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FORMULARY

EFFECTIVE JANUARY 1, 2018 LAST UPDATED OCTOBER 26, 2018 TABLE OF CONTENTS

INTRODUCTION...... 2 HOW TO USE THIS LIST ...... 2 COVERAGE AND LIMITATIONS ...... 3 PHARMACY SAVINGS PROGRAMS ...... 4 CONTACT US ...... 4 DRUG FORMULARY LIST ...... 5 ANTI-INFECTIVE ...... 5 AUTOIMMUNE INFLAMMATORY DISORDERS ...... 7 BLOOD MODIFYING DRUGS ...... 8 CANCER DRUGS ...... 8 CENTRAL NERVOUS SYSTEM ...... 9 GASTROINTESTINAL DRUGS ...... 12 GENITOURINARY DRUGS ...... 13 HEART AND CIRCULATORY DRUGS ...... 14 HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS ...... 18 MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ...... 21 MULTIPLE SCLEROSIS ...... 21 NEUROMUSCULAR DRUGS ...... 22 PAIN-RELIEF DRUGS ...... 23 RESPIRATORY, , ETC ...... 25 SUPPLEMENTS ...... 26 TOPICAL DRUGS ...... 26 MANAGED DOSE LIMITATIONS (MDL) ...... 31 PREAUTHORIZATION (PA) ...... 34 STEP-THERAPY (ST) ...... 38 WELLNESS MEDICATIONS ...... 41 INDEX ...... 43

1 ph-commercialformprivate-1018-2 INTRODUCTION Example: VESICARE - solefenacin This is the 2018 Health Alliance Drug Covered generic drugs appear in lowercase bold Formulary. In order to assist members and providers type, followed by their reference brand drug in in choosing covered prescription drugs for parentheses. (Exceptions are noted.) treatment, we encourage members to show this list Example: atenolol (Tenormin) to their physicians and pharmacists. In addition, we encourage prescribers to use this list when Generics considering treatment options. Final decisions Like brand drugs, generic drugs go through an regarding treatment options are made between the approval process by the Food and Drug physician and patient. Administration (FDA) and must meet similar The formulary is subject to change at any time. standards of effectiveness and chemical make-up as Members can access the most up-to-date version of branded drugs. this list by visiting the Pharmacy section of The main difference between the reference brand HealthAlliance.org. In addition, members can login drug and its generic equivalent is that the generic to OptumRx.com to access specific drug coverage often costs much less. and pricing information. As a general rule, generic drugs have the lowest The formulary does not provide information member copayment. Typically, when a generic about an individual’s specific coverage. Please refer enters the market the brand drug moves to Tier 3. to your plan documents for complete coverage Members who choose the brand name after the details. release of a generic version may pay the copayment plus the difference in cost between the brand and HOW TO USE THIS LIST generic drug. Generic drugs can help members save on out-of-pocket medication costs. This drug list is organized in sections by drug class or medical condition. Within each section are Generic Equivalent vs. Generic Alternative subsections to help locate medications. Most drugs Generic equivalents are medications that contain listed, whether generic or brand, are formulary the same active ingredient, with the same strength drugs. There are a few nonformulary drugs listed and dosage form as the brand medication. Generic and designated as Tier 3. equivalents are as safe and effective and produce To search within the PDF, choose the search the same results as the brand counterpart. function, enter a drug name and click “search” or Generic alternatives can produce the same “find.” You can also search using the index, which intended effect on the body as the comparable lists drugs alphabetically. brand. Generic alternatives are medications that work like a particular brand drug and are used to The list is organized first by therapeutic class. treat the same condition. However, the active ingredient in a generic alternative is different from THERAPEUTIC CLASS the brand medication. Talk to Your Doctor Then by sub-type (if applicable). If your doctor writes a prescription for a brand drug that does not have a generic equivalent, SUB-TYPE consider asking if an appropriate generic alternative is available. And last by additional sub-type (if applicable). As a patient, you can tell your pharmacist you are interested in generics. In most situations, your pharmacist can substitute a generic equivalent for ADDITIONAL SUB-TYPE its brand counterpart without a new prescription from your doctor. Covered brand-name drugs are listed in all For more information on generics, visit CAPITAL letters, followed by the generic name. AskForGenerics.org. (Exceptions are noted.)

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Drugs to Treat Multiple Conditions may qualify for a medical exception if they meet Doctors use some drugs to treat more than one one of these: medical condition. Within this document, each drug A. Documented failure of all formulary drugs is listed according to its first FDA-approved use. within the same therapeutic class Please check the index if you do not find your B. Documented allergy to a formulary drug, medication in the therapeutic class that corresponds with no other formulary choices to your condition. C. Successfully maintained condition on a specific drug where switching to an COVERAGE AND LIMITATIONS alternative drug may cause a health risk: o Antiarrhythmics Tier Information o products A drug’s copayment tier indicates what you will o Seizure medications pay for the medication with each fill. o Antipsychotics o Antidepressants

• The majority of generics are Tier 1. These are your least expensive prescription drugs. Physicians—Requesting a Medical • Formulary brands listed in this document are Exception available at the lowest brand tier, unless To request a Medical Exception for a otherwise noted. medication on behalf of a member, or to request • Specialty drugs may have a different further information, please call the Health Alliance copayment. For a complete listing of Pharmacy department at 1-800-851-3379, option 4, specialty drugs, please click on one of the or fax the Preauthorization/Medical Exception form links below: to 217-902-9798. Please provide the following information when requesting a Medical Exception: Standard Specialty Drug List • Patient name and Health Alliance State of Illinois Employee Specialty Drug identification number • List Physician name, address and phone number • Drug name and strength Depending on your plan, you may have a three- • Patient diagnosis tier or a six-tier copayment structure. Refer to your • Chart documentation/documentation of description of coverage documents for details. Your previous medical history pertaining to the pharmacy benefit includes coverage for the majority requested drug of prescription drugs, though some exclusions may apply. Preventive Health Wellness Benefit

For a complete listing of drugs covered at zero Utilization Management member cost-share, see our list of Wellness Some drugs on this list require utilization Medications at the end of this formulary. For more management (UM), i.e. preauthorization, managed information about coverage of contraceptives, dose limitations and step-therapy. If UM applies to please access the policy “Contraceptive Coverage a drug, it is indicated with one of the following Under Preventive Health Services in Wellness symbols in the column next to the drug name. Benefit” by logging into MyHealthAlliance.org.

• MDL- Managed Dose Limitations Medical procedures and devices covered at • PA- Preauthorization through Health zero cost-share can be found at the following link: Alliance Be Healthy Brochure • ST- Step-Therapy

Medical Exception (varies by plan design) General Exclusions Medical exception is a process for reviewing A. Over-the-counter (OTC) medications and coverage for drugs not on our formulary. Members their equivalents are not covered, unless

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otherwise specified within the Formulary. Freestyle Lite® and Freestyle InsuLinx® Nicotine smoking-cessation products (e.g., transdermal nicotine, nicotine gum, nicotine FreeStyle Lite® System inhaler) coverage is based on specific FreeStyle Freedom Lite® System member benefits. FreeStyle InsuLinx® System B. Any drugs used for cosmetic purposes are not covered. To get an Abbott product, call 1-866-224-8892 C. Experimental drugs, or any drug product and use offer code ZD218BKX. used in an experimental manner, are not covered. Or visit ChooseFreestyle.com and enter Offer D. Replacement of lost or stolen medication is Code ZD218BKX. not covered. E. Non-self-administered injectable drugs, The InsuLinx Systems are limited to one no-cost unless otherwise noted, are not covered product per member every three years. through the pharmacy benefit. Refer to your

description of coverage materials for details. F. Foreign drugs and drugs not approved by the DISCLAIMER FDA are not covered. Not all benefit plans include each of the programs listed above. Please refer to your description of coverage documents for more detail or contact the PHARMACY SAVINGS PROGRAMS Pharmacy department at 1-800-851-3379, option 4. Health Alliance offers members programs to lower their drug costs and to help members take CONTACT US their medications safely and correctly. Health Alliance Pharmacy Department 3310 Fields South Drive Retail 90 Champaign, IL 61822 1-800-851-3379, option 4 The Retail 90 program allows members to HealthAlliance.org purchase a 90-day supply of maintenance medication at a discounted copayment from participating retail pharmacies. Because this is a voluntary program designed to increase flexibility, members who prefer may continue purchasing the traditional 30-day supply from their pharmacy with their regular copayment.

Blood Glucose Monitors FREE By Mail Members with diabetes are eligible to receive a FREE blood glucose meter if they choose one of the preferred meters listed below and obtain the meter by mail. If a member picks up a blood glucose meter at their local pharmacy, the member’s Tier 2 copayment will apply when obtained with a prescription. Free meters are limited to one meter per member per year. The FreeStyle InsuLinx System is limited to one meter every three years.

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DRUG FORMULARY LIST UTILIZATION OTHER COVERAGE MANAGEMENT NOTES ANTI-INFECTIVE DRUGS

CEPHALOSPORINS cefadroxil (Duricef) cefdinir (Omnicef) cefixime (Suprax) cefpodoxime (Vantin) cefprozil (Cefzil) cefuroxime (Ceftin) cephalexin (Keflex) FLUOROQUINOLONES ciprofloxacin (Cipro) CIPRO SUSPENSION—ciprofloxacin suspension levofloxacin (Levaquin) moxifloxacin (Avelox) FUNGAL INFECTIONS fluconazole (Diflucan) flucytosine (Ancoban) griseofulvin microsize (Fulvicin, Grisfulvin) GRIFULVIN V—griseofulvin GRIS-PEG—griseofulvin itraconazole (Sporanox) ketoconazole tablets (Nizoral) nystatin oral (Mycostatin) terbinafine (Lamisil) voriconazole (Vfend) PA Specialty

HEPATITIS B EPIVIR HBV—lamivudine

MACROLIDES azithromycin (Zithromax) clarithromycin (Biaxin) clarithromycin ER (Biaxin XL) E.E.S. GRANULES—erythromycin ethylsuccinate

OTHER ANTI-INFECTIVES clindamycin (Cleocin) erythromycin/sulfisoxazole (Pediazole)

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UTILIZATION OTHER COVERAGE MANAGEMENT NOTES MEPRON—atovaquone suspension metronidazole (Flagyl) neomycin sulfamethoxazole/trimethoprim (Bactrim, Sulfatrim, Septra) tinidazole (Tindamax) trimethoprim vancomycin (Vancocin)

PENICILLINS amoxicillin/potassium clavulanate (Augmentin) amoxicillin/potassium clavulanate ER (Augmentin XR) amoxicillin (Amoxil) ampicillin dicloxacillin (Dicloxacillin) penicillin v potassium (Veetids)

TETRACYCLINES VIBRAMYCIN SYRUP—doxycycline syrup minocycline (Minocin) doxycycline hyclate (Vibramycin)

TUBERCULOSIS ethambutol (Myambutol) isoniazid (Laniazid, Nydrazid) isoniazid/rifampin (Rifamate) MYCOBUTIN—rifabutin pyrazinamide rifampin (Rifadin)

VIRAL INFECTIONS HEPATITIS B adefovir (Hepsara) PA entecavir (Baraclude) PA lamivudine (Epivir HBV) PA HEPATITIS C EPCLUSA—sofosbuvir/velpatasvir PA Specialty HARVONI—ledipasvir/sofosbuvir PA Specialty SOVALDI—sofosbuvir PA Specialty HERPES acyclovir (Zovirax) famciclovir (Famvir) valacyclovir (Valtrex)

6 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES HIV/AIDS abacavir (Ziagen) abacavir/lamivudine (Epzicom) APTIVUS—tipranavir CRIXIVAN—indinavir didanosine (Videx EC) EMTRIVA—emtricitabine INVIRASE—saquinavir ISENTRESS—raltegravir KALETRA—lopinavir-ritonavir lamivudine (Epivir) lamivudine/zidovudine (Combivir) nevirapine (Viramune) nevirapine ER (Viramune XR) NORVIR SOLUTION—ritonavir RESCRIPTOR—delavirdine REYATAZ—atazanavir stavudine (Zerit) SUSTIVA—efavirenz VIREAD—tenofovir zidovudine (Retrovir) INFLUENZA oseltamivir (Tamiflu) MDL rimantadine HCl (Flumadine) MALARIA atovaquone/proguanil 250-100 mg (Malarone) chloroquine phosphate (Aralen) COARTEM—artemether-lumefantrine hydroxychloroquine (Plaquenil) mefloquine (Larium) primaquine AUTOIMMUNE INFLAMMATORY DISORDERS DISEASE MODIFYING BIOLOGICS ENBREL—etanercept PA Specialty HUMIRA—adalimumab PA Specialty IMMUNOSUPPRESSANTS azathioprine (Imuran) cyclosporine (Sandimmune) cyclosporine modified capsules

7 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES mycophenolate mofetil (Cellcept) NEORAL—cyclosporine modified PROGRAF—tacrolimus RAPAMUNE—sirolimust SANDIMMUNE—cyclosporine tacrolimus (Prograf) BLOOD MODIFYING DRUGS (Agrylin) aspirin/ (Aggrenox) BRILINTA—ticagrelor (Pletal) clopidogrel (Plavix) COUMADIN—warfarin sodium cyanocobalamin injection dipyridamole (Persantine) ELIQUIS—apixaban enoxaparin (Lovenox) folic acid 1 mg tablets fondaparinux (Arixtra) FRAGMIN—dalteparin sodium, injection ER (Trental) PROMACTA—eltrombopag PA Specialty warfarin (Coumadin) XARELTO—rivaroxaban CANCER DRUGS anastrozole (Arimidex) bicalutamide (Casodex) capecitabine (Xeloda) PA Tier 3 CEENU—lomustine cyclophosphamide PA Tier 3 EMCYT—estramustine PA etoposide (Toposar) PA Tier 3 exemestane (Aromasin) FARESTON—toremifene PA flutamide (Eulexin) PA HEXALEN—altretamine PA hydroxyurea (Hydrea) letrozole (Femara) leucovorin calcium tablets (Folinic acid)

8 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES LEUKERAN—chlorambucil PA LYSODREN—mitotane PA megestrol (Megace) melphalan (Alkeran) PA mercaptopurine (Purinethol) MESNEX—mesna methotrexate (Trexall) MYLERAN—busulfan NILANDRON—nilutamide TABLOID—thioguanine tamoxifen (Nolvadex) Wellness topotecan (Hycamtin) PA TREXALL—methotrexate CENTRAL NERVOUS SYSTEM

ANXIETY alprazolam (Xanax) alprazolam ODT (Niravam) ST buspirone (Buspar) clorazepate (Valium) hydroxyzine (Atarax, Vistaril) lorazepam (Ativan) oxazepam

DEPRESSION (Elavil) bupropion (Wellbutrin) bupropion ext-release (Wellbutrin SR, Wellbutrin XL) citalopram (Celexa) (Anafranil) (Norpramin) (Sinequan) duloxetine (Cymbalta) EMSAM PATCHES—selegiline escitalopram (Lexapro) fluoxetine (Prozac) fluvoxamine (Luvox) fluvoxamine ER (Luvox CR) hcl (Tofranil)

9 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES (Remeron, Remeron SolTab) nefazodone (Serzone) (Pamelor) hcl (Paxil) paroxetine hcl ER (Paxil CR) PAXIL—paroxetine HCL, oral suspension phenelzine (Nardil) sertraline (Zoloft) tranylcypromine (Parnate) trazodone (Desyrel) venlafaxine (Effexor) venlafaxine ER capsules (Effexor XR)

HYPERACTIVITY/NARCOLEPSY amphetamine/detroamphetamine (Adderall) MDL amphetamine/detroamphetamine ER (Adderall XR) MDL armodafinil (Nuvigil) MDL atomoxetine (Strattera) MDL HCl ER DEXEDRINE—dextroamphetamine MDL dexmethylphenidate (Focalin) MDL dexmethylphenidate ER (Focalin XR) MDL dextroamphetamine MDL dextroamphetamine ER (Dexedrine Spansule) MDL guanfacine ER (Intuniv) METHYLIN—methylphenidate HCL MDL methylphenidate tablets (Ritalin) MDL methylphenidate ER (Metadate CD, Ritalin LA, Ritalin SR) MDL modafinil (Provigil) MDL OTHER CENTRAL NERVOUS SYSTEM DRUGS acamprosate ER bupropion ER (Zyban) CHANTIX—varenicline tartrate disulfiram (Antabuse) donepezil (Aricept, Aricept ODT) EMSAM—selegiline galantamine (Razadyne) galantamine ER (Razadyne ER) memantine (Namenda) naltrexone (ReVia)

10 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES NICOTROL INHALER—nicotine inhaler system NICOTROL NS—nicotine, nasal spray pimozide (Orap) rasagiline (Azilect) rivastigmine (Exelon) SARAFEM—fluoxetine ST

PSYCHOTIC AND BIPOLAR DISORDER aripiprazole (Abilify) (Thorazine) (Clozaril) fluphenazine (Prolixin) haloperidol (Haldol) LATUDA—lurasidone PA Tier 3 lithium carbonate lithium carbonate ER (Lithobid, Eskalith CR) (Loxitane) (Zyprexa, Zyprexa Zydis) olanzapine/fluoxetine (Symbyax) PA paliperidone (Invega) perphenazine (Trilafon) prochlorperazine (Compazine) (Seroquel) quetiapine ER (Seroquel XR) (Risperdal, Risperdal-M tablets) thiothixene (Navane) trifluoperazine (Stelazine) ziprasidone (Geodon)

SLEEP AIDS estazolam (Prosom) eszopiclone (Lunesta) flurazepam phenobarbital temazepam (Restoril) triazolam (Halcion) zaleplon (Sonata) zolpidem (Ambien) zolpidem ER (Ambien CR)

11 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES SMOKING CESSATION bupropion ER (Zyban) Wellness Chantix—varenicline Wellness Nicotrol Inhaler—nicotine Wellness Nicotrol NS—nicotine Wellness GASTROINTESTINAL DRUGS

DIGESTIVE ENZYMES CREON—pancrelipase ULTRESA—pancrelipase Tier 3 VIOKACE—pancrelipase Tier 3 ZENPEP—pancrelipase

NAUSEA AND VOMITING ANZEMET—dolasetron desylate aprepitant (Emend) MDL calcium acetate dronabinol (Marinol) granisetron (Kytril) (Antivert) ondansetron (Zofran, Zofran ODT) SANCUSO—granisetron MDL trimethobenzamide (Tigan)

OTHER GASTROINTESTINAL DRUGS 5-AMINOSALICYLIC ACID—mesalamine powder alosetron (Lotronex) AMITIZA—lubiprostone MDL APRISO—mesalamine balsalazide (Colazal) CANASA—mesalamine cromolyn sodium (Gastrocrom Oral) DELZICOL—mesalamine DIPENTUM—olsalazine sodium diphenoxylate/ tablets (Lomotil) lactulose (Enulose) LINZESS—linaclotide MDL mesalamine (Rowasa) (Reglan) RELISTOR—methylnaltrexone bromide, injection PA

12 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES sevelamer carbonate (Renvela) sulfasalazine (Azulfidine) sulfasalazine DR (Azulfidine EN-Tabs) ursodiol (Actigall, Urso 250, Urso Forte)

ULCER/REFLUX CARAFATE SUSPENSION—sucralfate chlordiazepoxide HCl/clidinium bromide (Librax) cimetidine (Tagamet) dicyclomine (Bentyl) famotidine (Pepcid) glycopyrrolate (Robinul) (Anaspaz, Levsin/SL) hyoscyamine ER (Levbid, Symax Duotab) lansoprazole DR (Prevacid) methscopolamine (Pamine, Pamine Forte) misoprostol (Cytotec) Nexium 24HR OTC (esomeprazole) MDL Tier 1 nizatidine (Axid) omeprazole DR (Prilosec) pantoprazole DR (Protonix) rabeprazole (Aciphex) ranitidine (Zantac) sucralfate tablets (Carafate) Zegerid OTC (omeprazole-sodium bicarbonate) Tier 1 GENITOURINARY DRUGS

BENIGN PROSTATIC HYPERPLASIA alfuzosin (Uroxatral) CARDURA XL—doxazosin mesylate CIALIS ONCE DAILY— ST Tier 3 dutasteride (Avodart) dutasteride/tamsulosin (Jalyn) finasteride (Proscar) tamsulosin (Flomax)

OTHER GENITOURINARY DRUGS ORACIT—sodium citrate and citric acid potassium citrate ER (Urocit-K) potassium citrate/citric acid (Polycitra-K) sodium citrate/citric acid (Shohls)

13 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES UROCIT-K—potassium citrate

URINARY TRACT INFECTIONS MACRODANTIN—nitrofurantoin macrocrystalline nitrofurantoin (Furadantin) nitrofurantoin macrocrystalline (Macrodantin) nitrofurantoin monohydrate/macrocrystalline (Macrobid)

URINARY TRACT SPASMS bethanecol (Urecholine) hydrobromide ER (Enablex) (Urispas) MYRBETRIQ—mirabegron (Ditropan) oxybutynin ER (Ditropan XL) (Detrol) tolterodine ER (Detrol LA) trospium (Sanctura) trospium ER VESICARE— succinate

VAGINAL PRODUCTS CLEOCIN—clindamycin phosphate clindamycin vaginal cream (Cleocin) ENDOMETRIN— vaginal cream (Estrace) ESTRING—estradiol metronidazole (MetroGel-Vaginal) terconazole (Terazol) HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS benazepril (Lotensin) benazepril/hydrochlorothiazide (Lotensin HCT) captopril (Capoten) captopril/hydrochlorothiazide (Capozide) enalapril (Vasotec) enalapril/hydrochlorothiazide (Vaseretic) fosinopril (Monopril) fosinopril/hydrochlorothiazide (Monopril HCT) lisinopril (Prinivil) lisinopril/hydrochlorothiazide (Prinizide)

14 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES moexipril (Univasc) moexipril/hydrochlorothiazide (Uniretic) perindopril (Aceon) quinapril (Accupril) quinapril/hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik)

ANGIOTENSIN II ANTAGONISTS (ARBS) AND COMBINATIONS amlodipine/olmesartan (Azor) ST amlodipine/valsartan (Exforge) candesartan (Atacand) eprosartan (Teveten) Tier 3 EXFORGE HCT—valsartan-amlodipine-hydrochlorothiazide irbesartan (Avapro) irbesartan/hydrochlorothiazide (Avalide) losartan (Cozaar) losartan/hydrochlorothiazide (Hyzaar) olmesartan (Benicar) ST olmesartan/amlodipine/hydrochlorothiazide (Tribenzor) ST olmesartan/hydrochlorothiazide (Benicar HCT) ST telmisartan (Micardis) telmisartan/amlodipine (Twynsta) valsartan (Diovan) valsartan/hydrochlorothiazide (Diovan HCT) BETA BLOCKERS AND COMBINATION AGENTS acebutolol (Sectral) atenolol (Tenormin) atenolol/chlorthalidone (Tenoretic) betaxolol HCl (Betoptic) bisoprolol (Zebeta) bisoprolol/hydrochlorothiazide (Ziac) BYSTOLIC—nebivolol carvedilol (Coreg) labetalol (Trandate) metoprolol succinate ER (Toprol XL) metoprolol tartrate (Lopressor) nadolol (Corgard) pindolol (Visken) ER (Inderal LA) propranolol tablets (Inderal) sotalol HCl (Betapace)

15 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine (Norvasc) amlodipine/benazepril (Lotrel) diltiazem (Cardizem) diltiazem ER (Cardizem CD, Cardizem LA, Dilacor XR, Tiazac) felodipine ER (Plendil) nifedipine ER (Adalat CC, Procardia XL) nimodipine (Nymalize) nisoldipine (Sular) (Calan) verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM)

CHEST PAIN DILATRATE SR—isosorbide dinitrate CR isosorbide dinitrate (Isordil) isosorbide mononitrate (Monoket) isosorbide mononitrate ER (Imdur) NITRO-BID—nitroglycerin NITRO-DUR—nitroglycerin patch nitroglycerin (Nitro-Dur) NITROMIST—nitroglycerin lingual NITROSTAT—nitroglycerin SL

CHOLESTEROL LOWERING atorvastatin (Lipitor) cholestyramine (Questran, Questran Light) colestipol (Colestid) ezetimibe (Zetia) ezetimibe/simvastatin (Vytorin) fenofibrate, micronized (Lofibra) fenofibric acid (Trilipix) fluvastatin (Lescol) fluvastatin sodium ER (Lescol XL) gemfibrozil (Lopid) lovastatin (Mevacor) niacin CR (Niaspan) omega-3-acid ethyl esters (Lovaza) PA pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor)

16 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES ERECTILE DYSFUNCTION CAVERJECT—alprostadil for injection MDL CIALIS—tadalafil MDL Tier 3 EDEX—alprostadil for injection kit MDL MUSE—alprostadil urethral pellet MDL

FLUID RETENTION acetazolamide (Diamox) acetazolamide ER (Diamox Sequels) amiloride (Midamor) amiloride/hydrochlorothiazide (Moduretic) bumetanide (Bumex) chlorthalidone (Thalitone) Tier 3 chlorothiazide (Diuril) Tier 2 furosemide (Lasix) hydrochlorothiazide (Microzide, Hydrodiuril) indapamide (Lozol) methazolamide (Neprazane) metolazone (Zaroxolyn) spironolactone (Aldactone) spironolactone/hydrochlorothiazide (Aldactazide) triamterene/hydrochlorothiazide (Dyazide, Maxzide) torsemide (Demadex)

HEART RHYTHM amiodarone (Cordarone, Pacerone) disopyramide (Norpace) flecainide (Tambocor) mexiletine HCl (Mexitil) MULTAQ—dronedarone NORPACE CR—disopyramide propafenone (Rythmol) propafenone ER (Rythmol SR) gluconate ER (Quinaglute) quinidine sulfate (Quinidex) sotalol (Betapace, Betapace AF)

OTHER RELATED DRUGS clonidine (Catapres, Catapres-TTS) digoxin (Lanoxin) doxazosin (Cardura)

17 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES eplerenone (Inspra) guanfacine (Tenex) hydralazine (Apresolutionine) methyldopa (Aldomet) minoxidil (Loniten) phenoxybenzamine HCl (Dibenzyline) PA, MDL prazosin (Minipress) terazosin (Hytrin)

RENIN INHIBITORS AND COMBINATIONS AMTURNIDE—aliskiren-amlodipine-hydrochlorothiazide TEKTURNA—aliskiren TEKTURNA HCT—aliskiren-hydrochlorothiazide HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS

BIRTH CONTROL levonorgestrel (Plan B) Wellness norelgestromin-ethinyl estradiol (Ortho Evra) Wellness NUVARING—etonogestrel-ethinyl estradiol Wellness oral contraceptives - all generics Wellness

CORTICOSTEROIDS dexamethasone DEXAMETHASONE INTENSOL—dexamethasone fludrocortisones (Florinef) hydrocortisone (Cortef) methylprednisolone (Medrol) MILLIPRED— prednisolone PREDNISONE INTENSOL—prednisone prednisolone (Prelone) prednisolone sodium phosphate (Orapred, Pediapred) prednisone tablets

DIABETES acarbose (Precose) BYDUREON— PA, MDL BYDUREON BCISE—exenatide PA, MDL BYETTA—exenatide PA, MDL FARXIGA—dapagliflozin PA, MDL Tier 3 glimepiride (Amaryl) glipizide (Glucotrol)

18 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES glipizide ER (Glucotrol XL) GLUCAGEN— GLUCAGON EMERGENCY KIT—glucagon glyburide (Micronase) glyburide micronized (Glynase) glyburide/metformin (Glucovance) GLYXAMBI—empagliflozin and linagliptin PA, MDL Tier 3 INVOKANA—canagliflozin ST, MDL INVOKAMET—canagliflozin-metformin ST, MDL INVOKAMET XR—canagliflozin-metformin ER ST, MDL JANUMET—sitagliptin-metformin ST, MDL JANUMET XR—sitagliptin-metformin ST, MDL JANUVIA—sitagliptin ST, MDL JARDIANCE—empagliflozin ST, MDL JENTADUETO—linagliptin-metformin ST, MDL JENTADUETO XR—linagliptin-metformin ST, MDL KAZANO—alogliptin-metformin PA, MDL Tier 3 KOMBIGLYZE— saxagliptin-metformin PA, MDL Tier 3 KOMBIGLYZE XR— saxagliptin-metformin ER PA, MDL Tier 3 metformin (Glucophage) metformin ER (Glucophage XR) miglitol (Glyset) nateglinide (Starlix) NESINA—alogliptin PA, MDL Tier 3 ONGLYZA—saxagliptin PA, MDL Tier 3 OSENI—alogliptin-pioglitazone PA, MDL Tier 3 pioglitazone (Actos) pioglitazone-glimepiride (Duetact) pioglitazone-metformin (Actoplus Met) QTERN—dapagliflozin-saxagliptin PA, MDL Tier 3 STEGLUJAN—ertugliflozin-sitagliptin PA, MDL Tier 3 SYNJARDY—empagliflozin-metformin ST, MDL TANZEUM— PA, MDL Tier 3 TRULICITY— PA, MDL TRADJENTA—linagliptin ST, MDL VICTOZA— PA, MDL DIABETES- BASAL LANTUS— MDL LANTUS SOLOSTAR—insulin glargine MDL LEVEMIR— MDL LEVEMIR FLEXTOUCH—insulin detemir MDL TOUJEO—insulin glargine MDL

19 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES TOUJEO MAX—insulin glargine MDL RAPID ACTING INSULIN HUMALOG— MDL SHORT ACTING INSULIN HUMULIN—insulin human nph, reg MDL DIABETES—TESTING SUPPLIES FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM MDL (Free by mail) FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM MDL (Free by mail) FREESTYLE LITE TEST STRIPS MDL FREESTYLE INSULINX BLOOD GLUCOSE SYSTEM (Free by MDL mail) FREESTYLE INSULINX TEST STRIPS MDL PRECISION XTRA BLOOD GLUCOSE SYSTEM (Free by mail) MDL * ALORA—estradiol estradiol (Climara, Estrace) estradiol patch (Vivelle Dot) estradiol/norethindrone acetate (Activella) estropiopate (Ogen, Ortho-Est) FEMHRT LOW DOSE—norethindrone acetate-ethinyl estradiol MENEST—esterified estrogens MENOSTAR—estradiol norethindrone acetate/ethinyl estradiol

INFERTILITY clomiphene (Clomid) PA FOLLISTIM AQ—follitropin PA Specialty ANDROGENS† ANDROGEL—testosterone gel PA danazol (Danocrine) oxandrolone (Oxandrin) testosterone cypionate (Depo-Testosterone) testosterone enanthate (Delatestryl) OTHER HORMONES alendronate tablets (Fosamax) (Dostinex)

* Prior Authorization is required for males. † Prior Authorization is required for females.

20 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES -salmon (Miacalcin) calcitriol (Rocaltrol) desmopressin (DDVAP) doxercalciferol (Hectoral) PA etidronate (Didronal) Tier 3 ibandronate oral (Boniva) OMNITROPE—somatropin Specialty OSPHENA—ospemifene Tier 3 paricalcitol (Zemplar) ST propylthiouracil raloxifene (Evista) Wellness risedronate (Actonel, Atelvia) ST STIMATE—desmopressin SYNAREL—nafarelin zoledronic acid (Reclast) Specialty

PROGESTINS medroxyprogesterone acetate (Provera) norethindrone acetate (Aygestin) progesterone micronized (Prometrium) THYROID REGULATION ARMOUR THYROID—thyroid levothyroxine (Synthroid, Levoxyl) liothyronine (Cytomel) methimazole (Tapazole) propylthiouracil SYNTHROID—levothyroxine THYROLAR—liotrix (T3-T4) MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES)

MISCELLANEOUS DRUGS sodium polystyrene sulfonate MULTIPLE SCLEROSIS AUBAGIO—teriflunomide Specialty AVONEX—interferon beta-1a Specialty BETASERON—interferon beta-1b Specialty COPAXONE—glatiramer acetate Specialty GLATOPA—glatiramer acetate Specialty PLEGRIDY—peginterferon beta-1a Specialty REBIF—interferon beta-1a Specialty

21 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES TECFIDERA—dimethyl fumarate Specialty NEUROMUSCULAR DRUGS

MUSCLE RELAXANTS baclofen (Lioresal) carisoprodol (Soma) chlorzoxazone (Parafon) (Fexmid) ST cyclobenzaprine (Flexeril) dantrolene (Dantrium) metaxalone (Skelaxin) methocarbamol (Robaxin) citrate ER (Norflex) orphenadrine/aspirin/ (Norgesic) tizanidine (Zanaflex)

OTHER NEUROMUSCULAR DRUGS POTASSIUM P-AMINOBENZOATE—potassium aminobenzoate powder pyridostigmine (Mestinon)

PARKINSON'S DISEASE amantadine (Symmetrel) benztropine (Cogentin) (Parlodel) carbidopa/levodopa (Parcopa, Sinemet) carbidopa/levodopa ER (Sinemet CR) entacapone (Comtan) pramipexole (Mirapex) rasagiline mesylate (Azilect) ropinirole (Requip) ropinirole ER (Requip XL) selegiline (Eldepryl) tolcapone (Tasmar) (Artane)

SEIZURES (Tegretol) carbamazepine ER (Carbatrol, Tegretol-XR) clonazepam (Klonopin) divalproex DR (Depakote Sprinkles, Depakote) divalproex ER (Depakote ER)

22 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES ethosuximide (Zarontin) FELBATOL— felbamate gabapentin (Neurontin) lamotrigine (Lamictal) lamotrigine ODT (Lamictal ODT) levetiracetam (Keppra) (Trileptal) phenytoin sodium ER (Dilantin, Phenytek) phenytoin suspenion (Dilantin) primidone (Mysolutionine) tiagabine (Gabitril) (Topamax Sprinkle, Topamax) valproic acid (Depakene, Depakote) zonisamide (Zonegran) PAIN-RELIEF DRUGS

GOUT allopurinol (Zyloprim) COLCRYS— colchicine probenecid (Benemid) ULORIC--febuxostat Tier 3 HEADACHES acetaminophen/isometheptene/dichloralphenazone (Midrin) (Axert) MDL /caffeine (Migergot) (Frova) MDL (Amerge) MDL (Maxalt) MDL rizatriptan ODT (Maxalt ODT) MDL injection, nasal spray, tablets (Imitrex) MDL tablets, ODT tablets (Zomig) MDL NARCOTIC DRUGS acetaminophen/codeine (Tylenol w/Codeine) buprenorphine (Subutex) butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine) DILAUDID-5—hydromorphone HCL fentanyl oral lozenge (Actiq) PA fentanyl patch (Duragesic) MDL hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab, Norco)

23 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) hydromorphone tablets (Dilaudid) hydromorphone ER (Exalgo) ST, MDL meperidine (Demerol) methadone solution methadone tablets (Dolophine) morphine sulfate ER (MS Contin) MDL morphine sulfate IR oxycodone (Roxicodone) oxycodone/acetaminophen (Percocet, Tylox) oxycodone/aspirin (Percodan) oxymorphone IR (Opana) tablets (Ultram) tramadol ER tablets (Ultram ER) ST, MDL tramadol/acetaminophen (Ultracet)

NON-NARCOTIC DRUGS butalbital/acetaminophen (Sedapap) butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet) butalbital/aspirin/caffeine (Fiorinal) diflunisal (Dolobid) PHRENILIN FORTE—butalbital-acetaminophen salsalate (Disalcid)

RHEUMATOID AND OSTEOARTHRITIS celecoxib (Celebrex) diclofenac potassium (Cataflam) diclofenac sodium DR (Voltaren) diclofenac sodium ER (Voltaren-XR) diclofenac sodium/misoprostol (Arthrotec) etodolac (Lodine) etodolac ER (Lodine XL) flurbiprofen ibuprofen (Motrin) indomethacin (Indocin) indomethacin ER (Indocin XR) ketoprofen (Oruvail) ketorolac tromethamine (Toradol) MDL leflunomide (Arava) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Relafen) naproxen (Naprosyn)

24 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES naproxen DR (EC-Naprosyn) naproxen sodium (Anaprox) oxaprozin (Daypro) piroxicam (Feldene) RIDAURA—auranofin sulindac (Clinoril) RESPIRATORY, ALLERGY, ETC.

ANTIHISTAMINES desloratadine (Clarinex) levocetirizine (Xyzal) ASTHMA/COPD albuterol 0.63 mg/3 mL, 1.25 mg/3 ml (Accuneb) albuterol inhaler solution, 0.0835, 0.5% (Ventolin) albuterol syrup, tablets (Ventolin) ASMANEX—mometasone furoate MDL ATROVENT HFA— HFA budesonide (Pulmicort Respules) COMBIVENT RESPIMAT—ipratropium-albuterol cromolym sodium inhal solution (Intal) DULERA—mometasone-formoterol ipratropium bromide solution (Atrovent, Aerovent) ipratropium/albuterol (Duoneb) levalbuterol hydrochloride (Xopenex) MAXAIR AUTOHALER—pirbuterol acetate montelukast sodium (Singulair) PULMICORT—budesonide PROAIR—albuterol MDL Tier 1 QVAR REDIHALER—beclomethasone dipropionate MDL SEREVENT DISKUS—salmeterol xinafoate SPIRIVA— SPIRIVA HANDIHALER—tiotropium STRIVERDI RESPIMAT—oladaterol SYMBICORT—budesonide-formoterol terbutaline (Brethine) theophylline (Theo-24) theophylline ER (Theo-Dur) TUDORZA— VENTOLIN HFA—albuterol MDL Tier 1 zafirlukast (Accolate)

25 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES

ANAPHYLACTIC TREATMENTS EPINEPHRINE MDL EPIPEN—epinephrine MDL Tier 3 EPIPEN-JR 2-PAK—epinephrine MDL Tier 3

IMMUNOTHERAPY AGENTS GRASTEK—timothy grass pollen allergen extract RAGWITEK—short ragweed pollen allergen extract NASAL AGENTS azelastine (Astelin, Astepro) budesonide (Rhinocort) flunisolide (Nasarel) fluticasone (Flonase) ipratropium bromide (Atrovent) mometasone (Nasonex) hydrochloride (Patanase) QNASL—beclomethasone dipropionate Tier 3 triamcinolone (Nasacort AQ) SUPPLEMENTS

VITAMINS ergocalciferol (Drisdol) GALZIN—zinc acetate NASCOBAL—cyanocobalamin MINERALS AND ELECTROLYTES potassium bicarbonate/chloride effervescent tablets potassium chloride potassium chloride ER potassium phosphate/sodium phosphates (K-Phos Neutral) sodium fluoride

MULTIVITAMINS prenatal vitamin/folic acid - all generics TOPICAL DRUGS

ANORECTAL AGENTS ANALPRAM E—HC-pramoxine CORTIFOAM—hydrocortisone acetate rectal foam hydrocortisone acetate rectal cream (Anusolution-HC, Proctocort)

26 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES hydrocortisone enema (Cortenema) hydrocortisone/lidocaine EAR acetic acid ear solution benzocaine/antipyrine ear solution fluocinolone acetonide ear solution hydrocortisone/acetic acid ear solution neomycin/polymyxin B/hydrocortisone ear solution, suspension (Cortisporin) ofloxacin ear solution (Floxin otic)

EYE ANTI-INFECTIVE bacitracin/polymyxin B eye ointment ciprofloxacin eye solution (Ciloxan) erythromycin eye ointment gentamicin eye ointment, solution (Garamycin) neomycin/polymyxin B/gramicidin eye solution (Neosporin) neomycin/polymyxin/bacitracin eye ointment ofloxacin eye solution (Ocuflox) polymyxin B/trimethoprim eye solution (Polytrim) sulfacetamide sodium eye solution (Bleph-10) tobramycin eye solution (Tobrex) trifluridine eye solution (Viroptic) ZYMAXID—gatifloxacin Tier 3 GLAUCOMA ALPHAGAN P—brimonidine tartrate apraclonidine (Iopidine) BETOPTIC-S—betaxolol HCL, ophthalmic suspension 0.25% brimonidine eye solution, 0.15% (Alphagan P) brimonidine eye solution, 0.2% carteolol eye solution (Ocupress) dorzolamide eye solution (Trusopt) dorzolamide/ maleate eye solution (Cosopt) lantanoprost eye solution (Xalatan) levobunolol eye solution, 0.5% (Betagan) LUMIFY—brimonidine tartrate, ophthalmic solution 0.025% LUMIGAN—bimatoprost, ophthalmic solution 0.01% metipranolol eye solution (Optipranolol) eye solution, 1%, 2%, 4% (Isopto Carpine) timolol maleate eye solution (Timoptic, Timoptic XE) SIMBRINZA—brinzolamide/brimonidine tartrate, ophthalmic Tier 3

27 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES suspension 1%/0.2% TIMOPTIC OCUDOSE—timolol maleate, ophthalmic solution 0.25% TRAVATAN Z—travopost OTHER EYE PRODUCTS ALOMIDE—lodoxamide tromethamine atropine sulfate eye ointment, solution (Isopto Atropine) azelastine eye solution (Optivar) cromolyn sodium eye solution (Opticrom) CYCLOGYL— HCL CYCLOMYDRIL—cyclopentolate wtih phenylephrine cyclopentolate eye solution (Cyclogyl) diclofenac eye solution (Voltaren) epinastine HCL eye solution (Elestat) flurbiprofen eye solution (Ocufen) ILEVRO—nepafenac Tier 3 ketorolac eye solution (Acular, Acular LS) LASTACAFT—alcaftadine Tier 3 PATADAY—olopatadine HCL Tier 3 PHOSPHOLINE IODIDE—echothiophate iodide PILOPINE HS—pilocarpine HCL RESTASIS—cyclosporine STEROIDS AND COMBINATION PRODUCTS BLEPHAMIDE S.O.P. —sulfacetamide sodium-prednisolone dexamethasone sodium phosphate eye solution FLAREX—fluorometholone acetate FML FORTE—fluorometholone fluorometholone eye suspension, 0.1% (FML Liquifilm) neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment neomycin/polymyxin B/dexamethasone eye ointment, suspenion (Maxitrol) PRED MILD—prednisolone acetate PRED-G—gentamicin-prednisolone PRED-G S.O.P.—gentamicin-prednisolone prednisolone acetate eye suspenion (Pred Forte) sulfacetamide sodium/prednisolone eye solution TOBRADEX—tobramycin-dexamethasone TOBRADEX ST—tobramycin-dexamethasone tobramycin/dexamethasone eye suspenion (Tobradex)

28 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES MOUTH AND THROAT—LOCAL cevimelene (Evoxac) chlorhexidine oral rinse (Peridex) clotrimazole troche (Mycelex Troche) lidocaine viscous nystatin suspension pilocarpine (Salagen) sodium fluoride (Prevident) triamcinolone dental paste (Kenalog in Orabase)

SKIN CONDITIONS/PRODUCTS ACNE adapalene (Differin) clindamycin (Cleocin-T) erythromycin gel, pads, solution metronidazole (Metrocream, Metrolotion) metronidazole topical gel (Metrogel) sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion tacrolimus (Protopic) MDL tazarotene (Tazorac) PA tretinoin (Retin-A) MDL ANTI-INFECTIVES ALTABAX—retapamulin ciclopirox gel, shampoo (Loprox) ciclopirox solution (Penlac) clotrimazole clotrimazole/betamethasone econazole (Spectazole) ketoconazole (Nizoral) mupirocin ointment (Bactroban) naftifine HCL (Naftin) ST nystatin topical nystatin/triamcinolone oxiconazole (Oxistat) ST silver sulfadiazine (Silvadene) CORTICOSTEROIDS alclometasone (Aclovate) amcinonide cream (Cyclocort) betamethasone dipropionate (Diprosone) betamethasone dipropionate, augmented (Diprolene) betamethasone valerate cream, lotion clobetasol (Olux, Temovate)

29 UTILIZATION OTHER COVERAGE MANAGEMENT NOTES desonide (Desowen) desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort) diflorasone ointment fluocinolone acetonide oil (Derma-Smoothe/FS) fluocinonide fluticasone propionate (Cutivate) halobetasol (Ultravate) hydrocortisone butyrate hydrocortisone valerate (Westcort) hydrocortisone topical mometasone (Elocon) prednicarbate triamcinolone cream; lotion; ointment, 0.025%, 0.1% OTHER SKIN PRODUCTS 8-MOP—methoxsalen, capsule 10 mg aluminum chloride (Drysol) calcipotriene solution (Dovonex) diclofenac 1% gel (Voltaren) DRYSOL—aluminum chloride fluorouracil (Efudex) imiquimod (Aldara) lidocaine patches (Lidoderm) lidocaine topical (Xylocaine) lindane OXSORALEN ULTRA—methoxsalen permethrin podofilox (Condylox) selenium sulfide (Selsun) SORIATANE—acitretin, capsule 10 mg MDL

30 DRUGS WITH MANAGED DOSE LIMITATIONS (MDL)

The table below contains the list of drugs with managed dose limitations. Certain products are subject to managed drug limitations based on FDA-approved dosage recommendations and the drug manufacturer’s package size. The pupose of these limitations is to encourage safe and cost- effective use of drug therapies. MDL quantities may vary depending on plan design.

90-Day Supply Drug Class Drug Name 30-Day Supply (Mail Order) ACNE isotretinoin oral (Claravis™ and N/A maximum 6 months Amnesteem®) of treatment ANAPHYLACTIC epinephrine 4 auto-injectors 12 auto-injectors TREATMENTS Epipen® Epipen Jr® 2-Pak ASTHMA Arcapta Neohaler™ 30 caps 90 caps Asmanex® 1 inhaler 3 inhalers Flovent® HFA 24gm (2 inhalers) 72gm (6 inhalers) ProAir® 3 inhalers 9 inhalers QVAR™ 2 inhalers 6 inhalers Ventolin® HFA 3 inhalers 9 inhalers BEHAVIORAL amphetamine/dextroamphetamine ER HEALTH: 5mg, 10mg, 15mg (Adderall XR®) 30 capsules N/A ADHD amphetamine/dextroamphetamine ER 20mg, 25mg, 30mg (Adderall XR®) 60 capsules N/A amphetamine/dextroamphetamine IR (Adderall®) 90 tablets N/A atomoxetine 40mg, 60mg, 80mg, 100mg (Strattera®) 30 capsules N/A atomoxetine 10mg, 18mg, 25mg (Strattera®) 60 capsules N/A Daytrana® 30 patches N/A dexmethylphenidate ER (Focalin XR®) 30 capsules N/A dexmethylphenidate IR (Focalin®) 60 tablets N/A dextroamphetamine ER (Dexedrine®) 150 capsules N/A dextroamphetamine IR (Dexedrine®) 180 tablets N/A Focalin XR® 30 capsules N/A Metadate ER® 90 tablets N/A methylphenidate IR 2.5mg or 5mg (Methylin®) 90 tablets N/A methylphenidate IR 10mg (Methylin®) 180 tablets N/A methylphenidate CD (Metadate CD®) 30 capsules N/A methylphenidate LA (Ritalin LA®) 30 capsules N/A methylphenidate solution (Methylin®) 900mL N/A methylphenidate IR (Ritalin®) 90 tablets N/A methylphenidate ER (Ritalin SR®) 90 tablets N/A methylphenidate ER 18mg, 27mg, 54mg (Concerta®) 30 tablets N/A methylphenidate ER 36mg (Concerta®) 60 tablets N/A Quillichew® ER 20mg, 40mg 30 tablets N/A Quillichew® ER 30mg 60 tablets N/A Quillivant XRTM 180mL N/A Ritalin LA® 30 capsules N/A Vyvanse® 30 capsules N/A Zenzedi® 60 tablets N/A 31 continued on next page 90-Day Supply Drug Class Drug Name 30-Day Supply (Mail Order) BEHAVIORAL aripiprazole 30 tablets 90 tablets HEALTH: paliperidone ER Antipsychotics quetiapine ER CARDIOVASCULAR: phenoxybenzamine 14 capsules2 42 capsules2 Miscellaneous Agents DERMATOLOGY1 Aczone® (dapsone) smallest package size N/A Azelex® (azelaic acid) Elidel® (pimecrolimus) Finacea® (azelaic acid) Mirvaso® (brimonidine) Picato® (ingenol mebutate) Rhofade™ (oxymetazoline) Soolantra® (ivermectin) tacrolimus tazarotene Tazorac® (tazarotene) tretinoin DIABETES: Janumet® XR 50-500mg/ 100-1000mg, 30 tablets 90 tablets DPP4 (Dipeptidyl/ Januvia®, Jentadueto® XR 5-1000mg, Peptidase IV) KombiglyzeTM XR 5-500mg/ 5-1000mg NesinaTM, OnglyzaTM, OseniTM, Tradjenta® Janumet®, Janumet® XR 50-1000mg, 60 tablets 180 tablets Jentadueto®, Jentadueto® XR 2.5-1000mg, KazanoTM, KombiglyzeTM XR 2.5-1000mg DIABETES: AdlyxinTM, Bydureon®, Bydureon® 1 box 3 boxes GLP-1 (Glucagon-like BCiseTM, Byetta®, Ozempic®, TrulicityTM, -1) Victoza® DIABETES: insulin vials 60ml (6 vials) 180ml (18 vials) Insulin insulin pens 4 boxes 12 boxes DIABETES: FarxigaTM, Invokana®, Jardiance®, 30 tablets 90 tablets SGLT-2 (Sodium Steglatro™, Xigduo® XR 5-500mg/ 10- glucose co-transporter 500mg/ 10-1000mg 2 inhibitor) Invokamet®, Invokamet® XR, 60 tablets 180 tablets Segluromet™, Synjardy®, Xigduo® XR 5-1000mg DIABETES: Glyxambi®, Qtern®, Steglujan™ 30 tablets 90 tablets SGLT-2/DPP4 Combination Products DIABETES: blood glucose test strips 150 test strips 450 test strips Testing Supplies ENDOCRINE: Caverject®/Edex®/Muse® 4 units3 12 units3 Impotency Cialis® 4 tablets3 12 tablets3 Levitra® 4 tablets3 12 tablets3 StaxynTM 4 tablets3 12 tablets3 StendraTM 4 tablets3 12 tablets3 Viagra® 4 tablets3 12 tablets3 GASTROINTESTINAL: TrulanceTM 30 tablets 90 tablets Chronic Idiopathic GASTROINTESTINAL: Akynzeo® 3 capsules4 9 capsules4 Emesis Emend® 6 tablets 18 tablets Sancuso® 1 patch 3 patches VarubiTM 2 tablets/28 days 6 tablets/84 days GASTROINTESTINAL: Movantik® 30 tablets 90 tablets Opioid Induced Symproic® Constipation

32 continued on next page 90-Day Supply Drug Class Drug Name 30-Day Supply (Mail Order) HEMATOLOGICAL Bevyxxa® 43 capsules/42 days N/A DISORDER: Thrombin Inhibitors INFECTIOUS SivextroTM 6 tablets N/A DISEASE: Antibacterial INFECTIOUS Incivek® 180 tablets N/A DISEASE: Victrelis® 360 tablets N/A Hepatitis C LOWER GI Amitiza® 60 capsules 180 capsules DISORDERS: Irritable LinzessTM 30 capsules 90 capsules Bowel Syndrome INFECTIOUS Relenza® 1 rx/6 months, max N/A DISEASE: quant 20 doses Influenza oseltamivir 1 rx/6 months, max N/A Tamiflu® quant 10 caps LOWER GI Amitiza® 60 capsules 180 capsules DISORDERS: Irritable LinzessTM 30 capsules 90 capsules Bowel Syndrome NEUROLOGY: AimovigTM 1 dose 3 doses Migraine almotriptan, frovatriptan, naratriptan, 9 tablets 27 tablets Relpax®, sumatriptan - tablets, zolmitriptan - tablets/ODT tablets Migranal® 8 units 24 units rizatriptan 12 tablets 36 tablets sumatriptan - injectable 2 kits (4 injections) 6 kits (12 injections) sumatriptan - nasal 6 nasal spray devices 18 nasal spray devices NEUROLOGY: armodafinil 30 tablets 90 tablets Narcolepsy modafinil 30 tablets 90 tablets PAIN AVINza®, Embeda®, hydromorphone 60 tablets N/A MANAGEMENT ER, morphine sulfate ER (Kadian®), Nucynta® ER, Opana® ER, Oxycontin®, tramadol ER tablets, Xtampza™ ER Belbuca™ 60 films N/A Butrans® 4 patches N/A fentanyl patch 15 patches N/A ketorolac tromethamine 20 tablets N/A morphine sulfate ER 30mg 90 tablets N/A Nucynta® 120 tablets N/A Sprix® nasal spray 5 nasal spray units N/A ZohydroTM ER 60 capsules N/A UPPER GI Nexium® 24HR OTC 120 capsules 360 capsules DISORDERS: Anti-ulcer preparation

Please Note: This applies to most Health Alliance plans. If you have questions, please contact the Pharmacy Department at 1-800-851-3379, option 4.

1 This is a partial list of products. Any antibacterial, , antiviral, steroid or acne product that is available in multiple package sizes is restricted to coverage of only the smallest package size. 2 See Managed Dose Limit section of phenoxybenzamine policy 3 Product excluded on some plans. Quantity may vary depending on plan setup: Iowa State = 6/12 Horizon = 6/12 Federal = 6/12 4 3 capsules per 28 days, 9 capsules per 84 days

33 ph-MDLdrugs-0918 DRUGS REQUIRING PREAUTHORIZATION

The table below outlines the medications requiring a review by the Clinical Pharmacist, and if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug designated as preauthorization required (PA), they must provide documentation to meet criteria for that particular medication. Provider must request prior authorization from Health Alliance for drugs on the following list:

Drug Class Drug Name Comments ASTHMA/ COPD Advair® (fluticasone-salmeterol) See Non-Preferred ICS/LABA Combination Breo™ Ellipta® (fluticasone-vilanterol) Inhalers policy Arnuity™ Ellipta® (fluticasone- See Non-Preferred ICS Inhalers policy salmeterol) ArmonAir™ RespiClick® (fluticasone propionate) Daliresp® () See Daliresp policy

BEHAVIORAL Dyanavel™ XR (amphetamine Member aged 6 to 12; documentation of HEALTH: suspension) inability to swallow tablets for members ADHD Quillichew® ER (methylphenidate ER) older than 12 Quillivant XR® (methylphenidate suspension) Vyvanse® chewable (lisdexamfetamine) BEHAVIORAL desvenlafaxine ER See Behavioral Health policy; HEALTH: Fetzima™ (levomilnacipran ER) one Tier 1 SSRI AND one Tier 1 SNRI Antidepressants Khedezla™ (desvenlafaxine ER) (duloxetine and venlafaxine/venlafaxine ER) Pristiq® (desvenlafaxine) AND one additional Tier 1 antidepressant Trintellix® (vortioxetine) Viibryd® (vilazodone) BEHAVIORAL Rexulti® (brexpiprazole) See Behavioral Health policy; HEALTH: as adjunct therapy for Major Depressive Atypical Disorder: documented failure of aripiprazole Antipsychotics or quetiapine ER used in combination with an antidepressant for a period of at least 3 months; for Bipolar Disorder and Schizophrenia: TWO of the following: aripiprazole, olanzapine, paliperidone ER, quetiapine, quetiapine ER, risperidone or ziprasidone Fanapt® (iloperidone) See Behavioral Health policy; Latuda® (lurasidone) for Bipolar Disorder and Schizophrenia: Saphris® (asenapine) TWO of the following: aripiprazole, Vraylar™ (cariprazine) olanzapine, paliperidone ER, quetiapine, quetiapine ER, risperidone or ziprasidone

continued on next page 34 Drug Class Drug Name Comments BEHAVIORAL Nuplazid™ See Nuplazid policy HEALTH: Parkinson’s Disease Psychosis CARDIOVASCULAR: Entresto™ (/valsartan) See Entresto policy ARNI CARDIOVASCULAR: omega-3-acid ethyl esters See Fish Oil (Lovaza and Vascepa) policy Lipotropics Vascepa® (icosapent ethyl) CARDIOVASCULAR: phenoxybenzamine See phenoxybenzamine policy Miscellaneous Agents CARDIOVASCULAR: Altoprev® (lovastatin ER) See Brand Name Statin policy Statins Lescol® XL (fluvastatin) Livalo® (pitavastatin) Zypitamag™ (pitavastatin) CENTRAL NERVOUS Qudexy™ XR (topiramate ER) See Qudexy XR and Trokendi policy SYSTEM: Trokendi™ XR (topiramate ER) DERMATOLOGY: Aczone® (dapsone) Documentation of acne vulgaris; trial of two Miscellaneous Agents Azelex® (azelaic acid) Tier 1 agents Picato® (ingenol mebutate) Documentation of a non-cosmetic diagnosis tazarotene (acne, actinic keratosis, etc.); trial of two Tier Tazorac® (tazarotene) 1 agents Eucrisa® (crisaborole) Documentation of mild to moderate atopic dermatitis; trial of topical corticosteroid; trial of tacrolimus ointment or Elidel Finacea® (azelaic acid) Documentation of rosacea; trial of doxycline Mirvaso® (brimonidine) and metronidazole cream, gel or lotion Rhofade™ (oxymetazoline) Soolantra® (ivermectin) DIABETES: alogliptin See Diabetes Drug Therapies policy DPP4 (Dipeptidyl/ alogliptin/ pioglitazone Peptidase IV) alogliptin/ metformin Kazano™ (alogliptin/ metformin) Kombiglyze™ (saxagliptin/ metformin) Kombiglyze™ XR (saxagliptin- metformin ER) Nesina™ (alogliptin) Onglyza® (saxagliptin) Oseni™ (alogliptin/ pioglitazone) DIABETES: Adlyxin™ () See Diabetes Drug Therapies policy GLP-1 (Glucagon-like Bydureon® (exenatide) peptide-1) Bydureon® BCise (exenatide multidose) Byetta® (exenatide) Ozempic® () Trulicity™ (dulaglutide) Victoza® (liraglutide) DIABETES: Soliqua™ (insulin glargine and See Diabetes Drug Therapies policy Long-Acting Insulin/ lixisenatide) GLP-1 (Glucagon- Xultophy® ( and like peptide-1) liraglutide) Combination Products DIABETES, MISC. Regranex® (becaplermin) Diagnosis of diabetic ulcers with failure on conventional therapy (dressings, soaks, debridement, etc.)

continued on next page 35 Drug Class Drug Name Comments DIABETES: Farxiga™ (dapagliflozin) See Diabetes Drug Therapies policy SGLT-2 (Sodium Xigduo™ XR (dapagliflozin/metformin) glucose co-transporter Segluromet™ (ertugliflozin/metformin) 2 inhibitor) Steglatro™ (ertugliflozin) DIABETES: Glyxambi® (empagliflozin/linagliptin) See Diabetes Drug Therapies policy SGLT-2/DPP4 Qtern® (dapagliflozin/saxagliptin) Combination Products Steglujan™ (ertugliflozin/sitagliptin) ENDOCRINE: Veltassa® (patiromer) See Veltassa policy Potassium Binders ENDOCRINE: All testosterone and testosterone- Use in females requires prior authorization; Testosterone containing medications see Testosterone (Implantable, Topical, Oral, Replacement Therapy and Nasal) policy ENDOCRINE: Androderm® (testosterone transdermal) See Testosterone (Implantable, Topical, Oral, Testosterone Androgel® (testosterone gel) and Nasal) policy Replacement Axiron® (testosterone topical) Fortesta® (testosterone gel) Natesto™ (testosterone nasal) Striant® (testosterone buccal) Testim® (testosterone gel) ENDOCRINE: doxercalciferol See doxercalciferol policy Vitamin D Analogs GOUT AGENTS Duzallo® (lesinurad/allopurinol) See Zurampic and Duzallo policy Zurampic® (lesinurad)

HEMATOLOGICAL Mircera® (methoxy polyethylene glycol- PA required for oncology indication DISORDER epoetin beta)

INFECTIOUS Xifaxan® (rifaximin) See Xifaxan policy DISEASE: Antibacterial, Misc LOWER GI Relistor® (methylnaltrexone) See Relistor policy for opioid induced DISORDERS: constipation Narcotic antagonists LOWER GI Fulyzaq™ (crofelemer) See Fulyzaq policy DISORDERS: other NEUROLOGY: Botox® (onabotulinumtoxinA) See Botox policy Botulinum toxins Myobloc® (rimabotulinumtoxinB) See Myobloc policy Xeomin® (incoboluminumtoxinA) See Xeomin policy NEUROLOGY: Savella® (milnacipran) Trial of TCA, muscle relaxant, gabapentin, Fibromyalgia agents duloxetine, and non-pharmacologic therapy

NEUROLOGY: Gralise® (gabapentin ER) See Gabapentin Coverage Requirement GABA analogs Horizant® (gabapentin ER) policy; FDA label diagnosis specific to product, and trial of Gabapentin NEUROLOGY: AimovigTM (erenumab-aooe) See Aimovig policy

continued on next page 36 Drug Class Drug Name Comments ONCOLOGY capecitabine PA follows NCCN Oncology Pathways cyclophosphamide guidance Emcyt® (estramustine) etoposide oral Fareston® (toremifene) flutamide Hexalen® (altretamine) Leukeran™ (chlorambucil) Lysodren™ (mitotane) melphalan topotecan tretinoin PAIN Abstral® (fentanyl sublingual tablet) See Fentanyl® Oral Dosage Formulation MANAGEMENT: fentanyl citrate lozenge policy; limited to cancer diagnosis and Analgesics, Narcotics Fentora® (fentanyl citrate) inability to swallow and concurrent long Onsolis® (fentalyl buccal film) acting agent requiring breakthrough agent Subsys® (fentanyl sublingual spray) UPPER GI Dexilant® (dexlansoprazole) See PPI policy; trial of three generic PPIs DISORDERS: and Nexium® 24HR OTC (at least 14 days in Anti-ulcer preparations duration) in addition to qualifying diagnosis

Note: This is an incomplete list. Products with one year or less from the date of product launch are excluded from coverage.

Please Note: This applies to most Health Alliance plans. If you have questions, please contact the Pharmacy Department at 1-800-851-3379, option 4. ph-preauthdrugs-0818 37 DRUGS REQUIRING STEP-THERAPY

Step-Therapy (ST) If a drug is covered as a “step-therapy” medication, one or more “prerequisite” medications must be tried first before the step-therapy medication will be covered under the pharmacy benefit. Prerequisite medications and their corresponding step-therapy medications are used to treat the same conditions. If it is medically necessary, a step-therapy medication can be obtained without trying a prerequisite medication first. In this case, the member’s physician must request coverage for a step-therapy medication as a medical exception.

Step-Therapy (ST) Drug Class Medication Prerequisite Medication BEHAVIORAL HEALTH alprazolam ODT alprazolam tablet Anti-anxiety BEHAVIORAL HEALTH Aplenzin® (bupropion) bupropion Antidepressants NDRI BEHAVIORAL HEALTH Oleptro™ (trazodone) trazodone Antidepressants SARI BEHAVIORAL HEALTH olanzapine/ fluoxetine olanzapine and fluoxetine Atypical Antipsychotics CENTRAL NERVOUS SYSTEM Aptiom® (eslicarbazepine acetate) oxcarbazepine Briviact®, Spritam® ODT levetiracetam solution, tablets or capsules CARDIOVASCULAR olmesartan candesartan, irbesartan, losartan, Angiotensin Receptor Blockers olmesartan/amlodipine telmisartan or valsartan (ARBs) olmesartan/amlodipine/ hydrochlorothiazide olmesartan/hydrochlorothiazide CARDIOVASCULAR Corlanor® (ivabradine) Tier 1 ACE-I or ARB, AND Tier 1 beta Miscellaneous Agents blocker

COPD (Chronic Obstructive Anoro™ Ellipta™ Incruse Ellipta®, Serevent®, Spiriva ® , Pulmonary Disease) (umeclidinium/ vilanterol) Striverdi® or Tudorza® Bevespi Aerosphere™ (glycopyrrolate/ formoterol fumarate) Stiolto™ Respimat® (tiotropium bromide/olodaterol) Utibron™ Neohaler® (indacaterol/ glycopyrrolate) DERMATOLOGY Denavir® (penciclovir) acyclovir Topical anti-infective All brand name topical anti-fungal Tier 1 generic topical antifungal DERMATOLOGY Flector® patch (diclofenac) diclofenac 1% gel Topical anti-inflammatory DERMATOLOGY Eurax® (crotamiton) two prescription fills of permethrin Other

38 continued on next page Step-Therapy (ST) Drug Class Medication Prerequisite Medication DIABETES Admelog® (insulin lispro) Humalog® (insulin lispro) Insulin NovoLIN® N (insulin NPH) HumuLIN® N (insulin NPH) NovoLIN® R (insulin regular) HumuLIN® R (insulin regular) NovoLIN® 70/30 (insulin NPH/ HumuLIN® 70/30 (insulin NPH/ insulin regular) insulin regular) NovoLog® () Humalog® (insulin lispro) NovoLog® 70/30 (insulin aspart Humalog® Mix, any strength (insulin protamine/insulin aspart) lispro protamine/insulin lispro) DIABETES Avandia® (rosiglitazone) metformin or a sulfonylurea TZDs (Thiazolidinedione) Avandaryl® (glimepiride, chlorpropamide, Avandamet® glipizide, glyburide, tolbutamide, tolazamide) DIABETES Janumet® (sitagliptin/ metformin) metformin or a sulfonylurea DPP4 (Dipeptidyl/Peptidase IV) Janumet® XR (sitagliptin/ (glimepiride, chlorpropamide, metformin ER) glipizide, glyburide, tolbutamide, Januvia® (sitagliptin) tolazamide) Jentadueto® (linagliptin/ metformin) Jentadueto® XR (linagliptin/ metformin ER) Tradjenta® (linagliptin) DIABETES Juvisync™ (simvastatin/ metformin or a sulfonylurea AND DPP4 (Dipeptidyl/Peptidase IV) sitagliptin) Tradjenta, Jentadueto, Jentadueto XR, Nesina, Oseni, or Kazano DIABETES Invokana® (canagliflozin) metformin or a sulfonylurea SGLT-2 (Sodium glucose co- Invokamet® (canagliflozin/ (glimepiride, chlorpropamide, transporter 2 inhibitor) metformin) glipizide, glyburide, tolbutamide, Invokamet® XR (canagliflozin/ tolazamide) metformin ER) Jardiance® (empagliflozin) Synjardy® (empagliflozin- metformin) DIABETES Glyxambi® (empagliflozin/ Invokana, Invokamet or Invokamet SGLT-2/DPP4 (Sodium glucose co- linagliptin) XR transporter 2 inhibitor/Dipeptidyl/ Peptidase IV) ENDOCRINE Binosto™ (alendronate) alendronate or ibandronate risedronate HEMATOLOGICAL DISORDER Effient® (prasugrel) New start prescriptions are restricted Anti-Platelet to cardiologists Plavix® (clopidogrel) clopidogrel Zontivity™ (vorapaxar) HEMATOLOGICAL DISORDER Savaysa™ (edoxaban) Eliquis® and Xarelto® Thrombin Inhibitors HYPERPARATHYROID AGENT paricalcitol calcitriol or Vitamin D

39 continued on next page Step-Therapy (ST) Drug Class Medication Prerequisite Medication INFECTIOUS DISEASE Dificid® (fidaxomicin) metronidazole or vancomycin Antibiotic INFECTIOUS DISEASE Tybost® (cobicistat) Requires concurrent treatment Antiviral with Reyataz® or Prezista® PAIN MANAGEMENT Avinza® (morphine ER) morphine sulfate ER or fentanyl Long Acting Opioid Embeda® (morphine/ naltrexone) hydromorphone ER Hysingla® ER (hydrocodone ER) morphine sulfate ER (Kadian®) Nucynta® ER (tapentadol ER) Opana® ER (oxymorphone ER) Oxycontin® (oxycodone) Xartemis™ XR (oxycodone/ acetaminophen) Xtampza™ ER (oxycodone) Zohydro™ ER (hydrocodone ER) PAIN MANAGEMENT Nucynta® (tapentadol) Tier 1 opioid Short Acting Opioid Ryzolt® (tramadol ER) tramadol IR tramadol ER tablets SKELETAL MUSCLE DISORDER cyclobenzaprine 7.5mg cyclobenzaprine 5mg or 10mg URINARY TRACT Cialis® (tadalafil) once daily tamsulosin, alfuzosin, Rapaflo®, BPH (Benign Prostatic Hypertrophy) finasteride, dutasteride or dutasteride/tamsulosin

ph-stdruglistMEMB-0818 40 WELLNESS MEDICATIONS Health Alliance emphasizes prevention through comprehensive wellness coverage, which includes these preventive health medications. All listed medications are covered at a $0 copay.

FAMILY PLANNING GILDESS 1/20 MONONESSA BIRTH CONTROL GILDESS FE 1.5/30 MYZILRA ALTAVERA GILDESS FE 1/20 NECON 0.5/35-28 ALYACEN 1/35 HEATHER NECON 1/35 ALYACEN 7/7/7 INTROVALE NECON 7/7/7 AMETHIA JENCYCLA NORA-BE AMETHIA LO JEVANTIQUE LO NORETHINDRONE APRI JINTELI /ETHINYL ESTRADIOL ARANELLE JOLESSA JOLIVETTE NORELGESTROMIN/ETHINYL AUBRA ESTRADIOL PATCH JUNEL 1.5/30 AVIANE NORGESTREL/ETHINYL AZURETTE JUNEL 1/20 ESTRADIOL BALZIVA JUNEL FE 1.5/30 NORTREL 0.5/35 (28) BRIELLYN JUNEL FE 1/20 NORTREL 1/35 CAMILA KARIVA NORTREL 1/35 (28) CAMRESE KELNOR 1/35 NORTREL 7/7/7 CAMRESE LO KURVELO NUVARING CAZIANT LARIN 1/20 OCELLA CESIA LARIN FE 1.5/30 ORSYTHIA CHATEAL LARIN FE 1/20 PHILITH CRYSELLE-28 LEENA PIMTREA CYCLAFEM 1/35 LESSINA PIRMELLA 1/35 CYCLAFEM 7/7/7 LESSINA-28 PIRMELLA 7/7/7 DASETTA 1/35 LEVONEST PORTIA-28 DASETTA 7/7/7 LEVONORGESTREL (PLAN B) PREVIFEM DAYSEE LEVONORGESTREL/ETHINYL QUASENSE ESTRADIOL DESOGESTREL/ETHINYL RECLIPSEN LEVORA 0.15/30-28 ESTRADIOL SOLIA LOPREEZA DROSPIRENONE/ETHINYL SPRINTEC 28 ESTRADIOL LORYNA SRONYX ELINEST LOW-OGESTREL SYEDA ELLA LUTERA TILIA FE EMOQUETTE LYZA TRI-ESTARYLLA ENPRESSE-28 MARLISSA TRI-LEGEST FE ENSKYCE MEDROXYPROGESTERONE TRI-LINYAH ERRIN (DEPO-PROVERA) TRI-LO-SPRINTEC ESTARYLLA MICROGESTIN 1.5/30 TRINESSA FALMINA MICROGESTIN 1/20 TRI-PREVIFEM FYAVOLV MICROGESTIN FE TRI-SPRINTEC GIANVI MICROGESTIN FE 1.5/30 TRIVORA-28 GILDAGIA MIMVEY VELIVET GILDESS 1.5/30 MIMVEY LO MONO-LINYAH VESTURA 41 continued on next page VIORELE BOWEL PREP KITS* Nicotine Replacement Patches† ® VYFEMLA PEG-3350/Electrolytes Nicotrol Inhaler† ® WERA PEG-3350/NaCl/Na Bicarbonate/KCl Nicotrol Nasal Spray† WYMZYA FE BREAST CANCER RISK OVER-THE-COUNTER XULANE REDUCTION ANALGESICS - NON NARCOTIC ZARAH Raloxifene Aspirin Tablet 81 MG ZENCHENT Tamoxifen 10 MG Aspirin Tablet 162 MG ZENCHENT FE Tamoxifen 20 MG Aspirin Tablet 325 MG ZEOSA SMOKING CESSATION Aspirin Buffered (Ca Carb-Mg Carb- ZOVIA 1/35E Mg Ox) Tablet 325 MG Bupropion Hydrochloride (Zyban®)† OVER-THE-COUNTER Aspirin-Al Hydro-Mg Hydro-Ca Carb Chantix®†† Tablet 325-50-50-87 MG Condoms - Female Nicotine Replacement Gum† Children’s Chewable Aspirin 81 MG Condoms - Male Nicotine Replacement Lozenges† VITAMINS, MINERALS & Nonoxynol Spermicide ELECTROLYTES Octoxynol Spermicide Dialyvite Vitamin D Capsule 5000 Units *Covered for patients ages 50 to 75; limit 1 kit per year. Dialyvite Vitamin D3 Max Capsule †Limit 3 months per 180 days. 50,000 Units ††Limit 6 months per 365 days. Folic Acid Capsule 0.8 MG Folic Acid Tablet 400 & 800 MCG Vitamin D 400, 1000, 2000, 5000, & 10,000 Units

ph-wellnessmeds-1017 42 INDEX amoxicillin/potassium clavulanate ER (Augmentin XR) ...... 6 5 amphetamine/detroamphetamine (Adderall) ...... 10 amphetamine/detroamphetamine ER (Adderall XR) ...... 10 5-AMINOSALICYLIC ACID ...... 12 ampicillin ...... 6 AMTURNIDE...... 18 8 anagrelide (Agrylin) ...... 8 ANALPRAM E...... 26 8-MOP ...... 30 anastrozole (Arimidex)...... 8 ANDROGEL ...... 20 A ANZEMET ...... 12 apraclonidine (Iopidine) ...... 27 abacavir (Ziagen) ...... 7 APRISO ...... 12 abacavir-lamivudine (Epzicom) ...... 7 APTIVUS ...... 7 acamprosate ER ...... 10 aripiprazole (Abilify) ...... 11 acarbose (Precose) ...... 18 armodafinil (Nuvigil) ...... 10 acebutolol (Sectral) ...... 15 ARMOUR THYROID ...... 21 acetaminophen/codeine ...... 23 ASMANEX ...... 25 acetaminophen/isometheptene/dichloralphenazone (Midrin).. 23 aspirin/dipyridamole (Aggrenox) ...... 8 acetazolamide (Diamox) ...... 17 atenolol (Tenormin) ...... 15 acetazolamide ER (Diamox Sequels) ...... 17 atenolol/chlorthalidone (Tenoretic) ...... 15 acetic acid ear solution ...... 27 atorvastatin (Lipitor) ...... 16 acyclovir (Zovirax) ...... 6 atovaquone/proguanil 250-100 mg (Malarone) ...... 7 adefovir (Hepsara) ...... 6 atropine sulfate eye ointment, solution (Isopto Atropine) ...... 28 ainocycline (Minocin) ...... 6 ATROVENT HFA...... 25 albuterol ...... 25 AUBAGIO ...... 21 albuterol inhaler solution...... 25 AVONEX...... 21 albuterol syrup, tablets ...... 25 azathioprine (Imuran) ...... 7 alclometasone (Aclovate) ...... 29 azelastine (Astelin, Astepro) ...... 26 alendronate tablets (Fosamax) ...... 20 azelastine eye solution (Optivar) ...... 28 alfuzosin (Uroxatral) ...... 13 azithromycin (Zithromax) ...... 5 allopurinol (Zyloprim) ...... 23 almotriptan (Axert) ...... 23 ALOMIDE...... 28 B ALORA ...... 20 baclofen (Lioresal)...... 22 alosetron (Lotronex) ...... 12 balsalazide (Colazal) ...... 12 ALPHAGAN P ...... 27 benazepril (Lotensin) ...... 14 alprazolam (Xanax) ...... 9 benazepril/hydrochlorothiazide (Lotensin HCT) ...... 14 alprazolam ODT (Niravam) ...... 9 benzocaine/antipyrine ear solution ...... 27 ALTABAX...... 29 benztropine (Cogentin) ...... 22 aluminum chloride (Drysol) ...... 30 betamethasone dipropionate (Diprosone) ...... 29 amantadine (Symmetrel) ...... 22 betamethasone dipropionate, augmented (Diprolene) ...... 29 amiloride (Midamor) ...... 17 betamethasone valerate cream, lotion ...... 29 amiloride/hydrochlorothiazide (Moduretic) ...... 17 BETASERON ...... 21 amiodarone (Cordarone, Pacerone) ...... 17 betaxolol HCl (Betoptic)...... 15 AMITIZA ...... 12 bethanecol (Urecholine) ...... 14 amitriptyline ...... 9 BETOPTIC-S ...... 27 amlodipine (Norvasc) ...... 16 bicalutamide (Casodex)...... 8 amlodipine/benazepril (Lotrel) ...... 16 bisoprolol (Zebeta) ...... 15 amlodipine/valsartan (Azor) ...... 15 bisoprolol/hydrochlorothiazide (Ziac) ...... 15 amlodipine/valsartan (Exforge) ...... 15 BLEPHAMIDE S.O.P...... 28 amoxicillin (Amoxil)...... 6 BRILINTA ...... 8 amoxicillin/potassium clavulanate (Augmentin) ...... 6 brimonidine eye solution, 0.15% (Alphagan P) ...... 27

43 brimonidine eye solution, 0.2%...... 27 chlordiazepoxide HCl/clidinium bromide (Librax) ...... 13 bromocriptine (Parlodel) ...... 22 chlorhexidine oral rinse (Peridex) ...... 29 budesonide (Pulmicort Respules) ...... 25 chloroquine phosphate (Aralen) ...... 7 budesonide (Rhinocort) ...... 26 chlorpromazine (Thorazaine)...... 11 bumetanide (Bumex) ...... 17 chlorthalidone 25 mg, 50 mg (Thalitone) ...... 17 buprenorphine (Subutex) ...... 23 chlorzoxazone (Parafon) ...... 22 bupropion (Wellbutrin) ...... 9 cholestyramine (Questran, Questran Light) ...... 16 bupropion ER (Zyban) ...... 10, 12 CIALIS ...... 17 bupropion ext-release (Wellbutrin SR, Wellbutrin XL) ...... 9 CIALIS ONCE DAILY ...... 13 buspirone (Buspar) ...... 9 ciclopirox gel, shampoo (Loprox) ...... 29 butalbital/acetaminophen ...... 24 ciclopirox solution (Penlac) ...... 29 butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet) cilostazol (Pletal) ...... 8 ...... 24 cimetidine (cimetidine) ...... 13 butalbital/aspirin/caffeine (Fiorinal) ...... 24 CIPRO SUSPENSION...... 5 butalbital/aspirin/caffeine/codeine ...... 23 ciprofloxacin (Cipro) ...... 5 BYDUREON ...... 18 citalopram (Celexa) ...... 9 BYDUREON BCISE ...... 18 clarithromycin (Biaxin) ...... 5 BYETTA ...... 18 clarithromycin ER (Biaxin XL) ...... 5 BYSTOLIC ...... 15 CLEOCIN ...... 14 clindamycin (Cleocin) ...... 5 C clindamycin vaginal cream (Cleocin) ...... 14 clobetasolution (Olux, Temovate) ...... 29 cabergoline (Dostinex) ...... 20 clomiphene (Clomid) ...... 20 calcipotriene solution (Dovonex) ...... 30 clomipramine (Anafranil) ...... 9 calcitonin-salmon (Miacalcin) ...... 21 clonazepam (Klonopin) ...... 22 calcitriol (Rocaltrol) ...... 21 clonidine (Catapres, Catapres-TTS) ...... 17 calcium acetate ...... 12 clonidine hcl ER ...... 10 CANASA ...... 12 clopidogrel (Plavix) ...... 8 candesartan (Atacand) ...... 15 clorazepate ...... 9 capecitabine (Xeloda) ...... 8 clotrimazole ...... 29 captopril (Capoten) ...... 14 clotrimazole troche (Mycelex Troche) ...... 29 captopril/hydrochlorothiazide (Capozide) ...... 14 clotrimazole/betamethasone ...... 29 CARAFATE SUSPENSION ...... 13 clozapine (Clozaril) ...... 11 carbamazepine (Tegretol) ...... 22 COARTEM ...... 7 carbamazepine ER (Carbatrol, Tegretol-XR) ...... 22 COLCRYS ...... 23 carbidopa/levodopa (Parcopa, Sinemet) ...... 22 colestipol (Colestid) ...... 16 carbidopa/levodopa ER (Sinemet CR) ...... 22 COMBIVENT...... 25 CARDURA XL ...... 13 COPAXONE ...... 21 carteolol eye solution (Ocupress) ...... 27 CORTIFOAM ...... 26 carvedilol (Coreg) ...... 15 COUMADIN...... 8 CAVERJECT ...... 17 CREON ...... 12 CEENU ...... 8 CRIXIVAN ...... 7 cefadroxil (Duricef) ...... 5 cromolym sodium inhal solution (Intal) ...... 25 cefdinir (Omnicef) ...... 5 cromolyn sodium (Gastrocrom Oral) ...... 12 cefixime (Suprax) ...... 5 cyanocobalmin injection ...... 8 cefpodoxime (Vantin) ...... 5 cyclobenzaprine (Fexmid) ...... 22 cefprozil (Cefzil) ...... 5 cyclobenzaprine (Flexeril) ...... 22 cefuroxime (Ceftin) ...... 5 CYCLOGYL ...... 28 celecoxib (Celebrex) ...... 24 CYCLOMYDRIL ...... 28 cephalexin (Keflex) ...... 5 cyclopentolate eye solution (Cyclogyl) ...... 28 cevimelene (Evoxac) ...... 29 cyclophosphamide ...... 8 Chantix ...... 12 cyclosporine (Sandimmune) ...... 7 CHANTIX ...... 10 cyclosporine modified capsules ...... 7 chlordiazepoxide ...... 9

44 D dutasteride/tamsulosin (Jalyn) ...... 13 danazol (Danocrine) ...... 20 E dantrolene (Dantrium) ...... 22 darifenacin hydrobromide ER (Enablex) ...... 14 E.E.S. GRANULES ...... 5 DELZICOL ...... 12 econazole (Spectazole) ...... 29 desipramine (Norpramin) ...... 9 EDEX ...... 17 desloratadine (Clarinex) ...... 25 ELIQUIS ...... 8 desmopressin (DDVAP) ...... 21 EMCYT ...... 8 desonide (Desowen) ...... 30 EMEND ...... 12 desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort) EMSAM...... 10 ...... 30 EMSAM PATCHES ...... 9 DEXAMETHASONE INTENSOL ...... 18 EMTRIVA ...... 7 dexmethylphenidate (Focalin)...... 10 enalapril (Vasotec) ...... 14 dexmethylphenidate ER (Focalin XR) ...... 10 enalapril/hydrochlorothiazide (Vaseretic)...... 14 dextroamphetamine ...... 10 ENBREL ...... 7 dextroamphetamine ER (Dexedrine Spansule) ...... 10 ENDOMETRIN ...... 14 diazepam (Valium) ...... 9 enoxaparin (Lovenox) ...... 8 diclofenac 1% gel (Voltaren) ...... 30 entacapone (Comtan) ...... 22 diclofenac eye solution (Voltaren) ...... 28 entecavir (Baraclude) ...... 6 diclofenac potassium (Cataflam) ...... 24 EPCLUSA ...... 6 diclofenac sodium DR (Voltaren) ...... 24 epinastine HCL eye solution (Elestat) ...... 28 diclofenac sodium ER (Voltaren-XR) ...... 24 EPINEPHRINE ...... 26 diclofenac sodium/misoprostol (Arthrotec) ...... 24 EPIPEN...... 26 dicloxacillin (Dicloxacillin) ...... 6 EPIPEN-JR 2-PAK ...... 26 dicyclomine (Bentyl) ...... 13 EPIVIR HBV ...... 5, 6 didanosine (Videx EC) ...... 7 eplerenone (Inspra)...... 18 diflorasone ointment ...... 30 eprosartan (Teveten) ...... 15 diflunisal (Dolobid) ...... 24 ergocalciferol (Drisdol)...... 26 digoxin (Lanoxin) ...... 17 ergotamine/caffeine (Migergot) ...... 23 DILATRATE SR ...... 16 erythromycin eye ointment ...... 27 DILAUDID-5 ...... 23 erythromycin gel, pads, solution ...... 29 diltiazem ER ...... 16 erythromycin/sulfisoxazole (Pediazole) ...... 5 diltizaem (Cardizem) ...... 16 escitalopram (Lexapro) ...... 9 DIPENTUM ...... 12 estazolam (Prosom) ...... 11 diphenoxylate/atropine tablets (Lomotil) ...... 12 estradiol (Climara, Estrace) ...... 20 dipyridamole (Persantine) ...... 8 estradiol patch (Vivelle Dot) ...... 20 disopyramide (Norpace) ...... 17 estradiol vaginal cream (Estrace) ...... 14 disulfiram (Antabuse) ...... 10 estradiol/norethindrone acetate (Activella) ...... 20 divalproex DR (Depakote Sprinkles, Depakote) ...... 22 ESTRING ...... 14 divalproex ER (Depakote ER)...... 22 estropiopate (Ogen, Ortho-Est) ...... 20 donepezil (Aricept, Aricept ODT) ...... 10 eszopiclone (Lunesta) ...... 11 dorzolamide eye solution (Trusopt)...... 27 ethambutol (Myambutol) ...... 6 dorzolamide/timolol maleate eye solution (Cosopt) ...... 27 ethosuximide (Zarontin)...... 23 doxazosin (Cardura)...... 17 etidronate (Didronal) ...... 21 doxepin (Sinequan) ...... 9 etodolac (Lodine) ...... 24 doxercalciferol (Hectoral) ...... 21 etodolac ER (Lodine XL) ...... 24 doxycycline hyclate (Vibramycin) ...... 6 etoposide (Toposar) ...... 8 dronabinol (Marinol) ...... 12 exemestane (Aromasin) ...... 8 DRYSOL ...... 30 EXFORGE HCT ...... 15 DULERA ...... 25 ezetimibe (Zetia) ...... 16 duloxetine (Cymbalta) ...... 9 ezetimibe/simvastatin (Vytorin) ...... 16 dutasteride (Avodart) ...... 13

45 F G famciclovir (Famvir) ...... 6 gabapentin (Neurontin) ...... 23 famotidine (Pepcid) ...... 13 galantamine (Razadyne) ...... 10 FARESTON ...... 8 galantamine ER (Razadyne ER) ...... 10 FARXIGA ...... 18 GALZIN ...... 26 FELBATOL ...... 23 gemfibrozil (Lopid)...... 16 felodipine ER (Plendil) ...... 16 gentamicin eye ointment, solution (Garamycin) ...... 27 FEMHRT LOW DOSE ...... 20 GLATOPA ...... 21 fenofibrate, micronized (Liofibra) ...... 16 glimepiride (Amaryl) ...... 18 fenofibric acid (Trilipix) ...... 16 glipizde (Glucotrol) ...... 18 fentanyl oral lozenge (Actiq) ...... 23 glipizde ER (Glucotrol XL) ...... 19 fentanyl patch (Duragesic) ...... 23 GLUCAGEN ...... 19 finasteride (Proscar) ...... 13 GLUCAGON EMERGENCY KIT ...... 19 FLAREX ...... 28 glyburide (Micronase) ...... 19 flavoxate (Urispas) ...... 14 glyburide micronized (Glynase) ...... 19 flecainide (Tambocor) ...... 17 glyburide/metformin (Glucovance) ...... 19 fluconazole (Diflucan) ...... 5 GLYXAMBI ...... 19 flucytosine (Ancoban) ...... 5 granisetron (Kytril) ...... 12 fludrocortisones (Florinef) ...... 18 GRASTEK ...... 26 flunisolide (Nasarel) ...... 26 GRIFULVIN V ...... 5 fluocinolone acetonide ear solution...... 27 griseofulvin microsize (Fulvicin, Grisfulvin)...... 5 fluocinonide ...... 30 GRIS-PEG ...... 5 fluorometholone eye suspenion, 0.1% (FML Liquifilm) ...... 28 guanfacine (Tenex) ...... 18 FLUOROQUINOLONES...... 5 guanfacine ER (Intuniv) ...... 10 fluorouracil (Efudex) ...... 30 fluoxetine (Prozac) ...... 9 H fluphenazine hcl tablets (Prolixin) ...... 11 flurazepam ...... 11 halobetasolution (Ultravate) ...... 30 flurbiprofen ...... 24 haloperidol (Haldol) ...... 11 flurbiprofen eye solution (Ocufen) ...... 28 HARVONI ...... 6 flutamide (Eulexin) ...... 8 HEXALEN ...... 8 fluticasone (Flonase) ...... 26 hlycopyrrolate (Robinul) ...... 13 fluticasone propionate (Cutivate) ...... 30 HUMALOG ...... 20 fluvastatin (Lescol) ...... 16 HUMIRA ...... 7 fluvastatin sodium ER (Lescol XL) ...... 16 HUMULIN ...... 20 fluvoxamine (Luvox) ...... 9 hydralazine (Apresolutionine) ...... 18 fluvoxamine ER (Luvox CR) ...... 9 hydrochlorothiazide (Microzide, Hydrodiuril) ...... 17 FML FORTE ...... 28 hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab, Norco) folic acid 1 mg tablets ...... 8 ...... 23 FOLLISTIM AQ ...... 20 hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) ..... 24 fondaparinux (Arixtra) ...... 8 hydrocortisone (Cortef) ...... 18 fosinopril (Monopril) ...... 14 hydrocortisone acetate ...... 26 FRAGMIN ...... 8 hydrocortisone butyrate ...... 30 FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM 20 hydrocortisone enema (Cortenema) ...... 27 FREESTYLE INSULINX BLOOD GLUCOSE SYST ...... 20 hydrocortisone topical ...... 30 FREESTYLE INSULINX TEST STRIPS ...... 20 hydrocortisone valerate (Westcort) ...... 30 FREESTYLE LITE BLOOD GLUCOSE MONITORING hydrocortisone/acetic acid ear solution ...... 27 SYSTEM ...... 20 hydrocortisone/lidocaine ...... 27 FREESTYLE LITE TEST STRIPS ...... 20 hydromorphone ER (Exalgo) ...... 24 frovatriptan (Frova) ...... 23 hydromorphone tablets (Dilaudid) ...... 24 furosemide (Lasix) ...... 17 hydroxychloroquine ...... 7 hydroxyurea (Hydrea) ...... 8 hydroxyzine (Atarax, Vistaril) ...... 9

46 hyoscyamine (Anaspaz, Levsin/SL) ...... 13 lactulose (Enulose) ...... 12 hyoscyamine ER (Levbid, Symax Duotab) ...... 13 lamivudine (Epivir)...... 7 lamivudine/zidovudine (Combivir) ...... 7 I lamotrigine (Lamictal) ...... 23 lamotrigine ODT (Lamictal ODT) ...... 23 ibandronate oral (Boniva) ...... 21 lansoprazole DR (Prevacid) ...... 13 ibuprofen (Motrin) ...... 24 lantanoprost eye solution (Xalatan) ...... 27 ILEVRO ...... 28 LANTUS ...... 19 imipramine hcl (Tofranil) ...... 9 LANTUS SOLOSTAR ...... 19 imiquimod (Aldara) ...... 30 LASTACAFT —alcaftadine ...... 28 indapamide (Lozol) ...... 17 LATUDA—lurasidone ...... 11 indomethacin (Indocin) ...... 24 leflunomide (Arava) ...... 24 indomethacin ER (Indocin XR) ...... 24 letrozole (Femara) ...... 8 INVIRASE ...... 7 leucovorin calcium tablets ...... 8 INVOKAMET ...... 19 LEUKERAN ...... 9 INVOKAMET XR ...... 19 levalbuterol hydrochloride (Xopenex) ...... 25 INVOKANA ...... 19 LEVEMIR ...... 19 ipratropium bromide (Atrovent) ...... 26 LEVEMIR FLEXTOUCH ...... 19 ipratropium bromide solution (Atrovent, Aerovent) ...... 25 levetiracetam (Keppra) ...... 23 ipratropium/albuterol (Duoneb) ...... 25 levobunolol eye solution, 0.5% (Betagan) ...... 27 irbesartan (Avapro)...... 15 levocetirizine (Xyzal) ...... 25 irbesartan/hydrochlorothiazide (Avalide) ...... 15 levofloxacin (Levaquin) ...... 5 ISENTRESS ...... 7 levonorgestrel (Plan B) ...... 18 isoniazid (Laniazid, Nydrazid) ...... 6 levothyroxine (Synthroid, Levoxyl) ...... 21 isoniazid/rifampin (Rifamate) ...... 6 lidocaine patches (Lidoderm) ...... 30 isosorbide dinitrate (Isordil) ...... 16 lidocaine topical (Xylocaine) ...... 30 isosorbide mononitrate (Monoket)...... 16 lidocaine viscous ...... 29 isosorbide mononitrate ER (Imdur) ...... 16 lindane ...... 30 itraconazole (Sporanox) ...... 5 LINZESS...... 12 liothyronine (Cytomel) ...... 21 J lisinopril ...... 14 lisinopril/hydrochlorothiazide (Prinizide)...... 14 JANUMET ...... 19 lithium carbonate ...... 11 JANUMET XR ...... 19 lithium carbonate ER (Lithobid, Eskalith CR) ...... 11 JANUVIA ...... 19 lorazepam (Ativan) ...... 9 JARDIANCE ...... 19 losartan (Cozaar)...... 15 JENTADUETO ...... 19 losartan/hydrochlorothiazide (Hyzaar) ...... 15 JENTADUETO XR ...... 19 lovastatin (Mevacor) ...... 16 loxapine (Loxitane) ...... 11 K LUMIFY...... 27 LUMIGAN ...... 27 KALETRA ...... 7 LYSODREN ...... 9 KAZANO ...... 19 ketoconazole (Nizoral) ...... 29 ketoconazole tablets (Nizoral) ...... 5 M ketoprofen (Oruvail) ...... 24 MACRODANTIN ...... 14 ketorolac eye solution (Acular, Acular LS) ...... 28 MAXAIR AUTOHALER ...... 25 ketorolac tromethamine (Toradol) ...... 24 meclizine (Antivert) ...... 12 KOMBIGLYZE ...... 19 medroxyprogesterone acetate (Provera) ...... 21 KOMBIGLYZE XR ...... 19 mefenamic acid (Ponstel) ...... 24 mefloquine (Larium) ...... 7 L megestrol (Megace) ...... 9 meloxicam (Mobic) ...... 24 labetalol (Trandate) ...... 15

47 melphalan (Alkeran) ...... 9 mycophenolate mofetil (Cellcept) ...... 8 memantine (Namenda) ...... 10 MYLERAN ...... 9 MENEST ...... 20 MYRBETRIQ...... 14 MENOSTAR ...... 20 meperidine (Demerol) ...... 24 N MEPRON ...... 6 mercaptopurine (Purinethol) ...... 9 nabumetone (Relafen) ...... 24 mesalamine (Rowasa) ...... 12 nadolol (Corgard) ...... 15 MESNEX ...... 9 naftifine HCL (Naftin) ...... 29 metaxalone (Skelaxin) ...... 22 naltrexone (ReVia) ...... 10 metformin (Glucophage) ...... 19 naproxen (Naprosyn) ...... 24 metformin ER (Glucophage XR) ...... 19 naproxen DR (EC-Naprosyn) ...... 25 methadone solution ...... 24 naproxen sodium (Anaprox) ...... 25 methadone tablets ...... 24 naratriptan (Amerge) ...... 23 methazolamide (Neprazane)...... 17 NASCOBAL ...... 26 methimazole (Tapaxzole) ...... 21 nateglinide (Starlix) ...... 19 methocarbamol (Robaxin) ...... 22 nefazodone (Serzone) ...... 10 methotrexate (Trexall) ...... 9 neomycin ...... 6 methscopolamine (Pamine, Pamine Forte) ...... 13 neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment methyldopa (Aldomet) ...... 18 ...... 28 METHYLIN ...... 10 neomycin/polymyxin B/dexamethasone eye ointment, methylphenidate ER (Metadate CD, Ritalin LA, Ritalin SR) .... 10 suspenion (Maxitrolo) ...... 28 methylphenidate tablets (Ritalin) ...... 10 neomycin/polymyxin B/gramicidin eye solution (Neosporin) ... 27 methylprednisolone (Medrol) ...... 18 neomycin/polymyxin B/hydrocortisone ear solution, suspension metipranolol eye solution (Optipranolol) ...... 27 (Cortisporin) ...... 27 metoclopramide (Reglan) ...... 12 neomycin/polymyxin/bacitracin eye ointment ...... 27 metolazone (Zaroxolyn) ...... 17 NEORAL ...... 8 metoprolol succinate ER...... 15 NESINA ...... 19 metoprolol tartrate (Lopressor) ...... 15 nevirapine (Viramune) ...... 7 metronidazole (Flagyl) ...... 6 nevirapine ER (Viramune XR) ...... 7 metronidazole (Metrocream, Metrolotion) ...... 29 Nexium 24HR OTC ...... 13 metronidazole (MetroGel-Vaginal) ...... 14 niacin CR (Niaspan) ...... 16 metronidazole topical gel (Metrogel)...... 29 Nicotrol Inhaler ...... 12 mexiletine HCl (Mexitil) ...... 17 NICOTROL INHALER ...... 11 miglitol (Glyset) ...... 19 Nicotrol NS ...... 12 MILLIPRED ...... 18 NICOTROL NS ...... 11 minoxidil (Loniten) ...... 18 nifedipine ER (Adalat CC, Procardia XL) ...... 16 mirtazapine (Remeron, Remeron SolTab) ...... 10 NILANDRON ...... 9 misoprostol (Cytotec) ...... 13 nimodipine (Nymalize) ...... 16 modafinil (Provigil) ...... 10 nisoldipine (Sular) ...... 16 moexipril (Univasc) ...... 15 NITRO-BID—nitroglycerin ...... 16 moexipril/hydrochlorothiazide (Uniretic) ...... 15 NITRO-DUR—nitroglycerin patch ...... 16 mometasone ...... 30 nitrofurantoin (Furadantin) ...... 14 mometasone (Nasonex) ...... 26 nitrofurantoin macrocrystalline (Macrodantin) ...... 14 montelukast sodium ...... 25 nitrofurantoin monohydrate/macrocrystalline (Macrobid) ...... 14 MOP ...... 30 nitroglycerin (Nitro-Dur) ...... 16 morphine sulfate ER (MS Contin) ...... 24 NITROMIST ...... 16 morphine sulfate IR ...... 24 NITROSTAT—nitroglycerin SL ...... 16 moxifloxacin (Avelox) ...... 5 nizatidine (Axid) ...... 13 MULTAQ ...... 17 norelgestromin-ethinyl estradiol (Ortho Evra) ...... 18 mupirocin ointment (Bactroban) ...... 29 norethindrone acetate (Aygestin) ...... 21 MUSE ...... 17 norethindrone acetate/ethinyl estradiol ...... 20 MYCOBUTIN ...... 6 NORPACE CR— ...... 17 nortriptyline (Pamelor) ...... 10

48 NORVIR SOLUTION ...... 7 perindopril (Aceon) ...... 15 NUVARING ...... 18 permethrin ...... 30 nystatin oral (Mycostatin) ...... 5 perphenazine (Trilafon) ...... 11 nystatin suspenion ...... 29 phenelzine (Nardil) ...... 10 nystatin topical ...... 29 phenobarbital ...... 11 nystatin/triamcinolone ...... 29 phenytoin sodium ER (Dilantin, Phenytek) ...... 23 phenytoin suspenion (Dilantin) ...... 23 O PHOSPHOLINE IODIDE ...... 28 PHRENILIN FORTE ...... 24 ofloxacin ear solution (Floxin otic) ...... 27 pilocarpine (Salagen) ...... 29 ofloxacin eye solution (Ocuflox) ...... 27 pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) ...... 27 triamcinolone cream; lotion ...... 30 PILOPINE HS ...... 28 olanzapine (Zyprexa, Zyprexa Zydis) ...... 11 pimozide (Orap) ...... 11 olanzapine/fluoxetine (Symbyax) ...... 11 pindolol (Visken) ...... 15 olmesartan (Benicar) ...... 15 pioglitazone (Actos) ...... 19 olmesartan/amlodipine/hydrochlorothiazide (Tribenzor) ...... 15 pioglitazone-glimepiride (Duetact) ...... 19 olmesartan/hydrochlorothiazide (Benicar HCT) ...... 15 pioglitazone-metformin (Actoplus Met)...... 19 olopatadine hydrochloride (Patanase) ...... 26 piroxicam (Feldene) ...... 25 omega-3-acid ethyl esters (Lovaza) ...... 16 PLEGRIDY ...... 21 omeprazole DR (Prilosec) ...... 13 podofilox (Condylox) ...... 30 OMNITROPE ...... 21 polymyxin B/trimethoprim eye solution (Polytrim)...... 27 ondansetron (Zofran, Zofran ODT) ...... 12 potassium chloride ER...... 26 ONGLYZA ...... 19 potassium citrate ER (Urocit-K) ...... 13 ORACIT ...... 13 potassium citrate/citric acid (Polycitra-K) ...... 13 oral contraceptives ...... 18 POTASSIUM P-AMINOBENZOATE...... 22 orphenadrine citrate ER (Norflex) ...... 22 potassium phosphate/sodium phosphates (K-Phos Neutral) .. 26 orphenadrine/aspirin/caffeine (Norgesic) ...... 22 pramipexole (Mirapex) ...... 22 oseltamivir (Tamiflu) ...... 7 pravastatin (Pravachol) ...... 16 OSENI ...... 19 prazosin (Minipress) ...... 18 OSPHENA ...... 21 PRECISION XTRA BLOOD GLUCOSE SYSTEM ...... 20 oxandrolone (Oxandrin) ...... 20 PRED MILD...... 28 oxaprozin (Daypro) ...... 25 PRED-G ...... 28 oxazepam ...... 9 PRED-G S.O.P...... 28 oxcarbazepine (Trileptal) ...... 23 prednicarbate ...... 30 oxiconazole (Oxistat) ...... 29 prednisolone (Prelone) ...... 18 OXSORALEN ULTRA ...... 30 prednisolutionone acetate eye suspenion (Pred Forte) ...... 28 oxybutynin (Ditropan) ...... 14 prednisolutionone sodium phosphate (Orapred, Pediapred) .. 18 oxybutynin ER (Ditropan XL) ...... 14 PREDNISONE INTENSOL ...... 18 oxycodone (Roxicodone) ...... 24 prednisone tablets ...... 18 oxycodone/acetaminophen(Percocet, Tylox) ...... 24 prenatal vitamin/folic acid - all generics ...... 26 oxycodone/aspirin (Percodan) ...... 24 primaquine ...... 7 oxymorphone IR (Opana) ...... 24 primidone (Mysolutionine) ...... 23 PROAIR ...... 25 P probenecid (Benemid) ...... 23 prochlorperazine (Compazine) ...... 11 paliperidone (Invega) ...... 11 progesterone micronized (Prometrium) ...... 21 pantoprazole DR (Protonix) ...... 13 PROGRAF ...... 8 paricalcitol (Zemplar) ...... 21 PROMACTA ...... 8 paroxetine hcl (Paxil) ...... 10 propafenone (Rythmol) ...... 17 paroxetine hcl ER (Paxil CR) ...... 10 propafenone ER (Rythmol SR) ...... 17 PATADAY —olopatadine ...... 28 propranolol ER (Inderal LA) ...... 15 PAXIL ...... 10 propranolol tablets (Inderal) ...... 15 penicillin v potassium (Veetids) ...... 6 propylthiouracil ...... 21 pentoxifylline ER (Trental) ...... 8

49 protriptyline ...... 10 sevelamer carbonate (Renvela) ...... 13 PULMICORT ...... 25 silver sulfadiazine (Silvadene) ...... 29 pyrazinamide ...... 6 SIMBRINZA...... 27 pyridostigmine (Mestinon) ...... 22 simvastatin (Zocor) ...... 16 sodium citrate/citric acid (Shohls) ...... 13 Q sodium fluoride ...... 26 sodium fluoride (Prevident) ...... 29 QNASL ...... 26 sodium polystyrene sulfonate ...... 21 QTERN ...... 19 SORIATANE ...... 30 quetiapine (Seroquel) ...... 11 sotalol (Betapace, Betapace AF) ...... 17 quetiapine ER (Seroquel XR) ...... 11 sotalol HCl (Betapace)...... 15 quinapril (Accupril) ...... 15 SOVALDI ...... 6 quinapril/hydrochlorothiazide (Accuretic) ...... 15 SPIRIVA ...... 25 quinidine gluconate ER (Quinaglute) ...... 17 SPIRIVA HANDIHALER ...... 25 quinidine sulfate (Quinidex) ...... 17 spironolactone (Aldactone) ...... 17 QVAR REDIHALER ...... 25 spironolactone/hydrochlorothiazide ...... 17 stavudine (Zerit) ...... 7 R STEGLUJAN ...... 19 STIMATE ...... 21 rabeprazole (Aciphex) ...... 13 STRIVERDI RESPIMAT ...... 25 RAGWITEK ...... 26 sucralfate tablets (Carafate) ...... 13 raloxifene (Evista) ...... 21 sulfacetamide sodium eye solution (Bleph-10) ...... 27 ramipril (Altace) ...... 15 sulfacetamide sodium/prednisolutionone eye solution ...... 28 ranitidine (Zantac)...... 13 sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion ... 29 RAPAMUNE ...... 8 sulfamethoxazole/trimethoprim (Bactrim, Sulfatrim, Septra) ..... 6 rasagiline (Azilect) ...... 11 sulfasalazine (Azulfidine) ...... 13 rasagiline mesylate (Azilect) ...... 22 sulfasalazine DR (Azulfidine EN-Tabs) ...... 13 REBIF ...... 21 sulindac (Clinoril) ...... 25 RELISTOR ...... 12 sumatriptan injection, nasal spray, tablets (Imitrex) ...... 23 RESCRIPTOR ...... 7 SUSTIVA ...... 7 RESTASIS ...... 28 SUSTIVA—efavirenz ...... 7 REYATAZ ...... 7 SYMBICORT...... 25 RIDAURA...... 25 SYNAREL ...... 21 rifampin (Rifadin) ...... 6 SYNJARDY ...... 19 rimantadine HCl (Flumadine) ...... 7 SYNTHROID ...... 21 risedronate (Actonel, Atelvia) ...... 21 risperidone (Risperdal, Risperdal-M tablets) ...... 11 T rivastigmine (Exelon) ...... 11 rizatriptan (Maxalt) ...... 23 TABLOID ...... 9 rizatriptan ODT (Maxalt ODT) ...... 23 tacrolimus (Prograf) ...... 8 ropinirole (Requip) ...... 22 tacrolimus (Protopic) ...... 29 ropinirole ER (Requip XL) ...... 22 tamoxifen (Nolvadex) ...... 9 rosuvastatin (Crestor) ...... 16 tamsulosin (Flomax) ...... 13 TANZEUM ...... 19 S tazarotene (Tazorac) ...... 29 TECFIDERA ...... 22 salsalate (Disalcid) ...... 24 TEKTURNA ...... 18 SANCUSO ...... 12 TEKTURNA HCT...... 18 SANDIMMUNE ...... 8 telmisartan (Micardis) ...... 15 SARAFEM ...... 11 telmisartan/amlodipine (Twynsta) ...... 15 selegiline (Eldepryl) ...... 22 temazepam (Restoril) ...... 11 selenium sulfide (Selsun) ...... 30 terazosin (Hytrin) ...... 18 SEREVENT DISKUS ...... 25 terbinafine (Lamisil) ...... 5 sertraline (Zoloft) ...... 10

50 terbutaline (Brethine) ...... 25 U terconazole (Terazol) ...... 14 testosterone cypionate (Depo-Testosterone) ...... 20 ULORIC ...... 23 testosterone enanthate (Delatestryl) ...... 20 ULTRESA ...... 12 theophylline (Theo-24) ...... 25 UROCIT-K ...... 14 theophylline ER (Theo-Dur) ...... 25 urosdiol (Actigall, Urso 250, Urso Forte) ...... 13 thioridazine ...... 11 thiothixene (Navane) ...... 11 V THYROLAR ...... 21 tiagabine (Gabitril) ...... 23 valacyclovir (Valtrex) ...... 6 timolol maleate eye solution (Timoptic, Timoptic XE) ...... 27 valproic acid (Depakene) ...... 23 TIMOPTIC OCUDOSE ...... 28 valsartan (Diovan) ...... 15 tinidazole (Tindamax) ...... 6 valsartan/hydrochlorothiazide (Diovan HCT) ...... 15 tizanidine (Zanaflex) ...... 22 vancomycin (Vancocin) ...... 6 TOBRADEX ...... 28 venlafaxine (Effexor) ...... 10 TOBRADEX ST ...... 28 venlafaxine ER capsules (Effexor XR) ...... 10 tobramycin eye solution (Tobrex) ...... 27 VENTOLIN HFA ...... 25 tobramycin/dexamethasone eye suspenion (Tobradex) ...... 28 verapamil (Calan) ...... 16 tolcapone (Tasmar) ...... 22 verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM) .. 16 tolterodine (Detrol) ...... 14 VESICARE ...... 14 tolterodine ER (Detrol LA) ...... 14 VIBRAMYCIN SYRUP ...... 6 topiramate (Topamax Sprinkle, Topamax) ...... 23 VICTOZA ...... 19 topotecan (Hycamtin) ...... 9 VIOKACE ...... 12 torsemide (Demadex) ...... 17 VIREAD ...... 7 TOUJEO ...... 19 voriconazole (Vfend) ...... 5 TOUJEO MAX ...... 20 TRADJENTA ...... 19 W tramadol ER tablets (Ultram ER) ...... 24 warfarin (Coumadin) tramadol tablets (Ultram) ...... 24 ...... 8 tramadol/acetaminophen (Ultracet)...... 24 trandolapril (Mavik) ...... 15 X tranylcypromine (Parnate) ...... 10 XARELTO ...... 8 TRAVATAN Z ...... 28 trazodone (Desyrel) ...... 10 tretinoin (Retin-A) ...... 29 Z TREXALL ...... 9 zafirlukast (Accolate) ...... 25 triamcinolone (Nasacort AQ)...... 26 zaleplon (Sonata) ...... 11 triamcinolone dental paste (Kenalog in Orabase) ...... 29 Zegerid OTC (omeprazole-sodium bicarbonate) ...... 13 triamterene/hydrochlorothiazide (Dyazide, Maxzide) ...... 17 ZENPEP ...... 12 triazolam (Halcion) ...... 11 zidovudine (Retrovir) ...... 7 trifluoperazine (Stelazine) ...... 11 ziprasidone (Geodon) ...... 11 trifluridine eye solution (Viroptic) ...... 27 zoledronic acid (Reclast) ...... 21 trihexyphenidyl (Artane) ...... 22 zolmitriptan tablets, ODT tablets (Zomig) ...... 23 trimethobenzamide (Tigan) ...... 12 zolpidem (Ambien) ...... 11 trimethoprim ...... 6 zolpidem ER(Ambien CR) ...... 11 trospium (Sanctura) ...... 14 zonisamide (Zonegran) ...... 23 trospium ER ...... 14 ZYMAXID —gatifloxacin ...... 27 TRULICITY ...... 19 TUDORZA ...... 25

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