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ACA Compliant Individual/Small Group Formulary

For the most current list of covered medications or if you have questions: Call Pharmacy Management Team at (855) 305-5062 Visit sanfordhealthplan.com/members and link to the OptumRx website to: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options HP-0370 08-15-2021 Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen by health care providers on Sanford Health Plan’s Pharmacy and About this formulary Therapeutics Committee. Selection criteria includes clinical Where differences exist between efficacy, safety, and cost. Medications on this list are approved this formulary and your benefit by the U.S. and Administration (FDA) for use in the plan documents, the benefit plan United States. documents rule. This may not be a complete list of medications, and not all medications listed may be How do I use my formulary? covered by your plan. Please look You and your doctor can consult the formulary to help you at the benefit plan documents select the most cost-effective prescription medications. provided by your employer or plan This guide tells you if a medication is generic or brand, and if sponsor for full details. special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the toll-free member phone number on your ID card.

2 Reading your formulary

The formulary gives you choices so you and your provider can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information Tiers are different cost levels you pay for a medication. This is how much you will pay when you fill a prescription. Using lower tier or preferred medications can help you pay your lowest outof- pocket cost. Your plan may have multiple or no tiers. Consult your Summary of Benefits and Coverage (SBC) to determine your cost for each of the tiers listed below.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost generic Use Tier 1 for the lowest out-of-pocket costs. medications

Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of Tier 3, to help reduce preferred brand-name your out-of-pocket costs.

Tier 3 $$$ Higher-cost Many Tier 3 drugs have lower-cost options in Tier 1 non-preferred or 2. Ask your doctor if they could work for you.

Tier 4 $$$$ Highest-cost Specialty medications typically require additional specialty medications information from you or your provider to determine coverage. Lower cost options may be available.

3 Reading your formulary

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

Prior Authorization – You or your provider must get pre-approval for the with Sanford Health Plan before you can get the prescription filled. NOTE: The PA Member is ultimately responsible for obtaining pre-approval from the Plan, but your provider may also request approval. High Deductible Health Plan Preventive Medication – Medication not subject to Deduct- PV ible and available at a Copay/Coinsurance under a High Deductible Health Plan. QL Quantity Limit / Amount Allowed – Medication may be limited to a certain quantity. Specialty Medication – Medication is designated as specialty. Specialty medications are typically used to treat complex medical conditions. These medications may require fre- SP quent dosing adjustments, close monitoring, special training, or compliance assistance. In addition, specialty medications may need special handling and/or administration, and may have limited or exclusive product availability and distribution. Step Therapy – Trial of a lower-cost medication(s) is required before a higher-cost ST medication can be covered. Formulary Exception – This medication will only be available to the member if they meet FE Sanford Health Plan criteria for a formulary override. Affordable Care Act – As part of the Affordable Care Act, certain drugs are available at a $0 copay (no member cost-share) if the member meets specific conditions (such ACA as age or gender). If the member does not meet the specific conditions, the usual member benefit will apply. Over-the-counter (OTC) – Medications, vitamins and/or supplements. Medications that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force and only when prescribed by a health care O Practitioner and/or Provider are available at a $0 copay (no member cost-share) if the member meets specific conditions (such as age or gender). If the member does not meet the specific conditions, the usual member benefit will apply.

4 Table of Contents Analgesics - Drugs for Pain...... 6 Gastrointestinal Agents - Drugs for Acid Analgesics - Drugs for Pain and Reflux and Ulcer...... 55 Inflammation...... 9 Gastrointestinal Agents - Drugs for Bowel, Anesthetics...... 11 Intestine and Stomach Conditions...... 56 Anti-Addiction / Substance Abuse Genetic or Disorder - Drugs for Treatment Agents...... 11 Replacement, Modification, Treatment....58 Antibacterials...... 12 Genitourinary Agents - Drugs for Bladder, Anticoagulants...... 16 Genital and Kidney Conditions...... 59 Anticonvulsants - Drugs for Seizures...... 16 Genitourinary Agents - Drugs for Prostate Antidementia Agents - Drugs for Conditions...... 60 Alzheimer's Disease and Dementia...... 18 Hormonal Agents - Adrenal...... 61 ...... 18 Hormonal Agents - Men's Health...... 61 Antiemetics - Drugs for and Hormonal Agents - Osteoporosis...... 62 ...... 21 Hormonal Agents - Pituitary...... 62 Antifungals...... 21 Hormonal Agents - Prostaglandins...... 63 Antigout Agents...... 23 Hormonal Agents - Sex Hormones and Anti-inflammatory Agents...... 23 Birth Control...... 63 Antimigraine Agents...... 23 Hormonal Agents - Thyroid...... 68 Antimyasthenic Agents...... 24 Immunological Agents - Drugs for Immune Antimycobacterials...... 24 System Stimulation or Suppression...... 69 Antineoplastics - Drugs for Cancer...... 24 Inflammatory Bowel Disease Agents...... 73 Antiparasitics...... 25 Metabolic Bone Disease Agents - Drugs Antiparkinson Agents...... 26 for Osteoporosis...... 74 Antiplatelets...... 27 Metabolic Bone Disease Agents - Other....74 - Drugs for Mood Disorders27 Miscellaneous Therapeutic Agents...... 74 Antivirals...... 28 Ophthalmic Agents - Drugs for Eye Anxiolytics - Drugs for Anxiety...... 31 Allergy, Infection and Inflammation...... 75 Bipolar Agents - Drugs for Mood Ophthalmic Agents - Drugs for Glaucoma. 77 Disorders...... 32 Ophthalmic Agents - Drugs for Blood Products and Modifiers - Drugs for Miscellaneous Eye Conditions...... 78 Blood Disorders...... 32 Otic Agents - Drugs for Ear Conditions...... 79 Cardiovascular Agents - Drugs for Heart Respiratory Tract / Pulmonary Agents - and Circulation Conditions...... 32 Drugs for Allergies, Cough, Cold...... 79 Central Nervous System Agents - Drugs Respiratory Tract / Pulmonary Agents - for Attention Deficit Disorder...... 39 Drugs for Asthma and Other Central Nervous System Agents - Drugs Conditions...... 81 for Multiple Sclerosis...... 40 Respiratory Tract / Pulmonary Agents - Central Nervous System Agents - Drugs for Cystic Fibrosis...... 85 Miscellaneous...... 41 Respiratory Tract / Pulmonary Agents - Dental and Oral Agents - Drugs for Mouth Drugs for Pulmonary ...... 86 and Throat Conditions...... 42 Skeletal Muscle Relaxants - Drugs for Dermatological Agents - Drugs for Skin Muscle Pain and Spasm...... 86 Conditions...... 43 Sleep Disorder Agents...... 87 Diabetes - Antidiabetic Agents...... 49 Stimulation or Suppression...... 87 Diabetes - Glucose Monitoring...... 51 Index of Drugs...... 88 Diabetes - Glycemic Agents...... 51 Diabetes - ...... 51 Electrolytes / Minerals / Metals / Vitamins. 53 5 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Analgesics - Drugs butalbital- for Pain acetaminophen oral 1 tablet 25-325 mg, 50- acetaminophen- 1 QL codeine #2 325 mg butalbital- acetaminophen- 1 QL codeine #3 acetaminophen oral 1 FE tablet 50-300 mg acetaminophen- 1 QL codeine #4 butalbital-apap-caff-cod 1 butalbital-apap- acetaminophen- 1 QL 1 codeine oral tablet oral capsule acetaminophen- butalbital-apap-caffeine codeine solution 120-12 1 QL oral tablet 50-325-40 1 mg/5ml oral mg ACTIQ 3 butalbital-asa-caff- 1 codeine ALLZITAL 3 PA; FE butalbital-aspirin- 3 FE; QL 1 APADAZ caffeine oral capsule apap-caff- tartrate 1 QL 1 QL dihydrocodeine oral nasal tablet 325-30-16 mg BUTRANS 3 QL ascomp-codeine 1 carisoprodol-aspirin- 1 1 bac codeine BELBUCA 3 QL codeine sulfate oral 1 QL BENZHYDROCODON 3 FE; QL tablet E-ACETAMINOPHEN CONZIP 3 PA; FE BUPAP ORAL TABLET 3 FE DILAUDID ORAL 3 QL 50-300 MG endocet oral tablet 10- buprenorphine 1 QL 325 mg, 2.5-325 mg, 5- 1 QL transdermal 325 mg, 7.5-325 mg butalbital- ESGIC 3 acetaminophen capsule 1 FE 50-300 mg oral fentanyl 1 QL BUTALBITAL- fentanyl citrate buccal 1 lozenge on a handle ACETAMINOPHEN 2 PA CAPSULE 50-300 MG FENTANYL CITRATE 3 ORAL BUCCAL TABLET

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 6 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required FENTORA BUCCAL hydromorphone hcl er 1 QL TABLET 100 MCG, 200 3 oral tablet extended MCG, 400 MCG, 600 release 24 hour MCG, 800 MCG hydromorphone hcl oral 1 QL FIORICET ORAL 3 HYSINGLA ER 3 QL CAPSULE LAZANDA NASAL FIORICET/CODEINE SOLUTION 100 3 FE ORAL CAPSULE 50- 3 MCG/ACT, 400 300-40-30 MG MCG/ACT hydrocodone bitartrate tartrate oral 1 QL er oral capsule 1 QL tablet 2 mg extended release 12 hour levorphanol tartrate oral 1 tablet 3 mg hydrocodone bitartrate er oral tablet er 24 hour 1 QL LORTAB ORAL ELIXIR 3 QL abuse-deterrent 10-300 MG/15ML hydrocodone- meperidine hcl oral 1 QL solution acetaminophen oral 1 QL solution 10-325 meperidine hcl oral 1 QL mg/15ml tablet 50 mg hydrocodone- methadone hcl intensol 1 acetaminophen oral methadone hcl oral 1 tablet 10-300 mg, 10- 1 QL methadose oral 325 mg, 5-300 mg, 5- 1 concentrate 10 mg/ml 325 mg, 7.5-300 mg, 7.5-325 mg methadose oral tablet 1 soluble hydrocodone- acetaminophen solution 1 QL methadose sugar-free 1 2.5-108 mg/5ml oral sulfate hydrocodone- (concentrate) oral 1 QL acetaminophen solution 1 QL solution 100 mg/5ml, 20 5-217 mg/10ml oral mg/ml hydrocodone- morphine sulfate er 1 QL acetaminophen solution 1 QL beads 7.5-325 mg/15ml oral morphine sulfate er oral hydrocodone- capsule extended 1 QL oral tablet 10-200 mg, 1 QL release 24 hour 5-200 mg, 7.5-200 mg morphine sulfate er oral 1 QL tablet extended release

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 7 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required morphine sulfate oral 1 QL OXYCODONE HCL ER solution 20 mg/5ml TABLET ER 12 HOUR 2 QL ABUSE-DETERRENT morphine sulfate oral 1 QL tablet 40 MG ORAL OXYCODONE HCL ER morphine sulfate 1 QL solution 10 mg/5ml oral TABLET ER 12 HOUR 3 FE; QL ABUSE-DETERRENT MS CONTIN ORAL 40 MG ORAL TABLET EXTENDED 3 QL RELEASE oxycodone hcl oral 1 QL capsule PA; FE; 3 NALOCET QL oxycodone hcl oral concentrate 100 1 QL 3 QL NUCYNTA mg/5ml NUCYNTA ER 3 FE; QL oxycodone hcl oral 1 QL PA; FE; OXAYDO ORAL 3 tablet TABLET QL oxycodone hcl solution 1 QL OXYCODONE HCL ER 5 mg/5ml oral ORAL TABLET ER 12 OXYCODONE- HOUR ABUSE- 3 FE; QL ACETAMINOPHEN 3 PA; FE DETERRENT 15 MG, ORAL SOLUTION 10- 30 MG, 60 MG, 80 MG 300 MG/5ML OXYCODONE HCL ER OXYCODONE- TABLET ER 12 HOUR 2 QL ACETAMINOPHEN PA; FE; ABUSE-DETERRENT 3 ORAL TABLET 10-300 QL 10 MG ORAL MG, 2.5-300 MG, 5-300 OXYCODONE HCL ER MG TABLET ER 12 HOUR 3 FE; QL oxycodone- ABUSE-DETERRENT acetaminophen oral 10 MG ORAL tablet 10-325 mg, 2.5- 1 QL OXYCODONE HCL ER 325 mg, 5-325 mg, 7.5- TABLET ER 12 HOUR 2 QL 325 mg ABUSE-DETERRENT OXYCONTIN ORAL 20 MG ORAL TABLET ER 12 HOUR 2 QL OXYCODONE HCL ER ABUSE-DETERRENT TABLET ER 12 HOUR 3 FE; QL oxymorphone hcl 1 QL ABUSE-DETERRENT 20 MG ORAL oxymorphone hcl er 1 QL -naloxone 1 QL hcl

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 8 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PERCOCET ORAL ZEBUTAL ORAL 3 TABLET 10-325 MG, 3 QL CAPSULE 50-325-40 2.5-325 MG, 5-325 MG, MG 7.5-325 MG Analgesics - Drugs for Pain and PROLATE ORAL 3 PA; FE SOLUTION Inflammation PA; FE; adult aspirin regimen 1 ACA; O PROLATE ORAL 3 TABLET QL ARTHROTEC ORAL QDOLO 3 PA; FE TABLET DELAYED 3 RELEASE ROXICODONE ORAL 3 QL TABLET aspirin adult low SUBSYS 3 strength oral tablet 1 ACA; O delayed release TENCON ORAL 3 PA; FE TABLET 50-325 MG aspirin childrens 1 ACA; O hcl er aspirin ec low dose 1 ACA; O (biphasic) oral tablet aspirin ec low strength 1 ACA; O extended release 24 1 aspirin ec oral tablet hour 100 mg, 200 mg, delayed release 325 1 ACA; O 300 mg mg TRAMADOL HCL ER aspirin low dose oral 1 ACA; O ORAL CAPSULE tablet delayed release EXTENDED RELEASE 3 PA; FE 24 HOUR 100 MG, 200 aspirin low dose tablet 1 ACA; O MG, 300 MG chewable 81 mg oral tramadol hcl er oral aspirin oral tablet 325 1 ACA; O tablet extended release 1 mg 24 hour aspirin oral tablet delayed release 325 1 ACA; O tramadol hcl oral tablet 1 100 mg mg, 81 mg CAMBIA 3 FE tramadol hcl oral tablet 1 QL 50 mg CATAFLAM 3 CELEBREX 3 tramadol- 1 QL acetaminophen celecoxib oral 1 ULTRACET TABLET 3 QL DAYPRO 3 37.5-325 MG ORAL DICLOFENAC CAP 3 PA; FE ULTRAM 3 QL 35MG VTOL LQ 2 PA PA; FE; DICLOFENAC PATCH 3 XTAMPZA ER 3 FE; QL EXTERNAL QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 9 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required diclofenac potassium 1 INDOMETHACIN diclofenac sodium er 1 ORAL CAPSULE 20 3 PA; FE MG diclofenac sodium 1 external solution indomethacin oral 1 capsule 25 mg, 50 mg diclofenac sodium gel 1 1 QL % external (rx) ketoprofen er 1 FE diclofenac sodium oral 1 ketoprofen oral 1 diclofenac-misoprostol ketorolac tromethamine oral tablet delayed 1 injection solution 15 1 release mg/ml diflunisal oral 1 ketorolac tromethamine intramuscular solution 1 3 PA; FE DUEXIS 60 mg/2ml 3 EC-NAPROSYN KETOROLAC ec- 1 TROMETHAMINE 3 PA; FE etodolac er 1 NASAL etodolac oral 1 ketorolac tromethamine 1 QL oral FELDENE 3 ketorolac tromethamine fenoprofen calcium oral 1 FE solution 30 mg/ml 1 fenortho oral capsule 1 FE injection 200 mg LICART PATCH 24 PA; FE; 3 HOUR 1.3 % 3 PA; FE FLECTOR EXTERNAL QL EXTERNAL flurbiprofen oral 1 LODINE 3 goodsense aspirin 1 ACA; O meclofenamate sodium 1 FE adults oral goodsense aspirin low 1 ACA; O mefenamic acid oral 1 dose meloxicam oral capsule 1 FE ibuprofen 1 meloxicam oral tablet 1 ibuprofen oral 1 MOBIC ORAL TABLET 3 suspension nabumetone oral 1 INDOCIN ORAL 3 NALFON ORAL INDOCIN RECTAL 3 PA; FE 3 FE CAPSULE 400 MG indomethacin er 1 NALFON ORAL 3 FE TABLET

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 10 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required NAPRELAN ORAL VIVLODEX 3 FE TABLET EXTENDED 3 ZIPSOR 3 PA; FE RELEASE 24 HOUR 3 PA; FE 375 MG, 500 MG ZORVOLEX Anesthetics NAPRELAN ORAL ethyl chloride 1 TABLET EXTENDED 3 PA; FE RELEASE 24 HOUR GEBAUERS PAIN 3 750 MG EASE NAPROSYN ORAL 3 GEBAUERS SPRAY 3 SUSPENSION AND STRETCH NAPROSYN ORAL 3 glydo external prefilled 1 TABLET 500 MG syringe naproxen oral 1 lidocaine external patch 1 naproxen sodium er 5 % oral tablet extended 1 lidocaine hcl external 1 release 24 hour 375 solution mg, 500 mg lidocaine hcl 1 NAPROXEN SODIUM urethral/mucosal ER ORAL TABLET 3 PA; FE lidocaine ointment 5 % EXTENDED RELEASE 1 external 24 HOUR 750 MG lidocaine-prilocaine naproxen sodium oral 1 1 external cream tablet 275 mg, 550 mg LIDOCAINE- naproxen- 1 FE TETRACAINE esomeprazole 3 PA; FE EXTERNAL CREAM 7- oxaprozin 1 7 % PA; FE; PENNSAID SOLUTION 3 LIDODERM 3 2 % EXTERNAL QL PLIAGLIS EXTERNAL 3 PA; FE piroxicam oral 1 CREAM QMIIZ ODT 3 PA; FE SYNERA 3 PA; FE RELAFEN 3 ZTLIDO 3 PA; FE RELAFEN DS 3 PA; FE Anti-Addiction / SPRIX 3 PA; FE Substance Abuse Treatment Agents sulindac oral 1 1 TIVORBEX ORAL acamprosate calcium 3 PA; FE ACA; PV; CAPSULE 20 MG 2 QL VIMOVO 3 FE APO-VARENICLINE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 11 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 QL BUNAVAIL SUBOXONE 3 QL SUBLINGUAL FILM buprenorphine hcl 1 QL sublingual ZUBSOLV 3 QL Antibacterials buprenorphine hcl- 1 QL naloxone hcl ACTICLATE 3 ACA; PV; hcl er 1 AEMCOLO 3 FE; QL (smoking det) QL ALTABAX 3 FE ACA; PV; 2 1 CHANTIX QL amoxicillin oral capsule amoxicillin oral CHANTIX ACA; PV; 2 suspension 1 CONTINUING MONTH QL PAK reconstituted ACA; PV; amoxicillin oral tablet 1 CHANTIX STARTING 2 MONTH PAK QL amoxicillin oral tablet 1 disulfiram oral 1 chewable 125 mg, 250 mg goodsense nicotine ACA; O; 1 amoxicillin-potassium mouth/throat lozenge 4 QL 1 mg clavulanate er ACA; O; amoxicillin-potassium 1 1 habitrol QL clavulanate oral LUCEMYRA 3 QL ampicillin oral capsule 1 500 mg naltrexone hcl oral 1 ARIKAYCE 4 SP; FE NARCAN 2 QL AUGMENTIN ES-600 3 ACA; O; 1 nicotine polacrilex mini QL AUGMENTIN ORAL SUSPENSION ACA; O; nicotine polacrilex 1 RECONSTITUTED 3 mouth/throat QL 125-31.25 MG/5ML, ACA; O; 250-62.5 MG/5ML 1 nicotine step 1 QL AUGMENTIN ORAL 3 ACA; O; TABLET 500-125 MG 1 nicotine step 2 QL avidoxy 1 ACA; O; 1 azithromycin oral 1 nicotine step 3 QL packet ACA; PV; 2 azithromycin oral NICOTROL QL suspension 1 ACA; PV; reconstituted 2 NICOTROL NS QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 12 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 azithromycin oral tablet 1 CLINDESSE 500 mg, 600 mg coremino 1 FE azithromycin tablet 250 1 demeclocycline hcl oral 1 mg oral dicloxacillin sodium 1 BACTRIM 3 DIFICID 3 ST; QL BACTRIM DS 3 DORYX MPC 3 PA; FE BAXDELA ORAL 3 PA DORYX ORAL TABLET benzalkonium chloride DELAYED RELEASE 3 external solution , 50 1 200 MG, 50 MG % DORYX ORAL TABLET cefaclor 1 DELAYED RELEASE 3 PA; FE cefaclor er 1 80 MG 1 cefadroxil doxycycline hyclate oral 1 cefdinir 1 capsule cefixime 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 1 1 cefpodoxime proxetil 20 mg, 50 mg, 75 mg 1 cefprozil doxycycline hyclate oral cefuroxime axetil oral 1 tablet delayed release 1 tablet 100 mg, 150 mg, 200 CENTANY 3 mg, 50 mg, 75 mg cephalexin 1 DOXYCYCLINE HYCLATE ORAL CIPRO ORAL 3 PA; FE TABLET DELAYED SUSPENSION 3 RELEASE 80 MG RECONSTITUTED doxycycline CIPRO ORAL TABLET 3 monohydrate oral 1 250 MG, 500 MG capsule 100 mg, 50 mg ciprofloxacin hcl oral 1 doxycycline clarithromycin er 1 monohydrate oral 1 FE clarithromycin oral 1 capsule 150 mg, 75 mg CLEOCIN 3 doxycycline monohydrate oral clindamycin hcl oral 1 1 suspension clindamycin palmitate 1 reconstituted hcl doxycycline 1 clindamycin phosphate 1 monohydrate oral tablet vaginal

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 13 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 E.E.S. 400 ORAL 2 MACROBID TABLET MACRODANTIN 3 E.E.S. GRANULES 3 mafenide acetate 1 ERYPED 200 3 external ERYPED 400 3 methenamine hippurate 1 ERY-TAB 3 metronidazole oral 1 ERYTHROCIN metronidazole vaginal 1 STEARATE ORAL 2 MINOCYCLINE HCL TABLET 250 MG ER ORAL CAPSULE 3 FE base oral 1 EXTENDED RELEASE 24 HOUR erythromycin 1 ethylsuccinate oral minocycline hcl er oral erythromycin oral 1 tablet extended release 1 FE 24 hour FIRVANQ 2 minocycline hcl oral 1 FLAGYL ORAL 3 CAPSULE MINOLIRA 3 PA; FE mondoxyne nl oral FLAGYL ORAL 3 1 TABLET 500 MG capsule 100 mg mondoxyne nl oral fosfomycin 1 1 FE tromethamine capsule 75 mg MONUROL 3 gentamicin sulfate 1 external morgidox oral capsule 1 HIPREX 3 100 mg HUMATIN 3 moxifloxacin hcl oral 1 mupirocin calcium 1 FE hydrogen peroxide 1 solution 30 % mupirocin external 1 1 KEFLEX ORAL 3 neomycin sulfate oral CAPSULE 750 MG nitrofurantoin 1 levofloxacin oral tablet 1 macrocrystal oral levofloxacin solution 25 1 nitrofurantoin mg/ml oral monohydrate 1 linezolid oral macrocrystals 1 PA suspension nitrofurantoin oral 1 reconstituted suspension 3 PA; FE linezolid tablet 600 mg 1 PA NUVESSA oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 14 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

NUZYRA ORAL 3 FE; QL SUPRAX ORAL 3 TABLET 150 MG TABLET CHEWABLE 3 ofloxacin oral tablet 300 1 TARGADOX mg, 400 mg tetracycline hcl oral 1 paromomycin sulfate 1 tinidazole oral 1 oral trimethoprim oral 1 penicillin v potassium 1 VANCOCIN 3 PRIMSOL 3 FE VANCOCIN HCL ORAL 3 SEYSARA 3 FE CAPSULE 125 MG SILVADENE 3 vancomycin hcl oral 1 silver sulfadiazine 1 vandazole 1 external VIBRAMYCIN 3 SIVEXTRO ORAL 3 PA; FE XENLETA ORAL 3 SOLODYN ORAL 3 TABLET EXTENDED XEPI 3 FE RELEASE 24 HOUR XIFAXAN ORAL 3 FE; QL 105 MG, 115 MG, 55 TABLET 200 MG MG, 65 MG, 80 MG XIFAXAN ORAL 2 SOLOSEC 3 FE; QL TABLET 550 MG ssd 1 XIMINO 3 FE 1 sulfadiazine oral ZITHROMAX ORAL 3 PACKET sulfamethoxazole- 1 trimethoprim oral tablet ZITHROMAX ORAL 3 sulfamethoxazole- SUSPENSION RECONSTITUTED trimethoprim 1 suspension 200-40 ZITHROMAX ORAL 3 mg/5ml oral TABLET 500 MG ZITHROMAX TABLET SULFAMYLON 3 PA; FE 3 EXTERNAL CREAM 250 MG ORAL ZITHROMAX TRI-PAK 3 SULFAMYLON 3 EXTERNAL PACKET ZITHROMAX Z-PAK 3 sulfatrim pediatric 1 ZYVOX ORAL SUSPENSION 3 PA SUPRAX ORAL 3 CAPSULE RECONSTITUTED SUPRAX ORAL ZYVOX TABLET 600 3 PA SUSPENSION 3 MG ORAL RECONSTITUTED

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 15 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Anticoagulants Anticonvulsants - ARIXTRA 3 PV Drugs for Seizures BEVYXXA 3 PV; QL APTIOM 3 FE ELIQUIS 2 PV BANZEL 3 ELIQUIS DVT/PE BRIVIACT ORAL 3 1 STARTER PACK 2 PV carbamazepine er ORAL TABLET carbamazepine oral 1 THERAPY PACK tablet enoxaparin sodium 1 PV carbamazepine oral 1 fondaparinux sodium 1 PV tablet chewable FRAGMIN carbamazepine SUBCUTANEOUS suspension 100 mg/5ml 1 SOLUTION 10000 oral UNIT/ML, 12500 CARBATROL 3 UNIT/0.5ML, 15000 2 UNIT/0.6ML, 18000 2 PV CELONTIN UNT/0.72ML, 2500 clobazam 1 UNIT/0.2ML, 5000 DEPAKOTE 3 UNIT/0.2ML, 7500 DEPAKOTE ER 3 UNIT/0.3ML, 95000 UNIT/3.8ML DEPAKOTE SPRINKLES ORAL heparin sodium 3 CAPSULE DELAYED (porcine) injection RELEASE SPRINKLE solution 1000 unit/ml, 1 PV 10000 unit/ml, 20000 DIACOMIT 4 PA; SP unit/ml, 5000 unit/ml DIASTAT ACUDIAL 3 QL heparin sodium DIASTAT PEDIATRIC 3 QL (porcine) pf injection 1 PV diazepam rectal 1 QL solution 5000 unit/0.5ml DILANTIN INFATABS 3 jantoven 1 PV DILANTIN ORAL LOVENOX 3 PV 3 CAPSULE 100 MG PRADAXA 3 PV; FE DILANTIN ORAL 2 SAVAYSA 3 PV; FE CAPSULE 30 MG warfarin sodium oral 1 PV DILANTIN ORAL 3 XARELTO 2 PV SUSPENSION divalproex sodium er XARELTO STARTER 2 PV PACK oral tablet extended 1 release 24 hour

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 16 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required divalproex sodium oral LAMICTAL XR ORAL capsule delayed 1 TABLET EXTENDED 3 release sprinkle RELEASE 24 HOUR 1 divalproex sodium oral 1 lamotrigine er tablet delayed release lamotrigine oral kit 25 & 1 ELEPSIA XR 3 FE 50 & 100 mg EPIDIOLEX 4 PA; SP lamotrigine oral tablet 1 1 epitol lamotrigine oral tablet 1 ethosuximide oral 1 chewable felbamate oral tablet 1 lamotrigine oral tablet 1 dispersible felbamate suspension 1 600 mg/5ml oral lamotrigine starter kit- 1 blue FELBATOL 3 lamotrigine starter kit- PA; SP; 1 4 green FINTEPLA QL lamotrigine starter kit- 3 1 FYCOMPA orange 1 gabapentin oral capsule levetiracetam er 1 gabapentin oral solution 1 levetiracetam oral tablet 1 300 mg/6ml levetiracetam solution 1 1 gabapentin oral tablet 100 mg/ml oral gabapentin solution 250 1 MYSOLINE 3 mg/5ml oral NAYZILAM 2 QL GABITRIL 3 NEURONTIN 3 KEPPRA ORAL 3 ONFI ORAL 3 3 KEPPRA XR SUSPENSION LAMICTAL ODT 3 ONFI ORAL TABLET 3 LAMICTAL ORAL 3 10 MG, 20 MG TABLET oxcarbazepine 1 LAMICTAL ORAL OXTELLAR XR 3 TABLET CHEWABLE 3 25 MG, 5 MG phenobarbital oral elixir 1 LAMICTAL STARTER 3 phenobarbital oral 1 tablet LAMICTAL XR ORAL 2 KIT PHENYTEK 3 phenytoin infatabs 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 17 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required phenytoin oral 1 valproic acid solution 1 suspension 125 mg/5ml 250 mg/5ml oral 2 QL phenytoin oral tablet 1 VALTOCO chewable vigabatrin 4 SP phenytoin sodium 1 vigadrone 4 SP extended VIMPAT ORAL 2 primidone oral 1 XCOPRI 2 QL QUDEXY XR 3 ZARONTIN 3 roweepra oral tablet 1 3 500 mg ZONEGRAN 1 rufinamide 1 zonisamide oral Antidementia Agents - SABRIL 4 SP Drugs for Alzheimer's SPRITAM 3 PA; FE Disease and Dementia subvenite 1 ARICEPT 3 subvenite starter kit- 1 donepezil hcl 1 blue EXELON 3 subvenite starter kit- 1 TRANSDERMAL green 1 subvenite starter kit- 1 hydrobromide orange galantamine 1 SYMPAZAN 3 FE hydrobromide er TEGRETOL ORAL 3 hcl er 1 SUSPENSION memantine hcl oral 1 TEGRETOL ORAL 3 solution 2 mg/ml TABLET memantine hcl oral 1 TEGRETOL-XR 3 tablet tiagabine hcl 1 NAMENDA TITRATION 3 TOPAMAX 3 PAK TOPAMAX SPRINKLE 3 NAMENDA XR 3 topiramate er 1 NAMZARIC 3 topiramate oral 1 RAZADYNE ER 3 TRILEPTAL 3 rivastigmine 1 TROKENDI XR 3 rivastigmine tartrate 1 Antidepressants valproic acid oral 1 capsule hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 18 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 1 DESVENLAFAXINE ER 3 ST; FE 3 ANAFRANIL desvenlafaxine 1 APLENZIN TABLET succinate er EXTENDED RELEASE 3 PA; FE hcl oral 1 24 HOUR 174 MG capsule ORAL doxepin hcl oral 1 APLENZIN TABLET concentrate EXTENDED RELEASE 3 PA; FE DRIZALMA SPRINKLE 3 FE 24 HOUR 348 MG 1 ORAL duloxetine hcl oral 3 APLENZIN TABLET EFFEXOR XR EMSAM 3 FE EXTENDED RELEASE 3 PA; FE 24 HOUR 522 MG escitalopram oxalate 1 PV ORAL oral tablet BRISDELLE 3 QL escitalopram oxalate 1 PV bupropion hcl er (sr) 1 solution 5 mg/5ml oral bupropion hcl er (xl) FETZIMA 3 ST; FE oral tablet extended 1 FETZIMA TITRATION 3 ST; FE release 24 hour 150 hcl (pmdd) mg, 300 mg 1 FE oral tablet BUPROPION HCL ER fluoxetine hcl oral (XL) ORAL TABLET 1 PV 3 FE capsule EXTENDED RELEASE 24 HOUR 450 MG fluoxetine hcl oral capsule delayed 1 PV bupropion hcl oral 1 release CELEXA ORAL 3 PV; QL fluoxetine hcl oral tablet TABLET 1 PV; QL 10 mg chlordiazepoxide- 1 fluoxetine hcl oral tablet amitriptyline 1 PV; FE 20 mg, 60 mg citalopram fluoxetine hcl solution hydrobromide oral 1 PV; QL 1 PV 20 mg/5ml oral tablet fluvoxamine maleate 1 PV citalopram hydrobromide solution 1 PV; QL fluvoxamine maleate er 1 PV 10 mg/5ml oral FORFIVO XL 3 FE hcl oral 1 hcl oral 1 CYMBALTA 3 imipramine pamoate 1 hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 19 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

LEXAPRO ORAL 3 PV SYMBYAX ORAL TABLET CAPSULE 3-25 MG, 6- 3 PV MARPLAN 3 25 MG oral 1 tranylcypromine sulfate 1 NARDIL 3 hcl oral 1 hcl 1 maleate 1 oral NORPRAMIN ORAL 3 TABLET 10 MG, 25 MG TRINTELLIX ORAL 2 ST; QL TABLET 10 MG hcl oral 1 TRINTELLIX TABLET 2 ST; QL -fluoxetine 1 PV 20 MG ORAL hcl TRINTELLIX TABLET 5 2 ST; QL PAMELOR ORAL 3 MG ORAL CAPSULE venlafaxine hcl 1 PARNATE 3 venlafaxine hcl er oral 1 PV; QL paroxetine hcl er capsule extended 1 paroxetine hcl oral 1 PV; QL release 24 hour tablet venlafaxine hcl er oral paroxetine mesylate 1 QL tablet extended release 1 FE PAXIL CR 3 PV; QL 24 hour 150 mg, 37.5 mg, 75 mg PV; FE; PAXIL ORAL 3 SUSPENSION QL venlafaxine hcl er oral tablet extended release 1 PAXIL ORAL TABLET 3 PV; QL 24 hour 225 mg - 1 VIIBRYD ORAL ST; FE; amitriptyline 3 TABLET QL PA; PV; 3 VIIBRYD STARTER ST; FE; PEXEVA FE 3 PACK QL phenelzine sulfate oral 1 WELLBUTRIN SR 3 PRISTIQ 3 WELLBUTRIN XL hcl 1 TABLET EXTENDED 3 RELEASE 24 HOUR PROZAC ORAL 3 PV CAPSULE 150 MG ORAL WELLBUTRIN XL REMERON ORAL 3 TABLET 15 MG, 30 MG TABLET EXTENDED 3 RELEASE 24 HOUR REMERON SOLTAB 3 300 MG ORAL sertraline hcl oral 1 PV ZOLOFT 3 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 20 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Antiemetics - Drugs 1 PV for Nausea and maleate oral Vomiting prochlorperazine AKYNZEO ORAL 3 QL suppository 25 mg 1 PV aprepitant 1 QL rectal compro 1 PV REGLAN ORAL 3 PA; FE; dronabinol 1 3 SANCUSO QL EMEND ORAL 3 QL CAPSULE 80 MG 1 EMEND ORAL SYNDROS 3 FE SUSPENSION 3 QL TRANSDERM SCOP 3 RECONSTITUTED (1.5 MG) EMEND TRI-PACK 3 QL TRANSDERM-SCOP 3 GIMOTI 3 PA; FE (1.5 MG) hcl hcl tablet 1 1 QL 1 mg oral oral MARINOL 3 VARUBI (180 MG 3 FE; QL DOSE) hcl oral tablet 1 12.5 mg, 50 mg ZOFRAN ORAL 3 TABLET 4 MG meclizine hcl tablet 25 1 mg oral (rx) ZUPLENZ 3 PA; FE Antifungals hcl oral 1 solution 5 mg/5ml ANCOBON 3 metoclopramide hcl oral 1 ciclodan external 1 tablet solution 1 metoclopramide hcl oral 1 ciclopirox external tablet dispersible CICLOPIROX 2 metoclopramide hcl OLAMINE solution 10 mg/10ml 1 ciclopirox olamine 1 oral external hcl oral 1 clotrimazole cream 1 % 1 tablet external (rx) ondansetron hcl 1 CLOTRIMAZOLE 2 solution 4 mg/5ml oral POWDER ondansetron odt 1 clotrimazole solution 1 1 perphenazine oral 1 PV % external (rx)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 21 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required clotrimazole troche 10 1 LOPROX EXTERNAL 3 mg mouth/throat SUSPENSION 3 PA; FE clotrimazole- 1 LULICONAZOLE betamethasone LUZU 3 PA; FE CRESEMBA ORAL 3 MENTAX 3 PA; FE DIFLUCAN 3 miconazole 3 vaginal 1 econazole nitrate 1 suppository external MICONAZOLE-ZINC 3 PA; FE ECOZA 3 PA; FE OXIDE-PETROLAT ERTACZO 3 PA; FE naftifine hcl 1 3 PA; FE EXELDERM NAFTIN EXTERNAL 3 EXTINA 3 GEL fluconazole oral 1 NOXAFIL ORAL 3 flucytosine oral 1 nyamyc 1 nystatin external 1 griseofulvin microsize 1 oral nystatin oral tablet 1 griseofulvin 1 nystatin suspension ultramicrosize 100000 unit/ml 1 GYNAZOLE-1 3 mouth/throat itraconazole oral 1 QL nystatin-triamcinolone 1 JUBLIA 3 FE nystop 1 KERYDIN 3 FE ORAVIG 3 PA; FE oxiconazole nitrate 1 external 1 cream OXISTAT EXTERNAL 3 CREAM ketoconazole external 1 foam OXISTAT EXTERNAL 3 PA; FE LOTION ketoconazole external 1 shampoo 2 % posaconazole 1 ketoconazole oral 1 SPORANOX 3 QL 1 ketodan external foam SPORANOX 3 QL PULSEPAK LOPROX EXTERNAL 3 CREAM SULCONAZOLE 3 PA; FE NITRATE LOPROX EXTERNAL 3 SHAMPOO tavaborole 1 terbinafine hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 22 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required terconazole 1 QL AJOVY SOLUTION ST; FE; TOLNAFTATE 2 PREFILLED SYRINGE 3 225 MG/1.5ML QL 3 PA; FE TOLSURA SUBCUTANEOUS 3 VFEND malate 1 QL 1 voriconazole oral AMERGE 3 QL 3 PA; FE VUSION CAFERGOT 3 3 PA; FE XOLEGEL D.H.E. 45 3 QL Antigout Agents 1 QL allopurinol oral 1 mesylate injection COLCHICINE ORAL 3 ST dihydroergotamine 1 QL CAPSULE mesylate nasal colchicine oral tablet 1 hydrobromide 1 QL colchicine-probenecid 1 EMGALITY 2 ST; QL COLCRYS 3 EMGALITY (300 MG 2 PA; QL febuxostat 1 ST DOSE) GLOPERBA 3 FE ERGOMAR 2 MITIGARE 3 ST -caffeine 1 probenecid oral 1 FROVA 3 QL ULORIC 3 ST succinate 1 QL ZYLOPRIM 3 IMITREX 3 QL Anti-inflammatory IMITREX STATDOSE Agents REFILL SUBCUTANEOUS 3 QL EMFLAZA 4 PA; SP SOLUTION Antimigraine Agents CARTRIDGE AIMOVIG SOLUTION IMITREX STATDOSE AUTO-INJECTOR 140 SYSTEM MG/ML 2 ST; QL SUBCUTANEOUS 3 QL SUBCUTANEOUS 140 SOLUTION AUTO- MG/ML INJECTOR AIMOVIG 2 ST; QL MAXALT ORAL 3 QL AJOVY SOLUTION TABLET 10 MG ST; FE; AUTO-INJECTOR 225 3 MAXALT-MLT ORAL MG/1.5ML QL TABLET DISPERSIBLE 3 QL SUBCUTANEOUS 10 MG MIGERGOT 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 23 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required MIGRANAL 3 QL Antimyasthenic hcl 1 QL Agents NURTEC 3 FE; QL MESTINON ORAL 3 SOLUTION ONZETRA XSAIL 3 MESTINON ORAL 3 QL 3 RELPAX TABLET 3 ST; QL REYVOW MESTINON ORAL benzoate 1 QL TABLET EXTENDED 3 nasal 1 QL RELEASE pyridostigmine bromide sumatriptan succinate 1 QL 1 oral er sumatriptan succinate pyridostigmine bromide 1 refill subcutaneous 1 QL oral solution solution cartridge pyridostigmine bromide 1 sumatriptan succinate oral tablet subcutaneous solution 1 QL Antimycobacterials 6 mg/0.5ml cycloserine oral 1 sumatriptan succinate dapsone oral 1 subcutaneous solution 1 QL 1 auto-injector 4 ethambutol hcl oral mg/0.5ml, 6 mg/0.5ml isoniazid oral 1 MYAMBUTOL ORAL sumatriptan-naproxen 1 FE 3 sodium TABLET 400 MG TOSYMRA 3 FE; QL MYCOBUTIN 3 QL PASER 2 TREXIMET ORAL 3 FE TABLET 85-500 MG PRETOMANID 2 UBRELVY TABLET 2 PA; QL PRIFTIN 2 100 MG ORAL pyrazinamide oral 1 UBRELVY TABLET 50 2 PA; QL 1 QL MG ORAL rifabutin PA; FE; rifampin oral 1 ZEMBRACE 3 SYMTOUCH QL SIRTURO 3 TRECATOR 2 3 QL NASAL Antineoplastics - zolmitriptan oral 1 QL Drugs for Cancer ZOMIG 3 QL anastrozole oral 1 ACA; PV ZOMIG ZMT 3 QL ARIMIDEX 3 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 24 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required AROMASIN 3 PV COARTEM 3 DROXIA 2 crotan 1 exemestane 1 ACA; PV DARAPRIM 4 PA; SP FARESTON 3 PV EMVERM 3 3 PV FEMARA hydroxychloroquine 1 HYDREA 3 sulfate oral hydroxyurea oral 1 IMPAVIDO 3 letrozole oral 1 PV ivermectin lotion 0.5 % 1 external (rx) leucovorin calcium oral 1 ivermectin oral 1 mercaptopurine oral 1 KRINTAFEL 2 QL MESNEX ORAL 2 LAMPIT 3 QL PANRETIN 2 lindane external 3 1 PURIXAN shampoo 3 FE SIKLOS MALARONE 3 3 ACA; PV SOLTAMOX malathion external 1 1 ACA; PV tamoxifen citrate oral mefloquine hcl 1 TARGRETIN 4 SP MEPRON 3 EXTERNAL NATROBA 3 toremifene citrate 1 PV NEBUPENT 3 Antiparasitics nitazoxanide oral 1 albendazole oral 1 OVIDE 3 ALBENZA 3 pentamidine isethionate 1 ALINIA ORAL inhalation SUSPENSION 2 RECONSTITUTED permethrin external 1 cream ALINIA ORAL TABLET 3 PLAQUENIL TABLET 3 FE 3 ARAKODA 200 MG ORAL 1 atovaquone oral praziquantel oral 1 atovaquone-proguanil 1 primaquine phosphate hcl oral tablet 26.3 (15 1 BENZNIDAZOLE 3 QL base) mg BILTRICIDE 3 pyrimethamine oral 4 PA; SP 3 chloroquine phosphate 1 QUALAQUIN oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 25 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required quinine sulfate oral 1 MIRAPEX ORAL spinosad 1 TABLET 0.125 MG, 0.5 3 MG, 0.75 MG, 1 MG STROMECTOL 3 NEUPRO 3 sulfurated lime 1 NOURIANZ 3 FE; QL Antiparkinson Agents ONGENTYS 2 QL hcl oral 1 capsule OSMOLEX ER 3 FE PARLODEL 3 amantadine hcl oral 1 tablet 1 dihydrochloride amantadine hcl syrup 1 50 mg/5ml oral pramipexole 1 APOKYN dihydrochloride er 1 SUBCUTANEOUS 4 SP mesylate oral SOLUTION hcl 1 CARTRIDGE ropinirole hcl er 1 AZILECT 3 RYTARY CAPSULE benztropine mesylate 1 EXTENDED RELEASE 3 ST oral 23.75-95 MG ORAL mesylate 1 RYTARY CAPSULE oral EXTENDED RELEASE 3 ST oral 1 36.25-145 MG ORAL carbidopa-levodopa 1 RYTARY CAPSULE carbidopa-levodopa er EXTENDED RELEASE 3 ST 48.75-195 MG ORAL oral tablet extended 1 release 25-100 mg, 50- RYTARY CAPSULE 200 mg EXTENDED RELEASE 3 ST 61.25-245 MG ORAL carbidopa-levodopa- 1 hcl oral 1 COMTAN 3 SINEMET ORAL entacapone 1 TABLET 10-100 MG, 3 25-100 MG PA; SP; 4 GOCOVRI FE STALEVO 100 3 INBRIJA 4 SP; FE STALEVO 125 3 KYNMOBI 4 SP; QL STALEVO 150 3 LODOSYN 3 STALEVO 200 3 MIRAPEX ER 3 STALEVO 50 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 26 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 PV; FE; STALEVO 75 ABILIFY MYCITE 3 MAINTENANCE KIT QL TASMAR ORAL 3 FE PV; FE; TABLET 100 MG ABILIFY MYCITE 3 1 FE STARTER KIT QL hcl 1 ABILIFY ORAL 3 PV; QL TABLET XADAGO 3 FE; QL ADASUVE 3 PV ZELAPAR 3 oral Antiplatelets 1 PV solution 1 PV aspirin-dipyridamole er aripiprazole oral tablet 1 PV; QL PA; PV; ASPIRIN- 3 aripiprazole oral tablet FE 1 PV; QL OMEPRAZOLE dispersible BRILINTA ORAL ST; PV; 2 PV 1 TABLET 60 MG maleate QL BRILINTA TABLET 90 ST; PV; 2 PV 3 MG ORAL CAPLYTA FE; QL PA; SP; 4 hcl oral QL 1 PV CABLIVI tablet 1 PV cilostazol oral tablet 1 PV clopidogrel bisulfate 1 PV clozapine oral tablet oral dispersible 12.5 mg, 25 1 PV dipyridamole oral 1 PV mg PA; PV; 3 clozapine tablet 1 PV DURLAZA FE dispersible 100 mg oral EFFIENT 3 PV clozapine tablet 1 PV dispersible 150 mg oral PLAVIX ORAL TABLET 3 PV 75 MG clozapine tablet 1 PV prasugrel hcl 1 PV dispersible 200 mg oral PA; PV; CLOZARIL 3 PV 3 YOSPRALA FE ST; PV; 3 ZONTIVITY 2 PV FANAPT FE; QL ST; PV; Antipsychotics - FANAPT TITRATION 3 Drugs for Mood PACK FE; QL Disorders hcl oral 1 PV PV; FE; 3 GEODON ORAL 3 PV QL ABILIFY MYCITE lactate oral 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 27 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required haloperidol oral 1 PV hcl 1 PV INVEGA 3 PV ZYPREXA ORAL 3 PV ST; PV; 3 PV 2 ZYPREXA ZYDIS LATUDA QL Antivirals succinate oral 1 PV abacavir sulfate oral 1 PV hcl 1 PV tablet ST; PV; abacavir sulfate NUPLAZID ORAL 2 1 PV CAPSULE QL solution 20 mg/ml oral ST; PV; abacavir sulfate- NUPLAZID ORAL 2 1 PV TABLET 10 MG QL lamivudine 1 PV olanzapine oral abacavir-lamivudine- 1 PV er 1 PV zidovudine 1 acyclovir external 1 FE cream fumarate 1 PV; QL acyclovir external 1 PV; QL 1 quetiapine fumarate er ointment ST; PV; 3 acyclovir oral 1 REXULTI FE; QL adefovir dipivoxil 1 RISPERDAL ORAL 3 PV SOLUTION APTIVUS ORAL 3 PV CAPSULE RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 3 PV atazanavir sulfate 1 PV 2 MG, 3 MG, 4 MG ATRIPLA 3 PV 1 PV BARACLUDE 3 ST; PV; BIKTARVY 2 PV 3 SAPHRIS FE; QL CIMDUO 2 PV ST; PV; 3 COMBIVIR 3 PV SECUADO FE; QL COMPLERA 2 PV SEROQUEL 3 PV; QL CRIXIVAN ORAL 2 PV SEROQUEL XR 3 PV; QL CAPSULE 400 MG hcl oral 1 PV DELSTRIGO 2 PV thiothixene oral 1 PV DENAVIR 3 PA; FE hcl oral 1 PV DESCOVY 2 PV VERSACLOZ 3 PV DOVATO 2 PV ST; PV; 2 EDURANT 2 PV VRAYLAR QL 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 28 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required efavirenz-emtricitab- 1 PV INVIRASE ORAL 2 PV tenofovir TABLET 2 PV efavirenz-lamivudine- 1 PV ISENTRESS tenofovir ISENTRESS HD 2 PV emtricitabine 1 PV JULUCA 2 PV emtricitabine-tenofovir 1 PV KALETRA ORAL 3 PV df SOLUTION EMTRIVA ORAL 3 PV KALETRA ORAL 3 PV CAPSULE TABLET EMTRIVA ORAL 2 PV lamivudine oral solution 1 PV SOLUTION lamivudine oral tablet 1 entecavir 1 100 mg EPCLUSA ORAL 4 PA; SP lamivudine oral tablet 1 PV; QL TABLET 200-50 MG 150 mg EPCLUSA ORAL PA; SP; 4 lamivudine oral tablet 1 PV TABLET 400-100 MG QL 300 mg EPIVIR HBV ORAL 2 lamivudine-zidovudine 1 PV SOLUTION PA; SP; LEDIPASVIR- 4 EPIVIR HBV ORAL 3 SOFOSBUVIR QL TABLET LEXIVA ORAL 2 PV EPIVIR ORAL 3 PV SUSPENSION SOLUTION LEXIVA ORAL TABLET 3 PV EPIVIR ORAL TABLET 3 PV; QL 1 PV 150 MG lopinavir-ritonavir PA; SP; EPIVIR ORAL TABLET 4 3 PV QL 300 MG MAVYRET 1 PV EPZICOM 3 PV nevirapine 1 PV etravirine 1 PV nevirapine er EVOTAZ 2 PV NORVIR ORAL 2 PV PACKET famciclovir oral 1 QL NORVIR ORAL 2 PV fosamprenavir calcium 1 PV SOLUTION GENVOYA 2 PV NORVIR ORAL 3 PV PA; SP; 4 TABLET HARVONI QL ODEFSEY 2 PV HEPSERA 3 oseltamivir phosphate 1 QL INTELENCE 3 PV oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 29 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PEGASYS SUSTIVA 3 PV SUBCUTANEOUS 4 SP SYMFI 3 PV SOLUTION SYMFI LO 3 PV PIFELTRO 2 PV SYMTUZA 2 PV PREVYMIS ORAL 4 SP; QL TAMIFLU ORAL 3 QL PREZCOBIX 2 PV CAPSULE PREZISTA ORAL 2 PV TAMIFLU ORAL SUSPENSION SUSPENSION 3 QL PREZISTA ORAL RECONSTITUTED 6 TABLET 150 MG, 600 2 PV MG/ML MG, 75 MG, 800 MG TEMIXYS 2 PV RELENZA DISKHALER 2 QL tenofovir disoproxil 1 PV RETROVIR ORAL 3 PV fumarate CAPSULE TIVICAY 3 PV RETROVIR ORAL 3 PV TIVICAY PD 3 PV SYRUP TRIUMEQ 2 PV REYATAZ ORAL 3 PV CAPSULE 150 MG, 3 PV TRIZIVIR 200 MG, 300 MG TRUVADA 3 PV TYBOST 3 PV REYATAZ ORAL 3 PV PACKET valacyclovir hcl oral 1 ribavirin inhalation 1 VALCYTE 3 ribavirin oral capsule 1 valganciclovir hcl 1 ribavirin oral tablet 200 1 VALTREX 3 mg VEMLIDY 3 hcl 1 SP; FE; 4 ritonavir 1 PV VIEKIRA PAK QL RUKOBIA 3 PV VIRACEPT ORAL 2 PV SELZENTRY 2 PV TABLET 3 FE SITAVIG VIRAMUNE ORAL 3 PV PA; SP; SUSPENSION SOFOSBUVIR- 4 VELPATASVIR QL VIRAMUNE XR ORAL SP; FE; TABLET EXTENDED 4 3 PV SOVALDI QL RELEASE 24 HOUR 400 MG stavudine oral capsule 1 PV VIRAZOLE 3 STRIBILD 2 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 30 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Anxiolytics - Drugs VIREAD ORAL 3 PV POWDER for Anxiety VIREAD ORAL alprazolam er 1 TABLET 150 MG, 200 2 PV alprazolam intensol 1 MG, 250 MG alprazolam oral tablet 1 VIREAD ORAL 3 PV TABLET 300 MG alprazolam oral tablet 1 FE dispersible PA; SP; 4 1 VOSEVI QL alprazolam xr 3 XERESE 3 PA; FE ATIVAN ORAL 1 XOFLUZA (40 MG hcl oral chlordiazepoxide hcl 1 DOSE) ORAL TABLET 3 QL THERAPY PACK 1 X clonazepam oral 1 40 MG clorazepate 1 XOFLUZA (40 MG dipotassium DOSE) TABLET 3 QL diazepam intensol 1 THERAPY PACK 2 X 20 MG ORAL diazepam oral 1 concentrate XOFLUZA (80 MG diazepam oral tablet 1 DOSE) ORAL TABLET 3 QL THERAPY PACK 1 X diazepam solution 5 1 80 MG mg/5ml oral XOFLUZA (80 MG DORAL 3 DOSE) TABLET 3 QL estazolam 1 THERAPY PACK 2 X 40 MG ORAL HALCION 3 SP; FE; hcl oral 4 1 ZEPATIER QL tablet ZIAGEN 3 PV hydroxyzine hcl syrup 1 10 mg/5ml oral zidovudine 1 PV hydroxyzine pamoate ZOVIRAX EXTERNAL 1 3 FE oral CREAM KLONOPIN 3 ZOVIRAX EXTERNAL 3 OINTMENT lorazepam intensol 1 lorazepam oral ZOVIRAX ORAL 3 1 SUSPENSION concentrate 2 mg/ml lorazepam oral tablet 1 meprobamate 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 31 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 1 PA; SP; midazolam hcl oral 4 oxazepam 1 PROMACTA QL PA; SP; quazepam 1 FE 4 TAVALISSE QL TRANXENE-T ORAL 3 TABLET 7.5 MG tranexamic acid oral 1 QL triazolam 1 Cardiovascular Agents - Drugs for VALIUM 3 Heart and Circulation VISTARIL 3 Conditions XANAX 3 ACCUPRIL 3 PV XANAX XR 3 ACCURETIC 3 PV Bipolar Agents - hcl oral 1 PV Drugs for Mood ALDACTAZIDE 3 PV Disorders ALDACTONE 3 PV EQUETRO 3 PV aliskiren fumarate 1 PV lithium carbonate er 1 ALTACE ORAL 1 3 PV lithium carbonate oral CAPSULE LITHOBID 3 PA; PV; 3 Blood Products and ALTOPREV FE; QL Modifiers - Drugs for amiloride hcl oral 1 PV Blood Disorders amiloride- 3 1 PV AGRYLIN hydrochlorothiazide AMICAR ORAL 3 amiodarone hcl oral 1 SOLUTION amlodipine besylate 1 PV AMICAR ORAL 3 oral TABLET amlodipine besylate- 1 PV aminocaproic acid oral 1 benazepril hcl solution amlodipine besylate- 1 PV aminocaproic acid oral 1 valsartan tablet amlodipine-atorvastatin 1 PV; QL anagrelide hcl 1 amlodipine-olmesartan 1 PV PA; SP; DOPTELET ORAL 4 TABLET 20 MG FE; QL amlodipine-valsartan- 1 PV hctz LYSTEDA 3 QL ANTARA ORAL PA; SP; PA; PV; 4 CAPSULE 30 MG, 90 3 QL FE MULPLETA MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 32 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required ATACAND 3 PV CADUET ORAL ATACAND HCT 3 PV TABLET 10-10 MG, 10- 20 MG, 10-40 MG, 10- 3 PV; QL 1 PV oral 80 MG, 5-10 MG, 5-20 atenolol-chlorthalidone 1 PV MG, 5-40 MG, 5-80 MG 3 PV atorvastatin calcium ACA; PV; CALAN SR 1 oral tablet 10 mg, 20 QL candesartan cilexetil 1 PV mg candesartan cilexetil- 1 PV atorvastatin calcium hctz oral tablet 40 mg, 80 1 PV; QL mg captopril oral 1 PV AVALIDE ORAL CARDIZEM CD 3 PV TABLET 150-12.5 MG, 3 PV CARDIZEM LA 3 PV 300-12.5 MG CARDIZEM ORAL AVAPRO 3 PV TABLET 120 MG, 30 3 PV AZOR 3 PV MG, 60 MG benazepril hcl oral 1 PV CARDURA 3 PV; QL CAROSPIR 3 PV; FE benazepril- 1 PV hydrochlorothiazide cartia xt 1 PV BENICAR 3 PV 1 PV BENICAR HCT 3 PV carvedilol phosphate er 1 PV BETAPACE AF 3 PV CATAPRES-TTS-1 3 PV BETAPACE ORAL CATAPRES-TTS-2 3 PV TABLET 120 MG, 160 3 PV CATAPRES-TTS-3 3 PV MG, 80 MG chlorthalidone oral 1 PV hcl oral 1 PV tablet 25 mg, 50 mg BIDIL 3 PV cholestyramine light 1 PV; QL fumarate oral 1 PV cholestyramine oral 1 PV; QL bisoprolol- 1 PV 1 PV hydrochlorothiazide clonidine hcl oral 1 PV bumetanide oral 1 PV colesevelam hcl oral 1 PV; FE BUMEX ORAL TABLET 3 PV packet 0.5 MG colesevelam hcl oral 1 PV BYSTOLIC 3 PV tablet COLESTID 3 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 33 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

COLESTID 3 PV disopyramide 1 FLAVORED phosphate oral colestipol hcl 1 PV DIURIL 2 PV PA; PV; 1 3 dofetilide CONJUPRI FE mesylate 1 PV; QL PA; PV; 3 oral CONSENSI FE 4 SP COREG 3 PV PA; PV; 3 COREG CR 3 PV DUTOPROL FE CORGARD 3 PV DYRENIUM 3 PV CORLANOR 3 EDARBI 3 PV; FE COZAAR 3 PV EDARBYCLOR 3 PV; FE CRESTOR 3 PV; QL EDECRIN 3 PV DEMSER 3 PV enalapril maleate oral 1 PV

DIBENZYLINE enalapril- 1 PV CAPSULE 10 MG 3 PV hydrochlorothiazide ORAL ENTRESTO 3 digitek 1 PV PA; PV; EPANED ORAL 3 digox 1 PV SOLUTION FE digoxin oral 1 PV eplerenone 1 PV DILATRATE-SR 2 PV ethacrynic acid oral 1 PV diltiazem hcl er beads 1 PV EXFORGE 3 PV 3 PV diltiazem hcl er coated 1 PV EXFORGE HCT beads PV; FE; 3 diltiazem hcl er oral EZALLOR SPRINKLE QL capsule extended 1 PV ezetimibe 1 PV; QL release 12 hour ezetimibe-simvastatin 1 PV; QL diltiazem hcl er oral felodipine er 1 PV capsule extended 1 PV release 24 hour 120 fenofibrate micronized 1 PV mg, 180 mg, 240 mg fenofibrate oral capsule 1 PV diltiazem hcl oral 1 PV 134 mg, 200 mg, 67 mg 1 PV dilt-xr fenofibrate oral capsule 1 PV; FE DIOVAN 3 PV 150 mg, 50 mg DIOVAN HCT 3 PV fenofibrate oral tablet 1 PV; FE 120 mg, 40 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 34 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required fenofibrate oral tablet INNOPRAN XL 1 PV PA; PV; 145 mg, 160 mg, 48 CAPSULE EXTENDED 3 mg, 54 mg RELEASE 24 HOUR 80 FE fenofibric acid oral MG ORAL capsule delayed 1 PV INNOPRAN XL ORAL PA; PV; release CAPSULE EXTENDED 3 RELEASE 24 HOUR FE fenofibric acid oral 1 PV; FE tablet 120 MG FENOGLIDE 3 PV; FE INSPRA 3 PV PA; PV; irbesartan 1 PV 3 FE FIBRICOR irbesartan- 1 PV flecainide acetate 1 hydrochlorothiazide FLOLIPID 3 PV; FE ISORDIL TITRADOSE 3 PV ACA; PV; isosorbide dinitrate oral 1 PV 1 fluvastatin sodium QL isosorbide mononitrate 1 PV ACA; PV; 1 isosorbide mononitrate 1 PV fluvastatin sodium er QL er fosinopril sodium 1 PV isradipine 1 PV 1 PV fosinopril sodium-hctz JUXTAPID ORAL SP; PV; CAPSULE 10 MG, 20 4 furosemide oral solution 1 PV FE 10 mg/ml, 8 mg/ml MG, 30 MG, 5 MG furosemide oral tablet 1 PV KAPSPARGO 3 PV; FE SPRINKLE gemfibrozil oral 1 PV KATERZIA 3 PV GONITRO 3 PV hcl oral 1 PV hcl oral 1 PV LANOXIN ORAL 4 SP; PV HEMANGEOL TABLET 125 MCG, 250 3 PV hydralazine hcl oral 1 PV MCG, 62.5 MCG hydrochlorothiazide oral 1 PV LASIX 3 PV HYZAAR 3 PV LESCOL XL 3 PV; QL icosapent ethyl 1 PV LIPITOR 3 PV; QL indapamide oral 1 PV LIPOFEN 3 PV; FE INDERAL LA 3 PV lisinopril oral 1 PV PA; PV; 3 lisinopril- 1 PV INDERAL XL FE hydrochlorothiazide

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 35 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PV; FE; 1 PV 3 minoxidil oral LIVALO QL moexipril hcl 1 PV LOPID 3 PV MULTAQ 2 LOPRESSOR ORAL 3 PV oral tablet 20 1 PV losartan potassium oral 1 PV mg, 40 mg, 80 mg 1 PV PA; PV; losartan potassium-hctz 2 LOTENSIN HCT ORAL NEXLETOL QL 3 PV PA; PV; TABLET 10-12.5 MG, 2 20-12.5 MG, 20-25 MG NEXLIZET QL

LOTENSIN ORAL 1 PV TABLET 10 MG, 20 3 PV (antihyperlipidemic) MG, 40 MG niacin er 1 PV LOTREL ORAL (antihyperlipidemic) CAPSULE 10-20 MG, 3 PV niacor 1 PV 10-40 MG, 5-10 MG, 5- 3 PV 20 MG NIASPAN ACA; PV; nicardipine hcl oral 1 PV 1 lovastatin oral QL er 1 PV 3 PV LOVAZA nifedipine er osmotic 1 PV matzim la 1 PV release 1 PV MAXZIDE 3 PV nifedipine oral 1 PV MAXZIDE-25 3 PV nimodipine oral 1 PV oral 1 PV nisoldipine er 2 PV metolazone 1 PV NITRO-BID succinate er 1 PV NITRO-DUR PATCH 24 HOUR 0.1 MG/HR 3 PV metoprolol tartrate oral 1 PV TRANSDERMAL metoprolol- 1 PV NITRO-DUR PATCH hydrochlorothiazide 24 HOUR 0.3 MG/HR 3 PV metyrosine 1 PV TRANSDERMAL mexiletine hcl oral 1 NITRO-DUR PATCH MICARDIS 3 PV 24 HOUR 0.8 MG/HR 3 PV TRANSDERMAL MICARDIS HCT 3 PV hcl 1 MINIPRESS 3 PV minitran 1 PV; FE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 36 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required NITRO-DUR PRALUENT PA; PV; TRANSDERMAL SUBCUTANEOUS 2 PATCH 24 HOUR 0.2 3 PV SOLUTION AUTO- QL MG/HR, 0.4 MG/HR, INJECTOR 0.6 MG/HR ACA; PV; 1 nitroglycerin sublingual 1 PV pravastatin sodium QL nitroglycerin hcl oral 1 PV transdermal patch 24 1 PV PRESTALIA 3 PV hour prevalite 1 PV; QL nitroglycerin 1 PV translingual solution PRINIVIL ORAL 3 PV TABLET 20 MG NITROLINGUAL 3 PV PROCARDIA XL 3 PV NITROMIST 3 PV hcl 1 NITROSTAT 3 PV propafenone hcl er 1 NORPACE 3 hcl er 1 PV NORPACE CR 2 propranolol hcl oral 1 PV NORTHERA 4 SP PA; PV; 3 NORVASC 3 PV QBRELIS FE olmesartan medoxomil 1 PV QUESTRAN 3 PV; QL oral QUESTRAN LIGHT 3 PV; QL olmesartan medoxomil- 1 PV ORAL POWDER hctz quinapril hcl 1 PV olmesartan-amlodipine- 1 PV hctz quinapril- 1 PV hydrochlorothiazide omega-3-acid ethyl 1 PV 1 esters gluconate er 1 PACERONE ORAL quinidine sulfate oral TABLET 100 MG, 200 3 ramipril 1 PV MG, 400 MG RANEXA 3 PV er 1 ranolazine er 1 PV perindopril erbumine 1 PV RECTIV 3 hcl PA; PV; 1 PV 2 oral REPATHA QL 1 PV REPATHA PA; PV; PUSHTRONEX 2 QL SYSTEM

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 37 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PA; PV; 3 PV REPATHA 2 TIAZAC SURECLICK QL TIKOSYN CAPSULE 3 rosuvastatin calcium 1 PV; QL 125 MCG ORAL PV; FE; 3 TIKOSYN CAPSULE 3 ROSZET QL 250 MCG ORAL 3 RYTHMOL SR TIKOSYN CAPSULE 3 500 MCG ORAL simvastatin oral tablet ACA; PV; 1 1 PV 10 mg, 20 mg, 40 mg, 5 QL maleate oral mg TOPROL XL 3 PV simvastatin oral tablet 1 PV; QL torsemide oral 1 PV 80 mg trandolapril 1 PV sorine 1 PV trandolapril-verapamil 1 PV hcl (af) 1 PV hcl er sotalol hcl oral 1 PV triamterene oral 1 PV SOTYLIZE 3 PV triamterene-hctz oral 1 PV spironolactone oral 1 PV capsule 37.5-25 mg 1 PV spironolactone-hctz triamterene-hctz oral 1 PV SULAR ORAL TABLET tablet 3 PV EXTENDED RELEASE 3 PV TRIBENZOR 24 HOUR 17 MG, 34 TRICOR 3 PV MG, 8.5 MG TRILIPIX 3 PV TARKA ORAL TABLET TWYNSTA 3 PV EXTENDED RELEASE 3 PV 2-180 MG, 2-240 MG, valsartan 1 PV 4-240 MG valsartan- 1 PV taztia xt 1 PV hydrochlorothiazide TEKTURNA 3 PV VASCEPA 2 PV TEKTURNA HCT 3 PV VASERETIC 3 PV telmisartan 1 PV VASOTEC 3 PV telmisartan-amlodipine 1 PV VECAMYL 3 PV telmisartan-hctz 1 PV verapamil hcl er oral 1 PV TENORETIC 100 3 PV capsule extended release 24 hour TENORETIC 50 3 PV verapamil hcl er oral TENORMIN 3 PV tablet extended release 1 PV tiadylt er 1 PV 120 mg, 180 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 38 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required verapamil hcl er tablet sulfate 1 extended release 240 1 PV amphetamine- 1 mg oral dextroamphetamine verapamil hcl oral 1 PV amphetamine- 1 VERELAN 3 PV dextroamphetamine er VERELAN PM 3 PV APTENSIO XR 3 FE VERQUVO 3 QL atomoxetine hcl 1 QL PA; SP; 1 4 clonidine hcl er VYNDAMAX QL CONCERTA 3 PA; SP; 4 COTEMPLA XR-ODT 3 FE VYNDAQEL QL DAYTRANA 3 VYTORIN 3 PV; QL DESOXYN 3 WELCHOL ORAL 3 PV; FE PACKET DEXEDRINE ORAL CAPSULE EXTENDED 3 WELCHOL ORAL 3 PV RELEASE 24 HOUR TABLET dexmethylphenidate hcl 1 ZESTORETIC 3 PV dexmethylphenidate hcl 1 ZESTRIL 3 PV er ZETIA 3 PV; QL dextroamphetamine 1 ZIAC 3 PV sulfate er

ZOCOR ORAL dextroamphetamine 1 TABLET 10 MG, 20 3 PV; QL sulfate oral MG, 40 MG, 80 MG DYANAVEL XR 3 FE PV; FE; ZYPITAMAG ORAL 3 EVEKEO 3 TABLET 2 MG, 4 MG QL EVEKEO ODT 3 FE Central Nervous System Agents - FOCALIN 3 Drugs for Attention FOCALIN XR 3 Deficit Disorder guanfacine hcl er 1 ADDERALL 3 INTUNIV 3 ADDERALL XR 3 JORNAY PM 3 FE ADHANSIA XR 3 FE KAPVAY TABLET 3 ADZENYS ER EXTENDED RELEASE 3 ADZENYS XR-ODT 3 12 HOUR 0.1 MG ORAL AMPHETAMINE ER 3 hcl 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 39 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

METHYLIN ORAL 3 RITALIN LA ORAL SOLUTION CAPSULE EXTENDED RELEASE 24 HOUR 10 3 hcl er 1 (cd) MG, 20 MG, 30 MG, 40 MG methylphenidate hcl er 1 (la) STRATTERA 3 QL VYVANSE 2 methylphenidate hcl er 1 (xr) ZENZEDI 3 methylphenidate hcl er Central Nervous oral tablet extended System Agents - release 10 mg, 18 mg, 1 Drugs for Multiple 20 mg, 27 mg, 36 mg, Sclerosis 54 mg PA; SP; 4 methylphenidate hcl er AMPYRA QL oral tablet extended 1 PA; SP; AUBAGIO TABLET 14 4 release 24 hour MG ORAL QL methylphenidate hcl er PA; SP; AUBAGIO TABLET 7 4 oral tablet extended 1 FE MG ORAL QL release 72 mg AVONEX PEN PA; SP; methylphenidate hcl 4 1 INTRAMUSCULAR QL oral solution 10 mg/5ml AUTO-INJECTOR KIT methylphenidate hcl 1 AVONEX PREFILLED oral tablet PA; SP; INTRAMUSCULAR 4 PREFILLED SYRINGE QL methylphenidate hcl 1 oral tablet chewable KIT PA; SP; methylphenidate hcl 1 4 solution 5 mg/5ml oral BAFIERTAM QL 3 FE PA; SP; MYDAYIS BETASERON 4 PROCENTRA 3 SUBCUTANEOUS KIT FE; QL QUILLICHEW ER 3 FE COPAXONE SOLUTION PA; SP; QUILLIVANT XR ORAL PREFILLED SYRINGE 4 3 QL SUSPENSION 40 MG/ML RECONSTITUTED ER SUBCUTANEOUS 1 FE relexxii COPAXONE RITALIN 3 SUBCUTANEOUS PA; SP; 4 SOLUTION QL PREFILLED SYRINGE 20 MG/ML

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 40 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PA; SP; 4 REBIF QL PA; SP; dalfampridine er SUBCUTANEOUS 4 PA; SP; SOLUTION QL 4 dimethyl fumarate oral QL PREFILLED SYRINGE PA; SP; REBIF TITRATION dimethyl fumarate 4 starter pack QL PACK PA; SP; SUBCUTANEOUS 4 PA; SP; QL EXTAVIA 4 SOLUTION QL SUBCUTANEOUS KIT PREFILLED SYRINGE PA; SP; GILENYA CAPSULE 4 PA; SP; QL 4 0.5 MG ORAL TECFIDERA QL PA; SP; 4 PA; SP; FE; QL 4 glatiramer acetate VUMERITY QL PA; SP; 4 PA; SP; FE; QL 4 glatopa ZEPOSIA FE; QL PA; SP; 4 ZEPOSIA 7-DAY PA; SP; QL 4 KESIMPTA STARTER PACK FE; QL PA; SP; 4 ZEPOSIA STARTER PA; SP; QL 4 MAVENCLAD KIT FE; QL PA; SP; 4 Central Nervous MAYZENT QL System Agents - PA; SP; Miscellaneous MAYZENT STARTER 4 QL PACK ADIPEX-P 3 PA PA; SP; 4 SP; FE; QL 4 PLEGRIDY AUSTEDO QL PA; SP; PLEGRIDY STARTER 4 benzphetamine hcl 1 PA PACK QL caffeine citrate oral 1 REBIF REBIDOSE PA; SP; CONTRAVE 3 PA; FE SUBCUTANEOUS 4 SOLUTION AUTO- QL diethylpropion hcl er 1 PA INJECTOR diethylpropion hcl oral 1 PA REBIF REBIDOSE GRALISE ORAL 3 FE TITRATION PACK PA; SP; TABLET 4 SUBCUTANEOUS QL SOLUTION AUTO- HORIZANT ORAL 3 INJECTOR TABLET EXTENDED RELEASE PA; SP; 4 IMCIVREE QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 41 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required SP; FE; 4 chlorhexidine gluconate INGREZZA QL solution 0.12 % 1 LOMAIRA 3 PA mouth/throat LYRICA 3 QL CLINPRO 5000 PASTE 3 1.1 % DENTAL ST; FE; 3 LYRICA CR QL DEBACTEROL SOLUTION 30-50 % 2 3 QL NUEDEXTA MOUTH/THROAT phendimetrazine 1 PA DENTA 5000 PLUS 3 tartrate DENTAGEL 3 phendimetrazine 1 PA tartrate er EVOXAC 3 phentermine hcl oral 1 PA FLUORIDEX 3 pregabalin er 1 ST; QL FLUORIDEX ENHANCED 1 QL 3 pregabalin oral WHITENING DENTAL QSYMIA 3 PA; FE PASTE RILUTEK 3 FLUORIDEX riluzole 1 SENSITIVITY RELIEF 3 DENTAL PASTE SAVELLA 2 ST; QL lidocaine hcl SAVELLA TITRATION 1 2 ST; QL mouth/throat PACK lidocaine viscous hcl PA; FE; 3 solution 2 % 1 SAXENDA QL mouth/throat PA; SP; 4 MI PASTE 2 TEGSEDI QL MI PASTE PLUS 2 tetrabenazine 4 PA; SP NAFRINSE DAILY TIGLUTIK 3 FE 2 ACIDULATED XENAZINE 4 PA; SP NAFRINSE 2 XENICAL 3 PA; FE DAILY/NEUTRAL Dental and Oral NAFRINSE WEEKLY 2 Agents - Drugs for oralone 1 Mouth and Throat Conditions PERIDEX 3 cavarest 1 periogard 1 cevimeline hcl 1 pilocarpine hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 42 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Dermatological PREVIDENT 5000 3 BOOSTER PLUS Agents - Drugs for Skin Conditions PREVIDENT 5000 DRY 3 MOUTH DENTAL GEL ABSORICA 3 PA; FE ABSORICA LD 3 FE PREVIDENT 5000 3 ENAMEL PROTECT ACANYA 3 PREVIDENT 5000 3 accutane oral capsule 1 ORTHO DEFENSE 20 mg, 30 mg, 40 mg PREVIDENT 5000 3 acitretin 1 PLUS ACZONE EXTERNAL 3 PREVIDENT 5000 3 GEL 5 % SENSITIVE ACZONE EXTERNAL 3 FE PREVIDENT DENTAL 3 GEL 7.5 % prevident mouth/throat 1 adapalene external 1 REMESENSE 3 cream SALAGEN 3 adapalene external gel 1 1 sf ADAPALENE 3 PA; FE sf 5000 plus 1 EXTERNAL PAD ADAPALENE sodium fluoride 5000 1 enamel EXTERNAL 3 FE SOLUTION sodium fluoride 5000 1 plus adapalene-benzoyl 1 peroxide external gel sodium fluoride 5000 1 ppm AKLIEF 3 FE ALA SCALP 3 PA; FE sodium fluoride 5000 1 sensitive ala-cort external cream 1 alclometasone sodium fluoride dental 1 1 cream dipropionate ALDARA 3 QL sodium fluoride dental 1 gel 1.1 % ALTRENO 3 sodium fluoride 1 ALUMINUM mouth/throat CHLORIDE 2 ANHYDROUS triamcinolone acetonide 1 mouth/throat

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 43 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

ALUMINUM betamethasone 1 CHLORIDE 2 valerate external HEXAHYDRATE BPCO 2 POWDER BRYHALI 3 PA; FE amcinonide external 1 FE 2 cream CALAMINE calcipotriene external amcinonide external 1 1 lotion cream CALCIPOTRIENE amcinonide external 1 FE 3 PA; FE ointment EXTERNAL FOAM ammonium lactate calcipotriene external 1 cream 12 % external 1 ointment (rx) calcipotriene external 1 solution ammonium lactate 1 lotion 12 % external (rx) calcipotriene-betameth 1 FE; QL amnesteem 1 diprop 3 AMZEEQ 3 FE CALCITRENE 1 APEXICON E 3 PA; FE calcitriol external 3 PA; FE ARAZLO 3 PA; FE CAPEX 2 ATRALIN 3 CARAC 1 AVITA 3 claravis azelaic acid external 1 CLEOCIN-T 3 EXTERNAL LOTION AZELEX 3 clindacin etz external 1 balsam peru-castor oil 1 swab BENZACLIN 3 clindacin-p 1 BENZACLIN WITH 3 CLINDAGEL 3 FE PUMP clindamycin phos- BENZAMYCIN 3 benzoyl perox external 1 benzoyl peroxide- 1 gel 1-5 %, 1.2-2.5 %, erythromycin 1.2-5 % 1 beser external lotion clindamycin phosphate 1 external foam betamethasone 1 dipropionate aug clindamycin phosphate 1 external lotion betamethasone 1 dipropionate external clindamycin phosphate 1 external solution

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 44 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required clindamycin phosphate 1 CUTIVATE EXTERNAL 3 external swab LOTION

CLINDAMYCIN dapsone external gel 5 1 PHOSPHATE GEL 1 % 3 FE % EXTERNAL DAPSONE EXTERNAL 3 FE clindamycin phosphate 1 GEL 7.5 % gel 1 % external DERMA-SMOOTHE/FS 3 clindamycin-tretinoin 1 BODY clobetasol prop 1 DERMA-SMOOTHE/FS 3 emollient base SCALP clobetasol propionate e 1 DESONATE 3 FE clobetasol propionate 1 desonide external 1 emulsion cream 1 FE clobetasol propionate 1 desonide external gel external desonide external lotion 1 CLOBEX 3 desonide external 1 CLOBEX SPRAY 3 ointment 1 clocortolone pivalate DESOWEN 3 EXTERNAL CREAM clodan external 1 shampoo desoximetasone 1 FE CLODERM 3 external cream 0.05 % desoximetasone coal tar external 1 1 solution external cream 0.25 % desoximetasone CONDYLOX 3 1 EXTERNAL GEL external gel desoximetasone CORDRAN EXTERNAL 3 PA; FE 1 CREAM 0.025 % external liquid desoximetasone CORDRAN EXTERNAL 3 CREAM 0.05 % external ointment 0.05 1 FE % CORDRAN EXTERNAL 3 LOTION desoximetasone external ointment 0.25 1 CORDRAN EXTERNAL 3 % OINTMENT desrx 1 FE CORDRAN EXTERNAL 3 PA; FE TAPE diclofenac sodium gel 3 1 % external

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 45 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

DIFFERIN EXTERNAL 3 erythromycin external 1 CREAM gel

DIFFERIN EXTERNAL 3 erythromycin external 1 GEL 0.3 % solution

DIFFERIN EXTERNAL 3 EUCRISA OINTMENT 3 PA; QL LOTION 2 % EXTERNAL 3 diflorasone diacetate 1 EVOCLIN external FABIOR 3 PA; FE DIPROLENE AF 3 FINACEA 3 DIPROLENE fluocinolone acetonide 1 EXTERNAL 3 body OINTMENT fluocinolone acetonide 1 DOVONEX EXTERNAL 3 external CREAM fluocinolone acetonide 1 doxepin hcl external 1 scalp doxycycline 1 FE fluocinonide emulsified 1 DRYSOL 2 base DUOBRII 3 PA; FE fluocinonide external 1 DUPIXENT FLUOROPLEX 2 SUBCUTANEOUS PA; SP; FLUOROURACIL 4 SOLUTION PEN- QL EXTERNAL CREAM 3 INJECTOR 300 0.5 % MG/2ML fluorouracil external 1 DUPIXENT cream 5 % PA; SP; SUBCUTANEOUS 4 SOLUTION QL fluorouracil external 1 PREFILLED SYRINGE solution flurandrenolide 1 EFUDEX EXTERNAL 3 CREAM fluticasone propionate 1 ELIDEL 3 external 2 ENSTILAR 3 PA; FE GORDOFILM 1 FE EPIDUO 3 halcinonide EPIDUO FORTE 2 halobetasol propionate 1 external cream EPIFOAM 2 HALOBETASOL ery 1 PROPIONATE 3 PA; FE ERYGEL 3 EXTERNAL FOAM

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 46 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 halobetasol propionate 1 KENALOG EXTERNAL external ointment KERALYT EXTERNAL 3 HALOG EXTERNAL 3 FE SHAMPOO CREAM KLARON 3 HALOG EXTERNAL 3 PA; FE KLISYRI 3 FE; QL OINTMENT lactic acid e 1 HALOG EXTERNAL 3 PA; FE SOLUTION lactic acid external 1 lotion hydrocortisone butyr 1 3 PA; FE lipo base LEXETTE LOCOID EXTERNAL hydrocortisone butyrate 1 FE 3 external cream LOTION LOCOID LIPOCREAM 3 hydrocortisone butyrate 1 external lotion LUXIQ 3 methoxsalen rapid 1 hydrocortisone butyrate 1 external ointment METROCREAM 3 hydrocortisone butyrate 1 METROGEL 3 external solution EXTERNAL GEL hydrocortisone cream 1 1 METROLOTION 3 % external (rx) metronidazole external 1 hydrocortisone external 1 mometasone furoate cream 2.5 % 1 external hydrocortisone external 1 myorisan 1 lotion 2.5 % NEO-SYNALAR hydrocortisone external 3 1 EXTERNAL CREAM ointment 2.5 % neuac external gel 1 hydrocortisone ointment 1 % external 1 nolix 1 (rx) NORITATE 3 PA; FE hydrocortisone valerate 1 OLUX 3 imiquimod external 1 QL OLUX-E 3 PA; FE; 3 ONEXTON GEL 1.2- 3 IMIQUIMOD PUMP QL 3.75 % EXTERNAL IMPOYZ 3 PA; FE ORACEA 3 FE isotretinoin oral 1 PANDEL 3 PA; FE ivermectin external 1 pimecrolimus 1 cream

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 47 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required podofilox external 1 TACLONEX SUSPENSION 0.005- 3 FE; QL prednicarbate external 1 ointment 0.064 % EXTERNAL PROTOPIC 3 tacrolimus external 1 ointment PRUDOXIN 3 tazarotene external 3 PA; FE 1 PSORCON cream PYROGALLIC ACID 2 TAZAROTENE 3 PA QBREXZA 3 ST; QL EXTERNAL FOAM RETIN-A 3 TAZORAC EXTERNAL 3 FE CREAM 0.05 % RETIN-A MICRO GEL 3 0.04 %, 0.1 % TAZORAC EXTERNAL 3 RETIN-A MICRO CREAM 0.1 % PUMP EXTERNAL 3 TAZORAC EXTERNAL 3 FE GEL 0.04 %, 0.1 % GEL 0.05 % RETIN-A MICRO TAZORAC EXTERNAL 3 PA; FE PUMP EXTERNAL 3 FE GEL 0.1 % GEL 0.06 %, 0.08 % TEMOVATE 3 RIAX 3 PA; FE EXTERNAL CREAM rosadan external cream 1 TEMOVATE rosadan external gel 1 EXTERNAL 3 OINTMENT SANTYL 3 TEXACORT 2 selenium sulfide 1 external lotion TOPICORT EXTERNAL CREAM 3 FE SERNIVO 3 FE 0.05 % SOOLANTRA 3 TOPICORT SORIATANE ORAL EXTERNAL CREAM 3 CAPSULE 10 MG, 25 3 0.25 % MG TOPICORT 3 SORILUX 3 PA; FE EXTERNAL GEL sulfacetamide sodium 1 TOPICORT (acne) EXTERNAL 3 FE SYNALAR 3 OINTMENT 0.05 % TACLONEX TOPICORT EXTERNAL 3 FE; QL EXTERNAL 3 OINTMENT OINTMENT 0.25 % TOPICORT SPRAY 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 48 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required tovet external foam 1 ZILXI 3 FE tretinoin external 1 ZONALON 3 tretinoin microsphere 1 ZYCLARA 3 FE; QL PA; FE; tretinoin microsphere 1 3 pump ZYCLARA PUMP QL triamcinolone acetonide Diabetes - external aerosol 1 Antidiabetic Agents solution acarbose oral 1 PV triamcinolone acetonide 1 ACTOPLUS MET 3 PV external cream ACTOS 3 PV; QL triamcinolone acetonide 1 ST; PV; external lotion 3 ADLYXIN FE; QL triamcinolone acetonide ST; PV; external ointment 0.025 1 ADLYXIN STARTER 3 FE; QL %, 0.1 %, 0.5 % PACK PV; FE; triamcinolone acetonide ALOGLIPTIN 3 QL external ointment 0.05 1 FE BENZOATE PV; FE; % ALOGLIPTIN- 3 QL TRIANEX 3 FE METFORMIN HCL PV; FE; triderm external cream 1 ALOGLIPTIN- 3 PIOGLITAZONE QL TRIDESILON 3 AMARYL 3 PV tritocin 1 FE ST; PV; BYDUREON BCISE 2 ULTRAVATE 3 PA; FE AUTOINJECTOR QL EXTERNAL LOTION ST; PV; 2 VANOS 3 BYETTA 10 MCG PEN QL VECTICAL 3 ST; PV; 2 VELTIN 3 PA; FE BYETTA 5 MCG PEN QL VENELEX 2 CYCLOSET 3 PV VERDESO 3 PA; FE DUETACT 3 PV 3 PA; FE VEREGEN FARXIGA TABLET 10 2 PV; QL WINLEVI 3 FE MG ORAL WYNZORA 3 FE FARXIGA TABLET 5 2 PV; QL MG ORAL XERAC AC 2 glimepiride 1 PV zenatane 1 glipizide er 1 PV ZIANA 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 49 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required glipizide ir 1 PV JARDIANCE 2 PV; QL 1 PV PV; FE; glipizide xl 3 glipizide-metformin hcl 1 PV JENTADUETO QL PV; FE; GLUCOTROL XL 3 PV 3 JENTADUETO XR QL GLUMETZA 3 PV; FE PV; FE; 1 PV 3 glyburide micronized KAZANO QL 1 PV glyburide oral KOMBIGLYZE XR 2 PV; QL 1 PV glyburide-metformin metformin hcl er 1 PV 3 PV GLYNASE metformin hcl er (mod) 1 PV; FE GLYXAMBI ORAL 2 PV; QL metformin hcl er (osm) TABLET 10-5 MG oral tablet extended 1 PV; FE GLYXAMBI TABLET 2 PV; QL release 24 hour 1000 25-5 MG ORAL mg, 500 mg PV; FE; 1 PV 3 metformin hcl ir QL INVOKAMET miglitol 1 PV PV; FE; 3 nateglinide 1 PV INVOKAMET XR QL PV; FE; PV; FE; 3 3 NESINA QL INVOKANA QL ONGLYZA 2 PV; QL JANUMET ORAL 2 PV; QL PV; FE; TABLET 50-1000 MG 3 OSENI QL JANUMET TABLET 50- 2 PV; QL ST; PV; 500 MG ORAL 2 OZEMPIC QL JANUMET XR ORAL pioglitazone hcl 1 PV; QL TABLET EXTENDED 2 PV; QL RELEASE 24 HOUR pioglitazone hcl- 1 PV 50-500 MG glimepiride

JANUMET XR TABLET pioglitazone hcl- 1 PV EXTENDED RELEASE 2 PV; QL metformin hcl 24 HOUR 100-1000 PRECOSE 3 PV MG ORAL QTERN 2 PV; QL JANUMET XR TABLET repaglinide 1 PV EXTENDED RELEASE 2 PV; QL 24 HOUR 50-1000 MG RIOMET 3 PV; FE ORAL ST; PV; 2 JANUVIA 2 PV; QL RYBELSUS QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 50 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PV; FE; 3 GLUCAGON SEGLUROMET QL EMERGENCY KIT 1 3 QL ST; PV; MG INJECTION 1 MG 2 QL SOLIQUA GLUCAGON 3 QL PV; FE; EMERGENCY KIT 3 QL STEGLATRO GVOKE HYPOPEN 1- 2 QL PV; FE; PACK 3 QL STEGLUJAN GVOKE HYPOPEN 2- 2 QL SYMLINPEN 120 3 PA; PV PACK SYMLINPEN 60 3 PA; PV GVOKE PFS 2 QL SYNJARDY 2 PV; QL PROGLYCEM 3 SYNJARDY XR 2 PV; QL Diabetes - Insulins tolbutamide 1 PV ADMELOG 3 PV; FE PV; FE; ADMELOG 3 TRADJENTA QL SOLOSTAR SOLUTION PEN- 2 PV; QL 3 PV; FE TRIJARDY XR INJECTOR 100 ST; PV; 2 UNIT/ML TRULICITY QL SUBCUTANEOUS ST; PV; 2 AFREZZA VICTOZA QL INHALATION XIGDUO XR 2 PV; QL POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 3 PV ST; PV; 2 UNIT, 90 X 4 UNIT & XULTOPHY QL 90X8 UNIT, 90 X 8 Diabetes - Glucose UNIT & 90X12 UNIT Monitoring APIDRA SOLOSTAR 3 PV; FE ONETOUCH ULTRA 2 QL APIDRA SOLUTION ONETOUCH VERIO 2 QL 100 UNIT/ML 3 PV; FE TEST STRIPS INJECTION Diabetes - Glycemic BASAGLAR KWIKPEN 3 PV; FE Agents FIASP 2 PV BAQSIMI ONE PACK 2 QL FIASP FLEXTOUCH 2 PV BAQSIMI TWO PACK 2 QL FIASP PENFILL 2 PV diazoxide oral 1 HUMALOG 3 PV; FE glucagon emergency kit 1 QL HUMALOG U-100 AND 1 mg injection 1 mg 3 PV; FE U-200 KWIKPEN

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 51 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

HUMALOG MIX 50/50 3 PV; FE LISPRO KWIKPEN SUBCUTANEOUS 3 PV; FE SOLUTION HUMALOG MIX 50/50 3 PV; FE VIAL LANTUS SOLOSTAR SOLUTION PEN- HUMALOG MIX 75/25 3 PV; FE KWIKPEN INJECTOR 100 2 PV UNIT/ML HUMALOG MIX 75/25 3 PV; FE SUBCUTANEOUS VIAL LANTUS U-100 VIAL 2 PV HUMALOG U-100 3 PV; FE JUNIOR KWIKPEN LEVEMIR U-100 2 PV FLEXTOUCH HUMULIN 70/30 3 PV; FE KWIKPEN LEVEMIR U-100 VIAL 2 PV HUMULIN 70/30 VIAL 3 PV; FE LYUMJEV KWIKPEN 3 PV; FE HUMULIN N KWIKPEN 3 PV; FE LYUMJEV VIAL 3 PV; FE HUMULIN N VIAL 3 PV; FE NOVOLIN 70/30 2 PV FLEXPEN HUMULIN R U-500 2 PV KWIKPEN NOVOLIN 70/30 2 PV FLEXPEN RELION HUMULIN R U-500 2 PV VIAL NOVOLIN 70/30 2 PV RELION HUMULIN R VIAL 3 PV; FE NOVOLIN 70/30 VIAL 2 PV INSULIN ASP PROT & 3 PV; FE ASP FLEXPEN NOVOLIN N FLEXPEN 2 3 PV; FE NOVOLIN N FLEXPEN 2 RELION INSULIN ASPART 3 PV; FE FLEXPEN NOVOLIN N RELION 2 PV NOVOLIN N VIAL 2 PV INSULIN ASPART 3 PV; FE PENFILL NOVOLIN R FLEXPEN 2

INSULIN ASPART 3 PV; FE NOVOLIN R FLEXPEN 2 PROT & ASPART RELION 2 PV (1 3 PV; FE NOVOLIN R RELION UNIT DIAL) NOVOLIN R VIAL 2 PV INSULIN LISPRO 3 PV; FE NOVOLOG 70/30 2 PV JUNIOR KWIKPEN FLEXPEN RELION INSULIN LISPRO 3 PV; FE NOVOLOG FLEXPEN 2 PV PROT & LISPRO RELION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 52 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

NOVOLOG U-100 2 PV CALCIUM LACTATE 2 FLEXPEN PENTAHYDRATE

NOVOLOG MIX 70/30 2 PV CALCIUM 2 FLEXPEN PHOSPHATE DIBASIC

NOVOLOG MIX 70/30 2 PV CALCIUM RELION PHOSPHATE 2 TRIBASIC NOVOLOG MIX 70/30 2 PV VIAL CARBAGLU 4 SP 3 NOVOLOG U-100 2 PV CARNITOR ORAL PENFILL CARNITOR SF 3 NOVOLOG RELION 2 PV CHEMET 2 NOVOLOG U-100 VIAL 2 PV CHOLINE SEMGLEE 3 PV; FE BITARTRATE 2 POWDER TOUJEO MAX 2 PV SOLOSTAR clovique 4 SP TOUJEO SOLOSTAR cyanocobalamin SOLUTION PEN- injection solution 1000 1 INJECTOR 300 2 PV mcg/ml UNIT/ML deferasirox 4 SP SUBCUTANEOUS deferasirox granules 4 SP TRESIBA 2 PV deferiprone 4 SP TRESIBA FLEXTOUCH 2 PV DL-ALANINE 2 Electrolytes / Minerals / Metals / Vitamins DL-LEUCINE 2 ALANINE 2 DL- 2 POWDER (RX) CALCIFOL 2 DL- 2 CALCIUM CHLORIDE 2 DIHYDRATE POWDER EFFER-K ORAL TABLET 3 CALCIUM 2 EFFERVESCENT 10 GLUCONATE MEQ, 20 MEQ CALCIUM effer-k tablet GLUCONATE 2 effervescent 25 meq 1 ANHYDROUS oral CALCIUM EXJADE 4 SP GLUCONATE 2 4 SP MONOHYDRATE FERRIPROX

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 53 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

FERRIPROX TWICE- 4 SP L-HISTIDINE POWDER 2 A-DAY (RX) 1 ACA fluoritab oral solution L-ISOLEUCINE 2 POWDER (RX) folic acid oral tablet 400 1 ACA; O mcg, 800 mcg L-LEUCINE 2 3 GALZIN L-METHIONINE 2 iodine strong oral 1 POWDER (RX) JADENU 4 SP LOKELMA 3 QL JADENU SPRINKLE 4 SP L-PHENYLALANINE 2 PA; SP; L-PROLINE 2 4 JYNARQUE QL L- 2 klor-con 10 1 L-VALINE POWDER 2 1 klor-con m10 MAGNESIUM 2 klor-con m15 1 CARBONATE HEAVY klor-con m20 1 MAGNESIUM CARBONATE 2 klor-con oral packet 20 1 POWDER meq MEPHYTON 3 klor-con oral tablet 1 extended release METHIONINE 2 POWDER (RX) klor-con/ef 1 nafrinse 1 ACA K-PHOS TABLET 500 2 MG ORAL nafrinse drops 1 ACA k-prime 1 NEOKE ALCAR 2 K-TAB 3 ONE VITE WOMENS 2 ACA; O L-ALANINE 2 ONE-A-DAY WOMENS 2 ACA; O PRENATAL 1 L-ARGININE 2 ORACIT SOLUTION 2 L-CYSTINE 490-640 MG/5ML 2 levocarnitine oral 1 ORAL solution phosphorous 1 1 levocarnitine oral tablet phytonadione oral 1 levocarnitine sf 1 potassium chloride crys 1 L-GLUTAMIC ACID 2 er L-HISTIDINE potassium chloride er 1 MONOHYDROCHLORI 2 DE POWDER

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 54 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 potassium chloride oral 1 UROCIT-K 15 packet UROCIT-K 5 3 potassium chloride oral VALINE 2 solution 40 meq/15ml 1 3 (20%) VELTASSA 1 potassium chloride virt-phos 250 neutral solution 20 meq/15ml 1 weekly-d 1 (10%) oral Gastrointestinal potassium citrate er 1 Agents - Drugs for Acid Reflux and Ulcer prenatal multi +dha oral capsule 27-0.8-228 mg, 1 ACA; O ACIPHEX 3 PV; QL 27-0.8-250 mg PA; PV; 3 ACIPHEX SPRINKLE FE; QL prenatal oral tablet 27- 1 ACA; O 0.8 mg CARAFATE 3 PV SAMSCA 4 SP cimetidine hcl oral 1 PV sod citrate-citric acid cimetidine oral 1 PV solution 500-334 1 CYTOTEC 3 PV mg/5ml oral PV; FE; SODIUM ASCORBATE 3 2 DEXILANT QL POWDER esomeprazole sodium fluoride oral magnesium capsule solution 1.1 (0.5 f) 1 ACA 1 PV; QL delayed release 20 mg mg/ml oral (rx) sodium fluoride oral 1 ACA esomeprazole tablet chewable magnesium oral 1 PV; QL sodium polystyrene 1 capsule delayed sulfonate oral powder release 40 mg sps 1 esomeprazole 1 PV; QL SYPRINE 4 SP magnesium oral packet TAURINE POWDER 2 ESOMEPRAZOLE PA; PV; THREONINE 2 STRONTIUM ORAL 3 CAPSULE DELAYED FE; QL TOLVAPTAN ORAL 4 SP RELEASE 49.3 MG TABLET 15 MG famotidine oral tolvaptan oral tablet 30 4 SP suspension 1 PV mg reconstituted trientine hcl 4 SP famotidine oral tablet 1 PV UROCIT-K 10 3 20 mg, 40 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 55 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required lansoprazole capsule PRILOSEC ORAL 3 PV delayed release 15 mg 1 PV; QL PACKET oral (rx) PV; FE; PROTONIX ORAL 3 lansoprazole oral PACKET QL capsule delayed 1 PV; QL PROTONIX ORAL release 30 mg TABLET DELAYED 3 PV; QL lansoprazole oral tablet PV; FE; RELEASE delayed release 1 QL RABEPRAZOLE PA; PV; dispersible 30 mg 3 SODIUM ORAL FE; QL lansoprazole tablet CAPSULE SPRINKLE delayed release 1 FE; QL rabeprazole sodium dispersible 15 mg oral oral tablet delayed 1 PV; QL (otc) release lansoprazole tablet sucralfate oral 1 PV delayed release PV; FE; 1 3 PV; QL dispersible 15 mg oral QL ZEGERID (rx) Gastrointestinal Agents - Drugs for misoprostol oral 1 PV Bowel, Intestine and NEXIUM 3 PV; QL Stomach Conditions nizatidine 1 PV hcl 1 omeprazole oral alvimopan 1 capsule delayed 1 PV; QL 2 QL release AMITIZA amoxicill-clarithro- OMEPRAZOLE+SYRS 3 PV 1 PV; QL PEND SF ALKA lansopraz ANASPAZ 3 omeprazole-sodium 1 PV; QL bicarbonate BISACODYL 2 bisacodyl ec 1 ACA; O pantoprazole sodium 1 PV; QL oral cascara sagrada oral 1 fluid extract PEPCID ORAL 3 PV TABLET CHENODAL 4 PA; SP PREVACID ORAL chlordiazepoxide- CAPSULE DELAYED 3 PV; QL clidinium capsule 5-2.5 1 RELEASE 30 MG mg oral PREVACID SOLUTAB citroma 1 ACA; O ORAL TABLET PV; FE; 3 clearlax oral powder 1 ACA; O DELAYED RELEASE QL DISPERSIBLE CLENPIQ 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 56 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required constulose 1 sulfate sl 1 1 cromolyn sodium oral hyoscyamine sulfate 1 CUVPOSA 3 tablet 0.125 mg oral dicyclomine hcl oral 1 hyoscyamine sulfate tablet dispersible 0.125 1 diphenoxylate- 1 mg oral oral liquid hyoscyamine sulfate diphenoxylate-atropine 1 tablet sublingual 0.125 1 oral tablet 2.5-0.025 mg mg sublingual 3 ED-SPAZ KRISTALOSE 3 PA; FE ENTEREG 3 lactulose 1 enulose 1 encephalopathy GASTROCROM 3 lactulose oral packet 1 FE GATTEX 4 PA; SP lactulose oral solution 1 gavilax oral powder 1 ACA; O 20 gm/30ml gavilyte-c 1 ACA lactulose solution 10 1 gm/15ml oral gavilyte-g 1 ACA LIBRAX 3 gavilyte-n with flavor 1 ACA pack LINZESS 2 QL generlac 1 LOMOTIL ORAL 3 TABLET gentle laxative oral 1 ACA; O loperamide hcl oral GIALAX 3 PA; FE 1 capsule GLYCATE 3 PA; FE LOTRONEX 3 1 ACA; O glycolax ST; FE; 3 glycopyrrolate oral 1 LUBIPROSTONE QL tablet 1 mg, 2 mg magnesium citrate oral 1 ACA; O GLYCOPYRROLATE 3 PA; FE solution 1.745 gm/30ml ORAL TABLET 1.5 MG methscopolamine 1 GOLYTELY ORAL bromide oral SOLUTION 3 mineral oil heavy oral 1 RECONSTITUTED 236 GM mm clearlax 1 ACA; O MOTEGRITY ORAL hyoscyamine sulfate 1 3 ST; QL oral elixir TABLET 1 MG MOTEGRITY TABLET hyoscyamine sulfate 1 3 ST; QL oral solution 2 MG ORAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 57 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required MOTOFEN 3 PA; FE RELTONE 3 PA; FE MOVANTIK 2 QL RESTORA RX 3 MOVIPREP SEROSTIM SOLUTION 2 SUBCUTANEOUS PA; SP; 4 RECONSTITUTED 100 SOLUTION FE GM ORAL RECONSTITUTED 4 MYTESI 3 MG, 5 MG, 6 MG NULEV 3 sodium bicarbonate 1 oral powder NULYTELY LEMON- 3 LIME SUPREP BOWEL 3 PREP KIT OMECLAMOX-PAK 3 PV; FE SUTAB 3 oscimin oral tablet 1 SYMPROIC 2 QL oscimin sublingual 1 PV; FE; 3 3 OSMOPREP TALICIA QL peg 3350-kcl-na bicarb- ST; FE; 1 ACA TRULANCE TABLET 3 3 nacl MG ORAL QL 1 ACA peg-3350/electrolytes URSO 250 3 peg- URSO FORTE 3 3350/electrolytes/ascor 1 bat ursodiol oral 1 VIBERZI 3 peg-kcl-nacl-nasulf-na 1 PA; SP; asc-c 4 peg-prep 1 XERMELO QL PLENVU SOLUTION ZELNORM 3 FE; QL 2 PA; SP; RECONSTITUTED 140 4 GM ORAL ZORBTIVE FE Genetic or Enzyme polyethylene glycol 1 ACA; O 3350 oral powder Disorder - Drugs for PYLERA 3 PV; FE Replacement, Modification, qc magnesium citrate 1 ACA; O Treatment RELISTOR ORAL 3 FE BUPHENYL ORAL 4 SP RELISTOR POWDER 3 GM/TSP SUBCUTANEOUS BUPHENYL ORAL 3 FE 4 SP SOLUTION 12 TABLET MG/0.6ML, 8 MG/0.4ML CERDELGA 4 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 58 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required CHOLBAM 4 PA; SP sapropterin CREON 2 dihydrochloride oral 4 PA; SP packet CYSTADANE 4 SP sapropterin 4 SP CYSTAGON dihydrochloride oral 4 PA; SP PA; SP; 4 tablet EVRYSDI QL sodium phenylbutyrate 4 SP PA; SP; 4 oral powder 3 gm/tsp GALAFOLD QL sodium phenylbutyrate 4 SP KUVAN ORAL 4 PA; SP oral tablet PACKET STRENSIQ 4 PA; SP 4 PA; SP KUVAN ORAL TABLET SUCRAID 4 PA; SP L-GLUTAMIC ACID 2 VIOKACE 3 HCL XURIDEN 4 SP miglustat 4 PA; SP ZAVESCA 4 PA; SP MYALEPT 4 PA; SP ZENPEP ORAL 4 SP nitisinone CAPSULE DELAYED NITYR 4 SP RELEASE PARTICLES SP; FE; 10000-32000 UNIT, 4 OCALIVA QL 15000-47000 UNIT, 3 20000-63000 UNIT, ORFADIN 4 SP 25000-79000 UNIT, PA; SP; 4 3000-10000 UNIT, PALYNZIQ QL 40000-126000 UNIT, PANCREAZE ORAL 5000-24000 UNIT CAPSULE DELAYED Genitourinary Agents RELEASE PARTICLES - Drugs for Bladder, 10500-35500 UNIT, Genital and Kidney 16800-56800 UNIT, 3 Conditions 21000-54700 UNIT, AURYXIA 3 2600-8800 UNIT, 37000-97300 UNIT, bethanechol chloride 1 4200-14200 UNIT oral PERTZYE 3 calcium acetate (phos 1 binder) PROCYSBI 4 SP; FE calcium acetate oral RAVICTI 4 PA; SP 1 tablet 667 mg

CIALIS ORAL TABLET 3 FE; QL 5 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 59 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

CUPRIMINE ORAL 3 FE phenazo oral tablet 200 1 CAPSULE 250 MG mg darifenacin 1 phenazopyridine hcl hydrobromide er oral tablet 100 mg, 200 1 DEPEN TITRATABS 4 SP mg DETROL 3 PHOSLYRA 3 DETROL LA 3 RENAGEL ORAL 3 TABLET 800 MG DITROPAN XL ORAL RENVELA 3 TABLET EXTENDED 3 RELEASE 24 HOUR 10 sevelamer carbonate 1 MG, 5 MG sevelamer hcl 1 ELMIRON 2 solifenacin succinate 1 hcl 1 oral tablet 5 mg 1 FE; QL FOSRENOL ORAL 3 THIOLA 4 SP PACKET THIOLA EC 4 SP FOSRENOL ORAL tiopronin oral 4 SP TABLET CHEWABLE 3 1000 MG, 500 MG, 750 tartrate 1 MG tolterodine tartrate er 1 GELNIQUE TOVIAZ 2 ST TRANSDERMAL GEL 3 FE trospium chloride 1 10 % 1 ST; FE; trospium chloride er 3 GEMTESA QL urin ds oral tablet 81.6 1 mg INTRAROSA 3 QL VELPHORO 3 lanthanum carbonate 1 VESICARE 3 LITHOSTAT 3 VESICARE LS 3 FE; QL MYRBETRIQ ORAL TABLET EXTENDED 2 ST Genitourinary Agents RELEASE 24 HOUR - Drugs for Prostate Conditions chloride er 1 hcl er 1 oxybutynin chloride oral 1 AVODART 3 OXYTROL 3 FE CARDURA XL 3 FE; QL penicillamine oral 1 capsule dutasteride oral 1 penicillamine oral tablet 4 SP dutasteride- 1 hcl

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 60 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required finasteride oral tablet 5 1 prednisolone sodium mg phosphate oral solution FLOMAX 3 10 mg/5ml, 15 mg/5ml, 1 20 mg/5ml, 6.7 (5 base) 3 JALYN mg/5ml 3 PROSCAR prednisolone sodium RAPAFLO 3 phosphate oral tablet 1 1 dispersible tamsulosin hcl 1 prednisolone sodium phosphate solution 25 1 hcl oral 1 PV mg/5ml oral UROXATRAL 3 prednisone intensol 1 Hormonal Agents - prednisone oral 1 Adrenal RAYOS 3 PA; FE ALKINDI SPRINKLE 3 PA; FE TAPERDEX 12-DAY 3 PA; FE CORTEF 3 TAPERDEX 6-DAY 3 PA; FE DECADRON ORAL 3 PA; FE TABLET TAPERDEX 7-DAY ORAL TABLET DEXABLISS 3 PA; FE 3 PA; FE THERAPY PACK 1.5 dexamethasone 1 MG (27) intensol Hormonal Agents - dexamethasone oral 1 Men's Health DXEVO 11-DAY 3 PA; FE ANDRODERM TRANSDERMAL 2 PA fludrocortisone acetate 1 oral PATCH 24 HOUR HIDEX 6-DAY 3 PA; FE ANDROGEL 3 PA hydrocortisone oral 1 ANDROGEL PUMP TRANSDERMAL GEL 3 PA MEDROL 3 20.25 MG/ACT (1.62%) methylprednisolone oral 1 danazol oral 1 MILLIPRED ORAL 3 PA; FE DEPO- TABLET 3 PA ORAPRED ODT 3 INTRAMUSCULAR PEDIAPRED 3 SOLUTION FORTESTA 3 PA prednisolone oral 1 solution PA; FE; 3 JATENZO QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 61 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required METHITEST 2 raloxifene hcl 1 ACA; PV Hormonal Agents - METHYLTESTOSTER 2 ONE Pituitary methyltestosterone oral 1 ACTHAR 4 PA; SP NATESTO 3 PA; FE 1 QL oxandrolone oral 1 DDAVP ORAL 3 3 PA TESTIM desmopressin ace 1 testosterone cypionate spray refrig 1 PA intramuscular solution desmopressin acetate 1 100 mg/ml, 200 mg/ml oral desmopressin acetate testosterone enanthate 1 PA 1 intramuscular solution spray PA; SP; testosterone gel 50 4 mg/5gm (1%) 1 PA GENOTROPIN FE transdermal PA; SP; GENOTROPIN 4 testosterone gel 50 MINIQUICK FE mg/5gm (1%) 1 PA; FE HUMATROPE 4 PA; SP transdermal INCRELEX 4 PA; SP testosterone PA; SP; transdermal gel 1.62 %, 4 QL 10 mg/act (2%), 12.5 ISTURISA SP; FE; mg/act (1%), 20.25 1 PA 4 mg/1.25gm (1.62%), MYCAPSSA QL 20.25 mg/act (1.62%), NORDITROPIN 25 mg/2.5gm (1%), FLEXPRO PA; SP; 40.5 mg/2.5gm (1.62%) 4 SUBCUTANEOUS FE SOLUTION PEN- testosterone 1 PA transdermal solution INJECTOR VOGELXO PUMP 3 PA; FE NUTROPIN AQ VOGELXO NUSPIN 10 4 PA; SP TRANSDERMAL GEL 3 PA SUBCUTANEOUS 50 MG/5GM (1%) SOLUTION PEN- INJECTOR XYOSTED 3 PA; FE NUTROPIN AQ Hormonal Agents - NUSPIN 20 Osteoporosis SUBCUTANEOUS 4 PA; SP EVISTA 3 PV SOLUTION PEN- OSPHENA 3 PV INJECTOR

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 62 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required NUTROPIN AQ Hormonal Agents - NUSPIN 5 Prostaglandins SUBCUTANEOUS 4 PA; SP KORLYM 4 PA; SP SOLUTION PEN- Hormonal Agents - INJECTOR Sex Hormones and octreotide acetate Birth Control injection solution 100 mcg/ml, 1000 mcg/ml, 4 SP ACTIVELLA ORAL 3 PV 200 mcg/ml, 50 mcg/ml, TABLET 1-0.5 MG 500 mcg/ml afirmelle 1 ACA; PV PV; FE; OMNITROPE 3 PA; SP; ALORA QL SUBCUTANEOUS 4 SOLUTION FE altavera 1 ACA; PV CARTRIDGE alyacen 1/35 1 ACA; PV OMNITROPE 1 ACA; PV PA; SP; alyacen 7/7/7 SUBCUTANEOUS 4 SOLUTION FE amabelz 1 PV RECONSTITUTED amethia 1 ACA; PV ORILISSA 2 PA; QL amethyst 1 ACA; PV PA; SP; 4 ANGELIQ 3 PV; FE FE SAIZEN PA; PV; PA; SP; 3 4 ANNOVERA FE SAIZENPREP FE apri 1 ACA; PV SANDOSTATIN aranelle 1 ACA; PV INJECTION SOLUTION 100 4 SP ashlyna 1 ACA; PV MCG/ML, 50 MCG/ML, aubra 1 ACA; PV 500 MCG/ML aubra eq 1 ACA; PV 4 PA; SP SIGNIFOR aurovela 1.5/30 1 ACA; PV 4 SP; FE SOMAVERT aurovela 1/20 1 ACA; PV 4 SP STIMATE aurovela 24 fe 1 ACA; PV 2 SYNAREL aurovela fe 1.5/30 1 ACA; PV PA; SP; 4 aurovela fe 1/20 1 ACA; PV ZOMACTON FE aviane 1 ACA; PV PA; SP; ZOMACTON (FOR 4 ZOMA-JET 10) FE AYGESTIN 3 ayuna 1 ACA; PV azurette 1 ACA; PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 63 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

BALCOLTRA TABLET PA; PV; DELESTROGEN 3 2 PV 0.1-20 MG-MCG(21) FE INTRAMUSCULAR OIL ORAL 10 MG/ML balziva 1 ACA; PV DELESTROGEN BEYAZ 3 PV INTRAMUSCULAR OIL 3 PV 20 MG/ML, 40 MG/ML BIJUVA 3 PV; FE delyla 1 ACA; PV blisovi 24 fe 1 ACA; PV DEPO-ESTRADIOL 2 PV blisovi fe 1.5/30 1 ACA; PV DEPO-PROVERA blisovi fe 1/20 1 ACA; PV INTRAMUSCULAR 3 PV briellyn 1 ACA; PV SUSPENSION 150 camila 1 ACA; PV MG/ML camrese 1 ACA; PV DEPO-PROVERA INTRAMUSCULAR camrese lo 1 ACA; PV 3 PV SUSPENSION caziant 1 ACA; PV PREFILLED SYRINGE charlotte 24 fe 1 ACA; PV DEPO-SUBQ chateal 1 ACA; PV PROVERA 104 SUBCUTANEOUS 3 PV chateal eq 1 ACA; PV SUSPENSION CLIMARA 3 PV; QL PREFILLED SYRINGE PV; FE; 3 desogestrel-ethinyl 1 ACA; PV CLIMARA PRO QL estradiol COMBIPATCH 2 PV; QL DIVIGEL 3 PV CRINONE VAGINAL 2 dolishale 1 ACA; PV GEL 4 % dotti 1 PV; QL cryselle-28 1 ACA; PV drospiren-eth estrad- 1 ACA; PV cyclafem 1/35 1 ACA; PV levomefol cyclafem 7/7/7 1 ACA; PV drospirenone-ethinyl 1 ACA; PV cyred 1 ACA; PV estradiol cyred eq 1 ACA; PV DUAVEE 3 PV dasetta 1/35 1 ACA; PV ELESTRIN 3 PV dasetta 7/7/7 1 ACA; PV elinest 1 ACA; PV daysee 1 ACA; PV ELLA 2 ACA; PV deblitane 1 ACA; PV eluryng 1 PV; QL emoquette 1 ACA; PV ENDOMETRIN 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 64 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required enpresse-28 1 ACA; PV hailey 1.5/30 1 ACA; PV 1 ACA; PV enskyce oral tablet 1 ACA; PV hailey 24 fe 0.15-30 mg-mcg hailey fe 1.5/30 1 ACA; PV errin 1 ACA; PV hailey fe 1/20 1 ACA; PV estarylla 1 ACA; PV heather 1 ACA; PV ESTRACE ORAL 3 PV hydroxyprogesterone 1 ESTRACE VAGINAL 3 caproate intramuscular estradiol oral 1 PV iclevia 1 ACA; PV 1 PV; QL estradiol transdermal IMVEXXY 3 estradiol vaginal 1 MAINTENANCE PACK estradiol valerate IMVEXXY STARTER 3 intramuscular oil 20 1 PV PACK mg/ml, 40 mg/ml incassia 1 ACA; PV 1 ACA; PV estradiol-norethindrone 1 PV introvale acet isibloom 1 ACA; PV ESTRING 2 QL jaimiess 1 ACA; PV ESTROGEL 3 PV jasmiel 1 ACA; PV ESTROSTEP FE 3 PV jencycla 1 ACA; PV ethynodiol diac-eth 1 ACA; PV jinteli 1 PV estradiol jolessa 1 ACA; PV etonogestrel-ethinyl 1 PV; QL 1 ACA; PV estradiol juleber 1 ACA; PV EVAMIST SOLUTION junel 1.5/30 1.53 MG/SPRAY 3 PV junel 1/20 1 ACA; PV TRANSDERMAL junel fe 1.5/30 1 ACA; PV falmina 1 ACA; PV junel fe 1/20 1 ACA; PV fayosim 1 ACA; PV junel fe 24 1 ACA; PV FEMHRT 3 PV kaitlib fe 1 ACA; PV FEMRING 2 QL kalliga 1 ACA; PV femynor 1 ACA; PV kariva 1 ACA; PV fyavolv 1 PV kelnor 1/35 1 ACA; PV gemmily 1 ACA; PV kelnor 1/50 1 ACA; PV GENERESS FE 3 PV kurvelo 1 ACA; PV gianvi 1 ACA; PV larin 1.5/30 1 ACA; PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 65 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required larin 1/20 1 ACA; PV lyllana 1 PV; QL larin 24 fe 1 ACA; PV lyza 1 ACA; PV 1 ACA; PV larin fe 1.5/30 MAKENA 3 larin fe 1/20 1 ACA; PV INTRAMUSCULAR larissia 1 ACA; PV MAKENA 3 FE SUBCUTANEOUS layolis fe 1 ACA; PV marlissa 1 ACA; PV leena 1 ACA; PV medroxyprogesterone 1 ACA; PV 1 ACA; PV lessina acetate intramuscular levonest 1 ACA; PV medroxyprogesterone 1 levonorgest-eth est & 1 ACA; PV acetate oral eth est megestrol acetate oral 1 levonorgest-eth estrad 1 ACA; PV tablet 91-day megestrol acetate 1 levonorgestrel oral 1 ACA; O suspension 40 mg/ml tablet 1.5 mg oral levonorgestrel-ethinyl 1 ACA; PV megestrol acetate estrad suspension 400 1 levonorg-eth estrad mg/10ml oral triphasic oral tablet 50- 1 ACA; PV megestrol acetate 30/75-40/ 125-30 mcg suspension 625 mg/5ml 1 levora 0.15/30 (28) 1 ACA; PV oral lillow 1 ACA; PV MENEST ORAL TABLET 0.3 MG, 0.625 3 PV; FE LO LOESTRIN FE 3 PV; FE MG, 1.25 MG 3 PV LOESTRIN 1.5/30 (21) PV; FE; 3 LOESTRIN 1/20 (21) 3 PV MENOSTAR QL LOESTRIN FE 1.5/30 3 PV merzee 1 ACA; PV LOESTRIN FE 1/20 3 PV mibelas 24 fe 1 ACA; PV lojaimiess 1 ACA; PV microgestin 1.5/30 1 ACA; PV loryna 1 ACA; PV microgestin 1/20 1 ACA; PV LOSEASONIQUE 3 PV microgestin 24 fe 1 ACA; PV low-ogestrel 1 ACA; PV microgestin fe 1.5/30 1 ACA; PV lo-zumandimine 1 ACA; PV microgestin fe 1/20 1 ACA; PV lutera 1 ACA; PV mili 1 ACA; PV lyleq 1 ACA; PV mimvey 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 66 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required MINASTRIN 24 FE 3 PV NUVARING 3 PV; QL PV; FE; 1 ACA; PV 3 nylia 7/7/7 MINIVELLE QL nymyo 1 ACA; PV MIRCETTE 3 PV ocella 1 ACA; PV mono-linyah 1 ACA; PV PA; PV; 2 NATAZIA 2 ACA; PV ORIAHNN QL necon 0.5/35 (28) 1 ACA; PV orsythia 1 ACA; PV nikki 1 ACA; PV philith 1 ACA; PV nora-be 1 ACA; PV pimtrea 1 ACA; PV 1 ACA; PV norethin ace-eth estrad- 1 ACA; PV pirmella 1/35 fe oral capsule pirmella 7/7/7 1 ACA; PV norethin ace-eth estrad- portia-28 1 ACA; PV fe oral tablet 1-20 mg- 1 ACA; PV 3 PV mcg, 1.5-30 mg-mcg PREFEST PREMARIN ORAL 2 PV norethin ace-eth estrad- 1 ACA; PV fe oral tablet chewable PREMARIN VAGINAL 2 PREMPHASE 2 PV norethindrone acetate 1 oral PREMPRO 2 PV norethindrone acet- 1 ACA; PV preventeza 1 ACA; O ethinyl est oral tablet previfem 1 ACA; PV norethindrone oral 1 ACA; PV progesterone 1 norethindrone-eth 1 PV intramuscular estradiol progesterone oral 1 norethin-eth estradiol-fe 1 ACA; PV PROMETRIUM 3 norgestimate-eth PROVERA 3 estradiol oral tablet 1 ACA; PV 0.25-35 mg-mcg QUARTETTE 3 PV reclipsen 1 ACA; PV norgestimate-ethinyl 1 ACA; PV estradiol triphasic rivelsa 1 ACA; PV norlyda 1 ACA; PV SAFYRAL 3 PV; FE norlyroc 1 ACA; PV SEASONIQUE 3 PV nortrel 0.5/35 (28) 1 ACA; PV setlakin 1 ACA; PV nortrel 1/35 (21) 1 ACA; PV sharobel 1 ACA; PV nortrel 1/35 (28) 1 ACA; PV simliya 1 ACA; PV nortrel 7/7/7 1 ACA; PV simpesse 1 ACA; PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 67 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required SLYND 3 PV; FE vestura 1 ACA; PV sprintec 28 1 ACA; PV vienva 1 ACA; PV sronyx 1 ACA; PV viorele 1 ACA; PV syeda 1 ACA; PV VIVELLE-DOT 3 PV; QL tarina 24 fe 1 ACA; PV volnea 1 ACA; PV tarina fe 1/20 1 ACA; PV vyfemla 1 ACA; PV tarina fe 1/20 eq 1 ACA; PV vylibra 1 ACA; PV TAYTULLA 3 PV; FE wera 1 ACA; PV tilia fe 1 ACA; PV wymzya fe 1 ACA; PV 1 ACA; PV ACA; PV; tri femynor 1 tri-estarylla 1 ACA; PV xulane QL tri-legest fe 1 ACA; PV YASMIN 28 3 PV tri-linyah 1 ACA; PV YAZ 3 PV tri-lo-estarylla 1 ACA; PV yuvafem 1 ACA; PV; tri-lo-marzia 1 ACA; PV 1 zafemy QL tri-lo-mili 1 ACA; PV zarah 1 ACA; PV tri-lo-sprintec 1 ACA; PV zovia 1/35 (28) 1 ACA; PV tri-mili 1 ACA; PV zovia 1/35e (28) 1 ACA; PV tri-nymyo 1 ACA; PV zumandimine 1 ACA; PV tri-previfem 1 ACA; PV Hormonal Agents - tri-sprintec 1 ACA; PV Thyroid 1 ACA; PV trivora (28) ARMOUR THYROID 2 1 ACA; PV tri-vylibra CYTOMEL 3 1 ACA; PV tri-vylibra lo euthyrox 1 1 ACA; PV tulana levo-t 1 PA; PV; 3 LEVOTHYROXINE FE; QL TWIRLA SODIUM ORAL 3 tyblume oral tablet 1 ACA; PV CAPSULE chewable levothyroxine sodium tydemy 1 ACA; PV oral tablet 137 mcg, 1 200 mcg, 25 mcg, 300 VAGIFEM VAGINAL 3 TABLET 10 MCG mcg velivet 1 ACA; PV levothyroxine sodium 1 tablet 100 mcg oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 68 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required levothyroxine sodium 1 WESTHROID ORAL tablet 112 mcg oral TABLET 130 MG, 195 2 MG, 32.5 MG, 65 MG, levothyroxine sodium 1 tablet 125 mcg oral 97.5 MG WP THYROID ORAL levothyroxine sodium 1 tablet 150 mcg oral TABLET 113.75 MG, 2 48.75 MG, 81.25 MG, levothyroxine sodium 1 97.5 MG tablet 175 mcg oral WP THYROID ORAL levothyroxine sodium 1 TABLET 130 MG, 3 tablet 50 mcg oral 16.25 MG, 32.5 MG, 65 levothyroxine sodium 1 MG tablet 75 mcg oral Immunological Agents - Drugs for levothyroxine sodium 1 tablet 88 mcg oral Immune System levoxyl 1 Stimulation or Suppression liothyronine sodium oral 1 PA; SP; methimazole oral 1 4 ACTEMRA ACTPEN QL 2 NATURE-THROID PA; SP; ACTEMRA 4 np thyroid 1 SUBCUTANEOUS QL propylthiouracil oral 1 ACTIMMUNE 4 PA; SP SYNTHROID 3 ARAVA 3 QL TAPAZOLE 3 ARCALYST THYQUIDITY 3 FE SOLUTION 4 PA; SP RECONSTITUTED 220 TIROSINT CAPSULE 3 MG SUBCUTANEOUS 75 MCG ORAL ASTAGRAF XL 3 PV TIROSINT ORAL CAPSULE 100 MCG, AZASAN 3 PV 112 MCG, 125 MCG, azathioprine oral 1 PV 13 MCG, 137 MCG, 3 BENLYSTA SOLUTION 150 MCG, 175 MCG, AUTO-INJECTOR 200 PA; SP; 200 MCG, 25 MCG, 50 4 MG/ML QL MCG, 88 MCG SUBCUTANEOUS TIROSINT-SOL 3 BENLYSTA unithroid 1 PA; SP; SUBCUTANEOUS 4 SOLUTION QL PREFILLED SYRINGE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 69 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required CELLCEPT 3 PV ENBREL SURECLICK PA; SP; SUBCUTANEOUS PA; SP; CIMZIA PREFILLED 4 4 KIT QL SOLUTION AUTO- QL INJECTOR PA; SP; 4 PA; SP; CIMZIA STARTER KIT QL 4 ENSPRYNG QL PA; SP; COSENTYX (300 MG 4 DOSE) QL ENVARSUS XR 3 PV COSENTYX 150 everolimus oral tablet MG/ML 0.25 mg, 0.5 mg, 0.75 1 PV PA; SP; mg SUBCUTANEOUS 4 SOLUTION QL FIRAZYR 4 PA; SP PREFILLED SYRINGE gengraf oral capsule 1 PV 150 MG/ML 100 mg, 25 mg COSENTYX PA; SP; gengraf oral solution 1 PV SENSOREADY (300 4 QL 4 PA; SP MG) HAEGARDA COSENTYX HUMIRA PEDIATRIC CROHNS START SENSOREADY PEN PA; SP; SUBCUTANEOUS 4 SUBCUTANEOUS PA; SP; QL 4 SOLUTION AUTO- PREFILLED SYRINGE QL INJECTOR 150 MG/ML KIT 80 MG/0.8ML, 80 MG/0.8ML & cyclosporine modified 1 PV 40MG/0.4ML cyclosporine oral 1 PV HUMIRA PEN PEN- capsule PA; SP; INJECTOR KIT 40 4 PA; SP; QL 4 MG/0.4ML ENBREL MINI QL SUBCUTANEOUS ENBREL HUMIRA PEN PA; SP; SUBCUTANEOUS 4 SUBCUTANEOUS PA; SP; QL 4 SOLUTION 25 PEN-INJECTOR KIT 40 QL MG/0.5ML MG/0.8ML, 80 ENBREL MG/0.8ML PA; SP; SUBCUTANEOUS 4 HUMIRA PEN- QL SOLUTION CD/UC/HS STARTER PA; SP; 4 PREFILLED SYRINGE PEN-INJECTOR KIT 80 QL ENBREL MG/0.8ML PA; SP; SUBCUTANEOUS SUBCUTANEOUS 4 SOLUTION QL RECONSTITUTED

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 70 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required HUMIRA PEN- methotrexate sodium 1 CD/UC/HS STARTER PA; SP; injection solution 4 SUBCUTANEOUS QL reconstituted PEN-INJECTOR KIT 40 methotrexate sodium 1 MG/0.8ML oral HUMIRA PEN- PA; SP; 4 mycophenolate mofetil 1 PV PEDIATRIC UC START QL oral HUMIRA PEN- mycophenolate sodium 1 PV PS/UV/ADOL HS PA; SP; MYFORTIC 3 PV START 4 SUBCUTANEOUS QL NEORAL 3 PV PEN-INJECTOR KIT 40 PA; SP; 4 MG/0.8ML OLUMIANT QL HUMIRA PEN- PA; SP; PA; SP; 4 4 PSOR/UVEIT QL ORENCIA CLICKJECT QL STARTER ORENCIA HUMIRA SUBCUTANEOUS PA; SP; PA; SP; 4 SUBCUTANEOUS 4 SOLUTION QL PREFILLED SYRINGE QL PREFILLED SYRINGE KIT PA; SP; 4 acetate 4 PA; SP ORLADEYO QL IMURAN 3 PV OTEZLA ORAL PA; SP; PA; SP; TABLET THERAPY 4 4 QL KEVZARA QL PACK PA; SP; KINERET OTEZLA TABLET 30 4 PA; SP; MG ORAL QL SUBCUTANEOUS 4 SOLUTION QL OTREXUP PREFILLED SYRINGE SUBCUTANEOUS leflunomide oral 1 QL SOLUTION AUTO- PA; SP; INJECTOR 10 4 LUPKYNIS PV; QL MG/0.4ML, 12.5 MG/0.4ML, 15 3 FE methotrexate oral 1 MG/0.4ML, 17.5 methotrexate sodium MG/0.4ML, 20 (pf) injection solution 1 1 MG/0.4ML, 22.5 gm/40ml, 250 mg/10ml, MG/0.4ML, 25 50 mg/2ml MG/0.4ML methotrexate sodium PROGRAF ORAL 3 PV injection solution 250 1 RAPAMUNE 3 PV mg/10ml, 50 mg/2ml

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 71 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

RASUVO SOLUTION SANDIMMUNE ORAL 3 PV AUTO-INJECTOR 10 3 FE CAPSULE MG/0.2ML SANDIMMUNE ORAL 2 PV SUBCUTANEOUS SOLUTION RASUVO SOLUTION PA; SP; 4 AUTO-INJECTOR 12.5 3 FE SILIQ QL MG/0.25ML SUBCUTANEOUS SIMPONI PA; SP; SUBCUTANEOUS 4 RASUVO SOLUTION SOLUTION AUTO- QL AUTO-INJECTOR 15 3 FE INJECTOR MG/0.3ML SUBCUTANEOUS SIMPONI PA; SP; SUBCUTANEOUS 4 RASUVO SOLUTION SOLUTION QL AUTO-INJECTOR 17.5 3 FE PREFILLED SYRINGE MG/0.35ML 1 PV SUBCUTANEOUS sirolimus oral PA; SP; RASUVO SOLUTION 4 SKYRIZI QL AUTO-INJECTOR 20 3 FE MG/0.4ML SKYRIZI (150 MG SUBCUTANEOUS DOSE) PREFILLED PA; SP; 4 RASUVO SOLUTION SYRINGE KIT 75 QL MG/0.83ML AUTO-INJECTOR 22.5 3 FE MG/0.45ML SUBCUTANEOUS PA; SP; SUBCUTANEOUS 4 QL RASUVO SOLUTION SKYRIZI PEN STELARA AUTO-INJECTOR 25 3 FE PA; SP; MG/0.5ML SUBCUTANEOUS 4 SUBCUTANEOUS SOLUTION 45 QL RASUVO SOLUTION MG/0.5ML STELARA AUTO-INJECTOR 30 3 FE PA; SP; MG/0.6ML SUBCUTANEOUS 4 SUBCUTANEOUS SOLUTION QL RASUVO SOLUTION PREFILLED SYRINGE tacrolimus oral 1 PV AUTO-INJECTOR 7.5 3 FE MG/0.15ML PA; SP; 4 SUBCUTANEOUS TALTZ QL RIDAURA 4 SP PA; SP; 4 TREMFYA QL RINVOQ TABLET PA; SP; 4 EXTENDED RELEASE QL TREXALL 2 24 HOUR 15 MG ORAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 72 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required VARIZIG DELZICOL 3 INTRAMUSCULAR 2 ACA DIPENTUM 3 FE SOLUTION ENTOCORT EC ORAL XATMEP 3 FE CAPSULE DELAYED 3 QL PA; SP; 4 RELEASE PARTICLES XELJANZ QL hydrocortisone 1 XELJANZ XR ORAL (perianal) TABLET EXTENDED PA; SP; 4 hydrocortisone rectal 1 RELEASE 24 HOUR 22 QL enema MG LIALDA 3 XELJANZ XR TABLET PA; SP; 4 mesalamine er oral EXTENDED RELEASE QL 1 24 HOUR 11 MG ORAL capsule 0.375 gm 1 ZORTRESS ORAL mesalamine oral TABLET 0.25 MG, 0.5 3 PV mesalamine rectal 1 MG, 0.75 MG mesalamine-cleanser 1 ZORTRESS ORAL PA; FE; 2 PV 3 TABLET 1 MG ORTIKOS QL Inflammatory Bowel PENTASA 2 Disease Agents PROCTOCORT 3 ANUSOL-HC 3 EXTERNAL EXTERNAL PROCTOFOAM HC 2 APRISO 3 EXTERNAL ASACOL HD 3 procto-med hc external 1 AZULFIDINE 3 procto-pak external 1 AZULFIDINE EN-TABS 3 proctozone-hc external 1 balsalazide disodium 1 ROWASA RECTAL 3 budesonide er oral SFROWASA 3 tablet extended release 1 QL sulfasalazine oral 1 24 hour UCERIS RECTAL 3 budesonide oral 1 QL UCERIS TABLET CANASA 3 EXTENDED RELEASE 3 QL COLAZAL 3 24 HOUR 9 MG ORAL CORTENEMA 3

CORTIFOAM 2 EXTERNAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 73 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required Metabolic Bone PA; SP; Disease Agents - 4 PV; FE; Drugs for (RECOMBINANT) QL Osteoporosis PA; SP; 4 ACTONEL ORAL TYMLOS PV; QL TABLET 150 MG, 35 3 PV Metabolic Bone MG Disease Agents - Other alendronate sodium 1 PV oral solution calcitriol oral 1 alendronate sodium cinacalcet hcl 1 oral tablet 10 mg, 35 1 PV 1 mg, 5 mg doxercalciferol oral PA; SP; alendronate sodium 4 1 PV PV tablet 70 mg oral NATPARA 1 ATELVIA 3 PV paricalcitol oral 3 BINOSTO 3 PV; FE ROCALTROL SENSIPAR 3 BONIVA ORAL 3 PV TABLET 150 MG ZEMPLAR ORAL 3 calcitonin (salmon) 1 PV CAPSULE 1 MCG, 2 MCG FORTEO Miscellaneous SUBCUTANEOUS PA; SP; Therapeutic Agents SOLUTION PEN- 4 PV; FE; INJECTOR 620 QL ASPARTAME 2 MCG/2.48ML ASPARTAME 2 (NUTRASWEET) FOSAMAX ORAL 3 PV TABLET 70 MG BREATHE EASE 2 PA; PV; LARGE 3 FOSAMAX PLUS D FE BREATHE EASE 2 MEDIUM ibandronate sodium 1 PV oral BREATHE EASE 2 SMALL MIACALCIN 3 PV INJECTION BROMELAIN 2 RAYALDEE 3 CETYLCIDE-G 2 risedronate sodium oral CHARCOAL 2 tablet 150 mg, 30 mg, 1 PV ACTIVATED 35 mg, 5 mg COMPACT SPACE 2 risedronate sodium oral 1 PV CHAMBER/LG MASK tablet delayed release

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 74 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 2 COMPACT SPACE 2 SACCHARIN CHAMBER/MED MASK sodium saccharin 1 COMPACT SPACE 2 powder CHAMBER/SM MASK TODAY SPONGE 2 ACA; O DOJOLVI 3 PA VCF VAGINAL EASIVENT 2 CONTRACEPTIVE 2 ACA; O ENDARI 3 VAGINAL FILM mesylates oral 1 vcf vaginal contraceptive vaginal 1 ACA; O 2 ACA; O FC FEMALE CONDOM gel FC2 FEMALE 2 ACA; O VISTOGARD 4 SP CONDOM ZOKINVY 4 PA; SP PA; SP; 4 FIRDAPSE FE; QL Ophthalmic Agents - Drugs for Eye Allergy, formaldehyde solution 1 Infection and 37 % external (rx) Inflammation 1 glutaraldehyde external ACULAR 3 3 GRASTEK ACULAR LS 3 1 methergine oral ACUVAIL 3 PA; FE methylergonovine 1 ALOCRIL 3 PA; FE maleate oral ALOMIDE 3 FE MICROCHAMBER 2 DEVICE ALREX 3 ST; FE ODACTRA 3 QL AZASITE 2 ORALAIR TABLET azelastine hcl 1 SUBLINGUAL 300 IR 2 ophthalmic SUBLINGUAL bacitracin ophthalmic 1 PA; SP; bepotastine besilate 1 4 OXBRYTA FE; QL BEPREVE 3 FE PALFORZIA 4 SP BESIVANCE 3 FE PHEXXI 3 FE BETADINE 3 POCKET SPACER 2 OPHTHALMIC PREP RADIOGARDASE 3 BLEPH-10 3 3 RAGWITEK bromfenac sodium 1 PA; SP; (once-daily) 4 RUZURGI QL BROMSITE 3 FE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 75 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

CILOXAN LOTEMAX 3 ST OPHTHALMIC 2 OPHTHALMIC GEL OINTMENT LOTEMAX CILOXAN OPHTHALMIC 3 ST; FE OPHTHALMIC 3 OINTMENT SOLUTION LOTEMAX 3 ST; FE ciprofloxacin hcl 1 OPHTHALMIC ophthalmic SUSPENSION 2 cromolyn sodium 1 LOTEMAX SM ophthalmic loteprednol etabonate 1 ST dexamethasone sodium 1 ophthalmic gel phosphate ophthalmic loteprednol etabonate 1 ST; FE diclofenac sodium 1 ophthalmic suspension ophthalmic MAXIDEX 2 DUREZOL 3 ST; FE MITOSOL 3 epinastine hcl 1 MOXEZA 3 FE erythromycin ointment 1 moxifloxacin hcl (2x 1 5 mg/gm ophthalmic day) EYSUVIS 3 FE moxifloxacin hcl 1 FLAREX 2 ophthalmic solution 3 fluorometholone 1 NATACYN ophthalmic NEVANAC 3 FE flurbiprofen sodium 1 OCUFLOX 3 FML 2 ofloxacin ophthalmic 1 FML FORTE 3 ST olopatadine hcl solution 1 FML LIQUIFILM 3 0.1 % ophthalmic (rx) 1 gatifloxacin ophthalmic olopatadine hcl solution 1 0.2 % ophthalmic (rx) gentak ophthalmic 1 ointment PATADAY OPHTHALMIC 3 FE gentamicin sulfate 1 ophthalmic solution SOLUTION 0.7 % ILEVRO 2 POVIDONE-IODINE 3 OPHTHALMIC INVELTYS 2 PRED FORTE 3 ketorolac tromethamine 1 ophthalmic PRED MILD 3 ST levofloxacin ophthalmic 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 76 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 1 prednisolone acetate 1 bimatoprost ophthalmic ophthalmic tartrate 1 prednisolone sodium 1 ophthalmic phosphate ophthalmic brinzolamide 1 PROLENSA 3 FE hcl 1 sulfacetamide sodium 1 COMBIGAN 3 ophthalmic COSOPT 3 tobramycin ophthalmic 1 COSOPT PF TOBREX OPHTHALMIC 3 OPHTHALMIC 2 SOLUTION 2-0.5 % OINTMENT dorzolamide hcl 1 TOBREX solution 2 % ophthalmic OPHTHALMIC 3 SOLUTION dorzolamide hcl-timolol 1 mal trifluridine ophthalmic 1 dorzolamide hcl-timolol 1 UPNEEQ 3 QL mal pf VIGAMOX 3 IOPIDINE ZERVIATE 3 FE OPHTHALMIC 3 ZIRGAN 3 SOLUTION 1 % ZYMAXID 3 ISOPTO CARPINE 3 Ophthalmic Agents - ISTALOL 3 Drugs for Glaucoma KEVEYIS 4 SP acetazolamide er 1 latanoprost ophthalmic 1 acetazolamide oral 1 hcl ALPHAGAN P ophthalmic solution 0.5 1 OPHTHALMIC 2 % SOLUTION 0.1 % LUMIGAN SOLUTION 2 ST ALPHAGAN P 0.01 % OPHTHALMIC OPHTHALMIC 3 methazolamide oral 1 SOLUTION 0.15 % pilocarpine hcl hcl 1 ophthalmic solution 1 1 AZOPT 3 %, 2 %, 4 % RHOPRESSA 2 betaxolol hcl 1 ophthalmic ROCKLATAN 2 ST BETIMOL 3 SIMBRINZA 3 BETOPTIC-S 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 77 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required 3 QL timolol maleate 1 CEQUA ocudose CYCLOGYL 3 timolol maleate cyclopentolate hcl 1 ophthalmic gel forming 1 FE ophthalmic solution CYSTADROPS 4 SP timolol maleate 1 4 SP ophthalmic solution CYSTARAN 1 timolol maleate pf 1 homatropaire 2 TIMOPTIC 3 ISOPTO ATROPINE 3 TIMOPTIC OCUDOSE 3 LACRISERT 3 FE TIMOPTIC-XE 3 FE LASTACAFT 3 TRAVATAN Z 3 FE MAXITROL travoprost (bak free) 1 neomycin-bacitracin zn- 1 polymyx TRUSOPT 3 neomycin-polymyxin- VYZULTA 3 ST; FE dexameth ophthalmic 1 XALATAN 3 ointment XELPROS 2 neomycin-polymyxin- ZIOPTAN 3 ST; FE dexameth ophthalmic 1 suspension 3.5-10000- Ophthalmic Agents - 0.1 Drugs for Miscellaneous Eye neomycin-polymyxin- Conditions gramicidin ophthalmic 1 solution 1.75-10000- 1 ak-poly-bac .025 altafrin ophthalmic 1 neomycin-polymyxin-hc solution 10 %, 2.5 % ophthalmic suspension 1 atropine sulfate 1 3.5-10000-1 ophthalmic ointment neo-polycin 1 atropine sulfate 1 neo-polycin hc 1 ophthalmic solution 1 % PA; SP; 4 bacitracin-polymyxin b OXERVATE QL ophthalmic ointment 1 500-10000 unit/gm hcl ophthalmic solution 10 1 bacitra-neomycin- 1 %, 2.5 % polymyxin-hc polycin 1 BLEPHAMIDE 2 BLEPHAMIDE S.O.P. 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 78 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required polymyxin b- 1 hydrocortisone-acetic 1 trimethoprim acid 3 POLYTRIM neomycin-polymyxin-hc 1 PRED-G 2 otic PRED-G S.O.P. 2 ofloxacin otic 1 RESTASIS 2 QL OTOVEL 3 PA; FE RESTASIS PRAMOTIC 3 Respiratory Tract / MULTIDOSE 2 QL EMULSION 0.05 % Pulmonary Agents - OPHTHALMIC Drugs for Allergies, sulfacetamide- Cough, Cold prednisolone 1 azelastine hcl nasal 1 ophthalmic solution azelastine-fluticasone 1 FE TOBRADEX 3 BECONASE AQ 3 FE TOBRADEX ST 2 benzonatate 1 tobramycin- 1 carbinoxamine maleate 1 dexamethasone oral solution XIIDRA 3 QL carbinoxamine maleate 1 ZYLET 3 oral tablet Otic Agents - Drugs cetirizine hcl oral 1 for Ear Conditions solution 1 acetic acid otic CLARINEX ORAL 3 CETRAXAL 3 FE TABLET CIPRO HC 3 FE CLARINEX-D 12 3 PA; FE HOUR CIPRODEX 3 fumarate 1 1 ciprofloxacin hcl otic oral syrup ciprofloxacin- 1 clemastine fumarate 1 dexamethasone oral tablet 2.68 mg CIPROFLOXACIN- 3 PA; FE hcl oral 1 FLUOCINOLONE PF desloratadine 1 CORTISPORIN-TC 3 dexchlorpheniramine 3 1 FE DERMOTIC maleate oral solution 1 flac diphen oral elixir 1 fluocinolone acetonide 1 di-phen oral elixir 1 otic

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 79 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required hcl levocetirizine elixir 12.5 mg/5ml oral 1 dihydrochloride tablet 5 1 (rx) mg oral (rx) DYMISTA 3 FE maxi-tuss ac 1 QL PA; SP; 4 mometasone furoate 1 QL FASENRA PEN QL nasal flunisolide nasal NASONEX 3 QL solution 25 mcg/act 1 NUCALA (0.025%) PA; SP; SUBCUTANEOUS 4 fluticasone propionate SOLUTION AUTO- QL suspension 50 mcg/act 1 QL INJECTOR nasal (rx) NUCALA 3 PA; FE PA; SP; GILPHEX TR SUBCUTANEOUS 4 guaiatussin ac 1 QL SOLUTION QL PREFILLED SYRINGE guaifenesin ac 1 QL olopatadine hcl nasal 1 HYCODAN 3 QL OMNARIS 3 FE hydrocodone polst- PATANASE 3 chlorphen polst er susp 1 QL oral suspension hcl oral 1 extended release promethazine hcl rectal 1 hydrocodone- 1 QL suppository 12.5 mg, homatropine oral tablet 25 mg hydrocodone- promethazine vc 1 homatropine syrup 5- 1 QL promethazine 1 QL 1.5 mg/5ml oral vc/codeine hydromet 1 QL promethazine-codeine 1 QL HYPERSAL 3 promethazine-dm oral 1 ipratropium bromide 1 syrup nasal promethazine- 1 QL KARBINAL ER ORAL phenyleph-codeine SUSPENSION 3 PA; FE promethazine- 1 EXTENDED RELEASE phenylephrine levocetirizine promethegan 1 dihydrochloride oral 1 solution pseudoeph-bromphen- dm syrup 30-2-10 1 mg/5ml oral (rx) QNASL 3 FE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 80 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required QNASL CHILDRENS 3 FE ADVAIR DISKUS AEROSOL POWDER RYCLORA ORAL 3 FE SOLUTION BREATH ACTIVATED 2 PV; QL 250-50 MCG/DOSE 1 FE ryvent INHALATION sodium chloride ADVAIR DISKUS inhalation nebulization 1 AEROSOL POWDER solution 0.9 %, 10 %, 3 BREATH ACTIVATED 2 PV; QL %, 7 % 500-50 MCG/DOSE TESSALON PERLES 3 INHALATION TUSSICAPS ORAL ADVAIR HFA CAPSULE EXTENDED PA; FE; 3 AEROSOL 115-21 2 PV; QL RELEASE 12 HOUR QL MCG/ACT 10-8 MG INHALATION PA; FE; 3 ADVAIR HFA TUXARIN ER QL AEROSOL 230-21 2 PV; QL MCG/ACT TUZISTRA XR ORAL PA; FE; 3 INHALATION SUSPENSION QL EXTENDED RELEASE ADVAIR HFA virtussin ac w/alc 1 QL AEROSOL 45-21 2 PV; QL MCG/ACT XHANCE 3 FE; QL INHALATION 3 FE ZETONNA PV; FE; 3 Respiratory Tract / AIRDUO DIGIHALER QL Pulmonary Agents - AIRDUO RESPICLICK PV; FE; Drugs for Asthma and 3 113/14 QL Other Lung PV; FE; Conditions AIRDUO RESPICLICK 3 232/14 QL ACCOLATE 3 PV AIRDUO RESPICLICK PV; FE; acetylcysteine 3 1 55/14 QL inhalation albuterol sulfate hfa ADVAIR DISKUS aerosol solution 108 AEROSOL POWDER 1 PV (90 base) mcg/act BREATH ACTIVATED 2 PV; QL inhalation 100-50 MCG/DOSE INHALATION albuterol sulfate hfa aerosol solution 108 1 PV; QL (90 base) mcg/act inhalation

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 81 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

ALBUTEROL ASMANEX (60 2 PV; QL SULFATE HFA METERED DOSES) AEROSOL SOLUTION 2 PV; QL ASMANEX (7 2 PV; QL 108 (90 BASE) METERED DOSES) MCG/ACT 2 PV; QL INHALATION ASMANEX HFA ATROVENT HFA 2 PV; QL albuterol sulfate 1 PV inhalation AUVI-Q INJECTION albuterol sulfate oral 1 PV SOLUTION AUTO- 3 FE; QL INJECTOR 0.1 PV; FE; 3 MG/0.1ML ALVESCO QL AUVI-Q INJECTION ANORO ELLIPTA SOLUTION AUTO- PA; FE; AEROSOL POWDER 3 INJECTOR 0.15 QL BREATH ACTIVATED 2 PV; QL MG/0.15ML, 0.3 62.5-25 MCG/INH MG/0.3ML INHALATION BEVESPI tartrate 1 PV; QL AEROSPHERE PV; FE; 3 PV; QL ARMONAIR 3 AEROSOL 9-4.8 DIGIHALER QL MCG/ACT ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREO ELLIPTA BREATH ACTIVATED 2 PV; QL AEROSOL POWDER 100 MCG/ACT BREATH ACTIVATED 2 PV; QL INHALATION 100-25 MCG/INH ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREO ELLIPTA BREATH ACTIVATED 2 PV; QL AEROSOL POWDER 200 MCG/ACT BREATH ACTIVATED 2 PV; QL INHALATION 200-25 MCG/INH ARNUITY ELLIPTA INHALATION INHALATION BREZTRI 2 PV; QL AEROSOL POWDER AEROSPHERE PV; FE; 3 BREATH ACTIVATED AEROSOL 160-9-4.8 QL 50 MCG/ACT MCG/ACT INHALATION ASMANEX (120 2 PV; QL PV; FE; METERED DOSES) 3 BROVANA QL ASMANEX (30 2 PV; QL METERED DOSES) budesonide inhalation 1 PV; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 82 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required

BUDESONIDE- PV; FE; FLOVENT DISKUS 3 QL INHALATION FUMARATE AEROSOL POWDER 2 PV; QL BREATH ACTIVATED COMBIVENT 2 PV; QL RESPIMAT 100 MCG/BLIST, 50 MCG/BLIST cromolyn sodium 1 PV inhalation FLOVENT HFA 2 PV; QL DALIRESP 2 PV fluticasone- aerosol powder breath PV; FE; 1 PV 3 activated 100-50 QL DUAKLIR PRESSAIR mcg/dose inhalation DULERA AEROSOL PV; FE; fluticasone-salmeterol 100-5 MCG/ACT 3 QL aerosol powder breath 1 PV; QL INHALATION activated 100-50 DULERA AEROSOL PV; FE; mcg/dose inhalation 3 200-5 MCG/ACT QL fluticasone-salmeterol INHALATION aerosol powder breath 1 PV DULERA INHALATION PV; FE; activated 250-50 3 AEROSOL 50-5 QL mcg/dose inhalation MCG/ACT fluticasone-salmeterol ELIXOPHYLLIN 3 PV aerosol powder breath 1 PV; QL activated 250-50 epinephrine injection 1 QL solution auto-injector mcg/dose inhalation EPIPEN 2-PAK FLUTICASONE- SALMETEROL INJECTION 3 FE; QL SOLUTION AUTO- INHALATION INJECTOR AEROSOL POWDER 2 PV; QL BREATH ACTIVATED EPIPEN JR 2-PAK 113-14 MCG/ACT, 232- INJECTION 3 FE; QL 14 MCG/ACT, 55-14 SOLUTION AUTO- MCG/ACT INJECTOR fluticasone-salmeterol PA; SP; 4 inhalation aerosol ESBRIET QL powder breath 1 PV FLOVENT DISKUS activated 500-50 AEROSOL POWDER mcg/dose BREATH ACTIVATED 2 PV; QL formoterol fumarate 250 MCG/BLIST 1 PV; QL inhalation INHALATION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 83 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required INCRUSE ELLIPTA PROVENTIL HFA AEROSOL POWDER AEROSOL SOLUTION PV; FE; 2 PV; QL 3 BREATH ACTIVATED 108 (90 BASE) QL 62.5 MCG/INH MCG/ACT INHALATION INHALATION ipratropium bromide 1 PV PULMICORT inhalation FLEXHALER ipratropium-albuterol 1 PV AEROSOL POWDER 2 PV; QL BREATH ACTIVATED levalbuterol hcl 90 MCG/ACT inhalation nebulization INHALATION solution 0.31 mg/3ml, 1 PV 0.63 mg/3ml, 1.25 PULMICORT mg/0.5ml, 1.25 mg/3ml FLEXHALER INHALATION 2 PV; QL LEVALBUTEROL HFA AEROSOL POWDER PV; FE; INHALATION 3 BREATH ACTIVATED QL AEROSOL 45 180 MCG/ACT MCG/ACT PULMICORT ST; PV; 3 PV; QL LONHALA MAGNAIR 3 SUSPENSION REFILL KIT QL QVAR REDIHALER 2 PV; QL ST; PV; LONHALA MAGNAIR 3 STARTER KIT QL SEREVENT DISKUS 2 PV; QL SINGULAIR 3 PV montelukast sodium 1 PV oral SPIRIVA 2 PV; QL PA; SP; HANDIHALER 4 OFEV QL SPIRIVA RESPIMAT PERFOROMIST 3 PV; QL AEROSOL SOLUTION 2 PV; QL 2.5 MCG/ACT PROAIR DIGIHALER INHALATION INHALATION PV; FE; SPIRIVA RESPIMAT AEROSOL POWDER 3 BREATH ACTIVATED QL INHALATION 2 PV; QL 108 (90 BASE) AEROSOL SOLUTION MCG/ACT 1.25 MCG/ACT PROAIR HFA 2 PV; QL STIOLTO RESPIMAT AEROSOL SOLUTION 2 PV; QL 2 PV; QL PROAIR RESPICLICK 2.5-2.5 MCG/ACT PROVENTIL HFA INHALATION AEROSOL SOLUTION STRIVERDI 2 PV; QL 3 PV; QL 108 (90 BASE) RESPIMAT MCG/ACT INHALATION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 84 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required SYMBICORT wixela inhub 1 PV AEROSOL 160-4.5 2 PV; QL XOPENEX NEB 3 PV MCG/ACT INHALATION XOPENEX 3 PV CONCENTRATE SYMBICORT PV; FE; AEROSOL 80-4.5 3 2 PV; QL QL MCG/ACT XOPENEX HFA INHALATION YUPELRI SOLUTION ST; PV; 3 SYMJEPI INJECTION 175 MCG/3ML QL INHALATION SOLUTION 2 QL PREFILLED SYRINGE zafirlukast 1 PV 0.3 MG/0.3ML zileuton er 1 PV sulfate oral 1 PV PA; PV; 3 THEO-24 3 PV ZYFLO FE theophylline er oral Respiratory Tract / Pulmonary Agents - tablet extended release 1 PV 12 hour 300 mg, 450 Drugs for Cystic mg Fibrosis theophylline er oral BETHKIS 4 SP; QL tablet extended release 1 PV BRONCHITOL 2 QL 24 hour CAYSTON 4 SP theophylline solution 80 1 PV PA; SP; mg/15ml oral 4 KALYDECO QL TRELEGY ELLIPTA KITABIS PAK 4 SP; QL AEROSOL POWDER PA; SP; BREATH ACTIVATED 2 PV; QL 4 100-62.5-25 MCG/INH ORKAMBI QL INHALATION PULMOZYME 4 SP TRELEGY ELLIPTA PA; SP; 4 AEROSOL POWDER SYMDEKO QL BREATH ACTIVATED 2 PV; QL TOBI NEBULIZER 4 SP; QL 200-62.5-25 MCG/INH INHALATION TOBI PODHALER 4 SP; QL TUDORZA PRESSAIR tobramycin inhalation INHALATION nebulization solution 4 SP; QL AEROSOL POWDER 3 PV; QL 300 mg/4ml BREATH ACTIVATED tobramycin nebulization 400 MCG/ACT solution 300 mg/5ml 4 SP; QL VENTOLIN HFA 2 PV; QL inhalation

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 85 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required TOBRAMYCIN TYVASO STARTER 4 PA; SP NEBULIZATION PA; SP; 4 SP; QL 4 SOLUTION 300 UPTRAVI QL MG/5ML INHALATION PA; SP; PA; SP; 4 4 VENTAVIS QL TRIKAFTA QL Skeletal Muscle Respiratory Tract / Relaxants - Drugs for Pulmonary Agents - Muscle Pain and Drugs for Pulmonary Spasm Hypertension AMRIX 3 FE PA; SP; 4 1 ADCIRCA QL baclofen oral PA; SP; carisoprodol oral 1 4 QL ADEMPAS chlorzoxazone oral 1 PA; SP; tablet 250 mg, 500 mg 4 QL alyq chlorzoxazone oral 1 FE PA; SP; tablet 375 mg, 750 mg 4 QL CYCLO/GABA 10/300 3 PA; FE PA; SP; hcl er 1 FE 4 QL cyclobenzaprine hcl 1 PA; SP; oral tablet 5 mg 4 LETAIRIS QL cyclobenzaprine hcl 1 FE PA; SP; oral tablet 7.5 mg 4 OPSUMIT QL cyclobenzaprine hcl 1 ORENITRAM 4 PA; SP tablet 10 mg oral REVATIO ORAL 3 PA; QL DANTRIUM ORAL 3 citrate oral CAPSULE 25 MG, 50 suspension 1 PA; QL MG reconstituted dantrolene sodium oral 1 FEXMID 3 FE sildenafil citrate oral 1 PA; QL tablet 20 mg LORZONE 3 FE PA; SP; 4 metaxalone 1 tadalafil (pah) QL methocarbamol oral 1 PA; SP; 4 NORGESIC FORTE 3 FE TRACLEER QL citrate er 1 TYVASO 4 PA; SP orphenadrine-asa- TYVASO REFILL 4 PA; SP 1 FE caffeine

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 86 Drug Limits/ Drug Limits/ Drug Name Drug Name Tier Required Tier Required PA; SP; ORPHENGESIC 4 FORTE ORAL TABLET 3 FE XYREM QL 50-770-60 MG PA; SP; 4 OZOBAX 3 PA; FE XYWAV QL SKELAXIN 3 1 QL SOMA 3 tartrate er 1 QL hcl oral 1 zolpidem tartrate oral 1 QL 3 VANADOM zolpidem tartrate 1 FE; QL ZANAFLEX 3 sublingual Sleep Disorder ZOLPIMIST 3 FE; QL Agents Stimulation or AMBIEN 3 QL Suppression PA; SP; AMBIEN CR 3 QL 4 TAKHZYRO QL 1 QL ST; FE; 3 BELSOMRA QL DAYVIGO 3 ST; QL doxepin hcl oral tablet 1 QL PA; FE; 3 EDLUAR QL 1 QL flurazepam hcl 1 LUNESTA 3 QL 1 QL NUVIGIL 3 QL PROVIGIL 3 QL ramelteon 1 RESTORIL 3 ROZEREM 3 SILENOR 3 QL SUNOSI 3 FE; QL temazepam 1 PA; SP; 4 WAKIX QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet. Created on 8/15/2021 87 Index of Drugs abacavir sulfate...... 28 ACZONE...... 43 alclometasone abacavir sulfate- adapalene...... 43 dipropionate...... 43 lamivudine...... 28 ADAPALENE...... 43 ALDACTAZIDE...... 32 abacavir-lamivudine- adapalene-benzoyl ALDACTONE...... 32 zidovudine...... 28 peroxide...... 43 ALDARA...... 43 ABILIFY...... 27 ADASUVE...... 27 alendronate sodium...... 74 ABILIFY MYCITE...... 27 ADCIRCA...... 86 alfuzosin hcl er...... 60 ABILIFY MYCITE ADDERALL...... 39 ALINIA...... 25 MAINTENANCE KIT...... 27 ADDERALL XR...... 39 aliskiren fumarate...... 32 ABILIFY MYCITE adefovir dipivoxil...... 28 ALKINDI SPRINKLE...... 61 STARTER KIT...... 27 ADEMPAS...... 86 allopurinol...... 23 ABSORICA...... 43 ADHANSIA XR...... 39 ALLZITAL...... 6 ABSORICA LD...... 43 ADIPEX-P...... 41 almotriptan malate...... 23 acamprosate calcium...... 11 ADLYXIN...... 49 ALOCRIL...... 75 ACANYA...... 43 ADLYXIN STARTER ALOGLIPTIN acarbose...... 49 PACK...... 49 BENZOATE...... 49 ACCOLATE...... 81 ADMELOG...... 51 ALOGLIPTIN- ACCUPRIL...... 32 ADMELOG SOLOSTAR.. 51 METFORMIN HCL...... 49 ACCURETIC...... 32 adult aspirin regimen...... 9 ALOGLIPTIN- accutane...... 43 ADVAIR DISKUS...... 81 PIOGLITAZONE...... 49 acebutolol hcl...... 32 ADVAIR HFA...... 81 ALOMIDE...... 75 acetaminophen-codeine.... 6 ADZENYS ER...... 39 ALORA...... 63 acetaminophen-codeine ADZENYS XR-ODT...... 39 alosetron hcl...... 56 #2...... 6 AEMCOLO...... 12 ALPHAGAN P...... 77 acetaminophen-codeine afirmelle...... 63 alprazolam...... 31 #3...... 6 AFREZZA...... 51 alprazolam er...... 31 acetaminophen-codeine AGRYLIN...... 32 alprazolam intensol...... 31 #4...... 6 AIMOVIG...... 23 alprazolam xr...... 31 acetazolamide...... 77 AIRDUO DIGIHALER...... 81 ALREX...... 75 acetazolamide er...... 77 AIRDUO RESPICLICK ALTABAX...... 12 acetic acid...... 79 113/14...... 81 ALTACE...... 32 acetylcysteine...... 81 AIRDUO RESPICLICK altafrin...... 78 ACIPHEX...... 55 232/14...... 81 altavera...... 63 ACIPHEX SPRINKLE...... 55 AIRDUO RESPICLICK ALTOPREV...... 32 acitretin...... 43 55/14...... 81 ALTRENO...... 43 ACTEMRA...... 69 AJOVY...... 23 ALUMINUM CHLORIDE ACTEMRA ACTPEN...... 69 AKLIEF...... 43 ANHYDROUS...... 43 ACTHAR...... 62 ak-poly-bac...... 78 ALUMINUM CHLORIDE ACTICLATE...... 12 AKYNZEO...... 21 HEXAHYDRATE...... 44 ACTIMMUNE...... 69 ALA SCALP...... 43 ALVESCO...... 82 ACTIQ...... 6 ala-cort...... 43 alvimopan...... 56 ACTIVELLA...... 63 ALANINE...... 53 alyacen 1/35...... 63 ACTONEL...... 74 albendazole...... 25 alyacen 7/7/7...... 63 ACTOPLUS MET...... 49 ALBENZA...... 25 alyq...... 86 ACTOS...... 49 albuterol sulfate...... 82 amabelz...... 63 ACULAR...... 75 albuterol sulfate hfa...... 81 amantadine hcl...... 26 ACULAR LS...... 75 ALBUTEROL SULFATE AMARYL...... 49 ACUVAIL...... 75 HFA...... 82 AMBIEN...... 87 acyclovir...... 28 AMBIEN CR...... 87

88 ambrisentan...... 86 ANGELIQ...... 63 ASMANEX HFA...... 82 amcinonide...... 44 ANNOVERA...... 63 ASPARTAME...... 74 AMERGE...... 23 ANORO ELLIPTA...... 82 ASPARTAME amethia...... 63 ANTARA...... 32 (NUTRASWEET)...... 74 amethyst...... 63 ANUSOL-HC...... 73 aspirin...... 9 AMICAR...... 32 APADAZ...... 6 aspirin adult low strength...9 amiloride hcl...... 32 apap-caff- aspirin childrens...... 9 amiloride- dihydrocodeine...... 6 aspirin ec...... 9 hydrochlorothiazide...... 32 APEXICON E...... 44 aspirin ec low dose...... 9 aminocaproic acid...... 32 APIDRA SOLOSTAR...... 51 aspirin ec low strength...... 9 amiodarone hcl...... 32 APIDRA VIAL...... 51 aspirin low dose...... 9 AMITIZA...... 56 APLENZIN...... 19 aspirin-dipyridamole er.... 27 amitriptyline hcl...... 18 APOKYN...... 26 ASPIRIN- amlodipine besylate...... 32 APO-VARENICLINE...... 11 OMEPRAZOLE...... 27 amlodipine besylate- apraclonidine hcl...... 77 ASTAGRAF XL...... 69 benazepril hcl...... 32 aprepitant...... 21 ATACAND...... 33 amlodipine besylate- apri...... 63 ATACAND HCT...... 33 valsartan...... 32 APRISO...... 73 atazanavir sulfate...... 28 amlodipine-atorvastatin....32 APTENSIO XR...... 39 ATELVIA...... 74 amlodipine-olmesartan.... 32 APTIOM...... 16 atenolol...... 33 amlodipine-valsartan- APTIVUS...... 28 atenolol-chlorthalidone.....33 hctz...... 32 ARAKODA...... 25 ATIVAN...... 31 ammonium lactate...... 44 aranelle...... 63 atomoxetine hcl...... 39 amnesteem...... 44 ARAVA...... 69 atorvastatin calcium...... 33 amoxapine...... 19 ARAZLO...... 44 atovaquone...... 25 amoxicill-clarithro- ARCALYST...... 69 atovaquone-proguanil hcl 25 lansopraz...... 56 arformoterol tartrate...... 82 ATRALIN...... 44 amoxicillin...... 12 ARICEPT...... 18 ATRIPLA...... 28 amoxicillin-potassium ARIKAYCE...... 12 atropine sulfate...... 78 clavulanate...... 12 ARIMIDEX...... 24 ATROVENT HFA...... 82 amoxicillin-potassium aripiprazole...... 27 AUBAGIO...... 40 clavulanate er...... 12 ARIXTRA...... 16 aubra...... 63 AMPHETAMINE ER...... 39 armodafinil...... 87 aubra eq...... 63 amphetamine sulfate...... 39 ARMONAIR DIGIHALER.82 AUGMENTIN...... 12 amphetamine- ARMOUR THYROID...... 68 AUGMENTIN ES-600...... 12 dextroamphetamine...... 39 ARNUITY ELLIPTA...... 82 aurovela 1.5/30...... 63 amphetamine- AROMASIN...... 25 aurovela 1/20...... 63 dextroamphetamine er.....39 ARTHROTEC...... 9 aurovela 24 fe...... 63 ampicillin...... 12 ASACOL HD...... 73 aurovela fe 1.5/30...... 63 AMPYRA...... 40 ascomp-codeine...... 6 aurovela fe 1/20...... 63 AMRIX...... 86 asenapine maleate...... 27 AURYXIA...... 59 AMZEEQ...... 44 ashlyna...... 63 AUSTEDO...... 41 ANAFRANIL...... 19 ASMANEX (120 AUVI-Q...... 82 anagrelide hcl...... 32 METERED DOSES)...... 82 AVALIDE...... 33 ANASPAZ...... 56 ASMANEX (30 AVAPRO...... 33 anastrozole...... 24 METERED DOSES)...... 82 aviane...... 63 ANCOBON...... 21 ASMANEX (60 avidoxy...... 12 ANDRODERM...... 61 METERED DOSES)...... 82 AVITA...... 44 ANDROGEL...... 61 ASMANEX (7 METERED AVODART...... 60 ANDROGEL PUMP...... 61 DOSES)...... 82 AVONEX PEN...... 40 89 AVONEX PREFILLED..... 40 BENZHYDROCODONE- BPCO...... 44 AYGESTIN...... 63 ACETAMINOPHEN...... 6 BREATHE EASE ayuna...... 63 BENZNIDAZOLE...... 25 LARGE...... 74 AZASAN...... 69 benzonatate...... 79 BREATHE EASE AZASITE...... 75 benzoyl peroxide- MEDIUM...... 74 azathioprine...... 69 erythromycin...... 44 BREATHE EASE SMALL 74 azelaic acid...... 44 benzphetamine hcl...... 41 BREO ELLIPTA...... 82 azelastine hcl...... 75, 79 benztropine mesylate...... 26 BREZTRI azelastine-fluticasone...... 79 bepotastine besilate...... 75 AEROSPHERE...... 82 AZELEX...... 44 BEPREVE...... 75 briellyn...... 64 AZILECT...... 26 beser...... 44 BRILINTA...... 27 azithromycin...... 12, 13 BESIVANCE...... 75 brimonidine tartrate...... 77 AZOPT...... 77 BETADINE brinzolamide...... 77 AZOR...... 33 OPHTHALMIC PREP...... 75 BRISDELLE...... 19 AZULFIDINE...... 73 betamethasone BRIVIACT...... 16 AZULFIDINE EN-TABS... 73 dipropionate...... 44 BROMELAIN...... 74 azurette...... 63 betamethasone bromfenac sodium bac...... 6 dipropionate aug...... 44 (once-daily)...... 75 bacitracin...... 75 betamethasone valerate.. 44 bromocriptine mesylate....26 bacitracin-polymyxin b..... 78 BETAPACE...... 33 BROMSITE...... 75 bacitra-neomycin- BETAPACE AF...... 33 BRONCHITOL...... 85 polymyxin-hc...... 78 BETASERON...... 40 BROVANA...... 82 baclofen...... 86 betaxolol hcl...... 33, 77 BRYHALI...... 44 BACTRIM...... 13 bethanechol chloride...... 59 budesonide...... 73, 82 BACTRIM DS...... 13 BETHKIS...... 85 budesonide er...... 73 BAFIERTAM...... 40 BETIMOL...... 77 BUDESONIDE- BALCOLTRA...... 64 BETOPTIC-S...... 77 FORMOTEROL balsalazide disodium...... 73 BEVESPI FUMARATE...... 83 balsam peru-castor oil..... 44 AEROSPHERE...... 82 bumetanide...... 33 balziva...... 64 BEVYXXA...... 16 BUMEX...... 33 BANZEL...... 16 BEYAZ...... 64 BUNAVAIL...... 12 BAQSIMI ONE PACK...... 51 BIDIL...... 33 BUPAP...... 6 BAQSIMI TWO PACK...... 51 BIJUVA...... 64 BUPHENYL...... 58 BARACLUDE...... 28 BIKTARVY...... 28 buprenorphine...... 6 BASAGLAR KWIKPEN....51 BILTRICIDE...... 25 buprenorphine hcl...... 12 BAXDELA...... 13 bimatoprost...... 77 buprenorphine hcl- BECONASE AQ...... 79 BINOSTO...... 74 naloxone hcl...... 12 BELBUCA...... 6 BISACODYL...... 56 bupropion hcl...... 19 BELSOMRA...... 87 bisacodyl ec...... 56 bupropion hcl er benazepril hcl...... 33 bisoprolol fumarate...... 33 (smoking det)...... 12 benazepril- bisoprolol- bupropion hcl er (sr)...... 19 hydrochlorothiazide...... 33 hydrochlorothiazide...... 33 bupropion hcl er (xl)...... 19 BENICAR...... 33 BLEPH-10...... 75 BUPROPION HCL ER BENICAR HCT...... 33 BLEPHAMIDE...... 78 (XL)...... 19 BENLYSTA...... 69 BLEPHAMIDE S.O.P...... 78 buspirone hcl...... 31 BENZACLIN...... 44 blisovi 24 fe...... 64 butalbital-acetaminophen...6 BENZACLIN WITH blisovi fe 1.5/30...... 64 BUTALBITAL- PUMP...... 44 blisovi fe 1/20...... 64 ACETAMINOPHEN...... 6 benzalkonium chloride.....13 BONIVA...... 74 butalbital-apap-caff-cod..... 6 BENZAMYCIN...... 44 bosentan...... 86 butalbital-apap-caffeine..... 6 90 butalbital-asa-caff- captopril...... 33 cephalexin...... 13 codeine...... 6 CARAC...... 44 CEQUA...... 78 butalbital-aspirin-caffeine...6 CARAFATE...... 55 CERDELGA...... 58 butorphanol tartrate...... 6 CARBAGLU...... 53 cetirizine hcl...... 79 BUTRANS...... 6 carbamazepine...... 16 CETRAXAL...... 79 BYDUREON BCISE carbamazepine er...... 16 CETYLCIDE-G...... 74 AUTOINJECTOR...... 49 CARBATROL...... 16 cevimeline hcl...... 42 BYETTA 10 MCG PEN....49 carbidopa...... 26 CHANTIX...... 12 BYETTA 5 MCG PEN...... 49 carbidopa-levodopa...... 26 CHANTIX CONTINUING BYSTOLIC...... 33 carbidopa-levodopa er.....26 MONTH PAK...... 12 cabergoline...... 62 carbidopa-levodopa- CHANTIX STARTING CABLIVI...... 27 entacapone...... 26 MONTH PAK...... 12 CADUET...... 33 carbinoxamine maleate....79 CHARCOAL CAFERGOT...... 23 CARDIZEM...... 33 ACTIVATED...... 74 caffeine citrate...... 41 CARDIZEM CD...... 33 charlotte 24 fe...... 64 CALAMINE...... 44 CARDIZEM LA...... 33 chateal...... 64 CALAN SR...... 33 CARDURA...... 33 chateal eq...... 64 CALCIFOL...... 53 CARDURA XL...... 60 CHEMET...... 53 calcipotriene...... 44 carisoprodol...... 86 CHENODAL...... 56 CALCIPOTRIENE...... 44 carisoprodol-aspirin- chlordiazepoxide hcl...... 31 calcipotriene-betameth codeine...... 6 chlordiazepoxide- diprop...... 44 CARNITOR...... 53 amitriptyline...... 19 calcitonin (salmon)...... 74 CARNITOR SF...... 53 chlordiazepoxide- CALCITRENE...... 44 CAROSPIR...... 33 clidinium...... 56 calcitriol...... 44, 74 carteolol hcl...... 77 chlorhexidine gluconate...42 calcium acetate...... 59 cartia xt...... 33 chloroquine phosphate.... 25 calcium acetate (phos carvedilol...... 33 chlorpromazine hcl...... 27 binder)...... 59 carvedilol phosphate er....33 chlorthalidone...... 33 CALCIUM CHLORIDE cascara sagrada...... 56 chlorzoxazone...... 86 DIHYDRATE...... 53 CATAFLAM...... 9 CHOLBAM...... 59 CALCIUM GLUCONATE. 53 CATAPRES-TTS-1...... 33 cholestyramine...... 33 CALCIUM GLUCONATE CATAPRES-TTS-2...... 33 cholestyramine light...... 33 ANHYDROUS...... 53 CATAPRES-TTS-3...... 33 CHOLINE BITARTRATE. 53 CALCIUM GLUCONATE cavarest...... 42 CIALIS...... 59 MONOHYDRATE...... 53 CAYSTON...... 85 ciclodan...... 21 CALCIUM LACTATE caziant...... 64 ciclopirox...... 21 PENTAHYDRATE...... 53 cefaclor...... 13 CICLOPIROX OLAMINE. 21 CALCIUM PHOSPHATE cefaclor er...... 13 ciclopirox olamine...... 21 DIBASIC...... 53 cefadroxil...... 13 cilostazol...... 27 CALCIUM PHOSPHATE cefdinir...... 13 CILOXAN...... 76 TRIBASIC...... 53 cefixime...... 13 CIMDUO...... 28 CAMBIA...... 9 cefpodoxime proxetil...... 13 cimetidine...... 55 camila...... 64 cefprozil...... 13 cimetidine hcl...... 55 camrese...... 64 cefuroxime axetil...... 13 CIMZIA PREFILLED KIT. 70 camrese lo...... 64 CELEBREX...... 9 CIMZIA STARTER KIT.... 70 CANASA...... 73 celecoxib...... 9 cinacalcet hcl...... 74 candesartan cilexetil...... 33 CELEXA...... 19 CIPRO...... 13 candesartan cilexetil-hctz 33 CELLCEPT...... 70 CIPRO HC...... 79 CAPEX...... 44 CELONTIN...... 16 CIPRODEX...... 79 CAPLYTA...... 27 CENTANY...... 13 ciprofloxacin hcl... 13, 76, 79 91 ciprofloxacin- clorazepate dipotassium..31 CORTIFOAM...... 73 dexamethasone...... 79 clotrimazole...... 21, 22 CORTISPORIN-TC...... 79 CIPROFLOXACIN- CLOTRIMAZOLE...... 21 COSENTYX (300 MG FLUOCINOLONE PF...... 79 clotrimazole- DOSE)...... 70 citalopram hydrobromide. 19 betamethasone...... 22 COSENTYX 150 MG/ML. 70 citroma...... 56 clovique...... 53 COSENTYX claravis...... 44 clozapine...... 27 SENSOREADY (300 CLARINEX...... 79 CLOZARIL...... 27 MG)...... 70 CLARINEX-D 12 HOUR.. 79 coal tar...... 45 COSENTYX clarithromycin...... 13 COARTEM...... 25 SENSOREADY PEN...... 70 clarithromycin er...... 13 codeine sulfate...... 6 COSOPT...... 77 clearlax...... 56 COLAZAL...... 73 COSOPT PF...... 77 clemastine fumarate...... 79 COLCHICINE...... 23 COTEMPLA XR-ODT...... 39 CLENPIQ...... 56 colchicine...... 23 COZAAR...... 34 CLEOCIN...... 13 colchicine-probenecid...... 23 CREON...... 59 CLEOCIN-T...... 44 COLCRYS...... 23 CRESEMBA...... 22 CLIMARA...... 64 colesevelam hcl...... 33 CRESTOR...... 34 CLIMARA PRO...... 64 COLESTID...... 33 CRINONE...... 64 clindacin etz...... 44 COLESTID FLAVORED.. 34 CRIXIVAN...... 28 clindacin-p...... 44 colestipol hcl...... 34 cromolyn sodium..57, 76, 83 CLINDAGEL...... 44 COMBIGAN...... 77 crotan...... 25 clindamycin hcl...... 13 COMBIPATCH...... 64 cryselle-28...... 64 clindamycin palmitate hcl.13 COMBIVENT CUPRIMINE...... 60 clindamycin phosphate RESPIMAT...... 83 CUTIVATE...... 45 ...... 13, 44, 45 COMBIVIR...... 28 CUVPOSA...... 57 CLINDAMYCIN COMPACT SPACE cyanocobalamin...... 53 PHOSPHATE...... 45 CHAMBER/LG MASK...... 74 cyclafem 1/35...... 64 clindamycin phosphate- COMPACT SPACE cyclafem 7/7/7...... 64 benzoyl peroxide...... 44 CHAMBER/MED MASK...75 CYCLO/GABA 10/300..... 86 clindamycin-tretinoin...... 45 COMPACT SPACE cyclobenzaprine hcl...... 86 CLINDESSE...... 13 CHAMBER/SM MASK..... 75 cyclobenzaprine hcl er.....86 CLINPRO 5000...... 42 COMPLERA...... 28 CYCLOGYL...... 78 clobazam...... 16 compro...... 21 cyclopentolate hcl...... 78 clobetasol prop emollient COMTAN...... 26 cycloserine...... 24 base...... 45 CONCERTA...... 39 CYCLOSET...... 49 clobetasol propionate...... 45 CONDYLOX...... 45 cyclosporine...... 70 clobetasol propionate e....45 CONJUPRI...... 34 cyclosporine modified...... 70 clobetasol propionate CONSENSI...... 34 CYMBALTA...... 19 emulsion...... 45 constulose...... 57 cyproheptadine hcl...... 79 CLOBEX...... 45 CONTRAVE...... 41 cyred...... 64 CLOBEX SPRAY...... 45 CONZIP...... 6 cyred eq...... 64 clocortolone pivalate...... 45 COPAXONE...... 40 CYSTADANE...... 59 clodan...... 45 CORDRAN...... 45 CYSTADROPS...... 78 CLODERM...... 45 COREG...... 34 CYSTAGON...... 59 clomipramine hcl...... 19 COREG CR...... 34 CYSTARAN...... 78 clonazepam...... 31 coremino...... 13 CYTOMEL...... 68 clonidine...... 33 CORGARD...... 34 CYTOTEC...... 55 clonidine hcl...... 33 CORLANOR...... 34 D.H.E. 45...... 23 clonidine hcl er...... 39 CORTEF...... 61 dalfampridine er...... 41 clopidogrel bisulfate...... 27 CORTENEMA...... 73 DALIRESP...... 83 92 danazol...... 61 desmopressin ace spray dicyclomine hcl...... 57 DANTRIUM...... 86 refrig...... 62 diethylpropion hcl...... 41 dantrolene sodium...... 86 desmopressin acetate...... 62 diethylpropion hcl er...... 41 dapsone...... 24, 45 desmopressin acetate DIFFERIN...... 46 DAPSONE...... 45 spray...... 62 DIFICID...... 13 DARAPRIM...... 25 desogestrel-ethinyl diflorasone diacetate...... 46 darifenacin estradiol...... 64 DIFLUCAN...... 22 hydrobromide er...... 60 DESONATE...... 45 diflunisal...... 10 dasetta 1/35...... 64 desonide...... 45 digitek...... 34 dasetta 7/7/7...... 64 DESOWEN...... 45 digox...... 34 DAYPRO...... 9 desoximetasone...... 45 digoxin...... 34 daysee...... 64 DESOXYN...... 39 dihydroergotamine DAYTRANA...... 39 desrx...... 45 mesylate...... 23 DAYVIGO...... 87 DESVENLAFAXINE ER...19 DILANTIN...... 16 DDAVP...... 62 desvenlafaxine succinate DILANTIN INFATABS...... 16 DEBACTEROL...... 42 er...... 19 DILATRATE-SR...... 34 deblitane...... 64 DETROL...... 60 DILAUDID...... 6 DECADRON...... 61 DETROL LA...... 60 diltiazem hcl...... 34 deferasirox...... 53 DEXABLISS...... 61 diltiazem hcl er...... 34 deferasirox granules...... 53 dexamethasone...... 61 diltiazem hcl er beads...... 34 deferiprone...... 53 dexamethasone intensol..61 diltiazem hcl er coated DELESTROGEN...... 64 dexamethasone sodium beads...... 34 DELSTRIGO...... 28 phosphate...... 76 dilt-xr...... 34 delyla...... 64 dexchlorpheniramine dimethyl fumarate...... 41 DELZICOL...... 73 maleate...... 79 dimethyl fumarate starter demeclocycline hcl...... 13 DEXEDRINE...... 39 pack...... 41 DEMSER...... 34 DEXILANT...... 55 DIOVAN...... 34 DENAVIR...... 28 dexmethylphenidate hcl...39 DIOVAN HCT...... 34 DENTA 5000 PLUS...... 42 dexmethylphenidate hcl DIPENTUM...... 73 DENTAGEL...... 42 er...... 39 diphen...... 79 DEPAKOTE...... 16 dextroamphetamine di-phen...... 79 DEPAKOTE ER...... 16 sulfate...... 39 diphenhydramine hcl...... 80 DEPAKOTE dextroamphetamine diphenoxylate-atropine.... 57 SPRINKLES...... 16 sulfate er...... 39 DIPROLENE...... 46 DEPEN TITRATABS...... 60 DIACOMIT...... 16 DIPROLENE AF...... 46 DEPO-ESTRADIOL...... 64 DIASTAT ACUDIAL...... 16 dipyridamole...... 27 DEPO-PROVERA...... 64 DIASTAT PEDIATRIC..... 16 disopyramide phosphate..34 DEPO-SUBQ PROVERA diazepam...... 16, 31 disulfiram...... 12 104...... 64 diazepam intensol...... 31 DITROPAN XL...... 60 DEPO- diazoxide...... 51 DIURIL...... 34 TESTOSTERONE...... 61 DIBENZYLINE...... 34 divalproex sodium...... 17 DERMA-SMOOTHE/FS DICLOFENAC CAP divalproex sodium er...... 16 BODY...... 45 35MG...... 9 DIVIGEL...... 64 DERMA-SMOOTHE/FS DICLOFENAC PATCH DL-ALANINE...... 53 SCALP...... 45 1.3%...... 9 DL-LEUCINE...... 53 DERMOTIC...... 79 diclofenac potassium...... 10 DL-METHIONINE...... 53 DESCOVY...... 28 diclofenac sodium 10, 45, 76 DL-PHENYLALANINE..... 53 desipramine hcl...... 19 diclofenac sodium er...... 10 dofetilide...... 34 desloratadine...... 79 diclofenac-misoprostol.....10 DOJOLVI...... 75 dicloxacillin sodium...... 13 dolishale...... 64 93 donepezil hcl...... 18 E.E.S. GRANULES...... 14 ENBREL MINI...... 70 DOPTELET...... 32 EASIVENT...... 75 ENBREL SURECLICK.....70 DORAL...... 31 EC-NAPROSYN...... 10 ENDARI...... 75 DORYX...... 13 ec-naproxen...... 10 endocet...... 6 DORYX MPC...... 13 econazole nitrate...... 22 ENDOMETRIN...... 64 dorzolamide hcl...... 77 ECOZA...... 22 enoxaparin sodium...... 16 dorzolamide hcl-timolol EDARBI...... 34 enpresse-28...... 65 mal...... 77 EDARBYCLOR...... 34 enskyce...... 65 dorzolamide hcl-timolol EDECRIN...... 34 ENSPRYNG...... 70 mal pf...... 77 EDLUAR...... 87 ENSTILAR...... 46 dotti...... 64 ED-SPAZ...... 57 entacapone...... 26 DOVATO...... 28 EDURANT...... 28 entecavir...... 29 DOVONEX...... 46 efavirenz...... 28 ENTEREG...... 57 doxazosin mesylate...... 34 efavirenz-emtricitab- ENTOCORT EC...... 73 doxepin hcl...... 19, 46, 87 tenofovir...... 29 ENTRESTO...... 34 doxercalciferol...... 74 efavirenz-lamivudine- enulose...... 57 doxycycline...... 46 tenofovir...... 29 ENVARSUS XR...... 70 doxycycline hyclate...... 13 EFFER-K...... 53 EPANED...... 34 DOXYCYCLINE effer-k...... 53 EPCLUSA...... 29 HYCLATE...... 13 EFFEXOR XR...... 19 EPIDIOLEX...... 17 doxycycline EFFIENT...... 27 EPIDUO...... 46 monohydrate...... 13 EFUDEX...... 46 EPIDUO FORTE...... 46 DRIZALMA SPRINKLE....19 ELEPSIA XR...... 17 EPIFOAM...... 46 dronabinol...... 21 ELESTRIN...... 64 epinastine hcl...... 76 drospiren-eth estrad- eletriptan hydrobromide...23 epinephrine...... 83 levomefol...... 64 ELIDEL...... 46 EPIPEN 2-PAK...... 83 drospirenone-ethinyl elinest...... 64 EPIPEN JR 2-PAK...... 83 estradiol...... 64 ELIQUIS...... 16 epitol...... 17 DROXIA...... 25 ELIQUIS DVT/PE EPIVIR...... 29 droxidopa...... 34 STARTER PACK...... 16 EPIVIR HBV...... 29 DRYSOL...... 46 ELIXOPHYLLIN...... 83 eplerenone...... 34 DUAKLIR PRESSAIR...... 83 ELLA...... 64 EPZICOM...... 29 DUAVEE...... 64 ELMIRON...... 60 EQUETRO...... 32 DUETACT...... 49 eluryng...... 64 ergoloid mesylates...... 75 DUEXIS...... 10 EMEND...... 21 ERGOMAR...... 23 DULERA...... 83 EMEND TRI-PACK...... 21 ergotamine-caffeine...... 23 duloxetine hcl...... 19 EMFLAZA...... 23 errin...... 65 DUOBRII...... 46 EMGALITY...... 23 ERTACZO...... 22 DUPIXENT...... 46 EMGALITY (300 MG ery...... 46 DUREZOL...... 76 DOSE)...... 23 ERYGEL...... 46 DURLAZA...... 27 emoquette...... 64 ERYPED 200...... 14 dutasteride...... 60 EMSAM...... 19 ERYPED 400...... 14 dutasteride-tamsulosin emtricitabine...... 29 ERY-TAB...... 14 hcl...... 60 emtricitabine-tenofovir df. 29 ERYTHROCIN DUTOPROL...... 34 EMTRIVA...... 29 STEARATE...... 14 DXEVO 11-DAY...... 61 EMVERM...... 25 erythromycin...... 14, 46, 76 DYANAVEL XR...... 39 enalapril maleate...... 34 erythromycin base...... 14 DYMISTA...... 80 enalapril- erythromycin DYRENIUM...... 34 hydrochlorothiazide...... 34 ethylsuccinate...... 14 E.E.S. 400...... 14 ENBREL...... 70 ESBRIET...... 83 94 escitalopram oxalate...... 19 ezetimibe-simvastatin...... 34 FIRVANQ...... 14 ESGIC...... 6 FABIOR...... 46 flac...... 79 esomeprazole falmina...... 65 FLAGYL...... 14 magnesium...... 55 famciclovir...... 29 FLAREX...... 76 ESOMEPRAZOLE famotidine...... 55 flavoxate hcl...... 60 STRONTIUM...... 55 FANAPT...... 27 flecainide acetate...... 35 estarylla...... 65 FANAPT TITRATION FLECTOR...... 10 estazolam...... 31 PACK...... 27 FLOLIPID...... 35 ESTRACE...... 65 FARESTON...... 25 FLOMAX...... 61 estradiol...... 65 FARXIGA...... 49 FLOVENT DISKUS...... 83 estradiol valerate...... 65 FASENRA PEN...... 80 FLOVENT HFA...... 83 estradiol-norethindrone fayosim...... 65 fluconazole...... 22 acet...... 65 FC FEMALE CONDOM... 75 flucytosine...... 22 ESTRING...... 65 FC2 FEMALE CONDOM. 75 fludrocortisone acetate.... 61 ESTROGEL...... 65 febuxostat...... 23 flunisolide...... 80 ESTROSTEP FE...... 65 felbamate...... 17 fluocinolone acetonide eszopiclone...... 87 FELBATOL...... 17 ...... 46, 79 ethacrynic acid...... 34 FELDENE...... 10 fluocinolone acetonide ethambutol hcl...... 24 felodipine er...... 34 body...... 46 ethosuximide...... 17 FEMARA...... 25 fluocinolone acetonide ethyl chloride...... 11 FEMHRT...... 65 scalp...... 46 ethynodiol diac-eth FEMRING...... 65 fluocinonide...... 46 estradiol...... 65 femynor...... 65 fluocinonide emulsified etodolac...... 10 fenofibrate...... 34, 35 base...... 46 etodolac er...... 10 fenofibrate micronized..... 34 FLUORIDEX...... 42 etonogestrel-ethinyl fenofibric acid...... 35 FLUORIDEX estradiol...... 65 FENOGLIDE...... 35 ENHANCED etravirine...... 29 fenoprofen calcium...... 10 WHITENING...... 42 EUCRISA...... 46 fenortho...... 10 FLUORIDEX euthyrox...... 68 fentanyl...... 6 SENSITIVITY RELIEF..... 42 EVAMIST...... 65 fentanyl citrate...... 6 fluoritab...... 54 EVEKEO...... 39 FENTANYL CITRATE...... 6 fluorometholone...... 76 EVEKEO ODT...... 39 FENTORA...... 7 FLUOROPLEX...... 46 everolimus...... 70 FERRIPROX...... 53 FLUOROURACIL...... 46 EVISTA...... 62 FERRIPROX TWICE-A- fluorouracil...... 46 EVOCLIN...... 46 DAY...... 54 fluoxetine hcl...... 19 EVOTAZ...... 29 FETZIMA...... 19 fluoxetine hcl (pmdd)...... 19 EVOXAC...... 42 FETZIMA TITRATION..... 19 fluphenazine hcl...... 27 EVRYSDI...... 59 FEXMID...... 86 flurandrenolide...... 46 EXELDERM...... 22 FIASP...... 51 flurazepam hcl...... 87 EXELON...... 18 FIASP FLEXTOUCH...... 51 flurbiprofen...... 10 exemestane...... 25 FIASP PENFILL...... 51 flurbiprofen sodium...... 76 EXFORGE...... 34 FIBRICOR...... 35 fluticasone propionate46, 80 EXFORGE HCT...... 34 FINACEA...... 46 fluticasone-salmeterol...... 83 EXJADE...... 53 finasteride...... 61 FLUTICASONE- EXTAVIA...... 41 FINTEPLA...... 17 SALMETEROL...... 83 EXTINA...... 22 FIORICET...... 7 fluvastatin sodium...... 35 EYSUVIS...... 76 FIORICET/CODEINE...... 7 fluvastatin sodium er...... 35 EZALLOR SPRINKLE...... 34 FIRAZYR...... 70 fluvoxamine maleate...... 19 ezetimibe...... 34 FIRDAPSE...... 75 fluvoxamine maleate er....19 95 FML...... 76 gengraf...... 70 griseofulvin FML FORTE...... 76 GENOTROPIN...... 62 ultramicrosize...... 22 FML LIQUIFILM...... 76 GENOTROPIN guaiatussin ac...... 80 FOCALIN...... 39 MINIQUICK...... 62 guaifenesin ac...... 80 FOCALIN XR...... 39 gentak...... 76 guanfacine hcl...... 35 folic acid...... 54 gentamicin sulfate...... 14, 76 guanfacine hcl er...... 39 fondaparinux sodium...... 16 gentle laxative...... 57 GVOKE HYPOPEN 1- FORFIVO XL...... 19 GENVOYA...... 29 PACK...... 51 formaldehyde...... 75 GEODON...... 27 GVOKE HYPOPEN 2- formoterol fumarate...... 83 GIALAX...... 57 PACK...... 51 FORTEO...... 74 gianvi...... 65 GVOKE PFS...... 51 FORTESTA...... 61 GILENYA...... 41 GYNAZOLE-1...... 22 FOSAMAX...... 74 GILPHEX TR...... 80 habitrol...... 12 FOSAMAX PLUS D...... 74 GIMOTI...... 21 HAEGARDA...... 70 fosamprenavir calcium.....29 glatiramer acetate...... 41 hailey 1.5/30...... 65 fosfomycin tromethamine.14 glatopa...... 41 hailey 24 fe...... 65 fosinopril sodium...... 35 glimepiride...... 49 hailey fe 1.5/30...... 65 fosinopril sodium-hctz...... 35 glipizide er...... 49 hailey fe 1/20...... 65 FOSRENOL...... 60 glipizide ir...... 50 halcinonide...... 46 FRAGMIN...... 16 glipizide xl...... 50 HALCION...... 31 FROVA...... 23 glipizide-metformin hcl.....50 halobetasol propionate frovatriptan succinate...... 23 GLOPERBA...... 23 ...... 46, 47 furosemide...... 35 glucagon emergency kit...51 HALOBETASOL fyavolv...... 65 GLUCAGON PROPIONATE...... 46 FYCOMPA...... 17 EMERGENCY KIT...... 51 HALOG...... 47 gabapentin...... 17 GLUCOTROL XL...... 50 haloperidol...... 28 GABITRIL...... 17 GLUMETZA...... 50 haloperidol lactate...... 27 GALAFOLD...... 59 glutaraldehyde...... 75 HARVONI...... 29 galantamine glyburide...... 50 heather...... 65 hydrobromide...... 18 glyburide micronized...... 50 HEMANGEOL...... 35 galantamine glyburide-metformin...... 50 heparin sodium (porcine).16 hydrobromide er...... 18 GLYCATE...... 57 heparin sodium (porcine) GALZIN...... 54 glycolax...... 57 pf...... 16 GASTROCROM...... 57 glycopyrrolate...... 57 HEPSERA...... 29 gatifloxacin...... 76 GLYCOPYRROLATE...... 57 HIDEX 6-DAY...... 61 GATTEX...... 57 glydo...... 11 HIPREX...... 14 gavilax...... 57 GLYNASE...... 50 homatropaire...... 78 gavilyte-c...... 57 GLYXAMBI...... 50 HORIZANT...... 41 gavilyte-g...... 57 GOCOVRI...... 26 HUMALOG...... 51 gavilyte-n with flavor GOLYTELY...... 57 HUMALOG KWIKPEN.....51 pack...... 57 GONITRO...... 35 HUMALOG MIX 50/50 GEBAUERS PAIN EASE.11 goodsense aspirin adults.10 KWIKPEN...... 52 GEBAUERS SPRAY goodsense aspirin low HUMALOG MIX 50/50 AND STRETCH...... 11 dose...... 10 VIAL...... 52 GELNIQUE...... 60 goodsense nicotine...... 12 HUMALOG MIX 75/25 gemfibrozil...... 35 GORDOFILM...... 46 KWIKPEN...... 52 gemmily...... 65 GRALISE...... 41 HUMALOG MIX 75/25 GEMTESA...... 60 granisetron hcl...... 21 VIAL...... 52 GENERESS FE...... 65 GRASTEK...... 75 HUMALOG U-100 generlac...... 57 griseofulvin microsize...... 22 JUNIOR KWIKPEN...... 52 96 HUMATIN...... 14 hydroxyprogesterone INSULIN ASPART HUMATROPE...... 62 caproate...... 65 FLEXPEN...... 52 HUMIRA...... 71 hydroxyurea...... 25 INSULIN ASPART HUMIRA PEDIATRIC hydroxyzine hcl...... 31 PENFILL...... 52 CROHNS START...... 70 hydroxyzine pamoate...... 31 INSULIN ASPART HUMIRA PEN...... 70 hyoscyamine sulfate...... 57 PROT & ASPART...... 52 HUMIRA PEN- hyoscyamine sulfate sl.....57 INSULIN LISPRO...... 52 CD/UC/HS STARTER70, 71 HYPERSAL...... 80 INSULIN LISPRO (1 HUMIRA PEN- HYSINGLA ER...... 7 UNIT DIAL)...... 52 PEDIATRIC UC START...71 HYZAAR...... 35 INSULIN LISPRO HUMIRA PEN- ibandronate sodium...... 74 JUNIOR KWIKPEN...... 52 PS/UV/ADOL HS START 71 ibuprofen...... 10 INSULIN LISPRO PROT HUMIRA PEN- icatibant acetate...... 71 & LISPRO...... 52 PSOR/UVEIT STARTER. 71 iclevia...... 65 INTELENCE...... 29 HUMULIN 70/30 icosapent ethyl...... 35 INTRAROSA...... 60 KWIKPEN...... 52 ILEVRO...... 76 introvale...... 65 HUMULIN 70/30 VIAL...... 52 IMCIVREE...... 41 INTUNIV...... 39 HUMULIN N KWIKPEN... 52 imipramine hcl...... 19 INVEGA...... 28 HUMULIN N VIAL...... 52 imipramine pamoate...... 19 INVELTYS...... 76 HUMULIN R U-500 imiquimod...... 47 INVIRASE...... 29 KWIKPEN...... 52 IMIQUIMOD PUMP...... 47 INVOKAMET...... 50 HUMULIN R U-500 VIAL. 52 IMITREX...... 23 INVOKAMET XR...... 50 HUMULIN R VIAL...... 52 IMITREX STATDOSE INVOKANA...... 50 HYCODAN...... 80 REFILL...... 23 iodine strong...... 54 hydralazine hcl...... 35 IMITREX STATDOSE IOPIDINE...... 77 HYDREA...... 25 SYSTEM...... 23 ipratropium bromide...80, 84 hydrochlorothiazide...... 35 IMPAVIDO...... 25 ipratropium-albuterol...... 84 hydrocodone bitartrate er...7 IMPOYZ...... 47 irbesartan...... 35 hydrocodone polst- IMURAN...... 71 irbesartan- chlorphen polst er susp....80 IMVEXXY hydrochlorothiazide...... 35 hydrocodone- MAINTENANCE PACK....65 ISENTRESS...... 29 acetaminophen...... 7 IMVEXXY STARTER ISENTRESS HD...... 29 hydrocodone- PACK...... 65 isibloom...... 65 homatropine...... 80 INBRIJA...... 26 isoniazid...... 24 hydrocodone-ibuprofen...... 7 incassia...... 65 ISOPTO ATROPINE...... 78 hydrocortisone..... 47, 61, 73 INCRELEX...... 62 ISOPTO CARPINE...... 77 hydrocortisone (perianal).73 INCRUSE ELLIPTA...... 84 ISORDIL TITRADOSE.....35 hydrocortisone butyr lipo indapamide...... 35 isosorbide dinitrate...... 35 base...... 47 INDERAL LA...... 35 isosorbide mononitrate.... 35 hydrocortisone butyrate... 47 INDERAL XL...... 35 isosorbide mononitrate hydrocortisone valerate... 47 INDOCIN...... 10 er...... 35 hydrocortisone-acetic INDOMETHACIN...... 10 isotretinoin...... 47 acid...... 79 indomethacin...... 10 isradipine...... 35 hydrogen peroxide...... 14 indomethacin er...... 10 ISTALOL...... 77 hydromet...... 80 INGREZZA...... 42 ISTURISA...... 62 hydromorphone hcl...... 7 INNOPRAN XL...... 35 itraconazole...... 22 hydromorphone hcl er...... 7 INSPRA...... 35 ivermectin...... 25, 47 hydroxychloroquine INSULIN ASP PROT & JADENU...... 54 sulfate...... 25 ASP FLEXPEN...... 52 JADENU SPRINKLE...... 54 INSULIN ASPART...... 52 jaimiess...... 65 97 JALYN...... 61 ketorolac tromethamine LANOXIN...... 35 jantoven...... 16 ...... 10, 76 lansoprazole...... 56 JANUMET...... 50 KETOROLAC lanthanum carbonate...... 60 JANUMET XR...... 50 TROMETHAMINE...... 10 LANTUS SOLOSTAR...... 52 JANUVIA...... 50 KEVEYIS...... 77 LANTUS U-100 VIAL...... 52 JARDIANCE...... 50 KEVZARA...... 71 L-ARGININE...... 54 jasmiel...... 65 KINERET...... 71 larin 1.5/30...... 65 JATENZO...... 61 KITABIS PAK...... 85 larin 1/20...... 66 jencycla...... 65 KLARON...... 47 larin 24 fe...... 66 JENTADUETO...... 50 KLISYRI...... 47 larin fe 1.5/30...... 66 JENTADUETO XR...... 50 KLONOPIN...... 31 larin fe 1/20...... 66 jinteli...... 65 klor-con...... 54 larissia...... 66 jolessa...... 65 klor-con 10...... 54 LASIX...... 35 JORNAY PM...... 39 klor-con m10...... 54 LASTACAFT...... 78 JUBLIA...... 22 klor-con m15...... 54 latanoprost...... 77 juleber...... 65 klor-con m20...... 54 LATUDA...... 28 JULUCA...... 29 klor-con/ef...... 54 layolis fe...... 66 junel 1.5/30...... 65 KOMBIGLYZE XR...... 50 LAZANDA...... 7 junel 1/20...... 65 KORLYM...... 63 L-CYSTINE...... 54 junel fe 1.5/30...... 65 K-PHOS...... 54 LEDIPASVIR- junel fe 1/20...... 65 k-prime...... 54 SOFOSBUVIR...... 29 junel fe 24...... 65 KRINTAFEL...... 25 leena...... 66 JUXTAPID...... 35 KRISTALOSE...... 57 leflunomide...... 71 JYNARQUE...... 54 K-TAB...... 54 LESCOL XL...... 35 kaitlib fe...... 65 kurvelo...... 65 lessina...... 66 KALETRA...... 29 KUVAN...... 59 LETAIRIS...... 86 kalliga...... 65 KYNMOBI...... 26 letrozole...... 25 KALYDECO...... 85 labetalol hcl...... 35 leucovorin calcium...... 25 KAPSPARGO LACRISERT...... 78 levalbuterol hcl...... 84 SPRINKLE...... 35 lactic acid...... 47 LEVALBUTEROL HFA.... 84 KAPVAY...... 39 lactic acid e...... 47 LEVEMIR U-100 KARBINAL ER...... 80 lactulose...... 57 FLEXTOUCH...... 52 kariva...... 65 lactulose LEVEMIR U-100 VIAL..... 52 KATERZIA...... 35 encephalopathy...... 57 levetiracetam...... 17 KAZANO...... 50 L-ALANINE...... 54 levetiracetam er...... 17 KEFLEX...... 14 LAMICTAL...... 17 levobunolol hcl...... 77 kelnor 1/35...... 65 LAMICTAL ODT...... 17 levocarnitine...... 54 kelnor 1/50...... 65 LAMICTAL STARTER..... 17 levocarnitine sf...... 54 KENALOG...... 47 LAMICTAL XR...... 17 levocetirizine KEPPRA...... 17 lamivudine...... 29 dihydrochloride...... 80 KEPPRA XR...... 17 lamivudine-zidovudine..... 29 levofloxacin...... 14, 76 KERALYT...... 47 lamotrigine...... 17 levonest...... 66 KERYDIN...... 22 lamotrigine er...... 17 levonorgest-eth est & eth KESIMPTA...... 41 lamotrigine starter kit- est...... 66 ketoconazole...... 22 blue...... 17 levonorgest-eth estrad ketodan...... 22 lamotrigine starter kit- 91-day...... 66 ketoprofen...... 10 green...... 17 levonorgestrel...... 66 ketoprofen er...... 10 lamotrigine starter kit- levonorgestrel-ethinyl orange...... 17 estrad...... 66 LAMPIT...... 25 98 levonorg-eth estrad LOCOID LIPOCREAM.....47 lutera...... 66 triphasic...... 66 LODINE...... 10 LUXIQ...... 47 levora 0.15/30 (28)...... 66 LODOSYN...... 26 LUZU...... 22 levorphanol tartrate...... 7 LOESTRIN 1.5/30 (21).... 66 L-VALINE...... 54 levo-t...... 68 LOESTRIN 1/20 (21)...... 66 lyleq...... 66 LEVOTHYROXINE LOESTRIN FE 1.5/30...... 66 lyllana...... 66 SODIUM...... 68 LOESTRIN FE 1/20...... 66 LYRICA...... 42 levothyroxine sodium.68, 69 lojaimiess...... 66 LYRICA CR...... 42 levoxyl...... 69 LOKELMA...... 54 LYSTEDA...... 32 LEXAPRO...... 20 LOMAIRA...... 42 LYUMJEV KWIKPEN...... 52 LEXETTE...... 47 LOMOTIL...... 57 LYUMJEV VIAL...... 52 LEXIVA...... 29 LONHALA MAGNAIR lyza...... 66 L-GLUTAMIC ACID...... 54 REFILL KIT...... 84 MACROBID...... 14 L-GLUTAMIC ACID HCL. 59 LONHALA MAGNAIR MACRODANTIN...... 14 L-HISTIDINE...... 54 STARTER KIT...... 84 mafenide acetate...... 14 L-HISTIDINE loperamide hcl...... 57 MAGNESIUM MONOHYDROCHLORID LOPID...... 36 CARBONATE...... 54 E...... 54 lopinavir-ritonavir...... 29 MAGNESIUM LIALDA...... 73 LOPRESSOR...... 36 CARBONATE HEAVY..... 54 LIBRAX...... 57 LOPROX...... 22 magnesium citrate...... 57 LICART...... 10 lorazepam...... 31 MAKENA...... 66 lidocaine...... 11 lorazepam intensol...... 31 MALARONE...... 25 lidocaine hcl...... 11, 42 LORTAB...... 7 malathion...... 25 lidocaine hcl loryna...... 66 MARINOL...... 21 urethral/mucosal...... 11 LORZONE...... 86 marlissa...... 66 lidocaine viscous hcl...... 42 losartan potassium...... 36 MARPLAN...... 20 lidocaine-prilocaine...... 11 losartan potassium-hctz...36 matzim la...... 36 LIDOCAINE- LOSEASONIQUE...... 66 MAVENCLAD...... 41 TETRACAINE...... 11 LOTEMAX...... 76 MAVYRET...... 29 LIDODERM...... 11 LOTEMAX SM...... 76 MAXALT...... 23 lillow...... 66 LOTENSIN...... 36 MAXALT-MLT...... 23 lindane...... 25 LOTENSIN HCT...... 36 MAXIDEX...... 76 linezolid...... 14 loteprednol etabonate...... 76 MAXITROL...... 78 LINZESS...... 57 LOTREL...... 36 maxi-tuss ac...... 80 liothyronine sodium...... 69 LOTRONEX...... 57 MAXZIDE...... 36 LIPITOR...... 35 lovastatin...... 36 MAXZIDE-25...... 36 LIPOFEN...... 35 LOVAZA...... 36 MAYZENT...... 41 lisinopril...... 35 LOVENOX...... 16 MAYZENT STARTER lisinopril- low-ogestrel...... 66 PACK...... 41 hydrochlorothiazide...... 35 loxapine succinate...... 28 meclizine hcl...... 21 L-ISOLEUCINE...... 54 lo-zumandimine...... 66 meclofenamate sodium....10 lithium carbonate...... 32 L-PHENYLALANINE...... 54 MEDROL...... 61 lithium carbonate er...... 32 L-PROLINE...... 54 medroxyprogesterone LITHOBID...... 32 L-TYROSINE...... 54 acetate...... 66 LITHOSTAT...... 60 LUBIPROSTONE...... 57 mefenamic acid...... 10 LIVALO...... 36 LUCEMYRA...... 12 mefloquine hcl...... 25 L-LEUCINE...... 54 LULICONAZOLE...... 22 megestrol acetate...... 66 L-METHIONINE...... 54 LUMIGAN...... 77 meloxicam...... 10 LO LOESTRIN FE...... 66 LUNESTA...... 87 memantine hcl...... 18 LOCOID...... 47 LUPKYNIS...... 71 memantine hcl er...... 18 99 MENEST...... 66 methylprednisolone...... 61 MIRAPEX...... 26 MENOSTAR...... 66 METHYLTESTOSTERO MIRAPEX ER...... 26 MENTAX...... 22 NE...... 62 MIRCETTE...... 67 meperidine hcl...... 7 methyltestosterone...... 62 mirtazapine...... 20 MEPHYTON...... 54 metoclopramide hcl...... 21 misoprostol...... 56 meprobamate...... 31 metolazone...... 36 MITIGARE...... 23 MEPRON...... 25 metoprolol succinate er....36 MITOSOL...... 76 mercaptopurine...... 25 metoprolol tartrate...... 36 mm clearlax...... 57 merzee...... 66 metoprolol- MOBIC...... 10 mesalamine...... 73 hydrochlorothiazide...... 36 modafinil...... 87 mesalamine er oral METROCREAM...... 47 moexipril hcl...... 36 capsule 0.375 gm...... 73 METROGEL...... 47 molindone hcl...... 28 mesalamine-cleanser...... 73 METROLOTION...... 47 mometasone furoate..47, 80 MESNEX...... 25 metronidazole...... 14, 47 mondoxyne nl...... 14 MESTINON...... 24 metyrosine...... 36 mono-linyah...... 67 metaxalone...... 86 mexiletine hcl...... 36 montelukast sodium...... 84 metformin hcl er...... 50 MI PASTE...... 42 MONUROL...... 14 metformin hcl er (mod).....50 MI PASTE PLUS...... 42 morgidox...... 14 metformin hcl er (osm).....50 MIACALCIN...... 74 morphine sulfate...... 8 metformin hcl ir...... 50 mibelas 24 fe...... 66 morphine sulfate methadone hcl...... 7 MICARDIS...... 36 (concentrate)...... 7 methadone hcl intensol...... 7 MICARDIS HCT...... 36 morphine sulfate er...... 7 methadose...... 7 miconazole 3...... 22 morphine sulfate er methadose sugar-free...... 7 MICONAZOLE-ZINC beads...... 7 methamphetamine hcl..... 39 OXIDE-PETROLAT...... 22 MOTEGRITY...... 57 methazolamide...... 77 MICROCHAMBER...... 75 MOTOFEN...... 58 methenamine hippurate...14 microgestin 1.5/30...... 66 MOVANTIK...... 58 methergine...... 75 microgestin 1/20...... 66 MOVIPREP...... 58 methimazole...... 69 microgestin 24 fe...... 66 MOXEZA...... 76 METHIONINE...... 54 microgestin fe 1.5/30...... 66 moxifloxacin hcl...... 14, 76 METHITEST...... 62 microgestin fe 1/20...... 66 moxifloxacin hcl (2x day). 76 methocarbamol...... 86 midazolam hcl...... 32 MS CONTIN...... 8 methotrexate...... 71 midodrine hcl...... 36 MULPLETA...... 32 methotrexate sodium...... 71 MIGERGOT...... 23 MULTAQ...... 36 methotrexate sodium (pf).71 miglitol...... 50 mupirocin...... 14 methoxsalen rapid...... 47 miglustat...... 59 mupirocin calcium...... 14 methscopolamine MIGRANAL...... 24 MYALEPT...... 59 bromide...... 57 mili...... 66 MYAMBUTOL...... 24 methyldopa...... 36 MILLIPRED...... 61 MYCAPSSA...... 62 methylergonovine mimvey...... 66 MYCOBUTIN...... 24 maleate...... 75 MINASTRIN 24 FE...... 67 mycophenolate mofetil.....71 METHYLIN...... 40 mineral oil heavy...... 57 mycophenolate sodium....71 methylphenidate hcl...... 40 MINIPRESS...... 36 MYDAYIS...... 40 methylphenidate hcl er.....40 minitran...... 36 MYFORTIC...... 71 methylphenidate hcl er MINIVELLE...... 67 myorisan...... 47 (cd)...... 40 minocycline hcl...... 14 MYRBETRIQ...... 60 methylphenidate hcl er MINOCYCLINE HCL ER..14 MYSOLINE...... 17 (la)...... 40 minocycline hcl er...... 14 MYTESI...... 58 methylphenidate hcl er MINOLIRA...... 14 nabumetone...... 10 (xr)...... 40 minoxidil...... 36 nadolol...... 36 100 nafrinse...... 54 neo-polycin hc...... 78 nolix...... 47 NAFRINSE DAILY NEORAL...... 71 nora-be...... 67 ACIDULATED...... 42 NEO-SYNALAR...... 47 NORDITROPIN NAFRINSE NESINA...... 50 FLEXPRO...... 62 DAILY/NEUTRAL...... 42 neuac...... 47 norethin ace-eth estrad- nafrinse drops...... 54 NEUPRO...... 26 fe...... 67 NAFRINSE WEEKLY...... 42 NEURONTIN...... 17 norethindrone...... 67 naftifine hcl...... 22 NEVANAC...... 76 norethindrone acetate...... 67 NAFTIN...... 22 nevirapine...... 29 norethindrone acet- NALFON...... 10 nevirapine er...... 29 ethinyl est...... 67 NALOCET...... 8 NEXIUM...... 56 norethindrone-eth naltrexone hcl...... 12 NEXLETOL...... 36 estradiol...... 67 NAMENDA TITRATION NEXLIZET...... 36 norethin-eth estradiol-fe...67 PAK...... 18 niacin NORGESIC FORTE...... 86 NAMENDA XR...... 18 (antihyperlipidemic)...... 36 norgestimate-eth NAMZARIC...... 18 niacin er estradiol...... 67 NAPRELAN...... 11 (antihyperlipidemic)...... 36 norgestimate-ethinyl NAPROSYN...... 11 niacor...... 36 estradiol triphasic...... 67 naproxen...... 11 NIASPAN...... 36 NORITATE...... 47 naproxen sodium...... 11 nicardipine hcl...... 36 norlyda...... 67 naproxen sodium er...... 11 nicotine polacrilex...... 12 norlyroc...... 67 NAPROXEN SODIUM nicotine polacrilex mini.....12 NORPACE...... 37 ER...... 11 nicotine step 1...... 12 NORPACE CR...... 37 naproxen-esomeprazole..11 nicotine step 2...... 12 NORPRAMIN...... 20 naratriptan hcl...... 24 nicotine step 3...... 12 NORTHERA...... 37 NARCAN...... 12 NICOTROL...... 12 nortrel 0.5/35 (28)...... 67 NARDIL...... 20 NICOTROL NS...... 12 nortrel 1/35 (21)...... 67 NASONEX...... 80 nifedipine...... 36 nortrel 1/35 (28)...... 67 NATACYN...... 76 nifedipine er...... 36 nortrel 7/7/7...... 67 NATAZIA...... 67 nifedipine er osmotic nortriptyline hcl...... 20 nateglinide...... 50 release...... 36 NORVASC...... 37 NATESTO...... 62 nikki...... 67 NORVIR...... 29 NATPARA...... 74 nimodipine...... 36 NOURIANZ...... 26 NATROBA...... 25 nisoldipine er...... 36 NOVOLIN 70/30 NATURE-THROID...... 69 nitazoxanide...... 25 FLEXPEN...... 52 NAYZILAM...... 17 nitisinone...... 59 NOVOLIN 70/30 NEBUPENT...... 25 NITRO-BID...... 36 FLEXPEN RELION...... 52 necon 0.5/35 (28)...... 67 NITRO-DUR...... 36, 37 NOVOLIN 70/30 nefazodone hcl...... 20 nitrofurantoin...... 14 RELION...... 52 NEOKE ALCAR...... 54 nitrofurantoin NOVOLIN 70/30 VIAL...... 52 neomycin sulfate...... 14 macrocrystal...... 14 NOVOLIN N FLEXPEN....52 neomycin-bacitracin zn- nitrofurantoin NOVOLIN N FLEXPEN polymyx...... 78 monohydrate RELION...... 52 neomycin-polymyxin- macrocrystals...... 14 NOVOLIN N RELION...... 52 dexameth...... 78 nitroglycerin...... 37 NOVOLIN N VIAL...... 52 neomycin-polymyxin- NITROLINGUAL...... 37 NOVOLIN R FLEXPEN....52 gramicidin...... 78 NITROMIST...... 37 NOVOLIN R FLEXPEN neomycin-polymyxin-hc NITROSTAT...... 37 RELION...... 52 ...... 78, 79 NITYR...... 59 NOVOLIN R RELION...... 52 neo-polycin...... 78 nizatidine...... 56 NOVOLIN R VIAL...... 52 101 NOVOLOG 70/30 olanzapine-fluoxetine hcl. 20 orphenadrine-asa- FLEXPEN RELION...... 52 olmesartan medoxomil.....37 caffeine...... 86 NOVOLOG FLEXPEN..... 53 olmesartan medoxomil- ORPHENGESIC FORTE.87 NOVOLOG FLEXPEN hctz...... 37 orsythia...... 67 RELION...... 52 olmesartan-amlodipine- ORTIKOS...... 73 NOVOLOG MIX 70/30 hctz...... 37 oscimin...... 58 FLEXPEN...... 53 olopatadine hcl...... 76, 80 oseltamivir phosphate...... 29 NOVOLOG MIX 70/30 OLUMIANT...... 71 OSENI...... 50 RELION...... 53 OLUX...... 47 OSMOLEX ER...... 26 NOVOLOG MIX 70/30 OLUX-E...... 47 OSMOPREP...... 58 VIAL...... 53 OMECLAMOX-PAK...... 58 OSPHENA...... 62 NOVOLOG PENFILL...... 53 omega-3-acid ethyl OTEZLA...... 71 NOVOLOG RELION...... 53 esters...... 37 OTOVEL...... 79 NOVOLOG U-100 VIAL...53 omeprazole...... 56 OTREXUP...... 71 NOXAFIL...... 22 OMEPRAZOLE+SYRSP OVIDE...... 25 np thyroid...... 69 END SF ALKA...... 56 oxandrolone...... 62 NUCALA...... 80 omeprazole-sodium oxaprozin...... 11 NUCYNTA...... 8 bicarbonate...... 56 OXAYDO...... 8 NUCYNTA ER...... 8 OMNARIS...... 80 oxazepam...... 32 NUEDEXTA...... 42 OMNITROPE...... 63 OXBRYTA...... 75 NULEV...... 58 ondansetron hcl...... 21 oxcarbazepine...... 17 NULYTELY LEMON- ondansetron odt...... 21 OXERVATE...... 78 LIME...... 58 ONE VITE WOMENS...... 54 oxiconazole nitrate...... 22 NUPLAZID...... 28 ONE-A-DAY WOMENS OXISTAT...... 22 NURTEC...... 24 PRENATAL 1...... 54 OXTELLAR XR...... 17 NUTROPIN AQ NUSPIN ONETOUCH ULTRA...... 51 oxybutynin chloride...... 60 10...... 62 ONETOUCH VERIO KIT oxybutynin chloride er...... 60 NUTROPIN AQ NUSPIN W/DEVICE...... 51 oxycodone hcl...... 8 20...... 62 ONEXTON...... 47 OXYCODONE HCL ER..... 8 NUTROPIN AQ NUSPIN ONFI...... 17 OXYCODONE- 5...... 63 ONGENTYS...... 26 ACETAMINOPHEN...... 8 NUVARING...... 67 ONGLYZA...... 50 oxycodone- NUVESSA...... 14 ONZETRA XSAIL...... 24 acetaminophen...... 8 NUVIGIL...... 87 OPSUMIT...... 86 OXYCONTIN...... 8 NUZYRA...... 15 ORACEA...... 47 oxymorphone hcl...... 8 nyamyc...... 22 ORACIT...... 54 oxymorphone hcl er...... 8 nylia 7/7/7...... 67 ORALAIR...... 75 OXYTROL...... 60 nymyo...... 67 oralone...... 42 OZEMPIC...... 50 nystatin...... 22 ORAPRED ODT...... 61 OZOBAX...... 87 nystatin-triamcinolone...... 22 ORAVIG...... 22 PACERONE...... 37 nystop...... 22 ORENCIA...... 71 PALFORZIA...... 75 OCALIVA...... 59 ORENCIA CLICKJECT....71 paliperidone er...... 28 ocella...... 67 ORENITRAM...... 86 PALYNZIQ...... 59 octreotide acetate...... 63 ORFADIN...... 59 PAMELOR...... 20 OCUFLOX...... 76 ORIAHNN...... 67 PANCREAZE...... 59 ODACTRA...... 75 ORILISSA...... 63 PANDEL...... 47 ODEFSEY...... 29 ORKAMBI...... 85 PANRETIN...... 25 OFEV...... 84 ORLADEYO...... 71 pantoprazole sodium...... 56 ofloxacin...... 15, 76, 79 orphenadrine citrate er.....86 paricalcitol...... 74 olanzapine...... 28 PARLODEL...... 26 102 PARNATE...... 20 phenylephrine hcl...... 78 pramipexole paromomycin sulfate...... 15 PHENYTEK...... 17 dihydrochloride er...... 26 paroxetine hcl...... 20 phenytoin...... 18 PRAMOTIC...... 79 paroxetine hcl er...... 20 phenytoin infatabs...... 17 prasugrel hcl...... 27 paroxetine mesylate...... 20 phenytoin sodium pravastatin sodium...... 37 PASER...... 24 extended...... 18 praziquantel...... 25 PATADAY...... 76 PHEXXI...... 75 prazosin hcl...... 37 PATANASE...... 80 philith...... 67 PRECOSE...... 50 PAXIL...... 20 PHOSLYRA...... 60 PRED FORTE...... 76 PAXIL CR...... 20 phosphorous...... 54 PRED MILD...... 76 PEDIAPRED...... 61 phytonadione...... 54 PRED-G...... 79 peg 3350-kcl-na bicarb- PIFELTRO...... 30 PRED-G S.O.P...... 79 nacl...... 58 pilocarpine hcl...... 42, 77 prednicarbate...... 48 peg-3350/electrolytes...... 58 pimecrolimus...... 47 prednisolone...... 61 peg- pimozide...... 28 prednisolone acetate...... 77 3350/electrolytes/ascorb pimtrea...... 67 prednisolone sodium at...... 58 pindolol...... 37 phosphate...... 61, 77 PEGASYS...... 30 pioglitazone hcl...... 50 prednisone...... 61 peg-kcl-nacl-nasulf-na pioglitazone hcl- prednisone intensol...... 61 asc-c...... 58 glimepiride...... 50 PREFEST...... 67 peg-prep...... 58 pioglitazone hcl- pregabalin...... 42 penicillamine...... 60 metformin hcl...... 50 pregabalin er...... 42 penicillin v potassium...... 15 pirmella 1/35...... 67 PREMARIN...... 67 PENNSAID...... 11 pirmella 7/7/7...... 67 PREMPHASE...... 67 pentamidine isethionate...25 piroxicam...... 11 PREMPRO...... 67 PENTASA...... 73 PLAQUENIL...... 25 prenatal...... 55 pentazocine-naloxone PLAVIX...... 27 prenatal multi +dha...... 55 hcl...... 8 PLEGRIDY...... 41 PRESTALIA...... 37 pentoxifylline er...... 37 PLEGRIDY STARTER PRETOMANID...... 24 PEPCID...... 56 PACK...... 41 PREVACID...... 56 PERCOCET...... 9 PLENVU...... 58 PREVACID SOLUTAB.....56 PERFOROMIST...... 84 PLIAGLIS...... 11 prevalite...... 37 PERIDEX...... 42 POCKET SPACER...... 75 preventeza...... 67 perindopril erbumine...... 37 podofilox...... 48 PREVIDENT...... 43 periogard...... 42 polycin...... 78 prevident...... 43 permethrin...... 25 polyethylene glycol 3350. 58 PREVIDENT 5000 perphenazine...... 21 polymyxin b-trimethoprim.79 BOOSTER PLUS...... 43 perphenazine- POLYTRIM...... 79 PREVIDENT 5000 DRY amitriptyline...... 20 portia-28...... 67 MOUTH...... 43 PERTZYE...... 59 posaconazole...... 22 PREVIDENT 5000 PEXEVA...... 20 potassium chloride...... 55 ENAMEL PROTECT...... 43 phenazo...... 60 potassium chloride crys PREVIDENT 5000 phenazopyridine hcl...... 60 er...... 54 ORTHO DEFENSE...... 43 phendimetrazine tartrate..42 potassium chloride er...... 54 PREVIDENT 5000 PLUS.43 phendimetrazine tartrate potassium citrate er...... 55 PREVIDENT 5000 er...... 42 POVIDONE-IODINE...... 76 SENSITIVE...... 43 phenelzine sulfate...... 20 PRADAXA...... 16 previfem...... 67 phenobarbital...... 17 PRALUENT...... 37 PREVYMIS...... 30 phenoxybenzamine hcl....37 pramipexole PREZCOBIX...... 30 phentermine hcl...... 42 dihydrochloride...... 26 PREZISTA...... 30 103 PRIFTIN...... 24 PROVIGIL...... 87 raloxifene hcl...... 62 PRILOSEC...... 56 PROZAC...... 20 ramelteon...... 87 primaquine phosphate..... 25 PRUDOXIN...... 48 ramipril...... 37 primidone...... 18 - RANEXA...... 37 PRIMSOL...... 15 bromphen-dm...... 80 ranolazine er...... 37 PRINIVIL...... 37 PSORCON...... 48 RAPAFLO...... 61 PRISTIQ...... 20 PULMICORT RAPAMUNE...... 71 PROAIR DIGIHALER...... 84 FLEXHALER...... 84 rasagiline mesylate...... 26 PROAIR HFA...... 84 PULMICORT RASUVO...... 72 PROAIR RESPICLICK.....84 SUSPENSION...... 84 RAVICTI...... 59 probenecid...... 23 PULMOZYME...... 85 RAYALDEE...... 74 PROCARDIA XL...... 37 PURIXAN...... 25 RAYOS...... 61 PROCENTRA...... 40 PYLERA...... 58 RAZADYNE ER...... 18 prochlorperazine...... 21 pyrazinamide...... 24 REBIF...... 41 prochlorperazine pyridostigmine bromide....24 REBIF REBIDOSE...... 41 maleate...... 21 pyridostigmine bromide REBIF REBIDOSE PROCTOCORT...... 73 er...... 24 TITRATION PACK...... 41 PROCTOFOAM HC...... 73 pyrimethamine...... 25 REBIF TITRATION procto-med hc...... 73 PYROGALLIC ACID...... 48 PACK...... 41 procto-pak...... 73 QBRELIS...... 37 reclipsen...... 67 proctozone-hc...... 73 QBREXZA...... 48 RECTIV...... 37 PROCYSBI...... 59 qc magnesium citrate...... 58 REGLAN...... 21 progesterone...... 67 QDOLO...... 9 RELAFEN...... 11 PROGLYCEM...... 51 QMIIZ ODT...... 11 RELAFEN DS...... 11 PROGRAF...... 71 QNASL...... 80 RELENZA DISKHALER...30 PROLATE...... 9 QNASL CHILDRENS...... 81 relexxii...... 40 PROLENSA...... 77 QSYMIA...... 42 RELISTOR...... 58 PROMACTA...... 32 QTERN...... 50 RELPAX...... 24 promethazine hcl...... 80 QUALAQUIN...... 25 RELTONE...... 58 promethazine vc...... 80 QUARTETTE...... 67 REMERON...... 20 promethazine vc/codeine.80 quazepam...... 32 REMERON SOLTAB...... 20 promethazine-codeine..... 80 QUDEXY XR...... 18 REMESENSE...... 43 promethazine-dm...... 80 QUESTRAN...... 37 RENAGEL...... 60 promethazine- QUESTRAN LIGHT...... 37 RENVELA...... 60 phenyleph-codeine...... 80 quetiapine fumarate...... 28 repaglinide...... 50 promethazine- quetiapine fumarate er.....28 REPATHA...... 37 phenylephrine...... 80 QUILLICHEW ER...... 40 REPATHA promethegan...... 80 QUILLIVANT XR...... 40 PUSHTRONEX PROMETRIUM...... 67 quinapril hcl...... 37 SYSTEM...... 37 propafenone hcl...... 37 quinapril- REPATHA SURECLICK.. 38 propafenone hcl er...... 37 hydrochlorothiazide...... 37 RESTASIS...... 79 propranolol hcl...... 37 quinidine gluconate er...... 37 RESTASIS MULTIDOSE.79 propranolol hcl er...... 37 quinidine sulfate...... 37 RESTORA RX...... 58 propylthiouracil...... 69 quinine sulfate...... 26 RESTORIL...... 87 PROSCAR...... 61 QVAR REDIHALER...... 84 RETIN-A...... 48 PROTONIX...... 56 RABEPRAZOLE RETIN-A MICRO GEL PROTOPIC...... 48 SODIUM...... 56 0.04 %, 0.1 %...... 48 protriptyline hcl...... 20 rabeprazole sodium...... 56 RETIN-A MICRO PUMP..48 PROVENTIL HFA...... 84 RADIOGARDASE...... 75 RETROVIR...... 30 PROVERA...... 67 RAGWITEK...... 75 REVATIO...... 86 104 REXULTI...... 28 SANCUSO...... 21 sirolimus...... 72 REYATAZ...... 30 SANDIMMUNE...... 72 SIRTURO...... 24 REYVOW...... 24 SANDOSTATIN...... 63 SITAVIG...... 30 RHOPRESSA...... 77 SANTYL...... 48 SIVEXTRO...... 15 RIAX...... 48 SAPHRIS...... 28 SKELAXIN...... 87 ribavirin...... 30 sapropterin SKYRIZI...... 72 RIDAURA...... 72 dihydrochloride...... 59 SKYRIZI (150 MG rifabutin...... 24 SAVAYSA...... 16 DOSE)...... 72 rifampin...... 24 SAVELLA...... 42 SKYRIZI PEN...... 72 RILUTEK...... 42 SAVELLA TITRATION SLYND...... 68 riluzole...... 42 PACK...... 42 sod citrate-citric acid...... 55 rimantadine hcl...... 30 SAXENDA...... 42 SODIUM ASCORBATE... 55 RINVOQ...... 72 scopolamine...... 21 sodium bicarbonate...... 58 RIOMET...... 50 SEASONIQUE...... 67 sodium chloride...... 81 risedronate sodium...... 74 SECUADO...... 28 sodium fluoride...... 43, 55 RISPERDAL...... 28 SEGLUROMET...... 51 sodium fluoride 5000 risperidone...... 28 selegiline hcl...... 26 enamel...... 43 RITALIN...... 40 selenium sulfide...... 48 sodium fluoride 5000 RITALIN LA...... 40 SELZENTRY...... 30 plus...... 43 ritonavir...... 30 SEMGLEE...... 53 sodium fluoride 5000 rivastigmine...... 18 SENSIPAR...... 74 ppm...... 43 rivastigmine tartrate...... 18 SEREVENT DISKUS...... 84 sodium fluoride 5000 rivelsa...... 67 SERNIVO...... 48 sensitive...... 43 rizatriptan benzoate...... 24 SEROQUEL...... 28 sodium phenylbutyrate.....59 ROCALTROL...... 74 SEROQUEL XR...... 28 sodium polystyrene ROCKLATAN...... 77 SEROSTIM...... 58 sulfonate...... 55 ropinirole hcl...... 26 sertraline hcl...... 20 sodium saccharin...... 75 ropinirole hcl er...... 26 setlakin...... 67 SOFOSBUVIR- rosadan...... 48 sevelamer carbonate...... 60 VELPATASVIR...... 30 rosuvastatin calcium...... 38 sevelamer hcl...... 60 solifenacin succinate...... 60 ROSZET...... 38 SEYSARA...... 15 SOLIQUA...... 51 ROWASA...... 73 sf...... 43 SOLODYN...... 15 roweepra...... 18 sf 5000 plus...... 43 SOLOSEC...... 15 ROXICODONE...... 9 SFROWASA...... 73 SOLTAMOX...... 25 ROZEREM...... 87 sharobel...... 67 SOMA...... 87 rufinamide...... 18 SIGNIFOR...... 63 SOMAVERT...... 63 RUKOBIA...... 30 SIKLOS...... 25 SOOLANTRA...... 48 RUZURGI...... 75 sildenafil citrate...... 86 SORIATANE...... 48 RYBELSUS...... 50 SILENOR...... 87 SORILUX...... 48 RYCLORA...... 81 SILIQ...... 72 sorine...... 38 RYTARY...... 26 silodosin...... 61 sotalol hcl...... 38 RYTHMOL SR...... 38 SILVADENE...... 15 sotalol hcl (af)...... 38 ryvent...... 81 silver sulfadiazine...... 15 SOTYLIZE...... 38 SABRIL...... 18 SIMBRINZA...... 77 SOVALDI...... 30 SACCHARIN...... 75 simliya...... 67 spinosad...... 26 SAFYRAL...... 67 simpesse...... 67 SPIRIVA HANDIHALER.. 84 SAIZEN...... 63 SIMPONI...... 72 SPIRIVA RESPIMAT...... 84 SAIZENPREP...... 63 simvastatin...... 38 spironolactone...... 38 SALAGEN...... 43 SINEMET...... 26 spironolactone-hctz...... 38 SAMSCA...... 55 SINGULAIR...... 84 SPORANOX...... 22 105 SPORANOX PULSEPAK 22 sumatriptan...... 24 tarina fe 1/20 eq...... 68 sprintec 28...... 68 sumatriptan succinate...... 24 TARKA...... 38 SPRITAM...... 18 sumatriptan succinate TASMAR...... 27 SPRIX...... 11 refill...... 24 TAURINE...... 55 sps...... 55 sumatriptan-naproxen tavaborole...... 22 sronyx...... 68 sodium...... 24 TAVALISSE...... 32 ssd...... 15 SUNOSI...... 87 TAYTULLA...... 68 STALEVO 100...... 26 SUPRAX...... 15 tazarotene...... 48 STALEVO 125...... 26 SUPREP BOWEL PREP TAZAROTENE...... 48 STALEVO 150...... 26 KIT...... 58 TAZORAC...... 48 STALEVO 200...... 26 SUSTIVA...... 30 taztia xt...... 38 STALEVO 50...... 26 SUTAB...... 58 TECFIDERA...... 41 STALEVO 75...... 27 syeda...... 68 TEGRETOL...... 18 stavudine...... 30 SYMBICORT...... 85 TEGRETOL-XR...... 18 STEGLATRO...... 51 SYMBYAX...... 20 TEGSEDI...... 42 STEGLUJAN...... 51 SYMDEKO...... 85 TEKTURNA...... 38 STELARA...... 72 SYMFI...... 30 TEKTURNA HCT...... 38 STIMATE...... 63 SYMFI LO...... 30 telmisartan...... 38 STIOLTO RESPIMAT...... 84 SYMJEPI...... 85 telmisartan-amlodipine.....38 STRATTERA...... 40 SYMLINPEN 120...... 51 telmisartan-hctz...... 38 STRENSIQ...... 59 SYMLINPEN 60...... 51 temazepam...... 87 STRIBILD...... 30 SYMPAZAN...... 18 TEMIXYS...... 30 STRIVERDI RESPIMAT.. 84 SYMPROIC...... 58 TEMOVATE...... 48 STROMECTOL...... 26 SYMTUZA...... 30 TENCON...... 9 SUBOXONE...... 12 SYNALAR...... 48 tenofovir disoproxil SUBSYS...... 9 SYNAREL...... 63 fumarate...... 30 subvenite...... 18 SYNDROS...... 21 TENORETIC 100...... 38 subvenite starter kit-blue..18 SYNERA...... 11 TENORETIC 50...... 38 subvenite starter kit- SYNJARDY...... 51 TENORMIN...... 38 green...... 18 SYNJARDY XR...... 51 terazosin hcl...... 61 subvenite starter kit- SYNTHROID...... 69 terbinafine hcl...... 22 orange...... 18 SYPRINE...... 55 terbutaline sulfate...... 85 SUCRAID...... 59 TACLONEX...... 48 terconazole...... 23 sucralfate...... 56 tacrolimus...... 48, 72 TERIPARATIDE SULAR...... 38 tadalafil...... 60 (RECOMBINANT)...... 74 SULCONAZOLE tadalafil (pah)...... 86 TESSALON PERLES...... 81 NITRATE...... 22 TAKHZYRO...... 87 TESTIM...... 62 sulfacetamide sodium...... 77 TALICIA...... 58 testosterone...... 62 sulfacetamide sodium TALTZ...... 72 testosterone cypionate.....62 (acne)...... 48 TAMIFLU...... 30 testosterone enanthate....62 sulfacetamide- tamoxifen citrate...... 25 tetrabenazine...... 42 prednisolone...... 79 tamsulosin hcl...... 61 tetracycline hcl...... 15 sulfadiazine...... 15 TAPAZOLE...... 69 TEXACORT...... 48 sulfamethoxazole- TAPERDEX 12-DAY...... 61 THEO-24...... 85 trimethoprim...... 15 TAPERDEX 6-DAY...... 61 theophylline...... 85 SULFAMYLON...... 15 TAPERDEX 7-DAY...... 61 theophylline er...... 85 sulfasalazine...... 73 TARGADOX...... 15 THIOLA...... 60 sulfatrim pediatric...... 15 TARGRETIN...... 25 THIOLA EC...... 60 sulfurated lime...... 26 tarina 24 fe...... 68 thioridazine hcl...... 28 sulindac...... 11 tarina fe 1/20...... 68 thiothixene...... 28 106 THREONINE...... 55 TOUJEO MAX trifluridine...... 77 THYQUIDITY...... 69 SOLOSTAR...... 53 trihexyphenidyl hcl...... 27 tiadylt er...... 38 TOUJEO SOLOSTAR...... 53 TRIJARDY XR...... 51 tiagabine hcl...... 18 tovet...... 49 TRIKAFTA...... 86 TIAZAC...... 38 TOVIAZ...... 60 tri-legest fe...... 68 TIGLUTIK...... 42 TRACLEER...... 86 TRILEPTAL...... 18 TIKOSYN...... 38 TRADJENTA...... 51 tri-linyah...... 68 tilia fe...... 68 TRAMADOL HCL ER...... 9 TRILIPIX...... 38 timolol maleate...... 38, 78 tramadol hcl er...... 9 tri-lo-estarylla...... 68 timolol maleate ocudose..78 tramadol hcl er (biphasic).. 9 tri-lo-marzia...... 68 timolol maleate pf...... 78 tramadol hcl ir...... 9 tri-lo-mili...... 68 TIMOPTIC...... 78 tramadol-acetaminophen...9 tri-lo-sprintec...... 68 TIMOPTIC OCUDOSE.... 78 trandolapril...... 38 trimethobenzamide hcl.....21 TIMOPTIC-XE...... 78 trandolapril-verapamil hcl trimethoprim...... 15 tinidazole...... 15 er...... 38 tri-mili...... 68 tiopronin...... 60 tranexamic acid...... 32 trimipramine maleate...... 20 TIROSINT...... 69 TRANSDERM SCOP TRINTELLIX...... 20 TIROSINT-SOL...... 69 (1.5 MG)...... 21 tri-nymyo...... 68 TIVICAY...... 30 TRANSDERM-SCOP tri-previfem...... 68 TIVICAY PD...... 30 (1.5 MG)...... 21 tri-sprintec...... 68 TIVORBEX...... 11 TRANXENE-T...... 32 tritocin...... 49 tizanidine hcl...... 87 tranylcypromine sulfate....20 TRIUMEQ...... 30 TOBI NEBULIZER...... 85 TRAVATAN Z...... 78 trivora (28)...... 68 TOBI PODHALER...... 85 travoprost (bak free)...... 78 tri-vylibra...... 68 TOBRADEX...... 79 trazodone hcl...... 20 tri-vylibra lo...... 68 TOBRADEX ST...... 79 TRECATOR...... 24 TRIZIVIR...... 30 tobramycin...... 77, 85 TRELEGY ELLIPTA...... 85 TROKENDI XR...... 18 TOBRAMYCIN...... 86 TREMFYA...... 72 trospium chloride...... 60 tobramycin- TRESIBA...... 53 trospium chloride er...... 60 dexamethasone...... 79 TRESIBA FLEXTOUCH...53 TRULANCE...... 58 TOBREX...... 77 tretinoin...... 49 TRULICITY...... 51 TODAY SPONGE...... 75 tretinoin microsphere...... 49 TRUSOPT...... 78 tolbutamide...... 51 tretinoin microsphere TRUVADA...... 30 tolcapone...... 27 pump...... 49 TUDORZA PRESSAIR.... 85 TOLNAFTATE...... 23 TREXALL...... 72 tulana...... 68 TOLSURA...... 23 TREXIMET...... 24 TUSSICAPS...... 81 tolterodine tartrate...... 60 tri femynor...... 68 TUXARIN ER...... 81 tolterodine tartrate er...... 60 triamcinolone acetonide TUZISTRA XR...... 81 TOLVAPTAN...... 55 ...... 43, 49 TWIRLA...... 68 tolvaptan...... 55 triamterene...... 38 TWYNSTA...... 38 TOPAMAX...... 18 triamterene-hctz...... 38 tyblume...... 68 TOPAMAX SPRINKLE.... 18 TRIANEX...... 49 TYBOST...... 30 TOPICORT...... 48 triazolam...... 32 tydemy...... 68 TOPICORT SPRAY...... 48 TRIBENZOR...... 38 TYMLOS...... 74 topiramate...... 18 TRICOR...... 38 TYVASO...... 86 topiramate er...... 18 triderm...... 49 TYVASO REFILL...... 86 TOPROL XL...... 38 TRIDESILON...... 49 TYVASO STARTER...... 86 toremifene citrate...... 25 trientine hcl...... 55 UBRELVY...... 24 torsemide...... 38 tri-estarylla...... 68 UCERIS...... 73 TOSYMRA...... 24 trifluoperazine hcl...... 28 ULORIC...... 23 107 ULTRACET...... 9 venlafaxine hcl er...... 20 vyfemla...... 68 ULTRAM...... 9 VENTAVIS...... 86 vylibra...... 68 ULTRAVATE...... 49 VENTOLIN HFA...... 85 VYNDAMAX...... 39 unithroid...... 69 verapamil hcl...... 39 VYNDAQEL...... 39 UPNEEQ...... 77 verapamil hcl er...... 38, 39 VYTORIN...... 39 UPTRAVI...... 86 VERDESO...... 49 VYVANSE...... 40 urin ds...... 60 VEREGEN...... 49 VYZULTA...... 78 UROCIT-K 10...... 55 VERELAN...... 39 WAKIX...... 87 UROCIT-K 15...... 55 VERELAN PM...... 39 warfarin sodium...... 16 UROCIT-K 5...... 55 VERQUVO...... 39 weekly-d...... 55 UROXATRAL...... 61 VERSACLOZ...... 28 WELCHOL...... 39 URSO 250...... 58 VESICARE...... 60 WELLBUTRIN SR...... 20 URSO FORTE...... 58 VESICARE LS...... 60 WELLBUTRIN XL...... 20 ursodiol...... 58 vestura...... 68 wera...... 68 VAGIFEM...... 68 VFEND...... 23 WESTHROID...... 69 valacyclovir hcl...... 30 VIBERZI...... 58 WINLEVI...... 49 VALCYTE...... 30 VIBRAMYCIN...... 15 wixela inhub...... 85 valganciclovir hcl...... 30 VICTOZA...... 51 WP THYROID...... 69 VALINE...... 55 VIEKIRA PAK...... 30 wymzya fe...... 68 VALIUM...... 32 vienva...... 68 WYNZORA...... 49 valproic acid...... 18 vigabatrin...... 18 XADAGO...... 27 valsartan...... 38 vigadrone...... 18 XALATAN...... 78 valsartan- VIGAMOX...... 77 XANAX...... 32 hydrochlorothiazide...... 38 VIIBRYD...... 20 XANAX XR...... 32 VALTOCO...... 18 VIIBRYD STARTER XARELTO...... 16 VALTREX...... 30 PACK...... 20 XARELTO STARTER VANADOM...... 87 VIMOVO...... 11 PACK...... 16 VANCOCIN...... 15 VIMPAT...... 18 XATMEP...... 73 VANCOCIN HCL...... 15 VIOKACE...... 59 XCOPRI...... 18 vancomycin hcl...... 15 viorele...... 68 XELJANZ...... 73 vandazole...... 15 VIRACEPT...... 30 XELJANZ XR...... 73 VANOS...... 49 VIRAMUNE...... 30 XELPROS...... 78 VARIZIG...... 73 VIRAMUNE XR...... 30 XENAZINE...... 42 VARUBI (180 MG VIRAZOLE...... 30 XENICAL...... 42 DOSE)...... 21 VIREAD...... 31 XENLETA...... 15 VASCEPA...... 38 virt-phos 250 neutral...... 55 XEPI...... 15 VASERETIC...... 38 virtussin ac w/alc...... 81 XERAC AC...... 49 VASOTEC...... 38 VISTARIL...... 32 XERESE...... 31 VCF VAGINAL VISTOGARD...... 75 XERMELO...... 58 CONTRACEPTIVE...... 75 VIVELLE-DOT...... 68 XHANCE...... 81 vcf vaginal contraceptive. 75 VIVLODEX...... 11 XIFAXAN...... 15 VECAMYL...... 38 VOGELXO...... 62 XIGDUO XR...... 51 VECTICAL...... 49 VOGELXO PUMP...... 62 XIIDRA...... 79 velivet...... 68 volnea...... 68 XIMINO...... 15 VELPHORO...... 60 voriconazole...... 23 XOFLUZA (40 MG VELTASSA...... 55 VOSEVI...... 31 DOSE)...... 31 VELTIN...... 49 VRAYLAR...... 28 XOFLUZA (80 MG VEMLIDY...... 30 VTOL LQ...... 9 DOSE)...... 31 VENELEX...... 49 VUMERITY...... 41 XOLEGEL...... 23 venlafaxine hcl...... 20 VUSION...... 23 108 XOPENEX ziprasidone hcl...... 28 CONCENTRATE...... 85 ZIPSOR...... 11 XOPENEX HFA...... 85 ZIRGAN...... 77 XOPENEX NEB...... 85 ZITHROMAX...... 15 XTAMPZA ER...... 9 ZITHROMAX TRI-PAK.... 15 xulane...... 68 ZITHROMAX Z-PAK...... 15 XULTOPHY...... 51 ZOCOR...... 39 XURIDEN...... 59 ZOFRAN...... 21 XYOSTED...... 62 ZOKINVY...... 75 XYREM...... 87 ZOLMITRIPTAN...... 24 XYWAV...... 87 zolmitriptan...... 24 YASMIN 28...... 68 ZOLOFT...... 20 YAZ...... 68 zolpidem tartrate...... 87 YOSPRALA...... 27 zolpidem tartrate er...... 87 YUPELRI...... 85 ZOLPIMIST...... 87 yuvafem...... 68 ZOMACTON...... 63 zafemy...... 68 ZOMACTON (FOR zafirlukast...... 85 ZOMA-JET 10)...... 63 zaleplon...... 87 ZOMIG...... 24 ZANAFLEX...... 87 ZOMIG ZMT...... 24 zarah...... 68 ZONALON...... 49 ZARONTIN...... 18 ZONEGRAN...... 18 ZAVESCA...... 59 zonisamide...... 18 ZEBUTAL...... 9 ZONTIVITY...... 27 ZEGERID...... 56 ZORBTIVE...... 58 ZELAPAR...... 27 ZORTRESS...... 73 ZELNORM...... 58 ZORVOLEX...... 11 ZEMBRACE zovia 1/35 (28)...... 68 SYMTOUCH...... 24 zovia 1/35e (28)...... 68 ZEMPLAR...... 74 ZOVIRAX...... 31 zenatane...... 49 ZTLIDO...... 11 ZENPEP...... 59 ZUBSOLV...... 12 ZENZEDI...... 40 zumandimine...... 68 ZEPATIER...... 31 ZUPLENZ...... 21 ZEPOSIA...... 41 ZYCLARA...... 49 ZEPOSIA 7-DAY ZYCLARA PUMP...... 49 STARTER PACK...... 41 ZYFLO...... 85 ZEPOSIA STARTER KIT.41 ZYLET...... 79 ZERVIATE...... 77 ZYLOPRIM...... 23 ZESTORETIC...... 39 ZYMAXID...... 77 ZESTRIL...... 39 ZYPITAMAG...... 39 ZETIA...... 39 ZYPREXA...... 28 ZETONNA...... 81 ZYPREXA ZYDIS...... 28 ZIAC...... 39 ZYVOX...... 15 ZIAGEN...... 31 ZIANA...... 49 zidovudine...... 31 zileuton er...... 85 ZILXI...... 49 ZIOPTAN...... 78 109 Non-discrimination notice

Sanford Health Plan does not discriminate against any future, current, or past Member on the basis of race; ethnicity; color; national origin; disability; sex; gender; sexual orientation; gender identity; religion; spiritual beliefs; medical condition, including a current or past history of mental health and substance use disorders; sources of payment for care; or age, in its coverage, treatment, or benefit decisions.

Sanford Health Plan:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, or other formats)  Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact Sanford Health Plan at (800) 752-5863 | TTY: 711.

If you believe that Sanford Health Plan has failed to provide these services or discriminated in any way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Civil Rights Coordinator at 300 Cherapa Place #201, Sioux Falls, SD 57103, call (800) 325-9402 | TTY: 711, fax (605) 328-6812, or e-mail [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the US Department of Health and Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: US Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, (800) 368-1019, TTY/TDD (800) 537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Free help in other languages

For help in any language other than English, please call 1-800-752-5863 | TTY: 711. If you have any questions, for example, about your benefits, a document, or how Sanford Health Plan pays for your care, please call us. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Sanford Health Plan, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-927-2969. Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Sanford Health Plan, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-844-923- 3519. Cushite: Isin yookan namni biraa isin deeggartan Sanford Health Plan irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1- 844-927-2968 tiin bilbilaa. Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Sanford Health Plan, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình hoàn toàn miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-927-2973. Chinese (Mandarin): 如果您，或您正在幫助的人，有關於 Sanford Health Plan 方面的問 題，您有權利免費以您的母語得到幫助和訊息。想要跟一位翻譯員通話，請致電 1-844-923-3524。 German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Sanford Health Plan haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-923- 3517 an.

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Sanford Health Plan, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-844-927-2967. Laotian: ຖ້າທ່ານ, ຫ ຼືຄົນທ ່ທ່ານກໍາລັງຊ່ວຍເຫ ຼືອ, ມ ຄໍາຖາມກ່ຽວກັບ Sanford Health Plan, ທ່ານມ ສິດທ ່ຈະໄດ້ຮັບການຊ່ວຍເຫ ຼືອແລະຂໍ້ມູນຂ່າວສານທ ່ເປັນພາສາຂອງທ່ານບໍ່ມ ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1-800-752-5863. Arabic: نإ ناك كيدل وأ ىدل صخش هدعاست ةلئسأ صوصخب Sanford Health Plan ، كيدلف قحال يف لوصحلا ىلع ةدعاسملا تامولعمالو ةيرورضلا كتغلب نم نود ةيا ةفلكت. ثدحتلل عم مجرتم لصتا ـب 1-844-923-3511. Karen:

1-844-923-3522 Amharic: Sanford Health Plan 1-800-752-5863

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Sanford Health Plan 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-844-923-3523로 오. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Sanford Health Plan, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-923-3516. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Sanford Health Plan, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-800-752-5863. Cambodian, Mon-Khmer: ប្រសិនររ ើ诒នក ឬន 㮶插ន ន ក់ដែ ល诒នកកំពុងដែ ជួយ 插ននស ណំ ួ 诒្ ំពី Sanford Health Plan ររ ,诒នក插ននសិរ ធិរ រ ួលជំនួយនិងព័ែ 插នន ររ កនុង徶ស ស់诒នក ររ យ插ិន诒 ស់រ្្ ក់ ។ រែ រ 插រីន ិ架យᾶ插ួ យ诒 ្នក កដប្រ សូ 插 1-844-923-3512។ Bantu: Nimba wewe canke umuntu uriko urafasha afise ibibazo vyerekeye Sanford Health Plan, utegerezwa kugira uburenganzira bwo kuronka ubufasha n’amakuru arambuye mu rurimi gwawe ataco utanze canke kurihira. Hamagara 1-800- 752-5863 uhamagara umusobanuzi. Swahili: Kama wewe, au mtu unaye mpa usaidizi ana maswali kuhusu Sanford Health Plan, Una haki ya kupata habari hii na msaada kwa lugha yako bila gharama. Kuzungumza na mkalimani, piga nambari hii: 1-844-927-2970.

Japanese: ご本人様、またはお客様の身の回りの方でも、Sanford Health Plan についてご質問がございまし たら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりませ ん。通訳とお話される場合、1-844-923-3521 までお電話ください。 Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Sanford Health Plan, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800- 752-5863. Nepali: यदि तपाईं आ굍ना लादि आफℂ आवेद नको काम द द , वा कस लाई मद्दत द द नुꅍछ, Sanford Health Plan बारे प्रश्नह셂 छन् भने आ굍नो मातृभाषामा िन : शुल्क सहायता वा जानकारी पाउने अदिकार छ । द ोभाषे ( इन्टरप्रेटर ) सँद कुरा द नु ुपरे 1-844-927-2961 मा फोन द नु ुहोस् । Norwegian: Hvis du, eller noen du hjelper, har spørsmål om Sanford Health Plan, har du rett til å få hjelp og informasjon på ditt språk uten kostnad. For å snakke med en tolk, ring 1-800-752-5863. Help understanding your health insurance is free. If you would like something in another format (for example, a larger font size of a file for use with assistive technology, like a screen reader), please call us at: (800) 752-5863 (toll-free) | TTY: 711

North Dakota Medicaid Expansion: Please call (855) 305-5060 (toll-free) | TTY: 711 HP-1186 01-01-2021