Page 1 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Acetaminophen 160mg/5mL oral Tylenol Age Limitation Acetaminophen 120mg Tylenol Usage Restriction Acetaminophen 650mg suppository Tylenol Acetaminophen 325mg Tylenol Quantity Limitation Acetaminophen 120mg-Codeine 12mg/5mL Tylenol with Codeine Age Limitation Acetaminophen 300mg-Codeine 30mg tablet Tylenol with Codeine Age Limitation Acetazolamide 250mg tablet Diamox Acetazolamide 500mg , extended release Diamox Acetic Acid 2% otic VoSol Acetylcysteine 10% solution Acetadote Acetylcysteine 20% solution Mucomist Acyclovir 200mg/5mL oral suspension Zovirax Acyclovir 400mg tablet Zovirax Acyclovir 800mg tablet Zovirax Aerochamber (Adult) Aerochamber (Pediatric) Albendazole 200mg tablet Albenza Usage Restriction Albuterol 0.63mg/3mL (0.021%) solution Accuneb Albuterol 1.25mg/3mL (0.042%) inhalation solution Accuneb Albuterol 2.5mg/3mL (0.083%) inhalation solution Accuneb Albuterol 2mg/5mL Proventil Albuterol 90mcg/inhalation HFA ProAir Alendronate 10mg tablet Fosamax Alendronate 70mg tablet Fosamax Allopurinol 100mg tablet Zyloprim Allopurinol 300mg tablet Zyloprim Aluminum Acetate topical Domeboro Aluminum Hydroxide 320mg/5mL suspension Antacid Usage Restriction Amantadine 100mg capsule Symmetrel Amerigel Wound Dressing gel Amerigel Usage Restriction Aminocaproic Acid 500mg tablet Amicar Amiodarone 200mg tablet Cordarone Amitriptyline 10mg tablet Elavil Amitriptyline 25mg tablet Elavil Amitriptyline 75mg tablet Elavil Amlodipine 5mg tablet Norvasc Amlodipine 10mg tablet Norvasc Amoxicillin 250mg capsule Amoxil Amoxicillin 500mg capsule Amoxil Amoxicillin 250mg/5mL oral suspension Amoxil Amoxicillin 400mg/5mL oral suspension Amoxil Amoxicillin 600mg-Clavulanate 42.9mg/5mL suspension Augmentin Usage Restriction Amoxicillin 875mg-Clavulanate 125mg tablet Augmentin Usage Restriction Anastrozole 1mg tablet Arimidex Apixaban 2.5mg tablet Eliquis Apixaban 5mg tablet Eliquis Apraclonidine 0.5% ophthalmic solution Usage Restriction Aripiprazole 2mg tablet Abilify Aripiprazole 5mg tablet Abilify Aripiprazole 10mg tablet Abilify Aripiprazole 15mg tablet Abilify Aripiprazole 20mg tablet Abilify Aripiprazole 30mg tablet Abilify Aripiprazole 300mg kit, extended release Abilify Aripiprazole 400mg injection kit, extended release Abilify Asenapine 5mg sublingual tablet Saphris Usage Restriction Asenapine 10mg sublingual tablet Saphris Usage Restriction Aspirin 25mg-Dipyridamole 200mg capsule Aggrenox

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 2 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Aspirin 81mg chewable tablet ASA Usage Restriction Aspirin 81mg tablet, enteric coated ASA Aspirin 325mg tablet, enteric coated ASA Atenolol 25mg tablet Tenormin Atenolol 50mg tablet Tenormin Atenolol 100mg tablet Tenormin Atomoxetine 10mg capsule Strattera Atomoxetine 18mg capsule Strattera Atomoxetine 25mg capsule Strattera Atomoxetine 40mg capsule Strattera Atomoxetine 60mg capsule Strattera Atomoxetine 80mg capsule Strattera Atomoxetine 100mg capsule Strattera Atorvastatin 10mg tablet Lipitor Atorvastatin 20mg tablet Lipitor Atorvastatin 40mg tablet Lipitor Atorvastatin 80mg tablet Lipitor Atropine 1% ophthalmic ointment Atropine 1% ophthalmic solution Azathioprine 50mg tablet Imuran Azithromycin 1 gram packet Z-Max Usage Restriction Azithromycin 100mg/5mL oral suspension Zithromax Usage Restriction Azithromycin 200mg/5mL oral suspension Zithromax Usage Restriction Azithromycin 250mg tablet Zithromax, Z-Pack Azithromycin 500mg tablet Zithromax Bacitracin 500 units/g ophthalmic ointment Bacitracin topical ointment Baclofen 10mg tablet Lioresal Baloxavir 20mg tablet (40mg dose) Xofluza Usage Restriction Baloxavir 40mg tablet (80mg dose) Xofluza Usage Restriction Balsam Peru-Castor Oil-Trypsin ointment Xenaderm Bamlanivimab 700mg/20mL injection Usage Restriction Benzonatate 100mg capsule Tessalon Perles Age Limitation Benzoyl Peroxide 5% water based gel Benzamycin Benztropine 0.5mg tablet Cogentin Benztropine 1mg tablet Cogentin Betamethasone 0.1% Betamethasone 6mg/mL injection Celestone Soluspan Betamethasone 0.05%-Clotrimazole 1% cream Lotrisone Betaxolol 0.25% ophthalmic suspension Betoptic Bethanechol 25mg tablet Urecholine Bisacodyl 5mg tablet, enteric coated Dulcolax Bisacodyl 10mg suppository Dulcolax Bowel Cleansing Kit Evac-Q-Kwik Brimonidine 0.15% ophthalmic solution Alphagan P Brivaracetam 10mg/mL oral solution Briviact Usage Restriction Brivaracetam 10mg tablet Briviact Usage Restriction Brivaracetam 25mg tablet Briviact Usage Restriction Brivaracetam 50mg tablet Briviact Usage Restriction Brivaracetam 75mg tablet Briviact Usage Restriction Brivaracetam 100mg tablet Briviact Usage Restriction Bromocriptine 2.5mg tablet Parlodel Usage Restriction Budesonide 0.25mg/2mL inhalation solution Pulmicort Age Limitation Budesonide 0.5mg/2mL inhalation solution Pulmicrot Age Limitation Bumetanide 0.5mg tablet Bumex Usage Restriction Bumetanide 1mg tablet Bumex Usage Restriction Bumetanide 2mg tablet Bumex Usage Restriction Bupivacaine 0.5% injection Marcaine

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 3 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Buprenorphine 2mg tablet, sublingual Subutex Buprenorphine 8mg tablet, sublingual Subutex Buprenorphine 100mg/0.5mL prefilled Sublocade Usage Restrictions Buprenorphine 300mg/1.5mL prefilled syringe Sublocade Usage Restrictions Buprenorphine 2mg-Naloxone 0.5mg film, sublingual Suboxone Buprenorphine 4mg-Naloxone 1mg film, sublingual Suboxone Buprenorphine 8mg-Naloxone 2mg film, sublingual Suboxone Buprenorphine 12mg-Naloxone 3mg film, sublingual Suboxone Bupropion 100mg tablet Wellbutrin Bupropion 150mg tablet, sustained release Wellbutrin SR Bupropion 150mg tablet, extended release Wellbutrin XL Bupropion 300mg tablet, extended release Wellbutrin XL Buspirone 15mg tablet Buspar Calcitonin 200units/inhalation Miacalcin Calcitriol 0.25mcg capsule Rocaltrol Usage Restriction Calcium Acetate 667mg gelcapsule PhosLo Usage Restriction Calcium Citrate 950mg tablet Caltrate Usage Restriction Canagliflozin 100mg tablet Invokana Canagliflozin 300mg tablet Invokana Canagliflozin 50mg-Metformin 500mg tablet, extended release Invokamet Canagliflozin 50mg-Metformin 1000mg tablet, extended release Invokamet Canagliflozin 150mg-Metformin 500mg tablet, extended release Invokamet Canagliflozin 150mg-Metformin 1000mg tablet, extended release Invokamet Carbachol 0.01% intraocular solution Miostat Usage Restriction Carbamazepine 100mg chewable tablet Tegretol Carbamazepine 200mg tablet Tegretol Carbidopa 10mg-Levodopa 100mg tablet Sinemet Carbidopa 25mg-Levodopa 100mg tablet Sinemet Carbidopa 25mg-Levodopa 250mg tablet Sinemet Carboxymethylcellulose 0.5% ophthalmic solution Refresh Plus Carvedilol 3.125mg tablet Coreg Carvedilol 6.25mg tablet Coreg Carvedilol 12.5mg tablet Coreg Carvedilol 25mg tablet Coreg Casirivimab 1200mg-Imdevimab 1200mg injection Usage Restriction Cefdinir 300mg capsule Omnicef Cefdinir 250mg/5mL oral suspension Omnicef Cefprozil 250mg/5mL oral suspension Cefzil Usage Restriction Ceftaroline 400mg injection Teflaro Ceftaroline 600mg injection Teflaro Cefuroxime 250mg tablet Ceftin Usage Restriction Cephalexin 250mg capsule Keflex Cephalexin 500mg capsule Keflex Cephalexin 250mg/5mL oral suspension Keflex Cetirizine 5mg/5mL oral solution Zyrtec Cetirizine 10mg tablet Zyrtec Chlorambucil 2mg tablet Leukaran Usage Restriction Chlorhexidine Gluconate 0.12% oral rinse Peridex Usage Restriction Chlorpromazine 25mg tablet Thorazine Chlorpromazine 50mg tablet Thorazine Chlorpromazine 100mg tablet Thorazine Chlorthalidone 25mg tablet Cholecalciferol 400units/mL oral Vitamin D3 Choice DM Cholestyramine 4 gram powder packet Questran Ciclopirox 8% topical nail lacquer Penlac Cimetidine 300mg/5mL oral solution Tagamet Ciprofloxacin 0.3% ophthalmic solution Cipro Ciprofloxacin 500mg tablet Cipro

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 4 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Ciprofloxacin 0.3%-Dexamethasone 0.1% otic suspension CiproDex Citalopram 10mg tablet Celexa Citalopram 20mg tablet Celexa Citalopram 40mg tablet Celexa Clarithromycin 500mg tablet Biaxin Usage Restriction Clindamycin 150mg capsule Cleocin Clindamycin 300mg capsule Cleocin Clindamycin 75mg/5mL oral solution Cleocin Clindamycin 1% topical pledget Cleocin T Clindamycin 2% vaginal cream Cleocin Clobazam 10mg tablet Onfi Clobazam 20mg tablet Onfi Clobetasol Propionate 0.05% cream Temovate Usage Restriction Clobetasol Propionate 0.05% topical solution Temovate Usage Restriction Clomiphene Citrate 50mg tablet Serophene Clonazepam 0.5mg tablet Klonopin Clonazepam 1mg tablet Klonopin Clonidine 0.1mg tablet Catapres Clonidine 0.2mg tablet Catapres Clopidogrel 75mg tablet Plavix Clotrimazole 1% cream Lotrimin Clotrimazole 1% topical solution Lotrimin Clotrimazole 1% vaginal cream Gyne Lotrimin Colchicine 0.6mg tablet Colestipol 1 gram tablet Colestid Collagenase Santyl 250 units/g ointment Santyl , lubricated latex Condoms, lubricated non-latex COVID19 vaccine (Moderna) 100mcg/0.5mL injection COVID19 vaccine (Pfizer) 30mcg/0.3mL injection Cyanocobalamin 1000mcg/mL injection Vitamin B12 Cyclobenzaprine 10mg tablet Flexeril Cyclopentolate 1% ophthalmic solution Cyclogyl Cyclophosphamide 50mg tablet Cytoxan Cyclosporine 0.05% ophthalmic Restasis Usage Restriction Cylcosporine 0.09% ophthalmic solution Cequa Usage Restriction Cyclosporine Non-Modified 25mg gelcap Sandimmune Usage Restriction Cyclosporine Non-Modified 100mg gelcap Sandimmune Usage Restriction Cyclosporine Non-Modified 100mg/mL oral solution Sandimmune Usage Restriction Cyproheptadine 4mg tablet Periactin Dabigatran 75mg capsule Pradaxa Usage Restriction Dabigatran 150mg capsule Pradaxa Usage Restriction Danazol 200mg capsule Dantrolene 25mg capsule Dantrium Dantrolene 100mg capsule Dantrium Dapsone 25mg tablet Demeclocycline 150mg tablet Declomycin Usage Restriction Denosumab 60mg/mL injection Prolia Usage Restriction Desmopressin 0.1mg/mL nasal solution DDAVP Usage Restriction Desmopressin 0.1mg tablet DDAVP Desmopressin 0.2mg tablet DDAVP 0.15mg-Ethinyl 30mcg tablet Reclipsen Desonide 0.05% cream DesOwen Desvenlafaxine 25mg tablet, extended release Pristiq Desvenlafaxine 50mg tablet, extended release Pristiq Desvenlafaxine 100mg tablet, extended release Pristiq

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 5 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Dexamethasone 0.5mg/5mL elixir Decadron Dexamethasone 0.1% ophthalmic solution Decadron Dexamethasone 0.5mg tablet Decadron Dexamethasone 0.75mg tablet Decadron Dexamethasone 4mg tablet Decadron Diazepam 5mg/mL injection Valium Diazepam 2.5mg rectal gel Diastat Diazepam 10mg rectal gel Diastat Diazepam 5mg tablet Valium Diclofenac 0.1% ophthalmic drops Voltaren Usage Restriction Diclofenac 1% topical gel Voltaren Dicloxacillin 250mg capsule Dicyclomine 10mg capsule Bentyl Dicyclomine 20mg tablet Bentyl Dicyclomine 10mg/5mL oral solution Bentyl Digoxin 0.25mg/5mL elixir Lanoxin Digoxin 0.125mg tablet Lanoxin Digoxin 0.25mg tablet Lanoxin Diltiazem 120mg capsule, extended release Tiazac Diltiazem 180mg capsule, extended release Tiazac Diltiazem 240mg capsule, extended release Tiazac Diltiazem 360mg capsule, extended release Tiazac Diltiazem 30mg tablet Cardizem Usage Restriction Diphenhydramine 25mg capsule Benadryl Usage Restriction Diphenhydramine 12.5mg/5mL oral liquid Benadryl Age Limitation Disulfiram 250mg tablet Antabuse Disulfiram 500mg tablet Antabuse Usage Restriction Divalproex 250mg tablet, extended release Depakote Divalproex 500mg tablet, extended release Depakote Divalproex 125mg sprinkle capsule Depakote Docusate 100mg capsule Colace Dofetilide 125mcg capsule Tikosyn Usage Restriction Dofetilide 250mcg capsule Tikosyn Usage Restriction Dofetilide 500mcg capsule Tikosyn Usage Restriction Dorzolamide 2% ophthalmic solution Trusopt Dorzolamide 2%-Timolol 0.5% ophthalmic solution Cosopt Doxazosin 1mg tablet Cardura Doxazosin 2mg tablet Cardura Doxazosin 4mg tablet Cardura Doxazosin 8mg tablet Cardura Doxepin 25mg capsule Doxycycline Monohydrate 100mg capsule Vibramycin Doxycycline 50mg/5mL syrup Vibramycin 3mg-Ethinyl Estradiol 30mcg tablet Yasmin Usage Restriction Duloxetine 20mg capsule Cymbalta Duloxetine 30mg capsule Cymbalta Duloxetine 60mg capsule Cymbalta Electrolyte oral solution Pedialyte Usage Restriction Emtricitabine 200mg-Tenofovir 300mg tablet Truvada Usage Restriction Enoxaparin 30mg/0.3mL syringe Lovenox Usage Restriction Enoxaparin 40mg/0.4mL syringe Lovenox Usage Restriction Enoxaparin 60mg/0.6mL syringe Lovenox Usage Restriction Enoxaparin 80mg/0.8mL syringe Lovenox Usage Restriction Enoxaparin 100mg/mL syringe Lovenox Usage Restriction Enoxaparin 100mg/mL 3mL vial Lovenox Usage Restriction Enoxaparin 120mg/0.8mL syringe Lovenox Usage Restriction Enoxaparin 150mg/mL syringe Lovenox Usage Restriction Ensure Usage Restriction Ensure Plus Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 6 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Epinephrine 0.15mg/0.3mL (Pediatric) injector Epi-Pen Jr Epinephrine 0.3mg/0.3mL (Adult) injector Epi-Pen Epinephrine Racemic 2.25% inhalation solution Usage Restriction Epoetin Alfa 4,000 units/mL inj Epogen, Procrit Epoetin Alfa 10,000 units/mL inj Epogen, Procrit Epoetin Alfa 20,000 units/mL inj Epgoen, Procrit Ergocalciferol 50,000 IU capsule Calcitrol Ergotamine 1mg-Caffeine 100mg tablet Cafergot Usage Restriction Erythromycin 400mg/5mL oral suspension Erythromycin 0.5% ophthalmic ointment Erythromycin 250mg tablet, enteric coated Erythromycin 2% topical solution Esterified 0.625mg-Methyltestosterone 1.25mg tablet Estratest HS Esterified Estrogen 1.25mg-Methyltestosterone 2.5mg tablet Estratest Estradiol 1mg tablet Estrace Estradiol 2mg tablet Estrace , Conjugated 0.3mg tablet Premarin Usage Restriction Estrogens, Conjugated 0.625mg tablet Premarin Usage Restriction Estrogens, Conjugated 1.25mg tablet Premarin Usage Restriction Estrogens, Conjugated 0.625mg/g vaginal cream Premarin Estrogens, Conjugated 25mg/5mL injection Premarin Estrogens, Esterified 0.3mg tablet Menest Estrogens, Esterified 0.625mg tablet Menest Estrogens, Esterified 1.25mg tablet Menest Estrogens, Esterified 2.5mg tablet Menest Ethambutol 400mg tablet Myambutol Ethosuximide 250mg capsule Zarontin 68mg subdermal Implanon Exemestane 25mg tablet Aromasin Eye irrigating solution Collyrium Usage Restriction Famotidine 20mg tablet Pepcid Famotidine 40mg/5mL oral suspension Pepcid Fenofibrate 54mg tablet Triglyde Usage Restriction Fenofibrate 160mg tablet Triglyde Usage Restriction Fentanyl 25mcg/hr patch Duragesic Usage Restriction Fentanyl 50mcg/hr Duragesic Usage Restriction Fentanyl 75mcg/hr transdermal patch Duragesic Usage Restriction Fentanyl 100mcg/hr transdermal patch Duragesic Usage Restriction Ferrous Gluconate 325mg tablet Ferrous Sulfate 15mg/mL oral solution Fidaxomicin 200mg tablet Dificid Usage Restriction Filgrastim 300mcg/mL injection Neupogen Usage Restriction Finasteride 5mg tablet Proscar Flecainide 100mg tablet Tambocor Usage Restriction Fluconazole 40mg/mL oral suspension Diflucan Usage Restriction Fluconazole 200mg tablet Diflucan Flucytosine 500mg capsule Ancobon Usage Restriction Fludrocortisone 0.1mg tablet Florinef Fluocinonide 0.05% cream Lidex Fluorometholone 0.1% ophthalmic suspension FML Fluorouracil 5% cream Efudex Fluoxetine 10mg capsule Prozac Fluoxetine 20mg capsule Prozac Fluoxetine 20mg/5mL oral solution Prozac Fluphenazine 2.5mg tablet Prolixin Fluticasone 44mcg HFA inhaler Flovent Age Limitation Fluticasone 110mcg HFA inhaler Flovent Age Limitation Fluticasone 50mcg nasal spray Flonase

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 7 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Fluticasone 45mcg-Salmeterol 21mcg HFA inhaler Advair Age Limitation Fluticasone 115mcg-Salmeterol 21mcg HFA inhaler Advair Age Limitation Fluticasone 100mcg-Salmeterol 50mcg diskus inhaler Advair Age Limitation Fluvoxamine 25mg tablet Luvox Fluvoxamine 50mg tablet Luvox Fluvoxamine 100mg tablet Luvox Folic Acid 1mg tablet Fosfomycin 3g oral powder packet Monurol Usage Restriction Fosinopril 10mg tablet Fosinopril 20mg tablet Fosinopril 40mg tablet Furosemide 10mg/mL oral solution Lasix Furosemide 20mg tablet Lasix Furosemide 40mg tablet Lasix Gabapentin 100mg capsule Neurontin Gabapentin 600mg tablet Neurontin Gabapentin 800mg tablet Neurontin Ganciclovir 0.15% ophthalmic gel Zirgan Gemfibrozil 600mg tablet Lopid Gentamicin 0.3% ophthalmic solution Glipizide 2.5mg tablet, extended release Glucotrol XL Glipizide 5mg tablet, extended release Glucotrol XL Glipizide 10mg tablet, extended release Glucotrol XL Glucagon 1mg/vial injection kit Glucerna Usage Restriction Glucose 24 gram gel tube Glutose Glucose 4 gram tablet Glyburide 5mg tablet Diabeta Glyburide 2.5mg-Metformin 500mg tablet Glucovance Glyburide 5mg-Metformin 500mg tablet Glucovance Glycerin suppository (Adult) Glycerin suppository (Pediatric) Griseofulvin 125mg/5mL oral suspension Grifulvin V Griseofulvin 500mg microsize tablet Grifulvin V Guaifenesin 100mg/5mL syrup Robitussin Age Limitation Guaifenesin 200mg tablet Mucinex Guaifenesin 100mg-Dextromethorphan 10mg/5mL syrup Robitussin DM Age Limitation Guanfacine 1mg tablet Tenex Guanfacine 2mg tablet Tenex Haloperidol 0.5mg tablet Haldol Haloperidol 1mg tablet Haldol Haloperidol 2mg tablet Haldol Haloperidol 5mg tablet Haldol Haloperidol 10mg tablet Haldol Haloperidol Decanoate 100mg/mL injection Haldol Hepatitis A vaccine Hepatitis B vaccine Homatropine 5% ophthalmic solution Human Papillomavirus Vaccine injection Gardasil-9 Hyaluronan 88mg/4mL injection Monovisc Hydralazine 10mg tablet Hydralazine 25mg tablet Hydralazine 50mg tablet Hydrochlorothiazide 25mg tablet HCTZ Hydrochlorothiazide 50mg tablet HCTZ Hydrocodone 7.5mg-Acetaminophen 325mg/15mL elixir Lortab Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 8 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Hydrocortisone 1% cream Hydrocortisone 10% Usage Restriction Hydrocortisone 25mg suppository Hydrocortisone 5mg tablet Hydrocortisone 20mg tablet Hydrophilic ointment 412 gram tub Usage Restriction Hydroxychloroquine 200mg tablet Plaquenil Hydroxyprogesterone Caproate 250mg/mL injection Makena Hydroxyurea 500mg capsule Hydrea Usage Restriction Hydroxyzine Pamoate 25mg capsule Vistaril Hydroxyzine 10mg/5mL syrup Atarax Hydroxyzine 10mg tablet Atarax Hydroxyzine 25mg tablet Atarax Hylan GF 20 48mg/6mL injection Synvisc One Hypromellose 0.4% ophthalmic solution Naturale Balance Tears Ibuprofen 100mg/5mL oral suspension Motrin Age Limitation Ibuprofen 400mg tablet Motrin Quantity Limitation Ibuprofen 800mg tablet Motrin Quantity Limitation Idarucizumab 2.5g/50mL injection Praxbind Usage Restriction Imipramine 25mg tablet Tofranil Indinavir 400mg capsule Crixivan Usage Restriction Indomethacin 25mg capsule Indocin Quantity Limitation Insulin Aspart 100 units/mL cartridge Novolog Penfill Age Limitation Insulin Aspart 100 units/mL flexpen Novolog Flexpen Insulin Aspart 100 units/mL vial Novolog Insulin Degludec 100 units/mL flextouch Tresiba Usage Restriction Insulin Degludec 200 units/mL flextouch Tresiba Usage Restriction Insulin Detemir 100 units/mL flexpen Levemir Flexpen Insulin Detemir 100 units/mL vial Levemir Insulin Echo pen device Novopen Echo Device Age Limitation Insulin Glargine *Concentrated* 300 units/mL flexpen Toujeo Usage Restriction Insulin Glargine *Concentrated* 300 units/mL flexpen Toujeo Max Insulin NPH (Human) 100 units/mL vial Novolin N Insulin Regular (Human) 100 units/mL vial Novolin R Insulin Regular *Concentrated* 500 units/mL kwikpen Humulin R U-500 Usage Restriction Insulin 70/30 (NPH/Regular) 100 units/mL vial NovoLIN 70/30 Insulin 70/30 (Protamine/Aspart) 100 units/mL flexpen NovoLOG 70/30 Flexpen Insulin 70/30 (Protamine/Aspart) 100 units/mL vial NovoLOG 70/30 Insulin syringe 0.5mL 31G 5/16IN Insulin syringe 1mL 30G 1/2IN Insulin syringe 1mL 31G 5/16IN Ipratropium 17mcg/inhalation HFA inhaler Atrovent Ipratropium 0.02% inhalation solution Atrovent Ipratropium 0.03% nasal solution Atrovent Ipratropium 0.5mg-Albuterol 3mg/3mL inhalation solution Duoneb Ipratropium 20mcg-Albuterol 100mcg inhaler Combivent Iron Dextran 50mg/mL injection Infed Iron Sucrose 20mg/mL injection Venofer Isoniazid 300mg tablet Isosorbide Dinitrate 5mg sublingual tablet Isordil Usage Restriction Isosorbide Mononitrate 30mg tablet, extended release Imdur Isosorbide Mononitrate 60mg tablet, extended release Imdur Itraconazole 100mg capsule Sporonox Usage Restriction Ivermectin 3mg tablet Stromectol Usage Restriction Ivermectin 0.5% topical lotion Sklice Ketorolac 0.5% ophthalmic solution Acular Ketorolac 30mg/mL injection Toradol Usage Restriction Ketorolac 60mg/2mL injection Toradol Usage Restriction Ketorolac 10mg tablet Toradol Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 9 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Ketotifen 0.025% ophthalmic solution Zaditor Labetalol 100mg tablet Trandate Labetalol 300mg tablet Trandate Labetalol 5mg/mL injection Trandate Usage Restriction Lacosamide 50mg tablet Vimpat Lacosamide 100mg tablet Vimpat Lacosamide 150mg tablet Vimpat Lacosamide 200mg tablet Vimpat Lacosamide 10mg/mL oral solution Vimpat Lactulose 10g/15mL syrup Lamivudine 150mg tablet 3TC, Epivir Usage Restriction Lamivudine 150mg-Zidovudine 300mg tablet Combivir Usage Restriction Lamotrigine 25mg tablet Lamictal Lamotrigine 100mg tablet Lamictal Lamotrigine 150mg tablet Lamictal Lamotrigine 200mg tablet Lamictal Lancets Latanoprost 0.005% ophthalmic solution Xalatan Usage Restriction LCD 15% lotion Coal tar solution Leflunomide 10mg tablet Arava Leucovorin 5mg tablet Leuprolide Acetate 3.75mg injection Lupron Usage Restriction Leuprolide 15mg injection Lupron Usage Restriction Levetiracetam 100mg/mL oral solution Keppra Levetiracetam 250mg tablet Keppra Levetiracetam 500mg tablet Keppra Levobunolol 0.25% ophthalmic solution Betagan Levobunolol 0.5% ophthalmic solution Betagan Levofloxacin 250mg tablet Levaquin Usage Restriction Levofloxacin 500mg tablet Levaquin Usage Restriction Levofloxacin 750mg tablet Levaquin Usage Restriction 1.5mg tablet Plan B, Next Choice Levonorgestrel 13.5mg intrauterine device Skyla Levonorgestrel 19.5mg intrauterine device Kyleena Levonorgestrel 52mg intrauterine device Mirena Levonorgestrel 0.15mg-Ethinyl Estradiol 30mcg tablet Levora Levothyroxine 0.025mg tablet Synthroid Usage Restriction Levothyroxine 0.05mg tablet Synthroid Usage Restriction Levothyroxine 0.075mg tablet Synthroid Usage Restriction Levothyroxine 0.088mg tablet Synthroid Usage Restriction Levothyroxine 0.1mg tablet Synthroid Usage Restriction Levothyroxine 0.112mg tablet Synthroid Usage Restriction Levothyroxine 0.125mg tablet Synthroid Usage Restriction Levothyroxine 0.137mg tablet Synthroid Usage Restriction Levothyroxine 0.15mg tablet Synthroid Usage Restriction Levothyroxine 0.175mg tablet Synthroid Usage Restriction Levothyroxine 0.2mg tablet Synthroid Usage Restriction Levothyroxine 0.3mg tablet Synthroid Usage Restriction Levothyroxine 0.5mg injection Synthroid Usage Restriction Lidocaine 2% jelly Lidocaine 5% topical patch Lidoderm Lidocaine 2% viscous liquid Lifitegrast 5% ophthalmic solution Xiidra Usage Restriction Linagliptin 2.5mg-Metformin 1000mg tablet, extended release Jentadueto XR Usage Restriction Linagliptin 5mg-Metformin 1000 mg tablet, extended release Jentadueto XR Usage Restriction Linezolid 600mg tablet Zyvox Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 10 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Lisinopril 2.5mg tablet Prinivil, Zestril Lisinopril 5mg tablet Prinivil, Zestril Lisinopril 10mg tablet Prinivil, Zestril Lisinopril 20mg tablet Prinivil, Zestril Lisinopril 40mg tablet Prinivil, Zestril Lithium Carbonate 300mg tablet Lithium Carbonate 300mg tablet, extended release Lithobid Loperamide 2mg capsule Immodium Usage Restriction Lopinavir 200mg-Ritonavir 50mg tablet Kaletra Usage Restriction Loratadine 10mg tablet Claritin Losartan 25mg tablet Cozaar Losartan 50mg tablet Cozaar Losartan 100mg tablet Loteprednol 0.5% ophthalmic suspension Lotemax Usage Restriction Loteprednol 0.5% ophthalmic ointment Lotemax Usage Restriction Lubricant, ocular Lubricant, surgical Magnesium Citrate oral solution Citroma Magnesium Oxide 400mg tablet MAGtab Meclizine 25mg tablet Antivert Medroxyprogesterone 2.5mg tablet Provera Medroxyprogesterone 10mg tablet Provera Medroxyprogesterone Acetate 150mg injection Depo Provera Megestrol 40mg/mL oral suspension Megace Megestrol 40mg tablet Megace Meloxicam 7.5mg tablet Mobic Quantity Limitation Meloxicam 15mg tablet Mobic Quantity Limitation Melphalan 2mg tablet Leukaran Mercaptopurine 50mg tablet Purinethol Mesalamine 400mg capsule, delayed release Delzicol DR Usage Restriction Metformin 500mg tablet Glucophage Metformin 1000mg tablet Glucophage Metformin 500mg tablet, extended release Glucophage XL Methimazole 10mg tablet Tapazole Methotrexate 2.5mg tablet Methotrexate 25mg/mL injection Usage Restriction Methyldopa 250mg tablet Aldomet Methylergonovine 0.2mg tablet Methergine Methylprednisolone 4mg tablet dosepak Medrol Dosepak Methylprednisolone Acetate 40mg/mL injection Depo Medrol Methylprednisolone Acetate 80mg/mL injection Depo Medrol Methylprednisolone Sodium Succinate 125mg injection Solu Medrol Metoclopramide 5mg/5mL syrup Reglan Metoclopramide 5mg tablet Reglan Metoclopramide 10mg tablet Reglan Metolazone 5mg tablet Zaroxolyn Metoprolol Succinate 25mg tablet, extended release Toprol XL Metoprolol Succinate 50mg tablet, extended release Toprol XL Metoprolol Succinate 100mg tablet, extended release Toprol XL Metoprolol Tartrate 25mg tablet Lopressor Metoprolol Tartrate 50mg tablet Lopressor Metoprolol Tartrate 100mg tablet Lopressor Metoprolol Tartrate 1mg/mL injection Lopressor Metronidazole 250mg tablet Flagyl Metronidazole 500mg tablet Flagyl Metronidazole 0.75% vaginal gel Vandazole Magnesium OH-Aluminum OH-Simethicone oral suspension Usage Restriction Midazolam 5mg/mL injection Versed Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 11 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Midodrine 2.5mg tablet Midodrine 5mg tablet Midodrine 10mg tablet Minocycline 50mg capsule Minocycline 100mg capsule Minoxidil 2.5mg tablet Loniten Minoxidil 10mg tablet Loniten Mirtazapine 15mg tablet Remeron Mirtazapine 30mg tablet Remeron Misoprostol 100mcg tablet Cytotec Usage Restriction Misoprostol 200mcg tablet Cytotec Usage Restriction Mometasone 110mcg inhaler Asmanex Mometasone 200mcg inhaler Asmanex Mometasone 100mcg-Formoterol 5mcg inhaler Dulera Mometasone 200mcg-Formoterol 5mcg inhaler Dulera Montelukast 4mg chewable tablet Singulair Montelukast 5mg chewable tablet Singulair Montelukast 10mg tablet Singulair Morphine 15mg tablet, immediate release Morphine 30mg tablet, sustained release Morphine 60mg tablet, sustained release Moxifloxacin 0.5% ophthalmic drops Vigamox Moxifloxacin 400mg tablet Avelox Multivitamin oral suspension Multivitamin with Folic Acid and Iron tablet Prenatal Vitamin Usage Restriction Mumps Skin Test Antigen injection Mupirocin 2% ointment Bactroban Mycophenolate Mofetil 250mg capsule Cellcept Usage Restriction Mycophenolate Mofetil 500mg tablet Cellcept Usage Restriction Naloxone 0.4mg auto injection kit Evzio Naloxone 4mg/0.1mL nasal spray Narcan Nasal Naltrexone 50mg tablet ReVia Naproxen 500mg tablet Naprosyn Needle, Pen 29 gauge, 1/2 inch Needle, Pen 30 gauge, 1/3 inch Needle, Pen 31 gauge, 3/16 inch Nelfinavir 625mg tablet Viracept Usage Restriction Neomycin-Polymyxin-Bacitracin ophthalmic ointment Neosporin Neomycin-Polymyxin-Bacitracin topical ointment Triple Antibiotic Neomycin-Polymyxin-Gramcidin ophthalmic solution Neosporin Neomycin-Polymyxin-Hydrocortisone ophthalmic suspension Cortisporin Neomycin-Polymyxin-Hydrocortisone otic solution Cortisporin Neomycin-Polymyxin-Hydrocortisone otic suspension Cortisporin Neomycin 500mg tablet Nephrocap Usage Restriction Niacin 500mg tablet, extended release Niaspan Niacin 1000mg tablet, extended release Niaspan Nicotine 7mg transdermal patch Usage Restriction Nicotine 14mg transdermal patch Usage Restriction Nicotine 21mg transdermal patch Usage Restriction Nifedipine 10mg capsule Procardia Nifedipine 30mg tablet, extended release Procardia XL Nifedipine 60mg tablet, extended release Procardia XL Nifedipine 90mg tablet, extended release Procardia XL Nitrofurantoin Monohydrate 100mg capsule Macrobid Nitrofurantoin 25mg/5mL oral suspension Macrodantin Nitroglycerin 2% ointment Nitroglycerin 0.4mg sublingual tablet Nitrostat Norethindrone 0.35mg tablet NorQD

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 12 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Norethindrone 0.5/0.75/1mg-Ethinyl Estradiol 35mcg tablet Necon 777 Norethindrone 1mg-Ethinyl Estradiol 35mcg tablet Norinyl 1/35 Norethindrone 1mg-Ethinyl Estradiol 20mcg-Iron 75mg tablet Microgestin FE 1/20 Norethindrone 1mg- 50mcg tablet Norinyl 1/50 0.18/0.215/0.25mg-Ethinyl Estradiol 35mcg tablet TriNessa Nortriptyline 10mg capsule Pamelor Nortriptyline 25mg capsule Pamelor Nystatin 100,00 unit/mL oral suspension Nystatin 500,000 unit tablet Nystatin 100,000 unit/g topical powder Ocular lubricant (propylene glycol 0.6%) Systane Complete Ocular lubricant (PEG400 0.4%-propylene glycol 0.3%) Systane Ultra Ofloxacin 0.3% otic solution Ocuflox Olopatadine 0.2% ophthalmic solution Pataday Omeprazole 20mg capsule Prilosec Onabotulinumtoxin A 200 unit vial Botox Usage Restriction Ondansetron 4mg tablet Zofran Ondansetron 8mg tablet Zofran Ondansetron 4mg tablet, orally disintegrating Zofran ODT Ondansetron 8mg tablet, orally disintegrating Zofran ODT Ondansetron 4mg/5mL oral solution Zofran Age Limitation Oseltamivir 30mg capsule Tamiflu Usage Restriction Oseltamivir 45mg capsule Tamiflu Usage Restriction Oseltamivir 75mg capsule Tamiflu Usage Restriction Oseltamivir 6mg/mL suspension Tamiflu Usage Restriction Oxcarbazepine 150mg tablet Trileptal Oxcarbazepine 300mg tablet Trileptal Oxcarbazepine 600mg tablet Trileptal Oxybutynin 5mg tablet Ditropan Oxycodone 5mg-Acetaminophen 325mg tablet Percocet Paliperidone Palmitate 39mg injection kit Invega Sustenna Usage Restriction Paliperidone Palmitate 78mg injection kit Invega Sustenna Usage Restriction Paliperidone Palmitate 117mg injection kit Invega Sustenna Usage Restriction Paliperidone Palmitate 156mg injection kit Invega Sustenna Usage Restriction Paliperidone Palmitate 234mg injection kit Invega Sustenna Usage Restriction Pancrelipase 12,000 unit capsule Patiromer 8.4g oral powder packet Veltassa Usage Restriction Patiromer 16.8g oral powder packet Veltassa Usage Restriction Patiromer 25.2g oral powder packet Veltassa Usage Restriction Pediasure Polyethylene glycol-3350 with Electrolytes oral solution Colyte, Golytely Usage Restriction Penicillamine 250mg tablet Cuprimine Usage Restriction Penicillin VK 250mg/5mL oral solution Penicillin VK 250mg tablet Penicillin VK 500mg tablet Perampanel 2mg tablet Fycompa Usage Restriction Perampanel 4mg tablet Fycompa Usage Restriction Perampanel 6mg tablet Fycompa Usage Restriction Permethrin 1% cream rinse Nix Permethrin 5% topical cream Elimite Petrolatum white ointment Usage Restriction Phenazopyridine 100mg tablet Pyridium Phenazopyridine 200mg tablet Pyridium Phenobarbital 15mg tablet Phenobarbital 30mg tablet Phenobarbital 100mg tablet Phenobarbital 20mg/5mL elixir Phenylephrine 2.5% ophthalmic solution AK Dilate

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 13 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Phenytoin 50mg chewable tablet Dilantin Phenytoin 100mg capsule Dilantin Phenytoin 125mg/5mL oral suspension Dilantin Phytonadione 5mg tablet Mephyton Pill Splitter Pilocarpine 1% ophthalmic solution Pilocarpine 2% ophthalmic solution Pilocarpine 4% ophthalmic solution Pilocarpine 4% ophthalmic gel Pilopine HS Pilocarpine 5mg tablet Pioglitazone 15mg tablet Pioglitazone 30mg tablet Actos Pioglitazone 45mg tablet Pneumococcal 13 Valent vaccine Prevnar 13 Pneumococcal 23 Polyvalent vaccine Pneumovax 23 Podofilox 0.5% topical gel Condylox Polymyxin-Bacitracin ophthalmic ointment Polysporin Polymyxin-Trimethoprim ophthalmic solution Polytrim Polyvinyl Alcohol 1.4% ophthalmic solution Potassium Chloride 40mEq/15mL oral solution Potassium Chloride 20mEq tablet, extended release K-Dur Potassium Iodide saturated solution Prasugrel 10mg tablet Effient Usage Restriction Pravastatin 20mg tablet Pravachol Pravastatin 40mg tablet Pravachol Pravastatin 80mg tablet Pravachol Prazosin 1mg capsule Minipress Prazosin 2mg capsule Minipress Prazosin 5mg capsule Minipress Prednisolone 1% ophthalmic suspension Pred Forte Prednisolone 15mg/5mL syrup Pediapred Prednisone 1mg tablet Prednisone 5mg tablet Prednisone 20mg tablet Prednisone 5mg/5mL oral solution Pregabalin 50mg capsule Lyrica Usage Restriction Pregabalin 75mg capsule Lyrica Usage Restriction Pregabalin 100mg capsule Lyrica Usage Restriction Pregabalin 150mg capsule Lyrica Usage Restriction Pregabalin 200mg capsule Lyrica Usage Restriction Pregabalin 225mg capsule Lyrica Usage Restriction Pregabalin 300mg capsule Lyrica Usage Restriction Primidone 50mg tablet Mysoline Primidone 250mg tablet Mysoline Probenecid 500mg tablet Benemid Procarbazine 50mg capsule Matulane Prochlorperazine 5mg/mL injection Compazine Usage Restriction 200mg capsule Prometrium Usage Restriction Promethazine 25mg suppository Phenergan Promethazine 25mg tablet Phenergan Proparacaine 0.5% ophthalmic solution Alcaine Propranolol 10mg tablet Inderal Propranolol 20mg tablet Inderal Propranolol 40mg tablet Inderal Propranolol 80mg tablet Inderal Propylthiouracil 50mg tablet ProRenal vitamin tablet Usage Restriction Pyrazinamide 500mg tablet Pyridostigmine 60mg tablet Mestinon

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 14 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Pyridoxine 50mg tablet Vitamin B6 Usage Restriction Quetiapine 25mg tablet Seroquel Quetiapine 50mg tablet Seroquel Quetiapine 100mg tablet Seroquel Quetiapine 200mg tablet Seroquel Quetiapine 400mg tablet Seroquel Quinidine Gluconate 324mg tablet Quinidex Usage Restriction Quinidine Sulfate 200mg tablet Raloxifene 60mg tablet Evista Raltegravir 400mg tablet Isentress Usage Restriction Ranitidine 150mg tablet Zantac Ranitidine 75mg/5mL syrup Zantac Ranolazine 500mg tablet, extended release Ranexa Usage Restriction Ranolazine 1000mg tablet, extended release Ranexa Usage Restriction Remdesivir 100mg/20mL injection Veklury Usage Restriction Renal capsule Usage Restriction Ribavirin 200mg capsule Ribasphere Rifabutin 150mg capsule Mycobutin Rifampin 300mg capsule Rifadin Risperidone 0.25mg tablet Risperdal Risperidone 0.5mg tablet Risperdal Risperidone 1mg tablet Risperdal Risperidone 2mg tablet Risperdal Risperidone 3mg tablet Risperdal Risperidone 4mg tablet Risperdal Risperidone 1mg/mL oral solution Risperdal Rivaroxaban 10mg tablet Xarelto Rivaroxaban 15mg tablet Xarelto Rivaroxaban 20mg tablet Xarelto Rizatriptan 5mg tablet, orally disintegrating Maxalt MLT Usage Restriction Rizatriptan 10mg tablet, orally disintegrating Maxalt MLT Usage Restriction Rosuvastatin 5mg tablet Crestor Rosuvastatin 10mg tablet Crestor Rosuvastatin 20mg tablet Crestor Rosuvastatin 40mg tablet Crestor Sacubitril 24mg-Valsartan 26mg tablet Entresto Usage Restriction Sacubitril 49mg-Valsartan 51mg tablet Entresto Usage Restriction Sacubitril 97mg-Valsartan 103mg tablet Entresto Usage Restriction Salmeterol 50mcg diskus inhaler Serevent Usage Restriction Salsalate 500mg tablet Saxagliptin 2.5mg tablet Onglyza Usage Restriction Saxagliptin 5mg tablet Onglyza Usage Restriction Scopolamine 1.5mg/72hrs topical patch Transderm Scop Selenium Sulfide 2.5% lotion Selsun Semaglutide (0.25 or 0.5mg dose) 2mg/1.5mL pen injection Ozempic Usage Restriction Semaglutide (1mg dose) 2mg/1.5mL pen injection Ozempic Usage Restriction Sertraline 25mg tablet Zoloft Sertraline 50mg tablet Zoloft Sertraline 100mg tablet Zoloft Sevelamer 800mg tablet Renvela Sodium Citrate-Citric Acid solution Shohl's solution Silver Sulfadiazine 1% cream Silvadene Simethicone 20mg/0.3mL drops Mylicon Usage Restriction Simvastatin 10mg tablet Zocor Simvastatin 20mg tablet Zocor Simvastatin 40mg tablet Zocor Simvastatin 80mg tablet Zocor Sodium Bicarbonate 650mg tablet Sodium Chloride 1g tablet Salt tablet

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 15 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Sodium Chloride 0.9% inhalation solution Sodium Chloride 3% inhalation solution Sodium Chloride 5% ophthalmic ointment Muro 128 Usage Restriction Sodium Chloride 5% ophthalmic solution Muro 128 Usage Restriction Sodium Fluoride 0.5mg/mL drops Sodium Fluoride 1.1% dental gel Prevident Usage Restriction Sodium Fluoride 1.1mg tablet Sodium Fluoride 2.2mg tablet Sodium Hyaluronate 1% 20mg/2mL Euflexxa Sodium Phosphate (Adult) Fleets Enema Usage Restriction Sodium Phosphate enema (Pediatric) Fleets Enema Usage Restriction Sodium Phosphate oral solution Fleets Usage Restriction Sodium Picosulfate-Magnesium Oxide-Citric Acid powder Clenpiq Sodium Polystyrene Sulfonate oral suspension Kayexalate, SPS Sorbitol 70% solution Usage Restriction Sotalol 80mg tablet Betapace Usage Restriction Sotalol 120mg tablet Betapace Usage Restriction Sotalol 160mg tablet Betapace Usage Restriction Spacer for Inhaler with mask (Pediatric) Spironolactone 25mg tablet Aldactone Spironolactone 100mg tablet Aldactone Sucralfate 1 gram tablet Carafate Sulfamethoxazole 200mg-Trimethoprim 40mg/5mL oral suspension Bactrim Sulfamethoxazole 800mg-Trimethoprim160mg tablet Bactrim DS Sulfasalazine 500mg tablet, enteric coated Azulfidine EC Sumatriptan 25mg tablet Imitrex Usage Restriction Sumatriptan 50mg tablet Imitrex Usage Restriction Sumatriptan 100mg tablet Imitrex Usage Restriction Tacrolimus 0.5mg capsule Prograf Usage Restriction Tacrolimus 1mg capsule Prograf Usage Restriction Tacrolimus 5mg capsule Prograf Usage Restriction Tamoxifen 10mg tablet Nolvadex Tamsulosin 0.4mg capsule Flomax Tedizolid 200mg tablet Sivextro Usage Restriction Tedizolid 200mg vial Sivextro Usage Restriction Telmisartan 40mg tablet Micardis Usage Restriction Telmisartan 80mg tablet Micardis Usage Restriction Terazosin 1mg capsule Hytrin Terazosin 2mg capsule Hytrin Terazosin 5mg capsule Hytrin Terazosin 10mg capsule Hytrin Terbinafine 250mg tablet Lamisil Terbutaline 5mg tablet Testosterone 1.62% topical gel (88g pump) Androgel Testosterone Cypionate 200mg/mL injection Depo Testosterone Tetracaine 0.5% ophthalmic solution Tetracycline 250mg capsule Tetracycline 500mg capsule Theophylline 100mg/24hrs capsule, extended release Theo-24 Theophylline 200mg/24hrs capsule, extended release Theo-24 Theophylline 300mg/24hrs capsule, extended release Theo-24 Thiamine 100mg tablet Vitamin B1 Usage Restriction Thioridazine 25mg tablet Mellaril Ticagrelor 60mg tablet Brilinta Usage Restriction Ticagrelor 90mg tablet Brilinta Usage Restriction Timolol 0.25% ophthalmic solution Timoptic Timolol 0.5% ophthalmic solution Timoptic Timolol 0.5% ophthalmic gel-forming solution Timoptic GFS

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 16 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Tiotropium 1.25mcg inhaler Spiriva Tiotropium 2.5mcg respimat inhaler Spiriva Tobramycin 0.3% ophthalmic ointment Tobramycin 0.3% ophthalmic solution Tobramycin 80mg/2mL injection Tobramycin-Dexamethasone ophthalmic ointment Tobradex

Tobramycin-Dexamethasone ophthalmic suspension Tobradex Tocilizumab 162mg/0.9mL Actemra Age Limitation Tocilizumab 80mg/4mL intravenous injection Actemra Age Limitation Tocilizumab 200mg/10mL intravenous injection Actemra Age Limitation Tocilizumab 400mg/20mL intravenous injection Actemra Age Limitation Tolterodine 2mg capsule, extended release Detrol LA Usage Restriction Tolterodine 4mg capsule, extended release Detrol LA Usage Restriction 15mg sprinkle capsule Topamax Topiramate 25mg sprinkle capsule Topamax Topiramate 25mg tablet Topamax Topiramate 50mg tablet Topamax Topiramate 100mg tablet Topamax Topiramate 200mg tablet Topamax Torsemide 20mg tablet Demadex Tramadol 50mg tablet Ultram Quantity Limitation Travoprost-Z 0.004% ophthalmic solution (2.5mL) Travatan-Z Usage Restriction Trazodone 50mg tablet Desyrel Trazodone 150mg tablet Desyrel Tretinoin 0.05% cream Retin A Triamcinolone 0.025% in lotion Triamcinolone 0.1% dental Triamcinolone 0.1% in lotion Triamcinolone 0.1% ointment Triamcinolone 0.1% cream Triamcinolone 0.5% cream Triamterene 100mg capsule Dyrenium Trichloroacetic Acid 85% topical solution Trientine 250mg capsule Syprine Usage Restriction Trifluoperazine 2mg tablet Stelazine Trifluoperazine 5mg tablet Stelazine Tropicamide 1% ophthalmic solution Mydriacyl Tuberculin Skin Test 5 units injection Tuberculin syringe 1mL 28G 1/2IN Usage Restriction Ursodiol 300mg capsule Actigall Valproic Acid 250mg/5mL syrup Vancomycin 125mg capsule Vancocin Usage Restriction Vancomycin 250mg capsule Vancocin Usage Restriction Varenicline 1mg tablet Chantix Usage Restriction Varenicline Starter Pack Chantix Usage Restriction Venlafaxine 75mg tablet Effexor Venlafaxine 37.5mg capsule, extended release Effexor XR Venlafaxine 75mg capsule, extended release Effexor XR Venlafaxine 150mg capsule, extended release Effexor XR Verapamil 80mg tablet Calan Usage Restriction Verapamil 120mg tablet, extended release Calan SR Verapamil 180mg tablet, extended release Calan SR Verapamil 240mg tablet, extended release Calan SR Vitamins A,D, & C with Fluoride 0.25mg drops Childrens Vitamin

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 17 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021

Generic Name Brand Name Limitations/Restrictions Warfarin 1mg tablet Coumadin Warfarin 2mg tablet Coumadin Warfarin 2.5mg tablet Coumadin Warfarin 3mg tablet Coumadin Warfarin 4mg tablet Coumadin Warfarin 5mg tablet Coumadin Warfarin 6mg tablet Coumadin Warfarin 7.5mg tablet Coumadin Zinc Oxide ointment Age Limitation Ziprasidone 20mg capsule Geodon Ziprasidone 40mg capsule Geodon Ziprasidone 60mg capsule Geodon Ziprasidone 80mg capsule Geodon Zolpidem 10mg tablet Ambien Zoster Vaccine 50mcg/0.5mL injection Shingrix Usage Restriction

* Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions