Molina Healthcare of Michigan Preferred Drug List (Formulary)

(10/01/2019)

INTRODUCTION ...... 4 PREFACE ...... 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...... 4 DRUG LIST PRODUCT DESCRIPTIONS ...... 4 GENERIC SUBSTITUTION ...... 4 PLAN DESIGN ...... 5 PRIOR AUTHORIZATION REQUEST PROCEDURE ...... 5 PRIOR AUTHORIZATION HELPFUL HINTS ...... 5 LEGEND ...... 5 REQUESTING FORMULARY CHANGES ...... 5 STATE OF MICHIGAN, MEDICAID CARVE-OUT ...... 6 STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST ...... 6 NON-COVERED MEDICATIONS ...... 8 NOTICE ...... 8 FORMULARY UPDATES ...... 9 ANALGESICS ...... 10 NSAIDs ...... 10 NSAIDs, TOPICAL ...... 10 COX-2 INHIBITORS...... 10 GOUT ...... 10 OPIOID ANALGESICS ...... 10 NON-OPIOID ANALGESICS ...... 11 VISCOSUPPLEMENTS ...... 11 ANTI-INFECTIVES ...... 11 ANTIBACTERIALS...... 11 ANTIFUNGALS ...... 12 ANTIMALARIALS ...... 13 ANTIRETROVIRAL AGENTS ...... 13 ANTITUBERCULAR AGENTS ...... 13 ANTIVIRALS ...... 13 MISCELLANEOUS...... 13 ANTINEOPLASTIC AGENTS ...... 14 ALKYLATING AGENTS ...... 14 ANTIMETABOLITES ...... 14 CYTOPROTECTIVE AGENTS ...... 14 HORMONAL ANTINEOPLASTIC AGENTS ...... 14 IMMUNOMODULATORS ...... 15 KINASE INHIBITORS ...... 15 TOPOISOMERASE INHIBITORS ...... 15 MISCELLANEOUS...... 15 CARDIOVASCULAR...... 15 ACE INHIBITORS ...... 15 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 16 ACE INHIBITOR/DIURETIC COMBINATIONS...... 16 ADRENOLYTICS, CENTRAL ...... 16 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATIONS ...... 16 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 16 ALPHA BLOCKERS ...... 16 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 16 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 16 ANTIARRHYTHMICS...... 16 ANTILIPEMICS ...... 16 BETA-BLOCKERS ...... 17 BETA-BLOCKER/DIURETIC COMBINATIONS ...... 17 CALCIUM CHANNEL BLOCKERS ...... 17

1 DIGITALIS GLYCOSIDES ...... 18 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 18 DIURETICS ...... 18 NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ...... 18 NITRATES ...... 19 PULMONARY ARTERIAL HYPERTENSION ...... 19 MISCELLANEOUS...... 19 CENTRAL NERVOUS SYSTEM ...... 19 ANTIANXIETY ...... 19 ANTICONVULSANTS ...... 19 ANTIDEMENTIA ...... 19 ANTIDEPRESSANTS ...... 20 ANTIPARKINSONIAN AGENTS ...... 20 ANTIPSYCHOTICS...... 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 20 FIBROMYALGIA ...... 20 HYPNOTICS ...... 20 MIGRAINE ...... 20 MOOD STABILIZERS ...... 21 MULTIPLE SCLEROSIS AGENTS ...... 21 MUSCULOSKELETAL THERAPY AGENTS ...... 21 MYASTHENIA GRAVIS ...... 21 NARCOLEPSY/CATAPLEXY ...... 21 PSYCHOTHERAPEUTIC-MISCELLANEOUS...... 21 ENDOCRINE AND METABOLIC ...... 22 ANDROGENS ...... 22 ANTIDIABETICS ...... 22 CALCIUM RECEPTOR ANTAGONISTS ...... 24 CALCIUM REGULATORS ...... 24 CONTRACEPTIVES ...... 24 ENDOMETRIOSIS ...... 25 ESTROGENS ...... 25 ESTROGEN/PROGESTINS ...... 26 GLUCOCORTICOIDS ...... 26 GLUCOSE ELEVATING AGENTS ...... 26 HUMAN GROWTH HORMONES ...... 26 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 26 INSULIN-LIKE GROWTH FACTORS ...... 26 PHOSPHATE BINDER AGENTS ...... 26 POTASSIUM-REMOVING AGENTS ...... 26 PROGESTINS ...... 26 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 27 THYROID AGENTS ...... 27 VASOPRESSINS ...... 27 MISCELLANEOUS...... 27 GASTROINTESTINAL ...... 27 ANTACIDS/COMBINATIONS ...... 27 ANTIDIARRHEALS ...... 27 ANTIEMETICS ...... 28 ANTISPASMODICS ...... 28 CHOLELITHOLYTICS...... 28 H2 RECEPTOR ANTAGONISTS ...... 28 INFLAMMATORY BOWEL DISEASE ...... 28 IRRITABLE BOWEL SYNDROME ...... 29 LAXATIVES/STOOL SOFTENERS ...... 29 PANCREATIC ENZYMES ...... 30 PROSTAGLANDINS ...... 30 PROTON PUMP INHIBITORS ...... 30 SALIVA STIMULANTS ...... 30 STEROIDS, RECTAL...... 30 MISCELLANEOUS...... 30 GENITOURINARY...... 30 BENIGN PROSTATIC HYPERPLASIA ...... 30 URINARY ANTISPASMODICS ...... 30 VAGINAL ANTI-INFECTIVES ...... 31

2 MISCELLANEOUS...... 31 HEMATOLOGIC ...... 31 ANTICOAGULANTS ...... 31 ANTIHEMOPHILIC AGENTS ...... 31 HEMATOPOIETIC GROWTH FACTORS ...... 32 PLATELET AGGREGATION INHIBITORS...... 32 PLATELET SYNTHESIS INHIBITORS ...... 32 MISCELLANEOUS...... 32 IMMUNOLOGIC AGENTS ...... 32 AUTOIMMUNE AGENTS ...... 32 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 32 IMMUNOMODULATORS ...... 32 IMMUNOSUPPRESSANTS ...... 32 VACCINES ...... 33 NUTRITIONAL/SUPPLEMENTS ...... 33 ELECTROLYTES ...... 33 VITAMINS AND MINERALS ...... 34 DIETARY PRODUCTS/NUTRITIONAL SUPPLEMENTS ...... 38 RESPIRATORY ...... 38 ANAPHYLAXIS TREATMENT AGENTS ...... 38 ANTICHOLINERGICS...... 38 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 38 ANTIHISTAMINES ...... 38 BETA AGONISTS ...... 39 COUGH AND COLD ...... 39 CYSTIC FIBROSIS ...... 40 LEUKOTRIENE MODULATORS ...... 40 MAST CELL STABILIZERS ...... 40 MEDICAL SUPPLIES...... 40 NASAL ANTIHISTAMINES ...... 41 NASAL STEROIDS ...... 41 RESPIRATORY SYNCYTIAL VIRUS ...... 41 SEVERE ASTHMA AGENTS ...... 41 STEROID/BETA AGONIST COMBINATIONS...... 41 STEROID INHALANTS ...... 41 XANTHINES ...... 41 MISCELLANEOUS...... 41 TOPICAL ...... 42 DERMATOLOGY ...... 42 MOUTH/THROAT/DENTAL AGENTS ...... 44 OPHTHALMIC ...... 44 OTIC ...... 46 NON-DISCRIMINATION STATEMENT ...... 47 INDEX ...... 49

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INTRODUCTION The Michigan Department of Health and Human Services has worked with its health plan partners to create a list of drugs that all Medicaid health plans must cover. This list is called the Michigan Medicaid Managed Care Common Formulary.

The 2019 Molina Healthcare of Michigan Preferred Drug List (Formulary) is the Michigan Medicaid Managed Care Common Formulary. We are pleased to provide this Formulary as a useful reference and informational tool. This document can assist medical providers in selecting clinically-appropriate and cost-effective products for their patients.

The drugs represented have been reviewed by a Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review.

The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. All the information in the document is provided as a reference for drug therapy selection.

The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

We assume 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. PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the Common Formulary Committee and Molina Healthcare’s Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. Both Committees' voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, general principles are noted below.

• Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. • When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. • If the OTC and Prescription versions of the product are covered, then both are listed. • Extended-release and delayed-release products require their own entry. • Dosage forms on the document will be consistent with the category and use where listed. 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 most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product to the market. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate.

Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

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• Approved by the U.S. Food and Drug Administration 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 extent compared to the brand-name drug (bioequivalence). 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 (therapeutic equivalence). PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non­ formulary prescription request criteria. Log in to www.molinahealthcare.com to check coverage. PRIOR AUTHORIZATION REQUEST PROCEDURE Prescriptions for medications requiring prior approval or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when formulary options have demonstrated ineffectiveness. When these exceptional situations arise, the physician may fax a completed drug prior authorization form to Molina at (888) 373-3059. The forms may be obtained by logging into the website www.molinahealthcare.com. Trials of pharmaceutical samples will not be considered as rationale for approving a prior authorization request. PRIOR AUTHORIZATION HELPFUL HINTS To ensure the quickest response possible from Molina Healthcare of Michigan Pharmacy Department, please provide relevant information with the Prior Authorization request. The following are examples:

Class of Medication/Diagnosis Requested Clinical Information Cholesterol Lowering Lipid Panel, Cardiovascular risk factors Diabetes A1c Report Non-Formulary/Non-Preferred Medication Medication Log and/or Progress Notes documenting previous use of Formulary medications LEGEND

AGE Age Limit OTC Over-the-counter, covered benefit with a prescription PA Prior Authorization QL Quantity Limit SP Specialty Drug; these drugs must be obtained through a specialty pharmacy ST Step Therapy 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

REQUESTING FORMULARY CHANGES If you are a prescriber and would like to request a formulary change, please submit your request and rationale to Molina’s Pharmacy Department with your contact information.

Fax: 888-373-3059

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STATE OF MICHIGAN, MEDICAID CARVE-OUT The State of Michigan enacted a carve-out for Medicaid beneficiaries. This impacts all Medicaid members including Healthy Michigan Medicaid members. Claims for these medications must be submitted directly to the State Fee-for-Service Pharmacy Program, Magellan. These medications are subject to a $1.10 or $3.30 copay. The Medicaid Carve-Out includes:

• ADHD Stimulants • Anticonvulsants • Antidepressants • Antipsychotics • Antiretroviral Agents • Benzodiazepines • Drugs to treat substance abuse disorders • Hemophilia Factor products • Hepatitis C Agents • Kinase Inhibitors • Mood Stabilizers STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST Medications on the Medicaid Carve-Out List include all dosage forms, i.e. oral, injectable, etc.

ABILIFY (aripiprazole) ATRIPLA (efavirenz-emtricitabine- CORTROSYN (cosyntropin) ABILIFY MYCITE (aripiprazole tab tenofovir disoproxil) COTELLIC (cobimetinib) with sensor) ATRYN (antithrombin) CRIXIVAN (indinavir) ACTHAR (corticotropin) BANZEL (rufinamide) CYKLOKAPRON (tranexamic acid) ACTHREL (corticorelin ovine) BELSOMRA (suvorexant) CYMBALTA (duloxetine DR) ADAGEN (pegademase bovine) BENEFIX (coagulation factor IX) CYSTADANE (betaine) ADASUVE (loxapine) BERINERT (C1 esterase inhibitor) DAKLINZA (daclatasvir) ADDERALL (amphetamine- BIKTARVY (bictegravir-emtricitabine- DALMANE (flurazepam) dextroamphetamine) tenofovir alafenamide) DAYTRANA (methylphenidate) ADDERALL XR (amphetamine- BOSULIF (bosutinib) DELSTRIGO (doravirine­lamivudine­ dextroamphetamine ER) BRISDELLE (paroxetine mesylate) tenofovir disoproxil) ADVATE (antihemophilic factor) BRIVIACT (brivaracetam) DEPACON (valproate) ADYNOVATE (antihemophilic factor) BUNAVAIL (buprenorphine-naloxone) DEPAKENE (valproic acid) ADZENYS XR-ODT (amphetamine ER) BUPHENYL (sodium phenylbutyrate) DEPAKOTE (divalproex sodium DR) AFSTYLA (antihemophilic factor) BUSPAR (buspirone) DEPAKOTE ER (divalproex sodium ER) ALBURX (albumin, human) BUTISOL (butabarbital) DESCOVY (emtricitabine- ALDURAZYME (laronidase) CABOMETYX (cabozantinib) tenofovir alafenamide) ALECENSA (alectinib) CAMPRAL (acamprosate) DESOXYN (methamphetamine) ALPHANATE (antihemophilic factor/VWF) CAPRELSA (vandetanib) DESYREL (trazodone) ALPHANINE SD (coagulation factor IX) CARBAGLU (carglumic acid) DEXEDRINE (dextroamphetamine) ALPROLIX (coagulation factor IX) CARBATROL (carbamazepine ER) DIASTAT (diazepam) ALUNBRIG (brigatinib) CARNITOR (levocarnitine) DILANTIN (phenytoin) AMBIEN (zolpidem) CELEXA (citalopram) DYANAVEL XR (amphetamine ER) AMBIEN CR (zolpidem ER) CELONTIN (methsuximide) EDURANT (rilpivirine) AMICAR (aminocaproic acid) CEPHULAC ** (lactulose) EFFEXOR (venlafaxine) AMMONUL (sodium benzoate- CEPROTIN (protein C concentrate) EFFEXOR XR (venlafaxine ER) sodium phenylacetate) CERDELGA (eliglustat) ELAPRASE (idursulfase) ANAFRANIL (clomipramine) CEREBYX (fosphenytoin) ELAVIL (amitriptyline) ANTABUSE (disulfiram) CEREDASE (alglucerase) ELELYSO (taliglucerase alfa) APLENZIN (bupropion ER) CEREZYME (imiglucerase) ELOCTATE (antihemophilic factor) APTENSIO XR (methylphenidate ER) CINRYZE (C1 esterase inhibitor) EMSAM (selegiline) APTIOM (eslicarbazepine) CLOZARIL (clozapine) EMTRIVA (emtricitabine) APTIVUS (tipranavir) COGENTIN (benztropine) EPCLUSA (sofosbuvir-velpatasvir) ARCALYST (rilonacept) COMBIVIR (lamivudine-zidovudine) EPIDIOLEX (cannabidiol) ARISTADA (aripiprazole lauroxil ER) COMETRIQ (cabozantinib) EPIVIR (lamivudine) ARTANE (trihexyphenidyl) CONCERTA (methylphenidate ER) EPZICOM (abacavir-lamivudine) ASENDIN (amoxapine) COPIKTRA (duvelisib) EQUETRO (carbamazepine ER) ATIVAN (lorazepam) CORIFACT (factor XIII concentrate) ESKALITH (lithium carbonate)

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ESKALITH CR (lithium carbonate ER) KLONOPIN (clonazepam) NOVOSEVEN (coagulation factor VIIa) ETRAFON (perphenazine-amitriptyline) KOATE-DVI (antihemophilic factor) NOVOSEVEN RT (coagulation factor VIIa) EVEKEO (amphetamine) KOGENATE FS (antihemophilic factor) NUPLAZID (pimavanserin) EVOTAZ (atazanavir-cobicistat) KUVAN (sapropterin) NUVIGIL (armodafinil) EXONDYS 51 (eteplirsen) KYPROLIS (carfilzomib) NUWIQ (antihemophilic factor) FABRAZYME (agalsidase beta) LAMICTAL (lamotrigine) OBIZUR (antihemophilic factor) FANAPT (iloperidone) LAMICTAL XR (lamotrigine ER) OCTAPLAS (plasma, human) FAZACLO (clozapine) LATUDA (lurasidone) ODEFSEY (emtricitabine-rilpivirine­ FEIBA VH (antiinhibitor coagulant LENVIMA (lenvatinib) tenofovir alafenamide) complex) LEXAPRO (escitalopram) OLEPTRO (trazodone ER) FELBATOL (felbamate) LEXIVA (fosamprenavir) ONFI (clobazam) FETZIMA (levomilnacipran) LIBRIUM (chlordiazepoxide) ORAP (pimozide) FIRDAPSE (amifampridine) LIMBITROL (amitriptyline­ ORFADIN (nitisinone) FOCALIN (dexmethylphenidate) chlordiazepoxide) ORKAMBI (lumacaftor-ivacaftor) FOCALIN XR (dexmethylphenidate ER) LIMBITROL DS (amitriptyline­ OXTELLAR XR (oxcarbazepine ER) FORFIVO XL (bupropion ER) chlordiazepoxide) PAMELOR (nortriptyline) FUZEON (enfuvirtide) LITHOBID (lithium carbonate ER) PANHEMATIN (hemin) FYCOMPA (perampanel) LITHOSTAT (acetohydroxamic acid) PARNATE (tranylcypromine) GABITRIL (tiagabine) LORBRENA (lorlatinib) PAXIL (paroxetine HCl) GALAFOLD (migalastat) LOXITANE (loxapine) PAXIL CR (paroxetine HCl ER) GENVOYA (elvitegravir-cobicistat­ LUDIOMIL (maprotiline) PEGANONE (ethotoin) emtricitabine-tenofovir alafenamide) LUMINAL (phenobarbital) PEGASYS (peginterferon alfa-2a) GEODON (ziprasidone) LUMIZYME (alglucosidase alfa) PEGINTRON (peginterferon alfa-2b) GILOTRIF (afatinib) LUNESTA (eszopiclone) PERMITAL (dimenhydrinate) GLEEVEC (imatinib) LUVOX (fluvoxamine) PERSERIS (risperidone ER injection) HAEGARDA (C1 esterase inhibitor) LUVOX CR (fluvoxamine ER) PEXEVA (paroxetine mesylate) HALCION (triazolam) LYNPARZA (olaparib) PHENYTEK (phenytoin ER) HALDOL (haloperidol) LYRICA (pregabalin) PIFELTRO (doravirine) HARVONI (ledipasvir-sofosbuvir) LYRICA CR (pregabalin ER) PLASMANATE (plasma protein fraction) HELIXATE (antihemophilic factor) LYSTEDA (tranexamic acid) POTIGA (ezogabine) HEMOFIL M (antihemophilic factor) MARPLAN (isocarboxazid) PREZCOBIX (darunavir-cobicistat) HETLIOZ (tasimelteon) MAVYRET (glecaprevir-pibrentasvir) PREZISTA (darunavir) HUMATE-P (antihemophilic factor/VFW) MEKINIST (trametinib) PRISTIQ (desvenlafaxine succinate ER) IBRANCE (palbociclib) MEKTOVI (binimetinib) PROLIXIN (fluphenazine) ICLUSIG (ponatinib) MELLARIL (thioridazine) PROSOM (estazolam) IDELVION (coagulation factor IX) METADATE CD (methylphenidate ER) PROVIGIL (modafinil) ILARIS (canakinumab) METADATE ER (methylphenidate ER) PROZAC (fluoxetine) IMBRUVICA (ibrutinib) METHYLIN (methylphenidate) PROZAC WEEKLY (fluoxetine DR) INAPSINE (droperidol) MILTOWN (meprobamate) QUDEXY XR (topiramate ER) INLYTA (axitinib) MOBAN (molindone) QUILLICHEW ER (methylphenidate INTELENCE (etravirine) MONOCLATE-P (antihemophilic factor) chew tab ER) INTERMEZZO (zolpidem) MONONINE (coagulation factor IX) QUILLIVANT XR (methylphenidate ER) INTUNIV (guanfacine ER) MYALEPT (metreleptin) RAVICTI (glycerol phenylbutyrate) INVEGA (paliperidone ER) MYDAYIS ER (amphetamine­ RECOMBINATE (antihemophilic factor) INVIRASE (saquinavir) dextroamphetamine) REMERON (mirtazapine) IRENKA (duloxetine DR) MYSOLINE (primidone) RESCRIPTOR (delavirdine) IRESSA (gefitinib) NAGLAZYME (galsulfase) RESTORIL (temazepam) ISENTRESS (raltegravir) NARDIL (phenelzine) RETROVIR (zidovudine) IXINITY (coagulation factor IX) NAVANE (thiothixene) REVCOVI (elapegademase) JIVI (antihemophilic factor, recombinant) NERLYNX (neratinib) REVIA (naltrexone) KALBITOR (ecallantide) NEURONTIN (gabapentin) REXULTI (brexpiprazole) KALETRA (lopinavir-ritonavir) NEXAVAR (sorafenib) REYATAZ (atazanavir) KALYDECO (ivacaftor) NINLARO (ixazomib) RIASTAP (fibrinogen) KAPVAY (clonidine ER) NIRAVAM (alprazolam) RIBAVIRIN (ribavirin) KEPPRA (levetiracetam) NITYR (nitisinone) RISPERDAL (risperidone) KEPPRA XR (levetiracetam ER) NORPRAMIN (desipramine) RITALIN (methylphenidate) KHEDEZLA (desvenlafaxine ER) NORTRIPTYLINE (nortriptyline solution) RITALIN LA, SR (methylphenidate ER) KINERET (anakinra) NORVIR (ritonavir) RIXUBIS (coagulation factor IX) KISQALI (ribociclib) NOVOEIGHT (antihemophilic factor) ROZEREM (ramelteon)

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RUBRACA (rucaparib) TECHNIVIE (ombitasvir-paritaprevir- VIMPAT (lacosamide) RUCONEST (C1 esterase inhibitor) ritonavir) VIRACEPT (nelfinavir) RYDAPT (midostaurin) TEGRETOL (carbamazepine) VIRAMUNE (nevirapine) SABRIL (vigabatrin) TEGRETOL XR (carbamazepine ER) VIRAMUNE XR (nevirapine ER) SAPHRIS (asenapine) THORAZINE (chlorpromazine) VIREAD (tenofovir disoproxil) SARAFEM (fluoxetine HCl) THROMBATE III (antithrombin III) VIVACTIL (protriptyline) SECONAL (secobarbital) TIVICAY (dolutegravir) VIVITROL (naltrexone ER) SELZENTRY (maraviroc) TOFRANIL (imipramine HCl) VIZIMPRO (dacomitinib) SERAX (oxazepam) TOFRANIL-PM (imipramine pamoate) VONVENDI (Von Willebrand factor) SEROQUEL (quetiapine) TOPAMAX (topiramate) VOSEVI (sofosbuvir-velpatasvir- SEROQUEL XR (quetiapine ER) TRANXENE (clorazepate) voxilaprevir) SERZONE (nefazodone) TRETTEN (coagulation factor XIII A- VOTRIENT (pazopanib) SILENOR (doxepin) subunit) VPRIV (velaglucerase alfa) SINEQUAN (doxepin) TRIAVIL (perphenazine-amitriptyline) VRAYLAR (cariprazine) SOLIRIS (eculizumab) TRILAFON (perphenazine) VYVANSE (lisdexamfetamine) SONATA (zaleplon) TRILEPTAL (oxcarbazepine) WELLBUTRIN (bupropion) SPRITAM (levetiracetam) TRINTELLIX (vortioxetine) WELLBUTRIN SR, XL (bupropion ER) SPRYCEL (dasatinib) TRIUMEQ (abacavir-dolutegravir- WILATE (antihemophilic factor/VFW) STELAZINE (trifluoperazine) lamivudine) XALKORI (crizotinib) STIVARGA (regorafenib) TRIZIVIR (abacavir-lamivudine- XANAX (alprazolam) STRATTERA (atomoxetine) zidovudine) XANAX XR (alprazolam ER) STRIBILD (elvitegravir-cobicistat- TROKENDI XR (topiramate ER) XOSPATA (gilteritinib) emtricitabine-tenofovir disoproxil) TRUVADA (emtricitabine- XYNTHA (antihemophilic factor) SUBOXONE (buprenorphine-naloxone) tenofovir disoproxil) ZARONTIN (ethosuximide) SUBUTEX (buprenorphine) TYBOST (cobicistat) ZAVESCA (miglustat) SURMONTIL (trimipramine) TYKERB (lapatinib) ZEJULA (niraparib) SUSTIVA (efavirenz) VALIUM (diazepam) ZELBORAF (vemurafenib) SUTENT (sunitinib) VANSPAR (buspirone) ZENZEDI (dextroamphetamine) SYMBYAX (olanzapine-fluoxetine) VELCADE (bortezomib) ZEPATIER (elbasvir-grazoprevir) SYMDEKO (tezacaftor-ivacaftor) VERSACLOZ (clozapine) ZERIT (stavudine) SYMTUZA (darunavir-cobicistat- VERZENIO (abemaciclib) ZIAGEN (abacavir) emtricitabine-tenofovir alafenamide) VIDEX (didanosine) ZOLOFT (sertraline) TAFINLAR (dabrafenib) VIDEX EC(didanosine DR) ZOLPIMIST (zolpidem tartrate) TAGRISSO (osimertinib) VIEKIRA (ombitasvir-paritaprevir- ZONEGRAN (zonisamide) TAKHZYRO (lanadelumab-flyo) ritonavir + dasabuvir) ZUBSOLV (buprenorphine-naloxone) TALZENNA (talazoparib) VIEKIRA XR (dasabuvir-ombitasvir- ZYDELIG (idelalisib) TARCEVA (erlotinib) paritaprevir-ritonavir ER) ZYKADIA (ceritinib) TASIGNA (nilotinib) VIIBRYD (vilazodone) ZYPREXA (olanzapine) VIMIZIM (elosulfase alfa)

** CEPHULAC (lactulose) is carved out for the treatment of Hepatic Encephalopathy only NON-COVERED MEDICATIONS Please note that certain medications are not covered. These may include, but are not limited to:

• Medications for Cosmetic Purposes • Experimental or Investigational Medications • Convenience Dosage Forms (Transdermal Patches), not listed in the Formulary • Fertility Drugs • Sexual Dysfunction Drugs • OTC Medications not listed on the Formulary • Medications used for non-FDA approved indications, unless approved by Medical Director NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

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FORMULARY UPDATES Please review the formulary changes which pertain to the Pharmacy Benefit unless denoted otherwise. If you have questions, contact Molina Health Plan's Pharmacy Help Desk.

Key

AL= Age Limit ST= Step Therapy OTC= Over the Counter PA= Prior Authorization

PA, QL= Quantity Limit is SP= Specialty Drugs; these drugs must applied after Prior QL= Quantity Limit be obtained through a specialty

Authorization approval pharmacy

Date Product Name Change Comments 10/1/19 ADEFOVIR DIPIVOXIL 10 MG TAB Add QL of Max #30/month 10/1/19 CIPROFLOXACIN HCL 100 MG TAB Removed from formulary 10/1/19 ECONAZOLE NITRATE 1% CREAM Removed from formulary

10/1/19 ENTECAVIR 0.5 MG TABLET Add QL of Max #30/month

10/1/19 ENTECAVIR 1 MG TABLET Add QL of Max #30/month Add to formulary with PA required, Minimum Age 10/1/19 KRINTAFEL 150 MG TABLET 16, Max #2/year 10/1/19 LAMIVUDINE 100 MG TABLET Add QL of Max #30/month

10/1/19 LAMIVUDINE HBV 100 MG TABLET Add QL of Max #30/month

Add to formulary with PA required, Minimum Age 10/1/19 SPIRIVA RESPIMAT 1.25 MCG INH 6, Max #1 inhaler/month 10/1/19 SYMJEPI 0.3 MG/0.3 ML SYRINGE Add to formulary, Max #2 pens/3 months

10/1/19 TETRACYCLINE 250 MG CAPSULE Removed from formulary

10/1/19 TETRACYCLINE 500 MG CAPSULE Removed from formulary

Requires trial of OTC Differin 10/1/19 TRETINOIN 0.025% CREAM Add to formulary with step therapy 0.1% Gel 10/1/19 TUDORZA PRESSAIR Removed from formulary

10/1/19 CERVICAL CAP Add to formulary

10/1/19 ENALAPRIL MALEATE TAB 10 MG Change QL to #60/month

10/1/19 LISINOPRIL TAB 10 MG Change QL to #60/month

10/1/19 FOSINOPRIL SODIUM TAB 20 MG Change QL to #60/month

10/1/19 BENAZEPRIL HCL TAB 10 MG Change QL to #60/month

9

ANALGESICS NSAIDs aspirin buffered 325 mg OTC, AGE Covered for ages 40-79 years old BUFFERIN aspirin chew tabs 81 mg OTC, QL Max #30/month aspirin delayed-rel 81 mg OTC, QL Max #30/month aspirin delayed-rel 325 mg OTC, AGE, QL Covered for ages 40-79 years old; Max #30/month aspirin supp 300 mg, 600 mg OTC aspirin tabs 325 mg OTC, AGE, QL Covered for ages 40-79 years old; Max #30/month choline magnesium trisalicylate liq diclofenac sodium delayed-rel diclofenac sodium ext-rel etodolac QL Max #60/month flurbiprofen ibuprofen caps OTC, QL Max #60/month ibuprofen chew tabs, tabs OTC ibuprofen drops 50 mg/1.25 mL OTC ibuprofen susp 100 mg/5 mL QL Max #480 mL/month ibuprofen susp 100 mg/5 mL OTC, QL Max #480 mL/month ibuprofen tabs indomethacin caps AGE Covered for ages 64 years old & under indomethacin ext-rel AGE Covered for ages 64 years old & under ketorolac tabs AGE Covered for ages 64 years old & under meloxicam tabs QL Max #30/month MOBIC nabumetone QL Max #60/month naproxen delayed-rel EC-NAPROSYN naproxen sodium caps OTC ALEVE naproxen sodium tabs OTC, QL Max #90/month ALEVE naproxen susp PA, AGE Covered for ages 12 years old & under NAPROSYN naproxen tabs NAPROSYN piroxicam QL Max #30/month FELDENE sulindac

NSAIDs, TOPICAL diclofenac sodium gel 1% QL Max #100 grams/month

COX-2 INHIBITORS celecoxib QL Max #30/month CELEBREX

GOUT allopurinol 100 mg QL Max #90/month ZYLOPRIM allopurinol 300 mg QL Max #30/month ZYLOPRIM colchicine caps QL Max #60/month MITIGARE colchicine tabs QL Max #60/month COLCRYS colchicine/probenecid febuxostat PA, QL Max #30/month ULORIC probenecid

OPIOID ANALGESICS butalbital/acetaminophen/caffeine/codeine 50/325/40/30 mg QL Max #240/month butalbital/aspirin/caffeine/codeine 50/325/40/30 mg QL Max #240/month codeine sulfate QL Max #90/month codeine/acetaminophen soln 12 mg/120 mg/5 mL QL Max #240 mL/month TYLENOL w/CODEINE codeine/acetaminophen tabs QL Max #180/month TYLENOL w/CODEINE fentanyl transdermal 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, Max #10/month DURAGESIC 100 mcg/hr PA, QL

10 hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg QL Max #180/month NORCO hydrocodone/acetaminophen soln 7.5/325 mg/15 mL QL Max #480 mL/month hydromorphone soln 1 mg/mL QL Max #960 mL/month DILAUDID hydromorphone supp QL Max #120/month hydromorphone tabs 2 mg, 4 mg QL Max #240/month DILAUDID meperidine soln AGE, QL Covered for ages 64 years old & under; Max #300 mL/month meperidine tabs AGE, QL Covered for ages 64 years old & under; Max #30/month methadone conc 10 mg/mL QL Max #240 mL/month methadone soln 5 mg/5 mL QL Max #900 mL/month methadone soln 10 mg/5 mL QL Max #600 mL/month methadone tabs 5 mg, 10 mg QL Max #240/month morphine sulfate ext-rel tabs QL Max #60/month MS CONTIN morphine sulfate oral soln QL Max #240 mL/month morphine sulfate tabs QL Max #120/month oxycodone soln 5 mg/5 mL QL Max #600 mL/month oxycodone tabs 5 mg QL Max #120/month ROXICODONE oxycodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg QL Max #180/month PERCOCET pentazocine/naloxone QL Max #360/month tramadol QL Max #240/month ULTRAM

NON-OPIOID ANALGESICS acetaminophen caps 500 mg OTC, QL Max #240/month acetaminophen chew tabs 80 mg OTC, QL Max #1500/month acetaminophen ext-rel 650 mg OTC, QL Max #180/month acetaminophen liq, soln, susp 160 mg/5 mL OTC, QL Max #3750 mL/month TYLENOL acetaminophen orally disintegrating tabs 80 mg OTC, QL Max #1500/month acetaminophen orally disintegrating tabs 160 mg OTC, QL Max #750/month acetaminophen supp 120 mg OTC, QL Max #90/month acetaminophen supp 325 mg OTC, QL Max #360/month acetaminophen supp 650 mg OTC, QL Max #180/month acetaminophen tabs 325 mg, 500 mg OTC, QL Max #240/month TYLENOL butalbital/acetaminophen 50/325 mg AGE, QL Covered for ages 10-64 years old; Max #120/month butalbital/acetaminophen/caffeine 50/325/40 mg AGE, QL Covered for ages 10-64 years old; Max ESGIC #120/month butalbital/aspirin/caffeine AGE, QL Covered for ages 64 years old & under; FIORINAL Max #120/month

VISCOSUPPLEMENTS sodium hyaluronate PA, SP EUFLEXXA

ANTI-INFECTIVES ANTIBACTERIALS Aminoglycosides neomycin paromomycin

Cephalosporins First Generation cefadroxil caps, tabs cefadroxil susp AGE Covered for ages 12 years old & under cephalexin caps 250 mg, 500 mg KEFLEX cephalexin susp AGE Covered for ages 12 years old & under

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Second Generation cefaclor caps cefaclor susp AGE Covered for ages 12 y ears oldr & unde cefprozil susp AGE Covered for ages 12 years old & under cefprozil tabs cefuroxime axetil tabs

Third Generation cefdinir caps cefdinir susp AGE Covered for ages 12 years old & under cefixime caps SUPRAX cefixime susp 100 mg/5 mL, 200 mg/5 mL AGE Covered for ages 12 years old & under SUPRAX cefixime susp 500 mg/5 mL AGE Covered for ages 12 years old & under SUPRAX cefpodoxime susp AGE Covered for ages 12 years old & under cefpodoxime tabs

Erythromycins/Macrolides azithromycin powder packets, tabs ZITHROMAX azithromycin susp AGE Covered for ages 12 years old & under ZITHROMAX clarithromycin susp AGE Covered for ages 12 years old & under clarithromycin tabs

Fluoroquinolones ciprofloxacin susp AGE Covered for ages 12 years old & under CIPRO ciprofloxacin tabs 250 mg, 500 mg, 750 mg CIPRO levofloxacin oral soln AGE Covered for ages 12 years old & under levofloxacin tabs LEVAQUIN ofloxacin

Penicillins amoxicillin caps, tabs amoxicillin chew tabs, susp AGE Covered for ages 12 years old & under amoxicillin/clavulanate chew tabs, susp AGE Covered for ages 12 years old & under amoxicillin/clavulanate ext-rel AUGMENTIN XR amoxicillin/clavulanate tabs AUGMENTIN ampicillin caps ampicillin susp AGE Covered for ages 12 years old & under dicloxacillin penicillin VK soln AGE Covered for ages 12 years old & under penicillin VK tabs

Sulfonamides sulfamethoxazole/trimethoprim BACTRIM sulfamethoxazole/trimethoprim susp SULFATRIM

Tetracyclines doxycycline hyclate tabs 100 mg doxycycline monohydrate 50 mg, 100 mg doxycycline monohydrate susp AGE Covered for ages 12 years old & under VIBRAMYCIN minocycline caps MINOCIN

ANTIFUNGALS fluconazole susp AGE Covered for ages 12 years old & under DIFLUCAN fluconazole tabs DIFLUCAN griseofulvin microsize susp griseofulvin ultramicrosize itraconazole caps SPORANOX ketoconazole tabs 200 mg QL Max #60/month

12 nystatin susp nystatin tabs terbinafine tabs QL Max #30/month

ANTIMALARIALS chloroquine QL Max #30/month mefloquine PA primaquine PRIMAQUINE tafenoquine PA, AGE, QL Covered for ages 16 years old & older; KRINTAFEL Max #2/year

ANTIRETROVIRAL AGENTS Antiretroviral Agents are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

ANTITUBERCULAR AGENTS cycloserine ethambutol MYAMBUTOL ethionamide TRECATOR isoniazid syrup AGE Covered for ages 12 years old & under isoniazid tabs pyrazinamide rifampin RIFADIN

ANTIVIRALS Cytomegalovirus Agents valganciclovir tabs PA, QL Max #60/month VALCYTE

Hepatitis Agents Hepatitis B adefovir dipivoxil QL Max #30/month HEPSERA entecavir tabs QL Max #30/month BARACLUDE lamivudine tabs 100 mg QL Max #30/month EPIVIR-HBV tenofovir alafenamide PA, QL Max #30/month VEMLIDY

Hepatitis C Hepatitis C Agents are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

Herpes Agents acyclovir caps, tabs QL Max #150/month ZOVIRAX acyclovir susp AGE Covered for ages 12 years old & under ZOVIRAX famciclovir QL Max #90/month valacyclovir 1 gram QL Max #90/month VALTREX valacyclovir 500 mg QL Max #30/month VALTREX

Influenza Agents oseltamivir caps QL Max #10/fill; Max #20/6 months TAMIFLU oseltamivir susp AGE, QL Covered for ages 12 years old & under; TAMIFLU Max #120 mL/fill; Max 240 mL/6 months rimantadine FLUMADINE zanamivir AGE, QL Covered for ages 5 years old & older; RELENZA Max #20/6 months

MISCELLANEOUS atovaquone PA MEPRON benznidazole PA BENZNIDAZOLE clindamycin caps CLEOCIN

13 clindamycin soln AGE Covered for ages 12 years old & under CLEOCIN dapsone ivermectin STROMECTOL linezolid susp, tabs PA ZYVOX metronidazole tabs FLAGYL nitrofurantoin ext-rel AGE, QL Covered for ages 64 years old & under; MACROBID Max #60/month nitrofurantoin macrocrystals 50 mg, 100 mg AGE, QL Covered for ages 64 years old & under; MACRODANTIN Max #60/month nitrofurantoin susp AGE Covered for ages 12 years old & under FURADANTIN pyrantel OTC REESES PINWORM MEDICINE pyrimethamine PA DARAPRIM rifabutin MYCOBUTIN tinidazole trimethoprim tabs vancomycin inj vancomycin oral soln FIRVANQ

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS altretamine PA HEXALEN busulfan PA MYLERAN chlorambucil PA LEUKERAN cyclophosphamide caps PA CYCLOPHOSPHAMIDE estramustine PA Males only EMCYT melphalan PA ALKERAN temozolomide PA, SP TEMODAR

ANTIMETABOLITES capecitabine PA, SP XELODA mercaptopurine tabs methotrexate inj 25 mg/mL, 250 mg/10 mL, 1 gram/40 mL methotrexate oral soln PA XATMEP methotrexate tabs 2.5 mg thioguanine PA TABLOID

CYTOPROTECTIVE AGENTS leucovorin calcium tabs

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens abiraterone PA YONSA abiraterone 250 mg PA, QL, SP Males only; Max #120/month ZYTIGA abiraterone 500 mg PA, QL, SP Males only; Max #60/month ZYTIGA apalutamide PA, QL, SP Max #120/month ERLEADA bicalutamide PA Males only CASODEX enzalutamide PA, QL, SP Males only; Max #120/month XTANDI flutamide PA Males only nilutamide PA NILANDRON

Antiestrogens tamoxifen tabs QL Females only; Max #60/month toremifene PA FARESTON

Aromatase Inhibitors anastrozole Females only ARIMIDEX

14 exemestane AROMASIN letrozole AGE, QL Covered for ages 18 years & older; Max FEMARA #30/month

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists goserelin acetate PA, SP ZOLADEX leuprolide acetate inj 1 mg/0.2 mL PA, SP

Progestins megestrol acetate tabs Females only

IMMUNOMODULATORS lenalidomide PA, SP REVLIMID pomalidomide PA, SP POMALYST thalidomide PA, SP THALOMID

KINASE INHIBITORS Kinase Inhibitors are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. encorafenib PA BRAFTOVI everolimus PA, QL, SP AFINITOR everolimus soluble tabs PA, QL, SP AFINITOR DISPERZ ruxolitinib PA, QL, SP Max #60/month JAKAFI

TOPOISOMERASE INHIBITORS topotecan caps PA HYCAMTIN

MISCELLANEOUS bexarotene caps PA, SP TARGRETIN enasidenib PA, SP IDHIFA etoposide PA glasdegib maleate PA, SP DAURISMO hydroxyurea DROXIA hydroxyurea HYDREA ivosidenib PA, QL, SP Max #60/month TIBSOVO mesna PA MESNEX mitotane PA LYSODREN panobinostat PA, SP FARYDAK procarbazine PA MATULANE sonidegib PA, SP ODOMZO tretinoin caps PA trifluridine/tipiracil PA, SP LONSURF venetoclax PA, SP VENCLEXTA vismodegib PA, QL, SP Max #30/month ERIVEDGE vorinostat PA, SP ZOLINZA

CARDIOVASCULAR ACE INHIBITORS benazepril 5 mg, 20 mg QL Max #45/month LOTENSIN benazepril 10 mg, 40 mg QL Max #60/month LOTENSIN enalapril 2.5 mg, 5 mg QL Max #45/month VASOTEC enalapril 10 mg, 20 mg QL Max #60/month VASOTEC enalapril oral soln AGE Covered for ages 12 years old & under EPANED fosinopril 10 mg QL Max #45/month fosinopril 20 mg, 40 mg QL Max #60/month lisinopril 2.5 mg, 5 mg, 20 mg QL Max #45/month ZESTRIL

15 lisinopril 10 mg, 30 mg, 40 mg QL Max #60/month ZESTRIL lisinopril oral soln AGE Covered for ages 12 years old & under QBRELIS perindopril 2 mg, 4 mg QL Max #45/month quinapril 5 mg, 10 mg, 20 mg QL Max #30/month ACCUPRIL quinapril 40 mg QL Max #60/month ACCUPRIL ramipril QL Max #30/month ALTACE trandolapril QL Max #30/month

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine QL Max #30/month LOTREL

ACE INHIBITOR/DIURETIC COMBINATIONS enalapril/hydrochlorothiazide QL Max #60/month VASERETIC lisinopril/hydrochlorothiazide QL Max #60/month ZESTORETIC quinapril/hydrochlorothiazide ACCURETIC

ADRENOLYTICS, CENTRAL clonidine tabs CATAPRES guanfacine QL Max #60/month methyldopa AGE Covered for ages 64 years old & under

ADRENOLYTICS, CENTRAL/DIURETIC COMBINATIONS methyldopa/hydrochlorothiazide

ALDOSTERONE RECEPTOR ANTAGONISTS spironolactone QL Max #60/month ALDACTONE

ALPHA BLOCKERS doxazosin 1 mg, 2 mg, 4 mg QL Max #30/month CARDURA doxazosin 8 mg QL Max #60/month CARDURA prazosin QL Max #60/month MINIPRESS terazosin 1 mg, 5 mg QL Max #30/month terazosin 2 mg, 10 mg QL Max #60/month

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/valsartan EXFORGE

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS irbesartan QL Max #30/month AVAPRO irbesartan/hydrochlorothiazide QL Max #30/month AVALIDE losartan QL Max #30/month COZAAR losartan/hydrochlorothiazide QL Max #30/month HYZAAR valsartan 40 mg, 80 mg, 160 mg QL Max #60/month DIOVAN valsartan 320 mg QL Max #30/month DIOVAN valsartan/hydrochlorothiazide QL Max #30/month DIOVAN HCT

ANTIARRHYTHMICS amiodarone disopyramide AGE Covered for ages 64 years old & under NORPACE flecainide mexiletine propafenone quinidine sulfate sotalol QL Max #60/month BETAPACE, BETAPACE AF

ANTILIPEMICS Bile Acid Resins cholestyramine cans QL Max #378 grams/month QUESTRAN

16 cholestyramine cans QL Max #239.4 grams/month QUESTRAN LIGHT cholestyramine packets QL Max #60 packets/month QUESTRAN, QUESTRAN LIGHT colestipol granules, tabs COLESTID

Cholesterol Absorption Inhibitors ezetimibe PA, QL Max #30/month ZETIA

Fibrates fenofibrate caps 50 mg QL Max #30/month LIPOFEN fenofibrate tabs 48 mg, 145 mg QL Max #30/month TRICOR fenofibrate tabs 54 mg, 160 mg QL Max #30/month fenofibrate micronized 43 mg QL Max #30/month fenofibrate micronized 67 mg, 134 mg, 200 mg QL Max #30/month fenofibric acid QL Max #30/month FIBRICOR fenofibric acid delayed-rel QL Max #30/month TRILIPIX gemfibrozil QL Max #60/month LOPID

HMG-CoA Reductase Inhibitors atorvastatin QL Max #30/month LIPITOR lovastatin QL Max #30/month pravastatin QL Max #30/month PRAVACHOL rosuvastatin QL Max #30/month CRESTOR simvastatin QL Max #30/month ZOCOR

Omega-3 Fatty Acids omega-3 acid ethyl esters PA LOVAZA

BETA-BLOCKERS acebutolol atenolol betaxolol bisoprolol 5 mg QL Max #45/month bisoprolol 10 mg QL Max #60/month carvedilol COREG labetalol TRANDATE metoprolol succinate ext-rel 25 mg, 50 mg, 100 mg QL Max #45/month TOPROL-XL metoprolol succinate ext-rel 200 mg QL Max #60/month TOPROL-XL metoprolol tartrate QL Max #90/month LOPRESSOR nadolol CORGARD propranolol QL Max #120/month propranolol ext-rel 60 mg QL Max #120/month INDERAL LA propranolol ext-rel 80 mg QL Max #90/month INDERAL LA propranolol ext-rel 120 mg, 160 mg QL Max #60/month INDERAL LA propranolol oral soln HEMANGEOL

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone bisoprolol/hydrochlorothiazide 2.5 mg/6.25 mg, 5 mg/6.25 mg QL Max #45/month ZIAC bisoprolol/hydrochlorothiazide 10 mg/6.25 mg QL Max #60/month ZIAC

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine QL Max #30/month NORVASC felodipine ext-rel 2.5 mg, 5 mg QL Max #30/month felodipine ext-rel 10 mg QL Max #60/month isradipine QL Max #60/month nicardipine QL Max #30/month

17 nifedipine AGE, QL Covered for ages 64 years old & under; PROCARDIA Max #120/month nifedipine ext-rel 30 mg QL Max #30/month PROCARDIA XL nifedipine ext-rel 30 mg, 60 mg QL Max #30/month ADALAT CC nifedipine ext-rel 60 mg, 90 mg QL Max #60/month PROCARDIA XL nifedipine ext-rel 90 mg QL Max #60/month ADALAT CC nimodipine caps

Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel caps QL Max #60/month Dilt-XR diltiazem ext-rel caps QL Max #30/month TIAZAC diltiazem ext-rel caps 120 mg, 240 mg, 300 mg QL Max #30/month CARDIZEM CD diltiazem ext-rel caps 180 mg QL Max #60/month CARDIZEM CD diltiazem ext-rel tabs 180 mg, 300 mg QL Max #30/month CARDIZEM LA verapamil CALAN verapamil ext-rel caps QL Max #30/month VERELAN PM verapamil ext-rel caps 120 mg, 180 mg, 240 mg QL Max #30/month VERELAN verapamil ext-rel tabs QL Max #30/month CALAN SR

DIGITALIS GLYCOSIDES digoxin tabs 125 mcg, 250 mcg LANOXIN

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren PA, QL Max #30/month TEKTURNA

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide QL Max #120/month acetazolamide ext-rel QL Max #60/month

Loop Diuretics bumetanide furosemide soln AGE Covered for ages 12 years old & under furosemide tabs QL Max #60/month LASIX torsemide 5 mg, 100 mg QL Max #60/month DEMADEX torsemide 10 mg, 20 mg QL Max #120/month DEMADEX

Potassium-sparing Diuretics amiloride QL Max #30/month

Thiazides and Thiazide-like Diuretics chlorothiazide oral susp AGE Covered for ages 12 years old & under DIURIL chlorothiazide tabs chlorthalidone 25 mg, 50 mg QL Max #120/month hydrochlorothiazide indapamide QL Max #30/month methyclothiazide metolazone QL Max #30/month ZAROXOLYN

Diuretic Combinations amiloride/hydrochlorothiazide QL Max #60/month spironolactone/hydrochlorothiazide 25 mg/25 mg QL Max #90/month ALDACTAZIDE triamterene/hydrochlorothiazide caps DYAZIDE triamterene/hydrochlorothiazide tabs MAXZIDE

NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS sacubitril/valsartan ST, QL Requires 30-day trial of high-dose ACE ENTRESTO

18

Inhibitor or Angiotensin II Receptor Antagonist; Max #60/mo

NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide dinitrate tabs ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel QL Max #60/month nitroglycerin ext-rel NITRO-TIME

Sublingual/Translingual nitroglycerin lingual spray ST Requires trial of nitroglycerin sublingual NITROLINGUAL or previous use of nitroglycerin lingual spray nitroglycerin sublingual NITROSTAT

Transdermal nitroglycerin oint NITRO-BID nitroglycerin transdermal 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Max #30/month NITRO-DUR QL

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists ambrisentan PA, QL, SP Max #30/month LETAIRIS bosentan soluble tabs AGE, PA, SP Covered for ages 3 to 12 years old TRACLEER bosentan tabs PA, QL, SP Max #60/month TRACLEER

Phosphodiesterase Inhibitors sildenafil PA, SP REVATIO tadalafil PA, QL, SP Max #60/month ADCIRCA

Soluble Guanylate Cyclase Stimulators riociguat PA, QL, SP Max #90/month ADEMPAS

MISCELLANEOUS hydralazine 10 mg, 25 mg, 50 mg QL Max #120/month hydralazine 100 mg QL Max #90/month hydralazine inj midodrine QL Max #90/month minoxidil ranolazine ext-rel PA, QL Max #60/month RANEXA

CENTRAL NERVOUS SYSTEM ANTIANXIETY Benzodiazepines Benzodiazepines are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

ANTICONVULSANTS Anticonvulsants are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

ANTIDEMENTIA donepezil tabs 5 mg AGE, QL Covered for ages 40 years & older; Max ARICEPT #30/month donepezil tabs 10 mg AGE, QL Covered for ages 40 years & older; Max ARICEPT #60/month

19 memantine tabs AGE, QL Covered for ages 40 years & older; Max NAMENDA #60/month memantine titration pak AGE, QL Covered for ages 40 years & older; Max NAMENDA PAK #1 pak/year rivastigmine caps AGE, QL Covered for ages 40 years & older; Max #60/month

ANTIDEPRESSANTS Antidepressants are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

ANTIPARKINSONIAN AGENTS Drugs in this category may be carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. amantadine caps QL Max #120/month amantadine syp QL Max #1200 mL/month bromocriptine 2.5 mg QL Max #180/month PARLODEL bromocriptine 5 mg QL Max #90/month PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR carbidopa/levodopa orally disintegrating tabs pramipexole 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg QL Max #90/month MIRAPEX pramipexole 1.5 mg QL Max #30/month MIRAPEX ropinirole QL Max #90/month REQUIP selegiline caps QL Max #60/month ELDEPRYL

ANTIPSYCHOTICS Antipsychotics are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADHD Stimulants are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

FIBROMYALGIA Fibromyalgia Agents are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

HYPNOTICS Drugs in this category may be carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. midazolam inj 5 mg/mL QL, * Max #4 mL/month

* Midazolam inj 5 mg/mL is not carved-out.

MIGRAINE Monoclonal Antibodies erenumab-aooe 70 mg AGE, PA, QL Covered for ages 19 years & over; Max AIMOVIG #1/month erenumab-aooe 140 mg AGE, PA, QL Covered for ages 19 years & over; Max AIMOVIG #2/60 days

Selective Serotonin Agonists naratriptan QL Max #9/month AMERGE rizatriptan orally disintegrating tabs QL Max #9/month MAXALT-MLT rizatriptan tabs QL Max #9/month MAXALT

20 sumatriptan auto-injectors, cartridges, vials PA, QL Max #8 inj/month IMITREX sumatriptan nasal spray PA, QL Max #1 mL/month IMITREX sumatriptan tabs QL Max #9/month IMITREX zolmitriptan orally disintegrating tabs ST, QL Requires trial of two of naratriptan, ZOMIG ZMT rizatriptan or sumatriptan; Max #9/month zolmitriptan tabs ST, QL Requires trial of two of naratriptan, ZOMIG rizatriptan or sumatriptan; Max #9/month

MOOD STABILIZERS Mood Stabilizers are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

MULTIPLE SCLEROSIS AGENTS dalfampridine ext-rel AGE, PA, QL, SP Covered for ages 18-70 years; Max AMPYRA #60/month dimethyl fumarate delayed-rel caps PA, SP TECFIDERA dimethyl fumarate delayed-rel starter pack PA, SP TECFIDERA STARTER PACK fingolimod PA, SP GILENYA glatiramer PA, SP COPAXONE interferon beta-1a PA, QL, SP Max #4 inj/month AVONEX

MUSCULOSKELETAL THERAPY AGENTS baclofen 10 mg QL Max #90/month baclofen 20 mg chlorzoxazone 500 mg AGE Covered for ages 18-64 years old cyclobenzaprine 5 mg, 10 mg AGE Covered for ages 15-64 years old methocarbamol AGE Covered for ages 16-64 years old ROBAXIN orphenadrine ext-rel AGE, QL Covered for ages 18-64 years old; Max #60/month tizanidine tabs AGE Covered for ages 18 years & older ZANAFLEX

MYASTHENIA GRAVIS pyridostigmine tabs 60 mg MESTINON

NARCOLEPSY/CATAPLEXY Drugs in this category may be carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. sodium oxybate PA, QL Max #540mL/month XYREM

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents Alcohol Deterrents are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

Opioid Antagonists Drugs in this category may be carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. naloxone inj QL Max #2 inj/90 days naloxone nasal spray QL Max #2/90 days NARCAN

Smoking Deterrents bupropion ext-rel QL Max #60/month ZYBAN nicotine inhaler QL Max #1 box/month NICOTROL nicotine nasal spray QL Max #10 mL/month NICOTROL NS

21 nicotine polacrilex gum 2 mg OTC, QL Max #900/month NICORETTE nicotine polacrilex gum 4 mg OTC, QL Max #720/month NICORETTE nicotine polacrilex lozenge OTC, QL Max #600/month NICORETTE nicotine transdermal OTC, QL Max #56/56 days NICODERM CQ varenicline QL Max #60/month; Max of two 12-week CHANTIX courses per year

ENDOCRINE AND METABOLIC ANDROGENS testosterone cypionate Males only DEPO-TESTOSTERONE

ANTIDIABETICS Alpha-glucosidase Inhibitors acarbose 25 mg, 50 mg QL Max #90/month PRECOSE acarbose 100 mg QL Max #120/month PRECOSE

Biguanides metformin 500 mg QL Max #90/month GLUCOPHAGE metformin 850 mg QL Max #90/month GLUCOPHAGE metformin 1000 mg QL Max #60/month GLUCOPHAGE metformin ext-rel 500 mg, 750 mg GLUCOPHAGE XR

Biguanide/Sulfonylurea Combinations glipizide/metformin glyburide/metformin tabs 1.25/250 mg QL Max #60/month glyburide/metformin tabs 2.5/500 mg, 5/500 mg

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin ST, QL Requires 3 month trial of metformin NESINA 1500 mg/day; Max #30/month linagliptin PA, QL Max #30/month TRADJENTA sitagliptin phosphate PA, QL Max #30/month JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations alogliptin/metformin ST, QL Requires 3 month trial of metformin KAZANO 1500 mg/day; Max #60/month linagliptin/metformin PA, QL Max #60/month JENTADUETO sitagliptin/metformin PA, QL Max #60/month JANUMET sitagliptin/metformin ext-rel PA, QL Max #30/month JANUMET XR

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/pioglitazone ST, QL Requires 3 month trial of metformin OSENI 1500 mg/day; Max #30/month

Incretin Mimetic Agents liraglutide PA, QL Max #9mL/month VICTOZA semaglutide 0.25 mg, 0.5 mg PA, QL Max #1.5 mL/month OZEMPIC semaglutide 1 mg PA, QL Max #3 mL/month OZEMPIC

Insulins * * Insulin vials are preferred. Insulin pens are covered only for ages 21 years and under. Prior authorization is available for members with documented retinopathy and neuropathy. insulin aspart protamine/insulin aspart pens AGE, QL Covered for ages 21 years & under; NOVOLOG MIX FLEXPEN Max #60 mL/month insulin aspart protamine/insulin aspart vials QL Max #60 mL/month NOVOLOG MIX insulin glargine pens QL Max #60 mL/month BASAGLAR KWIKPEN insulin human vials OTC, QL Max #60 mL/month HUMULIN R, NOVOLIN R

22 insulin human vials PA, QL Max #20 mL/month HUMULIN R U-500 insulin isophane human 70%/regular 30% pens OTC, AGE, QL Covered for ages 21 years & under; HUMULIN 70/30 KWIKPEN Max #60 mL/month insulin isophane human 70%/regular 30% vials OTC, QL Max #60 mL/month HUMULIN 70/30, NOVOLIN 70/30 insulin isophane human pens OTC, AGE, QL Covered for ages 21 years & under; HUMULIN N KWIKPEN Max #60 mL/month insulin isophane human vials OTC, QL Max #60 mL/month HUMULIN N, NOVOLIN N insulin lispro pens AGE, QL Covered for ages 21 years & under; ADMELOG SOLOSTAR Max #60 mL/month insulin lispro protamine/insulin lispro pens AGE, QL Covered for ages 21 years & under; HUMALOG MIX KWIKPEN Max #60 mL/month insulin lispro protamine/insulin lispro vials QL Max #60 mL/month HUMALOG MIX insulin lispro vials QL Max #60 mL/month ADMELOG insulin lispro vials PA, QL Max #30 mL/month HUMALOG

Insulin Sensitizers pioglitazone QL Max #30/month ACTOS

Meglitinides nateglinide QL Max #90/month STARLIX repaglinide QL Max #120/month PRANDIN

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors canagliflozin PA, QL Max #30/month INVOKANA empagliflozin PA, QL Max #30/month JARDIANCE ertugliflozin PA STEGLATRO

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations canagliflozin/metformin PA, QL Max #60/month INVOKAMET canagliflozin/metformin ext-rel PA, QL Max #60/month INVOKAMET XR empagliflozin/metformin PA, QL Max #60/month SYNJARDY empagliflozin/metformin ext-rel PA, QL Max #30/month SYNJARDY XR ertugliflozin/metformin PA SEGLUROMET

Sulfonylureas chlorpropamide AGE Covered for ages 64 years old & under glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL glyburide glyburide, micronized GLYNASE tolazamide tolbutamide

Supplies alcohol swabs OTC, QL Max #200/month blood glucose monitoring kits OTC, QL Max #1/year TRUE METRIX AIR kits blood glucose monitoring kits OTC, QL Max #1/year TRUE METRIX kits blood glucose test strips OTC, QL, ^ TRUE METRIX test strips insulin needles OTC, QL Max #200/month insulin syringes OTC, QL Max #150/month lancets OTC

^ Max of #50/month for non-insulin users. Max of #200/month for insulin users and pregnant members filling prenatal vitamins.

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CALCIUM RECEPTOR ANTAGONISTS cinacalcet 30 mg, 60 mg PA, QL, SP Max #60/month SENSIPAR cinacalcet 90 mg PA, QL, SP Max #120/month SENSIPAR

CALCIUM REGULATORS Bisphosphonates alendronate 5 mg, 10 mg, 40 mg QL Max #30/month FOSAMAX alendronate 35 mg, 70 mg QL Max #4/month FOSAMAX ibandronate QL Max #1 tab/month BONIVA

Calcitonins calcitonin-salmon nasal QL Max # 3.7 mL/month MIACALCIN

Parathyroid Hormones abaloparatide PA, SP TYMLOS teriparatide PA, QL, SP Max #1 pen/month FORTEO

CONTRACEPTIVES Covered for females only EE = ethinyl estradiol

Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Gianvi levonorgestrel/EE 0.1/20 Lutera norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron Junel 24 Fe, Microgestin Fe 1/20 norethindrone acetate/EE 1/20 and iron chew tabs PA MINASTRIN 24 FE

25 mcg Estrogen norethindrone acetate/EE 0.8/25 and iron GENERESS FE

30 mcg Estrogen desogestrel/EE 0.15/30 Apri drospirenone/EE 3/30 YASMIN drospirenone/EE/levomefolate 3/30 and levomefolate SAFYRAL levonorgestrel/EE 0.15/30 Levora norethindrone acetate/EE 1.5/30 Microgestin 1.5/30 norethindrone acetate/EE 1.5/30 and iron Microgestin Fe 1.5/30 norgestrel/EE 0.3/30 Low-Ogestrel

35 mcg Estrogen ethynodiol diacetate/EE 1/35 Zovia 1/35 norethindrone/EE 0.4/35 Zenchent norethindrone/EE 0.4/35 and iron PA norethindrone/EE 0.5/35 Necon 0.5/35, Nortrel 0.5/35 norethindrone/EE 1/35 ORTHO-NOVUM 1/35 norgestimate/EE 0.25/35 Sprintec

50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50 Ogestrel

Biphasic desogestrel/EE Kariva norethindrone/EE and iron LO LOESTRIN FE 1/10

24

Triphasic desogestrel/EE 0.1-0.025/0.125-0.025/0.15-0.025 mg-mg Velivet levonorgestrel/EE 0.05-30/0.075-40/0.125-30 mg-mcg Trivora norethindrone/EE 0.5-35/0.75-35/1-35 mg-mcg ORTHO-NOVUM 7/7/7 norethindrone/EE 0.5-35/1-35/0.5-35 mg-mcg Aranelle norethindrone/EE and iron 1-20/1-30/1-35 mg-mcg Tilia Fe norgestimate/EE 0.18-25/0.215-25/0.25-25 mg-mcg ORTHO TRI-CYCLEN LO norgestimate/EE 0.18-35/0.215-35/0.25-35 mg-mcg ORTHO TRI-CYCLEN

Extended Cycle levonorgestrel/EE 0.15/30 Jolessa

Continuous levonorgestrel/EE 0.09/20

Progestin Only norethindrone ORTHO MICRONOR

Emergency Contraception levonorgestrel 1.5 mg OTC PLAN B ONE-STEP ulipristal ELLA

Injectable medroxyprogesterone acetate 150 mg/mL QL Females only; Max #1 mL/90 days DEPO-PROVERA

Transdermal norelgestromin/EE QL Max #9/84 days Xulane

Vaginal etonogestrel/EE ring QL Max #1/month NUVARING

Miscellaneous cervical cap FEMCAP condoms, male and female OTC, QL Max #36/month diaphragm arc-spring CAYA diaphragm wide seal WIDE SEAL nonoxynol-9 foam 12.5% OTC VCF CONTRACEPTIVE nonoxynol-9 gel 3% OTC GYNOL II nonoxynol-9 sponge OTC TODAY CONTRACEPTIVE SPONGE

ENDOMETRIOSIS danazol

ESTROGENS Covered for females only

Oral estradiol AGE Covered for ages 64 years old & under ESTRACE estrogens, conjugated AGE, QL Covered for ages 64 years old & under; PREMARIN Max #30/month estrogens, esterified AGE Covered for ages 64 years old & under MENEST

Transdermal estradiol weekly AGE, QL Covered for ages 64 years old & under; CLIMARA Max #4 patches/month estradiol, twice weekly AGE, QL Covered for ages 64 years old & under; VIVELLE-DOT Max #8 patches/month

25

Vaginal estradiol vaginal crm QL Covered for females only; Max #42.5 ESTRACE CREAM grams/month estradiol vaginal tabs Yuvafem

ESTROGEN/PROGESTINS Covered for females only

Oral EE/norethindrone acetate 0.5 mg/2.5 mcg AGE, QL Covered for ages 64 years old & under; FEMHRT Max #28/month EE/norethindrone acetate 1 mg/5 mcg AGE Covered for ages 64 years old & under estradiol/norethindrone acetate AGE Covered for ages 64 years old & under ACTIVELLA estrogens, conjugated/medroxyprogesterone AGE, QL Covered for ages 64 years old & under; PREMPHASE, PREMPRO Max #28/month

GLUCOCORTICOIDS dexamethasone elixir, soln 0.5 mg/5 mL dexamethasone tabs fludrocortisone hydrocortisone CORTEF methylprednisolone prednisolone sodium phosphate soln 5 mg/5 mL, 15 mg/5 mL prednisolone syrup prednisone

GLUCOSE ELEVATING AGENTS glucagon, human recombinant QL Max 1 kit/month GLUCAGEN HYPOKIT, GLUCAGON EMERGENCY KIT

HUMAN GROWTH HORMONES somatropin PA, SP NORDITROPIN FLEXPRO

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol caps QL Max #120/month ROCALTROL calcitriol soln AGE Covered for ages 12 years old & under ROCALTROL

INSULIN-LIKE GROWTH FACTORS mecasermin PA, SP INCRELEX

PHOSPHATE BINDER AGENTS calcium acetate 667 mg lanthanum chew tabs PA FOSRENOL sevelamer carbonate tabs PA RENVELA sevelamer HCl PA RENAGEL

POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp Kionex sodium polystyrene sulfonate powder sodium polystyrene sulfonate rectal susp

PROGESTINS medroxyprogesterone acetate Females only PROVERA megestrol acetate susp 40 mg/mL norethindrone acetate QL Females only; Max #60/month AYGESTIN progesterone, micronized 100 mg QL Females only; Max #30/month PROMETRIUM

26 progesterone, micronized 200 mg QL Females only; Max #60/month PROMETRIUM

SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene AGE, QL Females only; Covered for ages 40 EVISTA years old & over; Max #30/month

THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil

Thyroid Supplements levothyroxine levothyroxine Levoxyl liothyronine CYTOMEL thyroid AGE Covered for ages 64 years old & under ARMOUR THYROID thyroid AGE Covered for ages 64 years old & under NATURE-THROID thyroid WESTHROID thyroid WP THYROID

VASOPRESSINS desmopressin spray PA, SP DDAVP desmopressin spray PA, SP STIMATE desmopressin tabs QL Max #180/month DDAVP

MISCELLANEOUS Drugs in this category may be carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6. cabergoline methylergonovine tabs AGE Covered for ages 12 years old & older Methergine octreotide acetate vials 50 mcg/mL, 100 mcg/mL, 200 mcg/mL, 1000 mcg/mL PA, SP

GASTROINTESTINAL ANTACIDS/COMBINATIONS aluminum hydroxide gel susp OTC aluminum hydroxide/magnesium carbonate OTC GAVISCON aluminum hydroxide/magnesium hydroxide/simethicone OTC GELUSIL aluminum hydroxide/magnesium hydroxide/simethicone OTC MAG-AL aluminum hydroxide/magnesium trisilicate OTC GAVISCON calcium carbonate OTC TUMS calcium carbonate/magnesium hydroxide OTC calcium carbonate/magnesium hydroxide/simethicone OTC calcium carbonate/simethicone OTC MAALOX ADVANCED calcium glycerophosphate OTC PRELIEF magnesium oxide/asafoetida OTC DEWEES CARMINATIVE sodium bicarbonate tabs OTC sodium bicarbonate/citric acid OTC ALKA-SELTZER HEARTBURN sodium bicarbonate/citric acid/simethicone granules OTC E-Z GAS II sodium bicarbonate/potassium bicarbonate OTC ALKA-SELTZER GOLD

ANTIDIARRHEALS bismuth subsalicylate OTC PEPTO-BISMOL diphenoxylate/atropine tabs LOMOTIL loperamide caps loperamide caps OTC

27 loperamide susp 1 mg/7.5 mL OTC paregoric tincture

ANTIEMETICS dimenhydrinate tabs OTC dronabinol PA MARINOL granisetron tabs ST, QL Requires trial of ondansetron; Max #4/month meclizine OTC meclizine metoclopramide soln, tabs REGLAN ondansetron oral soln AGE, QL Covered for ages 12 years old & under; ZOFRAN Max #300 mL/month ondansetron orally disintegrating tabs 4 mg, 8 mg QL Max #90/month ZOFRAN ODT ondansetron tabs 4 mg, 8 mg QL Max #90/month ZOFRAN ondansetron tabs 24 mg QL Max #30/month prochlorperazine supp QL Max #60/month COMPAZINE prochlorperazine tabs QL Max #120/month COMPAZINE promethazine AGE Covered for ages 2-64 years old promethazine supp AGE Covered for ages 2-64 years old

ANTISPASMODICS dicyclomine AGE Covered for ages 64 years old & under BENTYL glycopyrrolate tabs 1 mg, 2 mg ROBINUL, ROBINUL FORTE hyoscyamine sulfate AGE Covered for ages 64 years old & under hyoscyamine sulfate ext-rel tabs AGE Covered for ages 64 years old & under LEVBID

CHOLELITHOLYTICS ursodiol caps QL Max #150/month ACTIGALL ursodiol tabs URSO

H2 RECEPTOR ANTAGONISTS cimetidine tabs cimetidine tabs OTC TAGAMET HB famotidine tabs PEPCID famotidine tabs OTC PEPCID AC ranitidine syp QL Max #600 mL/month ZANTAC ranitidine tabs ZANTAC ranitidine tabs OTC ZANTAC OTC

INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide COLAZAL mesalamine delayed-rel ST, QL Requires trial of APRISO or DELZICOL; ASACOL HD Max #180/month mesalamine delayed-rel ST, QL Requires trial of balsalazide, DELZICOL sulfasalazine or sulfasalazine delayed- rel; Max #180/month mesalamine ext-rel ST, QL Requires trial of balsalazide, APRISO sulfasalazine or sulfasalazine delayed- rel; Max #120/month mesalamine ext-rel ST, QL Requires trial of APRISO or DELZICOL; PENTASA Max #240/month sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS

Rectal Agents mesalamine enema

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IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation lubiprostone PA, QL Max #60/month AMITIZA

LAXATIVES/STOOL SOFTENERS benzocaine/docusate enema OTC ENEMEEZ PLUS bisacodyl delayed-rel OTC DULCOLAX bisacodyl enema OTC FLEET BISACODYL bisacodyl supp OTC DULCOLAX calcium polycarbophil OTC FIBERCON calcium polycarbophil chew tabs OTC EQUALACTIN castor oil OTC cellulose powder OTC UNIFIBER CO2-releasing supp OTC CEO-TWO corn dextrin powder OTC Fiber Powder docusate calcium OTC docusate sodium 50 mg, 250 mg OTC docusate sodium caps 100 mg OTC, QL Max # 180/month COLACE docusate sodium enema OTC DOCUSOL KIDS docusate sodium liq 50 mg/5 mL OTC Docu Liquid docusate sodium liq 50 mg/15 mL OTC FLEET PEDIA-LAX fiber chew tabs OTC fiber liquid OTC HYFIBER WITH FOS fiber liquid OTC LIQUIFIBER glycerin enema OTC FLEET ENEMA glycerin supp OTC FLEET glycerin supp OTC PEDIA-LAX SUPP lactulose soln magnesium citrate soln OTC Citroma magnesium hydroxide OTC PHILLIPS' MILK OF MAGNESIA magnesium hydroxide chew tabs OTC PEDIA-LAX CHEWS magnesium oxide OTC PHILLIPS magnesium sulfate oral granules OTC EPSOM SALT mineral oil OTC mineral oil mineral oil emulsion OTC KONDREMUL mineral oil enema OTC FLEET MINERAL OIL peg 3350/electrolytes QL Max #4000 grams/year COLYTE peg 3350/electrolytes QL Max #4000 grams/year GOLYTELY peg 3350/electrolytes MOVIPREP peg 3350/electrolytes QL Max #4000 grams/year NULYTELY peg 3350/electrolytes with bisacodyl QL Gavilyte-H Kit polyethylene glycol 3350 powder polyethylene glycol 3350 powder OTC MIRALAX OTC psyllium OTC METAMUCIL psyllium powder OTC HYDROCIL psyllium powder OTC KONSYL psyllium wafer OTC METAMUCIL psyllium/calcium OTC METAMUCIL PLUS CALCIUM senna leaves OTC senna syrup OTC sennosides 8.6 mg OTC SENOKOT sennosides/docusate sodium OTC SENOKOT-S sennosides/psyllium OTC SENNA PROMPT sodium phosphates OSMOPREP sodium phosphates enema OTC FLEET

29 sodium phosphates soln OTC sodium picosulfate/magnesium oxide/citric acid PREPOPIK sodium sulfate/potassium sulfate/magnesium sulfate SUPREP wheat dextrin powder OTC BENEFIBER wheat dextrin/calcium chew tabs OTC

PANCREATIC ENZYMES pancrelipase QL Max #480 tabs/month VIOKACE pancrelipase delayed-rel 2,600 units, 4,200 units QL Max #720 caps/month PANCREAZE pancrelipase delayed-rel 3,000 units, 5,000 units, 10,000 units QL Max #720 caps/month ZENPEP pancrelipase delayed-rel 3,000 units, 6,000 units QL Max #720 caps/month CREON pancrelipase delayed-rel 8,000 units QL Max #720 caps/month PERTZYE pancrelipase delayed-rel 10,500 units, 16,800 units, 21,000 units QL Max #480 caps/month PANCREAZE pancrelipase delayed-rel 12,000 units, 24,000 units, 36,000 units QL Max #480 caps/month CREON pancrelipase delayed-rel 15,000 units, 20,000 units, 25,000 units, Max #480 caps/month ZENPEP 40,000 units QL pancrelipase delayed-rel 16,000 units, 24,000 units QL Max # 480 caps/month PERTZYE

PROSTAGLANDINS misoprostol QL Max #120/month CYTOTEC

PROTON PUMP INHIBITORS esomeprazole magnesium delayed-rel OTC, ST, QL Requires trial of omeprazole and NEXIUM 24HR OTC pantoprazole; Max #60/month lansoprazole delayed-rel caps OTC, ST, QL Requires trial of omeprazole and PREVACID 24HR OTC pantoprazole; Max #60/month lansoprazole delayed-rel caps 15 mg ST, QL Requires trial of omeprazole and PREVACID pantoprazole; Max #60/month lansoprazole delayed-rel caps 30 mg ST, QL Requires trial of omeprazole and PREVACID pantoprazole; Max #30/month lansoprazole susp AGE, QL Covered for ages 12 years old & under; FIRST-LANSOPRAZOLE Max #300 mL/month omeprazole delayed-rel caps QL Max #60/month omeprazole magnesium delayed-rel caps OTC, QL Max #60/month omeprazole susp AGE, QL Covered for ages 12 years old & under; FIRST-OMEPRAZOLE Max #300 mL/month pantoprazole delayed-rel tabs 20 mg QL Max #30/month PROTONIX pantoprazole delayed-rel tabs 40 mg QL Max #60/month PROTONIX

SALIVA STIMULANTS pilocarpine SALAGEN

STEROIDS, RECTAL hydrocortisone rectal crm 2.5% QL Max #45 grams/month

MISCELLANEOUS simethicone chew tabs OTC GAS-X simethicone susp 40 mg/0.6 mL OTC sucralfate tabs QL Max #120/month CARAFATE

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel UROXATRAL finasteride QL Males only; Max #30/month PROSCAR tamsulosin QL Max #60/month FLOMAX

URINARY ANTISPASMODICS flavoxate hydrochloride

30 oxybutynin ext-rel 5 mg QL Max #30/month DITROPAN XL oxybutynin ext-rel 10 mg, 15 mg QL Max #60/month DITROPAN XL oxybutynin syrup QL Max #600 mL/month oxybutynin tabs QL Max #90/month oxybutynin transdermal OTC OXYTROL FOR WOMEN tolterodine ST, QL Requires trial of oxybutynin; Max DETROL #60/month tolterodine ext-rel ST, QL Requires trial of oxybutynin; Max DETROL LA #30/month trospium ST, QL Requires trial of oxybutynin; Max #60/month

VAGINAL ANTI-INFECTIVES Females only clindamycin crm CLEOCIN clotrimazole crm OTC GYNE-LOTRIMIN metronidazole METROGEL-VAGINAL miconazole crm 2% OTC miconazole crm 2%, supp 100 mg OTC MONISTAT 3 COMBO KIT miconazole crm 2%, applicator 100 mg OTC MONISTAT 7 COMBO KIT miconazole supp OTC terconazole crm

MISCELLANEOUS bethanechol QL Max #120/month URECHOLINE methenamine hippurate HIPREX methenamine mandelate pentosan polysulfate sodium PA, QL Max #90/month ELMIRON phenazopyridine PYRIDIUM potassium citrate ext-rel 5 mEq, 10 mEq UROCIT-K potassium citrate/citric acid soln, powder packets CYTRA-K potassium phosphate K-PHOS potassium/sodium acid phosphates K-PHOS NO. 2 sodium citrate/citric acid soln Cytra-2

HEMATOLOGIC ANTICOAGULANTS Injectable enoxaparin pre-filled syringes PA, QL, SP Requires PA for treatment longer than 7 LOVENOX days heparin vials 5000 units/mL, 10000 units/mL

Oral apixaban starter pack AGE, PA, QL Covered for ages 18 years & older; Max ELIQUIS #1 pack apixaban tabs AGE, PA, QL Covered for ages 18 years & older; Max ELIQUIS #60/month rivaroxaban starter pack AGE, PA, QL Covered for ages 18 years & older; Max XARELTO #1 pack rivaroxaban tabs AGE, PA, QL Covered for ages 18 years & older; Max XARELTO #30 tabs/month warfarin COUMADIN warfarin Jantoven

ANTIHEMOPHILIC AGENTS Antihemophilic Agents are carved-out for Medicaid. Pharmacies bill State Fee-for-Service Pharmacy Program directly. Refer to the full list of carve-out drugs beginning on page 6.

31

HEMATOPOIETIC GROWTH FACTORS darbepoetin alfa PA, SP ARANESP epoetin alfa PA, SP EPOGEN epoetin alfa PA, SP PROCRIT epoetin alfa-epbx PA, SP RETACRIT filgrastim PA, SP NEUPOGEN filgrastim-aafi PA, SP NIVESTYM filgrastim-sndz PA, SP ZARXIO pegfilgrastim-jmdb PA, SP FULPHILA tbo-filgrastim vial PA, SP GRANIX

PLATELET AGGREGATION INHIBITORS aspirin chew tabs 81 mg OTC, QL Max #30/month aspirin delayed-rel 81 mg OTC, QL Max #30/month clopidogrel 75 mg QL Max #30/month PLAVIX clopidogrel 300 mg QL Max #1 tab/month PLAVIX dipyridamole QL Max #120/month

PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN

MISCELLANEOUS cilostazol QL Max #60/month L-glutamine oral powder PA, SP ENDARI pentoxifylline ext-rel succimer CHEMET

IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS abatacept subcutaneous PA, SP ORENCIA, ORENCIA CLICKJECT adalimumab PA, SP HUMIRA baricitinib PA, SP OLUMIANT brodalumab PA, SP, QL Max #3/month SILIQ certolizumab pegol PA, SP CIMZIA etanercept PA, SP ENBREL, ENBREL SURECLICK tocilizumab subcutaneous PA, SP ACTEMRA, ACTEMRA ACTPEN tofacitinib PA, SP, QL Max #60/month XELJANZ tofacitinib ext-rel PA, SP, QL Max #30/month XELJANZ XR

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide QL Max #30/month ARAVA

IMMUNOMODULATORS Interferons interferon alfa-2b PA, SP INTRON A

Miscellaneous apremilast 30 mg PA, SP OTEZLA apremilast starter pack PA, SP, QL Max # 1 fill per year OTEZLA

IMMUNOSUPPRESSANTS Antimetabolites azathioprine QL Max #240/month IMURAN

32 mycophenolate mofetil CELLCEPT mycophenolate mofetil susp AGE Covered for ages 12 years old & under CELLCEPT mycophenolate sodium delayed-rel ST Requires trial of mycophenolate mofetil MYFORTIC

Calcineurin Inhibitors cyclosporine caps SANDIMMUNE cyclosporine, modified NEORAL cyclosporine, modified soln AGE Covered for ages 12 years old & under NEORAL tacrolimus PROGRAF

Rapamycin Derivatives sirolimus tabs RAPAMUNE

VACCINES hepatitis A vaccine AGE, QL Covered for ages 19 years & over; Max HAVRIX, VAQTA #2 per lifetime hepatitis A, hepatitis B vaccine AGE, QL Covered for ages 19 years & over; Max TWINRIX #3 per lifetime hepatitis B vaccine AGE, QL Covered for ages 19 years & over; Max ENGERIX-B, HEPLISAV-B, #3 per lifetime; exclude 40 mcg dose RECOMBIVAX HB influenza virus vaccine quadrivalent AGE, QL Covered for ages 19 years & over; Max AFLURIA QUAD, AFLURIA #1 per year QUAD PF, FLUARIX QUAD, FLUCELVAX QUAD, FLULAVAL QUAD, FLUZONE QUAD influenza virus vaccine, quadrivalent recombinant AGE, QL Covered for ages 19 years & over; Max FLUBLOK QUAD #1 per year influenza virus vaccine, trivalent AGE, QL Covered for ages 19 years & over; Max AFLURIA, FLUAD, FLUZONE #1 per year pneumococcal vaccine AGE, QL Covered for ages 19 years & over; Max PNEUMOVAX 23 #2 per lifetime pneumococcal vaccine AGE, QL Covered for ages 19 years & over; Max PREVNAR 13 #1 per lifetime tetanus, diphtheria vaccine AGE, QL Covered for ages 19 years & over; Max TENIVAC #1 per 10 years tetanus, diphtheria, pertussis vaccine AGE, QL Covered for ages 19 years & over; and ADACEL, BOOSTRIX history of prenatal vitamin in past 90 days zoster vaccine live AGE, QL Covered for ages 50 years & over; Max ZOSTAVAX #1 per lifetime zoster vaccine recombinant AGE, QL Covered for ages 50 years & over; Max SHINGRIX #2 per lifetime

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Calcium/Combinations calcium carbonate OTC calcium carbonate/vitamin D OTC CALTRATE + D calcium carbonate/vitamin D/minerals OTC CALTRATE 600 + D PLUS calcium chloride inj calcium citrate OTC calcium citrate/vitamin D OTC CITRACAL + D calcium glubionate OTC CALCIONATE calcium gluconate OTC calcium lactate OTC calcium phosphate/vitamin D OTC calcium, oyster shell OTC calcium/boron OTC RA CALCIUM/BORON

33 calcium/magnesium OTC alccium/magnesium/vitamin C OTC LOCALNESIUM-C alccium/magnesium/vitamin D OTC calcium/magnesium/zinc OTC alccium/phosphorus/vitamin D OTC RISACAL-D calcium/vitamin C/vitamin D OTC calcium/vitamin D OTC calcium/vitamin D/minerals OTC CALTRATE 600 + MINERALS calcium/vitamin D/vitamin K OTC VIACTIV

Phosphates potassium phosphates inj potassium phosphates/sodium phosphates OTC PHOS-NAK sodium glycerophosphate inj GLYCOPHOS sodium phosphates inj

Potassium potassium bicarbonate effer tabs 25 mEq potassium bicarbonate/potassium chloride effer tabs 25 mEq potassium chloride ext-rel 8 mEq, 10 mEq potassium chloride microencapsulated crystal ext-rel tabs 10 mEq, KLOR-CON M10, KLOR-CON 20 mEq M20 potassium chloride oral soln

VITAMINS AND MINERALS Folic Acid/Combinations folic acid 1 mg folic acid 400 mcg OTC, QL Max #30/month folic acid 800 mcg OTC folic acid/vitamin B6/vitamin B12 FOLGARD RX folic acid/vitamin B6/vitamin B12 OTC Foltabs 800 folinic acid/vitamin B6/vitamin B12 OTC FOLINIC-PLUS l-methylfolate/vitamin B2/vitamin B6/vitamin B12 CEREFOLIN, METAFOLBIC l-methylfolate/vitamin B6/vitamin B12 FOLTX

Iron Supplements/Combinations carbonyl iron OTC FEOSOL, PERFECT IRON, IRON CHEWS carbonyl iron OTC ICAR PEDS ferrous fumarate OTC FERRETTS, FERRIMIN 150 ferrous fumarate OTC HEMOCYTE ferrous fumarate/folic acid/docusate sodium/vitamin B-complex/vitamin NEPHRON FA C ferrous fumarate/folic acid/intrinsic factor/vitamin B12/vitamin C ferrous fumarate/folic acid/vitamin B12/vitamin C ferrous fumarate/folic acid/vitamin B12/vitamin C HEMATOGEN FA ferrous fumarate/folic acid/vitamin B-complex/minerals ferrous gluconate OTC FERGON ferrous sulfate OTC FEOSOL ferrous sulfate delayed-rel OTC ferrous sulfate drops 15 mg/mL OTC, AGE Covered for ages 12 years old & under FER-IN-SOL ferrous sulfate elixir, liquid 220 mg/5 mL OTC, AGE Covered for ages 12 years old & under ferrous sulfate ext-rel OTC SLOW FE ferrous sulfate syrup 300 mg/5 mL OTC, AGE Covered for ages 12 years old & under iron combination CORVITE iron combination Hematogen iron combination elixir OTC I.L.X. B-12 iron heme polypeptide OTC PROFERRIN ES

34 iron polysaccharides complex OTC iron polysaccharides complex OTC NOVAFERRUM iron polysaccharides complex/vitamin B12/folic acid iron/vitamin B12/vitamin C/folic acid AGE Covered for ages 12 years old & under iron/vitamin B12/vitamin C/folic acid OTC, AGE Covered for ages 12 years old & under iron/vitamin C OTC ICAR-C iron/vitamin C OTC VITRON-C iron/vitamins OTC VITAFOL

Prenatal Vitamins * All prenatal vitamins are covered only for females ages 12-55 years old. prenatal vitamins without A/ferrous bisglycinate/folic acid 32-1 mg QL Max #30/month NESTABS prenatal vitamins without A/ferrous bisglycinate/folic acid 32-1 mg + NESTABS DHA PAK, TRI­ omega-3 TABS DHA prenatal vitamins without A/ferrous fumarate/folic acid 106.5-1 mg QL Max #30/month PRENATAL-U prenatal vitamins without A/iron carbonyl/folic acid 20-1 mg + vitamin B6 Max #30/month TARON-BC QL prenatal vitamins/docusate/ferrous fumarate/folic acid 29-1 mg QL Max #30/month Prenatal 19 prenatal vitamins/docusate/ferrous fumarate/folic acid 29-1 mg QL Max #30/month PRENATAL 19, SE-NATAL 19, THRIVITE 19 prenatal vitamins/docusate/ferrous fumarate/folic acid 90-1 mg QL Max #30/month MYNATE 90 PLUS prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg + omega-3 Max #30/month OBSTETRIX DHA PAK QL prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg QL Max #30/month OBSTETRIX EC prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg OTC, QL Max #30/month OBTREX prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg + omega-3 Max #30/month OBTREX DHA PAK OTC, QL prenatal vitamins/docusate/iron carbonyl/folic acid 90-1 mg QL Max #30/month Inatal GT prenatal vitamins/ferrous bisglycinate chelate/folic acid 29-1 mg QL Max #30/month ATABEX OB, VINATE II prenatal vitamins/ferrous fumarate/folic acid 14-0.4 mg OTC, QL Max #30/month PRENATAL COMPLETE prenatal vitamins/ferrous fumarate/folic acid 27-0.8 mg OTC, QL Max #30/month MULTIPRENATAL, PRENATAL LOW IRON, PRENATAL ONE DAILY, PRENATAL VITAMIN, RIGHT STEP PRENATAL prenatal vitamins/ferrous fumarate/folic acid 27-1 mg QL Max #30/month M-VIT, NIVA-PLUS, O-CAL FA, PNV FOLIC ACID + IRON, PNV PRENATAL PLUS, PRENATAL PLUS, PRENATAL LOW IRON, PREPLUS, TRICARE PRENATAL, VOL-PLUS prenatal vitamins/ferrous fumarate/folic acid 27-1 mg OTC, QL Max #30/month THERANATAL prenatal vitamins/ferrous fumarate/folic acid 28-0.8 mg OTC, QL Max #30/month CLASSIC PRENATAL, CVS PRENATAL, EQL PRENATAL FORMULA, GNP PRENATAL, GOODSENSE PRENATAL, HM PRENATAL, KP PRENATAL, PRENATAL/IRON, PRENATAL TAB, PX PRENATAL, QC PRENATAL, RA PRENATAL, SM PRENATAL prenatal vitamins/ferrous fumarate/folic acid 28-1 mg QL Max #30/month Trinate prenatal vitamins/ferrous fumarate/folic acid 60-1 mg QL Max #30/month TRINATAL RX1, VINATE ONE prenatal vitamins/ferrous fumarate/folic acid 65-1 mg QL Max #30/month MYNATAL PLUS, MYNATAL­

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Z, VITAFOL-OB prenatal vitamins/ferrous fumarate/folic acid chew tabs 29-1 mg QL Max #30/month Prenatal 19 prenatal vitamins/ferrous fumarate/folic acid chew tabs 29-1 mg QL Max #30/month COMPLETENATE CHEW, PRENATAL 19 CHEW, SE­ NATAL CHEW prenatal vitamins/ferrous fumarate/folic acid/omega-3 27-0.8-228 mg Max #30/month PRENATAL MULTI + DHA OTC, QL prenatal vitamins/iron carbonyl/folic acid 29-1 mg QL Max #30/month Prenatabs Rx prenatal vitamins/iron polysaccharide complex/iron heme HEMENATAL OB polypeptide/folic acid 28-6-1 mg prenatal vitamins/iron polysaccharide complex/iron heme PREFERA OB polypeptide/folic acid 34-1 mg prenatal vitamins/minerals/folic acid/fish oil chew tabs 0.4-113.5 mg Max #30/month CVS PRENATAL CHEW OTC, QL GUMMY prenatal vitamins/selenium/ferrous fumarate/folic acid 27-1 mg QL Max #30/month VINATE M

Vitamin B-Complex/Combinations vitamin B complex OTC vitamin B complex elixir OTC APETIGEN, APETEX vitamin B complex inj vitamin B complex/biotin/folic acid OTC vitamin B complex/biotin/folic acid ext-rel OTC vitamin B complex/folic acid OTC vitamin B complex/folic acid ext-rel OTC vitamin B complex/folic acid/vitamin C/zinc NEPHLEX vitamin B complex/iron OTC APETIGEN PLUS vitamin B complex/minerals OTC APETIGEN PLUS vitamin B complex/vitamin C OTC vitamin B complex/vitamin C/biotin/vitamin D/folic acid OTC DIALYVITE 800 PLUS D vitamin B complex/vitamin C/calcium OTC vitamin B complex/vitamin C/folic acid OTC FULL SPECTRUM B WITH C vitamin B complex/vitamin C/folic acid NEPHROCAPS, NEPHRO­ VITE RX vitamin B complex/vitamin C/folic acid OTC NEPHRO-VITE vitamin B complex/vitamin C/folic acid Virt-Vite Plus vitamin B complex/vitamin C/vitamin E/zinc OTC

Miscellaneous biotin OTC biotin liq OTC CYTO B7 biotin tab 800 mcg OTC brewers yeast OTC cholecalciferol caps, chew tabs 400 units, liquid 400 units/mL, tabs VITAMIN D-3 OTC cholecalciferol wafer 50,000 units OTC REPLESTA cyanocobalamin 100 mcg, 500 mcg, 1000 mcg OTC, QL Max #30/month VITAMIN B12 cyanocobalamin inj 1000 mcg/mL docosahexaenoic acid 200 mg OTC DHA OMEGA-3 electrolyte soln, oral OTC CERALYTE 70, ENFAMIL ENFALYTE electrolyte soln, oral OTC PEDIALYTE ergocalciferol (D2) caps ergocalciferol (D2) drops OTC, QL Max #60mL/month inositol niacinate caps OTC NIACIN FLUSH FREE lysine/thiamine/niacinamide OTC ALBA-LYBE magnesium OTC magnesium aspartate delayed-rel OTC MAGINEX 615 magnesium chloride inj

36 magnesium chloride/calcium delayed-rel OTC SLOW-MAG magnesium citrate OTC magnesium gluconate OTC magnesium glycinate OTC magnesium lactate ext-rel OTC MAG-TAB SR magnesium oxide OTC MAG-OX magnesium oxide OTC UROMAG magnesium sulfate inj melatonin caps 5 mg, 10 mg OTC, AGE, QL Covered for ages 12 years old & under; Max #30/month melatonin ext-rel tabs 10 mg OTC, AGE, QL Covered for ages 12 years old & under; Max #30/month melatonin liquid 1 mg/4 mL, 1 mg/mL OTC, AGE, QL Covered for ages 12 years old & under; Max #600 mL/month melatonin sublingual 5 mg OTC, AGE, QL Covered for ages 12 years old & under; Max #30/month melatonin tabs 1 mg, 3 mg, 5 mg OTC, AGE, QL Covered for ages 12 years old & under; Max #30/month multivitamins OTC OMNICAP, QUINTABS, SPECTRAVITE, STROVITE, THERA BETA, THERA-M multivitamins OTC ONE-A-DAY multivitamins inj M.V.I. ADULT multivitamins/calcium OTC ONE-A-DAY WOMEN'S multivitamins/iron OTC multivitamins/minerals OTC THERACAL, THEREMS-M multivitamins/minerals caps, chew tabs OTC AQUADEKS niacin OTC niacin ext-rel caps OTC niacin ext-rel tabs 250 mg, 750 mg OTC SLO-NIACIN niacin/inositol OTC niacinamide OTC niacinamide ext-rel OTC NIACINAMIDE PR niacinamide/zinc/copper/methylfolate NICOMIDE omega-3 fatty acids caps 500 mg OTC FISH OIL omega-3 fatty acids caps 1000 mg OTC Super Omega-3 omega-3 fatty acids delayed-rel caps 1000 mg OTC FISH OIL pediatric multiple vitamins/fluoride/iron drops AGE, QL Covered for ages 12 years & under; Max #60 mL/month pediatric multivitamins OTC pediatric multivitamins/fluoride chew tabs AGE, QL Covered for ages 12 years & under; Max #30/month pediatric multivitamins/fluoride soln AGE, QL Covered for ages 12 years & under; Max #60 mL/month pediatric multivitamins/iron OTC pediatric multivitamins/iron drops OTC POLY-VI-SOL WITH IRON pediatric multivitamins/minerals/vitamin C OTC pediatric multivitamins/minerals/vitamin C drops Aquadeks pediatric multivitamins/vitamin C drops OTC POLY-VI-SOL pediatric multivitamins/vitamin C/folic acid chew tabs OTC VITACRAVES pediatric vitamins ACD drops QL Max #60 mL/month pediatric vitamins ACD drops TRI-VI-SOL pediatric vitamins ACD/fluoride soln AGE Covered for ages 12 years & under pediatric vitamins ACD/fluoride/iron drops AGE, QL Covered for ages 12 years & under; Max #60 mL/month phytonadione QL Max #5 tabs/day, 5 day supply/month MEPHYTON pyridoxine tabs 25 mg OTC, QL Max #60/month VITAMIN B-6 pyridoxine tabs 50 mg, 100 mg OTC, QL Max #120/month VITAMIN B-6

37 riboflavin 25 mg OTC VITAMIN B-2 sodium fluoride chew tabs AGE, QL Covered for ages 16 years old & under; Max #30/month sodium fluoride drops 0.125 mg/drop, 0.25 mg/drop AGE, QL Covered for ages 16 years old & under; Max #60 mL/month sodium fluoride drops 0.5 mg/mL AGE, QL Covered for ages 16 years old & under; Max #120 mL/25 days sulbutiamine OTC ARKALIOX thiamine 50 mg, 100 mg OTC VITAMIN B-1 tocopherols/tocotrienols OTC AQUA-E vitamin E OTC vitamin E drops OTC, AGE Covered for ages 12 years old & under Aqueous E vitamin E oil OTC vitamins/lipotropics OTC vitamins/lipotropics ext-rel OTC wheat germ oil

DIETARY PRODUCTS/NUTRITIONAL SUPPLEMENTS calcium/folic acid/vitamin B6/vitamin E/herbs OTC MENS POTENT FORMULA ferrous sulfate/misc herbs OTC LYDIA PINKHAM HERBAL l-methylfolate/algae/vitamin B12/acetylcysteine CEREFOLIN NAC, METAFOLBIC PLUS RF nutritional supplement caps OTC Prostamen nutritional supplement liquid OTC FIBER-STAT LIQ, TYR COOLER LIQ nutritional supplement tabs OTC BLADDER 2.2 nutritional supplement, diet aid OTC Fiber Weight Management psyllium husk/misc natural products OTC COLOX

RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine 0.3 mg QL Max #2 pens/3 months SYMJEPI epinephrine auto-injector QL Max #2 pens/3 months

ANTICHOLINERGICS ipratropium soln ipratropium, CFC-free aerosol QL Max #1 inhaler/month ATROVENT HFA tiotropium PA, AGE, QL Covered for ages 6 years old & older; SPIRIVA RESPIMAT Max #1 inhaler/month umeclidinium QL Max #1 inhaler/month INCRUSE ELLIPTA

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS glycopyrrolate/formoterol ST Requires 2 month trial of SEREVENT or BEVESPI AEROSPHERE INCRUSE ELLIPTA ipratropium/albuterol soln QL Max #360 mL/month ipratropium/albuterol, CFC-free aerosol QL Max #1 inhaler/month COMBIVENT RESPIMAT

ANTIHISTAMINES Low Sedating cetirizine soln, syp AGE, QL Covered for ages 12 years old & under; Max #300 mL/month cetirizine soln, syp OTC, AGE, QL Covered for ages 12 years old & under; ZYRTEC OTC Max #300 mL/month cetirizine tabs OTC, QL Max #30/month ZYRTEC OTC

Nonsedating loratadine syp OTC, AGE, QL Covered for ages 12 years old & under; CLARITIN OTC Max #300 mL/month

38 loratadine tabs 10 mg OTC, QL Max #30/month CLARITIN OTC

Sedating carbinoxamine chlorpheniramine ext-rel OTC CHLOR-TRIMETON chlorpheniramine tabs OTC CHLOR-TRIMETON clemastine clemastine OTC TAVIST cyproheptadine AGE Covered for ages 64 years old & under diphenhydramine 25 mg, 50 mg OTC, AGE Covered for ages 64 years old & under BENADRYL diphenhydramine elixir diphenhydramine inj AGE Covered for ages 64 years old & under diphenhydramine liquid, syp OTC BENADRYL hydroxyzine HCl syrup AGE Covered for ages 12 years old & under hydroxyzine HCl tabs AGE Covered for ages 64 years old & under hydroxyzine pamoate 25 mg, 50 mg AGE Covered for ages 64 years old & under VISTARIL

BETA AGONISTS Inhalants Short Acting albuterol inhalation soln 0.083% albuterol inhalation soln 0.5% albuterol inhalation soln 0.63 mg/3 mL, 1.25 mg/3 mL QL Max #225 mL/month albuterol sulfate, CFC-free aerosol QL Max #1 inhaler/month albuterol sulfate, CFC-free aerosol QL Both brand and generic are covered. VENTOLIN HFA Max #1 inhaler/month levalbuterol tartrate, CFC-free aerosol ST, QL Requires trial of VENTOLIN; Max #1 XOPENEX HFA inhaler/month

Long Acting salmeterol xinafoate Max #60 units/month SEREVENT

Oral Agents albuterol syp metaproterenol tabs terbutaline

COUGH AND COLD Antihistamine/Decongestant Combinations brompheniramine/pseudoephedrine elixir OTC, QL Max #180 mL/fill; Max #360 mL/month DIMETAPP cetirizine/pseudoephedrine ext-rel tabs OTC, AGE, QL Covered for ages 4 years old & older; ZYRTEC-D Max #60/month diphenhydramine/phenylephrine liquid 6.25 mg-2.5 mg/5 mL OTC, Max #180 mL/fill; Max #360 mL/month TRIAMINIC NT QL diphenhydramine/phenylephrine tabs OTC BENADRYL-D loratadine/pseudoephedrine ext-rel 5 mg/120 mg OTC, QL Max #60/month CLARITIN-D 12 HOUR loratadine/pseudoephedrine ext-rel 10 mg/240 mg OTC, QL Max #30/month CLARITIN-D 24 HOUR promethazine/phenylephrine syp QL Max #180 mL/fill; Max #360 mL/month

Antitussives benzonatate caps 100 mg QL Max # 180/month TESSALON benzonatate caps 200 mg QL Max #150/month TESSALON dextromethorphan syp 7.5 mg/5 mL OTC, QL Covered for ages 4 years old & older; ROBITUSSIN CHILDREN'S Max #180 mL/fill; Max #360 mL/month

Antitussive Combinations Opioid codeine/guaifenesin AGE, QL Covered for ages 2 years old & older; Guaiatussin

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Max #180 mL/fill; Max #360 mL/month codeine/guaifenesin/pseudoephedrine QL Max #180 mL/fill; Max #360 mL/month Virtussin DAC codeine/promethazine syp AGE, QL Covered for ages 2 years old & older; Max #180 mL/fill; Max #360 mL/month codeine/promethazine/phenylephrine AGE, QL Covered for ages 2 years old & older; Max #180 mL/fill; Max #360 mL/month codeine/pyrilamine syp QL Max #180 mL/fill; Max #360 mL/month PRO-CLEAR AC hydrocodone/homatropine syp QL Max #180 mL/fill; Max #360 mL/month

Non-opioid dextromethorphan/brompheniramine/pseudoephedrine elixir OTC, Max #180 mL/fill; Max #360 mL/month Brotapp DM QL dextromethorphan/brompheniramine/pseudoephedrine syp QL Max #180 mL/fill; Max #360 mL/month Bromfed DM dextromethorphan/guaifenesin ext-rel 30-600 mg OTC, QL Max #60/month MUCINEX DM dextromethorphan/guaifenesin liquid 10-100 mg/5 mL, 10-200 mg/5 Max #180 mL/fill; Max #360 mL/month ROBITUSSIN DM mL OTC, QL dextromethorphan/guaifenesin syp 10-100 mg/5 mL OTC, QL Max #180 mL/fill; Max #360 mL/month ROBITUSSIN DM dextromethorphan/promethazine syp AGE, QL Covered for ages 4 years old & older; Max #180 mL/fill; Max #360 mL/month

Decongestant/Expectorant Combinations pseudoephedrine/guaifenesin ext-rel 60-600 mg OTC, AGE Covered for ages 4 years old & older MUCINEX D

Expectorants guaifenesin ext-rel 600 mg OTC, QL Max #60/month MUCINEX guaifenesin liq, syp OTC, AGE, QL Covered for ages 4 years old & older; ROBITUSSIN Max #180 mL/fill; Max #360 mL/month guaifenesin tabs OTC, AGE Covered for ages 4 years old & under ROBITUSSIN

CYSTIC FIBROSIS aztreonam lysine inhalation soln PA, SP CAYSTON dornase alfa PA, SP PULMOZYME tobramycin inhalation powder PA, SP TOBI PODHALER tobramycin inhalation soln PA, SP BETHKIS tobramycin inhalation soln PA, SP KITABIS PAK tobramycin inhalation soln PA, SP TOBI

LEUKOTRIENE MODULATORS montelukast QL Max #30/month SINGULAIR

MAST CELL STABILIZERS cromolyn sodium nasal spray OTC NASALCROM cromolyn soln for inhalation

MEDICAL SUPPLIES mask QL Max #1/year LITETOUCH, SIDESTREAM, SILICONE MASK peak flow meter OTC, QL Max #1/year AIRZONE, ASSESS METER FULL, ASTHMA CHECK, ASTHMAMENTOR, IN­ CHECK, MICROLIFE, MINI WRIGHT, PEAK AIR FLOW, PERSONAL BEST FULL, PIKO 1, POCKET PEAK METER, TRUZONE spacer QL Max #1/year AEROCHAMBER, BREATHERITE, EASIVENT, INSPIREASE, LITEAIR,

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MICROSPACER, OPTICHAMBER, POCKET CHAMBER, PRIMEAIRE, RITEFLO, VALVED HOLDING CHAMBER, VORTEX spacer OTC, QL Max #1/year ARIAL CHAMBER, EXPIRATORY MOUTHPIECE, PANDA, SIDESTREAM spacer/mask QL Max #4/year PRO COMFORT

NASAL ANTIHISTAMINES azelastine 0.1% spray QL Max #1 inhaler/month

NASAL STEROIDS flunisolide spray QL Max #1 inhaler/month fluticasone spray QL Max #1 inhaler/month fluticasone spray OTC, QL Max #1 inhaler/month FLONASE ALLERGY RELIEF triamcinolone acetonide spray OTC, QL Max #1 inhaler/month NASACORT ALLERGY 24HR

RESPIRATORY SYNCYTIAL VIRUS palivizumab PA, SP SYNAGIS

SEVERE ASTHMA AGENTS omalizumab PA, SP XOLAIR

STEROID/BETA AGONIST COMBINATIONS budesonide/formoterol AGE, QL Covered for ages 12 years & under; SYMBICORT Max #1 inhaler/month fluticasone/salmeterol QL Max #1 inhaler/month AIRDUO RESPICLICK fluticasone/salmeterol QL Max #1 inhaler/month WIXELA INHUB

STEROID INHALANTS beclomethasone breath-activated aerosol QL Max #1 inhaler/month; Max #2 months QVAR REDIHALER supply budesonide QL Max #1 inhaler/month; Max #2 months PULMICORT FLEXHALER supply budesonide inhalation susp AGE, QL Covered for ages 6 years old & under; PULMICORT RESPULES Max #120 mL/month fluticasone propionate QL Max #1 fill/month ARMONAIR RESPICLICK fluticasone propionate, CFC-free aerosol AGE, QL Covered for ages 12 years old & under; FLOVENT HFA Max #1 inhaler/month

XANTHINES theophylline elixir theophylline ext-rel tabs theophylline soln

MISCELLANEOUS acetylcysteine inhalation soln caffeine citrate oral soln AGE Covered for ages 1 year old & under ipratropium nasal spray QL Max #1 inhaler/month ATROVENT saline nasal spray OTC sodium chloride for inhalation 0.9% sodium chloride for inhalation 3% Nebusal sodium chloride for inhalation 7% HYPER-SAL

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TOPICAL DERMATOLOGY Acne Oral isotretinoin caps PA, QL Max #60 caps/month Claravis

Topical adapalene gel 0.1% OTC, QL Max #45 grams/month DIFFERIN OTC benzoyl peroxide gel 5% OTC benzoyl peroxide gel 10% OTC, QL Max #120 grams/month benzoyl peroxide liquid 4%, 5%, 10% OTC clindamycin pledgets, soln 1% CLEOCIN T erythromycin soln 2% sulfacetamide sodium/sulfur cleanser 10-5% tretinoin crm 0.025% ST Requires trial of DIFFERIN GEL 0.1% OTC

Actinic Keratosis diclofenac sodium gel 3% PA fluorouracil crm 0.5%, 5% PA

Antibiotics bacitracin oint OTC bacitracin zinc oint OTC bacitracin/neomycin/polymyxin B oint OTC NEOSPORIN gentamicin mupirocin oint QL Max #22 grams/month silver sulfadiazine crm 1% SSD

Antifungals ciclopirox topical soln 8% QL Max #6.6 mL/28 days PENLAC clotrimazole crm, soln clotrimazole/betamethasone crm QL Max #45 grams/month LOTRISONE ketoconazole crm 2% QL Max #60 grams/month ketoconazole shampoo 2% QL Max #120 mL/month NIZORAL miconazole crm 2% OTC MICATIN nystatin crm, oint nystatin powder QL Max #60 grams/month terbinafine crm 1% OTC LAMISIL AT tolnaftate crm, powder, aerosol powder OTC

Antipsoriatics Oral acitretin PA SORIATANE

Topical calcipotriene oint PA, QL Max #120 grams/month calcipotriene soln PA, QL Max #60 mL/month

Antiseborrheics selenium sulfide lotion 2.5%

Corticosteroids Low Potency hydrocortisone crm 2.5% QL Max #45 grams/month hydrocortisone crm 1%, lotion, oint hydrocortisone crm, oint OTC CORTIZONE hydrocortisone/aloe vera crm OTC

42

Medium Potency betamethasone valerate crm 0.1% QL Max #60 grams/month betamethasone valerate lotion 0.1% QL Max #60 mL/month betamethasone valerate oint 0.1% QL Max #45 grams/month fluticasone propionate crm 0.05% QL Max #45 grams/month CUTIVATE fluticasone propionate oint 0.005% QL Max #60 grams/month mometasone crm, oint 0.1% QL Max #45 grams/month ELOCON mometasone lotion 0.1% QL Max #60 mL/month ELOCON triamcinolone acetonide crm, oint 0.025% QL Max #16 grams/day, #480 grams/month triamcinolone acetonide crm, oint 0.1% QL Max #16 grams/day, #480 grams/month triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% QL Max #16 mL/day, #480 mL/month

High Potency betamethasone dipropionate augmented crm 0.05% QL Max #50 grams/month DIPROLENE AF betamethasone dipropionate augmented lotion 0.05% QL Max #60 mL/month DIPROLENE betamethasone dipropionate crm 0.05% QL Max #60 grams/month betamethasone dipropionate lotion 0.05% QL Max #60 mL/month betamethasone dipropionate oint 0.05% QL Max #45 grams/month fluocinonide crm, oint 0.05% QL Max #30 grams/month fluocinonide emollient crm 0.05% QL Max #30 grams/month fluocinonide soln 0.05% QL Max #60 mL/month triamcinolone acetonide crm 0.5% QL Max #16 grams/day, #480 grams/month triamcinolone acetonide oint 0.5%

Very High Potency betamethasone dipropionate augmented gel, oint 0.05% QL Max #50 grams/month DIPROLENE clobetasol propionate crm, oint 0.05% PA, QL Max #60 grams/month TEMOVATE clobetasol propionate soln 0.05% PA, QL Max #50 mL/month halobetasol propionate crm, oint 0.05% QL Max #50 grams/month ULTRAVATE

Emollients lactic acid (ammonium lactate) crm 12% LAC-HYDRIN lactic acid (ammonium lactate) lotion 12% LAC-HYDRIN vitamin E liq OTC

Immunomodulators pimecrolimus PA, QL Max #30 grams/month ELIDEL tacrolimus PA PROTOPIC

Local Analgesics capsaicin crm 0.025% OTC lidocaine patch 4% OTC, QL Max #30 patches/month Aspercreme

Local Anesthetics lidocaine crm 4% OTC, QL Preferred NDC 41167-0058-20; Max Aspercreme #153 grams/month lidocaine gel, jelly 2% lidocaine/prilocaine crm QL Max #30 grams/month

Rosacea metronidazole crm 0.75% METROCREAM metronidazole gel 0.75%

Scabicides and Pediculicides lindane QL Max #60 mL/month malathion ST, QL Requires trial of permethrin 1%; Max OVIDE

43

#59 mL/month permethrin cream rinse, lotion 1% OTC, QL Max #59 mL/month permethrin crm 5% QL Max #60 grams/month ELIMITE pyrethrins/piperonyl butoxide liq OTC, QL Max #59 mL/month PV Lice Killing Shampoo pyrethrins/piperonyl butoxide shampoo kit OTC, QL Max #1 box/month RID ESSENTIAL LICE KIT pyrethrins/piperonyl butoxide spray and shampoo kit QL Max #1 kit/month LICIDE TREATMENT KIT

Miscellaneous Skin and Mucous Membrane aluminum chloride DRYSOL collagenase QL Max #60 grams/month SANTYL docosanol OTC ABREVA imiquimod crm 5% QL Max #12 packets/month ALDARA insect repellent with DEET aerosol, lotion QL Max #360 mL/month podofilox soln CONDYLOX

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous 2%

Steroids - Mouth/Throat triamcinolone paste QL Max #5 grams/month

Miscellaneous chlorhexidine 0.12% Periogard clotrimazole troches QL Max #150/month sodium fluoride crm, gel PREVIDENT

OPHTHALMIC Antiallergics azelastine ST, QL Requires trial of ketotifen drops: Max #6 mL/month cromolyn sodium ketotifen OTC, QL Max #10 mL/month ZADITOR naphazoline/pheniramine OTC NAPHCON-A naphazoline/pheniramine OTC OPCON-A

Anti-infectives bacitracin bacitracin/neomycin/polymyxin B oint bacitracin/polymyxin B oint ciprofloxacin soln QL Max #10 mL/month CILOXAN erythromycin oint gentamicin oint, soln levofloxacin soln neomycin/polymyxin B/gramicidin soln NEOSPORIN ofloxacin soln OCUFLOX polymyxin B/trimethoprim soln POLYTRIM sulfacetamide oint, soln tobramycin soln TOBREX

Anti-infective/Anti-inflammatory Combinations bacitracin/neomycin/polymyxin B/hydrocortisone oint neomycin/polymyxin B/dexamethasone oint, soln MAXITROL sulfacetamide/prednisolone sodium phosphate soln tobramycin/dexamethasone susp 0.3%/0.1% TOBRADEX

44

Anti-inflammatories Nonsteroidal diclofenac sodium 0.1% flurbiprofen sodium ketorolac 0.5% QL Max #10 mL/month ACULAR

Steroidal dexamethasone sodium phosphate fluorometholone susp 0.1% QL Max #15 mL/month FML LIQUIFILM prednisolone acetate 1% PRED FORTE prednisolone sodium phosphate soln 1%

Antivirals trifluridine VIROPTIC

Beta-blockers betaxolol 0.5% carteolol levobunolol BETAGAN metipranolol timolol maleate soln TIMOPTIC

Carbonic Anhydrase Inhibitors dorzolamide QL Max #10 mL/month TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate QL Max #10 mL/month COSOPT

Mydriatics atropine sulfate oint atropine sulfate soln ISOPTO ATROPINE cyclopentolate 1%, 2% CYCLOGYL homatropine tropicamide MYDRIACYL

Parasympathomimetics pilocarpine soln ISOPTO CARPINE

Prostaglandins latanoprost QL Max #2.5 mL/25 days XALATAN

Sympathomimetics apraclonidine 0.5% QL Max #10 mL/month IOPIDINE brimonidine 0.2%

Miscellaneous artificial tears oint OTC Refresh Lacri-lube, Refresh PM carboxymethylcellulose sodium soln 0.5% OTC REFRESH TEARS carboxymethylcellulose sodium soln 1% OTC REFRESH CELLUVISC, REFRESH LIQUIGEL echothiophate iodide PHOSPHOLINE IODIDE hypromellose soln 0.4% OTC phenylephrine 2.5% polyethylene glycol/propylene glycol gel OTC SYSTANE GEL polyethylene glycol/propylene glycol soln OTC SYSTANE, SYSTANE ULTRA polyvinyl alcohol soln 1.4% OTC proparacaine 0.5%

45 propylene glycol/glycerin soln 1-0.3% OTC sodium chloride oint, soln 5% OTC

OTIC Anti-infectives acetic acid ciprofloxacin otic soln QL Max #14 mL/month CETRAXAL ofloxacin otic QL Max #5 mL/month

Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone ciprofloxacin/dexamethasone QL Max #7.5 mL/month CIPRODEX neomycin/polymyxin B/hydrocortisone

46

NON-DISCRIMINATION STATEMENT

47

48

INDEX

A ALDACTAZIDE, 18 ALDACTONE, 16 abaloparatide, 24 ALDARA, 44 abatacept subcutaneous, 32 alendronate 35 mg, 70 mg, 24 abiraterone, 14 alendronate 5 mg, 10 mg, 40 mg, 24 abiraterone 250 mg, 14 ALEVE, 10 abiraterone 500 mg, 14 alfuzosin ext-rel, 30 ABREVA, 44 aliskiren, 18 acarbose 100 mg, 22 ALKA-SELTZER GOLD, 27 acarbose 25 mg, 50 mg, 22 ALKA-SELTZER HEARTBURN, 27 ACCUPRIL, 16 ALKERAN, 14 ACCURETIC, 16 allopurinol 100 mg, 10 acebutolol, 17 allopurinol 300 mg, 10 acetaminophen caps 500 mg, 11 alogliptin, 22 acetaminophen chew tabs 80 mg, 11 alogliptin/metformin, 22 acetaminophen ext-rel 650 mg, 11 alogliptin/pioglitazone, 22 acetaminophen liq, soln, susp 160 mg/5 mL, 11 ALTACE, 16 acetaminophen orally disintegrating tabs 160 mg, 11 altretamine, 14 acetaminophen orally disintegrating tabs 80 mg, 11 aluminum chloride, 44 acetaminophen supp 120 mg, 11 aluminum hydroxide gel susp, 27 acetaminophen supp 325 mg, 11 aluminum hydroxide/magnesium carbonate, 27 acetaminophen supp 650 mg, 11 aluminum hydroxide/magnesium hydroxide/simethicone, 27 acetaminophen tabs 325 mg, 500 mg, 11 aluminum hydroxide/magnesium trisilicate, 27 acetazolamide, 18 amantadine caps, 20 acetazolamide ext-rel, 18 amantadine syp, 20 acetic acid, 46 AMARYL, 23 acetic acid/hydrocortisone, 46 ambrisentan, 19 acetylcysteine inhalation soln, 41 AMERGE, 20 acitretin, 42 amiloride, 18 ACTEMRA, 32 amiloride/hydrochlorothiazide, 18 ACTEMRA ACTPEN, 32 amiodarone, 16 ACTIGALL, 28 AMITIZA, 29 ACTIVELLA, 26 amlodipine, 17 ACTOS, 23 amlodipine/valsartan, 16 ACULAR, 45 amoxicillin caps, tabs, 12 acyclovir caps, tabs, 13 amoxicillin chew tabs, susp, 12 acyclovir susp, 13 amoxicillin/clavulanate chew tabs, susp, 12 ADACEL, 33 amoxicillin/clavulanate ext-rel, 12 ADALAT CC, 18 amoxicillin/clavulanate tabs, 12 adalimumab, 32 ampicillin caps, 12 adapalene gel 0.1%, 42 ampicillin susp, 12 ADCIRCA, 19 AMPYRA, 21 adefovir dipivoxil, 13 anagrelide, 32 ADEMPAS, 19 anastrozole, 14 ADMELOG, 23 apalutamide, 14 ADMELOG SOLOSTAR, 23 APETEX, 36 AEROCHAMBER, 40 APETIGEN, 36 AFINITOR, 15 APETIGEN PLUS, 36 AFINITOR DISPERZ, 15 apixaban starter pack, 31 AFLURIA, 33 apixaban tabs, 31 AFLURIA QUAD, 33 apraclonidine 0.5%, 45 AFLURIA QUAD PF, 33 apremilast 30 mg, 32 AGRYLIN, 32 apremilast starter pack, 32 AIMOVIG, 20 Apri, 24 AIRDUO RESPICLICK, 41 APRISO, 28 AIRZONE, 40 Aquadeks, 37 ALBA-LYBE, 36 AQUADEKS, 37 albuterol inhalation soln 0.083%, 39 AQUA-E, 38 albuterol inhalation soln 0.5%, 39 Aqueous E, 38 albuterol inhalation soln 0.63 mg/3 mL, 1.25 mg/3 mL, 39 Aranelle, 25 albuterol sulfate, CFC-free aerosol, 39 ARANESP, 32 albuterol syp, 39 ARAVA, 32 alcohol swabs, 23 ARIAL CHAMBER, 41

49

ARICEPT, 19 benzocaine/docusate enema, 29 ARIMIDEX, 14 benzonatate caps 100 mg, 39 ARKALIOX, 38 benzonatate caps 200 mg, 39 ARMONAIR RESPICLICK, 41 benzoyl peroxide gel 10%, 42 ARMOUR THYROID, 27 benzoyl peroxide gel 5%, 42 AROMASIN, 15 benzoyl peroxide liquid 4%, 5%, 10%, 42 artificial tears oint, 45 BETAGAN, 45 ASACOL HD, 28 betamethasone dipropionate augmented crm 0.05%, 43 Aspercreme, 43 betamethasone dipropionate augmented gel, oint 0.05%, 43 aspirin buffered 325 mg, 10 betamethasone dipropionate augmented lotion 0.05%, 43 aspirin chew tabs 81 mg, 10, 32 betamethasone dipropionate crm 0.05%, 43 aspirin delayed-rel 325 mg, 10 betamethasone dipropionate lotion 0.05%, 43 aspirin delayed-rel 81 mg, 10, 32 betamethasone dipropionate oint 0.05%, 43 aspirin supp 300 mg, 600 mg, 10 betamethasone valerate crm 0.1%, 43 aspirin tabs 325 mg, 10 betamethasone valerate lotion 0.1%, 43 ASSESS METER FULL, 40 betamethasone valerate oint 0.1%, 43 ASTHMA CHECK, 40 BETAPACE, 16 ASTHMAMENTOR, 40 BETAPACE AF, 16 ATABEX OB, 35 betaxolol, 17 atenolol, 17 betaxolol 0.5%, 45 atenolol/chlorthalidone, 17 bethanechol, 31 atorvastatin, 17 BETHKIS, 40 atovaquone, 13 BEVESPI AEROSPHERE, 38 atropine sulfate oint, 45 bexarotene caps, 15 atropine sulfate soln, 45 bicalutamide, 14 ATROVENT, 41 biotin, 36 ATROVENT HFA, 38 biotin liq, 36 AUGMENTIN, 12 biotin tab 800 mcg, 36 AUGMENTIN XR, 12 bisacodyl delayed-rel, 29 AVALIDE, 16 bisacodyl enema, 29 AVAPRO, 16 bisacodyl supp, 29 AVONEX, 21 bismuth subsalicylate, 27 AYGESTIN, 26 bisoprolol 10 mg, 17 azathioprine, 32 bisoprolol 5 mg, 17 azelastine, 44 bisoprolol/hydrochlorothiazide 10 mg/6.25 mg, 17 azelastine 0.1% spray, 41 bisoprolol/hydrochlorothiazide 2.5 mg/6.25 mg, 5 mg/6.25 mg, 17 azithromycin powder packets, tabs, 12 BLADDER 2.2, 38 azithromycin susp, 12 blood glucose monitoring kits, 23 aztreonam lysine inhalation soln, 40 blood glucose test strips, 23 AZULFIDINE, 28 BONIVA, 24 AZULFIDINE EN-TABS, 28 BOOSTRIX, 33 B bosentan soluble tabs, 19 bosentan tabs, 19 bacitracin, 44 BRAFTOVI, 15 bacitracin oint, 42 BREATHERITE, 40 bacitracin zinc oint, 42 brewers yeast, 36 bacitracin/neomycin/polymyxin B oint, 42, 44 brimonidine 0.2%, 45 bacitracin/neomycin/polymyxin B/hydrocortisone oint, 44 brodalumab, 32 bacitracin/polymyxin B oint, 44 Bromfed DM, 40 baclofen 10 mg, 21 bromocriptine 2.5 mg, 20 baclofen 20 mg, 21 bromocriptine 5 mg, 20 BACTRIM, 12 brompheniramine/pseudoephedrine elixir, 39 balsalazide, 28 Brotapp DM, 40 BARACLUDE, 13 budesonide, 41 baricitinib, 32 budesonide inhalation susp, 41 BASAGLAR KWIKPEN, 22 budesonide/formoterol, 41 beclomethasone breath-activated aerosol, 41 BUFFERIN, 10 BENADRYL, 39 bumetanide, 18 BENADRYL-D, 39 bupropion ext-rel, 21 benazepril 10 mg, 40 mg, 15 busulfan, 14 benazepril 5 mg, 20 mg, 15 butalbital/acetaminophen 50/325 mg, 11 benazepril/amlodipine, 16 butalbital/acetaminophen/caffeine 50/325/40 mg, 11 BENEFIBER, 30 butalbital/acetaminophen/caffeine/codeine 50/325/40/30 mg, 10 BENTYL, 28 butalbital/aspirin/caffeine, 11 benznidazole, 13 butalbital/aspirin/caffeine/codeine 50/325/40/30 mg, 10 BENZNIDAZOLE, 13

50

C CAYSTON, 40 cabergoline, 27 cefaclor caps, 12 caffeine citrate oral soln, 41 cefaclor susp, 12 CALAN, 18 cefadroxil caps, tabs, 11 CALAN SR, 18 cefadroxil susp, 11 CALCIONATE, 33 cefdinir caps, 12 calcipotriene oint, 42 cefdinir susp, 12 calcipotriene soln, 42 cefixime caps, 12 calcitonin-salmon nasal, 24 cefixime susp 100 mg/5 mL, 200 mg/5 mL, 12 calcitriol caps, 26 cefixime susp 500 mg/5 mL, 12 calcitriol soln, 26 cefpodoxime susp, 12 calcium acetate 667 mg, 26 cefpodoxime tabs, 12 calcium carbonate, 27, 33 cefprozil susp, 12 calcium carbonate/magnesium hydroxide, 27 cefprozil tabs, 12 calcium carbonate/magnesium hydroxide/simethicone, 27 cefuroxime axetil tabs, 12 calcium carbonate/simethicone, 27 CELEBREX, 10 calcium carbonate/vitamin D, 33 celecoxib, 10 calcium carbonate/vitamin D/minerals, 33 CELLCEPT, 33 calcium chloride inj, 33 cellulose powder, 29 calcium citrate, 33 CEO-TWO, 29 calcium citrate/vitamin D, 33 cephalexin caps 250 mg, 500 mg, 11 calcium glubionate, 33 cephalexin susp, 11 calcium gluconate, 33 CERALYTE 70, 36 calcium glycerophosphate, 27 CEREFOLIN, 34 calcium lactate, 33 CEREFOLIN NAC, 38 calcium phosphate/vitamin D, 33 certolizumab pegol, 32 calcium polycarbophil, 29 cervical cap, 25 calcium polycarbophil chew tabs, 29 cetirizine soln, syp, 38 calcium, oyster shell, 33 cetirizine tabs, 38 calcium/boron, 33 cetirizine/pseudoephedrine ext-rel tabs, 39 calcium/folic acid/vitamin B6/vitamin E/herbs, 38 CETRAXAL, 46 calcium/magnesium, 34 CHANTIX, 22 calcium/magnesium/vitamin C, 34 CHEMET, 32 calcium/magnesium/vitamin D, 34 chlorambucil, 14 calcium/magnesium/zinc, 34 chlorhexidine 0.12%, 44 calcium/phosphorus/vitamin D, 34 chloroquine, 13 calcium/vitamin C/vitamin D, 34 chlorothiazide oral susp, 18 calcium/vitamin D, 34 chlorothiazide tabs, 18 calcium/vitamin D/minerals, 34 chlorpheniramine ext-rel, 39 calcium/vitamin D/vitamin K, 34 chlorpheniramine tabs, 39 CALTRATE + D, 33 chlorpropamide, 23 CALTRATE 600 + D PLUS, 33 chlorthalidone 25 mg, 50 mg, 18 CALTRATE 600 + MINERALS, 34 CHLOR-TRIMETON, 39 canagliflozin, 23 chlorzoxazone 500 mg, 21 canagliflozin/metformin, 23 cholecalciferol caps, chew tabs 400 units, liquid 400 units/mL, tabs, 36 canagliflozin/metformin ext-rel, 23 cholecalciferol wafer 50,000 units, 36 capecitabine, 14 cholestyramine cans, 16, 17 capsaicin crm 0.025%, 43 cholestyramine packets, 17 CARAFATE, 30 choline magnesium trisalicylate liq, 10 carbidopa/levodopa, 20 ciclopirox topical soln 8%, 42 carbidopa/levodopa ext-rel, 20 cilostazol, 32 carbidopa/levodopa orally disintegrating tabs, 20 CILOXAN, 44 carbinoxamine, 39 cimetidine tabs, 28 carbonyl iron, 34 CIMZIA, 32 carboxymethylcellulose sodium soln 0.5%, 45 cinacalcet 30 mg, 60 mg, 24 carboxymethylcellulose sodium soln 1%, 45 cinacalcet 90 mg, 24 CARDIZEM, 18 CIPRO, 12 CARDIZEM CD, 18 CIPRODEX, 46 CARDIZEM LA, 18 ciprofloxacin otic soln, 46 CARDURA, 16 ciprofloxacin soln, 44 carteolol, 45 ciprofloxacin susp, 12 carvedilol, 17 ciprofloxacin tabs 250 mg, 500 mg, 750 mg, 12 CASODEX, 14 ciprofloxacin/dexamethasone, 46 castor oil, 29 CITRACAL + D, 33 CATAPRES, 16 Citroma, 29 CAYA, 25 Claravis, 42

51 clarithromycin susp, 12 cyanocobalamin 100 mcg, 500 mcg, 1000 mcg, 36 clarithromycin tabs, 12 cyanocobalamin inj 1000 mcg/mL, 36 CLARITIN OTC, 38, 39 cyclobenzaprine 5 mg, 10 mg, 21 CLARITIN-D 12 HOUR, 39 CYCLOGYL, 45 CLARITIN-D 24 HOUR, 39 cyclopentolate 1%, 2%, 45 CLASSIC PRENATAL, 35 CYCLOPHOSPHAMIDE, 14 clemastine, 39 cyclophosphamide caps, 14 CLEOCIN, 13, 14, 31 cycloserine, 13 CLEOCIN T, 42 cyclosporine caps, 33 CLIMARA, 25 cyclosporine, modified, 33 clindamycin caps, 13 cyclosporine, modified soln, 33 clindamycin crm, 31 cyproheptadine, 39 clindamycin pledgets, soln 1%, 42 CYTO B7, 36 clindamycin soln, 14 CYTOMEL, 27 clobetasol propionate crm, oint 0.05%, 43 CYTOTEC, 30 clobetasol propionate soln 0.05%, 43 Cytra-2, 31 clonidine tabs, 16 CYTRA-K, 31 clopidogrel 300 mg, 32 D clopidogrel 75 mg, 32 dalfampridine ext-rel, 21 clotrimazole crm, 31 danazol, 25 clotrimazole crm, soln, 42 dapsone, 14 clotrimazole troches, 44 DARAPRIM, 14 clotrimazole/betamethasone crm, 42 darbepoetin alfa, 32 CO2-releasing supp, 29 DAURISMO, 15 codeine sulfate, 10 DDAVP, 27 codeine/acetaminophen soln 12 mg/120 mg/5 mL, 10 DELZICOL, 28 codeine/acetaminophen tabs, 10 DEMADEX, 18 codeine/guaifenesin, 39 DEPO-PROVERA, 25 codeine/guaifenesin/pseudoephedrine, 40 DEPO-TESTOSTERONE, 22 codeine/promethazine syp, 40 desmopressin spray, 27 codeine/promethazine/phenylephrine, 40 desmopressin tabs, 27 codeine/pyrilamine syp, 40 desogestrel/EE, 24 COLACE, 29 desogestrel/EE 0.1-0.025/0.125-0.025/0.15-0.025 mg-mg, 25 COLAZAL, 28 desogestrel/EE 0.15/30, 24 colchicine caps, 10 DETROL, 31 colchicine tabs, 10 DETROL LA, 31 colchicine/probenecid, 10 DEWEES CARMINATIVE, 27 COLCRYS, 10 dexamethasone elixir, soln 0.5 mg/5 mL, 26 COLESTID, 17 dexamethasone sodium phosphate, 45 colestipol granules, tabs, 17 dexamethasone tabs, 26 collagenase, 44 dextromethorphan syp 7.5 mg/5 mL, 39 COLOX, 38 dextromethorphan/brompheniramine/pseudoephedrine elixir, 40 COLYTE, 29 dextromethorphan/brompheniramine/pseudoephedrine syp, 40 COMBIVENT RESPIMAT, 38 dextromethorphan/guaifenesin ext-rel 30-600 mg, 40 COMPAZINE, 28 dextromethorphan/guaifenesin liquid 10-100 mg/5 mL, 10-200 mg/5 mL, COMPLETENATE CHEW, 36 40 condoms, male and female, 25 dextromethorphan/guaifenesin syp 10-100 mg/5 mL, 40 CONDYLOX, 44 dextromethorphan/promethazine syp, 40 COPAXONE, 21 DHA OMEGA-3, 36 COREG, 17 DIALYVITE 800 PLUS D, 36 CORGARD, 17 diaphragm arc-spring, 25 corn dextrin powder, 29 diaphragm wide seal, 25 CORTEF, 26 diclofenac sodium 0.1%, 45 CORTIZONE, 42 diclofenac sodium delayed-rel, 10 CORVITE, 34 diclofenac sodium ext-rel, 10 COSOPT, 45 diclofenac sodium gel 1%, 10 COUMADIN, 31 diclofenac sodium gel 3%, 42 COZAAR, 16 dicloxacillin, 12 CREON, 30 dicyclomine, 28 CRESTOR, 17 DIFFERIN OTC, 42 cromolyn sodium, 44 DIFLUCAN, 12 cromolyn sodium nasal spray, 40 digoxin tabs 125 mcg, 250 mcg, 18 cromolyn soln for inhalation, 40 DILAUDID, 11 CUTIVATE, 43 diltiazem, 18 CVS PRENATAL, 35 diltiazem ext-rel caps, 18 CVS PRENATAL CHEW GUMMY, 36

52 diltiazem ext-rel caps 120 mg, 240 mg, 300 mg, 18 ELOCON, 43 diltiazem ext-rel caps 180 mg, 18 EMCYT, 14 diltiazem ext-rel tabs 180 mg, 300 mg, 18 empagliflozin, 23 Dilt-XR, 18 empagliflozin/metformin, 23 dimenhydrinate tabs, 28 empagliflozin/metformin ext-rel, 23 DIMETAPP, 39 enalapril 10 mg, 20 mg, 15 dimethyl fumarate delayed-rel caps, 21 enalapril 2.5 mg, 5 mg, 15 dimethyl fumarate delayed-rel starter pack, 21 enalapril oral soln, 15 DIOVAN, 16 enalapril/hydrochlorothiazide, 16 DIOVAN HCT, 16 enasidenib, 15 diphenhydramine 25 mg, 50 mg, 39 ENBREL, 32 diphenhydramine elixir, 39 ENBREL SURECLICK, 32 diphenhydramine inj, 39 encorafenib, 15 diphenhydramine liquid, syp, 39 ENDARI, 32 diphenhydramine/phenylephrine liquid 6.25 mg-2.5 mg/5 mL, 39 ENEMEEZ PLUS, 29 diphenhydramine/phenylephrine tabs, 39 ENFAMIL ENFALYTE, 36 diphenoxylate/atropine tabs, 27 ENGERIX-B, 33 DIPROLENE, 43 enoxaparin pre-filled syringes, 31 DIPROLENE AF, 43 entecavir tabs, 13 dipyridamole, 32 ENTRESTO, 18 disopyramide, 16 enzalutamide, 14 DITROPAN XL, 31 EPANED, 15 DIURIL, 18 epinephrine 0.3 mg, 38 docosahexaenoic acid 200 mg, 36 epinephrine auto-injector, 38 docosanol, 44 EPIVIR-HBV, 13 Docu Liquid, 29 epoetin alfa, 32 docusate calcium, 29 epoetin alfa-epbx, 32 docusate sodium 50 mg, 250 mg, 29 EPOGEN, 32 docusate sodium caps 100 mg, 29 EPSOM SALT, 29 docusate sodium enema, 29 EQL PRENATAL FORMULA, 35 docusate sodium liq 50 mg/15 mL, 29 EQUALACTIN, 29 docusate sodium liq 50 mg/5 mL, 29 erenumab-aooe 140 mg, 20 DOCUSOL KIDS, 29 erenumab-aooe 70 mg, 20 donepezil tabs 10 mg, 19 ergocalciferol (D2) caps, 36 donepezil tabs 5 mg, 19 ergocalciferol (D2) drops, 36 dornase alfa, 40 ERIVEDGE, 15 dorzolamide, 45 ERLEADA, 14 dorzolamide/timolol maleate, 45 ertugliflozin, 23 doxazosin 1 mg, 2 mg, 4 mg, 16 ertugliflozin/metformin, 23 doxazosin 8 mg, 16 erythromycin oint, 44 doxycycline hyclate tabs 100 mg, 12 erythromycin soln 2%, 42 doxycycline monohydrate 50 mg, 100 mg, 12 ESGIC, 11 doxycycline monohydrate susp, 12 esomeprazole magnesium delayed-rel, 30 dronabinol, 28 ESTRACE, 25 drospirenone/EE 3/20, 24 ESTRACE CREAM, 26 drospirenone/EE 3/30, 24 estradiol, 25 drospirenone/EE/levomefolate 3/30 and levomefolate, 24 estradiol vaginal crm, 26 DROXIA, 15 estradiol vaginal tabs, 26 DRYSOL, 44 estradiol weekly, 25 DULCOLAX, 29 estradiol, twice weekly, 25 DURAGESIC, 10 estradiol/norethindrone acetate, 26 DYAZIDE, 18 estramustine, 14 E estrogens, conjugated, 25 estrogens, conjugated/medroxyprogesterone, 26 EASIVENT, 40 estrogens, esterified, 25 echothiophate iodide, 45 etanercept, 32 EC-NAPROSYN, 10 ethambutol, 13 EE/norethindrone acetate 0.5 mg/2.5 mcg, 26 ethionamide, 13 EE/norethindrone acetate 1 mg/5 mcg, 26 ethynodiol diacetate/EE 1/35, 24 ELDEPRYL, 20 ethynodiol diacetate/EE 1/50, 24 electrolyte soln, oral, 36 etodolac, 10 ELIDEL, 43 etonogestrel/EE ring, 25 ELIMITE, 44 etoposide, 15 ELIQUIS, 31 EUFLEXXA, 11 ELLA, 25 everolimus, 15 ELMIRON, 31 everolimus soluble tabs, 15

53

EVISTA, 27 FLEET, 29 exemestane, 15 FLEET BISACODYL, 29 EXFORGE, 16 FLEET ENEMA, 29 EXPIRATORY MOUTHPIECE, 41 FLEET MINERAL OIL, 29 E-Z GAS II, 27 FLEET PEDIA-LAX, 29 ezetimibe, 17 FLOMAX, 30 F FLONASE ALLERGY RELIEF, 41 FLOVENT HFA, 41 famciclovir, 13 FLUAD, 33 famotidine tabs, 28 FLUARIX QUAD, 33 FARESTON, 14 FLUBLOK QUAD, 33 FARYDAK, 15 FLUCELVAX QUAD, 33 febuxostat, 10 fluconazole susp, 12 FELDENE, 10 fluconazole tabs, 12 felodipine ext-rel 10 mg, 17 fludrocortisone, 26 felodipine ext-rel 2.5 mg, 5 mg, 17 FLULAVAL QUAD, 33 FEMARA, 15 FLUMADINE, 13 FEMCAP, 25 flunisolide spray, 41 FEMHRT, 26 fluocinonide crm, oint 0.05%, 43 fenofibrate caps 50 mg, 17 fluocinonide emollient crm 0.05%, 43 fenofibrate micronized 43 mg, 17 fluocinonide soln 0.05%, 43 fenofibrate micronized 67 mg, 134 mg, 200 mg, 17 fluorometholone susp 0.1%, 45 fenofibrate tabs 48 mg, 145 mg, 17 fluorouracil crm 0.5%, 5%, 42 fenofibrate tabs 54 mg, 160 mg, 17 flurbiprofen, 10 fenofibric acid, 17 flurbiprofen sodium, 45 fenofibric acid delayed-rel, 17 flutamide, 14 fentanyl transdermal 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 fluticasone propionate, 41 mcg/hr, 10 fluticasone propionate crm 0.05%, 43 FEOSOL, 34 fluticasone propionate oint 0.005%, 43 FERGON, 34 fluticasone propionate, CFC-free aerosol, 41 FER-IN-SOL, 34 fluticasone spray, 41 FERRETTS, 34 fluticasone/salmeterol, 41 FERRIMIN 150, 34 FLUZONE, 33 ferrous fumarate, 34 FLUZONE QUAD, 33 ferrous fumarate/folic acid/docusate sodium/vitamin B-complex/vitamin C, 34 FML LIQUIFILM, 45 ferrous fumarate/folic acid/intrinsic factor/vitamin B12/vitamin C, 34 FOLGARD RX, 34 ferrous fumarate/folic acid/vitamin B12/vitamin C, 34 folic acid 1 mg, 34 ferrous fumarate/folic acid/vitamin B-complex/minerals, 34 folic acid 400 mcg, 34 ferrous gluconate, 34 folic acid 800 mcg, 34 ferrous sulfate, 34 folic acid/vitamin B6/vitamin B12, 34 ferrous sulfate delayed-rel, 34 folinic acid/vitamin B6/vitamin B12, 34 ferrous sulfate drops 15 mg/mL, 34 FOLINIC-PLUS, 34 ferrous sulfate elixir, liquid 220 mg/5 mL, 34 Foltabs 800, 34 ferrous sulfate ext-rel, 34 FOLTX, 34 ferrous sulfate syrup 300 mg/5 mL, 34 FORTEO, 24 ferrous sulfate/misc herbs, 38 FOSAMAX, 24 fiber chew tabs, 29 fosinopril 10 mg, 15 fiber liquid, 29 fosinopril 20 mg, 40 mg, 15 Fiber Powder, 29 FOSRENOL, 26 Fiber Weight Management, 38 FULL SPECTRUM B WITH C, 36 FIBERCON, 29 FULPHILA, 32 FIBER-STAT LIQ, 38 FURADANTIN, 14 FIBRICOR, 17 furosemide soln, 18 filgrastim, 32 furosemide tabs, 18 filgrastim-aafi, 32 filgrastim-sndz, 32 G finasteride, 30 GAS-X, 30 fingolimod, 21 Gavilyte-H Kit, 29 FIORINAL, 11 GAVISCON, 27 FIRST-LANSOPRAZOLE, 30 GELUSIL, 27 FIRST-OMEPRAZOLE, 30 gemfibrozil, 17 FIRVANQ, 14 GENERESS FE, 24 FISH OIL, 37 gentamicin, 42 FLAGYL, 14 gentamicin oint, soln, 44 flavoxate hydrochloride, 30 Gianvi, 24 flecainide, 16 GILENYA, 21

54 glasdegib maleate, 15 HUMULIN R U-500, 23 glatiramer, 21 HYCAMTIN, 15 glimepiride, 23 hydralazine 10 mg, 25 mg, 50 mg, 19 glipizide, 23 hydralazine 100 mg, 19 glipizide ext-rel, 23 hydralazine inj, 19 glipizide/metformin, 22 HYDREA, 15 GLUCAGEN HYPOKIT, 26 hydrochlorothiazide, 18 GLUCAGON EMERGENCY KIT, 26 HYDROCIL, 29 glucagon, human recombinant, 26 hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg, 11 GLUCOPHAGE, 22 hydrocodone/acetaminophen soln 7.5/325 mg/15 mL, 11 GLUCOPHAGE XR, 22 hydrocodone/homatropine syp, 40 GLUCOTROL, 23 hydrocortisone, 26 GLUCOTROL XL, 23 hydrocortisone crm 1%, lotion, oint, 42 glyburide, 23 hydrocortisone crm 2.5%, 42 glyburide, micronized, 23 hydrocortisone crm, oint, 42 glyburide/metformin tabs 1.25/250 mg, 22 hydrocortisone rectal crm 2.5%, 30 glyburide/metformin tabs 2.5/500 mg, 5/500 mg, 22 hydrocortisone/aloe vera crm, 42 glycerin enema, 29 hydromorphone soln 1 mg/mL, 11 glycerin supp, 29 hydromorphone supp, 11 GLYCOPHOS, 34 hydromorphone tabs 2 mg, 4 mg, 11 glycopyrrolate tabs 1 mg, 2 mg, 28 hydroxychloroquine, 32 glycopyrrolate/formoterol, 38 hydroxyurea, 15 GLYNASE, 23 hydroxyzine HCl syrup, 39 GNP PRENATAL, 35 hydroxyzine HCl tabs, 39 GOLYTELY, 29 hydroxyzine pamoate 25 mg, 50 mg, 39 GOODSENSE PRENATAL, 35 HYFIBER WITH FOS, 29 goserelin acetate, 15 hyoscyamine sulfate, 28 granisetron tabs, 28 hyoscyamine sulfate ext-rel tabs, 28 GRANIX, 32 HYPER-SAL, 41 griseofulvin microsize susp, 12 hypromellose soln 0.4%, 45 griseofulvin ultramicrosize, 12 HYZAAR, 16 Guaiatussin, 39 I guaifenesin ext-rel 600 mg, 40 I.L.X. B-12, 34 guaifenesin liq, syp, 40 ibandronate, 24 guaifenesin tabs, 40 ibuprofen caps, 10 guanfacine, 16 ibuprofen chew tabs, tabs, 10 GYNE-LOTRIMIN, 31 ibuprofen drops 50 mg/1.25 mL, 10 GYNOL II, 25 ibuprofen susp 100 mg/5 mL, 10 H ibuprofen tabs, 10 halobetasol propionate crm, oint 0.05%, 43 ICAR PEDS, 34 HAVRIX, 33 ICAR-C, 35 HEMANGEOL, 17 IDHIFA, 15 Hematogen, 34 imiquimod crm 5%, 44 HEMATOGEN FA, 34 IMITREX, 21 HEMENATAL OB, 36 IMURAN, 32 HEMOCYTE, 34 Inatal GT, 35 heparin vials 5000 units/mL, 10000 units/mL, 31 IN-CHECK, 40 hepatitis A vaccine, 33 INCRELEX, 26 hepatitis A, hepatitis B vaccine, 33 INCRUSE ELLIPTA, 38 hepatitis B vaccine, 33 indapamide, 18 HEPLISAV-B, 33 INDERAL LA, 17 HEPSERA, 13 indomethacin caps, 10 HEXALEN, 14 indomethacin ext-rel, 10 HIPREX, 31 influenza virus vaccine quadrivalent, 33 HM PRENATAL, 35 influenza virus vaccine, quadrivalent recombinant, 33 homatropine, 45 influenza virus vaccine, trivalent, 33 HUMALOG, 23 inositol niacinate caps, 36 HUMALOG MIX, 23 insect repellent with DEET aerosol, lotion, 44 HUMALOG MIX KWIKPEN, 23 INSPIREASE, 40 HUMIRA, 32 insulin aspart protamine/insulin aspart pens, 22 HUMULIN 70/30, 23 insulin aspart protamine/insulin aspart vials, 22 HUMULIN 70/30 KWIKPEN, 23 insulin glargine pens, 22 HUMULIN N, 23 insulin human vials, 22, 23 HUMULIN N KWIKPEN, 23 insulin isophane human 70%/regular 30% pens, 23 HUMULIN R, 22 insulin isophane human 70%/regular 30% vials, 23

55 insulin isophane human pens, 23 Kionex, 26 insulin isophane human vials, 23 KITABIS PAK, 40 insulin lispro pens, 23 KLOR-CON M10, 34 insulin lispro protamine/insulin lispro pens, 23 KLOR-CON M20, 34 insulin lispro protamine/insulin lispro vials, 23 KONDREMUL, 29 insulin lispro vials, 23 KONSYL, 29 insulin needles, 23 KP PRENATAL, 35 insulin syringes, 23 K-PHOS, 31 interferon alfa-2b, 32 K-PHOS NO. 2, 31 interferon beta-1a, 21 KRINTAFEL, 13 INTRON A, 32 L INVOKAMET, 23 labetalol, 17 INVOKAMET XR, 23 LAC-HYDRIN, 43 INVOKANA, 23 lactic acid (ammonium lactate) crm 12%, 43 IOPIDINE, 45 lactic acid (ammonium lactate) lotion 12%, 43 ipratropium nasal spray, 41 lactulose soln, 29 ipratropium soln, 38 LAMISIL AT, 42 ipratropium, CFC-free aerosol, 38 lamivudine tabs 100 mg, 13 ipratropium/albuterol soln, 38 lancets, 23 ipratropium/albuterol, CFC-free aerosol, 38 LANOXIN, 18 irbesartan, 16 lansoprazole delayed-rel caps, 30 irbesartan/hydrochlorothiazide, 16 lansoprazole delayed-rel caps 15 mg, 30 IRON CHEWS, 34 lansoprazole delayed-rel caps 30 mg, 30 iron combination, 34 lansoprazole susp, 30 iron combination elixir, 34 lanthanum chew tabs, 26 iron heme polypeptide, 34 LASIX, 18 iron polysaccharides complex, 35 latanoprost, 45 iron polysaccharides complex/vitamin B12/folic acid, 35 leflunomide, 32 iron/vitamin B12/vitamin C/folic acid, 35 lenalidomide, 15 iron/vitamin C, 35 LETAIRIS, 19 iron/vitamins, 35 letrozole, 15 isoniazid syrup, 13 leucovorin calcium tabs, 14 isoniazid tabs, 13 LEUKERAN, 14 ISOPTO ATROPINE, 45 leuprolide acetate inj 1 mg/0.2 mL, 15 ISOPTO CARPINE, 45 levalbuterol tartrate, CFC-free aerosol, 39 ISORDIL, 19 LEVAQUIN, 12 isosorbide dinitrate ext-rel tabs, 19 LEVBID, 28 isosorbide dinitrate tabs, 19 levobunolol, 45 isosorbide mononitrate, 19 levofloxacin oral soln, 12 isosorbide mononitrate ext-rel, 19 levofloxacin soln, 44 isotretinoin caps, 42 levofloxacin tabs, 12 isradipine, 17 levonorgestrel 1.5 mg, 25 itraconazole caps, 12 levonorgestrel/EE 0.05-30/0.075-40/0.125-30 mg-mcg, 25 ivermectin, 14 levonorgestrel/EE 0.09/20, 25 ivosidenib, 15 levonorgestrel/EE 0.1/20, 24 J levonorgestrel/EE 0.15/30, 24, 25 JAKAFI, 15 Levora, 24 Jantoven, 31 levothyroxine, 27 JANUMET, 22 Levoxyl, 27 JANUMET XR, 22 L-glutamine oral powder, 32 JANUVIA, 22 LICIDE TREATMENT KIT, 44 JARDIANCE, 23 lidocaine crm 4%, 43 JENTADUETO, 22 lidocaine gel, jelly 2%, 43 Jolessa, 25 lidocaine patch 4%, 43 Junel 24 Fe, 24 lidocaine viscous 2%, 44 K lidocaine/prilocaine crm, 43 linagliptin, 22 Kariva, 24 linagliptin/metformin, 22 KAZANO, 22 lindane, 43 KEFLEX, 11 linezolid susp, tabs, 14 ketoconazole crm 2%, 42 liothyronine, 27 ketoconazole shampoo 2%, 42 LIPITOR, 17 ketoconazole tabs 200 mg, 12 LIPOFEN, 17 ketorolac 0.5%, 45 LIQUIFIBER, 29 ketorolac tabs, 10 liraglutide, 22 ketotifen, 44

56 lisinopril 10 mg, 30 mg, 40 mg, 16 MAXALT-MLT, 20 lisinopril 2.5 mg, 5 mg, 20 mg, 15 MAXITROL, 44 lisinopril oral soln, 16 MAXZIDE, 18 lisinopril/hydrochlorothiazide, 16 mecasermin, 26 LITEAIR, 40 meclizine, 28 LITETOUCH, 40 medroxyprogesterone acetate, 26 l-methylfolate/algae/vitamin B12/acetylcysteine, 38 medroxyprogesterone acetate 150 mg/mL, 25 l-methylfolate/vitamin B2/vitamin B6/vitamin B12, 34 mefloquine, 13 l-methylfolate/vitamin B6/vitamin B12, 34 megestrol acetate susp 40 mg/mL, 26 LO LOESTRIN FE 1/10, 24 megestrol acetate tabs, 15 LOCALNESIUM-C, 34 melatonin caps 5 mg, 10 mg, 37 LOESTRIN 1/20, 24 melatonin ext-rel tabs 10 mg, 37 LOMOTIL, 27 melatonin liquid 1 mg/4 mL, 1 mg/mL, 37 LONSURF, 15 melatonin sublingual 5 mg, 37 loperamide caps, 27 melatonin tabs 1 mg, 3 mg, 5 mg, 37 loperamide susp 1 mg/7.5 mL, 28 meloxicam tabs, 10 LOPID, 17 melphalan, 14 LOPRESSOR, 17 memantine tabs, 20 loratadine syp, 38 memantine titration pak, 20 loratadine tabs 10 mg, 39 MENEST, 25 loratadine/pseudoephedrine ext-rel 10 mg/240 mg, 39 MENS POTENT FORMULA, 38 loratadine/pseudoephedrine ext-rel 5 mg/120 mg, 39 meperidine soln, 11 losartan, 16 meperidine tabs, 11 losartan/hydrochlorothiazide, 16 MEPHYTON, 37 LOTENSIN, 15 MEPRON, 13 LOTREL, 16 mercaptopurine tabs, 14 LOTRISONE, 42 mesalamine delayed-rel, 28 lovastatin, 17 mesalamine enema, 28 LOVAZA, 17 mesalamine ext-rel, 28 LOVENOX, 31 mesna, 15 Low-Ogestrel, 24 MESNEX, 15 lubiprostone, 29 MESTINON, 21 Lutera, 24 METAFOLBIC, 34 LYDIA PINKHAM HERBAL, 38 METAFOLBIC PLUS RF, 38 lysine/thiamine/niacinamide, 36 METAMUCIL, 29 LYSODREN, 15 METAMUCIL PLUS CALCIUM, 29 M metaproterenol tabs, 39 metformin 1000 mg, 22 M.V.I. ADULT, 37 metformin 500 mg, 22 MAALOX ADVANCED, 27 metformin 850 mg, 22 MACROBID, 14 metformin ext-rel 500 mg, 750 mg, 22 MACRODANTIN, 14 methadone conc 10 mg/mL, 11 MAG-AL, 27 methadone soln 10 mg/5 mL, 11 MAGINEX 615, 36 methadone soln 5 mg/5 mL, 11 magnesium, 36 methadone tabs 5 mg, 10 mg, 11 magnesium aspartate delayed-rel, 36 methenamine hippurate, 31 magnesium chloride inj, 36 methenamine mandelate, 31 magnesium chloride/calcium delayed-rel, 37 Methergine, 27 magnesium citrate, 37 methimazole, 27 magnesium citrate soln, 29 methocarbamol, 21 magnesium gluconate, 37 methotrexate inj 25 mg/mL, 250 mg/10 mL, 1 gram/40 mL, 14 magnesium glycinate, 37 methotrexate oral soln, 14 magnesium hydroxide, 29 methotrexate tabs 2.5 mg, 14 magnesium hydroxide chew tabs, 29 methyclothiazide, 18 magnesium lactate ext-rel, 37 methyldopa, 16 magnesium oxide, 29, 37 methyldopa/hydrochlorothiazide, 16 magnesium oxide/asafoetida, 27 methylergonovine tabs, 27 magnesium sulfate inj, 37 methylprednisolone, 26 magnesium sulfate oral granules, 29 metipranolol, 45 MAG-OX, 37 metoclopramide soln, tabs, 28 MAG-TAB SR, 37 metolazone, 18 malathion, 43 metoprolol succinate ext-rel 200 mg, 17 MARINOL, 28 metoprolol succinate ext-rel 25 mg, 50 mg, 100 mg, 17 mask, 40 metoprolol tartrate, 17 MATULANE, 15 METROCREAM, 43 MAXALT, 20 METROGEL-VAGINAL, 31

57 metronidazole, 31 N metronidazole crm 0.75%, 43 nabumetone, 10 metronidazole gel 0.75%, 43 nadolol, 17 metronidazole tabs, 14 naloxone inj, 21 mexiletine, 16 naloxone nasal spray, 21 MIACALCIN, 24 NAMENDA, 20 MICATIN, 42 NAMENDA PAK, 20 miconazole crm 2%, 31, 42 naphazoline/pheniramine, 44 miconazole crm 2%, applicator 100 mg, 31 NAPHCON-A, 44 miconazole crm 2%, supp 100 mg, 31 NAPROSYN, 10 miconazole supp, 31 naproxen delayed-rel, 10 Microgestin 1.5/30, 24 naproxen sodium caps, 10 Microgestin Fe 1.5/30, 24 naproxen sodium tabs, 10 Microgestin Fe 1/20, 24 naproxen susp, 10 MICROLIFE, 40 naproxen tabs, 10 MICROSPACER, 41 naratriptan, 20 midazolam inj 5 mg/mL, 20 NARCAN, 21 midodrine, 19 NASACORT ALLERGY 24HR, 41 MINASTRIN 24 FE, 24 NASALCROM, 40 mineral oil, 29 nateglinide, 23 mineral oil emulsion, 29 NATURE-THROID, 27 mineral oil enema, 29 Nebusal, 41 MINI WRIGHT, 40 Necon 0.5/35, 24 MINIPRESS, 16 neomycin, 11 MINOCIN, 12 neomycin/polymyxin B/dexamethasone oint, soln, 44 minocycline caps, 12 neomycin/polymyxin B/gramicidin soln, 44 minoxidil, 19 neomycin/polymyxin B/hydrocortisone, 46 MIRALAX OTC, 29 NEORAL, 33 MIRAPEX, 20 NEOSPORIN, 42, 44 misoprostol, 30 NEPHLEX, 36 MITIGARE, 10 NEPHROCAPS, 36 mitotane, 15 NEPHRON FA, 34 MOBIC, 10 NEPHRO-VITE, 36 mometasone crm, oint 0.1%, 43 NEPHRO-VITE RX, 36 mometasone lotion 0.1%, 43 NESINA, 22 MONISTAT 3 COMBO KIT, 31 NESTABS, 35 MONISTAT 7 COMBO KIT, 31 NESTABS DHA PAK, 35 montelukast, 40 NEUPOGEN, 32 morphine sulfate ext-rel tabs, 11 NEXIUM 24HR OTC, 30 morphine sulfate oral soln, 11 niacin, 37 morphine sulfate tabs, 11 niacin ext-rel caps, 37 MOVIPREP, 29 niacin ext-rel tabs 250 mg, 750 mg, 37 MS CONTIN, 11 NIACIN FLUSH FREE, 36 MUCINEX, 40 niacin/inositol, 37 MUCINEX D, 40 niacinamide, 37 MUCINEX DM, 40 niacinamide ext-rel, 37 MULTIPRENATAL, 35 NIACINAMIDE PR, 37 multivitamins, 37 niacinamide/zinc/copper/methylfolate, 37 multivitamins inj, 37 nicardipine, 17 multivitamins/calcium, 37 NICODERM CQ, 22 multivitamins/iron, 37 NICOMIDE, 37 multivitamins/minerals, 37 NICORETTE, 22 multivitamins/minerals caps, chew tabs, 37 nicotine inhaler, 21 mupirocin oint, 42 nicotine nasal spray, 21 M-VIT, 35 nicotine polacrilex gum 2 mg, 22 MYAMBUTOL, 13 nicotine polacrilex gum 4 mg, 22 MYCOBUTIN, 14 nicotine polacrilex lozenge, 22 mycophenolate mofetil, 33 nicotine transdermal, 22 mycophenolate mofetil susp, 33 NICOTROL, 21 mycophenolate sodium delayed-rel, 33 NICOTROL NS, 21 MYDRIACYL, 45 nifedipine, 18 MYFORTIC, 33 nifedipine ext-rel 30 mg, 18 MYLERAN, 14 nifedipine ext-rel 30 mg, 60 mg, 18 MYNATAL PLUS, 35 nifedipine ext-rel 60 mg, 90 mg, 18 MYNATAL-Z, 36 nifedipine ext-rel 90 mg, 18 MYNATE 90 PLUS, 35 NILANDRON, 14

58 nilutamide, 14 O nimodipine caps, 18 OBSTETRIX DHA PAK, 35 NITRO-BID, 19 OBSTETRIX EC, 35 NITRO-DUR, 19 OBTREX, 35 nitrofurantoin ext-rel, 14 OBTREX DHA PAK, 35 nitrofurantoin macrocrystals 50 mg, 100 mg, 14 O-CAL FA, 35 nitrofurantoin susp, 14 octreotide acetate vials 50 mcg/mL, 100 mcg/mL, 200 mcg/mL, 1000 nitroglycerin ext-rel, 19 mcg/mL, 27 nitroglycerin lingual spray, 19 OCUFLOX, 44 nitroglycerin oint, 19 ODOMZO, 15 nitroglycerin sublingual, 19 ofloxacin, 12 nitroglycerin transdermal 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr, 19 ofloxacin otic, 46 NITROLINGUAL, 19 ofloxacin soln, 44 NITROSTAT, 19 Ogestrel, 24 NITRO-TIME, 19 OLUMIANT, 32 NIVA-PLUS, 35 omalizumab, 41 NIVESTYM, 32 omega-3 acid ethyl esters, 17 NIZORAL, 42 omega-3 fatty acids caps 1000 mg, 37 nonoxynol-9 foam 12.5%, 25 omega-3 fatty acids caps 500 mg, 37 nonoxynol-9 gel 3%, 25 omega-3 fatty acids delayed-rel caps 1000 mg, 37 nonoxynol-9 sponge, 25 omeprazole delayed-rel caps, 30 NORCO, 11 omeprazole magnesium delayed-rel caps, 30 NORDITROPIN FLEXPRO, 26 omeprazole susp, 30 norelgestromin/EE, 25 OMNICAP, 37 norethindrone, 25 ondansetron oral soln, 28 norethindrone acetate, 26 ondansetron orally disintegrating tabs 4 mg, 8 mg, 28 norethindrone acetate/EE 0.8/25 and iron, 24 ondansetron tabs 24 mg, 28 norethindrone acetate/EE 1.5/30, 24 ondansetron tabs 4 mg, 8 mg, 28 norethindrone acetate/EE 1.5/30 and iron, 24 ONE-A-DAY, 37 norethindrone acetate/EE 1/20, 24 ONE-A-DAY WOMEN'S, 37 norethindrone acetate/EE 1/20 and iron, 24 OPCON-A, 44 norethindrone acetate/EE 1/20 and iron chew tabs, 24 OPTICHAMBER, 41 norethindrone/EE 0.5-35/1-35/0.5-35 mg-mcg, 25 ORENCIA, 32 norethindrone/EE 0.4/35, 24 ORENCIA CLICKJECT, 32 norethindrone/EE 0.4/35 and iron, 24 orphenadrine ext-rel, 21 norethindrone/EE 0.5/35, 24 ORTHO MICRONOR, 25 norethindrone/EE 0.5-35/0.75-35/1-35 mg-mcg, 25 ORTHO TRI-CYCLEN, 25 norethindrone/EE 1/35, 24 ORTHO TRI-CYCLEN LO, 25 norethindrone/EE and iron, 24 ORTHO-NOVUM 1/35, 24 norethindrone/EE and iron 1-20/1-30/1-35 mg-mcg, 25 ORTHO-NOVUM 7/7/7, 25 norgestimate/EE 0.18-25/0.215-25/0.25-25 mg-mcg, 25 oseltamivir caps, 13 norgestimate/EE 0.18-35/0.215-35/0.25-35 mg-mcg, 25 oseltamivir susp, 13 norgestimate/EE 0.25/35, 24 OSENI, 22 norgestrel/EE 0.3/30, 24 OSMOPREP, 29 norgestrel/EE 0.5/50, 24 OTEZLA, 32 NORPACE, 16 OVIDE, 43 Nortrel 0.5/35, 24 oxybutynin ext-rel 10 mg, 15 mg, 31 NORVASC, 17 oxybutynin ext-rel 5 mg, 31 NOVAFERRUM, 35 oxybutynin syrup, 31 NOVOLIN 70/30, 23 oxybutynin tabs, 31 NOVOLIN N, 23 oxybutynin transdermal, 31 NOVOLIN R, 22 oxycodone soln 5 mg/5 mL, 11 NOVOLOG MIX, 22 oxycodone tabs 5 mg, 11 NOVOLOG MIX FLEXPEN, 22 oxycodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg, 11 NULYTELY, 29 OXYTROL FOR WOMEN, 31 nutritional supplement caps, 38 OZEMPIC, 22 nutritional supplement liquid, 38 nutritional supplement tabs, 38 P nutritional supplement, diet aid, 38 palivizumab, 41 NUVARING, 25 PANCREAZE, 30 nystatin crm, oint, 42 pancrelipase, 30 nystatin powder, 42 pancrelipase delayed-rel 10,500 units, 16,800 units, 21,000 units, 30 nystatin susp, 13 pancrelipase delayed-rel 12,000 units, 24,000 units, 36,000 units, 30 nystatin tabs, 13 pancrelipase delayed-rel 15,000 units, 20,000 units, 25,000 units, 40,000 units, 30 pancrelipase delayed-rel 16,000 units, 24,000 units, 30

59 pancrelipase delayed-rel 2,600 units, 4,200 units, 30 pneumococcal vaccine, 33 pancrelipase delayed-rel 3,000 units, 5,000 units, 10,000 units, 30 PNEUMOVAX 23, 33 pancrelipase delayed-rel 3,000 units, 6,000 units, 30 PNV FOLIC ACID + IRON, 35 pancrelipase delayed-rel 8,000 units, 30 PNV PRENATAL PLUS, 35 PANDA, 41 POCKET CHAMBER, 41 panobinostat, 15 POCKET PEAK METER, 40 pantoprazole delayed-rel tabs 20 mg, 30 podofilox soln, 44 pantoprazole delayed-rel tabs 40 mg, 30 polyethylene glycol 3350 powder, 29 paregoric tincture, 28 polyethylene glycol/propylene glycol gel, 45 PARLODEL, 20 polyethylene glycol/propylene glycol soln, 45 paromomycin, 11 polymyxin B/trimethoprim soln, 44 PEAK AIR FLOW, 40 POLYTRIM, 44 peak flow meter, 40 polyvinyl alcohol soln 1.4%, 45 PEDIA-LAX CHEWS, 29 POLY-VI-SOL, 37 PEDIA-LAX SUPP, 29 POLY-VI-SOL WITH IRON, 37 PEDIALYTE, 36 pomalidomide, 15 pediatric multiple vitamins/fluoride/iron drops, 37 POMALYST, 15 pediatric multivitamins, 37 potassium bicarbonate effer tabs 25 mEq, 34 pediatric multivitamins/fluoride chew tabs, 37 potassium bicarbonate/potassium chloride effer tabs 25 mEq, 34 pediatric multivitamins/fluoride soln, 37 potassium chloride ext-rel 8 mEq, 10 mEq, 34 pediatric multivitamins/iron, 37 potassium chloride microencapsulated crystal ext-rel tabs 10 mEq, 20 pediatric multivitamins/iron drops, 37 mEq, 34 pediatric multivitamins/minerals/vitamin C, 37 potassium chloride oral soln, 34 pediatric multivitamins/minerals/vitamin C drops, 37 potassium citrate ext-rel 5 mEq, 10 mEq, 31 pediatric multivitamins/vitamin C drops, 37 potassium citrate/citric acid soln, powder packets, 31 pediatric multivitamins/vitamin C/folic acid chew tabs, 37 potassium phosphate, 31 pediatric vitamins ACD drops, 37 potassium phosphates inj, 34 pediatric vitamins ACD/fluoride soln, 37 potassium phosphates/sodium phosphates, 34 pediatric vitamins ACD/fluoride/iron drops, 37 potassium/sodium acid phosphates, 31 peg 3350/electrolytes, 29 pramipexole 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 20 peg 3350/electrolytes with bisacodyl, 29 pramipexole 1.5 mg, 20 pegfilgrastim-jmdb, 32 PRANDIN, 23 penicillin VK soln, 12 PRAVACHOL, 17 penicillin VK tabs, 12 pravastatin, 17 PENLAC, 42 prazosin, 16 PENTASA, 28 PRECOSE, 22 pentazocine/naloxone, 11 PRED FORTE, 45 pentosan polysulfate sodium, 31 prednisolone acetate 1%, 45 pentoxifylline ext-rel, 32 prednisolone sodium phosphate soln 1%, 45 PEPCID, 28 prednisolone sodium phosphate soln 5 mg/5 mL, 15 mg/5 mL, 26 PEPCID AC, 28 prednisolone syrup, 26 PEPTO-BISMOL, 27 prednisone, 26 PERCOCET, 11 PREFERA OB, 36 PERFECT IRON, 34 PRELIEF, 27 perindopril 2 mg, 4 mg, 16 PREMARIN, 25 Periogard, 44 PREMPHASE, 26 permethrin cream rinse, lotion 1%, 44 PREMPRO, 26 permethrin crm 5%, 44 Prenatabs Rx, 36 PERSONAL BEST FULL, 40 Prenatal 19, 35, 36 PERTZYE, 30 PRENATAL 19, 35 phenazopyridine, 31 PRENATAL 19 CHEW, 36 phenylephrine 2.5%, 45 PRENATAL COMPLETE, 35 PHILLIPS, 29 PRENATAL LOW IRON, 35 PHILLIPS' MILK OF MAGNESIA, 29 PRENATAL MULTI + DHA, 36 PHOS-NAK, 34 PRENATAL ONE DAILY, 35 PHOSPHOLINE IODIDE, 45 PRENATAL PLUS, 35 phytonadione, 37 PRENATAL TAB, 35 PIKO 1, 40 PRENATAL VITAMIN, 35 pilocarpine, 30 prenatal vitamins without A/ferrous bisglycinate/folic acid 32-1 mg, 35 pilocarpine soln, 45 prenatal vitamins without A/ferrous bisglycinate/folic acid 32-1 mg + omega­ pimecrolimus, 43 3, 35 pioglitazone, 23 prenatal vitamins without A/ferrous fumarate/folic acid 106.5-1 mg, 35 piroxicam, 10 prenatal vitamins without A/iron carbonyl/folic acid 20-1 mg + vitamin B6, 35 PLAN B ONE-STEP, 25 prenatal vitamins/docusate/ferrous fumarate/folic acid 29-1 mg, 35 PLAQUENIL, 32 prenatal vitamins/docusate/ferrous fumarate/folic acid 90-1 mg, 35 PLAVIX, 32 prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg, 35

60 prenatal vitamins/docusate/iron carbonyl/folic acid 29-1 mg + omega-3, 35 psyllium/calcium, 29 prenatal vitamins/docusate/iron carbonyl/folic acid 90-1 mg, 35 PULMICORT FLEXHALER, 41 prenatal vitamins/ferrous bisglycinate chelate/folic acid 29-1 mg, 35 PULMICORT RESPULES, 41 prenatal vitamins/ferrous fumarate/folic acid 14-0.4 mg, 35 PULMOZYME, 40 prenatal vitamins/ferrous fumarate/folic acid 27-0.8 mg, 35 PV Lice Killing Shampoo, 44 prenatal vitamins/ferrous fumarate/folic acid 27-1 mg, 35 PX PRENATAL, 35 prenatal vitamins/ferrous fumarate/folic acid 28-0.8 mg, 35 pyrantel, 14 prenatal vitamins/ferrous fumarate/folic acid 28-1 mg, 35 pyrazinamide, 13 prenatal vitamins/ferrous fumarate/folic acid 60-1 mg, 35 pyrethrins/piperonyl butoxide liq, 44 prenatal vitamins/ferrous fumarate/folic acid 65-1 mg, 35 pyrethrins/piperonyl butoxide shampoo kit, 44 prenatal vitamins/ferrous fumarate/folic acid chew tabs 29-1 mg, 36 pyrethrins/piperonyl butoxide spray and shampoo kit, 44 prenatal vitamins/ferrous fumarate/folic acid/omega-3 27-0.8-228 mg, 36 PYRIDIUM, 31 prenatal vitamins/iron carbonyl/folic acid 29-1 mg, 36 pyridostigmine tabs 60 mg, 21 prenatal vitamins/iron polysaccharide complex/iron heme polypeptide/folic pyridoxine tabs 25 mg, 37 acid 28-6-1 mg, 36 pyridoxine tabs 50 mg, 100 mg, 37 prenatal vitamins/iron polysaccharide complex/iron heme polypeptide/folic pyrimethamine, 14 acid 34-1 mg, 36 Q prenatal vitamins/minerals/folic acid/fish oil chew tabs 0.4-113.5 mg, 36 QBRELIS, 16 prenatal vitamins/selenium/ferrous fumarate/folic acid 27-1 mg, 36 QC PRENATAL, 35 PRENATAL/IRON, 35 QUESTRAN, 16, 17 PRENATAL-U, 35 QUESTRAN LIGHT, 17 PREPLUS, 35 quinapril 40 mg, 16 PREPOPIK, 30 quinapril 5 mg, 10 mg, 20 mg, 16 PREVACID, 30 quinapril/hydrochlorothiazide, 16 PREVACID 24HR OTC, 30 quinidine sulfate, 16 PREVIDENT, 44 QUINTABS, 37 PREVNAR 13, 33 QVAR REDIHALER, 41 primaquine, 13 PRIMAQUINE, 13 R PRIMEAIRE, 41 RA CALCIUM/BORON, 33 PRO COMFORT, 41 RA PRENATAL, 35 probenecid, 10 raloxifene, 27 procarbazine, 15 ramipril, 16 PROCARDIA, 18 RANEXA, 19 PROCARDIA XL, 18 ranitidine syp, 28 prochlorperazine supp, 28 ranitidine tabs, 28 prochlorperazine tabs, 28 ranolazine ext-rel, 19 PRO-CLEAR AC, 40 RAPAMUNE, 33 PROCRIT, 32 RECOMBIVAX HB, 33 PROFERRIN ES, 34 REESES PINWORM MEDICINE, 14 progesterone, micronized 100 mg, 26 REFRESH CELLUVISC, 45 progesterone, micronized 200 mg, 27 Refresh Lacri-lube, 45 PROGRAF, 33 REFRESH LIQUIGEL, 45 promethazine, 28 Refresh PM, 45 promethazine supp, 28 REFRESH TEARS, 45 promethazine/phenylephrine syp, 39 REGLAN, 28 PROMETRIUM, 26, 27 RELENZA, 13 propafenone, 16 RENAGEL, 26 proparacaine 0.5%, 45 RENVELA, 26 propranolol, 17 repaglinide, 23 propranolol ext-rel 120 mg, 160 mg, 17 REPLESTA, 36 propranolol ext-rel 60 mg, 17 REQUIP, 20 propranolol ext-rel 80 mg, 17 RETACRIT, 32 propranolol oral soln, 17 REVATIO, 19 propylene glycol/glycerin soln 1-0.3%, 46 REVLIMID, 15 propylthiouracil, 27 riboflavin 25 mg, 38 PROSCAR, 30 RID ESSENTIAL LICE KIT, 44 Prostamen, 38 rifabutin, 14 PROTONIX, 30 RIFADIN, 13 PROTOPIC, 43 rifampin, 13 PROVERA, 26 RIGHT STEP PRENATAL, 35 pseudoephedrine/guaifenesin ext-rel 60-600 mg, 40 rimantadine, 13 psyllium, 29 riociguat, 19 psyllium husk/misc natural products, 38 RISACAL-D, 34 psyllium powder, 29 RITEFLO, 41 psyllium wafer, 29 rivaroxaban starter pack, 31

61 rivaroxaban tabs, 31 sodium bicarbonate/potassium bicarbonate, 27 rivastigmine caps, 20 sodium chloride for inhalation 0.9%, 41 rizatriptan orally disintegrating tabs, 20 sodium chloride for inhalation 3%, 41 rizatriptan tabs, 20 sodium chloride for inhalation 7%, 41 ROBAXIN, 21 sodium chloride oint, soln 5%, 46 ROBINUL, 28 sodium citrate/citric acid soln, 31 ROBINUL FORTE, 28 sodium fluoride chew tabs, 38 ROBITUSSIN, 40 sodium fluoride crm, gel, 44 ROBITUSSIN CHILDREN'S, 39 sodium fluoride drops 0.125 mg/drop, 0.25 mg/drop, 38 ROBITUSSIN DM, 40 sodium fluoride drops 0.5 mg/mL, 38 ROCALTROL, 26 sodium glycerophosphate inj, 34 ropinirole, 20 sodium hyaluronate, 11 rosuvastatin, 17 sodium oxybate, 21 ROXICODONE, 11 sodium phosphates, 29 ruxolitinib, 15 sodium phosphates enema, 29 S sodium phosphates inj, 34 sodium phosphates soln, 30 sacubitril/valsartan, 18 sodium picosulfate/magnesium oxide/citric acid, 30 SAFYRAL, 24 sodium polystyrene sulfonate oral susp, 26 SALAGEN, 30 sodium polystyrene sulfonate powder, 26 saline nasal spray, 41 sodium polystyrene sulfonate rectal susp, 26 salmeterol xinafoate, 39 sodium sulfate/potassium sulfate/magnesium sulfate, 30 SANDIMMUNE, 33 somatropin, 26 SANTYL, 44 sonidegib, 15 SEGLUROMET, 23 SORIATANE, 42 selegiline caps, 20 sotalol, 16 selenium sulfide lotion 2.5%, 42 spacer, 40, 41 semaglutide 0.25 mg, 0.5 mg, 22 spacer/mask, 41 semaglutide 1 mg, 22 SPECTRAVITE, 37 SE-NATAL 19, 35 SPIRIVA RESPIMAT, 38 SE-NATAL CHEW, 36 spironolactone, 16 senna leaves, 29 spironolactone/hydrochlorothiazide 25 mg/25 mg, 18 SENNA PROMPT, 29 SPORANOX, 12 senna syrup, 29 Sprintec, 24 sennosides 8.6 mg, 29 SSD, 42 sennosides/docusate sodium, 29 STARLIX, 23 sennosides/psyllium, 29 STEGLATRO, 23 SENOKOT, 29 STIMATE, 27 SENOKOT-S, 29 STROMECTOL, 14 SENSIPAR, 24 STROVITE, 37 SEREVENT, 39 succimer, 32 sevelamer carbonate tabs, 26 sucralfate tabs, 30 sevelamer HCl, 26 sulbutiamine, 38 SHINGRIX, 33 sulfacetamide oint, soln, 44 SIDESTREAM, 40, 41 sulfacetamide sodium/sulfur cleanser 10-5%, 42 sildenafil, 19 sulfacetamide/prednisolone sodium phosphate soln, 44 SILICONE MASK, 40 sulfamethoxazole/trimethoprim, 12 SILIQ, 32 sulfamethoxazole/trimethoprim susp, 12 silver sulfadiazine crm 1%, 42 sulfasalazine, 28 simethicone chew tabs, 30 sulfasalazine delayed-rel, 28 simethicone susp 40 mg/0.6 mL, 30 SULFATRIM, 12 simvastatin, 17 sulindac, 10 SINEMET, 20 sumatriptan auto-injectors, cartridges, vials, 21 SINEMET CR, 20 sumatriptan nasal spray, 21 SINGULAIR, 40 sumatriptan tabs, 21 sirolimus tabs, 33 Super Omega-3, 37 sitagliptin phosphate, 22 SUPRAX, 12 sitagliptin/metformin, 22 SUPREP, 30 sitagliptin/metformin ext-rel, 22 SYMBICORT, 41 SLO-NIACIN, 37 SYMJEPI, 38 SLOW FE, 34 SYNAGIS, 41 SLOW-MAG, 37 SYNJARDY, 23 SM PRENATAL, 35 SYNJARDY XR, 23 sodium bicarbonate tabs, 27 SYSTANE, 45 sodium bicarbonate/citric acid, 27 SYSTANE GEL, 45 sodium bicarbonate/citric acid/simethicone granules, 27 SYSTANE ULTRA, 45

62

T tofacitinib, 32 TABLOID, 14 tofacitinib ext-rel, 32 tacrolimus, 33, 43 tolazamide, 23 tadalafil, 19 tolbutamide, 23 tafenoquine, 13 tolnaftate crm, powder, aerosol powder, 42 TAGAMET HB, 28 tolterodine, 31 TAMIFLU, 13 tolterodine ext-rel, 31 tamoxifen tabs, 14 topotecan caps, 15 tamsulosin, 30 TOPROL-XL, 17 TAPAZOLE, 27 toremifene, 14 TARGRETIN, 15 torsemide 10 mg, 20 mg, 18 TARON-BC, 35 torsemide 5 mg, 100 mg, 18 TAVIST, 39 TRACLEER, 19 tbo-filgrastim vial, 32 TRADJENTA, 22 TECFIDERA, 21 tramadol, 11 TECFIDERA STARTER PACK, 21 TRANDATE, 17 TEKTURNA, 18 trandolapril, 16 TEMODAR, 14 TRECATOR, 13 TEMOVATE, 43 tretinoin caps, 15 temozolomide, 14 tretinoin crm 0.025%, 42 TENIVAC, 33 triamcinolone acetonide crm 0.5%, 43 tenofovir alafenamide, 13 triamcinolone acetonide crm, oint 0.025%, 43 terazosin 1 mg, 5 mg, 16 triamcinolone acetonide crm, oint 0.1%, 43 terazosin 2 mg, 10 mg, 16 triamcinolone acetonide lotion 0.025%, 43 terbinafine crm 1%, 42 triamcinolone acetonide lotion 0.1%, 43 terbinafine tabs, 13 triamcinolone acetonide oint 0.5%, 43 terbutaline, 39 triamcinolone acetonide spray, 41 terconazole crm, 31 triamcinolone paste, 44 teriparatide, 24 TRIAMINIC NT, 39 TESSALON, 39 triamterene/hydrochlorothiazide caps, 18 testosterone cypionate, 22 triamterene/hydrochlorothiazide tabs, 18 tetanus, diphtheria vaccine, 33 TRICARE PRENATAL, 35 tetanus, diphtheria, pertussis vaccine, 33 TRICOR, 17 thalidomide, 15 trifluridine, 45 THALOMID, 15 trifluridine/tipiracil, 15 theophylline elixir, 41 TRILIPIX, 17 theophylline ext-rel tabs, 41 trimethoprim tabs, 14 theophylline soln, 41 TRINATAL RX1, 35 THERA BETA, 37 Trinate, 35 THERACAL, 37 TRI-TABS DHA, 35 THERA-M, 37 TRI-VI-SOL, 37 THERANATAL, 35 Trivora, 25 THEREMS-M, 37 tropicamide, 45 thiamine 50 mg, 100 mg, 38 trospium, 31 thioguanine, 14 TRUE METRIX AIR kits, 23 THRIVITE 19, 35 TRUE METRIX kits, 23 thyroid, 27 TRUE METRIX test strips, 23 TIAZAC, 18 TRUSOPT, 45 TIBSOVO, 15 TRUZONE, 40 Tilia Fe, 25 TUMS, 27 timolol maleate soln, 45 TWINRIX, 33 TIMOPTIC, 45 TYLENOL, 11 tinidazole, 14 TYLENOL w/CODEINE, 10 tiotropium, 38 TYMLOS, 24 tizanidine tabs, 21 TYR COOLER LIQ, 38 TOBI, 40 U TOBI PODHALER, 40 ulipristal, 25 TOBRADEX, 44 ULORIC, 10 tobramycin inhalation powder, 40 ULTRAM, 11 tobramycin inhalation soln, 40 ULTRAVATE, 43 tobramycin soln, 44 umeclidinium, 38 tobramycin/dexamethasone susp 0.3%/0.1%, 44 UNIFIBER, 29 TOBREX, 44 URECHOLINE, 31 tocilizumab subcutaneous, 32 UROCIT-K, 31 tocopherols/tocotrienols, 38 UROMAG, 37 TODAY CONTRACEPTIVE SPONGE, 25

63

UROXATRAL, 30 VITAMIN B-6, 37 URSO, 28 VITAMIN D-3, 36 ursodiol caps, 28 vitamin E, 38 ursodiol tabs, 28 vitamin E drops, 38 V vitamin E liq, 43 vitamin E oil, 38 valacyclovir 1 gram, 13 vitamins/lipotropics, 38 valacyclovir 500 mg, 13 vitamins/lipotropics ext-rel, 38 VALCYTE, 13 VITRON-C, 35 valganciclovir tabs, 13 VIVELLE-DOT, 25 valsartan 320 mg, 16 VOL-PLUS, 35 valsartan 40 mg, 80 mg, 160 mg, 16 vorinostat, 15 valsartan/hydrochlorothiazide, 16 VORTEX, 41 VALTREX, 13 VALVED HOLDING CHAMBER, 41 W vancomycin inj, 14 warfarin, 31 vancomycin oral soln, 14 WESTHROID, 27 VAQTA, 33 wheat dextrin powder, 30 varenicline, 22 wheat dextrin/calcium chew tabs, 30 VASERETIC, 16 wheat germ oil, 38 VASOTEC, 15 WIDE SEAL, 25 VCF CONTRACEPTIVE, 25 WIXELA INHUB, 41 Velivet, 25 WP THYROID, 27 VEMLIDY, 13 X VENCLEXTA, 15 XALATAN, 45 venetoclax, 15 XARELTO, 31 VENTOLIN HFA, 39 XATMEP, 14 verapamil, 18 XELJANZ, 32 verapamil ext-rel caps, 18 XELJANZ XR, 32 verapamil ext-rel caps 120 mg, 180 mg, 240 mg, 18 XELODA, 14 verapamil ext-rel tabs, 18 XOLAIR, 41 VERELAN, 18 XOPENEX HFA, 39 VERELAN PM, 18 XTANDI, 14 VIACTIV, 34 Xulane, 25 VIBRAMYCIN, 12 XYREM, 21 VICTOZA, 22 VINATE II, 35 Y VINATE M, 36 YASMIN, 24 VINATE ONE, 35 YONSA, 14 VIOKACE, 30 Yuvafem, 26 VIROPTIC, 45 Z Virtussin DAC, 40 ZADITOR, 44 Virt-Vite Plus, 36 ZANAFLEX, 21 vismodegib, 15 zanamivir, 13 VISTARIL, 39 ZANTAC, 28 VITACRAVES, 37 ZANTAC OTC, 28 VITAFOL, 35 ZAROXOLYN, 18 VITAFOL-OB, 36 ZARXIO, 32 vitamin B complex, 36 Zenchent, 24 vitamin B complex elixir, 36 ZENPEP, 30 vitamin B complex inj, 36 ZESTORETIC, 16 vitamin B complex/biotin/folic acid, 36 ZESTRIL, 15, 16 vitamin B complex/biotin/folic acid ext-rel, 36 ZETIA, 17 vitamin B complex/folic acid, 36 ZIAC, 17 vitamin B complex/folic acid ext-rel, 36 ZITHROMAX, 12 vitamin B complex/folic acid/vitamin C/zinc, 36 ZOCOR, 17 vitamin B complex/iron, 36 ZOFRAN, 28 vitamin B complex/minerals, 36 ZOFRAN ODT, 28 vitamin B complex/vitamin C, 36 ZOLADEX, 15 vitamin B complex/vitamin C/biotin/vitamin D/folic acid, 36 ZOLINZA, 15 vitamin B complex/vitamin C/calcium, 36 zolmitriptan orally disintegrating tabs, 21 vitamin B complex/vitamin C/folic acid, 36 zolmitriptan tabs, 21 vitamin B complex/vitamin C/vitamin E/zinc, 36 ZOMIG, 21 VITAMIN B-1, 38 ZOMIG ZMT, 21 VITAMIN B12, 36 ZOSTAVAX, 33 VITAMIN B-2, 38 zoster vaccine live, 33

64 zoster vaccine recombinant, 33 ZYRTEC OTC, 38 Zovia 1/35, 24 ZYRTEC-D, 39 ZOVIRAX, 13 ZYTIGA, 14 ZYBAN, 21 ZYVOX, 14 ZYLOPRIM, 10

65