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FEP 5 Tier Rx Drug Formulary (607) Standard Option

FEP 5 Tier Rx Drug Formulary (607) Standard Option

FEP 5 Tier Rx Formulary (607) Standard Option

Effective July 1, 2021

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name . Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION ...... 5 PREFACE ...... 5 EXCLUDED DRUGS ...... 6 PRIOR APPROVAL ...... 6 QUANTITY LIMITATIONS ...... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ...... 6 PRODUCT SELECTION CRITERIA ...... 6 FORMULARY PRODUCT DESCRIPTIONS ...... 7 GENERIC SUBSTITUTION ...... 7 DRUG STUDY IMPLEMENTATION DRUGS ...... 8 EDITOR ...... 8 NOTICE ...... 8 LEGEND ...... 8 ...... 10 ANALGESICS, OTHER ...... 10 NSAIDs ...... 10 NSAIDs, COMBINATIONS ...... 10 NSAIDs, TOPICAL ...... 10 COX-2 INHIBITORS ...... 10 ...... 10 ANALGESICS ...... 10 NON-OPIOID ANALGESICS ...... 11 VISCOSUPPLEMENTS ...... 11 ANTI-INFECTIVES ...... 12 ANTIBACTERIALS ...... 12 ...... 13 ANTIMALARIALS ...... 14 ANTIRETROVIRAL AGENTS ...... 14 ANTITUBERCULAR AGENTS ...... 15 ANTIVIRALS ...... 15 MISCELLANEOUS ...... 16 ANTINEOPLASTIC AGENTS ...... 17 ALKYLATING AGENTS ...... 17 ...... 17 HORMONAL ANTINEOPLASTIC AGENTS ...... 18 IMMUNOMODULATORS ...... 18 KINASE INHIBITORS ...... 18 ...... 20 INHIBITORS ...... 20 MISCELLANEOUS ...... 20 CARDIOVASCULAR ...... 22 ACE INHIBITORS ...... 22 ACE INHIBITOR/ COMBINATIONS ...... 23 ACE INHIBITOR/ COMBINATIONS ...... 23

1 ADRENOLYTICS, CENTRAL ...... 23 ANTAGONISTS ...... 23 ALPHA BLOCKERS ...... 23 II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 23 ANGIOTENSIN II / BLOCKER COMBINATIONS ...... 23 ANGIOTENSIN II RECEPTOR ANTAGONIST//DIURETIC COMBINATIONS ...... 23 ANTIARRHYTHMICS ...... 24 ANTILIPEMICS ...... 24 BETA-BLOCKERS ...... 25 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 25 CALCIUM CHANNEL BLOCKERS ...... 25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 26 ...... 26 DIRECT INHIBITORS/DIURETIC COMBINATIONS ...... 26 ...... 26 FAILURE ...... 26 ...... 27 PULMONARY ARTERIAL ...... 27 MISCELLANEOUS ...... 27 CENTRAL ...... 27 ANTIANXIETY ...... 28 ...... 28 ANTIDEMENTIA...... 29 ...... 29 ANTIPARKINSONIAN AGENTS ...... 30 ...... 31 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 31 ...... 32 ...... 32 ...... 33 STABILIZERS ...... 33 MOVEMENT DISORDERS ...... 33 ...... 33 MUSCULOSKELETAL AGENTS ...... 34 ...... 34 NARCOLEPSY/CATAPLEXY ...... 34 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 34 MISCELLANEOUS ...... 35 ENDOCRINE AND METABOLIC ...... 35 ...... 35 ANTIDIABETICS ...... 36 CALCIUM RECEPTOR ANTAGONISTS ...... 38 CALCIUM REGULATORS ...... 38 DEFICIENCY AGENTS ...... 39 CONTRACEPTIVES ...... 39 ...... 40 ...... 41 /PROGESTINS ...... 41 ESTROGEN/SELECTIVE MODULATOR COMBINATIONS ...... 41 FERTILITY REGULATORS ...... 41 GAUCHER DISEASE ...... 42 ...... 42 ELEVATING AGENTS ...... 42 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ...... 42 HUMAN GROWTH ...... 42 HYPERPARATHYROID TREATMENT, D ANALOGS ...... 43 -LIKE -1 AGENTS ...... 43 PHENYLKETONURIA TREATMENT AGENTS ...... 43 BINDER AGENTS ...... 43 -REMOVING AGENTS ...... 43 PROGESTINS ...... 43 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 43 AGENTS ...... 43 CYCLE DISORDERS ...... 44 UTERINE FIBROIDS ...... 44

2 ...... 44 MISCELLANEOUS ...... 44 GASTROINTESTINAL ...... 45 ANTIDIARRHEALS ...... 45 ...... 45 ...... 45 CHOLELITHOLYTICS ...... 45 H2 RECEPTOR ANTAGONISTS ...... 45 INFLAMMATORY BOWEL DISEASE ...... 46 ...... 46 ...... 46 OPIOID-INDUCED ...... 46 PANCREATIC ...... 46 ...... 47 PUMP INHIBITORS ...... 47 ...... 47 , RECTAL ...... 47 ULCER THERAPY COMBINATIONS ...... 47 MISCELLANEOUS ...... 47 GENITOURINARY ...... 47 BENIGN PROSTATIC HYPERPLASIA ...... 47 URINARY ANTISPASMODICS ...... 48 VAGINAL ANTI-INFECTIVES ...... 48 MISCELLANEOUS ...... 48 HEMATOLOGIC ...... 48 ...... 48 HEMATOPOIETIC GROWTH FACTORS ...... 48 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ...... 49 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...... 50 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ...... 50 AGGREGATION INHIBITORS ...... 50 PLATELET SYNTHESIS INHIBITORS ...... 50 SICKLE DISEASE ...... 50 STEM CELL MOBILIZERS ...... 50 AGENTS ...... 50 MISCELLANEOUS ...... 50 IMMUNOLOGIC AGENTS ...... 51 ALLERGENIC EXTRACTS ...... 51 AUTOIMMUNE AGENTS ...... 51 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 51 HEREDITARY AGENTS ...... 51 IMMUNE GLOBULINS ...... 52 IMMUNOMODULATORS ...... 52 IMMUNOSUPPRESSANTS ...... 52 NUTRITIONAL/SUPPLEMENTS ...... 53 ...... 53 AND ...... 53 MISCELLANEOUS ...... 53 RESPIRATORY ...... 53 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ...... 54 TREATMENT AGENTS ...... 54 ...... 54 /BETA COMBINATIONS ...... 54 ANTICHOLINERGIC/BETA AGONIST/ INHALANT COMBINATIONS ...... 54 , LOW SEDATING ...... 54 ANTIHISTAMINES, NONSEDATING ...... 54 ANTIHISTAMINES, SEDATING ...... 54 / COMBINATIONS ...... 55 ANTITUSSIVES ...... 55 ANTITUSSIVE COMBINATIONS ...... 55 BETA ...... 55 ...... 55 MODULATORS ...... 56 MAST CELL STABILIZERS ...... 56

3 NASAL ANTIHISTAMINES ...... 56 NASAL STEROIDS/COMBINATIONS ...... 56 -4 INHIBITORS...... 56 PULMONARY FIBROSIS AGENTS ...... 56 SEVERE AGENTS ...... 56 STEROID/BETA AGONIST COMBINATIONS ...... 56 STEROID INHALANTS ...... 56 ...... 57 MISCELLANEOUS ...... 57 TOPICAL ...... 57 ...... 57 MOUTH/THROAT/DENTAL AGENTS ...... 61 OPHTHALMIC ...... 61 OTIC ...... 64 WEBSITES ...... 65 2021 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART ...... 67 INDEX ...... 72

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The Retail and Mail Service Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.

INTRODUCTION FEP is pleased to provide the 2021 FEP 5 Tier Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication. PREFACE The formulary is organized by sections, which refer to either a or disease state. Unless exceptions are noted, all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 generic drugs preferred brand- non-preferred brand- preferred specialty non-preferred name drugs name drugs and all drugs specialty drugs compounded Standard Option $7.50 copayment 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance Preferred Retail for a 0 to 30-day Limit*: one 30-day Limit*: one 30-day Pharmacy supply supply fill at retail supply fill at retail ($22.50 copayment for a 31 to 90-day supply)

Medicare Part B $5 copayment for a Primary 0 to 30-day supply ($15 copayment for a 31 to 90-day supply) Standard Option 45% of average wholesale price plus any difference between our allowance and the billed amount Non-Preferred Retail Pharmacy Standard Option $15 copay $90 copay $125 copay Mail Pharmacy

Medicare Part B $10 copay Standard Option $65 for a 0 to 30- $85 for a 0 to 30- Specialty Drug day supply day supply Pharmacy Program $185 for 31 to 90- $240 for 31 to 90- day supply day supply

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* First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication.

Drug products shown in boldface type indicate generic availability.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non- preferred, typically if the cost-effectiveness is less than other similar drugs. EXCLUDED DRUGS Effective January 1, 2021, selected medications will no longer be covered on the Standard Option drug benefit plan. These excluded medications have available covered options in the same therapeutic class. For a full listing of these excluded medications please see the EXCLUDED DRUG LIST STANDARD OPTION CHART located on page 67 before the INDEX in this document.

Patients taking an excluded medication on or after January 1, 2021 should expect to pay the full cost of the prescription. PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page. QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page. PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes evaluating new medications, and making recommendations for the designation of preferred or non-preferred status on the FEP 5 Tier Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP. PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

• Safety • Efficacy • Comparison studies • Drug interactions • Approved indications • Formulation and administration • Adverse effects • Contraindications • • Patient compliance considerations • Medical outcome and pharmacoeconomic studies

When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a

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designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.

All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber. FORMULARY PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Preferred products include all strengths and dosage forms of the cited brand-name product. carbonate Renvela Oral packets, tabs and all strengths of Renvela would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not. acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry. / Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.

sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary.

Dosage forms will be consistent with the category and use where listed. The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI- INFECTIVES section of the formulary.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand- name equivalents. Prescription generic drugs are:

• Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. • Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. • Manufactured in the same strength and dosage form as the brand-name drugs.

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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. DRUG EFFICACY STUDY IMPLEMENTATION DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products. EDITOR Your comments and suggestions regarding this FEP 5 Tier Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 , AZ 85072-2115 NOTICE The information contained in this FEP 5 Tier Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of FEP. ©2021. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date. LEGEND † Generic contraceptives are covered at no charge to qualifying members ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval PA/ST Prior Approval with Step Therapy QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for both brands and generics ST Step Therapy - indicates the requirement for previous use of one or more drugs before coverage is provided for the targeted drug boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

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

ANALGESICS, OTHER Treatment recommendations for are available at: https://www.rheumatology.org

acetaminophen inj Tier 1 OFIRMEV Tier 3

NSAIDs delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 Tier 1 Tier 1 etodolac ext-rel Tier 1 Tier 1 Tier 1 indomethacin (except caps 20 mg, 40 mg) Tier 1 indomethacin ext-rel Tier 1 Tier 1 ketoprofen ext-rel Tier 1 Tier 1 tabs Tier 1 MOBIC Tier 3 Tier 1 Tier 1 NAPROSYN Tier 3 naproxen sodium Tier 1 Tier 1 DAYPRO Tier 3 Tier 1 FELDENE Tier 3 Tier 1 ibuprofen inj CALDOLOR Tier 2 indomethacin susp INDOCIN susp Tier 2 PA ketorolac tromethamine SPRIX Tier 3

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/ Tier 1 ARTHROTEC Tier 3

NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1 diclofenac sodium soln Tier 1

COX-2 INHIBITORS QL Tier 1 CELEBREX Tier 3

GOUT Tier 1 ZYLOPRIM Tier 3 Tier 1 COLCRYS Tier 3 colchicine Tier 1 MITIGARE Tier 3 PA Tier 1 ULORIC Tier 3 Tier 1 PA KRYSTEXXA Tier 5

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

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

QL Tier 1 BUTRANS Tier 3 QL /acetaminophen// Tier 1 FIORICET w/CODEINE Tier 3 QL butalbital//caffeine/codeine Tier 1 QL nasal spray Tier 1 QL codeine/acetaminophen Tier 1 PA citrate buccal Tier 1 FENTORA Tier 3 QL fentanyl transdermal Tier 1 DURAGESIC Tier 3 PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3 PA ext-rel caps Tier 1 ZOHYDRO ER Tier 3 QL hydrocodone/acetaminophen Tier 1 QL Tier 1 DILAUDID Tier 3 QL hydromorphone ext-rel Tier 1 QL Tier 1 QL Tier 1 QL morphine ext-rel Tier 1 QL morphine ext-rel Tier 1 MS CONTIN Tier 3 QL morphine supp Tier 1 QL Tier 1 ROXICODONE Tier 3 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3 QL Tier 1 OPANA Tier 3 QL (except 100 mg tabs) Tier 1 ULTRAM Tier 3 QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3 QL tramadol/acetaminophen Tier 1 QL morphine/ ext-rel EMBEDA Tier 2 QL oxycodone ext-rel XTAMPZA ER Tier 2 QL NUCYNTA Tier 2 QL tapentadol ext-rel NUCYNTA ER Tier 2 QL buprenorphine BELBUCA Tier 3 PA fentanyl sublingual spray SUBSYS Tier 3 PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3 QL morphine ext-rel MORPHABOND Tier 3 QL oxycodone ext-rel OXYCONTIN Tier 3 QL tramadol oral QDOLO Tier 3

NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3 QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3 PRIALT Tier 4

VISCOSUPPLEMENTS PA GEL-ONE Tier 4 PA sodium hyaluronate GELSYN-3 Tier 4 PA sodium hyaluronate HYALGAN Tier 4 PA sodium hyaluronate SUPARTZ FX Tier 4 PA high molecular weight hyaluronan HYMOVIS Tier 5 PA high molecular weight hyaluronan ORTHOVISC Tier 5 PA hyaluronate sodium TRIVISC Tier 5 PA hylan G-F 20 SYNVISC Tier 5 PA hylan G-F 20 SYNVISC-ONE Tier 5

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PA sodium hyaluronate DUROLANE Tier 5 PA sodium hyaluronate EUFLEXXA Tier 5 PA sodium hyaluronate MONOVISC Tier 5

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

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

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

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

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

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

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

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

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

ANTIBACTERIALS First Generation cephalexin Tier 1 KEFLEX Tier 3

Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1

Third Generation cefdinir Tier 1 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 SUPRAX Tier 2 QL cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 QL ceftriaxone Tier 1 ROCEPHIN Tier 3

Fourth Generation cefepime Tier 1

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Fifth Generation ceftaroline fosamil TEFLARO Tier 2

Erythromycins/ Tier 1 ZITHROMAX Tier 3 Tier 1 clarithromycin ext-rel Tier 1 delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3 erythromycin ethylsuccinate Tier 1 ERYPED Tier 3 erythromycin stearate Tier 1 DIFICID Tier 2

Fluoroquinolones Tier 1 CIPRO Tier 3 Tier 1 LEVAQUIN Tier 3 Tier 1

Penicillins , except film-coated tabs Tier 1 amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3 amoxicillin/clavulanate ext-rel Tier 1 amoxicillin/clavulanate susp 600 mg Tier 1 Tier 1 ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3 Tier 1 VK Tier 1 piperacillin/tazobactam Tier 1 ZOSYN Tier 3

Tetracyclines hyclate Tier 1 VIBRAMYCIN Tier 3 doxycycline hyclate delayed-rel tabs Tier 1 DORYX/MPC Tier 3 doxycycline monohydrate Tier 1 Tier 1 MINOCIN Tier 3 minocycline ext-rel Tier 1 SOLODYN Tier 3 Tier 1 QL NUZYRA Tier 3 SEYSARA Tier 3

Miscellaneous QL XENLETA Tier 3 QL delayed-rel AEMCOLO Tier 3

ANTIFUNGALS troches Tier 1 Tier 1 DIFLUCAN Tier 3 microsize Tier 1 griseofulvin ultramicrosize Tier 1 PA Tier 1 SPORANOX Tier 3 PA tabs Tier 1 Tier 1 MYCAMINE Tier 3 nystatin Tier 1 PA delayed-rel tabs Tier 1 NOXAFIL tabs Tier 3 tabs Tier 1 QL Tier 1 VFEND Tier 3

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complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 ERAXIS Tier 2 PA posaconazole susp NOXAFIL susp Tier 2 PA CRESEMBA Tier 3

ANTIMALARIALS /proguanil Tier 1 MALARONE Tier 3 Tier 1 Tier 1 primaquine Tier 1 PA pyrimethamine Tier 1 DARAPRIM Tier 3 artemether/lumefantrine COARTEM Tier 2 tafenoquine ARAKODA Tier 3 tafenoquine KRINTAFEL Tier 3

ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants TYBOST Tier 2

Antiretroviral Combinations / Tier 1 EPZICOM Tier 3 abacavir/lamivudine/ Tier 1 TRIZIVIR Tier 3 // fumarate Tier 1 ATRIPLA Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI Tier 3 efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI LO Tier 3 emtricitabine/tenofovir disoproxil fumarate Tier 1 TRUVADA Tier 3 lamivudine/zidovudine Tier 1 COMBIVIR Tier 3 abacavir//lamivudine TRIUMEQ Tier 2 /cobicistat EVOTAZ Tier 2 /emtricitabine/ BIKTARVY Tier 2 /cobicistat PREZCOBIX Tier 2 darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2 dolutegravir/lamivudine DOVATO Tier 2 /lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2 /cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2 emtricitabine//tenofovir alafenamide ODEFSEY Tier 2 emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 2 dolutegravir/rilpivirine JULUCA Tier 3 lamivudine/tenofovir disoproxil fumarate CIMDUO Tier 3 lamivudine/tenofovir disoproxil fumarate TEMIXYS Tier 3

Chemokine Receptor Antagonists SELZENTRY Tier 2

Fusion Inhibitors FUZEON Tier 4

Gp120-Directed Attachment Inhibitors ext-rel RUKOBIA Tier 2

Integrase Inhibitors dolutegravir TIVICAY Tier 2 ISENTRESS Tier 2

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Monoclonal Antibody PA -uiyk TROGARZO Tier 4

Non- Reverse Transcriptase Inhibitors efavirenz Tier 1 SUSTIVA Tier 3 Tier 1 VIRAMUNE Tier 3 nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3 INTELENCE Tier 2 rilpivirine EDURANT Tier 2 doravirine PIFELTRO Tier 3

Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 ZIAGEN Tier 3 abacavir soln Tier 1 ZIAGEN soln Tier 3 emtricitabine caps Tier 1 EMTRIVA Tier 2 lamivudine Tier 1 EPIVIR Tier 3 Tier 1 zidovudine Tier 1 RETROVIR Tier 3

Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate tabs 300 mg Tier 1 VIREAD Tier 2

Protease Inhibitors atazanavir caps Tier 1 REYATAZ Tier 3 Tier 1 LEXIVA Tier 3 tabs Tier 1 NORVIR Tier 2 darunavir PREZISTA Tier 2 CRIXIVAN Tier 2 /ritonavir KALETRA Tier 2 VIRACEPT Tier 2 mesylate INVIRASE Tier 2 APTIVUS Tier 2

ANTITUBERCULAR AGENTS ethambutol Tier 1 MYAMBUTOL Tier 3 Tier 1 Tier 1 rifampin Tier 1 RIFADIN Tier 3 pretomanid tabs PRETOMANID Tier 2 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 PRIFTIN Tier 2 SIRTURO Tier 3

ANTIVIRALS Cytomegalovirus Agents Tier 1 VISTIDE Tier 3 PA Tier 1 VALCYTE Tier 3 inj Tier 4 cytomegalovirus immune globulin CYTOGAM Tier 4 PA PREVYMIS Tier 4

Hepatitis Agents lamivudine Tier 1 EPIVIR-HBV Tier 3 PA, * dipivoxil Tier 4 HEPSERA Tier 5

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PA, * tabs Tier 4 BARACLUDE Tier 5 entecavir soln BARACLUDE soln Tier 4 TYZEKA Tier 4 tenofovir alafenamide VEMLIDY Tier 4

* Brand requires prior approval

Hepatitis C PA ledipasvir/sofosbuvir Tier 4 HARVONI Tier 4 PA caps Tier 4 PA ribavirin caps - Ribasphere Tier 4 PA ribavirin tabs Tier 4 PA sofosbuvir/velpatasvir Tier 4 EPCLUSA Tier 4 PA glecaprevir/pibrentasvir MAVYRET Tier 4 PA sofosbuvir SOVALDI Tier 4 PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4 PA elbasvir/grazoprevir ZEPATIER Tier 5

Herpes Agents acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3 Tier 1 valacyclovir Tier 1 VALTREX Tier 3

Influenza Agents QL oseltamivir Tier 1 TAMIFLU Tier 3 Tier 1 QL zanamivir RELENZA Tier 2 QL baloxavir XOFLUZA Tier 3

Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 4

MISCELLANEOUS PA Tier 1 ALBENZA Tier 3 atovaquone Tier 1 MEPRON Tier 3 aztreonam Tier 1 AZACTAM Tier 3 Tier 1 CLEOCIN Tier 3 QL Tier 1 ACZONE Tier 3 daptomycin 500 mg Tier 1 CUBICIN Tier 3 Tier 1 INVANZ Tier 3 / Tier 1 PRIMAXIN Tier 3 QL Tier 1 ZYVOX Tier 3 Tier 1 methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3 tabs Tier 1 FLAGYL Tier 3 tabs Tier 1 ALINIA Tier 2 ext-rel Tier 1 MACROBID Tier 3 nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3 Tier 1 MYCOBUTIN Tier 3 / Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 Tier 1 TYGACIL Tier 3 Tier 1 trimethoprim Tier 1 caps Tier 1 VANCOCIN Tier 3

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PA EMVERM Tier 2 IMPAVIDO Tier 2 QL XIFAXAN Tier 2 vancomycin oral soln FIRVANQ Tier 2 LAMPIT Tier 3 SOLOSEC Tier 3 QL SIVEXTRO Tier 3 telavancin VIBATIV Tier 3

ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org

ALKYLATING AGENTS Tier 1 BUSULFEX Tier 2 / Tier 1 Tier 4 BICNU Tier 5 caps Tier 4 CYCLOPHOSPHAMIDE Tier 4 CAPSULES cyclophosphamide inj Tier 4 Tier 4 inj Tier 4 ALKERAN inj Tier 5 melphalan tabs Tier 4 ALKERAN tabs Tier 5 PA, * caps Tier 4 TEMODAR caps Tier 5 Tier 4 TEPADINA Tier 5 busulfan MYLERAN Tier 2 LEUKERAN Tier 2 GLEOSTINE Tier 2 PA mechlorethamine gel VALCHLOR Tier 4 streptozocin ZANOSAR Tier 4 PA YONDELIS Tier 4 PA BELRAPZO Tier 5 PA bendamustine TREANDA Tier 5 PA lurbinectedin ZEPZELCA Tier 5 temozolomide inj TEMODAR inj Tier 5

* Brand TEMODAR caps requires prior approval

ANTIMETABOLITES Tier 1 PA, * Tier 4 XELODA Tier 5 Tier 4 Tier 4 CLOLAR Tier 5 Tier 4 Tier 4 Tier 4 inj Tier 4 inj Tier 4 GEMCITABINE Tier 4 thioguanine TABLOID Tier 2 ALIMTA Tier 4 NIPENT Tier 4 FOLOTYN Tier 4 ELITEK Tier 4 PA ONUREG Tier 5

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mercaptopurine susp PURIXAN Tier 5

* Brand XELODA requires prior approval

HORMONAL ANTINEOPLASTIC AGENTS Tier 1 CASODEX Tier 3 Tier 1 PA Tier 1 NILANDRON Tier 3 PA abiraterone Tier 4 ZYTIGA Tier 5 PA XTANDI Tier 4 PA abiraterone YONSA Tier 5 PA ERLEADA Tier 5 PA NUBEQA Tier 5

Antiestrogens Tier 1 Tier 1 FARESTON Tier 3 PA, * Tier 4 FASLODEX Tier 5

*Brand FASLODEX requires prior approval

Aromatase Inhibitors Tier 1 ARIMIDEX Tier 3 Tier 1 AROMASIN Tier 3 Tier 1 FEMARA Tier 3

Gonadotropin-Releasing (GnRH) Antagonists PA FIRMAGON Tier 4 PA ORGOVYX Tier 5

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 4 PA acetate ZOLADEX Tier 4 PA acetate VANTAS Tier 4 PA leuprolide acetate ELIGARD Tier 4 PA leuprolide acetate LUPRON DEPOT Tier 4 PA pamoate TRELSTAR Tier 4 PA triptorelin pamoate TRELSTAR DEPOT Tier 4 PA triptorelin pamoate TRELSTAR LA Tier 4 PA leuprolide acetate FENSOLVI Tier 5

Progestins acetate Tier 1

IMMUNOMODULATORS PA pembrolizumab KEYTRUDA Tier 4 PA POMALYST Tier 5

KINASE INHIBITORS PA Tier 4 PA 2.5 mg, 5 mg, 7.5 mg Tier 4 AFINITOR 2.5 mg, 5 mg, 7.5 mg Tier 5 PA mesylate Tier 4 GLEEVEC Tier 5 PA Tier 4 TYKERB Tier 5 Tier 4 TORISEL Tier 5 PA VERZENIO Tier 4

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PA acalabrutinib CALQUENCE Tier 4 PA GILOTRIF Tier 4 PA PIQRAY Tier 4 PA INLYTA Tier 4 PA BOSULIF Tier 4 PA CABOMETYX Tier 4 PA cabozantinib COMETRIQ Tier 4 PA ZYKADIA Tier 4 PA COTELLIC Tier 4 PA XALKORI Tier 4 PA TAFINLAR Tier 4 PA SPRYCEL Tier 4 PA ROZLYTREK Tier 4 PA erdafitinib BALVERSA Tier 4 PA everolimus 10 mg AFINITOR 10 mg Tier 4 PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 4 PA ibrutinib IMBRUVICA Tier 4 PA ZYDELIG Tier 4 PA VITRAKVI Tier 4 PA LENVIMA Tier 4 PA midostaurin RYDAPT Tier 4 PA IBRANCE Tier 4 PA VOTRIENT Tier 4 PA pexidartinib TURALIO Tier 4 PA ICLUSIG Tier 4 PA STIVARGA Tier 4 PA KISQALI Tier 4 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4 PA ruxolitinib JAKAFI Tier 4 PA RETEVMO Tier 4 PA KOSELUGO Tier 4 PA NEXAVAR Tier 4 PA SUTENT Tier 4 PA MEKINIST Tier 4 PA CAPRELSA Tier 4 PA ZELBORAF Tier 4 PA ALECENSA Tier 5 PA AYVAKIT Tier 5 PA MEKTOVI Tier 5 PA ALUNBRIG Tier 5 PA TABRECTA Tier 5 PA VIZIMPRO Tier 5 PA COPIKTRA Tier 5 PA BRAFTOVI Tier 5 PA fedratinib INREBIC Tier 5 PA IRESSA Tier 5 PA gilteritinib XOSPATA Tier 5 PA LORBRENA Tier 5 PA NERLYNX Tier 5 PA TASIGNA Tier 5 PA TAGRISSO Tier 5 PA PEMAZYRE Tier 5 PA GAVRETO Tier 5 PA QINLOCK Tier 5 PA tazemetostat TAZVERIK Tier 5 PA TUKYSA Tier 5

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PA zanubrutinib BRUKINSA Tier 5

MULTIPLE MYELOMA Immunomodulators PA REVLIMID Tier 4 THALOMID Tier 4 PA -irfc SARCLISA Tier 5

Proteasome Inhibitors PA NINLARO Tier 4 PA VELCADE Tier 5

TOPOISOMERASE INHIBITORS inj Tier 4 HYCAMTIN inj Tier 5 topotecan HYCAMTIN Tier 4 PA liposome inj ONIVYDE Tier 5

MISCELLANEOUS hydroxyurea Tier 1 HYDREA Tier 3 leucovorin calcium Tier 1 amifostine Tier 4 ETHYOL Tier 5 trioxide Tier 4 TRISENOX Tier 5 azacitidine Tier 4 VIDAZA Tier 5 PA caps Tier 4 TARGRETIN caps Tier 5 Tier 4 Tier 4 Tier 4 Tier 4 COSMEGEN Tier 5 Tier 4 Tier 4 DACOGEN Tier 5 dexrazoxane Tier 4 dexrazoxane Tier 4 TOTECT Tier 5 Tier 4 Tier 4 doxorubicin liposomal Tier 4 DOXIL Tier 5 Tier 4 epirubicin Tier 4 ELLENCE Tier 5 Tier 4 Tier 4 IDAMYCIN PFS Tier 5 ifosfamide Tier 4 IFEX Tier 5 irinotecan Tier 4 CAMPTOSAR Tier 5 levoleucovorin calcium Tier 4 mesna inj Tier 4 MESNEX inj Tier 5 mitomycin Tier 4 Tier 4 Tier 4 Tier 4 PA Tier 4 ISTODAX Tier 5 Tier 4 Tier 4 VALSTAR Tier 5 Tier 4 Tier 4 Tier 4 NAVELBINE Tier 5 PA LYSODREN Tier 2 PA ado- emtansine KADCYLA Tier 4 aldesleukin PROLEUKIN Tier 4

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ELSPAR Tier 4 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4 PA atezolizumab TECENTRIQ Tier 4 BCG live TICE BCG Tier 4 PA BELEODAQ Tier 4 PA bendamustine BENDEKA Tier 4 PA -awwb MVASI Tier 4 PA bevacizumab-bvzr ZIRABEV Tier 4 PA bexarotene gel TARGRETIN gel Tier 4 PA blinatumomab BLINCYTO Tier 4 PA brentuximab vedotin ADCETRIS Tier 4 PA JEVTANA Tier 4 PA ERBITUX Tier 4 PA DARZALEX Tier 4 PA decitabine-cedazuridine INQOVI Tier 4 doxorubicin ADRIAMYCIN Tier 4 PA EMPLICITI Tier 4 PA HALAVEN Tier 4 etoposide phosphate ETOPOPHOS Tier 4 glucarpidase VORAXAZE Tier 4 PA ipilimumab YERVOY Tier 4 IXEMPRA Tier 4 mesna tabs 400 mg MESNEX Tier 4 PA PORTRAZZA Tier 4 ARRANON Tier 4 PA ZEJULA Tier 4 PA nivolumab OPDIVO Tier 4 PA obinutuzumab GAZYVA Tier 4 PA ofatumumab ARZERRA Tier 4 PA LYNPARZA Tier 4 PA omacetaxine mepesuccinate SYNRIBO Tier 4 paclitaxel -bound particles ABRAXANE Tier 4 PA VECTIBIX Tier 4 PA ONCASPAR Tier 4 PA PERJETA Tier 4 PA pertuzumab/trastuzumab/hyaluronidase-zzxf PHESGO Tier 4 MATULANE Tier 4 PA rituximab-abbs TRUXIMA Tier 4 PA rituximab-arrx RIABNI Tier 4 PA rituximab-pvvr RUXIENCE Tier 4 PA RUBRACA Tier 4 PA TALZENNA Tier 4 PA talimogene laherparepvec IMLYGIC Tier 4 PA trastuzumab-anns KANJINTI Tier 4 PA trastuzumab-dkst OGIVRI Tier 4 PA trastuzumab-dttb ONTRUZANT Tier 4 PA trastuzumab-pkrb HERZUMA Tier 4 PA trastuzumab-qyyp TRAZIMERA Tier 4 PA VENCLEXTA Tier 4 PA vincristine sulfate liposomal MARQIBO Tier 4 PA vismodegib ERIVEDGE Tier 4 PA ZOLINZA Tier 4 PA ziv- ZALTRAP Tier 4 PA BAVENCIO Tier 5 PA belantamab mafodotin-blmf BLENREP Tier 5 PA bevacizumab AVASTIN Tier 5

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PA calaspargase pegol-mknl ASPARLAS Tier 5 PA KYPROLIS Tier 5 PA daratumumab/hyaluronidase-fihj DARZALEX FASPRO Tier 5 PA durvalumab IMFINZI Tier 5 PA IDHIFA Tier 5 PA enfortumab vedotin-ejfv PADCEV Tier 5 PA fam--nxki ENHERTU Tier 5 PA gemtuzumab ozogamicin MYLOTARG Tier 5 PA glasdegib DAURISMO Tier 5 PA hydroxyurea SIKLOS Tier 5 PA inotuzumab ozogamicin BESPONSA Tier 5 PA ivosidenib TIBSOVO Tier 5 levoleucovorin KHAPZORY Tier 5 PA melphalan EVOMELA Tier 5 PA mogamulizumab-kpkc POTELIGEO Tier 5 PA moxetumomab pasudotox-tdfk LUMOXITI Tier 5 PA FARYDAK Tier 5 PA polatuzumab vedotin-piiq POLIVY Tier 5 PA CYRAMZA Tier 5 PA rituximab RITUXAN Tier 5 PA rituximab/hyaluronidase human RITUXAN HYCELA Tier 5 PA sacituzumab govitecan-hziy TRODELVY Tier 5 PA XPOVIO Tier 5 PA sonidegib ODOMZO Tier 5 PA trastuzumab HERCEPTIN Tier 5 PA trastuzumab/hyaluronidase-oysk HERCEPTIN HYLECTA Tier 5 PA /tipiracil LONSURF Tier 5

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

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

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

Tier 1 LOTENSIN Tier 3 Tier 1 VASOTEC Tier 3 Tier 1 Tier 1 PRINIVIL Tier 3 lisinopril Tier 1 ZESTRIL Tier 3 Tier 1 quinapril Tier 1 ACCUPRIL Tier 3 ramipril Tier 1 ALTACE Tier 3 trandolapril Tier 1 enalapril oral soln EPANED Tier 3 lisinopril oral soln QBRELIS Tier 3

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ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/ Tier 1 LOTREL Tier 3 trandolapril/ ext-rel Tier 1 TARKA Tier 3 perindopril /amlodipine PRESTALIA Tier 3

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

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

ALDOSTERONE RECEPTOR ANTAGONISTS Tier 1 INSPRA Tier 3 Tier 1 ALDACTONE Tier 3

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

Tier 1 CARDURA Tier 3 Tier 1 MINIPRESS Tier 3 Tier 1

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

candesartan Tier 1 ATACAND Tier 3 candesartan/hydrochlorothiazide Tier 1 ATACAND HCT Tier 3 irbesartan Tier 1 AVAPRO Tier 3 irbesartan/hydrochlorothiazide Tier 1 AVALIDE Tier 3 Tier 1 COZAAR Tier 3 losartan/hydrochlorothiazide Tier 1 HYZAAR Tier 3 Tier 1 BENICAR Tier 3 olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3 Tier 1 MICARDIS Tier 3 telmisartan/hydrochlorothiazide Tier 1 MICARDIS HCT Tier 3 Tier 1 DIOVAN Tier 3 valsartan/hydrochlorothiazide Tier 1 DIOVAN HCT Tier 3 azilsartan EDARBI Tier 3 azilsartan/chlorthalidone EDARBYCLOR Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 AZOR Tier 3 amlodipine/telmisartan Tier 1 TWYNSTA Tier 3 amlodipine/valsartan Tier 1 EXFORGE Tier 3

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

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olmesartan/amlodipine/hydrochlorothiazide Tier 1 TRIBENZOR Tier 3

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

Tier 1 Tier 1 NORPACE Tier 3 Tier 1 Tier 1 ext-rel Tier 1 RYTHMOL SR Tier 3 gluconate ext-rel Tier 1 Tier 1 sotalol AF Tier 1 PA, * Tier 4 TIKOSYN Tier 5 disopyramide ext-rel NORPACE CR Tier 2 MULTAQ Tier 2

* Brand TIKOSYN requires prior approval

ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 ACL Inhibitor/Combinations PA bempedoic NEXLETOL Tier 3 PA / NEXLIZET Tier 3

Bile Acid Resins cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3 Tier 1 WELCHOL Tier 3 Tier 1 COLESTID Tier 3

Cholesterol Absorption Inhibitors ezetimibe Tier 1 ZETIA Tier 3

Fibrates Tier 1 LIPOFEN Tier 3 fenofibrate Tier 1 TRICOR Tier 3 fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3 Tier 1 LOPID Tier 3 fenofibrate ANTARA Tier 3

HMG-CoA Reductase Inhibitors/Combinations ‡, * Tier 1 LIPITOR Tier 3 ezetimibe/ Tier 1 VYTORIN Tier 3 ‡, * Tier 1 ‡, * fluvastatin ext-rel Tier 1 LESCOL XL Tier 3 ‡, * Tier 1 ‡, * Tier 1 PRAVACHOL Tier 3 ‡, * Tier 1 CRESTOR Tier 3 ‡, * simvastatin Tier 1 ZOCOR Tier 3 LIVALO Tier 3 rosuvastatin capsules EZALLOR SPRINKLE Tier 3

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* Generic cholesterol-lowering drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.

Microsomal Transfer Protein Inhibitors PA JUXTAPID Tier 4

Niacins ext-rel Tier 1 NIASPAN Tier 3

Omega-3 Fatty icosapent ethyl caps 1 gm Tier 1 VASCEPA Tier 2 omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3

PCSK9 Inhibitors PA REPATHA Tier 4 PA PRALUENT Tier 5

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

Tier 1 Tier 1 TENORMIN Tier 3 Tier 1 COREG Tier 3 carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3 Tier 1 BREVIBLOC Tier 3 succinate ext-rel Tier 1 TOPROL-XL Tier 3 metoprolol tartrate Tier 1 LOPRESSOR Tier 3 Tier 1 Tier 1 propranolol ext-rel Tier 1 INDERAL LA Tier 3 BYSTOLIC Tier 2 metoprolol succinate ext-rel KAPSPARGO Tier 3 LEVATOL Tier 3 propranolol ext-rel INNOPRAN XL Tier 3

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

atenolol/chlorthalidone Tier 1 /hydrochlorothiazide Tier 1 ZIAC Tier 3 metoprolol/hydrochlorothiazide Tier 1

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine tabs Tier 1 NORVASC Tier 3 ext-rel Tier 1 Tier 1 ext-rel Tier 1 nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3 Tier 1 NIMOTOP Tier 3 ext-rel Tier 1 SULAR Tier 3 maleate CONJUPRI Tier 3

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

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1 CADUET Tier 3

DIGITALIS GLYCOSIDES Tier 1 LANOXIN Tier 2

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS Tier 1 TEKTURNA Tier 3 aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2

DIURETICS Carbonic Anhydrase Inhibitors Tier 1 acetazolamide ext-rel Tier 1 Tier 1 PA dichlorphenamide KEVEYIS Tier 3

Loop Diuretics Tier 1 ethacrynic acid Tier 1 EDECRIN Tier 3 Tier 1 LASIX Tier 3 torsemide Tier 1

Potassium-sparing Diuretics Tier 1

Thiazides and -like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 Tier 1 Tier 1

Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3 /hydrochlorothiazide Tier 1 DYAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3 triamterene/hydrochlorothiazide 37.5/25 Tier 1 MAXZIDE-25 Tier 3 triamterene/hydrochlorothiazide 50/25 Tier 1

HEART FAILURE / BIDIL Tier 2 PA CORLANOR Tier 3 PA /valsartan ENTRESTO Tier 3 PA VYNDAMAX Tier 4 PA tafamidis meglumine VYNDAQEL Tier 4

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NITRATES Oral isosorbide dinitrate oral Tier 1 ISORDIL Tier 3 Tier 1 isosorbide mononitrate ext-rel Tier 1

Sublingual/Translingual lingual spray Tier 1 NITROLINGUAL Tier 3 nitroglycerin sublingual Tier 1 NITROSTAT Tier 3 nitroglycerin sublingual aerosol NITROMIST Tier 3 nitroglycerin sublingual powder GONITRO Tier 3

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

PULMONARY ARTERIAL HYPERTENSION Receptor Antagonists PA Tier 4 LETAIRIS Tier 5 PA Tier 4 TRACLEER Tier 5 PA OPSUMIT Tier 4

Phosphodiesterase Inhibitors PA Tier 4 REVATIO Tier 5 PA tabs 20 mg Tier 4 ADCIRCA Tier 5 PA tadalafil tabs 20 mg - Alyq Tier 4

Prostacyclin Receptor Agonists PA UPTRAVI Tier 5

Prostaglandin Vasodilators PA epoprostenol Tier 4 VELETRI Tier 5 PA epoprostenol sodium Tier 4 FLOLAN Tier 5 PA Tier 4 REMODULIN Tier 5 PA VENTAVIS Tier 4 PA treprostinil ext-rel ORENITRAM Tier 4 PA treprostinil TYVASO Tier 5

Soluble Stimulators PA ADEMPAS Tier 5

MISCELLANEOUS hydralazine Tier 1 Tier 1 tabs Tier 1 ext-rel Tier 1 RANEXA Tier 3 PA Tier 4 NORTHERA Tier 5 VECAMYL Tier 3

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

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ANTIANXIETY Tier 1 XANAX Tier 3 alprazolam ext-rel Tier 1 XANAX XR Tier 3 Tier 1 Tier 1 KLONOPIN Tier 3 Tier 1 TRANXENE T-TAB Tier 3 Tier 1 VALIUM Tier 3 Tier 1 ATIVAN Tier 3 Tier 1

Miscellaneous Tier 1 Tier 1 ANAFRANIL Tier 3 Tier 1 fluvoxamine ext-rel Tier 1 HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3

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

Tier 1 TEGRETOL Tier 3 carbamazepine ext-rel Tier 1 CARBATROL Tier 3 carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3 Tier 1 ONFI Tier 3 diazepam rectal gel Tier 1 DIASTAT Tier 3 divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3 divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3 divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3 Tier 1 ZARONTIN Tier 3 Tier 1 FELBATOL Tier 3 QL Tier 1 NEURONTIN Tier 3 Tier 1 LAMICTAL Tier 3 lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3 lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3 Tier 1 KEPPRA Tier 3 levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3 Tier 1 TRILEPTAL Tier 3 Tier 1 Tier 1 DILANTIN INFATABS Tier 3 phenytoin sodium extended Tier 1 DILANTIN Tier 3 Tier 1 MYSOLINE Tier 3 Tier 1 BANZEL Tier 3 Tier 1 GABITRIL Tier 3 Tier 1 TOPAMAX Tier 3 topiramate ext-rel Tier 1 QUDEXY XR Tier 3 valproic acid Tier 1 Tier 1 ZONEGRAN Tier 3 PA vigabatrin Tier 4 SABRIL Tier 5 PA vigabatrin powder - Vigadrone Tier 4 VIMPAT Tier 2 brivaracetam BRIVIACT Tier 3 PA XCOPRI Tier 3 PA diazepam nasal spray VALTOCO Tier 3

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eslicarbazepine APTIOM Tier 3 PA nasal spray NAYZILAM Tier 3 oxcarbazepine ext-rel OXTELLAR XR Tier 3 FYCOMPA Tier 3 topiramate ext-rel TROKENDI XR Tier 3 PA EPIDIOLEX Tier 5 PA FINTEPLA Tier 5 PA DIACOMIT Tier 5

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

donepezil Tier 1 ARICEPT Tier 3 donepezil orally disintegrating tabs Tier 1 Tier 1 galantamine ext-rel Tier 1 RAZADYNE ER Tier 3 soln Tier 1 memantine tabs Tier 1 NAMENDA tabs Tier 3 rivastigmine Tier 1 rivastigmine transdermal Tier 1 EXELON PATCH Tier 3

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

Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org

Monoamine Oxidase Inhibitors (MAOIs) Tier 1 NARDIL Tier 3 Tier 1 PARNATE Tier 3 MARPLAN Tier 3 transdermal EMSAM Tier 3

Selective Inhibitors (SSRIs) Tier 1 CELEXA Tier 3 Tier 1 LEXAPRO Tier 3 Tier 1 fluoxetine Tier 1 PROZAC Tier 3 fluoxetine delayed-rel Tier 1 HCl Tier 1 PAXIL Tier 3 paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3 Tier 1 ZOLOFT Tier 3 delayed-release sprinkle capsule DRIZALMA SPRINKLE Tier 3 paroxetine mesylate PEXEVA Tier 3 VIIBRYD Tier 3 TRINTELLIX Tier 3

Serotonin Reuptake Inhibitors (SNRIs) ext-rel Tier 1 PRISTIQ Tier 3 duloxetine delayed-rel Tier 1 CYMBALTA Tier 3 Tier 1 venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3 venlafaxine ext-rel tabs Tier 1 ext-rel FETZIMA Tier 3

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Tricyclic Antidepressants (TCAs) Tier 1 Tier 1 NORPRAMIN Tier 3 Tier 1 HCl Tier 1 imipramine pamoate Tier 1 Tier 1 PAMELOR Tier 3 Tier 1

Miscellaneous Agents amitriptyline/ Tier 1 Tier 1 bupropion ext-rel Tier 1 FORFIVO XL Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3 Tier 1 REMERON Tier 3 Tier 1 Tier 1 bupropion ext-rel APLENZIN Tier 3 PA nasal solution SPRAVATO Tier 3

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

, except tabs Tier 1 benztropine Tier 1 Tier 1 PARLODEL Tier 3 /levodopa Tier 1 SINEMET Tier 3 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3 Tier 1 entacapone Tier 1 COMTAN Tier 3 Tier 1 MIRAPEX Tier 3 pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3 Tier 1 AZILECT Tier 3 Tier 1 ropinirole ext-rel Tier 1 selegiline caps Tier 1 Tier 1 Tier 1 transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 PA amantadine ext-rel GOCOVRI Tier 3 PA amantadine ext-rel OSMOLEX ER Tier 3 PA KYNMOBI Tier 3 carbidopa/levodopa enteral susp DUOPA Tier 3 carbidopa/levodopa ext-rel RYTARY Tier 3 ONGENTYS Tier 3 XADAGO Tier 3 PA apomorphine APOKYN Tier 4 PA NOURIANZ Tier 5 PA levodopa inhalation powder INBRIJA Tier 5

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ANTIPSYCHOTICS Atypicals Tier 1 ABILIFY Tier 3 aripiprazole orally disintegrating tabs Tier 1 Tier 1 SAPHRIS Tier 3 Tier 1 CLOZARIL Tier 3 clozapine orally disintegrating tabs Tier 1 Tier 1 ZYPREXA/ZYPREXA Tier 3 olanzapine/fluoxetine Tier 1 ext-rel Tier 1 INVEGA Tier 3 Tier 1 SEROQUEL Tier 3 quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3 Tier 1 RISPERDAL Tier 3 risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3 Tier 1 GEODON Tier 3 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3 ext-rel inj ARISTADA Tier 3 PA aripiprazole tab with sensor ABILIFY MYCITE Tier 3 REXULTI Tier 3 VRAYLAR Tier 3 FANAPT Tier 3 CAPLYTA Tier 3 LATUDA Tier 3 PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3 paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3 risperidone ext-rel inj PERSERIS Tier 3

Miscellaneous Tier 1 Tier 1 inj Tier 1 HALDOL DECANOATE 100 Tier 3 haloperidol lactate inj Tier 1 HALDOL Tier 3 Tier 1 perphenazine Tier 1 Tier 1 thiothixene Tier 1 Tier 1 PA NUPLAZID Tier 5

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

PA ext-rel susp Tier 1 ADZENYS ER SUSP Tier 3 PA amphetamine sulfate Tier 1 EVEKEO Tier 3 PA amphetamine/ mixed Tier 1 Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR Tier 3 Tier 1 STRATTERA Tier 3 clonidine ext-rel Tier 1 KAPVAY Tier 3 PA dexmethylphenidate Tier 1 FOCALIN Tier 3 PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3 PA dextroamphetamine Tier 1 PA dextroamphetamine Tier 1 ZENZEDI Tier 3

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PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3 PA dextroamphetamine soln - Procentra Tier 1 ext-rel Tier 1 INTUNIV Tier 3 PA Tier 1 PA methylphenidate Tier 1 METHYLIN Tier 3 PA methylphenidate Tier 1 RITALIN Tier 3 PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3 PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3 PA methylphenidate ext-rel (except methylphenidate tab ER Tier 1 osmotic release 72 mg) PA methylphenidate ext-rel caps Tier 1 APTENSIO XR Tier 3 PA lisdexamfetamine VYVANSE Tier 2 PA amphetamine ext-rel orally disintegrating tabs ADZENYS XR-ODT Tier 3 PA amphetamine ext-rel suspension DYANAVEL XR Tier 3 PA amphetamine sulfate orally disintegrating EVEKEO ODT Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel MYDAYIS Tier 3 PA methylphenidate ext-rel caps ADHANSIA XR Tier 3 PA methylphenidate ext-rel chewable tabs QUILLICHEW ER Tier 3 PA methylphenidate ext-rel orally disintegrating tablets COTEMPLA XR-ODT Tier 3 PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3 PA methylphenidate transdermal DAYTRANA Tier 3

FIBROMYALGIA QL Tier 1 LYRICA Tier 3 QL SAVELLA Tier 3

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

Benzodiazepines QL estazolam Tier 1 QL Tier 1 quazepam Tier 1 DORAL Tier 3 QL Tier 1 RESTORIL Tier 3

Nonbenzodiazepines QL Tier 1 LUNESTA Tier 3 QL Tier 1 ROZEREM Tier 3 QL Tier 1 QL Tier 1 AMBIEN Tier 3 QL zolpidem ext-rel Tier 1 AMBIEN CR Tier 3 QL zolpidem sublingual Tier 1 QL DAYVIGO Tier 3 QL BELSOMRA Tier 3 QL zolpidem spray ZOLPIMIST Tier 3 QL zolpidem sublingual EDLUAR Tier 3 PA tasimelteon HETLIOZ Tier 4

Tricyclics doxepin Tier 1 SILENOR Tier 3

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

Calcitonin -Related Receptor Antagonist PA NURTEC ODT Tier 3

Ergotamine Derivatives inj Tier 1 D.H.E. 45 Tier 3 PA dihydroergotamine spray Tier 1 MIGRANAL Tier 3 /caffeine supp Tier 1 MIGERGOT Tier 1 ergotamine/caffeine tabs Tier 1 CAFERGOT Tier 3

Monoclonal Antibodies PA -aooe AIMOVIG Tier 2 PA -gnlm 100 mg/mL EMGALITY 100 mg/mL Tier 2 PA galcanezumab-gnlm 120 mg/mL EMGALITY 120 mg/mL Tier 2 PA -jjmr VYEPTI Tier 5

Selective Serotonin Agonists QL Tier 1 QL Tier 1 RELPAX Tier 3 QL Tier 1 FROVA Tier 3 QL Tier 1 AMERGE Tier 3 QL Tier 1 MAXALT/MAXALT-MLT Tier 3 QL Tier 1 IMITREX Tier 3 QL Tier 1 ZOMIG/ZOMIG-ZMT Tier 3 QL zolmitriptan nasal spray Tier 1 ZOMIG Tier 3 QL sumatriptan nasal powder ONZETRA XSAIL Tier 3 QL sumatriptan nasal spray TOSYMRA Tier 3

Selective Serotonin Agonist/ Anti-inflammatory Drug (NSAID) Combinations QL sumatriptan/naproxen sodium TREXIMET Tier 3

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

MOVEMENT DISORDERS PA Tier 4 XENAZINE Tier 5 PA AUSTEDO Tier 5

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

PA dalfampridine ext-rel Tier 4 PA dimethyl fumarate delayed-rel Tier 4 TECFIDERA Tier 5 PA glatiramer Tier 4 COPAXONE Tier 5 PA glatiramer - Glatopa Tier 4 PA fingolimod GILENYA Tier 4 PA beta-1a AVONEX Tier 4 PA interferon beta-1a REBIF Tier 4 PA interferon beta-1a REBIF REBIDOSE Tier 4

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PA interferon beta-1b BETASERON Tier 4 PA natalizumab TYSABRI Tier 4 PA ocrelizumab OCREVUS Tier 4 PA ozanimod ZEPOSIA Tier 4 PA peginterferon beta-1a PLEGRIDY Tier 4 PA peginterferon beta-1a PLEGRIDY PEN Tier 4 PA siponimod MAYZENT Tier 4 PA teriflunomide AUBAGIO Tier 4 PA alemtuzumab LEMTRADA Tier 5 PA cladribine MAVENCLAD Tier 5 PA diroximel fumarate delayed-rel VUMERITY Tier 5 PA interferon beta-1b EXTAVIA Tier 5 PA monomethyl fumarate BAFIERTAM Tier 5 PA ofatumumab KESIMPTA Tier 5

MUSCULOSKELETAL THERAPY AGENTS Tier 1 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 LIORESAL INTRATHECAL Tier 2 Tier 1 dantrolene Tier 1 DANTRIUM Tier 3

MYASTHENIA GRAVIS pyridostigmine Tier 1 MESTINON Tier 3 pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 3

NARCOLEPSY/CATAPLEXY PA Tier 1 NUVIGIL Tier 3 PA Tier 1 PROVIGIL Tier 3 PA XYREM Tier 2 PA calcium, , potassium, and sodium oxybates XYWAV Tier 3 PA solriamfetol SUNOSI Tier 3 PA WAKIX Tier 5

PSYCHOTHERAPEUTIC-MISCELLANEOUS Deterrents acamprosate calcium Tier 1 Tier 1 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 4

Opioid Antagonists PA, * auto-injector Tier 1 EVZIO Tier 3 naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 1

* Brand EVZIO requires prior approval

Partial Opioid Agonists QL buprenorphine Tier 1 PA buprenorphine ext-rel inj SUBLOCADE Tier 5

Partial Opioid Agonist/ Combinations QL buprenorphine/naloxone sublingual film Tier 1 SUBOXONE FILM Tier 3 QL buprenorphine/naloxone sublingual tabs Tier 1 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2

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Pseudobulbar Affect PA /quinidine NUEDEXTA Tier 2

Smoking Deterrents Treating Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2

MISCELLANEOUS Amyotrophic Lateral Sclerosis Tier 1 RILUTEK Tier 3 riluzole TIGLUTIK Tier 3 PA RADICAVA Tier 5

Botulinum PA abobotulinumtoxinA DYSPORT Tier 4 PA incobotulinumtoxinA XEOMIN Tier 4 PA onabotulinumtoxinA BOTOX Tier 4 PA rimabotulinumtoxinB MYOBLOC Tier 4

Duchenne Muscular Dystrophy PA EMFLAZA Tier 5 PA eteplirsen EXONDYS 51 Tier 5 PA golodirsen VYONDYS 53 Tier 5 PA viltolarsen VILTEPSO Tier 5

Lambert-Eaton Myasthenic Syndrome PA FIRDAPSE Tier 4 PA amifampridine RUZURGI Tier 5

Spinal Muscular Atrophy PA risdiplam EVRYSDI Tier 5

Tardive PA INGREZZA Tier 5

ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of are available at: https://www.aace.com

PA cypionate Tier 1 PA Tier 1 PA testosterone gel Tier 1 ANDROGEL Tier 3 PA testosterone gel Tier 1 FORTESTA Tier 3 PA testosterone gel Tier 1 TESTIM Tier 3 PA testosterone gel Tier 1 VOGELXO Tier 3 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone buccal STRIANT Tier 3 PA testosterone enanthate auto-injector XYOSTED Tier 3 PA inj AVEED Tier 4 PA testosterone pellets TESTOPEL Tier 5

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

Alpha-glucosidase Inhibitors Tier 1 PRECOSE Tier 3 Tier 1

Amylin Analogs SYMLINPEN Tier 2

Biguanides metformin Tier 1 * metformin ext-rel Tier 1 PA metformin ext-rel Tier 1 FORTAMET Tier 3 PA metformin oral soln Tier 1 RIOMET IR Tier 3

* Generic version of GLUMETZA (metformin ext-rel tabs) requires PA

Biguanide/ Combinations /metformin Tier 1 glyburide/metformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Tier 1 sitagliptin phosphate JANUVIA Tier 2

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/ Combinations alogliptin/metformin Tier 1 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/ Tier 1

Incretin Mimetic Agents TRULICITY Tier 2 VICTOZA Tier 2 OZEMPIC Tier 2 BYETTA Tier 3 exenatide ext-rel BYDUREON Tier 3 exenatide ext-rel BYDUREON BCISE Tier 3 ADLYXIN Tier 3 semaglutide RYBELSUS Tier 3

Incretin Mimetic Agent/Insulin Combinations PA liraglutide/ XULTOPHY Tier 3 PA lixisenatide/ SOLIQUA Tier 3

Insulins FIASP Tier 2 insulin aspart FIASP FLEXTOUCH Tier 2 insulin aspart INSULIN ASPART Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart 70%/insulin aspart 30% INSULIN ASPART PROTAMINE Tier 2 70%/INSULIN ASPART 30%

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insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2 insulin degludec TRESIBA Tier 2 LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin glargine LANTUS Tier 2 insulin glargine TOUJEO Tier 2 OTC insulin human HUMULIN R Tier 2 insulin human HUMULIN R U-500 Tier 2 OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human HUMULIN N Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 HUMALOG Tier 2 insulin lispro INSULIN LISPRO Tier 2 insulin lispro protamine/insulin lispro HUMALOG MIX Tier 2 insulin lispro protamine/insulin lispro INSULIN LISPRO Tier 2 PROTAMINE/INSULIN LISPRO APIDRA Tier 3 PA insulin human inhalation powder AFREZZA Tier 3 insulin lispro ADMELOG Tier 3 insulin lispro ADMELOG SOLOSTAR Tier 3 insulin lispro-aabc LYUMJEV/KWIKPEN Tier 3

Insulin Sensitizers pioglitazone Tier 1 ACTOS Tier 3 AVANDIA Tier 3

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3 pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 3

Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/ Tier 1 DUETACT Tier 3

Meglitinides Tier 1 STARLIX Tier 3 Tier 1

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST FARXIGA Tier 2 ST JARDIANCE Tier 2 PA/ST INVOKANA Tier 3 PA/ST STEGLATRO Tier 3

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST empagliflozin/metformin SYNJARDY Tier 2 ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2 PA/ST canagliflozin/metformin INVOKAMET Tier 3 PA/ST canagliflozin/metformin ext-rel INVOKAMET XR Tier 3 PA/ST ertugliflozin/metformin SEGLUROMET Tier 3

Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations ST dapagliflozin/ QTERN Tier 2 ST empagliflozin/ GLYXAMBI Tier 2

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PA/ST ertugliflozin/sitagliptin STEGLUJAN Tier 3

Sodium Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations PA/ST empagliflozin/linagliptin/metformin extended-release TRIJARDY XR Tier 3

Sulfonylureas glimepiride Tier 1 AMARYL Tier 3 glipizide Tier 1 GLUCOTROL Tier 3 glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3 glyburide Tier 1 glyburide, micronized Tier 1 GLYNASE Tier 3

Supplies PA blood glucose continuous monitoring receivers, sensors, FREESTYLE LIBRE / Tier 2 transmitters FREESTYLE LIBRE 2 CONTINUOUS GLUCOSE MONITORING SYST OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin pen needles NOVOFINE PEN NEEDLES Tier 2 OTC insulin syringes, needles BD INSULIN SYRINGES AND Tier 2 NEEDLES OTC lancet device ACCU-CHEK FASTCLIX LANCET Tier 2 DEVICE OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX Tier 2 LANCETS OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC test strips CHEMSTRIP K URINE Tier 2 STRIPS OTC urine test strips CHEMSTRIP UGK URINE Tier 2 GLUCOSE/KETONE STRIPS OTC urine test strips CHEMSTRIP UG URINE Tier 2 GLUCOSE STRIPS PA blood glucose continuous monitoring receivers, sensors, DEXCOM CONTINUOUS Tier 3 transmitters GLUCOSE MONITORING SYSTEM

CALCIUM RECEPTOR ANTAGONISTS PA Tier 4 SENSIPAR Tier 5 PA PARSABIV Tier 5

CALCIUM REGULATORS Guidelines of treatment and management of are available at: https://www.aace.com https://www.nof.org

Bisphosphonates alendronate Tier 1 FOSAMAX Tier 3 ibandronate Tier 1 BONIVA Tier 3 risedronate Tier 1 ACTONEL Tier 3

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risedronate delayed-rel Tier 1 ATELVIA Tier 3 pamidronate Tier 4 4 mg/100 mL Tier 4 PA, * zoledronic acid 5 mg/100 mL Tier 4 RECLAST Tier 5 alendronate/vitamin D3 FOSAMAX PLUS D Tier 3

* Brand RECLAST requires prior approval

Calcitonins -salmon spray Tier 1 MIACALCIN Tier 3 calcitonin-salmon inj MIACALCIN inj Tier 3

Parathyroid Hormones PA FORTEO Tier 4 PA TYMLOS Tier 5 PA (recombinant) NATPARA Tier 5

Miscellaneous PA PROLIA Tier 4 PA denosumab XGEVA Tier 4 PA -aqqg EVENITY Tier 5

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CARNITOR Tier 3

CONTRACEPTIVES EE = ethinyl

Monophasic 20 mcg Estrogen † /EE 3/20 Tier 1 YAZ Tier 3 † /EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 † norethindrone acetate/EE 1/20 and Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 TAYTULLA Tier 3

30 mcg Estrogen † /EE 0.15/30 Tier 1 † drospirenone/EE 3/30 Tier 1 YASMIN Tier 3 † drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 SAFYRAL Tier 3 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 † norethindrone acetate/EE 1.5/30 and iron Tier 1 † /EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 † norethindrone/EE 0.4/35 Tier 1 † norethindrone/EE 0.5/35 Tier 1 † norethindrone/EE 1/35 Tier 1 † /EE 0.25/35 Tier 1

50 mcg Estrogen † ethynodiol diacetate/EE 1/50 Tier 1

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† norgestrel/EE 0.5/50 Tier 1

Biphasic † desogestrel/EE Tier 1 MIRCETTE Tier 3 norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE Tier 3

Triphasic † desogestrel/EE Tier 1 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3 † norethindrone/EE Tier 1 † norgestimate/EE Tier 1

Four and /estradiol valerate NATAZIA Tier 3

Extended Cycle † levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3 † levonorgestrel/EE 0.15/30 - Jolessa Tier 1 † levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3

Continuous † levonorgestrel/EE 0.09/20 - Amethyst Tier 1

Progestin Only † norethindrone Tier 1 ORTHO MICRONOR Tier 3 drospirenone SLYND Tier 3

Implant ‡ implant NEXPLANON Tier 4

Injectable † acetate 150 mg/mL Tier 1 DEPO-PROVERA Tier 3

Intrauterine Devices ‡ intrauterine contraceptive PARAGARD T 380A Tier 2 ‡ levonorgestrel-releasing IUD KYLEENA Tier 4 ‡ levonorgestrel-releasing IUD MIRENA Tier 4 ‡ levonorgestrel-releasing IUD SKYLA Tier 4 levonorgestrel-releasing IUD LILETTA Tier 5

Transdermal † /EE Tier 1 ethinyl estradiol/levonorgestrel TWIRLA Tier 3

Vaginal †, * etonogestrel/EE - EluRyng Tier 1 NUVARING Tier 3 //potassium bitartrate gel PHEXXI Tier 3 acetate/EE ring ANNOVERA Tier 3

* Generic versions are covered at no charge to qualifying members

ENDOMETRIOSIS Tier 1 PA SYNAREL Tier 2 PA ORILISSA Tier 3

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leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4

ESTROGENS Guidelines of treatment and management of and are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf

Injectable estradiol valerate Tier 1 DELESTROGEN Tier 2

Oral estradiol Tier 1 ESTRACE Tier 3 estrogens, esterified/ Tier 1 estrogens, conjugated PREMARIN Tier 2

Transdermal estradiol Tier 1 CLIMARA Tier 3 estradiol Tier 1 MINIVELLE Tier 3 estradiol Tier 1 VIVELLE-DOT Tier 3 estradiol transdermal spray EVAMIST Tier 2 estradiol ALORA Tier 3 estradiol transdermal gel ESTROGEL Tier 3

Vaginal estradiol vaginal crm Tier 1 ESTRACE Tier 3 estradiol vaginal tabs Tier 1 VAGIFEM Tier 3 estradiol ESTRING Tier 2 estrogens, conjugated crm PREMARIN crm Tier 2 estradiol vaginal inserts IMVEXXY Tier 3 estradiol vaginal ring FEMRING Tier 3

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 FEMHRT Tier 3 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3 estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2 estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2 drospirenone/estradiol ANGELIQ Tier 3 estradiol/norgestimate PREFEST Tier 3 estradiol/ BIJUVA Tier 3

Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 estradiol/norethindrone acetate COMBIPATCH Tier 3

ESTROGEN/SELECTIVE ESTROGEN COMBINATIONS / DUAVEE Tier 3

FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic Tier 4 PA acetate inj Tier 4 GANIRELIX ACETATE Tier 4 PA LUTREPULSE Tier 2 PA CETROTIDE Tier 4 PA choriogonadotropin alfa OVIDREL Tier 4

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PA chorionic gonadotropin NOVAREL Tier 4 PA chorionic gonadotropin PREGNYL Tier 4 PA follitropin beta FOLLISTIM AQ Tier 4 PA MENOPUR Tier 4 PA follitropin alfa GONAL-F Tier 5 PA follitropin alfa GONAL-F RFF Tier 5

GAUCHER DISEASE PA CERDELGA Tier 4 PA CEREZYME Tier 4

GLUCOCORTICOIDS acetate Tier 1 Tier 1 Tier 1 Tier 1 CORTEF Tier 3 Tier 1 MEDROL Tier 3 Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally disintegrating tabs Tier 1 ORAPRED ODT Tier 3 prednisolone syrup Tier 1 Tier 1 PA dexamethasone HEMADY Tier 3 hydrocortisone ALKINDI SPRINKLE CAPS Tier 3 PA prednisone delayed-rel RAYOS Tier 3

GLUCOSE ELEVATING AGENTS Tier 1 PROGLYCEM Tier 3 , human recombinant (KIT) Tier 1 GLUCAGON EMERGENCY KIT Tier 3 glucagon nasal powder BAQSIMI Tier 2 glucagon subcutaneous soln GVOKE Tier 2 glucagon, human recombinant GLUCAGEN Tier 2

HEREDITARY TYROSINEMIA TYPE 1 AGENTS Tier 4 ORFADIN Tier 4 nitisinone NITYR Tier 5

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

PA somatropin NORDITROPIN Tier 4 PA, * somatropin Tier 4 PA, ** somatropin ZORBTIVE Tier 4 PA somatropin GENOTROPIN Tier 5 PA somatropin HUMATROPE Tier 5 PA somatropin NUTROPIN AQ Tier 5 PA somatropin NUTROPIN AQ NUSPIN Tier 5 PA somatropin OMNITROPE Tier 5 PA somatropin Tier 5 PA somatropin ZOMACTON Tier 5

* Indicated for AIDS wasting only ** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support

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HYPERPARATHYROID TREATMENT, ANALOGS (1,25-D3) Tier 1 ROCALTROL Tier 3 Tier 1 HECTOROL Tier 3 Tier 1 ZEMPLAR Tier 3 ext-rel RAYALDEE Tier 3

INSULIN-LIKE GROWTH FACTOR-1 AGENTS PA INCRELEX Tier 4

PHENYLKETONURIA TREATMENT AGENTS PA sapropterin Tier 4 KUVAN Tier 5 PA -pqpz PALYNZIQ Tier 5

PHOSPHATE BINDER AGENTS calcium acetate Tier 1 carbonate chew tabs Tier 1 FOSRENOL CHEWABLE Tier 3 TABLETS sevelamer carbonate Tier 1 RENVELA Tier 3 sevelamer HCl Tier 1 RENAGEL Tier 3 lanthanum oral powder FOSRENOL ORAL POWDER Tier 2 ferric citrate AURYXIA Tier 3 VELPHORO Tier 3

POTASSIUM-REMOVING AGENTS sodium Tier 1 PA VELTASSA Tier 3 PA sodium cyclosilicate LOKELMA Tier 3

PROGESTINS Injectable hydroxyprogesterone caproate Tier 4 MAKENA Tier 5

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

Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2

SELECTIVE ESTROGEN RECEPTOR MODULATORS Tier 1 EVISTA Tier 3 OSPHENA Tier 3

THYROID AGENTS Antithyroid Agents methimazole Tier 1 TAPAZOLE Tier 3 Tier 1

Thyroid Supplements Tier 1 SYNTHROID Tier 2 levothyroxine Tier 1 TIROSINT Tier 3 levothyroxine - Levoxyl Tier 1 Tier 1 CYTOMEL Tier 3 thyroid ARMOUR THYROID Tier 3

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UREA CYCLE DISORDERS PA Tier 4 BUPHENYL Tier 5

UTERINE FIBROIDS PA elagolix sodium/estradiol/norethindrone acetate ORIAHNN Tier 3

VASOPRESSINS spray, tabs Tier 1 DDAVP Tier 3

MISCELLANEOUS Tier 1 ACETADOTE Tier 3 methylergonovine Tier 1 trientine Tier 1 SYPRINE Tier 3 corticotropin powder Tier 4 PA Tier 4 ZAVESCA Tier 5 PA, * acetate Tier 4 SANDOSTATIN Tier 5 PA Tier 4 SAMSCA Tier 5 CYANOKIT Tier 2 vaginal inserts INTRAROSA Tier 3 PA triacetate XURIDEN Tier 3 PA agalsidase beta FABRAZYME Tier 4 PA LUMIZYME Tier 4 PA STRENSIQ Tier 4 betaine anhydrous CYSTADANE Tier 4 PA -twza CRYSVITA Tier 4 PA CARBAGLU Tier 4 CYSTAGON Tier 4 PA cysteamine delayed-rel PROCYSBI Tier 4 PA elosulfase alfa VIMIZIM Tier 4 PA galsulfase NAGLAZYME Tier 4 PA phenylbutyrate RAVICTI Tier 4 PA histrelin acetate SUPPRELIN LA Tier 4 PA idursulfase ELAPRASE Tier 4 PA acetate SOMATULINE DEPOT Tier 4 PA laronidase ALDURAZYME Tier 4 PA leuprolide acetate LUPRON DEPOT-PED Tier 4 PA lonafarnib ZOKINVY Tier 4 PA KORLYM Tier 4 PA octreotide acetate SANDOSTATIN LAR Tier 4 PA SIGNIFOR Tier 4 SOMAVERT Tier 4 PA KANUMA Tier 4 PA ELELYSO Tier 4 PA EGRIFTA Tier 4 thyrotropin alfa THYROGEN Tier 4 PA tolvaptan JYNARQUE Tier 4 PA VPRIV Tier 4 PA vestronidase alfa-vjbk MEPSEVII Tier 4 PA corticotropin ACTHAR Tier 5 PA elapegademase-lvlr REVCOVI Tier 5 PA TEGSEDI Tier 5 PA MYALEPT Tier 5 PA migalastat GALAFOLD Tier 5 PA octreotide MYCAPSSA Tier 5 PA octreotide acetate BYNFEZIA Tier 5

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PA phosphate ISTURISA Tier 5 PA triptorelin pamoate TRIPTODUR Tier 5

* Brand SANDOSTATIN requires prior approval

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

ANTIDIARRHEALS diphenoxylate/ Tier 1 LOMOTIL Tier 3 Tier 1 delayed-rel MYTESI Tier 3

ANTIEMETICS QL caps Tier 1 EMEND Tier 3 PA /pyridoxine delayed-rel Tier 1 DICLEGIS Tier 3 QL Tier 1 MARINOL Tier 3 Tier 1 Tier 1 Tier 1 REGLAN Tier 3 QL Tier 1 ZOFRAN Tier 3 QL ondansetron orally disintegrating tabs Tier 1 PA Tier 1 ALOXI Tier 3 Tier 1 Tier 1 transdermal Tier 1 TRANSDERM SCOP Tier 3 Tier 1 TIGAN Tier 3 QL granisetron transdermal SANCUSO Tier 2 QL VARUBI Tier 2 QL aprepitant CINVANTI Tier 3 QL aprepitant susp EMEND Tier 3 PA doxylamine/pyridoxine ext-rel BONJESTA Tier 3 PA granisetron ext-rel inj SUSTOL Tier 3 metoclopramide nasal spray GIMOTI Tier 3 QL /palonosetron AKYNZEO Tier 3

ANTISPASMODICS d atropine//scopolamine/phenobarbital Tier 1 chlordiazepoxide/clidinium Tier 1 dicyclomine Tier 1 d hyoscyamine sulfate Tier 1 LEVSIN Tier 3 d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3 propantheline 15 mg Tier 1

CHOLELITHOLYTICS ursodiol Tier 1 ACTIGALL Tier 3 ursodiol Tier 1 URSO Tier 3 ursodiol Tier 1 URSO FORTE Tier 3

H2 RECEPTOR ANTAGONISTS Tier 1 * Tier 1 Tier 1

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* Except OTC available versions like 10 mg and 20 mg

INFLAMMATORY BOWEL DISEASE Injectable Agents PA vedolizumab ENTYVIO Tier 5

Oral Agents balsalazide Tier 1 delayed-rel caps Tier 1 ENTOCORT EC Tier 3 mesalamine delayed-rel caps Tier 1 DELZICOL Tier 3 mesalamine delayed-rel tabs Tier 1 ASACOL HD Tier 3 mesalamine delayed-rel tabs Tier 1 LIALDA Tier 3 mesalamine ext-rel caps Tier 1 APRISO Tier 3 sulfasalazine Tier 1 AZULFIDINE Tier 3 sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3 mesalamine ext-rel caps PENTASA Tier 2 budesonide ext-rel caps ORTIKOS Tier 3 olsalazine DIPENTUM Tier 3

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

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA lubiprostone Tier 1 AMITIZA Tier 3 PA linaclotide LINZESS Tier 2 PA maleate ZELNORM Tier 3

Irritable Bowel Syndrome with Tier 1 LOTRONEX Tier 3 PA eluxadoline VIBERZI Tier 3

LAXATIVES lactulose soln Tier 1 peg 3350/electrolytes Tier 1 GOLYTELY Tier 3 peg 3350/electrolytes Tier 1 MOVIPREP Tier 3 peg 3350/electrolytes Tier 1 NULYTELY Tier 3 sodium sulfate// SUPREP Tier 2 lactulose KRISTALOSE pak Tier 3 peg 3350/electrolytes PLENVU Tier 3 sodium OSMOPREP Tier 3 sodium picosulfate/magnesium /citric acid CLENPIQ Tier 3 sodium picosulfate//citric acid PREPOPIK Tier 3 sodium sulfate/magnesium sulfate/ SUTAB Tier 3

OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK Tier 2 PA methylnaltrexone RELISTOR Tier 3

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

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pancrelipase delayed-rel PANCREAZE Tier 3

PROSTAGLANDINS misoprostol Tier 1 CYTOTEC Tier 3

PROTON PUMP INHIBITORS QL magnesium delayed-rel Tier 1 QL delayed-rel Tier 1 delayed-rel Tier 1 QL omeprazole/ Tier 1 QL delayed-rel Tier 1 QL delayed-rel (except rabeprazole capsule sprinkle Tier 1 delayed-rel) QL delayed-rel DEXILANT Tier 3

SALIVA STIMULANTS Tier 1 EVOXAC Tier 3 tabs Tier 1 SALAGEN Tier 3

STEROIDS, RECTAL d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2 d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2

ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + clarithromycin Tier 1 QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2 QL amoxicillin/rifabutin/omeprazole TALICIA Tier 3

MISCELLANEOUS alvimopan Tier 1 ENTEREG Tier 3 cromolyn sodium Tier 1 GASTROCROM Tier 3 Tier 1 QL dronabinol solution SYNDROS Tier 3 glycopyrrolate CUVPOSA Tier 3 nitroglycerin rectal oint 0.4% RECTIV Tier 3 PA plecanatide TRULANCE Tier 3 /sodium hyaluronate SOLESTA Tier 4 PA KEPIVANCE Tier 4 PA GATTEX Tier 4 PA CHOLBAM Tier 5 PA GIVLAARI Tier 5 PA OCALIVA Tier 5 PA telotristat XERMELO Tier 5

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

ext-rel Tier 1 Tier 1 AVODART Tier 3 dutasteride/ Tier 1 JALYN Tier 3 Tier 1 PROSCAR Tier 3 Tier 1 RAPAFLO Tier 3 PA tadalafil 2.5 mg, 5 mg Tier 1 CIALIS Tier 3 tamsulosin Tier 1 FLOMAX Tier 3

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URINARY ANTISPASMODICS ext-rel Tier 1 Tier 1 oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3 Tier 1 Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 ext-rel TOVIAZ Tier 2 ext-rel MYRBETRIQ Tier 2 oxybutynin gel GELNIQUE Tier 3 solifenacin VESICARE LS Tier 3

VAGINAL ANTI-INFECTIVES metronidazole vaginal Tier 1 crm Tier 1 terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2 clindamycin vaginal cream CLINDESSE Tier 2

MISCELLANEOUS Tier 1 Tier 1 PYRIDIUM Tier 3 ext-rel Tier 1 UROCIT-K Tier 3 PA Tier 1 THIOLA Tier 3 sodium ELMIRON Tier 2 PA tiopronin delayed-rel THIOLA EC Tier 3

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

Injectable enoxaparin Tier 1 LOVENOX Tier 3 dalteparin FRAGMIN Tier 2

Oral Tier 1 ELIQUIS Tier 2 XARELTO Tier 2 etexilate PRADAXA Tier 3

Synthetic -like Agents Tier 1 ARIXTRA Tier 3

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of are available at: https://www.asco.org

Guidelines for the management of associated with chronic disease are available at: https://www.kidney.org/professionals/guidelines#guidelines

PA ARANESP Tier 4

48

PA epoetin alfa-epbx RETACRIT Tier 4 PA -aafi NIVESTYM Tier 4 PA filgrastim-sndz ZARXIO Tier 4 PA -apgf NYVEPRIA Tier 4 PA pegfilgrastim-bmez ZIEXTENZO Tier 4 PA pegfilgrastim-cbqv UDENYCA Tier 4 PA pegfilgrastim-jmdb FULPHILA Tier 4 PA tbo-filgrastim GRANIX Tier 4 PA epoetin alfa EPOGEN Tier 5 PA epoetin alfa PROCRIT Tier 5 PA filgrastim NEUPOGEN Tier 5 PA methoxy /epoetin beta MIRCERA Tier 5 PA pegfilgrastim NEULASTA Tier 5 PA LEUKINE Tier 5

HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org

AHF, human/VWF, human HUMATE-P Tier 4 antihemophilic factor ALPHANATE Tier 4 antihemophilic factor HEMOFIL M Tier 4 antihemophilic factor KOATE-DVI Tier 4 antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 4 antihemophilic factor, recombinant ADVATE Tier 4 antihemophilic factor, recombinant AFSTYLA Tier 4 antihemophilic factor, recombinant KOGENATE FS Tier 4 antihemophilic factor, recombinant KOVALTRY Tier 4 antihemophilic factor, recombinant NOVOEIGHT Tier 4 antihemophilic factor, recombinant RECOMBINATE Tier 4 antihemophilic factor, recombinant XYNTHA Tier 4 antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4 anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4 factor IX (recombinant), glycopegylated REBINYN Tier 4 coagulation factor IX, recombinant IDELVION Tier 4 coagulation factor IX, recombinant IXINITY Tier 4 coagulation factor VIIa NOVOSEVEN RT Tier 4 coagulation , human COAGADEX Tier 4 desmopressin spray STIMATE Tier 4 emicizumab-kxwh HEMLIBRA Tier 4 factor IX concentrate ALPHANINE SD Tier 4 factor IX concentrate BENEFIX Tier 4 factor IX concentrate MONONINE Tier 4 factor IX concentrate PROFILNINE Tier 4 factor IX concentrate RIXUBIS Tier 4 factor IX recombinant, Fc fusion protein ALPROLIX Tier 4 factor XIII A-subunit recombinant TRETTEN Tier 4 factor XIII concentrate CORIFACT Tier 4 fibrinogen RIASTAP Tier 4 human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ Tier 4 von Willebrand factor, recombinant VONVENDI Tier 4 VWF, human/factor VIII complex WILATE Tier 4 antihemophilic factor (recombinant) pegylated ADYNOVATE Tier 5 antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 5 antihemophilic factor (recombinant) porcine sequence OBIZUR Tier 5 antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT Tier 5

49

coagulation factor VIIa-jncw SEVENFACT Tier 5 fibrinogen FIBRYGA Tier 5

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 4 PA romiplostim NPLATE Tier 4 PA fostamatinib TAVALISSE Tier 5

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PA eculizumab SOLIRIS Tier 4 PA ravulizumab-cwvz ULTOMIRIS Tier 5

PLATELET AGGREGATION INHIBITORS Tier 1 PLAVIX Tier 3 Tier 1 dipyridamole ext-rel/aspirin Tier 1 AGGRENOX Tier 3 Tier 1 EFFIENT Tier 3 PA aspirin ext-rel DURLAZA Tier 3 KENGREAL Tier 3 INTEGRILIN Tier 3 BRILINTA Tier 3 inj AGGRASTAT Tier 3 ZONTIVITY Tier 3

PLATELET SYNTHESIS INHIBITORS Tier 1 AGRYLIN Tier 3

SICKLE CELL DISEASE PA crizanlizumab-tmca ADAKVEO Tier 4 PA voxelotor OXBRYTA Tier 4

STEM CELL MOBILIZERS PA plerixafor MOZOBIL Tier 4

THROMBOCYTOPENIA AGENTS QL lusutrombopag MULPLETA Tier 5

MISCELLANEOUS aminocaproic acid Tier 1 AMICAR Tier 3 Tier 1 ext-rel Tier 1 tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3 tranexamic acid Tier 1 LYSTEDA Tier 3 PA deferasirox Tier 4 EXJADE Tier 5 PA deferasirox Tier 4 JADENU Tier 5 PA deferiprone Tier 4 FERRIPROX Tier 4 deferoxamine Tier 4 DESFERAL Tier 5 CATHFLO ACTIVASE Tier 2 PA luspatercept-aamt REBLOZYL Tier 4 PA concentrate, human CEPROTIN Tier 4 PA avatrombopag DOPTELET Tier 5 PA L- oral powder ENDARI Tier 5

50

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

ALLERGENIC EXTRACTS PA grass mixed pollen extract ORALAIR Tier 5 PA allergen-dfnp PALFORZIA Tier 5

AUTOIMMUNE AGENTS PA adalimumab HUMIRA Tier 4 PA OTEZLA Tier 4 PA etanercept ENBREL Tier 4 PA etanercept ENBREL SURECLICK Tier 4 PA golimumab SIMPONI 100 mg Tier 4 PA ixekizumab TALTZ Tier 4 PA risankizumab-rzaa SKYRIZI Tier 4 PA ACTEMRA Tier 4 PA XELJANZ Tier 4 PA tofacitinib ext-rel XELJANZ XR Tier 4 PA RINVOQ ER Tier 4 PA ustekinumab STELARA SUBCUTANEOUS Tier 4 PA abatacept ORENCIA Tier 5 PA anakinra KINERET Tier 5 PA baricitinib OLUMIANT Tier 5 PA brodalumab SILIQ Tier 5 PA certolizumab pegol CIMZIA Tier 5 PA golimumab SIMPONI 50 mg Tier 5 PA, * infliximab REMICADE PA, * infliximab-abda RENFLEXIS PA, * infliximab-dyyb INFLECTRA PA sarilumab KEVZARA Tier 5 PA satralizumab-mwge ENSPRYNG Tier 5 PA tildrakizumab-asmn ILUMYA Tier 5

* Medical Benefit only drug

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 PLAQUENIL Tier 3 leflunomide Tier 1 ARAVA Tier 3 inj Tier 1 methotrexate oral Tier 1 penicillamine tabs Tier 1 DEPEN Tier 3 auranofin RIDAURA Tier 3 PA methotrexate auto-injector RASUVO Tier 3 PA methotrexate inj OTREXUP Tier 3

HEREDITARY ANGIOEDEMA AGENTS PA Tier 4 FIRAZYR Tier 5 PA C1 esterase inhibitor BERINERT Tier 4 PA C1 esterase inhibitor CINRYZE Tier 4 PA ecallantide KALBITOR Tier 4 PA berotralstat ORLADEYO Tier 5 PA C1 esterase inhibitor HAEGARDA Tier 5 PA C1 esterase inhibitor, recombinant RUCONEST Tier 5

51

PA lanadelumab-flyo TAKHZYRO Tier 5

IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 4 hepatitis B immune globulin HYPERHEP B S-D Tier 4 hepatitis B immune globulin NABI-HB Tier 4 PA immune globulin (human)-ifas PANZYGA Tier 4 PA immune globulin, gamma GAMASTAN Tier 4 PA immune globulin, gamma GAMASTAN S-D Tier 4 PA immune globulin, gamma GAMUNEX-C Tier 4 PA immune globulin, gamma (IGG) GAMMAKED Tier 4 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4 PA immune globulin, intravenous BIVIGAM Tier 4 PA immune globulin, intravenous FLEBOGAMMA Tier 4 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4 PA immune globulin, intravenous GAMMAGARD S-D Tier 4 PA immune globulin, intravenous OCTAGAM Tier 4 PA immune globulin, intravenous PRIVIGEN Tier 4 PA immune globulin, subcutaneous HIZENTRA Tier 4 PA immune globulin/hyaluronidase HYQVIA Tier 4 Rho (D) immune globulin HYPERRHO S-D Tier 4 Rho (D) immune globulin MICRHOGAM Tier 4 Rho (D) immune globulin MICRHOGAM PLUS Tier 4 Rho (D) immune globulin RHOGAM Tier 4 Rho (D) immune globulin RHOGAM PLUS Tier 4 Rho (D) immune globulin RHOPHYLAC Tier 4 Rho (D) immune globulin WINRHO SDF Tier 4 varicella zoster immune globulin VARIZIG Tier 4 PA immune globulin (human)-klhw XEMBIFY Tier 5 PA immune globulin (human)-slra ASCENIV Tier 5 PA immune globulin, subcutaneous CUVITRU Tier 5 PA immune globulin-hipp CUTAQUIG Tier 5

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

Guidelines for the management of hepatitis are available at: https://www.aasld.org

Interferons PA interferon alfa-2b INTRON A Tier 4 PA -1b, recombinant ACTIMMUNE Tier 4 PA peginterferon alfa-2a PEGASYS Tier 4 PA peginterferon alfa-2b PEGINTRON Tier 4

Miscellaneous bezlotoxumab ZINPLAVA Tier 3 PA canakinumab ILARIS Tier 4 PA rilonacept ARCALYST Tier 4

IMMUNOSUPPRESSANTS Antimetabolites Tier 1 IMURAN Tier 3 mycophenolate mofetil Tier 1 CELLCEPT Tier 3 mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 3

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Calcineurin Inhibitors cyclosporine Tier 1 SANDIMMUNE Tier 3 cyclosporine, modified Tier 1 NEORAL Tier 3 Tier 1 PROGRAF Tier 3 tacrolimus ext-rel ASTAGRAF XL Tier 2 tacrolimus ext-rel ENVARSUS XR Tier 3 PA voclosporin LUPKYNIS Tier 5

Rapamycin Derivatives Tier 1 RAPAMUNE Tier 3 everolimus 0.25 mg, 0.5 mg, 0.75 mg Tier 4 ZORTRESS 0.25 mg, 0.5 mg, 0.75 Tier 5 mg everolimus 1 mg ZORTRESS 1 mg Tier 4

Miscellaneous belatacept NULOJIX Tier 4 PA belimumab BENLYSTA Tier 4

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

VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1

Prenatal Vitamins prenatal vitamins/folic acid DUET DHA Tier 2 prenatal vitamins/folic acid PRENATE ELITE Tier 2 prenatal vitamins//folic acid CITRANATAL RX Tier 3 prenatal vitamins/folic acid VITAFOL-OB Tier 3

Miscellaneous inj Tier 1 (D2) Tier 1 phytonadione Tier 1 MEPHYTON Tier 3 sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3 cyanocobalamin spray NASCOBAL Tier 2 iron inj VENOFER Tier 2 acetate GALZIN Tier 2 ferric carboxymaltose inj INJECTAFER Tier 3 inj MONOFERRIC Tier 3 ferumoxytol inj FERAHEME Tier 3

MISCELLANEOUS PA DOJOLVI Tier 5

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

53

https://goldcopd.org https://www.nhlbi.nih.gov

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

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS PA alpha-1 proteinase inhibitor ARALAST NP Tier 4 PA alpha-1 proteinase inhibitor GLASSIA Tier 4 PA alpha-1 proteinase inhibitor PROLASTIN-C Tier 4 PA alpha-1 proteinase inhibitor ZEMAIRA Tier 4

ANAPHYLAXIS TREATMENT AGENTS auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 3 epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 3 epinephrine inj (0.15 mg and 0.30 mg) SYMJEPI Tier 2

ANTICHOLINERGICS ipratropium soln Tier 1 ipratropium, CFC-free aerosol ATROVENT HFA Tier 2 tiotropium SPIRIVA Tier 2 tiotropium SPIRIVA RESPIMAT Tier 2 aclidinium TUDORZA PRESSAIR Tier 3 glycopyrrolate inhalation powder SEEBRI NEOHALER Tier 3 glycopyrrolate inhalation solution LONHALA MAGNAIR Tier 3 inhalation solution YUPELRI Tier 3 INCRUSE ELLIPTA Tier 3

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 3

Long Acting tiotropium/ STIOLTO RESPIMAT Tier 2 umeclidinium/ ANORO ELLIPTA Tier 2 / fumarate DUAKLIR PRESSAIR Tier 3 glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3 /glycopyrrolate inhalation powder UTIBRON NEOHALER Tier 3

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS /umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2 budesonide/glycopyrrolate/formoterol BREZTRI AEROSPHERE Tier 3

ANTIHISTAMINES, LOW SEDATING Tier 1

ANTIHISTAMINES, NONSEDATING Tier 1 CLARINEX Tier 3

ANTIHISTAMINES, SEDATING Tier 1 diphenhydramine Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3 promethazine Tier 1

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ANTIHISTAMINE/DECONGESTANT COMBINATIONS desloratadine/ ext-rel CLARINEX-D Tier 3

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

Tier 1 TESSALON Tier 3

ANTITUSSIVE COMBINATIONS Opioid QL codeine/promethazine Tier 1 QL codeine/promethazine/ Tier 1 QL hydrocodone/ Tier 1

BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 2 albuterol sulfate, CFC-free aerosol Tier 1 PROVENTIL HFA Tier 2 albuterol sulfate, CFC-free aerosol Tier 1 VENTOLIN HFA Tier 2 levalbuterol inhalation soln Tier 1 XOPENEX SOLUTION Tier 3 levalbuterol soln concentrate Tier 1 XOPENEX CONCENTRATE Tier 3 levalbuterol tartrate, CFC-free aerosol Tier 1 XOPENEX HFA Tier 3 albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2 albuterol sulfate aerosol powder 108mcg/actuation with sensor PROAIR DIGIHALER Tier 3

Long Acting Hand-held Active Inhalation xinafoate SEREVENT DISKUS Tier 2 formoterol inhalation caps FORADIL Tier 3 olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Tier 3

Nebulized Passive Inhalation soln BROVANA Tier 3 formoterol inhalation soln PERFOROMIST Tier 3

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

CYSTIC FIBROSIS inhalation soln Tier 4 BETHKIS Tier 5 tobramycin inhalation soln Tier 4 KITABIS PAK Tier 5 tobramycin inhalation soln Tier 4 TOBI Tier 5 aztreonam inhalation soln CAYSTON Tier 4 PA PULMOZYME Tier 4 PA elexacaftor/tezacaftor/ + ivacaftor TRIKAFTA Tier 4 PA ivacaftor KALYDECO Tier 4 PA lumacaftor/ivacaftor ORKAMBI Tier 4 PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4 tobramycin inhalation powder TOBI PODHALER Tier 4 PA liposome inhalation susp ARIKAYCE Tier 5

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PA inhalation powder BRONCHITOL Tier 5

LEUKOTRIENE MODULATORS Tier 1 SINGULAIR Tier 3 Tier 1 ACCOLATE Tier 3

MAST CELL STABILIZERS cromolyn soln Tier 1

NASAL ANTIHISTAMINES spray Tier 1 spray Tier 1 PATANASE Tier 3

NASAL STEROIDS/COMBINATIONS azelastine/fluticasone nasal spray Tier 1 DYMISTA Tier 3 spray Tier 1 fluticasone spray Tier 1 spray Tier 1 NASONEX Tier 3 spray OMNARIS Tier 2 spray VERAMYST Tier 2 beclomethasone spray BECONASE AQ Tier 3 PA XHANCE Tier 3

PHOSPHODIESTERASE-4 INHIBITORS DALIRESP Tier 3

PULMONARY FIBROSIS AGENTS PA OFEV Tier 4 PA ESBRIET Tier 4

SEVERE ASTHMA AGENTS PA XOLAIR Tier 4 PA mepolizumab NUCALA Tier 5

STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol Tier 1 SYMBICORT Tier 2 fluticasone/salmeterol Tier 1 ADVAIR Tier 3 fluticasone/salmeterol Tier 1 AIRDUO RESPICLICK Tier 3 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 2 mometasone/formoterol DULERA Tier 2 fluticasone/salmeterol AIRDUO DIGIHALER Tier 3

STEROID INHALANTS budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3 beclomethasone breath-activated aerosol QVAR REDIHALER Tier 2 beclomethasone, CFC-free aerosol QVAR Tier 2 budesonide PULMICORT FLEXHALER Tier 2 fluticasone ARNUITY ELLIPTA Tier 2 fluticasone FLOVENT Tier 2 fluticasone, CFC-free aerosol FLOVENT HFA Tier 2 ciclesonide ALVESCO Tier 3 fluticasone propionate ARMONAIR DIGIHALER Tier 3 mometasone ASMANEX Tier 3 mometasone, CFC-free aerosol ASMANEX HFA Tier 3

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XANTHINES Tier 1 CAFCIT Tier 3 ext-rel tabs Tier 1 theophylline ext-rel caps THEO-24 Tier 2 theophylline liquid ELIXOPHYLLIN Tier 2

MISCELLANEOUS ipratropium nasal spray Tier 1 PA benralizumab FASENRA Tier 5 PA reslizumab inj CINQAIR Tier 5

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

Oral Tier 1 PA, * isotretinoin Tier 1 ABSORICA Tier 3 minocycline ext-rel caps Tier 1 XIMINO Tier 3

* Brand ABSORICA requires PA

Topical PA crm, gel Tier 1 DIFFERIN Tier 3 PA adapalene/ Tier 1 EPIDUO Tier 3 benzoyl peroxide Tier 1 BENZAC AC Tier 3 QL clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 clindamycin/benzoyl peroxide Tier 1 ACANYA Tier 3 clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 3 PA clindamycin/ Tier 1 VELTIN Tier 3 PA clindamycin/tretinoin Tier 1 ZIANA Tier 3 QL erythromycin gel 2% Tier 1 ERYGEL Tier 3 QL erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3 QL, * sodium Tier 1 PA crm 0.1% Tier 1 TAZORAC Tier 3 PA tretinoin Tier 1 ATRALIN Tier 3 PA tretinoin Tier 1 RETIN-A Tier 3 PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3 PA adapalene/benzoyl peroxide EPIDUO FORTE Tier 3 AZELEX Tier 3 clindamycin/benzoyl peroxide ONEXTON Tier 3 QL minocycline hcl micronized foam AMZEEQ Tier 3 PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3 PA tazarotene foam 0.1% FABIOR Tier 3 PA tazarotene lotion 0.045% ARAZLO Tier 3 PA cream 0.005% AKLIEF Tier 3

* generic for OVACE and OVACE PLUS

Actinic Keratosis PA diclofenac sodium 3% gel Tier 1

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fluorouracil Tier 1 CARAC Tier 3 fluorouracil Tier 1 EFUDEX Tier 3 PA gel 10% AMELUZ Tier 3 PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3 fluorouracil FLUOROPLEX Tier 3 fluorouracil crm 4% TOLAK Tier 3 PA KLISYRI Tier 3

Antibiotics QL crm Tier 1 acetate packets 5% Tier 1 SULFAMYLON Tier 3 QL Tier 1 silver Tier 1 SILVADENE Tier 3 ALTABAX Tier 2 PA ozenoxacin XEPI Tier 3

Antifungals QL Tier 1 LOPROX Tier 3 QL clotrimazole Tier 1 QL clotrimazole/ Tier 1 QL Tier 1 QL ketoconazole Tier 1 PA Tier 1 LUZU Tier 3 QL / Tier 1 VUSION Tier 3 QL Tier 1 NAFTIN (EXCEPT 2% GEL) Tier 3 QL nystatin Tier 1 PA crm Tier 1 OXISTAT Tier 3 PA Tier 1 EXELDERM Tier 3 PA sol 5% Tier 1 KERYDIN Tier 3 QL naftifine gel 2% NAFTIN GEL 2% Tier 2 MENTAX Tier 3 PA econazole foam ECOZA Tier 3 PA JUBLIA Tier 3 PA ERTACZO Tier 3

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

Injectable PA guselkumab TREMFYA Tier 4 PA ustekinumab STELARA Tier 4 PA secukinumab COSENTYX Tier 5

Oral Tier 1 methoxsalen oral Tier 1 OXSORALEN-ULTRA Tier 3

Topical QL betamethasone dipropionate/calcipotriene oint, susp Tier 1 QL calcipotriene Tier 1 DOVONEX Tier 3 QL, * calcipotriene foam Tier 1 SORILUX Tier 3 calcitriol oint Tier 1 VECTICAL Tier 3 PA calcipotriene/betamethasone dipropionate cream WYNZORA Tier 3 QL calcipotriene/betamethasone foam ENSTILAR Tier 3

58

* Does not include NDC 73308-0357-60

Antiseborrheics QL ketoconazole 2% Tier 1 NIZORAL SHAMPOO Tier 3

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

Injectable PA dupilumab DUPIXENT Tier 5

Topical Tier 1 ELIDEL Tier 3 tacrolimus Tier 1 PROTOPIC Tier 3 PA oint EUCRISA Tier 3

Corticosteroids Low QL crm, oint 0.05% Tier 1 QL crm 0.05% Tier 1 DESOWEN Tier 3 QL desonide gel 0.05% Tier 1 DESONATE Tier 3 QL desonide lotion, oint 0.05% Tier 1 QL acetonide soln 0.01% Tier 1 QL hydrocortisone crm 2.5% Tier 1 QL desonide foam 0.05% VERDESO Tier 2 QL fluocinolone shampoo 0.01% CAPEX Tier 3 pramoxine/hydrocortisone PRAMOSONE Tier 3

Medium Potency QL crm, lotion, oint 0.1% Tier 1 QL pivalate crm 0.1% Tier 1 CLODERM Tier 3 QL crm, oint 0.05% Tier 1 QL crm, oint 0.025% Tier 1 SYNALAR Tier 3 QL fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3 QL flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3 QL fluticasone propionate crm 0.05%, oint 0.005% Tier 1 QL fluticasone propionate lotion 0.005% Tier 1 CUTIVATE Tier 3 QL crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3 QL hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1 LOCOID Tier 3 QL crm, oint 0.2% Tier 1 QL mometasone crm, lotion, oint 0.1% Tier 1 QL acetonide crm, lotion 0.025% Tier 1 QL crm, lotion, oint 0.1% Tier 1 QL flurandrenolide tape CORDRAN TAPE Tier 2 QL hydrocortisone probutate crm 0.1% PANDEL Tier 3

High Potency QL crm, lotion, oint 0.1% Tier 1 QL betamethasone dipropionate augmented crm 0.05% Tier 1 DIPROLENE AF Tier 3 QL betamethasone dipropionate augmented gel, lot 0.05% Tier 1 QL betamethasone dipropionate augmented oint 0.05% Tier 1 DIPROLENE Tier 3 QL betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 QL desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 TOPICORT Tier 3 QL diacetate crm 0.05% Tier 1 QL crm, gel, oint, soln 0.05% Tier 1

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QL triamcinolone acetonide crm 0.5% Tier 1 QL triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3 QL betamethasone dipropionate spray 0.05% SERNIVO Tier 3 QL emollient crm 0.05% APEXICON E Tier 3 QL crm, oint, soln 0.1% HALOG Tier 3

Very High Potency QL betamethasone dipropionate augmented gel, oint 0.05% Tier 1 DIPROLENE Tier 3 QL propionate crm, gel, oint, soln 0.05% Tier 1 TEMOVATE Tier 3 QL lotion, shampoo, spray 0.05% Tier 1 CLOBEX Tier 3 QL diflorasone diacetate oint 0.05% Tier 1 QL fluocinonide crm 0.1% Tier 1 QL halobetasol propionate crm, oint 0.05% Tier 1 ULTRAVATE Tier 3 QL clobetasol propionate lotion IMPEKLO Tier 3

Emollients ammonium lactate 12% Tier 1

Local Analgesics QL patch Tier 1 LIDODERM Tier 3 PA capsaicin 8% patch QUTENZA Tier 3

Local QL lidocaine Tier 1 XYLOCAINE Tier 3 QL lidocaine/ Tier 1

Rosacea PA azelaic acid gel Tier 1 FINACEA Tier 3 doxycycline monohydrate delayed-rel caps Tier 1 ORACEA Tier 3 PA crm 1% Tier 1 SOOLANTRA Tier 3 QL metronidazole crm 0.75% Tier 1 METROCREAM Tier 3 QL metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 METROGEL Tier 3 metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3 PA topical gel MIRVASO Tier 3 PA metronidazole crm NORITATE Tier 3 QL minocycline foam ZILXI Tier 3 PA crm 1% RHOFADE Tier 3

Scabicides and Pediculicides lotion Tier 1 EURAX lotion Tier 2 ivermectin Tier 1 Tier 1 5% Tier 1 Tier 1 NATROBA Tier 3 crotamiton crm EURAX crm Tier 2

Miscellaneous and Mucous Membrane acyclovir Tier 1 ZOVIRAX Tier 3 QL doxepin crm Tier 1 ZONALON Tier 3 d, PA hydrocortisone/aloe /iodoquinol Tier 1 d, PA hydrocortisone/iodoquinol Tier 1 PA imiquimod Tier 1 ALDARA Tier 3 PA imiquimod crm 3.75% Tier 1 ZYCLARA Tier 2 podofilox Tier 1 CONDYLOX Tier 3 PANRETIN Tier 2

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PA REGRANEX Tier 2 absorbable fibrin sealant TACHOSIL Tier 3 DENAVIR Tier 3 PA collagenase clostridium histolyticum XIAFLEX Tier 4 PA interferon alfa-n3 ALFERON N Tier 4

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

Steroids - Mouth/Throat triamcinolone paste Tier 1

Miscellaneous Tier 1 PREVIDENT Tier 3

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

Antiallergics Tier 1 BEPREVE Tier 3 cromolyn sodium Tier 1 Tier 1 olopatadine Tier 1 phenylephrine Tier 1 LASTACAFT Tier 3 ALOMIDE Tier 3 olopatadine PAZEO Tier 3

Antifungals NATACYN Tier 2

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

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

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tobramycin/ ZYLET Tier 2 gentamicin/ PRED-G Tier 3 sulfacetamide/prednisolone acetate oint 10%/0.2% BLEPHAMIDE SOP Tier 3

Anti-inflammatories Nonsteroidal sodium Tier 1 diclofenac sodium Tier 1 flurbiprofen Tier 1 ketorolac 0.5% Tier 1 ACULAR Tier 3 bromfenac 0.075% BROMSITE Tier 3 bromfenac sodium 0.07% PROLENSA Tier 3 ketorolac 0.45% ACUVAIL Tier 3 nepafenac NEVANAC Tier 3 nepafenac 0.3% ILEVRO Tier 3

Steroidal dexamethasone sodium phosphate Tier 1 Tier 1 FML Tier 3 loteprednol 0.5% gel, susp Tier 1 LOTEMAX Gel, Susp Tier 3 prednisolone acetate 1% Tier 1 PRED FORTE Tier 3 prednisolone phosphate 1% Tier 1 DUREZOL Tier 2 loteprednol LOTEMAX SM Tier 2 loteprednol 0.2% ALREX Tier 2 loteprednol oint LOTEMAX Oint Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 VEXOL Tier 2 dexamethasone MAXIDEX Tier 3 FLAREX Tier 3 loteprednol 1.0% INVELTYS Tier 3

Antivirals trifluridine Tier 1 ganciclovir ZIRGAN Tier 2

Beta-blockers Nonselective Tier 1 Tier 1 maleate Tier 1 ISTALOL Tier 3 timolol maleate Tier 1 TIMOPTIC Tier 3 timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3 timolol hemihydrate BETIMOL Tier 3

Selective BETOPTIC S Tier 3

Carbonic Anhydrase Inhibitors Topical Tier 1 AZOPT Tier 3 Tier 1 TRUSOPT Tier 3

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 COSOPT Tier 3

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

Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA XIIDRA Tier 2 PA cyclosporine eye solution CEQUA Tier 3 PA loteprednol etabonate EYSUVIS Tier 3

Mydriatics atropine sulfate soln Tier 1 Tier 1 CYCLOGYL Tier 3 scopolamine ISOPTO HYOSCINE Tier 2

Neurotrophic PA -bkbj OXERVATE Tier 4

Parasympathomimetics pilocarpine PILOPINE HS GEL Tier 3

Prostaglandins Tier 1 XALATAN Tier 3 Tier 1 TRAVATAN Z Tier 3 0.01% LUMIGAN Tier 2 latanoprost ophthalmic emulsion XELPROS Tier 3 latanoprostene bunod VYZULTA Tier 3 ZIOPTAN Tier 3

Retinal Disorders PA aflibercept EYLEA Tier 4 PA LUCENTIS Tier 4 PA -dbll BEOVU Tier 5

Rho Kinase Inhibitors RHOPRESSA Tier 3

Rho Kinase Inhibitor/ Combinations netarsudil/latanoprost ROCKLATAN Tier 3

Sympathomimetics brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3 brimonidine 0.2% Tier 1 brimonidine 0.1% ALPHAGAN P 0.1% Tier 2

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

Miscellaneous Tier 1 PA oxymetazoline opth soln UPNEEQ Tier 3 cysteamine CYSTARAN Tier 4 VISUDYNE Tier 4 cysteamine CYSTADROPS Tier 5 PA -trbw for IV soln TEPEZZA Tier 5

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

Anti-infectives Tier 1 ciprofloxacin otic Tier 1 CETRAXAL Tier 3 ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 ciprofloxacin/dexamethasone Tier 1 CIPRODEX Tier 3 neomycin/polymyxin B/hydrocortisone Tier 1 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2

Miscellaneous fluocinolone acetonide Tier 1 DERMOTIC Tier 3 triethanolamine polypeptide oleate CERUMENEX Tier 3

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

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

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

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

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Global Initiative for Asthma http://www.nfid.org https://ginasthma.org National Guideline Clearinghouse Infectious Diseases Society of America https://www.ahrq.gov https://www.idsociety.org National Heart, Lung and Blood Institute Institute for Safe Medication Practices https://www.nhlbi.nih.gov https://www.ismp.org National Institutes of Health Johns Hopkins AIDS Service https://www.nih.gov https://www.thebody.com/content/art12096.html National Kidney Foundation Juvenile Diabetes Research Foundation International https://www.kidney.org https://www.jdrf.org National Osteoporosis Foundation MedWatch https://www.nof.org https://www.fda.gov/Safety/MedWatch/default.htm North American Menopause Society National Agricultural Library https://www.menopause.org https://www.nal.usda.gov Department of Health and Human National Cancer Institute Services https://www.cancer.gov/about-cancer https://www.hhs.gov

National Comprehensive Cancer Network World Health Organization https://www.nccn.org https://www.who.int

National Foundation for Infectious Diseases

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2021 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will need to pay the full cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS* 2021 FOR STANDARD OPTION ACNE MINOLIRA azithromycin, doxycycline (except 20 mg), ORAL minocycline, minocycline ext-rel, sulfamethoxazole/trimethoprim, MINOCIN, SOLODYN, VIBRAMYCIN, ZITHROMAX ACNE adapalene pad, adapalene soln 0.1% adapalene crm, adapalene gel, DIFFERIN TOPICAL ABSORICA LD isotretinoin, ABSORICA

ALLERGIES 6 mg, RYVENT desloratadine, levocetirizine (Rx), montelukast, ANTIHISTAMINES zafirlukast, ACCOLATE, CLARINEX, CLARINEX- D, SINGULAIR ANAPHYLAXIS TREATMENT AUVI-Q epinephrine /auto-injector (0.15 mg, 0.30 mg), EPIPEN, EPIPEN JR., SYMJEPI ANTIDIARRHEALS tincture diphenoxylate/atropine, loperamide ANTIFUNGALS TOLSURA fluconazole, itraconazole, ketoconazole, posaconazole delayed-rel tabs, voriconazole, DIFLUCAN, NOXAFIL susp, NOXAFIL tabs, SPORANOX, VFEND ANTI-INFLAMMATORIES cap 200 mg, diclofenac DR/ER, diclofenac gel/soln, NONSTEROIDAL ANTI-INFLAMMATORIES indomethacin caps (20 mg, 40 mg), etodolac/ER, flurbiprofen, ibuprofen, (NSAIDs) meloxicam caps (5 mg, 10 indomethacin/ER (except indomethacin caps 20 mg), naproxen sodium ext-rel mg, 40 mg), ketoprofen/ER, meloxicam tabs, tablets, CAMBIA, FENORTHO, nabumetone, naproxen, oxaprozin, piroxicam, NAPRELAN, PENNSAID 2%, QMIIZ, sulindac RELAFEN DS, TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX ANTI-INFLAMMATORIES naproxen/esomeprazole magnesium diclofenac/misoprostol, esomeprazole NONSTEROIDAL ANTI-INFLAMMATORIES tabs DR, DUEXIS, VIMOVO magnesium delayed-rel, famotidine, ibuprofen, (NSAIDs) COMBINATIONS naproxen CONSENSI celecoxib, CELEBREX, AND amlodipine tabs, NORVASC

ANTIRHEUMATICS penicillamine caps, CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate, penicillamine tabs, DEPEN ANTISPASMODICS LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine DONNATAL atropine/hyoscyamine/scopolamine/phenobarbital

ASTHMA ext-rel, ZYFLO CR montelukast, zafirlukast, ACCOLATE, LEUKOTRIENE MODULATORS SINGULAIR

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BENIGN PROSTATIC HYPERPLASIA (BPH) UROXATRAL alfuzosin ext-rel, dutasteride, dutasteride/tamsulosin, finasteride, silodosin, tadalafil (2.5mg, 5mg), tamsulosin, AVODART, CIALIS (2.5mg, 5mg), JALYN, PROSCAR, RAPAFLO, FLOMAX BLADDER AGENTS DETROL, DETROL LA, ENABLEX, darifenacin ext-rel, oxybutynin, oxybutynin ext-rel, OXYTROL, VESICARE solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, DITROPAN XL, GELNIQUE, MYRBETRIQ, TOVIAZ, VESICARE LS CARDIOVASCULAR BETAPACE, BETAPACE AF sotalol, sotalol AF ANTIARRHYTHMICS CARDIOVASCULAR aspirin/omeprazole delayed-rel tabs, aspirin*** and esomeprazole magnesium HEART YOSPRALA delayed-rel, lansoprazole, omeprazole, pantoprazole, rabeprazole SYMBYAX olanzapine/fluoxetine COMBINATIONS CENTRAL NERVOUS SYSTEM methylphenidate tab ER osmotic amphetamine/dextroamphetamine mixed MISCELLANEOUS release 72 mg, DESOXYN, JORNAY salts/ER, amphetamine ext-rel susp, PM, RELEXXII amphetamine sulfate, dexmethylphenidate/ER, dextroamphetamine/ER, methylphenidate/ER (except methylphenidate tab ER osmotic release 72 mg), ADDERALL, ADDERALL XR, ADHANSIA XR, ADZENYS ER SUSP, ADZENYS XR-ODT, APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA, DEXEDRINE, DYANAVEL XR, EVEKEO, EVEKEO ODT, FOCALIN, FOCALIN XR, METHYLIN, MYDAYIS, PROCENTRA, QULLICHEW ER, QUILLIVANT XR, RITALIN, RITALIN LA, VYVANSE, ZENZEDI COTRICOSTEROIDS DEXABLISS, DXEVO 11-DAY, , dexamethasone, ORAL MILLIPRED fludrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednisone, CORTEF, MEDROL, ORAPRED ODT, RAYOS DERMATOLOGY ALCORTIN-A, XOLEGEL ciclopirox, clotrimazole, hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/aloe, ketoconazole 2% cream, naftifine, nystatin, terbinafine, ECOZA, NAFTIN DERMATOLOGY halobetasol propionate topical foam, betamethasone dipropionate (crm, lotion, oint), triamcinolone oint 0.05%, BRYHALI, betamethasone dipropionate augmented (crm, LEXETTE, NOVACORT, lotion, gel, oint), clobetasol propionate, OLUX/OLUX-E, PSORCON, diflorasone diacetate, fluocinonide (crm, gel, oint, TRIANEX, VANOS soln), halobetasol propionate crm, triamcinolone acetonide (except triamcinolone oint 0.05%), APEXICON E, CLOBEX, DIPROLENE, DIPROLENE AF, HALOG, KENALOG SPRAY, SERNIVO, TEMOVATE, TOPICORT, ULTRAVATE DERMATOLOGY XERESE acyclovir, hydrocortisone MISCELLANEOUS

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VEREGEN imiquimod, ALDARA, ZYCLARA

EXTINA ketoconazole foam 2%

OVACE, OVACE PLUS sulfacetamide sodium

DERMATOLOGY SORIATANE, TACLONEX acitretin, betamethasone PSORIASIS dipropionate/calcipotriene (oint, susp), calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA, SORILUX DIABETES JENTADUETO, JENTADUETO XR, alogliptin, alogliptin/metformin, DIPEPTIDYL PEPTIDASE-4 (DPP-4) KAZANO, KOMBIGLYZE XR, alogliptin/pioglitazone, JANUMET, JANUMET INHIBITORS/COMBINATIONS NESINA, ONGLYZA, OSENI, XR, JANUVIA TRADJENTA DIABETES SEMGLEE BASAGLAR, LANTUS, LEVEMIR, TOUJEO, TRESIBA DIABETES GLUMETZA, RIOMET ER metformin ext-rel, metformin oral soln, METFORMIN FORTAMET, RIOMET IR DIABETES CYCLOSET alogliptin, alogliptin/metformin, OTHER alogliptin/pioglitazone, bromocriptine mesylate, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide H2 RECEPTOR ANTAGONISTS PEPCID cimetidine, famotidine 40mg, nizatidine HIGH DUTOPROL metoprolol succinate ext-rel, hydrochlorothiazide BETA-BLOCKERS/COMBINATIONS HIGH CHOLESTEROL FENOGLIDE fenofibrate, fenofibric acid del-rel, gemfibrozil, ANTARA, LIPOFEN, LOPID, TRICOR, TRIPLEX HIGH CHOLESTEROL simvastatin susp, ALTOPREV, atorvastatin, ezetimibe/simvastatin, fluvastatin, FLOLIPID, ZYPITAMAG fluvastatin ext-rel, lovastatin, pravastatin, rosuvastatin, simvastatin, CRESTOR, EZALLOR SPRINKLE, LESCOL XL, LIPITOR, LIVALO, PRAVACHOL, VYTORIN, ZOCOR INFLUENZA AGENTS FLUMADINE oseltamivir, rimantadine, RELENZA, TAMIFLU, XOFLUZA LAXATIVES LACTULOSE PAK 10MG, PCP 100 lactulose solution, PEG 3350/electrolytes, CLENPIQ, GOLYTELY, KRISTALOSE, MOVIPREP, NULYTELY, OSMOPREP, PLENVU, PREPOPIK, SUPREP MIGRAINE AGENTS AJOVY AIMOVIG, EMGALITY 120 mg/mL, VYEPTI CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS UBRELVY NURTEC ODT

MIGRAINE AGENTS REYVOW almotriptan, eletriptan, frovatriptan, naratriptan, SELECTIVE SEROTONIN AGONISTS rizatriptan, sumatriptan, zolmitriptan, AMERGE, FROVA, IMITREX, MAXALT, MAXALT-MLT, ONZETRA XSAIL, RELPAX, TOSYMRA,

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ZOMIG, ZOMIG-ZMT MOVEMENT DISORDERS TASMAR amantadine, benztropine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, rasagiline, ropinirole/ER, selegiline, tolcapone, APOKYN, AZILECT, COMTAN, DUOPA, GOCOVRI, KYNMOBI, MIRAPEX, MIRAPEX XR, NEUPRO, OSMOLEX ER, PARLODEL, RYTARY, SINEMET, STALEVO, XADAGO, ZELAPAR MULTIPLE SCLEROSIS AMPYRA dalfampridine ER cyclobenzaprine ext-rel, AMRIX baclofen, cyclobenzaprine MUSCULOSKELETAL AGENTS tab (250mg, 375mg, chlorzoxazone tab 500mg MISCELLANEOUS 750mg), LORZONE AND THERAPY ANZEMET, ZUPLENZ granisetron, ondansetron, palonosetron, (5HT-3 BLOCKER) promethazine, ALOXI, SANCUSO, ZOFRAN OPHTHALMOLOGY BACIGUENT bacitracin ophthalmic ANTI-INFECTIVES OPHTHALMOLOGY atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate MISCELLANEOUS ophthalmic solution PAIN MEDICATIONS pregabalin ext-rel tabs, GRALISE, gabapentin, pregabalin (does not include ext-rel HORIZANT, LYRICA CR tabs), LYRICA, NEURONTIN PAIN MEDICATIONS /acetaminophen, codeine/acetaminophen, hydrocodone-acetaminophen sol 10- hydrocodone/acetaminophen, 325 mg/15 mL, oxycodone/acetaminophen (except 2.5 mg - 300, oxycodone/acetaminophen tab (2.5 5 mg - 300 mg, 10 mg - 300 mg tabs), mg - 300 mg, 5 mg - 300 mg, 10 mg tramadol/acetaminophen, ENDOCET, LORTAB, - 300 mg), APADAZ, NALOCET, PERCOCET PRIMLEV, PROLATE LAZANDA fentanyl buccal, fentanyl sublingual, fentanyl transmucosal, ACTIQ, FENTORA, SUBSYS

hydromorphone, morphine, oxycodone, tramadol (except 100mg tab), DILAUDID, NUCYNTA, OPANA, ROXICODONE

tramadol 100 mg tabs, CONZIP tramadol (except 100 mg tabs), tramadol ext-rel, tramadol/acetaminophen, ULTRAM, ULTRAM ER PAIN MEDICATIONS ZTLIDO lidocaine cream, lidocaine gel, lidocaine lotion, TOPICAL lidocaine ointment, lidocaine patch 5%, LIDODERM PATCH, QUTENZA PATCH, XYLOCAINE PROTON PUMP INHIBITORS esomeprazole , rabeprazole esomeprazole magnesium delayed-rel, capsule sprinkle delayed-rel, lansoprazole delayed-rel, omeprazole delayed- ACIPHEX, FIRST-LANSOPRAZOLE, rel, omeprazole/sodium bicarbonate, FIRST-OMEPRAZOLE, NEXIUM, pantoprazole delayed-rel, rabeprazole (except PREVACID, PREVACID SOLUTAB, rabeprazole capsule sprinkle delayed-rel), PRILOSEC, PROTONIX, ZEGERID DEXILANT SLEEP AGENTS SECONAL estazolam, eszopiclone, flurazepam, ramelteon,

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temazepam, , zaleplon, zolpidem/ER, AMBIEN, AMBIEN CR, BELSOMRA, EDLUAR, LUNESTA, ROZEREM, ZOLPIMIST ULCERATIVE COLITIS COLAZAL balsalazide, mesalamine delayed-rel (caps, tabs), mesalamine ext-rel caps, sulfasalazine, sulfasalazine delayed, rel, ASACOL HD, APRISO, AZULFIDINE, DELZICOL, DIPENTIUM, LIALDA, PENTASA ULCER THERAPY CARAFATE sucralfate MISCELLANEOUS

*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.

**For more covered options, consult 2021 Standard Option formulary.

***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 12 through 79 and for pregnant women at risk of preeclampsia.

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INDEX

A ADCIRCA, 27 ADDERALL, 31 abacavir, 15 ADDERALL XR, 31 abacavir soln, 15 adefovir dipivoxil, 15 abacavir/dolutegravir/lamivudine, 14 ADEMPAS, 27 abacavir/lamivudine, 14 ADHANSIA XR, 32 abacavir/lamivudine/zidovudine, 14 ADLYXIN, 36 abaloparatide, 39 ADMELOG, 37 abatacept, 51 ADMELOG SOLOSTAR, 37 ABELCET, 14 ado-, 20 abemaciclib, 18 ADRIAMYCIN, 21 ABILIFY, 31 ADVAIR, 56 ABILIFY MAINTENA, 31 ADVAIR HFA, 56 ABILIFY MYCITE, 31 ADVATE, 49 abiraterone, 18 ADYNOVATE, 49 abobotulinumtoxinA, 35 ADZENYS ER SUSP, 31 ABRAXANE, 21 ADZENYS XR-ODT, 32 absorbable fibrin sealant, 61 AEMCOLO, 13 ABSORICA, 57 afatinib, 19 acalabrutinib, 19 AFINITOR 10 mg, 19 acamprosate calcium, 34 AFINITOR 2.5 mg, 5 mg, 7.5 mg, 18 ACANYA, 57 AFINITOR DISPERZ, 19 acarbose, 36 aflibercept, 63 ACCOLATE, 56 AFREZZA, 37 ACCU-CHEK FASTCLIX LANCET DEVICE, 38 AFSTYLA, 49 ACCU-CHEK FASTCLIX LANCETS, 38 agalsidase beta, 44 ACCU-CHEK METERS AND KITS, 38 AGGRASTAT, 50 ACCU-CHEK TEST STRIPS, 38 AGGRENOX, 50 ACCUPRIL, 22 AGRYLIN, 50 ACCURETIC, 23 AHF, human/VWF, human, 49 acebutolol, 25 AIMOVIG, 33 ACETADOTE, 44 AIRDUO DIGIHALER, 56 acetaminophen inj, 10 AIRDUO RESPICLICK, 56 acetazolamide, 26 AKLIEF, 57 acetazolamide ext-rel, 26 AKYNZEO, 45 acetic acid, 64 albendazole, 16 acetic acid/hydrocortisone, 64 ALBENZA, 16 acetylcysteine, 44 albuterol, 55 acitretin, 58 albuterol ext-rel, 55 aclidinium bromide, 54 albuterol soln, 55 aclidinium bromide/formoterol fumarate, 54 albuterol sulfate aerosol powder 108mcg/actuation with sensor, 55 ACTEMRA, 51 albuterol sulfate aerosol powder breath-activated, 55 ACTHAR, 44 albuterol sulfate, CFC-free aerosol, 55 ACTIGALL, 45 alcaftadine, 61 ACTIMMUNE, 52 alclometasone crm, oint 0.05%, 59 ACTIQ, 11 ALDACTAZIDE, 26 ACTIVELLA, 41 ALDACTONE, 23 ACTONEL, 38 ALDARA, 60 ACTOPLUS MET, 37 aldesleukin, 20 ACTOPLUS MET XR, 37 ALDURAZYME, 44 ACTOS, 37 ALECENSA, 19 ACULAR, 62 alectinib, 19 ACUVAIL, 62 alemtuzumab, 34 acyclovir, 60 alendronate, 38 acyclovir caps, susp, tabs, 16 alendronate/vitamin D3, 39 ACZONE, 16 ALFERON N, 61 ADAKVEO, 50 alfuzosin ext-rel, 47 adalimumab, 51 alglucosidase alfa, 44 adapalene crm, gel, 57 ALIMTA, 17 adapalene/benzoyl peroxide, 57 ALINIA, 16 ADCETRIS, 21 alirocumab, 25

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aliskiren, 26 amoxicillin/clavulanate susp 600 mg, 13 aliskiren/hydrochlorothiazide, 26 amoxicillin/rifabutin/omeprazole, 47 alitretinoin, 60 amphetamine ext-rel orally disintegrating tabs, 32 ALKERAN inj, 17 amphetamine ext-rel susp, 31 ALKERAN tabs, 17 amphetamine ext-rel suspension, 32 ALKINDI SPRINKLE CAPS, 42 amphetamine sulfate, 31 allopurinol, 10 amphetamine sulfate orally disintegrating tablet, 32 almotriptan, 33 amphetamine/dextroamphetamine mixed salts, 31 alogliptin, 36 amphetamine/dextroamphetamine mixed salts ext-rel, 31, 32 alogliptin/metformin, 36 amphotericin B lipid complex inj, 14 alogliptin/pioglitazone, 36 amphotericin B liposome inj, 14 ALOMIDE, 61 ampicillin, 13 ALORA, 41 ampicillin sodium/sulbactam sodium, 13 alosetron, 46 AMZEEQ, 57 ALOXI, 45 ANAFRANIL, 28 alpelisib, 19 anagrelide, 50 alpha-1 proteinase inhibitor, 54 anakinra, 51 ALPHAGAN P 0.1%, 63 anastrozole, 18 ALPHAGAN P 0.15%, 63 ANDRODERM, 35 ALPHANATE, 49 ANDROGEL, 35 ALPHANINE SD, 49 ANGELIQ, 41 alprazolam, 28 anidulafungin, 14 alprazolam ext-rel, 28 ANNOVERA, 40 ALPROLIX, 49 ANORO ELLIPTA, 54 ALREX, 62 ANTARA, 24 ALTABAX, 58 antihemophilic factor, 49 ALTACE, 22 antihemophilic factor (recombinant) pegylated, 49 alteplase, 50 antihemophilic factor (recombinant) pegylated-aucl, 49 ALUNBRIG, 19 antihemophilic factor (recombinant) porcine sequence, 49 ALVESCO, 56 antihemophilic factor (recombinant), glycopegylated-exei, 49 alvimopan, 47 antihemophilic factor recombinant, Fc fusion protein, 49 amantadine ext-rel, 30 antihemophilic factor, recombinant, 49 amantadine, except tabs, 30 anti-inhibitor coagulant complex, 49 AMARYL, 38 apalutamide, 18 AMBIEN, 32 APEXICON E, 60 AMBIEN CR, 32 APIDRA, 37 AMBISOME, 14 apixaban, 48 ambrisentan, 27 APLENZIN, 30 amcinonide crm, lotion, oint 0.1%, 59 APOKYN, 30 AMELUZ, 58 apomorphine, 30 AMERGE, 33 apremilast, 51 AMICAR, 50 aprepitant, 45 amifampridine, 35 aprepitant caps, 45 amifostine, 20 aprepitant susp, 45 amikacin liposome inhalation susp, 55 APRISO, 46 amiloride, 26 APTENSIO XR, 32 amiloride/hydrochlorothiazide, 26 APTIOM, 29 aminocaproic acid, 50 APTIVUS, 15 aminolevulinic acid gel 10%, 58 ARAKODA, 14 aminolevulinic acid soln, 58 ARALAST NP, 54 amiodarone, 24 ARANESP, 48 AMITIZA, 46 ARAVA, 51 amitriptyline, 30 ARAZLO, 57 amitriptyline/perphenazine, 30 ARCALYST, 52 amlodipine tabs, 25 arformoterol soln, 55 amlodipine/atorvastatin, 26 ARICEPT, 29 amlodipine/olmesartan, 23 ARIKAYCE, 55 amlodipine/telmisartan, 23 ARIMIDEX, 18 amlodipine/valsartan, 23 aripiprazole, 31 amlodipine/valsartan/hydrochlorothiazide, 23 aripiprazole ext-rel inj, 31 ammonium lactate 12%, 60 aripiprazole lauroxil ext-rel inj, 31 amoxicillin, except film-coated tabs, 13 aripiprazole orally disintegrating tabs, 31 amoxicillin/clavulanate, 13 aripiprazole tab with sensor, 31 amoxicillin/clavulanate ext-rel, 13 ARISTADA, 31

73

ARIXTRA, 48 azelastine spray, 56 armodafinil, 34 azelastine/fluticasone nasal spray, 56 ARMONAIR DIGIHALER, 56 AZELEX, 57 ARMOUR THYROID, 43 AZILECT, 30 ARNUITY ELLIPTA, 56 azilsartan, 23 AROMASIN, 18 azilsartan/chlorthalidone, 23 ARRANON, 21 azithromycin, 13, 61 , 20 AZOPT, 62 artemether/lumefantrine, 14 AZOR, 23 ARTHROTEC, 10 aztreonam, 16 ARZERRA, 21 aztreonam lysine inhalation soln, 55 ASACOL HD, 46 AZULFIDINE, 46 ASCENIV, 52 AZULFIDINE EN-TABS, 46 asenapine, 31 B asfotase alfa, 44 bacitracin, 61 ASMANEX, 56 baclofen, 34 ASMANEX HFA, 56 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 34 asparaginase, 21 BAFIERTAM, 34 asparaginase Erwinia chrysanthemi, 21 baloxavir, 16 ASPARLAS, 22 balsalazide, 46 aspirin ext-rel, 50 BALVERSA, 19 ASTAGRAF XL, 53 BANZEL, 28 ATACAND, 23 BAQSIMI, 42 ATACAND HCT, 23 BARACLUDE, 16 atazanavir caps, 15 BARACLUDE soln, 16 atazanavir/cobicistat, 14 baricitinib, 51 ATELVIA, 39 BASAGLAR, 37 atenolol, 25 BAVENCIO, 21 atenolol/chlorthalidone, 25 BCG live vaccine, 21 atezolizumab, 21 BD INSULIN SYRINGES AND NEEDLES, 38 ATIVAN, 28 becaplermin, 61 atomoxetine, 31 beclomethasone breath-activated aerosol, 56 atorvastatin, 24 beclomethasone spray, 56 atovaquone, 16 beclomethasone, CFC-free aerosol, 56 atovaquone/proguanil, 14 BECONASE AQ, 56 ATRALIN, 57 bedaquiline, 15 ATRIPLA, 14 belantamab mafodotin-blmf, 21 atropine sulfate soln, 63 belatacept, 53 atropine/hyoscyamine/scopolamine/phenobarbital, 45 BELBUCA, 11 ATROVENT HFA, 54 BELEODAQ, 21 AUBAGIO, 34 belimumab, 53 AUGMENTIN, 13 belinostat, 21 auranofin, 51 BELRAPZO, 17 AURYXIA, 43 BELSOMRA, 32 AUSTEDO, 33 bempedoic acid, 24 AVALIDE, 23 bempedoic acid/ezetimibe, 24 AVANDIA, 37 benazepril, 22 avapritinib, 19 benazepril/amlodipine, 23 AVAPRO, 23 benazepril/hydrochlorothiazide, 23 AVASTIN, 21 bendamustine, 17, 21 avatrombopag, 50 BENDEKA, 21 AVEED, 35 BENEFIX, 49 avelumab, 21 BENICAR, 23 AVODART, 47 BENICAR HCT, 23 AVONEX, 33 BENLYSTA, 53 axitinib, 19 benralizumab, 57 AYGESTIN, 43 BENZAC AC, 57 AYVAKIT, 19 BENZACLIN, 57 azacitidine, 17, 20 BENZAMYCIN, 57 AZACTAM, 16 benzonatate, 55 AZASITE, 61 benzoyl peroxide, 57 azathioprine, 52 benztropine, 30 azelaic acid, 57 BEOVU, 63 azelaic acid gel, 60

74

bepotastine, 61 BRILINTA, 50 BEPREVE, 61 brimonidine 0.1%, 63 BERINERT, 51 brimonidine 0.15%, 63 berotralstat, 51 brimonidine 0.2%, 63 besifloxacin, 61 brimonidine topical gel, 60 BESIVANCE, 61 brimonidine/timolol, 63 BESPONSA, 22 brinzolamide, 62 betaine anhydrous, 44 brinzolamide/brimonidine, 63 betamethasone dipropionate augmented crm 0.05%, 59 brivaracetam, 28 betamethasone dipropionate augmented gel, lot 0.05%, 59 BRIVIACT, 28 betamethasone dipropionate augmented gel, oint 0.05%, 60 brodalumab, 51 betamethasone dipropionate augmented oint 0.05%, 59 brolucizumab-dbll, 63 betamethasone dipropionate crm, lotion, oint 0.05%, 59 bromfenac 0.075%, 62 betamethasone dipropionate spray 0.05%, 60 bromfenac sodium, 62 betamethasone dipropionate/calcipotriene oint, susp, 58 bromfenac sodium 0.07%, 62 betamethasone valerate crm, lotion, oint 0.1%, 59 bromocriptine, 30 BETASERON, 34 BROMSITE, 62 betaxolol, 62 BRONCHITOL, 56 bethanechol, 48 BROVANA, 55 BETHKIS, 55 BRUKINSA, 20 BETIMOL, 62 budesonide, 56 BETOPTIC S, 62 budesonide delayed-rel caps, 46 bevacizumab, 21 budesonide ext-rel caps, 46 bevacizumab-awwb, 21 budesonide inhalation suspension, 56 bevacizumab-bvzr, 21 budesonide/formoterol, 56 BEVESPI AEROSPHERE, 54 budesonide/glycopyrrolate/formoterol, 54 bexarotene caps, 20 bumetanide, 26 bexarotene gel, 21 BUPHENYL, 44 bezlotoxumab, 52 buprenorphine, 11, 34 bicalutamide, 18 buprenorphine ext-rel inj, 34 BICNU, 17 buprenorphine transdermal, 11 bictegravir/emtricitabine/tenofovir alafenamide, 14 buprenorphine/naloxone sublingual film, 34 BIDIL, 26 buprenorphine/naloxone sublingual tabs, 34 BIJUVA, 41 bupropion, 30 BIKTARVY, 14 bupropion ext-rel, 30, 35 bimatoprost 0.01%, 63 burosumab-twza, 44 binimetinib, 19 buspirone, 28 bismuth subsalicylate + metronidazole + tetracycline, 47 busulfan, 17 bisoprolol/hydrochlorothiazide, 25 BUSULFEX, 17 BIVIGAM, 52 butalbital/acetaminophen, 11 BLENREP, 21 butalbital/acetaminophen/caffeine, 11 bleomycin sulfate, 20 butalbital/acetaminophen/caffeine/codeine, 11 BLEPH-10, 61 butalbital/aspirin/caffeine, 11 BLEPHAMIDE SOP, 62 butalbital/aspirin/caffeine/codeine, 11 blinatumomab, 21 butenafine, 58 BLINCYTO, 21 butorphanol nasal spray, 11 blood glucose continuous monitoring receivers, sensors, transmitters, BUTRANS, 11 38 BYDUREON, 36 blood glucose meters and kits, 38 BYDUREON BCISE, 36 blood glucose test strips, 38 BYETTA, 36 BONIVA, 38 BYNFEZIA, 44 BONJESTA, 45 BYSTOLIC, 25 bortezomib, 20 C bosentan, 27 C1 esterase inhibitor, 51 BOSULIF, 19 C1 esterase inhibitor, recombinant, 51 bosutinib, 19 cabazitaxel, 21 BOTOX, 35 CABOMETYX, 19 BRAFTOVI, 19 cabozantinib, 19 brentuximab vedotin, 21 CADUET, 26 BREO ELLIPTA, 56 CAFCIT, 57 BREVIBLOC, 25 CAFERGOT, 33 brexpiprazole, 31 caffeine citrate, 57 BREZTRI AEROSPHERE, 54 CALAN SR, 26 brigatinib, 19

75

calaspargase pegol-mknl, 22 cefpodoxime, 12 calcifediol ext-rel, 43 cefprozil, 12 calcipotriene, 58 ceftaroline fosamil, 13 calcipotriene foam, 58 ceftazidime, 12 calcipotriene/betamethasone dipropionate cream, 58 ceftriaxone, 12 calcipotriene/betamethasone foam, 58 cefuroxime axetil, 12 calcitonin-salmon inj, 39 CELEBREX, 10 calcitonin-salmon spray, 39 celecoxib, 10 calcitriol (1,25-D3), 43 CELEXA, 29 calcitriol oint, 58 CELLCEPT, 52 calcium acetate, 43 cenegermin-bkbj, 63 calcium, magnesium, potassium, and sodium oxybates, 34 cenobamate, 28 CALDOLOR, 10 cephalexin, 12 CALQUENCE, 19 CEPROTIN, 50 CAMPTOSAR, 20 CEQUA, 63 canagliflozin, 37 CERDELGA, 42 canagliflozin/metformin, 37 CEREZYME, 42 canagliflozin/metformin ext-rel, 37 ceritinib, 19 canakinumab, 52 certolizumab pegol, 51 CANASA, 46 CERUMENEX, 64 candesartan, 23 CETRAXAL, 64 candesartan/hydrochlorothiazide, 23 cetrorelix, 41 cangrelor, 50 CETROTIDE, 41 cannabidiol, 29 cetuximab, 21 capecitabine, 17 cevimeline, 47 CAPEX, 59 CHANTIX, 35 CAPLYTA, 31 CHEMSTRIP K URINE KETONE STRIPS, 38 capmatinib, 19 CHEMSTRIP UG URINE GLUCOSE STRIPS, 38 CAPRELSA, 19 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 38 capsaicin 8% patch, 60 chlorambucil, 17 captopril/hydrochlorothiazide, 23 chlordiazepoxide, 28 CARAC, 58 chlordiazepoxide/clidinium, 45 CARBAGLU, 44 chloroquine, 14 carbamazepine, 28, 33 chlorthalidone, 26 carbamazepine ext-rel, 28 CHOLBAM, 47 CARBATROL, 28 cholestyramine pkt, 24 carbidopa/levodopa, 30 cholic acid, 47 carbidopa/levodopa enteral susp, 30 choriogonadotropin alfa, 41 carbidopa/levodopa ext-rel, 30 chorionic gonadotropin, 41, 42 carbidopa/levodopa orally disintegrating tabs, 30 CIALIS, 47 carbidopa/levodopa/entacapone, 30 ciclesonide, 56 carboplatin, 20 ciclesonide spray, 56 CARDIZEM, 26 ciclopirox, 58 CARDIZEM CD, 26 cidofovir, 15 CARDURA, 23 cilostazol, 50 carfilzomib, 22 CILOXAN, 61 carglumic acid, 44 CIMDUO, 14 cariprazine, 31 cimetidine, 45 carmustine, 17 CIMZIA, 51 CARNITOR, 39 cinacalcet, 38 carteolol, 62 CINQAIR, 57 carvedilol, 25 CINRYZE, 51 carvedilol phosphate ext-rel, 25 CINVANTI, 45 CASODEX, 18 CIPRO, 13 CATAPRES, 23 CIPRO HC OTIC, 64 CATAPRES-TTS, 23 CIPRODEX, 64 CATHFLO ACTIVASE, 50 ciprofloxacin, 13, 61 CAYSTON, 55 ciprofloxacin otic, 64 cefaclor, 12 ciprofloxacin/dexamethasone, 64 cefdinir, 12 ciprofloxacin/hydrocortisone, 64 cefepime, 12 cisplatin, 20 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 12 citalopram, 29 cefotaxime, 12 CITRANATAL RX, 53 cefoxitin, 12 cladribine, 17, 34

76

CLARINEX, 54 COMPLERA, 14 CLARINEX-D, 55 COMTAN, 30 clarithromycin, 13 CONCERTA, 32 clarithromycin ext-rel, 13 CONDYLOX, 60 CLENPIQ, 46 conjugated estrogens/bazedoxifene, 41 CLEOCIN, 16 CONJUPRI, 25 CLEOCIN T, 57 COPAXONE, 33 CLEOCIN vaginal supp, 48 COPIKTRA, 19 CLIMARA, 41 CORDRAN crm, lotion, oint, 59 CLIMARA PRO, 41 CORDRAN TAPE, 59 clindamycin, 16 COREG, 25 clindamycin gel, lotion, soln, 57 COREG CR, 25 clindamycin supp, 48 CORIFACT, 49 clindamycin swabs, 57 CORLANOR, 26 clindamycin vaginal cream, 48 CORTEF, 42 clindamycin/benzoyl peroxide, 57 corticotropin, 44 clindamycin/tretinoin, 57 corticotropin powder, 44 CLINDESSE, 48 CORTIFOAM, 46 clobazam, 28 cortisone acetate, 42 clobetasol propionate crm, gel, oint, soln 0.05%, 60 COSENTYX, 58 clobetasol propionate lotion, 60 COSMEGEN, 20 clobetasol propionate lotion, shampoo, spray 0.05%, 60 COSOPT, 62 CLOBEX, 60 COTELLIC, 19 crm 0.1%, 59 COTEMPLA XR-ODT, 32 CLODERM, 59 COZAAR, 23 clofarabine, 17 CREON, 46 CLOLAR, 17 CRESEMBA, 14 clomiphene, 41 CRESTOR, 24 clomipramine, 28 crisaborole oint, 59 clonazepam, 28 CRIXIVAN, 15 clonidine, 23 crizanlizumab-tmca, 50 clonidine ext-rel, 31 crizotinib, 19 clonidine transdermal, 23 crofelemer delayed-rel, 45 clopidogrel, 50 cromolyn sodium, 47, 61 clorazepate, 28 cromolyn soln, 56 clotrimazole, 58 crotamiton crm, 60 clotrimazole troches, 13 crotamiton lotion, 60 clotrimazole/betamethasone, 58 CRYSVITA, 44 clozapine, 31 CUBICIN, 16 clozapine orally disintegrating tabs, 31 CUTAQUIG, 52 CLOZARIL, 31 CUTIVATE, 59 COAGADEX, 49 CUVITRU, 52 coagulation factor IX (recombinant), glycopegylated, 49 CUVPOSA, 47 coagulation factor IX, recombinant, 49 cyanocobalamin inj, 53 coagulation factor VIIa, 49 cyanocobalamin spray, 53 coagulation factor VIIa-jncw, 50 CYANOKIT, 44 coagulation factor X, human, 49 cyclobenzaprine, 34 COARTEM, 14 CYCLOGYL, 63 cobicistat, 14 cyclopentolate, 63 cobimetinib, 19 cyclophosphamide caps, 17 codeine/acetaminophen, 11 CYCLOPHOSPHAMIDE CAPSULES, 17 codeine/promethazine, 55 cyclophosphamide inj, 17 codeine/promethazine/phenylephrine, 55 cyclosporine, 53 colchicine, 10 cyclosporine eye solution, 63 COLCRYS, 10 cyclosporine, emulsion, 63 colesevelam, 24 cyclosporine, modified, 53 COLESTID, 24 CYKLOKAPRON inj, 50 colestipol, 24 CYMBALTA, 29 collagenase clostridium histolyticum, 61 cyproheptadine, 54 COMBIGAN, 63 CYRAMZA, 22 COMBIPATCH, 41 CYSTADANE, 44 COMBIVENT RESPIMAT, 54 CYSTADROPS, 63 COMBIVIR, 14 CYSTAGON, 44 COMETRIQ, 19 CYSTARAN, 63

77

cysteamine, 44, 63 DESCOVY, 14 cysteamine delayed-rel, 44 DESFERAL, 50 cytarabine, 17 desipramine, 30 CYTOGAM, 15 desloratadine, 54 cytomegalovirus immune globulin, 15 desloratadine/pseudoephedrine ext-rel, 55 CYTOMEL, 43 desmopressin spray, 49 CYTOTEC, 47 desmopressin spray, tabs, 44 D desogestrel/EE, 40 desogestrel/EE 0.15/30, 39 D.H.E. 45, 33 DESONATE, 59 dabigatran etexilate, 48 desonide crm 0.05%, 59 dabrafenib, 19 desonide foam 0.05%, 59 dacarbazine, 17 desonide gel 0.05%, 59 DACOGEN, 20 desonide lotion, oint 0.05%, 59 dacomitinib, 19 DESOWEN, 59 dactinomycin, 20 desoximetasone crm, oint 0.05%, 59 dalfampridine ext-rel, 33 desoximetasone crm, oint, spray 0.25%, gel 0.05%, 59 DALIRESP, 56 desvenlafaxine ext-rel, 29 dalteparin, 48 deutetrabenazine, 33 danazol, 40 dexamethasone, 42, 62 DANTRIUM, 34 dexamethasone sodium phosphate, 62 dantrolene, 34 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 38 dapagliflozin, 37 DEXEDRINE SPANSULE, 32 dapagliflozin/metformin ext-rel, 37 DEXILANT, 47 dapagliflozin/saxagliptin, 37 dexlansoprazole delayed-rel, 47 dapsone, 16 dexmethylphenidate, 31 daptomycin 500 mg, 16 dexmethylphenidate ext-rel, 31 DARAPRIM, 14 dexrazoxane, 20 daratumumab, 21 dextranomer/sodium hyaluronate, 47 daratumumab/hyaluronidase-fihj, 22 dextroamphetamine, 31 darbepoetin alfa, 48 dextroamphetamine ext-rel, 32 darifenacin ext-rel, 48 dextroamphetamine soln - Procentra, 32 darolutamide, 18 dextromethorphan/quinidine, 35 darunavir, 15 DIACOMIT, 29 darunavir/cobicistat, 14 DIASTAT, 28 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 14 diazepam, 28 DARZALEX, 21 diazepam nasal spray, 28 DARZALEX FASPRO, 22 diazepam rectal gel, 28 dasatinib, 19 diazoxide, 42 daunorubicin, 20 dichlorphenamide, 26 DAURISMO, 22 DICLEGIS, 45 DAYPRO, 10 diclofenac sodium, 62 DAYTRANA, 32 diclofenac sodium 3% gel, 57 DAYVIGO, 32 diclofenac sodium delayed-rel, 10 DDAVP, 44 diclofenac sodium delayed-rel/misoprostol, 10 decitabine, 20 diclofenac sodium ext-rel, 10 decitabine-cedazuridine, 21 diclofenac sodium gel 1%, 10 deferasirox, 50 diclofenac sodium soln, 10 deferiprone, 50 dicloxacillin, 13 deferoxamine, 50 dicyclomine, 45 deflazacort, 35 DIFFERIN, 57 degarelix acetate, 18 DIFICID, 13 DELESTROGEN, 41 diflorasone diacetate crm 0.05%, 59 DELSTRIGO, 14 diflorasone diacetate emollient crm 0.05%, 60 DELZICOL, 46 diflorasone diacetate oint 0.05%, 60 DENAVIR, 61 DIFLUCAN, 13 denosumab, 39 diflunisal, 10 DEPAKOTE, 28 difluprednate, 62 DEPAKOTE ER, 28 digoxin, 26 DEPAKOTE SPRINKLE, 28 dihydroergotamine inj, 33 DEPEN, 51 dihydroergotamine spray, 33 DEPO-PROVERA, 40 DILANTIN, 28 DERMA-SMOOTHE/FS, 59 DILANTIN INFATABS, 28 DERMOTIC, 64 DILAUDID, 11

78

diltiazem, 26 DUETACT, 37 diltiazem ext-rel, 26 dulaglutide, 36 dimethyl fumarate delayed-rel, 33 DULERA, 56 DIOVAN, 23 duloxetine delayed-rel, 29 DIOVAN HCT, 23 duloxetine delayed-release sprinkle capsule, 29 DIPENTUM, 46 DUOPA, 30 diphenhydramine, 30, 54 dupilumab, 59 diphenoxylate/atropine, 45 DUPIXENT, 59 DIPROLENE, 59, 60 DURAGESIC, 11 DIPROLENE AF, 59 DUREZOL, 62 dipyridamole, 50 DURLAZA, 50 dipyridamole ext-rel/aspirin, 50 DUROLANE, 12 diroximel fumarate delayed-rel, 34 durvalumab, 22 disopyramide, 24 dutasteride, 47 disopyramide ext-rel, 24 dutasteride/tamsulosin, 47 disulfiram, 34 duvelisib, 19 DITROPAN XL, 48 DYANAVEL XR, 32 divalproex sodium delayed-rel, 28 DYAZIDE, 26 divalproex sodium ext-rel, 28 DYMISTA, 56 divalproex sodium sprinkle caps, 28 DYSPORT, 35 docetaxel, 20 E dofetilide, 24 E.E.S., 13 DOJOLVI, 53 ecallantide, 51 dolutegravir, 14 econazole, 58 dolutegravir/lamivudine, 14 econazole foam, 58 dolutegravir/rilpivirine, 14 ECOZA, 58 donepezil, 29 eculizumab, 50 donepezil orally disintegrating tabs, 29 edaravone, 35 DOPTELET, 50 EDARBI, 23 DORAL, 32 EDARBYCLOR, 23 doravirine, 15 EDECRIN, 26 doravirine/lamivudine/tenofovir disoproxil fumarate, 14 EDLUAR, 32 dornase alfa, 55 EDURANT, 15 DORYX/MPC, 13 EE/norethindrone acetate, 41 dorzolamide, 62 EE/norethindrone acetate - Jinteli, 41 dorzolamide/timolol maleate, 62 efavirenz, 15 DOVATO, 14 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 14 DOVONEX, 58 efavirenz/lamivudine/tenofovir disoproxil fumarate, 14 doxazosin, 23 EFFEXOR XR, 29 doxepin, 30, 32 EFFIENT, 50 doxepin crm, 60 efinaconazole, 58 doxercalciferol, 43 EFUDEX, 58 DOXIL, 20 EGRIFTA, 44 doxorubicin, 20, 21 elagolix, 40 doxorubicin liposomal, 20 elagolix sodium/estradiol/norethindrone acetate, 44 doxycycline hyclate, 13 elapegademase-lvlr, 44 doxycycline hyclate delayed-rel tabs, 13 ELAPRASE, 44 doxycycline monohydrate, 13 elbasvir/grazoprevir, 16 doxycycline monohydrate delayed-rel caps, 60 ELELYSO, 44 doxylamine/pyridoxine delayed-rel, 45 eletriptan, 33 doxylamine/pyridoxine ext-rel, 45 elexacaftor/tezacaftor/ivacaftor + ivacaftor, 55 DRIZALMA SPRINKLE, 29 ELIDEL, 59 dronabinol, 45 ELIGARD, 18 dronabinol solution, 47 eliglustat, 42 dronedarone, 24 ELIQUIS, 48 drospirenone, 40 ELITEK, 17 drospirenone/EE 3/20, 39 ELIXOPHYLLIN, 57 drospirenone/EE 3/30, 39 ELLENCE, 20 drospirenone/EE/levomefolate 3/30 and levomefolate, 39 ELMIRON, 48 drospirenone/estradiol, 41 ELOCTATE, 49 droxidopa, 27 elosulfase alfa, 44 DUAKLIR PRESSAIR, 54 elotuzumab, 21 DUAVEE, 41 ELSPAR, 21 DUET DHA, 53

79

eltrombopag, 50 eplerenone, 23 eluxadoline, 46 epoetin alfa, 49 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 14 epoetin alfa-epbx, 49 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 14 EPOGEN, 49 EMBEDA, 11 epoprostenol, 27 EMEND, 45 epoprostenol sodium, 27 EMFLAZA, 35 eptifibatide, 50 EMGALITY 100 mg/mL, 33 eptinezumab-jjmr, 33 EMGALITY 120 mg/mL, 33 EPZICOM, 14 emicizumab-kxwh, 49 EQUETRO, 33 empagliflozin, 37 ERAXIS, 14 empagliflozin/linagliptin, 37 ERBITUX, 21 empagliflozin/linagliptin/metformin extended-release, 38 erdafitinib, 19 empagliflozin/metformin, 37 erenumab-aooe, 33 empagliflozin/metformin ext-rel, 37 ergocalciferol (D2), 53 EMPLICITI, 21 ergotamine/caffeine supp, 33 EMSAM, 29 ergotamine/caffeine tabs, 33 emtricitabine caps, 15 eribulin, 21 emtricitabine/rilpivirine/tenofovir alafenamide, 14 ERIVEDGE, 21 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 14 ERLEADA, 18 emtricitabine/tenofovir alafenamide, 14 erlotinib, 18 emtricitabine/tenofovir disoproxil fumarate, 14 ERTACZO, 58 EMTRIVA, 15 ertapenem, 16 EMVERM, 17 ertugliflozin, 37 enalapril, 22 ertugliflozin/metformin, 37 enalapril oral soln, 22 ertugliflozin/sitagliptin, 38 enalapril/hydrochlorothiazide, 23 ERWINAZE, 21 enasidenib, 22 ERYGEL, 57 ENBREL, 51 ERYPED, 13 ENBREL SURECLICK, 51 erythromycin, 61 encorafenib, 19 erythromycin delayed-rel, 13 ENDARI, 50 erythromycin delayed-rel - Ery-tab, 13 ENDOMETRIN, 43 erythromycin ethylsuccinate, 13 enfortumab vedotin-ejfv, 22 erythromycin gel 2%, 57 enfuvirtide, 14 erythromycin soln, 57 ENHERTU, 22 erythromycin stearate, 13 enoxaparin, 48 erythromycin/benzoyl peroxide, 57 ENSPRYNG, 51 ESBRIET, 56 ENSTILAR, 58 escitalopram, 29 entacapone, 30 esketamine nasal solution, 30 entecavir soln, 16 eslicarbazepine, 29 entecavir tabs, 16 esmolol, 25 ENTEREG, 47 esomeprazole magnesium delayed-rel, 47 ENTOCORT EC, 46 ESPEROCT, 49 entrectinib, 19 estazolam, 32 ENTRESTO, 26 ESTRACE, 41 ENTYVIO, 46 estradiol, 41 ENVARSUS XR, 53 estradiol transdermal gel, 41 enzalutamide, 18 estradiol transdermal spray, 41 EPANED, 22 estradiol vaginal crm, 41 EPCLUSA, 16 estradiol vaginal inserts, 41 EPIDIOLEX, 29 estradiol vaginal ring, 41 EPIDUO, 57 estradiol vaginal tabs, 41 EPIDUO FORTE, 57 estradiol valerate, 41 EPIFOAM, 47 estradiol valerate and dienogest/estradiol valerate, 40 epinastine, 61 estradiol/levonorgestrel, 41 epinephrine auto-injector 0.15 mg, 54 estradiol/norethindrone acetate, 41 epinephrine auto-injector 0.30 mg, 54 estradiol/norgestimate, 41 epinephrine inj (0.15 mg and 0.30 mg), 54 estradiol/progesterone, 41 EPIPEN, 54 ESTRING, 41 EPIPEN JR., 54 ESTROGEL, 41 epirubicin, 20 estrogens, conjugated, 41 EPIVIR, 15 estrogens, conjugated crm, 41 EPIVIR-HBV, 15 estrogens, conjugated/medroxyprogesterone, 41

80

estrogens, esterified/methyltestosterone, 41 famciclovir, 16 ESTROSTEP FE, 40 famotidine, 45 eszopiclone, 32 fam-trastuzumab deruxtecan-nxki, 22 etanercept, 51 FANAPT, 31 etelcalcetide, 38 FARESTON, 18 eteplirsen, 35 FARXIGA, 37 ethacrynic acid, 26 FARYDAK, 22 ethambutol, 15 FASENRA, 57 ethinyl estradiol/levonorgestrel, 40 FASLODEX, 18 ethosuximide, 28 febuxostat, 10 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 39 fedratinib, 19 ethynodiol diacetate/EE 1/50, 39 FEIBA VH IMMUNO, 49 ETHYOL, 20 felbamate, 28 etodolac, 10 FELBATOL, 28 etodolac ext-rel, 10 FELDENE, 10 etonogestrel implant, 40 felodipine ext-rel, 25 etonogestrel/EE - EluRyng, 40 FEMARA, 18 ETOPOPHOS, 21 FEMHRT, 41 etoposide, 20 FEMRING, 41 etoposide phosphate, 21 fenfluramine, 29 etravirine, 15 fenofibrate, 24 EUCRISA, 59 fenofibric acid delayed-rel, 24 EUFLEXXA, 12 FENSOLVI, 18 EURAX crm, 60 fentanyl citrate buccal, 11 EURAX lotion, 60 fentanyl sublingual spray, 11 EVAMIST, 41 fentanyl transdermal, 11 EVEKEO, 31 fentanyl transmucosal lozenge, 11 EVEKEO ODT, 32 FENTORA, 11 EVENITY, 39 FERAHEME, 53 everolimus 0.25 mg, 0.5 mg, 0.75 mg, 53 ferric carboxymaltose inj, 53 everolimus 1 mg, 53 ferric citrate, 43 everolimus 10 mg, 19 ferric derisomaltose inj, 53 everolimus 2.5 mg, 5 mg, 7.5 mg, 18 FERRIPROX, 50 everolimus tabs for oral suspension, 19 FERRLECIT, 53 EVISTA, 43 ferumoxytol inj, 53 evolocumab, 25 fesoterodine ext-rel, 48 EVOMELA, 22 FETZIMA, 29 EVOTAZ, 14 FIASP, 36 EVOXAC, 47 FIASP FLEXTOUCH, 36 EVRYSDI, 35 fibrinogen, 49, 50 EVZIO, 34 FIBRYGA, 50 EXELDERM, 58 fidaxomicin, 13 EXELON PATCH, 29 filgrastim, 49 exemestane, 18 filgrastim-aafi, 49 exenatide, 36 filgrastim-sndz, 49 exenatide ext-rel, 36 FINACEA, 60 EXFORGE, 23 finasteride, 47 EXFORGE HCT, 23 fingolimod, 33 EXJADE, 50 FINTEPLA, 29 EXONDYS 51, 35 FIORICET, 11 EXTAVIA, 34 FIORICET w/CODEINE, 11 EYLEA, 63 FIORINAL, 11 EYSUVIS, 63 FIRAZYR, 51 EZALLOR SPRINKLE, 24 FIRDAPSE, 35 ezetimibe, 24 FIRMAGON, 18 ezetimibe/simvastatin, 24 FIRVANQ, 17 F FLAGYL, 16 FLAREX, 62 FABIOR, 57 FLEBOGAMMA, 52 FABRAZYME, 44 flecainide, 24 factor IX concentrate, 49 FLOLAN, 27 factor IX recombinant, Fc fusion protein, 49 FLOMAX, 47 factor XIII A-subunit recombinant, 49 FLOVENT, 56 factor XIII concentrate, 49 FLOVENT HFA, 56

81

floxuridine, 17 fostamatinib, 50 fluconazole, 13 fostemsavir ext-rel, 14 fludarabine, 17 FRAGMIN, 48 fludrocortisone, 42 FREESTYLE LIBRE / FREESTYLE LIBRE 2 CONTINUOUS flunisolide spray, 56 GLUCOSE MONITORING SYST, 38 fluocinolone acetonide, 64 FROVA, 33 fluocinolone acetonide crm, oint 0.025%, 59 frovatriptan, 33 fluocinolone acetonide oil 0.01%, 59 FULPHILA, 49 fluocinolone acetonide soln 0.01%, 59 fulvestrant, 18 fluocinolone shampoo 0.01%, 59 furosemide, 26 fluocinonide crm 0.1%, 60 FUZEON, 14 fluocinonide crm, gel, oint, soln 0.05%, 59 FYCOMPA, 29 fluorometholone, 62 G fluorometholone acetate, 62 gabapentin, 28 FLUOROPLEX, 58 GABITRIL, 28 fluorouracil, 58 GALAFOLD, 44 fluorouracil crm 4%, 58 galantamine, 29 fluorouracil inj, 17 galantamine ext-rel, 29 fluoxetine, 29 galcanezumab-gnlm 100 mg/mL, 33 fluoxetine delayed-rel, 29 galcanezumab-gnlm 120 mg/mL, 33 fluphenazine, 31 galsulfase, 44 flurandrenolide crm, lotion, oint 0.05%, 59 GALZIN, 53 flurandrenolide tape, 59 GAMASTAN, 52 flurazepam, 32 GAMASTAN S-D, 52 flurbiprofen, 10, 62 GAMMAGARD LIQUID, 52 flutamide, 18 GAMMAGARD S-D, 52 fluticasone, 56 GAMMAKED, 52 fluticasone furoate spray, 56 GAMMAPLEX, 52 fluticasone propionate, 56 GAMUNEX-C, 52 fluticasone propionate crm 0.05%, oint 0.005%, 59 ganciclovir, 62 fluticasone propionate lotion 0.005%, 59 ganciclovir inj, 15 fluticasone spray, 56 GANIRELIX ACETATE, 41 fluticasone, CFC-free aerosol, 56 ganirelix acetate inj, 41 fluticasone/salmeterol, 56 GASTROCROM, 47 fluticasone/salmeterol, CFC-free aerosol, 56 GATTEX, 47 fluticasone/umeclidinium/vilanterol, 54 GAVRETO, 19 fluticasone/vilanterol, 56 GAZYVA, 21 fluvastatin, 24 gefitinib, 19 fluvastatin ext-rel, 24 GELNIQUE, 48 fluvoxamine, 28 GEL-ONE, 11 fluvoxamine ext-rel, 28 GELSYN-3, 11 FML, 62 GEMCITABINE, 17 FOCALIN, 31 gemcitabine inj, 17 FOCALIN XR, 31 gemfibrozil, 24 folic acid, 53 gemtuzumab ozogamicin, 22 FOLLISTIM AQ, 42 GENOTROPIN, 42 follitropin alfa, 42 gentamicin crm, 58 follitropin beta, 42 gentamicin/prednisolone acetate, 62 FOLOTYN, 17 GENVOYA, 14 fondaparinux, 48 GEODON, 31 FORADIL, 55 GILENYA, 33 FORFIVO XL, 30 GILOTRIF, 19 formoterol inhalation caps, 55 gilteritinib, 19 formoterol inhalation soln, 55 GIMOTI, 45 FORTAMET, 36 GIVLAARI, 47 FORTEO, 39 givosiran, 47 FORTESTA, 35 glasdegib, 22 FOSAMAX, 38 GLASSIA, 54 FOSAMAX PLUS D, 39 glatiramer, 33 fosamprenavir, 15 glatiramer - Glatopa, 33 fosinopril, 22 glecaprevir/pibrentasvir, 16 fosinopril/hydrochlorothiazide, 23 GLEEVEC, 18 FOSRENOL CHEWABLE TABLETS, 43 GLEOSTINE, 17 FOSRENOL ORAL POWDER, 43

82

glimepiride, 38 HERZUMA, 21 glipizide, 38 HETLIOZ, 32 glipizide ext-rel, 38 high molecular weight hyaluronan, 11 glipizide/metformin, 36 HIPREX, 16 GLUCAGEN, 42 histrelin acetate, 18, 44 GLUCAGON EMERGENCY KIT, 42 HIZENTRA, 52 glucagon nasal powder, 42 HUMALOG, 37 glucagon subcutaneous soln, 42 HUMALOG MIX, 37 glucagon, human recombinant, 42 human coagulation factor VIII (rDNA) simoctocog alfa, 49 glucagon, human recombinant (KIT), 42 HUMATE-P, 49 glucarpidase, 21 HUMATROPE, 42 GLUCOTROL, 38 HUMIRA, 51 GLUCOTROL XL, 38 HUMULIN 70/30, 37 glyburide, 38 HUMULIN N, 37 glyburide, micronized, 38 HUMULIN R, 37 glyburide/metformin, 36 HUMULIN R U-500, 37 , 44 HYALGAN, 11 glycopyrrolate, 47 hyaluronate sodium, 11 glycopyrrolate inhalation powder, 54 HYCAMTIN, 20 glycopyrrolate inhalation solution, 54 HYCAMTIN inj, 20 glycopyrrolate/formoterol, 54 hydralazine, 27 GLYNASE, 38 HYDREA, 20 GLYXAMBI, 37 hydrochlorothiazide, 26 GOCOVRI, 30 hydrocodone ext-rel caps, 11 golimumab, 51 hydrocodone ext-rel tabs, 11 golodirsen, 35 hydrocodone/acetaminophen, 11 GOLYTELY, 46 hydrocodone/homatropine, 55 gonadorelin, 41 hydrocortisone, 42 GONAL-F, 42 hydrocortisone acetate foam, 46 GONAL-F RFF, 42 hydrocortisone acetate/pramoxine foam, 47 GONITRO, 27 hydrocortisone butyrate crm 0.1%, 59 goserelin acetate, 18 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 59 granisetron, 45 hydrocortisone crm 2.5%, 59 granisetron ext-rel inj, 45 hydrocortisone enema, 46 granisetron transdermal, 45 hydrocortisone probutate crm 0.1%, 59 GRANIX, 49 hydrocortisone valerate crm, oint 0.2%, 59 grass mixed pollen allergen extract, 51 hydrocortisone/aloe polysaccharide/iodoquinol, 60 griseofulvin microsize, 13 hydrocortisone/iodoquinol, 60 griseofulvin ultramicrosize, 13 hydromorphone, 11 guanfacine ext-rel, 32 hydromorphone ext-rel, 11 guselkumab, 58 hydroxocobalamin, 44 GVOKE, 42 hydroxychloroquine, 51 H hydroxyprogesterone caproate, 43 hydroxyurea, 20, 22 HAEGARDA, 51 hydroxyzine HCl, 28, 54 HALAVEN, 21 hydroxyzine pamoate, 28, 54 halcinonide crm, oint, soln 0.1%, 60 hylan G-F 20, 11 HALDOL, 31 HYMOVIS, 11 HALDOL DECANOATE 100, 31 hyoscyamine sulfate, 45 halobetasol propionate crm, oint 0.05%, 60 hyoscyamine sulfate ext-rel, 45 HALOG, 60 HYPERHEP B S-D, 52 haloperidol, 31 HYPERRHO S-D, 52 haloperidol decanoate inj, 31 HYQVIA, 52 haloperidol lactate inj, 31 HYSINGLA ER, 11 HARVONI, 16 HYZAAR, 23 HECTOROL, 43 HEMADY, 42 I HEMLIBRA, 49 ibalizumab-uiyk, 15 HEMOFIL M, 49 ibandronate, 38 HEPAGAM B, 52 IBRANCE, 19 hepatitis B immune globulin, 52 ibrutinib, 19 HEPSERA, 15 ibuprofen, 10 HERCEPTIN, 22 ibuprofen inj, 10 HERCEPTIN HYLECTA, 22 icatibant, 51

83

ICLUSIG, 19 INSPRA, 23 icosapent ethyl caps 1 gm, 25 insulin aspart, 36 IDAMYCIN PFS, 20 INSULIN ASPART, 36 idarubicin, 20 insulin aspart protamine 70%/insulin aspart 30%, 36, 37 idelalisib, 19 INSULIN ASPART PROTAMINE 70%/INSULIN ASPART 30%, 36 IDELVION, 49 insulin degludec, 37 IDHIFA, 22 insulin detemir, 37 idursulfase, 44 insulin glargine, 37 IFEX, 20 insulin glulisine, 37 ifosfamide, 20 insulin human, 37 ifosfamide/mesna, 17 insulin human inhalation powder, 37 ILARIS, 52 insulin isophane human, 37 ILEVRO, 62 insulin isophane human 70%/regular 30%, 37 iloperidone, 31 insulin lispro, 37 iloprost, 27 INSULIN LISPRO, 37 ILUMYA, 51 insulin lispro protamine/insulin lispro, 37 imatinib mesylate, 18 INSULIN LISPRO PROTAMINE/INSULIN LISPRO, 37 IMBRUVICA, 19 insulin lispro-aabc, 37 IMFINZI, 22 insulin pen needles, 38 imiglucerase, 42 insulin syringes, needles, 38 imipenem/cilastatin, 16 INTEGRILIN, 50 imipramine HCl, 30 INTELENCE, 15 imipramine pamoate, 30 interferon alfa-2b, 52 imiquimod, 60 interferon alfa-n3, 61 imiquimod crm 3.75%, 60 interferon beta-1a, 33 IMITREX, 33 interferon beta-1b, 34 IMLYGIC, 21 interferon gamma-1b, recombinant, 52 immune globulin (human)-ifas, 52 INTRAROSA, 44 immune globulin (human)-klhw, 52 intrauterine copper contraceptive, 40 immune globulin (human)-slra, 52 INTRON A, 52 immune globulin, gamma, 52 INTUNIV, 32 immune globulin, gamma (IGG), 52 INVANZ, 16 immune globulin, intravenous, 52 INVEGA, 31 immune globulin, subcutaneous, 52 INVEGA SUSTENNA, 31 immune globulin/hyaluronidase, 52 INVEGA TRINZA, 31 immune globulin-hipp, 52 INVELTYS, 62 IMPAVIDO, 17 INVIRASE, 15 IMPEKLO, 60 INVOKAMET, 37 IMURAN, 52 INVOKAMET XR, 37 IMVEXXY, 41 INVOKANA, 37 INBRIJA, 30 ipilimumab, 21 incobotulinumtoxinA, 35 ipratropium nasal spray, 57 INCRELEX, 43 ipratropium soln, 54 INCRUSE ELLIPTA, 54 ipratropium, CFC-free aerosol, 54 indacaterol/glycopyrrolate inhalation powder, 54 ipratropium/albuterol soln, 54 indapamide, 26 ipratropium/albuterol, CFC-free aerosol, 54 INDERAL LA, 25 irbesartan, 23 indinavir, 15 irbesartan/hydrochlorothiazide, 23 INDOCIN susp, 10 IRESSA, 19 indomethacin (except caps 20 mg, 40 mg), 10 irinotecan, 20 indomethacin ext-rel, 10 irinotecan liposome inj, 20 indomethacin susp, 10 inj, 53 INFLECTRA, 51 isatuximab-irfc, 20 infliximab, 51 isavuconazonium, 14 infliximab-abda, 51 ISENTRESS, 14 infliximab-dyyb, 51 isocarboxazid, 29 INGREZZA, 35 isoniazid, 15 INJECTAFER, 53 ISOPTO HYOSCINE, 63 INLYTA, 19 ISORDIL, 27 INNOPRAN XL, 25 isosorbide dinitrate oral, 27 inotersen, 44 isosorbide dinitrate/hydralazine, 26 inotuzumab ozogamicin, 22 isosorbide mononitrate, 27 INQOVI, 21 isosorbide mononitrate ext-rel, 27 INREBIC, 19 isotretinoin, 57

84

ISTALOL, 62 KITABIS PAK, 55 ISTODAX, 20 KLISYRI, 58 istradefylline, 30 KLONOPIN, 28 ISTURISA, 45 KOATE-DVI, 49 itraconazole, 13 KOGENATE FS, 49 ivabradine, 26 KORLYM, 44 ivacaftor, 55 KOSELUGO, 19 ivermectin, 60 KOVALTRY, 49 ivermectin crm 1%, 60 KRINTAFEL, 14 ivosidenib, 22 KRISTALOSE pak, 46 ixabepilone, 21 KRYSTEXXA, 10 ixazomib, 20 KUVAN, 43 ixekizumab, 51 KYLEENA, 40 IXEMPRA, 21 KYNMOBI, 30 IXINITY, 49 KYPROLIS, 22 J L JADENU, 50 lacosamide, 28 JAKAFI, 19 lactic acid/citric acid/potassium bitartrate gel, 40 JALYN, 47 lactulose, 46 JANUMET, 36 lactulose soln, 46 JANUMET XR, 36 LAMICTAL, 28 JANUVIA, 36 LAMICTAL ODT, 28 JARDIANCE, 37 LAMICTAL XR, 28 JEVTANA, 21 lamivudine, 15 JIVI, 49 lamivudine/tenofovir disoproxil fumarate, 14 JUBLIA, 58 lamivudine/zidovudine, 14 JULUCA, 14 lamotrigine, 28 JUXTAPID, 25 lamotrigine ext-rel, 28 JYNARQUE, 44 lamotrigine orally disintegrating tabs, 28 K LAMPIT, 17 lanadelumab-flyo, 52 KADCYLA, 20 lancet device, 38 KALBITOR, 51 lancets, 38 KALETRA, 15 LANOXIN, 26 KALYDECO, 55 lanreotide acetate, 44 KANJINTI, 21 lansoprazole + amoxicillin + clarithromycin, 47 KANUMA, 44 lansoprazole delayed-rel, 47 KAPSPARGO, 25 chew tabs, 43 KAPVAY, 31 lanthanum oral powder, 43 KEFLEX, 12 LANTUS, 37 KENALOG SPRAY, 60 lapatinib, 18 KENGREAL, 50 laronidase, 44 KEPIVANCE, 47 larotrectinib, 19 KEPPRA, 28 LASIX, 26 KEPPRA XR, 28 LASTACAFT, 61 KERYDIN, 58 latanoprost, 63 KESIMPTA, 34 latanoprost ophthalmic emulsion, 63 ketoconazole, 58 latanoprostene bunod, 63 ketoconazole shampoo 2%, 59 LATUDA, 31 ketoconazole tabs, 13 ledipasvir/sofosbuvir, 16 ketoprofen, 10 lefamulin, 13 ketoprofen ext-rel, 10 leflunomide, 51 ketorolac, 10 lemborexant, 32 ketorolac 0.45%, 62 LEMTRADA, 34 ketorolac 0.5%, 62 lenalidomide, 20 ketorolac tromethamine nasal spray, 10 lenvatinib, 19 KEVEYIS, 26 LENVIMA, 19 KEVZARA, 51 LESCOL XL, 24 KEYTRUDA, 18 LETAIRIS, 27 KHAPZORY, 22 letermovir, 15 KINERET, 51 letrozole, 18 KISQALI, 19 leucovorin calcium, 20 KISQALI FEMARA CO-PACK, 19 LEUKERAN, 17

85

LEUKINE, 49 lixisenatide, 36 leuprolide acetate, 18, 44 lixisenatide/insulin glargine, 36 leuprolide acetate/norethindrone acetate, 41 LO LOESTRIN FE, 40 levalbuterol inhalation soln, 55 LOCOID, 59 levalbuterol nebulizer soln concentrate, 55 LOCOID LIPOCREAM, 59 levalbuterol tartrate, CFC-free aerosol, 55 lodoxamide, 61 levamlodipine maleate, 25 LOKELMA, 43 LEVAQUIN, 13 lomitapide, 25 LEVATOL, 25 LOMOTIL, 45 LEVBID, 45 lomustine, 17 LEVEMIR, 37 lonafarnib, 44 levetiracetam, 28 LONHALA MAGNAIR, 54 levetiracetam ext-rel, 28 LONSURF, 22 levobunolol, 62 loperamide, 45 levocarnitine, 39 LOPID, 24 levocetirizine, 54 lopinavir/ritonavir, 15 levodopa inhalation powder, 30 LOPRESSOR, 25 levofloxacin, 13, 61 LOPROX, 58 levoleucovorin, 22 lorazepam, 28 levoleucovorin calcium, 20 LORBRENA, 19 levomilnacipran ext-rel, 29 lorlatinib, 19 levonorgestrel/EE - Trivora, 40 losartan, 23 levonorgestrel/EE 0.09/20 - Amethyst, 40 losartan/hydrochlorothiazide, 23 levonorgestrel/EE 0.1/20, 39 LOSEASONIQUE, 40 levonorgestrel/EE 0.1/20 and EE 10, 40 LOTEMAX Gel, Susp, 62 levonorgestrel/EE 0.15/30, 39 LOTEMAX Oint, 62 levonorgestrel/EE 0.15/30 - Jolessa, 40 LOTEMAX SM, 62 levonorgestrel/EE 0.15/30 - Levora, 39 LOTENSIN, 22 levonorgestrel/EE 0.15/30 and EE 10, 40 LOTENSIN HCT, 23 levonorgestrel-releasing IUD, 40 loteprednol, 62 levothyroxine, 43 loteprednol 0.2%, 62 levothyroxine - Levoxyl, 43 loteprednol 0.5% gel, susp, 62 LEVSIN, 45 loteprednol 1.0%, 62 LEVULAN KERASTICK, 58 loteprednol etabonate, 63 LEXAPRO, 29 loteprednol oint, 62 LEXIVA, 15 LOTREL, 23 L-glutamine oral powder, 50 LOTRONEX, 46 LIALDA, 46 lovastatin, 24 lidocaine, 60 LOVAZA, 25 lidocaine patch, 60 LOVENOX, 48 lidocaine viscous, 61 loxapine, 31 lidocaine/prilocaine, 60 lubiprostone, 46 LIDODERM, 60 LUCENTIS, 63 lifitegrast, 63 luliconazole, 58 LILETTA, 40 lumacaftor/ivacaftor, 55 linaclotide, 46 lumateperone, 31 lindane, 60 LUMIGAN, 63 linezolid, 16 LUMIZYME, 44 LINZESS, 46 LUMOXITI, 22 LIORESAL INTRATHECAL, 34 LUNESTA, 32 liothyronine, 43 LUPANETA PACK, 41 LIPITOR, 24 LUPKYNIS, 53 LIPOFEN, 24 LUPRON DEPOT, 18 liraglutide, 36 LUPRON DEPOT-PED, 44 liraglutide/insulin degludec, 36 lurasidone, 31 lisdexamfetamine, 32 lurbinectedin, 17 lisinopril, 22 luspatercept-aamt, 50 lisinopril oral soln, 22 lusutrombopag, 50 lisinopril/hydrochlorothiazide, 23 LUTREPULSE, 41 lithium carbonate, 33 LUZU, 58 lithium carbonate ext-rel tabs 300 mg, 33 LYNPARZA, 21 lithium carbonate ext-rel tabs 450 mg, 33 LYRICA, 32 LITHOBID, 33 LYSODREN, 20 LIVALO, 24 LYSTEDA, 50

86

LYUMJEV/KWIKPEN, 37 metformin ext-rel, 36 M metformin oral soln, 36 methadone, 11 macitentan, 27 methamphetamine, 32 MACROBID, 16 methazolamide, 26 MACRODANTIN, 16 methenamine hippurate, prophylaxis, 16 mafenide acetate packets 5%, 58 methimazole, 43 MAKENA, 43 methotrexate auto-injector, 51 MALARONE, 14 methotrexate inj, 51 mannitol inhalation powder, 56 methotrexate oral, 51 maraviroc, 14 methoxsalen oral, 58 MARINOL, 45 methoxy polyethylene glycol/epoetin beta, 49 MARPLAN, 29 methylergonovine, 44 MARQIBO, 21 METHYLIN, 32 MATULANE, 21 methylnaltrexone, 46 MAVENCLAD, 34 methylphenidate, 32 MAVYRET, 16 methylphenidate ext-rel, 32 MAXALT/MAXALT-MLT, 33 methylphenidate ext-rel (except methylphenidate tab ER osmotic MAXIDEX, 62 release 72 mg), 32 MAXITROL, 61 methylphenidate ext-rel caps, 32 MAXZIDE, 26 methylphenidate ext-rel chewable tabs, 32 MAXZIDE-25, 26 methylphenidate ext-rel orally disintegrating tablets, 32 MAYZENT, 34 methylphenidate ext-rel susp, 32 mebendazole, 17 methylphenidate transdermal, 32 mecamylamine, 27 methylprednisolone, 42 mecasermin, 43 metoclopramide, 45 mechlorethamine gel, 17 metoclopramide nasal spray, 45 meclizine, 45 metolazone, 26 MEDROL, 42 metoprolol succinate ext-rel, 25 medroxyprogesterone acetate, 43 metoprolol tartrate, 25 medroxyprogesterone acetate 150 mg/mL, 40 metoprolol/hydrochlorothiazide, 25 mefloquine, 14 metreleptin, 44 megestrol acetate, 18 METROCREAM, 60 megestrol acetate susp, 43 METROGEL, 60 MEKINIST, 19 METROLOTION, 60 MEKTOVI, 19 metronidazole crm, 60 meloxicam tabs, 10 metronidazole crm 0.75%, 60 melphalan, 22 metronidazole gel 0.75%, 60 melphalan inj, 17 metronidazole gel 1%, 60 melphalan tabs, 17 metronidazole lotion 0.75%, 60 memantine soln, 29 metronidazole tabs, 16 memantine tabs, 29 metronidazole vaginal, 48 MENOPUR, 42 mexiletine, 24 menotropins, 42 MIACALCIN, 39 MENTAX, 58 MIACALCIN inj, 39 MEPHYTON, 53 micafungin, 13 mepolizumab, 56 MICARDIS, 23 MEPRON, 16 MICARDIS HCT, 23 MEPSEVII, 44 miconazole nitrate/zinc oxide, 58 mercaptopurine, 17 MICRHOGAM, 52 mercaptopurine susp, 18 MICRHOGAM PLUS, 52 meropenem, 16 midazolam nasal spray, 29 mesalamine delayed-rel caps, 46 midodrine, 27 mesalamine delayed-rel tabs, 46 midostaurin, 19 mesalamine ext-rel caps, 46 mifepristone, 44 mesalamine rectal susp, 46 migalastat, 44 mesalamine supp, 46 MIGERGOT, 33 mesna inj, 20 miglitol, 36 mesna tabs 400 mg, 21 miglustat, 44 MESNEX, 21 MIGRANAL, 33 MESNEX inj, 20 milnacipran, 32 MESTINON, 34 miltefosine, 17 MESTINON TIMESPAN, 34 MINIPRESS, 23 metformin, 36 MINIVELLE, 41

87

MINOCIN, 13 N minocycline, 13 NABI-HB, 52 minocycline ext-rel, 13 nabumetone, 10 minocycline ext-rel caps, 57 nafarelin, 40 minocycline foam, 60 naftifine, 58 minocycline hcl micronized foam, 57 naftifine gel 2%, 58 minoxidil tabs, 27 NAFTIN (EXCEPT 2% GEL), 58 mirabegron ext-rel, 48 NAFTIN GEL 2%, 58 MIRAPEX, 30 NAGLAZYME, 44 MIRAPEX ER, 30 naloxegol, 46 MIRCERA, 49 naloxone auto-injector, 34 MIRCETTE, 40 naloxone inj, 34 MIRENA, 40 naloxone nasal spray, 34 mirtazapine, 30 naltrexone, 34 MIRVASO, 60 naltrexone microspheres, 34 misoprostol, 47 NAMENDA tabs, 29 MITIGARE, 10 naphazoline, 63 mitomycin, 20 NAPROSYN, 10 mitotane, 20 naproxen, 10 mitoxantrone, 20 naproxen sodium, 10 MOBIC, 10 naratriptan, 33 modafinil, 34 NARCAN, 34 mogamulizumab-kpkc, 22 NARDIL, 29 mometasone, 56 NASCOBAL, 53 mometasone crm, lotion, oint 0.1%, 59 NASONEX, 56 mometasone spray, 56 NATACYN, 61 mometasone, CFC-free aerosol, 56 natalizumab, 34 mometasone/formoterol, 56 natamycin, 61 MONOFERRIC, 53 NATAZIA, 40 monomethyl fumarate, 34 nateglinide, 37 MONONINE, 49 NATPARA, 39 MONOVISC, 12 NATROBA, 60 montelukast, 56 NAVELBINE, 20 MORPHABOND, 11 NAYZILAM, 29 morphine, 11 nebivolol, 25 morphine ext-rel, 11 necitumumab, 21 morphine supp, 11 nefazodone, 30 morphine/naltrexone ext-rel, 11 nelarabine, 21 MOVANTIK, 46 nelfinavir, 15 MOVIPREP, 46 neomycin/dexamethasone, 61 moxetumomab pasudotox-tdfk, 22 neomycin/polymyxin B/dexamethasone, 61 MOXEZA, 61 neomycin/polymyxin B/gramicidin, 61 moxifloxacin, 61 neomycin/polymyxin B/hydrocortisone, 64 MOZOBIL, 50 neomycin/polymyxin B/hydrocortisone susp, 61 MS CONTIN, 11 NEORAL, 53 MULPLETA, 50 nepafenac, 62 MULTAQ, 24 nepafenac 0.3%, 62 mupirocin, 58 neratinib, 19 MVASI, 21 NERLYNX, 19 MYALEPT, 44 netarsudil, 63 MYAMBUTOL, 15 netarsudil/latanoprost, 63 MYCAMINE, 13 netupitant/palonosetron, 45 MYCAPSSA, 44 NEULASTA, 49 MYCOBUTIN, 16 NEUPOGEN, 49 mycophenolate mofetil, 52 NEUPRO, 30 mycophenolate sodium delayed-rel, 52 NEURONTIN, 28 MYDAYIS, 32 NEVANAC, 62 MYFORTIC, 52 nevirapine, 15 MYLERAN, 17 nevirapine ext-rel, 15 MYLOTARG, 22 NEXAVAR, 19 MYOBLOC, 35 NEXLETOL, 24 MYRBETRIQ, 48 NEXLIZET, 24 MYSOLINE, 28 NEXPLANON, 40 MYTESI, 45

88

niacin ext-rel, 25 NOVAREL, 42 NIASPAN, 25 NOVOEIGHT, 49 nicardipine, 25 NOVOFINE PEN NEEDLES, 38 nifedipine ext-rel, 25 NOVOLIN 70/30, 37 nifurtimox, 17 NOVOLIN N, 37 NILANDRON, 18 NOVOLIN R, 37 nilotinib, 19 NOVOLOG, 36 nilutamide, 18 NOVOLOG MIX 70/30, 37 nimodipine, 25 NOVOSEVEN RT, 49 NIMOTOP, 25 NOXAFIL susp, 14 NINLARO, 20 NOXAFIL tabs, 13 nintedanib, 56 NPLATE, 50 NIPENT, 17 NUBEQA, 18 niraparib, 21 NUCALA, 56 nisoldipine ext-rel, 25 NUCYNTA, 11 nitazoxanide tabs, 16 NUCYNTA ER, 11 nitisinone, 42 NUEDEXTA, 35 NITRO-BID, 27 NULOJIX, 53 NITRO-DUR, 27 NULYTELY, 46 nitrofurantoin ext-rel, 16 NUPLAZID, 31 nitrofurantoin macrocrystals, 16 NURTEC ODT, 33 nitroglycerin lingual spray, 27 NUTROPIN AQ, 42 nitroglycerin ointment, 27 NUTROPIN AQ NUSPIN, 42 nitroglycerin rectal oint 0.4%, 47 NUVARING, 40 nitroglycerin sublingual, 27 NUVIGIL, 34 nitroglycerin sublingual aerosol, 27 NUWIQ, 49 nitroglycerin sublingual powder, 27 NUZYRA, 13 nitroglycerin transdermal, 27 nystatin, 13, 58 NITROLINGUAL, 27 NYVEPRIA, 49 NITROMIST, 27 O NITROSTAT, 27 obeticholic acid, 47 NITYR, 42 obinutuzumab, 21 NIVESTYM, 49 OBIZUR, 49 nivolumab, 21 OCALIVA, 47 nizatidine, 45 ocrelizumab, 34 NIZORAL SHAMPOO, 59 OCREVUS, 34 NORDITROPIN, 42 OCTAGAM, 52 norelgestromin/EE, 40 octreotide, 44 norethindrone, 40 octreotide acetate, 44 norethindrone acetate, 43 OCUFLOX, 61 norethindrone acetate/EE 1.5/30, 39 ODEFSEY, 14 norethindrone acetate/EE 1.5/30 and iron, 39 ODOMZO, 22 norethindrone acetate/EE 1/10 and EE 10 and iron, 40 ofatumumab, 21, 34 norethindrone acetate/EE 1/20, 39 OFEV, 56 norethindrone acetate/EE 1/20 and iron, 39 OFIRMEV, 10 norethindrone acetate/EE and iron, 40 ofloxacin, 13, 61 norethindrone/EE, 40 ofloxacin otic, 64 norethindrone/EE 0.4/35, 39 OGIVRI, 21 norethindrone/EE 0.5/35, 39 olanzapine, 31 norethindrone/EE 1/35, 39 olanzapine pamoate ext-rel inj, 31 norgestimate/EE, 40 olanzapine/fluoxetine, 31 norgestimate/EE 0.25/35, 39 olaparib, 21 norgestrel/EE 0.3/30 - Cryselle, 39 olmesartan, 23 norgestrel/EE 0.3/30 - Low-Ogestrel, 39 olmesartan/amlodipine/hydrochlorothiazide, 24 norgestrel/EE 0.5/50, 40 olmesartan/hydrochlorothiazide, 23 NORITATE, 60 olodaterol, CFC-free aerosol, 55 NORPACE, 24 olopatadine, 61 NORPACE CR, 24 olopatadine spray, 56 NORPRAMIN, 30 olsalazine, 46 NORTHERA, 27 OLUMIANT, 51 nortriptyline, 30 omacetaxine mepesuccinate, 21 NORVASC, 25 omadacycline, 13 NORVIR, 15 omalizumab, 56 NOURIANZ, 30

89

omega-3 acid ethyl esters, 25 oxycodone soln, 11 omeprazole delayed-rel, 47 oxycodone/acetaminophen 5/325, 11 omeprazole/sodium bicarbonate, 47 OXYCONTIN, 11 OMNARIS, 56 oxymetazoline crm 1%, 60 OMNITROPE, 42 oxymetazoline opth soln, 63 onabotulinumtoxinA, 35 oxymorphone, 11 ONCASPAR, 21 ozanimod, 34 ondansetron, 45 OZEMPIC, 36 ondansetron orally disintegrating tabs, 45 ozenoxacin, 58 ONETOUCH LANCETS, 38 P ONETOUCH METERS AND KITS, 38 paclitaxel, 20 ONETOUCH TEST STRIPS, 38 paclitaxel protein-bound particles, 21 ONEXTON, 57 PADCEV, 22 ONFI, 28 palbociclib, 19 ONGENTYS, 30 PALFORZIA, 51 ONIVYDE, 20 palifermin, 47 ONTRUZANT, 21 paliperidone ext-rel, 31 ONUREG, 17 paliperidone palmitate ext-rel inj, 31 ONZETRA XSAIL, 33 palivizumab, 16 OPANA, 11 palonosetron, 45 OPDIVO, 21 PALYNZIQ, 43 opicapone, 30 PAMELOR, 30 OPSUMIT, 27 pamidronate, 39 ORACEA, 60 PANCREAZE, 47 ORALAIR, 51 pancrelipase, 46 ORAPRED ODT, 42 pancrelipase delayed-rel, 46, 47 ORENCIA, 51 PANDEL, 59 ORENITRAM, 27 panitumumab, 21 ORFADIN, 42 panobinostat, 22 ORGOVYX, 18 PANRETIN, 60 ORIAHNN, 44 pantoprazole delayed-rel, 47 ORILISSA, 40 PANZYGA, 52 ORKAMBI, 55 PARAGARD T 380A, 40 ORLADEYO, 51 parathyroid hormone (recombinant), 39 ORTHO MICRONOR, 40 paricalcitol, 43 ORTHOVISC, 11 PARLODEL, 30 ORTIKOS, 46 PARNATE, 29 oseltamivir, 16 paroxetine HCl, 29 osilodrostat phosphate, 45 paroxetine HCl ext-rel, 29 osimertinib, 19 paroxetine mesylate, 29 OSMOLEX ER, 30 PARSABIV, 38 OSMOPREP, 46 pasireotide, 44 ospemifene, 43 PATANASE, 56 OSPHENA, 43 patiromer, 43 OTEZLA, 51 PAXIL, 29 OTREXUP, 51 PAXIL CR, 29 OVIDREL, 41 PAZEO, 61 oxaliplatin, 20 pazopanib, 19 oxaprozin, 10 peanut allergen-dfnp, 51 oxazepam, 28 peg 3350/electrolytes, 46 OXBRYTA, 50 pegaspargase, 21 oxcarbazepine, 28 PEGASYS, 52 oxcarbazepine ext-rel, 29 pegfilgrastim, 49 OXERVATE, 63 pegfilgrastim-apgf, 49 oxiconazole crm, 58 pegfilgrastim-bmez, 49 OXISTAT, 58 pegfilgrastim-cbqv, 49 OXSORALEN-ULTRA, 58 pegfilgrastim-jmdb, 49 OXTELLAR XR, 29 peginterferon alfa-2a, 52 oxybutynin, 48 peginterferon alfa-2b, 52 oxybutynin ext-rel, 48 peginterferon beta-1a, 34 oxybutynin gel, 48 PEGINTRON, 52 oxycodone, 11 pegloticase, 10 oxycodone concentrate 20 mg/mL, 11 pegvaliase-pqpz, 43 oxycodone ext-rel, 11

90

pegvisomant, 44 POLYTRIM, 61 PEMAZYRE, 19 pomalidomide, 18 pembrolizumab, 18 POMALYST, 18 pemetrexed, 17 ponatinib, 19 pemigatinib, 19 PORTRAZZA, 21 penbutolol, 25 posaconazole delayed-rel tabs, 13 penciclovir, 61 posaconazole susp, 14 penicillamine tabs, 51 potassium chloride ext-rel, 53 penicillin VK, 13 potassium chloride liquid, 53 PENTASA, 46 potassium chloride powder, 53 pentosan polysulfate sodium, 48 potassium citrate ext-rel, 48 pentostatin, 17 POTELIGEO, 22 pentoxifylline ext-rel, 50 PRADAXA, 48 perampanel, 29 pralatrexate, 17 PERCOCET, 11 pralsetinib, 19 PERFOROMIST, 55 PRALUENT, 25 perindopril, 22 pramipexole, 30 perindopril arginine/amlodipine, 23 pramipexole ext-rel, 30 PERJETA, 21 pramlintide, 36 permethrin 5%, 60 PRAMOSONE, 59 perphenazine, 31 pramoxine/hydrocortisone, 59 PERSERIS, 31 prasterone vaginal inserts, 44 pertuzumab, 21 prasugrel, 50 pertuzumab/trastuzumab/hyaluronidase-zzxf, 21 PRAVACHOL, 24 PEXEVA, 29 pravastatin, 24 pexidartinib, 19 prazosin, 23 phenazopyridine, 48 PRECOSE, 36 phenelzine, 29 PRED FORTE, 62 phenobarbital, 28 PRED MILD, 62 phenylephrine, 61 PRED-G, 62 phenytoin, 28 prednisolone, 42 phenytoin sodium extended, 28 prednisolone acetate 0.12%, 62 PHESGO, 21 prednisolone acetate 1%, 62 PHEXXI, 40 prednisolone phosphate 1%, 62 phytonadione, 53 prednisolone sodium phosphate, 42 PIFELTRO, 15 prednisolone sodium phosphate orally disintegrating tabs, 42 pilocarpine, 63 prednisolone syrup, 42 pilocarpine tabs, 47 prednisone, 42 PILOPINE HS GEL, 63 prednisone delayed-rel, 42 pimavanserin, 31 PREFEST, 41 pimecrolimus, 59 pregabalin, 32 pindolol, 25 PREGNYL, 42 pioglitazone, 37 PREMARIN, 41 pioglitazone/glimepiride, 37 PREMARIN crm, 41 pioglitazone/metformin, 37 PREMPHASE, 41 pioglitazone/metformin ext-rel, 37 PREMPRO, 41 piperacillin/tazobactam, 13 prenatal vitamins/docusate/folic acid, 53 PIQRAY, 19 prenatal vitamins/folic acid, 53 pirfenidone, 56 PRENATE ELITE, 53 piroxicam, 10 PREPOPIK, 46 pitavastatin, 24 PRESTALIA, 23 pitolisant, 34 PRETOMANID, 15 PLAQUENIL, 51 pretomanid tabs, 15 PLAVIX, 50 PREVIDENT, 61 plecanatide, 47 PREVYMIS, 15 PLEGRIDY, 34 PREZCOBIX, 14 PLEGRIDY PEN, 34 PREZISTA, 15 PLENVU, 46 PRIALT, 11 plerixafor, 50 PRIFTIN, 15 podofilox, 60 primaquine, 14 polatuzumab vedotin-piiq, 22 PRIMAXIN, 16 POLIVY, 22 primidone, 28 polymyxin B/bacitracin, 61 PRINIVIL, 22 polymyxin B/trimethoprim, 61 PRISTIQ, 29

91

PRIVIGEN, 52 QVAR REDIHALER, 56 PROAIR DIGIHALER, 55 R PROAIR HFA, 55 rabeprazole delayed-rel (except rabeprazole capsule sprinkle delayed- PROAIR RESPICLICK, 55 rel), 47 probenecid, 10 RADICAVA, 35 procarbazine, 21 raloxifene, 43 PROCARDIA XL, 25 raltegravir, 14 prochlorperazine, 45 ramelteon, 32 PROCRIT, 49 ramipril, 22 PROCTOFOAM-HC, 47 ramucirumab, 22 PROCYSBI, 44 RANEXA, 27 PROFILNINE, 49 ranibizumab, 63 progesterone vaginal inserts, 43 ranolazine ext-rel, 27 progesterone, micronized, 43 RAPAFLO, 47 PROGLYCEM, 42 RAPAMUNE, 53 PROGRAF, 53 rasagiline, 30 PROLASTIN-C, 54 rasburicase, 17 PROLENSA, 62 RASUVO, 51 PROLEUKIN, 20 RAVICTI, 44 PROLIA, 39 ravulizumab-cwvz, 50 PROMACTA, 50 RAYALDEE, 43 promethazine, 45, 54 RAYOS, 42 PROMETRIUM, 43 RAZADYNE ER, 29 propafenone ext-rel, 24 REBIF, 33 propantheline 15 mg, 45 REBIF REBIDOSE, 33 propranolol, 25 REBINYN, 49 propranolol ext-rel, 25 REBLOZYL, 50 propylthiouracil, 43 RECLAST, 39 PROSCAR, 47 RECOMBINATE, 49 protein C concentrate, human, 50 RECTIV, 47 PROTOPIC, 59 REGLAN, 45 protriptyline, 30 regorafenib, 19 PROVENTIL HFA, 55 REGRANEX, 61 PROVERA, 43 RELENZA, 16 PROVIGIL, 34 RELISTOR, 46 PROZAC, 29 RELPAX, 33 PULMICORT FLEXHALER, 56 relugolix, 18 PULMICORT RESPULES, 56 REMERON, 30 PULMOZYME, 55 REMICADE, 51 PURIXAN, 18 REMODULIN, 27 PYLERA, 47 RENAGEL, 43 pyrazinamide, 15 RENFLEXIS, 51 PYRIDIUM, 48 RENVELA, 43 pyridostigmine, 34 repaglinide, 37 pyridostigmine ext-rel tabs 180 mg, 34 REPATHA, 25 pyrimethamine, 14 reslizumab inj, 57 Q RESTASIS, 63 QBRELIS, 22 RESTORIL, 32 QDOLO, 11 RETACRIT, 49 QINLOCK, 19 retapamulin, 58 QTERN, 37 RETEVMO, 19 quazepam, 32 RETIN-A, 57 QUDEXY XR, 28 RETIN-A MICRO, 57 QUESTRAN/QUESTRAN LIGHT, 24 RETROVIR, 15 quetiapine, 31 REVATIO, 27 quetiapine ext-rel, 31 REVCOVI, 44 QUILLICHEW ER, 32 revefenacin inhalation solution, 54 QUILLIVANT XR, 32 REVLIMID, 20 quinapril, 22 REXULTI, 31 quinapril/hydrochlorothiazide, 23 REYATAZ, 15 quinidine gluconate ext-rel, 24 Rho (D) immune globulin, 52 QUTENZA, 60 RHOFADE, 60 QVAR, 56 RHOGAM, 52

92

RHOGAM PLUS, 52 romosozumab-aqqg, 39 RHOPHYLAC, 52 ropinirole, 30 RHOPRESSA, 63 ropinirole ext-rel, 30 RIABNI, 21 rosiglitazone, 37 RIASTAP, 49 rosuvastatin, 24 ribavirin caps, 16 rosuvastatin capsules, 24 ribavirin caps - Ribasphere, 16 rotigotine transdermal, 30 ribavirin tabs, 16 ROWASA, 46 ribociclib, 19 ROXICODONE, 11 ribociclib + letrozole, 19 ROZEREM, 32 RIDAURA, 51 ROZLYTREK, 19 rifabutin, 16 RUBRACA, 21 RIFADIN, 15 rucaparib, 21 rifampin, 15 RUCONEST, 51 rifampin/isoniazid/pyrazinamide, 15 rufinamide, 28 rifamycin delayed-rel, 13 RUKOBIA, 14 rifapentine, 15 RUXIENCE, 21 RIFATER, 15 ruxolitinib, 19 rifaximin, 17 RUZURGI, 35 rilonacept, 52 RYBELSUS, 36 rilpivirine, 15 RYDAPT, 19 RILUTEK, 35 RYTARY, 30 riluzole, 35 RYTHMOL SR, 24 rimabotulinumtoxinB, 35 S rimantadine, 16 SABRIL, 28 rimegepant, 33 sacituzumab govitecan-hziy, 22 rimexolone, 62 sacubitril/valsartan, 26 RINVOQ ER, 51 safinamide, 30 riociguat, 27 SAFYRAL, 39 RIOMET IR, 36 SAIZEN, 42 ripretinib, 19 SALAGEN, 47 risankizumab-rzaa, 51 salmeterol xinafoate, 55 risdiplam, 35 SAMSCA, 44 risedronate, 38 SANCUSO, 45 risedronate delayed-rel, 39 SANDIMMUNE, 53 RISPERDAL, 31 SANDOSTATIN, 44 RISPERDAL CONSTA, 31 SANDOSTATIN LAR, 44 RISPERDAL M-TABS, 31 SAPHRIS, 31 risperidone, 31 sapropterin, 43 risperidone ext-rel inj, 31 saquinavir mesylate, 15 risperidone long-acting inj, 31 SARCLISA, 20 risperidone orally disintegrating tabs, 31 sarecycline, 13 RITALIN, 32 sargramostim, 49 RITALIN LA, 32 sarilumab, 51 ritonavir tabs, 15 satralizumab-mwge, 51 RITUXAN, 22 SAVELLA, 32 RITUXAN HYCELA, 22 scopolamine, 63 rituximab, 22 scopolamine transdermal, 45 rituximab/hyaluronidase human, 22 SEASONIQUE, 40 rituximab-abbs, 21 sebelipase alfa, 44 rituximab-arrx, 21 secnidazole, 17 rituximab-pvvr, 21 secukinumab, 58 rivaroxaban, 48 SEEBRI NEOHALER, 54 rivastigmine, 29 /EE ring, 40 rivastigmine transdermal, 29 SEGLUROMET, 37 RIXUBIS, 49 selegiline caps, 30 rizatriptan, 33 selegiline orally disintegrating tabs, 30 ROCALTROL, 43 selegiline transdermal, 29 ROCEPHIN, 12 selexipag, 27 ROCKLATAN, 63 selinexor, 22 roflumilast, 56 selpercatinib, 19 rolapitant, 45 selumetinib, 19 romidepsin, 20 SELZENTRY, 14 romiplostim, 50

93

semaglutide, 36 SOMAVERT, 44 SENSIPAR, 38 sonidegib, 22 SEREVENT DISKUS, 55 SOOLANTRA, 60 SERNIVO, 60 sorafenib, 19 SEROQUEL, 31 SORILUX, 58 SEROQUEL XR, 31 sotalol, 24 SEROSTIM, 42 sotalol AF, 24 sertaconazole, 58 SOVALDI, 16 sertraline, 29 spinosad, 60 sevelamer carbonate, 43 SPIRIVA, 54 sevelamer HCl, 43 SPIRIVA RESPIMAT, 54 SEVENFACT, 50 spironolactone, 23 SEYSARA, 13 spironolactone/hydrochlorothiazide, 26 SIGNIFOR, 44 SPORANOX, 13 SIKLOS, 22 SPRAVATO, 30 sildenafil, 27 SPRIX, 10 SILENOR, 32 SPRYCEL, 19 SILIQ, 51 STALEVO, 30 silodosin, 47 STARLIX, 37 SILVADENE, 58 stavudine, 15 , 58 STEGLATRO, 37 SIMBRINZA, 63 STEGLUJAN, 38 SIMPONI 100 mg, 51 STELARA, 58 SIMPONI 50 mg, 51 STELARA SUBCUTANEOUS, 51 simvastatin, 24 STIMATE, 49 SINEMET, 30 STIOLTO RESPIMAT, 54 SINGULAIR, 56 stiripentol, 29 siponimod, 34 STIVARGA, 19 sirolimus, 53 STRATTERA, 31 SIRTURO, 15 STRENSIQ, 44 sitagliptin phosphate, 36 streptozocin, 17 sitagliptin/metformin, 36 STRIANT, 35 sitagliptin/metformin ext-rel, 36 STRIBILD, 14 SIVEXTRO, 17 STRIVERDI RESPIMAT, 55 SKYLA, 40 SUBLOCADE, 34 SKYRIZI, 51 SUBOXONE FILM, 34 SLYND, 40 SUBSYS, 11 sodium ferric gluconate inj, 53 sucralfate, 47 sodium fluoride, 61 sucroferric oxyhydroxide, 43 sodium hyaluronate, 11, 12 SULAR, 25 sodium oxybate, 34 sulconazole, 58 sodium phenylbutyrate, 44 sulfacetamide sodium, 57 sodium phosphates, 46 sulfacetamide soln 10%, 61 sodium picosulfate/magnesium oxide/citric acid, 46 sulfacetamide/prednisolone acetate oint 10%/0.2%, 62 sodium polystyrene sulfonate, 43 sulfacetamide/prednisolone phosphate 10%/0.25%, 61 sodium sulfate/magnesium sulfate/potassium chloride, 46 sulfamethoxazole/trimethoprim, 16 sodium sulfate/potassium sulfate/magnesium sulfate, 46 sulfamethoxazole/trimethoprim DS, 16 sodium zirconium cyclosilicate, 43 SULFAMYLON, 58 sofosbuvir, 16 sulfasalazine, 46 sofosbuvir/velpatasvir, 16 sulfasalazine delayed-rel, 46 sofosbuvir/velpatasvir/voxilaprevir, 16 sulindac, 10 SOFTCLIX LANCET DEVICE, 38 sumatriptan, 33 SOFTCLIX LANCETS, 38 sumatriptan nasal powder, 33 SOFTTOUCH LANCET DEVICE, 38 sumatriptan nasal spray, 33 SOFTTOUCH LANCETS, 38 sumatriptan/naproxen sodium, 33 SOLESTA, 47 sunitinib, 19 solifenacin, 48 SUNOSI, 34 SOLIQUA, 36 SUPARTZ FX, 11 SOLIRIS, 50 SUPPRELIN LA, 44 SOLODYN, 13 SUPRAX, 12 SOLOSEC, 17 SUPREP, 46 solriamfetol, 34 SUSTIVA, 15 somatropin, 42 SUSTOL, 45 SOMATULINE DEPOT, 44 SUTAB, 46

94

SUTENT, 19 tbo-filgrastim, 49 suvorexant, 32 TECENTRIQ, 21 SYMBICORT, 56 TECFIDERA, 33 SYMDEKO, 55 tedizolid, 17 SYMFI, 14 teduglutide, 47 SYMFI LO, 14 TEFLARO, 13 SYMJEPI, 54 tegaserod maleate, 46 SYMLINPEN, 36 TEGRETOL, 28 SYMTUZA, 14 TEGRETOL-XR, 28 SYNAGIS, 16 TEGSEDI, 44 SYNALAR, 59 TEKTURNA, 26 SYNAREL, 40 TEKTURNA HCT, 26 SYNDROS, 47 telavancin, 17 SYNJARDY, 37 telbivudine, 16 SYNJARDY XR, 37 telmisartan, 23 SYNRIBO, 21 telmisartan/hydrochlorothiazide, 23 SYNTHROID, 43 telotristat, 47 SYNVISC, 11 temazepam, 32 SYNVISC-ONE, 11 TEMIXYS, 14 SYPRINE, 44 TEMODAR caps, 17 T TEMODAR inj, 17 TEMOVATE, 60 TABLOID, 17 temozolomide caps, 17 TABRECTA, 19 temozolomide inj, 17 TACHOSIL, 61 temsirolimus, 18 tacrolimus, 53, 59 teniposide, 20 tacrolimus ext-rel, 53 tenofovir alafenamide, 16 tadalafil 2.5 mg, 5 mg, 47 tenofovir disoproxil fumarate tabs 300 mg, 15 tadalafil tabs 20 mg, 27 TENORMIN, 25 tadalafil tabs 20 mg - Alyq, 27 TEPADINA, 17 tafamidis, 26 TEPEZZA, 63 tafamidis meglumine, 26 teprotumumab-trbw for IV soln, 63 tafenoquine, 14 terazosin, 23 TAFINLAR, 19 terbinafine tabs, 13 tafluprost, 63 terbutaline, 55 TAGRISSO, 19 terconazole crm, 48 TAKHZYRO, 52 terconazole supp 80 mg, 48 talazoparib, 21 teriflunomide, 34 TALICIA, 47 teriparatide, 39 taliglucerase alfa, 44 tesamorelin, 44 talimogene laherparepvec, 21 TESSALON, 55 TALTZ, 51 TESTIM, 35 TALZENNA, 21 TESTOPEL, 35 TAMIFLU, 16 testosterone buccal, 35 tamoxifen, 18 , 35 tamsulosin, 47 testosterone enanthate, 35 TAPAZOLE, 43 testosterone enanthate auto-injector, 35 tapentadol, 11 testosterone gel, 35 tapentadol ext-rel, 11 testosterone pellets, 35 TARGRETIN caps, 20 testosterone soln, 35 TARGRETIN gel, 21 testosterone transdermal, 35 TARKA, 23 testosterone undecanoate inj, 35 TASIGNA, 19 tetrabenazine, 33 tasimelteon, 32 tetracycline, 13 tavaborole sol 5%, 58 tezacaftor/ivacaftor + ivacaftor, 55 TAVALISSE, 50 thalidomide, 20 TAYTULLA, 39 THALOMID, 20 tazarotene crm 0.05%, gel 0.05%, 0.1%, 57 THEO-24, 57 tazarotene crm 0.1%, 57 theophylline ext-rel caps, 57 tazarotene foam 0.1%, 57 theophylline ext-rel tabs, 57 tazarotene lotion 0.045%, 57 theophylline liquid, 57 tazemetostat, 19 thioguanine, 17 TAZORAC, 57 THIOLA, 48 TAZVERIK, 19 THIOLA EC, 48

95

thioridazine, 31 trabectedin, 17 thiotepa, 17 TRACLEER, 27 thiothixene, 31 tramadol (except 100 mg tabs), 11 THYROGEN, 44 tramadol ext-rel, 11 thyroid, 43 tramadol oral solution, 11 thyrotropin alfa, 44 tramadol/acetaminophen, 11 tiagabine, 28 trametinib, 19 TIAZAC, 26 trandolapril, 22 TIBSOVO, 22 trandolapril/verapamil ext-rel, 23 ticagrelor, 50 tranexamic acid, 50 TICE BCG, 21 TRANSDERM SCOP, 45 TIGAN, 45 TRANXENE T-TAB, 28 tigecycline, 16 tranylcypromine, 29 TIGLUTIK, 35 trastuzumab, 22 TIKOSYN, 24 trastuzumab/hyaluronidase-oysk, 22 tildrakizumab-asmn, 51 trastuzumab-anns, 21 timolol hemihydrate, 62 trastuzumab-dkst, 21 timolol maleate, 62 trastuzumab-dttb, 21 timolol maleate gel, 62 trastuzumab-pkrb, 21 TIMOPTIC, 62 trastuzumab-qyyp, 21 TIMOPTIC-XE, 62 TRAVATAN Z, 63 tinidazole, 16 travoprost, 63 tiopronin, 48 TRAZIMERA, 21 tiopronin delayed-rel, 48 trazodone, 30 tiotropium, 54 TREANDA, 17 tiotropium/olodaterol, 54 TRELEGY ELLIPTA, 54 tipranavir, 15 TRELSTAR, 18 tirbanibulin, 58 TRELSTAR DEPOT, 18 tirofiban inj, 50 TRELSTAR LA, 18 TIROSINT, 43 TREMFYA, 58 TIVICAY, 14 treprostinil, 27 TOBI, 55 treprostinil ext-rel, 27 TOBI PODHALER, 55 TRESIBA, 37 TOBRADEX OINTMENT, 61 tretinoin, 57 TOBRADEX SUSPENSION, 61 tretinoin gel microsphere, 57 tobramycin, 61 TRETTEN, 49 tobramycin inhalation powder, 55 TREXIMET, 33 tobramycin inhalation soln, 55 triamcinolone acetonide crm 0.5%, 60 tobramycin/dexamethasone oint 0.3%/0.1%, 61 triamcinolone acetonide crm, lotion 0.025%, 59 tobramycin/dexamethasone susp 0.3%/0.1%, 61 triamcinolone acetonide crm, lotion, oint 0.1%, 59 tobramycin/loteprednol, 62 triamcinolone acetonide topical spray, 60 TOBREX, 61 triamcinolone paste, 61 tocilizumab, 51 triamterene/hydrochlorothiazide, 26 tofacitinib, 51 triamterene/hydrochlorothiazide 37.5/25, 26 tofacitinib ext-rel, 51 triamterene/hydrochlorothiazide 50/25, 26 TOLAK, 58 TRIBENZOR, 24 tolcapone, 30 TRICOR, 24 tolterodine, 48 trientine, 44 tolterodine ext-rel, 48 triethanolamine polypeptide oleate, 64 tolvaptan, 44 trifarotene cream 0.005%, 57 TOPAMAX, 28 trifluoperazine, 31 TOPICORT, 59 trifluridine, 62 topiramate, 28 trifluridine/tipiracil, 22 topiramate ext-rel, 28, 29 triheptanoin, 53 topotecan, 20 trihexyphenidyl, 30 topotecan inj, 20 TRIJARDY XR, 38 TOPROL-XL, 25 TRIKAFTA, 55 toremifene, 18 TRILEPTAL, 28 TORISEL, 18 TRILIPIX, 24 torsemide, 26 trimethobenzamide, 45 TOSYMRA, 33 trimethoprim, 16 TOTECT, 20 TRINTELLIX, 29 TOUJEO, 37 TRIPTODUR, 45 TOVIAZ, 48 triptorelin pamoate, 18, 45

96

TRISENOX, 20 VALTREX, 16 TRIUMEQ, 14 VANCOCIN, 16 TRIVISC, 11 vancomycin caps, 16 TRIZIVIR, 14 vancomycin oral soln, 17 TRODELVY, 22 vandetanib, 19 TROGARZO, 15 VANTAS, 18 TROKENDI XR, 29 varenicline, 35 trospium, 48 varicella zoster immune globulin, 52 trospium ext-rel, 48 VARIZIG, 52 TRULANCE, 47 VARUBI, 45 TRULICITY, 36 VASCEPA, 25 TRUSOPT, 62 VASERETIC, 23 TRUVADA, 14 VASOTEC, 22 TRUXIMA, 21 VECAMYL, 27 tucatinib, 19 VECTIBIX, 21 TUDORZA PRESSAIR, 54 VECTICAL, 58 TUKYSA, 19 vedolizumab, 46 TURALIO, 19 velaglucerase alfa, 44 TWIRLA, 40 VELCADE, 20 TWYNSTA, 23 VELETRI, 27 TYBOST, 14 VELPHORO, 43 TYGACIL, 16 VELTASSA, 43 TYKERB, 18 VELTIN, 57 TYMLOS, 39 VEMLIDY, 16 TYSABRI, 34 vemurafenib, 19 TYVASO, 27 VENCLEXTA, 21 TYZEKA, 16 venetoclax, 21 U venlafaxine, 29 venlafaxine ext-rel, 29 UDENYCA, 49 venlafaxine ext-rel tabs, 29 ULORIC, 10 VENOFER, 53 ULTOMIRIS, 50 VENTAVIS, 27 ULTRAM, 11 VENTOLIN HFA, 55 ULTRAM ER, 11 VERAMYST, 56 ULTRAVATE, 60 verapamil, 26 umeclidinium bromide, 54 verapamil ext-rel, 26 umeclidinium/vilanterol, 54 VERDESO, 59 UNASYN, 13 verteporfin, 63 upadacitinib, 51 VERZENIO, 18 UPNEEQ, 63 VESICARE LS, 48 UPTRAVI, 27 vestronidase alfa-vjbk, 44 , 44 VEXOL, 62 urine test strips, 38 VFEND, 13 UROCIT-K, 48 VIBATIV, 17 URSO, 45 VIBERZI, 46 URSO FORTE, 45 VIBRAMYCIN, 13 ursodiol, 45 VICTOZA, 36 ustekinumab, 51, 58 VIDAZA, 20 UTIBRON NEOHALER, 54 vigabatrin, 28 V vigabatrin powder - Vigadrone, 28 VAGIFEM, 41 VIGAMOX, 61 valacyclovir, 16 VIIBRYD, 29 valbenazine, 35 vilazodone, 29 VALCHLOR, 17 VILTEPSO, 35 VALCYTE, 15 viltolarsen, 35 valganciclovir, 15 VIMIZIM, 44 VALIUM, 28 VIMPAT, 28 valproic acid, 28 vinblastine, 20 valrubicin, 20 vincristine, 20 valsartan, 23 vincristine sulfate liposomal, 21 valsartan/hydrochlorothiazide, 23 vinorelbine, 20 VALSTAR, 20 VIOKACE, 46 VALTOCO, 28 VIRACEPT, 15 VIRAMUNE, 15

97

VIRAMUNE XR, 15 XGEVA, 39 VIREAD, 15 XHANCE, 56 vismodegib, 21 XIAFLEX, 61 VISTARIL, 28, 54 XIFAXAN, 17 VISTIDE, 15 XIGDUO XR, 37 VISUDYNE, 63 XIIDRA, 63 VITAFOL-OB, 53 XIMINO, 57 VITRAKVI, 19 XOFLUZA, 16 VIVELLE-DOT, 41 XOLAIR, 56 VIVITROL, 34 XOPENEX CONCENTRATE, 55 VIZIMPRO, 19 XOPENEX HFA, 55 voclosporin, 53 XOPENEX SOLUTION, 55 VOGELXO, 35 XOSPATA, 19 von Willebrand factor, recombinant, 49 XPOVIO, 22 VONVENDI, 49 XTAMPZA ER, 11 vorapaxar, 50 XTANDI, 18 VORAXAZE, 21 XULTOPHY, 36 voriconazole, 13 XURIDEN, 44 vorinostat, 21 XYLOCAINE, 60 vortioxetine, 29 XYNTHA, 49 VOSEVI, 16 XYNTHA SOLOFUSE, 49 VOTRIENT, 19 XYOSTED, 35 voxelotor, 50 XYREM, 34 VPRIV, 44 XYWAV, 34 VRAYLAR, 31 Y VUMERITY, 34 YASMIN, 39 VUSION, 58 YAZ, 39 VWF, human/factor VIII complex, 49 YERVOY, 21 VYEPTI, 33 YONDELIS, 17 VYNDAMAX, 26 YONSA, 18 VYNDAQEL, 26 YUPELRI, 54 VYONDYS 53, 35 VYTORIN, 24 Z VYVANSE, 32 zafirlukast, 56 VYZULTA, 63 zaleplon, 32 W ZALTRAP, 21 zanamivir, 16 WAKIX, 34 ZANOSAR, 17 warfarin, 48 zanubrutinib, 20 WELCHOL, 24 ZARONTIN, 28 WELLBUTRIN SR, 30 ZARXIO, 49 WELLBUTRIN XL, 30 ZAVESCA, 44 WILATE, 49 ZEJULA, 21 WINRHO SDF, 52 ZELAPAR, 30 WYNZORA, 58 ZELBORAF, 19 X ZELNORM, 46 XADAGO, 30 ZEMAIRA, 54 XALATAN, 63 ZEMPLAR, 43 XALKORI, 19 ZENPEP, 46 XANAX, 28 ZENZEDI, 31 XANAX XR, 28 ZEPATIER, 16 XARELTO, 48 ZEPOSIA, 34 XCOPRI, 28 ZEPZELCA, 17 XELJANZ, 51 ZESTORETIC, 23 XELJANZ XR, 51 ZESTRIL, 22 XELODA, 17 ZETIA, 24 XELPROS, 63 ZIAC, 25 XEMBIFY, 52 ZIAGEN, 15 XENAZINE, 33 ZIAGEN soln, 15 XENLETA, 13 ZIANA, 57 XEOMIN, 35 ziconotide, 11 XEPI, 58 zidovudine, 15 XERMELO, 47 ZIEXTENZO, 49

98

ZILXI, 60 ZOLPIMIST, 32 , 53 ZOMACTON, 42 ZINPLAVA, 52 ZOMIG, 33 ZIOPTAN, 63 ZOMIG/ZOMIG-ZMT, 33 ziprasidone, 31 ZONALON, 60 ZIRABEV, 21 ZONEGRAN, 28 ZIRGAN, 62 zonisamide, 28 ZITHROMAX, 13 ZONTIVITY, 50 ziv-aflibercept, 21 ZORBTIVE, 42 ZOCOR, 24 ZORTRESS 0.25 mg, 0.5 mg, 0.75 mg, 53 ZOFRAN, 45 ZORTRESS 1 mg, 53 ZOHYDRO ER, 11 ZOSYN, 13 ZOKINVY, 44 ZOVIRAX, 16, 60 ZOLADEX, 18 ZUBSOLV, 34 zoledronic acid 4 mg/100 mL, 39 ZYCLARA, 60 zoledronic acid 5 mg/100 mL, 39 ZYDELIG, 19 ZOLINZA, 21 ZYKADIA, 19 zolmitriptan, 33 ZYLET, 62 zolmitriptan nasal spray, 33 ZYLOPRIM, 10 ZOLOFT, 29 ZYPREXA RELPREVV, 31 zolpidem, 32 ZYPREXA/ZYPREXA ZYDIS, 31 zolpidem ext-rel, 32 ZYTIGA, 18 zolpidem spray, 32 ZYVOX, 16 zolpidem sublingual, 32

99