E&I CA I000042357 BPLB9216 Access 4 Tier

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2019 California Access Large Group 4-Tier PPO Prescription Drug List Please note: This Prescription Drug List (PDL) is accurate as of May 1, 2019 and is subject to change after this date. All previous versions of this PDL are no longer in effect. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan. This PDL can also be accessed online at myuhc.com > Pharmacy Information > California Prescription Drug Lists (PDL) and Formulary (For Pre-Members/ Members). Plan-specific coverage documents may be accessed online at uhc.com/statedruglists > Large Group Plans > California. If you are a UnitedHealthcare member, please register or log on to myuhc.com or call the toll-free number on your health plan ID card to find pharmacy information specific to your benefit plan. This PDL is applicable to the following health insurance products offered by UnitedHealthcare: • Navigate • Core • Navigate Plus • Core Essential • Choice • Options PPO • Choice Plus • Non-Differential PPO • Select • Select Plus

At UnitedHealthcare, we want to help you better understand your medication options...... 3

How do I use my PDL? ...... 4

What are tiers? ...... 5

When does the PDL change?...... 5

Utilization Management Programs ...... 6

Your Right to Request Access to a Non-formulary Drug ...... 6

Requesting a Prior Authorization or Step Therapy Exception...... 7

How do I locate and fill a prescription through a retail network pharmacy?...... 7

How do I locate and fill a prescription through the mail order pharmacy? ...... 7

How do I locate and fill a prescription at a specialty pharmacy? ...... 8

How do I get updated information about my pharmacy benefit?...... 8

Nondiscrimination notice and access to communication services...... 9

Prescription Drug List...... 12

2 At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly used terms and their definitions as well as frequently asked questions: Brand-name drug means a Prescription Drug Product (1) which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that we identify as a brand-name product, based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “brand-name” by the manufacturer, pharmacy, or your Physician will be classified as brand-name by us. A brand- name drug is listed in this PDL in all CAPITAL letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug. Exception request means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or Prescription Drug List (PDL) means a list that categorizes into tiers medications or products that have been approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and modification (generally quarterly, but no more than six times per calendar year). Generic drug means a Prescription Drug Product: (1) that is Chemically Equivalent to a Brand-name drug; or (2) that we identify as a Generic product based on available data resources. This includes, data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “generic” by the manufacturer, pharmacy or your Physician will be classified as a Generic by us. A generic drug is listed in this PDL in italicized lowercase letters. Medically Necessary means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary. Non-formulary drug means a Prescription Drug Product that is not listed on this PDL. Out-of-pocket costs means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered. Prescribing provider means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription means an oral, written, or electronic order from a prescribing provider authorizing a Prescription Drug Product to be provided to a specific individual. Prescription Drug Product means a medication or product that has been approved by the U.S. Food and Drug Administration (FDA) and that can, under federal or state law, be dispensed only according to a Prescription Order or Refill. A Prescription Drug

3 Product includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non- skilled caregiver. We will provide coverage for a Prescription Drug Product which includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. This definition includes: Inhalers (with spacers); Insulin; the following diabetic supplies: standard insulin syringes with needles; blood-testing strips - glucose; urine-testing strips - glucose; ketone-testing strips and tablets; lancets and lancet devices; and glucose meters (does not include continuous glucose monitors which are covered under the Evidence of Coverage); disposable devices which are Medically Necessary for the administration of a covered outpatient Prescription Drug Product. Benefits also include FDA-approved contraceptive drugs, devices, and products available over-the-counter when prescribed by a Network provider. Prior Authorization means a process by your health insurer to determine that a health care benefit is medically necessary for you. If a Prescription Drug Product is subject to prior authorization in this PDL, your prescribing provider must request approval from your health insurer to cover the drug before you fill your prescription. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy means a specific sequence in which Prescription Drug Products for a particular medical condition must be tried. If a drug is subject to step therapy in this PDL, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug. How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if special programs apply. Bring this list with you when you see your doctor. It is organized by therapeutic category and class. The therapeutic category and class are based on the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification and the U.S. Pharmacopeial Convention (USP) Medicare Model Guidelines. You may also find a drug by its brand or generic name in the alphabetical index. If a generic equivalent for a brand- name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name. This is the way Prescription Drug Products appear in the PDL: 1. A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs; 2. The generic name for a brand- name drug is included after the brand- name in parentheses and all lowercase italicized letters; 3. If a generic equivalent for a brand- name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase italicized letters; and

4. If a generic drug is marketed under a proprietary, trademark-protected brand- name, the brand- name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Example:

If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.

4 Below is a list of drug tier numbers, abbreviations, and designations used in the PDL as well as an explanation for each.

Drug Tier 1 Lower-cost medications covered under the outpatient prescription drug benefit. Drug Tier 2 Mid-range cost medications covered under the outpatient prescription drug benefit. Drug Tier 3 Mid-range cost medications covered under the outpatient prescription drug benefit. Drug Tier 4 Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit. PA Prior authorization required SL Supply Limit ST Step Therapy H May be part of health care reform preventive H-PA May be part of health care reform preventive with prior authorization SP Specialty medication CM Orally administered anticancer medication What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see if there is a Tier 1 option available. Discuss these options with your doctor. For orally administered anti-cancer medications on any Tier, the total amount of copayments and/or coinsurance shall not exceed $250 for an individual prescription of up to a 30-day supply. For high deductible health plans, the $250 maximum only applies once the deductible has been met. Check your benefit plan documents to find out your specific pharmacy plan costs, including any maximum dollar amount of cost sharing that may apply to a drug. Preferred medications are found in tier 1, tier 2 or tier 3 and may vary depending on the medication and the condition it treats.

$ Drug tier Includes Helpful tips

Tier 1 Medications that provide the highest Use Tier 1 drugs for the lowest out‑of- Your lowest overall value. Mostly generic drugs. Some pocket costs. brand-name drugs may also be included. cost Tier 2 and 3 Medications that provide good overall Use Tier 2 or Tier 3 drugs instead Your mid-range value. A mix of brand-name and generic of Tier 4 to help reduce your out-of- drugs. pocket costs. cost Tier 4 Medications that provide the lowest Many Tier 4 drugs have lower‑cost Your highest overall value. Mostly brand-name drugs, options in Tier 1, 2 or 3. Ask your as well as some generics. doctor if they could work for you. cost

Please note: If you have a high deductible plan, the tier cost levels may apply once you reach your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan. When does the PDL change? This PDL is required to be updated on a monthly basis. • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or become non-formulary most often on January 1 or July 1. • Medications may become subject to new or revised utilization management procedures, such as prior authorization, step therapy or supply limits, at any time but most often upon FDA approval of the medication or its generic, January 1, or July 1. 5 When a medication changes tiers, you may have to pay a different amount for that medication. The presence of a Prescription Drug Product on the PDL does not guarantee that you will be prescribed that Prescription Drug Product by your provider for a particular medical condition. Utilization Management Programs Prior authorization required — Your doctor is required to provide additional information to us to determine coverage. For specific prior authorization requirements, please refer to your Evidence of Coverage.

Supply limit — Amount of medication covered per copayment or in a specific time period.

Step therapy — Requires you to try one or more other medications before the medication you are requesting may be covered. For specific step therapy requirements, please refer to your Evidence of Coverage.

Health Care Reform Preventive with Prior Authorization — This medication is part of a health care reform preventive benefit and may be available at no cost to you if prior authorization criteria is met. For more information, please refer to the California Traditional, Access, and Enhanced PPO Prescription Drug List (PDL) PPACA $0 Cost-Share Preventive Care Medications list.

Designated specialty program — For certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products, which are identified in the Coverage Requirements and Limits column of the Prescription Drug List (PDL). If you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program by contacting us at myuhc.com or the telephone number on your ID card.

To learn more about a pharmacy program or to find out if it applies to you, please visitmyuhc.com or call the toll-free member phone number on your health plan ID card. If you are a pre-enrollee and you would like to learn more about your specific pharmacy benefit, please contact your employer. Drugs administered by a healthcare professional are generally covered under the medical benefit while drugs that are self- administered are covered under the pharmacy benefit. In order to obtain medical benefits for drugs that are administered by a healthcare professional, your provider may also be required to obtain a prior authorization. The provider may contact UnitedHealthcare for more information or uhcprovider.com. Your Right to Request Access to a Non-formulary Drug This plan must cover all Medically Necessary Prescription Drug Products. When a Prescription Drug Product is not on our PDL, you or your representative may request an exception to gain access to that Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. If approved, we will cover the Prescription Drug Product for the duration of the prescription, including refills. Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. If approved, we will cover the Prescription Drug Product for the duration of the exigency. External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of its determination within 72 hours. Expedited External Review If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours.

6 If we deny your exception request, you may appeal. Please refer to your Evidence of coverage for details. The complaint and appeals process, including independent review, is described under Section 6: Questions, Complaints and Appeals. You may also call the telephone number listed on your identification (ID) card. Requesting a Prior Authorization or Step Therapy Exception Before certain Prescription Drug Products are dispensed to you, your prescribing provider or your pharmacist is required to obtain prior authorization or step therapy exception from us. Your prescribing provider can submit a request by contacting us at uhcprovider.com. You may determine whether a particular Prescription Drug Product is subject to prior authorization or step therapy requirements through the Internet at myuhc.com or by calling at the toll-free phone number on the back of your health plan ID card. If you are changing policies, we will not require you to repeat step therapy when you are already being treated for a medical condition by a Prescription Drug Product provided the Prescription Drug Product is appropriately prescribed and considered safe and effective for your medical condition. However, we may impose a prior authorization requirement for the continued coverage of a Prescription Drug Product prescribed pursuant to step therapy requirements imposed by the former policy. Your prescribing provider may also prescribe another Prescription Drug Product covered under your policy that is medically appropriate for your medical condition. If you are currently taking a Prescription Drug Product which was approved by UnitedHealthcare for a specific medical condition and that drug is removed from the Prescription Drug List (PDL) and the prescribing provider continues to prescribe the Prescription Drug Product for your medical condition, we will continue to cover the Prescription Drug Product provided that the drug is appropriately prescribed and is considered safe and effective for treating your medical condition. In the case of a standard prior authorization or step therapy exception request, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 72 hours following receipt of the request. In the case of an expedited prior authorization or step therapy exception request based on exigent circumstances, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 24 hours following receipt of the request. If we fail to respond to you, your designee, or your prescribing provider within the prescribed time limits, the request is deemed approved and we may not deny the request thereafter. If you disagree with a determination, you can request an appeal. The complaint and appeals process, including independent medical review, is described in the Evidence of Coverage under Section 6: Questions, Complaints and Appeals. You may also call at the telephone number on your ID card. How do I locate and fill a prescription through a retail network pharmacy? UnitedHealthcare has a well-established Network of pharmacies including most major pharmacy and supermarket chains as well as many independent pharmacies. For a listing of Network Pharmacies, call the toll-free phone number on your health plan ID card to help locate a Network Pharmacy near you or visit our web site at myuhc.com for an up-to-date list. How do I locate and fill a prescription through the mail order pharmacy? UnitedHealthcare offers a Mail Order Pharmacy Program through OptumRx®. Here’s how to fill prescriptions through the Mail Order Pharmacy Program. 1. Call your prescribing provider to obtain a new prescription for each medication. When you call, ask the Physician to write the prescription for a 90-day supply which represents three Prescription Units with up to three additional refills. The doctor will tell you when to pick up the written prescription. (Note: OptumRx must have a new prescription to process any new Mail Order request.) 2. After picking up the prescription, complete the Mail Order Form included in your enrollment materials. (To obtain additional forms or for assistance in completing the form, contact UnitedHealthcare’s Customer Service Department by calling the telephone number on the back of your ID card. You can also find the form at the web site addressoptumrx.com .) 3. Enclose the prescription and appropriate copayment via check, money order, or credit card. Your Pharmacy Schedule of Benefits will have the applicable copayment for the Mail Order Pharmacy Program. Make the check or money order payable to OptumRx. No cash please.

7 Note: Prescription Drug Products such as Schedule II substances (e.g., Morphine, Ritalin and Dexedrine), antibiotics, drugs used for short-term or acute illnesses, and drugs that require special packaging (including refrigeration), are not available through our Mail Order Pharmacy Program. Prescription medications prescribed for the treatment of sexual dysfunction are not available through the Mail Order Pharmacy Program. Important Tip: If you are starting a new Prescription Drug Product, please request two prescriptions from your licensed physician. Have one filled immediately at a Network Pharmacy while mailing the second prescription to UnitedHealthcare’s Mail Order Pharmacy. Once you receive your medication through the Mail Order Pharmacy Program, you should stop filling the prescription at the Network Pharmacy. How do I locate and fill a prescription at a specialty pharmacy? Call the phone number on the back of your health plan ID card or visit BriovaRx.com to locate a designated specialty pharmacy for your medication.

Designated Pharmacies If you require certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Specialty Prescription Drug Products. There are both retail and mail pharmacies in the Designated Pharmacy network. Note that not all contracted retail pharmacies are in the Designated Pharmacy network. Only retail pharmacies that are in the Designated Pharmacy network will provide access to these Specialty Prescription Drug Products. If you choose not to obtain your Specialty Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program through the Internet at [myuhc.com] or by calling the telephone number on your ID card. If you want to opt-out of the program and fill your Specialty Prescription Drug Product at a non-Designated Pharmacy but do not inform us, you will be responsible for the entire cost of the Specialty Prescription Drug Product and no Benefits will be paid. In urgent or emergent circumstances, you may contact Customer Service by calling the telephone number on the back of your ID card. This will allow you access to the retail network override process and allow the urgent or emergent prescription claim to pay at your local pharmacy for same day access if they have the Prescription Drug Product available. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log in to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by ZIP code • Your prescription history

And, if home delivery services are included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set up reminders for refills • Manage your account

Call the toll-free member phone number on your health plan ID card, or visit myuhc.com® for more information.

8 Nondiscrimination notice and access to communication services

UnitedHealthcare Services, Inc. on behalf of itself and its affiliates does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. If you think you were treated unfairly for any of these reasons, you can send a complaint to: Online: [email protected] Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card. If you think you were treated unfairly because of your race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can also send a complaint to the California Department of Insurance: California Department of Insurance Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013 1-800-927-HELP (1-800-927-4357) 1-800-482-4833 (TTY) Internet Web site: www.insurance.ca.gov

If you think you were treated unfairly because of your sex, age, race, color, national origin, or disability, you can also file a complaint with the U.S. Dept. of Health and Human services: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

9 English IMPORTANT: You can get an interpreter at no cost to talk to your doctor or health insurance company. To get an interpreter or to ask about written information in your language, first call your insurance company’s phone number at 1-800-842-2656. Someone who speaks your language can help you. If you need more help, call the Department of Insurance Hotline at 1-800-927-4357.

Español IMPORTANTE: Puede obtener la ayuda de un intérprete sin costo alguno para hablar con su médico o con su compañía de seguros. Para obtener la ayuda de un intérprete o preguntar sobre información escrita en español, primero llame al número de teléfono de su compañía de seguros al 1-800-842-2656. Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame a la línea directa del Departamento de seguros al 1-800-927-4357. (Spanish)

中文

重要事項﹕您與您的醫生或醫療保險公司交談時，可獲得免費口譯服務。如欲請翻譯員提供口譯，或欲查詢中文書面資料，請先致電您的保險公司，電話號碼1-800-842-2656

說中文人士將為您提供協助。如需更多協助，請致電保險部熱線 1-800-927-4357 (Chinese)

10 ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-866-260-2723.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請致電：1-866-260-2723.

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다.귀하 의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русским (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

ﺗﻨﺒﯿﮫ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻌﺮﺑﯿﺔ (Arabic)، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ اﻟﻤﺠﺎﻧﯿﺔ ﻣﺘﺎﺣﺔ ﻟﻚ. اﻟﺮﺟﺎء اﻻﺗﺼﺎل ﻋﻠﻰ رﻗﻢ اﻟﮭﺎﺗﻒ اﻟﻤﻮﺟﻮد ﻋﻠﻰ ّﻣﻌﺮف اﻟﻌﻀﻮﯾﺔ. اﻟﻤﺠﺎﻧﻲ

注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証に記載されているフリーダイヤルにお電話ください。

ﺗﻮﺟﮫ: اﮔﺮ زﺑﺎن ﺷﻤﺎ ﻓﺎرﺳﯽ (Farsi) اﺳﺖ، ﺧﺪﻣﺎت اﻣﺪاد زﺑﺎﻧﯽ ﺑﮫ طﻮر راﯾﮕﺎن در اﺧﺘﯿﺎر ﺷﻤﺎ ﻣﯽ ﺑﺎﺷﺪ. ﻟﻄﻔﺎ ﺑﺎ ﺷﻤﺎره ﺗﻠﻔﻦ راﯾﮕﺎﻧﯽ ﮐﮫ روی ﮐﺎرت ﺷﻨﺎﺳﺎﯾﯽ ﺷﻤﺎ ﻗﯿﺪ ﺷﺪه ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ.

�यान ��: य�� आप हंद (Hindi) भाषी ह� तो आपके लए भाषा सहायता सेवाएं �न:शुक उपल�� ह�� कृ पया अपने पहचान प पर ��ए टोल- फ़ोन नंबर पर काल कर� �

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

��ខមែ��ស��ខែ (Khmer, Cambodian) �ស��ស�� សូមទូខស��ស��ខ�ស��

ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե հայերեն (Armenian) եք խոսում, անվճար լեզվական օգնության ծառայություններ են հասնում Ձեզ: Խնդրվում է զանգահարել անվճար հեռախոսահամարով, որը նշվել է Ձեր ճանաչողական քարտի վրա:

ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ� ਪੰ ਜ ਾ ਬ ੀ (Punjabi) ਬੋਲਦੇ ਹੋ, ਤ� ਤੁਹਾਡੇ ਲਈ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਸੇਵਾਵ� ਿਬਲਕੁਲ ਮੁਫ਼ਤ ਉਪਲਬਧ ਹਨ। ਿਕਰਪਾ ਕਰਕੇ ਆਪਣੇ ਪਛਾਣ-ਪੱ ਤ ਰ 'ਤੇ ਿਦੱ ਤ ੇ ਗਏ ਟੋਲ ਫ਼ੀ ਨੰ ਬ ਰ 'ਤੇ ਕਾੱਲ ਕਰੋ।

โปรดทราบ: หากคุณพูดภาษาไทย (Thai) มีบริการความชวยเห่ ลือด ้านภาษาให ้แก่คุณโดยที คุณไม่ต ้องเสยค่าใชี จ่ายแต่อย่างใด้ โปรดโทรศพท์ถึงหั มายเลขโทรฟรีทีอยู่บนบัตรประจําตัวของคุณ 11 Table of Contents of Prescription Drug List

Informational Section...... 1 Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 12 Anesthetics - Drugs for Numbing...... 19 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence...... 20 Antibacterials - Drugs to Treat Bacterial Infections...... 21 Anticonvulsants - Drugs to Treat Seizures...... 29 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia...... 34 Antidepressants - Drugs to Treat Depression...... 34 Antiemetics - Drugs to Treat Nausea and Vomiting...... 38 Antifungals - Drugs to Treat Fungal Infections...... 39 Antigout Agents - Drugs to Treat Gout...... 42 Anti-inflammatory Agents - Drugs to Treat Inflammation...... 42 Antimigraine Agents - Drugs to Treat Migraines...... 42 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis...... 44 Antimycobacterials - Drugs to Treat Infections...... 44 Antineoplastics - Drugs to Treat Cancer...... 45 Antiparasitics - Drugs to Treat Parasitic Infections...... 52 Antiparkinson Agents - Drugs to Treat Parkinson's Disease...... 53 Antipsychotics - Drugs to Treat Mood Disorders...... 55 Antispasticity Agents...... 57 Antivirals - Drugs to Treat Viral Infections...... 57 Anxiolytics - Drugs to Treat Anxiety...... 64 Bipolar Agents - Drugs to Treat Mood Disorders...... 65 Blood Glucose Regulators - Drugs to Regulate Blood Sugar...... 66 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders...... 71 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions...... 77 Central Nervous System Agents - Drugs to Treat Nerve Conditions...... 90 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions...... 95 Dermatological Agents - Drugs to Treat Skin Conditions...... 96 Electrolytes/Minerals/Metals/Vitamins...... 105 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions...... 111 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 116 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...... 118 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones...... 121 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones...... 127 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones...... 127 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones...... 127 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones...... 138 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones...... 139 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones...... 139 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones...... 140 Immunological Agents - Drugs that Stimulate or Suppress the Immune System...... 141 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease...... 146 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions...... 147 Miscellaneous Therapeutic Agents...... 149 Ophthalmic Agents - Drugs to Treat Eye Conditions...... 153 Otic Agents - Drugs to Treat Ear Conditions...... 159 Respiratory Tract Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 160 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 160 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm...... 170 TOC-1 Sleep Disorder Agents - Drugs for Sedation and Sleep...... 170

TOC-2 Coverage Requirements & Prescription Drug Name Drug Tier Limits Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics ALLZITAL ORAL TABLET 25-325 MG (butalbital- 4 acetaminophen) butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) 4 butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 butalbital-apap oral tablet 50-325 mg 1 butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 1 SL (6 capsules per day) mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 duraxin oral capsule 300-200-20 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap-caffeine) 4 SL (6 tablets per day) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 4 SL (6 capsules per day) caffeine) FIORINAL ORAL CAPSULE 50-325-40 MG (butalbital-aspirin- 4 caffeine) MEDI-DERM-RX EXTERNAL CREAM 0.035-5-20 % (capsaicin- 3 menthol-methyl sal) MEDROX-RX EXTERNAL OINTMENT 0.05-7-20 % (capsaicin- 3 menthol-methyl sal) butalbital-apap-caffeine (Phrenilin Forte Oral Capsule 50-300- 1 SL (6 capsules per day) 40 Mg) tencon oral tablet 50-325 mg 1 TURPENTINE EXTERNAL SPIRIT 3 VANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML 2 (butalbital-apap-caffeine) VANATOL S ORAL SOLUTION 50-325-40 MG/15ML 2 (butalbital-apap-caffeine) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) 1 SL (6 capsules per day)

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 4 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 4 levodopa-entacapone) Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs AZILECT ORAL TABLET 0.5 MG, 1 MG (rasagiline mesylate) 4 rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs ADASUVE INHALATION AEROSOL POWDER BREATH 3 ACTIVATED 10 MG (loxapine) chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 1 50 mg fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 haloperidol lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1 loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 molindone hcl oral tablet 10 mg, 25 mg, 5 mg 1 pimozide oral tablet 1 mg, 2 mg 1 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 2nd Generation/Atypical - Mood Disorder Drugs aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 SL (1 tablet per day) Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits aripiprazole oral tablet 2 mg 1 SL (2 tablets per day) aripiprazole oral tablet 5 mg 1 SL (1.5 tablets per day) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (1 tablet per day) FANAPT ORAL TABLET 1 MG (iloperidone) 4 SL (86 tablets per year) FANAPT ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG, 8 MG 4 SL (2 tablets per day) (iloperidone) FANAPT ORAL TABLET 2 MG (iloperidone) 4 SL (56 tablets per year) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG SL (8 tablets (1 pack) per 3 (iloperidone) 365 days) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG 2 SL (1 tablet per day) (lurasidone hcl) LATUDA ORAL TABLET 80 MG (lurasidone hcl) 2 SL (2 tablets per day) NUPLAZID ORAL CAPSULE 34 MG (pimavanserin tartrate) 4 PA NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 4 PA olanzapine oral tablet 10 mg, 15 mg, 20 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet 2.5 mg 1 SL (2 tablets per day) olanzapine oral tablet 5 mg 1 SL (3 tablets per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 1 SL (1 tablet per day) mg, 9 mg paliperidone er oral tablet extended release 24 hour 6 mg 1 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 1 SL (31 tablets per 31 days) mg quetiapine fumarate er oral tablet extended release 24 hour 200 1 SL (1 tablet per day) mg quetiapine fumarate er oral tablet extended release 24 hour 300 1 SL (62 tablets per 31 days) mg, 400 mg SL (13 tablets per year for quetiapine fumarate er oral tablet extended release 24 hour 50 1 initial fill 3 tablets per day for mg maintenance fill) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 4 ST; SL (1 tablet per day) MG, 4 MG (brexpiprazole)

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT 4 PA; SP (antihemophil fact single chain) ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 2 SP UNIT, 250 UNIT, 500 UNIT (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION 2 RECONSTITUTED 1000 UNIT (coagulation factor ix) ALPHANINE SD INTRAVENOUS SOLUTION 2 SP RECONSTITUTED 1500 UNIT, 500 UNIT (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 3 SP UNIT (coagulation factor ix (rfixfc)) AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic acid) 3 AMICAR ORAL TABLET 1000 MG (aminocaproic acid) 3 AMICAR ORAL TABLET 500 MG (aminocaproic acid) 4 aminocaproic acid oral tablet 1000 mg, 500 mg 1 ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 2 SP UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 2 SP 250 UNIT, 500 UNIT (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor xiii 2 SP concentrate human) ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4 PA; SP 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihemophilic factor rfviiifc) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 2 SP (antiinhibitor coagulant cmplx) HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 2 PA; SP MG/ML, 30 MG/ML, 60 MG/0.4ML (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 2 SP 1700 UNIT (antihemophilic factor) Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT 2 SP (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT 4 SP (coagulation factor ix (rix-fp)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihemophilic factor 2 (recomb)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (antihemophilic factor (recomb)) LYSTEDA ORAL TABLET 650 MG (tranexamic acid) 3 SL (30 tablets per 5 days) MONOCLATE-P INTRAVENOUS KIT 1000 UNIT 2 SP (antihemophilic factor) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT (coagulation factor ix) monsels ferric subsulfate external solution 1 NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (antihemophilic factor (recomb)) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 2 SP 1500 UNIT (antihemophilic factor (recomb)) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation 2 SP factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil 2 SP fact (bdd-rfviii)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 2 SP UNIT, 500 UNIT (antihemophil fact (bdd-rfviii)) PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 2 SP 1000 UNIT, 1500 UNIT, 500 UNIT (factor ix complex)

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAFRINSE WEEKLY MOUTH/THROAT SOLUTION 4 RECONSTITUTED 0.2 % (sodium fluoride) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) 1 paroex mouth/throat solution 0.12 % 1 PERIDEX MOUTH/THROAT SOLUTION 0.12 % (chlorhexidine 4 gluconate) chlorhexidine gluconate (Periogard Mouth/Throat Solution 0.12 1 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % (sodium 4 fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium 4 fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) 4 SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) 4 sf 5000 plus dental cream 1.1 % 1 sf dental gel 1.1 % 1 TOPEX TOPICAL ANESTHETIC MOUTH/THROAT AEROSOL 3 20 % (benzocaine) triamcinolone acetonide mouth/throat paste 0.1 % 1 Dermatological Agents - Drugs to Treat Skin Conditions ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- 4 benzoyl perox) acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 ACZONE EXTERNAL GEL 5 % (dapsone) 1 ACZONE EXTERNAL GEL 7.5 % (dapsone) 2 adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 AKTIPAK EXTERNAL PACKET 5-3 % (benzoyl peroxide- 4 erythromycin) ALDARA EXTERNAL CREAM 5 % (imiquimod) 4 Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALEVAMAX EXTERNAL CREAM 4 AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) 3 isotretinoin (Amnesteem Oral Capsule 10 Mg) 1 amnesteem oral capsule 20 mg, 40 mg 1 sulfacetamide sodium-sulfur (Avar Cleanser External Emulsion 1 10-5 %) AVAR EXTERNAL PAD 9.5-5 % (sulfacetamide sodium-sulfur) 4 AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) AVAR LS EXTERNAL PAD 10-2 % (sulfacetamide sodium- 4 sulfur) sulfacetamide sodium-sulfur (Avar-E Emollient External Cream 3 10-5 %) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) tretinoin (Avita External Cream 0.025 %) 1 PA tretinoin (Avita External Gel 0.025 %) 1 PA azelaic acid external gel 15 % 1 AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 balsam peru-castor oil external ointment 1 BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 2 erythromycin) BENZIQ WASH EXTERNAL LIQUID 5.25 % (benzoyl peroxide) 4 benzoin compound external tincture 1 BENZOIN EXTERNAL TINCTURE 3 benzoyl peroxide-erythromycin external gel 5-3 % 1 BORIC ACID EXTERNAL GRANULES 3 bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 calcipotriene external cream 0.005 % 1 calcipotriene external ointment 0.005 % 1 calcipotriene external solution 0.005 % 1 calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits calcipotriene (Calcitrene External Ointment 0.005 %) 3 calcitriol external ointment 3 mcg/gm 1 CARAC EXTERNAL CREAM 0.5 % (fluorouracil) 2 urea (Cerovel External Lotion 40 %) 1 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 CLEOCIN-T EXTERNAL GEL 1 % (clindamycin phosphate) 4 CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin phosphate) 4 CLEOCIN-T EXTERNAL SOLUTION 1 % (clindamycin 4 phosphate) CLEOCIN-T EXTERNAL SWAB 1 % (clindamycin phosphate) 4 CLINDACIN ETZ EXTERNAL KIT 1 % (clindamycin phos & 4 cleanser) clindacin etz external swab 1 % 1 CLINDACIN PAC EXTERNAL KIT 1 % (clindamycin phos & 4 cleanser) clindamycin phosphate (Clindacin-P External Swab 1 %) 1 CLINDAGEL EXTERNAL GEL 1 % (clindamycin phosphate) 4 SL (1 bottle (45 grams) per clindamycin phos-benzoyl perox external gel 1.2-5 % 1 month) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 clindamycin phosphate external foam 1 % 1 clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 clindamycin phosphate external swab 1 % 1 CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL 1 % 4 clindamycin phosphate gel 1 % external 1 % 1 clindamycin-tretinoin external gel 1.2-0.025 % 1 CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & cleanser) 4 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 COAL TAR EXTERNAL SOLUTION 20 % 3 CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 3 CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML (hc- 4 pramoxine-chloroxylenol)

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1 clobetasol propionate external solution 0.05 % 1 CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol 3 propionate) clocortolone pivalate external cream 0.1 % 1 clocortolone pivalate pump external cream 0.1 % 1 clobetasol propionate (Clodan External Shampoo 0.05 %) 1 CORDRAN EXTERNAL LOTION 0.05 % (flurandrenolide) 4 CORDRAN EXTERNAL OINTMENT 0.05 % (flurandrenolide) 4 CORDRAN EXTERNAL TAPE 4 MCG/SQCM (flurandrenolide) 3 CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 4 (hydrocortisone) cortisone acetate oral tablet 25 mg 1 CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone 3 propionate) prednisone (Deltasone Oral Tablet 20 Mg) 1 DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % 4 (fluocinolone acetonide) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % 4 (fluocinolone acetonide) DERMASORB HC EXTERNAL KIT 2 % (hydrocortisone- 4 cleanser) DERMASORB TA EXTERNAL KIT 0.1 % (triamcinolone & 4 emollient) DESONATE EXTERNAL GEL 0.05 % (desonide) 3 desonide external cream 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 DESOWEN EXTERNAL CREAM 0.05 % (desonide) 3 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 dexamethasone intensol oral concentrate 1 mg/ml 1 Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 1 mg, 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg 1 (35), 1.5 mg (51) dexamethasone (Dexpak 10 Day Oral Tablet Therapy Pack 1.5 4 Mg (35)) dexamethasone (Dexpak 13 Day Oral Tablet Therapy Pack 1.5 4 Mg (51)) DEXPAK 6 DAY ORAL TABLET THERAPY PACK 1.5 MG (21) 4 (dexamethasone) diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1 DIPROLENE AF EXTERNAL CREAM 0.05 % (betamethasone 4 dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % (betamethasone 4 dipropionate aug) ELOCON EXTERNAL CREAM 0.1 % (mometasone furoate) 4 fludrocortisone acetate oral tablet 0.1 mg 1 fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 % 1 fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1 fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluticasone propionate external ointment 0.005 % 1 halobetasol propionate external cream 0.05 % 1 halobetasol propionate external ointment 0.05 % 1 HALOG EXTERNAL CREAM 0.1 % (halcinonide) 3 HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) 3 dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 Mg 4 (21)) PA; ST; SL (20 ml per 24 HP ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 4 days); SP hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 LOCOID EXTERNAL CREAM 0.1 % (hydrocortisone butyrate) 4 LOCOID EXTERNAL SOLUTION 0.1 % (hydrocortisone 4 butyrate) MEDROL ORAL TABLET 16 MG, 4 MG, 8 MG 4 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET 32 MG (methylprednisolone) 3 MEDROL ORAL TABLET THERAPY PACK 4 MG 4 (methylprednisolone) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 methylprednisolone oral tablet therapy pack 4 mg 1 MICORT-HC EXTERNAL CREAM 2.5 % (hydrocortisone 4 acetate) MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 2 MG (48) (prednisolone)

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP INJECTION SOLUTION 4 MCG/ML (desmopressin 4 acetate) DDAVP NASAL SOLUTION 0.01 % (desmopressin acetate 4 spray) DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin 4 acetate) DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % 3 (desmopressin ace refrigerated) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate spray nasal solution 0.01 % 1 INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA; SL (52 vials per month); 2 (mecasermin) SP NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 SL (1 tablet per day) 55.3 MCG (desmopressin acetate) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 PA; SL (18 ml (9 cartridges) 2 MG/2ML (somatropin) per month); SP NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 20 PA; SL (10 ml (5 cartridges) 2 MG/2ML (somatropin) per month); SP NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 5 PA; SL (36 ml (18 cartridges) 2 MG/2ML (somatropin) per month); SP STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM ORAL TABLET 300 MG (mifepristone) 3 PA; SP Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs ANADROL-50 ORAL TABLET 50 MG (oxymetholone) 3 Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 2 SL (1 patch per day) MG/24HR, 4 MG/24HR (testosterone) danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 3 MG/ML (testosterone cypionate) DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 4 MG/ML (testosterone cypionate) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) 2 SL (1 insert per day) METHITEST ORAL TABLET 10 MG 2 methyltestosterone oral capsule 10 mg 1 oxandrolone oral tablet 10 mg, 2.5 mg 1 STRIANT BUCCAL 30 MG (testosterone) 3 SL (2 tablets per day) SL (100 mg Testosterone (2 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) (testosterone) 1 X 5 grams tubes = 10 grams) per day) testosterone cypionate intramuscular solution 100 mg/ml, 200 1 mg/ml testosterone enanthate intramuscular solution 200 mg/ml 1 Estrogens - Hormone Replacement/Modifying Drugs ACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG (estradiol- 4 norethindrone acet) ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 SL (8 patches (1 box) per 28 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 days) (estradiol) altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 amethia lo oral tablet 0.1-0.02 & 0.01 mg 1 H levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 1 H &0.01 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H balziva oral tablet 0.4-35 mg-mcg 1 H bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BI-EST 80:20 PROGESTERONE TRANSDERMAL CREAM 3 BIEST/PROGESTERONE TRANSDERMAL CREAM (estradiol- 3 estriol-progesterone) blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- 1 H 0.02 & 0.01 Mg) camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 2 SL (4 patches per month) 0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol-norethindrone 2 SL (8 patches per 28 days) acet) covaryx hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest (Covaryx Oral Tablet 1.25-2.5 Mg) 1 Cryselle-28 Oral Tablet 0.3-30 Mg-Mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 Mg- 1 H Mcg) cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H

Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, PA; SL (2 tablets per day); 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 4 SP (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PA; SL (200 tablets per 4 (selexipag) year); SP VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 2 PA; SP (iloprost) Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis PA; SL (9 capsules per day); ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 2 SP PA; SL (9 tablets per day); ESBRIET ORAL TABLET 267 MG (pirfenidone) 2 SP PA; SL (3 tablets per day); ESBRIET ORAL TABLET 801 MG (pirfenidone) 2 SP PA; SL (2 capsules per day); OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib esylate) 4 SP Respiratory Tract Agents, Other - Asthma/Lung Drugs acetylcysteine inhalation solution 10 %, 20 % 1 ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 1 SL (2 blisters per day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 SL (1 inhaler per month) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day) vilanterol) benzonatate oral capsule 100 mg, 150 mg, 200 mg 1 BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 2 SL (10.7 grams per month) MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 inhalers per day) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 SL (2 blisters per day) ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) pseudoeph-bromphen-dm (Bromfed Dm Oral Syrup 30-2-10 1 Mg/5Ml) Drug Tier 1: Lower-cost medications covered under the outpatient prescription drug benefit; Drug Tier 2: Mid- range cost medications covered under the outpatient prescription drug benefit; Drug Tier 3: Mid-range cost medications covered under the outpatient prescription drug benefit; Drug Tier 4: Highest-cost medications, such as specialty, covered under the outpatient prescription drug benefit; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-PA: May be part of health care reform preventive with prior authorization; SP: Specialty medication; CM: Orally administered anticancer medication. 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION SL (8 grams (2 inhalers) per 2 20-100 MCG/ACT (ipratropium-albuterol) month) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 ST; SL (1 canister per 4 MCG/ACT (mometasone furo-formoterol fum) month) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 (azelastine-fluticasone) FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 1 SL (1 inhaler per month) MCG/ACT, 55-14 MCG/ACT GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) GILTUSS TR ORAL TABLET 10-28-388 MG (phenylephrine- 3 dm-gg) GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 4 PA; SL (1 tablet per day) (timothy grass pollen allergen) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 hydrocodone polst-cpm polst er oral suspension extended 1 PA release 10-8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 PA hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA hydromet oral syrup 5-1.5 mg/5ml 1 PA HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 2 7 % (sodium chloride) ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 sodium chloride (Nebusal Inhalation Nebulization Solution 3 %) 1 NEBUSAL INHALATION NEBULIZATION SOLUTION 6 % 3 (sodium chloride) NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML 3 (phenylephrine-chlorphen-dm) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 4 PA; SL (1 tablet per day) (dust mite mixed allergen ext) ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET 4 PA; SL (1 tablet per day) SUBLINGUAL 300 IR (grass mix pollens allergen ext)

172 amlodipine besylate-benazepril ARCALYST...... 144 AVAR LS CLEANSER...... 97 hcl...... 82 ARICEPT...... 34 Avar-E Emollient...... 97 amlodipine besylate-valsartan.. 83 ARIKAYCE...... 21 AVAR-E GREEN...... 97 amlodipine-atorvastatin...... 83 aripiprazole...... 55, 56 AVAR-E LS...... 97 amlodipine-olmesartan...... 83 ARIXTRA...... 71 AVC VAGINAL...... 39 amlodipine-valsartan-hctz...... 83 armodafinil...... 171 aviane...... 129 Amnesteem...... 97 ARMOUR THYROID...... 141 avidoxy...... 28 amnesteem...... 97 ARNUITY ELLIPTA...... 161 AVIDOXY DK...... 28 amoxapine...... 37 AROMASIN...... 47 Avita...... 97 amoxicill-clarithro-lansopraz... 112 ARTHROTEC...... 13 AVONEX PEN...... 94 amoxicillin...... 25 ARTISS...... 74 AVONEX PREFILLED...... 94 amoxicillin-potassium ARZOL SILVER NIT AVONEX VIAL clavulanate...... 26 APPLICATORS...... 22 INTRAMUSCULAR KIT...... 94 amoxicillin-potassium Ascomp-Codeine...... 16 AYGESTIN...... 137 clavulanate er...... 25 ashlyna...... 128 AZASAN...... 141 amphetamine sulfate...... 90 ASMANEX 120 METERED AZASITE...... 156 amphetamine- DOSES...... 161 azathioprine...... 141 dextroamphetamine...... 90 ASMANEX 14 METERED azelaic acid...... 97 ampicillin...... 26 DOSES...... 161 azelastine hcl...... 155, 160 ANADROL-50...... 127 ASMANEX 30 METERED AZELEX...... 97 anagrelide hcl...... 72 DOSES...... 161 AZESCO...... 109 ANALPRAM HC...... 146 ASMANEX 60 METERED AZILECT...... 55 ANALPRAM HC SINGLES..... 146 DOSES...... 162 azithromycin...... 26 ANALPRAM-HC...... 146 ASMANEX 7 METERED AZOPT...... 157 ANASPAZ...... 111 DOSES...... 162 AZULFIDINE...... 147 anastrozole...... 47 ASMANEX HFA...... 162 AZULFIDINE EN-TABS...... 147 ANCOBON...... 39 aspirin-dipyridamole er...... 77 azurette...... 129 ANDRODERM...... 128 ASTRINGYN...... 74 bacitracin...... 156 ANGELIQ...... 128 ATACAND...... 78 bacitracin-polymyxin b...... 153 ANORO ELLIPTA...... 167 ATACAND HCT...... 83 bacitra-neomycin-polymyxin-hc ANTABUSE...... 20 atazanavir sulfate...... 63 ...... 153 ANTARA...... 86 atenolol...... 80 baclofen...... 170 anticoagulant cit dext soln a...... 71 atenolol-chlorthalidone...... 83 BACTRIM...... 27 ANTICOAGULANT SODIUM atomoxetine hcl...... 91 BACTRIM DS...... 27 CITRATE...... 71 atorvastatin calcium...... 87 balsalazide disodium...... 146 anucort-hc...... 42 atovaquone...... 52 balsam peru-castor oil...... 97 ANUSOL-HC...... 146 atovaquone-proguanil hcl...... 52 balziva...... 129 ANZEMET...... 38 ATRIPLA...... 60 BANZEL...... 32 apap-caff-dihydrocodeine...... 16 atropine sulfate...... 153 BARACLUDE...... 58 APEXICON E...... 121 ATROVENT HFA...... 163 BASAGLAR KWIKPEN...... 69 APLENZIN...... 34 AUBAGIO...... 94 BAXDELA...... 27 APOKYN...... 53 aubra...... 129 BAYER BREEZE 2 CONTROL apraclonidine hcl...... 157 aubra eq...... 129 ...... 149 aprepitant...... 38 AUGMENTIN...... 26 BAYER CONTOUR...... 149 apri...... 128 AURYXIA...... 109 BAYER CONTOUR NEXT APRISO...... 146 AUSTEDO...... 92 CONTROL...... 149 APTENSIO XR...... 91 AUTOLET II CLINISAFE...... 149 BAYER CONTOUR NEXT APTIOM...... 32 AVALIDE...... 83 MONITOR...... 149 APTIVUS...... 63 AVANDIA...... 66 BAYER CONTOUR NEXT aranelle...... 128 AVAPRO...... 78 TEST...... 149 ARANESP (ALBUMIN FREE) AVAR...... 97 BAYER MICROLET 2 ...... 72, 73 Avar Cleanser...... 97 LANCING DEVIC...... 149 ARAVA...... 144 AVAR LS...... 97 BECONASE AQ...... 162

173 bekyree...... 129 bisoprolol-hydrochlorothiazide.. 83 BYSTOLIC...... 80 BELBUCA...... 14 BLEPH-10...... 27 BYVALSON...... 83 BELLADONNA ALKALOIDS- BLEPHAMIDE...... 153 cabergoline...... 139 OPIUM...... 112 BLEPHAMIDE S.O.P...... 154 CABOMETYX...... 48 belladonna-opium...... 112 blisovi 24 fe...... 129 CAFERGOT...... 42 BELSOMRA...... 171 blisovi fe 1.5/30...... 129 caffeine citrate...... 92 BELVIQ...... 92 blisovi fe 1/20...... 129 CALAN...... 81 BELVIQ XR...... 92 BONIVA...... 148 CALAN SR...... 81 benazepril hcl...... 78 BORIC ACID...... 97 CALCIFOL...... 109 benazepril-hydrochlorothiazide. 83 BOSULIF...... 48 calcipotriene...... 97 BENEFIX...... 74 bp 10-1...... 97 calcipotriene-betameth diprop...97 BENLYSTA...... 145 bp cleansing wash...... 97 calcitonin (salmon)...... 148 BENZALKONIUM CHLORIDE.. 22 BRAFTOVI...... 48 Calcitrene...... 98 benzalkonium chloride...... 22 BREO ELLIPTA...... 167 calcitriol...... 98, 148 BENZAMYCIN...... 97 briellyn...... 129 calcium acetate (phos binder).109 BENZIQ WASH...... 97 BRILINTA...... 77 calcium-folic acid plus d...... 109 BENZNIDAZOLE...... 52 brimonidine tartrate...... 157 CALQUENCE...... 48 BENZOIN...... 97 BRIVIACT...... 29 CAMBIA...... 13 benzoin compound...... 97 Bromfed Dm...... 167 camila...... 137 benzonatate...... 167 bromfenac sodium (once-daily) camrese...... 129 benzoyl peroxide-erythromycin. 97 ...... 158 Camrese Lo...... 129 benzphetamine hcl...... 92 bromocriptine mesylate...... 54 CANASA...... 146 benztropine mesylate...... 53 brompheniramine tannate...... 160 candesartan cilexetil...... 78 BEPREVE...... 156 BROMSITE...... 158 candesartan cilexetil-hctz...... 83 BERINERT...... 141 BROVANA...... 164 CAPEX...... 121 BESIVANCE...... 156 budesonide...... 147, 162 CAPRELSA...... 48 BETADINE OPHTHALMIC bumetanide...... 85 captopril...... 78 PREP...... 22 BUMEX...... 85 captopril-hydrochlorothiazide.... 83 betamethasone dipropionate.. 121 BUNAVAIL...... 20 CARAC...... 98 betamethasone dipropionate Bupap...... 12 CARAFATE...... 115, 116 aug...... 121 BUPHENYL...... 116 CARBAGLU...... 105 betamethasone valerate...... 121 buprenorphine hcl...... 20 carbamazepine...... 32, 33 BETAPACE AF...... 79 buprenorphine hcl-naloxone carbamazepine er...... 32 BETASERON...... 94 hcl...... 20 CARBATROL...... 33 betaxolol hcl...... 80, 157 bupropion hcl...... 35 carbidopa...... 54 bethanechol chloride...... 120 bupropion hcl er (smoking det). 21 carbidopa-levodopa...... 54 BETHKIS...... 165 bupropion hcl er (sr)...... 34 carbidopa-levodopa er...... 54 BETIMOL...... 157 bupropion hcl er (xl)...... 35 carbidopa-levodopa- BETOPTIC-S...... 157 BUPROPION HCL ER (XL)...... 35 entacapone...... 54 BEVESPI AEROSPHERE...... 167 buspirone hcl...... 64 carbinoxamine maleate...... 160 BEVYXXA...... 71 butalbital-acetaminophen...... 12 CARDIOVID PLUS...... 150 bicalutamide...... 45 butalbital-apap...... 12 CARDURA...... 77 BIDIL...... 83 butalbital-apap-caff-cod...... 16 CARDURA XL...... 119 BI-EST 80:20 butalbital-apap-caffeine...... 12 CARETOUCH PROGESTERONE...... 129 butalbital-asa-caff-codeine...... 16 LANCING/EJECTOR...... 150 BIEST/PROGESTERONE...... 129 butalbital-aspirin-caffeine...... 12 carisoprodol...... 170 BIKTARVY...... 61 BUTISOL SODIUM...... 171 carisoprodol-aspirin...... 170 BILTRICIDE...... 52 butorphanol tartrate...... 16 carisoprodol-aspirin-codeine.....16 bimatoprost...... 159 BYDUREON...... 66 CARNITOR...... 105 BINOSTO...... 148 BYDUREON BCISE CARNITOR SF...... 105 BIO-STATIN...... 39 AUTOINJECTOR...... 66 CAROSPIR...... 86 bio-statin...... 39 BYETTA 10 MCG PEN...... 66 carteolol hcl...... 157 bisoprolol fumarate...... 80 BYETTA 5 MCG PEN...... 66 Cartia Xt...... 81

174 carvedilol...... 80 chlorthalidone...... 86 clobazam...... 30 carvedilol phosphate er...... 80 chlorzoxazone...... 170 clobetasol prop emollient base121 cascara sagrada...... 114 CHOLBAM...... 116 clobetasol propionate...... 121, 122 CASODEX...... 45 cholestyramine...... 87 clobetasol propionate e...... 121 CATAPRES...... 77 cholestyramine light...... 87 clobetasol propionate emulsion CATAPRES-TTS-1...... 77 choline fenofibrate...... 86 ...... 121 CATAPRES-TTS-2...... 77 choline-mag trisalicylate...... 13 CLOBEX SPRAY...... 122 CATAPRES-TTS-3...... 77 CIALIS...... 119, 120 clocortolone pivalate...... 122 cavarest...... 95 Ciclodan...... 39 clocortolone pivalate pump..... 122 CAVERJECT...... 120 CICLODAN SOLUTION...... 39 CLODAN...... 98 CAVERJECT IMPULSE...... 120 ciclopirox...... 39 Clodan...... 122 CAYA...... 150 ciclopirox olamine...... 39 clomipramine hcl...... 37 CAYSTON...... 165 ciclopirox treatment...... 39 clonazepam...... 64 caziant...... 129 cilostazol...... 77 clonidine...... 77 cefaclor...... 24 CILOXAN...... 156 clonidine hcl...... 77 CEFACLOR...... 24 CIMDUO...... 61 clonidine hcl er...... 91 cefaclor er...... 24 cimetidine...... 114 clopidogrel bisulfate...... 77 cefadroxil...... 24, 25 cimetidine hcl...... 114 clorazepate dipotassium...... 64 cefdinir...... 25 CIMZIA PREFILLED KIT...... 141 clotrimazole...... 39 cefditoren pivoxil...... 25 CIMZIA STARTER KIT...... 141 clotrimazole-betamethasone.....98 cefixime...... 25 cinacalcet hcl...... 148 clozapine...... 57 cefpodoxime proxetil...... 25 CIPRO...... 27 CLOZARIL...... 57 cefprozil...... 25 CIPRO HC...... 159 COAGADEX...... 74 cefuroxime axetil...... 25 CIPRODEX...... 160 COAL TAR...... 98 celecoxib...... 13 ciprofloxacin...... 27 COARTEM...... 52 CELONTIN...... 30 ciprofloxacin hcl...... 27, 156, 159 codeine sulfate...... 16 CENTANY...... 22 ciprofloxacin-ciproflox hcl er...... 27 colchicine-probenecid...... 42 CENTANY AT...... 22 citalopram hydrobromide...... 35 COLCIGEL...... 150 cephalexin...... 25 CITRANATAL MEDLEY...... 109 COLESTID...... 87, 88 CERDELGA...... 116 claravis...... 98 COLESTID FLAVORED...... 87 Cerovel...... 98 CLARINEX...... 160 colestipol hcl...... 88 CERVIDIL...... 120 CLARINEX-D 12 HOUR...... 168 colistimethate sodium (cba)...... 22 CESAMET...... 38 clarithromycin...... 26 Colocort...... 147 CETRAXAL...... 159 clarithromycin er...... 26 COLY-MYCIN M...... 22 cevimeline hcl...... 95 clemastine fumarate...... 160 COLY-MYCIN S...... 160 CHANTIX...... 21 CLENPIQ...... 114 COLYTE WITH FLAVOR CHANTIX CONTINUING CLEOCIN...... 22 PACKS...... 114 MONTH PAK...... 21 CLEOCIN-T...... 98 COMBIGAN...... 157 CHANTIX STARTING MONTH CLIMARA PRO...... 129 COMBIPATCH...... 129 PAK...... 21 CLINDACIN ETZ...... 98 COMBIVENT RESPIMAT...... 168 chateal...... 129 clindacin etz...... 98 COMBIVIR...... 61 chateal eq...... 129 CLINDACIN PAC...... 98 COMETRIQ (100 MG DAILY CHEMET...... 108 Clindacin-P...... 98 DOSE)...... 48 CHEMSTRIP UGK...... 150 CLINDAGEL...... 98 COMETRIQ (140 MG DAILY CHENODAL...... 113 clindamycin hcl...... 22 DOSE)...... 48 chlordiazepoxide hcl...... 64 clindamycin palmitate hcl...... 22 COMETRIQ (60 MG DAILY chlordiazepoxide-amitriptyline...35 clindamycin phosphate...... 22, 98 DOSE)...... 48 chlordiazepoxide-clidinium...... 112 CLINDAMYCIN PHOSPHATE.. 98 COMPLERA...... 61 chlorhexidine gluconate...... 95 clindamycin phosphate- Compro...... 38 chloroquine phosphate...... 52 benzoyl peroxide...... 98 COMTAN...... 53 chlorothiazide...... 86 clindamycin-tretinoin...... 98 CONCERTA...... 91 chlorpromazine hcl...... 55 CLINDESSE...... 22 CONDYLOX...... 98 chlorpropamide...... 66 clinpro 5000...... 95 constulose...... 114

175 CONTRAVE...... 92 Cyred Eq...... 129 DERMA-SMOOTHE/FS CONZIP...... 14 CYSTADANE...... 116 SCALP...... 122 COPIKTRA...... 46 CYSTAGON...... 116 DERMASORB HC...... 122 CORDRAN...... 122 CYSTARAN...... 154 DERMASORB TA...... 122 COREG...... 80 CYTOMEL...... 138 DERMASORB XM...... 99 CORGARD...... 80 CYTOTEC...... 116 Dermazene...... 39 CORIFACT...... 74 cytra k crystals...... 106 DERMOTIC...... 160 CORLANOR...... 83 DAKLINZA...... 58 DESCOVY...... 62 CORTANE-B...... 98 dalfampridine er...... 94 desipramine hcl...... 37 CORTEF...... 122 DALIRESP...... 165, 166 desloratadine...... 160 CORTENEMA...... 147 danazol...... 128 desmopressin ace spray refrig 127 cortic-nd...... 160 DANTRIUM...... 170 desmopressin acetate...... 127 CORTIFOAM...... 147 dantrolene sodium...... 170 desmopressin acetate spray... 127 cortisone acetate...... 122 dapsone...... 44 desogestrel-ethinyl estradiol... 130 CORTISPORIN...... 99 DARAPRIM...... 52 DESONATE...... 122 CORTROSYN...... 150 darifenacin hydrobromide er... 118 desonide...... 122 COSENTYX 150 MG/ML...... 99 dasetta 1/35...... 129 DESOWEN...... 122 COSENTYX 300 DOSE...... 99 dasetta 7/7/7...... 129 desoximetasone...... 122 COSENTYX SENSOREADY DAURISMO...... 48 DESOXYN...... 90 300 DOSE...... 99 DAYPRO...... 13 DESVENLAFAXINE ER...... 35 COSENTYX SENSOREADY daysee...... 130 desvenlafaxine succinate er...... 35 PEN...... 99 DAYTRANA...... 91 dexamethasone...... 123 COSOPT...... 157 DDAVP...... 127 dexamethasone intensol...... 122 cosyntropin...... 150 DDAVP RHINAL TUBE...... 127 dexamethasone sodium COTELLIC...... 48 DEBACTEROL...... 95 phosphate...... 158 COTEMPLA XR-ODT...... 91 deblitane...... 137 dexchlorpheniramine maleate.160 COUMADIN...... 71 deferasirox...... 108 DEXEDRINE...... 90 Covaryx...... 129 DELESTROGEN...... 130 DEXILANT...... 116 covaryx hs...... 129 DELSTRIGO...... 61 dexmethylphenidate hcl...... 91 COZAAR...... 78 Deltasone...... 122 dexmethylphenidate hcl er...... 91 CREON...... 116 delyla...... 130 Dexpak 10 Day...... 123 CRESEMBA...... 39 DEMADEX...... 85 Dexpak 13 Day...... 123 CRINONE...... 137 demeclocycline hcl...... 28 DEXPAK 6 DAY...... 123 CRIXIVAN...... 63 DEMSER...... 83 dextroamphetamine sulfate...... 90 cromolyn sodium.....113, 156, 165 DENAVIR...... 60 dextroamphetamine sulfate er.. 90 crotan...... 53 denta 5000 plus...... 95 DIASTAT ACUDIAL...... 30 Cryselle-28...... 129 dentagel...... 95 DIASTAT PEDIATRIC...... 30 CUPRIMINE...... 108 DEPAKENE...... 30 diazepam...... 30, 64 CUTIVATE...... 122 DEPAKOTE...... 65 Diazepam Intensol...... 64 CUVPOSA...... 112 DEPAKOTE ER...... 65 DICLOFENAC EPOLAMINE.....13 cyclafem 1/35...... 129 DEPAKOTE SPRINKLES...... 65 diclofenac potassium...... 13 cyclafem 7/7/7...... 129 DEPEN TITRATABS...... 108 diclofenac sodium...... 13, 99, 158 cyclobenzaprine hcl...... 170 DEPO-ESTRADIOL...... 130 diclofenac sodium er...... 13 CYCLOGYL...... 154 DEPO-PROVERA...... 137 diclofenac-misoprostol...... 13 CYCLOMYDRIL...... 156 DEPO-SUBQ PROVERA 104.137 dicloxacillin sodium...... 26 cyclopentolate hcl...... 154 DEPO-TESTOSTERONE...... 128 dicyclomine hcl...... 112 cyclophosphamide...... 45 DERMACINRX DUOPATCH didanosine...... 62 cycloserine...... 44 PHARMAPAK...... 19 diethylpropion hcl...... 93 CYCLOSET...... 66 DERMACINRX NEUROTRAL diethylpropion hcl er...... 92 cyclosporine...... 142 PHARMAPAK...... 19 DIFICID...... 26 cyclosporine modified...... 141 DERMA-SMOOTHE/FS BODY difil-g forte...... 166 cyproheptadine hcl...... 160 ...... 122 diflorasone diacetate...... 123 cyred...... 129 DIFLUCAN...... 39

176 diflunisal...... 13 duloxetine hcl...... 93 emoquette...... 130 Digitek...... 83 DUOPA...... 54 EMSAM...... 35 digox...... 83 DUPIXENT...... 99 EMTRIVA...... 62 digoxin...... 83 duraxin...... 12 EMVERM...... 52 dihydroergotamine mesylate.....42 DUREZOL...... 158 enalapril maleate...... 78 DILANTIN...... 33 dutasteride...... 119 enalapril-hydrochlorothiazide.... 83 DILANTIN INFATABS...... 33 dutasteride-tamsulosin hcl...... 119 ENBREL...... 142 DILATRATE-SR...... 89 DVORAH...... 17 ENBREL MINI...... 142 DILAUDID...... 17 DYANAVEL XR...... 90 ENBREL SURECLICK...... 142 diltiazem hcl...... 81 DYAZIDE...... 83 ENDARI...... 106 diltiazem hcl er...... 81 DYMISTA...... 168 Endocet...... 17 diltiazem hcl er beads...... 81 DYRENIUM...... 86 ENDOMETRIN...... 137 diltiazem hcl er coated beads... 81 E.E.S. GRANULES...... 26 enoxaparin sodium...... 71 dilt-xr...... 81 EASIVENT...... 150 enpresse-28...... 130 DIPENTUM...... 146 EASYMAX CONTROL...... 150 enskyce...... 130 diphenhydramine hcl...... 160 EASYPLUS BLOOD ENSTILAR...... 99 diphenoxylate-atropine...... 113 GLUCOSE TEST...... 150 entacapone...... 53 DIPROLENE...... 123 EC-NAPROXEN...... 13 entecavir...... 58 DIPROLENE AF...... 123 econazole nitrate...... 39 ENTEREG...... 113 dipyridamole...... 77 ECOZA...... 39 ENTRESTO...... 84 disopyramide phosphate...... 79 EC-RX DHEA...... 150 enulose...... 114 disulfiram...... 20 EDARBI...... 78 EPANED...... 78 DITROPAN XL...... 118 EDARBYCLOR...... 83 EPCLUSA...... 58 DIURIL...... 86 EDECRIN...... 85 EPIDIOLEX...... 29 divalproex sodium...... 65 EDEX...... 120 EPIDUO...... 99 divalproex sodium er...... 65 EDLUAR...... 170 EPIDUO FORTE...... 99 DIVIGEL...... 130 ed-spaz...... 111 EPIFOAM...... 99 dofetilide...... 79 EDURANT...... 61 epinastine hcl...... 156 DOLOPHINE...... 14 eemt...... 130 EPINEPHRINE...... 164 donepezil hcl...... 34 eemt hs...... 130 epinephrine...... 164 DOPTELET...... 73 efavirenz...... 61 Epitol...... 33 DORAL...... 65 EFFER-K...... 106 EPIVIR...... 62 DORYX MPC...... 28 effer-k...... 106 EPIVIR HBV...... 58 dorzolamide hcl...... 157 EFUDEX...... 99 eplerenone...... 86 dorzolamide hcl-timolol mal.... 157 EGRIFTA...... 139 EPOGEN...... 73 dorzolamide hcl-timolol mal pf 157 ELESTRIN...... 130 eprosartan mesylate...... 78 DOVONEX...... 99 eletriptan hydrobromide...... 43 EQUETRO...... 33, 65 doxazosin mesylate...... 78 ELIDEL...... 99 ERGOCAL...... 109 doxepin hcl...... 37, 99 ELIGARD...... 140 ergocalciferol...... 109 doxercalciferol...... 148 ELIMITE...... 53 ergoloid mesylates...... 150 doxycycline...... 28 elinest...... 130 ERGOMAR...... 42 doxycycline hyclate...... 28 ELIQUIS...... 71 ergotamine-caffeine...... 42 doxycycline monohydrate...... 28 ELIQUIS STARTER PACK...... 71 ERIVEDGE...... 48 D-PENAMINE...... 120 ELIXOPHYLLIN...... 166 ERLEADA...... 45 DRISDOL...... 109 ELLA...... 137 errin...... 137 dronabinol...... 38 ELMIRON...... 120 ery...... 99 drospiren-eth estrad-levomefol130 ELOCON...... 123 ERYGEL...... 99 drospirenone-ethinyl estradiol.130 ELOCTATE...... 74 ERYPED 200...... 26 DROXIA...... 46 EMADINE...... 156 ERYPED 400...... 26 DRYSOL...... 99 EMCYT...... 46 ERY-TAB...... 26 DUAVEE...... 130 EMEND...... 38 ERYTHROCIN STEARATE...... 26 DUETACT...... 66 EMEND TRI-PACK...... 38 erythromycin...... 99, 156 DULERA...... 168 EMGALITY...... 19, 43 erythromycin base...... 26, 27

177 erythromycin ethylsuccinate...... 27 FARESTON...... 46 FLUCELVAX ESBRIET...... 167 FARYDAK...... 49 QUADRIVALENT...... 145 ESCAVITE...... 109 Fayosim...... 131 fluconazole...... 40 escitalopram oxalate...... 36 FAZACLO...... 57 flucytosine...... 40 ESGIC...... 12 FEIBA...... 74 fludrocortisone acetate...... 123 est estrogens-methyltest...... 130 felbamate...... 31 FLULAVAL QUADRIVALENT est estrogens-methyltest ds.... 130 FELBATOL...... 31 ...... 145, 146 est estrogens-methyltest hs.... 130 FELDENE...... 13 FLUMADINE...... 64 Estarylla...... 130 felodipine er...... 81 FLUMIST QUADRIVALENT....146 estazolam...... 65 FEM PH...... 22 flunisolide...... 162 ESTRACE...... 130 FEMHRT LOW DOSE...... 131 fluocinolone acetonide.... 123, 160 estradiol...... 130, 131 FEMRING...... 131 fluocinolone acetonide body... 123 estradiol valerate...... 131 femynor...... 131 fluocinolone acetonide scalp...123 estradiol-norethindrone acet... 131 fenofibrate...... 86 fluocinonide...... 123 ESTRING...... 131 fenofibrate micronized...... 86 fluocinonide emulsified base...123 ESTROGEL...... 131 fenofibric acid...... 86 FLUORABON...... 106 ESTROSTEP FE...... 131 fentanyl...... 15 fluoridex...... 95 eszopiclone...... 171 fentanyl citrate...... 17 fluoridex daily renewal...... 95 ethacrynic acid...... 85 FENTORA...... 17 fluoridex enhanced whitening... 95 ethambutol hcl...... 44 FERRIPROX...... 108 fluoridex sensitivity relief...... 95 ethosuximide...... 30 FETZIMA...... 36 fluorometholone...... 158 ethynodiol diac-eth estradiol... 131 FETZIMA TITRATION...... 36 FLUOROPLEX...... 100 etidronate disodium...... 148 FEXMID...... 170 FLUOROURACIL...... 100 etodolac...... 13 FINACEA...... 100 fluorouracil...... 100 etodolac er...... 13 finasteride...... 119 fluoxetine hcl...... 36 etoposide...... 47 FIORICET...... 12 fluoxetine hcl (pmdd)...... 36 EUCRISA...... 99 FIORINAL...... 12 fluphenazine hcl...... 55 EURAX...... 53 FIORINAL/CODEINE #3...... 17 FLURA-DROPS...... 106 euthyrox...... 138 FIRAZYR...... 141 flurandrenolide...... 123 Euthyrox...... 138 FIRMAGON...... 140 flurazepam hcl...... 171 EVAMIST...... 131 FIRST-VANCOMYCIN 25...... 21 flurbiprofen...... 13 EVEKEO...... 90 FIRST-VANCOMYCIN 50...... 28 flurbiprofen sodium...... 158 EVOCLIN...... 99 FIRVANQ...... 23 flutamide...... 45 EVOTAZ...... 63 Flac...... 160 fluticasone propionate EVOXAC...... 95 FLAGYL...... 23 ...... 123, 124, 162 EVZIO...... 21 FLAREX...... 158 FLUTICASONE- EXELDERM...... 39, 40 flavoxate hcl...... 118 SALMETEROL...... 168 exemestane...... 47 flecainide acetate...... 79 fluvastatin sodium...... 87 EXJADE...... 108 FLECTOR...... 13 fluvastatin sodium er...... 87 exoderm...... 40 FLEXICHAMBER ADULT fluvoxamine maleate...... 36 exotic-hc...... 160 MASK/SMALL...... 150 fluvoxamine maleate er...... 36 EXTINA...... 40 FLEXICHAMBER CHILD FLUZONE HIGH-DOSE...... 146 EZ FLU SHOT-FLUCELVAX MASK/LARGE...... 150 FLUZONE QUADRIVALENT.. 146 QUAD...... 145 FLEXICHAMBER CHILD FML...... 158 ezetimibe...... 88 MASK/SMALL...... 150 FML FORTE...... 158 ezetimibe-simvastatin...... 88 FLOLIPID...... 87 FML LIQUIFILM...... 158 FABIOR...... 100 FLORIVA...... 106 FOCALIN...... 91 FALESSA...... 131 FLORIVA PLUS...... 109 folic acid...... 106 Falmina...... 131 FLOVENT DISKUS...... 162 fondaparinux sodium...... 71 famciclovir...... 60 FLOVENT HFA...... 162 FORANE...... 150 famotidine...... 114 FLUAD...... 145 FORFIVO XL...... 35 FANAPT...... 56 FLUARIX QUADRIVALENT....145 Formadon...... 100 FANAPT TITRATION PACK..... 56 formaldehyde...... 100

178 FORMALDEHYDE...... 100 glipizide xl...... 66 HETLIOZ...... 171 FORMA-RAY...... 100 glipizide-metformin hcl...... 66 Hidex 6-Day...... 124 FORTEO...... 148 GLUCAGEN HYPOKIT...... 69 HIPREX...... 23 FORTISCARE CONTROL...... 150 GLUCAGON EMERGENCY..... 69 Homatropaire...... 154 FOSAMAX...... 148 GLUCOPHAGE...... 66 homatropine hbr...... 154 FOSAMAX PLUS D...... 148 GLUCOPHAGE XR...... 67 HORIZANT...... 93 fosamprenavir calcium...... 63 GLUCOTROL...... 67 HP ACTHAR...... 124 fosinopril sodium...... 78 GLUCOTROL XL...... 67 HUMALOG KWIKPEN...... 69 fosinopril sodium-hctz...... 84 GLUTARALDEHYDE...... 23 HUMALOG MIX 50/50 FOSRENOL...... 109 glyburide...... 67 KWIKPEN...... 69 FRAGMIN...... 71 glyburide micronized...... 67 HUMALOG MIX 50/50 VIAL...... 69 FROVA...... 43 glyburide-metformin...... 67 HUMALOG MIX 75/25 frovatriptan succinate...... 43 GLYCATE...... 112 KWIKPEN...... 70 FULPHILA...... 73 glycopyrrolate...... 112 HUMALOG MIX 75/25 VIAL...... 70 FURADANTIN...... 23 GLYCOPYRROLATE...... 112 HUMALOG U-100 JUNIOR furosemide...... 85 GLYNASE...... 67 KWIKPEN...... 70 FUZEON...... 63 GLYSET...... 67 HUMALOG U-100 VIAL AND Fyavolv...... 131 GLYXAMBI...... 67 CARTRIDGE...... 70 FYCOMPA...... 31 GOLYTELY...... 115 HUMATE-P...... 75 gabapentin...... 30 GONITRO...... 89 HUMIRA...... 143 GABITRIL...... 30 GORDOFILM...... 100 HUMIRA PEDIATRIC GALAFOLD...... 117 GORDONS UREA...... 100 CROHNS START...... 142 galantamine hydrobromide...... 34 grafco silver nit applicator...... 23 HUMIRA PEN...... 142 galantamine hydrobromide er... 34 granisetron hcl...... 38 HUMIRA PEN-CD/UC/HS GALZIN...... 106 GRASTEK...... 168 STARTER...... 142 GASTROCROM...... 113 griseofulvin microsize...... 40 HUMIRA PEN-PS/UV/ADOL gatifloxacin...... 156 griseofulvin ultramicrosize...... 40 HS START...... 142 GATTEX...... 113 guaiatussin ac...... 168 HUMULIN 70/30 KWIKPEN...... 70 Gavilyte-C...... 115 guaifenesin ac...... 168 HUMULIN 70/30 VIAL...... 70 Gavilyte-G...... 115 guanfacine hcl...... 77 HUMULIN N KWIKPEN...... 70 gavilyte-h...... 115 guanfacine hcl er...... 91 HUMULIN N VIAL...... 70 gavilyte-n with flavor pack...... 115 GUANIDINE HCL...... 44 HUMULIN R U-500 KWIKPEN..70 GELCLAIR...... 95 GYNAZOLE-1...... 40 HUMULIN R U-500 VIAL GELFILM...... 154 HAEGARDA...... 141 (CONCENTRATED)...... 70 GELNIQUE...... 118 hailey 24 fe...... 131 HUMULIN R VIAL...... 70 GELNIQUE PUMP...... 118 HALCION...... 65 HYCAMTIN...... 47 gemfibrozil...... 86 halobetasol propionate...... 124 hydralazine hcl...... 89 GENADUR...... 150 HALOG...... 124 HYDREA...... 46 generlac...... 115 haloperidol...... 55 HYDRO 40...... 100 Gengraf...... 142 haloperidol lactate...... 55 hydrochlorothiazide...... 86 gentak...... 156 HARVONI...... 58 hydrocodone polst-cpm polst gentamicin sulfate...... 22, 156 heather...... 137 er...... 168 GENVOYA...... 60 hematinic/folic acid...... 106 hydrocodone-acetaminophen... 17 gianvi...... 131 HEMLIBRA...... 74 hydrocodone-homatropine...... 168 GILENYA...... 94 Hemmorex-Hc...... 42 hydrocodone-ibuprofen...... 17 GILOTRIF...... 49 hemocyte-f...... 106 hydrocortisone...... 124, 147 GILPHEX TR...... 168 HEMOFIL M...... 74 hydrocortisone ace-pramoxine GILTUSS TR...... 168 hemorrhoidal-hc...... 42 ...... 100, 147 glatiramer acetate...... 94 heparin lock flush...... 150 hydrocortisone acetate...... 42 GLEOSTINE...... 45 heparin sodium (porcine)...... 71 hydrocortisone butyr lipo base 124 glimepiride...... 66 heparin sodium (porcine) pf...... 71 hydrocortisone butyrate...... 124 glipizide er...... 66 heparin sodium lock flush...... 150 hydrocortisone valerate...... 124 glipizide ir...... 66 HEPSERA...... 58 hydrocortisone-acetic acid...... 160

179 hydrocortisone-iodoquinol...... 40 INOVA 8/2 ACNE CONTROL jinteli...... 131 hydromet...... 168 THERAPY...... 100 JIVI...... 151 hydromorphone hcl...... 17 INSPIREASE RESERVOIR Jolessa...... 132 hydromorphone hcl er...... 15 BAGS...... 150 jolivette...... 137 hydroxychloroquine sulfate...... 52 INSPRA...... 86 JUBLIA...... 40 hydroxyurea...... 46 INSULIN PEN NEEDLES...... 151 juleber...... 132 hydroxyzine hcl...... 64 INSULIN SYRINGES...... 151 JULUCA...... 61 hydroxyzine pamoate...... 160 INTELENCE...... 61 junel 1.5/30...... 132 HYLIRA...... 100 INTRAROSA...... 128 junel 1/20...... 132 hyophen...... 118 INTRON A...... 59 junel fe 1.5/30...... 132 hyoscyamine sulfate...... 111, 112 introvale...... 131 junel fe 1/20...... 132 hyoscyamine sulfate er...... 111 INVIRASE...... 63 junel fe 24...... 132 hyoscyamine sulfate sl...... 111 INVOKAMET...... 67 JUXTAPID...... 88 hyosyne...... 111 INVOKAMET XR...... 67 JYNARQUE...... 108 HYPERSAL...... 168 INVOKANA...... 67 KADIAN...... 17 HYPOCYN...... 154 IODINE STRONG...... 151 kaitlib fe...... 132 HYZAAR...... 84 iodine tincture...... 23 KALETRA...... 63 ibandronate sodium...... 148 IOPIDINE...... 157 KALYDECO...... 165 IBRANCE...... 49 ipratropium bromide...... 163 KAPSPARGO SPRINKLE...... 80 Ibu...... 13 ipratropium-albuterol...... 168 KARBINAL ER...... 161 ibudone...... 17 irbesartan...... 78 kariva...... 132 ibuprofen...... 13 irbesartan-hydrochlorothiazide..84 KAZANO...... 67 ICLUSIG...... 49 IRESSA...... 49 KEFLEX...... 25 IDELVION...... 75 ISENTRESS...... 60 Kelnor 1/35...... 132 IDHIFA...... 49 ISENTRESS HD...... 60 Kelnor 1/50...... 132 ILEVRO...... 158 isibloom...... 131 KEPPRA...... 29 imatinib mesylate...... 49 isoflurane...... 151 KEPPRA XR...... 29 IMBRUVICA...... 49 isoniazid...... 44 KERALYT SCALP...... 100 imipramine hcl...... 37 ISOPTO ATROPINE...... 154 KERYDIN...... 40 imipramine pamoate...... 37 ISOPTO CARPINE...... 157 KETOCARE...... 151 imiquimod...... 100 ISORDIL TITRADOSE...... 89 ketoconazole...... 40 IMITREX...... 43 isosorbide dinitrate...... 89 ketoprofen...... 14 IMPAVIDO...... 52 isosorbide dinitrate er...... 89 ketoprofen er...... 13 IMVEXXY MAINTENANCE isosorbide mononitrate...... 89 ketorolac tromethamine.... 14, 158 PACK...... 131 isosorbide mononitrate er...... 89 KETOSTIX...... 151 IMVEXXY STARTER PACK... 131 isotretinoin...... 100 KEVEYIS...... 85 INBRIJA...... 150 isoxsuprine hcl...... 84 KEVZARA...... 145 incassia...... 137 isradipine...... 81 KHEDEZLA...... 36 INCRELEX...... 127 ISTALOL...... 157 KINERET...... 143 INCRUSE ELLIPTA...... 163 itraconazole...... 40 kionex...... 108 indapamide...... 86 ivermectin...... 52 KISQALI 200 DOSE...... 46 INDERAL LA...... 80 JADENU...... 108 KISQALI 400 DOSE...... 46 INDERAL XL...... 80 JADENU SPRINKLE...... 108 KISQALI 600 DOSE...... 46 INDOCIN...... 13 JAKAFI...... 49 KISQALI FEMARA 200 DOSE..46 indomethacin...... 13 Jantoven...... 71 KISQALI FEMARA 400 DOSE..46 indomethacin er...... 13 JANUMET...... 67 KISQALI FEMARA 600 DOSE..47 INGREZZA...... 93 JANUMET XR...... 67 KLARON...... 100 INLYTA...... 49 JANUVIA...... 67 KLONOPIN...... 65 INNOPRAN XL...... 80 JARDIANCE...... 67 Klor-Con...... 106 INOVA...... 100 jasmiel...... 131 Klor-Con 10...... 106 INOVA 4/1 ACNE CONTROL jencycla...... 137 Klor-Con M10...... 106 THERAPY...... 100 JENTADUETO...... 67 KLOR-CON M15...... 106 JENTADUETO XR...... 67 Klor-Con M20...... 106

180 Klor-Con Sprinkle...... 106 leflunomide...... 145 lidocaine...... 19 Klor-Con/Ef...... 106 LENVIMA 10 MG DAILY lidocaine hcl...... 19 KOATE...... 75 DOSE...... 49 lidocaine viscous...... 19 KOATE-DVI...... 75 LENVIMA 12 MG DAILY lidocaine-hydrocortisone ace.... 42 KOGENATE FS...... 75 DOSE...... 49 lidocaine-prilocaine...... 19 KOMBIGLYZE XR...... 68 LENVIMA 14 MG DAILY LIDOPIN...... 19 KORLYM...... 127 DOSE...... 49 lillow...... 132 KOVALTRY...... 75 LENVIMA 18 MG DAILY lindane...... 53 K-PHOS...... 106 DOSE...... 49 linezolid...... 23 K-PHOS NO 2...... 106 LENVIMA 20 MG DAILY LINZESS...... 114 K-PHOS-NEUTRAL...... 106 DOSE...... 50 liothyronine sodium...... 139 k-prime...... 107 LENVIMA 24 MG DAILY LIPOFEN...... 86 KRISTALOSE...... 115 DOSE...... 50 lisinopril...... 78 K-TAB...... 107 LENVIMA 4 MG DAILY DOSE..50 lisinopril-hydrochlorothiazide.....84 kurvelo...... 132 LENVIMA 8 MG DAILY DOSE..50 lithium...... 65 KUVAN...... 117 lessina...... 132 lithium carbonate...... 65 KYNAMRO...... 88 LETAIRIS...... 166 lithium carbonate er...... 65 labetalol hcl...... 80 letrozole...... 47 LITHOBID...... 66 LACRISERT...... 154 leucovorin calcium...... 47 LITHOSTAT...... 120 lactulose...... 115 LEUKERAN...... 45 LIVALO...... 87 lactulose encephalopathy...... 115 LEUKINE...... 73 LO LOESTRIN FE...... 133 LAMICTAL...... 31 leuprolide acetate...... 140 LOCOID...... 124 LAMICTAL ODT...... 31 levalbuterol hcl...... 164 LOESTRIN 1.5/30 (21)...... 133 LAMICTAL STARTER...... 31 LEVALBUTEROL HFA...... 164 LOESTRIN 1/20 (21)...... 133 LAMICTAL XR...... 31 LEVAQUIN...... 27 LOESTRIN FE 1.5/30...... 133 lamivudine...... 58, 62 LEVBID...... 111 LOESTRIN FE 1/20...... 133 lamivudine-zidovudine...... 62 LEVEMIR U-100 FLEXTOUCH.70 LOMAIRA...... 93 lamotrigine...... 32 LEVEMIR U-100 VIAL...... 70 LOMOTIL...... 113 lamotrigine er...... 31 levetiracetam...... 29 LONHALA MAGNAIR REFILL lamotrigine starter kit-blue...... 32 levetiracetam er...... 29 KIT...... 163 lamotrigine starter kit-green...... 32 levobunolol hcl...... 157 LONHALA MAGNAIR lamotrigine starter kit-orange.... 32 levocarnitine...... 107 STARTER KIT...... 163 LANCETS...... 151 levocetirizine dihydrochloride..161 LONSURF...... 47 LANOXIN...... 84 levofloxacin...... 27, 156 LOPID...... 87 lansoprazole...... 116 levonest...... 132 lopinavir-ritonavir...... 63 lanthanum carbonate...... 109 levonorgest-eth est & eth est.. 132 Lopreeza...... 133 larin 1.5/30...... 132 levonorgest-eth estrad 91-day 132 lopreeza...... 133 Larin 1/20...... 132 levonorgestrel...... 137 LOPRESSOR...... 80 larin 24 fe...... 132 levonorgestrel-ethinyl estrad...132 LOPRESSOR HCT...... 84 larin fe 1.5/30...... 132 levonorg-eth estrad triphasic...132 LOPROX...... 40 larin fe 1/20...... 132 levora 0.15/30 (28)...... 132 lorazepam...... 65 larissia...... 132 levorphanol tartrate...... 15 Lorazepam Intensol...... 65 LASIX...... 86 levo-t...... 138 Lorcet...... 17 LASTACAFT...... 154 Levo-T...... 138 Lorcet Hd...... 17 latanoprost...... 159 levothyroxine sodium...... 138 Lorcet Plus...... 17 LATRIX XM...... 100 levothyroxine-liothyronine...... 141 LORTAB...... 17 LATUDA...... 56 Levoxyl...... 139 loryna...... 133 Layolis Fe...... 132 levoxyl...... 139 LORZONE...... 170 LAZANDA...... 17 LEVSIN...... 112 losartan potassium...... 78 L-CYSTINE...... 151 LEVSIN/SL...... 112 losartan potassium-hctz...... 84 lecithin...... 151 LEVULAN KERASTICK...... 100 LOSEASONIQUE...... 133 LEDIPASVIR-SOFOSBUVIR.... 58 LEXIVA...... 63 LOTEMAX...... 158, 159 leena...... 132 LIALDA...... 146 LOTENSIN...... 78

181 LOTENSIN HCT...... 84 megestrol acetate...... 137 methylphenidate hcl er (cd)...... 91 LOTREL...... 84 MEKINIST...... 50 methylphenidate hcl er (la)..91, 92 LOTRISONE...... 101 MEKTOVI...... 50 methylprednisolone...... 124 LOUTREX...... 101 melodetta 24 fe...... 133 methyltestosterone...... 128 lovastatin...... 87 meloxicam...... 14 metoclopramide hcl...... 38, 113 LOVENOX...... 71, 72 melphalan...... 45 metolazone...... 86 low-ogestrel...... 133 memantine hcl...... 34 Metopic...... 101 loxapine succinate...... 55 memantine hcl er...... 34 metoprolol succinate er...... 80 LUCEMYRA...... 20 MENEST...... 133 metoprolol tartrate...... 80 lugols...... 23 MENOSTAR...... 133 metoprolol-hydrochlorothiazide.84 LULICONAZOLE...... 40 MENTAX...... 40 METROCREAM...... 23 LUMIGAN...... 159 meperidine hcl...... 18 METROLOTION...... 23 LUPRON DEPOT (4-MONTH) MEPHYTON...... 110 metronidazole...... 23 INTRAMUSCULAR KIT 30MG 140 meprobamate...... 64 mexiletine hcl...... 79 LUPRON DEPOT (6-MONTH) mercaptopurine...... 46 MIACALCIN...... 148 INTRAMUSCULAR KIT 45MG 140 mesalamine...... 146 Mibelas 24 Fe...... 133 lutera...... 133 mesalamine-cleanser...... 146 miconazole 3...... 40 LUZU...... 40 MESNEX...... 52 MICONAZOLE-ZINC OXIDE- LYNPARZA...... 50 MESTINON...... 44 PETROLAT...... 40 LYRICA...... 94 Metadate Er...... 91 MICORT-HC...... 124 LYRICA CR...... 93 metaproterenol sulfate...... 164 microgestin 1.5/30...... 133 LYSODREN...... 139 Metaxall...... 170 microgestin 1/20...... 133 LYSTEDA...... 75 metaxalone...... 170 microgestin fe 1.5/30...... 133 Lyza...... 137 metformin hcl er...... 68 Microgestin Fe 1/20...... 133 MACROBID...... 23 METFORMIN HCL IR...... 68 MICROLET NEXT LANCING MACRODANTIN...... 23 metformin hcl ir...... 68 DEVICE...... 151 mafenide acetate...... 23 methadone hcl...... 15 midazolam hcl...... 65 MAGNEBIND 400...... 110 Methadone Hcl Intensol...... 15 midodrine hcl...... 77 MALARONE...... 52 methadose...... 15 MIGERGOT...... 42 malathion...... 53 Methadose...... 15 miglitol...... 68 maprotiline hcl...... 36 methadose sugar-free...... 15 miglustat...... 117 MARINOL...... 38 methamphetamine hcl...... 90 mili...... 133 marlissa...... 133 methazolamide...... 85 MILLIPRED...... 125 MARPLAN...... 35 methenamine hippurate...... 23 MILLIPRED DP...... 125 MASK VORTEX...... 151 methenamine mandelate...... 23 MILLIPRED DP 12-DAY...... 124 MATULANE...... 45 Methergine...... 151 Mimvey...... 133 Matzim La...... 81 methimazole...... 140 mimvey lo...... 133 MAVYRET...... 58 METHITEST...... 128 mineral oil heavy...... 115 MAXI-COMFORT SAFETY methocarbamol...... 170 MINIPRESS...... 78 PEN NEEDLE...... 151 methotrexate...... 143 Minitran...... 89 MAXIDEX...... 159 methotrexate (anti-rheumatic).145 MINIVELLE...... 133 MAXITROL...... 154 methotrexate sodium...... 143 minocycline hcl...... 28 MAXZIDE...... 84 methoxsalen...... 101 minoxidil...... 89 MAXZIDE-25...... 84 methoxsalen rapid...... 101 MIRAPEX...... 54 me/naphos/mb/hyo1...... 118 methscopolamine bromide...... 112 MIRCETTE...... 134 meclofenamate sodium...... 14 methyclothiazide...... 86 mirtazapine...... 35 MEDI-DERM-RX...... 12 methyl salicylate...... 101 MIRVASO...... 101 MEDROL...... 124 methyldopa...... 77 misoprostol...... 116 MEDROX-RX...... 12 methyldopa- MITIGARE...... 42 medroxyprogesterone acetate 137 hydrochlorothiazide...... 84 MITOSOL...... 159 mefenamic acid...... 14 METHYLIN...... 91 M-NATAL PLUS...... 110 mefloquine hcl...... 52 methylphenidate hcl...... 92 MOBIC...... 14 MEGACE ES...... 137 methylphenidate hcl er...... 92 modafinil...... 171

182 moderiba...... 59 n-acetyl-l-cysteine...... 110 NEURONTIN...... 30 moderiba 1200 dose pack...... 59 nadolol...... 80 neutral sodium fluoride...... 107 moexipril hcl...... 78 nadolol-bendroflumethiazide.....84 NEVANAC...... 159 molindone hcl...... 55 NAFRINSE DAILY nevirapine...... 61 mometasone furoate...... 125, 162 ACIDULATED...... 95 nevirapine er...... 61 Mondoxyne Nl...... 28 NAFRINSE DAILY/NEUTRAL...95 NEXAVAR...... 50 MONOCLATE-P...... 75 NAFRINSE WEEKLY...... 96 NEXIUM...... 116 mono-linyah...... 134 naftifine hcl...... 40 niacin er (antihyperlipidemic).... 88 mononessa...... 134 NAFTIN...... 40 niacor...... 88 MONONINE...... 75 naloxone hcl...... 21 NIASPAN...... 88 monsels ferric subsulfate...... 75 naltrexone hcl...... 20 nicardipine hcl...... 81 montelukast sodium...... 163 NAMENDA...... 34 NICOMIDE...... 110 MONUROL...... 23 NAMENDA TITRATION PAK....34 NICORETTE...... 21 MORGIDOX...... 29 NAMENDA XR TITRATION nicotine polacrilex...... 21 Morgidox...... 29 PACK...... 34 nicotine step 1...... 21 morphine sulfate...... 18 NAMZARIC...... 93 nicotine step 2...... 21 MORPHINE SULFATE...... 18 NAPROSYN...... 14 nicotine step 3...... 21 morphine sulfate (concentrate). 18 naproxen...... 14 NICOTROL...... 21 morphine sulfate er...... 15, 18 naproxen dr...... 14 NICOTROL NS...... 21 morphine sulfate er beads...... 15 naproxen sodium...... 14 nifedipine...... 81 MOTOFEN...... 113 naproxen sodium er...... 14 nifedipine er...... 81 MOVIPREP...... 115 naratriptan hcl...... 43 nifedipine er osmotic release.... 81 MOXEZA...... 27 NARCAN...... 21 Nikki...... 134 moxifloxacin hcl...... 27 NARDIL...... 35 nilutamide...... 45 MOZOBIL...... 73 NASCOBAL...... 110 nimodipine...... 82 MS CONTIN...... 15 NATACYN...... 40 NINLARO...... 47 MULPLETA...... 73 NATAZIA...... 134 nisoldipine er...... 82 MULTAQ...... 79 nateglinide...... 68 NITRO-BID...... 89 multi-vit/iron/fluoride...... 110 NATPARA...... 148 NITRO-DUR...... 89 multivitamin/fluoride...... 110 NATURE-THROID...... 141 nitrofurantoin...... 24 MULTIVITAMIN/FLUORIDE... 110 NEBUPENT...... 53 nitrofurantoin macrocrystal...... 23 multi-vitamin/fluoride...... 110 Nebusal...... 168 nitrofurantoin monohydrate multivitamin/fluoride/iron...... 110 NEBUSAL...... 168 macrocrystals...... 24 multi-vitamin/fluoride/iron...... 110 necon 0.5/35 (28)...... 134 nitroglycerin...... 89 multivitamins/fluoride...... 110 nefazodone hcl...... 36 nitroglycerin er...... 89 mupirocin...... 23 neomycin sulfate...... 22 NITROMIST...... 89 mupirocin calcium...... 23 neomycin-bacitracin zn- NITROSTAT...... 89 MUSE...... 120 polymyx...... 154 Nitro-Time...... 90 mvc-fluoride...... 110 neomycin-polymyxin-dexameth NITYR...... 117 MYALEPT...... 113 ...... 154 nizatidine...... 114 MYAMBUTOL...... 44 neomycin-polymyxin- NIZORAL...... 40 MYCOBUTIN...... 44 gramicidin...... 154 NOCDURNA...... 127 mycophenolate mofetil...... 143 neomycin-polymyxin-hc.. 154, 160 Nolix...... 125 mycophenolate sodium...... 143 Neo-Polycin...... 154 nora-be...... 138 MYDAYIS...... 90 Neo-Polycin Hc...... 154 NORCO...... 18 MYLERAN...... 45 NEO-SYNALAR...... 23, 101 norethin ace-eth estrad-fe...... 134 myorisan...... 101 NEOTUSS PLUS...... 168 norethindrone...... 138 Myorisan...... 101 NERLYNX...... 50 norethindrone acetate...... 138 MYRBETRIQ...... 118 NESINA...... 68 norethindrone acet-ethinyl est.134 MYSOLINE...... 30 Neuac...... 101 norethindrone-eth estradiol..... 134 MYTESI...... 113 NEUAC...... 101 norethin-eth estradiol-fe...... 134 myzilra...... 134 NEULASTA...... 73 norgestimate-eth estradiol...... 134 nabumetone...... 14 NEUPRO...... 54

183 norgestimate-ethinyl estradiol ODOMZO...... 50 ORENCIA CLICKJECT...... 143 triphasic...... 134 OFEV...... 167 ORENITRAM...... 166 norlyda...... 138 ofloxacin...... 27, 156, 159 ORILISSA...... 140 norlyroc...... 138 ogestrel...... 134 ORKAMBI...... 165 NORPACE...... 79 okebo...... 29 orphenadrine citrate er...... 170 NORPACE CR...... 79 olanzapine...... 56 orsythia...... 134 NORPRAMIN...... 37 olanzapine-fluoxetine hcl...... 35 ORTHO MICRONOR...... 138 NORTHERA...... 77 olmesartan medoxomil...... 78 ORTHO TRI-CYCLEN (28)..... 134 nortrel 0.5/35 (28)...... 134 olmesartan medoxomil-hctz...... 84 ORTHO-CYCLEN (28)...... 134 nortrel 1/35 (21)...... 134 olmesartan-amlodipine-hctz...... 84 ORTHO-NOVUM 1/35 (28)..... 135 nortrel 1/35 (28)...... 134 olopatadine hcl...... 156, 161 ORTHO-NOVUM 7/7/7 (28).... 135 nortrel 7/7/7...... 134 OMECLAMOX-PAK...... 113 oscimin...... 112 nortriptyline hcl...... 37 omega-3-acid ethyl esters...... 88 oscimin sr...... 112 NORVASC...... 82 omeprazole...... 116 oseltamivir phosphate...... 64 NORVIR...... 63 OMNARIS...... 162 OSENI...... 68 NOVOEIGHT...... 75 ondansetron hcl...... 38, 39 OSMOPREP...... 115 NOVOFINE AUTOCOVER ondansetron odt...... 39 OSPHENA...... 138 PEN NEEDLE...... 151 ONE TOUCH VERIO KIT OTEZLA...... 145 NOVOFINE PEN NEEDLE..... 151 W/DEVICE...... 152 OTICIN HC NR...... 160 NOVOFINE PLUS PEN ONETOUCH DELICA OTOVEL...... 159 NEEDLE...... 151 LANCING DEV...... 151 OVACE PLUS...... 101 NOVOPEN ECHO...... 151 ONETOUCH ULTRA 2...... 151 OVACE PLUS WASH...... 101 NOVOSEVEN RT...... 75 ONETOUCH ULTRA BLUE OVACE WASH...... 101 NOVOTWIST PEN NEEDLE.. 151 TEST STRIPS...... 151 OVIDE...... 53 NOXAFIL...... 40, 41 ONETOUCH ULTRA MINI...... 151 oxandrolone...... 128 np thyroid...... 141 ONETOUCH VERIO FLEX oxaprozin...... 14 NUCORT...... 125 SYSTEM KIT W/DEVICE...... 152 oxazepam...... 65 NUCYNTA...... 18 ONETOUCH VERIO IQ oxcarbazepine...... 33 NUCYNTA ER...... 15, 16 SYSTEM...... 152 oxiconazole nitrate...... 41 NUEDEXTA...... 93 ONETOUCH VERIO SYNC OXISTAT...... 41 Nulev...... 112 SYSTEM KIT W/DEVICE...... 152 OXSORALEN ULTRA...... 101 NULYTELY WITH FLAVOR ONEXTON...... 101 oxybutynin chloride...... 118 PACKS...... 115 ONFI...... 30 oxybutynin chloride er...... 118 NUPLAZID...... 56 ONGLYZA...... 68 oxycodone hcl...... 18 NUTRIDOX...... 29 ONZETRA XSAIL...... 43 oxycodone-acetaminophen...... 18 NUTROPIN AQ NUSPIN 10... 127 OPANA...... 18 oxycodone-aspirin...... 18 NUTROPIN AQ NUSPIN 20... 127 opium...... 113 oxycodone-ibuprofen...... 18 NUTROPIN AQ NUSPIN 5..... 127 OPSUMIT...... 166 oxymorphone hcl...... 18 NUVAIL...... 101 ORACEA...... 29 oxymorphone hcl er...... 16 NUVARING...... 134 ORACIT...... 107 OZEMPIC...... 68 NUVESSA...... 24 ORALAIR...... 169 Pacerone...... 79 NUWIQ...... 75 ORALAIR ADULT SAMPLE paliperidone er...... 56 nyamyc...... 41 KIT...... 168 PALYNZIQ...... 117 NYMALIZE...... 82 ORALAIR ADULT STARTER PAMELOR...... 38 nystatin...... 41 PACK...... 169 PANCREAZE...... 117 nystatin-triamcinolone...... 41 ORALAIR CHILDRENS PANDEL...... 125 Nystop...... 41 SAMPLE KIT...... 169 PANRETIN...... 51 OCALIVA...... 113 ORALAIR CHILDRENS pantoprazole sodium...... 116 ocella...... 134 STARTER PACK...... 169 paregoric...... 113 octreotide acetate...... 140 Oralone...... 96 paricalcitol...... 148 OCUFLOX...... 156 ORAPRED ODT...... 125 PARNATE...... 35 ODACTRA...... 168 ORAVIG...... 41 paroex...... 96 ODEFSEY...... 61 ORENCIA...... 143 paromomycin sulfate...... 22

184 paroxetine hcl...... 36 phospho-trin 250 neutral...... 107 prasugrel hcl...... 77 paroxetine hcl er...... 36 PHOTREXA-PHOTREXA PRAVACHOL...... 87 paroxetine mesylate...... 36 VISCOUS KIT...... 154 pravastatin sodium...... 87 PASER...... 44 Phrenilin Forte...... 12 praziquantel...... 52 PATANASE...... 161 phytonadione...... 110 prazosin hcl...... 78 PAXIL...... 36 PICATO...... 101 PRECISION XTRA KETONE..152 PAXIL CR...... 36 pilocarpine hcl...... 96, 157 PRECOSE...... 68 PAZEO...... 156 pimecrolimus...... 101 PRED FORTE...... 159 PCP 100...... 115 pimozide...... 55 PRED MILD...... 159 PEDIAPRED...... 125 Pimtrea...... 135 PRED-G...... 155 peg 3350/electrolytes...... 115 pindolol...... 80 PRED-G S.O.P...... 155 peg 3350-kcl-na bicarb-nacl....115 pioglitazone hcl...... 68 prednicarbate...... 125 peg-3350/electrolytes...... 115 pioglitazone hcl-glimepiride...... 68 prednisolone...... 125 PEGANONE...... 33 pioglitazone hcl-metformin hcl.. 68 prednisolone acetate...... 159 PEGASYS...... 59 pirmella 1/35...... 135 prednisolone sodium PEGASYS PROCLICK...... 59 pirmella 7/7/7...... 135 phosphate...... 125, 159 PEGINTRON...... 59 piroxicam...... 14 prednisone...... 125 peg-prep...... 115 PLAN B ONE-STEP...... 138 prednisone intensol...... 125 penicillin v potassium...... 26 PLAQUENIL...... 53 PREFEST...... 135 pentazocine-naloxone hcl...... 18 PLEGRIDY...... 94 PREMARIN...... 135 pentoxifylline er...... 84 PLEGRIDY STARTER PACK... 94 PREMESISRX...... 110 PERFOROMIST...... 164 PLENVU...... 115 premium lidocaine...... 20 PERIDEX...... 96 PLEXION...... 102 PREMPHASE...... 135 perindopril erbumine...... 79 PLEXION CLEANSER...... 102 PREMPRO...... 135 Periogard...... 96 PLEXION CLEANSING prenatal...... 110 permethrin...... 53 CLOTH...... 102 prenatal plus iron...... 111 perphenazine...... 38 pnv prenatal plus multivit+dha 110 PREPIDIL...... 120 perphenazine-amitriptyline...... 35 podocon...... 102 PREPOPIK...... 115 PERTZYE...... 117 podofilox...... 102 PREVACID SOLUTAB...... 116 PEXEVA...... 36, 37 Polycin...... 155 Prevalite...... 88 phenadoz...... 161 polymyxin b-trimethoprim...... 155 PREVIDENT...... 96, 107 Phenazo...... 120 POLYTRIM...... 155 PREVIDENT 5000 BOOSTER phenazopyridine hcl...... 120 POLY-VI-FLOR...... 110 PLUS...... 96 phendimetrazine tartrate...... 93 POLY-VI-FLOR/IRON...... 110 PREVIDENT 5000 DRY PHENDIMETRAZINE POMALYST...... 45 MOUTH...... 96 TARTRATE ER...... 93 Portia-28...... 135 PREVIDENT 5000 ENAMEL phenelzine sulfate...... 35 pot bicarb-pot chloride...... 107 PROTECT...... 96 phenobarbital...... 29, 30 POTABA...... 110 PREVIDENT 5000 PLUS...... 96 PHENOL...... 24 potassium bicarbonate...... 107 PREVIDENT 5000 SENSITIVE.96 phenoxybenzamine hcl...... 78 potassium chloride...... 107 previfem...... 135 phentermine hcl...... 93 potassium chloride crys er...... 107 PREVYMIS...... 58 phenylephrine hcl...... 154 potassium chloride er...... 107 PREZCOBIX...... 63 phenylephrine-guaifenesin...... 169 potassium citrate er...... 107 PREZISTA...... 63 PHENYTEK...... 33 potassium citrate-citric acid.....107 PRIFTIN...... 44 phenytoin...... 33 PRADAXA...... 72 PRILOSEC...... 116 Phenytoin Infatabs...... 33 PRALUENT...... 88 primaquine phosphate...... 53 phenytoin sodium extended...... 33 pramcort...... 147 primidone...... 31 philith...... 135 pramipexole dihydrochloride..... 54 PRIMSOL...... 24 PHOSLYRA...... 109 pramosone...... 102 PRINIVIL...... 79 Phospha 250 Neutral...... 107 PRAMOSONE...... 102 PRISTIQ...... 37 phosphasal...... 118 PRAMOTIC...... 160 PROAIR HFA...... 164 PHOSPHOLINE IODIDE...... 157 pramox...... 19 PROAIR RESPICLICK...... 164 phosphorous...... 107 PRANDIN...... 68 probenecid...... 42

185 PROCARDIA...... 82 Pulmosal...... 169 RECOTHROM...... 76 PROCARDIA XL...... 82 PULMOZYME...... 169 RECOTHROM SPRAY KIT...... 76 PROCENTRA...... 90 PURIXAN...... 46 RECTIV...... 90 prochlorperazine...... 38 PYLERA...... 113 REGLAN...... 113 prochlorperazine maleate...... 55 pyrazinamide...... 44 REGRANEX...... 102 PROCORT...... 147 PYRIDIUM...... 120 RELENZA DISKHALER...... 64 PROCRIT...... 73 pyridostigmine bromide...... 44 RELION ULTIMA TEST...... 152 PROCTOCORT...... 42 pyridostigmine bromide er...... 44 RELISTOR...... 113 PROCTOFOAM HC...... 147 PYROGALLIC ACID...... 102 RELNATE DHA...... 111 Procto-Med Hc...... 147 QBRELIS...... 79 REMERON...... 35 Procto-Pak...... 147 QNASL...... 163 REMERON SOLTAB...... 35 proctosol hc...... 147 QNASL CHILDRENS...... 162 REMIGEN...... 102 proctozone-hc...... 147 QSYMIA...... 93 RENAGEL...... 109 PROCYSBI...... 117 QUALAQUIN...... 53 RENVELA...... 109 PROFILNINE...... 75 quazepam...... 65 repaglinide...... 68 PROFILNINE SD...... 76 QUDEXY XR...... 32 repaglinide-metformin hcl...... 68 progesterone...... 138 QUESTRAN...... 88 REPATHA...... 88 progesterone micronized...... 138 QUESTRAN LIGHT...... 88 REPATHA PUSHTRONEX PROGLYCEM...... 69 quetiapine fumarate...... 56 SYSTEM...... 88 PROLENSA...... 159 quetiapine fumarate er...... 56 REPATHA SURECLICK...... 88 PROMACTA...... 73 QUFLORA PEDIATRIC...... 111 RESCRIPTOR...... 61 promethazine hcl...... 161 QUILLICHEW ER...... 92 RESTASIS...... 155 promethazine-codeine...... 169 QUILLIVANT XR...... 92 RESTASIS MULTIDOSE...... 155 promethazine-dm...... 169 quinapril hcl...... 79 RESTORA RX...... 113 promethazine-phenyleph- quinapril-hydrochlorothiazide.... 84 RESTORIL...... 65, 171 codeine...... 169 quinidine gluconate er...... 79 RETIN-A MICRO PUMP...... 102 promethazine-phenylephrine.. 169 quinidine sulfate...... 79 RETROVIR...... 62 Promethegan...... 161 quinine sulfate...... 53 REVATIO...... 166 PROMETRIUM...... 138 QVAR REDIHALER...... 163 REVLIMID...... 45 PROMISEB...... 102 rabeprazole sodium...... 116 REXULTI...... 56 PROMISEB COMPLETE...... 102 RADIOGARDASE...... 152 REYATAZ...... 63 propafenone hcl...... 79 RAGWITEK...... 169 RHOFADE...... 102 propafenone hcl er...... 79 raloxifene hcl...... 138 Ribasphere...... 59 propantheline bromide...... 112 ramipril...... 79 ribasphere...... 59 proparacaine hcl...... 155 RANEXA...... 84 ribasphere ribapak...... 59 propranolol hcl...... 80 ranitidine hcl...... 114 ribavirin...... 57, 59 propranolol hcl er...... 80 ranolazine er...... 85 RIDAURA...... 145 propranolol-hctz...... 84 RAPAFLO...... 119 rifabutin...... 44 propylthiouracil...... 140 RAPAMUNE...... 143 RIFADIN...... 44 PROSCAR...... 119 RAPID GEL RX...... 152 RIFAMATE...... 44 PROSTIN E2...... 120 rasagiline mesylate...... 55 rifampin...... 44 PROTONIX...... 116 RASUVO...... 143, 144 RIFATER...... 44 protriptyline hcl...... 38 RAVICTI...... 117 RILUTEK...... 93 PROVENTIL HFA...... 164 RAZADYNE...... 34 riluzole...... 93 PROVERA...... 138 RAZADYNE ER...... 34 rimantadine hcl...... 64 PRUDOXIN...... 102 REBETOL...... 59 RIOMET...... 68 pseudoeph-chlorphen- REBIF...... 95 risedronate sodium...... 148 hydrocod...... 169 REBIF REBIDOSE...... 94 risperidone...... 57 pseudoephedrine-bromphen- REBIF REBIDOSE Risperidone M-Tab...... 57 dm...... 169 TITRATION PACK...... 95 RITALIN...... 92 PSORCON...... 125 REBIF TITRATION PACK...... 95 ritonavir...... 63 PULMICORT FLEXHALER.....162 reclipsen...... 135 rivastigmine...... 34 PULMICORT SUSPENSION.. 162 RECOMBINATE...... 76 rivastigmine tartrate...... 34

186 rivelsa...... 135 sevelamer hcl...... 109 SPIRIVA RESPIMAT...... 164 RIXUBIS...... 76 sevoflurane...... 152 spironolactone...... 86 rizatriptan benzoate...... 43 sf...... 96 spironolactone-hctz...... 85 ROBAXIN...... 170 sf 5000 plus...... 96 SPORANOX...... 41 ROBAXIN-750...... 170 SFROWASA...... 146 SPORANOX PULSEPAK...... 41 ROCALTROL...... 148 sharobel...... 138 sprintec 28...... 135 ropinirole hcl...... 54 SHARPS CONTAINER...... 152 SPRIX...... 14 ropinirole hcl er...... 54 SIGNIFOR...... 140 SPRYCEL...... 50 Rosadan...... 24 sildenafil citrate...... 120, 166 Sps...... 108 ROSADAN...... 102 SILENOR...... 171 sronyx...... 135 rosuvastatin calcium...... 87 SILIQ...... 103 Ssd...... 28 ROWASA...... 146 silodosin...... 119 SSKI...... 152 Roweepra...... 29 SILVADENE...... 28 sss 10-5...... 103 Roweepra Xr...... 30 silver nitrate...... 24 STALEVO 100...... 54 ROXICODONE...... 18 silver sulfadiazine...... 28 STALEVO 125...... 54 ROZEREM...... 171 SIMBRINZA...... 157 STALEVO 150...... 54 RUBRACA...... 47 SIMPONI...... 144 STALEVO 200...... 55 RUCONEST...... 141 simvastatin...... 87 STALEVO 50...... 55 RYDAPT...... 50 SINEMET...... 54 STALEVO 75...... 55 RYTHMOL SR...... 79 SINEMET CR...... 54 STARLIX...... 68 SABRIL...... 31 SINGULAIR...... 163 stavudine...... 62 SALAGEN...... 96 sirolimus...... 144 STAXYN...... 120 salicylic acid...... 102 SIRTURO...... 44 STELARA...... 103 salimez...... 102 SIVEXTRO...... 24 STENDRA...... 120 salsalate...... 14 SKLICE...... 52 STIMATE...... 127 SALVAX DUO PLUS...... 103 sod citrate-citric acid...... 107 STIVARGA...... 50 SAMSCA...... 108 SODIUM BICARBONATE...... 113 STRATTERA...... 92 SANDIMMUNE...... 144 sodium chloride...... 169 STRENSIQ...... 117 SANDOSTATIN...... 140 sodium fluoride...... 107 STRIANT...... 128 SANTYL...... 103 sodium hyaluronate...... 103 STRIBILD...... 60 SAPHRIS...... 57 sodium phenylbutyrate...... 117 STRIVERDI RESPIMAT...... 165 SAVAYSA...... 72 sodium polystyrene sulfonate. 108 STROMECTOL...... 52 SAVELLA...... 94 sodium sulfacetamide...... 103 SUBOXONE...... 20 SAVELLA TITRATION PACK... 94 sodium sulfacetamide wash....103 Subvenite...... 32 SAXENDA...... 93 SOFOSBUVIR-VELPATASVIR.58 Subvenite Starter Kit-Blue...... 32 SCALACORT DK...... 103 SOLIQUA...... 68 Subvenite Starter Kit-Green...... 32 SCARZEN SKIN REPAIR...... 103 SOLOSEC...... 24 Subvenite Starter Kit-Orange....32 SEASONIQUE...... 135 Soloxide...... 29 SUCRAID...... 117 SECONAL...... 171 SOLTAMOX...... 46 sucralfate...... 116 SEEBRI NEOHALER...... 163 SOMA...... 170 SULAR...... 82 selegiline hcl...... 55 SOMATULINE DEPOT...... 140 sulfacetamide sodium...... 28, 103 selenium sulfide...... 103 SOMAVERT...... 140 sulfacetamide sodium (acne).. 103 selenium sulf-pyrithione-urea..103 SOOLANTRA...... 103 sulfacetamide sodium-sulfur SELZENTRY...... 63 SORIATANE...... 103 ...... 103, 104 SEMPREX-D...... 169 SORILUX...... 103 sulfacetamide sod-sulfur wash 104 SENSIPAR...... 148 sotalol hcl...... 79 sulfacetamide-prednisolone.... 155 SEREVENT DISKUS...... 165 sotalol hcl (af)...... 79 sulfacetamide-sulfur in urea....104 SERNIVO...... 125 SOTYLIZE...... 79 sulfacetamide-sulfur- SEROQUEL XR...... 57 SOVALDI...... 59 sunscreen...... 104 SEROSTIM...... 113 SPECTRACEF...... 25 Sulfacleanse 8/4...... 104 sertraline hcl...... 37 SPEEDGEL RX...... 152 sulfadiazine...... 28 setlakin...... 135 spinosad...... 53 sulfamethoxazole-trimethoprim.28 sevelamer carbonate...... 109 SPIRIVA HANDIHALER...... 163 sulfamez wash...... 104

187 SULFAMYLON...... 24 tadalafil (pah)...... 166 TEXACORT...... 126 sulfasalazine...... 147 TAFINLAR...... 50 THALOMID...... 45 Sulfatrim Pediatric...... 28 TAGRISSO...... 50 THEO-24...... 166 SULFURATED LIME...... 53 TAKHZYRO...... 141 Theochron...... 166 sulindac...... 14 TALTZ...... 104 theophylline...... 166 SUMADAN XLT...... 104 tamoxifen citrate...... 46 theophylline er...... 166 sumatriptan...... 43 tamsulosin hcl...... 119 THIOLA...... 120 sumatriptan succinate...... 43 TAPAZOLE...... 140 thioridazine hcl...... 55 sumatriptan succinate refill...... 43 TAPERDEX 12-DAY...... 126 thiothixene...... 55 SUMAXIN...... 104 TAPERDEX 6-DAY...... 126 THROMBIN-JMI...... 76 SUMAXIN CP...... 104 TAPERDEX 7-DAY...... 126 THROMBIN-JMI EPISTAXIS.... 76 SUMAXIN WASH...... 104 TARCEVA...... 50 THROMBOGEN...... 76 SUPRAX...... 25 TARGRETIN...... 51, 52 THYROLAR-1...... 139 SUPREP BOWEL PREP KIT..115 Tarina 24 Fe...... 135 THYROLAR-1/2...... 139 SURESTEP PRO HIGH tarina fe 1/20...... 135 THYROLAR-1/4...... 139 GLUCOSE...... 152 tarina fe 1/20 eq...... 135 THYROLAR-2...... 139 SURESTEP PRO LOW TARKA...... 85 THYROLAR-3...... 139 GLUCOSE...... 152 taron-crystals...... 107 tiagabine hcl...... 31 SURESTEP PRO NORMAL TASIGNA...... 51 TIAZAC...... 82 GLUCOSE...... 152 TAVALISSE...... 76 TIBSOVO...... 51 SURMONTIL...... 38 TAYTULLA...... 135 TIGAN...... 38 SUSTIVA...... 61 TAZORAC...... 104 TIKOSYN...... 79 SUTENT...... 50 Taztia Xt...... 82 tilia fe...... 136 syeda...... 135 TECFIDERA...... 95 timolol maleate...... 80, 157 SYLATRON...... 59 TEGRETOL...... 33 TIMOPTIC...... 158 SYMAX DUOTAB...... 112 TEGRETOL-XR...... 33 TIMOPTIC OCUDOSE...... 158 Symax-Sl...... 112 TEGSEDI...... 118 TIMOPTIC-XE...... 158 Symax-Sr...... 112 TEKTURNA...... 85 tinidazole...... 24 SYMBICORT...... 169 TEKTURNA HCT...... 85 TIROSINT...... 139 SYMBYAX...... 35 telmisartan...... 78 TISSEEL...... 76 SYMDEKO...... 165 telmisartan-amlodipine...... 85 TISSEEL VHSD...... 76 SYMFI...... 61 telmisartan-hctz...... 85 TIVICAY...... 60 SYMFI LO...... 61 temazepam...... 65, 171 TIVORBEX...... 14 SYMJEPI...... 165 TEMODAR...... 45 TIZANIDINE COMFORT PAC.. 57 SYMLINPEN 120...... 68 TEMOVATE...... 126 tizanidine hcl...... 170 SYMLINPEN 60...... 69 temozolomide...... 45 TL-FLUORIVITE...... 111 SYMPROIC...... 114 tencon...... 12 TOBI PODHALER...... 165 SYMTUZA...... 63 tenofovir disoproxil fumarate.....62 TOBRADEX...... 155 SYNALAR...... 125, 126 terazosin hcl...... 120 TOBRADEX ST...... 155 SYNALAR (CREAM)...... 104 terbinafine hcl...... 41 tobramycin...... 156 SYNALAR (OINTMENT)...... 104 terbutaline sulfate...... 165 tobramycin-dexamethasone....155 SYNALAR TS...... 104 terconazole...... 41 TOBREX...... 156 SYNAREL...... 140 Terrell...... 152 TOFRANIL...... 38 SYNDROS...... 39 TESSALON PERLES...... 169 TOLAK...... 104 SYNJARDY...... 69 TESTIM...... 128 tolazamide...... 69 SYNJARDY XR...... 69 testosterone cypionate...... 128 tolbutamide...... 69 SYNRIBO...... 47 testosterone enanthate...... 128 tolcapone...... 53 SYNTHROID...... 139 tetcaine...... 155 tolmetin sodium...... 14 SYNVEXIA TC...... 20 tetrabenazine...... 93 tolterodine tartrate...... 118 SYPRINE...... 108 tetracaine hcl...... 155 tolterodine tartrate er...... 118 TABLOID...... 46 tetracycline hcl...... 29 TOPAMAX...... 32 TACLONEX...... 104 Tetravisc...... 155 TOPAMAX SPRINKLE...... 32 tacrolimus...... 104, 144 tetravisc forte...... 155

188 TOPEX TOPICAL tri-linyah...... 136 TYVASO STARTER...... 166 ANESTHETIC...... 96 tri-lo-estarylla...... 136 UCERIS...... 147 TOPICORT...... 126 tri-lo-marzia...... 136 ULESFIA...... 53 topiramate...... 32 tri-lo-sprintec...... 136 ULORIC...... 42 topiramate er...... 32 Trilyte...... 115 ULTANE...... 153 TOPROL XL...... 81 trimethobenzamide hcl...... 38 ULTRACET...... 19 toremifene citrate...... 46 trimethoprim...... 24 ULTRAM...... 19 torsemide...... 86 tri-mili...... 136 ULTRAVATE...... 126 TOVIAZ...... 118 trimipramine maleate...... 38 UMECTA MOUSSE...... 105 TRACLEER...... 166 TRI-NORINYL (28)...... 136 UNISTIK 2 EXTRA...... 153 TRADJENTA...... 69 TRINTELLIX...... 37 UNISTIK 2 SUPER...... 153 TRAMADOL HCL ER...... 16 tri-previfem...... 136 UNISTRIP CONTROL...... 153 tramadol hcl er...... 16, 19 tri-sprintec...... 136 unithroid...... 139 tramadol hcl er (biphasic)...... 18 TRIUMEQ...... 60 Unithroid...... 139 tramadol hcl ir...... 19 TRI-VI-FLOR...... 111 UPTRAVI...... 167 tramadol-acetaminophen...... 19 TRI-VI-FLORO...... 111 URAMAXIN...... 105 trandolapril...... 79 tri-vitamin/fluoride...... 111 urea...... 105 trandolapril-verapamil hcl er...... 85 tri-vite/fluoride...... 111 urea in zn undecyl-lactic acid..105 tranexamic acid...... 76 Trivora (28)...... 136 urea nail...... 105 TRANSDERM-SCOP (1.5 MG).38 Tri-Vylibra...... 136 urea-c40...... 105 TRANXENE-T...... 65 Tri-Vylibra Lo...... 136 URECHOLINE...... 120 tranylcypromine sulfate...... 35 TRIZIVIR...... 62 urelle...... 119 TRANZGEL...... 152 trospium chloride...... 119 uremez-40...... 105 TRAVATAN Z...... 159 trospium chloride er...... 118 uretron d/s...... 119 trazodone hcl...... 37 TRUE METRIX BLOOD URIBEL...... 119 TRECATOR...... 44 GLUCOSE TEST...... 152 URIMAR-T...... 119 TRELEGY ELLIPTA...... 169 TRUE METRIX LEVEL 1...... 153 urin ds...... 119 TREMFYA...... 104 TRUE METRIX LEVEL 2...... 153 uro-458...... 119 TRESIBA...... 70 TRUE METRIX LEVEL 3...... 153 UROCIT-K 10...... 108 TRESIBA FLEXTOUCH...... 70 TRUEPLUS 5-BEVEL PEN UROCIT-K 15...... 108 tretinoin...... 52, 105 NEEDLES...... 153 UROCIT-K 5...... 108 tretinoin microsphere...... 105 TRUETRACK TEST...... 153 UROGESIC-BLUE...... 119 tretinoin microsphere pump.... 105 TRULANCE...... 114 uro-mp...... 119 TRETTEN...... 76 TRULICITY...... 69 UROXATRAL...... 120 TREXALL...... 144 TRUSOPT...... 158 URSO 250...... 114 trezix...... 19 TRUVADA...... 62 URSO FORTE...... 114 tri femynor...... 136 TRYPTOPHAN...... 153 ursodiol...... 114 triamcinolone acetonide.... 96, 126 TUDORZA PRESSAIR...... 164 URYL...... 119 triamterene-hctz...... 85 tulana...... 138 ustell...... 119 triazolam...... 65 TURPENTINE...... 12 uticap...... 119 TRICARE PRENATAL DHA TUSSICAPS...... 169 utira-c...... 119 ONE...... 111 TUSSIONEX PENNKINETIC UTOPIC...... 105 TRI-CHLOR...... 105 ER...... 169 utrona-c...... 119 TRICITRASOL...... 72 TUXARIN ER...... 170 valacyclovir hcl...... 60 tricitrates...... 107 TUZISTRA XR...... 170 VALCHLOR...... 45 Triderm...... 126 TYBOST...... 60 VALCYTE...... 58 tridesilon...... 126 Tydemy...... 136 valganciclovir hcl...... 58 tri-estarylla...... 136 TYKERB...... 51 valproate sodium...... 31 trifluoperazine hcl...... 55 TYLENOL WITH CODEINE #3. 19 valproic acid...... 31 trifluridine...... 60 TYLENOL WITH CODEINE #4. 19 valsartan...... 78 trihexyphenidyl hcl...... 53 TYMLOS...... 148 valsartan-hydrochlorothiazide... 85 tri-legest fe...... 136 TYVASO...... 166 VANATOL LQ...... 12 TRILEPTAL...... 33 TYVASO REFILL...... 166 VANATOL S...... 12

189 VANCOCIN HCL...... 24 VIMPAT...... 33 XOLEGEL DUO/XOLEX...... 42 vancomycin hcl...... 24 VIOKACE...... 118 XOPENEX HFA...... 165 Vandazole...... 24 viorele...... 136 XOSPATA...... 51 vardenafil hcl...... 120 VIRACEPT...... 64 XTAMPZA ER...... 16 VARUBI...... 39 VIRAMUNE...... 61 XTANDI...... 45 VASCEPA...... 88 VIRAZOLE...... 58 xulane...... 136 VECAMYL...... 85 VIREAD...... 62 XURIDEN...... 118 VECTICAL...... 105 VIROPTIC...... 60 XYNTHA...... 76 velivet...... 136 virt-phos 250 neutral...... 108 XYNTHA SOLOFUSE...... 76, 77 VELPHORO...... 109 VISTARIL...... 161 XYREM...... 171 VELTASSA...... 108 VISTOGARD...... 153 YASMIN 28...... 136 VELTIN...... 105 vitamin d (ergocalciferol)...... 111 YAZ...... 136 VEMLIDY...... 58 vitamins acd-fluoride...... 111 Yuvafem...... 137 VENCLEXTA...... 51 VITRAKVI...... 51 ZACARE...... 105 VENCLEXTA STARTING VIVELLE-DOT...... 136 zaclir cleansing...... 105 PACK...... 51 VIZIMPRO...... 51 zafirlukast...... 163 VENELEX...... 105 VOLTAREN...... 14 zaleplon...... 171 venlafaxine hcl...... 37 VONVENDI...... 76 ZANAFLEX...... 170 venlafaxine hcl er...... 37 voriconazole...... 41 Zarah...... 137 VENTAVIS...... 167 VOSEVI...... 59 ZARONTIN...... 30 VENTOLIN HFA...... 165 VOTRIENT...... 51 ZARXIO...... 73 verapamil hcl...... 82 VRAYLAR...... 57 Zebutal...... 12 verapamil hcl er...... 82 VUSION...... 41 ZEJULA...... 47 VERDESO...... 126 vyfemla...... 136 ZELAPAR...... 55 verdrocet...... 19 vylibra...... 136 ZELBORAF...... 51 VEREGEN...... 105 VYTORIN...... 88 ZEMBRACE SYMTOUCH...... 43 VERELAN...... 82 VYVANSE...... 90, 91 ZEMPLAR...... 148 VERELAN PM...... 82 warfarin sodium...... 72 zenatane...... 105 VERIPRED 20...... 126 WELCHOL...... 89 Zenatane...... 105 VERSACLOZ...... 57 wera...... 136 ZENPEP...... 118 VERZENIO...... 47 WESTHROID...... 141 ZEPATIER...... 59 VESICARE...... 119 WHEAT GERM OIL...... 111 ZETONNA...... 163 VFEND...... 41 WIDE-SEAL DIAPHRAGM 60 153 ZIAC...... 85 V-GO 20...... 153 WILATE...... 76 ZIAGEN...... 62 V-GO 30...... 153 WP THYROID...... 141 zidovudine...... 62 V-GO 40...... 153 Wymzya Fe...... 136 zileuton er...... 163 VIBERZI...... 114 XALATAN...... 159 ZIOPTAN...... 159 VIBRAMYCIN...... 29 XALKORI...... 51 ziprasidone hcl...... 57 Vicodin...... 19 XARELTO...... 72 ZIPSOR...... 14 Vicodin Es...... 19 XARELTO STARTER PACK.....72 ZIRGAN...... 58 Vicodin Hp...... 19 XATMEP...... 144 ZITHROMAX...... 27 VICTOZA...... 69 XELJANZ...... 144 ZITHROMAX TRI-PAK...... 27 VIDEX...... 62 XELJANZ XR...... 144 ZITHROMAX Z-PAK...... 27 VIDEX EC...... 62 XELODA...... 46 ZOCOR...... 87 VIEKIRA PAK...... 59 XENICAL...... 93 ZOFRAN...... 39 vienva...... 136 XERMELO...... 114 ZOHYDRO ER...... 16 vigabatrin...... 31 XIFAXAN...... 114 ZOLINZA...... 47 Vigadrone...... 31 XIIDRA...... 155 zolmitriptan...... 43 VIGAMOX...... 27 XIMINO...... 29 zolpidem tartrate...... 171 VIIBRYD...... 37 XOLEGEL...... 42 zolpidem tartrate er...... 171 VIIBRYD STARTER PACK...... 37 XOLEGEL COREPAK...... 41 ZOLPIMIST...... 171 vilamit mb...... 119 XOLEGEL DUO/HEAD & ZOMIG...... 43 vilevev mb...... 119 SHOULDERS...... 41 ZOMIG ZMT...... 43

190 ZONALON...... 105 ZONEGRAN...... 30 zonisamide...... 30 ZONTIVITY...... 72 ZORBTIVE...... 114 ZORTRESS...... 144 ZORVOLEX...... 14 zovia 1/35e (28)...... 137 ZOVIRAX...... 60 ZUBSOLV...... 21 ZUPLENZ...... 39 ZYDELIG...... 51 ZYFLO...... 163 ZYFLO CR...... 163 ZYKADIA...... 51 ZYLET...... 155 ZYLOPRIM...... 42 ZYMAXID...... 156 ZYTIGA...... 45 ZYVOX...... 24

191