDI CROHNS STARTER T4 PA

77 Drug Tier Notes HUMIRA(CF) PEN SUBCUTANEOUS PEN T4 PA INJECTOR KIT 40 MG/0.4 ML hydroxychloroquine T1 KEVZARA Tier 5 KINERET T4 PA leflunomide T1 MAYZENT Tier 5 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 DYs) methotrexate sodium injection T1 QL (16 ML per 28 DYs) methotrexate sodium oral T1 OLUMIANT T4 PA ORENCIA T4 PA ORENCIA CLICKJECT T4 PA OTEZLA T4 PA OTEZLA STARTER T4 PA PLEGRIDY Tier 5 POMALYST T4 PA REBIF (WITH ALBUMIN) T4 PA REBIF REBIDOSE T4 PA REBIF TITRATION PACK T4 PA REVLIMID T4 PA RIDAURA T2 SANDIMMUNE ORAL SOLUTION Tier 5 SIMPONI T4 PA STELARA SUBCUTANEOUS T4 PA sulfasalazine T1 TECFIDERA T4 PA TREXALL T3 PA XELJANZ T4 PA XELJANZ XR T4 PA Immunosuppressive Agents azathioprine T1 CELLCEPT ORAL SUSPENSION FOR T2 RECONSTITUTION 78 Drug Tier Notes cyclophosphamide oral capsule T3 PA cyclosporine modified oral capsule T1 cyclosporine modified oral solution T1 AL (Max 12 Years) MAVENCLAD (10 TABLET PACK) T4 PA mercaptopurine T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 DYs) methotrexate sodium injection T1 QL (16 ML per 28 DYs) methotrexate sodium oral T1 mycophenolate mofetil oral capsule T1 mycophenolate mofetil oral tablet T1 mycophenolate sodium T1 pimecrolimus Tier 5 PURIXAN T3 PA SANDIMMUNE ORAL SOLUTION Tier 5 sirolimus oral solution T1 AL (Max 12 Years) sirolimus oral tablet T1 tacrolimus oral T1 TREXALL T3 PA ZORTRESS T2 Other Miscellaneous Therapeutic Agents acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days) acetylcysteine solution 200 mg/ml (20 %) T1 CARNITOR (SUGAR-FREE) T2 CERDELGA T4 PA cinacalcet T3 PA dalfampridine T4 PA ENDARI T4 PA GRASTEK Tier 5 levocarnitine (with sugar) T1 miglustat T4 PA nitisinone Tier 5 NITYR T4 PA octreotide acetate injection solution T4 PA

79 Drug Tier Notes octreotide acetate injection syringe T3 PA ORALAIR SUBLINGUAL TABLET 300 INDX Tier 5 REACTIVITY ORFADIN ORAL CAPSULE 20 MG Tier 5 ORFADIN ORAL SUSPENSION Tier 5 RAGWITEK Tier 5 Protective Agents ELMIRON T2 Oxytocics Oxytocics methylergonovine oral T1 QL (30 EA per 30 days) Pharmaceutical Aids Pharmaceutical Aids water for injection, sterile intravenous Tier 5 Respiratory Tract Agents Alpha And Beta Adrenergic Agonist(Respr) epinephrine injection auto-injector T1 QL (6 EA per 365 DYs) EPIPEN 2-PAK T2 Anticholinergic Agents (Respir.Tract) ANORO ELLIPTA T3 ST ATROVENT HFA T2 QL (25.8 QY per 30 DYs) COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) diphenoxylate-atropine T1 ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs) ipratropium-albuterol T1 QL (570 QY per 30 DYs) SPIRIVA RESPIMAT T2 QL (4 GM per 30 days) TUDORZA PRESSAIR T2 QL (1 QY per 30 DYs) Antifibrotic Agents ESBRIET T4 PA OFEV Tier 5 Antitussives benzonatate oral capsule 100 mg, 200 mg T1

80 Drug Tier Notes codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) NUEDEXTA T3 PA promethazine-dm T1 AL (Min 2 Years) Cystic Fibrosis (Cftr) Correctors ORKAMBI T4 PA SYMDEKO T4 PA Cystic Fibrosis (Cftr) Potentiators KALYDECO T4 PA ORKAMBI T4 PA SYMDEKO T4 PA First Generation Antihist.(Respir Tract) BONJESTA Tier 5 cyproheptadine T1 DICLEGIS Tier 5 promethazine oral T1 AL (Min 2 Years) PROMETHAZINE VC T1 AL (Min 2 Years) promethazine-dm T1 AL (Min 2 Years) Interleukin Antagonists DUPIXENT T4 PA Leukotriene Modifiers montelukast oral granules in packet T1 AL (Max 2 Years) montelukast oral tablet T1 montelukast oral tablet,chewable T1 Mast-Cell Stabilizers cromolyn inhalation T1 cromolyn ophthalmic (eye) T1 cromolyn oral T1 Mucolytic Agents acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days) acetylcysteine solution 200 mg/ml (20 %) T1 PULMOZYME T4 PA

81 Drug Tier Notes Nasal Preparations (Steroids) budesonide nasal T1 QL (8.6 GM per 30 DYs) fluticasone propionate nasal T1 QL (16 QY per 30 DYs) Orally Inhaled Preparations (Steroids) ADVAIR HFA T3 PA ARNUITY ELLIPTA T2 QL (60 EA per 30 days) ASMANEX HFA T2 QL (26 GM per 30 days) ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs) BREO ELLIPTA T3 PA budesonide inhalation suspension for nebulization T1 QL (120 QY per 30 DYs) 0.25 mg/2 ml budesonide inhalation suspension for nebulization T1 QL (240 QY per 30 DYs) 0.5 mg/2 ml budesonide inhalation suspension for nebulization T1 QL (120 ML per 30 days) 1 mg/2 ml DULERA T2 QL (13 QY per 30 DYs) FLOVENT DISKUS T2 QL (120 QY per 30 DYs) FLOVENT HFA INHALATION HFA AEROSOL T2 QL (24 QY per 30 DYs) INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL T2 QL (21.2 QY per 30 DYs) INHALER 44 MCG/ACTUATION fluticasone propion-salmeterol inhalation aerosol T1 QL (1 EA per 30 days) powdr breath activated 113-14 mcg/actuation, 55- 14 mcg/actuation fluticasone propion-salmeterol inhalation aerosol T1 powdr breath activated 232-14 mcg/actuation fluticasone propion-salmeterol inhalation blister T1 QL (60 EA per 30 days) with device PULMICORT FLEXHALER T2 QL (2 EA per 30 days) PULMICORT INHALATION SUSPENSION T2 QL (120 QY per 30 DYs) FOR NEBULIZATION 1 MG/2 ML QVAR REDIHALER T2 QL (21.2 GM per 30 days) SYMBICORT T2 QL (10.2 QY per 30 DYs) WIXELA INHUB T1 QL (60 EA per 30 days) Phosphodiesterase Type 4 Inhibitors

82 Drug Tier Notes DALIRESP T3 PA Second Generation Antihist(Respir Tract) desloratadine oral tablet T1 Select.Beta-2-Adrenergic Agonist(Respir) ADVAIR HFA T3 PA albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days) albuterol sulfate inhalation solution for T1 nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml albuterol sulfate inhalation solution for T1 QL (525 QY per 30 DYs) nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for T1 QL (100 QY per 30 DYs) nebulization 5 mg/ml albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years) albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs) albuterol sulfate oral tablet extended release 12 hr Tier 5 ANORO ELLIPTA T3 ST ARCAPTA NEOHALER T2 QL (30 EA per 30 days) BREO ELLIPTA T3 PA BROVANA T3 PA COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) DULERA T2 QL (13 QY per 30 DYs) fluticasone propion-salmeterol inhalation aerosol T1 QL (1 EA per 30 days) powdr breath activated 113-14 mcg/actuation, 55- 14 mcg/actuation fluticasone propion-salmeterol inhalation aerosol T1 powdr breath activated 232-14 mcg/actuation fluticasone propion-salmeterol inhalation blister T1 QL (60 EA per 30 days) with device ipratropium-albuterol T1 QL (570 QY per 30 DYs) levalbuterol hcl inhalation solution for T3 ST; QL (240 QY per 30 DYs) nebulization 0.31 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (360 QY per 30 DYs) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (150 QY per 30 DYs) nebulization 1.25 mg/0.5 ml 83 Drug Tier Notes levalbuterol tartrate T3 ST; QL (30 GM per 30 days) PERFOROMIST Tier 5 PROAIR RESPICLICK T2 QL (2 EA per 30 days) SEREVENT DISKUS T3 PA STRIVERDI RESPIMAT T2 QL (4 GM per 30 days) SYMBICORT T2 QL (10.2 QY per 30 DYs) terbutaline oral T1 WIXELA INHUB T1 QL (60 EA per 30 days) Vasodilating Agents (Respiratory Tract) ADEMPAS T4 PA bosentan Tier 5 LETAIRIS T4 PA OPSUMIT Tier 5 ORENITRAM Tier 5 sildenafil (pulm.hypertension) intravenous Tier 5 sildenafil (pulm.hypertension) oral suspension for Tier 5 reconstitution sildenafil (pulm.hypertension) oral tablet T3 PA tadalafil (pulm. hypertension) T3 PA treprostinil sodium T4 PA TYVASO T4 PA TYVASO INSTITUTIONAL START KIT T4 PA TYVASO REFILL KIT T4 PA TYVASO STARTER KIT T4 PA UPTRAVI T4 PA VENTAVIS T4 PA Xanthine Derivatives theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Skin And Mucous Membrane Agents Antibacterials (Skin, Mucous Membrane) AKTIPAK Tier 5

84 Drug Tier Notes CLEOCIN VAGINAL SUPPOSITORY T2 clindamycin phosphate topical gel T1 clindamycin phosphate topical lotion T1 clindamycin phosphate topical solution T1 clindamycin phosphate topical swab T1 clindamycin phosphate vaginal T1 clindamycin-benzoyl peroxide Tier 5 clindamycin-tretinoin Tier 5 erythromycin with ethanol topical gel T1 erythromycin with ethanol topical solution T1 erythromycin-benzoyl peroxide Tier 5 metronidazole topical cream T1 QL (45 QY per 30 DYs) metronidazole topical gel 0.75 % T1 QL (45 QY per 30 DYs) metronidazole topical gel 1 % T3 ST; QL (60 QY per 30 DYs) metronidazole topical gel with pump T3 ST; QL (60 QY per 30 DYs) metronidazole topical lotion T1 QL (59 QY per 30 DYs) metronidazole vaginal T1 mupirocin T1 mupirocin calcium Tier 5 NEUAC Tier 5 NEUAC KIT Tier 5 ONEXTON TOPICAL GEL WITH PUMP Tier 5 Anti-Inflammatory Agents (Skin, Mucous) alclometasone Tier 5 amcinonide Tier 5 ANUCORT-HC T1 ANUSOL-HC RECTAL CREAM WITH T1 APPLICATOR APEXICON E Tier 5 AQUANIL HC Tier 5 BETA-HC Tier 5 betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs) betamethasone dipropionate topical lotion Tier 5 QL (240 QY per 30 DYs)

85 Drug Tier Notes betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs) betamethasone valerate topical cream T1 QL (240 QY per 30 DYs) betamethasone valerate topical foam Tier 5 betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs) betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs) betamethasone, augmented T1 QL (120 QY per 30 DYs) CAPEX Tier 5 clobetasol scalp T1 QL (100 ML per 30 days) clobetasol topical cream T1 QL (120 GM per 30 days) clobetasol topical foam Tier 5 clobetasol topical gel T1 QL (120 GM per 30 days) clobetasol topical lotion Tier 5 clobetasol topical ointment T1 QL (120 GM per 30 days) clobetasol topical shampoo T1 QL (118 ML per 30 days) clobetasol topical spray,non-aerosol Tier 5 clobetasol-emollient Tier 5 clocortolone pivalate Tier 5 CLODAN KIT Tier 5 clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs) CORDRAN TAPE LARGE ROLL Tier 5 CORDRAN TOPICAL CREAM 0.025 % Tier 5 DERMAREST ECZEMA (HYDROCORT) Tier 5 DERMASORB TA COMPLETE KIT Tier 5 DESONATE Tier 5 desonide Tier 5 desoximetasone topical cream 0.05 % Tier 5 desoximetasone topical cream 0.25 % T1 QL (60 QY per 30 DYs) desoximetasone topical gel Tier 5 desoximetasone topical ointment Tier 5 desoximetasone topical spray,non-aerosol Tier 5 diflorasone Tier 5 EUCRISA Tier 5 fluocinolone and shower cap T1 QL (119 ML per 30 DYs)

86 Drug Tier Notes fluocinolone topical cream 0.01 % Tier 5 fluocinolone topical cream 0.025 % Tier 5 QL (240 QY per 30 DYs) fluocinolone topical oil T1 QL (119 ML per 30 DYs) fluocinolone topical ointment Tier 5 fluocinolone topical solution T1 QL (120 ML per 30 DYs) fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs) fluocinonide topical cream 0.1 % Tier 5 fluocinonide topical gel T1 QL (240 QY per 30 DYs) fluocinonide topical ointment T1 QL (240 QY per 30 DYs) fluocinonide topical solution T1 QL (240 QY per 30 DYs) FLUOCINONIDE-E Tier 5 fluocinonide-emollient Tier 5 flurandrenolide Tier 5 fluticasone propionate topical cream T1 QL (240 QY per 30 DYs) fluticasone propionate topical lotion Tier 5 fluticasone propionate topical ointment Tier 5 halobetasol propionate topical cream T1 QL (120 GM per 30 days) halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs) HALOG Tier 5 hydrocortisone butyrate Tier 5 hydrocortisone butyr-emollient Tier 5 hydrocortisone rectal T1 hydrocortisone topical cream 1 %, 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone topical cream with perineal Tier 5 applicator 1 % hydrocortisone topical lotion 1 % Tier 5 hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone topical ointment 1 %, 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone valerate Tier 5 mometasone topical cream T1 QL (60 QY per 30 DYs) mometasone topical ointment T1 QL (240 QY per 30 DYs) mometasone topical solution T1 QL (240 QY per 30 DYs) NOLIX TOPICAL LOTION Tier 5

87 Drug Tier Notes PANDEL Tier 5 prednicarbate Tier 5 PROCTOFOAM HC T2 PROCTO-PAK Tier 5 PROCTOZONE-HC T1 QL (60 GM per 30 DYs) PSORCON Tier 5 SCALACORT Tier 5 SCALPICIN ANTI-ITCH Tier 5 SERNIVO Tier 5 SYNALAR OINTMENT KIT Tier 5 TEXACORT Tier 5 TOPICORT TOPICAL GEL Tier 5 triamcinolone acetonide dental T1 triamcinolone acetonide topical aerosol Tier 5 triamcinolone acetonide topical cream 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs) triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs) triamcinolone acetonide topical ointment 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 fills) TRIANEX Tier 5 ULTRAVATE TOPICAL LOTION Tier 5 ULTRAVATE X Tier 5 VERDESO Tier 5 Anti-Inflammatory Agents, Misc (Skin) EUCRISA Tier 5 Antipruritics And Local Anesthetics lidocaine topical adhesive patch,medicated T1 lidocaine topical cream 4 % T1 QL (60 GM per 30 days) lidocaine topical ointment T1 QL (60 QY per 30 DYs) lidocaine-prilocaine topical cream T1 phenazopyridine oral tablet 100 mg, 200 mg T1

88 Drug Tier Notes PROCTOFOAM HC T2 Antivirals (Skin And Mucous Membrane) acyclovir topical ointment T3 PA DENAVIR T3 PA ZOVIRAX TOPICAL CREAM T3 PA Astringents aluminum chloride T1 QL (75 ML per 30 days) Azoles (Skin And Mucous Membrane) clotrimazole mucous membrane T1 clotrimazole topical cream T1 QL (180 QY per 30 DYs) clotrimazole topical solution T1 clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs) econazole T1 QL (340 QY per 30 DYs) GYNAZOLE-1 T1 JUBLIA Tier 5 ketoconazole topical cream T1 ketoconazole topical shampoo T1 MICONAZOLE-3 VAGINAL SUPPOSITORY T1 terconazole T1 Basic Lotions And Liniments ammonium lactate topical lotion T1 Basic Ointments And Protectants ammonium lactate topical cream T1 Cell Stimulants And Proliferants ALTRENO Tier 5 clindamycin-tretinoin Tier 5 RETIN-A MICRO PUMP TOPICAL GEL WITH Tier 5 PUMP 0.06 %, 0.08 % tretinoin microspheres Tier 5 tretinoin topical cream T1 QL (20 QY per 30 DYs); AL (Max 30 Years) tretinoin topical gel 0.01 %, 0.025 % T1 QL (15 QY per 30 DYs); AL (Max 30 Years)

89 Drug Tier Notes Corticosteroids (Skin, Mucous Membrane) alclometasone Tier 5 amcinonide Tier 5 ANUCORT-HC T1 ANUSOL-HC RECTAL CREAM WITH T1 APPLICATOR APEXICON E Tier 5 AQUANIL HC Tier 5 BETA-HC Tier 5 betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs) betamethasone dipropionate topical lotion Tier 5 QL (240 QY per 30 DYs) betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs) betamethasone valerate topical cream T1 QL (240 QY per 30 DYs) betamethasone valerate topical foam Tier 5 betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs) betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs) betamethasone, augmented T1 QL (120 QY per 30 DYs) CAPEX Tier 5 clobetasol scalp T1 QL (100 ML per 30 days) clobetasol topical cream T1 QL (120 GM per 30 days) clobetasol topical foam Tier 5 clobetasol topical gel T1 QL (120 GM per 30 days) clobetasol topical lotion Tier 5 clobetasol topical ointment T1 QL (120 GM per 30 days) clobetasol topical shampoo T1 QL (118 ML per 30 days) clobetasol topical spray,non-aerosol Tier 5 clobetasol-emollient Tier 5 clocortolone pivalate Tier 5 CLODAN KIT Tier 5 clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs) CORDRAN TAPE LARGE ROLL Tier 5 CORDRAN TOPICAL CREAM 0.025 % Tier 5 DERMAREST ECZEMA (HYDROCORT) Tier 5

90 Drug Tier Notes DERMASORB TA COMPLETE KIT Tier 5 DESONATE Tier 5 desonide Tier 5 desoximetasone topical cream 0.05 % Tier 5 desoximetasone topical cream 0.25 % T1 QL (60 QY per 30 DYs) desoximetasone topical gel Tier 5 desoximetasone topical ointment Tier 5 desoximetasone topical spray,non-aerosol Tier 5 diflorasone Tier 5 fluocinolone and shower cap T1 QL (119 ML per 30 DYs) fluocinolone topical cream 0.01 % Tier 5 fluocinolone topical cream 0.025 % Tier 5 QL (240 QY per 30 DYs) fluocinolone topical oil T1 QL (119 ML per 30 DYs) fluocinolone topical ointment Tier 5 fluocinolone topical solution T1 QL (120 ML per 30 DYs) fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs) fluocinonide topical cream 0.1 % Tier 5 fluocinonide topical gel T1 QL (240 QY per 30 DYs) fluocinonide topical ointment T1 QL (240 QY per 30 DYs) fluocinonide topical solution T1 QL (240 QY per 30 DYs) FLUOCINONIDE-E Tier 5 fluocinonide-emollient Tier 5 flurandrenolide Tier 5 fluticasone propionate topical cream T1 QL (240 QY per 30 DYs) fluticasone propionate topical lotion Tier 5 fluticasone propionate topical ointment Tier 5 halobetasol propionate topical cream T1 QL (120 GM per 30 days) halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs) HALOG Tier 5 hydrocortisone butyrate Tier 5 hydrocortisone butyr-emollient Tier 5 hydrocortisone rectal T1 hydrocortisone topical cream 1 %, 2.5 % T1 QL (240 QY per 30 DYs)

91 Drug Tier Notes hydrocortisone topical cream with perineal Tier 5 applicator 1 % hydrocortisone topical lotion 1 % Tier 5 hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone topical ointment 1 %, 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone valerate Tier 5 mometasone topical cream T1 QL (60 QY per 30 DYs) mometasone topical ointment T1 QL (240 QY per 30 DYs) mometasone topical solution T1 QL (240 QY per 30 DYs) NOLIX TOPICAL LOTION Tier 5 PANDEL Tier 5 prednicarbate Tier 5 PROCTOFOAM HC T2 PROCTO-PAK Tier 5 PROCTOZONE-HC T1 QL (60 GM per 30 DYs) PSORCON Tier 5 SCALACORT Tier 5 SCALPICIN ANTI-ITCH Tier 5 SERNIVO Tier 5 SYNALAR OINTMENT KIT Tier 5 TEXACORT Tier 5 TOPICORT TOPICAL GEL Tier 5 triamcinolone acetonide dental T1 triamcinolone acetonide topical aerosol Tier 5 triamcinolone acetonide topical cream 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs) triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs) triamcinolone acetonide topical ointment 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 fills) TRIANEX Tier 5 ULTRAVATE TOPICAL LOTION Tier 5 ULTRAVATE X Tier 5

92 Drug Tier Notes VERDESO Tier 5 Hydroxypyridones (Skin, Mucous Membrane) ciclopirox topical cream T1 QL (90 QY per 30 DYs) ciclopirox topical solution T1 QL (6.6 ML per 30 days) Keratolytic Agents benzoyl peroxide topical cleanser 10 %, 6 % T1 clindamycin-benzoyl peroxide Tier 5 NEUAC Tier 5 NEUAC KIT Tier 5 ONEXTON TOPICAL GEL WITH PUMP Tier 5 sulfacetamide sodium-sulfur topical cleanser 10-5 T1 QL (170 GM per 30 days) % (w/w) urea topical cream 40 % T1 QL (198.4 GM per 30 days) Keratoplastic Agents coal tar (bulk) T1 Local Anti-Infectives, Miscellaneous selenium sulfide topical lotion T1 silver sulfadiazine T1 sulfacetamide sodium topical cleanser, gel T3 PA sulfacetamide sodium-sulfur topical cleanser 10-5 T1 QL (170 GM per 30 days) % (w/w) ULESFIA Tier 5 Nonsteroidal Anti-Inflammat.Agents(Skin) diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days) diclofenac sodium topical gel 3 % Tier 5 FLECTOR Tier 5 PENNSAID TOPICAL SOLUTION IN Tier 5 METERED-DOSE PUMP Oxaboroles KERYDIN Tier 5 Pigmenting Agents methoxsalen T1 QL (12 EA per 28 DYs) Polyenes (Skin And Mucous Membrane)

93 Drug Tier Notes nystatin topical cream T1 QL (120 QY per 30 DYs) nystatin topical ointment T1 QL (120 QY per 30 DYs) nystatin topical powder T1 QL (1280 QY per 30 DYs) nystatin-triamcinolone T1 QL (480 QY per 30 DYs) Scabicides And Pediculicides CROTAN Tier 5 EURAX TOPICAL CREAM Tier 5 LICE KILLING (PERMETHRIN) T1 malathion T3 PA permethrin topical cream T1 SKLICE Tier 5 spinosad T3 PA ULESFIA Tier 5 Skin And Mucous Membrane Agents, Misc. ABSORICA Tier 5 acitretin T3 PA adapalene topical cream T3 QL (45 GM per 30 days); AL (Max 30 Years) adapalene topical gel 0.1 % Tier 5 adapalene topical gel 0.3 % T3 ST; QL (45 GM per 30 days); AL (Max 30 Years) adapalene topical gel with pump T3 ST adapalene topical lotion Tier 5 adapalene topical solution Tier 5 adapalene topical swab Tier 5 adapalene-benzoyl peroxide Tier 5 AVAGE Tier 5 azelaic acid T3 PA AZELEX T3 PA calcipotriene scalp T1 QL (60 ML per 30 days) calcipotriene topical T1 QL (60 QY per 30 DYs) COSENTYX T4 PA COSENTYX (2 SYRINGES) T4 PA

94 Drug Tier Notes COSENTYX PEN T4 PA COSENTYX PEN (2 PENS) T4 PA diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days) diclofenac sodium topical gel 3 % Tier 5 DUPIXENT T4 PA ENBREL T4 PA ENBREL MINI T4 PA ENBREL SURECLICK T4 PA EPIDUO FORTE Tier 5 FABIOR Tier 5 FINACEA TOPICAL FOAM T3 PA FLECTOR Tier 5 fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs) HUMIRA PEDIATRIC CROHNS START T4 PA HUMIRA PEN T4 PA HUMIRA PEN CROHNS-UC-HS START T4 PA HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T4 PA MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) T4 PA HUMIRA(CF) PEDI CROHNS STARTER T4 PA SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN T4 PA INJECTOR KIT 40 MG/0.4 ML imiquimod topical cream in packet T1 AL (Min 12 Years) isotretinoin T3 PA OTEZLA T4 PA OTEZLA STARTER T4 PA PENNSAID TOPICAL SOLUTION IN Tier 5 METERED-DOSE PUMP pimecrolimus Tier 5 podofilox T1 RECTIV T3 PA SANTYL T2 QL (30 GM per 30 days) 95 Drug Tier Notes SILIQ Tier 5 STELARA SUBCUTANEOUS T4 PA tacrolimus topical ointment 0.03 % T3 ST; QL (30 GM per 30 days) tacrolimus topical ointment 0.1 % T3 ST; QL (30 GM per 30 days); AL (Min 2 Years) TALTZ AUTOINJECTOR T4 PA TALTZ AUTOINJECTOR (2 PACK) T4 PA TALTZ AUTOINJECTOR (3 PACK) T4 PA TALTZ SYRINGE T4 PA tazarotene Tier 5 TAZORAC TOPICAL CREAM 0.05 % Tier 5 TAZORAC TOPICAL GEL Tier 5 TREMFYA Tier 5 XYLIMELTS Tier 5 Smooth Muscle Relaxants Antimuscarinics darifenacin Tier 5 flavoxate Tier 5 GELNIQUE TRANSDERMAL GEL IN Tier 5 METERED-DOSE PUMP 100 MG/GRAM (10 %) GELNIQUE TRANSDERMAL GEL IN PACKET Tier 5 oxybutynin chloride T1 OXYTROL Tier 5 solifenacin Tier 5 tolterodine oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days) tolterodine oral tablet T3 ST; QL (60 EA per 30 days) TOVIAZ Tier 5 trospium oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days) trospium oral tablet T3 ST; QL (60 EA per 30 days) Respiratory Smooth Muscle Relaxants theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 96 Drug Tier Notes Selective Beta-3-Adrenergic Agonists MYRBETRIQ Tier 5 Vitamins Multivitamin Preparations ATABEX EC T2 QL (30 QY per 30 DYs) BIOTECT PLUS T1 CLASSIC PRENATAL T2 COMPLETENATE T1 QL (30 QY per 30 DYs) ELITE-OB 400 T1 QL (30 QY per 30 DYs) EZFE FORTE T1 QL (30 QY per 30 DYs) FOLIVANE-OB T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T1 QL (30 QY per 30 DYs) MULTI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) TABLET,CHEWABLE 0.5 MG, 1 MG MYNATE 90 PLUS T1 QL (30 QY per 30 DYs) NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NESTABS T1 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) O-CAL FA T2 QL (30 QY per 30 DYs) PRENATA T1 QL (30 QY per 30 DYs) PRENATAL LOW IRON T1 QL (30 QY per 30 DYs) PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN ORAL TABLET T1 QL (30 QY per 30 DYs) PRENATAL VITAMIN ORAL TABLET 27 MG T1 IRON- 0.8 MG PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRENATAL-U T1 QL (30 QY per 30 DYs) PRETAB T1 QL (30 EA per 30 days) PUREFE OB PLUS T1 QL (30 QY per 30 DYs) SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs)

97 Drug Tier Notes STROVITE FORTE T2 THERANATAL COMPLETE T1 QL (60 QY per 30 DYs) TRIADVANCE T1 TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VEMAVITE-PRX-2 T1 QL (30 QY per 30 DYs) VIC-FORTE T1 VINATE II T1 VINATE M T1 QL (30 QY per 30 DYs) VINATE ONE T1 QL (30 QY per 30 DYs) VINATE PN CARE T1 QL (30 QY per 30 DYs) VINATE ULTRA T1 QL (30 EA per 30 days) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VITAMED MD ONE RX T2 QL (30 EA per 30 days) VITAMED MD PLUS RX T1 QL (60 QY per 30 DYs) VOL-NATE T1 QL (30 EA per 30 days) VP-CH PLUS T1 QL (30 EA per 30 days) VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 ZINGIBER T1 QL (60 QY per 30 DYs) Vitamin A TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Vitamin B Complex ATABEX EC T2 QL (30 QY per 30 DYs) BONJESTA Tier 5 CLASSIC PRENATAL T2 cyanocobalamin (vitamin b-12) injection T1 QL (1 QY per 30 DYs)

98 Drug Tier Notes DIALYVITE 800 ORAL TABLET T1 DIALYVITE ORAL TABLET 100-1 MG T2 DICLEGIS Tier 5 ELITE-OB 400 T1 QL (30 QY per 30 DYs) EZFE FORTE T1 QL (30 QY per 30 DYs) folic acid oral tablet T1 FOLIVANE-OB T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T1 QL (30 QY per 30 DYs) L-METHYLFOLATE T1 MYNEPHROCAPS T1 NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NESTABS T1 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) O-CAL FA T2 QL (30 QY per 30 DYs) PRENATA T1 QL (30 QY per 30 DYs) PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN ORAL TABLET 27 MG T1 IRON- 0.8 MG PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRETAB T1 QL (30 EA per 30 days) PUREFE OB PLUS T1 QL (30 QY per 30 DYs) SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs) STROVITE FORTE T2 THERANATAL COMPLETE T1 QL (60 QY per 30 DYs) TRIADVANCE T1 TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VEMAVITE-PRX-2 T1 QL (30 QY per 30 DYs)

99 Drug Tier Notes VIC-FORTE T1 VINATE M T1 QL (30 QY per 30 DYs) VINATE ONE T1 QL (30 QY per 30 DYs) VINATE ULTRA T1 QL (30 EA per 30 days) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VITAMED MD ONE RX T2 QL (30 EA per 30 days) VITAMED MD PLUS RX T1 QL (60 QY per 30 DYs) VOL-NATE T1 QL (30 EA per 30 days) VP-CH PLUS T1 QL (30 EA per 30 days) VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 ZINGIBER T1 QL (60 QY per 30 DYs) Vitamin C DIALYVITE 800 ORAL TABLET T1 DIALYVITE ORAL TABLET 100-1 MG T2 MYNEPHROCAPS T1 TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Vitamin D calcitriol oral capsule T1 calcitriol oral solution T1 AL (Max 12 Years) FOSAMAX PLUS D Tier 5 TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML VITAMIN D2 T1 Vitamin K Activity phytonadione (vitamin k1) oral tablet 5 mg T1

100 Index

A ADMELOG U-100 INSULIN amlodipine-olmesartan .. 22, 23, abacavir ...... 6 LISPRO ...... 68, 71 26, 29, 30, 31, 33 abacavir-lamivudine- ADVAIR HFA ... 17, 61, 82, 83 amlodipine-valsartan22, 23, 26, zidovudine ...... 6 ADZENYS ER ...... 34 29, 30, 31, 33 abiraterone ...... 10 ADZENYS XR-ODT ...... 35 amlodipine-valsartan-hcthiazid ABSORICA ...... 94 AEROCHAMBER PLUS ...... 22, 23, 26, 29, 30, 32, 53 acarbose ...... 63 FLOW-VU,S MSK ...... 50 ammonium lactate ...... 89 ACCU-CHEK AVIVA AEROECLIPSE II amoxicillin ...... 3 CONTROL SOLN...... 49 NEBULIZER ...... 50 amoxicillin-pot clavulanate .... 3 ACCU-CHEK AVIVA PLUS AFINITOR ...... 10 amphetamine sulfate ...... 35 TEST STRP ...... 50 AFINITOR DISPERZ ...... 10 ampicillin ...... 3 ACCU-CHEK GUIDE ...... 50 AIMOVIG AUTOINJECTOR anagrelide ...... 22 ACCU-CHEK GUIDE ...... 38, 42 anastrozole ...... 11, 63 GLUCOSE METER ...... 49 AIMOVIG AUTOINJECTOR ANDRODERM ...... 63 ACCU-CHEK GUIDE L1-L2 (2 PACK) ...... 38, 42 ANDROGEL ...... 63 CTRL SOL ...... 49 AJOVY ...... 38, 42 ANNOVERA ...... 64 ACCU-CHEK GUIDE ME AKTIPAK ...... 84 ANORO ELLIPTA .. 15, 18, 80, GLUCOSE MTR ...... 49 AKYNZEO (NETUPITANT) 83 ACCU-CHEK MULTICLIX ...... 58, 60 ANUCORT-HC ...... 85, 90 LANCET ...... 49 albendazole ...... 3 ANUSOL-HC ...... 85, 90 ACCU-CHEK SMARTVIEW albuterol sulfate ...... 17, 18, 83 APEXICON E ...... 85, 90 CONTRL SOL ...... 49 alclometasone ...... 85, 90 aprepitant ...... 60 ACCU-CHEK SMARTVIEW ALECENSA ...... 11 APTENSIO XR ...... 46 TEST STRIP ...... 50 alendronate ...... 74 APTIOM ...... 36 ACCU-CHEK SOFT DEV alfuzosin ...... 17 APTIVUS ...... 7 LANCETS ...... 49 ALINIA ...... 4 AQUANIL HC ...... 85, 90 ACCU-CHEK SOFTCLIX aliskiren ...... 32 ARANESP (IN LANCET DEV ...... 50 ALKERAN ...... 11 POLYSORBATE) ...... 19 ACCU-CHEK SOFTCLIX allopurinol ...... 74 ARCAPTA NEOHALER .... 18, LANCETS ...... 50 almotriptan malate ...... 47 83 acebutolol ...... 18, 25, 28, 31 alogliptin ...... 66 aripiprazole ...... 37, 39, 40 acetaminophen-codeine .. 35, 43 alogliptin-metformin ...... 64, 66 armodafinil ...... 49 acetazolamide ...... 27, 51, 55 alogliptin-pioglitazone.... 66, 73 ARMOUR THYROID ...... 73 acetic acid ...... 56 alosetron ...... 58 ARNUITY ELLIPTA ..... 61, 82 acetylcysteine ...... 79, 81 ALPHAGAN P ...... 54 ARYMO ER ...... 43 acitretin ...... 94 ALTAFLUOR ...... 50, 57 ASMANEX HFA ...... 61, 82 ACTEMRA ...... 75, 77 ALTRENO ...... 89 ASMANEX TWISTHALER ACTHAR H.P...... 50, 70 aluminum chloride ...... 89 ...... 61, 82 ACUVAIL (PF) ...... 56 ALUNBRIG ...... 11 aspirin-dipyridamole . 22, 33, 47 acyclovir ...... 8, 89 amcinonide ...... 85, 90 ASTHMAPACK adapalene ...... 94 AMETHIA...... 64 CHILDREN'S ...... 50 adapalene-benzoyl peroxide . 94 amiloride ...... 32, 52 ATABEX EC 20, 52, 58, 97, 98 ADASUVE ...... 39 amiodarone ...... 29 atazanavir ...... 7 adefovir...... 8 AMITIZA ...... 58 atenolol ...... 19, 25, 28 ADEMPAS ...... 33, 84 amitriptyline ...... 49 atenolol-chlorthalidone .. 19, 25, ADMELOG SOLOSTAR U- amlodipine .... 26, 29, 30, 31, 33 28, 33, 53 100 INSULIN ...... 68, 71 amlodipine-benazepril ... 24, 26, atomoxetine ...... 42 29, 30, 31, 33 atorvastatin ...... 30 101 atovaquone ...... 4 bicalutamide ...... 11 capecitabine ...... 11 atovaquone-proguanil ...... 3 bimatoprost ...... 57 CAPEX ...... 86, 90 ATRIPLA ...... 6 BINOSTO ...... 74 CAPRELSA ...... 11 atropine ...... 57 BIOTECT PLUS ...... 20, 97 captopril ...... 24 ATROVENT HFA ...... 15, 80 bisoprolol fumarate... 19, 25, 28 carbamazepine ...... 36, 37 AUBAGIO ...... 77 bisoprolol-hydrochlorothiazide carbidopa ...... 42 AUGMENTIN ...... 3 ...... 19, 25, 28, 33, 53 carbidopa-levodopa ...... 42 AURYXIA ...... 51 BLEPHAMIDE ...... 54 carbidopa-levodopa- AUSTEDO ...... 42, 49 BLEPHAMIDE S.O.P...... 54 entacapone ...... 42, 43 AVAGE ...... 94 BONJESTA ...... 58, 81, 98 CARDURA XL ...... 16, 22, 31 AVONEX ...... 77 bosentan ...... 33, 84 CARNITOR (SUGAR-FREE) AVONEX (WITH ALBUMIN) BOSULIF ...... 11 ...... 79 ...... 77 BRAFTOVI ...... 11 carvedilol 16, 17, 22, 25, 28, 31 azathioprine ...... 75, 77, 78 BREATHERITE VALVED carvedilol phosphate 16, 17, 22, azelaic acid ...... 94 MDI SPACER ...... 50 25, 29, 31 azelastine ...... 54 BREO ELLIPTA 18, 61, 82, 83 CAYSTON ...... 8 AZELEX ...... 94 BRILINTA ...... 22 cefaclor ...... 2 azithromycin ...... 9 brimonidine ...... 54 cefadroxil ...... 1 B BRIVIACT ...... 36 cefdinir ...... 2 bacitracin ...... 54 bromfenac ...... 56 cefixime ...... 2 bacitracin-polymyxin b ...... 54 bromocriptine ...... 43 cefpodoxime ...... 2 baclofen ...... 16 BROMSITE ...... 57 cefprozil ...... 2 BALCOLTRA ...... 64 BROVANA ...... 18, 83 CEFTIN ...... 2 balsalazide ...... 58 budesonide ...... 56, 61, 62, 82 cefuroxime axetil ...... 2 BALVERSA ...... 11 bumetanide ...... 31, 51 celecoxib ...... 42 BANZEL ...... 36 BUNAVAIL ...... 45 CELLCEPT ...... 78 BARACLUDE ...... 8 buprenorphine hcl ...... 45 cephalexin ...... 1 BASAGLAR KWIKPEN U- buprenorphine-naloxone ...... 45 CERDELGA ...... 79 100 INSULIN ...... 68, 70 bupropion hcl ...... 37 CHANTIX ...... 16 BELSOMRA ...... 39 bupropion hcl (smoking deter) CHANTIX STARTING BELVIQ ...... 48 ...... 37 MONTH BOX ...... 16 BELVIQ XR ...... 48 buspirone ...... 39 CHATEAL (28) ...... 65 benazepril ...... 24 butalbital-acetaminophen-caff CHEMET ...... 61, 73 benazepril-hydrochlorothiazide ...... 35, 38, 40, 46 chlordiazepoxide hcl ...... 41 ...... 24, 32, 53 BYDUREON ...... 68 chlorhexidine gluconate ...... 56 benzonatate ...... 80 BYDUREON BCISE ...... 68 chloroquine phosphate ...... 3 benzoyl peroxide ...... 93 BYETTA ...... 68 chlorothiazide ...... 33, 53 benzphetamine ...... 35 C chlorpromazine ...... 46 benztropine ...... 16, 36 cabergoline ...... 43 chlorthalidone ...... 33, 53, 54 BEPREVE ...... 54 CABOMETYX ...... 11 cholestyramine (with sugar) . 26 BETA-HC...... 85, 90 calcipotriene ...... 94 CHOLESTYRAMINE LIGHT betamethasone dipropionate 85, calcitonin (salmon) ... 64, 70, 74 ...... 26 86, 90 calcitriol ...... 100 choline,magnesium salicylate betamethasone valerate .. 86, 90 calcium acetate ...... 51 ...... 47 betamethasone, augmented.. 86, calcium gluconate ...... 52 ciclopirox ...... 93 90 CALQUENCE ...... 11 cilostazol ...... 22, 32 betaxolol ...... 55 CAMRESE LO ...... 64 cimetidine ...... 60 bethanechol chloride ...... 17 candesartan ...... 22, 23 cimetidine hcl ...... 60 BETHKIS ...... 2 candesartan-hydrochlorothiazid CIMZIA ...... 59, 75, 77 bexarotene ...... 11 ...... 23, 33, 53

102 CIMZIA POWDER FOR COMPLETENATE ...... 97 DERMAREST ECZEMA RECONST ...... 59, 75, 77 CONTRAVE ...... 36 (HYDROCORT) ...... 86, 90 CIMZIA STARTER KIT .... 59, COPIKTRA ...... 11 DERMASORB TA 75, 77 CORDRAN ...... 86, 90 COMPLETE KIT ...... 86, 91 cinacalcet ...... 64, 79 CORDRAN TAPE LARGE DESCOVY ...... 7 CIPRODEX ...... 55, 56 ROLL...... 86, 90 desipramine ...... 49 ciprofloxacin...... 4, 9 COSENTYX ...... 94 desloratadine ...... 1, 83 ciprofloxacin (mixture) ...... 4, 9 COSENTYX (2 SYRINGES) desmopressin ...... 20, 70 ciprofloxacin hcl ...... 4, 9, 55 ...... 94 DESONATE ...... 86, 91 citalopram ...... 48 COSENTYX PEN ...... 95 desonide ...... 86, 91 clarithromycin ...... 4, 9 COSENTYX PEN (2 PENS) 95 desoximetasone ...... 86, 91 CLASSIC PRENATAL 20, 97, COTELLIC ...... 11 desvenlafaxine ...... 47 98 COTEMPLA XR-ODT ...... 46 desvenlafaxine fumarate ...... 47 CLEOCIN...... 85 COVARYX ...... 63, 67 desvenlafaxine succinate ...... 47 CLIMARA PRO ...... 66 COVARYX H.S...... 63, 67 dexamethasone ...... 62 clindamycin hcl ...... 8 CREON ...... 59 DEXAMETHASONE clindamycin palmitate hcl ...... 8 CRESEMBA ...... 4 INTENSOL ...... 62 clindamycin phosphate ...... 85 CRINONE ...... 71 dexamethasone sodium clindamycin-benzoyl peroxide CRIXIVAN ...... 7 phosphate ...... 56 ...... 85, 93 cromolyn ...... 54, 81 DEXILANT ...... 61 clindamycin-tretinoin ..... 85, 89 CROTAN...... 94 dexmethylphenidate ...... 46 CLINIMIX 4.25%/D5W CRYSELLE (28) ...... 65 dextroamphetamine ...... 35 SULFIT FREE...... 51 cyanocobalamin (vitamin b-12) dextroamphetamine- clobazam...... 41 ...... 98 amphetamine ...... 35 clobetasol ...... 86, 90 CYCLAFEM 1/35 (28) ...... 65 dextrose 70 % in water (d70w) clobetasol-emollient ...... 86, 90 cyclobenzaprine ...... 16 ...... 51 clocortolone pivalate ...... 86, 90 cyclopentolate ...... 57 DIALYVITE ...... 99, 100 CLODAN KIT...... 86, 90 cyclophosphamide ...... 11, 79 DIALYVITE 800 ...... 99, 100 clomipramine ...... 49 cycloserine ...... 4 diazepam ...... 41 clonazepam ...... 41 cyclosporine modified ... 75, 77, DICLEGIS ...... 58, 81, 99 clonidine ...... 15, 28 79 diclofenac potassium ...... 45 clonidine hcl ...... 15, 28 cyproheptadine ...... 1, 81 diclofenac sodium .... 11, 45, 57, clopidogrel ...... 22 CYTRA K CRYSTALS ...... 50 93, 95 clotrimazole ...... 89 D diclofenac-misoprostol ... 45, 60 clotrimazole-betamethasone 86, DAKLINZA ...... 5 dicloxacillin ...... 9 89, 90 dalfampridine...... 79 dicyclomine ...... 15 clozapine...... 40 DALIRESP ...... 83 didanosine ...... 7 coal tar (bulk) ...... 93 danazol...... 63 diethylpropion ...... 34 codeine sulfate ...... 43, 81 dapsone ...... 3, 4 DIFICID ...... 9 colchicine ...... 74 DARAPRIM ...... 3 diflorasone ...... 86, 91 colesevelam ...... 26, 63 darifenacin ...... 96 digoxin ...... 25, 28 colestipol ...... 26 DAURISMO ...... 11 DILANTIN ...... 28, 43 COMBIGAN ...... 54, 55 DAYTRANA...... 46 DILATRATE-SR ...... 31 COMBIPATCH ...... 66, 71 DDAVP ...... 20, 70 diltiazem hcl ...... 26, 27, 29, 34 COMBIVENT RESPIMAT 15, deferasirox ...... 61 diphenoxylate-atropine .. 15, 58, 18, 80, 83 DENAVIR ...... 89 80 COMETRIQ ...... 11 DENTA 5000 PLUS ...... 75 dipyridamole ...... 22, 34 COMPACT COMPRESSOR DEPO-ESTRADIOL ...... 67 disopyramide phosphate ...... 28 NEBULIZER ...... 50 DEPO-SUBQ PROVERA 104 disulfiram ...... 73 COMPLERA ...... 6 ...... 71 DIURIL ...... 33, 53

103 divalproex ...... 36, 37, 38 enalapril maleate...... 24 EURAX ...... 94 dofetilide...... 29 enalapril-hydrochlorothiazide exemestane ...... 11, 64 donepezil ...... 17 ...... 24, 33, 53 EXTAVIA ...... 77 DOPTELET (10 TAB PACK) ENBREL ...... 76, 77, 95 ezetimibe ...... 28 ...... 19 ENBREL MINI ...... 76, 77, 95 EZFE FORTE ...... 97, 99 DOPTELET (15 TAB PACK) ENBREL SURECLICK 76, 77, F ...... 19 95 FABIOR ...... 95 dorzolamide ...... 55 ENDARI ...... 59, 79 FALMINA (28) ...... 65 dorzolamide-timolol ...... 55 ENDOMETRIN...... 71 famciclovir ...... 9 doxazosin ...... 16, 22, 31 enoxaparin ...... 20 famotidine ...... 60 doxepin ...... 49 entacapone ...... 42 FANAPT ...... 40 doxycycline hyclate ...... 10, 55 entecavir ...... 8 FARESTON ...... 11, 66 doxycycline monohydrate .... 10 ENTRESTO...... 23, 32 FARXIGA ...... 72 dronabinol...... 58 ENUCLENE ...... 56 FARYDAK ...... 11 drospirenone-e.estradiol-lm.fa ENULOSE ...... 51 FAYOSIM ...... 65 ...... 65 EPIDUO FORTE ...... 95 febuxostat ...... 74 DULERA ...... 18, 62, 82, 83 epinastine ...... 54 felbamate ...... 36 duloxetine ...... 43, 47 epinephrine ...... 15, 80 felodipine ...... 27, 29, 30, 31, 34 DUPIXENT ...... 81, 95 EPIPEN 2-PAK ...... 80 fenofibrate ...... 30 DUREZOL ...... 56 eplerenone ...... 31, 32 fenofibrate micronized ...... 30 dutasteride ...... 73 EPOGEN ...... 19 fenofibrate nanocrystallized . 30 DYANAVEL XR ...... 35 eprosartan ...... 23 fenofibric acid ...... 30 E EPZICOM ...... 7 fenofibric acid (choline) ...... 30 econazole ...... 89 EQUETRO ...... 36, 38 fentanyl ...... 43 EDARBI ...... 23 ERIVEDGE ...... 11 FINACEA ...... 95 EDARBYCLOR ...... 23, 33, 54 ERLEADA ...... 11 finasteride ...... 73 EDLUAR ...... 39 erlotinib ...... 11 FIORICET ...... 35, 38, 40, 46 EDURANT ...... 6 ERYTHROCIN (AS FIRMAGON KIT W efavirenz ...... 6 STEARATE) ...... 5, 8 DILUENT SYRINGE 11, 64, EGRIFTA ...... 72 erythromycin ...... 5, 8, 55 77 eletriptan ...... 47 erythromycin ethylsuccinate.. 5, FIRVANQ ...... 5 ELIGARD ...... 11, 67, 68 8 flavoxate ...... 96 ELIGARD (3 MONTH) 11, 67, erythromycin with ethanol.... 85 flecainide ...... 28 68 erythromycin-benzoyl peroxide FLECTOR ...... 45, 93, 95 ELIGARD (4 MONTH) 11, 67, ...... 85 FLOVENT DISKUS ...... 62, 82 68 ESBRIET ...... 80 FLOVENT HFA ...... 62, 82 ELIGARD (6 MONTH) 11, 67, escitalopram oxalate ...... 48 fluconazole ...... 4 68 estazolam ...... 41 fludrocortisone ...... 62 ELIPHOS ...... 51 ESTRACE ...... 67 fluocinolone ...... 87, 91 ELIQUIS ...... 19 estradiol ...... 67 fluocinolone acetonide oil .... 56 ELITE-OB 400 ...... 20, 97, 99 estradiol valerate...... 67 fluocinolone and shower cap ELLA ...... 65 ESTRING ...... 67 ...... 86, 91 ELMIRON ...... 80 ESTROGEL...... 67 fluocinonide ...... 87, 91 EMADINE ...... 54 eszopiclone ...... 39 FLUOCINONIDE-E ...... 87, 91 EMCYT ...... 11 ethambutol ...... 4 fluocinonide-emollient ... 87, 91 EMEND ...... 60 ethosuximide ...... 48 FLUOR-A-DAY ...... 75 EMFLAZA ...... 62 etidronate disodium ...... 74 fluorescein-benoxinate ...... 57 EMGALITY PEN ...... 38, 42 etodolac ...... 45 fluoride (sodium) ...... 75 EMGALITY SYRINGE . 38, 42 etoposide ...... 11 FLUORIDEX DAILY EMTRIVA ...... 7 EUCRISA ...... 86, 88 DEFENSE ...... 75

104 FLUORITAB ...... 75 GLUCAGON EMERGENCY HUMIRA(CF) PEN . 60, 76, 78, fluorometholone ...... 56 KIT (HUMAN)...... 67, 73 95 fluorouracil ...... 12, 95 glyburide ...... 73 HUMULIN 70/30 U-100 fluoxetine ...... 48 glyburide-metformin ...... 64, 73 INSULIN ...... 69, 72 fluphenazine hcl ...... 46 glycopyrrolate ...... 15 HUMULIN 70/30 U-100 FLURA-DROPS ...... 75 GLYXAMBI ...... 66, 72 KWIKPEN ...... 69, 72 flurandrenolide ...... 87, 91 granisetron hcl ...... 58 HUMULIN N NPH INSULIN flurazepam ...... 41 GRANIX ...... 19 KWIKPEN ...... 69 flurbiprofen...... 45 GRASTEK...... 14, 79 HUMULIN N NPH U-100 flurbiprofen sodium ...... 57 griseofulvin microsize ...... 3 INSULIN ...... 69 flutamide...... 12 griseofulvin ultramicrosize ..... 3 HUMULIN R REGULAR U- fluticasone propionate ... 56, 82, guanfacine ...... 28, 42 100 INSULN ...... 69, 72 87, 91 GYNAZOLE-1 ...... 89 HUMULIN R U-500 (CONC) fluticasone propion-salmeterol H INSULIN ...... 69, 72 ...... 18, 62, 82, 83 HAEGARDA...... 75 HUMULIN R U-500 (CONC) fluvoxamine ...... 48 halobetasol propionate .... 87, 91 KWIKPEN ...... 69, 72 folic acid ...... 99 HALOG ...... 87, 91 HYCAMTIN ...... 12 FOLIVANE-OB ...... 21, 97, 99 haloperidol ...... 42 hydralazine ...... 30 FORTEO ...... 70, 74 haloperidol lactate ...... 42 hydrochlorothiazide ...... 33, 53 FOSAMAX PLUS D .... 74, 100 heparin (porcine) ...... 20 hydrocodone-acetaminophen fosamprenavir ...... 7 HETLIOZ ...... 39 ...... 35, 43, 44 fosinopril ...... 24 HEXALEN ...... 12 hydrocortisone .... 62, 87, 91, 92 FREESTYLE LIBRE 10 DAY HOMATROPAIRE ...... 57 hydrocortisone butyrate .. 87, 91 READER ...... 50 HUMALOG JUNIOR hydrocortisone butyr-emollient FREESTYLE LIBRE 10 DAY KWIKPEN U-100 ...... 68, 71 ...... 87, 91 SENSOR...... 50 HUMALOG MIX 50-50 hydrocortisone valerate .. 87, 92 frovatriptan ...... 47 INSULN U-100 .... 68, 69, 71 hydrocortisone-acetic acid .... 56 FULPHILA...... 19 HUMALOG MIX 50-50 hydromorphone ...... 44 furosemide ...... 31, 51 KWIKPEN...... 68, 69, 71 hydroxychloroquine .... 3, 76, 78 FUZEON ...... 6 HUMALOG MIX 75-25 hydroxyprogest(pf)(preg presv) G KWIKPEN...... 68, 69, 71 ...... 71 gabapentin ...... 35, 36 HUMALOG MIX 75-25(U- hydroxyprogesterone galantamine ...... 17 100)INSULN ...... 69, 72 cap(ppres) ...... 71 GELNIQUE ...... 96 HUMAPEN LUXURA HD .. 50 hydroxyurea ...... 12 gemfibrozil ...... 30 HUMATROPE ...... 70 hydroxyzine hcl ...... 1, 39 GENOTROPIN ...... 70 HUMIRA ...... 60, 76, 77, 95 hydroxyzine pamoate ...... 1, 39 GENOTROPIN MINIQUICK HUMIRA PEDIATRIC hyoscyamine sulfate ...... 15 ...... 70 CROHNS START ..... 59, 76, I gentamicin ...... 55 77, 95 ibandronate ...... 74 GENVOYA ...... 6, 7 HUMIRA PEN ... 59, 76, 77, 95 IBRANCE ...... 12 GIANVI (28) ...... 65 HUMIRA PEN CROHNS-UC- ibuprofen ...... 45 GILENYA ...... 77 HS START ..... 59, 76, 77, 95 icatibant ...... 75 GILOTRIF ...... 12 HUMIRA PEN PSOR- ICLUSIG ...... 12 glatiramer ...... 77 UVEITS-ADOL HS .. 59, 76, IDHIFA ...... 12 GLATOPA ...... 77 77, 95 ILEVRO ...... 57 GLEOSTINE ...... 12 HUMIRA(CF) .... 60, 76, 77, 95 imatinib ...... 12 glimepiride ...... 73 HUMIRA(CF) PEDI IMBRUVICA ...... 12 glipizide ...... 73 CROHNS STARTER 60, 76, imipramine hcl ...... 49 glipizide-metformin ...... 64, 73 77, 95 imiquimod ...... 95 indapamide ...... 33, 54

105 INDOCIN ...... 45, 74 KETOSTIX ...... 50 lidocaine hcl ...... 57 indomethacin ...... 45, 74 KEVZARA ...... 76, 78 LIDOCAINE VISCOUS ...... 57 INGREZZA ...... 42, 49 KINERET ...... 76, 78 lidocaine-prilocaine ...... 88 INLYTA ...... 12 KIONEX (WITH SORBITOL) linezolid ...... 9 INREBIC ...... 12 ...... 51, 73 LINZESS ...... 60 insulin lispro ...... 69, 72 KISQALI ...... 12 liothyronine ...... 73 INTELENCE ...... 6 KLOR-CON M15 ...... 52 lisinopril ...... 24 INVIRASE ...... 7 KOMBIGLYZE XR ...... 64, 66 lisinopril-hydrochlorothiazide INVOKAMET ...... 64, 72 KPN ...... 21, 97, 99 ...... 24, 33, 53 INVOKAMET XR ...... 64, 72 L lithium carbonate ...... 38 INVOKANA ...... 72 labetalol ...... 16, 17, 22, 25, 29 lithium citrate ...... 38 ipratropium bromide ...... 15, 80 lactulose ...... 51 LITHOBID ...... 38 ipratropium-albuterol .... 15, 18, lamivudine ...... 7 L-METHYLFOLATE ...... 99 80, 83 lamivudine-zidovudine ...... 7 LO LOESTRIN FE ...... 65 irbesartan ...... 23 lamotrigine...... 36, 38 LOKELMA ...... 52 irbesartan-hydrochlorothiazide lansoprazole ...... 61 LOMAIRA ...... 34 ...... 23, 33, 53 lanthanum ...... 51, 73 LONSURF ...... 12 IRESSA ...... 12 LANTUS SOLOSTAR U-100 loperamide ...... 58 ISENTRESS ...... 6 INSULIN ...... 69, 70 lorazepam ...... 41 ISENTRESS HD ...... 6 LANTUS U-100 INSULIN . 69, LORBRENA ...... 12 isoniazid ...... 4 70 losartan ...... 23 ISORDIL ...... 32 LASTACAFT ...... 54 losartan-hydrochlorothiazide isosorbide dinitrate ...... 32 latanoprost ...... 57 ...... 23, 33, 53 isosorbide mononitrate ...... 32 LATUDA...... 40 lovastatin ...... 30 isotretinoin ...... 95 ledipasvir-sofosbuvir ...... 5, 6 loxapine succinate ...... 39 itraconazole ...... 4 LEENA 28 ...... 65 LUDENT FLUORIDE ...... 75 ivermectin ...... 3 leflunomide ...... 76, 78 LUMIGAN ...... 57 J LENVIMA...... 12 LUPANETA PACK (1 JADENU ...... 61 LETAIRIS ...... 34, 84 MONTH) ...... 12, 67, 68, 71 JADENU SPRINKLE ...... 61 letrozole ...... 12, 64 LUPANETA PACK (3 JAKAFI ...... 12 leucovorin calcium ...... 73 MONTH) ...... 12, 67, 68, 71 JANTOVEN ...... 19 LEUKERAN ...... 12 LUPRON DEPOT .... 12, 67, 68 JANUMET ...... 64, 66 leuprolide ...... 12, 67, 68 LUPRON DEPOT (3 JANUMET XR ...... 64, 66 levalbuterol hcl ...... 18, 83 MONTH) ...... 12, 67, 68 JANUVIA...... 66 levalbuterol tartrate...... 18, 84 LUPRON DEPOT (4 JARDIANCE ...... 72 LEVEMIR FLEXTOUCH U- MONTH) ...... 12, 67, 68 JENTADUETO ...... 64, 66 100 INSULN ...... 69, 70 LUPRON DEPOT-PED 12, 67, JOLESSA ...... 65 LEVEMIR U-100 INSULIN 68 JUBLIA ...... 89 ...... 69, 70 LUPRON DEPOT-PED (3 JUNEL FE 1.5/30 (28) ...... 65 levetiracetam ...... 36, 37 MONTH) ...... 12, 67, 68 JUNEL FE 1/20 (28) ...... 65 levobunolol ...... 55 LYNPARZA ...... 13 JUNEL FE 24 ...... 65 levocarnitine (with sugar) ..... 79 LYSODREN ...... 13 K levocetirizine ...... 1 M KALBITOR ...... 75 levofloxacin ...... 4, 9 MAKENA (PF) ...... 71 KALETRA ...... 7 levonorgestrel-ethinyl estrad 65 malathion ...... 94 KALYDECO ...... 81 levothyroxine ...... 73 MATULANE ...... 13 KELNOR 1/35 (28) ...... 65 LEXIVA ...... 7 MAVENCLAD (10 TABLET KERYDIN ...... 93 LICE KILLING PACK) ...... 79 ketoconazole ...... 4, 89 (PERMETHRIN) ...... 94 MAVYRET ...... 5, 6 ketorolac ...... 45, 57 lidocaine ...... 88 MAYZENT ...... 78

106 meclizine ...... 1, 58 MONONESSA (28) ...... 65 NERLYNX ...... 13 MEDROL ...... 62 montelukast ...... 81 NESSI SPACER ...... 50 medroxyprogesterone ...... 71 MORPHABOND ER ...... 44 NESTABS ...... 21, 52, 97, 99 mefloquine ...... 3 morphine ...... 44 NEUAC ...... 85, 93 megestrol ...... 13, 71 morphine concentrate ...... 44 NEUAC KIT ...... 85, 93 MEKINIST ...... 13 MOVANTIK ...... 60 NEULASTA ...... 20 MEKTOVI ...... 13 MOVIPREP ...... 59 NEUPOGEN ...... 20 meloxicam ...... 45 moxifloxacin ...... 4, 10 NEVANAC ...... 57 memantine ...... 42 MOZOBIL ...... 19 nevirapine ...... 6 MENOSTAR ...... 67 MULPLETA ...... 20 NEXAVAR ...... 13 mercaptopurine ...... 13, 79 MULTAQ ...... 29 niacin ...... 25 mesalamine ...... 58 MULTI-VITAMIN WITH NIACOR ...... 25 metformin ...... 64 FLUORIDE ...... 75, 97 nicotine ...... 16 methadone ...... 44 mupirocin...... 85 nicotine (polacrilex) ...... 16 methamphetamine ...... 35 mupirocin calcium ...... 85 NICOTROL ...... 16 methimazole ...... 64 MURO 128 ...... 56 NICOTROL NS ...... 16 methocarbamol ...... 16 MY WAY ...... 65 nifedipine ...... 27, 29, 30, 31, 34 methotrexate sodium 13, 76, 78, mycophenolate mofetil ...... 79 NINLARO ...... 13 79 mycophenolate sodium ...... 79 nitisinone ...... 79 methotrexate sodium (pf) .... 13, MYLERAN ...... 13 NITRO-BID ...... 32 76, 78, 79 MYNATE 90 PLUS ...... 97 nitrofurantoin ...... 10 methoxsalen ...... 93 MYNEPHROCAPS...... 99, 100 nitrofurantoin macrocrystal .. 10 methyldopa ...... 15, 28 MYRBETRIQ ...... 97 nitrofurantoin monohyd/m- methyldopa- MYZILRA ...... 65 cryst ...... 10 hydrochlorothiazide ... 15, 28, N nitroglycerin ...... 32 33, 53 nabumetone ...... 45 NITYR ...... 79 methylergonovine ...... 80 nadolol ...... 16, 25, 26, 29 NIVESTYM ...... 20 methylphenidate hcl ...... 46, 47 naloxone ...... 45, 73 NOLIX ...... 87, 92 methylprednisolone ...... 62 NAMZARIC ...... 17, 42 NORA-BE ...... 65 metoclopramide hcl ...... 60 naproxen ...... 45, 74 NORDITROPIN FLEXPRO 70 metolazone ...... 33, 54 naproxen sodium ...... 45, 74 noreth-ethinyl estradiol-iron . 65 metoprolol succinate 19, 25, 29 naratriptan ...... 47 norethindrone acetate ...... 71 metoprolol tartrate ... 19, 25, 26, NARCAN ...... 45, 73 norethindrone ac-eth estradiol 29 NATACHEW (FE BIS- ...... 67, 71 metronidazole ...... 2, 4, 85 GLYCINATE) ...... 21, 97, 99 norethindrone-e.estradiol-iron mexiletine ...... 28 NATAZIA ...... 65 ...... 65 MIBELAS 24 FE ...... 65 nateglinide ...... 70 norgestimate-ethinyl estradiol MICONAZOLE-3 ...... 89 NATESTO ...... 63 ...... 65 MICROGESTIN 1.5/30 (21) 65 NATURE-THROID ...... 73 NORPACE CR ...... 28 MICROGESTIN 1/20 (21) ... 65 NEBUPENT ...... 4 NORTREL 0.5/35 (28) ...... 65 midazolam ...... 41 nefazodone...... 48 NORTREL 7/7/7 (28) ...... 65 midodrine ...... 15 neomycin ...... 2 nortriptyline ...... 49 miglustat ...... 79 neomycin-bacitracin-poly-hc NORVIR ...... 7 minocycline ...... 10 ...... 55, 56 NOVOLIN N NPH U-100 minoxidil ...... 30 neomycin-polymyxin b- INSULIN ...... 69 MIRCERA ...... 19 dexameth ...... 55, 56 NOVOLIN R REGULAR U- mirtazapine ...... 37 neomycin-polymyxin- 100 INSULN ...... 69, 72 misoprostol ...... 60 gramicidin ...... 55 NOVOLOG MIX 70-30 U-100 modafinil ...... 49 neomycin-polymyxin-hc 55, 56 INSULN ...... 69, 72 mometasone ...... 87, 92 NEO-POLYCIN ...... 55

107 NOVOLOG MIX 70- ORENCIA CLICKJECT 76, 78 phenobarb-hyoscy-atropine- 30FLEXPEN U-100 .. 69, 70, ORENITRAM ...... 34, 84 scop ...... 15, 40, 41 72 ORFADIN ...... 80 phenobarbital ...... 40, 41 NOXAFIL ...... 4 ORILISSA ...... 64 PHENOHYTRO ...... 16, 40, 41 NP THYROID ...... 73 ORKAMBI ...... 81 phenoxybenzamine ...... 17, 31 NPLATE...... 20 ORTHO DIAPHRAGM ALL- phentermine ...... 34 NUBEQA ...... 13 FLEX 65 ...... 49 phenytoin ...... 28, 43 NUCYNTA ER ...... 44 ORTHO DIAPHRAGM ALL- phenytoin sodium extended . 28, NUEDEXTA ...... 42, 81 FLEX 70 ...... 49 43 NUTROPIN AQ NUSPIN ... 70 ORTHO DIAPHRAGM ALL- PHILITH ...... 66 NUVARING...... 65 FLEX 75 ...... 49 PHOSLYRA ...... 51 nystatin ...... 9, 94 ORTHO DIAPHRAGM ALL- PHRENILIN FORTE(WITH nystatin-triamcinolone ...... 94 FLEX 80 ...... 49 CAFFEINE) .... 36, 38, 41, 47 O oseltamivir ...... 8 phytonadione (vitamin k1) .. 74, OB COMPLETE PREMIER OTEZLA ...... 76, 78, 95 100 ...... 21, 52, 97, 99 OTEZLA STARTER 76, 78, 95 pilocarpine hcl ...... 17, 57 OBSTETRIX EC 21, 59, 97, 99 oxandrolone ...... 63 pimecrolimus ...... 79, 95 O-CAL FA...... 21, 52, 97, 99 oxaprozin ...... 45 pimozide ...... 39 OCALIVA ...... 60 oxcarbazepine ...... 37 pindolol ...... 16, 25, 26, 29, 31 octreotide acetate ...... 72, 79, 80 oxybutynin chloride ...... 96 pioglitazone ...... 73 ODACTRA...... 14 oxycodone ...... 44 PIQRAY ...... 13 ODEFSEY ...... 6, 7 oxycodone-acetaminophen .. 36, piroxicam ...... 46 ODOMZO ...... 13 44 PKU TRIO ...... 51 OFEV ...... 80 OXYCONTIN ...... 44 PLEGRIDY ...... 78 ofloxacin ...... 10, 55 oxymorphone ...... 44 podofilox ...... 95 OGESTREL (28) ...... 65 OXYTROL ...... 96 polyethylene glycol 3350 ..... 59 olanzapine...... 38, 40 OZEMPIC ...... 68 polymyxin b sulf-trimethoprim olmesartan ...... 23 P ...... 55 olmesartan-amlodipin- paliperidone ...... 40 POMALYST ...... 13, 78 hcthiazid .. 23, 27, 29, 30, 33, PANDEL ...... 88, 92 posaconazole ...... 5 34, 53 pantoprazole ...... 61 potassium chloride ...... 52 olmesartan- paromomycin ...... 2 potassium citrate ...... 51 hydrochlorothiazide ... 23, 33, paroxetine hcl ...... 48 POTIGA ...... 37 53 PASER...... 4 PRADAXA ...... 19 olopatadine ...... 54 PAZEO ...... 54 PRALUENT PEN ...... 32 OLUMIANT...... 76, 78 PCE ...... 5, 8 pramipexole ...... 43 omega-3 acid ethyl esters ..... 25 peg 3350-electrolytes ...... 59 prasugrel ...... 22 OMEPPI ...... 61 PEG-3350 WITH FLAVOR pravastatin ...... 30 omeprazole ...... 61 PACKS ...... 59 praziquantel ...... 3 omeprazole-sodium penicillin v potassium ...... 8 prazosin ...... 17, 22 bicarbonate ...... 61 PENNSAID ...... 46, 93, 95 PRED MILD ...... 56 OMNITROPE...... 71 pentoxifylline...... 20 prednicarbate ...... 88, 92 ondansetron ...... 58 PERFOROMIST ...... 18, 84 prednisolone ...... 62 ondansetron hcl ...... 58 perindopril erbumine ...... 24 prednisolone acetate ...... 56 ONEXTON...... 85, 93 permethrin ...... 94 prednisolone sodium phosphate ONGLYZA...... 66 perphenazine ...... 46 ...... 56, 62 ONMEL ...... 5 PHENADOZ ...... 1, 39 prednisone ...... 62 OPSUMIT ...... 34, 84 phenazopyridine ...... 88 PREDNISONE INTENSOL . 62 ORALAIR ...... 14, 80 phendimetrazine tartrate ...... 34 pregabalin ...... 36, 37, 43 ORENCIA ...... 76, 78 PREMARIN ...... 67

108 PREMPHASE ...... 67 PULMICORT FLEXHALER risedronate ...... 74 PREMPRO ...... 67 ...... 62, 82 risperidone ...... 38, 40 PRENATA ...... 21, 97, 99 PULMOZYME ...... 54, 81 RITALIN LA ...... 47 PRENATAL LOW IRON .... 97 PUREFE OB PLUS .. 21, 97, 99 ritonavir ...... 7 PRENATAL PLUS .. 21, 97, 99 PURIXAN ...... 13, 79 rivastigmine ...... 17 PRENATAL PLUS pyrazinamide ...... 4 rivastigmine tartrate ...... 17 (CALCIUM CARB) .. 21, 97, pyridostigmine bromide ...... 17 RIVELSA ...... 66 99 Q rizatriptan ...... 47 PRENATAL VITAMIN 21, 52, QSYMIA ...... 34, 37 ropinirole ...... 43 97, 99 quazepam ...... 41 rosuvastatin ...... 30 PRENATAL VITAMIN WITH quetiapine ...... 38, 40 ROZLYTREK ...... 13 MINERALS ...... 21, 97, 99 QUILLICHEW ER ...... 47 RUBRACA ...... 13 prenatal vits96-iron fum-folic QUILLIVANT XR ...... 47 RYDAPT ...... 13 ...... 21, 97, 99 quinapril...... 24 S PRENATAL-U ...... 97 quinidine gluconate ...... 3, 28 SAIZEN ...... 71 PRE-PEN ...... 50 quinidine sulfate ...... 3, 28 salsalate ...... 47 PREPOPIK ...... 59 QVAR REDIHALER ..... 62, 82 SAMSCA ...... 54 PRETAB...... 21, 52, 97, 99 R SANDIMMUNE ...... 76, 78, 79 PREVALITE ...... 26 rabeprazole ...... 61 SANTYL ...... 95 PREVIDENT ...... 75 RAGWITEK ...... 14, 80 SAPHRIS ...... 38, 40 PREVIDENT 5000 BOOSTER raloxifene ...... 66, 74 SAVAYSA ...... 19 PLUS ...... 75 ramelteon ...... 39 SAXENDA ...... 68 PREZISTA ...... 7 ramipril ...... 24 SCALACORT ...... 88, 92 PRIFTIN ...... 4, 10 ranitidine hcl ...... 60 SCALPICIN ANTI-ITCH ... 88, primaquine ...... 3 ranolazine ...... 27 92 primidone ...... 40 REBIF (WITH ALBUMIN) . 78 scopolamine base ...... 58 PRIMLEV ...... 36, 44 REBIF REBIDOSE ...... 78 SEGLUROMET ...... 64, 72 PROAIR RESPICLICK . 18, 84 REBIF TITRATION PACK . 78 SELECT-OB (FOLIC ACID) probenecid ...... 54, 74 RECLIPSEN (28) ...... 66 ...... 21, 97, 99 prochlorperazine ...... 46, 58 RECTIV...... 95 selegiline hcl ...... 43 prochlorperazine maleate 46, 58 RELENZA DISKHALER ...... 8 selenium sulfide ...... 93 PROCRIT ...... 20 RELISTOR ...... 60 SELZENTRY ...... 6 PROCTOFOAM HC 88, 89, 92 repaglinide ...... 70 SEREVENT DISKUS .... 18, 84 PROCTO-PAK ...... 88, 92 REPATHA PUSHTRONEX 32 SERNIVO ...... 88, 92 PROCTOZONE-HC...... 88, 92 REPATHA SURECLICK .... 32 SEROSTIM ...... 71 progesterone micronized ...... 71 REPATHA SYRINGE ...... 32 sertraline ...... 48 PROLENSA ...... 57 RESCRIPTOR ...... 6 sevelamer carbonate ...... 51, 74 PROMACTA ...... 20 RESTASIS...... 56 sevelamer hcl ...... 51, 74 promethazine ...... 1, 39, 81 RESTASIS MULTIDOSE ... 56 sildenafil (pulm.hypertension) PROMETHAZINE VC ... 1, 15, RETACRIT ...... 20 ...... 32, 84 81 RETIN-A MICRO PUMP .... 89 SILENOR ...... 49 promethazine-dm ...... 1, 81 REVLIMID ...... 13, 78 SILICONE MASK - INFANT propafenone ...... 28 REXULTI ...... 40 ...... 50 proparacaine ...... 57 ribavirin ...... 9 SILIQ ...... 96 propranolol .. 16, 25, 26, 29, 31, RIDAURA ...... 61, 76, 78 silver sulfadiazine ...... 93 39 rifabutin ...... 4, 10 SIMPONI ...... 60, 76, 78 propylthiouracil ...... 64 RIFAMATE...... 4, 10 simvastatin ...... 30 PROTONIX ...... 61 rifampin ...... 4, 10 sirolimus ...... 79 PSORCON ...... 88, 92 RIFATER ...... 10 SIRTURO ...... 4 PULMICORT ...... 62, 82 riluzole ...... 42 SKLICE ...... 94

109 SLYND...... 66, 71 SYEDA ...... 66 tetrabenazine ...... 42, 49 sodium chloride .. 50, 51, 52, 56 SYMBICORT ..... 18, 63, 82, 84 tetracycline ...... 10 SODIUM POLYSTYRENE SYMDEKO ...... 81 TEXACORT ...... 88, 92 (SORB FREE) ...... 52, 74 SYMPROIC...... 60 theophylline ...... 30, 51, 84, 96 sodium polystyrene sulfonate SYNALAR OINTMENT KIT THERANATAL COMPLETE ...... 52, 74 ...... 88, 92 ...... 21, 98, 99 sodium saccharin (bulk) ...... 53 SYNAREL...... 68 thioridazine ...... 46 sofosbuvir-velpatasvir ...... 5, 6 SYNJARDY ...... 64, 72 thiothixene ...... 49 SOFT TOUCH LANCETS .. 50 SYNJARDY XR...... 64, 72 thyroid (pork) ...... 73 solifenacin ...... 96 SYNRIBO ...... 13 tiagabine ...... 37 SOLTAMOX ...... 13, 66 T TIBSOVO ...... 14 SOMAVERT ...... 72 TABLOID ...... 13 timolol maleate ...... 55 sotalol ...... 16, 25, 26, 29, 31 tacrolimus ...... 79, 96 tinidazole ...... 4 SOVALDI ...... 5 tadalafil (pulm. hypertension) TIVICAY ...... 6 spinosad ...... 94 ...... 32, 84 tizanidine ...... 16 SPIRIVA RESPIMAT ... 16, 80 TAFINLAR ...... 13 TOBI PODHALER ...... 2 spironolactone ...... 31, 32, 52 TAGRISSO ...... 13 TOBRADEX ...... 55, 56 spironolacton-hydrochlorothiaz TAKHZYRO ...... 75 tobramycin ...... 55 ...... 31, 32, 33, 52, 53 TALTZ AUTOINJECTOR .. 96 tobramycin in 0.225 % nacl .... 2 SPRYCEL ...... 13 TALTZ AUTOINJECTOR (2 tobramycin with nebulizer ...... 2 SPS (WITH SORBITOL).... 52, PACK) ...... 96 tobramycin-dexamethasone . 55, 74 TALTZ AUTOINJECTOR (3 56 stavudine...... 7 PACK) ...... 96 tolcapone ...... 42 STEGLATRO...... 72 TALTZ SYRINGE ...... 96 tolterodine ...... 96 STEGLUJAN ...... 66, 72 TALZENNA ...... 14 TOPICORT ...... 88, 92 STELARA ...... 76, 78, 96 tamoxifen ...... 14, 66 topiramate ...... 37 STIMATE...... 20, 71 tamsulosin ...... 17 torsemide ...... 31, 51 STIOLTO RESPIMAT .. 16, 18 TASIGNA ...... 14 TOUJEO MAX U-300 STIVARGA ...... 13 TAVALISSE ...... 19 SOLOSTAR ...... 69, 70 STRIBILD ...... 6, 7 TAYTULLA ...... 66 TOUJEO SOLOSTAR U-300 STRIVERDI RESPIMAT ... 18, tazarotene...... 96 INSULIN ...... 69, 70 84 TAZORAC ...... 96 TOVIAZ ...... 96 STROVITE FORTE . 21, 98, 99 TECFIDERA ...... 78 TRADJENTA ...... 66 SUBOXONE ...... 45 TECHNIVIE ...... 5, 6, 8 tramadol ...... 44 sucralfate ...... 61 TEKTURNA HCT ... 32, 33, 53 tramadol-acetaminophen36, 39, sulfacetamide sodium ..... 55, 93 telmisartan ...... 23, 24 44 sulfacetamide sodium-sulfur 93 telmisartan-amlodipine .. 23, 24, trandolapril ...... 24 sulfacetamide-prednisolone .. 55 27, 30, 34 tranexamic acid ...... 20 sulfadiazine...... 10 telmisartan-hydrochlorothiazid TRAVATAN Z ...... 57 sulfamethoxazole-trimethoprim ...... 23, 24, 33, 53 trazodone ...... 48 ...... 10 temazepam ...... 42 TRECATOR ...... 4 sulfasalazine ...... 10, 58, 76, 78 temozolomide ...... 14 TREMFYA ...... 96 sulindac...... 46 tenofovir disoproxil fumarate . 7 treprostinil sodium ...... 34, 84 sumatriptan ...... 47 terazosin...... 17, 22, 31 TRESIBA FLEXTOUCH U- sumatriptan succinate ...... 48 terbinafine hcl ...... 2 100 ...... 69, 70 sumatriptan-naproxen ..... 46, 48 terbutaline ...... 18, 84 TRESIBA FLEXTOUCH U- SUPRAX ...... 2 terconazole...... 89 200 ...... 69, 70 SUPREP BOWEL PREP KIT testosterone ...... 63 TRESIBA U-100 INSULIN 69, ...... 59 testosterone cypionate ...... 63 70 SUTENT...... 13 testosterone enanthate...... 63 tretinoin ...... 89

110 tretinoin (chemotherapy) ...... 14 valganciclovir ...... 9 VIRT-SELECT .. 21, 53, 59, 98, tretinoin microspheres ...... 89 valproic acid ...... 37, 38, 39 100 TREXALL ...... 14, 76, 78, 79 valproic acid (as sodium salt) VITAFOL GUMMIES .. 21, 53, TRIADVANCE .. 21, 52, 98, 99 ...... 37, 38, 39 98, 100 triamcinolone acetonide . 88, 92 valsartan...... 23, 24 VITAMED MD ONE RX ... 21, triamterene-hydrochlorothiazid valsartan-hydrochlorothiazide 98, 100 ...... 32, 33, 52, 53 ...... 23, 24, 33, 53 VITAMED MD PLUS RX .. 21, TRIANEX ...... 88, 92 vancomycin ...... 5 98, 100 triazolam ...... 42 vancomycin in dextrose 5 % .. 5 VITAMIN D2 ...... 100 trifluoperazine ...... 46 VARIZIG...... 15 VITRAKVI ...... 14 trifluridine...... 55 VASCEPA ...... 25 VIVOTIF BERNA VACCINE trihexyphenidyl...... 16, 36 VELIVET TRIPHASIC ...... 15 TRI-LEGEST FE...... 66 REGIMEN (28) ...... 66 VIZIMPRO ...... 14 trimethoprim ...... 10 VELPHORO ...... 51 VOL-NATE ...... 21, 98, 100 TRINATAL GT...... 21, 98, 99 VELTASSA...... 52 voriconazole ...... 5 TRINTELLIX...... 48 VEMAVITE-PRX-2 21, 52, 59, VOSEVI ...... 5, 6 TRI-SPRINTEC (28)...... 66 98, 99 VOTRIENT ...... 14 TRIUMEQ ...... 6, 7 VEMLIDY...... 9 VP-CH PLUS ... 22, 59, 98, 100 TRIVEEN-ONE . 21, 52, 98, 99 VENCLEXTA ...... 14 VP-HEME ONE ..... 22, 98, 100 TRIVEEN-PRX RNF .... 21, 52, VENCLEXTA STARTING VRAYLAR ...... 40 59, 98, 99 PACK ...... 14 VYVANSE ...... 35 TRI-VITAMIN WITH venlafaxine ...... 47 VYZULTA ...... 57 FLUORIDE ...... 75, 98, 100 VENTAVIS ...... 34, 84 W tropicamide ...... 57 verapamil ...... 26, 27, 29, 34 warfarin ...... 19 trospium ...... 96 VERDESO...... 88, 93 water for injection, sterile ..... 80 TRULICITY ...... 68 VERSACLOZ ...... 40 WELCHOL ...... 63 TRUVADA ...... 7 VERZENIO ...... 14 WIDE-SEAL DIAPHRAGM TRUZONE PEAK FLOW VIC-FORTE ...... 98, 100 60 ...... 49 METER ...... 50 VICODIN ES ...... 36, 44 WIXELA INHUB .... 18, 63, 82, TUDORZA PRESSAIR . 16, 80 VICODIN HP ...... 36, 44 84 TURALIO ...... 14 VICTOZA 2-PAK ...... 68 X TYKERB ...... 14 VICTOZA 3-PAK ...... 68 XALKORI ...... 14 TYMLOS ...... 70, 74 VIDEX 2 GRAM PEDIATRIC XARELTO ...... 19 TYVASO ...... 34, 84 ...... 7 XELJANZ ...... 76, 78 TYVASO INSTITUTIONAL VIDEX 4 GRAM PEDIATRIC XELJANZ XR ...... 77, 78 START KIT...... 34, 84 ...... 7 XELPROS ...... 57 TYVASO REFILL KIT . 34, 84 VIEKIRA PAK...... 5, 6, 8 XENICAL ...... 60 TYVASO STARTER KIT .. 34, VIIBRYD ...... 48 XIFAXAN ...... 10 84 VIMPAT ...... 37 XIGDUO XR ...... 64, 72 U VINATE II ...... 98 XIIDRA ...... 56 ULESFIA ...... 93, 94 VINATE M...... 21, 98, 100 XOSPATA ...... 14 ULTIMATECARE ONE NF VINATE ONE .. 21, 52, 98, 100 XPOVIO ...... 14 ...... 21, 52, 98, 99 VINATE PN CARE ...... 98 XTAMPZA ER ...... 44 ULTRAVATE ...... 88, 92 VINATE ULTRA .... 21, 53, 59, XTANDI ...... 14 ULTRAVATE X ...... 88, 92 98, 100 XULANE ...... 66 UPTRAVI...... 34, 84 VIORELE (28) ...... 66 XYLIMELTS ...... 96 urea ...... 93 VIRACEPT ...... 8 XYREM ...... 42 ursodiol ...... 59 VIRAMUNE ...... 6 Y V VIREAD ...... 7 YONSA ...... 14 valacyclovir ...... 9 YUVAFEM ...... 67

111 Z zinc sulfate ...... 53 zonisamide ...... 37 zaleplon ...... 39 ZINGIBER ...... 53, 98, 100 ZORBTIVE ...... 71 ZARXIO ...... 20 ZIOPTAN (PF) ...... 57 ZORTRESS ...... 79 ZATEAN-CH .... 22, 53, 59, 98, ziprasidone hcl ...... 38, 40 ZOVIA 1/50E (28) ...... 66 100 ZIRGAN ...... 55 ZOVIRAX ...... 89 ZEJULA ...... 14 ZOLINZA ...... 14 ZUBSOLV ...... 45 ZELBORAF ...... 14 zolmitriptan ...... 48 ZYDELIG ...... 14 ZENPEP ...... 59 zolpidem ...... 39 ZYKADIA ...... 14 ZENZEDI ...... 35 ZOLPIMIST ...... 39 ZYTIGA ...... 14 ZEPATIER ...... 5, 6 ZOMACTON ...... 71 zidovudine ...... 7 ZOMIG ...... 48

112