FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option

Effective September 1, 2017

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

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

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

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

INTRODUCTION...... 5 PREFACE ...... 5 MANAGED NOT COVERED DRUGS ...... 6 PRIOR APPROVAL ...... 6 QUANTITY LIMITATIONS ...... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ...... 6 PRODUCT SELECTION CRITERIA...... 6 FORMULARY PRODUCT DESCRIPTIONS ...... 7 GENERIC SUBSTITUTION ...... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ...... 8 EDITOR ...... 8 NOTICE ...... 8 LEGEND ...... 9 ANALGESICS...... 10 ANALGESICS, OTHER ...... 10 NSAIDs ...... 10 NSAIDs, COMBINATIONS ...... 10 NSAIDs, TOPICAL ...... 10 COX-2 INHIBITORS ...... 10 GOUT ...... 10 OPIOID ANALGESICS ...... 11 NON-OPIOID ANALGESICS ...... 11 VISCOSUPPLEMENTS ...... 11 ANTI-INFECTIVES ...... 12 ANTIBACTERIALS ...... 12 ANTIFUNGALS ...... 13 ANTIMALARIALS ...... 14 ANTIRETROVIRAL AGENTS ...... 14 ANTITUBERCULAR AGENTS ...... 15 ANTIVIRALS...... 15 MISCELLANEOUS ...... 16 ANTINEOPLASTIC AGENTS ...... 16 ALKYLATING AGENTS ...... 17 ANTIMETABOLITES ...... 17 HORMONAL ANTINEOPLASTIC AGENTS ...... 17 IMMUNOMODULATORS ...... 18 KINASE INHIBITORS ...... 18 TOPOISOMERASE INHIBITORS ...... 19 MISCELLANEOUS ...... 19 CARDIOVASCULAR ...... 20 ACE INHIBITORS...... 21 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 21 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 21 ADRENOLYTICS, CENTRAL ...... 21

1 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 21 ALPHA BLOCKERS ...... 21 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 21 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 22 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 22 ANTIARRHYTHMICS ...... 22 ANTILIPEMICS...... 22 BETA-BLOCKERS ...... 23 BETA-BLOCKER/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ...... 23 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 23 CALCIUM CHANNEL BLOCKERS ...... 24 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 24 DIGITALIS GLYCOSIDES ...... 24 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 24 DIURETICS ...... 24 HEART FAILURE ...... 25 NITRATES ...... 25 PULMONARY ARTERIAL HYPERTENSION ...... 25 MISCELLANEOUS ...... 25 CENTRAL NERVOUS SYSTEM ...... 26 ANTIANXIETY ...... 26 ANTICONVULSANTS ...... 26 ANTIDEMENTIA ...... 27 ANTIDEPRESSANTS ...... 27 ANTIPARKINSONIAN AGENTS ...... 28 ANTIPSYCHOTICS ...... 28 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 29 FIBROMYALGIA...... 30 HUNTINGTON'S DISEASE AGENTS ...... 30 HYPNOTICS...... 30 MIGRAINE ...... 30 MOOD STABILIZERS ...... 31 MULTIPLE SCLEROSIS ...... 31 MUSCULOSKELETAL THERAPY AGENTS ...... 31 MYASTHENIA GRAVIS ...... 31 NARCOLEPSY/CATAPLEXY ...... 31 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 32 MISCELLANEOUS ...... 32 ENDOCRINE AND METABOLIC ...... 32 ANDROGENS ...... 32 ANTIDIABETICS ...... 33 CALCIUM RECEPTOR ANTAGONISTS ...... 35 CALCIUM REGULATORS ...... 35 CARNITINE DEFICIENCY AGENTS ...... 35 CONTRACEPTIVES ...... 35 ENDOMETRIOSIS ...... 37 ESTROGENS ...... 37 ESTROGEN/PROGESTINS ...... 37 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ...... 38 FERTILITY REGULATORS ...... 38 GLUCOCORTICOIDS ...... 38 GLUCOSE ELEVATING AGENTS ...... 38 HUMAN GROWTH HORMONES ...... 38 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 39 INSULIN-LIKE GROWTH FACTOR-1 AGENTS ...... 39 PHENYLKETONURIA TREATMENT AGENTS ...... 39 PHOSPHATE BINDER AGENTS ...... 39 PROGESTINS ...... 39 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 39 THYROID AGENTS ...... 39 VASOPRESSINS ...... 39 MISCELLANEOUS ...... 39 GASTROINTESTINAL ...... 40 ANTIDIARRHEALS ...... 40 ANTIEMETICS ...... 40

2 ANTISPASMODICS ...... 41 CHOLELITHOLYTICS ...... 41 H2 RECEPTOR ANTAGONISTS ...... 41 INFLAMMATORY BOWEL DISEASE ...... 41 IRRITABLE BOWEL SYNDROME ...... 42 LAXATIVES ...... 42 OPIOID-INDUCED CONSTIPATION ...... 42 PANCREATIC ENZYMES ...... 42 PROSTAGLANDINS ...... 42 PROTON PUMP INHIBITORS ...... 42 SALIVA STIMULANTS ...... 42 STEROIDS, RECTAL ...... 42 ULCER THERAPY COMBINATIONS ...... 43 MISCELLANEOUS ...... 43 GENITOURINARY ...... 43 BENIGN PROSTATIC HYPERPLASIA ...... 43 URINARY ANTISPASMODICS ...... 43 VAGINAL ANTI-INFECTIVES ...... 43 MISCELLANEOUS ...... 43 HEMATOLOGIC ...... 44 ANTICOAGULANTS ...... 44 HEMATOPOIETIC GROWTH FACTORS ...... 44 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ...... 44 HEREDITARY ANGIOEDEMA AGENTS ...... 45 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...... 45 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ...... 45 PLATELET AGGREGATION INHIBITORS ...... 45 PLATELET SYNTHESIS INHIBITORS ...... 45 STEM CELL MOBILIZERS ...... 46 MISCELLANEOUS ...... 46 IMMUNOLOGIC AGENTS ...... 46 ALLERGENIC EXTRACTS ...... 46 BIOLOGIC DISEASE-MODIFYING AGENTS ...... 46 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 46 IMMUNE GLOBULINS ...... 46 IMMUNOMODULATORS ...... 47 IMMUNOSUPPRESSANTS ...... 47 NUTRITIONAL/SUPPLEMENTS ...... 48 ELECTROLYTES ...... 48 VITAMINS AND MINERALS ...... 48 RESPIRATORY ...... 48 ANAPHYLAXIS TREATMENT AGENTS ...... 48 ANTICHOLINERGICS ...... 49 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 49 ANTIHISTAMINES, SEDATING ...... 49 ANTITUSSIVES...... 49 ANTITUSSIVE COMBINATIONS ...... 49 BETA AGONISTS ...... 49 CYSTIC FIBROSIS ...... 50 LEUKOTRIENE MODIFIERS ...... 50 MAST CELL STABILIZERS ...... 50 NASAL ANTIHISTAMINES ...... 50 NASAL STEROIDS ...... 50 PHOSPHODIESTERASE-4 INHIBITORS ...... 50 PULMONARY FIBROSIS AGENTS ...... 50 STEROID/BETA AGONIST COMBINATIONS ...... 50 STEROID INHALANTS ...... 51 XANTHINES ...... 51 MISCELLANEOUS ...... 51 TOPICAL ...... 51 DERMATOLOGY...... 51 MOUTH/THROAT/DENTAL AGENTS ...... 55 OPHTHALMIC ...... 55 OTIC ...... 57

3 WEBSITES ...... 59 MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART ...... 61 INDEX ...... 63

INTRODUCTION FEP is pleased to provide the 2017 FEP 5 Tier Managed Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Managed Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

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

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

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

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 generic preferred non-preferred brand preferred non-preferred drugs brand products and all specialty specialty products compounded medications products products Basic Option Retail Up to Up to $50 60% coinsurance* Up to $65 Up to $90 Pharmacy $10 Limit***: one Limit***: one 30-day supply fill 30-day supply fill at retail at retail Basic Option $55 for up to a $80 for up to a Specialty 30-day supply 30-day supply Pharmacy $165 for up to a $240 for up to a 90-day supply 90-day supply Basic Option Retail Up to Up to $45 50% coinsurance** Up to $60 Up to $80 Pharmacy (Med B) $10 Limit***: one Limit***: one 30-day supply fill 30-day supply fill at retail at retail Basic Option Mail Up to Up to $90 Up to $115 Pharmacy (Med B) $20 Basic Option $50 for up to a $70 for up to a Specialty 30-day supply 30-day supply Pharmacy (Med B) $140 for up to a $195 for up to a 90-day supply 90-day supply * With a minimum payment of $65 up to a 30-day supply ($195 up to a 90-day supply)

** With a minimum payment of $55 up to a 30-day supply ($165 up to a 90-day supply)

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

Drug products shown in boldface type in Tier 2, Tier 3, Tier 4 and Tier 5 have generic versions.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non-preferred, typically if the cost-effectiveness is less than other similar drugs. MANAGED NOT COVERED DRUGS Effective January 1, 2017, selected medications will no longer be covered on the Basic Option drug benefit plan. These medications known as Managed Not Covered drugs have available covered options in the same therapeutic class. For a full listing of these Managed Not Covered medications please see the MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART located on page 61 before the INDEX in this document.

Patients taking a Managed Not Covered medication on or after January 1, 2017 should expect to pay the full cost of the prescription. PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page. QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page. PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes the evaluation of new medications, and making recommendations to FEP for their designation as preferred or non-preferred on the FEP 5 Tier Managed Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP. PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

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

When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

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

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

Preferred products include all strengths and dosage forms of the cited brand-name product.

lanthanum Fosrenol Chewable tabs, oral powder and all strengths of Fosrenol would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not.

acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry.

sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.

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

Dosage forms will be consistent with the category and use where listed.

neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry, the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the formulary. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

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

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

• Manufactured in the same strength and dosage form as the brand-name drugs.

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

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

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

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date.

LEGEND † Generic contraceptives are covered at no charge to the member ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for both brands and generics. boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

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

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

acetaminophen inj OFIRMEV Tier 3

NSAIDs diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac ext-rel Tier 1 fenoprofen Tier 1 NALFON Tier 3 flurbiprofen Tier 1 ibuprofen Tier 1 indomethacin Tier 1 indomethacin ext-rel Tier 1 ketoprofen Tier 1 ketoprofen ext-rel Tier 1 ketorolac Tier 1 meloxicam Tier 1 MOBIC Tier 3 nabumetone Tier 1 naproxen Tier 1 naproxen sodium Tier 1 naproxen sodium ext-rel Tier 1 oxaprozin Tier 1 DAYPRO Tier 3 piroxicam Tier 1 sulindac Tier 1 ibuprofen inj CALDOLOR Tier 2 indomethacin susp INDOCIN susp Tier 3 PA ketorolac tromethamine nasal spray SPRIX Tier 3

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/ Tier 1 misoprostol

NSAIDs, TOPICAL diclofenac sodium gel Tier 1 VOLTAREN GEL Tier 3 diclofenac sodium soln Tier 1

COX-2 INHIBITORS PA celecoxib Tier 1 CELEBREX Tier 3

GOUT allopurinol Tier 1 ZYLOPRIM Tier 3 colchicine Tier 1 COLCRYS Tier 3 probenecid Tier 1 febuxostat ULORIC Tier 2 colchicine MITIGARE Tier 3 PA lesinurad ZURAMPIC Tier 3 PA pegloticase KRYSTEXXA Tier 5

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

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

QL buprenorphine transdermal Tier 1 BUTRANS Tier 3 QL butalbital/acetaminophen/caffeine/ Tier 1 FIORICET w/CODEINE Tier 3 codeine QL butalbital/aspirin/caffeine/codeine Tier 1 FIORINAL w/CODEINE Tier 3 QL butorphanol nasal spray Tier 1 codeine/acetaminophen Tier 1 TYLENOL w/CODEINE Tier 3 QL fentanyl transdermal Tier 1 DURAGESIC Tier 3 PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3 hydrocodone/acetaminophen - Vicodin Tier 1 hydrocodone/acetaminophen - Tier 1 Vicodin ES QL hydromorphone Tier 1 DILAUDID Tier 3 QL hydromorphone ext-rel Tier 1 EXALGO Tier 3 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 KADIAN Tier 3 QL morphine ext-rel Tier 1 MS CONTIN Tier 3 morphine supp Tier 1 QL oxycodone Tier 1 ROXICODONE Tier 3 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3 QL oxymorphone Tier 1 OPANA Tier 3 QL tramadol Tier 1 ULTRAM Tier 3 QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3 PA fentanyl citrate buccal FENTORA Tier 2 QL tapentadol NUCYNTA Tier 2 QL tapentadol ext-rel NUCYNTA ER Tier 2 PA fentanyl citrate nasal spray LAZANDA Tier 3 PA fentanyl sublingual spray SUBSYS Tier 3 PA fentanyl sublingual tablets ABSTRAL Tier 3 PA hydrocodone ext-rel caps ZOHYDRO ER Tier 3 PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3 QL morphine ext-rel MORPHABOND Tier 3 QL morphine/naltrexone ext-rel EMBEDA Tier 3 QL oxycodone ext-rel OXYCONTIN Tier 3 QL oxycodone ext-rel XTAMPZA ER Tier 3 oxycodone/acetaminophen PRIMLEV Tier 3 QL oxymorphone ext-rel OPANA ER Tier 3

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

VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 4 PA sodium hyaluronate GELSYN-3 Tier 4

PA sodium hyaluronate HYALGAN Tier 4 PA sodium hyaluronate SUPARTZ FX Tier 4 PA high molecular weight hyaluronan ORTHOVISC Tier 5 PA hylan G-F 20 SYNVISC Tier 5 PA hylan G-F 20 SYNVISC-ONE Tier 5 PA sodium hyaluronate EUFLEXXA Tier 5 PA sodium hyaluronate MONOVISC Tier 5

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

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

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

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

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm

International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: http://www.cdc.gov/flu/

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

ANTIBACTERIALS Cephalosporins First Generation cephalexin Tier 1 KEFLEX Tier 3

Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1 CEFTIN Tier 3

Third Generation cefdinir Tier 1 cefditoren Tier 1 SPECTRACEF Tier 3 cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 FORTAZ Tier 3 ceftibuten Tier 1 CEDAX Tier 3 ceftriaxone Tier 1 ROCEPHIN Tier 3 cefixime SUPRAX Tier 2

Fourth Generation cefepime Tier 1

Fifth Generation ceftaroline fosamil TEFLARO Tier 2

Erythromycins/Macrolides azithromycin Tier 1 ZITHROMAX Tier 3 clarithromycin Tier 1 BIAXIN Tier 3 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3 erythromycin ethylsuccinate Tier 1 ERYPED Tier 3 erythromycin stearate Tier 1 azithromycin ext-rel ZMAX Tier 2 fidaxomicin DIFICID Tier 2 erythromycin dispertabs PCE Tier 3

Fluoroquinolones ciprofloxacin Tier 1 CIPRO Tier 3 ciprofloxacin ext-rel Tier 1 levofloxacin Tier 1 LEVAQUIN Tier 3 moxifloxacin Tier 1 AVELOX Tier 3 ofloxacin Tier 1 gemifloxacin FACTIVE Tier 3

Ketolides telithromycin KETEK Tier 3

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

Tetracyclines doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3 doxycycline monohydrate Tier 1 ADOXA Tier 3 doxycycline monohydrate Tier 1 MONODOX Tier 3 minocycline Tier 1 MINOCIN Tier 3 minocycline ext-rel Tier 1 SOLODYN Tier 3 tetracycline Tier 1

ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1 DIFLUCAN Tier 3 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 GRIS-PEG Tier 3 PA itraconazole caps Tier 1 SPORANOX caps Tier 3 PA ketoconazole tabs Tier 1

nystatin Tier 1 PA terbinafine tabs Tier 1 LAMISIL Tier 3 voriconazole Tier 1 VFEND Tier 3 amphotericin B lipid complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 anidulafungin ERAXIS Tier 2 posaconazole NOXAFIL Tier 2 PA isavuconazonium CRESEMBA Tier 3 PA itraconazole oral soln SPORANOX oral soln Tier 3 micafungin MYCAMINE Tier 3

ANTIMALARIALS atovaquone/proguanil Tier 1 MALARONE Tier 3 chloroquine Tier 1 ARALEN Tier 3 mefloquine Tier 1 primaquine Tier 2 artemether/lumefantrine COARTEM Tier 2 PA pyrimethamine DARAPRIM Tier 2

ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants cobicistat TYBOST Tier 2

Antiretroviral Combinations abacavir/lamivudine Tier 1 EPZICOM Tier 3 abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3 lamivudine/zidovudine Tier 1 COMBIVIR Tier 3 abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 atazanavir/cobicistat EVOTAZ Tier 2 darunavir/cobicistat PREZCOBIX Tier 2 efavirenz/emtricitabine/tenofovir ATRIPLA Tier 2 elvitegravir/cobicistat/emtricitabine/ STRIBILD Tier 2 tenofovir elvitegravir/cobicistat/emtricitabine/ GENVOYA Tier 2 tenofovir alafenamide emtricitabine/rilpivirine/tenofovir COMPLERA Tier 2 emtricitabine/rilpivirine/ ODEFSEY Tier 2 tenofovir alafenamide emtricitabine/tenofovir TRUVADA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 3

Chemokine Receptor Antagonists maraviroc SELZENTRY Tier 2

Fusion Inhibitors enfuvirtide FUZEON Tier 4

Integrase Inhibitors dolutegravir TIVICAY Tier 2 raltegravir ISENTRESS Tier 2

Non-nucleoside Reverse Transcriptase Inhibitors nevirapine Tier 1 VIRAMUNE Tier 3 nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3 delavirdine RESCRIPTOR Tier 2 efavirenz SUSTIVA Tier 2 etravirine INTELENCE Tier 2

rilpivirine EDURANT Tier 2

Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 ZIAGEN Tier 3 didanosine delayed-rel Tier 1 VIDEX EC Tier 3 lamivudine Tier 1 EPIVIR Tier 3 stavudine Tier 1 ZERIT Tier 3 zidovudine Tier 1 RETROVIR Tier 3 abacavir soln ZIAGEN soln Tier 2 didanosine soln VIDEX soln Tier 2 emtricitabine EMTRIVA Tier 2 stavudine soln ZERIT soln Tier 3

Nucleotide Reverse Transcriptase Inhibitors tenofovir VIREAD Tier 2

Protease Inhibitors atazanavir REYATAZ Tier 2 darunavir PREZISTA Tier 2 fosamprenavir LEXIVA Tier 2 indinavir CRIXIVAN Tier 2 lopinavir/ritonavir KALETRA Tier 2 nelfinavir VIRACEPT Tier 2 ritonavir NORVIR Tier 2 saquinavir mesylate INVIRASE Tier 2 tipranavir APTIVUS Tier 2

ANTITUBERCULAR AGENTS ethambutol Tier 1 MYAMBUTOL Tier 3 isoniazid Tier 1 pyrazinamide Tier 1 rifampin Tier 1 RIFADIN Tier 3 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 rifapentine PRIFTIN Tier 2 bedaquiline SIRTURO Tier 3

ANTIVIRALS Cytomegalovirus Agents cidofovir Tier 1 VISTIDE Tier 3 PA valganciclovir Tier 1 VALCYTE Tier 2 ganciclovir inj Tier 4 CYTOVENE inj Tier 5 cytomegalovirus immune globulin CYTOGAM Tier 4

Hepatitis Agents Hepatitis B lamivudine Tier 1 EPIVIR-HBV Tier 3 adefovir dipivoxil Tier 4 HEPSERA Tier 5 entecavir tabs Tier 4 BARACLUDE Tier 5 entecavir soln BARACLUDE soln Tier 4 telbivudine TYZEKA Tier 4 tenofovir alafenamide VEMLIDY Tier 4

Hepatitis C PA ribavirin caps Tier 4 REBETOL Tier 4 PA ribavirin caps - Ribasphere Tier 4 PA ribavirin tabs Tier 4 COPEGUS Tier 5 PA ledipasvir/sofosbuvir HARVONI Tier 4

PA ribavirin oral soln REBETOL Tier 4 PA sofosbuvir SOVALDI Tier 4 PA sofosbuvir/velpatasvir EPCLUSA Tier 4 PA daclatasvir DAKLINZA Tier 5 PA elbasvir/grazoprevir ZEPATIER Tier 5 PA ombitasvir/paritaprevir/ritonavir TECHNIVIE Tier 5 PA simeprevir OLYSIO Tier 5

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

Influenza Agents amantadine, except tabs Tier 1 QL oseltamivir caps Tier 1 TAMIFLU caps Tier 3 rimantadine Tier 1 FLUMADINE Tier 3 QL oseltamivir susp TAMIFLU Tier 2 QL zanamivir RELENZA Tier 2

Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 4

MISCELLANEOUS atovaquone Tier 1 MEPRON Tier 3 aztreonam Tier 1 AZACTAM Tier 3 clindamycin Tier 1 CLEOCIN Tier 3 dapsone Tier 1 daptomycin Tier 1 CUBICIN Tier 2 doripenem Tier 1 DORIBAX Tier 3 QL linezolid Tier 1 ZYVOX Tier 3 meropenem Tier 1 MERREM Tier 3 methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3 metronidazole tabs Tier 1 FLAGYL Tier 3 nitrofurantoin ext-rel Tier 1 MACROBID Tier 3 nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3 rifabutin Tier 1 MYCOBUTIN Tier 3 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1 TINDAMAX Tier 3 trimethoprim Tier 1 vancomycin Tier 1 VANCOCIN Tier 3 ertapenem INVANZ Tier 2 imipenem/cilastatin PRIMAXIN Tier 2 miltefosine IMPAVIDO Tier 2 nitazoxanide ALINIA Tier 2 PA rifaximin XIFAXAN Tier 2 QL tedizolid SIVEXTRO Tier 2 telavancin VIBATIV Tier 3 tigecycline TYGACIL Tier 3

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

ALKYLATING AGENTS busulfan Tier 1 BUSULFEX Tier 2 ifosfamide/mesna Tier 1 cyclophosphamide inj Tier 4 dacarbazine Tier 4 melphalan inj Tier 4 ALKERAN inj Tier 5 temozolomide Tier 4 TEMODAR Tier 5 thiotepa Tier 4 altretamine HEXALEN Tier 2 busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 carmustine BICNU Tier 4 cyclophosphamide caps CYCLOPHOSPHAMIDE CAPSULES Tier 4 mechlorethamine MUSTARGEN Tier 4 PA mechlorethamine gel VALCHLOR Tier 4 melphalan tabs ALKERAN tabs Tier 4 streptozocin ZANOSAR Tier 4 trabectedin YONDELIS Tier 4 PA bendamustine TREANDA Tier 5

ANTIMETABOLITES mercaptopurine Tier 1 thioguanine Tier 1 capecitabine Tier 4 XELODA Tier 5 cladribine Tier 4 clofarabine Tier 4 CLOLAR Tier 5 cytarabine Tier 4 floxuridine Tier 4 fludarabine Tier 4 FLUDARA Tier 4 fluorouracil inj Tier 4 gemcitabine Tier 4 GEMZAR Tier 5 cytarabine liposome DEPOCYT Tier 4 fluorouracil inj ADRUCIL Tier 4 pemetrexed ALIMTA Tier 4 pentostatin NIPENT Tier 4 pralatrexate FOLOTYN Tier 4 rasburicase ELITEK Tier 4 mercaptopurine susp PURIXAN Tier 5

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 CASODEX Tier 3 flutamide Tier 1 PA nilutamide Tier 1 NILANDRON Tier 3 PA abiraterone ZYTIGA Tier 4 PA enzalutamide XTANDI Tier 4

Antiestrogens tamoxifen Tier 1 toremifene FARESTON Tier 2 fulvestrant FASLODEX Tier 4

Aromatase Inhibitors anastrozole Tier 1 ARIMIDEX Tier 3 exemestane Tier 1 AROMASIN Tier 3 letrozole Tier 1 FEMARA Tier 3

Gonadotropin-Releasing Hormone (GnRH) Antagonists degarelix acetate FIRMAGON Tier 4

Luteinizing Hormone-releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 4 PA goserelin acetate ZOLADEX Tier 4 PA histrelin acetate VANTAS Tier 4 PA leuprolide acetate ELIGARD Tier 4 PA leuprolide acetate LUPRON DEPOT Tier 4 PA triptorelin pamoate TRELSTAR Tier 4 PA triptorelin pamoate TRELSTAR DEPOT Tier 4 PA triptorelin pamoate TRELSTAR LA Tier 4

Progestins megestrol acetate Tier 1 MEGACE Tier 3

IMMUNOMODULATORS PA pembrolizumab KEYTRUDA Tier 4 thalidomide THALOMID Tier 4 PA lenalidomide REVLIMID Tier 5 PA pomalidomide POMALYST Tier 5

KINASE INHIBITORS PA imatinib mesylate Tier 4 GLEEVEC Tier 5 PA afatinib GILOTRIF Tier 4 PA axitinib INLYTA Tier 4 PA bosutinib BOSULIF Tier 4 PA cabozantinib COMETRIQ Tier 4 PA ceritinib ZYKADIA Tier 4 PA cobimetinib COTELLIC Tier 4 PA crizotinib XALKORI Tier 4 PA dabrafenib TAFINLAR Tier 4 PA dasatinib SPRYCEL Tier 4 PA erlotinib TARCEVA Tier 4 PA everolimus AFINITOR Tier 4 PA ibrutinib IMBRUVICA Tier 4 PA idelalisib ZYDELIG Tier 4 PA lapatinib TYKERB Tier 4 PA lenvatinib LENVIMA Tier 4 PA nilotinib TASIGNA Tier 4 PA palbociclib IBRANCE Tier 4 PA pazopanib VOTRIENT Tier 4 PA ponatinib ICLUSIG Tier 4 PA regorafenib STIVARGA Tier 4 PA ruxolitinib JAKAFI Tier 4 PA sorafenib NEXAVAR Tier 4 sunitinib SUTENT Tier 4 temsirolimus TORISEL Tier 4 PA trametinib MEKINIST Tier 4 PA vandetanib CAPRELSA Tier 4 PA vemurafenib ZELBORAF Tier 4 PA alectinib ALECENSA Tier 5 PA gefitinib IRESSA Tier 5 PA osimertinib TAGRISSO Tier 5

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

MISCELLANEOUS hydroxyurea Tier 1 HYDREA Tier 3 leucovorin calcium Tier 1 amifostine Tier 4 ETHYOL Tier 5 azacitidine Tier 4 VIDAZA Tier 5 PA bexarotene caps Tier 4 TARGRETIN caps Tier 5 bleomycin sulfate Tier 4 carboplatin Tier 4 cisplatin Tier 4 dactinomycin Tier 4 COSMEGEN Tier 5 daunorubicin Tier 4 CERUBIDINE Tier 5 decitabine Tier 4 DACOGEN Tier 5 dexrazoxane Tier 4 TOTECT Tier 5 dexrazoxane Tier 4 ZINECARD Tier 5 docetaxel Tier 4 TAXOTERE Tier 5 doxorubicin Tier 4 doxorubicin liposomal Tier 4 DOXIL Tier 5 epirubicin Tier 4 epirubicin Tier 4 ELLENCE Tier 5 etoposide Tier 4 idarubicin Tier 4 IDAMYCIN PFS Tier 5 ifosfamide Tier 4 IFEX Tier 5 irinotecan Tier 4 CAMPTOSAR Tier 5 levoleucovorin calcium Tier 4 FUSILEV Tier 4 mesna inj Tier 4 MESNEX inj Tier 5 mitomycin Tier 4 mitoxantrone Tier 4 oxaliplatin Tier 4 paclitaxel Tier 4 teniposide Tier 4 vinblastine Tier 4 vincristine Tier 4 vinorelbine Tier 4 NAVELBINE Tier 5 mitotane LYSODREN Tier 2 PA ado-trastuzumab emtansine KADCYLA Tier 4 aldesleukin PROLEUKIN Tier 4 PA alemtuzumab CAMPATH Tier 4 arsenic trioxide TRISENOX Tier 4 asparaginase ELSPAR Tier 4 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4 BCG live vaccine THERACYS Tier 4 BCG live vaccine TICE BCG Tier 4 PA belinostat BELEODAQ Tier 4 PA bendamustine BENDEKA Tier 4 PA bevacizumab AVASTIN Tier 4 PA bexarotene gel TARGRETIN gel Tier 4 PA blinatumomab BLINCYTO Tier 4 PA brentuximab vedotin ADCETRIS Tier 4 PA cabazitaxel JEVTANA Tier 4 cetuximab ERBITUX Tier 4 PA daratumumab DARZALEX Tier 4 doxorubicin ADRIAMYCIN Tier 4

PA elotuzumab EMPLICITI Tier 4 PA eribulin HALAVEN Tier 4 etoposide phosphate ETOPOPHOS Tier 4 glucarpidase VORAXAZE Tier 4 PA ipilimumab YERVOY Tier 4 ixabepilone IXEMPRA Tier 4 PA ixazomib NINLARO Tier 4 mesna tabs 400 mg MESNEX Tier 4 methoxsalen inj UVADEX Tier 4 necitumumab PORTRAZZA Tier 4 nelarabine ARRANON Tier 4 PA nivolumab OPDIVO Tier 4 PA obinutuzumab GAZYVA Tier 4 PA ofatumumab ARZERRA Tier 4 PA olaparib LYNPARZA Tier 4 PA olaratumab LARTRUVO Tier 4 PA omacetaxine mepesuccinate SYNRIBO Tier 4 paclitaxel protein-bound particles ABRAXANE Tier 4 panitumumab VECTIBIX Tier 4 pegaspargase ONCASPAR Tier 4 PA pertuzumab PERJETA Tier 4 porfimer sodium PHOTOFRIN Tier 4 procarbazine MATULANE Tier 4 PA romidepsin ISTODAX Tier 4 samarium sm 153 lexidronam QUADRAMET Tier 4 PA sipuleucel-T PROVENGE Tier 4 PA talimogene laherparepvec IMLYGIC Tier 4 PA trastuzumab HERCEPTIN Tier 4 valrubicin VALSTAR Tier 4 PA venetoclax VENCLEXTA Tier 4 PA vincristine sulfate liposomal MARQIBO Tier 4 PA vismodegib ERIVEDGE Tier 4 PA vorinostat ZOLINZA Tier 4 PA ziv-aflibercept ZALTRAP Tier 4 PA bortezomib VELCADE Tier 5 PA carfilzomib KYPROLIS Tier 5 PA melphalan EVOMELA Tier 5 PA panobinostat FARYDAK Tier 5 ramucirumab CYRAMZA Tier 5 PA rituximab RITUXAN Tier 5 PA sonidegib ODOMZO Tier 5 PA trifluridine/tipiracil LONSURF Tier 5

CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org

benazepril Tier 1 LOTENSIN Tier 3 enalapril Tier 1 VASOTEC Tier 3 fosinopril Tier 1 lisinopril Tier 1 PRINIVIL Tier 3 lisinopril Tier 1 ZESTRIL Tier 3 perindopril Tier 1 ACEON Tier 3 quinapril Tier 1 ACCUPRIL Tier 3 ramipril Tier 1 ALTACE Tier 3 trandolapril Tier 1 MAVIK Tier 3 enalapril oral soln EPANED Tier 3 lisinopril oral soln QBRELIS Tier 3

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

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

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

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

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497

doxazosin Tier 1 CARDURA Tier 3 prazosin Tier 1 MINIPRESS Tier 3 terazosin Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 eprosartan Tier 1 irbesartan Tier 1

irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 BENICAR Tier 3 olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1

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

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

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

amiodarone Tier 1 CORDARONE Tier 3 disopyramide Tier 1 NORPACE Tier 3 flecainide Tier 1 mexiletine Tier 1 propafenone ext-rel Tier 1 RYTHMOL SR Tier 3 quinidine gluconate ext-rel Tier 1 sotalol Tier 1 BETAPACE Tier 3 dofetilide Tier 4 TIKOSYN Tier 5 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2

ANTILIPEMICS The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults is available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a

Bile Acid Resins cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3 colestipol Tier 1 COLESTID Tier 3 colesevelam WELCHOL Tier 2

Cholesterol Absorption Inhibitors ezetimibe Tier 1 ZETIA Tier 3

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

HMG-CoA Reductase Inhibitors/Combinations atorvastatin Tier 1 fluvastatin Tier 1 fluvastatin ext-rel Tier 1 lovastatin Tier 1 pravastatin Tier 1 rosuvastatin Tier 1 simvastatin Tier 1

Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID Tier 4

Niacins niacin ext-rel Tier 1 NIASPAN Tier 3

Omega-3 Fatty Acids omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3 icosapent ethyl VASCEPA Tier 3

PCSK9 Inhibitors PA evolocumab REPATHA Tier 4 PA alirocumab PRALUENT Tier 5

Miscellaneous PA mipomersen KYNAMRO Tier 4

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

acebutolol Tier 1 atenolol Tier 1 TENORMIN Tier 3 carvedilol Tier 1 COREG Tier 3 esmolol Tier 1 BREVIBLOC Tier 3 metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3 metoprolol tartrate Tier 1 LOPRESSOR Tier 3 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 INDERAL LA Tier 3 carvedilol phosphate ext-rel COREG CR Tier 2 nebivolol BYSTOLIC Tier 2 penbutolol LEVATOL Tier 3 propranolol ext-rel INNOPRAN XL Tier 3

BETA-BLOCKER/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS nebivolol/valsartan BYVALSON Tier 3

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

atenolol/chlorthalidone Tier 1 TENORETIC Tier 3 bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3

metoprolol/hydrochlorothiazide Tier 1 LOPRESSOR HCT Tier 3 metoprolol succinate ext-rel/ DUTOPROL Tier 3 hydrochlorothiazide

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1 NORVASC Tier 3 felodipine ext-rel Tier 1 nicardipine Tier 1 nifedipine ext-rel Tier 1 ADALAT CC Tier 3 nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3 nimodipine Tier 1 NIMOTOP Tier 3 nisoldipine ext-rel Tier 1 SULAR Tier 3

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

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1

DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2

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

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

Loop Diuretics bumetanide Tier 1 ethacrynic acid Tier 1 EDECRIN Tier 3 furosemide Tier 1 LASIX Tier 3 torsemide Tier 1 DEMADEX Tier 3

Potassium-sparing Diuretics amiloride Tier 1

Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1

Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3

triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 MAXZIDE-25 Tier 3 37.5/25 triamterene/hydrochlorothiazide 50/25 Tier 1

HEART FAILURE isosorbide dinitrate/hydralazine BIDIL Tier 2 PA ivabradine CORLANOR Tier 3 PA sacubitril/valsartan ENTRESTO Tier 3

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

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

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

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan LETAIRIS Tier 4 PA bosentan TRACLEER Tier 4 PA macitentan OPSUMIT Tier 5

Phosphodiesterase Inhibitors PA sildenafil tabs Tier 4 REVATIO tabs Tier 5 PA sildenafil inj REVATIO inj Tier 5 PA sildenafil oral susp REVATIO susp Tier 5 PA tadalafil ADCIRCA Tier 5

Prostacyclin Receptor Agonists PA selexipag UPTRAVI Tier 5

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

Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Tier 5

MISCELLANEOUS hydralazine Tier 1 midodrine Tier 1 minoxidil Tier 1

ranolazine ext-rel RANEXA Tier 2 mecamylamine VECAMYL Tier 3 PA droxidopa NORTHERA Tier 5

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

ANTIANXIETY Benzodiazepines alprazolam Tier 1 XANAX Tier 3 alprazolam ext-rel Tier 1 XANAX XR Tier 3 chlordiazepoxide Tier 1 clonazepam tabs Tier 1 KLONOPIN Tier 3 clorazepate Tier 1 TRANXENE T-TAB Tier 3 diazepam Tier 1 VALIUM Tier 3 lorazepam Tier 1 ATIVAN Tier 3 oxazepam Tier 1

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

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

carbamazepine Tier 1 TEGRETOL Tier 3 carbamazepine ext-rel Tier 1 CARBATROL Tier 3 carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3 diazepam rectal gel Tier 1 DIASTAT Tier 3 divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3 divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3 divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3 ethosuximide Tier 1 ZARONTIN Tier 3 felbamate Tier 1 FELBATOL Tier 3 gabapentin Tier 1 NEURONTIN Tier 3 lamotrigine Tier 1 LAMICTAL Tier 3 lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3 lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3 levetiracetam Tier 1 KEPPRA Tier 3 levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3 oxcarbazepine Tier 1 TRILEPTAL Tier 3 phenobarbital Tier 1 phenytoin Tier 1 DILANTIN INFATABS Tier 3 phenytoin sodium extended Tier 1 DILANTIN Tier 3 primidone Tier 1 MYSOLINE Tier 3 tiagabine Tier 1 GABITRIL Tier 3 topiramate Tier 1 TOPAMAX Tier 3 topiramate ext-rel Tier 1 QUDEXY XR Tier 3 valproic acid Tier 1 DEPAKENE Tier 3 zonisamide Tier 1 ZONEGRAN Tier 3

clobazam ONFI Tier 2 lacosamide VIMPAT Tier 2 rufinamide BANZEL Tier 2 brivaracetam BRIVIACT Tier 3 eslicarbazepine APTIOM Tier 3 ezogabine POTIGA Tier 3 levetiracetam tabs for oral suspension SPRITAM Tier 3 oxcarbazepine ext-rel OXTELLAR XR Tier 3 perampanel FYCOMPA Tier 3 topiramate ext-rel TROKENDI XR Tier 3 PA vigabatrin SABRIL Tier 5

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

donepezil Tier 1 ARICEPT Tier 3 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 RAZADYNE Tier 3 galantamine ext-rel Tier 1 RAZADYNE ER Tier 3 memantine tabs Tier 1 NAMENDA tabs Tier 3 rivastigmine Tier 1 EXELON Tier 3 rivastigmine transdermal Tier 1 EXELON PATCH Tier 3 memantine soln NAMENDA soln Tier 2

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

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

Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 NARDIL Tier 3 tranylcypromine Tier 1 PARNATE Tier 3 isocarboxazid MARPLAN Tier 3 selegiline transdermal EMSAM Tier 3

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 CELEXA Tier 3 escitalopram Tier 1 LEXAPRO Tier 3 fluoxetine Tier 1 PROZAC Tier 3 fluoxetine Tier 1 SARAFEM Tier 3 fluoxetine delayed-rel Tier 1 paroxetine HCl Tier 1 PAXIL Tier 3 paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3 sertraline Tier 1 ZOLOFT Tier 3 paroxetine mesylate PEXEVA Tier 3 vilazodone VIIBRYD Tier 3 vortioxetine TRINTELLIX Tier 3

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 KHEDEZLA Tier 3 desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3 duloxetine delayed-rel Tier 1 CYMBALTA Tier 3 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3

venlafaxine ext-rel tabs Tier 1 levomilnacipran ext-rel FETZIMA Tier 3

Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 desipramine Tier 1 NORPRAMIN Tier 3 doxepin Tier 1 imipramine HCl Tier 1 TOFRANIL Tier 3 imipramine pamoate Tier 1 nortriptyline Tier 1 PAMELOR Tier 3 protriptyline Tier 1

Miscellaneous Agents amitriptyline/perphenazine Tier 1 bupropion Tier 1 bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3 mirtazapine Tier 1 REMERON Tier 3 nefazodone Tier 1 trazodone Tier 1 bupropion ext-rel APLENZIN Tier 3 bupropion ext-rel FORFIVO XL Tier 3 trazodone ext-rel OLEPTRO ER Tier 3

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

amantadine, except tabs Tier 1 benztropine Tier 1 bromocriptine Tier 1 PARLODEL Tier 3 carbidopa/levodopa Tier 1 SINEMET Tier 3 carbidopa/levodopa ext-rel Tier 1 SINEMET CR Tier 3 carbidopa/levodopa orally Tier 1 disintegrating tabs carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3 diphenhydramine Tier 1 entacapone Tier 1 COMTAN Tier 3 pramipexole Tier 1 MIRAPEX Tier 3 pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3 rasagiline mesylate Tier 1 AZILECT Tier 3 ropinirole Tier 1 REQUIP Tier 3 ropinirole ext-rel Tier 1 REQUIP XL Tier 3 selegiline caps Tier 1 ELDEPRYL Tier 3 tolcapone Tier 1 TASMAR Tier 3 trihexyphenidyl Tier 1 rotigotine transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 carbidopa/levodopa enteral susp DUOPA Tier 3 carbidopa/levodopa ext-rel RYTARY Tier 3 apomorphine APOKYN Tier 4

ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 ABILIFY Tier 3 aripiprazole orally disintegrating tabs Tier 1 clozapine Tier 1 CLOZARIL Tier 3

clozapine orally disintegrating tabs Tier 1 FAZACLO Tier 3 olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3 olanzapine/fluoxetine Tier 1 SYMBYAX Tier 3 paliperidone ext-rel Tier 1 INVEGA Tier 3 quetiapine Tier 1 SEROQUEL Tier 3 quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3 risperidone Tier 1 RISPERDAL Tier 3 risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3 ziprasidone Tier 1 GEODON Tier 3 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3 aripiprazole lauroxil ext-rel inj ARISTADA Tier 3 asenapine SAPHRIS Tier 3 brexpiprazole REXULTI Tier 3 iloperidone FANAPT Tier 3 lurasidone LATUDA Tier 3 PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3 paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3

Miscellaneous fluphenazine Tier 1 haloperidol Tier 1 haloperidol decanoate inj Tier 1 HALDOL DECANOATE 100 Tier 3 haloperidol lactate inj Tier 1 HALDOL Tier 3 loxapine Tier 1 perphenazine Tier 1 thioridazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1 PA pimavanserin NUPLAZID Tier 5

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

PA amphetamine/dextroamphetamine Tier 1 ADDERALL Tier 3 mixed salts PA amphetamine/dextroamphetamine Tier 1 ADDERALL XR Tier 3 mixed salts ext-rel atomoxetine Tier 1 STRATTERA Tier 2 clonidine ext-rel Tier 1 KAPVAY Tier 3 PA dexmethylphenidate Tier 1 FOCALIN Tier 3 PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3 PA dextroamphetamine Tier 1 PA dextroamphetamine Tier 1 ZENZEDI Tier 3 PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3 PA dextroamphetamine soln Tier 1 PROCENTRA Tier 3 guanfacine ext-rel Tier 1 INTUNIV Tier 3 PA methamphetamine Tier 1 DESOXYN Tier 3 PA methylphenidate Tier 1 METHYLIN Tier 3 PA methylphenidate Tier 1 RITALIN Tier 3 PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3 PA methylphenidate ext-rel Tier 1 METADATE CD Tier 3 PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3 PA lisdexamfetamine VYVANSE Tier 2

PA methylphenidate ext-rel 10 mg RITALIN LA 10 mg Tier 2 PA amphetamine ext-rel orally disintegrating ADZENYS XR-ODT Tier 3 tabs PA amphetamine sulfate EVEKEO Tier 3 PA methylphenidate ext-rel caps APTENSIO XR Tier 3 PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3 PA methylphenidate transdermal DAYTRANA Tier 3

FIBROMYALGIA QL pregabalin LYRICA Tier 2 QL milnacipran SAVELLA Tier 3

HUNTINGTON'S DISEASE AGENTS PA tetrabenazine Tier 4 XENAZINE Tier 5

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

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

Nonbenzodiazepines QL eszopiclone Tier 1 QL zaleplon Tier 1 QL zolpidem Tier 1 QL zolpidem ext-rel Tier 1 butabarbital BUTISOL SODIUM Tier 3 secobarbital SECONAL Tier 3 QL suvorexant BELSOMRA Tier 3 QL zolpidem spray ZOLPIMIST Tier 3 QL zolpidem sublingual EDLUAR Tier 3 PA tasimelteon HETLIOZ Tier 4

Tricyclics doxepin SILENOR Tier 3

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

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

Selective Serotonin Agonists QL almotriptan Tier 1 AXERT Tier 3 QL frovatriptan Tier 1 FROVA Tier 3 QL naratriptan Tier 1 AMERGE Tier 3 QL rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3 QL sumatriptan Tier 1 IMITREX Tier 3 QL zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3

QL eletriptan RELPAX Tier 3 QL sumatriptan inj ALSUMA Tier 3 QL sumatriptan inj SUMAVEL DOSEPRO Tier 3 QL zolmitriptan nasal spray ZOMIG Tier 3

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

Miscellaneous d acetaminophen/dichloralphenazone/ Tier 1 isometheptene diclofenac potassium packets CAMBIA Tier 3

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

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

PA glatiramer 20 mg/mL Tier 4 COPAXONE 20 mg/mL Tier 5 PA dimethyl fumarate delayed-rel TECFIDERA Tier 4 PA fingolimod GILENYA Tier 4 PA glatiramer 40 mg/mL COPAXONE 40 mg/mL Tier 4 PA interferon beta-1a AVONEX Tier 4 PA interferon beta-1b EXTAVIA Tier 4 PA alemtuzumab LEMTRADA Tier 5 PA daclizumab ZINBRYTA Tier 5 PA dalfampridine ext-rel AMPYRA Tier 5 PA interferon beta-1a REBIF Tier 5 PA interferon beta-1b BETASERON Tier 5 PA natalizumab TYSABRI Tier 5 PA peginterferon beta-1a PLEGRIDY Tier 5 PA teriflunomide AUBAGIO Tier 5

MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 cyclobenzaprine Tier 1 dantrolene Tier 1 DANTRIUM Tier 3 baclofen intrathecal LIORESAL INTRATHECAL Tier 2 cyclobenzaprine ext-rel AMRIX Tier 3

MYASTHENIA GRAVIS pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 2 pyridostigmine tabs 60 mg Tier 1 MESTINON Tier 3 pyridostigmine syrup MESTINON syrup Tier 2

NARCOLEPSY/CATAPLEXY PA armodafinil Tier 1 NUVIGIL Tier 3 PA modafinil Tier 1 PROVIGIL Tier 3 PA sodium oxybate XYREM Tier 2

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1 ANTABUSE Tier 3 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 4

Opioid Antagonists naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 2

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

Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2

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

bupropion ext-rel Tier 1 ZYBAN Tier 3 OTC nicotine transdermal Tier 1 varenicline CHANTIX Tier 2

MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 RILUTEK Tier 3

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

Duchenne Muscular Dystrophy PA eteplirsen EXONDYS 51 Tier 5

Restless Legs Syndrome gabapentin enacarbil ext-rel HORIZANT Tier 3

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

PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 PA testosterone gel Tier 1 FORTESTA Tier 3 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone buccal STRIANT Tier 3 PA testosterone soln AXIRON Tier 3

PA testosterone undecanoate inj AVEED Tier 4

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professionals.diabetes.org

Alpha-glucosidase Inhibitors acarbose Tier 1 PRECOSE Tier 3 miglitol Tier 1 GLYSET Tier 3

Amylin Analogs pramlintide SYMLINPEN Tier 2

Biguanides * metformin Tier 1 GLUCOPHAGE Tier 3 metformin ext-rel Tier 1 FORTAMET Tier 3 metformin ext-rel Tier 1 GLUCOPHAGE XR Tier 3 metformin soln RIOMET Tier 2

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

Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 glyburide/metformin Tier 1 GLUCOVANCE Tier 3

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

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations linagliptin/metformin JENTADUETO Tier 2 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2 linagliptin/metformin ext-rel JENTADUETO XR Tier 3

Incretin Mimetic Agents exenatide BYETTA Tier 2 exenatide ext-rel BYDUREON Tier 2 liraglutide VICTOZA Tier 2 albiglutide TANZEUM Tier 3 dulaglutide TRULICITY Tier 3 lixisenatide ADLYXIN Tier 3

Insulins insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/ NOVOLOG MIX 70/30 Tier 2 insulin aspart 30% insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin human HUMULIN R U-500 Tier 2 OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 insulin degludec TRESIBA Tier 3 insulin glargine LANTUS Tier 3 insulin glargine TOUJEO Tier 3 PA insulin human inhalation powder AFREZZA Tier 3

Insulin Sensitizers pioglitazone Tier 1 ACTOS Tier 3 rosiglitazone AVANDIA Tier 3

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

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

Meglitinides nateglinide Tier 1 STARLIX Tier 3 repaglinide Tier 1 PRANDIN Tier 3

Meglitinide/Biguanide Combinations repaglinide/metformin Tier 1

Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors PA canagliflozin INVOKANA Tier 3 PA dapagliflozin FARXIGA Tier 3 PA empagliflozin JARDIANCE Tier 3

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

Sodium-Glucose Co-transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations PA empagliflozin/linagliptin GLYXAMBI Tier 3

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

Supplies OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin syringes BD INSULIN SYRINGES Tier 2 OTC lancet device ACCU-CHEK FASTCLIX LANCET Tier 2 DEVICE OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX LANCETS Tier 2 OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC urine test strips CHEMSTRIP K URINE KETONE STRIPS Tier 2 OTC urine test strips CHEMSTRIP UGK URINE GLUCOSE/ Tier 2 KETONE STRIPS OTC urine test strips CHEMSTRIP UG URINE GLUCOSE Tier 2 STRIPS

Miscellaneous bromocriptine CYCLOSET Tier 3

CALCIUM RECEPTOR ANTAGONISTS cinacalcet SENSIPAR Tier 4

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

Bisphosphonates alendronate Tier 1 FOSAMAX Tier 3 etidronate Tier 1 ibandronate Tier 1 BONIVA Tier 3 risedronate Tier 1 ACTONEL Tier 3 risedronate delayed-rel Tier 1 ATELVIA Tier 3 pamidronate Tier 4 zoledronic acid Tier 4 RECLAST Tier 5 zoledronic acid Tier 4 ZOMETA Tier 5 alendronate/vitamin D3 FOSAMAX PLUS D Tier 3

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

Parathyroid Hormones teriparatide FORTEO Tier 4 PA parathyroid hormone (recombinant) NATPARA Tier 5

Miscellaneous PA denosumab PROLIA Tier 4 PA denosumab XGEVA Tier 4

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CARNITOR Tier 3

CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol

Monophasic 20 mcg Estrogen † drospirenone/EE 3/20 - Gianvi Tier 1 YAZ Tier 3 † levonorgestrel/EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 LOESTRIN 1/20 Tier 3 † norethindrone acetate/EE 1/20 and iron Tier 1 LOESTRIN FE 1/20 Tier 3 † norethindrone acetate/EE 1/20 and iron - Tier 1 Lomedia 24 FE

30 mcg Estrogen † desogestrel/EE 0.15/30 Tier 1 DESOGEN Tier 3 † drospirenone/EE 3/30 Tier 1 YASMIN Tier 3 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 LOESTRIN 1.5/30 Tier 3

† norethindrone acetate/EE 1.5/30 and Tier 1 LOESTRIN FE 1.5/30 Tier 3 iron † norgestrel/EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Tier 1 Zovia 1/35 † norethindrone/EE 0.4/35 Tier 1 OVCON 35 Tier 3 † norethindrone/EE 0.5/35 Tier 1 BREVICON Tier 3 † norethindrone/EE 0.5/35 Tier 1 MODICON Tier 3 † norethindrone/EE 1/35 Tier 1 NORINYL 1+35 Tier 3 † norethindrone/EE 1/35 Tier 1 ORTHO-NOVUM 1/35 Tier 3 † norgestimate/EE 0.25/35 Tier 1 ORTHO-CYCLEN Tier 3

50 mcg Estrogen † ethynodiol diacetate/EE 1/50 - Tier 1 Zovia 1/50 † norethindrone/ME 1/50 Tier 1 † norgestrel/EE 0.5/50 Tier 1

Biphasic † desogestrel/EE Tier 1 MIRCETTE Tier 3 norethindrone/EE NECON 10/11 Tier 3

Triphasic † desogestrel/EE Tier 1 CYCLESSA Tier 3 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3 † norethindrone/EE Tier 1 ORTHO-NOVUM 7/7/7 Tier 3 † norethindrone/EE Tier 1 TRI-NORINYL Tier 3 † norgestimate/EE Tier 1 ORTHO TRI-CYCLEN Tier 3 † norgestimate/EE Tier 1 ORTHO TRI-CYCLEN LO Tier 3

Four Phase estradiol valerate and dienogest/estradiol NATAZIA Tier 3 valerate

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

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

Progestin Only † norethindrone Tier 1 NOR-QD Tier 3 † norethindrone Tier 1 ORTHO MICRONOR Tier 3

Implant etonogestrel implant IMPLANON Tier 4 ‡ etonogestrel implant NEXPLANON Tier 4

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

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

Transdermal † norelgestromin/EE Tier 1

Vaginal ‡ etonogestrel/EE ring NUVARING Tier 2

ENDOMETRIOSIS danazol Tier 1 PA nafarelin SYNAREL Tier 2 leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4

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

Injectable estradiol valerate Tier 1 DELESTROGEN Tier 2

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

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

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

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

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

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene DUAVEE Tier 3

FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic gonadotropin Tier 4 PA chorionic gonadotropin - Novarel Tier 4 PA chorionic gonadotropin - Pregnyl Tier 4 PA gonadorelin LUTREPULSE Tier 2 PA cetrorelix CETROTIDE Tier 4 PA choriogonadotropin alfa OVIDREL Tier 4 PA follitropin beta FOLLISTIM AQ Tier 4 PA ganirelix acetate GANIRELIX Tier 4 PA menotropins MENOPUR Tier 4 PA follitropin alfa GONAL-F Tier 5 PA follitropin alfa GONAL-F RFF Tier 5

GLUCOCORTICOIDS cortisone acetate Tier 1 dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 methylprednisolone Tier 1 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally Tier 1 disintegrating tabs prednisolone syrup Tier 1 prednisone Tier 1

GLUCOSE ELEVATING AGENTS diazoxide PROGLYCEM Tier 2 glucagon, human recombinant GLUCAGON EMERGENCY KIT Tier 2

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

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

* Indicated for AIDS wasting only

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3 doxercalciferol Tier 1 HECTOROL Tier 3 paricalcitol Tier 1 ZEMPLAR Tier 3 calcifediol ext-rel RAYALDEE Tier 3

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

PHENYLKETONURIA TREATMENT AGENTS PA sapropterin KUVAN Tier 4

PHOSPHATE BINDER AGENTS calcium acetate Tier 1 PHOSLO Tier 3 lanthanum FOSRENOL Tier 2 sevelamer carbonate RENVELA Tier 2 sevelamer HCl RENAGEL Tier 3 sucroferric oxyhydroxide VELPHORO Tier 3

PROGESTINS Injectable hydroxyprogesterone caproate MAKENA Tier 5

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

Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2

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

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

Thyroid Supplements levothyroxine Tier 1 SYNTHROID Tier 2 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 CYTOMEL Tier 3 thyroid Tier 1 ARMOUR THYROID Tier 3 liotrix THYROLAR Tier 3

VASOPRESSINS desmopressin Tier 1 DDAVP Tier 3

MISCELLANEOUS acetylcysteine Tier 1 ACETADOTE Tier 3 methylergonovine Tier 1 corticotropin powder Tier 4 octreotide acetate Tier 4 SANDOSTATIN Tier 5 PA sodium phenylbutyrate powder Tier 4 BUPHENYL powder Tier 5

hydroxocobalamin CYANOKIT Tier 2 trientine SYPRINE Tier 2 acetylcysteine effervescent tabs CETYLEV Tier 3 prasterone vaginal inserts INTRAROSA Tier 3 PA uridine triacetate XURIDEN Tier 3 PA agalsidase beta FABRAZYME Tier 4 PA alglucosidase alfa LUMIZYME Tier 4 PA asfotase alfa STRENSIQ Tier 4 betaine anhydrous CYSTADANE Tier 4 PA carglumic acid CARBAGLU Tier 4 cysteamine CYSTAGON Tier 4 PA cysteamine delayed-rel PROCYSBI Tier 4 PA eliglustat CERDELGA Tier 4 PA elosulfase alfa VIMIZIM Tier 4 PA galsulfase NAGLAZYME Tier 4 PA glycerol phenylbutyrate RAVICTI Tier 4 PA histrelin acetate SUPPRELIN LA Tier 4 PA idursulfase ELAPRASE Tier 4 PA imiglucerase CEREZYME Tier 4 PA lanreotide acetate SOMATULINE DEPOT Tier 4 PA laronidase ALDURAZYME Tier 4 PA leuprolide acetate LUPRON DEPOT-PED Tier 4 PA mifepristone KORLYM Tier 4 PA miglustat ZAVESCA Tier 4 nitisinone ORFADIN Tier 4 PA octreotide acetate SANDOSTATIN LAR Tier 4 PA pasireotide SIGNIFOR Tier 4 pegademase, bovine ADAGEN Tier 4 pegvisomant SOMAVERT Tier 4 PA sebelipase alfa KANUMA Tier 4 PA sodium phenylbutyrate tabs BUPHENYL tabs Tier 4 PA taliglucerase alfa ELELYSO Tier 4 PA tesamorelin EGRIFTA Tier 4 thyrotropin alfa THYROGEN Tier 4 tolvaptan SAMSCA Tier 4 PA velaglucerase alfa VPRIV Tier 4 PA corticotropin ACTHAR H.P. Tier 5 PA metreleptin MYALEPT Tier 5

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

ANTIDIARRHEALS diphenoxylate/atropine Tier 1 LOMOTIL Tier 3 loperamide Tier 1 opium tincture Tier 1 crofelemer delayed-rel FULYZAQ Tier 3

ANTIEMETICS QL aprepitant caps Tier 1 EMEND Tier 3 dronabinol Tier 1 MARINOL Tier 3 granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 REGLAN Tier 3

ondansetron Tier 1 ZOFRAN Tier 3 ondansetron orally disintegrating tabs Tier 1 ZOFRAN ODT Tier 3 prochlorperazine Tier 1 promethazine Tier 1 trimethobenzamide Tier 1 TIGAN Tier 3 granisetron transdermal SANCUSO Tier 2 ondansetron oral soluble film ZUPLENZ Tier 2 palonosetron ALOXI Tier 2 scopolamine transdermal TRANSDERM SCOP Tier 2 QL aprepitant susp EMEND Tier 3 dolasetron ANZEMET Tier 3 doxylamine/pyridoxine delayed-rel DICLEGIS Tier 3 granisetron ext-rel inj SUSTOL Tier 3 nabilone CESAMET Tier 3 QL netupitant/palonosetron AKYNZEO Tier 3 QL rolapitant VARUBI Tier 3

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

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

H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 * famotidine Tier 1 PEPCID Tier 3 famotidine susp Tier 1 PEPCID susp Tier 3 nizatidine Tier 1 ranitidine Tier 1 ZANTAC Tier 3

* Except 20 mg

INFLAMMATORY BOWEL DISEASE Injectable Agents PA vedolizumab ENTYVIO Tier 5

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

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

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation linaclotide LINZESS Tier 2 lubiprostone AMITIZA Tier 3

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

LAXATIVES lactulose Tier 1 peg 3350/electrolytes Tier 1 COLYTE Tier 3 peg 3350/electrolytes Tier 1 GOLYTELY Tier 3 peg 3350/electrolytes Tier 1 NULYTELY Tier 3 peg 3350/electrolytes MOVIPREP Tier 2 sodium phosphates VISICOL Tier 2 sodium sulfate/potassium sulfate/ SUPREP Tier 2 magnesium sulfate sodium phosphates OSMOPREP Tier 3 sodium picosulfate/ PREPOPIK Tier 3 magnesium oxide/citric acid

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

PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 pancrelipase delayed-rel ZENPEP Tier 2 pancrelipase delayed-rel PANCREAZE Tier 3

PROSTAGLANDINS misoprostol Tier 1 CYTOTEC Tier 3

PROTON PUMP INHIBITORS QL esomeprazole delayed-rel Tier 1 QL lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 QL omeprazole/sodium bicarbonate Tier 1 QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel Tier 1

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

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

ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + Tier 1 PREVPAC Tier 3 clarithromycin QL bismuth subsalicylate + metronidazole + PYLERA Tier 2 tetracycline

MISCELLANEOUS cromolyn sodium Tier 1 GASTROCROM Tier 3 sucralfate Tier 1 CARAFATE Tier 3 sacrosidase SUCRAID Tier 2 sucralfate susp CARAFATE susp Tier 2 alvimopan ENTEREG Tier 3 glycopyrrolate CUVPOSA Tier 3 nitroglycerin rectal oint 0.4% RECTIV Tier 3 dextranomer/sodium hyaluronate SOLESTA Tier 4 PA palifermin KEPIVANCE Tier 4 PA teduglutide GATTEX Tier 4 PA cholic acid CHOLBAM Tier 5 PA obeticholic acid OCALIVA Tier 5

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

alfuzosin ext-rel Tier 1 UROXATRAL Tier 3 dutasteride Tier 1 AVODART Tier 3 dutasteride/tamsulosin Tier 1 JALYN Tier 3 finasteride Tier 1 PROSCAR Tier 3 tamsulosin Tier 1 FLOMAX Tier 3 silodosin RAPAFLO Tier 2 PA tadalafil 2.5 mg, 5 mg CIALIS Tier 3

URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 ENABLEX Tier 3 oxybutynin Tier 1 oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3 tolterodine Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 solifenacin succinate VESICARE Tier 2 mirabegron ext-rel MYRBETRIQ Tier 3 oxybutynin gel GELNIQUE Tier 3

VAGINAL ANTI-INFECTIVES metronidazole Tier 1 METROGEL-VAGINAL Tier 3 terconazole crm Tier 1 TERAZOL 3 crm Tier 3 terconazole crm Tier 1 TERAZOL 7 crm Tier 3 terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2

MISCELLANEOUS bethanechol Tier 1 URECHOLINE Tier 3 phenazopyridine Tier 1 PYRIDIUM Tier 3 potassium citrate ext-rel Tier 1 UROCIT-K Tier 3

potassium citrate ext-rel 15 mEq Tier 1 UROCIT-K 15 mEq Tier 2 pentosan polysulfate sodium ELMIRON Tier 2

HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines- 9th-Ed

Injectable enoxaparin Tier 1 LOVENOX Tier 3 dalteparin FRAGMIN Tier 2 desirudin IPRIVASK Tier 2

Oral warfarin Tier 1 COUMADIN Tier 3 apixaban ELIQUIS Tier 2 rivaroxaban XARELTO Tier 2 dabigatran etexilate PRADAXA Tier 3

Synthetic Heparinoid-like Agents fondaparinux Tier 1 ARIXTRA Tier 3

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

Guidelines for the management of anemia associated with chronic kidney disease are available at: http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines

PA darbepoetin alfa ARANESP Tier 4 PA epoetin alfa PROCRIT Tier 4 PA filgrastim-sndz ZARXIO Tier 4 PA tbo-filgrastim GRANIX Tier 4 PA epoetin alfa EPOGEN Tier 5 PA filgrastim NEUPOGEN Tier 5 PA pegfilgrastim NEULASTA Tier 5 PA sargramostim LEUKINE Tier 5

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

AHF, human/VWF, human HUMATE-P Tier 4 antihemophilic factor ALPHANATE Tier 4 antihemophilic factor HEMOFIL M Tier 4 antihemophilic factor KOATE-DVI Tier 4 antihemophilic factor MONOCLATE-P Tier 4 antihemophilic factor recombinant, ELOCTATE Tier 4 Fc fusion protein antihemophilic factor, recombinant ADVATE Tier 4 antihemophilic factor, recombinant AFSTYLA Tier 4 antihemophilic factor, recombinant HELIXATE FS Tier 4 antihemophilic factor, recombinant KOGENATE FS Tier 4 antihemophilic factor, recombinant KOVALTRY Tier 4 antihemophilic factor, recombinant NOVOEIGHT Tier 4 antihemophilic factor, recombinant RECOMBINATE Tier 4

antihemophilic factor, recombinant XYNTHA Tier 4 antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4 anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4 coagulation factor IX, recombinant IDELVION Tier 4 coagulation factor IX, recombinant IXINITY Tier 4 coagulation factor VIIa NOVOSEVEN RT Tier 4 coagulation factor X, human COAGADEX Tier 4 desmopressin spray STIMATE Tier 4 factor IX concentrate ALPHANINE SD Tier 4 factor IX concentrate BEBULIN Tier 4 factor IX concentrate BENEFIX Tier 4 factor IX concentrate MONONINE Tier 4 factor IX concentrate PROFILNINE SD Tier 4 factor IX concentrate RIXUBIS Tier 4 factor IX recombinant, Fc fusion protein ALPROLIX Tier 4 factor XIII A-subunit recombinant TRETTEN Tier 4 factor XIII concentrate CORIFACT Tier 4 fibrinogen RIASTAP Tier 4 human coagulation factor VIII (rDNA) NUWIQ Tier 4 simoctocog alfa von Willebrand factor, recombinant VONVENDI Tier 4 VWF, human/factor VIII complex WILATE Tier 4 antihemophilic factor (recombinant) ADYNOVATE Tier 5 pegylated

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

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 4 PA romiplostim NPLATE Tier 4

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PA eculizumab SOLIRIS Tier 4

PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 PLAVIX Tier 3 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 AGGRENOX Tier 3 prasugrel EFFIENT Tier 2 abciximab REOPRO Tier 3 PA aspirin ext-rel DURLAZA Tier 3 cangrelor KENGREAL Tier 3 eptifibatide INTEGRILIN Tier 3 ticagrelor BRILINTA Tier 3 tirofiban inj AGGRASTAT Tier 3 vorapaxar ZONTIVITY Tier 3

PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 AGRYLIN Tier 3

STEM CELL MOBILIZERS plerixafor MOZOBIL Tier 4

MISCELLANEOUS cilostazol Tier 1 pentoxifylline ext-rel Tier 1 tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3 tranexamic acid Tier 1 LYSTEDA Tier 3 deferoxamine Tier 4 DESFERAL Tier 5 alteplase CATHFLO ACTIVASE Tier 2 aminocaproic acid AMICAR Tier 2 PA deferasirox EXJADE Tier 4 PA deferiprone FERRIPROX Tier 4 PA protein C concentrate, human CEPROTIN Tier 4 PA deferasirox JADENU Tier 5

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

ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 5

BIOLOGIC DISEASE-MODIFYING AGENTS PA adalimumab HUMIRA Tier 4 PA etanercept ENBREL Tier 4 PA abatacept ORENCIA Tier 5 PA anakinra KINERET Tier 5 PA certolizumab pegol CIMZIA Tier 5 PA golimumab SIMPONI Tier 5 PA infliximab REMICADE Tier 5 PA infliximab-dyyb INFLECTRA Tier 5 PA ixekizumab TALTZ Tier 5

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 PLAQUENIL Tier 3 leflunomide Tier 1 ARAVA Tier 3 PA methotrexate inj Tier 1 methotrexate oral Tier 1 penicillamine CUPRIMINE Tier 2 auranofin RIDAURA Tier 3 methotrexate RHEUMATREX Tier 3 PA methotrexate auto-injector RASUVO Tier 3 PA methotrexate inj OTREXUP Tier 3 PA tofacitinib XELJANZ Tier 5 PA tofacitinib ext-rel XELJANZ XR Tier 5

IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 4 hepatitis B immune globulin HYPERHEP B S-D Tier 4 hepatitis B immune globulin NABI-HB Tier 4 PA immune globulin, gamma GAMASTAN S-D Tier 4 PA immune globulin, gamma GAMUNEX-C Tier 4 PA immune globulin, gamma (IGG) GAMMAKED Tier 4 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4 PA immune globulin, intravenous BIVIGAM Tier 4

PA immune globulin, intravenous CARIMUNE NF Tier 4 PA immune globulin, intravenous FLEBOGAMMA Tier 4 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4 PA immune globulin, intravenous GAMMAGARD S-D Tier 4 PA immune globulin, intravenous GAMUNEX Tier 4 PA immune globulin, intravenous OCTAGAM Tier 4 PA immune globulin, intravenous PRIVIGEN Tier 4 PA immune globulin, subcutaneous HIZENTRA Tier 4 PA immune globulin/hyaluronidase HYQVIA Tier 4 Rho (D) immune globulin HYPERRHO S-D Tier 4 Rho (D) immune globulin MICRHOGAM Tier 4 Rho (D) immune globulin MICRHOGAM PLUS Tier 4 Rho (D) immune globulin RHOGAM Tier 4 Rho (D) immune globulin RHOGAM PLUS Tier 4 Rho (D) immune globulin RHOPHYLAC Tier 4 Rho (D) immune globulin WINRHO SDF Tier 4 PA varicella zoster immune globulin VARIZIG Tier 4 PA immune globulin, subcutaneous CUVITRU Tier 5

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

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

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

Miscellaneous PA canakinumab ILARIS Tier 4 PA rilonacept ARCALYST Tier 4 PA apremilast OTEZLA Tier 5 PA tocilizumab ACTEMRA Tier 5

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

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

Rapamycin Derivatives sirolimus Tier 1 RAPAMUNE Tier 3 everolimus ZORTRESS Tier 4

Miscellaneous belatacept NULOJIX Tier 4 PA belimumab BENLYSTA Tier 4

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

Potassium-Removing Agents sodium polystyrene sulfonate Tier 1 KAYEXALATE Tier 3 PA patiromer VELTASSA Tier 3

VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1

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

Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 fluoride drops Tier 1 LURIDE Tier 3 fluoride tabs Tier 1 LURIDE LOZI-TABS Tier 3 multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1 sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3 vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1 cyanocobalamin spray NASCOBAL Tier 2 ferumoxytol inj FERAHEME Tier 2 iron sucrose inj VENOFER Tier 2 phytonadione MEPHYTON Tier 2 zinc acetate GALZIN Tier 2 ferric carboxymaltose inj INJECTAFER Tier 3

RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com http://www.nhlbi.nih.gov

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

ANAPHYLAXIS TREATMENT AGENTS epinephrine inj (0.15 mg and 0.30 mg) Tier 1 epinephrine EPIPEN Tier 2 epinephrine EPIPEN JR. Tier 2

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

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 2

Long Acting umeclidinium/vilanterol ANORO ELLIPTA Tier 2 glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3 indacaterol/glycopyrrolate inhalation UTIBRON NEOHALER Tier 3 powder tiotropium/olodaterol STIOLTO RESPIMAT Tier 3

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

ANTITUSSIVES Clinical practice guidelines are available at: http://journal.publications.chestnet.org/article.aspx?articleID=1084267

benzonatate Tier 1 TESSALON Tier 3

ANTITUSSIVE COMBINATIONS Opioid codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/chlorpheniramine/ Tier 1 ZUTRIPRO Tier 3 pseudoephedrine hydrocodone/homatropine Tier 1 hydrocodone/pseudoephedrine REZIRA Tier 3

BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol soln Tier 1 VENTOLIN Tier 3 levalbuterol inhalation soln Tier 1 XOPENEX Tier 3 levalbuterol nebulizer soln concentrate Tier 1 XOPENEX SOLUTION Tier 3 albuterol sulfate, CFC-free aerosol PROAIR HFA Tier 2 albuterol sulfate, CFC-free aerosol PROVENTIL HFA Tier 2 albuterol sulfate, CFC-free aerosol VENTOLIN HFA Tier 2

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

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

Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 VOSPIRE ER Tier 3 metaproterenol Tier 1 terbutaline Tier 1

CYSTIC FIBROSIS tobramycin inhalation soln Tier 4 TOBI Tier 5 aztreonam lysine inhalation soln CAYSTON Tier 4 PA dornase alfa PULMOZYME Tier 4 PA ivacaftor KALYDECO Tier 4 PA lumacaftor/ivacaftor ORKAMBI Tier 4 tobramycin inhalation powder TOBI PODHALER Tier 4 tobramycin inhalation soln BETHKIS Tier 4

LEUKOTRIENE MODIFIERS montelukast Tier 1 SINGULAIR Tier 3 zafirlukast Tier 1 ACCOLATE Tier 3 zileuton ext-rel Tier 1 ZYFLO CR Tier 3

MAST CELL STABILIZERS cromolyn soln Tier 1

NASAL ANTIHISTAMINES azelastine spray Tier 1 azelastine spray Tier 1 ASTEPRO Tier 3 olopatadine spray Tier 1 PATANASE Tier 3

NASAL STEROIDS budesonide spray Tier 1 flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 triamcinolone acetonide nasal spray Tier 1

PHOSPHODIESTERASE-4 INHIBITORS roflumilast DALIRESP Tier 3

PULMONARY FIBROSIS AGENTS PA nintedanib OFEV Tier 4 PA pirfenidone ESBRIET Tier 4

STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol SYMBICORT Tier 2 fluticasone/salmeterol ADVAIR Tier 2 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2

mometasone/formoterol DULERA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 3

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

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

MISCELLANEOUS ipratropium nasal spray Tier 1 alpha-1 proteinase inhibitor ARALAST NP Tier 4 alpha-1 proteinase inhibitor GLASSIA Tier 4 alpha-1 proteinase inhibitor PROLASTIN-C Tier 4 alpha-1 proteinase inhibitor ZEMAIRA Tier 4 PA omalizumab XOLAIR Tier 4 PA mepolizumab NUCALA Tier 5 PA reslizumab inj CINQAIR Tier 5

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

Oral isotretinoin Tier 1 isotretinoin ABSORICA Tier 3

Topical PA adapalene Tier 1 DIFFERIN Tier 3 benzoyl peroxide Tier 1 BENZAC AC Tier 3 clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 3 clindamycin/benzoyl peroxide Tier 1 DUAC Tier 3 PA clindamycin/tretinoin Tier 1 ZIANA Tier 3 erythromycin gel 2% Tier 1 ERYGEL Tier 3 erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3 PA tazarotene crm 0.1% Tier 1 TAZORAC Tier 3 PA tretinoin Tier 1 ATRALIN Tier 2 PA tretinoin Tier 1 RETIN-A Tier 3 PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3 PA adapalene/benzoyl peroxide EPIDUO Tier 2 azelaic acid AZELEX Tier 3

clindamycin/benzoyl peroxide ACANYA Tier 3 PA clindamycin/tretinoin VELTIN Tier 3 PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3

Actinic Keratosis PA diclofenac sodium Tier 1 SOLARAZE Tier 3 fluorouracil Tier 1 CARAC Tier 3 fluorouracil Tier 1 EFUDEX Tier 3 PA aminolevulinic acid gel 10% AMELUZ Tier 3 PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3 fluorouracil FLUOROPLEX Tier 3 fluorouracil crm 4% TOLAK Tier 3 ingenol mebutate PICATO Tier 3

Antibiotics gentamicin Tier 1 mupirocin Tier 1 BACTROBAN Tier 3 silver sulfadiazine Tier 1 SILVADENE Tier 3 retapamulin ALTABAX Tier 2 mafenide SULFAMYLON Tier 3

Antifungals ciclopirox Tier 1 clotrimazole Tier 1 clotrimazole/betamethasone Tier 1 econazole Tier 1 ketoconazole Tier 1 naftifine Tier 1 nystatin Tier 1 oxiconazole Tier 1 PA econazole foam ECOZA Tier 3 PA sulconazole EXELDERM Tier 3

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

Injectable PA secukinumab COSENTYX Tier 5 PA ustekinumab STELARA Tier 5

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

Topical betamethasone Tier 1 dipropionate/calcipotriene calcipotriene Tier 1 DOVONEX Tier 3 calcitriol oint Tier 1 VECTICAL Tier 3

Antiseborrheics ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3 selenium sulfide shampoo 2.5% Tier 1

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org/education/clinical-guidelines

Topical tacrolimus Tier 1 PROTOPIC Tier 3 pimecrolimus ELIDEL Tier 2

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

Medium Potency betamethasone valerate crm, lotion, Tier 1 oint 0.1% clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3 desoximetasone crm, oint 0.05% Tier 1 TOPICORT LP Tier 3 fluocinolone acetonide crm, Tier 1 oint 0.025% fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3 flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3 fluticasone propionate crm, Tier 1 CUTIVATE Tier 3 lotion 0.05%, oint 0.005% hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3 hydrocortisone butyrate crm, oint, Tier 1 LOCOID Tier 3 soln 0.1% hydrocortisone valerate crm, oint 0.2% Tier 1 WESTCORT Tier 3 mometasone crm, lotion, oint 0.1% Tier 1 ELOCON Tier 3 triamcinolone acetonide crm, Tier 1 lotion 0.025% triamcinolone acetonide crm, lotion, Tier 1 oint 0.1% flurandrenolide tape CORDRAN TAPE Tier 2 hydrocortisone butyrate lotion 0.1% LOCOID LOTION Tier 3 hydrocortisone probutate crm 0.1% PANDEL Tier 3

High Potency amcinonide crm, lotion, oint 0.1% Tier 1 betamethasone dipropionate Tier 1 DIPROLENE AF Tier 3 augmented crm 0.05% betamethasone dipropionate Tier 1 DIPROLENE Tier 3 augmented lotion 0.05% betamethasone dipropionate crm, Tier 1 lotion, oint 0.05% desoximetasone crm, oint 0.25%, Tier 1 TOPICORT Tier 3 gel 0.05% diflorasone diacetate crm 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1

triamcinolone acetonide crm 0.5% Tier 1 triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3 diflorasone diacetate emollient crm 0.05% APEXICON E Tier 3 halcinonide crm, oint 0.1% HALOG Tier 3

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

Emollients ammonium lactate 12% Tier 1 LAC-HYDRIN Tier 3 urea URAMAXIN Tier 2 urea 45% URAMAXIN GT Tier 2

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

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

Rosacea doxycycline monohydrate Tier 1 ORACEA Tier 3 metronidazole crm 0.75% Tier 1 METROCREAM Tier 3 metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 METROGEL Tier 3 metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3 sulfacetamide/sulfur Tier 1 azelaic acid gel FINACEA Tier 3 PA brimonidine topical gel MIRVASO Tier 3

Scabicides and Pediculicides lindane Tier 1 permethrin 5% Tier 1 spinosad Tier 1 NATROBA Tier 3 crotamiton EURAX Tier 2 ivermectin SKLICE Tier 2 benzyl alcohol ULESFIA Tier 3

Miscellaneous Skin and Mucous Membrane acyclovir oint Tier 1 ZOVIRAX oint Tier 3 QL doxepin crm Tier 1 ZONALON Tier 3 PA imiquimod Tier 1 ALDARA Tier 3 podofilox Tier 1 CONDYLOX Tier 3 acyclovir ZOVIRAX crm Tier 2 alitretinoin PANRETIN Tier 2 PA becaplermin REGRANEX Tier 2 PA imiquimod ZYCLARA Tier 2

absorbable fibrin sealant TACHOSIL Tier 3 acyclovir/hydrocortisone XERESE Tier 3 d, PA hydrocortisone/aloe polysaccharide/ ALCORTIN A Tier 3 iodoquinol sinecatechins VEREGEN Tier 3 PA tretinoin emollient RENOVA Tier 3 PA collagenase clostridium histolyticum XIAFLEX Tier 4 PA interferon alfa-n3 ALFERON N Tier 4 living, bilayered skin substitute APLIGRAF Tier 4

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

Steroids - Mouth/Throat triamcinolone paste Tier 1

Miscellaneous sodium fluoride Tier 1 PREVIDENT Tier 3

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

Antiallergics cromolyn sodium Tier 1 epinastine Tier 1 ELESTAT Tier 3 olopatadine Tier 1 PATANOL Tier 3 phenylephrine Tier 1 lodoxamide ALOMIDE Tier 2 alcaftadine LASTACAFT Tier 3 bepotastine BEPREVE Tier 3 olopatadine PATADAY Tier 3

Antifungals natamycin NATACYN Tier 2

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

Anti-infective/Anti-inflammatory Combinations neomycin/dexamethasone Tier 1 neomycin/polymyxin B/ Tier 1 MAXITROL Tier 3 dexamethasone neomycin/polymyxin B/hydrocortisone Tier 1 susp sulfacetamide/prednisolone phosphate Tier 1 10%/0.25% tobramycin/dexamethasone susp Tier 1 TOBRADEX SUSPENSION Tier 3 0.3%/0.1% gentamicin/prednisolone acetate PRED-G Tier 2 tobramycin/dexamethasone oint TOBRADEX OINTMENT Tier 2 0.3%/0.1% tobramycin/loteprednol ZYLET Tier 2 sulfacetamide/prednisolone acetate oint BLEPHAMIDE SOP Tier 3 10%/0.2%

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

Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 FML Tier 3 prednisolone acetate 1% Tier 1 PRED FORTE Tier 3 prednisolone phosphate 1% Tier 1 dexamethasone OZURDEX Tier 2 difluprednate DUREZOL Tier 2 loteprednol 0.2% ALREX Tier 2 loteprednol 0.5% LOTEMAX Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 rimexolone VEXOL Tier 2 dexamethasone MAXIDEX Tier 3 fluorometholone acetate FLAREX Tier 3

Antivirals trifluridine Tier 1 VIROPTIC Tier 3 ganciclovir ZIRGAN Tier 2

Beta-blockers Nonselective carteolol Tier 1 levobunolol Tier 1 BETAGAN Tier 3 metipranolol Tier 1 timolol maleate Tier 1 TIMOPTIC Tier 3 timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3 timolol hemihydrate BETIMOL Tier 3 timolol maleate ISTALOL Tier 3

Selective betaxolol BETOPTIC S Tier 3

Carbonic Anhydrase Inhibitors Topical dorzolamide Tier 1 TRUSOPT Tier 3 brinzolamide AZOPT Tier 2

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

Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA lifitegrast XIIDRA Tier 3

Mydriatics atropine Tier 1 cyclopentolate Tier 1 CYCLOGYL Tier 3 homatropine Tier 1 ISOPTO HOMATROPINE Tier 3 scopolamine ISOPTO HYOSCINE Tier 2

Parasympathomimetics pilocarpine PILOPINE HS GEL Tier 3

Prostaglandins bimatoprost 0.03% Tier 1 latanoprost Tier 1 XALATAN Tier 3 travoprost Tier 1 travoprost TRAVATAN Z Tier 2 tafluprost ZIOPTAN Tier 3 unoprostone isopropyl RESCULA Tier 3

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

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

Miscellaneous naphazoline Tier 1 aflibercept EYLEA Tier 4 cysteamine CYSTARAN Tier 4 PA ocriplasmin JETREA Tier 4 ranibizumab LUCENTIS Tier 4 verteporfin VISUDYNE Tier 4 pegaptanib sodium MACUGEN Tier 5

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

Anti-infectives acetic acid Tier 1 acetic acid/aluminum acetate Tier 1 ciprofloxacin otic Tier 1 CETRAXAL Tier 3

ofloxacin otic Tier 1

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

Miscellaneous fluocinolone acetonide Tier 1 DERMOTIC Tier 3 d hydrocortisone/pramoxine/chloroxylenol CORTANE-B Tier 3 triethanolamine polypeptide oleate CERUMENEX Tier 3

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

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

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

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

Global Initiative for Asthma National Foundation for Infectious Diseases http://www.ginasthma.com http://www.nfid.org

Infectious Diseases Society of America National Guideline Clearinghouse http://www.idsociety.org http://www.guideline.gov

Institute for Safe Medication Practices National Heart, Lung and Blood Institute http://www.ismp.org http://www.nhlbi.nih.gov

Johns Hopkins AIDS Service National Institutes of Health http://www.thebody.com/content/art12096.html http://www.nih.gov

Juvenile Diabetes Research Foundation International National Kidney Foundation http://jdrf.org http://www.kidney.org

MedWatch National Osteoporosis Foundation http://www.fda.gov/Safety/MedWatch/default.htm http://www.nof.org

National Agricultural Library North American Menopause Society http://www.nal.usda.gov http://www.menopause.org

National Cancer Institute United States Department of Health and Human http://www.cancer.gov/cancertopics Services http://www.hhs.gov National Comprehensive Cancer Network http://www.nccn.org World Health Organization http://www.who.int

MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART These listed drugs are not covered under Basic Option. If you use any of these Managed Not Covered Drugs, you will need to pay the full cost of the drug(s).

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

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS 2017 FOR BASIC OPTION ALLERGIES NASAL STEROIDS BECONASE AQ, DYMISTA, budesonide spray, flunisolide spray, NASACORT AQ, NASONEX, OMNARIS, fluticasone spray, QNASL, RHINOCORT AQUA, VERAMYST, triamcinolone spray ZETONNA ALLERGIES LESS SEDATING cetirizine solution, desloratadine, montelukast, zafirlukast, ANTIHISTAMINES levocetirizine, CLARINEX, CLARINEX-D, ACCOLATE, SINGULAIR XYZAL ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection (0.15 mg and 0.30 mg), EPIPEN, EPIPEN JR. CARDIOVASCULAR - HEART YOSPRALA aspirin***, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole DERMATOLOGY - ROSACEA NORITATE doxycycline (except 20 mg), metronidazole cream/gel/lotion, sulfacetamide/sulfur, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVASO, ORACEA, SOOLANTRA DIABETES - BIGUANIDES GLUMETZA metformin ER DIABETES DIPEPTIDYL PEPTIDASE-4 NESINA, ONGLYZA JANUVIA, TRADJENTA (DPP-4) INHIBITORS DIABETES DIPEPTIDYL PEPTIDASE-4 KAZANO, KOMBIGLYZE XR, OSENI JANUMET, JANUMET XR, (DPP-4) INHIBITOR COMBINATIONS JENTADUETO DIABETES INSULINS APIDRA/SOLOSTAR HUMALOG NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 NOVOLIN 70/30 HUMULIN N NOVOLIN N HUMULIN R NOVOLIN R NOTE: HUMULIN R U-500 concentrate will continue to be covered FUNGAL INFECTIONS ERTACZO, JUBLIA, KERYDIN, ciclopirox, clotrimazole, LOPROX, LOTRISONE, LUZU, MENTAX, clotrimazole/betamethasone, NAFTIN, OXISTAT, VUSION, XOLEGEL econazole, ketoconazole, naftifine, nystatin, terbinafine, ECOZA, EXELDERM, LAMISIL GASTROINTESTINAL AGENTS ACIPHEX, DEXILANT, esomeprazole, lansoprazole, PROTON PUMP INHIBITORS FIRST-LANSOPRAZOLE, NEXIUM, omeprazole, PREVACID, PRILOSEC, PROTONIX, omeprazole/sodium bicarbonate, ZEGERID pantoprazole, rabeprazole GLAUCOMA PROSTAGLANDIN LUMIGAN latanoprost, travoprost, RESCULA, ANALOGS TRAVATAN Z, XALATAN, ZIOPTAN

CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS** DRUG CLASS 2017 FOR BASIC OPTION HIGH BLOOD PRESSURE - ATACAND, AVAPRO, COZAAR, DIOVAN, candesartan, eprosartan, irbesartan, ANGIOTENSIN II RECEPTOR EDARBI, MICARDIS, TEVETEN losartan, telmisartan, valsartan, BLOCKERS BENICAR HIGH BLOOD PRESSURE - ATACAND HCT, AVALIDE, HYZAAR, candesartan/HCTZ, eprosartan, ANGIOTENSIN II RECEPTOR BLOCKER / DIOVAN HCT, EDARBYCLOR, irbesartan/HCTZ, losartan/HCTZ, DIURETIC COMBINATIONS MICARDIS HCT, TEVETEN HCT telmisartan/HCTZ, valsartan/HCTZ, BENICAR/HCT HIGH CHOLESTEROL ADVICOR, ALTOPREV, CADUET, amlodipine/atorvastatin, atorvastatin, CRESTOR, LESCOL/XL, LIPITOR, fluvastatin, lovastatin, pravastatin, LIPTRUZET, LIVALO, MEVACOR, rosuvastatin, simvastatin PRAVACHOL, SIMCOR, VYTORIN, ZOCOR OVERACTIVE BLADDER / DETROL, OXYTROL, TOVIAZ oxybutynin ext-rel, tolterodine, INCONTINENCE URINARY tolterodine ext-rel, trospium, ANTISPASMODICS trospium ext-rel, ENABLEX, GELNIQUE, MYRBETRIQ, VESICARE PAIN AND INFLAMMATION - CORTEF, DELTASONE, MEDROL, cortisone, dexamethasone, CORTICOSTEROIDS MILLIPRED, ORAPRED ODT, RAYOS fludrocortisone, hydrocortisone, methylprednisolone, prednisone PAIN AND INFLAMMATION - ANAPROX DS, FELDENE, NAPRELAN, diclofenac DR/ER, NON STEROIDAL NAPROSYN, PENNSAID diclofenac gel/soln, etodolac/ER, ANTI - INFLAMMATORIES (NSAIDS) flurbiprofen, ibuprofen, indomethacin ER, ketoprofen/ER, meloxicam, nabumetone, naproxen/ER, oxaprozin, piroxicam, sulindac, VOLTAREN GEL PAIN AND INFLAMMATION - ARTHROTEC, DUEXIS, VIMOVO diclofenac/misoprostol, NON STEROIDAL esomeprazole, famotidine, ANTI - INFLAMMATORIES (NSAIDS) ibuprofen, naproxen, ranitidine COMBINATIONS PSORIASIS SORIATANE, TACLONEX acitretin, calcipotriene/betamethasone, calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA SLEEP HYPNOTICS, AMBIEN, AMBIEN CR, INTERMEZZO, eszopiclone, zaleplon, zolpidem/ER NON BENZODIAZEPINES LUNESTA, ROZEREM, SONATA SKIN - CORTICOSTEROIDS OLUX, OLUX-E clobetasol propionate, fluocinonide, halobetasol propionate TESTOSTERONE REPLACEMENT ANDROGEL, NATESTO, TESTIM, testosterone gel, ANDRODERM, ANDROGENS VOGELXO AXIRON, FORTESTA

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

**For more covered options, consult 2017 Basic Option formulary.

***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 55 through 79 and for pregnant women at risk of preeclampsia.

INDEX

A ADCETRIS, 19 ADCIRCA, 25 abacavir, 15 ADDERALL, 29 abacavir soln, 15 ADDERALL XR, 29 abacavir/dolutegravir/lamivudine, 14 adefovir dipivoxil, 15 abacavir/lamivudine, 14 ADEMPAS, 25 abacavir/lamivudine/zidovudine, 14 ADLYXIN, 33 abatacept, 46 ado-trastuzumab emtansine, 19 abciximab, 45 ADOXA, 13 ABELCET, 14 ADRIAMYCIN, 19 ABILIFY, 28 ADRUCIL, 17 ABILIFY MAINTENA, 29 ADVAIR, 50 abiraterone, 17 ADVAIR HFA, 50 abobotulinumtoxinA, 32 ADVATE, 44 ABRAXANE, 20 ADYNOVATE, 45 absorbable fibrin sealant, 55 ADZENYS XR-ODT, 30 ABSORICA, 51 afatinib, 18 ABSTRAL, 11 AFINITOR, 18 acamprosate calcium, 32 aflibercept, 57 ACANYA, 52 AFREZZA, 33 acarbose, 33 AFSTYLA, 44 ACCOLATE, 50 agalsidase beta, 40 ACCU-CHEK FASTCLIX LANCET DEVICE, 34 AGGRASTAT, 45 ACCU-CHEK FASTCLIX LANCETS, 34 AGGRENOX, 45 ACCU-CHEK METERS AND KITS, 34 AGRYLIN, 45 ACCU-CHEK TEST STRIPS, 34 AHF, human/VWF, human, 44 ACCUPRIL, 21 AKYNZEO, 41 ACCURETIC, 21 albiglutide, 33 acebutolol, 23 albuterol, 50 ACEON, 21 albuterol ext-rel, 50 ACETADOTE, 39 albuterol soln, 49 acetaminophen inj, 10 albuterol sulfate, CFC-free aerosol, 49 acetaminophen/dichloralphenazone/isometheptene, 31 alcaftadine, 55 acetazolamide, 24 alclometasone crm, oint 0.05%, 53 acetazolamide ext-rel, 24 ALCORTIN A, 55 acetic acid, 57 ALDACTAZIDE, 24 acetic acid/aluminum acetate, 57 ALDACTONE, 21 acetic acid/hydrocortisone, 58 ALDARA, 54 acetylcysteine, 39 aldesleukin, 19 acetylcysteine effervescent tabs, 40 ALDURAZYME, 40 acitretin, 52 ALECENSA, 18 aclidinium bromide, 49 alectinib, 18 ACLOVATE, 53 alemtuzumab, 19, 31 ACTEMRA, 47 alendronate, 35 ACTHAR H.P., 40 alendronate/vitamin D3, 35 ACTIGALL, 41 ALFERON N, 55 ACTIMMUNE, 47 alfuzosin ext-rel, 43 ACTIQ, 11 alglucosidase alfa, 40 ACTIVELLA, 37 ALIMTA, 17 ACTONEL, 35 ALINIA, 16 ACTOPLUS MET, 34 alirocumab, 23 ACTOPLUS MET XR, 34 aliskiren, 24 ACTOS, 34 aliskiren/hydrochlorothiazide, 24 ACULAR, 56 alitretinoin, 54 ACUVAIL, 56 ALKERAN inj, 17 acyclovir, 54 ALKERAN tabs, 17 acyclovir caps, susp, tabs, 16 allopurinol, 10 acyclovir oint, 54 almotriptan, 30 acyclovir/hydrocortisone, 55 ALOMIDE, 55 ADAGEN, 40 ALORA, 37 ADALAT CC, 24 alosetron, 42 adalimumab, 46 ALOXI, 41 adapalene, 51 alpha-1 proteinase inhibitor, 51 adapalene/benzoyl peroxide, 51 ALPHAGAN P 0.1%, 57

ALPHAGAN P 0.15%, 57 antihemophilic factor, recombinant, 44, 45 ALPHANATE, 44 anti-inhibitor coagulant complex, 45 ALPHANINE SD, 45 ANZEMET, 41 alprazolam, 26 APEXICON E, 54 alprazolam ext-rel, 26 apixaban, 44 ALPROLIX, 45 APLENZIN, 28 ALREX, 56 APLIGRAF, 55 ALSUMA, 31 APOKYN, 28 ALTABAX, 52 apomorphine, 28 ALTACE, 21 apremilast, 47 alteplase, 46 aprepitant caps, 40 altretamine, 17 aprepitant susp, 41 ALVESCO, 51 APRISO, 41 alvimopan, 43 APTENSIO XR, 30 amantadine, except tabs, 16, 28 APTIOM, 27 AMARYL, 34 APTIVUS, 15 AMBISOME, 14 ARALAST NP, 51 ambrisentan, 25 ARALEN, 14 amcinonide crm, lotion, oint 0.1%, 53 ARANESP, 44 AMELUZ, 52 ARAVA, 46 AMERGE, 30 ARCALYST, 47 AMICAR, 46 ARCAPTA NEOHALER, 50 amifostine, 19 arformoterol soln, 50 amiloride, 24 ARICEPT, 27 amiloride/hydrochlorothiazide, 24 ARIMIDEX, 17 aminocaproic acid, 46 aripiprazole, 28 aminolevulinic acid gel 10%, 52 aripiprazole ext-rel inj, 29 aminolevulinic acid soln, 52 aripiprazole lauroxil ext-rel inj, 29 amiodarone, 22 aripiprazole orally disintegrating tabs, 28 AMITIZA, 42 ARISTADA, 29 amitriptyline, 28 ARIXTRA, 44 amitriptyline/perphenazine, 28 armodafinil, 31 amlodipine, 24 ARMOUR THYROID, 39 amlodipine/atorvastatin, 24 ARNUITY ELLIPTA, 51 amlodipine/olmesartan, 22 AROMASIN, 17 amlodipine/telmisartan, 22 ARRANON, 20 amlodipine/valsartan, 22 arsenic trioxide, 19 amlodipine/valsartan/hydrochlorothiazide, 22 artemether/lumefantrine, 14 ammonium lactate 12%, 54 ARZERRA, 20 amoxicillin ext-rel, 13 ASACOL HD, 41 amoxicillin, except film-coated tabs, 13 asenapine, 29 amoxicillin/clavulanate, 13 asfotase alfa, 40 amoxicillin/clavulanate ext-rel, 13 ASMANEX, 51 amoxicillin/clavulanate susp 600 mg, 13 asparaginase, 19 amphetamine ext-rel orally disintegrating tabs, 30 asparaginase Erwinia chrysanthemi, 19 amphetamine sulfate, 30 aspirin ext-rel, 45 amphetamine/dextroamphetamine mixed salts, 29 ASTAGRAF XL, 47 amphetamine/dextroamphetamine mixed salts ext-rel, 29 ASTEPRO, 50 amphotericin B lipid complex inj, 14 atazanavir, 15 amphotericin B liposome inj, 14 atazanavir/cobicistat, 14 ampicillin, 13 ATELVIA, 35 ampicillin sodium/sulbactam sodium, 13 atenolol, 23 AMPYRA, 31 atenolol/chlorthalidone, 23 AMRIX, 31 ATIVAN, 26 ANAFRANIL, 26 atomoxetine, 29 anagrelide, 45 atorvastatin, 23 anakinra, 46 atovaquone, 16 anastrozole, 17 atovaquone/proguanil, 14 ANDRODERM, 32 ATRALIN, 51 anidulafungin, 14 ATRIPLA, 14 ANORO ELLIPTA, 49 atropine, 57 ANTABUSE, 32 atropine/hyoscyamine/scopolamine/phenobarbital, 41 ANTARA, 22 ATROVENT HFA, 49 antihemophilic factor, 44 AUBAGIO, 31 antihemophilic factor (recombinant) pegylated, 45 AUGMENTIN, 13 antihemophilic factor recombinant, Fc fusion protein, 44 AUGMENTIN XR, 13

64 auranofin, 46 benzyl alcohol, 54 AVANDIA, 34 bepotastine, 55 AVASTIN, 19 BEPREVE, 55 AVEED, 33 BERINERT, 45 AVELOX, 13 besifloxacin, 55 AVODART, 43 BESIVANCE, 55 AVONEX, 31 BETAGAN, 56 AXERT, 30 betaine anhydrous, 40 AXIRON, 32 betamethasone dipropionate augmented crm 0.05%, 53 axitinib, 18 betamethasone dipropionate augmented gel, oint 0.05%, 54 AYGESTIN, 39 betamethasone dipropionate augmented lotion 0.05%, 53 azacitidine, 19 betamethasone dipropionate crm, lotion, oint 0.05%, 53 AZACTAM, 16 betamethasone dipropionate/calcipotriene, 52 AZASITE, 55 betamethasone valerate crm, lotion, oint 0.1%, 53 azathioprine, 47 BETAPACE, 22 azelaic acid, 51 BETASERON, 31 azelaic acid gel, 54 betaxolol, 57 azelastine spray, 50 bethanechol, 43 AZELEX, 51 BETHKIS, 50 AZILECT, 28 BETIMOL, 56 azithromycin, 13, 55 BETOPTIC S, 57 azithromycin ext-rel, 13 bevacizumab, 19 AZOPT, 57 BEVESPI AEROSPHERE, 49 AZOR, 22 bexarotene caps, 19 aztreonam, 16 bexarotene gel, 19 aztreonam lysine inhalation soln, 50 BIAXIN, 13 AZULFIDINE, 41 bicalutamide, 17 AZULFIDINE EN-TABS, 41 BICNU, 17 B BIDIL, 25 bimatoprost 0.03%, 57 bacitracin, 55 bismuth subsalicylate + metronidazole + tetracycline, 43 baclofen, 31 bisoprolol/hydrochlorothiazide, 23 baclofen intrathecal, 31 BIVIGAM, 46 BACTROBAN, 52 bleomycin sulfate, 19 balsalazide, 41 BLEPH-10, 55 BANZEL, 27 BLEPHAMIDE SOP, 56 BARACLUDE, 15 blinatumomab, 19 BARACLUDE soln, 15 BLINCYTO, 19 BASAGLAR, 33 blood glucose meters and kits, 34 BCG live vaccine, 19 blood glucose test strips, 34 BD INSULIN SYRINGES, 34 BONIVA, 35 BEBULIN, 45 bortezomib, 20 becaplermin, 54 bosentan, 25 beclomethasone, CFC-free aerosol, 51 BOSULIF, 18 bedaquiline, 15 bosutinib, 18 belatacept, 48 BOTOX, 32 BELEODAQ, 19 brentuximab vedotin, 19 belimumab, 48 BREO ELLIPTA, 51 belinostat, 19 BREVIBLOC, 23 BELSOMRA, 30 BREVICON, 36 benazepril, 21 brexpiprazole, 29 benazepril/amlodipine, 21 BRILINTA, 45 benazepril/hydrochlorothiazide, 21 brimonidine 0.1%, 57 bendamustine, 17, 19 brimonidine 0.15%, 57 BENDEKA, 19 brimonidine 0.2%, 57 BENEFIX, 45 brimonidine topical gel, 54 BENICAR, 22 brimonidine/timolol, 57 BENICAR HCT, 22 brinzolamide, 57 BENLYSTA, 48 brivaracetam, 27 BENTYL, 41 BRIVIACT, 27 BENZAC AC, 51 bromfenac 0.075%, 56 BENZACLIN, 51 bromfenac sodium, 56 BENZAMYCIN, 51 bromfenac sodium 0.07%, 56 benzonatate, 49 bromocriptine, 28, 35 benzoyl peroxide, 51 BROMSITE, 56 benztropine, 28 BROVANA, 50

65 budesonide, 51 CARAFATE susp, 43 budesonide delayed-rel caps, 41 CARBAGLU, 40 budesonide inhalation suspension, 51 carbamazepine, 26, 31 budesonide spray, 50 carbamazepine ext-rel, 26 budesonide/formoterol, 50 CARBATROL, 26 bumetanide, 24 carbidopa/levodopa, 28 BUPHENYL powder, 39 carbidopa/levodopa enteral susp, 28 BUPHENYL tabs, 40 carbidopa/levodopa ext-rel, 28 buprenorphine, 32 carbidopa/levodopa orally disintegrating tabs, 28 buprenorphine transdermal, 11 carbidopa/levodopa/entacapone, 28 buprenorphine/naloxone sublingual film, 32 carboplatin, 19 buprenorphine/naloxone sublingual tabs, 32 CARDIZEM, 24 bupropion, 28 CARDIZEM CD, 24 bupropion ext-rel, 28, 32 CARDURA, 21 buspirone, 26 carfilzomib, 20 busulfan, 17 carglumic acid, 40 BUSULFEX, 17 CARIMUNE NF, 47 butabarbital, 30 carmustine, 17 butalbital/acetaminophen, 11 CARNITOR, 35 butalbital/acetaminophen/caffeine, 11 carteolol, 56 butalbital/acetaminophen/caffeine/codeine, 11 carvedilol, 23 butalbital/aspirin/caffeine, 11 carvedilol phosphate ext-rel, 23 butalbital/aspirin/caffeine/codeine, 11 CASODEX, 17 BUTISOL SODIUM, 30 CATAPRES, 21 butorphanol nasal spray, 11 CATAPRES-TTS, 21 BUTRANS, 11 CATHFLO ACTIVASE, 46 BYDUREON, 33 CAYSTON, 50 BYETTA, 33 CEDAX, 12 BYSTOLIC, 23 cefaclor, 12 BYVALSON, 23 cefdinir, 12 C cefditoren, 12 cefepime, 13 C1 esterase inhibitor, 45 cefixime, 12 C1 esterase inhibitor, recombinant, 45 cefotaxime, 12 cabazitaxel, 19 cefoxitin, 12 cabozantinib, 18 cefpodoxime, 12 CAFCIT, 51 cefprozil, 12 CAFERGOT, 30 ceftaroline fosamil, 13 caffeine citrate, 51 ceftazidime, 12 CALAN, 24 ceftibuten, 12 CALAN SR, 24 CEFTIN, 12 calcifediol ext-rel, 39 ceftriaxone, 12 calcipotriene, 52 cefuroxime axetil, 12 calcitonin-salmon inj, 35 CELEBREX, 10 calcitonin-salmon spray, 35 celecoxib, 10 calcitriol (1,25-D3), 39 CELEXA, 27 calcitriol oint, 52 CELLCEPT, 47 calcium acetate, 39 cephalexin, 12 CALDOLOR, 10 CEPROTIN, 46 CAMBIA, 31 CERDELGA, 40 CAMPATH, 19 CEREZYME, 40 CAMPTOSAR, 19 ceritinib, 18 canagliflozin, 34 certolizumab pegol, 46 canagliflozin/metformin, 34 CERUBIDINE, 19 canakinumab, 47 CERUMENEX, 58 CANASA, 42 CESAMET, 41 candesartan, 21 CETRAXAL, 57 candesartan/hydrochlorothiazide, 21 cetrorelix, 38 cangrelor, 45 CETROTIDE, 38 capecitabine, 17 cetuximab, 19 CAPEX, 53 CETYLEV, 40 CAPRELSA, 18 cevimeline, 42 capsaicin 8% patch, 54 CHANTIX, 32 captopril/hydrochlorothiazide, 21 CHEMSTRIP K URINE KETONE STRIPS, 34 CARAC, 52 CHEMSTRIP UG URINE GLUCOSE STRIPS, 34 CARAFATE, 43 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 34

66 chlorambucil, 17 clozapine, 28 chlordiazepoxide, 26 clozapine orally disintegrating tabs, 29 chloroquine, 14 CLOZARIL, 28 chlorthalidone, 24 COAGADEX, 45 CHOLBAM, 43 coagulation factor IX, recombinant, 45 cholestyramine pkt, 22 coagulation factor VIIa, 45 cholic acid, 43 coagulation factor X, human, 45 choriogonadotropin alfa, 38 COARTEM, 14 chorionic gonadotropin, 38 cobicistat, 14 chorionic gonadotropin - Novarel, 38 cobimetinib, 18 chorionic gonadotropin - Pregnyl, 38 codeine/acetaminophen, 11 CIALIS, 43 codeine/promethazine, 49 ciclesonide, 51 codeine/promethazine/phenylephrine, 49 ciclopirox, 52 COLAZAL, 41 cidofovir, 15 colchicine, 10 cilostazol, 46 COLCRYS, 10 CILOXAN, 55 colesevelam, 22 cimetidine, 41 COLESTID, 22 CIMZIA, 46 colestipol, 22 cinacalcet, 35 collagenase clostridium histolyticum, 55 CINQAIR, 51 COLYTE, 42 CINRYZE, 45 COMBIGAN, 57 CIPRO, 13 COMBIPATCH, 38 CIPRO HC OTIC, 58 COMBIVENT RESPIMAT, 49 CIPRODEX, 58 COMBIVIR, 14 ciprofloxacin, 13, 55 COMETRIQ, 18 ciprofloxacin ext-rel, 13 COMPLERA, 14 ciprofloxacin otic, 57 COMTAN, 28 ciprofloxacin/dexamethasone, 58 CONCERTA, 29 ciprofloxacin/hydrocortisone, 58 CONDYLOX, 54 cisplatin, 19 conjugated estrogens/bazedoxifene, 38 citalopram, 27 COPAXONE 20 mg/mL, 31 CITRANATAL RX, 48 COPAXONE 40 mg/mL, 31 cladribine, 17 COPEGUS, 15 clarithromycin, 13 CORDARONE, 22 clarithromycin ext-rel, 13 CORDRAN crm, lotion, oint, 53 CLEOCIN, 16 CORDRAN TAPE, 53 CLEOCIN T, 51 COREG, 23 CLEOCIN vaginal supp, 43 COREG CR, 23 CLIMARA, 37 CORIFACT, 45 CLIMARA PRO, 38 CORLANOR, 25 clindamycin, 16 CORTANE-B, 58 clindamycin gel, lotion, soln, 51 corticotropin, 40 clindamycin supp, 43 corticotropin powder, 39 clindamycin swabs, 51 CORTIFOAM, 42 clindamycin/benzoyl peroxide, 51, 52 cortisone acetate, 38 clindamycin/tretinoin, 51, 52 CORTISPORIN OTIC, 58 clobazam, 27 COSENTYX, 52 clobetasol propionate crm, gel, oint, soln 0.05%, 54 COSMEGEN, 19 clobetasol propionate lotion, shampoo, spray 0.05%, 54 COSOPT, 57 CLOBEX, 54 COTELLIC, 18 clocortolone pivalate crm 0.1%, 53 COUMADIN, 44 CLODERM, 53 CREON, 42 clofarabine, 17 CRESEMBA, 14 CLOLAR, 17 CRIXIVAN, 15 clomiphene, 38 crizotinib, 18 clomipramine, 26 crofelemer delayed-rel, 40 clonazepam tabs, 26 cromolyn sodium, 43, 55 clonidine, 21 cromolyn soln, 50 clonidine ext-rel, 29 crotamiton, 54 clonidine transdermal, 21 CUBICIN, 16 clopidogrel, 45 CUPRIMINE, 46 clorazepate, 26 CUTIVATE, 53 clotrimazole, 52 CUVITRU, 47 clotrimazole troches, 13 CUVPOSA, 43 clotrimazole/betamethasone, 52 cyanocobalamin inj, 48

67 cyanocobalamin spray, 48 deferoxamine, 46 CYANOKIT, 40 degarelix acetate, 18 CYCLESSA, 36 delavirdine, 14 cyclobenzaprine, 31 DELESTROGEN, 37 cyclobenzaprine ext-rel, 31 DELZICOL, 41 CYCLOGYL, 57 DEMADEX, 24 cyclopentolate, 57 denosumab, 35 cyclophosphamide caps, 17 DEPAKENE, 26 CYCLOPHOSPHAMIDE CAPSULES, 17 DEPAKOTE, 26 cyclophosphamide inj, 17 DEPAKOTE ER, 26 CYCLOSET, 35 DEPAKOTE SPRINKLE, 26 cyclosporine, 47 DEPOCYT, 17 cyclosporine, emulsion, 57 DEPO-PROVERA, 36 cyclosporine, modified, 47 DERMA-SMOOTHE/FS, 53 CYKLOKAPRON inj, 46 DERMOTIC, 58 CYMBALTA, 27 DESCOVY, 14 cyproheptadine, 49 DESFERAL, 46 CYRAMZA, 20 desipramine, 28 CYSTADANE, 40 desirudin, 44 CYSTAGON, 40 desmopressin, 39 CYSTARAN, 57 desmopressin spray, 45 cysteamine, 40, 57 DESOGEN, 35 cysteamine delayed-rel, 40 desogestrel/EE, 36 cytarabine, 17 desogestrel/EE 0.15/30, 35 cytarabine liposome, 17 DESONATE, 53 CYTOGAM, 15 desonide crm, lotion, oint 0.05%, 53 cytomegalovirus immune globulin, 15 desonide foam 0.05%, 53 CYTOMEL, 39 desonide gel 0.05%, 53 CYTOTEC, 42 DESOWEN, 53 CYTOVENE inj, 15 desoximetasone crm, oint 0.05%, 53 D desoximetasone crm, oint 0.25%, gel 0.05%, 53 DESOXYN, 29 D.H.E. 45, 30 desvenlafaxine ext-rel, 27 dabigatran etexilate, 44 dexamethasone, 38, 56 dabrafenib, 18 dexamethasone sodium phosphate, 56 dacarbazine, 17 DEXEDRINE SPANSULE, 29 daclatasvir, 16 dexmethylphenidate, 29 daclizumab, 31 dexmethylphenidate ext-rel, 29 DACOGEN, 19 dexrazoxane, 19 dactinomycin, 19 dextranomer/sodium hyaluronate, 43 DAKLINZA, 16 dextroamphetamine, 29 dalfampridine ext-rel, 31 dextroamphetamine ext-rel, 29 DALIRESP, 50 dextroamphetamine soln, 29 dalteparin, 44 dextromethorphan/quinidine, 32 danazol, 37 DIAMOX SEQUELS, 24 DANTRIUM, 31 DIASTAT, 26 dantrolene, 31 diazepam, 26 dapagliflozin, 34 diazepam rectal gel, 26 dapagliflozin/metformin ext-rel, 34 diazoxide, 38 dapsone, 16 dichlorphenamide, 24 daptomycin, 16 DICLEGIS, 41 DARAPRIM, 14 diclofenac potassium packets, 31 daratumumab, 19 diclofenac sodium, 52, 56 darbepoetin alfa, 44 diclofenac sodium delayed-rel, 10 darifenacin ext-rel, 43 diclofenac sodium delayed-rel/misoprostol, 10 darunavir, 15 diclofenac sodium ext-rel, 10 darunavir/cobicistat, 14 diclofenac sodium gel, 10 DARZALEX, 19 diclofenac sodium soln, 10 dasatinib, 18 dicloxacillin, 13 daunorubicin, 19 dicyclomine, 41 DAYPRO, 10 didanosine delayed-rel, 15 DAYTRANA, 30 didanosine soln, 15 DDAVP, 39 DIFFERIN, 51 decitabine, 19 DIFICID, 13 deferasirox, 46 diflorasone diacetate crm 0.05%, 53 deferiprone, 46 diflorasone diacetate emollient crm 0.05%, 54

68 diflorasone diacetate oint 0.05%, 54 dutasteride, 43 DIFLUCAN, 13 dutasteride/tamsulosin, 43 diflunisal, 10 DUTOPROL, 24 difluprednate, 56 DYAZIDE, 24 digoxin, 24 DYSPORT, 32 dihydroergotamine inj, 30 E DILANTIN, 26 E.E.S., 13 DILANTIN INFATABS, 26 ecallantide, 45 DILAUDID, 11 econazole, 52 diltiazem, 24 econazole foam, 52 diltiazem ext-rel, 24 ECOZA, 52 dimethyl fumarate delayed-rel, 31 eculizumab, 45 DIPENTUM, 41 EDECRIN, 24 diphenhydramine, 28, 49 EDLUAR, 30 diphenoxylate/atropine, 40 EDURANT, 15 DIPROLENE, 53, 54 EE/norethindrone acetate, 37 DIPROLENE AF, 53 EE/norethindrone acetate - Jinteli, 37 dipyridamole, 45 efavirenz, 14 dipyridamole ext-rel/aspirin, 45 efavirenz/emtricitabine/tenofovir, 14 disopyramide, 22 EFFEXOR XR, 27 disopyramide ext-rel, 22 EFFIENT, 45 disulfiram, 32 EFUDEX, 52 DITROPAN XL, 43 EGRIFTA, 40 divalproex sodium delayed-rel, 26 ELAPRASE, 40 divalproex sodium ext-rel, 26 elbasvir/grazoprevir, 16 divalproex sodium sprinkle caps, 26 ELDEPRYL, 28 docetaxel, 19 ELELYSO, 40 dofetilide, 22 ELESTAT, 55 dolasetron, 41 eletriptan, 31 dolutegravir, 14 ELIDEL, 53 donepezil, 27 ELIGARD, 18 donepezil orally disintegrating tabs, 27 eliglustat, 40 DONNATAL, 41 ELIQUIS, 44 DORAL, 30 ELITEK, 17 DORIBAX, 16 ELIXOPHYLLIN, 51 doripenem, 16 ELLENCE, 19 dornase alfa, 50 ELMIRON, 44 dorzolamide, 57 ELOCON, 53 dorzolamide/timolol maleate, 57 ELOCTATE, 44 DOVONEX, 52 elosulfase alfa, 40 doxazosin, 21 elotuzumab, 20 doxepin, 28, 30 ELSPAR, 19 doxepin crm, 54 eltrombopag, 45 doxercalciferol, 39 eluxadoline, 42 DOXIL, 19 elvitegravir/cobicistat/emtricitabine/tenofovir, 14 doxorubicin, 19 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 14 doxorubicin liposomal, 19 EMBEDA, 11 doxycycline hyclate, 13 EMEND, 40, 41 doxycycline monohydrate, 13, 54 empagliflozin, 34 doxylamine/pyridoxine delayed-rel, 41 empagliflozin/linagliptin, 34 dronabinol, 40 empagliflozin/metformin, 34 dronedarone, 22 EMPLICITI, 20 drospirenone/EE 3/20 - Gianvi, 35 EMSAM, 27 drospirenone/EE 3/30, 35 emtricitabine, 15 droxidopa, 26 emtricitabine/rilpivirine/tenofovir, 14 DUAC, 51 emtricitabine/rilpivirine/tenofovir alafenamide, 14 DUAVEE, 38 emtricitabine/tenofovir, 14 DUET DHA, 48 emtricitabine/tenofovir alafenamide, 14 DUETACT, 34 EMTRIVA, 15 dulaglutide, 33 ENABLEX, 43 DULERA, 51 enalapril, 21 duloxetine delayed-rel, 27 enalapril oral soln, 21 DUOPA, 28 enalapril/hydrochlorothiazide, 21 DURAGESIC, 11 ENBREL, 46 DUREZOL, 56 ENDOMETRIN, 39 DURLAZA, 45

69 enfuvirtide, 14 estradiol valerate, 37 enoxaparin, 44 estradiol valerate and dienogest/estradiol valerate, 36 entacapone, 28 estradiol/levonorgestrel, 38 entecavir soln, 15 estradiol/norethindrone acetate, 37, 38 entecavir tabs, 15 estradiol/norgestimate, 37 ENTEREG, 43 ESTROGEL, 37 ENTOCORT EC, 41 estrogens, conjugated, 37 ENTRESTO, 25 estrogens, conjugated crm, 37 ENTYVIO, 41 estrogens, conjugated/medroxyprogesterone, 37 ENVARSUS XR, 47 estrogens, esterified/methyltestosterone, 37 enzalutamide, 17 estropipate, 37 EPANED, 21 ESTROSTEP FE, 36 EPCLUSA, 16 eszopiclone, 30 EPIDUO, 51 etanercept, 46 EPIFOAM, 42 eteplirsen, 32 epinastine, 55 ethacrynic acid, 24 epinephrine, 48 ethambutol, 15 epinephrine inj (0.15 mg and 0.30 mg), 48 ethosuximide, 26 EPIPEN, 48 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 36 EPIPEN JR., 48 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 36 epirubicin, 19 ETHYOL, 19 EPIVIR, 15 etidronate, 35 EPIVIR-HBV, 15 etodolac, 10 eplerenone, 21 etodolac ext-rel, 10 epoetin alfa, 44 etonogestrel implant, 36 EPOGEN, 44 etonogestrel/EE ring, 37 epoprostenol, 25 ETOPOPHOS, 20 epoprostenol sodium, 25 etoposide, 19 eprosartan, 21 etoposide phosphate, 20 eptifibatide, 45 etravirine, 14 EPZICOM, 14 EUFLEXXA, 12 EQUETRO, 31 EURAX, 54 ERAXIS, 14 EVAMIST, 37 ERBITUX, 19 EVEKEO, 30 ergocalciferol (D2), 48 everolimus, 18, 47 ergotamine/caffeine, 30 EVISTA, 39 ergotamine/caffeine supp, 30 evolocumab, 23 eribulin, 20 EVOMELA, 20 ERIVEDGE, 20 EVOTAZ, 14 erlotinib, 18 EVOXAC, 42 ertapenem, 16 EXALGO, 11 ERWINAZE, 19 EXELDERM, 52 ERYGEL, 51 EXELON, 27 ERYPED, 13 EXELON PATCH, 27 erythromycin, 55 exemestane, 17 erythromycin delayed-rel, 13 exenatide, 33 erythromycin delayed-rel - Ery-tab, 13 exenatide ext-rel, 33 erythromycin dispertabs, 13 EXFORGE, 22 erythromycin ethylsuccinate, 13 EXFORGE HCT, 22 erythromycin gel 2%, 51 EXJADE, 46 erythromycin soln, 51 EXONDYS 51, 32 erythromycin stearate, 13 EXTAVIA, 31 erythromycin/benzoyl peroxide, 51 EYLEA, 57 ESBRIET, 50 ezetimibe, 22 escitalopram, 27 ezogabine, 27 eslicarbazepine, 27 F esmolol, 23 FABRAZYME, 40 esomeprazole delayed-rel, 42 FACTIVE, 13 estazolam, 30 factor IX concentrate, 45 ESTRACE, 37 factor IX recombinant, Fc fusion protein, 45 estradiol, 37 factor XIII A-subunit recombinant, 45 estradiol transdermal gel, 37 factor XIII concentrate, 45 estradiol transdermal spray, 37 famciclovir, 16 estradiol vaginal crm, 37 famotidine, 41 estradiol vaginal ring, 37 famotidine susp, 41 estradiol vaginal tabs, 37

FANAPT, 29 fluoride tabs, 48 FARESTON, 17 fluorometholone, 56 FARXIGA, 34 fluorometholone acetate, 56 FARYDAK, 20 FLUOROPLEX, 52 FASLODEX, 17 fluorouracil, 52 FAZACLO, 29 fluorouracil crm 4%, 52 febuxostat, 10 fluorouracil inj, 17 FEIBA VH IMMUNO, 45 fluoxetine, 27 felbamate, 26 fluoxetine delayed-rel, 27 FELBATOL, 26 fluphenazine, 29 felodipine ext-rel, 24 flurandrenolide crm, lotion, oint 0.05%, 53 FEMARA, 17 flurandrenolide tape, 53 FEMHRT, 37 flurazepam, 30 FEMRING, 37 flurbiprofen, 10, 56 fenofibrate, 22 flutamide, 17 fenofibric acid delayed-rel, 22 fluticasone, 51 fenoprofen, 10 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 53 fentanyl citrate buccal, 11 fluticasone spray, 50 fentanyl citrate nasal spray, 11 fluticasone, CFC-free aerosol, 51 fentanyl sublingual spray, 11 fluticasone/salmeterol, 50 fentanyl sublingual tablets, 11 fluticasone/salmeterol, CFC-free aerosol, 50 fentanyl transdermal, 11 fluticasone/vilanterol, 51 fentanyl transmucosal lozenge, 11 fluvastatin, 23 FENTORA, 11 fluvastatin ext-rel, 23 FERAHEME, 48 fluvoxamine, 26 ferric carboxymaltose inj, 48 fluvoxamine ext-rel, 26 FERRIPROX, 46 FML, 56 FERRLECIT, 48 FOCALIN, 29 ferumoxytol inj, 48 FOCALIN XR, 29 FETZIMA, 28 folic acid, 48 fibrinogen, 45 FOLLISTIM AQ, 38 fidaxomicin, 13 follitropin alfa, 38 filgrastim, 44 follitropin beta, 38 filgrastim-sndz, 44 FOLOTYN, 17 FINACEA, 54 fondaparinux, 44 finasteride, 43 FORADIL, 50 fingolimod, 31 FORFIVO XL, 28 FIORICET, 11 formoterol inhalation caps, 50 FIORICET w/CODEINE, 11 formoterol inhalation soln, 50 FIORINAL, 11 FORTAMET, 33 FIORINAL w/CODEINE, 11 FORTAZ, 12 FIRAZYR, 45 FORTEO, 35 FIRMAGON, 18 FORTESTA, 32 FLAGYL, 16 FOSAMAX, 35 FLAREX, 56 FOSAMAX PLUS D, 35 FLEBOGAMMA, 47 fosamprenavir, 15 flecainide, 22 fosinopril, 21 FLOLAN, 25 fosinopril/hydrochlorothiazide, 21 FLOMAX, 43 FOSRENOL, 39 FLOVENT, 51 FRAGMIN, 44 FLOVENT HFA, 51 FROVA, 30 floxuridine, 17 frovatriptan, 30 fluconazole, 13 fulvestrant, 17 FLUDARA, 17 FULYZAQ, 40 fludarabine, 17 furosemide, 24 fludrocortisone, 38 FUSILEV, 19 FLUMADINE, 16 FUZEON, 14 flunisolide spray, 50 FYCOMPA, 27 fluocinolone acetonide, 58 G fluocinolone acetonide crm, oint 0.025%, 53 gabapentin, 26 fluocinolone acetonide oil 0.01%, 53 gabapentin enacarbil ext-rel, 32 fluocinolone acetonide soln 0.01%, 53 GABITRIL, 26 fluocinolone shampoo 0.01%, 53 galantamine, 27 fluocinonide crm 0.1%, 54 galantamine ext-rel, 27 fluocinonide crm, gel, oint, soln 0.05%, 53 galsulfase, 40 fluoride drops, 48

GALZIN, 48 granisetron transdermal, 41 GAMASTAN S-D, 46 GRANIX, 44 GAMMAGARD LIQUID, 47 grass mixed pollen allergen extract, 46 GAMMAGARD S-D, 47 griseofulvin microsize, 13 GAMMAKED, 46 griseofulvin ultramicrosize, 13 GAMMAPLEX, 46 GRIS-PEG, 13 GAMUNEX, 47 guanfacine ext-rel, 29 GAMUNEX-C, 46 H ganciclovir, 56 HALAVEN, 20 ganciclovir inj, 15 halcinonide crm, oint 0.1%, 54 GANIRELIX, 38 HALDOL, 29 ganirelix acetate, 38 HALDOL DECANOATE 100, 29 GARAMYCIN, 55 halobetasol propionate crm, oint 0.05%, 54 GASTROCROM, 43 HALOG, 54 GATTEX, 43 haloperidol, 29 GAZYVA, 20 haloperidol decanoate inj, 29 gefitinib, 18 haloperidol lactate inj, 29 GELNIQUE, 43 HARVONI, 15 GEL-ONE, 11 HECTOROL, 39 GELSYN-3, 11 HELIXATE FS, 44 gemcitabine, 17 HEMOFIL M, 44 gemfibrozil, 22 HEPAGAM B, 46 gemifloxacin, 13 hepatitis B immune globulin, 46 GEMZAR, 17 HEPSERA, 15 GENOTROPIN, 38 HERCEPTIN, 20 gentamicin, 52, 55 HETLIOZ, 30 gentamicin/prednisolone acetate, 56 HEXALEN, 17 GENVOYA, 14 high molecular weight hyaluronan, 12 GEODON, 29 HIPREX, 16 GILENYA, 31 histrelin acetate, 18, 40 GILOTRIF, 18 HIZENTRA, 47 GLASSIA, 51 homatropine, 57 glatiramer 20 mg/mL, 31 HORIZANT, 32 glatiramer 40 mg/mL, 31 human coagulation factor VIII (rDNA) simoctocog alfa, 45 GLEEVEC, 18 HUMATE-P, 44 glimepiride, 34 HUMATROPE, 38 glipizide, 34 HUMIRA, 46 glipizide ext-rel, 34 HUMULIN R U-500, 33 glipizide/metformin, 33 HYALGAN, 12 GLUCAGON EMERGENCY KIT, 38 HYCAMTIN, 19 glucagon, human recombinant, 38 HYCAMTIN inj, 19 glucarpidase, 20 hydralazine, 25 GLUCOPHAGE, 33 HYDREA, 19 GLUCOPHAGE XR, 33 hydrochlorothiazide, 24 GLUCOTROL, 34 hydrocodone ext-rel caps, 11 GLUCOTROL XL, 34 hydrocodone ext-rel tabs, 11 GLUCOVANCE, 33 hydrocodone/acetaminophen - Vicodin, 11 glyburide, 34 hydrocodone/acetaminophen - Vicodin ES, 11 glyburide, micronized, 34 hydrocodone/chlorpheniramine/pseudoephedrine, 49 glyburide/metformin, 33 hydrocodone/homatropine, 49 glycerol phenylbutyrate, 40 hydrocodone/pseudoephedrine, 49 glycopyrrolate, 43 hydrocortisone, 38 glycopyrrolate inhalation powder, 49 hydrocortisone acetate foam, 42 glycopyrrolate/formoterol, 49 hydrocortisone acetate/pramoxine foam, 42 GLYNASE, 34 hydrocortisone butyrate crm 0.1%, 53 GLYSET, 33 hydrocortisone butyrate crm, oint, soln 0.1%, 53 GLYXAMBI, 34 hydrocortisone butyrate lotion 0.1%, 53 golimumab, 46 hydrocortisone crm 2.5%, 53 GOLYTELY, 42 hydrocortisone enema, 42 gonadorelin, 38 hydrocortisone lotion 1%, 53 GONAL-F, 38 hydrocortisone probutate crm 0.1%, 53 GONAL-F RFF, 38 hydrocortisone valerate crm, oint 0.2%, 53 GONITRO, 25 hydrocortisone/aloe polysaccharide/iodoquinol, 55 goserelin acetate, 18 hydrocortisone/pramoxine/chloroxylenol, 58 granisetron, 40 hydromorphone, 11 granisetron ext-rel inj, 41

72 hydromorphone ext-rel, 11 INFLECTRA, 46 hydroxocobalamin, 40 infliximab, 46 hydroxychloroquine, 46 infliximab-dyyb, 46 hydroxyprogesterone caproate, 39 ingenol mebutate, 52 hydroxyurea, 19 INJECTAFER, 48 hydroxyzine HCl, 26, 49 INLYTA, 18 hydroxyzine pamoate, 26, 49 INNOPRAN XL, 23 hylan G-F 20, 12 INSPRA, 21 hyoscyamine sulfate, 41 insulin aspart, 33 hyoscyamine sulfate ext-rel, 41 insulin aspart protamine 70%/insulin aspart 30%, 33 HYPERHEP B S-D, 46 insulin degludec, 33 HYPERRHO S-D, 47 insulin detemir, 33 HYQVIA, 47 insulin glargine, 33 HYSINGLA ER, 11 insulin human, 33 I insulin human inhalation powder, 33 insulin isophane human, 33 ibandronate, 35 insulin isophane human 70%/regular 30%, 33 IBRANCE, 18 insulin syringes, 34 ibrutinib, 18 INTEGRILIN, 45 ibuprofen, 10 INTELENCE, 14 ibuprofen inj, 10 interferon alfa-2b, 47 icatibant, 45 interferon alfacon-1, 47 ICLUSIG, 18 interferon alfa-n3, 55 icosapent ethyl, 23 interferon beta-1a, 31 IDAMYCIN PFS, 19 interferon beta-1b, 31 idarubicin, 19 interferon gamma-1b, recombinant, 47 idelalisib, 18 INTRAROSA, 40 IDELVION, 45 intrauterine copper contraceptive, 37 idursulfase, 40 INTRON A, 47 IFEX, 19 INTUNIV, 29 ifosfamide, 19 INVANZ, 16 ifosfamide/mesna, 17 INVEGA, 29 ILARIS, 47 INVEGA SUSTENNA, 29 ILEVRO, 56 INVEGA TRINZA, 29 iloperidone, 29 INVIRASE, 15 iloprost, 25 INVOKAMET, 34 imatinib mesylate, 18 INVOKANA, 34 IMBRUVICA, 18 ipilimumab, 20 imiglucerase, 40 ipratropium nasal spray, 51 imipenem/cilastatin, 16 ipratropium soln, 49 imipramine HCl, 28 ipratropium, CFC-free aerosol, 49 imipramine pamoate, 28 ipratropium/albuterol soln, 49 imiquimod, 54 ipratropium/albuterol, CFC-free aerosol, 49 IMITREX, 30 IPRIVASK, 44 IMLYGIC, 20 irbesartan, 21 immune globulin, gamma, 46 irbesartan/hydrochlorothiazide, 22 immune globulin, gamma (IGG), 46 IRESSA, 18 immune globulin, intravenous, 46, 47 irinotecan, 19 immune globulin, subcutaneous, 47 irinotecan liposome inj, 19 immune globulin/hyaluronidase, 47 iron sucrose inj, 48 IMPAVIDO, 16 isavuconazonium, 14 IMPLANON, 36 ISENTRESS, 14 IMURAN, 47 isocarboxazid, 27 incobotulinumtoxinA, 32 isoniazid, 15 INCRELEX, 39 ISOPTO HOMATROPINE, 57 INCRUSE ELLIPTA, 49 ISOPTO HYOSCINE, 57 indacaterol, 50 ISORDIL, 25 indacaterol/glycopyrrolate inhalation powder, 49 isosorbide dinitrate oral, 25 indapamide, 24 isosorbide dinitrate/hydralazine, 25 INDERAL LA, 23 isosorbide mononitrate, 25 indinavir, 15 isosorbide mononitrate ext-rel, 25 INDOCIN susp, 10 isotretinoin, 51 indomethacin, 10 ISTALOL, 56 indomethacin ext-rel, 10 ISTODAX, 20 indomethacin susp, 10 itraconazole caps, 13 INFERGEN, 47 itraconazole oral soln, 14

73 ivabradine, 25 LAMICTAL, 26 ivacaftor, 50 LAMICTAL ODT, 26 ivermectin, 54 LAMICTAL XR, 26 ixabepilone, 20 LAMISIL, 14 ixazomib, 20 lamivudine, 15 ixekizumab, 46 lamivudine/zidovudine, 14 IXEMPRA, 20 lamotrigine, 26 IXINITY, 45 lamotrigine ext-rel, 26 J lamotrigine orally disintegrating tabs, 26 lancet device, 34 JADENU, 46 lancets, 34 JAKAFI, 18 LANOXIN, 24 JALYN, 43 lanreotide acetate, 40 JANUMET, 33 lansoprazole + amoxicillin + clarithromycin, 43 JANUMET XR, 33 lansoprazole delayed-rel, 42 JANUVIA, 33 lanthanum, 39 JARDIANCE, 34 LANTUS, 33 JENTADUETO, 33 lapatinib, 18 JENTADUETO XR, 33 laronidase, 40 JETREA, 57 LARTRUVO, 20 JEVTANA, 19 LASIX, 24 JUXTAPID, 23 LASTACAFT, 55 K latanoprost, 57 KADCYLA, 19 LATUDA, 29 KADIAN, 11 LAZANDA, 11 KALBITOR, 45 ledipasvir/sofosbuvir, 15 KALETRA, 15 leflunomide, 46 KALYDECO, 50 LEMTRADA, 31 KANUMA, 40 lenalidomide, 18 KAPVAY, 29 lenvatinib, 18 KAYEXALATE, 48 LENVIMA, 18 KEFLEX, 12 lesinurad, 10 KENALOG SPRAY, 54 LETAIRIS, 25 KENGREAL, 45 letrozole, 17 KEPIVANCE, 43 leucovorin calcium, 19 KEPPRA, 26 LEUKERAN, 17 KEPPRA XR, 26 LEUKINE, 44 KETEK, 13 leuprolide acetate, 18, 40 ketoconazole, 52 leuprolide acetate/norethindrone acetate, 37 ketoconazole shampoo 2%, 52 levalbuterol inhalation soln, 49 ketoconazole tabs, 13 levalbuterol nebulizer soln concentrate, 49 ketoprofen, 10 LEVAQUIN, 13 ketoprofen ext-rel, 10 LEVATOL, 23 ketorolac, 10 LEVBID, 41 ketorolac 0.45%, 56 LEVEMIR, 33 ketorolac 0.5%, 56 levetiracetam, 26 ketorolac tromethamine nasal spray, 10 levetiracetam ext-rel, 26 KEVEYIS, 24 levetiracetam tabs for oral suspension, 27 KEYTRUDA, 18 levobunolol, 56 KHEDEZLA, 27 levocarnitine, 35 KINERET, 46 levofloxacin, 13, 55 KLONOPIN, 26 levoleucovorin calcium, 19 KOATE-DVI, 44 levomilnacipran ext-rel, 28 KOGENATE FS, 44 levonorgestrel/EE - Trivora, 36 KORLYM, 40 levonorgestrel/EE 0.09/20 - Amethyst, 36 KOVALTRY, 44 levonorgestrel/EE 0.1/20, 35 KRYSTEXXA, 10 levonorgestrel/EE 0.1/20 and EE 10, 36 KUVAN, 39 levonorgestrel/EE 0.15/30, 35 KYLEENA, 37 levonorgestrel/EE 0.15/30 - Jolessa, 36 KYNAMRO, 23 levonorgestrel/EE 0.15/30 - Levora, 35 KYPROLIS, 20 levonorgestrel/EE 0.15/30 and EE 10, 36 L levonorgestrel-releasing IUD, 37 levothyroxine, 39 LAC-HYDRIN, 54 levothyroxine - Levoxyl, 39 lacosamide, 27 LEVSIN, 41 lactulose, 42 LEVULAN KERASTICK, 52

LEXAPRO, 27 lumacaftor/ivacaftor, 50 LEXIVA, 15 LUMIZYME, 40 LIALDA, 41 LUPANETA PACK, 37 lidocaine, 54 LUPRON DEPOT, 18 lidocaine patch, 54 LUPRON DEPOT-PED, 40 lidocaine viscous, 55 lurasidone, 29 lidocaine/prilocaine, 54 LURIDE, 48 LIDODERM, 54 LURIDE LOZI-TABS, 48 lifitegrast, 57 LUTREPULSE, 38 LILETTA, 37 LYNPARZA, 20 linaclotide, 42 LYRICA, 30 linagliptin, 33 LYSODREN, 19 linagliptin/metformin, 33 LYSTEDA, 46 linagliptin/metformin ext-rel, 33 M lindane, 54 macitentan, 25 linezolid, 16 MACROBID, 16 LINZESS, 42 MACRODANTIN, 16 LIORESAL INTRATHECAL, 31 MACUGEN, 57 liothyronine, 39 mafenide, 52 liotrix, 39 MAKENA, 39 LIPOFEN, 22 MALARONE, 14 liraglutide, 33 maraviroc, 14 lisdexamfetamine, 29 MARINOL, 40 lisinopril, 21 MARPLAN, 27 lisinopril oral soln, 21 MARQIBO, 20 lisinopril/hydrochlorothiazide, 21 MATULANE, 20 lithium carbonate, 31 MAVIK, 21 lithium carbonate ext-rel tabs 300 mg, 31 MAXALT/MAXALT-MLT, 30 lithium carbonate ext-rel tabs 450 mg, 31 MAXIDEX, 56 LITHOBID, 31 MAXITROL, 56 living, bilayered skin substitute, 55 MAXZIDE, 25 lixisenatide, 33 MAXZIDE-25, 25 LOCOID, 53 mecamylamine, 26 LOCOID LIPOCREAM, 53 mecasermin, 39 LOCOID LOTION, 53 mechlorethamine, 17 lodoxamide, 55 mechlorethamine gel, 17 LOESTRIN 1.5/30, 35 meclizine, 40 LOESTRIN 1/20, 35 medroxyprogesterone acetate, 39 LOESTRIN FE 1.5/30, 36 medroxyprogesterone acetate 150 mg/mL, 36 LOESTRIN FE 1/20, 35 mefloquine, 14 LOFIBRA, 22 MEGACE, 18 lomitapide, 23 MEGACE ES, 39 LOMOTIL, 40 megestrol acetate, 18 LONSURF, 20 megestrol acetate susp, 39 loperamide, 40 MEKINIST, 18 LOPID, 22 meloxicam, 10 lopinavir/ritonavir, 15 melphalan, 20 LOPRESSOR, 23 melphalan inj, 17 LOPRESSOR HCT, 24 melphalan tabs, 17 lorazepam, 26 memantine soln, 27 losartan, 22 memantine tabs, 27 losartan/hydrochlorothiazide, 22 MENOPUR, 38 LOSEASONIQUE, 36 menotropins, 38 LOTEMAX, 56 MEPHYTON, 48 LOTENSIN, 21 mepolizumab, 51 LOTENSIN HCT, 21 MEPRON, 16 loteprednol 0.2%, 56 mercaptopurine, 17 loteprednol 0.5%, 56 mercaptopurine susp, 17 LOTREL, 21 meropenem, 16 LOTRONEX, 42 MERREM, 16 lovastatin, 23 mesalamine delayed-rel caps, 41 LOVAZA, 23 mesalamine delayed-rel tabs, 41 LOVENOX, 44 mesalamine ext-rel caps, 41 loxapine, 29 mesalamine rectal susp, 42 lubiprostone, 42 mesalamine supp, 42 LUCENTIS, 57

75 mesna inj, 19 MINOCIN, 13 mesna tabs 400 mg, 20 minocycline, 13 MESNEX, 20 minocycline ext-rel, 13 MESNEX inj, 19 minoxidil, 25 MESTINON, 31 mipomersen, 23 MESTINON syrup, 31 mirabegron ext-rel, 43 MESTINON TIMESPAN, 31 MIRAPEX, 28 METADATE CD, 29 MIRAPEX ER, 28 metaproterenol, 50 MIRCETTE, 36 metformin, 33 MIRENA, 37 metformin ext-rel, 33 mirtazapine, 28 metformin soln, 33 MIRVASO, 54 methadone, 11 misoprostol, 42 methamphetamine, 29 MITIGARE, 10 methazolamide, 24 mitomycin, 19 methenamine hippurate, prophylaxis, 16 mitotane, 19 methimazole, 39 mitoxantrone, 19 methotrexate, 46 MOBIC, 10 methotrexate auto-injector, 46 modafinil, 31 methotrexate inj, 46 MODICON, 36 methotrexate oral, 46 mometasone, 51 methoxsalen inj, 20 mometasone crm, lotion, oint 0.1%, 53 methoxsalen oral, 52 mometasone spray, 50 methylergonovine, 39 mometasone/formoterol, 51 METHYLIN, 29 MONOCLATE-P, 44 methylnaltrexone, 42 MONODOX, 13 methylphenidate, 29 MONONINE, 45 methylphenidate ext-rel, 29 MONOVISC, 12 methylphenidate ext-rel 10 mg, 30 montelukast, 50 methylphenidate ext-rel caps, 30 MORPHABOND, 11 methylphenidate ext-rel susp, 30 morphine, 11 methylphenidate transdermal, 30 morphine ext-rel, 11 methylprednisolone, 38 morphine supp, 11 metipranolol, 56 morphine/naltrexone ext-rel, 11 metoclopramide, 40 MOVANTIK, 42 metolazone, 24 MOVIPREP, 42 metoprolol succinate ext-rel, 23 MOXATAG, 13 metoprolol succinate ext-rel/hydrochlorothiazide, 24 MOXEZA, 55 metoprolol tartrate, 23 moxifloxacin, 13, 55 metoprolol/hydrochlorothiazide, 24 MOZOBIL, 46 metreleptin, 40 MS CONTIN, 11 METROCREAM, 54 MULTAQ, 22 METROGEL, 54 multivitamins/fluoride drops, tabs, 48 METROGEL-VAGINAL, 43 multivitamins/fluoride/iron drops, tabs, 48 METROLOTION, 54 mupirocin, 52 metronidazole, 43 MUSTARGEN, 17 metronidazole crm 0.75%, 54 MYALEPT, 40 metronidazole gel 0.75%, 54 MYAMBUTOL, 15 metronidazole gel 1%, 54 MYCAMINE, 14 metronidazole lotion 0.75%, 54 MYCOBUTIN, 16 metronidazole tabs, 16 mycophenolate mofetil, 47 mexiletine, 22 mycophenolate sodium delayed-rel, 47 MIACALCIN, 35 MYFORTIC, 47 MIACALCIN inj, 35 MYLERAN, 17 micafungin, 14 MYOBLOC, 32 MICRHOGAM, 47 MYRBETRIQ, 43 MICRHOGAM PLUS, 47 MYSOLINE, 26 midodrine, 25 N mifepristone, 40 NABI-HB, 46 MIGERGOT, 30 nabilone, 41 miglitol, 33 nabumetone, 10 miglustat, 40 nafarelin, 37 milnacipran, 30 naftifine, 52 miltefosine, 16 NAGLAZYME, 40 MINIPRESS, 21 NALFON, 10 MINIVELLE, 37

76 naloxegol, 42 NITRO-DUR, 25 naloxone inj, 32 nitrofurantoin ext-rel, 16 naloxone nasal spray, 32 nitrofurantoin macrocrystals, 16 naltrexone, 32 nitroglycerin lingual spray, 25 naltrexone microspheres, 32 nitroglycerin ointment, 25 NAMENDA soln, 27 nitroglycerin rectal oint 0.4%, 43 NAMENDA tabs, 27 nitroglycerin sublingual, 25 naphazoline, 57 nitroglycerin sublingual aerosol, 25 naproxen, 10 nitroglycerin sublingual powder, 25 naproxen sodium, 10 nitroglycerin transdermal, 25 naproxen sodium ext-rel, 10 NITROLINGUAL, 25 naratriptan, 30 NITROMIST, 25 NARCAN, 32 NITROSTAT, 25 NARDIL, 27 nivolumab, 20 NASCOBAL, 48 nizatidine, 41 NATACYN, 55 NIZORAL SHAMPOO, 52 natalizumab, 31 NORDITROPIN, 38 natamycin, 55 norelgestromin/EE, 37 NATAZIA, 36 norethindrone, 36 nateglinide, 34 norethindrone acetate, 39 NATPARA, 35 norethindrone acetate/EE 1.5/30, 35 NATROBA, 54 norethindrone acetate/EE 1.5/30 and iron, 36 NAVELBINE, 19 norethindrone acetate/EE 1/20, 35 nebivolol, 23 norethindrone acetate/EE 1/20 and iron, 35 nebivolol/valsartan, 23 norethindrone acetate/EE 1/20 and iron - Lomedia 24 FE, 35 necitumumab, 20 norethindrone acetate/EE and iron, 36 NECON 10/11, 36 norethindrone/EE, 36 nefazodone, 28 norethindrone/EE 0.4/35, 36 nelarabine, 20 norethindrone/EE 0.5/35, 36 nelfinavir, 15 norethindrone/EE 1/35, 36 neomycin/dexamethasone, 56 norethindrone/ME 1/50, 36 neomycin/polymyxin B/dexamethasone, 56 norgestimate/EE, 36 neomycin/polymyxin B/gramicidin, 55 norgestimate/EE 0.25/35, 36 neomycin/polymyxin B/hydrocortisone, 58 norgestrel/EE 0.3/30 - Cryselle, 36 neomycin/polymyxin B/hydrocortisone susp, 56 norgestrel/EE 0.3/30 - Low-Ogestrel, 36 NEORAL, 47 norgestrel/EE 0.5/50, 36 NEOSPORIN, 55 NORINYL 1+35, 36 nepafenac, 56 NORPACE, 22 nepafenac 0.3%, 56 NORPACE CR, 22 netupitant/palonosetron, 41 NORPRAMIN, 28 NEULASTA, 44 NOR-QD, 36 NEUPOGEN, 44 NORTHERA, 26 NEUPRO, 28 nortriptyline, 28 NEURONTIN, 26 NORVASC, 24 NEVANAC, 56 NORVIR, 15 nevirapine, 14 NOVOEIGHT, 44 nevirapine ext-rel, 14 NOVOLIN 70/30, 33 NEXAVAR, 18 NOVOLIN N, 33 NEXPLANON, 36 NOVOLIN R, 33 niacin ext-rel, 23 NOVOLOG, 33 NIASPAN, 23 NOVOLOG MIX 70/30, 33 nicardipine, 24 NOVOSEVEN RT, 45 nicotine transdermal, 32 NOXAFIL, 14 nifedipine ext-rel, 24 NPLATE, 45 NILANDRON, 17 NUCALA, 51 nilotinib, 18 NUCYNTA, 11 nilutamide, 17 NUCYNTA ER, 11 nimodipine, 24 NUEDEXTA, 32 NIMOTOP, 24 NULOJIX, 48 NINLARO, 20 NULYTELY, 42 nintedanib, 50 NUPLAZID, 29 NIPENT, 17 NUTROPIN AQ, 38 nisoldipine ext-rel, 24 NUTROPIN AQ NUSPIN, 38 nitazoxanide, 16 NUVARING, 37 nitisinone, 40 NUVIGIL, 31 NITRO-BID, 25 NUWIQ, 45

77 nystatin, 14, 52 ORTHOVISC, 12 O oseltamivir caps, 16 oseltamivir susp, 16 obeticholic acid, 43 osimertinib, 18 obinutuzumab, 20 OSMOPREP, 42 OCALIVA, 43 ospemifene, 39 ocriplasmin, 57 OSPHENA, 39 OCTAGAM, 47 OTEZLA, 47 octreotide acetate, 39, 40 OTREXUP, 46 OCUFEN, 56 OVCON 35, 36 OCUFLOX, 55 OVIDREL, 38 ODEFSEY, 14 oxaliplatin, 19 ODOMZO, 20 oxaprozin, 10 ofatumumab, 20 oxazepam, 26 OFEV, 50 oxcarbazepine, 26 OFIRMEV, 10 oxcarbazepine ext-rel, 27 ofloxacin, 13, 55 oxiconazole, 52 ofloxacin otic, 58 OXSORALEN-ULTRA, 52 olanzapine, 29 OXTELLAR XR, 27 olanzapine pamoate ext-rel inj, 29 oxybutynin, 43 olanzapine/fluoxetine, 29 oxybutynin ext-rel, 43 olaparib, 20 oxybutynin gel, 43 olaratumab, 20 oxycodone, 11 OLEPTRO ER, 28 oxycodone concentrate 20 mg/mL, 11 olmesartan, 22 oxycodone ext-rel, 11 olmesartan/amlodipine/hydrochlorothiazide, 22 oxycodone soln, 11 olmesartan/hydrochlorothiazide, 22 oxycodone/acetaminophen, 11 olodaterol, CFC-free aerosol, 50 oxycodone/acetaminophen 5/325, 11 olopatadine, 55 OXYCONTIN, 11 olopatadine spray, 50 oxymorphone, 11 olsalazine, 41 oxymorphone ext-rel, 11 OLYSIO, 16 OZURDEX, 56 omacetaxine mepesuccinate, 20 omalizumab, 51 P ombitasvir/paritaprevir/ritonavir, 16 paclitaxel, 19 omega-3 acid ethyl esters, 23 paclitaxel protein-bound particles, 20 omeprazole delayed-rel, 42 palbociclib, 18 omeprazole/sodium bicarbonate, 42 palifermin, 43 OMNITROPE, 38 paliperidone ext-rel, 29 onabotulinumtoxinA, 32 paliperidone palmitate ext-rel inj, 29 ONCASPAR, 20 palivizumab, 16 ondansetron, 41 palonosetron, 41 ondansetron oral soluble film, 41 PAMELOR, 28 ondansetron orally disintegrating tabs, 41 pamidronate, 35 ONETOUCH LANCETS, 34 PANCREAZE, 42 ONETOUCH METERS AND KITS, 34 pancrelipase, 42 ONETOUCH TEST STRIPS, 34 pancrelipase delayed-rel, 42 ONFI, 27 PANDEL, 53 ONIVYDE, 19 panitumumab, 20 OPANA, 11 panobinostat, 20 OPANA ER, 11 PANRETIN, 54 OPDIVO, 20 pantoprazole delayed-rel, 42 opium tincture, 40 PARAGARD T 380A, 37 OPSUMIT, 25 parathyroid hormone (recombinant), 35 ORACEA, 54 paricalcitol, 39 ORALAIR, 46 PARLODEL, 28 ORENCIA, 46 PARNATE, 27 ORENITRAM, 25 paroxetine HCl, 27 ORFADIN, 40 paroxetine HCl ext-rel, 27 ORKAMBI, 50 paroxetine mesylate, 27 ORTHO MICRONOR, 36 pasireotide, 40 ORTHO TRI-CYCLEN, 36 PATADAY, 55 ORTHO TRI-CYCLEN LO, 36 PATANASE, 50 ORTHO-CYCLEN, 36 PATANOL, 55 ORTHO-NOVUM 1/35, 36 patiromer, 48 ORTHO-NOVUM 7/7/7, 36 PAXIL, 27

PAXIL CR, 27 POLYTRIM, 55 pazopanib, 18 pomalidomide, 18 PCE, 13 POMALYST, 18 peg 3350/electrolytes, 42 ponatinib, 18 pegademase, bovine, 40 porfimer sodium, 20 pegaptanib sodium, 57 PORTRAZZA, 20 pegaspargase, 20 posaconazole, 14 PEGASYS, 47 potassium chloride ext-rel, 48 pegfilgrastim, 44 potassium chloride liquid, 48 peginterferon alfa-2a, 47 potassium chloride powder, 48 peginterferon alfa-2b, 47 potassium citrate ext-rel, 43 peginterferon beta-1a, 31 potassium citrate ext-rel 15 mEq, 44 PEGINTRON, 47 POTIGA, 27 pegloticase, 10 PRADAXA, 44 pegvisomant, 40 pralatrexate, 17 pembrolizumab, 18 PRALUENT, 23 pemetrexed, 17 pramipexole, 28 penbutolol, 23 pramipexole ext-rel, 28 penicillamine, 46 pramlintide, 33 penicillin VK, 13 PRAMOSONE, 53 PENTASA, 41 PRAMOSONE E, 53 pentosan polysulfate sodium, 44 pramoxine/hydrocortisone, 53 pentostatin, 17 pramoxine/hydrocortisone/emollient, 53 pentoxifylline ext-rel, 46 PRANDIN, 34 PEPCID, 41 prasterone vaginal inserts, 40 PEPCID susp, 41 prasugrel, 45 perampanel, 27 pravastatin, 23 PERCOCET, 11 prazosin, 21 PERFOROMIST, 50 PRECOSE, 33 perindopril, 21 PRED FORTE, 56 perindopril arginine/amlodipine, 21 PRED MILD, 56 PERJETA, 20 PRED-G, 56 permethrin 5%, 54 prednisolone, 38 perphenazine, 29 prednisolone acetate 0.12%, 56 pertuzumab, 20 prednisolone acetate 1%, 56 PEXEVA, 27 prednisolone phosphate 1%, 56 phenazopyridine, 43 prednisolone sodium phosphate, 38 phenelzine, 27 prednisolone sodium phosphate orally disintegrating phenobarbital, 26 tabs, 38 phenylephrine, 55 prednisolone syrup, 38 phenytoin, 26 prednisone, 38 phenytoin sodium extended, 26 PREFEST, 37 PHOSLO, 39 pregabalin, 30 PHOTOFRIN, 20 PREMARIN, 37 phytonadione, 48 PREMARIN crm, 37 PICATO, 52 PREMPHASE, 37 pilocarpine, 57 PREMPRO, 37 pilocarpine tabs, 42 prenatal vitamins/docusate/folic acid, 48 PILOPINE HS GEL, 57 prenatal vitamins/folic acid, 48 pimavanserin, 29 PRENATE ELITE, 48 pimecrolimus, 53 PREPOPIK, 42 pindolol, 23 PRESTALIA, 21 pioglitazone, 34 PREVIDENT, 55 pioglitazone/glimepiride, 34 PREVPAC, 43 pioglitazone/metformin, 34 PREZCOBIX, 14 pioglitazone/metformin ext-rel, 34 PREZISTA, 15 piperacillin/tazobactam, 13 PRIALT, 11 pirfenidone, 50 PRIFTIN, 15 piroxicam, 10 primaquine, 14 PLAQUENIL, 46 PRIMAXIN, 16 PLAVIX, 45 primidone, 26 PLEGRIDY, 31 PRIMLEV, 11 plerixafor, 46 PRINIVIL, 21 podofilox, 54 PRISTIQ, 27 polymyxin B/bacitracin, 55 PRIVIGEN, 47 polymyxin B/trimethoprim, 55 PROAIR HFA, 49

79 probenecid, 10 RANEXA, 26 procarbazine, 20 ranibizumab, 57 PROCARDIA XL, 24 ranitidine, 41 PROCENTRA, 29 ranolazine ext-rel, 26 prochlorperazine, 41 RAPAFLO, 43 PROCRIT, 44 RAPAMUNE, 47 PROCTOFOAM-HC, 42 rasagiline mesylate, 28 PROCYSBI, 40 rasburicase, 17 PROFILNINE SD, 45 RASUVO, 46 progesterone vaginal inserts, 39 RAVICTI, 40 progesterone, micronized, 39 RAYALDEE, 39 PROGLYCEM, 38 RAZADYNE, 27 PROGRAF, 47 RAZADYNE ER, 27 PROLASTIN-C, 51 REBETOL, 15, 16 PROLENSA, 56 REBIF, 31 PROLEUKIN, 19 RECLAST, 35 PROLIA, 35 RECOMBINATE, 44 PROMACTA, 45 RECTIV, 43 promethazine, 41, 49 REGLAN, 40 PROMETRIUM, 39 regorafenib, 18 propafenone ext-rel, 22 REGRANEX, 54 propantheline 15 mg, 41 RELENZA, 16 propranolol, 23 RELISTOR, 42 propranolol ext-rel, 23 RELPAX, 31 propylthiouracil, 39 REMERON, 28 PROSCAR, 43 REMICADE, 46 protein C concentrate, human, 46 REMODULIN, 25 PROTOPIC, 53 RENAGEL, 39 protriptyline, 28 RENOVA, 55 PROVENGE, 20 RENVELA, 39 PROVENTIL HFA, 49 REOPRO, 45 PROVERA, 39 repaglinide, 34 PROVIGIL, 31 repaglinide/metformin, 34 PROZAC, 27 REPATHA, 23 PULMICORT FLEXHALER, 51 REQUIP, 28 PULMICORT RESPULES, 51 REQUIP XL, 28 PULMOZYME, 50 RESCRIPTOR, 14 PURIXAN, 17 RESCULA, 57 PYLERA, 43 reslizumab inj, 51 pyrazinamide, 15 RESTASIS, 57 PYRIDIUM, 43 RESTORIL, 30 pyridostigmine ext-rel tabs 180 mg, 31 retapamulin, 52 pyridostigmine syrup, 31 RETIN-A, 51 pyridostigmine tabs 60 mg, 31 RETIN-A MICRO, 51 pyrimethamine, 14 RETROVIR, 15 Q REVATIO inj, 25 REVATIO susp, 25 QBRELIS, 21 REVATIO tabs, 25 QUADRAMET, 20 REVLIMID, 18 quazepam, 30 REXULTI, 29 QUDEXY XR, 26 REYATAZ, 15 QUESTRAN/QUESTRAN LIGHT, 22 REZIRA, 49 quetiapine, 29 RHEUMATREX, 46 quetiapine ext-rel, 29 Rho (D) immune globulin, 47 QUILLIVANT XR, 30 RHOGAM, 47 quinapril, 21 RHOGAM PLUS, 47 quinapril/hydrochlorothiazide, 21 RHOPHYLAC, 47 quinidine gluconate ext-rel, 22 RIASTAP, 45 QUTENZA, 54 ribavirin caps, 15 QVAR, 51 ribavirin caps - Ribasphere, 15 R ribavirin oral soln, 16 rabeprazole delayed-rel, 42 ribavirin tabs, 15 raloxifene, 39 RIDAURA, 46 raltegravir, 14 rifabutin, 16 ramipril, 21 RIFADIN, 15 ramucirumab, 20 rifampin, 15

80 rifampin/isoniazid/pyrazinamide, 15 saquinavir mesylate, 15 rifapentine, 15 SARAFEM, 27 RIFATER, 15 sargramostim, 44 rifaximin, 16 SAVELLA, 30 rilonacept, 47 scopolamine, 57 rilpivirine, 15 scopolamine transdermal, 41 RILUTEK, 32 SEASONIQUE, 36 riluzole, 32 sebelipase alfa, 40 rimabotulinumtoxinB, 32 secobarbital, 30 rimantadine, 16 SECONAL, 30 rimexolone, 56 secukinumab, 52 riociguat, 25 SEEBRI NEOHALER, 49 RIOMET, 33 selegiline caps, 28 risedronate, 35 selegiline orally disintegrating tabs, 28 risedronate delayed-rel, 35 selegiline transdermal, 27 RISPERDAL, 29 selenium sulfide shampoo 2.5%, 52 RISPERDAL CONSTA, 29 selexipag, 25 RISPERDAL M-TABS, 29 SELZENTRY, 14 risperidone, 29 SENSIPAR, 35 risperidone long-acting inj, 29 SEREVENT DISKUS, 50 risperidone orally disintegrating tabs, 29 SEROQUEL, 29 RITALIN, 29 SEROQUEL XR, 29 RITALIN LA, 29 SEROSTIM, 38 RITALIN LA 10 mg, 30 sertraline, 27 ritonavir, 15 sevelamer carbonate, 39 RITUXAN, 20 sevelamer HCl, 39 rituximab, 20 SIGNIFOR, 40 rivaroxaban, 44 sildenafil inj, 25 rivastigmine, 27 sildenafil oral susp, 25 rivastigmine transdermal, 27 sildenafil tabs, 25 RIXUBIS, 45 SILENOR, 30 rizatriptan, 30 silodosin, 43 ROCALTROL, 39 SILVADENE, 52 ROCEPHIN, 12 silver sulfadiazine, 52 roflumilast, 50 simeprevir, 16 rolapitant, 41 SIMPONI, 46 romidepsin, 20 simvastatin, 23 romiplostim, 45 sinecatechins, 55 ropinirole, 28 SINEMET, 28 ropinirole ext-rel, 28 SINEMET CR, 28 rosiglitazone, 34 SINGULAIR, 50 rosuvastatin, 23 sipuleucel-T, 20 rotigotine transdermal, 28 sirolimus, 47 ROWASA, 42 SIRTURO, 15 ROXICODONE, 11 sitagliptin phosphate, 33 RUCONEST, 45 sitagliptin/metformin, 33 rufinamide, 27 sitagliptin/metformin ext-rel, 33 ruxolitinib, 18 SIVEXTRO, 16 RYTARY, 28 SKLICE, 54 RYTHMOL SR, 22 SKYLA, 37 S sodium ferric gluconate inj, 48 sodium fluoride, 55 SABRIL, 27 sodium hyaluronate, 11, 12 sacrosidase, 43 sodium oxybate, 31 sacubitril/valsartan, 25 sodium phenylbutyrate powder, 39 SAIZEN, 38 sodium phenylbutyrate tabs, 40 SALAGEN, 42 sodium phosphates, 42 salmeterol xinafoate, 50 sodium picosulfate/magnesium oxide/citric acid, 42 samarium sm 153 lexidronam, 20 sodium polystyrene sulfonate, 48 SAMSCA, 40 sodium sulfate/potassium sulfate/magnesium sulfate, 42 SANCUSO, 41 sofosbuvir, 16 SANDIMMUNE, 47 sofosbuvir/velpatasvir, 16 SANDOSTATIN, 39 SOFTCLIX LANCET DEVICE, 34 SANDOSTATIN LAR, 40 SOFTCLIX LANCETS, 34 SAPHRIS, 29 SOFTTOUCH LANCET DEVICE, 34 sapropterin, 39 SOFTTOUCH LANCETS, 34

SOLARAZE, 52 SUTENT, 18 SOLESTA, 43 suvorexant, 30 solifenacin succinate, 43 SYLATRON, 47 SOLIRIS, 45 SYMBICORT, 50 SOLODYN, 13 SYMBYAX, 29 somatropin, 38 SYMLINPEN, 33 SOMATULINE DEPOT, 40 SYNAGIS, 16 SOMAVERT, 40 SYNAREL, 37 sonidegib, 20 SYNJARDY, 34 sorafenib, 18 SYNRIBO, 20 sotalol, 22 SYNTHROID, 39 SOVALDI, 16 SYNVISC, 12 SPECTRACEF, 12 SYNVISC-ONE, 12 spinosad, 54 SYPRINE, 40 SPIRIVA, 49 T SPIRIVA RESPIMAT, 49 TACHOSIL, 55 spironolactone, 21 tacrolimus, 47, 53 spironolactone/hydrochlorothiazide, 24 tacrolimus ext-rel, 47 SPORANOX caps, 13 tadalafil, 25 SPORANOX oral soln, 14 tadalafil 2.5 mg, 5 mg, 43 SPRITAM, 27 TAFINLAR, 18 SPRIX, 10 tafluprost, 57 SPRYCEL, 18 TAGRISSO, 18 STALEVO, 28 taliglucerase alfa, 40 STARLIX, 34 talimogene laherparepvec, 20 stavudine, 15 TALTZ, 46 stavudine soln, 15 TAMIFLU, 16 STELARA, 52 TAMIFLU caps, 16 STIMATE, 45 tamoxifen, 17 STIOLTO RESPIMAT, 49 tamsulosin, 43 STIVARGA, 18 TANZEUM, 33 STRATTERA, 29 TAPAZOLE, 39 STRENSIQ, 40 tapentadol, 11 streptozocin, 17 tapentadol ext-rel, 11 STRIANT, 32 TARCEVA, 18 STRIBILD, 14 TARGRETIN caps, 19 STRIVERDI RESPIMAT, 50 TARGRETIN gel, 19 SUBOXONE FILM, 32 TARKA, 21 SUBSYS, 11 TASIGNA, 18 SUCRAID, 43 tasimelteon, 30 sucralfate, 43 TASMAR, 28 sucralfate susp, 43 TAXOTERE, 19 sucroferric oxyhydroxide, 39 tazarotene crm 0.05%, gel 0.05%, 0.1%, 52 SULAR, 24 tazarotene crm 0.1%, 51 sulconazole, 52 TAZORAC, 51, 52 sulfacetamide soln 10%, 55 tbo-filgrastim, 44 sulfacetamide/prednisolone acetate oint 10%/0.2%, 56 TECFIDERA, 31 sulfacetamide/prednisolone phosphate 10%/0.25%, 56 TECHNIVIE, 16 sulfacetamide/sulfur, 54 tedizolid, 16 sulfamethoxazole/trimethoprim, 16 teduglutide, 43 sulfamethoxazole/trimethoprim DS, 16 TEFLARO, 13 SULFAMYLON, 52 TEGRETOL, 26 sulfasalazine, 41 TEGRETOL-XR, 26 sulfasalazine delayed-rel, 41 TEKTURNA, 24 sulindac, 10 TEKTURNA HCT, 24 sumatriptan, 30 telavancin, 16 sumatriptan inj, 31 telbivudine, 15 sumatriptan/naproxen sodium, 31 telithromycin, 13 SUMAVEL DOSEPRO, 31 telmisartan, 22 sunitinib, 18 telmisartan/hydrochlorothiazide, 22 SUPARTZ FX, 12 temazepam, 30 SUPPRELIN LA, 40 TEMODAR, 17 SUPRAX, 12 TEMOVATE, 54 SUPREP, 42 temozolomide, 17 SUSTIVA, 14 temsirolimus, 18 SUSTOL, 41

82 teniposide, 19 tobramycin/dexamethasone oint 0.3%/0.1%, 56 tenofovir, 15 tobramycin/dexamethasone susp 0.3%/0.1%, 56 tenofovir alafenamide, 15 tobramycin/loteprednol, 56 TENORETIC, 23 TOBREX, 55 TENORMIN, 23 tocilizumab, 47 TERAZOL 3 crm, 43 tofacitinib, 46 TERAZOL 7 crm, 43 tofacitinib ext-rel, 46 terazosin, 21 TOFRANIL, 28 terbinafine tabs, 14 TOLAK, 52 terbutaline, 50 tolcapone, 28 terconazole crm, 43 tolterodine, 43 terconazole supp 80 mg, 43 tolterodine ext-rel, 43 teriflunomide, 31 tolvaptan, 40 teriparatide, 35 TOPAMAX, 26 tesamorelin, 40 TOPICORT, 53 TESSALON, 49 TOPICORT LP, 53 testosterone buccal, 32 topiramate, 26 testosterone cypionate, 32 topiramate ext-rel, 26, 27 testosterone enanthate, 32 topotecan, 19 testosterone gel, 32 topotecan inj, 19 testosterone soln, 32 TOPROL-XL, 23 testosterone transdermal, 32 toremifene, 17 testosterone undecanoate inj, 33 TORISEL, 18 tetrabenazine, 30 torsemide, 24 tetracycline, 13 TOTECT, 19 thalidomide, 18 TOUJEO, 33 THALOMID, 18 trabectedin, 17 THEO-24, 51 TRACLEER, 25 theophylline ext-rel caps, 51 TRADJENTA, 33 theophylline ext-rel tabs, 51 tramadol, 11 theophylline liquid, 51 tramadol ext-rel, 11 THERACYS, 19 trametinib, 18 thioguanine, 17 trandolapril, 21 thioridazine, 29 trandolapril/verapamil ext-rel, 21 thiotepa, 17 tranexamic acid, 46 thiothixene, 29 TRANSDERM SCOP, 41 THYROGEN, 40 TRANXENE T-TAB, 26 thyroid, 39 tranylcypromine, 27 THYROLAR, 39 trastuzumab, 20 thyrotropin alfa, 40 TRAVATAN Z, 57 tiagabine, 26 travoprost, 57 TIAZAC, 24 trazodone, 28 ticagrelor, 45 trazodone ext-rel, 28 TICE BCG, 19 TREANDA, 17 TIGAN, 41 TRELSTAR, 18 tigecycline, 16 TRELSTAR DEPOT, 18 TIKOSYN, 22 TRELSTAR LA, 18 timolol hemihydrate, 56 treprostinil, 25 timolol maleate, 56 treprostinil ext-rel, 25 timolol maleate gel, 56 TRESIBA, 33 TIMOPTIC, 56 tretinoin, 51 TIMOPTIC-XE, 56 tretinoin emollient, 55 TINDAMAX, 16 tretinoin gel microsphere, 51 tinidazole, 16 TRETTEN, 45 tiotropium, 49 TREXIMET, 31 tiotropium/olodaterol, 49 triamcinolone acetonide crm 0.5%, 54 tipranavir, 15 triamcinolone acetonide crm, lotion 0.025%, 53 tirofiban inj, 45 triamcinolone acetonide crm, lotion, oint 0.1%, 53 TIVICAY, 14 triamcinolone acetonide nasal spray, 50 TOBI, 50 triamcinolone acetonide topical spray, 54 TOBI PODHALER, 50 triamcinolone paste, 55 TOBRADEX OINTMENT, 56 triamterene/hydrochlorothiazide, 24, 25 TOBRADEX SUSPENSION, 56 triamterene/hydrochlorothiazide 37.5/25, 25 tobramycin, 55 triamterene/hydrochlorothiazide 50/25, 25 tobramycin inhalation powder, 50 TRIBENZOR, 22 tobramycin inhalation soln, 50 TRICOR, 22

83 trientine, 40 VALIUM, 26 triethanolamine polypeptide oleate, 58 valproic acid, 26 trifluoperazine, 29 valrubicin, 20 trifluridine, 56 valsartan, 22 trifluridine/tipiracil, 20 valsartan/hydrochlorothiazide, 22 TRIGLIDE, 22 VALSTAR, 20 trihexyphenidyl, 28 VALTREX, 16 TRILEPTAL, 26 VANCOCIN, 16 TRILIPIX, 22 vancomycin, 16 trimethobenzamide, 41 vandetanib, 18 trimethoprim, 16 VANOS, 54 TRI-NORINYL, 36 VANTAS, 18 TRINTELLIX, 27 varenicline, 32 triptorelin pamoate, 18 varicella zoster immune globulin, 47 TRISENOX, 19 VARIZIG, 47 TRIUMEQ, 14 VARUBI, 41 TRIZIVIR, 14 VASCEPA, 23 TROKENDI XR, 27 VASERETIC, 21 trospium, 43 VASOTEC, 21 trospium ext-rel, 43 VECAMYL, 26 TRULICITY, 33 VECTIBIX, 20 TRUSOPT, 57 VECTICAL, 52 TRUVADA, 14 vedolizumab, 41 TUDORZA PRESSAIR, 49 velaglucerase alfa, 40 TWYNSTA, 22 VELCADE, 20 TYBOST, 14 VELETRI, 25 TYGACIL, 16 VELPHORO, 39 TYKERB, 18 VELTASSA, 48 TYLENOL w/CODEINE, 11 VELTIN, 52 TYSABRI, 31 VEMLIDY, 15 TYVASO, 25 vemurafenib, 18 TYZEKA, 15 VENCLEXTA, 20 U venetoclax, 20 venlafaxine, 27 ULESFIA, 54 venlafaxine ext-rel, 27 ULORIC, 10 venlafaxine ext-rel tabs, 28 ULTRAM, 11 VENOFER, 48 ULTRAM ER, 11 VENTAVIS, 25 ULTRAVATE, 54 VENTOLIN, 49 umeclidinium bromide, 49 VENTOLIN HFA, 49 umeclidinium/vilanterol, 49 verapamil, 24 UNASYN, 13 verapamil ext-rel, 24 unoprostone isopropyl, 57 VERDESO, 53 UPTRAVI, 25 VEREGEN, 55 URAMAXIN, 54 verteporfin, 57 URAMAXIN GT, 54 VESICARE, 43 urea, 54 VEXOL, 56 urea 45%, 54 VFEND, 14 URECHOLINE, 43 VIBATIV, 16 uridine triacetate, 40 VIBERZI, 42 urine test strips, 34 VIBRAMYCIN, 13 UROCIT-K, 43 VICTOZA, 33 UROCIT-K 15 mEq, 44 VIDAZA, 19 UROXATRAL, 43 VIDEX EC, 15 URSO, 41 VIDEX soln, 15 URSO FORTE, 41 vigabatrin, 27 ursodiol, 41 VIGAMOX, 55 ustekinumab, 52 VIIBRYD, 27 UTIBRON NEOHALER, 49 vilazodone, 27 UVADEX, 20 VIMIZIM, 40 V VIMPAT, 27 VAGIFEM, 37 vinblastine, 19 valacyclovir, 16 vincristine, 19 VALCHLOR, 17 vincristine sulfate liposomal, 20 VALCYTE, 15 vinorelbine, 19 valganciclovir, 15 VIOKACE, 42

VIRACEPT, 15 Y VIRAMUNE, 14 YASMIN, 35 VIRAMUNE XR, 14 YAZ, 35 VIREAD, 15 YERVOY, 20 VIROPTIC, 56 YONDELIS, 17 VISICOL, 42 vismodegib, 20 Z VISTARIL, 26, 49 zafirlukast, 50 VISTIDE, 15 zaleplon, 30 VISUDYNE, 57 ZALTRAP, 20 VITAFOL-OB, 48 zanamivir, 16 vitamin ADC/fluoride drops, 48 ZANOSAR, 17 vitamin ADC/fluoride/iron drops, 48 ZANTAC, 41 VIVELLE-DOT, 37 ZARONTIN, 26 VIVITROL, 32 ZARXIO, 44 VOLTAREN GEL, 10 ZAVESCA, 40 von Willebrand factor, recombinant, 45 ZELAPAR, 28 VONVENDI, 45 ZELBORAF, 18 vorapaxar, 45 ZEMAIRA, 51 VORAXAZE, 20 ZEMPLAR, 39 voriconazole, 14 ZENPEP, 42 vorinostat, 20 ZENZEDI, 29 vortioxetine, 27 ZEPATIER, 16 VOSPIRE ER, 50 ZERIT, 15 VOTRIENT, 18 ZERIT soln, 15 VPRIV, 40 ZESTORETIC, 21 VWF, human/factor VIII complex, 45 ZESTRIL, 21 VYVANSE, 29 ZETIA, 22 ZIAC, 23 W ZIAGEN, 15 warfarin, 44 ZIAGEN soln, 15 WELCHOL, 22 ZIANA, 51 WELLBUTRIN SR, 28 ziconotide, 11 WELLBUTRIN XL, 28 zidovudine, 15 WESTCORT, 53 zileuton ext-rel, 50 WILATE, 45 ZINBRYTA, 31 WINRHO SDF, 47 zinc acetate, 48 X ZINECARD, 19 XALATAN, 57 ZIOPTAN, 57 XALKORI, 18 ziprasidone, 29 XANAX, 26 ZIRGAN, 56 XANAX XR, 26 ZITHROMAX, 13 XARELTO, 44 ziv-aflibercept, 20 XELJANZ, 46 ZMAX, 13 XELJANZ XR, 46 ZOFRAN, 41 XELODA, 17 ZOFRAN ODT, 41 XENAZINE, 30 ZOHYDRO ER, 11 XEOMIN, 32 ZOLADEX, 18 XERESE, 55 zoledronic acid, 35 XGEVA, 35 ZOLINZA, 20 XIAFLEX, 55 zolmitriptan, 30 XIFAXAN, 16 zolmitriptan nasal spray, 31 XIGDUO XR, 34 ZOLOFT, 27 XIIDRA, 57 zolpidem, 30 XOLAIR, 51 zolpidem ext-rel, 30 XOPENEX, 49 zolpidem spray, 30 XOPENEX SOLUTION, 49 zolpidem sublingual, 30 XTAMPZA ER, 11 ZOLPIMIST, 30 XTANDI, 17 ZOMACTON, 38 XURIDEN, 40 ZOMETA, 35 XYLOCAINE, 54 ZOMIG, 31 XYNTHA, 45 ZOMIG/ZOMIG-ZMT, 30 XYNTHA SOLOFUSE, 45 ZONALON, 54 XYREM, 31 ZONEGRAN, 26 zonisamide, 26 ZONTIVITY, 45

ZORBTIVE, 38 ZYCLARA, 54 ZORTRESS, 47 ZYDELIG, 18 ZOSYN, 13 ZYFLO CR, 50 ZOVIRAX, 16 ZYKADIA, 18 ZOVIRAX crm, 54 ZYLET, 56 ZOVIRAX oint, 54 ZYLOPRIM, 10 ZUBSOLV, 32 ZYPREXA RELPREVV, 29 ZUPLENZ, 41 ZYPREXA/ZYPREXA ZYDIS, 29 ZURAMPIC, 10 ZYTIGA, 17 ZUTRIPRO, 49 ZYVOX, 16 ZYBAN, 32