3 Tier Drug Formulary - 2021 DAKOTACARE-ONE 2021 3-Tier Drug Formulary

EFFECTIVE 04/01/2021

PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs.

WHAT IS THE DAKOTACARE DRUG FORMULARY? ...... 4 CAN THE DRUG FORMULARY CHANGE?...... 4 HOW DO I USE THE DRUG FORMULARY? ...... 4 DAKOTACARE DRUG FORMULARY ...... 4 WHAT IF MY DRUG IS NOT ON THE DRUG FORMULARY? ...... 5 HOW LIKELY IS IT THAT I WILL GET THE FORMULARY EXCEPTION? ...... 5 WHAT DO THE TIERS MEAN ON THE DRUG FORMULARY? ...... 6 NOTICE ...... 6 ANALGESICS...... 7 NSAIDs ...... 7 NSAIDs, COMBINATIONS ...... 7 NSAIDs, TOPICAL ...... 7 COX-2 INHIBITORS ...... 7 GOUT ...... 7 OPIOID ANALGESICS ...... 7 ANTI-INFECTIVES ...... 8 ANTIBACTERIALS ...... 8 ANTIFUNGALS ...... 9 ANTIMALARIALS ...... 9 ANTIRETROVIRAL AGENTS ...... 9 ANTITUBERCULAR AGENTS ...... 10 ANTIVIRALS...... 11 MISCELLANEOUS ...... 11 CARDIOVASCULAR ...... 12 ACE INHIBITORS ...... 12 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 12 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 12 ADRENOLYTICS, CENTRAL ...... 12 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 12 ALPHA BLOCKERS ...... 12 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 13 ANTIARRHYTHMICS ...... 13 ANTILIPEMICS...... 13 BETA-BLOCKERS ...... 14 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 15 CALCIUM CHANNEL BLOCKERS ...... 15 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 15 DIGITALIS GLYCOSIDES ...... 15 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 15 DIURETICS ...... 15 HEART FAILURE ...... 16 NITRATES ...... 16 PULMONARY ARTERIAL HYPERTENSION ...... 16 MISCELLANEOUS ...... 16 CENTRAL NERVOUS SYSTEM ...... 17 ANTIANXIETY ...... 17 ANTICONVULSANTS ...... 17

1 ANTIDEMENTIA ...... 18 ANTIDEPRESSANTS ...... 18 ANTIPARKINSONIAN AGENTS ...... 19 ANTIPSYCHOTICS ...... 19 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 20 FIBROMYALGIA ...... 20 HYPNOTICS ...... 20 MIGRAINE ...... 21 MOOD STABILIZERS ...... 21 MOVEMENT DISORDERS ...... 21 MULTIPLE SCLEROSIS AGENTS ...... 21 MUSCULOSKELETAL THERAPY AGENTS ...... 22 MYASTHENIA GRAVIS ...... 22 NARCOLEPSY ...... 22 POSTHERPETIC NEURALGIA (PHN)...... 22 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 22 ENDOCRINE AND METABOLIC ...... 23 ACROMEGALY ...... 23 ANDROGENS ...... 23 ANTIDIABETICS ...... 23 CALCIUM RECEPTOR ANTAGONISTS ...... 25 CALCIUM REGULATORS ...... 25 CARNITINE DEFICIENCY AGENTS ...... 25 CONTRACEPTIVES ...... 25 ENDOMETRIOSIS ...... 26 GAUCHER DISEASE ...... 26 GLUCOCORTICOIDS ...... 26 GLUCOSE ELEVATING AGENTS ...... 26 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ...... 27 HUMAN GROWTH HORMONES ...... 27 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 27 MENOPAUSAL SYMPTOM AGENTS ...... 27 PHENYLKETONURIA TREATMENT AGENTS ...... 27 PHOSPHATE BINDER AGENTS ...... 27 POLYNEUROPATHY ...... 27 POTASSIUM-REMOVING AGENTS ...... 28 PROGESTINS ...... 28 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 28 THYROID AGENTS ...... 28 UTERINE FIBROIDS ...... 28 VASOPRESSINS ...... 28 MISCELLANEOUS ...... 28 GASTROINTESTINAL ...... 28 ANTIDIARRHEALS ...... 28 ANTIEMETICS ...... 28 ANTISPASMODICS ...... 29 CHOLELITHOLYTICS ...... 29 INFLAMMATORY BOWEL DISEASE ...... 29 IRRITABLE BOWEL SYNDROME ...... 29 LAXATIVES ...... 29 OPIOID-INDUCED CONSTIPATION ...... 30 PANCREATIC ENZYMES ...... 30 PROSTAGLANDINS ...... 30 PROTON PUMP INHIBITORS ...... 30 SALIVA STIMULANTS ...... 30 STEROIDS, RECTAL ...... 30 ULCER THERAPY COMBINATIONS ...... 30 MISCELLANEOUS ...... 30 GENITOURINARY ...... 30 BENIGN PROSTATIC HYPERPLASIA ...... 30 URINARY ANTISPASMODICS ...... 30 VAGINAL ANTI-INFECTIVES ...... 31 MISCELLANEOUS ...... 31 HEMATOLOGIC ...... 31 ANTICOAGULANTS ...... 31

2 PLATELET AGGREGATION INHIBITORS ...... 31 PLATELET SYNTHESIS INHIBITORS ...... 31 THROMBOCYTOPENIA AGENTS ...... 31 MISCELLANEOUS ...... 31 IMMUNOLOGIC AGENTS ...... 32 ALLERGENIC EXTRACTS ...... 32 AUTOIMMUNE AGENTS (PHYSICIAN-ADMINISTERED) ...... 32 AUTOIMMUNE AGENTS (SELF-ADMINISTERED) ...... 32 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 32 HEREDITARY ANGIOEDEMA ...... 32 IMMUNOMODULATORS ...... 32 IMMUNOSUPPRESSANTS ...... 32 NUTRITIONAL/SUPPLEMENTS ...... 33 ELECTROLYTES ...... 33 VITAMINS AND MINERALS ...... 33 RESPIRATORY ...... 33 ANAPHYLAXIS TREATMENT AGENTS...... 33 ANTICHOLINERGICS ...... 33 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 33 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ...... 34 ANTIHISTAMINES, SEDATING ...... 34 ANTITUSSIVES...... 34 ANTITUSSIVE COMBINATIONS ...... 34 BETA AGONISTS ...... 34 CYSTIC FIBROSIS ...... 35 LEUKOTRIENE MODULATORS ...... 35 MAST CELL STABILIZERS ...... 35 NASAL ANTIHISTAMINES ...... 35 NASAL STEROIDS/COMBINATIONS ...... 35 PHOSPHODIESTERASE-4 INHIBITORS ...... 35 PULMONARY FIBROSIS AGENTS ...... 35 SEVERE ASTHMA AGENTS ...... 35 STEROID/BETA AGONIST COMBINATIONS ...... 35 STEROID INHALANTS ...... 35 XANTHINES ...... 35 MISCELLANEOUS ...... 36 TOPICAL ...... 36 DERMATOLOGY ...... 36 MOUTH/THROAT/DENTAL AGENTS ...... 38 OPHTHALMIC ...... 38 OTIC ...... 41 WEBSITES ...... 42 INDEX ...... 44 Drug name, page number ...... 44

What is the DAKOTACARE Drug Formulary? The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. DAKOTACARE works with a team of health care providers to choose drugs that provide quality treatment. DAKOTACARE covers drugs on the Drug Formulary that are:

 Medically necessary  Approved by the United States Food and Drug Administration (FDA)  Filled at a participating pharmacy

For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials. Can the Drug Formulary change? The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by DAKOTACARE. To get updated information about the drugs covered by DAKOTACARE, please visit us online at DAKOTACARE.com or call CVS Caremark Customer Care toll-free at 1-866-406-8773. How do I use the Drug Formulary? There are two ways to find your drug on the drug list:

1. Medical Condition

The drugs on this Drug Formulary are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under CARDIOVASCULAR.

 If you know what your drug is used for, look for the category name in the table of contents  Then look under the category name for your drug

2. Alphabetical Listing

If you are not sure what category to look under, look for your drug in the Index. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.

 Look in the Index and find your drug  Next to your drug, see the page number where you can find coverage information  Turn to the page listed in the Index and find the name of your drug in the first column of the list

For more information about your DAKOTACARE prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call CVS Caremark Customer Care toll-free at 1-866-406-8773 or visit us online at DAKOTACARE.com. DAKOTACARE Drug Formulary The Drug Formulary gives you information about the drugs covered by DAKOTACARE. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary.

The second column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case bold (e.g., atorvastatin).

The third column will list what tier the brand drug is placed on in the Drug Formulary. If no brand name is listed, the tier represents the tire of the generic product. Refer to your Summary of Benefits and Coverage to find the associated co- pay for that drug tier.

The first column tells you if DAKOTACARE has any special requirements for coverage of your drug. These requirements and limits may include:

 Preauthorization (PA): DAKOTACARE needs your healthcare provider to get preauthorization for certain drugs by submitting a request online at www.dkc-pa.com. This means that approval from DAKOTACARE must be obtained before you fill your prescription. If you don't get approval, DAKOTACARE will not cover the cost of the drug. Additional information can be found online at DAKOTACARE.com.  Quantity Limits (QL): For certain drugs, DAKOTACARE limits the amount of the drug that it will cover. For example, DAKOTACARE only covers 18 tablets of sumatriptan 50 mg per 30 days. DAKOTACARE also limits the amount of drugs you may receive within a class of drugs. For these classes, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.  Step Therapy (ST): DAKOTACARE utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, DAKOTACARE will cover the step-two drugs. Visit us online at DAKOTACARE.com to review a list of Step Therapy Programs.  Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age.  Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on gender. What if my drug is not on the Drug Formulary? If your drug is not on this Drug Formulary, you have two choices:

 Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you.  You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following:

• Why no other prescription on the Drug Formulary will work as well as the requested drug

• A list of other drugs that have been tried and how you responded to these drugs

• Medical documentation to support the medical necessity

How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescriptions co-pays.

What do the tiers mean on the Drug Formulary?

Tier Type of Drugs Included

Tier 1 Generic drugs

Tier 2 Preferred brand drugs

Tier 3 Non-preferred brand drugs

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

DAKOTACARE and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by DAKOTACARE or CVS Caremark.

ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org

NSAIDs diclofenac sodium delayed-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 ibuprofen Tier 1 meloxicam Tier 1 nabumetone Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1 oxaprozin Tier 1 sulindac Tier 1

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1

NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1

COX-2 INHIBITORS QL celecoxib Tier 1

GOUT allopurinol Tier 1 QL colchicine tabs Tier 1 probenecid Tier 1 QL colchicine Tier 2 MITIGARE

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org

Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html

QL buprenorphine transdermal Tier 1 QL codeine/acetaminophen Tier 1 QL fentanyl transdermal Tier 1 QL fentanyl transmucosal lozenge Tier 1 QL hydrocodone ext-rel Tier 1 QL hydrocodone/acetaminophen Tier 1 QL hydromorphone Tier 1 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine supp Tier 1 QL oxycodone caps 5 mg Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln 5 mg/5 mL Tier 1 QL oxycodone tabs 5 mg, 15 mg, 30 mg Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 QL, * tramadol Tier 1 QL tramadol ext-rel Tier 1 buprenorphine Tier 2 BELBUCA QL, ST oxycodone ext-rel Tier 2 XTAMPZA ER QL tapentadol Tier 2 NUCYNTA QL, ST tapentadol ext-rel Tier 2 NUCYNTA ER

* Listing does not include NDC 52817019610. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org

Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org

HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html

International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html

Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

ANTIBACTERIALS Cephalosporins First Generation cefadroxil Tier 1 cephalexin Tier 3 KEFLEX

Second Generation cefprozil Tier 1 cefuroxime axetil Tier 1

PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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Third Generation cefdinir Tier 1 cefixime Tier 2 SUPRAX

Erythromycins/Macrolides clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 QL fidaxomicin Tier 2 DIFICID azithromycin Tier 3 ZITHROMAX

Fluoroquinolones levofloxacin Tier 1 moxifloxacin Tier 1 ciprofloxacin Tier 3 CIPRO

Penicillins amoxicillin Tier 1 amoxicillin/clavulanate ext-rel Tier 1 ampicillin Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1 amoxicillin/clavulanate Tier 3 AUGMENTIN

Tetracyclines doxycycline hyclate 20 mg Tier 1 minocycline Tier 1 tetracycline Tier 1 doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS clotrimazole troches Tier 1 griseofulvin ultramicrosize Tier 1 QL itraconazole Tier 1 nystatin Tier 1 terbinafine tabs Tier 1 fluconazole Tier 3 DIFLUCAN QL voriconazole Tier 3 VFEND

ANTIMALARIALS chloroquine Tier 1 mefloquine Tier 1 atovaquone/proguanil Tier 3 MALARONE

ANTIRETROVIRAL AGENTS Antiretroviral Combinations efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 1 QL efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 QL abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ QL atazanavir/cobicistat Tier 2 EVOTAZ

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QL bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY QL darunavir/cobicistat Tier 2 PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 SYMTUZA dolutegravir/lamivudine Tier 2 DOVATO elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil Tier 2 STRIBILD fumarate QL emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA QL emtricitabine/tenofovir alafenamide Tier 2 DESCOVY emtricitabine/tenofovir disoproxil fumarate Tier 2 TRUVADA QL lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO QL lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS abacavir/lamivudine Tier 3 EPZICOM lamivudine/zidovudine Tier 3 COMBIVIR

Fusion Inhibitors QL enfuvirtide Tier 2 FUZEON

Integrase Inhibitors QL dolutegravir Tier 2 TIVICAY QL raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 nevirapine Tier 1 QL nevirapine ext-rel Tier 1 QL etravirine Tier 2 INTELENCE QL rilpivirine Tier 2 EDURANT

Nucleoside Reverse Transcriptase Inhibitors didanosine delayed-rel Tier 1 stavudine Tier 1 QL emtricitabine Tier 2 EMTRIVA abacavir tabs Tier 3 ZIAGEN lamivudine Tier 3 EPIVIR zidovudine Tier 3 RETROVIR

Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate Tier 2 VIREAD

Protease Inhibitors atazanavir Tier 1 QL darunavir Tier 2 PREZISTA lopinavir/ritonavir tabs Tier 2 KALETRA ritonavir Tier 2 NORVIR lopinavir/ritonavir soln Tier 3 KALETRA

ANTITUBERCULAR AGENTS isoniazid Tier 1 pyrazinamide Tier 1 ethambutol Tier 3 MYAMBUTOL

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rifampin Tier 3 RIFADIN

ANTIVIRALS Cytomegalovirus Agents valganciclovir Tier 1

Hepatitis Agents Hepatitis B entecavir tabs Tier 1 lamivudine Tier 1 tenofovir alafenamide Tier 2 VEMLIDY entecavir soln Tier 3 BARACLUDE

Hepatitis C ribavirin Tier 1 PA, QL, † ledipasvir/sofosbuvir Tier 2 HARVONI PA, QL, † sofosbuvir/velpatasvir Tier 2 EPCLUSA PA, QL, † sofosbuvir/velpatasvir/voxilaprevir Tier 2 VOSEVI

† HARVONI only for genotypes 1, 4, 5, and 6 EPCLUSA for genotypes 1, 2, 3, 4, 5, 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).

Herpes Agents acyclovir caps, tabs Tier 1 famciclovir Tier 1 valacyclovir Tier 1

Influenza Agents QL oseltamivir Tier 1 QL zanamivir Tier 2 RELENZA

MISCELLANEOUS dapsone Tier 1 QL linezolid Tier 1 nitrofurantoin macrocrystals Tier 1 * nitrofurantoin susp Tier 1 pyrimethamine Tier 1 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1 trimethoprim Tier 1 mebendazole chewable Tier 2 EMVERM rifaximin 550 mg Tier 2 XIFAXAN clindamycin Tier 3 CLEOCIN ivermectin Tier 3 STROMECTOL metronidazole Tier 3 FLAGYL nitrofurantoin ext-rel Tier 3 MACROBID

* Listing does not include NDC 70408023932. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org

captopril Tier 1 fosinopril Tier 1 perindopril Tier 1 trandolapril Tier 1 benazepril Tier 3 LOTENSIN enalapril Tier 3 VASOTEC lisinopril Tier 3 ZESTRIL quinapril Tier 3 ACCUPRIL ramipril Tier 3 ALTACE

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril Tier 3 LOTREL trandolapril/verapamil ext-rel Tier 3 TARKA

ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide Tier 1 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 benazepril/hydrochlorothiazide Tier 3 LOTENSIN HCT enalapril/hydrochlorothiazide Tier 3 VASERETIC quinapril/hydrochlorothiazide Tier 3 ACCURETIC

ADRENOLYTICS, CENTRAL guanfacine Tier 1 clonidine Tier 3 CATAPRES QL clonidine transdermal Tier 3 CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS QL eplerenone Tier 3 INSPRA spironolactone Tier 3 ALDACTONE

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

terazosin Tier 1

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doxazosin Tier 3 CARDURA

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 olmesartan/amlodipine/hydrochlorothiazide Tier 3 TRIBENZOR

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org

amiodarone Tier 1 flecainide Tier 1 propafenone Tier 1 sotalol Tier 1 QL dronedarone Tier 2 MULTAQ disopyramide Tier 3 NORPACE disopyramide ext-rel Tier 3 NORPACE CR dofetilide Tier 3 TIKOSYN propafenone ext-rel Tier 3 RYTHMOL SR

ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625

ACL Inhibitors/Combinations bempedoic acid Tier 2 NEXLETOL bempedoic acid/ezetimibe Tier 2 NEXLIZET

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Bile Acid Resins colesevelam Tier 1 cholestyramine Tier 3 QUESTRAN/QUESTRAN LIGHT colestipol Tier 3 COLESTID

Cholesterol Absorption Inhibitors ezetimibe Tier 1

Fibrates * fenofibrate Tier 1 fenofibrate Tier 3 ANTARA fenofibric acid delayed-rel Tier 3 TRILIPIX gemfibrozil Tier 3 LOPID

* Listing does not include fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg.

HMG-CoA Reductase Inhibitors/Combinations QL atorvastatin Tier 1 fluvastatin Tier 1 lovastatin Tier 1 QL rosuvastatin Tier 1 ezetimibe/simvastatin Tier 3 VYTORIN pravastatin Tier 3 PRAVACHOL simvastatin Tier 3 ZOCOR

Niacins QL niacin ext-rel Tier 3 NIASPAN

Omega-3 Fatty Acids QL icosapent ethyl Tier 2 VASCEPA QL omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors PA, QL alirocumab Tier 2 PRALUENT

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol Tier 1 bisoprolol Tier 1 QL carvedilol phosphate ext-rel Tier 1 labetalol Tier 1 metoprolol succinate ext-rel Tier 1 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 QL nebivolol Tier 2 BYSTOLIC carvedilol Tier 3 COREG metoprolol tartrate Tier 3 LOPRESSOR nadolol Tier 3 CORGARD

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BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 3 ZIAC metoprolol/hydrochlorothiazide Tier 3 LOPRESSOR HCT

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1 felodipine ext-rel Tier 1 nifedipine ext-rel Tier 1 nifedipine ext-rel Tier 3 PROCARDIA XL

Nondihydropyridines * diltiazem ext-rel Tier 1 diltiazem ext-rel Tier 3 TIAZAC verapamil ext-rel Tier 3 CALAN SR

* Listing does not include generics for CARDIZEM LA.

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES digoxin 0.125 mg, 0.25 mg Tier 1 digoxin ped elixir Tier 1 digoxin 0.0625 mg, 0.1875 mg Tier 3 LANOXIN

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS QL aliskiren Tier 1 QL aliskiren/hydrochlorothiazide Tier 2 TEKTURNA HCT

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1

Loop Diuretics bumetanide Tier 1 torsemide Tier 1 furosemide Tier 3 LASIX

Potassium-sparing Diuretics amiloride Tier 1 triamterene Tier 1

Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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indapamide Tier 1 metolazone Tier 1

Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 3 ALDACTAZIDE triamterene/hydrochlorothiazide Tier 3 DYAZIDE triamterene/hydrochlorothiazide Tier 3 MAXZIDE

HEART FAILURE isosorbide dinitrate/hydralazine Tier 2 BIDIL QL ivabradine Tier 2 CORLANOR sacubitril/valsartan Tier 2 ENTRESTO

NITRATES Oral * isosorbide dinitrate Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1

* Listing does not include isosorbide dinitrate 40 mg.

Sublingual/Translingual nitroglycerin lingual spray Tier 3 NITROLINGUAL nitroglycerin sublingual Tier 3 NITROSTAT

Transdermal nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 3 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, QL ambrisentan Tier 1 PA, QL bosentan Tier 1 PA, QL macitentan Tier 2 OPSUMIT

Phosphodiesterase Inhibitors PA, QL tadalafil Tier 1 QL sildenafil Tier 3 REVATIO

Prostacyclin Receptor Agonists PA, QL selexipag Tier 2 UPTRAVI

Prostaglandin Vasodilators PA treprostinil Tier 1 PA, QL treprostinil ext-rel Tier 2 ORENITRAM

Soluble Guanylate Cyclase Stimulators PA, QL riociguat Tier 2 ADEMPAS

MISCELLANEOUS hydralazine Tier 1 methyldopa Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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midodrine Tier 1 QL ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org

ANTIANXIETY Benzodiazepines alprazolam Tier 1 oxazepam Tier 1 clonazepam Tier 3 KLONOPIN diazepam Tier 3 VALIUM lorazepam Tier 3 ATIVAN

Miscellaneous buspirone Tier 1 fluvoxamine Tier 1 clomipramine Tier 3 ANAFRANIL

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com

carbamazepine ext-rel Tier 1 PA clobazam Tier 1 lamotrigine Tier 1 QL lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1 phenobarbital Tier 1 QL rufinamide Tier 1 tiagabine Tier 1 ** topiramate ext-rel Tier 1 valproic acid Tier 1 QL vigabatrin Tier 1 zonisamide Tier 1 QL cenobamate Tier 2 XCOPRI diazepam nasal spray Tier 2 VALTOCO QL lacosamide Tier 2 VIMPAT midazolam nasal spray Tier 2 NAYZILAM oxcarbazepine ext-rel Tier 2 OXTELLAR XR QL perampanel Tier 2 FYCOMPA QL topiramate ext-rel Tier 2 TROKENDI XR carbamazepine Tier 3 TEGRETOL carbamazepine ext-rel Tier 3 CARBATROL diazepam rectal gel Tier 3 DIASTAT divalproex sodium delayed-rel Tier 3 DEPAKOTE divalproex sodium ext-rel Tier 3 DEPAKOTE ER ethosuximide Tier 3 ZARONTIN ST, * gabapentin Tier 3 NEURONTIN levetiracetam Tier 3 KEPPRA QL levetiracetam ext-rel Tier 3 KEPPRA XR PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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oxcarbazepine Tier 3 TRILEPTAL phenytoin Tier 3 DILANTIN INFATABS phenytoin sodium extended Tier 3 DILANTIN primidone Tier 3 MYSOLINE topiramate Tier 3 TOPAMAX

** Listing does not include topiramate ext-rel capsule (generics for QUDEXY XR).

* ST applies to brand products only

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com

QL memantine ext-rel Tier 1 QL rivastigmine Tier 1 QL memantine/donepezil Tier 2 NAMZARIC QL donepezil Tier 3 ARICEPT QL galantamine Tier 3 RAZADYNE QL galantamine ext-rel Tier 3 RAZADYNE ER QL memantine Tier 3 NAMENDA QL rivastigmine transdermal Tier 3 EXELON

ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.

Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 3 NARDIL tranylcypromine Tier 3 PARNATE

Selective Serotonin Reuptake Inhibitors (SSRIs) escitalopram Tier 1 * fluoxetine Tier 1 paroxetine HCl Tier 1 paroxetine HCl ext-rel Tier 1 sertraline Tier 1 QL vortioxetine Tier 2 TRINTELLIX citalopram Tier 3 CELEXA

* Listing does not include fluoxetine tablet 60 mg, fluoxetine tablet (generics for SARAFEM)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) QL desvenlafaxine ext-rel Tier 1 duloxetine delayed-rel Tier 1 venlafaxine Tier 1 venlafaxine ext-rel Tier 1

Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 doxepin Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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imipramine HCl Tier 1 desipramine Tier 3 NORPRAMIN nortriptyline Tier 3 PAMELOR

Miscellaneous Agents bupropion Tier 1 trazodone Tier 1 QL, ST, * bupropion ext-rel Tier 3 WELLBUTRIN SR QL, ST, * bupropion ext-rel Tier 3 WELLBUTRIN XL QL mirtazapine tabs 7.5 mg, orally disintegrating Tier 3 REMERON mirtazapine tabs 15 mg, 30 mg, 45 mg Tier 3 REMERON

* ST applies to brand products only

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com

amantadine Tier 1 benztropine Tier 1 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 QL pramipexole ext-rel Tier 1 QL rasagiline Tier 1 ropinirole Tier 1 selegiline Tier 1 trihexyphenidyl Tier 1 levodopa inhalation powder Tier 2 INBRIJA rotigotine transdermal Tier 2 NEUPRO bromocriptine Tier 3 PARLODEL carbidopa/levodopa Tier 3 SINEMET carbidopa/levodopa/entacapone Tier 3 STALEVO entacapone Tier 3 COMTAN QL pramipexole Tier 3 MIRAPEX QL ropinirole ext-rel Tier 3 REQUIP XL

ANTIPSYCHOTICS Atypicals QL aripiprazole Tier 1 QL quetiapine ext-rel Tier 1 QL ziprasidone Tier 1 QL cariprazine Tier 2 VRAYLAR QL lurasidone Tier 2 LATUDA QL clozapine Tier 3 CLOZARIL olanzapine Tier 3 ZYPREXA quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL

Miscellaneous chlorpromazine Tier 1 fluphenazine Tier 1 haloperidol Tier 1

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perphenazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org

amphetamine/dextroamphetamine mixed salts Tier 1 ^ amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 dexmethylphenidate ext-rel Tier 1 dextroamphetamine Tier 1 QL guanfacine ext-rel Tier 1 QL, ^ methylphenidate ext-rel Tier 1 QL amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS QL lisdexamfetamine Tier 2 VYVANSE QL atomoxetine Tier 3 STRATTERA dexmethylphenidate Tier 3 FOCALIN dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE methylphenidate Tier 3 METHYLIN methylphenidate Tier 3 RITALIN

^ Listing does not include certain NDCs. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

FIBROMYALGIA QL pregabalin Tier 1

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org

Benzodiazepines QL temazepam Tier 3 RESTORIL

Nonbenzodiazepines QL eszopiclone Tier 1 ramelteon Tier 1 QL zolpidem sublingual Tier 1 QL zolpidem Tier 3 AMBIEN QL zolpidem ext-rel Tier 3 AMBIEN CR

Tricyclics QL doxepin Tier 1

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MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com

Acute Migraine Agents Ergotamine Derivatives dihydroergotamine inj Tier 3 D.H.E. 45

Triptans QL naratriptan Tier 1 QL rizatriptan Tier 1 QL sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH QL sumatriptan nasal powder Tier 2 ONZETRA XSAIL QL zolmitriptan nasal spray Tier 2 ZOMIG QL eletriptan Tier 3 RELPAX QL sumatriptan Tier 3 IMITREX QL sumatriptan inj Tier 3 IMITREX QL sumatriptan nasal spray Tier 3 IMITREX QL zolmitriptan Tier 3 ZOMIG

Miscellaneous PA, QL lasmiditan Tier 2 REYVOW PA, QL rimegepant Tier 2 NURTEC ODT PA, QL ubrogepant Tier 2 UBRELVY

Preventive Migraine Agents Monoclonal Antibodies PA erenumab-aooe Tier 2 AIMOVIG PA fremanezumab-vfrm Tier 2 AJOVY PA galcanezumab-gnlm Tier 2 EMGALITY

MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 3 LITHOBID

MOVEMENT DISORDERS PA tetrabenazine Tier 1 PA deutetrabenazine Tier 2 AUSTEDO PA, QL valbenazine Tier 2 INGREZZA

MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com

PA, QL dimethyl fumarate delayed-rel Tier 1 PA diroximel fumarate delayed-rel Tier 2 VUMERITY PA fingolimod Tier 2 GILENYA PA, QL glatiramer Tier 2 COPAXONE PA, QL interferon beta-1a Tier 2 REBIF PA, QL interferon beta-1b Tier 2 BETASERON PA ocrelizumab Tier 2 OCREVUS PA ofatumumab Tier 2 KESIMPTA PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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PA ozanimod Tier 2 ZEPOSIA PA siponimod Tier 2 MAYZENT PA, QL teriflunomide Tier 2 AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 QL carisoprodol Tier 1 * chlorzoxazone 500 mg Tier 1 ** cyclobenzaprine Tier 1 dantrolene Tier 3 DANTRIUM metaxalone 800 mg Tier 3 SKELAXIN *** methocarbamol Tier 3 ROBAXIN tizanidine tabs Tier 3 ZANAFLEX

* Listing does not include NDC 73007001303. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

** Listing does not include cyclobenzaprine tablet 7.5 mg.

*** Listing does not include NDCs 69036091010, 69036093090 and 70868090190. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

MYASTHENIA GRAVIS pyridostigmine ext-rel Tier 1 pyridostigmine soln, tabs 60 mg Tier 1 QL pyridostigmine tabs 30 mg Tier 3

NARCOLEPSY QL armodafinil Tier 1 QL solriamfetol Tier 2 SUNOSI

POSTHERPETIC NEURALGIA (PHN) gabapentin ext-rel Tier 2 GRALISE

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 3 ANTABUSE

Opioid Antagonists naltrexone Tier 1 QL naloxone nasal spray Tier 2 NARCAN

Partial Opioid Agonist/Opioid Antagonist Combinations buprenorphine/naloxone sublingual Tier 1 PA buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV

Pseudobulbar Affect Agents dextromethorphan/quinidine Tier 2 NUEDEXTA

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ENDOCRINE AND METABOLIC ACROMEGALY lanreotide acetate Tier 2 SOMATULINE DEPOT

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com testosterone cypionate Tier 1 testosterone enanthate Tier 1 QL, * testosterone gel Tier 1 QL testosterone soln Tier 1 QL testosterone transdermal Tier 2 ANDRODERM

* Listing does not include the authorized generics for TESTIM and VOGELXO.

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org

Alpha-glucosidase Inhibitors acarbose Tier 3 PRECOSE

Amylin Analogs PA, QL pramlintide Tier 2 SYMLINPEN

Biguanides metformin Tier 1 * metformin ext-rel Tier 1

* Listing does not include generics for FORTAMET and GLUMETZA.

Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors QL sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations QL sitagliptin/metformin Tier 2 JANUMET QL sitagliptin/metformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents QL dulaglutide Tier 2 TRULICITY QL liraglutide Tier 2 VICTOZA QL semaglutide Tier 2 OZEMPIC QL, ST semaglutide Tier 2 RYBELSUS

Incretin Mimetic Agent/Insulin Combinations QL, ST liraglutide/insulin degludec Tier 2 XULTOPHY QL, ST lixisenatide/insulin glargine Tier 2 SOLIQUA

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Insulins insulin aspart Tier 2 FIASP insulin aspart Tier 2 NOVOLOG insulin aspart protamine 70%/insulin aspart 30% Tier 2 NOVOLOG MIX 70/30 insulin degludec Tier 2 TRESIBA insulin detemir Tier 2 LEVEMIR insulin glargine Tier 2 BASAGLAR insulin glargine Tier 2 TOUJEO insulin human Tier 2 HUMULIN R U-500 insulin human Tier 2 NOVOLIN R insulin isophane human Tier 2 NOVOLIN N insulin isophane human 70%/regular 30% Tier 2 NOVOLIN 70/30

Insulin Sensitizers pioglitazone Tier 1

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 3 ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations QL pioglitazone/glimepiride Tier 3 DUETACT

Meglitinides nateglinide Tier 1 repaglinide Tier 1

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors QL, ST dapagliflozin Tier 2 FARXIGA QL, ST empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations QL, ST dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR QL, ST empagliflozin/metformin Tier 2 SYNJARDY QL, ST empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations QL, ST empagliflozin/linagliptin Tier 2 GLYXAMBI

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST empagliflozin/linagliptin/metformin ext-rel Tier 2 TRIJARDY XR

Sulfonylureas glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies QL blood glucose monitoring kits, test strips Tier 2 ONETOUCH ULTRA kits and test strips QL blood glucose monitoring kits, test strips Tier 2 ONETOUCH VERIO kits and test strips insulin infusion disposable pump Tier 2 OMNIPOD DASH INSULIN INFUSION PUMP PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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insulin infusion disposable pump Tier 2 OMNIPOD INSULIN INFUSION PUMP insulin infusion disposable pump Tier 2 V-GO INSULIN INFUSION PUMP QL insulin syringes, needles Tier 2 BD ULTRAFINE insulin syringes and needles QL lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS cinacalcet Tier 1

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates QL alendronate Tier 3 FOSAMAX QL ibandronate Tier 3 BONIVA QL risedronate Tier 3 ACTONEL QL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones PA, QL abaloparatide Tier 2 TYMLOS PA, QL teriparatide Tier 2 FORTEO

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1 norethindrone acetate/EE 1/20 Tier 1 norethindrone acetate/EE 1/20 and iron Tier 1 norethindrone acetate/EE 1/20 and iron chewable Tier 1

30 mcg Estrogen desogestrel/EE 0.15/30 Tier 1 drospirenone/EE 3/30 Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1 norethindrone acetate/EE 1.5/30 Tier 1 norethindrone acetate/EE 1.5/30 and iron Tier 1 norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 norethindrone/EE 0.5/35 Tier 1 norethindrone/EE 1/35 Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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norgestimate/EE 0.25/35 Tier 1

Biphasic ST norethindrone acetate/EE 1/10 and EE 10 and iron Tier 2 LO LOESTRIN FE ST, * desogestrel/EE Tier 3 MIRCETTE

* ST applies to brand products only

Triphasic desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1 norethindrone/EE Tier 1 norgestimate/EE Tier 1

Extended Cycle QL levonorgestrel/EE 0.15/30 Tier 1 QL, ST, * levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE QL, ST, * levonorgestrel/EE 0.15/30 and EE 10 Tier 3 SEASONIQUE

* ST applies to brand products only

Progestin Only norethindrone Tier 1 ST, * norethindrone Tier 3 ORTHO MICRONOR

* ST applies to brand products only

Transdermal norelgestromin/EE Tier 1

Vaginal etonogestrel/EE ring Tier 1 segesterone acetate/EE ring Tier 2 ANNOVERA

ENDOMETRIOSIS danazol Tier 1 QL elagolix Tier 2 ORILISSA

GAUCHER DISEASE PA, QL eliglustat Tier 2 CERDELGA

GLUCOCORTICOIDS dexamethasone Tier 1 fludrocortisone Tier 1 prednisolone Tier 1 prednisone Tier 1 hydrocortisone Tier 3 CORTEF methylprednisolone Tier 3 MEDROL

GLUCOSE ELEVATING AGENTS glucagon nasal powder Tier 2 BAQSIMI glucagon subcutaneous soln Tier 2 GVOKE glucagon, human recombinant Tier 2 GLUCAGEN HYPOKIT PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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glucagon, human recombinant Tier 2 GLUCAGON EMERGENCY KIT

HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 2 ORFADIN

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines

PA somatropin Tier 2 GENOTROPIN PA somatropin Tier 2 NORDITROPIN

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 3 ROCALTROL doxercalciferol Tier 3 HECTOROL paricalcitol Tier 3 ZEMPLAR

MENOPAUSAL SYMPTOM AGENTS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf

Oral EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone Tier 1 QL estrogens, conjugated/bazedoxifene Tier 2 DUAVEE estrogens, conjugated/medroxyprogesterone Tier 2 PREMPHASE estrogens, conjugated/medroxyprogesterone Tier 2 PREMPRO estradiol Tier 3 ESTRACE

Transdermal QL estradiol Tier 1 QL estradiol Tier 2 DIVIGEL QL estradiol Tier 2 EVAMIST QL estradiol/levonorgestrel Tier 2 CLIMARA PRO QL estradiol/norethindrone acetate Tier 2 COMBIPATCH QL estradiol Tier 3 CLIMARA

Vaginal estradiol vaginal crm Tier 1 estradiol vaginal inserts Tier 2 IMVEXXY estradiol vaginal tabs Tier 2 VAGIFEM

PHENYLKETONURIA TREATMENT AGENTS PA sapropterin Tier 1

PHOSPHATE BINDER AGENTS calcium acetate Tier 1 sevelamer carbonate Tier 1 calcium acetate Tier 2 PHOSLYRA

POLYNEUROPATHY PA inotersen Tier 2 TEGSEDI PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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POTASSIUM-REMOVING AGENTS patiromer sorbitex Tier 2 VELTASSA sodium zirconium cyclosilicate Tier 2 LOKELMA

PROGESTINS Oral megestrol acetate susp Tier 1 medroxyprogesterone acetate Tier 3 PROVERA norethindrone acetate Tier 3 AYGESTIN progesterone, micronized Tier 3 PROMETRIUM

Vaginal progesterone gel Tier 2 CRINONE

SELECTIVE ESTROGEN RECEPTOR MODULATORS QL raloxifene Tier 3 EVISTA

THYROID AGENTS Antithyroid Agents propylthiouracil Tier 1 methimazole Tier 3 TAPAZOLE

Thyroid Supplements levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 levothyroxine Tier 2 SYNTHROID

UTERINE FIBROIDS QL elagolix sodium/estradiol/norethindrone acetate Tier 2 ORIAHNN

VASOPRESSINS desmopressin spray, tabs Tier 3 DDAVP

MISCELLANEOUS cabergoline Tier 1

GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org

ANTIDIARRHEALS loperamide Tier 1 diphenoxylate/atropine Tier 3 LOMOTIL

ANTIEMETICS aprepitant Tier 1 QL doxylamine/pyridoxine delayed-rel Tier 1 QL granisetron Tier 1 meclizine Tier 1 prochlorperazine Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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promethazine Tier 1 QL scopolamine transdermal Tier 1 QL granisetron transdermal Tier 2 SANCUSO dronabinol Tier 3 MARINOL metoclopramide Tier 3 REGLAN QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

ANTISPASMODICS dicyclomine Tier 1 hyoscyamine sulfate ext-rel caps Tier 1 hyoscyamine sulfate orally disintegrating tabs Tier 1 hyoscyamine sulfate Tier 3 LEVSIN

CHOLELITHOLYTICS ursodiol Tier 3 ACTIGALL ursodiol Tier 3 URSO

INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 QL mesalamine delayed-rel caps Tier 1 QL, * mesalamine delayed-rel tabs Tier 1 QL mesalamine ext-rel caps Tier 1 QL mesalamine delayed-rel tabs Tier 2 ASACOL HD QL mesalamine ext-rel caps Tier 2 PENTASA sulfasalazine Tier 3 AZULFIDINE sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS

* Listing does not include mesalamine delayed-rel tablet 800 mg.

Rectal Agents hydrocortisone enema Tier 1 mesalamine supp Tier 1 hydrocortisone acetate foam Tier 2 CORTIFOAM mesalamine susp Tier 3 ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation QL linaclotide Tier 2 LINZESS

Irritable Bowel Syndrome with Diarrhea QL alosetron Tier 1 QL eluxadoline Tier 2 VIBERZI

LAXATIVES lactulose soln Tier 1 peg 3350/electrolytes Tier 1 sodium picosulfate/magnesium oxide/citric acid Tier 2 CLENPIQ peg 3350/electrolytes Tier 3 NULYTELY

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OPIOID-INDUCED CONSTIPATION naldemedine Tier 2 SYMPROIC QL naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES pancrelipase Tier 2 VIOKACE pancrelipase delayed-rel Tier 2 CREON pancrelipase delayed-rel Tier 2 ZENPEP

PROSTAGLANDINS misoprostol Tier 3 CYTOTEC

PROTON PUMP INHIBITORS QL pantoprazole delayed-rel tabs Tier 1 QL dexlansoprazole delayed-rel Tier 2 DEXILANT

SALIVA STIMULANTS cevimeline Tier 3 EVOXAC pilocarpine tabs Tier 3 SALAGEN

STEROIDS, RECTAL hydrocortisone acetate/pramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 3 ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1 bismuth/metronidazole/tetracycline Tier 2 PYLERA

MISCELLANEOUS sucralfate tablet Tier 1

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines

QL alfuzosin ext-rel Tier 1 QL silodosin Tier 1 QL dutasteride Tier 3 AVODART QL finasteride Tier 3 PROSCAR tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS QL darifenacin ext-rel Tier 1 oxybutynin Tier 1 QL solifenacin Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 QL fesoterodine ext-rel Tier 2 TOVIAZ QL mirabegron ext-rel Tier 2 MYRBETRIQ oxybutynin ext-rel Tier 3 DITROPAN XL PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES metronidazole Tier 1 QL terconazole Tier 1 clindamycin crm Tier 3 CLEOCIN

MISCELLANEOUS bethanechol Tier 1 potassium citrate ext-rel Tier 3 UROCIT-K

HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org

ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular

Injectable QL enoxaparin Tier 1 dalteparin Tier 3 FRAGMIN

Oral warfarin Tier 1 apixaban Tier 2 ELIQUIS rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents fondaparinux Tier 3 ARIXTRA

PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 dipyridamole Tier 1 QL prasugrel Tier 1 QL ticagrelor Tier 2 BRILINTA dipyridamole ext-rel/aspirin Tier 3 AGGRENOX

PLATELET SYNTHESIS INHIBITORS anagrelide Tier 3 AGRYLIN

THROMBOCYTOPENIA AGENTS PA avatrombopag Tier 2 DOPTELET PA lusutrombopag Tier 2 MULPLETA

MISCELLANEOUS cilostazol Tier 1

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IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org

ALLERGENIC EXTRACTS QL grass mixed pollen allergen extract Tier 2 ORALAIR QL ragweed pollen allergen extract Tier 2 RAGWITEK QL timothy grass pollen allergen extract Tier 2 GRASTEK

AUTOIMMUNE AGENTS (PHYSICIAN-ADMINISTERED) PA, QL golimumab Tier 2 SIMPONI ARIA PA, QL infliximab Tier 2 REMICADE PA, QL ustekinumab Tier 2 STELARA INTRAVENOUS

AUTOIMMUNE AGENTS (SELF-ADMINISTERED) PA, QL adalimumab Tier 2 HUMIRA PA, QL apremilast Tier 2 OTEZLA PA, QL etanercept Tier 2 ENBREL PA, QL guselkumab Tier 2 TREMFYA PA, QL risankizumab-rzaa Tier 2 SKYRIZI PA, QL secukinumab Tier 2 COSENTYX PA, QL tofacitinib Tier 2 XELJANZ PA, QL tofacitinib ext-rel Tier 2 XELJANZ XR PA, QL upadacitinib Tier 2 RINVOQ PA, QL ustekinumab Tier 2 STELARA SUBCUTANEOUS

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) methotrexate Tier 1 methotrexate auto-injector Tier 2 RASUVO hydroxychloroquine Tier 3 PLAQUENIL leflunomide Tier 3 ARAVA

HEREDITARY ANGIOEDEMA C1 esterase inhibitor, recombinant Tier 2 RUCONEST icatibant Tier 2 FIRAZYR lanadelumab-flyo Tier 2 TAKHZYRO

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons interferon alfa-2b Tier 2 INTRON A QL peginterferon alfa-2a Tier 2 PEGASYS

IMMUNOSUPPRESSANTS Antimetabolites mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 2 AZASAN PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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azathioprine Tier 3 IMURAN

Calcineurin Inhibitors cyclosporine Tier 1 cyclosporine, modified Tier 1 tacrolimus Tier 1

Rapamycin Derivatives everolimus Tier 1 sirolimus Tier 1

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1

VITAMINS AND MINERALS Prenatal Vitamins prenatal vitamins Tier 1 prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM

RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov

The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org

ANAPHYLAXIS TREATMENT AGENTS QL epinephrine auto-injector Tier 1 QL epinephrine Tier 2 SYMJEPI QL epinephrine auto-injector Tier 2 EPIPEN QL epinephrine auto-injector Tier 2 EPIPEN JR.

ANTICHOLINERGICS ipratropium soln Tier 1 revefenacin inhalation soln Tier 2 YUPELRI QL tiotropium Tier 2 SPIRIVA

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1

Long Acting QL tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT QL umeclidinium/vilanterol Tier 2 ANORO ELLIPTA

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ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS budesonide/glycopyrrolate/formoterol Tier 2 BREZTRI AEROSPHERE QL fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES, SEDATING clemastine 2.68 mg Tier 1 cyproheptadine Tier 1 hydroxyzine HCl Tier 1

ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf

* benzonatate Tier 3 TESSALON

* Listing does not include NDCs 69336012615 and 69499032915. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTITUSSIVE COMBINATIONS Opioid codeine/guaifenesin liquid Tier 1 codeine/guaifenesin/pseudoephedrine Tier 1 codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/homatropine Tier 1

Non-opioid dextromethorphan/brompheniramine/pseudoephedri Tier 1 ne dextromethorphan/promethazine Tier 1

BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate CFC-free aerosol Tier 1 QL levalbuterol tartrate, CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT QL salmeterol xinafoate Tier 2 SEREVENT

Nebulized Passive Inhalation QL formoterol inhalation soln Tier 2 PERFOROMIST

Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 terbutaline Tier 1

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CYSTIC FIBROSIS QL tobramycin inhalation soln Tier 1 QL tobramycin inhalation soln Tier 2 BETHKIS dornase alfa Tier 3 PULMOZYME

LEUKOTRIENE MODULATORS montelukast Tier 1 QL zafirlukast Tier 1

MAST CELL STABILIZERS cromolyn soln Tier 1

NASAL ANTIHISTAMINES QL azelastine spray Tier 1 olopatadine spray Tier 3 PATANASE

NASAL STEROIDS/COMBINATIONS flunisolide spray Tier 1 QL mometasone spray Tier 1 QL azelastine/fluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS QL roflumilast Tier 2 DALIRESP

PULMONARY FIBROSIS AGENTS PA, QL nintedanib Tier 2 OFEV PA, QL pirfenidone Tier 2 ESBRIET

SEVERE ASTHMA AGENTS PA dupilumab Tier 2 DUPIXENT PA mepolizumab Tier 2 NUCALA

STEROID/BETA AGONIST COMBINATIONS QL fluticasone/salmeterol Tier 1 ADVAIR DISKUS QL budesonide/formoterol Tier 2 SYMBICORT QL, ^ fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA QL, ^ fluticasone/vilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER QL budesonide Tier 2 PULMICORT FLEXHALER QL fluticasone Tier 2 ARNUITY ELLIPTA QL fluticasone Tier 2 FLOVENT DISKUS QL fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA QL budesonide inhalation susp Tier 3 PULMICORT RESPULES

XANTHINES theophylline ext-rel tabs Tier 1

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MISCELLANEOUS QL ipratropium spray Tier 1

TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Oral isotretinoin Tier 1

Topical adapalene Tier 1 * clindamycin gel Tier 1 clindamycin/benzoyl peroxide Tier 1 erythromycin gel 2% Tier 1 erythromycin soln Tier 1 tazarotene Tier 1 tretinoin Tier 1 tretinoin - Avita Tier 1 QL tretinoin gel microsphere Tier 1 QL adapalene/benzoyl peroxide Tier 2 EPIDUO QL adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE clindamycin/benzoyl peroxide Tier 2 ONEXTON clindamycin gel, lotion, soln Tier 3 CLEOCIN T erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN sulfacetamide lotion 10% Tier 3 KLARON tretinoin Tier 3 RETIN-A

* Listing does not include NDC 68682046275. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

Actinic Keratosis fluorouracil crm 5%, soln 5%, soln 2% Tier 1 fluorouracil crm 4% Tier 2 TOLAK imiquimod Tier 2 ZYCLARA QL ingenol mebutate Tier 2 PICATO

Antibiotics gentamicin Tier 1 mupirocin oint Tier 1 silver sulfadiazine Tier 3 SILVADENE

Antifungals clotrimazole Tier 1 econazole Tier 1 ketoconazole crm 2% Tier 1 nystatin Tier 1 ST, * naftifine Tier 2 NAFTIN

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ST, * ciclopirox Tier 3 LOPROX

* ST applies to brand products only

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org

Oral QL acitretin Tier 3 SORIATANE PA methoxsalen oral Tier 3 OXSORALEN-ULTRA

Antiseborrheics ketoconazole shampoo 2% Tier 1 selenium sulfide lotion 2.5% Tier 1

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Injectable PA dupilumab Tier 2 DUPIXENT

Topical QL pimecrolimus Tier 1 tacrolimus Tier 1 crisaborole Tier 2 EUCRISA

Corticosteroids Low Potency alclometasone crm, oint 0.05% Tier 1 fluocinolone acetonide soln 0.01% Tier 1 hydrocortisone crm 2.5% Tier 1 desonide crm, lotion, oint 0.05% Tier 3 DESOWEN

Medium Potency betamethasone valerate crm, lotion, oint 0.1% Tier 1 desoximetasone crm 0.05% Tier 1 fluocinolone acetonide crm, oint 0.025% Tier 1 fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1 hydrocortisone butyrate crm, oint, soln 0.1% Tier 1 hydrocortisone valerate crm, oint 0.2% Tier 1 mometasone crm, lotion, oint 0.1% Tier 1 triamcinolone acetonide crm, lotion 0.025% Tier 1 triamcinolone acetonide crm, lotion, oint 0.1% Tier 1

High Potency betamethasone dipropionate augmented lotion 0.05% Tier 1 betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 desoximetasone crm, oint 0.25%, gel 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1 triamcinolone acetonide crm 0.5% Tier 1 PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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halobetasol propionate lotion 0.01% Tier 2 BRYHALI betamethasone dipropionate augmented crm 0.05% Tier 3 DIPROLENE AF

Very High Potency clobetasol propionate foam 0.05% Tier 1 betamethasone dipropionate augmented gel, oint Tier 3 DIPROLENE 0.05% clobetasol propionate crm, gel, oint, soln 0.05% Tier 3 TEMOVATE clobetasol propionate lotion, shampoo 0.05% Tier 3 CLOBEX halobetasol propionate crm, oint 0.05% Tier 3 ULTRAVATE

Local Analgesics QL lidocaine patch Tier 3 LIDODERM

Rosacea azelaic acid gel Tier 1 metronidazole gel 0.75% Tier 1 azelaic acid foam Tier 2 FINACEA FOAM doxycycline monohydrate delayed-rel caps Tier 2 ORACEA ivermectin Tier 2 SOOLANTRA metronidazole crm 0.75% Tier 3 METROCREAM metronidazole gel 1% Tier 3 METROGEL metronidazole lotion 0.75% Tier 3 METROLOTION

Scabicides and Pediculicides permethrin 5% Tier 1 malathion Tier 3 OVIDE

Miscellaneous Skin and Mucous Membrane imiquimod Tier 1 podofilox Tier 3 CONDYLOX

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1

Protectants - Mouth/Throat benzyl alcohol/carbomer 941/glycerin Tier 2 MUGARD soy phospholipid/glycerol dioleate Tier 2 EPISIL

Steroids - Mouth/Throat triamcinolone paste Tier 1

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org

Antiallergics azelastine Tier 1 cromolyn sodium Tier 1 olopatadine Tier 1 alcaftadine Tier 2 LASTACAFT olopatadine Tier 2 PAZEO PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, boldface: indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name; delayed-rel: delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification; ext-rel: extended-release (also known as sustained-release), refer to the reference brand listed for clarification; Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

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Anti-infectives bacitracin Tier 1 erythromycin Tier 1 gentamicin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1 polymyxin B/bacitracin Tier 1 sulfacetamide oint 10% Tier 1 besifloxacin Tier 2 BESIVANCE ciprofloxacin oint Tier 2 CILOXAN ciprofloxacin soln Tier 3 CILOXAN moxifloxacin Tier 3 VIGAMOX ofloxacin Tier 3 OCUFLOX polymyxin B/trimethoprim Tier 3 POLYTRIM sulfacetamide soln 10% Tier 3 BLEPH-10 tobramycin Tier 3 TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone Tier 1 oint neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone oint 0.3%/0.1% Tier 2 TOBRADEX tobramycin/dexamethasone susp 0.3%/0.05% Tier 2 TOBRADEX ST neomycin/polymyxin B/dexamethasone Tier 3 MAXITROL tobramycin/dexamethasone susp 0.3%/0.1% Tier 3 TOBRADEX

Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 ketorolac tromethamine Tier 2 ACUVAIL nepafenac Tier 2 ILEVRO nepafenac Tier 2 NEVANAC ketorolac Tier 3 ACULAR

Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 loteprednol Tier 1 prednisolone acetate 1% Tier 1 dexamethasone Tier 2 MAXIDEX difluprednate Tier 2 DUREZOL fluorometholone Tier 2 FML FORTE fluorometholone Tier 2 FML S.O.P. prednisolone acetate Tier 2 PRED MILD prednisolone phosphate 1% Tier 3

Antivirals trifluridine Tier 1

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Beta-blockers Nonselective levobunolol Tier 1 timolol maleate gel Tier 1 timolol hemihydrate Tier 2 BETIMOL timolol maleate Tier 3 TIMOPTIC

Selective betaxolol Tier 2 BETOPTIC S

Carbonic Anhydrase Inhibitors Topical brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 3 COSOPT

Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine Tier 2 SIMBRINZA

Dry Eye Disease QL cyclosporine, emulsion Tier 2 RESTASIS QL lifitegrast Tier 2 XIIDRA

Prostaglandins travoprost Tier 1 ST bimatoprost 0.01% Tier 2 LUMIGAN ST tafluprost Tier 2 ZIOPTAN ST, * latanoprost Tier 3 XALATAN

* ST applies to brand products only

Retinal Disorders aflibercept Tier 2 EYLEA ranibizumab Tier 2 LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase Inhibitor/Prostaglandin Combinations netarsudil/latanoprost Tier 2 ROCKLATAN

Sympathomimetics brimonidine 0.2% Tier 1 brimonidine Tier 2 ALPHAGAN P

Sympathomimetic/Beta-blocker Combinations brimonidine/timolol Tier 2 COMBIGAN

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OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org

Anti-infectives acetic acid Tier 1 ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone Tier 1 neomycin/polymyxin B/hydrocortisone Tier 1

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WEBSITES Agency for Healthcare Research and Quality American Congress of Obstetricians and https://www.ahrq.gov Gynecologists https://www.acog.org Alzheimer's Association https://www.alz.org American Diabetes Association http://www.diabetes.org American Academy of Allergy, Asthma and Immunology American Gastroenterological Association https://www.aaaai.org https://www.gastro.org

American Academy of Child & Adolescent Psychiatry American Headache Society Committee for Headache https://www.aacap.org Education https://americanheadachesociety.org American Academy of Dermatology https://www.aad.org American Heart Association https://professional.heart.org American Academy of Neurology https://www.aan.com American Lung Association https://www.lung.org American Academy of Ophthalmology https://www.aao.org American Medical Association https://www.ama-assn.org American Academy of Pediatrics https://www.aap.org American Psychiatric Association https://www.psychiatry.org American Association for the Study of Liver Disease https://www.aasld.org American Society of Anesthesiologists https://www.asahq.org American Association of Clinical Endocrinologists https://www.aace.com American Society of Clinical Oncology https://www.asco.org American Association of Diabetes Educators https://www.diabeteseducator.org American Society of Interventional Pain Physicians https://www.asipp.org American Cancer Society https://www.cancer.org American Urological Association https://www.auanet.org American College of Allergy, Asthma and Immunology https://www.acaai.org Centers for Disease Control and Prevention https://www.cdc.gov American College of Cardiology https://www.acc.org Centers for Disease Control and Prevention Guideline topics: AIDS American College of Chest Physicians https://www.cdc.gov/hiv/default.html https://www.chestnet.org Centers for Disease Control and Prevention American College of Gastroenterology Guideline topics: Sexually Transmitted Diseases https://gi.org https://www.cdc.gov/std/treatment/default.htm

American College of Physicians CVS Caremark https://www.acponline.org https://www.caremark.com

American College of Rheumatology The Food and Drug Administration https://www.rheumatology.org https://www.fda.gov

Global Initiative for Asthma National Foundation for Infectious Diseases https://ginasthma.org http://www.nfid.org

Infectious Diseases Society of America National Guideline Clearinghouse https://www.idsociety.org https://www.ahrq.gov

Institute for Safe Medication Practices National Heart, Lung and Blood Institute https://www.ismp.org https://www.nhlbi.nih.gov

Johns Hopkins AIDS Service National Institutes of Health https://www.thebody.com/content/art12096.html https://www.nih.gov

Juvenile Diabetes Research Foundation International National Kidney Foundation https://www.jdrf.org https://www.kidney.org

MedWatch National Osteoporosis Foundation https://www.fda.gov/Safety/MedWatch/default.htm https://www.nof.org

National Agricultural Library North American Menopause Society https://www.nal.usda.gov https://www.menopause.org

National Cancer Institute United States Department of Health and Human https://www.cancer.gov/about-cancer Services https://www.hhs.gov National Comprehensive Cancer Network https://www.nccn.org World Health Organization https://www.who.int

INDEX Drug name, page number

A amlodipine/telmisartan, 13 amlodipine/valsartan, 13 abacavir tabs, 10 amlodipine/valsartan/hydrochlorothiazide, 13 abacavir/dolutegravir/lamivudine, 9 amoxicillin, 9 abacavir/lamivudine, 10 amoxicillin/clavulanate, 9 abaloparatide, 25 amoxicillin/clavulanate ext-rel, 9 acamprosate calcium, 22 amphetamine/dextroamphetamine mixed salts, 20 acarbose, 23 amphetamine/dextroamphetamine mixed salts ext-rel, 20 ACCUPRIL, 12 ampicillin, 9 ACCURETIC, 12 ANAFRANIL, 17 acetazolamide, 15 anagrelide, 31 acetazolamide ext-rel, 15 ANDRODERM, 23 acetic acid, 41 ANNOVERA, 26 acitretin, 37 ANORO ELLIPTA, 33 ACTIGALL, 29 ANTABUSE, 22 ACTONEL, 25 ANTARA, 14 ACTOPLUS MET, 24 ANUSOL-HC, 30 ACULAR, 39 apixaban, 31 ACUVAIL, 39 apremilast, 32 acyclovir caps, tabs, 11 aprepitant, 28 adalimumab, 32 ARAVA, 32 adapalene, 36 ARICEPT, 18 adapalene/benzoyl peroxide, 36 aripiprazole, 19 ADEMPAS, 16 ARIXTRA, 31 ADVAIR DISKUS, 35 armodafinil, 22 ADVAIR HFA, 35 ARNUITY ELLIPTA, 35 aflibercept, 40 ASACOL HD, 29 AGGRENOX, 31 atazanavir, 10 AGRYLIN, 31 atazanavir/cobicistat, 9 AIMOVIG, 21 ATELVIA, 25 AJOVY, 21 atenolol, 14 albuterol, 34 atenolol/chlorthalidone, 15 albuterol ext-rel, 34 ATIVAN, 17 albuterol soln, 34 atomoxetine, 20 albuterol sulfate CFC-free aerosol, 34 atorvastatin, 14 alcaftadine, 38 atovaquone/proguanil, 9 alclometasone crm, oint 0.05%, 37 AUBAGIO, 22 ALDACTAZIDE, 16 AUGMENTIN, 9 ALDACTONE, 12 AUSTEDO, 21 alendronate, 25 avatrombopag, 31 alfuzosin ext-rel, 30 AVODART, 30 alirocumab, 14 AYGESTIN, 28 aliskiren, 15 AZASAN, 32 aliskiren/hydrochlorothiazide, 15 azathioprine, 32, 33 allopurinol, 7 azelaic acid foam, 38 alosetron, 29 azelaic acid gel, 38 ALPHAGAN P, 40 azelastine, 38 alprazolam, 17 azelastine spray, 35 ALTACE, 12 azelastine/fluticasone spray, 35 amantadine, 19 azithromycin, 9 AMARYL, 24 AZOPT, 40 AMBIEN, 20 AZULFIDINE, 29 AMBIEN CR, 20 AZULFIDINE EN-TABS, 29 ambrisentan, 16 amiloride, 15 B amiloride/hydrochlorothiazide, 16 bacitracin, 39 amiodarone, 13 baclofen, 22 amitriptyline, 18 balsalazide, 29 amlodipine, 15 BAQSIMI, 26 amlodipine/atorvastatin, 15 BARACLUDE, 11 amlodipine/benazepril, 12 BASAGLAR, 24 amlodipine/olmesartan, 13 BD ULTRAFINE insulin syringes and needles, 25

44 beclomethasone breath-activated aerosol, 35 calcitriol (1,25-D3), 27 BELBUCA, 8 calcium acetate, 27 bempedoic acid, 13 candesartan, 13 bempedoic acid/ezetimibe, 13 candesartan/hydrochlorothiazide, 13 benazepril, 12 captopril, 12 benazepril/hydrochlorothiazide, 12 captopril/hydrochlorothiazide, 12 BENZAMYCIN, 36 carbamazepine, 17 benzonatate, 34 carbamazepine ext-rel, 17 benztropine, 19 CARBATROL, 17 benzyl alcohol/carbomer 941/glycerin, 38 carbidopa/levodopa, 19 besifloxacin, 39 carbidopa/levodopa ext-rel, 19 BESIVANCE, 39 carbidopa/levodopa orally disintegrating tabs, 19 betamethasone dipropionate augmented crm 0.05%, 38 carbidopa/levodopa/entacapone, 19 betamethasone dipropionate augmented gel, oint 0.05%, 38 CARDURA, 13 betamethasone dipropionate augmented lotion 0.05%, 37 cariprazine, 19 betamethasone dipropionate crm, lotion, oint 0.05%, 37 carisoprodol, 22 betamethasone valerate crm, lotion, oint 0.1%, 37 carvedilol, 14 BETASERON, 21 carvedilol phosphate ext-rel, 14 betaxolol, 40 CATAPRES, 12 bethanechol, 31 CATAPRES-TTS, 12 BETHKIS, 35 cefadroxil, 8 BETIMOL, 40 cefdinir, 9 BETOPTIC S, 40 cefixime, 9 bictegravir/emtricitabine/tenofovir alafenamide, 10 cefprozil, 8 BIDIL, 16 cefuroxime axetil, 8 BIKTARVY, 10 celecoxib, 7 bimatoprost 0.01%, 40 CELEXA, 18 bismuth/metronidazole/tetracycline, 30 cenobamate, 17 bisoprolol, 14 cephalexin, 8 bisoprolol/hydrochlorothiazide, 15 CERDELGA, 26 BLEPH-10, 39 cevimeline, 30 blood glucose monitoring kits, test strips, 24 chloroquine, 9 BONIVA, 25 chlorpromazine, 19 bosentan, 16 chlorthalidone, 15 BREO ELLIPTA, 35 chlorzoxazone 500 mg, 22 BREZTRI AEROSPHERE, 34 cholestyramine, 14 BRILINTA, 31 ciclopirox, 37 brimonidine, 40 cilostazol, 31 brimonidine 0.2%, 40 CILOXAN, 39 brimonidine/timolol, 40 CIMDUO, 10 brinzolamide, 40 cinacalcet, 25 brinzolamide/brimonidine, 40 CIPRO, 9 bromfenac sodium, 39 ciprofloxacin, 9 bromocriptine, 19 ciprofloxacin oint, 39 BRYHALI, 38 ciprofloxacin soln, 39 budesonide, 35 ciprofloxacin/dexamethasone, 41 budesonide delayed-rel caps, 29 citalopram, 18 budesonide inhalation susp, 35 CITRANATAL B-CALM, 33 budesonide/formoterol, 35 CITRANATAL RX, 33 budesonide/glycopyrrolate/formoterol, 34 clarithromycin, 9 bumetanide, 15 clarithromycin ext-rel, 9 buprenorphine, 8 clemastine 2.68 mg, 34 buprenorphine transdermal, 7 CLENPIQ, 29 buprenorphine/naloxone sublingual, 22 CLEOCIN, 11, 31 buprenorphine/naloxone sublingual tabs, 22 CLEOCIN T, 36 bupropion, 19 CLIMARA, 27 bupropion ext-rel, 19 CLIMARA PRO, 27 buspirone, 17 clindamycin, 11 BYSTOLIC, 14 clindamycin crm, 31 C clindamycin gel, 36 clindamycin gel, lotion, soln, 36 C1 esterase inhibitor, recombinant, 32 clindamycin/benzoyl peroxide, 36 cabergoline, 28 clobazam, 17 CADUET, 15 clobetasol propionate crm, gel, oint, soln 0.05%, 38 CALAN SR, 15 clobetasol propionate foam 0.05%, 38 calcitonin-salmon spray, 25 clobetasol propionate lotion, shampoo 0.05%, 38

CLOBEX, 38 desogestrel/EE, 26 clomipramine, 17 desogestrel/EE 0.15/30, 25 clonazepam, 17 desonide crm, lotion, oint 0.05%, 37 clonidine, 12 DESOWEN, 37 clonidine transdermal, 12 desoximetasone crm 0.05%, 37 clopidogrel, 31 desoximetasone crm, oint 0.25%, gel 0.05%, 37 clotrimazole, 36 desvenlafaxine ext-rel, 18 clotrimazole troches, 9 DETROL, 31 clozapine, 19 deutetrabenazine, 21 CLOZARIL, 19 dexamethasone, 26, 39 codeine/acetaminophen, 7 dexamethasone sodium phosphate, 39 codeine/guaifenesin liquid, 34 DEXEDRINE SPANSULE, 20 codeine/guaifenesin/pseudoephedrine, 34 DEXILANT, 30 codeine/promethazine, 34 dexlansoprazole delayed-rel, 30 codeine/promethazine/phenylephrine, 34 dexmethylphenidate, 20 colchicine, 7 dexmethylphenidate ext-rel, 20 colchicine tabs, 7 dextroamphetamine, 20 colesevelam, 14 dextroamphetamine ext-rel, 20 COLESTID, 14 dextromethorphan/brompheniramine/pseudoephedrine, 34 colestipol, 14 dextromethorphan/promethazine, 34 COMBIGAN, 40 dextromethorphan/quinidine, 22 COMBIPATCH, 27 DIASTAT, 17 COMBIVIR, 10 diazepam, 17 COMPLERA, 10 diazepam nasal spray, 17 COMTAN, 19 diazepam rectal gel, 17 CONDYLOX, 38 diclofenac sodium, 39 COPAXONE, 21 diclofenac sodium delayed-rel, 7 COREG, 14 diclofenac sodium delayed-rel/misoprostol, 7 CORGARD, 14 diclofenac sodium gel 1%, 7 CORLANOR, 16 dicloxacillin, 9 CORTEF, 26 dicyclomine, 29 CORTIFOAM, 29 didanosine delayed-rel, 10 COSENTYX, 32 DIFICID, 9 COSOPT, 40 DIFLUCAN, 9 CREON, 30 diflunisal, 7 CRINONE, 28 difluprednate, 39 crisaborole, 37 digoxin 0.0625 mg, 0.1875 mg, 15 cromolyn sodium, 38 digoxin 0.125 mg, 0.25 mg, 15 cromolyn soln, 35 digoxin ped elixir, 15 cyclobenzaprine, 22 dihydroergotamine inj, 21 cyclosporine, 33 DILANTIN, 18 cyclosporine, emulsion, 40 DILANTIN INFATABS, 18 cyclosporine, modified, 33 diltiazem ext-rel, 15 cyproheptadine, 34 dimethyl fumarate delayed-rel, 21 CYTOTEC, 30 diphenoxylate/atropine, 28 D DIPROLENE, 38 DIPROLENE AF, 38 D.H.E. 45, 21 dipyridamole, 31 DALIRESP, 35 dipyridamole ext-rel/aspirin, 31 dalteparin, 31 diroximel fumarate delayed-rel, 21 danazol, 26 disopyramide, 13 DANTRIUM, 22 disopyramide ext-rel, 13 dantrolene, 22 disulfiram, 22 dapagliflozin, 24 DITROPAN XL, 30 dapagliflozin/metformin ext-rel, 24 divalproex sodium delayed-rel, 17 dapsone, 11 divalproex sodium ext-rel, 17 darifenacin ext-rel, 30 DIVIGEL, 27 darunavir, 10 dofetilide, 13 darunavir/cobicistat, 10 dolutegravir, 10 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 10 dolutegravir/lamivudine, 10 DDAVP, 28 donepezil, 18 DEPAKOTE, 17 DOPTELET, 31 DEPAKOTE ER, 17 dornase alfa, 35 DESCOVY, 10 dorzolamide, 40 desipramine, 19 dorzolamide/timolol maleate, 40 desmopressin spray, tabs, 28 DOVATO, 10

46 doxazosin, 13 EPIPEN JR., 33 doxepin, 18, 20 EPISIL, 38 doxercalciferol, 27 EPIVIR, 10 doxycycline hyclate, 9 eplerenone, 12 doxycycline hyclate 20 mg, 9 EPZICOM, 10 doxycycline monohydrate delayed-rel caps, 38 erenumab-aooe, 21 doxylamine/pyridoxine delayed-rel, 28 erythromycin, 39 dronabinol, 29 erythromycin delayed-rel, 9 dronedarone, 13 erythromycin ethylsuccinate, 9 drospirenone/EE 3/20, 25 erythromycin gel 2%, 36 drospirenone/EE 3/30, 25 erythromycin soln, 36 DUAVEE, 27 erythromycin stearate, 9 DUETACT, 24 erythromycin/benzoyl peroxide, 36 dulaglutide, 23 ESBRIET, 35 duloxetine delayed-rel, 18 escitalopram, 18 dupilumab, 35, 37 ESTRACE, 27 DUPIXENT, 35, 37 estradiol, 27 DUREZOL, 39 estradiol vaginal crm, 27 dutasteride, 30 estradiol vaginal inserts, 27 DYAZIDE, 16 estradiol vaginal tabs, 27 DYMISTA, 35 estradiol/levonorgestrel, 27 E estradiol/norethindrone, 27 estradiol/norethindrone acetate, 27 econazole, 36 estrogens, conjugated/bazedoxifene, 27 EDURANT, 10 estrogens, conjugated/medroxyprogesterone, 27 EE/norethindrone acetate - Jinteli, 27 eszopiclone, 20 efavirenz, 10 etanercept, 32 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 9 ethambutol, 10 efavirenz/lamivudine/tenofovir disoproxil fumarate, 9 ethosuximide, 17 elagolix, 26 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 25 elagolix sodium/estradiol/norethindrone acetate, 28 etodolac, 7 eletriptan, 21 etonogestrel/EE ring, 26 eliglustat, 26 etravirine, 10 ELIQUIS, 31 EUCRISA, 37 eluxadoline, 29 EVAMIST, 27 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 everolimus, 33 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, EVISTA, 28 10 EVOTAZ, 9 EMGALITY, 21 EVOXAC, 30 empagliflozin, 24 EXELON, 18 empagliflozin/linagliptin, 24 EYLEA, 40 empagliflozin/linagliptin/metformin ext-rel, 24 ezetimibe, 14 empagliflozin/metformin, 24 ezetimibe/simvastatin, 14 empagliflozin/metformin ext-rel, 24 emtricitabine, 10 F emtricitabine/rilpivirine/tenofovir alafenamide, 10 famciclovir, 11 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 10 FARXIGA, 24 emtricitabine/tenofovir alafenamide, 10 felodipine ext-rel, 15 emtricitabine/tenofovir disoproxil fumarate, 10 fenofibrate, 14 EMTRIVA, 10 fenofibric acid delayed-rel, 14 EMVERM, 11 fentanyl transdermal, 7 enalapril, 12 fentanyl transmucosal lozenge, 7 enalapril/hydrochlorothiazide, 12 fesoterodine ext-rel, 30 ENBREL, 32 FIASP, 24 enfuvirtide, 10 fidaxomicin, 9 enoxaparin, 31 FINACEA FOAM, 38 entacapone, 19 finasteride, 30 entecavir soln, 11 fingolimod, 21 entecavir tabs, 11 FIRAZYR, 32 ENTRESTO, 16 FLAGYL, 11 EPCLUSA, 11 flecainide, 13 EPIDUO, 36 FLOMAX, 30 EPIDUO FORTE, 36 FLOVENT DISKUS, 35 epinephrine, 33 FLOVENT HFA, 35 epinephrine auto-injector, 33 fluconazole, 9 EPIPEN, 33 fludrocortisone, 26

47 flunisolide spray, 35 guselkumab, 32 fluocinolone acetonide crm, oint 0.025%, 37 GVOKE, 26 fluocinolone acetonide soln 0.01%, 37 H fluocinonide crm, gel, oint, soln 0.05%, 37 halobetasol propionate crm, oint 0.05%, 38 fluorometholone, 39 halobetasol propionate lotion 0.01%, 38 fluorouracil crm 4%, 36 haloperidol, 19 fluorouracil crm 5%, soln 5%, soln 2%, 36 HARVONI, 11 fluoxetine, 18 HECTOROL, 27 fluphenazine, 19 HUMIRA, 32 fluticasone, 35 HUMULIN R U-500, 24 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 37 hydralazine, 16 fluticasone, CFC-free aerosol, 35 hydrochlorothiazide, 15 fluticasone/salmeterol, 35 hydrocodone ext-rel, 7 fluticasone/salmeterol, CFC-free aerosol, 35 hydrocodone/acetaminophen, 7 fluticasone/umeclidinium/vilanterol, 34 hydrocodone/homatropine, 34 fluticasone/vilanterol, 35 hydrocortisone, 26 fluvastatin, 14 hydrocortisone acetate foam, 29 fluvoxamine, 17 hydrocortisone acetate/pramoxine foam, 30 FML FORTE, 39 hydrocortisone butyrate crm, oint, soln 0.1%, 37 FML S.O.P., 39 hydrocortisone crm, 30 FOCALIN, 20 hydrocortisone crm 2.5%, 37 fondaparinux, 31 hydrocortisone enema, 29 formoterol inhalation soln, 34 hydrocortisone valerate crm, oint 0.2%, 37 FORTEO, 25 hydromorphone, 7 FOSAMAX, 25 hydromorphone ext-rel, 7 fosinopril, 12 hydroxychloroquine, 32 fosinopril/hydrochlorothiazide, 12 hydroxyzine HCl, 34 FRAGMIN, 31 hyoscyamine sulfate, 29 fremanezumab-vfrm, 21 hyoscyamine sulfate ext-rel caps, 29 furosemide, 15 hyoscyamine sulfate orally disintegrating tabs, 29 FUZEON, 10 FYCOMPA, 17 I G ibandronate, 25 ibuprofen, 7 gabapentin, 17 icatibant, 32 gabapentin ext-rel, 22 icosapent ethyl, 14 galantamine, 18 ILEVRO, 39 galantamine ext-rel, 18 imipramine HCl, 19 galcanezumab-gnlm, 21 imiquimod, 36, 38 gemfibrozil, 14 IMITREX, 21 GENOTROPIN, 27 IMURAN, 33 gentamicin, 36, 39 IMVEXXY, 27 GENVOYA, 10 INBRIJA, 19 GILENYA, 21 indapamide, 16 glatiramer, 21 infliximab, 32 glimepiride, 24 ingenol mebutate, 36 glipizide, 24 INGREZZA, 21 glipizide ext-rel, 24 inotersen, 27 glipizide/metformin, 23 INSPRA, 12 GLUCAGEN HYPOKIT, 26 insulin aspart, 24 GLUCAGON EMERGENCY KIT, 27 insulin aspart protamine 70%/insulin aspart 30%, 24 glucagon nasal powder, 26 insulin degludec, 24 glucagon subcutaneous soln, 26 insulin detemir, 24 glucagon, human recombinant, 26, 27 insulin glargine, 24 GLUCOTROL, 24 insulin human, 24 GLUCOTROL XL, 24 insulin infusion disposable pump, 24, 25 GLYXAMBI, 24 insulin isophane human, 24 golimumab, 32 insulin isophane human 70%/regular 30%, 24 GRALISE, 22 insulin syringes, needles, 25 granisetron, 28 INTELENCE, 10 granisetron transdermal, 29 interferon alfa-2b, 32 grass mixed pollen allergen extract, 32 interferon beta-1a, 21 GRASTEK, 32 interferon beta-1b, 21 griseofulvin ultramicrosize, 9 INTRON A, 32 guanfacine, 12 ipratropium soln, 33 guanfacine ext-rel, 20 ipratropium spray, 36

48 ipratropium/albuterol soln, 33 levonorgestrel/EE 0.15/30 - Levora, 25 irbesartan, 13 levonorgestrel/EE 0.15/30 and EE 10, 26 irbesartan/hydrochlorothiazide, 13 levothyroxine, 28 ISENTRESS, 10 levothyroxine - Levoxyl, 28 isoniazid, 10 LEVSIN, 29 isosorbide dinitrate, 16 lidocaine patch, 38 isosorbide dinitrate/hydralazine, 16 lidocaine viscous, 38 isosorbide mononitrate, 16 LIDODERM, 38 isosorbide mononitrate ext-rel, 16 lifitegrast, 40 isotretinoin, 36 linaclotide, 29 itraconazole, 9 linezolid, 11 ivabradine, 16 LINZESS, 29 ivermectin, 11, 38 liothyronine, 28 J liraglutide, 23 liraglutide/insulin degludec, 23 JANUMET, 23 lisdexamfetamine, 20 JANUMET XR, 23 lisinopril, 12 JANUVIA, 23 lisinopril/hydrochlorothiazide, 12 JARDIANCE, 24 lithium carbonate, 21 K lithium carbonate ext-rel tabs 300 mg, 21 KALETRA, 10 lithium carbonate ext-rel tabs 450 mg, 21 KEFLEX, 8 LITHOBID, 21 KEPPRA, 17 lixisenatide/insulin glargine, 23 KEPPRA XR, 17 LO LOESTRIN FE, 26 KESIMPTA, 21 LOKELMA, 28 ketoconazole crm 2%, 36 LOMOTIL, 28 ketoconazole shampoo 2%, 37 loperamide, 28 ketorolac, 39 LOPID, 14 ketorolac tromethamine, 39 lopinavir/ritonavir soln, 10 KLARON, 36 lopinavir/ritonavir tabs, 10 KLONOPIN, 17 LOPRESSOR, 14 L LOPRESSOR HCT, 15 LOPROX, 37 labetalol, 14 lorazepam, 17 lacosamide, 17 losartan, 13 lactulose soln, 29 losartan/hydrochlorothiazide, 13 lamivudine, 10, 11 LOSEASONIQUE, 26 lamivudine/tenofovir disoproxil fumarate, 10 LOTENSIN, 12 lamivudine/zidovudine, 10 LOTENSIN HCT, 12 lamotrigine, 17 loteprednol, 39 lamotrigine ext-rel, 17 LOTREL, 12 lamotrigine orally disintegrating tabs, 17 lovastatin, 14 lanadelumab-flyo, 32 LOVAZA, 14 lancets, 25 LUCENTIS, 40 LANOXIN, 15 LUMIGAN, 40 lanreotide acetate, 23 lurasidone, 19 lansoprazole + amoxicillin + clarithromycin, 30 lusutrombopag, 31 LASIX, 15 lasmiditan, 21 M LASTACAFT, 38 macitentan, 16 latanoprost, 40 MACROBID, 11 LATUDA, 19 MALARONE, 9 ledipasvir/sofosbuvir, 11 malathion, 38 leflunomide, 32 MARINOL, 29 levalbuterol tartrate, CFC-free aerosol, 34 MAXIDEX, 39 LEVEMIR, 24 MAXITROL, 39 levetiracetam, 17 MAXZIDE, 16 levetiracetam ext-rel, 17 MAYZENT, 22 levobunolol, 40 mebendazole chewable, 11 levocarnitine, 25 meclizine, 28 levodopa inhalation powder, 19 MEDROL, 26 levofloxacin, 9, 39 medroxyprogesterone acetate, 28 levonorgestrel/EE - Trivora, 26 mefloquine, 9 levonorgestrel/EE 0.1/20 - Lessina, 25 megestrol acetate susp, 28 levonorgestrel/EE 0.1/20 and EE 10, 26 meloxicam, 7 levonorgestrel/EE 0.15/30, 26 memantine, 18

49 memantine ext-rel, 18 N memantine/donepezil, 18 nabumetone, 7 mepolizumab, 35 nadolol, 14 mesalamine delayed-rel caps, 29 naftifine, 36 mesalamine delayed-rel tabs, 29 NAFTIN, 36 mesalamine ext-rel caps, 29 naldemedine, 30 mesalamine supp, 29 naloxegol, 30 mesalamine susp, 29 naloxone nasal spray, 22 metaxalone 800 mg, 22 naltrexone, 22 metformin, 23 NAMENDA, 18 metformin ext-rel, 23 NAMZARIC, 18 methadone, 7 naproxen sodium tabs, 7 methazolamide, 15 naproxen tabs, 7 methimazole, 28 naratriptan, 21 methocarbamol, 22 NARCAN, 22 methotrexate, 32 NARDIL, 18 methotrexate auto-injector, 32 nateglinide, 24 methoxsalen oral, 37 NAYZILAM, 17 methyldopa, 16 nebivolol, 14 METHYLIN, 20 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 39 methylphenidate, 20 neomycin/polymyxin B/dexamethasone, 39 methylphenidate ext-rel, 20 neomycin/polymyxin B/gramicidin, 39 methylprednisolone, 26 neomycin/polymyxin B/hydrocortisone, 41 metoclopramide, 29 neomycin/polymyxin B/hydrocortisone susp, 39 metolazone, 16 nepafenac, 39 metoprolol succinate ext-rel, 14 netarsudil, 40 metoprolol tartrate, 14 netarsudil/latanoprost, 40 metoprolol/hydrochlorothiazide, 15 NEUPRO, 19 METROCREAM, 38 NEURONTIN, 17 METROGEL, 38 NEVANAC, 39 METROLOTION, 38 nevirapine, 10 metronidazole, 11, 31 nevirapine ext-rel, 10 metronidazole crm 0.75%, 38 NEXLETOL, 13 metronidazole gel 0.75%, 38 NEXLIZET, 13 metronidazole gel 1%, 38 niacin ext-rel, 14 metronidazole lotion 0.75%, 38 NIASPAN, 14 midazolam nasal spray, 17 nifedipine ext-rel, 15 midodrine, 17 nintedanib, 35 minocycline, 9 nitisinone, 27 mirabegron ext-rel, 30 NITRO-DUR, 16 MIRAPEX, 19 nitrofurantoin ext-rel, 11 MIRCETTE, 26 nitrofurantoin macrocrystals, 11 mirtazapine tabs 15 mg, 30 mg, 45 mg, 19 nitrofurantoin susp, 11 mirtazapine tabs 7.5 mg, orally disintegrating, 19 nitroglycerin lingual spray, 16 misoprostol, 30 nitroglycerin sublingual, 16 MITIGARE, 7 nitroglycerin transdermal, 16 mometasone crm, lotion, oint 0.1%, 37 NITROLINGUAL, 16 mometasone spray, 35 NITROSTAT, 16 montelukast, 35 NORDITROPIN, 27 morphine, 7 norelgestromin/EE, 26 morphine ext-rel, 7 norethindrone, 26 morphine supp, 7 norethindrone acetate, 28 MOVANTIK, 30 norethindrone acetate/EE 1.5/30, 25 moxifloxacin, 9, 39 norethindrone acetate/EE 1.5/30 and iron, 25 MUGARD, 38 norethindrone acetate/EE 1/10 and EE 10 and iron, 26 MULPLETA, 31 norethindrone acetate/EE 1/20, 25 MULTAQ, 13 norethindrone acetate/EE 1/20 and iron, 25 mupirocin oint, 36 norethindrone acetate/EE 1/20 and iron chewable, 25 MYAMBUTOL, 10 norethindrone/EE, 26 mycophenolate mofetil, 32 norethindrone/EE 0.5/35, 25 mycophenolate sodium delayed-rel, 32 norethindrone/EE 1/35, 25 MYDAYIS, 20 norgestimate/EE, 26 MYRBETRIQ, 30 norgestimate/EE 0.25/35, 26 MYSOLINE, 18 norgestrel/EE 0.3/30 - Low-Ogestrel, 25 NORPACE, 13 NORPACE CR, 13

NORPRAMIN, 19 OZEMPIC, 23 nortriptyline, 19 P NORVIR, 10 PAMELOR, 19 NOVOLIN 70/30, 24 pancrelipase, 30 NOVOLIN N, 24 pancrelipase delayed-rel, 30 NOVOLIN R, 24 pantoprazole delayed-rel tabs, 30 NOVOLOG, 24 paricalcitol, 27 NOVOLOG MIX 70/30, 24 PARLODEL, 19 NUCALA, 35 PARNATE, 18 NUCYNTA, 8 paroxetine HCl, 18 NUCYNTA ER, 8 paroxetine HCl ext-rel, 18 NUEDEXTA, 22 PATANASE, 35 NULYTELY, 29 patiromer sorbitex, 28 NURTEC ODT, 21 PAZEO, 38 nystatin, 9, 36 peg 3350/electrolytes, 29 O PEGASYS, 32 ocrelizumab, 21 peginterferon alfa-2a, 32 OCREVUS, 21 penicillin VK, 9 OCUFLOX, 39 PENTASA, 29 ODEFSEY, 10 perampanel, 17 ofatumumab, 21 PERFOROMIST, 34 OFEV, 35 perindopril, 12 ofloxacin, 39 permethrin 5%, 38 ofloxacin otic, 41 perphenazine, 20 olanzapine, 19 phenelzine, 18 olmesartan, 13 phenobarbital, 17 olmesartan/amlodipine/hydrochlorothiazide, 13 phenytoin, 18 olmesartan/hydrochlorothiazide, 13 phenytoin sodium extended, 18 olodaterol, CFC-free aerosol, 34 PHOSLYRA, 27 olopatadine, 38 PICATO, 36 olopatadine spray, 35 pilocarpine tabs, 30 omega-3 acid ethyl esters, 14 pimecrolimus, 37 OMNIPOD DASH INSULIN INFUSION PUMP, 24 pindolol, 14 OMNIPOD INSULIN INFUSION PUMP, 25 pioglitazone, 24 ondansetron, 29 pioglitazone/glimepiride, 24 ONETOUCH ULTRA kits and test strips, 24 pioglitazone/metformin, 24 ONETOUCH VERIO kits and test strips, 24 pirfenidone, 35 ONEXTON, 36 PLAQUENIL, 32 ONZETRA XSAIL, 21 podofilox, 38 OPSUMIT, 16 polymyxin B/bacitracin, 39 ORACEA, 38 polymyxin B/trimethoprim, 39 ORALAIR, 32 POLYTRIM, 39 ORENITRAM, 16 potassium chloride ext-rel, 33 ORFADIN, 27 potassium chloride liquid, 33 ORIAHNN, 28 potassium citrate ext-rel, 31 ORILISSA, 26 PRALUENT, 14 ORTHO MICRONOR, 26 pramipexole, 19 oseltamivir, 11 pramipexole ext-rel, 19 OTEZLA, 32 pramlintide, 23 OVIDE, 38 prasugrel, 31 oxaprozin, 7 PRAVACHOL, 14 oxazepam, 17 pravastatin, 14 oxcarbazepine, 18 PRECOSE, 23 oxcarbazepine ext-rel, 17 PRED MILD, 39 OXSORALEN-ULTRA, 37 prednisolone, 26 OXTELLAR XR, 17 prednisolone acetate, 39 oxybutynin, 30 prednisolone acetate 1%, 39 oxybutynin ext-rel, 30 prednisolone phosphate 1%, 39 oxycodone caps 5 mg, 7 prednisone, 26 oxycodone concentrate 20 mg/mL, 8 pregabalin, 20 oxycodone ext-rel, 8 PREMPHASE, 27 oxycodone soln 5 mg/5 mL, 8 PREMPRO, 27 oxycodone tabs 5 mg, 15 mg, 30 mg, 8 prenatal vitamins, 33 oxycodone/acetaminophen 5/325, 8 prenatal vitamins/docusate/folic acid, 33 ozanimod, 22 prenatal vitamins/folic acid + pyridoxine, 33

PREZCOBIX, 10 rifampin, 11 PREZISTA, 10 rifaximin 550 mg, 11 primidone, 18 rilpivirine, 10 probenecid, 7 rimegepant, 21 PROCARDIA XL, 15 RINVOQ, 32 prochlorperazine, 28 riociguat, 16 PROCTOFOAM-HC, 30 risankizumab-rzaa, 32 progesterone gel, 28 risedronate, 25 progesterone, micronized, 28 risedronate delayed-rel, 25 promethazine, 29 RISPERDAL, 19 PROMETRIUM, 28 risperidone, 19 propafenone, 13 RITALIN, 20 propafenone ext-rel, 13 ritonavir, 10 propranolol, 14 rivaroxaban, 31 propranolol ext-rel, 14 rivastigmine, 18 propylthiouracil, 28 rivastigmine transdermal, 18 PROSCAR, 30 rizatriptan, 21 PROVERA, 28 ROBAXIN, 22 PULMICORT FLEXHALER, 35 ROCALTROL, 27 PULMICORT RESPULES, 35 ROCKLATAN, 40 PULMOZYME, 35 roflumilast, 35 PYLERA, 30 ropinirole, 19 pyrazinamide, 10 ropinirole ext-rel, 19 pyridostigmine ext-rel, 22 rosuvastatin, 14 pyridostigmine soln, tabs 60 mg, 22 rotigotine transdermal, 19 pyridostigmine tabs 30 mg, 22 ROWASA, 29 pyrimethamine, 11 RUCONEST, 32 Q rufinamide, 17 RYBELSUS, 23 QUESTRAN/QUESTRAN LIGHT, 14 RYTHMOL SR, 13 quetiapine, 19 quetiapine ext-rel, 19 S quinapril, 12 sacubitril/valsartan, 16 quinapril/hydrochlorothiazide, 12 SALAGEN, 30 QVAR REDIHALER, 35 salmeterol xinafoate, 34 R SANCUSO, 29 sapropterin, 27 ragweed pollen allergen extract, 32 scopolamine transdermal, 29 RAGWITEK, 32 SEASONIQUE, 26 raloxifene, 28 secukinumab, 32 raltegravir, 10 segesterone acetate/EE ring, 26 ramelteon, 20 selegiline, 19 ramipril, 12 selenium sulfide lotion 2.5%, 37 ranibizumab, 40 selexipag, 16 ranolazine ext-rel, 17 semaglutide, 23 rasagiline, 19 SEREVENT, 34 RASUVO, 32 SEROQUEL, 19 RAZADYNE, 18 sertraline, 18 RAZADYNE ER, 18 sevelamer carbonate, 27 REBIF, 21 sildenafil, 16 REGLAN, 29 silodosin, 30 RELENZA, 11 SILVADENE, 36 RELPAX, 21 silver sulfadiazine, 36 REMERON, 19 SIMBRINZA, 40 REMICADE, 32 SIMPONI ARIA, 32 repaglinide, 24 simvastatin, 14 REQUIP XL, 19 SINEMET, 19 RESTASIS, 40 siponimod, 22 RESTORIL, 20 sirolimus, 33 RETIN-A, 36 sitagliptin phosphate, 23 RETROVIR, 10 sitagliptin/metformin, 23 REVATIO, 16 sitagliptin/metformin ext-rel, 23 revefenacin inhalation soln, 33 SKELAXIN, 22 REYVOW, 21 SKYRIZI, 32 RHOPRESSA, 40 sodium picosulfate/magnesium oxide/citric acid, 29 ribavirin, 11 sodium zirconium cyclosilicate, 28 RIFADIN, 11

52 sofosbuvir/velpatasvir, 11 TEMOVATE, 38 sofosbuvir/velpatasvir/voxilaprevir, 11 tenofovir alafenamide, 11 solifenacin, 30 tenofovir disoproxil fumarate, 10 SOLIQUA, 23 terazosin, 12 solriamfetol, 22 terbinafine tabs, 9 somatropin, 27 terbutaline, 34 SOMATULINE DEPOT, 23 terconazole, 31 SOOLANTRA, 38 teriflunomide, 22 SORIATANE, 37 teriparatide, 25 sotalol, 13 TESSALON, 34 soy phospholipid/glycerol dioleate, 38 testosterone cypionate, 23 SPIRIVA, 33 testosterone enanthate, 23 spironolactone, 12 testosterone gel, 23 spironolactone/hydrochlorothiazide, 16 testosterone soln, 23 STALEVO, 19 testosterone transdermal, 23 stavudine, 10 tetrabenazine, 21 STELARA INTRAVENOUS, 32 tetracycline, 9 STELARA SUBCUTANEOUS, 32 theophylline ext-rel tabs, 35 STIOLTO RESPIMAT, 33 thiothixene, 20 STRATTERA, 20 tiagabine, 17 STRIBILD, 10 TIAZAC, 15 STRIVERDI RESPIMAT, 34 ticagrelor, 31 STROMECTOL, 11 TIGAN, 29 sucralfate tablet, 30 TIKOSYN, 13 sulfacetamide lotion 10%, 36 timolol hemihydrate, 40 sulfacetamide oint 10%, 39 timolol maleate, 40 sulfacetamide soln 10%, 39 timolol maleate gel, 40 sulfacetamide/prednisolone phosphate 10%/0.25%, 39 TIMOPTIC, 40 sulfamethoxazole/trimethoprim, 11 timothy grass pollen allergen extract, 32 sulfamethoxazole/trimethoprim DS, 11 tinidazole, 11 sulfasalazine, 29 tiotropium, 33 sulfasalazine delayed-rel, 29 tiotropium/olodaterol, 33 sulindac, 7 TIVICAY, 10 sumatriptan, 21 tizanidine tabs, 22 sumatriptan inj, 21 TOBRADEX, 39 sumatriptan nasal powder, 21 TOBRADEX ST, 39 sumatriptan nasal spray, 21 tobramycin, 39 SUNOSI, 22 tobramycin inhalation soln, 35 SUPRAX, 9 tobramycin/dexamethasone oint 0.3%/0.1%, 39 SYMBICORT, 35 tobramycin/dexamethasone susp 0.3%/0.05%, 39 SYMJEPI, 33 tobramycin/dexamethasone susp 0.3%/0.1%, 39 SYMLINPEN, 23 TOBREX, 39 SYMPROIC, 30 tofacitinib, 32 SYMTUZA, 10 tofacitinib ext-rel, 32 SYNJARDY, 24 TOLAK, 36 SYNJARDY XR, 24 tolterodine, 31 SYNTHROID, 28 tolterodine ext-rel, 30 T TOPAMAX, 18 topiramate, 18 tacrolimus, 33, 37 topiramate ext-rel, 17 tadalafil, 16 torsemide, 15 tafluprost, 40 TOUJEO, 24 TAKHZYRO, 32 TOVIAZ, 30 tamsulosin, 30 tramadol, 8 TAPAZOLE, 28 tramadol ext-rel, 8 tapentadol, 8 trandolapril, 12 tapentadol ext-rel, 8 trandolapril/verapamil ext-rel, 12 TARKA, 12 tranylcypromine, 18 tazarotene, 36 travoprost, 40 TEGRETOL, 17 trazodone, 19 TEGSEDI, 27 TRELEGY ELLIPTA, 34 TEKTURNA HCT, 15 TREMFYA, 32 telmisartan, 13 treprostinil, 16 telmisartan/hydrochlorothiazide, 13 treprostinil ext-rel, 16 temazepam, 20 TRESIBA, 24 TEMIXYS, 10 tretinoin, 36

53 tretinoin - Avita, 36 vigabatrin, 17 tretinoin gel microsphere, 36 VIGAMOX, 39 triamcinolone acetonide crm 0.5%, 37 VIMPAT, 17 triamcinolone acetonide crm, lotion 0.025%, 37 VIOKACE, 30 triamcinolone acetonide crm, lotion, oint 0.1%, 37 VIREAD, 10 triamcinolone paste, 38 voriconazole, 9 triamterene, 15 vortioxetine, 18 triamterene/hydrochlorothiazide, 16 VOSEVI, 11 TRIBENZOR, 13 VRAYLAR, 19 trifluoperazine, 20 VUMERITY, 21 trifluridine, 39 VYTORIN, 14 trihexyphenidyl, 19 VYVANSE, 20 TRIJARDY XR, 24 W TRILEPTAL, 18 warfarin, 31 TRILIPIX, 14 WELLBUTRIN SR, 19 trimethobenzamide, 29 WELLBUTRIN XL, 19 trimethoprim, 11 TRINTELLIX, 18 X TRIUMEQ, 9 XALATAN, 40 TROKENDI XR, 17 XARELTO, 31 trospium, 30 XCOPRI, 17 trospium ext-rel, 30 XELJANZ, 32 TRULICITY, 23 XELJANZ XR, 32 TRUSOPT, 40 XIFAXAN, 11 TRUVADA, 10 XIGDUO XR, 24 TYMLOS, 25 XIIDRA, 40 U XTAMPZA ER, 8 XULTOPHY, 23 UBRELVY, 21 ubrogepant, 21 Y ULTRAVATE, 38 YUPELRI, 33 umeclidinium/vilanterol, 33 Z upadacitinib, 32 zafirlukast, 35 UPTRAVI, 16 ZANAFLEX, 22 UROCIT-K, 31 zanamivir, 11 URSO, 29 ZARONTIN, 17 ursodiol, 29 ZEMBRACE SYMTOUCH, 21 ustekinumab, 32 ZEMPLAR, 27 V ZENPEP, 30 VAGIFEM, 27 ZEPOSIA, 22 valacyclovir, 11 ZESTRIL, 12 valbenazine, 21 ZIAC, 15 valganciclovir, 11 ZIAGEN, 10 VALIUM, 17 zidovudine, 10 valproic acid, 17 ZIOPTAN, 40 valsartan, 13 ziprasidone, 19 valsartan/hydrochlorothiazide, 13 ZITHROMAX, 9 VALTOCO, 17 ZOCOR, 14 VASCEPA, 14 ZOFRAN, 29 VASERETIC, 12 zolmitriptan, 21 VASOTEC, 12 zolmitriptan nasal spray, 21 VELTASSA, 28 zolpidem, 20 VEMLIDY, 11 zolpidem ext-rel, 20 venlafaxine, 18 zolpidem sublingual, 20 venlafaxine ext-rel, 18 ZOMIG, 21 verapamil ext-rel, 15 zonisamide, 17 VFEND, 9 ZUBSOLV, 22 V-GO INSULIN INFUSION PUMP, 25 ZYCLARA, 36 VIBERZI, 29 ZYPREXA, 19 VIBRAMYCIN, 9 VICTOZA, 23