PREFERRED DRUG LIST 3-TIER PRESCRIPTION DRUG PLAN

FOR LARGE GROUP PLANS AND SMALL GROUP NON-ACA COMPLIANT PLANS

Note: The copayment for specialty medication is plan dependent and is specified in your Copayment Summary. Most specialty medications require a Prior Authorization and may be limited to a 30-day supply.

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Western Health Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Western Health Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Western Health Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, contact the Member Services Manager. If you believe that Western Health Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services Manager, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833, 888.563.2250 or 916.563.2250, 888.877.5378 (TTY), 916.568.0126 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Member Services Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Mail: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Phone: 800.368.1019 or 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ENGLISH If you, or someone you’re helping, have questions about Western Health Advantage, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 888.563.2250 or TTY 888.877.5378. SPANISH Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Western Health Advantage, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 888.563.2250, o al TTY 888.877.5378 si tiene dificultades auditivas.

CHINESE 如果您，或是您正在協助的對象，有關於Western Health Advantage方面的問題，您有權利免費以您的母語得到幫助和 訊息。洽詢一位翻譯員，請撥電話888.563.2250或聽障人士專線(TTY) 888.877.5378。

VIETNAMESE Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Western Health Advantage, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số 888.563.2250, hoặc gọi đường dây TTY dành cho người khiếm thính tại số 888.877.5378.

TAGALOG Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Western Health Advantage, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 888.563.2250 o TTY para sa may kapansanan sa pandinig sa 888.877.5378.

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KOREAN 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Western Health Advantage에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담 없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 888.563.2250이나 청각 장애인용 TTY 888.877.5378로 연락하십시오.

ARMENIAN Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի Western Health Advantage-ի մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք 888.563.2250 համարով կամ TTY 888.877.5378՝ լսողության հետ խնդիրներ ունեցողների համար։

PERSIAN-FARSI اﮔر ﺷﻣﺎ، ﯾﺎ ﮐﺳﯽ ﮐﮫ ﺷﻣﺎ ﺑﮫ او ﮐﻣﮏ ﻣﯾﮑﻧﯾد ، ﺳوال در ﻣورد Western Health Advantage (وﺳﺗرن ھﻠث اَدوﻧﺗﯾﺞ) داﺷﺗﮫ ﺑﺎﺷﯾد ﺣق اﯾن را دارﯾد ﮐﮫ ﮐﻣﮏ و اطﻼﻋﺎت ﺑﮫ زﺑﺎن ﺧود را ﺑﮫ طور راﯾﮕﺎن درﯾﺎﻓت ﻧﻣﺎﯾﯾد. ﻟطﻔﺎ ﺑﺎ ﺷﻣﺎره ﺗﻠﻔن 888.563.2250 ﺗﻣﺎس ﺑﮕﯾرﯾد. اﻓراد ﻧﺎﺷﻧوا ﻣﯽ ﺗواﻧﻧد ﺑﮫ ﺷﻣﺎره888.877.5378 ﭘﯾﺎم ﺗﺎﯾﭘﯽ ارﺳﺎل ﮐﻧﻧد.

RUSSIAN Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Western Health Advantage, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 888.563.2250 или воспользуйтесь линией TTY для лиц с нарушениями слуха по номеру 888.877.5378.

JAPANESE ご本人様、またはお客様の身の回りの方でも、Western Health Advantageについてご質問がございましたら、ご希望 の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場 合、888.563.2250までお電話ください。聴覚障がい者用TTYをご利用の場合は、888.877.5378までお電話ください。

ARABIC إن ﻛﺎن ﻟدﯾك أو ﻟدى ﺷﺧص ﺗﺳﺎﻋده أﺳﺋﻠﺔ ﺑﺧﺻوص Western Health Advantage، ﻓﻠدﯾك اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة واﻟﻣﻌﻠوﻣﺎت اﻟﺿرورﯾﺔ ﺑﻠﻐﺗك ﻣن دون اﯾﺔ ﺗﻛﻠﻔﺔ. ﻟﻠﺗﺣدث ﻣﻊ ﻣﺗرﺟم اﺗﺻل ﺑـ 888.563.2250، أو ﺑرﻗم اﻟﮭﺎﺗف اﻟﻧﺻﻲ (TTY) ﻟﺿﻌﺎف اﻟﺳﻣﻊ 888.877.5378.

PUNJABI ਜੇਕਰ ਤੁਸ, ਜ ਿਜਸ ਿਕਸੇ ਦੀ ਤੁਸ ਮਦਦ ਕਰ ਰਹੇ ਹੋ, ਦੇ Western Health Advantage ਬਾਰੇ ਸਵਾਲ ਹਨ ਤ, ਤੁਹਾਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਹਾਸਲ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ। ਦੁਭਾਸੀਏ ਨਾਲ ਗੱਲ ਕਰਨ ਲਈ, 888.563.2250 ‘ਤੇ ਜ ਪੂਰੀ ਤਰ ਸੁਣਨ ਿਵੱਚ ਅਸਮਰਥ ਟੀਟੀਵਾਈ ਲਈ 888.877.5378 ‘ਤੇ ਕਾਲ ਕਰੋ।

CAMBODIAN-MON-KHMER បសិនេបើអក ឬនរក់ែដលកំពុងជួយអក នសំណរអំពី Western Health Advantage េទ, អកនសិទិទទួលជំនួយនឹងព័ត៌ន េកងរបស់អក េយមិនអស់ក់។ េដើមីនិយមួយអកបកែប សូមទូរស័ព 888.563.2250 ឬ TTY សប់អកតេចៀកធន់ មេលខ 888.877.5378។

HMONG Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Western Health Advantage, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 888.563.2250 los sis TTY rau cov neeg uas tsis hnov lus zoo nyob ntawm 888.877.5378.

HINDI यद आप, या िजस कसी क आप मदद कर रहे हो, के Western Health Advantage के ब ा र े म न ह त ो , आपको अपनी भाषा म मदद तथा जानकार ात करने का अधकार है। दभाशएु के साथ बात करने के लए, 888.563.2250 पर या परू तरह वण म असमथ टटवाई के लए 888.877.5378 पर कॉल करो।

THAI หากคุณ หรือคนทีคุณกํ าลั งช่วยเหลือมีคําถามเกียวกับ Western Health Advantage คุ ณมีสิทธิทีจะได้รับความช่วยเหลือและข้อมูลในภาษาของคุณได้โดยไม่มีค่าใช้จ่าย เพือพู ดคุ ยกั บล่าม โทร 888.563.2250 หรือใช้ TTY สําหรับคนหูหนวกโดยโทร 888.877.5378

3 of 104 Western Health Advantage Preferred Drug List

5-Alpha-Reductase Inhibitors / UROLOGICALS Tier Generic Name Brand Name Notes 1 FINASTERIDE 2 DUTASTERIDE AVODART 3 DUTASTERIDE/TAMSULOSIN HCL JALYN 3 FINASTERIDE PROSCAR

5-HT2C Receptor Antagonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 LORCASERIN BELVIQ 5

5-HT3 Receptor Antagonists / ANTIEMETICS Tier Generic Name Brand Name Notes 1 GRANISETRON HCL 1 ONDANSETRON ONDANSETRON ODT 3 DOLASETRON ANZEMET 3 GRANISETRON SANCUSO 3 ONDANSETRON ZOFRAN ODT 4 GRANISETRON EXTENDED-RELEASE INJECTION SUSTOL 4

5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand Name Notes 3 NETUPITANT/PALONOSETRON AKYNZEO 5

ADHD Amphetamines / CNS AGENTS Tier Generic Name Brand Name Notes 1 AMPHET ASP/AMPHET/D-AMPHET DEXTROAMPHETAMINE-AMPHETAMINE 1 AMPHET ASP/AMPHET/D-AMPHET AMPHETAMINE SALT COMBO 1 DEXTROAMPHETAMINE SULFATE 1 METHAMPHETAMINE HCL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL XR 3 DEXTROAMPHETAMINE SULFATE DEXEDRINE

ADHD Non-Amphetamine / CNS AGENTS Tier Generic Name Brand Name Notes 2 ATOMOXETINE HCL STRATTERA 3 CLONIDINE KAPVAY 3 GUANFACINE HCL INTUNIV

AMPA Receptor Antagonist / ANTICONVULSANTS Tier Generic Name Brand Name Notes 2 PERAMPANEL FYCOMPA

ANTILEISHMAIAL / ANTIPARASITICS Tier Generic Name Brand Name Notes 2 MILTEFOSINE CAPSULES IMPAVIDO

4 - Office/Clinic Administration 5 - Prior Authorization

4 of 104 Acidifying Agents / UROLOGICALS Tier Generic Name Brand Name Notes 3 POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL

Adrenals / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CORTISONE ACETATE 1 DEXAMETHASONE 1 FLUDROCORTISONE ACETATE 1 METHYLPREDNISOLONE 1 PREDNISOLONE 1 PREDNISOLONE MILLIPRED 2 PREDNISOLONE SOD PHOSPHATE ORAPRED ODT 3 HYDROCORTISONE CORTEF 3 METHYLPREDNISOLONE MEDROL 3 PREDNISOLONE ACETATE FLO-PRED

Adrenals / GI AGENTS Tier Generic Name Brand Name Notes 1 BUDESONIDE BUDESONIDE EC 3 BUDESONIDE ENTOCORT EC

Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS Tier Generic Name Brand Name Notes 1 BETAMETHASONE DIPROPIONATE 1 BETAMETHASONE VALERATE BETA-VAL 1 BETAMETHASONE VALERATE 1 CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE 1 DEXAMETHASONE 1 HYDROCORTISONE VALERATE 1 PREDNISONE 2 DEXAMETHASONE DEXAMETHASONE INTENSOL 3 BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3 BETAMETHASONE VALERATE LUXIQ 3 CALCIPOTRIENE/BETAMETHASONE TACLONEX 3 DEXAMETHASONE MAXIDEX 3 HYDROCORTISONE BUTYRATE LOCOID 3 HYDROCORTISONE BUTYRATE/EMOLL LOCOID LIPOCREAM 3 HYDROCORTISONE/PRAMOXINE PRAMOSONE 3 HYDROCORTISONE/PRAMOXINE EPIFOAM 3 HYDROCORTISONE/PRAMOXINE/ALOE NOVACORT

Adrenocortical Insufficiency / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CORTICOTROPIN H.P. ACTHAR 5

Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 DISULFIRAM 3 ACAMPROSATE CALCIUM CAMPRAL 3 DISULFIRAM ANTABUSE

5 - Prior Authorization

5 of 104 Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE (cont.) Tier Generic Name Brand Name Notes 4 NALTREXONE HCL VIVITROL 5

Alkalinizing Agents / UROLOGICALS Tier Generic Name Brand Name Notes 1 CITRIC ACID/SODIUM CITRATE SODIUM CITRATE & CITRIC ACID 1 CITRIC ACID/SODIUM CITRATE CYTRA-2 1 POTASSIUM CITRATE 1 POTASSIUM CITRATE/CITRIC ACID CYTRA-K 1 POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE-CITRIC ACID 3 POTASSIUM CITRATE UROCIT-K

Alkylating Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 BUSULFAN 1 CARMUSTINE 1 CHLORAMBUCIL 1 CYCLOPHOSPHAMIDE 1 MECHLORETHAMINE 1 MELPHALAN 1 PROCARBAZINE 1 THIOTEPA 2 LOMUSTINE CEENU 3 MECHLORETHAMINE VALCHLOR 5 4 BENDAMUSTINE TREANDA 4 4 CISPLATIN 4

Allergen / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 GRASS POLLEN GRASTEK 3 GRASS POLLEN ORALAIR 3 RAGWEEK POLLEN RAGWITEK

Allylamines / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 TERBINAFINE HCL 3 TERBINAFINE HCL LAMISIL

Alpha- And Beta-Adrenergic Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 DROXIDOPA NORTHERA 5

Alpha- And Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 EPINEPHRINE TWINJECT

Alpha-Adrenergic Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CLONIDINE

4 - Office/Clinic Administration 5 - Prior Authorization

6 of 104 Alpha-Adrenergic Agonists / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 DIHYDROERGOTAMINE MESYLATE 2 EPINEPHRINE EPIPEN 2 EPINEPHRINE EPIPEN 2-PAK 2 EPINEPHRINE EPIPEN JR 2 EPINEPHRINE EPIPEN JR 2-PAK 3 CLONIDINE HCL KAPVAY 3 CLONIDINE HCL NEXICLON XR

Alpha-Adrenergic Agonists / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 BRIMONIDINE TOPICAL MIRVASO 3 OXYMETAZOLINE HCL 1% CREAM RHOFADE 5

Alpha-Adrenergic Agonists (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BRIMONIDINE TARTRATE 2 BRIMONIDINE TARTRATE ALPHAGAN P 3 BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN

Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 ERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 DIHYDROERGOTAMINE MESYLATE MIGRANAL

Alpha-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ALFUZOSIN HCL 1 DOXAZOSIN MESYLATE 1 PRAZOSIN HCL 1 TAMSULOSIN HCL 1 TERAZOSIN HCL 2 DOXAZOSIN MESYLATE CARDURA XL 3 ALFUZOSIN HCL UROXATRAL 3 PRAZOSIN HCL MINIPRESS 3 SILODOSIN RAPAFLO 3 TAMSULOSIN HCL FLOMAX

Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 ACARBOSE 3 MIGLITOL GLYSET

Amebicides / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 PAROMOMYCIN SULFATE 1 TINIDAZOLE

Aminoglycosides / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 NEOMYCIN SULFATE

5 - Prior Authorization

7 of 104 Aminoglycosides / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 3 TOBRAMYCIN IN 0.225% NACL TOBI 5 4 AMIKACIN 4 4 GENTAMICIN 4 4 KANAMYCIN 4 4 NETILMICIN NETROMYCIN 4 4 TOBRAMYCIN 4

Aminoglycosides / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes 4 CAPREOMYCIN CAPASTAT 4

Aminosalicylates / INFLAMMATORY BOWEL AGENTS Tier Generic Name Brand Name Notes 2 MESALAMINE ASACOL HD 2 MESALAMINE ASACOL 2 MESALAMINE PENTASA 3 MESALAMINE W/CLEANSING WIPES ROWASA

Ammonia Detoxicants / GI AGENTS Tier Generic Name Brand Name Notes 1 LACTULOSE 1 LACTULOSE ENULOSE 1 LACTULOSE GENERLAC 2 LACTULOSE KRISTALOSE

Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 LISDEXAMFETAMINE DIMESYLATE VYVANSE

Amylinomimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 4 PRAMLINTIDE ACETATE SYMLINPEN 120 5 4 PRAMLINTIDE ACETATE SYMLINPEN 60 5

Analgesics And Antipyretics- Misc. / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 ISOMETHEPT/ACETAMINOP/DICHLPHN EPIDRIN 1 ISOMETHEPT/ACETAMINOP/DICHLPHN ISOMETHEPT-DICHLORALP-ACETAMIN

Analgesics And Antipyretics- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BUTALB/ACETAMINOPHEN/CAFFEINE ZEBUTAL 1 BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 3 BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET 3 BUTALBITAL/ACETAMINOPHEN PHRENILIN FORTE

4 - Office/Clinic Administration 5 - Prior Authorization

8 of 104 Androgens / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 DANAZOL

Androgens / HORMONE: PITUITARY Tier Generic Name Brand Name Notes 2 TESTOSTERONE ANDROGEL 3 TESTOSTERONE 3 TESTOSTERONE ANDRODERM 3 TESTOSTERONE NASAL GEL NATESTO 4 TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 5

Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CANDESARTAN 7 1 CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN-HYDROCHLOROTHIAZID 7 1 IRBESARTAN 1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 1 LOSARTAN POTASSIUM 1 LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN-HYDROCHLOROTHIAZIDE 1 TELMISARTAN/AMLODIPINE 7 1 VALSARTAN 1 VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE 2 CANDESARTAN CILEXETIL ATACAND 7 2 CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT 7 2 OLMESARTAN MEDOXOMIL BENICAR 7 2 OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT 7 2 TELMISARTAN MICARDIS 7 2 TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT 7 3 AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 7 3 AZILSARTAN MEDOXOMIL EDARBI 7 3 IRBESARTAN AVAPRO 3 IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 3 LOSARTAN POTASSIUM COZAAR 3 OLMESARTAN MED/AMLODIPINE/HCTZ TRIBENZOR 7 3 TELMISARTAN/AMLODIPINE TWYNSTA 7 3 VALSARTAN DIOVAN 3 VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCTZ

Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 BENAZEPRIL HCL 1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 1 CAPTOPRIL 1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL-HYDROCHLOROTHIAZIDE 1 ENALAPRIL MALEATE 1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE 1 FOSINOPRIL SODIUM 1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL-HYDROCHLOROTHIAZIDE 1 LISINOPRIL 1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL-HYDROCHLOROTHIAZIDE

5 - Prior Authorization 7 - Step Therapy

9 of 104 Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 PERINDOPRIL ERBUMINE 1 QUINAPRIL HCL 1 RAMIPRIL 3 ENALAPRIL MALEATE VASOTEC 3 LISINOPRIL ZESTRIL 3 QUINAPRIL HCL ACCUPRIL 3 QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC 3 RAMIPRIL ALTACE 3 TRANDOLAPRIL/VERAPAMIL HCL TARKA

Anorex.-Respir.-Cerebral Stimulants-Misc / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 METHYLPHENIDATE HCL METHYLPHENIDATE ER 1 METHYLPHENIDATE HCL METADATE ER 1 METHYLPHENIDATE HCL 1 METHYLPHENIDATE HCL METHYLPHENIDATE SR 1 MODAFINIL 2 METHYLPHENIDATE HCL RITALIN CAPSULE 10, 60 MG 3 ARMODAFINIL NUVIGIL 3 DEXMETHYLPHENIDATE HCL FOCALIN XR 3 DEXMETHYLPHENIDATE HCL FOCALIN 3 METHYLPHENIDATE DAYTRANA 3 METHYLPHENIDATE HCL CONCERTA 3 METHYLPHENIDATE HCL METHYLIN ER 3 METHYLPHENIDATE HCL METADATE CD 3 METHYLPHENIDATE HCL RITALIN 3 METHYLPHENIDATE HCL RITALIN LA CAPSULES 20, 30, 40 MG 3 METHYLPHENIDATE HCL METHYLIN 3 MODAFINIL PROVIGIL

Anthelmintics / ANTIPARASITICS Tier Generic Name Brand Name Notes 1 MEBENDAZOLE 2 IVERMECTIN STROMECTOL 3 ALBENDAZOLE ALBENZA 3 PRAZIQUANTEL BILTRICIDE

Anti HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes 2 COBICISTAT TYBOST 2 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR STRIBILD

Anti-Cytomegalovirus / ANTIVIRALS Tier Generic Name Brand Name Notes 3 GANCICLOVIR ZIRGAN 3 VALGANCICLOVIR VALCYTE 4 CIDOFOVIR 4

Anti-HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes 2 DOLUTEGRAVIR TIVICAY

4 - Office/Clinic Administration

10 of 104 Anti-HIV Other / ANTIVIRALS (cont.) Tier Generic Name Brand Name Notes 2 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN GENVOYA OFOVIR ALAFENAMIDE 2 RALTEGRAVIR POTASSIUM ISENTRESS 2 RITONAVIR NORVIR 4 ENFUVIRTIDE FUZEON 5

Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes 1 BALSALAZIDE DISODIUM 1 MESALAMINE 2 MESALAMINE CANASA 2 MESALAMINE LIALDA 3 MESALAMINE APRISO

Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ALCLOMETASONE DIPROPIONATE 1 CLOBETASOL PROPIONATE CORMAX 1 CLOBETASOL PROPIONATE 1 CLOBETASOL PROPIONATE/EMOLL CLOBETASOL EMOLLIENT 1 DESONIDE 1 DESOXIMETASONE 1 FLUOCINOLONE ACETONIDE 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE EMOLLIENT 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE-E 1 HALOBETASOL PROPIONATE CREAM AND HALOBETASOL PROPIONATE OINTMENT 1 MOMETASONE FUROATE 1 PREDNICARBATE 1 TRIAMCINOLONE ACETONIDE 2 DESONIDE DESONATE 2 DESONIDE VERDESO 2 FLURANDRENOLIDE CORDRAN 2 FLUTICASONE PROPIONATE CUTIVATE 3 CLOBETASOL PROPIONATE OLUX 3 CLOBETASOL PROPIONATE CLOBEX 3 CLOBETASOL PROPIONATE/EMOLL OLUX-E 3 CLOCORTOLONE PIVALATE CLODERM 3 DESOXIMETASONE TOPICORT 3 FLUOCINOLONE ACETONIDE CAPEX SHAMPOO 3 FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS 3 FLUOCINONIDE VANOS 3 FLURANDRENOLIDE CORDRAN SP 3 HALCINONIDE HALOG 3 HALOBETASOL PROPIONATE CREAM AND ULTRAVATE OINTMENT 3 HALOBETASOL PROPIONATE LOTION ULTRAVATE 5 3 MOMETASONE FUROATE ELOCON 3 TRIAMCINOLONE ACETONIDE KENALOG

Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE COLOCORT

5 - Prior Authorization

11 of 104 Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 1 HYDROCORTISONE 1 HYDROCORTISONE PROCTOZONE-HC 1 HYDROCORTISONE PROCTOSOL-HC 1 HYDROCORTISONE PROCTOCORT 1 HYDROCORTISONE ACETATE 1 HYDROCORTISONE ACETATE HEMRIL 1 HYDROCORTISONE ACETATE SUPPOSITORIES ANUCORT-HC 5 1 HYDROCORTISONE/PRAMOXINE HYDROCORTISONE-PRAMOXINE 2 HYDROCORTISONE ACETATE CORTIFOAM 2 HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 3 HYDROCORTISONE ACETATE SUPPOSITORIES ANUSOL-HC 5 3 HYDROCORTISONE/PRAMOXINE ANALPRAM HC

Anti-Influenza / ANTIVIRALS Tier Generic Name Brand Name Notes 1 AMANTADINE HCL AMANTADINE 2 OSELTAMIVIR PHOSPHATE TAMIFLU 6 3 ZANAMIVIR RELENZA 4 INFLUENZA VACCINE FLUZONE 4

Antiallergic Agents / NASAL STEROID Tier Generic Name Brand Name Notes 1 OLOPATADINE HCL OLOPATADINE NASAL 3 OLOPATADINE HCL PATANASE

Antiallergic Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 AZELASTINE HCL 1 EPINASTINE HCL 2 LODOXAMIDE TROMETHAMINE ALOMIDE 3 ALCAFTADINE LASTACAFT 3 AZELASTINE HCL OPTIVAR 3 BEPOTASTINE BESILATE BEPREVE 3 EPINASTINE HCL ELESTAT 3 OLOPATADINE HCL PATADAY 3 OLOPATADINE HCL PATANOL 3 PEMIROLAST POTASSIUM ALAMAST

Antiallergic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 AZELASTINE 1 AZELASTINE HCL 3 AZELASTINE HCL ASTELIN 3 AZELASTINE HCL ASTEPRO 3 AZELASTINE/FLUTICASONE DYMISTA

Antiandrogen / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 ENZALUTAMIDE XTANDI 5

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

12 of 104 Antiangiogenic Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 PAZOPANIB VOTRIENT 5 3 SORAFENIB NEXAVAR 5 3 SUNITINIB MALATE SUTENT 4 BEVACIZUMAB AVASTIN 4

Antiarrhythmics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMIODARONE HCL 1 DIGOXIN 1 FLECAINIDE ACETATE 1 MEXILETINE HCL 1 PROPAFENONE HCL 1 QUINIDINE GLUCONATE 1 QUINIDINE SULFATE 2 AMIODARONE HCL PACERONE 2 DISOPYRAMIDE PHOSPHATE NORPACE CR 3 DIGOXIN LANOXIN 3 DOFETILIDE TIKOSYN 3 DRONEDARONE HCL MULTAQ 3 PROPAFENONE HCL RYTHMOL SR 4 ADENOSINE ADENOCARD 4

Antibacterials (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HC 1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HYDROCORT 3 CIPROFLOXACIN HCL/DEXAMETH CIPRODEX 3 CIPROFLOXACIN/FLUOCINOLONE ACETONIDE OTOVEL 3 CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3 NEOMY SULF/COLIST SUL/HC/THONZ COLY-MYCIN S 3 NEOMY SULF/COLIST SUL/HC/THONZ CORTISPORIN-TC

Antibacterials (Eent) / DENTAL AGENT Tier Generic Name Brand Name Notes 3 MINOCYCLINE HCL MICROSPHERES ARESTIN 4

Antibacterials (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BACITRACIN 1 BACITRACIN/POLYMYXIN B SULFATE AK-POLY-BAC 1 CIPROFLOXACIN HCL 1 GENTAMICIN SULFATE 1 GENTAMICIN SULFATE GENTAK 1 LEVOFLOXACIN 1 NEO/POLYMYX B SULF/DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH 1 NEOMY SULF/BACITRA/POLYMYXIN B NEO-POLYCIN 1 NEOMY SULF/BACITRA/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN 1 NEOMY SULF/BACITRAC ZN/POLY/HC NEO-POLYCIN HC

4 - Office/Clinic Administration 5 - Prior Authorization

13 of 104 Antibacterials (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name Brand Name Notes 1 NEOMY SULF/BACITRAC ZN/POLY/HC NEOMYCIN-BACITRACIN-POLY-HC 1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN 1 OFLOXACIN 1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM 1 SULFACETAMIDE SODIUM SULFAMIDE 1 SULFACETAMIDE SODIUM 1 SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE 1 TOBRAMYCIN 1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE 2 SULFACETAMIDE SODIUM BLEPH-10 2 TOBRAMYCIN TOBREX 2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX OPTHALMIC OINTMENT 3 AZITHROMYCIN AZASITE 3 BESIFLOXACIN HCL BESIVANCE 3 CIPROFLOXACIN HCL CILOXAN 3 GATIFLOXACIN ZYMAXID 3 GATIFLOXACIN ZYMAR 3 MOXIFLOXACIN HCL VIGAMOX 3 MOXIFLOXACIN HCL MOXEZA 3 NEO/POLYMYX B SULF/DEXAMETH MAXITROL 3 POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE S.O.P. 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE 3 TOBRAMYCIN/DEXAMETHASONE TOBRADEX 3 TOBRAMYCIN/LOTEPRED ETAB ZYLET

Antibacterials (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 MUPIROCIN CALCIUM BACTROBAN NASAL

Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN PHOS-BENZOYL PEROX 1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN-BENZOYL PEROXIDE 1 CLINDAMYCIN PHOSPHATE 1 ERYTHROMYCIN BASE/ETHANOL ERY 1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN-BENZOYL PEROXIDE 1 MUPIROCIN 2 CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA 2 ERYTHROMYCIN/BENZOYL PEROXIDE BENZAMYCINPAK 2 METRONIDAZOLE METROGEL 2 METRONIDAZOLE NORITATE 3 CLINDAMYCIN PHOS/BENZOYL PEROX DUAC 3 CLINDAMYCIN PHOS/BENZOYL PEROX BENZACLIN 3 CLINDAMYCIN PHOSPHATE CLINDAGEL 3 CLINDAMYCIN/TRETINOIN ZIANA 5 3 CLINDAMYCIN/TRETINOIN VELTIN 5 3 ERYTHROMYCIN BASE AKNE-MYCIN 3 METRONIDAZOLE METROLOTION 3 MUPIROCIN BACTROBAN 3 RETAPAMULIN ALTABAX

5 - Prior Authorization

14 of 104 Antibacterials (Skin & Mucous Membrane) / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 NEOMY SULF/POLYMYXIN B SULFATE NEOSPORIN G.U. IRRIGANT

Antibacterials (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 CLINDAMYCIN PHOSPHATE 1 METRONIDAZOLE VANDAZOLE 2 CLINDAMYCIN PHOSPHATE CLEOCIN 3 METRONIDAZOLE METROGEL-VAGINAL

Antibacterials- Miscellaneous / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 CLINDAMYCIN HCL 1 CLINDAMYCIN PALMITATE HCL 1 CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 1 VANCOMYCIN HCL 3 CLINDAMYCIN HCL CLEOCIN HCL 3 LINEZOLID ZYVOX 5 3 RIFAXIMIN XIFAXAN 5 3 VANCOMYCIN HCL VANCOCIN HCL

Antibacterials- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 BISMUTH SAL/METRONID/TETRACYC HELIDAC 3 BISMUTH/METRONID/TETRACYCLINE PYLERA

Antibacterials- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 BEZLOTOXUMAB INJECTION ZINPLAVA 4

Anticholinergics / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 BENZTROPINE MESYLATE 1 TRIHEXYPHENIDYL HCL 3 TRIHEXYPHENIDYL HCL ARTANE

Anticoagulants / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 1 WARFARIN SODIUM 2 DABIGATRAN ETEXILATE MESYLATE PRADAXA 3 WARFARIN SODIUM COUMADIN 4 DALTEPARIN SODIUM,PORCINE FRAGMIN 5 4 DARBEPOETIN ALFA ARANESP 5 4 ENOXAPARIN SODIUM LOVENOX 5 4 ENOXAPARIN SODIUM 5 4 FONDAPARINUX SODIUM 5

Anticonvulsants- Miscellaneous / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 FELBAMATE

4 - Office/Clinic Administration 5 - Prior Authorization

15 of 104 Anticonvulsants- Miscellaneous / ANTICONVULSANTS (cont.) Tier Generic Name Brand Name Notes 1 LEVETIRACETAM 2 TIAGABINE HCL GABITRIL 3 BRIVARACETAM ORAL SOLUTION BRIVIACT 3 BRIVARACETAM TABLETS BRIVIACT 4 BRIVARACETAM FOR INJECTION BRIVIACT 4

Anticonvulsants- Other / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE EPITOL 2 EZOGABINE POTIGA 2 METHSUXIMIDE CELONTIN 3 CARBAMAZEPINE EQUETRO 3 LACOSAMIDE VIMPAT

Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 DESVENLAFAXINE SUCCINATE 1 MIRTAZAPINE 1 NEFAZODONE HCL 1 OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 3 DESVENLAFAXINE SUCCINATE PRISTIQ ER 3 DOXEPIN HCL SILENOR 3 MIRTAZAPINE REMERON 3 OLANZAPINE/FLUOXETINE HCL SYMBYAX 3 VILAZODONE HYDROCHLORIDE VIIBRYD

Antidiarrhea Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE 1 LOPERAMIDE HCL LOPERAMIDE 3 CROFELEMER FULYZAQ 5 3 DIPHENOXYLATE HCL/ATROPINE LOMOTIL 3 OPIUM TINCTURE OPIUM

Antidotes / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 2 LEUCOVORIN CALCIUM

Antiemetics- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 SCOPOLAMINE TRANSDERM-SCOP 3 SCOPOLAMINE HYDROBROMIDE SCOPACE

Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 3 DOXYLAMINE/PYRIDOXINE DICLEGIS

4 - Office/Clinic Administration 5 - Prior Authorization

16 of 104 Antiestrogen / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 TAMOXIFEN CITRATE

Antifungal Antibiotics / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 FLUCYTOSINE 1 GRISEOFULVIN ULTRAMICROSIZE 1 GRISEOFULVIN,MICROSIZE GRISEOFULVIN 1 NYSTATIN 3 GRISEOFULVIN ULTRAMICROSIZE GRIS-PEG 3 GRISEOFULVIN,MICROSIZE GRIFULVIN V

Antifungals (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 NATAMYCIN NATACYN

Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 CICLOPIROX 1 CLOTRIMAZOLE 1 ECONAZOLE NITRATE 1 KETOCONAZOLE KETODAN 1 NYSTATIN NYSTOP 1 NYSTATIN NYAMYC 1 NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE 2 SULCONAZOLE NITRATE EXELDERM 3 CICLOPIROX/NAIL LACQ/FT DEOD#4 PEDIPIROX-4 3 KETOCONAZOLE NIZORAL 3 KETOCONAZOLE XOLEGEL 3 MICONAZOLE NITRATE/ZINC OX/PET VUSION 3 NAFTIFINE HCL NAFTIN 3 OXICONAZOLE NITRATE OXISTAT 3 SERTACONAZOLE NITRATE ERTACZO

Antifungals (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 TERCONAZOLE

Antihemophilic / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 3 COAGULATION FACTOR IX RECOMBINANT FOR IDELVION 4 INJ 4 ANTIHEMOPHILIC FACTOR ELOCTATE 4 4 ANTIHEMOPHILIC FACTOR RECOMBINANT NUWIQ 4 4 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT AFSTYLA 4 4 ANTIHEMOPHYLIC FACTOR [RECOMBINANT] ADYNOVATE 4 PEGYLATED INJECTION 4 COAGULATION FACTOR IX, RECOMBINANT IXINITY 4 4 COAGULATION FACTOR VIII, RECOMBINANT KOVALTRY 4 4 COAGULATION FACTOR X [HUMAN] FOR COAGADEX 4 INJECTION

4 - Office/Clinic Administration

17 of 104 Antihemophilic / OFFICE ADMINISTERED (cont.) Tier Generic Name Brand Name Notes 4 VON WILLEBRAND FACTOR RECOMBINANT FOR VONVENDI 4 INJ

Antihepatitis / ANTIVIRALS Tier Generic Name Brand Name Notes 1 RIBAVIRIN RIBASPHERE 5 1 RIBAVIRIN RIBAPAK 5 1 RIBAVIRIN 5 2 LEDIPASVIR/SOFOSBUVIR HARVONI 5 2 SOFOSBUVIR/VELPATASVIR EPCLUSA 5 2 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR VOSEVI 5 3 BOCEPREVIR VICTRELIS 5 3 GLECAPREVIR/PIBRENTASVIR MAVYRET 5 3 GRAZOPREVIR/ELBASVIR ZEPATIER 5 3 PARITAPREVIR;/RITON/OMBITAS/DASA VIEKIRA PAK 5 3 RIBAVIRIN REBETOL 5 3 RIBAVIRIN COPEGUS 5 3 SIMEPREVIR OLYSIO 5 3 SOFOSBUVIR SOLVALDI 5 3 TELAPREVIR INCIVEK 5 4 DACLATASVIR DAKLINZA 5 4 OMBITASVIR/PARITAPREVIR/RITONAVIR TECHNIVIE 5 4 PEGINTERFERON ALFA-2A PEGASYS PROCLICK 5 4 PEGINTERFERON ALFA-2A PEGASYS 5 4 PEGINTERFERON ALFA-2B PEGINTRON REDIPEN 5

Antiherpetic / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ACYCLOVIR 6 1 VALACYCLOVIR HCL VALACYCLOVIR 6 3 ACYCLOVIR ZOVIRAX 6 3 ACYCLOVIR SITAVIG 3 VALACYCLOVIR HCL VALTREX 6

Antihistamines (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes 1 MECLIZINE HCL 1 PROCHLORPERAZINE MALEATE COMPRO 1 PROCHLORPERAZINE MALEATE 1 TRIMETHOBENZAMIDE HCL 3 MECLIZINE HCL ANTIVERT

Antimalarial Agents / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 CHLOROQUINE PHOSPHATE 1 HYDROXYCHLOROQUINE SULFATE

4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit

18 of 104 Antimalarial Agents / ANTI - INFECTIVES (cont.) Tier Generic Name Brand Name Notes 1 MEFLOQUINE HCL 2 PRIMAQUINE PHOSPHATE PRIMAQUINE 2 PYRIMETHAMINE DARAPRIM 3 HYDROXYCHLOROQUINE SULFATE PLAQUENIL

Antimalarials / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 1 QUININE SULFATE 3 ATOVAQUONE/PROGUANIL HCL MALARONE

Antimetabolite / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 MERCAPTOPURINE 1 THIOGUANINE 2 METHOTREXATE SODIUM TREXALL 4 METHOTREXATE SODIUM METHOTREXATE 5

Antimuscarinic/Beta Agonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 UMECLIDINIUM/VILANTEROL ANORO ELLIPTA

Antimuscarinics/Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes 1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM 1 DICYCLOMINE HCL 1 GLYCOPYRROLATE 1 PROPANTHELINE BROMIDE

Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 IPRATROPIUM BROMIDE 6 1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM-ALBUTEROL 6 2 IPRATROPIUM BROMIDE ATROVENT HFA 6 2 TIOTROPIUM BROMIDE SPIRIVA 6 3 ACLIDINIUM BROMIDE TUDORZA PRESSAIR 3 GLYCOPYRROLATE INHALATION POWDER SEEBRI NEOHALER 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT 6 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT 6

Antineoplastic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 BICALUTAMIDE 1 HYDROXYUREA 1 IMATINIB MESYLATE 5 1 MEGESTROL ACETATE

5 - Prior Authorization 6 - Quantity Limit

19 of 104 Antineoplastic Agents / ANTINEOPLASTICS (cont.) Tier Generic Name Brand Name Notes 2 MEGESTROL ACETATE MEGACE ES 2 THIOGUANINE TABLOID 2 TOREMIFENE CITRATE FARESTON 3 ABIRATERONE ACETATE ZYTIGA 3 CABOZANTINIB COMETRIQ 5 3 CABOZANTINIB CABOMETYX 5 3 CAPECITABINE XELODA 3 CRIZOTINIB XALKORI 3 DASATINIB SPRYCEL 3 ERLOTINIB HCL TARCEVA 5 3 EVEROLIMUS AFINITOR 3 IMATINIB MESYLATE GLEEVEC 5 3 LAPATINIB DITOSYLATE TYKERB 3 LETROZOLE FEMARA 3 NIRAPARIB CAPSULES ZEJULA 5 3 REGORAFENIB STIVARGA 3 TEMOZOLOMIDE TEMODAR 3 VISMODEGIB ERIVEDGE 5 4 LEUPROLIDE ACETATE 5 4 PONATINIB ICLUSIG 5 4 RADIUM RA 223 XOFIGO 5 4 TRIFLURIDINE/TIPIRACIL LONSURF 5

Antineoplastic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 LEUPROLIDE ACETATE LUPRON DEPOT 4

Antineoplastic Other / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 DINUTUXIMAB FOR INJECTION UNITUXIN 4 4 OMACETAXINE MEPESUCCINATE FOR INJECTION SYNRIBO 4 4 SONIDEGIB CAPSULES ODOMZO 5 4 TRABECTEDIN FOR INJECTION YONDELIS 4 4 VINBLASTINE VELBAN 4 4 VINCRISTINE ONCOVIN 4 4 VINORELBINE NAVELBINE 4

Antiparkinsonian Agents / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 CARBIDOPA 3 CARBIDOPA LODOSYN

Antiprotozoals / ANTIPARASITICS Tier Generic Name Brand Name Notes 1 CHLOROQUINE 1 METRONIDAZOLE 1 TINIDAZOLE 3 NITAZOXANIDE ALINIA

4 - Office/Clinic Administration 5 - Prior Authorization

20 of 104 Antiprotozoals / ANTIPARASITICS (cont.) Tier Generic Name Brand Name Notes 3 TINIDAZOLE TINDAMAX

Antipruritics And Local Anesthetics / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 DOXEPIN HCL ZONALON 3 NORFLURANE/HFC 245FA PAIN EASE 3 TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE

Antipruritics And Local Anesthetics / UROLOGICALS Tier Generic Name Brand Name Notes 1 PHENAZOPYRIDINE HCL

Antiretrovirals / ANTIVIRALS Tier Generic Name Brand Name Notes 1 DIDANOSINE 1 LAMIVUDINE 1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 1 NEVIRAPINE 2 EFAVIRENZ SUSTIVA 2 EFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA 2 EMTRICITAB/RILPIVIRINE/TENOFOV COMPLERA 2 EMTRICITABINE EMTRIVA 2 ETRAVIRINE INTELENCE 2 MARAVIROC SELZENTRY 2 NEVIRAPINE VIRAMUNE 2 TENOFOVIR ALAFENAMIDE TABLETS VEMLIDY 5 2 TENOFOVIR DISOPROXIL FUMARATE VIREAD 3 NEVIRAPINE VIRAMUNE XR

Antisense Oligonucleotide / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ETEPLIRSEN INJECTION EXONDYS 51 4 4 NUSINERSEN INJECTION SPINRAZA 4

Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes 1 HYOSCYAMINE SULFATE HYOMAX-SR 1 HYOSCYAMINE SULFATE 1 HYOSCYAMINE SULFATE OSCIMIN 1 HYOSCYAMINE SULFATE OSCIMIN SR 1 HYOSCYAMINE SULFATE HYOMAX-SL 1 HYOSCYAMINE SULFATE HYOMAX-FT 1 HYOSCYAMINE SULFATE OSCIMIN SL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP QUADRAPAX 1 PHENOBARB/HYOSCY/ATROPINE/SCOP SE-DONNA PB HYOS 3 PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL

4 - Office/Clinic Administration 5 - Prior Authorization

21 of 104 Antithyroid Agents / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 METHIMAZOLE 1 PROPYLTHIOURACIL 3 POTASSIUM IODIDE SSKI

Antituberculosis Agents / ANTIMYCOBACTERIALS Tier Generic Name Brand Name Notes 1 ETHAMBUTOL HCL MYAMBUTOL 1 ETHAMBUTOL HCL 1 ISONIAZID 1 PYRAZINAMIDE 1 RIFAMPIN 2 BEDAQUILINE SIRTURO 5 2 RIFABUTIN MYCOBUTIN 3 RIFAPENTINE PRIFTIN

Antitussives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 BENZONATATE 1 BROMPHENIRAMIN/PE/DEXTROMETHOR LOHIST-DM 1 CODEINE/PROMETHAZINE HCL PROMETHAZINE-CODEINE 1 D-METHORPHAN HB/PROMETH HCL PROMETHAZINE-DM 1 GUAIFENESIN/CODEINE PHOSPHATE IOPHEN-C NR 1 GUAIFENESIN/CODEINE PHOSPHATE CHERATUSSIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE 1 GUAIFENESIN/CODEINE PHOSPHATE DEX-TUSS 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE-HOMATROPINE MBR 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROMET 1 HYDROCODONE/CHLORPHEN POLIS HYDROCODONE-CHLORPHENIRAMINE 1 P-EPHED HCL/CODEINE/GUAIFEN CHERATUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN MYTUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN GUAIFENESIN DAC 1 PHENYLEPHRINE HCL/COD/PROMETH PROMETHAZINE VC-CODEINE 3 D-METHORPHAN HB/P-EPD HCL/BPM BROMFED DM 3 HYDROCODONE/CHLORPHEN POLIS TUSSICAPS

Antivirals (Eent) / ANTIVIRALS Tier Generic Name Brand Name Notes 1 TRIFLURIDINE

Antivirals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 ACYCLOVIR/HYDROCORTISONE XERESE 3 PENCICLOVIR DENAVIR

Antivirals- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 HUMAN PAPILLOMAVIRUS GARDASIL/CERVARIX 4

4 - Office/Clinic Administration 5 - Prior Authorization

22 of 104 Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BUSPIRONE HCL 1 CHLORAL HYDRATE 1 ESZOPICLONE 6 1 ZALEPLON 6 1 ZOLPIDEM TARTRATE 6 1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER 6 2 CHLORAL HYDRATE SOMNOTE 3 ESZOPICLONE LUNESTA 6 3 RAMELTEON ROZEREM 3 ZALEPLON SONATA 6 3 ZOLPIDEM TARTRATE EDLUAR 6 3 ZOLPIDEM TARTRATE AMBIEN 6 3 ZOLPIDEM TARTRATE INTERMEZZO 6 3 ZOLPIDEM TARTRATE AMBIEN CR 6

Anxiolytics- Sedatives & Hypnotics-Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 DICHLORALPHENAZONE

Anxiolytics- Sedatives & Hypnotics-Misc. / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE

Aromatase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 ANASTROZOLE 1 EXEMESTANE 1 LETROZOLE 3 ANASTROZOLE ARIMIDEX

Astringents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ALUMINUM CHLORIDE HYPERCARE 3 ALUMINUM CHLORIDE XERAC AC 3 ALUMINUM CHLORIDE DRYSOL

Atypical/2nd Generation / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 OLANZAPINE OLANZAPINE ODT 1 OLANZAPINE 1 QUETIAPINE FUMARATE 1 RISPERIDONE RISPERIDONE ODT 1 RISPERIDONE 1 RISPERIDONE RISPERIDONE M-TAB 1 ZIPRASIDONE HCL 2 ARIPIPRAZOLE ABILIFY DISCMELT 2 ARIPIPRAZOLE ABILIFY 3 ASENAPINE MALEATE SAPHRIS

6 - Quantity Limit

23 of 104 Atypical/2nd Generation / ANTIPSYCHOTICS (cont.) Tier Generic Name Brand Name Notes 3 BREXPIPRAZOLE REXULTI 3 CARIPRAZINE VRAYLAR 7 3 ILOPERIDONE FANAPT 3 LURASIDONE HCL LATUDA 3 OLANZAPINE ZYPREXA 3 OLANZAPINE ZYPREXA ZYDIS 3 PALIPERIDONE INVEGA 3 PIMAVANSERIN TABLETS NUPLAZID 5 3 QUETIAPINE FUMARATE SEROQUEL 3 QUETIAPINE FUMARATE SEROQUEL XR 3 ZIPRASIDONE HCL GEODON 4 PALIPERIDONE PALMITATE INVEGA SUSTENNA 5

Azoles / ANTIFUNGALS Tier Generic Name Brand Name Notes 1 CLOTRIMAZOLE 1 FLUCONAZOLE 1 ITRACONAZOLE 1 KETOCONAZOLE 1 VORICONAZOLE 5 3 EFINACONAZOLE JUBLIA 5 3 FLUCONAZOLE DIFLUCAN 3 ISAVUCONAZOMIUN CRESEMBA 5 3 LULICONAZOLE LUZU 3 POSACONAZOLE NOXAFIL

B-lymphocyte stimulator / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 BELIMUMAB BENLYSTA 5

BCL-2 INHIBITOR / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 VENETOCLAX TABLETS VENCLEXTA 5

BILE ACID SYNTHESIS DISORDER / ENDOCRINE Tier Generic Name Brand Name Notes 4 CHOLIC ACID CAPSULES CHOLBAM 5

BPH / GI AGENTS Tier Generic Name Brand Name Notes 1 ALFUZOSIN 1 DOXAZOSIN MESYLATE DOXAZOSIN 1 TAMSULOSIN 1 TERAZOSIN HCL TERAZOSIN 3 SILODOSIN RAPAFLO 3 TAMSULOSIN FLOMAX

BRAF Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 DABRAFENIB TAFINLAR 5

5 - Prior Authorization 7 - Step Therapy

24 of 104 BRAF Inhibitor / ANTINEOPLASTICS (cont.) Tier Generic Name Brand Name Notes 3 VEMURAFENIB ZELBORAF 5

Barbiturates (Anticonvulsants) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 PRIMIDONE

Barbiturates (Anxiolytic- Sedative/Hyp) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 PHENOBARBITAL

Basic Lotions And Liniments / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AMMONIUM LACTATE

Basic Ointments And Protectants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AMMONIUM LACTATE LAC-HYDRIN

Benzodiazepines (Anticonvulsants) / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CLONAZEPAM 3 CLOBAZAM ONFI 3 CLONAZEPAM KLONOPIN 3 DIAZEPAM DIASTAT ACUDIAL

Benzodiazepines (Anxiolytic) / ANXIOLYTICS Tier Generic Name Brand Name Notes 1 ALPRAZOLAM ALPRAZOLAM ER 1 ALPRAZOLAM 1 ALPRAZOLAM ALPRAZOLAM ODT 1 ALPRAZOLAM ALPRAZOLAM XR 1 CHLORDIAZEPOXIDE HCL 1 CLORAZEPATE DIPOTASSIUM 1 DIAZEPAM 1 LORAZEPAM LORAZEPAM INTENSOL 1 LORAZEPAM 1 OXAZEPAM 3 ALPRAZOLAM XANAX 3 DIAZEPAM VALIUM 3 LORAZEPAM ATIVAN

Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS Tier Generic Name Brand Name Notes 1 ESTAZOLAM 1 FLURAZEPAM HCL 6

5 - Prior Authorization 6 - Quantity Limit

25 of 104 Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS (cont.) Tier Generic Name Brand Name Notes 1 TEMAZEPAM 6 1 TRIAZOLAM 6

Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 LEVALBUTEROL HCL LEVALBUTEROL 6 2 ALBUTEROL SULFATE VENTOLIN HFA 6 2 ALBUTEROL SULFATE PROVENTIL HFA 6 2 ALBUTEROL SULFATE PROAIR HFA 6 3 ARFORMOTEROL TARTRATE BROVANA 3 INDACATEROL MALEATE ARCAPTA NEOHALER 3 LEVALBUTEROL TARTRATE XOPENEX HFA 6

Beta-Adrenergic Blocking Agents / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 PROPRANOLOL HCL

Beta-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ATENOLOL 1 ATENOLOL/CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE 1 BISOPROLOL FUMARATE 1 BISOPROLOL FUMARATE/HCTZ BISOPROLOL-HYDROCHLOROTHIAZIDE 1 CARVEDILOL 1 LABETALOL HCL 1 METOPROLOL SUCCINATE 1 METOPROLOL TARTRATE 1 METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL-HYDROCHLOROTHIAZIDE 1 NADOLOL 1 PINDOLOL 1 PROPRANOLOL HCL 1 SOTALOL HCL SOTALOL 1 SOTALOL HCL SOTALOL AF 2 CARVEDILOL PHOSPHATE COREG CR 3 ATENOLOL TENORMIN 3 CARVEDILOL COREG 3 METOPROLOL SUCCINATE TOPROL XL 3 NADOLOL CORGARD 3 NEBIVOLOL HCL BYSTOLIC 3 PROPRANOLOL HCL HEMANGEOL 3 PROPRANOLOL HCL INDERAL LA 3 PROPRANOLOL HCL INNOPRAN XL

Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BETAXOLOL HCL 1 LEVOBUNOLOL HCL 1 TIMOLOL MALEATE 2 BETAXOLOL HCL BETOPTIC S 2 TIMOLOL MALEATE ISTALOL

6 - Quantity Limit

26 of 104 Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name Brand Name Notes 2 TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE 3 TIMOLOL BETIMOL 3 TIMOLOL MALEATE TIMOPTIC

Beta-Lactam, Other / ANTIBACTERIALS Tier Generic Name Brand Name Notes 4 AZTREONAM AZACTAM 4 4 IMIPENEM PRIMAXIN 4 4 IMIPENEM/CILASTATN IMIPENEM/CILASTATIN 4 4 MEROPENEM 4

Biguanides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 METFORMIN HCL METFORMIN HCL ER 1 METFORMIN HCL 1 METFORMIN HCL ER (MOD) METFORMIN ER (MOD) 5 1 METFORMIN HCL ER (OSM) 2 METFORMIN HCL METFORMIN HYDROCHLORIDE 2 METFORMIN HCL RIOMET 3 METFORMIN HCL GLUCOPHAGE 3 METFORMIN HCL ER GLUCOPHAGE XR 3 METFORMIN HCL ER (MOD) GLUMETZA 5 3 METFORMIN HCL ER (OSM) FORTAMET

Bile Acid Sequestrants / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE 1 CHOLESTYRAMINE/ASPARTAME PREVALITE 1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT 1 COLESTIPOL HCL 3 COLESEVELAM HCL WELCHOL

Bipolar - Other / BIPOLAR AGENTS Tier Generic Name Brand Name Notes 1 ALPRAZOLAM 1 DIAZEPAM 1 OLANZAPINE 3 ARIPIPRAZOLE ABILIFY 3 LURASIDONE HCL LATUDA

Blood Formation Modifiers / ANTICONVULSANTS Tier Generic Name Brand Name Notes 3 EDOXABAN SAVAYSA

Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 2 APIXABAN ELIQUIS 5

4 - Office/Clinic Administration 5 - Prior Authorization

27 of 104 Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS (cont.) Tier Generic Name Brand Name Notes 2 RIVAROXABAN XARELTO 3 CLOPIDOGREL BISULFATE PLAVIX 4 FONDAPARINUX SODIUM ARIXTRA 5 4 HEPARIN 4

Bone Resorption Inhibitors / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 ALENDRONATE SODIUM 1 IBANDRONATE SODIUM 1 RISEDRONATE 2 ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D 3 ALENDRONATE SODIUM FOSAMAX 3 ALENDRONATE SODIUM BINOSTO 3 IBANDRONATE SODIUM BONIVA 3 RISEDRONATE SODIUM ATELVIA 3 RISEDRONATE SODIUM ACTONEL

C1 Esterase Inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 C1 ESTERASE INHIBITOR RUCONEST 4

CYSTIC FIBROSIS TRANSMEMBRANE REGULATOR PROTEIN / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 4 LUMACAFTOR/IVACAFTOR ORKAMBI 5

Calcium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 ETHOSUXIMIDE 1 LAMOTRIGINE 2 LAMOTRIGINE LAMICTAL (GREEN) 2 LAMOTRIGINE LAMICTAL (ORANGE) 3 LAMOTRIGINE LAMICTAL ODT (ORANGE) 3 LAMOTRIGINE LAMICTAL 3 LAMOTRIGINE LAMICTAL ODT 3 LAMOTRIGINE LAMICTAL XR 3 LEVETIRACETAM KEPPRA XR 3 LEVETIRACETAM KEPPRA

Calcium Channel Blocker/ARB / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE/VALSARTAN 7 3 AMLODIPINE/VALSARTAN EXFORGE 7 3 AMLODIPINE/VALSARTAN/HCTZ EXFORGE HCT 7

Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 DILTIAZEM HCL TAZTIA XT

4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step Therapy

28 of 104 Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes 1 DILTIAZEM HCL CARTIA XT 1 DILTIAZEM HCL DILTIAZEM 24HR CD 1 DILTIAZEM HCL DILT-XR 1 DILTIAZEM HCL MATZIM LA 1 DILTIAZEM HCL DILTIAZEM 24HR ER 1 DILTIAZEM HCL DILTIAZEM ER 1 DILTIAZEM HCL 1 VERAPAMIL HCL 1 VERAPAMIL HCL VERAPAMIL ER 1 VERAPAMIL HCL VERAPAMIL ER PM 3 DILTIAZEM HCL CARDIZEM CD 3 DILTIAZEM HCL CARDIZEM LA 3 DILTIAZEM HCL TIAZAC 3 VERAPAMIL HCL CALAN SR

Carbonic Anhydrase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ACETAZOLAMIDE 3 ACETAZOLAMIDE DIAMOX SEQUELS

Carbonic Anhydrase Inhibitors (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 ACETAZOLAMIDE 1 DORZOLAMIDE HCL 1 DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE-TIMOLOL 1 METHAZOLAMIDE 2 BRINZOLAMIDE AZOPT 3 DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT 3 DORZOLAMIDE/TIMOLOL/PF COSOPT PF

Cardiac Drugs- Miscellaneous / CARDIOVASCULAR Tier Generic Name Brand Name Notes 2 Ivabradine HCL Corlanor 3 RANOLAZINE RANEXA 3 SACUBITRIL/VALSARTAN ENTRESTO 5

Cariostatic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 SODIUM FLUORIDE RENAF 1 SODIUM FLUORIDE FLUORITAB 1 SODIUM FLUORIDE FLUORIDE 1 SODIUM FLUORIDE EPIFLUR 1 SODIUM FLUORIDE 1 SODIUM FLUORIDE LUDENT FLUORIDE 2 SODIUM FLUORIDE FLURA-DROPS 2 SODIUM FLUORIDE FLUORABON 2 SODIUM FLUORIDE FLUOR-A-DAY

Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 ENTACAPONE

5 - Prior Authorization

29 of 104 Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (cont.) Tier Generic Name Brand Name Notes 2 ENTACAPONE COMTAN

Cell Stimulants And Proliferants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 TRETINOIN 5 2 TRETINOIN AVITA 5 2 TRETINOIN ATRALIN 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO 5

Central Alpha-Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 GUANFACINE HCL 1 METHYLDOPA

Central Monoamine-Depleting Agent / CNS AGENTS Tier Generic Name Brand Name Notes 3 VALBENAZINE CAPSULES INGREZZA 5 4 DEUTETRABENAZINE TABLETS AUSTEDO 5

Central Nervous System Agents- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 5

Central Nervous System Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 RILUZOLE RILUTEK

Centrally Acting Skeletal Muscle Relaxnt / ANTISPASTICITY AGENTS Tier Generic Name Brand Name Notes 1 CARISOPRODOL 1 CHLORZOXAZONE 1 CYCLOBENZAPRINE HCL 1 METAXALONE 1 METHOCARBAMOL 1 TIZANIDINE HCL 3 CARISOPRODOL SOMA 3 CYCLOBENZAPRINE HCL AMRIX 3 METAXALONE SKELAXIN

Cephalosporins / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 CEFACLOR 1 CEFADROXIL HYDRATE CEFADROXIL 1 CEFAZOLIN 1 CEFDINIR 1 CEFPROZIL

5 - Prior Authorization

30 of 104 Cephalosporins / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 1 CEFUROXIME AXETIL CEFUROXIME 1 CEPHALEXIN 3 CEFIXIME SUPRAX 3 CEFRADINE VELOSEF 3 CEFTIBUTEN CEDAX 3 CEFTIBUTEN DIHYDRATE CEDAX 3 CEFUROXIME AXETIL CEFTIN 3 CEPHALEXIN KEFLEX 4 CEFEPIME MAXIPIME 4 4 CEFOTAXIME CLAFORAN 4 4 CEFOTETAN CEFOTAN 4 4 CEFOXITAN MEFOXIN 4

Chelator / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 DEFERASIROX EXJADE 5

Cholelitholytic Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 URSODIOL 3 URSODIOL ACTIGALL

Cholesterol Absorption Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 LOMITAPIDE JUXTAPID 5 4 MIPOMERSEN KYNAMRO 5

Cholinesterase Inhibitors / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes 1 DONEPEZIL HCL 1 GALANTAMINE 1 RIVASTIGMINE 3 RIVASTIGMINE EXELON PATCH

Coagulant - Vitamin K / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 2 PHYTONADIONE MEPHYTON

Complement Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 4 ICATIBANT ACETATE FIRAZYR 5

Contraceptives / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 DESOG-ET ESTRA/ETHIN ESTRA KARIVA 3

3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization

31 of 104 Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes 1 DESOG-ET ESTRA/ETHIN ESTRA VIORELE 1 DESOG-ET ESTRA/ETHIN ESTRA AZURETTE 3 1 DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN 3 1 DESOGESTREL-ETHINYL ESTRADIOL APRI 3 1 DESOGESTREL-ETHINYL ESTRADIOL VELIVET 1 DESOGESTREL-ETHINYL ESTRADIOL CAZIANT 3 1 DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA LEVONORG-ETH ESTRAD ETH ESTRAD 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE 3 1 LEVONORGESTREL NEXT CHOICE 3 1 LEVONORGESTREL-ETH ESTRADIOL LESSINA 3 1 LEVONORGESTREL-ETH ESTRADIOL AVIANE 3 1 LEVONORGESTREL-ETH ESTRADIOL MYZILRA 3 1 LEVONORGESTREL-ETH ESTRADIOL AMETHYST 3 1 LEVONORGESTREL-ETH ESTRADIOL ENPRESSE 3 1 LEVONORGESTREL-ETH ESTRADIOL ALTAVERA 1 LEVONORGESTREL-ETH ESTRADIOL JOLESSA 3 1 LEVONORGESTREL-ETH ESTRADIOL TRIVORA-28 3 1 LEVONORGESTREL-ETH ESTRADIOL SRONYX 3 1 LEVONORGESTREL-ETH ESTRADIOL QUASENSE 3 1 LEVONORGESTREL-ETH ESTRADIOL PORTIA 3 1 LEVONORGESTREL-ETH ESTRADIOL LUTERA 3 1 LEVONORGESTREL-ETH ESTRADIOL ORSYTHIA 3 1 LEVONORGESTREL-ETH ESTRADIOL INTROVALE 3 1 LEVONORGESTREL-ETH ESTRADIOL LEVORA-28 3 1 NORELGESTROMIN/ETHIN.ESTRADIOL NORELGESTROMIN/ETH ESTRADIOL 3 1 NORETH A-ET ESTRA/FE FUMARATE JUNEL FE 3 1 NORETH A-ET ESTRA/FE FUMARATE GILDESS FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TILIA FE 3 1 NORETH A-ET ESTRA/FE FUMARATE MICROGESTIN FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TRI-LEGEST FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZENCHENT FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZEOSA 3 1 NORETHINDRONE CAMILA 1 NORETHINDRONE HEATHER 1 NORETHINDRONE JOLIVETTE 3 1 NORETHINDRONE NORA-BE 3 1 NORETHINDRONE 1 NORETHINDRONE ERRIN 1 NORETHINDRONE A-E ESTRADIOL MICROGESTIN 3 1 NORETHINDRONE A-E ESTRADIOL GILDESS 3 1 NORETHINDRONE A-E ESTRADIOL JUNEL 3 1 NORETHINDRONE-ETHINYL ESTRAD BRIELLYN 3 1 NORETHINDRONE-ETHINYL ESTRAD ARANELLE 3 1 NORETHINDRONE-ETHINYL ESTRAD LEENA 3 1 NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM 3 1 NORETHINDRONE-ETHINYL ESTRAD ZENCHENT 3

3 - No copay

32 of 104 Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes 1 NORETHINDRONE-ETHINYL ESTRAD NECON 3 1 NORETHINDRONE-ETHINYL ESTRAD NORTREL 3 1 NORETHINDRONE-ETHINYL ESTRAD ALYACEN 1 NORETHINDRONE-ETHINYL ESTRAD DASETTA 3 1 NORETHINDRONE-ETHINYL ESTRAD BALZIVA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL 3 1 NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 3 1 NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL 3 1 NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINY ESTRA 3 1 NORGESTREL-ETHINYL ESTRADIOL CRYSELLE 3 1 NORGESTREL-ETHINYL ESTRADIOL ELINEST 3 1 NORGESTREL-ETHINYL ESTRADIOL OGESTREL 3 2 DESOGESTREL-ETHINYL ESTRADIOL ORTHO-CEPT 2 ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 2 NORETH A-ET ESTRA/FE FUMARATE LO LOESTRIN FE 2 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN 24 FE 2 NORETH-ETHINYL ESTRADIOL/IRON GENERESS FE 2 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO 3 DESOG-ET ESTRA/ETHIN ESTRA MIRCETTE 3 DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA BEYAZ 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL 3 ESTRADIOL VALERATE/DIENOGEST NATAZIA 3 ETHINYL ESTRADIOL/DROSPIRENONE YAZ 3 ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28 3 L-NORGEST-ETH ESTR/ETHIN ESTRA SEASONIQUE 3 LEVONORGESTREL-ETH ESTRADIOL SEASONALE 3 LEVONORGESTREL-ETH ESTRADIOL LYBREL 3 LEVONORGESTREL-ETH ESTRADIOL NORDETTE-28 3 NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA 3 NORETH A-ET ESTRA/FE FUMARATE ESTROSTEP FE 3 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN FE 3 NORETH-ETHINYL ESTRADIOL/IRON FEMCON FE 3 NORETHINDRONE MICRONOR 3 NORETHINDRONE A-E ESTRADIOL LOESTRIN 3 NORETHINDRONE-ETHINYL ESTRAD OVCON-35 3 NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM 3 NORETHINDRONE-ETHINYL ESTRAD BREVICON 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 3 NORGESTREL-ETHINYL ESTRADIOL LO-OVRAL-28 3 ULIPRISTAL ACETATE ELLA 4 LEVONORGESTREL-RELEASING INTRAUTERINE KYLEENA 4 SYSTEM

Contraceptives (E.G. Foams- Devices) / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 DIAPHRAGMS, ARC-SPRING ORTHO ALL-FLEX

3 - No copay 4 - Office/Clinic Administration

33 of 104 Corticosteroids / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 DEFLAZACORT EMFLAZA 5 4 CORTICOTROPIN ACTHAR H.P. 5

Corticosteroids (Eent) / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 FLUOCINOLONE ACETONIDE OIL DERMOTIC

Corticosteroids (Eent) / GI AGENTS Tier Generic Name Brand Name Notes 3 BUDESONIDE UCERIS 5

Corticosteroids (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 FLUOROMETHOLONE 1 PREDNISOLONE ACETATE 1 PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE 2 FLUOROMETHOLONE FML FORTE 2 FLUOROMETHOLONE FML S.O.P. 2 PREDNISOLONE ACETATE PRED MILD 3 DIFLUPREDNATE DUREZOL 3 FLUOROMETHOLONE ACETATE FLAREX 3 LOTEPREDNOL ETABONATE ALREX 3 LOTEPREDNOL ETABONATE LOTEMAX 3 PREDNISOLONE ACETATE PRED FORTE 3 RIMEXOLONE VEXOL

Corticosteroids (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 2 BECLOMETHASONE DIPROPIONATE BECONASE AQ 3 BECLOMETHASONE DIPROPIONATE QNASL 3 BUDESONIDE RHINOCORT AQUA 3 CICLESONIDE OMNARIS 3 CICLESONIDE ZETONNA 3 FLUTICASONE FUROATE VERAMYST 3 FLUTICASONE PROPIONATE FLONASE 3 MOMETASONE FUROATE NASONEX 3 TRIAMCINOLONE ACETONIDE NASACORT AQ

Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 BUDESONIDE 2 BECLOMETHASONE DIPROPIONATE QVAR 2 BUDESONIDE PULMICORT FLEXHALER 2 BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2 FLUTICASONE FUROATE ARNUITY ELLIPTA 2 FLUTICASONE PROPIONATE FLOVENT HFA 2 FLUTICASONE PROPIONATE FLOVENT DISKUS

5 - Prior Authorization

34 of 104 Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS (cont.) Tier Generic Name Brand Name Notes 2 FLUTICASONE/SALMETEROL ADVAIR HFA 6 2 FLUTICASONE/VILANTEROL BREO ELLIPTA 2 MOMETASONE FUROATE ASMANEX 3 BUDESONIDE PULMICORT 3 CICLESONIDE ALVESCO 3 MOMETASONE/FORMOTEROL DULERA

Cystine depleting agent / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 CYSTEAMINE PROCYSBI 5

Cystine depleting agent / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 CYSTEAMINE CYSTARAN 5

Devices / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 NEEDLES, INSULIN DISPOSABLE NOVOTWIST 2 SYR W-NDL,INS 0.3 ML HALF MARK INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.3ML ULTICARE 2 SYRING W-NDL,DISP,INSUL,0.3ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML ULTRA COMFORT 2 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE 3 INSULIN ADMIN. SUPPLIES HUMAPEN LUXURA HD 3 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE

Devices / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 SALIVA SUBSTITUTION COMBO NO.2 CAPHOSOL

Devices / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 GLY/CARB HOMOPOLY A/POT HYDROX MUGARD

Devices / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 2 INHALER, ASSIST DEVICES BREATHERITE 2 INHALER, ASSIST DEVICES OPTICHAMBER 2 INHALER, ASSIST DEVICES OPTIHALER 2 INHALER, ASSIST DEVICES EASIVENT 2 INHALER, ASSIST DEVICES MICROCHAMBER 2 INHALER, ASSIST DEVICES VORTEX 2 INHALER, ASSIST DEVICES E-Z SPACER 2 INHALER, ASSIST DEVICES PROCHAMBER 2 INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER DIAMOND

5 - Prior Authorization 6 - Quantity Limit

35 of 104 Devices / ENDOCRINE/DIABETES (cont.) Tier Generic Name Brand Name Notes 2 NEEDLES, INSULIN DISPOSABLE PEN NEEDLE 2 SYRING W-NDL,DISP,INSUL,0.3ML SURE COMFORT 2 SYRING W-NDL,DISP,INSUL,0.5ML EASY TOUCH 2 SYRINGE & NEEDLE,INSULIN,1 ML PRECISION 2 SYRINGE & NEEDLE,INSULIN,1 ML MONOJECT INSULIN SYRINGE 3 BISMUTH TRIBROMOPH/PETROLATUM XEROFORM PETROLATUM DRESSING 3 NEEDLES, DISPOSABLE SPECIALTY USE NEEDLES 3 NEEDLES, DISPOSABLE REGULAR BEVEL NEEDLES 3 NEEDLES, DISPOSABLE NEEDLE 3 NEEDLES, DISPOSABLE NEEDLES

Devices / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER MAX 2 INHALER, ASSIST DEVICES AEROCHAMBER 2 INHALER, ASSIST DEVICES AEROCHAMBER MV 2 INHALER, ASSIST DEVICES AEROCHAMBER PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER WITH FLOWSIGNAL

Digestants / GI AGENTS Tier Generic Name Brand Name Notes 1 LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 2 LIPASE/PROTEASE/AMYLASE ZENPEP 2 LIPASE/PROTEASE/AMYLASE CREON 5 2 LIPASE/PROTEASE/AMYLASE PANCREAZE

Dihydropyridines / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE BESYLATE 1 AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE-BENAZEPRIL 1 FELODIPINE FELODIPINE ER 1 NIFEDIPINE NIFEDIPINE ER 1 NIFEDIPINE AFEDITAB CR 1 NIFEDIPINE NIFEDIAC CC 1 NIFEDIPINE NIFEDICAL XL 1 NIFEDIPINE 1 NISOLDIPINE 3 AMLODIPINE BES/OLMESARTAN MED AZOR 7 3 AMLODIPINE BESYLATE NORVASC 3 AMLODIPINE BESYLATE/BENAZEPRIL LOTREL 3 NICARDIPINE HCL CARDENE SR 3 NIFEDIPINE ADALAT CC 3 NISOLDIPINE SULAR

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 SAXAGLIPTIN HCL ONGLYZA

5 - Prior Authorization 7 - Step Therapy

36 of 104 Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS (cont.) Tier Generic Name Brand Name Notes 2 SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR 2 SITAGLIPTIN PHOSPHATE JANUVIA 3 ALOGLIPTIN NESINA 3 LINAGLIPTIN TRADJENTA 3 LINAGLIPTIN/METFORMIN HCL JENTADUETO

Direct Vasodilators / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 HYDRALAZINE HCL 1 MINOXIDIL

Direct-Acting Skeletal Muscle Relaxants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 DANTROLENE SODIUM

Disease-Modifying Antirheumatic Agents / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 LEFLUNOMIDE 3 ANAKINRA KINERET 3 LEFLUNOMIDE ARAVA 4 ABATACEPT ORENCIA 5 4 ADALIMUMAB HUMIRA 5 4 ADALIMUMAB HUMIRA PEDIATRIC CROHNS 5 4 ETANERCEPT ENBREL 5 4 GOLIMUMAB SIMPONI 5

Disease-Modifying Antirheumatic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 INFLIXIMAB FOR INJECTION REMICADE 4

Dopamine Agonists / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 AMANTADINE HCL AMANTADINE 1 BROMOCRIPTINE MESYLATE 1 PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1 ROPINIROLE HCL 3 AMANTADINE HCL SYMMETREL 3 BROMOCRIPTINE MESYLATE CYCLOSET 3 PRAMIPEXOLE DI-HCL MIRAPEX ER 3 PRAMIPEXOLE DI-HCL MIRAPEX 3 ROPINIROLE HCL REQUIP 3 ROPINIROLE HCL REQUIP XL 3 ROTIGOTINE NEUPRO

Dopamine Antagonist / ANTIEMETICS Tier Generic Name Brand Name Notes 1 PROCLORPERAZINE

4 - Office/Clinic Administration 5 - Prior Authorization

37 of 104 Dopamine Antagonist / ANTIEMETICS (cont.) Tier Generic Name Brand Name Notes 1 PROMETHAZINE HCL PROMETHEGAN 4 DROPERIDOL INAPSINE 4

Dopamine Precursors/AA Decarbox Inhibitor / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 3 CARBIDOPA/LEVODOPA RYTARY 3 CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 4 CARBIDOPA/LEVODOPA DUOPA 1

Dopamine Receptor Agonists / EMETOGENIC THERAPY Tier Generic Name Brand Name Notes 4 APOMORPHINE APOKYN 4

Dopamine Receptor Agonists / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CABERGOLINE

Dopamine Reuptake Blocker / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD

Dyslipidemics, Other / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 EZETIMIBE 1 EZETIMIBE/SIMVASTATIN 2 NIACIN NIASPAN 2 NIACIN/LOVASTATIN ADVICOR 2 NIACIN/SIMVASTATIN SIMCOR 3 EZETIMIBE ZETIA 3 EZETIMIBE/SIMVASTATIN VYTORIN 3 NIACIN NIACOR 3 OMEGA-3 ACID ETHYL ESTERS LOVAZA

Eent Anti-Infectives- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 1 CHLORHEXIDINE GLUCONATE

Eent Anti-Inflammatory Agents- Misc. / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 CYCLOSPORINE RESTASIS 3 LIFITEGRAST OPTH SOLUTION XIIDRA 5

1 - Home Health 4 - Office/Clinic Administration 5 - Prior Authorization

38 of 104 Eent Drugs- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes 3 AMLEXANOX APHTHASOL

Eent Drugs- Miscellaneous / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 3 EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 3 HYDROXYPROPYL CELLULOSE LACRISERT

Eent Nonsteroidal Anti-Inflam. Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 BROMFENAC SODIUM 2 BROMFENAC SODIUM BROMDAY 2 KETOROLAC TROMETHAMINE/PF ACUVAIL 2 NEPAFENAC NEVANAC 3 BROMFENAC SODIUM XIBROM 3 KETOROLAC TROMETHAMINE ACULAR LS 3 KETOROLAC TROMETHAMINE ACULAR

Emollients / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 EMOLLIENT COMBINATION NO.53 HPR PLUS 3 EMOLLIENT COMBINATION NO.10 BIAFINE 3 EMOLLIENT COMBINATION NO.32 EPICERAM 3 EMOLLIENT COMBINATION NO.35 MIMYX 3 EMOLLIENT COMBINATION NO.43 PROMISEB 3 EMOLLIENT COMBINATION NO.44 HYLATOPIC 3 EMOLLIENT COMBINATION NO.53 HYLATOPIC PLUS 3 EMOLLIENT COMBINATION NO.60 ATRAPRO HYDROGEL 3 VITE AC/GRAPE/HYALURONIC ACID ATOPICLAIR

Endothelin Receptor Antagonist / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 RAMUCIRUMAB CYRAMZA 4

Endothelin Receptor Antagonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 MACITENTAN OPSUMIT 5

Enzyme Replacement / ENZYME REPLACEMENT Tier Generic Name Brand Name Notes 3 ELIGLUSTAT CERDELGA 5 4 AGALSIDASE BETA FABRAZYME 4

Enzyme Replacement / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ELOSULFASE ALFA VIMIZIM 4

4 - Office/Clinic Administration 5 - Prior Authorization

39 of 104 Enzymes / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 DORNASE ALFA PULMOZYME 5

Ergot Alkaloids / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 DIHYDROERGOTAMINE MESYLATE 2 ERGOTAMINE TARTRATE ERGOMAR 2 ERGOTAMINE TARTRATE/CAFFEINE CAFERGOT

Estrogen Agonist-Antagonists / HORMONE: ER RECEPTOR MODIFIER Tier Generic Name Brand Name Notes 1 RALOXIFENE 3 ESTROGEN/BAZEDOXIFENE DUAVEE 3 OSPEMIFENE OSPHENA 3 RALOXIFENE EVISTA 4 CLOMIPHENE CITRATE 2

Estrogens / HORMONE: ESTROGENS Tier Generic Name Brand Name Notes 1 ESTRADIOL 1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE ACETAT 1 ESTROPIPATE 2 ESTRADIOL ALORA 2 ESTRADIOL ESTRACE 0.01% CREAM 2 ESTRADIOL MICRONIZED ESTRADIOL 3 ESTRADIOL DIVIGEL 3 ESTRADIOL EVAMIST 3 ESTRADIOL ESTROGEL 3 ESTRADIOL ELESTRIN 3 ESTRADIOL ESTRING 3 ESTRADIOL CLIMARA 3 ESTRADIOL ESTRACE TABLETS 3 ESTRADIOL ACETATE FEMRING 3 ESTRADIOL/NORETHINDRONE ACET ACTIVELLA 3 ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 3 ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA 3 NORETHIND AC/ETHINYL ESTRADIOL FEMHRT

Estrogens / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 ESTRADIOL/NORETHINDRONE ACET MIMVEY 1 NORETHIND AC/ETHINYL ESTRADIOL JINTELI 1 NORETHIND AC/ETHINYL ESTRADIOL JEVANTIQUE 2 ESTRADIOL VAGIFEM 2 ESTRADIOL/LEVONORGESTREL CLIMARA PRO 2 ESTRADIOL/NORGESTIMATE PREFEST 2 ESTROGEN,CON/M-PROGEST ACET PREMPRO 2 ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2 ESTROGENS, CONJUGATED PREMARIN

2 - Infertility 5 - Prior Authorization

40 of 104 Estrogens / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes 3 DROSPIRENONE/ESTRADIOL ANGELIQ 3 ESTRADIOL MENOSTAR 3 ESTRADIOL VIVELLE-DOT 3 ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 3 ESTROGENS,ESTERIFIED MENEST 4 ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5

Ethanolamine Derivatives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 DIPHENHYDRAMINE HCL

Farnesoid X Receptor Agonists / GI AGENTS Tier Generic Name Brand Name Notes 3 OBETICHOLIC ACID TABLETS OCALIVA 5

Fibric Acid Derivatives / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 1 FENOFIBRIC ACID (CHOLINE) FENOFIBRIC ACID 1 GEMFIBROZIL 3 FENOFIBRATE FENOGLIDE 3 FENOFIBRATE LIPOFEN 3 FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 3 FENOFIBRATE NANOCRYSTALLIZED TRICOR 3 FENOFIBRATE,MICRONIZED ANTARA 3 FENOFIBRIC ACID (CHOLINE) TRILIPIX

Fibromyalgia Agents / CNS AGENTS Tier Generic Name Brand Name Notes 1 GABAPENTIN 3 MILNACIPRAN HCL SAVELLA 3 PREGABALIN LYRICA

First Gen. Antihist. Derivatives- Misc. / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 CYPROHEPTADINE HCL

Folic Acid Reductase Inhibitor / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 METHOTREXATE OTREXUP 5

GABA Augmenting Agents / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 GABAPENTIN ENACARBIL HORIZANT

GABA Augmenting Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 DIVALPROEX SODIUM

5 - Prior Authorization

41 of 104 GABA Augmenting Agents / ANTICONVULSANTS (cont.) Tier Generic Name Brand Name Notes 1 DIVALPROEX SODIUM DIVALPROEX SODIUM ER 1 VALPROATE SODIUM VALPROIC ACID 3 DIVALPROEX SODIUM DEPAKOTE 3 DIVALPROEX SODIUM DEPAKOTE ER 3 DIVALPROEX SODIUM DEPAKOTE SPRINKLE 3 GABAPENTIN GRALISE 3 TIAGABINE GABITRIL 3 VIGABATRIN SABRIL 5

GLP-2 analog / GI AGENTS Tier Generic Name Brand Name Notes 4 TEDUGLUTIDE GATTEX 5

Gaba-Derivative Skeletal Muscle Relaxant / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 BACLOFEN

Genitourinary Smooth Muscle Relaxants / UROLOGICALS Tier Generic Name Brand Name Notes 1 FLAVOXATE HCL 1 OXYBUTYNIN CHLORIDE 1 OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER 1 TOLTERODINE TARTRATE 3 DARIFENACIN HYDROBROMIDE ENABLEX 3 FESOTERODINE FUMARATE TOVIAZ 3 MIRABEGRON MYRBETRIQ 3 OXYBUTYNIN GELNIQUE 3 SOLIFENACIN SUCCINATE VESICARE 3 TOLTERODINE TARTRATE DETROL LA 3 TOLTERODINE TARTRATE DETROL 3 TROSPIUM CHLORIDE SANCTURA XR

Gi Drugs- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes 3 CERTOLIZUMAB PEGOL CIMZIA 5 3 ELUXADOLINE TABLETS VIBERZI 3 LINACLOTIDE LINZESS 3 PLECANATIDE TABLETS TRULANCE 5

Glutamate Reducing Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 GABAPENTIN 3 GABAPENTIN NEURONTIN

Glycogenolytic Agents / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 3 GLUCAGON,HUMAN RECOMBINANT GLUCAGON EMERGENCY KIT 3 GLUCAGON,HUMAN RECOMBINANT GLUCAGEN

5 - Prior Authorization

42 of 104 Gonadotropin-Releasing Hormone Antagnts / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CETRORELIX ACETATE CETROTIDE 2 4 GANIRELIX ACETATE 2

Gonadotropins / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 4 CHORIONIC GONADOTROPIN, HUMAN CHORIONIC GONADOTROPIN 2 4 CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F RFF 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F 2 4 FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 2 4 HCG ALPHA,RECOMBINANT OVIDREL 2 4 MENOTROPINS MENOPUR 2 4 UROFOLLITROPIN BRAVELLE 2

Gonadotropins / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 4 CHORIONIC GONADOTROPIN NOVAREL 2

Growth Hormone Releasing Factor / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 4 TESAMORELIN EGRIFTA 5

HER2 Targeted Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 ADO-TRASTUZUMAB KADCYLA 5 4 TRASTUZUMAB HERCEPTIN 5

HYPOPHOSPHATASIA / ENDOCRINE Tier Generic Name Brand Name Notes 4 ASFOTASE ALFA INJECTION STRENSIQ 5

Hematopoietic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 TBO-FILGRASTIM GRANIX 5

Hematopoietic Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 ELTROMBOPAG OLAMINE PROMACTA 5 4 ROMIPLOSTIM NPLATE 5

Hematopoietic Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 EPOETIN ALFA PROCRIT 5 4 PEGFILGRASTIM NEULASTA 5

2 - Infertility 5 - Prior Authorization

43 of 104 Hematopoietic Agents / IMMUNOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 4 PLERIXAFOR MOZOBIL 5

Hematopoietic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 EPOETIN ALFA EPOGEN 4 4 FILGRASTIM NEUPOGEN 4

Hemorrheologic Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 PENTOXIFYLLINE

Hemostatic / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 COAGULATION FACTOR IX ALPROLIX 4 4 COAGULATION FACTOR IX RIXUBIS 4 4 COAGULATION FACTOR XIII TRETTEN 4

Hemostatics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 AMINOCAPROIC ACID 4 ANTIHEMOPH.FVIII PLAS/ALB FREE ADVATE 5

Hemostatics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 TRANEXAMIC ACID 3 TRANEXAMIC ACID LYSTEDA

Hereditary Tyrosinemia / ENDOCRINE Tier Generic Name Brand Name Notes 3 NITISINONE ORFADIN 5

Heterocyclic Antidepressants / ANTIDEPRESSANTS, OTHER Tier Generic Name Brand Name Notes 1 AMOXAPINE 1 MAPROTILINE HCL 1 MIRTAZAPINE

Histamine H2-Antagonists / GI AGENTS Tier Generic Name Brand Name Notes 1 CIMETIDINE 1 FAMOTIDINE 1 NIZATIDINE 1 RANITIDINE HCL 3 FAMOTIDINE PEPCID

4 - Office/Clinic Administration 5 - Prior Authorization

44 of 104 Histamine H2-Antagonists / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 3 RANITIDINE HCL ZANTAC 25

Histone inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 PANOBINOSTAT FARYDAK 5 3 VORINOSTAT ZOLINZA 5

Histone inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 BELINOSTAT BELEODAQ 4

Hmg-Coa Reductase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMLODIPINE/ATORVASTATIN AMLODIPINE-ATORVASTATIN 1 ATORVASTATIN CALCIUM 1 FLUVASTATIN SODIUM 1 LOVASTATIN 1 PRAVASTATIN SODIUM 1 SIMVASTATIN 3 ATORVASTATIN CALCIUM LIPITOR 3 FLUVASTATIN SODIUM LESCOL XL 3 FLUVASTATIN SODIUM LESCOL 3 LOVASTATIN ALTOPREV 3 PITAVASTATIN CALCIUM LIVALO 3 PRAVASTATIN SODIUM PRAVACHOL 3 ROSUVASTATIN CALCIUM CRESTOR 3 SIMVASTATIN ZOCOR

Human Leptin / GENETIC DISORDERS Tier Generic Name Brand Name Notes 4 METRELEPTN MYALEPT 5

INTERLEUKIN-17A RECEPTOR ANTAGONIST / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 IXEKIZUMAB FOR SUBCUTANEOUS INJ TALTZ 5

Immunomodulator / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 APREMILAST OTEZLA 5 3 LENALIDOMIDE REVLIMID 5 3 POMALIDOMIDE POMALYST 5 3 THALIDOMIDE THALOMID 5 3 TOFACITINIB XELJANZ 5 4 INTERFERON ALFACON 1 INFERGEN 5

Immunosuppressive Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 AZATHIOPRINE

4 - Office/Clinic Administration 5 - Prior Authorization

45 of 104 Immunosuppressive Agents / IMMUNOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 1 CYCLOSPORINE 1 CYCLOSPORINE, MODIFIED GENGRAF 1 CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 1 MYCOPHENOLATE MOFETIL 1 TACROLIMUS 2 CYCLOSPORINE SANDIMMUNE 2 CYCLOSPORINE, MODIFIED NEORAL 2 MYCOPHENOLATE SODIUM MYFORTIC 2 SIROLIMUS RAPAMUNE 3 MYCOPHENOLATE MOFETIL CELLCEPT 3 TACROLIMUS PROGRAF 4 TOCILIZUMAB ACTEMRA SQ 5 4 TOCILIZUMAB ACTEMRA 5

Incretin Mimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 EXENATIDE BYETTA 5 2 EXENATIDE EXTENDED RELEASE BYDUREON BCISE 5 2 EXENATIDE MICROSPHERES BYDUREON 5 2 LIRAGLUTIDE VICTOZA 2-PAK 5 2 LIRAGLUTIDE VICTOZA 3-PAK 5 3 ALBIGLUTIDE TANZEUM 5 3 DULAGLUTIDE TRULICITY 5 3 LIXISENATIDE INJECTION ADLYXIN 5

Incretin Mimetics / OBESITY Tier Generic Name Brand Name Notes 4 LIRAGLUTIDE SAXENDA 5

Inhibit DNA polymerases / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 1 TEMOZOLOMIDE

Inhibit DNA polymerases / ANTIVIRALS Tier Generic Name Brand Name Notes 3 GANCICLOVIR CYTOVENE 5

Inhibit Protein Synthesis / ANTIFUNGALS Tier Generic Name Brand Name Notes 3 TAVABOROLE KERYDIN 5

Inhibit Protein Synthesis / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 OMACETAXINE SYNRIBO 5

Inhibit Protein Synthesis / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 MIGLUSTAT ZAVESCA 5

5 - Prior Authorization

46 of 104 Insulins / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 HUM INSULIN NPH/REG INSULIN HM HUMULIN 70-30 2 HUM INSULIN NPH/REG INSULIN HM NOVOLIN 70-30 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2 INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO 2 INSULIN LISPRO HUMALOG 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25 2 INSULIN REGULAR, HUMAN HUMULIN R 2 INSULIN REGULAR, HUMAN NOVOLIN R 2 NPH, HUMAN INSULIN ISOPHANE HUMULIN N 2 NPH, HUMAN INSULIN ISOPHANE NOVOLIN N 3 INSULIN ASPART NOVOLOG 7 3 INSULIN ASPART NOVOLOG FLEXPEN 7 3 INSULIN DEGLUDEC INJECTION TRESIBA 7 3 INSULIN DETEMIR LEVEMIR FLEXTOUCH 7 3 INSULIN DETEMIR LEVEMIR 7 3 INSULIN GLARGINE,HUM.REC.ANLOG Basaglar KwikPen 7 3 INSULIN GLULISINE APIDRA SOLOSTAR 3 INSULIN GLULISINE APIDRA 3 INSULIN INHALED AFREZZA 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 7 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 7

Integrase Strand Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes 2 ELVITEGRAVIR VITEKTA

Interferons / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 INTERFERON ALFA-2B,RECOMB. INTRON A 5 4 INTERFERON ALFA-2B,RECOMB. PEG-INTRON 5 4 INTERFERON ALFA-2B,RECOMB. SYLATRON 5

Interleukin / CARDIOVASCULAR Tier Generic Name Brand Name Notes 4 OPRELVEKIN NEUMEGA 5

Interleukin / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 SECUKINUMAB COSENTYX 5

Interleukin / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 SILTUXIMAB SYLVANT 4

4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step Therapy

47 of 104 Intravitreal injection / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 4 OCRIPLASMIN JETREA 5

Keratolytic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 BENZOYL PEROXIDE LAVOCLEN-4 1 BENZOYL PEROXIDE BENZEPRO 1 BENZOYL PEROXIDE 1 BENZOYL PEROXIDE BP WASH 1 BENZOYL PEROXIDE BPO 1 BENZOYL PEROXIDE BP WASH ACNE TREATMENT 1 SALICYLIC ACID 1 SULFACET SOD/SULFUR/WITCH HAZ SE 10-5 SS 1 SULFACETAMIDE SODIUM/SULFUR ZENCIA 1 SULFACETAMIDE SODIUM/SULFUR SULFACETAMIDE SODIUM-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR PRASCION 1 SULFACETAMIDE SODIUM/SULFUR PRASCION FC 1 SULFACETAMIDE SODIUM/SULFUR BP 10-1 1 UREA 2 BENZOYL PEROXIDE BENZEFOAM ULTRA 2 BENZOYL PEROXIDE BENZAC AC 2 SULFACETAMIDE SODIUM/SULFUR CLARIFOAM EF 3 SALICYLIC ACID KERALYT 3 SALICYLIC ACID/CERAMIDE CMB #1 SALEX 3 SULFACETAMIDE SODIUM/SULFUR CLENIA

Keratoplastic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ANTHRALIN DRITHOCREME HP 3 COAL TAR

Kinase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 CERITINIB ZYKADIA 5 3 IDELALISIB ZYDELIG 5 3 LENVATINIB LENVIMA 5 3 RIBOCICLIB TABLETS KISQALI 5 3 RUXOLITINIB JAKAFI 5 3 TRAMETINIB MEKINIST 5

LIPOSOMAL ACID LIPASE DEFICIENCY / ENDOCRINE Tier Generic Name Brand Name Notes 4 SEBELIPASE ALFA INJECTION KANUMA 4

Laxatives / GI AGENTS Tier Generic Name Brand Name Notes 1 PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE

4 - Office/Clinic Administration 5 - Prior Authorization

48 of 104 Laxatives / GI AGENTS (cont.) Tier Generic Name Brand Name Notes 1 PEG 3350/NA SULF,BICARB,CL/KCL PEG-3350 AND ELECTROLYTES 1 PEG 3350/NA SULF,BICARB,CL/KCL GAVILYTE 1 POLYETHYLENE GLYCOL 3350 2 NAPHOS M-B M-H/NA PHOS,DI-BA OSMOPREP 2 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY PACKETS 3 BISAC/NACL/NAHCO3/KCL/PEG 3350 HALFLYTELY-BISACODYL 3 LUBIPROSTONE AMITIZA 3 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY 3 PEG 3350/NA SULF,BICARB,CL/KCL COLYTE WITH FLAVOR PACKETS 3 PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP 3 SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 3 SODIUM,POTASSIUM,&MAG SULFATES SUPREP

Leprosy / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes 2 DAPSONE 3 CLOFAZIMINE LAMPRENE

Leukotriene Modifiers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 MONTELUKAST SODIUM 1 ZAFIRLUKAST 3 MONTELUKAST SODIUM SINGULAIR 3 ZAFIRLUKAST ACCOLATE 3 ZILEUTON ZYFLO CR 5

Local Anesthetics / ANESTHETICS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE AC/LIDOCAINE LIDOCAINE-HYDROCORTISONE 1 LIDOCAINE HCL 1 LIDOCAINE HCL LIDOCAINE HCL VISCOUS 1 LIDOCAINE/PRILOCAINE LIDOCAINE-PRILOCAINE 3 LIDOCAINE LIDODERM

Local Anesthetics (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes 1 ANTIPYRINE/BENZOCAINE/GLYCERIN AURODEX 1 ANTIPYRINE/BENZOCAINE/GLYCERIN ANTIPYRINE-BENZOCAINE 3 ANTIPY/BENZOCAINE/POLICOS NO.1 OTIC CARE 3 ANTIPYRINE/BENZOCAINE AURAX

Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL 1 SELENIUM SULFIDE 1 SILVER SULFADIAZINE SSD 1 SILVER SULFADIAZINE THERMAZENE 1 SILVER SULFADIAZINE 1 SULFACETAMIDE SOD/SULFUR/UREA CLEANSING WASH

5 - Prior Authorization

49 of 104 Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 1 SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SODIUM SEB-PREV 1 SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE 1 SULFACETM NA/AVOBENZONE/SULFUR PRASCION RA 2 SELENIUM SULFIDE TERSI FOAM 3 HEXACHLOROPHENE PHISOHEX 3 SILVER SULFADIAZINE SILVADENE

Loop Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 BUMETANIDE 1 FUROSEMIDE 1 TORSEMIDE 2 ETHACRYNIC ACID EDECRIN 3 FUROSEMIDE LASIX

MAO Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 PHENELZINE SULFATE 1 TRANYLCYPROMINE SULFATE

MEK Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 COBIMETINIB TABLETS COTELLIC 5

MIXED 5HT1A AGONIST HT2A ANTAGONIST / CNS AGENTS Tier Generic Name Brand Name Notes 4 FLIBANSERIN ADDYI 5

MS / CNS AGENTS Tier Generic Name Brand Name Notes 2 GLATIRAMER ACETATE GLATOPA 5 3 DALFAMPRIDINE AMPYRA 5 3 DIMETHYL FUMARATE TECFIDERA 5 3 TERIFLUNOMIDE AUBAGIO 5 4 GLATIRAMER ACETATE COPAXONE 5 4 INTERFERON BETA-1A AVONEX 5 4 INTERFERON BETA-1A AVONEX PEN 5 4 INTERFERON BETA-1A/ALBUMIN REBIF 5 4 INTERFERON BETA-1A/ALBUMIN AVONEX ADMINISTRATION PACK 5 4 INTERFERON BETA-1B BETASERON 5

Macrolides / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 AZITHROMYCIN 1 CLARITHROMYCIN CLARITHROMYCIN ER 1 CLARITHROMYCIN 1 ERYTHROMYCIN BASE ERYTHROMYCIN

5 - Prior Authorization

50 of 104 Macrolides / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes 1 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400 1 ERYTHROMYCIN ETHYLSUCCINATE 1 ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 2 ERYTHROMYCIN BASE ERY-TAB 2 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 3 AZITHROMYCIN ZITHROMAX 3 AZITHROMYCIN ZMAX

Mast-Cell Stabilizers / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 CROMOLYN SODIUM 3 NEDOCROMIL SODIUM ALOCRIL

Mast-Cell Stabilizers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 CROMOLYN SODIUM

Meglitinides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 NATEGLINIDE 3 NATEGLINIDE STARLIX

Meglitinides / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 REPAGLINIDE 3 REPAGLINIDE PRANDIN

Melatonin Receptor Agonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 TASIMELTEON HETLIOZ 5

Miotics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 PILOCARPINE HCL

Miscellaneous Anti-Infectives (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID

Miscellaneous Anti-Infectives (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes 1 ACETIC ACID 1 ACETIC ACID/HYDROCORTISONE ACETASOL HC

Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM

5 - Prior Authorization

51 of 104 Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES (cont.) Tier Generic Name Brand Name Notes 3 METRONIDAZOLE FLAGYL ER 3 METRONIDAZOLE FLAGYL

Miscellaneous B-Lactam Antibiotics / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 3 AZTREONAM LYSINE CAYSTON

Miscellaneous Gi Drugs / GI AGENTS Tier Generic Name Brand Name Notes 3 ALOSETRON HCL LOTRONEX 4 OCTREOTIDE ACETATE SANDOSTATIN 5

Monoamine Oxidase B Inhibitors / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes 1 SELEGILINE HCL 3 SELEGILINE EMSAM

Monoamine Oxidase B Inhibitors / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 RASAGILINE MESYLATE AZILECT

Monoamine Transporter Inhibitor / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 TETRABENAZINE XENAZINE 5

Monoclonal Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 ATEZOLIZUMAB FOR INJECTION TECENTRIQ 4 4 AVELUMAB INJECTION BAVENCIO 4 4 BRENTUXIMAB ADCETRIS 4 4 CANAKINUMAB ILARIS 5 4 DARATUMUMAB INJECTION DARZALEX 4 4 DENOSUMAB XGEVA 5 4 ELOTUZUMAB INJECTION EMPLICITI 4 4 NECITUMUMAB FOR INJECTION PORTRAZZA 4 4 OLARATUMAB INJECTION LARTRUVO 4 4 PEMBROLIZUMAB KEYTRUDA 4

Monoclonal Antibody / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 DUPILUMAB SUBCUTANEOUS INJECTION DUPIXENT 5

Monoclonal Antibody / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 DENOSUMAB PROLIA 4

4 - Office/Clinic Administration 5 - Prior Authorization

52 of 104 Monoclonal Antibody / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 3 RESLIZUMAB INJECTION CINQAIR 4 4 MEPOLIZUMAB INJECTION NUCALA 4 4 OMALIZUMAB XOLAIR 4 4 RITUXIMAB RITUXAN 4 4 SYNAGIS PALIVIZUMAB 4

Mood Stabilizers / BIPOLAR AGENTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE 1 LAMOTRIGINE 1 LITHIUM CARBONATE 1 LITHIUM CITRATE LITHIUM 1 VALPROATE SODIUM VALPROIC ACID 3 LITHIUM CARBONATE LITHOBID

Mucolytic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 ACETYLCYSTEINE

Multiple Sclerosis / CNS AGENTS Tier Generic Name Brand Name Notes 3 FINGOLIMOD HCL GILENYA 5 4 PEGINTERFERON ALFA-1A PLEGRIDY 5

Multiple Sclerosis / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ALEMTUZUMAB LEMTRADA 4 4 NATALIZUMAB TYSABRI 4 4 OCRELIZUMAB INJECTION OCREVUS 4

Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 FLUORIDE/IRON/VIT A,C TRI-VIT WITH FLUORIDE-IRON 1 FLUORIDE/VITAMINS A,C,AND D TRIPHLUORIVIT 1 MULTIVITAMINS WITH FLUORIDE MULTI-VITAMIN WITH FLUORIDE 1 MULTIVITAMINS WITH FLUORIDE PHLUORIVIT 1 MULTIVITS WITH IRON & FLUORIDE MULTI-VITAMIN W-FLUORIDE-IRON 1 PED MV A,C,D3 #21 W-FLUORIDE TRIPLE-VITAMIN W-FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE VITAMINS A,C,D & FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE 1 PEDI MVI NO.12/SODIUM FLUORIDE MVC-FLUORIDE 1 PNV COMBO #22/IRON/FA/OM3/DHA HEMENATAL OB + DHA 1 PNV NO.22/IRON CBN&GLUC/FA/DSS VINACAL 1 PNV W-O CA NO5/FE FUMARATE/FA PRENATAL-U 3 1 PNV WITH CA,NO.72/IRON,CARB/FA PRENATAL PLUS 3

3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization

53 of 104 Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES (cont.) Tier Generic Name Brand Name Notes 1 PNV66/IRON FUMARATE/FA/DSS/DHA PNV-DHA + DOCUSATE 1 PNV66/IRON FUMARATE/FA/DSS/DHA FOLCAL DHA 1 PNV66/IRON FUMARATE/FA/DSS/DHA VEMAVITE-PRX 2 1 PNV77/SOD IRON EDTA& PS/FA/OM3 VENATAL COMPLETE DHA 1 PRENATAL NO.25/IRON/FA #6/DHA PRENA1 1 PRENATAL VIT 15/IRON CB/FA/DSS TRIADVANCE 3 1 PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL AD 3 1 PRENATAL VIT 16/IRON CB/FA/DSS VINATE GT 1 PRENATAL VIT 18/IRON CB/FA/DSS VINATE ULTRA 3 1 PRENATAL VIT NO.78/IRON/FA PRENATABS FA 3 1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL 19 1 PRENATAL VITAMINS#21, IRON, FA HEMENATAL OB 3 PED MV A,C,D3 #38 W-FLUORIDE TRI-VI-FLOR 3 PEDI MULTIVIT #37 W-FLUORIDE POLY-VI-FLOR 3 PN W-CA64/IRON CB&GL/FA/DSS/DH CITRANATAL 90 DHA 3 PNV #38/IRON FUM/FOLATE/DHA PRENATE DHA 3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PREQUE 10 3 PNV COMBO #19/IRON/FOL AC/DHA PREFERA-OB ONE 3 PNV COMBO #22/IRON/FA/OM3/DHA PREFERA-OB PLUS DHA 3 PNV WITH CA,NO.71/IRON/FA VOL-PLUS 3 PNV WITH CA,NO63/IRON/FA/B6 CITRANATAL B-CALM 3 PNV#79/IRON/FA/LMFOLATE CA/DHA NEEVO DHA 3 PNV/FA/B6/CALCIUM PHOS/GINGER B-NEXA 3 PNV22/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL DHA 3 PNV38/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL ASSURE 3 PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS 3 PNV66/IRON FUMARATE/FA/DSS/DHA PRENEXA 3 PNV69/IRON,CARBONYL/FA/DSS/DHA CITRANATAL HARMONY 3 PNV80/IRON FUMARATE/FA/DSS/DHA NEXA SELECT 3 PRENATAL NO.25/IRON/FA #6/DHA VITAMEDMD ONE RX 3 PRENATAL NO.39/IRON/FA #6/DHA VITAMEDMD PLUS RX 3 PRENATAL VIT #76/IRON,CARB/FA VOL-TAB RX 3 PRENATAL VIT NO.44/IRON/FA/DHA PRENATE MINI 3 PRENATAL VIT NO.78/IRON/FA VENATAL-FA 3 PRENATAL VIT#36/IRON/FA CMB#6 PRENATE ELITE 3 PRENATAL VIT#42/FA CMB#6 VITAMEDMD REDICHEW RX 3 PRENATAL VITAMINS#21, IRON, FA PREFERA OB

Mydriatics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 ATROPINE SULFATE ATROPINE CARE 1 ATROPINE SULFATE/PF ATROPINE SULFATE 1 CYCLOPENTOLATE HCL 1 HOMATROPINE HBR HOMATROPAIRE 2 CYCLOPENTOLATE HCL CYCLOGYL 2 SCOPOLAMINE HYDROBROMIDE ISOPTO HYOSCINE 3 HOMATROPINE HBR ISOPTO HOMATROPINE

NMDA Receptor Blocker / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes 3 MEMANTINE HCL NAMENDA

Nephropathic Cystinosis / ENDOCRINE Tier Generic Name Brand Name Notes 3 CYSTEAMINE PROCYSBI 5

3 - No copay 5 - Prior Authorization 54 of 104 Neurotoxin / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 ONABOTULINUMTOXINA BOTOX 4

Nitrates And Nitrites / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 ISOSORBIDE DINITRATE 1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER 1 NITROGLYCERIN NITRO-BID 2 NITROGLYCERIN NITROMIST 2 NITROGLYCERIN NITROSTAT 2 NITROGLYCERIN NITRO-DUR 3 ISOSORBIDE MONONITRATE IMDUR

Nitrogen Binding Agent / UROLOGICALS Tier Generic Name Brand Name Notes 3 GLYCEROL PHENYLBUTYRATE RAVICTI 5

Non-Nucleoside Reverse Transcriptase Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes 1 NEVIRAPINE 2 DELAVIRDINE RESCRIPTOR 2 EFAVIRENZ SUSTIVA 2 ETRAVIRINE INTELENCE 2 RILPIVIRINE EDURANT 3 NEVIRAPINE VIRAMUNE

Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY Tier Generic Name Brand Name Notes 1 BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 1 CELECOXIB 7 1 DICLOFENAC SODIUM 1 DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM-MISOPROSTOL 1 ETODOLAC 1 IBUPROFEN 1 INDOMETHACIN 1 KETOPROFEN 1 KETOROLAC TROMETHAMINE 1 MELOXICAM 1 NABUMETONE 1 NAPROXEN 1 OXAPROZIN 1 PIROXICAM 1 SALSALATE 1 SULINDAC 2 NAPROXEN SODIUM NAPRELAN 3 ASPIRIN EXTENDED-RELEASE CAPSULES DURLAZA 5 3 BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL

4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step Therapy

55 of 104 Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY (cont.) Tier Generic Name Brand Name Notes 3 CELECOXIB CELEBREX 7 3 DICLOFENAC EPOLAMINE FLECTOR 5 3 DICLOFENAC POTASSIUM CAMBIA 3 DICLOFENAC POTASSIUM ZIPSOR 3 DICLOFENAC SODIUM PENNSAID 5 3 DICLOFENAC SODIUM VOLTAREN 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 3 INDOMETHACIN INDOCIN 3 KETOROLAC TROMETHAMINE SPRIX 3 MELOXICAM MOBIC 3 OXAPROZIN DAYPRO

Nucleoside/Nucleotide RT Inhibitors / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ABACAVIR SULFATE ABACAVIR 1 LAMIVUDINE 1 ZIDOVUDINE 1 ZIDOVUDINE/LAMIVUDINE 2 ABACAVIR SULFATE/LAMIVUDINE EPZICOM 2 ABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR 2 EMTRICITABINE/RILPIVIRINE/TENOFOVIR ODFESEY 2 EMTRICITABINE/TENOFOVIR TRUVADA 2 LAMIVUDINE EPIVIR HBV 3 ABACAVIR SULFATE ZIAGEN 3 LAMIVUDINE/ZIDOVUDINE COMBIVIR 3 ZIDOVUDINE RETROVIR

Nucleosides And Nucleotides / ANTIVIRALS Tier Generic Name Brand Name Notes 1 ENTECAVIR 1 FAMCICLOVIR 2 ADEFOVIR DIPIVOXIL HEPSERA 2 TELBIVUDINE TYZEKA 3 ENTECAVIR BARACLUDE 3 FAMCICLOVIR FAMVIR 3 VALGANCICLOVIR HCL VALCYTE

ONCOLYTIC VIRUS / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 TALIMOGENE LAHERPAREPVEC IMLYGIC 4

Ophthalmic Antiinflammatory / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 4 DESAMETHASONE INTRAVITREAL OZURDEX 4

Opiate Agonists, Short Acting / ANALGESICS Tier Generic Name Brand Name Notes 1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE

4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step Therapy

56 of 104 Opiate Agonists, Short Acting / ANALGESICS (cont.) Tier Generic Name Brand Name Notes 1 BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN 1 CODEINE/BUTALBITAL/ASA/CAFFEIN BUTALBITAL COMPOUND-CODEINE 1 CODEINE/BUTALBITAL/ASA/CAFFEIN ASCOMP WITH CODEINE 1 HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE BIT-IBUPROFEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE-IBUPROFEN 1 HYDROMORPHONE HCL 1 MEPERIDINE HCL 1 MORPHINE SULFATE 1 OXYCODONE HCL OXYCODONE CONCENTRATE 1 OXYCODONE HCL 1 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 1 OXYCODONE HCL/ACETAMINOPHEN ENDOCET 1 OXYCODONE HCL/ASPIRIN ENDODAN 1 OXYCODONE HCL/OXYCODON TER/ASA OXYCODONE-ASPIRIN 1 OXYMORPHONE HCL 1 TRAMADOL HCL 1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN 2 HYDROMORPHONE HCL DILAUDID 2 METHADONE HCL 2 MORPHINE SULFATE AVINZA 2 MORPHINE SULFATE KADIAN 2 OXYCODONE HCL/ACETAMINOPHEN ROXICET 3 ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.3 3 FENTANYL DURAGESIC 3 FENTANYL CITRATE FENTORA 3 FENTANYL CITRATE ABSTRAL 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN HP 3 HYDROCODONE BIT/ACETAMINOPHEN LORTAB 3 HYDROCODONE BIT/ACETAMINOPHEN NORCO 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN 3 HYDROCODONE BITARTRATE ZOHYDRO 3 HYDROCODONE BITARTRATE 3 HYDROCODONE/IBUPROFEN IBUDONE 3 HYDROCODONE/IBUPROFEN REPREXAIN 3 HYDROCODONE/IBUPROFEN VICOPROFEN 3 HYDROMORPHONE HCL EXALGO 3 OXYCODONE HCL/ACETAMINOPHEN PERCOCET 3 TAPENTADOL HCL NUCYNTA 3 TRAMADOL HCL RYBIX ODT 3 TRAMADOL HCL ULTRAM

Opiate Agonists,Long Acting / ANALGESICS Tier Generic Name Brand Name Notes 1 FENTANYL TRANSDERMAL FENTANYL 1 HYDROMORPHONE ER 1 MORPHINE SULFATE MORPHINE SULFATE ER 2 OXYCODONE HCL OXYCONTIN 3 HYDROCODONE BITARTRATE HYSINGLA ER 3 MORPHINE SULFATE MS CONTIN 3 OXYCODONE HCL XARTEMIS XR 3 OXYMORPHONE HCL OPANA ER 3 TAPENTADOL HCL NUCYNTA ER 3 TRAMADOL HCL ULTRAM ER

Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 NALOXONE

57 of 104 Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE (cont.) Tier Generic Name Brand Name Notes 4 NALOXONE EVZIO 5

Opiate Antagonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 NALTREXONE HCL

Opiate Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand Name Notes 3 METHYLNALTREXONE BROMIDE TABLETS RELISTOR 5

Opiate Antagonists / GI AGENTS Tier Generic Name Brand Name Notes 3 NALOXEGOL MOVANTIK 5

Opiate Antagonists / OBESITY Tier Generic Name Brand Name Notes 3 NALOXONE/BUPROPION CONTRAVE 5

Opiate Partial Agonists / ANALGESICS Tier Generic Name Brand Name Notes 3 BUPRENORPHINE BUTRANS 3 BUPRENORPHINE BUCCAL FILM BELBUCA

Opiate Partial Agonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE/NALOXONE SL TABS 5 3 BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE SL TABS 5 4 BUPRENORPHINE IMPLANT PROBUPHINE 4

Other Miscellaneous Therapeutic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 OCTREOTIDE ACETATE 5

Other Miscellaneous Therapeutic Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE 3 LEVOCARNITINE CARNITOR SF 3 LEVOCARNITINE CARNITOR

Other Miscellaneous Therapeutic Agents / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 CINACALCET HCL SENSIPAR 5 3 SAPROPTERIN DIHYDROCHLORIDE KUVAN

4 - Office/Clinic Administration 5 - Prior Authorization

58 of 104 Other Miscellaneous Therapeutic Agents / UROLOGICALS Tier Generic Name Brand Name Notes 3 PENTOSAN POLYSULFATE SODIUM ELMIRON

Other Miscellaneous Therapeutic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 3 BAICALIN/CATECHIN/CITRATED ZNC LIMBREL250

Oxazolidinone / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 3 TEDIZOLID SIVEXTRO

Oxytocics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes 1 METHYLERGONOVINE MALEATE 3 METHYLERGONOVINE MALEATE METHERGINE

PCSK9 INHIBITOR / CARDIOVASCULAR Tier Generic Name Brand Name Notes 4 ALIROCUMAB PRALUENT 5 4 EVOLOCUMAB REPATHA 5

PO4 scavengers / GENETIC DISORDERS Tier Generic Name Brand Name Notes 3 CARGLUMIC ACID CARBAGLU 5

Parasympathomimetic (Cholinergic Agents) / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 1 PYRIDOSTIGMINE BROMIDE 2 PYRIDOSTIGMINE BROMIDE MESTINON

Parasympathomimetic (Cholinergic Agents) / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 CEVIMELINE HCL 2 CEVIMELINE HCL EVOXAC

Parasympathomimetic (Cholinergic Agents) / UROLOGICALS Tier Generic Name Brand Name Notes 1 BETHANECHOL CHLORIDE

Parasympathomimetics / ANTIMYASTHENIC AGNETS Tier Generic Name Brand Name Notes 1 NEOSTIGMINE 1 PYRIDOSTIGMINE

Parathyroid / ENDOCRINE Tier Generic Name Brand Name Notes 4 PARATHYROID HORMONE FOR INJECTION NATPARA 5

5 - Prior Authorization

59 of 104 Parathyroid / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 1 CALCITONIN,SALMON,SYNTHETIC FORTICAL

Parathyroid / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 4 TERIPARATIDE FORTEO 5

Pediculicides/Scabicides / ANTIPARASITICS Tier Generic Name Brand Name Notes 3 NITAZOXANIDE ALINIA

Penicillins / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 AMOXICILLIN 1 AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN-CLAVULANATE ER 1 AMOXICILLIN/POTASSIUM CLAV AMOX TR-POTASSIUM CLAVULANATE 1 AMPICILLIN TRIHYDRATE 1 CARBENICILLIN 1 DICLOXACILLIN SODIUM 1 PENICILLIN V POTASSIUM 2 AMOXICILLIN/POTASSIUM CLAV AUGMENTIN 4 NAFCILLIN NAFCIL 4 4 OXACILLIN 4 4 PENICILLIN G BICILLIN LA 4 4 PIPERACILLIN PIPRACIL 4

Pharmaceutical Aids / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 PYRITHIONE ZINC ZINC PYRITHIONE

Pharmaceutical Aids / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 2 PREGNENOLONE, MICRONIZED PREGNENOLONE MICRONIZED 3 PREGNENOLONE

Pharmaceutical Aids / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 7-OXODEHYDROEPIANDROSTERONE,MC 7-KETO DHEA

Phenothiazine Derivatives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 PHENYLEPHRINE HCL/PROMETH HCL PROMETHAZINE VC 1 PROMETHAZINE HCL PHENADOZ 1 PROMETHAZINE HCL

Phosphate-Removing Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 FERRIC CITRATE AURYXIA

4 - Office/Clinic Administration 5 - Prior Authorization

60 of 104 Phosphate-Removing Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 CALCIUM ACETATE 1 SAVELAMER 2 SEVELAMER HCL RENAGEL 3 FERRIC CITRATE 3 LANTHANUM CARBONATE FOSRENOL 3 SEVELAMER CARBONATE RENVELA 3 SUCROFERRIC OXYHYDROXIDE VELPHORO

Phosphodiesterase Type 5 Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes ED AVANAFIL STENDRA 6

Phosphodiesterase Type 5 Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 SILDENAFIL CITRATE SILDENAFIL 5 3 SILDENAFIL CITRATE REVATIO 5 3 TADALAFIL ADCIRCA

Phosphodiesterase Type 5 Inhibitors / UROLOGICALS Tier Generic Name Brand Name Notes ED SILDENAFIL CITRATE VIAGRA 6 ED TADALAFIL CIALIS 6 ED VARDENAFIL HCL STAXYN 6 ED VARDENAFIL HCL LEVITRA 6

Photosensitizer / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 METHOXSALEN, RAPID OXSORALEN-ULTRA

Pituitary / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN ACETATE 3 DESMOPRESSIN (NONREFRIGERATED) DDAVP 3 DESMOPRESSIN ACETATE STIMATE

Pituitary / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 SOMATROPIN HUMATROPE 5 4 SOMATROPIN NORDITROPIN FLEXPRO 5 4 SOMATROPIN GENOTROPIN 5 4 SOMATROPIN NUTROPIN AQ NUSPIN 5 4 SOMATROPIN NORDITROPIN NORDIFLEX 5 4 SOMATROPIN OMNITROPE 5 4 SOMATROPIN NUTROPIN AQ 5

Pituitary - Androgens / HORMONE: PITUITARY Tier Generic Name Brand Name Notes 1 ESTROGEN,ESTER/ME-TESTOSTERONE COVARYX H.S.

5 - Prior Authorization 6 - Quantity Limit

61 of 104 Pituitary - Androgens / HORMONE: PITUITARY (cont.) Tier Generic Name Brand Name Notes 1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT H.S. 1 ESTROGEN,ESTER/ME-TESTOSTERONE ESTROGEN & METHYLTESTOSTERONE 1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT 3 METHYLTESTOSTERONE ANDROID 3 METHYLTESTOSTERONE 3 METHYLTESTOSTERONE METHITEST 3 TESTOSTERONE TESTIM 3 TESTOSTERONE AXIRON 3 TESTOSTERONE FORTESTA 4 TESTOSTERONE CYPIONATE 5 4 TESTOSTERONE ENANTHATE DELATESTRYL 5

Platelet Modifying Agents / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes 1 ANAGRELIDE HCL 1 CILOSTAZOL 1 CLOPIDOGREL BISULFATE CLOPIDOGREL 1 TICLOPIDINE HCL 2 CLOPIDOGREL BISULFATE PLAVIX 3 ASPIRIN/DIPYRIDAMOLE AGGRENOX 3 PRASUGREL HCL EFFIENT 3 TICAGRELOR BRILINTA

Potassium Sparing Diuretic / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ 1 SPIRONOLACTONE 3 SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE

Potassium-Removing Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 PATIROMER ORAL SUSPENSION VELTASSA

Potassium-Removing Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 SODIUM POLYSTYRENE SULFONATE KALEXATE 1 SODIUM POLYSTYRENE SULFONATE KIONEX

Potassium-Sparing Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 AMILORIDE HCL 1 AMILORIDE/HYDROCHLOROTHIAZIDE AMILORIDE-HYDROCHLOROTHIAZIDE 1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HCTZ 1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HYDROCHLOROTHIAZID 3 TRIAMTERENE DYRENIUM 3 TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE 3 TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE-25 MG

Progestins / HORMONE: PROGESTINS Tier Generic Name Brand Name Notes 1 MEDROXYPROGESTERONE ACETATE

5 - Prior Authorization

62 of 104 Progestins / HORMONE: PROGESTINS (cont.) Tier Generic Name Brand Name Notes 1 NORETHINDRONE ACETATE 1 PROGESTERONE 3 MEDROXYPROGESTERONE ACETATE PROVERA 3 PROGESTERONE,MICRONIZED ENDOMETRIN 3 PROGESTERONE,MICRONIZED PROGESTERONE 3 PROGESTERONE,MICRONIZED CRINONE 3 PROGESTERONE,MICRONIZED PROMETRIUM 4 HYDROXYPROGESTERONE CAPROATE MAKENA 5 4 PROGESTERONE PROGESTERONE IN OIL 2

Prokinetic Agents / GI AGENTS Tier Generic Name Brand Name Notes 1 METOCLOPRAMIDE HCL 3 METOCLOPRAMIDE HCL METOZOLV ODT

Prostacyclin Vasodilator / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 TREPROSTINIL ORENITRAM 5

Prostaglandins / GI AGENTS Tier Generic Name Brand Name Notes 1 MISOPROSTOL

Prostaglandins / HORMONE: PROSTAGLANDINS Tier Generic Name Brand Name Notes 1 LATANOPROST 2 BIMATOPROST LUMIGAN 2 TRAVOPROST TRAVATAN Z 3 ILOPROST VENTAVIS 5 3 LATANOPROST XALATAN 3 TAFLUPROST/PF ZIOPTAN 3 UNOPROSTONE RESCULA

Protease Inhibitors / ANTIVIRALS Tier Generic Name Brand Name Notes 2 ATAZANAVIR SULFATE REYATAZ 2 DARUNAVIR ETHANOLATE PREZISTA 2 FOSAMPRENAVIR CALCIUM LEXIVA 2 INDINAVIR CRIXIVAN 2 LOPINAVIR/RITONAVIR KALETRA 2 RITONAVIR NORVIR 2 SAQUINAVIR INVIRASE 2 TIPRANAVIR APTIVUS

Protease Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 VORAPAXAR ZONTIVITY

2 - Infertility 5 - Prior Authorization

63 of 104 Proteasome Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 BORTEZOMIB VELCADE 5 4 IXAZOMIB CAPSULES NINLARO 5

Protectants / GI AGENTS Tier Generic Name Brand Name Notes 1 SUCRALFATE 3 SUCRALFATE CARAFATE

Proteinase / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 COLLAGENASE CLOSTRIDIUM XIAFLEX 4

Proton-Pump Inhibitors / GI AGENTS Tier Generic Name Brand Name Notes 1 ESOMEPRAZOLE MAGNESIUM 1 LANSOPRAZOLE 1 OMEPRAZOLE 1 OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE 5 1 PANTOPRAZOLE SODIUM 1 RABEPRAZOLE SODIUM RABEPRAZOLE 2 ESOMEPRAZOLE MAGNESIUM NEXIUM PACKETS 3 DEXLANSOPRAZOLE DEXILANT 3 ESOMEPRAZOLE MAGNESIUM NEXIUM 3 LANSOPRAZOLE PREVACID 3 LANSOPRAZOLE/AMOXICILN/CLARITH PREVPAC 3 OMEPRAZOLE PRILOSEC 3 OMEPRAZOLE/CLARITH/AMOXICILLIN OMECLAMOX-PAK 3 OMEPRAZOLE/SODIUM BICARBONATE ZEGERID 5 3 PANTOPRAZOLE SODIUM PROTONIX 3 RABEPRAZOLE SODIUM ACIPHEX

Quinolones / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 CIPROFLOXACIN HCL 1 LEVOFLOXACIN 1 OFLOXACIN 2 MOXIFLOXACIN HCL AVELOX 2 MOXIFLOXACIN HCL AVELOX ABC PACK 3 CIPROFLOXACIN HCL CIPRO 3 LEVOFLOXACIN LEVAQUIN 3 NORFLOXACIN NOROXIN

RESPIRATORY INHALANT COMBINATIONS / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 GLYCOPYRROLATE/FORMOTEROL FUMARATE BEVESPI AEROSPHERE INHALATION 3 INDACATEROL/GLYCOPYRROLATE INHALATION UTIBRON NEOHALER POWDER

4 - Office/Clinic Administration 5 - Prior Authorization

64 of 104 Renin Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes 2 ALISKIREN HEMIFUMARATE TEKTURNA 3 ALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT 3 ALISKIREN/VALSARTAN VALTURNA 7

Replacement Preparations / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE 3 SODIUM CHLORIDE FOR INHALATION HYPER-SAL

Replacement Preparations / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE 1 POTASSIUM BICARBONATE/CIT AC KLOR-CON-EF 1 POTASSIUM CHLORIDE KLOR-CON 1 POTASSIUM CHLORIDE 1 POTASSIUM CHLORIDE EPIKLOR 1 ZINC SULFATE 2 POTASSIUM BICARBONATE/CIT AC EFFER-K 2 POTASSIUM CHLORIDE K-TAB

Respiratory Smooth Muscle Relaxants / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 THEOPHYLLINE ANHYDROUS 2 THEOPHYLLINE ANHYDROUS THEO-24

Respiratory Tract Agents- Miscellaneous / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 2 TIOTROPIUM BROMIDE/OLODATEROL STIOLTO RESPIMAT INHALATION SPRAY 3 ROFLUMILAST DALIRESP

Retinoids / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 ALITRETINOIN PANRETIN 5 3 TRETINOIN VESANOID 5

Ribose Polymerase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 OLAPARIB LYNPARZA 5 3 RUCAPARIB TABLETS RUBRACA 5

Scabicides And Pediculicides / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 PERMETHRIN 2 CROTAMITON EURAX

5 - Prior Authorization 7 - Step Therapy

65 of 104 Scabicides And Pediculicides / DERMATOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 3 BENZYL ALCOHOL ULESFIA 3 IVERMECTIN SOOLANTRA 3 SPINOSAD NATROBA

Second Generation Antihistamines / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 DESLORATADINE 1 FEXOFENADINE HCL 1 FEXOFENADINE/PSEUDOEPHEDRINE FEXOFENADINE-PSE ER 1 LEVOCETIRIZINE DIHYDROCHLORIDE 3 DESLORATADINE CLARINEX 3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12 HOUR 3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 24 HOUR 3 FEXOFENADINE HCL ALLEGRA 3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 24 HOUR 3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 12 HOUR 3 LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL

Selective Serotonin Agonists / ANTIMIGRAINE Tier Generic Name Brand Name Notes 1 NARATRIPTAN HCL 6 1 RIZATRIPTAN BENZOATE RIZATRIPTAN 6 1 RIZATRIPTAN MLT 6 1 SUMATRIPTAN 6 1 ZOLMITRIPTAN 6 2 ALMOTRIPTAN MALATE AXERT 6 2 ELETRIPTAN HBR RELPAX 6 2 ZOLMITRIPTAN ZOMIG SPRAY 6 3 FROVATRIPTAN SUCCINATE FROVA 6 3 NARATRIPTAN HCL AMERGE 6 3 RIZATRIPTAN BENZOATE MAXALT MLT 6 3 RIZATRIPTAN BENZOATE MAXALT 6 3 SUMATRIPTAN NASAL POWDER ONZETRA XSAIL 5 3 SUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET 6 3 SUMATRIPTAN SUCCINATE SUMAVEL DOSEPRO 6 3 SUMATRIPTAN SUCCINATE IMITREX 6 3 ZOLMITRIPTAN ZOMIG ZMT TABLETS 6 3 ZOLMITRIPTAN ZOMIG TABLETS 6

Selective Serotonin Agonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes 3 PAROXETINE HCL BRISDELLE 3 VORTIOXETINE BRINTELLIX

Selective Serotonin Reuptake Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 CITALOPRAM HYDROBROMIDE CITALOPRAM HBR 1 ESCITALOPRAM OXALATE

5 - Prior Authorization 6 - Quantity Limit

66 of 104 Selective Serotonin Reuptake Inhibitor / ANTIDEPRESSANTS (cont.) Tier Generic Name Brand Name Notes 1 FLUOXETINE HCL CAPSULE FLUOXETINE HCL 1 FLUOXETINE HCL DR CAPSULE FLUOXETINE DR 1 FLUOXETINE HCL TABLETS FLUOXETINE HCL 5 1 PAROXETINE HCL 1 SERTRALINE HCL 3 CITALOPRAM HYDROBROMIDE CELEXA 3 ESCITALOPRAM OXALATE LEXAPRO 3 FLUOXETINE HCL CAPSULE PROZAC 3 FLUOXETINE HCL TABLETS SARAFEM 5 3 PAROXETINE HCL PAXIL CR 3 PAROXETINE HCL PAXIL 3 SERTRALINE HCL ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitor / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPROPION HCL BUPROPION HCL SR

Serotonin Norepinephrine Reuptake Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 BUPROPION HCL BUPROPION XL 1 BUPROPION HCL BUDEPRION XL 1 BUPROPION HCL 1 BUPROPION HCL BUDEPRION SR 1 DULOXETINE HCL DULOXETINE 1 VENLAFAXINE HCL 1 VENLAFAXINE HCL VENLAFAXINE HCL ER 2 BUPROPION HCL FORFIVO XL 3 BUPROPION HBR APLENZIN 3 BUPROPION HCL WELLBUTRIN XL 3 BUPROPION HCL WELLBUTRIN SR 3 BUPROPION HCL WELLBUTRIN 3 DULOXETINE HCL CYMBALTA 3 LEVOMILNACIPRAN FETZIMA 3 VENLAFAXINE HCL EFFEXOR XR

Serotonin Reptake Blocker / ANTIDEPRESSANTS, OTHER Tier Generic Name Brand Name Notes 1 TRAZODONE HCL 3 TRAZODONE HCL OLEPTRO ER

Serums / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 IMMUNE GLOBULIN,GAMMA(IGG) HIZENTRA 5

Skin And Mucous Membrane Agents- Misc. / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 1 ADAPALENE 1 ADAPALENE 5 1 CALCIPOTRIENE CALCITRENE

5 - Prior Authorization

67 of 104 Skin And Mucous Membrane Agents- Misc. / DERMATOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes 1 CALCIPOTRIENE 1 FLUOROURACIL 1 IMIQUIMOD 1 ISOTRETINOIN CLARAVIS 5 1 ISOTRETINOIN AMNESTEEM 5 1 ISOTRETINOIN ZENATANE 5 1 ISOTRETINOIN MYORISAN 5 1 PODOFILOX 1 TAZAROTENE TAZAROTENE 0.1% CREAM 5 2 AZELAIC ACID FINACEA 2 BECAPLERMIN REGRANEX 5 2 FLUOROURACIL CARAC 2 ISOTRETINOIN ABSORICA 5 2 PODOFILOX CONDYLOX 3 ACITRETIN SORIATANE 3 ADAPALENE DIFFERIN 5 3 ADAPALENE/BENZOYL PEROXIDE EPIDUO 3 AZELAIC ACID AZELEX 3 CALCIPOTRIENE DOVONEX 3 CALCIPOTRIENE SORILUX 3 CALCITRIOL VECTICAL 3 COLLAGENASE CLOSTRIDIUM HIST. SANTYL 3 DAPSONE ACZONE 5 3 DICLOFENAC SODIUM SOLARAZE 5 3 IMIQUIMOD ALDARA 3 IMIQUIMOD ZYCLARA 3 INGENOL MEBUTATE PICATO 3 PIMECROLIMUS ELIDEL 3 PODOPHYLLUM RESIN PODOCON-25 3 TACROLIMUS PROTOPIC 3 TAZAROTENE TAZORAC 0.05% 5 3 TAZAROTENE TAZORAC 0.1% CREAM 5 3 TAZAROTENE TAZORAC 0.1% GEL 5 3 TRYPSIN/BALSAM PERU/CASTOR OIL XENADERM

Skin And Mucous Membrane Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 3 FORMALDEHYDE LAZERFORMALYDE

Skin And Mucous Membrane Agents- Misc. / GI AGENTS Tier Generic Name Brand Name Notes 3 NITROGLYCERIN RECTIV

Smoking Cessation / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes 1 BUPROPION SR BUPROBAN 3 1 BUPROPION SR BUPROPION HCL SR 3 2 VARENICLINE TARTRATE CHANTIX 3 3 BUPROPION SR ZYBAN 3

3 - No copay 5 - Prior Authorization

68 of 104 Sodium Channel Agents / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 CARBAMAZEPINE TEGRETOL

Sodium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes 1 CARBAMAZEPINE CARBAMAZEPINE ER 1 CARBAMAZEPINE CARBAMAZEPINE XR 1 CARBAMAZEPINE 1 OXCARBAZEPINE 1 PHENYTOIN 1 PHENYTOIN SODIUM EXTENDED 1 TOPIRAMATE 1 ZONISAMIDE 3 CARBAMAZEPINE CARBATROL 3 CARBAMAZEPINE TEGRETOL XR 3 OXCARBAZEPINE TRILEPTAL 3 PHENYTOIN SODIUM EXTENDED PHENYTEK 3 TOPIRAMATE TOPAMAX

Sodium Channel Agents / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 TOPIRAMATE

Sodium Channel Inhibitor / AANTICONVULSANTS Tier Generic Name Brand Name Notes 3 PHENYTOIN SODIUM EXTENDED DILANTIN

Sodium Channel Inhibitor / ANTICONVULSANTS Tier Generic Name Brand Name Notes 3 ESLICARBAZEPINE APTIOM 3 RUFINAMIDE BANZEL 5

Sodium Glucose Transporter 2 / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 2 CANAGLIFLOZIN INVOKANA 2 EMPAGLIFLOZIN JARDIANCE

Sodium Glucose Transporter 2 / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 3 DAPAGLIFLOZIN FARXIGA

Somatostatin Analogue / ENDOCRINE Tier Generic Name Brand Name Notes 3 PASIREOTIDE SIGNIFOR 5

Stimulant guanylate cyclase / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 RIOCIGUAT ADEMPAS 5

5 - Prior Authorization

69 of 104 Substance P Antagonist / ANTIEMETICS Tier Generic Name Brand Name Notes 3 APREPITANT EMEND 3 ROLAPITANT TABLETS VARUBI 6

Sulfonamides (Systemic) / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 SULFASALAZINE SULFAZINE 1 SULFASALAZINE SULFAZINE EC

Sulfonamides (Systemic) / INFLAMMATORY BOWEL AGENTS Tier Generic Name Brand Name Notes 1 SULFASALAZINE SULFASALAZINE DR 1 SULFASALAZINE

Sulfonylureas / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 GLIMEPIRIDE 1 GLIPIZIDE GLIPIZIDE ER 1 GLIPIZIDE 1 GLIPIZIDE GLIPIZIDE XL 1 GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 1 GLYBURIDE 1 GLYBURIDE/METFORMIN HCL GLYBURIDE-METFORMIN HCL 1 TOLAZAMIDE 1 TOLBUTAMIDE 3 GLIPIZIDE GLUCOTROL XL 3 GLYBURIDE/METFORMIN HCL GLUCOVANCE

Sympathomimetic (Adrenergic) Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes 1 MIDODRINE HCL

Sympathomimetic (Adrenergic) Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 1 ALBUTEROL SULFATE 6 1 EPINEPHRINE 1 TERBUTALINE SULFATE 2 FLUTICASONE/SALMETEROL ADVAIR DISKUS 6 2 FORMOTEROL FUMARATE FORADIL 2 SALMETEROL XINAFOATE SEREVENT DISKUS 3 LEVALBUTEROL HCL XOPENEX 6 3 PIRBUTEROL ACETATE MAXAIR AUTOHALER

T Cell Blocker / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 4 BELATACEPT NULOJIX 5

TNF Inhibitor / RESPIRATORY AGENTS OTHER Tier Generic Name Brand Name Notes 3 PIRFENIDONE ESBRIET 5

5 - Prior Authorization 6 - Quantity Limit

70 of 104 Tetracyclines / ANTIBACTERIALS Tier Generic Name Brand Name Notes 1 DEMECLOCYCLINE HCL 1 DOXYCYCLINE HYCLATE DR TABLETS DOXYCYCLINE HYCLATE 5 1 DOXYCYCLINE HYCLATE IR TABLETS DOXYCYCLINE HYCLATE 1 DOXYCYCLINE MONOHYDRATE 1 MINOCYCLINE HCL CAPSULES MINOCYCLINE HCL 1 MINOCYCLINE HCL TABLETS MINOCYCLINE HCL 5 1 TETRACYCLINE HCL 3 DOXYCYCLINE HYCLATE CAPSULE VIBRAMYCIN 3 DOXYCYCLINE HYCLATE DR TABLETS DORYX 5 3 DOXYCYCLINE MONOHYDRATE MONODOX 3 DOXYCYCLINE MONOHYDRATE ORACEA 5 3 MINOCYCLINE HCL CAPSULES MINOCIN 3 MINOCYCLINE HCL TABLET EXTENDED RELEASE SOLODYN 5

Thiazide Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 CHLOROTHIAZIDE 1 CHLORTHALIDONE 1 HYDROCHLOROTHIAZIDE 1 INDAPAMIDE 1 METOLAZONE 3 CHLOROTHIAZIDE DIURIL

Thiazolidinediones / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes 1 PIOGLITAZONE HCL 1 PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE-METFORMIN 3 PIOGLITAZONE HCL ACTOS 3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET 3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET XR

Thyroid Agents / HORMONE: THYROID Tier Generic Name Brand Name Notes 1 LEVOTHYROXINE SODIUM LEVOXYL 1 LEVOTHYROXINE SODIUM 1 THYROID,PORK WESTHROID 1 THYROID,PORK NATURE-THROID 2 LIOTHYRONINE SODIUM 2 LIOTHYRONINE SODIUM PCCA T3 SODIUM DILUTION 2 THYROID,PORK ARMOUR THYROID 2 THYROID,PORK THYROID 2 THYROID,PORK NATURE-THROID 3 LEVOTHYROXINE SODIUM SYNTHROID 3 LEVOTHYROXINE SODIUM LEVOTHROID 3 LEVOTHYROXINE SODIUM TIROSINT 3 LIOTHYRONINE SODIUM CYTOMEL

Topical Analgesic / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 CAPSAICIN QUTENZA 5

5 - Prior Authorization

71 of 104 Treatment Resistant / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 CLOZAPINE

Tricyclic Antidepressants / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes 1 AMITRIPTYLINE HCL 1 CLOMIPRAMINE HCL 1 DESIPRAMINE HCL 1 DOXEPIN HCL 1 IMIPRAMINE HCL 1 NORTRIPTYLINE HCL 3 CLOMIPRAMINE HCL ANAFRANIL 3 TRIMIPRAMINE MALEATE SURMONTIL

Tricyclic Antidepressants / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes 1 AMITRIPTYLINE HCL

Tryptophan Hydroxylase Inhibitor / GI AGENTS Tier Generic Name Brand Name Notes 3 TELOTRISTAT ETHYL TABLETS XERMELO 5

Typical/1st Generation / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes 1 CHLORPROMAZINE HCL 1 FLUPHENAZINE HCL 1 HALOPERIDOL 1 LOXAPINE 1 PERPHENAZINE 1 PROLIXIN 1 STELAZINE 1 THIORIDAZINE HCL 1 THIOTHIXENE 4 HALOPERIDOL LACTATE 5

Tyrosine Kinase / ANTINEOPLASTICS Tier Generic Name Brand Name Notes 3 AFATINIB GILOTRIF 5 3 IRBRUTINIB IMBRUVICA 5 3 NILOTINIB TASIGNA 5 3 OSIMERTINIB TABLETS TAGRISSO 5 3 PALBOCICLIB IBRANCE 5 4 ALECTINIB CAPSULES ALECENSA 5

Tyrosine Kinase / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes 4 USTEKINUMAB STELARA 5

Tyrosine Kinase / RESPIRATORY AGENTS OTHER Tier Generic Name Brand Name Notes 3 NINTEDANIB OFEV 5

5 - Prior Authorization

72 of 104 Uric Acid Synthesis Inhibitor / ANTIGOUT Tier Generic Name Brand Name Notes 1 ALLOPURINOL

Uric Acid Transporter 1 Inhibitor / ANTIGOUT Tier Generic Name Brand Name Notes 3 LESINURAD TABLETS ZURAMPIC 5

Uricosuric Agents / ANTIGOUT Tier Generic Name Brand Name Notes 1 COLCHICINE/PROBENECID PROBENECID-COLCHICINE 2 COLCHICINE COLCRYS

Uricosuric Agents / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes 1 PROBENECID

Uridine Triacetate / ENDOCRINE Tier Generic Name Brand Name Notes 4 URIDINE TRIACETATE XURIDEN 5

Urinary Anti-Infectives / ANTI - INFECTIVES Tier Generic Name Brand Name Notes 1 NITROFURANTOIN 1 NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN 1 NITROFURANTOIN MONOHYD/M-CRYST NITROFURANTOIN MONO-MACRO 1 TRIMETHOPRIM 2 NITROFURANTOIN MACROCRYSTAL MACRODANTIN 3 FOSFOMYCIN TROMETHAMINE MONUROL 3 NITROFURANTOIN MONOHYD/M-CRYST MACROBID

Urinary Anti-Infectives / UROLOGICALS Tier Generic Name Brand Name Notes 3 MTH/ME BLUE/SOD PHOS/PHEN/HYOS URIBEL

Vaccines / ANTIBACTERIALS Tier Generic Name Brand Name Notes 4 MENINGOCOCCAL GR B VACCINE BEXSERO 4

Vaccines / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes 3 CHOLERA VACCINE, LIVE, ORAL SUSPENSION VAXCHORA 3 TYPHOID VACC,LIVE,ATTENUATED VIVOTIF BERNA

Vascular Endothelial Growth Factor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 AFLIBERCEPT EYLEA 4

4 - Office/Clinic Administration 5 - Prior Authorization

73 of 104 Vasoconstrictors / OPHTHALMOLOGY Tier Generic Name Brand Name Notes 1 NAPHAZOLINE HCL 1 PHENYLEPHRINE HCL

Vasodilating Agents- Miscellaneous / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes 3 AMBRISENTAN LETAIRIS 5 3 BOSENTAN TRACLEER 5 4 TREPROSTINIL REMODULIN 5 4 TREPROSTINIL TYVASO 5

Vasodilating Agents- Miscellaneous / UROLOGICALS Tier Generic Name Brand Name Notes ED ALPROSTADIL EDEX 6 ED ALPROSTADIL MUSE 6

Vasodilator, Arterial/Venous / CARDIOVASCULAR Tier Generic Name Brand Name Notes 1 NITROGLYCERIN 1 NITROGLYCERIN NITROGLYCERIN PATCH 3 NITROGLYCERIN NITROLINGUAL

Vasopressin Related / CARDIOVASCULAR Tier Generic Name Brand Name Notes 3 TOLVAPTAN SAMSCA 5

Vitamin B Complex / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 FOLIC ACID 3 ACETYL/METHYL-B12/LMEFOLATE CA CEREFOLIN NAC 3 CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL 3 CYANOCOBALAMIN/FA/PYRIDOXINE FOLGARD RX 3 VIT B CMPLX 3/FA/VIT C/BIOTIN NEPHRO-VITE RX 4 CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 5

Vitamin D / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes 1 CALCITRIOL 2 PARICALCITOL ZEMPLAR 3 CALCIFEDIOL EXTENDED-RELEASE CAPSULES RAYALDEE 3 DOXERCALCIFEROL HECTOROL

Vitamin D / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes 1 ERGOCALCIFEROL (VITAMIN D2) VITAMIN D2

Xanthine Oxidase Inhibitor / ANTIGOUT Tier Generic Name Brand Name Notes 3 FEBUXOSTAT ULORIC 5

5 - Prior Authorization 6 - Quantity Limit

74 of 104 integrin receptor antagonist / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes 4 VEDOLIZUMAB ENTYVIO 4

75 of 104 Index

7 A (cont.) 7-KETO DHEA 60 ADEFOVIR DIPIVOXIL 56 7-OXODEHYDROEPIANDROSTERONE,MC 60 ADEMPAS 69 ADENOCARD 13 A ADENOSINE 13 ABACAVIR 56 ADLYXIN 46 ABACAVIR SULFATE 56 ADO-TRASTUZUMAB 43 ABACAVIR SULFATE/LAMIVUDINE 56 ADVAIR DISKUS 70 ABACAVIR/LAMIVUDINE/ZIDOVUDINE 56 ADVAIR HFA 35 ABATACEPT 37 ADVATE 44 ABILIFY 23, 27 ADVICOR 38 ABILIFY DISCMELT 23 ADYNOVATE 17 ABIRATERONE ACETATE 20 AEROCHAMBER 36 ABSORICA 68 AEROCHAMBER MAX 36 ABSTRAL 57 AEROCHAMBER MV 36 ACAMPROSATE CALCIUM 5 AEROCHAMBER PLUS 36 ACANYA 14 AEROCHAMBER WITH FLOWSIGNAL 36 ACARBOSE 7 AEROCHAMBER Z-STAT PLUS 36 ACCOLATE 49 AFATINIB 72 ACCUPRIL 10 AFEDITAB CR 36 ACCURETIC 10 AFINITOR 20 ACETAMINOPHEN WITH CODEINE 56, 57 AFLIBERCEPT 73 ACETAMINOPHEN-CODEINE 56 AFREZZA 47 ACETASOL HC 51 AFSTYLA 17 ACETAZOLAMIDE 29 AGALSIDASE BETA 39 ACETIC ACID 51 AGGRENOX 62 ACETIC ACID/HYDROCORTISONE 51 AK-POLY-BAC 13 ACETYL/METHYL-B12/LMEFOLATE CA 74 AKNE-MYCIN 14 ACETYLCYSTEINE 53 AKYNZEO 4 ACIPHEX 64 ALAMAST 12 ACITRETIN 68 ALBENDAZOLE 10 ACLIDINIUM BROMIDE 19 ALBENZA 10 ACTEMRA 46 ALBIGLUTIDE 46 ACTEMRA SQ 46 ALBUTEROL SULFATE 26, 70 ACTHAR H.P. 34 ALCAFTADINE 12 ACTIGALL 31 ALCLOMETASONE DIPROPIONATE 11 ACTIVELLA 40 ALDACTAZIDE 62 ACTONEL 28 ALDARA 68 ACTOPLUS MET 71 ALECENSA 72 ACTOPLUS MET XR 71 ALECTINIB CAPSULES 72 ACTOS 71 ALEMTUZUMAB 53 ACULAR 39 ALENDRONATE SODIUM 28 ACULAR LS 39 ALENDRONATE SODIUM/VITAMIN D3 28 ACUVAIL 39 ALFUZOSIN 24 ACYCLOVIR 18 ALFUZOSIN HCL 7 ACYCLOVIR/HYDROCORTISONE 22 ALINIA 20, 60 ACZONE 68 ALIROCUMAB 59 ADALAT CC 36 ALISKIREN HEMIFUMARATE 65 ADALIMUMAB 37 ALISKIREN/HYDROCHLOROTHIAZIDE 65 ADAPALENE 67, 68 ALISKIREN/VALSARTAN 65 ADAPALENE/BENZOYL PEROXIDE 68 ALITRETINOIN 65 ADCETRIS 52 ALLEGRA 66 ADCIRCA 61 ALLEGRA-D 12 HOUR 66 ADDERALL 4 ALLEGRA-D 24 HOUR 66 ADDERALL XR 4 ALLOPURINOL 73 ADDYI 50 ALMOTRIPTAN MALATE 66

76 of 104 A (cont.) A (cont.) ALOCRIL 51 AMRIX 30 ALOGLIPTIN 37 ANAFRANIL 72 ALOMIDE 12 ANAGRELIDE HCL 62 ALORA 40 ANAKINRA 37 ALOSETRON HCL 52 ANALPRAM HC 12 ALPHAGAN P 7 ANASTROZOLE 23 ALPRAZOLAM 25, 27 ANDRODERM 9 ALPRAZOLAM ER 25 ANDROGEL 9 ALPRAZOLAM ODT 25 ANDROID 62 ALPRAZOLAM XR 25 ANGELIQ 41 ALPROLIX 44 ANORO ELLIPTA 19 ALPROSTADIL 74 ANTABUSE 5 ALREX 34 ANTARA 41 ALTABAX 14 ANTHRALIN 48 ALTACE 10 ANTIHEMOPH.FVIII PLAS/ALB FREE 44 ALTAVERA 32 ANTIHEMOPHILIC FACTOR 17 ALTOPREV 45 ANTIHEMOPHILIC FACTOR RECOMBINANT 17 ALUMINUM CHLORIDE 23 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT 17 ALVESCO 35 ANTIHEMOPHYLIC FACTOR [RECOMBINANT] ALYACEN 33 PEGYLATED INJECTION 17 AMANTADINE 12, 37 ANTIPY/BENZOCAINE/POLICOS NO.1 49 AMANTADINE HCL 12, 37 ANTIPYRINE-BENZOCAINE 49 AMBIEN 23 ANTIPYRINE/BENZOCAINE 49 AMBIEN CR 23 ANTIPYRINE/BENZOCAINE/GLYCERIN 49 AMBRISENTAN 74 ANTIVERT 18 AMERGE 66 ANUCORT-HC 12 AMETHIA 32 ANUSOL-HC 12 AMETHIA LO 32 ANZEMET 4 AMETHYST 32 APHTHASOL 39 AMIKACIN 8 APIDRA 47 AMILORIDE HCL 62 APIDRA SOLOSTAR 47 AMILORIDE-HYDROCHLOROTHIAZIDE 62 APIXABAN 27 AMILORIDE/HYDROCHLOROTHIAZIDE 62 APLENZIN 67 AMINOCAPROIC ACID 44 APOKYN 38 AMIODARONE HCL 13 APOMORPHINE 38 AMITIZA 49 APREMILAST 45 AMITRIPTYLINE HCL 72 APREPITANT 70 AMLEXANOX 39 APRI 32 AMLODIPINE BES/OLMESARTAN MED 36 APRISO 11 AMLODIPINE BESYLATE 36 APTIOM 69 AMLODIPINE BESYLATE-BENAZEPRIL 36 APTIVUS 63 AMLODIPINE BESYLATE/BENAZEPRIL 36 ARANELLE 32 AMLODIPINE-ATORVASTATIN 45 ARANESP 15 AMLODIPINE/ATORVASTATIN 45 ARAVA 37 AMLODIPINE/VALSARTAN 28 ARCAPTA NEOHALER 26 AMLODIPINE/VALSARTAN/HCTZ 28 ARESTIN 13 AMMONIUM LACTATE 25 ARFORMOTEROL TARTRATE 26 AMNESTEEM 68 ARIMIDEX 23 AMOX TR-POTASSIUM CLAVULANATE 60 ARIPIPRAZOLE 23, 27 AMOXAPINE 44 ARIXTRA 28 AMOXICILLIN 60 ARMODAFINIL 10 AMOXICILLIN-CLAVULANATE ER 60 ARMOUR THYROID 71 AMOXICILLIN/POTASSIUM CLAV 60 ARNUITY ELLIPTA 34 AMPHET ASP/AMPHET/D-AMPHET 4 ARTANE 15 AMPHETAMINE SALT COMBO 4 ARTHROTEC 50 56 AMPICILLIN TRIHYDRATE 60 ARTHROTEC 75 56 AMPYRA 50 ASACOL 8

77 of 104 A (cont.) A (cont.) ASACOL HD 8 AZELASTINE HCL 12 ASCOMP WITH CODEINE 57 AZELASTINE/FLUTICASONE 12 ASENAPINE MALEATE 23 AZELEX 68 ASFOTASE ALFA INJECTION 43 AZILECT 52 ASMANEX 35 AZILSARTAN MED/CHLORTHALIDONE 9 ASPIRIN EXTENDED-RELEASE CAPSULES 55 AZILSARTAN MEDOXOMIL 9 ASPIRIN/DIPYRIDAMOLE 62 AZITHROMYCIN 14, 50, 51 ASTELIN 12 AZOPT 29 ASTEPRO 12 AZOR 36 ATACAND 9 AZTREONAM 27 ATACAND HCT 9 AZTREONAM LYSINE 52 ATAZANAVIR SULFATE 63 AZURETTE 32 ATELVIA 28 ATENOLOL 26 B ATENOLOL-CHLORTHALIDONE 26 B-NEXA 54 ATENOLOL/CHLORTHALIDONE 26 BACITRACIN 13 ATEZOLIZUMAB FOR INJECTION 52 BACITRACIN/POLYMYXIN B SULFATE 13 ATIVAN 25 BACLOFEN 42 ATOMOXETINE HCL 4 BACTROBAN 14 ATOPICLAIR 39 BACTROBAN NASAL 14 ATORVASTATIN CALCIUM 45 BAICALIN/CATECHIN/CITRATED ZNC 59 ATOVAQUONE-PROGUANIL HCL 19 BALSALAZIDE DISODIUM 11 ATOVAQUONE/PROGUANIL HCL 19 BALZIVA 33 ATRALIN 30 BANZEL 69 ATRAPRO HYDROGEL 39 BARACLUDE 56 ATRIPLA 21 BAVENCIO 52 ATROPINE CARE 54 BECAPLERMIN 68 ATROPINE SULFATE 54 BECLOMETHASONE DIPROPIONATE 34 ATROPINE SULFATE/PF 54 BECONASE AQ 34 ATROVENT HFA 19 BEDAQUILINE 22 AUBAGIO 50 BELATACEPT 70 AUGMENTIN 60 BELBUCA 58 AURAX 49 BELEODAQ 45 AURODEX 49 BELIMUMAB 24 AURYXIA 60 BELINOSTAT 45 AUSTEDO 30 BELLADONNA-PHENOBARBITAL 21 AVALIDE 9 BELVIQ 4 AVANAFIL 61 BENAZEPRIL HCL 9 AVAPRO 9 BENAZEPRIL-HYDROCHLOROTHIAZIDE 9 AVASTIN 13 BENAZEPRIL/HYDROCHLOROTHIAZIDE 9 AVELOX 64 BENDAMUSTINE 6 AVELOX ABC PACK 64 BENICAR 9 AVELUMAB INJECTION 52 BENICAR HCT 9 AVIANE 32 BENLYSTA 24 AVINZA 57 BENZAC AC 48 AVITA 30 BENZACLIN 14 AVODART 4 BENZAMYCINPAK 14 AVONEX 50 BENZEFOAM ULTRA 48 AVONEX ADMINISTRATION PACK 50 BENZEPRO 48 AVONEX PEN 50 BENZONATATE 22 AXERT 66 BENZOYL PEROXIDE 48 AXIRON 62 BENZOYL PEROXIDE/HYDROCORTISON 5 AZACTAM 27 BENZTROPINE MESYLATE 15 AZASITE 14 BENZYL ALCOHOL 66 AZATHIOPRINE 45 BEPOTASTINE BESILATE 12 AZELAIC ACID 68 BEPREVE 12 AZELASTINE 12 BESIFLOXACIN HCL 14

78 of 104 B (cont.) B (cont.) BESIVANCE 14 BROMDAY 39 BETA-VAL 5 BROMFED DM 22 BETAMETHASONE DIPROPIONATE 5 BROMFENAC SODIUM 39 BETAMETHASONE VALERATE 5 BROMOCRIPTINE MESYLATE 37 BETASERON 50 BROMPHENIRAMIN/PE/DEXTROMETHOR 22 BETAXOLOL HCL 26 BROVANA 26 BETHANECHOL CHLORIDE 59 BUDEPRION SR 67 BETIMOL 27 BUDEPRION XL 67 BETOPTIC S 26 BUDESONIDE 5, 34, 35 BEVACIZUMAB 13 BUDESONIDE EC 5 BEVESPI AEROSPHERE 64 BUDESONIDE/FORMOTEROL FUMARATE 34 BEXSERO 73 BUMETANIDE 50 BEYAZ 33 BUPRENORPHINE 58 BEZLOTOXUMAB INJECTION 15 BUPRENORPHINE BUCCAL FILM 58 BIAFINE 39 BUPRENORPHINE HCL/NALOXONE HCL 58 BICALUTAMIDE 19 BUPRENORPHINE IMPLANT 58 BICILLIN LA 60 BUPRENORPHINE/NALOXONE SL TABS 58 BILTRICIDE 10 BUPROBAN 68 BIMATOPROST 63 BUPROPION HBR 67 BINOSTO 28 BUPROPION HCL 67 BISAC/NACL/NAHCO3/KCL/PEG 3350 49 BUPROPION HCL SR 67, 68 BISMUTH SAL/METRONID/TETRACYC 15 BUPROPION SR 68 BISMUTH TRIBROMOPH/PETROLATUM 36 BUPROPION XL 67 BISMUTH/METRONID/TETRACYCLINE 15 BUSPIRONE HCL 23 BISOPROLOL FUMARATE 26 BUSULFAN 6 BISOPROLOL FUMARATE/HCTZ 26 BUTALB-CAFF-ACETAMINOPH-CODEIN 57 BISOPROLOL-HYDROCHLOROTHIAZIDE 26 BUTALB/ACETAMINOPHEN/CAFFEINE 8 BLEPH-10 14 BUTALBIT/ACETAMIN/CAFF/CODEINE 57 BLEPHAMIDE 14 BUTALBITAL COMPOUND-CODEINE 57 BLEPHAMIDE S.O.P. 14 BUTALBITAL-ACETAMINOPHEN-CAFFE 8 BOCEPREVIR 18 BUTALBITAL-ASPIRIN-CAFFEINE 55 BONIVA 28 BUTALBITAL/ACETAMINOPHEN 8 BORTEZOMIB 64 BUTALBITAL/ASPIRIN/CAFFEINE 55 BOSENTAN 74 BUTRANS 58 BOTOX 55 BYDUREON 46 BP 10-1 48 BYDUREON BCISE 46 BP WASH 48 BYETTA 46 BP WASH ACNE TREATMENT 48 BYSTOLIC 26 BPO 48 Basaglar KwikPen 47 BRAVELLE 43 BREATHERITE 35 C BRENTUXIMAB 52 C1 ESTERASE INHIBITOR 28 BREO ELLIPTA 35 CABERGOLINE 38 BREVICON 33 CABOMETYX 20 BREXPIPRAZOLE 24 CABOZANTINIB 20 BRIELLYN 32 CAFERGOT 40 BRILINTA 62 CALAN SR 29 BRIMONIDINE TARTRATE 7 CALCIFEDIOL EXTENDED-RELEASE CAPSULES 74 BRIMONIDINE TARTRATE/TIMOLOL 7 CALCIPOTRIENE 67, 68 BRIMONIDINE TOPICAL 7 CALCIPOTRIENE/BETAMETHASONE 5 BRINTELLIX 66 CALCITONIN,SALMON,SYNTHETIC 60 BRINZOLAMIDE 29 CALCITONIN-SALMON 60 BRISDELLE 66 CALCITRENE 67 BRIVARACETAM FOR INJECTION 16 CALCITRIOL 68, 74 BRIVARACETAM ORAL SOLUTION 16 CALCIUM ACETATE 61 BRIVARACETAM TABLETS 16 CAMBIA 56 BRIVIACT 16 CAMILA 32

79 of 104 C (cont.) C (cont.) CAMPRAL 5 CEFOTAXIME 31 CAMRESE 32 CEFOTETAN 31 CAMRESE LO 32 CEFOXITAN 31 CANAGLIFLOZIN 69 CEFPROZIL 30 CANAKINUMAB 52 CEFRADINE 31 CANASA 11 CEFTIBUTEN 31 CANDESARTAN 9 CEFTIBUTEN DIHYDRATE 31 CANDESARTAN CILEXETIL 9 CEFTIN 31 CANDESARTAN-HYDROCHLOROTHIAZID 9 CEFUROXIME 31 CANDESARTAN/HYDROCHLOROTHIAZID 9 CEFUROXIME AXETIL 31 CAPASTAT 8 CELEBREX 56 CAPECITABINE 20 CELECOXIB 55, 56 CAPEX SHAMPOO 11 CELEXA 67 CAPHOSOL 35 CELLCEPT 46 CAPREOMYCIN 8 CELONTIN 16 CAPSAICIN 71 CENESTIN 40 CAPTOPRIL 9 CEPHALEXIN 31 CAPTOPRIL-HYDROCHLOROTHIAZIDE 9 CERDELGA 39 CAPTOPRIL/HYDROCHLOROTHIAZIDE 9 CEREFOLIN NAC 74 CARAC 68 CERITINIB 48 CARAFATE 64 CERTOLIZUMAB PEGOL 42 CARBAGLU 59 CETACAINE 21 CARBAMAZEPINE 16, 53, 69 CETRORELIX ACETATE 43 CARBAMAZEPINE ER 69 CETROTIDE 43 CARBAMAZEPINE XR 69 CEVIMELINE HCL 59 CARBATROL 69 CHANTIX 68 CARBENICILLIN 60 CHERATUSSIN AC 22 CARBIDOPA 20 CHERATUSSIN DAC 22 CARBIDOPA-LEVODOPA 38 CHLORAL HYDRATE 23 CARBIDOPA-LEVODOPA-ENTACAPONE 38 CHLORAMBUCIL 6 CARBIDOPA/LEVODOPA 38 CHLORDIAZEPOXIDE HCL 25 CARBIDOPA/LEVODOPA/ENTACAPONE 38 CHLORDIAZEPOXIDE-CLIDINIUM 19 CARDENE SR 36 CHLORDIAZEPOXIDE/CLIDINIUM BR 19 CARDIZEM CD 29 CHLORHEXIDINE GLUCONATE 38 CARDIZEM LA 29 CHLOROQUINE 20 CARDURA XL 7 CHLOROQUINE PHOSPHATE 18 CARGLUMIC ACID 59 CHLOROTHIAZIDE 71 CARIPRAZINE 24 CHLORPROMAZINE HCL 72 CARISOPRODOL 30 CHLORTHALIDONE 71 CARMUSTINE 6 CHLORZOXAZONE 30 CARNITOR 58 CHOLBAM 24 CARNITOR SF 58 CHOLERA VACCINE, LIVE, ORAL SUSPENSION 73 CARTIA XT 29 CHOLESTYRAMINE 27 CARVEDILOL 26 CHOLESTYRAMINE (WITH SUGAR) 27 CARVEDILOL PHOSPHATE 26 CHOLESTYRAMINE LIGHT 27 CAYSTON 52 CHOLESTYRAMINE/ASPARTAME 27 CAZIANT 32 CHOLIC ACID CAPSULES 24 CEDAX 31 CHORIONIC GONADOTROPIN 43 CEENU 6 CHORIONIC GONADOTROPIN, HUMAN 43 CEFACLOR 30 CIALIS 61 CEFADROXIL 30 CICLESONIDE 34, 35 CEFADROXIL HYDRATE 30 CICLOPIROX 17 CEFAZOLIN 30 CICLOPIROX/NAIL LACQ/FT DEOD#4 17 CEFDINIR 30 CIDOFOVIR 10 CEFEPIME 31 CILOSTAZOL 62 CEFIXIME 31 CILOXAN 14 CEFOTAN 31 CIMETIDINE 44

80 of 104 C (cont.) C (cont.) CIMZIA 42 CLORAZEPATE DIPOTASSIUM 25 CINACALCET HCL 58 CLOTRIMAZOLE 17, 24 CINQAIR 53 CLOTRIMAZOLE-BETAMETHASONE 5 CIPRO 64 CLOTRIMAZOLE/BETAMETHASONE DIP 5 CIPRO HC 13 CLOZAPINE 72 CIPRODEX 13 COAGADEX 17 CIPROFLOXACIN HCL 13, 14, 64 COAGULATION FACTOR IX 44 CIPROFLOXACIN HCL/DEXAMETH 13 COAGULATION FACTOR IX RECOMBINANT FOR INJ CIPROFLOXACIN/FLUOCINOLONE ACETONIDE 13 17 CIPROFLOXACIN/HYDROCORTISONE 13 COAGULATION FACTOR IX, RECOMBINANT 17 CISPLATIN 6 COAGULATION FACTOR VIII, RECOMBINANT 17 CITALOPRAM HBR 66 COAGULATION FACTOR X [HUMAN] FOR INJECTION CITALOPRAM HYDROBROMIDE 66, 67 17 CITRANATAL 90 DHA 54 COAGULATION FACTOR XIII 44 CITRANATAL ASSURE 54 COAL TAR 48 CITRANATAL B-CALM 54 COBICISTAT 10 CITRANATAL DHA 54 COBIMETINIB TABLETS 50 CITRANATAL HARMONY 54 CODEINE/BUTALBITAL/ASA/CAFFEIN 57 CITRIC ACID/SODIUM CITRATE 6 CODEINE/PROMETHAZINE HCL 22 CLAFORAN 31 COLCHICINE 73 CLARAVIS 68 COLCHICINE/PROBENECID 73 CLARIFOAM EF 48 COLCRYS 73 CLARINEX 66 COLESEVELAM HCL 27 CLARINEX-D 12 HOUR 66 COLESTIPOL HCL 27 CLARINEX-D 24 HOUR 66 COLLAGENASE CLOSTRIDIUM 64 CLARITHROMYCIN 50 COLLAGENASE CLOSTRIDIUM HIST. 68 CLARITHROMYCIN ER 50 COLOCORT 11 CLEANSING WASH 49 COLY-MYCIN S 13 CLENIA 48 COLYTE WITH FLAVOR PACKETS 49 CLEOCIN 15 COMBIGAN 7 CLEOCIN HCL 15 COMBIPATCH 41 CLEOCIN PALMITATE 15 COMBIVENT 19 CLIMARA 40 COMBIVENT RESPIMAT 19 CLIMARA PRO 40 COMBIVIR 56 CLINDAGEL 14 COMETRIQ 20 CLINDAMYCIN HCL 15 COMPLERA 21 CLINDAMYCIN PALMITATE HCL 15 COMPRO 18 CLINDAMYCIN PHOS-BENZOYL PEROX 14 COMTAN 30 CLINDAMYCIN PHOS/BENZOYL PEROX 14 CONCERTA 10 CLINDAMYCIN PHOSPHATE 14, 15 CONDYLOX 68 CLINDAMYCIN-BENZOYL PEROXIDE 14 CONTRAVE 58 CLINDAMYCIN/TRETINOIN 14 COPAXONE 50 CLOBAZAM 25 COPEGUS 18 CLOBETASOL EMOLLIENT 11 CORDRAN 11 CLOBETASOL PROPIONATE 11 CORDRAN SP 11 CLOBETASOL PROPIONATE/EMOLL 11 COREG 26 CLOBEX 11 COREG CR 26 CLOCORTOLONE PIVALATE 11 CORGARD 26 CLODERM 11 CORMAX 11 CLOFAZIMINE 49 CORTEF 5 CLOMIPHENE CITRATE 40 CORTICOTROPIN 5, 34 CLOMIPRAMINE HCL 72 CORTIFOAM 12 CLONAZEPAM 25 CORTISONE ACETATE 5 CLONIDINE 4, 6 CORTISPORIN-TC 13 CLONIDINE HCL 7 COSENTYX 47 CLOPIDOGREL 62 COSOPT 29 CLOPIDOGREL BISULFATE 28, 62 COSOPT PF 29

81 of 104 C (cont.) D (cont.) COTELLIC 50 DARZALEX 52 COUMADIN 15 DASATINIB 20 COVARYX H.S. 61 DASETTA 33 COZAAR 9 DAYPRO 56 CREON 36 DAYTRANA 10 CRESEMBA 24 DDAVP 61 CRESTOR 45 DEFERASIROX 31 CRINONE 63 DEFLAZACORT 34 CRIXIVAN 63 DELATESTRYL 62 CRIZOTINIB 20 DELAVIRDINE 55 CROFELEMER 16 DEMECLOCYCLINE HCL 71 CROMOLYN SODIUM 51 DENAVIR 22 CROTAMITON 65 DENOSUMAB 52 CRYSELLE 33 DEPAKOTE 42 CUTIVATE 11 DEPAKOTE ER 42 CYANOCOBALAMIN (VITAMIN B-12) 74 DEPAKOTE SPRINKLE 42 CYANOCOBALAMIN INJECTION 74 DEPO-ESTRADIOL 41 CYANOCOBALAMIN/FA/PYRIDOXINE 74 DEPO-TESTOSTERONE 9 CYCLAFEM 32 DERMA-SMOOTHE-FS 11 CYCLOBENZAPRINE HCL 30 DERMOTIC 34 CYCLOGYL 54 DESAMETHASONE INTRAVITREAL 56 CYCLOPENTOLATE HCL 54 DESIPRAMINE HCL 72 CYCLOPHOSPHAMIDE 6 DESLORATADINE 66 CYCLOSET 37 DESLORATADINE/PSEUDOEPHEDRINE 66 CYCLOSPORINE 38, 46 DESMOPRESSIN (NONREFRIGERATED) 61 CYCLOSPORINE MODIFIED 46 DESMOPRESSIN ACETATE 61 CYCLOSPORINE, MODIFIED 46 DESOG-ET ESTRA/ETHIN ESTRA 31, 32, 33 CYMBALTA 67 DESOGEN 33 CYPROHEPTADINE HCL 41 DESOGESTREL-ETHINYL ESTRADIOL 32, 33 CYRAMZA 39 DESONATE 11 CYSTARAN 35 DESONIDE 11 CYSTEAMINE 35, 54 DESOXIMETASONE 11 CYTOMEL 71 DESVENLAFAXINE SUCCINATE 16 CYTOVENE 46 DETROL 42 CYTRA-2 6 DETROL LA 42 CYTRA-K 6 DEUTETRABENAZINE TABLETS 30 Corlanor 29 DEX-TUSS 22 DEXAMETHASONE 5 D DEXAMETHASONE INTENSOL 5 D-METHORPHAN HB/P-EPD HCL/BPM 22 DEXEDRINE 4 D-METHORPHAN HB/PROMETH HCL 22 DEXILANT 64 DABIGATRAN ETEXILATE MESYLATE 15 DEXLANSOPRAZOLE 64 DABRAFENIB 24 DEXMETHYLPHENIDATE HCL 10 DACLATASVIR 18 DEXTROAMPHETAMINE SULFATE 4 DAKLINZA 18 DEXTROAMPHETAMINE-AMPHETAMINE 4 DALFAMPRIDINE 50 DEXTROMETHORPHAN HBR/QUINIDINE 30 DALIRESP 65 DIAMOX SEQUELS 29 DALTEPARIN SODIUM,PORCINE 15 DIAPHRAGMS, ARC-SPRING 33 DANAZOL 9 DIASTAT ACUDIAL 25 DANTROLENE SODIUM 37 DIAZEPAM 25, 27 DAPAGLIFLOZIN 69 DICHLORALPHENAZONE 23 DAPSONE 49, 68 DICLEGIS 16 DARAPRIM 19 DICLOFENAC EPOLAMINE 56 DARATUMUMAB INJECTION 52 DICLOFENAC POTASSIUM 56 DARBEPOETIN ALFA 15 DICLOFENAC SODIUM 55, 56, 68 DARIFENACIN HYDROBROMIDE 42 DICLOFENAC SODIUM-MISOPROSTOL 55 DARUNAVIR ETHANOLATE 63 DICLOFENAC SODIUM/MISOPROSTOL 55, 56

82 of 104 D (cont.) D (cont.) DICLOXACILLIN SODIUM 60 DUAC 14 DICYCLOMINE HCL 19 DUAVEE 40 DIDANOSINE 21 DULAGLUTIDE 46 DIFFERIN 68 DULERA 35 DIFLUCAN 24 DULOXETINE 67 DIFLUPREDNATE 34 DULOXETINE HCL 67 DIGOXIN 13 DUOPA 38 DIHYDROERGOTAMINE MESYLATE 7, 40 DUPILUMAB SUBCUTANEOUS INJECTION 52 DILANTIN 69 DUPIXENT 52 DILAUDID 57 DURAGESIC 57 DILT-XR 29 DUREZOL 34 DILTIAZEM 24HR CD 29 DURLAZA 55 DILTIAZEM 24HR ER 29 DUTASTERIDE 4 DILTIAZEM ER 29 DUTASTERIDE/TAMSULOSIN HCL 4 DILTIAZEM HCL 28, 29 DYAZIDE 62 DIMETHYL FUMARATE 50 DYMISTA 12 DINUTUXIMAB FOR INJECTION 20 DYRENIUM 62 DIOVAN 9 DIOVAN HCTZ 9 E DIPHENHYDRAMINE HCL 41 E-Z SPACER 35 DIPHENOXYLATE HCL/ATROPINE 16 E.E.S. 200 51 DIPHENOXYLATE-ATROPINE 16 E.E.S. 400 51 DISOPYRAMIDE PHOSPHATE 13 EASIVENT 35 DISULFIRAM 5 EASY TOUCH 36 DIURIL 71 ECONAZOLE NITRATE 17 DIVALPROEX SODIUM 41, 42 EDARBI 9 DIVALPROEX SODIUM ER 42 EDARBYCLOR 9 DIVIGEL 40 EDECRIN 50 DOFETILIDE 13 EDEX 74 DOLASETRON 4 EDLUAR 23 DOLUTEGRAVIR 10 EDOXABAN 27 DONEPEZIL HCL 31 EDURANT 55 DONNATAL 21 EEMT 62 DORNASE ALFA 40 EEMT H.S. 62 DORYX 71 EFAVIRENZ 21, 55 DORZOLAMIDE HCL 29 EFAVIRENZ/EMTRICITAB/TENOFOVIR 21 DORZOLAMIDE HCL/TIMOLOL MALEAT 29 EFFER-K 65 DORZOLAMIDE-TIMOLOL 29 EFFEXOR XR 67 DORZOLAMIDE/TIMOLOL/PF 29 EFFIENT 62 DOVONEX 68 EFINACONAZOLE 24 DOXAZOSIN 24 EGRIFTA 43 DOXAZOSIN MESYLATE 7, 24 ELESTAT 12 DOXEPIN HCL 16, 21, 72 ELESTRIN 40 DOXERCALCIFEROL 74 ELETRIPTAN HBR 66 DOXYCYCLINE HYCLATE 71 ELIDEL 68 DOXYCYCLINE HYCLATE CAPSULE 71 ELIGLUSTAT 39 DOXYCYCLINE HYCLATE DR TABLETS 71 ELINEST 33 DOXYCYCLINE HYCLATE IR TABLETS 71 ELIQUIS 27 DOXYCYCLINE MONOHYDRATE 71 ELLA 33 DOXYLAMINE/PYRIDOXINE 16 ELMIRON 59 DRITHOCREME HP 48 ELOCON 11 DRONEDARONE HCL 13 ELOCTATE 17 DROPERIDOL 38 ELOSULFASE ALFA 39 DROSPIR/ETH ESTRA/LEVOMEFOL CA 33 ELOTUZUMAB INJECTION 52 DROSPIRENONE/ESTRADIOL 41 ELTROMBOPAG OLAMINE 43 DROXIDOPA 6 ELUXADOLINE TABLETS 42 DRYSOL 23 ELVITEGRAVIR 47

83 of 104 E (cont.) E (cont.) ELVITEGRAVIR/COBIC/EMT/TENOFOVIR 10 EPZICOM 56 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOF EQUETRO 16 OVIR ALAFENAMIDE 11 ERGOCALCIFEROL (VITAMIN D2) 74 EMEND 70 ERGOMAR 40 EMFLAZA 34 ERGOTAMINE TARTRATE 40 EMOLLIENT COMBINATION NO.10 39 ERGOTAMINE TARTRATE/CAFFEINE 7, 40 EMOLLIENT COMBINATION NO.32 39 ERIVEDGE 20 EMOLLIENT COMBINATION NO.35 39 ERLOTINIB HCL 20 EMOLLIENT COMBINATION NO.43 39 ERRIN 32 EMOLLIENT COMBINATION NO.44 39 ERTACZO 17 EMOLLIENT COMBINATION NO.53 39 ERY 14 EMOLLIENT COMBINATION NO.60 39 ERY-TAB 51 EMOQUETTE 32 ERYPED 200 51 EMPAGLIFLOZIN 69 ERYPED 400 51 EMPLICITI 52 ERYTHROCIN STEARATE 51 EMSAM 52 ERYTHROMYCIN 50 EMTRICITAB/RILPIVIRINE/TENOFOV 21 ERYTHROMYCIN BASE 14, 50, 51 EMTRICITABINE 21 ERYTHROMYCIN BASE/ETHANOL 14 EMTRICITABINE/RILPIVIRINE/TENOFOVIR 56 ERYTHROMYCIN ETHYLSUCCINATE 51 EMTRICITABINE/TENOFOVIR 56 ERYTHROMYCIN STEARATE 51 EMTRIVA 21 ERYTHROMYCIN-BENZOYL PEROXIDE 14 ENABLEX 42 ERYTHROMYCIN/BENZOYL PEROXIDE 14 ENALAPRIL MALEATE 9, 10 ESBRIET 70 ENALAPRIL-HYDROCHLOROTHIAZIDE 9 ESCITALOPRAM OXALATE 66, 67 ENALAPRIL/HYDROCHLOROTHIAZIDE 9 ESLICARBAZEPINE 69 ENBREL 37 ESOMEPRAZOLE MAGNESIUM 64 ENDOCET 57 ESTAZOLAM 25 ENDODAN 57 ESTRACE 0.01% CREAM 40 ENDOMETRIN 63 ESTRACE TABLETS 40 ENFUVIRTIDE 11 ESTRADIOL 40, 41 ENJUVIA 40 ESTRADIOL ACETATE 40 ENOXAPARIN SODIUM 15 ESTRADIOL CYPIONATE 41 ENPRESSE 32 ESTRADIOL MICRONIZED 40 ENTACAPONE 29, 30 ESTRADIOL VALERATE/DIENOGEST 33 ENTECAVIR 56 ESTRADIOL-NORETHINDRONE ACETAT 40 ENTOCORT EC 5 ESTRADIOL/LEVONORGESTREL 40 ENTRESTO 29 ESTRADIOL/NORETHINDRONE ACET 40, 41 ENTYVIO 75 ESTRADIOL/NORGESTIMATE 40 ENULOSE 8 ESTRING 40 ENZALUTAMIDE 12 ESTROGEL 40 EPCLUSA 18 ESTROGEN & METHYLTESTOSTERONE 62 EPICERAM 39 ESTROGEN,CON/M-PROGEST ACET 40 EPIDRIN 8 ESTROGEN,ESTER/ME-TESTOSTERONE 61, 62 EPIDUO 68 ESTROGEN/BAZEDOXIFENE 40 EPIFLUR 29 ESTROGENS, CONJUGATED 40 EPIFOAM 5 ESTROGENS,CONJ.,SYNTHETIC A 40 EPIKLOR 65 ESTROGENS,CONJ.,SYNTHETIC B 40 EPINASTINE HCL 12 ESTROGENS,ESTERIFIED 41 EPINEPHRINE 6, 7, 70 ESTROPIPATE 40 EPIPEN 7 ESTROSTEP FE 33 EPIPEN 2-PAK 7 ESZOPICLONE 23 EPIPEN JR 7 ETANERCEPT 37 EPIPEN JR 2-PAK 7 ETEPLIRSEN INJECTION 21 EPITOL 16 ETHACRYNIC ACID 50 EPIVIR HBV 56 ETHAMBUTOL HCL 22 EPOETIN ALFA 43, 44 ETHINYL ESTRADIOL/DROSPIRENONE 33 EPOGEN 44 ETHOSUXIMIDE 28

84 of 104 E (cont.) F (cont.) ETHYNODIOL D-ETHINYL ESTRADIOL 32 FETZIMA 67 ETODOLAC 55 FEXOFENADINE HCL 66 ETONOGESTREL/ETHINYL ESTRADIOL 33 FEXOFENADINE-PSE ER 66 ETRAVIRINE 21, 55 FEXOFENADINE/PSEUDOEPHEDRINE 66 EURAX 65 FILGRASTIM 44 EVAMIST 40 FINACEA 68 EVEROLIMUS 20 FINASTERIDE 4 EVISTA 40 FINGOLIMOD HCL 53 EVOLOCUMAB 59 FIORICET 8 EVOXAC 59 FIORINAL 55 EVZIO 58 FIRAZYR 31 EXALGO 57 FLAGYL 52 EXELDERM 17 FLAGYL ER 52 EXELON PATCH 31 FLAREX 34 EXEMESTANE 23 FLAVOXATE HCL 42 EXENATIDE 46 FLECAINIDE ACETATE 13 EXENATIDE EXTENDED RELEASE 46 FLECTOR 56 EXENATIDE MICROSPHERES 46 FLIBANSERIN 50 EXFORGE 28 FLO-PRED 5 EXFORGE HCT 28 FLOMAX 7, 24 EXJADE 31 FLONASE 34 EXONDYS 51 21 FLOVENT DISKUS 34 EYE LUBRICANT COMBINATION NO.1 39 FLOVENT HFA 34 EYLEA 73 FLUCONAZOLE 24 EZETIMIBE 38 FLUCYTOSINE 17 EZETIMIBE/SIMVASTATIN 38 FLUDROCORTISONE ACETATE 5 EZOGABINE 16 FLUNISOLIDE 34 FLUOCINOLONE ACETONIDE 11 F FLUOCINOLONE ACETONIDE OIL 34 FABRAZYME 39 FLUOCINONIDE 11 FAMCICLOVIR 56 FLUOCINONIDE EMOLLIENT 11 FAMOTIDINE 44 FLUOCINONIDE-E 11 FAMVIR 56 FLUOCINONIDE/EMOLLIENT 11 FANAPT 24 FLUOR-A-DAY 29 FARESTON 20 FLUORABON 29 FARXIGA 69 FLUORIDE 29 FARYDAK 45 FLUORIDE/IRON/VIT A,C FEBUXOSTAT 74 FLUORIDE/VITAMINS A,C,AND D 53 FELBAMATE 15 FLUORITAB 29 FELODIPINE 36 FLUOROMETHOLONE 34 FELODIPINE ER 36 FLUOROMETHOLONE ACETATE 34 FEMARA 20 FLUOROURACIL 68 FEMCON FE 33 FLUOXETINE DR 67 FEMHRT 40 FLUOXETINE HCL 67 FEMRING 40 FLUOXETINE HCL CAPSULE 67 FENOFIBRATE 41 FLUOXETINE HCL DR CAPSULE 67 FENOFIBRATE NANOCRYSTALLIZED 41 FLUOXETINE HCL TABLETS 67 FENOFIBRATE,MICRONIZED 41 FLUPHENAZINE HCL 72 FENOFIBRIC ACID 41 FLURA-DROPS 29 FENOFIBRIC ACID (CHOLINE) 41 FLURANDRENOLIDE 11 FENOGLIDE 41 FLURAZEPAM HCL 25 FENTANYL 57 FLUTICASONE FUROATE 34 FENTANYL CITRATE 57 FLUTICASONE PROPIONATE 11, 34 FENTANYL TRANSDERMAL 57 FLUTICASONE/SALMETEROL 35, 70 FENTORA 57 FLUTICASONE/VILANTEROL 35 FERRIC CITRATE 60, 61 FLUVASTATIN SODIUM 45 FESOTERODINE FUMARATE 42 FLUZONE 12

85 of 104 F (cont.) G (cont.) FML FORTE 34 GEODON 24 FML S.O.P. 34 GILDESS 32 FOCALIN 10 GILDESS FE 32 FOCALIN XR 10 GILENYA 53 FOLCAL DHA 54 GILOTRIF 72 FOLGARD RX 74 GLATIRAMER ACETATE 50 FOLIC ACID 74 GLATOPA 50 FOLLISTIM AQ 43 GLECAPREVIR/PIBRENTASVIR 18 FOLLITROPIN ALFA, RECOMB 43 GLEEVEC 20 FOLLITROPIN BETA,RECOMB 43 GLIMEPIRIDE 70 FONDAPARINUX SODIUM 15, 28 GLIPIZIDE 70 FORADIL 70 GLIPIZIDE ER 70 FORFIVO XL 67 GLIPIZIDE XL 70 FORMALDEHYDE 68 GLIPIZIDE-METFORMIN 70 FORMOTEROL FUMARATE 70 GLIPIZIDE/METFORMIN HCL 70 FORTAMET 27 GLUCAGEN 42 FORTEO 60 GLUCAGON EMERGENCY KIT 42 FORTESTA 62 GLUCAGON,HUMAN RECOMBINANT 42 FORTICAL 60 GLUCOPHAGE 27 FOSAMAX 28 GLUCOPHAGE XR 27 FOSAMAX PLUS D 28 GLUCOTROL XL 70 FOSAMPRENAVIR CALCIUM 63 GLUCOVANCE 70 FOSFOMYCIN TROMETHAMINE 73 GLUMETZA 27 FOSINOPRIL SODIUM 9 GLY/CARB HOMOPOLY A/POT HYDROX 35 FOSINOPRIL-HYDROCHLOROTHIAZIDE 9 GLYBURIDE 70 FOSINOPRIL/HYDROCHLOROTHIAZIDE 9 GLYBURIDE-METFORMIN HCL 70 FOSRENOL 61 GLYBURIDE/METFORMIN HCL 70 FRAGMIN 15 GLYCEROL PHENYLBUTYRATE 55 FRESHKOTE 39 GLYCOPYRROLATE 19 FROVA 66 GLYCOPYRROLATE INHALATION POWDER 19 FROVATRIPTAN SUCCINATE 66 GLYCOPYRROLATE/FORMOTEROL FUMARATE FULYZAQ 16 INHALATION 64 FUROSEMIDE 50 GLYSET 7 FUZEON 11 GOLIMUMAB 37 FYCOMPA 4 GOLYTELY 49 GOLYTELY PACKETS 49 G GONAL-F 43 GABAPENTIN 41, 42 GONAL-F RFF 43 GABAPENTIN ENACARBIL 41 GRALISE 42 GABITRIL 16, 42 GRANISETRON 4 GALANTAMINE 31 GRANISETRON EXTENDED-RELEASE INJECTION 4 GANCICLOVIR 10, 46 GRANISETRON HCL 4 GANIRELIX ACETATE 43 GRANIX 43 GARDASIL/CERVARIX 22 GRASS POLLEN 6 GATIFLOXACIN 14 GRASTEK 6 GATTEX 42 GRAZOPREVIR/ELBASVIR 18 GAVILYTE 49 GRIFULVIN V 17 GELNIQUE 42 GRIS-PEG 17 GEMFIBROZIL 41 GRISEOFULVIN 17 GENERESS FE 33 GRISEOFULVIN ULTRAMICROSIZE 17 GENERLAC 8 GRISEOFULVIN,MICROSIZE 17 GENGRAF 46 GUAIFENESIN AC 22 GENOTROPIN 61 GUAIFENESIN DAC 22 GENTAK 13 GUAIFENESIN-CODEINE 22 GENTAMICIN 8 GUAIFENESIN/CODEINE PHOSPHATE 22 GENTAMICIN SULFATE 13 GUANFACINE HCL 4, 30 GENVOYA 11 H H.P. ACTHAR 5

86 of 104 H (cont.) H (cont.) HALCINONIDE 11 HYDROCORTISONE BUTYRATE/EMOLL 5 HALFLYTELY-BISACODYL 49 HYDROCORTISONE VALERATE 5 HALOBETASOL PROPIONATE 11 HYDROCORTISONE-ACETIC ACID 51 HALOBETASOL PROPIONATE CREAM AND HYDROCORTISONE-IODOQUINOL 49 OINTMENT 11 HYDROCORTISONE-PRAMOXINE 12 HALOBETASOL PROPIONATE LOTION 11 HYDROCORTISONE/IODOQUINOL 49 HALOG 11 HYDROCORTISONE/PRAMOXINE 5, 12 HALOPERIDOL 72 HYDROCORTISONE/PRAMOXINE/ALOE 5 HALOPERIDOL LACTATE 72 HYDROMET 22 HARVONI 18 HYDROMORPHONE ER 57 HCG ALPHA,RECOMBINANT 43 HYDROMORPHONE HCL 57 HEATHER 32 HYDROXYCHLOROQUINE SULFATE 18, 19 HECTOROL 74 HYDROXYPROGESTERONE CAPROATE 63 HELIDAC 15 HYDROXYPROPYL CELLULOSE 39 HEMANGEOL 26 HYDROXYUREA 19 HEMENATAL OB 54 HYDROXYZINE HCL 23 HEMENATAL OB + DHA 53 HYDROXYZINE PAMOATE 23 HEMRIL 12 HYLATOPIC 39 HEPARIN 28 HYLATOPIC PLUS 39 HEPSERA 56 HYOMAX-FT 21 HERCEPTIN 43 HYOMAX-SL 21 HETLIOZ 51 HYOMAX-SR 21 HEXACHLOROPHENE 50 HYOSCYAMINE SULFATE 21 HIZENTRA 67 HYPER-SAL 65 HOMATROPAIRE 54 HYPERCARE 23 HOMATROPINE HBR 54 HYSINGLA ER 57 HORIZANT 41 HPR PLUS 39 I HUM INSULIN NPH/REG INSULIN HM 47 IBANDRONATE SODIUM 28 HUMALOG 47 IBRANCE 72 HUMALOG MIX 50-50 47 IBUDONE 57 HUMALOG MIX 75-25 47 IBUPROFEN 55 HUMAN PAPILLOMAVIRUS 22 ICATIBANT ACETATE 31 HUMAPEN LUXURA HD 35 ICLUSIG 20 HUMATROPE 61 IDELALISIB 48 HUMIRA 37 IDELVION 17 HUMIRA PEDIATRIC CROHNS 37 ILARIS 52 HUMULIN 70-30 47 ILOPERIDONE 24 HUMULIN N 47 ILOPROST 63 HUMULIN R 47 IMATINIB MESYLATE 19, 20 HYDRALAZINE HCL 37 IMBRUVICA 72 HYDROCHLOROTHIAZIDE 71 IMDUR 55 HYDROCODONE BIT-IBUPROFEN 57 IMIPENEM 27 HYDROCODONE BIT/ACETAMINOPHEN 57 IMIPENEM/CILASTATIN 27 HYDROCODONE BIT/HOMATROP ME-BR 22 IMIPENEM/CILASTATN 27 HYDROCODONE BITARTRATE 57 IMIPRAMINE HCL 72 HYDROCODONE-ACETAMINOPHEN 57 IMIQUIMOD 68 HYDROCODONE-CHLORPHENIRAMINE 22 IMITREX 66 HYDROCODONE-HOMATROPINE MBR 22 IMLYGIC 56 HYDROCODONE-IBUPROFEN 57 IMMUNE GLOBULIN,GAMMA(IGG) 67 HYDROCODONE/CHLORPHEN POLIS 22 IMPAVIDO 4 HYDROCODONE/IBUPROFEN 57 INAPSINE 38 HYDROCORTISONE 5, 11, 12 INCIVEK 18 HYDROCORTISONE AC/LIDOCAINE 49 INDACATEROL MALEATE 26 HYDROCORTISONE ACETATE 12 INDACATEROL/GLYCOPYRROLATE INHALATION HYDROCORTISONE ACETATE SUPPOSITORIES 12 POWDER 64 HYDROCORTISONE BUTYRATE 5 INDAPAMIDE 71

87 of 104 I (cont.) I (cont.) INDERAL LA 26 ISTALOL 26 INDINAVIR 63 ITRACONAZOLE 24 INDOCIN 56 IVERMECTIN 10, 66 INDOMETHACIN 55, 56 IXAZOMIB CAPSULES 64 INFERGEN 45 IXEKIZUMAB FOR SUBCUTANEOUS INJ 45 INFLIXIMAB FOR INJECTION 37 IXINITY 17 INFLUENZA VACCINE 12 Ivabradine HCL 29 INGENOL MEBUTATE 68 INGREZZA 30 J INHALER, ASSIST DEVICES 35, 36 JAKAFI 48 INHALER,ASSIST DEVICE,ACCESORY 35 JALYN 4 INNOPRAN XL 26 JANUMET 37 INSULIN ADMIN. SUPPLIES 35 JANUMET XR 37 INSULIN ASPART 47 JANUVIA 37 INSULIN DEGLUDEC INJECTION 47 JARDIANCE 69 INSULIN DETEMIR 47 JENTADUETO 37 INSULIN GLARGINE,HUM.REC.ANLOG 47 JETREA 48 INSULIN GLULISINE 47 JEVANTIQUE 40 INSULIN INHALED 47 JINTELI 40 INSULIN LISPRO 47 JOLESSA 32 INSULIN NPL/INSULIN LISPRO 47 JOLIVETTE 32 INSULIN REGULAR, HUMAN 47 JUBLIA 24 INSULIN SYRINGE 35 JUNEL 32 INSULN ASP PRT/INSULIN ASPART 47 JUNEL FE 32 INTELENCE 21, 55 JUXTAPID 31 INTERFERON ALFA-2B,RECOMB. 47 INTERFERON ALFACON 1 45 K INTERFERON BETA-1A 50 K-PHOS ORIGINAL 5 INTERFERON BETA-1A/ALBUMIN 50 K-TAB 65 INTERFERON BETA-1B 50 KADCYLA 43 INTERMEZZO 23 KADIAN 57 INTRON A 47 KALETRA 63 INTROVALE 32 KALEXATE 62 INTUNIV 4 KANAMYCIN 8 INVEGA 24 KANUMA 48 INVEGA SUSTENNA 24 KAPVAY 4, 7 INVIRASE 63 KARIVA 31 INVOKANA 69 KEFLEX 31 IOPHEN-C NR 22 KELNOR 1-35 32 IPRATROPIUM BROMIDE 19 KENALOG 11 IPRATROPIUM-ALBUTEROL 19 KEPPRA 28 IPRATROPIUM/ALBUTEROL SULFATE 19 KEPPRA XR 28 IRBESARTAN 9 KERALYT 48 IRBESARTAN-HYDROCHLOROTHIAZIDE 9 KERYDIN 46 IRBESARTAN/HYDROCHLOROTHIAZIDE 9 KETOCONAZOLE 17, 24 IRBRUTINIB 72 KETODAN 17 ISAVUCONAZOMIUN 24 KETOPROFEN 55 ISENTRESS 11 KETOROLAC TROMETHAMINE 39, 55, 56 ISOMETHEPT-DICHLORALP-ACETAMIN 8 KETOROLAC TROMETHAMINE/PF 39 ISOMETHEPT/ACETAMINOP/DICHLPHN 8 KEYTRUDA 52 ISONIAZID 22 KINERET 37 ISOPTO HOMATROPINE 54 KIONEX 62 ISOPTO HYOSCINE 54 KISQALI 48 ISOSORBIDE DINITRATE 55 KLONOPIN 25 ISOSORBIDE MONONITRATE 55 KLOR-CON 65 ISOSORBIDE MONONITRATE ER 55 KLOR-CON-EF 65 ISOTRETINOIN 68 KOMBIGLYZE XR 37

88 of 104 K (cont.) L (cont.) KOVALTRY 17 LEVAQUIN 64 KRISTALOSE 8 LEVEMIR 47 KUVAN 58 LEVEMIR FLEXTOUCH 47 KYLEENA 33 LEVETIRACETAM 16, 28 KYNAMRO 31 LEVITRA 61 LEVOBUNOLOL HCL 26 L LEVOCARNITINE 58 L-NORGEST-ETH ESTR/ETHIN ESTRA 32, 33 LEVOCARNITINE (WITH SUGAR) 58 LABETALOL HCL 26 LEVOCETIRIZINE DIHYDROCHLORIDE 66 LAC-HYDRIN 25 LEVOFLOXACIN 13, 64 LACOSAMIDE 16 LEVOMILNACIPRAN 67 LACRISERT 39 LEVONORG-ETH ESTRAD ETH ESTRAD 32 LACTULOSE 8 LEVONORGESTREL 32 LAMICTAL 28 LEVONORGESTREL-ETH ESTRADIOL 32, 33 LAMICTAL (GREEN) 28 LEVONORGESTREL-RELEASING INTRAUTERINE LAMICTAL (ORANGE) 28 SYSTEM 33 LAMICTAL ODT 28 LEVORA-28 32 LAMICTAL ODT (ORANGE) 28 LEVOTHROID 71 LAMICTAL XR 28 LEVOTHYROXINE SODIUM 71 LAMISIL 6 LEVOXYL 71 LAMIVUDINE 21, 56 LEXAPRO 67 LAMIVUDINE-ZIDOVUDINE 21 LEXIVA 63 LAMIVUDINE/ZIDOVUDINE 21, 56 LIALDA 11 LAMOTRIGINE 28, 53 LIDOCAINE 49 LAMPRENE 49 LIDOCAINE HCL 49 LANOXIN 13 LIDOCAINE HCL VISCOUS 49 LANSOPRAZOLE 64 LIDOCAINE-HYDROCORTISONE 49 LANSOPRAZOLE/AMOXICILN/CLARITH 64 LIDOCAINE-PRILOCAINE 49 LANTHANUM CARBONATE 61 LIDOCAINE/PRILOCAINE 49 LANTUS 47 LIDODERM 49 LANTUS SOLOSTAR 47 LIFITEGRAST OPTH SOLUTION 38 LAPATINIB DITOSYLATE 20 LIMBREL250 59 LARTRUVO 52 LINACLOTIDE 42 LASIX 50 LINAGLIPTIN 37 LASTACAFT 12 LINAGLIPTIN/METFORMIN HCL 37 LATANOPROST 63 LINEZOLID 15 LATUDA 24, 27 LINZESS 42 LAVOCLEN-4 48 LIOTHYRONINE SODIUM 71 LAZERFORMALYDE 68 LIPASE/PROTEASE/AMYLASE 36 LEDIPASVIR/SOFOSBUVIR 18 LIPITOR 45 LEENA 32 LIPOFEN 41 LEFLUNOMIDE 37 LIRAGLUTIDE 46 LEMTRADA 53 LISDEXAMFETAMINE DIMESYLATE 8 LENALIDOMIDE 45 LISINOPRIL 9, 10 LENVATINIB 48 LISINOPRIL-HYDROCHLOROTHIAZIDE 9 LENVIMA 48 LISINOPRIL/HYDROCHLOROTHIAZIDE 9 LESCOL 45 LITHIUM 53 LESCOL XL 45 LITHIUM CARBONATE 53 LESINURAD TABLETS 73 LITHIUM CITRATE 53 LESSINA 32 LITHOBID 53 LETAIRIS 74 LIVALO 45 LETROZOLE 20, 23 LIXISENATIDE INJECTION 46 LEUCOVORIN CALCIUM 16 LO LOESTRIN FE 33 LEUPROLIDE ACETATE 20 LO-OVRAL-28 33 LEVALBUTEROL 26 LOCOID 5 LEVALBUTEROL HCL 26, 70 LOCOID LIPOCREAM 5 LEVALBUTEROL TARTRATE 26 LODOSYN 20

89 of 104 L (cont.) M (cont.) LODOXAMIDE TROMETHAMINE 12 MAXIDEX 5 LOESTRIN 33 MAXIPIME 31 LOESTRIN 24 FE 33 MAXITROL 14 LOESTRIN FE 33 MAXZIDE-25 MG 62 LOHIST-DM 22 MEBENDAZOLE 10 LOMITAPIDE 31 MECHLORETHAMINE 6 LOMOTIL 16 MECLIZINE HCL 18 LOMUSTINE 6 MEDROL 5 LONSURF 20 MEDROXYPROGESTERONE ACETATE 62, 63 LOPERAMIDE 16 MEFLOQUINE HCL 19 LOPERAMIDE HCL 16 MEFOXIN 31 LOPINAVIR/RITONAVIR 63 MEGACE ES 20 LORAZEPAM 25 MEGESTROL ACETATE 19, 20 LORAZEPAM INTENSOL 25 MEKINIST 48 LORCASERIN 4 MELOXICAM 55, 56 LORTAB 57 MELPHALAN 6 LOSARTAN POTASSIUM 9 MEMANTINE HCL 54 LOSARTAN-HYDROCHLOROTHIAZIDE 9 MENEST 41 LOSARTAN/HYDROCHLOROTHIAZIDE 9 MENINGOCOCCAL GR B VACCINE 73 LOTEMAX 34 MENOPUR 43 LOTEPREDNOL ETABONATE 34 MENOSTAR 41 LOTREL 36 MENOTROPINS 43 LOTRONEX 52 MEPERIDINE HCL 57 LOVASTATIN 45 MEPHYTON 31 LOVAZA 38 MEPOLIZUMAB INJECTION 53 LOVENOX 15 MERCAPTOPURINE 19 LOW-OGESTREL 33 MEROPENEM 27 LOXAPINE 72 MESALAMINE 8, 11 LUBIPROSTONE 49 MESALAMINE W/CLEANSING WIPES 8 LUDENT FLUORIDE 29 MESTINON 59 LULICONAZOLE 24 METADATE CD 10 LUMACAFTOR/IVACAFTOR 28 METADATE ER 10 LUMIGAN 63 METAXALONE 30 LUNESTA 23 METFORMIN ER (MOD) 27 LUPRON DEPOT 20 METFORMIN HCL 27 LURASIDONE HCL 24, 27 METFORMIN HCL ER 27 LUTERA 32 METFORMIN HCL ER (MOD) 27 LUXIQ 5 METFORMIN HCL ER (OSM) 27 LUZU 24 METFORMIN HYDROCHLORIDE 27 LYBREL 33 METHADONE HCL 57 LYNPARZA 65 METHAMPHETAMINE HCL 4 LYRICA 41 METHAZOLAMIDE 29 LYSTEDA 44 METHERGINE 59 METHIMAZOLE 22 M METHITEST 62 MACITENTAN 39 METHOCARBAMOL 30 MACROBID 73 METHOTREXATE 19, 41 MACRODANTIN 73 METHOTREXATE SODIUM 19 MAKENA 63 METHOXSALEN, RAPID 61 MALARONE 19 METHSUXIMIDE 16 MAPROTILINE HCL 44 METHYLDOPA 30 MARAVIROC 21 METHYLERGONOVINE MALEATE 59 MATZIM LA 29 METHYLIN 10 MAVYRET 18 METHYLIN ER 10 MAXAIR AUTOHALER 70 METHYLNALTREXONE BROMIDE TABLETS 58 MAXALT 66 METHYLPHENIDATE 10 MAXALT MLT 66 METHYLPHENIDATE ER 10

90 of 104 M (cont.) M (cont.) METHYLPHENIDATE HCL 10, 38 MONONESSA 33 METHYLPHENIDATE HCL CD 38 MONTELUKAST SODIUM 49 METHYLPHENIDATE SR 10 MONUROL 73 METHYLPREDNISOLONE 5 MORPHINE SULFATE 57 METHYLTESTOSTERONE 62 MORPHINE SULFATE ER 57 METOCLOPRAMIDE HCL 63 MOVANTIK 58 METOLAZONE 71 MOVIPREP 49 METOPROLOL SUCCINATE 26 MOXEZA 14 METOPROLOL TARTRATE 26 MOXIFLOXACIN HCL 14, 64 METOPROLOL-HYDROCHLOROTHIAZIDE 26 MOZOBIL 44 METOPROLOL/HYDROCHLOROTHIAZIDE 26 MS CONTIN 57 METOZOLV ODT 63 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 73 METRELEPTN 45 MUGARD 35 METROGEL 14 MULTAQ 13 METROGEL-VAGINAL 15 MULTI-VITAMIN W-FLUORIDE-IRON 53 METROLOTION 14 MULTI-VITAMIN WITH FLUORIDE 53 METRONIDAZOLE 14, 15, 20, 52 MULTIVITAMINS WITH FLUORIDE 53 MEXILETINE HCL 13 MULTIVITS WITH IRON & FLUORIDE 53 MICARDIS 9 MUPIROCIN 14 MICARDIS HCT 9 MUPIROCIN CALCIUM 14 MICONAZOLE NITRATE/ZINC OX/PET 17 MUSE 74 MICROCHAMBER 35 MVC-FLUORIDE 53 MICROGESTIN 32 MYALEPT 45 MICROGESTIN FE 32 MYAMBUTOL 22 MICRONOR 33 MYCOBUTIN 22 MIDODRINE HCL 70 MYCOPHENOLATE MOFETIL 46 MIGERGOT 7 MYCOPHENOLATE SODIUM 46 MIGLITOL 7 MYFORTIC 46 MIGLUSTAT 46 MYORISAN 68 MIGRANAL 7 MYRBETRIQ 42 MILLIPRED 5 MYTUSSIN DAC 22 MILNACIPRAN HCL 41 MYZILRA 32 MILTEFOSINE CAPSULES 4 MIMVEY 40 N MIMYX 39 NABUMETONE 55 MINIPRESS 7 NADOLOL 26 MINOCIN 71 NAFCIL 60 MINOCYCLINE HCL 71 NAFCILLIN 60 MINOCYCLINE HCL CAPSULES 71 NAFTIFINE HCL 17 MINOCYCLINE HCL MICROSPHERES 13 NAFTIN 17 MINOCYCLINE HCL TABLET EXTENDED RELEASE 71 NALOXEGOL 58 MINOCYCLINE HCL TABLETS 71 NALOXONE 57, 58 MINOXIDIL 37 NALOXONE/BUPROPION 58 MIPOMERSEN 31 NALTREXONE HCL 6, 58 MIRABEGRON 42 NAMENDA 54 MIRAPEX 37 NAPHAZOLINE HCL 74 MIRAPEX ER 37 NAPHOS M-B M-H/NA PHOS,DI-BA 49 MIRCETTE 33 NAPRELAN 55 MIRTAZAPINE 16, 44 NAPROXEN 55 MIRVASO 7 NAPROXEN SODIUM 55 MISOPROSTOL 63 NARATRIPTAN HCL 66 MOBIC 56 NASACORT AQ 34 MODAFINIL 10 NASCOBAL 74 MOMETASONE FUROATE 11, 34, 35 NASONEX 34 MOMETASONE/FORMOTEROL 35 NATACYN 17 MONODOX 71 NATALIZUMAB 53 MONOJECT INSULIN SYRINGE 36 NATAMYCIN 17

91 of 104 N (cont.) N (cont.) NATAZIA 33 NIACIN/LOVASTATIN 38 NATEGLINIDE 51 NIACIN/SIMVASTATIN 38 NATESTO 9 NIACOR 38 NATPARA 59 NIASPAN 38 NATROBA 66 NICARDIPINE HCL 36 NATURE-THROID 71 NIFEDIAC CC 36 NAVELBINE 20 NIFEDICAL XL 36 NEBIVOLOL HCL 26 NIFEDIPINE 36 NECITUMUMAB FOR INJECTION 52 NIFEDIPINE ER 36 NECON 33 NILOTINIB 72 NEDOCROMIL SODIUM 51 NINLARO 64 NEEDLE 36 NINTEDANIB 72 NEEDLES 36 NIRAPARIB CAPSULES 20 NEEDLES, DISPOSABLE 36 NISOLDIPINE 36 NEEDLES, INSULIN DISPOSABLE 35, 36 NITAZOXANIDE 20, 60 NEEVO DHA 54 NITISINONE 44 NEFAZODONE HCL 16 NITRO-BID 55 NEO-POLYCIN 13 NITRO-DUR 55 NEO-POLYCIN HC 13 NITROFURANTOIN 73 NEO/POLYMYX B SULF/DEXAMETH 13, 14 NITROFURANTOIN MACROCRYSTAL 73 NEOMY SULF/BACITRA/POLYMYXIN B 13 NITROFURANTOIN MONO-MACRO 73 NEOMY SULF/BACITRAC ZN/POLY/HC 13, 14 NITROFURANTOIN MONOHYD/M-CRYST 73 NEOMY SULF/COLIST SUL/HC/THONZ 13 NITROGLYCERIN 55, 68, 74 NEOMY SULF/POLYMYXIN B SULFATE 15 NITROGLYCERIN PATCH 74 NEOMYCIN SULFATE 7 NITROLINGUAL 74 NEOMYCIN-BACITRACIN-POLY-HC 14 NITROMIST 55 NEOMYCIN-BACITRACIN-POLYMYXIN 13 NITROSTAT 55 NEOMYCIN-POLYMYXIN-DEXAMETH 13 NIZATIDINE 44 NEOMYCIN-POLYMYXIN-GRAMICIDIN 14 NIZORAL 17 NEOMYCIN-POLYMYXIN-HC 13 NORA-BE 32 NEOMYCIN-POLYMYXIN-HYDROCORT 13 NORCO 57 NEOMYCIN/POLYMYXIN B SULF/HC 13 NORDETTE-28 33 NEOMYCIN/POLYMYXN B/GRAMICIDIN 14 NORDITROPIN FLEXPRO 61 NEORAL 46 NORDITROPIN NORDIFLEX 61 NEOSPORIN G.U. IRRIGANT 15 NORELGESTROMIN/ETH ESTRADIOL 32 NEOSTIGMINE 59 NORELGESTROMIN/ETHIN.ESTRADIOL 32, 33 NEPAFENAC 39 NORETH A-ET ESTRA/FE FUMARATE 32, 33 NEPHRO-VITE RX 74 NORETH-ETHINYL ESTRADIOL/IRON 32, 33 NESINA 37 NORETHIND AC/ETHINYL ESTRADIOL 40 NETILMICIN 8 NORETHINDRONE 32, 33 NETROMYCIN 8 NORETHINDRONE A-E ESTRADIOL 32, 33 NETUPITANT/PALONOSETRON 4 NORETHINDRONE ACETATE 63 NEULASTA 43 NORETHINDRONE-ETHINYL ESTRAD 32, 33 NEUMEGA 47 NORFLOXACIN 64 NEUPOGEN 44 NORFLURANE/HFC 245FA 21 NEUPRO 37 NORGESTIMATE-ETHINYL ESTRADIOL 33 NEURONTIN 42 NORGESTREL-ETHINY ESTRA 33 NEVANAC 39 NORGESTREL-ETHINYL ESTRADIOL 33 NEVIRAPINE 21, 55 NORITATE 14 NEXA PLUS 54 NOROXIN 64 NEXA SELECT 54 NORPACE CR 13 NEXAVAR 13 NORTHERA 6 NEXICLON XR 7 NORTREL 33 NEXIUM 64 NORTRIPTYLINE HCL 72 NEXIUM PACKETS 64 NORVASC 36 NEXT CHOICE 32 NORVIR 11, 63 NIACIN 38 NOVACORT 5

92 of 104 N (cont.) O (cont.) NOVAREL 43 OMACETAXINE 46 NOVOLIN 70-30 47 OMACETAXINE MEPESUCCINATE FOR INJECTION 20 NOVOLIN N 47 OMALIZUMAB 53 NOVOLIN R 47 OMBITASVIR/PARITAPREVIR/RITONAVIR 18 NOVOLOG 47 OMECLAMOX-PAK 64 NOVOLOG FLEXPEN 47 OMEGA-3 ACID ETHYL ESTERS 38 NOVOLOG MIX 70-30 47 OMEPRAZOLE 64 NOVOLOG MIX 70-30 FLEXPEN 47 OMEPRAZOLE-SODIUM BICARBONATE 64 NOVOTWIST 35 OMEPRAZOLE/CLARITH/AMOXICILLIN 64 NOXAFIL 24 OMEPRAZOLE/SODIUM BICARBONATE 64 NPH, HUMAN INSULIN ISOPHANE 47 OMNARIS 34 NPLATE 43 OMNITROPE 61 NUCALA 53 ONABOTULINUMTOXINA 55 NUCYNTA 57 ONCOVIN 20 NUCYNTA ER 57 ONDANSETRON 4 NUEDEXTA 30 ONDANSETRON ODT 4 NULOJIX 70 ONFI 25 NUPLAZID 24 ONGLYZA 36 NUSINERSEN INJECTION 21 ONZETRA XSAIL 66 NUTROPIN AQ 61 OPANA ER 57 NUTROPIN AQ NUSPIN 61 OPIUM 16 NUVARING 33 OPIUM TINCTURE 16 NUVIGIL 10 OPRELVEKIN 47 NUWIQ 17 OPSUMIT 39 NYAMYC 17 OPTICHAMBER 35 NYSTATIN 17 OPTICHAMBER DIAMOND 35 NYSTATIN-TRIAMCINOLONE 17 OPTIHALER 35 NYSTATIN/TRIAMCIN 17 OPTIVAR 12 NYSTOP 17 ORACEA 71 ORALAIR 6 O ORAPRED ODT 5 OBETICHOLIC ACID TABLETS 41 ORENCIA 37 OCALIVA 41 ORENITRAM 63 OCRELIZUMAB INJECTION 53 ORFADIN 44 OCREVUS 53 ORKAMBI 28 OCRIPLASMIN 48 ORSYTHIA 32 OCTREOTIDE ACETATE 52, 58 ORTHO ALL-FLEX 33 ODFESEY 56 ORTHO EVRA 33 ODOMZO 20 ORTHO TRI-CYCLEN 33 OFEV 72 ORTHO TRI-CYCLEN LO 33 OFLOXACIN 14, 64 ORTHO-CEPT 33 OGESTREL 33 ORTHO-CYCLEN 33 OLANZAPINE 23, 24, 27 ORTHO-NOVUM 33 OLANZAPINE ODT 23 OSCIMIN 21 OLANZAPINE-FLUOXETINE HCL 16 OSCIMIN SL 21 OLANZAPINE/FLUOXETINE HCL 16 OSCIMIN SR 21 OLAPARIB 65 OSELTAMIVIR PHOSPHATE 12 OLARATUMAB INJECTION 52 OSIMERTINIB TABLETS 72 OLEPTRO ER 67 OSMOPREP 49 OLMESARTAN MED/AMLODIPINE/HCTZ 9 OSPEMIFENE 40 OLMESARTAN MEDOXOMIL 9 OSPHENA 40 OLMESARTAN/HYDROCHLOROTHIAZIDE 9 OTEZLA 45 OLOPATADINE HCL 12 OTIC CARE 49 OLOPATADINE NASAL 12 OTOVEL 13 OLUX 11 OTREXUP 41 OLUX-E 11 OVCON-35 33 OLYSIO 18 OVIDREL 43

93 of 104 O (cont.) P (cont.) OXACILLIN 60 PEG-INTRON 47 OXAPROZIN 55, 56 PEG3350/SOD SUL/NACL/ASB/C/KCL 49 OXAZEPAM 25 PEGASYS 18 OXCARBAZEPINE 69 PEGASYS PROCLICK 18 OXICONAZOLE NITRATE 17 PEGFILGRASTIM 43 OXISTAT 17 PEGINTERFERON ALFA-1A 53 OXSORALEN-ULTRA 61 PEGINTERFERON ALFA-2A 18 OXYBUTYNIN 42 PEGINTERFERON ALFA-2B 18 OXYBUTYNIN CHLORIDE 42 PEGINTRON REDIPEN 18 OXYBUTYNIN CHLORIDE ER 42 PEMBROLIZUMAB 52 OXYCODONE CONCENTRATE 57 PEMIROLAST POTASSIUM 12 OXYCODONE HCL 57 PEN NEEDLE 36 OXYCODONE HCL/ACETAMINOPHEN 57 PENCICLOVIR 22 OXYCODONE HCL/ASPIRIN 57 PENICILLIN G 60 OXYCODONE HCL/OXYCODON TER/ASA 57 PENICILLIN V POTASSIUM 60 OXYCODONE-ACETAMINOPHEN 57 PENNSAID 56 OXYCODONE-ASPIRIN 57 PENTASA 8 OXYCONTIN 57 PENTOSAN POLYSULFATE SODIUM 59 OXYMETAZOLINE HCL 1% CREAM 7 PENTOXIFYLLINE 44 OXYMORPHONE HCL 57 PEPCID 44 OZURDEX 56 PERAMPANEL 4 PERCOCET 57 P PERINDOPRIL ERBUMINE 10 P-EPHED HCL/CODEINE/GUAIFEN 22 PERMETHRIN 65 PACERONE 13 PERPHENAZINE 72 PAIN EASE 21 PHENADOZ 60 PALBOCICLIB 72 PHENAZOPYRIDINE HCL 21 PALIPERIDONE 24 PHENELZINE SULFATE 50 PALIPERIDONE PALMITATE 24 PHENOBARB/HYOSCY/ATROPINE/SCOP 21 PALIVIZUMAB 53 PHENOBARBITAL 25 PANCREAZE 36 PHENYLEPHRINE HCL 74 PANCRELIPASE 5,000 36 PHENYLEPHRINE HCL/COD/PROMETH 22 PANOBINOSTAT 45 PHENYLEPHRINE HCL/PROMETH HCL 60 PANRETIN 65 PHENYTEK 69 PANTOPRAZOLE SODIUM 64 PHENYTOIN 69 PARATHYROID HORMONE FOR INJECTION 59 PHENYTOIN SODIUM EXTENDED 69 PARICALCITOL 74 PHISOHEX 50 PARITAPREVIR;/RITON/OMBITAS/DASA 18 PHLUORIVIT 53 PAROMOMYCIN SULFATE 7 PHRENILIN FORTE 8 PAROXETINE HCL 66, 67 PHYTONADIONE 31 PASIREOTIDE 69 PICATO 68 PATADAY 12 PILOCARPINE HCL 51 PATANASE 12 PIMAVANSERIN TABLETS 24 PATANOL 12 PIMECROLIMUS 68 PATIROMER ORAL SUSPENSION 62 PINDOLOL 26 PAXIL 67 PIOGLITAZONE HCL 71 PAXIL CR 67 PIOGLITAZONE HCL/METFORMIN HCL 71 PAZOPANIB 13 PIOGLITAZONE-METFORMIN 71 PCCA T3 SODIUM DILUTION 71 PIPERACILLIN 60 PED MV A,C,D3 #21 W-FLUORIDE 53 PIPRACIL 60 PED MV A,C,D3 #38 W-FLUORIDE 54 PIRBUTEROL ACETATE 70 PEDI MULTIVIT #37 W-FLUORIDE 54 PIRFENIDONE 70 PEDI MVI NO.12/SODIUM FLUORIDE 53 PIROXICAM 55 PEDIPIROX-4 17 PITAVASTATIN CALCIUM 45 PEG 3350-ELECTROLYTE 48 PLAQUENIL 19 PEG 3350/NA SULF,BICARB,CL/KCL 48, 49 PLAVIX 28, 62 PEG-3350 AND ELECTROLYTES 49 PLECANATIDE TABLETS 42

94 of 104 P (cont.) P (cont.) PLEGRIDY 53 PRAVASTATIN SODIUM 45 PLERIXAFOR 44 PRAZIQUANTEL 10 PN W-CA64/IRON CB&GL/FA/DSS/DH 54 PRAZOSIN HCL 7 PNV #38/IRON FUM/FOLATE/DHA 54 PRECISION 36 PNV 18/FE,CARB/FA/DSS/UBI/DHA 54 PRED FORTE 34 PNV COMBO #19/IRON/FOL AC/DHA 54 PRED MILD 34 PNV COMBO #22/IRON/FA/OM3/DHA 53, 54 PREDNICARBATE 11 PNV NO.22/IRON CBN&GLUC/FA/DSS 53 PREDNISOLONE 5 PNV W-O CA NO5/FE FUMARATE/FA 53 PREDNISOLONE ACETATE 5, 34 PNV WITH CA,NO.71/IRON/FA 54 PREDNISOLONE SOD PHOSPHATE 5, 34 PNV WITH CA,NO.72/IRON,CARB/FA 53 PREDNISOLONE SODIUM PHOSPHATE 34 PNV WITH CA,NO63/IRON/FA/B6 54 PREDNISONE 5 PNV#79/IRON/FA/LMFOLATE CA/DHA 54 PREFERA OB 54 PNV-DHA + DOCUSATE 54 PREFERA-OB ONE 54 PNV/FA/B6/CALCIUM PHOS/GINGER 54 PREFERA-OB PLUS DHA 54 PNV22/IRON CBN&GLUC/FA/DSS/DHA 54 PREFEST 40 PNV38/IRON CBN&GLUC/FA/DSS/DHA 54 PREGABALIN 41 PNV53/IRON FUM/FA/DOCUSATE/DHA 54 PREGNENOLONE 60 PNV66/IRON FUMARATE/FA/DSS/DHA 54 PREGNENOLONE MICRONIZED 60 PNV69/IRON,CARBONYL/FA/DSS/DHA 54 PREGNENOLONE, MICRONIZED 60 PNV77/SOD IRON EDTA& PS/FA/OM3 54 PREGNYL 43 PNV80/IRON FUMARATE/FA/DSS/DHA 54 PREMARIN 40 PODOCON-25 68 PREMPHASE 40 PODOFILOX 68 PREMPRO 40 PODOPHYLLUM RESIN 68 PRENA1 54 POLY-VI-FLOR 54 PRENATABS FA 54 POLYETHYLENE GLYCOL 3350 49 PRENATAL 19 54 POLYMYXIN B SUL-TRIMETHOPRIM 14 PRENATAL AD 54 POLYMYXIN B SULF/TRIMETHOPRIM 14 PRENATAL NO.25/IRON/FA #6/DHA 54 POLYTRIM 14 PRENATAL NO.39/IRON/FA #6/DHA 54 POMALIDOMIDE 45 PRENATAL PLUS 53 POMALYST 45 PRENATAL VIT #76/IRON,CARB/FA 54 PONATINIB 20 PRENATAL VIT 15/IRON CB/FA/DSS 54 PORTIA 32 PRENATAL VIT 16/IRON CB/FA/DSS 54 PORTRAZZA 52 PRENATAL VIT 18/IRON CB/FA/DSS 54 POSACONAZOLE 24 PRENATAL VIT NO.44/IRON/FA/DHA 54 POTASSIUM BICARBONATE 65 PRENATAL VIT NO.78/IRON/FA 54 POTASSIUM BICARBONATE/CIT AC 65 PRENATAL VIT#36/IRON/FA CMB#6 54 POTASSIUM CHLORIDE 65 PRENATAL VIT#42/FA CMB#6 54 POTASSIUM CITRATE 6 PRENATAL VIT/IRON FUMARATE/FA 54 POTASSIUM CITRATE-CITRIC ACID 6 PRENATAL VITAMINS#21, IRON, FA 54 POTASSIUM CITRATE/CITRIC ACID 6 PRENATAL-U 53 POTASSIUM IODIDE 22 PRENATE DHA 54 POTASSIUM PHOSPHATE,MONOBASIC 5 PRENATE ELITE 54 POTIGA 16 PRENATE MINI 54 PRADAXA 15 PRENEXA 54 PRALUENT 59 PREPOPIK 49 PRAMIPEXOLE DI-HCL 37 PREQUE 10 54 PRAMIPEXOLE DIHYDROCHLORIDE 37 PREVACID 64 PRAMLINTIDE ACETATE 8 PREVALITE 27 PRAMOSONE 5 PREVIFEM 33 PRANDIN 51 PREVPAC 64 PRASCION 48 PREZISTA 63 PRASCION FC 48 PRIFTIN 22 PRASCION RA 50 PRILOSEC 64 PRASUGREL HCL 62 PRIMAQUINE 19 PRAVACHOL 45 PRIMAQUINE PHOSPHATE 19

95 of 104 P (cont.) Q (cont.) PRIMAXIN 27 QUETIAPINE FUMARATE 23, 24 PRIMIDONE 25 QUINAPRIL HCL 10 PRISTIQ ER 16 QUINAPRIL/HYDROCHLOROTHIAZIDE 10 PROAIR HFA 26 QUINIDINE GLUCONATE 13 PROBENECID 73 QUINIDINE SULFATE 13 PROBENECID-COLCHICINE 73 QUININE SULFATE 19 PROBUPHINE 58 QUTENZA 71 PROCARBAZINE 6 QVAR 34 PROCHAMBER 35 PROCHLORPERAZINE MALEATE 18 R PROCLORPERAZINE 37 RABEPRAZOLE 64 PROCRIT 43 RABEPRAZOLE SODIUM 64 PROCTOCORT 12 RADIUM RA 223 20 PROCTOFOAM-HC 12 RAGWEEK POLLEN 6 PROCTOSOL-HC 12 RAGWITEK 6 PROCTOZONE-HC 12 RALOXIFENE 40 PROCYSBI 35, 54 RALTEGRAVIR POTASSIUM 11 PROGESTERONE 63 RAMELTEON 23 PROGESTERONE IN OIL 63 RAMIPRIL 10 PROGESTERONE,MICRONIZED 63 RAMUCIRUMAB 39 PROGRAF 46 RANEXA 29 PROLIA 52 RANITIDINE HCL 44, 45 PROLIXIN 72 RANOLAZINE 29 PROMACTA 43 RAPAFLO 7, 24 PROMETHAZINE HCL 38, 60 RAPAMUNE 46 PROMETHAZINE VC 60 RASAGILINE MESYLATE 52 PROMETHAZINE VC-CODEINE 22 RAVICTI 55 PROMETHAZINE-CODEINE 22 RAYALDEE 74 PROMETHAZINE-DM 22 REBETOL 18 PROMETHEGAN 38 REBIF 50 PROMETRIUM 63 RECLIPSEN 32 PROMISEB 39 RECTIV 68 PROPAFENONE HCL 13 REGORAFENIB 20 PROPANTHELINE BROMIDE 19 REGRANEX 68 PROPRANOLOL HCL 26 REGULAR BEVEL NEEDLES 36 PROPYLTHIOURACIL 22 RELENZA 12 PROSCAR 4 RELISTOR 58 PROTONIX 64 RELPAX 66 PROTOPIC 68 REMERON 16 PROVENTIL HFA 26 REMICADE 37 PROVERA 63 REMODULIN 74 PROVIGIL 10 RENAF 29 PROZAC 67 RENAGEL 61 PULMICORT 35 RENVELA 61 PULMICORT FLEXHALER 34 REPAGLINIDE 51 PULMOZYME 40 REPATHA 59 PYLERA 15 REPREXAIN 57 PYRAZINAMIDE 22 REQUIP 37 PYRIDOSTIGMINE 59 REQUIP XL 37 PYRIDOSTIGMINE BROMIDE 59 RESCRIPTOR 55 PYRIMETHAMINE 19 RESCULA 63 PYRITHIONE ZINC 60 RESLIZUMAB INJECTION 53 RESTASIS 38 Q RETAPAMULIN 14 QNASL 34 RETIN-A MICRO 30 QUADRAPAX 21 RETIN-A MICRO PUMP 30 QUASENSE 32 RETROVIR 56

96 of 104 R (cont.) S (cont.) REVATIO 61 SACUBITRIL/VALSARTAN 29 REVLIMID 45 SAFYRAL 33 REXULTI 24 SALEX 48 REYATAZ 63 SALICYLIC ACID 48 RHINOCORT AQUA 34 SALICYLIC ACID/CERAMIDE CMB #1 48 RHOFADE 7 SALIVA SUBSTITUTION COMBO NO.2 35 RIBAPAK 18 SALMETEROL XINAFOATE 70 RIBASPHERE 18 SALSALATE 55 RIBAVIRIN 18 SAMSCA 74 RIBOCICLIB TABLETS 48 SANCTURA XR 42 RIFABUTIN 22 SANCUSO 4 RIFAMPIN 22 SANDIMMUNE 46 RIFAPENTINE 22 SANDOSTATIN 52 RIFAXIMIN 15 SANTYL 68 RILPIVIRINE 55 SAPHRIS 23 RILUTEK 30 SAPROPTERIN DIHYDROCHLORIDE 58 RILUZOLE 30 SAQUINAVIR 63 RIMEXOLONE 34 SARAFEM 67 RIOCIGUAT 69 SAVAYSA 27 RIOMET 27 SAVELAMER 61 RISEDRONATE 28 SAVELLA 41 RISEDRONATE SODIUM 28 SAXAGLIPTIN HCL 36 RISPERIDONE 23 SAXAGLIPTIN HCL/METFORMIN HCL 37 RISPERIDONE M-TAB 23 SAXENDA 46 RISPERIDONE ODT 23 SCOPACE 16 RITALIN 10 SCOPOLAMINE 16 RITALIN CAPSULE 10, 60 MG 10 SCOPOLAMINE HYDROBROMIDE 16, 54 RITALIN LA CAPSULES 20, 30, 40 MG 10 SE 10-5 SS 48 RITONAVIR 11, 63 SE-DONNA PB HYOS 21 RITUXAN 53 SEASONALE 33 RITUXIMAB 53 SEASONIQUE 33 RIVAROXABAN 28 SEB-PREV 50 RIVASTIGMINE 31 SEBELIPASE ALFA INJECTION 48 RIXUBIS 44 SECUKINUMAB 47 RIZATRIPTAN 66 SEEBRI NEOHALER 19 RIZATRIPTAN BENZOATE 66 SELEGILINE 52 RIZATRIPTAN MLT 66 SELEGILINE HCL 52 ROFLUMILAST 65 SELENIUM SULFIDE 49, 50 ROLAPITANT TABLETS 70 SELZENTRY 21 ROMIPLOSTIM 43 SENSIPAR 58 ROPINIROLE HCL 37 SEREVENT DISKUS 70 ROSUVASTATIN CALCIUM 45 SEROQUEL 24 ROTIGOTINE 37 SEROQUEL XR 24 ROWASA 8 SERTACONAZOLE NITRATE 17 ROXICET 57 SERTRALINE HCL 67 ROZEREM 23 SEVELAMER CARBONATE 61 RUBRACA 65 SEVELAMER HCL 61 RUCAPARIB TABLETS 65 SIGNIFOR 69 RUCONEST 28 SILDENAFIL 61 RUFINAMIDE 69 SILDENAFIL CITRATE 61 RUXOLITINIB 48 SILENOR 16 RYBIX ODT 57 SILODOSIN 7, 24 RYTARY 38 SILTUXIMAB 47 RYTHMOL SR 13 SILVADENE 50 SILVER SULFADIAZINE 49, 50 S SIMCOR 38 SABRIL 42 SIMEPREVIR 18

97 of 104 S (cont.) S (cont.) SIMPONI 37 STIMATE 61 SIMVASTATIN 45 STIOLTO RESPIMAT 65 SINGULAIR 49 STIVARGA 20 SIROLIMUS 46 STRATTERA 4 SIRTURO 22 STRENSIQ 43 SITAGLIPTIN PHOS/METFORMIN HCL 37 STRIBILD 10 SITAGLIPTIN PHOSPHATE 37 STROMECTOL 10 SITAVIG 18 SUBOXONE SL TABS 58 SIVEXTRO 59 SUCRALFATE 64 SKELAXIN 30 SUCROFERRIC OXYHYDROXIDE 61 SOD PICOSULF/MAG OX/CITRIC AC 49 SULAR 36 SODIUM CHLORIDE 65 SULCONAZOLE NITRATE 17 SODIUM CHLORIDE FOR INHALATION 65 SULFACET SOD/SULFUR/WITCH HAZ 48 SODIUM CITRATE & CITRIC ACID 6 SULFACETAMIDE SOD/SULFUR/UREA 49, 50 SODIUM FLUORIDE 29 SULFACETAMIDE SODIUM 14, 50 SODIUM POLYSTYRENE SULFONATE 62 SULFACETAMIDE SODIUM-SULFUR 48 SODIUM SULFACETAMIDE 50 SULFACETAMIDE SODIUM/SULFUR 48 SODIUM SULFACETAMIDE-SULFUR 48, 50 SULFACETAMIDE-PREDNISOLONE 14 SODIUM,POTASSIUM,&MAG SULFATES 49 SULFACETAMIDE/PREDNISOLONE SP 14 SOFOSBUVIR 18 SULFACETM NA/AVOBENZONE/SULFUR 50 SOFOSBUVIR/VELPATASVIR 18 SULFACETM NA/PREDNISOL AC 14 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR 18 SULFAMETHOXAZOLE-TRIMETHOPRIM 51 SOLARAZE 68 SULFAMETHOXAZOLE/TRIMETHOPRIM 51 SOLIFENACIN SUCCINATE 42 SULFAMIDE 14 SOLODYN 71 SULFASALAZINE 70 SOLVALDI 18 SULFASALAZINE DR 70 SOMA 30 SULFAZINE 70 SOMATROPIN 61 SULFAZINE EC 70 SOMNOTE 23 SULINDAC 55 SONATA 23 SUMATRIPTAN 66 SONIDEGIB CAPSULES 20 SUMATRIPTAN NASAL POWDER 66 SOOLANTRA 66 SUMATRIPTAN SUCC/NAPROXEN SOD 66 SORAFENIB 13 SUMATRIPTAN SUCCINATE 66 SORIATANE 68 SUMAVEL DOSEPRO 66 SORILUX 68 SUNITINIB MALATE 13 SOTALOL 26 SUPRAX 31 SOTALOL AF 26 SUPREP 49 SOTALOL HCL 26 SURE COMFORT 36 SPECIALTY USE NEEDLES 36 SURMONTIL 72 SPINOSAD 66 SUSTIVA 21, 55 SPINRAZA 21 SUSTOL 4 SPIRIVA 19 SUTENT 13 SPIRONOLACT/HYDROCHLOROTHIAZID 62 SYLATRON 47 SPIRONOLACTONE 62 SYLVANT 47 SPIRONOLACTONE-HCTZ 62 SYMBICORT 34 SPRINTEC 33 SYMBYAX 16 SPRIX 56 SYMLINPEN 120 8 SPRYCEL 20 SYMLINPEN 60 8 SRONYX 32 SYMMETREL 37 SSD 49 SYNAGIS 53 SSKI 22 SYNRIBO 20, 46 STALEVO 38 SYNTHROID 71 STARLIX 51 SYR W-NDL,INS 0.3 ML HALF MARK 35 STAXYN 61 SYRING W-NDL,DISP,INSUL,0.3ML 35, 36 STELARA 72 SYRING W-NDL,DISP,INSUL,0.5ML 35, 36 STELAZINE 72 SYRINGE & NEEDLE,INSULIN,1 ML 35, 36 STENDRA 61 T TABLOID 20

98 of 104 T (cont.) T (cont.) TACLONEX 5 TESTOSTERONE 9, 62 TACROLIMUS 46, 68 TESTOSTERONE CYPIONATE 9, 62 TADALAFIL 61 TESTOSTERONE ENANTHATE 62 TAFINLAR 24 TESTOSTERONE NASAL GEL 9 TAFLUPROST/PF 63 TETRABENAZINE 52 TAGRISSO 72 TETRACAINE/BENZOCAINE/BUTAMBEN 21 TALIMOGENE LAHERPAREPVEC 56 TETRACYCLINE HCL 71 TALTZ 45 THALIDOMIDE 45 TAMIFLU 12 THALOMID 45 TAMOXIFEN CITRATE 17 THEO-24 65 TAMSULOSIN 24 THEOPHYLLINE ANHYDROUS 65 TAMSULOSIN HCL 7 THERMAZENE 49 TANZEUM 46 THIOGUANINE 19, 20 TAPENTADOL HCL 57 THIORIDAZINE HCL 72 TARCEVA 20 THIOTEPA 6 TARKA 10 THIOTHIXENE 72 TASIGNA 72 THYROID 71 TASIMELTEON 51 THYROID,PORK 71 TAVABOROLE 46 TIAGABINE 42 TAZAROTENE 68 TIAGABINE HCL 16 TAZAROTENE 0.1% CREAM 68 TIAZAC 29 TAZORAC 0.05% 68 TICAGRELOR 62 TAZORAC 0.1% CREAM 68 TICLOPIDINE HCL 62 TAZORAC 0.1% GEL 68 TIKOSYN 13 TAZTIA XT 28 TILIA FE 32 TBO-FILGRASTIM 43 TIMOLOL 27 TECENTRIQ 52 TIMOLOL MALEATE 26, 27 TECFIDERA 50 TIMOLOL MALEATE/PF 27 TECHNIVIE 18 TIMOPTIC 27 TEDIZOLID 59 TIMOPTIC OCUDOSE 27 TEDUGLUTIDE 42 TINDAMAX 21 TEGRETOL 69 TINIDAZOLE 7, 20, 21 TEGRETOL XR 69 TIOTROPIUM BROMIDE 19 TEKTURNA 65 TIOTROPIUM BROMIDE/OLODATEROL INHALATION TEKTURNA HCT 65 SPRAY 65 TELAPREVIR 18 TIPRANAVIR 63 TELBIVUDINE 56 TIROSINT 71 TELMISARTAN 9 TIVICAY 10 TELMISARTAN/AMLODIPINE 9 TIZANIDINE HCL 30 TELMISARTAN/HYDROCHLOROTHIAZID 9 TOBI 8 TELOTRISTAT ETHYL TABLETS 72 TOBRADEX 14 TEMAZEPAM 26 TOBRADEX OPTHALMIC OINTMENT 14 TEMODAR 20 TOBRADEX ST 14 TEMOZOLOMIDE 20, 46 TOBRAMYCIN 8, 14 TENOFOVIR ALAFENAMIDE TABLETS 21 TOBRAMYCIN IN 0.225% NACL 8 TENOFOVIR DISOPROXIL FUMARATE 21 TOBRAMYCIN-DEXAMETHASONE 14 TENORMIN 26 TOBRAMYCIN/DEXAMETHASONE 14 TERAZOSIN 24 TOBRAMYCIN/LOTEPRED ETAB 14 TERAZOSIN HCL 7, 24 TOBREX 14 TERBINAFINE HCL 6 TOCILIZUMAB 46 TERBUTALINE SULFATE 70 TOFACITINIB 45 TERCONAZOLE 17 TOLAZAMIDE 70 TERIFLUNOMIDE 50 TOLBUTAMIDE 70 TERIPARATIDE 60 TOLTERODINE TARTRATE 42 TERSI FOAM 50 TOLVAPTAN 74 TESAMORELIN 43 TOPAMAX 69 TESTIM 62 TOPICORT 11

99 of 104 T (cont.) T (cont.) TOPIRAMATE 69 TRIZIVIR 56 TOPROL XL 26 TROSPIUM CHLORIDE 42 TOREMIFENE CITRATE 20 TRULANCE 42 TORSEMIDE 50 TRULICITY 46 TOUJEO 47 TRUVADA 56 TOVIAZ 42 TRYPSIN/BALSAM PERU/CASTOR OIL 68 TRABECTEDIN FOR INJECTION 20 TUDORZA PRESSAIR 19 TRACLEER 74 TUSSICAPS 22 TRADJENTA 37 TWINJECT 6 TRAMADOL HCL 57 TWYNSTA 9 TRAMADOL HCL-ACETAMINOPHEN 57 TYBOST 10 TRAMADOL HCL/ACETAMINOPHEN 57 TYKERB 20 TRAMETINIB 48 TYLENOL-CODEINE NO.3 57 TRANDOLAPRIL/VERAPAMIL HCL 10 TYPHOID VACC,LIVE,ATTENUATED 73 TRANEXAMIC ACID 44 TYSABRI 53 TRANSDERM-SCOP 16 TYVASO 74 TRANYLCYPROMINE SULFATE 50 TYZEKA 56 TRASTUZUMAB 43 TRAVATAN Z 63 U TRAVOPROST 63 UCERIS 34 TRAZODONE HCL 67 ULESFIA 66 TREANDA 6 ULIPRISTAL ACETATE 33 TREPROSTINIL 63, 74 ULORIC 74 TRESIBA 47 ULTICARE 35 TRETINOIN 30, 65 ULTRA COMFORT 35 TRETINOIN MICROSPHERES 30 ULTRAM 57 TRETTEN 44 ULTRAM ER 57 TREXALL 19 ULTRAVATE 11 TREXIMET 66 UMECLIDINIUM/VILANTEROL 19 TRI-LEGEST FE 32 UNITUXIN 20 TRI-PREVIFEM 33 UNOPROSTONE 63 TRI-SPRINTEC 33 UREA 48 TRI-VI-FLOR 54 URIBEL 73 TRI-VIT WITH FLUORIDE-IRON 53 URIDINE TRIACETATE 73 TRI-VITAMIN WITH FLUORIDE 53 UROCIT-K 6 TRIADVANCE 54 UROFOLLITROPIN 43 TRIAMCINOLONE ACETONIDE 11, 34 UROXATRAL 7 TRIAMTERENE 62 URSODIOL 31 TRIAMTERENE-HCTZ 62 USTEKINUMAB 72 TRIAMTERENE-HYDROCHLOROTHIAZID 62 UTIBRON NEOHALER 64 TRIAMTERENE/HYDROCHLOROTHIAZID 62 TRIAZOLAM 26 V TRIBENZOR 9 VAGIFEM 40 TRICOR 41 VALACYCLOVIR 18 TRIFLURIDINE 22 VALACYCLOVIR HCL 18 TRIFLURIDINE/TIPIRACIL 20 VALBENAZINE CAPSULES 30 TRIGLIDE 41 VALCHLOR 6 TRIHEXYPHENIDYL HCL 15 VALCYTE 10, 56 TRILEPTAL 69 VALGANCICLOVIR 10 TRILIPIX 41 VALGANCICLOVIR HCL 56 TRIMETHOBENZAMIDE HCL 18 VALIUM 25 TRIMETHOPRIM 73 VALPROATE SODIUM 42, 53 TRIMIPRAMINE MALEATE 72 VALPROIC ACID 42, 53 TRINESSA 33 VALSARTAN 9 TRIPHLUORIVIT 53 VALSARTAN-HYDROCHLOROTHIAZIDE 9 TRIPLE-VITAMIN W-FLUORIDE 53 VALSARTAN/HYDROCHLOROTHIAZIDE 9 TRIVORA-28 32 VALTREX 18

100 of 104 V (cont.) V (cont.) VALTURNA 65 VINATE ULTRA 54 VANCOCIN HCL 15 VINBLASTINE 20 VANCOMYCIN HCL 15 VINCRISTINE 20 VANDAZOLE 15 VINORELBINE 20 VANOS 11 VIORELE 32 VANOXIDE-HC 5 VIRAMUNE 21, 55 VARDENAFIL HCL 61 VIRAMUNE XR 21 VARENICLINE TARTRATE 68 VIREAD 21 VARUBI 70 VISMODEGIB 20 VASOTEC 10 VIT B CMPLX 3/FA/VIT C/BIOTIN 74 VAXCHORA 73 VITAMEDMD ONE RX 54 VECTICAL 68 VITAMEDMD PLUS RX 54 VEDOLIZUMAB 75 VITAMEDMD REDICHEW RX 54 VELBAN 20 VITAMIN D2 74 VELCADE 64 VITAMINS A,C,D & FLUORIDE 53 VELIVET 32 VITE AC/GRAPE/HYALURONIC ACID 39 VELOSEF 31 VITEKTA 47 VELPHORO 61 VIVELLE-DOT 41 VELTASSA 62 VIVITROL 6 VELTIN 14 VIVOTIF BERNA 73 VEMAVITE-PRX 2 54 VOL-PLUS 54 VEMLIDY 21 VOL-TAB RX 54 VEMURAFENIB 25 VOLTAREN 56 VENATAL COMPLETE DHA 54 VON WILLEBRAND FACTOR RECOMBINANT FOR INJ VENATAL-FA 54 18 VENCLEXTA 24 VONVENDI 18 VENETOCLAX TABLETS 24 VORAPAXAR 63 VENLAFAXINE HCL 67 VORICONAZOLE 24 VENLAFAXINE HCL ER 67 VORINOSTAT 45 VENTAVIS 63 VORTEX 35 VENTOLIN HFA 26 VORTIOXETINE 66 VERAMYST 34 VOSEVI 18 VERAPAMIL ER 29 VOTRIENT 13 VERAPAMIL ER PM 29 VRAYLAR 24 VERAPAMIL HCL 29 VUSION 17 VERDESO 11 VYTORIN 38 VESANOID 65 VYVANSE 8 VESICARE 42 VEXOL 34 W VIAGRA 61 WARFARIN SODIUM 15 VIBERZI 42 WELCHOL 27 VIBRAMYCIN 71 WELLBUTRIN 67 VICODIN 57 WELLBUTRIN SR 67 VICODIN HP 57 WELLBUTRIN XL 67 VICOPROFEN 57 WESTHROID 71 VICTOZA 2-PAK 46 WYMZYA FE 32 VICTOZA 3-PAK 46 VICTRELIS 18 X VIEKIRA PAK 18 XALATAN 63 VIGABATRIN 42 XALKORI 20 VIGAMOX 14 XANAX 25 VIIBRYD 16 XARELTO 28 VILAZODONE HYDROCHLORIDE 16 XARTEMIS XR 57 VIMIZIM 39 XELJANZ 45 VIMPAT 16 XELODA 20 VINACAL 53 XENADERM 68 VINATE GT 54 XENAZINE 52

101 of 104 X (cont.) Z (cont.) XERAC AC 23 ZMAX 51 XERESE 22 ZOCOR 45 XERMELO 72 ZOFRAN ODT 4 XEROFORM PETROLATUM DRESSING 36 ZOHYDRO 57 XGEVA 52 ZOLINZA 45 XIAFLEX 64 ZOLMITRIPTAN 66 XIBROM 39 ZOLOFT 67 XIFAXAN 15 ZOLPIDEM TARTRATE 23 XIIDRA 38 ZOLPIDEM TARTRATE ER 23 XOFIGO 20 ZOMIG SPRAY 66 XOLAIR 53 ZOMIG TABLETS 66 XOLEGEL 17 ZOMIG ZMT TABLETS 66 XOPENEX 70 ZONALON 21 XOPENEX HFA 26 ZONISAMIDE 69 XTANDI 12 ZONTIVITY 63 XURIDEN 73 ZOVIA 1-35E 32 XYZAL 66 ZOVIA 1-50E 32 ZOVIRAX 18 Y ZURAMPIC 73 YASMIN 28 33 ZYBAN 68 YAZ 33 ZYCLARA 68 YONDELIS 20 ZYDELIG 48 ZYFLO CR 49 Z ZYKADIA 48 ZAFIRLUKAST 49 ZYLET 14 ZALEPLON 23 ZYMAR 14 ZANAMIVIR 12 ZYMAXID 14 ZANTAC 25 45 ZYPREXA 24 ZAVESCA 46 ZYPREXA ZYDIS 24 ZEBUTAL 8 ZYTIGA 20 ZEGERID 64 ZYVOX 15 ZEJULA 20 ZELBORAF 25 ZEMPLAR 74 ZENATANE 68 ZENCHENT 32 ZENCHENT FE 32 ZENCIA 48 ZENPEP 36 ZEOSA 32 ZEPATIER 18 ZESTRIL 10 ZETIA 38 ZETONNA 34 ZIAGEN 56 ZIANA 14 ZIDOVUDINE 56 ZIDOVUDINE/LAMIVUDINE 56 ZILEUTON 49 ZINC PYRITHIONE 60 ZINC SULFATE 65 ZINPLAVA 15 ZIOPTAN 63 ZIPRASIDONE HCL 23, 24 ZIPSOR 56 ZIRGAN 10 ZITHROMAX 51

102 of 104 Notes

1 - Home Health 2 - Infertility 3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit 7 - Step Therapy

103 of 104 2349 Gateway Oaks Drive, Suite 100 Sacramento, California 95833 916.563.2250 888.563.2250 toll-free 888.877.5378 tty 916.563.3182 fax

Published 03.18

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