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Your 2021 Premium Value Formulary Effective July 1, 2021

Understanding your formulary

What is a formulary? What are tiers? A formulary is a list of prescribed medications or other Tiers are the different cost levels you pay for a pharmacy care products, services or supplies chosen medication. Each tier is assigned a cost, set by your for their safety, cost, and effectiveness. Medications employer or plan sponsor. are listed by categories or classes and are placed into The formulary gives you choices so you and your cost levels known as tiers. It includes both brand and doctor can decide your best course of treatment. In generic prescription medications. this formulary, brand-name medications are shown in UPPERCASE (for example, BRAND DRUG). Generic medications are shown in lowercase (for example, ).

Reading your formulary

About this formulary This formulary may not be a complete list of When differences between this formulary and your medications that are covered by your plan. Please benefit plan exist, the benefit plan documents rule. review your benefit plan for full details.

Tier information

Drug Tier Includes Helpful Tips Tier 1 $ Lower-cost medications Brand name and generic medications can be Tier 2 $$ Low-cost medications found in any of the 4 tiers. The lower the tier, $$$ Tier 3 Mid-range cost medications the less your medications will cost. Tier 4 $$$$ Higher-cost medications

Drug list information

Prior Authorization – Your doctor is required to give OptumRx more information to PA determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity.

SP Specialty Medication – Medication is designated as specialty.

Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can ST be covered. Table of Contents - Drugs for ...... 4 Analgesics - Drugs for Pain and ...... 4 Anesthetics...... 6 Anti-Addiction / Substance Abuse Treatment Agents...... 7 Antibacterials...... 7 Anticoagulants...... 10 - Drugs for Seizures...... 10 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia...... 11 ...... 11 Antiemetics - Drugs for and ...... 12 ...... 13 Antigout Agents...... 13 Anti-inflammatory Agents...... 13 Antimigraine Agents...... 13 Antimyasthenic Agents...... 14 Antimycobacterials...... 14 Antineoplastics - Drugs for Cancer...... 14 Antiparasitics...... 18 Antiparkinson Agents...... 18 Antiplatelets...... 18 Antipsychotics - Drugs for Mood Disorders...... 19 Antivirals...... 19 Anxiolytics - Drugs for ...... 21 Bipolar Agents - Drugs for Mood Disorders...... 21 Products and Modifiers - Drugs for Blood Disorders...... 21 Cardiovascular Agents - Drugs for Heart and Circulation Conditions...... 22 Central Nervous System Agents - Drugs for Attention Deficit Disorder...... 26 Central Nervous System Agents - Drugs for Multiple Sclerosis...... 26 Central Nervous System Agents - Miscellaneous...... 27 Dental and Oral Agents - Drugs for Mouth and Throat Conditions...... 27 Dermatological Agents - Drugs for Conditions...... 27 Diabetes - Antidiabetic Agents...... 30 Diabetes - Glucose Monitoring...... 31 Diabetes - Glycemic Agents...... 31 Diabetes - ...... 31 Electrolytes / Minerals / Metals / Vitamins...... 33 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...... 35 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...... 36 Genetic or Disorder - Drugs for Replacement, Modification, Treatment...... 36 Genitourinary Agents - Drugs for Bladder, Genital and Conditions...... 37 Genitourinary Agents - Drugs for Conditions...... 38 Hormonal Agents - Adrenal...... 38 Hormonal Agents - Men's Health...... 39 Hormonal Agents - Osteoporosis...... 39 Hormonal Agents - Pituitary...... 39 Hormonal Agents - ...... 40 Hormonal Agents - Sex and ...... 40 Hormonal Agents - Thyroid...... 43 Immunological Agents - Drugs for Immune System Stimulation or Suppression...... 43 Immunological Agents - Drugs for Vaccination...... 45 Inflammatory Bowel Disease Agents...... 46

2 Metabolic Bone Disease Agents - Drugs for Osteoporosis...... 46 Metabolic Bone Disease Agents - Other...... 47 Miscellaneous Therapeutic Agents...... 47 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...... 48 Ophthalmic Agents - Drugs for Glaucoma...... 48 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions...... 49 Otic Agents - Drugs for Ear Conditions...... 49 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, , Cold...... 50 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...... 51 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis...... 52 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary ...... 52 Relaxants - Drugs for Muscle Pain and Spasm...... 52 Agents...... 53

3 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Analgesics - Drugs tromethamine 1 for Pain and intramuscular Inflammation ketorolac tromethamine 1 QL adult regimen 1 oral aspirin adult low meloxicam oral 1 strength oral tablet 1 nabumetone oral 1 delayed release oral tablet 1 aspirin childrens 1 naproxen oral tablet 1 aspirin ec low dose 1 delayed release aspirin ec low strength 1 naproxen sodium oral 1 aspirin ec oral tablet tablet 275 mg, 550 mg delayed release 325 1 oxaprozin 1 mg piroxicam oral 1 aspirin low dose 1 sulindac oral 1 aspirin oral tablet 1 tolmetin sodium 2 aspirin oral tablet 1 delayed release tri-buffered aspirin 1 oral 1 QL Analgesics - Drugs for Pain 1 acetaminophen- 1 QL diclofenac sodium er 1 diclofenac sodium acetaminophen- 1 QL 1 QL external gel 1 % codeine #2 diclofenac sodium oral 1 acetaminophen- 1 QL diclofenac-misoprostol 2 codeine #3 oral 1 acetaminophen- 1 QL 1 codeine #4 etodolac er 1 ascomp-codeine 2 hcl oral 1 4 1 buprenorphine ibuprofen 1 patch ibuprofen oral weekly 10 mcg/hr, 15 2 PA; QL 1 mcg/hr, 20 mcg/hr, 5 indomethacin er 1 mcg/hr indomethacin oral buprenorphine 1 25 mg, 50 mg 3 PA; QL weekly 7.5 mcg/hr indomethacin sodium 1 - oral capsule 3 acetaminophen oral 2 50 mg, 75 mg tablet 50-325 mg ketorolac tromethamine 1 butalbital-apap-caff-cod 1 injection For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

4 Drug Name Drug Tier Notes Drug Name Drug Tier Notes butalbital-apap- 1 hcl intensol 1 butalbital-asa-caff- methadone hcl oral 2 1 codeine concentrate butalbital-aspirin- methadone hcl oral 1 1 caffeine solution tartrate methadone hcl oral 1 1 PA injection tablet butorphanol tartrate methadone hcl oral 1 QL 2 nasal tablet soluble -aspirin- methadose oral tablet 1 2 codeine soluble codeine 1 QL methadose sugar-free 1 endocet 1 QL sulfate (concentrate) oral 2 PA; QL 1 QL solution 100 mg/5ml, fentanyl citrate buccal 3 PA; QL 20 mg/ml lozenge on a handle morphine sulfate er 3 PA; QL bitartrate beads er oral capsule 3 PA; QL extended release 12 morphine sulfate er oral hour capsule extended 2 PA; QL release 24 hour hydrocodone- 1 QL morphine sulfate er oral acetaminophen 1 PA; QL tablet extended release hydrocodone-ibuprofen 1 QL morphine sulfate oral 1 QL hcl er 3 PA; QL hcl injection 1 hydromorphone hcl injection solution 2 2 HCL ER 3 PA; QL mg/ml, 4 mg/ml oxycodone hcl oral 1 QL HYDROMORPHONE capsule 2 HCL INTRAVENOUS oxycodone hcl oral hydromorphone hcl oral 1 QL concentrate 100 2 QL mg/5ml hydromorphone hcl pf 2 oxycodone hcl oral 1 QL HYDROMORPHONE solution HCL SOLUTION 1 2 oxycodone hcl oral MG/ML INJECTION 1 QL tablet hydromorphone hcl solution 1 mg/ml 2 oxycodone- injection acetaminophen oral tablet 10-325 mg, 2.5- 1 QL meperidine hcl injection 1 325 mg, 5-325 mg, 7.5- meperidine hcl oral 325 mg 1 QL solution oxycodone-aspirin 1 QL methadone hcl injection 1 hcl 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

5 Drug Name Drug Tier Notes Drug Name Drug Tier Notes oxymorphone hcl er 3 PA; QL HCL -naloxone SOLUTION 1 % 1 2 QL hcl INJECTION lidocaine hcl solution 1 hcl er 1 QL 1 % injection tramadol hcl er 1 QL (biphasic) LIDOCAINE HCL SOLUTION 2 % 1 tramadol hcl oral tablet 1 INJECTION 100 mg lidocaine hcl solution 2 tramadol hcl oral tablet 1 1 QL % injection 50 mg lidocaine hcl tramadol- 1 1 QL urethral/mucosal acetaminophen lidocaine-epinephrine Anesthetics injection solution 0.5 %- 1:200000, 1 %- 1 1 fisiopharma 1:100000, 1.5 %- bupivacaine hcl (pf) 1 1:200000, 2 %- 1:200000 bupivacaine hcl lidocaine- injection solution 0.25 1 1 %, 0.5 % external cream bupivacaine- polocaine-mpf injection 1 1 epinephrine solution 2 % bupivacaine- hcl 1 1 epinephrine (pf) injection solution glydo 1 SENSORCAINE 1 lidocaine external patch sensorcaine-mpf 2 5 % solution 0.25 % 1 injection lidocaine hcl (cardiac) intravenous solution SENSORCAINE-MPF 1 prefilled syringe 100 SOLUTION 0.25 % 1 mg/5ml, 50 mg/5ml INJECTION lidocaine hcl (cardiac) sensorcaine-mpf 1 1 pf solution 0.5 % injection lidocaine hcl (pf) 1 SENSORCAINE-MPF SOLUTION 0.5 % 1 lidocaine hcl external 1 INJECTION solution SENSORCAINE- lidocaine hcl injection 1 MPF/EPINEPHRINE solution 0.5 % INJECTION 1 LIDOCAINE HCL SOLUTION 0.5% - INJECTION 1:200000 SOLUTION 1 XYLOCAINE PREFILLED SYRINGE INJECTION 1 10 MG/ML, 60 MG/3ML SOLUTION 1 % For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

6 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Anti-Addiction / azithromycin 1 Substance Abuse intravenous Treatment Agents azithromycin oral 1 acamprosate 2 aztreonam 2 buprenorphine hcl 1 QL BICILLIN L-A 3 sublingual cefaclor er 2 buprenorphine hcl- 2 QL naloxone hcl cefaclor oral capsule 1 hcl er cefaclor oral 1 QL (smoking det) suspension 3 reconstituted CHANTIX 3 QL cefadroxil 1 CHANTIX cefazolin sodium CONTINUING MONTH 3 QL 1 PAK injection CHANTIX STARTING CEFAZOLIN SODIUM 3 QL INTRAVENOUS MONTH PAK 2 SOLUTION disulfiram oral 1 PREFILLED SYRINGE naloxone hcl injection 1 cefazolin sodium naltrexone hcl oral 1 intravenous solution 1 NARCAN 2 reconstituted SUBLOCADE 3 SP cefazolin sodium- dextrose intravenous 1 VIVITROL 3 SP solution 1-4 gm/50ml- Antibacterials %, 2-4 gm/100ml-% amikacin sulfate cefdinir 1 2 injection cefepime hcl injection 1 amoxicillin 1 cefepime hcl 2 amoxicillin-potassium intravenous solution 2 clavulanate er cefepime-dextrose 2 amoxicillin-potassium 1 cefixime oral capsule 1 clavulanate oral cefixime oral ampicillin 1 suspension 2 ampicillin sodium 1 reconstituted ampicillin-sulbactam cefotaxime sodium 1 1 sodium cefoxitin sodium 1 ARIKAYCE 4 SP cefpodoxime proxetil AUGMENTIN ORAL oral suspension 2 SUSPENSION reconstituted 3 RECONSTITUTED cefpodoxime proxetil 1 125-31.25 MG/5ML oral tablet avidoxy 1 cefprozil 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

7 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ceftazidime and DIFICID ORAL 2 4 dextrose TABLET ceftazidime injection 1 doxy 100 2 ceftriaxone sodium in doxycycline hyclate 1 2 dextrose intravenous ceftriaxone sodium doxycycline hyclate oral 1 1 injection capsule ceftriaxone sodium doxycycline hyclate oral 1 1 intravenous tablet 100 mg, 20 mg ceftriaxone sodium- doxycycline 1 dextrose monohydrate oral 1 cefuroxime axetil 1 capsule 100 mg, 50 mg cefuroxime sodium 1 doxycycline monohydrate oral 1 cephalexin 1 suspension CIPRO ORAL reconstituted SUSPENSION 2 doxycycline 1 RECONSTITUTED monohydrate oral tablet ciprofloxacin hcl oral 1 ertapenem sodium 3 ciprofloxacin in d5w 1 base oral er 2 capsule delayed 2 clarithromycin oral release particles suspension 2 erythromycin base oral 3 reconstituted tablet clarithromycin oral erythromycin base oral 1 2 tablet tablet delayed release clindamycin hcl oral 1 erythromycin 3 clindamycin palmitate ethylsuccinate oral 2 hcl erythromycin oral 2 clindamycin phosphate FORTAZ INJECTION 1 in d5w SOLUTION 4 CLINDAMYCIN RECONSTITUTED 500 2 PHOSPHATE IN NACL MG clindamycin phosphate FORTAZ 1 4 injection INTRAVENOUS clindamycin phosphate gentamicin in saline 1 1 vaginal gentamicin sulfate 1 colistimethate sodium external 3 (cba) gentamicin sulfate 1 daptomycin 3 injection hcl 2 imipenem-cilastatin 3 dicloxacillin sodium 1 levofloxacin in d5w 1 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

8 Drug Name Drug Tier Notes Drug Name Drug Tier Notes levofloxacin mupirocin external 1 2 intravenous nafcillin sodium 3 levofloxacin oral NAFCILLIN SODIUM 2 3 solution IN DEXTROSE levofloxacin oral tablet 1 sulfate oral 1 lincomycin hcl injection 2 neomycin-polymyxin b 1 linezolid in sodium gu 4 chloride nitrofurantoin 1 linezolid intravenous 3 macrocrystal linezolid oral nitrofurantoin suspension 3 QL monohydrate 1 reconstituted macrocrystals linezolid oral tablet 2 QL ofloxacin oral 2 mafenide oxacillin sodium 3 3 external paromomycin sulfate 2 meropenem 2 oral MEROPENEM- penicillin g potassium 1 2 SODIUM CHLORIDE penicillin v potassium 1 methenamine hippurate 1 piperacillin sod- 1 metronidazole in nacl tazobactam so intravenous solution 5- silver sulfadiazine 1 1 0.79 mg/ml-%, 500- external 0.79 mg/100ml-% streptomycin sulfate metronidazole oral 4 2 intramuscular capsule sulfadiazine oral 3 metronidazole oral 1 tablet sulfamethoxazole- trimethoprim 2 metronidazole vaginal 1 intravenous MINOCIN sulfamethoxazole- 3 1 INTRAVENOUS trimethoprim oral hcl oral 1 sulfatrim pediatric 1 capsule tazicef injection 1 minocycline hcl oral 2 tablet TAZICEF INTRAVENOUS 2 mondoxyne nl oral 1 SOLUTION capsule 100 mg tazicef intravenous 1 morgidox oral 1 solution reconstituted moxifloxacin hcl in nacl 2 tetracycline hcl oral 2 MOXIFLOXACIN HCL 2 tinidazole oral 1 INTRAVENOUS tobramycin sulfate 1 moxifloxacin hcl oral 1 injection solution For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

9 Drug Name Drug Tier Notes Drug Name Drug Tier Notes tobramycin sulfate heparin sodium injection solution 3 (porcine) injection 1 reconstituted solution trimethoprim oral 1 heparin sodium 1 vancomycin hcl in (porcine) pf dextrose intravenous jantoven 1 solution 1-5 gm/200ml- 1 PRADAXA 2 QL %, 500-5 mg/100ml-%, 750-5 mg/150ml-% THROMBATE III 3 SP vancomycin hcl in nacl warfarin sodium oral 1 intravenous solution 1- XARELTO 2 QL 0.9 gm/200ml-%, 500- 1 XARELTO STARTER 2 QL 0.9 mg/100ml-%, 750- PACK 0.9 mg/150ml-% Anticonvulsants - vancomycin hcl Drugs for Seizures intravenous solution 1 BANZEL ORAL reconstituted 3 PA TABLET vancomycin hcl oral 2 capsule BRIVIACT 3 ST vancomycin hcl oral er 2 1 solution reconstituted carbamazepine oral 1 vandazole 1 CELONTIN 3 XEPI 2 clobazam oral 2 PA ZITHROMAX ORAL suspension 1 PACKET clobazam oral tablet 1 PA ZOSYN 1 DIACOMIT 3 PA; SP ZYVOX diazepam rectal 3 QL INTRAVENOUS 4 divalproex sodium er 1 SOLUTION 200 MG/100ML divalproex sodium oral 1 Anticoagulants EPIDIOLEX 3 PA; SP ELIQUIS 2 QL epitol 1 ELIQUIS DVT/PE oral 2 2 QL STARTER PACK 3 enoxaparin sodium 2 SP; QL sodium 1 fondaparinux sodium 3 SP; QL FYCOMPA 3 ST FRAGMIN 3 SP; QL oral 1 HEPARIN (PORCINE) er 2 IN NACL lamotrigine oral kit 3 INTRAVENOUS 2 SOLUTION 5000-0.9 lamotrigine oral tablet 1 UT/500ML-% lamotrigine oral tablet 1 chewable For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

10 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lamotrigine oral tablet vigabatrin 4 PA; SP 3 ST dispersible vigadrone 4 PA; SP lamotrigine starter kit- 3 VIMPAT 3 ST blue oral 1 lamotrigine starter kit- 3 green Antidementia Agents - Drugs for lamotrigine starter kit- 3 Alzheimer's Disease orange and Dementia er 1 donepezil hcl 1 levetiracetam galantamine 1 1 intravenous hydrobromide er levetiracetam oral 1 galantamine oral hydrobromide oral 2 2 suspension solution oxcarbazepine oral galantamine 1 tablet hydrobromide oral 1 oral 1 tablet infatabs 1 hcl er 2 QL memantine hcl oral phenytoin oral 1 3 ST solution phenytoin sodium 1 memantine hcl oral extended 1 tablet phenytoin sodium 1 injection rivastigmine 2 oral 1 rivastigmine tartrate 1 roweepra 1 Antidepressants 3 PA hcl oral 1 subvenite 1 1 subvenite starter kit- bupropion hcl er (sr) 1 QL 3 blue bupropion hcl er (xl) subvenite starter kit- oral tablet extended 3 1 QL green release 24 hour 150 mg, 300 mg subvenite starter kit- 3 orange bupropion hcl oral 1 chlordiazepoxide- SYMPAZAN 3 PA 1 amitriptyline tiagabine hcl 3 citalopram 1 er 3 ST hydrobromide topiramate oral 1 hcl oral 2 sodium 1 hcl oral 1 intravenous desvenlafaxine 1 QL valproic acid oral 1 succinate er For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

11 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hcl oral venlafaxine hcl 1 1 capsule venlafaxine hcl er oral doxepin hcl oral capsule extended 1 1 concentrate release 24 hour duloxetine hcl oral 1 QL venlafaxine hcl er oral escitalopram oxalate tablet extended release 2 2 oral solution 24 hour 225 mg escitalopram oxalate Antiemetics - Drugs 1 oral tablet for Nausea and Vomiting hcl (pmdd) 2 aprepitant oral 3 QL fluoxetine hcl oral 1 aprepitant oral capsule capsule 2 QL 125 mg, 40 mg, 80 mg fluoxetine hcl oral aprepitant oral capsule capsule delayed 2 QL 3 QL release 80 & 125 mg fluoxetine hcl oral CINVANTI 3 1 solution compro 2 fluoxetine hcl oral tablet dronabinol 2 PA; QL 1 10 mg, 60 mg hcl 1 fluvoxamine maleate 1 intravenous fluvoxamine maleate er 2 QL granisetron hcl oral 2 QL hcl oral 1 hcl oral tablet 1 imipramine pamoate 2 hcl 1 hcl 2 injection metoclopramide hcl oral 1 1 oral solution hcl 1 metoclopramide hcl 1 hcl oral 1 oral tablet -fluoxetine metoclopramide hcl 2 QL 2 ST hcl oral tablet dispersible hcl 1 hcl 1 paroxetine hcl er 1 injection paroxetine mesylate 2 QL ondansetron hcl oral 1 QL phenelzine sulfate oral 1 solution ondansetron hcl oral hcl 2 1 QL tablet 24 mg sertraline hcl oral 1 ondansetron hcl oral 1 tranylcypromine sulfate 2 tablet 4 mg, 8 mg hcl oral 1 ondansetron odt 1 maleate hcl 2 1 oral intravenous solution

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

12 Drug Name Drug Tier Notes Drug Name Drug Tier Notes palonosetron hcl oral 2 PA intravenous solution 3 capsule prefilled syringe itraconazole oral 3 PA oral 1 solution 2 external 1 prochlorperazine cream 1 edisylate injection ketoconazole external 1 prochlorperazine shampoo 1 maleate oral ketoconazole oral 1 1 3 1 hcl naftifine hcl external 1 2 oral cream Antifungals nyamyc 1 ABELCET 3 nystatin external 1 AMBISOME 3 nystatin mouth/throat 1 BIO-STATIN ORAL nystatin oral 1 1 CAPSULE nystatin- 1 caspofungin acetate 3 nystop 1 ciclodan 1 terbinafine hcl oral 1 QL external 1 terconazole 1 ciclopirox olamine 1 4 external intravenous 3 1 voriconazole oral clotrimazole external 1 suspension 4 clotrimazole reconstituted 1 mouth/throat voriconazole oral tablet 3 clotrimazole- Antigout Agents 1 oral 1 CRESEMBA 4 allopurinol sodium 1 econazole nitrate 1 colchicine oral tablet 2 external colchicine-probenecid 1 fluconazole in sodium 1 chloride probenecid 1 fluconazole oral 1 Anti-inflammatory Agents flucytosine oral 4 EMFLAZA 4 PA; SP griseofulvin microsize 2 oral Antimigraine Agents griseofulvin malate 2 QL 2 ultramicrosize 3 PA; QL mesylate injection

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

13 Drug Name Drug Tier Notes Drug Name Drug Tier Notes dihydroergotamine pyrazinamide oral 2 3 PA; QL mesylate nasal rifabutin 3 hydrobromide 1 QL rifampin intravenous 2 EMGALITY 3 PA; QL rifampin oral 1 EMGALITY (300 MG 3 PA; QL SIRTURO 4 DOSE) TRECATOR 2 -caffeine 3 Antineoplastics - hcl 1 QL Drugs for Cancer benzoate 1 QL 3 PA; SP nasal 3 ST; QL ABRAXANE 4 SP sumatriptan succinate 1 QL ADCETRIS 4 PA; SP oral adriamycin intravenous sumatriptan succinate 1 SP 3 ST; QL solution refill adriamycin intravenous sumatriptan succinate 3 SP 1 ST; QL solution reconstituted subcutaneous solution AFINITOR DISPERZ 4 PA; SP sumatriptan succinate AFINITOR ORAL subcutaneous solution 3 ST; QL 4 PA; SP; QL auto-injector TABLET 10 MG sumatriptan succinate ALECENSA 4 PA; SP subcutaneous solution 2 ST; QL ALIMTA 4 SP prefilled syringe ALIQOPA 4 PA; SP oral 1 QL ALUNBRIG 4 PA; SP; QL Antimyasthenic oral 1 Agents ARRANON 3 SP pyridostigmine bromide 3 arsenic trioxide er 4 SP intravenous pyridostigmine bromide 3 oral solution ARZERRA 4 PA; SP pyridostigmine bromide AVASTIN 3 PA; SP 1 oral tablet azacitidine 4 SP Antimycobacterials BALVERSA 4 PA; SP CAPASTAT SULFATE 4 BELEODAQ 4 PA; SP dapsone oral 1 BELRAPZO 4 PA; SP ethambutol hcl oral 1 BENDEKA 4 PA; SP isoniazid injection 1 bexarotene 4 PA; SP isoniazid oral syrup 3 1 isoniazid oral tablet 1 bleomycin sulfate 1 SP PASER 1 BLINCYTO 4 PA; SP PRIFTIN 2 BORTEZOMIB 4 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

14 Drug Name Drug Tier Notes Drug Name Drug Tier Notes BOSULIF 4 PA; SP doxorubicin hcl 1 SP BRAFTOVI 4 PA; SP doxorubicin hcl 3 SP busulfan 4 SP liposomal CABOMETYX 4 PA; SP DROXIA 1 CALQUENCE 4 PA; SP ELITEK 4 SP CAMPATH 4 SP EMPLICITI 4 PA; SP capecitabine 3 PA; SP ENHERTU 4 PA; SP CAPRELSA ORAL epirubicin hcl 2 SP 4 PA; SP; QL TABLET 100 MG ERBITUX 4 PA; SP CAPRELSA ORAL ERIVEDGE 4 PA; SP 4 PA; SP TABLET 300 MG ERLEADA 4 PA; SP carboplatin 1 SP erlotinib hcl oral tablet 3 PA; SP carmustine 4 SP 100 mg, 150 mg cisplatin intravenous erlotinib hcl oral tablet 1 SP 3 PA; SP; QL solution 25 mg 3 SP ETHYOL 3 clofarabine 4 SP ETOPOPHOS 2 SP COMETRIQ 4 PA; SP etoposide intravenous 1 SP COPIKTRA 4 PA; SP etoposide oral 3 SP COTELLIC 4 PA; SP oral tablet 4 SP cyclophosphamide 2.5 mg, 5 mg, 7.5 mg 3 SP injection 2 cyclophosphamide oral FARYDAK 4 PA; SP 3 capsule floxuridine injection 4 SP CYRAMZA 4 PA; SP fludarabine phosphate 3 SP cytarabine 1 SP fluorouracil intravenous 1 SP cytarabine (pf) 1 SP 1 dacarbazine 2 SP FOLOTYN 4 PA; SP dactinomycin 4 SP 3 SP DARZALEX 4 PA; SP GAVRETO 4 PA; SP daunorubicin hcl 2 SP GAZYVA 4 PA; SP DAURISMO 4 PA; SP gemcitabine hcl 2 SP decitabine 4 PA; SP GILOTRIF 4 PA; SP; QL dexrazoxane hcl 3 SP GLEOSTINE 3 SP intravenous 2 SP GLIADEL WAFER 4 concentrate HALAVEN 4 PA; SP docetaxel intravenous 3 SP solution HERCEPTIN 4 PA; SP HYCAMTIN ORAL 4 SP For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

15 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hydroxyurea oral 1 oral 1 IBRANCE 4 PA; SP leucovorin calcium 2 ICLUSIG ORAL injection solution TABLET 10 MG, 15 4 PA; SP; QL leucovorin calcium MG injection solution 1 ICLUSIG ORAL reconstituted TABLET 30 MG, 45 4 PA; SP leucovorin calcium oral 2 MG LEUKERAN 3 idarubicin hcl 4 SP LONSURF 4 PA; SP IDHIFA 4 PA; SP; QL LORBRENA 4 PA; SP ifosfamide 3 SP LYNPARZA 4 PA; SP imatinib mesylate 3 PA; SP LYSODREN 3 IMBRUVICA 4 PA; SP MARQIBO 4 SP IMFINZI 4 PA; SP MATULANE 3 SP INLYTA 4 PA; SP MEKINIST 4 PA; SP IRESSA 4 PA; SP MEKTOVI 4 PA; SP irinotecan hcl 2 SP melphalan 2 SP IXEMPRA KIT 4 SP melphalan hcl 3 SP JAKAFI ORAL TABLET 4 PA; SP; QL mercaptopurine oral 1 10 MG mesna 2 SP JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 4 PA; SP MESNEX ORAL 3 SP 5 MG mitomycin intravenous 3 SP JEVTANA 4 PA; SP mitoxantrone hcl 4 PA; SP KADCYLA 4 PA; SP mutamycin 4 SP KEYTRUDA 4 PA; SP MYLERAN 3 KISQALI FEMARA 4 PA; SP NAVELBINE 4 SP KISQALI ORAL NERLYNX 4 PA; SP; QL TABLET THERAPY 4 PA; SP NEXAVAR 4 PA; SP PACK 200 MG 4 SP KOSELUGO 4 PA; SP NINLARO 4 PA; SP KYPROLIS 4 PA; SP NIPENT 3 SP lapatinib ditosylate 4 PA; SP ODOMZO 4 PA; SP LENVIMA ORAL CAPSULE THERAPY ONIVYDE 4 SP PACK 10 & 4 MG, 10 OPDIVO 4 PA; SP MG, 10 MG & 2 X 4 4 PA; SP oxaliplatin intravenous MG, 2 X 10 MG, 2 X 10 solution 100 mg/20ml, 2 SP MG & 4 MG, 2 X 4 MG, 50 mg/10ml 3 X 4 MG, 4 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

16 Drug Name Drug Tier Notes Drug Name Drug Tier Notes oxaliplatin intravenous TARGRETIN 3 SP 4 PA; SP solution reconstituted EXTERNAL paclitaxel 2 SP TASIGNA 4 PA; SP PADCEV 4 PA; SP TECENTRIQ INTRAVENOUS PANRETIN 4 4 PA; SP SOLUTION 1200 paraplatin 1 SP MG/20ML PERJETA 4 PA; SP TEMODAR 3 SP PIQRAY 4 PA; SP INTRAVENOUS POLIVY temozolomide 3 PA; SP INTRAVENOUS teniposide 4 SP SOLUTION 4 PA; SP RECONSTITUTED 140 THALOMID 4 PA; SP MG thiotepa injection 3 SP POMALYST 4 PA; SP TIBSOVO 4 PA; SP PORTRAZZA 4 PA; SP toposar 1 SP POTELIGEO 4 PA; SP topotecan hcl 3 SP PROLEUKIN 4 SP intravenous solution PURIXAN 3 SP topotecan hcl intravenous solution 2 SP QINLOCK 4 PA; SP reconstituted RETEVMO 4 PA; SP citrate 3 REVLIMID 4 PA; SP TOTECT 3 SP RITUXAN 4 PA; SP tretinoin oral 4 SP RITUXAN HYCELA 4 PA; SP TUKYSA 4 PA; SP RUBRACA 4 PA; SP TURALIO 4 PA; SP RYDAPT 4 PA; SP UNITUXIN 4 PA; SP SPRYCEL 4 PA; SP VALCHLOR 4 PA; SP STIVARGA 4 PA; SP valrubicin 4 SP SUTENT 4 PA; SP VECTIBIX 4 SP SYLVANT 4 PA; SP VELCADE 4 PA; SP SYNRIBO 4 PA; SP VENCLEXTA 4 PA; SP TABLOID 3 SP VENCLEXTA 3 PA; SP TAFINLAR 4 PA; SP STARTING PACK TAGRISSO ORAL VERZENIO 4 PA; SP 4 PA; SP; QL TABLET 40 MG vinblastine sulfate 2 SP TAGRISSO ORAL 4 PA; SP vincristine sulfate 1 SP TABLET 80 MG vinorelbine tartrate 2 SP TALZENNA 4 PA; SP VITRAKVI 4 PA; SP citrate oral 1 VIZIMPRO 4 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

17 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VOTRIENT 4 PA; SP isethionate 2 VYXEOS 4 PA; SP permethrin external 1 XALKORI 4 PA; SP praziquantel oral 3 XOFIGO 4 primaquine phosphate 1 XOSPATA 4 PA; SP pyrimethamine oral 4 PA; SP XTANDI 4 PA; SP quinine sulfate oral 2 PA YERVOY 4 PA; SP spinosad 2 YONDELIS 4 SP Antiparkinson Agents YONSA 4 PA; SP hcl oral 1 ZALTRAP 4 PA; SP benztropine mesylate 3 ZANOSAR 3 SP injection benztropine mesylate ZEJULA 4 PA; SP 1 oral ZELBORAF 4 PA; SP mesylate 2 ZEPZELCA 4 PA; SP oral ZOLINZA 4 PA; SP carbidopa oral 3 ZYDELIG 4 PA; SP carbidopa-levodopa 1 Antiparasitics carbidopa-levodopa er 1 albendazole oral 3 PA carbidopa-levodopa- 2 ALINIA ORAL entacapone SUSPENSION 3 entacapone 2 RECONSTITUTED INBRIJA 3 PA; SP ARAKODA 2 KYNMOBI 3 PA; SP; QL atovaquone oral 3 KYNMOBI TITRATION atovaquone-proguanil 3 PA; SP; QL 2 KIT hcl 1 BENZNIDAZOLE 3 dihydrochloride chloroquine phosphate pramipexole 2 3 ST oral dihydrochloride er COARTEM 2 rasagiline mesylate oral 3 hydroxychloroquine 1 hcl 1 sulfate oral ropinirole hcl er 1 IMPAVIDO 4 selegiline hcl oral 1 oral 1 tolcapone 4 ST KRINTAFEL 2 hcl 1 lindane 2 Antiplatelets malathion 2 aspirin- er 2 hcl 1 BRILINTA 3 nitazoxanide 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

18 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CABLIVI 4 PA; SP; QL LATUDA 3 ST; QL 1 succinate 1 bisulfate olanzapine 1 1 oral intramuscular dipyridamole oral 1 olanzapine oral 1 QL hcl 1 er 3 ST; QL Antipsychotics - 2 Drugs for Mood fumarate 1 QL Disorders quetiapine fumarate er 1 QL ABILIFY MAINTENA 3 REXULTI 3 QL oral 3 QL solution RISPERDAL CONSTA 3 aripiprazole oral tablet 1 QL 1 QL aripiprazole oral tablet hcl oral 1 3 ST; QL dispersible thiothixene 1 ARISTADA 3 hcl 1 ARISTADA INITIO 3 VERSACLOZ 3 QL hcl VRAYLAR ORAL 3 3 ST; QL injection CAPSULE chlorpromazine hcl oral 2 hcl 1 QL oral tablet 1 QL ziprasidone mesylate 1 clozapine oral tablet ZYPREXA RELPREVV 3 2 QL dispersible Antivirals FANAPT 3 ST; QL abacavir sulfate oral 2 solution 1 decanoate injection abacavir sulfate oral 1 fluphenazine hcl tablet 2 injection abacavir sulfate- 2 fluphenazine hcl oral lamivudine 2 concentrate abacavir-lamivudine- 3 fluphenazine hcl oral zidovudine 1 elixir acyclovir external 1 fluphenazine hcl oral ointment 2 tablet acyclovir oral capsule 1 decanoate acyclovir oral 1 2 intramuscular suspension haloperidol lactate 1 acyclovir oral tablet 1 haloperidol oral 1 acyclovir sodium 1 INVEGA SUSTENNA 3 adefovir dipivoxil 3 SP INVEGA TRINZA 3 APTIVUS 3 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

19 Drug Name Drug Tier Notes Drug Name Drug Tier Notes atazanavir sulfate 3 HARVONI ORAL 4 PA; SP; QL BARACLUDE ORAL TABLET 3 SP; QL SOLUTION INTELENCE 3 BIKTARVY 3 INTRON A 3 PA; SP cidofovir intravenous 3 INVIRASE 3 CIMDUO 3 ISENTRESS 3 COMPLERA 3 ISENTRESS HD 3 CRIXIVAN 3 JULUCA 3 DELSTRIGO 3 KALETRA ORAL 3 DOVATO 3 TABLET EDURANT 3 lamivudine oral solution 1 lamivudine oral tablet 3 2 SP 100 mg efavirenz-emtricitab- 3 lamivudine oral tablet tenofovir 1 150 mg, 300 mg efavirenz-lamivudine- 3 tenofovir lamivudine-zidovudine 2 LEXIVA ORAL emtricitabine 2 3 SUSPENSION emtricitabine-tenofovir 3 df lopinavir- 3 EMTRIVA ORAL MAVYRET 4 PA; SP; QL 2 SOLUTION nevirapine er 2 entecavir 3 SP; QL nevirapine oral 3 EPCLUSA 4 PA; SP; QL suspension EPIVIR HBV ORAL nevirapine oral tablet 1 2 SP SOLUTION NORVIR ORAL 2 EVOTAZ 3 PACKET NORVIR ORAL famciclovir oral 1 2 SOLUTION fosamprenavir calcium 3 ODEFSEY 3 FUZEON 3 oseltamivir phosphate 1 QL GANCICLOVIR 4 oral capsule ganciclovir sodium 4 oseltamivir phosphate intravenous solution oral suspension 2 QL ganciclovir sodium reconstituted intravenous solution 3 PEGASYS 4 PA; SP reconstituted PEGINTRON 3 PA; SP GENVOYA 3 PIFELTRO 3 HARVONI ORAL 4 SP PREVYMIS PACKET 2 SP INTRAVENOUS PREVYMIS ORAL 4 SP For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

20 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PREZCOBIX 3 Anxiolytics - Drugs PREZISTA 3 for Anxiety RETROVIR alprazolam er 1 QL 2 INTRAVENOUS alprazolam intensol 2 QL REYATAZ ORAL alprazolam oral tablet 1 QL 3 PACKET alprazolam xr 1 QL ribavirin oral 2 SP hcl oral 1 hcl 2 chlordiazepoxide hcl 1 QL ritonavir 2 clonazepam oral 1 QL SELZENTRY 3 PA clorazepate 2 QL stavudine 2 dipotassium STRIBILD 3 diazepam intensol 1 SYMTUZA 3 diazepam oral 1 TEMIXYS 3 estazolam 1 QL tenofovir disoproxil hcl oral 1 3 fumarate hydroxyzine pamoate 1 TIVICAY 3 oral TRIUMEQ 3 injection 1 TROGARZO 4 PA lorazepam intensol 1 QL TYBOST 2 lorazepam oral 1 QL valacyclovir hcl oral 1 QL concentrate 2 mg/ml valganciclovir hcl 3 lorazepam oral tablet 1 QL VEMLIDY 3 SP 2 VIRACEPT 3 oxazepam 1 QL VIREAD ORAL triazolam 1 QL 3 POWDER Bipolar Agents - VIREAD ORAL Drugs for Mood TABLET 150 MG, 200 3 Disorders MG, 250 MG EQUETRO 2 VOSEVI 4 PA; SP; QL 1 XOFLUZA (40 MG er 1 2 QL DOSE) lithium carbonate oral 1 XOFLUZA (80 MG 2 QL Blood Products and DOSE) Modifiers - Drugs for ZEPATIER 4 PA; SP; QL Blood Disorders zidovudine oral capsule 2 ADVATE 4 SP zidovudine oral syrup 2 ADYNOVATE 4 SP zidovudine oral tablet 1 AFSTYLA 4 SP ALPHANATE 4 SP For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

21 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ALPHANINE SD 4 SP PROMACTA ORAL 4 PA; SP ALPROLIX 4 SP TABLET aminocaproic acid REBINYN 3 intravenous INTRAVENOUS SOLUTION 4 SP aminocaproic acid oral 3 RECONSTITUTED anagrelide hcl 3 2000 UNIT ARANESP (ALBUMIN REBLOZYL 4 PA; SP 3 PA; SP FREE) RECOMBINATE 4 SP BENEFIX 4 SP RETACRIT 3 PA; SP COAGADEX 4 SP RIASTAP 4 SP CORIFACT 4 SP RIXUBIS 4 SP DOPTELET 4 PA; SP SOLIRIS 4 PA; SP ELOCTATE 4 SP TAVALISSE 4 PA; SP FEIBA 4 SP tranexamic acid 1 FIBRYGA 4 SP intravenous HEMLIBRA 4 SP tranexamic acid oral 1 HEMOFIL M 4 SP TRETTEN 4 SP HUMATE-P 4 SP VONVENDI 4 SP IDELVION 4 SP WILATE 4 SP IXINITY 4 SP XYNTHA 4 SP KOATE 4 SP XYNTHA SOLOFUSE 4 SP KOATE-DVI 4 SP ZARXIO 3 PA; SP KOGENATE FS 4 SP Cardiovascular KOVALTRY 4 SP Agents - Drugs for Heart and Circulation LEUKINE 3 PA; SP Conditions MOZOBIL 4 PA; SP; QL hcl oral 1 NEULASTA 4 PA; SP sodium 2 NEULASTA ONPRO 4 PA; SP intravenous NOVOEIGHT 4 SP solution 12 mg/4ml, 6 1 NOVOSEVEN RT 4 SP mg/2ml NPLATE 4 PA; SP alprostadil injection 2 NUWIQ 4 SP hcl oral 1 amiloride- OBIZUR 3 SP 1 PANHEMATIN 4 SP hcl 1 PROFILNINE 4 SP besylate PROMACTA ORAL 1 4 PA; SP oral PACKET 12.5 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

22 Drug Name Drug Tier Notes Drug Name Drug Tier Notes amlodipine besylate- digitek 1 1 benazepril hcl digox 1 amlodipine besylate- 1 digoxin injection 1 valsartan digoxin oral 1 amlodipine-olmesartan 1 hcl er beads 1 amlodipine-valsartan- 1 diltiazem hcl er coated hctz 1 beads oral 1 diltiazem hcl er oral atenolol-chlorthalidone 1 capsule extended 2 atorvastatin calcium release 12 hour 1 oral diltiazem hcl er oral benazepril hcl oral 1 capsule extended 1 benazepril- release 24 hour 1 hydrochlorothiazide diltiazem hcl 2 hcl oral 1 intravenous fumarate oral 1 diltiazem hcl oral 1 bisoprolol- DILTIAZEM HCL- 1 2 hydrochlorothiazide DEXTROSE 1 dilt-xr 1 cilexetil 1 2 phosphate candesartan cilexetil- 1 hctz hcl 2 captopril oral 1 dobutamine in d5w 2 captopril- 1 1 hydrochlorothiazide hcl 1 cartia xt 1 intravenous mesylate 1 1 oral carvedilol phosphate er 2 4 PA; SP sodium 1 enalapril maleate oral 1 chlorthalidone 1 enalapril- 1 cholestyramine light 2 hydrochlorothiazide cholestyramine oral 2 ENTRESTO 3 QL 1 eplerenone 1 clonidine hcl oral 1 ethacrynic acid 3 ST colestipol hcl oral 2 ezetimibe 1 granules er 1 colestipol hcl oral 2 packet fenofibrate micronized oral capsule 134 mg, 1 colestipol hcl oral tablet 1 200 mg, 43 mg, 67 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

23 Drug Name Drug Tier Notes Drug Name Drug Tier Notes fenofibrate oral capsule lisinopril- 1 1 134 mg, 200 mg, 67 mg hydrochlorothiazide fenofibrate oral tablet losartan potassium oral 1 145 mg, 160 mg, 48 1 losartan potassium-hctz 1 mg, 54 mg lovastatin oral 1 fenofibric acid oral capsule delayed 1 intravenous 1 release matzim la 1 acetate 1 1 fosinopril sodium 1 methyldopa- 1 fosinopril sodium-hctz 1 hydrochlorothiazide injection 1 1 furosemide oral 1 succinate er 1 metoprolol tartrate gemfibrozil oral 1 1 intravenous hcl 1 metoprolol tartrate oral 1 hcl 1 metoprolol- injection 1 hydrochlorothiazide hydralazine hcl oral 1 hcl oral 1 hydrochlorothiazide 1 oral hcl 1 fumarate 3 milrinone lactate 2 milrinone lactate in 1 2 dextrose irbesartan 1 oral 1 irbesartan- 1 hydrochlorothiazide moexipril hcl 1 er isosorbide dinitrate oral 1 tablet 10 mg, 20 mg, 30 1 (antihyperlipidemic) mg, 5 mg hcl 2 isosorbide mononitrate 1 NICARDIPINE HCL IN isosorbide mononitrate NACL INTRAVENOUS 1 2 er SOLUTION PREFILLED SYRINGE 1 er 1 JUXTAPID 4 PA; SP; QL nifedipine er osmotic hcl 1 1 release intravenous solution nifedipine oral 1 labetalol hcl oral 1 oral 3 LANOXIN ORAL 3 TABLET 62.5 MCG er 2 lisinopril oral 1 NITRO-DUR 3 ST nitroglycerin sublingual 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

24 Drug Name Drug Tier Notes Drug Name Drug Tier Notes nitroglycerin 1 1 transdermal PRALUENT 3 PA; QL nitroglycerin 2 pravastatin sodium 1 translingual hcl oral 1 NORTHERA 4 PA; SP prevalite 2 olmesartan medoxomil 1 hcl oral 2 injection olmesartan medoxomil- 1 hctz hcl 1 olmesartan-amlodipine- propafenone hcl er 2 1 hctz hcl er 1 omega-3-acid ethyl propranolol hcl 1 PA 1 intravenous OSMITROL 3 propranolol hcl oral 1 er 1 propranolol-hctz 1 perindopril erbumine 1 quinapril hcl 1 hcl quinapril- 4 1 oral hydrochlorothiazide gluconate er 3 HCL (PRESSORS) quinidine sulfate 1 INTRAVENOUS 2 SOLUTION ramipril 1 PREFILLED SYRINGE er 2 1 MG/10ML REPATHA 3 PA; QL phenylephrine hcl REPATHA intravenous solution 10 1 PUSHTRONEX 3 PA; QL mg/ml SYSTEM PHENYLEPHRINE REPATHA 3 PA; QL HCL INTRAVENOUS SURECLICK SOLUTION 2 PREFILLED SYRINGE rosuvastatin calcium 1 0.4 MG/10ML, 1 simvastatin oral 1 MG/10ML sorine 1 PHENYLEPHRINE hcl (af) 1 HCL-NACL SOTALOL HCL INTRAVENOUS 2 3 SOLUTION 20-0.9 INTRAVENOUS MG/250ML-% sotalol hcl oral 1 PHENYLEPHRINE SOTYLIZE 3 HCL-NACL oral 1 INTRAVENOUS 2 SOLUTION spironolactone-hctz 1 PREFILLED SYRINGE taztia xt 1 0.5-0.9 MG/5ML-% For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

25 Drug Name Drug Tier Notes Drug Name Drug Tier Notes telmisartan 1 methylphenidate hcl er 2 PA; QL telmisartan-hctz 1 (la) tiadylt er 1 methylphenidate hcl er oral tablet extended maleate oral 1 release 10 mg, 18 mg, 2 PA; QL torsemide 1 27 mg, 36 mg, 54 mg, trandolapril 1 72 mg trandolapril- methylphenidate hcl er 2 hcl er oral tablet extended 2 PA; QL release 24 hour -hctz 1 methylphenidate hcl 1 PA; QL valsartan 1 oral solution valsartan- methylphenidate hcl 1 1 PA; QL hydrochlorothiazide oral tablet verapamil hcl er 1 methylphenidate hcl 2 PA; QL verapamil hcl oral tablet chewable 1 intravenous relexxii 2 PA; QL verapamil hcl oral 1 Central Nervous WELCHOL 2 System Agents - Central Nervous Drugs for Multiple System Agents - Sclerosis Drugs for Attention AUBAGIO 4 PA; SP; QL Deficit Disorder AVONEX PEN 4 PA; SP; QL ADDERALL XR 1 PA; QL AVONEX PREFILLED 4 PA; SP; QL sulfate 2 PA; QL BETASERON 4 PA; SP; QL amphetamine- 1 PA; QL dalfampridine er 3 PA; SP; QL dextroamphetamine oral 4 PA; SP; QL hcl 2 QL dimethyl fumarate 4 PA; SP; QL clonidine hcl er 1 starter pack dexmethylphenidate hcl 1 PA; QL EXTAVIA 4 PA; SP; QL dexmethylphenidate hcl 1 PA; QL GILENYA 4 PA; SP; QL er glatiramer acetate 3 PA; SP; QL dextroamphetamine 2 PA; QL sulfate er glatopa 3 PA; SP; QL dextroamphetamine LEMTRADA 4 PA; SP 2 PA; QL sulfate oral solution OCREVUS 4 PA; SP; QL dextroamphetamine REBIF 4 PA; SP; QL 1 PA; QL sulfate oral tablet REBIF REBIDOSE 4 PA; SP; QL guanfacine hcl er 1 REBIF REBIDOSE 4 PA; SP; QL methylphenidate hcl er TITRATION PACK 2 PA; QL (cd) REBIF TITRATION 4 PA; SP; QL PACK For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

26 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TYSABRI 4 PA; SP; QL lidocaine hcl 1 Central Nervous mouth/throat System Agents - lidocaine viscous hcl 1 Miscellaneous oralone 1 AUSTEDO 4 PA; SP; QL periogard 1 benzphetamine hcl oral 1 PA hcl oral 1 tablet 50 mg PREVIDENT 5000 1 caffeine citrate 3 BOOSTER PLUS diethylpropion hcl er 1 PA PREVIDENT 5000 1 diethylpropion hcl oral 1 PA DRY MOUTH phendimetrazine PREVIDENT 5000 1 PA 1 tartrate ENAMEL PROTECT phendimetrazine PREVIDENT 5000 1 PA 1 tartrate er ORTHO DEFENSE phentermine hcl oral 1 PA PREVIDENT 5000 1 oral capsule 1 QL PLUS PREVIDENT 5000 RADICAVA 4 PA; SP 1 SENSITIVE 2 PA; QL PREVIDENT DENTAL 1 TEGSEDI 4 PA; SP sf 5000 plus 1 tetrabenazine 4 PA; SP sodium fluoride 5000 1 TIGLUTIK 3 PA; SP; QL enamel Dental and Oral sodium fluoride 5000 1 Agents - Drugs for plus Mouth and Throat sodium fluoride 5000 Conditions 1 ppm cavarest 1 sodium fluoride 5000 1 hcl 2 sensitive chlorhexidine gluconate 1 sodium fluoride dental 1 mouth/throat TOPEX TOPICAL 1 CLINPRO 5000 1 ANESTHETIC DENTA 5000 PLUS 1 1 DENTAGEL 1 mouth/throat FLUORIDEX 1 Dermatological FLUORIDEX Agents - Drugs for ENHANCED 1 Skin Conditions WHITENING accutane 2 PA FLUORIDEX acitretin 3 1 SENSITIVITY RELIEF adapalene external 2 PA KEPIVANCE 4 SP cream adapalene external gel 1 PA For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

27 Drug Name Drug Tier Notes Drug Name Drug Tier Notes adapalene-benzoyl betamethasone 1 peroxide external gel valerate external 1 ala-cort 1 ointment CALAMINE 4 1 dipropionate calcipotriene external 2 ALTRENO 2 PA cream calcipotriene external ALUMINUM 2 CHLORIDE 4 ointment ANHYDROUS calcipotriene external 1 ALUMINUM solution CHLORIDE calcitriol external 3 4 HEXAHYDRATE claravis 2 PA POWDER clindacin etz external external 1 3 swab lotion clindacin-p 1 ammonium lactate 1 external clindamycin phos- benzoyl perox external 1 amnesteem 2 PA gel 1.2-5 % external 2 clindamycin phosphate- benzoyl peroxide- benzoyl peroxide 2 1 erythromycin external gel 1-5 % beser external lotion 2 clindamycin phosphate 2 betamethasone external foam dipropionate aug 1 clindamycin phosphate 1 external cream external gel betamethasone clindamycin phosphate 1 dipropionate aug 1 external lotion external gel clindamycin phosphate 1 betamethasone external solution dipropionate aug 2 clindamycin phosphate 1 external lotion external swab betamethasone clindamycin-tretinoin 3 dipropionate aug 1 prop external ointment 1 emollient base betamethasone 1 dipropionate external e 1 betamethasone clobetasol propionate 1 2 valerate external cream emulsion betamethasone clobetasol propionate 2 1 valerate external foam external cream betamethasone clobetasol propionate 1 2 valerate external lotion external foam

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

28 Drug Name Drug Tier Notes Drug Name Drug Tier Notes clobetasol propionate acetonide 1 1 external gel external clobetasol propionate 2 1 external liquid scalp clobetasol propionate emulsified 2 2 external lotion base clobetasol propionate fluocinonide external 1 1 external ointment fluorouracil external 2 clobetasol propionate cream 5 % 2 external shampoo fluorouracil external 1 clobetasol propionate solution 1 external solution 1 pivalate 2 external cream clodan external fluticasone propionate 2 2 shampoo external lotion external fluticasone propionate 1 1 cream external ointment desonide external lotion 2 halobetasol propionate 1 desonide external external cream 1 ointment halobetasol propionate 1 external ointment 1 external cream 0.25 % butyrate 2 desoximetasone external cream 2 external gel hydrocortisone butyrate 2 desoximetasone external ointment 2 external liquid hydrocortisone butyrate 2 desoximetasone external solution external ointment 0.25 2 hydrocortisone external 1 % cream 1 %, 2.5 % DRYSOL 1 hydrocortisone external 1 DUPIXENT lotion 2.5 % SUBCUTANEOUS hydrocortisone external 3 PA; SP; QL 1 SOLUTION ointment 1 %, 2.5 % PREFILLED SYRINGE hydrocortisone valerate 1 ery 1 imiquimod external 1 erythromycin external 1 oral 2 PA EUCRISA 3 ST methoxsalen rapid 3 oral tablet 1 metronidazole external 1 1 mg cream fluocinolone acetonide metronidazole external 1 1 body gel

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

29 Drug Name Drug Tier Notes Drug Name Drug Tier Notes metronidazole external BYDUREON BCISE 2 3 ST; QL lotion AUTOINJECTOR furoate FARXIGA 2 ST 1 external 1 myorisan 2 PA er 1 neuac external gel 1 glipizide ir 1 pimecrolimus 3 ST glipizide xl 1 podofilox external 1 glipizide-metformin hcl 1 1 glyburide micronized 1 rosadan external cream 1 glyburide oral 1 rosadan external gel 1 glyburide-metformin 1 SCENESSE 4 PA; SP JARDIANCE 2 ST selenium sulfide 1 KAZANO 2 ST external lotion metformin hcl er 1 sulfacetamide sodium 2 metformin hcl oral () 3 solution external 2 metformin hcl oral ointment 1 tablet tazarotene external 2 PA miglitol 2 tovet external foam 2 1 tretinoin external cream 1 PA NESINA 2 ST tretinoin external gel 2 PA OSENI 2 ST tretinoin microsphere 3 PA OZEMPIC 3 ST; QL tretinoin microsphere 3 PA pump pioglitazone hcl 1 triamcinolone acetonide pioglitazone hcl- 1 2 external cream glimepiride triamcinolone acetonide pioglitazone hcl- 1 1 external lotion metformin hcl triamcinolone acetonide 1 external ointment 0.025 1 SOLIQUA 3 ST; QL %, 0.1 %, 0.5 % SYMLINPEN 120 3 PA TRI-CHLOR 2 SYMLINPEN 60 3 PA triderm 1 SYNJARDY 2 ST XERAC AC 1 SYNJARDY XR 2 ST zenatane 2 PA 1 Diabetes - TRULICITY 3 ST; QL Antidiabetic Agents VICTOZA 3 ST; QL acarbose oral 1 XIGDUO XR 2 ST

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

30 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Diabetes - Glucose ENLITE GLUCOSE 2 Monitoring SENSOR CEQUR SIMPLICITY EVERSENSE 1 2 2U SENSOR/HOLDER CEQUR SIMPLICITY EVERSENSE SMART 1 2 INSERTER TRANSMITTER CEQUR SIMPLICITY GUARDIAN CONNECT 1 2 STARTER TRANSMITTER CONTOUR CONTROL GUARDIAN LINK 3 1 2 SOLUTION TRANSMITTER CONTOUR MONITOR GUARDIAN SENSOR 1 2 DEVICE (3) CONTOUR MONITOR GUARDIAN SENSOR 1 2 KIT W/DEVICE 3 CONTOUR NEXT INPEN 100-BLUE- 1 1 CONTROL SOLUTION LILLY CONTOUR NEXT EZ INPEN 100-BLUE- 1 1 KIT W/DEVICE NOVO CONTOUR NEXT LINK INPEN 100-GRAY- 1 1 KIT W/DEVICE LILLY CONTOUR NEXT INPEN 100-GREY- 1 MONITOR KIT 1 NOVO W/DEVICE INPEN 100-PINK- 1 CONTOUR NEXT ONE LILLY 1 KIT INPEN 100-PINK- 1 CONTOUR NEXT NOVO 1 QL TEST STRIPS LANCETS 1 CONTOUR TEST 1 QL NOVOPEN ECHO 1 STRIPS Diabetes - Glycemic DEXCOM G4 / G5 / G6 Agents RECEIVER, TRANSMITTER, diazoxide oral 3 SENSOR (INCLUDING 1 GLUCAGON PLATINUM, EMERGENCY KIT 3 PLATINUM INJECTION KIT PEDIATRIC) Diabetes - Insulins DEXCOM G4 / G5 / G6 BASAGLAR KWIKPEN 1 RECEIVER, BD AUTOSHIELD DUO TRANSMITTER, 1 SENSOR (INCLUDING 1 PEN NEEDLES PLATINUM, BD ULTRA-FINE 1 PLATINUM SYRINGES PEDIATRIC) DEVICE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

31 Drug Name Drug Tier Notes Drug Name Drug Tier Notes BD ULTRA-FINE PEN INSULIN SYRINGES 1 NEEDLES 28G X 1/2" 0.5 ML, BD VEO INSULIN SYR 28G X 1/2" 1 ML, 29G 1 U/F 1/2UNIT X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" DROPLET MICRON 1 1 ML, 30G X 1/2" 0.3 HUMALOG KWIKPEN 2 ML, 30G X 1/2" 0.5 ML, HUMALOG MIX 50/50 30G X 1/2" 1 ML, 30G 2 KWIKPEN X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 1 HUMALOG MIX 50/50 2 5/16" 1 ML, 31G X VIAL 15/64" 0.3 ML, 31G X HUMALOG MIX 75/25 15/64" 0.5 ML, 31G X 2 KWIKPEN 15/64" 1 ML, 31G X HUMALOG MIX 75/25 5/16" 0.3 ML, 31G X 2 VIAL 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X HUMALOG U-100 2 5/16" 0.5 ML, 32G X JUNIOR KWIKPEN 5/16" 1 ML HUMALOG VIAL 2 LANTUS SOLOSTAR 1 HUMULIN 70/30 1 LANTUS U-100 VIAL 1 KWIKPEN MAXICOMFORT SYR 1 HUMULIN 70/30 VIAL 1 27G X 1/2" HUMULIN N KWIKPEN 1 NOVOFINE HUMULIN N VIAL 1 AUTOCOVER PEN 1 HUMULIN R U-500 NEEDLE 1 KWIKPEN NOVOFINE PEN 1 HUMULIN R U-500 NEEDLE 2 VIAL NOVOFINE PLUS PEN 1 HUMULIN R VIAL 2 NEEDLE INSULIN PEN NOVOTWIST PEN 1 1 NEEDLES NEEDLE TOUJEO MAX 1 SOLOSTAR TOUJEO SOLOSTAR 1 TRUE COMFORT PRO INSULIN SYR 32G X 1 5/16" 0.5 ML TRUE COMFORT PRO PEN NEEDLES 31G X 8 MM , 32G X 5 MM , 1 32G X 6 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

32 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ULTIGUARD dextrose-nacl SAFEPACK 1 intravenous solution 5- 1 SYR/NEEDLE 0.2 %, 5-0.3 %, 5-0.33 Electrolytes / Minerals %, 5-0.45 %, 5-0.9 % / Metals / Vitamins dextrose-sodium 1 airavite 1 chloride 4 DL-ALANINE 4 argyle sterile saline 1 DL-LEUCINE 4 argyle sterile water 1 DL- 4 ATABEX OB 1 EFFER-K ORAL TABLET 1 4 EFFERVESCENT 10 DIHYDRATE POWDER MEQ, 20 MEQ CALCIUM effer-k oral tablet 4 1 GLUCONATE effervescent 25 meq CALCIUM ergocalciferol oral 1 GLUCONATE 4 capsule ANHYDROUS fabb 1 CALCIUM fa-vitamin b-6-vitamin GLUCONATE 4 1 MONOHYDRATE b-12 CALCIUM LACTATE fluoritab oral tablet 4 chewable 0.55 (0.25 f) PENTAHYDRATE 1 mg, 1.1 (0.5 f) mg, 2.2 CALCIUM 4 (1 f) mg PHOSPHATE DIBASIC folbee 1 CALCIUM folic acid oral tablet 1 PHOSPHATE 4 1 TRIBASIC mg CARBAGLU 4 SP folplex 2.2 1 hematinic/folic acid 1 BITARTRATE 4 hemocyte-f 1 POWDER HYDROXOCOBALAMI 1 clovique 4 PA; SP N ACETATE cyanocobalamin JYNARQUE ORAL 4 SP; QL injection solution 1000 1 TABLET mcg/ml JYNARQUE ORAL deferasirox 4 PA TABLET THERAPY deferasirox granules 4 PA PACK 15 MG, 45 & 15 4 SP; QL MG, 60 & 30 MG, 90 & dextrose in lactated 1 30 MG ringers kcl in dextrose-nacl 1 klor-con 10 1 klor-con m10 1 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

33 Drug Name Drug Tier Notes Drug Name Drug Tier Notes KLOR-CON M15 1 multivitamin/fluoride klor-con m20 1 oral tablet chewable 1 0.25 mg, 0.5 mg, 1 mg klor-con oral packet 2 na ferric gluc cplx in klor-con oral tablet 2 1 sucrose extended release nafrinse 1 klor-con/ef 1 nafrinse drops 1 lactated ringers 1 intravenous NEONATAL PLUS 1 L-ALANINE 4 NESTABS 1 L-ARGININE 4 normal saline flush 1 L-CYSTINE 4 nufol 1 levocarnitine oral ONE VITE WOMENS 1 1 solution PLUS PHOSPHA 250 levocarnitine oral tablet 1 1 NEUTRAL levocarnitine sf 1 phosphorous 1 L- 4 phospho-trin 250 1 L-HISTIDINE 4 neutral L-HISTIDINE potassium acetate 1 MONOHYDROCHLORI 4 intravenous DE POWDER potassium chloride crys 1 L-LEUCINE 4 er L-PHENYLALANINE 4 potassium chloride er 1 L- 4 potassium chloride 2 L- 4 intravenous L- 4 potassium chloride oral 2 L-VALINE POWDER 4 solution potassium citrate er 1 4 CARBONATE HEAVY prenatal oral tablet 27- MAGNESIUM 0.8 mg, 27-1 mg, 28- 1 CARBONATE 4 0.8 mg POWDER prenatal plus iron 1 magnesium chloride prenatal vitamin plus 2 1 injection low iron M-NATAL PLUS 1 PRETAB 1 monoject flush syringe 1 RELNATE DHA 1 monoject sodium saline flush 1 1 chloride flush saline flush zr 1 multivitamin/fluoride SODIUM ASCORBATE 1 4 oral solution POWDER

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

34 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sodium bicarbonate WESTAB PLUS 1 1 intravenous Gastrointestinal sodium chloride (pf) 1 Agents - Drugs for sodium chloride flush 1 Acid Reflux and Ulcer sodium chloride hcl 1 1 injection cimetidine oral 1 sodium chloride esomeprazole 1 intravenous magnesium oral 1 QL sodium chloride capsule delayed 1 irrigation release sodium fluoride oral 1 famotidine intravenous 1 sodium polystyrene famotidine oral 1 sulfonate suspension 1 reconstituted sterile water for 1 famotidine oral tablet irrigation 1 20 mg, 40 mg swabflush saline flush 1 famotidine premixed 1 TAURINE POWDER 4 lansoprazole oral THREONINE 4 capsule delayed 1 QL ORAL release 4 SP; QL TABLET 15 MG lansoprazole oral tablet tolvaptan oral tablet 30 delayed release 3 ST; QL 4 SP; QL mg dispersible 15 mg trientine hcl 4 PA; SP misoprostol oral 1 TRINATE 1 nizatidine oral capsule 1 tri-vite/fluoride 1 nizatidine oral solution 2 TRYPTOPHAN 4 omeprazole oral UDAMIN SP 1 capsule delayed 1 QL release VALINE 4 pantoprazole sodium 1 VINATE ONE 1 intravenous virt-gard 1 pantoprazole sodium virt-phos 250 neutral 1 oral tablet delayed 1 QL vitamin d release (ergocalciferol) oral rabeprazole sodium 1 capsule 1.25 mg oral tablet delayed 1 QL (50000 ut) release vitamins acd-fluoride 1 sucralfate oral tablet 1 water for irrigation, 1 sterile westab mini 1 westab one 1 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

35 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Gastrointestinal sulfate 1 Agents - Drugs for sublingual Bowel, Intestine and hyosyne 1 Stomach Conditions lactulose 1 hcl 3 PA encephalopathy amoxicill-clarithro- 3 lactulose oral solution 1 lansopraz LINZESS 2 ST; QL ANASPAZ 1 hcl oral 1 sulfate capsule injection solution 8 1 methscopolamine mg/20ml 1 bromide oral atropine sulfate injection solution mineral heavy oral 1 2 prefilled syringe 0.25 NULEV 1 mg/5ml oscimin 1 atropine sulfate peg 3350-kcl-na bicarb- 1 1 intravenous solution nacl constulose 1 peg-3350/electrolytes 1 cromolyn sodium oral 3 SUPREP BOWEL 1 dicyclomine hcl PREP KIT 1 intramuscular SYMPROIC 2 ST; QL dicyclomine hcl oral 1 ursodiol oral 2 diphenoxylate-atropine 3 XERMELO 4 PA; SP; QL oral liquid Genetic or Enzyme diphenoxylate-atropine 1 Disorder - Drugs for oral tablet Replacement, ED-SPAZ 1 Modification, enulose 1 Treatment GATTEX 4 PA; SP CERDELGA 4 PA; SP gavilyte-c 1 CEREZYME 4 PA; SP gavilyte-g 1 CHOLBAM 4 PA; SP gavilyte-n with flavor CREON 3 1 pack CRYSVITA 4 PA; SP generlac 1 CYSTAGON 2 SP glycopyrrolate injection ELAPRASE 4 PA; SP 1 solution ELELYSO 4 PA; SP glycopyrrolate oral 1 FABRAZYME 4 PA; SP tablet 1 mg, 2 mg KANUMA 4 PA; SP hyoscyamine sulfate 1 L-GLUTAMIC ACID oral 4 HCL hyoscyamine sulfate sl 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

36 Drug Name Drug Tier Notes Drug Name Drug Tier Notes LUMIZYME 4 PA; SP Genitourinary Agents MEPSEVII 4 PA; SP - Drugs for Bladder, Genital and Kidney miglustat 4 PA; SP Conditions MYALEPT 4 PA; SP irrigation 1 NAGLAZYME 3 PA; SP chloride 1 nitisinone 4 PA; SP oral NITYR 4 PA; SP calcium acetate (phos 1 OCALIVA 4 PA; SP; QL binder) ORFADIN ORAL calcium acetate oral 4 PA; SP 1 CAPSULE 20 MG tablet 667 mg ORFADIN ORAL 4 PA; SP 2 SUSPENSION hydrobromide er PALYNZIQ 4 PA; SP; QL hcl 1 PROCYSBI ORAL GELNIQUE 3 ST CAPSULE DELAYED 4 PA; SP lanthanum carbonate 3 RELEASE chloride er 1 RAVICTI 4 PA; SP oxybutynin chloride oral 1 REVCOVI 4 PA; SP penicillamine oral 4 PA; SP sapropterin capsule 4 PA; SP dihydrochloride penicillamine oral tablet 4 SP sod benz-sod phenazo oral tablet 200 4 1 phenylacet mg sodium phenylbutyrate 4 SP hcl oral oral tablet 100 mg, 200 1 STRENSIQ 4 PA; SP mg SUCRAID 4 SP sevelamer carbonate 3 VIMIZIM 4 PA; SP oral packet sevelamer carbonate VPRIV 4 PA; SP 2 oral tablet XURIDEN 4 PA; SP; QL sevelamer hcl 3 ZENPEP ORAL CAPSULE DELAYED sildenafil citrate oral RELEASE PARTICLES tablet 100 mg, 25 mg, 1 QL 10000-32000 UNIT, 50 mg 15000-47000 UNIT, 3 succinate 1 20000-63000 UNIT, tadalafil oral 1 QL 3000-14000 UNIT, 40000-126000 UNIT, tartrate 1 5000-24000 UNIT tolterodine tartrate er 1 1 trospium chloride er 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

37 Drug Name Drug Tier Notes Drug Name Drug Tier Notes uretron d/s 3 KENALOG INJECTION urin ds 3 SUSPENSION 10 1 MG/ML Genitourinary Agents - Drugs for Prostate METHYLPREDNISOL Conditions ONE ACETATE INJECTION 1 hcl er 1 SUSPENSION 50 oral 1 MG/ML dutasteride- 2 hcl acetate suspension 40 1 finasteride oral tablet 5 mg/ml injection 1 mg METHYLPREDNISOL ONE ACETATE 1 1 SUSPENSION 40 tamsulosin hcl 1 MG/ML INJECTION hcl 1 methylprednisolone Hormonal Agents - acetate suspension 80 1 Adrenal mg/ml injection DEPO-MEDROL METHYLPREDNISOL INJECTION ONE ACETATE 1 1 SUSPENSION 20 SUSPENSION 80 MG/ML MG/ML INJECTION methylprednisolone 1 (LA) INJECTION oral 1 SUSPENSION 8 methylprednisolone MG/ML sodium succ injection dexamethasone oral solution reconstituted 1 1 elixir 1000 mg, 125 mg, 40 dexamethasone oral mg 1 solution oral 1 dexamethasone oral solution 1 tablet prednisolone sodium 1 dexamethasone oral phosphate oral solution 2 tablet therapy pack prednisolone sodium dexamethasone sod phosphate oral tablet 2 phosphate pf injection 1 dispersible solution intensol 2 dexamethasone prednisone oral 1 sodium phosphate 1 SOLU-CORTEF 1 injection triamcinolone acetonide acetate 1 injection suspension 40 1 oral mg/ml hydrocortisone oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

38 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Hormonal Agents - GENOTROPIN 3 PA; SP Men's Health MINIQUICK ANDRODERM 2 PA HUMATROPE 3 PA; SP oral 2 INCRELEX 4 PA; SP METHYLTESTOSTER leuprolide acetate 4 3 PA; SP ONE injection oral 3 PA; QL LUPANETA PACK 3 PA; SP; QL cypionate LUPRON DEPOT (1- 1 PA 3 PA; SP intramuscular MONTH) LUPRON DEPOT (3- 1 PA 3 PA; SP intramuscular MONTH) testosterone LUPRON DEPOT (4- 2 PA transdermal MONTH) 3 PA; SP Hormonal Agents - INTRAMUSCULAR KIT Osteoporosis 30MG hcl 1 LUPRON DEPOT (6- MONTH) 3 PA; SP Hormonal Agents - INTRAMUSCULAR KIT Pituitary 45MG ACTHAR 4 PA; SP LUPRON DEPOT-PED 3 PA; SP 1 (1-MONTH) CETROTIDE 3 PA; SP LUPRON DEPOT-PED 4 PA; SP chorionic (3-MONTH) 2 PA; SP intramuscular MENOPUR 4 PA; SP clomiphene citrate oral 1 NOCDURNA 2 desmopressin ace novarel intramuscular 2 spray refrig solution reconstituted 2 PA; SP desmopressin acetate 10000 unit 3 injection NOVAREL desmopressin acetate INTRAMUSCULAR 1 oral SOLUTION 2 PA; SP RECONSTITUTED desmopressin acetate 2 5000 UNIT spray octreotide acetate 3 PA; SP EGRIFTA SV 4 PA; SP; QL OVIDREL 1 PA; SP ELIGARD 3 PA; SP; QL oxytocin injection 1 FENSOLVI (6 MONTH) 4 PA; SP; QL pregnyl 2 PA; SP FIRMAGON 3 PA; SP; QL SIGNIFOR 4 PA; SP; QL FIRMAGON (240 MG 3 PA; SP; QL DOSE) SOMATULINE DEPOT 4 PA; SP FOLLISTIM AQ 3 PA; SP SOMAVERT 4 PA; SP GENOTROPIN 3 PA; SP SUPPRELIN LA 4 PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

39 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TRELSTAR MIXJECT 3 PA; SP; QL camila 1 TRIPTODUR 4 PA; SP; QL camrese 1 QL VANTAS 3 PA; SP; QL camrese lo 1 QL ZOLADEX 3 SP; QL caziant 1 Hormonal Agents - charlotte 24 fe 2 Prostaglandins chateal 1 KORLYM 4 PA; SP; QL chateal eq 1 Hormonal Agents - CLIMARA PRO 2 Sex Hormones and Birth Control cryselle-28 1 afirmelle 1 cyclafem 1/35 1 altavera 1 cyclafem 7/7/7 1 alyacen 1/35 1 cyred 1 alyacen 7/7/7 1 cyred eq 1 amabelz 1 dasetta 1/35 1 amethia 1 QL dasetta 7/7/7 1 amethia lo 1 QL daysee 1 QL amethyst 1 deblitane 1 apri 1 delyla 1 -ethinyl aranelle 1 1 ashlyna 1 QL DIVIGEL aubra 1 TRANSDERMAL GEL aubra eq 1 0.25 MG/0.25GM, 0.5 2 aurovela 1.5/30 1 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM aurovela 1/20 1 dotti 1 aurovela 24 fe 1 drospiren-eth estrad- 1 aurovela fe 1.5/30 1 levomefol aurovela fe 1/20 1 -ethinyl 1 aviane 1 estradiol ayuna 1 elinest 1 azurette 1 ELLA 1 balziva 1 eluryng 2 bekyree 1 emoquette 1 blisovi 24 fe 1 enpresse-28 1 blisovi fe 1.5/30 1 enskyce 1 blisovi fe 1/20 1 errin 1 briellyn 1 estarylla 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

40 Drug Name Drug Tier Notes Drug Name Drug Tier Notes estradiol oral 1 kariva 1 estradiol transdermal 1 kelnor 1/35 1 estradiol vaginal 1 kelnor 1/50 1 kurvelo 1 1 intramuscular larin 1.5/30 1 estradiol-norethindrone 1 larin 1/20 1 acet larin 24 fe 1 ethynodiol diac-eth 1 estradiol larin fe 1.5/30 1 -ethinyl larin fe 1/20 1 2 estradiol larissia 1 falmina 1 layolis fe 1 fayosim 1 QL leena 1 femynor 1 lessina 1 fyavolv 1 levonest 1 hailey 1.5/30 1 levonorgest-eth est & 1 QL hailey 24 fe 1 eth est levonorgest-eth estrad hailey fe 1.5/30 1 1 QL 91-day hailey fe 1/20 1 -ethinyl 1 heather 1 estrad hydroxyprogesterone levonorg-eth estrad 3 PA; SP 1 caproate intramuscular triphasic iclevia 1 QL levora 0.15/30 (28) 1 incassia 1 lillow 1 introvale 1 QL lojaimiess 1 QL isibloom 1 loryna 1 jaimiess 1 QL low-ogestrel 1 jasmiel 1 lo-zumandimine 1 jencycla 1 lutera 1 jinteli 1 lyleq 1 jolessa 1 QL lyllana 1 juleber 1 lyza 1 junel 1.5/30 1 marlissa 1 junel 1/20 1 junel fe 1.5/30 1 acetate intramuscular 1 QL junel fe 1/20 1 suspension junel fe 24 1 kalliga 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

41 Drug Name Drug Tier Notes Drug Name Drug Tier Notes medroxyprogesterone -eth 1 acetate intramuscular estradiol 2 QL suspension prefilled norgestimate-ethinyl 1 syringe estradiol triphasic medroxyprogesterone 1 norlyda 1 acetate oral norlyroc 1 acetate oral suspension 40 mg/ml, 1 nortrel 0.5/35 (28) 1 400 mg/10ml nortrel 1/35 (21) 1 oral nortrel 1/35 (28) 1 3 suspension 625 mg/5ml nortrel 7/7/7 1 megestrol acetate oral 1 nylia 7/7/7 1 tablet nymyo 1 melodetta 24 fe 2 ocella 1 mibelas 24 fe 2 orsythia 1 microgestin 1.5/30 1 philith 1 microgestin 1/20 1 pimtrea 1 microgestin 24 fe 1 pirmella 1/35 1 microgestin fe 1.5/30 1 pirmella 7/7/7 1 microgestin fe 1/20 1 portia-28 1 mili 1 PREMARIN ORAL 2 mimvey 1 PREMPHASE 2 mono-linyah 1 PREMPRO 2 necon 0.5/35 (28) 1 previfem 1 nikki 1 1 nora-be 1 intramuscular norethin ace-eth progesterone 1 1 estrad-fe oral tablet micronized oral norethin ace-eth reclipsen 1 estrad-fe oral tablet 2 chewable rivelsa 1 QL norethindrone acetate setlakin 1 QL 1 oral sharobel 1 norethindrone acet- simliya 1 1 ethinyl est simpesse 1 QL norethindrone oral 1 sprintec 28 1 norethindrone-eth 1 sronyx 1 estradiol syeda 1 norethin-eth estradiol-fe 1 tarina 24 fe 1 tarina fe 1/20 1 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

42 Drug Name Drug Tier Notes Drug Name Drug Tier Notes tarina fe 1/20 eq 1 Hormonal Agents - tilia fe 1 Thyroid tri femynor 1 ARMOUR THYROID 1 tri-estarylla 1 euthyrox 1 tri-legest fe 1 levo-t 1 tri-linyah 1 levothyroxine sodium intravenous solution 3 tri-lo-estarylla 1 reconstituted tri-lo-marzia 1 levothyroxine sodium 1 tri-lo-mili 1 oral tablet tri-lo-sprintec 1 levoxyl 1 tri-mili 1 liothyronine sodium 1 tri-nymyo 1 intravenous tri-previfem 1 liothyronine sodium oral 1 tri-sprintec 1 methimazole oral 1 trivora (28) 1 NATURE-THROID 1 tri-vylibra 1 np thyroid 1 tri-vylibra lo 1 propylthiouracil oral 1 tulana 1 unithroid 1 tyblume 1 WESTHROID 1 tydemy 1 WP THYROID 1 velivet 1 Immunological Agents - Drugs for vestura 1 Immune System vienva 1 Stimulation or viorele 1 Suppression volnea 1 ACTEMRA 4 PA; SP vyfemla 1 ACTEMRA ACTPEN 4 PA; SP vylibra 1 ACTIMMUNE 4 PA; SP wera 1 ARCALYST 4 PA; SP wymzya fe 1 AZASAN 3 xulane 2 oral 1 yuvafem 1 azathioprine sodium 1 zafemy 2 BENLYSTA 4 PA; SP zarah 1 BERINERT 4 PA; SP; QL zovia 1/35 (28) 1 BIVIGAM 4 PA; SP zovia 1/35e (28) 1 CARIMUNE NF 4 PA; SP zumandimine 1 CELLCEPT 3 SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

43 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CIMZIA PREFILLED HUMIRA PEN- 3 PA; SP KIT PSOR/UVEIT 3 PA; SP CIMZIA STARTER KIT 3 PA; SP STARTER CINRYZE 4 PA; SP HYPERRHO S/D 2 SP CUVITRU 4 PA; SP HYQVIA 4 PA; SP cyclosporine ILARIS 4 PA; SP; QL 1 SP intravenous IMURAN 3 cyclosporine modified 2 SP INFLECTRA 3 PA; SP cyclosporine oral 3 SP KALBITOR 4 PA; SP; QL CYTOGAM 3 PA; SP KINERET 4 PA; SP ENTYVIO 4 PA; SP oral 1 everolimus oral tablet oral 1 0.25 mg, 0.5 mg, 0.75 3 SP methotrexate sodium 1 mg methotrexate sodium 1 FLEBOGAMMA DIF 4 PA; SP (pf) GAMASTAN 2 PA; SP MICRHOGAM ULTRA- 2 SP GAMIFANT 4 PA; SP FILTERED PLUS GAMMAGARD 4 PA; SP mycophenolate mofetil 2 SP GAMMAGARD S/D hcl 4 PA; SP LESS IGA mycophenolate mofetil 2 SP GAMMAKED 4 PA; SP oral capsule GAMMAPLEX 4 PA; SP mycophenolate mofetil oral suspension 3 SP GAMUNEX-C 4 PA; SP reconstituted gengraf 2 SP mycophenolate mofetil 2 SP HAEGARDA 4 PA; SP oral tablet HIZENTRA 4 PA; SP mycophenolate sodium 3 SP HUMIRA 3 PA; SP MYFORTIC 3 SP HUMIRA PEDIATRIC NEORAL 3 SP 3 PA; SP CROHNS START NULOJIX 3 SP HUMIRA PEN 3 PA; SP OCTAGAM 4 PA; SP HUMIRA PEN- 3 PA; SP ORENCIA 4 PA; SP CD/UC/HS STARTER ORENCIA CLICKJECT 4 PA; SP HUMIRA PEN- PEDIATRIC UC 3 PA; SP OTEZLA 3 PA; SP START PRIVIGEN 4 PA; SP HUMIRA PEN- PROGRAF ORAL 3 SP PS/UV/ADOL HS 3 PA; SP PACKET START RAPAMUNE ORAL 3 SP SOLUTION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

44 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RENFLEXIS 3 PA; SP ENGERIX-B 1 RHOGAM ULTRA- FLUAD 1 2 SP FILTERED PLUS FLUAD 1 RINVOQ 3 PA; SP QUADRIVALENT RUCONEST 4 PA; SP; QL FLUARIX 1 SANDIMMUNE ORAL 3 SP QUADRIVALENT FLUBLOK SIMPONI 3 PA; SP 1 QUADRIVALENT oral 3 SP FLUCELVAX SKYRIZI (150 MG 1 3 PA; SP QUADRIVALENT DOSE) FLULAVAL STELARA 1 3 PA; SP; QL QUADRIVALENT SUBCUTANEOUS FLUMIST 1 SYNAGIS 3 PA; SP QUADRIVALENT tacrolimus oral 2 SP FLUZONE HIGH- TALTZ 4 PA; SP DOSE 1 4 SP QUADRIVALENT FLUZONE THYMOGLOBULIN 3 1 QUADRIVALENT TICE BCG 3 SP GARDASIL 9 2 TREMFYA 3 PA; SP HAVRIX 1 XATMEP 3 ST HEPLISAV-B 2 XELJANZ 3 PA; SP HIBERIX 1 XELJANZ XR 3 PA; SP IMOVAX RABIES 3 ZORTRESS 3 SP INFANRIX 1 Immunological Agents - Drugs for IPOL 1 Vaccination IXIARO 2 ACTHIB 1 JANSSEN COVID-19 1 ADACEL 1 VACCINE AFLURIA KINRIX 1 1 QUADRIVALENT MENACTRA 2 ASTRAZENECA MENQUADFI 2 1 COVID-19 VACCINE MENVEO 2 BCG VACCINE 2 M-M-R II 1 BEXSERO 2 MODERNA COVID-19 1 BOOSTRIX 1 VACCINE DAPTACEL 1 PEDIARIX 1 DIPHTHERIA- PEDVAX HIB 1 TETANUS TOXOIDS 1 PENTACEL 2 DT

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

45 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PFIZER-BIONTECH mesalamine oral tablet 1 COVID-19 VACC delayed release 800 3 PNEUMOVAX 23 2 mg PREVNAR 13 2 mesalamine rectal 3 PROQUAD 2 mesalamine-cleanser 3 QUADRACEL 1 procto-med hc 1 RABAVERT 3 procto-pak 1 RECOMBIVAX HB 1 proctozone-hc 1 ROTARIX 2 SFROWASA 3 ROTATEQ 1 sulfasalazine oral 1 SHINGRIX 2 UCERIS RECTAL 3 STAMARIL 2 Metabolic Bone Disease Agents - TDVAX 1 Drugs for TENIVAC 1 Osteoporosis TETANUS- alendronate sodium 2 DIPHTHERIA 1 oral solution TOXOIDS TD alendronate sodium 1 TRUMENBA 2 oral tablet 10 mg, 5 mg TWINRIX 2 alendronate sodium TYPHIM VI 1 oral tablet 35 mg, 70 1 QL mg VAQTA 1 calcitonin (salmon) 1 QL VARIVAX 2 ibandronate sodium 1 QL VAXCHORA 2 pamidronate disodium 1 SP VIVOTIF 1 intravenous solution YF-VAX 2 pamidronate disodium Inflammatory Bowel intravenous solution 2 SP Disease Agents reconstituted APRISO 2 PROLIA 3 PA; SP; QL balsalazide disodium 2 RAYALDEE 3 er 3 risedronate sodium oral 1 QL budesonide oral 2 tablet 150 mg, 35 mg hydrocortisone risedronate sodium oral 1 1 (perianal) tablet 30 mg, 5 mg risedronate sodium oral hydrocortisone rectal 2 2 QL tablet delayed release LIALDA 2 TERIPARATIDE 3 PA; SP mesalamine oral (RECOMBINANT) capsule delayed 3 release 400 mg TYMLOS 3 PA; SP XGEVA 3 PA; SP For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

46 Drug Name Drug Tier Notes Drug Name Drug Tier Notes zoledronic acid 2 SP CLEVER CHOICE 1 Metabolic Bone HOLDING CHAMBER Disease Agents - COMPACT SPACE 1 Other CHAMBER/LG MASK calcitriol intravenous 1 COMPACT SPACE calcitriol oral 1 CHAMBER/MED 1 MASK cinacalcet hcl 3 PA COMPACT SPACE doxercalciferol 1 3 CHAMBER/SM MASK intravenous deferoxamine mesylate 2 NATPARA 4 PA; SP; QL hcl in paricalcitol intravenous 2 nacl intravenous paricalcitol oral 1 solution 200 mcg/50ml, 3 Miscellaneous 200-0.9 mcg/50ml-%, Therapeutic Agents 400 mcg/100ml DEXMEDETOMIDINE 3 intravenous HCL INTRAVENOUS SOLUTION 1000 3 ADAKVEO 4 PA; SP MCG/10ML, 400 ALBUKED 25 2 MCG/4ML ALBUKED 5 2 dexmedetomidine hcl albumin human 2 intravenous solution 1 200 mcg/2ml albumin-zlb 2 DUROLANE 2 PA; SP alburx 2 DYSPORT 3 PA; SP ALBUTEIN 2 EASIVENT 1 ASPARTAME 4 mesylates oral 3 ASPARTAME 4 (NUTRASWEET) EUFLEXXA 2 PA; SP BOTOX 3 PA; SP FIRDAPSE 4 PA; SP BREATHE EASE FLEXBUMIN 2 1 LARGE flumazenil intravenous 1 BREATHE EASE GELSYN-3 2 PA; SP 1 MEDIUM heparin lock flush 1 BREATHE EASE heparin sodium lock 1 1 SMALL flush BROMELAIN 4 HUMAN ALBUMIN 2 CETYLCIDE-G 4 GRIFOLS CHARCOAL kedbumin 2 4 ACTIVATED methergine 3 QL CHLORHEXIDINE methylergonovine 1 GLUCONATE 2 maleate injection SOLUTION 20 % For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

47 Drug Name Drug Tier Notes Drug Name Drug Tier Notes methylergonovine diclofenac sodium 3 QL 1 maleate oral ophthalmic MICROCHAMBER 1 epinastine hcl 1 MYOBLOC 3 PA; SP erythromycin 1 PLASBUMIN-25 2 ophthalmic PLASBUMIN-5 2 1 POCKET SPACER 1 flurbiprofen sodium 1 PRO COMFORT FML FORTE 2 1 SPACER ADULT gatifloxacin ophthalmic 1 PRO COMFORT gentak 1 1 SPACER CHILD gentamicin sulfate 1 PRO COMFORT ophthalmic 1 SPACER INFANT ketorolac tromethamine 1 PROCARE ophthalmic SPACER/ADULT 1 levofloxacin ophthalmic 2 MASK moxifloxacin hcl PROCARE 1 1 ophthalmic solution SPACER/CHILD MASK NATACYN 3 SACCHARIN 4 ofloxacin ophthalmic 1 sodium thiosulfate 2 hcl intravenous 1 ophthalmic VISTOGARD 4 prednisolone acetate 1 XEOMIN 3 PA; SP ophthalmic XIAFLEX 4 PA; SP prednisolone sodium 1 Ophthalmic Agents - phosphate ophthalmic Drugs for Eye Allergy, sulfacetamide sodium 1 Infection and ophthalmic Inflammation tobramycin ophthalmic 1 azelastine hcl 1 ophthalmic trifluridine 2 bacitracin ophthalmic 1 Ophthalmic Agents - Drugs for Glaucoma bromfenac sodium 2 QL (once-daily) acetazolamide er 1 ciprofloxacin hcl acetazolamide oral 2 1 ophthalmic hcl 1 cromolyn sodium betaxolol hcl 1 1 ophthalmic ophthalmic dexamethasone bimatoprost ophthalmic 2 QL sodium phosphate 1 tartrate 1 ophthalmic ophthalmic hcl 1 For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

48 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DORZOLAMIDE HCL LUCENTIS 3 PA; SP SOLUTION 2 % 1 neomycin-bacitracin zn- 1 OPHTHALMIC polymyx dorzolamide hcl 1 neomycin-polymyxin- solution 2 % ophthalmic dexameth ophthalmic 1 dorzolamide hcl-timolol ointment 1 mal neomycin-polymyxin- dorzolamide hcl-timolol dexameth ophthalmic 1 1 mal pf suspension 3.5-10000- KEVEYIS 4 PA; SP; QL 0.1 neomycin-polymyxin- latanoprost ophthalmic 1 1 gramicidin hcl 1 neomycin-polymyxin-hc 2 LUMIGAN 2 QL ophthalmic methazolamide oral 3 neo-polycin 1 pilocarpine hcl 1 neo-polycin hc 1 ophthalmic OXERVATE 4 PA; SP; QL timolol maleate 1 phenylephrine hcl ophthalmic solution 1 ophthalmic travoprost (bak free) 2 QL polycin 1 Ophthalmic Agents - polymyxin b- Drugs for 1 Miscellaneous Eye trimethoprim Conditions proparacaine hcl 1 ak-poly-bac 1 ophthalmic ALTACAINE 1 sulfacetamide- prednisolone 1 altafrin 1 ophthalmic solution atropine sulfate hcl 1 1 ophthalmic ointment ophthalmic atropine sulfate tobramycin- 1 1 ophthalmic solution 1 % dexamethasone bacitracin-polymyxin b 1 VISUDYNE 3 SP ophthalmic Otic Agents - Drugs bacitra-neomycin- 1 for Ear Conditions polymyxin-hc acetic acid otic 1 hcl 1 ophthalmic ciprofloxacin hcl otic 1 fluocinolone acetonide CYSTADROPS 4 PA; SP; QL 1 otic CYSTARAN 4 PA; SP; QL hydrocortisone-acetic 2 EYLEA 3 PA; SP acid homatropaire 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

49 Drug Name Drug Tier Notes Drug Name Drug Tier Notes neomycin-polymyxin-hc desloratadine oral 1 2 otic tablet dispersible ofloxacin otic 1 diphen oral elixir 1 Respiratory Tract / hcl 1 Pulmonary Agents - injection Drugs for Allergies, diphenhydramine hcl 1 Cough, Cold oral elixir 12 hour allergy-d 1 FASENRA 4 PA; SP all day allergy d 1 FASENRA PEN 4 PA; SP allergy 24hour 1 nasal 1 QL indoor/outdoor fluticasone propionate 1 allergy relief cetirizine 1 nasal allergy relief childrens hydrocodone polst- 1 1 PA; QL oral solution chlorphen polst er susp allergy relief oral tablet hydrocodone- 1 1 PA; QL 5 mg allergy hydromet 1 PA; QL relief/indoor/outdoor 1 oral tablet 10 mg 1 nasal allergy relief/nasal decongest oral tablet levocetirizine 1 1 extended release 12 dihydrochloride oral hour mometasone furoate 1 QL azelastine hcl nasal 1 QL nasal azelastine-fluticasone 2 NUCALA 4 PA; SP; QL benzonatate 1 olopatadine hcl nasal 2 QL maleate hcl 1 1 oral solution injection carbinoxamine maleate promethazine hcl oral 1 1 oral tablet 4 mg promethazine hcl rectal 2 cetirizine hcl childrens promethazine vc 1 1 alrgy promethazine 1 PA; QL cetirizine hcl oral vc/codeine 1 solution promethazine-codeine 1 PA; QL cetirizine hcl oral tablet 1 promethazine-dm 1 cetirizine- promethazine- 1 1 PA; QL er phenyleph-codeine CINQAIR 3 PA; SP promethazine- 1 hcl oral 1 phenylephrine desloratadine oral promethegan 2 1 tablet

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

50 Drug Name Drug Tier Notes Drug Name Drug Tier Notes pseudoephedrine- ASMANEX (30 1 bromphen-dm METERED DOSES) INHALATION ryvent 1 2 AEROSOL POWDER sodium chloride 1 BREATH ACTIVATED inhalation 220 MCG/INH XOLAIR 3 PA; SP ASMANEX (60 2 Respiratory Tract / METERED DOSES) Pulmonary Agents - ASMANEX (7 2 QL Drugs for Asthma and METERED DOSES) Other Lung Conditions ASMANEX HFA 2 QL acetylcysteine ATROVENT HFA 3 ST; QL 1 inhalation BREO ELLIPTA 2 QL ADVAIR DISKUS 2 QL BROVANA 3 ST; QL ADVAIR HFA 2 QL budesonide inhalation 2 QL albuterol sulfate hfa COMBIVENT 2 QL aerosol solution 108 RESPIMAT 1 QL (90 base) mcg/act cromolyn sodium 3 inhalation inhalation ALBUTEROL DALIRESP 3 PA SULFATE HFA AEROSOL SOLUTION epinephrine injection 1 QL 2 108 (90 BASE) solution auto-injector MCG/ACT ESBRIET 4 PA; SP INHALATION FLUTICASONE- albuterol sulfate 1 QL inhalation INHALATION AEROSOL POWDER ANORO ELLIPTA 2 QL 2 QL BREATH ACTIVATED ARALAST NP 4 PA; SP 113-14 MCG/ACT, 232- ARNUITY ELLIPTA 2 QL 14 MCG/ACT, 55-14 ASMANEX (120 MCG/ACT 2 METERED DOSES) GLASSIA 4 PA; SP ASMANEX (14 INCRUSE ELLIPTA 2 QL 2 METERED DOSES) ipratropium bromide 1 QL ASMANEX (30 inhalation METERED DOSES) ipratropium-albuterol 1 QL INHALATION 2 QL LONHALA MAGNAIR AEROSOL POWDER 3 ST; QL BREATH ACTIVATED REFILL KIT 110 MCG/INH LONHALA MAGNAIR 3 ST; QL STARTER KIT montelukast sodium 1 oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

51 Drug Name Drug Tier Notes Drug Name Drug Tier Notes OFEV 4 PA; SP Respiratory Tract / PROLASTIN-C 4 PA; SP Pulmonary Agents - Drugs for Pulmonary QVAR REDIHALER 2 QL Hypertension SEREVENT DISKUS 2 QL ADEMPAS 4 PA; SP; QL SPIRIVA 2 QL alyq 3 PA; SP; QL HANDIHALER ambrisentan 4 PA; SP; QL SPIRIVA RESPIMAT 2 QL bosentan 4 PA; SP; QL STIOLTO RESPIMAT 2 QL epoprostenol sodium 3 PA; SP STRIVERDI 2 QL RESPIMAT OPSUMIT 4 PA; SP; QL SYMBICORT 2 QL ORENITRAM 4 PA; SP sulfate sildenafil citrate 1 2 PA; SP injection intravenous terbutaline sulfate oral 2 sildenafil citrate oral suspension 4 PA; SP; QL 2 reconstituted theophylline er oral sildenafil citrate oral 1 PA; SP; QL tablet extended release 2 tablet 20 mg 12 hour tadalafil (pah) 3 PA; SP; QL theophylline er oral tablet extended release 1 TRACLEER 32 MG 4 PA; SP; QL 24 hour treprostinil injection 4 PA; SP TRELEGY ELLIPTA solution 50 mg/20ml INHALATION TYVASO 4 PA; SP; QL AEROSOL POWDER 2 QL TYVASO REFILL 4 PA; SP; QL BREATH ACTIVATED 100-62.5-25 MCG/INH TYVASO STARTER 4 PA; SP; QL VENTOLIN HFA 1 QL UPTRAVI 4 PA; SP; QL YUPELRI 3 ST; QL VENTAVIS 4 PA; SP; QL zafirlukast 1 Skeletal Muscle Relaxants - Drugs for ZEMAIRA 4 PA; SP Muscle Pain and Respiratory Tract / Spasm Pulmonary Agents - oral 1 Drugs for Cystic Fibrosis carisoprodol oral 1 oral KALYDECO 4 PA; SP 1 tablet 500 mg ORKAMBI 4 PA; SP; QL hcl 1 PULMOZYME 4 PA; SP oral tablet 10 mg, 5 mg SYMDEKO 4 PA; SP; QL dantrolene sodium oral 1 tobramycin inhalation 4 SP metaxalone 2 TRIKAFTA 4 PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

52 Drug Name Drug Tier Notes methocarbamol 1 injection methocarbamol oral 1 citrate er 1 orphenadrine citrate 1 injection hcl oral 1 Sleep Disorder Agents 1 PA; QL doxepin hcl oral tablet 3 QL eszopiclone 1 QL flurazepam hcl 1 PA; QL HETLIOZ 4 PA; SP; QL 1 PA; QL temazepam 1 QL XYREM 4 PA; SP; QL zaleplon 1 QL zolpidem tartrate er 1 QL zolpidem tartrate oral 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

53 Index of Drugs 12 hour allergy-d...... 50 ALANINE...... 33 amcinonide...... 28 abacavir sulfate...... 19 albendazole...... 18 amethia...... 40 abacavir sulfate-lamivudine...... 19 ALBUKED 25...... 47 amethia lo...... 40 abacavir-lamivudine- ALBUKED 5...... 47 amethyst...... 40 zidovudine...... 19 albumin human...... 47 amikacin sulfate...... 7 ABELCET...... 13 albumin-zlb...... 47 amiloride hcl...... 22 ABILIFY MAINTENA...... 19 alburx...... 47 amiloride-hydrochlorothiazide... 22 abiraterone acetate...... 14 ALBUTEIN...... 47 aminocaproic acid...... 22 ABRAXANE...... 14 albuterol sulfate...... 51 amiodarone hcl...... 22 acamprosate calcium...... 7 albuterol sulfate hfa...... 51 amitriptyline hcl...... 11 acarbose...... 30 ALBUTEROL SULFATE HFA... 51 amlodipine besylate...... 22 accutane...... 27 alclometasone dipropionate...... 28 amlodipine besylate-benazepril acebutolol hcl...... 22 ALECENSA...... 14 hcl...... 23 acetaminophen-codeine...... 4 alendronate sodium...... 46 amlodipine besylate-valsartan.. 23 acetaminophen-codeine #2...... 4 alfuzosin hcl er...... 38 amlodipine-olmesartan...... 23 acetaminophen-codeine #3...... 4 ALIMTA...... 14 amlodipine-valsartan-hctz...... 23 acetaminophen-codeine #4...... 4 ALINIA...... 18 ammonium lactate...... 28 acetazolamide...... 48 ALIQOPA...... 14 amnesteem...... 28 acetazolamide er...... 48 all day allergy d...... 50 amoxapine...... 11 acetazolamide sodium...... 22 allergy 24hour indoor/outdoor... 50 amoxicill-clarithro-lansopraz..... 36 acetic acid...... 37, 49 allergy relief...... 50 amoxicillin...... 7 acetylcysteine...... 47, 51 allergy relief cetirizine...... 50 amoxicillin-potassium acitretin...... 27 allergy relief childrens...... 50 clavulanate...... 7 ACTEMRA...... 43 allergy relief/indoor/outdoor...... 50 amoxicillin-potassium ACTEMRA ACTPEN...... 43 allergy relief/nasal decongest... 50 clavulanate er...... 7 ACTHAR...... 39 allopurinol...... 13 amphetamine sulfate...... 26 ACTHIB...... 45 allopurinol sodium...... 13 amphetamine- ACTIMMUNE...... 43 almotriptan malate...... 13 dextroamphetamine...... 26 acyclovir...... 19 alosetron hcl...... 36 ampicillin...... 7 acyclovir sodium...... 19 ALPHANATE...... 21 ampicillin sodium...... 7 ADACEL...... 45 ALPHANINE SD...... 22 ampicillin-sulbactam sodium...... 7 ADAKVEO...... 47 alprazolam...... 21 anagrelide hcl...... 22 adapalene...... 27 alprazolam er...... 21 ANASPAZ...... 36 adapalene-benzoyl peroxide.....28 alprazolam intensol...... 21 anastrozole...... 14 ADCETRIS...... 14 alprazolam xr...... 21 ANDRODERM...... 39 ADDERALL XR...... 26 ALPROLIX...... 22 ANORO ELLIPTA...... 51 adefovir dipivoxil...... 19 alprostadil...... 22 apraclonidine hcl...... 48 ADEMPAS...... 52 ALTACAINE...... 49 aprepitant...... 12 adenosine...... 22 altafrin...... 49 apri...... 40 adriamycin...... 14 altavera...... 40 APRISO...... 46 adult aspirin regimen...... 4 ALTRENO...... 28 APTIVUS...... 19 ADVAIR DISKUS...... 51 ALUMINUM CHLORIDE ARAKODA...... 18 ADVAIR HFA...... 51 ANHYDROUS...... 28 ARALAST NP...... 51 ADVATE...... 21 ALUMINUM CHLORIDE aranelle...... 40 ADYNOVATE...... 21 HEXAHYDRATE...... 28 ARANESP (ALBUMIN FREE)...22 AFINITOR...... 14 ALUNBRIG...... 14 ARCALYST...... 43 AFINITOR DISPERZ...... 14 alyacen 1/35...... 40 argyle sterile saline...... 33 afirmelle...... 40 alyacen 7/7/7...... 40 argyle sterile water...... 33 AFLURIA QUADRIVALENT...... 45 alyq...... 52 ARIKAYCE...... 7 AFSTYLA...... 21 amabelz...... 40 aripiprazole...... 19 airavite...... 33 amantadine hcl...... 18 ARISTADA...... 19 ak-poly-bac...... 49 AMBISOME...... 13 ARISTADA INITIO...... 19 ala-cort...... 28 ambrisentan...... 52 armodafinil...... 53 54 ARMOUR THYROID...... 43 avidoxy...... 7 betaxolol hcl...... 23, 48 ARNUITY ELLIPTA...... 51 AVONEX PEN...... 26 bethanechol chloride...... 37 ARRANON...... 14 AVONEX PREFILLED...... 26 bexarotene...... 14 arsenic trioxide...... 14 ayuna...... 40 BEXSERO...... 45 ARZERRA...... 14 azacitidine...... 14 bicalutamide...... 14 ascomp-codeine...... 4 AZASAN...... 43 BICILLIN L-A...... 7 ashlyna...... 40 azathioprine...... 43 BIKTARVY...... 20 ASMANEX (120 METERED azathioprine sodium...... 43 bimatoprost...... 48 DOSES)...... 51 azelaic acid...... 28 BIO-STATIN...... 13 ASMANEX (14 METERED azelastine hcl...... 48, 50 bisoprolol fumarate...... 23 DOSES)...... 51 azelastine-fluticasone...... 50 bisoprolol-hydrochlorothiazide.. 23 ASMANEX (30 METERED azithromycin...... 7 BIVIGAM...... 43 DOSES)...... 51 aztreonam...... 7 bleomycin sulfate...... 14 ASMANEX (60 METERED azurette...... 40 BLINCYTO...... 14 DOSES)...... 51 bacitracin...... 48 blisovi 24 fe...... 40 ASMANEX (7 METERED bacitracin-polymyxin b...... 49 blisovi fe 1.5/30...... 40 DOSES)...... 51 bacitra-neomycin-polymyxin-hc 49 blisovi fe 1/20...... 40 ASMANEX HFA...... 51 baclofen...... 52 BOOSTRIX...... 45 ASPARTAME...... 47 balsalazide disodium...... 46 BORTEZOMIB...... 14 ASPARTAME BALVERSA...... 14 bosentan...... 52 (NUTRASWEET)...... 47 balziva...... 40 BOSULIF...... 15 aspirin...... 4 BANZEL...... 10 BOTOX...... 47 aspirin adult low strength...... 4 BARACLUDE...... 20 BRAFTOVI...... 15 aspirin childrens...... 4 BASAGLAR KWIKPEN...... 31 BREATHE EASE LARGE...... 47 aspirin ec...... 4 BCG VACCINE...... 45 BREATHE EASE MEDIUM...... 47 aspirin ec low dose...... 4 BD AUTOSHIELD DUO PEN BREATHE EASE SMALL...... 47 aspirin ec low strength...... 4 NEEDLES...... 31 BREO ELLIPTA...... 51 aspirin low dose...... 4 BD ULTRA-FINE INSULIN briellyn...... 40 aspirin-dipyridamole er...... 18 SYRINGES...... 31 BRILINTA...... 18 ASTRAZENECA COVID-19 BD ULTRA-FINE PEN brimonidine tartrate...... 48 VACCINE...... 45 NEEDLES...... 32 BRIVIACT...... 10 ATABEX OB...... 33 BD VEO INSULIN SYR U/F BROMELAIN...... 47 atazanavir sulfate...... 20 1/2UNIT...... 32 bromfenac sodium (once-daily).48 atenolol...... 23 bekyree...... 40 bromocriptine mesylate...... 18 atenolol-chlorthalidone...... 23 BELEODAQ...... 14 BROVANA...... 51 atomoxetine hcl...... 26 BELRAPZO...... 14 budesonide...... 46, 51 atorvastatin calcium...... 23 benazepril hcl...... 23 budesonide er...... 46 atovaquone...... 18 benazepril-hydrochlorothiazide. 23 bumetanide...... 23 atovaquone-proguanil hcl...... 18 BENDEKA...... 14 bupivacaine fisiopharma...... 6 atropine sulfate...... 36, 49 BENEFIX...... 22 bupivacaine hcl...... 6 ATROVENT HFA...... 51 BENLYSTA...... 43 bupivacaine hcl (pf)...... 6 AUBAGIO...... 26 BENZNIDAZOLE...... 18 bupivacaine-epinephrine...... 6 aubra...... 40 benzonatate...... 50 bupivacaine-epinephrine (pf)...... 6 aubra eq...... 40 benzoyl peroxide-erythromycin. 28 buprenorphine...... 4 AUGMENTIN...... 7 benzphetamine hcl...... 27 buprenorphine hcl...... 4, 7 aurovela 1.5/30...... 40 benztropine mesylate...... 18 buprenorphine hcl-naloxone aurovela 1/20...... 40 BERINERT...... 43 hcl...... 7 aurovela 24 fe...... 40 beser...... 28 bupropion hcl...... 11 aurovela fe 1.5/30...... 40 betamethasone dipropionate.... 28 bupropion hcl er (smoking det)... 7 aurovela fe 1/20...... 40 betamethasone dipropionate bupropion hcl er (sr)...... 11 AUSTEDO...... 27 aug...... 28 bupropion hcl er (xl)...... 11 AVASTIN...... 14 betamethasone valerate...... 28 buspirone hcl...... 21 aviane...... 40 BETASERON...... 26 busulfan...... 15

55 butalbital-acetaminophen...... 4 CARIMUNE NF...... 43 CHANTIX STARTING MONTH butalbital-apap-caff-cod...... 4 carisoprodol...... 52 PAK...... 7 butalbital-apap-caffeine...... 5 carisoprodol-aspirin-codeine...... 5 CHARCOAL ACTIVATED...... 47 butalbital-asa-caff-codeine...... 5 carmustine...... 15 charlotte 24 fe...... 40 butalbital-aspirin-caffeine...... 5 carteolol hcl...... 48 chateal...... 40 butorphanol tartrate...... 5 cartia xt...... 23 chateal eq...... 40 BYDUREON BCISE carvedilol...... 23 chlordiazepoxide hcl...... 21 AUTOINJECTOR...... 30 carvedilol phosphate er...... 23 chlordiazepoxide-amitriptyline...11 cabergoline...... 39 caspofungin acetate...... 13 chlorhexidine gluconate...... 27 CABLIVI...... 19 cavarest...... 27 CHLORHEXIDINE CABOMETYX...... 15 caziant...... 40 GLUCONATE...... 47 caffeine citrate...... 27 cefaclor...... 7 chloroquine phosphate...... 18 CALAMINE...... 28 cefaclor er...... 7 chlorothiazide sodium...... 23 calcipotriene...... 28 cefadroxil...... 7 chlorpromazine hcl...... 19 calcitonin (salmon)...... 46 cefazolin sodium...... 7 chlorthalidone...... 23 calcitriol...... 28, 47 CEFAZOLIN SODIUM...... 7 chlorzoxazone...... 52 calcium acetate...... 37 cefazolin sodium-dextrose...... 7 CHOLBAM...... 36 calcium acetate (phos binder)...37 cefdinir...... 7 cholestyramine...... 23 CALCIUM CHLORIDE cefepime hcl...... 7 cholestyramine light...... 23 DIHYDRATE...... 33 cefepime-dextrose...... 7 CHOLINE BITARTRATE...... 33 ...... 33 cefixime...... 7 chorionic gonadotropin...... 39 CALCIUM GLUCONATE cefotaxime sodium...... 7 ciclodan...... 13 ANHYDROUS...... 33 cefoxitin sodium...... 7 ciclopirox...... 13 CALCIUM GLUCONATE cefpodoxime proxetil...... 7 ciclopirox olamine...... 13 MONOHYDRATE...... 33 cefprozil...... 7 cidofovir...... 20 CALCIUM LACTATE ceftazidime...... 8 cilostazol...... 19 PENTAHYDRATE...... 33 ceftazidime and dextrose...... 8 CIMDUO...... 20 CALCIUM PHOSPHATE ceftriaxone sodium...... 8 cimetidine...... 35 DIBASIC...... 33 ceftriaxone sodium in dextrose... 8 cimetidine hcl...... 35 CALCIUM PHOSPHATE ceftriaxone sodium-dextrose...... 8 CIMZIA PREFILLED KIT...... 44 TRIBASIC...... 33 cefuroxime axetil...... 8 CIMZIA STARTER KIT...... 44 CALQUENCE...... 15 cefuroxime sodium...... 8 cinacalcet hcl...... 47 camila...... 40 celecoxib...... 4 CINQAIR...... 50 CAMPATH...... 15 CELLCEPT...... 43 CINRYZE...... 44 camrese...... 40 CELONTIN...... 10 CINVANTI...... 12 camrese lo...... 40 cephalexin...... 8 CIPRO...... 8 candesartan cilexetil...... 23 CEQUR SIMPLICITY 2U...... 31 ciprofloxacin hcl...... 8, 48, 49 candesartan cilexetil-hctz...... 23 CEQUR SIMPLICITY ciprofloxacin in d5w...... 8 CAPASTAT SULFATE...... 14 INSERTER...... 31 cisplatin...... 15 capecitabine...... 15 CEQUR SIMPLICITY citalopram hydrobromide...... 11 CAPRELSA...... 15 STARTER...... 31 cladribine...... 15 captopril...... 23 CERDELGA...... 36 claravis...... 28 captopril-hydrochlorothiazide.... 23 CEREZYME...... 36 clarithromycin...... 8 CARBAGLU...... 33 cetirizine hcl...... 50 clarithromycin er...... 8 carbamazepine...... 10 cetirizine hcl childrens alrgy...... 50 CLEVER CHOICE HOLDING carbamazepine er...... 10 cetirizine-pseudoephedrine er...50 CHAMBER...... 47 carbidopa...... 18 CETROTIDE...... 39 CLIMARA PRO...... 40 carbidopa-levodopa...... 18 CETYLCIDE-G...... 47 clindacin etz...... 28 carbidopa-levodopa er...... 18 cevimeline hcl...... 27 clindacin-p...... 28 carbidopa-levodopa- CHANTIX...... 7 clindamycin hcl...... 8 entacapone...... 18 CHANTIX CONTINUING clindamycin palmitate hcl...... 8 carbinoxamine maleate...... 50 MONTH PAK...... 7 clindamycin phosphate...... 8, 28 carboplatin...... 15 clindamycin phosphate in d5w.... 8

56 CLINDAMYCIN PHOSPHATE CONTOUR NEXT EZ KIT daysee...... 40 IN NACL...... 8 W/DEVICE...... 31 deblitane...... 40 clindamycin phosphate- CONTOUR NEXT LINK KIT decitabine...... 15 benzoyl peroxide...... 28 W/DEVICE...... 31 deferasirox...... 33 clindamycin-tretinoin...... 28 CONTOUR NEXT MONITOR deferasirox granules...... 33 CLINPRO 5000...... 27 KIT W/DEVICE...... 31 deferoxamine mesylate...... 47 clobazam...... 10 CONTOUR NEXT ONE KIT...... 31 DELSTRIGO...... 20 clobetasol prop emollient base. 28 CONTOUR NEXT TEST delyla...... 40 clobetasol propionate...... 28, 29 STRIPS...... 31 demeclocycline hcl...... 8 clobetasol propionate e...... 28 CONTOUR TEST STRIPS...... 31 DENTA 5000 PLUS...... 27 clobetasol propionate emulsion 28 COPIKTRA...... 15 DENTAGEL...... 27 clocortolone pivalate...... 29 CORIFACT...... 22 DEPO-MEDROL...... 38 clodan...... 29 COTELLIC...... 15 desipramine hcl...... 11 clofarabine...... 15 CREON...... 36 desloratadine...... 50 clomiphene citrate...... 39 CRESEMBA...... 13 desmopressin ace spray refrig..39 clomipramine hcl...... 11 CRIXIVAN...... 20 desmopressin acetate...... 39 clonazepam...... 21 cromolyn sodium...... 36, 48, 51 desmopressin acetate spray..... 39 clonidine...... 23 cryselle-28...... 40 desogestrel-ethinyl estradiol..... 40 clonidine hcl...... 23 CRYSVITA...... 36 desonide...... 29 clonidine hcl er...... 26 CUVITRU...... 44 desoximetasone...... 29 clopidogrel bisulfate...... 19 cyanocobalamin...... 33 desvenlafaxine succinate er...... 11 clorazepate dipotassium...... 21 cyclafem 1/35...... 40 dexamethasone...... 38 clotrimazole...... 13 cyclafem 7/7/7...... 40 DEXAMETHASONE (LA)...... 38 clotrimazole 3...... 13 cyclobenzaprine hcl...... 52 dexamethasone sod clotrimazole-betamethasone.....13 cyclopentolate hcl...... 49 phosphate pf...... 38 clovique...... 33 cyclophosphamide...... 15 dexamethasone sodium clozapine...... 19 cyclosporine...... 44 phosphate...... 38, 48 COAGADEX...... 22 cyclosporine modified...... 44 DEXCOM G4 / G5 / G6 COARTEM...... 18 cyproheptadine hcl...... 50 RECEIVER, TRANSMITTER, codeine sulfate...... 5 CYRAMZA...... 15 SENSOR (INCLUDING colchicine...... 13 cyred...... 40 PLATINUM, PLATINUM colchicine-probenecid...... 13 cyred eq...... 40 PEDIATRIC)...... 31 colestipol hcl...... 23 CYSTADROPS...... 49 DEXMEDETOMIDINE HCL...... 47 colistimethate sodium (cba)...... 8 CYSTAGON...... 36 dexmedetomidine hcl...... 47 COMBIVENT RESPIMAT...... 51 CYSTARAN...... 49 dexmedetomidine hcl in nacl.....47 COMETRIQ...... 15 cytarabine...... 15 dexmethylphenidate hcl...... 26 COMPACT SPACE cytarabine (pf)...... 15 dexmethylphenidate hcl er...... 26 CHAMBER/LG MASK...... 47 CYTOGAM...... 44 dexrazoxane hcl...... 15 COMPACT SPACE dacarbazine...... 15 dextroamphetamine sulfate...... 26 CHAMBER/MED MASK...... 47 dactinomycin...... 15 dextroamphetamine sulfate er.. 26 COMPACT SPACE dalfampridine er...... 26 dextrose in lactated ringers...... 33 CHAMBER/SM MASK...... 47 DALIRESP...... 51 dextrose-nacl...... 33 COMPLERA...... 20 danazol...... 39 dextrose-sodium chloride...... 33 compro...... 12 dantrolene sodium...... 52 DIACOMIT...... 10 constulose...... 36 dapsone...... 14 diazepam...... 10, 21 CONTOUR CONTROL DAPTACEL...... 45 diazepam intensol...... 21 SOLUTION...... 31 daptomycin...... 8 diazoxide...... 31 CONTOUR MONITOR darifenacin hydrobromide er..... 37 diclofenac potassium...... 4 DEVICE...... 31 DARZALEX...... 15 diclofenac sodium...... 4, 48 CONTOUR MONITOR KIT dasetta 1/35...... 40 diclofenac sodium er...... 4 W/DEVICE...... 31 dasetta 7/7/7...... 40 diclofenac-misoprostol...... 4 CONTOUR NEXT CONTROL daunorubicin hcl...... 15 dicloxacillin sodium...... 8 SOLUTION...... 31 DAURISMO...... 15 dicyclomine hcl...... 36

57 diethylpropion hcl...... 27 DROPLET MICRON...... 32 ENTRESTO...... 23 diethylpropion hcl er...... 27 drospiren-eth estrad-levomefol. 40 ENTYVIO...... 44 DIFICID...... 8 drospirenone-ethinyl estradiol...40 enulose...... 36 diflunisal...... 4 DROXIA...... 15 EPCLUSA...... 20 digitek...... 23 droxidopa...... 23 EPIDIOLEX...... 10 digox...... 23 DRYSOL...... 29 epinastine hcl...... 48 digoxin...... 23 duloxetine hcl...... 12 epinephrine...... 51 dihydroergotamine mesylate DUPIXENT...... 29 epirubicin hcl...... 15 ...... 13, 14 DUROLANE...... 47 epitol...... 10 diltiazem hcl...... 23 dutasteride...... 38 EPIVIR HBV...... 20 diltiazem hcl er...... 23 dutasteride-tamsulosin hcl...... 38 eplerenone...... 23 diltiazem hcl er beads...... 23 DYSPORT...... 47 epoprostenol sodium...... 52 diltiazem hcl er coated beads... 23 EASIVENT...... 47 EQUETRO...... 21 DILTIAZEM HCL-DEXTROSE.. 23 econazole nitrate...... 13 ERBITUX...... 15 dilt-xr...... 23 ED-SPAZ...... 36 ergocalciferol...... 33 dimethyl fumarate...... 26 EDURANT...... 20 ergoloid mesylates...... 47 dimethyl fumarate starter pack..26 efavirenz...... 20 ergotamine-caffeine...... 14 diphen...... 50 efavirenz-emtricitab-tenofovir....20 ERIVEDGE...... 15 diphenhydramine hcl...... 50 efavirenz-lamivudine-tenofovir.. 20 ERLEADA...... 15 diphenoxylate-atropine...... 36 EFFER-K...... 33 erlotinib hcl...... 15 DIPHTHERIA-TETANUS effer-k...... 33 errin...... 40 TOXOIDS DT...... 45 EGRIFTA SV...... 39 ertapenem sodium...... 8 dipyridamole...... 19 ELAPRASE...... 36 ery...... 29 disopyramide phosphate...... 23 ELELYSO...... 36 erythromycin...... 8, 29, 48 disulfiram...... 7 eletriptan hydrobromide...... 14 erythromycin base...... 8 divalproex sodium...... 10 ELIGARD...... 39 erythromycin ethylsuccinate...... 8 divalproex sodium er...... 10 elinest...... 40 ESBRIET...... 51 DIVIGEL...... 40 ELIQUIS...... 10 escitalopram oxalate...... 12 DL-ALANINE...... 33 ELIQUIS DVT/PE STARTER esomeprazole magnesium...... 35 DL-LEUCINE...... 33 PACK...... 10 estarylla...... 40 DL-PHENYLALANINE...... 33 ELITEK...... 15 estazolam...... 21 dobutamine hcl...... 23 ELLA...... 40 estradiol...... 41 dobutamine in d5w...... 23 ELOCTATE...... 22 estradiol valerate...... 41 docetaxel...... 15 eluryng...... 40 estradiol-norethindrone acet..... 41 dofetilide...... 23 EMFLAZA...... 13 eszopiclone...... 53 donepezil hcl...... 11 EMGALITY...... 14 ethacrynic acid...... 23 dopamine hcl...... 23 EMGALITY (300 MG DOSE).... 14 ethambutol hcl...... 14 DOPTELET...... 22 emoquette...... 40 ethosuximide...... 10 DORZOLAMIDE HCL...... 49 EMPLICITI...... 15 ethynodiol diac-eth estradiol..... 41 dorzolamide hcl...... 49 emtricitabine...... 20 ETHYOL...... 15 dorzolamide hcl-timolol mal...... 49 emtricitabine-tenofovir df...... 20 etodolac...... 4 dorzolamide hcl-timolol mal pf.. 49 EMTRIVA...... 20 etodolac er...... 4 dotti...... 40 enalapril maleate...... 23 etonogestrel-ethinyl estradiol.... 41 DOVATO...... 20 enalapril-hydrochlorothiazide.... 23 ETOPOPHOS...... 15 doxazosin mesylate...... 23 endocet...... 5 etoposide...... 15 doxepin hcl...... 12, 53 ENGERIX-B...... 45 EUCRISA...... 29 doxercalciferol...... 47 ENHERTU...... 15 EUFLEXXA...... 47 doxorubicin hcl...... 15 ENLITE GLUCOSE SENSOR...31 euthyrox...... 43 doxorubicin hcl liposomal...... 15 enoxaparin sodium...... 10 everolimus...... 15, 44 doxy 100...... 8 enpresse-28...... 40 EVERSENSE doxycycline hyclate...... 8 enskyce...... 40 SENSOR/HOLDER...... 31 doxycycline monohydrate...... 8 entacapone...... 18 EVERSENSE SMART dronabinol...... 12 entecavir...... 20 TRANSMITTER...... 31

58 EVOTAZ...... 20 fluocinolone acetonide...... 29, 49 GAMMAGARD S/D LESS IGA..44 exemestane...... 15 fluocinolone acetonide body..... 29 GAMMAKED...... 44 EXTAVIA...... 26 fluocinolone acetonide scalp.....29 GAMMAPLEX...... 44 EYLEA...... 49 fluocinonide...... 29 GAMUNEX-C...... 44 ezetimibe...... 23 fluocinonide emulsified base.....29 GANCICLOVIR...... 20 fabb...... 33 FLUORIDEX...... 27 ganciclovir sodium...... 20 FABRAZYME...... 36 FLUORIDEX ENHANCED GARDASIL 9...... 45 falmina...... 41 WHITENING...... 27 gatifloxacin...... 48 famciclovir...... 20 FLUORIDEX SENSITIVITY GATTEX...... 36 famotidine...... 35 RELIEF...... 27 gavilyte-c...... 36 famotidine premixed...... 35 fluoritab...... 33 gavilyte-g...... 36 FANAPT...... 19 fluorometholone...... 48 gavilyte-n with flavor pack...... 36 FARXIGA...... 30 fluorouracil...... 15, 29 GAVRETO...... 15 FARYDAK...... 15 fluoxetine hcl...... 12 GAZYVA...... 15 FASENRA...... 50 fluoxetine hcl (pmdd)...... 12 GELNIQUE...... 37 FASENRA PEN...... 50 fluphenazine decanoate...... 19 GELSYN-3...... 47 fa-vitamin b-6-vitamin b-12...... 33 fluphenazine hcl...... 19 gemcitabine hcl...... 15 fayosim...... 41 flurazepam hcl...... 53 gemfibrozil...... 24 FEIBA...... 22 flurbiprofen...... 4 generlac...... 36 felbamate...... 10 flurbiprofen sodium...... 48 gengraf...... 44 felodipine er...... 23 flutamide...... 15 GENOTROPIN...... 39 femynor...... 41 fluticasone propionate...... 29, 50 GENOTROPIN MINIQUICK...... 39 fenofibrate...... 24 FLUTICASONE- gentak...... 48 fenofibrate micronized...... 23 SALMETEROL...... 51 gentamicin in saline...... 8 fenofibric acid...... 24 fluvoxamine maleate...... 12 gentamicin sulfate...... 8, 48 FENSOLVI (6 MONTH)...... 39 fluvoxamine maleate er...... 12 GENVOYA...... 20 fentanyl...... 5 FLUZONE HIGH-DOSE GILENYA...... 26 fentanyl citrate...... 5 QUADRIVALENT...... 45 GILOTRIF...... 15 FIBRYGA...... 22 FLUZONE QUADRIVALENT.... 45 GLASSIA...... 51 finasteride...... 29, 38 FML FORTE...... 48 glatiramer acetate...... 26 FIRDAPSE...... 47 folbee...... 33 glatopa...... 26 FIRMAGON...... 39 folic acid...... 33 GLEOSTINE...... 15 FIRMAGON (240 MG DOSE)... 39 FOLLISTIM AQ...... 39 GLIADEL WAFER...... 15 flavoxate hcl...... 37 FOLOTYN...... 15 glimepiride...... 30 FLEBOGAMMA DIF...... 44 folplex 2.2...... 33 glipizide er...... 30 flecainide acetate...... 24 fondaparinux sodium...... 10 glipizide ir...... 30 FLEXBUMIN...... 47 FORTAZ...... 8 glipizide xl...... 30 floxuridine...... 15 fosamprenavir calcium...... 20 glipizide-metformin hcl...... 30 FLUAD...... 45 fosinopril sodium...... 24 GLUCAGON EMERGENCY FLUAD QUADRIVALENT...... 45 fosinopril sodium-hctz...... 24 KIT...... 31 FLUARIX QUADRIVALENT...... 45 fosphenytoin sodium...... 10 glyburide...... 30 FLUBLOK QUADRIVALENT.....45 FRAGMIN...... 10 glyburide micronized...... 30 FLUCELVAX fulvestrant...... 15 glyburide-metformin...... 30 QUADRIVALENT...... 45 furosemide...... 24 glycopyrrolate...... 36 fluconazole...... 13 FUZEON...... 20 glydo...... 6 fluconazole in sodium chloride..13 fyavolv...... 41 granisetron hcl...... 12 flucytosine...... 13 FYCOMPA...... 10 griseofulvin microsize...... 13 fludarabine phosphate...... 15 gabapentin...... 10 griseofulvin ultramicrosize...... 13 fludrocortisone acetate...... 38 galantamine hydrobromide...... 11 guanfacine hcl...... 24 FLULAVAL QUADRIVALENT... 45 galantamine hydrobromide er... 11 guanfacine hcl er...... 26 flumazenil...... 47 GAMASTAN...... 44 GUARDIAN CONNECT FLUMIST QUADRIVALENT...... 45 GAMIFANT...... 44 TRANSMITTER...... 31 flunisolide...... 50 GAMMAGARD...... 44

59 GUARDIAN LINK 3 HUMIRA PEN-PEDIATRIC UC IDHIFA...... 16 TRANSMITTER...... 31 START...... 44 ifosfamide...... 16 GUARDIAN SENSOR (3)...... 31 HUMIRA PEN-PS/UV/ADOL ILARIS...... 44 GUARDIAN SENSOR 3...... 31 HS START...... 44 imatinib mesylate...... 16 HAEGARDA...... 44 HUMIRA PEN-PSOR/UVEIT IMBRUVICA...... 16 hailey 1.5/30...... 41 STARTER...... 44 IMFINZI...... 16 hailey 24 fe...... 41 HUMULIN 70/30 KWIKPEN...... 32 imipenem-cilastatin...... 8 hailey fe 1.5/30...... 41 HUMULIN 70/30 VIAL...... 32 imipramine hcl...... 12 hailey fe 1/20...... 41 HUMULIN N KWIKPEN...... 32 imipramine pamoate...... 12 HALAVEN...... 15 HUMULIN N VIAL...... 32 imiquimod...... 29 halobetasol propionate...... 29 HUMULIN R U-500 KWIKPEN..32 IMOVAX RABIES...... 45 haloperidol...... 19 HUMULIN R U-500 VIAL...... 32 IMPAVIDO...... 18 ...... 19 HUMULIN R VIAL...... 32 IMURAN...... 44 haloperidol lactate...... 19 HYCAMTIN...... 15 INBRIJA...... 18 HARVONI...... 20 hydralazine hcl...... 24 incassia...... 41 HAVRIX...... 45 hydrochlorothiazide...... 24 INCRELEX...... 39 heather...... 41 hydrocodone bitartrate er...... 5 INCRUSE ELLIPTA...... 51 hematinic/folic acid...... 33 hydrocodone polst-chlorphen indapamide...... 24 HEMLIBRA...... 22 polst er susp...... 50 indomethacin...... 4 hemocyte-f...... 33 hydrocodone-acetaminophen..... 5 indomethacin er...... 4 HEMOFIL M...... 22 hydrocodone-homatropine...... 50 indomethacin sodium...... 4 HEPARIN (PORCINE) IN hydrocodone-ibuprofen...... 5 INFANRIX...... 45 NACL...... 10 hydrocortisone...... 29, 38, 46 INFLECTRA...... 44 heparin lock flush...... 47 hydrocortisone (perianal)...... 46 INLYTA...... 16 heparin sodium (porcine)...... 10 hydrocortisone butyrate...... 29 INPEN 100-BLUE-LILLY...... 31 heparin sodium (porcine) pf...... 10 hydrocortisone valerate...... 29 INPEN 100-BLUE-NOVO...... 31 heparin sodium lock flush...... 47 hydrocortisone-acetic acid...... 49 INPEN 100-GRAY-LILLY...... 31 HEPLISAV-B...... 45 hydromet...... 50 INPEN 100-GREY-NOVO...... 31 HERCEPTIN...... 15 hydromorphone hcl...... 5 INPEN 100-PINK-LILLY...... 31 HETLIOZ...... 53 HYDROMORPHONE HCL...... 5 INPEN 100-PINK-NOVO...... 31 HIBERIX...... 45 hydromorphone hcl er...... 5 INSULIN PEN NEEDLES...... 32 HIZENTRA...... 44 hydromorphone hcl pf...... 5 INSULIN SYRINGES...... 32 homatropaire...... 49 HYDROXOCOBALAMIN INTELENCE...... 20 HUMALOG KWIKPEN...... 32 ACETATE...... 33 INTRON A...... 20 HUMALOG MIX 50/50 hydroxychloroquine sulfate...... 18 introvale...... 41 KWIKPEN...... 32 hydroxyprogesterone caproate. 41 INVEGA SUSTENNA...... 19 HUMALOG MIX 50/50 VIAL...... 32 hydroxyurea...... 16 INVEGA TRINZA...... 19 HUMALOG MIX 75/25 hydroxyzine hcl...... 21 INVIRASE...... 20 KWIKPEN...... 32 hydroxyzine pamoate...... 21 IPOL...... 45 HUMALOG MIX 75/25 VIAL...... 32 hyoscyamine sulfate...... 36 ipratropium bromide...... 50, 51 HUMALOG U-100 JUNIOR hyoscyamine sulfate sl...... 36 ipratropium-albuterol...... 51 KWIKPEN...... 32 hyosyne...... 36 irbesartan...... 24 HUMALOG VIAL...... 32 HYPERRHO S/D...... 44 irbesartan-hydrochlorothiazide..24 HUMAN ALBUMIN GRIFOLS... 47 HYQVIA...... 44 IRESSA...... 16 HUMATE-P...... 22 ibandronate sodium...... 46 irinotecan hcl...... 16 HUMATROPE...... 39 IBRANCE...... 16 ISENTRESS...... 20 HUMIRA...... 44 ibuprofen...... 4 ISENTRESS HD...... 20 HUMIRA PEDIATRIC ibuprofen lysine...... 4 isibloom...... 41 CROHNS START...... 44 ibutilide fumarate...... 24 isoniazid...... 14 HUMIRA PEN...... 44 iclevia...... 41 isosorbide dinitrate...... 24 HUMIRA PEN-CD/UC/HS ICLUSIG...... 16 isosorbide mononitrate...... 24 STARTER...... 44 idarubicin hcl...... 16 isosorbide mononitrate er...... 24 IDELVION...... 22 isotretinoin...... 29

60 isradipine...... 24 klor-con m20...... 34 levetiracetam...... 11 itraconazole...... 13 klor-con/ef...... 34 levetiracetam er...... 11 ivermectin...... 18 KOATE...... 22 levobunolol hcl...... 49 IXEMPRA KIT...... 16 KOATE-DVI...... 22 levocarnitine...... 34 IXIARO...... 45 KOGENATE FS...... 22 levocarnitine sf...... 34 IXINITY...... 22 KORLYM...... 40 levocetirizine dihydrochloride....50 jaimiess...... 41 KOSELUGO...... 16 levofloxacin...... 9, 48 JAKAFI...... 16 KOVALTRY...... 22 levofloxacin in d5w...... 8 JANSSEN COVID-19 KRINTAFEL...... 18 levonest...... 41 VACCINE...... 45 kurvelo...... 41 levonorgest-eth est & eth est.... 41 jantoven...... 10 KYNMOBI...... 18 levonorgest-eth estrad 91-day.. 41 JARDIANCE...... 30 KYNMOBI TITRATION KIT...... 18 levonorgestrel-ethinyl estrad.....41 jasmiel...... 41 KYPROLIS...... 16 levonorg-eth estrad triphasic.....41 jencycla...... 41 labetalol hcl...... 24 levora 0.15/30 (28)...... 41 JEVTANA...... 16 lactated ringers...... 34 levo-t...... 43 jinteli...... 41 lactulose...... 36 levothyroxine sodium...... 43 jolessa...... 41 lactulose encephalopathy...... 36 levoxyl...... 43 juleber...... 41 L-ALANINE...... 34 LEXIVA...... 20 JULUCA...... 20 lamivudine...... 20 L-GLUTAMIC ACID...... 34 junel 1.5/30...... 41 lamivudine-zidovudine...... 20 L-GLUTAMIC ACID HCL...... 36 junel 1/20...... 41 lamotrigine...... 10, 11 L-HISTIDINE...... 34 junel fe 1.5/30...... 41 lamotrigine er...... 10 L-HISTIDINE junel fe 1/20...... 41 lamotrigine starter kit-blue...... 11 MONOHYDROCHLORIDE...... 34 junel fe 24...... 41 lamotrigine starter kit-green...... 11 LIALDA...... 46 JUXTAPID...... 24 lamotrigine starter kit-orange.... 11 lidocaine...... 6 JYNARQUE...... 33 LANCETS...... 31 lidocaine hcl...... 6, 27 KADCYLA...... 16 LANOXIN...... 24 LIDOCAINE HCL...... 6 KALBITOR...... 44 lansoprazole...... 35 lidocaine hcl (cardiac)...... 6 KALETRA...... 20 lanthanum carbonate...... 37 lidocaine hcl (cardiac) pf...... 6 kalliga...... 41 LANTUS SOLOSTAR...... 32 lidocaine hcl (pf)...... 6 KALYDECO...... 52 LANTUS U-100 VIAL...... 32 lidocaine hcl urethral/mucosal.....6 KANUMA...... 36 lapatinib ditosylate...... 16 lidocaine viscous hcl...... 27 kariva...... 41 L-ARGININE...... 34 lidocaine-epinephrine...... 6 KAZANO...... 30 larin 1.5/30...... 41 lidocaine-prilocaine...... 6 kcl in dextrose-nacl...... 33 larin 1/20...... 41 lillow...... 41 kedbumin...... 47 larin 24 fe...... 41 lincomycin hcl...... 9 kelnor 1/35...... 41 larin fe 1.5/30...... 41 lindane...... 18 kelnor 1/50...... 41 larin fe 1/20...... 41 linezolid...... 9 KENALOG...... 38 larissia...... 41 linezolid in sodium chloride...... 9 KEPIVANCE...... 27 latanoprost...... 49 LINZESS...... 36 ketoconazole...... 13 LATUDA...... 19 liothyronine sodium...... 43 ketoprofen...... 4 layolis fe...... 41 lisinopril...... 24 ketorolac tromethamine...... 4, 48 L-CYSTINE...... 34 lisinopril-hydrochlorothiazide.....24 KEVEYIS...... 49 leena...... 41 lithium...... 21 KEYTRUDA...... 16 leflunomide...... 44 lithium carbonate...... 21 KINERET...... 44 LEMTRADA...... 26 lithium carbonate er...... 21 KINRIX...... 45 LENVIMA...... 16 L-LEUCINE...... 34 KISQALI...... 16 lessina...... 41 lojaimiess...... 41 KISQALI FEMARA...... 16 letrozole...... 16 LONHALA MAGNAIR REFILL klor-con...... 34 leucovorin calcium...... 16 KIT...... 51 klor-con 10...... 33 LEUKERAN...... 16 LONHALA MAGNAIR klor-con m10...... 33 LEUKINE...... 22 STARTER KIT...... 51 KLOR-CON M15...... 34 leuprolide acetate...... 39 LONSURF...... 16

61 loperamide hcl...... 36 medroxyprogesterone acetate METHYLPREDNISOLONE lopinavir-ritonavir...... 20 ...... 41, 42 ACETATE...... 38 lorazepam...... 21 mefloquine hcl...... 18 methylprednisolone acetate...... 38 lorazepam intensol...... 21 megestrol acetate...... 42 methylprednisolone sodium LORBRENA...... 16 MEKINIST...... 16 succ...... 38 loryna...... 41 MEKTOVI...... 16 ...... 39 losartan potassium...... 24 melodetta 24 fe...... 42 metoclopramide hcl...... 12 losartan potassium-hctz...... 24 meloxicam...... 4 metolazone...... 24 lovastatin...... 24 melphalan...... 16 metoprolol succinate er...... 24 low-ogestrel...... 41 melphalan hcl...... 16 metoprolol tartrate...... 24 loxapine succinate...... 19 memantine hcl...... 11 metoprolol-hydrochlorothiazide.24 lo-zumandimine...... 41 memantine hcl er...... 11 metronidazole...... 9, 29, 30 L-PHENYLALANINE...... 34 MENACTRA...... 45 metronidazole in nacl...... 9 L-PROLINE...... 34 MENOPUR...... 39 mexiletine hcl...... 24 L-TRYPTOPHAN...... 34 MENQUADFI...... 45 mibelas 24 fe...... 42 L-TYROSINE...... 34 MENVEO...... 45 miconazole 3...... 13 LUCENTIS...... 49 meperidine hcl...... 5 MICRHOGAM ULTRA- LUMIGAN...... 49 meprobamate...... 21 FILTERED PLUS...... 44 LUMIZYME...... 37 MEPSEVII...... 37 MICROCHAMBER...... 48 LUPANETA PACK...... 39 mercaptopurine...... 16 microgestin 1.5/30...... 42 LUPRON DEPOT (1-MONTH)..39 meropenem...... 9 microgestin 1/20...... 42 LUPRON DEPOT (3-MONTH)..39 MEROPENEM-SODIUM microgestin 24 fe...... 42 LUPRON DEPOT (4-MONTH) CHLORIDE...... 9 microgestin fe 1.5/30...... 42 INTRAMUSCULAR KIT 30MG..39 mesalamine...... 46 microgestin fe 1/20...... 42 LUPRON DEPOT (6-MONTH) mesalamine-cleanser...... 46 midodrine hcl...... 24 INTRAMUSCULAR KIT 45MG..39 mesna...... 16 miglitol...... 30 LUPRON DEPOT-PED (1- MESNEX...... 16 miglustat...... 37 MONTH)...... 39 metaxalone...... 52 mili...... 42 LUPRON DEPOT-PED (3- metformin hcl er...... 30 milrinone lactate...... 24 MONTH)...... 39 metformin hcl ir...... 30 milrinone lactate in dextrose..... 24 lutera...... 41 methadone hcl...... 5 mimvey...... 42 L-VALINE...... 34 methadone hcl intensol...... 5 mineral oil heavy...... 36 lyleq...... 41 methadose...... 5 MINOCIN...... 9 lyllana...... 41 methadose sugar-free...... 5 minocycline hcl...... 9 LYNPARZA...... 16 methazolamide...... 49 minoxidil...... 24 LYSODREN...... 16 methenamine hippurate...... 9 mirtazapine...... 12 lyza...... 41 methergine...... 47 misoprostol...... 35 mafenide acetate...... 9 methimazole...... 43 mitomycin...... 16 MAGNESIUM CARBONATE.... 34 methocarbamol...... 53 mitoxantrone hcl...... 16 MAGNESIUM CARBONATE methotrexate...... 44 M-M-R II...... 45 HEAVY...... 34 methotrexate sodium...... 44 M-NATAL PLUS...... 34 magnesium chloride...... 34 methotrexate sodium (pf)...... 44 modafinil...... 53 malathion...... 18 methoxsalen rapid...... 29 MODERNA COVID-19 mannitol...... 24 methscopolamine bromide...... 36 VACCINE...... 45 maprotiline hcl...... 12 methyldopa...... 24 moexipril hcl...... 24 marlissa...... 41 methyldopa- mometasone furoate...... 30, 50 MARQIBO...... 16 hydrochlorothiazide...... 24 mondoxyne nl...... 9 MATULANE...... 16 methylergonovine maleate..47, 48 monoject flush syringe...... 34 matzim la...... 24 methylphenidate hcl...... 26 monoject sodium chloride flush.34 MAVYRET...... 20 methylphenidate hcl er...... 26 mono-linyah...... 42 MAXICOMFORT SYR 27G X methylphenidate hcl er (cd)...... 26 montelukast sodium...... 51 1/2"...... 32 methylphenidate hcl er (la)...... 26 morgidox...... 9 meclizine hcl...... 12 methylprednisolone...... 38 morphine sulfate...... 5

62 morphine sulfate (concentrate)... 5 NERLYNX...... 16 NOVOEIGHT...... 22 morphine sulfate er...... 5 NESINA...... 30 NOVOFINE AUTOCOVER morphine sulfate er beads...... 5 NESTABS...... 34 PEN NEEDLE...... 32 MOXIFLOXACIN HCL...... 9 neuac...... 30 NOVOFINE PEN NEEDLE...... 32 moxifloxacin hcl...... 9, 48 NEULASTA...... 22 NOVOFINE PLUS PEN moxifloxacin hcl in nacl...... 9 NEULASTA ONPRO...... 22 NEEDLE...... 32 MOZOBIL...... 22 nevirapine...... 20 NOVOPEN ECHO...... 31 multivitamin/fluoride...... 34 nevirapine er...... 20 NOVOSEVEN RT...... 22 mupirocin...... 9 NEXAVAR...... 16 NOVOTWIST PEN NEEDLE.... 32 mutamycin...... 16 niacin er (antihyperlipidemic).... 24 np thyroid...... 43 MYALEPT...... 37 nicardipine hcl...... 24 NPLATE...... 22 mycophenolate mofetil...... 44 NICARDIPINE HCL IN NACL... 24 NUCALA...... 50 mycophenolate mofetil hcl...... 44 nifedipine...... 24 nufol...... 34 mycophenolate sodium...... 44 nifedipine er...... 24 NULEV...... 36 MYFORTIC...... 44 nifedipine er osmotic release.... 24 NULOJIX...... 44 MYLERAN...... 16 nikki...... 42 NUWIQ...... 22 MYOBLOC...... 48 nilutamide...... 16 nyamyc...... 13 myorisan...... 30 nimodipine...... 24 nylia 7/7/7...... 42 na ferric gluc cplx in sucrose.....34 NINLARO...... 16 nymyo...... 42 nabumetone...... 4 NIPENT...... 16 nystatin...... 13 nafcillin sodium...... 9 nisoldipine er...... 24 nystatin-triamcinolone...... 13 NAFCILLIN SODIUM IN nitazoxanide...... 18 nystop...... 13 DEXTROSE...... 9 nitisinone...... 37 OBIZUR...... 22 nafrinse...... 34 NITRO-DUR...... 24 OCALIVA...... 37 nafrinse drops...... 34 nitrofurantoin macrocrystal...... 9 ocella...... 42 naftifine hcl...... 13 nitrofurantoin monohydrate OCREVUS...... 26 NAGLAZYME...... 37 macrocrystals...... 9 OCTAGAM...... 44 nalbuphine hcl...... 5 nitroglycerin...... 24, 25 octreotide acetate...... 39 naloxone hcl...... 7 NITYR...... 37 ODEFSEY...... 20 naltrexone hcl...... 7 nizatidine...... 35 ODOMZO...... 16 naproxen...... 4 NOCDURNA...... 39 OFEV...... 52 naproxen sodium...... 4 nora-be...... 42 ofloxacin...... 9, 48, 50 naratriptan hcl...... 14 norethin ace-eth estrad-fe...... 42 olanzapine...... 19 NARCAN...... 7 norethindrone...... 42 olanzapine-fluoxetine hcl...... 12 NATACYN...... 48 norethindrone acetate...... 42 olmesartan medoxomil...... 25 nateglinide...... 30 norethindrone acet-ethinyl est...42 olmesartan medoxomil-hctz...... 25 NATPARA...... 47 norethindrone-eth estradiol...... 42 olmesartan-amlodipine-hctz...... 25 NATURE-THROID...... 43 norethin-eth estradiol-fe...... 42 olopatadine hcl...... 48, 50 NAVELBINE...... 16 norgestimate-eth estradiol...... 42 omega-3-acid ethyl esters...... 25 necon 0.5/35 (28)...... 42 norgestimate-ethinyl estradiol omeprazole...... 35 nefazodone hcl...... 12 triphasic...... 42 ondansetron hcl...... 12 neomycin sulfate...... 9 norlyda...... 42 ondansetron odt...... 12 neomycin-bacitracin zn- norlyroc...... 42 ONE VITE WOMENS PLUS..... 34 polymyx...... 49 normal saline flush...... 34 ONIVYDE...... 16 neomycin-polymyxin b gu...... 9 NORTHERA...... 25 OPDIVO...... 16 neomycin-polymyxin-dexameth 49 nortrel 0.5/35 (28)...... 42 OPSUMIT...... 52 neomycin-polymyxin- nortrel 1/35 (21)...... 42 oralone...... 27 gramicidin...... 49 nortrel 1/35 (28)...... 42 ORENCIA...... 44 neomycin-polymyxin-hc...... 49, 50 nortrel 7/7/7...... 42 ORENCIA CLICKJECT...... 44 NEONATAL PLUS...... 34 nortriptyline hcl...... 12 ORENITRAM...... 52 neo-polycin...... 49 NORVIR...... 20 ORFADIN...... 37 neo-polycin hc...... 49 novarel...... 39 ORKAMBI...... 52 NEORAL...... 44 NOVAREL...... 39 orphenadrine citrate...... 53

63 orphenadrine citrate er...... 53 pentoxifylline er...... 25 portia-28...... 42 orsythia...... 42 perindopril erbumine...... 25 PORTRAZZA...... 17 oscimin...... 36 periogard...... 27 potassium acetate...... 34 oseltamivir phosphate...... 20 PERJETA...... 17 potassium chloride...... 34 OSENI...... 30 permethrin...... 18 potassium chloride crys er...... 34 OSMITROL...... 25 perphenazine...... 13 potassium chloride er...... 34 OTEZLA...... 44 PFIZER-BIONTECH COVID- potassium citrate er...... 34 OVIDREL...... 39 19 VACC...... 46 POTELIGEO...... 17 oxacillin sodium...... 9 phenazo...... 37 PRADAXA...... 10 oxaliplatin...... 16, 17 phenazopyridine hcl...... 37 PRALUENT...... 25 oxandrolone...... 39 phendimetrazine tartrate...... 27 pramipexole dihydrochloride..... 18 oxaprozin...... 4 phendimetrazine tartrate er...... 27 pramipexole dihydrochloride er.18 oxazepam...... 21 phenelzine sulfate...... 12 prasugrel hcl...... 19 oxcarbazepine...... 11 phenobarbital...... 11 pravastatin sodium...... 25 OXERVATE...... 49 phenoxybenzamine hcl...... 25 praziquantel...... 18 oxybutynin chloride...... 37 phentermine hcl...... 27 prazosin hcl...... 25 oxybutynin chloride er...... 37 phenylephrine hcl...... 25, 49 prednicarbate...... 30 oxycodone hcl...... 5 PHENYLEPHRINE HCL...... 25 prednisolone...... 38 OXYCODONE HCL ER...... 5 PHENYLEPHRINE HCL prednisolone acetate...... 48 oxycodone-acetaminophen...... 5 (PRESSORS)...... 25 prednisolone sodium oxycodone-aspirin...... 5 PHENYLEPHRINE HCL-NACL.25 phosphate...... 38, 48 oxymorphone hcl...... 5 phenytoin...... 11 prednisone...... 38 oxymorphone hcl er...... 6 phenytoin infatabs...... 11 prednisone intensol...... 38 oxytocin...... 39 phenytoin sodium...... 11 pregabalin...... 27 OZEMPIC...... 30 phenytoin sodium extended...... 11 pregnyl...... 39 paclitaxel...... 17 philith...... 42 PREMARIN...... 42 PADCEV...... 17 PHOSPHA 250 NEUTRAL...... 34 PREMPHASE...... 42 paliperidone er...... 19 phosphorous...... 34 PREMPRO...... 42 palonosetron hcl...... 12, 13 phospho-trin 250 neutral...... 34 prenatal...... 34 PALYNZIQ...... 37 PIFELTRO...... 20 prenatal plus iron...... 34 pamidronate disodium...... 46 pilocarpine hcl...... 27, 49 prenatal vitamin plus low iron....34 PANHEMATIN...... 22 pimecrolimus...... 30 PRETAB...... 34 PANRETIN...... 17 pimozide...... 19 prevalite...... 25 pantoprazole sodium...... 35 pimtrea...... 42 PREVIDENT...... 27 paraplatin...... 17 pindolol...... 25 PREVIDENT 5000 BOOSTER paricalcitol...... 47 pioglitazone hcl...... 30 PLUS...... 27 paromomycin sulfate...... 9 pioglitazone hcl-glimepiride...... 30 PREVIDENT 5000 DRY paroxetine hcl...... 12 pioglitazone hcl-metformin hcl.. 30 MOUTH...... 27 paroxetine hcl er...... 12 piperacillin sod-tazobactam so....9 PREVIDENT 5000 ENAMEL paroxetine mesylate...... 12 PIQRAY...... 17 PROTECT...... 27 PASER...... 14 pirmella 1/35...... 42 PREVIDENT 5000 ORTHO PEDIARIX...... 45 pirmella 7/7/7...... 42 DEFENSE...... 27 PEDVAX HIB...... 45 piroxicam...... 4 PREVIDENT 5000 PLUS...... 27 peg 3350-kcl-na bicarb-nacl...... 36 PLASBUMIN-25...... 48 PREVIDENT 5000 SENSITIVE.27 peg-3350/electrolytes...... 36 PLASBUMIN-5...... 48 previfem...... 42 PEGASYS...... 20 PNEUMOVAX 23...... 46 PREVNAR 13...... 46 PEGINTRON...... 20 POCKET SPACER...... 48 PREVYMIS...... 20 penicillamine...... 37 podofilox...... 30 PREZCOBIX...... 21 penicillin g potassium...... 9 POLIVY...... 17 PREZISTA...... 21 penicillin v potassium...... 9 polocaine-mpf...... 6 PRIFTIN...... 14 PENTACEL...... 45 polycin...... 49 primaquine phosphate...... 18 pentamidine isethionate...... 18 polymyxin b-trimethoprim...... 49 primidone...... 11 pentazocine-naloxone hcl...... 6 POMALYST...... 17 PRIVIGEN...... 44

64 PRO COMFORT SPACER QINLOCK...... 17 RINVOQ...... 45 ADULT...... 48 QUADRACEL...... 46 risedronate sodium...... 46 PRO COMFORT SPACER quetiapine fumarate...... 19 RISPERDAL CONSTA...... 19 CHILD...... 48 quetiapine fumarate er...... 19 risperidone...... 19 PRO COMFORT SPACER quinapril hcl...... 25 ritonavir...... 21 INFANT...... 48 quinapril-hydrochlorothiazide.... 25 RITUXAN...... 17 probenecid...... 13 quinidine gluconate er...... 25 RITUXAN HYCELA...... 17 procainamide hcl...... 25 quinidine sulfate...... 25 rivastigmine...... 11 PROCARE SPACER/ADULT quinine sulfate...... 18 rivastigmine tartrate...... 11 MASK...... 48 QVAR REDIHALER...... 52 rivelsa...... 42 PROCARE SPACER/CHILD RABAVERT...... 46 RIXUBIS...... 22 MASK...... 48 rabeprazole sodium...... 35 rizatriptan benzoate...... 14 prochlorperazine...... 13 RADICAVA...... 27 ropinirole hcl...... 18 prochlorperazine edisylate...... 13 raloxifene hcl...... 39 ropinirole hcl er...... 18 prochlorperazine maleate...... 13 ramipril...... 25 ropivacaine hcl...... 6 procto-med hc...... 46 ranolazine er...... 25 rosadan...... 30 procto-pak...... 46 RAPAMUNE...... 44 rosuvastatin calcium...... 25 proctozone-hc...... 46 rasagiline mesylate...... 18 ROTARIX...... 46 PROCYSBI...... 37 RAVICTI...... 37 ROTATEQ...... 46 PROFILNINE...... 22 RAYALDEE...... 46 roweepra...... 11 progesterone...... 42 REBIF...... 26 RUBRACA...... 17 progesterone micronized...... 42 REBIF REBIDOSE...... 26 RUCONEST...... 45 PROGRAF...... 44 REBIF REBIDOSE rufinamide...... 11 PROLASTIN-C...... 52 TITRATION PACK...... 26 RYDAPT...... 17 PROLEUKIN...... 17 REBIF TITRATION PACK...... 26 ryvent...... 51 PROLIA...... 46 REBINYN...... 22 SACCHARIN...... 48 PROMACTA...... 22 REBLOZYL...... 22 saline flush...... 34 promethazine hcl...... 50 reclipsen...... 42 saline flush zr...... 34 promethazine vc...... 50 RECOMBINATE...... 22 SANDIMMUNE...... 45 promethazine vc/codeine...... 50 RECOMBIVAX HB...... 46 sapropterin dihydrochloride...... 37 promethazine-codeine...... 50 relexxii...... 26 SCENESSE...... 30 promethazine-dm...... 50 RELNATE DHA...... 34 scopolamine...... 13 promethazine-phenyleph- RENFLEXIS...... 45 selegiline hcl...... 18 codeine...... 50 repaglinide...... 30 selenium sulfide...... 30 promethazine-phenylephrine.... 50 REPATHA...... 25 SELZENTRY...... 21 promethegan...... 50 REPATHA PUSHTRONEX SENSORCAINE...... 6 propafenone hcl...... 25 SYSTEM...... 25 sensorcaine-mpf...... 6 propafenone hcl er...... 25 REPATHA SURECLICK...... 25 SENSORCAINE-MPF...... 6 proparacaine hcl...... 49 RETACRIT...... 22 SENSORCAINE- propranolol hcl...... 25 RETEVMO...... 17 MPF/EPINEPHRINE...... 6 propranolol hcl er...... 25 RETROVIR...... 21 SEREVENT DISKUS...... 52 propranolol-hctz...... 25 REVCOVI...... 37 sertraline hcl...... 12 propylthiouracil...... 43 REVLIMID...... 17 setlakin...... 42 PROQUAD...... 46 REXULTI...... 19 sevelamer carbonate...... 37 protriptyline hcl...... 12 REYATAZ...... 21 sevelamer hcl...... 37 pseudoephedrine-bromphen- RHOGAM ULTRA-FILTERED sf 5000 plus...... 27 dm...... 51 PLUS...... 45 SFROWASA...... 46 PULMOZYME...... 52 RIASTAP...... 22 sharobel...... 42 PURIXAN...... 17 ribavirin...... 21 SHINGRIX...... 46 pyrazinamide...... 14 rifabutin...... 14 SIGNIFOR...... 39 pyridostigmine bromide...... 14 rifampin...... 14 sildenafil citrate...... 37, 52 pyridostigmine bromide er...... 14 riluzole...... 27 silodosin...... 38 pyrimethamine...... 18 rimantadine hcl...... 21 silver sulfadiazine...... 9

65 simliya...... 42 subvenite starter kit-green...... 11 TDVAX...... 46 simpesse...... 42 subvenite starter kit-orange...... 11 TECENTRIQ...... 17 SIMPONI...... 45 SUCRAID...... 37 TEGSEDI...... 27 simvastatin...... 25 sucralfate...... 35 telmisartan...... 26 sirolimus...... 45 sulfacetamide sodium...... 48 telmisartan-hctz...... 26 SIRTURO...... 14 sulfacetamide sodium (acne).... 30 temazepam...... 53 SKYRIZI (150 MG DOSE)...... 45 sulfacetamide-prednisolone...... 49 TEMIXYS...... 21 sod benz-sod phenylacet...... 37 sulfadiazine...... 9 TEMODAR...... 17 SODIUM ASCORBATE...... 34 sulfamethoxazole-trimethoprim...9 temozolomide...... 17 sodium bicarbonate...... 35 sulfasalazine...... 46 temsirolimus...... 45 sodium chloride...... 35, 51 sulfatrim pediatric...... 9 teniposide...... 17 sodium chloride (pf)...... 35 sulindac...... 4 TENIVAC...... 46 sodium chloride flush...... 35 sumatriptan...... 14 tenofovir disoproxil fumarate.....21 sodium fluoride...... 27, 35 sumatriptan succinate...... 14 terazosin hcl...... 38 sodium fluoride 5000 enamel....27 sumatriptan succinate refill...... 14 terbinafine hcl...... 13 sodium fluoride 5000 plus...... 27 SUPPRELIN LA...... 39 terbutaline sulfate...... 52 sodium fluoride 5000 ppm...... 27 SUPREP BOWEL PREP KIT....36 terconazole...... 13 sodium fluoride 5000 sensitive..27 SUTENT...... 17 TERIPARATIDE sodium phenylbutyrate...... 37 swabflush saline flush...... 35 (RECOMBINANT)...... 46 sodium polystyrene sulfonate... 35 syeda...... 42 testosterone...... 39 sodium thiosulfate...... 48 SYLVANT...... 17 ...... 39 solifenacin succinate...... 37 SYMBICORT...... 52 testosterone enanthate...... 39 SOLIQUA...... 30 SYMDEKO...... 52 TETANUS-DIPHTHERIA SOLIRIS...... 22 SYMLINPEN 120...... 30 TOXOIDS TD...... 46 SOLU-CORTEF...... 38 SYMLINPEN 60...... 30 tetrabenazine...... 27 SOMATULINE DEPOT...... 39 SYMPAZAN...... 11 tetracaine hcl...... 49 SOMAVERT...... 39 SYMPROIC...... 36 tetracycline hcl...... 9 sorine...... 25 SYMTUZA...... 21 THALOMID...... 17 SOTALOL HCL...... 25 SYNAGIS...... 45 theophylline...... 52 sotalol hcl...... 25 SYNJARDY...... 30 theophylline er...... 52 sotalol hcl (af)...... 25 SYNJARDY XR...... 30 thioridazine hcl...... 19 SOTYLIZE...... 25 SYNRIBO...... 17 thiotepa...... 17 spinosad...... 18 TABLOID...... 17 thiothixene...... 19 SPIRIVA HANDIHALER...... 52 tacrolimus...... 30, 45 THREONINE...... 35 SPIRIVA RESPIMAT...... 52 tadalafil...... 37 THROMBATE III...... 10 spironolactone...... 25 tadalafil (pah)...... 52 THYMOGLOBULIN...... 45 spironolactone-hctz...... 25 TAFINLAR...... 17 tiadylt er...... 26 sprintec 28...... 42 TAGRISSO...... 17 tiagabine hcl...... 11 SPRYCEL...... 17 TALTZ...... 45 TIBSOVO...... 17 sronyx...... 42 TALZENNA...... 17 TICE BCG...... 45 STAMARIL...... 46 tamoxifen citrate...... 17 TIGLUTIK...... 27 stavudine...... 21 tamsulosin hcl...... 38 tilia fe...... 43 STELARA...... 45 TARGRETIN...... 17 timolol maleate...... 26, 49 sterile water for irrigation...... 35 tarina 24 fe...... 42 tinidazole...... 9 STIOLTO RESPIMAT...... 52 tarina fe 1/20...... 42 TIVICAY...... 21 STIVARGA...... 17 tarina fe 1/20 eq...... 43 tizanidine hcl...... 53 STRENSIQ...... 37 TASIGNA...... 17 tobramycin...... 48, 52 streptomycin sulfate...... 9 TAURINE...... 35 tobramycin sulfate...... 9, 10 STRIBILD...... 21 TAVALISSE...... 22 tobramycin-dexamethasone...... 49 STRIVERDI RESPIMAT...... 52 tazarotene...... 30 tolbutamide...... 30 SUBLOCADE...... 7 tazicef...... 9 tolcapone...... 18 subvenite...... 11 TAZICEF...... 9 tolmetin sodium...... 4 subvenite starter kit-blue...... 11 taztia xt...... 25 tolterodine tartrate...... 37

66 tolterodine tartrate er...... 37 tri-lo-sprintec...... 43 valproic acid...... 11 TOLVAPTAN...... 35 trimethobenzamide hcl...... 13 valrubicin...... 17 tolvaptan...... 35 trimethoprim...... 10 valsartan...... 26 TOPEX TOPICAL tri-mili...... 43 valsartan-hydrochlorothiazide... 26 ANESTHETIC...... 27 trimipramine maleate...... 12 vancomycin hcl...... 10 topiramate...... 11 TRINATE...... 35 vancomycin hcl in dextrose...... 10 topiramate er...... 11 tri-nymyo...... 43 vancomycin hcl in nacl...... 10 toposar...... 17 tri-previfem...... 43 vandazole...... 10 topotecan hcl...... 17 TRIPTODUR...... 40 VANTAS...... 40 toremifene citrate...... 17 tri-sprintec...... 43 VAQTA...... 46 torsemide...... 26 TRIUMEQ...... 21 VARIVAX...... 46 TOTECT...... 17 tri-vite/fluoride...... 35 VAXCHORA...... 46 TOUJEO MAX SOLOSTAR...... 32 trivora (28)...... 43 VECTIBIX...... 17 TOUJEO SOLOSTAR...... 32 tri-vylibra...... 43 VELCADE...... 17 tovet...... 30 tri-vylibra lo...... 43 velivet...... 43 TRACLEER...... 52 TROGARZO...... 21 VEMLIDY...... 21 tramadol hcl er...... 6 trospium chloride...... 37 VENCLEXTA...... 17 tramadol hcl er (biphasic)...... 6 trospium chloride er...... 37 VENCLEXTA STARTING tramadol hcl ir...... 6 TRUE COMFORT PRO PACK...... 17 tramadol-acetaminophen...... 6 INSULIN SYR...... 32 venlafaxine hcl...... 12 trandolapril...... 26 TRUE COMFORT PRO PEN venlafaxine hcl er...... 12 trandolapril-verapamil hcl er...... 26 NEEDLES...... 32 VENTAVIS...... 52 tranexamic acid...... 22 TRULICITY...... 30 VENTOLIN HFA...... 52 tranylcypromine sulfate...... 12 TRUMENBA...... 46 verapamil hcl...... 26 travoprost (bak free)...... 49 TRYPTOPHAN...... 35 verapamil hcl er...... 26 trazodone hcl...... 12 TUKYSA...... 17 VERSACLOZ...... 19 TRECATOR...... 14 tulana...... 43 VERZENIO...... 17 TRELEGY ELLIPTA...... 52 TURALIO...... 17 vestura...... 43 TRELSTAR MIXJECT...... 40 TWINRIX...... 46 VICTOZA...... 30 TREMFYA...... 45 tyblume...... 43 vienva...... 43 treprostinil...... 52 TYBOST...... 21 vigabatrin...... 11 tretinoin...... 17, 30 tydemy...... 43 vigadrone...... 11 tretinoin microsphere...... 30 TYMLOS...... 46 VIMIZIM...... 37 tretinoin microsphere pump...... 30 TYPHIM VI...... 46 VIMPAT...... 11 TRETTEN...... 22 TYSABRI...... 27 VINATE ONE...... 35 tri femynor...... 43 TYVASO...... 52 vinblastine sulfate...... 17 triamcinolone acetonide 27, 30, 38 TYVASO REFILL...... 52 vincristine sulfate...... 17 triamterene-hctz...... 26 TYVASO STARTER...... 52 vinorelbine tartrate...... 17 triazolam...... 21 UCERIS...... 46 viorele...... 43 tri-buffered aspirin...... 4 UDAMIN SP...... 35 VIRACEPT...... 21 TRI-CHLOR...... 30 ULTIGUARD SAFEPACK VIREAD...... 21 triderm...... 30 SYR/NEEDLE...... 33 virt-gard...... 35 trientine hcl...... 35 unithroid...... 43 virt-phos 250 neutral...... 35 tri-estarylla...... 43 UNITUXIN...... 17 VISTOGARD...... 48 trifluoperazine hcl...... 19 UPTRAVI...... 52 VISUDYNE...... 49 trifluridine...... 48 uretron d/s...... 38 vitamin d (ergocalciferol)...... 35 trihexyphenidyl hcl...... 18 urin ds...... 38 vitamins acd-fluoride...... 35 TRIKAFTA...... 52 ursodiol...... 36 VITRAKVI...... 17 tri-legest fe...... 43 valacyclovir hcl...... 21 VIVITROL...... 7 tri-linyah...... 43 VALCHLOR...... 17 VIVOTIF...... 46 tri-lo-estarylla...... 43 valganciclovir hcl...... 21 VIZIMPRO...... 17 tri-lo-marzia...... 43 VALINE...... 35 volnea...... 43 tri-lo-mili...... 43 valproate sodium...... 11 VONVENDI...... 22

67 voriconazole...... 13 ZALTRAP...... 18 VOSEVI...... 21 ZANOSAR...... 18 VOTRIENT...... 18 zarah...... 43 VPRIV...... 37 ZARXIO...... 22 VRAYLAR...... 19 ZEJULA...... 18 vyfemla...... 43 ZELBORAF...... 18 vylibra...... 43 ZEMAIRA...... 52 VYXEOS...... 18 zenatane...... 30 warfarin sodium...... 10 ZENPEP...... 37 water for irrigation, sterile...... 35 ZEPATIER...... 21 WELCHOL...... 26 ZEPZELCA...... 18 wera...... 43 zidovudine...... 21 westab mini...... 35 ziprasidone hcl...... 19 westab one...... 35 ziprasidone mesylate...... 19 WESTAB PLUS...... 35 ZITHROMAX...... 10 WESTHROID...... 43 ZOLADEX...... 40 WILATE...... 22 zoledronic acid...... 47 WP THYROID...... 43 ZOLINZA...... 18 wymzya fe...... 43 zolmitriptan...... 14 XALKORI...... 18 zolpidem tartrate...... 53 XARELTO...... 10 zolpidem tartrate er...... 53 XARELTO STARTER PACK.....10 zonisamide...... 11 XATMEP...... 45 ZORTRESS...... 45 XELJANZ...... 45 ZOSYN...... 10 XELJANZ XR...... 45 zovia 1/35 (28)...... 43 XEOMIN...... 48 zovia 1/35e (28)...... 43 XEPI...... 10 zumandimine...... 43 XERAC AC...... 30 ZYDELIG...... 18 XERMELO...... 36 ZYPREXA RELPREVV...... 19 XGEVA...... 46 ZYVOX...... 10 XIAFLEX...... 48 XIGDUO XR...... 30 XOFIGO...... 18 XOFLUZA (40 MG DOSE)...... 21 XOFLUZA (80 MG DOSE)...... 21 XOLAIR...... 51 XOSPATA...... 18 XTANDI...... 18 xulane...... 43 XURIDEN...... 37 XYLOCAINE...... 6 XYNTHA...... 22 XYNTHA SOLOFUSE...... 22 XYREM...... 53 YERVOY...... 18 YF-VAX...... 46 YONDELIS...... 18 YONSA...... 18 YUPELRI...... 52 yuvafem...... 43 zafemy...... 43 zafirlukast...... 52 zaleplon...... 53

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