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Plan for your best health

2020 Aetna Pharmacy Drug Guide Aetna Standard Plan

05.02.472.1 (01/01) aetna.com Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. 2020 Pharmacy Drug Guide - Aetna Standard Plan

Table of Contents

INFORMATIONAL SECTION...... 8 *5-HT4 *** - DRUGS FOR THE STOMACH...... 8 *ADENOSINE RECEPTOR ANTAGONIST*** - DRUGS FOR THE NERVOUS SYSTEM...... 8 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 8 *AGENTS FOR NARCOTIC WITHDRAWAL*** - DRUGS FOR ADDICTION...... 9 *AGENTS FOR WITHDRAWAL*** - DRUGS FOR ADDICTION...... 10 *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS...... 10 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 10 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 10 *AMINOMETHYLCYCLINES*** - DRUGS FOR INFECTIONS...... 10 * - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 10 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 14 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 16 *ANDROGENS-ANABOLIC* - HORMONES...... 20 *ANORECTAL AGENTS* - RECTAL PREPARATIONS...... 21 *ANTACIDS* - DRUGS FOR THE STOMACH...... 21 ** - DRUGS FOR INFECTIONS...... 21 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 22 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 22 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 23 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 23 *ANTICOAGULANTS - MISC.*** - DRUGS FOR THE BLOOD...... 26 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 26 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 27 *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM...... 29 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 29 *ANTIDIABETICS* - HORMONES...... 31 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 35 *ANTIDIARRHEALS* - DRUGS FOR THE STOMACH...... 35 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...35 *ANTIDOTES* - DRUGS FOR OVERDOSE OR POISONING...... 35 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 36 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 37 *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD...... 37 ** - DRUGS FOR THE LUNGS...... 37 *ANTIHYPERLIPIDEMICS MISC. COMBINATIONS*** - DRUGS FOR THE HEART...... 38 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 38 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 40 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 42 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 43 *ANTIMYASTHENIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 43 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 43 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 43 *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR ...... 44

TOC-3 *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER...... 44 *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER...... 44 *ANTINEOPLASTIC OR PREMALIGNANT LESION AGENT - COMB*** - DRUGS FOR CANCER...... 44 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 44 *ANTI-OBESITY AGENT COMBINATIONS** - DRUGS FOR EATING DISORDERS...... 49 *ANTIPARKINSON AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 49 *ANTIPSORIATIC COMBINATIONS*** - DRUGS FOR THE SKIN...... 50 */ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 50 *ANTIRETROVIRALS ADJUVANTS*** - DRUGS THAT ALTER ...... 52 *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - HORMONES...... 52 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 52 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 52 *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD...... 55 *ASSORTED CLASSES* - VITAMINS AND MINERALS...... 55 *ATOPIC - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE LUNGS...... 56 *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS...... 56 *B-COMPLEX W/ E & FOLIC ACID*** - DRUGS FOR NUTRITION...... 57 *BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB*** - DRUGS FOR THE HEART...... 57 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 57 *BIGUANIDE-DIABETIC SUPPLIES COMBINATIONS*** - HORMONES...... 58 *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH...... 58 *BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 58 *CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM...... 58 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 58 *CARDIOTONICS* - DRUGS FOR THE HEART...... 59 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 60 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 61 *CHEMICALS*...... 61 *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR THE STOMACH...... 62 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 62 *CORTICOSTEROIDS* - HORMONES...... 68 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 70 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER...... 71 *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR THE LUNGS...... 71 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 71 *DIAGNOSTIC PRODUCTS*...... 90 *DIAGNOSTIC RADIOPHARMACEUTICALS - GASES***...... 98 *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION98 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 99 *DIGITAL THERAPY***...... 99 *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD...... 99 *DIURETICS* - DRUGS FOR THE HEART...... 100 * AND REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR THE NERVOUS SYSTEM...... 100 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 101 TOC-4 * COMBINATIONS*** - HORMONES...... 104 *ESTROGEN-ANDROGEN-PROGESTIN*** - HORMONES...... 104 ** - HORMONES...... 104 *ESTROGEN-SELECTIVE MODULATOR COMB*** - HORMONES.. 105 *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE LIVER...... 105 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 105 *GABA - NEUROACTIVE *** - DRUGS FOR THE NERVOUS SYSTEM...... 105 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 106 *GENERAL * - DRUGS FOR PAIN AND FEVER...... 107 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM 107 *GLYCOPEPTIDES*** - DRUGS FOR INFECTIONS...... 109 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 109 *GROWTH HORMONE RELEASING HORMONES (GHRH) COMBINATIONS***...... 109 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 109 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 111 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 115 *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR INFECTIONS...... 115 *HYPNOTIC COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM...... 116 *HYPNOTICS* - DRUGS FOR THE NERVOUS SYSTEM...... 116 *IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS*** - DRUGS FOR THE STOMACH.....116 *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** - DRUGS FOR THE STOMACH...... 116 *IMPOTENCE AGENT COMBINATIONS*** - DRUGS FOR THE URINARY SYSTEM...... 117 *IN VITRO/LOCK ANTICOAGULANTS*** - DRUGS FOR THE BLOOD...... 117 *-INCRETIN MIMETIC COMBINATIONS*** - HORMONES...... 117 *INTEGRIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH...... 117 *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR THE STOMACH...... 117 *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR THE LUNGS...... 117 *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR THE LUNGS...... 118 *INTERLEUKIN-6 (IL-6) ANTAGONISTS*** - DRUGS FOR CANCER...... 118 *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER...... 118 *LAXATIVES* - DRUGS FOR THE STOMACH...... 118 *LHRH/GNRH ANALOG COMBINATIONS*** - HORMONES...... 120 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 120 *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - DRUGS FOR THE EYE...... 120 *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR METABOLIC DISEASE...... 120 *MACROLIDES* - DRUGS FOR INFECTIONS...... 120 *MEDICAL DEVICES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 121 *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 161 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 161 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 162 *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS...... 163 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 163 *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR METABOLIC DISEASE...... 165 *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR THE NERVOUS SYSTEM...... 165 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - VITAMINS AND MINERALS...... 165 TOC-5 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** - DRUGS FOR NUTRITION...... 165 *MULTIPLE VITAMINS WITH FOLIC ACID*** - DRUGS FOR NUTRITION...... 165 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 166 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 174 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 175 *NASAL ANESTHETICS*** - DRUGS FOR THE NOSE...... 176 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR THE HEART...... 176 *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR THE HEART...... 176 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 176 *N-METHYL-D- (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 176 *NSAID COMBINATIONS*** - DRUGS FOR PAIN AND FEVER...... 176 *NSAID-VITAMINS AND/OR MINERALS COMBINATIONS*** - DRUGS FOR PAIN AND FEVER...... 177 *NUTRIENTS* - DRUGS FOR NUTRITION...... 177 *ONCOLYTIC VIRAL AGENTS - HSV1*** - BIOLOGICAL AGENTS...... 177 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 177 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR THE EYE...... 182 *OPHTHALMIC PHOTOENHANCER COMBINATIONS*** - DRUGS FOR THE EYE...... 182 *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR THE EYE...... 182 *OREXIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 182 *OTIC AGENTS* - DRUGS FOR THE ...... 182 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN...... 183 *OXYTOCICS* - HORMONES...... 183 *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR INFECTIONS...... 183 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS...... 183 *PASSIVE IMMUNIZING AGENTS* - BIOLOGICAL AGENTS...... 183 *PCSK9 INHIBITORS*** - DRUGS FOR THE HEART...... 184 *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE*** - DRUGS FOR NUTRITION...... 184 *PEDIATRIC MULTIPLE VITAMINS W/FLUORIDE-IRON-*** - DRUGS FOR NUTRITION...... 184 *PENICILLINS* - DRUGS FOR INFECTIONS...... 184 *PHARMACEUTICAL ADJUVANTS*...... 185 *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER...... 187 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN...... 187 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR PAIN AND FEVER...... 187 *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE HEART...... 187 *PLEUROMUTILINS*** - DRUGS FOR INFECTIONS...... 187 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** - DRUGS FOR CANCER...... 187 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER...... 187 *POSTHERPETIC NEURALGIA (PHN) COMBINATION AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 188 *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 188 TOC-6 *POSTHERPETIC NEURALGIA(PHN)/NEUROPATHIC PAIN COMB AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM...... 188 *POTASSIUM REMOVING AGENTS*** - DRUGS FOR NUTRITION...... 188 *PRENATAL MV & MINERALS W/ FA WITHOUT IRON*** - DRUGS FOR NUTRITION...... 188 *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION...... 188 *PROGESTINS* - HORMONES...... 189 *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD...... 189 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 189 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR CANCER...... 192 *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS...... 192 *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR THE HEART...... 192 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 192 *SCAR TREATMENT PRODUCTS - COMBINATIONS*** - DRUGS FOR THE SKIN...... 193 *SCLEROSTIN INHIBITORS*** - HORMONES...... 193 *SEBORRHEIC KERATOSIS PRODUCTS** - DRUGS FOR THE SKIN...... 193 *SEPTAL AGENTS - ABLATION** - DRUGS FOR THE HEART...... 193 * 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM...... 193 *SEROTONIN MODULATORS*** - DRUGS FOR THE NERVOUS SYSTEM...... 193 *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** - HORMONES...... 193 *SINUS NODE INHIBITORS** - DRUGS FOR THE HEART...... 194 *SNRIS & ANESTHETICS/ANALGESICS*** - DRUGS FOR THE SKIN...... 194 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** - HORMONES...... 194 *SPLEEN KINASE (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD...... 194 * - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT.... 194 *SULFONAMIDES*...... 194 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 194 *THYROID AGENTS* - HORMONES...... 195 *TOPICAL GASES*** - DRUGS FOR THE SKIN...... 196 * STABILIZERS*** - HORMONES...... 196 *ULCER DRUGS* - DRUGS FOR THE STOMACH...... 196 *URINARY ANTI-INFECTIVES* - DRUGS FOR THE URINARY SYSTEM...... 198 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 198 *VACCINES* - BIOLOGICAL AGENTS...... 199 *VAGINAL PRODUCTS* - DRUGS FOR WOMEN...... 199 *VASOPRESSORS* - DRUGS FOR THE HEART...... 200 *VITAMINS* - DRUGS FOR NUTRITION...... 201

TOC-7 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes You’re covered for all types of medicine — some more expensive, and some less. • Brand and generic drugs that are hand-picked for their quality and effectiveness • Generic: the lowest cost • A specialty pharmacy that fills specialty prescriptions • Preferred brand: a slightly higher cost (ones that are injected, infused or taken by mouth) — • Non-preferred brand: a higher cost and provides services that include personal • Preferred Specialty: lower cost for specialty drugs support, helpful resources and training, and free secure home delivery • Non-preferred specialty: higher cost for non-preferred specialty drugs • A home delivery pharmacy that delivers maintenance drugs to your home or wherever Your pharmacy plan may not have all the coverage levels you choose (for drugs that are taken regularly to listed above so check your plan documents to see how treat conditions like or asthma) much you will pay.

What you can expect to pay For your exact coverage and cost, and to learn more about your plan With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee Visit the website that’s on your member ID card. or a percentage of the drug’s/medicine’s price. Then log in to your account, where you can:

Each drug is grouped as a generic, a brand or a • Find out the coverage* and estimate of cost for specialty drug. The preferred drugs within these specific drugs groups will generally save you money compared • View your deductibles and plan limits to a non-preferred drug. Typically, generic drugs • Order medications are less expensive than brands. • Check your pharmacy order status Specialty prescription drugs typically include higher-cost • Get a member ID card drugs that require special handling, special storage or • View your claims, Explanation of Benefits and more. monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and cessation.

1 Have more questions about your CVS Caremark Mail Service Pharmacy® pharmacy benefits? You can have maintenance drugs sent right to your home We’re here to help. There are several ways you can or anywhere else you choose by CVS Caremark Mail learn more about your benefits: Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. • Check your Plan Design and Benefits Summary in Depending on your plan, you can get up to a 90-day your enrollment kit. supply of medicine for less cost. It’s fast and convenient, • Call the toll-free number on your member ID card. and standard shipping is always free. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on Get started right away your member ID card to search for the “Pharmacy FAQ.” You can submit your order using one of these options:

Specialty Pharmacy Network 1. Online — Visit your secure member website and An in-network specialty pharmacy can fill your sign in to your account. There you can add or prescriptions for specialty drugs. These are the types remove your prescriptions. of drugs that may be injected, infused or taken by 2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. mouth. They often need special storage and handling. If you need the help of a telephone device for the And they need to be delivered quickly. A nurse or deaf, call 1-877-833-2779. pharmacist may monitor you during your treatment, if needed. With this type of pharmacy, you can get 3. Mail — Get a new prescription from your doctor. Then this medicine sent right to your home. mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. How to get started with a specialty pharmacy

Ordering your prescriptions through our specialty Your doctor can submit your order using one pharmacy is easy. And we typically offer a 30-day of these options: medicine supply. 1. Online — They can submit your prescriptions using • To transfer your prescription, just call us toll-free the e-prescribe services on our provider website. at 1-866-353-1892. 2. Fax — They can fax your prescription to • For a new prescription, your doctor can send it to 1-877-270-3317. Make sure they include your member us in one of four ways: ID number, date of birth and mailing address on the 1. Electronically: Through e-prescribe fax cover sheet. Only a doctor may fax a prescription. 2. Fax: 1-866-FAX-ASRX (1-866-329-2779)

3. Phone: 1-866-782-ASRX (1-866-782-2779), option 2

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

2 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. They drugs instead of brand-name drugs. treat the same condition as the step therapy drug. • Our home delivery pharmacy may save you money. If you don’t try the appropriate prerequisite drug first, For more information, visit the website on your you may need to pay full cost for the step-therapy drug. member ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is precertification? • Quantity limits over time — Limits prescription Precertification is one way that we can help you and your coverage to a specific number of units over a specific doctor find safe, appropriate drugs and keep costs amount of time down. Precertification means that you or your doctor need to get approval from the plan before certain drugs What if I need a drug that requires an will be covered. Generally, precertification applies to exception to the precertification, step therapy drugs that: or quantity limits requirements? Or what if I • Are often taken in the wrong way need a drug that’s not covered under my plan? • Should only be used for certain conditions In certain cases, you or your prescriber can request a • Often cost more than other drugs that are proven medical exception to the precertification, step therapy to be just as effective or quantity limits requirements or for a drug that’s not covered on your plan. You can ask for your request to be Keep in mind that your doctor must contact us to expedited. Expedited coverage decisions are made request approval of coverage for these drugs. within 24 hours.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

3 How can your provider request a medical Can the formulary change during the year? exception? The formulary can change throughout the year. • Submit their request through our secure provider Some reasons why it can change include: website on NaviNet®. • New drugs are approved. • Call the Aetna Pharmacy Precertification Unit at • Existing drugs are removed from the market. 1-855-240-0535. • Prescription drugs may become available over the • Fax the completed request form to 1-877-269-9916. counter (without a prescription). Over-the-counter • Mail the completed request form to: drugs are not generally covered in a formulary. Aetna Pharmacy Management • Brand-name drugs lose patent protection and generic 1300 East Campbell Road versions become available. When this happens, the Richardson, TX 75081 generic drug will be covered in place of the brand-name drug. The brand-name drug is likely to become Pharmacy and Therapeutics (P&T) committee non-formulary or covered at a higher cost. See the We use the services of an independent National “What are generic drugs?” section above for more Pharmacy and Therapeutics Committee (“P&T information. Committee”) to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee, but no CVS Caremark or Aetna employee may vote on issues before the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

4 Commercial 1557 Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and their affiliates (Aetna).

5 6 7 8 9 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Pharmacy Drug Guide (formulary) may be subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Louisiana members: depending on your specific plan and the prescription medication in question, you may in some instances be subject to an excess consumer cost burden for prescription drugs as defined by your state. Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna may receive rebates from certain drug manufacturers. Generally, such rebates do not directly reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. However, these programs are available to self-funded plans. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug Guide (formulary), Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists or removed from the Pharmacy Drug Guide (formulary) will continue to have those medications covered, for as long as the prescriber continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. Aetna and CVS Caremark Mail Service Pharmacy are part of the CVS Health family of companies.

aetna.com ©2019 Aetna Inc. 2020 Pharmacy Drug Guide - Aetna Standard Plan Drug Notes CE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may Drug Tier apply. FE = Formulary Excluded IBC = Indication Based Coverage G = Generics LGC = Lowest Generic Copay NPB = Non-Preferred Brands Applies NPSB = Non-Preferred Specialty SPC = Select Plan Coverage: lowercase italics = Generic drugs Brands Only available for select plans. UPPERCASE = Brand name PB = Preferred Brands Refer to member plan documents drugs PSB = Preferred Specialty Brands for coverage. Prescription Drug Name Drug Tier Drug Notes *5-HT4 RECEPTOR AGONISTS*** - DRUGS FOR THE STOMACH MOTEGRITY (prucalopride succinate) FE *ADENOSINE RECEPTOR ANTAGONIST*** - DRUGS FOR THE NERVOUS SYSTEM NOURIANZ (istradefylline) FE *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM ADDERALL XR (-dextroamphetamine) NPB ADHANSIA XR ( hcl) FE ADZENYS ER (amphetamine) NPB ADZENYS XR-ODT (amphetamine) NPB amphetamine sulfate G amphetamine-dextroamphet er G amphetamine-dextroamphetamine G APTENSIO XR (methylphenidate hcl) NPB G hcl G citrate oral G clonidine hcl er G COTEMPLA XR-ODT (methylphenidate) FE DAYTRANA (methylphenidate) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 8 Prescription Drug Name Drug Tier Drug Notes hcl G dexmethylphenidate hcl er G dextroamphetamine sulfate er G dextroamphetamine sulfate oral G DYANAVEL XR (amphetamine) NPB EVEKEO (amphetamine sulfate) FE EVEKEO ODT (amphetamine sulfate) FE guanfacine hcl er G INTUNIV (guanfacine hcl) FE JORNAY PM (methylphenidate hcl) FE LOMAIRA (phentermine hcl) FE methylphenidate hcl (Metadate Er Oral Extended G Release 20 Mg) hcl G methylphenidate hcl er (cd) G methylphenidate hcl er (la) G methylphenidate hcl er oral tablet extended release 10 mg, 18 G mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour G methylphenidate hcl er oral tablet extended release 72 mg NPB methylphenidate hcl oral G G MYDAYIS (amphetamine-dextroamphetamine) PB NUVIGIL (armodafinil) FE QSYMIA (phentermine-) FE QUILLICHEW ER (methylphenidate hcl) NPB QUILLIVANT XR (methylphenidate hcl) NPB RELEXXII (methylphenidate hcl) FE VYVANSE (lisdexamfetamine dimesylate) PB dextroamphetamine sulfate (Zenzedi) G *AGENTS FOR NARCOTIC WITHDRAWAL*** - DRUGS FOR ADDICTION LUCEMYRA (lofexidine hcl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 9 Prescription Drug Name Drug Tier Drug Notes *AGENTS FOR OPIOID WITHDRAWAL*** - DRUGS FOR ADDICTION LUCEMYRA (lofexidine hcl) FE *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS co-balamin FE co-veratrol FE EC-RX DHEA ( (dhea)) FE NEOKE RA LIPOIC (alpha-lipoic acid) FE reservapak FE reservapak plus FE *AMEBICIDES* - DRUGS FOR INFECTIONS SOLOSEC (secnidazole) FE *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS ARIKAYCE (amikacin sulfate ) NPB BETHKIS (tobramycin) PSB KITABIS PAK (tobramycin) NPSB neomycin sulfate oral G paromomycin sulfate oral G TOBI (tobramycin) FE TOBI PODHALER (tobramycin) FE tobramycin G *AMINOMETHYLCYCLINES*** - DRUGS FOR INFECTIONS NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPB *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER ACTEMRA (tocilizumab) FE ACTEMRA ACTPEN (tocilizumab) FE ARCALYST (rilonacept) NPSB ARTHROTEC ORAL TABLET DELAYED RELEASE FE (diclofenac-misoprostol) CAPXIB (celecoxib--menthol) FE celecoxib oral G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 10 Prescription Drug Name Drug Tier Drug Notes DERMA SILKRX ANODYNEXA PAK (diclofen-ranitidine- FE capsaicin) DERMA SILKRX DICLOPAK (diclofenac sodium-capsaicin) FE dermacinrx combopak FE DERMACINRX INFLAMMATRAL PAK (diclofen- FE ranitidine-capsaicin) dfs dr/ms/menth/cap pak FE diclofenac potassium G diclofenac sodium er G diclofenac sodium oral G diclofenac-misoprostol oral tablet delayed release G DUEXIS (-famotidine) NPB DYLOJECT (diclofenac sodium) FE IBC (Preferred agent for all ENBREL MINI (etanercept) PSB conditions except ) ENBREL SUBCUTANEOUS PREFILLED IBC (Preferred agent for all PSB (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSB RECONSTITUTED (etanercept) conditions except Psoriasis) ENBREL SURECLICK SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSB AUTO-INJECTOR (etanercept) conditions except Psoriasis) etodolac er G etodolac oral G fenoprofen calcium oral FE fenoprofen calcium oral tablet G FENORTHO (fenoprofen calcium) FE flexizol combipak FE flurbiprofen oral G HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PSB MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSB (adalimumab) HUMIRA PEN-CD/UC/HS STARTER (adalimumab) PSB HUMIRA PEN-PS/UV/ADOL HS START (adalimumab) PSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 11 Prescription Drug Name Drug Tier Drug Notes HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PSB KIT (adalimumab) ibuprofen (Ibu) G ibuprofen oral G ibuprofen oral tablet 400 mg, 600 mg, 800 mg G ILARIS SUBCUTANEOUS SOLUTION (canakinumab) NPSB INDOCIN ORAL (indomethacin) FE INDOCIN RECTAL (indomethacin) FE indomethacin er G indomethacin oral G diclofenac sodium-capsaicin (Inflammacin) FE inflammation reduction pack FE INFLATHERM (diclofenac sod-trolamine sal) FE ketoprofen er G ketoprofen oral capsule 25 mg FE ketorolac tromethamine oral G KEVZARA (sarilumab) PSB KINERET SUBCUTANEOUS SOLUTION PREFILLED FE SYRINGE (anakinra) leflunomide oral G lidoxib FE LODINE (etodolac) FE meclofenamate sodium oral G oral G meloxicam oral tablet G nabumetone oral G NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NPB NAPRELAN ORAL TABLET EXTENDED RELEASE 24 FE HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL TABLET 500 MG (naproxen) NPB naproxen dr G naproxen oral suspension FE naproxen oral tablet G naproxen sodium er FE naproxen sodium oral tablet 275 mg, 550 mg G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 12 Prescription Drug Name Drug Tier Drug Notes diclofenac sodium-capsaicin (Nudiclo Tabpak) FE NUDROXIPAK (celecoxib-capsaic-men-methsal) FE NUDROXIPAK DSDR-50 (diclofenac sodium-) FE NUDROXIPAK DSDR-75 (diclofenac sodium-liniment) FE NUDROXIPAK E-400 (etodolac-liniment) FE NUDROXIPAK I-800 (ibuprofen-liniment) FE NUDROXIPAK M-15 (meloxicam-liniment) FE NUDROXIPAK N-500 (nabumetone-liniment) FE OLUMIANT (baricitinib) FE IBC (Preferred agent for Rheumatoid Arthritis. Not ORENCIA CLICKJECT (abatacept) PSB covered for other conditions) ORENCIA INTRAVENOUS (abatacept) FE IBC (Preferred agent for ORENCIA SUBCUTANEOUS SOLUTION PREFILLED Rheumatoid Arthritis. Not PSB SYRINGE (abatacept) covered for other conditions) OTREXUP (methotrexate (anti-rheumatic)) FE oxaprozin G piroxicam oral G PREVIDOLRX ANALGESIC (diclofenac-omeprazole- FE capsicum) QMIIZ ODT (meloxicam) FE RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 PSB MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) READYSHARP ANESTH + KETOROLAC (ketorolac & FE & lido) READYSHARP KETOROLAC (ketorolac tromethamine) FE RIDAURA (auranofin) NPB IBC (Preferred agent for RINVOQ (upadacitinib) PSB Rheumatoid Arthritis) SIMPONI ARIA (golimumab) PSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 13 Prescription Drug Name Drug Tier Drug Notes SIMPONI SUBCUTANEOUS SOLUTION AUTO- FE INJECTOR (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED FE SYRINGE (golimumab) SPRIX (ketorolac tromethamine) FE sulindac oral G TIVORBEX (indomethacin) FE tolmetin sodium G TORONOVA II SUIK (ketorolac trometh & anesthetic) FE TORONOVA SUIK (ketorolac trometh & anesthetic) FE VIMOVO (naproxen-esomeprazole) NPB VIVLODEX (meloxicam) FE IBC (Preferred agent for XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) PSB Ulcerative Colitis (after failure of Humira)) IBC (Preferred agent for Rheumatoid Arthritis and Ulcerative Colitis (after XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) PSB failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Rheumatoid Arthritis. Not XELJANZ XR (tofacitinib citrate) PSB covered for Psoriatic Arthritis.) YBUPHEN (ibuprofen-acetaminophen) FE ZIPSOR (diclofenac potassium) NPB ZORVOLEX (diclofenac) FE *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER ALLZITAL (butalbital-acetaminophen) FE aspirin adult low dose G CE aspirin ec low strength G CE aspirin low dose oral tablet chewable G CE aspirin low dose oral tablet delayed release G CE aspirin oral tablet chewable G CE aspirin oral tablet delayed release 81 mg G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 14 Prescription Drug Name Drug Tier Drug Notes ASPIR-LOW (aspirin) G CE BAYER ASPIRIN EC LOW DOSE (aspirin) G CE BAYER LOW DOSE (aspirin) G CE butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) G butalbital-acetaminophen oral tablet G butalbital-apap-caffeine oral capsule FE butalbital-apap-caffeine oral tablet 50-325-40 mg G butalbital-aspirin-caffeine oral capsule G butalbital-apap-caffeine (Capacet) FE childrens aspirin G CE childrens aspirin low strength G CE choline-mag trisalicylate G cvs aspirin low dose G CE cvs aspirin low strength oral tablet delayed release G CE diflunisal oral G duraxin G ECOTRIN LOW STRENGTH (aspirin) G CE eq childrens aspirin G CE eql aspirin low dose oral tablet chewable G CE butalbital-apap-caffeine (Esgic Oral Capsule) FE FIORICET ORAL CAPSULE (butalbital-apap-caffeine) FE gnp adult aspirin low strength oral tablet chewable G CE gnp aspirin oral tablet delayed release 81 mg G CE h-e-b aspirin G CE hm aspirin oral tablet chewable G CE kls aspirin low dose G CE kp aspirin G CE MINIPRIN LOW DOSE (aspirin) G CE butalbital-apap-caffeine (Phrenilin Forte Oral Capsule 50-300- FE 40 Mg) px aspirin oral tablet chewable G CE px enteric aspirin oral tablet delayed release 81 mg G CE qc childrens aspirin G CE ra aspirin adult low dose G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 15 Prescription Drug Name Drug Tier Drug Notes ra aspirin childrens G CE ra aspirin ec adult low st G CE ra childrens aspirin G CE salsalate oral G sb childrens aspirin G CE sm aspirin adult low strength G CE sm childrens aspirin G CE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE G CE (aspirin) TENCON ORAL TABLET 50-325 MG (butalbital- G acetaminophen) tgt aspirin low dose oral tablet delayed release G CE tgt aspirin oral tablet chewable G CE tgt aspirin oral tablet delayed release G CE tgt childrens aspirin G CE VANATOL LQ (butalbital-apap-caffeine) FE VANATOL S (butalbital-apap-caffeine) FE butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) FE *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER ABSTRAL (fentanyl citrate) NPB acetaminophen- #3 G acetaminophen-codeine oral solution G acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg G ACTIQ (fentanyl citrate) NPB APADAZ (benzhydrocodone-acetaminophen) FE apap-caff-dihydrocodeine oral capsule G ARYMO ER ( sulfate) FE butalbital-asa-caff-codeine (Ascomp-Codeine) G BELBUCA ( hcl) PB BUNAVAIL (buprenorphine hcl-naloxone hcl) NPB buprenorphine hcl sublingual G buprenorphine hcl-naloxone hcl G buprenorphine FE butalbital-apap-caff-cod G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 16 Prescription Drug Name Drug Tier Drug Notes butalbital-asa-caff-codeine G butorphanol tartrate nasal G BUTRANS (buprenorphine) FE codeine sulfate oral tablet 60 mg NPB CONZIP ( hcl) NPB DILAUDID (hydromorphone hcl) FE DILAUDID ORAL (hydromorphone hcl) NPB DOLOPHINE ( hcl) NPB DSUVIA (sufentanil citrate) NPB DURAGESIC-100 (fentanyl) NPB DURAGESIC-12 (fentanyl) NPB DURAGESIC-25 (fentanyl) NPB DURAGESIC-50 (fentanyl) NPB DURAGESIC-75 (fentanyl) NPB DVORAH (apap-caff-dihydrocodeine) G EMBEDA (morphine-naltrexone) PB oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, G 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) fentanyl G fentanyl citrate buccal lozenge on a handle G fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 G mcg FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NPB MCG, 600 MCG, 800 MCG (fentanyl citrate) hydrocodone-acetaminophen oral solution 5-217 mg/10ml G hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, G 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 G mg hydromorphone hcl er G hydromorphone hcl oral G hydromorphone hcl rectal NPB HYSINGLA ER (hydrocodone bitartrate) FE IBUDONE ORAL TABLET 10-200 MG (hydrocodone- G ibuprofen)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 17 Prescription Drug Name Drug Tier Drug Notes IONSYS (fentanyl hcl) FE KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, NPB 50 MG, 60 MG, 80 MG (morphine sulfate) LAZANDA (fentanyl citrate) FE tartrate oral FE hydrocodone-acetaminophen (Lorcet) G hydrocodone-acetaminophen (Lorcet Hd) G hydrocodone-acetaminophen (Lorcet Plus Oral Tablet 7.5-325 G Mg) LORTAB ORAL 10-300 MG/15ML (hydrocodone- NPB acetaminophen) meperidine hcl oral G methadone hcl (Methadone Hcl Intensol) G methadone hcl oral G methadone hcl solution 10 mg/ml injection G methadone hcl solution 10 mg/ml injection NPB METHADOSE ORAL CONCENTRATE 10 MG/ML NPB (methadone hcl) methadone hcl (Methadose Oral Tablet Soluble) G METHADOSE SUGAR-FREE (methadone hcl) NPB MORPHABOND ER (morphine sulfate) FE morphine sulfate (concentrate) oral solution 20 mg/ml G morphine sulfate er beads G morphine sulfate er oral capsule extended release 24 hour G morphine sulfate er oral tablet extended release G morphine sulfate oral G morphine sulfate rectal G MS CONTIN ORAL TABLET EXTENDED RELEASE NPB (morphine sulfate) nalocet FE NORCO (hydrocodone-acetaminophen) NPB NUCYNTA ( hcl) PB NUCYNTA ER (tapentadol hcl) PB OPANA ORAL (oxymorphone hcl) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 18 Prescription Drug Name Drug Tier Drug Notes OXAYDO (oxycodone hcl) FE oxycodone hcl er oral tablet er 12 hour abuse-deterrent G oxycodone hcl oral capsule G oxycodone hcl oral concentrate 100 mg/5ml G oxycodone hcl oral solution G oxycodone hcl oral tablet G oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- G 325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg G oxycodone-ibuprofen G OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- FE DETERRENT (oxycodone hcl) oxymorphone hcl G oxymorphone hcl er G pentazocine-naloxone hcl G PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- FE 325 MG, 7.5-325 MG (oxycodone-acetaminophen) PRIMLEV (oxycodone-acetaminophen) FE PROBUPHINE IMPLANT KIT (buprenorphine hcl) FE ROXICODONE ORAL TABLET (oxycodone hcl) NPB ROXYBOND (oxycodone hcl) FE SUBLOCADE (buprenorphine) FE SUBOXONE SUBLINGUAL FILM (buprenorphine hcl- FE naloxone hcl) SUBSYS (fentanyl) PB tramadol hcl er G tramadol hcl er (biphasic) oral tablet extended release 24 hour G 100 mg, 200 mg, 300 mg tramadol hcl oral G tramadol-acetaminophen G TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- G dihydrocodeine) TYLENOL WITH CODEINE #3 (acetaminophen-codeine) NPB TYLENOL WITH CODEINE #4 (acetaminophen-codeine) NPB ULTRACET (tramadol-acetaminophen) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 19 Prescription Drug Name Drug Tier Drug Notes ULTRAM (tramadol hcl) PB hydrocodone-acetaminophen (Vicodin Es Oral Tablet 7.5-300 G Mg) hydrocodone-acetaminophen (Vicodin Hp Oral Tablet 10-300 G Mg) hydrocodone-acetaminophen (Vicodin Oral Tablet 5-300 Mg) G XTAMPZA ER (oxycodone) PB ZAMICET (hydrocodone-acetaminophen) FE ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE- FE DETERRENT (hydrocodone bitartrate) ZUBSOLV (buprenorphine hcl-naloxone hcl) PB *ANDROGENS-ANABOLIC* - HORMONES ANADROL-50 () NPB ANDRODERM 24 HOUR PB () ANDROGEL 50 MG/5GM (1%) TRANSDERMAL FE (testosterone) ANDROGEL PUMP GEL 12.5 MG/ACT (1%) FE TRANSDERMAL (testosterone) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), FE 50 MG/5GM (1%) (testosterone) oral G DEPO-TESTOSTERONE INTRAMUSCULAR NPB SOLUTION () ec-rx testosterone FE FORTESTA (testosterone) FE methitest NPB oral G NATESTO (testosterone) FE oxandrolone oral G STRIANT (testosterone) NPB TESTIM (testosterone) FE TESTONE CIK (testosterone cypionate) FE TESTOPEL (testosterone) NPB testosterone compounding kit FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 20 Prescription Drug Name Drug Tier Drug Notes testosterone cypionate intramuscular solution 100 mg/ml, 200 G mg/ml intramuscular solution G testosterone gel 12.5 mg/act (1%) transdermal G testosterone gel 12.5 mg/act (1%) transdermal FE testosterone gel 50 mg/5gm (1%) transdermal G testosterone gel 50 mg/5gm (1%) transdermal FE testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm G (1.62%) testosterone transdermal solution G VOGELXO GEL 50 MG/5GM (1%) TRANSDERMAL FE (testosterone) VOGELXO PUMP (testosterone) FE VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) FE (testosterone) XYOSTED (testosterone enanthate) FE *ANORECTAL AGENTS* - RECTAL PREPARATIONS hydrocortisone (Colocort) G CORTIFOAM (hydrocortisone acetate) PB hydrocortisone ace-pramoxine rectal 1-1 % G hydrocortisone rectal G PROCORT (hydrocortisone ace-pramoxine) NPB PROCTOFOAM HC (hydrocortisone ace-pramoxine) PB hydrocortisone (Procto-Med Hc) G hydrocortisone (Procto-Pak) G hydrocortisone (Proctosol Hc) G hydrocortisone (Proctozone-Hc Rectal) G RECTIV (nitroglycerin) NPB UCERIS RECTAL (budesonide) NPB *ANTACIDS* - DRUGS FOR THE STOMACH sodium bicarbonate oral NPB *ANTHELMINTICS* - DRUGS FOR INFECTIONS albendazole oral G benznidazole NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 21 Prescription Drug Name Drug Tier Drug Notes EMVERM (mebendazole) PB oral G praziquantel oral G *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART DILATRATE-SR (isosorbide dinitrate) NPB GONITRO (nitroglycerin) FE ISORDIL TITRADOSE ORAL TABLET 40 MG (isosorbide PB dinitrate) isosorbide dinitrate er G isosorbide dinitrate oral G isosorbide mononitrate G isosorbide mononitrate er G nitroglycerin (Minitran) G NITRO-BID (nitroglycerin) NPB NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 PB MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual G nitroglycerin transdermal patch 24 hour G nitroglycerin translingual solution G NITROMIST (nitroglycerin) NPB er G *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM alprazolam er G ALPRAZOLAM INTENSOL (alprazolam) NPB alprazolam oral G alprazolam xr G buspirone hcl oral G chlordiazepoxide hcl G clorazepate dipotassium G oral concentrate G diazepam oral solution 5 mg/5ml G diazepam oral tablet G hydroxyzine hcl oral G hydroxyzine hcl oral tablet G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 22 Prescription Drug Name Drug Tier Drug Notes hydroxyzine pamoate oral G oral G meprobamate G oxazepam G XANAX (alprazolam) FE XANAX XR (alprazolam) FE *ANTIARRHYTHMICS* - DRUGS FOR THE HEART hcl oral G disopyramide phosphate oral G G acetate G hcl oral G MULTAQ (dronedarone hcl) PB NORPACE CR (disopyramide phosphate) PB amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 G Mg) propafenone hcl G propafenone hcl er G gluconate er G quinidine sulfate oral G TIKOSYN (dofetilide) NPSB *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS ADVAIR HFA (fluticasone-salmeterol) PB AEROSPAN (flunisolide hfa) FE AIRDUO RESPICLICK 113/14 (fluticasone-salmeterol) FE AIRDUO RESPICLICK 232/14 (fluticasone-salmeterol) FE AIRDUO RESPICLICK 55/14 (fluticasone-salmeterol) FE albuterol sulfate er G albuterol sulfate hfa inhalation aerosol solution 108 (90 base) G mcg/act albuterol sulfate inhalation G albuterol sulfate oral G ALVESCO (ciclesonide) FE ANORO ELLIPTA (umeclidinium-vilanterol) PB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 23 Prescription Drug Name Drug Tier Drug Notes ARCAPTA NEOHALER (indacaterol maleate) NPB ARMONAIR RESPICLICK 113 (fluticasone propionate FE (inhal)) ARMONAIR RESPICLICK 232 (fluticasone propionate FE (inhal)) ARMONAIR RESPICLICK 55 (fluticasone propionate FE (inhal)) ARNUITY ELLIPTA (fluticasone furoate) PB ASMANEX (120 METERED DOSES) (mometasone furoate) FE ASMANEX (14 METERED DOSES) (mometasone furoate) FE ASMANEX (30 METERED DOSES) (mometasone furoate) FE ASMANEX (60 METERED DOSES) (mometasone furoate) FE ASMANEX (7 METERED DOSES) (mometasone furoate) FE ASMANEX HFA (mometasone furoate) FE ATROVENT HFA (ipratropium bromide hfa) NPB BEVESPI AEROSPHERE (glycopyrrolate-formoterol) PB BREO ELLIPTA (fluticasone furoate-vilanterol) PB BROVANA (arformoterol tartrate) NPB budesonide inhalation G COMBIVENT (ipratropium-albuterol) FE cromolyn sodium inhalation G DALIRESP (roflumilast) PB dyphylline-guaifenesin (Difil-G Forte) G DULERA (mometasone furo-formoterol fum) FE ELIXOPHYLLIN (theophylline) NPB FLOVENT DISKUS (fluticasone propionate (inhal)) PB FLOVENT HFA (fluticasone propionate hfa) PB fluticasone-salmeterol inhalation aerosol powder breath FE activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act INCRUSE ELLIPTA (umeclidinium bromide) PB ipratropium bromide inhalation G ipratropium-albuterol G levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, G 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 24 Prescription Drug Name Drug Tier Drug Notes LONHALA MAGNAIR REFILL KIT (glycopyrrolate) FE LONHALA MAGNAIR STARTER KIT (glycopyrrolate) FE metaproterenol sulfate oral syrup G montelukast sodium oral G PERFOROMIST (formoterol fumarate) PB PROAIR DIGIHALER (albuterol sulfate) FE PROAIR HFA (albuterol sulfate) FE PROAIR RESPICLICK (albuterol sulfate) FE PROVENTIL HFA (albuterol sulfate) FE PULMICORT FLEXHALER (budesonide) PB QVAR REDIHALER (beclomethasone diprop hfa) PB SEEBRI NEOHALER (glycopyrrolate) FE SEREVENT DISKUS (salmeterol xinafoate) PB SINGULAIR (montelukast sodium) FE SPIRIVA HANDIHALER (tiotropium bromide monohydrate) PB SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium PB bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- PB olodaterol) STRIVERDI RESPIMAT (olodaterol hcl) PB SYMBICORT (budesonide-formoterol fumarate) PB terbutaline sulfate oral G THEO-24 (theophylline) NPB THEOCHRON ORAL TABLET EXTENDED RELEASE G 12 HOUR 100 MG, 200 MG (theophylline) theophylline (Theochron Oral Tablet Extended Release 12 G Hour 300 Mg) theophylline G theophylline er oral tablet extended release 12 hour 300 mg, 450 G mg theophylline er oral tablet extended release 24 hour G TRELEGY ELLIPTA (fluticasone-umeclidin-vilant) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 25 Prescription Drug Name Drug Tier Drug Notes TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT FE (aclidinium bromide) UTIBRON NEOHALER (indacaterol-glycopyrrolate) FE VENTOLIN HFA (albuterol sulfate) FE XOLAIR (omalizumab) PSB XOPENEX HFA (levalbuterol tartrate) FE YUPELRI (revefenacin) FE zafirlukast G zileuton er G ZYFLO (zileuton) NPB *ANTICOAGULANTS - MISC.*** - DRUGS FOR THE BLOOD DEFITELIO (defibrotide sodium) FE *ANTICOAGULANTS* - DRUGS FOR THE BLOOD acd formula a NPB ACD-A NOCLOT-50 (anticoagulant cit dext soln a) NPB anticoagulant cit dext soln a NPB ANTICOAGULANT COMPOUND (anticoag cit phos dex NPB soln) anticoagulant sodium citrate NPB BEVYXXA (betrixaban maleate) FE COUMADIN ORAL (warfarin sodium) FE ELIQUIS (apixaban) PB ELIQUIS STARTER PACK (apixaban) PB enoxaparin sodium G fondaparinux sodium G FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 PB UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 G unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml G hepmed FE warfarin sodium (Jantoven) G LGC 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 26 Prescription Drug Name Drug Tier Drug Notes PRADAXA (dabigatran etexilate mesylate) FE SAVAYSA (edoxaban tosylate) FE solu-pref FE TRICITRASOL (anticoagulant sodium citrate) NPB warfarin sodium oral G LGC XARELTO (rivaroxaban) PB XARELTO STARTER PACK (rivaroxaban) PB *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM APTIOM () NPB BANZEL () NPB BRIVIACT ORAL (brivaracetam) NPB er G carbamazepine oral G CELONTIN (methsuximide) NPB clobazam G oral G DIACOMIT (stiripentol) NPB diazepam rectal G DILANTIN ORAL CAPSULE 30 MG ( sodium NPB extended) divalproex sodium er oral tablet extended release 24 hour G divalproex sodium oral capsule delayed release sprinkle G divalproex sodium oral tablet delayed release G EPIDIOLEX () NPSB carbamazepine (Epitol) G ethosuximide oral G FANATREX FUSEPAQ () FE felbamate G FYCOMPA (perampanel) PB gabapentin oral G LAMICTAL ODT () FE LAMICTAL ORAL TABLET (lamotrigine) FE LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG FE (lamotrigine) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 27 Prescription Drug Name Drug Tier Drug Notes LAMICTAL STARTER (lamotrigine) FE LAMICTAL XR (lamotrigine) FE lamotrigine er G lamotrigine oral tablet G lamotrigine oral tablet chewable G lamotrigine oral tablet dispersible G lamotrigine starter kit-blue G lamotrigine starter kit-green G lamotrigine starter kit-orange G levetiracetam er G levetiracetam oral G LYRICA ORAL CAPSULE 25 MG () FE NAYZILAM (midazolam (anticonvulsant)) FE ONFI ORAL SUSPENSION (clobazam) FE ONFI ORAL TABLET 10 MG, 20 MG (clobazam) FE G OXTELLAR XR (oxcarbazepine) PB PEGANONE (ethotoin) NPB phenytoin oral suspension 125 mg/5ml G phenytoin oral tablet chewable G phenytoin sodium extended G pregabalin oral G oral G levetiracetam (Roweepra) G levetiracetam (Roweepra Xr) G SABRIL (vigabatrin) FE SPRITAM (levetiracetam) FE lamotrigine (Subvenite) G lamotrigine (Subvenite Starter Kit-Blue) G lamotrigine (Subvenite Starter Kit-Green) G lamotrigine (Subvenite Starter Kit-Orange) G SYMPAZAN (clobazam) FE tiagabine hcl G topiramate er G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 28 Prescription Drug Name Drug Tier Drug Notes topiramate oral G TROKENDI XR (topiramate) PB valproic acid oral capsule G valproic acid oral solution G vigabatrin G vigabatrin (Vigadrone) G VIMPAT ORAL (lacosamide) PB ZONEGRAN () FE zonisamide oral G *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM NAMZARIC (memantine hcl-donepezil hcl) PB *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM hcl oral G G APLENZIN ( hbr) NPB bupropion hcl er (sr) G bupropion hcl er (xl) G bupropion hcl oral G hydrobromide oral solution G citalopram hydrobromide oral tablet G LGC hcl oral G CYMBALTA ( hcl) FE hcl oral G er tablet extended release 24 hour 100 mg oral G desvenlafaxine er tablet extended release 24 hour 100 mg oral NPB desvenlafaxine er tablet extended release 24 hour 50 mg oral G desvenlafaxine er tablet extended release 24 hour 50 mg oral NPB desvenlafaxine succinate er G hcl oral G duloxetine hcl oral G EFFEXOR XR ( hcl) FE ELAVIL (amitriptyline hcl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 29 Prescription Drug Name Drug Tier Drug Notes EMSAM () NPB oxalate G FETZIMA ( hcl) NPB FETZIMA TITRATION (levomilnacipran hcl) NPB hcl oral capsule G LGC fluoxetine hcl oral capsule delayed release G fluoxetine hcl oral solution G fluoxetine hcl oral tablet G maleate G fluvoxamine maleate er G hcl oral G imipramine pamoate G LEXAPRO ORAL TABLET (escitalopram oxalate) FE hcl G MARPLAN () NPB mirtazapine oral G hcl G hcl oral G hcl er G paroxetine hcl oral tablet G LGC PAXIL ORAL SUSPENSION (paroxetine hcl) NPB PEXEVA (paroxetine mesylate) NPB sulfate oral G pramlyte FE PRISTIQ (desvenlafaxine succinate) FE hcl G PROZAC ORAL CAPSULE (fluoxetine hcl) FE hcl oral concentrate G sertraline hcl oral tablet G LGC sulfate G hcl oral G maleate oral G TRINTELLIX ( hbr) PB venlafaxine hcl G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 30 Prescription Drug Name Drug Tier Drug Notes venlafaxine hcl er oral capsule extended release 24 hour G venlafaxine hcl er oral tablet extended release 24 hour 150 mg, FE 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg G VIIBRYD ORAL TABLET ( hcl) PB VIIBRYD STARTER PACK (vilazodone hcl) PB *ANTIDIABETICS* - HORMONES acarbose oral G ACTOS ( hcl) FE ADLYXIN (lixisenatide) FE ADLYXIN STARTER PACK (lixisenatide) FE ADMELOG (insulin lispro) FE AFREZZA INHALATION POWDER 12 UNIT, 30 X 4 UNIT & 60X8 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 60 X 4 UNIT & 30X8 UNIT, 60 X 8 UNIT & 30X12 UNIT, 8 UNIT, FE 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT (insulin regular human) alogliptin benzoate FE alogliptin-metformin hcl FE alogliptin-pioglitazone FE APIDRA (insulin glulisine) FE APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION FE PEN-INJECTOR (insulin glulisine) AVANDIA ORAL TABLET 2 MG, 4 MG ( NPB maleate) BAQSIMI ONE PACK (glucagon) FE BAQSIMI TWO PACK (glucagon) FE BASAGLAR KWIKPEN (insulin glargine) PB BYDUREON BCISE (exenatide) FE BYDUREON SUBCUTANEOUS PEN-INJECTOR FE (exenatide) BYDUREON SUBCUTANEOUS SUSPENSION FE RECONSTITUTED ER (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION FE PEN-INJECTOR (exenatide) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION FE PEN-INJECTOR (exenatide) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 31 Prescription Drug Name Drug Tier Drug Notes CYCLOSET (bromocriptine mesylate) NPB FARXIGA (dapagliflozin propanediol) PB FIASP (insulin aspart (w/niacinamide)) PB FIASP FLEXTOUCH (insulin aspart (w/niacinamide)) PB FORTAMET (metformin hcl) FE G LGC er G LGC glipizide oral G LGC glipizide xl G LGC glipizide-metformin hcl G LGC GLUCAGEN HYPOKIT (glucagon hcl (rdna)) PB GLUCAGON EMERGENCY (glucagon (rdna)) PB GLUMETZA (metformin hcl) FE glyburide micronized oral tablet 1.5 mg G glyburide micronized oral tablet 3 mg, 6 mg G LGC glyburide oral G LGC glyburide-metformin G LGC GVOKE PFS (glucagon) FE HUMALOG (insulin lispro) FE HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION FE PEN-INJECTOR 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 (insulin lispro prot & lispro) FE HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS FE SUSPENSION PEN-INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 75/25 (insulin lispro prot & lispro) FE HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS FE SUSPENSION PEN-INJECTOR (insulin lispro prot & lispro) HUMULIN 70/30 (insulin nph isophane & regular) FE HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin nph isophane & FE regular) HUMULIN N (insulin nph human (isophane)) FE HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin nph human FE (isophane)) HUMULIN R (insulin regular human) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 32 Prescription Drug Name Drug Tier Drug Notes HUMULIN R U-500 (CONCENTRATED) (insulin regular PB human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS PB SOLUTION PEN-INJECTOR (insulin regular human) INVOKANA (canagliflozin) FE JANUMET (sitagliptin-metformin hcl) PB JANUMET XR (sitagliptin-metformin hcl) PB JANUVIA (sitagliptin phosphate) PB JARDIANCE (empagliflozin) PB JENTADUETO (linagliptin-metformin hcl) FE JENTADUETO XR (linagliptin-metformin hcl) FE KAZANO (alogliptin-metformin hcl) FE KOMBIGLYZE XR (saxagliptin-metformin) FE LANTUS (insulin glargine) FE LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION FE PEN-INJECTOR (insulin glargine) LEVEMIR (insulin detemir) PB LEVEMIR FLEXTOUCH (insulin detemir) PB metformin hcl er (mod) FE metformin hcl er (osm) oral tablet extended release 24 hour FE 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg G LGC metformin hcl er oral tablet extended release 24 hour 750 mg G metformin hcl oral solution NPB metformin hcl oral tablet G LGC miglitol G MYXREDLIN (insulin regular(human) in nacl) FE G LGC NESINA (alogliptin benzoate) FE NOVOLIN 70/30 (insulin nph isophane & regular) PB NOVOLIN 70/30 FLEXPEN (insulin nph isophane & regular) PB NOVOLIN 70/30 FLEXPEN RELION (insulin nph isophane FE & regular) NOVOLIN 70/30 RELION (insulin nph isophane & regular) FE NOVOLIN N (insulin nph human (isophane)) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 33 Prescription Drug Name Drug Tier Drug Notes NOVOLIN N RELION (insulin nph human (isophane)) FE NOVOLIN R (insulin regular human) PB NOVOLIN R RELION (insulin regular human) FE NOVOLOG (insulin aspart) PB NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR (insulin aspart) NOVOLOG MIX 70/30 (insulin aspart prot & aspart) PB NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin aspart prot & PB aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE (insulin aspart) ONGLYZA (saxagliptin hcl) FE OSENI (alogliptin-pioglitazone) FE OZEMPIC (0.25 OR 0.5 MG/DOSE) (semaglutide) PB OZEMPIC (1 MG/DOSE) (semaglutide) PB pioglitazone hcl G LGC pioglitazone hcl-glimepiride G pioglitazone hcl-metformin hcl G LGC PROGLYCEM () NPB G LGC repaglinide-metformin hcl G RIOMET (metformin hcl) FE RYBELSUS (semaglutide) FE STEGLATRO (ertugliflozin l-pyroglutamicac) FE SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR (pramlintide acetate) TANZEUM (albiglutide) FE G TRADJENTA (linagliptin) FE TRESIBA (insulin degludec) PB TRESIBA FLEXTOUCH (insulin degludec) PB TRULICITY (dulaglutide) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 34 Prescription Drug Name Drug Tier Drug Notes VICTOZA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR (liraglutide) *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH prodigen NPB provad FE RESTORA RX (lactobacillus casei-folic acid) NPB RESTORA SPRINKLES (lactobacillus casei-folic acid) FE VSL#3 DS (probiotic product) NPB zelac FE *ANTIDIARRHEALS* - DRUGS FOR THE STOMACH diphenoxylate- G loperamide hcl oral capsule G MOTOFEN (difenoxin-atropine) FE MYTESI (crofelemer) NPB opium G paregoric G prodigen NPB provad FE RESTORA RX (lactobacillus casei-folic acid) NPB RESTORA SPRINKLES (lactobacillus casei-folic acid) FE VSL#3 DS (probiotic product) NPB zelac FE *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING BRIDION (sugammadex sodium) FE CETYLEV (acetylcysteine) FE deferoxamine mesylate G DESFERAL INJECTION SOLUTION RECONSTITUTED NPSB 500 MG (deferoxamine mesylate) PROVAYBLUE ( (antidote)) FE RADIOGARDASE (prussian blue insoluble) NPB *ANTIDOTES* - DRUGS FOR OVERDOSE OR POISONING BRIDION (sugammadex sodium) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 35 Prescription Drug Name Drug Tier Drug Notes CETYLEV (acetylcysteine) FE CHEMET (succimer) NPB deferasirox G deferoxamine mesylate G DESFERAL INJECTION SOLUTION RECONSTITUTED NPSB 500 MG (deferoxamine mesylate) EVZIO (naloxone hcl) FE EXJADE (deferasirox) NPSB FERRIPROX ORAL SOLUTION (deferiprone) FE FERRIPROX ORAL TABLET 500 MG (deferiprone) NPB JADENU (deferasirox) NPSB JADENU SPRINKLE (deferasirox) NPSB naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml G naloxone hcl injection solution cartridge G naloxone hcl injection solution prefilled syringe G naltrexone hcl oral G NARCAN (naloxone hcl) PB PROVAYBLUE (methylene blue (antidote)) FE RADIOGARDASE (prussian blue insoluble) NPB VIVITROL (naltrexone) NPSB *ANTIEMETICS* - DRUGS FOR THE STOMACH AKYNZEO ORAL (netupitant-palonosetron) NPB ANZEMET ORAL (dolasetron mesylate) NPB aprepitant G BONJESTA (doxylamine-pyridoxine) FE CESAMET () NPB CINVANTI (aprepitant) FE DICLEGIS (doxylamine-pyridoxine) NPB doxylamine-pyridoxine G dronabinol G EMEND ORAL SUSPENSION RECONSTITUTED NPB (aprepitant) granisetron hcl oral G hcl oral tablet G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 36 Prescription Drug Name Drug Tier Drug Notes ondansetron G ondansetron hcl oral G SANCUSO (granisetron) PB scopolamine G SUSTOL (granisetron) FE SYNDROS (dronabinol) FE TRANSDERM SCOP (1.5 MG) (scopolamine base) FE TRANSDERM-SCOP (1.5 MG) (scopolamine base) FE trimethobenzamide hcl oral G VARUBI ORAL (rolapitant hcl) PB ZUPLENZ (ondansetron) FE *ANTIFUNGALS* - DRUGS FOR INFECTIONS bio-statin oral capsule NPB bio-statin oral powder G CRESEMBA ORAL (isavuconazonium sulfate) NPB fluconazole oral G flucytosine oral G griseofulvin microsize oral G griseofulvin ultramicrosize G itraconazole oral G ketoconazole oral G NOXAFIL ORAL (posaconazole) NPB nystatin oral tablet G terbinafine hcl oral G tolsura FE voriconazole oral G *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD HEMLIBRA (emicizumab-kxwh) NPSB *ANTIHISTAMINES* - DRUGS FOR THE LUNGS tannate oral tablet chewable G carbinoxamine maleate oral solution G carbinoxamine maleate oral tablet 4 mg G carbinoxamine maleate oral tablet 6 mg FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 37 Prescription Drug Name Drug Tier Drug Notes cetirizine hcl oral solution 1 mg/ml G clemastine fumarate oral tablet 2.68 mg G hcl oral G desloratadine G dexchlorpheniramine maleate oral solution G hcl oral elixir G KARBINAL ER ORAL SUSPENSION EXTENDED NPB RELEASE (carbinoxamine maleate) levocetirizine dihydrochloride oral G hcl (Phenadoz) G promethazine hcl oral syrup G promethazine hcl oral tablet G promethazine hcl rectal G promethazine hcl (Promethegan) G RYCLORA ORAL SOLUTION (dexchlorpheniramine G maleate) RYVENT (carbinoxamine maleate) G *ANTIHYPERLIPIDEMICS MISC. COMBINATIONS*** - DRUGS FOR THE HEART omega-3 rx complete FE OMEGA-3/D-3 WELLNESS PACK (omega-3-acid ethyl FE esters & d3) sure result o3d3 system FE *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART ALTOPREV (lovastatin) FE ANTARA ORAL CAPSULE 30 MG, 90 MG ( NPB micronized) atorvastatin calcium oral tablet 10 mg, 20 mg G CE; LGC atorvastatin calcium oral tablet 40 mg, 80 mg G LGC cholestyramine light G cholestyramine oral G colesevelam hcl G colestipol hcl G CRESTOR (rosuvastatin calcium) FE equapax/atorvastatin/coq10 FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 38 Prescription Drug Name Drug Tier Drug Notes EZALLOR SPRINKLE (rosuvastatin calcium) FE ezetimibe G ezetimibe-simvastatin G fenofibrate micronized G fenofibrate oral capsule 150 mg, 50 mg G fenofibrate oral tablet 120 mg FE fenofibrate oral tablet 145 mg, 160 mg, 40 mg, 48 mg, 54 mg G fenofibric acid oral capsule delayed release G fenofibric acid oral tablet 105 mg G FENOGLIDE ORAL TABLET 120 MG (fenofibrate) FE FIBRICOR (fenofibric acid) NPB flolipid FE fluvastatin sodium G fluvastatin sodium er G oral G LGC JUXTAPID (lomitapide mesylate) NPSB KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED NPSB SYRINGE (mipomersen sodium) LESCOL XL (fluvastatin sodium) FE LIPITOR (atorvastatin calcium) FE LIVALO (pitavastatin calcium) FE lovastatin G LGC (antihyperlipidemic) G niacin er (antihyperlipidemic) G NIACOR (niacin (antihyperlipidemic)) G omega-3-acid ethyl esters G pravastatin sodium G LGC cholestyramine light (Prevalite) G rosuvastatin calcium G LGC simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg G CE; LGC simvastatin oral tablet 80 mg G LGC TRICOR (fenofibrate) FE TRIGLIDE ORAL TABLET 160 MG (fenofibrate) NPB VASCEPA (icosapent ethyl) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 39 Prescription Drug Name Drug Tier Drug Notes ZETIA (ezetimibe) FE ZYPITAMAG (pitavastatin magnesium) FE *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART aliskiren fumarate G besy-benazepril hcl G LGC amlodipine besylate-valsartan G LGC amlodipine-olmesartan G LGC amlodipine-valsartan-hctz G LGC ATACAND (candesartan cilexetil) FE ATACAND HCT (candesartan cilexetil-hctz) FE atenolol-chlorthalidone G benazepril hcl oral G LGC benazepril-hydrochlorothiazide G LGC BENICAR (olmesartan medoxomil) FE BENICAR HCT (olmesartan medoxomil-hctz) FE bisoprolol-hydrochlorothiazide G LGC candesartan cilexetil G LGC candesartan cilexetil-hctz G LGC captopril oral G LGC captopril-hydrochlorothiazide G clonidine G clonidine hcl oral G LGC DEMSER (metyrosine) NPB DIOVAN (valsartan) FE DIOVAN HCT (valsartan-hydrochlorothiazide) FE doxazosin mesylate oral G DUTOPROL (metoprolol-hydrochlorothiazide) FE EDARBI (azilsartan medoxomil) FE EDARBYCLOR (azilsartan-chlorthalidone) FE enalapril maleate oral G LGC enalapril-hydrochlorothiazide G LGC EPANED ORAL SOLUTION (enalapril maleate) NPB eplerenone G eprosartan mesylate G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 40 Prescription Drug Name Drug Tier Drug Notes EXFORGE (amlodipine besylate-valsartan) FE EXFORGE HCT (amlodipine-valsartan-hctz) FE fosinopril sodium G LGC fosinopril sodium-hctz G LGC guanfacine hcl oral G hcl oral tablet 10 mg, 100 mg, 50 mg G hydralazine hcl oral tablet 25 mg G LGC irbesartan G LGC irbesartan-hydrochlorothiazide G LGC lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC lisinopril oral tablet 30 mg, 40 mg G lisinopril-hydrochlorothiazide G LGC losartan potassium G LGC losartan potassium-hctz G LGC oral G methyldopa-hydrochlorothiazide G metoprolol-hydrochlorothiazide G oral G moexipril hcl G NIPRIDE RTU (nitroprusside sodium-nacl) FE olmesartan medoxomil oral G LGC olmesartan medoxomil-hctz G LGC olmesartan-amlodipine-hctz G LGC perindopril erbumine G LGC phenoxybenzamine hcl oral G prazosin hcl oral G PRESTALIA (perindopril arg-amlodipine) FE -hctz G QBRELIS (lisinopril) NPB quinapril hcl G LGC quinapril-hydrochlorothiazide G LGC ramipril G LGC TEKTURNA (aliskiren fumarate) NPB TEKTURNA HCT (aliskiren-hydrochlorothiazide) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 41 Prescription Drug Name Drug Tier Drug Notes G LGC telmisartan-amlodipine G LGC telmisartan-hctz G LGC terazosin hcl oral G LGC trandolapril G LGC trandolapril- hcl er G valsartan G LGC valsartan-hydrochlorothiazide G LGC VECAMYL (mecamylamine hcl) NPB *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS AEMCOLO (rifamycin sodium) NPB ALINIA (nitazoxanide) NPB atovaquone oral G CLIN SINGLE USE (clindamycin phosphate) FE clindamycin hcl oral G clindamycin palmitate hcl G dapsone oral G FIRST-METRONIDAZOLE (metronidazole benzoate) FE IMPAVIDO (miltefosine) NPB oral G METRONIDAZOLE BENZO+SYRSPEND (metronidazole FE benzoate) metronidazole oral G NEBUPENT (pentamidine isethionate) NPB PRIMSOL (trimethoprim hcl) NPB SIVEXTRO ORAL (tedizolid phosphate) NPB sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml G sulfamethoxazole-trimethoprim oral tablet G sulfamethoxazole-trimethoprim (Sulfatrim Pediatric) G tinidazole oral G trimethoprim oral G TYGACIL (tigecycline) FE XIFAXAN ORAL TABLET 200 MG (rifaximin) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 42 Prescription Drug Name Drug Tier Drug Notes XIFAXAN ORAL TABLET 550 MG (rifaximin) PB *ANTIMALARIALS* - DRUGS FOR INFECTIONS ARAKODA (tafenoquine succinate) FE atovaquone-proguanil hcl G phosphate oral G COARTEM (artemether-lumefantrine) NPB DARAPRIM (pyrimethamine) NPB hydroxychloroquine sulfate oral G KRINTAFEL (tafenoquine succinate) FE mefloquine hcl G primaquine phosphate oral G quinine sulfate oral G *ANTIMYASTHENIC AGENTS* - DRUGS FOR NERVES AND MUSCLES FIRDAPSE ( phosphate) NPB guanidine hcl oral NPB MESTINON ORAL SOLUTION (pyridostigmine bromide) NPB MESTINON ORAL TABLET (pyridostigmine bromide) NPB pyridostigmine bromide er G pyridostigmine bromide oral solution G pyridostigmine bromide oral tablet 60 mg G RUZURGI (amifampridine) NPB *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES FIRDAPSE (amifampridine phosphate) NPB guanidine hcl oral NPB MESTINON ORAL SOLUTION (pyridostigmine bromide) NPB MESTINON ORAL TABLET (pyridostigmine bromide) NPB pyridostigmine bromide er G pyridostigmine bromide oral solution G pyridostigmine bromide oral tablet 60 mg G RUZURGI (amifampridine) NPB *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS oral G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 43 Prescription Drug Name Drug Tier Drug Notes ethambutol hcl oral G oral G PASER (aminosalicylic acid) NPB PRIFTIN (rifapentine) NPB pyrazinamide oral G rifabutin G RIFAMATE (isoniazid-rifampin) NPB rifampin oral G RIFAMPIN+SYRSPEND SF (rifampin) FE RIFATER (isoniazid-rifamp-pyrazinamide) NPB TRECATOR (ethionamide) NPB *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR CANCER BALVERSA (erdafitinib) FE *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER ROZLYTREK (entrectinib) FE VITRAKVI ORAL CAPSULE (larotrectinib sulfate) NPSB *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER XPOVIO (100 MG ONCE WEEKLY) (selinexor) FE XPOVIO (60 MG ONCE WEEKLY) (selinexor) FE XPOVIO (80 MG ONCE WEEKLY) (selinexor) FE XPOVIO (80 MG TWICE WEEKLY) (selinexor) FE *ANTINEOPLASTIC OR PREMALIGNANT LESION AGENT - COMB*** - DRUGS FOR CANCER hyalucil-4 FE ORMECA (diclofenac-b6-fa-b12) FE *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER G ACTIMMUNE (interferon gamma-1b) NPSB AFINITOR (everolimus) PSB AFINITOR DISPERZ (everolimus) PSB ALECENSA (alectinib hcl) NPSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 44 Prescription Drug Name Drug Tier Drug Notes ALUNBRIG (brigatinib) NPSB anastrozole oral G BELRAPZO (bendamustine hcl) FE bexarotene G bicalutamide G BLEO 15K (bleomycin sulfate) FE BOSULIF (bosutinib) PSB CABOMETYX (cabozantinib s-malate) PSB capecitabine G CAPRELSA ORAL TABLET 300 MG (vandetanib) NPB COMETRIQ (100 MG DAILY DOSE) (cabozantinib s- NPSB malate) COMETRIQ (140 MG DAILY DOSE) (cabozantinib s- NPSB malate) COMETRIQ (60 MG DAILY DOSE) (cabozantinib s-malate) NPSB COTELLIC (cobimetinib fumarate) NPSB cyclophosphamide oral capsule G CYRAMZA (ramucirumab) NPB DAURISMO (glasdegib maleate) FE ELIGARD (leuprolide acetate (3 month)) PSB EMCYT ( phosphate sodium) PB ERIVEDGE (vismodegib) NPSB ERLEADA (apalutamide) PSB erlotinib hcl G ERWINAZE INJECTION (asparaginase erwinia chrysanth) NPB oral G EVOMELA (melphalan hcl) FE exemestane G FARYDAK (panobinostat lactate) FE FIRMAGON (degarelix acetate) NPSB flutamide G GLEEVEC (imatinib mesylate) FE GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG NPB (lomustine) GLIADEL WAFER (carmustine in polifeprosan) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 45 Prescription Drug Name Drug Tier Drug Notes HERCEPTIN HYLECTA (trastuzumab-hyaluronidase-oysk) FE HYCAMTIN ORAL (topotecan hcl) NPSB hydroxyurea oral G imatinib mesylate G INFUGEM (gemcitabine hcl-nacl) FE INLYTA (axitinib) NPSB INREBIC (fedratinib hcl) FE INTRON A (interferon alfa-2b) NPSB IRESSA (gefitinib) PSB JAKAFI (ruxolitinib phosphate) NPSB KANJINTI (trastuzumab-anns) FE KHAPZORY (levoleucovorin) FE KISQALI FEMARA (400 MG DOSE) (ribociclib-) PSB KISQALI FEMARA (600 MG DOSE) (ribociclib-letrozole) PSB KISQALI FEMARA(200 MG DOSE) (ribociclib-letrozole) PSB LENVIMA (10 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (12 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (14 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (18 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (20 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (24 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (4 MG DAILY DOSE) (lenvatinib mesylate) NPSB LENVIMA (8 MG DAILY DOSE) (lenvatinib mesylate) NPSB letrozole oral G leucovorin calcium oral G LEUKERAN (chlorambucil) PB leuprolide acetate injection G LONSURF (trifluridine-tipiracil) NPSB LORBRENA (lorlatinib) NPSB LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NPSB 3.75 MG (leuprolide acetate) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT FE 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NPSB 11.25 MG (leuprolide acetate (3 month)) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 46 Prescription Drug Name Drug Tier Drug Notes LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT FE 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) (leuprolide acetate (4 FE month)) LUPRON DEPOT (6-MONTH) (leuprolide acetate (6 FE month)) LYSODREN (mitotane) PB MATULANE ( hcl) PB megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml G megestrol acetate oral tablet G MEKINIST (trametinib dimethyl sulfoxide) NPSB melphalan G mercaptopurine oral G MESNEX ORAL (mesna) NPB methotrexate sodium (pf) injection solution 1 gm/40ml, 250 G mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml G methotrexate sodium injection solution reconstituted G methotrexate sodium oral G MVASI (bevacizumab-awwb) FE MYLERAN (busulfan) PB NERLYNX (neratinib maleate) NPSB NEXAVAR (sorafenib tosylate) NPSB NILANDRON (nilutamide) FE nilutamide G NINLARO (ixazomib citrate) NPSB NUBEQA (darolutamide) PSB ODOMZO (sonidegib phosphate) PSB POLIVY (polatuzumab vedotin-piiq) FE POMALYST (pomalidomide) NPSB PORTRAZZA (necitumumab) NPB PURIXAN (mercaptopurine) NPSB RYDAPT (midostaurin) PSB SOLTAMOX ( citrate) NPB SPRYCEL (dasatinib) PSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 47 Prescription Drug Name Drug Tier Drug Notes STIVARGA (regorafenib) NPSB SUTENT (sunitinib malate) PSB SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, NPSB 600 MCG (peginterferon alfa-2b) SYNRIBO (omacetaxine mepesuccinate) NPB TABLOID (thioguanine) PB TAFINLAR (dabrafenib mesylate) NPSB TAGRISSO (osimertinib mesylate) NPSB tamoxifen citrate oral G CE TARCEVA (erlotinib hcl) NPSB TARGRETIN ORAL (bexarotene) NPSB TASIGNA (nilotinib hcl) FE TEMODAR (temozolomide) NPSB temozolomide G TICE BCG (bcg live) NPB citrate G TOTECT (dexrazoxane hcl) FE TREANDA INTRAVENOUS SOLUTION NPSB RECONSTITUTED (bendamustine hcl) TRELSTAR MIXJECT (triptorelin pamoate) NPSB tretinoin oral G TREXALL (methotrexate sodium) PB TURALIO (pexidartinib hcl) FE TYKERB (lapatinib ditosylate) PSB VANTAS (histrelin acetate) NPSB VIZIMPRO (dacomitinib) FE VOTRIENT (pazopanib hcl) PSB XALKORI (crizotinib) NPSB XELODA (capecitabine) NPSB XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML FE (radium ra 223 dichloride) XOSPATA (gilteritinib fumarate) FE XTANDI (enzalutamide) PSB YONSA (abiraterone acetate) PSB ZELBORAF (vemurafenib) NPSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 48 Prescription Drug Name Drug Tier Drug Notes ZOLADEX (goserelin acetate) NPSB ZOLINZA (vorinostat) PSB ZYKADIA (ceritinib) NPSB ZYTIGA (abiraterone acetate) FE *ANTI-OBESITY AGENT COMBINATIONS** - DRUGS FOR EATING DISORDERS SPC (Only available for CONTRAVE (naltrexone-bupropion hcl) FE select plans) *ANTIPARKINSON AGENTS* - DRUGS FOR THE NERVOUS SYSTEM hcl oral G APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NPSB (apomorphine hcl) benztropine mesylate oral G bromocriptine mesylate oral G oral G carbidopa-levodopa G carbidopa-levodopa er oral tablet extended release 25-100 mg, G 50-200 mg carbidopa-levodopa- G entacapone G GOCOVRI (amantadine hcl) FE INBRIJA (levodopa) FE NEUPRO (rotigotine) PB OSMOLEX ER (amantadine hcl) FE pramipexole dihydrochloride G pramipexole dihydrochloride er G mesylate oral G ropinirole hcl G ropinirole hcl er G RYTARY (carbidopa-levodopa) NPB selegiline hcl oral G G trihexyphenidyl hcl G XADAGO ( mesylate) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 49 Prescription Drug Name Drug Tier Drug Notes ZELAPAR (selegiline hcl) NPB *ANTIPSORIATIC COMBINATIONS*** - DRUGS FOR THE SKIN NUDERMRXPAK 120 (calcipotriene-dimethicone) FE NUDERMRXPAK 60 (calcipotriene-dimethicone) FE *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PB SYRINGE (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR PB SUSPENSION RECONSTITUTED ER (aripiprazole) ABILIFY MYCITE (aripiprazole) FE ABILIFY ORAL TABLET (aripiprazole) FE ADASUVE () NPB aripiprazole G ARISTADA (aripiprazole lauroxil) PB ARISTADA INITIO (aripiprazole lauroxil) PB chlorpromazine hcl injection NPB chlorpromazine hcl oral G clozapine G prochlorperazine (Compro) G EQUETRO (carbamazepine ()) NPB FANAPT (iloperidone) FE FANAPT TITRATION PACK (iloperidone) FE fluphenazine decanoate injection G fluphenazine hcl injection G fluphenazine hcl oral G GEODON INTRAMUSCULAR ( mesylate) NPB haloperidol decanoate intramuscular solution 100 mg/ml, 50 G mg/ml haloperidol lactate injection solution 5 mg/ml G haloperidol lactate oral G haloperidol oral G INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE (paliperidone NPB palmitate) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 50 Prescription Drug Name Drug Tier Drug Notes INVEGA TRINZA INTRAMUSCULAR SUSPENSION FE PREFILLED SYRINGE (paliperidone palmitate) LATUDA (lurasidone hcl) PB lithium NPB lithium carbonate er G lithium carbonate oral G loxapine succinate oral G molindone hcl G NUPLAZID ORAL CAPSULE (pimavanserin tartrate) NPSB NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSB olanzapine G paliperidone er G perphenazine oral G PERSERIS (risperidone) FE prochlorperazine G prochlorperazine edisylate injection solution 10 mg/2ml, 50 G mg/10ml prochlorperazine maleate oral G fumarate G quetiapine fumarate er G REXULTI (brexpiprazole) NPB RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER (risperidone PB microspheres) risperidone G SAPHRIS (asenapine maleate) NPB SEROQUEL XR (quetiapine fumarate) FE hcl oral G thiothixene oral G trifluoperazine hcl oral G VERSACLOZ (clozapine) NPB VRAYLAR (cariprazine hcl) PB ziprasidone hcl G ZYPREXA RELPREVV (olanzapine pamoate) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 51 Prescription Drug Name Drug Tier Drug Notes *ANTIRETROVIRALS ADJUVANTS*** - DRUGS THAT ALTER METABOLISM TYBOST (cobicistat) NPSB *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - HORMONES TEGSEDI (inotersen sodium) FE *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS benzalkonium chloride external solution , 50 % NPB chlorhexidine gluconate solution 20 % NPB formaldehyde external solution 10 % G formaldehyde external solution 37 % NPB glutaraldehyde external NPB hydrogen peroxide solution 30 % G external tincture 2 % NPB *ANTIVIRALS* - DRUGS FOR INFECTIONS abacavir sulfate G abacavir sulfate-lamivudine G abacavir-lamivudine-zidovudine G acyclovir oral G adefovir dipivoxil G APTIVUS (tipranavir) NPSB atazanavir sulfate G ATRIPLA (-emtricitab-tenofovir) PSB BARACLUDE ORAL SOLUTION (entecavir) PSB BARACLUDE ORAL TABLET (entecavir) FE BIKTARVY (bictegravir-emtricitab-tenofov) PSB CIMDUO (lamivudine-tenofovir) PSB COMPLERA (emtricitab-rilpivir-tenofovir) FE CRIXIVAN ORAL CAPSULE 200 MG, 400 MG (indinavir NPSB sulfate) DAKLINZA (daclatasvir dihydrochloride) FE DELSTRIGO (doravirin-lamivudin-tenofov df) FE DESCOVY (emtricitabine-tenofovir af) PSB didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 52 Prescription Drug Name Drug Tier Drug Notes DOVATO (dolutegravir-lamivudine) FE EDURANT (rilpivirine hcl) PSB efavirenz G EMTRIVA (emtricitabine) PSB entecavir G EPIVIR HBV (lamivudine) FE EVOTAZ (atazanavir-cobicistat) PSB famciclovir oral G fosamprenavir calcium G FUZEON SUBCUTANEOUS SOLUTION PSB RECONSTITUTED (enfuvirtide) GENVOYA (elviteg-cobic-emtricit-tenofaf) PSB HEPSERA (adefovir dipivoxil) FE INTELENCE (etravirine) PSB INVIRASE ORAL TABLET (saquinavir mesylate) NPSB ISENTRESS (raltegravir potassium) PSB ISENTRESS HD (raltegravir potassium) PSB JULUCA (dolutegravir-rilpivirine) NPSB KALETRA ORAL TABLET (lopinavir-ritonavir) PSB lamivudine G lamivudine-zidovudine G LEXIVA ORAL SUSPENSION (fosamprenavir calcium) NPSB lopinavir-ritonavir G nevirapine G nevirapine er G NORVIR ORAL PACKET (ritonavir) PSB NORVIR ORAL SOLUTION (ritonavir) PSB ODEFSEY (emtricitab-rilpivir-tenofov af) PSB OLYSIO (simeprevir sodium) FE oseltamivir phosphate oral G PEGASYS PROCLICK (peginterferon alfa-2a) FE PEGASYS SUBCUTANEOUS SOLUTION (peginterferon FE alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML NPSB (peginterferon alfa-2b) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 53 Prescription Drug Name Drug Tier Drug Notes PIFELTRO (doravirine) FE PREVYMIS ORAL (letermovir) NPB PREZCOBIX (darunavir-cobicistat) PSB PREZISTA ORAL SUSPENSION (darunavir ethanolate) PSB PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 PSB MG (darunavir ethanolate) RELENZA DISKHALER (zanamivir) PB RESCRIPTOR ORAL TABLET 200 MG (delavirdine NPSB mesylate) REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NPSB (atazanavir sulfate) REYATAZ ORAL PACKET (atazanavir sulfate) NPSB ribavirin (Ribasphere Oral Capsule) G ribavirin (Ribasphere Oral Tablet 200 Mg) G RIBASPHERE ORAL TABLET 400 MG (ribavirin) FE RIBASPHERE ORAL TABLET 600 MG (ribavirin) G RIBASPHERE RIBAPAK (1000 PACK) (ribavirin) NPSB RIBASPHERE RIBAPAK (1200 PACK) (ribavirin) NPSB RIBASPHERE RIBAPAK (600 PACK) (ribavirin) NPSB RIBASPHERE RIBAPAK (800 PACK) (ribavirin) NPSB ribavirin inhalation G ribavirin oral capsule G ribavirin oral tablet 200 mg G rimantadine hcl G ritonavir G SELZENTRY (maraviroc) NPSB SITAVIG (acyclovir) NPB SOVALDI (sofosbuvir) NPSB stavudine oral capsule G STRIBILD (elviteg-cobic-emtricit-tenofdf) FE SYMFI (efavirenz-lamivudine-tenofovir) PSB SYMFI LO (efavirenz-lamivudine-tenofovir) PSB SYMTUZA (darun-cobic-emtricit-tenofaf) FE TEMIXYS (lamivudine-tenofovir) PSB tenofovir disoproxil fumarate G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 54 Prescription Drug Name Drug Tier Drug Notes TIVICAY (dolutegravir sodium) PSB TRIUMEQ (abacavir-dolutegravir-lamivud) PSB TRUVADA (emtricitabine-tenofovir df) PSB valacyclovir hcl oral G VALCYTE (valganciclovir hcl) FE valganciclovir hcl G VALTREX (valacyclovir hcl) FE VEMLIDY (tenofovir alafenamide fumarate) FE VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 NPSB MG (didanosine) VIDEX ORAL SOLUTION RECONSTITUTED 2 GM NPSB (didanosine) VIRACEPT ORAL TABLET (nelfinavir mesylate) NPSB VIREAD (tenofovir disoproxil fumarate) NPSB zidovudine G *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD CABLIVI (caplacizumab-yhdp) FE *ASSORTED CLASSES* - VITAMINS AND MINERALS AMPHADASE (hyaluronidase bovine) FE water for irrigation, sterile (Argyle Sterile Water) G ASTAGRAF XL (tacrolimus) FE AZASAN (azathioprine) PB azathioprine oral G BENLYSTA INTRAVENOUS (belimumab) NPSB BENLYSTA SUBCUTANEOUS (belimumab) FE CELLCEPT (mycophenolate mofetil) FE CELLCEPT INTRAVENOUS (mycophenolate mofetil hcl) FE cyclosporine modified G cyclosporine oral capsule G DEPEN TITRATABS (penicillamine) NPB d-penamine FE ENVARSUS XR (tacrolimus) FE cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) G cyclosporine modified (Gengraf Oral Solution) G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 55 Prescription Drug Name Drug Tier Drug Notes sodium polystyrene sulfonate (Kionex Oral Suspension) G lactated ringers irrigation G LOKELMA (sodium zirconium cyclosilicate) PB mycophenolate mofetil G mycophenolate sodium G MYFORTIC (mycophenolate sodium) FE penicillamine oral G phoxillum b22k4/0 FE phoxillum bk4/2.5 FE irrigation solns physiological (Physiolyte) G irrigation solns physiological (Physiosol Irrigation) G PROGRAF ORAL (tacrolimus) FE RAPAMUNE (sirolimus) FE REVLIMID (lenalidomide) PSB ringers irrigation G SANDIMMUNE ORAL SOLUTION (cyclosporine) NPSB sirolimus oral G sodium polystyrene sulfonate oral G sodium polystyrene sulfonate rectal G sodium polystyrene sulfonate (Sps) G sterile water for irrigation G tacrolimus oral G THALOMID (thalidomide) PSB ringers irrigation (Tis-U-Sol) G trientine hcl G VELTASSA (patiromer sorbitex calcium) PB WELLMIND VERTIGO (homeopathic products) NPB ZORTRESS (everolimus) FE *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE LUNGS DUPIXENT (dupilumab) PSB *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS ZINPLAVA (bezlotoxumab) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 56 Prescription Drug Name Drug Tier Drug Notes *B-COMPLEX W/ E & FOLIC ACID*** - DRUGS FOR NUTRITION fibrik FE folica-be FE folica-v FE folic-k FE *BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB*** - DRUGS FOR THE HEART BYVALSON (nebivolol-valsartan) FE *BETA BLOCKERS* - DRUGS FOR THE HEART acebutolol hcl oral G atenolol oral G LGC ATENOLOL+SYRSPEND SF (atenolol) FE BETAPACE AF ( hcl af) FE BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG FE (sotalol hcl) betaxolol hcl oral G bisoprolol fumarate G BYSTOLIC (nebivolol hcl) PB carvedilol G LGC carvedilol phosphate er G FIRST - METOPROLOL (metoprolol tartrate) FE FIRST-ATENOLOL (atenolol) FE HEMANGEOL (propranolol hcl) NPB INDERAL XL (propranolol hcl sr beads) NPB INNOPRAN XL (propranolol hcl sr beads) NPB KAPSPARGO SPRINKLE (metoprolol succinate) FE labetalol hcl oral G metoprolol succinate er G metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg G LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg G nadolol oral tablet 20 mg, 40 mg, 80 mg G pindolol G propranolol hcl er G propranolol hcl oral solution G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 57 Prescription Drug Name Drug Tier Drug Notes propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC propranolol hcl oral tablet 60 mg G sotalol hcl (Sorine Oral Tablet 120 Mg, 80 Mg) G LGC sotalol hcl (Sorine Oral Tablet 160 Mg, 240 Mg) G sotalol hcl (af) oral tablet 120 mg G LGC sotalol hcl (af) oral tablet 160 mg, 80 mg G sotalol hcl oral tablet 120 mg, 80 mg G LGC sotalol hcl oral tablet 160 mg, 240 mg G sotalol hydrochloride oral tablet 120 mg G LGC sotalol hydrochloride oral tablet 160 mg, 80 mg G SOTYLIZE (sotalol hcl) NPB timolol maleate oral G TOPROL XL (metoprolol succinate) FE *BIGUANIDE-DIABETIC SUPPLIES COMBINATIONS*** - HORMONES D-CARE DM2 (metformin hcl-diagnostic test) FE *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH CHOLBAM (cholic acid) NPSB *BIOLOGICALS MISC* - BIOLOGICAL AGENTS GRASTEK (timothy grass pollen allergen) PB RAGWITEK (short ragweed pollen ext) PB *CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM AIMOVIG (erenumab-aooe) PB AIMOVIG (140 MG DOSE) (erenumab-aooe) PB AJOVY (fremanezumab-vfrm) PB EMGALITY (galcanezumab-gnlm) PB EMGALITY (300 MG DOSE) (galcanezumab-gnlm) FE *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART AMLODIPINE BES+SYRSPEND SF (amlodipine besylate) FE amlodipine besylate oral G LGC CARDIZEM CD ( hcl coated beads) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 58 Prescription Drug Name Drug Tier Drug Notes CARDIZEM LA (diltiazem hcl coated beads) FE CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG FE (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt) G diltiazem hcl er beads G diltiazem hcl er coated beads oral capsule extended release 24 G hour diltiazem hcl er coated beads oral tablet extended release 24 FE hour diltiazem hcl er oral capsule extended release 12 hour G diltiazem hcl er oral capsule extended release 24 hour 180 mg, G 240 mg diltiazem hcl oral G LGC dilt-xr G er G G KATERZIA (amlodipine benzoate) FE diltiazem hcl coated beads (Matzim La) FE hcl oral G er G nifedipine er osmotic release G nifedipine oral G oral G er G NORVASC (amlodipine besylate) FE NYMALIZE (nimodipine) NPB diltiazem hcl er beads (Taztia Xt) G verapamil hcl er oral capsule extended release 24 hour G verapamil hcl er oral tablet extended release 120 mg G LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg G verapamil hcl oral G LGC *CARDIOTONICS* - DRUGS FOR THE HEART digoxin (Digitek) G digoxin (Digox) G digoxin oral G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 59 Prescription Drug Name Drug Tier Drug Notes LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) FE LANOXIN ORAL TABLET 62.5 MCG (digoxin) PB *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART ADCIRCA (tadalafil (pah)) FE ADEMPAS (riociguat) PSB tadalafil (pah) (Alyq) G ambrisentan G amlodipine-atorvastatin G LGC BIDIL (isosorb dinitrate-hydralazine) PB bosentan G cardioplegic G SPC (Only available for CIALIS (tadalafil) FE select plans) epoprostenol sodium G FLOLAN (epoprostenol sodium) NPSB IFE-PG20 (alprostadil (vasodilator)) FE LETAIRIS (ambrisentan) NPSB OPSUMIT (macitentan) PSB ORENITRAM (treprostinil diolamine) PSB REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NPSB MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO (sildenafil citrate) FE sildenafil citrate oral suspension reconstituted G sildenafil citrate oral tablet 20 mg G SPC (Only available for STENDRA (avanafil) FE select plans) tadalafil (pah) G TRACLEER (bosentan) NPSB treprostinil G TYVASO (treprostinil) NPSB TYVASO REFILL (treprostinil) NPSB TYVASO STARTER (treprostinil) NPSB VELETRI (epoprostenol sodium) NPSB VENTAVIS (iloprost) NPSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 60 Prescription Drug Name Drug Tier Drug Notes SPC (Only available for VIAGRA (sildenafil citrate) FE select plans) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS cefaclor G cefaclor er NPB cefadroxil G cefdinir G cefditoren pivoxil G cefixime G cefpodoxime proxetil G cefprozil G cefuroxime axetil oral tablet G cephalexin G DAXBIA (cephalexin) FE SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE (cefixime) PB *CHEMICALS* almond oil (sweet) NPB base g almond oil (sweet) NPB benzyl benzoate NPB calcium folinate NPB castor oil NPB coconut oil NPB cottonseed oil NPB soya protein NPB hydroxyprogesterone caproate NPB leucovorin calcium NPB linseed oil NPB macadamia nut oil NPB olive oil NPB peanut oil NPB pyrimethamine NPB safflower oil NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 61 Prescription Drug Name Drug Tier Drug Notes sesame oil NPB oil NPB *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR THE STOMACH TRULANCE (plecanatide) NPB *CONTRACEPTIVES* - DRUGS FOR WOMEN levonorgestrel-ethinyl estrad (Afirmelle) G CE AFTERA (levonorgestrel) G CE levonorgestrel-ethinyl estrad (Altavera) G CE alyacen 1/35 G CE alyacen 7/7/7 G CE levonorgest-eth estrad 91-day (Amethia) G CE levonorgest-eth estrad 91-day (Amethia Lo) G CE levonorgestrel-ethinyl estrad (Amethyst) G CE ANNOVERA (segesterone-ethinyl ) FE desogestrel-ethinyl estradiol (Apri) G CE norethin-eth estrad triphasic (Aranelle) G CE levonorgest-eth estrad 91-day (Ashlyna) G CE levonorgestrel-ethinyl estrad (Aubra) G CE levonorgestrel-ethinyl estrad (Aubra Eq) G CE norethindrone acet-ethinyl est (Aurovela 1.5/30) G CE norethindrone acet-ethinyl est (Aurovela 1/20) G CE norethin ace-eth estrad-fe (Aurovela 24 Fe) G CE norethin ace-eth estrad-fe (Aurovela Fe 1.5/30) G CE norethin ace-eth estrad-fe (Aurovela Fe 1/20) G CE levonorgestrel-ethinyl estrad (Aviane) G CE levonorgestrel-ethinyl estrad (Ayuna) G CE desogestrel-ethinyl estradiol (Azurette) G CE BALCOLTRA (levonorgest-eth estrad-fe bisg) NPB norethindrone-eth estradiol (Balziva) G CE desogestrel-ethinyl estradiol (Bekyree) G CE BEYAZ (drospiren-eth estrad-levomefol) FE norethin ace-eth estrad-fe (Blisovi 24 Fe) G CE norethin ace-eth estrad-fe (Blisovi Fe 1.5/30) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 62 Prescription Drug Name Drug Tier Drug Notes norethin ace-eth estrad-fe (Blisovi Fe 1/20) G CE briellyn G CE norethindrone (Camila) G CE levonorgest-eth estrad 91-day (Camrese) G CE levonorgest-eth estrad 91-day (Camrese Lo) G CE desogestrel-ethinyl estradiol (Caziant) G CE levonorgestrel-ethinyl estrad (Chateal) G CE levonorgestrel-ethinyl estrad (Chateal Eq) G CE norgestrel-ethinyl estradiol (Cryselle-28) G CE norethindrone-eth estradiol (Cyclafem 1/35) G CE norethin-eth estrad triphasic (Cyclafem 7/7/7) G CE desogestrel-ethinyl estradiol (Cyred) G CE desogestrel-ethinyl estradiol (Cyred Eq) G CE norethindrone-eth estradiol (Dasetta 1/35) G CE norethin-eth estrad triphasic (Dasetta 7/7/7) G CE levonorgest-eth estrad 91-day (Daysee) G CE norethindrone (Deblitane) G CE levonorgestrel-ethinyl estrad (Delyla) G CE DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE PB (medroxyprogesterone acetate) desogestrel-ethinyl estradiol G CE drospiren-eth estrad-levomefol G CE drospirenone-ethinyl estradiol G CE ECONTRA EZ (levonorgestrel) G CE ECONTRA ONE-STEP (levonorgestrel) G CE norgestrel-ethinyl estradiol (Elinest) G CE ELLA (ulipristal acetate) NPB CE desogestrel-ethinyl estradiol (Emoquette) G CE levonorg-eth estrad triphasic (Enpresse-28) G CE desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- G CE Mcg) norethindrone (Errin) G CE norgestimate-eth estradiol (Estarylla) G CE ethynodiol diac-eth estradiol G CE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 63 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Falmina) G CE levonorgest-eth estrad 91-day (Fayosim) G CE norgestimate-eth estradiol (Femynor) G CE drospirenone-ethinyl estradiol (Gianvi) G CE norethindrone acet-ethinyl est (Hailey 1.5/30) G CE norethin ace-eth estrad-fe (Hailey 24 Fe) G CE norethindrone (Heather) G CE norethindrone (Incassia) G CE levonorgest-eth estrad 91-day (Introvale) G CE desogestrel-ethinyl estradiol (Isibloom) G CE drospirenone-ethinyl estradiol (Jasmiel) G CE norethindrone (Jencycla) G CE levonorgest-eth estrad 91-day (Jolessa) G CE desogestrel-ethinyl estradiol (Juleber) G CE norethindrone acet-ethinyl est (Junel 1.5/30) G CE norethindrone acet-ethinyl est (Junel 1/20) G CE norethin ace-eth estrad-fe (Junel Fe 1.5/30) G CE norethin ace-eth estrad-fe (Junel Fe 1/20) G CE norethin ace-eth estrad-fe (Junel Fe 24) G CE norethin-eth estradiol-fe (Kaitlib Fe) G CE desogestrel-ethinyl estradiol (Kalliga) G CE desogestrel-ethinyl estradiol (Kariva) G CE ethynodiol diac-eth estradiol (Kelnor 1/35) G CE ethynodiol diac-eth estradiol (Kelnor 1/50) G CE levonorgestrel-ethinyl estrad (Kurvelo) G CE norethindrone acet-ethinyl est (Larin 1.5/30) G CE norethindrone acet-ethinyl est (Larin 1/20) G CE norethin ace-eth estrad-fe (Larin 24 Fe) G CE norethin ace-eth estrad-fe (Larin Fe 1.5/30) G CE norethin ace-eth estrad-fe (Larin Fe 1/20) G CE levonorgestrel-ethinyl estrad (Larissia) G CE norethin-eth estradiol-fe (Layolis Fe) G CE norethin-eth estrad triphasic (Leena) G CE levonorgestrel-ethinyl estrad (Lessina) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 64 Prescription Drug Name Drug Tier Drug Notes levonorg-eth estrad triphasic (Levonest) G CE levonorgest-eth est & eth est G CE levonorgest-eth estrad 91-day G CE levonorgestrel oral tablet 1.5 mg G CE levonorgestrel-ethinyl estrad G CE levonorg-eth estrad triphasic G CE levonorgestrel-ethinyl estrad (Levora 0.15/30 (28)) G CE LILETTA (52 MG) INTRAUTERINE INTRAUTERINE FE DEVICE 19.5 MCG/DAY (levonorgestrel) levonorgestrel-ethinyl estrad (Lillow) G CE LO LOESTRIN FE (norethin-eth estrad-fe biphas) FE drospirenone-ethinyl estradiol (Loryna) G CE norgestrel-ethinyl estradiol (Low-Ogestrel) G CE drospirenone-ethinyl estradiol (Lo-Zumandimine) G CE levonorgestrel-ethinyl estrad (Lutera) G CE norethindrone (Lyza) G CE marlissa G CE medroxyprogesterone acetate intramuscular G CE norethin ace-eth estrad-fe (Melodetta 24 Fe) G CE norethin ace-eth estrad-fe (Mibelas 24 Fe) G CE norethindrone acet-ethinyl est (Microgestin 1.5/30) G CE norethindrone acet-ethinyl est (Microgestin 1/20) G CE norethin ace-eth estrad-fe (Microgestin Fe 1.5/30) G CE norethin ace-eth estrad-fe (Microgestin Fe 1/20) G CE norgestimate-eth estradiol (Mili) G CE MINASTRIN 24 FE (norethin ace-eth estrad-fe) FE norgestimate-eth estradiol (Mono-Linyah) G CE MY CHOICE (levonorgestrel) G CE MY WAY (levonorgestrel) G CE NATAZIA (-dienogest) FE norethindrone-eth estradiol (Necon 0.5/35 (28)) G CE NEW DAY (levonorgestrel) G CE drospirenone-ethinyl estradiol (Nikki) G CE norethindrone (Nora-Be) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 65 Prescription Drug Name Drug Tier Drug Notes norethin ace-eth estrad-fe G CE norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg G CE norethindrone oral G CE norethin-eth estradiol-fe G CE norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg G CE norgestim-eth estrad triphasic G CE norethindrone (Norlyda) G CE norethindrone (Norlyroc) G CE norethindrone-eth estradiol (Nortrel 0.5/35 (28)) G CE norethindrone-eth estradiol (Nortrel 1/35 (21)) G CE norethindrone-eth estradiol (Nortrel 1/35 (28)) G CE norethin-eth estrad triphasic (Nortrel 7/7/7) G CE NUVARING (etonogestrel-ethinyl estradiol) PB CE drospirenone-ethinyl estradiol (Ocella) G CE OGESTREL (norgestrel-ethinyl estradiol) G CE OPCICON ONE-STEP (levonorgestrel) G CE OPTION 2 (levonorgestrel) G CE levonorgestrel-ethinyl estrad (Orsythia) G CE ORTHO TRI-CYCLEN LO (norgestim-eth estrad triphasic) FE PARAGARD INTRAUTERINE (copper) NPB CE norethindrone-eth estradiol (Philith) G CE desogestrel-ethinyl estradiol (Pimtrea) G CE norethindrone-eth estradiol (Pirmella 1/35) G CE norethin-eth estrad triphasic (Pirmella 7/7/7) G CE levonorgestrel-ethinyl estrad (Portia-28) G CE PREVENTEZA (levonorgestrel) G CE norgestimate-eth estradiol (Previfem) G CE REACT (levonorgestrel) G CE desogestrel-ethinyl estradiol (Reclipsen) G CE levonorgest-eth estrad 91-day (Rivelsa) G CE SAFYRAL (drospiren-eth estrad-levomefol) NPB levonorgest-eth estrad 91-day (Setlakin) G CE norethindrone (Sharobel) G CE desogestrel-ethinyl estradiol (Simliya) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 66 Prescription Drug Name Drug Tier Drug Notes levonorgest-eth estrad 91-day (Simpesse) G CE SLYND (drospirenone) FE norgestimate-eth estradiol (Sprintec 28) G CE levonorgestrel-ethinyl estrad (Sronyx) G CE drospirenone-ethinyl estradiol (Syeda) G CE TAKE ACTION (levonorgestrel) G CE norethin ace-eth estrad-fe (Tarina 24 Fe) G CE norethin ace-eth estrad-fe (Tarina Fe 1/20) G CE norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq) G CE TAYTULLA (norethin ace-eth estrad-fe) FE norethindron-ethinyl estrad-fe (Tilia Fe) G CE norgestim-eth estrad triphasic (Tri Femynor) G CE norgestim-eth estrad triphasic (Tri-Estarylla) G CE norethindron-ethinyl estrad-fe (Tri-Legest Fe) G CE norgestim-eth estrad triphasic (Tri-Linyah) G CE norgestim-eth estrad triphasic (Tri-Lo-Estarylla) G CE norgestim-eth estrad triphasic (Tri-Lo-Marzia) G CE norgestim-eth estrad triphasic (Tri-Lo-Mili) G CE norgestim-eth estrad triphasic (Tri-Lo-Sprintec) G CE norgestim-eth estrad triphasic (Tri-Mili) G CE norgestim-eth estrad triphasic (Tri-Previfem) G CE norgestim-eth estrad triphasic (Tri-Sprintec) G CE levonorg-eth estrad triphasic (Trivora (28)) G CE norgestim-eth estrad triphasic (Tri-Vylibra) G CE norgestim-eth estrad triphasic (Tri-Vylibra Lo) G CE norethindrone (Tulana) G CE drospiren-eth estrad-levomefol (Tydemy) G CE desogestrel-ethinyl estradiol (Velivet) G CE levonorgestrel-ethinyl estrad (Vienva) G CE viorele G CE norethindrone-eth estradiol (Vyfemla) G CE norgestimate-eth estradiol (Vylibra) G CE norethindrone-eth estradiol (Wera) G CE norethin-eth estradiol-fe (Wymzya Fe) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 67 Prescription Drug Name Drug Tier Drug Notes XULANE (norelgestromin-eth estradiol) G CE YAZ (drospirenone-ethinyl estradiol) FE drospirenone-ethinyl estradiol (Zarah) G CE ethynodiol diac-eth estradiol (Zovia 1/35E (28)) G CE drospirenone-ethinyl estradiol (Zumandimine) G CE *CORTICOSTEROIDS* - HORMONES arze-ject-a FE beta 1 kit FE betamethasone combo FE budesonide er oral tablet extended release 24 hour G budesonide oral G CELESTONE SOLUSPAN (betamethasone sod phos & acet) FE CONTRAST ALLERGY PREMED PACK (prednisone- FE diphenhydramine hcl) cortisone acetate oral G dexamethasone (Decadron) G DERMACINRX CINLONE-I CPI (triamcinolone-lido-prilo) FE dexamethasone (la) injection suspension 8 mg/ml FE DEXAMETHASONE INTENSOL (dexamethasone) NPB dexamethasone oral G DEXONTO 0.4% (dexamethasone sodium phosphate) FE DEXOPIN (dexamet sod phos pf & ropiv pf) FE dexamethasone (Dexpak 10 Day Oral Tablet Therapy Pack) FE dexamethasone (Dexpak 13 Day Oral Tablet Therapy Pack) FE dexamethasone (Dexpak 6 Day Oral Tablet Therapy Pack) FE DMT SUIK (dexameth sod phos & anesthetic) FE DXEVO 11-DAY (dexamethasone) FE EMFLAZA (deflazacort) FE fludrocortisone acetate oral G dexamethasone (Hidex 6-Day) G hydrocortisone oral G lidocidex i FE LIDOCILONE I (triamcinolone acet & ) FE LOCORT 11-DAY (dexamethasone) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 68 Prescription Drug Name Drug Tier Drug Notes LOCORT 7-DAY (dexamethasone) FE MEDPREDKIT (methylpred&omep-bicarb&k&gel) FE MEDROL ORAL TABLET 2 MG (methylprednisolone) NPB MEDROLOAN II SUIK (methylprednisolone & anesth) FE MEDROLOAN SUIK (methylprednisolone & anesth) FE methylprednisolone oral G MILLIPRED (prednisolone sodium phosphate) FE MILLIPRED DP 12-DAY ORAL TABLET THERAPY FE PACK (prednisolone) MILLIPRED DP ORAL TABLET THERAPY PACK FE (prednisolone) p-care d40 FE p-care d40g FE p-care d40mx FE p-care d80 FE p-care d80g combination FE p-care d80mx FE pod-care 100c FE prednisolone oral solution G prednisolone sodium phosphate oral solution 10 mg/5ml, 15 G mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible G PREDNISONE INTENSOL (prednisone) NPB prednisone oral G PRO-C-DURE 6 (triamcinolone acetonide) FE RAYOS (prednisone) FE READYSHARP ANESTH + DEXAMETH (dexameth sod FE phos-bupiv-lido) READYSHARP ANESTH + METHYLPRED FE (methylprednisol & bupiv & lido) READYSHARP BETAMETHASONE (betamethasone sod FE phos & acet) READYSHARP DEXAMETHASONE (dexamethasone FE sodium phosphate) READYSHARP METHYLPREDNISOLONE FE (methylprednisolone acetate) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 69 Prescription Drug Name Drug Tier Drug Notes READYSHARP-P40 (methylprednisol & bupiv & lido) FE READYSHARP-P80 (methylprednisol & bupiv & lido) FE ROPIDEX (dexamet sod phos pf & ropiv pf) FE TAPERDEX 12-DAY (dexamethasone) FE dexamethasone (Taperdex 6-Day) FE TAPERDEX 7-DAY ORAL TABLET THERAPY PACK FE 1.5 MG (27) (dexamethasone) ZILRETTA (triamcinolone acetonide) FE ZODEX 12-DAY (dexamethasone) FE dexamethasone (Zodex 6-Day) FE ZONACORT 11 DAY (dexamethasone) FE ZONACORT 7 DAY (dexamethasone) FE *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS acetylcysteine inhalation G benzonatate capsule 150 mg oral FE benzonatate capsule 150 mg oral G benzonatate oral capsule 100 mg, 200 mg G pseudoeph-bromphen-dm (Bromfed Dm) G CLARINEX-D 12 HOUR (desloratadine-pseudoephedrine) NPB FLOWTUSS (hydrocodone-guaifenesin) FE g tussin ac G GILPHEX TR (phenylephrine-guaifenesin) NPB GILTUSS TR ORAL TABLET (phenylephrine-dm-gg) NPB guaiatussin ac G guaifenesin-codeine oral solution G hydrocod polst-cpm polst er oral suspension extended release G hydrocodone-homatropine G hydromet G HYPERSAL INHALATION NEBULIZATION NPB SOLUTION 3.5 % (sodium chloride) sodium chloride (Nebusal Inhalation Nebulization Solution 3 G %) NEBUSAL INHALATION NEBULIZATION SOLUTION NPB 6 % (sodium chloride) NEOTUSS PLUS (phenylephrine-chlorphen-dm) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 70 Prescription Drug Name Drug Tier Drug Notes OBREDON (hydrocodone-guaifenesin) FE phenylephrine-guaifenesin oral G promethazine-codeine G promethazine-dm oral syrup G promethazine-phenyleph-codeine G promethazine-phenylephrine G pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml G pseudoeph-chlorphen-hydrocod G sodium chloride (Pulmosal) G SEMPREX-D (acrivastine-pseudoephedrine) NPB sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 G %, 7 % TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 NPB HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER (chlorpheniramine-codeine) FE TUZISTRA XR ORAL SUSPENSION EXTENDED NPB RELEASE (codeine polst-chlorphen polst) virtussin a/c G virtussin dac G *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER IBRANCE (palbociclib) PSB KISQALI (200 MG DOSE) (ribociclib succinate) PSB KISQALI (400 MG DOSE) (ribociclib succinate) PSB KISQALI (600 MG DOSE) (ribociclib succinate) PSB VERZENIO (abemaciclib) FE *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR THE LUNGS ORKAMBI ORAL TABLET (lumacaftor-ivacaftor) NPSB *DERMATOLOGICALS* - DRUGS FOR THE SKIN lidocaine hcl (7T Lido) G 7topic FE ABSORICA (isotretinoin) NPB ACANYA (clindamycin phos-benzoyl perox) FE ACCUCAINE (lido-pentaf-tetrafl-ultrasound) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 71 Prescription Drug Name Drug Tier Drug Notes aceso ag FE acitretin G ACTICOAT 7 EXTERNAL PAD (silver) NPB ACTICOAT ABSORBENT EXTERNAL PAD (silver) NPB ACTICOAT ANTIMICROBIAL (silver) NPB ACTICOAT FLEX 3 4"X4" (wound dressings) NPB ACUICYN EXTERNAL SOLUTION (eyelid cleansers) FE acyclovir external G ACZONE EXTERNAL GEL 7.5 % (dapsone) NPB adapalene external cream G adapalene external gel G adapalene external G adapalene external pad FE adapalene-benzoyl peroxide G ADVANCED ALLERGY COLLECTION (hydrocortisone) FE aftertest topical pain relief FE AKTIPAK (benzoyl peroxide-erythromycin) FE ALA SCALP (hydrocortisone) NPB ala-cort external cream G alclometasone dipropionate G ALCORTIN A (iodoquinol-hc-aloe polysacch) FE alevamax NPB ALEVICYN ANTIPRURITIC (dermatological products, FE misc.) ALEVICYN ANTIPRURITIC SG EXTERNAL GEL FE (dermatological products, misc.) wound cleansers (Alevicyn Dermal Spray) FE ALEVICYN PLUS (dermatological products, misc.) FE ALLEVYN AG ADHESIVE EXTERNAL PAD NPB 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM (silver) ALLEVYN AG NON-ADHESIVE EXTERNAL PAD NPB 2"X2" , 4"X4" , 6"X6" , 8"X8" (silver) ALLEVYN AG SACRUM 6-3/4" (silver) NPB ALLEVYN AG SACRUM 9"X9" (silver) NPB ALLEVYN GENTLE (wound dressings) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 72 Prescription Drug Name Drug Tier Drug Notes ALLO-PAX (levocetirizine-loratadine) FE ALOQUIN (iodoquinol-aloe polysaccharide) FE ALTABAX (retapamulin) NPB ALTRENO (tretinoin) FE amcinonide external cream G amcinonide external lotion G amcinonide external ointment NPB AMELUZ (aminolevulinic acid hcl) FE ammonium lactate external G isotretinoin (Amnesteem) G ANACAINE () NPB anastia FE APEXICON E (diflorasone diacet emoll base) FE APRIZIO PAK (lidocaine--dressing) FE AQUACEL AG BURN (silver-carboxymethylcellulose) FE arnica flower NPB ASTERO (lidocaine hcl) FE atopaderm NPB ATOPICLAIR (dermatological products, misc.) NPB ATRAPRO CP (wound dressings) FE ATRAPRO DERMAL SPRAY (wound cleansers) FE ATRAPRO HYDROGEL (wound dressings) FE AVAR EXTERNAL FOAM (sulfacetamide sodium-sulfur) FE AVAR LS EXTERNAL FOAM (sulfacetamide sodium-sulfur) FE AVENOVA (eyelid cleansers) FE AVENOVA/NEUTROX (eyelid cleansers) FE tretinoin (Avita) G azelaic acid external G AZELEX (azelaic acid) NPB balsam peru-castor oil FE beau rx FE bensal hp FE BENZACLIN (clindamycin phos-benzoyl perox) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 73 Prescription Drug Name Drug Tier Drug Notes BENZACLIN WITH PUMP (clindamycin phos-benzoyl FE perox) BENZEPRO EXTERNAL (benzoyl peroxide) FE BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % (benzoyl FE peroxide) benzoyl peroxide (Benzepro External Foam 5.3 %) G BENZEPRO EXTERNAL LIQUID (benzoyl peroxide) FE benzoyl peroxide (Benzepro Short Contact) G BENZIQ (benzoyl peroxide) NPB BENZIQ LS (benzoyl peroxide) NPB BENZIQ WASH (benzoyl peroxide) G benzoin external tincture NPB benzoyl perox-hydrocortisone G benzoyl peroxide external foam 9.8 % G benzoyl peroxide-erythromycin G BESER EXTERNAL KIT (fluticasone-emollient) FE fluticasone propionate (Beser External Lotion) G betamethasone dipropionate aug G betamethasone dipropionate external G betamethasone valerate external G boric acid external granules NPB bp foam G bp wash external liquid 2.5 %, 7 % G bpco FE BRYHALI (halobetasol propionate) FE CADIRAMD (lido-prilocaine-blood collect) FE calcipotriene external cream FE calcipotriene external ointment G calcipotriene external solution G calcipotriene-betameth diprop G calcipotriene (Calcitrene) G calcitriol external FE CAPEX (fluocinolone acetonide) PB CARAC (fluorouracil) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 74 Prescription Drug Name Drug Tier Drug Notes scar treatment products (Celacyn) G CENTANY (mupirocin) NPB CERAMAX (dermatological products, misc.) FE CETACAINE EXTERNAL LIQUID (butamben-- FE benzocaine) ciclopirox (Ciclodan External Solution) G ciclopirox G ciclopirox olamine external G isotretinoin (Claravis) G clindamycin phosphate (Clindacin Etz External Swab) G clindamycin phosphate (Clindacin-P) G clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, G 1.2-5 % clindamycin phosphate external G clindamycin-tretinoin G clobetasol prop emollient base G clobetasol propionate e G clobetasol propionate G clobetasol propionate external cream G clobetasol propionate external foam G clobetasol propionate external gel G clobetasol propionate external liquid FE clobetasol propionate external lotion G clobetasol propionate external ointment G clobetasol propionate external G clobetasol propionate external solution G CLOBEX SPRAY (clobetasol propionate) FE clobetasol propionate (Clodan External Shampoo) G CLODERM (clocortolone pivalate) NPB clotrimazole external cream G clotrimazole external solution G clotrimazole-betamethasone G coal tar external solution G COLLATYL (silver) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 75 Prescription Drug Name Drug Tier Drug Notes CONDYLOX EXTERNAL GEL (podofilox) PB COPASIL EXTERNAL (scar treatment products) NPB CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) NPB CORDRAN EXTERNAL OINTMENT (flurandrenolide) FE CORDRAN EXTERNAL TAPE (flurandrenolide) NPB CORTISPORIN EXTERNAL (neomycin-polymyxin-hc) NPB IBC (Preferred agent for Ankylosing Spondylitis and COSENTYX (secukinumab) PSB Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for Ankylosing Spondylitis and COSENTYX (300 MG DOSE) (secukinumab) PSB Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for Ankylosing Spondylitis and COSENTYX SENSOREADY (300 MG) (secukinumab) PSB Psoriatic Arthritis. Not covered for Psoriasis) COSENTYX SENSOREADY PEN SUBCUTANEOUS PSB SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) crotamiton (Crotan) G CURITY HYPERTONIC NACL STRIP (wound dressings) NPB CURITY NACL DRESSING 6"X6-3/4" (wound dressings) NPB dapsone external G wound cleansers (Deluo) G DENAVIR (penciclovir) NPB DERMACINRX CLORHEXACIN (chlorhex-mupir-dimeth- FE silicone) DERMACINRX DUOPATCH PHARMAPAK (methyl FE salicylate-lido-menthol) DERMACINRX LEXITRAL PHARMAPAK (diclofenac FE sodium-capsaicin) DERMACINRX NEUROTRAL PHARMAPAK (lidocaine- FE capsaicin) DERMACINRX PHN (lidocaine-dimethicone) FE dermacinrx silapak external kit 0.1 & 5 % FE dermacinrx surgical combopak FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 76 Prescription Drug Name Drug Tier Drug Notes DERMACINRX SURGICAL PHARMAPAK (chlorhex- FE mupir-dimeth-silicone) DERMACINRX THERAZOLE PAK (clotrimazole-betameth FE & zn ox) DERMACINRX ZRM (lidocaine-emollient) FE DERMAWERX SURGICAL PLUS PAK (chlorhex-mupir- FE dimeth-silicone) DERMAZONE (triamcinolone acet-silicone) FE DERMAZYL (lidocaine-dimethicone) FE DERMULCERA (balsam peru-castor oil) FE DESONATE (desonide) NPB desonide external G desoximetasone external G DEXERYL (dermatological products, misc.) NPB dfs/ms/menth/cap pak FE DIAB EXTERNAL GEL (wound dressings) NPB DIAB F.D.G. FREEZE-DRIED (wound dressings) NPB DICLO GEL (diclofenac sodium) FE DICLO GEL WITH XRYLIX SHEETS TRANSDERMAL FE (diclofenac sod-adhesive sheet) diclofenac epolamine G diclofenac sodium gel 1 % transdermal G diclofenac sodium gel 1 % transdermal FE diclofenac sodium transdermal gel 3 % G diclofenac sodium transdermal solution G diclofenac sodium-capsaicin (Diclofex Dc Combination FE Therapy Pack 1.5 & 0.025 %) DICLOFONO (diclofenac sodium) FE diclopr FE diclosaicin FE diclovix FE diclozor FE diflorasone diacetate external FE dimentho FE DIPENTOCAINE (diclofenac-gabapentin-lido) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 77 Prescription Drug Name Drug Tier Drug Notes DITHOL (diclofenac sodium-menthol) FE DOLOTRANZ (lidocaine-prilocaine) FE doxepin hcl external FE doxycycline G DRYSOL (aluminum chloride) NPB ds prep pak FE DST PLUS PAK (diclofenac sodium) FE DUOBRII (halobetasol prop-tazarotene) FE DYNABAC 5.0 (diclofenac sodium-) FE econazole nitrate external G ECOZA (econazole nitrate) NPB ELETONE (dermatological products, misc.) NPB ELETONE TWINPACK (dermatological products, misc.) NPB ELIDEL (pimecrolimus) NPB ELLZIA PAK (triamcinolone acet-dimethicone) FE EMULSION SB (dermatological products, misc.) NPB enovarx-diclofenac sodium FE ENSTILAR (calcipotriene-betameth diprop) NPB ENTTY SPRAY EMULSION (dermatological products, NPB misc.) EPICERAM (dermatological products, misc.) FE EPICYN (hypochlorous acid) FE EPIDUO FORTE (adapalene-benzoyl peroxide) PB EPIFOAM (pramoxine-hc) NPB ERTACZO (sertaconazole nitrate) NPB ery G erythromycin external G essentra wipes 9x9" NPB EURAX EXTERNAL CREAM (crotamiton) NPB EXELDERM (sulconazole nitrate) NPB EXODERM EXTERNAL LOTION (sod thiosulfate-salicylic NPB acd) EXTINA (ketoconazole) FE FABIOR (tazarotene) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 78 Prescription Drug Name Drug Tier Drug Notes FINACEA EXTERNAL FOAM (azelaic acid) PB FINACEA EXTERNAL GEL (azelaic acid) FE flexin FE fluocinolone acetonide body G fluocinolone acetonide external G fluocinolone acetonide scalp G fluocinonide emulsified base G fluocinonide external cream 0.05 % G fluocinonide external cream 0.1 % FE fluocinonide external gel G fluocinonide external ointment G fluocinonide external solution G FLUOROPLEX (fluorouracil) NPB fluorouracil external cream 0.5 % FE fluorouracil external cream 5 % G fluorouracil external solution G fluovix FE flurandrenolide external cream G flurandrenolide external lotion G flurandrenolide external ointment FE fluticasone propionate external G FROTEK (ketoprofen) FE fungimez FE GEBAUERS PAIN EASE (pentafluoroprop-tetrafluoroeth) NPB GEBAUERS SPRAY AND STRETCH (pentafluoroprop- NPB tetrafluoroeth) gen7t FE gen7t plus FE GENADUR EXTERNAL (dermatological products, misc.) NPB gentamicin sulfate external G glycolic acid solution NPB lidocaine hcl (Glydo External Prefilled Syringe) G GORDOFILM (salicylic acid-lactic acid) NPB halcinonide G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 79 Prescription Drug Name Drug Tier Drug Notes halobetasol propionate external cream G halobetasol propionate external foam FE halobetasol propionate external ointment G HALOG EXTERNAL OINTMENT (halcinonide) NPB HPR (dermatological products, misc.) NPB HPR PLUS (dermatological products, misc.) NPB HPR PLUS HYDROGEL (dermatological products, misc.) NPB HPR PLUS-MB HYDROGEL (emollient foam & wound gel) NPB HYCLODEX (hypochlorous acid) FE hydrocortisone butyr lipo base G hydrocortisone butyrate external G hydrocortisone external cream 1 %, 2.5 % G hydrocortisone external lotion 2.5 % G hydrocortisone external ointment 1 %, 2.5 % G hydrocortisone (Hydrocortisone In Absorbase) FE hydrocortisone valerate G HYDROFERA BLUE 6"X6" (wound dressings) NPB HYDROFERA BLUE FOAM DRESSING (wound dressings) NPB HYDROFERA BLUE FOAM/TUNNELING (wound NPB dressings) HYDROFERA BLUE MRF DRESSING (wound dressings) NPB HYDROFERA BLUE READY FOAM (wound dressings) NPB hygel external gel 2.5 % FE HYLATOPIC PLUS (dermatological products, misc.) NPB HYLIRA EXTERNAL LOTION (hyaluronate sodium NPB (emollient)) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) NPB ILUMYA (tildrakizumab-asmn) FE imiquimod external G imiquimod pump G IMPOYZ (clobetasol propionate) FE inflamma-k FE isotretinoin oral G IV INFUSION CPI (lidocaine-prilocaine-nacl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 80 Prescription Drug Name Drug Tier Drug Notes iv novice pack FE JUBLIA (efinaconazole) NPB KAMDOY (dermatological products, misc.) FE KELARX (scar treatment products) FE KENDALL ALGINATE 12" ROPE (wound dressings) NPB KENDALL ALGINATE DRESS 2"X2" (wound dressings) NPB KENDALL ALGINATE DRESS 4"X4" (hydroactive NPB dressings) KENDALL ALGINATE DRESS 4"X8" (wound dressings) NPB KENDALL AMORPHOUS WOUND (wound dressings) NPB KENDALL HYDROGEL GAUZE 2"X2" (hydroactive NPB dressings) KENDALL HYDROGEL GAUZE 4"X4" (hydroactive NPB dressings) KENDALL HYDROGEL GAUZE 4"X8" (hydroactive NPB dressings) KENDALL HYDROGEL WOUND DRESS (hydroactive NPB dressings) KERAGEL (wound dressings) NPB KERAGELT (wound dressings) NPB KERAMATRIX REPLICINE 10CMX10CM EXTERNAL NPB SHEET (wound dressings) KERAMATRIX REPLICINE 5CMX5CM EXTERNAL NPB SHEET (wound dressings) ketoconazole external cream G ketoconazole external foam G ketoconazole external shampoo 2 % G KETOPHENE RAPIDPAQ (ketoprofen) FE KIVIK (dermatological products, misc.) FE L.E.T. (lido-epinephrine-tetracaine) FE lactic acid e G lactic acid external lotion G LDO PLUS (lidocaine hcl) FE levatio FE LEVICYN (dermatological products, misc.) FE wound cleansers (Levicyn Dermal Spray) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 81 Prescription Drug Name Drug Tier Drug Notes LEXETTE (halobetasol propionate) FE LEXIXRYL (diclofenac sod-adhesive sheet) FE lidocaine external ointment G lidocaine external patch 5 % G lidocaine hcl external solution G lidocaine hcl urethral/mucosal G lidocaine-prilocaine external cream G lidocaine-tetracaine FE LIDODERM (lidocaine) PB lidopac FE LIDOPURE PATCH (lidocaine-adhesive sheets) FE LIDO-RX 4.1 (lidocaine-capsaicin) FE lidosol-hc FE LIDOTHOL (lidocaine-menthol) FE LIDOTRAL (lidocaine hcl) FE LIDOTRANS 5 PAK (lidocaine-transparent dressing) FE LIDOTREX (lidocaine-collagen-aloe vera) FE lidovex FE lidovin FE lidozol FE external shampoo G LMR PLUS (lidocaine-camphor-menthol) FE LOPROX EXTERNAL CREAM (ciclopirox olamine) FE LOPROX EXTERNAL KIT 0.77 % (SUSP) (ciclopirox FE olamine-cleanser) LOPROX EXTERNAL SUSPENSION (ciclopirox olamine) FE loutrex NPB LOYON (dermatological products, misc.) NPB luliconazole G LURADROX (hyaluronate sodium) FE LUXAMEND (wound dressings) NPB mafenide acetate external G malathion external G MB HYDROGEL (dermatological products, misc.) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 82 Prescription Drug Name Drug Tier Drug Notes MENTAX (butenafine hcl) NPB mentho-caine FE methoxsalen rapid G metronidazole external G mezparox-hc forte FE miconazole-zinc oxide-petrolat G MICORT-HC (hydrocortisone acetate) FE MICROCYN EXTERNAL LIQUID 0.023 % (wound NPB cleansers) MIMYX (dermatological products, misc.) NPB MIRVASO (brimonidine tartrate) NPB mometasone furoate external G mupirocin calcium FE mupirocin external G isotretinoin (Myorisan) G naftifine hcl external cream G NAFTIN EXTERNAL GEL (naftifine hcl) PB NEOCERA (dermatological products, misc.) NPB NEOSALUS (dermatological products, misc.) NPB NEOSALUS CP (dermatological products, misc.) NPB NEO-SYNALAR EXTERNAL CREAM (neomycin- NPB fluocinolone) clindamycin-benzoyl per (refr) (Neuac External Gel) G NEURAPTINE (gabapentin) FE NEURCAINE (lidocaine-emollient) FE NIVATOPIC PLUS (dermatological products, misc.) NPB flurandrenolide (Nolix) G NORITATE (metronidazole) FE NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) FE NOXIPAK (fluocinolone-urea-silicone) FE NUCARACLINPAK (clindamycin phos- moisturizer) FE NUCARARXPAK (clindamycin-benzoyl per-moist) FE diclofenac sodium-capsaicin (Nudiclo Solupak) FE numbonex FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 83 Prescription Drug Name Drug Tier Drug Notes NUSURGEPAK SURGICAL PREP/CARE (chlorhex-mupir- FE dimeth-silicone) NUTRASEB (antiseborrheic products, misc.) NPB NUVAIL (dermatological products, misc.) NPB nystatin (Nyamyc) G nystatin external G nystatin-triamcinolone G nystatin (Nystop) G OLUX-E (clobetasol propionate emulsion) FE ONEXTON (clindamycin phos-benzoyl perox) FE OVACE PLUS EXTERNAL FOAM (sulfacetamide sodium) FE oxiconazole nitrate G OXISTAT EXTERNAL LOTION (oxiconazole nitrate) NPB paingo kft FE PANDEL (hydrocortisone probutate) NPB PANRETIN (alitretinoin) NPB PENLAC (ciclopirox) NPB PENLEN (dermatological products, misc.) FE PENNSAID TRANSDERMAL SOLUTION 2 % (diclofenac FE sodium) permethrin external cream G PHLAG SPRAY (dermatological products, misc.) NPB PICATO (ingenol mebutate) PB PICO WOUND THERAPY SYSTEM (wound dressings) NPB pimecrolimus G PLIAGLIS (lidocaine-tetracaine) FE PLIXDA (adapalene) FE podofilox external G PR BENZOYL PEROXIDE (benzoyl peroxide) FE benzoyl peroxide (Pr Benzoyl Peroxide Wash) G PR CREAM (dermatological products, misc.) NPB pramoxine hcl (Pramox) G PRE & POST SX POUCH (chlorhex-mupirocin-dimethicone) FE prednicarbate G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 84 Prescription Drug Name Drug Tier Drug Notes premium scar FE prepiv supply FE PRESERA (dermatological products, misc.) NPB PRIZOTRAL (lidocaine-prilocaine) FE PROMISEB (antiseborrheic products, misc.) NPB PROTOPIC (tacrolimus) NPB PROTYL AG (silver) FE PRUCLAIR (dermatological products, misc.) NPB PRUMYX (dermatological products, misc.) NPB psorcon FE pyrogallic acid NPB QBREXZA (glycopyrronium tosylate) NPB QUINIXIL (mometasone furo-dimethicone) FE QUINJA (iodoquinol-aloe polysaccharide) FE QUINOSONE (mometasone-ammonium lactate) FE QUTENZA (capsaicin-cleansing gel) NPB QUTENZA (2 PATCH) (capsaicin-cleansing gel) NPB RADIAGEL (wound dressings) NPB RADIAPLEXRX (wound dressings) NPB RECEDO (scar treatment products) FE RECURA (misc antifungal combo products) FE REGENECARE (lidocaine-collagen-aloe vera) NPB REGRANEX (becaplermin) NPB rematex FE remigen NPB renuu FE resorcinol-sulfur G RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , NPB 4"X4.75" (calcium alginate-silver) RESTORE SILVER DRESSING EXTERNAL PAD 4"X4" , NPB 4"X5" , 6"X8" (silver) RETIN-A MICRO (tretinoin microsphere) NPB RETIN-A MICRO PUMP (tretinoin microsphere) NPB REXASIL PATCH & VITAMIN E LIQ (silicone-vitamin e) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 85 Prescription Drug Name Drug Tier Drug Notes rezesol FE RHOFADE (oxymetazoline hcl) NPB RIAX (benzoyl peroxide) NPB metronidazole (Rosadan External Cream) G metronidazole (Rosadan External Gel) G RRB PAK (betameth diprop aug-silver) FE RTD WOUND CARE DRESSING (wound dressings) NPB rynoderm FE salimez G salimez forte NPB salisol FE salitech FE SANTYL (collagenase) NPB scarcin external gel NPB scarcin external liquid FE scarsilk external FE SCARZEN SKIN REPAIR (triamcinolone-dimeth-silicone) FE SEBUDERM (dermatological products, misc.) NPB sulfide external lotion G SERNIVO (betamethasone dipropionate) NPB SILALITE PAK (triamcinolone acet-silicone) FE SILAZONE PHARMAPAK (triamcinolone acet-silicone) FE SILAZONE-II (triamcinolone acet-silicone) FE SILIQ (brodalumab) FE SIL-K PAD LARGE (wound dressings) FE SIL-K PAD MEDIUM (wound dressings) FE SIL-K PAD SMALL (wound dressings) FE silmanix pain relieiving FE silver sulfadiazine external G SKLICE (ivermectin) NPB IBC (Preferred agent for SKYRIZI (150 MG DOSE) (risankizumab-rzaa) PSB Psoriasis) sodium hyaluronate external gel G sodium sulfacetamide wash NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 86 Prescription Drug Name Drug Tier Drug Notes solupak FE SOOLANTRA (ivermectin) PB SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % (lido- FE capsaicin-men-methyl sal) SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) NPB SORILUX (calcipotriene) FE sp antipruritic FE sp scar management FE spinosad G silver sulfadiazine (Ssd) G IBC (Preferred agent for Psoriasis and Crohn's STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PSB Disease (after failure of (ustekinumab) Humira). Not covered for Psoriatic Arthritis) IBC (Preferred agent for Psoriasis and Crohn's STELARA SUBCUTANEOUS SOLUTION PREFILLED PSB Disease (after failure of SYRINGE (ustekinumab) Humira). Not covered for Psoriatic Arthritis) sulfacetamide sodium (acne) G sulfacetamide sodium-sulfur external pad 10-4 % G sulfamez wash G SULFAMYLON EXTERNAL CREAM (mafenide acetate) NPB sulfurated lime NPB suvicort FE SX1 MEDICATED POST-OPERATIVE (lidocaine hcl & FE post-op system) SYNERA (lidocaine-tetracaine) NPB SYNERDERM (dermatological products, misc.) FE TACLONEX EXTERNAL SUSPENSION (calcipotriene- NPB betameth diprop) tacrolimus external G IBC (Preferred agent for Psoriasis. Not covered for TALTZ (ixekizumab) PSB Psoriatic Arthritis or Ankylosing Spondylitis)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 87 Prescription Drug Name Drug Tier Drug Notes TARGRETIN EXTERNAL (bexarotene) NPSB tazarotene external G TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) PB TAZORAC EXTERNAL GEL (tazarotene) PB TEGADERM AG MESH (silver) NPB tetravex FE TETRIX EXTERNAL CREAM (dermatological products, NPB misc.) TEXACORT (hydrocortisone) PB THERAHONEY (wound dressings) NPB THERAPEVO (hyaluronate sodium) FE TOLAK (fluorouracil) PB TRANZAREL (lidocaine hcl) FE IBC (Preferred agent for TREMFYA (guselkumab) PSB Psoriasis) tretinoin external G tretinoin microsphere G tretinoin microsphere pump G triamcinolone acetonide external G TRIAMSIL COMBIPAK EXTERNAL THERAPY PACK FE (triamcinolone acet-silicone) triamsil multipak FE TRIANEX (triamcinolone acetonide) NPB triamcinolone acetonide (Triderm External Cream) G triple complex formula 3 kit FE TRIXYLITRAL (diclofenac& lido & adhes sheet) FE turpentine external NPB ULESFIA (benzyl ) NPB ULTRAVATE EXTERNAL LOTION (halobetasol NPB propionate) uraliss FE urea (Uredeb) G URESOL (urea) FE urevaz FE benzoyl perox-hydrocortisone (Vanoxide-Hc) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 88 Prescription Drug Name Drug Tier Drug Notes VAROPHEN (diclofenac& menthol-methyl sal) FE VASCUDERM HYDROGEL (wound dressings) NPB VASHE CLEANSING (wound cleansers) G VECTICAL (calcitriol) FE VELTIN (clindamycin-tretinoin) FE VENELEX (balsam peru-castor oil) NPB VENIPUNCTURE CPI (lido-prilocaine-blood collect) FE VENIPUNCTURE PX1 PHLEBOTOMY (lidocaine hcl-blood FE collection) VERDESO (desonide) NPB VEREGEN (sinecatechins) NPB vexasyn FE VOLTAREN TRANSDERMAL (diclofenac sodium) NPB vopac mds FE vp gkl kit FE wpr plus wound healing system FE XALIX (salicylic acid) FE diclofenac sodium-capsaicin (Xelitral) FE XEPI (ozenoxacin) NPB XERAC AC (aluminum chloride in alcohol) NPB XERALUX (dermatological products, misc.) NPB XERESE (acyclovir-hydrocortisone) NPB XERFORM OIL EMULSION ROLL (bismuth tribromoph- NPB petrolatum) XEROFORM OIL EMULSION 2"X2" (bismuth tribromoph- NPB petrolatum) XEROFORM OIL EMULSION GAUZE (bismuth NPB tribromoph-petrolatum) XEROFORM OIL EMULSION STRIP (bismuth tribromoph- NPB petrolatum) XEROFORM PETROLAT GAUZE 1"X8" (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT PATCH 2"X2" (bismuth NPB tribromoph-petrolatum) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 89 Prescription Drug Name Drug Tier Drug Notes XEROFORM PETROLAT PATCH 4"X4" (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' (bismuth NPB tribromoph-petrolatum) XILAPAK (fluocinolone-cleanser-silicone) FE XOLEGEL (ketoconazole) FE XRYLIDERM (lidocaine-adhesive sheets) FE XRYLIX (diclofenac sod-adhesive sheet) FE zaclir cleansing external lotion 8 % NPB zanabin hydrogel NPB isotretinoin (Zenatane) G zenevix FE ZEYOCAINE (lidocaine-adhesive sheets) FE ZIANA (clindamycin-tretinoin) FE ZILACAINE PATCH (lidocaine-silicone) FE ZTLIDO (lidocaine) FE ZYCLARA (imiquimod) PB ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) PB *DIAGNOSTIC PRODUCTS* 12-PANEL POC TOXICOLOGY SYSTEM (drug assay NPB (urine)) ACCU-CHEK AVIVA PLUS IN VITRO (glucose blood) PB ACCU-CHEK COMPACT PLUS (glucose blood) PB ACCU-CHEK GUIDE IN VITRO (glucose blood) PB ACCU-CHEK SMARTVIEW (glucose blood) PB ACCUTREND GLUCOSE (glucose blood) FE ADVANCE INTUITION TEST (glucose blood) FE ADVANCE MICRO-DRAW TEST (glucose blood) FE ADVOCATE REDI-CODE IN VITRO (glucose blood) FE ADVOCATE REDI-CODE+ TEST (glucose blood) FE ADVOCATE TEST (glucose blood) FE AGAMATRIX AMP TEST (glucose blood) FE AGAMATRIX JAZZ TEST (glucose blood) FE AGAMATRIX KEYNOTE TEST (glucose blood) FE AGAMATRIX PRESTO TEST (glucose blood) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 90 Prescription Drug Name Drug Tier Drug Notes ASSURE 3 TEST (glucose blood) FE ASSURE 4 TEST (glucose blood) FE ASSURE II (glucose blood) FE ASSURE II CHECK (glucose blood) FE ASSURE PLATINUM (glucose blood) FE ASSURE PRISM MULTI TEST (glucose blood) FE ASSURE PRO TEST (glucose blood) FE AT LAST TEST (glucose blood) FE barium sulfate NPB BAYER BREEZE 2 TEST (glucose blood) FE BIOSCANNER GLUCOSE TEST (glucose blood) FE blood glucose test FE BREEZE 2 TEST (glucose blood) FE CAREONE BLOOD GLUCOSE TEST (glucose blood) FE CARESENS N GLUCOSE TEST (glucose blood) FE CARETOUCH TEST (glucose blood) FE cervical specimen collection NPB CHEMSTRIP K (acetone (urine) test) NPB CHEMSTRIP UGK (urine glucose-ketones test) NPB CLEVER CHEK AUTO-CODE TEST (glucose blood) FE CLEVER CHEK AUTO-CODE VOICE IN VITRO (glucose FE blood) CLEVER CHEK TEST (glucose blood) FE CLEVER CHOICE AUTO-CODE TEST (glucose blood) FE CLEVER CHOICE MICRO TEST (glucose blood) FE CLEVER CHOICE NO CODING (glucose blood) FE CLEVER CHOICE TALK SYSTEM IN VITRO (glucose FE blood) CONTOUR NEXT TEST (glucose blood) FE CONTOUR TEST (glucose blood) FE CONTROL AST (glucose blood) FE CONTROL TEST (glucose blood) FE COOL BLOOD GLUCOSE TEST STRIPS (glucose blood) FE CVS ADVANCED GLUCOSE TEST (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 91 Prescription Drug Name Drug Tier Drug Notes CVS KETONE CARE (urine glucose-ketones test) NPB CYSTOGRAFIN (diatrizoate meglumine) NPB CYSTOGRAFIN-DILUTE (diatrizoate meglumine) NPB CYSVIEW (hexaminolevulinate hcl) NPB D-CARE BLOOD GLUCOSE (glucose blood) FE DIASTIX (glucose urine test-glucose ox) NPB diathrive blood glucose test FE diathrive glucose test FE diatrue plus test FE DRIHEP ARTERIAL LINE SYRINGE KIT (arterial blood NPB gas kits) DRIHEP PLUS PREFILLED SYRINGE (arterial blood gas NPB kits) DUO-CARE TEST (glucose blood) FE d-xylose NPB easy plus blood glucose test FE easy plus ii glucose test FE EASY STEP TEST (glucose blood) FE easy talk blood glucose test FE EASY TOUCH HEALTHPRO TEST (glucose blood) FE EASY TOUCH TEST (glucose blood) FE easy trak blood glucose test FE EASYGLUCO IN VITRO (glucose blood) FE EASYGLUCO PLUS IN VITRO (glucose blood) FE EASYMAX 15 TEST (glucose blood) FE EASYMAX TEST (glucose blood) FE easyplus blood glucose test FE EASYPRO BLOOD GLUCOSE TEST (glucose blood) FE EASYPRO PLUS IN VITRO (glucose blood) FE element compact test FE ELEMENT TEST (glucose blood) FE EMBRACE BLOOD GLUCOSE TEST (glucose blood) FE EMBRACE EVO BLOOD GLUCOSE TEST (glucose blood) FE EMBRACE PRO GLUCOSE TEST (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 92 Prescription Drug Name Drug Tier Drug Notes EMBRACE TALK GLUCOSE TEST (glucose blood) FE eq blood glucose test FE EVENCARE + BLOOD GLUCOSE TEST (glucose blood) FE EVENCARE BLOOD GLUCOSE TEST (glucose blood) FE EVENCARE G2 TEST (glucose blood) FE EVENCARE G3 TEST (glucose blood) FE EVENCARE MINI GLUCOSE TEST (glucose blood) FE EVOLUTION AUTOCODE IN VITRO (glucose blood) FE EXACTECH R-S-G TEST (glucose blood) FE EXACTECH TEST (glucose blood) FE EZ SMART BLOOD GLUCOSE TEST (glucose blood) FE EZ SMART PLUS GLUCOSE TEST (glucose blood) FE E-Z-HD (barium sulfate) NPB E-Z-PAQUE (barium sulfate) NPB FIFTY50 GLUCOSE TEST 2.0 (glucose blood) FE FORA BLOOD GLUCOSE TEST (glucose blood) FE FORA D15G BLOOD GLUCOSE TEST (glucose blood) FE FORA D20 BLOOD GLUCOSE TEST (glucose blood) FE FORA D40/G31 BLOOD GLUCOSE (glucose blood) FE FORA G20 BLOOD GLUCOSE TEST (glucose blood) FE FORA G30/PREM V10 GLUCOSE TEST (glucose blood) FE FORA GD20 TEST (glucose blood) FE FORA GD50 BLOOD GLUCOSE TEST (glucose blood) FE FORA GTEL BLOOD GLUCOSE TEST (glucose blood) FE FORA GTEL BLOOD KETONE TEST (ketone blood test) NPB FORA TN'G/TN'G VOICE (glucose blood) FE FORA V10 BLOOD GLUCOSE TEST (glucose blood) FE FORA V12 BLOOD GLUCOSE TEST (glucose blood) FE FORA V20 BLOOD GLUCOSE TEST (glucose blood) FE FORA V30A BLOOD GLUCOSE TEST (glucose blood) FE FORACARE GD40 TEST (glucose blood) FE FORACARE PREMIUM V10 TEST (glucose blood) FE FORACARE TEST N GO TEST (glucose blood) FE FORTISCARE TEST (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 93 Prescription Drug Name Drug Tier Drug Notes FREESTYLE INSULINX TEST (glucose blood) FE FREESTYLE LITE TEST (glucose blood) FE FREESTYLE PRECISION NEO TEST (glucose blood) FE FREESTYLE TEST (glucose blood) FE ge100 blood glucose test FE GENSTRIP 50 (glucose blood) FE GENULTIMATE TEST (glucose blood) NPB ght test FE glass syringe 3 ml NPB glass syringe 5 ml kit NPB GLEOLAN (aminolevulinic acid hcl) NPB GLUCO PERFECT 3 TEST (glucose blood) FE GLUCOCARD 01 SENSOR PLUS (glucose blood) FE GLUCOCARD EXPRESSION TEST (glucose blood) FE GLUCOCARD SHINE TEST (glucose blood) FE GLUCOCARD VITAL TEST (glucose blood) FE GLUCOCARD X-SENSOR (glucose blood) FE GLUCOCOM TEST (glucose blood) FE GLUCONAVII BLOOD GLUCOSE TEST (glucose blood) FE glucose meter test FE gnp easy touch glucose test FE goodsense blood glucose in vitro FE HW EMBRACE PRO GLUCOSE TEST (glucose blood) FE HW EMBRACE TALK GLUCOSE TEST (glucose blood) FE IGLUCOSE TEST STRIPS (glucose blood) FE IN TOUCH BLOOD GLUCOSE TEST (glucose blood) FE INFINITY BLOOD GLUCOSE TEST (glucose blood) FE INFINITY VOICE IN VITRO STRIP (glucose blood) FE KETO-DIASTIX (urine glucose-ketones test) NPB ketone test NPB KETOSTIX (acetone (urine) test) NPB kroger blood glucose test FE kroger premium glucose test FE kroger test FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 94 Prescription Drug Name Drug Tier Drug Notes LEU TECHNELITE (technet tc 99m ) FE LIBERTY NEXT GENERATION TEST (glucose blood) FE liberty test FE LIQUID E-Z-PAQUE (barium sulfate) NPB LIQUIHEP II PREFILLED SYRINGE (arterial blood gas NPB kits) LIQUIHEP PREFILLED SYRINGE (arterial blood gas kits) NPB LITHIUM HEPARIN PREFILLED SYR (arterial blood gas NPB kits) lyophil lith hep prefilled syr NPB MACRILEN (macimorelin acetate) FE diatrizoate meglumine & sodium (Md-Gastroview) G meijer blood glucose test FE meijer essential glucose test FE meijer premium glucose test FE MEIJER TRUETEST TEST (glucose blood) FE MEIJER TRUETRACK TEST (glucose blood) FE METOPIRONE (metyrapone) NPB MICRODOT TEST (glucose blood) FE MM EASY TOUCH GLUCOSE (glucose blood) FE MYGLUCOHEALTH TEST (glucose blood) FE NEUTEK 2TEK TEST (glucose blood) FE NEXGEN TEST (glucose blood) FE NOVA MAX GLUCOSE TEST (glucose blood) FE NOVA MAX PLUS KETONE TEST (ketone blood test) NPB OMNIPAQUE ORAL (iohexol) NPB ON CALL EXPRESS BLOOD GLUCOSE (glucose blood) FE ON CALL PLUS BLOOD GLUCOSE (glucose blood) FE ON CALL VIVID BLOOD GLUCOSE (glucose blood) FE one drop test FE ONETOUCH ULTRA BLUE (glucose blood) FE ONETOUCH VERIO IN VITRO STRIP (glucose blood) FE OPTIUM TEST (glucose blood) FE OPTIUMEZ TEST (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 95 Prescription Drug Name Drug Tier Drug Notes OPTUMRX BLOOD GLUCOSE TEST (glucose blood) FE ph strips NPB PHARMACIST CHOICE AUTOCODE (glucose blood) FE pharmacist choice no coding FE POCKETCHEM EZ TEST (glucose blood) FE PRECISION PCX (glucose blood) FE PRECISION PCX PLUS TEST (glucose blood) FE PRECISION POINT OF CARE TEST (glucose blood) FE PRECISION QID TEST (glucose blood) FE PRECISION SOF-TACT TEST (glucose blood) FE PRECISION XTRA BLOOD GLUCOSE (glucose blood) FE PRECISION XTRA KETONE (ketone blood test) NPB premium blood glucose test FE pro voice v8/v9 glucose FE PRODIGY NO CODING BLOOD GLUC IN VITRO FE (glucose blood) PROVOCHOLINE (methacholine chloride) NPB PTS PANELS GLUCOSE TEST (glucose blood) FE PTS PANELS KETONE TEST (ketone blood test) NPB QUICKTEK TEST (glucose blood) FE QUINTET AC BLOOD GLUCOSE TEST (glucose blood) FE QUINTET BLOOD GLUCOSE TEST (glucose blood) FE RA TRUETEST TEST (glucose blood) FE READI-CAT 2 ORAL SUSPENSION 2 % (barium sulfate) NPB REFUAH PLUS BLOOD GLUCOSE TEST (glucose blood) FE RELION BLOOD GLUCOSE TEST (glucose blood) FE RELION CONFIRM/MICRO TEST (glucose blood) FE RELION KETONE (acetone (urine) test) NPB RELION KETONE TEST (acetone (urine) test) NPB RELION PRIME TEST (glucose blood) FE RELION ULTIMA TEST (glucose blood) FE REVEAL BLOOD GLUCOSE TEST (glucose blood) FE REXALL BLOOD GLUCOSE TEST (glucose blood) FE RIGHTEST GS100 BLOOD GLUCOSE (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 96 Prescription Drug Name Drug Tier Drug Notes RIGHTEST GS300 BLOOD GLUCOSE (glucose blood) FE RIGHTEST GS550 BLOOD GLUCOSE (glucose blood) FE SMART SENSE PREMIUM TEST (glucose blood) FE SMART SENSE VALUE TEST (glucose blood) FE SMARTEST BLOOD GLUCOSE TEST (glucose blood) FE SOLUS V2 TEST (glucose blood) FE SUPREME TEST (glucose blood) FE SURE EDGE TEST (glucose blood) FE SURECHEK BLOOD GLUCOSE TEST (glucose blood) FE SURE-TEST EASYPLUS MINI TEST (glucose blood) FE TAGITOL V (barium sulfate) NPB TECHNELITE (technet tc 99m pertechnetate) FE TELCARE BLOOD GLUCOSE TEST (glucose blood) FE tgt blood glucose test FE TOXICOLOGY MED COLLECTION SYS (drug assay NPB (urine)) true focus blood glucose strip FE TRUE METRIX BLOOD GLUCOSE TEST (glucose blood) FE TRUETEST TEST (glucose blood) FE TRUETRACK TEST (glucose blood) FE ULTIMA TEST (glucose blood) FE ULTRATRAK PRO TEST (glucose blood) FE ULTRATRAK ULTIMATE TEST (glucose blood) FE UNISTRIP1 GENERIC (glucose blood) FE VARIBAR HONEY (barium sulfate) NPB VARIBAR NECTAR (barium sulfate) NPB VARIBAR PUDDING (barium sulfate) NPB VARIBAR THIN HONEY (barium sulfate) NPB VARIBAR THIN LIQUID (barium sulfate) NPB verasens blood glucose test FE VICTORY AGM-4000 TEST (glucose blood) FE VIVAGUARD INO TEST STRIPS (glucose blood) FE VOCAL POINT BLOOD GLUCOSE TEST (glucose blood) FE WAVESENSE PRESTO (glucose blood) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 97 Prescription Drug Name Drug Tier Drug Notes *DIAGNOSTIC RADIOPHARMACEUTICALS - GASES*** xe 133 NPB *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION AMINOPMRMS (nutritional supplements) NPB APP SLIM RMS (nutritional supp - diet aids) NPB nutritional supplements (Asilnasalrms) G ASTAMED MYO (astaxanthin-tocotrienol-zn-d3) FE CAMINO PRO COMPLETE/GLYTACTIN (nutritional NPB supplements) ELFOLATE PLUS (l-methylfolate-b6-b12) FE FOSTEUM (genistein-zn chelate-vit d) FE FOSTEUM PLUS (dietary management product) FE GALAXTRA (galactose) FE GLYGEST (2-fucosyllact-lacto-n-neotetra) FE GLYTACTIN BUILD 10PE (nutritional supplements) NPB GLYTACTIN COMPLETE 10PE (nutritional supplements) NPB GLYTACTIN SWIRL 15PE (nutritional supplements) NPB HCU EASY (nutritional supplements) FE KETOVIE (nutritional supplements) NPB KETOVIE PEPTIDE (nutritional supplements) NPB LDL CARE (dietary management product) FE mebolic FE MSUD EASY (nutritional supplements) FE neoke bhb FE NICAPRIN (dietary management product) FE nicazyme FE NOURISH (nutritional supplements) NPB omnivex FE PKU EASY (nutritional supplements) FE PROMACTIN AA PLUS 20PE (nutritional supplements) FE rheumate FE ribozel FE sodium saccharin NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 98 Prescription Drug Name Drug Tier Drug Notes SULFZIX ORAL POWDER (dietary management product) FE thrivacin 30 NPB thrivacin detox NPB TOBAKIENT (dietary management product) FE TYLACTIN COMPLETE 15 PE (nutritional supplements) NPB TYR EASY (nutritional supplements) FE VASCULERA (dietary management product) FE vb6 p5p FE vp-gstn FE XAQUIL XR (levomefolate glucosamine) FE xyzbac FE zyvit FE *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH CREON (pancrelipase (lip-prot-amyl)) PB enzadyne FE PANCREAZE (pancrelipase (lip-prot-amyl)) NPB PERTZYE (pancrelipase (lip-prot-amyl)) NPB SUCRAID (sacrosidase) NPB VIOKACE (pancrelipase (lip-prot-amyl)) PB ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000- PB 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl)) *DIGITAL THERAPY*** RESET FOR ANDROID APP (digital therapy) FE RESET FOR IOS APP (digital therapy) FE RESET FOR IOS OR ANDROID APP (digital therapy) FE RESET-O FOR ANDROID APP (digital therapy) FE RESET-O FOR IOS APP (digital therapy) FE RESET-O FOR IOS OR ANDROID APP (digital therapy) FE *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD BRILINTA (ticagrelor) PB KENGREAL (cangrelor tetrasodium) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 99 Prescription Drug Name Drug Tier Drug Notes *DIURETICS* - DRUGS FOR THE HEART acetazolamide er G acetazolamide oral G ALDACTAZIDE ORAL TABLET 50-50 MG NPB (-hctz) hcl oral G amiloride-hydrochlorothiazide G LGC bumetanide oral G CAROSPIR (spironolactone) FE chlorothiazide oral G chlorthalidone oral tablet 25 mg, 50 mg G DIURIL (chlorothiazide) NPB DYRENIUM () FE ethacrynic acid oral G oral solution 10 mg/ml, 8 mg/ml G furosemide oral tablet G LGC hydrochlorothiazide oral capsule G LGC hydrochlorothiazide oral tablet 12.5 mg G hydrochlorothiazide oral tablet 25 mg, 50 mg G LGC indapamide oral G methazolamide oral G metolazone G spironolactone oral tablet 100 mg, 50 mg G spironolactone oral tablet 25 mg G LGC spironolactone-hctz G torsemide oral G triamterene oral G triamterene-hctz oral capsule 37.5-25 mg G LGC triamterene-hctz oral tablet G LGC *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR THE NERVOUS SYSTEM SUNOSI ( hcl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 100 Prescription Drug Name Drug Tier Drug Notes *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES ACTHAR (corticotropin) NPSB ALDURAZYME (laronidase) NPSB alendronate sodium G BINOSTO (alendronate sodium) NPB BRAVELLE (urofollitropin purified) FE BUPHENYL ORAL POWDER 3 GM/TSP (sodium FE phenylbutyrate) BUPHENYL ORAL TABLET (sodium phenylbutyrate) FE cabergoline G calcitonin (salmon) G calcitriol oral G CARNITOR ORAL (levocarnitine) FE CARNITOR SF (levocarnitine) FE CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix SPC (Only available for PSB acetate) select plans) cinacalcet hcl G SPC (Only available for clomiphene citrate oral G select plans) DDAVP RHINAL TUBE (desmopressin ace refrigerated) PB desmopressin ace spray refrig G desmopressin acetate oral G desmopressin acetate spray G doxercalciferol oral G EGRIFTA SUBCUTANEOUS SOLUTION NPSB RECONSTITUTED 1 MG (tesamorelin acetate) ELAPRASE (idursulfase) NPSB etidronate disodium G FABRAZYME (agalsidase beta) NPSB FOLLISTIM AQ INJECTION SOLUTION 75 UNT/0.5ML FE (follitropin beta) FOLLISTIM AQ SUBCUTANEOUS (follitropin beta) FE FORTEO SUBCUTANEOUS SOLUTION 600 SPC (Only available for PSB MCG/2.4ML (teriparatide (recombinant)) select plans) FOSAMAX PLUS D (alendronate-cholecalciferol) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 101 Prescription Drug Name Drug Tier Drug Notes GENOTROPIN (somatropin) FE GENOTROPIN MINIQUICK (somatropin) FE SPC (Only available for GONAL-F (follitropin alfa) PSB select plans) SPC (Only available for GONAL-F RFF (follitropin alfa) PSB select plans) SPC (Only available for GONAL-F RFF REDIJECT (follitropin alfa) PSB select plans) SPC (Only available for hcg FE select plans) HUMATROPE (somatropin) PSB ibandronate sodium oral G INCRELEX (mecasermin) NPSB KUVAN (sapropterin dihydrochloride) NPSB levocarnitine oral solution G levocarnitine oral tablet G LUMIZYME (alglucosidase alfa) NPSB LUPRON DEPOT-PED (1-MONTH) (leuprolide acetate) NPSB LUPRON DEPOT-PED (3-MONTH) (leuprolide acetate (3 NPSB month)) SPC (Only available for MENOPUR (menotropins) NPSB select plans) MIACALCIN (calcitonin (salmon)) FE NAGLAZYME (galsulfase) NPSB SPC (Only available for NATPARA (parathyroid hormone (recomb)) NPSB select plans) NOCDURNA (desmopressin acetate) FE NOCTIVA (desmopressin acetate) FE NORDITROPIN FLEXPRO (somatropin) FE NUTROPIN AQ NUSPIN 10 (somatropin) FE NUTROPIN AQ NUSPIN 20 (somatropin) FE NUTROPIN AQ NUSPIN 5 (somatropin) FE octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, G 200 mcg/ml, 50 mcg/ml, 500 mcg/ml OMNITROPE (somatropin) FE ORFADIN (nitisinone) PSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 102 Prescription Drug Name Drug Tier Drug Notes ORILISSA (elagolix sodium) PB OSPHENA () PB SPC (Only available for OVIDREL (choriogonadotropin alfa) PSB select plans) PALYNZIQ (pegvaliase-pqpz) FE paricalcitol oral G PARSABIV (etelcalcetide hcl) FE PROLIA SUBCUTANEOUS SOLUTION PREFILLED SPC (Only available for PSB SYRINGE (denosumab) select plans) hcl G CE RAVICTI (glycerol phenylbutyrate) FE RAYALDEE (calcifediol) NPB RECLAST (zoledronic acid) NPSB risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg G risedronate sodium oral tablet delayed release G SAIZEN (somatropin (non-refrigerated)) FE SAIZEN CLICK.EASY (somatropin (non-refrigerated)) FE SAIZENPREP (somatropin (non-refrigerated)) FE SAMSCA (tolvaptan) NPSB SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, NPSB 50 MCG/ML, 500 MCG/ML (octreotide acetate) SANDOSTATIN LAR DEPOT (octreotide acetate) FE SENSIPAR (cinacalcet hcl) PSB SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSB refrigerated)) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 40 MG, 60 MG (pasireotide NPSB pamoate) sodium phenylbutyrate oral powder 3 gm/tsp G sodium phenylbutyrate oral tablet G SOMATULINE DEPOT (lanreotide acetate) PSB SOMAVERT (pegvisomant) PSB STIMATE (desmopressin acetate) NPSB SUPPRELIN LA (histrelin acetate (cpp)) NPSB SYNAREL (nafarelin acetate) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 103 Prescription Drug Name Drug Tier Drug Notes TRIPTODUR (triptorelin pamoate) FE TYMLOS (abaloparatide) PSB SPC (Only available for XGEVA (denosumab) NPSB select plans) zoledronic acid intravenous concentrate G zoledronic acid intravenous solution 5 mg/100ml G ZOMACTON (somatropin) FE ZORBTIVE (somatropin (non-refrigerated)) NPSB *ESTROGEN COMBINATIONS*** - HORMONES bi-est 50:50 FE *ESTROGEN-ANDROGEN-PROGESTIN*** - HORMONES bi-est progest-testosterone FE *ESTROGENS* - HORMONES ALORA (estradiol) NPB estradiol-norethindrone acet (Amabelz) G ANGELIQ (drospirenone-estradiol) NPB bi-est 80:20 FE BIEST/PROGESTERONE (estradiol--progesterone) FE BIJUVA (estradiol-progesterone) FE CLIMARA PRO (estradiol-levonorgestrel) PB COMBIPATCH (estradiol-norethindrone acet) PB DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML NPB (estradiol valerate) DEPO-ESTRADIOL () NPB DIVIGEL (estradiol) PB estradiol (Dotti) G ec-rx estradiol FE ELESTRIN (estradiol) NPB estradiol oral G estradiol transdermal G estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml G estradiol-norethindrone acet G estriol-progesterone micro FE ESTROGEL (estradiol) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 104 Prescription Drug Name Drug Tier Drug Notes EVAMIST (estradiol) PB norethindrone-eth estradiol (Fyavolv) G norethindrone-eth estradiol (Jinteli) G estradiol-norethindrone acet (Lopreeza) G MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NPB () MENOSTAR (estradiol) NPB estradiol-norethindrone acet (Mimvey) G estradiol-norethindrone acet (Mimvey Lo) G MINIVELLE (estradiol) FE norethindrone-eth estradiol G PREFEST (estradiol-norgestimate) NPB PREMARIN ORAL (estrogens conjugated) PB PREMPHASE (conj estrog-medroxyprogest ace) PB PREMPRO (conj estrog-medroxyprogest ace) PB VIVELLE-DOT (estradiol) FE *ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB*** - HORMONES DUAVEE (conj estrogens-) PB *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE LIVER OCALIVA (obeticholic acid) NPSB *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS BAXDELA ORAL (delafloxacin meglumine) NPB CIPRO ORAL SUSPENSION RECONSTITUTED 250 NPB MG/5ML (5%) (ciprofloxacin) ciprofloxacin hcl oral G ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%) G levofloxacin oral G moxifloxacin hcl oral G ofloxacin oral tablet 300 mg, 400 mg G *GABA RECEPTOR MODULATOR - NEUROACTIVE STEROID*** - DRUGS FOR THE NERVOUS SYSTEM ZULRESSO (brexanolone) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 105 Prescription Drug Name Drug Tier Drug Notes *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH alosetron hcl G AMITIZA (lubiprostone) PB APRISO (mesalamine) PB ASACOL HD (mesalamine) FE AURYXIA (ferric citrate) NPB balsalazide disodium G calcium acetate (phos binder) G CHENODAL (chenodiol) NPB CIMZIA PREFILLED (certolizumab pegol) FE CIMZIA STARTER KIT (certolizumab pegol) FE CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab FE pegol) COLAZAL (balsalazide disodium) FE cromolyn sodium oral G DELZICOL (mesalamine) FE DIPENTUM (olsalazine sodium) NPB ENTEREG (alvimopan) NPB enulose G FOSRENOL ORAL PACKET (lanthanum carbonate) FE FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 FE MG, 750 MG (lanthanum carbonate) GATTEX (teduglutide (rdna)) NPSB generlac G INFLECTRA (infliximab-dyyb) FE lactulose encephalopathy G lanthanum carbonate G LIALDA (mesalamine) FE LINZESS (linaclotide) PB LOTRONEX (alosetron hcl) NPB mesalamine oral capsule delayed release G mesalamine oral tablet delayed release 1.2 gm G mesalamine oral tablet delayed release 800 mg FE mesalamine rectal G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 106 Prescription Drug Name Drug Tier Drug Notes mesalamine-cleanser G metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml G metoclopramide hcl oral tablet G metoclopramide hcl oral tablet dispersible 10 mg NPB metoclopramide hcl oral tablet dispersible 5 mg G MOVANTIK (naloxegol oxalate) PB PENTASA (mesalamine) PB PHOSLYRA (calcium acetate (phos binder)) PB RELISTOR ORAL (methylnaltrexone bromide) NPB RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, NPB 8 MG/0.4ML (methylnaltrexone bromide) REMICADE (infliximab) PSB RENFLEXIS (infliximab-abda) FE sevelamer carbonate G sevelamer hcl G SFROWASA (mesalamine) NPB sulfasalazine oral G SYMPROIC (naldemedine tosylate) PB ursodiol oral G URSODIOL+SYRSPEND SF (ursodiol) FE VELPHORO (sucroferric oxyhydroxide) PB *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER anesthesia s/i-40 FE anesthesia s/i-40a FE anesthesia s/i-40h FE anesthesia s/i-40s FE anesthesia s/i-60 FE G G G isoflurane (Terrell) G *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 107 Prescription Drug Name Drug Tier Drug Notes alfuzosin hcl er G aminoacetic acid G sodium chloride (gu irrigant) (Argyle Sterile Saline) G CARDURA XL (doxazosin mesylate) NPB sodium chloride (gu irrigant) (Curity Sterile Saline) G CYSTAGON (cysteamine bitartrate) PSB cytra k crystals G dutasteride oral G dutasteride-tamsulosin hcl G ELMIRON (pentosan polysulfate sodium) NPB finasteride oral tablet 5 mg G glycine irrigation G JALYN (dutasteride-tamsulosin hcl) FE K-PHOS NO 2 (pot & sod ac phosphates) NPB LITHOSTAT (acetohydroxamic acid) NPB neomycin-polymyxin b gu G ORACIT (sod citrate-citric acid) NPB phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) G pot & sod cit-cit ac G potassium citrate er G potassium citrate-citric acid oral solution G PROCYSBI (cysteamine bitartrate) FE RAPAFLO (silodosin) FE RENACIDIN (citric ac-gluconolact-mg carb) NPB RESECTISOL (mannitol (gu irrigant)) NPB RIMSO-50 (dimethyl sulfoxide) FE silodosin G sod citrate-citric acid G sodium chloride irrigation solution 0.9 % G sorbitol irrigation NPB sorbitol-mannitol NPB tamsulosin hcl G potassium citrate-citric acid (Taron-Crystals) G THIOLA EC (tiopronin) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 108 Prescription Drug Name Drug Tier Drug Notes tricitrates G UROXATRAL (alfuzosin hcl) FE *GLYCOPEPTIDES*** - DRUGS FOR INFECTIONS FIRVANQ (vancomycin hcl) FE vancomycin hcl oral capsule G VANCOMYCIN+SYRSPEND SF (vancomycin hcl) FE *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER allopurinol oral G oral G colchicine-probenecid G COLCRYS (colchicine) FE DUZALLO (lesinurad-allopurinol) FE febuxostat G KRYSTEXXA (pegloticase) NPSB probenecid oral G ZURAMPIC (lesinurad) FE *GROWTH HORMONE RELEASING HORMONES (GHRH) COMBINATIONS*** ghrp2-ghrp6-sermorelin FE ghrp2-sermorelin FE *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD ADVATE (antihemophilic factor rahf-pfm) NPSB adynovate PSB AFSTYLA (antihemophil fact single chain) NPSB AGGRASTAT INTRAVENOUS CONCENTRATE FE (tirofiban hcl) ALBUMINEX (albumin human-kjda) FE ALPHANATE/VWF COMPLEX/HUMAN (antihemophilic NPSB factor-vwf) ALPHANINE SD ( ) NPSB ALPROLIX (coagulation factor ix (rfixfc)) FE anagrelide hcl G aspirin-dipyridamole er G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 109 Prescription Drug Name Drug Tier Drug Notes BENEFIX INTRAVENOUS KIT (coagulation factor ix NPSB (recomb)) BERINERT (c1 esterase inhibitor (human)) FE BRILINTA (ticagrelor) PB cilostazol G CINRYZE (c1 esterase inhibitor (human)) NPSB clopidogrel bisulfate oral G COAGADEX (coagulation (human)) NPSB dipyridamole oral G ELOCTATE (antihemophilic factor rfviiifc) FE FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant NPSB cmplx) FIRAZYR (icatibant acetate) NPSB HAEGARDA (c1 esterase inhibitor (human)) NPSB HELIXATE FS (antihemophilic factor (recomb)) FE HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 NPSB UNIT (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- NPSB 1200 UNIT (antihemophilic factor-vwf) icatibant acetate G IDELVION (coagulation factor ix (rix-fp)) NPSB IXINITY (coagulation factor ix (recomb)) NPSB JIVI (antihemoph fact rcmb peg-aucl) PSB KENGREAL (cangrelor tetrasodium) FE KOATE (antihemophilic factor) NPSB KOATE-DVI (antihemophilic factor) NPSB KOGENATE FS (antihemophilic factor (recomb)) PSB KOVALTRY (antihemophilic factor (recomb)) PSB MONONINE INTRAVENOUS SOLUTION NPSB RECONSTITUTED 1000 UNIT (coagulation factor ix) NOVOEIGHT (antihemophilic factor (recomb)) PSB NOVOSEVEN RT (coagulation factor viia recomb) NPSB NUWIQ (antihemophil fact (bdd-rfviii)) PSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 110 Prescription Drug Name Drug Tier Drug Notes obizur FE pentoxifylline er G PLAVIX (clopidogrel bisulfate) FE prasugrel hcl G PROFILNINE (factor ix complex) NPSB REBINYN (coagulation factor ix glycopeg) PSB RECOMBINATE (antihemophilic factor (recomb)) NPSB RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 FE UNIT (reteplase) RETAVASE INTRAVENOUS KIT 2 X 10 UNIT (reteplase) FE rixubis NPSB RUCONEST (c1 esterase inhibitor (recomb)) PSB SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML NPSB (eculizumab) ULTOMIRIS (ravulizumab-cwvz) FE VONVENDI (von willebrand factor (recomb)) FE WILATE INTRAVENOUS KIT (antihemophilic factor-vwf) NPSB XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, NPSB 250 UNIT, 500 UNIT (antihemophilic factor rahf-paf) XYNTHA SOLOFUSE (antihemophilic factor rahf-paf) NPSB YOSPRALA (aspirin-omeprazole) FE *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION cyanocobalamin-methylcobalamin (Abaneu-Sl) G active fe NPB folic acid-vit b6-vit b12 (Airavite) G ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSB 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PSB PREFILLED SYRINGE (darbepoetin alfa) axifol FE b-6 folic acid NPB bp vit 3 NPB CENFOL (folic acid-vit b6-vit b12) NPB CERDELGA (eliglustat tartrate) PSB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 111 Prescription Drug Name Drug Tier Drug Notes CEREZYME INTRAVENOUS SOLUTION PSB RECONSTITUTED 400 UNIT (imiglucerase) iron-folic acid-c-b6-b12-zinc (Corvita 150) G CORVITE 150 ORAL TABLET (iron combinations) NPB corvite fe NPB cvs folic acid oral tablet 800 mcg G CE cyanocobalamin injection solution 1000 mcg/ml G CYFOLEX (folic acid-d3-ca carb-collagen) FE DOPTELET ORAL TABLET 20 MG ( FE maleate) DROXIA (hydroxyurea) NPB ELELYSO (taliglucerase alfa) FE EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 FE UNIT/ML (epoetin alfa) FA-8 (folic acid) G CE fabb G fa-vitamin b-6-vitamin b-12 G FERIVA 21/7 (feasp-b12-fa-c-dss-succac-zn) FE ferocon G ferotrinsic G ferraplus 90 NPB fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet) G FERRO-PLEX HEMATINIC (fe fum-dss-c-e-b12-if-fa) NPB FERROTRIN (iron-b12-vit c-fa-ifc) NPB folbee G folic acid injection G folic acid oral capsule 0.8 mg G CE folic acid oral tablet 1 mg G CE FOLI-D (folic acid-cholecalciferol) FE folika-d FE folite FE FOLIVANE-F (fe fum-fepoly-fa-vit c-vit b3) NPB FOLIVANE-PLUS (fefum-fepoly-fa-b cmp-c-biot) NPB folplex 2.2 G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 112 Prescription Drug Name Drug Tier Drug Notes foltrin G folic acid-cholecalciferol (Folvite-D) G FULPHILA (pegfilgrastim-jmdb) FE FUSION PLUS (iron-fa-b cmp-c-biot-probiotic) NPB FUSION SPRINKLES (fefum-fepoly-fa-c-probiotic) FE GENICIN VITA-D (folic acid-cholecalciferol) FE GRANIX (tbo-filgrastim) FE hematinic plus vit/minerals G hematinic/folic acid G HEMOCYTE PLUS (fe fum-fa-b cmp-c-zn-mg-mn-cu) NPB ferrous fumarate-folic acid (Hemocyte-F Oral Tablet) G hemocyte-plus oral tablet 106-1 mg G hydroxocobalamin acetate G ICAR-C PLUS (iron-vit c-vit b12-folic acid) FE iron polysacch cmplx-b12-fa (Iferex 150 Forte) G INTEGRA F (fe fum-fepoly-fa-vit c-vit b3) NPB INTEGRA PLUS (fefum-fepoly-fa-b cmp-c-biot) NPB IS 24/6 (fe-succ ac-b cmplx-c-ca-fa) NPB fefum-fepo-fa-b cmp-c-zn-mn-cu (K-Tan Plus) G LEUKINE INJECTION SOLUTION RECONSTITUTED NPSB (sargramostim) miglustat G MIRCERA INJECTION SOLUTION PREFILLED FE SYRINGE (methoxy peg-epoetin beta) MULPLETA () PSB MULTIGEN (fe-succ-c-thre-b12-des stomach) NPB MULTIGEN FOLIC (fe asp gly-succ-c-thre-b12-fa) NPB MULTIGEN PLUS (feasp-fefum -suc-c-thre-b12-fa) NPB NASCOBAL (cyanocobalamin) NPB NEULASTA ONPRO (pegfilgrastim) PSB NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE (pegfilgrastim) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 FE MCG/1.6ML (filgrastim)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 113 Prescription Drug Name Drug Tier Drug Notes NEUPOGEN INJECTION SOLUTION PREFILLED FE SYRINGE (filgrastim) NIVESTYM (filgrastim-aafi) PSB noxifol-d FE NPLATE () NPSB NUFERA (iron combinations) NPB folic acid-vit b6-vit b12 (Nufol) G ortho d FE ortho df FE ortho-folic FE poly-iron 150 forte G polysaccharide iron forte G PROCRIT (epoetin alfa) FE PROMACTA ( olamine) NPSB RETACRIT (epoetin alfa-epbx) PSB revesta FE roxifol-d FE SIKLOS (hydroxyurea) NPB sm folic acid G CE TALIVA (fa-b6-b12-omega 3-) FE taron forte NPB tl gard rx G tl icon G tl-hem 150 G fe fumarate-b12-vit c-fa-ifc (Tricon) G TRIFERIC (ferric pyrophosphate citrate) FE trigels-f forte G UDENYCA (pegfilgrastim-cbqv) PSB virt-fefa plus FE folic acid-vit b6-vit b12 (Virt-Gard) G VITAMEZ (fa-b6-b12-omega 3-phytosterols) NPB VPRIV (velaglucerase alfa) NPSB yl folic acid G CE ZARXIO (filgrastim-sndz) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 114 Prescription Drug Name Drug Tier Drug Notes zavara FE ZAVESCA (miglustat) NPB *HEMOSTATICS* - DRUGS FOR THE BLOOD AMICAR ORAL SOLUTION () FE aminocaproic acid oral tablet G ARTISS EXTERNAL SOLUTION (fibrin sealant component) NPB GEL-FLOW (gelatin absorb-) FE GELFOAM-JMI POWDER (gelatin absorb-thrombin) FE GELFOAM-JMI SPONGE (gelatin absorb-thrombin) FE RAPLIXA (-thrombin) FE RECOTHROM EXTERNAL SOLUTION NPB RECONSTITUTED 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT (thrombin (recombinant)) NPB THROMBIN-JMI (thrombin) NPB THROMBIN-JMI EPISTAXIS (thrombin) NPB THROMBOGEN (thrombin) NPB TISSEEL (fibrin sealant component) NPB oral G *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR INFECTIONS IBC (Preferred for all EPCLUSA (sofosbuvir-velpatasvir) PSB genotypes) IBC (Preferred for HARVONI (ledipasvir-sofosbuvir) PSB genotypes 1,4,5,6) ledipasvir-sofosbuvir FE MAVYRET (glecaprevir-pibrentasvir) FE sofosbuvir-velpatasvir FE TECHNIVIE (ombitasvir-paritaprev-ritonav) FE VIEKIRA PAK (ombitas-paritapre-ritona-dasab) FE VIEKIRA XR (ombitas-paritapre-ritona-dasab) FE IBC (Preferred for all VOSEVI (sofosbuv-velpatasv-voxilaprev) PSB genotypes) ZEPATIER (elbasvir-grazoprevir) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 115 Prescription Drug Name Drug Tier Drug Notes *HYPNOTIC COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM mko melt dose pack FE *HYPNOTICS* - DRUGS FOR THE NERVOUS SYSTEM BUTISOL SODIUM ORAL TABLET 30 MG (butabarbital NPB sodium) EDLUAR (zolpidem tartrate) NPB estazolam G eszopiclone G hcl G INTERMEZZO (zolpidem tartrate) FE LUNESTA (eszopiclone) FE midazolam hcl oral G MIDAZOLAM+SYRSPEND SF (midazolam) FE phenobarbital oral elixir G phenobarbital oral tablet G quazepam G ramelteon G ROZEREM (ramelteon) FE SECONAL (secobarbital sodium) NPB SILENOR (doxepin hcl) PB temazepam G triazolam G zaleplon G zolpidem tartrate G zolpidem tartrate er G ZOLPIMIST (zolpidem tartrate) FE *IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS*** - DRUGS FOR THE STOMACH ZELNORM (tegaserod maleate) FE *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** - DRUGS FOR THE STOMACH VIBERZI (eluxadoline) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 116 Prescription Drug Name Drug Tier Drug Notes *IMPOTENCE AGENT COMBINATIONS*** - DRUGS FOR THE URINARY SYSTEM SPC (Only available for bi-mix FE select plans) IFE-BIMIX 30/1 (papaverine-phentolamine) FE quad-mix FE SPC (Only available for super bi-mix FE select plans) SPC (Only available for super quad-mix FE select plans) SPC (Only available for super tri-mix FE select plans) tri-mix FE *IN VITRO/LOCK ANTICOAGULANTS*** - DRUGS FOR THE BLOOD acd formula a NPB ACD-A NOCLOT-50 (anticoagulant cit dext soln a) NPB anticoagulant cit dext soln a NPB ANTICOAGULANT COMPOUND (anticoag cit phos dex NPB soln) anticoagulant sodium citrate NPB TRICITRASOL (anticoagulant sodium citrate) NPB *INSULIN-INCRETIN MIMETIC COMBINATIONS*** - HORMONES SOLIQUA (insulin glargine-lixisenatide) PB XULTOPHY (insulin degludec-liraglutide) PB *INTEGRIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH ENTYVIO (vedolizumab) FE *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR THE STOMACH STELARA INTRAVENOUS (ustekinumab) FE *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR THE LUNGS FASENRA (benralizumab) PSB NUCALA (mepolizumab) PSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 117 Prescription Drug Name Drug Tier Drug Notes *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR THE LUNGS CINQAIR (reslizumab) FE *INTERLEUKIN-6 (IL-6) ANTAGONISTS*** - DRUGS FOR CANCER SYLVANT (siltuximab) NPB *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER IDHIFA (enasidenib mesylate) NPSB *LAXATIVES* - DRUGS FOR THE STOMACH ALOPHEN (bisacodyl) G CE bisacodyl ec G CE bisacodyl rectal G CE cascara sagrada oral fluid extract NPB CLENPIQ (sod picosulfate-mag ox-cit acd) NPB CE constulose G correct G CE CORRECTOL (bisacodyl) G CE cvs c-lax laxative G CE ducodyl G CE eq womens laxative G CE eql gentle laxative G CE eql laxative oral tablet delayed release G CE FEENAMINT (bisacodyl) G CE peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-C) G CE peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G) G CE bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H) G CE peg 3350-kcl-na bicarb-nacl (Gavilyte-N With Flavor Pack) G CE gentle laxative oral G CE GIALAX (polyethylene glycol 3350) FE GNP BISA-LAX ORAL (bisacodyl) G CE gnp gentle laxative G CE gnp laxative rectal G CE gnp womens gentle laxative G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 118 Prescription Drug Name Drug Tier Drug Notes GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 NPB CE GM (peg 3350-kcl-nabcb-nacl-nasulf) hm laxative G CE kp bisacodyl G CE KRISTALOSE (lactulose) NPB lactulose oral packet FE lactulose oral solution G laxative oral tablet delayed release G CE laxative rectal G CE mineral oil heavy oral G MOVIPREP (peg-kcl-nacl-nasulf-na asc-c) FE CE OSMOPREP (sod phos mono-sod phos dibasic) FE CE PCP 100 (mgcit-bisacod-pet-peg-metoclop) FE peg 3350/electrolytes G CE peg 3350-kcl-na bicarb-nacl G CE peg-3350/electrolytes G CE bisacodyl-peg-kcl-nabicar-nacl (Peg-Prep) G CE PLENVU (peg-kcl-nacl-nasulf-na asc-c) FE POLY-PREP (bisacodyl-peg 3350-lido-hc) FE PREPOPIK (sod picosulfate-mag ox-cit acd) NPB CE qc gentle laxative G CE ra fast relief laxative G CE ra laxative oral tablet delayed release G CE ra stimulant laxative G CE sb bisacodyl laxative ec G CE sb laxative G CE sm gentle laxative G CE sm laxative rectal G CE stimulant laxative G CE SUPREP BOWEL PREP KIT (na sulfate-k sulfate-mg sulf) PB CE THE MAGIC BULLET (bisacodyl) G CE peg 3350-kcl-na bicarb-nacl (Trilyte) G CE veracolate G CE womans laxative oral tablet delayed release G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 119 Prescription Drug Name Drug Tier Drug Notes *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** - HORMONES LUPANETA PACK (leuprolide & norethindrone) NPSB *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER bl injection FE buffered lidocaine FE d-care 100x FE lidocaine in dextrose NPB MLD (lidocaine-bupivacaine-dextrose) FE p-care 100mx FE p-care m FE READYSHARP-A (lidocaine hcl-bupivacaine hcl) FE reck FE *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - DRUGS FOR THE EYE XIIDRA (lifitegrast) PB *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR METABOLIC DISEASE KANUMA (sebelipase alfa) NPSB *MACROLIDES* - DRUGS FOR INFECTIONS azithromycin oral packet G azithromycin oral suspension reconstituted G azithromycin oral tablet 250 mg, 500 mg, 600 mg G clarithromycin er G clarithromycin oral G DIFICID (fidaxomicin) PB E.E.S. 400 ORAL TABLET (erythromycin ethylsuccinate) G E.E.S. GRANULES (erythromycin ethylsuccinate) FE ERYPED 200 (erythromycin ethylsuccinate) FE ERYPED 400 (erythromycin ethylsuccinate) FE erythromycin base (Ery-Tab) G ERYTHROCIN STEARATE ORAL TABLET 250 MG G (erythromycin stearate) erythromycin base oral capsule delayed release particles G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 120 Prescription Drug Name Drug Tier Drug Notes erythromycin base oral tablet G erythromycin ethylsuccinate oral G erythromycin oral G *MEDICAL DEVICES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1st tier unifine pentips FE 1st tier unifine pentips plus FE 1st tier unilet comfortouch PB ACCU-CHEK AVIVA (blood glucose monitoring suppl) PB ACCU-CHEK AVIVA CONNECT (blood glucose monitoring PB suppl) ACCU-CHEK AVIVA PLUS (blood glucose monitoring suppl) PB ACCU-CHEK COMPACT PLUS CARE (blood glucose PB monitoring suppl) ACCU-CHEK FASTCLIX LANCET (lancets misc.) NPB ACCU-CHEK FASTCLIX LANCETS (lancets) PB ACCU-CHEK FLEXLINK PLUS 10MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 6MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 8MM (insulin infusion NPB pump supplies) ACCU-CHEK GUIDE (blood glucose monitoring suppl) PB ACCU-CHEK GUIDE ME (blood glucose monitoring suppl) PB ACCU-CHEK LINKASSIST (insulin pump accessories) NPB ACCU-CHEK MULTICLIX LANCET DEV (lancets misc.) NPB ACCU-CHEK MULTICLIX LANCETS (lancets) PB ACCU-CHEK NANO SMARTVIEW (blood glucose PB monitoring suppl) ACCU-CHEK PLASTIC CARTRIDGE (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D INFUSION SET (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D LINK (insulin NPB supplies) ACCU-CHEK SAFE-T PRO LANCETS (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 121 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK SOFT TOUCH LANCETS (lancets) PB ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets NPB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) PB ACCU-CHEK SPIRIT BATTERY KIT (insulin pump NPB accessories) ACCU-CHEK TENDER II SET 24" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 31" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 43" (insulin infusion pump NPB supplies) ACCU-CHEK ULTRAFLEX INF SET (insulin infusion NPB pump supplies) ACCU-CHEK ULTRAFLEX-1 INF SET (insulin infusion NPB pump supplies) acti-lance 28g PB acti-lance lite lancets 28g PB acti-lance special lancets 17g PB acti-lance universal 23g PB adjustable lancing device NPB ADVANCE INTUITION METER (blood glucose monitoring FE suppl) ADVANCE INTUITION MONITOR (blood glucose FE monitoring suppl) ADVANCE MICRO-DRAW METER (blood glucose FE monitoring suppl) ADVOCATE ARM BPM (blood monitoring) FE ADVOCATE BLOOD GLUCOSE MONITOR (blood FE glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) ADVOCATE DUO (blood glucose-bp monitor) NPB ADVOCATE INSULIN PEN NEEDLES (insulin pen needle) FE ADVOCATE INSULIN SYRINGE (insulin syringe-needle u- FE 100) ADVOCATE LANCETS 30G (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 122 Prescription Drug Name Drug Tier Drug Notes ADVOCATE LANCING DEVICE (lancet devices) NPB ADVOCATE RAPID-SAFE LANCING (lancet devices) NPB ADVOCATE REDI-CODE (blood glucose monitoring suppl) FE ADVOCATE REDI-CODE+ (blood glucose monitoring suppl) FE ADVOCATE REDI-CODE+ TALKING (blood glucose FE monitoring suppl) ADVOCATE SAFETY LANCETS (lancets) PB ADVOCATE SAFETY LANCETS 26G (lancets) PB AGAMATRIX AMP (blood glucose monitoring suppl) FE AGAMATRIX JAZZ WIRELESS 2 (blood glucose FE monitoring suppl) AGAMATRIX PRESTO (blood glucose monitoring suppl) FE AGAMATRIX PRESTO PRO METER (blood glucose FE monitoring suppl) AGAMATRIX ULTRA-THIN LANCETS (lancets) PB aimsco twist lancets 32g PB AIMSCO TWIST LANCETS 33G (lancets) PB ALCOH-GLOVE CONTOURED WIPE (alcohol swabs) NPB alcohol pads NPB alcohol prep NPB alcohol swabs pad NPB ALCOHOL SWABSTICK PAD 70 % (alcohol swabs) NPB alcohol wipes pad 70 % NPB alcoh-wipe NPB alternate site lancing device NPB AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6" NPB (gauze pads & dressings) anti-stick insulin syringe FE APLICARE ALCOHOL SWABSTICK (alcohol swabs) NPB AQUALANCE LANCETS 30G (lancets) PB ASSURE 3 METER (blood glucose monitoring suppl) FE ASSURE 4 METER (blood glucose monitoring suppl) FE assure comfort lancets 28g PB ASSURE ID INSULIN SAFETY SYR (insulin syringe-needle FE u-100)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 123 Prescription Drug Name Drug Tier Drug Notes ASSURE ID SAFETY PEN NEEDLES (insulin pen needle) FE ASSURE LANCETS (lancets) PB ASSURE PLATINUM METER (blood glucose monitoring FE suppl) ASSURE PRO BLOOD GLUCOSE METER (blood glucose FE monitoring suppl) AT LAST BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) aurora lancet super thin 30g PB aurora lancet thin 23g PB aurora pen needles FE aurora unifine pentips FE AUTO-LANCET (lancet devices) NPB AUTO-LANCET MINI (lancet devices) NPB AUTOLET II CLINISAFE (lancets misc.) NPB AUTOLET LITE CLINISAFE (lancets misc.) NPB AUTOLET LITE STARTER PACK (lancets misc.) NPB AUTOLET MINI (lancet devices) NPB AUTOLET PLATFORMS (lancets misc.) PB AUTOLET PLUS (lancet devices) NPB AUTOSOFT 30 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT 90 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT XC INFUSION SET (insulin infusion pump NPB supplies) BAYER BREEZE 2 SYSTEM (blood glucose monitoring FE suppl) BAYER CONTOUR LINK 2.4 (blood glucose monitoring FE suppl) BAYER CONTOUR LINK MONITOR (blood glucose FE monitoring suppl) BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD AUTOSHIELD DUO (insulin pen needle) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 124 Prescription Drug Name Drug Tier Drug Notes BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G PB X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100) BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin PB (disposable)) BD INSULIN SYRINGE U-500 (insulin syringe/needle u-500) PB BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 PB ML (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) PB BD LANCET ULTRAFINE 33G (lancets) PB BD LATITUDE DIABETES (blood glucose monitoring suppl) FE BD LATITUDE DIABETES SYSTEM (blood glucose FE monitoring suppl) BD LOGIC BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) BD MICROTAINER LANCETS (lancets) PB BD PEN NEEDLE MICRO U/F (insulin pen needle) PB BD PEN NEEDLE MINI U/F (insulin pen needle) PB BD PEN NEEDLE NANO 2ND GEN (insulin pen needle) PB BD PEN NEEDLE NANO U/F (insulin pen needle) PB BD PEN NEEDLE ORIGINAL U/F (insulin pen needle) PB BD PEN NEEDLE SHORT U/F (insulin pen needle) PB BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 PB ML, 31G X 15/64" 0.3 ML (insulin syringe-needle u-100) BD SWAB SINGLE USE REGULAR (alcohol swabs) NPB BD SWABS SINGLE USE BUTTERFLY (alcohol swabs) NPB BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BIOFREQUENCY INSOLES (foot care products) NPB BIOGUARD GAUZE SPONGES (gauze pads & dressings) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 125 Prescription Drug Name Drug Tier Drug Notes BIOGUARD ISLAND DRESSINGS (gauze pads & NPB dressings) BIOGUARD NON-ADHERENT DRESSING (gauze pads & NPB dressings) BIOTEL CARE BLOOD GLUCOSE SYST (blood glucose FE monitoring suppl) blood glucose monitor system FE blood glucose system pak FE bullseye mini safety lancets PB BULLSEYE SAFETY LANCETS (lancets) PB CARDIOCOM LANCING DEVICE (lancet devices) NPB CAREFINE PEN NEEDLES (insulin pen needle) FE careone advanced lancing dev NPB CAREONE BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) careone insulin syringe FE careone lancet thin 23g PB careone lancet ultra thin 28g PB careone unifine pentips FE careone unifine pentips plus FE CARESENS N GLUCOSE SYSTEM (blood glucose FE monitoring suppl) CARESENS N VOICE SYSTEM (blood glucose monitoring FE suppl) CARETOUCH ALCOHOL PREP (alcohol swabs) NPB CARETOUCH INSULIN SYRINGE (insulin syringe-needle FE u-100) CARETOUCH LANCING/EJECTOR (lancet devices) NPB CARETOUCH MONITOR SYSTEM (blood glucose FE monitoring suppl) CARETOUCH PEN NEEDLES (insulin pen needle) FE CARETOUCH SAFETY LANCETS 26G (lancets) PB CARETOUCH TWIST LANCETS 28G (lancets) PB CARETOUCH TWIST LANCETS 30G (lancets) PB CARETOUCH TWIST LANCETS 33G (lancets) PB cartridge ir 1000 3ml NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 126 Prescription Drug Name Drug Tier Drug Notes cartridge ir 1200 NPB cartridge pump NPB CAYA (diaphragm arc-spring) NPB CE CGMS REPLACEMENT CABLE (continuous glucose NPB monitor sup) CGMS SOFTWARE (continuous glucose monitor sup) NPB CHOICE DM DIABETES RISK TEST (blood glucose FE monitoring suppl) CLEANLET LANCETS 28G (lancets) PB CLEO 90 INFUSION SET 24"/6MM (insulin infusion pump NPB supplies) CLEO 90 INFUSION SET 24"/9MM (insulin infusion pump NPB supplies) CLEO 90 INFUSION SET 31"/6MM (insulin infusion pump NPB supplies) CLEO 90 INFUSION SET 31"/9MM (insulin infusion pump NPB supplies) CLEVER CHEK AUTO-CODE (blood glucose-bp monitor) NPB CLEVER CHEK AUTO-CODE SYSTEM (blood glucose FE monitoring suppl) CLEVER CHEK AUTO-CODE VOICE (blood glucose FE monitoring suppl) CLEVER CHEK LANCETS (lancets) PB CLEVER CHEK SYSTEM (blood glucose monitoring suppl) FE CLEVER CHOICE AUTO-CODE SYSTEM (blood glucose FE monitoring suppl) CLEVER CHOICE COMFORT EZ (insulin pen needle) FE CLEVER CHOICE LANCETS 21G (lancets) PB CLEVER CHOICE LANCETS 23G (lancets) PB CLEVER CHOICE LANCETS 28G (lancets) PB CLEVER CHOICE MICRO SYSTEM (blood glucose FE monitoring suppl) CLEVER CHOICE MINI SYSTEM (blood glucose FE monitoring suppl) CLEVER CHOICE TALK SYSTEM (blood glucose FE monitoring suppl)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 127 Prescription Drug Name Drug Tier Drug Notes CLICKFINE PEN NEEDLES 31G X 5 MM (insulin pen FE needle) clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm FE COAGUCHEK LANCETS (lancets) PB COMFORT ASSIST INSULIN SYRINGE (insulin syringe- FE needle u-100) comfort assured lancets 28g PB comfort assured lancets 33g PB COMFORT EZ INSULIN SYRINGE (insulin syringe-needle FE u-100) COMFORT EZ MICRO PEN NEEDLES (insulin pen needle) FE COMFORT EZ PEN NEEDLES (insulin pen needle) FE COMFORT EZ SHORT PEN NEEDLES (insulin pen needle) FE COMFORT INFUSION SET 23"/17MM (insulin infusion NPB pump supplies) COMFORT INFUSION SET 31"/17MM (insulin infusion NPB pump supplies) COMFORT INFUSION SET 32"/17MM (insulin infusion NPB pump supplies) COMFORT INFUSION SET 43"/17MM (insulin infusion NPB pump supplies) comfort lancets PB COMFORT SHORT INF SET 23"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 31"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 32"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 43"/13MM (insulin infusion NPB pump supplies) CONTACT DETACH INF SET 23"/8MM (insulin infusion NPB pump supplies) CONTACT DETACH INF SET 32"/6MM (insulin infusion NPB pump supplies) CONTACT DETACH INF SET 32"/8MM (insulin infusion NPB pump supplies)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 128 Prescription Drug Name Drug Tier Drug Notes CONTACT DETACH INF SET 43" 6MM (insulin infusion NPB pump supplies) CONTACT DETACH INF SET 43" 8MM (insulin infusion NPB pump supplies) CONTOUR MONITOR (blood glucose monitoring suppl) FE CONTOUR NEXT EZ (blood glucose monitoring suppl) FE CONTOUR NEXT LINK (blood glucose monitoring suppl) FE CONTOUR NEXT MONITOR (blood glucose monitoring FE suppl) CONTOUR NEXT ONE (blood glucose monitoring suppl) FE CONTROL BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) COOL MONITOR (blood glucose monitoring suppl) FE COOL MONITOR KIT (blood glucose monitoring suppl) FE CURITY ALCOHOL PREPS (alcohol swabs) NPB CURITY ALCOHOL SWABS (alcohol swabs) NPB CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4" NPB (gauze pads & dressings) CURITY AMD ANTIMICROBIAL STRIP (gauze pads & NPB dressings) CURITY IODOFORM PACKING STRIP (gauze pads & NPB dressings) CURITY WOUND CLOSURE 1/2"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X1.5" (adhesive NPB bandages) CURITY WOUND CLOSURE 1/4"X3" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/8"X3" (adhesive bandages) NPB CVS BLOOD GLUCOSE METER (blood glucose monitoring FE suppl) cvs lancets 21g PB cvs lancets micro thin 33g PB cvs lancets original PB cvs lancets thin 26g PB cvs lancets ultra thin 30g PB cvs lancets ultra-thin 30g PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 129 Prescription Drug Name Drug Tier Drug Notes cvs lancing device NPB cvs prep NPB cvs ultra thin lancets PB D-CARE GLUCOMETER (blood glucose monitoring suppl) FE DELTEC COZMO CLEO SET 42" 6MM (insulin infusion NPB pump supplies) DELTEC COZMO CLEO SET 42" 9MM (insulin infusion NPB pump supplies) DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G6 RECEIVER (continuous blood gluc receiver) PB DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DEXCOM RECEIVER KIT (continuous blood gluc receiver) PB diathrive blood glucose meter FE diathrive lancet ultra thin 30 PB diathrive lancets PB diathrive lancing device NPB diatrue plus blood glucose FE DROPLET INSULIN SYRINGE (insulin syringe-needle u- FE 100) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 130 Prescription Drug Name Drug Tier Drug Notes DROPLET LANCETS ULTRA THIN 30G (lancets) PB DROPLET LANCING DEVICE (lancet devices) NPB DROPLET PEN NEEDLES (insulin pen needle) FE dropsafe safety pen needles FE drug mart lancets thin 26g PB DRUG MART ON-THE-GO LANCET 30G (lancets) PB drug mart unifine pentips FE drug mart unifine pentips plus FE easy comfort alcohol pads NPB easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x FE 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml easy comfort lancets PB easy comfort lancets twist top PB easy comfort pen needles FE easy glide pen needles FE easy mini eject lancing device NPB easy mini lancing device NPB easy plus blood glucose system FE easy plus ii glucose system FE EASY STEP GLUCOSE MONITOR (blood glucose FE monitoring suppl) easy talk blood glucose system FE EASY TOUCH ALCOHOL PREP MEDIUM (alcohol swabs) NPB EASY TOUCH FLIPLOCK INSULIN SY (insulin syringe- FE needle u-100) EASY TOUCH GLUCOSE SYSTEM (blood glucose FE monitoring suppl) EASY TOUCH HEALTHPRO SYSTEM (blood glucose FE monitoring suppl) EASY TOUCH INSULIN SAFETY SYR (insulin syringe- FE needle u-100) EASY TOUCH INSULIN SYRINGE (insulin syringe-needle FE u-100) EASY TOUCH LANCETS 21G (lancets) PB EASY TOUCH LANCETS 23G (lancets) PB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 131 Prescription Drug Name Drug Tier Drug Notes EASY TOUCH LANCETS 26G/TWIST (lancets) PB EASY TOUCH LANCETS 28G (lancets) PB EASY TOUCH LANCETS 30G (lancets) PB EASY TOUCH LANCETS 32G (lancets) PB EASY TOUCH LANCETS 33G/TWIST (lancets) PB EASY TOUCH LANCING DEVICE (lancet devices) NPB EASY TOUCH PEN NEEDLES (insulin pen needle) FE EASY TOUCH SAFETY PEN NEEDLES (insulin pen FE needle) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML FE (insulin syringe-needle u-100) easy trak blood glucose system FE EASYGLUCO (blood glucose monitoring suppl) FE EASYGLUCO PLUS (blood glucose monitoring suppl) FE EASYGLUCO PLUS STARTER (blood glucose monitoring FE suppl) EASYMAX L BLOOD GLUCOSE (blood glucose monitoring FE suppl) EASYMAX N BLOOD GLUCOSE (blood glucose monitoring FE suppl) EASYMAX NG BLOOD GLUCOSE (blood glucose FE monitoring suppl) EASYMAX V BLOOD GLUCOSE (blood glucose monitoring FE suppl) EASYMAX V2 BLOOD GLUCOSE (blood glucose FE monitoring suppl) easyplus r13n blood glucose FE easyplus v blood glucose FE EASYPRO BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) EASYPRO PLUS (blood glucose monitoring suppl) FE ELEMENT AUTOCODE SYSTEM (blood glucose FE monitoring suppl) element compact glucose system FE element compact v glucose sys FE ELEMENT PLUS (blood glucose monitoring suppl) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 132 Prescription Drug Name Drug Tier Drug Notes elite-thin insulin syringe FE EMBRACE BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) EMBRACE EVO GLUCOSE MONITORING (blood glucose FE monitoring suppl) EMBRACE LANCETS ULTRA THIN 30G (lancets) PB EMBRACE PRO GLUCOSE METER (blood glucose FE monitoring suppl) EMBRACE TALK BLOOD GLUCOSE (blood glucose FE monitoring suppl) EMBRACE TALK MONITORING SYSTEM (blood glucose FE monitoring suppl) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) FE ENLITE SERTER (insulin infusion pump supplies) NPB eql alcohol swabs NPB eql color lancets 21g PB eql color lancets micro 33g PB eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 FE ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml eql super thin lancets 30g PB eql thin lancets 26g PB EROS-CTD (clitoral vacuum device) NPB EVENCARE G2 MONITOR (blood glucose monitoring suppl) FE EVENCARE G3 MONITOR (blood glucose monitoring suppl) FE EVENCARE GLUCOSE MONITORING (blood glucose FE monitoring suppl) EVENCARE MINI MONITOR (blood glucose monitoring FE suppl) EVERSENSE SENSOR/HOLDER (continuous blood gluc NPB sensor) EVERSENSE SMART TRANSMITTER (continuous blood NPB gluc transmit) EVOLUTION AUTOCODE (blood glucose monitoring suppl) FE EXCILON AMD DRAIN SPONGES (gauze pads & NPB dressings)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 133 Prescription Drug Name Drug Tier Drug Notes EXEL COMFORT POINT INSULIN SYR (insulin syringe- FE needle u-100) EXEL COMFORT POINT PEN NEEDLE (insulin pen FE needle) E-Z JECT LANCET MICRO-THIN 33G (lancets) PB E-Z JECT LANCET SUPER THIN 30G (lancets) PB E-Z JECT LANCETS (lancets) PB E-Z JECT LANCETS 21G (lancets) PB E-Z JECT LANCETS THIN 26G (lancets) PB EZ SMART BLOOD GLUCOSE LANCETS (lancets) PB EZ SMART MONITORING SYSTEM (blood glucose FE monitoring suppl) EZ SMART PLUS MONITORING SYS (blood glucose FE monitoring suppl) EZ-LETS LANCETS 21G (lancets) PB EZ-LETS LANCETS 23G (lancets) PB EZ-LETS LANCETS 26G (lancets) PB EZ-LETS LANCETS 28G (lancets) PB EZ-LETS LANCETS 30G (lancets) PB FC FEMALE CONDOM (condoms - female) NPB CE FC2 FEMALE CONDOM (condoms - female) NPB CE FEMCAP (cervical caps) NPB CE FIFTY50 GLUCOSE METER 2.0 (blood glucose monitoring FE suppl) FIFTY50 PEN NEEDLES (insulin pen needle) FE FIFTY50 SUPERIOR COMFORT SYR (insulin syringe- FE needle u-100) FIFTY50 UNILET LANCETS 33G (lancets) PB FINGERSTIX LANCETS (lancets) PB FORA D10 2-IN-1 MONITOR (blood glucose-bp monitor) NPB FORA D15G 2-IN-1 MONITOR (blood glucose-bp monitor) NPB FORA D20 2-IN-1 MONITOR (blood glucose-bp monitor) NPB FORA D40 GLUCOSE/PRESSURE (blood glucose-bp FE monitor) FORA D40G GLUCOSE/PRESSURE (blood glucose-bp FE monitor) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 134 Prescription Drug Name Drug Tier Drug Notes FORA G20 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA G30A BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA GD20 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA GD50 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA GTEL BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA LANCETS (lancets) PB FORA LANCING DEVICE (lancet devices) NPB FORA PREMIUM V10 BLE SYSTEM (blood glucose FE monitoring suppl) FORA TEST N' GO MONITOR (blood glucose monitoring FE suppl) FORA TN'G VOICE (blood glucose monitoring suppl) FE FORA V10 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA V10/V12/D10/D20 TEST (blood glucose monitoring FE suppl) FORA V12 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA V20 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) FORACARE GD40 MONITOR (blood glucose monitoring FE suppl) FORACARE PREMIUM V10 (blood glucose monitoring FE suppl) FORACARE TEST N GO MONITOR (blood glucose FE monitoring suppl) FORTISCARE GLUCOSE SYSTEM (blood glucose FE monitoring suppl) freds pharmacy autolet lancing NPB freds pharmacy unifine pentip+ FE freds pharmacy unifine pentips FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 135 Prescription Drug Name Drug Tier Drug Notes FREESTYLE FLASH SYSTEM (blood glucose monitoring FE suppl) FREESTYLE FREEDOM (blood glucose monitoring suppl) FE FREESTYLE FREEDOM LITE (blood glucose monitoring FE suppl) FREESTYLE INSULINX SYSTEM (blood glucose FE monitoring suppl) FREESTYLE LIBRE 14 DAY READER (continuous blood FE gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood FE gluc sensor) FREESTYLE LIBRE READER (continuous blood gluc FE receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood FE gluc sensor) FREESTYLE LITE (blood glucose monitoring suppl) FE FREESTYLE PRECISION INS SYR (insulin syringe-needle FE u-100) FREESTYLE PRECISION NEO SYSTEM (blood glucose FE monitoring suppl) FREESTYLE SIDEKICK II (blood glucose monitoring suppl) FE FREESTYLE SYSTEM (blood glucose monitoring suppl) FE FREESTYLE UNISTICK II LANCETS (lancets) PB GAMMACORE (nerve stimulator) FE GAMMACORE SAPPHIRE 31-DAY (nerve stimulator) FE GAMMACORE SAPPHIRE REFILL KIT (nerve stimulator) FE ge100 blood glucose system FE GENTEEL BUTTERFLY TOUCH LANCET (lancets) PB GENTEEL CONTACT TIPS (BLUE) (lancets misc.) PB GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) PB GENTEEL CONTACT TIPS (GREEN) (lancets misc.) PB GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) PB GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) PB GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) PB GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) PB GENTEEL LANCING DEVICE (BLACK) (lancet devices) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 136 Prescription Drug Name Drug Tier Drug Notes GENTEEL LANCING DEVICE (BLUE) (lancet devices) NPB GENTEEL LANCING DEVICE (GOLD) (lancet devices) NPB GENTEEL LANCING DEVICE (PINK) (lancet devices) NPB GENTEEL LANCING DEVICE (WHITE) (lancet devices) NPB GENTEEL LANCING DEVICE(PLATNM) (lancet devices) NPB GENTEEL LANCING DEVICE(PURPLE) (lancet devices) NPB GENTEEL LANCING DEVICE(SILVER) (lancet devices) NPB GENTEEL LANCING KIT (BLUE) (lancets misc.) NPB GENTEEL NOZZLES (lancets misc.) PB GENTLE-LET GP LANCETS (lancets) PB GENTLE-LET LANCETS (lancets) PB GENTLE-LET PLATFORMS (lancets misc.) PB ght blood glucose monitor FE global alcohol prep ease NPB global ease inject pen needles FE global easy glide insulin syr FE global easy glide pen needles FE global inject ease insulin syr FE global inject ease lancets 28g PB global inject ease lancets 30g PB global insulin syringes FE global lancing device NPB GLUCO PERFECT 3 METER (blood glucose monitoring FE suppl) GLUCOCARD 01 BLOOD GLUCOSE (blood glucose FE monitoring suppl) GLUCOCARD 01-MINI GLUCOSE (blood glucose FE monitoring suppl) GLUCOCARD EXPRESSION MONITOR (blood glucose FE monitoring suppl) GLUCOCARD SHINE CONNEX (blood glucose monitoring FE suppl) GLUCOCARD SHINE EXPRESS (blood glucose monitoring FE suppl) GLUCOCARD SHINE XL (blood glucose monitoring suppl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 137 Prescription Drug Name Drug Tier Drug Notes GLUCOCARD VITAL MONITOR (blood glucose FE monitoring suppl) GLUCOCARD X-METER (blood glucose monitoring suppl) FE GLUCOCOM BLOOD GLUCOSE MONITOR (blood FE glucose monitoring suppl) GLUCOCOM LANCETS 28G (lancets) PB GLUCOCOM LANCETS 30G (lancets) PB GLUCOCOM LANCETS 33G (lancets) PB GLUCOCOM MONITOR (blood glucose monitoring suppl) FE GLUCONAVII BLOOD GLUCOSE SYS (blood glucose FE monitoring suppl) GLUCOPRO INSULIN SYRINGE (insulin syringe-needle u- FE 100) GLUCOPRO SYR RES 3ML 22GX3/8" (insulin infusion NPB pump supplies) gnp alcohol swabs pad 70 % NPB gnp clickfine pen needles FE GNP EASY TOUCH GLUCOSE METER (blood glucose FE monitoring suppl) gnp insulin syringe FE gnp lancets PB gnp lancets 21g PB gnp lancets micro thin 33g PB gnp lancets thin PB gnp lancets thin 26g PB gnp micro thin lancets 33g PB gnp super thin lancets 30g PB gnp ultra com insulin syringe FE goodsense blood glucose FE goodsense clickfine pen needle FE goodsense lancets 26g univ PB goodsense lancets 30g univ PB goodsense lancets 33g NPB goodsense lancets 33g univ PB goodsense lancing device NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 138 Prescription Drug Name Drug Tier Drug Notes GOODSENSE PEN NEEDLE PENFINE (insulin pen needle) FE GUARDIAN CONNECT TRANSMITTER (continuous FE blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NPB gluc transmit) GUARDIAN REAL-TIME CHARGER (continuous glucose NPB monitor sup) GUARDIAN REAL-TIME REPLACE PED (continuous NPB blood gluc receiver) GUARDIAN REAL-TIME REPLACEMENT (continuous NPB blood gluc receiver) GUARDIAN REAL-TIME STARTER (continuous glucose NPB monitor) GUARDIAN REAL-TIME SYSTEM (continuous glucose NPB monitor) GUARDIAN REAL-TIME SYSTEM PED (continuous NPB glucose monitor) GUARDIAN REAL-TIME TEST PLUG (continuous glucose NPB monitor sup) GUARDIAN RT SOFTWARE (continuous glucose monitor NPB sup) GUARDIAN RT STARTER (continuous glucose monitor) NPB GUARDIAN SENSOR (3) (continuous blood gluc sensor) FE GUARDIAN TRANSMITTER (continuous blood gluc NPB transmit) HEALTH CARE LANCING DEVICE (lancet devices) NPB healthwise insulin syr/needle FE healthwise micron pen needles FE healthwise mini pen needles FE healthwise pen needles FE healthwise short pen needles FE healthwise unifine pentips FE healthy accents lancing device NPB healthy accents unifine pentip FE healthy accents unilet lancets PB h-e-b incontrol adv lancing NPB h-e-b incontrol alcohol NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 139 Prescription Drug Name Drug Tier Drug Notes h-e-b incontrol lancets 28g PB h-e-b incontrol lancets 30g PB h-e-b incontrol lancets 33g PB h-e-b incontrol pen needles FE H-E-B INCONTROL UNIFINE PENTIP (insulin pen needle) FE HM EMBRACE TALK SYSTEM (blood glucose monitoring FE suppl) hm sterile alcohol prep NPB HM ULTICARE INSULIN SYRINGE (insulin syringe- FE needle u-100) HM ULTICARE SHORT PEN NEEDLES (insulin pen FE needle) HW EMBRACE PRO GLUCOSE METER (blood glucose FE monitoring suppl) HW EMBRACE TALK BLOOD GLUCOSE (blood glucose FE monitoring suppl) HY-VEE LANCETS (lancets) PB hy-vee thin lancets PB IBG STAR BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) IGLUCOSE MONITORING SYSTEM (blood glucose FE monitoring suppl) IN TOUCH DEVICE (blood glucose monitoring suppl) FE IN TOUCH LANCING DEVICE (lancet devices) NPB IN TOUCH STERILE LANCETS 30G (lancets) PB INFINITY BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) INFINITY VOICE (blood glucose monitoring suppl) FE infusion catheter soft 23" NPB infusion catheter soft 31" NPB infusion catheter soft 43" NPB INPEN 100-BLUE-LILLY (injection device for insulin) NPB INPEN 100-BLUE-NOVO (injection device for insulin) NPB INPEN 100-GRAY-LILLY (injection device for insulin) NPB INPEN 100-GREY-NOVO (injection device for insulin) NPB INPEN 100-PINK-LILLY (injection device for insulin) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 140 Prescription Drug Name Drug Tier Drug Notes INPEN 100-PINK-NOVO (injection device for insulin) NPB INSET 30 INFUSION SET 23" (insulin infusion pump NPB supplies) INSET INFUSION SET 23" 9MM (insulin infusion pump NPB supplies) INSET INFUSION SET 43" 9MM (insulin infusion pump NPB supplies) insulin cartridge 3ml NPB insulin syringe FE insulin syringe/needle FE insulin syringe-needle u-100 FE insupen pen needles FE INSUPEN SENSITIVE (insulin pen needle) FE INSUPEN ULTRAFIN (insulin pen needle) FE KERLIX AMD ANTIMICROBIAL (gauze pads & dressings) NPB KERLIX AMD SUPER SPONGES (gauze pads & dressings) NPB kinney lancets PB kinney thin lancets PB kinray insulin syringe FE kmart valu insulin syringe 29g FE kmart valu insulin syringe 30g FE kroger blood glucose FE kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 FE ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger lancets PB kroger lancets super thin PB kroger lancets thin PB kroger pen needles FE kroger premium blood glucose FE lancet device NPB lancet device with ejector NPB lancet transporter case PB lancets PB lancets micro thin 33g PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 141 Prescription Drug Name Drug Tier Drug Notes lancets thin PB LANCETS ULTRA FINE (lancets) PB lancets ultra thin 30g PB lancing device NPB LANZO (lancet devices) NPB ldr blood glucose truetest FE leader insulin syringe FE LEADER UNIFINE PENTIPS (insulin pen needle) FE LEADER UNIFINE PENTIPS PLUS (insulin pen needle) FE liberty blood glucose meter FE liberty blood glucose monitor FE LIBERTY NXT GENERATION MONITOR (blood glucose FE monitoring suppl) LIFESCAN UNISTIK 2 (lancets) PB LIFESCAN UNISTIK II LANCETS (lancets) PB lite touch lancets PB LITE TOUCH LANCING PEN (lancet devices) NPB LITETOUCH INSULIN SYRINGE (insulin syringe-needle u- FE 100) LITETOUCH LANCETS (lancets) PB LITETOUCH PEN NEEDLES (insulin pen needle) FE live better adv lancing device NPB live better lancet ultra thin PB longs insulin syringe 31g x 5/16" 0.5 ml FE longs lancets standard PB longs lancets thin PB longs lancets ultra thin PB MAGELLAN INSULIN SAFETY SYR (insulin syringe- FE needle u-100) MARATHON MEDICAL PENTIPS (insulin pen needle) FE MAXICOMFORT II PEN NEEDLE (insulin pen needle) FE MAXI-COMFORT INSULIN SYRINGE (insulin syringe- FE needle u-100) MAXI-COMFORT SAFETY PEN NEEDLE (insulin pen FE needle)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 142 Prescription Drug Name Drug Tier Drug Notes MAXICOMFORT SYR 27G X 1/2" (insulin syringe-needle u- FE 100) medic insulin syringe FE medichoice safety lancet extra PB medicine shoppe pen needles FE MEDISENSE THIN LANCETS (lancets) PB MEDLANCE PLUS EXTRA 21G (lancets) PB MEDLANCE PLUS LANCETS (lancets) PB MEDLANCE PLUS LITE 25G (lancets) PB MEDLANCE PLUS SPECIAL 0.8MM (lancets) PB MEDLANCE PLUS SUPERLITE 30G (lancets) PB MEDLANCE PLUS UNIVERSAL 21G (lancets) PB meijer blood glucose FE meijer essential blood glucose FE MEIJER LANCETS THIN (lancets) PB MEIJER LANCETS UNIVERSAL 21G (lancets) PB MEIJER LANCETS UNIVERSAL 30G (lancets) PB MEIJER LANCETS UNIVERSAL 33G (lancets) PB meijer pen needles FE meijer premium blood glucose FE MEIJER SUPER THIN LANCETS (lancets) PB MEIJER TRUE2GO BLOOD GLUCOSE (blood glucose FE monitoring suppl) MEIJER TRUERESULT GLUCOSE SYS (blood glucose FE monitoring suppl) MEIJER TRUETRACK GLUCOSE SYS (blood glucose FE monitoring suppl) MI (dentifrices) NPB MI PASTE PLUS (dentifrices) NPB MICRODOT BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) MICROLET LANCETS (lancets) PB MICROLET NEXT LANCING DEVICE (lancet devices) NPB MICROTAINER SAFETY FLOW LANCET (lancets) PB mini lancing device NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 143 Prescription Drug Name Drug Tier Drug Notes MINILINK REAL-TIME REPLACEMENT (insulin pump NPB accessories) MINILINK REAL-TIME TRANSMITTER (insulin pump FE accessories) MINILINK-REAL-TIME STARTER (insulin pump NPB accessories) MINIMED 630G GUARDIAN PRESS (insulin pump NPB accessories) MINIMED GUARDIAN LINK 3 (insulin pump accessories) FE MINIMED GUARDIAN SENSOR 3 (continuous blood gluc FE sensor) MINIMED PRO-SET INFUSION 24" (insulin infusion pump NPB supplies) MINIMED PRO-SET INFUSION 42" (insulin infusion pump NPB supplies) MINIMED PUMP RESERVOIR 3ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 1.8ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 3ML (insulin infusion pump NPB supplies) MIO INFUSION SET 18" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 23" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 9MM (insulin infusion pump NPB supplies) MM EASY TOUCH GLUCOSE METER (blood glucose FE monitoring suppl) mm insulin syringe/needle FE MM PEN NEEDLES (insulin pen needle) FE MONOJECT INSULIN SYRINGE (insulin syringe-needle u- FE 100) MONOJECT ULTRA COMFORT SYRINGE (insulin FE syringe-needle u-100) MONOLET LANCETS (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 144 Prescription Drug Name Drug Tier Drug Notes MONOLET OPD LANCETS (lancets) PB MONOLETTOR SAFETY LANCETS (lancets) PB MOORE MONO INSULIN SYRINGE (insulin syringe- FE needle u-100) mpd safety lancet 21g PB mpd safety lancet 23g PB mpd safety lancet 28g PB mpd safety lancet 30g PB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x FE 5/16" 1 ml MULTI-LANCET DEVICE 2 (lancets misc.) NPB MYGLUCOHEALTH BLOOD GLUCOSE (blood glucose FE monitoring suppl) MYGLUCOHEALTH LANCETS 30G (lancets) PB NEUTEK 2TEK GLUCOSE/PRESSURE (blood glucose-bp NPB monitor) NEXGEN METER (blood glucose monitoring suppl) FE NORDIPEN 5 INJECTION DEVICE (injection device) FE NORDIPEN DELIVERY SYSTEM (injection device) FE NOVA MAX BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) NOVA SAFETY LANCETS 23G (lancets) PB NOVA SAFETY LANCETS 28G (lancets) PB NOVA SUREFLEX LANCETS (lancets) PB NOVA SUREFLEX LANCING DEVICE (lancet devices) NPB NOVOFINE (insulin pen needle) FE NOVOFINE AUTOCOVER (insulin pen needle) FE NOVOFINE PLUS (insulin pen needle) FE NOVOPEN ECHO (injection device for insulin) NPB NOVOTWIST 32G X 5 MM (insulin pen needle) FE OMNIFLEX DIAPHRAGM (diaphragms) NPB CE OMNIPOD DASH 5 PACK (insulin disposable pump) PB OMNIPOD STARTER (insulin disposable pump) PB OMNITROPE PEN 10 INJ DEVICE (injection device) FE OMNITROPE PEN 5 INJ DEVICE (injection device) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 145 Prescription Drug Name Drug Tier Drug Notes ON CALL EXPRESS GLUCOSE METER (blood glucose FE monitoring suppl) ON CALL EXPRESS MONITORING SYS (blood glucose FE monitoring suppl) ON CALL LANCETS (lancets) PB ON CALL LANCING DEVICE (lancet devices) NPB ON CALL PLUS LANCETS (lancets) PB ON CALL PLUS LANCING DEVICE (lancet devices) NPB ON CALL PLUS METER (blood glucose monitoring suppl) FE ON CALL PLUS MONITORING SYSTEM (blood glucose FE monitoring suppl) ON CALL VIVID GLUCOSE METER (blood glucose FE monitoring suppl) ON CALL VIVID METER (blood glucose monitoring suppl) FE ON CALL VIVID MONITORING (blood glucose monitoring FE suppl) ON CALL VIVID PAL METER (blood glucose monitoring FE suppl) one drop blood glucose monitor FE ONETOUCH CLUB LANCETS FINE PT (lancets) PB ONETOUCH COMBO PACK (lancets) PB ONETOUCH DELICA LANCETS 33G (lancets) PB ONETOUCH DELICA LANCETS FINE (lancets) PB ONETOUCH DELICA LANCING DEV (lancet devices) NPB ONETOUCH DELICA PLUS LANCET30G (lancets) PB ONETOUCH DELICA PLUS LANCET33G (lancets) PB ONETOUCH DELICA PLUS LANCING (lancet devices) NPB ONETOUCH SURESOFT LANCING DEV (lancets misc.) NPB ONETOUCH ULTRA 2 (blood glucose monitoring suppl) FE ONETOUCH ULTRA MINI (blood glucose monitoring suppl) FE ONETOUCH ULTRALINK (blood glucose monitoring suppl) FE ONETOUCH ULTRASOFT LANCETS (lancets) PB ONETOUCH VERIO (blood glucose monitoring suppl) FE ONETOUCH VERIO FLEX SYSTEM (blood glucose FE monitoring suppl)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 146 Prescription Drug Name Drug Tier Drug Notes ONETOUCH VERIO IQ SYSTEM (blood glucose monitoring FE suppl) ONETOUCH VERIO SYNC SYSTEM (blood glucose FE monitoring suppl) OPTIUM BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) OPTIUM GLUCOSE MONITOR SYSTEM (blood glucose FE monitoring suppl) OPTUMRX BLOOD GLUCOSE METER (blood glucose FE monitoring suppl) OPTUMRX BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) PARADIGM LINK GLUCOSE MONITOR (blood glucose FE monitoring suppl) PARADIGM PATHWAY UPGRADE (insulin pump NPB accessories) PARADIGM POLYFIN QR/WINGS 24" (insulin infusion NPB pump supplies) PARADIGM POLYFIN QR/WINGS 42" (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 1.8ML (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 3ML (insulin infusion NPB pump supplies) PARADIGM QUICK-SET 18" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 9MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 9MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 43" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 43" 9MM (insulin infusion pump NPB supplies)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 147 Prescription Drug Name Drug Tier Drug Notes PARADIGM REAL-TIME STARTER (continuous glucose NPB monitor) PARADIGM REAL-TIME TRANSMITTER (insulin pump NPB accessories) PARADIGM SILHOUETTE 18" 13MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE 32" 17MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE COMBO 23" (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE FULL 23" (insulin infusion NPB pump supplies) PARADIGM SOF-SET MICRO QR 24" (insulin infusion NPB pump supplies) PARADIGM SOF-SET MICRO QR 42" (insulin infusion NPB pump supplies) PARADIGM SURE-T 23" 6MM (insulin infusion pump NPB supplies) PARADIGM SURE-T 23" 8MM (insulin infusion pump NPB supplies) pc lancets super thin 30g PB pc unifine pentips FE pen needles FE pen needles 1/2" FE pen needles 3/16" FE pen needles 5/16" FE PENLET II BLOOD SAMPLER (lancets misc.) NPB PENLET II REPLACEMENT CAP (lancets misc.) PB PENTIPS (insulin pen needle) FE PERFECT LANCETS 28G (lancets) PB PERFECT LANCETS 30G (lancets) PB PHARMACIST CHOICE AUTOCODE SYS (blood glucose FE monitoring suppl) PHARMACIST CHOICE LANCETS (lancets) PB PHARMACIST CHOICE MINI SYSTEM (blood glucose FE monitoring suppl) PHARMACY COUNTER LANCETS (lancets) PB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 148 Prescription Drug Name Drug Tier Drug Notes pip lancets 28g PB pip lancets 30g PB POCKETCHEM EZ SYSTEM (blood glucose monitoring FE suppl) POLYFIN INFUSION SET 24" (insulin infusion pump NPB supplies) POLYFIN INFUSION SET 42" (insulin infusion pump NPB supplies) POLYFIN QR INFUSION SET 42" (insulin infusion pump NPB supplies) POLYFIN TUBING SET 60" (insulin infusion pump supplies) NPB PRECISION LINK (blood glucose monitoring suppl) FE PRECISION QID MONITOR (blood glucose monitoring FE suppl) PRECISION SOF-TACT MONITOR (blood glucose FE monitoring suppl) PRECISION SUREDOSE PLUS SYR (insulin syringe-needle FE u-100) PRECISION SURE-DOSE SYRINGE (insulin syringe-needle FE u-100) PRECISION XTRA (blood glucose monitoring suppl) FE PRECISION XTRA MONITOR (blood glucose monitoring FE suppl) preferred plus insulin syringe FE preferred plus lancets colored PB preferred plus lancets thin PB preferred plus unifine pentips FE pressure activat safety lancet PB PREVENT SAFETY PEN NEEDLES (insulin pen needle) FE pro comfort alcohol NPB PRO COMFORT INSULIN SYRINGE (insulin syringe- FE needle u-100) pro comfort lancets 30g PB pro comfort lancets 31g PB pro comfort pen needles FE pro voice v8 glucose system FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 149 Prescription Drug Name Drug Tier Drug Notes pro voice v9 glucose system FE PRODIGY AUTOCODE BLOOD GLUCOSE (blood glucose FE monitoring suppl) PRODIGY INSULIN SYRINGE (insulin syringe-needle u- FE 100) PRODIGY LANCETS 28G (lancets) PB PRODIGY LANCING DEVICE (lancet devices) NPB PRODIGY POCKET BLOOD GLUCOSE KIT (blood FE glucose monitoring suppl) PRODIGY SAFETY LANCETS 26G (lancets) PB PRODIGY VOICE BLOOD GLUCOSE (blood glucose FE monitoring suppl) PSS SELECT GP LANCETS (lancets) PB PSS SELECT PLATFORMS (lancets misc.) PB PSS SELECT SAFETY LANCETS (lancets) PB push button safety lancets PB push button safety lancets 28g PB px extra short pen needles FE px insulin syringe FE px lancet auto injector NPB px lancets ultra thin PB px mini pen needles FE px pen needle FE px shortlength pen needles FE qc advanced lancing device NPB qc alcohol swabs NPB qc lancets super thin 30g PB qc lancets ultra thin PB qc pen needles FE qc unifine pentips FE qc unilet lancets 28g PB qc unilet lancets micro thin PB QUICKTEK (blood glucose monitoring suppl) FE QUICKTEK/METER (blood glucose monitoring suppl) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 150 Prescription Drug Name Drug Tier Drug Notes QUINTET AC BLOOD GLUCOSE (blood glucose FE monitoring suppl) QUINTET BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) ra alcohol swabs NPB ra blood glucose monitor FE RA E-ZJECT COLOR LANCETS 33G (lancets) PB RA E-ZJECT LANCETS 28G (lancets) PB RA E-ZJECT LANCETS THIN 26G (lancets) PB RA E-ZJECT LANCETS THIN 28G (lancets) PB RA E-ZJECT LANCETS ULTRA THIN (lancets) PB ra insulin syringe FE ra pen needles FE RA TRUE2GO BLOOD GLUCOSE (blood glucose FE monitoring suppl) RA TRUERESULT BLOOD GLUCOSE (blood glucose FE monitoring suppl) RAPPORT RLS (impotence aid device) NPB RAPPORT VTD (impotence aid device) NPB READYLANCE SAFETY LANCETS (lancets) PB reality insulin syringe FE reality lancets PB reality swabs NPB reality trigger lancets PB REFUAH PLUS MONITORING SYSTEM (blood glucose FE monitoring suppl) RELION ALL-IN-ONE (blood gluc meter disp-strips) FE RELION CONFIRM GLUCOSE MONITOR (blood glucose FE monitoring suppl) RELI-ON INSULIN SYRINGE (insulin syringe-needle u-100) FE RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G FE X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) RELION INSULIN SYRINGE 31G X 15/64" 0.5 ML (insulin PB syringe-needle u-100) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 151 Prescription Drug Name Drug Tier Drug Notes RELION LANCET DEVICES 30G (lancet devices) NPB RELION LANCETS MICRO-THIN 33G (lancets) PB RELION LANCETS STANDARD 21G (lancets) PB RELION LANCETS THIN 26G (lancets) PB RELION LANCETS ULTRA-THIN 30G (lancets) PB RELION LANCING DEVICE (lancets misc.) NPB RELION MICRO (blood glucose monitoring suppl) FE RELION MINI PEN NEEDLES (insulin pen needle) FE RELION PEN NEEDLES (insulin pen needle) FE RELION PREMIER BLU MONITOR (blood glucose FE monitoring suppl) RELION PREMIER COMPACT SYSTEM (blood glucose FE monitoring suppl) RELION PREMIER VOICE MONITOR (blood glucose FE monitoring suppl) RELION PRIME MONITOR (blood glucose monitoring FE suppl) RELION SHORT PEN NEEDLES (insulin pen needle) FE RELION ULTIMA GLUCOSE SYSTEM (blood glucose FE monitoring suppl) RELION ULTRA THIN LANCETS 30G (lancets) PB RELION ULTRA THIN PLUS LANCETS (lancets) PB REMESENSE (dental desensitizing product) NPB REVEAL BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) REXALL BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) PB RIGHTEST GD500 LANCING DEVICE (lancet devices) NPB RIGHTEST GL300 LANCETS (lancets) PB RIGHTEST GM100 BLOOD GLUCOSE (blood glucose FE monitoring suppl) RIGHTEST GM300 BLOOD GLUCOSE (blood glucose FE monitoring suppl) RIGHTEST GM550 BLOOD GLUCOSE (blood glucose FE monitoring suppl)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 152 Prescription Drug Name Drug Tier Drug Notes RIGHTSOURCE BLOOD GLUCOSE (blood glucose FE monitoring suppl) SAFESNAP INSULIN SYRINGE (insulin syringe-needle u- FE 100) SAFE-T-LANCE (lancets) PB SAFE-T-LANCE PLUS (lancets) PB safety insulin syringes FE SAFETY LET LANCETS (lancets) PB SAFETY SEAL LANCETS (lancets) PB saps care alcohol prep NPB saps health care alcohol prep NPB saps health twist top lancets NPB saps twist top lancets PB sapscare twist top lancets PB sb alcohol prep NPB sb insulin syringe FE sb lancets thin PB sb lancets ultra thin PB schnucks insulin syringe FE select-lite lancing device NPB SHOPKO ALCOHOL SWABS (alcohol swabs) NPB SHOPKO AUTOLET LANCING DEVICE (lancet devices) NPB SHOPKO UNIFINE PENTIPS (insulin pen needle) FE SHOPKO UNIFINE PENTIPS PLUS (insulin pen needle) FE side button safety lancet PB SIDEKICK BLOOD GLUCOSE SYSTEM (blood gluc meter NPB disp-strips) SILHOUETTE 13MM (insulin infusion pump supplies) NPB SILHOUETTE 17MM (insulin infusion pump supplies) NPB SILHOUETTE INFUSION SET 23" (insulin infusion pump NPB supplies) SILHOUETTE INFUSION SET 43" (insulin infusion pump NPB supplies) SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NPB SINGLE-LET (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 153 Prescription Drug Name Drug Tier Drug Notes sm alcohol prep pad 70 % NPB sm insulin syringe 31g x 5/16" 1 ml FE sm lancets 33g PB SM TRUEDRAW LANCING DEVICE (lancet devices) NPB SMART DIABETES VANTAGE LANCING (lancet devices) NPB SMART SENSE COLOR LANCETS 33G (lancets) PB SMART SENSE PREMIUM SYSTEM (blood glucose FE monitoring suppl) SMART SENSE STANDARD LANCETS (lancets) PB SMART SENSE SUPER THIN LANCETS (lancets) PB SMART SENSE THIN LANCETS 26G (lancets) PB SMART SENSE VALUE GLUCOSE SYS (blood glucose FE monitoring suppl) SMARTEST EJECT (blood glucose monitoring suppl) FE SMARTEST EJECT STARTER (blood glucose monitoring FE suppl) SMARTEST LANCETS 28G (lancets) PB SMARTEST PERSONA STARTER (blood glucose FE monitoring suppl) SMARTEST PRONTO STARTER (blood glucose monitoring FE suppl) SMARTEST PROTEGE (blood glucose monitoring suppl) FE SMARTEST PROTEGE STARTER (blood glucose FE monitoring suppl) SOF-SENSOR (continuous blood gluc sensor) NPB SOF-SET INFUSION SET 24" (insulin infusion pump supplies) NPB SOF-SET INFUSION SET 42" (insulin infusion pump supplies) NPB SOF-SET MICRO QR INFUSION 24" (insulin infusion pump NPB supplies) SOF-SET MICRO QR INFUSION 42" (insulin infusion pump NPB supplies) SOF-SET ULTIMATE QR 24" (insulin infusion pump NPB supplies) SOF-SET ULTIMATE QR 42" (insulin infusion pump NPB supplies) SOLUS V2 BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 154 Prescription Drug Name Drug Tier Drug Notes SOLUS V2 LANCETS 28G (lancets) PB SOLUS V2 LANCING DEVICE (lancet devices) NPB SOLUS V2 TWIST LANCETS 30G (lancets) PB STERILANCE PA (lancets misc.) PB STERILANCE TL (lancets) PB sure comfort alcohol prep NPB sure comfort insulin syringe FE sure comfort lancets 18g PB sure comfort lancets 21g PB sure comfort lancets 23g PB sure comfort lancets 30g PB sure comfort lancing pen NPB sure comfort pen needles FE SURE EDGE GLUCOSE MONITOR (blood glucose FE monitoring suppl) SURECHEK BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) SURE-FINE PEN NEEDLES (insulin pen needle) FE SURE-JECT INSULIN SYRINGE (insulin syringe-needle u- FE 100) SURE-LANCE FLAT LANCETS (lancets) PB SURE-LANCE LANCETS 26G (lancets) PB SURELITE LANCETS (lancets) PB SURE-PEN (lancet devices) NPB SURE-T INFUSION SET 18" (subcutaneous infusion set) NPB SURE-T INFUSION SET 23" (subcutaneous infusion set) NPB SURE-T INFUSION SET 32" (subcutaneous infusion set) NPB SURE-T INFUSION SET 6MM (subcutaneous infusion set) NPB SURE-T INFUSION SET 8MM (subcutaneous infusion set) NPB SURE-TEST EASYPLUS MINI METER (blood glucose FE monitoring suppl) SURE-TOUCH LANCETS UNIVERSAL (lancets) PB T:30 INFUSION SET (insulin infusion pump supplies) NPB T:90 INFUSION SET (insulin infusion pump supplies) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 155 Prescription Drug Name Drug Tier Drug Notes T:FLEX INSULIN CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) T:FLEX T:LOCK CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) T:SLIM G4 INSULIN CARTRIDGE (insulin infusion pump NPB supplies) T:SLIM INSULIN CARTRIDGE 3ML (insulin infusion pump NPB supplies) T:SLIM T:LOCK INSULIN CART 3ML (insulin infusion NPB pump supplies) techlite insulin syringe FE TECHLITE PEN NEEDLES (insulin pen needle) FE TELCARE BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) TELFA AMD ISLAND DRESSING (gauze pads & dressings) NPB TELFA AMD NON-ADHERENT (gauze pads & dressings) NPB tgt blood glucose monitoring FE tgt lancet micro thin 33g PB tgt lancet thin 26g PB tgt lancet ultra thin 30g PB tgt lancing device NPB THINLETS GP LANCETS (lancets) PB todays health mini pen needles FE todays health pen needles FE todays health short pen needle FE topcare clickfine pen needles FE topcare lancets micro-thin 33g PB topcare ultra comfort ins syr FE topco insulin syringe FE travel lancets PB TRAVEL LANCETS ADVANCED 28G (lancets) PB true comfort insulin syringe FE true comfort pen needles FE true comfort twist top lancets PB TRUE FOCUS BLOOD GLUCOSE METER (blood glucose FE monitoring suppl) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 156 Prescription Drug Name Drug Tier Drug Notes TRUE METRIX AIR GLUCOSE METER (blood glucose FE monitoring suppl) TRUE METRIX GO GLUCOSE METER (blood glucose FE monitoring suppl) TRUE METRIX METER (blood glucose monitoring suppl) FE TRUE2GO BLOOD GLUCOSE MONITOR (blood glucose FE monitoring suppl) TRUEDRAW LANCING DEVICE (lancet devices) NPB TRUEPLUS 5-BEVEL PEN NEEDLES (insulin pen needle) FE TRUEPLUS INSULIN SYRINGE (insulin syringe-needle u- FE 100) TRUEPLUS LANCETS 26G (lancets) PB TRUEPLUS LANCETS 28G (lancets) PB TRUEPLUS LANCETS 30G (lancets) PB TRUEPLUS LANCETS 33G (lancets) PB TRUEPLUS PEN NEEDLES (insulin pen needle) FE TRUEPLUS SAFETY LANCETS 28G (lancets) PB TRUERESULT BLOOD GLUCOSE (blood glucose FE monitoring suppl) TRUETRACK BLOOD GLUCOSE (blood glucose FE monitoring suppl) TRUETRACK SMART SYSTEM (blood glucose monitoring FE suppl) TRUSTEEL INFUSION SET (insulin infusion pump supplies) NPB ULTICARE ALCOHOL SWABS PAD (alcohol swabs) NPB ULTICARE INSULIN SAFETY SYR (insulin syringe-needle FE u-100) ULTICARE INSULIN SYRINGE (insulin syringe-needle u- FE 100) ULTICARE MICRO PEN NEEDLES (insulin pen needle) FE ULTICARE MINI PEN NEEDLES (insulin pen needle) FE ULTICARE PEN NEEDLES (insulin pen needle) FE ULTICARE SHORT PEN NEEDLES (insulin pen needle) FE ULTI-LANCE AUTOMATIC (lancet devices) NPB ultilet alcohol swabs NPB ULTILET CLASSIC LANCETS (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 157 Prescription Drug Name Drug Tier Drug Notes ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G FE X 5/16" 0.3 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) ULTILET INSULIN SYRINGE SHORT (insulin syringe- FE needle u-100) ULTILET LANCETS (lancets) PB ULTILET PEN NEEDLE (insulin pen needle) FE ULTILET SAFETY LANCETS (lancets) PB ULTILET SAFETY LANCETS 23G (lancets) PB ULTIMA (blood glucose monitoring suppl) FE ultra comfort insulin syringe 30g x 5/16" 0.3 ml FE ultra thin lancets 31g PB ULTRA THIN PEN NEEDLES (insulin pen needle) FE ULTRA TRAK PRO BLOOD GLUCOSE (blood glucose FE monitoring suppl) ultracare insulin syringe FE ultra-care lancets 30g PB ultracare pen needles FE ultra-comfort insulin syringe FE ULTRALANCE (lancets misc.) PB ULTRA-THIN II AUTO LANCET (lancets) PB ULTRA-THIN II INS SYR SHORT (insulin syringe-needle u- FE 100) ULTRA-THIN II INSULIN SYRINGE (insulin syringe- FE needle u-100) ULTRA-THIN II LANCETS (lancets) PB ULTRA-THIN II MINI PEN NEEDLE (insulin pen needle) FE ULTRA-THIN II PEN NEEDLE SHORT (insulin pen needle) FE ULTRA-THIN II PEN NEEDLES (insulin pen needle) FE ULTRATRAK ACTIVE (blood glucose monitoring suppl) FE ULTRATRAK PRO (blood glucose monitoring suppl) FE ULTRATRAK ULTIMATE MONITOR (blood glucose FE monitoring suppl) UNIFINE PENTIPS (insulin pen needle) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 158 Prescription Drug Name Drug Tier Drug Notes unifine pentips plus FE UNILET COMFORTOUCH LANCET (lancets) PB UNILET EXCELITE (lancets) PB UNILET EXCELITE II (lancets) PB UNILET G.P. LANCET (lancets) PB UNILET G.P. SUPERLITE LANCET (lancets) PB UNILET GP 28 ULTRA THIN (lancets) PB UNILET LANCET (lancets) PB UNILET MICRO-THIN 33G (lancets) PB UNILET SUPERLITE LANCET (lancets) PB UNILET SUPER-THIN 30G (lancets) PB UNILET ULTRA-THIN 28G (lancets) PB UNISTIK 1 (lancets misc.) PB UNISTIK 2 (lancets misc.) PB UNISTIK 2 COMFORT (lancets misc.) PB UNISTIK 2 EXTRA (lancets misc.) PB UNISTIK 2 NEONATAL (lancets misc.) PB UNISTIK 2 NORMAL (lancets misc.) PB UNISTIK 2 SUPER (lancets misc.) PB UNISTIK 3 (lancets misc.) PB UNISTIK 3 COMFORT (lancets misc.) PB UNISTIK 3 EXTRA (lancets misc.) PB UNISTIK 3 GENTLE (lancets) PB UNISTIK 3 NEONATAL (lancets misc.) PB UNISTIK 3 NORMAL (lancets misc.) PB UNISTIK CZT COMFORT (lancets misc.) PB UNISTIK CZT NORMAL (lancets misc.) PB UNISTIK PRO SAFETY LANCET (lancets) PB UNISTIK SAFETY LANCETS 28G (lancets) PB UNISTIK SAFETY LANCETS 30G (lancets) PB UNISTIK TOUCH SAFETY LANC 21G (lancets) PB UNISTIK TOUCH SAFETY LANC 23G (lancets) PB UNISTIK TOUCH SAFETY LANC 28G (lancets) PB UNISTIK TOUCH SAFETY LANC 30G (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 159 Prescription Drug Name Drug Tier Drug Notes UNIVERSAL 1 LANCETS THIN 26G (lancets) PB UNIVERSAL 1 LANCETS THIN 33G (lancets) PB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) PB value health insulin syringe FE value plus lancet standard 21g PB value plus lancets super thin PB valumark lancet ultra thin 28g PB valumark pen needles FE VANISHPOINT INSULIN SYRINGE (insulin syringe-needle FE u-100) VARISOFT INFUSION SET (insulin infusion pump supplies) NPB verasens blood glucose meter FE verasens blood glucose system FE V-GO 20 (insulin disposable pump) PB V-GO 30 (insulin disposable pump) PB V-GO 40 (insulin disposable pump) PB VICTORY BLOOD GLUCOSE SYSTEM (blood glucose FE monitoring suppl) VIDA MIA UNIFINE PENTIPS (insulin pen needle) FE VITALET PRO LANCETS (lancets) PB VITALET PRO PLUS LANCETS (lancets) PB VIVAGUARD INO GLUCOSE METER (blood glucose FE monitoring suppl) VIVAGUARD LANCETS (lancets) PB VIVAGUARD LANCING DEVICE (lancet devices) NPB VOCAL POINT BLOOD GLUCOSE SYS (blood glucose FE monitoring suppl) vp insulin syringe FE V-R MONO INSULIN SYRINGE (insulin syringe-needle u- FE 100) walgreens adv travel lancets PB WALGREENS LANCETS (lancets) PB walgreens lancets micro thin PB walgreens lancets super thin PB WALGREENS THIN LANCETS (lancets) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 160 Prescription Drug Name Drug Tier Drug Notes WALGREENS ULTRA THIN LANCETS (lancets) PB WAVESENSE AMP (blood glucose monitoring suppl) FE WAVESENSE KEYNOTE (blood glucose monitoring suppl) FE WAVESENSE KEYNOTE PRO METER (blood glucose FE monitoring suppl) WEBCOL ALCOHOL PREP LARGE (alcohol swabs) NPB WEBCOL ALCOHOL PREP MEDIUM (alcohol swabs) NPB wegmans unifine pentips plus FE WIDE-SEAL DIAPHRAGM 60 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 65 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 70 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 75 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 80 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 85 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 90 (diaphragm wide seal) NPB CE WIDE-SEAL DIAPHRAGM 95 (diaphragm wide seal) NPB CE *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM VYLEESI (bremelanotide acetate) FE *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM almotriptan malate G CAFERGOT (ergotamine-caffeine) FE CAMBIA (diclofenac potassium) FE dihydroergotamine mesylate injection G dihydroergotamine mesylate nasal FE eletriptan hydrobromide G ERGOMAR (ergotamine tartrate) NPB ergotamine-caffeine G frovatriptan succinate G MIGRAINE PACK (-homeopathic prod) FE MIGRANAL (dihydroergotamine mesylate) NPB MIGRANOW (sumatriptan & camphor-menthol) FE naratriptan hcl G ONZETRA XSAIL (sumatriptan succinate) PB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 161 Prescription Drug Name Drug Tier Drug Notes rizatriptan benzoate G sumatriptan nasal G sumatriptan succinate oral G sumatriptan succinate refill subcutaneous solution cartridge G sumatriptan succinate subcutaneous solution 6 mg/0.5ml G sumatriptan succinate subcutaneous solution auto-injector 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 G mg/0.5ml sumatriptan-naproxen sodium G SUMAVEL DOSEPRO SUBCUTANEOUS SOLUTION FE JET-INJECTOR (sumatriptan succinate) TOSYMRA (sumatriptan) FE ZEMBRACE SYMTOUCH (sumatriptan succinate) PB zolmitriptan oral G ZOMIG NASAL (zolmitriptan) PB *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION CALCIFOL (ca carb-fa-d-b6-b12-boron-mg) NPB EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NPB MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 G Meq) FLORIVA ORAL LIQUID (sodium fluoride-vitamin d) NPB CE FLUORABON (sodium fluoride) NPB CE fluoritab G CE FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) G CE MG/DROP (sodium fluoride) GALZIN (zinc acetate (oral)) NPB iodine strong oral G potassium chloride (Klor-Con 10) G potassium chloride crys er (Klor-Con M10) G KLOR-CON M15 (potassium chloride crys er) G potassium chloride crys er (Klor-Con M20) G potassium chloride (Klor-Con Oral Packet 20 Meq) G KLOR-CON ORAL PACKET 25 MEQ (potassium chloride) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 162 Prescription Drug Name Drug Tier Drug Notes potassium chloride (Klor-Con Oral Tablet Extended Release) G potassium chloride (Klor-Con Sprinkle) G potassium bicarbonate (Klor-Con/Ef) G K-PHOS (potassium phosphate monobasic) NPB potassium bicarbonate (K-Prime) G LIQUIVIDA HYDRATION (sodium chloride) FE sodium fluoride (Ludent) G CE sodium fluoride (Nafrinse) G CE sodium fluoride (Nafrinse Drops) G CE k phos mono-sod phos di & mono (Phospha 250 Neutral) G phosphorous G k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral) G pot bicarb-pot chloride G potassium bicarbonate oral G potassium chloride crys er G potassium chloride er G potassium chloride oral packet G potassium chloride oral solution 20 meq/15ml (10%), 40 G meq/15ml (20%) sodium fluoride oral G CE THE LIQUILIFT TRACE (trace minerals cr-cu-mn-se-zn) FE virt-phos 250 neutral G *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS ODACTRA (dust mite mixed allergen ext) NPB ORALAIR (grass mix pollens allergen ext) PSB sorrel/dock mix FE *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT AQUORAL MOUTH/THROAT SOLUTION (artificial NPB saliva) BOCASAL (artificial saliva) NPB CAPHOSOL MOUTH/THROAT SOLUTION (artificial NPB saliva) sodium fluoride (Cavarest) G CE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 163 Prescription Drug Name Drug Tier Drug Notes cevimeline hcl G chlorhexidine gluconate mouth/throat G sodium fluoride (Clinpro 5000) G CE clotrimazole mouth/throat G sodium fluoride (Denta 5000 Plus) G CE sodium fluoride (Dentagel) G CE EASYGEL DENTAL (stannous fluoride) G CE stannous fluoride (Fluoridex Daily Renewal) G CE sodium fluoride (Fluoridex Enhanced Whitening Dental Paste) G CE sod fluoride-potassium nitrate (Fluoridex Sensitivity Relief G CE Dental Paste) GELCLAIR (povidone-nahyaluron-glycyrrhet) NPB lidocaine hcl mouth/throat G lidocaine viscous hcl G MUCOSITISRX (artificial saliva) FE NAFRINSE DAILY ACIDULATED (sodium fluoride- NPB CE phosphoric acd) NAFRINSE DAILY/NEUTRAL (sodium fluoride) NPB CE NAFRINSE WEEKLY (sodium fluoride) NPB CE neutral sodium fluoride G CE NEUTRASAL (artificial saliva) NPB NUMOISYN MOUTH/THROAT LIQUID (artificial saliva) NPB nystatin mouth/throat G ORAFATE (sucralfate-malate) NPB triamcinolone acetonide (Oralone) G ORAVIG (miconazole) NPB chlorhexidine gluconate (Paroex) G chlorhexidine gluconate (Periogard) G pilocarpine hcl oral G PREVIDENT (sodium fluoride) FE PREVIDENT 5000 BOOSTER PLUS (sodium fluoride) FE PREVIDENT 5000 DRY MOUTH DENTAL GEL (sodium FE fluoride) PREVIDENT 5000 ENAMEL PROTECT (sod fluoride- FE potassium nitrate) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 164 Prescription Drug Name Drug Tier Drug Notes PREVIDENT 5000 ORTHO DEFENSE (sodium fluoride) FE PREVIDENT 5000 PLUS (sodium fluoride) FE PREVIDENT 5000 SENSITIVE (sod fluoride-potassium FE nitrate) PROTHELIAL (sucralfate-malate) NPB SALIVAMAX (artificial saliva) NPB sf G CE sf 5000 plus G CE triamcinolone acetonide mouth/throat G XEROSTOMIA RELIEF SPRAY (artificial saliva) NPB *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR METABOLIC DISEASE VIMIZIM (elosulfase alfa) NPSB *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR THE NERVOUS SYSTEM MAVENCLAD (10 TABS) (cladribine) NPSB MAVENCLAD (4 TABS) (cladribine) NPSB MAVENCLAD (5 TABS) (cladribine) NPSB MAVENCLAD (6 TABS) (cladribine) NPSB MAVENCLAD (7 TABS) (cladribine) NPSB MAVENCLAD (8 TABS) (cladribine) NPSB MAVENCLAD (9 TABS) (cladribine) NPSB *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - VITAMINS AND MINERALS multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 FE mg, 1-0.3 mg *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE- IRON-FOLIC ACID*** - DRUGS FOR NUTRITION QUFLORA FE (multi vit-min-fluoride-fe-fa) FE *MULTIPLE VITAMINS WITH FOLIC ACID*** - DRUGS FOR NUTRITION folika-v FE GENICIN VITA-Q (multiple vitamins with fa) FE vitaxyme FE vitazyme FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 165 Prescription Drug Name Drug Tier Drug Notes *MULTIVITAMINS* - DRUGS FOR NUTRITION activite G adc/f (0.5mg/ml) G ADRENAL C FORMULA (bioflavonoid products) NPB advanced am/pm NPB ALIVE PRENATAL (prenatal mv & min w/fa-dha) FE ap-zel NPB ATABEX EC (prenatal vit-dss-fe cbn-fa) NPB ATABEX OB (prenatal vit w/ fe bisg-fa) NPB azesco FE BAL-CARE DHA (prenat-fepoly-fered-fa-omega 3) NPB biocel G b-plex G b-plex plus G cadeau dha FE CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL B-CALM (prenat w/o a fecbnfeglu-fa &b6) PB CITRANATAL BLOOM (prenatal-dss-fecb-fegl-fa) PB CITRANATAL BLOOM DHA (prenat w/o a-fecbgl-dss-fa- PB dha) CITRANATAL DHA (prenat w/o a-fecbgl-dss-fa-dha) PB CITRANATAL HARMONY ORAL CAPSULE 27-1-260 PB MG (prenat-fefmcb-dss-fa-dha w/o a) CITRANATAL MEDLEY (prenat-fecb-fefum-fa-dha w/o a) PB CITRANATAL RX (prenat w/o a-fecb-fegl-dss-fa) PB c-nate dha NPB cod liver oil oral oil NPB complete natal dha NPB completenate NPB CO-NATAL FA (prenatal vit-fe fumarate-fa) NPB CONCEPT DHA (prenat-fefum-fepo-fa-omega 3) NPB CONCEPT OB (prenat w/o a vit-fefum-fepo-fa) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 166 Prescription Drug Name Drug Tier Drug Notes CORVITA (multiple vitamins-minerals-fa) G multiple vitamins-minerals (Corvite Free) G cvs prenatal gummy oral tablet chewable 0.4-25 mg FE b complex-c-folic acid (Dexifol) FE DUET DHA 400 (prenat-fepoly-fered-fa-omega 3) NPB DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NPB fepoly-fered-fa-omega 3) ELITE-OB (prenatal vit-iron carbonyl-fa) G ENBRACE HR (prenat vit-fe gly cys-fa-omega) FE ESCAVITE (ped multivitamins-fl-iron) NPB ESCAVITE D (ped multivitamins-fl-iron) NPB escavite lq oral liquid G FLORIVA PLUS (pediatric multivitamins-fl) NPB folbee plus G FOLBEE PLUS CZ (b-complex-c-biotin-minerals-fa) G FOLET DHA (prenat-fe-methylfol-dss-dha) NPB FOLET ONE (prenat-fe-methyl-dss-dha w/o a) NPB FOLGARD OS (multiple vit-min-calcium-fa) NPB folika-t FE FOLIVANE-OB (prenat w/o a vit-fefum-fepo-fa) NPB FORTAVIT ORAL CAPSULE (multiple vitamins-minerals) NPB b complex-c-folic acid (Genicin Vita-S) FE hylavite FE INATAL GT (prenatal vit-dss-fe cbn-fa) G INFUVITE ADULT (multiple vitamin) NPB INFUVITE PEDIATRIC INTRAVENOUS SOLUTION NPB (pediatric multiple vitamins) kosher prenatal plus iron FE lorid FE multiple vitamins-minerals (Lysiplex Plus Oral Tablet) G M.V.I. ADULT (multiple vitamin) NPB M.V.I. PEDIATRIC INTRAVENOUS SOLUTION NPB RECONSTITUTED (pediatric multiple vitamins) M.V.I.-12 (WITHOUT ) (multiple vitamin) NPB MARNATAL-F (prenat w/o a-fe poly cmplx-fa) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 167 Prescription Drug Name Drug Tier Drug Notes m-natal plus FE MTERYTI (prenatal vit-fe fumarate-fa) FE MTERYTI FOLIC 5 (prenatal vit-fe fumarate-fa) FE multi-vit/iron/fluoride G multivitamin/fluoride oral solution G multi-vitamin/fluoride oral solution 0.5 mg/ml G multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg G multivitamin/fluoride/iron G multi-vitamin/fluoride/iron G pediatric multivitamins-fl (Mvc-Fluoride) G M-VIT (prenatal vit-fe fumarate-fa) NPB MYNATAL (prenatal multivit-min-fe-fa) NPB MYNATAL ADVANCE (prenatal vit-dss-fe cbn-fa) NPB mynatal plus NPB mynatal-z NPB mynate 90 plus NPB NATACHEW ORAL TABLET CHEWABLE 28-1 MG NPB (prenatal vit-fe fum-fe bisg-fa) NATALVIT (prenatal vit-fe fumarate-fa) NPB NATELLE ONE ORAL CAPSULE 28-1-250 MG (prenat w/o NPB a-fe fum-fa-omega 3) NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NPB fefum-methf-omegas) NEONATAL PLUS (prenatal vit-fe fumarate-fa) NPB NEPHROCAPS QT (b complex-c-biotin-d-fa) NPB b complex-c-folic acid (Nephronex Oral Tablet) G NESTABS (prenat-fe bisgly-fa-w/o vit a) NPB NESTABS DHA (prenat-w/oa-fe bisgly-fa-omega) NPB NESTABS ONE (prenat-fe-methylfol-dha w/o a) FE NEXA PLUS (prenat-fefum-doc-fa-dha w/o a) NPB NICADAN (multiple vitamins-minerals) NPB NICAZEL (multiple vitamins-minerals) FE NICAZEL FORTE (multiple vitamins-minerals) FE NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide- NPB zn-cu-methfo-se-cr) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 168 Prescription Drug Name Drug Tier Drug Notes NIVA-PLUS (prenatal vit-fe fumarate-fa) FE NUTRICAP (multiple vitamins-minerals) NPB multiple vitamins-minerals (Nutrifac Zx) G NUTRIVIT (b complex-lysine-min-fe-fa) NPB OB COMPLETE ADVANCED (prenat w/o a-fe-methf-fa- FE omega) OB COMPLETE GOLD (prenat w/o a-fecbn-meth-fa-dha) FE OB COMPLETE ONE (prenat-fecbn-feaspgl-fa-fish) NPB OB COMPLETE ORAL TABLET (prenatal vit-iron carbonyl- NPB fa) OB COMPLETE PETITE (prenat-fecbn-feaspgl-fa-omega) NPB OB COMPLETE PREMIER (prenatal-fe cbn-fe asp gly-fa) NPB OB COMPLETE/DHA (prenat-fecbn-feaspgl-fa-omega) NPB OBSTETRIX DHA (prenatal-fecbn-fa-dss-omega 3) NPB OBSTETRIX EC (prenatal vit-dss-fe cbn-fa) NPB OBSTETRIX ONE (prenat-fe-methyl-dss-dha w/o a) FE O-CAL FA (prenatal vit-fe fumarate-fa) NPB O-CAL PRENATAL (prenatal vit-fe fumarate-fa) NPB ONE A DAY PRENATAL (prenatal mv & min w/fa-dha) FE ONE-A-DAY WOMENS PRENATAL 1 (prenat-fe carbonyl- FE fa-omega 3) onevite NPB pnv folic acid + iron NPB pnv prenatal plus multivit+dha NPB pnv tabs 29-1 NPB pnv-dha G pnv-dha+docusate NPB pnv-omega NPB pnv-select G POLY-VI-FLOR (pediatric multivitamins-fl) NPB POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG FE (pediatric multivitamins-fl) POLY-VI-FLOR FS ORAL STRIP 1 MG (pediatric NPB multivitamins-fl) POLY-VI-FLOR/IRON (ped multivitamins-fl-iron) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 169 Prescription Drug Name Drug Tier Drug Notes PR NATAL 400 (prenat-febis-fepro-fa-ca-omega) NPB PR NATAL 400 EC (prenat-febis-fepro-fa-ca-omega) NPB PR NATAL 430 (prenat-febis-fepro-fa-ca-omega) NPB PR NATAL 430 EC (prenat-febis-fepro-fa-ca-omega) NPB PREFERA OB ORAL TABLET 34-1 MG (prenatal vit- FE fepoly-fehempo-fa) PREFERAOB +DHA (prenat fepoly-fehempo-fa-dha) FE pregenna FE PREMESISRX (prenatal ca-b6-b12-fa-ginger) NPB prena 1 true NPB prena1 NPB prena1 pearl NPB prenaissance NPB prenaissance plus NPB PRENATA (prenatal w/o a vit-fe fum-fa) NPB PRENATABS RX (prenatal vit-iron carbonyl-fa) G prenatal + complete multi FE PRENATAL + DHA (prenatal-fefum-fa-dha w/o a) FE prenatal 19 oral tablet G prenatal 19 oral tablet 29-1 mg NPB prenatal 19 oral tablet chewable G prenatal 19 oral tablet chewable 29-1 mg NPB prenatal gummies/dha & fa FE prenatal multi +dha oral capsule 27-0.8-200 mg FE prenatal oral tablet 27-1 mg NPB prenatal plus iron NPB prenatal vitamin plus low iron NPB PRENATAL-U (prenatal w/o a vit-fe fum-fa) NPB PRENATE (prenat mv-min-methylfolate-fa) NPB PRENATE AM (prenatal ca-b6-b12-fa-ginger) NPB PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG NPB (prenat-feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG NPB (prenatal-feaspgly-methylfol-fa) PRENATE ENHANCE (prenat w/o a-fe-methfol-fa-dha) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 170 Prescription Drug Name Drug Tier Drug Notes PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 NPB MG (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG NPB (prenat-fecbn-feasp-meth-fa-dha) PRENATE PIXIE (prenat-feasp-meth-fa-dha w/o a) NPB PRENATE RESTORE (prenat w/o a-fe-methfol-fa-dha) NPB preplus NPB pretab NPB PRIMACARE ORAL CAPSULE (pren-fe-meth-fa-omeg w/o FE a) PROVIDA DHA (prenat-fefum-fepo-fa-dha w/o a) FE PROVIDA OB (prenat w/o a vit-fefum-fepo-fa) NPB QUFLORA FE PEDIATRIC (ped multivitamins-fl-iron) FE QUFLORA GUMMIES (pediatric multivitamins-fl) FE QUFLORA PEDIATRIC (pediatric multivitamins-fl) NPB relnate dha NPB RENATABS (b complex-c-biotin-e-fa) NPB RENATABS WITH IRON (b complex-c-biotin-e-fa-fe cbn) NPB reno caps G REQ 49+ (multiple vitamins-minerals) NPB R-NATAL OB (prenatal-fe cbn-fa-dha w/o a) NPB SELECT-OB (prenatal vit-fe psac cmplx-fa) NPB SELECT-OB+DHA (prenatal vit-fepoly-fa-dha) NPB se-natal 19 NPB SIDEROL ORAL TABLET (multiple vitamins-minerals) NPB STROVITE FORTE ORAL SYRUP (multiple vitamins- NPB minerals-fa) SUPERVITE (b complex-lysine-zn-fa) NPB support NPB SUPPORT-500 (specialty vitamins products) NPB SYNAGEX (multiple vitamins-minerals-fa) NPB SYNATEK (multiple vitamins-minerals-fa) NPB TARON-BC (prenatal w/o vit a-fecbn-fa-b6) NPB TARON-C DHA (prenat-fefum-fepo-fa-omega 3) NPB TARON-PREX (prenat-fefum-dss-fa-dha w/o a) NPB 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 171 Prescription Drug Name Drug Tier Drug Notes THERANATAL ONE (prenatal-fefum-fa-dha w/o a) FE thrivite 19 NPB thrivite rx NPB tl folate NPB TL G-FOL OS (multiple vit-min-calcium-fa) NPB tl-care dha NPB tl-fluorivite NPB tl-select NPB TRICARE (prenatal vit-fe fumarate-fa) NPB TRICARE PRENATAL (prenatal-fe pyroph-methf w/o a) FE TRICARE PRENATAL DHA ONE ORAL CAPSULE 0.8 FE MG (prenatal multivit-min-fe-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NPB 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 NPB TRINATE (prenatal vit-fe fumarate-fa) G trinaz FE triphrocaps G tristart dha FE TRISTART ONE (prenat w/o a-fecbn-meth-fa-dha) FE tri-tabs dha NPB TRIVEEN-DUO DHA (prenat-febis-fepro-fa-ca-omega) NPB TRI-VI-FLOR (ped vit a-c-d-methylfolate-fl) NPB tri-vi-floro NPB tri-vite/fluoride G tronvite FE UDAMIN SP (multiple vitamins-minerals-fa) NPB ultimatecare one NPB urosex G v-c forte G vena-bal dha NPB multiple vitamins-minerals (Vic-Forte) G VINATE DHA RF (prenat w/oa-fefum-methf-omegas) NPB VINATE II (prenatal vit w/ fe bisg-fa) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 172 Prescription Drug Name Drug Tier Drug Notes VINATE M (prenatal vit-sel-fe fum-fa) NPB VINATE ONE (prenatal vit-fe fumarate-fa) NPB virt-c dha NPB virt-caps G virt-nate dha NPB virt-pn dha NPB virt-pn plus NPB multiple vitamins-minerals (Vita S Forte) G multiple vitamins-minerals (Vitacel) G VITAFOL FE+ (prenat-fepoly-metf-fa-dha-dss) NPB VITAFOL GUMMIES (prenatal vit-fe phos-fa-omega) FE VITAFOL STRIPS (prenatal-b6-b12-d3-folic acid) FE VITAFOL ULTRA (prenat-fe poly-methfol-fa-dha) NPB VITAFOL-NANO (prenatal-fe fum-methf-fa w/o a) NPB VITAFOL-OB (prenatal vit-fe fumarate-fa) NPB VITAFOL-OB+DHA (prenatal mv-min-fe fum-fa-dha) NPB VITAFOL-ONE (prenatal vit-fepoly-fa-dha) NPB pediatric multivit-minerals-c (Vitamax Pediatric) G VITAMEDMD ONE RX/QUATREFOLIC (prenat w/o a-fe- NPB methfol-fa-dha) VITAMEDMD REDICHEW RX ORAL TABLET NPB CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa) vita-min G vitamins acd-fluoride G VITAPEARL (prenat-fefum-fered-fa-dha w/oa) NPB vitasure G VITATRUE (prenat-fechel-fa-dha w/o vit a) NPB VIVA DHA (prenatal vit-fe fum-fa-omega) NPB vol-care rx G vol-nate NPB vol-plus NPB vol-tab rx NPB vp-heme ob + dha NPB vp-pnv-dha NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 173 Prescription Drug Name Drug Tier Drug Notes vp-vite rx G xvite FE zalvit FE ZATEAN-PN DHA (prenat w/o a-fe-methfol-fa-dha) NPB ZATEAN-PN PLUS (prenat w/o a-fe-methf-fa-omega) NPB *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES AMRIX ( hcl) FE oral G carisoprodol oral G carisoprodol-aspirin G carisoprodol-aspirin-codeine G oral tablet 250 mg, 375 mg, 750 mg FE chlorzoxazone oral tablet 500 mg G cyclo/gaba 10/300 FE cyclobenzaprine hcl er G cyclobenzaprine hcl oral G CYCLOPHENE RAPIDPAQ (cyclobenzaprine hcl) FE CYCLOTENS REFILL PAK (cyclobenzaprine hcl-elect pads) FE CYCLOTENS STARTER PAK (cyclobenzaprine-elect FE dev/pads) dantrolene sodium oral G DUROLANE INTRA-ARTICULAR (sodium hyaluronate FE (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION FE PREFILLED SYRINGE (sodium hyaluronate (viscosup)) FIRST-BACLOFEN (baclofen) FE GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE PSB (cross-linked hyaluronate) GELSYN-3 (sodium hyaluronate (viscosup)) PSB GENVISC 850 (sodium hyaluronate (viscosup)) FE HYALGAN (sodium hyaluronate (viscosup)) FE HYMOVIS (hyaluronan) FE LORVATUS PHARMAPAK (metaxalone-diclofenac sodium) FE LORZONE (chlorzoxazone) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 174 Prescription Drug Name Drug Tier Drug Notes MACI (autolog cult chond coll membr) FE METAXALL CP (metaxalone-capsaicin) FE metaxalone G methocarbamol oral G MONOVISC (hyaluronan) FE norgesic forte FE citrate er G ORPHENGESIC FORTE (orphenadrine-aspirin-caffeine) FE ORTHOVISC INTRA-ARTICULAR SOLUTION FE PREFILLED SYRINGE (hyaluronan) SUPARTZ FX (sodium hyaluronate (viscosup)) PSB SYNVISC INTRA-ARTICULAR SOLUTION FE PREFILLED SYRINGE (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION FE PREFILLED SYRINGE (hylan) TABRADOL FUSEPAQ (cyclobenzaprine hcl-msm) FE TABRADOL RAPIDPAQ (cyclobenzaprine hcl-msm) FE tizanidine hcl oral G TRIVISC (sodium hyaluronate (viscosup)) FE VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED PSB SYRINGE (sodium hyaluronate (viscosup)) *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE ADRENALIN NASAL (epinephrine hcl (nasal)) NPB ALZAIR ALLERGY (hypromellose) FE azelastine hcl nasal solution 0.15 %, 137 mcg/spray G BECONASE AQ (beclomethasone diprop monohyd) FE DERMACINRX AZENASE PAK (azelastine-fluticasone) FE DERMACINRX TICANASE PAK (fluticasone-sodium FE chloride) DYMISTA (azelastine-fluticasone) PB flunisolide nasal solution 25 mcg/act (0.025%) G fluticasone propionate nasal G ipratropium bromide nasal G mometasone furoate nasal G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 175 Prescription Drug Name Drug Tier Drug Notes olopatadine hcl nasal G OMNARIS (ciclesonide) FE QNASL (beclomethasone diprop (nasal)) FE QNASL CHILDRENS (beclomethasone diprop (nasal)) FE RHINOCORT AQUA (budesonide) FE SINUVA (mometasone furoate) FE TICALAST (azelastine-fluticasone-nacl) FE TICASPRAY (fluticasone-sodium chloride) FE VERAMYST (fluticasone furoate) FE XHANCE (fluticasone propionate) NPB ZETONNA (ciclesonide) FE *NASAL ANESTHETICS*** - DRUGS FOR THE NOSE goprelto FE *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR THE HEART ENTRESTO (sacubitril-valsartan) PB *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR THE HEART NORTHERA (droxidopa) FE *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES BOTOX (onabotulinumtoxina) NPSB DYSPORT (abobotulinumtoxina) NPSB G TIGLUTIK (riluzole) FE XEOMIN (incobotulinumtoxina) NPSB *N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM SPRAVATO (56 MG DOSE) ( hcl) NPSB SPRAVATO (84 MG DOSE) (esketamine hcl) NPSB *NSAID COMBINATIONS*** - DRUGS FOR PAIN AND FEVER anodyne ile FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 176 Prescription Drug Name Drug Tier Drug Notes *NSAID-VITAMINS AND/OR MINERALS COMBINATIONS*** - DRUGS FOR PAIN AND FEVER equapax/ibuprofen/minrex FE *NUTRIENTS* - DRUGS FOR NUTRITION amino acids (Aminoamrms) G AMINOPROTECT (amino acid infusion) FE amino acids (Aminoreliefrms) G bcaa FE calm FE CARDIOVID PLUS (dha-epa-vit b6-b12-folic acid) NPB CLINOLIPID (fat emulsion plant based) FE ELCYS (cysteine hcl) FE INTRALIPID INTRAVENOUS EMULSION 20 % (fat FE emulsion plant based) lecithin oral granules NPB lipo-c FE n-acetyl-l-cysteine oral G NEOKE ALCAR (acetylcarnitine) FE NEOKE MCT70 (medium chain triglycerides) FE nutrilipid intravenous emulsion 20 % FE OMEGAVEN (fish oil triglyceride based) FE tri-amino FE oral NPB *ONCOLYTIC VIRAL AGENTS - HSV1*** - BIOLOGICAL AGENTS IMLYGIC (talimogene laherparepvec) NPSB *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE ACUVAIL (ketorolac tromethamine) PB ak-poly-bac G AKTEN (lidocaine hcl) NPB ALOCRIL (nedocromil sodium) NPB ALOMIDE (lodoxamide tromethamine) NPB ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB (brimonidine tartrate) ALREX (loteprednol etabonate) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 177 Prescription Drug Name Drug Tier Drug Notes tetracaine hcl (Altacaine) G altafluor benox G phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) G apraclonidine hcl G atropine sulfate ophthalmic ointment NPB AZASITE (azithromycin) NPB azelastine hcl ophthalmic G AZOPT (brinzolamide) PB bacitracin ophthalmic G bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm G bacitra-neomycin-polymyxin-hc G BEPREVE (bepotastine besilate) NPB BESIVANCE (besifloxacin hcl) PB BETADINE OPHTHALMIC PREP (povidone-iodine) NPB betaxolol hcl ophthalmic G BETIMOL (timolol hemihydrate) PB BETOPTIC-S (betaxolol hcl) PB bimatoprost ophthalmic G BLEPHAMIDE (sulfacetamide-prednisolone) NPB BLEPHAMIDE S.O.P. (sulfacetamide-prednisolone) NPB brimonidine tartrate ophthalmic G bromfenac sodium (once-daily) G BROMSITE (bromfenac sodium) NPB carteolol hcl G CEQUA (cyclosporine) FE CILOXAN OPHTHALMIC OINTMENT (ciprofloxacin hcl) PB ciprofloxacin hcl ophthalmic G COMBIGAN (brimonidine tartrate-timolol) PB cromolyn sodium ophthalmic G CYCLOMYDRIL (cyclopentolate-phenylephrine) NPB cyclopentolate hcl ophthalmic G CYCLOSPORINE IN KLARITY (cyclosporine) FE dexamethasone sodium phosphate ophthalmic G DEXTENZA (dexamethasone) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 178 Prescription Drug Name Drug Tier Drug Notes DEXYCU (dexamethasone) FE diclofenac sodium ophthalmic G dorzolamide hcl solution 2 % ophthalmic NPB dorzolamide hcl solution 2 % ophthalmic G dorzolamide hcl-timolol mal G dorzolamide hcl-timolol mal pf G double pm FE DUREZOL (difluprednate) PB epinastine hcl G erythromycin ophthalmic G EYLEA INTRAVITREAL (aflibercept) PSB FLAREX (fluorometholone acetate) FE -benoxinate G fluorescein sodium (Fluor-I-Strips A.T.) G fluorometholone ophthalmic G FLURA-SAFE (fluorexon-benoxinate) NPB flurbiprofen sodium G FML (fluorometholone) PB FML FORTE (fluorometholone) PB FML LIQUIFILM (fluorometholone) FE gatifloxacin ophthalmic G GELFILM OPHTHALMIC (gelatin adsorbable) NPB GENTAK OPHTHALMIC OINTMENT (gentamicin sulfate) G gentamicin sulfate ophthalmic solution G ILEVRO (nepafenac) PB INVELTYS (loteprednol etabonate) FE IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NPB hcl) ISOPTO ATROPINE (atropine sulfate) FE ketorolac tromethamine ophthalmic G KLARITY-A (azithromycin) FE KLARITY-B (betamethasone sodium phosphate) FE KLARITY-L (loteprednol etabonate) FE LACRISERT (artificial tear insert) NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 179 Prescription Drug Name Drug Tier Drug Notes LASTACAFT (alcaftadine) PB latanoprost ophthalmic G levobunolol hcl ophthalmic solution 0.5 % G levofloxacin ophthalmic G lissamine green G LOTEMAX (loteprednol etabonate) FE LOTEMAX SM (loteprednol etabonate) FE loteprednol etabonate G LUCENTIS INTRAVITREAL (ranibizumab) PSB LUMIGAN OPHTHALMIC SOLUTION 0.01 % PB (bimatoprost) MAXIDEX (dexamethasone) PB MITOSOL (mitomycin) NPB MOXEZA (moxifloxacin hcl) PB moxifloxacin hcl ophthalmic G NATACYN (natamycin) NPB neomycin-bacitracin zn-polymyx G neomycin-polymyxin-dexameth ophthalmic ointment G neomycin-polymyxin-dexameth ophthalmic suspension 3.5- G 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- G 10000-.025 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 G neomycin-bacitracin zn-polymyx (Neo-Polycin) G bacitracin-polymyx-neo-hc (Neo-Polycin Hc) G NEVANAC (nepafenac) PB ofloxacin ophthalmic G olopatadine hcl ophthalmic G OZURDEX INTRAVITREAL (dexamethasone) NPSB PAREMYD (hydroxyamphetamine-tropicamide) NPB PAZEO (olopatadine hcl) PB phenylephrine hcl ophthalmic solution 10 %, 2.5 % G PHOSPHOLINE IODIDE (echothiophate iodide) NPB pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % G bacitracin-polymyxin b (Polycin) G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 180 Prescription Drug Name Drug Tier Drug Notes polymyxin b-trimethoprim G povidone-iodine ophthalmic NPB PRED FORTE (prednisolone acetate) FE PRED MILD (prednisolone acetate) PB PRED-G (gentamicin-prednisolone acet) NPB PRED-G S.O.P. (gentamicin-prednisolone acet) NPB prednisolone acetate ophthalmic G prednisolone acetate p-f FE prednisolone sodium phosphate ophthalmic NPB prednisolone-gatifloxacin ophthalmic suspension FE PROLENSA (bromfenac sodium) NPB proparacaine hcl ophthalmic G proparacaine-fluorescein G RESTASIS (cyclosporine) PB RESTASIS MULTIDOSE OPHTHALMIC EMULSION PB 0.05 % (cyclosporine) ROSE GLO (rose bengal) NPB SIMBRINZA (brinzolamide-brimonidine) PB sulfacetamide sodium ophthalmic G sulfacetamide-prednisolone ophthalmic solution G tetracaine hcl (Tetcaine) G tetracaine hcl ophthalmic G timolol maleate ophthalmic G TIMOPTIC OCUDOSE (timolol maleate) FE TOBRADEX OPHTHALMIC OINTMENT (tobramycin- PB dexamethasone) TOBRADEX ST (tobramycin-dexamethasone) PB tobramycin ophthalmic G tobramycin-dexamethasone G TOBREX OPHTHALMIC OINTMENT (tobramycin) NPB TRAVATAN Z (travoprost) PB trifluridine ophthalmic G triple pmb FE triple pmk FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 181 Prescription Drug Name Drug Tier Drug Notes tropicamide ophthalmic G VYZULTA (latanoprostene bunod) NPB XELPROS (latanoprost) FE YUTIQ (fluocinolone acetonide) FE ZIOPTAN (tafluprost) NPB ZIRGAN (ganciclovir) NPB ZYLET (loteprednol-tobramycin) FE *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR THE EYE ROCKLATAN (netarsudil-latanoprost) FE *OPHTHALMIC PHOTOENHANCER COMBINATIONS*** - DRUGS FOR THE EYE PHOTREXA VISCOUS (riboflavin 5-phosphate-dextran) FE PHOTREXA-PHOTREXA VISCOUS KIT (riboflav5 & FE riboflav5-dextran) *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR THE EYE RHOPRESSA (netarsudil dimesylate) PB *OREXIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM BELSOMRA (suvorexant) PB *OTIC AGENTS* - DRUGS FOR THE EAR acetic acid otic G CIPRO HC (ciprofloxacin-hydrocortisone) NPB CIPRODEX (ciprofloxacin-dexamethasone) PB ciprofloxacin hcl otic G COLY-MYCIN S (neomycin-colist-hc-thonzonium) NPB CORTISPORIN-TC (neomycin-colist-hc-thonzonium) NPB fluocinolone acetonide (Flac) G FLOXIN OTIC (ofloxacin) FE fluocinolone acetonide otic G hydrocortisone-acetic acid G neomycin-polymyxin-hc otic solution 3.5-10000-1 G neomycin-polymyxin-hc otic suspension G ofloxacin otic G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 182 Prescription Drug Name Drug Tier Drug Notes OTIPRIO (ciprofloxacin) FE OTOVEL (ciprofloxacin-fluocinolone) FE *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN KERYDIN (tavaborole) NPB *OXYTOCICS* - HORMONES CERVIDIL (dinoprostone) NPB methylergonovine maleate (Methergine Oral) G methylergonovine maleate oral G PREPIDIL (dinoprostone) NPB PROSTIN E2 (dinoprostone) NPB *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR INFECTIONS XOFLUZA (baloxavir marboxil) FE *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS HYQVIA (immune globulin-hyaluronidase) FE *PASSIVE IMMUNIZING AGENTS* - BIOLOGICAL AGENTS BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML NPSB (immune globulin (human)) CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM (immune globulin NPSB (human)) CUTAQUIG (immune globulin (human)-hipp) FE CUVITRU (immune globulin (human)) FE FLEBOGAMMA DIF (immune globulin (human)) NPSB GAMMAGARD (immune globulin (human)) NPSB GAMMAGARD S/D LESS IGA (immune globulin (human)) NPSB GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 NPSB GM/200ML, 5 GM/50ML (immune globulin (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, NPSB 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML NPSB (immune globulin (human)) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 183 Prescription Drug Name Drug Tier Drug Notes HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NPSB (human)) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 NPSB GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML NPB (immune globulin (human)) PANZYGA (immune globulin (human)-ifas) FE PRIVIGEN (immune globulin (human)) NPSB SYNAGIS (palivizumab) NPSB *PCSK9 INHIBITORS*** - DRUGS FOR THE HEART PRALUENT SUBCUTANEOUS SOLUTION PREFILLED FE SYRINGE 75 MG/ML (alirocumab) REPATHA (evolocumab) PSB REPATHA PUSHTRONEX SYSTEM (evolocumab) PSB REPATHA SURECLICK (evolocumab) PSB *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA ORAL TABLET CHEWABLE (ped multiple vit- NPB minerals-fl) *PEDIATRIC MULTIPLE VITAMINS W/FLUORIDE- IRON-ZINC*** - DRUGS FOR NUTRITION TEXAVITE LQ (ped multivitamins-fl-iron-zinc) FE *PENICILLINS* - DRUGS FOR INFECTIONS amoxicillin oral capsule G amoxicillin oral suspension reconstituted G amoxicillin oral tablet G amoxicillin oral tablet chewable 125 mg, 250 mg G amoxicillin-pot clavulanate er G amoxicillin-pot clavulanate oral G ampicillin oral capsule 500 mg G AUGMENTIN ORAL SUSPENSION RECONSTITUTED NPB 125-31.25 MG/5ML (amoxicillin-pot clavulanate) dicloxacillin sodium G penicillin v potassium G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 184 Prescription Drug Name Drug Tier Drug Notes PFIZERPEN (penicillin g potassium) FE *PHARMACEUTICAL ADJUVANTS* base x NPB benzyl alcohol NPB capsule 0 clear dr NPB capsule coni-snap #0 clear NPB capsule coni-snap #0 purple NPB capsule coni-snap #00 white NPB capsule coni-snap #000 clear NPB capsule coni-snap #1 red/blue NPB capsule coni-snap #1 veggie NPB capsule coni-snap #2 white NPB capsule coni-snap #3 clear NPB capsule coni-snap #3 yellow NPB capsule coni-snap #4 white NPB capsule ezeefit #0 clear NPB capsule ezeefit #00 clear NPB cherry NPB cocoa butter NPB corn (syrup) NPB DRCAPS SIZE 0 (gelatin capsules (empty)) NPB DRCAPS SIZE 00 (gelatin capsules (empty)) NPB DRCAPS SIZE 1 (gelatin capsules (empty)) NPB empty capsule size 0 white/opa NPB empty capsule size 00 clear NPB empty capsule size 1 clear NPB empty capsule size 1 veg clear NPB empty capsule size 2 clear NPB empty capsule size 3 clear NPB empty capsule size 4 clear NPB empty capsule size 5 clear NPB empty capsule size 7 clear NPB FLAVOR BLEND (oral vehicles) NPB flavor plus NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 185 Prescription Drug Name Drug Tier Drug Notes flavor sweet NPB flavor sweet-sf oral syrup NPB mouth wash-gp NPB -af NPB mouthwash-om NPB ORA-BLEND (oral vehicles) NPB ORA-BLEND SF (oral vehicles) NPB ORA-PLUS (oral vehicles) NPB ORA-SWEET (oral vehicles) NPB ORA-SWEET SF (oral vehicles) NPB PCCA SWEET-SF (oral vehicles) NPB PCCA SYRUP VEHICLE (oral vehicles) NPB PCCA-PLUS (oral vehicles) NPB polypeg NPB purified water NPB simple syrup NPB sorbitol solution NPB spg supposi-base NPB blend NPB SUSPENDRX W/BITTERBLOC SWEET (oral vehicles) NPB SUSPENDRX W/BITTERBLOC UNSWEET (oral vehicles) NPB suspension vehicle NPB SYRPALTA (RED) (oral vehicles) NPB syrpalta oral syrup 85 % NPB SYRSPEND SF ORAL LIQUID (oral vehicles) NPB SYRSPEND SF PH4 (oral vehicles) NPB syrup vehicle NPB syrup vehicle sf NPB vegetable capsule #0 green NPB vegetable capsule #0 white NPB vegetable capsule #00 white NPB vegetable capsule #1 white NPB vegetable capsule #2 white NPB vegetable capsule #3 white NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 186 Prescription Drug Name Drug Tier Drug Notes vegetable capsule #4 white NPB VERSAFREE (oral vehicles) NPB VERSAPLUS (oral vehicles) NPB WITEPSOL (hydrogenated vegetable oil) NPB *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER COPIKTRA (duvelisib) FE PIQRAY (200 MG DAILY DOSE) (alpelisib) FE PIQRAY (250 MG DAILY DOSE) (alpelisib) FE PIQRAY (300 MG DAILY DOSE) (alpelisib) FE ZYDELIG (idelalisib) NPSB *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN EUCRISA (crisaborole) PB *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR PAIN AND FEVER IBC (Preferred agent for OTEZLA ORAL TABLET (apremilast) PSB Psoriasis and Psoriatic Arthritis) IBC (Preferred agent for OTEZLA ORAL TABLET THERAPY PACK (apremilast) PSB Psoriasis and Psoriatic Arthritis) *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE HEART TAKHZYRO (lanadelumab-flyo) FE *PLEUROMUTILINS*** - DRUGS FOR INFECTIONS XENLETA ORAL (lefamulin acetate) NPB *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** - DRUGS FOR CANCER LYNPARZA (olaparib) PSB RUBRACA (rucaparib camsylate) PSB TALZENNA (talazoparib tosylate) FE ZEJULA (niraparib tosylate) PSB *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER LYNPARZA (olaparib) PSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 187 Prescription Drug Name Drug Tier Drug Notes RUBRACA (rucaparib camsylate) PSB TALZENNA (talazoparib tosylate) FE ZEJULA (niraparib tosylate) PSB *POSTHERPETIC NEURALGIA (PHN) COMBINATION AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM CONVENIENCE PAK (gabapentin & lidocaine) FE SMARTRX GABA (gabapentin & lidocaine-menthol) FE SMARTRX GABA-V (gabapentin & meth sal-men-cap) FE *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM GRALISE (gabapentin (once-daily)) PB GRALISE STARTER (gabapentin (once-daily)) PB LYRICA CR (pregabalin) FE *POSTHERPETIC NEURALGIA(PHN)/NEUROPATHIC PAIN COMB AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM CONVENIENCE PAK (gabapentin & lidocaine) FE SMARTRX GABA (gabapentin & lidocaine-menthol) FE SMARTRX GABA-V (gabapentin & meth sal-men-cap) FE *POTASSIUM REMOVING AGENTS*** - DRUGS FOR NUTRITION sodium polystyrene sulfonate (Kionex Oral Suspension) G LOKELMA (sodium zirconium cyclosilicate) PB sodium polystyrene sulfonate oral G sodium polystyrene sulfonate rectal G sodium polystyrene sulfonate (Sps) G VELTASSA (patiromer sorbitex calcium) PB *PRENATAL MV & MINERALS W/ FA WITHOUT IRON*** - DRUGS FOR NUTRITION cvs prenatal gummy oral tablet chewable 0.4 mg FE *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION ALIVE PRENATAL (prenatal mv & min w/fa-dha) FE cvs prenatal gummy oral tablet chewable 0.4-25 mg FE ONE A DAY PRENATAL (prenatal mv & min w/fa-dha) FE 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 188 Prescription Drug Name Drug Tier Drug Notes prenatal + complete multi oral therapy pack 0.267 & 373 mg FE prenatal gummies/dha & fa FE PRENATE (prenat mv-min-methylfolate-fa) NPB *PROGESTINS* - HORMONES ec-rx progesterone FE hydroxyprogesterone caproate intramuscular oil G MAKENA (hydroxyprogesterone caproate) NPSB medroxyprogesterone acetate oral G megestrol acetate oral suspension 625 mg/5ml G norethindrone acetate oral G progesterone compounding kit FE progesterone intramuscular G progesterone micronized oral G *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD ZONTIVITY (vorapaxar sulfate) NPB *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium G AMPYRA (dalfampridine) NPSB AUBAGIO (teriflunomide) PSB AUSTEDO () PSB AVONEX (interferon beta-1a) FE AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR FE KIT (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED FE SYRINGE KIT (interferon beta-1a) BETASERON SUBCUTANEOUS KIT (interferon beta-1b) PSB bupropion hcl er (smoking det) G CE CHANTIX (varenicline tartrate) PB CE CHANTIX CONTINUING MONTH PAK (varenicline PB CE tartrate) CHANTIX STARTING MONTH PAK (varenicline tartrate) PB CE chlordiazepoxide-amitriptyline G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 189 Prescription Drug Name Drug Tier Drug Notes COPAXONE SUBCUTANEOUS SOLUTION PSB PREFILLED SYRINGE (glatiramer acetate) cvs mouth/throat gum G CE cvs nicotine polacrilex G CE cvs nicotine transdermal G CE dalfampridine er G oral G donepezil hcl G eq nicotine mouth/throat gum 4 mg G CE eq nicotine mouth/ G CE eq nicotine polacrilex G CE eq nicotine step 3 G CE eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr G CE eql nicotine polacrilex G CE ergoloid mesylates oral G EXTAVIA SUBCUTANEOUS KIT (interferon beta-1b) FE fluoxetine hcl (pmdd) G galantamine hydrobromide G galantamine hydrobromide er G GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) PSB glatiramer acetate G glatiramer acetate (Glatopa) G gnp nicotine G CE gnp nicotine mini G CE gnp nicotine polacrilex G CE goodsense nicotine mouth/throat gum G CE goodsense nicotine mouth/throat lozenge 4 mg G CE GRALISE (gabapentin (once-daily)) PB GRALISE STARTER (gabapentin (once-daily)) PB hm nicotine G CE hm nicotine polacrilex G CE HORIZANT ORAL TABLET EXTENDED RELEASE FE () INGREZZA ( tosylate) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 190 Prescription Drug Name Drug Tier Drug Notes KLS QUIT2 (nicotine polacrilex) G CE KLS QUIT4 (nicotine polacrilex) G CE LEMTRADA (alemtuzumab) FE LYRICA CR (pregabalin) FE MAYZENT (siponimod fumarate) FE memantine hcl er G memantine hcl oral G NAMENDA XR TITRATION PACK (memantine hcl) NPB NICORELIEF MOUTH/THROAT GUM 2 MG (nicotine G CE polacrilex) nicotine mini mouth/throat lozenge 2 mg G CE nicotine polacrilex mouth/throat G CE nicotine step 1 G CE nicotine step 2 G CE nicotine step 3 G CE nicotine transdermal patch 24 hour 21 mg/24hr G CE NICOTROL (nicotine) NPB CE NICOTROL NS (nicotine) NPB CE NUEDEXTA (-quinidine) PB olanzapine-fluoxetine hcl G paroxetine mesylate G perphenazine-amitriptyline G G PLEGRIDY (peginterferon beta-1a) FE PLEGRIDY STARTER PACK (peginterferon beta-1a) FE ra mini nicotine G CE ra nicotine G CE ra nicotine polacrilex mouth/throat gum G CE REBIF REBIDOSE SUBCUTANEOUS SOLUTION PSB AUTO-INJECTOR (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR PSB (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE (interferon beta-1a)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 191 Prescription Drug Name Drug Tier Drug Notes REBIF TITRATION PACK SUBCUTANEOUS PSB SOLUTION PREFILLED SYRINGE (interferon beta-1a) rivastigmine G rivastigmine tartrate G SAVELLA ( hcl) NPB SAVELLA TITRATION PACK (milnacipran hcl) NPB sm nicotine G CE sm nicotine polacrilex G CE sr nicotine G CE TECFIDERA (dimethyl fumarate) PSB G tgt nicotine mouth/throat gum 4 mg G CE tgt nicotine polacrilex G CE tgt nicotine step one G CE THRIVE MOUTH/THROAT GUM 2 MG (nicotine G CE polacrilex) TYSABRI (natalizumab) PSB XENAZINE (tetrabenazine) FE ZINBRYTA (daclizumab) FE *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR CANCER OFEV (nintedanib esylate) PSB *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS ESBRIET (pirfenidone) PSB *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR THE HEART UPTRAVI (selexipag) PSB *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase NPSB inhibitor) CUROSURF INTRATRACHEAL SUSPENSION 120 NPB MG/1.5ML, 240 MG/3ML (poractant alfa) GLASSIA (alpha1-proteinase inhibitor) NPSB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 192 Prescription Drug Name Drug Tier Drug Notes INFASURF INTRATRACHEAL (calfactant in nacl) NPB KALYDECO ORAL PACKET 50 MG, 75 MG (ivacaftor) NPSB KALYDECO ORAL TABLET (ivacaftor) NPSB PROLASTIN-C INTRAVENOUS SOLUTION (alpha1- PB proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION PSB RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) PULMOZYME (dornase alfa) NPSB SURVANTA INTRATRACHEAL (beractant in nacl) NPB ZEMAIRA (alpha1-proteinase inhibitor) FE *SCAR TREATMENT PRODUCTS - COMBINATIONS*** - DRUGS FOR THE SKIN renuu nl FE silipac FE *SCLEROSTIN INHIBITORS*** - HORMONES EVENITY (romosozumab-aqqg) FE *SEBORRHEIC KERATOSIS PRODUCTS** - DRUGS FOR THE SKIN ESKATA (hydrogen peroxide) FE *SEPTAL AGENTS - ABLATION** - DRUGS FOR THE HEART ABLYSINOL (dehydrated alcohol) FE *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM ADDYI (flibanserin) FE *SEROTONIN MODULATORS*** - DRUGS FOR THE NERVOUS SYSTEM nefazodone hcl G trazodone hcl oral G TRINTELLIX (vortioxetine hbr) PB VIIBRYD ORAL TABLET (vilazodone hcl) PB VIIBRYD STARTER PACK (vilazodone hcl) PB *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** - HORMONES GLYXAMBI (empagliflozin-linagliptin) PB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 193 Prescription Drug Name Drug Tier Drug Notes QTERN (dapagliflozin-saxagliptin) FE STEGLUJAN (ertugliflozin-sitagliptin) FE *SINUS NODE INHIBITORS** - DRUGS FOR THE HEART CORLANOR ORAL SOLUTION (ivabradine hcl) FE CORLANOR ORAL TABLET (ivabradine hcl) PB *SNRIS & ANESTHETICS/ANALGESICS*** - DRUGS FOR THE SKIN DERMACINRX DPN PAK (duloxetine-lidocaine-menthol) FE *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** - HORMONES INVOKAMET (canagliflozin-metformin hcl) FE INVOKAMET XR (canagliflozin-metformin hcl) FE SEGLUROMET (ertugliflozin-metformin hcl) FE SYNJARDY (empagliflozin-metformin hcl) PB SYNJARDY XR (empagliflozin-metformin hcl) PB XIGDUO XR (dapagliflozin-metformin hcl) PB *SPLEEN (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD TAVALISSE ( disodium) FE *STEROIDS - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT triamcinolone acetonide (Oralone) G triamcinolone acetonide mouth/throat G *SULFONAMIDES* sulfadiazine oral NPB *TETRACYCLINES* - DRUGS FOR INFECTIONS ACTICLATE (doxycycline hyclate) FE avidoxy G BENZODOX (doxycycline-benzoyl peroxide) FE minocycline hcl (Coremino) G demeclocycline hcl oral G DORYX MPC (doxycycline hyclate) FE DORYX ORAL TABLET DELAYED RELEASE 200 MG, FE 50 MG (doxycycline hyclate)

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 194 Prescription Drug Name Drug Tier Drug Notes doxycycline hyclate oral capsule G doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 50 mg, G 75 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, G 200 mg, 50 mg, 75 mg doxycycline monohydrate oral G MINOCIN ORAL (minocycline hcl) FE minocycline hcl er G minocycline hcl oral G MINOLIRA (minocycline hcl) FE doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 G Mg, 75 Mg) MONODOX ORAL CAPSULE 100 MG, 75 MG FE (doxycycline monohydrate) MORGIDOX COMBINATION KIT 1 X 50 MG FE (doxycycline hyclate-cleanser) doxycycline hyclate (Morgidox Oral) G doxycycline monohydrate (Okebo Oral Capsule 75 Mg) G SEYSARA (sarecycline hcl) FE TARGADOX (doxycycline hyclate) FE tetracycline hcl oral G VIBRAMYCIN ORAL SYRUP (doxycycline calcium) PB XIMINO (minocycline hcl) FE *THYROID AGENTS* - HORMONES ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, NPB 300 MG (thyroid) sodium (Euthyrox) G levothyroxine sodium (Levo-T) G levothyroxine sodium oral G levothyroxine sodium (Levoxyl) G sodium oral G methimazole oral G NATURE-THROID (thyroid) NPB np thyroid G oral G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 195 Prescription Drug Name Drug Tier Drug Notes thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg G TIROSINT (levothyroxine sodium) FE TIROSINT-SOL (levothyroxine sodium) FE levothyroxine sodium (Unithroid) G WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NPB 65 MG, 97.5 MG (thyroid) WP THYROID (thyroid) NPB * GASES*** - DRUGS FOR THE SKIN GEBAUERS PAIN EASE (pentafluoroprop-tetrafluoroeth) NPB GEBAUERS SPRAY AND STRETCH (pentafluoroprop- NPB tetrafluoroeth) *TRANSTHYRETIN STABILIZERS*** - HORMONES VYNDAMAX (tafamidis) FE VYNDAQEL (tafamidis meglumine (cardiac)) FE *ULCER DRUGS* - DRUGS FOR THE STOMACH ACIPHEX (rabeprazole sodium) FE ACIPHEX SPRINKLE (rabeprazole sodium) FE amoxicill-clarithro-lansopraz G belladonna alkaloids-opium NPB CARAFATE (sucralfate) FE chlordiazepoxide-clidinium G cimetidine hcl oral G cimetidine oral G CUVPOSA (glycopyrrolate) NPB DEXILANT (dexlansoprazole) PB dicyclomine hcl oral G ed-spaz G ESOMEP-EZS (esomeprazole magnesium) FE esomeprazole magnesium oral capsule delayed release G esomeprazole strontium oral capsule delayed release 49.3 mg NPB famotidine oral suspension reconstituted G famotidine oral tablet 20 mg, 40 mg G GLYCATE (glycopyrrolate) FE glycopyrrolate oral tablet 1 mg, 2 mg G 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 196 Prescription Drug Name Drug Tier Drug Notes GLYRX-PF (glycopyrrolate) FE hyoscyamine sulfate er oral tablet extended release 12 hour G hyoscyamine sulfate oral G hyoscyamine sulfate sublingual G lansoprazole oral capsule delayed release G lansoprazole oral tablet delayed release dispersible G methscopolamine bromide oral G misoprostol oral G NEXIUM (esomeprazole magnesium) FE nizatidine G hyoscyamine sulfate (Nulev) G OMECLAMOX-PAK (amoxicill-clarithro-omeprazole) NPB omeprazole-sodium bicarbonate (Omeppi) FE omeprazole oral capsule delayed release G omeprazole-sodium bicarbonate FE oscimin G oscimin sr G pantoprazole sodium oral G PREVACID (lansoprazole) FE PRILOSEC ORAL PACKET (omeprazole magnesium) NPB propantheline bromide oral G PROTONIX ORAL (pantoprazole sodium) FE PYLERA (bis subcit-metronid-tetracyc) PB rabeprazole sodium oral capsule sprinkle NPB rabeprazole sodium oral tablet delayed release G ranitidine hcl oral capsule G ranitidine hcl oral syrup G ranitidine hcl oral tablet 150 mg, 300 mg G sucralfate oral tablet G SYMAX DUOTAB (hyoscyamine sulfate) NPB hyoscyamine sulfate (Symax-Sr) G ZEGERID (omeprazole-sodium bicarbonate) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 197 Prescription Drug Name Drug Tier Drug Notes *URINARY ANTI-INFECTIVES* - DRUGS FOR THE URINARY SYSTEM HYOPHEN (meth-hyo-m bl-benz acd-ph sal) G MACRODANTIN (nitrofurantoin macrocrystal) FE me/naphos/mb/hyo1 G methenamine hippurate G methenamine mandelate oral G MONUROL (fosfomycin tromethamine) NPB nitrofurantoin macrocrystal oral G nitrofurantoin monohyd macro G nitrofurantoin oral suspension G meth-hyo-m bl-na phos-ph sal (Phosphasal) G meth-hyo-m bl-na phos-ph sal (Uretron D/S) G meth-hyo-m bl-na phos-ph sal (Uribel) G URIMAR-T (meth-hyo-m bl-na phos-ph sal) G urin ds G uro-458 G uro-mp G methen-hyosc-meth blue-na phos (Uryl) G meth-hyo-m bl-na phos-ph sal (Ustell) G uticap G meth-hyo-m bl-na phos-ph sal (Utira-C) G meth-hyo-m bl-na phos-ph sal (Utrona-C) G meth-hyo-m bl-na phos-ph sal (Vilamit Mb) G meth-hyo-m bl-na phos-ph sal (Vilevev Mb) G *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM bethanechol chloride oral G darifenacin hydrobromide er G DETROL LA (tolterodine tartrate) FE ENABLEX (darifenacin hydrobromide) FE flavoxate hcl G GELNIQUE PUMP (oxybutynin chloride) NPB GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NPB chloride) 2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 198 Prescription Drug Name Drug Tier Drug Notes MYRBETRIQ (mirabegron) PB oxybutynin chloride er G oxybutynin chloride oral G OXYTROL (oxybutynin) FE solifenacin succinate G tolterodine tartrate G tolterodine tartrate er G TOVIAZ (fesoterodine fumarate) PB trospium chloride G trospium chloride er G *VACCINES* - BIOLOGICAL AGENTS FLUMIST QUADRIVALENT (influenza virus vac live quad) NPB ROTARIX (rotavirus vaccine live oral) NPB ROTATEQ ORAL SOLUTION (rotavirus vac live NPB pentavalent) VAXCHORA (cholera vac live attenuated) NPB VIVOTIF (typhoid vaccine) NPB *VAGINAL PRODUCTS* - DRUGS FOR WOMEN AVC VAGINAL (sulfanilamide) NPB CLEOCIN VAGINAL SUPPOSITORY (clindamycin NPB phosphate) clindamycin phosphate vaginal G CLINDESSE (clindamycin phosphate (1 dose)) NPB CRINONE (progesterone) PB ENCARE VAGINAL SUPPOSITORY (nonoxynol-9) NPB CE ENDOMETRIN (progesterone) PB estradiol vaginal G ESTRING (estradiol) PB FEMRING () NPB GYNAZOLE-1 (butoconazole nitrate (1 dose)) NPB IMVEXXY MAINTENANCE PACK (estradiol) NPB IMVEXXY STARTER PACK (estradiol) NPB INTRAROSA (prasterone) NPB metronidazole vaginal G

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 199 Prescription Drug Name Drug Tier Drug Notes miconazole 3 vaginal suppository G NUVESSA (metronidazole) FE OPTIONS GYNOL II CONTRACEPTIVE (nonoxynol-9) NPB CE PREMARIN VAGINAL (estrogens, conjugated) PB SHUR-SEAL CONTRACEPTIVE (nonoxynol-9) NPB CE terconazole G TRIMO-SAN VAGINAL GEL 0.025-0.01 % (oxyquinoline- FE sod lauryl sulf) metronidazole (Vandazole) G VCF VAGINAL CONTRACEPTIVE VAGINAL FILM NPB CE (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM NPB CE (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL G CE (nonoxynol-9) estradiol (Yuvafem) G *VASOPRESSORS* - DRUGS FOR THE HEART ADRENACLICK INJECTION SOLUTION AUTO- FE INJECTOR (epinephrine) ADRENALIN INJECTION (epinephrine) NPB ADYPHREN (epinephrine) FE ADYPHREN AMP (epinephrine) FE ADYPHREN AMP II (epinephrine) FE ADYPHREN II (epinephrine) FE AKOVAZ (ephedrine sulfate (pressors)) FE AUVI-Q INJECTION SOLUTION AUTO-INJECTOR FE (epinephrine) epinephrine injection solution 1 mg/ml, 30 mg/30ml FE epinephrine injection solution auto-injector G epinephrine pf injection solution prefilled syringe FE epinephrine professional FE EPINEPHRINESNAP-EMS (epinephrine) FE EPINEPHRINESNAP-V (epinephrine) FE EPISNAP (epinephrine) FE GIAPREZA (angiotensin ii acetate) FE

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 200 Prescription Drug Name Drug Tier Drug Notes midodrine hcl G SYMJEPI (epinephrine) FE *VITAMINS* - DRUGS FOR NUTRITION aminobenzoate potassium oral packet G AQUASOL A (vitamin a) NPB ASCOR (ascorbic acid) FE ergocal FE ergocalciferol oral capsule G phytonadione injection solution 1 mg/0.5ml, 10 mg/ml G phytonadione oral G POTABA ORAL CAPSULE (potassium aminobenzoate) NPB pyridoxine hcl injection G thiamine hcl injection G vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) G vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml G wheat germ oil oral oil NPB

2020 Pharmacy Drug Guide - Aetna Standard Plan The formulary is updated the first week of each month

01/01/2020 201 Index 12-PANEL POC ACCU-CHEK NANO ACTICOAT ABSORBENT....72 TOXICOLOGY SYSTEM...... 90 SMARTVIEW...... 121 ACTICOAT 1st tier unifine pentips...... 121 ACCU-CHEK PLASTIC ANTIMICROBIAL...... 72 1st tier unifine pentips plus...... 121 CARTRIDGE...... 121 ACTICOAT FLEX 3 4"X4"....72 1st tier unilet comfortouch...... 121 ACCU-CHEK RAPID-D acti-lance 28g...... 122 7T Lido...... 71 INFUSION SET...... 121 acti-lance lite lancets 28g...... 122 7topic...... 71 ACCU-CHEK RAPID-D acti-lance special lancets 17g.. 122 abacavir sulfate...... 52 LINK...... 121 acti-lance universal 23g...... 122 abacavir sulfate-lamivudine...... 52 ACCU-CHEK SAFE-T PRO ACTIMMUNE...... 44 abacavir-lamivudine-zidovudine 52 LANCETS...... 121 ACTIQ...... 16 Abaneu-Sl...... 111 ACCU-CHEK active fe...... 111 ABILIFY...... 50 SMARTVIEW...... 90 activite...... 166 ABILIFY MAINTENA...... 50 ACCU-CHEK SOFT ACTOS...... 31 ABILIFY MYCITE...... 50 TOUCH LANCETS...... 122 ACUICYN...... 72 abiraterone acetate...... 44 ACCU-CHEK SOFTCLIX ACUVAIL...... 177 ABLYSINOL...... 193 LANCET DEV...... 122 acyclovir...... 52, 72 ABSORICA...... 71 ACCU-CHEK SOFTCLIX ACZONE...... 72 ABSTRAL...... 16 LANCETS...... 122 adapalene...... 72 acamprosate calcium...... 189 ACCU-CHEK SPIRIT adapalene-benzoyl peroxide...... 72 ACANYA...... 71 BATTERY KIT...... 122 ADASUVE...... 50 acarbose...... 31 ACCU-CHEK TENDER II adc/f (0.5mg/ml)...... 166 ACCUCAINE...... 71 SET 24"...... 122 ADCIRCA...... 60 ACCU-CHEK AVIVA...... 121 ACCU-CHEK TENDER II ADDERALL XR...... 8 ACCU-CHEK AVIVA SET 31"...... 122 ADDYI...... 193 CONNECT...... 121 ACCU-CHEK TENDER II adefovir dipivoxil...... 52 ACCU-CHEK AVIVA PLUS SET 43"...... 122 ADEMPAS...... 60 ...... 90, 121 ACCU-CHEK ADHANSIA XR...... 8 ACCU-CHEK COMPACT ULTRAFLEX INF SET...... 122 adjustable lancing device...... 122 PLUS...... 90 ACCU-CHEK ADLYXIN...... 31 ACCU-CHEK COMPACT ULTRAFLEX-1 INF SET....122 ADLYXIN STARTER PLUS CARE...... 121 ACCUTREND GLUCOSE....90 PACK...... 31 ACCU-CHEK FASTCLIX acd formula a...... 26, 117 ADMELOG...... 31 LANCET...... 121 ACD-A NOCLOT-50...... 26, 117 ADRENACLICK...... 200 ACCU-CHEK FASTCLIX acebutolol hcl...... 57 ADRENAL C FORMULA.. 166 LANCETS...... 121 aceso ag...... 72 ADRENALIN...... 175, 200 ACCU-CHEK FLEXLINK acetaminophen-codeine...... 16 ADVAIR HFA...... 23 PLUS 10MM...... 121 acetaminophen-codeine #3...... 16 ADVANCE INTUITION ACCU-CHEK FLEXLINK acetazolamide...... 100 METER...... 122 PLUS 6MM...... 121 acetazolamide er...... 100 ADVANCE INTUITION ACCU-CHEK FLEXLINK acetic acid...... 107, 182 MONITOR...... 122 PLUS 8MM...... 121 acetylcysteine...... 70 ADVANCE INTUITION ACCU-CHEK GUIDE... 90, 121 ACIPHEX...... 196 TEST...... 90 ACCU-CHEK GUIDE ME..121 ACIPHEX SPRINKLE...... 196 ADVANCE MICRO-DRAW ACCU-CHEK LINKASSIST acitretin...... 72 METER...... 122 ...... 121 ACTEMRA...... 10 ADVANCE MICRO-DRAW ACCU-CHEK MULTICLIX ACTEMRA ACTPEN...... 10 TEST...... 90 LANCET DEV...... 121 ACTHAR...... 101 ADVANCED ALLERGY ACCU-CHEK MULTICLIX ACTICLATE...... 194 COLLECTION...... 72 LANCETS...... 121 ACTICOAT 7...... 72 advanced am/pm...... 166 202 ADVATE...... 109 AGAMATRIX KEYNOTE ALEVICYN ADVOCATE ARM BPM..... 122 TEST...... 90 ANTIPRURITIC...... 72 ADVOCATE BLOOD AGAMATRIX PRESTO...... 123 ALEVICYN GLUCOSE MONITOR...... 122 AGAMATRIX PRESTO ANTIPRURITIC SG...... 72 ADVOCATE BLOOD PRO METER...... 123 Alevicyn Dermal Spray...... 72 GLUCOSE SYSTEM...... 122 AGAMATRIX PRESTO ALEVICYN PLUS...... 72 ADVOCATE DUO...... 122 TEST...... 90 alfuzosin hcl er...... 108 ADVOCATE INSULIN PEN AGAMATRIX ULTRA- ALINIA...... 42 NEEDLES...... 122 THIN LANCETS...... 123 aliskiren fumarate...... 40 ADVOCATE INSULIN AGGRASTAT...... 109 ALIVE PRENATAL.....166, 188 SYRINGE...... 122 AIMOVIG...... 58 ALLEVYN AG ADHESIVE..72 ADVOCATE LANCETS AIMOVIG (140 MG DOSE)...58 ALLEVYN AG NON- 30G...... 122 aimsco twist lancets 32g...... 123 ADHESIVE...... 72 ADVOCATE LANCING AIMSCO TWIST LANCETS ALLEVYN AG SACRUM 6- DEVICE...... 123 33G...... 123 3/4"...... 72 ADVOCATE RAPID-SAFE Airavite...... 111 ALLEVYN AG SACRUM LANCING...... 123 AIRDUO RESPICLICK 9"X9"...... 72 ADVOCATE REDI-CODE 113/14...... 23 ALLEVYN GENTLE...... 72 ...... 90, 123 AIRDUO RESPICLICK ALLO-PAX...... 73 ADVOCATE REDI-CODE+123 232/14...... 23 allopurinol...... 109 ADVOCATE REDI-CODE+ AIRDUO RESPICLICK ALLZITAL...... 14 TALKING...... 123 55/14...... 23 almond oil (sweet)...... 61 ADVOCATE REDI-CODE+ AJOVY...... 58 almotriptan malate...... 161 TEST...... 90 AKOVAZ...... 200 ALOCRIL...... 177 ADVOCATE SAFETY ak-poly-bac...... 177 alogliptin benzoate...... 31 LANCETS...... 123 AKTEN...... 177 alogliptin-metformin hcl...... 31 ADVOCATE SAFETY AKTIPAK...... 72 alogliptin-pioglitazone...... 31 LANCETS 26G...... 123 AKYNZEO...... 36 ALOMIDE...... 177 ADVOCATE TEST...... 90 ALA SCALP...... 72 ALOPHEN...... 118 adynovate...... 109 ala-cort...... 72 ALOQUIN...... 73 ADYPHREN...... 200 albendazole...... 21 ALORA...... 104 ADYPHREN AMP...... 200 ALBUMINEX...... 109 alosetron hcl...... 106 ADYPHREN AMP II...... 200 albuterol sulfate...... 23 ALPHAGAN P...... 177 ADYPHREN II...... 200 albuterol sulfate er...... 23 ALPHANATE/VWF ADZENYS ER...... 8 albuterol sulfate hfa...... 23 COMPLEX/HUMAN...... 109 ADZENYS XR-ODT...... 8 alclometasone dipropionate...... 72 ALPHANINE SD...... 109 AEMCOLO...... 42 ALCOH-GLOVE alprazolam...... 22 AEROSPAN...... 23 CONTOURED WIPE...... 123 alprazolam er...... 22 AFINITOR...... 44 alcohol pads...... 123 ALPRAZOLAM INTENSOL 22 AFINITOR DISPERZ...... 44 alcohol prep...... 123 alprazolam xr...... 22 Afirmelle...... 62 alcohol swabs...... 123 ALPROLIX...... 109 AFREZZA...... 31 ALCOHOL SWABSTICK....123 ALREX...... 177 AFSTYLA...... 109 alcohol wipes...... 123 ALTABAX...... 73 AFTERA...... 62 alcoh-wipe...... 123 Altacaine...... 178 aftertest topical pain relief...... 72 ALCORTIN A...... 72 altafluor benox...... 178 AGAMATRIX AMP...... 123 ALDACTAZIDE...... 100 Altafrin...... 178 AGAMATRIX AMP TEST... 90 ALDURAZYME...... 101 Altavera...... 62 AGAMATRIX JAZZ TEST...90 ALECENSA...... 44 alternate site lancing device.... 123 AGAMATRIX JAZZ alendronate sodium...... 101 ALTOPREV...... 38 WIRELESS 2...... 123 alevamax...... 72 ALTRENO...... 73 203 ALUNBRIG...... 45 AMPYRA...... 189 AQUASOL A...... 201 ALVESCO...... 23 AMRIX...... 174 AQUORAL...... 163 alyacen 1/35...... 62 ANACAINE...... 73 ARAKODA...... 43 alyacen 7/7/7...... 62 ANADROL-50...... 20 ARALAST NP...... 192 Alyq...... 60 anagrelide hcl...... 109 Aranelle...... 62 ALZAIR ALLERGY anastia...... 73 ARANESP (ALBUMIN NASAL SPRAY...... 175 anastrozole...... 45 FREE)...... 111 Amabelz...... 104 ANDRODERM...... 20 ARCALYST...... 10 amantadine hcl...... 49 ANDROGEL...... 20 ARCAPTA NEOHALER...... 24 ambrisentan...... 60 ANDROGEL PUMP...... 20 Argyle Sterile Saline...... 108 amcinonide...... 73 anesthesia s/i-40...... 107 Argyle Sterile Water...... 55 AMD FOAM DRESSING... 123 anesthesia s/i-40a...... 107 ARIKAYCE...... 10 AMELUZ...... 73 anesthesia s/i-40h...... 107 aripiprazole...... 50 Amethia...... 62 anesthesia s/i-40s...... 107 ARISTADA...... 50 Amethia Lo...... 62 anesthesia s/i-60...... 107 ARISTADA INITIO...... 50 Amethyst...... 62 ANGELIQ...... 104 armodafinil...... 8 AMICAR...... 115 ANNOVERA...... 62 ARMONAIR RESPICLICK amiloride hcl...... 100 anodyne ile...... 176 113...... 24 amiloride-hydrochlorothiazide 100 ANORO ELLIPTA...... 23 ARMONAIR RESPICLICK aminoacetic acid...... 108 ANTARA...... 38 232...... 24 Aminoamrms...... 177 anticoagulant cit dext soln a ARMONAIR RESPICLICK aminobenzoate potassium...... 201 ...... 26, 117 55...... 24 aminocaproic acid...... 115 ANTICOAGULANT ARMOUR THYROID...... 195 AMINOPMRMS...... 98 COMPOUND...... 26, 117 arnica flower...... 73 AMINOPROTECT...... 177 anticoagulant sodium citrate ARNUITY ELLIPTA...... 24 Aminoreliefrms...... 177 ...... 26, 117 ARTHROTEC...... 10 amiodarone hcl...... 23 anti-stick insulin syringe...... 123 ARTISS...... 115 AMITIZA...... 106 ANZEMET...... 36 ARYMO ER...... 16 amitriptyline hcl...... 29 APADAZ...... 16 arze-ject-a...... 68 AMLODIPINE apap-caff-dihydrocodeine...... 16 ASACOL HD...... 106 BES+SYRSPEND SF...... 58 APEXICON E...... 73 Ascomp-Codeine...... 16 amlodipine besy-benazepril hcl..40 APIDRA...... 31 ASCOR...... 201 amlodipine besylate...... 58 APIDRA SOLOSTAR...... 31 Ashlyna...... 62 amlodipine besylate-valsartan...40 APLENZIN...... 29 Asilnasalrms...... 98 amlodipine-atorvastatin...... 60 APLICARE ALCOHOL ASMANEX (120 METERED amlodipine-olmesartan...... 40 SWABSTICK...... 123 DOSES)...... 24 amlodipine-valsartan-hctz...... 40 APOKYN...... 49 ASMANEX (14 METERED ammonium lactate...... 73 APP SLIM RMS...... 98 DOSES)...... 24 Amnesteem...... 73 apraclonidine hcl...... 178 ASMANEX (30 METERED amoxapine...... 29 aprepitant...... 36 DOSES)...... 24 amoxicill-clarithro-lansopraz..196 Apri...... 62 ASMANEX (60 METERED amoxicillin...... 184 APRISO...... 106 DOSES)...... 24 amoxicillin-pot clavulanate.....184 APRIZIO PAK...... 73 ASMANEX (7 METERED amoxicillin-pot clavulanate er. 184 APTENSIO XR...... 8 DOSES)...... 24 AMPHADASE...... 55 APTIOM...... 27 ASMANEX HFA...... 24 amphetamine sulfate...... 8 APTIVUS...... 52 aspirin...... 14 amphetamine-dextroamphet er... 8 ap-zel...... 166 aspirin adult low dose...... 14 amphetamine- AQUACEL AG BURN...... 73 aspirin ec low strength...... 14 dextroamphetamine...... 8 AQUALANCE LANCETS aspirin low dose...... 14 ampicillin...... 184 30G...... 123 aspirin-dipyridamole er...... 109 204 ASPIR-LOW...... 15 Aubra...... 62 AZELEX...... 73 ASSURE 3 METER...... 123 Aubra Eq...... 62 azesco...... 166 ASSURE 3 TEST...... 91 AUGMENTIN...... 184 azithromycin...... 120 ASSURE 4 METER...... 123 aurora lancet super thin 30g....124 AZOPT...... 178 ASSURE 4 TEST...... 91 aurora lancet thin 23g...... 124 Azurette...... 62 assure comfort lancets 28g...... 123 aurora pen needles...... 124 b-6 folic acid...... 111 ASSURE ID INSULIN aurora unifine pentips...... 124 bacitracin...... 178 SAFETY SYR...... 123 Aurovela 1.5/30...... 62 bacitracin-polymyxin b...... 178 ASSURE ID SAFETY PEN Aurovela 1/20...... 62 bacitra-neomycin-polymyxin- NEEDLES...... 124 Aurovela 24 Fe...... 62 hc...... 178 ASSURE II...... 91 Aurovela Fe 1.5/30...... 62 baclofen...... 174 ASSURE II CHECK...... 91 Aurovela Fe 1/20...... 62 BAL-CARE DHA...... 166 ASSURE LANCETS...... 124 AURYXIA...... 106 BALCOLTRA...... 62 ASSURE PLATINUM...... 91 AUSTEDO...... 189 balsalazide disodium...... 106 ASSURE PLATINUM AUTO-LANCET...... 124 balsam peru-castor oil...... 73 METER...... 124 AUTO-LANCET MINI...... 124 BALVERSA...... 44 ASSURE PRISM MULTI AUTOLET II CLINISAFE.. 124 Balziva...... 62 TEST...... 91 AUTOLET LITE BANZEL...... 27 ASSURE PRO BLOOD CLINISAFE...... 124 BAQSIMI ONE PACK...... 31 GLUCOSE METER...... 124 AUTOLET LITE STARTER BAQSIMI TWO PACK...... 31 ASSURE PRO TEST...... 91 PACK...... 124 BARACLUDE...... 52 ASTAGRAF XL...... 55 AUTOLET MINI...... 124 barium sulfate...... 91 ASTAMED MYO...... 98 AUTOLET PLATFORMS... 124 BASAGLAR KWIKPEN...... 31 ASTERO...... 73 AUTOLET PLUS...... 124 base g almond oil (sweet)...... 61 AT LAST BLOOD AUTOSOFT 30 INFUSION base x...... 185 GLUCOSE SYSTEM...... 124 SET...... 124 BAXDELA...... 105 AT LAST TEST...... 91 AUTOSOFT 90 INFUSION BAYER ASPIRIN EC LOW ATABEX EC...... 166 SET...... 124 DOSE...... 15 ATABEX OB...... 166 AUTOSOFT XC INFUSION BAYER BREEZE 2 ATACAND...... 40 SET...... 124 SYSTEM...... 124 ATACAND HCT...... 40 AUVI-Q...... 200 BAYER BREEZE 2 TEST...... 91 atazanavir sulfate...... 52 AVANDIA...... 31 BAYER CONTOUR LINK atenolol...... 57 AVAR...... 73 2.4...... 124 ATENOLOL+SYRSPEND AVAR LS...... 73 BAYER CONTOUR LINK SF...... 57 AVC VAGINAL...... 199 MONITOR...... 124 atenolol-chlorthalidone...... 40 AVENOVA...... 73 BAYER LOW DOSE...... 15 atomoxetine hcl...... 8 AVENOVA/NEUTROX...... 73 bcaa...... 177 atopaderm...... 73 Aviane...... 62 BD AUTOSHIELD...... 124 ATOPICLAIR...... 73 avidoxy...... 194 BD AUTOSHIELD DUO.... 124 atorvastatin calcium...... 38 Avita...... 73 BD INSULIN SYRINGE.....125 atovaquone...... 42 AVONEX...... 189 BD INSULIN SYRINGE atovaquone-proguanil hcl...... 43 AVONEX PEN...... 189 MICROFINE...... 125 ATRAPRO CP...... 73 AVONEX PREFILLED...... 189 BD INSULIN SYRINGE ATRAPRO DERMAL axifol...... 111 U/F...... 125 SPRAY...... 73 Ayuna...... 62 BD INSULIN SYRINGE U- ATRAPRO HYDROGEL...... 73 AZASAN...... 55 500...... 125 ATRIPLA...... 52 AZASITE...... 178 BD INSULIN SYRINGE atropine sulfate...... 178 azathioprine...... 55 ULTRAFINE...... 125 ATROVENT HFA...... 24 azelaic acid...... 73 BD LANCET ULTRAFINE AUBAGIO...... 189 azelastine hcl...... 175, 178 30G...... 125 205 BD LANCET ULTRAFINE BENZIQ LS...... 74 BIOFREQUENCY 33G...... 125 BENZIQ WASH...... 74 INSOLES...... 125 BD LATITUDE DIABETES125 benznidazole...... 21 BIOGUARD GAUZE BD LATITUDE DIABETES BENZODOX...... 194 SPONGES...... 125 SYSTEM...... 125 benzoin...... 74 BIOGUARD ISLAND BD LOGIC BLOOD benzonatate...... 70 DRESSINGS...... 126 GLUCOSE MONITOR...... 125 benzoyl perox-hydrocortisone... 74 BIOGUARD NON- BD MICROTAINER benzoyl peroxide...... 74 ADHERENT DRESSING... 126 LANCETS...... 125 benzoyl peroxide-erythromycin.74 BIOSCANNER GLUCOSE BD PEN NEEDLE MICRO benztropine mesylate...... 49 TEST...... 91 U/F...... 125 benzyl alcohol...... 185 bio-statin...... 37 BD PEN NEEDLE MINI benzyl benzoate...... 61 BIOTEL CARE BLOOD U/F...... 125 BEPREVE...... 178 GLUCOSE SYST...... 126 BD PEN NEEDLE NANO BERINERT...... 110 bisacodyl...... 118 2ND GEN...... 125 BESER...... 74 bisacodyl ec...... 118 BD PEN NEEDLE NANO Beser...... 74 bisoprolol fumarate...... 57 U/F...... 125 BESIVANCE...... 178 bisoprolol-hydrochlorothiazide..40 BD PEN NEEDLE beta 1 kit...... 68 BIVIGAM...... 183 ORIGINAL U/F...... 125 BETADINE OPHTHALMIC bl injection...... 120 BD PEN NEEDLE SHORT PREP...... 178 BLEO 15K...... 45 U/F...... 125 betamethasone combo...... 68 BLEPHAMIDE...... 178 BD SAFETYGLIDE betamethasone dipropionate..... 74 BLEPHAMIDE S.O.P...... 178 INSULIN SYRINGE...... 125 betamethasone dipropionate Blisovi 24 Fe...... 62 BD SWAB SINGLE USE aug...... 74 Blisovi Fe 1.5/30...... 62 REGULAR...... 125 betamethasone valerate...... 74 Blisovi Fe 1/20...... 63 BD SWABS SINGLE USE BETAPACE...... 57 blood glucose monitor system..126 BUTTERFLY...... 125 BETAPACE AF...... 57 blood glucose system pak...... 126 BD VEO INSULIN BETASERON...... 189 blood glucose test...... 91 SYRINGE U/F...... 125 betaxolol hcl...... 57, 178 BOCASAL...... 163 beau rx...... 73 bethanechol chloride...... 198 BONJESTA...... 36 BECONASE AQ...... 175 BETHKIS...... 10 boric acid...... 74 Bekyree...... 62 BETIMOL...... 178 bosentan...... 60 BELBUCA...... 16 BETOPTIC-S...... 178 BOSULIF...... 45 belladonna alkaloids-opium.....196 BEVESPI AEROSPHERE..... 24 BOTOX...... 176 BELRAPZO...... 45 BEVYXXA...... 26 bp foam...... 74 BELSOMRA...... 182 bexarotene...... 45 bp vit 3...... 111 benazepril hcl...... 40 BEYAZ...... 62 bp wash...... 74 benazepril-hydrochlorothiazide.40 bicalutamide...... 45 bpco...... 74 BENEFIX...... 110 BIDIL...... 60 b-plex...... 166 BENICAR...... 40 bi-est 50:50...... 104 b-plex plus...... 166 BENICAR HCT...... 40 bi-est 80:20 progesterone...... 104 BRAVELLE...... 101 BENLYSTA...... 55 bi-est progest-testosterone...... 104 BREEZE 2 TEST...... 91 bensal hp...... 73 BIEST/PROGESTERONE...104 BREO ELLIPTA...... 24 BENZACLIN...... 73 BIJUVA...... 104 BRIDION...... 35 BENZACLIN WITH PUMP..74 BIKTARVY...... 52 briellyn...... 63 benzalkonium chloride...... 52 bimatoprost...... 178 BRILINTA...... 99, 110 BENZEPRO...... 74 bi-mix...... 117 brimonidine tartrate...... 178 Benzepro...... 74 BINOSTO...... 101 BRIVIACT...... 27 Benzepro Short Contact...... 74 biocel...... 166 Bromfed Dm...... 70 BENZIQ...... 74 206 bromfenac sodium (once-daily) calcitonin (salmon)...... 101 CARDIZEM LA...... 59 ...... 178 Calcitrene...... 74 CARDURA XL...... 108 bromocriptine mesylate...... 49 calcitriol...... 74, 101 CAREFINE PEN NEEDLES brompheniramine tannate...... 37 calcium acetate (phos binder).106 ...... 126 BROMSITE...... 178 calcium folinate...... 61 careone advanced lancing dev..126 BROVANA...... 24 calm...... 177 CAREONE BLOOD BRYHALI...... 74 CAMBIA...... 161 GLUCOSE SYSTEM...... 126 budesonide...... 24, 68 Camila...... 63 CAREONE BLOOD budesonide er...... 68 CAMINO PRO GLUCOSE TEST...... 91 buffered lidocaine...... 120 COMPLETE/GLYTACTIN...98 careone insulin syringe...... 126 bullseye mini safety lancets.....126 Camrese...... 63 careone lancet thin 23g...... 126 BULLSEYE SAFETY Camrese Lo...... 63 careone lancet ultra thin 28g...126 LANCETS...... 126 candesartan cilexetil...... 40 careone unifine pentips...... 126 bumetanide...... 100 candesartan cilexetil-hctz...... 40 careone unifine pentips plus.....126 BUNAVAIL...... 16 Capacet...... 15 CARESENS N GLUCOSE Bupap...... 15 capecitabine...... 45 SYSTEM...... 126 BUPHENYL...... 101 CAPEX...... 74 CARESENS N GLUCOSE buprenorphine...... 16 CAPHOSOL...... 163 TEST...... 91 buprenorphine hcl...... 16 CAPRELSA...... 45 CARESENS N VOICE buprenorphine hcl-naloxone hcl.16 capsule 0 clear dr...... 185 SYSTEM...... 126 bupropion hcl...... 29 capsule coni-snap #0 clear...... 185 CARETOUCH ALCOHOL bupropion hcl er (smoking det) capsule coni-snap #0 purple.... 185 PREP...... 126 ...... 189 capsule coni-snap #00 white....185 CARETOUCH INSULIN bupropion hcl er (sr)...... 29 capsule coni-snap #000 clear.. 185 SYRINGE...... 126 bupropion hcl er (xl)...... 29 capsule coni-snap #1 red/blue. 185 CARETOUCH buspirone hcl...... 22 capsule coni-snap #1 veggie.... 185 LANCING/EJECTOR...... 126 butalbital-acetaminophen...... 15 capsule coni-snap #2 white..... 185 CARETOUCH MONITOR butalbital-apap-caff-cod...... 16 capsule coni-snap #3 clear...... 185 SYSTEM...... 126 butalbital-apap-caffeine...... 15 capsule coni-snap #3 yellow....185 CARETOUCH PEN butalbital-asa-caff-codeine...... 17 capsule coni-snap #4 white..... 185 NEEDLES...... 126 butalbital-aspirin-caffeine...... 15 capsule ezeefit #0 clear...... 185 CARETOUCH SAFETY BUTISOL SODIUM...... 116 capsule ezeefit #00 clear...... 185 LANCETS 26G...... 126 butorphanol tartrate...... 17 captopril...... 40 CARETOUCH TEST...... 91 BUTRANS...... 17 captopril-hydrochlorothiazide...40 CARETOUCH TWIST BYDUREON...... 31 CAPXIB...... 10 LANCETS 28G...... 126 BYDUREON BCISE...... 31 CARAC...... 74 CARETOUCH TWIST BYETTA 10 MCG PEN...... 31 CARAFATE...... 196 LANCETS 30G...... 126 BYETTA 5 MCG PEN...... 31 carbamazepine...... 27 CARETOUCH TWIST BYSTOLIC...... 57 carbamazepine er...... 27 LANCETS 33G...... 126 BYVALSON...... 57 carbidopa...... 49 CARIMUNE NF...... 183 cabergoline...... 101 carbidopa-levodopa...... 49 carisoprodol...... 174 CABLIVI...... 55 carbidopa-levodopa er...... 49 carisoprodol-aspirin...... 174 CABOMETYX...... 45 carbidopa-levodopa-entacapone 49 carisoprodol-aspirin-codeine... 174 cadeau dha...... 166 carbinoxamine maleate...... 37 CARNITOR...... 101 CADIRAMD...... 74 CARDIOCOM LANCING CARNITOR SF...... 101 CAFERGOT...... 161 DEVICE...... 126 CAROSPIR...... 100 caffeine citrate...... 8 cardioplegic...... 60 carteolol hcl...... 178 CALCIFOL...... 162 CARDIOVID PLUS...... 177 Cartia Xt...... 59 calcipotriene...... 74 CARDIZEM...... 59 cartridge ir 1000 3ml...... 126 calcipotriene-betameth diprop...74 CARDIZEM CD...... 58 cartridge ir 1200...... 127 207 cartridge pump...... 127 CHEMSTRIP K...... 91 CITRANATAL HARMONY carvedilol...... 57 CHEMSTRIP UGK...... 91 ...... 166 carvedilol phosphate er...... 57 CHENODAL...... 106 CITRANATAL MEDLEY...166 cascara sagrada...... 118 cherry...... 185 CITRANATAL RX...... 166 castor oil...... 61 childrens aspirin...... 15 Claravis...... 75 Cavarest...... 163 childrens aspirin low strength....15 CLARINEX-D 12 HOUR...... 70 CAYA...... 127 chlordiazepoxide hcl...... 22 clarithromycin...... 120 Caziant...... 63 chlordiazepoxide-amitriptyline189 clarithromycin er...... 120 cefaclor...... 61 chlordiazepoxide-clidinium..... 196 CLEANLET LANCETS 28G cefaclor er...... 61 chlorhexidine gluconate.....52, 164 ...... 127 cefadroxil...... 61 chloroquine phosphate...... 43 clemastine fumarate...... 38 cefdinir...... 61 chlorothiazide...... 100 CLENPIQ...... 118 cefditoren pivoxil...... 61 chlorpromazine hcl...... 50 CLEO 90 INFUSION SET cefixime...... 61 chlorthalidone...... 100 24"/6MM...... 127 cefpodoxime proxetil...... 61 chlorzoxazone...... 174 CLEO 90 INFUSION SET cefprozil...... 61 CHOICE DM DIABETES 24"/9MM...... 127 cefuroxime axetil...... 61 RISK TEST...... 127 CLEO 90 INFUSION SET Celacyn...... 75 CHOLBAM...... 58 31"/6MM...... 127 celecoxib...... 10 cholestyramine...... 38 CLEO 90 INFUSION SET CELESTONE SOLUSPAN....68 cholestyramine light...... 38 31"/9MM...... 127 CELLCEPT...... 55 choline-mag trisalicylate...... 15 CLEOCIN...... 199 CELLCEPT CIALIS...... 60 CLEVER CHEK AUTO- INTRAVENOUS...... 55 Ciclodan...... 75 CODE...... 127 CELONTIN...... 27 ciclopirox...... 75 CLEVER CHEK AUTO- CENFOL...... 111 ciclopirox olamine...... 75 CODE SYSTEM...... 127 CENTANY...... 75 cilostazol...... 110 CLEVER CHEK AUTO- cephalexin...... 61 CILOXAN...... 178 CODE TEST...... 91 CEQUA...... 178 CIMDUO...... 52 CLEVER CHEK AUTO- CERAMAX...... 75 cimetidine...... 196 CODE VOICE...... 91, 127 CERDELGA...... 111 cimetidine hcl...... 196 CLEVER CHEK LANCETS 127 CEREZYME...... 112 CIMZIA...... 106 CLEVER CHEK SYSTEM.. 127 cervical specimen collection...... 91 CIMZIA PREFILLED...... 106 CLEVER CHEK TEST...... 91 CERVIDIL...... 183 CIMZIA STARTER KIT..... 106 CLEVER CHOICE AUTO- CESAMET...... 36 cinacalcet hcl...... 101 CODE SYSTEM...... 127 CETACAINE...... 75 CINQAIR...... 118 CLEVER CHOICE AUTO- cetirizine hcl...... 38 CINRYZE...... 110 CODE TEST...... 91 CETROTIDE...... 101 CINVANTI...... 36 CLEVER CHOICE CETYLEV...... 35, 36 CIPRO...... 105 COMFORT EZ...... 127 cevimeline hcl...... 164 CIPRO HC...... 182 CLEVER CHOICE CGMS REPLACEMENT CIPRODEX...... 182 LANCETS 21G...... 127 CABLE...... 127 ciprofloxacin...... 105 CLEVER CHOICE CGMS SOFTWARE...... 127 ciprofloxacin hcl...... 105, 178, 182 LANCETS 23G...... 127 CHANTIX...... 189 citalopram hydrobromide...... 29 CLEVER CHOICE CHANTIX CONTINUING CITRANATAL 90 DHA...... 166 LANCETS 28G...... 127 MONTH PAK...... 189 CITRANATAL ASSURE.... 166 CLEVER CHOICE MICRO CHANTIX STARTING CITRANATAL B-CALM.... 166 SYSTEM...... 127 MONTH PAK...... 189 CITRANATAL BLOOM..... 166 CLEVER CHOICE MICRO Chateal...... 63 CITRANATAL BLOOM TEST...... 91 Chateal Eq...... 63 DHA...... 166 CLEVER CHOICE MINI CHEMET...... 36 CITRANATAL DHA...... 166 SYSTEM...... 127 208 CLEVER CHOICE NO colchicine...... 109 CO-NATAL FA...... 166 CODING...... 91 colchicine-probenecid...... 109 CONCEPT DHA...... 166 CLEVER CHOICE TALK COLCRYS...... 109 CONCEPT OB...... 166 SYSTEM...... 91, 127 colesevelam hcl...... 38 CONDYLOX...... 76 CLICKFINE PEN colestipol hcl...... 38 constulose...... 118 NEEDLES...... 128 COLLATYL...... 75 CONTACT DETACH INF clickfine pen needles...... 128 Colocort...... 21 SET 23"/8MM...... 128 CLIMARA PRO...... 104 COLY-MYCIN S...... 182 CONTACT DETACH INF CLIN SINGLE USE...... 42 COMBIGAN...... 178 SET 32"/6MM...... 128 Clindacin Etz...... 75 COMBIPATCH...... 104 CONTACT DETACH INF Clindacin-P...... 75 COMBIVENT RESPIMAT....24 SET 32"/8MM...... 128 clindamycin hcl...... 42 COMETRIQ (100 MG CONTACT DETACH INF clindamycin palmitate hcl...... 42 DAILY DOSE)...... 45 SET 43" 6MM...... 129 clindamycin phos-benzoyl COMETRIQ (140 MG CONTACT DETACH INF perox...... 75 DAILY DOSE)...... 45 SET 43" 8MM...... 129 clindamycin phosphate...... 75, 199 COMETRIQ (60 MG DAILY CONTOUR MONITOR...... 129 clindamycin-tretinoin...... 75 DOSE)...... 45 CONTOUR NEXT EZ...... 129 CLINDESSE...... 199 COMFORT ASSIST CONTOUR NEXT LINK.... 129 CLINOLIPID...... 177 INSULIN SYRINGE...... 128 CONTOUR NEXT Clinpro 5000...... 164 comfort assured lancets 28g.... 128 MONITOR...... 129 clobazam...... 27 comfort assured lancets 33g.... 128 CONTOUR NEXT ONE...... 129 clobetasol prop emollient base...75 COMFORT EZ INSULIN CONTOUR NEXT TEST...... 91 clobetasol propionate...... 75 SYRINGE...... 128 CONTOUR TEST...... 91 clobetasol propionate e...... 75 COMFORT EZ MICRO CONTRAST ALLERGY clobetasol propionate emulsion. 75 PEN NEEDLES...... 128 PREMED PACK...... 68 CLOBEX SPRAY...... 75 COMFORT EZ PEN CONTRAVE...... 49 Clodan...... 75 NEEDLES...... 128 CONTROL AST...... 91 CLODERM...... 75 COMFORT EZ SHORT CONTROL BLOOD clomiphene citrate...... 101 PEN NEEDLES...... 128 GLUCOSE SYSTEM...... 129 clomipramine hcl...... 29 COMFORT INFUSION SET CONTROL TEST...... 91 clonazepam...... 27 23"/17MM...... 128 CONVENIENCE PAK...... 188 clonidine...... 40 COMFORT INFUSION SET CONZIP...... 17 clonidine hcl...... 40 31"/17MM...... 128 COOL BLOOD GLUCOSE clonidine hcl er...... 8 COMFORT INFUSION SET TEST STRIPS...... 91 clopidogrel bisulfate...... 110 32"/17MM...... 128 COOL MONITOR...... 129 clorazepate dipotassium...... 22 COMFORT INFUSION SET COOL MONITOR KIT...... 129 clotrimazole...... 75, 164 43"/17MM...... 128 COPASIL...... 76 clotrimazole-betamethasone..... 75 comfort lancets...... 128 COPAXONE...... 190 clozapine...... 50 COMFORT SHORT INF COPIKTRA...... 187 c-nate dha...... 166 SET 23"/13MM...... 128 CORDRAN...... 76 COAGADEX...... 110 COMFORT SHORT INF Coremino...... 194 COAGUCHEK LANCETS..128 SET 31"/13MM...... 128 CORLANOR...... 194 coal tar...... 75 COMFORT SHORT INF corn (syrup)...... 185 COARTEM...... 43 SET 32"/13MM...... 128 correct...... 118 co-balamin...... 10 COMFORT SHORT INF CORRECTOL...... 118 cocoa butter...... 185 SET 43"/13MM...... 128 CORTIFOAM...... 21 coconut oil...... 61 COMPLERA...... 52 cortisone acetate...... 68 cod liver oil...... 166 complete natal dha...... 166 CORTISPORIN...... 76 codeine sulfate...... 17 completenate...... 166 CORTISPORIN-TC...... 182 COLAZAL...... 106 Compro...... 50 CORVITA...... 167 209 Corvita 150...... 112 CUTAQUIG...... 183 Cyred Eq...... 63 CORVITE 150...... 112 CUVITRU...... 183 CYSTAGON...... 108 corvite fe...... 112 CUVPOSA...... 196 CYSTOGRAFIN...... 92 Corvite Free...... 167 CVS ADVANCED CYSTOGRAFIN-DILUTE....92 COSENTYX...... 76 GLUCOSE TEST...... 91 CYSVIEW...... 92 COSENTYX (300 MG cvs aspirin low dose...... 15 cytra k crystals...... 108 DOSE)...... 76 cvs aspirin low strength...... 15 DAKLINZA...... 52 COSENTYX CVS BLOOD GLUCOSE dalfampridine er...... 190 SENSOREADY (300 MG)..... 76 METER...... 129 DALIRESP...... 24 COSENTYX cvs c-lax laxative...... 118 danazol...... 20 SENSOREADY PEN...... 76 cvs folic acid...... 112 dantrolene sodium...... 174 COTELLIC...... 45 CVS KETONE CARE...... 92 dapsone...... 42, 76 COTEMPLA XR-ODT...... 8 cvs lancets 21g...... 129 DARAPRIM...... 43 cottonseed oil...... 61 cvs lancets micro thin 33g...... 129 darifenacin hydrobromide er... 198 COUMADIN...... 26 cvs lancets original...... 129 Dasetta 1/35...... 63 co-veratrol...... 10 cvs lancets thin 26g...... 129 Dasetta 7/7/7...... 63 CREON...... 99 cvs lancets ultra thin 30g...... 129 DAURISMO...... 45 CRESEMBA...... 37 cvs lancets ultra-thin 30g...... 129 DAXBIA...... 61 CRESTOR...... 38 cvs lancing device...... 130 Daysee...... 63 CRINONE...... 199 cvs nicotine...... 190 DAYTRANA...... 8 CRIXIVAN...... 52 cvs nicotine polacrilex...... 190 d-care 100x...... 120 cromolyn sodium...... 24, 106, 178 cvs prenatal gummy...... 167, 188 D-CARE BLOOD Crotan...... 76 cvs prep...... 130 GLUCOSE...... 92 Cryselle-28...... 63 cvs ultra thin lancets...... 130 D-CARE DM2...... 58 CURITY ALCOHOL PREPS cyanocobalamin...... 112 D-CARE GLUCOMETER.. 130 ...... 129 Cyclafem 1/35...... 63 DDAVP RHINAL TUBE.....101 CURITY ALCOHOL Cyclafem 7/7/7...... 63 Deblitane...... 63 SWABS...... 129 cyclo/gaba 10/300...... 174 Decadron...... 68 CURITY AMD cyclobenzaprine hcl...... 174 deferasirox...... 36 ANTIMICROBIAL SPNGE 129 cyclobenzaprine hcl er...... 174 deferoxamine mesylate...... 35, 36 CURITY AMD CYCLOMYDRIL...... 178 DEFITELIO...... 26 ANTIMICROBIAL STRIP.. 129 cyclopentolate hcl...... 178 DELESTROGEN...... 104 CURITY HYPERTONIC CYCLOPHENE RAPIDPAQ DELSTRIGO...... 52 NACL STRIP...... 76 ...... 174 DELTEC COZMO CLEO CURITY IODOFORM cyclophosphamide...... 45 SET 42" 6MM...... 130 PACKING STRIP...... 129 cycloserine...... 43 DELTEC COZMO CLEO CURITY NACL DRESSING CYCLOSET...... 32 SET 42" 9MM...... 130 6"X6-3/4"...... 76 cyclosporine...... 55 Deluo...... 76 Curity Sterile Saline...... 108 CYCLOSPORINE IN Delyla...... 63 CURITY WOUND KLARITY...... 178 DELZICOL...... 106 CLOSURE 1/2"X4"...... 129 cyclosporine modified...... 55 demeclocycline hcl...... 194 CURITY WOUND CYCLOTENS REFILL PAK DEMSER...... 40 CLOSURE 1/4"X1.5"...... 129 ...... 174 DENAVIR...... 76 CURITY WOUND CYCLOTENS STARTER Denta 5000 Plus...... 164 CLOSURE 1/4"X3"...... 129 PAK...... 174 Dentagel...... 164 CURITY WOUND CYFOLEX...... 112 DEPEN TITRATABS...... 55 CLOSURE 1/4"X4"...... 129 CYMBALTA...... 29 DEPO-ESTRADIOL...... 104 CURITY WOUND cyproheptadine hcl...... 38 DEPO-SUBQ PROVERA CLOSURE 1/8"X3"...... 129 CYRAMZA...... 45 104...... 63 CUROSURF...... 192 Cyred...... 63 DEPO-TESTOSTERONE...... 20 210 DERMA SILKRX desvenlafaxine er...... 29 DIAB F.D.G. FREEZE- ANODYNEXA PAK...... 11 desvenlafaxine succinate er...... 29 DRIED...... 77 DERMA SILKRX DETROL LA...... 198 DIACOMIT...... 27 DICLOPAK...... 11 dexamethasone...... 68 DIASTIX...... 92 dermacinrx analgesic dexamethasone (la)...... 68 diathrive blood glucose meter..130 combopak...... 11 DEXAMETHASONE diathrive blood glucose test...... 92 DERMACINRX AZENASE INTENSOL...... 68 diathrive glucose test...... 92 PAK...... 175 dexamethasone sodium diathrive lancet ultra thin 30... 130 DERMACINRX CINLONE- phosphate...... 178 diathrive lancets...... 130 I CPI...... 68 dexchlorpheniramine maleate... 38 diathrive lancing device...... 130 DERMACINRX DEXCOM G4 PLAT PED diatrue plus blood glucose...... 130 CLORHEXACIN...... 76 RCV/SHARE...... 130 diatrue plus test...... 92 DERMACINRX DPN PAK 194 DEXCOM G4 PLAT PED diazepam...... 22, 27 DERMACINRX RECEIVER...... 130 DICLEGIS...... 36 DUOPATCH DEXCOM G4 PLATINUM DICLO GEL...... 77 PHARMAPAK...... 76 RCV/SHARE...... 130 DICLO GEL WITH DERMACINRX DEXCOM G4 PLATINUM XRYLIX SHEETS...... 77 INFLAMMATRAL PAK...... 11 RECEIVER...... 130 diclofenac epolamine...... 77 DERMACINRX DEXCOM G4 PLATINUM diclofenac potassium...... 11 LEXITRAL PHARMAPAK..76 TRANSMITTER...... 130 diclofenac sodium...... 11, 77, 179 DERMACINRX DEXCOM G4 SENSOR...... 130 diclofenac sodium er...... 11 NEUROTRAL DEXCOM G5 MOB/G4 diclofenac-misoprostol...... 11 PHARMAPAK...... 76 PLAT SENSOR...... 130 Diclofex Dc...... 77 DERMACINRX PHN...... 76 DEXCOM G5 MOBILE DICLOFONO...... 77 dermacinrx silapak...... 76 RECEIVER...... 130 diclopr...... 77 dermacinrx surgical combopak. 76 DEXCOM G5 MOBILE diclosaicin...... 77 DERMACINRX TRANSMITTER...... 130 diclovix...... 77 SURGICAL PHARMAPAK. 77 DEXCOM G6 RECEIVER.. 130 dicloxacillin sodium...... 184 DERMACINRX DEXCOM G6 SENSOR...... 130 diclozor...... 77 THERAZOLE PAK...... 77 DEXCOM G6 dicyclomine hcl...... 196 DERMACINRX TRANSMITTER...... 130 didanosine...... 52 TICANASE PAK...... 175 DEXCOM RECEIVER KIT 130 DIFICID...... 120 DERMACINRX ZRM...... 77 DEXERYL...... 77 Difil-G Forte...... 24 DERMAWERX SURGICAL Dexifol...... 167 diflorasone diacetate...... 77 PLUS PAK...... 77 DEXILANT...... 196 diflunisal...... 15 DERMAZONE...... 77 dexmethylphenidate hcl...... 9 Digitek...... 59 DERMAZYL...... 77 dexmethylphenidate hcl er...... 9 Digox...... 59 DERMULCERA...... 77 DEXONTO 0.4%...... 68 digoxin...... 59 DESCOVY...... 52 DEXOPIN...... 68 dihydroergotamine mesylate... 161 DESFERAL...... 35, 36 Dexpak 10 Day...... 68 DILANTIN...... 27 desflurane...... 107 Dexpak 13 Day...... 68 DILATRATE-SR...... 22 desipramine hcl...... 29 Dexpak 6 Day...... 68 DILAUDID...... 17 desloratadine...... 38 DEXTENZA...... 178 diltiazem hcl...... 59 desmopressin ace spray refrig. 101 dextroamphetamine sulfate...... 9 diltiazem hcl er...... 59 desmopressin acetate...... 101 dextroamphetamine sulfate er.....9 diltiazem hcl er beads...... 59 desmopressin acetate spray..... 101 DEXYCU...... 179 diltiazem hcl er coated beads.... 59 desogestrel-ethinyl estradiol...... 63 dfs dr/ms/menth/cap pak...... 11 dilt-xr...... 59 DESONATE...... 77 dfs/ms/menth/cap pak...... 77 dimentho...... 77 desonide...... 77 DIAB...... 77 DIOVAN...... 40 desoximetasone...... 77 DIOVAN HCT...... 40 211 DIPENTOCAINE...... 77 drospiren-eth estrad-levomefol..63 easy glide pen needles...... 131 DIPENTUM...... 106 drospirenone-ethinyl estradiol...63 easy mini eject lancing device..131 diphenhydramine hcl...... 38 DROXIA...... 112 easy mini lancing device...... 131 diphenoxylate-atropine...... 35 drug mart lancets thin 26g...... 131 easy plus blood glucose system 131 dipyridamole...... 110 DRUG MART ON-THE-GO easy plus blood glucose test...... 92 disopyramide phosphate...... 23 LANCET 30G...... 131 easy plus ii glucose system...... 131 disulfiram...... 190 drug mart unifine pentips...... 131 easy plus ii glucose test...... 92 DITHOL...... 78 drug mart unifine pentips plus. 131 EASY STEP GLUCOSE DIURIL...... 100 DRYSOL...... 78 MONITOR...... 131 divalproex sodium...... 27 ds prep pak...... 78 EASY STEP TEST...... 92 divalproex sodium er...... 27 DST PLUS PAK...... 78 easy talk blood glucose system 131 DIVIGEL...... 104 DSUVIA...... 17 easy talk blood glucose test...... 92 DMT SUIK...... 68 DUAVEE...... 105 EASY TOUCH ALCOHOL dofetilide...... 23 ducodyl...... 118 PREP MEDIUM...... 131 DOLOPHINE...... 17 DUET DHA 400...... 167 EASY TOUCH FLIPLOCK DOLOTRANZ...... 78 DUET DHA BALANCED...167 INSULIN SY...... 131 donepezil hcl...... 190 DUEXIS...... 11 EASY TOUCH GLUCOSE DOPTELET...... 112 DULERA...... 24 SYSTEM...... 131 DORYX...... 194 duloxetine hcl...... 29 EASY TOUCH DORYX MPC...... 194 DUOBRII...... 78 HEALTHPRO SYSTEM...... 131 dorzolamide hcl...... 179 DUO-CARE TEST...... 92 EASY TOUCH dorzolamide hcl-timolol mal....179 DUPIXENT...... 56 HEALTHPRO TEST...... 92 dorzolamide hcl-timolol mal pf179 DURAGESIC-100...... 17 EASY TOUCH INSULIN Dotti...... 104 DURAGESIC-12...... 17 SAFETY SYR...... 131 double pm...... 179 DURAGESIC-25...... 17 EASY TOUCH INSULIN DOVATO...... 53 DURAGESIC-50...... 17 SYRINGE...... 131 doxazosin mesylate...... 40 DURAGESIC-75...... 17 EASY TOUCH LANCETS doxepin hcl...... 29, 78 duraxin...... 15 21G...... 131 doxercalciferol...... 101 DUREZOL...... 179 EASY TOUCH LANCETS doxycycline...... 78 DUROLANE...... 174 23G...... 131 doxycycline hyclate...... 195 dutasteride...... 108 EASY TOUCH LANCETS doxycycline monohydrate...... 195 dutasteride-tamsulosin hcl...... 108 26G/TWIST...... 132 doxylamine-pyridoxine...... 36 DUTOPROL...... 40 EASY TOUCH LANCETS d-penamine...... 55 DUZALLO...... 109 28G...... 132 DRCAPS SIZE 0...... 185 DVORAH...... 17 EASY TOUCH LANCETS DRCAPS SIZE 00...... 185 DXEVO 11-DAY...... 68 30G...... 132 DRCAPS SIZE 1...... 185 d-xylose...... 92 EASY TOUCH LANCETS DRIHEP ARTERIAL LINE DYANAVEL XR...... 9 32G...... 132 SYRINGE...... 92 DYLOJECT...... 11 EASY TOUCH LANCETS DRIHEP PLUS DYMISTA...... 175 33G/TWIST...... 132 PREFILLED SYRINGE...... 92 DYNABAC 5.0...... 78 EASY TOUCH LANCING dronabinol...... 36 DYRENIUM...... 100 DEVICE...... 132 DROPLET INSULIN DYSPORT...... 176 EASY TOUCH PEN SYRINGE...... 130 E.E.S. 400...... 120 NEEDLES...... 132 DROPLET LANCETS E.E.S. GRANULES...... 120 EASY TOUCH SAFETY ULTRA THIN 30G...... 131 easy comfort alcohol pads...... 131 PEN NEEDLES...... 132 DROPLET LANCING easy comfort insulin syringe....131 EASY TOUCH DEVICE...... 131 easy comfort lancets...... 131 SHEATHLOCK SYRINGE.132 DROPLET PEN NEEDLES 131 easy comfort lancets twist top. 131 EASY TOUCH TEST...... 92 dropsafe safety pen needles..... 131 easy comfort pen needles...... 131 easy trak blood glucose system132 212 easy trak blood glucose test...... 92 ELEMENT AUTOCODE EMGALITY (300 MG EASYGEL...... 164 SYSTEM...... 132 DOSE)...... 58 EASYGLUCO...... 92, 132 element compact glucose Emoquette...... 63 EASYGLUCO PLUS...... 92, 132 system...... 132 empty capsule size 0 white/opa 185 EASYGLUCO PLUS element compact test...... 92 empty capsule size 00 clear..... 185 STARTER...... 132 element compact v glucose sys.132 empty capsule size 1 clear...... 185 EASYMAX 15 TEST...... 92 ELEMENT PLUS...... 132 empty capsule size 1 veg clear. 185 EASYMAX L BLOOD ELEMENT TEST...... 92 empty capsule size 2 clear...... 185 GLUCOSE...... 132 ELESTRIN...... 104 empty capsule size 3 clear...... 185 EASYMAX N BLOOD ELETONE...... 78 empty capsule size 4 clear...... 185 GLUCOSE...... 132 ELETONE TWINPACK...... 78 empty capsule size 5 clear...... 185 EASYMAX NG BLOOD eletriptan hydrobromide...... 161 empty capsule size 7 clear...... 185 GLUCOSE...... 132 ELFOLATE PLUS...... 98 EMSAM...... 30 EASYMAX TEST...... 92 ELIDEL...... 78 EMTRIVA...... 53 EASYMAX V BLOOD ELIGARD...... 45 EMULSION SB...... 78 GLUCOSE...... 132 Elinest...... 63 EMVERM...... 22 EASYMAX V2 BLOOD ELIQUIS...... 26 ENABLEX...... 198 GLUCOSE...... 132 ELIQUIS STARTER PACK..26 enalapril maleate...... 40 easyplus blood glucose test...... 92 ELITE-OB...... 167 enalapril-hydrochlorothiazide... 40 easyplus r13n blood glucose.... 132 elite-thin insulin syringe...... 133 ENBRACE HR...... 167 easyplus v blood glucose...... 132 ELIXOPHYLLIN...... 24 ENBREL...... 11 EASYPRO BLOOD ELLA...... 63 ENBREL MINI...... 11 GLUCOSE MONITOR...... 132 ELLZIA PAK...... 78 ENBREL SURECLICK...... 11 EASYPRO BLOOD ELMIRON...... 108 ENCARE...... 199 GLUCOSE TEST...... 92 ELOCTATE...... 110 Endocet...... 17 EASYPRO PLUS...... 92, 132 EMBEDA...... 17 ENDOMETRIN...... 199 econazole nitrate...... 78 EMBRACE BLOOD ENLITE GLUCOSE ECONTRA EZ...... 63 GLUCOSE MONITOR...... 133 SENSOR...... 133 ECONTRA ONE-STEP...... 63 EMBRACE BLOOD ENLITE SERTER...... 133 ECOTRIN LOW GLUCOSE TEST...... 92 enovarx-diclofenac sodium...... 78 STRENGTH...... 15 EMBRACE EVO BLOOD enoxaparin sodium...... 26 ECOZA...... 78 GLUCOSE TEST...... 92 Enpresse-28...... 63 EC-RX DHEA...... 10 EMBRACE EVO GLUCOSE Enskyce...... 63 ec-rx estradiol...... 104 MONITORING...... 133 ENSTILAR...... 78 ec-rx progesterone...... 189 EMBRACE LANCETS entacapone...... 49 ec-rx testosterone...... 20 ULTRA THIN 30G...... 133 entecavir...... 53 EDARBI...... 40 EMBRACE PRO GLUCOSE ENTEREG...... 106 EDARBYCLOR...... 40 METER...... 133 ENTRESTO...... 176 EDLUAR...... 116 EMBRACE PRO GLUCOSE ENTTY SPRAY ed-spaz...... 196 TEST...... 92 EMULSION...... 78 EDURANT...... 53 EMBRACE TALK BLOOD ENTYVIO...... 117 efavirenz...... 53 GLUCOSE...... 133 enulose...... 106 EFFER-K...... 162 EMBRACE TALK ENVARSUS XR...... 55 Effer-K...... 162 GLUCOSE TEST...... 93 enzadyne...... 99 EFFEXOR XR...... 29 EMBRACE TALK EPANED...... 40 EGRIFTA...... 101 MONITORING SYSTEM... 133 EPCLUSA...... 115 ELAPRASE...... 101 EMCYT...... 45 EPICERAM...... 78 ELAVIL...... 29 EMEND...... 36 EPICYN...... 78 ELCYS...... 177 EMFLAZA...... 68 EPIDIOLEX...... 27 ELELYSO...... 112 EMGALITY...... 58 EPIDUO FORTE...... 78 213 EPIFOAM...... 78 ERYTHROCIN STEARATE EVENCARE GLUCOSE epinastine hcl...... 179 ...... 120 MONITORING...... 133 epinephrine...... 200 erythromycin...... 78, 121, 179 EVENCARE MINI epinephrine pf...... 200 erythromycin base...... 120, 121 GLUCOSE TEST...... 93 epinephrine professional...... 200 erythromycin ethylsuccinate....121 EVENCARE MINI EPINEPHRINESNAP-EMS 200 ESBRIET...... 192 MONITOR...... 133 EPINEPHRINESNAP-V...... 200 ESCAVITE...... 167 EVENITY...... 193 EPISNAP...... 200 ESCAVITE D...... 167 EVERSENSE Epitol...... 27 escavite lq...... 167 SENSOR/HOLDER...... 133 EPIVIR HBV...... 53 escitalopram oxalate...... 30 EVERSENSE SMART eplerenone...... 40 Esgic...... 15 TRANSMITTER...... 133 EPOGEN...... 112 ESKATA...... 193 EVOLUTION AUTOCODE epoprostenol sodium...... 60 ESOMEP-EZS...... 196 ...... 93, 133 eprosartan mesylate...... 40 esomeprazole magnesium...... 196 EVOMELA...... 45 eq blood glucose test...... 93 esomeprazole strontium...... 196 EVOTAZ...... 53 eq childrens aspirin...... 15 essentra wipes 9x9"...... 78 EVZIO...... 36 eq nicotine...... 190 Estarylla...... 63 EXACTECH R-S-G TEST..... 93 eq nicotine polacrilex...... 190 estazolam...... 116 EXACTECH TEST...... 93 eq nicotine step 3...... 190 estradiol...... 104, 199 EXCILON AMD DRAIN eq womens laxative...... 118 estradiol valerate...... 104 SPONGES...... 133 eql alcohol swabs...... 133 estradiol-norethindrone acet... 104 EXEL COMFORT POINT eql aspirin low dose...... 15 ESTRING...... 199 INSULIN SYR...... 134 eql color lancets 21g...... 133 estriol-progesterone micro...... 104 EXEL COMFORT POINT eql color lancets micro 33g...... 133 ESTROGEL...... 104 PEN NEEDLE...... 134 eql gentle laxative...... 118 eszopiclone...... 116 EXELDERM...... 78 eql insulin syringe...... 133 ethacrynic acid...... 100 exemestane...... 45 eql laxative...... 118 ethambutol hcl...... 44 EXFORGE...... 41 eql nicotine polacrilex...... 190 ethosuximide...... 27 EXFORGE HCT...... 41 eql super thin lancets 30g...... 133 ethynodiol diac-eth estradiol..... 63 EXJADE...... 36 eql thin lancets 26g...... 133 etidronate disodium...... 101 EXODERM...... 78 equapax/atorvastatin/coq10...... 38 etodolac...... 11 EXTAVIA...... 190 equapax/ibuprofen/minrex...... 177 etodolac er...... 11 EXTINA...... 78 EQUETRO...... 50 etoposide...... 45 EYLEA...... 179 ergocal...... 201 EUCRISA...... 187 E-Z JECT LANCET ergocalciferol...... 201 EUFLEXXA...... 174 MICRO-THIN 33G...... 134 ergoloid mesylates...... 190 EURAX...... 78 E-Z JECT LANCET SUPER ERGOMAR...... 161 Euthyrox...... 195 THIN 30G...... 134 ergotamine-caffeine...... 161 EVAMIST...... 105 E-Z JECT LANCETS...... 134 ERIVEDGE...... 45 EVEKEO...... 9 E-Z JECT LANCETS 21G....134 ERLEADA...... 45 EVEKEO ODT...... 9 E-Z JECT LANCETS THIN erlotinib hcl...... 45 EVENCARE + BLOOD 26G...... 134 EROS-CTD...... 133 GLUCOSE TEST...... 93 EZ SMART BLOOD Errin...... 63 EVENCARE BLOOD GLUCOSE LANCETS...... 134 ERTACZO...... 78 GLUCOSE TEST...... 93 EZ SMART BLOOD ERWINAZE...... 45 EVENCARE G2 MONITOR GLUCOSE TEST...... 93 ery...... 78 ...... 133 EZ SMART MONITORING ERYPED 200...... 120 EVENCARE G2 TEST...... 93 SYSTEM...... 134 ERYPED 400...... 120 EVENCARE G3 MONITOR EZ SMART PLUS Ery-Tab...... 120 ...... 133 GLUCOSE TEST...... 93 EVENCARE G3 TEST...... 93 214 EZ SMART PLUS ferraplus 90...... 112 FLOWTUSS...... 70 MONITORING SYS...... 134 FERRIPROX...... 36 FLOXIN OTIC...... 182 EZALLOR SPRINKLE...... 39 Ferrocite Plus...... 112 fluconazole...... 37 ezetimibe...... 39 FERRO-PLEX flucytosine...... 37 ezetimibe-simvastatin...... 39 HEMATINIC...... 112 fludrocortisone acetate...... 68 E-Z-HD...... 93 FERROTRIN...... 112 FLUMIST EZ-LETS LANCETS 21G.... 134 FETZIMA...... 30 QUADRIVALENT...... 199 EZ-LETS LANCETS 23G.... 134 FETZIMA TITRATION...... 30 flunisolide...... 175 EZ-LETS LANCETS 26G.... 134 FIASP...... 32 fluocinolone acetonide...... 79, 182 EZ-LETS LANCETS 28G.... 134 FIASP FLEXTOUCH...... 32 fluocinolone acetonide body...... 79 EZ-LETS LANCETS 30G.... 134 FIBRICOR...... 39 fluocinolone acetonide scalp...... 79 E-Z-PAQUE...... 93 fibrik...... 57 fluocinonide...... 79 FA-8...... 112 FIFTY50 GLUCOSE fluocinonide emulsified base...... 79 fabb...... 112 METER 2.0...... 134 FLUORABON...... 162 FABIOR...... 78 FIFTY50 GLUCOSE TEST fluorescein-benoxinate...... 179 FABRAZYME...... 101 2.0...... 93 Fluoridex Daily Renewal...... 164 Falmina...... 64 FIFTY50 PEN NEEDLES... 134 Fluoridex Enhanced famciclovir...... 53 FIFTY50 SUPERIOR Whitening...... 164 famotidine...... 196 COMFORT SYR...... 134 Fluoridex Sensitivity Relief....164 FANAPT...... 50 FIFTY50 UNILET Fluor-I-Strips A.T...... 179 FANAPT TITRATION LANCETS 33G...... 134 fluoritab...... 162 PACK...... 50 FINACEA...... 79 fluorometholone...... 179 FANATREX FUSEPAQ...... 27 finasteride...... 108 FLUOROPLEX...... 79 FARXIGA...... 32 FINGERSTIX LANCETS... 134 fluorouracil...... 79 FARYDAK...... 45 FIORICET...... 15 fluovix...... 79 FASENRA...... 117 FIRAZYR...... 110 fluoxetine hcl...... 30 fa-vitamin b-6-vitamin b-12.....112 FIRDAPSE...... 43 fluoxetine hcl (pmdd)...... 190 Fayosim...... 64 FIRMAGON...... 45 fluphenazine decanoate...... 50 FC FEMALE CONDOM..... 134 FIRST - METOPROLOL...... 57 fluphenazine hcl...... 50 FC2 FEMALE CONDOM... 134 FIRST-ATENOLOL...... 57 FLURA-DROPS...... 162 febuxostat...... 109 FIRST-BACLOFEN...... 174 flurandrenolide...... 79 FEENAMINT...... 118 FIRST-METRONIDAZOLE.42 FLURA-SAFE...... 179 FEIBA...... 110 FIRVANQ...... 109 flurazepam hcl...... 116 felbamate...... 27 Flac...... 182 flurbiprofen...... 11 felodipine er...... 59 FLAREX...... 179 flurbiprofen sodium...... 179 FEMCAP...... 134 FLAVOR BLEND...... 185 flutamide...... 45 FEMRING...... 199 flavor plus...... 185 fluticasone propionate...... 79, 175 Femynor...... 64 flavor sweet...... 186 fluticasone-salmeterol...... 24 fenofibrate...... 39 flavor sweet-sf...... 186 fluvastatin sodium...... 39 fenofibrate micronized...... 39 flavoxate hcl...... 198 fluvastatin sodium er...... 39 fenofibric acid...... 39 FLEBOGAMMA DIF...... 183 fluvoxamine maleate...... 30 FENOGLIDE...... 39 flecainide acetate...... 23 fluvoxamine maleate er...... 30 fenoprofen calcium...... 11 flexin...... 79 FML...... 179 FENORTHO...... 11 flexizol combipak...... 11 FML FORTE...... 179 fentanyl...... 17 FLOLAN...... 60 FML LIQUIFILM...... 179 fentanyl citrate...... 17 flolipid...... 39 folbee...... 112 FENTORA...... 17 FLORIVA...... 162, 184 folbee plus...... 167 FERIVA 21/7...... 112 FLORIVA PLUS...... 167 FOLBEE PLUS CZ...... 167 ferocon...... 112 FLOVENT DISKUS...... 24 FOLET DHA...... 167 ferotrinsic...... 112 FLOVENT HFA...... 24 FOLET ONE...... 167 215 FOLGARD OS...... 167 FORA GD50 BLOOD FORTISCARE GLUCOSE folic acid...... 112 GLUCOSE TEST...... 93 SYSTEM...... 135 folica-be...... 57 FORA GTEL BLOOD FORTISCARE TEST...... 93 folica-v...... 57 GLUCOSE SYSTEM...... 135 FOSAMAX PLUS D...... 101 folic-k...... 57 FORA GTEL BLOOD fosamprenavir calcium...... 53 FOLI-D...... 112 GLUCOSE TEST...... 93 fosinopril sodium...... 41 folika-d...... 112 FORA GTEL BLOOD fosinopril sodium-hctz...... 41 folika-t...... 167 KETONE TEST...... 93 FOSRENOL...... 106 folika-v...... 165 FORA LANCETS...... 135 FOSTEUM...... 98 folite...... 112 FORA LANCING DEVICE 135 FOSTEUM PLUS...... 98 FOLIVANE-F...... 112 FORA PREMIUM V10 BLE FRAGMIN...... 26 FOLIVANE-OB...... 167 SYSTEM...... 135 freds pharmacy autolet lancing135 FOLIVANE-PLUS...... 112 FORA TEST N' GO freds pharmacy unifine pentip+ FOLLISTIM AQ...... 101 MONITOR...... 135 ...... 135 folplex 2.2...... 112 FORA TN'G VOICE...... 135 freds pharmacy unifine pentips 135 foltrin...... 113 FORA TN'G/TN'G VOICE....93 FREESTYLE FLASH Folvite-D...... 113 FORA V10 BLOOD SYSTEM...... 136 fondaparinux sodium...... 26 GLUCOSE SYSTEM...... 135 FREESTYLE FREEDOM... 136 FORA BLOOD GLUCOSE FORA V10 BLOOD FREESTYLE FREEDOM TEST...... 93 GLUCOSE TEST...... 93 LITE...... 136 FORA D10 2-IN-1 FORA V10/V12/D10/D20 FREESTYLE INSULINX MONITOR...... 134 TEST...... 135 SYSTEM...... 136 FORA D15G 2-IN-1 FORA V12 BLOOD FREESTYLE INSULINX MONITOR...... 134 GLUCOSE SYSTEM...... 135 TEST...... 94 FORA D15G BLOOD FORA V12 BLOOD FREESTYLE LIBRE 14 GLUCOSE TEST...... 93 GLUCOSE TEST...... 93 DAY READER...... 136 FORA D20 2-IN-1 FORA V20 BLOOD FREESTYLE LIBRE 14 MONITOR...... 134 GLUCOSE SYSTEM...... 135 DAY SENSOR...... 136 FORA D20 BLOOD FORA V20 BLOOD FREESTYLE LIBRE GLUCOSE TEST...... 93 GLUCOSE TEST...... 93 READER...... 136 FORA D40 FORA V30A BLOOD FREESTYLE LIBRE GLUCOSE/PRESSURE...... 134 GLUCOSE SYSTEM...... 135 SENSOR SYSTEM...... 136 FORA D40/G31 BLOOD FORA V30A BLOOD FREESTYLE LITE...... 136 GLUCOSE...... 93 GLUCOSE TEST...... 93 FREESTYLE LITE TEST...... 94 FORA D40G FORACARE GD40 FREESTYLE PRECISION GLUCOSE/PRESSURE...... 134 MONITOR...... 135 INS SYR...... 136 FORA G20 BLOOD FORACARE GD40 TEST..... 93 FREESTYLE PRECISION GLUCOSE SYSTEM...... 135 FORACARE PREMIUM NEO SYSTEM...... 136 FORA G20 BLOOD V10...... 135 FREESTYLE PRECISION GLUCOSE TEST...... 93 FORACARE PREMIUM NEO TEST...... 94 FORA G30/PREM V10 V10 TEST...... 93 FREESTYLE SIDEKICK II 136 GLUCOSE TEST...... 93 FORACARE TEST N GO FREESTYLE SYSTEM...... 136 FORA G30A BLOOD MONITOR...... 135 FREESTYLE TEST...... 94 GLUCOSE SYSTEM...... 135 FORACARE TEST N GO FREESTYLE UNISTICK II FORA GD20 BLOOD TEST...... 93 LANCETS...... 136 GLUCOSE SYSTEM...... 135 formaldehyde...... 52 FROTEK...... 79 FORA GD20 TEST...... 93 FORTAMET...... 32 frovatriptan succinate...... 161 FORA GD50 BLOOD FORTAVIT...... 167 FULPHILA...... 113 GLUCOSE SYSTEM...... 135 FORTEO...... 101 fungimez...... 79 FORTESTA...... 20 furosemide...... 100 216 FUSION PLUS...... 113 GENICIN VITA-Q...... 165 GENVISC 850...... 174 FUSION SPRINKLES...... 113 Genicin Vita-S...... 167 GENVOYA...... 53 FUZEON...... 53 GENOTROPIN...... 102 GEODON...... 50 Fyavolv...... 105 GENOTROPIN ghrp2-ghrp6-sermorelin...... 109 FYCOMPA...... 27 MINIQUICK...... 102 ghrp2-sermorelin...... 109 g tussin ac...... 70 GENSTRIP 50...... 94 ght blood glucose monitor...... 137 gabapentin...... 27 GENTAK...... 179 ght test...... 94 galantamine hydrobromide..... 190 gentamicin sulfate...... 79, 179 GIALAX...... 118 galantamine hydrobromide er..190 GENTEEL BUTTERFLY Gianvi...... 64 GALAXTRA...... 98 TOUCH LANCET...... 136 GIAPREZA...... 200 GALZIN...... 162 GENTEEL CONTACT TIPS GILENYA...... 190 GAMMACORE...... 136 (BLUE)...... 136 GILPHEX TR...... 70 GAMMACORE SAPPHIRE GENTEEL CONTACT TIPS GILTUSS TR...... 70 31-DAY...... 136 (CLEAR)...... 136 glass syringe 3 ml...... 94 GAMMACORE SAPPHIRE GENTEEL CONTACT TIPS glass syringe 5 ml...... 94 REFILL KIT...... 136 (GREEN)...... 136 GLASSIA...... 192 GAMMAGARD...... 183 GENTEEL CONTACT TIPS glatiramer acetate...... 190 GAMMAGARD S/D LESS (ORANGE)...... 136 Glatopa...... 190 IGA...... 183 GENTEEL CONTACT TIPS GLEEVEC...... 45 GAMMAKED...... 183 (RAINBOW)...... 136 GLEOLAN...... 94 GAMMAPLEX...... 183 GENTEEL CONTACT TIPS GLEOSTINE...... 45 GAMUNEX-C...... 183 (VIOLET)...... 136 GLIADEL WAFER...... 45 gatifloxacin...... 179 GENTEEL CONTACT TIPS glimepiride...... 32 GATTEX...... 106 (YELLOW)...... 136 glipizide...... 32 Gavilyte-C...... 118 GENTEEL LANCING glipizide er...... 32 Gavilyte-G...... 118 DEVICE (BLACK)...... 136 glipizide xl...... 32 Gavilyte-H...... 118 GENTEEL LANCING glipizide-metformin hcl...... 32 Gavilyte-N With Flavor Pack118 DEVICE (BLUE)...... 137 global alcohol prep ease...... 137 ge100 blood glucose system.....136 GENTEEL LANCING global ease inject pen needles.. 137 ge100 blood glucose test...... 94 DEVICE (GOLD)...... 137 global easy glide insulin syr.....137 GEBAUERS PAIN EASE GENTEEL LANCING global easy glide pen needles... 137 ...... 79, 196 DEVICE (PINK)...... 137 global inject ease insulin syr....137 GEBAUERS SPRAY AND GENTEEL LANCING global inject ease lancets 28g.. 137 STRETCH...... 79, 196 DEVICE (WHITE)...... 137 global inject ease lancets 30g.. 137 GELCLAIR...... 164 GENTEEL LANCING global insulin syringes...... 137 GELFILM...... 179 DEVICE(PLATNM)...... 137 global lancing device...... 137 GEL-FLOW...... 115 GENTEEL LANCING GLUCAGEN HYPOKIT...... 32 GELFOAM-JMI POWDER.115 DEVICE(PURPLE)...... 137 GLUCAGON GELFOAM-JMI SPONGE.. 115 GENTEEL LANCING EMERGENCY...... 32 GELNIQUE...... 198 DEVICE(SILVER)...... 137 GLUCO PERFECT 3 GELNIQUE PUMP...... 198 GENTEEL LANCING KIT METER...... 137 GEL-ONE...... 174 (BLUE)...... 137 GLUCO PERFECT 3 TEST...94 GELSYN-3...... 174 GENTEEL NOZZLES...... 137 GLUCOCARD 01 BLOOD gemfibrozil...... 39 gentle laxative...... 118 GLUCOSE...... 137 gen7t...... 79 GENTLE-LET GP GLUCOCARD 01 SENSOR gen7t plus...... 79 LANCETS...... 137 PLUS...... 94 GENADUR...... 79 GENTLE-LET LANCETS...137 GLUCOCARD 01-MINI generlac...... 106 GENTLE-LET GLUCOSE...... 137 Gengraf...... 55 PLATFORMS...... 137 GLUCOCARD GENICIN VITA-D...... 113 GENULTIMATE TEST...... 94 EXPRESSION MONITOR.. 137 217 GLUCOCARD GLYTACTIN SWIRL 15PE.. 98 guaiatussin ac...... 70 EXPRESSION TEST...... 94 GLYXAMBI...... 193 guaifenesin-codeine...... 70 GLUCOCARD SHINE gnp adult aspirin low strength... 15 guanfacine hcl...... 41 CONNEX...... 137 gnp alcohol swabs...... 138 guanfacine hcl er...... 9 GLUCOCARD SHINE gnp aspirin...... 15 guanidine hcl...... 43 EXPRESS...... 137 GNP BISA-LAX...... 118 GUARDIAN CONNECT GLUCOCARD SHINE gnp clickfine pen needles...... 138 TRANSMITTER...... 139 TEST...... 94 GNP EASY TOUCH GUARDIAN LINK 3 GLUCOCARD SHINE XL..137 GLUCOSE METER...... 138 TRANSMITTER...... 139 GLUCOCARD VITAL gnp easy touch glucose test...... 94 GUARDIAN REAL-TIME MONITOR...... 138 gnp gentle laxative...... 118 CHARGER...... 139 GLUCOCARD VITAL gnp insulin syringe...... 138 GUARDIAN REAL-TIME TEST...... 94 gnp lancets...... 138 REPLACE PED...... 139 GLUCOCARD X-METER.. 138 gnp lancets 21g...... 138 GUARDIAN REAL-TIME GLUCOCARD X-SENSOR...94 gnp lancets micro thin 33g...... 138 REPLACEMENT...... 139 GLUCOCOM BLOOD gnp lancets thin...... 138 GUARDIAN REAL-TIME GLUCOSE MONITOR...... 138 gnp lancets thin 26g...... 138 STARTER...... 139 GLUCOCOM LANCETS gnp laxative...... 118 GUARDIAN REAL-TIME 28G...... 138 gnp micro thin lancets 33g...... 138 SYSTEM...... 139 GLUCOCOM LANCETS gnp nicotine...... 190 GUARDIAN REAL-TIME 30G...... 138 gnp nicotine mini...... 190 SYSTEM PED...... 139 GLUCOCOM LANCETS gnp nicotine polacrilex...... 190 GUARDIAN REAL-TIME 33G...... 138 gnp super thin lancets 30g...... 138 TEST PLUG...... 139 GLUCOCOM MONITOR... 138 gnp ultra com insulin syringe...138 GUARDIAN RT GLUCOCOM TEST...... 94 gnp womens gentle laxative.....118 SOFTWARE...... 139 GLUCONAVII BLOOD GOCOVRI...... 49 GUARDIAN RT STARTER GLUCOSE SYS...... 138 GOLYTELY...... 119 ...... 139 GLUCONAVII BLOOD GONAL-F...... 102 GUARDIAN SENSOR (3)...139 GLUCOSE TEST...... 94 GONAL-F RFF...... 102 GUARDIAN GLUCOPRO INSULIN GONAL-F RFF REDIJECT 102 TRANSMITTER...... 139 SYRINGE...... 138 GONITRO...... 22 GVOKE PFS...... 32 GLUCOPRO SYR RES 3ML goodsense blood glucose.... 94, 138 GYNAZOLE-1...... 199 22GX3/8"...... 138 goodsense clickfine pen needle.138 HAEGARDA...... 110 glucose meter test...... 94 goodsense lancets 26g univ...... 138 Hailey 1.5/30...... 64 GLUMETZA...... 32 goodsense lancets 30g univ...... 138 Hailey 24 Fe...... 64 glutaraldehyde...... 52 goodsense lancets 33g...... 138 halcinonide...... 79 glyburide...... 32 goodsense lancets 33g univ...... 138 halobetasol propionate...... 80 glyburide micronized...... 32 goodsense lancing device...... 138 HALOG...... 80 glyburide-metformin...... 32 goodsense nicotine...... 190 haloperidol...... 50 GLYCATE...... 196 GOODSENSE PEN haloperidol decanoate...... 50 glycine...... 108 NEEDLE PENFINE...... 139 haloperidol lactate...... 50 glycine soya protein...... 61 goprelto...... 176 HARVONI...... 115 glycolic acid...... 79 GORDOFILM...... 79 hcg...... 102 glycopyrrolate...... 196 GRALISE...... 188, 190 HCU EASY...... 98 Glydo...... 79 GRALISE STARTER...188, 190 HEALTH CARE LANCING GLYGEST...... 98 granisetron hcl...... 36 DEVICE...... 139 GLYRX-PF...... 197 GRANIX...... 113 healthwise insulin syr/needle... 139 GLYTACTIN BUILD 10PE.. 98 GRASTEK...... 58 healthwise micron pen needles.139 GLYTACTIN COMPLETE griseofulvin microsize...... 37 healthwise mini pen needles.....139 10PE...... 98 griseofulvin ultramicrosize...... 37 healthwise pen needles...... 139 218 healthwise short pen needles....139 HUMALOG MIX 50/50...... 32 hydrocortisone-acetic acid...... 182 healthwise unifine pentips...... 139 HUMALOG MIX 50/50 HYDROFERA BLUE 6"X6". 80 healthy accents lancing device.139 KWIKPEN...... 32 HYDROFERA BLUE healthy accents unifine pentip. 139 HUMALOG MIX 75/25...... 32 FOAM DRESSING...... 80 healthy accents unilet lancets.. 139 HUMALOG MIX 75/25 HYDROFERA BLUE Heather...... 64 KWIKPEN...... 32 FOAM/TUNNELING...... 80 h-e-b aspirin...... 15 HUMATE-P...... 110 HYDROFERA BLUE MRF h-e-b incontrol adv lancing...... 139 HUMATROPE...... 102 DRESSING...... 80 h-e-b incontrol alcohol...... 139 HUMIRA...... 12 HYDROFERA BLUE h-e-b incontrol lancets 28g...... 140 HUMIRA PEDIATRIC READY FOAM...... 80 h-e-b incontrol lancets 30g...... 140 CROHNS START...... 11 hydrogen peroxide...... 52 h-e-b incontrol lancets 33g...... 140 HUMIRA PEN...... 11 hydromet...... 70 h-e-b incontrol pen needles...... 140 HUMIRA PEN-CD/UC/HS hydromorphone hcl...... 17 H-E-B INCONTROL STARTER...... 11 hydromorphone hcl er...... 17 UNIFINE PENTIP...... 140 HUMIRA PEN- hydroxocobalamin acetate...... 113 HELIXATE FS...... 110 PS/UV/ADOL HS START..... 11 hydroxychloroquine sulfate...... 43 HEMANGEOL...... 57 HUMULIN 70/30...... 32 hydroxyprogesterone caproate hematinic plus vit/minerals...... 113 HUMULIN 70/30 ...... 61, 189 hematinic/folic acid...... 113 KWIKPEN...... 32 hydroxyurea...... 46 HEMLIBRA...... 37 HUMULIN N...... 32 hydroxyzine hcl...... 22 HEMOCYTE PLUS...... 113 HUMULIN N KWIKPEN.....32 hydroxyzine pamoate...... 23 Hemocyte-F...... 113 HUMULIN R...... 32 hygel...... 80 hemocyte-plus...... 113 HUMULIN R U-500 HYLATOPIC PLUS...... 80 HEMOFIL M...... 110 (CONCENTRATED)...... 33 hylavite...... 167 heparin sodium (porcine)...... 26 HUMULIN R U-500 HYLIRA...... 80 heparin sodium (porcine) pf..... 26 KWIKPEN...... 33 HYMOVIS...... 174 hepmed...... 26 HW EMBRACE PRO HYOPHEN...... 198 HEPSERA...... 53 GLUCOSE METER...... 140 hyoscyamine sulfate...... 197 HERCEPTIN HYLECTA...... 46 HW EMBRACE PRO hyoscyamine sulfate er...... 197 Hidex 6-Day...... 68 GLUCOSE TEST...... 94 HYPERSAL...... 70 HIZENTRA...... 184 HW EMBRACE TALK HYPOCYN...... 80 hm aspirin...... 15 BLOOD GLUCOSE...... 140 HYQVIA...... 183 HM EMBRACE TALK HW EMBRACE TALK HYSINGLA ER...... 17 SYSTEM...... 140 GLUCOSE TEST...... 94 HY-VEE LANCETS...... 140 hm laxative...... 119 HYALGAN...... 174 hy-vee thin lancets...... 140 hm nicotine...... 190 hyalucil-4...... 44 ibandronate sodium...... 102 hm nicotine polacrilex...... 190 HYCAMTIN...... 46 IBG STAR BLOOD hm sterile alcohol prep...... 140 HYCLODEX...... 80 GLUCOSE SYSTEM...... 140 HM ULTICARE INSULIN hydralazine hcl...... 41 IBRANCE...... 71 SYRINGE...... 140 hydrochlorothiazide...... 100 Ibu...... 12 HM ULTICARE SHORT hydrocod polst-cpm polst er...... 70 IBUDONE...... 17 PEN NEEDLES...... 140 hydrocodone-acetaminophen.....17 ibuprofen...... 12 HORIZANT...... 190 hydrocodone-homatropine...... 70 ICAR-C PLUS...... 113 HPR...... 80 hydrocodone-ibuprofen...... 17 icatibant acetate...... 110 HPR PLUS...... 80 hydrocortisone...... 21, 68, 80 IDELVION...... 110 HPR PLUS HYDROGEL...... 80 hydrocortisone ace-pramoxine.. 21 IDHIFA...... 118 HPR PLUS-MB hydrocortisone butyr lipo base.. 80 IFE-BIMIX 30/1...... 117 HYDROGEL...... 80 hydrocortisone butyrate...... 80 IFE-PG20...... 60 HUMALOG...... 32 Hydrocortisone In Absorbase. 80 Iferex 150 Forte...... 113 HUMALOG KWIKPEN...... 32 hydrocortisone valerate...... 80 219 IGLUCOSE MONITORING INFUVITE ADULT...... 167 IS 24/6...... 113 SYSTEM...... 140 INFUVITE PEDIATRIC..... 167 ISENTRESS...... 53 IGLUCOSE TEST STRIPS....94 INGREZZA...... 190 ISENTRESS HD...... 53 ILARIS...... 12 INLYTA...... 46 Isibloom...... 64 ILEVRO...... 179 INNOPRAN XL...... 57 isoflurane...... 107 ILUMYA...... 80 INPEN 100-BLUE-LILLY... 140 isoniazid...... 44 imatinib mesylate...... 46 INPEN 100-BLUE-NOVO... 140 ISOPTO ATROPINE...... 179 imipramine hcl...... 30 INPEN 100-GRAY-LILLY.. 140 ISORDIL TITRADOSE...... 22 imipramine pamoate...... 30 INPEN 100-GREY-NOVO...140 isosorbide dinitrate...... 22 imiquimod...... 80 INPEN 100-PINK-LILLY....140 isosorbide dinitrate er...... 22 imiquimod pump...... 80 INPEN 100-PINK-NOVO.... 141 isosorbide mononitrate...... 22 IMLYGIC...... 177 INREBIC...... 46 isosorbide mononitrate er...... 22 IMPAVIDO...... 42 INSET 30 INFUSION SET isotretinoin...... 80 IMPOYZ...... 80 23"...... 141 isradipine...... 59 IMVEXXY INSET INFUSION SET 23" itraconazole...... 37 MAINTENANCE PACK.....199 9MM...... 141 IV INFUSION CPI...... 80 IMVEXXY STARTER INSET INFUSION SET 43" iv novice pack...... 81 PACK...... 199 9MM...... 141 ivermectin...... 22 IN TOUCH...... 140 insulin cartridge 3ml...... 141 IXINITY...... 110 IN TOUCH BLOOD insulin syringe...... 141 JADENU...... 36 GLUCOSE TEST...... 94 insulin syringe/needle...... 141 JADENU SPRINKLE...... 36 IN TOUCH LANCING insulin syringe-needle u-100.... 141 JAKAFI...... 46 DEVICE...... 140 insupen pen needles...... 141 JALYN...... 108 IN TOUCH STERILE INSUPEN SENSITIVE...... 141 Jantoven...... 26 LANCETS 30G...... 140 INSUPEN ULTRAFIN...... 141 JANUMET...... 33 INATAL GT...... 167 INTEGRA F...... 113 JANUMET XR...... 33 INBRIJA...... 49 INTEGRA PLUS...... 113 JANUVIA...... 33 Incassia...... 64 INTELENCE...... 53 JARDIANCE...... 33 INCRELEX...... 102 INTERMEZZO...... 116 Jasmiel...... 64 INCRUSE ELLIPTA...... 24 INTRALIPID...... 177 Jencycla...... 64 indapamide...... 100 INTRAROSA...... 199 JENTADUETO...... 33 INDERAL XL...... 57 INTRON A...... 46 JENTADUETO XR...... 33 INDOCIN...... 12 Introvale...... 64 Jinteli...... 105 indomethacin...... 12 INTUNIV...... 9 JIVI...... 110 indomethacin er...... 12 INVEGA SUSTENNA...... 50 Jolessa...... 64 INFASURF...... 193 INVEGA TRINZA...... 51 JORNAY PM...... 9 INFINITY BLOOD INVELTYS...... 179 JUBLIA...... 81 GLUCOSE SYSTEM...... 140 INVIRASE...... 53 Juleber...... 64 INFINITY BLOOD INVOKAMET...... 194 JULUCA...... 53 GLUCOSE TEST...... 94 INVOKAMET XR...... 194 Junel 1.5/30...... 64 INFINITY VOICE...... 94, 140 INVOKANA...... 33 Junel 1/20...... 64 Inflammacin...... 12 iodine strong...... 162 Junel Fe 1.5/30...... 64 inflamma-k...... 80 iodine tincture...... 52 Junel Fe 1/20...... 64 inflammation reduction pack.... 12 IONSYS...... 18 Junel Fe 24...... 64 INFLATHERM...... 12 IOPIDINE...... 179 JUXTAPID...... 39 INFLECTRA...... 106 ipratropium bromide...... 24, 175 KADIAN...... 18 INFUGEM...... 46 ipratropium-albuterol...... 24 Kaitlib Fe...... 64 infusion catheter soft 23"...... 140 irbesartan...... 41 KALETRA...... 53 infusion catheter soft 31"...... 140 irbesartan-hydrochlorothiazide. 41 Kalliga...... 64 infusion catheter soft 43"...... 140 IRESSA...... 46 KALYDECO...... 193 220 KAMDOY...... 81 KETOVIE PEPTIDE...... 98 kroger insulin syringe...... 141 KANJINTI...... 46 KEVZARA...... 12 kroger lancets...... 141 KANUMA...... 120 KHAPZORY...... 46 kroger lancets super thin...... 141 KAPSPARGO SPRINKLE....57 KINERET...... 12 kroger lancets thin...... 141 KARBINAL ER...... 38 kinney lancets...... 141 kroger pen needles...... 141 Kariva...... 64 kinney thin lancets...... 141 kroger premium blood glucose.141 KATERZIA...... 59 kinray insulin syringe...... 141 kroger premium glucose test..... 94 KAZANO...... 33 Kionex...... 56, 188 kroger test...... 94 KELARX...... 81 KISQALI (200 MG DOSE).... 71 KRYSTEXXA...... 109 Kelnor 1/35...... 64 KISQALI (400 MG DOSE).... 71 K-Tan Plus...... 113 Kelnor 1/50...... 64 KISQALI (600 MG DOSE).... 71 Kurvelo...... 64 KENDALL ALGINATE 12" KISQALI FEMARA (400 KUVAN...... 102 ROPE...... 81 MG DOSE)...... 46 KYNAMRO...... 39 KENDALL ALGINATE KISQALI FEMARA (600 L.E.T...... 81 DRESS 2"X2"...... 81 MG DOSE)...... 46 labetalol hcl...... 57 KENDALL ALGINATE KISQALI FEMARA(200 LACRISERT...... 179 DRESS 4"X4"...... 81 MG DOSE)...... 46 lactated ringers...... 56 KENDALL ALGINATE KITABIS PAK...... 10 lactic acid...... 81 DRESS 4"X8"...... 81 KIVIK...... 81 lactic acid e...... 81 KENDALL AMORPHOUS KLARITY-A...... 179 lactulose...... 119 WOUND...... 81 KLARITY-B...... 179 lactulose encephalopathy...... 106 KENDALL HYDROGEL KLARITY-L...... 179 LAMICTAL...... 27 GAUZE 2"X2"...... 81 Klor-Con...... 162, 163 LAMICTAL ODT...... 27 KENDALL HYDROGEL KLOR-CON...... 162 LAMICTAL STARTER...... 28 GAUZE 4"X4"...... 81 Klor-Con 10...... 162 LAMICTAL XR...... 28 KENDALL HYDROGEL Klor-Con M10...... 162 lamivudine...... 53 GAUZE 4"X8"...... 81 KLOR-CON M15...... 162 lamivudine-zidovudine...... 53 KENDALL HYDROGEL Klor-Con M20...... 162 lamotrigine...... 28 WOUND DRESS...... 81 Klor-Con Sprinkle...... 163 lamotrigine er...... 28 KENGREAL...... 99, 110 Klor-Con/Ef...... 163 lamotrigine starter kit-blue...... 28 KERAGEL...... 81 kls aspirin low dose...... 15 lamotrigine starter kit-green.....28 KERAGELT...... 81 KLS QUIT2...... 191 lamotrigine starter kit-orange...28 KERAMATRIX KLS QUIT4...... 191 lancet device...... 141 REPLICINE 10CMX10CM... 81 kmart valu insulin syringe 29g.141 lancet device with ejector...... 141 KERAMATRIX kmart valu insulin syringe 30g.141 lancet transporter case...... 141 REPLICINE 5CMX5CM...... 81 KOATE...... 110 lancets...... 141 KERLIX AMD KOATE-DVI...... 110 lancets micro thin 33g...... 141 ANTIMICROBIAL...... 141 KOGENATE FS...... 110 lancets thin...... 142 KERLIX AMD SUPER KOMBIGLYZE XR...... 33 LANCETS ULTRA FINE....142 SPONGES...... 141 kosher prenatal plus iron...... 167 lancets ultra thin 30g...... 142 KERYDIN...... 183 KOVALTRY...... 110 lancing device...... 142 ketoconazole...... 37, 81 kp aspirin...... 15 LANOXIN...... 60 KETO-DIASTIX...... 94 kp bisacodyl...... 119 lansoprazole...... 197 ketone test...... 94 K-PHOS...... 163 lanthanum carbonate...... 106 KETOPHENE RAPIDPAQ...81 K-PHOS NO 2...... 108 LANTUS...... 33 ketoprofen...... 12 K-Prime...... 163 LANTUS SOLOSTAR...... 33 ketoprofen er...... 12 KRINTAFEL...... 43 LANZO...... 142 ketorolac tromethamine.... 12, 179 KRISTALOSE...... 119 Larin 1.5/30...... 64 KETOSTIX...... 94 kroger blood glucose...... 141 Larin 1/20...... 64 KETOVIE...... 98 kroger blood glucose test...... 94 Larin 24 Fe...... 64 221 Larin Fe 1.5/30...... 64 LEVEMIR...... 33 LIDOTREX...... 82 Larin Fe 1/20...... 64 LEVEMIR FLEXTOUCH..... 33 lidovex...... 82 Larissia...... 64 levetiracetam...... 28 lidovin...... 82 LASTACAFT...... 180 levetiracetam er...... 28 lidoxib...... 12 latanoprost...... 180 LEVICYN...... 81 lidozol...... 82 LATUDA...... 51 Levicyn Dermal Spray...... 81 LIFESCAN UNISTIK 2...... 142 laxative...... 119 levobunolol hcl...... 180 LIFESCAN UNISTIK II Layolis Fe...... 64 levocarnitine...... 102 LANCETS...... 142 LAZANDA...... 18 levocetirizine dihydrochloride... 38 LILETTA (52 MG)...... 65 LDL CARE...... 98 levofloxacin...... 105, 180 Lillow...... 65 LDO PLUS...... 81 Levonest...... 65 lindane...... 82 ldr blood glucose truetest...... 142 levonorgest-eth est & eth est..... 65 linezolid...... 42 leader insulin syringe...... 142 levonorgest-eth estrad 91-day... 65 linseed oil...... 61 LEADER UNIFINE levonorgestrel...... 65 LINZESS...... 106 PENTIPS...... 142 levonorgestrel-ethinyl estrad.....65 liothyronine sodium...... 195 LEADER UNIFINE levonorg-eth estrad triphasic.....65 LIPITOR...... 39 PENTIPS PLUS...... 142 Levora 0.15/30 (28)...... 65 lipo-c...... 177 lecithin...... 177 levorphanol tartrate...... 18 LIQUID E-Z-PAQUE...... 95 ledipasvir-sofosbuvir...... 115 Levo-T...... 195 LIQUIHEP II PREFILLED Leena...... 64 levothyroxine sodium...... 195 SYRINGE...... 95 leflunomide...... 12 Levoxyl...... 195 LIQUIHEP PREFILLED LEMTRADA...... 191 LEXAPRO...... 30 SYRINGE...... 95 LENVIMA (10 MG DAILY LEXETTE...... 82 LIQUIVIDA HYDRATION 163 DOSE)...... 46 LEXIVA...... 53 lisinopril...... 41 LENVIMA (12 MG DAILY LEXIXRYL...... 82 lisinopril-hydrochlorothiazide... 41 DOSE)...... 46 LIALDA...... 106 lissamine green...... 180 LENVIMA (14 MG DAILY liberty blood glucose meter..... 142 lite touch lancets...... 142 DOSE)...... 46 liberty blood glucose monitor.. 142 LITE TOUCH LANCING LENVIMA (18 MG DAILY LIBERTY NEXT PEN...... 142 DOSE)...... 46 GENERATION TEST...... 95 LITETOUCH INSULIN LENVIMA (20 MG DAILY LIBERTY NXT SYRINGE...... 142 DOSE)...... 46 GENERATION MONITOR 142 LITETOUCH LANCETS.....142 LENVIMA (24 MG DAILY liberty test...... 95 LITETOUCH PEN DOSE)...... 46 lidocaine...... 82 NEEDLES...... 142 LENVIMA (4 MG DAILY lidocaine hcl...... 82, 164 lithium...... 51 DOSE)...... 46 lidocaine hcl urethral/mucosal...82 lithium carbonate...... 51 LENVIMA (8 MG DAILY lidocaine in dextrose...... 120 lithium carbonate er...... 51 DOSE)...... 46 lidocaine viscous hcl...... 164 LITHIUM HEPARIN LESCOL XL...... 39 lidocaine-prilocaine...... 82 PREFILLED SYR...... 95 Lessina...... 64 lidocaine-tetracaine...... 82 LITHOSTAT...... 108 LETAIRIS...... 60 lidocidex i...... 68 LIVALO...... 39 letrozole...... 46 LIDOCILONE I...... 68 live better adv lancing device...142 LEU TECHNELITE...... 95 LIDODERM...... 82 live better lancet ultra thin...... 142 leucovorin calcium...... 46, 61 lidopac...... 82 LMR PLUS...... 82 LEUKERAN...... 46 LIDOPURE PATCH...... 82 LO LOESTRIN FE...... 65 LEUKINE...... 113 LIDO-RX 4.1...... 82 LOCORT 11-DAY...... 68 leuprolide acetate...... 46 lidosol-hc...... 82 LOCORT 7-DAY...... 69 levalbuterol hcl...... 24 LIDOTHOL...... 82 LODINE...... 12 levalbuterol tartrate...... 24 LIDOTRAL...... 82 LOKELMA...... 56, 188 levatio...... 81 LIDOTRANS 5 PAK...... 82 LOMAIRA...... 9 222 longs insulin syringe...... 142 LUPRON DEPOT (6- MAXI-COMFORT SAFETY longs lancets standard...... 142 MONTH)...... 47 PEN NEEDLE...... 142 longs lancets thin...... 142 LUPRON DEPOT-PED (1- MAXICOMFORT SYR 27G longs lancets ultra thin...... 142 MONTH)...... 102 X 1/2"...... 143 LONHALA MAGNAIR LUPRON DEPOT-PED (3- MAXIDEX...... 180 REFILL KIT...... 25 MONTH)...... 102 MAYZENT...... 191 LONHALA MAGNAIR LURADROX...... 82 MB HYDROGEL...... 82 STARTER KIT...... 25 Lutera...... 65 Md-Gastroview...... 95 LONSURF...... 46 LUXAMEND...... 82 me/naphos/mb/hyo1...... 198 loperamide hcl...... 35 LYNPARZA...... 187 mebolic...... 98 lopinavir-ritonavir...... 53 lyophil lith hep prefilled syr...... 95 meclizine hcl...... 36 Lopreeza...... 105 LYRICA...... 28 meclofenamate sodium...... 12 LOPROX...... 82 LYRICA CR...... 188, 191 medic insulin syringe...... 143 lorazepam...... 23 Lysiplex Plus...... 167 medichoice safety lancet extra 143 LORBRENA...... 46 LYSODREN...... 47 medicine shoppe pen needles....143 Lorcet...... 18 Lyza...... 65 MEDISENSE THIN Lorcet Hd...... 18 M.V.I. ADULT...... 167 LANCETS...... 143 Lorcet Plus...... 18 M.V.I. PEDIATRIC...... 167 MEDLANCE PLUS EXTRA lorid...... 167 M.V.I.-12 (WITHOUT 21G...... 143 LORTAB...... 18 VITAMIN K)...... 167 MEDLANCE PLUS LORVATUS PHARMAPAK macadamia nut oil...... 61 LANCETS...... 143 ...... 174 MACI...... 175 MEDLANCE PLUS LITE Loryna...... 65 MACRILEN...... 95 25G...... 143 LORZONE...... 174 MACRODANTIN...... 198 MEDLANCE PLUS losartan potassium...... 41 mafenide acetate...... 82 SPECIAL 0.8MM...... 143 losartan potassium-hctz...... 41 MAGELLAN INSULIN MEDLANCE PLUS LOTEMAX...... 180 SAFETY SYR...... 142 SUPERLITE 30G...... 143 LOTEMAX SM...... 180 MAKENA...... 189 MEDLANCE PLUS loteprednol etabonate...... 180 malathion...... 82 UNIVERSAL 21G...... 143 LOTRONEX...... 106 maprotiline hcl...... 30 MEDPREDKIT...... 69 loutrex...... 82 MARATHON MEDICAL MEDROL...... 69 lovastatin...... 39 PENTIPS...... 142 MEDROLOAN II SUIK...... 69 Low-Ogestrel...... 65 marlissa...... 65 MEDROLOAN SUIK...... 69 loxapine succinate...... 51 MARNATAL-F...... 167 medroxyprogesterone acetate LOYON...... 82 MARPLAN...... 30 ...... 65, 189 Lo-Zumandimine...... 65 MATULANE...... 47 mefenamic acid...... 12 LUCEMYRA...... 9, 10 Matzim La...... 59 mefloquine hcl...... 43 LUCENTIS...... 180 MAVENCLAD (10 TABS)...165 megestrol acetate...... 47, 189 Ludent...... 163 MAVENCLAD (4 TABS).....165 meijer blood glucose...... 143 luliconazole...... 82 MAVENCLAD (5 TABS).....165 meijer blood glucose test...... 95 LUMIGAN...... 180 MAVENCLAD (6 TABS).....165 meijer essential blood glucose..143 LUMIZYME...... 102 MAVENCLAD (7 TABS).....165 meijer essential glucose test...... 95 LUNESTA...... 116 MAVENCLAD (8 TABS).....165 MEIJER LANCETS THIN.. 143 LUPANETA PACK...... 120 MAVENCLAD (9 TABS).....165 MEIJER LANCETS LUPRON DEPOT (1- MAVYRET...... 115 UNIVERSAL 21G...... 143 MONTH)...... 46 MAXICOMFORT II PEN MEIJER LANCETS LUPRON DEPOT (3- NEEDLE...... 142 UNIVERSAL 30G...... 143 MONTH)...... 46, 47 MAXI-COMFORT MEIJER LANCETS LUPRON DEPOT (4- INSULIN SYRINGE...... 142 UNIVERSAL 33G...... 143 MONTH)...... 47 meijer pen needles...... 143 223 meijer premium blood glucose. 143 methimazole...... 195 MIDAZOLAM+SYRSPEN meijer premium glucose test...... 95 methitest...... 20 D SF...... 116 MEIJER SUPER THIN methocarbamol...... 175 midodrine hcl...... 201 LANCETS...... 143 methotrexate sodium...... 47 miglitol...... 33 MEIJER TRUE2GO methotrexate sodium (pf)...... 47 miglustat...... 113 BLOOD GLUCOSE...... 143 methoxsalen rapid...... 83 MIGRAINE PACK...... 161 MEIJER TRUERESULT methscopolamine bromide...... 197 MIGRANAL...... 161 GLUCOSE SYS...... 143 methyldopa...... 41 MIGRANOW...... 161 MEIJER TRUETEST TEST.. 95 methyldopa- Mili...... 65 MEIJER TRUETRACK hydrochlorothiazide...... 41 MILLIPRED...... 69 GLUCOSE SYS...... 143 methylergonovine maleate...... 183 MILLIPRED DP...... 69 MEIJER TRUETRACK methylphenidate hcl...... 9 MILLIPRED DP 12-DAY..... 69 TEST...... 95 methylphenidate hcl er...... 9 Mimvey...... 105 MEKINIST...... 47 methylphenidate hcl er (cd)...... 9 Mimvey Lo...... 105 Melodetta 24 Fe...... 65 methylphenidate hcl er (la)...... 9 MIMYX...... 83 meloxicam...... 12 methylprednisolone...... 69 MINASTRIN 24 FE...... 65 melphalan...... 47 methyltestosterone...... 20 mineral oil heavy...... 119 memantine hcl...... 191 metoclopramide hcl...... 107 mini lancing device...... 143 memantine hcl er...... 191 metolazone...... 100 MINILINK REAL-TIME MENEST...... 105 METOPIRONE...... 95 REPLACEMENT...... 144 MENOPUR...... 102 metoprolol succinate er...... 57 MINILINK REAL-TIME MENOSTAR...... 105 metoprolol tartrate...... 57 TRANSMITTER...... 144 MENTAX...... 83 metoprolol-hydrochlorothiazide 41 MINILINK-REAL-TIME mentho-caine...... 83 metronidazole...... 42, 83, 199 STARTER...... 144 meperidine hcl...... 18 METRONIDAZOLE MINIMED 630G meprobamate...... 23 BENZO+SYRSPEND...... 42 GUARDIAN PRESS...... 144 mercaptopurine...... 47 mexiletine hcl...... 23 MINIMED GUARDIAN mesalamine...... 106 mezparox-hc forte...... 83 LINK 3...... 144 mesalamine-cleanser...... 107 MI PASTE...... 143 MINIMED GUARDIAN MESNEX...... 47 MI PASTE PLUS...... 143 SENSOR 3...... 144 MESTINON...... 43 MIACALCIN...... 102 MINIMED PRO-SET Metadate Er...... 9 Mibelas 24 Fe...... 65 INFUSION 24"...... 144 metaproterenol sulfate...... 25 miconazole 3...... 200 MINIMED PRO-SET METAXALL CP...... 175 miconazole-zinc oxide-petrolat. 83 INFUSION 42"...... 144 metaxalone...... 175 MICORT-HC...... 83 MINIMED PUMP metformin hcl...... 33 MICROCYN...... 83 RESERVOIR 3ML...... 144 metformin hcl er...... 33 MICRODOT BLOOD MINIMED RESERVOIR metformin hcl er (mod)...... 33 GLUCOSE SYSTEM...... 143 1.8ML...... 144 metformin hcl er (osm)...... 33 MICRODOT TEST...... 95 MINIMED RESERVOIR methadone hcl...... 18 Microgestin 1.5/30...... 65 3ML...... 144 Methadone Hcl Intensol...... 18 Microgestin 1/20...... 65 MINIPRIN LOW DOSE...... 15 METHADOSE...... 18 Microgestin Fe 1.5/30...... 65 Minitran...... 22 Methadose...... 18 Microgestin Fe 1/20...... 65 MINIVELLE...... 105 METHADOSE SUGAR- MICROLET LANCETS...... 143 MINOCIN...... 195 FREE...... 18 MICROLET NEXT minocycline hcl...... 195 methamphetamine hcl...... 9 LANCING DEVICE...... 143 minocycline hcl er...... 195 methazolamide...... 100 MICROTAINER SAFETY MINOLIRA...... 195 methenamine hippurate...... 198 FLOW LANCET...... 143 minoxidil...... 41 methenamine mandelate...... 198 midazolam hcl...... 116 MIO INFUSION SET 18" Methergine...... 183 6MM...... 144 224 MIO INFUSION SET 23" MOTOFEN...... 35 mynatal-z...... 168 6MM...... 144 mouth wash-gp...... 186 mynate 90 plus...... 168 MIO INFUSION SET 32" mouthwash-af...... 186 Myorisan...... 83 6MM...... 144 mouthwash-om...... 186 MYRBETRIQ...... 199 MIO INFUSION SET 32" MOVANTIK...... 107 MYTESI...... 35 9MM...... 144 MOVIPREP...... 119 MYXREDLIN...... 33 MIRCERA...... 113 MOXEZA...... 180 nabumetone...... 12 mirtazapine...... 30 moxifloxacin hcl...... 105, 180 n-acetyl-l-cysteine...... 177 MIRVASO...... 83 mpd safety lancet 21g...... 145 nadolol...... 57 misoprostol...... 197 mpd safety lancet 23g...... 145 Nafrinse...... 163 MITOSOL...... 180 mpd safety lancet 28g...... 145 NAFRINSE DAILY mko melt dose pack...... 116 mpd safety lancet 30g...... 145 ACIDULATED...... 164 MLD...... 120 MS CONTIN...... 18 NAFRINSE MM EASY TOUCH ms insulin syringe...... 145 DAILY/NEUTRAL...... 164 GLUCOSE...... 95 MSUD EASY...... 98 Nafrinse Drops...... 163 MM EASY TOUCH MTERYTI...... 168 NAFRINSE WEEKLY...... 164 GLUCOSE METER...... 144 MTERYTI FOLIC 5...... 168 naftifine hcl...... 83 mm insulin syringe/needle...... 144 MUCOSITISRX...... 164 NAFTIN...... 83 MM PEN NEEDLES...... 144 MULPLETA...... 113 NAGLAZYME...... 102 m-natal plus...... 168 MULTAQ...... 23 NALFON...... 12 modafinil...... 9 MULTIGEN...... 113 nalocet...... 18 moexipril hcl...... 41 MULTIGEN FOLIC...... 113 naloxone hcl...... 36 molindone hcl...... 51 MULTIGEN PLUS...... 113 naltrexone hcl...... 36 mometasone furoate...... 83, 175 MULTI-LANCET DEVICE NAMENDA XR Mondoxyne Nl...... 195 2...... 145 TITRATION PACK...... 191 MONODOX...... 195 multi-vit/iron/fluoride...... 168 NAMZARIC...... 29 MONOJECT INSULIN multivitamin/fluoride...... 165, 168 NAPRELAN...... 12 SYRINGE...... 144 multi-vitamin/fluoride...... 168 NAPROSYN...... 12 MONOJECT ULTRA multivitamin/fluoride/iron...... 168 naproxen...... 12 COMFORT SYRINGE...... 144 multi-vitamin/fluoride/iron...... 168 naproxen dr...... 12 MONOLET LANCETS...... 144 mupirocin...... 83 naproxen sodium...... 12 MONOLET OPD LANCETS mupirocin calcium...... 83 naproxen sodium er...... 12 ...... 145 MVASI...... 47 naratriptan hcl...... 161 MONOLETTOR SAFETY Mvc-Fluoride...... 168 NARCAN...... 36 LANCETS...... 145 M-VIT...... 168 NASCOBAL...... 113 Mono-Linyah...... 65 MY CHOICE...... 65 NATACHEW...... 168 MONONINE...... 110 MY WAY...... 65 NATACYN...... 180 MONOVISC...... 175 mycophenolate mofetil...... 56 NATALVIT...... 168 montelukast sodium...... 25 mycophenolate sodium...... 56 NATAZIA...... 65 MONUROL...... 198 MYDAYIS...... 9 nateglinide...... 33 MOORE MONO INSULIN MYFORTIC...... 56 NATELLE ONE...... 168 SYRINGE...... 145 MYGLUCOHEALTH NATESTO...... 20 MORGIDOX...... 195 BLOOD GLUCOSE...... 145 NATPARA...... 102 Morgidox...... 195 MYGLUCOHEALTH NATURE-THROID...... 195 MORPHABOND ER...... 18 LANCETS 30G...... 145 NAYZILAM...... 28 morphine sulfate...... 18 MYGLUCOHEALTH TEST. 95 NEBUPENT...... 42 morphine sulfate (concentrate).18 MYLERAN...... 47 Nebusal...... 70 morphine sulfate er...... 18 MYNATAL...... 168 NEBUSAL...... 70 morphine sulfate er beads...... 18 MYNATAL ADVANCE...... 168 Necon 0.5/35 (28)...... 65 MOTEGRITY...... 8 mynatal plus...... 168 NEEVO DHA...... 168 225 nefazodone hcl...... 30, 193 niacin (antihyperlipidemic)...... 39 norethin ace-eth estrad-fe...... 66 NEOCERA...... 83 niacin er (antihyperlipidemic).. 39 norethindrone...... 66 NEOKE ALCAR...... 177 NIACOR...... 39 norethindrone acetate...... 189 neoke bhb...... 98 NICADAN...... 168 norethindrone acet-ethinyl est...66 NEOKE MCT70...... 177 NICAPRIN...... 98 norethindrone-eth estradiol..... 105 NEOKE RA LIPOIC...... 10 nicardipine hcl...... 59 norethin-eth estradiol-fe...... 66 neomycin sulfate...... 10 NICAZEL...... 168 norgesic forte...... 175 neomycin-bacitracin zn- NICAZEL FORTE...... 168 norgestimate-eth estradiol...... 66 polymyx...... 180 nicazyme...... 98 norgestim-eth estrad triphasic...66 neomycin-polymyxin b gu...... 108 NICOMIDE...... 168 NORITATE...... 83 neomycin-polymyxin-dexameth NICORELIEF...... 191 Norlyda...... 66 ...... 180 nicotine...... 191 Norlyroc...... 66 neomycin-polymyxin- nicotine mini...... 191 NORPACE CR...... 23 gramicidin...... 180 nicotine polacrilex...... 191 NORTHERA...... 176 neomycin-polymyxin-hc.. 180, 182 nicotine step 1...... 191 Nortrel 0.5/35 (28)...... 66 NEONATAL PLUS...... 168 nicotine step 2...... 191 Nortrel 1/35 (21)...... 66 Neo-Polycin...... 180 nicotine step 3...... 191 Nortrel 1/35 (28)...... 66 Neo-Polycin Hc...... 180 NICOTROL...... 191 Nortrel 7/7/7...... 66 NEOSALUS...... 83 NICOTROL NS...... 191 nortriptyline hcl...... 30 NEOSALUS CP...... 83 nifedipine...... 59 NORVASC...... 59 NEO-SYNALAR...... 83 nifedipine er...... 59 NORVIR...... 53 NEOTUSS PLUS...... 70 nifedipine er osmotic release..... 59 NOURIANZ...... 8 NEPHROCAPS QT...... 168 Nikki...... 65 NOURISH...... 98 Nephronex...... 168 NILANDRON...... 47 NOVA MAX BLOOD NERLYNX...... 47 nilutamide...... 47 GLUCOSE SYSTEM...... 145 NESINA...... 33 nimodipine...... 59 NOVA MAX GLUCOSE NESTABS...... 168 NINLARO...... 47 TEST...... 95 NESTABS DHA...... 168 NIPRIDE RTU...... 41 NOVA MAX PLUS NESTABS ONE...... 168 nisoldipine er...... 59 KETONE TEST...... 95 Neuac...... 83 NITRO-BID...... 22 NOVA SAFETY LANCETS NEULASTA...... 113 NITRO-DUR...... 22 23G...... 145 NEULASTA ONPRO...... 113 nitrofurantoin...... 198 NOVA SAFETY LANCETS NEUPOGEN...... 113, 114 nitrofurantoin macrocrystal.... 198 28G...... 145 NEUPRO...... 49 nitrofurantoin monohyd macro198 NOVA SUREFLEX NEURAPTINE...... 83 nitroglycerin...... 22 LANCETS...... 145 NEURCAINE...... 83 NITROMIST...... 22 NOVA SUREFLEX NEUTEK 2TEK NIVA-PLUS...... 169 LANCING DEVICE...... 145 GLUCOSE/PRESSURE...... 145 NIVATOPIC PLUS...... 83 NOVACORT...... 83 NEUTEK 2TEK TEST...... 95 NIVESTYM...... 114 NOVOEIGHT...... 110 neutral sodium fluoride...... 164 nizatidine...... 197 NOVOFINE...... 145 NEUTRASAL...... 164 NOCDURNA...... 102 NOVOFINE AUTOCOVER 145 NEVANAC...... 180 NOCTIVA...... 102 NOVOFINE PLUS...... 145 nevirapine...... 53 Nolix...... 83 NOVOLIN 70/30...... 33 nevirapine er...... 53 Nora-Be...... 65 NOVOLIN 70/30 FLEXPEN..33 NEW DAY...... 65 NORCO...... 18 NOVOLIN 70/30 FLEXPEN NEXA PLUS...... 168 NORDIPEN 5 INJECTION RELION...... 33 NEXAVAR...... 47 DEVICE...... 145 NOVOLIN 70/30 RELION.....33 NEXGEN METER...... 145 NORDIPEN DELIVERY NOVOLIN N...... 33 NEXGEN TEST...... 95 SYSTEM...... 145 NOVOLIN N RELION...... 34 NEXIUM...... 197 NORDITROPIN FLEXPRO102 NOVOLIN R...... 34 226 NOVOLIN R RELION...... 34 NUTROPIN AQ NUSPIN 20 OMECLAMOX-PAK...... 197 NOVOLOG...... 34 ...... 102 omega-3 rx complete...... 38 NOVOLOG FLEXPEN...... 34 NUTROPIN AQ NUSPIN 5 102 OMEGA-3/D-3 WELLNESS NOVOLOG MIX 70/30...... 34 NUVAIL...... 84 PACK...... 38 NOVOLOG MIX 70/30 NUVARING...... 66 omega-3-acid ethyl esters...... 39 FLEXPEN...... 34 NUVESSA...... 200 OMEGAVEN...... 177 NOVOLOG PENFILL...... 34 NUVIGIL...... 9 Omeppi...... 197 NOVOPEN ECHO...... 145 NUWIQ...... 110 omeprazole...... 197 NOVOSEVEN RT...... 110 NUZYRA...... 10 omeprazole-sodium NOVOTWIST...... 145 Nyamyc...... 84 bicarbonate...... 197 NOXAFIL...... 37 NYMALIZE...... 59 OMNARIS...... 176 noxifol-d...... 114 nystatin...... 37, 84, 164 OMNIFLEX DIAPHRAGM145 NOXIPAK...... 83 nystatin-triamcinolone...... 84 OMNIPAQUE...... 95 np thyroid...... 195 Nystop...... 84 OMNIPOD DASH 5 PACK.145 NPLATE...... 114 OB COMPLETE...... 169 OMNIPOD STARTER...... 145 NUBEQA...... 47 OB COMPLETE OMNITROPE...... 102 NUCALA...... 117 ADVANCED...... 169 OMNITROPE PEN 10 INJ NUCARACLINPAK...... 83 OB COMPLETE GOLD...... 169 DEVICE...... 145 NUCARARXPAK...... 83 OB COMPLETE ONE...... 169 OMNITROPE PEN 5 INJ NUCYNTA...... 18 OB COMPLETE PETITE.... 169 DEVICE...... 145 NUCYNTA ER...... 18 OB COMPLETE PREMIER 169 omnivex...... 98 NUDERMRXPAK 120...... 50 OB COMPLETE/DHA...... 169 ON CALL EXPRESS NUDERMRXPAK 60...... 50 obizur...... 111 BLOOD GLUCOSE...... 95 Nudiclo Solupak...... 83 OBREDON...... 71 ON CALL EXPRESS Nudiclo Tabpak...... 13 OBSTETRIX DHA...... 169 GLUCOSE METER...... 146 NUDROXIPAK...... 13 OBSTETRIX EC...... 169 ON CALL EXPRESS NUDROXIPAK DSDR-50.... 13 OBSTETRIX ONE...... 169 MONITORING SYS...... 146 NUDROXIPAK DSDR-75.... 13 O-CAL FA...... 169 ON CALL LANCETS...... 146 NUDROXIPAK E-400...... 13 O-CAL PRENATAL...... 169 ON CALL LANCING NUDROXIPAK I-800...... 13 OCALIVA...... 105 DEVICE...... 146 NUDROXIPAK M-15...... 13 Ocella...... 66 ON CALL PLUS BLOOD NUDROXIPAK N-500...... 13 OCTAGAM...... 184 GLUCOSE...... 95 NUEDEXTA...... 191 octreotide acetate...... 102 ON CALL PLUS LANCETS146 NUFERA...... 114 ODACTRA...... 163 ON CALL PLUS LANCING Nufol...... 114 ODEFSEY...... 53 DEVICE...... 146 Nulev...... 197 ODOMZO...... 47 ON CALL PLUS METER....146 numbonex...... 83 OFEV...... 192 ON CALL PLUS NUMOISYN...... 164 ofloxacin...... 105, 180, 182 MONITORING SYSTEM... 146 NUPLAZID...... 51 OGESTREL...... 66 ON CALL VIVID BLOOD NUSURGEPAK Okebo...... 195 GLUCOSE...... 95 SURGICAL PREP/CARE..... 84 olanzapine...... 51 ON CALL VIVID NUTRASEB...... 84 olanzapine-fluoxetine hcl...... 191 GLUCOSE METER...... 146 NUTRICAP...... 169 olive oil...... 61 ON CALL VIVID METER.. 146 Nutrifac Zx...... 169 olmesartan medoxomil...... 41 ON CALL VIVID nutrilipid...... 177 olmesartan medoxomil-hctz...... 41 MONITORING...... 146 NUTRIVIT...... 169 olmesartan-amlodipine-hctz...... 41 ON CALL VIVID PAL NUTROPIN AQ NUSPIN 10 olopatadine hcl...... 176, 180 METER...... 146 ...... 102 OLUMIANT...... 13 ondansetron...... 37 OLUX-E...... 84 ondansetron hcl...... 37 OLYSIO...... 53 227 ONE A DAY PRENATAL OPTIONS GYNOL II OVACE PLUS...... 84 ...... 169, 188 CONTRACEPTIVE...... 200 OVIDREL...... 103 one drop blood glucose monitor OPTIUM BLOOD oxandrolone...... 20 ...... 146 GLUCOSE MONITOR...... 147 oxaprozin...... 13 one drop test...... 95 OPTIUM GLUCOSE OXAYDO...... 19 ONE-A-DAY WOMENS MONITOR SYSTEM...... 147 oxazepam...... 23 PRENATAL 1...... 169 OPTIUM TEST...... 95 oxcarbazepine...... 28 ONETOUCH CLUB OPTIUMEZ TEST...... 95 oxiconazole nitrate...... 84 LANCETS FINE PT...... 146 OPTUMRX BLOOD OXISTAT...... 84 ONETOUCH COMBO GLUCOSE METER...... 147 OXTELLAR XR...... 28 PACK...... 146 OPTUMRX BLOOD oxybutynin chloride...... 199 ONETOUCH DELICA GLUCOSE SYSTEM...... 147 oxybutynin chloride er...... 199 LANCETS 33G...... 146 OPTUMRX BLOOD oxycodone hcl...... 19 ONETOUCH DELICA GLUCOSE TEST...... 96 oxycodone hcl er...... 19 LANCETS FINE...... 146 ORA-BLEND...... 186 oxycodone-acetaminophen...... 19 ONETOUCH DELICA ORA-BLEND SF...... 186 oxycodone-aspirin...... 19 LANCING DEV...... 146 ORACIT...... 108 oxycodone-ibuprofen...... 19 ONETOUCH DELICA ORAFATE...... 164 OXYCONTIN...... 19 PLUS LANCET30G...... 146 ORALAIR...... 163 oxymorphone hcl...... 19 ONETOUCH DELICA Oralone...... 164, 194 oxymorphone hcl er...... 19 PLUS LANCET33G...... 146 ORA-PLUS...... 186 OXYTROL...... 199 ONETOUCH DELICA ORA-SWEET...... 186 OZEMPIC (0.25 OR 0.5 PLUS LANCING...... 146 ORA-SWEET SF...... 186 MG/DOSE)...... 34 ONETOUCH SURESOFT ORAVIG...... 164 OZEMPIC (1 MG/DOSE)...... 34 LANCING DEV...... 146 ORENCIA...... 13 OZURDEX...... 180 ONETOUCH ULTRA 2...... 146 ORENCIA CLICKJECT...... 13 Pacerone...... 23 ONETOUCH ULTRA ORENITRAM...... 60 paingo kft...... 84 BLUE...... 95 ORFADIN...... 102 paliperidone er...... 51 ONETOUCH ULTRA MINI ORILISSA...... 103 PALYNZIQ...... 103 ...... 146 ORKAMBI...... 71 PANCREAZE...... 99 ONETOUCH ULTRALINK146 ORMECA...... 44 PANDEL...... 84 ONETOUCH ULTRASOFT orphenadrine citrate er...... 175 PANRETIN...... 84 LANCETS...... 146 ORPHENGESIC FORTE.... 175 pantoprazole sodium...... 197 ONETOUCH VERIO..... 95, 146 Orsythia...... 66 PANZYGA...... 184 ONETOUCH VERIO FLEX ortho d...... 114 PARADIGM LINK SYSTEM...... 146 ortho df...... 114 GLUCOSE MONITOR...... 147 ONETOUCH VERIO IQ ORTHO TRI-CYCLEN LO...66 PARADIGM PATHWAY SYSTEM...... 147 ortho-folic...... 114 UPGRADE...... 147 ONETOUCH VERIO SYNC ORTHOVISC...... 175 PARADIGM POLYFIN SYSTEM...... 147 oscimin...... 197 QR/WINGS 24"...... 147 onevite...... 169 oscimin sr...... 197 PARADIGM POLYFIN ONEXTON...... 84 oseltamivir phosphate...... 53 QR/WINGS 42"...... 147 ONFI...... 28 OSENI...... 34 PARADIGM PUMP ONGLYZA...... 34 OSMOLEX ER...... 49 RESERVOIR 1.8ML...... 147 ONZETRA XSAIL...... 161 OSMOPREP...... 119 PARADIGM PUMP OPANA...... 18 OSPHENA...... 103 RESERVOIR 3ML...... 147 OPCICON ONE-STEP...... 66 OTEZLA...... 187 PARADIGM QUICK-SET opium...... 35 OTIPRIO...... 183 18" 6MM...... 147 OPSUMIT...... 60 OTOVEL...... 183 PARADIGM QUICK-SET OPTION 2...... 66 OTREXUP...... 13 23" 6MM...... 147 228 PARADIGM QUICK-SET p-care d80...... 69 PHARMACIST CHOICE 23" 9MM...... 147 p-care d80g...... 69 AUTOCODE SYS...... 148 PARADIGM QUICK-SET p-care d80mx...... 69 PHARMACIST CHOICE 32" 6MM...... 147 p-care m...... 120 LANCETS...... 148 PARADIGM QUICK-SET PCCA SWEET-SF...... 186 PHARMACIST CHOICE 32" 9MM...... 147 PCCA SYRUP VEHICLE.... 186 MINI SYSTEM...... 148 PARADIGM QUICK-SET PCCA-PLUS...... 186 pharmacist choice no coding..... 96 43" 6MM...... 147 PCP 100...... 119 PHARMACY COUNTER PARADIGM QUICK-SET peanut oil...... 61 LANCETS...... 148 43" 9MM...... 147 peg 3350/electrolytes...... 119 Phenadoz...... 38 PARADIGM REAL-TIME peg 3350-kcl-na bicarb-nacl.... 119 Phenazo...... 108 STARTER...... 148 peg-3350/electrolytes...... 119 phenelzine sulfate...... 30 PARADIGM REAL-TIME PEGANONE...... 28 phenobarbital...... 116 TRANSMITTER...... 148 PEGASYS...... 53 phenoxybenzamine hcl...... 41 PARADIGM SILHOUETTE PEGASYS PROCLICK...... 53 phenylephrine hcl...... 180 18" 13MM...... 148 PEGINTRON...... 53 phenylephrine-guaifenesin...... 71 PARADIGM SILHOUETTE Peg-Prep...... 119 phenytoin...... 28 32" 17MM...... 148 pen needles...... 148 phenytoin sodium extended...... 28 PARADIGM SILHOUETTE pen needles 1/2"...... 148 Philith...... 66 COMBO 23"...... 148 pen needles 3/16"...... 148 PHLAG SPRAY...... 84 PARADIGM SILHOUETTE pen needles 5/16"...... 148 PHOSLYRA...... 107 FULL 23"...... 148 penicillamine...... 56 Phospha 250 Neutral...... 163 PARADIGM SOF-SET penicillin v potassium...... 184 Phosphasal...... 198 MICRO QR 24"...... 148 PENLAC...... 84 PHOSPHOLINE IODIDE....180 PARADIGM SOF-SET PENLEN...... 84 phosphorous...... 163 MICRO QR 42"...... 148 PENLET II BLOOD Phospho-Trin 250 Neutral.....163 PARADIGM SURE-T 23" SAMPLER...... 148 PHOTREXA VISCOUS...... 182 6MM...... 148 PENLET II PHOTREXA-PHOTREXA PARADIGM SURE-T 23" REPLACEMENT CAP...... 148 VISCOUS KIT...... 182 8MM...... 148 PENNSAID...... 84 phoxillum b22k4/0...... 56 PARAGARD PENTASA...... 107 phoxillum bk4/2.5...... 56 INTRAUTERINE COPPER..66 pentazocine-naloxone hcl...... 19 Phrenilin Forte...... 15 paregoric...... 35 PENTIPS...... 148 Physiolyte...... 56 PAREMYD...... 180 pentoxifylline er...... 111 Physiosol Irrigation...... 56 paricalcitol...... 103 PERCOCET...... 19 phytonadione...... 201 Paroex...... 164 PERFECT LANCETS 28G.. 148 PICATO...... 84 paromomycin sulfate...... 10 PERFECT LANCETS 30G.. 148 PICO WOUND THERAPY paroxetine hcl...... 30 PERFOROMIST...... 25 SYSTEM...... 84 paroxetine hcl er...... 30 perindopril erbumine...... 41 PIFELTRO...... 54 paroxetine mesylate...... 191 Periogard...... 164 pilocarpine hcl...... 164, 180 PARSABIV...... 103 permethrin...... 84 pimecrolimus...... 84 PASER...... 44 perphenazine...... 51 pimozide...... 191 PAXIL...... 30 perphenazine-amitriptyline..... 191 Pimtrea...... 66 PAZEO...... 180 PERSERIS...... 51 pindolol...... 57 pc lancets super thin 30g...... 148 PERTZYE...... 99 pioglitazone hcl...... 34 pc unifine pentips...... 148 PEXEVA...... 30 pioglitazone hcl-glimepiride...... 34 p-care 100mx...... 120 PFIZERPEN...... 185 pioglitazone hcl-metformin hcl..34 p-care d40...... 69 ph strips...... 96 pip lancets 28g...... 149 p-care d40g...... 69 PHARMACIST CHOICE pip lancets 30g...... 149 p-care d40mx...... 69 AUTOCODE...... 96 229 PIQRAY (200 MG DAILY pot & sod cit-cit ac...... 108 PRECISION XTRA DOSE)...... 187 pot bicarb-pot chloride...... 163 MONITOR...... 149 PIQRAY (250 MG DAILY POTABA...... 201 PRED FORTE...... 181 DOSE)...... 187 potassium bicarbonate...... 163 PRED MILD...... 181 PIQRAY (300 MG DAILY potassium chloride...... 163 PRED-G...... 181 DOSE)...... 187 potassium chloride crys er...... 163 PRED-G S.O.P...... 181 Pirmella 1/35...... 66 potassium chloride er...... 163 prednicarbate...... 84 Pirmella 7/7/7...... 66 potassium citrate er...... 108 prednisolone...... 69 piroxicam...... 13 potassium citrate-citric acid....108 prednisolone acetate...... 181 PKU EASY...... 98 povidone-iodine...... 181 prednisolone acetate p-f...... 181 PLAVIX...... 111 PR BENZOYL PEROXIDE...84 prednisolone sodium phosphate PLEGRIDY...... 191 Pr Benzoyl Peroxide Wash...... 84 ...... 69, 181 PLEGRIDY STARTER PR CREAM...... 84 prednisolone-gatifloxacin...... 181 PACK...... 191 PR NATAL 400...... 170 prednisone...... 69 PLENVU...... 119 PR NATAL 400 EC...... 170 PREDNISONE INTENSOL.. 69 PLIAGLIS...... 84 PR NATAL 430...... 170 PREFERA OB...... 170 PLIXDA...... 84 PR NATAL 430 EC...... 170 PREFERAOB +DHA...... 170 pnv folic acid + iron...... 169 PRADAXA...... 27 preferred plus insulin syringe...149 pnv prenatal plus multivit+dha 169 PRALUENT...... 184 preferred plus lancets colored..149 pnv tabs 29-1...... 169 pramipexole dihydrochloride.....49 preferred plus lancets thin...... 149 pnv-dha...... 169 pramipexole dihydrochloride er.49 preferred plus unifine pentips.. 149 pnv-dha+docusate...... 169 pramlyte...... 30 PREFEST...... 105 pnv-omega...... 169 Pramox...... 84 pregabalin...... 28 pnv-select...... 169 prasugrel hcl...... 111 pregenna...... 170 POCKETCHEM EZ pravastatin sodium...... 39 PREMARIN...... 105, 200 SYSTEM...... 149 praziquantel...... 22 PREMESISRX...... 170 POCKETCHEM EZ TEST.....96 prazosin hcl...... 41 premium blood glucose test...... 96 pod-care 100c...... 69 PRE & POST SX POUCH...... 84 premium scar...... 85 podofilox...... 84 PRECISION LINK...... 149 PREMPHASE...... 105 POLIVY...... 47 PRECISION PCX...... 96 PREMPRO...... 105 Polycin...... 180 PRECISION PCX PLUS prena 1 true...... 170 POLYFIN INFUSION SET TEST...... 96 prena1...... 170 24"...... 149 PRECISION POINT OF prena1 pearl...... 170 POLYFIN INFUSION SET CARE TEST...... 96 prenaissance...... 170 42"...... 149 PRECISION QID prenaissance plus...... 170 POLYFIN QR INFUSION MONITOR...... 149 PRENATA...... 170 SET 42"...... 149 PRECISION QID TEST...... 96 PRENATABS RX...... 170 POLYFIN TUBING SET 60" PRECISION SOF-TACT prenatal...... 170 ...... 149 MONITOR...... 149 prenatal + complete multi170, 189 poly-iron 150 forte...... 114 PRECISION SOF-TACT PRENATAL + DHA...... 170 polymyxin b-trimethoprim...... 181 TEST...... 96 prenatal 19...... 170 polypeg...... 186 PRECISION SUREDOSE prenatal gummies/dha & fa POLY-PREP...... 119 PLUS SYR...... 149 ...... 170, 189 polysaccharide iron forte...... 114 PRECISION SURE-DOSE prenatal multi +dha...... 170 POLY-VI-FLOR...... 169 SYRINGE...... 149 prenatal plus iron...... 170 POLY-VI-FLOR FS...... 169 PRECISION XTRA...... 149 prenatal vitamin plus low iron. 170 POLY-VI-FLOR/IRON...... 169 PRECISION XTRA BLOOD PRENATAL-U...... 170 POMALYST...... 47 GLUCOSE...... 96 PRENATE...... 170, 189 Portia-28...... 66 PRECISION XTRA PRENATE AM...... 170 PORTRAZZA...... 47 KETONE...... 96 PRENATE DHA...... 170 230 PRENATE ELITE...... 170 pro comfort lancets 30g...... 149 PROMACTIN AA PLUS PRENATE ENHANCE...... 170 pro comfort lancets 31g...... 149 20PE...... 98 PRENATE ESSENTIAL...... 171 pro comfort pen needles...... 149 promethazine hcl...... 38 PRENATE MINI...... 171 pro voice v8 glucose system.....149 promethazine-codeine...... 71 PRENATE PIXIE...... 171 pro voice v8/v9 glucose...... 96 promethazine-dm...... 71 PRENATE RESTORE...... 171 pro voice v9 glucose system.....150 promethazine-phenyleph- PREPIDIL...... 183 PROAIR DIGIHALER...... 25 codeine...... 71 prepiv supply...... 85 PROAIR HFA...... 25 promethazine-phenylephrine..... 71 preplus...... 171 PROAIR RESPICLICK...... 25 Promethegan...... 38 PREPOPIK...... 119 probenecid...... 109 PROMISEB...... 85 PRESERA...... 85 PROBUPHINE IMPLANT propafenone hcl...... 23 pressure activat safety lancet.. 149 KIT...... 19 propafenone hcl er...... 23 PRESTALIA...... 41 PRO-C-DURE 6...... 69 propantheline bromide...... 197 pretab...... 171 prochlorperazine...... 51 proparacaine hcl...... 181 PREVACID...... 197 prochlorperazine edisylate...... 51 proparacaine-fluorescein...... 181 Prevalite...... 39 prochlorperazine maleate...... 51 propranolol hcl...... 57, 58 PREVENT SAFETY PEN PROCORT...... 21 propranolol hcl er...... 57 NEEDLES...... 149 PROCRIT...... 114 propranolol-hctz...... 41 PREVENTEZA...... 66 PROCTOFOAM HC...... 21 propylthiouracil...... 195 PREVIDENT...... 164 Procto-Med Hc...... 21 PROSTIN E2...... 183 PREVIDENT 5000 Procto-Pak...... 21 PROTHELIAL...... 165 BOOSTER PLUS...... 164 Proctosol Hc...... 21 PROTONIX...... 197 PREVIDENT 5000 DRY Proctozone-Hc...... 21 PROTOPIC...... 85 MOUTH...... 164 PROCYSBI...... 108 protriptyline hcl...... 30 PREVIDENT 5000 prodigen...... 35 PROTYL AG...... 85 ENAMEL PROTECT...... 164 PRODIGY AUTOCODE provad...... 35 PREVIDENT 5000 ORTHO BLOOD GLUCOSE...... 150 PROVAYBLUE...... 35, 36 DEFENSE...... 165 PRODIGY INSULIN PROVENTIL HFA...... 25 PREVIDENT 5000 PLUS.....165 SYRINGE...... 150 PROVIDA DHA...... 171 PREVIDENT 5000 PRODIGY LANCETS 28G..150 PROVIDA OB...... 171 SENSITIVE...... 165 PRODIGY LANCING PROVOCHOLINE...... 96 PREVIDOLRX DEVICE...... 150 PROZAC...... 30 ANALGESIC...... 13 PRODIGY NO CODING PRUCLAIR...... 85 Previfem...... 66 BLOOD GLUC...... 96 PRUMYX...... 85 PREVYMIS...... 54 PRODIGY POCKET pseudoeph-bromphen-dm...... 71 PREZCOBIX...... 54 BLOOD GLUCOSE...... 150 pseudoeph-chlorphen-hydrocod. 71 PREZISTA...... 54 PRODIGY SAFETY psorcon...... 85 PRIFTIN...... 44 LANCETS 26G...... 150 PSS SELECT GP LANCETS150 PRILOSEC...... 197 PRODIGY VOICE BLOOD PSS SELECT PLATFORMS 150 PRIMACARE...... 171 GLUCOSE...... 150 PSS SELECT SAFETY primaquine phosphate...... 43 PROFILNINE...... 111 LANCETS...... 150 primidone...... 28 progesterone...... 189 PTS PANELS GLUCOSE PRIMLEV...... 19 progesterone compounding kit.189 TEST...... 96 PRIMSOL...... 42 progesterone micronized...... 189 PTS PANELS KETONE PRISTIQ...... 30 PROGLYCEM...... 34 TEST...... 96 PRIVIGEN...... 184 PROGRAF...... 56 PULMICORT PRIZOTRAL...... 85 PROLASTIN-C...... 193 FLEXHALER...... 25 pro comfort alcohol...... 149 PROLENSA...... 181 Pulmosal...... 71 PRO COMFORT INSULIN PROLIA...... 103 PULMOZYME...... 193 SYRINGE...... 149 PROMACTA...... 114 purified water...... 186 231 PURIXAN...... 47 quinapril hcl...... 41 RADIAPLEXRX...... 85 push button safety lancets...... 150 quinapril-hydrochlorothiazide...41 RADIOGARDASE...... 35, 36 push button safety lancets 28g.150 quinidine gluconate er...... 23 RAGWITEK...... 58 px aspirin...... 15 quinidine sulfate...... 23 raloxifene hcl...... 103 px enteric aspirin...... 15 quinine sulfate...... 43 ramelteon...... 116 px extra short pen needles...... 150 QUINIXIL...... 85 ramipril...... 41 px insulin syringe...... 150 QUINJA...... 85 ranitidine hcl...... 197 px lancet auto injector...... 150 QUINOSONE...... 85 ranolazine er...... 22 px lancets ultra thin...... 150 QUINTET AC BLOOD RAPAFLO...... 108 px mini pen needles...... 150 GLUCOSE...... 151 RAPAMUNE...... 56 px pen needle...... 150 QUINTET AC BLOOD RAPLIXA...... 115 px shortlength pen needles...... 150 GLUCOSE TEST...... 96 RAPPORT RLS...... 151 PYLERA...... 197 QUINTET BLOOD RAPPORT VTD...... 151 pyrazinamide...... 44 GLUCOSE SYSTEM...... 151 rasagiline mesylate...... 49 pyridostigmine bromide...... 43 QUINTET BLOOD RASUVO...... 13 pyridostigmine bromide er...... 43 GLUCOSE TEST...... 96 RAVICTI...... 103 pyridoxine hcl...... 201 QUTENZA...... 85 RAYALDEE...... 103 pyrimethamine...... 61 QUTENZA (2 PATCH)...... 85 RAYOS...... 69 pyrogallic acid...... 85 QVAR REDIHALER...... 25 REACT...... 66 QBRELIS...... 41 ra alcohol swabs...... 151 READI-CAT 2...... 96 QBREXZA...... 85 ra aspirin adult low dose...... 15 READYLANCE SAFETY qc advanced lancing device...... 150 ra aspirin childrens...... 16 LANCETS...... 151 qc alcohol swabs...... 150 ra aspirin ec adult low st...... 16 READYSHARP ANESTH + qc childrens aspirin...... 15 ra blood glucose monitor...... 151 DEXAMETH...... 69 qc gentle laxative...... 119 ra childrens aspirin...... 16 READYSHARP ANESTH + qc lancets super thin 30g...... 150 RA E-ZJECT COLOR KETOROLAC...... 13 qc lancets ultra thin...... 150 LANCETS 33G...... 151 READYSHARP ANESTH + qc pen needles...... 150 RA E-ZJECT LANCETS METHYLPRED...... 69 qc unifine pentips...... 150 28G...... 151 READYSHARP qc unilet lancets 28g...... 150 RA E-ZJECT LANCETS BETAMETHASONE...... 69 qc unilet lancets micro thin..... 150 THIN 26G...... 151 READYSHARP QMIIZ ODT...... 13 RA E-ZJECT LANCETS DEXAMETHASONE...... 69 QNASL...... 176 THIN 28G...... 151 READYSHARP QNASL CHILDRENS...... 176 RA E-ZJECT LANCETS KETOROLAC...... 13 QSYMIA...... 9 ULTRA THIN...... 151 READYSHARP QTERN...... 194 ra fast relief laxative...... 119 METHYLPREDNISOLONE.69 quad-mix...... 117 ra insulin syringe...... 151 READYSHARP-A...... 120 quazepam...... 116 ra laxative...... 119 READYSHARP-P40...... 70 quetiapine fumarate...... 51 ra mini nicotine...... 191 READYSHARP-P80...... 70 quetiapine fumarate er...... 51 ra nicotine...... 191 reality insulin syringe...... 151 QUFLORA FE...... 165 ra nicotine polacrilex...... 191 reality lancets...... 151 QUFLORA FE PEDIATRIC ra pen needles...... 151 reality swabs...... 151 ...... 171 ra stimulant laxative...... 119 reality trigger lancets...... 151 QUFLORA GUMMIES...... 171 RA TRUE2GO BLOOD REBIF...... 191 QUFLORA PEDIATRIC.....171 GLUCOSE...... 151 REBIF REBIDOSE...... 191 QUICKTEK...... 150 RA TRUERESULT BLOOD REBIF REBIDOSE QUICKTEK TEST...... 96 GLUCOSE...... 151 TITRATION PACK...... 191 QUICKTEK/METER...... 150 RA TRUETEST TEST...... 96 REBIF TITRATION PACK 192 QUILLICHEW ER...... 9 rabeprazole sodium...... 197 REBINYN...... 111 QUILLIVANT XR...... 9 RADIAGEL...... 85 RECEDO...... 85 232 reck...... 120 RELION PREMIER VOICE RESTASIS...... 181 RECLAST...... 103 MONITOR...... 152 RESTASIS MULTIDOSE....181 Reclipsen...... 66 RELION PRIME RESTORA RX...... 35 RECOMBINATE...... 111 MONITOR...... 152 RESTORA SPRINKLES...... 35 RECOTHROM...... 115 RELION PRIME TEST...... 96 RESTORE SILVER RECOTHROM SPRAY KIT RELION SHORT PEN DRESSING...... 85 ...... 115 NEEDLES...... 152 RETACRIT...... 114 RECTIV...... 21 RELION ULTIMA RETAVASE...... 111 RECURA...... 85 GLUCOSE SYSTEM...... 152 RETAVASE HALF-KIT...... 111 REFUAH PLUS BLOOD RELION ULTIMA TEST...... 96 RETIN-A MICRO...... 85 GLUCOSE TEST...... 96 RELION ULTRA THIN RETIN-A MICRO PUMP...... 85 REFUAH PLUS LANCETS 30G...... 152 REVATIO...... 60 MONITORING SYSTEM... 151 RELION ULTRA THIN REVEAL BLOOD REGENECARE...... 85 PLUS LANCETS...... 152 GLUCOSE MONITOR...... 152 REGRANEX...... 85 RELISTOR...... 107 REVEAL BLOOD RELENZA DISKHALER...... 54 relnate dha...... 171 GLUCOSE TEST...... 96 RELEXXII...... 9 rematex...... 85 revesta...... 114 RELION ALL-IN-ONE...... 151 REMESENSE...... 152 REVLIMID...... 56 RELION BLOOD REMICADE...... 107 REXALL BLOOD GLUCOSE TEST...... 96 remigen...... 85 GLUCOSE SYSTEM...... 152 RELION CONFIRM REMODULIN...... 60 REXALL BLOOD GLUCOSE MONITOR...... 151 RENACIDIN...... 108 GLUCOSE TEST...... 96 RELION RENATABS...... 171 REXASIL PATCH & CONFIRM/MICRO TEST.... 96 RENATABS WITH IRON...171 VITAMIN E LIQ...... 85 RELION INSULIN RENFLEXIS...... 107 REXULTI...... 51 SYRINGE...... 151 reno caps...... 171 REYATAZ...... 54 RELI-ON INSULIN renuu...... 85 rezesol...... 86 SYRINGE...... 151 renuu nl...... 193 rheumate...... 98 RELION KETONE...... 96 repaglinide...... 34 RHINOCORT AQUA...... 176 RELION KETONE TEST...... 96 repaglinide-metformin hcl...... 34 RHOFADE...... 86 RELION LANCET REPATHA...... 184 RHOPRESSA...... 182 DEVICES 30G...... 152 REPATHA PUSHTRONEX RIAX...... 86 RELION LANCETS SYSTEM...... 184 Ribasphere...... 54 MICRO-THIN 33G...... 152 REPATHA SURECLICK.... 184 RIBASPHERE...... 54 RELION LANCETS REQ 49+...... 171 RIBASPHERE RIBAPAK STANDARD 21G...... 152 RESCRIPTOR...... 54 (1000 PACK)...... 54 RELION LANCETS THIN RESECTISOL...... 108 RIBASPHERE RIBAPAK 26G...... 152 reservapak...... 10 (1200 PACK)...... 54 RELION LANCETS reservapak plus...... 10 RIBASPHERE RIBAPAK ULTRA-THIN 30G...... 152 RESET FOR ANDROID (600 PACK)...... 54 RELION LANCING APP...... 99 RIBASPHERE RIBAPAK DEVICE...... 152 RESET FOR IOS APP...... 99 (800 PACK)...... 54 RELION MICRO...... 152 RESET FOR IOS OR ribavirin...... 54 RELION MINI PEN ANDROID APP...... 99 ribozel...... 98 NEEDLES...... 152 RESET-O FOR ANDROID RIDAURA...... 13 RELION PEN NEEDLES....152 APP...... 99 rifabutin...... 44 RELION PREMIER BLU RESET-O FOR IOS APP...... 99 RIFAMATE...... 44 MONITOR...... 152 RESET-O FOR IOS OR rifampin...... 44 RELION PREMIER ANDROID APP...... 99 RIFAMPIN+SYRSPEND COMPACT SYSTEM...... 152 resorcinol-sulfur...... 85 SF...... 44 233 RIFATER...... 44 ROXYBOND...... 19 SAVELLA TITRATION RIGHTEST ALTERNATE ROZEREM...... 116 PACK...... 192 SITE ADAPT...... 152 ROZLYTREK...... 44 sb alcohol prep...... 153 RIGHTEST GD500 RRB PAK...... 86 sb bisacodyl laxative ec...... 119 LANCING DEVICE...... 152 RTD WOUND CARE sb childrens aspirin...... 16 RIGHTEST GL300 DRESSING...... 86 sb insulin syringe...... 153 LANCETS...... 152 RUBRACA...... 187, 188 sb lancets thin...... 153 RIGHTEST GM100 BLOOD RUCONEST...... 111 sb lancets ultra thin...... 153 GLUCOSE...... 152 RUZURGI...... 43 sb laxative...... 119 RIGHTEST GM300 BLOOD RYBELSUS...... 34 scarcin...... 86 GLUCOSE...... 152 RYCLORA...... 38 scarsilk...... 86 RIGHTEST GM550 BLOOD RYDAPT...... 47 SCARZEN SKIN REPAIR....86 GLUCOSE...... 152 rynoderm...... 86 schnucks insulin syringe...... 153 RIGHTEST GS100 BLOOD RYTARY...... 49 scopolamine...... 37 GLUCOSE...... 96 RYVENT...... 38 SEBUDERM...... 86 RIGHTEST GS300 BLOOD SABRIL...... 28 SECONAL...... 116 GLUCOSE...... 97 SAFESNAP INSULIN SEEBRI NEOHALER...... 25 RIGHTEST GS550 BLOOD SYRINGE...... 153 SEGLUROMET...... 194 GLUCOSE...... 97 SAFE-T-LANCE...... 153 select-lite lancing device...... 153 RIGHTSOURCE BLOOD SAFE-T-LANCE PLUS...... 153 SELECT-OB...... 171 GLUCOSE...... 153 safety insulin syringes...... 153 SELECT-OB+DHA...... 171 riluzole...... 176 SAFETY LET LANCETS.... 153 selegiline hcl...... 49 rimantadine hcl...... 54 SAFETY SEAL LANCETS..153 selenium sulfide...... 86 RIMSO-50...... 108 safflower oil...... 61 SELZENTRY...... 54 ringers irrigation...... 56 SAFYRAL...... 66 SEMPREX-D...... 71 RINVOQ...... 13 SAIZEN...... 103 se-natal 19...... 171 RIOMET...... 34 SAIZEN CLICK.EASY...... 103 SENSIPAR...... 103 risedronate sodium...... 103 SAIZENPREP...... 103 SEREVENT DISKUS...... 25 RISPERDAL CONSTA...... 51 salimez...... 86 SERNIVO...... 86 risperidone...... 51 salimez forte...... 86 SEROQUEL XR...... 51 ritonavir...... 54 salisol...... 86 SEROSTIM...... 103 rivastigmine...... 192 salitech...... 86 sertraline hcl...... 30 rivastigmine tartrate...... 192 SALIVAMAX...... 165 sesame oil...... 62 Rivelsa...... 66 salsalate...... 16 Setlakin...... 66 rixubis...... 111 SAMSCA...... 103 sevelamer carbonate...... 107 rizatriptan benzoate...... 162 SANCUSO...... 37 sevelamer hcl...... 107 R-NATAL OB...... 171 SANDIMMUNE...... 56 sevoflurane...... 107 ROCKLATAN...... 182 SANDOSTATIN...... 103 SEYSARA...... 195 ROPIDEX...... 70 SANDOSTATIN LAR sf...... 165 ropinirole hcl...... 49 DEPOT...... 103 sf 5000 plus...... 165 ropinirole hcl er...... 49 SANTYL...... 86 SFROWASA...... 107 Rosadan...... 86 SAPHRIS...... 51 Sharobel...... 66 ROSE GLO...... 181 saps care alcohol prep...... 153 SHOPKO ALCOHOL rosuvastatin calcium...... 39 saps health care alcohol prep...153 SWABS...... 153 ROTARIX...... 199 saps health twist top lancets....153 SHOPKO AUTOLET ROTATEQ...... 199 saps twist top lancets...... 153 LANCING DEVICE...... 153 Roweepra...... 28 sapscare twist top lancets...... 153 SHOPKO UNIFINE Roweepra Xr...... 28 SAVAYSA...... 27 PENTIPS...... 153 ROXICODONE...... 19 SAVELLA...... 192 SHOPKO UNIFINE roxifol-d...... 114 PENTIPS PLUS...... 153 234 SHUR-SEAL sm insulin syringe...... 154 sodium sulfacetamide wash...... 86 CONTRACEPTIVE...... 200 sm lancets 33g...... 154 sofosbuvir-velpatasvir...... 115 side button safety lancet...... 153 sm laxative...... 119 SOF-SENSOR...... 154 SIDEKICK BLOOD sm nicotine...... 192 SOF-SET INFUSION SET GLUCOSE SYSTEM...... 153 sm nicotine polacrilex...... 192 24"...... 154 SIDEROL...... 171 SM TRUEDRAW SOF-SET INFUSION SET SIGNIFOR LAR...... 103 LANCING DEVICE...... 154 42"...... 154 SIKLOS...... 114 SMART DIABETES SOF-SET MICRO QR SILALITE PAK...... 86 VANTAGE LANCING...... 154 INFUSION 24"...... 154 SILAZONE PHARMAPAK.. 86 SMART SENSE COLOR SOF-SET MICRO QR SILAZONE-II...... 86 LANCETS 33G...... 154 INFUSION 42"...... 154 sildenafil citrate...... 60 SMART SENSE PREMIUM SOF-SET ULTIMATE QR SILENOR...... 116 SYSTEM...... 154 24"...... 154 SILHOUETTE 13MM...... 153 SMART SENSE PREMIUM SOF-SET ULTIMATE QR SILHOUETTE 17MM...... 153 TEST...... 97 42"...... 154 SILHOUETTE INFUSION SMART SENSE solifenacin succinate...... 199 SET 23"...... 153 STANDARD LANCETS..... 154 SOLIQUA...... 117 SILHOUETTE INFUSION SMART SENSE SUPER SOLIRIS...... 111 SET 43"...... 153 THIN LANCETS...... 154 SOLOSEC...... 10 silipac...... 193 SMART SENSE THIN SOLTAMOX...... 47 SILIQ...... 86 LANCETS 26G...... 154 solupak...... 87 SIL-K PAD LARGE...... 86 SMART SENSE VALUE solu-pref...... 27 SIL-K PAD MEDIUM...... 86 GLUCOSE SYS...... 154 SOLUS V2 BLOOD SIL-K PAD SMALL...... 86 SMART SENSE VALUE GLUCOSE SYSTEM...... 154 silmanix pain relieiving...... 86 TEST...... 97 SOLUS V2 LANCETS 28G.. 155 silodosin...... 108 SMARTEST BLOOD SOLUS V2 LANCING silver sulfadiazine...... 86 GLUCOSE TEST...... 97 DEVICE...... 155 SIMBRINZA...... 181 SMARTEST EJECT...... 154 SOLUS V2 TEST...... 97 Simliya...... 66 SMARTEST EJECT SOLUS V2 TWIST Simpesse...... 67 STARTER...... 154 LANCETS 30G...... 155 SIMPLE DIAGNOSTICS SMARTEST LANCETS 28G SOMATULINE DEPOT...... 103 LANCING DEV...... 153 ...... 154 SOMAVERT...... 103 simple syrup...... 186 SMARTEST PERSONA SOOLANTRA...... 87 SIMPONI...... 14 STARTER...... 154 SOOTHEE...... 87 SIMPONI ARIA...... 13 SMARTEST PRONTO sorbitol...... 108, 186 simvastatin...... 39 STARTER...... 154 sorbitol-mannitol...... 108 SINGLE-LET...... 153 SMARTEST PROTEGE...... 154 SORIATANE...... 87 SINGULAIR...... 25 SMARTEST PROTEGE SORILUX...... 87 SINUVA...... 176 STARTER...... 154 Sorine...... 58 sirolimus...... 56 SMARTRX GABA...... 188 sorrel/dock mix...... 163 SITAVIG...... 54 SMARTRX GABA-V...... 188 sotalol hcl...... 58 SIVEXTRO...... 42 sod citrate-citric acid...... 108 sotalol hcl (af)...... 58 SKLICE...... 86 sodium bicarbonate...... 21 sotalol hydrochloride...... 58 SKYRIZI (150 MG DOSE).... 86 sodium chloride...... 71, 108 SOTYLIZE...... 58 SLYND...... 67 sodium fluoride...... 163 SOVALDI...... 54 sm alcohol prep...... 154 sodium hyaluronate...... 86 ...... 62 sm aspirin adult low strength.... 16 sodium phenylbutyrate...... 103 sp antipruritic...... 87 sm childrens aspirin...... 16 sodium polystyrene sulfonate sp scar management...... 87 sm folic acid...... 114 ...... 56, 188 spg supposi-base...... 186 sm gentle laxative...... 119 sodium saccharin...... 98 spinosad...... 87 235 SPIRIVA HANDIHALER.....25 sulfurated lime...... 87 SURE-T INFUSION SET SPIRIVA RESPIMAT...... 25 SULFZIX...... 99 23"...... 155 spironolactone...... 100 sulindac...... 14 SURE-T INFUSION SET spironolactone-hctz...... 100 sumatriptan...... 162 32"...... 155 SPRAVATO (56 MG DOSE)176 sumatriptan succinate...... 162 SURE-T INFUSION SET SPRAVATO (84 MG DOSE)176 sumatriptan succinate refill.....162 6MM...... 155 Sprintec 28...... 67 sumatriptan-naproxen sodium.162 SURE-T INFUSION SET SPRITAM...... 28 SUMAVEL DOSEPRO...... 162 8MM...... 155 SPRIX...... 14 SUNOSI...... 100 SURE-TEST EASYPLUS SPRYCEL...... 47 SUPARTZ FX...... 175 MINI METER...... 155 Sps...... 56, 188 super bi-mix...... 117 SURE-TEST EASYPLUS sr nicotine...... 192 super quad-mix...... 117 MINI TEST...... 97 Sronyx...... 67 super tri-mix...... 117 SURE-TOUCH LANCETS Ssd...... 87 SUPERVITE...... 171 UNIVERSAL...... 155 ST JOSEPH LOW DOSE...... 16 support...... 171 SURVANTA...... 193 stavudine...... 54 SUPPORT-500...... 171 SUSPENDRX STEGLATRO...... 34 suppository blend...... 186 W/BITTERBLOC SWEET... 186 STEGLUJAN...... 194 SUPPRELIN LA...... 103 SUSPENDRX STELARA...... 87, 117 SUPRAX...... 61 W/BITTERBLOC STENDRA...... 60 SUPREME TEST...... 97 UNSWEET...... 186 STERILANCE PA...... 155 SUPREP BOWEL PREP KIT suspension vehicle...... 186 STERILANCE TL...... 155 ...... 119 SUSTOL...... 37 sterile water for irrigation...... 56 sure comfort alcohol prep...... 155 SUTENT...... 48 STIMATE...... 103 sure comfort insulin syringe.... 155 suvicort...... 87 stimulant laxative...... 119 sure comfort lancets 18g...... 155 SX1 MEDICATED POST- STIOLTO RESPIMAT...... 25 sure comfort lancets 21g...... 155 OPERATIVE...... 87 STIVARGA...... 48 sure comfort lancets 23g...... 155 Syeda...... 67 STRIANT...... 20 sure comfort lancets 30g...... 155 SYLATRON...... 48 STRIBILD...... 54 sure comfort lancing pen...... 155 SYLVANT...... 118 STRIVERDI RESPIMAT...... 25 sure comfort pen needles...... 155 SYMAX DUOTAB...... 197 STROVITE FORTE...... 171 SURE EDGE GLUCOSE Symax-Sr...... 197 SUBLOCADE...... 19 MONITOR...... 155 SYMBICORT...... 25 SUBOXONE...... 19 SURE EDGE TEST...... 97 SYMFI...... 54 SUBSYS...... 19 sure result o3d3 system...... 38 SYMFI LO...... 54 Subvenite...... 28 SURECHEK BLOOD SYMJEPI...... 201 Subvenite Starter Kit-Blue...... 28 GLUCOSE MONITOR...... 155 SYMLINPEN 120...... 34 Subvenite Starter Kit-Green....28 SURECHEK BLOOD SYMLINPEN 60...... 34 Subvenite Starter Kit-Orange.. 28 GLUCOSE TEST...... 97 SYMPAZAN...... 28 SUCRAID...... 99 SURE-FINE PEN SYMPROIC...... 107 sucralfate...... 197 NEEDLES...... 155 SYMTUZA...... 54 sulfacetamide sodium...... 181 SURE-JECT INSULIN SYNAGEX...... 171 sulfacetamide sodium (acne).... 87 SYRINGE...... 155 SYNAGIS...... 184 sulfacetamide sodium-sulfur...... 87 SURE-LANCE FLAT SYNAREL...... 103 sulfacetamide-prednisolone..... 181 LANCETS...... 155 SYNATEK...... 171 sulfadiazine...... 194 SURE-LANCE LANCETS SYNDROS...... 37 sulfamethoxazole-trimethoprim 42 26G...... 155 SYNERA...... 87 sulfamez wash...... 87 SURELITE LANCETS...... 155 SYNERDERM...... 87 SULFAMYLON...... 87 SURE-PEN...... 155 SYNJARDY...... 194 sulfasalazine...... 107 SURE-T INFUSION SET SYNJARDY XR...... 194 Sulfatrim Pediatric...... 42 18"...... 155 SYNRIBO...... 48 236 SYNVISC...... 175 TARON-PREX...... 171 TETRIX...... 88 SYNVISC ONE...... 175 TASIGNA...... 48 TEXACORT...... 88 syrpalta...... 186 TAVALISSE...... 194 TEXAVITE LQ...... 184 SYRPALTA (RED)...... 186 TAYTULLA...... 67 tgt aspirin...... 16 SYRSPEND SF...... 186 tazarotene...... 88 tgt aspirin low dose...... 16 SYRSPEND SF PH4...... 186 TAZORAC...... 88 tgt blood glucose monitoring... 156 syrup vehicle...... 186 Taztia Xt...... 59 tgt blood glucose test...... 97 syrup vehicle sf...... 186 TECFIDERA...... 192 tgt childrens aspirin...... 16 T:30 INFUSION SET...... 155 techlite insulin syringe...... 156 tgt lancet micro thin 33g...... 156 T:90 INFUSION SET...... 155 TECHLITE PEN NEEDLES156 tgt lancet thin 26g...... 156 T:FLEX INSULIN TECHNELITE...... 97 tgt lancet ultra thin 30g...... 156 CARTRIDGE 4.8ML...... 156 TECHNIVIE...... 115 tgt lancing device...... 156 T:FLEX T:LOCK TEGADERM AG MESH...... 88 tgt nicotine...... 192 CARTRIDGE 4.8ML...... 156 TEGSEDI...... 52 tgt nicotine polacrilex...... 192 T:SLIM G4 INSULIN TEKTURNA...... 41 tgt nicotine step one...... 192 CARTRIDGE...... 156 TEKTURNA HCT...... 41 THALOMID...... 56 T:SLIM INSULIN TELCARE BLOOD THE LIQUILIFT TRACE... 163 CARTRIDGE 3ML...... 156 GLUCOSE SYSTEM...... 156 THE MAGIC BULLET...... 119 T:SLIM T:LOCK INSULIN TELCARE BLOOD THEO-24...... 25 CART 3ML...... 156 GLUCOSE TEST...... 97 THEOCHRON...... 25 TABLOID...... 48 TELFA AMD ISLAND Theochron...... 25 TABRADOL FUSEPAQ...... 175 DRESSING...... 156 theophylline...... 25 TABRADOL RAPIDPAQ... 175 TELFA AMD NON- theophylline er...... 25 TACLONEX...... 87 ADHERENT...... 156 THERAHONEY...... 88 tacrolimus...... 56, 87 telmisartan...... 42 THERANATAL ONE...... 172 tadalafil (pah)...... 60 telmisartan-amlodipine...... 42 THERAPEVO...... 88 TAFINLAR...... 48 telmisartan-hctz...... 42 thiamine hcl...... 201 TAGITOL V...... 97 temazepam...... 116 THINLETS GP LANCETS..156 TAGRISSO...... 48 TEMIXYS...... 54 THIOLA EC...... 108 TAKE ACTION...... 67 TEMODAR...... 48 thioridazine hcl...... 51 TAKHZYRO...... 187 temozolomide...... 48 thiothixene...... 51 TALIVA...... 114 TENCON...... 16 thrivacin 30...... 99 TALTZ...... 87 tenofovir disoproxil fumarate....54 thrivacin detox...... 99 TALZENNA...... 187, 188 terazosin hcl...... 42 THRIVE...... 192 tamoxifen citrate...... 48 terbinafine hcl...... 37 thrivite 19...... 172 tamsulosin hcl...... 108 terbutaline sulfate...... 25 thrivite rx...... 172 TANZEUM...... 34 terconazole...... 200 THROMBIN-JMI...... 115 TAPERDEX 12-DAY...... 70 Terrell...... 107 THROMBIN-JMI Taperdex 6-Day...... 70 TESTIM...... 20 EPISTAXIS...... 115 TAPERDEX 7-DAY...... 70 TESTONE CIK...... 20 THROMBOGEN...... 115 TARCEVA...... 48 TESTOPEL...... 20 thyroid...... 196 TARGADOX...... 195 testosterone...... 21 tiagabine hcl...... 28 TARGRETIN...... 48, 88 testosterone compounding kit....20 TICALAST...... 176 Tarina 24 Fe...... 67 testosterone cypionate...... 21 TICASPRAY...... 176 Tarina Fe 1/20...... 67 testosterone enanthate...... 21 TICE BCG...... 48 Tarina Fe 1/20 Eq...... 67 Tetcaine...... 181 TIGLUTIK...... 176 taron forte...... 114 tetrabenazine...... 192 TIKOSYN...... 23 TARON-BC...... 171 tetracaine hcl...... 181 Tilia Fe...... 67 TARON-C DHA...... 171 tetracycline hcl...... 195 timolol maleate...... 58, 181 Taron-Crystals...... 108 tetravex...... 88 TIMOPTIC OCUDOSE...... 181 237 tinidazole...... 42 TRACLEER...... 60 TRICOR...... 39 TIROSINT...... 196 TRADJENTA...... 34 Triderm...... 88 TIROSINT-SOL...... 196 tramadol hcl...... 19 trientine hcl...... 56 TISSEEL...... 115 tramadol hcl er...... 19 Tri-Estarylla...... 67 Tis-U-Sol...... 56 tramadol hcl er (biphasic)...... 19 TRIFERIC...... 114 TIVICAY...... 55 tramadol-acetaminophen...... 19 trifluoperazine hcl...... 51 TIVORBEX...... 14 trandolapril...... 42 trifluridine...... 181 tizanidine hcl...... 175 trandolapril-verapamil hcl er.... 42 trigels-f forte...... 114 tl folate...... 172 tranexamic acid...... 115 TRIGLIDE...... 39 tl gard rx...... 114 TRANSDERM SCOP (1.5 trihexyphenidyl hcl...... 49 TL G-FOL OS...... 172 MG)...... 37 Tri-Legest Fe...... 67 tl icon...... 114 TRANSDERM-SCOP (1.5 Tri-Linyah...... 67 tl-care dha...... 172 MG)...... 37 Tri-Lo-Estarylla...... 67 tl-fluorivite...... 172 tranylcypromine sulfate...... 30 Tri-Lo-Marzia...... 67 tl-hem 150...... 114 TRANZAREL...... 88 Tri-Lo-Mili...... 67 tl-select...... 172 TRAVATAN Z...... 181 Tri-Lo-Sprintec...... 67 TOBAKIENT...... 99 travel lancets...... 156 Trilyte...... 119 TOBI...... 10 TRAVEL LANCETS trimethobenzamide hcl...... 37 TOBI PODHALER...... 10 ADVANCED 28G...... 156 trimethoprim...... 42 TOBRADEX...... 181 trazodone hcl...... 30, 193 Tri-Mili...... 67 TOBRADEX ST...... 181 TREANDA...... 48 trimipramine maleate...... 30 tobramycin...... 10, 181 TRECATOR...... 44 tri-mix...... 117 tobramycin-dexamethasone.... 181 TRELEGY ELLIPTA...... 25 TRIMO-SAN...... 200 TOBREX...... 181 TRELSTAR MIXJECT...... 48 trinatal rx 1...... 172 todays health mini pen needles 156 TREMFYA...... 88 TRINATE...... 172 todays health pen needles...... 156 treprostinil...... 60 trinaz...... 172 todays health short pen needle.156 TRESIBA...... 34 TRINTELLIX...... 30, 193 TOLAK...... 88 TRESIBA FLEXTOUCH...... 34 triphrocaps...... 172 tolbutamide...... 34 tretinoin...... 48, 88 triple complex formula 3 kit...... 88 tolcapone...... 49 tretinoin microsphere...... 88 triple pmb...... 181 tolmetin sodium...... 14 tretinoin microsphere pump...... 88 triple pmk...... 181 tolsura...... 37 TREXALL...... 48 Tri-Previfem...... 67 tolterodine tartrate...... 199 TREZIX...... 19 TRIPTODUR...... 104 tolterodine tartrate er...... 199 Tri Femynor...... 67 Tri-Sprintec...... 67 topcare clickfine pen needles... 156 triamcinolone acetonide tristart dha...... 172 topcare lancets micro-thin 33g 156 ...... 88, 165, 194 TRISTART ONE...... 172 topcare ultra comfort ins syr...156 tri-amino...... 177 tri-tabs dha...... 172 topco insulin syringe...... 156 TRIAMSIL COMBIPAK...... 88 TRIUMEQ...... 55 topiramate...... 29 triamsil multipak...... 88 TRIVEEN-DUO DHA...... 172 topiramate er...... 28 triamterene...... 100 TRI-VI-FLOR...... 172 TOPROL XL...... 58 triamterene-hctz...... 100 tri-vi-floro...... 172 toremifene citrate...... 48 TRIANEX...... 88 TRIVISC...... 175 TORONOVA II SUIK...... 14 triazolam...... 116 tri-vite/fluoride...... 172 TORONOVA SUIK...... 14 TRICARE...... 172 Trivora (28)...... 67 torsemide...... 100 TRICARE PRENATAL...... 172 Tri-Vylibra...... 67 TOSYMRA...... 162 TRICARE PRENATAL Tri-Vylibra Lo...... 67 TOTECT...... 48 DHA ONE...... 172 TRIXYLITRAL...... 88 TOVIAZ...... 199 TRICITRASOL...... 27, 117 TROKENDI XR...... 29 TOXICOLOGY MED tricitrates...... 109 tronvite...... 172 COLLECTION SYS...... 97 Tricon...... 114 tropicamide...... 182 238 trospium chloride...... 199 TUXARIN ER...... 71 ULTILET SAFETY trospium chloride er...... 199 TUZISTRA XR...... 71 LANCETS 23G...... 158 true comfort insulin syringe.....156 TYBOST...... 52 ULTIMA...... 158 true comfort pen needles...... 156 Tydemy...... 67 ULTIMA TEST...... 97 true comfort twist top lancets..156 TYGACIL...... 42 ultimatecare one...... 172 TRUE FOCUS BLOOD TYKERB...... 48 ULTOMIRIS...... 111 GLUCOSE METER...... 156 TYLACTIN COMPLETE 15 ultra comfort insulin syringe... 158 true focus blood glucose strip....97 PE...... 99 ultra thin lancets 31g...... 158 TRUE METRIX AIR TYLENOL WITH ULTRA THIN PEN GLUCOSE METER...... 157 CODEINE #3...... 19 NEEDLES...... 158 TRUE METRIX BLOOD TYLENOL WITH ULTRA TRAK PRO GLUCOSE TEST...... 97 CODEINE #4...... 19 BLOOD GLUCOSE...... 158 TRUE METRIX GO TYMLOS...... 104 ultracare insulin syringe...... 158 GLUCOSE METER...... 157 TYR EASY...... 99 ultra-care lancets 30g...... 158 TRUE METRIX METER.... 157 TYSABRI...... 192 ultracare pen needles...... 158 TRUE2GO BLOOD TYVASO...... 60 ULTRACET...... 19 GLUCOSE MONITOR...... 157 TYVASO REFILL...... 60 ultra-comfort insulin syringe...158 TRUEDRAW LANCING TYVASO STARTER...... 60 ULTRALANCE...... 158 DEVICE...... 157 UCERIS...... 21 ULTRAM...... 20 TRUEPLUS 5-BEVEL PEN UDAMIN SP...... 172 ULTRA-THIN II AUTO NEEDLES...... 157 UDENYCA...... 114 LANCET...... 158 TRUEPLUS INSULIN ULESFIA...... 88 ULTRA-THIN II INS SYR SYRINGE...... 157 ULTICARE ALCOHOL SHORT...... 158 TRUEPLUS LANCETS 26G157 SWABS...... 157 ULTRA-THIN II INSULIN TRUEPLUS LANCETS 28G157 ULTICARE INSULIN SYRINGE...... 158 TRUEPLUS LANCETS 30G157 SAFETY SYR...... 157 ULTRA-THIN II LANCETS TRUEPLUS LANCETS 33G157 ULTICARE INSULIN ...... 158 TRUEPLUS PEN NEEDLES SYRINGE...... 157 ULTRA-THIN II MINI PEN ...... 157 ULTICARE MICRO PEN NEEDLE...... 158 TRUEPLUS SAFETY NEEDLES...... 157 ULTRA-THIN II PEN LANCETS 28G...... 157 ULTICARE MINI PEN NEEDLE SHORT...... 158 TRUERESULT BLOOD NEEDLES...... 157 ULTRA-THIN II PEN GLUCOSE...... 157 ULTICARE PEN NEEDLES NEEDLES...... 158 TRUETEST TEST...... 97 ...... 157 ULTRATRAK ACTIVE...... 158 TRUETRACK BLOOD ULTICARE SHORT PEN ULTRATRAK PRO...... 158 GLUCOSE...... 157 NEEDLES...... 157 ULTRATRAK PRO TEST.... 97 TRUETRACK SMART ULTI-LANCE ULTRATRAK ULTIMATE SYSTEM...... 157 AUTOMATIC...... 157 MONITOR...... 158 TRUETRACK TEST...... 97 ultilet alcohol swabs...... 157 ULTRATRAK ULTIMATE TRULANCE...... 62 ULTILET CLASSIC TEST...... 97 TRULICITY...... 34 LANCETS...... 157 ULTRAVATE...... 88 TRUSTEEL INFUSION ULTILET INSULIN UNIFINE PENTIPS...... 158 SET...... 157 SYRINGE...... 158 unifine pentips plus...... 159 TRUVADA...... 55 ULTILET INSULIN UNILET COMFORTOUCH tryptophan...... 177 SYRINGE SHORT...... 158 LANCET...... 159 TUDORZA PRESSAIR...... 26 ULTILET LANCETS...... 158 UNILET EXCELITE...... 159 Tulana...... 67 ULTILET PEN NEEDLE.... 158 UNILET EXCELITE II...... 159 TURALIO...... 48 ULTILET SAFETY UNILET G.P. LANCET...... 159 turpentine...... 88 LANCETS...... 158 UNILET G.P. SUPERLITE TUSSICAPS...... 71 LANCET...... 159 239 UNILET GP 28 ULTRA Uredeb...... 88 VARUBI...... 37 THIN...... 159 URESOL...... 88 VASCEPA...... 39 UNILET LANCET...... 159 Uretron D/S...... 198 VASCUDERM UNILET MICRO-THIN 33G urevaz...... 88 HYDROGEL...... 89 ...... 159 Uribel...... 198 VASCULERA...... 99 UNILET SUPERLITE URIMAR-T...... 198 VASHE CLEANSING...... 89 LANCET...... 159 urin ds...... 198 VAXCHORA...... 199 UNILET SUPER-THIN 30G uro-458...... 198 vb6 p5p...... 99 ...... 159 uro-mp...... 198 v-c forte...... 172 UNILET ULTRA-THIN urosex...... 172 VCF VAGINAL 28G...... 159 UROXATRAL...... 109 CONTRACEPTIVE...... 200 UNISTIK 1...... 159 ursodiol...... 107 VECAMYL...... 42 UNISTIK 2...... 159 URSODIOL+SYRSPEND VECTICAL...... 89 UNISTIK 2 COMFORT...... 159 SF...... 107 vegetable capsule #0 green...... 186 UNISTIK 2 EXTRA...... 159 Uryl...... 198 vegetable capsule #0 white...... 186 UNISTIK 2 NEONATAL.... 159 Ustell...... 198 vegetable capsule #00 white....186 UNISTIK 2 NORMAL...... 159 UTIBRON NEOHALER...... 26 vegetable capsule #1 white...... 186 UNISTIK 2 SUPER...... 159 uticap...... 198 vegetable capsule #2 white...... 186 UNISTIK 3...... 159 Utira-C...... 198 vegetable capsule #3 white...... 186 UNISTIK 3 COMFORT...... 159 Utrona-C...... 198 vegetable capsule #4 white...... 187 UNISTIK 3 EXTRA...... 159 valacyclovir hcl...... 55 VELETRI...... 60 UNISTIK 3 GENTLE...... 159 VALCYTE...... 55 Velivet...... 67 UNISTIK 3 NEONATAL.... 159 valganciclovir hcl...... 55 VELPHORO...... 107 UNISTIK 3 NORMAL...... 159 valproic acid...... 29 VELTASSA...... 56, 188 UNISTIK CZT COMFORT.159 valsartan...... 42 VELTIN...... 89 UNISTIK CZT NORMAL...159 valsartan-hydrochlorothiazide...42 VEMLIDY...... 55 UNISTIK PRO SAFETY VALTREX...... 55 vena-bal dha...... 172 LANCET...... 159 value health insulin syringe..... 160 VENELEX...... 89 UNISTIK SAFETY value plus lancet standard 21g.160 VENIPUNCTURE CPI...... 89 LANCETS 28G...... 159 value plus lancets super thin.... 160 VENIPUNCTURE PX1 UNISTIK SAFETY valumark lancet ultra thin 28g 160 PHLEBOTOMY...... 89 LANCETS 30G...... 159 valumark pen needles...... 160 venlafaxine hcl...... 30 UNISTIK TOUCH SAFETY VANATOL LQ...... 16 venlafaxine hcl er...... 31 LANC 21G...... 159 VANATOL S...... 16 VENTAVIS...... 60 UNISTIK TOUCH SAFETY vancomycin hcl...... 109 VENTOLIN HFA...... 26 LANC 23G...... 159 VANCOMYCIN+SYRSPEN veracolate...... 119 UNISTIK TOUCH SAFETY D SF...... 109 VERAMYST...... 176 LANC 28G...... 159 Vandazole...... 200 verapamil hcl...... 59 UNISTIK TOUCH SAFETY VANISHPOINT INSULIN verapamil hcl er...... 59 LANC 30G...... 159 SYRINGE...... 160 verasens blood glucose meter...160 UNISTRIP1 GENERIC...... 97 Vanoxide-Hc...... 88 verasens blood glucose system.160 Unithroid...... 196 VANTAS...... 48 verasens blood glucose test...... 97 UNIVERSAL 1 LANCETS VARIBAR HONEY...... 97 VERDESO...... 89 THIN 26G...... 160 VARIBAR NECTAR...... 97 VEREGEN...... 89 UNIVERSAL 1 LANCETS VARIBAR PUDDING...... 97 VERSACLOZ...... 51 THIN 33G...... 160 VARIBAR THIN HONEY.... 97 VERSAFREE...... 187 UNIVERSAL 1 LANCETS VARIBAR THIN LIQUID.... 97 VERSAPLUS...... 187 ULTRA THIN...... 160 VARISOFT INFUSION SET VERZENIO...... 71 UPTRAVI...... 192 ...... 160 vexasyn...... 89 uraliss...... 88 VAROPHEN...... 89 V-GO 20...... 160 240 V-GO 30...... 160 Vitacel...... 173 vol-tab rx...... 173 V-GO 40...... 160 VITAFOL FE+...... 173 VOLTAREN...... 89 VIAGRA...... 61 VITAFOL GUMMIES...... 173 VONVENDI...... 111 VIBERZI...... 116 VITAFOL STRIPS...... 173 vopac mds...... 89 VIBRAMYCIN...... 195 VITAFOL ULTRA...... 173 voriconazole...... 37 Vic-Forte...... 172 VITAFOL-NANO...... 173 VOSEVI...... 115 Vicodin...... 20 VITAFOL-OB...... 173 VOTRIENT...... 48 Vicodin Es...... 20 VITAFOL-OB+DHA...... 173 vp gkl kit...... 89 Vicodin Hp...... 20 VITAFOL-ONE...... 173 vp insulin syringe...... 160 VICTORY AGM-4000 TEST. 97 VITALET PRO LANCETS..160 vp-gstn...... 99 VICTORY BLOOD VITALET PRO PLUS vp-heme ob + dha...... 173 GLUCOSE SYSTEM...... 160 LANCETS...... 160 vp-pnv-dha...... 173 VICTOZA...... 35 Vitamax Pediatric...... 173 VPRIV...... 114 VIDA MIA UNIFINE VITAMEDMD ONE vp-vite rx...... 174 PENTIPS...... 160 RX/QUATREFOLIC...... 173 V-R MONO INSULIN VIDEX...... 55 VITAMEDMD REDICHEW SYRINGE...... 160 VIDEX EC...... 55 RX...... 173 VRAYLAR...... 51 VIEKIRA PAK...... 115 VITAMEZ...... 114 VSL#3 DS...... 35 VIEKIRA XR...... 115 vita-min...... 173 Vyfemla...... 67 Vienva...... 67 vitamin d (ergocalciferol)...... 201 VYLEESI...... 161 vigabatrin...... 29 vitamin k1...... 201 Vylibra...... 67 Vigadrone...... 29 vitamins acd-fluoride...... 173 VYNDAMAX...... 196 VIIBRYD...... 31, 193 VITAPEARL...... 173 VYNDAQEL...... 196 VIIBRYD STARTER PACK vitasure...... 173 VYVANSE...... 9 ...... 31, 193 VITATRUE...... 173 VYZULTA...... 182 Vilamit Mb...... 198 vitaxyme...... 165 walgreens adv travel lancets....160 Vilevev Mb...... 198 vitazyme...... 165 WALGREENS LANCETS...160 VIMIZIM...... 165 VITRAKVI...... 44 walgreens lancets micro thin... 160 VIMOVO...... 14 VIVA DHA...... 173 walgreens lancets super thin....160 VIMPAT...... 29 VIVAGUARD INO WALGREENS THIN VINATE DHA RF...... 172 GLUCOSE METER...... 160 LANCETS...... 160 VINATE II...... 172 VIVAGUARD INO TEST WALGREENS ULTRA VINATE M...... 173 STRIPS...... 97 THIN LANCETS...... 161 VINATE ONE...... 173 VIVAGUARD LANCETS... 160 warfarin sodium...... 27 VIOKACE...... 99 VIVAGUARD LANCING WAVESENSE AMP...... 161 viorele...... 67 DEVICE...... 160 WAVESENSE KEYNOTE...161 VIRACEPT...... 55 VIVELLE-DOT...... 105 WAVESENSE KEYNOTE VIREAD...... 55 VIVITROL...... 36 PRO METER...... 161 virt-c dha...... 173 VIVLODEX...... 14 WAVESENSE PRESTO...... 97 virt-caps...... 173 VIVOTIF...... 199 WEBCOL ALCOHOL PREP virt-fefa plus...... 114 VIZIMPRO...... 48 LARGE...... 161 Virt-Gard...... 114 VOCAL POINT BLOOD WEBCOL ALCOHOL PREP virt-nate dha...... 173 GLUCOSE SYS...... 160 MEDIUM...... 161 virt-phos 250 neutral...... 163 VOCAL POINT BLOOD wegmans unifine pentips plus.. 161 virt-pn dha...... 173 GLUCOSE TEST...... 97 WELLMIND VERTIGO...... 56 virt-pn plus...... 173 VOGELXO...... 21 Wera...... 67 virtussin a/c...... 71 VOGELXO PUMP...... 21 WESTHROID...... 196 virtussin dac...... 71 vol-care rx...... 173 wheat germ oil...... 201 VISCO-3...... 175 vol-nate...... 173 WIDE-SEAL DIAPHRAGM Vita S Forte...... 173 vol-plus...... 173 60...... 161 241 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT YUPELRI...... 26 65...... 161 GAUZE 1"X8"...... 89 YUTIQ...... 182 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT Yuvafem...... 200 70...... 161 GAUZE 5"X9"...... 89 zaclir cleansing...... 90 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT zafirlukast...... 26 75...... 161 PATCH 2"X2"...... 89 zaleplon...... 116 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT zalvit...... 174 80...... 161 PATCH 4"X4"...... 90 ZAMICET...... 20 WIDE-SEAL DIAPHRAGM XEROFORM zanabin hydrogel...... 90 85...... 161 PETROLATUM ROLL Zarah...... 68 WIDE-SEAL DIAPHRAGM 4"X9'...... 90 ZARXIO...... 114 90...... 161 XEROSTOMIA RELIEF ZATEAN-PN DHA...... 174 WIDE-SEAL DIAPHRAGM SPRAY...... 165 ZATEAN-PN PLUS...... 174 95...... 161 XGEVA...... 104 zavara...... 115 WILATE...... 111 XHANCE...... 176 ZAVESCA...... 115 WITEPSOL...... 187 XIFAXAN...... 42, 43 Zebutal...... 16 womans laxative...... 119 XIGDUO XR...... 194 ZEGERID...... 197 WP THYROID...... 196 XIIDRA...... 120 ZEJULA...... 187, 188 wpr plus wound healing system. 89 XILAPAK...... 90 zelac...... 35 Wymzya Fe...... 67 XIMINO...... 195 ZELAPAR...... 50 XADAGO...... 49 XOFIGO...... 48 ZELBORAF...... 48 XALIX...... 89 XOFLUZA...... 183 ZELNORM...... 116 XALKORI...... 48 XOLAIR...... 26 ZEMAIRA...... 193 XANAX...... 23 XOLEGEL...... 90 ZEMBRACE SYMTOUCH. 162 XANAX XR...... 23 XOPENEX HFA...... 26 Zenatane...... 90 XAQUIL XR...... 99 XOSPATA...... 48 zenevix...... 90 XARELTO...... 27 XPOVIO (100 MG ONCE ZENPEP...... 99 XARELTO STARTER WEEKLY)...... 44 Zenzedi...... 9 PACK...... 27 XPOVIO (60 MG ONCE ZEPATIER...... 115 Xelitral...... 89 WEEKLY)...... 44 ZETIA...... 40 XELJANZ...... 14 XPOVIO (80 MG ONCE ZETONNA...... 176 XELJANZ XR...... 14 WEEKLY)...... 44 ZEYOCAINE...... 90 XELODA...... 48 XPOVIO (80 MG TWICE ZIANA...... 90 XELPROS...... 182 WEEKLY)...... 44 zidovudine...... 55 XENAZINE...... 192 XRYLIDERM...... 90 ZILACAINE PATCH...... 90 XENLETA...... 187 XRYLIX...... 90 zileuton er...... 26 xenon xe 133...... 98 XTAMPZA ER...... 20 ZILRETTA...... 70 XEOMIN...... 176 XTANDI...... 48 ZINBRYTA...... 192 XEPI...... 89 XULANE...... 68 ZINPLAVA...... 56 XERAC AC...... 89 XULTOPHY...... 117 ZIOPTAN...... 182 XERALUX...... 89 xvite...... 174 ziprasidone hcl...... 51 XERESE...... 89 XYNTHA...... 111 ZIPSOR...... 14 XERFORM OIL XYNTHA SOLOFUSE...... 111 ZIRGAN...... 182 EMULSION ROLL...... 89 XYOSTED...... 21 ZODEX 12-DAY...... 70 XEROFORM OIL xyzbac...... 99 Zodex 6-Day...... 70 EMULSION 2"X2"...... 89 YAZ...... 68 ZOHYDRO ER...... 20 XEROFORM OIL YBUPHEN...... 14 ZOLADEX...... 49 EMULSION GAUZE...... 89 yl folic acid...... 114 zoledronic acid...... 104 XEROFORM OIL YONSA...... 48 ZOLINZA...... 49 EMULSION STRIP...... 89 YOSPRALA...... 111 zolmitriptan...... 162 242 zolpidem tartrate...... 116 zolpidem tartrate er...... 116 ZOLPIMIST...... 116 ZOMACTON...... 104 ZOMIG...... 162 ZONACORT 11 DAY...... 70 ZONACORT 7 DAY...... 70 ZONEGRAN...... 29 zonisamide...... 29 ZONTIVITY...... 189 ZORBTIVE...... 104 ZORTRESS...... 56 ZORVOLEX...... 14 Zovia 1/35E (28)...... 68 ZTLIDO...... 90 ZUBSOLV...... 20 ZULRESSO...... 105 Zumandimine...... 68 ZUPLENZ...... 37 ZURAMPIC...... 109 ZYCLARA...... 90 ZYCLARA PUMP...... 90 ZYDELIG...... 187 ZYFLO...... 26 ZYKADIA...... 49 ZYLET...... 182 ZYPITAMAG...... 40 ZYPREXA RELPREVV...... 51 ZYTIGA...... 49 zyvit...... 99

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