Primechoice™ Accord Formulary, April 2020

PrimeChoice™ Accord Formulary, April 2020

Your prescription drug benefit plan may not cover certain products or drug categories, regardless of their appearance in this document. Questions may be directed to Prime Therapeutics LLC, P.O. Box 64812, St. Paul, MN 55164-0812, Phone 800.858.0723. Thank you for your cooperation.

GENERIC BRAND GENERIC BRAND DR ...... Delayed-release tobramycin inhal soln VIDEX ER ...... Extended-release SULFADIAZINE VIREAD, NF = 300 mg IR ...... Immediate-release VOSEVI ANTIMYCOBACTERIAL AGENTS NF ...... Non-formulary ANTIMALARIALS ODT ...... Orally disintegrating tablets ethambutol ISONIAZID syrup OSM ...... Osmotic-release isoniazid tabs PRIFTIN atovaquone/proguanil CHLOROQUINE 250 mg SL ...... Sublingual pyrazinamide chloroquine 500 mg COARTEM rifabutin hydroxychloroquine DARAPRIM This formulary list was current at time of printing and is subject to rifampin primaquine MEFLOQUINE change. To access a searchable version of this formulary visit our ANTHELMINTICS website at MyPrime.com. ANTIFUNGALS fluconazole NOXAFIL susp albendazole BENZNIDAZOLE GENERIC BRAND flucytosine ivermectin tabs praziquantel ANTI-INFECTIVE AGENTS griseofulvin microsize itraconazole ANTI-INFECTIVE AGENTS - MISC. PENICILLINS nystatin oral clindamycin ALINIA amoxicillin caps, susp, tabs AMOXICILLIN chew tabs posaconazole DR dapsone tabs IMPAVIDO amoxicillin/potassium clavulanate AMOXICILLIN/CLAVULANATE terbinafine linezolid NEBUPENT for susp; IR tabs chew tabs; ER, 1000-62.5 mg voriconazole metronidazole tabs SIVEXTRO dicloxacillin AMPICILLIN ANTIVIRALS pentamidine XIFAXAN 550 mg penicillin v potassium tabs AUGMENTIN susp, 125 mg/5 mL sulfamethoxazole/trimethoprim PENICILLIN V POTASSIUM soln abacavir ATRIPLA abacavir/lamivudine BARACLUDE soln trimethoprim CEPHALOSPORINS abacavir/lamivudine/zidovudine BIKTARVY vancomycin cefaclor caps SUPRAX chew tabs; susp acyclovir CIMDUO BIOLOGICALS cefadroxil adefovir DELSTRIGO SYNAGIS cefdinir atazanavir caps DESCOVY cefixime didanosine DR caps, 200 mg, DIDANOSINE caps, 400 mg ANTINEOPLASTIC AGENTS cefpodoxime 250 mg EPCLUSA abiraterone ACTIMMUNE cefprozil efavirenz EPIVIR HBV soln anastrozole AFINITOR ceftriaxone entecavir EVOTAZ bexarotene AFINITOR DISPERZ cefuroxime famciclovir GENVOYA bicalutamide ALECENSA cephalexin, NF = tabs lamivudine HARVONI capecitabine ALUNBRIG MACROLIDES lamivudine/zidovudine INTELENCE cyclophosphamide BOSULIF lopinavir/ritonavir soln ISENTRESS erlotinib CAPRELSA azithromycin susp, tabs AZITHROMYCIN packets nevirapine IR susp; tabs, 200 mg; ISENTRESS HD everolimus COMETRIQ clarithromycin tabs; ER CLARITHROMYCIN susp ER 400 mg KALETRA tabs exemestane COTELLIC TETRACYCLINES oseltamivir LEDIPASVIR/SOFOSBUVIR flutamide EMCYT demeclocycline ribavirin 200 mg MAVYRET hydroxyurea ERIVEDGE doxycycline hyclate caps, 50 mg, ritonavir tabs NEVIRAPINE ER tabs, 100 mg imatinib ERLEADA 100 mg; tabs, 20 mg, 100 mg stavudine NORVIR, NF = tabs letrozole ETOPOSIDE caps doxycycline monohydrate, NF = tenofovir disoproxil fumarate tabs, ODEFSEY leucovorin calcium tabs, 5 mg, FARYDAK susp 300 mg PEGASYS 25 mg GILOTRIF minocycline IR valacyclovir PREZCOBIX megestrol GLEOSTINE tetracycline valganciclovir PREZISTA melphalan HYCAMTIN caps zidovudine SOFOSBUVIR/VELPATASVIR mercaptopurine IBRANCE FLUOROQUINOLONES SOVALDI methotrexate tabs ICLUSIG ciprofloxacin tabs, 250 mg, CIPROFLOXACIN tabs, 100 mg SYMFI nilutamide IMBRUVICA 500 mg, 750 mg SYMFI LO tamoxifen INLYTA levofloxacin TEMIXYS temozolomide IRESSA ofloxacin tabs, 400 mg TIVICAY toremifene JAKAFI AMINOGLYCOSIDES TRIUMEQ tretinoin caps KISQALI KISQALI FEMARA dose pack neomycin sulfate PAROMOMYCIN TRUVADA

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2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 1 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND LENVIMA testosterone gel, 1%, 1.62%; Intermediate-Acting Insulins LEUCOVORIN CALCIUM tabs, soln, 30 mg/act INSULIN ASPART PROTAMINE 10 mg, 15 mg ESTROGENS LEUKERAN NOVOLIN N LONSURF estradiol CLIMARA PRO NOVOLIN 70/30 LYNPARZA estradiol/norethindrone acetate DIVIGEL NOVOLOG MIX 70/30 LYSODREN norethindrone acetate/ethinyl ESTROGEL Basal Insulins estradiol PREMARIN tabs MATULANE LANTUS MEKINIST PREMPHASE PREMPRO LEVEMIR MESNEX tabs TOUJEO MAX SOLOSTAR MYLERAN CONTRACEPTIVES TOUJEO SOLOSTAR NEXAVAR medroxyprogesterone acetate inj, ELLA TRESIBA NINLARO 150 mg/mL MIRENA TRESIBA FLEXTOUCH NUBEQA oral contraceptive generics, NF = NUVARING THYROID AGENTS ODOMZO drospirenone/ethinyl estradiol/ OGESTREL PIQRAY DAILY DOSE levomefolate; levonorgestrel/ SKYLA levothyroxine POMALYST ethinyl estradiol 90-20 mcg XULANE liothyronine PURIXAN oral contraceptive generics, NF = methimazole ROZLYTREK levonorgestrel/ethinyl estradiol propylthiouracil RUBRACA 0.15-0.02/0.025/0.03 mg/ OXYTOCICS RYDAPT ethinyl estradiol 0.01 mg; methylergonovine SOLTAMOX norethindrone/ethinyl ENDOCRINE and METABOLIC AGENTS - MISC. SPRYCEL estradiol/fe 0.8 mg-25 mcg, STIVARGA 1 mg-20 mcg alendronate tabs, 10 mg, 35 mg, ALENDRONATE 5 mg SUTENT 70 mg CHORIONIC GONADOTROPIN PROGESTINS SYLATRON cabergoline CLOMIPHENE CITRATE TABLOID medroxyprogesterone acetate calcitonin-salmon CYSTADANE TAFINLAR tabs calcitriol FOLLISTIM AQ TAGRISSO norethindrone acetate cinacalcet INCRELEX TASIGNA progesterone micronized desmopressin MENOPUR TYKERB ANTIDIABETICS ganirelix acetate NITYR VENCLEXTA acarbose GLUCAGON EMERGENCY KIT ibandronate NORDITROPIN FLEXPRO VERZENIO glimepiride GLYXAMBI levocarnitine NOVAREL VITRAKVI glipizide IR, ER GVOKE PFS nitisinone caps, 2 mg, 5 mg, OCTREOTIDE 200, 1000 mcg/mL VOTRIENT glipizide/metformin INVOKAMET 10 mg ORFADIN XALKORI glyburide micronized INVOKAMET XR octreotide ORILISSA XTANDI glyburide/metformin INVOKANA paricalcitol PREGNYL YONSA glyburide, distributor of Diabeta JANUMET raloxifene PROLIA ZELBORAF glyburide, generics of Micronase JANUMET XR risedronate IR REVCOVI ZOLINZA metformin IR, ER; NF = modified JANUVIA SANDOSTATIN LAR DEPOT ZYDELIG release, OSM, soln JARDIANCE STIMATE ZYKADIA nateglinide KOMBIGLYZE XR STRENSIQ ZYTIGA 500 mg pioglitazone ONGLYZA TYMLOS ENDOCRINE AND METABOLIC DRUGS pioglitazone/metformin OZEMPIC CARDIOVASCULAR AGENTS CORTICOSTEROIDS repaglinide PROGLYCEM CARDIOTONICS RYBELSUS budesonide DR caps, 3 mg CORTISONE digoxin DIGOXIN soln SYNJARDY dexamethasone, NF = therapy DEXAMETHASONE soln; tabs, SYNJARDY XR ANTIANGINAL AGENTS pack 1 mg, 2 mg TRULICITY fludrocortisone DEXAMETHASONE INTENSOL isosorbide dinitrate 5 mg, 10 mg, NITRO-BID VICTOZA hydrocortisone PREDNISOLONE syrup 20 mg, 30 mg methylprednisolone PREDNISONE soln, 5 mg/5 mL Rapid-Acting Insulins isosorbide mononitrate IR, ER nitroglycerin patches, SL tabs prednisolone sodium phosphate FIASP soln, 5 mg/5 mL, 15 mg/5 mL INSULIN ASPART BETA BLOCKERS prednisone tabs NOVOLOG acebutolol PROPRANOLOL soln ANDROGEN-ANABOLIC Short-Acting Insulins atenolol TIMOLOL 10 mg, 20 mg bisoprolol danazol TESTOSTERONE ENANTHATE HUMULIN R U-500 carvedilol testosterone cypionate NOVOLIN R

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2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 2 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND labetalol moexipril bosentan OPSUMIT metoprolol succinate ER olmesartan sildenafil 20 mg TRACLEER tabs for oral susp metoprolol tartrate 25 mg, 50 mg, olmesartan/hydrochlorothiazide tadalafil UPTRAVI 100 mg perindopril tadalafil (pah) VYNDAMAX nadolol phenoxybenzamine VYNDAQEL pindolol prazosin RESPIRATORY AGENTS propranolol IR, ER quinapril sotalol quinapril/hydrochlorothiazide ANTIHISTAMINES sotalol AF ramipril cetirizine syrup DESLORATADINE ODT timolol 5 mg telmisartan cyproheptadine PROMETHEGAN 50 mg CALCIUM CHANNEL BLOCKERS telmisartan/hydrochlorothiazide desloratadine terazosin levocetirizine tabs, soln amlodipine DILT-XR trandolapril promethazine supp 12.5 mg, diltiazem IR; ER caps – 24 hr VERAPAMIL SR caps, 360 mg valsartan 25 mg; syrup, tabs dosing valsartan/hydrochlorothiazide felodipine ER NASAL AGENTS - SYSTEMIC and TOPICAL nifedipine ER DIURETICS azelastine FLUNISOLIDE nimodipine acetazolamide IR, ER CHLOROTHIAZIDE fluticasone propionate verapamil IR, ER, NF = caps, amiloride ipratropium 100 mg, 200 mg, 300 mg amiloride/hydrochlorothiazide mometasone ANTIARRHYTHMICS bumetanide COUGH/COLD/ALLERGY chlorthalidone 25 mg, 50 mg acetylcysteine inhal soln amiodarone MEXILETINE furosemide, NF = soln, 8 mg/mL disopyramide MULTAQ hydrochlorothiazide ANTIASTHMATIC and BRONCHODILATOR AGENTS flecainide QUINIDINE SULFATE IR indapamide albuterol, NF = ER ADVAIR HFA propafenone IR, ER methazolamide budesonide inhal susp ANORO ELLIPTA quinidine gluconate ER metolazone cromolyn sodium inhal soln ARNUITY ELLIPTA ANTIHYPERTENSIVES spironolactone ipratropium inhal soln ASMANEX HFA amlodipine/benazepril CAPTOPRIL/ spironolactone/ ipratropium/albuterol sulfate inhal ASMANEX TWISTHALER amlodipine/valsartan HYDROCHLOROTHIAZIDE hydrochlorothiazide soln ATROVENT HFA amlodipine/valsartan/ METOPROLOL/ torsemide levalbuterol inhal soln BREO ELLIPTA hydrochlorothiazide HYDROCHLOROTHIAZIDE triamterene/hydrochlorothiazide, montelukast COMBIVENT RESPIMAT atenolol/chlorthalidone 100/50 mg NF = 50-25 mg terbutaline DULERA benazepril PROPRANOLOL/ VASOPRESSORS theophylline ER 400 mg, 600 mg FLOVENT DISKUS zafirlukast FLOVENT HFA benazepril/hydrochlorothiazide HYDROCHLOROTHIAZIDE epinephrine auto-injector, SYMJEPI FLUTICASONE/SALMETEROL bisoprolol/hydrochlorothiazide 0.15 mg, 0.3 mg/0.3mL AER POWDER 55-14, 113-14, candesartan midodrine candesartan/hydrochlorothiazide 232-14 mcg/act captopril ANTIHYPERLIPIDEMICS INCRUSE ELLIPTA clonidine IR atorvastatin REPATHA PROAIR HFA clonidine td patch cholestyramine REPATHA PUSHTRONEX PROAIR RESPICLICK doxazosin colesevelam REPATHA SURECLICK QVAR REDIHALER enalapril colestipol SEREVENT DISKUS enalapril/hydrochlorothiazide ezetimibe SPIRIVA HANDIHALER eplerenone ezetimibe/simvastatin SPIRIVA RESPIMAT fosinopril fenofibrate tabs, 48 mg, 54 mg, STIOLTO RESPIMAT fosinopril/hydrochlorothiazide 145 mg, 160 mg SYMBICORT guanfacine IR fenofibrate micronized 67 mg, THEOPHYLLINE ER 300 mg, hydralazine 134 mg, 200 mg 450 mg irbesartan fenofibric acid DR TRELEGY ELLIPTA irbesartan/hydrochlorothiazide gemfibrozil VENTOLIN HFA lisinopril lovastatin RESPIRATORY AGENTS - MISC. lisinopril/hydrochlorothiazide niacin ER KALYDECO losartan pravastatin PULMOZYME losartan/hydrochlorothiazide rosuvastatin SYMDEKO methyldopa simvastatin tabs TRIKAFTA metoprolol/hydrochlorothiazide CARDIOVASCULAR AGENTS - MISC. 50/25 mg, 100/25 mg minoxidil ambrisentan ENTRESTO

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2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 3 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND GASTROINTESTINAL AGENTS URINARY ANTISPASMODICS haloperidol lactate conc lithium carbonate IR, ER LAXATIVES oxybutynin IR, ER loxapine lactulose, soln; NF = oral crystal solifenacin olanzapine IR, ODT packet tolterodine IR, ER perphenazine PEG-electrolytes for VAGINAL PRODUCTS prochlorperazine soln, generics of Colyte, clindamycin crm ENDOMETRIN quetiapine IR, ER Golytely, Nulytely estradiol vaginal crm TERCONAZOLE crm, 0.8% risperidone IR; ODT, 0.5 mg, ANTIDIARRHEALS metronidazole gel VAGIFEM 1 mg, 2 mg, 3 mg, 4 mg thiothixene diphenoxylate/atropine tabs DIPHENOXYLATE/ATROPINE terconazole crm, 0.4%; supp trifluoperazine loperamide soln GENITOURINARY AGENTS - MISC. ziprasidone ULCER DRUGS alfuzosin ER CYSTAGON HYPNOTICS cimetidine, tabs, 300 mg, 400 mg, CIMETIDINE, soln,300 mg/5 mL dutasteride K-PHOS NO. 2 estazolam BELSOMRA 800 mg NEXIUM packets finasteride eszopiclone dicyclomine PROPANTHELINE potassium citrate phenobarbital, NF = 64.8 mg, esomeprazole magnesium sodium citrate/citric acid 97.2 mg famotidine tabs tamsulosin temazepam glycopyrrolate 1 mg, 2 mg CENTRAL NERVOUS SYSTEM DRUGS zaleplon lansoprazole DR, NF = ODT ANTIANXIETY AGENTS zolpidem IR, ER methscopolamine misoprostol alprazolam, NF = ODT DIAZEPAM soln ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS buspirone, NF = 7.5 mg HYDROXYZINE PAMOATE omeprazole DR amphetamine/ ADDERALL XR diazepam tabs 100 mg pantoprazole DR dextroamphetamine IR, ER CONCERTA hydroxyzine hcl ranitidine armodafinil SUNOSI hydroxyzine pamoate 25 mg, sucralfate tabs atomoxetine VYVANSE 50 mg caffeine citrate soln ANTIEMETICS lorazepam dexmethylphenidate IR, ER aprepitant caps, therapy pack EMEND for oral susp; soln ANTIDEPRESSANTS dextroamphetamine IR tabs; ER fosaprepitant ONDANSETRON tabs, 24 mg guanfacine ER granisetron amitriptyline NORTRIPTYLINE soln methylphenidate IR tabs; ER meclizine bupropion IR, ER; NF = 450 mg tabs, 10 mg, 20 mg ondansetron ODT; soln; tabs, citalopram modafinil 4 mg, 8 mg clomipramine scopolamine desipramine PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. desvenlafaxine succinate ER trimethobenzamide acamprosate DR AUBAGIO doxepin caps, NF = 150 mg; conc bupropion ER – smoking AVONEX DIGESTIVE AIDS duloxetine DR deterrent BETASERON CREON escitalopram disulfiram CHANTIX ZENPEP fluoxetine, NF = 60 mg; DR; donepezil IR, ODT COPAXONE PMDD GASTROINTESTINAL AGENTS- MISC. galantamine IR, ER GALANTAMINE soln fluvoxamine IR glatiramer GILENYA balsalazide APRISO imipramine hcl memantine MAVENCLAD calcium acetate CHENODAL mirtazapine, NF = ODT rivastigmine caps MAYZENT, NF = starter pack lactulose SYMPROIC nortriptyline caps tetrabenazine NICOTROL INHALER mesalamine DR caps, tabs; ER TRULANCE paroxetine hcl IR, ER NICOTROL NS mesalamine enema, supp VELPHORO phenelzine PIMOZIDE metoclopramide, NF = ODT VIBERZI sertraline PLEGRIDY sevelamer carbonate tranylcypromine REBIF sulfasalazine trazodone TECFIDERA sulfasalazine DR venlafaxine IR, ER caps ursodiol ANALGESICS AND ANESTHETICS ANTIPSYCHOTICS GENITOURINARY AGENTS ANALGESICS - NON-NARCOTIC aripiprazole tabs FLUPHENAZINE HCL URINARY ANTI-INFECTIVES chlorpromazine LITHIUM CARBONATE caps, butalbital/acetaminophen tabs, TENCON nitrofurantoin susp clozapine, NF = ODT 150 mg 50-325 mg nitrofurantoin macrocrystalline fluphenazine decanoate LITHIUM soln butalbital/acetaminophen/caffeine nitrofurantoin monohydrate/ haloperidol RISPERIDONE ODT, 0.25 mg tabs, 50-325-40 mg macrocrystalline haloperidol decanoate butalbital/aspirin/caffeine caps

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2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 4 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND ANALGESICS - NARCOTIC divalproex DR, ER DIASTAT potassium phosphate/sodium POTASSIUM CHLORIDE ER 8 ethosuximide DILANTIN-125 susp phosphates mEq acetaminophen/codeine MORPHINE SULFATE ER bead gabapentin DILANTIN, NF = INFATABS sodium fluoride chew tabs; soln, SODIUM FLUORIDE tabs buprenorphine caps lamotrigine tabs; tabs, chewable EPIDIOLEX 0.275 mg/drop, 1.1 mg/mL butalbital/aspirin/caffeine/codeine NUCYNTA ER dispersible HEMATOLOGICAL AGENTS codeine sulfate tabs, 30 mg OXYCODONE/ASPIRIN levetiracetam IR, ER fentanyl patches, NF = 37.5 mcg, OXYCONTIN oxcarbazepine HEMATOPOIETIC AGENTS 62.5 mcg, 87.5 mcg/hr phenytoin IR, ER cyanocobalamin inj ARANESP fentanyl citrate lozenge pregabalin folic acid 1 mg FULPHILA hydrocodone/acetaminophen, primidone GRANIX tabs, 5-325 mg, topiramate NEULASTA 7.5-325 mg, 10-325 mg; valproic acid NEULASTA ONPRO KIT soln,7.5-325 mg/15 mL vigabatrin NEUPOGEN hydrocodone/ibuprofen, NF = zonisamide NIVESTYM 2.5-200 mg ANTIPARKINSON AGENTS PROCRIT hydromorphone soln, tabs RETACRIT methadone conc, soln, tabs amantadine, NF = tabs CARBIDOPA/LEVODOPA/ UDENYCA morphine sulfate conc; ER,IR benztropine ENTACAPONE ZARXIO tabs; soln carbidopa/levodopa IR, ER, ODT INBRIJA oxycodone entacapone SELEGILINE tabs ANTICOAGULANTS oxycodone/acetaminophen, NF = pramipexole enoxaparin ELIQUIS 2.5-325 mg soln rasagiline warfarin XARELTO tramadol IR, ER; NF = biphasic ropinirole HEMATOLOGICAL AGENTS - MISC. tramadol/acetaminophen selegiline caps anagrelide BRILINTA trihexyphenidyl ANALGESICS - ANTI-INFLAMMATORY cilostazol CINRYZE celecoxib ENBREL NEUROMUSCULAR AGENTS clopidogrel 75 mg HAEGARDA diclofenac potassium ENBREL MINI riluzole dipyridamole diclofenac sodium DR, ER ENBREL SURECLICK MUSCULOSKELETAL THERAPY AGENTS icatibant etodolac IR, ER HUMIRA pentoxifylline ER flurbiprofen ILARIS baclofen 10 mg, 20 mg CHLORZOXAZONE 500 mg prasugrel cyclobenzaprine tabs, 5 mg, EUFLEXXA ibuprofen OTEZLA TOPICAL PRODUCTS indomethacin, NF = ER; supp OTREXUP 10 mg SYNVISC/ONE OPHTHALMIC AGENTS leflunomide RINVOQ dantrolene meloxicam methocarbamol azelastine soln ALPHAGAN P 0.1% nabumetone orphenadrine ER bacitracin/polymyxin B oint ALREX naproxen tizanidine brimonidine soln, 0.15%, 0.2% ATROPINE SULFATE soln naproxen sodium, NF = ER ANTIMYASTHENIC AGENTS ciprofloxacin soln AZOPT oxaprozin pyridostigmine tabs, 60 mg cromolyn sodium soln BACITRACIN oint piroxicam cyclopentolate soln, 1% CARTEOLOL soln NUTRITIONAL PRODUCTS sulindac diclofenac soln CILOXAN oint VITAMINS dorzolamide soln DEXAMETHASONE SODIUM MIGRAINE PRODUCTS ergocalciferol dorzolamide/timolol maleate soln, PHOSPHATE soln dihydroergotamine mesylate inj AIMOVIG phytonadione NF = PF FLURBIPROFEN soln eletriptan EMGALITY erythromycin oint GENTAK naratriptan MIGRANAL MULTIVITAMINS fluorometholone susp, 0.1% LOTEMAX gel, oint rizatriptan IR, ODT SUMATRIPTAN prefilled syringe KOSHER PRENATAL PLUS gentamicin soln LOTEMAX SM sumatriptan auto-injector; 6 mg/0.5 mL IRON ketorolac soln LUMIGAN cartridge; inj, 6 mg/0.5 mL; PRENATABS RX latanoprost soln NATACYN nasal spray; tabs PRENATAL PLUS IRON levobunolol soln, 0.5% NEOMYCIN/POLYMYXIN/ GOUT AGENTS PRENATAL VITAMINS PLUS loteprednol susp GRAMICIDIN soln LOW allopurinol MITIGARE moxifloxacin soln PAZEO PRENATAL 19/U probenecid neomycin/polymyxin B/bacitracin PREDNISOLONE ACETATE susp SE-NATAL 19 probenecid/colchicine oint SIMBRINZA TRINATE neomycin/polymyxin B/bacitracin/ SULFACETAMIDE SODIUM/ NEUROMUSCULAR DRUGS VINATE II/M/ONE hydrocortisone oint PREDNISOLONE soln ANTICONVULSANTS MINERALS and ELECTROLYTES neomycin/polymyxin B/ TIMOLOL MALEATE gel forming dexamethasone oint, susp soln carbamazepine IR, ER BANZEL tabs potassium chloride ER, 8 mEq, 10 FLURA-DROPS 0.55 mg/drop ofloxacin soln TRAVATAN Z clonazepam, NF = ODT CELONTIN mEq; packets; soln K-PHOS

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2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 5 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND olopatadine soln TRIFLURIDINE soln fluticasone propionate MEDICAL DEVICES pilocarpine soln ZYLET gentamicin topical polymyxin B/trimethoprim soln halobetasol INHALER ASSIST DEVICES - sulfacetamide sodium soln hydrocortisone valerate SPACERS timolol maleate soln, 0.25, 0.5%, hydrocortisone 2.5% ASSORTED CLASSES NF = once daily imiquimod 5% azathioprine DEPEN TITRATABS tobramycin soln isotretinoin caps buprenorphine/naloxone REVLIMID tobramycin/dexamethasone susp ivermectin crm cyclosporine THALOMID travoprost soln ketoconazole crm; shampoo, 2% cyclosporine modified ZORTRESS tropicamide soln lidocaine/prilocaine crm; NF = kits mycophenolate mofetil OTIC AGENTS lidocaine, NF = crm, lotn mycophenolate sodium DR malathion acetic acid CIPRO HC penicillamine tabs metronidazole topical sirolimus hydrocortisone/acetic acid CIPRODEX mometasone neomycin/polymyxin B/ sodium polystyrene sulfonate mupirocin oint tacrolimus caps hydrocortisone nystatin topical ofloxacin nystatin/triamcinolone MOUTH/THROAT/DENTAL AGENTS permethrin cevimeline pimecrolimus chlorhexidine podofilox clotrimazole troche selenium sulfide lotn lidocaine viscous silver sulfadiazine nystatin susp sulfacetamide sodium lotn pilocarpine tabs tacrolimus oint sodium fluoride crm, gel tazarotene crm, 0.1% triamcinolone dental paste tretinoin microsphere tretinoin, NF = emollient crm; ANORECTAL AGENTS Avita gel hydrocortisone crm, 2.5%; enema CORTIFOAM triamcinolone crm, lotn; oint, hydrocortisone acetate supp, 0.025%, 0,1%, 0.5% 25 mg MISCELLANEOUS PRODUCTS DERMATOLOGICALS ANTIDOTES acitretin AMCINONIDE crm naloxone inj, 0.4 mg/mL, CHEMET adapalene crm, gel AUGMENTED 4 mg/10mL NALOXONE inj, 0.4 mg/mL adapalene/benzoyl peroxide gel, BETAMETHASONE naltrexone NARCAN 0.1-2.5% DIPROPIONATE gel alclometasone CARAC DIABETIC SUPPLIES azelaic acid gel COSENTYX ASCENCIA CONTOUR, betamethasone dipropionate DIFFERIN lotn CONTOUR NEXT calibration betamethasone dipropionate, ENSTILAR liquid; test strips augmented crm, lotn, oint EPIDUO FORTE ASCENSIA CONTOUR, betamethasone valerate crm, lotn, ERY pads CONTOUR NEXT/EZ/LINK/ oint FINACEA foam ONE blood glucose meter calcipotriene crm, oin, soln FLUOROPLEX ASCENSIA DIASTIX, KETO- ciclopirox, NF = topical kit FLUOROURACIL soln DIASTIX, KETOSTIX urine test clindamycin gel, lotn, pads, soln LIDOCAINE, gel, 2% products clindamycin/benzoyl peroxide, NF LINDANE shampoo DEXCOM G5/G6 RECEIVER/ = 1.2-2.5% ORACEA SENSOR/TRANSMITTER clobetasol PICATO continuous blood glucose desonide SKYRIZI system desoximetasone crm, oint, 0.25% SOOLANTRA FREESTYLE LIBRE READER/ diclofenac sodium gel STELARA SENSOR/FLASH continuous econazole TAZORAC crm, 0.05%; gel blood glucose system erythromycin gel, soln TREMFYA INSULIN PEN NEEDLES - erythromycin/benzoyl peroxide VALCHLOR Various fluocinolone ZYCLARA INSULIN SYRINGES - Various fluocinonide LANCET DEVICES - Various fluorouracil crm, 5% LANCETS – Various