You < Tiered Generic Prescription Drug Guide

October 2019

For questions about the Tiered Generic Prescription Drug Guide, call the customer service number on the back of your Blue Cross ID card The Tiered Generic Prescription Drug Guide is regularly updated.

Contents Therapeutic Class Drug List

Introduction ...... I Anti-Infective Drugs ...... 1 How drugs are selected ...... I Cancer Drugs ...... 5 Coverage Considerations ...... I Hormones, Diabetes, and Related Drugs ...... 8 Member Prescription Benefit ...... II Heart and Circulatory Drugs ...... 15 Brand Drugs and Generic Drugs ...... II Respiratory Agents ...... 22 Classification ...... II Gastrointestinal Drugs ...... 25 Generic Substitution ...... II Genitourinary Drugs ...... 27 Affordable Care Act ...... II Central Nervous System Drugs ...... 28 Compound Drugs ...... III Pain Relief Drugs ...... 33 Contraceptives ...... III Neuromuscular Drugs ...... 35 Specialty ...... III Supplements ...... 37 Utilization Management ...... III Blood Modifying Drugs ...... 38 Step Therapy ...... III Topical Drugs ...... 39 Prior Authorization ...... III Miscellaneous Categories ...... 42 Dispensing Limits ...... IV Index...... 46 Notice ...... IV Key ...... IV

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

4157-I AL © Prime Therapeutics LLC 10/19

Introduction The Tiered Generic Prescription Drug Guide includes a list of all Preferred Brand drugs and select Generic drugs.

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand.

Brand prescription drugs are shown in capital letters followed by the generic name.

Tiered Generic Prescription Drug Guide is organized into broad therapeutic categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). Members are encouraged to show this drug guide to their physicians and pharmacists. Physicians are encouraged to prescribe drugs in this guide, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician.

How Drugs are Selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from the health insurer or claims administrator of your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Newly marketed prescription drugs may not be covered until the committee has had an opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based on safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a new drug is medically necessary prior to committee evaluation, a non-formulary exception request for coverage may be submitted.

Coverage Considerations Coverage is limited to prescription products approved by the Food and Drug Administration (FDA) as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act). In addition, some plans may exclude coverage for certain agents or drug categories, like those used for sexual dysfunction (example: Viagra) or infertility (example: Follistim AQ).

The drug benefit includes most prescription drugs, although some restrictions and exclusions apply. Investigational drugs and drugs indicated for cosmetic purposes (e.g., Propecia for hair growth) are not covered. Coverage and copayment levels vary depending on the plan. You should refer to your benefit plan booklet for details about your particular benefits.

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Member Prescription Benefit The prescription benefit is multi-tiered, placing prescription drugs into one of five copayment levels; select Generic drugs and select Preferred Brand Drugs (Tier 1), Preferred Brand drugs and non-select Generic drugs (Tier 2), Non-Preferred Brand drugs (Tier 3), other Non-Preferred Brand drugs and other Non-select Generic drugs (Tier 4), and Specialty drugs (Tier 5). Drugs that require Prior Authorization, Step Therapy, or Dispensing Limits are noted in the Tiered Generic Prescription Drug Guide.

Tier 1 – select Generic drugs and select Preferred Brand Drugs – listed Tier 2 – Preferred Brand drugs and non-select Generic drugs – only Preferred Brands are listed

Tier 3 – Non-Preferred Brand drugs – unlisted

Tier 4 – other Non-Preferred Brand drugs and other -non-select Generic drugs - unlisted Tier 5 – Specialty (if applicable)

Brand Drugs and Generic Drugs Classification

Prescription drugs are classified as either a Brand drug or a Generic drug. The Brand or Generic status provided by a nationally recognized company providing drug product information. The Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and change from Brand to Generic (or Generic to Brand). Such changes might change your copayment/co-insurance share. Brand drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have trade names.

Generic Substitution Generic drug utilization is encouraged as a way to provide high quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict requirements of FDA’s current Good Manufacturing Practice regulations required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality.

An FDA-approved Generic drug may be substituted for the Brand counterpart when it:

• Contains the same active ingredient(s) as the brand drug; • Is identical in strength, dosage form and route of administration; and • Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.

Affordable Care Act Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act. Examples of categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices.

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Compound Drugs Compound drugs are defined as a drug product made or modified to have characteristics that are specifically prescribed for an individual patient when commercial drug products are not available or appropriate. To be eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. All compounded drugs are subject to review and may require prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria and utilization management edits. Compounds are covered only when medically necessary. Compound drugs are always classified as the highest cost-sharing non-specialty drug Tier.

Contraceptives Some or all of the contraceptives listed in this Prescription Drug Guide may not be covered under your prescription plan if your employer has an objection. To find out, ask your employer.

Specialty Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self- administered or administered by a health care professional.

Some Blue Cross members must obtain their specialty drugs from the Pharmacy Select Network as the preferred provider. If the preferred provider is not utilized you may be responsible for up to 100 percent of the drug cost. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty drugs or your prescription drug benefit, call the number on the back of your ID card.

Utilization Management Your plan is committed to supporting proper selection and use of drugs for its members. To help assure these goals are met, several programs have been developed to promote drug selection that encourages both effectiveness and safety Preferred generic or brand drugs requiring Prior Authorization or Step Therapy, or drugs with Dispensing Limits will be noted in the Therapeutic Class Drug List portion of the Tiered Generic Prescription Drug Guide.

Step Therapy Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the step therapy column.

Prior Authorization Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. If prior authorization is required for a medication listed in this document, it will be noted next to the medication with a dot under the prior authorization column.

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Dispensing Limits Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows

There may also be limits for members within a certain age range, and coverage only for members of a specific gender.

Notice The purpose of the Tiered Generic Prescription Drug Guide is to provide a guide to coverage. This Tiered Generic Prescription Drug Guide is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Key cap ...... capsules odt...... orally disintegrating tabs chew ...... chewable oint ...... ointment conc ...... concentrate ophth ...... ophthalmic cr...... controlled release osm ...... osmotic release dr ...... delayed release powd ...... powder ec ...... enteric coated sa ...... sustained action effe...... effervescent sl ...... sublingual equiv ...... equivalent soln ...... solution er...... extended release sr ...... sustained release inhal...... inhalation suppos ...... suppositories inj ...... injection susp ...... suspension liq ...... liquid tab ...... tablets lotn ...... lotion td ...... transdermal nebu ...... nebulizer

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits ANTI-INFECTIVE DRUGS penicillin v potassium tab 1 PENICILLINS 250 mg 1 amoxicillin (trihydrate) cap 1 penicillin v potassium tab 250 mg 500 mg amoxicillin (trihydrate) cap 1 CEPHALOSPORINS 500 mg cefaclor cap 250 mg 1 amoxicillin (trihydrate) for susp 1 cefaclor cap 500 mg 1 125 mg/5ml cefadroxil cap 500 mg 1 1 amoxicillin (trihydrate) for susp cefadroxil for susp 250 mg/5ml 1 200 mg/5ml cefadroxil tab 1 gm 1 amoxicillin (trihydrate) for susp 1 1 250 mg/5ml cefdinir cap 300 mg 1 amoxicillin (trihydrate) for susp 1 cefdinir for susp 125 mg/5ml 400 mg/5ml cefdinir for susp 250 mg/5ml 1 amoxicillin (trihydrate) tab 1 cefprozil for susp 125 mg/5ml 1 500 mg cefprozil tab 250 mg 1 1 amoxicillin (trihydrate) tab cefprozil tab 500 mg 1 875 mg 1 1 cefuroxime axetil tab 250 mg amoxicillin & k clavulanate for (Ceftin) susp 200-28.5 mg/5ml cefuroxime axetil tab 500 mg 1 amoxicillin & k clavulanate for 1 1 susp 400-57 mg/5ml cephalexin cap 250 mg (Keflex) 1 amoxicillin & k clavulanate 1 cephalexin cap 500 mg (Keflex) for susp 600-42.9 mg/5ml cephalexin for susp 125 mg/5ml 1 (Augmentin es-600) cephalexin for susp 250 mg/5ml 1 1 amoxicillin & k clavulanate tab SUPRAX – cefixime cap 400 mg 2 500-125 mg (Augmentin) 2 1 SUPRAX – cefixime chew tab 100 amoxicillin & k clavulanate tab mg 875-125 mg (Augmentin) SUPRAX – cefixime chew tab 200 2 AMPICILLIN – ampicillin cap 500 1 mg mg 2 1 SUPRAX – cefixime for susp 500 dicloxacillin sodium cap 250 mg mg/5ml dicloxacillin sodium cap 500 mg 1 MACROLIDES PENICILLIN V POTASSIUM – 1 azithromycin for susp 1 penicillin v potassium for soln 100 mg/5ml (Zithromax) 125 mg/5ml azithromycin for susp 1 PENICILLIN V POTASSIUM – 1 200 mg/5ml (Zithromax) penicillin v potassium for soln 1 250 mg/5ml azithromycin tab 250 mg (Zithromax)

Tiered Generics Prescription Drug Guide October 2019 1 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits azithromycin tab 500 mg 1 levofloxacin tab 500 mg 1 (Zithromax) (Levaquin) azithromycin tab 600 mg 1 levofloxacin tab 750 mg 1 (Zithromax) (Levaquin) clarithromycin tab 250 mg 1 AMINOGLYCOSIDES clarithromycin tab 500 mg 1 neomycin sulfate tab 500 mg 1 (Biaxin) TUBERCULOSIS TETRACYCLINES ethambutol hcl tab 100 mg 1 doxycycline hyclate cap 50 mg 1 (Myambutol) doxycycline hyclate cap 100 mg 1 isoniazid tab 100 mg 1 (Vibramycin) isoniazid tab 300 mg 1 1 doxycycline hyclate tab 20 mg PRIFTIN – rifapentine tab 150 mg 2 1 doxycycline hyclate tab 100 mg FUNGAL INFECTIONS 1 doxycycline monohydrate cap fluconazole for susp 10 mg/ml 1 50 mg (Diflucan) 1 doxycycline monohydrate cap fluconazole for susp 40 mg/ml 1 100 mg (Monodox) (Diflucan) 1 doxycycline monohydrate tab fluconazole tab 50 mg (Diflucan) 1 50 mg (Adoxa) fluconazole tab 100 mg (Diflucan) 1 doxycycline monohydrate tab 1 1 75 mg fluconazole tab 150 mg (Diflucan) 1 doxycycline monohydrate tab 1 fluconazole tab 200 mg (Diflucan) 100 mg (Adoxa pak 1/100) NOXAFIL – posaconazole tab 2 minocycline hcl cap 50 mg 1 delayed release 100 mg (Minocin) NOXAFIL – posaconazole susp 40 2 minocycline hcl cap 75 mg 1 mg/ml (Minocin) terbinafine hcl tab 250 mg 1 minocycline hcl cap 100 mg 1 (Lamisil) (Minocin) VIRAL INFECTIONS FLUOROQUINOLONES Hepatitis ciprofloxacin hcl tab 250 mg 1 BARACLUDE – entecavir oral soln 2 (base equiv) (Cipro) 0.05 mg/ml ciprofloxacin hcl tab 500 mg 1 EPCLUSA – sofosbuvir-velpatasvir 2 • • (base equiv) (Cipro) tab 400-100 mg ciprofloxacin hcl tab 750 mg 1 HARVONI – ledipasvir-sofosbuvir 2 • • (base equiv) tab 90-400 mg levofloxacin tab 250 mg 1 LEDIPASVIR/SOFOSBUVIR – 2 • • (Levaquin) ledipasvir-sofosbuvir tab 90-400 mg

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits MAVYRET – glecaprevir- 2 • • DESCOVY – emtricitabine- 2 • pibrentasvir tab 100-40 mg tenofovir alafenamide fumarate PEGASYS – peginterferon alfa-2a 2 • • tab 200-25 mg inj 180 mcg/ml EVOTAZ – atazanavir sulfate- 2 • PEGASYS – peginterferon alfa-2a 2 • • cobicistat tab 300-150 mg (base inj 180 mcg/0.5ml equiv) 2 PEGASYS PROCLICK – 2 • • GENVOYA – elvitegrav-cobic- • peginterferon alfa-2a inj 180 emtricitab-tenofov af tab mcg/0.5ml 150-150-200-10 mg 2 SOFOSBUVIR/VELPATASVIR 2 • • INTELENCE – etravirine tab 25 mg • – sofosbuvir-velpatasvir tab INTELENCE – etravirine tab 100 2 • 400-100 mg mg SOVALDI – sofosbuvir tab 400 mg 2 • • INTELENCE – etravirine tab 200 2 • VOSEVI – sofosbuvir-velpatasvir- 2 • • mg voxilaprevir tab 400-100-100 mg ISENTRESS – raltegravir 2 • Herpes potassium packet for susp 100 mg (base equiv) acyclovir cap 200 mg (Zovirax) 1 ISENTRESS – raltegravir 2 • 1 acyclovir tab 400 mg (Zovirax) potassium tab 400 mg (base acyclovir tab 800 mg (Zovirax) 1 equiv) famciclovir tab 125 mg (Famvir) 1 ISENTRESS – raltegravir 2 • potassium chew tab 25 mg (base famciclovir tab 250 mg (Famvir) 1 equiv) famciclovir tab 500 mg (Famvir) 1 ISENTRESS – raltegravir 2 • 1 valacyclovir hcl tab 500 mg potassium chew tab 100 mg (Valtrex) (base equiv) 1 valacyclovir hcl tab 1 gm ISENTRESS HD – raltegravir 2 • (Valtrex) potassium tab 600 mg (base HIV/AIDS equiv) ATRIPLA – efavirenz-emtricitabine- 2 • KALETRA – lopinavir-ritonavir tab 2 • tenofovir df tab 600-200-300 mg 100-25 mg BIKTARVY – bictegravir- 2 • KALETRA – lopinavir-ritonavir tab 2 • emtricitabine-tenofovir af tab 200-50 mg 50-200-25 mg nevirapine tab 200 mg (Viramune) 1 • 2 CIMDUO – lamivudine-tenofovir • NORVIR – ritonavir oral soln 80 2 • disoproxil fumarate tab 300-300 mg/ml mg NORVIR – ritonavir powder packet 2 • 2 DELSTRIGO – doravirine- • 100 mg lamivudine-tenofovir df tab 2 100-300-300 mg ODEFSEY – emtricitabine- • rilpivirine-tenofovir af tab 200-25-25 mg

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits PREZCOBIX – darunavir-cobicistat 2 • VIREAD – tenofovir disoproxil 2 • tab 800-150 mg fumarate tab 200 mg PREZISTA – darunavir ethanolate 2 • VIREAD – tenofovir disoproxil 2 • susp 100 mg/ml (base equiv) fumarate tab 250 mg PREZISTA – darunavir ethanolate 2 • zidovudine tab 300 mg 1 • tab 75 mg (base equiv) MALARIA 2 PREZISTA – darunavir ethanolate • CHLOROQUINE PHOSPHATE – 2 tab 150 mg (base equiv) chloroquine phosphate tab 250 PREZISTA – darunavir ethanolate 2 • mg tab 600 mg (base equiv) chloroquine phosphate tab 1 PREZISTA – darunavir ethanolate 2 • 500 mg (Aralen) tab 800 mg (base equiv) DARAPRIM – pyrimethamine tab 2 SYMFI – efavirenz-lamivudine- 2 • 25 mg tenofovir df tab 600-300-300 mg MEFLOQUINE HCL – mefloquine 1 SYMFI LO – efavirenz-lamivudine- 2 • hcl tab 250 mg tenofovir df tab 400-300-300 mg WORM INFECTIONS 2 TIVICAY – dolutegravir sodium tab • BENZNIDAZOLE – benznidazole 2 10 mg (base equiv) tab 12.5 mg 2 TIVICAY – dolutegravir sodium tab • BENZNIDAZOLE – benznidazole 2 25 mg (base equiv) tab 100 mg 2 TIVICAY – dolutegravir sodium tab • ivermectin tab 3 mg (Stromectol) 1 50 mg (base equiv) OTHER ANTI-INFECTIVES TRIUMEQ – abacavir-dolutegravir- 2 • 2 lamivudine tab 600-50-300 mg ALINIA – nitazoxanide tab 500 mg • 2 TRUVADA – emtricitabine-tenofovir 2 • ALINIA – nitazoxanide for susp 100 • disoproxil fumarate tab 100-150 mg/5ml mg clindamycin hcl cap 75 mg 1 TRUVADA – emtricitabine-tenofovir 2 • (Cleocin) disoproxil fumarate tab 133-200 clindamycin hcl cap 150 mg 1 mg (Cleocin) TRUVADA – emtricitabine-tenofovir 2 • clindamycin hcl cap 300 mg 1 disoproxil fumarate tab 167-250 (Cleocin) mg dapsone tab 25 mg 2 TRUVADA – emtricitabine-tenofovir 2 • dapsone tab 100 mg 2 disoproxil fumarate tab 200-300 2 mg IMPAVIDO – miltefosine cap 50 mg 1 VIDEX – didanosine for soln 2 gm 2 • metronidazole tab 250 mg (Flagyl) VIREAD – tenofovir disoproxil 2 • 1 fumarate oral powder 40 mg/gm metronidazole tab 500 mg (Flagyl) VIREAD – tenofovir disoproxil 2 • fumarate tab 150 mg

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits SULFADIAZINE – sulfadiazine tab 2 CAPRELSA – vandetanib tab 100 2 • • • 500 mg mg sulfamethoxazole-trimethoprim 1 CAPRELSA – vandetanib tab 300 2 • • • susp 200-40 mg/5ml mg sulfamethoxazole-trimethoprim 1 COMETRIQ – cabozantinib s- 2 • • • tab 400-80 mg (Bactrim) malate cap 3 x 20 mg (60 mg sulfamethoxazole-trimethoprim 1 dose) kit tab 800-160 mg (Bactrim ds) COMETRIQ – cabozantinib s-mal 2 • • • trimethoprim tab 100 mg 1 cap 1 x 80 mg & 1 x 20 mg (100 dose) kit XIFAXAN – rifaximin tab 550 mg 2 COMETRIQ – cabozantinib s-mal 2 • • • CANCER DRUGS cap 1 x 80 mg & 3 x 20 mg (140 ACTIMMUNE – interferon 2 • dose) kit gamma-1b inj 100 mcg/0.5ml COTELLIC – cobimetinib fumarate 2 • • • (2000000 unit/0.5ml) tab 20 mg (base equivalent) 2 AFINITOR – everolimus tab 2.5 mg • • • EMCYT – estramustine phosphate 2 AFINITOR – everolimus tab 5 mg 2 • • • sodium cap 140 mg AFINITOR – everolimus tab 7.5 mg 2 • • • ERIVEDGE – vismodegib cap 150 2 • • • AFINITOR – everolimus tab 10 mg 2 • • • mg 2 AFINITOR DISPERZ – everolimus 2 • • • ERLEADA – apalutamide tab 60 • • • tab for oral susp 2 mg mg 2 AFINITOR DISPERZ – everolimus 2 • • • ETOPOSIDE – etoposide cap 50 tab for oral susp 3 mg mg 2 AFINITOR DISPERZ – everolimus 2 • • • FARESTON – toremifene citrate tab for oral susp 5 mg tab 60 mg (base equivalent) 2 ALECENSA – alectinib hcl cap 150 2 • • • FARYDAK – panobinostat lactate • • • mg (base equivalent) cap 10 mg (base equivalent) 2 ALUNBRIG – brigatinib tab 2 • • • FARYDAK – panobinostat lactate • • • initiation therapy pack 90 mg & cap 15 mg (base equivalent) 180 mg FARYDAK – panobinostat lactate 2 • • • ALUNBRIG – brigatinib tab 30 mg 2 • • • cap 20 mg (base equivalent) 2 ALUNBRIG – brigatinib tab 90 mg 2 • • • GILOTRIF – afatinib dimaleate tab • • • 20 mg (base equivalent) ALUNBRIG – brigatinib tab 180 mg 2 • • • GILOTRIF – afatinib dimaleate tab 2 • • • 1 anastrozole tab 1 mg (Arimidex) 30 mg (base equivalent) 1 bicalutamide tab 50 mg GILOTRIF – afatinib dimaleate tab 2 • • • (Casodex) 40 mg (base equivalent) 2 BOSULIF – bosutinib tab 100 mg • • • GLEOSTINE – lomustine cap 10 2 BOSULIF – bosutinib tab 400 mg 2 • • • mg BOSULIF – bosutinib tab 500 mg 2 • • • GLEOSTINE – lomustine cap 40 2 mg

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits GLEOSTINE – lomustine cap 100 2 KISQALI – ribociclib succinate tab 2 • • • mg pack 400 mg daily dose (200 mg HYCAMTIN – topotecan hcl cap 2 • • tab) 0.25 mg (base equiv) KISQALI – ribociclib succinate tab 2 • • • HYCAMTIN – topotecan hcl cap 1 2 • • pack 600 mg daily dose (200 mg mg (base equiv) tab) 2 hydroxyurea cap 500 mg 1 KISQALI FEMARA 200 DOSE – • • • (Hydrea) ribociclib 200 mg dose (200 mg tab) & letrozole 2.5 mg tbpk IBRANCE – palbociclib cap 75 mg 2 • • • KISQALI FEMARA 400 DOSE – 2 • • • 2 IBRANCE – palbociclib cap 100 mg • • • ribociclib 400 mg dose (200 mg IBRANCE – palbociclib cap 125 mg 2 • • • tab) & letrozole 2.5 mg tbpk ICLUSIG – ponatinib hcl tab 15 mg 2 • • • KISQALI FEMARA 600 DOSE – 2 • • • (base equiv) ribociclib 600 mg dose (200 mg ICLUSIG – ponatinib hcl tab 45 mg 2 • • • tab) & letrozole 2.5 mg tbpk (base equiv) LENVIMA 10 MG DAILY DOSE – 2 • • • IMBRUVICA – ibrutinib cap 70 mg 2 • • • lenvatinib cap therapy pack 10 mg (10 mg daily dose) IMBRUVICA – ibrutinib cap 140 mg 2 • • • LENVIMA 12MG DAILY DOSE – 2 • • • 2 IMBRUVICA – ibrutinib tab 140 mg • • • lenvatinib cap therapy pack 4 (3) IMBRUVICA – ibrutinib tab 280 mg 2 • • • mg (12 mg daily dose) IMBRUVICA – ibrutinib tab 420 mg 2 • • • LENVIMA 14 MG DAILY DOSE – 2 • • • lenvatinib cap therapy pack 10 & IMBRUVICA – ibrutinib tab 560 mg 2 • • • 4 mg (14 mg daily dose) INLYTA – axitinib tab 1 mg 2 • • • LENVIMA 18 MG DAILY DOSE – 2 • • • 2 INLYTA – axitinib tab 5 mg • • • lenvatinib cap therapy pack 10 & IRESSA – gefitinib tab 250 mg 2 • • • 4 (2) mg (18 mg daily dose) JAKAFI – ruxolitinib phosphate tab 2 • • • LENVIMA 20 MG DAILY DOSE – 2 • • • 5 mg (base equivalent) lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) JAKAFI – ruxolitinib phosphate tab 2 • • • 10 mg (base equivalent) LENVIMA 24 MG DAILY DOSE – 2 • • • lenvatinib cap therapy pack 10 JAKAFI – ruxolitinib phosphate tab 2 • • • (2) & 4 mg (24 mg daily dose) 15 mg (base equivalent) LENVIMA 4 MG DAILY DOSE – 2 • • • JAKAFI – ruxolitinib phosphate tab 2 • • • lenvatinib cap therapy pack 4 mg 20 mg (base equivalent) (4 mg daily dose) JAKAFI – ruxolitinib phosphate tab 2 • • • LENVIMA 8 MG DAILY DOSE – 2 • • • 25 mg (base equivalent) lenvatinib cap therapy pack 4 (2) KISQALI – ribociclib succinate tab 2 • • • mg (8 mg daily dose) pack 200 mg daily dose letrozole tab 2.5 mg (Femara) 1 LEUCOVORIN CALCIUM – 2 leucovorin calcium tab 10 mg

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Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits LEUCOVORIN CALCIUM – 2 POMALYST – pomalidomide cap 2 2 • • • leucovorin calcium tab 15 mg mg leucovorin calcium tab 5 mg 1 POMALYST – pomalidomide cap 3 2 • • • LEUKERAN – chlorambucil tab 2 2 mg mg POMALYST – pomalidomide cap 4 2 • • • LONSURF – trifluridine-tipiracil tab 2 • • • mg 15-6.14 mg PURIXAN – mercaptopurine susp 2 • LONSURF – trifluridine-tipiracil tab 2 • • • 2000 mg/100ml (20 mg/ml) 20-8.19 mg RYDAPT – midostaurin cap 25 mg 2 • • • LYNPARZA – olaparib tab 100 mg 2 • • • SPRYCEL – dasatinib tab 20 mg 2 • • • LYNPARZA – olaparib tab 150 mg 2 • • • SPRYCEL – dasatinib tab 50 mg 2 • • • LYSODREN – mitotane tab 500 mg 2 • • SPRYCEL – dasatinib tab 70 mg 2 • • • MATULANE – procarbazine hcl cap 2 • • SPRYCEL – dasatinib tab 80 mg 2 • • • 50 mg SPRYCEL – dasatinib tab 100 mg 2 • • • 1 megestrol acetate susp 40 mg/ml SPRYCEL – dasatinib tab 140 mg 2 • • • (Megace oral) STIVARGA – regorafenib tab 40 2 • • • 1 megestrol acetate tab 20 mg mg 1 megestrol acetate tab 40 mg SUTENT – sunitinib malate cap 2 • • • MEKINIST – trametinib dimethyl 2 • • • 12.5 mg (base equivalent) sulfoxide tab 0.5 mg (base SUTENT – sunitinib malate cap 25 2 • • • equivalent) mg (base equivalent) 2 MEKINIST – trametinib dimethyl • • • SUTENT – sunitinib malate cap 2 • • • sulfoxide tab 2 mg (base 37.5 mg (base equivalent) equivalent) SUTENT – sunitinib malate cap 50 2 • • • 1 methotrexate sodium tab 2.5 mg mg (base equivalent) (base equiv) SYLATRON – peginterferon alfa-2b 2 • • 2 MYLERAN – busulfan tab 2 mg for inj kit 200 mcg 2 NEXAVAR – sorafenib tosylate tab • • • SYLATRON – peginterferon alfa-2b 2 • • 200 mg (base equivalent) for inj kit 300 mcg 2 NINLARO – ixazomib citrate cap • • • SYLATRON – peginterferon alfa-2b 2 • • 2.3 mg (base equivalent) for inj kit 600 mcg 2 NINLARO – ixazomib citrate cap 3 • • • TABLOID – thioguanine tab 40 mg 2 mg (base equivalent) TAFINLAR – dabrafenib mesylate 2 • • • 2 NINLARO – ixazomib citrate cap 4 • • • cap 50 mg (base equivalent) mg (base equivalent) TAFINLAR – dabrafenib mesylate 2 • • • 2 ODOMZO – sonidegib phosphate • • • cap 75 mg (base equivalent) cap 200 mg (base equivalent) TAGRISSO – osimertinib mesylate 2 • • • 2 POMALYST – pomalidomide cap 1 • • • tab 40 mg (base equivalent) mg

Tiered Generics Prescription Drug Guide October 2019 7 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits TAGRISSO – osimertinib mesylate 2 • • • ZYTIGA – abiraterone acetate tab 2 • • • tab 80 mg (base equivalent) 500 mg tamoxifen citrate tab 10 mg 1 HORMONES, DIABETES AND RELATED DRUGS (base equivalent) CORTICOSTEROIDS 1 tamoxifen citrate tab 20 mg CORTISONE ACETATE – 2 (base equivalent) cortisone acetate tab 25 mg 2 TASIGNA – nilotinib hcl cap 50 mg • • • DEXAMETHASONE – 2 (base equivalent) dexamethasone tab 1 mg 2 TASIGNA – nilotinib hcl cap 150 • • • DEXAMETHASONE – 2 mg (base equivalent) dexamethasone tab 2 mg 2 TASIGNA – nilotinib hcl cap 200 • • • dexamethasone elixir 0.5 mg/5ml 1 mg (base equivalent) dexamethasone tab 0.5 mg 1 TYKERB – lapatinib ditosylate tab 2 • • • 1 250 mg (base equiv) dexamethasone tab 0.75 mg 1 VENCLEXTA – venetoclax tab 10 2 • • • dexamethasone tab 1.5 mg mg dexamethasone tab 4 mg 1 VENCLEXTA – venetoclax tab 50 2 • • • dexamethasone tab 6 mg 1 mg fludrocortisone acetate tab 1 VENCLEXTA – venetoclax tab 100 2 • • • 0.1 mg mg hydrocortisone tab 5 mg (Cortef) 1 VENCLEXTA STARTING PACK – 2 • • • hydrocortisone tab 10 mg 1 venetoclax tab therapy starter (Cortef) pack 10 & 50 & 100 mg 1 2 hydrocortisone tab 20 mg VOTRIENT – pazopanib hcl tab • • • (Cortef) 200 mg (base equiv) methylprednisolone tab therapy 1 XALKORI – crizotinib cap 200 mg 2 • • • pack 4 mg (21) (Medrol XALKORI – crizotinib cap 250 mg 2 • • • dosepak) XTANDI – enzalutamide cap 40 mg 2 • • • methylprednisolone tab 4 mg 1 YONSA – abiraterone acetate tab 2 • • • (Medrol) 125 mg methylprednisolone tab 8 mg 1 ZELBORAF – vemurafenib tab 240 2 • • • (Medrol) mg methylprednisolone tab 16 mg 1 ZOLINZA – vorinostat cap 100 mg 2 • • • (Medrol) 1 ZYDELIG – idelalisib tab 100 mg 2 • • • methylprednisolone tab 32 mg (Medrol) ZYDELIG – idelalisib tab 150 mg 2 • • • PREDNISOLONE – prednisolone 1 2 ZYKADIA – ceritinib cap 150 mg • • • syrup 15 mg/5ml (usp solution ZYKADIA – ceritinib tab 150 mg 2 • • • equivalent) ZYTIGA – abiraterone acetate tab 2 • • • 250 mg

Tiered Generics Prescription Drug Guide October 2019 8 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits prednisolone sod phosph oral 1 PREMARIN – estrogens, 2 soln 6.7 mg/5ml (5 mg/5ml conjugated tab 0.625 mg base) (Pediapred) PREMARIN – estrogens, 2 prednisolone sod phosphate 1 conjugated tab 0.9 mg oral soln 15 mg/5ml (base PREMARIN – estrogens, 2 equiv) conjugated tab 1.25 mg 1 prednisone tab 1 mg PREMPHASE – conj est 0.625(14)/ 2 prednisone tab 2.5 mg 1 conj est-medroxypro ac tab prednisone tab 5 mg 1 0.625-5mg(14) 2 prednisone tab 10 mg 1 PREMPRO – conjugated estrogen- medroxyprogest acetate tab 1 prednisone tab 20 mg 0.3-1.5 mg MALE HORMONES PREMPRO – conjugated estrogen- 2 testosterone cypionate im 1 medroxyprogest acetate tab inj in oil 100 mg/ml (Depo- 0.45-1.5 mg testosterone) PREMPRO – conjugated estrogen- 2 testosterone cypionate im 1 medroxyprogest acetate tab inj in oil 200 mg/ml (Depo- 0.625-2.5 mg testosterone) PREMPRO – conjugated estrogen- 2 testosterone enanthate im inj in 1 medroxyprogest acetate tab oil 200 mg/ml 0.625-5 mg ESTROGENS PROGESTINS CLIMARA PRO – estradiol- 2 • medroxyprogesterone acetate 1 levonorgestrel td patch weekly tab 2.5 mg (Provera) 0.045-0.015 mg/day medroxyprogesterone acetate 1 DIVIGEL – estradiol td gel 0.25 2 • tab 5 mg (Provera) mg/0.25gm (0.1%) medroxyprogesterone acetate 1 DIVIGEL – estradiol td gel 0.5 2 • tab 10 mg (Provera) mg/0.5gm (0.1%) progesterone micronized cap 1 DIVIGEL – estradiol td gel 0.75 2 • 100 mg (Prometrium) mg/0.75gm (0.1%) BIRTH CONTROL 2 DIVIGEL – estradiol td gel 1 mg/gm • desogest-eth estrad & eth estrad 1 (0.1%) tab 0.15-0.02/0.01 mg(21/5) estradiol tab 0.5 mg (Estrace) 1 (Mircette) estradiol tab 1 mg (Estrace) 1 desogest-ethin est tab 1 estradiol tab 2 mg (Estrace) 1 0.1-0.025/0.125-0.025/0.15-0.025mg- mg (Cyclessa) 2 PREMARIN – estrogens, 1 conjugated tab 0.3 mg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) 2 PREMARIN – estrogens, 1 conjugated tab 0.45 mg drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)

Tiered Generics Prescription Drug Guide October 2019 9 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits drospirenone-ethinyl estradiol 1 norethindrone ace & ethinyl 1 tab 3-0.03 mg (Yasmin 28) estradiol-fe tab 1 mg-20 mcg ELLA – ulipristal acetate tab 30 mg 2 (Loestrin fe 1/20) 1 ethynodiol diacetate & ethinyl 1 norethindrone ace & ethinyl estradiol tab 1 mg-35 mcg estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) 1 ethynodiol diacetate & ethinyl 1 estradiol tab 1 mg-50 mcg norethindrone tab 0.35 mg (Nor- qd) 1 levonorgestrel & ethinyl 1 estradiol (91-day) tab norethindrone-eth estradiol tab 0.15-0.03 mg 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7) 1 levonorgestrel & ethinyl 1 estradiol tab 0.1 mg-20 mcg norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri- 1 levonorgestrel & ethinyl norinyl 28) estradiol tab 0.15 mg-30 mcg norgestimate & ethinyl estradiol 1 1 levonorgestrel-eth estra tab tab 0.25 mg-35 mcg (Ortho- 0.05-30/0.075-40/0.125-30mg- cyclen) mcg norgestimate-eth estrad tab 1 1 medroxyprogesterone acetate im 0.18-25/0.215-25/0.25-25 mg- susp prefilled syr 150 mg/ml mcg (Ortho tri-cyclen lo) (Depo-provera contrac) norgestimate-eth estrad tab 1 1 medroxyprogesterone acetate im 0.18-35/0.215-35/0.25-35 mg- susp 150 mg/ml (Depo-provera mcg (Ortho tri-cyclen) contrac) norgestrel & ethinyl estradiol tab 1 1 norethindrone & ethinyl estradiol 0.3 mg-30 mcg tab 0.4 mg-35 mcg (Ovcon-35) NUVARING – etonogestrel-ethinyl 2 1 norethindrone & ethinyl estradiol va ring 0.120-0.015 estradiol tab 0.5 mg-35 mcg mg/24hr (Brevicon-28) INFERTILITY 1 norethindrone & ethinyl estradiol 2 tab 1 mg-35 mcg (Norinyl 1+35) CHORIONIC GONADOTROPIN – • chorionic gonadotropin for im inj 1 norethindrone ac-ethinyl estrad- 10000 unit fe tab 1-20/1-30/1-35 mg-mcg 2 (Estrostep fe) CLOMIPHENE CITRATE – clomiphene citrate tab 50 mg 1 norethindrone ace & ethinyl 2 estradiol tab 1 mg-20 mcg FOLLISTIM AQ – follitropin beta inj • (Loestrin 1/20-21) 300 unit/0.36ml 2 norethindrone ace & ethinyl 1 FOLLISTIM AQ – follitropin beta inj • estradiol tab 1.5 mg-30 mcg 600 unit/0.72ml (Loestrin 1.5/30-21) FOLLISTIM AQ – follitropin beta inj 2 • 900 unit/1.08ml

Tiered Generics Prescription Drug Guide October 2019 10 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits GANIRELIX ACETATE – ganirelix 2 • glipizide tab er 24hr 5 mg 1 acetate inj 250 mcg/0.5ml (Glucotrol xl) LUPRON DEPOT-PED (1-MONTH 2 • glipizide tab er 24hr 10 mg 1 – leuprolide acetate for inj (Glucotrol xl) pediatric kit 7.5 mg glipizide tab 5 mg (Glucotrol) 1 2 LUPRON DEPOT-PED (1-MONTH • glipizide tab 10 mg (Glucotrol) 1 – leuprolide acetate for inj 1 pediatric kit 11.25 mg glipizide-metformin hcl tab 2.5-250 mg LUPRON DEPOT-PED (1-MONTH 2 • 1 – leuprolide acetate for inj glipizide-metformin hcl tab pediatric kit 15 mg 2.5-500 mg 1 LUPRON DEPOT-PED (3-MONTH 2 • glipizide-metformin hcl tab – leuprolide acetate (3 month) for 5-500 mg inj pediatric kit 11.25 mg GLUCAGON EMERGENCY KIT – 2 LUPRON DEPOT-PED (3-MONTH 2 • glucagon (rdna) for inj kit 1 mg – leuprolide acetate (3 month) for glyburide micronized tab 1.5 mg 1 inj pediatric kit 30 mg (Glynase) MENOPUR – menotropins for 2 • glyburide micronized tab 3 mg 1 subcutaneous inj 75 unit (Glynase) NOVAREL – chorionic 2 • glyburide micronized tab 6 mg 1 gonadotropin for im inj 5000 unit (Glynase) ORILISSA – elagolix sodium tab 2 • • glyburide tab 1.25 mg 1 150 mg (base equiv) glyburide tab 2.5 mg 1 ORILISSA – elagolix sodium tab 2 • • glyburide tab 5 mg 1 200 mg (base equiv) glyburide-metformin tab 1 PREGNYL W/DILUENT BENZYL – 2 • 1.25-250 mg (Glucovance) chorionic gonadotropin for im inj 1 10000 unit glyburide-metformin tab 2.5-500 mg (Glucovance) SYNAREL – nafarelin acetate 2 1 nasal soln 2 mg/ml (200 mcg/act) glyburide-metformin tab (base eq) 5-500 mg (Glucovance) 2 DIABETES GLYXAMBI – empagliflozin- • linagliptin tab 10-5 mg acarbose tab 25 mg (Precose) 1 2 1 GLYXAMBI – empagliflozin- • acarbose tab 50 mg (Precose) linagliptin tab 25-5 mg 1 acarbose tab 100 mg (Precose) INVOKAMET – canagliflozin- 2 • glimepiride tab 1 mg (Amaryl) 1 metformin hcl tab 50-500 mg glimepiride tab 2 mg (Amaryl) 1 INVOKAMET – canagliflozin- 2 • glimepiride tab 4 mg (Amaryl) 1 metformin hcl tab 50-1000 mg 2 glipizide tab er 24hr 2.5 mg 1 INVOKAMET – canagliflozin- • (Glucotrol xl) metformin hcl tab 150-500 mg

Tiered Generics Prescription Drug Guide October 2019 11 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits INVOKAMET – canagliflozin- 2 • KOMBIGLYZE XR – saxagliptin- 2 • metformin hcl tab 150-1000 mg metformin hcl tab er 24hr INVOKAMET XR – canagliflozin- 2 • 2.5-1000 mg metformin hcl tab er 24hr 50-500 KOMBIGLYZE XR – saxagliptin- 2 • mg metformin hcl tab er 24hr 5-500 INVOKAMET XR – canagliflozin- 2 • mg metformin hcl tab er 24hr KOMBIGLYZE XR – saxagliptin- 2 • 50-1000 mg metformin hcl tab er 24hr 5-1000 INVOKAMET XR – canagliflozin- 2 • mg metformin hcl tab er 24hr metformin hcl tab er 24hr 500 mg 1 150-500 mg (Glucophage xr) INVOKAMET XR – canagliflozin- 2 • metformin hcl tab er 24hr 750 mg 1 metformin hcl tab er 24hr (Glucophage xr) 150-1000 mg metformin hcl tab 500 mg 1 INVOKANA – canagliflozin tab 100 2 • (Glucophage) mg metformin hcl tab 850 mg 1 INVOKANA – canagliflozin tab 300 2 • (Glucophage) mg metformin hcl tab 1000 mg 1 JANUMET – sitagliptin-metformin 2 • (Glucophage) hcl tab 50-500 mg ONGLYZA – saxagliptin hcl tab 2.5 2 • JANUMET – sitagliptin-metformin 2 • mg (base equiv) hcl tab 50-1000 mg ONGLYZA – saxagliptin hcl tab 5 2 • JANUMET XR – sitagliptin- 2 • mg (base equiv) metformin hcl tab er 24hr 50-500 OZEMPIC – semaglutide soln 2 • • mg pen-inj 0.25 or 0.5 mg/dose (2 JANUMET XR – sitagliptin- 2 • mg/1.5ml) metformin hcl tab er 24hr OZEMPIC – semaglutide soln pen- 2 • • 50-1000 mg inj 1 mg/dose (2 mg/1.5ml) 2 JANUMET XR – sitagliptin- • pioglitazone hcl tab 15 mg (base 1 • metformin hcl tab er 24hr equiv) (Actos) 100-1000 mg 1 • 2 pioglitazone hcl tab 30 mg (base JANUVIA – sitagliptin phosphate • equiv) (Actos) tab 25 mg (base equiv) 1 • 2 pioglitazone hcl tab 45 mg (base JANUVIA – sitagliptin phosphate • equiv) (Actos) tab 50 mg (base equiv) repaglinide tab 0.5 mg (Prandin) 1 JANUVIA – sitagliptin phosphate 2 • 1 tab 100 mg (base equiv) repaglinide tab 1 mg (Prandin) 1 JARDIANCE – empagliflozin tab 10 2 • repaglinide tab 2 mg (Prandin) mg SYNJARDY – empagliflozin- 2 • JARDIANCE – empagliflozin tab 25 2 • metformin hcl tab 5-500 mg mg

Tiered Generics Prescription Drug Guide October 2019 12 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits SYNJARDY – empagliflozin- 2 • HUMULIN R U-500 (CONCENTR 2 metformin hcl tab 5-1000 mg – insulin regular (human) inj 500 SYNJARDY – empagliflozin- 2 • unit/ml metformin hcl tab 12.5-500 mg HUMULIN R U-500 KWIKPEN – 2 SYNJARDY – empagliflozin- 2 • insulin regular (human) soln pen- metformin hcl tab 12.5-1000 mg injector 500 unit/ml 2 SYNJARDY XR – empagliflozin- 2 • NOVOLIN R – insulin regular metformin hcl tab er 24hr 5-1000 (human) inj 100 unit/ml mg Intermediate-Acting Insulins SYNJARDY XR – empagliflozin- 2 • NOVOLIN N – insulin nph (human) 2 metformin hcl tab er 24hr (isophane) inj 100 unit/ml 10-1000 mg NOVOLIN 70/30 – insulin nph 2 SYNJARDY XR – empagliflozin- 2 • isophane & regular human inj metformin hcl tab er 24hr 100 unit/ml (70-30) 12.5-1000 mg NOVOLIN 70/30 FLEXPEN – 2 SYNJARDY XR – empagliflozin- 2 • insulin nph & regular susp pen-inj metformin hcl tab er 24hr 100 unit/ml (70-30) 25-1000 mg NOVOLOG MIX 70/30 – insulin 2 TRULICITY – dulaglutide soln pen- 2 • • aspart prot & aspart (human) inj injector 0.75 mg/0.5ml 100 unit/ml (70-30) TRULICITY – dulaglutide soln pen- 2 • • NOVOLOG MIX 70/30 PREFILL – 2 injector 1.5 mg/0.5ml insulin aspart prot & aspart sus VICTOZA – liraglutide soln pen- 2 • • pen-inj 100 unit/ml (70-30) injector 18 mg/3ml (6 mg/ml) Basal Insulins DIABETES - INSULINS LANTUS – insulin glargine inj 100 2 Rapid-Acting Insulins unit/ml 2 FIASP – insulin aspart (with 2 LANTUS SOLOSTAR – insulin niacinamide) inj 100 unit/ml glargine soln pen-injector 100 unit/ml FIASP FLEXTOUCH – insulin 2 2 aspart (with niacinamide) sol LEVEMIR – insulin detemir inj 100 pen-inj 100 unit/ml unit/ml 2 NOVOLOG – insulin aspart inj 100 2 LEVEMIR FLEXTOUCH – insulin unit/ml detemir soln pen-injector 100 unit/ml NOVOLOG FLEXPEN – insulin 2 2 aspart soln pen-injector 100 unit/ TOUJEO MAX SOLOSTAR – ml insulin glargine soln pen-injector 300 unit/ml NOVOLOG PENFILL – insulin 2 2 aspart soln cartridge 100 unit/ml TOUJEO SOLOSTAR – insulin glargine soln pen-injector 300 Short-Acting Insulins unit/ml

Tiered Generics Prescription Drug Guide October 2019 13 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits TRESIBA – insulin degludec inj 2 methimazole tab 10 mg 1 100 unit/ml (Tapazole) TRESIBA FLEXTOUCH – insulin 2 SYNTHROID – levothyroxine 2 degludec soln pen-injector 100 sodium tab 25 mcg unit/ml SYNTHROID – levothyroxine 2 TRESIBA FLEXTOUCH – insulin 2 sodium tab 50 mcg degludec soln pen-injector 200 SYNTHROID – levothyroxine 2 unit/ml sodium tab 75 mcg THYROID REGULATION SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 88 mcg 25 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 100 mcg 50 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 112 mcg 75 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 125 mcg 88 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 137 mcg 100 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 150 mcg 112 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 175 mcg 125 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 200 mcg 137 mcg (Synthroid) SYNTHROID – levothyroxine 2 levothyroxine sodium tab 1 sodium tab 300 mcg 150 mcg (Synthroid) GROWTH HORMONE 1 levothyroxine sodium tab INCRELEX – mecasermin inj 40 2 • 175 mcg (Synthroid) mg/4ml (10 mg/ml) 1 levothyroxine sodium tab OMNITROPE – somatropin inj 5 2 • • 200 mcg (Synthroid) mg/1.5ml 1 levothyroxine sodium tab OMNITROPE – somatropin inj 10 2 • • 300 mcg (Synthroid) mg/1.5ml 1 liothyronine sodium tab 5 mcg OMNITROPE – somatropin for inj 2 • • (Cytomel) 5.8 mg 1 liothyronine sodium tab 25 mcg OTHER HORMONES AND RELATED DRUGS (Cytomel) alendronate sodium tab 5 mg 1 • liothyronine sodium tab 50 mcg 1 1 (Cytomel) alendronate sodium tab 10 mg • 1 methimazole tab 5 mg (Tapazole) 1 alendronate sodium tab 35 mg •

Tiered Generics Prescription Drug Guide October 2019 14 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits alendronate sodium tab 70 mg 1 • SENSIPAR – cinacalcet hcl tab 30 2 (Fosamax) mg (base equiv) calcitriol cap 0.25 mcg (Rocaltrol) 1 SENSIPAR – cinacalcet hcl tab 60 2 calcitriol cap 0.5 mcg (Rocaltrol) 1 mg (base equiv) 2 CYSTADANE – betaine powder for 2 SENSIPAR – cinacalcet hcl tab 90 oral solution mg (base equiv) 2 DDAVP – desmopressin acetate 2 STIMATE – desmopressin acetate nasal soln 0.01% (refrigerated) nasal soln 1.5 mg/ml 2 ibandronate sodium tab 150 mg 1 • STRENSIQ – asfotase alfa • • (base equivalent) (Boniva) subcutaneous inj 18 mg/0.45ml 2 LUPRON DEPOT-PED (1-MONTH 2 • STRENSIQ – asfotase alfa • • – leuprolide acetate for inj subcutaneous inj 28 mg/0.7ml pediatric kit 7.5 mg STRENSIQ – asfotase alfa 2 • • LUPRON DEPOT-PED (1-MONTH 2 • subcutaneous inj 40 mg/ml – leuprolide acetate for inj STRENSIQ – asfotase alfa 2 • • pediatric kit 11.25 mg subcutaneous inj 80 mg/0.8ml LUPRON DEPOT-PED (1-MONTH 2 • TYMLOS – abaloparatide 2 • • • – leuprolide acetate for inj subcutaneous soln pen-injector pediatric kit 15 mg 3120 mcg/1.56ml NITYR – nitisinone tab 2 mg 2 • HEART AND CIRCULATORY DRUGS NITYR – nitisinone tab 5 mg 2 • ANGIOTENSIN CONVERTING ENZYME (ACE) NITYR – nitisinone tab 10 mg 2 • INHIBITORS AND COMBINATI 1 ORFADIN – nitisinone susp 4 mg/ 2 • benazepril & ml hydrochlorothiazide tab 5-6.25 mg ORFADIN – nitisinone cap 2 mg 2 • benazepril & 1 2 ORFADIN – nitisinone cap 5 mg • hydrochlorothiazide tab ORFADIN – nitisinone cap 10 mg 2 • 10-12.5 mg (Lotensin hct) ORFADIN – nitisinone cap 20 mg 2 • benazepril & 1 REVCOVI – elapegademase-lvlr im 2 hydrochlorothiazide tab soln 2.4 mg/1.5ml (1.6 mg/ml) 20-12.5 mg (Lotensin hct) 1 SANDOSTATIN LAR DEPOT – 2 • benazepril & octreotide acetate for im inj kit 10 hydrochlorothiazide tab mg 20-25 mg (Lotensin hct) 1 SANDOSTATIN LAR DEPOT – 2 • benazepril hcl tab 5 mg octreotide acetate for im inj kit 20 benazepril hcl tab 10 mg 1 mg (Lotensin) SANDOSTATIN LAR DEPOT – 2 • benazepril hcl tab 20 mg 1 octreotide acetate for im inj kit 30 (Lotensin) mg benazepril hcl tab 40 mg 1 (Lotensin)

Tiered Generics Prescription Drug Guide October 2019 15 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits captopril tab 12.5 mg 1 perindopril erbumine tab 2 mg 1 enalapril maleate & 1 perindopril erbumine tab 4 mg 1 hydrochlorothiazide tab (Aceon) 5-12.5 mg perindopril erbumine tab 8 mg 1 enalapril maleate & 1 (Aceon) hydrochlorothiazide tab quinapril hcl tab 5 mg (Accupril) 1 10-25 mg (Vaseretic) quinapril hcl tab 10 mg (Accupril) 1 enalapril maleate tab 2.5 mg 1 1 (Vasotec) quinapril hcl tab 20 mg (Accupril) 1 enalapril maleate tab 5 mg 1 quinapril hcl tab 40 mg (Accupril) (Vasotec) quinapril-hydrochlorothiazide 1 enalapril maleate tab 10 mg 1 tab 10-12.5 mg (Accuretic) (Vasotec) quinapril-hydrochlorothiazide 1 enalapril maleate tab 20 mg 1 tab 20-12.5 mg (Accuretic) (Vasotec) quinapril-hydrochlorothiazide 1 fosinopril sodium & 1 tab 20-25 mg (Accuretic) hydrochlorothiazide tab ramipril cap 1.25 mg (Altace) 1 10-12.5 mg ramipril cap 2.5 mg (Altace) 1 1 fosinopril sodium & ramipril cap 5 mg (Altace) 1 hydrochlorothiazide tab 1 20-12.5 mg ramipril cap 10 mg (Altace) 1 fosinopril sodium tab 10 mg 1 trandolapril tab 1 mg (Mavik) 1 fosinopril sodium tab 20 mg 1 trandolapril tab 2 mg (Mavik) 1 fosinopril sodium tab 40 mg 1 trandolapril tab 4 mg (Mavik) lisinopril & hydrochlorothiazide 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) tab 10-12.5 mg (Zestoretic) AND COMBINATIONS 1 lisinopril & hydrochlorothiazide 1 irbesartan tab 75 mg (Avapro) tab 20-12.5 mg (Zestoretic) irbesartan tab 150 mg (Avapro) 1 lisinopril & hydrochlorothiazide 1 irbesartan tab 300 mg (Avapro) 1 tab 20-25 mg (Zestoretic) irbesartan-hydrochlorothiazide 1 lisinopril tab 2.5 mg (Zestril) 1 tab 150-12.5 mg (Avalide) lisinopril tab 5 mg (Prinivil) 1 irbesartan-hydrochlorothiazide 1 lisinopril tab 10 mg (Prinivil) 1 tab 300-12.5 mg (Avalide) 1 lisinopril tab 20 mg (Prinivil) 1 losartan potassium & hydrochlorothiazide tab (Zestril) 1 lisinopril tab 30 mg 50-12.5 mg (Hyzaar) (Zestril) 1 lisinopril tab 40 mg losartan potassium & 1 moexipril hcl tab 7.5 mg 1 hydrochlorothiazide tab (Univasc) 100-12.5 mg (Hyzaar) moexipril hcl tab 15 mg (Univasc) 1

Tiered Generics Prescription Drug Guide October 2019 16 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits losartan potassium & 1 betaxolol hcl tab 10 mg (Kerlone) 1 hydrochlorothiazide tab betaxolol hcl tab 20 mg 1 100-25 mg (Hyzaar) 1 1 bisoprolol & hydrochlorothiazide losartan potassium tab 25 mg tab 2.5-6.25 mg (Ziac) (Cozaar) 1 1 bisoprolol & hydrochlorothiazide losartan potassium tab 50 mg tab 5-6.25 mg (Ziac) (Cozaar) 1 1 bisoprolol & hydrochlorothiazide losartan potassium tab 100 mg tab 10-6.25 mg (Ziac) (Cozaar) 1 1 bisoprolol fumarate tab 5 mg telmisartan tab 20 mg (Micardis) (Zebeta) 1 telmisartan tab 40 mg (Micardis) bisoprolol fumarate tab 10 mg 1 telmisartan tab 80 mg (Micardis) 1 (Zebeta) valsartan tab 40 mg (Diovan) 1 carvedilol tab 3.125 mg (Coreg) 1 valsartan tab 80 mg (Diovan) 1 carvedilol tab 6.25 mg (Coreg) 1 valsartan tab 160 mg (Diovan) 1 carvedilol tab 12.5 mg (Coreg) 1 valsartan tab 320 mg (Diovan) 1 carvedilol tab 25 mg (Coreg) 1 valsartan-hydrochlorothiazide 1 labetalol hcl tab 100 mg 1 tab 80-12.5 mg (Diovan hct) (Trandate) valsartan-hydrochlorothiazide 1 labetalol hcl tab 200 mg 1 tab 160-12.5 mg (Diovan hct) (Trandate) valsartan-hydrochlorothiazide 1 labetalol hcl tab 300 mg 1 tab 160-25 mg (Diovan hct) metoprolol & 1 valsartan-hydrochlorothiazide 1 hydrochlorothiazide tab tab 320-12.5 mg (Diovan hct) 50-25 mg (Lopressor hct) valsartan-hydrochlorothiazide 1 metoprolol & 1 tab 320-25 mg (Diovan hct) hydrochlorothiazide tab BETA BLOCKERS AND COMBINATIONS 100-25 mg (Lopressor hct) 1 acebutolol hcl cap 200 mg 1 metoprolol succinate tab er 24hr (Sectral) 25 mg (tartrate equiv) (Toprol xl) 1 acebutolol hcl cap 400 mg 1 metoprolol succinate tab er 24hr (Sectral) 50 mg (tartrate equiv) (Toprol xl) 1 atenolol & chlorthalidone tab 1 metoprolol succinate tab er 24hr 50-25 mg (Tenoretic 50) 100 mg (tartrate equiv) (Toprol xl) 1 atenolol & chlorthalidone tab 1 100-25 mg (Tenoretic 100) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol 1 atenolol tab 25 mg (Tenormin) xl) 1 atenolol tab 50 mg (Tenormin) metoprolol tartrate tab 25 mg 1 1 atenolol tab 100 mg (Tenormin) metoprolol tartrate tab 50 mg 1 (Lopressor)

Tiered Generics Prescription Drug Guide October 2019 17 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits metoprolol tartrate tab 100 mg 1 amlodipine besylate-valsartan 1 (Lopressor) tab 10-320 mg (Exforge) pindolol tab 5 mg 1 DILT-XR – diltiazem hcl cap er 1 propranolol hcl cap er 24hr 1 24hr 120 mg 60 mg (Inderal la) diltiazem hcl cap er 24hr 180 mg 1 propranolol hcl cap er 24hr 1 diltiazem hcl cap er 24hr 240 mg 1 80 mg (Inderal la) diltiazem hcl coated beads cap 1 propranolol hcl tab 10 mg 1 er 24hr 120 mg (Cardizem cd) propranolol hcl tab 20 mg 1 diltiazem hcl coated beads cap 1 propranolol hcl tab 40 mg 1 er 24hr 180 mg (Cardizem cd) 1 propranolol hcl tab 60 mg 1 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) propranolol hcl tab 80 mg 1 diltiazem hcl coated beads cap 1 CALCIUM CHANNEL BLOCKERS AND er 24hr 300 mg COMBINATIONS diltiazem hcl extended release 1 1 amlodipine besylate tab 2.5 mg beads cap er 24hr 120 mg (base equivalent) (Norvasc) (Tiazac) 1 amlodipine besylate tab 5 mg diltiazem hcl extended release 1 (base equivalent) (Norvasc) beads cap er 24hr 180 mg amlodipine besylate tab 10 mg 1 (Tiazac) (base equivalent) (Norvasc) diltiazem hcl extended release 1 amlodipine besylate-benazepril 1 beads cap er 24hr 240 mg hcl cap 2.5-10 mg (Lotrel) (Tiazac) amlodipine besylate-benazepril 1 diltiazem hcl extended release 1 hcl cap 5-10 mg (Lotrel) beads cap er 24hr 300 mg (Tiazac) amlodipine besylate-benazepril 1 hcl cap 5-20 mg (Lotrel) diltiazem hcl extended release 1 amlodipine besylate-benazepril 1 beads cap er 24hr 360 mg (Tiazac) hcl cap 5-40 mg (Lotrel) 1 amlodipine besylate-benazepril 1 diltiazem hcl extended release hcl cap 10-20 mg (Lotrel) beads cap er 24hr 420 mg (Tiazac) 1 amlodipine besylate-benazepril 1 hcl cap 10-40 mg (Lotrel) diltiazem hcl tab 30 mg (Cardizem) 1 amlodipine besylate-valsartan 1 tab 5-160 mg (Exforge) diltiazem hcl tab 60 mg (Cardizem) 1 amlodipine besylate-valsartan 1 tab 5-320 mg (Exforge) diltiazem hcl tab 90 mg 1 amlodipine besylate-valsartan 1 diltiazem hcl tab 120 mg (Cardizem) tab 10-160 mg (Exforge) ENTRESTO – sacubitril-valsartan 2 tab 24-26 mg

Tiered Generics Prescription Drug Guide October 2019 18 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits ENTRESTO – sacubitril-valsartan 2 ISOSORBIDE DINITRATE – 1 tab 49-51 mg isosorbide dinitrate tab 30 mg ENTRESTO – sacubitril-valsartan 2 isosorbide dinitrate tab 5 mg 1 tab 97-103 mg (Isordil titradose) felodipine tab er 24hr 2.5 mg 1 isosorbide mononitrate tab er 1 felodipine tab er 24hr 5 mg 1 24hr 30 mg 1 felodipine tab er 24hr 10 mg 1 isosorbide mononitrate tab er 24hr 60 mg 1 nifedipine tab er 24hr 30 mg 1 (Adalat cc) isosorbide mononitrate tab er 24hr 120 mg 1 nifedipine tab er 24hr 60 mg 1 (Adalat cc) isosorbide mononitrate tab 10 mg 1 nifedipine tab er 24hr 90 mg 1 (Adalat cc) isosorbide mononitrate tab 20 mg 1 nifedipine tab er 24hr osmotic 1 release 30 mg (Procardia xl) nitroglycerin cap er 2.5 mg 1 nifedipine tab er 24hr osmotic 1 nitroglycerin cap er 6.5 mg release 60 mg (Procardia xl) nitroglycerin sl tab 0.3 mg 1 nifedipine tab er 24hr osmotic 1 (Nitrostat) release 90 mg (Procardia xl) nitroglycerin sl tab 0.4 mg 1 verapamil hcl cap er 24hr 120 mg 1 (Nitrostat) (Verelan) nitroglycerin sl tab 0.6 mg 1 verapamil hcl cap er 24hr 180 mg 1 (Nitrostat) (Verelan) nitroglycerin td patch 24hr 1 VERAPAMIL HCL ER – verapamil 1 0.1 mg/hr (Nitro-dur) hcl cap er 24hr 100 mg nitroglycerin td patch 24hr 1 verapamil hcl tab er 120 mg 1 0.2 mg/hr (Nitro-dur) (Calan sr) nitroglycerin td patch 24hr 1 verapamil hcl tab er 180 mg 1 0.4 mg/hr (Nitro-dur) (Calan sr) nitroglycerin td patch 24hr 1 verapamil hcl tab er 240 mg 1 0.6 mg/hr (Nitro-dur) (Calan sr) CHOLESTEROL LOWERING verapamil hcl tab 40 mg 1 atorvastatin calcium tab 10 mg 1 verapamil hcl tab 80 mg (Calan) 1 (base equivalent) (Lipitor) 1 verapamil hcl tab 120 mg (Calan) 1 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) VERELAN PM – verapamil hcl cap 2 1 er 24hr 100 mg atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) VERELAN PM – verapamil hcl cap 2 1 er 24hr 300 mg atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) CHEST PAIN

Tiered Generics Prescription Drug Guide October 2019 19 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits choline fenofibrate cap dr 45 mg 1 rosuvastatin calcium tab 10 mg 1 (fenofibric acid equiv) (Trilipix) (Crestor) colestipol hcl granule packets 1 rosuvastatin calcium tab 20 mg 1 5 gm (Colestid flavored) (Crestor) fenofibrate micronized cap 1 rosuvastatin calcium tab 40 mg 1 43 mg (Crestor) fenofibrate micronized cap 1 simvastatin tab 5 mg (Zocor) 1 67 mg (Lofibra) simvastatin tab 10 mg (Zocor) 1 1 fenofibrate micronized cap simvastatin tab 20 mg (Zocor) 1 134 mg (Lofibra) simvastatin tab 40 mg (Zocor) 1 fenofibrate tab 48 mg (Tricor) 1 simvastatin tab 80 mg (Zocor) 1 fenofibrate tab 54 mg (Lofibra) 1 VASCEPA – icosapent ethyl cap 2 1 fenofibrate tab 145 mg (Tricor) 0.5 gm 1 fenofibrate tab 160 mg (Lofibra) VASCEPA – icosapent ethyl cap 1 2 gemfibrozil tab 600 mg (Lopid) 1 gm LIPOFEN – fenofibrate cap 50 mg 2 FLUID RETENTION LIPOFEN – fenofibrate cap 150 mg 2 acetazolamide tab 125 mg 1 lovastatin tab 10 mg 1 amiloride & hydrochlorothiazide 1 lovastatin tab 20 mg (Mevacor) 1 tab 5-50 mg 1 lovastatin tab 40 mg (Mevacor) 1 amiloride hcl tab 5 mg 1 pravastatin sodium tab 10 mg 1 bumetanide tab 0.5 mg 1 pravastatin sodium tab 20 mg 1 bumetanide tab 1 mg (Pravachol) bumetanide tab 2 mg 1 pravastatin sodium tab 40 mg 1 chlorothiazide tab 500 mg 1 (Pravachol) chlorthalidone tab 25 mg 1 1 pravastatin sodium tab 80 mg chlorthalidone tab 50 mg 1 (Pravachol) furosemide oral soln 10 mg/ml 1 REPATHA – evolocumab 2 • • 1 subcutaneous soln prefilled furosemide tab 20 mg (Lasix) syringe 140 mg/ml furosemide tab 40 mg (Lasix) 1 REPATHA PUSHTRONEX 2 • • furosemide tab 80 mg (Lasix) 1 SYSTEM – evolocumab hydrochlorothiazide cap 12.5 mg 1 subcutaneous soln cartridge/ (Microzide) infusor 420 mg/3.5ml hydrochlorothiazide tab 12.5 mg 1 REPATHA SURECLICK – 2 • • 1 evolocumab subcutaneous soln hydrochlorothiazide tab 25 mg auto-injector 140 mg/ml hydrochlorothiazide tab 50 mg 1 rosuvastatin calcium tab 5 mg 1 indapamide tab 1.25 mg 1 (Crestor) indapamide tab 2.5 mg 1

Tiered Generics Prescription Drug Guide October 2019 20 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits metolazone tab 2.5 mg 1 sotalol hcl tab 80 mg (Betapace) 1 (Zaroxolyn) sotalol hcl tab 120 mg (Betapace) 1 1 metolazone tab 5 mg (Zaroxolyn) sotalol hcl tab 160 mg (Betapace) 1 1 spironolactone & sotalol hcl tab 240 mg 1 hydrochlorothiazide tab 25-25 mg (Aldactazide) OTHER HEART RELATED DRUGS 1 spironolactone tab 25 mg 1 clonidine hcl tab 0.1 mg (Aldactone) (Catapres) 1 spironolactone tab 50 mg 1 clonidine hcl tab 0.2 mg (Aldactone) (Catapres) 1 spironolactone tab 100 mg 1 clonidine hcl tab 0.3 mg (Aldactone) (Catapres) 1 torsemide tab 5 mg (Demadex) 1 digoxin tab 125 mcg (0.125 mg) (Lanoxin) torsemide tab 10 mg (Demadex) 1 1 1 digoxin tab 250 mcg (0.25 mg) torsemide tab 20 mg (Demadex) (Lanoxin) 1 torsemide tab 100 mg (Demadex) doxazosin mesylate tab 1 mg 1 triamterene & 1 (Cardura) hydrochlorothiazide cap doxazosin mesylate tab 2 mg 1 37.5-25 mg (Dyazide) (Cardura) 1 triamterene & doxazosin mesylate tab 4 mg 1 hydrochlorothiazide tab (Cardura) 37.5-25 mg (Maxzide-25) 1 1 doxazosin mesylate tab 8 mg triamterene & (Cardura) hydrochlorothiazide tab 1 75-50 mg (Maxzide) guanfacine hcl tab 1 mg (Tenex) 1 HEART RHYTHM guanfacine hcl tab 2 mg (Tenex) 1 amiodarone hcl tab 200 mg 1 hydralazine hcl tab 10 mg (Cordarone) hydralazine hcl tab 25 mg 1 flecainide acetate tab 50 mg 1 hydralazine hcl tab 50 mg 1 flecainide acetate tab 100 mg 1 hydralazine hcl tab 100 mg 1 flecainide acetate tab 150 mg 1 LETAIRIS – ambrisentan tab 5 mg 2 • • • MULTAQ – dronedarone hcl tab 2 LETAIRIS – ambrisentan tab 10 mg 2 • • • 400 mg (base equivalent) methyldopa tab 250 mg 1 1 propafenone hcl tab 150 mg methyldopa tab 500 mg 1 (Rythmol) midodrine hcl tab 2.5 mg 1 propafenone hcl tab 225 mg 1 1 (Rythmol) minoxidil tab 2.5 mg 1 sotalol hcl (afib/afl) tab 80 mg 1 minoxidil tab 10 mg (Betapace af) OPSUMIT – macitentan tab 10 mg 2 • • •

Tiered Generics Prescription Drug Guide October 2019 21 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits prazosin hcl cap 1 mg (Minipress) 1 SYMJEPI – epinephrine solution 2 prazosin hcl cap 2 mg (Minipress) 1 prefilled syringe 0.3 mg/0.3ml (1:1000) prazosin hcl cap 5 mg (Minipress) 1 RESPIRATORY AGENTS terazosin hcl cap 1 mg (base 1 equivalent) ANTIHISTAMINES 1 terazosin hcl cap 2 mg (base 1 carbinoxamine maleate soln equivalent) 4 mg/5ml (Palgic) 1 terazosin hcl cap 5 mg (base 1 carbinoxamine maleate tab 4 mg equivalent) (Palgic) 1 terazosin hcl cap 10 mg (base 1 cetirizine hcl oral soln 1 mg/ml equivalent) (5 mg/5ml) 1 TRACLEER – bosentan tab for oral 2 • • • cyproheptadine hcl syrup susp 32 mg 2 mg/5ml 1 TRACLEER – bosentan tab 62.5 2 • • • cyproheptadine hcl tab 4 mg mg desloratadine tab 5 mg (Clarinex) 1 TRACLEER – bosentan tab 125 2 • • • levocetirizine dihydrochloride 1 mg tab 5 mg (Xyzal) UPTRAVI – selexipag tab therapy 2 • • • promethazine hcl syrup 1 pack 200 mcg (140) & 800 mcg 6.25 mg/5ml (60) promethazine hcl tab 12.5 mg 1 2 UPTRAVI – selexipag tab 200 mcg • • • promethazine hcl tab 25 mg 1 2 UPTRAVI – selexipag tab 400 mcg • • • promethazine hcl tab 50 mg 1 2 UPTRAVI – selexipag tab 600 mcg • • • NASAL PRODUCTS 2 UPTRAVI – selexipag tab 800 mcg • • • azelastine hcl nasal spray 0.1% 1 • UPTRAVI – selexipag tab 1000 2 • • • (137 mcg/spray) mcg fluticasone propionate nasal 1 • UPTRAVI – selexipag tab 1200 2 • • • susp 50 mcg/act (Flonase) mcg ipratropium bromide nasal soln 1 • UPTRAVI – selexipag tab 1400 2 • • • 0.03% (21 mcg/spray) (Atrovent) mcg ipratropium bromide nasal soln 1 • UPTRAVI – selexipag tab 1600 2 • • • 0.06% (42 mcg/spray) (Atrovent) mcg COUGH/COLD/ALLERGY BEE STING KITS benzonatate cap 100 mg 1 EPINEPHRINE (Mylan products) – 2 (Tessalon perles) epinephrine solution auto-injector benzonatate cap 150 mg 1 0.15 mg/0.3ml (1:2000) benzonatate cap 200 mg 1 epinephrine solution auto- 2 1 injector 0.3 mg/0.3ml (1:1000) guaifenesin-codeine soln (Epipen 2-pak) 100-10 mg/5ml

Tiered Generics Prescription Drug Guide October 2019 22 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits M-CLEAR WC – guaifenesin- 1 albuterol sulfate soln nebu 1 codeine soln 100-6.3 mg/5ml 0.63 mg/3ml (base equiv) promethazine w/ codeine syrup 1 albuterol sulfate soln nebu 1 6.25-10 mg/5ml 1.25 mg/3ml (base equiv) PROMETHAZINE/ 1 albuterol sulfate syrup 2 mg/5ml 1 DEXTROMETHOR – ANORO ELLIPTA – umeclidinium- 2 • promethazine-dm syrup 6.25-15 vilanterol aero powd ba 62.5-25 mg/5ml mcg/inh 1 PROMETHAZINE/ ARNUITY ELLIPTA – fluticasone 2 • PHENYLEPHRIN – furoate aerosol powder breath promethazine & phenylephrine activ 50 mcg/act syrup 6.25-5 mg/5ml ARNUITY ELLIPTA – fluticasone 2 • 1 PROMETHAZINE/ furoate aerosol powder breath PHENYLEPHRIN – activ 100 mcg/act promethazine-phenylephrine- 2 codeine syrup 6.25-5-10 mg/5ml ARNUITY ELLIPTA – fluticasone • furoate aerosol powder breath 1 pseudoephed-bromphen-dm activ 200 mcg/act syrup 30-2-10 mg/5ml ASMANEX HFA – mometasone 2 • ASTHMA/COPD furoate inhal aerosol suspension ADVAIR DISKUS – fluticasone- 2 • 100 mcg/act salmeterol aer powder ba 100-50 ASMANEX HFA – mometasone 2 • mcg/dose furoate inhal aerosol suspension ADVAIR DISKUS – fluticasone- 2 • 200 mcg/act salmeterol aer powder ba 250-50 ASMANEX TWISTHALER 120 2 • mcg/dose ME – mometasone furoate ADVAIR DISKUS – fluticasone- 2 • inhal powd 220 mcg/inh (breath salmeterol aer powder ba 500-50 activated) mcg/dose ASMANEX TWISTHALER 30 2 • ADVAIR HFA – fluticasone- 2 • MET – mometasone furoate salmeterol inhal aerosol 45-21 inhal powd 110 mcg/inh (breath mcg/act activated) ADVAIR HFA – fluticasone- 2 • ASMANEX TWISTHALER 30 2 • salmeterol inhal aerosol 115-21 MET – mometasone furoate mcg/act inhal powd 220 mcg/inh (breath ADVAIR HFA – fluticasone- 2 • activated) salmeterol inhal aerosol 230-21 ASMANEX TWISTHALER 60 2 • mcg/act MET – mometasone furoate albuterol sulfate soln nebu 1 inhal powd 220 mcg/inh (breath 0.083% (2.5 mg/3ml) activated) 2 albuterol sulfate soln nebu 0.5% 1 ATROVENT HFA – ipratropium • (5 mg/ml) bromide hfa inhal aerosol 17 mcg/act

Tiered Generics Prescription Drug Guide October 2019 23 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits BREO ELLIPTA – fluticasone 2 • INCRUSE ELLIPTA – umeclidinium 2 • furoate-vilanterol aero powd ba br aero powd breath act 62.5 100-25 mcg/inh mcg/inh (base eq) BREO ELLIPTA – fluticasone 2 • ipratropium bromide inhal soln 1 furoate-vilanterol aero powd ba 0.02% 200-25 mcg/inh ipratropium-albuterol nebu soln 1 COMBIVENT RESPIMAT – 2 • 0.5-2.5(3) mg/3ml ipratropium-albuterol inhal montelukast sodium chew tab 1 • aerosol soln 20-100 mcg/act 4 mg (base equiv) (Singulair) 2 DULERA – mometasone furoate- • montelukast sodium chew tab 1 • formoterol fumarate aerosol 5 mg (base equiv) (Singulair) 100-5 mcg/act 1 • 2 montelukast sodium tab 10 mg DULERA – mometasone furoate- • (base equiv) (Singulair) formoterol fumarate aerosol 2 200-5 mcg/act PROAIR HFA – albuterol sulfate • inhal aero 108 mcg/act (90mcg 2 FLOVENT DISKUS – fluticasone • base equiv) propionate aer pow ba 50 mcg/ 2 blister PROAIR RESPICLICK – albuterol • sulfate aer pow ba 108 mcg/act 2 FLOVENT DISKUS – fluticasone • (90 mcg base equiv) propionate aer pow ba 100 mcg/ 2 blister QVAR REDIHALER – • beclomethasone diprop hfa 2 FLOVENT DISKUS – fluticasone • breath act inh aer 40 mcg/act propionate aer pow ba 250 mcg/ 2 blister QVAR REDIHALER – • beclomethasone diprop hfa 2 FLOVENT HFA – fluticasone • breath act inh aer 80 mcg/act propionate hfa inhal aero 44 2 mcg/act (50/valve) SEREVENT DISKUS – salmeterol • xinafoate aer pow ba 50 mcg/ 2 FLOVENT HFA – fluticasone • dose (base equiv) propionate hfa inhal aer 110 mcg/ 2 act (125/valve) SPIRIVA HANDIHALER – • tiotropium bromide monohydrate 2 FLOVENT HFA – fluticasone • inhal cap 18 mcg (base equiv) propionate hfa inhal aer 220 2 mcg/act (250/valve) SPIRIVA RESPIMAT – tiotropium • bromide monohydrate inhal 2 FLUTICASONE PROPIONATE/ • aerosol 1.25 mcg/act SA – fluticasone-salmeterol aer 2 powder ba 55-14 mcg/act SPIRIVA RESPIMAT – tiotropium • bromide monohydrate inhal 2 FLUTICASONE PROPIONATE/ • aerosol 2.5 mcg/act SA – fluticasone-salmeterol aer 2 powder ba 113-14 mcg/act STIOLTO RESPIMAT – tiotropium • br-olodaterol inhal aero soln 2 FLUTICASONE PROPIONATE/ • 2.5-2.5 mcg/act SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act

Tiered Generics Prescription Drug Guide October 2019 24 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits STRIVERDI RESPIMAT – 2 • peg 3350-kcl-sod bicarb-nacl 1 olodaterol hcl inhal aerosol soln for soln 420 gm (Nulytely/flavor 2.5 mcg/act (base equiv) pack) SYMBICORT – budesonide- 2 • peg 3350-kcl-na bicarb-nacl- 1 formoterol fumarate dihyd na sulfate for soln 236 gm aerosol 80-4.5 mcg/act (Golytely) SYMBICORT – budesonide- 2 • peg 3350-kcl-na bicarb-nacl-na 1 formoterol fumarate dihyd sulfate for soln 240 gm (Colyte- aerosol 160-4.5 mcg/act flavor packs) theophylline tab er 12hr 100 mg 1 ANTIDIARRHEALS theophylline tab er 12hr 200 mg 1 diphenoxylate w/ atropine tab 1 theophylline tab er 24hr 400 mg 1 2.5-0.025 mg (Lomotil) 1 theophylline tab er 24hr 600 mg 1 loperamide hcl cap 2 mg TRELEGY ELLIPTA – fluticasone- 2 • ULCER/GERD umeclidinium-vilanterol aepb CIMETIDINE HCL – cimetidine hcl 1 100-62.5-25 mcg/inh soln 300 mg/5ml VENTOLIN HFA – albuterol sulfate 2 • cimetidine tab 200 mg 1 inhal aero 108 mcg/act (90mcg cimetidine tab 300 mg 1 base equiv) cimetidine tab 400 mg 1 OTHER RESPIRATORY DRUGS 1 2 dicyclomine hcl cap 10 mg KALYDECO – ivacaftor tab 150 mg • • • (Bentyl) 2 KALYDECO – ivacaftor packet 25 • • • dicyclomine hcl oral soln 1 mg 10 mg/5ml 2 KALYDECO – ivacaftor packet 50 • • • dicyclomine hcl tab 20 mg 1 mg (Bentyl) 2 KALYDECO – ivacaftor packet 75 • • • famotidine tab 20 mg (Pepcid) 1 mg famotidine tab 40 mg (Pepcid) 1 PULMOZYME – dornase alfa inhal 2 • 1 soln 1 mg/ml glycopyrrolate tab 1 mg (Robinul) 1 SYMDEKO – tezacaftor-ivacaftor 2 • • • glycopyrrolate tab 2 mg (Robinul 50-75 mg & ivacaftor 75 mg tab forte) tbpk lansoprazole cap delayed 1 • SYMDEKO – tezacaftor-ivacaftor 2 • • • release 15 mg (Prevacid) 100-150 mg & ivacaftor 150 mg lansoprazole cap delayed 1 • tab tbpk release 30 mg (Prevacid) GASTROINTESTINAL DRUGS misoprostol tab 100 mcg 1 LAXATIVES (Cytotec) 1 lactulose solution 10 gm/15ml 1 misoprostol tab 200 mcg (Cytotec)

Tiered Generics Prescription Drug Guide October 2019 25 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits NEXIUM – esomeprazole 2 • meclizine hcl tab 12.5 mg 1 magnesium for delayed release meclizine hcl tab 25 mg 1 susp pack 2.5 mg 1 • 2 ondansetron hcl oral soln NEXIUM – esomeprazole • 4 mg/5ml (Zofran) magnesium for delayed release 1 susp packet 5 mg ondansetron hcl tab 4 mg • (Zofran) NEXIUM – esomeprazole 2 • 1 magnesium for delayed release ondansetron hcl tab 8 mg • susp packet 10 mg (Zofran) 1 NEXIUM – esomeprazole 2 • ondansetron orally • magnesium for delayed release disintegrating tab 4 mg (Zofran susp packet 20 mg odt) 1 NEXIUM – esomeprazole 2 • ondansetron orally • magnesium for delayed release disintegrating tab 8 mg (Zofran susp packet 40 mg odt) 2 nizatidine cap 150 mg 1 TRANSDERM SCOP – scopolamine td patch 72hr 1 1 nizatidine cap 300 mg (Axid) mg/3days 1 omeprazole cap delayed release • TRANSDERM-SCOP – 2 10 mg (Prilosec) scopolamine td patch 72hr 1 omeprazole cap delayed release 1 • mg/3days 20 mg (Prilosec) DIGESTIVE ENZYMES 1 omeprazole cap delayed release • CREON – pancrelipase (lip-prot- 2 40 mg (Prilosec) amyl) dr cap 3000-9500-15000 pantoprazole sodium ec tab 1 • unit 20 mg (base equiv) (Protonix) CREON – pancrelipase (lip-prot- 2 pantoprazole sodium ec tab 1 • amyl) dr cap 6000-19000-30000 40 mg (base equiv) (Protonix) unit rabeprazole sodium ec tab 1 • CREON – pancrelipase (lip-prot- 2 20 mg (Aciphex) amyl) dr cap 12000-38000-60000 ranitidine hcl cap 150 mg 1 unit 2 ranitidine hcl cap 300 mg 1 CREON – pancrelipase (lip-prot-amyl) dr cap 1 ranitidine hcl syrup 15 mg/ml 24000-76000-120000 unit (75 mg/5ml) CREON – pancrelipase 2 1 ranitidine hcl tab 150 mg (Zantac) (lip-prot-amyl) dr cap ranitidine hcl tab 300 mg (Zantac) 1 36000-114000-180000 unit sucralfate tab 1 gm (Carafate) 1 ZENPEP – pancrelipase (lip-prot- 2 amyl) dr cap 3000-10000-14000 NAUSEA AND VOMITING unit EMEND – aprepitant for oral susp 2 • 125 mg (125 mg/5ml) granisetron hcl tab 1 mg 1 •

Tiered Generics Prescription Drug Guide October 2019 26 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits ZENPEP – pancrelipase (lip-prot- 2 VELPHORO – sucroferric 2 amyl) dr cap 5000-17000-24000 oxyhydroxide chew tab 500 mg unit VIBERZI – eluxadoline tab 75 mg 2 2 ZENPEP – pancrelipase (lip-prot- VIBERZI – eluxadoline tab 100 mg 2 amyl) dr cap 10000-32000-42000 unit GENITOURINARY DRUGS ZENPEP – pancrelipase (lip-prot- 2 URINARY TRACT INFECTIONS amyl) dr cap 15000-47000-63000 nitrofurantoin macrocrystalline 1 unit cap 50 mg (Macrodantin) ZENPEP – pancrelipase (lip-prot- 2 nitrofurantoin macrocrystalline 1 amyl) dr cap 20000-63000-84000 cap 100 mg (Macrodantin) unit nitrofurantoin monohydrate 1 ZENPEP – pancrelipase 2 macrocrystalline cap 100 mg (lip-prot-amyl) dr cap (Macrobid) 25000-79000-105000 unit URINARY TRACT SPASMS ZENPEP – pancrelipase 2 bethanechol chloride tab 5 mg 1 (lip-prot-amyl) dr cap (Urecholine) 40000-126000-168000 unit bethanechol chloride tab 10 mg 1 OTHER GASTROINTESTINAL DRUGS (Urecholine) 2 APRISO – mesalamine cap er 24hr MYRBETRIQ – mirabegron tab er 2 0.375 gm 24 hr 25 mg 2 CANASA – mesalamine suppos MYRBETRIQ – mirabegron tab er 2 1000 mg 24 hr 50 mg CHENODAL – chenodiol tab 250 2 • oxybutynin chloride syrup 1 mg 5 mg/5ml DELZICOL – mesalamine cap dr 2 oxybutynin chloride tab er 24hr 1 400 mg 5 mg (Ditropan xl) 1 lactulose (encephalopathy) oxybutynin chloride tab er 24hr 1 solution 10 gm/15ml 10 mg (Ditropan xl) 1 metoclopramide hcl soln oxybutynin chloride tab er 24hr 1 5 mg/5ml (10 mg/10ml) (base 15 mg (Ditropan xl) equiv) oxybutynin chloride tab 5 mg 1 metoclopramide hcl tab 5 mg 1 (base equivalent) (Reglan) VAGINAL PRODUCTS 2 metoclopramide hcl tab 10 mg 1 ENDOMETRIN – progesterone (base equivalent) (Reglan) vaginal insert 100 mg 1 sulfasalazine tab delayed release 1 TERCONAZOLE – terconazole 500 mg (Azulfidine en-tabs) vaginal cream 0.8% 1 sulfasalazine tab 500 mg 1 terconazole vaginal cream 0.4% (Azulfidine) (Terazol 7)

Tiered Generics Prescription Drug Guide October 2019 27 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits VAGIFEM – estradiol vaginal tab 2 diazepam tab 10 mg (Valium) 1 10 mcg hydroxyzine hcl syrup 10 mg/5ml 1 OTHER GENITOURINARY DRUGS hydroxyzine hcl tab 10 mg 1 1 alfuzosin hcl tab er 24hr 10 mg hydroxyzine hcl tab 25 mg 1 (Uroxatral) hydroxyzine hcl tab 50 mg 1 CYSTAGON – cysteamine 2 • 1 bitartrate cap 50 mg hydroxyzine pamoate cap 25 mg (Vistaril) CYSTAGON – cysteamine 2 • 1 bitartrate cap 150 mg hydroxyzine pamoate cap 50 mg (Vistaril) dutasteride cap 0.5 mg (Avodart) 1 lorazepam tab 0.5 mg (Ativan) 1 finasteride tab 5 mg (Proscar) 1 lorazepam tab 1 mg (Ativan) 1 tamsulosin hcl cap 0.4 mg 1 1 (Flomax) lorazepam tab 2 mg (Ativan) 1 CENTRAL NERVOUS SYSTEM DRUGS OXAZEPAM – oxazepam cap 10 mg ANXIETY DEPRESSION alprazolam tab er 24hr 0.5 mg 1 1 (Xanax xr) amitriptyline hcl tab 10 mg 1 alprazolam tab er 24hr 1 mg 1 amitriptyline hcl tab 25 mg (Xanax xr) amitriptyline hcl tab 50 mg 1 alprazolam tab er 24hr 2 mg 1 amitriptyline hcl tab 75 mg 1 (Xanax xr) amitriptyline hcl tab 100 mg 1 1 alprazolam tab er 24hr 3 mg bupropion hcl tab er 12hr 1 • (Xanax xr) 100 mg (Wellbutrin sr) (Xanax) 1 alprazolam tab 0.25 mg bupropion hcl tab er 12hr 1 • alprazolam tab 0.5 mg (Xanax) 1 150 mg (Wellbutrin sr) alprazolam tab 1 mg (Xanax) 1 bupropion hcl tab er 12hr 1 • alprazolam tab 2 mg (Xanax) 1 200 mg (Wellbutrin sr) 1 buspirone hcl tab 5 mg 1 bupropion hcl tab er 24hr • 150 mg (Wellbutrin xl) buspirone hcl tab 7.5 mg 1 1 • 1 bupropion hcl tab er 24hr buspirone hcl tab 10 mg 300 mg (Wellbutrin xl) 1 buspirone hcl tab 15 mg bupropion hcl tab 75 mg 1 • buspirone hcl tab 30 mg 1 (Wellbutrin) chlordiazepoxide hcl cap 5 mg 1 bupropion hcl tab 100 mg 1 • chlordiazepoxide hcl cap 10 mg 1 (Wellbutrin) 1 chlordiazepoxide hcl cap 25 mg 1 citalopram hydrobromide tab • 10 mg (base equiv) (Celexa) diazepam tab 2 mg (Valium) 1 citalopram hydrobromide tab 1 • 1 diazepam tab 5 mg (Valium) 20 mg (base equiv) (Celexa)

Tiered Generics Prescription Drug Guide October 2019 28 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits citalopram hydrobromide tab 1 • mirtazapine orally disintegrating 1 • 40 mg (base equiv) (Celexa) tab 15 mg (Remeron soltab) DOXEPIN HCL – doxepin hcl cap 1 mirtazapine orally disintegrating 1 • 150 mg tab 30 mg (Remeron soltab) doxepin hcl cap 10 mg 1 mirtazapine orally disintegrating 1 • doxepin hcl cap 25 mg 1 tab 45 mg (Remeron soltab) 1 doxepin hcl cap 50 mg 1 mirtazapine tab 15 mg (Remeron) • 1 doxepin hcl cap 100 mg 1 mirtazapine tab 30 mg (Remeron) • 1 doxepin hcl conc 10 mg/ml 1 mirtazapine tab 45 mg (Remeron) • 1 duloxetine hcl enteric coated 1 • nortriptyline hcl cap 10 mg pellets cap 20 mg (base eq) (Pamelor) (Cymbalta) nortriptyline hcl cap 25 mg 1 duloxetine hcl enteric coated 1 • (Pamelor) pellets cap 30 mg (base eq) nortriptyline hcl cap 50 mg 1 (Cymbalta) (Pamelor) duloxetine hcl enteric coated 1 • nortriptyline hcl cap 75 mg 1 pellets cap 60 mg (base eq) (Pamelor) (Cymbalta) paroxetine hcl tab 10 mg (Paxil) 1 • 1 escitalopram oxalate tab 5 mg • paroxetine hcl tab 20 mg (Paxil) 1 • (base equiv) (Lexapro) paroxetine hcl tab 30 mg (Paxil) 1 • escitalopram oxalate tab 10 mg 1 • 1 (base equiv) (Lexapro) paroxetine hcl tab 40 mg (Paxil) • 1 escitalopram oxalate tab 20 mg 1 • sertraline hcl tab 25 mg (Zoloft) • (base equiv) (Lexapro) sertraline hcl tab 50 mg (Zoloft) 1 • fluoxetine hcl cap 10 mg (Prozac) 1 • sertraline hcl tab 100 mg (Zoloft) 1 • fluoxetine hcl cap 20 mg (Prozac) 1 • trazodone hcl tab 50 mg 1 fluoxetine hcl cap 40 mg (Prozac) 1 • trazodone hcl tab 100 mg 1 fluoxetine hcl solution 1 • trazodone hcl tab 150 mg 1 20 mg/5ml venlafaxine hcl cap er 24hr 1 • fluoxetine hcl tab 10 mg 1 • 37.5 mg (base equivalent) fluvoxamine maleate tab 25 mg 1 • (Effexor xr) 1 fluvoxamine maleate tab 50 mg 1 • venlafaxine hcl cap er 24hr • 1 75 mg (base equivalent) fluvoxamine maleate tab 100 mg • (Effexor xr) 1 imipramine hcl tab 10 mg venlafaxine hcl cap er 24hr 1 • (Tofranil) 150 mg (base equivalent) imipramine hcl tab 25 mg 1 (Effexor xr) (Tofranil) venlafaxine hcl tab 25 mg (base 1 • imipramine hcl tab 50 mg 1 equivalent) (Tofranil)

Tiered Generics Prescription Drug Guide October 2019 29 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits venlafaxine hcl tab 37.5 mg 1 • olanzapine orally disintegrating 1 • (base equivalent) tab 5 mg (Zyprexa zydis) venlafaxine hcl tab 50 mg (base 1 • olanzapine tab 2.5 mg (Zyprexa) 1 • equivalent) olanzapine tab 5 mg (Zyprexa) 1 • 1 venlafaxine hcl tab 75 mg (base • olanzapine tab 7.5 mg (Zyprexa) 1 • equivalent) olanzapine tab 10 mg (Zyprexa) 1 • venlafaxine hcl tab 100 mg (base 1 • 1 equivalent) olanzapine tab 15 mg (Zyprexa) • 1 PSYCHOTIC AND BIPOLAR DISORDERS olanzapine tab 20 mg (Zyprexa) • 1 clozapine tab 25 mg (Clozaril) 1 • perphenazine tab 2 mg 1 FLUPHENAZINE HCL – 1 prochlorperazine maleate fluphenazine hcl tab 1 mg tab 5 mg (base equivalent) (Compazine) haloperidol decanoate im soln 1 1 50 mg/ml (Haldol decanoate 50) prochlorperazine maleate tab 1 10 mg (base equivalent) haloperidol lactate inj 5 mg/ml (Compazine) (Haldol) 1 • 1 quetiapine fumarate tab 25 mg haloperidol lactate oral conc (Seroquel) 2 mg/ml 1 • 1 quetiapine fumarate tab 50 mg haloperidol tab 0.5 mg (Seroquel) 1 haloperidol tab 1 mg quetiapine fumarate tab 100 mg 1 • haloperidol tab 2 mg 1 (Seroquel) haloperidol tab 5 mg 1 quetiapine fumarate tab 200 mg 1 • haloperidol tab 10 mg 1 (Seroquel) 1 lithium carbonate cap 150 mg 1 quetiapine fumarate tab 300 mg • (Lithium carbonate) (Seroquel) 1 lithium carbonate cap 300 mg 1 quetiapine fumarate tab 400 mg • (Seroquel) 1 lithium carbonate cap 600 mg 1 (Lithium carbonate) risperidone soln 1 mg/ml • (Risperdal) 1 lithium carbonate tab er 300 mg 1 (Lithobid) risperidone tab 0.25 mg • (Risperdal) lithium carbonate tab er 450 mg 1 risperidone tab 0.5 mg 1 • 1 lithium carbonate tab 300 mg (Risperdal) 1 loxapine succinate cap 5 mg risperidone tab 1 mg (Risperdal) 1 • (Loxitane) risperidone tab 2 mg (Risperdal) 1 • loxapine succinate cap 10 mg 1 risperidone tab 3 mg (Risperdal) 1 • loxapine succinate cap 25 mg 1 risperidone tab 4 mg (Risperdal) 1 • loxapine succinate cap 50 mg 1 thiothixene cap 1 mg 1

Tiered Generics Prescription Drug Guide October 2019 30 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits trifluoperazine hcl tab 1 mg 1 ADDERALL XR – amphetamine- 2 • (base equivalent) dextroamphetamine cap er 24hr trifluoperazine hcl tab 2 mg 1 10 mg (base equivalent) ADDERALL XR – amphetamine- 2 • ziprasidone hcl cap 20 mg 1 • dextroamphetamine cap er 24hr (Geodon) 15 mg 2 ziprasidone hcl cap 40 mg 1 • ADDERALL XR – amphetamine- • (Geodon) dextroamphetamine cap er 24hr 20 mg 1 • ziprasidone hcl cap 60 mg 2 (Geodon) ADDERALL XR – amphetamine- • dextroamphetamine cap er 24hr 1 ziprasidone hcl cap 80 mg • 25 mg (Geodon) ADDERALL XR – amphetamine- 2 • SLEEP AIDS dextroamphetamine cap er 24hr estazolam tab 1 mg 1 30 mg estazolam tab 2 mg 1 CONCERTA – methylphenidate hcl 2 • tab er osmotic release (osm) 18 eszopiclone tab 1 mg (Lunesta) 1 • mg eszopiclone tab 2 mg (Lunesta) 1 • CONCERTA – methylphenidate hcl 2 • 1 eszopiclone tab 3 mg (Lunesta) • tab er osmotic release (osm) 27 phenobarbital tab 16.2 mg 1 mg phenobarbital tab 32.4 mg 1 CONCERTA – methylphenidate hcl 2 • tab er osmotic release (osm) 36 phenobarbital tab 64.8 mg 1 mg phenobarbital tab 97.2 mg 1 CONCERTA – methylphenidate hcl 2 • 1 temazepam cap 15 mg (Restoril) tab er osmotic release (osm) 54 temazepam cap 30 mg (Restoril) 1 mg zaleplon cap 5 mg (Sonata) 1 • guanfacine hcl tab er 24hr 1 mg 1 • (base equiv) (Intuniv) zaleplon cap 10 mg (Sonata) 1 • guanfacine hcl tab er 24hr 2 mg 1 • zolpidem tartrate tab er 6.25 mg 1 • (Intuniv) (Ambien cr) (base equiv) guanfacine hcl tab er 24hr 3 mg 1 • zolpidem tartrate tab er 12.5 mg 1 • (Intuniv) (Ambien cr) (base equiv) guanfacine hcl tab er 24hr 4 mg 1 • zolpidem tartrate tab 5 mg 1 • (Intuniv) (Ambien) (base equiv) VYVANSE – lisdexamfetamine 2 • zolpidem tartrate tab 10 mg 1 • dimesylate cap 10 mg (Ambien) VYVANSE – lisdexamfetamine 2 • HYPERACTIVITY/NARCOLEPSY dimesylate cap 20 mg ADDERALL XR – amphetamine- 2 • VYVANSE – lisdexamfetamine 2 • dextroamphetamine cap er 24hr dimesylate cap 30 mg 5 mg

Tiered Generics Prescription Drug Guide October 2019 31 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits VYVANSE – lisdexamfetamine 2 • PLEGRIDY – peginterferon 2 • • dimesylate cap 40 mg beta-1a soln prefilled syringe 125 VYVANSE – lisdexamfetamine 2 • mcg/0.5ml dimesylate cap 50 mg PLEGRIDY STARTER PACK – 2 • • VYVANSE – lisdexamfetamine 2 • peginterferon beta-1a soln pen- dimesylate cap 60 mg inj 63 & 94 mcg/0.5ml pack 2 VYVANSE – lisdexamfetamine 2 • PLEGRIDY STARTER PACK – • • dimesylate cap 70 mg peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack VYVANSE – lisdexamfetamine 2 • 2 dimesylate chew tab 10 mg REBIF – interferon beta-1a soln • • pref syr 22 mcg/0.5ml (12mu/ml) VYVANSE – lisdexamfetamine 2 • 2 dimesylate chew tab 20 mg REBIF – interferon beta-1a soln • • pref syr 44 mcg/0.5ml (24mu/ml) VYVANSE – lisdexamfetamine 2 • 2 dimesylate chew tab 30 mg REBIF REBIDOSE – interferon • • beta-1a soln auto-inj 22 2 VYVANSE – lisdexamfetamine • mcg/0.5ml (12mu/ml) dimesylate chew tab 40 mg REBIF REBIDOSE – interferon 2 • • 2 VYVANSE – lisdexamfetamine • beta-1a soln auto-inj 44 dimesylate chew tab 50 mg mcg/0.5ml (24mu/ml) 2 VYVANSE – lisdexamfetamine • REBIF REBIDOSE TITRATION – 2 • • dimesylate chew tab 60 mg interferon beta-1a auto-inj 6x8.8 MULTIPLE SCLEROSIS mcg/0.2ml & 6x22 mcg/0.5ml AUBAGIO – teriflunomide tab 7 mg 2 • • REBIF TITRATION PACK – 2 • • AUBAGIO – teriflunomide tab 14 2 • • interferon beta-1a pref syr 6x8.8 mg mcg/0.2ml & 6x22 mcg/0.5ml 2 AVONEX – interferon beta-1a im 2 • • TECFIDERA – dimethyl fumarate • • prefilled syringe kit 30 mcg/0.5ml capsule delayed release 120 mg 2 AVONEX PEN – interferon beta-1a 2 • • TECFIDERA – dimethyl fumarate • • im auto-injector kit 30 mcg/0.5ml capsule delayed release 240 mg 2 BETASERON – interferon beta-1b 2 • • TECFIDERA STARTER PACK – • • for inj kit 0.3 mg dimethyl fumarate capsule dr starter pack 120 mg & 240 mg GILENYA – fingolimod hcl cap 0.5 2 • • mg (base equiv) OTHER CENTRAL NERVOUS SYSTEM DRUGS 1 MAYZENT – siponimod fumarate 2 • • bupropion hcl (smoking tab 0.25 mg (base equiv) deterrent) tab er 12hr 150 mg (Zyban) 2 MAYZENT – siponimod fumarate • • 2 tab 2 mg (base equiv) CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) 2 PLEGRIDY – peginterferon beta-1a • • 2 soln pen-injector 125 mcg/0.5ml CHANTIX – varenicline tartrate tab 1 mg (base equiv)

Tiered Generics Prescription Drug Guide October 2019 32 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits CHANTIX CONTINUING MONTH 2 CODEINE SULFATE – codeine 2 • • – varenicline tartrate tab 1 mg sulfate tab 60 mg (base equiv) MORPHINE SULFATE – morphine 2 • • CHANTIX STARTING MONTH PA 2 sulfate tab 15 mg – varenicline tartrate tab 0.5 mg x MORPHINE SULFATE – morphine 2 • • 11 & tab 1 mg x 42 pack sulfate tab 30 mg 1 donepezil hydrochloride orally tramadol hcl tab 50 mg (Ultram) 1 • • disintegrating tab 5 mg (Aricept 1 odt) tramadol-acetaminophen tab • • 37.5-325 mg (Ultracet) donepezil hydrochloride orally 1 disintegrating tab 10 mg RHEUMATOID AND OSTEOARTHRITIS (Aricept odt) celecoxib cap 50 mg (Celebrex) 1 • donepezil hydrochloride tab 1 celecoxib cap 100 mg (Celebrex) 1 • (Aricept) 5 mg celecoxib cap 200 mg (Celebrex) 1 • 1 donepezil hydrochloride tab diclofenac potassium tab 50 mg 1 10 mg (Aricept) (Cataflam) 1 memantine hcl tab 5 mg diclofenac sodium tab delayed 1 (Namenda) release 50 mg 1 memantine hcl tab 10 mg diclofenac sodium tab delayed 1 (Namenda) release 75 mg NICOTROL INHALER – nicotine 2 diclofenac sodium tab er 24hr 1 inhaler system 10 mg (4 mg 100 mg delivered) 2 2 ENBREL – etanercept for • • • NICOTROL NS – nicotine nasal subcutaneous inj 25 mg spray 10 mg/ml (0.5 mg/spray) ENBREL – etanercept 2 • • • PAIN RELIEF DRUGS subcutaneous soln prefilled NON-NARCOTIC DRUGS syringe 25 mg/0.5ml butalbital-acetaminophen- 1 • ENBREL – etanercept 2 • • • caffeine tab 50-325-40 mg subcutaneous soln prefilled (Esgic) syringe 50 mg/ml NARCOTIC DRUGS ENBREL MINI – etanercept 2 • • • acetaminophen w/ codeine soln 1 • • subcutaneous solution cartridge 120-12 mg/5ml 50 mg/ml 2 acetaminophen w/ codeine tab 1 • • ENBREL SURECLICK – • • • 300-15 mg (Tylenol/codeine) etanercept subcutaneous solution auto-injector 50 mg/ml acetaminophen w/ codeine tab 1 • • 1 300-30 mg (Tylenol/codeine #3) etodolac cap 200 mg 1 acetaminophen w/ codeine tab 1 • • etodolac tab 400 mg 300-60 mg (Tylenol/codeine #4) etodolac tab 500 mg 1 buprenorphine hcl sl tab 2 mg 1 • • flurbiprofen tab 50 mg 1 (base equiv)

Tiered Generics Prescription Drug Guide October 2019 33 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits flurbiprofen tab 100 mg 1 ILARIS – canakinumab 2 • • • HUMIRA – adalimumab prefilled 2 • • • subcutaneous inj 150 mg/ml syringe kit 10 mg/0.1ml indomethacin cap er 75 mg 1 HUMIRA – adalimumab prefilled 2 • • • indomethacin cap 25 mg 1 syringe kit 10 mg/0.2ml indomethacin cap 50 mg 1 2 HUMIRA – adalimumab prefilled • • • ketorolac tromethamine im inj 1 syringe kit 20 mg/0.2ml 60 mg/2ml (30 mg/ml) 2 HUMIRA – adalimumab prefilled • • • ketorolac tromethamine inj 1 syringe kit 20 mg/0.4ml 15 mg/ml 2 HUMIRA – adalimumab prefilled • • • ketorolac tromethamine inj 1 syringe kit 40 mg/0.8ml 30 mg/ml 2 HUMIRA – adalimumab prefilled • • • ketorolac tromethamine tab 1 syringe kit 40 mg/0.4ml 10 mg 2 HUMIRA PEDIATRIC CROHNS D • • • meloxicam tab 7.5 mg (Mobic) 1 – adalimumab prefilled syringe kit 1 40 mg/0.8ml meloxicam tab 15 mg (Mobic) 1 HUMIRA PEDIATRIC CROHNS D 2 • • • nabumetone tab 500 mg – adalimumab prefilled syringe kit nabumetone tab 750 mg 1 80 mg/0.8ml naproxen sodium tab 275 mg 1 HUMIRA PEDIATRIC CROHNS D 2 • • • (Anaprox) – adalimumab prefilled syringe kit naproxen tab ec 375 mg (Ec- 1 80 mg/0.8ml & 40 mg/0.4ml naprosyn) HUMIRA PEN – adalimumab pen- 2 • • • naproxen tab ec 500 mg (Ec- 1 injector kit 40 mg/0.8ml naprosyn) HUMIRA PEN – adalimumab pen- 2 • • • naproxen tab 250 mg (Naprosyn) 1 injector kit 40 mg/0.4ml naproxen tab 375 mg (Naprosyn) 1 HUMIRA PEN-CD/UC/HS START 2 • • • 1 – adalimumab pen-injector kit 40 naproxen tab 500 mg (Naprosyn) mg/0.8ml OTEZLA – apremilast tab starter 2 • • • HUMIRA PEN-CD/UC/HS START 2 • • • therapy pack 10 mg & 20 mg & – adalimumab pen-injector kit 80 30 mg mg/0.8ml OTEZLA – apremilast tab 30 mg 2 • • • HUMIRA PEN-PS/UV STARTER – 2 • • • OTREXUP – methotrexate soln pf 2 • adalimumab pen-injector kit 40 auto-injector 10 mg/0.4ml mg/0.8ml OTREXUP – methotrexate soln pf 2 • HUMIRA PEN-PS/UV STARTER – 2 • • • auto-injector 12.5 mg/0.4ml adalimumab pen-injector kit 80 OTREXUP – methotrexate soln pf 2 • mg/0.8ml & 40 mg/0.4ml auto-injector 15 mg/0.4ml 1 ibuprofen tab 400 mg OTREXUP – methotrexate soln pf 2 • ibuprofen tab 600 mg 1 auto-injector 17.5 mg/0.4ml ibuprofen tab 800 mg 1

Tiered Generics Prescription Drug Guide October 2019 34 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits OTREXUP – methotrexate soln pf 2 • rizatriptan benzoate oral 1 • auto-injector 20 mg/0.4ml disintegrating tab 10 mg (base OTREXUP – methotrexate soln pf 2 • eq) (Maxalt-mlt) auto-injector 22.5 mg/0.4ml rizatriptan benzoate tab 5 mg 1 • OTREXUP – methotrexate soln pf 2 • (base equivalent) (Maxalt) auto-injector 25 mg/0.4ml rizatriptan benzoate tab 10 mg 1 • piroxicam cap 10 mg (Feldene) 1 (base equivalent) (Maxalt) 2 piroxicam cap 20 mg (Feldene) 1 sumatriptan nasal spray 5 mg/ • act (Imitrex) SIMPONI – golimumab 2 • • • 2 subcutaneous soln auto-injector sumatriptan nasal spray 20 mg/ • 50 mg/0.5ml act (Imitrex) 1 SIMPONI – golimumab 2 • • • sumatriptan succinate tab 25 mg • subcutaneous soln auto-injector (Imitrex) 100 mg/ml sumatriptan succinate tab 50 mg 1 • SIMPONI – golimumab 2 • • • (Imitrex) subcutaneous soln prefilled sumatriptan succinate tab 1 • syringe 50 mg/0.5ml 100 mg (Imitrex) SIMPONI – golimumab 2 • • • GOUT subcutaneous soln prefilled allopurinol tab 100 mg (Zyloprim) 1 syringe 100 mg/ml allopurinol tab 300 mg (Zyloprim) 1 sulindac tab 150 mg 1 1 1 colchicine w/ probenecid tab sulindac tab 200 mg 0.5-500 mg MIGRAINE HEADACHES MITIGARE – colchicine cap 0.6 mg 2 2 AIMOVIG – erenumab-aooe • • probenecid tab 500 mg 1 subcutaneous soln auto-injector 70 mg/ml NEUROMUSCULAR DRUGS AIMOVIG – erenumab-aooe 2 • • SEIZURES subcutaneous soln auto-injector carbamazepine chew tab 100 mg 1 140 mg/ml carbamazepine tab er 12hr 1 EMGALITY – galcanezumab-gnlm 2 • • 100 mg (Tegretol-xr) subcutaneous soln auto-injector clonazepam orally disintegrating 1 120 mg/ml tab 0.125 mg EMGALITY – galcanezumab-gnlm 2 • • clonazepam orally disintegrating 1 subcutaneous soln prefilled syr tab 0.25 mg 120 mg/ml 1 1 clonazepam orally disintegrating naratriptan hcl tab 1 mg (base • tab 0.5 mg equiv) (Amerge) 1 1 clonazepam tab 0.5 mg rizatriptan benzoate oral • (Klonopin) disintegrating tab 5 mg (base 1 eq) (Maxalt-mlt) clonazepam tab 1 mg (Klonopin) clonazepam tab 2 mg (Klonopin) 1

Tiered Generics Prescription Drug Guide October 2019 35 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits DIASTAT ACUDIAL – diazepam 2 levetiracetam tab er 24hr 500 mg 1 rectal gel delivery system 10 mg (Keppra xr) DIASTAT ACUDIAL – diazepam 2 levetiracetam tab 250 mg 1 rectal gel delivery system 20 mg (Keppra) DIASTAT PEDIATRIC – diazepam 2 levetiracetam tab 500 mg 1 rectal gel delivery system 2.5 mg (Keppra) DILANTIN – phenytoin sodium 2 levetiracetam tab 750 mg 1 extended cap 30 mg (Keppra) DILANTIN – phenytoin sodium 2 levetiracetam tab 1000 mg 1 extended cap 100 mg (Keppra) divalproex sodium tab delayed 1 oxcarbazepine tab 150 mg 1 release 125 mg (Depakote) (Trileptal) divalproex sodium tab delayed 1 oxcarbazepine tab 300 mg 1 release 250 mg (Depakote) (Trileptal) divalproex sodium tab delayed 1 oxcarbazepine tab 600 mg 1 release 500 mg (Depakote) (Trileptal) EPIDIOLEX – cannabidiol soln 100 2 • • phenytoin chew tab 50 mg 1 mg/ml (Dilantin infatabs) gabapentin cap 100 mg 1 • phenytoin sodium extended cap 1 (Neurontin) 100 mg (Dilantin) gabapentin cap 300 mg 1 • phenytoin susp 125 mg/5ml 1 (Neurontin) (Dilantin) gabapentin cap 400 mg 1 • primidone tab 50 mg (Mysoline) 1 (Neurontin) primidone tab 250 mg (Mysoline) 1 1 gabapentin tab 600 mg • topiramate tab 25 mg (Topamax) 1 (Neurontin) topiramate tab 50 mg (Topamax) 1 gabapentin tab 800 mg 1 • 1 (Neurontin) topiramate tab 100 mg (Topamax) 1 lamotrigine tab chewable 1 topiramate tab 200 mg (Topamax) dispersible 5 mg (Lamictal valproate sodium oral soln 1 chewable di) 250 mg/5ml (base equiv) lamotrigine tab chewable 1 (Depakene) dispersible 25 mg (Lamictal valproic acid cap 250 mg 1 chewable di) (Depakene) lamotrigine tab 25 mg (Lamictal) 1 zonisamide cap 25 mg 1 lamotrigine tab 100 mg (Lamictal) 1 (Zonegran) 1 lamotrigine tab 150 mg (Lamictal) 1 zonisamide cap 50 mg 1 lamotrigine tab 200 mg (Lamictal) 1 zonisamide cap 100 mg (Zonegran) levetiracetam oral soln 100 mg/ 1 ml (Keppra) PARKINSON'S DISEASE

Tiered Generics Prescription Drug Guide October 2019 36 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits amantadine hcl syrup 50 mg/5ml 1 ropinirole hydrochloride tab 1 benztropine mesylate tab 0.5 mg 1 4 mg (Requip) 1 benztropine mesylate tab 1 mg 1 ropinirole hydrochloride tab 5 mg (Requip) benztropine mesylate tab 2 mg 1 trihexyphenidyl hcl elixir 0.4 mg/ 1 1 carbidopa & levodopa orally ml disintegrating tab 10-100 mg trihexyphenidyl hcl tab 2 mg 1 1 carbidopa & levodopa tab er 1 25-100 mg (Sinemet cr) trihexyphenidyl hcl tab 5 mg carbidopa & levodopa tab er 1 MUSCLE RELAXANTS 50-200 mg (Sinemet cr) baclofen tab 10 mg 1 carbidopa & levodopa tab 1 baclofen tab 20 mg 1 10-100 mg (Sinemet) CHLORZOXAZONE – 1 carbidopa & levodopa tab 1 chlorzoxazone tab 500 mg 25-100 mg (Sinemet) cyclobenzaprine hcl tab 5 mg 1 1 carbidopa & levodopa tab cyclobenzaprine hcl tab 10 mg 1 25-250 mg (Sinemet) 1 2 methocarbamol tab 500 mg INBRIJA – levodopa inhal powder • (Robaxin) cap 42 mg 1 1 methocarbamol tab 750 mg pramipexole dihydrochloride tab (Robaxin-750) 0.125 mg (Mirapex) 1 1 orphenadrine citrate tab er 12hr pramipexole dihydrochloride tab 100 mg 0.25 mg (Mirapex) 1 1 tizanidine hcl tab 2 mg (base pramipexole dihydrochloride tab equivalent) 0.5 mg (Mirapex) 1 1 tizanidine hcl tab 4 mg (base pramipexole dihydrochloride tab equivalent) (Zanaflex) 0.75 mg (Mirapex) SUPPLEMENTS pramipexole dihydrochloride tab 1 1 mg (Mirapex) VITAMINS 1 pramipexole dihydrochloride tab 1 ergocalciferol cap 50000 unit 1.5 mg (Mirapex) (Drisdol) ropinirole hydrochloride tab 1 MINERALS AND ELECTROLYTES 0.25 mg (Requip) potassium chloride cap er 8 meq 1 ropinirole hydrochloride tab 1 (Micro-k) 0.5 mg (Requip) potassium chloride cap er 10 1 ropinirole hydrochloride tab 1 meq (Micro-k) 1 mg (Requip) POTASSIUM CHLORIDE ER – 1 ropinirole hydrochloride tab 1 potassium chloride tab er 8 meq 2 mg (Requip) (600 mg) ropinirole hydrochloride tab 1 3 mg (Requip)

Tiered Generics Prescription Drug Guide October 2019 37 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits potassium chloride 1 EPOGEN – epoetin alfa inj 4000 2 • microencapsulated crys er tab unit/ml 10 meq EPOGEN – epoetin alfa inj 10000 2 • potassium chloride 1 unit/ml microencapsulated crys er tab EPOGEN – epoetin alfa inj 20000 2 • 20 meq unit/ml 1 potassium chloride tab er 8 meq FIRAZYR – icatibant acetate inj 30 2 • • • (600 mg) mg/3ml (base equivalent) 1 potassium chloride tab er 10 folic acid tab 1 mg 1 meq (K-tab) FULPHILA – pegfilgrastim-jmdb 2 • 1 sodium fluoride chew tab soln prefilled syringe 6 mg/0.6ml 0.25 mg f (from 0.55 mg naf) 2 (Luride) GRANIX – tbo-filgrastim soln • prefilled syringe 300 mcg/0.5ml sodium fluoride chew tab 0.5 mg 1 2 f (from 1.1 mg naf) (Luride) GRANIX – tbo-filgrastim soln • prefilled syringe 480 mcg/0.8ml sodium fluoride chew tab 1 mg f 1 2 (from 2.2 mg naf) (Luride) GRANIX – tbo-filgrastim • subcutaneous inj 300 mcg/ml sodium fluoride soln 0.5 mg/ml f 1 2 (from 1.1 mg/ml naf) (Luride) GRANIX – tbo-filgrastim • subcutaneous inj 480 mcg/1.6ml BLOOD MODIFYING DRUGS (300 mcg/ml) 2 BRILINTA – ticagrelor tab 60 mg HAEGARDA – c1 esterase inhibitor 2 • • • BRILINTA – ticagrelor tab 90 mg 2 (human) for subcutaneous inj cilostazol tab 50 mg (Pletal) 1 2000 unit 2 cilostazol tab 100 mg (Pletal) 1 HAEGARDA – c1 esterase inhibitor • • • (human) for subcutaneous inj 1 clopidogrel bisulfate tab 75 mg 3000 unit (base equiv) (Plavix) MULPLETA – lusutrombopag tab 3 2 • • • 1 cyanocobalamin inj 1000 mcg/ml mg 1 dipyridamole tab 25 mg NEULASTA – pegfilgrastim soln 2 • (Persantine) prefilled syringe 6 mg/0.6ml 1 dipyridamole tab 50 mg NEULASTA ONPRO KIT – 2 • (Persantine) pegfilgrastim soln prefilled ELIQUIS – apixaban tab 2.5 mg 2 • syringe kit 6 mg/0.6ml ELIQUIS – apixaban tab 5 mg 2 • NEUPOGEN – filgrastim soln 2 • ELIQUIS STARTER PACK – 2 • prefilled syringe 300 mcg/0.5ml apixaban tab 5 mg NEUPOGEN – filgrastim soln 2 • EPOGEN – epoetin alfa inj 2000 2 • prefilled syringe 480 mcg/0.8ml unit/ml (600 mcg/ml) 2 EPOGEN – epoetin alfa inj 3000 2 • NEUPOGEN – filgrastim inj 300 • unit/ml mcg/ml

Tiered Generics Prescription Drug Guide October 2019 38 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits NEUPOGEN – filgrastim inj 480 2 • warfarin sodium tab 2.5 mg 1 mcg/1.6ml (300 mcg/ml) (Coumadin) NIVESTYM – filgrastim-aafi soln 2 • warfarin sodium tab 3 mg 1 prefilled syringe 300 mcg/0.5ml (Coumadin) NIVESTYM – filgrastim-aafi soln 2 • warfarin sodium tab 4 mg 1 prefilled syringe 480 mcg/0.8ml (Coumadin) NIVESTYM – filgrastim-aafi inj 300 2 • warfarin sodium tab 5 mg 1 mcg/ml (Coumadin) NIVESTYM – filgrastim-aafi inj 480 2 • warfarin sodium tab 6 mg 1 mcg/1.6ml (300 mcg/ml) (Coumadin) pentoxifylline tab er 400 mg 1 warfarin sodium tab 7.5 mg 1 PROCRIT – epoetin alfa inj 2000 2 • (Coumadin) unit/ml warfarin sodium tab 10 mg 1 PROCRIT – epoetin alfa inj 3000 2 • (Coumadin) unit/ml XARELTO – rivaroxaban tab 2.5 2 • PROCRIT – epoetin alfa inj 4000 2 • mg unit/ml XARELTO – rivaroxaban tab 10 mg 2 • PROCRIT – epoetin alfa inj 10000 2 • XARELTO – rivaroxaban tab 15 mg 2 • unit/ml XARELTO – rivaroxaban tab 20 mg 2 • 2 PROCRIT – epoetin alfa inj 20000 • XARELTO STARTER PACK – 2 • unit/ml rivaroxaban tab starter therapy PROCRIT – epoetin alfa inj 40000 2 • pack 15 mg & 20 mg unit/ml ZARXIO – filgrastim-sndz soln 2 • RETACRIT – epoetin alfa-epbx inj 2 • prefilled syringe 300 mcg/0.5ml 2000 unit/ml ZARXIO – filgrastim-sndz soln 2 • RETACRIT – epoetin alfa-epbx inj 2 • prefilled syringe 480 mcg/0.8ml 3000 unit/ml TOPICAL DRUGS 2 RETACRIT – epoetin alfa-epbx inj • EYE 4000 unit/ml Anti-infectives RETACRIT – epoetin alfa-epbx inj 2 • 2 10000 unit/ml BACITRACIN – bacitracin ophth oint 500 unit/gm RETACRIT – epoetin alfa-epbx inj 2 • 1 40000 unit/ml bacitracin-polymyxin b ophth oint UDENYCA – pegfilgrastim-cbqv 2 • 1 soln prefilled syringe 6 mg/0.6ml ciprofloxacin hcl ophth soln 1 0.3% (base equivalent) warfarin sodium tab 1 mg (Ciloxan) (Coumadin) 1 1 erythromycin ophth oint 5 mg/ warfarin sodium tab 2 mg gm (Coumadin) gentamicin sulfate ophth soln 1 0.3% (Garamycin)

Tiered Generics Prescription Drug Guide October 2019 39 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits NATACYN – natamycin ophth susp 2 brimonidine tartrate ophth soln 1 5% 0.2% neomycin-bacitrac zn-polymyx 1 CARTEOLOL HCL – carteolol hcl 1 5(3.5)mg-400unt-10000unt op ophth soln 1% oin dorzolamide hcl ophth soln 2% 1 NEOMYCIN/POLYMYXIN/GRAMIC 1 (Trusopt) – neomycin-polymy-gramicid op dorzolamide hcl-timolol maleate 1 sol 1.75-10000-0.025mg-unt-mg/ ophth soln 22.3-6.8 mg/ml ml (Cosopt) 1 ofloxacin ophth soln 0.3% latanoprost ophth soln 0.005% 1 • (Ocuflox) (Xalatan) 1 polymyxin b-trimethoprim levobunolol hcl ophth soln 0.5% 1 ophth soln 10000 unit/ml-0.1% (Betagan) (Polytrim) LUMIGAN – bimatoprost ophth 2 • 1 sulfacetamide sodium ophth soln 0.01% soln 10% (Bleph-10) 1 1 pilocarpine hcl ophth soln 1% tobramycin ophth soln 0.3% (Isopto carpine) (Tobrex) pilocarpine hcl ophth soln 2% 1 Steroids and Combination Products (Isopto carpine) 1 bacitracin-polymyxin-neomycin- timolol maleate ophth soln 1 hc ophth oint 1% 0.25% (Timoptic) 2 LOTEMAX – loteprednol etabonate timolol maleate ophth soln 0.5% 1 ophth susp 0.5% (Timoptic) 2 LOTEMAX – loteprednol etabonate TRAVATAN Z – travoprost ophth 2 • ophth oint 0.5% soln 0.004% (benzalkonium free) LOTEMAX – loteprednol etabonate 2 (bak free) ophth gel 0.5% Other Eye Products 2 LOTEMAX SM – loteprednol azelastine hcl ophth soln 0.05% 1 etabonate ophth gel 0.38% cromolyn sodium ophth soln 4% 1 neomycin-polymyxin- 1 1 dexamethasone ophth oint cyclopentolate hcl ophth soln 0.1% (Maxitrol) 0.5% (Cyclogyl) 1 neomycin-polymyxin- 1 cyclopentolate hcl ophth soln dexamethasone ophth susp 1% (Cyclogyl) 0.1% (Maxitrol) cyclopentolate hcl ophth soln 1 SULFACETAMIDE SODIUM/ 1 2% (Cyclogyl) PRED – sulfacetamide sodium- diclofenac sodium ophth soln 1 prednisolone ophth soln 0.1% 10-0.23(0.25)% epinastine hcl ophth soln 0.05% 1 Glaucoma (Elestat) betaxolol hcl ophth soln 0.5% 1

Tiered Generics Prescription Drug Guide October 2019 40 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits ketorolac tromethamine ophth 1 clindamycin phosphate swab 1% 1 soln 0.5% (Acular) (Cleocin-t) olopatadine hcl ophth soln 0.1% 1 DIFFERIN – adapalene lotion 0.1% 2 (base equivalent) (Patanol) erythromycin soln 2% 1 2 PAZEO – olopatadine hcl ophth FINACEA – azelaic acid foam 15% 2 soln 0.7% (base equivalent) SOOLANTRA – ivermectin cream 2 1 phenylephrine hcl ophth soln 1% 10% TAZORAC – tazarotene cream 2 1 proparacaine hcl ophth soln 0.05% 0.5% (Alcaine) TAZORAC – tazarotene gel 0.05% 2 tetracaine hcl ophth soln 0.5% 1 TAZORAC – tazarotene gel 0.1% 2 EAR Anti-infectives acetic acid otic soln 2% 1 1 2 ciclopirox olamine cream 0.77% CIPRODEX – ciprofloxacin- (base equiv) dexamethasone otic susp 1 0.3-0.1% ciclopirox solution 8% (Penlac • • nail lacquer) MOUTH AND THROAT (LOCAL) 1 1 clotrimazole w/ betamethasone chlorhexidine gluconate soln cream 1-0.05% (Lotrisone) 0.12% (Peridex) CORTISPORIN – neomycin- 2 1 clotrimazole troche 10 mg polymyxin-hc crm 3.5 mg/ lidocaine hcl viscous soln 2% 1 gm-10000 unt/gm-0.5% nystatin susp 100000 unit/ml 1 CORTISPORIN – bacitracin- 2 sodium fluoride cream 1.1% 1 polymyxin-neomycin hc oint 1% (Prevident 5000 plus) gentamicin sulfate cream 0.1% 1 sodium fluoride gel 1.1% (0.5% f) 1 ketoconazole shampoo 2% 1 (Prevident fluoride) (Nizoral) sodium fluoride paste 1.1% 1 MENTAX – butenafine hcl cream 2 (Prevident 5000 boost) 1% sodium fluoride rinse 0.2% 1 mupirocin oint 2% (Bactroban) 1 (Prevident) nystatin cream 100000 unit/gm 1 ANORECTAL AGENTS nystatin oint 100000 unit/gm 1 2 CORTIFOAM – hydrocortisone nystatin topical powder 100000 1 acetate rectal foam 10% (90 mg/ unit/gm dose) 1 1 silver sulfadiazine cream 1% hydrocortisone rectal cream 1% (Silvadene) (Proctocort) Corticosteroids SKIN CONDITIONS/PRODUCTS betamethasone dipropionate 1 Acne augmented cream 0.05% (Diprolene af)

Tiered Generics Prescription Drug Guide October 2019 41 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits betamethasone dipropionate 1 triamcinolone acetonide oint 1 lotion 0.05% 0.5% betamethasone valerate cream 1 Other Skin Products 0.1% (base equivalent) COSENTYX – secukinumab 2 • • • betamethasone valerate oint 1 subcutaneous soln prefilled 0.1% (base equivalent) syringe 150 mg/ml ENSTILAR – calcipotriene- 2 • COSENTYX SENSOREADY PEN 2 • • • betamethasone dipropionate – secukinumab subcutaneous foam 0.005-0.064% soln auto-injector 150 mg/ml fluticasone propionate cream 1 ELIDEL – pimecrolimus cream 1% 2 • 0.05% (Cutivate) lactic acid (ammonium lactate) 1 fluticasone propionate oint 1 cream 12% (Lac-hydrin) 0.005% (Cutivate) lidocaine hcl gel 2% 1 1 hydrocortisone cream 2.5% lidocaine hcl soln 4% (Xylocaine) 1 1 hydrocortisone lotion 2.5% lidocaine hcl urethral/ 1 hydrocortisone oint 2.5% 1 mucosal gel 2% mometasone furoate cream 0.1% 1 PICATO – ingenol mebutate gel 2 • • (Elocon) 0.015% mometasone furoate oint 0.1% 1 PICATO – ingenol mebutate gel 2 • • (Elocon) 0.05% mometasone furoate solution 1 selenium sulfide lotion 2.5% 1 0.1% (lotion) (Elocon) SKYRIZI – risankizumab-rzaa 2 • • • TACLONEX – calcipotriene- 2 • sol prefilled syringe 2 x 75 betamethasone dipropionate mg/0.83ml kit susp 0.005-0.064% STELARA – ustekinumab inj 45 2 • • • triamcinolone acetonide cream 1 mg/0.5ml 0.025% STELARA – ustekinumab soln 2 • • • triamcinolone acetonide cream 1 prefilled syringe 45 mg/0.5ml 0.1% STELARA – ustekinumab soln 2 • • • triamcinolone acetonide cream 1 prefilled syringe 90 mg/ml 0.5% TREMFYA – guselkumab soln pen- 2 • • • triamcinolone acetonide lotion 1 injector 100 mg/ml 0.025% TREMFYA – guselkumab soln 2 • • • triamcinolone acetonide lotion 1 prefilled syringe 100 mg/ml 0.1% VALCHLOR – mechlorethamine hcl 2 • triamcinolone acetonide oint 1 gel 0.016% (base equivalent) 0.025% MISCELLANEOUS CATEGORIES (includes supplies triamcinolone acetonide oint 1 and devices) 0.1% DIABETIC SUPPLIES

Tiered Generics Prescription Drug Guide October 2019 42 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits CONTOUR BLOOD GLUCOSE 2 MONOJECT ALLERGIST TRAY/P 2 MON – blood glucose monitoring – allergy tray kit 1 ml 28 x 1/2" devices MONOJECT INSULIN SYRINGE – 2 CONTOUR BLOOD GLUCOSE 2 • insulin syringe (disp) u-100 1 ml TES – glucose blood test strip MONOJECT INSULIN SYRINGE/ – 2 CONTOUR HIGH CONTROL – 2 insulin syringe (disp) u-100 1 ml blood glucose calibration - liquid MONOJECT INSULIN SYRINGE/ – 2 - high insulin syringe/needle u-100 0.3 CONTOUR LOW CONTROL – 2 ml 29 x 1/2" blood glucose calibration - liquid MONOJECT INSULIN SYRINGE/ – 2 - low insulin syringe/needle u-100 0.3 CONTOUR NEXT BLOOD 2 • ml 30 x 5/16" GLUCOS – glucose blood test MONOJECT INSULIN SYRINGE/ – 2 strip insulin syringe/needle u-100 1/2 CONTOUR NEXT BLOOD 2 ml 28 x 1/2" GLUCOS – blood glucose MONOJECT INSULIN SYRINGE/ – 2 monitoring kit w/ device insulin syringe/needle u-100 1/2 CONTOUR NEXT CONTROL 2 ml 29 x 1/2" LEVE – blood glucose calibration MONOJECT INSULIN SYRINGE/ – 2 - liquid - normal insulin syringe/needle u-100 1/2 CONTOUR NEXT CONTROL 2 ml 30 x 5/16" LEVE – blood glucose calibration MONOJECT INSULIN SYRINGE/ – 2 - liquid - low insulin syringe/needle u-100 1 ml CONTOUR NEXT EZ BLOOD GLU 2 25 x 5/8" – blood glucose monitoring kit w/ MONOJECT INSULIN SYRINGE/ – 2 device insulin syringe/needle u-100 1 ml CONTOUR NEXT LINK BLOOD G 2 27 x 1/2" – blood glucose monitoring kit w/ MONOJECT INSULIN SYRINGE/ – 2 device insulin syringe/needle u-100 1 ml CONTOUR NEXT LINK WIRELES 2 28 x 1/2" – blood glucose monitoring kit w/ MONOJECT INSULIN SYRINGE/ – 2 device insulin syringe/needle u-100 1 ml CONTOUR NEXT ONE BLOOD 2 29 x 1/2" GL – blood glucose monitoring kit MONOJECT INSULIN SYRINGE/ – 2 CONTOUR NORMAL CONTROL – 2 insulin syringe/needle u-100 1 ml blood glucose calibration - liquid - 30 x 5/16" normal MONOJECT INSULIN SYRINGE/ – 2 FINGERSTIX LANCETS – lancets 2 insulin syringe/needle u-100 1 ml MICROLET LANCETS – lancets 2 31 x 5/16" 2 MONOJECT ALLERGIST TRAY/P 2 MONOJECT ULTRA COMFORT – allergy tray kit 1/2 ml 28 x 1/2" IN – insulin syringe/needle u-100 0.3 ml 29 x 1/2"

Tiered Generics Prescription Drug Guide October 2019 43 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits MONOJECT ULTRA COMFORT 2 CYCLOSPORINE MODIFIED – 2 IN – insulin syringe/needle u-100 cyclosporine modified cap 50 mg 0.3 ml 30 x 5/16" DEPEN TITRATABS – 2 • MONOJECT ULTRA COMFORT 2 penicillamine tab 250 mg IN – insulin syringe/needle u-100 JADENU – deferasirox tab 90 mg 2 • 1/2 ml 31 x 5/16" JADENU – deferasirox tab 180 mg 2 • MONOJECT ULTRA COMFORT 2 2 IN – insulin syringe/needle u-100 JADENU – deferasirox tab 360 mg • 1/2 ml 28 x 1/2" mycophenolate mofetil cap 1 MONOJECT ULTRA COMFORT 2 250 mg (Cellcept) IN – insulin syringe/needle u-100 mycophenolate mofetil tab 1 1/2 ml 29 x 1/2" 500 mg (Cellcept) MONOJECT ULTRA COMFORT 2 NALOXONE HCL – naloxone hcl 1 IN – insulin syringe/needle u-100 soln cartridge 0.4 mg/ml 1/2 ml 30 x 5/16" NALOXONE HCL – naloxone hcl 1 MONOJECT ULTRA COMFORT IN 2 soln prefilled syringe 2 mg/2ml – insulin syringe/needle u-100 1 naloxone hcl inj 0.4 mg/ml 1 ml 28 x 1/2" naloxone hcl inj 4 mg/10ml 1 MONOJECT ULTRA COMFORT IN 2 1 – insulin syringe/needle u-100 1 naltrexone hcl tab 50 mg (Revia) ml 29 x 1/2" NARCAN – naloxone hcl nasal 2 MONOJECT ULTRA COMFORT 2 spray 4 mg/0.1ml IN – insulin syringe/needle u-100 RAPAMUNE – sirolimus oral soln 1 2 0.3 ml 31 x 5/16" mg/ml REALITY INSULIN SYRINGE/U – 2 REVLIMID – lenalidomide caps 2.5 2 • • • insulin syringe/needle u-100 1/2 mg ml 28 x 1/2" REVLIMID – lenalidomide cap 5 2 • • • REALITY INSULIN SYRINGE/U – 2 mg insulin syringe/needle u-100 1/2 REVLIMID – lenalidomide cap 10 2 • • • ml 29 x 1/2" mg REALITY INSULIN SYRINGE/U – 2 REVLIMID – lenalidomide cap 15 2 • • • insulin syringe/needle u-100 1 ml mg 28 x 1/2" REVLIMID – lenalidomide cap 20 2 • • • REALITY INSULIN SYRINGE/U – 2 mg insulin syringe/needle u-100 1 ml 2 29 x 1/2" REVLIMID – lenalidomide cap 25 • • • mg SINGLE-LET – lancets 2 SANDIMMUNE – cyclosporine oral 2 MISCELLANEOUS DRUGS soln 100 mg/ml azathioprine tab 50 mg (Imuran) 1 sodium polystyrene sulfonate 1 CHEMET – succimer cap 100 mg 2 oral susp 15 gm/60ml

Tiered Generics Prescription Drug Guide October 2019 44 2019

Drug Name Tier Designation Specialty Prior Authorization Step Therapy Dispensing Limits SUBOXONE – buprenorphine hcl- 2 • naloxone hcl sl film 2-0.5 mg (base equiv) SUBOXONE – buprenorphine hcl- 2 • naloxone hcl sl film 4-1 mg (base equiv) SUBOXONE – buprenorphine hcl- 2 • naloxone hcl sl film 8-2 mg (base equiv) SUBOXONE – buprenorphine hcl- 2 • naloxone hcl sl film 12-3 mg (base equiv) tacrolimus cap 0.5 mg (Prograf) 1 THALOMID – thalidomide cap 50 2 • • • mg THALOMID – thalidomide cap 100 2 • • • mg THALOMID – thalidomide cap 150 2 • • • mg THALOMID – thalidomide cap 200 2 • • • mg ZORTRESS – everolimus tab 0.25 2 mg ZORTRESS – everolimus tab 0.5 2 mg ZORTRESS – everolimus tab 0.75 2 mg ZORTRESS – everolimus tab 1 mg 2

Tiered Generics Prescription Drug Guide October 2019 45 2019

AFINITOR – everolimus tab 7.5 mg...... 5 INDEX AFINITOR – everolimus tab 10 mg...... 5 AIMOVIG – erenumab-aooe subcutaneous soln auto- A injector 70 mg/ml...... 35 AIMOVIG – erenumab-aooe subcutaneous soln auto- acarbose tab 25 mg (Precose)...... 11 injector 140 mg/ml...... 35 acarbose tab 50 mg (Precose)...... 11 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...... 23 acarbose tab 100 mg (Precose)...... 11 albuterol sulfate soln nebu 0.5% (5 mg/ml)...... 23 acebutolol hcl cap 200 mg (Sectral)...... 17 albuterol sulfate soln nebu 0.63 mg/3ml (base acebutolol hcl cap 400 mg (Sectral)...... 17 equiv)...... 23 acetaminophen w/ codeine soln 120-12 mg/5ml...... 33 albuterol sulfate soln nebu 1.25 mg/3ml (base acetaminophen w/ codeine tab 300-15 mg (Tylenol/ equiv)...... 23 codeine)...... 33 albuterol sulfate syrup 2 mg/5ml...... 23 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ ALECENSA – alectinib hcl cap 150 mg (base codeine #3)...... 33 equivalent)...... 5 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ alendronate sodium tab 5 mg...... 14 codeine #4)...... 33 alendronate sodium tab 10 mg...... 14 acetazolamide tab 125 mg...... 20 alendronate sodium tab 35 mg...... 14 acetic acid otic soln 2%...... 41 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml alendronate sodium tab 70 mg (Fosamax)...... 15 (2000000 unit/0.5ml)...... 5 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)...... 28 ALINIA – nitazoxanide for susp 100 mg/5ml...... 4 acyclovir cap 200 mg (Zovirax)...... 3 ALINIA – nitazoxanide tab 500 mg...... 4 acyclovir tab 400 mg (Zovirax)...... 3 allopurinol tab 100 mg (Zyloprim)...... 35 acyclovir tab 800 mg (Zovirax)...... 3 ADDERALL XR – amphetamine-dextroamphetamine cap allopurinol tab 300 mg (Zyloprim)...... 35 er 24hr 5 mg...... 31 alprazolam tab er 24hr 0.5 mg (Xanax xr)...... 28 ADDERALL XR – amphetamine-dextroamphetamine cap alprazolam tab er 24hr 1 mg (Xanax xr)...... 28 er 24hr 10 mg...... 31 alprazolam tab er 24hr 2 mg (Xanax xr)...... 28 ADDERALL XR – amphetamine-dextroamphetamine cap alprazolam tab er 24hr 3 mg (Xanax xr)...... 28 er 24hr 15 mg...... 31 alprazolam tab 0.25 mg (Xanax)...... 28 ADDERALL XR – amphetamine-dextroamphetamine cap alprazolam tab 0.5 mg (Xanax)...... 28 er 24hr 20 mg...... 31 alprazolam tab 1 mg (Xanax)...... 28 ADDERALL XR – amphetamine-dextroamphetamine cap alprazolam tab 2 mg (Xanax)...... 28 ALUNBRIG – brigatinib tab initiation therapy pack 90 mg & er 24hr 25 mg...... 31 180 mg...... 5 ADDERALL XR – amphetamine-dextroamphetamine cap ALUNBRIG – brigatinib tab 30 mg...... 5 er 24hr 30 mg...... 31 ALUNBRIG – brigatinib tab 90 mg...... 5 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba ALUNBRIG – brigatinib tab 180 mg...... 5 100-50 mcg/dose...... 23 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba amantadine hcl syrup 50 mg/5ml...... 37 250-50 mcg/dose...... 23 amiloride & hydrochlorothiazide tab 5-50 mg...... 20 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba amiloride hcl tab 5 mg...... 20 500-50 mcg/dose...... 23 amiodarone hcl tab 200 mg (Cordarone)...... 21 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 amitriptyline hcl tab 10 mg...... 28 mcg/act...... 23 amitriptyline hcl tab 25 mg...... 28 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 amitriptyline hcl tab 50 mg...... 28 mcg/act...... 23 amitriptyline hcl tab 75 mg...... 28 ADVAIR HFA – fluticasone-salmeterol inhal aerosol amitriptyline hcl tab 100 mg...... 28 230-21 mcg/act...... 23 amlodipine besylate-benazepril hcl cap 2.5-10 mg AFINITOR DISPERZ – everolimus tab for oral susp 2 (Lotrel)...... 18 mg...... 5 amlodipine besylate-benazepril hcl cap 5-10 mg AFINITOR DISPERZ – everolimus tab for oral susp 3 (Lotrel)...... 18 mg...... 5 amlodipine besylate-benazepril hcl cap 5-20 mg AFINITOR DISPERZ – everolimus tab for oral susp 5 (Lotrel)...... 18 mg...... 5 amlodipine besylate-benazepril hcl cap 5-40 mg AFINITOR – everolimus tab 2.5 mg...... 5 (Lotrel)...... 18 AFINITOR – everolimus tab 5 mg...... 5 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)...... 18

Tiered Generics Prescription Drug Guide October 2019 46 2019 amlodipine besylate-benazepril hcl cap 10-40 mg atenolol & chlorthalidone tab 50-25 mg (Tenoretic (Lotrel)...... 18 50)...... 17 amlodipine besylate tab 2.5 mg (base equivalent) atenolol & chlorthalidone tab 100-25 mg (Tenoretic (Norvasc)...... 18 100)...... 17 amlodipine besylate tab 5 mg (base equivalent) atenolol tab 25 mg (Tenormin)...... 17 (Norvasc)...... 18 atenolol tab 50 mg (Tenormin)...... 17 amlodipine besylate tab 10 mg (base equivalent) atenolol tab 100 mg (Tenormin)...... 17 (Norvasc)...... 18 atorvastatin calcium tab 10 mg (base equivalent) amlodipine besylate-valsartan tab 5-160 mg (Lipitor)...... 19 (Exforge)...... 18 atorvastatin calcium tab 20 mg (base equivalent) amlodipine besylate-valsartan tab 5-320 mg (Lipitor)...... 19 (Exforge)...... 18 atorvastatin calcium tab 40 mg (base equivalent) amlodipine besylate-valsartan tab 10-160 mg (Lipitor)...... 19 (Exforge)...... 18 atorvastatin calcium tab 80 mg (base equivalent) amlodipine besylate-valsartan tab 10-320 mg (Lipitor)...... 19 (Exforge)...... 18 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab amoxicillin & k clavulanate for susp 200-28.5 600-200-300 mg...... 3 mg/5ml...... 1 ATROVENT HFA – ipratropium bromide hfa inhal aerosol amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 17 mcg/act...... 23 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml AUBAGIO – teriflunomide tab 7 mg...... 32 (Augmentin es-600)...... 1 AUBAGIO – teriflunomide tab 14 mg...... 32 amoxicillin & k clavulanate tab 500-125 mg AVONEX – interferon beta-1a im prefilled syringe kit 30 (Augmentin)...... 1 mcg/0.5ml...... 32 amoxicillin & k clavulanate tab 875-125 mg AVONEX PEN – interferon beta-1a im auto-injector kit 30 (Augmentin)...... 1 mcg/0.5ml...... 32 amoxicillin (trihydrate) cap 250 mg...... 1 azathioprine tab 50 mg (Imuran)...... 44 amoxicillin (trihydrate) cap 500 mg...... 1 azelastine hcl nasal spray 0.1% (137 mcg/spray)...... 22 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 azelastine hcl ophth soln 0.05%...... 40 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 azithromycin for susp 100 mg/5ml (Zithromax)...... 1 amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 azithromycin for susp 200 mg/5ml (Zithromax)...... 1 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 azithromycin tab 250 mg (Zithromax)...... 1 amoxicillin (trihydrate) tab 500 mg...... 1 azithromycin tab 500 mg (Zithromax)...... 2 amoxicillin (trihydrate) tab 875 mg...... 1 azithromycin tab 600 mg (Zithromax)...... 2 AMPICILLIN – ampicillin cap 500 mg...... 1 B anastrozole tab 1 mg (Arimidex)...... 5 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba BACITRACIN – bacitracin ophth oint 500 unit/gm...... 39 62.5-25 mcg/inh...... 23 bacitracin-polymyxin b ophth oint...... 39 APRISO – mesalamine cap er 24hr 0.375 gm...... 27 bacitracin-polymyxin-neomycin-hc ophth oint 1%...... 40 ARNUITY ELLIPTA – fluticasone furoate aerosol powder baclofen tab 10 mg...... 37 breath activ 50 mcg/act...... 23 baclofen tab 20 mg...... 37 ARNUITY ELLIPTA – fluticasone furoate aerosol powder BARACLUDE – entecavir oral soln 0.05 mg/ml...... 2 breath activ 100 mcg/act...... 23 benazepril & hydrochlorothiazide tab 5-6.25 mg...... 15 ARNUITY ELLIPTA – fluticasone furoate aerosol powder benazepril & hydrochlorothiazide tab 10-12.5 mg breath activ 200 mcg/act...... 23 (Lotensin hct)...... 15 ASMANEX HFA – mometasone furoate inhal aerosol benazepril & hydrochlorothiazide tab 20-12.5 mg suspension 100 mcg/act...... 23 (Lotensin hct)...... 15 ASMANEX HFA – mometasone furoate inhal aerosol benazepril & hydrochlorothiazide tab 20-25 mg suspension 200 mcg/act...... 23 (Lotensin hct)...... 15 ASMANEX TWISTHALER 120 ME – mometasone furoate benazepril hcl tab 5 mg...... 15 inhal powd 220 mcg/inh (breath activated)...... 23 benazepril hcl tab 10 mg (Lotensin)...... 15 ASMANEX TWISTHALER 30 MET – mometasone furoate benazepril hcl tab 20 mg (Lotensin)...... 15 inhal powd 110 mcg/inh (breath activated)...... 23 benazepril hcl tab 40 mg (Lotensin)...... 15 ASMANEX TWISTHALER 30 MET – mometasone furoate BENZNIDAZOLE – benznidazole tab 12.5 mg...... 4 inhal powd 220 mcg/inh (breath activated)...... 23 BENZNIDAZOLE – benznidazole tab 100 mg...... 4 ASMANEX TWISTHALER 60 MET – mometasone furoate benzonatate cap 150 mg...... 22 inhal powd 220 mcg/inh (breath activated)...... 23 benzonatate cap 200 mg...... 22

Tiered Generics Prescription Drug Guide October 2019 47 2019 benzonatate cap 100 mg (Tessalon perles)...... 22 butalbital-acetaminophen-caffeine tab 50-325-40 mg benztropine mesylate tab 0.5 mg...... 37 (Esgic)...... 33 benztropine mesylate tab 1 mg...... 37 C benztropine mesylate tab 2 mg...... 37 betamethasone dipropionate augmented cream 0.05% calcitriol cap 0.25 mcg (Rocaltrol)...... 15 (Diprolene af)...... 41 calcitriol cap 0.5 mcg (Rocaltrol)...... 15 betamethasone dipropionate lotion 0.05%...... 42 CANASA – mesalamine suppos 1000 mg...... 27 betamethasone valerate cream 0.1% (base CAPRELSA – vandetanib tab 100 mg...... 5 equivalent)...... 42 CAPRELSA – vandetanib tab 300 mg...... 5 betamethasone valerate oint 0.1% (base captopril tab 12.5 mg...... 16 equivalent)...... 42 carbamazepine chew tab 100 mg...... 35 BETASERON – interferon beta-1b for inj kit 0.3 mg...... 32 carbamazepine tab er 12hr 100 mg (Tegretol-xr)...... 35 betaxolol hcl ophth soln 0.5%...... 40 carbidopa & levodopa orally disintegrating tab 10-100 betaxolol hcl tab 20 mg...... 17 mg...... 37 betaxolol hcl tab 10 mg (Kerlone)...... 17 carbidopa & levodopa tab er 25-100 mg (Sinemet bethanechol chloride tab 5 mg (Urecholine)...... 27 cr)...... 37 bethanechol chloride tab 10 mg (Urecholine)...... 27 carbidopa & levodopa tab er 50-200 mg (Sinemet bicalutamide tab 50 mg (Casodex)...... 5 cr)...... 37 BIKTARVY – bictegravir-emtricitabine-tenofovir af tab carbidopa & levodopa tab 10-100 mg (Sinemet)...... 37 50-200-25 mg...... 3 carbidopa & levodopa tab 25-100 mg (Sinemet)...... 37 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg carbidopa & levodopa tab 25-250 mg (Sinemet)...... 37 (Ziac)...... 17 carbinoxamine maleate soln 4 mg/5ml (Palgic)...... 22 bisoprolol & hydrochlorothiazide tab 5-6.25 mg carbinoxamine maleate tab 4 mg (Palgic)...... 22 (Ziac)...... 17 CARTEOLOL HCL – carteolol hcl ophth soln 1%...... 40 bisoprolol & hydrochlorothiazide tab 10-6.25 mg carvedilol tab 3.125 mg (Coreg)...... 17 (Ziac)...... 17 carvedilol tab 6.25 mg (Coreg)...... 17 bisoprolol fumarate tab 5 mg (Zebeta)...... 17 carvedilol tab 12.5 mg (Coreg)...... 17 bisoprolol fumarate tab 10 mg (Zebeta)...... 17 carvedilol tab 25 mg (Coreg)...... 17 BOSULIF – bosutinib tab 100 mg...... 5 cefaclor cap 250 mg...... 1 BOSULIF – bosutinib tab 400 mg...... 5 cefaclor cap 500 mg...... 1 BOSULIF – bosutinib tab 500 mg...... 5 cefadroxil cap 500 mg...... 1 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd cefadroxil for susp 250 mg/5ml...... 1 ba 100-25 mcg/inh...... 24 cefadroxil tab 1 gm...... 1 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd cefdinir cap 300 mg...... 1 ba 200-25 mcg/inh...... 24 cefdinir for susp 125 mg/5ml...... 1 BRILINTA – ticagrelor tab 60 mg...... 38 cefdinir for susp 250 mg/5ml...... 1 BRILINTA – ticagrelor tab 90 mg...... 38 cefprozil for susp 125 mg/5ml...... 1 brimonidine tartrate ophth soln 0.2%...... 40 cefprozil tab 250 mg...... 1 bumetanide tab 0.5 mg...... 20 cefprozil tab 500 mg...... 1 bumetanide tab 1 mg...... 20 cefuroxime axetil tab 500 mg...... 1 bumetanide tab 2 mg...... 20 cefuroxime axetil tab 250 mg (Ceftin)...... 1 buprenorphine hcl sl tab 2 mg (base equiv)...... 33 celecoxib cap 50 mg (Celebrex)...... 33 bupropion hcl (smoking deterrent) tab er 12hr 150 mg celecoxib cap 100 mg (Celebrex)...... 33 (Zyban)...... 32 celecoxib cap 200 mg (Celebrex)...... 33 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 28 cephalexin cap 250 mg (Keflex)...... 1 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 28 cephalexin cap 500 mg (Keflex)...... 1 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...... 28 cephalexin for susp 125 mg/5ml...... 1 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)...... 28 cephalexin for susp 250 mg/5ml...... 1 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)...... 28 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...... 22 bupropion hcl tab 75 mg (Wellbutrin)...... 28 CHANTIX CONTINUING MONTH – varenicline tartrate tab bupropion hcl tab 100 mg (Wellbutrin)...... 28 1 mg (base equiv)...... 33 buspirone hcl tab 5 mg...... 28 CHANTIX STARTING MONTH PA – varenicline tartrate buspirone hcl tab 7.5 mg...... 28 tab 0.5 mg x 11 & tab 1 mg x 42 pack...... 33 buspirone hcl tab 10 mg...... 28 CHANTIX – varenicline tartrate tab 0.5 mg (base buspirone hcl tab 15 mg...... 28 equiv)...... 32 buspirone hcl tab 30 mg...... 28 CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 32

Tiered Generics Prescription Drug Guide October 2019 48 2019

CHEMET – succimer cap 100 mg...... 44 clonidine hcl tab 0.1 mg (Catapres)...... 21 CHENODAL – chenodiol tab 250 mg...... 27 clonidine hcl tab 0.2 mg (Catapres)...... 21 chlordiazepoxide hcl cap 5 mg...... 28 clonidine hcl tab 0.3 mg (Catapres)...... 21 chlordiazepoxide hcl cap 10 mg...... 28 clopidogrel bisulfate tab 75 mg (base equiv) chlordiazepoxide hcl cap 25 mg...... 28 (Plavix)...... 38 chlorhexidine gluconate soln 0.12% (Peridex)...... 41 clotrimazole troche 10 mg...... 41 CHLOROQUINE PHOSPHATE – chloroquine phosphate clotrimazole w/ betamethasone cream 1-0.05% tab 250 mg...... 4 (Lotrisone)...... 41 chloroquine phosphate tab 500 mg (Aralen)...... 4 clozapine tab 25 mg (Clozaril)...... 30 chlorothiazide tab 500 mg...... 20 CODEINE SULFATE – codeine sulfate tab 60 mg...... 33 chlorthalidone tab 25 mg...... 20 colchicine w/ probenecid tab 0.5-500 mg...... 35 chlorthalidone tab 50 mg...... 20 colestipol hcl granule packets 5 gm (Colestid CHLORZOXAZONE – chlorzoxazone tab 500 mg...... 37 flavored)...... 20 choline fenofibrate cap dr 45 mg (fenofibric acid COMBIVENT RESPIMAT – ipratropium-albuterol inhal equiv) (Trilipix)...... 20 aerosol soln 20-100 mcg/act...... 24 CHORIONIC GONADOTROPIN – chorionic gonadotropin COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 for im inj 10000 unit...... 10 mg dose) kit...... 5 ciclopirox olamine cream 0.77% (base equiv)...... 41 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 ciclopirox solution 8% (Penlac nail lacquer)...... 41 mg (100 dose) kit...... 5 cilostazol tab 50 mg (Pletal)...... 38 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 cilostazol tab 100 mg (Pletal)...... 38 mg (140 dose) kit...... 5 CIMDUO – lamivudine-tenofovir disoproxil fumarate tab CONCERTA – methylphenidate hcl tab er osmotic release 300-300 mg...... 3 (osm) 18 mg...... 31 CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml...... 25 CONCERTA – methylphenidate hcl tab er osmotic release cimetidine tab 200 mg...... 25 (osm) 27 mg...... 31 cimetidine tab 300 mg...... 25 CONCERTA – methylphenidate hcl tab er osmotic release cimetidine tab 400 mg...... 25 (osm) 36 mg...... 31 CIPRODEX – ciprofloxacin-dexamethasone otic susp CONCERTA – methylphenidate hcl tab er osmotic release 0.3-0.1%...... 41 (osm) 54 mg...... 31 ciprofloxacin hcl ophth soln 0.3% (base equivalent) CONTOUR BLOOD GLUCOSE MON – blood glucose (Ciloxan)...... 39 monitoring devices...... 43 ciprofloxacin hcl tab 750 mg (base equiv)...... 2 CONTOUR BLOOD GLUCOSE TES – glucose blood test ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 2 strip...... 43 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 2 CONTOUR HIGH CONTROL – blood glucose calibration - citalopram hydrobromide tab 10 mg (base equiv) liquid - high...... 43 (Celexa)...... 28 CONTOUR LOW CONTROL – blood glucose calibration - citalopram hydrobromide tab 20 mg (base equiv) liquid - low...... 43 (Celexa)...... 28 CONTOUR NEXT BLOOD GLUCOS – blood glucose citalopram hydrobromide tab 40 mg (base equiv) monitoring kit w/ device...... 43 (Celexa)...... 29 CONTOUR NEXT BLOOD GLUCOS – glucose blood test clarithromycin tab 250 mg...... 2 strip...... 43 clarithromycin tab 500 mg (Biaxin)...... 2 CONTOUR NEXT CONTROL LEVE – blood glucose CLIMARA PRO – estradiol-levonorgestrel td patch weekly calibration - liquid - low...... 43 0.045-0.015 mg/day...... 9 CONTOUR NEXT CONTROL LEVE – blood glucose clindamycin hcl cap 75 mg (Cleocin)...... 4 calibration - liquid - normal...... 43 clindamycin hcl cap 150 mg (Cleocin)...... 4 CONTOUR NEXT EZ BLOOD GLU – blood glucose clindamycin hcl cap 300 mg (Cleocin)...... 4 monitoring kit w/ device...... 43 clindamycin phosphate swab 1% (Cleocin-t)...... 41 CONTOUR NEXT LINK BLOOD G – blood glucose CLOMIPHENE CITRATE – clomiphene citrate tab 50 monitoring kit w/ device...... 43 mg...... 10 CONTOUR NEXT LINK WIRELES – blood glucose clonazepam orally disintegrating tab 0.125 mg...... 35 monitoring kit w/ device...... 43 clonazepam orally disintegrating tab 0.25 mg...... 35 CONTOUR NEXT ONE BLOOD GL – blood glucose clonazepam orally disintegrating tab 0.5 mg...... 35 monitoring kit...... 43 clonazepam tab 0.5 mg (Klonopin)...... 35 CONTOUR NORMAL CONTROL – blood glucose clonazepam tab 1 mg (Klonopin)...... 35 calibration - liquid - normal...... 43 clonazepam tab 2 mg (Klonopin)...... 35

Tiered Generics Prescription Drug Guide October 2019 49 2019

CORTIFOAM – hydrocortisone acetate rectal foam 10% desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (90 mg/dose)...... 41 (Desogen)...... 9 CORTISONE ACETATE – cortisone acetate tab 25 mg...... 8 DEXAMETHASONE – dexamethasone tab 1 mg...... 8 CORTISPORIN – bacitracin-polymyxin-neomycin hc oint DEXAMETHASONE – dexamethasone tab 2 mg...... 8 1%...... 41 dexamethasone elixir 0.5 mg/5ml...... 8 CORTISPORIN – neomycin-polymyxin-hc crm 3.5 mg/ dexamethasone tab 0.5 mg...... 8 gm-10000 unt/gm-0.5%...... 41 dexamethasone tab 0.75 mg...... 8 COSENTYX – secukinumab subcutaneous soln prefilled dexamethasone tab 1.5 mg...... 8 syringe 150 mg/ml...... 42 dexamethasone tab 4 mg...... 8 COSENTYX SENSOREADY PEN – secukinumab dexamethasone tab 6 mg...... 8 subcutaneous soln auto-injector 150 mg/ml...... 42 DIASTAT ACUDIAL – diazepam rectal gel delivery system COTELLIC – cobimetinib fumarate tab 20 mg (base 10 mg...... 36 equivalent)...... 5 DIASTAT ACUDIAL – diazepam rectal gel delivery system CREON – pancrelipase (lip-prot-amyl) dr cap 20 mg...... 36 3000-9500-15000 unit...... 26 DIASTAT PEDIATRIC – diazepam rectal gel delivery CREON – pancrelipase (lip-prot-amyl) dr cap system 2.5 mg...... 36 6000-19000-30000 unit...... 26 diazepam tab 2 mg (Valium)...... 28 CREON – pancrelipase (lip-prot-amyl) dr cap diazepam tab 5 mg (Valium)...... 28 12000-38000-60000 unit...... 26 diazepam tab 10 mg (Valium)...... 28 CREON – pancrelipase (lip-prot-amyl) dr cap diclofenac potassium tab 50 mg (Cataflam)...... 33 24000-76000-120000 unit...... 26 diclofenac sodium ophth soln 0.1%...... 40 CREON – pancrelipase (lip-prot-amyl) dr cap diclofenac sodium tab delayed release 50 mg...... 33 36000-114000-180000 unit...... 26 diclofenac sodium tab delayed release 75 mg...... 33 cromolyn sodium ophth soln 4%...... 40 diclofenac sodium tab er 24hr 100 mg...... 33 cyanocobalamin inj 1000 mcg/ml...... 38 dicloxacillin sodium cap 250 mg...... 1 cyclobenzaprine hcl tab 5 mg...... 37 dicloxacillin sodium cap 500 mg...... 1 cyclobenzaprine hcl tab 10 mg...... 37 dicyclomine hcl cap 10 mg (Bentyl)...... 25 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)...... 40 dicyclomine hcl oral soln 10 mg/5ml...... 25 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 40 dicyclomine hcl tab 20 mg (Bentyl)...... 25 cyclopentolate hcl ophth soln 2% (Cyclogyl)...... 40 DIFFERIN – adapalene lotion 0.1%...... 41 CYCLOSPORINE MODIFIED – cyclosporine modified cap digoxin tab 125 mcg (0.125 mg) (Lanoxin)...... 21 50 mg...... 44 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...... 21 cyproheptadine hcl syrup 2 mg/5ml...... 22 DILANTIN – phenytoin sodium extended cap 30 mg...... 36 cyproheptadine hcl tab 4 mg...... 22 DILANTIN – phenytoin sodium extended cap 100 mg...... 36 CYSTADANE – betaine powder for oral solution...... 15 diltiazem hcl cap er 24hr 180 mg...... 18 CYSTAGON – cysteamine bitartrate cap 50 mg...... 28 diltiazem hcl cap er 24hr 240 mg...... 18 CYSTAGON – cysteamine bitartrate cap 150 mg...... 28 diltiazem hcl coated beads cap er 24hr 300 mg...... 18 D diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd)...... 18 dapsone tab 25 mg...... 4 diltiazem hcl coated beads cap er 24hr 180 mg dapsone tab 100 mg...... 4 (Cardizem cd)...... 18 DARAPRIM – pyrimethamine tab 25 mg...... 4 diltiazem hcl coated beads cap er 24hr 240 mg DDAVP – desmopressin acetate nasal soln 0.01% (Cardizem cd)...... 18 (refrigerated)...... 15 diltiazem hcl extended release beads cap er 24hr 120 DELSTRIGO – doravirine-lamivudine-tenofovir df tab mg (Tiazac)...... 18 100-300-300 mg...... 3 diltiazem hcl extended release beads cap er 24hr 180 DELZICOL – mesalamine cap dr 400 mg...... 27 mg (Tiazac)...... 18 DEPEN TITRATABS – penicillamine tab 250 mg...... 44 diltiazem hcl extended release beads cap er 24hr 240 DESCOVY – emtricitabine-tenofovir alafenamide fumarate mg (Tiazac)...... 18 tab 200-25 mg...... 3 diltiazem hcl extended release beads cap er 24hr 300 desloratadine tab 5 mg (Clarinex)...... 22 mg (Tiazac)...... 18 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 diltiazem hcl extended release beads cap er 24hr 360 mg(21/5) (Mircette)...... 9 mg (Tiazac)...... 18 desogest-ethin est tab diltiazem hcl extended release beads cap er 24hr 420 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)...... 9 mg (Tiazac)...... 18 diltiazem hcl tab 90 mg...... 18

Tiered Generics Prescription Drug Guide October 2019 50 2019 diltiazem hcl tab 30 mg (Cardizem)...... 18 duloxetine hcl enteric coated pellets cap 30 mg (base diltiazem hcl tab 60 mg (Cardizem)...... 18 eq) (Cymbalta)...... 29 diltiazem hcl tab 120 mg (Cardizem)...... 18 duloxetine hcl enteric coated pellets cap 60 mg (base DILT-XR – diltiazem hcl cap er 24hr 120 mg...... 18 eq) (Cymbalta)...... 29 diphenoxylate w/ atropine tab 2.5-0.025 mg dutasteride cap 0.5 mg (Avodart)...... 28 (Lomotil)...... 25 E dipyridamole tab 25 mg (Persantine)...... 38 dipyridamole tab 50 mg (Persantine)...... 38 ELIDEL – pimecrolimus cream 1%...... 42 divalproex sodium tab delayed release 125 mg ELIQUIS – apixaban tab 2.5 mg...... 38 (Depakote)...... 36 ELIQUIS – apixaban tab 5 mg...... 38 divalproex sodium tab delayed release 250 mg ELIQUIS STARTER PACK – apixaban tab 5 mg...... 38 (Depakote)...... 36 ELLA – ulipristal acetate tab 30 mg...... 10 divalproex sodium tab delayed release 500 mg EMCYT – estramustine phosphate sodium cap 140 mg...... 5 (Depakote)...... 36 EMEND – aprepitant for oral susp 125 mg (125 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...... 9 mg/5ml)...... 26 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...... 9 EMGALITY – galcanezumab-gnlm subcutaneous soln DIVIGEL – estradiol td gel 0.75 mg/0.75gm (0.1%)...... 9 auto-injector 120 mg/ml...... 35 DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...... 9 EMGALITY – galcanezumab-gnlm subcutaneous soln donepezil hydrochloride orally disintegrating tab 5 mg prefilled syr 120 mg/ml...... 35 (Aricept odt)...... 33 enalapril maleate & hydrochlorothiazide tab 5-12.5 donepezil hydrochloride orally disintegrating tab 10 mg...... 16 mg (Aricept odt)...... 33 enalapril maleate & hydrochlorothiazide tab 10-25 mg donepezil hydrochloride tab 5 mg (Aricept)...... 33 (Vaseretic)...... 16 donepezil hydrochloride tab 10 mg (Aricept)...... 33 enalapril maleate tab 2.5 mg (Vasotec)...... 16 dorzolamide hcl ophth soln 2% (Trusopt)...... 40 enalapril maleate tab 5 mg (Vasotec)...... 16 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 enalapril maleate tab 10 mg (Vasotec)...... 16 mg/ml (Cosopt)...... 40 enalapril maleate tab 20 mg (Vasotec)...... 16 doxazosin mesylate tab 1 mg (Cardura)...... 21 ENBREL – etanercept for subcutaneous inj 25 mg...... 33 doxazosin mesylate tab 2 mg (Cardura)...... 21 ENBREL – etanercept subcutaneous soln prefilled syringe doxazosin mesylate tab 4 mg (Cardura)...... 21 25 mg/0.5ml...... 33 doxazosin mesylate tab 8 mg (Cardura)...... 21 ENBREL – etanercept subcutaneous soln prefilled syringe doxepin hcl cap 10 mg...... 29 50 mg/ml...... 33 doxepin hcl cap 25 mg...... 29 ENBREL MINI – etanercept subcutaneous solution doxepin hcl cap 50 mg...... 29 cartridge 50 mg/ml...... 33 doxepin hcl cap 100 mg...... 29 ENBREL SURECLICK – etanercept subcutaneous doxepin hcl conc 10 mg/ml...... 29 solution auto-injector 50 mg/ml...... 33 DOXEPIN HCL – doxepin hcl cap 150 mg...... 29 ENDOMETRIN – progesterone vaginal insert 100 mg...... 27 doxycycline hyclate cap 50 mg...... 2 ENSTILAR – calcipotriene-betamethasone dipropionate doxycycline hyclate cap 100 mg (Vibramycin)...... 2 foam 0.005-0.064%...... 42 doxycycline hyclate tab 20 mg...... 2 ENTRESTO – sacubitril-valsartan tab 24-26 mg...... 18 doxycycline hyclate tab 100 mg...... 2 ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 19 doxycycline monohydrate cap 50 mg...... 2 ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 19 doxycycline monohydrate cap 100 mg (Monodox)...... 2 EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg...... 2 doxycycline monohydrate tab 75 mg...... 2 EPIDIOLEX – cannabidiol soln 100 mg/ml...... 36 doxycycline monohydrate tab 50 mg (Adoxa)...... 2 epinastine hcl ophth soln 0.05% (Elestat)...... 40 doxycycline monohydrate tab 100 mg (Adoxa pak EPINEPHRINE (Mylan products) – epinephrine solution 1/100)...... 2 auto-injector 0.15 mg/0.3ml (1:2000)...... 22 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin epinephrine solution auto-injector 0.3 mg/0.3ml 28)...... 10 (1:1000) (Epipen 2-pak)...... 22 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)...... 9 EPOGEN – epoetin alfa inj 2000 unit/ml...... 38 DULERA – mometasone furoate-formoterol fumarate EPOGEN – epoetin alfa inj 3000 unit/ml...... 38 aerosol 100-5 mcg/act...... 24 EPOGEN – epoetin alfa inj 4000 unit/ml...... 38 DULERA – mometasone furoate-formoterol fumarate EPOGEN – epoetin alfa inj 10000 unit/ml...... 38 aerosol 200-5 mcg/act...... 24 EPOGEN – epoetin alfa inj 20000 unit/ml...... 38 duloxetine hcl enteric coated pellets cap 20 mg (base ergocalciferol cap 50000 unit (Drisdol)...... 37 eq) (Cymbalta)...... 29 ERIVEDGE – vismodegib cap 150 mg...... 5

Tiered Generics Prescription Drug Guide October 2019 51 2019

ERLEADA – apalutamide tab 60 mg...... 5 FIASP – insulin aspart (with niacinamide) inj 100 unit/ erythromycin ophth oint 5 mg/gm...... 39 ml...... 13 erythromycin soln 2%...... 41 FINACEA – azelaic acid foam 15%...... 41 escitalopram oxalate tab 5 mg (base equiv) finasteride tab 5 mg (Proscar)...... 28 (Lexapro)...... 29 FINGERSTIX LANCETS – lancets...... 43 escitalopram oxalate tab 10 mg (base equiv) FIRAZYR – icatibant acetate inj 30 mg/3ml (base (Lexapro)...... 29 equivalent)...... 38 escitalopram oxalate tab 20 mg (base equiv) flecainide acetate tab 50 mg...... 21 (Lexapro)...... 29 flecainide acetate tab 100 mg...... 21 estazolam tab 1 mg...... 31 flecainide acetate tab 150 mg...... 21 estazolam tab 2 mg...... 31 FLOVENT DISKUS – fluticasone propionate aer pow ba estradiol tab 0.5 mg (Estrace)...... 9 50 mcg/blister...... 24 estradiol tab 1 mg (Estrace)...... 9 FLOVENT DISKUS – fluticasone propionate aer pow ba estradiol tab 2 mg (Estrace)...... 9 100 mcg/blister...... 24 eszopiclone tab 1 mg (Lunesta)...... 31 FLOVENT DISKUS – fluticasone propionate aer pow ba eszopiclone tab 2 mg (Lunesta)...... 31 250 mcg/blister...... 24 eszopiclone tab 3 mg (Lunesta)...... 31 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 ethambutol hcl tab 100 mg (Myambutol)...... 2 mcg/act (125/valve)...... 24 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg...... 10 mcg/act (250/valve)...... 24 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg...... 10 mcg/act (50/valve)...... 24 etodolac cap 200 mg...... 33 fluconazole for susp 10 mg/ml (Diflucan)...... 2 etodolac tab 400 mg...... 33 fluconazole for susp 40 mg/ml (Diflucan)...... 2 etodolac tab 500 mg...... 33 fluconazole tab 50 mg (Diflucan)...... 2 ETOPOSIDE – etoposide cap 50 mg...... 5 fluconazole tab 100 mg (Diflucan)...... 2 EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg fluconazole tab 150 mg (Diflucan)...... 2 (base equiv)...... 3 fluconazole tab 200 mg (Diflucan)...... 2 F fludrocortisone acetate tab 0.1 mg...... 8 fluoxetine hcl cap 10 mg (Prozac)...... 29 famciclovir tab 125 mg (Famvir)...... 3 fluoxetine hcl cap 20 mg (Prozac)...... 29 famciclovir tab 250 mg (Famvir)...... 3 fluoxetine hcl cap 40 mg (Prozac)...... 29 famciclovir tab 500 mg (Famvir)...... 3 fluoxetine hcl solution 20 mg/5ml...... 29 famotidine tab 20 mg (Pepcid)...... 25 fluoxetine hcl tab 10 mg...... 29 famotidine tab 40 mg (Pepcid)...... 25 FLUPHENAZINE HCL – fluphenazine hcl tab 1 mg...... 30 FARESTON – toremifene citrate tab 60 mg (base flurbiprofen tab 50 mg...... 33 equivalent)...... 5 flurbiprofen tab 100 mg...... 34 FARYDAK – panobinostat lactate cap 10 mg (base FLUTICASONE PROPIONATE/SA – fluticasone- equivalent)...... 5 salmeterol aer powder ba 55-14 mcg/act...... 24 FARYDAK – panobinostat lactate cap 15 mg (base FLUTICASONE PROPIONATE/SA – fluticasone- equivalent)...... 5 salmeterol aer powder ba 113-14 mcg/act...... 24 FARYDAK – panobinostat lactate cap 20 mg (base FLUTICASONE PROPIONATE/SA – fluticasone- equivalent)...... 5 salmeterol aer powder ba 232-14 mcg/act...... 24 felodipine tab er 24hr 2.5 mg...... 19 fluticasone propionate cream 0.05% (Cutivate)...... 42 felodipine tab er 24hr 5 mg...... 19 fluticasone propionate nasal susp 50 mcg/act felodipine tab er 24hr 10 mg...... 19 (Flonase)...... 22 fenofibrate micronized cap 43 mg...... 20 fluticasone propionate oint 0.005% (Cutivate)...... 42 fenofibrate micronized cap 67 mg (Lofibra)...... 20 fluvoxamine maleate tab 25 mg...... 29 fenofibrate micronized cap 134 mg (Lofibra)...... 20 fluvoxamine maleate tab 50 mg...... 29 fenofibrate tab 54 mg (Lofibra)...... 20 fluvoxamine maleate tab 100 mg...... 29 fenofibrate tab 160 mg (Lofibra)...... 20 folic acid tab 1 mg...... 38 fenofibrate tab 48 mg (Tricor)...... 20 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml...... 10 fenofibrate tab 145 mg (Tricor)...... 20 FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml...... 10 FIASP FLEXTOUCH – insulin aspart (with niacinamide) FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml...... 10 sol pen-inj 100 unit/ml...... 13 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg...... 16

Tiered Generics Prescription Drug Guide October 2019 52 2019 fosinopril sodium & hydrochlorothiazide tab 20-12.5 glyburide tab 2.5 mg...... 11 mg...... 16 glyburide tab 5 mg...... 11 fosinopril sodium tab 10 mg...... 16 glycopyrrolate tab 1 mg (Robinul)...... 25 fosinopril sodium tab 20 mg...... 16 glycopyrrolate tab 2 mg (Robinul forte)...... 25 fosinopril sodium tab 40 mg...... 16 GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg...... 11 FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg...... 11 mg/0.6ml...... 38 granisetron hcl tab 1 mg...... 26 furosemide oral soln 10 mg/ml...... 20 GRANIX – tbo-filgrastim soln prefilled syringe 300 furosemide tab 20 mg (Lasix)...... 20 mcg/0.5ml...... 38 furosemide tab 40 mg (Lasix)...... 20 GRANIX – tbo-filgrastim soln prefilled syringe 480 furosemide tab 80 mg (Lasix)...... 20 mcg/0.8ml...... 38 GRANIX – tbo-filgrastim subcutaneous inj 300 mcg/ml..... 38 G GRANIX – tbo-filgrastim subcutaneous inj 480 mcg/1.6ml gabapentin cap 100 mg (Neurontin)...... 36 (300 mcg/ml)...... 38 gabapentin cap 300 mg (Neurontin)...... 36 guaifenesin-codeine soln 100-10 mg/5ml...... 22 gabapentin cap 400 mg (Neurontin)...... 36 guanfacine hcl tab er 24hr 1 mg (base equiv) gabapentin tab 600 mg (Neurontin)...... 36 (Intuniv)...... 31 gabapentin tab 800 mg (Neurontin)...... 36 guanfacine hcl tab er 24hr 2 mg (base equiv) GANIRELIX ACETATE – ganirelix acetate inj 250 (Intuniv)...... 31 mcg/0.5ml...... 11 guanfacine hcl tab er 24hr 3 mg (base equiv) gemfibrozil tab 600 mg (Lopid)...... 20 (Intuniv)...... 31 gentamicin sulfate cream 0.1%...... 41 guanfacine hcl tab er 24hr 4 mg (base equiv) gentamicin sulfate ophth soln 0.3% (Garamycin)...... 39 (Intuniv)...... 31 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab guanfacine hcl tab 1 mg (Tenex)...... 21 150-150-200-10 mg...... 3 guanfacine hcl tab 2 mg (Tenex)...... 21 GILENYA – fingolimod hcl cap 0.5 mg (base equiv)...... 32 GILOTRIF – afatinib dimaleate tab 20 mg (base H equivalent)...... 5 HAEGARDA – c1 esterase inhibitor (human) for GILOTRIF – afatinib dimaleate tab 30 mg (base subcutaneous inj 2000 unit...... 38 equivalent)...... 5 HAEGARDA – c1 esterase inhibitor (human) for GILOTRIF – afatinib dimaleate tab 40 mg (base subcutaneous inj 3000 unit...... 38 equivalent)...... 5 haloperidol decanoate im soln 50 mg/ml (Haldol GLEOSTINE – lomustine cap 10 mg...... 5 decanoate 50)...... 30 GLEOSTINE – lomustine cap 40 mg...... 5 haloperidol lactate inj 5 mg/ml (Haldol)...... 30 GLEOSTINE – lomustine cap 100 mg...... 6 haloperidol lactate oral conc 2 mg/ml...... 30 glimepiride tab 1 mg (Amaryl)...... 11 haloperidol tab 0.5 mg...... 30 glimepiride tab 2 mg (Amaryl)...... 11 haloperidol tab 1 mg...... 30 glimepiride tab 4 mg (Amaryl)...... 11 haloperidol tab 2 mg...... 30 glipizide-metformin hcl tab 2.5-250 mg...... 11 haloperidol tab 5 mg...... 30 glipizide-metformin hcl tab 2.5-500 mg...... 11 haloperidol tab 10 mg...... 30 glipizide-metformin hcl tab 5-500 mg...... 11 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg...... 2 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 11 HUMIRA – adalimumab prefilled syringe kit 10 glipizide tab er 24hr 5 mg (Glucotrol xl)...... 11 mg/0.1ml...... 34 glipizide tab er 24hr 10 mg (Glucotrol xl)...... 11 HUMIRA – adalimumab prefilled syringe kit 10 glipizide tab 5 mg (Glucotrol)...... 11 mg/0.2ml...... 34 glipizide tab 10 mg (Glucotrol)...... 11 HUMIRA – adalimumab prefilled syringe kit 20 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj mg/0.2ml...... 34 kit 1 mg...... 11 HUMIRA – adalimumab prefilled syringe kit 20 glyburide-metformin tab 1.25-250 mg mg/0.4ml...... 34 (Glucovance)...... 11 HUMIRA – adalimumab prefilled syringe kit 40 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 11 mg/0.8ml...... 34 glyburide-metformin tab 5-500 mg (Glucovance)...... 11 HUMIRA – adalimumab prefilled syringe kit 40 glyburide micronized tab 1.5 mg (Glynase)...... 11 mg/0.4ml...... 34 glyburide micronized tab 3 mg (Glynase)...... 11 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled glyburide micronized tab 6 mg (Glynase)...... 11 syringe kit 40 mg/0.8ml...... 34 glyburide tab 1.25 mg...... 11

Tiered Generics Prescription Drug Guide October 2019 53 2019

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled ILARIS – canakinumab subcutaneous inj 150 mg/ml...... 34 syringe kit 80 mg/0.8ml...... 34 IMBRUVICA – ibrutinib cap 70 mg...... 6 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled IMBRUVICA – ibrutinib cap 140 mg...... 6 syringe kit 80 mg/0.8ml & 40 mg/0.4ml...... 34 IMBRUVICA – ibrutinib tab 140 mg...... 6 HUMIRA PEN – adalimumab pen-injector kit 40 IMBRUVICA – ibrutinib tab 280 mg...... 6 mg/0.8ml...... 34 IMBRUVICA – ibrutinib tab 420 mg...... 6 HUMIRA PEN – adalimumab pen-injector kit 40 IMBRUVICA – ibrutinib tab 560 mg...... 6 mg/0.4ml...... 34 imipramine hcl tab 10 mg (Tofranil)...... 29 HUMIRA PEN-CD/UC/HS START – adalimumab pen- imipramine hcl tab 25 mg (Tofranil)...... 29 injector kit 40 mg/0.8ml...... 34 imipramine hcl tab 50 mg (Tofranil)...... 29 HUMIRA PEN-CD/UC/HS START – adalimumab pen- IMPAVIDO – miltefosine cap 50 mg...... 4 injector kit 80 mg/0.8ml...... 34 INBRIJA – levodopa inhal powder cap 42 mg...... 37 HUMIRA PEN-PS/UV STARTER – adalimumab pen- INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 14 injector kit 40 mg/0.8ml...... 34 INCRUSE ELLIPTA – umeclidinium br aero powd breath HUMIRA PEN-PS/UV STARTER – adalimumab pen- act 62.5 mcg/inh (base eq)...... 24 injector kit 80 mg/0.8ml & 40 mg/0.4ml...... 34 indapamide tab 1.25 mg...... 20 HUMULIN R U-500 (CONCENTR – insulin regular indapamide tab 2.5 mg...... 20 (human) inj 500 unit/ml...... 13 indomethacin cap er 75 mg...... 34 HUMULIN R U-500 KWIKPEN – insulin regular (human) indomethacin cap 25 mg...... 34 soln pen-injector 500 unit/ml...... 13 indomethacin cap 50 mg...... 34 HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)...... 6 INLYTA – axitinib tab 1 mg...... 6 HYCAMTIN – topotecan hcl cap 1 mg (base equiv)...... 6 INLYTA – axitinib tab 5 mg...... 6 hydralazine hcl tab 10 mg...... 21 INTELENCE – etravirine tab 25 mg...... 3 hydralazine hcl tab 25 mg...... 21 INTELENCE – etravirine tab 100 mg...... 3 hydralazine hcl tab 50 mg...... 21 INTELENCE – etravirine tab 200 mg...... 3 hydralazine hcl tab 100 mg...... 21 INVOKAMET – canagliflozin-metformin hcl tab 50-500 hydrochlorothiazide cap 12.5 mg (Microzide)...... 20 mg...... 11 hydrochlorothiazide tab 12.5 mg...... 20 INVOKAMET – canagliflozin-metformin hcl tab 50-1000 hydrochlorothiazide tab 25 mg...... 20 mg...... 11 hydrochlorothiazide tab 50 mg...... 20 INVOKAMET – canagliflozin-metformin hcl tab 150-500 hydrocortisone cream 2.5%...... 42 mg...... 11 hydrocortisone lotion 2.5%...... 42 INVOKAMET – canagliflozin-metformin hcl tab 150-1000 hydrocortisone oint 2.5%...... 42 mg...... 12 hydrocortisone rectal cream 1% (Proctocort)...... 41 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydrocortisone tab 5 mg (Cortef)...... 8 50-500 mg...... 12 hydrocortisone tab 10 mg (Cortef)...... 8 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydrocortisone tab 20 mg (Cortef)...... 8 50-1000 mg...... 12 hydroxyurea cap 500 mg (Hydrea)...... 6 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydroxyzine hcl syrup 10 mg/5ml...... 28 150-500 mg...... 12 hydroxyzine hcl tab 10 mg...... 28 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydroxyzine hcl tab 25 mg...... 28 150-1000 mg...... 12 hydroxyzine hcl tab 50 mg...... 28 INVOKANA – canagliflozin tab 100 mg...... 12 hydroxyzine pamoate cap 25 mg (Vistaril)...... 28 INVOKANA – canagliflozin tab 300 mg...... 12 hydroxyzine pamoate cap 50 mg (Vistaril)...... 28 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 24 I ipratropium bromide inhal soln 0.02%...... 24 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ibandronate sodium tab 150 mg (base equivalent) (Atrovent)...... 22 (Boniva)...... 15 ipratropium bromide nasal soln 0.06% (42 mcg/spray) IBRANCE – palbociclib cap 75 mg...... 6 (Atrovent)...... 22 IBRANCE – palbociclib cap 100 mg...... 6 irbesartan-hydrochlorothiazide tab 150-12.5 mg IBRANCE – palbociclib cap 125 mg...... 6 (Avalide)...... 16 ibuprofen tab 400 mg...... 34 irbesartan-hydrochlorothiazide tab 300-12.5 mg ibuprofen tab 600 mg...... 34 (Avalide)...... 16 ibuprofen tab 800 mg...... 34 irbesartan tab 75 mg (Avapro)...... 16 ICLUSIG – ponatinib hcl tab 15 mg (base equiv)...... 6 irbesartan tab 150 mg (Avapro)...... 16 ICLUSIG – ponatinib hcl tab 45 mg (base equiv)...... 6 irbesartan tab 300 mg (Avapro)...... 16

Tiered Generics Prescription Drug Guide October 2019 54 2019

IRESSA – gefitinib tab 250 mg...... 6 KALETRA – lopinavir-ritonavir tab 200-50 mg...... 3 ISENTRESS HD – raltegravir potassium tab 600 mg (base KALYDECO – ivacaftor packet 25 mg...... 25 equiv)...... 3 KALYDECO – ivacaftor packet 50 mg...... 25 ISENTRESS – raltegravir potassium chew tab 25 mg KALYDECO – ivacaftor packet 75 mg...... 25 (base equiv)...... 3 KALYDECO – ivacaftor tab 150 mg...... 25 ISENTRESS – raltegravir potassium chew tab 100 mg ketoconazole shampoo 2% (Nizoral)...... 41 (base equiv)...... 3 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ ISENTRESS – raltegravir potassium packet for susp 100 ml)...... 34 mg (base equiv)...... 3 ketorolac tromethamine inj 15 mg/ml...... 34 ISENTRESS – raltegravir potassium tab 400 mg (base ketorolac tromethamine inj 30 mg/ml...... 34 equiv)...... 3 ketorolac tromethamine ophth soln 0.5% (Acular)...... 41 isoniazid tab 100 mg...... 2 ketorolac tromethamine tab 10 mg...... 34 isoniazid tab 300 mg...... 2 KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30 (200 mg tab) & letrozole 2.5 mg tbpk...... 6 mg...... 19 KISQALI FEMARA 400 DOSE – ribociclib 400 mg dose isosorbide dinitrate tab 5 mg (Isordil titradose)...... 19 (200 mg tab) & letrozole 2.5 mg tbpk...... 6 isosorbide mononitrate tab er 24hr 30 mg...... 19 KISQALI FEMARA 600 DOSE – ribociclib 600 mg dose isosorbide mononitrate tab er 24hr 60 mg...... 19 (200 mg tab) & letrozole 2.5 mg tbpk...... 6 isosorbide mononitrate tab er 24hr 120 mg...... 19 KISQALI – ribociclib succinate tab pack 200 mg daily isosorbide mononitrate tab 10 mg...... 19 dose...... 6 isosorbide mononitrate tab 20 mg...... 19 KISQALI – ribociclib succinate tab pack 400 mg daily dose ivermectin tab 3 mg (Stromectol)...... 4 (200 mg tab)...... 6 KISQALI – ribociclib succinate tab pack 600 mg daily dose J (200 mg tab)...... 6 JADENU – deferasirox tab 90 mg...... 44 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr JADENU – deferasirox tab 180 mg...... 44 2.5-1000 mg...... 12 JADENU – deferasirox tab 360 mg...... 44 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr JAKAFI – ruxolitinib phosphate tab 5 mg (base 5-500 mg...... 12 equivalent)...... 6 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr JAKAFI – ruxolitinib phosphate tab 10 mg (base 5-1000 mg...... 12 equivalent)...... 6 JAKAFI – ruxolitinib phosphate tab 15 mg (base L equivalent)...... 6 labetalol hcl tab 300 mg...... 17 JAKAFI – ruxolitinib phosphate tab 20 mg (base labetalol hcl tab 100 mg (Trandate)...... 17 equivalent)...... 6 labetalol hcl tab 200 mg (Trandate)...... 17 JAKAFI – ruxolitinib phosphate tab 25 mg (base lactic acid (ammonium lactate) cream 12% (Lac- equivalent)...... 6 hydrin)...... 42 JANUMET – sitagliptin-metformin hcl tab 50-500 mg...... 12 lactulose (encephalopathy) solution 10 gm/15ml...... 27 JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 12 lactulose solution 10 gm/15ml...... 25 JANUMET XR – sitagliptin-metformin hcl tab er 24hr lamotrigine tab chewable dispersible 5 mg (Lamictal 50-500 mg...... 12 chewable di)...... 36 JANUMET XR – sitagliptin-metformin hcl tab er 24hr lamotrigine tab chewable dispersible 25 mg (Lamictal 50-1000 mg...... 12 chewable di)...... 36 JANUMET XR – sitagliptin-metformin hcl tab er 24hr lamotrigine tab 25 mg (Lamictal)...... 36 100-1000 mg...... 12 lamotrigine tab 100 mg (Lamictal)...... 36 JANUVIA – sitagliptin phosphate tab 25 mg (base lamotrigine tab 150 mg (Lamictal)...... 36 equiv)...... 12 lamotrigine tab 200 mg (Lamictal)...... 36 JANUVIA – sitagliptin phosphate tab 50 mg (base lansoprazole cap delayed release 15 mg equiv)...... 12 (Prevacid)...... 25 JANUVIA – sitagliptin phosphate tab 100 mg (base lansoprazole cap delayed release 30 mg equiv)...... 12 (Prevacid)...... 25 JARDIANCE – empagliflozin tab 10 mg...... 12 LANTUS – insulin glargine inj 100 unit/ml...... 13 JARDIANCE – empagliflozin tab 25 mg...... 12 LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml...... 13 K latanoprost ophth soln 0.005% (Xalatan)...... 40 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 3

Tiered Generics Prescription Drug Guide October 2019 55 2019

LEDIPASVIR/SOFOSBUVIR – ledipasvir-sofosbuvir tab levothyroxine sodium tab 137 mcg (Synthroid)...... 14 90-400 mg...... 2 levothyroxine sodium tab 150 mcg (Synthroid)...... 14 LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy levothyroxine sodium tab 175 mcg (Synthroid)...... 14 pack 10 & 4 mg (14 mg daily dose)...... 6 levothyroxine sodium tab 200 mcg (Synthroid)...... 14 LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy levothyroxine sodium tab 300 mcg (Synthroid)...... 14 pack 10 & 4 (2) mg (18 mg daily dose)...... 6 lidocaine hcl gel 2%...... 42 LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy lidocaine hcl soln 4% (Xylocaine)...... 42 pack 10 (2) & 4 mg (24 mg daily dose)...... 6 lidocaine hcl urethral/mucosal gel 2%...... 42 LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy lidocaine hcl viscous soln 2%...... 41 pack 10 mg (10 mg daily dose)...... 6 liothyronine sodium tab 5 mcg (Cytomel)...... 14 LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy liothyronine sodium tab 25 mcg (Cytomel)...... 14 pack 4 (3) mg (12 mg daily dose)...... 6 liothyronine sodium tab 50 mcg (Cytomel)...... 14 LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy LIPOFEN – fenofibrate cap 50 mg...... 20 pack 10 (2) mg (20 mg daily dose)...... 6 LIPOFEN – fenofibrate cap 150 mg...... 20 LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy lisinopril & hydrochlorothiazide tab 10-12.5 mg pack 4 mg (4 mg daily dose)...... 6 (Zestoretic)...... 16 LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy lisinopril & hydrochlorothiazide tab 20-12.5 mg pack 4 (2) mg (8 mg daily dose)...... 6 (Zestoretic)...... 16 LETAIRIS – ambrisentan tab 5 mg...... 21 lisinopril & hydrochlorothiazide tab 20-25 mg LETAIRIS – ambrisentan tab 10 mg...... 21 (Zestoretic)...... 16 letrozole tab 2.5 mg (Femara)...... 6 lisinopril tab 5 mg (Prinivil)...... 16 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 lisinopril tab 10 mg (Prinivil)...... 16 mg...... 6 lisinopril tab 20 mg (Prinivil)...... 16 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 lisinopril tab 2.5 mg (Zestril)...... 16 mg...... 7 lisinopril tab 30 mg (Zestril)...... 16 leucovorin calcium tab 5 mg...... 7 lisinopril tab 40 mg (Zestril)...... 16 LEUKERAN – chlorambucil tab 2 mg...... 7 lithium carbonate cap 300 mg...... 30 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector lithium carbonate cap 150 mg (Lithium carbonate)...... 30 100 unit/ml...... 13 lithium carbonate cap 600 mg (Lithium carbonate)...... 30 LEVEMIR – insulin detemir inj 100 unit/ml...... 13 lithium carbonate tab er 450 mg...... 30 levetiracetam oral soln 100 mg/ml (Keppra)...... 36 lithium carbonate tab er 300 mg (Lithobid)...... 30 levetiracetam tab er 24hr 500 mg (Keppra xr)...... 36 lithium carbonate tab 300 mg...... 30 levetiracetam tab 250 mg (Keppra)...... 36 LONSURF – trifluridine-tipiracil tab 15-6.14 mg...... 7 levetiracetam tab 500 mg (Keppra)...... 36 LONSURF – trifluridine-tipiracil tab 20-8.19 mg...... 7 levetiracetam tab 750 mg (Keppra)...... 36 loperamide hcl cap 2 mg...... 25 levetiracetam tab 1000 mg (Keppra)...... 36 lorazepam tab 0.5 mg (Ativan)...... 28 levobunolol hcl ophth soln 0.5% (Betagan)...... 40 lorazepam tab 1 mg (Ativan)...... 28 levocetirizine dihydrochloride tab 5 mg (Xyzal)...... 22 lorazepam tab 2 mg (Ativan)...... 28 levofloxacin tab 250 mg (Levaquin)...... 2 losartan potassium & hydrochlorothiazide tab 50-12.5 levofloxacin tab 500 mg (Levaquin)...... 2 mg (Hyzaar)...... 16 levofloxacin tab 750 mg (Levaquin)...... 2 losartan potassium & hydrochlorothiazide tab 100-12.5 levonorgestrel & ethinyl estradiol (91-day) tab mg (Hyzaar)...... 16 0.15-0.03 mg...... 10 losartan potassium & hydrochlorothiazide tab 100-25 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mg (Hyzaar)...... 17 mcg...... 10 losartan potassium tab 25 mg (Cozaar)...... 17 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 losartan potassium tab 50 mg (Cozaar)...... 17 mcg...... 10 losartan potassium tab 100 mg (Cozaar)...... 17 levonorgestrel-eth estra tab LOTEMAX – loteprednol etabonate ophth gel 0.5%...... 40 0.05-30/0.075-40/0.125-30mg-mcg...... 10 LOTEMAX – loteprednol etabonate ophth oint 0.5%...... 40 levothyroxine sodium tab 25 mcg (Synthroid)...... 14 LOTEMAX – loteprednol etabonate ophth susp 0.5%...... 40 levothyroxine sodium tab 50 mcg (Synthroid)...... 14 LOTEMAX SM – loteprednol etabonate ophth gel levothyroxine sodium tab 75 mcg (Synthroid)...... 14 0.38%...... 40 levothyroxine sodium tab 88 mcg (Synthroid)...... 14 lovastatin tab 10 mg...... 20 levothyroxine sodium tab 100 mcg (Synthroid)...... 14 lovastatin tab 20 mg (Mevacor)...... 20 levothyroxine sodium tab 112 mcg (Synthroid)...... 14 lovastatin tab 40 mg (Mevacor)...... 20 levothyroxine sodium tab 125 mcg (Synthroid)...... 14 loxapine succinate cap 10 mg...... 30

Tiered Generics Prescription Drug Guide October 2019 56 2019 loxapine succinate cap 25 mg...... 30 methimazole tab 5 mg (Tapazole)...... 14 loxapine succinate cap 50 mg...... 30 methimazole tab 10 mg (Tapazole)...... 14 loxapine succinate cap 5 mg (Loxitane)...... 30 methocarbamol tab 750 mg (Robaxin-750)...... 37 LUMIGAN – bimatoprost ophth soln 0.01%...... 40 methocarbamol tab 500 mg (Robaxin)...... 37 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for methotrexate sodium tab 2.5 mg (base equiv)...... 7 inj pediatric kit 7.5 mg...... 11,15 methyldopa tab 250 mg...... 21 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for methyldopa tab 500 mg...... 21 inj pediatric kit 11.25 mg...... 11,15 methylprednisolone tab 4 mg (Medrol)...... 8 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for methylprednisolone tab 8 mg (Medrol)...... 8 inj pediatric kit 15 mg...... 11,15 methylprednisolone tab 16 mg (Medrol)...... 8 LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 methylprednisolone tab 32 mg (Medrol)...... 8 month) for inj pediatric kit 11.25 mg...... 11 methylprednisolone tab therapy pack 4 mg (21) LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 (Medrol dosepak)...... 8 month) for inj pediatric kit 30 mg...... 11 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base LYNPARZA – olaparib tab 100 mg...... 7 equiv)...... 27 LYNPARZA – olaparib tab 150 mg...... 7 metoclopramide hcl tab 5 mg (base equivalent) LYSODREN – mitotane tab 500 mg...... 7 (Reglan)...... 27 M metoclopramide hcl tab 10 mg (base equivalent) (Reglan)...... 27 MATULANE – procarbazine hcl cap 50 mg...... 7 metolazone tab 2.5 mg (Zaroxolyn)...... 21 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg...... 3 metolazone tab 5 mg (Zaroxolyn)...... 21 MAYZENT – siponimod fumarate tab 0.25 mg (base metoprolol & hydrochlorothiazide tab 50-25 mg equiv)...... 32 (Lopressor hct)...... 17 MAYZENT – siponimod fumarate tab 2 mg (base metoprolol & hydrochlorothiazide tab 100-25 mg equiv)...... 32 (Lopressor hct)...... 17 M-CLEAR WC – guaifenesin-codeine soln 100-6.3 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) mg/5ml...... 23 (Toprol xl)...... 17 meclizine hcl tab 12.5 mg...... 26 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) meclizine hcl tab 25 mg...... 26 (Toprol xl)...... 17 medroxyprogesterone acetate im susp 150 mg/ml metoprolol succinate tab er 24hr 100 mg (tartrate (Depo-provera contrac)...... 10 equiv) (Toprol xl)...... 17 medroxyprogesterone acetate im susp prefilled syr metoprolol succinate tab er 24hr 200 mg (tartrate 150 mg/ml (Depo-provera contrac)...... 10 equiv) (Toprol xl)...... 17 medroxyprogesterone acetate tab 2.5 mg (Provera)...... 9 metoprolol tartrate tab 25 mg...... 17 medroxyprogesterone acetate tab 5 mg (Provera)...... 9 metoprolol tartrate tab 50 mg (Lopressor)...... 17 medroxyprogesterone acetate tab 10 mg (Provera)...... 9 metoprolol tartrate tab 100 mg (Lopressor)...... 18 MEFLOQUINE HCL – mefloquine hcl tab 250 mg...... 4 metronidazole tab 250 mg (Flagyl)...... 4 megestrol acetate susp 40 mg/ml (Megace oral)...... 7 metronidazole tab 500 mg (Flagyl)...... 4 megestrol acetate tab 20 mg...... 7 MICROLET LANCETS – lancets...... 43 megestrol acetate tab 40 mg...... 7 midodrine hcl tab 2.5 mg...... 21 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg minocycline hcl cap 50 mg (Minocin)...... 2 (base equivalent)...... 7 minocycline hcl cap 75 mg (Minocin)...... 2 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base minocycline hcl cap 100 mg (Minocin)...... 2 equivalent)...... 7 minoxidil tab 2.5 mg...... 21 meloxicam tab 7.5 mg (Mobic)...... 34 minoxidil tab 10 mg...... 21 meloxicam tab 15 mg (Mobic)...... 34 mirtazapine orally disintegrating tab 15 mg (Remeron memantine hcl tab 5 mg (Namenda)...... 33 soltab)...... 29 memantine hcl tab 10 mg (Namenda)...... 33 mirtazapine orally disintegrating tab 30 mg (Remeron MENOPUR – menotropins for subcutaneous inj 75 soltab)...... 29 unit...... 11 mirtazapine orally disintegrating tab 45 mg (Remeron MENTAX – butenafine hcl cream 1%...... 41 soltab)...... 29 metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 12 mirtazapine tab 15 mg (Remeron)...... 29 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 12 mirtazapine tab 30 mg (Remeron)...... 29 metformin hcl tab 500 mg (Glucophage)...... 12 mirtazapine tab 45 mg (Remeron)...... 29 metformin hcl tab 850 mg (Glucophage)...... 12 misoprostol tab 100 mcg (Cytotec)...... 25 metformin hcl tab 1000 mg (Glucophage)...... 12 misoprostol tab 200 mcg (Cytotec)...... 25

Tiered Generics Prescription Drug Guide October 2019 57 2019

MITIGARE – colchicine cap 0.6 mg...... 35 montelukast sodium chew tab 4 mg (base equiv) moexipril hcl tab 7.5 mg (Univasc)...... 16 (Singulair)...... 24 moexipril hcl tab 15 mg (Univasc)...... 16 montelukast sodium chew tab 5 mg (base equiv) mometasone furoate cream 0.1% (Elocon)...... 42 (Singulair)...... 24 mometasone furoate oint 0.1% (Elocon)...... 42 montelukast sodium tab 10 mg (base equiv) mometasone furoate solution 0.1% (lotion) (Singulair)...... 24 (Elocon)...... 42 MORPHINE SULFATE – morphine sulfate tab 15 mg...... 33 MONOJECT ALLERGIST TRAY/P – allergy tray kit 1/2 ml MORPHINE SULFATE – morphine sulfate tab 30 mg...... 33 28 x 1/2"...... 43 MULPLETA – lusutrombopag tab 3 mg...... 38 MONOJECT ALLERGIST TRAY/P – allergy tray kit 1 ml MULTAQ – dronedarone hcl tab 400 mg (base 28 x 1/2"...... 43 equivalent)...... 21 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle mupirocin oint 2% (Bactroban)...... 41 u-100 1/2 ml 28 x 1/2"...... 43 mycophenolate mofetil cap 250 mg (Cellcept)...... 44 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle mycophenolate mofetil tab 500 mg (Cellcept)...... 44 u-100 1/2 ml 29 x 1/2"...... 43 MYLERAN – busulfan tab 2 mg...... 7 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle MYRBETRIQ – mirabegron tab er 24 hr 25 mg...... 27 u-100 1/2 ml 30 x 5/16"...... 43 MYRBETRIQ – mirabegron tab er 24 hr 50 mg...... 27 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle N u-100 0.3 ml 29 x 1/2"...... 43 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle nabumetone tab 500 mg...... 34 u-100 0.3 ml 30 x 5/16"...... 43 nabumetone tab 750 mg...... 34 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle naloxone hcl inj 0.4 mg/ml...... 44 u-100 1 ml 25 x 5/8"...... 43 naloxone hcl inj 4 mg/10ml...... 44 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ u-100 1 ml 27 x 1/2"...... 43 ml...... 44 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle NALOXONE HCL – naloxone hcl soln prefilled syringe 2 u-100 1 ml 28 x 1/2"...... 43 mg/2ml...... 44 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle naltrexone hcl tab 50 mg (Revia)...... 44 u-100 1 ml 29 x 1/2"...... 43 naproxen sodium tab 275 mg (Anaprox)...... 34 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle naproxen tab ec 375 mg (Ec-naprosyn)...... 34 u-100 1 ml 30 x 5/16"...... 43 naproxen tab ec 500 mg (Ec-naprosyn)...... 34 MONOJECT INSULIN SYRINGE/ – insulin syringe/needle naproxen tab 250 mg (Naprosyn)...... 34 u-100 1 ml 31 x 5/16"...... 43 naproxen tab 375 mg (Naprosyn)...... 34 MONOJECT INSULIN SYRINGE/ – insulin syringe (disp) naproxen tab 500 mg (Naprosyn)...... 34 u-100 1 ml...... 43 naratriptan hcl tab 1 mg (base equiv) (Amerge)...... 35 MONOJECT INSULIN SYRINGE – insulin syringe (disp) NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 44 u-100 1 ml...... 43 NATACYN – natamycin ophth susp 5%...... 40 MONOJECT ULTRA COMFORT IN – insulin syringe/ NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy- needle u-100 1/2 ml 31 x 5/16"...... 44 gramicid op sol 1.75-10000-0.025mg-unt-mg/ml...... 40 MONOJECT ULTRA COMFORT IN – insulin syringe/ neomycin-bacitrac zn-polymyx needle u-100 1/2 ml 28 x 1/2"...... 44 5(3.5)mg-400unt-10000unt op oin...... 40 MONOJECT ULTRA COMFORT IN – insulin syringe/ neomycin-polymyxin-dexamethasone ophth oint 0.1% needle u-100 1/2 ml 29 x 1/2"...... 44 (Maxitrol)...... 40 MONOJECT ULTRA COMFORT IN – insulin syringe/ neomycin-polymyxin-dexamethasone ophth susp needle u-100 1/2 ml 30 x 5/16"...... 44 0.1% (Maxitrol)...... 40 MONOJECT ULTRA COMFORT IN – insulin syringe/ neomycin sulfate tab 500 mg...... 2 needle u-100 0.3 ml 29 x 1/2"...... 43 NEULASTA ONPRO KIT – pegfilgrastim soln prefilled MONOJECT ULTRA COMFORT IN – insulin syringe/ syringe kit 6 mg/0.6ml...... 38 needle u-100 0.3 ml 30 x 5/16"...... 44 NEULASTA – pegfilgrastim soln prefilled syringe 6 MONOJECT ULTRA COMFORT IN – insulin syringe/ mg/0.6ml...... 38 needle u-100 1 ml 28 x 1/2"...... 44 NEUPOGEN – filgrastim inj 300 mcg/ml...... 38 MONOJECT ULTRA COMFORT IN – insulin syringe/ NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ needle u-100 1 ml 29 x 1/2"...... 44 ml)...... 39 MONOJECT ULTRA COMFORT IN – insulin syringe/ NEUPOGEN – filgrastim soln prefilled syringe 300 needle u-100 0.3 ml 31 x 5/16"...... 44 mcg/0.5ml...... 38

Tiered Generics Prescription Drug Guide October 2019 58 2019

NEUPOGEN – filgrastim soln prefilled syringe 480 NIVESTYM – filgrastim-aafi soln prefilled syringe 300 mcg/0.8ml (600 mcg/ml)...... 38 mcg/0.5ml...... 39 nevirapine tab 200 mg (Viramune)...... 3 NIVESTYM – filgrastim-aafi soln prefilled syringe 480 NEXAVAR – sorafenib tosylate tab 200 mg (base mcg/0.8ml...... 39 equivalent)...... 7 nizatidine cap 150 mg...... 26 NEXIUM – esomeprazole magnesium for delayed release nizatidine cap 300 mg (Axid)...... 26 susp packet 5 mg...... 26 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Brevicon-28)...... 10 susp packet 10 mg...... 26 norethindrone & ethinyl estradiol tab 1 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Norinyl 1+35)...... 10 susp packet 20 mg...... 26 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Ovcon-35)...... 10 susp packet 40 mg...... 26 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 NEXIUM – esomeprazole magnesium for delayed release mcg (Loestrin fe 1/20)...... 10 susp pack 2.5 mg...... 26 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 NICOTROL INHALER – nicotine inhaler system 10 mg (4 mcg (Loestrin fe 1.5/30)...... 10 mg delivered)...... 33 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ (Loestrin 1/20-21)...... 10 spray)...... 33 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 nifedipine tab er 24hr 30 mg (Adalat cc)...... 19 mcg (Loestrin 1.5/30-21)...... 10 nifedipine tab er 24hr 60 mg (Adalat cc)...... 19 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 nifedipine tab er 24hr 90 mg (Adalat cc)...... 19 mg-mcg (Estrostep fe)...... 10 nifedipine tab er 24hr osmotic release 30 mg norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg- (Procardia xl)...... 19 mcg (Ortho-novum 7/7/7)...... 10 nifedipine tab er 24hr osmotic release 60 mg norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg- (Procardia xl)...... 19 mcg (Tri-norinyl 28)...... 10 nifedipine tab er 24hr osmotic release 90 mg norethindrone tab 0.35 mg (Nor-qd)...... 10 (Procardia xl)...... 19 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg NINLARO – ixazomib citrate cap 2.3 mg (base (Ortho-cyclen)...... 10 equivalent)...... 7 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 NINLARO – ixazomib citrate cap 3 mg (base mg-mcg (Ortho tri-cyclen)...... 10 equivalent)...... 7 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 NINLARO – ixazomib citrate cap 4 mg (base mg-mcg (Ortho tri-cyclen lo)...... 10 equivalent)...... 7 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg...... 10 nitrofurantoin macrocrystalline cap 50 mg nortriptyline hcl cap 10 mg (Pamelor)...... 29 (Macrodantin)...... 27 nortriptyline hcl cap 25 mg (Pamelor)...... 29 nitrofurantoin macrocrystalline cap 100 mg nortriptyline hcl cap 50 mg (Pamelor)...... 29 (Macrodantin)...... 27 nortriptyline hcl cap 75 mg (Pamelor)...... 29 nitrofurantoin monohydrate macrocrystalline cap 100 NORVIR – ritonavir oral soln 80 mg/ml...... 3 mg (Macrobid)...... 27 NORVIR – ritonavir powder packet 100 mg...... 3 nitroglycerin cap er 2.5 mg...... 19 NOVAREL – chorionic gonadotropin for im inj 5000 nitroglycerin cap er 6.5 mg...... 19 unit...... 11 nitroglycerin sl tab 0.3 mg (Nitrostat)...... 19 NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp nitroglycerin sl tab 0.4 mg (Nitrostat)...... 19 pen-inj 100 unit/ml (70-30)...... 13 nitroglycerin sl tab 0.6 mg (Nitrostat)...... 19 NOVOLIN 70/30 – insulin nph isophane & regular human nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)...... 19 inj 100 unit/ml (70-30)...... 13 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)...... 19 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)...... 19 ml...... 13 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)...... 19 NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 13 NITYR – nitisinone tab 2 mg...... 15 NOVOLOG FLEXPEN – insulin aspart soln pen-injector NITYR – nitisinone tab 5 mg...... 15 100 unit/ml...... 13 NITYR – nitisinone tab 10 mg...... 15 NOVOLOG – insulin aspart inj 100 unit/ml...... 13 NIVESTYM – filgrastim-aafi inj 300 mcg/ml...... 39 NOVOLOG MIX 70/30 – insulin aspart prot & aspart NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ (human) inj 100 unit/ml (70-30)...... 13 ml)...... 39 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)...... 13

Tiered Generics Prescription Drug Guide October 2019 59 2019

NOVOLOG PENFILL – insulin aspart soln cartridge 100 OTREXUP – methotrexate soln pf auto-injector 12.5 unit/ml...... 13 mg/0.4ml...... 34 NOXAFIL – posaconazole susp 40 mg/ml...... 2 OTREXUP – methotrexate soln pf auto-injector 15 NOXAFIL – posaconazole tab delayed release 100 mg...... 2 mg/0.4ml...... 34 NUVARING – etonogestrel-ethinyl estradiol va ring OTREXUP – methotrexate soln pf auto-injector 17.5 0.120-0.015 mg/24hr...... 10 mg/0.4ml...... 34 nystatin cream 100000 unit/gm...... 41 OTREXUP – methotrexate soln pf auto-injector 20 nystatin oint 100000 unit/gm...... 41 mg/0.4ml...... 35 nystatin susp 100000 unit/ml...... 41 OTREXUP – methotrexate soln pf auto-injector 22.5 nystatin topical powder 100000 unit/gm...... 41 mg/0.4ml...... 35 OTREXUP – methotrexate soln pf auto-injector 25 O mg/0.4ml...... 35 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab OXAZEPAM – oxazepam cap 10 mg...... 28 200-25-25 mg...... 3 oxcarbazepine tab 150 mg (Trileptal)...... 36 ODOMZO – sonidegib phosphate cap 200 mg (base oxcarbazepine tab 300 mg (Trileptal)...... 36 equivalent)...... 7 oxcarbazepine tab 600 mg (Trileptal)...... 36 ofloxacin ophth soln 0.3% (Ocuflox)...... 40 oxybutynin chloride syrup 5 mg/5ml...... 27 olanzapine orally disintegrating tab 5 mg (Zyprexa oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)...... 27 zydis)...... 30 oxybutynin chloride tab er 24hr 10 mg (Ditropan olanzapine tab 2.5 mg (Zyprexa)...... 30 xl)...... 27 olanzapine tab 5 mg (Zyprexa)...... 30 oxybutynin chloride tab er 24hr 15 mg (Ditropan olanzapine tab 7.5 mg (Zyprexa)...... 30 xl)...... 27 olanzapine tab 10 mg (Zyprexa)...... 30 oxybutynin chloride tab 5 mg...... 27 olanzapine tab 15 mg (Zyprexa)...... 30 OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2 olanzapine tab 20 mg (Zyprexa)...... 30 mg/1.5ml)...... 12 olopatadine hcl ophth soln 0.1% (base equivalent) OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose (Patanol)...... 41 (2 mg/1.5ml)...... 12 omeprazole cap delayed release 10 mg (Prilosec)...... 26 omeprazole cap delayed release 20 mg (Prilosec)...... 26 P omeprazole cap delayed release 40 mg (Prilosec)...... 26 pantoprazole sodium ec tab 20 mg (base equiv) OMNITROPE – somatropin for inj 5.8 mg...... 14 (Protonix)...... 26 OMNITROPE – somatropin inj 5 mg/1.5ml...... 14 pantoprazole sodium ec tab 40 mg (base equiv) OMNITROPE – somatropin inj 10 mg/1.5ml...... 14 (Protonix)...... 26 ondansetron hcl oral soln 4 mg/5ml (Zofran)...... 26 paroxetine hcl tab 10 mg (Paxil)...... 29 ondansetron hcl tab 4 mg (Zofran)...... 26 paroxetine hcl tab 20 mg (Paxil)...... 29 ondansetron hcl tab 8 mg (Zofran)...... 26 paroxetine hcl tab 30 mg (Paxil)...... 29 ondansetron orally disintegrating tab 4 mg (Zofran paroxetine hcl tab 40 mg (Paxil)...... 29 odt)...... 26 PAZEO – olopatadine hcl ophth soln 0.7% (base ondansetron orally disintegrating tab 8 mg (Zofran equivalent)...... 41 odt)...... 26 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...... 3 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)...... 12 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml...... 3 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)...... 12 PEGASYS PROCLICK – peginterferon alfa-2a inj 180 OPSUMIT – macitentan tab 10 mg...... 21 mcg/0.5ml...... 3 ORFADIN – nitisinone cap 2 mg...... 15 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ORFADIN – nitisinone cap 5 mg...... 15 (Colyte-flavor packs)...... 25 ORFADIN – nitisinone cap 10 mg...... 15 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ORFADIN – nitisinone cap 20 mg...... 15 (Golytely)...... 25 ORFADIN – nitisinone susp 4 mg/ml...... 15 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ORILISSA – elagolix sodium tab 150 mg (base equiv)...... 11 (Nulytely/flavor pack)...... 25 ORILISSA – elagolix sodium tab 200 mg (base equiv)...... 11 PENICILLIN V POTASSIUM – penicillin v potassium for orphenadrine citrate tab er 12hr 100 mg...... 37 soln 125 mg/5ml...... 1 OTEZLA – apremilast tab 30 mg...... 34 PENICILLIN V POTASSIUM – penicillin v potassium for OTEZLA – apremilast tab starter therapy pack 10 mg & 20 soln 250 mg/5ml...... 1 mg & 30 mg...... 34 penicillin v potassium tab 250 mg...... 1 OTREXUP – methotrexate soln pf auto-injector 10 penicillin v potassium tab 500 mg...... 1 mg/0.4ml...... 34 pentoxifylline tab er 400 mg...... 39

Tiered Generics Prescription Drug Guide October 2019 60 2019 perindopril erbumine tab 2 mg...... 16 pravastatin sodium tab 20 mg (Pravachol)...... 20 perindopril erbumine tab 4 mg (Aceon)...... 16 pravastatin sodium tab 40 mg (Pravachol)...... 20 perindopril erbumine tab 8 mg (Aceon)...... 16 pravastatin sodium tab 80 mg (Pravachol)...... 20 perphenazine tab 2 mg...... 30 prazosin hcl cap 1 mg (Minipress)...... 22 phenobarbital tab 16.2 mg...... 31 prazosin hcl cap 2 mg (Minipress)...... 22 phenobarbital tab 32.4 mg...... 31 prazosin hcl cap 5 mg (Minipress)...... 22 phenobarbital tab 64.8 mg...... 31 PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp phenobarbital tab 97.2 mg...... 31 solution equivalent)...... 8 phenylephrine hcl ophth soln 10%...... 41 prednisolone sod phosphate oral soln 15 mg/5ml phenytoin chew tab 50 mg (Dilantin infatabs)...... 36 (base equiv)...... 9 phenytoin sodium extended cap 100 mg (Dilantin)...... 36 prednisolone sod phosph oral soln 6.7 mg/5ml (5 phenytoin susp 125 mg/5ml (Dilantin)...... 36 mg/5ml base) (Pediapred)...... 9 PICATO – ingenol mebutate gel 0.015%...... 42 prednisone tab 1 mg...... 9 PICATO – ingenol mebutate gel 0.05%...... 42 prednisone tab 2.5 mg...... 9 pilocarpine hcl ophth soln 1% (Isopto carpine)...... 40 prednisone tab 5 mg...... 9 pilocarpine hcl ophth soln 2% (Isopto carpine)...... 40 prednisone tab 10 mg...... 9 pindolol tab 5 mg...... 18 prednisone tab 20 mg...... 9 pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 12 PREGNYL W/DILUENT BENZYL – chorionic gonadotropin pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 12 for im inj 10000 unit...... 11 pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 12 PREMARIN – estrogens, conjugated tab 0.3 mg...... 9 piroxicam cap 10 mg (Feldene)...... 35 PREMARIN – estrogens, conjugated tab 0.45 mg...... 9 piroxicam cap 20 mg (Feldene)...... 35 PREMARIN – estrogens, conjugated tab 0.625 mg...... 9 PLEGRIDY – peginterferon beta-1a soln pen-injector 125 PREMARIN – estrogens, conjugated tab 0.9 mg...... 9 mcg/0.5ml...... 32 PREMARIN – estrogens, conjugated tab 1.25 mg...... 9 PLEGRIDY – peginterferon beta-1a soln prefilled syringe PREMPHASE – conj est 0.625(14)/conj est-medroxypro 125 mcg/0.5ml...... 32 ac tab 0.625-5mg(14)...... 9 PLEGRIDY STARTER PACK – peginterferon beta-1a soln PREMPRO – conjugated estrogen-medroxyprogest pen-inj 63 & 94 mcg/0.5ml pack...... 32 acetate tab 0.3-1.5 mg...... 9 PLEGRIDY STARTER PACK – peginterferon beta-1a soln PREMPRO – conjugated estrogen-medroxyprogest pref syr 63 & 94 mcg/0.5ml pack...... 32 acetate tab 0.45-1.5 mg...... 9 polymyxin b-trimethoprim ophth soln 10000 unit/ PREMPRO – conjugated estrogen-medroxyprogest ml-0.1% (Polytrim)...... 40 acetate tab 0.625-2.5 mg...... 9 POMALYST – pomalidomide cap 1 mg...... 7 PREMPRO – conjugated estrogen-medroxyprogest POMALYST – pomalidomide cap 2 mg...... 7 acetate tab 0.625-5 mg...... 9 POMALYST – pomalidomide cap 3 mg...... 7 PREZCOBIX – darunavir-cobicistat tab 800-150 mg...... 4 POMALYST – pomalidomide cap 4 mg...... 7 PREZISTA – darunavir ethanolate susp 100 mg/ml (base potassium chloride cap er 8 meq (Micro-k)...... 37 equiv)...... 4 potassium chloride cap er 10 meq (Micro-k)...... 37 PREZISTA – darunavir ethanolate tab 75 mg (base POTASSIUM CHLORIDE ER – potassium chloride tab er equiv)...... 4 8 meq (600 mg)...... 37 PREZISTA – darunavir ethanolate tab 150 mg (base potassium chloride microencapsulated crys er tab 10 equiv)...... 4 meq...... 38 PREZISTA – darunavir ethanolate tab 600 mg (base potassium chloride microencapsulated crys er tab 20 equiv)...... 4 meq...... 38 PREZISTA – darunavir ethanolate tab 800 mg (base potassium chloride tab er 10 meq (K-tab)...... 38 equiv)...... 4 potassium chloride tab er 8 meq (600 mg)...... 38 PRIFTIN – rifapentine tab 150 mg...... 2 pramipexole dihydrochloride tab 0.125 mg primidone tab 50 mg (Mysoline)...... 36 (Mirapex)...... 37 primidone tab 250 mg (Mysoline)...... 36 pramipexole dihydrochloride tab 0.25 mg PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (Mirapex)...... 37 (90mcg base equiv)...... 24 pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 37 PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 pramipexole dihydrochloride tab 0.75 mg mcg/act (90 mcg base equiv)...... 24 (Mirapex)...... 37 probenecid tab 500 mg...... 35 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 37 prochlorperazine maleate tab 5 mg (base equivalent) pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 37 (Compazine)...... 30 pravastatin sodium tab 10 mg...... 20

Tiered Generics Prescription Drug Guide October 2019 61 2019 prochlorperazine maleate tab 10 mg (base equivalent) QVAR REDIHALER – beclomethasone diprop hfa breath (Compazine)...... 30 act inh aer 80 mcg/act...... 24 PROCRIT – epoetin alfa inj 2000 unit/ml...... 39 R PROCRIT – epoetin alfa inj 3000 unit/ml...... 39 PROCRIT – epoetin alfa inj 4000 unit/ml...... 39 rabeprazole sodium ec tab 20 mg (Aciphex)...... 26 PROCRIT – epoetin alfa inj 10000 unit/ml...... 39 ramipril cap 1.25 mg (Altace)...... 16 PROCRIT – epoetin alfa inj 20000 unit/ml...... 39 ramipril cap 2.5 mg (Altace)...... 16 PROCRIT – epoetin alfa inj 40000 unit/ml...... 39 ramipril cap 5 mg (Altace)...... 16 progesterone micronized cap 100 mg (Prometrium)...... 9 ramipril cap 10 mg (Altace)...... 16 PROMETHAZINE/DEXTROMETHOR – promethazine-dm ranitidine hcl cap 150 mg...... 26 syrup 6.25-15 mg/5ml...... 23 ranitidine hcl cap 300 mg...... 26 PROMETHAZINE/PHENYLEPHRIN – promethazine & ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 26 phenylephrine syrup 6.25-5 mg/5ml...... 23 ranitidine hcl tab 150 mg (Zantac)...... 26 PROMETHAZINE/PHENYLEPHRIN – promethazine- ranitidine hcl tab 300 mg (Zantac)...... 26 phenylephrine-codeine syrup 6.25-5-10 mg/5ml...... 23 RAPAMUNE – sirolimus oral soln 1 mg/ml...... 44 promethazine hcl syrup 6.25 mg/5ml...... 22 REALITY INSULIN SYRINGE/U – insulin syringe/needle promethazine hcl tab 12.5 mg...... 22 u-100 1/2 ml 28 x 1/2"...... 44 promethazine hcl tab 25 mg...... 22 REALITY INSULIN SYRINGE/U – insulin syringe/needle promethazine hcl tab 50 mg...... 22 u-100 1/2 ml 29 x 1/2"...... 44 promethazine w/ codeine syrup 6.25-10 mg/5ml...... 23 REALITY INSULIN SYRINGE/U – insulin syringe/needle propafenone hcl tab 150 mg (Rythmol)...... 21 u-100 1 ml 28 x 1/2"...... 44 propafenone hcl tab 225 mg (Rythmol)...... 21 REALITY INSULIN SYRINGE/U – insulin syringe/needle proparacaine hcl ophth soln 0.5% (Alcaine)...... 41 u-100 1 ml 29 x 1/2"...... 44 propranolol hcl cap er 24hr 60 mg (Inderal la)...... 18 REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml propranolol hcl cap er 24hr 80 mg (Inderal la)...... 18 (12mu/ml)...... 32 propranolol hcl tab 10 mg...... 18 REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml propranolol hcl tab 20 mg...... 18 (24mu/ml)...... 32 propranolol hcl tab 40 mg...... 18 REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 propranolol hcl tab 60 mg...... 18 mcg/0.5ml (12mu/ml)...... 32 propranolol hcl tab 80 mg...... 18 REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 pseudoephed-bromphen-dm syrup 30-2-10 mcg/0.5ml (24mu/ml)...... 32 mg/5ml...... 23 REBIF REBIDOSE TITRATION – interferon beta-1a auto- PULMOZYME – dornase alfa inhal soln 1 mg/ml...... 25 inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 32 PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ REBIF TITRATION PACK – interferon beta-1a pref syr ml)...... 7 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 32 repaglinide tab 0.5 mg (Prandin)...... 12 Q repaglinide tab 1 mg (Prandin)...... 12 quetiapine fumarate tab 25 mg (Seroquel)...... 30 repaglinide tab 2 mg (Prandin)...... 12 quetiapine fumarate tab 50 mg (Seroquel)...... 30 REPATHA – evolocumab subcutaneous soln prefilled quetiapine fumarate tab 100 mg (Seroquel)...... 30 syringe 140 mg/ml...... 20 quetiapine fumarate tab 200 mg (Seroquel)...... 30 REPATHA PUSHTRONEX SYSTEM – evolocumab quetiapine fumarate tab 300 mg (Seroquel)...... 30 subcutaneous soln cartridge/infusor 420 mg/3.5ml...... 20 quetiapine fumarate tab 400 mg (Seroquel)...... 30 REPATHA SURECLICK – evolocumab subcutaneous soln quinapril hcl tab 5 mg (Accupril)...... 16 auto-injector 140 mg/ml...... 20 quinapril hcl tab 10 mg (Accupril)...... 16 RETACRIT – epoetin alfa-epbx inj 2000 unit/ml...... 39 quinapril hcl tab 20 mg (Accupril)...... 16 RETACRIT – epoetin alfa-epbx inj 3000 unit/ml...... 39 quinapril hcl tab 40 mg (Accupril)...... 16 RETACRIT – epoetin alfa-epbx inj 4000 unit/ml...... 39 quinapril-hydrochlorothiazide tab 10-12.5 mg RETACRIT – epoetin alfa-epbx inj 10000 unit/ml...... 39 (Accuretic)...... 16 RETACRIT – epoetin alfa-epbx inj 40000 unit/ml...... 39 quinapril-hydrochlorothiazide tab 20-12.5 mg REVCOVI – elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 (Accuretic)...... 16 mg/ml)...... 15 quinapril-hydrochlorothiazide tab 20-25 mg REVLIMID – lenalidomide cap 5 mg...... 44 (Accuretic)...... 16 REVLIMID – lenalidomide cap 10 mg...... 44 QVAR REDIHALER – beclomethasone diprop hfa breath REVLIMID – lenalidomide cap 15 mg...... 44 act inh aer 40 mcg/act...... 24 REVLIMID – lenalidomide cap 20 mg...... 44 REVLIMID – lenalidomide cap 25 mg...... 44

Tiered Generics Prescription Drug Guide October 2019 62 2019

REVLIMID – lenalidomide caps 2.5 mg...... 44 simvastatin tab 10 mg (Zocor)...... 20 risperidone soln 1 mg/ml (Risperdal)...... 30 simvastatin tab 20 mg (Zocor)...... 20 risperidone tab 0.25 mg (Risperdal)...... 30 simvastatin tab 40 mg (Zocor)...... 20 risperidone tab 0.5 mg (Risperdal)...... 30 simvastatin tab 80 mg (Zocor)...... 20 risperidone tab 1 mg (Risperdal)...... 30 SINGLE-LET – lancets...... 44 risperidone tab 2 mg (Risperdal)...... 30 SKYRIZI – risankizumab-rzaa sol prefilled syringe 2 x 75 risperidone tab 3 mg (Risperdal)...... 30 mg/0.83ml kit...... 42 risperidone tab 4 mg (Risperdal)...... 30 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) rizatriptan benzoate oral disintegrating tab 5 mg (base (Luride)...... 38 eq) (Maxalt-mlt)...... 35 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) rizatriptan benzoate oral disintegrating tab 10 mg (Luride)...... 38 (base eq) (Maxalt-mlt)...... 35 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) rizatriptan benzoate tab 5 mg (base equivalent) (Luride)...... 38 (Maxalt)...... 35 sodium fluoride cream 1.1% (Prevident 5000 plus)...... 41 rizatriptan benzoate tab 10 mg (base equivalent) sodium fluoride gel 1.1% (0.5% f) (Prevident (Maxalt)...... 35 fluoride)...... 41 ropinirole hydrochloride tab 0.25 mg (Requip)...... 37 sodium fluoride paste 1.1% (Prevident 5000 boost).....41 ropinirole hydrochloride tab 0.5 mg (Requip)...... 37 sodium fluoride rinse 0.2% (Prevident)...... 41 ropinirole hydrochloride tab 1 mg (Requip)...... 37 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) ropinirole hydrochloride tab 2 mg (Requip)...... 37 (Luride)...... 38 ropinirole hydrochloride tab 3 mg (Requip)...... 37 sodium polystyrene sulfonate oral susp 15 ropinirole hydrochloride tab 4 mg (Requip)...... 37 gm/60ml...... 44 ropinirole hydrochloride tab 5 mg (Requip)...... 37 SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab rosuvastatin calcium tab 5 mg (Crestor)...... 20 400-100 mg...... 3 rosuvastatin calcium tab 10 mg (Crestor)...... 20 SOOLANTRA – ivermectin cream 1%...... 41 rosuvastatin calcium tab 20 mg (Crestor)...... 20 sotalol hcl (afib/afl) tab 80 mg (Betapace af)...... 21 rosuvastatin calcium tab 40 mg (Crestor)...... 20 sotalol hcl tab 240 mg...... 21 RYDAPT – midostaurin cap 25 mg...... 7 sotalol hcl tab 80 mg (Betapace)...... 21 S sotalol hcl tab 120 mg (Betapace)...... 21 sotalol hcl tab 160 mg (Betapace)...... 21 SANDIMMUNE – cyclosporine oral soln 100 mg/ml...... 44 SOVALDI – sofosbuvir tab 400 mg...... 3 SANDOSTATIN LAR DEPOT – octreotide acetate for im SPIRIVA HANDIHALER – tiotropium bromide inj kit 10 mg...... 15 monohydrate inhal cap 18 mcg (base equiv)...... 24 SANDOSTATIN LAR DEPOT – octreotide acetate for im SPIRIVA RESPIMAT – tiotropium bromide monohydrate inj kit 20 mg...... 15 inhal aerosol 1.25 mcg/act...... 24 SANDOSTATIN LAR DEPOT – octreotide acetate for im SPIRIVA RESPIMAT – tiotropium bromide monohydrate inj kit 30 mg...... 15 inhal aerosol 2.5 mcg/act...... 24 selenium sulfide lotion 2.5%...... 42 spironolactone & hydrochlorothiazide tab 25-25 mg SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)...... 15 (Aldactazide)...... 21 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)...... 15 spironolactone tab 25 mg (Aldactone)...... 21 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)...... 15 spironolactone tab 50 mg (Aldactone)...... 21 SEREVENT DISKUS – salmeterol xinafoate aer pow ba spironolactone tab 100 mg (Aldactone)...... 21 50 mcg/dose (base equiv)...... 24 SPRYCEL – dasatinib tab 20 mg...... 7 sertraline hcl tab 25 mg (Zoloft)...... 29 SPRYCEL – dasatinib tab 50 mg...... 7 sertraline hcl tab 50 mg (Zoloft)...... 29 SPRYCEL – dasatinib tab 70 mg...... 7 sertraline hcl tab 100 mg (Zoloft)...... 29 SPRYCEL – dasatinib tab 80 mg...... 7 silver sulfadiazine cream 1% (Silvadene)...... 41 SPRYCEL – dasatinib tab 100 mg...... 7 SIMPONI – golimumab subcutaneous soln auto-injector SPRYCEL – dasatinib tab 140 mg...... 7 50 mg/0.5ml...... 35 STELARA – ustekinumab inj 45 mg/0.5ml...... 42 SIMPONI – golimumab subcutaneous soln auto-injector STELARA – ustekinumab soln prefilled syringe 45 100 mg/ml...... 35 mg/0.5ml...... 42 SIMPONI – golimumab subcutaneous soln prefilled STELARA – ustekinumab soln prefilled syringe 90 mg/ syringe 50 mg/0.5ml...... 35 ml...... 42 SIMPONI – golimumab subcutaneous soln prefilled STIMATE – desmopressin acetate nasal soln 1.5 mg/ syringe 100 mg/ml...... 35 ml...... 15 simvastatin tab 5 mg (Zocor)...... 20

Tiered Generics Prescription Drug Guide October 2019 63 2019

STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero SYLATRON – peginterferon alfa-2b for inj kit 600 mcg...... 7 soln 2.5-2.5 mcg/act...... 24 SYMBICORT – budesonide-formoterol fumarate dihyd STIVARGA – regorafenib tab 40 mg...... 7 aerosol 80-4.5 mcg/act...... 25 STRENSIQ – asfotase alfa subcutaneous inj 18 SYMBICORT – budesonide-formoterol fumarate dihyd mg/0.45ml...... 15 aerosol 160-4.5 mcg/act...... 25 STRENSIQ – asfotase alfa subcutaneous inj 28 SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg/0.7ml...... 15 mg tab tbpk...... 25 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor ml...... 15 150 mg tab tbpk...... 25 STRENSIQ – asfotase alfa subcutaneous inj 80 SYMFI – efavirenz-lamivudine-tenofovir df tab mg/0.8ml...... 15 600-300-300 mg...... 4 STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln SYMFI LO – efavirenz-lamivudine-tenofovir df tab 2.5 mcg/act (base equiv)...... 25 400-300-300 mg...... 4 SUBOXONE – buprenorphine hcl-naloxone hcl sl film SYMJEPI – epinephrine solution prefilled syringe 0.3 2-0.5 mg (base equiv)...... 45 mg/0.3ml (1:1000)...... 22 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mg (base equiv)...... 45 mcg/act) (base eq)...... 11 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 SYNJARDY – empagliflozin-metformin hcl tab 5-500 mg (base equiv)...... 45 mg...... 12 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 SYNJARDY – empagliflozin-metformin hcl tab 5-1000 mg (base equiv)...... 45 mg...... 13 sucralfate tab 1 gm (Carafate)...... 26 SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 SULFACETAMIDE SODIUM/PRED – sulfacetamide mg...... 13 sodium-prednisolone ophth soln 10-0.23(0.25)%...... 40 SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000 sulfacetamide sodium ophth soln 10% (Bleph-10)...... 40 mg...... 13 SULFADIAZINE – sulfadiazine tab 500 mg...... 5 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr sulfamethoxazole-trimethoprim susp 200-40 5-1000 mg...... 13 mg/5ml...... 5 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr sulfamethoxazole-trimethoprim tab 400-80 mg 10-1000 mg...... 13 (Bactrim)...... 5 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr sulfamethoxazole-trimethoprim tab 800-160 mg 12.5-1000 mg...... 13 (Bactrim ds)...... 5 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr sulfasalazine tab delayed release 500 mg (Azulfidine 25-1000 mg...... 13 en-tabs)...... 27 SYNTHROID – levothyroxine sodium tab 25 mcg...... 14 sulfasalazine tab 500 mg (Azulfidine)...... 27 SYNTHROID – levothyroxine sodium tab 50 mcg...... 14 sulindac tab 150 mg...... 35 SYNTHROID – levothyroxine sodium tab 75 mcg...... 14 sulindac tab 200 mg...... 35 SYNTHROID – levothyroxine sodium tab 88 mcg...... 14 sumatriptan nasal spray 5 mg/act (Imitrex)...... 35 SYNTHROID – levothyroxine sodium tab 100 mcg...... 14 sumatriptan nasal spray 20 mg/act (Imitrex)...... 35 SYNTHROID – levothyroxine sodium tab 112 mcg...... 14 sumatriptan succinate tab 25 mg (Imitrex)...... 35 SYNTHROID – levothyroxine sodium tab 125 mcg...... 14 sumatriptan succinate tab 50 mg (Imitrex)...... 35 SYNTHROID – levothyroxine sodium tab 137 mcg...... 14 sumatriptan succinate tab 100 mg (Imitrex)...... 35 SYNTHROID – levothyroxine sodium tab 150 mcg...... 14 SUPRAX – cefixime cap 400 mg...... 1 SYNTHROID – levothyroxine sodium tab 175 mcg...... 14 SUPRAX – cefixime chew tab 100 mg...... 1 SYNTHROID – levothyroxine sodium tab 200 mcg...... 14 SUPRAX – cefixime chew tab 200 mg...... 1 SYNTHROID – levothyroxine sodium tab 300 mcg...... 14 SUPRAX – cefixime for susp 500 mg/5ml...... 1 T SUTENT – sunitinib malate cap 12.5 mg (base equivalent)...... 7 TABLOID – thioguanine tab 40 mg...... 7 SUTENT – sunitinib malate cap 25 mg (base TACLONEX – calcipotriene-betamethasone dipropionate equivalent)...... 7 susp 0.005-0.064%...... 42 SUTENT – sunitinib malate cap 37.5 mg (base tacrolimus cap 0.5 mg (Prograf)...... 45 equivalent)...... 7 TAFINLAR – dabrafenib mesylate cap 50 mg (base SUTENT – sunitinib malate cap 50 mg (base equivalent)...... 7 equivalent)...... 7 TAFINLAR – dabrafenib mesylate cap 75 mg (base SYLATRON – peginterferon alfa-2b for inj kit 200 mcg...... 7 equivalent)...... 7 SYLATRON – peginterferon alfa-2b for inj kit 300 mcg...... 7

Tiered Generics Prescription Drug Guide October 2019 64 2019

TAGRISSO – osimertinib mesylate tab 40 mg (base topiramate tab 50 mg (Topamax)...... 36 equivalent)...... 7 topiramate tab 100 mg (Topamax)...... 36 TAGRISSO – osimertinib mesylate tab 80 mg (base topiramate tab 200 mg (Topamax)...... 36 equivalent)...... 8 torsemide tab 5 mg (Demadex)...... 21 tamoxifen citrate tab 10 mg (base equivalent)...... 8 torsemide tab 10 mg (Demadex)...... 21 tamoxifen citrate tab 20 mg (base equivalent)...... 8 torsemide tab 20 mg (Demadex)...... 21 tamsulosin hcl cap 0.4 mg (Flomax)...... 28 torsemide tab 100 mg (Demadex)...... 21 TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 8 TOUJEO MAX SOLOSTAR – insulin glargine soln pen- TASIGNA – nilotinib hcl cap 150 mg (base equivalent)...... 8 injector 300 unit/ml...... 13 TASIGNA – nilotinib hcl cap 200 mg (base equivalent)...... 8 TOUJEO SOLOSTAR – insulin glargine soln pen-injector TAZORAC – tazarotene cream 0.05%...... 41 300 unit/ml...... 13 TAZORAC – tazarotene gel 0.05%...... 41 TRACLEER – bosentan tab for oral susp 32 mg...... 22 TAZORAC – tazarotene gel 0.1%...... 41 TRACLEER – bosentan tab 62.5 mg...... 22 TECFIDERA – dimethyl fumarate capsule delayed release TRACLEER – bosentan tab 125 mg...... 22 120 mg...... 32 tramadol-acetaminophen tab 37.5-325 mg TECFIDERA – dimethyl fumarate capsule delayed release (Ultracet)...... 33 240 mg...... 32 tramadol hcl tab 50 mg (Ultram)...... 33 TECFIDERA STARTER PACK – dimethyl fumarate trandolapril tab 1 mg (Mavik)...... 16 capsule dr starter pack 120 mg & 240 mg...... 32 trandolapril tab 2 mg (Mavik)...... 16 telmisartan tab 20 mg (Micardis)...... 17 trandolapril tab 4 mg (Mavik)...... 16 telmisartan tab 40 mg (Micardis)...... 17 TRANSDERM-SCOP – scopolamine td patch 72hr 1 telmisartan tab 80 mg (Micardis)...... 17 mg/3days...... 26 temazepam cap 15 mg (Restoril)...... 31 TRANSDERM SCOP – scopolamine td patch 72hr 1 temazepam cap 30 mg (Restoril)...... 31 mg/3days...... 26 terazosin hcl cap 1 mg (base equivalent)...... 22 TRAVATAN Z – travoprost ophth soln 0.004% terazosin hcl cap 2 mg (base equivalent)...... 22 (benzalkonium free) (bak free)...... 40 terazosin hcl cap 5 mg (base equivalent)...... 22 trazodone hcl tab 50 mg...... 29 terazosin hcl cap 10 mg (base equivalent)...... 22 trazodone hcl tab 100 mg...... 29 terbinafine hcl tab 250 mg (Lamisil)...... 2 trazodone hcl tab 150 mg...... 29 TERCONAZOLE – terconazole vaginal cream 0.8%...... 27 TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol terconazole vaginal cream 0.4% (Terazol 7)...... 27 aepb 100-62.5-25 mcg/inh...... 25 testosterone cypionate im inj in oil 100 mg/ml (Depo- TREMFYA – guselkumab soln pen-injector 100 mg/ml..... 42 testosterone)...... 9 TREMFYA – guselkumab soln prefilled syringe 100 mg/ testosterone cypionate im inj in oil 200 mg/ml (Depo- ml...... 42 testosterone)...... 9 TRESIBA FLEXTOUCH – insulin degludec soln pen- testosterone enanthate im inj in oil 200 mg/ml...... 9 injector 100 unit/ml...... 14 tetracaine hcl ophth soln 0.5%...... 41 TRESIBA FLEXTOUCH – insulin degludec soln pen- THALOMID – thalidomide cap 50 mg...... 45 injector 200 unit/ml...... 14 THALOMID – thalidomide cap 100 mg...... 45 TRESIBA – insulin degludec inj 100 unit/ml...... 14 THALOMID – thalidomide cap 150 mg...... 45 triamcinolone acetonide cream 0.025%...... 42 THALOMID – thalidomide cap 200 mg...... 45 triamcinolone acetonide cream 0.1%...... 42 theophylline tab er 12hr 100 mg...... 25 triamcinolone acetonide cream 0.5%...... 42 theophylline tab er 12hr 200 mg...... 25 triamcinolone acetonide lotion 0.025%...... 42 theophylline tab er 24hr 400 mg...... 25 triamcinolone acetonide lotion 0.1%...... 42 theophylline tab er 24hr 600 mg...... 25 triamcinolone acetonide oint 0.025%...... 42 thiothixene cap 1 mg...... 30 triamcinolone acetonide oint 0.1%...... 42 timolol maleate ophth soln 0.25% (Timoptic)...... 40 triamcinolone acetonide oint 0.5%...... 42 timolol maleate ophth soln 0.5% (Timoptic)...... 40 triamterene & hydrochlorothiazide cap 37.5-25 mg TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 4 (Dyazide)...... 21 TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 4 triamterene & hydrochlorothiazide tab 37.5-25 mg TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 4 (Maxzide-25)...... 21 tizanidine hcl tab 2 mg (base equivalent)...... 37 triamterene & hydrochlorothiazide tab 75-50 mg tizanidine hcl tab 4 mg (base equivalent) (Maxzide)...... 21 (Zanaflex)...... 37 trifluoperazine hcl tab 1 mg (base equivalent)...... 31 tobramycin ophth soln 0.3% (Tobrex)...... 40 trifluoperazine hcl tab 2 mg (base equivalent)...... 31 topiramate tab 25 mg (Topamax)...... 36 trihexyphenidyl hcl elixir 0.4 mg/ml...... 37

Tiered Generics Prescription Drug Guide October 2019 65 2019 trihexyphenidyl hcl tab 2 mg...... 37 valsartan tab 160 mg (Diovan)...... 17 trihexyphenidyl hcl tab 5 mg...... 37 valsartan tab 320 mg (Diovan)...... 17 trimethoprim tab 100 mg...... 5 VASCEPA – icosapent ethyl cap 0.5 gm...... 20 TRIUMEQ – abacavir-dolutegravir-lamivudine tab VASCEPA – icosapent ethyl cap 1 gm...... 20 600-50-300 mg...... 4 VELPHORO – sucroferric oxyhydroxide chew tab 500 TRULICITY – dulaglutide soln pen-injector 0.75 mg...... 27 mg/0.5ml...... 13 VENCLEXTA STARTING PACK – venetoclax tab therapy TRULICITY – dulaglutide soln pen-injector 1.5 starter pack 10 & 50 & 100 mg...... 8 mg/0.5ml...... 13 VENCLEXTA – venetoclax tab 10 mg...... 8 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VENCLEXTA – venetoclax tab 50 mg...... 8 tab 100-150 mg...... 4 VENCLEXTA – venetoclax tab 100 mg...... 8 TRUVADA – emtricitabine-tenofovir disoproxil fumarate venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) tab 133-200 mg...... 4 (Effexor xr)...... 29 TRUVADA – emtricitabine-tenofovir disoproxil fumarate venlafaxine hcl cap er 24hr 75 mg (base equivalent) tab 167-250 mg...... 4 (Effexor xr)...... 29 TRUVADA – emtricitabine-tenofovir disoproxil fumarate venlafaxine hcl cap er 24hr 150 mg (base equivalent) tab 200-300 mg...... 4 (Effexor xr)...... 29 TYKERB – lapatinib ditosylate tab 250 mg (base equiv)..... 8 venlafaxine hcl tab 25 mg (base equivalent)...... 29 TYMLOS – abaloparatide subcutaneous soln pen-injector venlafaxine hcl tab 37.5 mg (base equivalent)...... 30 3120 mcg/1.56ml...... 15 venlafaxine hcl tab 50 mg (base equivalent)...... 30 U venlafaxine hcl tab 75 mg (base equivalent)...... 30 venlafaxine hcl tab 100 mg (base equivalent)...... 30 UDENYCA – pegfilgrastim-cbqv soln prefilled syringe 6 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act mg/0.6ml...... 39 (90mcg base equiv)...... 25 UPTRAVI – selexipag tab 200 mcg...... 22 verapamil hcl cap er 24hr 120 mg (Verelan)...... 19 UPTRAVI – selexipag tab 400 mcg...... 22 verapamil hcl cap er 24hr 180 mg (Verelan)...... 19 UPTRAVI – selexipag tab 600 mcg...... 22 VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100 UPTRAVI – selexipag tab 800 mcg...... 22 mg...... 19 UPTRAVI – selexipag tab 1000 mcg...... 22 verapamil hcl tab er 120 mg (Calan sr)...... 19 UPTRAVI – selexipag tab 1200 mcg...... 22 verapamil hcl tab er 180 mg (Calan sr)...... 19 UPTRAVI – selexipag tab 1400 mcg...... 22 verapamil hcl tab er 240 mg (Calan sr)...... 19 UPTRAVI – selexipag tab 1600 mcg...... 22 verapamil hcl tab 40 mg...... 19 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & verapamil hcl tab 80 mg (Calan)...... 19 800 mcg (60)...... 22 verapamil hcl tab 120 mg (Calan)...... 19 V VERELAN PM – verapamil hcl cap er 24hr 100 mg...... 19 VERELAN PM – verapamil hcl cap er 24hr 300 mg...... 19 VAGIFEM – estradiol vaginal tab 10 mcg...... 28 VIBERZI – eluxadoline tab 75 mg...... 27 valacyclovir hcl tab 1 gm (Valtrex)...... 3 VIBERZI – eluxadoline tab 100 mg...... 27 valacyclovir hcl tab 500 mg (Valtrex)...... 3 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ VALCHLOR – mechlorethamine hcl gel 0.016% (base ml)...... 13 equivalent)...... 42 VIDEX – didanosine for soln 2 gm...... 4 valproate sodium oral soln 250 mg/5ml (base equiv) VIREAD – tenofovir disoproxil fumarate oral powder 40 (Depakene)...... 36 mg/gm...... 4 valproic acid cap 250 mg (Depakene)...... 36 VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 4 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 4 hct)...... 17 VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 4 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab hct)...... 17 400-100-100 mg...... 3 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 8 hct)...... 17 VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 31 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 31 hct)...... 17 VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 31 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 32 hct)...... 17 VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 32 valsartan tab 40 mg (Diovan)...... 17 VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 32 valsartan tab 80 mg (Diovan)...... 17 VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 32

Tiered Generics Prescription Drug Guide October 2019 66 2019

VYVANSE – lisdexamfetamine dimesylate chew tab 10 ZENPEP – pancrelipase (lip-prot-amyl) dr cap mg...... 32 20000-63000-84000 unit...... 27 VYVANSE – lisdexamfetamine dimesylate chew tab 20 ZENPEP – pancrelipase (lip-prot-amyl) dr cap mg...... 32 25000-79000-105000 unit...... 27 VYVANSE – lisdexamfetamine dimesylate chew tab 30 ZENPEP – pancrelipase (lip-prot-amyl) dr cap mg...... 32 40000-126000-168000 unit...... 27 VYVANSE – lisdexamfetamine dimesylate chew tab 40 zidovudine tab 300 mg...... 4 mg...... 32 ziprasidone hcl cap 20 mg (Geodon)...... 31 VYVANSE – lisdexamfetamine dimesylate chew tab 50 ziprasidone hcl cap 40 mg (Geodon)...... 31 mg...... 32 ziprasidone hcl cap 60 mg (Geodon)...... 31 VYVANSE – lisdexamfetamine dimesylate chew tab 60 ziprasidone hcl cap 80 mg (Geodon)...... 31 mg...... 32 ZOLINZA – vorinostat cap 100 mg...... 8 W zolpidem tartrate tab er 6.25 mg (Ambien cr)...... 31 zolpidem tartrate tab er 12.5 mg (Ambien cr)...... 31 warfarin sodium tab 1 mg (Coumadin)...... 39 zolpidem tartrate tab 5 mg (Ambien)...... 31 warfarin sodium tab 2 mg (Coumadin)...... 39 zolpidem tartrate tab 10 mg (Ambien)...... 31 warfarin sodium tab 2.5 mg (Coumadin)...... 39 zonisamide cap 50 mg...... 36 warfarin sodium tab 3 mg (Coumadin)...... 39 zonisamide cap 25 mg (Zonegran)...... 36 warfarin sodium tab 4 mg (Coumadin)...... 39 zonisamide cap 100 mg (Zonegran)...... 36 warfarin sodium tab 5 mg (Coumadin)...... 39 ZORTRESS – everolimus tab 0.25 mg...... 45 warfarin sodium tab 6 mg (Coumadin)...... 39 ZORTRESS – everolimus tab 0.5 mg...... 45 warfarin sodium tab 7.5 mg (Coumadin)...... 39 ZORTRESS – everolimus tab 0.75 mg...... 45 warfarin sodium tab 10 mg (Coumadin)...... 39 ZORTRESS – everolimus tab 1 mg...... 45 X ZYDELIG – idelalisib tab 100 mg...... 8 ZYDELIG – idelalisib tab 150 mg...... 8 XALKORI – crizotinib cap 200 mg...... 8 ZYKADIA – ceritinib cap 150 mg...... 8 XALKORI – crizotinib cap 250 mg...... 8 ZYKADIA – ceritinib tab 150 mg...... 8 XARELTO – rivaroxaban tab 2.5 mg...... 39 ZYTIGA – abiraterone acetate tab 250 mg...... 8 XARELTO – rivaroxaban tab 10 mg...... 39 ZYTIGA – abiraterone acetate tab 500 mg...... 8 XARELTO – rivaroxaban tab 15 mg...... 39 XARELTO – rivaroxaban tab 20 mg...... 39 XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg...... 39 XIFAXAN – rifaximin tab 550 mg...... 5 XTANDI – enzalutamide cap 40 mg...... 8 Y YONSA – abiraterone acetate tab 125 mg...... 8 Z zaleplon cap 5 mg (Sonata)...... 31 zaleplon cap 10 mg (Sonata)...... 31 ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...... 39 ZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...... 39 ZELBORAF – vemurafenib tab 240 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000 unit...... 26 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000 unit...... 27 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-32000-42000 unit...... 27 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-47000-63000 unit...... 27

Tiered Generics Prescription Drug Guide October 2019 67