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Fidelis Care Healthier Life and Medicaid Formulary

07/01/2021 v2

INTRODUCTION ...... 4 NOTICE OF NONDISCRIMINATION ...... 4 PREFACE...... 7 PHARMACY AND THERAPEUTICS COMMITTEE ...... 7 DRUG LIST PRODUCT DESCRIPTIONS ...... 7 GENERIC SUBSTITUTION ...... 8 NON-COVERED MEDICATIONS ...... 8 NON-PREFERRED REQUEST ...... 8 QUANTITY LIMITATIONS ...... 9 SPECIALTY DRUGS ...... 12 PRIOR AUTHORIZATION ...... 12 STEP THERAPY ...... 14 ONCOLOGY AND SUPPORTIVE CARE ...... 14 APPEALS INFORMATION/PROCESS ...... 15 EDITOR...... 15 NOTICE...... 15 LEGEND ...... 15 ANALGESICS...... 16 ANALGESICS, OTHER ...... 16 NSAIDs...... 16 NSAIDs, TOPICAL ...... 16 COX-2 INHIBITORS ...... 16 GOUT ...... 16 OPIOID ANALGESICS ...... 16 NON-OPIOID ANALGESICS ...... 17 ANTI-INFECTIVES ...... 17 ANTIBACTERIALS ...... 17 ANTIFUNGALS ...... 18 ANTIMALARIALS ...... 18 ANTIRETROVIRAL AGENTS ...... 18 ANTITUBERCULAR AGENTS ...... 20 ANTIVIRALS...... 20 MISCELLANEOUS ...... 20 ANTINEOPLASTIC AGENTS ...... 21 ALKYLATING AGENTS ...... 21 ANTIMETABOLITES ...... 21 HORMONAL ANTINEOPLASTIC AGENTS ...... 21 KINASE INHIBITORS ...... 21 KINASE INHIBITORS FOR CML ...... 22 MULTIPLE MYELOMA ...... 22 MISCELLANEOUS ...... 22 CARDIOVASCULAR ...... 22 ACE INHIBITORS ...... 22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 22 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 22 ADRENOLYTICS, CENTRAL ...... 23 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATION ...... 23 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 23 ALPHA BLOCKERS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 23 ANTIARRHYTHMICS ...... 23 ANTILIPEMICS...... 23 BETA-BLOCKERS ...... 24 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 24

1 CALCIUM CHANNEL BLOCKERS ...... 24 DIGITALIS GLYCOSIDES ...... 25 DIURETICS ...... 25 HEART FAILURE ...... 25 NITRATES...... 25 PULMONARY ARTERIAL HYPERTENSION ...... 25 MISCELLANEOUS ...... 26 CENTRAL NERVOUS SYSTEM ...... 26 ANTIANXIETY...... 26 ANTICONVULSANTS ...... 26 ANTIDEMENTIA ...... 27 ANTIDEPRESSANTS ...... 27 ANTIPARKINSONIAN AGENTS ...... 27 ANTIPSYCHOTICS ...... 28 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 28 FIBROMYALGIA ...... 29 HUNTINGTON'S DISEASE AGENTS ...... 29 HYPNOTICS ...... 29 MIGRAINE ...... 29 MOOD STABILIZERS ...... 30 MULTIPLE SCLEROSIS AGENTS ...... 30 MUSCULOSKELETAL THERAPY AGENTS ...... 30 MYASTHENIA GRAVIS ...... 30 NARCOLEPSY/CATAPLEXY ...... 30 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 30 ENDOCRINE AND METABOLIC ...... 31 ANDROGENS ...... 31 ANTIDIABETICS ...... 31 CALCIUM RECEPTOR ANTAGONISTS ...... 32 CALCIUM REGULATORS ...... 32 CONTRACEPTIVES ...... 33 ENDOMETRIOSIS ...... 34 ESTROGENS ...... 34 ESTROGEN/PROGESTINS ...... 35 FERTILITY REGULATORS ...... 35 GAUCHER DISEASE ...... 35 ...... 35 GLUCOSE ELEVATING AGENTS ...... 35 HUMAN GROWTH HORMONES AND RELATED DISORDERS ...... 35 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 35 PHENYLKETONURIA TREATMENT AGENTS ...... 36 PHOSPHATE BINDER AGENTS ...... 36 PROGESTINS, ORAL ...... 36 SELECTIVE MODULATORS ...... 36 THYROID AGENTS ...... 36 UREA CYCLE DISORDERS ...... 36 VASOPRESSINS ...... 36 MISCELLANEOUS ...... 36 GASTROINTESTINAL ...... 36 ANTACIDS ...... 36 ANTIDIARRHEALS ...... 37 ANTIEMETICS ...... 37 ANTISPASMODICS ...... 37 CHOLELITHOLYTICS ...... 37 H2 RECEPTOR ANTAGONISTS ...... 37 INFLAMMATORY BOWEL DISEASE ...... 37 IRRITABLE BOWEL SYNDROME ...... 38 LAXATIVES/STOOL SOFTENERS ...... 38 OPIOID-INDUCED CONSTIPATION ...... 38 PANCREATIC ENZYMES ...... 38 PROSTAGLANDINS ...... 38 PROTON PUMP INHIBITORS ...... 38 SALIVA STIMULANTS ...... 38 , RECTAL ...... 38 MISCELLANEOUS ...... 39

2 GENITOURINARY ...... 39 BENIGN PROSTATIC HYPERPLASIA ...... 39 URINARY ANTISPASMODICS ...... 39 VAGINAL ANTI-INFECTIVES ...... 39 MISCELLANEOUS ...... 39 HEMATOLOGIC ...... 39 ANTICOAGULANTS ...... 39 HEMATOPOIETIC GROWTH FACTORS ...... 40 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ...... 40 PLATELET AGGREGATION INHIBITORS ...... 40 PLATELET SYNTHESIS INHIBITORS ...... 40 THROMBOCYTOPENIA AGENTS ...... 40 MISCELLANEOUS ...... 40 IMMUNOLOGIC AGENTS ...... 41 AUTOIMMUNE AGENTS ...... 41 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 41 IMMUNOMODULATORS ...... 41 IMMUNOSUPPRESSANTS ...... 41 VACCINES ...... 41 NUTRITIONAL/SUPPLEMENTS ...... 42 ELECTROLYTES ...... 42 VITAMINS AND MINERALS ...... 42 RESPIRATORY ...... 43 TREATMENT AGENTS...... 43 ...... 43 /BETA COMBINATIONS ...... 43 ANTICHOLINERGIC/BETA AGONIST/ INHALANT COMBINATIONS ...... 43 , LOW SEDATING...... 43 ANTIHISTAMINES, NONSEDATING ...... 43 ANTIHISTAMINES, SEDATING ...... 43 / COMBINATIONS ...... 43 ANTITUSSIVE...... 43 ANTITUSSIVE COMBINATIONS ...... 44 BETA ...... 44 ...... 44 MODULATORS ...... 44 NASAL ANTIHISTAMINES ...... 44 NASAL ...... 44 NASAL STEROIDS ...... 44 RESPIRATORY DEVICES ...... 45 RESPIRATORY SYNCYTIAL VIRUS ...... 45 SEVERE AGENTS ...... 45 STEROID/BETA AGONIST COMBINATIONS ...... 45 STEROID INHALANTS ...... 45 ...... 45 MISCELLANEOUS ...... 45 TOPICAL ...... 45 DERMATOLOGY ...... 45 MOUTH/THROAT/DENTAL AGENTS ...... 48 OPHTHALMIC...... 48 OTIC ...... 50 INDEX ...... 51

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INTRODUCTION Fidelis Care is pleased to provide the Fidelis Care Formulary for Healthier Life (HARP) and Medicaid members as a useful reference and informational tool. The Fidelis Care Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for members.

The drugs on this formulary have been reviewed by the Fidelis Care Pharmacy and Therapeutics (P&T) Committee and found appropriate for formulary inclusion. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee.

This edition incorporates drugs added to the formulary since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the Fidelis Care Formulary is reflective of current medical practice as of the date of review.

The information contained in the Fidelis Care Formulary and its appendices is provided by Fidelis Care, solely for the convenience of medical providers. Fidelis Care does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The Fidelis Care Formulary is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical provider in their choice of prescription drugs. Fidelis Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. NOTICE OF NONDISCRIMINATION Fidelis Care complies with Federal civil rights laws. Fidelis Care does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Fidelis Care provides the following:  Free aids and services to people with disabilities to help you communicate with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)  Free language services to people whose first language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, call Fidelis Care at 1-888-343-3547. For TTY/TDD services, call 711.

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If you believe that Fidelis Care has not given you these services or treated you differently because of race, color, national origin, age, disability or sex, you can file a grievance with Fidelis Care by:

• Mail: 25-01 Jackson Avenue, Long Island City, NY 11101 • Phone: 1-888-343-3547 (TTY: 711) • Fax: 1-315-849-3885 • In person: 31 British American Boulevard, Latham, NY 12110 • Email: [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by:

• Web: Office for Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf • Mail: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201 Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html • Phone: 1-800-368-1019 (TTY/TDD 800-537-7697)

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PREFACE The Fidelis Care Formulary is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Fidelis Care Formulary. PHARMACY AND THERAPEUTICS COMMITTEE The Fidelis Care P&T Committee considers all new-to-market drugs for inclusion in the formulary. The evaluation includes a literature review and expert external opinion may also be sought. Formal reviews are prepared that typically address the following information:

 Safety  Efficacy  Comparison studies  Approved indications  Adverse effects  Contraindications/Warnings/Precautions   Patient administration/compliance considerations  Medical outcome and pharmacoeconomic studies  Cost

When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on the formulary. In addition, entire therapeutic classes are periodically evaluated.

All the information in the Fidelis Care Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Listed products on the document generally include all strengths and dosage forms of the cited brand- name product. Zofran Oral solution, tablets, disintegrating tablets, and all strengths of Zofran would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on the document. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry. tolterodine Detrol The immediate-release product listing of Detrol alone would not include the extended-release product Detrol LA.

tolterodine ext-rel Detrol LA A separate entry for Detrol LA confirms that the extended-release product is on the document.

Dosage forms on the document will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the document.

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GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

Fidelis Care has a mandatory generic pharmacy benefit. If a medication is available as generic, then the generic product must be dispensed. Certain specific products are exempt from the mandatory generic requirement and are indicated as such within the formulary. Exempt products include: Clozaril, Dilantin, Lanoxin, Levoxyl, Neoral, Sandimmune, Synthroid, Tegretol, Unithroid and Zarontin. Generic drugs are usually priced lower than their brand- name equivalents. Prescription generic drugs are:

 Approved by the U.S. Food and Drug Administration (FDA) for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.  Tested in humans to assure the generic is absorbed into the bloodstream in a similar time and amount compared to the brand-name drug. Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.  Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. NON-COVERED MEDICATIONS  Pharmaceuticals determined by the FDA to be less than effective and identical, related, or similar drugs (commonly referred to as DESI 5 and 6 drugs).  Fidelis Care only covers drugs from manufacturers participating in the Federal Medicaid Drug Rebate program. NON-PREFERRED REQUEST Acknowledging the medical necessity for certain non-preferred drugs in specific patient populations, Fidelis Care has developed a means of review for authorizing coverage of non-preferred drugs when medical necessity warrants their use. The non-preferred request review policy permits coverage of non-preferred drugs when at least one of the following criteria is met:

1. Documented allergic/adverse reaction to a preferred agent. 2. Documented failure of preferred agents. 3. Documented patient stability/control issues in patients with concomitant drug/disease states where a preferred agent is contraindicated or a change in therapy is not advisable.

In making decisions with regard to non-preferred request and the overall formulary, Fidelis Care applies recommendations of national evidence-based guidelines, professional expertise and judgment. Fidelis Care looks for the appropriate usages of drugs and drug products as established by or in: (1) evidence-based national guidelines, (2) peer-reviewed literature, (3) the American Hospital Formulary Service-Drug Information, (4) the American Medical Association-Drug Evaluations, (5) the United States Pharmacopeia-Drug Information, (6) other such standard compendia, and (7) the professional guidance of pharmacists.

Fidelis Care adheres to Article 49 guidelines for providing responses to non-preferred requests. All requests will be reviewed and decision on these requests made within 3 business days from the day of receipt. Generally, requests are processed in the order received. However, urgent requests should be identified as such when submitted, and will be reviewed within the same day, if feasible. A response will be forwarded to the requesting provider as soon as a determination has been made on the request (both verbal and written). Members will be notified of the decision verbally and by a letter as well.

To request a non-preferred medication, prescribers need to fill out and fax over to Fidelis a "Medication Request Form." To obtain the form, providers may contact Fidelis Care at 1-888-343-3547 or download the form from Fidelis' Web site: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services

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QUANTITY LIMITATIONS Quantity Limits (QL) provide for a maximum quantity of a drug product that a member may receive per prescription over a specified period of time.

The following brand-name drugs, and generic versions if available, are subject to QL:

Boniva abacavir/ brimonidine 0.2% abacavir/lamivudine/ Abilify tabs buprenorphine/naloxone sublingual tabs acamprosate ext-rel Accolate buspirone Aciphex butalbital/acetaminophen Actos butalbital/acetaminophen/caffeine tabs - Esgic Actoplus Met Calan SR tabs Adderall capsaicin crm, patch 0.025% Adderall XR Capzasin-HP Admelog Capzasin-P Advair Diskus Castiva Airduo Respiclick cefpodoxime Albenza Celebrex 50 mg, 100 mg, 200 mg albuterol inhalation solution Chantix cream, ointment 0.05% chlordiazepoxide Aldara chloroquine Alinia Cimduo Allevess Ciprodex Alphagan P Cleocin T Ambien propionate crm, gel, lotion, ointment, Ambien CR spray 0.05% Amerge emollient cream 0.05% Anoro Ellipta clomiphene Anusol-HC clotrimazole crm, solution 1% (OTC and Rx) Anzemet codeine/acetaminophen Aptivus codeine/chlorpheniramine/ Arnuity Ellipta codeine/guaifenesin liquid Arthritis & Muscle Pain Relief codeine/guaifenesin/pseudoephedrine Arthritis Pain Cream codeine/promethazine Asmanex HFA codeine/promethazine/ Ativan Colcrys Atripla Combivent Respimat Atrovent HFA Complera Avalide Concerta Avapro condoms, female Avodart condoms, male Azilect Crestor bacitracin ophthalmic ointment Crixivan Baqsimi Cutter Backwoods Insect Repellent Baraclude tabs Cutter Skinsations Insect Repellent BD Ultrafine insulin syringes and needles Cymbalta Benicar Delstrigo Benicar HCT Depo-Subq Provera 104 Bentyl injection Derma-Smoothe/FS dipropionate cream, lotion, Descovy ointment 0.05% Detrol cream, lotion, Detrol LA ointment 0.1% Dexedrine Spansule Bicillin L-A tabs 5 mg, 10 mg Biktarvy diaphragm bimatoprost 0.03% diclofenac sodium soln 1.5%

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Differin gel (only OTC covered) hydrocodone/acetaminophen tabs 5 mg/325 mg, Dilaudid 7.5 mg/325 mg, 10 mg/325 mg Diovan hydrocodone/homatropine Diovan HCT hydrocodone/ibuprofen Diprolene Icy Hot Diprolene AF Imitrex Dovato Incruse Ellipta Dovonex indomethacin dronabinol indomethacin ext-rel Duragesic Insulin Aspart Edurant Intelence Effexor XR Intuniv Effient ipratropium-albuterol inhalation solution Elmiron ipratropium inhalation solution Emend caps ipratropium nasal spray Emtriva Isentress Enablex Isentress HD Entocort EC Juluca Entresto Kaletra tabs epinephrine auto-injector Kazano Epipen crm 2% Epipen Jr. Klonopin tabs Epivir-HBV tabs Kyleena erythromycin gel, solution 2% lamivudine esomeprazole magnesium delayed-rel lamivudine/zidovudine estazolam lancets Eucrisa levalbuterol inhalation solution Evista levocetirizine (OTC and Rx) Evotaz levofloxacin Fiorinal Lexapro First-Lansoprazole lidocaine crm, patch 4% - Aspercreme/Lidocaine First-Omeprazole lidocaine/ kit Firvanq lidocaine/prilocaine crm 2.5/2.5% acetonide cream, ointment 0.025% Lidoderm solution 0.01% Liletta cream, gel, ointment 0.05% Lipitor flurazepam l-methylfolate nasal spray (only OTC covered) lovastatin fluticasone propionate cream 0.05%, Lovaza ointment 0.005% Lunesta Focalin Lynparza Focalin XR Lyrica Fosamax 35 mg, 40 mg, 70 mg Lysteda fosamprenavir tabs Malarone Freestyle Freedom Lite kits and test strips Miacalcin Freestyle Insulinx Lite kits and test strips Mirapex ER Freestyle Lite kits and test strips Maxalt/Maxalt-MLT Fuzeon mefloquine Genvoya Mepron granisetron Metadate CD Guadalupano methadone tabs 5 mg, 10 mg halobetasol propionate cream, ointment 0.05% Methylin Hepsera Micardis Humulin N Micardis HCT Humulin R Mirena Humulin 70/30 cream, lotion, ointment 0.1% hydrocodone/acetaminophen soln 7.5/325 mg/ Monurol 15 mL morphine moxifloxacin tabs

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MS Contin Requip XL Namenda Restoril 15 mg, 30 mg Natrapel Insect Repellent Reyataz Nesina Risperdal Neurontin Ritalin Nexium 40 mg Ritalin LA Nexplanon rivastigmine caps Nicoderm CQ Rukobia Rybelsus Nicotrol Inhaler Santyl Nicotrol NS Savaysa Nimotop Sawyer Insect Repellent Norvir Segluromet Novolin N Selzentry Novolin R Semglee Novolin 70/30 Seroquel XR nystatin/ Seroquel 100 mg nystatin crm ointment, powder Shingrix Odefsey Singulair Off Active Insect Repellent Skyla Off Deep Woods Insect Repellent sofosbuvir/velpatasvir Off Family Care Insect Repellent Solu-Cortef 100 mg/mL omeprazole delayed-rel caps, tabs Spiriva Respimat 1.25 mcg omeprazole magnesium delayed-rel caps, tabs stavudine Omnipod Dash Steglatro Oseni Steglujan oxazepam Stiolto Respimat oxycodone caps, tabs Strattera oxymorphone ext-rel Stribild Ozempic Striverdi Respimat Paragard Suboxone film Pataday (only OTC covered) Sustiva Paxil CR Symbicort pentoxifylline ext-rel Symbyax Percocet Symfi Percodan Symfi Lo Pifeltro Symtuza piroxicam Tamiflu pravastatin tinidazole Precision Xtra kits and test strips Tivicay Prevacid Tivicay PD Prevacid 24HR Tobradex ointment Prezcobix tramadol ext-rel tabs Prezista Travatan Z primaquine Trelegy Ellipta Pristiq nasal spray Proair HFA Triumeq Proair Respiclick trospium ext-rel Proctofoam-HC Trulicity Protonix Truvada Protopic Tybost Proventil HFA Ultracet Pulmicort Respules Ultram ramelteon Uroxatral Ranexa Valium Reliaderm Vancocin 125 mg Relpax verapamil Repel Sportsmen Insect Repellent Verelan SR Repel Sportsmen Max Insect Repellent Vesicare

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Vfend tabs Zenzedi Vibramycin suspension Zetia Viracept zidovudine Viramune Ziks Viramune XR Zocor Viread Zofran Voltaren gel (OTC and Rx) zoledronic acid Wixela Inhub Zomig nasal spray Xalatan Zomig/Zomig-ZMT Xanax tabs Zostavax Xanax XR Zostrix HP Xopenex HFA Zyprexa/Zyprexa Zydis zaleplon Zyvox tabs

SPECIALTY DRUGS Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable medications, but they may also include oral agents. Specialty drugs identified in the document by (SP) are available through AcariaHealth Specialty Pharmacy.

Fidelis Care requires prior authorization (PA) for many drugs before they will be approved for coverage. Prior authorization for specialty drugs should be obtained by the physician's office prior to AcariaHealth Specialty Pharmacy being contacted. The physician's office must contact Fidelis Care by telephone at 1-888-343-3547 or by fax at 1-877-533-2405 to obtain a prior authorization.

Once prior authorization is obtained, getting started with AcariaHealth Specialty Pharmacy is easy. Providers may contact AcariaHealth Specialty Pharmacy by telephone at 1-844-584-1072 or by fax at 1-833-368-6385. Additional information can also be found online at acariahealth.com. AcariaHealth Specialty Pharmacy provides comprehensive patient education, clinical programs and support, and access to multilingual health care experts and pharmacists 24 hours a day. PRIOR AUTHORIZATION The advantages of Prior Authorization (PA) are: 1) enforcement of treatment protocols/guidelines, 2) prevention of drug use for unlabeled indications, 3) the ability to "risk manage" drugs with serious side effects, 4) decreased utilization of certain drugs, and 5) cost control.

Prior authorized drugs cannot be obtained through Fidelis' pharmacy benefit unless the prior authorization process has been completed. The procedure for prior authorization of a non-specialty drug is as follows:

When the patient takes the prescription for a drug requiring prior authorization to a community pharmacist with an on- line system, the community pharmacist will enter the Fidelis Care member eligibility number and drug. The community pharmacist will receive the message "prior authorization required" on their computer screen and they will not be able to put the prescription through the system. The pharmacist must contact the physician's office and instruct them to call Fidelis Care at 1-888-343-3547 and indicate that they need a prior authorization for a Fidelis Care patient. The physician should be prepared to supply the following information: 1) patient name, ID number, and date of birth, 2) physician name, address and phone number, 3) drug name, strength and directions, 4) diagnosis and clinical information as indicated on the "Medication Request Form." Once Fidelis receives the completed "Medication Request Form," the request will be reviewed to determine if it meets medical necessity criteria for the drug in question.

If the patient does meet the criteria, a prior authorization will be entered into the on-line system, and the community pharmacist will be able to bill the prescription. If the patient does not meet the established criteria, prior authorization will not be granted. Fidelis Care staff will be responsible for notifying the physician regarding the approval/denial.

The criteria of use for each drug follows the FDA-approved labeled indications and standards of physicians' practice. These criteria can change based on newly approved indications and/or at least two well-designed peer-reviewed studies showing effectiveness and safety.

Fidelis Care adheres to Article 49 guidelines for providing responses to prior authorization requests. Urgent requests should be identified as such when submitted. A response will be forwarded to the physician as soon as determination has been made on the request. Requests are processed in the order received.

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Fidelis Care currently requires prior authorization for the following drugs, and generic versions, if available: abacavir/lamivudine/ dextroamphetamine tabs Kevzara zidovudine 5 mg, 10 mg Koate Abilify Maintena Diclegis Koate-DVI Actiq Dibenzyline Kogenate FS Adcirca doxepin Kovaltry Adderall dronabinol Kuvan Adderall XR Edurant Letairis Advate Elmiron leuprolide acetate Adynovate Eloctate Lidoderm Afinitor Emend caps Lomotil Afstyla Emgality Lupron Depot Aimovig Enbrel Lynparza Ajovy Epclusa Lysodren Alphanate Erivedge Macrobid Alphanine SD Esperoct Macrodantin Alprolix Eucrisa Matulane Amitiza Exjade Mayzent amitriptyline Extavia Mekinist Amnesteem Fasenra Metadate CD Androgel Feiba NF Methylin Aranesp Feraheme methyltestosterone Aristada Ferrlecit Mononine Aristada Initio First-Lansoprazole Movantik Atripla First-Omeprazole Myorisan Aubagio Flolan Nexavar Avonex Focalin nitrofurantoin Benefix Focalin XR Norditropin Benlysta subcutaneous Fuzeon Norpramin Bosulif Gazyva Novoeight Buphenyl Gilenya Novoseven RT Cayston Gilotrif Nuvigil Cerdelga Gleevec Nuwiq Ciprodex glyburide nystatin/triamcinolone Claravis glyburide/metformin Obizur Coagadex Glynase Odefsey codeine/acetaminophen Hemlibra Opsumit codeine/chlorpheniramine/ Hemofil M Orenitram pseudoephedrine Humate-P Orfadin codeine/guaifenesin liquid Humira Oriahnn codeine/promethazine hydrocodone/homatropine Orilissa codeine/promethazine/ Idelvion Pamelor phenylephrine Imbruvica caps Pegasys Complera imipramine HCl Pepcid suspension Concerta Imitrex inj, nasal spray Perseris Copaxone Increlex Plegridy Corifact Kit InFeD Pomalyst Cosentyx Intron A Praluent Creon Invega Primsol Cubicin Invega Sustenna Profilnine Cyramza Invega Trinza Promacta tabs Cystagon isotretinoin Protopic DDAVP tabs Ixinity Provigil Delatestryl Jadenu Pulmicort Respules Depen Janenu Sprinkle Pulmozyme Depo-Provera 400 mg/mL Jivi Rebif Depo-Testosterone Juluca Recombinate Dexedrine Spansule Kaletra solution Regranex

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Remodulin Synagis Ventavis Retacrit Synarel Vonvendi Retin-A Tafinlar Votrient Revatio Tamiflu suspension Wilate Revlimid Tarceva Xeljanz Risperdal Consta Targretin caps Xeljanz XR Ritalin Tasigna Xeloda Ritalin LA Tecfidera Xenazine Rixubis Temodar Xifaxan Rubraca Testim Xiidra Rukobia tetracycline caps Xylocaine Rydapt Thalomid Xyntha Sandostatin Tikosyn Xyrem Sandostatin LAR Tobi Zarxio Santyl Tracleer Zenatane Selzentry tramadol ext-rel tabs Zenzedi Sensipar tretinoin caps Ziextenzo Serostim Tretten Zocor 80 mg Siliq Tygacil Zolinza Somavert Tykerb Zykadia Soriatane Tymlos Zyprexa Sporanox Tyvaso Zyprexa Relprevv Sprycel Ultracet Zyprexa Zydis stavudine Ultram Zyvox susp Sutent Valchlor Symbyax Venofer

STEP THERAPY Step Therapy (ST) requires the use of one or more prerequisite drugs that meet specific conditions prior to the use of another drug or drugs. Fidelis Care requires step therapy for the following drugs, and generic versions if available:

Ambien CR Ovide Avodart oxymorphone ext-rel bimatoprost 0.03% Ozempic ciclopirox solution 8% Ranexa Enablex Razadyne ER First-Lansoprazole Renvela tabs First-Omeprazole rivastigmine caps Kazano Rybelsus l-methylfolate Segluromet levalbuterol inhalation solution Spiriva Respimat 1.25 mcg Lyrica Seroquel XR Metrogel 1% Steglatro Namenda Steglujan Natroba SymlinPen Nesina tinidazole Omnipod Dash Travatan Z Oseni Trulicity ONCOLOGY AND SUPPORTIVE CARE Oncology medications and supportive agents will require prior authorization (PA) from New Century Health (NCH) before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members 18 and over. PA can be requested by visiting NCH's Web portal at my.newcenturyhealth.com or by calling 1-888-999-7713, option 1.

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APPEALS INFORMATION/PROCESS For appeals information/process call Fidelis Care at 1-888-FIDELIS (343-3547) or visit the Fidelis Care Web site at: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services EDITOR Your comments and suggestions regarding the Fidelis Care Formulary are encouraged. Your input is vital to the continued success of the Fidelis Care Formulary. All responses will be reviewed and considered. Please send your comments to:

Pharmacy Manager Fidelis Care 59-17 Junction Blvd Elmhurst, NY 11373 NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of Fidelis Care. ©2021. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Fidelis Care. These trademarked brand names are included for informational purposes only and are not intended to imply or suggest any affiliation between Fidelis Care and such third-party pharmaceutical companies.

Fidelis Care does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Fidelis Care.

When viewing this formulary via the Internet, please be advised that the document is updated periodically and changes may appear prior to their effective date to allow for client notification. LEGEND AL Age Limit OTC Over-the-counter product. Covered only with valid prescription. PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy boldface Indicates generic availability delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

15

ANALGESICS ANALGESICS, OTHER OTC acetaminophen

NSAIDs OTC aspirin BAYER OTC aspirin buffered BUFFERIN OTC aspirin delayed-rel ECOTRIN OTC ibuprofen ADVIL OTC naproxen sodium 220 mg ALEVE diclofenac sodium delayed-rel 50 mg, 75 mg diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL indomethacin 25 mg, 50 mg QL indomethacin ext-rel ketorolac meloxicam MOBIC nabumetone naproxen tabs oxaprozin DAYPRO QL piroxicam sulindac

NSAIDs, TOPICAL OTC, QL diclofenac sodium gel 1% VOLTAREN GEL QL diclofenac sodium gel 1% VOLTAREN GEL QL diclofenac sodium soln 1.5%

COX-2 INHIBITORS QL celecoxib 50 mg, 100 mg, 200 mg CELEBREX

GOUT allopurinol ZYLOPRIM QL colchicine COLCRYS colchicine/probenecid probenecid

OPIOID ANALGESICS Note: Per State of New York regulation, opioid analgesic prescriptions are limited to 4 per 30 days. Additional prescriptions require a PA. Excluded from this PA criteria are members who have cancer, sickle cell disease or are on hospice care.

The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MME) per day. For members who are opioid-naïve, first fill will be limited to seven days.

PA*, QL codeine/acetaminophen QL fentanyl transdermal DURAGESIC PA fentanyl transmucosal ACTIQ QL hydrocodone/acetaminophen soln 7.5/325 mg/15 mL QL hydrocodone/acetaminophen tabs 5 mg/325 mg, 7.5 mg/325 mg, 10 mg/325 mg QL hydrocodone/ibuprofen

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 16

QL hydromorphone tabs DILAUDID QL methadone tabs 5 mg, 10 mg QL morphine QL morphine ext-rel MS CONTIN morphine suppository QL oxycodone caps, tabs oxycodone solution 5 mg/5 mL QL oxycodone/acetaminophen 5/325 PERCOCET QL oxycodone/aspirin PERCODAN ST, QL oxymorphone ext-rel PA**, QL tramadol 50 mg ULTRAM PA, QL tramadol ext-rel tabs PA**, QL tramadol/acetaminophen ULTRACET

PA* Prior authorization required for members 12 years of age and younger PA** Prior authorization required for members 17 years of age and younger

NON-OPIOID ANALGESICS OTC acetaminophen/caffeine EXCEDRIN TENSION HEADACHE OTC aspirin/caffeine BACK & BODY QL butalbital/acetaminophen QL butalbital/acetaminophen/caffeine tabs - Esgic QL butalbital/aspirin/caffeine FIORINAL

ANTI-INFECTIVES ANTIBACTERIALS Cephalosporins First Generation cefadroxil cephalexin KEFLEX

Second Generation cefaclor cefprozil axetil

Third Generation cefdinir QL cefpodoxime

Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin clarithromycin ext-rel erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate erythromycin stearate

Fluoroquinolones ciprofloxacin CIPRO QL levofloxacin QL moxifloxacin

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 17

Penicillins amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin VK QL penicillin G benzathine BICILLIN L-A

Sulfonamides sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS sulfadiazine

Tetracyclines demeclocycline doxycycline hyclate caps 50 mg, 100 mg VIBRAMYCIN doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate caps 50 mg, 100 mg QL doxycycline monohydrate suspension 25 mg/5 mL VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 100 mg minocycline MINOCIN PA tetracycline caps

ANTIFUNGALS clotrimazole troches fluconazole DIFLUCAN griseofulvin microsize tabs griseofulvin ultramicrosize PA itraconazole SPORANOX ketoconazole terbinafine tabs voriconazole inj VFEND QL voriconazole tabs VFEND

ANTIMALARIALS QL atovaquone/proguanil MALARONE QL chloroquine QL mefloquine QL primaquine

ANTIRETROVIRAL AGENTS Limit of four different antiretroviral agents per month. If additional antiretroviral agents are needed, a PA is required.

Antiretroviral Adjuvants QL cobicistat TYBOST

Antiretroviral Combinations QL abacavir/lamivudine PA, QL abacavir/lamivudine/zidovudine PA, QL efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL emtricitabine/tenofovir disoproxil fumarate TRUVADA QL lamivudine/zidovudine QL abacavir/dolutegravir/lamivudine TRIUMEQ QL atazanavir/cobicistat EVOTAZ

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 18

QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY QL darunavir/cobicistat PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL dolutegravir/lamivudine DOVATO PA, QL dolutegravir/rilpivirine JULUCA QL doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD PA, QL emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY PA, QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA QL emtricitabine/tenofovir alafenamide DESCOVY QL lamivudine/tenofovir disoproxil fumarate CIMDUO

Attachment Inhibitors PA, QL fostemsavir ext-rel RUKOBIA

Chemokine Receptor Antagonists PA, QL maraviroc SELZENTRY

Fusion Inhibitors PA, SP, QL enfuvirtide FUZEON

Integrase Inhibitors QL dolutegravir tabs TIVICAY QL dolutegravir tabs for oral suspension TIVICAY PD QL raltegravir ISENTRESS QL raltegravir ISENTRESS HD

Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz SUSTIVA QL nevirapine VIRAMUNE QL nevirapine ext-rel VIRAMUNE XR QL doravirine PIFELTRO QL etravirine INTELENCE PA, QL rilpivirine EDURANT

Nucleoside Reverse Transcriptase Inhibitors QL abacavir QL emtricitabine EMTRIVA QL lamivudine PA, QL stavudine QL zidovudine

Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate VIREAD

Protease Inhibitors QL atazanavir REYATAZ QL fosamprenavir tabs PA* lopinavir/ soln KALETRA QL ritonavir NORVIR QL darunavir PREZISTA fosamprenavir susp LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir tabs KALETRA QL VIRACEPT

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 19

QL tipranavir APTIVUS

PA* Prior authorization is required for brand product

ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN

ANTIVIRALS Cytomegalovirus Agents valganciclovir VALCYTE

Hepatitis Agents Hepatitis B QL adefovir dipivoxil HEPSERA QL entecavir tabs BARACLUDE QL lamivudine tabs EPIVIR-HBV QL tenofovir disoproxil fumarate VIREAD entecavir soln BARACLUDE

Hepatitis C SP ribavirin caps, tabs QL, SP sofosbuvir/velpatasvir EPCLUSA

Herpes Agents acyclovir caps, suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX

Influenza Agents QL oseltamivir caps TAMIFLU PA*, QL oseltamivir suspension TAMIFLU RELENZA

PA* Prior authorization required for members 9 years of age and older

MISCELLANEOUS OTC pyrantel - Reese's Pinworm Medicine QL ALBENZA QL atovaquone MEPRON clindamycin CLEOCIN dapsone PA daptomycin CUBICIN QL fosfomycin MONUROL ivermectin STROMECTOL PA linezolid susp ZYVOX QL linezolid tabs ZYVOX methenamine mandelate metronidazole tabs FLAGYL PA* nitrofurantoin ext-rel MACROBID PA* nitrofurantoin macrocrystals MACRODANTIN PA** nitrofurantoin suspension rifabutin MYCOBUTIN PA tigecycline TYGACIL

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 20

ST, QL tinidazole trimethoprim QL vancomycin caps 125 mg VANCOCIN QL nitazoxanide ALINIA pentamidine aerosol NEBUPENT PA rifaximin XIFAXAN PA trimethoprim solution PRIMSOL QL vancomycin oral soln FIRVANQ

PA* Prior authorization only required for members of age 65 and older PA** Prior authorization required for members 10 years of age and older

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS cyclophosphamide caps melphalan ALKERAN PA, SP temozolomide TEMODAR busulfan MYLERAN chlorambucil LEUKERAN lomustine GLEOSTINE PA mechlorethamine gel VALCHLOR

ANTIMETABOLITES PA, SP capecitabine XELODA mercaptopurine thioguanine TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX flutamide

Antiestrogens fulvestrant FASLODEX tamoxifen toremifene FARESTON

Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA, SP leuprolide acetate PA, SP leuprolide acetate LUPRON DEPOT

Progestins PA medroxyprogesterone acetate 400 mg/mL DEPO-PROVERA

KINASE INHIBITORS PA, SP erlotinib TARCEVA PA, SP everolimus AFINITOR PA, SP TYKERB PA, SP afatinib GILOTRIF PA, SP bosutinib BOSULIF

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 21

PA, SP ceritinib ZYKADIA PA, SP dabrafenib TAFINLAR PA, SP dasatinib SPRYCEL PA, SP ibrutinib caps IMBRUVICA PA, SP midostaurin RYDAPT PA, SP nilotinib TASIGNA PA, SP pazopanib VOTRIENT PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST

KINASE INHIBITORS FOR CML PA, SP imatinib mesylate GLEEVEC

MULTIPLE MYELOMA Immunomodulators PA, SP lenalidomide REVLIMID PA, SP pomalidomide POMALYST PA, SP thalidomide THALOMID

MISCELLANEOUS PA, SP bexarotene caps TARGRETIN dexrazoxane etoposide hydroxyurea HYDREA SP leucovorin inj leucovorin tabs PA tretinoin caps hydroxyurea DROXIA PA LYSODREN PA, SP obinutuzumab GAZYVA PA, SP, QL olaparib LYNPARZA PA procarbazine MATULANE PA ramucirumab CYRAMZA PA, SP rucaparib RUBRACA PA, SP vismodegib ERIVEDGE PA, SP vorinostat ZOLINZA

CARDIOVASCULAR ACE INHIBITORS benazepril LOTENSIN enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL ramipril ALTACE trandolapril

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL

ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 22

quinapril/hydrochlorothiazide ACCURETIC

ADRENOLYTICS, CENTRAL clonidine clonidine transdermal CATAPRES-TTS guanfacine

ADRENOLYTICS, CENTRAL/DIURETIC COMBINATION clonidine/chlorthalidone

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone INSPRA spironolactone ALDACTONE

ALPHA BLOCKERS doxazosin CARDURA prazosin MINIPRESS terazosin

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS QL irbesartan AVAPRO QL irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR QL olmesartan BENICAR QL olmesartan/hydrochlorothiazide BENICAR HCT QL telmisartan MICARDIS QL telmisartan/hydrochlorothiazide MICARDIS HCT QL valsartan DIOVAN QL valsartan/hydrochlorothiazide DIOVAN HCT

ANTIARRHYTHMICS amiodarone tabs 200 mg, 400 mg disopyramide NORPACE PA, SP dofetilide TIKOSYN flecainide mexiletine propafenone propafenone ext-rel RYTHMOL SR quinidine sulfate sotalol BETAPACE sotalol BETAPACE AF disopyramide ext-rel NORPACE CR

ANTILIPEMICS Bile Acid Resins cholestyramine QUESTRAN/QUESTRAN LIGHT colestipol COLESTID

Cholesterol Absorption Inhibitors QL ezetimibe ZETIA

Fibrates fenofibrate caps 67 mg, 134 mg, 200 mg fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 23

fenofibric acid delayed-rel tabs 35 mg, 105 mg gemfibrozil LOPID

HMG-CoA Reductase Inhibitors QL atorvastatin LIPITOR QL lovastatin QL pravastatin QL rosuvastatin CRESTOR PA, QL simvastatin ZOCOR

PA Required only for products containing 80 mg of simvastatin

Niacins OTC niacin ext-rel SLO-NIACIN niacin ext-rel NIASPAN

Omega-3 Fatty Acids QL omega-3 acid ethyl esters LOVAZA

PCSK9 Inhibitors PA alirocumab PRALUENT

BETA-BLOCKERS atenolol TENORMIN bisoprolol COREG labetalol TRANDATE metoprolol succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone bisoprolol/hydrochlorothiazide ZIAC

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nifedipine ext-rel nifedipine ext-rel PROCARDIA XL QL nimodipine NIMOTOP

Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC diltiazem ext-rel, except 120 mg CARDIZEM LA QL verapamil QL verapamil ext-rel caps 120 mg, 180 mg, 240 mg VERELAN SR QL verapamil ext-rel tabs CALAN SR

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 24

DIGITALIS GLYCOSIDES * LANOXIN digoxin pediatric elixir

* Mandatory generic requirement does not apply

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide

Loop Diuretics bumetanide furosemide LASIX torsemide

Potassium-sparing Diuretics amiloride spironolactone ALDACTONE

Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone

Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide 25 mg/25 mg ALDACTAZIDE triamterene/hydrochlorothiazide triamterene/hydrochlorothiazide MAXZIDE triamterene/hydrochlorothiazide MAXZIDE-25

HEART FAILURE QL sacubitril/valsartan ENTRESTO

NITRATES Oral isosorbide dinitrate 5 mg, 10 mg, 20 mg, 30 mg ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel

Sublingual nitroglycerin sublingual NITROSTAT

Transdermal nitroglycerin transdermal nitroglycerin transdermal 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.6 mg NITRO-DUR nitroglycerin ointment NITRO-BID

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, SP ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP macitentan OPSUMIT

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 25

Phosphodiesterase Inhibitors PA, SP sildenafil REVATIO PA, SP tadalafil ADCIRCA

Prostaglandin Vasodilators PA, SP epoprostenol sodium FLOLAN PA, SP iloprost VENTAVIS PA, SP treprostinil REMODULIN PA, SP treprostinil TYVASO PA, SP treprostinil ext-rel ORENITRAM

MISCELLANEOUS hydralazine methyldopa methyldopa/hydrochlorothiazide midodrine PA phenoxybenzamine DIBENZYLINE ST, QL ranolazine ext-rel RANEXA

CENTRAL NERVOUS SYSTEM ANTIANXIETY Benzodiazepines QL alprazolam ext-rel XANAX XR QL alprazolam tabs XANAX QL chlordiazepoxide QL clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL oxazepam

Miscellaneous QL buspirone fluvoxamine

ANTICONVULSANTS * carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER * ethosuximide ZARONTIN QL gabapentin NEURONTIN LAMICTAL lamotrigine ext-rel LAMICTAL XR levetiracetam KEPPRA levetiracetam ext-rel KEPPRA XR oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS * phenytoin sodium extended DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic acid

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 26

zonisamide ZONEGRAN

* Mandatory generic requirement does not apply

ANTIDEMENTIA donepezil ARICEPT galantamine ST galantamine ext-rel RAZADYNE ER ST, QL memantine NAMENDA ST, QL rivastigmine caps

ANTIDEPRESSANTS Monoamine Oxidase Inhibitors (MAOIs) phenelzine NARDIL PARNATE isocarboxazid MARPLAN

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram CELEXA QL escitalopram LEXAPRO fluoxetine caps PROZAC fluvoxamine QL HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL sertraline ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) QL desvenlafaxine ext-rel PRISTIQ QL duloxetine delayed-rel CYMBALTA venlafaxine QL venlafaxine ext-rel caps EFFEXOR XR

Tricyclic Antidepressants (TCAs) PA* amitriptyline PA* desipramine NORPRAMIN PA* doxepin PA* imipramine HCl PA* nortriptyline PAMELOR

PA* Prior authorization only required for members of age 65 and older

Miscellaneous Agents bupropion bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON mirtazapine orally disintegrating tabs REMERON SOLTAB trazodone 50 mg, 100 mg, 150 mg

ANTIPARKINSONIAN AGENTS amantadine benztropine bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone STALEVO

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 27

entacapone COMTAN pramipexole MIRAPEX QL pramipexole ext-rel MIRAPEX ER QL rasagiline AZILECT QL ropinirole ext-rel selegiline trihexyphenidyl

ANTIPSYCHOTICS Atypicals QL aripiprazole tabs ABILIFY * clozapine CLOZARIL PA*, QL olanzapine ZYPREXA PA*, QL olanzapine orally disintegrating tabs ZYPREXA ZYDIS PA*, QL olanzapine/fluoxetine SYMBYAX PA paliperidone ext-rel INVEGA quetiapine SEROQUEL QL quetiapine 100 mg SEROQUEL ST, QL quetiapine ext-rel SEROQUEL XR QL risperidone RISPERDAL ziprasidone GEODON PA aripiprazole ext-rel inj ABILIFY MAINTENA PA aripiprazole lauroxil ext-rel inj ARISTADA PA aripiprazole lauroxil ext-rel inj ARISTADA INITIO PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV PA paliperidone palmitate ext-rel inj INVEGA SUSTENNA PA paliperidone palmitate ext-rel inj INVEGA TRINZA PA risperidone ext-rel inj PERSERIS PA risperidone long-acting inj RISPERDAL CONSTA

AL Covered for members age 6 or older * Mandatory generic requirement does not apply PA* Prior authorization only required for members under 18 years of age

Miscellaneous chlorpromazine fluphenazine haloperidol haloperidol decanoate inj HALDOL DECANOATE loxapine perphenazine pimozide thioridazine thiothixene trifluoperazine

ATTENTION DEFICIT HYPERACTIVITY DISORDER PA, QL amphetamine/dextroamphetamine mixed salts ADDERALL PA, QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR QL atomoxetine STRATTERA PA, QL dexmethylphenidate FOCALIN PA, QL dexmethylphenidate ext-rel FOCALIN XR PA, QL dextroamphetamine ext-rel DEXEDRINE SPANSULE PA, QL dextroamphetamine tabs 5 mg, 10 mg PA, QL dextroamphetamine tabs 5 mg, 10 mg - Zenzedi

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 28

QL guanfacine ext-rel INTUNIV PA, QL methylphenidate METHYLIN PA, QL methylphenidate RITALIN PA, QL methylphenidate ext-rel CONCERTA PA, QL methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg RITALIN LA PA, QL methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, METADATE CD 60 mg

PA Required for members over 18 years of age

FIBROMYALGIA ST, QL pregabalin LYRICA

HUNTINGTON'S DISEASE AGENTS PA, SP tetrabenazine XENAZINE

HYPNOTICS Benzodiazepines QL estazolam QL flurazepam QL temazepam 15 mg, 30 mg RESTORIL

Nonbenzodiazepines OTC diphenhydramine NYTOL OTC doxylamine UNISOM OTC melatonin QL eszopiclone LUNESTA QL ramelteon QL zaleplon *, QL zolpidem AMBIEN ST, QL zolpidem ext-rel AMBIEN CR

* Gender restriction - In accordance with product labeling, females must begin therapy with 5 mg dose.

MIGRAINE Acute Migraine Agents Triptans Note: Limit of 1 prescription in class per 25 days.

QL eletriptan RELPAX QL AMERGE QL rizatriptan MAXALT QL rizatriptan orally disintegrating tabs MAXALT-MLT PA, QL injection IMITREX PA, QL sumatriptan nasal spray IMITREX QL sumatriptan tabs IMITREX QL zolmitriptan ZOMIG QL zolmitriptan orally disintegrating tabs ZOMIG-ZMT QL zolmitriptan nasal spray ZOMIG

PA Required for members under 18 years of age

Miscellaneous OTC acetaminophen/aspirin/caffeine EXCEDRIN MIGRAINE

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 29

Preventive Migraine Agents Monoclonal Antibodies PA erenumab-aooe AIMOVIG PA fremanezumab-vfrm AJOVY PA galcanezumab-gnlm EMGALITY

MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg

MULTIPLE SCLEROSIS AGENTS PA, SP dimethyl fumarate delayed-rel TECFIDERA PA, SP glatiramer COPAXONE PA, SP fingolimod GILENYA PA, SP interferon beta-1a AVONEX PA, SP interferon beta-1a REBIF PA, SP interferon beta-1b EXTAVIA PA, SP peginterferon beta-1a PLEGRIDY PA, SP siponimod MAYZENT PA, SP teriflunomide AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS baclofen 10 mg, 20 mg chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM methocarbamol tizanidine tabs ZANAFLEX

MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN

NARCOLEPSY/CATAPLEXY PA armodafinil NUVIGIL PA modafinil PROVIGIL PA sodium oxybate XYREM

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents QL acamprosate calcium disulfiram naltrexone microspheres VIVITROL

Opioid Antagonists naloxone inj naltrexone naloxone nasal spray NARCAN

Partial Opioid Agonists buprenorphine sublingual

Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film SUBOXONE FILM QL buprenorphine/naloxone sublingual tabs

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 30

Smoking Deterrents OTC, QL nicotine polacrilex gum, lozenge NICORETTE OTC, QL nicotine transdermal NICODERM CQ QL bupropion ext-rel QL nicotine inhaler NICOTROL INHALER QL nicotine nasal spray NICOTROL NS QL varenicline CHANTIX

ENDOCRINE AND METABOLIC ANDROGENS PA methyltestosterone PA testosterone cypionate inj DEPO-TESTOSTERONE PA testosterone enanthate inj DELATESTRYL PA testosterone gel 1% ANDROGEL PA testosterone gel 1% TESTIM

ANTIDIABETICS Alpha-glucosidase Inhibitors acarbose PRECOSE

Amylin Analogs ST pramlintide SYMLINPEN

Biguanides metformin metformin ext-rel 500 mg, 750 mg

Biguanide/Sulfonylurea Combinations glipizide/metformin PA* glyburide/metformin

PA* Prior authorization only required for members of age 65 and older

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST, QL alogliptin NESINA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST, QL alogliptin/metformin KAZANO

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations ST, QL alogliptin/pioglitazone OSENI

Incretin Mimetic Agents ST, QL dulaglutide TRULICITY ST, QL semaglutide OZEMPIC ST, QL semaglutide RYBELSUS

Insulins QL insulin aspart protamine 70%/insulin aspart 30% INSULIN ASPART QL insulin glargine SEMGLEE QL insulin human HUMULIN R QL insulin human NOVOLIN R QL insulin isophane human HUMULIN N QL insulin isophane human NOVOLIN N QL insulin isophane human 70%/regular 30% HUMULIN 70/30 QL insulin isophane human 70%/regular 30% NOVOLIN 70/30

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 31

QL insulin lispro ADMELOG

Insulin Sensitizers QL pioglitazone ACTOS

Insulin Sensitizer/Biguanide Combinations QL pioglitazone/metformin ACTOPLUS MET

Meglitinides nateglinide STARLIX repaglinide

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST, QL ertugliflozin STEGLATRO

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST, QL ertugliflozin/metformin SEGLUROMET

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase (DPP-4) Inhibitor Combinations ST, QL ertugliflozin/sitagliptin STEGLUJAN

Sulfonylureas glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL PA* glyburide PA* glyburide, micronized GLYNASE tolbutamide

PA* Prior authorization only required for members of age 65 and older

Supplies OTC, QL blood glucose monitoring kits, test strips FREESTYLE FREEDOM LITE kits and test strips OTC, QL blood glucose monitoring kits, test strips FREESTYLE INSULINX kits and test strips OTC, QL blood glucose monitoring kits, test strips FREESTYLE LITE kits and test strips OTC, QL blood glucose monitoring kits, test strips PRECISION XTRA kits and test strips OTC, QL insulin syringes, needles BD ULTRAFINE insulin syringes and needles OTC, QL lancets ST, QL insulin infusion disposable pump OMNIPOD DASH INSULIN INFUSION PUMP

CALCIUM RECEPTOR ANTAGONISTS PA, SP cinacalcet SENSIPAR

CALCIUM REGULATORS Bisphosphonates alendronate tabs 5 mg, 10 mg FOSAMAX QL alendronate tabs 35 mg, 40 mg, 70 mg FOSAMAX QL ibandronate BONIVA QL, SP zoledronic acid

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 32

Calcitonins QL calcitonin-salmon MIACALCIN

Parathyroid Hormones PA, SP abaloparatide TYMLOS

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen drospirenone/EE 3/20 YAZ drospirenone/EE/levomefolate 3/20 and levomefolate BEYAZ levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 (24) and iron norethindrone acetate/EE 1/20 and iron norethindrone acetate/EE 1/20 and iron chewable MINASTRIN 24 FE

25 mcg Estrogen norethindrone acetate/EE 0.8/25 and iron GENERESS FE

30 mcg Estrogen /EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN drospirenone/EE/levomefolate 3/30 and levomefolate SAFYRAL levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 norethindrone acetate/EE 1.5/30 and iron norgestrel/EE 0.3/30

35 mcg Estrogen ethynodiol diacetate/EE 1/35 norethindrone/EE 0.4/35 norethindrone/EE 0.4/35 and iron chewable norethindrone/EE 0.5/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35

50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50

Biphasic desogestrel/EE MIRCETTE

Triphasic desogestrel/EE levonorgestrel/EE norethindrone/EE norethindrone/EE and iron ESTROSTEP FE norgestimate/EE

Extended Cycle levonorgestrel/EE 0.1/20 and EE 10 LOSEASONIQUE levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10 QUARTETTE

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 33

levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10 SEASONIQUE

Continuous levonorgestrel/EE 0.09/20

Progestin Only norethindrone ORTHO MICRONOR

Emergency Contraception OTC levonorgestrel - Next Choice One Dose PLAN B ONE-STEP ulipristal ELLA

Implant QL implant NEXPLANON

Injectable medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA QL medroxyprogesterone acetate 104 mg/0.65 mL DEPO-SUBQ PROVERA 104

Intrauterine Devices QL intrauterine copper contraceptive PARAGARD QL levonorgestrel releasing IUD KYLEENA QL levonorgestrel releasing IUD LILETTA QL levonorgestrel releasing IUD MIRENA QL levonorgestrel releasing IUD SKYLA

Transdermal norelgestromin/EE

Vaginal etonogestrel/EE ring NUVARING

Miscellaneous OTC, QL condoms, female OTC, QL condoms, male OTC nonoxynol-9 CONCEPTROL OTC nonoxynol-9 SHUR-SEAL QL diaphragm

ENDOMETRIOSIS PA elagolix ORILISSA PA nafarelin SYNAREL

ESTROGENS Oral estradiol ESTRACE estrogens, conjugated PREMARIN estrogens, esterified MENEST

Transdermal estradiol CLIMARA estradiol VIVELLE-DOT estradiol/levonorgestrel CLIMARA PRO

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 34

Vaginal estradiol vaginal cream ESTRACE estradiol vaginal tabs - Yuvafem estradiol vaginal ring FEMRING estrogens, conjugated cream PREMARIN

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone acetate ACTIVELLA estradiol/norgestimate PREFEST estrogens, conjugated/medroxyprogesterone PREMPHASE estrogens, conjugated/medroxyprogesterone PREMPRO

Transdermal estradiol/norethindrone acetate COMBIPATCH

FERTILITY REGULATORS Ovulation Stimulants, Synthetic *, AL, QL clomiphene

* Gender restriction - Coverage for females only AL Covered for female members 21 to 44 years of age

GAUCHER DISEASE PA eliglustat CERDELGA

GLUCOCORTICOIDS acetate hydrocortisone CORTEF QL hydrocortisone inj 100 mg/mL SOLU-CORTEF MEDROL sodium phosphate solution 5 mg/5 mL prednisolone syrup

GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGON EMERGENCY KIT QL glucagon nasal powder BAQSIMI glucagon, human recombinant GLUCAGEN HYPOKIT

HUMAN GROWTH HORMONES AND RELATED DISORDERS PA, SP mecasermin INCRELEX PA, SP somatropin NORDITROPIN PA, SP somatropin SEROSTIM

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL paricalcitol ZEMPLAR

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 35

PHENYLKETONURIA TREATMENT AGENTS PA, SP sapropterin KUVAN

PHOSPHATE BINDER AGENTS calcium acetate ST sevelamer carbonate tabs RENVELA

PROGESTINS, ORAL medroxyprogesterone acetate PROVERA norethindrone AYGESTIN , micronized PROMETRIUM

SELECTIVE ESTROGEN RECEPTOR MODULATORS QL raloxifene EVISTA

THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil

Thyroid Supplements * levothyroxine SYNTHROID * levothyroxine UNITHROID * levothyroxine - Levoxyl liothyronine CYTOMEL thyroid ARMOUR THYROID thyroid NATURE-THROID thyroid NP THYROID thyroid WP THYROID

* Mandatory generic requirement does not apply

UREA CYCLE DISORDERS PA, SP sodium phenylbutyrate BUPHENYL

VASOPRESSINS desmopressin spray DDAVP PA desmopressin tabs DDAVP desmopressin spray STIMATE

MISCELLANEOUS cabergoline levocarnitine CARNITOR PA, SP nitisinone ORFADIN PA, SP octreotide acetate SANDOSTATIN PA, SP cysteamine bitartrate CYSTAGON PA elagolix/estradiol/norethindrone + elagolix ORIAHNN PA, SP octreotide acetate SANDOSTATIN LAR PA, SP pegvisomant SOMAVERT

GASTROINTESTINAL ANTACIDS OTC alumina/magnesia MAALOX OTC alumina/magnesia/simethicone MYLANTA OTC aluminum hydroxide OTC calcium carbonate TUMS

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 36

ANTIDIARRHEALS OTC bismuth subsalicylate PEPTO-BISMOL OTC loperamide IMODIUM A-D PA * diphenoxylate/atropine LOMOTIL

PA* Prior authorization required for members 65 years of age and older

ANTIEMETICS OTC dimenhydrinate DRAMAMINE PA, QL aprepitant caps EMEND PA doxylamine/pyridoxine delayed-rel DICLEGIS PA, QL dronabinol QL granisetron meclizine metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine promethazine injection promethazine oral soln, syrup, tabs promethazine supp 12.5 mg, 25 mg trimethobenzamide TIGAN QL dolasetron ANZEMET

ANTISPASMODICS dicyclomine caps, syrup, tabs QL dicyclomine inj BENTYL glycopyrrolate tabs hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs propantheline scopolamine methylbromide

CHOLELITHOLYTICS ursodiol ursodiol URSO

H2 RECEPTOR ANTAGONISTS OTC OTC famotidine cimetidine PA* famotidine susp PEPCID famotidine tabs PEPCID

PA* Prior authorization required for members 9 years of age and older

INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide QL budesonide delayed-rel caps ENTOCORT EC mesalamine delayed-rel caps DELZICOL mesalamine delayed-rel tabs ASACOL HD mesalamine delayed-rel tabs LIALDA mesalamine ext-rel caps APRISO sulfasalazine AZULFIDINE

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 37

sulfasalazine delayed-rel AZULFIDINE EN-TABS

Rectal Agents hydrocortisone enema mesalamine rectal suspension ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation/Chronic Idiopathic Constipation PA lubiprostone AMITIZA

LAXATIVES/STOOL SOFTENERS OTC docusate sodium COLACE OTC magnesium citrate soln OTC polyethylene glycol 3350 OTC psyllium METAMUCIL lactulose soln peg 3350/electrolytes peg 3350/electrolytes GOLYTELY

OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK

PANCREATIC ENZYMES PA pancrelipase delayed-rel CREON

PROSTAGLANDINS misoprostol CYTOTEC

PROTON PUMP INHIBITORS OTC, QL esomeprazole magnesium delayed-rel OTC, QL lansoprazole delayed-rel 15 mg PREVACID 24HR OTC, QL omeprazole magnesium delayed-rel caps OTC, QL omeprazole magnesium delayed-rel tabs OTC omeprazole/sodium bicarbonate ZEGERID OTC OTC, QL omeprazole delayed-rel tabs QL esomeprazole delayed-rel caps 40 mg NEXIUM QL lansoprazole delayed-rel 30 mg PREVACID QL omeprazole delayed-rel caps QL pantoprazole delayed-rel tabs PROTONIX QL rabeprazole ACIPHEX PA *, ST *, QL lansoprazole suspension FIRST-LANSOPRAZOLE PA *, ST *, QL omeprazole suspension FIRST-OMEPRAZOLE

PA* Prior authorization required for members 4 years of age and older ST* Step therapy required for members 3 years of age and younger

SALIVA STIMULANTS cevimeline EVOXAC pilocarpine tabs SALAGEN

STEROIDS, RECTAL QL hydrocortisone cream ANUSOL-HC QL lidocaine/hydrocortisone kit QL /pramoxine foam PROCTOFOAM-HC

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 38

MISCELLANEOUS cromolyn sodium GASTROCROM sucralfate tabs

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA QL alfuzosin ext-rel UROXATRAL *, ST, QL AVODART * finasteride PROSCAR tamsulosin FLOMAX

* Gender restriction - Coverage for males only

URINARY ANTISPASMODICS ST, QL darifenacin ext-rel ENABLEX oxybutynin oxybutynin ext-rel DITROPAN XL QL solifenacin VESICARE QL tolterodine DETROL QL tolterodine ext-rel DETROL LA trospium QL trospium ext-rel

VAGINAL ANTI-INFECTIVES OTC clotrimazole GYNE-LOTRIMIN OTC MONISTAT clindamycin cream CLEOCIN metronidazole gel 0.75% terconazole butoconazole GYNAZOLE-1 clindamycin suppository CLEOCIN

MISCELLANEOUS bethanechol phenazopyridine PYRIDIUM potassium citrate ext-rel UROCIT-K sodium citrate/citric acid PA, QL pentosan polysulfate sodium ELMIRON

HEMATOLOGIC ANTICOAGULANTS Injectable enoxaparin LOVENOX heparin

Oral warfarin apixaban ELIQUIS QL edoxaban SAVAYSA rivaroxaban 2.5 mg XARELTO

Synthetic Heparinoid-like Agents ARIXTRA

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 39

HEMATOPOIETIC GROWTH FACTORS PA, SP darbepoetin alfa ARANESP PA, SP epoetin alfa-epbx RETACRIT PA, SP filgrastim-sndz ZARXIO PA, SP pegfilgrastim-bmez ZIEXTENZO

HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS PA, SP antihemophilic factor (human) HEMOFIL M PA, SP antihemophilic factor (human) KOATE PA, SP antihemophilic factor (human) KOATE-DVI PA, SP antihemophilic factor (recombinant porcine) OBIZUR PA, SP antihemophilic factor (recombinant) ADVATE PA, SP antihemophilic factor (recombinant) AFSTYLA PA, SP antihemophilic factor (recombinant) ELOCTATE PA, SP antihemophilic factor (recombinant) KOGENATE FS PA, SP antihemophilic factor (recombinant) KOVALTRY PA, SP antihemophilic factor (recombinant) NOVOEIGHT PA, SP antihemophilic factor (recombinant) NUWIQ PA, SP antihemophilic factor (recombinant) RECOMBINATE PA, SP antihemophilic factor (recombinant) XYNTHA PA, SP antihemophilic factor (recombinant) pegylated ADYNOVATE PA, SP antihemophilic factor (recombinant) pegylated-aucl JIVI PA, SP antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT PA, SP antihemophilic factor/von Willebrand factor complex (human) ALPHANATE PA, SP antihemophilic factor/von Willebrand factor complex (human) HUMATE-P PA, SP antihemophilic factor/von Willebrand factor complex (human) WILATE PA, SP anti-inhibitor coagulant complex FEIBA NF PA, SP coagulation factor IX ALPHANINE SD PA, SP coagulation factor IX MONONINE PA, SP coagulation factor IX (recombinant) ALPROLIX PA, SP coagulation factor IX (recombinant) BENEFIX PA, SP coagulation factor IX (recombinant) IDELVION PA, SP coagulation factor IX (recombinant) IXINITY PA, SP coagulation factor IX (recombinant) RIXUBIS PA, SP coagulation factor VIIa (recombinant) NOVOSEVEN RT PA, SP coagulation factor X (human) COAGADEX PA, SP coagulation factor XIII A-subunit (recombinant) TRETTEN PA, SP emicizumab-kxwh HEMLIBRA PA, SP factor IX complex PROFILNINE PA, SP factor XIII concentrate (human) CORIFACT KIT PA, SP von Willebrand factor (recombinant) VONVENDI

PLATELET AGGREGATION INHIBITORS OTC aspirin 81 mg clopidogrel PLAVIX dipyridamole QL prasugrel EFFIENT

PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN

THROMBOCYTOPENIA AGENTS PA, SP tabs PROMACTA

MISCELLANEOUS cilostazol

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 40

PA, SP deferasirox EXJADE PA, SP deferasirox granules JADENU SPRINKLE PA, SP deferasirox tabs JADENU QL pentoxifylline ext-rel QL tranexamic acid LYSTEDA

IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS PA, SP adalimumab HUMIRA PA, SP brodalumab SILIQ PA, SP etanercept ENBREL PA, SP sarilumab KEVZARA PA, SP secukinumab COSENTYX PA, SP tofacitinib XELJANZ PA, SP tofacitinib ext-rel XELJANZ XR

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate 2.5 mg PA penicillamine DEPEN

IMMUNOMODULATORS Interferons PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2a PEGASYS

IMMUNOSUPPRESSANTS Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT

Calcineurin Inhibitors * cyclosporine SANDIMMUNE * cyclosporine, modified NEORAL tacrolimus PROGRAF

* Mandatory generic requirement does not apply

Rapamycin Derivatives sirolimus RAPAMUNE

Systemic Lupus Erythematosus PA, SP belimumab subcutaneous BENLYSTA

VACCINES * influenza vaccine AFLURIA * influenza vaccine FLUARIX * influenza vaccine FLUCELVAX * influenza vaccine FLULAVAL * influenza vaccine FLUZONE AL, QL zoster vaccine SHINGRIX AL, QL zoster vaccine ZOSTAVAX

* For members 18 years of age and younger, vaccine must be billed to Vaccine For Children (VFC) program AL Covered for members age 50 or older

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 41

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel caps 8 mEq, 10 mEq potassium chloride ext-rel tabs 20 mEq potassium chloride liquid 20 mEq/15 mL

Miscellaneous OTC electrolyte solution, oral PEDIALYTE

VITAMINS AND MINERALS Folic Acid Agents folic acid ST, QL l-methylfolate

Prenatal Vitamins prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal AD prenatal vitamins/ferrous fumarate/docusate/folic acid - Prenatal 19

Miscellaneous OTC ascorbic acid VITAMIN C OTC calcium carbonate OS-CAL OTC cholecalciferol (D3) VITAMIN D3 OTC cyanocobalamin tabs 1000 mcg VITAMIN B-12 OTC ergocalciferol (D2) VITAMIN D2 OTC ferrous gluconate FERGON OTC ferrous sulfate FEOSOL OTC magnesium oxide MAG-OX OTC multivitamins/minerals CENTRUM OTC niacin OTC omega-3 fatty acids FISH OIL OTC omega-3 fatty acids/vitamin E FISH OIL OTC pyridoxine VITAMIN B-6 OTC thiamine VITAMIN B-1 OTC vitamin A VITAMIN A OTC vitamin E VITAMIN E cyanocobalamin injection VITAMIN B-12 ergocalciferol (D2) * fluoride drops, tabs multivitamins, pediatric * multivitamins/fluoride drops, tabs * multivitamins/fluoride/iron drops, tabs multivitamins/iron, pediatric phytonadione MEPHYTON PA sodium ferric gluconate injection FERRLECIT * vitamin ADC/fluoride drops * vitamin ADC/fluoride/iron drops PA ferumoxytol FERAHEME PA iron dextran INFED PA iron sucrose injection VENOFER

* Covered for members through 17 years of age

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 42

RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS QL epinephrine auto-injector QL epinephrine auto-injector EPIPEN QL epinephrine auto-injector EPIPEN JR.

ANTICHOLINERGICS QL ipratropium inhalation solution QL ipratropium, CFC-free aerosol ATROVENT HFA ST, QL, AL tiotropium 1.25 mcg SPIRIVA RESPIMAT QL umeclidinium INCRUSE ELLIPTA

AL Covered for members age 6 years or older

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol inhalation solution QL ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT

Long Acting QL tiotropium/ STIOLTO RESPIMAT QL umeclidinium/ ANORO ELLIPTA

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS QL fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA

ANTIHISTAMINES, LOW SEDATING OTC cetirizine OTC, QL levocetirizine QL levocetirizine

ANTIHISTAMINES, NONSEDATING OTC fexofenadine OTC loratadine OTC loratadine orally disintegrating tabs

ANTIHISTAMINES, SEDATING OTC chlorpheniramine CHLOR-TRIMETON ALLERGY OTC diphenhydramine BENADRYL clemastine cyproheptadine hydroxyzine HCl, except inj hydroxyzine pamoate VISTARIL

ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC cetirizine/pseudoephedrine ext-rel OTC chlorpheniramine/phenylephrine ACTIFED COLD & ALLERGY OTC dexbrompheniramine/pseudoephedrine ext-rel DRIXORAL OTC fexofenadine/pseudoephedrine ext-rel OTC loratadine/pseudoephedrine ext-rel

ANTITUSSIVE benzonatate TESSALON

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 43

ANTITUSSIVE COMBINATIONS Opioid PA, QL codeine/chlorpheniramine/pseudoephedrine PA, QL codeine/guaifenesin liquid PA, QL codeine/promethazine PA, QL codeine/promethazine/phenylephrine PA, QL hydrocodone/homatropine

PA Prior authorization required for members 18 years of age and younger

Non-opioid OTC dextromethorphan/guaifenesin ROBITUSSIN + CHEST CONGESTION DM OTC dextromethorphan/guaifenesin/pseudoephedrine ROBITUSSIN MULTI­ SYMPTOM COLD dextromethorphan/promethazine

BETA AGONISTS Inhalants Short Acting QL albuterol inhalation solution QL albuterol sulfate, CFC-free aerosol PROAIR HFA QL albuterol sulfate, CFC-free aerosol PROVENTIL HFA ST, QL levalbuterol inhalation solution QL levalbuterol tartrate, CFC-free aerosol XOPENEX HFA QL albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK

Long Acting QL olodaterol, CFC-free aerosol STRIVERDI RESPIMAT

Oral Agents albuterol albuterol ext-rel

CYSTIC FIBROSIS PA, SP tobramycin inhalation solution TOBI PA aztreonam lysine inhalation solution CAYSTON PA, SP dornase alfa PULMOZYME

LEUKOTRIENE MODULATORS QL, * SINGULAIR QL, * ACCOLATE

* May be dispensed as a 90-day supply

NASAL ANTIHISTAMINES spray 0.1%

NASAL DECONGESTANTS OTC spray AFRIN OTC phenylephrine spray NEO-SYNEPHRINE

NASAL STEROIDS OTC, QL budesonide spray OTC, QL fluticasone spray OTC, QL triamcinolone acetonide spray

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 44

RESPIRATORY DEVICES respiratory devices AEROTRACH PLUS HOLDING CHAMBER respiratory devices BREATHERITE PRODUCTS respiratory devices EASIVENT PRODUCTS respiratory devices INSPIREASE PRODUCTS respiratory devices MICROCHAMBER PRODUCTS

RESPIRATORY SYNCYTIAL VIRUS PA, SP palivizumab SYNAGIS

SEVERE ASTHMA AGENTS PA, SP benralizumab FASENRA

STEROID/BETA AGONIST COMBINATIONS QL, * budesonide/ SYMBICORT QL, * fluticasone/ AIRDUO RESPICLICK QL, * fluticasone/salmeterol - Wixela Inhub ADVAIR DISKUS

* May be dispensed as a 90-day supply

STEROID INHALANTS PA, QL, * budesonide inhalation solution PULMICORT RESPULES QL, * ARNUITY ELLIPTA QL, * mometasone ASMANEX HFA

PA Required for members over 8 years of age * May be dispensed as a 90-day supply

XANTHINES * ext-rel tabs * theophylline ext-rel caps THEO-24 * theophylline liquid ELIXOPHYLLIN

* May be dispensed as a 90-day supply

MISCELLANEOUS OTC cromolyn nasal spray NASALCROM OTC sodium chloride OCEAN QL ipratropium nasal spray sodium chloride

TOPICAL DERMATOLOGY Acne Oral PA isotretinoin PA isotretinoin - Amnesteem PA isotretinoin - Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane

Topical benzoyl peroxide BENZAC AC QL clindamycin gel, lotion, pads, solution CLEOCIN T

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 45

QL erythromycin gel 2% QL erythromycin solution 2% PA tretinoin RETIN-A OTC, QL adapalene gel 0.1% DIFFERIN

Actinic Keratosis fluorouracil crm 5% EFUDEX

Antibiotics OTC bacitracin gentamicin oint silver sulfadiazine SILVADENE

Antifungals OTC, QL clotrimazole crm, solution 1% OTC miconazole MICATIN OTC tolnaftate TINACTIN OTC terbinafine LAMISIL AT ST ciclopirox solution 8% QL clotrimazole crm, solution 1% clotrimazole/betamethasone crm QL ketoconazole crm 2% QL nystatin crm, ointment, powder PA, QL nystatin/triamcinolone

PA Required for members 5 years of age and older

Antipsoriatics Oral PA acitretin SORIATANE

Topical anthralin QL calcipotriene DOVONEX

PA Required for quantity of 60 gm and larger

Antiseborrheics ketoconazole shampoo 2% selenium sulfide lotion 2.5%

Atopic PA, QL tacrolimus PROTOPIC PA, QL crisaborole ointment 2% EUCRISA

Corticosteroids Low Potency OTC hydrocortisone cream, ointment 0.5%, 1% QL alclometasone cream, ointment 0.05% fluocinolone acetonide cream 0.01% QL fluocinolone acetonide solution 0.01% hydrocortisone cream 2.5% hydrocortisone lotion 1%

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 46

Medium Potency QL betamethasone valerate cream, lotion, ointment 0.1% QL fluocinolone acetonide cream, ointment 0.025% QL fluocinolone acetonide oil 0.01% DERMA-SMOOTHE/FS QL fluticasone propionate cream 0.05%, ointment 0.005% QL mometasone cream, lotion, ointment 0.1% triamcinolone acetonide cream, lotion, ointment 0.025% triamcinolone acetonide cream, lotion, ointment 0.1%

High Potency QL betamethasone dipropionate augmented cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream, lotion, ointment 0.05% QL fluocinonide cream, gel, ointment 0.05% fluocinonide emollient cream 0.05% fluocinonide solution 0.05% triamcinolone acetonide cream, ointment 0.5%

Very High Potency QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE QL clobetasol propionate cream 0.05% TEMOVATE clobetasol propionate emollient cream 0.05% QL clobetasol propionate gel 0.05% QL clobetasol propionate lotion 0.05% CLOBEX QL clobetasol propionate ointment 0.05% TEMOVATE QL clobetasol propionate spray 0.05% CLOBEX QL halobetasol propionate cream, ointment 0.05%

Emollients ammonium lactate 12%

Local Analgesics OTC, QL capsaicin crm 0.1% CAPZASIN-HP OTC, QL capsaicin crm, patch 0.025% OTC, QL lidocaine crm, patch 4% - Aspercreme/Lidocaine OTC lidocaine/menthol patch 4/1% LIDOPATCH OTC, QL capsaicin crm 0.035% CAPZASIN-P OTC, QL capsaicin crm 0.075% ARTHRITIS PAIN CREAM OTC, QL capsaicin lotion 0.035% CASTIVA OTC, QL capsaicin plaster 0.15% GUADALUPANO OTC, QL capsaicin stick 0.075% ZOSTRIX HP OTC, QL capsaicin/menthol patch 0.025/5% ICY HOT OTC, QL capsaicin/menthol patch 0.05/5% ALLEVESS OTC, QL capsaicin/menthol/methyl salicylate crm 0.025/1/12% ZIKS OTC, QL capsaicin/menthol/methyl salicylate crm 0.035/10/25% RELIADERM OTC, QL lidocaine/menthol crm 4/1% ICY HOT OTC, QL lidocaine/trolamine salicylate/capsaicin soln 4/10/0.035% ARTHRITIS & MUSCLE PAIN RELIEF PA lidocaine gel 2% XYLOCAINE PA, QL lidocaine patch 5% LIDODERM

Local Anesthetics QL lidocaine/prilocaine crm 2.5/2.5%

Rosacea metronidazole cream 0.75% METROCREAM metronidazole gel 0.75%

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 47

ST metronidazole gel 1% METROGEL metronidazole lotion 0.75% METROLOTION

Scabicides and Pediculicides OTC permethrin 1% NIX CREME RINSE OTC pyrethrins/piperonyl butoxide 4% A-200 SHAMPOO OTC pyrethrins/piperonyl butoxide 4% LICE KILLING SHAMPOO OTC pyrethrins/piperonyl butoxide 4% RID SHAMPOO ST spinosad NATROBA ST malathion OVIDE permethrin 5%

Miscellaneous Skin and Mucous Membrane OTC, QL insect repellent, DEET 7% CUTTER SKINSATIONS OTC, QL insect repellent, DEET 15% OFF ACTIVE OTC, QL insect repellent, DEET 15% OFF FAMILY CARE OTC, QL insect repellent, DEET 25% CUTTER BACKWOODS OTC, QL insect repellent, DEET 25% OFF DEEP WOODS OTC, QL insect repellent, DEET 25% REPEL SPORTSMEN OTC, QL insect repellent, DEET 40% REPEL SPORTSMEN MAX OTC, QL insect repellent, picaridin 20% NATRAPEL OTC, QL insect repellent, picaridin 20% SAWYER QL imiquimod ALDARA podofilox solution trypsin/balsam/castor oil PA becaplermin REGRANEX PA, QL collagenase SANTYL

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous

Steroids - Mouth/Throat triamcinolone paste

Miscellaneous chlorhexidine gluconate PERIDEX

OPHTHALMIC Antiallergics OTC ketotifen ZADITOR OTC, QL PATADAY cromolyn sodium

Anti-infectives Ointments are also available for many of the products and they should be considered on the drug list.

QL bacitracin ciprofloxacin solution CILOXAN erythromycin gentamicin levofloxacin /polymyxin B/gramicidin ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 48

sulfacetamide solution 10% BLEPH-10 tobramycin solution TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone ointment neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone suspension sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX sulfacetamide/ 10%/0.2% BLEPHAMIDE QL tobramycin/dexamethasone ointment 0.3%/0.1% TOBRADEX

Anti-inflammatories Ointments are also available for many of the products and they should be considered on the drug list.

Nonsteroidal diclofenac sodium flurbiprofen ketorolac 0.4% ACULAR LS ketorolac 0.5% ACULAR

Steroidal dexamethasone sodium phosphate FML prednisolone acetate 1% PRED FORTE fluorometholone 0.25% FML FORTE fluorometholone ointment 0.1% FML S.O.P. prednisolone acetate 0.12% PRED MILD prednisolone phosphate 1%

Antivirals trifluridine

Beta-blockers Nonselective carteolol levobunolol timolol maleate TIMOPTIC

Selective betaxolol BETOPTIC S

Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT

Dry Eye Disease PA lifitegrast XIIDRA

Mydriatics cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE tropicamide

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 49

atropine cyclopentolate/phenylephrine CYCLOMYDRIL

Parasympathomimetics pilocarpine ISOPTO CARPINE

Prostaglandins ST, QL bimatoprost 0.03% QL latanoprost XALATAN ST, QL travoprost TRAVATAN Z

Sympathomimetics QL brimonidine 0.15% ALPHAGAN P QL brimonidine 0.2%

Miscellaneous OTC artificial tears ointment, solution OTC sodium chloride MURO-128

OTIC Anti-infectives acetic acid ofloxacin otic

Anti-infective/Anti-inflammatory Combinations PA, QL ciprofloxacin/dexamethasone CIPRODEX neomycin/polymyxin B/hydrocortisone

Fidelis Care mandates the use of generic drugs, if available (indicated by boldface). Brand names listed are for reference only. 50

INDEX

A alendronate tabs 35 mg, 40 mg, 70 mg, 32 alendronate tabs 5 mg, 10 mg, 32 A-200 SHAMPOO, 48 ALEVE, 16 abacavir, 19 alfuzosin ext-rel, 39 abacavir/dolutegravir/lamivudine, 18 ALINIA, 21 abacavir/lamivudine, 18 alirocumab, 24 abacavir/lamivudine/zidovudine, 18 ALKERAN, 21 abaloparatide, 33 ALLEVESS, 47 ABILIFY, 28 allopurinol, 16 ABILIFY MAINTENA, 28 alogliptin, 31 acamprosate calcium, 30 alogliptin/metformin, 31 acarbose, 31 alogliptin/pioglitazone, 31 ACCOLATE, 44 ALPHAGAN P, 50 ACCUPRIL, 22 ALPHANATE, 40 ACCURETIC, 23 ALPHANINE SD, 40 acetaminophen, 16 alprazolam ext-rel, 26 acetaminophen/aspirin/caffeine, 29 alprazolam tabs, 26 acetaminophen/caffeine, 17 ALPROLIX, 40 acetazolamide, 25 ALTACE, 22 acetazolamide ext-rel, 25 alumina/magnesia, 36 acetic acid, 50 alumina/magnesia/simethicone, 36 ACIPHEX, 38 aluminum hydroxide, 36 acitretin, 46 amantadine, 27 ACTIFED COLD & ALLERGY, 43 AMARYL, 32 ACTIQ, 16 AMBIEN, 29 ACTIVELLA, 35 AMBIEN CR, 29 ACTOPLUS MET, 32 ambrisentan, 25 ACTOS, 32 AMERGE, 29 ACULAR, 49 amiloride, 25 ACULAR LS, 49 amiloride/hydrochlorothiazide, 25 acyclovir caps, suspension, tabs, 20 amiodarone tabs 200 mg, 400 mg, 23 adalimumab, 41 AMITIZA, 38 adapalene gel 0.1%, 46 amitriptyline, 27 ADCIRCA, 26 amlodipine, 24 ADDERALL, 28 amlodipine/benazepril, 22 ADDERALL XR, 28 ammonium lactate 12%, 47 adefovir dipivoxil, 20 amoxicillin, 18 ADMELOG, 32 amoxicillin/clavulanate, 18 ADVAIR DISKUS, 45 amphetamine/dextroamphetamine mixed salts, 28 ADVATE, 40 amphetamine/dextroamphetamine mixed salts ext-rel, 28 ADVIL, 16 ampicillin, 18 ADYNOVATE, 40 anagrelide, 40 AEROTRACH PLUS HOLDING CHAMBER, 45 anastrozole, 21 afatinib, 21 ANDROGEL, 31 AFINITOR, 21 ANORO ELLIPTA, 43 AFLURIA, 41 anthralin, 46 AFRIN, 44 antihemophilic factor (human), 40 AFSTYLA, 40 antihemophilic factor (recombinant porcine), 40 AGRYLIN, 40 antihemophilic factor (recombinant), 40 AIMOVIG, 30 antihemophilic factor (recombinant) pegylated, 40 AIRDUO RESPICLICK, 45 antihemophilic factor (recombinant) pegylated-aucl, 40 AJOVY, 30 antihemophilic factor (recombinant), glycopegylated-exei, 40 albendazole, 20 antihemophilic factor/von Willebrand factor complex (human), 40 ALBENZA, 20 anti-inhibitor coagulant complex, 40 albuterol, 44 ANUSOL-HC, 38 albuterol ext-rel, 44 ANZEMET, 37 albuterol inhalation solution, 44 apixaban, 39 albuterol sulfate aerosol powder breath-activated, 44 aprepitant caps, 37 albuterol sulfate, CFC-free aerosol, 44 APRISO, 37 alclometasone cream, ointment 0.05%, 46 APTIVUS, 20 ALDACTAZIDE, 25 ARANESP, 40 ALDACTONE, 23, 25 ARAVA, 41 ALDARA, 48 ARICEPT, 27

51

ARIMIDEX, 21 BENLYSTA, 41 aripiprazole ext-rel inj, 28 benralizumab, 45 aripiprazole lauroxil ext-rel inj, 28 BENTYL, 37 aripiprazole tabs, 28 BENZAC AC, 45 ARISTADA, 28 benzonatate, 43 ARISTADA INITIO, 28 benzoyl peroxide, 45 ARIXTRA, 39 benztropine, 27 armodafinil, 30 betamethasone dipropionate augmented cream 0.05%, 47 ARMOUR THYROID, 36 betamethasone dipropionate augmented ointment 0.05%, 47 ARNUITY ELLIPTA, 45 betamethasone dipropionate cream, lotion, ointment 0.05%, AROMASIN, 21 47 ARTHRITIS & MUSCLE PAIN RELIEF, 47 betamethasone valerate cream, lotion, ointment 0.1%, 47 ARTHRITIS PAIN CREAM, 47 BETAPACE, 23 artificial tears ointment, solution, 50 BETAPACE AF, 23 ASACOL HD, 37 betaxolol, 49 ascorbic acid, 42 bethanechol, 39 ASMANEX HFA, 45 BETOPTIC S, 49 aspirin, 16 bexarotene caps, 22 aspirin 81 mg, 40 BEYAZ, 33 aspirin buffered, 16 bicalutamide, 21 aspirin delayed-rel, 16 BICILLIN L-A, 18 aspirin/caffeine, 17 bictegravir/emtricitabine/tenofovir alafenamide, 19 atazanavir, 19 BIKTARVY, 19 atazanavir/cobicistat, 18 bimatoprost 0.03%, 50 atenolol, 24 bismuth subsalicylate, 37 atenolol/chlorthalidone, 24 bisoprolol, 24 ATIVAN, 26 bisoprolol/hydrochlorothiazide, 24 atomoxetine, 28 BLEPH-10, 49 atorvastatin, 24 BLEPHAMIDE, 49 atovaquone, 20 blood glucose monitoring kits, test strips, 32 atovaquone/proguanil, 18 BONIVA, 32 ATRIPLA, 18 bosentan, 25 atropine, 50 BOSULIF, 21 ATROVENT HFA, 43 bosutinib, 21 AUBAGIO, 30 BREATHERITE PRODUCTS, 45 AUGMENTIN, 18 brimonidine 0.15%, 50 AVALIDE, 23 brimonidine 0.2%, 50 AVAPRO, 23 brodalumab, 41 AVODART, 39 bromocriptine, 27 AVONEX, 30 budesonide delayed-rel caps, 37 AYGESTIN, 36 budesonide inhalation solution, 45 azathioprine, 41 budesonide spray, 44 azelastine spray 0.1%, 44 budesonide/formoterol, 45 AZILECT, 28 BUFFERIN, 16 azithromycin, 17 bumetanide, 25 aztreonam lysine inhalation solution, 44 BUPHENYL, 36 AZULFIDINE, 37 buprenorphine sublingual, 30 AZULFIDINE EN-TABS, 38 buprenorphine/naloxone sublingual film, 30 B buprenorphine/naloxone sublingual tabs, 30 bupropion, 27 bacitracin, 46, 48 bupropion ext-rel, 27, 31 BACK & BODY, 17 buspirone, 26 baclofen 10 mg, 20 mg, 30 busulfan, 21 balsalazide, 37 butalbital/acetaminophen, 17 BAQSIMI, 35 butalbital/acetaminophen/caffeine tabs - Esgic, 17 BARACLUDE, 20 butalbital/aspirin/caffeine, 17 BAYER, 16 butoconazole, 39 BD ULTRAFINE insulin syringes and needles, 32 becaplermin, 48 C belimumab subcutaneous, 41 cabergoline, 36 BENADRYL, 43 CALAN SR, 24 benazepril, 22 calcipotriene, 46 benazepril/hydrochlorothiazide, 22 calcitonin-salmon, 33 BENEFIX, 40 calcitriol (1,25-D3), 35 BENICAR, 23 calcium acetate, 36 BENICAR HCT, 23 calcium carbonate, 36, 42

52 capecitabine, 21 cinacalcet, 32 capsaicin crm 0.035%, 47 CIPRO, 17 capsaicin crm 0.075%, 47 CIPRODEX, 50 capsaicin crm 0.1%, 47 ciprofloxacin, 17 capsaicin crm, patch 0.025%, 47 ciprofloxacin solution, 48 capsaicin lotion 0.035%, 47 ciprofloxacin/dexamethasone, 50 capsaicin plaster 0.15%, 47 citalopram, 27 capsaicin stick 0.075%, 47 clarithromycin, 17 capsaicin/menthol patch 0.025/5%, 47 clarithromycin ext-rel, 17 capsaicin/menthol patch 0.05/5%, 47 clemastine, 43 capsaicin/menthol/methyl salicylate crm 0.025/1/12%, 47 CLEOCIN, 20, 39 capsaicin/menthol/methyl salicylate crm 0.035/10/25%, 47 CLEOCIN T, 45 CAPZASIN-HP, 47 CLIMARA, 34 CAPZASIN-P, 47 CLIMARA PRO, 34 carbamazepine, 26 clindamycin, 20 carbamazepine ext-rel, 26 clindamycin cream, 39 CARBATROL, 26 clindamycin gel, lotion, pads, solution, 45 carbidopa/levodopa, 27 clindamycin suppository, 39 carbidopa/levodopa ext-rel, 27 clobetasol propionate cream 0.05%, 47 carbidopa/levodopa/entacapone, 27 clobetasol propionate emollient cream 0.05%, 47 CARDIZEM, 24 clobetasol propionate gel 0.05%, 47 CARDIZEM CD, 24 clobetasol propionate lotion 0.05%, 47 CARDIZEM LA, 24 clobetasol propionate ointment 0.05%, 47 CARDURA, 23 clobetasol propionate spray 0.05%, 47 CARNITOR, 36 CLOBEX, 47 carteolol, 49 clomiphene, 35 carvedilol, 24 clonazepam tabs, 26 CASODEX, 21 clonidine, 23 CASTIVA, 47 clonidine transdermal, 23 CATAPRES-TTS, 23 clonidine/chlorthalidone, 23 CAYSTON, 44 clopidogrel, 40 cefaclor, 17 clotrimazole, 39 cefadroxil, 17 clotrimazole crm, solution 1%, 46 cefdinir, 17 clotrimazole troches, 18 cefpodoxime, 17 clotrimazole/betamethasone crm, 46 cefprozil, 17 clozapine, 28 cefuroxime axetil, 17 CLOZARIL, 28 CELEBREX, 16 COAGADEX, 40 celecoxib 50 mg, 100 mg, 200 mg, 16 coagulation factor IX, 40 CELEXA, 27 coagulation factor IX (recombinant), 40 CELLCEPT, 41 coagulation factor VIIa (recombinant), 40 CENTRUM, 42 coagulation factor X (human), 40 cephalexin, 17 coagulation factor XIII A-subunit (recombinant), 40 CERDELGA, 35 cobicistat, 18 ceritinib, 22 codeine/acetaminophen, 16 cetirizine, 43 codeine/chlorpheniramine/pseudoephedrine, 44 cetirizine/pseudoephedrine ext-rel, 43 codeine/guaifenesin liquid, 44 cevimeline, 38 codeine/promethazine, 44 CHANTIX, 31 codeine/promethazine/phenylephrine, 44 chlorambucil, 21 COLACE, 38 chlordiazepoxide, 26 colchicine, 16 chlorhexidine gluconate, 48 colchicine/probenecid, 16 chloroquine, 18 COLCRYS, 16 chlorpheniramine, 43 COLESTID, 23 chlorpheniramine/phenylephrine, 43 colestipol, 23 chlorpromazine, 28 collagenase, 48 chlorthalidone, 25 COMBIPATCH, 35 CHLOR-TRIMETON ALLERGY, 43 COMBIVENT RESPIMAT, 43 chlorzoxazone 500 mg, 30 COMPLERA, 19 cholecalciferol (D3), 42 COMTAN, 28 cholestyramine, 23 CONCEPTROL, 34 ciclopirox solution 8%, 46 CONCERTA, 29 cilostazol, 40 condoms, female, 34 CILOXAN, 48 condoms, male, 34 CIMDUO, 19 COPAXONE, 30 cimetidine, 37 COREG, 24

53

CORGARD, 24 desmopressin tabs, 36 CORIFACT KIT, 40 desogestrel/EE, 33 CORTEF, 35 desogestrel/EE 0.15/30 - Apri, 33 , 35 desvenlafaxine ext-rel, 27 COSENTYX, 41 DETROL, 39 COSOPT, 49 DETROL LA, 39 COZAAR, 23 dexamethasone, 35 CREON, 38 dexamethasone sodium phosphate, 49 CRESTOR, 24 dexbrompheniramine/pseudoephedrine ext-rel, 43 crisaborole ointment 2%, 46 DEXEDRINE SPANSULE, 28 CRIXIVAN, 19 dexmethylphenidate, 28 cromolyn nasal spray, 45 dexmethylphenidate ext-rel, 28 cromolyn sodium, 39, 48 dexrazoxane, 22 CUBICIN, 20 dextroamphetamine ext-rel, 28 CUTTER BACKWOODS, 48 dextroamphetamine tabs 5 mg, 10 mg, 28 CUTTER SKINSATIONS, 48 dextroamphetamine tabs 5 mg, 10 mg - Zenzedi, 28 cyanocobalamin injection, 42 dextromethorphan/guaifenesin, 44 cyanocobalamin tabs 1000 mcg, 42 dextromethorphan/guaifenesin/pseudoephedrine, 44 cyclobenzaprine 5 mg, 10 mg, 30 dextromethorphan/promethazine, 44 CYCLOGYL, 49 diaphragm, 34 CYCLOMYDRIL, 50 DIASTAT, 26 cyclopentolate, 49 diazepam, 26 cyclopentolate/phenylephrine, 50 diazepam rectal gel, 26 cyclophosphamide caps, 21 DIBENZYLINE, 26 cyclosporine, 41 DICLEGIS, 37 cyclosporine, modified, 41 diclofenac sodium, 49 CYMBALTA, 27 diclofenac sodium delayed-rel 50 mg, 75 mg, 16 cyproheptadine, 43 diclofenac sodium ext-rel, 16 CYRAMZA, 22 diclofenac sodium gel 1%, 16 CYSTAGON, 36 diclofenac sodium soln 1.5%, 16 cysteamine bitartrate, 36 dicloxacillin, 18 CYTOMEL, 36 dicyclomine caps, syrup, tabs, 37 CYTOTEC, 38 dicyclomine inj, 37 D DIFFERIN, 46 DIFLUCAN, 18 dabrafenib, 22 diflunisal, 16 danazol, 34 digoxin, 25 DANTRIUM, 30 digoxin pediatric elixir, 25 dantrolene, 30 DILANTIN, 26 dapsone, 20 DILANTIN INFATABS, 26 daptomycin, 20 DILAUDID, 17 darbepoetin alfa, 40 diltiazem, 24 darifenacin ext-rel, 39 diltiazem ext-rel, 24 darunavir, 19 diltiazem ext-rel, except 120 mg, 24 darunavir/cobicistat, 19 dimenhydrinate, 37 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 19 dimethyl fumarate delayed-rel, 30 dasatinib, 22 DIOVAN, 23 DAYPRO, 16 DIOVAN HCT, 23 DDAVP, 36 diphenhydramine, 29, 43 deferasirox, 41 diphenoxylate/atropine, 37 deferasirox granules, 41 DIPROLENE, 47 deferasirox tabs, 41 DIPROLENE AF, 47 DELATESTRYL, 31 dipyridamole, 40 DELSTRIGO, 19 disopyramide, 23 DELZICOL, 37 disopyramide ext-rel, 23 demeclocycline, 18 disulfiram, 30 DEPAKOTE, 26 DITROPAN XL, 39 DEPAKOTE ER, 26 divalproex sodium delayed-rel, 26 DEPEN, 41 divalproex sodium ext-rel, 26 DEPO-PROVERA, 21, 34 docusate sodium, 38 DEPO-SUBQ PROVERA 104, 34 dofetilide, 23 DEPO-TESTOSTERONE, 31 dolasetron, 37 DERMA-SMOOTHE/FS, 47 dolutegravir tabs, 19 DESCOVY, 19 dolutegravir tabs for oral suspension, 19 desipramine, 27 dolutegravir/lamivudine, 19 desmopressin spray, 36 dolutegravir/rilpivirine, 19

54 donepezil, 27 EMTRIVA, 19 doravirine, 19 ENABLEX, 39 doravirine/lamivudine/tenofovir disoproxil fumarate, 19 enalapril, 22 dornase alfa, 44 enalapril/hydrochlorothiazide, 22 dorzolamide, 49 ENBREL, 41 dorzolamide/timolol maleate, 49 enfuvirtide, 19 DOVATO, 19 enoxaparin, 39 DOVONEX, 46 entacapone, 28 doxazosin, 23 entecavir soln, 20 doxepin, 27 entecavir tabs, 20 doxercalciferol, 35 ENTOCORT EC, 37 doxycycline hyclate caps 50 mg, 100 mg, 18 ENTRESTO, 25 doxycycline hyclate tabs 20 mg, 100 mg, 18 EPCLUSA, 20 doxycycline monohydrate caps 50 mg, 100 mg, 18 epinephrine auto-injector, 43 doxycycline monohydrate suspension 25 mg/5 mL, 18 EPIPEN, 43 doxycycline monohydrate tabs 50 mg, 100 mg, 18 EPIPEN JR., 43 doxylamine, 29 EPIVIR-HBV, 20 doxylamine/pyridoxine delayed-rel, 37 eplerenone, 23 DRAMAMINE, 37 epoetin alfa-epbx, 40 DRIXORAL, 43 epoprostenol sodium, 26 dronabinol, 37 erenumab-aooe, 30 drospirenone/EE 3/20, 33 ergocalciferol (D2), 42 drospirenone/EE 3/30, 33 ERIVEDGE, 22 drospirenone/EE/levomefolate 3/20 and levomefolate, 33 erlotinib, 21 drospirenone/EE/levomefolate 3/30 and levomefolate, 33 ertugliflozin, 32 DROXIA, 22 ertugliflozin/metformin, 32 dulaglutide, 31 ertugliflozin/sitagliptin, 32 duloxetine delayed-rel, 27 erythromycin, 48 DURAGESIC, 16 erythromycin base, 17 dutasteride, 39 erythromycin delayed-rel, 17 E erythromycin ethylsuccinate, 17 erythromycin gel 2%, 46 EASIVENT PRODUCTS, 45 erythromycin solution 2%, 46 ECOTRIN, 16 erythromycin stearate, 17 edoxaban, 39 escitalopram, 27 EDURANT, 19 esomeprazole delayed-rel caps 40 mg, 38 EE/norethindrone acetate, 35 esomeprazole magnesium delayed-rel, 38 EE/norethindrone acetate - Jinteli, 35 ESPEROCT, 40 efavirenz, 19 estazolam, 29 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 18 ESTRACE, 34, 35 efavirenz/lamivudine/tenofovir disoproxil fumarate, 18 estradiol, 34 EFFEXOR XR, 27 estradiol vaginal cream, 35 EFFIENT, 40 estradiol vaginal ring, 35 EFUDEX, 46 estradiol vaginal tabs - Yuvafem, 35 elagolix, 34 estradiol/levonorgestrel, 34 elagolix/estradiol/norethindrone + elagolix, 36 estradiol/norethindrone acetate, 35 electrolyte solution, oral, 42 estradiol/norgestimate, 35 eletriptan, 29 estrogens, conjugated, 34 eliglustat, 35 estrogens, conjugated cream, 35 ELIQUIS, 39 estrogens, conjugated/medroxyprogesterone, 35 ELIXOPHYLLIN, 45 estrogens, esterified, 34 ELLA, 34 ESTROSTEP FE, 33 ELMIRON, 39 eszopiclone, 29 ELOCTATE, 40 etanercept, 41 eltrombopag tabs, 40 ethambutol, 20 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 19 ethosuximide, 26 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, ethynodiol diacetate/EE 1/35, 33 19 ethynodiol diacetate/EE 1/50, 33 EMEND, 37 etodolac, 16 EMGALITY, 30 etodolac ext-rel, 16 emicizumab-kxwh, 40 etonogestrel implant, 34 emtricitabine, 19 etonogestrel/EE ring, 34 emtricitabine/rilpivirine/tenofovir alafenamide, 19 etoposide, 22 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 19 etravirine, 19 emtricitabine/tenofovir alafenamide, 19 EUCRISA, 46 emtricitabine/tenofovir disoproxil fumarate, 18 everolimus, 21

55

EVISTA, 36 fluorometholone ointment 0.1%, 49 EVOTAZ, 18 fluorouracil crm 5%, 46 EVOXAC, 38 fluoxetine caps, 27 EXCEDRIN MIGRAINE, 29 fluphenazine, 28 EXCEDRIN TENSION HEADACHE, 17 flurazepam, 29 exemestane, 21 flurbiprofen, 16, 49 EXJADE, 41 flutamide, 21 EXTAVIA, 30 fluticasone furoate, 45 ezetimibe, 23 fluticasone propionate cream 0.05%, ointment 0.005%, 47 F fluticasone spray, 44 fluticasone/salmeterol, 45 factor IX complex, 40 fluticasone/salmeterol - Wixela Inhub, 45 factor XIII concentrate (human), 40 fluticasone/umeclidinium/vilanterol, 43 famciclovir, 20 fluvoxamine, 26, 27 famotidine, 37 FLUZONE, 41 famotidine susp, 37 FML, 49 famotidine tabs, 37 FML FORTE, 49 FARESTON, 21 FML S.O.P., 49 FASENRA, 45 FOCALIN, 28 FASLODEX, 21 FOCALIN XR, 28 FEIBA NF, 40 folic acid, 42 felodipine ext-rel, 24 fondaparinux, 39 FEMARA, 21 FOSAMAX, 32 FEMHRT, 35 fosamprenavir susp, 19 FEMRING, 35 fosamprenavir tabs, 19 fenofibrate caps 67 mg, 134 mg, 200 mg, 23 fosfomycin, 20 fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg, 23 fosinopril, 22 fenofibric acid delayed-rel tabs 35 mg, 105 mg, 24 fosinopril/hydrochlorothiazide, 22 fentanyl transdermal, 16 fostemsavir ext-rel, 19 fentanyl transmucosal, 16 FREESTYLE FREEDOM LITE kits and test strips, 32 FEOSOL, 42 FREESTYLE INSULINX kits and test strips, 32 FERAHEME, 42 FREESTYLE LITE kits and test strips, 32 FERGON, 42 fremanezumab-vfrm, 30 FERRLECIT, 42 fulvestrant, 21 ferrous gluconate, 42 furosemide, 25 ferrous sulfate, 42 FUZEON, 19 ferumoxytol, 42 fexofenadine, 43 G fexofenadine/pseudoephedrine ext-rel, 43 gabapentin, 26 filgrastim-sndz, 40 GABITRIL, 26 finasteride, 39 galantamine, 27 fingolimod, 30 galantamine ext-rel, 27 FIORINAL, 17 galcanezumab-gnlm, 30 FIRST-LANSOPRAZOLE, 38 GASTROCROM, 39 FIRST-OMEPRAZOLE, 38 GAZYVA, 22 FIRVANQ, 21 gemfibrozil, 24 FISH OIL, 42 GENERESS FE, 33 FLAGYL, 20 gentamicin, 46, 48 flecainide, 23 GENVOYA, 19 FLOLAN, 26 GEODON, 28 FLOMAX, 39 GILENYA, 30 FLUARIX, 41 GILOTRIF, 21 FLUCELVAX, 41 glatiramer, 30 fluconazole, 18 GLEEVEC, 22 fludrocortisone, 35 GLEOSTINE, 21 FLULAVAL, 41 glimepiride, 32 fluocinolone acetonide cream 0.01%, 46 glipizide, 32 fluocinolone acetonide cream, ointment 0.025%, 47 glipizide ext-rel, 32 fluocinolone acetonide oil 0.01%, 47 glipizide/metformin, 31 fluocinolone acetonide solution 0.01%, 46 GLUCAGEN HYPOKIT, 35 fluocinonide cream, gel, ointment 0.05%, 47 GLUCAGON EMERGENCY KIT, 35 fluocinonide emollient cream 0.05%, 47 glucagon nasal powder, 35 fluocinonide solution 0.05%, 47 glucagon, human recombinant, 35 fluoride drops, tabs, 42 GLUCOTROL, 32 fluorometholone, 49 GLUCOTROL XL, 32 fluorometholone 0.25%, 49 glyburide, 32

56 glyburide, micronized, 32 imiquimod, 48 glyburide/metformin, 31 IMITREX, 29 glycopyrrolate tabs, 37 IMODIUM A-D, 37 GLYNASE, 32 IMURAN, 41 GOLYTELY, 38 INCRELEX, 35 granisetron, 37 INCRUSE ELLIPTA, 43 griseofulvin microsize tabs, 18 indapamide, 25 griseofulvin ultramicrosize, 18 INDERAL LA, 24 GUADALUPANO, 47 indinavir, 19 guanfacine, 23 indomethacin 25 mg, 50 mg, 16 guanfacine ext-rel, 29 indomethacin ext-rel, 16 GYNAZOLE-1, 39 INFED, 42 GYNE-LOTRIMIN, 39 influenza vaccine, 41 H insect repellent, DEET 15%, 48 insect repellent, DEET 25%, 48 HALDOL DECANOATE, 28 insect repellent, DEET 40%, 48 halobetasol propionate cream, ointment 0.05%, 47 insect repellent, DEET 7%, 48 haloperidol, 28 insect repellent, picaridin 20%, 48 haloperidol decanoate inj, 28 INSPIREASE PRODUCTS, 45 HECTOROL, 35 INSPRA, 23 HEMLIBRA, 40 INSULIN ASPART, 31 HEMOFIL M, 40 insulin aspart protamine 70%/insulin aspart 30%, 31 heparin, 39 insulin glargine, 31 HEPSERA, 20 insulin human, 31 homatropine, 49 insulin infusion disposable pump, 32 HUMATE-P, 40 insulin isophane human, 31 HUMIRA, 41 insulin isophane human 70%/regular 30%, 31 HUMULIN 70/30, 31 insulin lispro, 32 HUMULIN N, 31 insulin syringes, needles, 32 HUMULIN R, 31 INTELENCE, 19 hydralazine, 26 interferon alfa-2b, 41 HYDREA, 22 interferon beta-1a, 30 hydrochlorothiazide, 25 interferon beta-1b, 30 hydrocodone/acetaminophen soln 7.5/325 mg/15 mL, 16 intrauterine copper contraceptive, 34 hydrocodone/acetaminophen tabs 5 mg/325 mg, 7.5 mg/325 INTRON A, 41 mg, 10 mg/325 mg, 16 INTUNIV, 29 hydrocodone/homatropine, 44 INVEGA, 28 hydrocodone/ibuprofen, 16 INVEGA SUSTENNA, 28 hydrocortisone, 35 INVEGA TRINZA, 28 hydrocortisone acetate/pramoxine foam, 38 ipratropium inhalation solution, 43 hydrocortisone cream, 38 ipratropium nasal spray, 45 hydrocortisone cream 2.5%, 46 ipratropium, CFC-free aerosol, 43 hydrocortisone cream, ointment 0.5%, 1%, 46 ipratropium/albuterol inhalation solution, 43 hydrocortisone enema, 38 ipratropium/albuterol, CFC-free aerosol, 43 hydrocortisone inj 100 mg/mL, 35 irbesartan, 23 hydrocortisone lotion 1%, 46 irbesartan/hydrochlorothiazide, 23 hydromorphone tabs, 17 iron dextran, 42 hydroxychloroquine, 41 iron sucrose injection, 42 hydroxyurea, 22 ISENTRESS, 19 hydroxyzine HCl, except inj, 43 ISENTRESS HD, 19 hydroxyzine pamoate, 43 isocarboxazid, 27 hyoscyamine sulfate, 37 isoniazid, 20 hyoscyamine sulfate ext-rel, 37 ISOPTO CARPINE, 50 hyoscyamine sulfate ext-rel caps, 37 ISOPTO HOMATROPINE, 49 hyoscyamine sulfate orally disintegrating tabs, 37 ISORDIL, 25 HYZAAR, 23 isosorbide dinitrate 5 mg, 10 mg, 20 mg, 30 mg, 25 I isosorbide mononitrate, 25 ibandronate, 32 isosorbide mononitrate ext-rel, 25 ibrutinib caps, 22 isotretinoin, 45 ibuprofen, 16 isotretinoin - Amnesteem, 45 ICY HOT, 47 isotretinoin - Claravis, 45 IDELVION, 40 isotretinoin - Myorisan, 45 iloprost, 26 isotretinoin - Zenatane, 45 imatinib mesylate, 22 itraconazole, 18 IMBRUVICA, 22 ivermectin, 20 imipramine HCl, 27 IXINITY, 40

57

J levonorgestrel releasing IUD, 34 JADENU, 41 levonorgestrel/EE, 33 JADENU SPRINKLE, 41 levonorgestrel/EE 0.09/20, 34 JIVI, 40 levonorgestrel/EE 0.1/20, 33 JULUCA, 19 levonorgestrel/EE 0.1/20 and EE 10, 33 levonorgestrel/EE 0.15/20, 0.15/25, 0.15/30 and EE 10, 33 K levonorgestrel/EE 0.15/30, 33, 34 KALETRA, 19 levonorgestrel/EE 0.15/30 and EE 10, 34 KAZANO, 31 levothyroxine, 36 KEFLEX, 17 levothyroxine - Levoxyl, 36 KEPPRA, 26 LEVSIN, 37 KEPPRA XR, 26 LEXAPRO, 27 ketoconazole, 18 LEXIVA, 19 ketoconazole crm 2%, 46 LIALDA, 37 ketoconazole shampoo 2%, 46 LICE KILLING SHAMPOO, 48 ketorolac, 16 lidocaine crm, patch 4% - Aspercreme/Lidocaine, 47 ketorolac 0.4%, 49 lidocaine gel 2%, 47 ketorolac 0.5%, 49 lidocaine patch 5%, 47 ketotifen, 48 lidocaine viscous, 48 KEVZARA, 41 lidocaine/hydrocortisone kit, 38 KLONOPIN, 26 lidocaine/menthol crm 4/1%, 47 KOATE, 40 lidocaine/menthol patch 4/1%, 47 KOATE-DVI, 40 lidocaine/prilocaine crm 2.5/2.5%, 47 KOGENATE FS, 40 lidocaine/trolamine salicylate/capsaicin soln 4/10/0.035%, 47 KOVALTRY, 40 LIDODERM, 47 KUVAN, 36 LIDOPATCH, 47 KYLEENA, 34 lifitegrast, 49 L LILETTA, 34 labetalol, 24 linezolid susp, 20 lactulose soln, 38 linezolid tabs, 20 LAMICTAL, 26 liothyronine, 36 LAMICTAL XR, 26 LIPITOR, 24 LAMISIL AT, 46 lisinopril, 22 lamivudine, 19 lisinopril/hydrochlorothiazide, 22 lamivudine tabs, 20 lithium carbonate, 30 lamivudine/tenofovir disoproxil fumarate, 19 lithium carbonate ext-rel tabs 300 mg, 30 lamivudine/zidovudine, 18 lithium carbonate ext-rel tabs 450 mg, 30 lamotrigine, 26 LITHOBID, 30 lamotrigine ext-rel, 26 l-methylfolate, 42 lancets, 32 LOMOTIL, 37 LANOXIN, 25 lomustine, 21 lansoprazole delayed-rel 15 mg, 38 loperamide, 37 lansoprazole delayed-rel 30 mg, 38 LOPID, 24 lansoprazole suspension, 38 lopinavir/ritonavir soln, 19 lapatinib, 21 lopinavir/ritonavir tabs, 19 LASIX, 25 LOPRESSOR, 24 latanoprost, 50 loratadine, 43 leflunomide, 41 loratadine orally disintegrating tabs, 43 lenalidomide, 22 loratadine/pseudoephedrine ext-rel, 43 LETAIRIS, 25 lorazepam, 26 letrozole, 21 losartan, 23 leucovorin inj, 22 losartan/hydrochlorothiazide, 23 leucovorin tabs, 22 LOSEASONIQUE, 33 LEUKERAN, 21 LOTENSIN, 22 leuprolide acetate, 21 LOTENSIN HCT, 22 levalbuterol inhalation solution, 44 LOTREL, 22 levalbuterol tartrate, CFC-free aerosol, 44 lovastatin, 24 LEVBID, 37 LOVAZA, 24 levetiracetam, 26 LOVENOX, 39 levetiracetam ext-rel, 26 loxapine, 28 levobunolol, 49 lubiprostone, 38 levocarnitine, 36 LUNESTA, 29 levocetirizine, 43 LUPRON DEPOT, 21 levofloxacin, 17, 48 LYNPARZA, 22 levonorgestrel - Next Choice One Dose, 34 LYRICA, 29 LYSODREN, 22

58

LYSTEDA, 41 metoclopramide, 37 M metolazone, 25 metoprolol succinate ext-rel, 24 MAALOX, 36 metoprolol tartrate 25 mg, 50 mg, 100 mg, 24 macitentan, 25 METROCREAM, 47 MACROBID, 20 METROGEL, 48 MACRODANTIN, 20 METROLOTION, 48 magnesium citrate soln, 38 metronidazole cream 0.75%, 47 magnesium oxide, 42 metronidazole gel 0.75%, 39, 47 MAG-OX, 42 metronidazole gel 1%, 48 MALARONE, 18 metronidazole lotion 0.75%, 48 malathion, 48 metronidazole tabs, 20 maraviroc, 19 mexiletine, 23 MARPLAN, 27 MIACALCIN, 33 MATULANE, 22 MICARDIS, 23 MAXALT, 29 MICARDIS HCT, 23 MAXALT-MLT, 29 MICATIN, 46 MAXITROL, 49 miconazole, 39, 46 MAXZIDE, 25 MICROCHAMBER PRODUCTS, 45 MAXZIDE-25, 25 midodrine, 26 MAYZENT, 30 midostaurin, 22 mecasermin, 35 MINASTRIN 24 FE, 33 mechlorethamine gel, 21 MINIPRESS, 23 meclizine, 37 MINOCIN, 18 MEDROL, 35 minocycline, 18 medroxyprogesterone acetate, 36 MIRAPEX, 28 medroxyprogesterone acetate 104 mg/0.65 mL, 34 MIRAPEX ER, 28 medroxyprogesterone acetate 150 mg/mL, 34 MIRCETTE, 33 medroxyprogesterone acetate 400 mg/mL, 21 MIRENA, 34 mefloquine, 18 mirtazapine, 27 megestrol acetate, 21 mirtazapine orally disintegrating tabs, 27 MEKINIST, 22 misoprostol, 38 melatonin, 29 mitotane, 22 meloxicam, 16 MOBIC, 16 melphalan, 21 modafinil, 30 memantine, 27 mometasone, 45 MENEST, 34 mometasone cream, lotion, ointment 0.1%, 47 MEPHYTON, 42 MONISTAT, 39 MEPRON, 20 MONONINE, 40 mercaptopurine, 21 montelukast, 44 mesalamine delayed-rel caps, 37 MONUROL, 20 mesalamine delayed-rel tabs, 37 morphine, 17 mesalamine ext-rel caps, 37 morphine ext-rel, 17 mesalamine rectal suspension, 38 morphine suppository, 17 MESTINON, 30 MOVANTIK, 38 MESTINON TIMESPAN, 30 moxifloxacin, 17 METADATE CD, 29 MS CONTIN, 17 METAMUCIL, 38 multivitamins, pediatric, 42 metformin, 31 multivitamins/fluoride drops, tabs, 42 metformin ext-rel 500 mg, 750 mg, 31 multivitamins/fluoride/iron drops, tabs, 42 methadone tabs 5 mg, 10 mg, 17 multivitamins/iron, pediatric, 42 methazolamide, 25 multivitamins/minerals, 42 methenamine mandelate, 20 mupirocin oint, 46 methimazole, 36 MURO-128, 50 methocarbamol, 30 MYAMBUTOL, 20 methotrexate 2.5 mg, 41 MYCOBUTIN, 20 methyldopa, 26 mycophenolate mofetil, 41 methyldopa/hydrochlorothiazide, 26 MYLANTA, 36 METHYLIN, 29 MYLERAN, 21 methylphenidate, 29 MYSOLINE, 26 methylphenidate ext-rel, 29 methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 29 N methylphenidate ext-rel 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, nabumetone, 16 60 mg, 29 nadolol, 24 methylprednisolone, 35 nafarelin, 34 methyltestosterone, 31 naloxegol, 38

59 naloxone inj, 30 norethindrone acetate/EE 1.5/30, 33 naloxone nasal spray, 30 norethindrone acetate/EE 1.5/30 and iron, 33 naltrexone, 30 norethindrone acetate/EE 1/20, 33 naltrexone microspheres, 30 norethindrone acetate/EE 1/20 (24) and iron, 33 NAMENDA, 27 norethindrone acetate/EE 1/20 and iron, 33 naproxen sodium 220 mg, 16 norethindrone acetate/EE 1/20 and iron chewable, 33 naproxen tabs, 16 norethindrone/EE, 33 naratriptan, 29 norethindrone/EE 0.4/35, 33 NARCAN, 30 norethindrone/EE 0.4/35 and iron chewable, 33 NARDIL, 27 norethindrone/EE 0.5/35, 33 NASALCROM, 45 norethindrone/EE 1/35, 33 nateglinide, 32 norethindrone/EE and iron, 33 NATRAPEL, 48 norgestimate/EE, 33 NATROBA, 48 norgestimate/EE 0.25/35, 33 NATURE-THROID, 36 norgestrel/EE 0.3/30, 33 NEBUPENT, 21 norgestrel/EE 0.5/50, 33 nelfinavir, 19 NORPACE, 23 neomycin/polymyxin B/bacitracin/hydrocortisone ointment, NORPACE CR, 23 49 NORPRAMIN, 27 neomycin/polymyxin B/dexamethasone, 49 nortriptyline, 27 neomycin/polymyxin B/gramicidin, 48 NORVASC, 24 neomycin/polymyxin B/hydrocortisone, 50 NORVIR, 19 neomycin/polymyxin B/hydrocortisone suspension, 49 NOVOEIGHT, 40 NEORAL, 41 NOVOLIN 70/30, 31 NEO-SYNEPHRINE, 44 NOVOLIN N, 31 NESINA, 31 NOVOLIN R, 31 NEURONTIN, 26 NOVOSEVEN RT, 40 nevirapine, 19 NP THYROID, 36 nevirapine ext-rel, 19 NUVARING, 34 NEXAVAR, 22 NUVIGIL, 30 NEXIUM, 38 NUWIQ, 40 NEXPLANON, 34 nystatin crm, ointment, powder, 46 niacin, 42 nystatin/triamcinolone, 46 niacin ext-rel, 24 NYTOL, 29 NIASPAN, 24 O NICODERM CQ, 31 obinutuzumab, 22 NICORETTE, 31 OBIZUR, 40 nicotine inhaler, 31 OCEAN, 45 nicotine nasal spray, 31 octreotide acetate, 36 nicotine polacrilex gum, lozenge, 31 OCUFLOX, 48 nicotine transdermal, 31 ODEFSEY, 19 NICOTROL INHALER, 31 OFF ACTIVE, 48 NICOTROL NS, 31 OFF DEEP WOODS, 48 nifedipine ext-rel, 24 OFF FAMILY CARE, 48 nilotinib, 22 ofloxacin, 48 nimodipine, 24 ofloxacin otic, 50 NIMOTOP, 24 olanzapine, 28 nitazoxanide, 21 olanzapine orally disintegrating tabs, 28 nitisinone, 36 olanzapine pamoate ext-rel inj, 28 NITRO-BID, 25 olanzapine/fluoxetine, 28 NITRO-DUR, 25 olaparib, 22 nitrofurantoin ext-rel, 20 olmesartan, 23 nitrofurantoin macrocrystals, 20 olmesartan/hydrochlorothiazide, 23 nitrofurantoin suspension, 20 olodaterol, CFC-free aerosol, 44 nitroglycerin ointment, 25 olopatadine, 48 nitroglycerin sublingual, 25 omega-3 acid ethyl esters, 24 nitroglycerin transdermal, 25 omega-3 fatty acids, 42 nitroglycerin transdermal 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.6 omega-3 fatty acids/vitamin E, 42 mg, 25 omeprazole delayed-rel caps, 38 NITROSTAT, 25 omeprazole delayed-rel tabs, 38 NIX CREME RINSE, 48 omeprazole magnesium delayed-rel caps, 38 nonoxynol-9, 34 omeprazole magnesium delayed-rel tabs, 38 NORDITROPIN, 35 omeprazole suspension, 38 norelgestromin/EE, 34 omeprazole/sodium bicarbonate, 38 norethindrone, 34, 36 OMNIPOD DASH INSULIN INFUSION PUMP, 32 norethindrone acetate/EE 0.8/25 and iron, 33

60 ondansetron, 37 phenobarbital, 26 OPSUMIT, 25 phenoxybenzamine, 26 ORENITRAM, 26 phenylephrine spray, 44 ORFADIN, 36 PHENYTEK, 26 ORIAHNN, 36 phenytoin, 26 ORILISSA, 34 phenytoin sodium extended, 26 ORTHO MICRONOR, 34 phytonadione, 42 OS-CAL, 42 PIFELTRO, 19 oseltamivir caps, 20 pilocarpine, 50 oseltamivir suspension, 20 pilocarpine tabs, 38 OSENI, 31 pimozide, 28 OVIDE, 48 pindolol, 24 oxaprozin, 16 pioglitazone, 32 oxazepam, 26 pioglitazone/metformin, 32 oxcarbazepine, 26 piroxicam, 16 oxybutynin, 39 PLAN B ONE-STEP, 34 oxybutynin ext-rel, 39 PLAQUENIL, 41 oxycodone caps, tabs, 17 PLAVIX, 40 oxycodone solution 5 mg/5 mL, 17 PLEGRIDY, 30 oxycodone/acetaminophen 5/325, 17 podofilox solution, 48 oxycodone/aspirin, 17 polyethylene glycol 3350, 38 oxymetazoline spray, 44 polymyxin B/bacitracin, 48 oxymorphone ext-rel, 17 polymyxin B/trimethoprim, 48 OZEMPIC, 31 POLYTRIM, 48 P pomalidomide, 22 POMALYST, 22 paliperidone ext-rel, 28 potassium chloride ext-rel caps 8 mEq, 10 mEq, 42 paliperidone palmitate ext-rel inj, 28 potassium chloride ext-rel tabs 20 mEq, 42 palivizumab, 45 potassium chloride liquid 20 mEq/15 mL, 42 PAMELOR, 27 potassium citrate ext-rel, 39 pancrelipase delayed-rel, 38 PRALUENT, 24 pantoprazole delayed-rel tabs, 38 pramipexole, 28 PARAGARD, 34 pramipexole ext-rel, 28 paricalcitol, 35 pramlintide, 31 PARLODEL, 27 prasugrel, 40 PARNATE, 27 pravastatin, 24 paroxetine HCl ext-rel, 27 prazosin, 23 paroxetine HCl tabs, 27 PRECISION XTRA kits and test strips, 32 PATADAY, 48 PRECOSE, 31 PAXIL, 27 PRED FORTE, 49 PAXIL CR, 27 PRED MILD, 49 pazopanib, 22 prednisolone acetate 0.12%, 49 PEDIALYTE, 42 prednisolone acetate 1%, 49 peg 3350/electrolytes, 38 prednisolone phosphate 1%, 49 PEGASYS, 41 prednisolone sodium phosphate solution 5 mg/5 mL, 35 pegfilgrastim-bmez, 40 prednisolone syrup, 35 peginterferon alfa-2a, 41 prednisone, 35 peginterferon beta-1a, 30 PREFEST, 35 pegvisomant, 36 pregabalin, 29 penicillamine, 41 PREMARIN, 34, 35 penicillin G benzathine, 18 PREMPHASE, 35 penicillin VK, 18 PREMPRO, 35 pentamidine aerosol, 21 prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal pentosan polysulfate sodium, 39 AD, 42 pentoxifylline ext-rel, 41 prenatal vitamins/ferrous fumarate/docusate/folic acid - PEPCID, 37 Prenatal 19, 42 PEPTO-BISMOL, 37 PREVACID, 38 PERCOCET, 17 PREVACID 24HR, 38 PERCODAN, 17 PREZCOBIX, 19 PERIDEX, 48 PREZISTA, 19 permethrin 1%, 48 primaquine, 18 permethrin 5%, 48 primidone, 26 perphenazine, 28 PRIMSOL, 21 PERSERIS, 28 PRISTIQ, 27 phenazopyridine, 39 PROAIR HFA, 44 phenelzine, 27 PROAIR RESPICLICK, 44

61 probenecid, 16 REMERON SOLTAB, 27 procarbazine, 22 REMODULIN, 26 PROCARDIA XL, 24 RENVELA, 36 prochlorperazine, 37 repaglinide, 32 PROCTOFOAM-HC, 38 REPEL SPORTSMEN, 48 PROFILNINE, 40 REPEL SPORTSMEN MAX, 48 progesterone, micronized, 36 respiratory devices, 45 PROGRAF, 41 RESTORIL, 29 PROMACTA, 40 RETACRIT, 40 promethazine injection, 37 RETIN-A, 46 promethazine oral soln, syrup, tabs, 37 REVATIO, 26 promethazine supp 12.5 mg, 25 mg, 37 REVLIMID, 22 PROMETRIUM, 36 REYATAZ, 19 propafenone, 23 ribavirin caps, tabs, 20 propafenone ext-rel, 23 RID SHAMPOO, 48 propantheline, 37 rifabutin, 20 propranolol, 24 RIFADIN, 20 propranolol ext-rel, 24 rifampin, 20 propylthiouracil, 36 rifaximin, 21 PROSCAR, 39 rilpivirine, 19 PROTONIX, 38 RISPERDAL, 28 PROTOPIC, 46 RISPERDAL CONSTA, 28 PROVENTIL HFA, 44 risperidone, 28 PROVERA, 36 risperidone ext-rel inj, 28 PROVIGIL, 30 risperidone long-acting inj, 28 PROZAC, 27 RITALIN, 29 psyllium, 38 RITALIN LA, 29 PULMICORT RESPULES, 45 ritonavir, 19 PULMOZYME, 44 rivaroxaban 2.5 mg, 39 pyrantel - Reese's Pinworm Medicine, 20 rivastigmine caps, 27 pyrazinamide, 20 RIXUBIS, 40 pyrethrins/piperonyl butoxide 4%, 48 rizatriptan, 29 PYRIDIUM, 39 rizatriptan orally disintegrating tabs, 29 pyridostigmine, 30 ROBITUSSIN COUGH + CHEST CONGESTION DM, 44 pyridostigmine ext-rel, 30 ROBITUSSIN MULTI-SYMPTOM COLD, 44 pyridoxine, 42 ROCALTROL, 35 Q ropinirole, 28 ropinirole ext-rel, 28 QUARTETTE, 33 rosuvastatin, 24 QUESTRAN/QUESTRAN LIGHT, 23 ROWASA, 38 quetiapine, 28 RUBRACA, 22 quetiapine 100 mg, 28 rucaparib, 22 quetiapine ext-rel, 28 RUKOBIA, 19 quinapril, 22 RYBELSUS, 31 quinapril/hydrochlorothiazide, 23 RYDAPT, 22 quinidine sulfate, 23 RYTHMOL SR, 23 R S rabeprazole, 38 sacubitril/valsartan, 25 raloxifene, 36 SAFYRAL, 33 raltegravir, 19 SALAGEN, 38 ramelteon, 29 SANDIMMUNE, 41 ramipril, 22 SANDOSTATIN, 36 ramucirumab, 22 SANDOSTATIN LAR, 36 RANEXA, 26 SANTYL, 48 ranolazine ext-rel, 26 sapropterin, 36 RAPAMUNE, 41 sarilumab, 41 rasagiline, 28 SAVAYSA, 39 RAZADYNE ER, 27 SAWYER, 48 REBIF, 30 scopolamine methylbromide, 37 RECOMBINATE, 40 SEASONIQUE, 34 REGLAN, 37 secukinumab, 41 REGRANEX, 48 SEGLUROMET, 32 RELENZA, 20 selegiline, 28 RELIADERM, 47 selenium sulfide lotion 2.5%, 46 RELPAX, 29 SELZENTRY, 19 REMERON, 27

62 semaglutide, 31 SUSTIVA, 19 SEMGLEE, 31 SUTENT, 22 SENSIPAR, 32 SYMBICORT, 45 SEROQUEL, 28 SYMBYAX, 28 SEROQUEL XR, 28 SYMFI, 18 SEROSTIM, 35 SYMFI LO, 18 sertraline, 27 SYMLINPEN, 31 sevelamer carbonate tabs, 36 SYMTUZA, 19 SHINGRIX, 41 SYNAGIS, 45 SHUR-SEAL, 34 SYNAREL, 34 sildenafil, 26 SYNTHROID, 36 SILIQ, 41 T SILVADENE, 46 TABLOID, 21 silver sulfadiazine, 46 tacrolimus, 41, 46 simvastatin, 24 tadalafil, 26 SINEMET, 27 TAFINLAR, 22 SINGULAIR, 44 TAMIFLU, 20 siponimod, 30 tamoxifen, 21 sirolimus, 41 tamsulosin, 39 SKYLA, 34 TAPAZOLE, 36 SLO-NIACIN, 24 TARCEVA, 21 sodium chloride, 45, 50 TARGRETIN, 22 sodium citrate/citric acid, 39 TASIGNA, 22 sodium ferric gluconate injection, 42 TECFIDERA, 30 sodium oxybate, 30 TEGRETOL, 26 sodium phenylbutyrate, 36 TEGRETOL-XR, 26 sofosbuvir/velpatasvir, 20 telmisartan, 23 solifenacin, 39 telmisartan/hydrochlorothiazide, 23 SOLU-CORTEF, 35 temazepam 15 mg, 30 mg, 29 somatropin, 35 TEMODAR, 21 SOMAVERT, 36 TEMOVATE, 47 sorafenib, 22 temozolomide, 21 SORIATANE, 46 tenofovir disoproxil fumarate, 19, 20 sotalol, 23 TENORMIN, 24 spinosad, 48 terazosin, 23 SPIRIVA RESPIMAT, 43 terbinafine, 46 spironolactone, 23, 25 terbinafine tabs, 18 spironolactone/hydrochlorothiazide 25 mg/25 mg, 25 terbutaline, 44 SPORANOX, 18 terconazole, 39 SPRYCEL, 22 teriflunomide, 30 STALEVO, 27 TESSALON, 43 STARLIX, 32 TESTIM, 31 stavudine, 19 testosterone cypionate inj, 31 STEGLATRO, 32 testosterone enanthate inj, 31 STEGLUJAN, 32 testosterone gel 1%, 31 STIMATE, 36 tetrabenazine, 29 STIOLTO RESPIMAT, 43 tetracycline caps, 18 STRATTERA, 28 thalidomide, 22 STRIBILD, 19 THALOMID, 22 STRIVERDI RESPIMAT, 44 THEO-24, 45 STROMECTOL, 20 theophylline ext-rel caps, 45 SUBOXONE FILM, 30 theophylline ext-rel tabs, 45 sucralfate tabs, 39 theophylline liquid, 45 sulfacetamide solution 10%, 49 thiamine, 42 sulfacetamide/prednisolone acetate 10%/0.2%, 49 thioguanine, 21 sulfacetamide/prednisolone phosphate 10%/0.25%, 49 thioridazine, 28 sulfadiazine, 18 thiothixene, 28 sulfamethoxazole/trimethoprim, 18 thyroid, 36 sulfamethoxazole/trimethoprim DS, 18 tiagabine, 26 sulfasalazine, 37 TIAZAC, 24 sulfasalazine delayed-rel, 38 TIGAN, 37 sulindac, 16 tigecycline, 20 sumatriptan injection, 29 TIKOSYN, 23 sumatriptan nasal spray, 29 timolol, 24 sumatriptan tabs, 29 timolol maleate, 49 sunitinib, 22

63

TIMOPTIC, 49 TUMS, 36 TINACTIN, 46 TYBOST, 18 tinidazole, 21 TYGACIL, 20 tiotropium 1.25 mcg, 43 TYKERB, 21 tiotropium/olodaterol, 43 TYMLOS, 33 tipranavir, 20 TYVASO, 26 TIVICAY, 19 U TIVICAY PD, 19 ulipristal, 34 tizanidine tabs, 30 ULTRACET, 17 TOBI, 44 ULTRAM, 17 TOBRADEX, 49 umeclidinium, 43 tobramycin inhalation solution, 44 umeclidinium/vilanterol, 43 tobramycin solution, 49 UNISOM, 29 tobramycin/dexamethasone ointment 0.3%/0.1%, 49 UNITHROID, 36 tobramycin/dexamethasone suspension 0.3%/0.1%, 49 UROCIT-K, 39 TOBREX, 49 UROXATRAL, 39 tofacitinib, 41 URSO, 37 tofacitinib ext-rel, 41 ursodiol, 37 tolbutamide, 32 tolnaftate, 46 V tolterodine, 39 valacyclovir, 20 tolterodine ext-rel, 39 VALCHLOR, 21 TOPAMAX, 26 VALCYTE, 20 topiramate sprinkle caps, tabs, 26 valganciclovir, 20 TOPROL-XL, 24 VALIUM, 26 toremifene, 21 valproic acid, 26 torsemide, 25 valsartan, 23 TRACLEER, 25 valsartan/hydrochlorothiazide, 23 tramadol 50 mg, 17 VALTREX, 20 tramadol ext-rel tabs, 17 VANCOCIN, 21 tramadol/acetaminophen, 17 vancomycin caps 125 mg, 21 trametinib, 22 vancomycin oral soln, 21 TRANDATE, 24 varenicline, 31 trandolapril, 22 VASERETIC, 22 tranexamic acid, 41 VASOTEC, 22 tranylcypromine, 27 venlafaxine, 27 TRAVATAN Z, 50 venlafaxine ext-rel caps, 27 travoprost, 50 VENOFER, 42 trazodone 50 mg, 100 mg, 150 mg, 27 VENTAVIS, 26 TRELEGY ELLIPTA, 43 verapamil, 24 treprostinil, 26 verapamil ext-rel caps 120 mg, 180 mg, 240 mg, 24 treprostinil ext-rel, 26 verapamil ext-rel tabs, 24 tretinoin, 46 VERELAN SR, 24 tretinoin caps, 22 VESICARE, 39 TRETTEN, 40 VFEND, 18 triamcinolone acetonide cream, lotion, ointment 0.025%, 47 VIBRAMYCIN, 18 triamcinolone acetonide cream, lotion, ointment 0.1%, 47 VIRACEPT, 19 triamcinolone acetonide cream, ointment 0.5%, 47 VIRAMUNE, 19 triamcinolone acetonide spray, 44 VIRAMUNE XR, 19 triamcinolone paste, 48 VIREAD, 19, 20 triamterene/hydrochlorothiazide, 25 vismodegib, 22 trifluoperazine, 28 VISTARIL, 43 trifluridine, 49 vitamin A, 42 trihexyphenidyl, 28 VITAMIN A, 42 TRILEPTAL, 26 vitamin ADC/fluoride drops, 42 trimethobenzamide, 37 vitamin ADC/fluoride/iron drops, 42 trimethoprim, 21 VITAMIN B-1, 42 trimethoprim solution, 21 VITAMIN B-12, 42 TRIUMEQ, 18 VITAMIN B-6, 42 tropicamide, 49 VITAMIN C, 42 trospium, 39 VITAMIN D2, 42 trospium ext-rel, 39 VITAMIN D3, 42 TRULICITY, 31 vitamin E, 42 TRUSOPT, 49 VITAMIN E, 42 TRUVADA, 18 VIVELLE-DOT, 34 trypsin/balsam/castor oil, 48 VIVITROL, 30

64

VOLTAREN GEL, 16 ZARONTIN, 26 von Willebrand factor (recombinant), 40 ZARXIO, 40 VONVENDI, 40 ZEGERID OTC, 38 voriconazole inj, 18 ZEMPLAR, 35 voriconazole tabs, 18 ZESTORETIC, 22 vorinostat, 22 ZESTRIL, 22 VOTRIENT, 22 ZETIA, 23 W ZIAC, 24 zidovudine, 19 warfarin, 39 ZIEXTENZO, 40 WELLBUTRIN SR, 27 ZIKS, 47 WELLBUTRIN XL, 27 ziprasidone, 28 WILATE, 40 ZITHROMAX, 17 WP THYROID, 36 ZOCOR, 24 X ZOFRAN, 37 XALATAN, 50 zoledronic acid, 32 XANAX, 26 ZOLINZA, 22 XANAX XR, 26 zolmitriptan, 29 XARELTO, 39 zolmitriptan nasal spray, 29 XELJANZ, 41 zolmitriptan orally disintegrating tabs, 29 XELJANZ XR, 41 ZOLOFT, 27 XELODA, 21 zolpidem, 29 XENAZINE, 29 zolpidem ext-rel, 29 XIFAXAN, 21 ZOMIG, 29 XIIDRA, 49 ZOMIG-ZMT, 29 XOPENEX HFA, 44 ZONEGRAN, 27 XYLOCAINE, 47 zonisamide, 27 XYNTHA, 40 ZOSTAVAX, 41 XYREM, 30 zoster vaccine, 41 Y ZOSTRIX HP, 47 ZOVIRAX, 20 YASMIN, 33 ZYKADIA, 22 YAZ, 33 ZYLOPRIM, 16 Z ZYPREXA, 28 ZADITOR, 48 ZYPREXA RELPREVV, 28 zafirlukast, 44 ZYPREXA ZYDIS, 28 zaleplon, 29 ZYVOX, 20 ZANAFLEX, 30 zanamivir, 20

65