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Effective October 2021

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All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. XB0001338-50-17 Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost. How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers. How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs. Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage. Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary . An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug. Prior authorization and step therapy requests are considered based on coverage criteria requirements approved by the P&T Committee. To request review of an exception to Kaiser Permanente requirements for coverage of prescription drugs, you or your prescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request an exception. If the evidence your prescriber provides meets medical necessity, an exception may be approved. Exceptions to required therapy that may be approved include: contraindications, clinical factors associated with adverse reactions, clinical factors reducing effect, other risks of clinical harm, and barriers to compliance with clinical care. Your prescriber may also request temporary coverage while the exception request is being processed. Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share. The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 60 days prior to the effective date.

Drug Formulary Tiers

Tier Description Tier 1 Preferred generic Tier 2 Preferred brand Tier 3 Non-preferred

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:  Preferred blood glucose strips: o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required  Disposable and needles  Lancing devices and lancets Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions. To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order Pharmacy PO Box 34383 Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630-4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non- preferred contraceptive will be covered in full.

Excluded Prescription Products for Medications that have Over-The-Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), (Rhinocort Aqua), nasal spray (Nasacort), and propionate nasal spray (Flonase).

Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage. How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.

The most current drug formulary is available at www.kp.org/wa/formulary. Kaiser Foundation Health Plan of Washington Table of Contents Analgesics - Drugs for Pain and Inflammation ...... 11 Analgesics - Drugs for Pain ...... 12 Anesthetics ...... 14 Anti-Addiction / Substance Abuse Treatment Agents...... 15 Antibacterials ...... 16 Anticoagulants ...... 18 Anticonvulsants - Drugs for Seizures ...... 19 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia ...... 20 Antidepressants ...... 21 Antiemetics - Drugs for Nausea and Vomiting ...... 22 Antifungals ...... 23 Antigout Agents ...... 24 Anti-inflammatory Agents ...... 24 Antimigraine Agents ...... 24 Antimyasthenic Agents ...... 24 Antimycobacterials ...... 25 Antineoplastics - Drugs for Cancer ...... 25 Antiparasitics ...... 27 Antiparkinson Agents ...... 28 Antiplatelets ...... 28 Antipsychotics - Drugs for Mood Disorders ...... 29 Antivirals ...... 30 Anxiolytics - Drugs for Anxiety ...... 32 Bipolar Agents - Drugs for Mood Disorders ...... 32 Blood Products and Modifiers - Drugs for Blood Disorders ...... 32 Cardiovascular Agents - Drugs for Heart and Circulation Conditions ...... 33 Central Nervous System Agents - Drugs for Attention Deficit Disorder ...... 38 Central Nervous System Agents - Drugs for ...... 39 Central Nervous System Agents - Miscellaneous ...... 39 Dental and Oral Agents - Drugs for Mouth and Throat Conditions ...... 39 Dermatological Agents - Drugs for Skin Conditions ...... 40 - Antidiabetic Agents ...... 46 Diabetes - Glucose Monitoring ...... 48 Diabetes - Glycemic Agents ...... 49 Diabetes - ...... 49

9 Electrolytes / Minerals / Metals / Vitamins ...... 51 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ...... 52 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ...... 53 Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment ...... 54 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ...... 55 Genitourinary Agents - Drugs for Prostate Conditions ...... 56 Hormonal Agents - Adrenal ...... 56 Hormonal Agents - Men's Health ...... 57 Hormonal Agents - Osteoporosis ...... 58 Hormonal Agents - Pituitary ...... 58 Hormonal Agents - ...... 59 Hormonal Agents - Sex Hormones and Birth Control ...... 59 Hormonal Agents - Thyroid ...... 63 Immunological Agents - Drugs for Immune System Stimulation or Suppression ...... 63 Immunological Agents - Drugs for Vaccination ...... 65 Inflammatory Bowel Disease Agents ...... 66 Metabolic Bone Disease Agents - Drugs for Osteoporosis ...... 67 Metabolic Bone Disease Agents - Other ...... 67 Miscellaneous Therapeutic Agents ...... 67 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ...... 70 Ophthalmic Agents - Drugs for Glaucoma ...... 71 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ...... 72 Otic Agents - Drugs for Ear Conditions ...... 73 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ...... 74 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions ...... 75 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ...... 77 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ...... 77 Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ...... 77 Sleep Disorder Agents ...... 78 Stimulation or Suppression ...... 78 Index of Drugs ...... 80

10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for Pain and 3 INDOCIN Inflammation indomethacin er 1 ARTHROTEC 3 indomethacin oral 1 CAMBIA 3 PA 25 mg, 50 mg CATAFLAM 3 ketoprofen er 3 CELEBREX 3 ketoprofen oral 3 celecoxib oral 1 ketorolac tromethamine 15 1 DAYPRO 3 mg/ml DICLOFENAC CAP 3 PA ketorolac tromethamine 35MG 1 intramuscular DICLOFENAC PATCH 3 KETOROLAC 1.3% TROMETHAMINE 3 diclofenac potassium 1 NASAL diclofenac sodium er 1 ketorolac tromethamine 3 diclofenac sodium oral 3 external 1 % ketorolac tromethamine diclofenac sodium solution 30 mg/ml 1 3 external solution injection diclofenac sodium oral 1 KETOROLAC TROMETHAMINE 3 diclofenac-misoprostol 3 SOLUTION 30 MG/ML DICLOFONO 3 INJECTION diflunisal oral 1 LICART 3 DUEXIS 3 PA; QL LODINE 3 meclofenamate sodium EC-NAPROSYN 3 1 oral ec-naproxen 3 mefenamic acid oral 3 etodolac 1 meloxicam oral capsule 3 etodolac er 3 meloxicam oral 1 FELDENE 3 MOBIC 3 fenoprofen calcium oral 3 nabumetone oral 1 fenortho 3 NALFON 3 FLECTOR 3 NAPRELAN 3 flurbiprofen oral 1 NAPROSYN 3 GABAPENTIN- 3 NAPROXEN CMPD KIT naproxen oral 1 ibuprofen oral suspension naproxen oral tablet 1 3 100 mg/5ml naproxen oral tablet 3 ibuprofen oral tablet 400 delayed release 1 mg, 600 mg, 800 mg naproxen sodium er oral ibuprofen-famotidine 3 PA; QL tablet extended release 3 24 hour 375 mg, 500 mg Effective Date: 10/01/2021 11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier naproxen sodium oral buprenorphine hcl buccal 1 tablet 275 mg, 550 mg film 150 mcg, 300 mcg, 3 QL naproxen-esomeprazole 3 PA; QL 450 mcg, 600 mcg, 75 mcg, 750 mcg, 900 mcg oxaprozin 3 butalbital-acetaminophen 3 PENNSAID 3 PA capsule 50-300 mg oral piroxicam oral 1 BUTALBITAL- ACETAMINOPHEN QMIIZ ODT ORAL 3 TABLET DISPERSIBLE 3 CAPSULE 50-300 MG 15 MG, 7.5 MG ORAL butalbital-acetaminophen RELAFEN 3 3 oral tablet RELAFEN DS 3 PA butalbital-apap-caff-cod 3 QL salsalate oral 1 butalbital-apap-caffeine 3 SPRIX 3 oral capsule sulindac oral 1 butalbital-apap-caffeine 1 TIVORBEX 3 oral tablet butalbital-asa-caff- VIMOVO 3 PA; QL 3 QL codeine VIVLODEX 3 butalbital-aspirin-caffeine 1 ZIPSOR 3 PA butorphanol tartrate nasal 3 QL ZORVOLEX 3 PA BUTRANS 3 PA; QL ZYNRELEF 3 carisoprodol-aspirin- 3 PA Analgesics - Drugs for Pain codeine acetaminophen-codeine 1 QL codeine sulfate 1 QL acetaminophen-codeine CONZIP 3 ST; QL 1 QL #2 DILAUDID ORAL 3 QL acetaminophen-codeine 1 QL endocet 1 QL #3 ESGIC 3 acetaminophen-codeine 1 QL fentanyl citrate buccal #4 3 PA; QL lozenge on a handle ACTIQ 3 PA; QL FENTANYL CITRATE 3 3 PA; QL ALLZITAL BUCCAL TABLET APADAZ 3 QL fentanyl apap-caff-dihydrocodeine 3 QL patch 72 hour 100 ascomp-codeine 3 QL mcg/hr, 12 mcg/hr, 25 1 PA; QL mcg/hr, 50 mcg/hr, 75 bac 1 mcg/hr BELBUCA 3 PA; QL fentanyl transdermal BENZHYDROCODONE- patch 72 hour 37.5 3 QL 3 PA; QL ACETAMINOPHEN mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr BUPAP 3 FENTORA 3 PA; QL buprenorphine 3 PA; QL FIORICET 3 Effective Date: 10/01/2021 12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FIORICET/CODEINE 3 QL sulfate er beads 3 ST; QL hydrocodone bitartrate er 3 PA; QL morphine sulfate er oral hydrocodone- capsule extended release 3 PA; QL acetaminophen oral 3 QL 24 hour solution 10-325 mg/15ml morphine sulfate er oral 1 ST; QL hydrocodone- tablet extended release acetaminophen oral morphine sulfate oral 1 QL solution 2.5-108 mg/5ml, 1 QL morphine sulfate rectal 1 QL 5-217 mg/10ml, 7.5-325 mg/15ml MS CONTIN 3 ST; QL hydrocodone- NALOCET 3 QL acetaminophen oral tablet NUCYNTA 3 PA; QL 3 QL 10-300 mg, 5-300 mg, NUCYNTA ER 3 ST; QL 7.5-300 mg OXAYDO 3 QL hydrocodone- acetaminophen oral tablet OXYCODONE HCL ER 2 ST; QL 1 QL 10-325 mg, 5-325 mg, oxycodone hcl oral 3 QL 7.5-325 mg capsule hydrocodone-ibuprofen 3 QL oxycodone hcl oral 1 QL hydromorphone hcl er 3 ST; QL concentrate 100 mg/5ml oxycodone hcl oral hydromorphone hcl oral 1 QL 1 QL solution hydromorphone hcl rectal 1 QL oxycodone hcl oral tablet 1 QL HYSINGLA ER 3 PA; QL OXYCODONE- LAZANDA 3 PA; QL ACETAMINOPHEN 3 ST; QL levorphanol tartrate oral 1 PA; QL ORAL SOLUTION LORTAB 3 QL OXYCODONE- meperidine hcl oral tablet 3 QL ACETAMINOPHEN ORAL TABLET 10-300 3 QL methadone hcl intensol 3 ST; QL MG, 2.5-300 MG, 5-300 methadone hcl oral MG 3 ST; QL concentrate oxycodone- methadone hcl oral acetaminophen oral tablet 1 ST; QL 1 QL solution 10-325 mg, 2.5-325 mg, methadone hcl oral tablet 1 ST; QL 5-325 mg, 7.5-325 mg methadone hcl oral tablet OXYCONTIN 2 ST; QL 1 ST; QL soluble oxymorphone hcl 3 QL methadose oral oxymorphone hcl er 3 ST; QL 3 ST; QL concentrate 10 mg/ml pentazocine-naloxone hcl 3 QL methadose oral tablet 1 ST; QL PERCOCET 3 QL soluble PROLATE ORAL 3 ST; QL methadose sugar-free 3 ST; QL SOLUTION morphine sulfate PROLATE ORAL 3 QL (concentrate) oral solution 1 QL TABLET 100 mg/5ml, 20 mg/ml QDOLO 3 PA; QL

Effective Date: 10/01/2021 13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ROXICODONE 3 QL LEVATIO 3 SUBSYS 3 PA; QL LIDO BDK 3 tencon 3 lidocaine external 3 tramadol hcl er (biphasic) 3 ST; QL ointment 5 % lidocaine external patch 5 TRAMADOL HCL ER 1 ORAL CAPSULE % 3 ST; QL EXTENDED RELEASE lidocaine hcl (pf) injection 3 24 HOUR solution 0.5 %, 1.5 % tramadol hcl er oral tablet lidocaine hcl (pf) injection 3 ST; QL 1 extended release 24 hour solution 1 %, 2 % tramadol hcl ir 1 QL lidocaine hcl external 3 tramadol-acetaminophen 1 QL 3 % TREZIX 3 QL LIDOCAINE HCL EXTERNAL CREAM 4.12 3 ULTRACET 3 QL % ULTRAM 3 QL lidocaine hcl external 3 PA VTOL LQ 3 XTAMPZA ER 3 ST; QL lidocaine hcl external 3 solution ZEBUTAL 3 lidocaine hcl injection Anesthetics 1 solution 0.5 % 1ST MEDX-PATCH/ LIDOCAINE HCL LIDOCAINE EXTERNAL 3 INJECTION SOLUTION PATCH 4-0.0375-5-20 % PREFILLED 10 3 7T LIDO 3 MG/ML, 100 MG/5ML, 200 MG/10ML, 60 AGONEAZE 3 MG/3ML 3 ANODYNE LPT LIDOCAINE HCL ASTERO 3 SOLUTION 1 % 3 INJECTION COCAINE HCL NASAL 3 lidocaine hcl solution 1 % 3 1 CRYODOSE TA injection DERMACINRX LIDOGEL 3 LIDOCAINE HCL EHA 3 SOLUTION 2 % 3 INJECTION ethyl chloride 3 lidocaine hcl solution 2 % 1 FLEXIN 3 injection GEBAUERS PAIN EASE 3 lidocaine hcl 1 GEBAUERS SPRAY AND urethral/mucosal 3 STRETCH LIDOCAINE HCL- 3 GEN7T 3 TETRACAINE HCL glydo 1 lidocaine-epinephrine injection solution 1 %- 3 GOPRELTO 3 1:100000 LDO PLUS 3 lidocaine-prilocaine 1 Effective Date: 10/01/2021 14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LIDOCANNA 3 ZTLIDO 3 Anti-Addiction / Substance Abuse LIDODERM 3 Treatment Agents LIDOMAR 3 acamprosate calcium 1 lidopin external cream 3 3 % APO-VARENICLINE 2 LIDOPRIL 3 BUNAVAIL 3 QL buprenorphine hcl LIDOPRIL XR 3 1 QL sublingual LIDO-PRILO CAINE 3 PACK buprenorphine hcl- naloxone hcl sublingual 3 QL LIDORX 3 PA film LIDO-SORB 3 PA buprenorphine hcl- LIDOTHOL EXTERNAL 3 naloxone hcl sublingual 1 QL PATCH tablet sublingual LIDOTRAL 3 bupropion hcl er ( 1 LIVIXIL PAK 3 det) 2 LYDEXA 3 CHANTIX CHANTIX CONTINUING NUMBRINO 3 2 MONTH PAK premium lidocaine 3 CHANTIX STARTING 2 PRILOLID 3 MONTH PAK PRILOVIX 3 disulfiram oral 1 PRILOVIX LITE 3 goodsense nicotine mouth/ 4 2 3 PRILOVIX LITE PLUS mg 3 PRILOVIX PLUS habitrol 1 1 prilovix ultralite KLOXXADO 3 prilovix ultralite plus 1 LIFEMS NALOXONE 3 PA; QL RELADOR PAK 3 LUCEMYRA 3 PA; QL RELADOR PAK PLUS 3 naloxone hcl injection 1 SOOTHEE 3 naltrexone hcl oral 1 SYNERA 3 NARCAN 1 VEXATROL 3 NICORETTE XYLOCAINE 3 MOUTH/THROAT GUM 2 2 MG XYLOCAINE/EPINEPHRI NE INJECTION 3 NICORETTE SOLUTION 1 %-1:100000 MOUTH/THROAT 2 LOZENGE 4 MG XYLOCAINE-MPF 3 nicotine polacrilex mini 2 ZERUVIA 3 nicotine polacrilex 2 ZIONODIL 3 PA mouth/throat ZIONODIL 100 3 PA nicotine step 1 1 Effective Date: 10/01/2021 15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nicotine step 2 1 cefixime 1 nicotine step 3 1 cefpodoxime proxetil 3 nicotine transdermal kit 1 cefprozil 1 SUBOXONE 3 QL ceftazidime injection VIVITROL 2 QL solution reconstituted 1 1 gm ZUBSOLV 3 QL ceftriaxone sodium Antibacterials injection solution 1 ACTICLATE 3 reconstituted 1 gm, 2 gm, 250 mg, 500 mg AEMCOLO 3 PA cefuroxime axetil 1 ALTABAX 3 CENTANY 3 amoxicillin 1 cephalexin oral capsule amoxicillin-potassium 1 1 250 mg, 500 mg clavulanate cephalexin oral capsule amoxicillin-potassium 3 3 750 mg clavulanate er cephalexin oral 1 ampicillin 1 suspension reconstituted ampicillin sodium injection cephalexin oral tablet 3 solution reconstituted 1 1 gm, 125 mg, 250 mg, 500 CIPRO ORAL SUSPENSION mg 2 RECONSTITUTED 250 ARIKAYCE 3 MG/5ML (5%) AUGMENTIN 3 CIPRO ORAL SUSPENSION AUGMENTIN ES-600 3 3 RECONSTITUTED 500 avidoxy 1 MG/5ML (10%) azithromycin oral 1 CIPRO ORAL TABLET 3 BACTRIM 3 ciprofloxacin hcl oral 1 BACTRIM DS 3 clarithromycin er 3 BAXDELA ORAL 3 QL clarithromycin oral 1 2 BICILLIN L-A CLEOCIN 3 cefaclor 3 CLEOCIN PHOSPHATE cefaclor er 3 INJECTION SOLUTION 3 300 MG/2ML cefadroxil 1 clindamycin hcl oral 1 cefazolin sodium injection solution reconstituted 1 1 clindamycin palmitate hcl 1 gm clindamycin phosphate cefdinir 1 injection solution 300 1 mg/2ml cefepime hcl injection clindamycin phosphate solution reconstituted 1 3 1 gm vaginal CLINDESSE 3 Effective Date: 10/01/2021 16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier colistimethate sodium FORTAZ INJECTION 3 (cba) SOLUTION 3 RECONSTITUTED 1 GM COLY-MYCIN M 3 coremino 3 PA fosfomycin tromethamine 3 gentamicin sulfate demeclocycline hcl 3 1 external dicloxacillin sodium 1 gentamicin sulfate DIFICID 3 PA; QL injection solution 40 1 DORYX 3 mg/ml DORYX MPC 3 HIPREX 3 doxycycline hyclate oral HUMATIN 3 1 capsule KEFLEX 3 doxycycline hyclate oral levofloxacin oral 1 tablet 100 mg, 150 mg, 50 1 mg, 75 mg LINCOCIN 3 doxycycline hyclate oral lincomycin hcl injection 3 tablet delayed release linezolid oral suspension 3 1 QL 100 mg, 150 mg, 200 mg, reconstituted 50 mg, 75 mg linezolid oral tablet 1 DOXYCYCLINE HYCLATE ORAL MACROBID 3 3 TABLET DELAYED MACRODANTIN 3 RELEASE 80 MG mafenide acetate external 3 doxycycline monohydrate 1 oral capsule methenamine hippurate 1 methenamine mandelate doxycycline monohydrate 3 oral suspension 3 oral reconstituted metronidazole oral 3 doxycycline monohydrate capsule 1 oral tablet metronidazole oral tablet 1 E.E.S. 400 3 metronidazole vaginal 1 E.E.S. GRANULES 3 minocycline hcl er oral ERYPED 200 3 tablet extended release 3 PA 24 hour ERYPED 400 3 minocycline hcl oral 1 ERY-TAB 3 capsule ERYTHROCIN 3 minocycline hcl oral tablet 3 STEARATE MINOLIRA 3 PA erythromycin base 3 mondoxyne nl 1 erythromycin 3 3 ethylsuccinate oral MONUROL 1 erythromycin oral 3 morgidox oral 1 FIRVANQ 2 moxifloxacin hcl oral 1 FLAGYL 3 mupirocin calcium Effective Date: 10/01/2021 17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 SUPRAX ORAL TABLET mupirocin external 3 CHEWABLE neomycin sulfate oral 1 TARGADOX 3 neomycin-polymyxin b gu 3 tazicef injection solution 1 nitrofurantoin 1 reconstituted 1 gm nitrofurantoin 1 hcl oral 3 macrocrystal tinidazole oral 3 nitrofurantoin monohydrate 1 trimethoprim oral 1 macrocrystals VANCOCIN 3 PA; QL NUVESSA 3 VANCOCIN HCL 3 PA; QL NUZYRA ORAL 3 QL vancomycin hcl oral 1 QL ofloxacin oral 3 capsule vancomycin hcl oral paromomycin sulfate oral 3 1 solution reconstituted penicillin v potassium 1 vandazole 1 PRIMSOL 2 VIBRAMYCIN 3 SEYSARA 3 PA; QL XENLETA ORAL 3 SILVADENE 3 XEPI 3 silver nitrate external 3 XIFAXAN 3 PA; QL silver sulfadiazine 1 external XIMINO 3 PA SIVEXTRO ORAL 2 QL ZITHROMAX ORAL 3 SOLODYN 3 PA ZITHROMAX TRI-PAK 3 SOLOSEC 3 ZITHROMAX Z-PAK 3 ssd 1 ZYVOX ORAL SUSPENSION 3 QL streptomycin sulfate 3 RECONSTITUTED intramuscular ZYVOX ORAL TABLET 3 PA sulfadiazine oral 3 Anticoagulants sulfamethoxazole- 1 trimethoprim oral ARIXTRA 3 PA; QL SULFAMYLON 3 ELIQUIS 3 PA ELIQUIS DVT/PE sulfatrim pediatric 1 3 PA STARTER PACK SUPRAX ORAL 3 CAPSULE enoxaparin sodium 1 QL SUPRAX ORAL fondaparinux sodium 1 QL SUSPENSION 3 RECONSTITUTED 100 MG/5ML, 200 MG/5ML SUPRAX ORAL SUSPENSION 2 RECONSTITUTED 500 MG/5ML Effective Date: 10/01/2021 18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FRAGMIN DIASTAT PEDIATRIC 1 QL SUBCUTANEOUS rectal 1 QL SOLUTION 10000 UNIT/ML, 12500 DILANTIN INFATABS 3 UNIT/0.5ML, 15000 DILANTIN ORAL 3 3 UNIT/0.6ML, 18000 CAPSULE 100 MG UNT/0.72ML, 2500 DILANTIN ORAL UNIT/0.2ML, 5000 2 CAPSULE 30 MG UNIT/0.2ML, 7500 DILANTIN ORAL UNIT/0.3ML 3 SUSPENSION FRAGMIN SUBCUTANEOUS divalproex sodium er 1 3 PA SOLUTION 95000 divalproex sodium oral 1 UNIT/3.8ML ELEPSIA XR 3 PA; QL heparin sodium (porcine) injection solution 1000 EPIDIOLEX 3 PA; QL 1 unit/ml, 10000 unit/ml, epitol 1 5000 unit/ml ethosuximide oral 1 heparin sodium (porcine) 1 felbamate oral pf 3 suspension jantoven 1 felbamate oral tablet 3 QL LOVENOX 1 QL FELBATOL ORAL 3 PA PRADAXA 2 SUSPENSION SAVAYSA 3 PA FELBATOL ORAL 3 PA; QL warfarin sodium oral 1 TABLET XARELTO 2 PA FINTEPLA 3 PA; QL XARELTO STARTER FYCOMPA 3 ST; QL 2 PA PACK gabapentin oral 1 Anticonvulsants - Drugs for Seizures GABITRIL 3 APTIOM 3 PA; QL KEPPRA ORAL 3 BANZEL 3 QL KEPPRA XR 3 BRIVIACT ORAL 3 PA; QL LAMICTAL 3 1 carbamazepine er LAMICTAL ODT 3 1 carbamazepine oral LAMICTAL STARTER 3 3 CARBATROL LAMICTAL XR 3 CELONTIN 2 lamotrigine er 3 clobazam 3 QL lamotrigine oral kit 3 DEPAKOTE 3 lamotrigine oral tablet 1 3 DEPAKOTE ER lamotrigine oral tablet 1 DEPAKOTE SPRINKLES 3 chewable DIACOMIT 3 PA; QL lamotrigine oral tablet 3 DIASTAT ACUDIAL 3 QL dispersible

Effective Date: 10/01/2021 19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 3 subvenite starter kit- lamotrigine starter kit-blue 3 orange lamotrigine starter kit- 3 green SYMPAZAN 3 QL lamotrigine starter kit- TEGRETOL 3 3 orange TEGRETOL-XR 3 levetiracetam er 1 tiagabine hcl 3 levetiracetam oral 1 TOPAMAX 3 MYSOLINE 3 PA; QL TOPAMAX SPRINKLE 3 NAYZILAM 2 PA; QL topiramate er 3 PA NEMBUTAL 3 topiramate oral 1 NEURONTIN 3 TRILEPTAL 3 ONFI 3 PA; QL TROKENDI XR 3 PA oxcarbazepine 1 valproic acid oral 1 OXTELLAR XR 3 VALTOCO 2 PA; QL pentobarbital sodium 3 vigabatrin oral packet 3 injection vigabatrin oral tablet 3 PA phenobarbital oral 1 vigadrone 3 phenobarbital sodium injection solution 130 1 VIMPAT ORAL 3 mg/ml XCOPRI 3 PA; QL PHENYTEK 3 ZARONTIN 3 phenytoin infatabs 1 ZONEGRAN 3 phenytoin oral 1 zonisamide oral 1 phenytoin sodium Antidementia Agents - Drugs for extended oral capsule 1 Alzheimer's Disease and Dementia 100 mg ARICEPT 3 phenytoin sodium donepezil hcl oral tablet extended oral capsule 3 1 200 mg, 300 mg 10 mg, 5 mg phenytoin sodium donepezil hcl oral tablet 1 3 injection 23 mg donepezil hcl oral tablet primidone oral 1 QL 3 dispersible QUDEXY XR 3 PA EXELON 3 roweepra 1 galantamine 1 rufinamide 3 QL hydrobromide SABRIL 3 PA galantamine 1 SPRITAM 3 hydrobromide er subvenite 1 memantine hcl er 3 PA memantine hcl oral subvenite starter kit-blue 3 3 solution subvenite starter kit-green 3

Effective Date: 10/01/2021 20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier memantine hcl oral tablet 3 1 DRIZALMA SPRINKLE 10 mg, 5 mg duloxetine hcl oral memantine hcl oral tablet capsule delayed release 3 1 28 x 5 mg & 21 x 10 mg particles 20 mg, 30 mg, NAMENDA TITRATION 60 mg 3 PAK duloxetine hcl oral NAMENDA XR 3 PA capsule delayed release 3 particles 40 mg NAMZARIC 3 EFFEXOR XR 3 RAZADYNE ER 3 EMSAM 3 rivastigmine 3 escitalopram oxalate 1 rivastigmine tartrate 1 FETZIMA 3 ST Antidepressants FETZIMA TITRATION 3 PA amitriptyline hcl oral 1 fluoxetine hcl (pmdd) 3 amoxapine 1 fluoxetine hcl oral capsule 1 ANAFRANIL 3 fluoxetine hcl oral capsule 3 APLENZIN 3 delayed release BRISDELLE 3 fluoxetine hcl oral solution 1 bupropion hcl er (sr) 1 fluoxetine hcl oral tablet 3 bupropion hcl er (xl) oral fluvoxamine maleate 1 tablet extended release 1 fluvoxamine maleate er 3 24 hour 150 mg, 300 mg FORFIVO XL 3 ST BUPROPION HCL ER (XL) ORAL TABLET imipramine hcl oral 1 3 ST EXTENDED RELEASE imipramine pamoate 3 24 HOUR 450 MG LEXAPRO 3 bupropion hcl oral 1 MARPLAN 3 CELEXA 3 mirtazapine oral 1 chlordiazepoxide- 3 QL amitriptyline NARDIL 3 citalopram hydrobromide 1 nefazodone hcl 3 clomipramine hcl oral 1 NORPRAMIN 3 CYMBALTA 3 nortriptyline hcl oral 1 desipramine hcl oral 1 olanzapine-fluoxetine hcl 3 DESVENLAFAXINE ER PAMELOR 3 (authorized generic 3 PA PARNATE 3 Khedezla) 1 desvenlafaxine succinate paroxetine hcl 3 er paroxetine hcl er 3 doxepin hcl oral capsule 1 paroxetine mesylate 3 doxepin hcl oral 1 PAXIL CR 3 concentrate Effective Date: 10/01/2021 21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PAXIL ORAL BONJESTA 3 PA 2 SUSPENSION compro 1 PAXIL ORAL TABLET 3 DICLEGIS 3 PA perphenazine- 1 dimenhydrinate injection 1 amitriptyline doxylamine-pyridoxine 3 PA PEXEVA 3 dronabinol 1 phenelzine sulfate oral 1 EMEND ORAL 3 PRISTIQ 3 PA EMEND TRI-PACK 3 protriptyline hcl 1 GIMOTI 3 PA PROZAC 3 granisetron hcl oral 3 PA REMERON 3 MARINOL 3 REMERON SOLTAB 3 meclizine hcl oral tablet 3 sertraline hcl oral 1 metoclopramide hcl 1 SYMBYAX 3 injection tranylcypromine sulfate 1 metoclopramide hcl oral 1 trazodone hcl oral 1 solution metoclopramide hcl oral trimipramine maleate oral 3 1 tablet TRINTELLIX 3 ST metoclopramide hcl oral 3 venlafaxine hcl 1 tablet dispersible venlafaxine hcl er oral ondansetron hcl injection 1 capsule extended release 1 24 hour ondansetron hcl oral 1 venlafaxine hcl er oral ondansetron odt 1 tablet extended release 3 perphenazine oral 1 24 hour prochlorperazine 1 VIIBRYD 3 ST prochlorperazine VIIBRYD STARTER 1 3 ST edisylate injection PACK prochlorperazine maleate 1 WELLBUTRIN SR 3 oral WELLBUTRIN XL 3 REGLAN 3 ZOLOFT 3 SANCUSO 3 PA Antiemetics - Drugs for Nausea and scopolamine 3 Vomiting SYNDROS 3 AKYNZEO ORAL 3 TIGAN 3 aprepitant oral 1 TRANSDERM-SCOP (1.5 3 aprepitant oral capsule MG) 125 mg, 80 & 125 mg, 80 1 trimethobenzamide hcl mg 3 oral aprepitant oral capsule 40 3 VARUBI (180 MG DOSE) 3 PA mg

Effective Date: 10/01/2021 22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOFRAN 3 ketodan external foam 3 3 LOPROX EXTERNAL ZUPLENZ 3 CREAM Antifungals LOPROX EXTERNAL KIT ANCOBON 3 PA; QL 3 0.77 % (SUSP) BREXAFEMME 3 PA LOPROX EXTERNAL 3 ciclodan 1 1 LOPROX EXTERNAL ciclopirox external gel 3 SUSPENSION ciclopirox external 3 shampoo LULICONAZOLE 3 ciclopirox external 3 1 LUZU solution 3 3 ciclopirox olamine 1 MICONAZOLE- external 3 OXIDE-PETROLAT clotrimazole external 3 naftifine hcl 3 clotrimazole mouth/throat 1 NAFTIN 3 clotrimazole- 1 NOXAFIL ORAL 3 PA; QL SUSPENSION CRESEMBA ORAL 2 PA; QL NOXAFIL ORAL TABLET 3 PA DIFLUCAN 3 DELAYED RELEASE econazole nitrate external 3 nyamyc 1 ECOZA 3 nystatin external 1 ERTACZO 3 nystatin mouth/throat 1 EXELDERM 3 nystatin oral 1 EXTINA 3 nystatin-triamcinolone 1 fluconazole oral 1 nystop 1 flucytosine oral 2 QL ORAVIG 3 griseofulvin microsize oral 1 oxiconazole nitrate 3 griseofulvin ultramicrosize 1 OXISTAT 3 GYNAZOLE-1 3 posaconazole 3 PA itraconazole oral 1 PA SPORANOX 3 PA JUBLIA 3 PA SPORANOX PULSEPAK 3 PA KERYDIN 3 PA tavaborole 3 PA external 1 terbinafine hcl oral 1 cream terconazole 3 ketoconazole external 3 foam TOLSURA 3 PA ketoconazole external VFEND 3 PA 1 shampoo voriconazole oral 1 PA ketoconazole oral 1 VUSION 3

Effective Date: 10/01/2021 23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XOLEGEL 3 IMITREX 3 Antigout Agents IMITREX STATDOSE 3 REFILL allopurinol oral 1 IMITREX STATDOSE COLCHICINE ORAL 3 1 SYSTEM CAPSULE MAXALT 3 colchicine oral tablet 1 MAXALT-MLT 3 colchicine-probenecid 1 MIGERGOT 2 COLCRYS 3 MIGRANAL 3 PA febuxostat 3 PA naratriptan hcl 1 GLOPERBA 3 NURTEC 3 PA; QL MITIGARE 3 RELPAX 3 probenecid 1 REYVOW 3 PA; QL ULORIC 3 PA rizatriptan benzoate 1 ZYLOPRIM 3 nasal 1 Anti-inflammatory Agents sumatriptan succinate 1 EMFLAZA 3 PA; QL oral Antimigraine Agents sumatriptan succinate 1 AIMOVIG refill SUBCUTANEOUS sumatriptan succinate 1 SOLUTION AUTO- 3 PA subcutaneous INJECTOR 140 MG/ML, sumatriptan-naproxen 70 MG/ML 3 ST sodium AJOVY 3 PA TOSYMRA 3 almotriptan malate 3 ST TREXIMET 3 ST AMERGE 3 UBRELVY 3 PA; QL CAFERGOT 3 ZEMBRACE SYMTOUCH 3 D.H.E. 45 3 PA; QL ZOLMITRIPTAN NASAL 3 dihydroergotamine 1 QL mesylate injection zolmitriptan oral 1 dihydroergotamine ZOMIG 3 1 mesylate nasal Antimyasthenic Agents eletriptan hydrobromide 3 MESTINON ORAL 2 EMGALITY 3 PA SOLUTION EMGALITY (300 MG MESTINON ORAL 3 PA 3 DOSE) TABLET ERGOMAR 2 MESTINON ORAL TABLET EXTENDED 3 ergotamine-caffeine 1 RELEASE FROVA 3 ST pyridostigmine bromide er 1 frovatriptan succinate 3 ST

Effective Date: 10/01/2021 24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier pyridostigmine bromide CALQUENCE 2 PA; QL 1 oral capecitabine 1 QL Antimycobacterials CAPRELSA 3 PA; QL cycloserine oral 3 CASODEX 3 dapsone oral 1 COMETRIQ 3 PA; QL ethambutol hcl oral 1 COPIKTRA 3 PA; QL isoniazid oral 1 COTELLIC 2 PA; QL 3 cyclophosphamide oral MYAMBUTOL 1 capsule MYCOBUTIN 3 CYCLOPHOSPHAMIDE 3 PASER 3 ORAL TABLET PRIFTIN 2 DAURISMO 3 PA; QL pyrazinamide oral 1 DROXIA 2 rifabutin 1 EMCYT 3 QL rifampin oral 1 ERIVEDGE 3 PA SIRTURO 3 PA; QL ERLEADA 3 PA; QL TRECATOR 3 erlotinib hcl 1 PA Antineoplastics - Drugs for Cancer etoposide oral 1 QL everolimus oral tablet 2.5 abiraterone acetate 1 QL 1 PA; QL mg, 5 mg, 7.5 mg AFINITOR DISPERZ 2 PA; QL AFINITOR ORAL exemestane 1 2 PA; QL TABLET 10 MG FARESTON 3 PA AFINITOR ORAL FARYDAK 3 PA; QL TABLET 2.5 MG, 5 MG, 3 PA; QL FEMARA 3 7.5 MG flutamide 1 ALECENSA 3 PA; QL FOTIVDA 3 PA; QL ALKERAN ORAL 3 QL GAVRETO 3 PA; QL ALUNBRIG 3 PA; QL GILOTRIF 2 PA; QL anastrozole oral 1 GLEEVEC 3 PA; QL ARIMIDEX 3 GLEOSTINE 2 AROMASIN 3 HYCAMTIN ORAL 3 QL AYVAKIT 3 PA; QL HYDREA 3 BALVERSA 3 PA; QL hydroxyurea oral 1 bexarotene 3 PA; QL IBRANCE 3 PA; QL bicalutamide 1 ICLUSIG 3 PA; QL BOSULIF 3 PA; QL IDHIFA 3 PA; QL BRAFTOVI 3 PA; QL imatinib mesylate 1 QL BRUKINSA 2 PA; QL IMBRUVICA ORAL CABOMETYX 3 PA 2 PA; QL CAPSULE

Effective Date: 10/01/2021 25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IMBRUVICA ORAL MYLERAN 2 QL TABLET 140 MG, 420 2 PA; QL NERLYNX 3 PA; QL MG, 560 MG NEXAVAR 2 PA IMBRUVICA ORAL 3 PA; QL TABLET 280 MG NILANDRON 3 PA INLYTA 3 PA; QL nilutamide 3 PA INQOVI 3 PA; QL NINLARO 3 PA; QL INREBIC 3 PA; QL NUBEQA 3 PA; QL IRESSA 2 PA; QL ODOMZO 3 PA; QL JAKAFI 3 PA ONUREG 3 PA; QL KISQALI FEMARA 3 PA; QL ORGOVYX 3 PA; QL KISQALI ORAL TABLET PANRETIN 3 PA; QL 3 PA; QL THERAPY PACK 200 MG PEMAZYRE 3 PA; QL KOSELUGO 3 PA; QL PIQRAY 3 PA; QL lapatinib ditosylate 1 PA; QL POMALYST 3 PA; QL LENVIMA ORAL PURIXAN 3 PA CAPSULE THERAPY QINLOCK 3 PA; QL PACK 10 & 4 MG, 10 MG, 3 PA; QL 2 X 10 MG, 2 X 10 MG & RETEVMO 3 PA; QL 4 MG, 3 X 4 MG, 4 MG REVLIMID 2 PA; QL LENVIMA ORAL ROZLYTREK 2 PA; QL CAPSULE THERAPY 3 PA RUBRACA 3 PA; QL PACK 10 MG & 2 X 4 MG, 2 X 4 MG RYDAPT 2 PA; QL letrozole oral 1 SIKLOS 3 PA; QL leucovorin calcium SOLTAMOX 3 injection solution 100 3 SPRYCEL 2 PA; QL mg/10ml STIVARGA 2 PA leucovorin calcium oral 1 sunitinib malate 2 PA; QL LEUKERAN 2 SUTENT 2 PA; QL LONSURF 3 PA; QL TABLOID 2 LORBRENA 3 PA; QL TABRECTA 3 PA; QL LUMAKRAS 3 PA; QL TAFINLAR 2 PA; QL LYNPARZA 3 PA; QL TAGRISSO 2 PA; QL LYSODREN 3 PA TALZENNA 3 PA; QL MATULANE 2 QL tamoxifen citrate oral 1 MEKINIST 2 PA; QL TARCEVA 3 PA MEKTOVI 3 PA; QL TARGRETIN 3 PA; QL melphalan 1 QL TASIGNA 3 PA; QL mercaptopurine oral 1 TAZVERIK 3 PA; QL mesna 1 TEMODAR ORAL 3 PA; QL MESNEX ORAL 2 Effective Date: 10/01/2021 26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier temozolomide 1 QL XPOVIO (80 MG TWICE 3 PA; QL TEPMETKO 3 PA; QL WEEKLY) THALOMID 2 PA; QL XTANDI ORAL CAPSULE 2 PA; QL TIBSOVO 3 PA; QL XTANDI ORAL TABLET 3 PA; QL toremifene citrate 3 PA YONSA 3 QL tretinoin oral 1 QL ZEJULA 3 PA; QL TRUSELTIQ (100MG ZELBORAF 2 PA 3 PA; QL DAILY DOSE) ZOLINZA 3 PA; QL TRUSELTIQ (125MG ZYDELIG 2 PA; QL 3 PA; QL DAILY DOSE) ZYKADIA 3 PA; QL TRUSELTIQ (50MG 3 PA; QL ZYTIGA 3 PA; QL DAILY DOSE) Antiparasitics TRUSELTIQ (75MG 3 PA; QL DAILY DOSE) albendazole oral 1 TUKYSA 3 PA; QL ALBENZA 3 TURALIO 3 PA; QL ALINIA ORAL TYKERB 3 PA; QL SUSPENSION 2 RECONSTITUTED UKONIQ 3 PA; QL ALINIA ORAL TABLET 3 VALCHLOR 3 PA; QL atovaquone 1 VENCLEXTA 2 PA; QL BENZNIDAZOLE 3 QL VENCLEXTA STARTING 2 PA; QL PACK BILTRICIDE 3 chloroquine phosphate VERZENIO 3 PA; QL 1 oral VITRAKVI 3 PA; QL VIZIMPRO 3 PA; QL COARTEM 3 VOTRIENT 2 PA; QL crotan 2 XALKORI 3 PA; QL DARAPRIM 3 PA; QL XELODA 3 PA; QL EMVERM 3 hydroxychloroquine XOSPATA 3 PA; QL 1 sulfate oral tablet 200 mg XPOVIO (100 MG ONCE 3 PA; QL WEEKLY) IMPAVIDO 3 PA; QL XPOVIO (40 MG ONCE ivermectin external lotion 3 3 PA; QL WEEKLY) ivermectin oral 3 XPOVIO (40 MG TWICE 3 PA; QL KRINTAFEL 2 WEEKLY) LAMPIT 3 XPOVIO (60 MG ONCE 3 PA; QL WEEKLY) lindane 3 XPOVIO (60 MG TWICE 3 3 PA; QL malathion WEEKLY) MEPRON 3 PA XPOVIO (80 MG ONCE 3 PA; QL NATROBA 3 WEEKLY) NEBUPENT 3 Effective Date: 10/01/2021 27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 2 KYNMOBI TITRATION nitazoxanide oral 3 PA; QL KIT OVIDE 3 LODOSYN 3 PENTAM 3 MIRAPEX 3 pentamidine isethionate 3 MIRAPEX ER 3 permethrin external 1 NEUPRO 3 PLAQUENIL 3 NOURIANZ 3 PA; QL praziquantel oral 1 ONGENTYS 3 PA primaquine phosphate 1 OSMOLEX ER 3 PA pyrimethamine oral 1 PA; QL PARLODEL 3 QUALAQUIN 3 pramipexole 1 quinine sulfate oral 3 dihydrochloride spinosad 3 pramipexole 3 STROMECTOL 3 dihydrochloride er Antiparkinson Agents rasagiline mesylate oral 1 PA ropinirole hcl 1 amantadine hcl oral 1 APOKYN 3 QL ropinirole hcl er 3 AZILECT 3 PA RYTARY 3 PA benztropine mesylate 1 selegiline hcl oral 1 bromocriptine mesylate SINEMET 3 1 oral STALEVO 100 3 carbidopa oral 1 STALEVO 125 3 carbidopa-levodopa er 1 STALEVO 150 3 carbidopa-levodopa oral 1 STALEVO 200 3 tablet STALEVO 50 3 carbidopa-levodopa oral tablet dispersible 10-100 1 STALEVO 75 3 mg, 25-100 mg TASMAR 3 PA; QL carbidopa-levodopa oral tolcapone 3 QL tablet dispersible 25-250 3 mg trihexyphenidyl hcl 1 carbidopa-levodopa- XADAGO 3 PA 1 entacapone ZELAPAR 3 QL COGENTIN 3 Antiplatelets COMTAN 3 aspirin-dipyridamole er 1 DUOPA 2 PA BRILINTA 2 entacapone 1 CABLIVI 3 PA; QL GOCOVRI 3 PA; QL cilostazol 1 INBRIJA 3 PA; QL clopidogrel bisulfate oral 1 KYNMOBI 3 PA; QL dipyridamole oral 1 Effective Date: 10/01/2021 28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 3 HALDOL INJECTION DURLAZA 3 SOLUTION 5 MG/ML EFFIENT 3 haloperidol decanoate 1 PLAVIX 3 intramuscular prasugrel hcl 1 haloperidol lactate 1 YOSPRALA 3 haloperidol oral 1 ZONTIVITY 3 INVEGA 3 ST Antipsychotics - Drugs for Mood Disorders INVEGA SUSTENNA 2 ABILIFY 3 INVEGA TRINZA 2 QL ABILIFY MAINTENA 2 QL LATUDA 3 PA ABILIFY MYCITE 3 PA; QL loxapine succinate 1 ABILIFY MYCITE 3 PA; QL molindone hcl 3 MAINTENANCE KIT NUPLAZID 3 PA; QL ABILIFY MYCITE 3 PA; QL STARTER KIT olanzapine 1 aripiprazole oral solution 1 paliperidone er 3 ST aripiprazole oral tablet 1 PERSERIS 2 aripiprazole oral tablet pimozide 1 3 dispersible quetiapine fumarate 1 ARISTADA 2 QL quetiapine fumarate er 1 ARISTADA INITIO 2 QL REXULTI 3 PA asenapine maleate 3 ST RISPERDAL 3 CAPLYTA 3 PA; QL RISPERDAL CONSTA 2 chlorpromazine hcl 1 injection risperidone oral solution 1 chlorpromazine hcl oral risperidone oral tablet 1 3 concentrate risperidone oral tablet 3 chlorpromazine hcl oral dispersible 1 tablet SAPHRIS 3 ST clozapine oral tablet 1 SECUADO 3 ST clozapine oral tablet SEROQUEL 3 3 dispersible SEROQUEL XR 3 CLOZARIL 3 thioridazine hcl oral 3 FANAPT 3 ST thiothixene 1 FANAPT TITRATION 3 ST PACK trifluoperazine hcl 1 fluphenazine decanoate VERSACLOZ 3 1 injection VRAYLAR 3 PA; QL fluphenazine hcl 1 ziprasidone hcl 1 GEODON 3 ziprasidone mesylate 3 HALDOL DECANOATE 3 ZYPREXA 3 Effective Date: 10/01/2021 29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZYPREXA RELPREVV 2 EPCLUSA 2 PA; QL ZYPREXA ZYDIS 3 EPIVIR 3 EPIVIR HBV ORAL Antivirals 2 SOLUTION abacavir sulfate 1 EPIVIR HBV ORAL abacavir sulfate- 3 PA 1 QL TABLET lamivudine EPZICOM 3 PA; QL abacavir-lamivudine- 1 QL zidovudine etravirine 1 acyclovir external 3 EVOTAZ 3 QL acyclovir oral 1 famciclovir oral 3 adefovir dipivoxil 1 QL fosamprenavir calcium 1 QL APTIVUS 2 QL FUZEON 3 QL atazanavir sulfate 1 QL GENVOYA 2 ATRIPLA 3 PA; QL HARVONI 2 PA; QL BARACLUDE ORAL HEPSERA 3 PA; QL 2 QL SOLUTION INTELENCE ORAL BARACLUDE ORAL TABLET 100 MG, 200 3 3 PA; QL TABLET MG INTELENCE ORAL BIKTARVY 2 QL 2 TABLET 25 MG CIMDUO 2 QL INTRON A 2 QL COMBIVIR 3 PA INVIRASE 2 COMPLERA 2 PA; QL ISENTRESS HD 2 CRIXIVAN 2 ISENTRESS ORAL DELSTRIGO 3 PA; QL 3 PACKET DENAVIR 3 ISENTRESS ORAL 2 DESCOVY 2 PA; QL TABLET DOVATO 2 QL ISENTRESS ORAL 2 EDURANT 2 TABLET CHEWABLE JULUCA 2 QL efavirenz 1 efavirenz-emtricitab- KALETRA 3 2 QL tenofovir lamivudine 1 efavirenz-lamivudine- 1 lamivudine-zidovudine 1 tenofovir LEDIPASVIR- 2 PA; QL emtricitabine 1 SOFOSBUVIR emtricitabine-tenofovir df 1 LEXIVA ORAL 2 QL EMTRIVA ORAL SUSPENSION 3 PA CAPSULE LEXIVA ORAL TABLET 3 PA; QL EMTRIVA ORAL 1 2 lopinavir-ritonavir SOLUTION MAVYRET 3 PA; QL entecavir 1 QL Effective Date: 10/01/2021 30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nevirapine er 1 SUSTIVA 3 PA nevirapine oral SYMFI 1 3 suspension SYMFI LO 1 nevirapine oral tablet 1 SYMTUZA 2 QL NORVIR ORAL PACKET 2 TAMIFLU 2 NORVIR ORAL 2 TEMIXYS 2 QL SOLUTION tenofovir disoproxil 1 NORVIR ORAL TABLET 3 fumarate ODEFSEY 2 QL TIVICAY 2 oseltamivir phosphate 1 TIVICAY PD 2 oral TRIUMEQ 2 QL PEGASYS 2 QL TRIZIVIR 3 PA; QL PIFELTRO 3 PA; QL TRUVADA 3 QL PREVYMIS ORAL 2 PA; QL TYBOST 2 PA PREZCOBIX 2 QL valacyclovir hcl oral 1 PREZISTA 2 VALCYTE 3 PA; QL RELENZA DISKHALER 2 valganciclovir hcl 1 QL RETROVIR ORAL 3 VALTREX 3 REYATAZ ORAL 3 PA; QL CAPSULE VEMLIDY 3 PA; QL REYATAZ ORAL VIEKIRA PAK 3 PA; QL 2 PACKET VIRACEPT 2 ribavirin 3 VIRAMUNE 3 PA ribavirin oral 1 QL VIRAMUNE XR 3 PA rimantadine hcl 1 VIRAZOLE 3 ritonavir 1 VIREAD ORAL 2 RUKOBIA 3 PA; QL VIREAD ORAL TABLET SELZENTRY ORAL 150 MG, 200 MG, 250 2 2 QL SOLUTION MG VIREAD ORAL TABLET SELZENTRY ORAL 3 PA TABLET 150 MG, 300 2 QL 300 MG MG VOSEVI 2 PA; QL SELZENTRY ORAL 2 XERESE 3 TABLET 25 MG, 75 MG XOFLUZA (40 MG 3 SITAVIG 3 DOSE) SOFOSBUVIR- XOFLUZA (80 MG 2 PA; QL 3 VELPATASVIR DOSE) SOVALDI 3 PA; QL ZEPATIER 3 PA; QL stavudine 1 ZIAGEN 3 STRIBILD 2 PA; QL zidovudine 1

Effective Date: 10/01/2021 31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOVIRAX 3 midazolam hcl (pf) injection solution 10 1 QL Anxiolytics - Drugs for Anxiety mg/2ml, 5 mg/ml alprazolam er 1 QL midazolam hcl injection alprazolam intensol 3 QL solution 10 mg/2ml, 5 1 QL alprazolam oral tablet 1 QL mg/ml alprazolam oral tablet midazolam hcl oral 3 QL 3 QL dispersible oxazepam 1 QL alprazolam xr 1 QL quazepam 3 QL ATIVAN INJECTION 3 QL TRANXENE-T 3 QL SOLUTION 2 MG/ML triazolam 1 QL ATIVAN ORAL 3 QL VALIUM 3 QL buspirone hcl oral 1 VISTARIL 3 chlordiazepoxide hcl 1 QL XANAX 3 QL clonazepam oral 1 QL XANAX XR 3 QL clorazepate dipotassium 1 QL Bipolar Agents - Drugs for Mood Disorders diazepam intensol 3 QL EQUETRO 3 diazepam intramuscular 1 QL lithium carbonate er 1 diazepam oral 3 QL concentrate lithium carbonate oral 1 diazepam oral solution 1 QL LITHOBID 3 Blood Products and Modifiers - Drugs for diazepam oral tablet 1 QL Blood Disorders diazepam solution 5 1 QL mg/ml injection AGRYLIN 3 DIAZEPAM SOLUTION 5 3 3 QL AMICAR MG/ML INJECTION aminocaproic acid oral 3 DORAL 3 QL anagrelide hcl 1 estazolam 3 QL ARANESP (ALBUMIN 3 PA HALCION 3 QL FREE) hydroxyzine hcl oral 1 DOPTELET 3 PA; QL hydroxyzine pamoate oral 1 EPOGEN 2 PA KLONOPIN 3 QL FULPHILA 3 PA; QL lorazepam injection 1 QL GRANIX 3 QL solution 2 mg/ml HEMLIBRA 2 PA; QL lorazepam intensol 1 QL LEUKINE 2 lorazepam oral 1 QL LYSTEDA 3 QL concentrate 2 mg/ml MIRCERA 3 PA lorazepam oral tablet 1 QL MULPLETA 3 PA; QL meprobamate 3 NEULASTA 3 PA; QL NEULASTA ONPRO 3 PA; QL

Effective Date: 10/01/2021 32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NEUPOGEN 2 QL amlodipine-valsartan-hctz 3 NIVESTYM 2 QL ANTARA 3 NYVEPRIA 3 PA; QL ATACAND 3 PROCRIT 2 PA ATACAND HCT 3 PROMACTA 3 PA; QL atenolol oral 1 RETACRIT 3 PA atenolol-chlorthalidone 1 TAVALISSE 3 PA; QL atorvastatin calcium oral 1 tranexamic acid oral 1 QL AVALIDE 3 UDENYCA 3 PA; QL AVAPRO 3 ZARXIO 2 QL AZOR 3 ZIEXTENZO 3 PA; QL Cardiovascular Agents - Drugs for Heart benazepril hcl oral 1 and Circulation Conditions benazepril- 1 hydrochlorothiazide ACCUPRIL 3 BENICAR 3 ACCURETIC 3 BENICAR HCT 3 acebutolol hcl oral 1 BETAPACE 3 acetazolamide sodium 3 ALDACTAZIDE ORAL BETAPACE AF 3 3 TABLET 25-25 MG betaxolol hcl oral 1 ALDACTAZIDE ORAL 2 BIDIL 3 TABLET 50-50 MG bisoprolol fumarate oral 1 ALDACTONE 3 bisoprolol- 1 aliskiren fumarate 3 ST hydrochlorothiazide alprostadil injection 1 BRETYLIUM TOSYLATE 3 ALTACE 3 bumetanide oral 1 ALTOPREV 3 BUMEX 3 amiloride hcl oral 1 BYSTOLIC 3 amiloride- 1 CADUET 3 hydrochlorothiazide CALAN SR 3 amiodarone hcl oral tablet 3 100 mg, 400 mg candesartan cilexetil 3 amiodarone hcl oral tablet candesartan cilexetil-hctz 3 1 200 mg captopril oral 1 amlodipine besylate oral 1 CARDIZEM 3 amlodipine besylate- 1 CARDIZEM CD 3 benazepril hcl CARDIZEM LA 3 amlodipine besylate- 3 ST valsartan CARDURA 3 amlodipine-atorvastatin 3 CAROSPIR 3 amlodipine-olmesartan 1 cartia xt 1 Effective Date: 10/01/2021 33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carvedilol 1 diltiazem hcl er coated beads oral capsule carvedilol phosphate er 3 3 extended release 24 hour CATAPRES-TTS-1 3 360 mg CATAPRES-TTS-2 3 diltiazem hcl er coated beads oral tablet 3 CATAPRES-TTS-3 3 extended release 24 hour chlorthalidone 1 diltiazem hcl oral 1 cholestyramine light 1 dilt-xr 1 cholestyramine oral 1 DIOVAN 3 clonidine 1 DIOVAN HCT 3 clonidine hcl oral 1 disopyramide phosphate 1 colesevelam hcl 3 DIURIL 2 COLESTID 3 dofetilide 3 PA 3 COLESTID FLAVORED doxazosin mesylate oral 1 colestipol hcl 1 droxidopa 3 PA; QL CONJUPRI 3 PA DUTOPROL 3 CONSENSI 3 PA; QL DYRENIUM 3 COREG 3 EDARBI 3 ST COREG CR 3 EDARBYCLOR 3 ST CORGARD 3 EDECRIN 3 PA CORLANOR 3 PA enalapril maleate oral 3 COZAAR 3 solution enalapril maleate oral CRESTOR 3 1 tablet DEMSER 3 enalapril- 1 DIBENZYLINE 3 PA hydrochlorothiazide digitek 1 ENTRESTO 2 PA digox 1 EPANED 3 digoxin injection 1 EPINEPHRINE INJECTION SOLUTION digoxin oral 1 3 PREFILLED SYRINGE DILATRATE-SR ORAL 0.2 MG/0.2ML CAPSULE EXTENDED 3 RELEASE 40 MG epinephrine pf 1 diltiazem hcl er 1 eplerenone 1 diltiazem hcl er beads 3 ethacrynic acid 1 PA diltiazem hcl er coated EXFORGE 3 ST beads oral capsule EXFORGE HCT 3 extended release 24 hour 1 EZALLOR SPRINKLE 3 120 mg, 180 mg, 240 mg, 300 mg ezetimibe 1

Effective Date: 10/01/2021 34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ezetimibe-simvastatin 1 irbesartan 1 1 irbesartan- felodipine er 1 hydrochlorothiazide fenofibrate micronized 1 ISORDIL TITRADOSE 3 fenofibrate oral capsule 1 134 mg, 200 mg, 67 mg isosorbide dinitrate 1 fenofibrate oral capsule 1 3 isosorbide mononitrate 150 mg, 50 mg isosorbide mononitrate er 1 fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 3 isradipine 1 mg JUXTAPID 3 PA; QL fenofibrate oral tablet 160 KAPSPARGO SPRINKLE 3 1 mg, 54 mg KATERZIA 3 fenofibric acid oral 3 capsule delayed release labetalol hcl oral 1 fenofibric acid oral tablet 1 LANOXIN 3 FENOGLIDE 3 LANOXIN PEDIATRIC 3 3 FIBRICOR 3 LASIX flecainide acetate 1 LESCOL XL 3 3 FLOLIPID 3 LIPITOR fluvastatin sodium 3 LIPOFEN 3 1 fluvastatin sodium er 3 lisinopril oral lisinopril- fosinopril sodium 1 1 hydrochlorothiazide fosinopril sodium-hctz 1 LIVALO 3 furosemide injection 1 LOPID 3 furosemide oral 1 LOPRESSOR 3 gemfibrozil oral 1 losartan potassium oral 1 GONITRO 3 losartan potassium-hctz 1 guanfacine hcl 1 LOTENSIN 3 HEMANGEOL 3 PA LOTENSIN HCT 3 hydralazine hcl oral 1 LOTREL 3 hydrochlorothiazide oral 1 lovastatin oral 1 HYZAAR 3 LOVAZA 3 icosapent ethyl 3 PA matzim la 3 indapamide 1 MAXZIDE 3 INDERAL LA 3 MAXZIDE-25 3 INDERAL XL 3 methyldopa 1 INNOPRAN XL 3 metolazone 1 INSPRA 3 metoprolol succinate er 1 Effective Date: 10/01/2021 35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier metoprolol tartrate oral 1 nitroglycerin translingual 3 metoprolol- 3 1 NITROLINGUAL hydrochlorothiazide NITROMIST 3 metyrosine 3 NITROSTAT 3 mexiletine hcl oral 1 nitro-time oral capsule 1 MICARDIS 3 extended release 9 mg MICARDIS HCT 3 NORPACE 3 midodrine hcl 1 NORPACE CR 2 MINIPRESS 3 NORTHERA 3 PA; QL minitran 1 NORVASC 3 minoxidil oral 1 NYMALIZE 3 QL olmesartan medoxomil moexipril hcl 1 1 oral MULTAQ 3 olmesartan medoxomil- 1 nadolol oral 1 hctz NEXLETOL 3 PA olmesartan-amlodipine- 3 NEXLIZET 3 PA hctz niacin (antihyperlipidemic) 3 omega-3-acid ethyl esters 3 niacin er pacerone oral tablet 100 3 3 (antihyperlipidemic) mg pacerone oral tablet 200 niacor 3 1 mg NIASPAN 3 PACERONE ORAL 3 nicardipine hcl oral 1 TABLET 400 MG nifedipine er 1 papaverine hcl injection 1 nifedipine er osmotic 1 pentoxifylline er 1 release perindopril erbumine 1 nifedipine oral 1 phenoxybenzamine hcl 1 nimodipine oral 1 oral nisoldipine er 3 phentolamine mesylate 1 NITRO-BID 2 injection NITRO-DUR pindolol 1 PRALUENT 3 PA; QL 24 HOUR 0.1 MG/HR, 0.2 3 pravastatin sodium 1 MG/HR, 0.4 MG/HR, 0.6 MG/HR prazosin hcl oral 1 NITRO-DUR PRESTALIA 3 TRANSDERMAL PATCH 2 prevalite 1 24 HOUR 0.3 MG/HR, 0.8 MG/HR PRINIVIL 3 nitroglycerin sublingual 1 procainamide hcl injection 1 nitroglycerin transdermal 1 PROCARDIA XL 3 Effective Date: 10/01/2021 36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier propafenone hcl 1 telmisartan-amlodipine 3 propafenone hcl er 3 telmisartan-hctz 3 propranolol hcl er 1 TENORETIC 100 3 propranolol hcl oral 1 TENORETIC 50 3 PROSTIN VR 3 TENORMIN 3 QBRELIS 3 tiadylt er 3 QUESTRAN 3 TIAZAC 3 QUESTRAN LIGHT 3 TIKOSYN 3 PA quinapril hcl 1 timolol maleate oral 1 quinapril- TOPROL XL 3 1 hydrochlorothiazide torsemide 1 quinidine gluconate er 1 trandolapril 1 quinidine sulfate 1 trandolapril-verapamil hcl 3 ramipril 1 er RANEXA 3 PA triamterene oral 1 ranolazine er 3 PA triamterene-hctz 1 RECTIV 2 TRIBENZOR 3 REPATHA 3 PA TRICOR 3 REPATHA 3 PA TRILIPIX 3 PUSHTRONEX SYSTEM TWYNSTA 3 REPATHA SURECLICK 3 PA valsartan 1 rosuvastatin calcium 1 valsartan- 1 ROSZET 3 PA hydrochlorothiazide RYTHMOL SR 3 VASCEPA 3 PA simvastatin oral 1 VASERETIC 3 sorine 1 VASOTEC 3 sotalol hcl (af) 1 VECAMYL 3 sotalol hcl oral 1 verapamil hcl er oral capsule extended release SOTYLIZE 3 3 24 hour 100 mg, 200 mg, spironolactone oral 1 300 mg spironolactone-hctz 1 verapamil hcl er oral capsule extended release SULAR 3 1 24 hour 120 mg, 180 mg, TARKA 3 240 mg, 360 mg taztia xt 3 verapamil hcl er oral 1 TEKTURNA 3 ST tablet extended release TEKTURNA HCT 3 ST verapamil hcl oral 1 telmisartan 3 VERELAN 3

Effective Date: 10/01/2021 37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 3 dextroamphetamine VERELAN PM 3 sulfate oral solution VERQUVO 3 PA dextroamphetamine VYNDAMAX 3 PA; QL sulfate oral tablet 10 mg, 1 VYNDAQEL 3 PA; QL 5 mg VYTORIN 3 dextroamphetamine WELCHOL 3 sulfate oral tablet 15 mg, 3 20 mg, 30 mg ZESTORETIC 3 DYANAVEL XR 3 ST ZESTRIL 3 EVEKEO 3 PA ZETIA 3 EVEKEO ODT 3 PA 3 ZIAC FOCALIN 3 ZOCOR 3 FOCALIN XR 3 ST; QL ZYPITAMAG 3 guanfacine hcl er 1 Central Nervous System Agents - Drugs for INTUNIV 3 Attention Deficit Disorder JORNAY PM 3 ST; QL ADDERALL 3 KAPVAY 3 ADDERALL XR 3 QL methamphetamine hcl 3 ADHANSIA XR 3 ST; QL 3 ADZENYS ER 3 PA METHYLIN ADZENYS XR-ODT 3 PA methylphenidate hcl er 1 QL methylphenidate hcl er AMPHETAMINE ER 3 PA 1 QL (cd) amphetamine sulfate 3 PA methylphenidate hcl er amphetamine- 1 (la) oral capsule extended 3 ST; QL dextroamphetamine release 24 hour 10 mg amphetamine- 1 QL methylphenidate hcl er dextroamphetamine er (la) oral capsule extended 1 ST; QL APTENSIO XR 3 ST; QL release 24 hour 20 mg, 30 mg, 40 mg, 60 mg atomoxetine hcl 1 methylphenidate hcl er 3 ST; QL clonidine hcl er 3 (xr) CONCERTA 3 QL methylphenidate hcl oral 3 COTEMPLA XR-ODT 3 PA; QL solution DAYTRANA 3 ST; QL methylphenidate hcl oral 1 tablet DESOXYN 3 methylphenidate hcl oral DEXEDRINE 3 QL 3 tablet chewable 1 dexmethylphenidate hcl MYDAYIS 3 PA; QL dexmethylphenidate hcl 3 ST; QL PROCENTRA 3 er QELBREE 3 PA dextroamphetamine 1 QL sulfate er QUILLICHEW ER 3 PA QUILLIVANT XR 3 ST; QL

Effective Date: 10/01/2021 38 Drug Drug Drug Name Notes Drug Name Notes Tier Tier relexxii 1 QL PONVORY STARTER 3 PA; QL PACK RITALIN 3 REBIF 2 PA; QL RITALIN LA 3 ST; QL REBIF REBIDOSE 2 PA; QL STRATTERA 3 REBIF REBIDOSE VYVANSE 3 PA; QL 2 PA; QL TITRATION PACK ZENZEDI ORAL TABLET REBIF TITRATION PACK 2 PA; QL 15 MG, 2.5 MG, 20 MG, 3 30 MG, 7.5 MG TECFIDERA 3 PA; QL ZENZEDI TABLET 10 MG VUMERITY 3 PA; QL 3 ORAL ZEPOSIA 3 PA; QL zenzedi tablet 10 mg oral 1 ZEPOSIA 7-DAY 3 PA; QL ZENZEDI TABLET 5 MG STARTER PACK 3 ORAL ZEPOSIA STARTER KIT 3 PA; QL zenzedi tablet 5 mg oral 1 Central Nervous System Agents -

Central Nervous System Agents - Drugs for Miscellaneous

Multiple Sclerosis AUSTEDO 3 PA; QL AMPYRA 3 PA; QL caffeine citrate oral 1 AUBAGIO 3 PA; QL CAFFEINE-SODIUM 3 AVONEX PEN 2 PA; QL BENZOATE AVONEX PREFILLED 2 PA; QL EXSERVAN 3 PA; QL BAFIERTAM 3 PA; QL GRALISE ORAL TABLET 3 BETASERON 3 PA; QL HORIZANT 3 COPAXONE 3 PA; QL IMCIVREE 3 PA; QL dalfampridine er 3 PA; QL INGREZZA 3 PA; QL dimethyl fumarate oral 1 LYRICA 3 QL dimethyl fumarate starter LYRICA CR 3 PA 1 pack NUEDEXTA 3 PA EXTAVIA 1 QL pregabalin 1 QL GILENYA 2 PA; QL pregabalin er 3 PA glatiramer acetate 1 QL RILUTEK 3 PA; QL glatopa 1 QL riluzole 1 QL KESIMPTA 3 PA; QL SAVELLA 3 ST MAVENCLAD 3 PA; QL SAVELLA TITRATION 3 ST MAYZENT 3 PA; QL PACK MAYZENT STARTER TEGSEDI 3 PA; QL 3 PA; QL PACK tetrabenazine 3 PA; QL PLEGRIDY 3 PA; QL TIGLUTIK 3 QL PLEGRIDY STARTER 3 PA; QL XENAZINE 3 PA; QL PACK Dental and Oral Agents - Drugs for Mouth

PONVORY 3 PA; QL and Throat Conditions

Effective Date: 10/01/2021 39 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 3 ADAPALENE EXTERNAL BOCASAL 3 SOLUTION cevimeline hcl 3 adapalene-benzoyl chlorhexidine gluconate 3 1 peroxide external gel mouth/throat ADAPALENE-BENZOYL DEBACTEROL 3 PEROXIDE EXTERNAL 3 PA EVOXAC 3 PAD FIRST- ADVANCED ALLERGY 3 3 BLM COLLECTION lidocaine hcl mouth/throat 3 AKLIEF 3 PA lidocaine viscous hcl 1 ALA SCALP 3 ala-cort external cream 1 MUCOSITISRX 3 3 % NEUTRASAL 3 ala-cort external cream 1 NUMOISYN 2.5 % MOUTH/THROAT 3 LOZENGE 1 dipropionate oralone 1 ALDARA 3 periogard 1 ALTRENO 3 pilocarpine hcl oral tablet 1 5 mg amcinonide 3 pilocarpine hcl oral tablet AMELUZ 2 QL 3 7.5 mg ammonium lactate 3 SALAGEN 3 external SALIVAMAX 3 amnesteem 1 AMZEEQ 3 1 mouth/throat ANACAINE 3 XEROSTOMIA RELIEF 3 APEXICON E 3 SPRAY ARAZLO 3 Dermatological Agents - Drugs for Skin

Conditions arzol silver nit applicators 3 ABSORICA 3 ATOPADERM 3 ABSORICA LD 3 ATOPICLAIR 3 ACANYA 3 ATRALIN 3 accutane 1 avar cleanser 1 acitretin 1 QL AVAR LS CLEANSER 3 ACNESIC 3 AVAR-E EMOLLIENT 3 ACZONE 3 AVAR-E GREEN 3 adapalene external cream 1 AVAR-E LS 3 adapalene external gel 1 avita 1 ADAPALENE EXTERNAL azelaic acid external 1 3 PAD Effective Date: 10/01/2021 40 Drug Drug Drug Name Notes Drug Name Notes Tier Tier AZELEX 2 claravis 1 BENZACLIN 3 CLEOCIN-T 3 3 clindacin etz external BENZACLIN WITH PUMP 1 swab BENZAMYCIN 3 clindacin-p 1 benzepro foaming cloths 3 CLINDAGEL 3 BENZOYL PEROX- 3 clindamycin phos-benzoyl perox external gel 1.2-2.5 3 BENZOYL PEROXIDE % EXTERNAL GEL 6.5 %, 8 3 % clindamycin phos-benzoyl perox external gel 1-5 %, 1 BENZOYL PEROXIDE 3 1.2-5 % FORTE- HC clindamycin phosphate benzoyl peroxide- 3 1 external foam erythromycin clindamycin phosphate beser external lotion 3 1 external lotion betamethasone 1 clindamycin phosphate dipropionate aug 1 external solution betamethasone 1 clindamycin phosphate dipropionate external 1 external swab 1 CLINDAMYCIN external PHOSPHATE GEL 1 % 3 bp 10-1 3 EXTERNAL bp cleansing wash 3 clindamycin phosphate 1 gel 1 % external BRYHALI 3 clindamycin-tretinoin 3 calcipotriene external 1 prop emollient cream 1 CALCIPOTRIENE base 3 EXTERNAL FOAM e 1 calcipotriene external clobetasol propionate 1 3 ointment calcipotriene external clobetasol propionate 1 1 solution external cream calcipotriene-betameth clobetasol propionate 3 3 diprop external foam 1 clobetasol propionate calcitrene 1 external gel calcitriol external 1 clobetasol propionate 2 3 CAPEX external CARAC 2 clobetasol propionate 1 cem-urea 3 external lotion clobetasol propionate CERACADE 3 1 external ointment ceramax external cream 3 Effective Date: 10/01/2021 41 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clobetasol propionate 3 3 desrx external shampoo DEXERYL 3 clobetasol propionate 1 diclofenac sodium external solution 3 external gel 3 % CLOBEX 3 DIFFERIN EXTERNAL 1 CLOBEX SPRAY 3 CREAM 3 DIFFERIN EXTERNAL pivalate 3 GEL 0.3 % clodan external shampoo 3 DIFFERIN EXTERNAL 2 CLODERM 3 LOTION CONDYLOX 2 diacetate 3 CORDRAN EXTERNAL 3 DIPROLENE 3 CREAM DIPROLENE AF 3 CORDRAN EXTERNAL 3 LOTION DOVONEX 3 CORDRAN EXTERNAL 3 3 doxepin hcl external OINTMENT doxycycline 3 CORDRAN EXTERNAL 2 TAPE DRITHO-CREME HP 3 CUTIVATE 3 DRYSOL 2 DUPIXENT 3 PA; QL dapsone external gel 5 % 3 DAPSONE EXTERNAL EFUDEX 3 3 GEL 7.5 % ELETONE 3 DERMA-SMOOTHE/FS 3 ELIDEL 3 BODY EMULSION SB 3 DERMA-SMOOTHE/FS 3 SCALP ENSTILAR 3 DESONATE 3 ENTTY SPRAY 3 external cream 1 EPICERAM 3 desonide external gel 3 EPIDUO 3 desonide external lotion 1 EPIDUO FORTE 3 desonide external EPIFOAM 3 1 ointment ery 3 DESOWEN 3 ERYGEL 3 external 1 erythromycin external 1 cream EUCRISA 3 PA; QL desoximetasone external 1 gel EVOCLIN 3 desoximetasone external FABIOR 3 3 liquid FINACEA EXTERNAL 2 desoximetasone external FOAM 1 ointment

Effective Date: 10/01/2021 42 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FINACEA EXTERNAL 3 3 HPR PLUS GEL HYDRO 40 3 acetonide 1 hydrocortisone ace- body pramoxine external cream 1 1 2.5-1 % external hydrocortisone butyr lipo fluocinolone acetonide 3 1 base scalp emulsified 1 1 external cream base hydrocortisone butyrate fluocinonide external 3 1 external lotion cream 0.05 % hydrocortisone butyrate fluocinonide external 1 3 external ointment cream 0.1 % hydrocortisone butyrate 1 fluocinonide external gel 1 external solution fluocinonide external hydrocortisone cream 1 % 1 3 ointment external (rx) fluocinonide external hydrocortisone external 1 1 solution cream 2.5 % FLUOROPLEX 2 hydrocortisone external 1 FLUOROURACIL lotion 2.5 % EXTERNAL CREAM 0.5 2 hydrocortisone external 1 % ointment 2.5 % fluorouracil external hydrocortisone ointment 1 1 1 cream 5 % % external (rx) fluorouracil external 1 1 solution HYLAGUARD 3 flurandrenolide 3 HYLATOPIC PLUS 3 1 EXTERNAL CREAM external cream ILIDERM 3 fluticasone propionate 3 imiquimod external cream external lotion 3 3.75 % fluticasone propionate 1 imiquimod external cream external ointment 1 5 % 3 IMIQUIMOD PUMP 3 halobetasol propionate 1 IMPEKLO 3 PA external cream IMPOYZ 3 PA HALOBETASOL PROPIONATE 3 isotretinoin oral 1 EXTERNAL FOAM ivermectin external cream 3 halobetasol propionate 1 KAMDOY 3 external ointment KENALOG EXTERNAL 3 HALOG 3 KERALAC 3 Effective Date: 10/01/2021 43 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KERALYT EXTERNAL 3 3 nolix GEL 6 % NORITATE 3 KERALYT EXTERNAL 3 NOVACORT EXTERNAL SHAMPOO 3 GEL 1-2 % KIVIK 3 NUCORT 3 KLARON 3 OLUX 3 KLISYRI 3 PA; QL OLUX-E 3 lactic acid e 3 ONEXTON 3 lactic acid external 3 ORACEA 3 PA LEVULAN KERASTICK 2 QL OVACE PLUS 3 LEXETTE 3 EXTERNAL CREAM LIDOCAINE- OVACE PLUS 3 HYDROCORTISONE 3 EXTERNAL FOAM ACE EXTERNAL OVACE PLUS 3 LOCOID 3 EXTERNAL SHAMPOO LOCOID LIPOCREAM 3 OVACE PLUS WASH 3 LUXIQ 3 OVACE WASH 3 methoxsalen rapid 1 QL PANDEL 3 METROCREAM 3 PENLEN 3 METROGEL 3 PHLAG SPRAY 3 METROLOTION 3 pimecrolimus cream 1 % 1 metronidazole external external 1 cream PIMECROLIMUS CREAM 1 metronidazole external 1 % EXTERNAL 1 gel 0.75 % PLEXION 3 metronidazole external 3 PLEXION CLEANSER 3 gel 1 % PLEXION CLEANSING metronidazole external 3 3 CLOTH lotion podocon 3 MIMYX 3 podofilox external 1 MIRVASO 3 PRAMOSONE furoate 1 EXTERNAL CREAM 1-1 2 external % myorisan 1 PRAMOSONE NEOSALUS EXTERNAL EXTERNAL CREAM 1- 3 3 CREAM 2.5 % NEOSALUS EXTERNAL PRAMOSONE 3 2 FOAM EXTERNAL LOTION NEO-SYNALAR pramox 3 3 EXTERNAL CREAM 3 neuac external gel 1 Effective Date: 10/01/2021 44 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 3 sodium sulfacetamide PRESERA 3 wash PROSILK EXTERNAL 3 SODIUM PROTEXA 3 SULFACETAMIDE- 3 PROTOPIC 3 BAKUCHIOL PRUCLAIR 3 SOOLANTRA 3 PRUDOXIN 3 SORIATANE 3 PA; QL PRUMYX 3 SORILUX 3 PSORCON 3 sss 10-5 3 sulfacetamide sodium PYROGALLIC ACID 3 1 (acne) QBREXZA 3 PA; QL sulfacetamide sodium 3 RESORCINOL-SULFUR 3 external RETIN-A 1 sulfacetamide sodium- 3 RETIN-A MICRO GEL sulfur external cream 1 0.04 %, 0.1 % sulfacetamide sodium- 1 RETIN-A MICRO PUMP sulfur external emulsion EXTERNAL GEL 0.04 %, 1 sulfacetamide sodium- 3 0.1 % sulfur external liquid RETIN-A MICRO PUMP sulfacetamide sodium- EXTERNAL GEL 0.06 %, 3 sulfur external lotion 10-5 1 0.08 % % RHOFADE 3 sulfacetamide sodium- rosadan external cream 1 sulfur external lotion 9.8- 3 4.8 % rosadan external gel 1 sulfacetamide sodium- ROSADAN EXTERNAL 3 3 sulfur external pad KIT sulfacetamide sodium- 3 SALEX 3 sulfur external suspension salicylic acid external 3 sulfacetamide sod-sulfur 3 salicylic acid wart wash 3 remover sulfacetamide-sulfur in 1 salimez 3 urea 3 SALIMEZ FORTE 3 sulfacleanse 8/4 3 SALVAX 3 sulfamez wash 3 SANTYL 2 SUMADAN WASH selenium sulfide external SUMAXIN 3 1 lotion SUVICORT 3 selenium sulfide external 3 synalar external cream 1 shampoo 2.25 % synalar external ointment 1 SERNIVO 3 SYNALAR EXTERNAL 3 sodium sulfacetamide 1 SOLUTION

Effective Date: 10/01/2021 45 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SYNERDERM 3 TRIDESILON 3 TACLONEX 3 tritocin 3 tacrolimus external 1 ULTRAVATE 3 tazarotene external cream 1 UMECTA MOUSSE 3 TAZAROTENE 3 3 URAMAXIN EXTERNAL FOAM urea external cream 39 TAZORAC EXTERNAL 3 2 %, 41 %, 45 %, 47 % CREAM 0.05 % urea external cream 40 % 1 TAZORAC EXTERNAL 3 CREAM 0.1 % UREA EXTERNAL FOAM 3 TAZORAC EXTERNAL urea hydrating 3 2 GEL urea nail 3 TEMOVATE 3 uredeb 3 TETRIX 3 uremez-40 1 TEXACORT 3 URESOL 3 TOPICORT 3 UTOPIC 3 TOPICORT SPRAY 3 VANOS 3 tovet external foam 3 VANOXIDE-HC 3 tretinoin external cream 1 VECTICAL 1 tretinoin external gel 0.01 1 VELTIN 3 %, 0.025 % VERDESO 3 tretinoin external gel 0.05 3 % VEREGEN 3 tretinoin microsphere 1 VIRASAL 3 tretinoin microsphere WINLEVI 3 PA 1 pump WYNZORA 3 PA; QL triamcinolone acetonide 3 XALIX 3 external aerosol solution XERALUX 3 triamcinolone acetonide 1 external cream xurea 3 triamcinolone acetonide zaclir cleansing 3 1 external lotion zenatane 1 triamcinolone acetonide ZIANA 3 external ointment 0.025 1 %, 0.1 %, 0.5 % ZITHRANOL 3 triamcinolone acetonide ZONALON 3 3 external ointment 0.05 % ZYCLARA 3 triamcinolone in 3 ZYCLARA PUMP 3 absorbase Diabetes - Antidiabetic Agents trianex 3 acarbose oral 1 triderm 1 ACTOPLUS MET 3 Effective Date: 10/01/2021 46 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACTOS 3 KOMBIGLYZE XR 3 PA ADLYXIN 3 PA; QL metformin hcl er 1 ADLYXIN STARTER metformin hcl er (mod) 3 PA 3 PA; QL PACK metformin hcl er (osm) ALOGLIPTIN BENZOATE 3 PA oral tablet extended 3 PA ALOGLIPTIN- release 24 hour 1000 mg 3 PA METFORMIN HCL metformin hcl er (osm) ALOGLIPTIN- oral tablet extended 3 3 PA PIOGLITAZONE release 24 hour 500 mg AMARYL 3 metformin hcl ir 1 BYDUREON BCISE miglitol 3 3 PA; QL nateglinide 3 BYETTA 10 MCG PEN 3 PA; QL NESINA 3 PA BYETTA 5 MCG PEN 3 PA; QL ONGLYZA 3 PA CYCLOSET 3 ST OSENI 3 PA DUETACT 3 OZEMPIC 3 PA; QL FARXIGA 3 PA; QL pioglitazone hcl 3 glimepiride 1 pioglitazone hcl- 3 glipizide er 1 glimepiride pioglitazone hcl- glipizide ir 1 3 metformin hcl glipizide xl 1 PRECOSE 3 glipizide-metformin hcl 3 QTERN 3 PA; QL GLUCOTROL XL 3 repaglinide 3 GLUMETZA 3 PA RIOMET 3 glyburide micronized 3 RYBELSUS 3 PA glyburide oral 1 SEGLUROMET 3 PA; QL glyburide-metformin 3 SOLIQUA 3 PA; QL GLYNASE 3 STEGLATRO 3 PA; QL GLYXAMBI 3 PA STEGLUJAN 3 PA; QL INVOKAMET 3 PA; QL SYMLINPEN 120 3 INVOKAMET XR 3 PA; QL SYMLINPEN 60 3 INVOKANA 3 PA; QL SYNJARDY 3 PA; QL JANUMET 3 PA SYNJARDY XR 3 PA; QL JANUMET XR 3 PA tolbutamide 1 JANUVIA 3 PA TRADJENTA 3 PA JARDIANCE 2 PA; QL TRIJARDY XR 3 PA; QL JENTADUETO 3 PA TRULICITY 3 PA; QL JENTADUETO XR 3 PA VICTOZA 3 PA; QL KAZANO 3 PA Effective Date: 10/01/2021 47 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XIGDUO XR 3 PA; QL DIATHRIVE LANCING 1 XULTOPHY 3 PA DEVICE DROPLET GENTEEL Diabetes - Glucose Monitoring 1 LANCING DEVICE

EASY TRAK II CONTROL 1 ACCU-CHEK COMPACT 1 EASYMAX 15 LEVEL 2-3 PLUS CONTROL 1 CONTROL ACCU-CHEK FASTCLIX 1 LANCET KIT EASYMAX CONTROL 1 ACCU-CHEK GUIDE GLUCOSE CONTROL 1 1 CONTROL ACCU-CHEK GUIDE EMBRACE LANCING 1 PA; QL 1 TEST STRIPS DEVICE/EJECTOR ACCU-CHEK EMBRACE TALK 1 1 SMARTVIEW CONTROL GLUCOSE CONTROL ACCU-CHEK SOFTCLIX FORTISCARE CONTROL 1 1 LANCET DEVICE KIT FREESTYLE TEST 1 PA; QL AGAMATRIX CONTROL GENTEEL LANCING KIT 1 1 LEVEL 2 (BLUE) AGAMATRIX CONTROL 1 GOJJI CONTROL 1 LEVEL 4 GOJJI LANCING AUTOLET LANCING 1 1 DEVICE/CLEAR CAP DEVICE LANCETS 1 BLULINK CONTROL 1 MICROLET NEXT HIGH & LOW 1 LANCING DEVICE CARETOUCH CONTROL 1 OMNIPOD DASH SOL LEVEL 2 3 PA SYSTEM CARETOUCH 1 LANCING/EJECTOR OMNIPOD STARTER 3 PA ONETOUCH DELICA CHEMSTRIP 10 MD 2 1 LANCING DEV CHEMSTRIP 10/SG 2 ONETOUCH DELICA 1 CHEMSTRIP 2 GP 2 PLUS LANCING 2 ONETOUCH DELICA CHEMSTRIP 5 OB 1 SAFETY LANCING CHEMSTRIP 7 2 ONETOUCH ULTRA 1 QL CHEMSTRIP 9 2 TEST STRIPS CONTOUR CONTROL ONETOUCH VERIO IN 1 1 SOLUTION VITRO SOLUTION HIGH CONTOUR NEXT ONETOUCH VERIO 1 1 QL CONTROL SOLUTION TEST STRIPS CONTOUR NEXT TEST SURESTEP PRO HIGH 1 PA; QL 1 STRIPS GLUCOSE DIATHRIVE GLUCOSE SURESTEP PRO LOW 1 1 CONTROL SOLN GLUCOSE Effective Date: 10/01/2021 48 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SURESTEP PRO BD AUTOSHIELD DUO 1 1 NORMAL GLUCOSE PEN NEEDLES 1 BD ULTRA-FINE TRUE METRIX LEVEL 1 1 INSULIN SYRINGES TRUE METRIX LEVEL 2 1 BD ULTRA-FINE PEN 1 TRUE METRIX LEVEL 3 1 NEEDLES UNISTRIP CONTROL IN 1 FIASP 3 VITRO SOLUTION LOW FIASP FLEXTOUCH 3 V-GO 20 3 PA V-GO 30 3 PA FIASP PENFILL 3 V-GO 40 3 PA HUMALOG 2 VIVAGUARD INO HUMALOG KWIKPEN 2 1 CONTROL SOLUTION HUMALOG MIX 50/50 3 VIVAGUARD LANCING KWIKPEN 1 DEVICE HUMALOG MIX 50/50 3 Diabetes - Glycemic Agents VIAL HUMALOG MIX 75/25 BAQSIMI ONE PACK 2 3 KWIKPEN BAQSIMI TWO PACK 2 HUMALOG MIX 75/25 3 diazoxide oral 2 VIAL GLUCAGEN HYPOKIT 2 HUMALOG U-100 2 glucagon emergency kit 1 JUNIOR KWIKPEN 1 mg injection 1 mg HUMULIN 70/30 1 GLUCAGON KWIKPEN EMERGENCY KIT 1 MG 2 HUMULIN 70/30 VIAL 1 INJECTION 1 MG HUMULIN N KWIKPEN 1 GLUCAGON 3 EMERGENCY KIT HUMULIN N VIAL 1 GVOKE HYPOPEN 1- HUMULIN R U-500 3 QL 1 PACK KWIKPEN GVOKE HYPOPEN 2- HUMULIN R U-500 VIAL 1 3 QL PACK HUMULIN R VIAL 1 GVOKE PFS 3 QL INSULIN ASP PROT & 3 PROGLYCEM 3 ASP FLEXPEN ZEGALOGUE 3 PA INSULIN ASPART 3 INSULIN ASPART Diabetes - Insulins 3 FLEXPEN ADMELOG 3 INSULIN ASPART 3 ADMELOG SOLOSTAR 3 PENFILL AFREZZA 3 PA INSULIN ASPART PROT 3 APIDRA SOLOSTAR 3 & ASPART APIDRA VIAL 3 BASAGLAR KWIKPEN 3 PA

Effective Date: 10/01/2021 49 Drug Drug Drug Name Notes Drug Name Notes Tier Tier INSULIN LISPRO (1 LANTUS U-100 VIAL 2 PA UNIT DIAL) SOLUTION LEVEMIR U-100 2 PA PEN-INJECTOR 100 2 FLEXTOUCH UNIT/ML SUBCUTANEOUS LEVEMIR U-100 VIAL 2 PA INSULIN LISPRO (1 LYUMJEV KWIKPEN 3 PA UNIT DIAL) SOLUTION LYUMJEV VIAL 3 PA PEN-INJECTOR 100 3 NOVOFINE UNIT/ML AUTOCOVER PEN 1 SUBCUTANEOUS NEEDLE INSULIN LISPRO NOVOFINE PEN 3 1 JUNIOR KWIKPEN NEEDLE INSULIN LISPRO PROT NOVOFINE PLUS PEN 3 1 & LISPRO NEEDLE INSULIN LISPRO NOVOLIN 70/30 3 ST SOLUTION 100 UNIT/ML 2 FLEXPEN SUBCUTANEOUS NOVOLIN 70/30 3 ST INSULIN LISPRO FLEXPEN RELION SOLUTION 100 UNIT/ML 3 SUBCUTANEOUS NOVOLIN 70/30 RELION 3 ST INSULIN PEN NEEDLES NOVOLIN 70/30 VIAL 3 ST 29G X 12.7MM , 29G X NOVOLIN N FLEXPEN 3 ST 12MM , 29G X 5MM , NOVOLIN N FLEXPEN 29G X 8MM , 30G X 5 3 ST RELION MM , 30G X 8 MM , 31G X 4 MM , 31G X 5 MM , NOVOLIN N RELION 3 ST 1 31G X 6 MM , 31G X 8 NOVOLIN N VIAL 3 ST MM , 32G X 4 MM , 32G NOVOLIN R FLEXPEN 3 ST X 5 MM , 32G X 6 MM , NOVOLIN R FLEXPEN 32G X 8 MM , 33G X 4 3 ST MM , 33G X 5 MM , 33G RELION X 6 MM NOVOLIN R RELION 3 ST INSULIN SYRINGES 27G NOVOLIN R VIAL 3 ST X 1/2" 0.5 ML, 27G X 1/2" NOVOLOG 70/30 1 ML, 28G X 1/2" 0.5 ML, 3 28G X 1/2" 1 ML, 29G X FLEXPEN RELION 1/2" 0.3 ML, 29G X 1/2" NOVOLOG FLEXPEN 3 0.5 ML, 29G X 1/2" 1 ML, NOVOLOG FLEXPEN 3 30G X 1/2" 0.3 ML, 30G X RELION 1/2" 0.5 ML, 30G X 1/2" 1 1 NOVOLOG MIX 70/30 ML, 30G X 5/16" 0.3 ML, 3 30G X 5/16" 0.5 ML, 30G FLEXPEN X 5/16" 1 ML, 31G X NOVOLOG MIX 70/30 3 15/64" 0.3 ML, 31G X RELION 15/64" 0.5 ML, 31G X NOVOLOG MIX 70/30 15/64" 1 ML, 31G X 5/16" 3 VIAL 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML NOVOLOG PENFILL 3 LANTUS SOLOSTAR 2 PA NOVOLOG RELION 3

Effective Date: 10/01/2021 50 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NOVOLOG U-100 VIAL 3 EXJADE 3 PA; QL NOVOTWIST PEN FERRIPROX ORAL 1 3 PA NEEDLE SOLUTION FERRIPROX TWICE-A- SEMGLEE 3 PA 3 PA; QL DAY TOUJEO MAX 3 PA SOLOSTAR fluoritab 3 TOUJEO SOLOSTAR 3 PA folic acid injection 1 TRESIBA 3 PA folic acid oral tablet 1 mg 1 TRESIBA FLEXTOUCH 3 PA FOLVITE-D 3 ULTIGUARD SAFEPACK 1 GENICIN VITA-D 3 SYR/NEEDLE iodine strong oral 3 Electrolytes / Minerals / Metals / Vitamins JADENU 3 PA; QL ACCRUFER 3 PA JADENU SPRINKLE 3 PA; QL argyle sterile saline 1 JYNARQUE ORAL 3 PA; QL argyle sterile water 3 TABLET 30 MG CARBAGLU 3 PA; QL JYNARQUE ORAL CARNITOR ORAL 1 TABLET THERAPY 3 PA; QL PACK CARNITOR SF 1 klor-con 1 CHEMET 3 klor-con 10 1 clovique 3 PA; QL klor-con m10 1 curity sterile saline 1 klor-con m15 2 cyanocobalamin injection 1 solution 1000 mcg/ml klor-con m20 1 cytra k crystals 1 klor-con/ef 3 DECARA K 3 K-PHOS 3 deferasirox granules 3 QL K-PHOS NO 2 3 deferasirox oral packet 3 QL K-PHOS-NEUTRAL 3 deferasirox oral tablet 3 PA; QL k-prime 3 deferasirox oral tablet 3 PA; QL K-TAB 3 soluble levocarnitine oral solution 1 deferiprone 3 PA; QL levocarnitine oral tablet 1 DEXPANTHENOL 3 INJECTION levocarnitine sf 1 DRISDOL 3 LOKELMA 3 PA; QL MAGNESIUM SULFATE EFFER-K ORAL TABLET 3 EFFERVESCENT 10 3 INJECTION MEQ, 20 MEQ MEPHYTON 1 effer-k oral tablet 3 MIFEPREX 3 effervescent 25 meq 3 ergocalciferol oral capsule 1

Effective Date: 10/01/2021 51 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nafrinse 1 tricitrates 1 nafrinse drops 3 trientine hcl 3 PA; QL ORACIT 2 UROCIT-K 10 3 phospha 250 neutral 1 UROCIT-K 15 3 phosphorous 1 UROCIT-K 5 3 phospho-trin 250 neutral 1 VELTASSA 3 PA phytonadione injection 1 virt-phos 250 neutral 1 phytonadione oral 1 vitamin d (ergocalciferol) oral capsule 1.25 mg 1 pot & sod cit-cit ac 1 (50000 ut) potassium chloride crys er vitamin k1 injection 1 oral tablet extended 1 release 10 meq, 20 meq water for irrigation, sterile 3 Gastrointestinal Agents - Drugs for Acid potassium chloride crys er oral tablet extended 2 Reflux and Ulcer release 15 meq ACIPHEX 3 ST potassium chloride er 1 ACIPHEX SPRINKLE 3 PA potassium chloride oral 1 CARAFATE 3 potassium citrate er 1 cimetidine hcl 1 potassium citrate-citric 1 cimetidine oral 1 acid CYTOTEC 3 SAMSCA ORAL TABLET 3 PA; QL 30 MG DEXILANT 3 PA esomeprazole sod citrate- 1 3 PA magnesium oral packet sodium chloride (pf) 1 ESOMEPRAZOLE 3 PA sodium chloride irrigation 1 STRONTIUM sodium fluoride oral famotidine oral 1 1 solution 1.1 (0.5 f) mg/ml suspension reconstituted sodium fluoride oral tablet famotidine oral tablet 20 1 1 1.1 (0.5 f) mg mg, 40 mg sodium fluoride oral tablet FIRST-LANSOPRAZOLE 3 3 2.2 (1 f) mg FIRST-OMEPRAZOLE 3 sodium fluoride oral tablet 1 lansoprazole oral capsule chewable 1 delayed release sodium polystyrene 1 lansoprazole oral tablet sulfonate delayed release 3 PA sps 1 dispersible sterile water for irrigation 3 misoprostol oral 1 SYPRINE 3 PA; QL NEXIUM ORAL PACKET 3 PA tolvaptan oral tablet 30 3 PA; QL nizatidine 3 mg

Effective Date: 10/01/2021 52 Drug Drug Drug Name Notes Drug Name Notes Tier Tier omeprazole oral capsule 1 1 diphenoxylate- delayed release ed-spaz 3 OMEPRAZOLE+SYRSPE 3 ND SF ALKA ENTEREG 3 omeprazole-sodium enulose 1 3 PA bicarbonate oral packet GASTROCROM 3 pantoprazole sodium oral 3 GATTEX 3 PA; QL packet gavilyte-c 1 pantoprazole sodium oral 1 tablet delayed release gavilyte-g 1 PEPCID 3 gavilyte-n with flavor pack 1 PREVACID 3 generlac 1 glycopyrrolate injection PREVACID SOLUTAB 3 PA 1 solution PRILOSEC 3 glycopyrrolate oral tablet 1 PROTONIX ORAL 3 1 mg, 2 mg rabeprazole sodium oral GLYCOPYRROLATE 1 ST 3 tablet delayed release ORAL TABLET 1.5 MG sucralfate oral 1 GOLYTELY 3 ZEGERID ORAL 3 PA HELIDAC THERAPY 2 PACKET hyoscyamine sulfate er 3 Gastrointestinal Agents - Drugs for Bowel, hyoscyamine sulfate Intestine and Stomach Conditions 3 injection alosetron hcl 3 QL hyoscyamine sulfate oral 3 alvimopan 3 hyoscyamine sulfate sl 3 AMITIZA 3 PA; QL hyoscyamine sulfate amoxicill-clarithro- 3 3 sublingual lansopraz hyosyne 3 ANASPAZ 3 KRISTALOSE 3 belladonna alkaloids- 1 QL opium lactulose encephalopathy 1 BENTYL 3 lactulose oral packet 3 CHENODAL 3 lactulose oral solution 1 chlordiazepoxide- LEVBID 3 1 QL clidinium LEVSIN 3 CLENPIQ 3 LEVSIN/SL 3 1 constulose LIBRAX 3 QL cromolyn sodium oral 3 LINZESS ORAL CUVPOSA 3 CAPSULE 145 MCG, 290 3 PA; QL MCG dicyclomine hcl 3 LINZESS ORAL intramuscular 3 PA CAPSULE 72 MCG dicyclomine hcl oral 1 Effective Date: 10/01/2021 53 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LOMOTIL 3 SYMAX DUOTAB 3 loperamide hcl oral 3 1 symax-sl capsule symax-sr 3 LOTRONEX 3 PA; QL SYMPROIC 3 PA; QL LUBIPROSTONE 3 PA; QL TALICIA 3 methscopolamine 3 bromide oral TRULANCE 3 PA; QL MOTEGRITY 3 PA; QL URSO 250 3 MOTOFEN 3 URSO FORTE 3 MOVANTIK 3 PA; QL URSODIOL ORAL CAPSULE 200 MG, 400 3 PA; QL MOVIPREP 3 MG MYTESI 3 ursodiol oral capsule 300 1 nulev 3 mg NULYTELY LEMON- ursodiol oral tablet 1 3 LIME VIBERZI 3 PA OMECLAMOX-PAK 3 XERMELO 3 PA; QL opium 1 QL ZELNORM 3 PA; QL oscimin 3 ZORBTIVE 3 PA; QL Genetic or Enzyme Disorder - Drugs for oscimin sr 3 Replacement, Modification, Treatment OSMOPREP 3 BUPHENYL 3 PA; QL peg 3350-kcl-na bicarb- 1 nacl CERDELGA 2 PA; QL peg-3350/electrolytes 1 CHOLBAM 3 PA; QL peg- CREON 2 3350/electrolytes/ascorba 3 CRYSVITA 3 PA; QL t CYSTADANE 3 peg-kcl-nacl-nasulf-na 3 asc-c CYSTAGON 2 PA EVRYSDI 3 PA; QL peg-prep 3 GALAFOLD 3 PA; QL PLENVU 3 KUVAN 3 PA; QL PROBICHEW 3 miglustat 3 PA; QL PYLERA 2 MYALEPT 3 PA; QL RELISTOR ORAL 3 PA; QL nitisinone 3 PA; QL RELISTOR 2 PA SUBCUTANEOUS NITYR 3 PA; QL RELTONE 3 PA; QL OCALIVA 3 PA; QL SEROSTIM 3 PA; QL ORFADIN ORAL CAPSULE 10 MG, 2 MG, 3 PA; QL SUPREP BOWEL PREP 3 5 MG KIT ORFADIN ORAL 3 PA SUTAB 3 CAPSULE 20 MG Effective Date: 10/01/2021 54 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORFADIN ORAL GEMTESA 3 PA 3 PA; QL SUSPENSION hyophen 3 PANCREAZE 3 INTRAROSA 3 PA; QL PERTZYE 3 lanthanum carbonate 3 QL PROCYSBI 3 PA; QL LITHOSTAT 3 RAVICTI 3 PA; QL me/naphos/mb/hyo1 3 sapropterin 3 PA; QL MYRBETRIQ ORAL dihydrochloride SUSPENSION 3 PA sodium phenylbutyrate 3 QL RECONSTITUTED ER oral MYRBETRIQ ORAL STRENSIQ 3 PA; QL TABLET EXTENDED 3 ST SUCRAID 3 PA RELEASE 24 HOUR VIOKACE 3 oxybutynin chloride er 1 ZAVESCA 3 PA; QL oxybutynin chloride oral 1 ZENPEP 2 OXYTROL 3 ST Genitourinary Agents - Drugs for Bladder, penicillamine oral capsule 1 PA; QL

Genital and Kidney Conditions penicillamine oral tablet 2 PA; QL acetic acid irrigation 1 PENTOSAN AURYXIA 3 PA; QL POLYSULFATE SODIUM 2 ORAL bethanechol chloride oral 1 phenazo oral tablet 200 calcium acetate (phos 1 1 mg binder) phenazopyridine hcl oral calcium acetate oral tablet 1 1 tablet 100 mg, 200 mg 667 mg PHOSLYRA 3 CERVIDIL 2 phosphasal 3 CUPRIMINE 3 PA; QL PREPIDIL 2 darifenacin hydrobromide 1 er PYRIDIUM 3 DEPEN TITRATABS 3 PA; QL RENACIDIN 3 DETROL 3 RENAGEL 3 DETROL LA 3 RENVELA 3 DITROPAN XL 3 RIMSO-50 3 ELMIRON 2 sevelamer carbonate 1 FEM PH 3 sevelamer hcl 1 flavoxate hcl 1 solifenacin succinate 1 FOSRENOL ORAL THIOLA 3 3 PACKET THIOLA EC 3 PA FOSRENOL ORAL 3 PA; QL tiopronin oral 3 TABLET CHEWABLE tolterodine tartrate 1 GELNIQUE 3 ST

Effective Date: 10/01/2021 55 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tolterodine tartrate er 1 BETAMETHASONE SODIUM PHOSPHATE 3 TOVIAZ 3 ST INJECTION trospium chloride 1 CORTEF 3 trospium chloride er 1 DECADRON 3 urelle 3 DEPO-MEDROL uribel 3 INJECTION 2 SUSPENSION 20 MG/ML URIMAR-T 3 DEPO-MEDROL urin ds 3 INJECTION 3 URO-458 3 SUSPENSION 40 UROGESIC-BLUE 3 MG/ML, 80 MG/ML 3 uro-mp 3 DEXABLISS 3 ustell 3 (LA) 2 utira-c 3 dexamethasone intensol VELPHORO 3 PA; QL dexamethasone oral 1 dexamethasone oral VESICARE 3 1 solution VESICARE LS 3 dexamethasone oral 1 vilamit mb 3 tablet VILEVEV MB 3 dexamethasone oral 3 Genitourinary Agents - Drugs for Prostate tablet therapy pack

Conditions dexamethasone sod phosphate pf injection 1 alfuzosin hcl er 1 solution 3 AVODART dexamethasone sodium CARDURA XL 3 phosphate injection 1 solution 100 mg/10ml, dutasteride oral 1 120 mg/30ml, 20 mg/5ml 3 dutasteride-tamsulosin hcl DEXAMETHASONE finasteride oral tablet 5 SODIUM PHOSPHATE 1 3 mg SOLUTION 10 MG/ML FLOMAX 3 INJECTION dexamethasone sodium JALYN 3 phosphate solution 10 1 PROSCAR 3 mg/ml injection RAPAFLO 3 DEXAMETHASONE SODIUM PHOSPHATE silodosin 3 3 SOLUTION 4 MG/ML tamsulosin hcl 1 INJECTION terazosin hcl 1 dexamethasone sodium UROXATRAL 3 phosphate solution 4 1 mg/ml injection Hormonal Agents - Adrenal DEXONTO 0.4% 3 ALKINDI SPRINKLE 3 PA; QL DXEVO 11-DAY 3 Effective Date: 10/01/2021 56 Drug Drug Drug Name Notes Drug Name Notes Tier Tier acetate SOLU-MEDROL 1 oral INJECTION SOLUTION 3 HEMADY 3 PA RECONSTITUTED 125 MG HIDEX 6-DAY 3 TAPERDEX 12-DAY 3 hydrocortisone oral 1 TAPERDEX 6-DAY 3 KENALOG INJECTION 3 TAPERDEX 7-DAY 3 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 3 TRIAMCINOLONE MG ACETONIDE INJECTION 3 SUSPENSION 50 MG/ML MEDROL ORAL TABLET 2 2 MG triamcinolone acetonide suspension 40 mg/ml 3 MEDROL ORAL TABLET 3 injection THERAPY PACK TRIAMCINOLONE METHYLPREDNISOLON ACETONIDE 3 3 E ACE-LIDO SUSPENSION 40 MG/ML METHYLPREDNISOLON INJECTION E ACETATE INJECTION TRIAMCINOLONE 3 3 SUSPENSION 40 DIACETATE INJECTION MG/ML, 80 MG/ML ZCORT 7-DAY 3 oral 1 Hormonal Agents - Men's Health methylprednisolone sodium succ injection ANDRODERM 3 PA; QL 1 solution reconstituted 125 ANDROGEL 3 PA; QL mg ANDROGEL PUMP 3 PA; QL MILLIPRED 3 oral 1 ORAPRED ODT 3 DEPO-TESTOSTERONE PEDIAPRED 3 (brand testosterone 1 PA cypionate intramuscular) oral solution 1 FORTESTA 3 PA; QL prednisolone sodium phosphate oral solution 3 JATENZO 3 PA 10 mg/5ml, 20 mg/5ml METHITEST 3 PA prednisolone sodium methyltestosterone oral 3 PA phosphate oral solution 1 NATESTO 3 PA; QL 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml oxandrolone oral 3 prednisolone sodium TESTIM 3 PA; QL phosphate oral tablet 3 TESTONE CIK 3 dispersible TESTOSTERONE 1 PA intensol 3 CYPIONATE INJECTION prednisone oral 1 testosterone cypionate 1 PA RAYOS 3 PA intramuscular testosterone enanthate SOLU-CORTEF 2 1 PA intramuscular

Effective Date: 10/01/2021 57 Drug Drug Drug Name Notes Drug Name Notes Tier Tier testosterone transdermal leuprolide acetate 1 gel 1.62 %, 12.5 mg/act injection (1%), 20.25 mg/act 1 PA; QL LUPRON DEPOT (1- 2 (1.62%), 25 mg/2.5gm MONTH) (1%), 50 mg/5gm (1%) LUPRON DEPOT (3- 2 testosterone transdermal MONTH) gel 10 mg/act (2%), 20.25 3 PA; QL mg/1.25gm (1.62%), 40.5 LUPRON DEPOT (4- MONTH) mg/2.5gm (1.62%) 2 INTRAMUSCULAR KIT testosterone transdermal 3 PA; QL 30MG solution LUPRON DEPOT (6- VOGELXO 3 PA; QL MONTH) 2 VOGELXO PUMP 3 PA; QL INTRAMUSCULAR KIT XYOSTED 3 PA 45MG LUPRON DEPOT-PED Hormonal Agents - Osteoporosis 2 (1-MONTH) EVISTA 3 LUPRON DEPOT-PED 2 OSPHENA 3 PA (3-MONTH) raloxifene hcl 1 MYCAPSSA 3 PA; QL Hormonal Agents - Pituitary NOCDURNA 3 PA NORDITROPIN ACTHAR 2 PA; QL 3 PA; QL FLEXPRO cabergoline 1 NUTROPIN AQ NUSPIN 3 3 PA; QL DDAVP 10 DDAVP PF 3 NUTROPIN AQ NUSPIN 3 PA; QL desmopressin ace spray 20 1 refrig NUTROPIN AQ NUSPIN 3 PA; QL desmopressin acetate 5 1 injection octreotide acetate 1 DESMOPRESSIN 2 OMNITROPE 2 PA; QL ACETATE NASAL ORILISSA 3 PA; QL desmopressin acetate 1 oral SAIZEN 3 PA; QL desmopressin acetate pf 1 SAIZENPREP 3 PA; QL desmopressin acetate SANDOSTATIN 3 PA 1 spray SANDOSTATIN LAR 2 QL EGRIFTA SV 3 QL DEPOT SIGNIFOR 3 PA; QL ELIGARD 3 SOMATULINE DEPOT 3 PA GENOTROPIN 3 PA; QL SOMAVERT 3 PA; QL GENOTROPIN 3 PA; QL MINIQUICK STIMATE 2 HUMATROPE 3 PA; QL SYNAREL 3 QL INCRELEX 3 PA; QL ZOMACTON 3 PA; QL ISTURISA 3 PA; QL Effective Date: 10/01/2021 58 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOMACTON (FOR 1 3 PA; QL blisovi fe 1.5/30 ZOMA-JET 10) blisovi fe 1/20 1 Hormonal Agents - Prostaglandins briellyn 1 KORLYM 3 PA; QL camila 1 Hormonal Agents - Sex Hormones and Birth

Control camrese 3 ACTIVELLA 3 camrese lo 3 afirmelle 1 caziant 1 AFTERPILL 1 charlotte 24 fe 3 ALORA 3 chateal 1 altavera 1 chateal eq 1 alyacen 1/35 1 CLIMARA 1 alyacen 7/7/7 1 CLIMARA PRO 3 amabelz 3 COMBIPATCH 3 amethia 3 covaryx 3 amethyst 3 covaryx hs 3 ANGELIQ 3 CRINONE 3 ANNOVERA 3 cryselle-28 1 apri 1 cyclafem 1/35 1 aranelle 1 cyclafem 7/7/7 1 ashlyna 3 cyred 1 aubra 1 cyred eq 1 aubra eq 1 dasetta 1/35 1 aurovela 1.5/30 1 dasetta 7/7/7 1 aurovela 1/20 1 daysee 3 aurovela 24 fe 3 deblitane 1 aurovela fe 1.5/30 1 DELESTROGEN 2 aurovela fe 1/20 1 delyla 1 aviane 1 DEPO-ESTRADIOL 2 AYGESTIN 3 DEPO-PROVERA 3 DEPO-SUBQ PROVERA ayuna 1 3 104 azurette 3 -ethinyl BALCOLTRA 3 estradiol oral tablet 0.15- 3 balziva 1 0.02/0.01 mg (21/5) desogestrel-ethinyl BEYAZ 3 estradiol oral tablet 0.15- 1 BIJUVA 3 30 mg-mcg blisovi 24 fe 3 DIVIGEL 3 Effective Date: 10/01/2021 59 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dolishale 3 ESTROGEL 3 dotti 3 ESTROSTEP FE 3 drospiren-eth estrad- ethynodiol diac-eth 3 1 levomefol estradiol drospirenone-ethinyl -ethinyl 1 estradiol oral tablet 3-0.02 3 estradiol mg EVAMIST 3 drospirenone-ethinyl falmina 1 estradiol oral tablet 3-0.03 1 mg fayosim 3 DUAVEE 3 FEMHRT 3 eemt 3 FEMRING 2 eemt hs 3 femynor 1 3 FIRST- ELESTRIN 3 VGS elinest 1 fyavolv 3 ELLA 2 gemmily 3 eluryng 1 GENERESS FE 3 emoquette 1 gianvi oral tablet 3-0.02 3 ENDOMETRIN 3 mg enpresse-28 1 hailey 1.5/30 1 enskyce 1 hailey 24 fe 3 errin 1 hailey fe 1.5/30 1 est estrogens-methyltest 3 hailey fe 1/20 1 est estrogens-methyltest 3 heather 1 ds hydroxyprogesterone est estrogens-methyltest 1 3 caproate intramuscular oil hs iclevia 3 estarylla 1 IMVEXXY 3 ESTRACE 3 MAINTENANCE PACK estradiol oral 1 IMVEXXY STARTER 3 estradiol transdermal PACK 3 patch twice weekly incassia 1 estradiol transdermal 1 introvale 3 patch weekly isibloom 1 estradiol vaginal 1 jaimiess 3 estradiol valerate 1 intramuscular jasmiel 3 estradiol-norethindrone jencycla 1 3 acet jinteli 3 ESTRING 2 jolessa 3 Effective Date: 10/01/2021 60 Drug Drug Drug Name Notes Drug Name Notes Tier Tier juleber 1 LOESTRIN 1.5/30 (21) 3 junel 1.5/30 1 LOESTRIN 1/20 (21) 3 junel 1/20 1 LOESTRIN FE 1.5/30 3 junel fe 1.5/30 1 LOESTRIN FE 1/20 3 junel fe 1/20 1 lojaimiess 3 junel fe 24 3 loryna 3 kaitlib fe 3 LOSEASONIQUE 3 kalliga 1 low-ogestrel 1 kariva 3 lo-zumandimine 3 kelnor 1/35 1 lutera 1 kelnor 1/50 1 lyleq 1 kurvelo 1 lyllana 3 larin 1.5/30 1 lyza 1 1 MAKENA larin 1/20 3 PA INTRAMUSCULAR larin 24 fe 3 MAKENA 2 QL larin fe 1.5/30 1 SUBCUTANEOUS larin fe 1/20 1 marlissa 1 larissia 1 medroxyprogesterone 1 layolis fe 3 acetate intramuscular medroxyprogesterone leena 1 1 acetate oral lessina 1 oral levonest 1 suspension 40 mg/ml, 1 levonorgest-eth est & eth 400 mg/10ml 3 est megestrol acetate oral 3 levonorgest-eth estrad suspension 625 mg/5ml 3 91-day megestrol acetate oral 1 levonorgestrel 1 tablet levonorgestrel-ethinyl MENEST 3 estrad oral tablet 0.1-20 1 MENOSTAR 3 mg-mcg, 0.15-30 mg-mcg merzee 3 levonorgestrel-ethinyl estrad oral tablet 90-20 3 mibelas 24 fe 3 mcg microgestin 1.5/30 1 levonorg-eth estrad 1 microgestin 1/20 1 triphasic microgestin 24 fe 3 levora 0.15/30 (28) 1 microgestin fe 1.5/30 1 LILETTA (52 MG) 3 microgestin fe 1/20 1 lillow 1 mili 1 LO LOESTRIN FE 3 Effective Date: 10/01/2021 61 Drug Drug Drug Name Notes Drug Name Notes Tier Tier mimvey 3 ORIAHNN 3 PA; QL MINASTRIN 24 FE 3 orsythia 1 MINIVELLE 3 PARAGARD INTRAUTERINE 2 MIRCETTE 3 COPPER MIRENA (52 MG) 2 philith 1 mono-linyah 1 pimtrea 3 MYFEMBREE 3 PA; QL pirmella 1/35 1 NATAZIA 3 pirmella 7/7/7 1 necon 0.5/35 (28) 1 PLAN B ONE-STEP 3 NEXTSTELLIS 3 portia-28 1 nikki 3 PREFEST 3 nora-be 1 PREMARIN ORAL 3 ST norethin ace-eth estrad-fe 3 PREMARIN VAGINAL 2 oral capsule PREMPHASE 3 norethin ace-eth estrad-fe 1 oral tablet PREMPRO 3 norethin ace-eth estrad-fe 1 3 preventeza oral tablet chewable previfem 1 norethindrone acetate 1 progesterone oral 1 intramuscular norethindrone acet-ethinyl 1 est progesterone oral 1 norethindrone oral 1 PROMETRIUM 3 norethindrone-eth PROVERA 3 3 estradiol QUARTETTE 3 norethin-eth estradiol-fe 3 reclipsen 1 norgestimate-eth estradiol 1 rivelsa 3 norgestimate-ethinyl 1 SAFYRAL 3 estradiol triphasic SEASONIQUE 3 norlyda 1 setlakin 3 norlyroc 1 sharobel 1 nortrel 0.5/35 (28) 1 simliya 3 nortrel 1/35 (21) 1 simpesse 3 nortrel 1/35 (28) 1 SKYLA 2 nortrel 7/7/7 1 SLYND 3 NUVARING 3 sprintec 28 1 nylia 7/7/7 1 sronyx 1 nymyo 1 syeda 1 ocella 1 Effective Date: 10/01/2021 62 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tarina 24 fe 3 wera 1 tarina fe 1/20 1 wymzya fe 3 tarina fe 1/20 eq 1 xulane 1 taysofy 3 YASMIN 28 3 TAYTULLA CAPSULE 1- 3 3 YAZ 20 MG-MCG(24) ORAL yuvafem 1 TAYTULLA CAPSULE 1- 3 PA 20 MG-MCG(24) ORAL zafemy 1 tilia fe 3 zarah 1 tri femynor 1 zovia 1/35 (28) 1 tri-estarylla 1 zovia 1/35e (28) 1 tri-legest fe 3 zumandimine 1 tri-linyah 1 Hormonal Agents - Thyroid tri-lo-estarylla 1 ARMOUR THYROID 3 tri-lo-marzia 1 CYTOMEL 3 tri-lo-mili 1 euthyrox 3 tri-lo-sprintec 1 levo-t 3 LEVOTHYROXINE tri-mili 1 SODIUM ORAL 3 tri-nymyo 1 CAPSULE tri-previfem 1 levothyroxine sodium oral 1 tablet tri-sprintec 1 levoxyl 3 trivora (28) 1 liothyronine sodium oral 1 tri-vylibra 1 methimazole oral 1 tri-vylibra lo 1 NATURE-THROID 3 tulana 1 np thyroid 3 TWIRLA 3 propylthiouracil oral 1 tyblume 1 SYNTHROID 3 tydemy 3 TAPAZOLE 3 VAGIFEM 3 THYQUIDITY 3 velivet 1 TIROSINT 3 vestura 3 TIROSINT-SOL 3 vienva 1 unithroid 3 viorele 3 WESTHROID 3 VIVELLE-DOT 3 WP THYROID 3 volnea 3 Immunological Agents - Drugs for Immune vyfemla 1 System Stimulation or Suppression vylibra 1 ACTEMRA ACTPEN 3 PA; QL Effective Date: 10/01/2021 63 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACTEMRA HIZENTRA 2 PA; QL 3 PA; QL SUBCUTANEOUS HUMIRA 2 PA; QL ACTIMMUNE 3 QL HUMIRA PEDIATRIC 2 PA; QL ALFERON N 3 CROHNS START ARAVA 3 HUMIRA PEN 2 PA; QL HUMIRA PEN-CD/UC/HS ARCALYST 3 PA; QL 2 PA; QL STARTER ASTAGRAF XL 3 HUMIRA PEN- 2 PA; QL AZASAN 3 PEDIATRIC UC START azathioprine oral 1 HUMIRA PEN- 2 PA; QL BENLYSTA PS/UV/ADOL HS START 3 PA; QL SUBCUTANEOUS HUMIRA PEN- 2 PA; QL BERINERT 2 PA; QL PSOR/UVEIT STARTER CELLCEPT 3 HYPERHEP B 2 CIMZIA 3 PA; QL HYPERRAB INJECTION SOLUTION 1500 3 CIMZIA PREFILLED KIT 3 PA; QL UNIT/5ML, 300 UNIT/ML CIMZIA STARTER KIT 3 PA; QL HYPERRAB INJECTION CINRYZE 3 PA; QL SOLUTION 900 3 PA COSENTYX (300 MG UNIT/3ML 2 PA; QL DOSE) HYPERTET S/D 3 COSENTYX 150 MG/ML 2 PA; QL HYQVIA 2 PA; QL COSENTYX 2 PA; QL icatibant acetate 2 PA; QL SENSOREADY (300 MG) IMOGAM RABIES-HT 3 COSENTYX 2 PA; QL SENSOREADY PEN IMURAN 3 CUTAQUIG 3 PA; QL KEDRAB 3 CUVITRU 2 PA; QL KEVZARA 3 PA; QL cyclosporine modified 1 KINERET 3 PA; QL cyclosporine oral 1 leflunomide oral 1 ENBREL 2 PA; QL LUPKYNIS 3 PA; QL ENBREL MINI 2 PA; QL methotrexate oral 1 ENBREL SURECLICK 2 PA; QL methotrexate sodium 1 ENSPRYNG 3 PA; QL methotrexate sodium (pf) 1 ENVARSUS XR 3 mycophenolate mofetil 1 everolimus oral tablet oral 3 QL 0.25 mg, 0.5 mg, 0.75 mg mycophenolate sodium 1 FIRAZYR 3 PA; QL MYFORTIC 3 gengraf 1 NABI-HB 2 HAEGARDA 3 PA; QL NEORAL 3 HEPAGAM B 3 OLUMIANT 3 PA; QL

Effective Date: 10/01/2021 64 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORENCIA CLICKJECT 2 PA; QL XATMEP 3 QL ORENCIA XELJANZ ORAL 2 PA; QL 3 PA; QL SUBCUTANEOUS SOLUTION ORLADEYO 3 PA; QL XELJANZ ORAL TABLET 2 PA; QL OTEZLA 2 PA; QL XELJANZ XR 2 PA; QL OTREXUP XEMBIFY 3 PA; QL SUBCUTANEOUS ZORTRESS 3 QL SOLUTION AUTO- INJECTOR 10 MG/0.4ML, Immunological Agents - Drugs for 3 PA 12.5 MG/0.4ML, 15 Vaccination MG/0.4ML, 17.5 ACTHIB 2 MG/0.4ML, 22.5 2 MG/0.4ML, 25 MG/0.4ML ADACEL AFLURIA OTREXUP 1 SUBCUTANEOUS QUADRIVALENT 3 SOLUTION AUTO- BEXSERO 2 INJECTOR 20 MG/0.4ML BIOTHRAX 3 PROGRAF ORAL 3 BOOSTRIX 2 RAPAMUNE 3 DAPTACEL 2 2 RASUVO DIPHTHERIA-TETANUS 2 REDITREX 3 PA TOXOIDS DT REZUROCK 3 PA; QL ENGERIX-B 2 RHOPHYLAC 3 FLUAD QUADRIVALENT 3 RIDAURA 2 QL FLUARIX 1 RINVOQ 3 PA; QL QUADRIVALENT FLUBLOK RUCONEST 3 PA; QL 1 QUADRIVALENT sajazir 2 PA; QL FLUCELVAX 1 SANDIMMUNE ORAL 3 QUADRIVALENT SILIQ 3 PA; QL FLULAVAL 1 SIMPONI 3 PA; QL QUADRIVALENT 1 FLUMIST sirolimus oral 1 QUADRIVALENT SKYRIZI 2 PA; QL FLUZONE HIGH-DOSE SKYRIZI (150 MG DOSE) 2 PA; QL 1 QUADRIVALENT SKYRIZI PEN 2 PA; QL FLUZONE STELARA 1 2 PA; QL QUADRIVALENT SUBCUTANEOUS GARDASIL 9 2 tacrolimus oral 1 HAVRIX 2 TALTZ 3 PA; QL HEPLISAV-B 2 TREMFYA 2 PA; QL HIBERIX 2 TREXALL 3 INFANRIX 2 VARIZIG 3

Effective Date: 10/01/2021 65 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IPOL 2 AZULFIDINE EN-TABS 3 KINRIX 2 balsalazide disodium 1 MENACTRA 2 budesonide er 3 PA; QL budesonide oral (generic MENQUADFI 2 3 PA Entocort) MENVEO 2 CANASA 3 M-M-R II 2 COLAZAL 3 PEDIARIX 2 CORTENEMA 3 PEDVAX HIB 2 CORTIFOAM 2 PENTACEL 2 DELZICOL 3 ST PNEUMOVAX 23 2 DIPENTUM 3 ST; QL PREVNAR 13 2 ENTOCORT EC 3 PA PREVNAR 20 3 hemmorex-hc rectal 3 PROQUAD 2 25 mg QUADRACEL 2 HEMMOREX-HC RECTAL SUPPOSITORY 3 RECOMBIVAX HB 2 30 MG ROTARIX 2 hydrocortisone (perianal) 3 ROTATEQ 2 external cream 1 % hydrocortisone (perianal) SHINGRIX 2 1 external cream 2.5 % TDVAX 2 hydrocortisone ace- TENIVAC 2 pramoxine external cream 3 TETANUS-DIPHTHERIA 1-1 % 2 TOXOIDS TD 3 TRUMENBA 2 rectal TWINRIX 3 hydrocortisone rectal 1 VAQTA LIALDA 1 INTRAMUSCULAR lidocaine-hydrocort 2 3 SUSPENSION 50 (perianal) UNIT/ML LIDOCAINE- VARIVAX 2 HYDROCORTISONE 3 VAXELIS 2 ACE RECTAL GEL Inflammatory Bowel Disease Agents lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 3 ANALPRAM-HC 3 % anucort-hc 3 LIDOCORT 3 ANUSOL-HC EXTERNAL 3 mesalamine er oral 1 ST anusol-hc rectal 3 capsule 0.375 gm mesalamine oral capsule APRISO 1 ST 1 ST delayed release 400 mg ASACOL HD 3 PA AZULFIDINE 3 Effective Date: 10/01/2021 66 Drug Drug Drug Name Notes Drug Name Notes Tier Tier mesalamine oral tablet risedronate sodium oral 1 3 delayed release 1.2 gm tablet delayed release mesalamine oral tablet TERIPARATIDE 3 PA 3 PA; QL delayed release 800 mg (RECOMBINANT) mesalamine rectal 1 TYMLOS 3 PA mesalamine-cleanser 3 Metabolic Bone Disease Agents - Other ORTIKOS ORAL calcitriol oral 1 CAPSULE EXTENDED 3 PA; QL cinacalcet hcl 1 PA RELEASE 24 HOUR 9 MG doxercalciferol oral 3 PENTASA 2 PA NATPARA 3 PA; QL PROCORT 3 paricalcitol oral 3 PROCTOCORT 3 ROCALTROL 3 PROCTOFOAM HC 2 SENSIPAR 3 PA procto-med hc 1 ZEMPLAR ORAL 3 procto-pak 3 Miscellaneous Therapeutic Agents ACACIA proctozone-hc 1 3 SUBCUTANEOUS ROWASA 3 ACREMONIUM 3 SFROWASA 3 AEROCHAMBER MINI 2 sulfasalazine oral 1 CHAMBER UCERIS ORAL 3 PA; QL AEROCHAMBER MV 2 UCERIS RECTAL 3 AEROCHAMBER PLUS 2 Metabolic Bone Disease Agents - Drugs for FLO-VU

Osteoporosis AEROCHAMBER PLUS 2 ACTONEL 3 FLOW VU AEROCHAMBER alendronate sodium 1 2 W/FLOWSIGNAL ATELVIA 3 ALCOHOL PREP PADS 1 BINOSTO 3 PAD 3 ALCOHOL PREP PADS BONIVA 1 PAD 70 % calcitonin (salmon) 3 ALCOHOL PREP PADS FORTEO 3 PA; QL 1 SHEET 70 % FOSAMAX 3 ALDER 3 FOSAMAX PLUS D 3 AMERICAN BEECH 3 ibandronate sodium oral 1 ANTIVENIN MIACALCIN INJECTION 3 LATRODECTUS 3 RAYALDEE 3 PA MACTANS risedronate sodium oral ARIZONA CYPRESS 3 1 tablet AUREOBASIDIUM 3 AUSTRALIAN PINE 3 Effective Date: 10/01/2021 67 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BALD CYPRESS 3 DOG EPITHELIUM SUBCUTANEOUS 3 BOTRYTIS 3 SOLUTION 1:20 SUBCUTANEOUS DOJOLVI 3 PA; QL BREATHE EASE LARGE 2 DRECHSLERA 3 BREATHE EASE 2 MEDIUM DUST MITE MIXED ALLERGEN EXT 3 BREATHE EASE SMALL 2 SUBCUTANEOUS BROME 3 EASIVENT 2 BYLVAY 3 PA; QL ENDARI 3 PA; QL BYLVAY (PELLETS) 3 PA; QL EPICOCCUM 3 CALCIUM DISODIUM 3 VERSENATE ergoloid mesylates oral 3 CALIFORNIA PEPPER FEMCAP 2 3 TREE FIRDAPSE 3 PA; QL CANDIDA ALBICANS 3 FIRE ANT 3 EXTRACT FLEXICHAMBER 2 CATTLE EPITHELIUM 3 FLEXICHAMBER ADULT 2 CAYA 2 MASK/SMALL CEDAR ELM 3 FLEXICHAMBER CHILD 2 CLADOSPORIUM MASK/LARGE CLADOSPORIOIDES 3 FLEXICHAMBER CHILD 2 SUBCUTANEOUS MASK/SMALL CLADOSPORIUM 3 3 FUSARIUM SPHAEROSPERMUM GERMAN COCKROACH 3 CLEVER CHOICE 2 GLUCAGEN HOLDING CHAMBER 2 DIAGNOSTIC COMPACT SPACE 2 GLUCAGON HCL CHAMBER 2 (DIAGNOSTIC) COMPACT SPACE 2 GRASTEK 3 PA CHAMBER/LG MASK COMPACT SPACE HACKBERRY 3 2 CHAMBER/MED MASK BEE VENOM 3 COMPACT SPACE HONEY BEE VENOM 2 3 CHAMBER/SM MASK PROTEIN CURVULARIA 3 HORSE EPITHELIUM CYTOTINE ORAL SUBCUTANEOUS 3 3 POWDER SOLUTION 1:10 JUNE GRASS POLLEN deferoxamine mesylate 3 injection solution 1 STANDARDIZED reconstituted 500 mg KAPOK 3 DESFERAL 3 KATE FARMS PEPTIDE 3 1.5 ENTERAL

Effective Date: 10/01/2021 68 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KATE FARMS ORALAIR CHILDRENS 3 PA STANDARD 1.4 3 STARTER PACK ENTERAL OXBRYTA 3 PA; QL KERENDIA 3 PA PALFORZIA 3 PA; QL MELALEUCA 3 PANDA MASK LARGE 2 methergine 1 PANDA MASK MEDIUM 2 methylergonovine 1 PANDA MASK SMALL 2 maleate PEDIATRIC PANDA 2 MICROCHAMBER 2 MASK MIXED ASPERGILLUS 3 PENICILLIUM NOTATUM SUBCUTANEOUS MIXED FEATHERS 3 3 SOLUTION 20000 MIXED VESPID VENOM 3 PNU/ML PROTEIN INJECTION PHEXXI 3 mixed vespid venom protein subcutaneous PHYSOSTIGMINE 3 3 solution reconstituted SALICYLATE 1100-1100-1100 mcg pocket spacer 2 MIXED VESPID VENOM PRO COMFORT 2 PROTEIN SPACER ADULT SUBCUTANEOUS 3 PRO COMFORT SOLUTION 2 RECONSTITUTED 120- SPACER CHILD 120-120 MCG PRO COMFORT 2 MUCOR SPACER INFANT 3 SUBCUTANEOUS PROCARE 2 NOZIN NASAL SPACER/ADULT MASK 1 SANITIZER POPSWAB PROCARE 2 ODACTRA 3 PA SPACER/CHILD MASK OLIVE TREE 3 QUEEN PALM 3 OMNIPOD 5 PACK 3 PA RABBIT EPITHELIUM SUBCUTANEOUS 3 OMNIPOD DASH 5 3 PA SOLUTION 1:10 PACK PODS RAGWITEK 3 PA OPTICHAMBER 2 DIAMOND RED MAPLE 3 OPTICHAMBER RHIZOPUS 3 2 DIAMOND-LG MASK RUZURGI 3 PA; QL OPTICHAMBER 2 SACCHAROMYCES DIAMOND-MD MASK CEREVISIAE 3 OPTICHAMBER SUBCUTANEOUS 2 DIAMOND-SM MASK SPINY PIGWEED 3 ORALAIR 3 PA STEMPHYLIUM 3 ORALAIR ADULT 3 PA SWEET GUM 3 STARTER PACK

Effective Date: 10/01/2021 69 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SWEET VERNAL GRASS WIDE-SEAL 3 2 POLLEN DIAPHRAGM 95 3 YELLOW HORNET TACHOSIL 3 VENOM PROTEIN TALL RAGWEED 3 YELLOW JACKET 3 TRICHOPHYTON 3 VENOM PROTEIN VENOMIL HONEY BEE 3 ZOKINVY 3 PA; QL VENOM Ophthalmic Agents - Drugs for Eye Allergy, VENOMIL MIXED 3 Infection and Inflammation VESPID VENOM ACULAR 2 VENOMIL WASP 3 VENOM ACULAR LS 3 VENOMIL WHITE ACUVAIL 3 3 FACED HORNET ALOCRIL 3 VENOMIL YELLOW 3 ALOMIDE 2 HORNET VENOM VENOMIL YELLOW ALREX 3 3 JACKET VENOM AZASITE 3 VISTOGARD 3 PA; QL azelastine hcl ophthalmic 1 VORTEX VALVED 2 bacitracin ophthalmic 1 HOLDING CHAMBER bepotastine besilate 3 WASP VENOM PROTEIN 3 BEPREVE 3 WESTERN JUNIPER 3 BESIVANCE 3 WHITE BIRCH 3 BETADINE WHITE FACED HORNET 3 3 OPHTHALMIC PREP VENOM BLEPH-10 3 WHITE MULBERRY 3 bromfenac sodium (once- WHITE-FACED HORNET 3 3 daily) VENOM BROMSITE 3 WIDE-SEAL 2 CILOXAN OPHTHALMIC DIAPHRAGM 60 2 OINTMENT WIDE-SEAL 2 CILOXAN OPHTHALMIC DIAPHRAGM 65 3 SOLUTION WIDE-SEAL 2 ciprofloxacin hcl DIAPHRAGM 70 1 ophthalmic WIDE-SEAL 2 cromolyn sodium DIAPHRAGM 75 1 ophthalmic WIDE-SEAL 2 dexamethasone sodium DIAPHRAGM 80 1 phosphate ophthalmic WIDE-SEAL 2 diclofenac sodium DIAPHRAGM 85 1 ophthalmic WIDE-SEAL 2 DIAPHRAGM 90 DUREZOL 2 epinastine hcl 3 Effective Date: 10/01/2021 70 Drug Drug Drug Name Notes Drug Name Notes Tier Tier erythromycin ophthalmic 1 PRED MILD 2 EYSUVIS 3 PA PREDNISOL ACE- 3 MOXIFLOX-BROMFEN FLAREX 3 1 1 ophthalmic flurbiprofen sodium 1 prednisolone acetate p-f 1 FML 2 prednisolone sodium 3 FML FORTE 2 phosphate ophthalmic PREDNISOLON- FML LIQUIFILM 3 3 MOXIFLOX-NEPAFENAC gatifloxacin ophthalmic 1 PROLENSA 3 gentak 1 sulfacetamide sodium gentamicin sulfate 1 1 ophthalmic ophthalmic tobramycin ophthalmic 1 ILEVRO 3 TOBREX OPHTHALMIC 2 INVELTYS 3 OINTMENT ketorolac tromethamine TOBREX OPHTHALMIC 1 3 ophthalmic SOLUTION KLARITY-A 3 trifluridine 1 KLARITY-L 3 UPNEEQ 3 PA levofloxacin ophthalmic 3 VIGAMOX 2 LOTEMAX 3 ZERVIATE 3 LOTEMAX SM 3 ZIRGAN 3 etabonate 3 ZYMAXID 3 MAXIDEX 3 Ophthalmic Agents - Drugs for Glaucoma MOXEZA 3 acetazolamide er 1 moxifloxacin hcl (2x day) 1 acetazolamide oral 1 moxifloxacin hcl 1 ALPHAGAN P 3 ophthalmic solution apraclonidine hcl 3 NATACYN 2 AZOPT 3 NEVANAC 3 betaxolol hcl ophthalmic 1 OCUFLOX 3 BETIMOL 3 ofloxacin ophthalmic 1 BETOPTIC-S 2 olopatadine hcl 1 ophthalmic solution 0.1 % bimatoprost ophthalmic 1 olopatadine hcl brimonidine tartrate 3 ophthalmic solution 0.2 % ophthalmic solution 0.15 3 % POVIDONE-IODINE 3 brimonidine tartrate OPHTHALMIC 1 ophthalmic solution 0.2 % PRED FORTE 3

Effective Date: 10/01/2021 71 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BRIMONIDINE- TIMOLOL-BRIMON- 3 3 DORZOLAMIDE DORZOL-LATANOPR brinzolamide 1 TIMOLOL- BRIMONIDINE- 3 carteolol hcl 1 DORZOLAMID COMBIGAN 3 TIMOLOL- COSOPT 3 DORZOLAMID- 3 LATANOPROST COSOPT PF 3 3 DORZOLAMIDE HCL TIMOPTIC SOLUTION 2 % 3 TIMOPTIC OCUDOSE 3 OPHTHALMIC TIMOPTIC-XE 3 dorzolamide hcl solution 2 1 TRAVATAN Z 3 % ophthalmic dorzolamide hcl-timolol travoprost (bak free) 1 1 mal TRUSOPT 3 dorzolamide hcl-timolol 3 VYZULTA 3 PA mal pf XALATAN 3 IOPIDINE 3 XELPROS 3 ISOPTO CARPINE 3 ZIOPTAN 3 ISTALOL 3 Ophthalmic Agents - Drugs for

KEVEYIS 3 PA; QL Miscellaneous Eye Conditions latanoprost ophthalmic 1 ACUICYN 3 LATANOPROST- 3 ak-poly-bac 1 TIMOLOL MALEATE AKTEN 3 levobunolol hcl 1 ALCAINE 3 LUMIGAN 2 altacaine 3 methazolamide oral 1 altafrin 1 pilocarpine hcl ophthalmic 1 atropine sulfate 1 RHOPRESSA 3 PA ophthalmic ointment ROCKLATAN 3 PA ATROPINE SULFATE SIMBRINZA 3 OPHTHALMIC 1 SOLUTION 0.01 % timolol maleate ocudose 3 atropine sulfate 1 timolol maleate ophthalmic solution 1 % ophthalmic gel forming 1 solution AVENOVA 3 bacitracin-polymyxin b timolol maleate 1 ophthalmic solution 0.25 1 ophthalmic %, 0.5 % bacitra-neomycin- 1 timolol maleate polymyxin-hc ophthalmic solution 0.5 % 3 BLEPHAMIDE 2 (daily) BLEPHAMIDE S.O.P. 2 timolol maleate pf 3 Effective Date: 10/01/2021 72 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CEQUA 2 PA PREDNISOLONE ACET- 3 MOXIFLOXACIN CYCLOGYL 3 PREDNISOLONE- CYCLOMYDRIL 3 3 BROMFENAC cyclopentolate hcl 1 PREDNISOLONE- ophthalmic 3 GATIFLOXACIN CYCLOSPORINE IN 2 PA PREDNISOLONE- KLARITY 3 MOXIFLOXACIN CYSTADROPS 3 PA PREDNISOLON- CYSTARAN 3 GATIFLOX- 3 GELFILM OPHTHALMIC 3 BROMFENAC PREDNISOLON- homatropaire 1 MOXIFLOX- 3 HYPOCYN 3 BROMFENAC ISOPTO ATROPINE 2 proparacaine hcl 3 ophthalmic LACRISERT 2 RESTASIS 3 PA LASTACAFT 3 RESTASIS MULTIDOSE 3 PA MAXITROL 3 sulfacetamide- neomycin-bacitracin zn- 3 prednisolone ophthalmic 1 polymyx solution neomycin-polymyxin- tetracaine hcl ophthalmic 3 dexameth ophthalmic 1 ointment TOBRADEX OPHTHALMIC 2 neomycin-polymyxin- OINTMENT dexameth ophthalmic 1 suspension 3.5-10000-0.1 TOBRADEX OPHTHALMIC 3 neomycin-polymyxin- 1 SUSPENSION gramicidin TOBRADEX ST 3 neomycin-polymyxin-hc 3 tobramycin- ophthalmic 1 dexamethasone neo-polycin 3 TROPICAMIDE- 3 neo-polycin hc 1 CYCLOPENTOLATE-PE OXERVATE 3 PA; QL TROPICAMIDE- 3 phenylephrine hcl PHENYLEPHRINE 1 ophthalmic TROPIC-PROPARACA- 3 polycin 1 PE-KETOROLAC polymyxin b-trimethoprim 1 XIIDRA 2 PA POLYTRIM 3 ZYLET 3 PRED-G 2 Otic Agents - Drugs for Ear Conditions PRED-G S.O.P. 2 acetic acid otic 1 PREDNISOLONE CETRAXAL 3 3 ACETATE-NEPAFENAC CIPRO HC 2

Effective Date: 10/01/2021 73 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CIPRODEX 3 desloratadine 1 3 dexchlorpheniramine ciprofloxacin hcl otic 3 maleate oral ciprofloxacin- 1 dexamethasone di-phen 3 CORTISPORIN-TC 3 diphen oral elixir 3 3 diphenhydramine hcl DERMOTIC 1 injection flac 3 diphenhydramine hcl oral fluocinolone acetonide 3 3 elixir otic DYMISTA 3 hydrocortisone-acetic acid 3 FASENRA PEN 3 PA; QL neomycin-polymyxin-hc 1 otic nasal 1 ofloxacin otic 1 HYCODAN 3 hydrocodone polst- OTOVEL 3 3 chlorphen polst er susp PRAMOTIC 3 hydrocodone- Respiratory Tract / Pulmonary Agents - 1 homatropine Drugs for Allergies, Cough, Cold hydromet 1 ADRENALIN NASAL 3 HYPERSAL 3 azelastine hcl nasal 1 INFASURF 3 azelastine-fluticasone 3 ipratropium bromide nasal 1 BECONASE AQ 3 PA KARBINAL ER 3 benzonatate oral capsule 1 levocetirizine 100 mg, 200 mg 1 dihydrochloride oral benzonatate oral capsule 3 150 mg MICLARA LQ 3 BROMPHENIRAMINE mometasone furoate 3 PA MALEATE 3 nasal INTRAMUSCULAR NASONEX 3 PA carbinoxamine maleate 1 NUCALA SUBCUTANEOUS cetirizine hcl oral solution 3 3 PA; QL SOLUTION AUTO- CLARINEX 3 INJECTOR CLARINEX-D 12 HOUR 3 NUCALA clemastine fumarate oral SUBCUTANEOUS 1 3 PA; QL SOLUTION PREFILLED clemastine fumarate oral SYRINGE 1 tablet 2.68 mg olopatadine hcl nasal 3 CUROSURF 3 OMNARIS 3 PA cyproheptadine hcl oral 1 PATANASE 3 DERMACINRX PHENERGAN 3 3 AZENASE PAK promethazine hcl injection 3 Effective Date: 10/01/2021 74 Drug Drug Drug Name Notes Drug Name Notes Tier Tier 1 AIRDUO RESPICLICK promethazine hcl oral 3 PA 232/14 promethazine hcl rectal 1 AIRDUO RESPICLICK 3 PA promethazine vc 1 55/14 promethazine vc/codeine 3 PA albuterol sulfate hfa promethazine-codeine 3 PA aerosol solution 108 (90 1 QL base) mcg/act inhalation promethazine-dm 1 promethazine-phenyleph- ALBUTEROL SULFATE 3 PA HFA AEROSOL codeine SOLUTION 108 (90 1 QL promethazine- 1 BASE) MCG/ACT phenylephrine INHALATION promethegan 1 albuterol sulfate inhalation pseudoephedrine- nebulization solution (2.5 3 bromphen-dm mg/3ml) 0.083%, 0.63 1 mg/3ml, 1.25 mg/3ml, 2.5 QNASL 3 PA mg/0.5ml QNASL CHILDRENS 3 PA ALBUTEROL SULFATE RYCLORA 3 NEBULIZATION 3 SOLUTION (5 MG/ML) ryvent 1 0.5% INHALATION sodium chloride inhalation albuterol sulfate nebulization solution 0.9 1 nebulization solution (5 1 %, 3 %, 7 % mg/ml) 0.5% inhalation sodium chloride inhalation 3 1 nebulization solution 10 % albuterol sulfate oral 2 SSKI 2 ALVESCO ANORO ELLIPTA 3 PA SURVANTA 2 arformoterol tartrate 3 PA TESSALON PERLES 3 ARMONAIR DIGIHALER 3 PA TUSSICAPS 3 ARNUITY ELLIPTA 3 PA TUXARIN ER 3 QL ASMANEX (120 2 ST TUZISTRA XR 3 PA METERED DOSES) XHANCE 3 PA ASMANEX (14 2 ST ZETONNA 3 PA METERED DOSES) Respiratory Tract / Pulmonary Agents - ASMANEX (30 2 ST Drugs for Asthma and Other Lung METERED DOSES) Conditions ASMANEX (60 2 ST ACCOLATE 3 METERED DOSES) ASMANEX (7 METERED acetylcysteine inhalation 1 2 ST DOSES) ADVAIR DISKUS 3 ASMANEX HFA 2 ST ADVAIR HFA 2 ATROVENT HFA 2 AIRDUO DIGIHALER 3 PA AUVI-Q 3 PA AIRDUO RESPICLICK 3 PA 113/14 BEVESPI AEROSPHERE 3 PA Effective Date: 10/01/2021 75 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BREO ELLIPTA 3 PA FLUTICASONE- BREZTRI AEROSPHERE 3 PA SALMETEROL INHALATION AEROSOL BROVANA 3 PA POWDER BREATH 3 PA budesonide inhalation 1 ACTIVATED 113-14 MCG/ACT, 232-14 BUDESONIDE- MCG/ACT, 55-14 FORMOTEROL 2 PA MCG/ACT FUMARATE formoterol fumarate 2 3 COMBIVENT inhalation cromolyn sodium 1 INCRUSE ELLIPTA 3 PA inhalation ipratropium bromide 1 DALIRESP 3 inhalation DUAKLIR PRESSAIR 3 PA ipratropium-albuterol 1 DULERA 3 PA; QL isoproterenol hcl injection 3 ELIXOPHYLLIN 3 ISUPREL 3 epinephrine injection 1 3 solution auto-injector levalbuterol hcl inhalation EPINEPHRINE LEVALBUTEROL HFA 3 PROFESSIONAL INHALATION AEROSOL 3 QL 45 MCG/ACT EPINEPHRINESNAP- 3 LONHALA MAGNAIR EMS 3 PA REFILL KIT EPINEPHRINESNAP-V 3 LONHALA MAGNAIR 3 PA EPIPEN 2-PAK 3 STARTER KIT EPIPEN JR 2-PAK 3 montelukast sodium oral 1 EPISNAP 3 OFEV 2 PA; QL ESBRIET 2 PA; QL PERFOROMIST 3 FLOVENT DISKUS 2 PA PROAIR DIGIHALER 3 QL FLOVENT HFA PROAIR HFA 3 QL INHALATION AEROSOL 2 PA PROAIR RESPICLICK 3 QL 110 MCG/ACT, 220 MCG/ACT PROVENTIL HFA 3 QL PULMICORT FLOVENT HFA 3 PA INHALATION AEROSOL 2 FLEXHALER 44 MCG/ACT PULMICORT 3 fluticasone-salmeterol SUSPENSION inhalation aerosol powder QVAR REDIHALER 3 PA breath activated 100-50 1 SEREVENT DISKUS 2 ST mcg/dose, 250-50 mcg/dose, 500-50 SINGULAIR 3 mcg/dose SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT INHALATION AEROSOL 2 ST SOLUTION 1.25 MCG/ACT Effective Date: 10/01/2021 76 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SPIRIVA RESPIMAT tobramycin inhalation INHALATION AEROSOL nebulization solution 300 3 PA; QL 2 SOLUTION 2.5 mg/4ml MCG/ACT tobramycin nebulization STIOLTO RESPIMAT 2 solution 300 mg/5ml 1 PA; QL inhalation STRIVERDI RESPIMAT 2 PA TOBRAMYCIN SYMBICORT 2 PA; QL NEBULIZATION 3 PA; QL SYMJEPI 3 SOLUTION 300 MG/5ML terbutaline sulfate INHALATION 3 injection TRIKAFTA 3 PA; QL terbutaline sulfate oral 1 Respiratory Tract / Pulmonary Agents -

THEO-24 3 Drugs for Pulmonary Hypertension ADCIRCA 3 PA; QL theophylline 1 ADEMPAS 3 PA; QL theophylline er 1 alyq 3 PA; QL TRELEGY ELLIPTA 3 PA ambrisentan 1 PA; QL TUDORZA PRESSAIR 3 bosentan 1 PA; QL VENTOLIN HFA 3 QL LETAIRIS 3 PA; QL wixela inhub 1 OPSUMIT 2 PA; QL XOPENEX NEB 3 ORENITRAM 3 PA; QL XOPENEX 3 REVATIO ORAL CONCENTRATE SUSPENSION 3 PA; QL XOPENEX HFA 3 QL RECONSTITUTED YUPELRI 3 PA REVATIO ORAL TABLET 3 PA zafirlukast 3 sildenafil citrate oral 3 PA; QL zileuton er 3 PA; QL suspension reconstituted sildenafil citrate oral tablet ZYFLO 3 PA; QL 1 PA 20 mg Respiratory Tract / Pulmonary Agents -

Drugs for Cystic Fibrosis tadalafil (pah) 3 PA; QL BETHKIS 3 PA; QL TRACLEER 3 PA; QL BRONCHITOL 3 PA; QL TYVASO 2 PA; QL BRONCHITOL TYVASO REFILL 2 PA; QL 3 PA; QL TOLERANCE TEST TYVASO STARTER 2 PA; QL CAYSTON 3 PA; QL UPTRAVI ORAL 2 PA; QL KALYDECO 3 PA; QL VENTAVIS 2 PA; QL KITABIS PAK 3 PA; QL Skeletal Muscle Relaxants - Drugs for

ORKAMBI 3 PA; QL Muscle Pain and Spasm PULMOZYME 2 AMRIX 3 PA; QL SYMDEKO 3 PA; QL baclofen oral 1 TOBI 3 PA; QL carisoprodol oral 3 PA; QL TOBI PODHALER 3 PA; QL Effective Date: 10/01/2021 77 Drug Drug Drug Name Notes Drug Name Notes Tier Tier chlorzoxazone oral tablet DAYVIGO 3 PA 3 250 mg doxepin hcl oral tablet 3 chlorzoxazone oral tablet 3 QL EDLUAR 3 QL 375 mg, 500 mg, 750 mg eszopiclone 1 QL cyclobenzaprine hcl er 3 PA; QL flurazepam hcl 1 QL cyclobenzaprine hcl oral 1 QL tablet 10 mg, 5 mg HETLIOZ 3 PA; QL cyclobenzaprine hcl oral HETLIOZ LQ 3 PA; QL 3 QL tablet 7.5 mg LUNESTA 3 QL DANTRIUM ORAL 3 modafinil 1 dantrolene sodium oral 1 NUVIGIL 3 PA FEXMID 3 QL PROVIGIL 3 FIRST-BACLOFEN 3 ramelteon 3 LORZONE 3 QL RESTORIL 3 QL metaxalone 3 QL ROZEREM 3 methocarbamol injection 1 SILENOR 3 methocarbamol oral 1 QL SUNOSI 3 PA; QL NORGESIC FORTE 3 QL temazepam oral capsule 1 QL orphenadrine citrate er 1 QL 15 mg, 30 mg, 7.5 mg orphenadrine citrate temazepam oral capsule 3 3 QL injection 22.5 mg orphenadrine-asa- WAKIX 3 PA; QL 3 QL caffeine XYREM 3 PA; QL ORPHENGESIC FORTE 3 QL XYWAV 3 PA; QL OZOBAX 3 zaleplon 1 QL ROBAXIN 3 zolpidem tartrate er 3 QL SKELAXIN 3 QL zolpidem tartrate oral 1 QL SOMA 3 PA; QL zolpidem tartrate 3 QL tizanidine hcl oral capsule 3 sublingual ZOLPIMIST 3 QL tizanidine hcl oral tablet 1 VANADOM 3 PA; QL Stimulation or Suppression TAKHZYRO 3 PA; QL ZANAFLEX 3 Sleep Disorder Agents AMBIEN 3 QL AMBIEN CR 3 QL AMYTAL SODIUM 3 armodafinil 3 PA AZSTARYS 3 PA BELSOMRA 3 PA

Effective Date: 10/01/2021 78 Effective Date: 10/01/2021 79 Index of Drugs

1 acetazolamide er ...... 71 AEROCHAMBER MINI 1ST MEDX-PATCH/ acetazolamide sodium ..... 33 CHAMBER ...... 67 LIDOCAINE ...... 14 acetic acid ...... 55, 73 AEROCHAMBER MV ...... 67 7 acetylcysteine ...... 75 AEROCHAMBER PLUS 7T LIDO ...... 14 ACIPHEX ...... 52 FLO-VU ...... 67 A ACIPHEX SPRINKLE ...... 52 AEROCHAMBER PLUS abacavir sulfate ...... 30 acitretin ...... 40 FLOW VU ...... 67 abacavir sulfate-lamivudine ACNESIC ...... 40 AEROCHAMBER ...... 30 ACREMONIUM ...... 67 W/FLOWSIGNAL ...... 67 abacavir-lamivudine- ACTEMRA...... 64 AFINITOR ...... 25 zidovudine ...... 30 ACTEMRA ACTPEN ...... 63 AFINITOR DISPERZ ...... 25 ABILIFY ...... 29 ACTHAR ...... 58 afirmelle ...... 59 ABILIFY MAINTENA ...... 29 ACTHIB ...... 65 AFLURIA QUADRIVALENT ABILIFY MYCITE ...... 29 ACTICLATE ...... 16 ...... 65 ABILIFY MYCITE ACTIMMUNE ...... 64 AFREZZA...... 49 MAINTENANCE KIT .... 29 ACTIQ ...... 12 AFTERPILL ...... 59 ABILIFY MYCITE ACTIVELLA ...... 59 AGAMATRIX CONTROL STARTER KIT ...... 29 ACTONEL ...... 67 LEVEL 2 ...... 48 abiraterone acetate...... 25 ACTOPLUS MET ...... 46 AGAMATRIX CONTROL ABSORICA ...... 40 ACTOS ...... 47 LEVEL 4 ...... 48 ABSORICA LD ...... 40 ACUICYN ...... 72 AGONEAZE ...... 14 ACACIA ...... 67 ACULAR ...... 70 AGRYLIN ...... 32 acamprosate calcium ...... 15 ACULAR LS ...... 70 AIMOVIG...... 24 ACANYA ...... 40 ACUVAIL ...... 70 AIRDUO DIGIHALER ...... 75 acarbose ...... 46 acyclovir ...... 30 AIRDUO RESPICLICK ACCOLATE ...... 75 ACZONE ...... 40 113/14 ...... 75 ACCRUFER ...... 51 ADACEL ...... 65 AIRDUO RESPICLICK ACCU-CHEK AVIVA adapalene ...... 40 232/14 ...... 75 DEVICE ...... 48 ADAPALENE ...... 40 AIRDUO RESPICLICK ACCU-CHEK COMPACT adapalene-benzoyl peroxide 55/14 ...... 75 PLUS CONTROL ...... 48 ...... 40 AJOVY ...... 24 ACCU-CHEK FASTCLIX ADAPALENE-BENZOYL AKLIEF ...... 40 LANCET KIT ...... 48 PEROXIDE ...... 40 ak-poly-bac ...... 72 ACCU-CHEK GUIDE ADCIRCA ...... 77 AKTEN ...... 72 CONTROL ...... 48 ADDERALL ...... 38 AKYNZEO ...... 22 ACCU-CHEK GUIDE TEST ADDERALL XR ...... 38 ALA SCALP ...... 40 STRIPS ...... 48 adefovir dipivoxil ...... 30 ala-cort ...... 40 ACCU-CHEK SMARTVIEW ADEMPAS...... 77 albendazole ...... 27 CONTROL ...... 48 ADHANSIA XR ...... 38 ALBENZA...... 27 ACCU-CHEK SOFTCLIX ADLYXIN ...... 47 albuterol sulfate ...... 75 LANCET DEVICE KIT .. 48 ADLYXIN STARTER PACK ALBUTEROL SULFATE .. 75 ACCUPRIL ...... 33 ...... 47 albuterol sulfate hfa ...... 75 ACCURETIC ...... 33 ADMELOG ...... 49 ALBUTEROL SULFATE accutane ...... 40 ADMELOG SOLOSTAR .. 49 HFA ...... 75 acebutolol hcl ...... 33 ADRENALIN ...... 74 ALCAINE...... 72 acetaminophen-codeine .. 12 ADVAIR DISKUS...... 75 alclometasone dipropionate acetaminophen-codeine #2 ADVAIR HFA ...... 75 ...... 40 ...... 12 ADVANCED ALLERGY ALCOHOL PREP PADS .. 67 acetaminophen-codeine #3 COLLECTION ...... 40 ALDACTAZIDE ...... 33 ...... 12 ADZENYS ER ...... 38 ALDACTONE ...... 33 acetaminophen-codeine #4 ADZENYS XR-ODT ...... 38 ALDARA ...... 40 ...... 12 AEMCOLO ...... 16 ALDER ...... 67 acetazolamide ...... 71 ALECENSA ...... 25

80 alendronate sodium ...... 67 amiloride- anusol-hc ...... 66 ALFERON N ...... 64 hydrochlorothiazide ..... 33 ANUSOL-HC ...... 66 alfuzosin hcl er ...... 56 aminocaproic acid ...... 32 APADAZ ...... 12 ALINIA ...... 27 amiodarone hcl ...... 33 apap-caff-dihydrocodeine 12 aliskiren fumarate ...... 33 AMITIZA ...... 53 APEXICON E ...... 40 ALKERAN ...... 25 amitriptyline hcl ...... 21 APIDRA SOLOSTAR ...... 49 ALKINDI SPRINKLE ...... 56 amlodipine besylate ...... 33 APIDRA VIAL ...... 49 allopurinol ...... 24 amlodipine besylate- APLENZIN ...... 21 ALLZITAL ...... 12 benazepril hcl ...... 33 APOKYN ...... 28 almotriptan malate ...... 24 amlodipine besylate- APO-VARENICLINE ...... 15 ALOCRIL ...... 70 valsartan ...... 33 apraclonidine hcl ...... 71 ALOGLIPTIN BENZOATE amlodipine-atorvastatin ... 33 aprepitant ...... 22 ...... 47 amlodipine-olmesartan .... 33 apri ...... 59 ALOGLIPTIN-METFORMIN amlodipine-valsartan-hctz 33 APRISO ...... 66 HCL ...... 47 ammonium lactate ...... 40 APTENSIO XR ...... 38 ALOGLIPTIN- amnesteem ...... 40 APTIOM ...... 19 PIOGLITAZONE ...... 47 amoxapine...... 21 APTIVUS...... 30 ALOMIDE ...... 70 amoxicill-clarithro-lansopraz aranelle ...... 59 ALORA ...... 59 ...... 53 ARANESP (ALBUMIN alosetron hcl ...... 53 amoxicillin ...... 16 FREE) ...... 32 ALPHAGAN P ...... 71 amoxicillin-potassium ARAVA ...... 64 alprazolam ...... 32 clavulanate ...... 16 ARAZLO ...... 40 alprazolam er ...... 32 amoxicillin-potassium ARCALYST ...... 64 alprazolam intensol...... 32 clavulanate er ...... 16 arformoterol tartrate ...... 75 alprazolam xr ...... 32 AMPHETAMINE ER ...... 38 argyle sterile saline ...... 51 alprostadil ...... 33 amphetamine sulfate ...... 38 argyle sterile water ...... 51 ALREX ...... 70 amphetamine- ARICEPT ...... 20 ALTABAX ...... 16 dextroamphetamine ..... 38 ARIKAYCE ...... 16 altacaine ...... 72 amphetamine- ARIMIDEX ...... 25 ALTACE ...... 33 dextroamphetamine er . 38 aripiprazole ...... 29 altafrin ...... 72 ampicillin ...... 16 ARISTADA ...... 29 altavera ...... 59 ampicillin sodium ...... 16 ARISTADA INITIO ...... 29 ALTOPREV ...... 33 AMPYRA ...... 39 ARIXTRA ...... 18 ALTRENO ...... 40 AMRIX ...... 77 ARIZONA CYPRESS ...... 67 ALUNBRIG ...... 25 AMYTAL SODIUM ...... 78 armodafinil ...... 78 ALVESCO ...... 75 AMZEEQ ...... 40 ARMONAIR DIGIHALER . 75 alvimopan ...... 53 ANACAINE ...... 40 ARMOUR THYROID ...... 63 alyacen 1/35 ...... 59 ANAFRANIL ...... 21 ARNUITY ELLIPTA ...... 75 alyacen 7/7/7 ...... 59 anagrelide hcl ...... 32 AROMASIN ...... 25 alyq ...... 77 ANALPRAM-HC ...... 66 ARTHROTEC ...... 11 amabelz ...... 59 ANASPAZ ...... 53 arzol silver nit applicators 40 amantadine hcl ...... 28 anastrozole...... 25 ASACOL HD ...... 66 AMARYL ...... 47 ANCOBON ...... 23 ascomp-codeine ...... 12 AMBIEN ...... 78 ANDRODERM ...... 57 asenapine maleate ...... 29 AMBIEN CR ...... 78 ANDROGEL ...... 57 ashlyna ...... 59 ambrisentan...... 77 ANDROGEL PUMP ...... 57 ASMANEX (120 METERED amcinonide ...... 40 ANGELIQ ...... 59 DOSES) ...... 75 AMELUZ ...... 40 ANNOVERA ...... 59 ASMANEX (14 METERED AMERGE ...... 24 ANODYNE LPT ...... 14 DOSES) ...... 75 AMERICAN BEECH ...... 67 ANORO ELLIPTA ...... 75 ASMANEX (30 METERED amethia ...... 59 ANTARA ...... 33 DOSES) ...... 75 amethyst ...... 59 ANTIVENIN ASMANEX (60 METERED AMICAR ...... 32 LATRODECTUS DOSES) ...... 75 amiloride hcl ...... 33 MACTANS ...... 67 ASMANEX (7 METERED anucort-hc ...... 66 DOSES) ...... 75

81 ASMANEX HFA ...... 75 AZASAN ...... 64 BENZACLIN WITH PUMP aspirin-dipyridamole er .... 28 AZASITE ...... 70 ...... 41 ASTAGRAF XL ...... 64 azathioprine ...... 64 BENZAMYCIN ...... 41 ASTERO ...... 14 azelaic acid ...... 40 benzepro foaming cloths . 41 ATACAND ...... 33 azelastine hcl ...... 70, 74 BENZHYDROCODONE- ATACAND HCT ...... 33 azelastine-fluticasone ...... 74 ACETAMINOPHEN ..... 12 atazanavir sulfate ...... 30 AZELEX ...... 41 BENZNIDAZOLE ...... 27 ATELVIA ...... 67 AZILECT ...... 28 benzonatate ...... 74 atenolol ...... 33 azithromycin ...... 16 BENZOYL PEROX- atenolol-chlorthalidone .... 33 AZOPT ...... 71 HYDROCORTISONE .. 41 ATIVAN ...... 32 AZOR ...... 33 BENZOYL PEROXIDE .... 41 atomoxetine hcl ...... 38 AZSTARYS ...... 78 BENZOYL PEROXIDE ATOPADERM ...... 40 AZULFIDINE ...... 66 FORTE- HC ...... 41 ATOPICLAIR ...... 40 AZULFIDINE EN-TABS ... 66 benzoyl peroxide- atorvastatin calcium ...... 33 azurette ...... 59 erythromycin ...... 41 atovaquone ...... 27 B benztropine mesylate ...... 28 ATRALIN ...... 40 bac ...... 12 bepotastine besilate ...... 70 ATRIPLA ...... 30 bacitracin ...... 70 BEPREVE ...... 70 atropine sulfate ...... 72 bacitracin-polymyxin b ..... 72 BERINERT ...... 64 ATROPINE SULFATE ..... 72 bacitra-neomycin- beser ...... 41 ATROVENT HFA ...... 75 polymyxin-hc ...... 72 BESIVANCE ...... 70 AUBAGIO ...... 39 baclofen ...... 77 BETADINE OPHTHALMIC aubra ...... 59 BACTRIM ...... 16 PREP ...... 70 aubra eq ...... 59 BACTRIM DS ...... 16 betamethasone AUGMENTIN ...... 16 BAFIERTAM ...... 39 dipropionate ...... 41 AUGMENTIN ES-600 ...... 16 BALCOLTRA ...... 59 betamethasone AUREOBASIDIUM ...... 67 BALD CYPRESS ...... 67 dipropionate aug ...... 41 aurovela 1.5/30 ...... 59 balsalazide disodium ...... 66 BETAMETHASONE aurovela 1/20...... 59 BALVERSA ...... 25 SODIUM PHOSPHATE56 aurovela 24 fe ...... 59 balziva ...... 59 betamethasone valerate .. 41 aurovela fe 1.5/30 ...... 59 BANZEL ...... 19 BETAPACE ...... 33 aurovela fe 1/20 ...... 59 BAQSIMI ONE PACK ...... 49 BETAPACE AF ...... 33 AURYXIA ...... 55 BAQSIMI TWO PACK ..... 49 BETASERON ...... 39 AUSTEDO ...... 39 BARACLUDE ...... 30 betaxolol hcl ...... 33, 71 AUSTRALIAN PINE ...... 67 BASAGLAR KWIKPEN.... 49 bethanechol chloride ...... 55 AUTOLET LANCING BAXDELA ...... 16 BETHKIS...... 77 DEVICE ...... 48 BD AUTOSHIELD DUO BETIMOL ...... 71 AUVI-Q ...... 75 PEN NEEDLES ...... 49 BETOPTIC-S ...... 71 AVALIDE ...... 33 BD ULTRA-FINE INSULIN BEVESPI AEROSPHERE75 AVAPRO ...... 33 SYRINGES ...... 49 bexarotene ...... 25 avar cleanser ...... 40 BD ULTRA-FINE PEN BEXSERO ...... 65 AVAR LS CLEANSER ..... 40 NEEDLES ...... 49 BEYAZ ...... 59 AVAR-E EMOLLIENT ...... 40 BECONASE AQ ...... 74 bicalutamide ...... 25 AVAR-E GREEN ...... 40 BELBUCA ...... 12 BICILLIN L-A ...... 16 AVAR-E LS ...... 40 belladonna alkaloids-opium BIDIL ...... 33 AVENOVA ...... 72 ...... 53 BIJUVA ...... 59 aviane...... 59 BELSOMRA ...... 78 BIKTARVY ...... 30 avidoxy ...... 16 benazepril hcl ...... 33 BILTRICIDE ...... 27 avita ...... 40 benazepril- bimatoprost ...... 71 AVODART ...... 56 hydrochlorothiazide ..... 33 BINOSTO ...... 67 AVONEX PEN ...... 39 BENICAR ...... 33 BIOTHRAX ...... 65 AVONEX PREFILLED ..... 39 BENICAR HCT ...... 33 bisoprolol fumarate ...... 33 AYGESTIN ...... 59 BENLYSTA ...... 64 bisoprolol- ayuna ...... 59 BENTYL ...... 53 hydrochlorothiazide ..... 33 AYVAKIT ...... 25 BENZACLIN ...... 41 BLEPH-10 ...... 70

82 BLEPHAMIDE ...... 72 BUPHENYL ...... 54 CAMBIA ...... 11 BLEPHAMIDE S.O.P...... 72 buprenorphine ...... 12 camila ...... 59 blisovi 24 fe ...... 59 buprenorphine hcl...... 12, 15 camrese ...... 59 blisovi fe 1.5/30 ...... 59 buprenorphine hcl-naloxone camrese lo ...... 59 blisovi fe 1/20 ...... 59 hcl ...... 15 CANASA ...... 66 BLULINK CONTROL HIGH bupropion hcl ...... 21 candesartan cilexetil ...... 33 & LOW ...... 48 bupropion hcl er (smoking candesartan cilexetil-hctz 33 BOCASAL ...... 40 det) ...... 15 CANDIDA ALBICANS BONIVA ...... 67 bupropion hcl er (sr) ...... 21 EXTRACT ...... 68 BONJESTA ...... 22 bupropion hcl er (xl) ...... 21 capecitabine ...... 25 BOOSTRIX ...... 65 BUPROPION HCL ER (XL) CAPEX ...... 41 bosentan ...... 77 ...... 21 CAPLYTA...... 29 BOSULIF ...... 25 buspirone hcl ...... 32 CAPRELSA ...... 25 BOTRYTIS ...... 68 butalbital-acetaminophen 12 captopril ...... 33 bp 10-1 ...... 41 BUTALBITAL- CARAC ...... 41 bp cleansing wash ...... 41 ACETAMINOPHEN ..... 12 CARAFATE ...... 52 BRAFTOVI ...... 25 butalbital-apap-caff-cod ... 12 CARBAGLU ...... 51 BREATHE EASE LARGE 68 butalbital-apap-caffeine ... 12 carbamazepine ...... 19 BREATHE EASE MEDIUM butalbital-asa-caff-codeine carbamazepine er ...... 19 ...... 68 ...... 12 CARBATROL ...... 19 BREATHE EASE SMALL 68 butalbital-aspirin-caffeine . 12 carbidopa ...... 28 BREO ELLIPTA ...... 75 butorphanol tartrate ...... 12 carbidopa-levodopa ...... 28 BRETYLIUM TOSYLATE 33 BUTRANS ...... 12 carbidopa-levodopa er..... 28 BREXAFEMME ...... 23 BYDUREON BCISE carbidopa-levodopa- BREZTRI AEROSPHERE75 AUTOINJECTOR ...... 47 entacapone ...... 28 briellyn ...... 59 BYETTA 10 MCG PEN .... 47 carbinoxamine maleate ... 74 BRILINTA ...... 28 BYETTA 5 MCG PEN ...... 47 CARDIZEM ...... 33 brimonidine tartrate...... 71 BYLVAY ...... 68 CARDIZEM CD ...... 33 BRIMONIDINE- BYLVAY (PELLETS) ...... 68 CARDIZEM LA ...... 33 DORZOLAMIDE ...... 71 BYSTOLIC ...... 33 CARDURA ...... 33 brinzolamide ...... 71 C CARDURA XL ...... 56 BRISDELLE...... 21 cabergoline...... 58 CARETOUCH CONTROL BRIVIACT ...... 19 CABLIVI ...... 28 SOL LEVEL 2 ...... 48 BROME ...... 68 CABOMETYX ...... 25 CARETOUCH bromfenac sodium (once- CADUET ...... 33 LANCING/EJECTOR ... 48 daily) ...... 70 CAFERGOT ...... 24 carisoprodol ...... 77 bromocriptine mesylate ... 28 caffeine citrate ...... 39 carisoprodol-aspirin-codeine BROMPHENIRAMINE CAFFEINE-SODIUM ...... 12 MALEATE ...... 74 BENZOATE ...... 39 CARNITOR ...... 51 BROMSITE ...... 70 CALAN SR ...... 33 CARNITOR SF ...... 51 BRONCHITOL ...... 77 calcipotriene ...... 41 CAROSPIR ...... 33 BRONCHITOL CALCIPOTRIENE ...... 41 carteolol hcl ...... 71 TOLERANCE TEST..... 77 calcipotriene-betameth cartia xt ...... 33 BROVANA ...... 75 diprop ...... 41 carvedilol ...... 34 BRUKINSA ...... 25 calcitonin (salmon) ...... 67 carvedilol phosphate er ... 34 BRYHALI ...... 41 calcitrene ...... 41 CASODEX ...... 25 budesonide ...... 66, 76 calcitriol ...... 41, 67 CATAFLAM ...... 11 budesonide er ...... 66 calcium acetate ...... 55 CATAPRES-TTS-1 ...... 34 BUDESONIDE- calcium acetate (phos CATAPRES-TTS-2 ...... 34 FORMOTEROL binder) ...... 55 CATAPRES-TTS-3 ...... 34 FUMARATE ...... 76 CALCIUM DISODIUM CATTLE EPITHELIUM .... 68 bumetanide ...... 33 VERSENATE ...... 68 CAYA ...... 68 BUMEX ...... 33 CALIFORNIA PEPPER CAYSTON ...... 77 BUNAVAIL ...... 15 TREE...... 68 caziant ...... 59 BUPAP ...... 12 CALQUENCE ...... 25 CEDAR ELM ...... 68

83 cefaclor ...... 16 cholestyramine ...... 34 clobetasol prop emollient cefaclor er ...... 16 cholestyramine light ...... 34 base ...... 41 cefadroxil ...... 16 ciclodan ...... 23 clobetasol propionate 41, 42 cefazolin sodium ...... 16 ciclopirox ...... 23 clobetasol propionate e ... 41 cefdinir...... 16 ciclopirox olamine ...... 23 clobetasol propionate cefepime hcl ...... 16 cilostazol ...... 28 emulsion ...... 41 cefixime ...... 16 CILOXAN ...... 70 CLOBEX ...... 42 cefpodoxime proxetil ...... 16 CIMDUO ...... 30 CLOBEX SPRAY ...... 42 cefprozil ...... 16 cimetidine ...... 52 ...... 42 ceftazidime ...... 16 cimetidine hcl ...... 52 clodan ...... 42 ceftriaxone sodium ...... 16 CIMZIA ...... 64 CLODERM ...... 42 cefuroxime axetil ...... 16 CIMZIA PREFILLED KIT . 64 clomipramine hcl ...... 21 CELEBREX ...... 11 CIMZIA STARTER KIT .... 64 clonazepam ...... 32 celecoxib ...... 11 cinacalcet hcl ...... 67 clonidine ...... 34 CELEXA ...... 21 CINRYZE ...... 64 clonidine hcl ...... 34 CELLCEPT ...... 64 CIPRO ...... 16 clonidine hcl er ...... 38 CELONTIN ...... 19 CIPRO HC...... 73 clopidogrel bisulfate ...... 28 cem-urea ...... 41 CIPRODEX ...... 73 clorazepate dipotassium .. 32 CENTANY ...... 16 ciprofloxacin hcl ... 16, 70, 73 clotrimazole ...... 23 cephalexin ...... 16 ciprofloxacin- clotrimazole-betamethasone CEQUA ...... 72 dexamethasone ...... 73 ...... 23 CERACADE ...... 41 citalopram hydrobromide . 21 clovique ...... 51 ceramax ...... 41 CLADOSPORIUM clozapine ...... 29 CERDELGA...... 54 CLADOSPORIOIDES .. 68 CLOZARIL ...... 29 CERVIDIL ...... 55 CLADOSPORIUM COARTEM ...... 27 cetirizine hcl...... 74 SPHAEROSPERMUM . 68 COCAINE HCL ...... 14 CETRAXAL ...... 73 claravis ...... 41 codeine sulfate ...... 12 cevimeline hcl ...... 40 CLARINEX ...... 74 COGENTIN ...... 28 CHANTIX ...... 15 CLARINEX-D 12 HOUR .. 74 COLAZAL...... 66 CHANTIX CONTINUING clarithromycin ...... 16 colchicine ...... 24 MONTH PAK ...... 15 clarithromycin er ...... 16 COLCHICINE ...... 24 CHANTIX STARTING clemastine fumarate ...... 74 colchicine-probenecid ..... 24 MONTH PAK ...... 15 CLENPIQ ...... 53 COLCRYS ...... 24 charlotte 24 fe ...... 59 CLEOCIN ...... 16 colesevelam hcl...... 34 chateal...... 59 CLEOCIN PHOSPHATE . 16 COLESTID ...... 34 chateal eq ...... 59 CLEOCIN-T ...... 41 COLESTID FLAVORED .. 34 CHEMET ...... 51 CLEVER CHOICE colestipol hcl ...... 34 CHEMSTRIP 10 MD ...... 48 HOLDING CHAMBER . 68 colistimethate sodium (cba) CHEMSTRIP 10/SG ...... 48 CLIMARA ...... 59 ...... 17 CHEMSTRIP 2 GP ...... 48 CLIMARA PRO ...... 59 COLY-MYCIN M ...... 17 CHEMSTRIP 5 OB ...... 48 clindacin etz ...... 41 COMBIGAN ...... 72 CHEMSTRIP 7 ...... 48 clindacin-p ...... 41 COMBIPATCH ...... 59 CHEMSTRIP 9 ...... 48 CLINDAGEL ...... 41 COMBIVENT RESPIMAT 76 CHENODAL ...... 53 clindamycin hcl ...... 16 COMBIVIR ...... 30 chlordiazepoxide hcl ...... 32 clindamycin palmitate hcl . 16 COMETRIQ ...... 25 chlordiazepoxide- clindamycin phosphate ... 16, COMPACT SPACE amitriptyline ...... 21 41 CHAMBER ...... 68 chlordiazepoxide-clidinium CLINDAMYCIN COMPACT SPACE ...... 53 PHOSPHATE ...... 41 CHAMBER/LG MASK . 68 chlorhexidine gluconate ... 40 clindamycin phosphate- COMPACT SPACE chloroquine phosphate .... 27 benzoyl peroxide ...... 41 CHAMBER/MED MASK chlorpromazine hcl ...... 29 clindamycin-tretinoin ...... 41 ...... 68 chlorthalidone ...... 34 CLINDESSE ...... 16 COMPACT SPACE chlorzoxazone ...... 77 clobazam ...... 19 CHAMBER/SM MASK . 68 CHOLBAM ...... 54 COMPLERA ...... 30

84 compro ...... 22 CUTAQUIG ...... 64 deblitane ...... 59 COMTAN ...... 28 CUTIVATE ...... 42 DECADRON ...... 56 CONCERTA ...... 38 CUVITRU ...... 64 DECARA K ...... 51 CONDYLOX ...... 42 CUVPOSA...... 53 deferasirox ...... 51 CONJUPRI ...... 34 cyanocobalamin ...... 51 deferasirox granules ...... 51 CONSENSI ...... 34 cyclafem 1/35 ...... 59 deferiprone ...... 51 constulose ...... 53 cyclafem 7/7/7 ...... 59 deferoxamine mesylate ... 68 CONTOUR CONTROL cyclobenzaprine hcl ... 77, 78 DELESTROGEN ...... 59 SOLUTION ...... 48 cyclobenzaprine hcl er ..... 77 DELSTRIGO ...... 30 CONTOUR NEXT CYCLOGYL ...... 72 delyla ...... 59 CONTROL SOLUTION 48 CYCLOMYDRIL ...... 72 DELZICOL ...... 66 CONTOUR NEXT TEST cyclopentolate hcl ...... 72 demeclocycline hcl ...... 17 STRIPS ...... 48 cyclophosphamide ...... 25 DEMSER...... 34 CONZIP ...... 12 CYCLOPHOSPHAMIDE .. 25 DENAVIR ...... 30 COPAXONE ...... 39 cycloserine ...... 25 DEPAKOTE ...... 19 COPIKTRA ...... 25 CYCLOSET ...... 47 DEPAKOTE ER...... 19 CORDRAN ...... 42 cyclosporine ...... 64 DEPAKOTE SPRINKLES 19 COREG ...... 34 CYCLOSPORINE IN DEPEN TITRATABS ...... 55 COREG CR ...... 34 KLARITY ...... 73 DEPO-ESTRADIOL ...... 59 coremino ...... 17 cyclosporine modified ...... 64 DEPO-MEDROL ...... 56 CORGARD ...... 34 CYMBALTA ...... 21 DEPO-PROVERA ...... 59 CORLANOR ...... 34 cyproheptadine hcl ...... 74 DEPO-SUBQ PROVERA CORTEF ...... 56 cyred ...... 59 104 ...... 59 CORTENEMA ...... 66 cyred eq ...... 59 DEPO-TESTOSTERONE 57 CORTIFOAM ...... 66 CYSTADANE ...... 54 DERMACINRX AZENASE CORTISPORIN-TC ...... 73 CYSTADROPS ...... 73 PAK ...... 74 COSENTYX (300 MG CYSTAGON ...... 54 DERMACINRX LIDOGEL 14 DOSE) ...... 64 CYSTARAN ...... 73 DERMA-SMOOTHE/FS COSENTYX 150 MG/ML . 64 CYTOMEL ...... 63 BODY ...... 42 COSENTYX CYTOTEC ...... 52 DERMA-SMOOTHE/FS SENSOREADY (300 MG) CYTOTINE ...... 68 SCALP ...... 42 ...... 64 cytra k crystals ...... 51 DERMOTIC ...... 74 COSENTYX D DESCOVY ...... 30 SENSOREADY PEN ... 64 D.H.E. 45 ...... 24 DESFERAL ...... 68 COSOPT ...... 72 dalfampridine er ...... 39 desipramine hcl ...... 21 COSOPT PF...... 72 DALIRESP ...... 76 desloratadine ...... 74 COTELLIC ...... 25 danazol ...... 57 desmopressin ace spray COTEMPLA XR-ODT ...... 38 DANTRIUM ...... 78 refrig ...... 58 covaryx ...... 59 dantrolene sodium ...... 78 desmopressin acetate ..... 58 covaryx hs ...... 59 dapsone ...... 25, 42 DESMOPRESSIN COZAAR ...... 34 DAPSONE...... 42 ACETATE ...... 58 CREON ...... 54 DAPTACEL ...... 65 desmopressin acetate pf . 58 CRESEMBA ...... 23 DARAPRIM ...... 27 desmopressin acetate spray CRESTOR ...... 34 darifenacin hydrobromide er ...... 58 CRINONE ...... 59 ...... 55 desogestrel-ethinyl estradiol CRIXIVAN ...... 30 dasetta 1/35 ...... 59 ...... 59 cromolyn sodium . 53, 70, 76 dasetta 7/7/7 ...... 59 DESONATE ...... 42 crotan ...... 27 DAURISMO ...... 25 desonide ...... 42 CRYODOSE TA ...... 14 DAYPRO ...... 11 DESOWEN ...... 42 cryselle-28 ...... 59 daysee ...... 59 desoximetasone ...... 42 CRYSVITA ...... 54 DAYTRANA ...... 38 DESOXYN ...... 38 CUPRIMINE ...... 55 DAYVIGO ...... 78 desrx ...... 42 curity sterile saline ...... 51 DDAVP ...... 58 DESVENLAFAXINE ER .. 21 CUROSURF ...... 74 DDAVP PF ...... 58 desvenlafaxine succinate er CURVULARIA ...... 68 DEBACTEROL ...... 40 ...... 21

85 DETROL ...... 55 digitek ...... 34 DOVONEX ...... 42 DETROL LA ...... 55 digox ...... 34 doxazosin mesylate ...... 34 DEXABLISS ...... 56 digoxin ...... 34 doxepin hcl ...... 21, 42, 78 dexamethasone ...... 56 dihydroergotamine mesylate doxercalciferol ...... 67 DEXAMETHASONE (LA) 56 ...... 24 doxycycline ...... 42 dexamethasone intensol .. 56 DILANTIN ...... 19 doxycycline hyclate ...... 17 dexamethasone sod DILANTIN INFATABS ..... 19 DOXYCYCLINE HYCLATE phosphate pf ...... 56 DILATRATE-SR ...... 34 ...... 17 dexamethasone sodium DILAUDID ...... 12 doxycycline monohydrate 17 phosphate ...... 56, 70 diltiazem hcl ...... 34 doxylamine-pyridoxine..... 22 DEXAMETHASONE diltiazem hcl er ...... 34 DRECHSLERA ...... 68 SODIUM PHOSPHATE56 diltiazem hcl er beads ...... 34 DRISDOL ...... 51 dexchlorpheniramine diltiazem hcl er coated DRITHO-CREME HP ...... 42 maleate...... 74 beads ...... 34 DRIZALMA SPRINKLE ... 21 DEXEDRINE ...... 38 dilt-xr ...... 34 dronabinol ...... 22 DEXERYL ...... 42 dimenhydrinate ...... 22 DROPLET GENTEEL DEXILANT ...... 52 dimethyl fumarate ...... 39 LANCING DEVICE ...... 48 dexmethylphenidate hcl ... 38 dimethyl fumarate starter drospiren-eth estrad- dexmethylphenidate hcl er pack ...... 39 levomefol ...... 60 ...... 38 DIOVAN ...... 34 drospirenone-ethinyl DEXONTO 0.4% ...... 56 DIOVAN HCT ...... 34 estradiol ...... 60 DEXPANTHENOL ...... 51 DIPENTUM ...... 66 DROXIA ...... 25 dextroamphetamine sulfate diphen ...... 74 droxidopa ...... 34 ...... 38 di-phen ...... 74 DRYSOL ...... 42 dextroamphetamine sulfate diphenhydramine hcl ...... 74 DUAKLIR PRESSAIR...... 76 er ...... 38 diphenoxylate-atropine .... 53 DUAVEE ...... 60 DIACOMIT ...... 19 DIPHTHERIA-TETANUS DUETACT ...... 47 DIASTAT ACUDIAL ...... 19 TOXOIDS DT ...... 65 DUEXIS ...... 11 DIASTAT PEDIATRIC ..... 19 DIPROLENE ...... 42 DULERA ...... 76 DIATHRIVE GLUCOSE DIPROLENE AF ...... 42 duloxetine hcl ...... 21 CONTROL SOLN ...... 48 dipyridamole ...... 28 DUOPA ...... 28 DIATHRIVE LANCING disopyramide phosphate . 34 DUPIXENT ...... 42 DEVICE ...... 48 disulfiram ...... 15 DUREZOL ...... 70 diazepam ...... 19, 32 DITROPAN XL ...... 55 DURLAZA ...... 28 DIAZEPAM ...... 32 DIURIL ...... 34 DUST MITE MIXED diazepam intensol ...... 32 divalproex sodium ...... 19 ALLERGEN EXT ...... 68 diazoxide ...... 49 divalproex sodium er ...... 19 dutasteride ...... 56 DIBENZYLINE ...... 34 DIVIGEL ...... 59 dutasteride-tamsulosin hcl DICLEGIS ...... 22 dofetilide ...... 34 ...... 56 DICLOFENAC CAP 35MG DOG EPITHELIUM ...... 68 DUTOPROL ...... 34 ...... 11 DOJOLVI ...... 68 DXEVO 11-DAY ...... 56 DICLOFENAC PATCH dolishale ...... 60 DYANAVEL XR ...... 38 1.3% ...... 11 donepezil hcl ...... 20 DYMISTA ...... 74 diclofenac potassium ...... 11 DOPTELET ...... 32 DYRENIUM ...... 34 diclofenac sodium 11, 42, 70 DORAL ...... 32 E diclofenac sodium er ...... 11 DORYX ...... 17 E.E.S. 400 ...... 17 diclofenac-misoprostol ..... 11 DORYX MPC ...... 17 E.E.S. GRANULES ...... 17 DICLOFONO ...... 11 dorzolamide hcl ...... 72 EASIVENT ...... 68 dicloxacillin sodium ...... 17 DORZOLAMIDE HCL ...... 72 EASY TRAK II CONTROL dicyclomine hcl ...... 53 dorzolamide hcl-timolol mal ...... 48 DIFFERIN ...... 42 ...... 72 EASYMAX 15 LEVEL 2-3 DIFICID ...... 17 dorzolamide hcl-timolol mal CONTROL...... 48 ...... 42 pf ...... 72 EASYMAX CONTROL .... 48 DIFLUCAN ...... 23 dotti ...... 60 EC-NAPROSYN ...... 11 diflunisal ...... 11 DOVATO ...... 30 ec-naproxen ...... 11

86 econazole nitrate ...... 23 enalapril- erlotinib hcl ...... 25 ECOZA ...... 23 hydrochlorothiazide ..... 34 errin ...... 60 EDARBI ...... 34 ENBREL ...... 64 ERTACZO ...... 23 EDARBYCLOR ...... 34 ENBREL MINI ...... 64 ery ...... 42 EDECRIN ...... 34 ENBREL SURECLICK .... 64 ERYGEL ...... 42 EDLUAR ...... 78 ENDARI ...... 68 ERYPED 200 ...... 17 ed-spaz ...... 53 endocet ...... 12 ERYPED 400 ...... 17 EDURANT ...... 30 ENDOMETRIN ...... 60 ERY-TAB ...... 17 eemt ...... 60 ENGERIX-B ...... 65 ERYTHROCIN STEARATE eemt hs ...... 60 enoxaparin sodium ...... 18 ...... 17 efavirenz ...... 30 enpresse-28 ...... 60 erythromycin ...... 17, 42, 70 efavirenz-emtricitab- enskyce ...... 60 erythromycin base ...... 17 tenofovir...... 30 ENSPRYNG ...... 64 erythromycin ethylsuccinate efavirenz-lamivudine- ENSTILAR...... 42 ...... 17 tenofovir...... 30 entacapone ...... 28 ESBRIET...... 76 effer-k ...... 51 entecavir ...... 30 escitalopram oxalate ...... 21 EFFER-K ...... 51 ENTEREG ...... 53 ESGIC ...... 12 EFFEXOR XR ...... 21 ENTOCORT EC ...... 66 esomeprazole magnesium EFFIENT ...... 29 ENTRESTO ...... 34 ...... 52 EFUDEX ...... 42 ENTTY SPRAY ...... 42 ESOMEPRAZOLE EGRIFTA SV ...... 58 enulose ...... 53 STRONTIUM ...... 52 EHA ...... 14 ENVARSUS XR ...... 64 est estrogens-methyltest . 60 ELEPSIA XR ...... 19 EPANED ...... 34 est estrogens-methyltest ds ELESTRIN ...... 60 EPCLUSA ...... 30 ...... 60 ELETONE ...... 42 EPICERAM ...... 42 est estrogens-methyltest hs eletriptan hydrobromide ... 24 EPICOCCUM ...... 68 ...... 60 ELIDEL ...... 42 EPIDIOLEX ...... 19 estarylla ...... 60 ELIGARD ...... 58 EPIDUO ...... 42 estazolam...... 32 elinest ...... 60 EPIDUO FORTE ...... 42 ESTRACE ...... 60 ELIQUIS ...... 18 EPIFOAM ...... 42 estradiol ...... 60 ELIQUIS DVT/PE epinastine hcl ...... 70 estradiol valerate ...... 60 STARTER PACK ...... 18 epinephrine ...... 76 estradiol-norethindrone acet ELIXOPHYLLIN ...... 76 EPINEPHRINE ...... 34 ...... 60 ELLA ...... 60 epinephrine pf ...... 34 ESTRING ...... 60 ELMIRON ...... 55 EPINEPHRINE ESTROGEL ...... 60 eluryng ...... 60 PROFESSIONAL ...... 76 ESTROSTEP FE ...... 60 EMBRACE LANCING EPINEPHRINESNAP-EMS eszopiclone ...... 78 DEVICE/EJECTOR ..... 48 ...... 76 ethacrynic acid ...... 34 EMBRACE TALK EPINEPHRINESNAP-V ... 76 ethambutol hcl ...... 25 GLUCOSE CONTROL . 48 EPIPEN 2-PAK ...... 76 ethosuximide ...... 19 EMCYT ...... 25 EPIPEN JR 2-PAK ...... 76 ethyl chloride ...... 14 EMEND ...... 22 EPISNAP ...... 76 ethynodiol diac-eth estradiol EMEND TRI-PACK ...... 22 epitol ...... 19 ...... 60 EMFLAZA ...... 24 EPIVIR ...... 30 etodolac ...... 11 EMGALITY ...... 24 EPIVIR HBV ...... 30 etodolac er ...... 11 EMGALITY (300 MG eplerenone ...... 34 etonogestrel-ethinyl DOSE) ...... 24 EPOGEN ...... 32 estradiol ...... 60 emoquette ...... 60 EPZICOM ...... 30 etoposide ...... 25 EMSAM ...... 21 EQUETRO ...... 32 etravirine ...... 30 emtricitabine ...... 30 ergocalciferol ...... 51 EUCRISA ...... 42 emtricitabine-tenofovir df . 30 ergoloid mesylates ...... 68 euthyrox ...... 63 EMTRIVA ...... 30 ERGOMAR...... 24 EVAMIST ...... 60 EMULSION SB ...... 42 ergotamine-caffeine ...... 24 EVEKEO ...... 38 EMVERM ...... 27 ERIVEDGE...... 25 EVEKEO ODT ...... 38 enalapril maleate ...... 34 ERLEADA ...... 25 everolimus ...... 25, 64

87 EVISTA ...... 58 FETZIMA ...... 21 flunisolide ...... 74 EVOCLIN ...... 42 FETZIMA TITRATION ..... 21 fluocinolone acetonide.... 43, EVOTAZ ...... 30 FEXMID ...... 78 74 EVOXAC ...... 40 FIASP ...... 49 fluocinolone acetonide body EVRYSDI ...... 54 FIASP FLEXTOUCH ...... 49 ...... 43 EXELDERM...... 23 FIASP PENFILL ...... 49 fluocinolone acetonide scalp EXELON ...... 20 FIBRICOR ...... 35 ...... 43 exemestane ...... 25 FINACEA ...... 42, 43 fluocinonide ...... 43 EXFORGE ...... 34 finasteride ...... 56 fluocinonide emulsified base EXFORGE HCT ...... 34 FINTEPLA ...... 19 ...... 43 EXJADE ...... 51 FIORICET ...... 12 fluoritab ...... 51 EXSERVAN ...... 39 FIORICET/CODEINE ...... 13 fluorometholone ...... 71 EXTAVIA ...... 39 FIRAZYR ...... 64 FLUOROPLEX ...... 43 EXTINA ...... 23 FIRDAPSE ...... 68 fluorouracil ...... 43 EYSUVIS ...... 70 FIRE ANT ...... 68 FLUOROURACIL ...... 43 EZALLOR SPRINKLE ..... 34 FIRST-BACLOFEN ...... 78 fluoxetine hcl ...... 21 ezetimibe ...... 34 FIRST-LANSOPRAZOLE 52 fluoxetine hcl (pmdd) ...... 21 ezetimibe-simvastatin ...... 35 FIRST-MOUTHWASH BLM fluphenazine decanoate .. 29 F ...... 40 fluphenazine hcl ...... 29 FABIOR ...... 42 FIRST-OMEPRAZOLE .... 52 flurandrenolide ...... 43 falmina...... 60 FIRST-PROGESTERONE flurazepam hcl ...... 78 famciclovir ...... 30 VGS ...... 60 flurbiprofen ...... 11 famotidine ...... 52 FIRVANQ ...... 17 flurbiprofen sodium ...... 71 FANAPT ...... 29 flac ...... 74 flutamide ...... 25 FANAPT TITRATION PACK FLAGYL ...... 17 fluticasone propionate ..... 43 ...... 29 FLAREX ...... 70 fluticasone-salmeterol ..... 76 FARESTON ...... 25 flavoxate hcl ...... 55 FLUTICASONE- FARXIGA ...... 47 flecainide acetate ...... 35 SALMETEROL ...... 76 FARYDAK ...... 25 FLECTOR ...... 11 fluvastatin sodium ...... 35 FASENRA PEN ...... 74 FLEXICHAMBER ...... 68 fluvastatin sodium er ...... 35 fayosim ...... 60 FLEXICHAMBER ADULT fluvoxamine maleate ...... 21 febuxostat ...... 24 MASK/SMALL ...... 68 fluvoxamine maleate er ... 21 felbamate ...... 19 FLEXICHAMBER CHILD FLUZONE HIGH-DOSE FELBATOL ...... 19 MASK/LARGE ...... 68 QUADRIVALENT ...... 65 FELDENE ...... 11 FLEXICHAMBER CHILD FLUZONE felodipine er ...... 35 MASK/SMALL ...... 68 QUADRIVALENT ...... 65 FEM PH ...... 55 FLEXIN ...... 14 FML ...... 71 FEMARA ...... 25 FLOLIPID ...... 35 FML FORTE ...... 71 FEMCAP ...... 68 FLOMAX ...... 56 FML LIQUIFILM ...... 71 FEMHRT ...... 60 FLOVENT DISKUS ...... 76 FOCALIN ...... 38 FEMRING ...... 60 FLOVENT HFA ...... 76 FOCALIN XR ...... 38 femynor ...... 60 FLUAD QUADRIVALENT 65 folic acid ...... 51 fenofibrate ...... 35 FLUARIX QUADRIVALENT FOLVITE-D ...... 51 fenofibrate micronized ..... 35 ...... 65 fondaparinux sodium ...... 18 fenofibric acid ...... 35 FLUBLOK QUADRIVALENT FORFIVO XL ...... 21 FENOGLIDE...... 35 ...... 65 formoterol fumarate ...... 76 fenoprofen calcium ...... 11 FLUCELVAX FORTAZ ...... 17 fenortho ...... 11 QUADRIVALENT ...... 65 FORTEO ...... 67 fentanyl ...... 12 fluconazole ...... 23 FORTESTA ...... 57 fentanyl citrate ...... 12 flucytosine ...... 23 FORTISCARE CONTROL FENTANYL CITRATE ..... 12 fludrocortisone acetate .... 57 ...... 48 FENTORA ...... 12 FLULAVAL FOSAMAX ...... 67 FERRIPROX ...... 51 QUADRIVALENT ...... 65 FOSAMAX PLUS D ...... 67 FERRIPROX TWICE-A- FLUMIST QUADRIVALENT fosamprenavir calcium .... 30 DAY ...... 51 ...... 65 fosfomycin tromethamine 17

88 fosinopril sodium ...... 35 gianvi...... 60 GYNAZOLE-1 ...... 23 fosinopril sodium-hctz ...... 35 GILENYA ...... 39 H FOSRENOL...... 55 GILOTRIF ...... 25 habitrol ...... 15 FOTIVDA ...... 25 GIMOTI ...... 22 HACKBERRY ...... 68 FRAGMIN ...... 19 glatiramer acetate...... 39 HAEGARDA ...... 64 FREESTYLE TEST ...... 48 glatopa ...... 39 hailey 1.5/30 ...... 60 FROVA ...... 24 GLEEVEC ...... 25 hailey 24 fe ...... 60 frovatriptan succinate ...... 24 GLEOSTINE ...... 25 hailey fe 1.5/30 ...... 60 FULPHILA ...... 32 glimepiride ...... 47 hailey fe 1/20 ...... 60 furosemide ...... 35 glipizide er ...... 47 halcinonide ...... 43 FUSARIUM ...... 68 glipizide ir ...... 47 HALCION ...... 32 FUZEON ...... 30 glipizide xl ...... 47 HALDOL ...... 29 fyavolv ...... 60 glipizide-metformin hcl ..... 47 HALDOL DECANOATE ... 29 FYCOMPA ...... 19 GLOPERBA ...... 24 halobetasol propionate .... 43 G GLUCAGEN DIAGNOSTIC HALOBETASOL gabapentin ...... 19 ...... 68 PROPIONATE ...... 43 GABAPENTIN-NAPROXEN GLUCAGEN HYPOKIT.... 49 HALOG ...... 43 CMPD KIT ...... 11 glucagon emergency kit... 49 haloperidol ...... 29 GABITRIL ...... 19 GLUCAGON EMERGENCY haloperidol decanoate ..... 29 GALAFOLD ...... 54 KIT ...... 49 haloperidol lactate ...... 29 galantamine hydrobromide GLUCAGON HCL HARVONI...... 30 ...... 20 (DIAGNOSTIC) ...... 68 HAVRIX ...... 65 galantamine hydrobromide GLUCOSE CONTROL heather ...... 60 er ...... 20 SOLUTIONS...... 48 HELIDAC THERAPY ...... 53 GARDASIL 9 ...... 65 GLUCOTROL XL...... 47 HEMADY...... 57 GASTROCROM ...... 53 GLUMETZA ...... 47 HEMANGEOL ...... 35 gatifloxacin ...... 71 glyburide ...... 47 HEMLIBRA ...... 32 GATTEX ...... 53 glyburide micronized ...... 47 hemmorex-hc ...... 66 gavilyte-c ...... 53 glyburide-metformin ...... 47 HEMMOREX-HC ...... 66 gavilyte-g ...... 53 glycopyrrolate ...... 53 HEPAGAM B ...... 64 gavilyte-n with flavor pack 53 GLYCOPYRROLATE ...... 53 heparin sodium (porcine) . 19 GAVRETO ...... 25 glydo ...... 14 heparin sodium (porcine) pf GEBAUERS PAIN EASE . 14 GLYNASE ...... 47 ...... 19 GEBAUERS SPRAY AND GLYXAMBI ...... 47 HEPLISAV-B ...... 65 STRETCH ...... 14 GOCOVRI ...... 28 HEPSERA ...... 30 GELFILM ...... 73 GOJJI CONTROL ...... 48 HETLIOZ ...... 78 GELNIQUE ...... 55 GOJJI LANCING HETLIOZ LQ ...... 78 gemfibrozil ...... 35 DEVICE/CLEAR CAP .. 48 HIBERIX ...... 65 gemmily ...... 60 GOLYTELY ...... 53 HIDEX 6-DAY ...... 57 GEMTESA ...... 55 GONITRO ...... 35 HIPREX ...... 17 GEN7T ...... 14 goodsense nicotine ...... 15 HIZENTRA ...... 64 GENERESS FE ...... 60 GOPRELTO ...... 14 homatropaire ...... 73 generlac ...... 53 GRALISE ...... 39 HONEY BEE VENOM ..... 68 gengraf ...... 64 granisetron hcl ...... 22 HONEY BEE VENOM GENICIN VITA-D ...... 51 GRANIX ...... 32 PROTEIN ...... 68 GENOTROPIN ...... 58 GRASTEK ...... 68 HORIZANT ...... 39 GENOTROPIN MINIQUICK griseofulvin microsize ...... 23 HORSE EPITHELIUM ..... 68 ...... 58 griseofulvin ultramicrosize23 HPR PLUS ...... 43 gentak ...... 71 guanfacine hcl ...... 35 HUMALOG ...... 49 gentamicin sulfate ..... 17, 71 guanfacine hcl er ...... 38 HUMALOG KWIKPEN..... 49 GENTEEL LANCING KIT GVOKE HYPOPEN 1-PACK HUMALOG MIX 50/50 (BLUE) ...... 48 ...... 49 KWIKPEN ...... 49 GENVOYA ...... 30 GVOKE HYPOPEN 2-PACK HUMALOG MIX 50/50 VIAL GEODON ...... 29 ...... 49 ...... 49 GERMAN COCKROACH. 68 GVOKE PFS ...... 49

89 HUMALOG MIX 75/25 hydromet ...... 74 IMVEXXY MAINTENANCE KWIKPEN ...... 49 hydromorphone hcl ...... 13 PACK ...... 60 HUMALOG MIX 75/25 VIAL hydromorphone hcl er ..... 13 IMVEXXY STARTER PACK ...... 49 hydroxychloroquine sulfate ...... 60 HUMALOG U-100 JUNIOR ...... 27 INBRIJA ...... 28 KWIKPEN ...... 49 hydroxyprogesterone incassia ...... 60 HUMATIN ...... 17 caproate ...... 60 INCRELEX ...... 58 HUMATROPE ...... 58 hydroxyurea ...... 25 INCRUSE ELLIPTA ...... 76 HUMIRA ...... 64 hydroxyzine hcl ...... 32 indapamide ...... 35 HUMIRA PEDIATRIC hydroxyzine pamoate ...... 32 INDERAL LA ...... 35 CROHNS START ...... 64 HYLAGUARD ...... 43 INDERAL XL ...... 35 HUMIRA PEN ...... 64 HYLATOPIC PLUS ...... 43 INDOCIN ...... 11 HUMIRA PEN-CD/UC/HS hyophen ...... 55 indomethacin ...... 11 STARTER ...... 64 hyoscyamine sulfate ...... 53 indomethacin er...... 11 HUMIRA PEN-PEDIATRIC hyoscyamine sulfate er .... 53 INFANRIX ...... 65 UC START ...... 64 hyoscyamine sulfate sl .... 53 INFASURF ...... 74 HUMIRA PEN-PS/UV/ADOL hyosyne ...... 53 INGREZZA ...... 39 HS START ...... 64 HYPERHEP B ...... 64 INLYTA ...... 26 HUMIRA PEN- HYPERRAB ...... 64 INNOPRAN XL ...... 35 PSOR/UVEIT STARTER HYPERSAL ...... 74 INQOVI ...... 26 ...... 64 HYPERTET S/D ...... 64 INREBIC ...... 26 HUMULIN 70/30 KWIKPEN HYPOCYN ...... 73 INSPRA ...... 35 ...... 49 HYQVIA ...... 64 INSULIN ASP PROT & ASP HUMULIN 70/30 VIAL ..... 49 HYSINGLA ER ...... 13 FLEXPEN ...... 49 HUMULIN N KWIKPEN ... 49 HYZAAR ...... 35 INSULIN ASPART ...... 49 HUMULIN N VIAL ...... 49 I INSULIN ASPART HUMULIN R U-500 ibandronate sodium ...... 67 FLEXPEN ...... 49 KWIKPEN ...... 49 IBRANCE ...... 25 INSULIN ASPART PENFILL HUMULIN R U-500 VIAL . 49 ibuprofen ...... 11 ...... 49 HUMULIN R VIAL ...... 49 ibuprofen-famotidine ...... 11 INSULIN ASPART PROT & HYCAMTIN ...... 25 icatibant acetate ...... 64 ASPART ...... 49 HYCODAN ...... 74 iclevia ...... 60 INSULIN LISPRO ...... 50 hydralazine hcl ...... 35 ICLUSIG ...... 25 INSULIN LISPRO (1 UNIT HYDREA ...... 25 icosapent ethyl ...... 35 DIAL) ...... 50 HYDRO 40 ...... 43 IDHIFA ...... 25 INSULIN LISPRO JUNIOR hydrochlorothiazide ...... 35 ILEVRO ...... 71 KWIKPEN ...... 50 hydrocodone bitartrate er 13 ILIDERM ...... 43 INSULIN LISPRO PROT & hydrocodone polst- imatinib mesylate...... 25 LISPRO ...... 50 chlorphen polst er susp 74 IMBRUVICA ...... 25, 26 INSULIN PEN NEEDLES 50 hydrocodone- IMCIVREE ...... 39 INSULIN SYRINGES ...... 50 acetaminophen ...... 13 imipramine hcl ...... 21 INTELENCE ...... 30 hydrocodone-homatropine imipramine pamoate ...... 21 INTRAROSA ...... 55 ...... 74 imiquimod ...... 43 INTRON A ...... 30 hydrocodone-ibuprofen .... 13 IMIQUIMOD PUMP ...... 43 introvale ...... 60 hydrocortisone ..... 43, 57, 66 IMITREX ...... 24 INTUNIV ...... 38 hydrocortisone (perianal) . 66 IMITREX STATDOSE INVEGA ...... 29 hydrocortisone ace- REFILL ...... 24 INVEGA SUSTENNA ...... 29 pramoxine ...... 43, 66 IMITREX STATDOSE INVEGA TRINZA ...... 29 hydrocortisone acetate .... 66 SYSTEM ...... 24 INVELTYS ...... 71 hydrocortisone butyr lipo IMOGAM RABIES-HT ..... 64 INVIRASE ...... 30 base ...... 43 IMPAVIDO...... 27 INVOKAMET ...... 47 hydrocortisone butyrate ... 43 IMPEKLO ...... 43 INVOKAMET XR ...... 47 hydrocortisone valerate ... 43 IMPOYZ ...... 43 INVOKANA ...... 47 hydrocortisone-acetic acid IMURAN ...... 64 iodine strong ...... 51 ...... 74 IOPIDINE ...... 72

90 IPOL ...... 66 JYNARQUE ...... 51 klor-con m20 ...... 51 ipratropium bromide ... 74, 76 K klor-con/ef ...... 51 ipratropium-albuterol ...... 76 kaitlib fe ...... 61 KLOXXADO ...... 15 irbesartan ...... 35 KALETRA ...... 30 KOMBIGLYZE XR ...... 47 irbesartan- kalliga ...... 61 KORLYM ...... 59 hydrochlorothiazide ..... 35 KALYDECO ...... 77 KOSELUGO ...... 26 IRESSA ...... 26 KAMDOY ...... 43 K-PHOS ...... 51 ISENTRESS ...... 30 KAPOK ...... 68 K-PHOS NO 2 ...... 51 ISENTRESS HD ...... 30 KAPSPARGO SPRINKLE35 K-PHOS-NEUTRAL ...... 51 isibloom ...... 60 KAPVAY ...... 38 k-prime ...... 51 isoniazid ...... 25 KARBINAL ER ...... 74 KRINTAFEL ...... 27 isoproterenol hcl ...... 76 kariva ...... 61 KRISTALOSE ...... 53 ISOPTO ATROPINE ...... 73 KATE FARMS PEPTIDE 1.5 K-TAB ...... 51 ISOPTO CARPINE ...... 72 ...... 68 kurvelo ...... 61 ISORDIL TITRADOSE ..... 35 KATE FARMS STANDARD KUVAN ...... 54 isosorbide dinitrate ...... 35 1.4 ...... 68 KYNMOBI ...... 28 isosorbide mononitrate .... 35 KATERZIA...... 35 KYNMOBI TITRATION KIT isosorbide mononitrate er 35 KAZANO ...... 47 ...... 28 isotretinoin ...... 43 KEDRAB ...... 64 L isradipine ...... 35 KEFLEX ...... 17 labetalol hcl ...... 35 ISTALOL ...... 72 kelnor 1/35 ...... 61 LACRISERT ...... 73 ISTURISA ...... 58 kelnor 1/50 ...... 61 lactic acid ...... 44 ISUPREL ...... 76 KENALOG ...... 43, 57 lactic acid e ...... 44 itraconazole ...... 23 KEPPRA ...... 19 lactulose ...... 53 ivermectin ...... 27, 43 KEPPRA XR ...... 19 lactulose encephalopathy 53 J KERALAC ...... 43 LAMICTAL ...... 19 JADENU ...... 51 KERALYT ...... 44 LAMICTAL ODT ...... 19 JADENU SPRINKLE ...... 51 KERENDIA ...... 69 LAMICTAL STARTER ..... 19 jaimiess ...... 60 KERYDIN ...... 23 LAMICTAL XR ...... 19 JAKAFI ...... 26 KESIMPTA ...... 39 lamivudine ...... 30 JALYN ...... 56 ketoconazole ...... 23 lamivudine-zidovudine ..... 30 jantoven ...... 19 ketodan ...... 23 lamotrigine ...... 19 JANUMET ...... 47 ketoprofen ...... 11 lamotrigine er ...... 19 JANUMET XR ...... 47 ketoprofen er ...... 11 lamotrigine starter kit-blue20 JANUVIA ...... 47 ketorolac tromethamine .. 11, lamotrigine starter kit-green JARDIANCE ...... 47 71 ...... 20 jasmiel ...... 60 KETOROLAC lamotrigine starter kit- JATENZO ...... 57 TROMETHAMINE ...... 11 orange ...... 20 jencycla ...... 60 KEVEYIS ...... 72 LAMPIT ...... 27 JENTADUETO ...... 47 KEVZARA ...... 64 LANCETS ...... 48 JENTADUETO XR...... 47 KINERET ...... 64 LANOXIN ...... 35 jinteli ...... 60 KINRIX ...... 66 LANOXIN PEDIATRIC .... 35 jolessa ...... 60 KISQALI ...... 26 lansoprazole ...... 52 JORNAY PM ...... 38 KISQALI FEMARA ...... 26 lanthanum carbonate ...... 55 JUBLIA ...... 23 KITABIS PAK ...... 77 LANTUS SOLOSTAR...... 50 juleber ...... 61 KIVIK ...... 44 LANTUS U-100 VIAL ...... 50 JULUCA ...... 30 KLARITY-A...... 71 lapatinib ditosylate ...... 26 JUNE GRASS POLLEN KLARITY-L ...... 71 larin 1.5/30 ...... 61 STANDARDIZED ...... 68 KLARON ...... 44 larin 1/20 ...... 61 junel 1.5/30 ...... 61 KLISYRI ...... 44 larin 24 fe ...... 61 junel 1/20 ...... 61 KLONOPIN...... 32 larin fe 1.5/30 ...... 61 junel fe 1.5/30 ...... 61 klor-con ...... 51 larin fe 1/20 ...... 61 junel fe 1/20 ...... 61 klor-con 10 ...... 51 larissia ...... 61 junel fe 24 ...... 61 klor-con m10 ...... 51 LASIX ...... 35 JUXTAPID ...... 35 klor-con m15 ...... 51 LASTACAFT ...... 73

91 latanoprost ...... 72 LEXAPRO ...... 21 LITHOSTAT ...... 55 LATANOPROST-TIMOLOL LEXETTE ...... 44 LIVALO ...... 35 MALEATE ...... 72 LEXIVA ...... 30 LIVIXIL PAK ...... 15 LATUDA ...... 29 LIALDA ...... 66 LO LOESTRIN FE ...... 61 layolis fe ...... 61 LIBRAX ...... 53 LOCOID ...... 44 LAZANDA ...... 13 LICART ...... 11 LOCOID LIPOCREAM .... 44 LDO PLUS ...... 14 LIDO BDK ...... 14 LODINE ...... 11 LEDIPASVIR- lidocaine ...... 14 LODOSYN ...... 28 SOFOSBUVIR ...... 30 lidocaine hcl ...... 14, 40 LOESTRIN 1.5/30 (21) .... 61 leena ...... 61 LIDOCAINE HCL ...... 14 LOESTRIN 1/20 (21) ...... 61 leflunomide ...... 64 lidocaine hcl (pf) ...... 14 LOESTRIN FE 1.5/30 ...... 61 LENVIMA ...... 26 lidocaine hcl LOESTRIN FE 1/20 ...... 61 LESCOL XL ...... 35 urethral/mucosal ...... 14 lojaimiess ...... 61 lessina ...... 61 LIDOCAINE HCL- LOKELMA ...... 51 LETAIRIS ...... 77 TETRACAINE HCL...... 14 LOMOTIL ...... 54 letrozole ...... 26 lidocaine viscous hcl ...... 40 LONHALA MAGNAIR leucovorin calcium ...... 26 lidocaine-epinephrine ...... 14 REFILL KIT ...... 76 LEUKERAN ...... 26 lidocaine-hydrocort LONHALA MAGNAIR LEUKINE ...... 32 (perianal) ...... 66 STARTER KIT ...... 76 leuprolide acetate ...... 58 lidocaine-hydrocortisone LONSURF ...... 26 levalbuterol hcl ...... 76 ace ...... 66 loperamide hcl ...... 54 LEVALBUTEROL HFA .... 76 LIDOCAINE- LOPID ...... 35 LEVATIO ...... 14 HYDROCORTISONE lopinavir-ritonavir ...... 30 LEVBID ...... 53 ACE ...... 44, 66 LOPRESSOR ...... 35 LEVEMIR U-100 lidocaine-prilocaine ...... 14 LOPROX ...... 23 FLEXTOUCH ...... 50 LIDOCANNA ...... 15 lorazepam ...... 32 LEVEMIR U-100 VIAL ..... 50 LIDOCORT...... 66 lorazepam intensol ...... 32 levetiracetam ...... 20 LIDODERM ...... 15 LORBRENA ...... 26 levetiracetam er ...... 20 LIDOMAR ...... 15 LORTAB ...... 13 levobunolol hcl ...... 72 lidopin ...... 15 loryna ...... 61 levocarnitine ...... 51 LIDOPRIL ...... 15 LORZONE ...... 78 levocarnitine sf ...... 51 LIDOPRIL XR ...... 15 losartan potassium ...... 35 levocetirizine LIDO-PRILO CAINE PACK losartan potassium-hctz .. 35 dihydrochloride ...... 74 ...... 15 LOSEASONIQUE ...... 61 levofloxacin ...... 17, 71 LIDORX ...... 15 LOTEMAX ...... 71 levonest ...... 61 LIDO-SORB ...... 15 LOTEMAX SM ...... 71 levonorgest-eth est & eth LIDOTHOL ...... 15 LOTENSIN ...... 35 est ...... 61 LIDOTRAL...... 15 LOTENSIN HCT ...... 35 levonorgest-eth estrad 91- LIFEMS NALOXONE ...... 15 loteprednol etabonate ..... 71 day ...... 61 LILETTA (52 MG) ...... 61 LOTREL ...... 35 levonorgestrel ...... 61 lillow ...... 61 LOTRONEX ...... 54 levonorgestrel-ethinyl estrad LINCOCIN ...... 17 lovastatin ...... 35 ...... 61 lincomycin hcl ...... 17 LOVAZA ...... 35 levonorg-eth estrad triphasic lindane ...... 27 LOVENOX ...... 19 ...... 61 linezolid ...... 17 low-ogestrel ...... 61 levora 0.15/30 (28) ...... 61 LINZESS ...... 53 loxapine succinate ...... 29 levorphanol tartrate...... 13 liothyronine sodium ...... 63 lo-zumandimine ...... 61 levo-t ...... 63 LIPITOR ...... 35 LUBIPROSTONE ...... 54 levothyroxine sodium ...... 63 LIPOFEN ...... 35 LUCEMYRA ...... 15 LEVOTHYROXINE lisinopril ...... 35 LULICONAZOLE ...... 23 SODIUM ...... 63 lisinopril-hydrochlorothiazide LUMAKRAS ...... 26 levoxyl ...... 63 ...... 35 LUMIGAN...... 72 LEVSIN ...... 53 lithium carbonate ...... 32 LUNESTA ...... 78 LEVSIN/SL ...... 53 lithium carbonate er ...... 32 LUPKYNIS ...... 64 LEVULAN KERASTICK ... 44 LITHOBID ...... 32

92 LUPRON DEPOT (1- meclofenamate sodium ... 11 methylergonovine maleate MONTH) ...... 58 MEDROL ...... 57 ...... 69 LUPRON DEPOT (3- medroxyprogesterone METHYLIN ...... 38 MONTH) ...... 58 acetate ...... 61 methylphenidate hcl ...... 38 LUPRON DEPOT (4- mefenamic acid ...... 11 methylphenidate hcl er .... 38 MONTH) megestrol acetate ...... 61 methylphenidate hcl er (cd) INTRAMUSCULAR KIT MEKINIST ...... 26 ...... 38 30MG ...... 58 MEKTOVI ...... 26 methylphenidate hcl er (la) LUPRON DEPOT (6- MELALEUCA ...... 69 ...... 38 MONTH) meloxicam ...... 11 methylphenidate hcl er (xr) INTRAMUSCULAR KIT melphalan ...... 26 ...... 38 45MG ...... 58 memantine hcl ...... 20, 21 methylprednisolone ...... 57 LUPRON DEPOT-PED (1- memantine hcl er ...... 20 METHYLPREDNISOLONE MONTH) ...... 58 MENACTRA ...... 66 ACE-LIDO ...... 57 LUPRON DEPOT-PED (3- MENEST ...... 61 METHYLPREDNISOLONE MONTH) ...... 58 MENOSTAR ...... 61 ACETATE ...... 57 lutera ...... 61 MENQUADFI ...... 66 methylprednisolone sodium LUXIQ ...... 44 MENVEO ...... 66 succ...... 57 LUZU ...... 23 meperidine hcl ...... 13 methyltestosterone ...... 57 LYDEXA ...... 15 MEPHYTON ...... 51 metoclopramide hcl ...... 22 lyleq ...... 61 meprobamate ...... 32 metolazone ...... 35 lyllana ...... 61 MEPRON ...... 27 metoprolol succinate er ... 35 LYNPARZA ...... 26 mercaptopurine ...... 26 metoprolol tartrate ...... 36 LYRICA ...... 39 merzee ...... 61 metoprolol- LYRICA CR ...... 39 mesalamine ...... 66, 67 hydrochlorothiazide ..... 36 LYSODREN...... 26 mesalamine er oral capsule METROCREAM ...... 44 LYSTEDA ...... 32 0.375 gm ...... 66 METROGEL ...... 44 LYUMJEV KWIKPEN ...... 50 mesalamine-cleanser ...... 67 METROLOTION ...... 44 LYUMJEV VIAL ...... 50 mesna ...... 26 metronidazole ...... 17, 44 lyza ...... 61 MESNEX ...... 26 metyrosine ...... 36 M MESTINON ...... 24 mexiletine hcl ...... 36 MACROBID ...... 17 metaxalone...... 78 MIACALCIN ...... 67 MACRODANTIN ...... 17 metformin hcl er ...... 47 mibelas 24 fe ...... 61 mafenide acetate ...... 17 metformin hcl er (mod) .... 47 MICARDIS ...... 36 MAGNESIUM SULFATE . 51 metformin hcl er (osm) .... 47 MICARDIS HCT ...... 36 MAKENA ...... 61 metformin hcl ir ...... 47 MICLARA LQ ...... 74 malathion ...... 27 methadone hcl ...... 13 miconazole 3 ...... 23 MARINOL ...... 22 methadone hcl intensol ... 13 MICONAZOLE-ZINC marlissa ...... 61 methadose ...... 13 OXIDE-PETROLAT ..... 23 MARPLAN ...... 21 methadose sugar-free ..... 13 MICROCHAMBER ...... 69 MATULANE ...... 26 methamphetamine hcl ..... 38 microgestin 1.5/30 ...... 61 matzim la ...... 35 methazolamide ...... 72 microgestin 1/20 ...... 61 MAVENCLAD ...... 39 methenamine hippurate ... 17 microgestin 24 fe ...... 61 MAVYRET ...... 30 methenamine mandelate . 17 microgestin fe 1.5/30 ...... 61 MAXALT ...... 24 methergine ...... 69 microgestin fe 1/20 ...... 61 MAXALT-MLT ...... 24 methimazole ...... 63 MICROLET NEXT MAXIDEX ...... 71 METHITEST ...... 57 LANCING DEVICE ...... 48 MAXITROL ...... 73 methocarbamol ...... 78 midazolam hcl ...... 32 MAXZIDE ...... 35 methotrexate ...... 64 midazolam hcl (pf) ...... 32 MAXZIDE-25 ...... 35 methotrexate sodium ...... 64 midodrine hcl ...... 36 MAYZENT ...... 39 methotrexate sodium (pf) . 64 MIFEPREX ...... 51 MAYZENT STARTER methoxsalen rapid ...... 44 mifepristone ...... 51 PACK ...... 39 methscopolamine bromide MIGERGOT ...... 24 me/naphos/mb/hyo1 ...... 55 ...... 54 miglitol ...... 47 meclizine hcl ...... 22 methyldopa...... 35 miglustat ...... 54

93 MIGRANAL ...... 24 MULPLETA ...... 32 NEMBUTAL ...... 20 mili ...... 61 MULTAQ ...... 36 neomycin sulfate ...... 18 MILLIPRED ...... 57 mupirocin ...... 18 neomycin-bacitracin zn- mimvey ...... 62 mupirocin calcium...... 17 polymyx ...... 73 MIMYX ...... 44 MYALEPT ...... 54 neomycin-polymyxin b gu 18 MINASTRIN 24 FE ...... 62 MYAMBUTOL ...... 25 neomycin-polymyxin- MINIPRESS...... 36 MYCAPSSA ...... 58 dexameth ...... 73 minitran ...... 36 MYCOBUTIN ...... 25 neomycin-polymyxin- MINIVELLE ...... 62 mycophenolate mofetil .... 64 gramicidin ...... 73 minocycline hcl ...... 17 mycophenolate sodium ... 64 neomycin-polymyxin-hc .. 73, minocycline hcl er ...... 17 MYDAYIS ...... 38 74 MINOLIRA ...... 17 MYFEMBREE ...... 62 neo-polycin ...... 73 minoxidil ...... 36 MYFORTIC ...... 64 neo-polycin hc ...... 73 MIRAPEX ...... 28 MYLERAN ...... 26 NEORAL ...... 64 MIRAPEX ER ...... 28 myorisan ...... 44 NEOSALUS ...... 44 MIRCERA ...... 32 MYRBETRIQ ...... 55 NEO-SYNALAR ...... 44 MIRCETTE ...... 62 MYSOLINE...... 20 NERLYNX ...... 26 MIRENA (52 MG) ...... 62 MYTESI ...... 54 NESINA ...... 47 mirtazapine ...... 21 N neuac ...... 44 MIRVASO ...... 44 NABI-HB ...... 64 NEULASTA ...... 32 misoprostol ...... 52 nabumetone ...... 11 NEULASTA ONPRO ...... 32 MITIGARE ...... 24 nadolol ...... 36 NEUPOGEN ...... 33 MIXED ASPERGILLUS ... 69 nafrinse ...... 52 NEUPRO...... 28 MIXED FEATHERS ...... 69 nafrinse drops ...... 52 NEURONTIN ...... 20 mixed vespid venom protein naftifine hcl ...... 23 NEUTRASAL ...... 40 ...... 69 NAFTIN ...... 23 NEVANAC ...... 71 MIXED VESPID VENOM NALFON ...... 11 nevirapine ...... 31 PROTEIN ...... 69 NALOCET ...... 13 nevirapine er ...... 31 M-M-R II ...... 66 naloxone hcl ...... 15 NEXAVAR ...... 26 MOBIC ...... 11 naltrexone hcl ...... 15 NEXIUM ...... 52 modafinil ...... 78 NAMENDA TITRATION NEXLETOL ...... 36 moexipril hcl ...... 36 PAK ...... 21 NEXLIZET ...... 36 molindone hcl ...... 29 NAMENDA XR ...... 21 NEXTSTELLIS ...... 62 mometasone furoate .. 44, 74 NAMZARIC ...... 21 niacin (antihyperlipidemic) mondoxyne nl ...... 17 NAPRELAN ...... 11 ...... 36 mono-linyah ...... 62 NAPROSYN ...... 11 niacin er montelukast sodium ...... 76 naproxen ...... 11 (antihyperlipidemic) ..... 36 MONUROL ...... 17 naproxen sodium ...... 12 niacor ...... 36 morgidox ...... 17 naproxen sodium er ...... 11 NIASPAN ...... 36 morphine sulfate ...... 13 naproxen-esomeprazole .. 12 nicardipine hcl ...... 36 morphine sulfate naratriptan hcl ...... 24 NICORETTE ...... 15 (concentrate) ...... 13 NARCAN ...... 15 nicotine ...... 16 morphine sulfate er ...... 13 NARDIL ...... 21 nicotine polacrilex ...... 15 morphine sulfate er beads NASONEX...... 74 nicotine polacrilex mini .... 15 ...... 13 NATACYN ...... 71 nicotine step 1 ...... 15 MOTEGRITY ...... 54 NATAZIA ...... 62 nicotine step 2 ...... 16 MOTOFEN ...... 54 nateglinide ...... 47 nicotine step 3 ...... 16 MOVANTIK ...... 54 NATESTO ...... 57 nifedipine...... 36 MOVIPREP ...... 54 NATPARA ...... 67 nifedipine er ...... 36 MOXEZA ...... 71 NATROBA ...... 27 nifedipine er osmotic moxifloxacin hcl ...... 17, 71 NATURE-THROID ...... 63 release ...... 36 moxifloxacin hcl (2x day) . 71 NAYZILAM ...... 20 nikki ...... 62 MS CONTIN ...... 13 NEBUPENT ...... 27 NILANDRON ...... 26 MUCOR ...... 69 necon 0.5/35 (28) ...... 62 nilutamide...... 26 MUCOSITISRX ...... 40 nefazodone hcl ...... 21 nimodipine ...... 36

94 NINLARO ...... 26 NOVOFINE PEN NEEDLE NUTROPIN AQ NUSPIN 20 nisoldipine er ...... 36 ...... 50 ...... 58 nitazoxanide ...... 27 NOVOFINE PLUS PEN NUTROPIN AQ NUSPIN 5 nitisinone ...... 54 NEEDLE ...... 50 ...... 58 NITRO-BID ...... 36 NOVOLIN 70/30 FLEXPEN NUVARING ...... 62 NITRO-DUR ...... 36 ...... 50 NUVESSA ...... 18 nitrofurantoin ...... 18 NOVOLIN 70/30 FLEXPEN NUVIGIL ...... 78 nitrofurantoin macrocrystal RELION ...... 50 NUZYRA ...... 18 ...... 18 NOVOLIN 70/30 RELION 50 nyamyc ...... 23 nitrofurantoin monohydrate NOVOLIN 70/30 VIAL ..... 50 nylia 7/7/7...... 62 macrocrystals ...... 18 NOVOLIN N FLEXPEN ... 50 NYMALIZE ...... 36 nitroglycerin ...... 36 NOVOLIN N FLEXPEN nymyo ...... 62 NITROLINGUAL ...... 36 RELION ...... 50 nystatin ...... 23 NITROMIST...... 36 NOVOLIN N RELION ...... 50 nystatin-triamcinolone ..... 23 NITROSTAT ...... 36 NOVOLIN N VIAL ...... 50 nystop ...... 23 nitro-time ...... 36 NOVOLIN R FLEXPEN ... 50 NYVEPRIA ...... 33 NITYR ...... 54 NOVOLIN R FLEXPEN O NIVESTYM ...... 33 RELION ...... 50 OCALIVA ...... 54 nizatidine ...... 52 NOVOLIN R RELION ...... 50 ocella ...... 62 NOCDURNA...... 58 NOVOLIN R VIAL ...... 50 octreotide acetate ...... 58 nolix ...... 44 NOVOLOG 70/30 OCUFLOX ...... 71 nora-be ...... 62 FLEXPEN RELION ...... 50 ODACTRA ...... 69 NORDITROPIN FLEXPRO NOVOLOG FLEXPEN ..... 50 ODEFSEY ...... 31 ...... 58 NOVOLOG FLEXPEN ODOMZO ...... 26 norethin ace-eth estrad-fe 62 RELION ...... 50 OFEV ...... 76 norethindrone ...... 62 NOVOLOG MIX 70/30 ofloxacin ...... 18, 71, 74 norethindrone acetate ...... 62 FLEXPEN ...... 50 olanzapine ...... 29 norethindrone acet-ethinyl NOVOLOG MIX 70/30 olanzapine-fluoxetine hcl . 21 est ...... 62 RELION ...... 50 OLIVE TREE ...... 69 norethindrone-eth estradiol NOVOLOG MIX 70/30 VIAL olmesartan medoxomil .... 36 ...... 62 ...... 50 olmesartan medoxomil-hctz norethin-eth estradiol-fe ... 62 NOVOLOG PENFILL ...... 50 ...... 36 NORGESIC FORTE ...... 78 NOVOLOG RELION ...... 50 olmesartan-amlodipine-hctz norgestimate-eth estradiol NOVOLOG U-100 VIAL ... 51 ...... 36 ...... 62 NOVOTWIST PEN olopatadine hcl ...... 71, 74 norgestimate-ethinyl NEEDLE ...... 51 OLUMIANT ...... 64 estradiol triphasic ...... 62 NOXAFIL ...... 23 OLUX ...... 44 NORITATE ...... 44 NOZIN NASAL SANITIZER OLUX-E ...... 44 norlyda ...... 62 POPSWAB ...... 69 OMECLAMOX-PAK ...... 54 norlyroc ...... 62 np thyroid ...... 63 omega-3-acid ethyl esters36 NORPACE ...... 36 NUBEQA ...... 26 omeprazole ...... 53 NORPACE CR ...... 36 NUCALA ...... 74 OMEPRAZOLE+SYRSPEN NORPRAMIN ...... 21 NUCORT ...... 44 D SF ALKA ...... 53 NORTHERA ...... 36 NUCYNTA ...... 13 omeprazole-sodium nortrel 0.5/35 (28) ...... 62 NUCYNTA ER ...... 13 bicarbonate ...... 53 nortrel 1/35 (21) ...... 62 NUEDEXTA ...... 39 OMNARIS ...... 74 nortrel 1/35 (28) ...... 62 nulev ...... 54 OMNIPOD 5 PACK ...... 69 nortrel 7/7/7 ...... 62 NULYTELY LEMON-LIME OMNIPOD DASH 5 PACK nortriptyline hcl ...... 21 ...... 54 PODS ...... 69 NORVASC ...... 36 NUMBRINO ...... 15 OMNIPOD DASH SYSTEM NORVIR ...... 31 NUMOISYN ...... 40 ...... 48 NOURIANZ ...... 28 NUPLAZID ...... 29 OMNIPOD STARTER ..... 48 NOVACORT ...... 44 NURTEC ...... 24 OMNITROPE ...... 58 NOVOFINE AUTOCOVER NUTROPIN AQ NUSPIN 10 ondansetron hcl...... 22 PEN NEEDLE ...... 50 ...... 58 ondansetron odt ...... 22

95 ONETOUCH DELICA OSMOLEX ER ...... 28 paroxetine hcl ...... 21 LANCING DEV ...... 48 OSMOPREP ...... 54 paroxetine hcl er...... 21 ONETOUCH DELICA PLUS OSPHENA...... 58 paroxetine mesylate ...... 21 LANCING ...... 48 OTEZLA ...... 65 PASER ...... 25 ONETOUCH DELICA OTOVEL ...... 74 PATANASE ...... 74 SAFETY LANCING ...... 48 OTREXUP ...... 65 PAXIL ...... 21, 22 ONETOUCH ULTRA TEST OVACE PLUS ...... 44 PAXIL CR...... 21 STRIPS ...... 48 OVACE PLUS WASH ...... 44 PEDIAPRED ...... 57 ONETOUCH VERIO KIT OVACE WASH ...... 44 PEDIARIX ...... 66 W/DEVICE ...... 48 OVIDE ...... 27 PEDIATRIC PANDA MASK ONEXTON ...... 44 oxandrolone ...... 57 ...... 69 ONFI ...... 20 oxaprozin ...... 12 PEDVAX HIB ...... 66 ONGENTYS ...... 28 OXAYDO ...... 13 peg 3350-kcl-na bicarb-nacl ONGLYZA ...... 47 oxazepam ...... 32 ...... 54 ONUREG ...... 26 OXBRYTA ...... 69 peg-3350/electrolytes ...... 54 opium ...... 54 oxcarbazepine ...... 20 peg- OPSUMIT ...... 77 OXERVATE ...... 73 3350/electrolytes/ascorba OPTICHAMBER DIAMOND oxiconazole nitrate ...... 23 t ...... 54 ...... 69 OXISTAT ...... 23 PEGASYS ...... 31 OPTICHAMBER OXTELLAR XR ...... 20 peg-kcl-nacl-nasulf-na asc-c DIAMOND-LG MASK ... 69 oxybutynin chloride ...... 55 ...... 54 OPTICHAMBER oxybutynin chloride er ..... 55 peg-prep ...... 54 DIAMOND-MD MASK .. 69 oxycodone hcl ...... 13 PEMAZYRE ...... 26 OPTICHAMBER OXYCODONE HCL ER ... 13 penicillamine ...... 55 DIAMOND-SM MASK .. 69 oxycodone-acetaminophen penicillin v potassium ...... 18 ORACEA ...... 44 ...... 13 PENICILLIUM NOTATUM69 ORACIT ...... 52 OXYCODONE- PENLEN ...... 44 ORALAIR ...... 69 ACETAMINOPHEN ..... 13 PENNSAID ...... 12 ORALAIR ADULT OXYCONTIN ...... 13 PENTACEL ...... 66 STARTER PACK ...... 69 oxymorphone hcl ...... 13 PENTAM ...... 28 ORALAIR CHILDRENS oxymorphone hcl er ...... 13 pentamidine isethionate .. 28 STARTER PACK ...... 69 OXYTROL ...... 55 PENTASA ...... 67 oralone ...... 40 OZEMPIC ...... 47 pentazocine-naloxone hcl 13 ORAPRED ODT ...... 57 OZOBAX ...... 78 pentobarbital sodium ...... 20 ORAVIG ...... 23 P PENTOSAN ORENCIA ...... 65 pacerone ...... 36 POLYSULFATE SODIUM ORENCIA CLICKJECT .... 65 PACERONE ...... 36 ...... 55 ORENITRAM ...... 77 PALFORZIA ...... 69 pentoxifylline er ...... 36 ORFADIN ...... 54, 55 paliperidone er ...... 29 PEPCID ...... 53 ORGOVYX ...... 26 PAMELOR...... 21 PERCOCET ...... 13 ORIAHNN ...... 62 PANCREAZE ...... 55 PERFOROMIST ...... 76 ORILISSA ...... 58 PANDA MASK LARGE .... 69 perindopril erbumine ...... 36 ORKAMBI ...... 77 PANDA MASK MEDIUM . 69 periogard ...... 40 ORLADEYO ...... 65 PANDA MASK SMALL .... 69 permethrin ...... 28 orphenadrine citrate ...... 78 PANDEL ...... 44 perphenazine ...... 22 orphenadrine citrate er .... 78 PANRETIN ...... 26 perphenazine-amitriptyline orphenadrine-asa-caffeine pantoprazole sodium ...... 53 ...... 22 ...... 78 papaverine hcl ...... 36 PERSERIS ...... 29 ORPHENGESIC FORTE . 78 PARAGARD PERTZYE ...... 55 orsythia ...... 62 INTRAUTERINE PEXEVA ...... 22 ORTIKOS ...... 67 COPPER ...... 62 phenazo ...... 55 oscimin ...... 54 paricalcitol ...... 67 phenazopyridine hcl ...... 55 oscimin sr ...... 54 PARLODEL ...... 28 phenelzine sulfate ...... 22 oseltamivir phosphate ...... 31 PARNATE ...... 21 PHENERGAN ...... 74 OSENI ...... 47 paromomycin sulfate ...... 18 phenobarbital ...... 20

96 phenobarbital sodium ...... 20 POMALYST ...... 26 PREDNISOLON- phenoxybenzamine hcl .... 36 PONVORY ...... 39 GATIFLOX- phentolamine mesylate .... 36 PONVORY STARTER BROMFENAC ...... 73 phenylephrine hcl ...... 73 PACK ...... 39 PREDNISOLON- PHENYTEK ...... 20 portia-28 ...... 62 MOXIFLOX- phenytoin ...... 20 posaconazole ...... 23 BROMFENAC ...... 73 phenytoin infatabs ...... 20 pot & sod cit-cit ac ...... 52 PREDNISOLON- phenytoin sodium ...... 20 potassium chloride ...... 52 MOXIFLOX- phenytoin sodium extended potassium chloride crys er NEPAFENAC ...... 71 ...... 20 ...... 52 prednisone ...... 57 PHEXXI ...... 69 potassium chloride er ...... 52 prednisone intensol ...... 57 philith ...... 62 potassium citrate er ...... 52 PREFEST ...... 62 PHLAG SPRAY ...... 44 potassium citrate-citric acid pregabalin ...... 39 PHOSLYRA ...... 55 ...... 52 pregabalin er ...... 39 phospha 250 neutral ...... 52 POVIDONE-IODINE ...... 71 PREMARIN ...... 62 phosphasal ...... 55 PRADAXA ...... 19 premium lidocaine ...... 15 phosphorous...... 52 PRALUENT ...... 36 PREMPHASE ...... 62 phospho-trin 250 neutral .. 52 pramipexole dihydrochloride PREMPRO ...... 62 PHYSOSTIGMINE ...... 28 PREPIDIL...... 55 SALICYLATE ...... 69 pramipexole dihydrochloride PRESERA ...... 45 phytonadione ...... 52 er ...... 28 PRESTALIA ...... 36 PIFELTRO ...... 31 PRAMOSONE ...... 44 PREVACID ...... 53 pilocarpine hcl ...... 40, 72 PRAMOTIC ...... 74 PREVACID SOLUTAB .... 53 pimecrolimus ...... 44 pramox ...... 44 prevalite ...... 36 PIMECROLIMUS ...... 44 prasugrel hcl ...... 29 preventeza ...... 62 pimozide ...... 29 pravastatin sodium ...... 36 previfem ...... 62 pimtrea ...... 62 praziquantel ...... 28 PREVNAR 13 ...... 66 pindolol ...... 36 prazosin hcl ...... 36 PREVNAR 20 ...... 66 pioglitazone hcl ...... 47 PRECOSE...... 47 PREVYMIS ...... 31 pioglitazone hcl-glimepiride PRED FORTE ...... 71 PREZCOBIX ...... 31 ...... 47 PRED MILD ...... 71 PREZISTA ...... 31 pioglitazone hcl-metformin PRED-G ...... 73 PRIFTIN ...... 25 hcl ...... 47 PRED-G S.O.P...... 73 PRILOLID...... 15 PIQRAY ...... 26 prednicarbate ...... 44 PRILOSEC ...... 53 pirmella 1/35 ...... 62 PREDNISOL ACE- PRILOVIX ...... 15 pirmella 7/7/7 ...... 62 MOXIFLOX-BROMFEN PRILOVIX LITE ...... 15 piroxicam ...... 12 ...... 71 PRILOVIX LITE PLUS ..... 15 PLAN B ONE-STEP ...... 62 prednisolone ...... 57 PRILOVIX PLUS ...... 15 PLAQUENIL ...... 28 prednisolone acetate ...... 71 prilovix ultralite ...... 15 PLAVIX ...... 29 prednisolone acetate p-f .. 71 prilovix ultralite plus ...... 15 PLEGRIDY ...... 39 PREDNISOLONE primaquine phosphate ..... 28 PLEGRIDY STARTER ACETATE-NEPAFENAC primidone ...... 20 PACK ...... 39 ...... 73 PRIMSOL ...... 18 PLENVU ...... 54 PREDNISOLONE ACET- PRINIVIL ...... 36 PLEXION ...... 44 MOXIFLOXACIN ...... 73 PRISTIQ ...... 22 PLEXION CLEANSER ..... 44 prednisolone sodium PRO COMFORT SPACER PLEXION CLEANSING phosphate ...... 57, 71 ADULT ...... 69 CLOTH ...... 44 PREDNISOLONE- PRO COMFORT SPACER PNEUMOVAX 23 ...... 66 BROMFENAC ...... 73 CHILD ...... 69 pocket spacer ...... 69 PREDNISOLONE- PRO COMFORT SPACER podocon ...... 44 GATIFLOXACIN ...... 73 INFANT ...... 69 podofilox ...... 44 PREDNISOLONE- PROAIR DIGIHALER ...... 76 polycin ...... 73 MOXIFLOXACIN ...... 73 PROAIR HFA ...... 76 polymyxin b-trimethoprim. 73 PROAIR RESPICLICK .... 76 POLYTRIM ...... 73 probenecid ...... 24

97 PROBICHEW ...... 54 PROZAC ...... 22 ramipril ...... 37 procainamide hcl ...... 36 PRUCLAIR ...... 45 RANEXA ...... 37 PROCARDIA XL ...... 36 PRUDOXIN ...... 45 ranolazine er ...... 37 PROCARE PRUMYX ...... 45 RAPAFLO ...... 56 SPACER/ADULT MASK pseudoephedrine- RAPAMUNE ...... 65 ...... 69 bromphen-dm ...... 75 rasagiline mesylate ...... 28 PROCARE SPACER/CHILD PSORCON ...... 45 RASUVO ...... 65 MASK ...... 69 PULMICORT FLEXHALER RAVICTI ...... 55 PROCENTRA ...... 38 ...... 76 RAYALDEE ...... 67 prochlorperazine ...... 22 PULMICORT RAYOS ...... 57 prochlorperazine edisylate SUSPENSION ...... 76 RAZADYNE ER...... 21 ...... 22 PULMOZYME ...... 77 REBIF ...... 39 prochlorperazine maleate 22 PURIXAN ...... 26 REBIF REBIDOSE ...... 39 PROCORT ...... 67 PYLERA ...... 54 REBIF REBIDOSE PROCRIT ...... 33 pyrazinamide ...... 25 TITRATION PACK ...... 39 PROCTOCORT ...... 67 PYRIDIUM...... 55 REBIF TITRATION PACK39 PROCTOFOAM HC ...... 67 pyridostigmine bromide ... 24 reclipsen ...... 62 procto-med hc ...... 67 pyridostigmine bromide er24 RECOMBIVAX HB ...... 66 procto-pak ...... 67 pyrimethamine ...... 28 RECTIV ...... 37 proctozone-hc ...... 67 PYROGALLIC ACID ...... 45 RED MAPLE ...... 69 PROCYSBI ...... 55 Q REDITREX ...... 65 progesterone ...... 62 QBRELIS ...... 37 REGLAN ...... 22 PROGLYCEM ...... 49 QBREXZA ...... 45 RELADOR PAK...... 15 PROGRAF ...... 65 QDOLO ...... 13 RELADOR PAK PLUS .... 15 PROLATE ...... 13 QELBREE ...... 38 RELAFEN ...... 12 PROLENSA ...... 71 QINLOCK ...... 26 RELAFEN DS ...... 12 PROMACTA ...... 33 QMIIZ ODT...... 12 RELENZA DISKHALER .. 31 promethazine hcl ...... 74 QNASL ...... 75 relexxii ...... 39 promethazine vc ...... 74 QNASL CHILDRENS ...... 75 RELISTOR ...... 54 promethazine vc/codeine . 74 QTERN ...... 47 RELPAX ...... 24 promethazine-codeine ..... 74 QUADRACEL ...... 66 RELTONE ...... 54 promethazine-dm ...... 75 QUALAQUIN ...... 28 REMERON ...... 22 promethazine-phenyleph- QUARTETTE ...... 62 REMERON SOLTAB ...... 22 codeine ...... 75 quazepam ...... 32 RENACIDIN ...... 55 promethazine- QUDEXY XR ...... 20 RENAGEL ...... 55 phenylephrine ...... 75 QUEEN PALM ...... 69 RENVELA ...... 55 promethegan ...... 75 QUESTRAN ...... 37 repaglinide ...... 47 PROMETRIUM ...... 62 QUESTRAN LIGHT ...... 37 REPATHA ...... 37 propafenone hcl ...... 37 quetiapine fumarate ...... 29 REPATHA PUSHTRONEX propafenone hcl er ...... 37 quetiapine fumarate er .... 29 SYSTEM ...... 37 proparacaine hcl ...... 73 QUILLICHEW ER ...... 38 REPATHA SURECLICK .. 37 propranolol hcl ...... 37 QUILLIVANT XR ...... 38 RESORCINOL-SULFUR . 45 propranolol hcl er ...... 37 quinapril hcl ...... 37 RESTASIS ...... 73 propylthiouracil ...... 63 quinapril- RESTASIS MULTIDOSE . 73 PROQUAD ...... 66 hydrochlorothiazide ..... 37 RESTORIL ...... 78 PROSCAR ...... 56 quinidine gluconate er ..... 37 RETACRIT ...... 33 PROSILK ...... 45 quinidine sulfate ...... 37 RETEVMO ...... 26 PROSTIN VR ...... 37 quinine sulfate ...... 28 RETIN-A ...... 45 PROTEXA ...... 45 QVAR REDIHALER ...... 76 RETIN-A MICRO GEL 0.04 PROTONIX ...... 53 R %, 0.1 % ...... 45 PROTOPIC ...... 45 RABBIT EPITHELIUM ..... 69 RETIN-A MICRO PUMP .. 45 protriptyline hcl ...... 22 rabeprazole sodium ...... 53 RETROVIR ...... 31 PROVENTIL HFA ...... 76 RAGWITEK ...... 69 REVATIO ...... 77 PROVERA ...... 62 raloxifene hcl ...... 58 REVLIMID ...... 26 PROVIGIL ...... 78 ramelteon ...... 78 REXULTI ...... 29

98 REYATAZ ...... 31 S SIKLOS ...... 26 REYVOW ...... 24 SABRIL ...... 20 sildenafil citrate ...... 77 REZUROCK ...... 65 SACCHAROMYCES SILENOR ...... 78 RHIZOPUS ...... 69 CEREVISIAE ...... 69 SILIQ ...... 65 RHOFADE ...... 45 SAFYRAL ...... 62 silodosin ...... 56 RHOPHYLAC ...... 65 SAIZEN ...... 58 SILVADENE ...... 18 RHOPRESSA ...... 72 SAIZENPREP ...... 58 silver nitrate ...... 18 ribavirin ...... 31 sajazir ...... 65 silver sulfadiazine ...... 18 RIDAURA ...... 65 SALAGEN ...... 40 SIMBRINZA ...... 72 rifabutin ...... 25 SALEX ...... 45 simliya ...... 62 rifampin ...... 25 salicylic acid ...... 45 simpesse ...... 62 RILUTEK ...... 39 salicylic acid wart remover SIMPONI ...... 65 riluzole ...... 39 ...... 45 simvastatin ...... 37 rimantadine hcl ...... 31 salimez ...... 45 SINEMET ...... 28 RIMSO-50 ...... 55 SALIMEZ FORTE ...... 45 SINGULAIR ...... 76 RINVOQ ...... 65 SALIVAMAX ...... 40 sirolimus ...... 65 RIOMET ...... 47 salsalate ...... 12 SIRTURO ...... 25 risedronate sodium ...... 67 SALVAX ...... 45 SITAVIG ...... 31 RISPERDAL ...... 29 SAMSCA ...... 52 SIVEXTRO ...... 18 RISPERDAL CONSTA .... 29 SANCUSO ...... 22 SKELAXIN ...... 78 risperidone ...... 29 SANDIMMUNE ...... 65 SKYLA ...... 62 RITALIN ...... 39 SANDOSTATIN ...... 58 SKYRIZI ...... 65 RITALIN LA ...... 39 SANDOSTATIN LAR SKYRIZI (150 MG DOSE)65 ritonavir ...... 31 DEPOT ...... 58 SKYRIZI PEN ...... 65 rivastigmine ...... 21 SANTYL ...... 45 SLYND ...... 62 rivastigmine tartrate ...... 21 SAPHRIS ...... 29 sod citrate-citric acid ...... 52 rivelsa ...... 62 sapropterin dihydrochloride sodium chloride ...... 52, 75 rizatriptan benzoate ...... 24 ...... 55 sodium chloride (pf) ...... 52 ROBAXIN ...... 78 SAVAYSA ...... 19 sodium fluoride ...... 52 ROCALTROL ...... 67 SAVELLA ...... 39 sodium phenylbutyrate .... 55 ROCKLATAN ...... 72 SAVELLA TITRATION sodium polystyrene ropinirole hcl ...... 28 PACK ...... 39 sulfonate ...... 52 ropinirole hcl er ...... 28 scopolamine ...... 22 sodium sulfacetamide ..... 45 rosadan ...... 45 SEASONIQUE ...... 62 sodium sulfacetamide wash ROSADAN ...... 45 SECUADO ...... 29 ...... 45 rosuvastatin calcium ...... 37 SEGLUROMET ...... 47 SODIUM ROSZET ...... 37 selegiline hcl ...... 28 SULFACETAMIDE- ROTARIX ...... 66 selenium sulfide ...... 45 BAKUCHIOL ...... 45 ROTATEQ ...... 66 SELZENTRY ...... 31 SOFOSBUVIR- ROWASA ...... 67 SEMGLEE ...... 51 VELPATASVIR ...... 31 roweepra ...... 20 SENSIPAR ...... 67 solifenacin succinate ...... 55 ROXICODONE ...... 14 SEREVENT DISKUS ...... 76 SOLIQUA ...... 47 ROZEREM ...... 78 SERNIVO ...... 45 SOLODYN ...... 18 ROZLYTREK ...... 26 SEROQUEL ...... 29 SOLOSEC ...... 18 RUBRACA ...... 26 SEROQUEL XR ...... 29 SOLTAMOX ...... 26 RUCONEST ...... 65 SEROSTIM ...... 54 SOLU-CORTEF ...... 57 rufinamide ...... 20 sertraline hcl ...... 22 SOLU-MEDROL ...... 57 RUKOBIA ...... 31 setlakin ...... 62 SOMA ...... 78 RUZURGI ...... 69 sevelamer carbonate ...... 55 SOMATULINE DEPOT .... 58 RYBELSUS ...... 47 sevelamer hcl ...... 55 SOMAVERT ...... 58 RYCLORA ...... 75 SEYSARA ...... 18 SOOLANTRA ...... 45 RYDAPT ...... 26 SFROWASA ...... 67 SOOTHEE ...... 15 RYTARY ...... 28 sharobel ...... 62 SORIATANE ...... 45 RYTHMOL SR ...... 37 SHINGRIX ...... 66 SORILUX ...... 45 ryvent ...... 75 SIGNIFOR ...... 58 sorine ...... 37

99 sotalol hcl ...... 37 sulfacetamide sodium SYMJEPI...... 77 sotalol hcl (af) ...... 37 (acne) ...... 45 SYMLINPEN 120 ...... 47 SOTYLIZE ...... 37 sulfacetamide sodium-sulfur SYMLINPEN 60 ...... 47 SOVALDI ...... 31 ...... 45 SYMPAZAN ...... 20 spinosad ...... 28 sulfacetamide sod-sulfur SYMPROIC ...... 54 SPINY PIGWEED ...... 69 wash ...... 45 SYMTUZA ...... 31 SPIRIVA HANDIHALER .. 76 sulfacetamide-prednisolone synalar ...... 45 SPIRIVA RESPIMAT ...... 76 ...... 73 SYNALAR ...... 45 spironolactone ...... 37 sulfacetamide-sulfur in urea SYNAREL ...... 58 spironolactone-hctz ...... 37 ...... 45 SYNDROS ...... 22 SPORANOX ...... 23 sulfacleanse 8/4 ...... 45 SYNERA ...... 15 SPORANOX PULSEPAK 23 sulfadiazine ...... 18 SYNERDERM ...... 46 sprintec 28 ...... 62 sulfamethoxazole- SYNJARDY ...... 47 SPRITAM ...... 20 trimethoprim ...... 18 SYNJARDY XR ...... 47 SPRIX ...... 12 sulfamez wash ...... 45 SYNTHROID ...... 63 SPRYCEL ...... 26 SULFAMYLON ...... 18 SYPRINE ...... 52 sps ...... 52 sulfasalazine ...... 67 T sronyx...... 62 sulfatrim pediatric ...... 18 TABLOID...... 26 ssd ...... 18 sulindac ...... 12 TABRECTA ...... 26 SSKI ...... 75 SUMADAN WASH ...... 45 TACHOSIL ...... 69 sss 10-5 ...... 45 sumatriptan ...... 24 TACLONEX ...... 46 STALEVO 100 ...... 28 sumatriptan succinate ..... 24 tacrolimus...... 46, 65 STALEVO 125 ...... 28 sumatriptan succinate refill tadalafil (pah) ...... 77 STALEVO 150 ...... 28 ...... 24 TAFINLAR ...... 26 STALEVO 200 ...... 28 sumatriptan-naproxen TAGRISSO ...... 26 STALEVO 50 ...... 28 sodium...... 24 TAKHZYRO ...... 78 STALEVO 75 ...... 28 SUMAXIN ...... 45 TALICIA ...... 54 stavudine ...... 31 sunitinib malate ...... 26 TALL RAGWEED ...... 69 STEGLATRO ...... 47 SUNOSI ...... 78 TALTZ ...... 65 STEGLUJAN ...... 47 SUPRAX ...... 18 TALZENNA ...... 26 STELARA ...... 65 SUPREP BOWEL PREP TAMIFLU...... 31 STEMPHYLIUM ...... 69 KIT ...... 54 tamoxifen citrate ...... 26 sterile water for irrigation . 52 SURESTEP PRO HIGH tamsulosin hcl ...... 56 STIMATE ...... 58 GLUCOSE ...... 48 TAPAZOLE ...... 63 STIOLTO RESPIMAT ...... 76 SURESTEP PRO LOW TAPERDEX 12-DAY ...... 57 STIVARGA ...... 26 GLUCOSE ...... 49 TAPERDEX 6-DAY ...... 57 STRATTERA ...... 39 SURESTEP PRO NORMAL TAPERDEX 7-DAY ...... 57 STRENSIQ ...... 55 GLUCOSE ...... 49 TARCEVA ...... 26 streptomycin sulfate ...... 18 SURVANTA ...... 75 TARGADOX ...... 18 STRIBILD ...... 31 SUSTIVA ...... 31 TARGRETIN ...... 26 STRIVERDI RESPIMAT .. 76 SUTAB ...... 54 tarina 24 fe ...... 63 STROMECTOL ...... 28 SUTENT ...... 26 tarina fe 1/20 ...... 63 SUBOXONE ...... 16 SUVICORT...... 45 tarina fe 1/20 eq ...... 63 SUBSYS ...... 14 SWEET GUM ...... 69 TARKA ...... 37 subvenite ...... 20 SWEET VERNAL GRASS TASIGNA ...... 26 subvenite starter kit-blue . 20 POLLEN ...... 69 TASMAR ...... 28 subvenite starter kit-green syeda ...... 62 tavaborole ...... 23 ...... 20 SYMAX DUOTAB ...... 54 TAVALISSE ...... 33 subvenite starter kit-orange symax-sl ...... 54 taysofy ...... 63 ...... 20 symax-sr ...... 54 TAYTULLA ...... 63 SUCRAID ...... 55 SYMBICORT ...... 76 tazarotene ...... 46 sucralfate ...... 53 SYMBYAX ...... 22 TAZAROTENE ...... 46 SULAR ...... 37 SYMDEKO ...... 77 tazicef ...... 18 sulfacetamide sodium 45, 71 SYMFI ...... 31 TAZORAC ...... 46 SYMFI LO ...... 31 taztia xt ...... 37

100 TAZVERIK ...... 26 tiagabine hcl ...... 20 tovet ...... 46 TDVAX ...... 66 TIAZAC ...... 37 TOVIAZ ...... 56 TECFIDERA ...... 39 TIBSOVO ...... 27 TRACLEER ...... 77 TEGRETOL ...... 20 TIGAN ...... 22 TRADJENTA ...... 47 TEGRETOL-XR ...... 20 TIGLUTIK ...... 39 tramadol hcl er ...... 14 TEGSEDI ...... 39 TIKOSYN ...... 37 TRAMADOL HCL ER ...... 14 TEKTURNA ...... 37 tilia fe ...... 63 tramadol hcl er (biphasic) 14 TEKTURNA HCT ...... 37 timolol maleate ...... 37, 72 tramadol hcl ir ...... 14 telmisartan ...... 37 timolol maleate ocudose .. 72 tramadol-acetaminophen . 14 telmisartan-amlodipine .... 37 timolol maleate pf ...... 72 trandolapril ...... 37 telmisartan-hctz ...... 37 TIMOLOL-BRIMON- trandolapril-verapamil hcl er temazepam ...... 78 DORZOL-LATANOPR . 72 ...... 37 TEMIXYS ...... 31 TIMOLOL-BRIMONIDINE- tranexamic acid ...... 33 TEMODAR ...... 26 DORZOLAMID ...... 72 TRANSDERM-SCOP (1.5 TEMOVATE...... 46 TIMOLOL-DORZOLAMID- MG) ...... 22 temozolomide ...... 26 LATANOPROST ...... 72 TRANXENE-T ...... 32 tencon ...... 14 TIMOPTIC ...... 72 tranylcypromine sulfate ... 22 TENIVAC ...... 66 TIMOPTIC OCUDOSE .... 72 TRAVATAN Z ...... 72 tenofovir disoproxil fumarate TIMOPTIC-XE ...... 72 travoprost (bak free) ...... 72 ...... 31 tinidazole ...... 18 trazodone hcl ...... 22 TENORETIC 100 ...... 37 tiopronin ...... 55 TRECATOR ...... 25 TENORETIC 50 ...... 37 TIROSINT ...... 63 TRELEGY ELLIPTA ...... 77 TENORMIN ...... 37 TIROSINT-SOL ...... 63 TREMFYA ...... 65 TEPMETKO...... 26 TIVICAY ...... 31 TRESIBA...... 51 terazosin hcl ...... 56 TIVICAY PD ...... 31 TRESIBA FLEXTOUCH .. 51 terbinafine hcl ...... 23 TIVORBEX ...... 12 tretinoin ...... 27, 46 terbutaline sulfate ...... 77 tizanidine hcl ...... 78 tretinoin microsphere ...... 46 terconazole ...... 23 TOBI NEBULIZER ...... 77 tretinoin microsphere pump TERIPARATIDE TOBI PODHALER ...... 77 ...... 46 (RECOMBINANT) ...... 67 TOBRADEX ...... 73 TREXALL ...... 65 TESSALON PERLES ...... 75 TOBRADEX ST ...... 73 TREXIMET ...... 24 TESTIM ...... 57 tobramycin...... 71, 77 TREZIX ...... 14 TESTONE CIK ...... 57 TOBRAMYCIN ...... 77 tri femynor ...... 63 testosterone ...... 58 tobramycin-dexamethasone triamcinolone acetonide . 40, testosterone cypionate .... 57 ...... 73 46, 57 TESTOSTERONE TOBREX ...... 71 TRIAMCINOLONE CYPIONATE ...... 57 tolbutamide...... 47 ACETONIDE ...... 57 testosterone enanthate .... 57 tolcapone ...... 28 TRIAMCINOLONE TETANUS-DIPHTHERIA TOLSURA ...... 23 DIACETATE ...... 57 TOXOIDS TD...... 66 tolterodine tartrate ...... 55 triamcinolone in absorbase tetrabenazine...... 39 tolterodine tartrate er ...... 56 ...... 46 tetracaine hcl ...... 73 tolvaptan ...... 52 triamterene ...... 37 tetracycline hcl ...... 18 TOPAMAX...... 20 triamterene-hctz ...... 37 TETRIX ...... 46 TOPAMAX SPRINKLE .... 20 trianex ...... 46 TEXACORT ...... 46 TOPICORT...... 46 triazolam ...... 32 THALOMID ...... 27 TOPICORT SPRAY ...... 46 TRIBENZOR ...... 37 THEO-24 ...... 77 topiramate ...... 20 TRICHOPHYTON ...... 70 theophylline ...... 77 topiramate er ...... 20 tricitrates ...... 52 theophylline er ...... 77 TOPROL XL ...... 37 TRICOR ...... 37 THIOLA ...... 55 toremifene citrate...... 27 triderm ...... 46 THIOLA EC ...... 55 torsemide ...... 37 TRIDESILON ...... 46 thioridazine hcl ...... 29 TOSYMRA ...... 24 trientine hcl ...... 52 thiothixene ...... 29 TOUJEO MAX SOLOSTAR tri-estarylla ...... 63 THYQUIDITY ...... 63 ...... 51 trifluoperazine hcl ...... 29 tiadylt er ...... 37 TOUJEO SOLOSTAR ..... 51 trifluridine ...... 71

101 trihexyphenidyl hcl ...... 28 TUSSICAPS ...... 75 UTOPIC ...... 46 TRIJARDY XR ...... 47 TUXARIN ER ...... 75 V TRIKAFTA ...... 77 TUZISTRA XR ...... 75 VAGIFEM ...... 63 tri-legest fe ...... 63 TWINRIX ...... 66 valacyclovir hcl ...... 31 TRILEPTAL ...... 20 TWIRLA ...... 63 VALCHLOR ...... 27 tri-linyah ...... 63 TWYNSTA...... 37 VALCYTE...... 31 TRILIPIX ...... 37 tyblume ...... 63 valganciclovir hcl ...... 31 tri-lo-estarylla ...... 63 TYBOST ...... 31 VALIUM ...... 32 tri-lo-marzia ...... 63 tydemy ...... 63 valproic acid ...... 20 tri-lo-mili ...... 63 TYKERB ...... 27 valsartan ...... 37 tri-lo-sprintec...... 63 TYMLOS ...... 67 valsartan- trimethobenzamide hcl .... 22 TYVASO ...... 77 hydrochlorothiazide ..... 37 trimethoprim ...... 18 TYVASO REFILL...... 77 VALTOCO ...... 20 tri-mili...... 63 TYVASO STARTER ...... 77 VALTREX...... 31 trimipramine maleate ...... 22 U VANADOM ...... 78 TRINTELLIX ...... 22 UBRELVY ...... 24 VANCOCIN ...... 18 tri-nymyo ...... 63 UCERIS ...... 67 VANCOCIN HCL ...... 18 tri-previfem ...... 63 UDENYCA...... 33 vancomycin hcl ...... 18 tri-sprintec ...... 63 UKONIQ ...... 27 vandazole...... 18 tritocin...... 46 ULORIC ...... 24 VANOS ...... 46 TRIUMEQ ...... 31 ULTIGUARD SAFEPACK VANOXIDE-HC ...... 46 trivora (28) ...... 63 SYR/NEEDLE ...... 51 VAQTA ...... 66 tri-vylibra ...... 63 ULTRACET ...... 14 VARIVAX ...... 66 tri-vylibra lo ...... 63 ULTRAM ...... 14 VARIZIG ...... 65 TRIZIVIR ...... 31 ULTRAVATE ...... 46 VARUBI (180 MG DOSE) 22 TROKENDI XR ...... 20 UMECTA MOUSSE ...... 46 VASCEPA ...... 37 TROPICAMIDE- UNISTRIP CONTROL ..... 49 VASERETIC ...... 37 CYCLOPENTOLATE-PE unithroid ...... 63 VASOTEC ...... 37 ...... 73 UPNEEQ ...... 71 VAXELIS ...... 66 TROPICAMIDE- UPTRAVI ...... 77 VECAMYL ...... 37 PHENYLEPHRINE ...... 73 URAMAXIN ...... 46 VECTICAL ...... 46 TROPIC-PROPARACA-PE- urea ...... 46 velivet ...... 63 KETOROLAC ...... 73 UREA ...... 46 VELPHORO ...... 56 trospium chloride ...... 56 urea hydrating ...... 46 VELTASSA ...... 52 trospium chloride er ...... 56 urea nail ...... 46 VELTIN ...... 46 TRUE METRIX LEVEL 1 . 49 uredeb ...... 46 VEMLIDY ...... 31 TRUE METRIX LEVEL 2 . 49 urelle ...... 56 VENCLEXTA ...... 27 TRUE METRIX LEVEL 3 . 49 uremez-40 ...... 46 VENCLEXTA STARTING TRULANCE ...... 54 URESOL ...... 46 PACK ...... 27 TRULICITY ...... 47 uribel ...... 56 venlafaxine hcl ...... 22 TRUMENBA ...... 66 URIMAR-T...... 56 venlafaxine hcl er ...... 22 TRUSELTIQ (100MG urin ds ...... 56 VENOMIL HONEY BEE DAILY DOSE) ...... 27 URO-458 ...... 56 VENOM ...... 70 TRUSELTIQ (125MG UROCIT-K 10 ...... 52 VENOMIL MIXED VESPID DAILY DOSE) ...... 27 UROCIT-K 15 ...... 52 VENOM ...... 70 TRUSELTIQ (50MG DAILY UROCIT-K 5 ...... 52 VENOMIL WASP VENOM DOSE) ...... 27 UROGESIC-BLUE ...... 56 ...... 70 TRUSELTIQ (75MG DAILY uro-mp ...... 56 VENOMIL WHITE FACED DOSE) ...... 27 UROXATRAL ...... 56 HORNET ...... 70 TRUSOPT ...... 72 URSO 250 ...... 54 VENOMIL YELLOW TRUVADA ...... 31 URSO FORTE ...... 54 HORNET VENOM ...... 70 TUDORZA PRESSAIR .... 77 ursodiol ...... 54 VENOMIL YELLOW TUKYSA ...... 27 URSODIOL ...... 54 JACKET VENOM ...... 70 tulana ...... 63 ustell...... 56 VENTAVIS ...... 77 TURALIO ...... 27 utira-c ...... 56 VENTOLIN HFA ...... 77

102 verapamil hcl ...... 37 VOGELXO PUMP ...... 58 wymzya fe ...... 63 verapamil hcl er ...... 37 volnea ...... 63 WYNZORA ...... 46 VERDESO ...... 46 voriconazole ...... 23 X VEREGEN ...... 46 VORTEX VALVED XADAGO...... 28 VERELAN ...... 37 HOLDING CHAMBER . 70 XALATAN...... 72 VERELAN PM ...... 38 VOSEVI ...... 31 XALIX ...... 46 VERQUVO ...... 38 VOTRIENT ...... 27 XALKORI ...... 27 VERSACLOZ ...... 29 VRAYLAR ...... 29 XANAX ...... 32 VERZENIO ...... 27 VTOL LQ ...... 14 XANAX XR ...... 32 VESICARE ...... 56 VUMERITY...... 39 XARELTO ...... 19 VESICARE LS ...... 56 VUSION ...... 23 XARELTO STARTER PACK vestura ...... 63 vyfemla ...... 63 ...... 19 VEXATROL ...... 15 vylibra ...... 63 XATMEP ...... 65 VFEND ...... 23 VYNDAMAX ...... 38 XCOPRI ...... 20 V-GO 20 ...... 49 VYNDAQEL ...... 38 XELJANZ ...... 65 V-GO 30 ...... 49 VYTORIN ...... 38 XELJANZ XR ...... 65 V-GO 40 ...... 49 VYVANSE ...... 39 XELODA ...... 27 VIBERZI ...... 54 VYZULTA ...... 72 XELPROS ...... 72 VIBRAMYCIN ...... 18 W XEMBIFY ...... 65 VICTOZA ...... 47 WAKIX ...... 78 XENAZINE ...... 39 VIEKIRA PAK ...... 31 warfarin sodium ...... 19 XENLETA...... 18 vienva ...... 63 WASP VENOM PROTEIN XEPI ...... 18 vigabatrin ...... 20 ...... 70 XERALUX ...... 46 vigadrone ...... 20 water for irrigation, sterile 52 XERESE ...... 31 VIGAMOX ...... 71 WELCHOL ...... 38 XERMELO ...... 54 VIIBRYD ...... 22 WELLBUTRIN SR ...... 22 XEROSTOMIA RELIEF VIIBRYD STARTER PACK WELLBUTRIN XL ...... 22 SPRAY ...... 40 ...... 22 wera ...... 63 XHANCE ...... 75 vilamit mb ...... 56 WESTERN JUNIPER ...... 70 XIFAXAN...... 18 VILEVEV MB ...... 56 WESTHROID ...... 63 XIGDUO XR ...... 48 VIMOVO ...... 12 WHITE BIRCH ...... 70 XIIDRA ...... 73 VIMPAT ...... 20 WHITE FACED HORNET XIMINO ...... 18 VIOKACE ...... 55 VENOM ...... 70 XOFLUZA (40 MG DOSE) viorele...... 63 WHITE MULBERRY ...... 70 ...... 31 VIRACEPT ...... 31 WHITE-FACED HORNET XOFLUZA (80 MG DOSE) VIRAMUNE ...... 31 VENOM ...... 70 ...... 31 VIRAMUNE XR ...... 31 WIDE-SEAL DIAPHRAGM XOLEGEL ...... 23 VIRASAL ...... 46 60 ...... 70 XOPENEX VIRAZOLE ...... 31 WIDE-SEAL DIAPHRAGM CONCENTRATE ...... 77 VIREAD ...... 31 65 ...... 70 XOPENEX HFA...... 77 virt-phos 250 neutral ...... 52 WIDE-SEAL DIAPHRAGM XOPENEX NEB ...... 77 VISTARIL ...... 32 70 ...... 70 XOSPATA ...... 27 VISTOGARD ...... 70 WIDE-SEAL DIAPHRAGM XPOVIO (100 MG ONCE vitamin d (ergocalciferol) . 52 75 ...... 70 WEEKLY) ...... 27 vitamin k1 ...... 52 WIDE-SEAL DIAPHRAGM XPOVIO (40 MG ONCE VITRAKVI ...... 27 80 ...... 70 WEEKLY) ...... 27 VIVAGUARD INO WIDE-SEAL DIAPHRAGM XPOVIO (40 MG TWICE CONTROL SOLUTION 49 85 ...... 70 WEEKLY) ...... 27 VIVAGUARD LANCING WIDE-SEAL DIAPHRAGM XPOVIO (60 MG ONCE DEVICE ...... 49 90 ...... 70 WEEKLY) ...... 27 VIVELLE-DOT ...... 63 WIDE-SEAL DIAPHRAGM XPOVIO (60 MG TWICE VIVITROL ...... 16 95 ...... 70 WEEKLY) ...... 27 VIVLODEX ...... 12 WINLEVI ...... 46 XPOVIO (80 MG ONCE VIZIMPRO ...... 27 wixela inhub ...... 77 WEEKLY) ...... 27 VOGELXO ...... 58 WP THYROID ...... 63

103 XPOVIO (80 MG TWICE ZELBORAF ...... 27 zolmitriptan ...... 24 WEEKLY) ...... 27 ZELNORM...... 54 ZOLMITRIPTAN ...... 24 XTAMPZA ER ...... 14 ZEMBRACE SYMTOUCH ZOLOFT ...... 22 XTANDI ...... 27 ...... 24 zolpidem tartrate ...... 78 xulane...... 63 ZEMPLAR ...... 67 zolpidem tartrate er ...... 78 XULTOPHY ...... 48 zenatane ...... 46 ZOLPIMIST ...... 78 xurea ...... 46 ZENPEP ...... 55 ZOMACTON ...... 58 XYLOCAINE ...... 15 zenzedi ...... 39 ZOMACTON (FOR ZOMA- XYLOCAINE/EPINEPHRIN ZENZEDI ...... 39 JET 10) ...... 59 E ...... 15 ZEPATIER...... 31 ZOMIG ...... 24 XYLOCAINE-MPF ...... 15 ZEPOSIA ...... 39 ZONALON ...... 46 XYOSTED ...... 58 ZEPOSIA 7-DAY STARTER ZONEGRAN ...... 20 XYREM ...... 78 PACK ...... 39 zonisamide ...... 20 XYWAV ...... 78 ZEPOSIA STARTER KIT . 39 ZONTIVITY ...... 29 Y ZERUVIA ...... 15 ZORBTIVE ...... 54 YASMIN 28 ...... 63 ZERVIATE...... 71 ZORTRESS ...... 65 YAZ ...... 63 ZESTORETIC ...... 38 ZORVOLEX ...... 12 YELLOW HORNET VENOM ZESTRIL ...... 38 zovia 1/35 (28) ...... 63 PROTEIN ...... 70 ZETIA ...... 38 zovia 1/35e (28) ...... 63 YELLOW JACKET VENOM ZETONNA ...... 75 ZOVIRAX ...... 32 PROTEIN ...... 70 ZIAC ...... 38 ZTLIDO ...... 15 YONSA ...... 27 ZIAGEN ...... 31 ZUBSOLV ...... 16 YOSPRALA ...... 29 ZIANA ...... 46 zumandimine ...... 63 YUPELRI ...... 77 zidovudine ...... 31 ZUPLENZ...... 22 yuvafem ...... 63 ZIEXTENZO ...... 33 ZYCLARA ...... 46 Z zileuton er ...... 77 ZYCLARA PUMP ...... 46 zaclir cleansing ...... 46 ZIONODIL ...... 15 ZYDELIG...... 27 zafemy ...... 63 ZIONODIL 100 ...... 15 ZYFLO ...... 77 zafirlukast ...... 77 ZIOPTAN ...... 72 ZYKADIA...... 27 zaleplon ...... 78 ziprasidone hcl ...... 29 ZYLET ...... 73 ZANAFLEX ...... 78 ziprasidone mesylate ...... 29 ZYLOPRIM ...... 24 zarah ...... 63 ZIPSOR ...... 12 ZYMAXID ...... 71 ZARONTIN ...... 20 ZIRGAN ...... 71 ZYNRELEF ...... 12 ZARXIO ...... 33 ZITHRANOL ...... 46 ZYPITAMAG ...... 38 ZAVESCA ...... 55 ZITHROMAX ...... 18 ZYPREXA ...... 29 ZCORT 7-DAY ...... 57 ZITHROMAX TRI-PAK .... 18 ZYPREXA RELPREVV ... 30 ZEBUTAL ...... 14 ZITHROMAX Z-PAK ...... 18 ZYPREXA ZYDIS ...... 30 ZEGALOGUE ...... 49 ZOCOR ...... 38 ZYTIGA ...... 27 ZEGERID ...... 53 ZOFRAN ...... 22 ZYVOX ...... 18 ZEJULA ...... 27 ZOKINVY ...... 70 ZELAPAR ...... 28 ZOLINZA ...... 27

104 Kaiser Permanente Nondiscrimination Notice and Language Access Services

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© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted 2018-XB-7_ACA_Notice_Taglines LANGUAGE ACCESS SERVICES English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711). Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711). 中文 (Chinese)：注意：如果您使用繁體中文，您可 以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。 Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711). 한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오. Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711). Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

徶羶ខ្មែរ (Khmer)៖ របយ័ត៖ េេបើសិនអកនិខ្យមរ , េ សជំនួខ្យផក េយមិនគិតល គឺចនសំប់បំេរអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។ 日本語 (Japanese): 注意事項：日本語を話される場 合、無料の言語支援をご利用いただけます。 1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、 お電話にてご連絡ください。 አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711). Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711). ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।ﹱ ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸਾ ਧ 1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ। العربية :(Arabic) لديكم حق الحصول على مساعدة ومعلومات في ملحوظة :إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان .اتصل برقم 4636-901-888-1 رقم هاتف الصم والبكم: (1-800-833-6388 / 711) . Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711). ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວ ້ າພາສາລາວ, ການບໍ ິລການຊ່ ວຍເຫ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່ າ, ແມ່ ນມີ ພ້ ອມ ໃຫ້ ທ່ ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711). Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711). Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711). Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711). فارسی :(Farsi) توجه :اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد .با (TTY: 1-800-833-6388 / 711) 4636-901-888-1 تماس بگيريد.

XB0001444-56-18