January 2019

PrimeChoice Accord Formulary

Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

The drug list, also known as a formulary, is regularly updated. You can view the most up-to-date list, or the specialty drug list, at MyPrime.com.

Contents Therapeutic Class Drug List Introduction ...... I Anti-Infective Agents ...... 1 Coverage considerations ...... I Biologicals ...... 5 Abbreviation/acronym key ...... I Antineoplastic Agents ...... 5 Endocrine and Metabolic Drugs ...... 7 Cardiovascular Agents ...... 13 Respiratory Agents ...... 19 Gastrointestinal Agents ...... 21 Genitourinary Agents ...... 23 Central Nervous System Drugs ...... 24 Analgesics and Anesthetics ...... 29 Neuromuscular Drugs ...... 32 Nutritional Products...... 34 Hematological Agents ...... 35 Topical Products ...... 36 Miscellaneous Products ...... 40 Index ...... 42

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2060-B © Prime Therapeutics LLC 01/19 Introduction The PrimeChoice Accord Formulary contains covered drugs for a broad range of diseases.

Generics drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand.

Brand prescription drugs are shown in capital letters followed by the generic name. The PrimeChoice Accord Formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). To save the most money on prescription drugs, take this drug list with you each time you visit your physician. Consider asking your physician to prescribe generic and formulary drugs, if appropriate. Any and all decisions that require or pertain to independent professional medical judgment or training, or the need for, and dosage of, a prescription drug must be made solely by you and your physician in accordance with the patient/physician relationship.

Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss.

Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits.

Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Abbreviation/acronym key caps ...... capsules odt ...... orally disintegrating tablets chew ...... chewable oint ...... ointment conc ...... concentrate ophth ...... ophthalmic cr ...... controlled release osm ...... osmotic release dr ...... delayed release powd ...... powder ec ...... enteric coated sa ...... sustained action effe...... effervescent sl ...... sublingual equiv ...... equivalent soln ...... solution er ...... extended release sr ...... sustained release inhal...... inhalation suppos...... suppositories inj ...... injection susp ...... suspension liq ...... liquid tab ...... tablets lotn ...... lotion td ...... transdermal nebu ...... nebulizer

PrimeChoice Accord Formulary, January 2019 I 2018

Drug Name Drug Name ANTI-INFECTIVE AGENTS cefaclor cap 500 mg PENICILLINS cefadroxil cap 500 mg AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg cefadroxil for susp 250 mg/5ml AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg cefadroxil for susp 500 mg/5ml amoxicillin (trihydrate) cap 250 mg cefadroxil tab 1 gm amoxicillin (trihydrate) cap 500 mg cefdinir cap 300 mg amoxicillin (trihydrate) for susp 125 mg/5ml cefdinir for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml cefdinir for susp 250 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml cefixime for susp 100 mg/5ml (Suprax) amoxicillin (trihydrate) for susp 400 mg/5ml cefixime for susp 200 mg/5ml (Suprax) amoxicillin (trihydrate) tab 500 mg cefpodoxime proxetil for susp 50 mg/5ml amoxicillin (trihydrate) tab 875 mg cefpodoxime proxetil for susp 100 mg/5ml amoxicillin & k clavulanate for susp 200-28.5 mg/5ml cefpodoxime proxetil tab 100 mg amoxicillin & k clavulanate for susp 250-62.5 mg/5ml cefpodoxime proxetil tab 200 mg (Augmentin) cefprozil for susp 125 mg/5ml amoxicillin & k clavulanate for susp 400-57 mg/5ml cefprozil for susp 250 mg/5ml amoxicillin & k clavulanate for susp 600-42.9 mg/5ml cefprozil tab 250 mg (Augmentin es-600) cefprozil tab 500 mg amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg (Augmentin xr) ceftriaxone sodium for inj 250 mg amoxicillin & k clavulanate tab 250-125 mg ceftriaxone sodium for inj 500 mg (Rocephin) amoxicillin & k clavulanate tab 500-125 mg ceftriaxone sodium for inj 1 gm (Rocephin) (Augmentin) ceftriaxone sodium for inj 2 gm amoxicillin & k clavulanate tab 875-125 mg cefuroxime axetil tab 250 mg (Ceftin) (Augmentin) cefuroxime axetil tab 500 mg (Ceftin) AMOXICILLIN/CLAVULANATE P – amoxicillin & k cephalexin cap 250 mg (Keflex) clavulanate chew tab 200-28.5 mg cephalexin cap 500 mg (Keflex) AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate chew tab 400-57 mg cephalexin for susp 125 mg/5ml AMPICILLIN – ampicillin cap 500 mg cephalexin for susp 250 mg/5ml AUGMENTIN – amoxicillin & k clavulanate for susp SUPRAX – cefixime cap 400 mg 125-31.25 mg/5ml SUPRAX – cefixime for susp 500 mg/5ml dicloxacillin sodium cap 250 mg SUPRAX – cefixime chew tab 100 mg dicloxacillin sodium cap 500 mg SUPRAX – cefixime chew tab 200 mg PENICILLIN V POTASSIUM – penicillin v potassium for MACROLIDES soln 125 mg/5ml AZITHROMYCIN – azithromycin powd pack for susp 1 PENICILLIN V POTASSIUM – penicillin v potassium for gm soln 250 mg/5ml azithromycin for susp 100 mg/5ml (Zithromax) penicillin v potassium tab 250 mg azithromycin for susp 200 mg/5ml (Zithromax) penicillin v potassium tab 500 mg azithromycin tab 250 mg (Zithromax) CEPHALOSPORINS azithromycin tab 500 mg (Zithromax) cefaclor cap 250 mg azithromycin tab 600 mg (Zithromax)

PrimeChoice Accord Formulary, January 2018 1 2018

Drug Name Drug Name CLARITHROMYCIN – clarithromycin for susp 125 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg mg/5ml (base eq) (Cipro xr) CLARITHROMYCIN – clarithromycin for susp 250 ciprofloxacin-ciprofloxacin hcl tab er 24hr mg/5ml 1000 mg(base eq) (Cipro xr) clarithromycin tab er 24hr 500 mg levofloxacin oral soln 25 mg/ml (Levaquin) clarithromycin tab 250 mg (Biaxin) levofloxacin tab 250 mg (Levaquin) clarithromycin tab 500 mg (Biaxin) levofloxacin tab 500 mg (Levaquin) TETRACYCLINES levofloxacin tab 750 mg (Levaquin) demeclocycline hcl tab 150 mg ofloxacin tab 400 mg demeclocycline hcl tab 300 mg AMINOGLYCOSIDES doxycycline hyclate cap 50 mg neomycin sulfate tab 500 mg doxycycline hyclate cap 100 mg (Vibramycin) paromomycin sulfate cap 250 mg doxycycline hyclate tab 20 mg tobramycin nebu soln 300 mg/5ml (Tobi) doxycycline hyclate tab 100 mg SULFADIAZINE – sulfadiazine tab 500 mg doxycycline monohydrate cap 50 mg ANTIMYCOBACTERIAL AGENTS doxycycline monohydrate cap 75 mg (Monodox) ethambutol hcl tab 100 mg (Myambutol) doxycycline monohydrate cap 100 mg (Monodox) ethambutol hcl tab 400 mg (Myambutol) doxycycline monohydrate cap 150 mg (Adoxa) ISONIAZID – isoniazid syrup 50 mg/5ml doxycycline monohydrate tab 50 mg (Adoxa) isoniazid tab 100 mg doxycycline monohydrate tab 75 mg (Adoxa) isoniazid tab 300 mg doxycycline monohydrate tab 100 mg (Adoxa pak PRIFTIN – rifapentine tab 150 mg 1/100) pyrazinamide tab 500 mg doxycycline monohydrate tab 150 mg (Adoxa pak rifabutin cap 150 mg (Mycobutin) 1/150) rifampin cap 150 mg (Rifadin) minocycline hcl cap 50 mg (Minocin) rifampin cap 300 mg (Rifadin) minocycline hcl cap 75 mg (Minocin) ANTIFUNGALS minocycline hcl cap 100 mg (Minocin) fluconazole for susp 10 mg/ml (Diflucan) minocycline hcl tab 50 mg fluconazole for susp 40 mg/ml (Diflucan) minocycline hcl tab 75 mg fluconazole tab 50 mg (Diflucan) minocycline hcl tab 100 mg fluconazole tab 100 mg (Diflucan) tetracycline hcl cap 250 mg (Tetracycline hcl) fluconazole tab 150 mg (Diflucan) tetracycline hcl cap 500 mg (Tetracycline hcl) fluconazole tab 200 mg (Diflucan) FLUOROQUINOLONES flucytosine cap 250 mg (Ancobon) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) flucytosine cap 500 mg (Ancobon) CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg griseofulvin microsize susp 125 mg/5ml (base equiv) griseofulvin microsize tab 500 mg (Grifulvin v) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) itraconazole cap 100 mg (Sporanox) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) itraconazole oral soln 10 mg/ml (Sporanox) ciprofloxacin hcl tab 750 mg (base equiv) NOXAFIL – posaconazole tab delayed release 100 mg NOXAFIL – posaconazole susp 40 mg/ml

PrimeChoice Accord Formulary, January 2018 2 2018

Drug Name Drug Name nystatin tab 500000 unit famciclovir tab 125 mg (Famvir) SPORANOX – itraconazole oral soln 10 mg/ml famciclovir tab 250 mg (Famvir) terbinafine hcl tab 250 mg (Lamisil) famciclovir tab 500 mg (Famvir) voriconazole for susp 40 mg/ml (Vfend) GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab voriconazole tab 50 mg (Vfend) 150-150-200-10 mg voriconazole tab 200 mg (Vfend) HARVONI – ledipasvir-sofosbuvir tab 90-400 mg ANTIVIRALS INTELENCE – etravirine tab 25 mg abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) INTELENCE – etravirine tab 100 mg abacavir sulfate tab 300 mg (base equiv) (Ziagen) INTELENCE – etravirine tab 200 mg abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv) abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir) ISENTRESS – raltegravir potassium tab 400 mg (base equiv) acyclovir cap 200 mg (Zovirax) ISENTRESS – raltegravir potassium chew tab 25 mg acyclovir susp 200 mg/5ml (Zovirax) (base equiv) acyclovir tab 400 mg (Zovirax) ISENTRESS – raltegravir potassium chew tab 100 mg acyclovir tab 800 mg (Zovirax) (base equiv) adefovir dipivoxil tab 10 mg (Hepsera) ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) atazanavir sulfate cap 150 mg (base equiv) (Reyataz) KALETRA – lopinavir-ritonavir tab 100-25 mg atazanavir sulfate cap 200 mg (base equiv) (Reyataz) KALETRA – lopinavir-ritonavir tab 200-50 mg atazanavir sulfate cap 300 mg (base equiv) (Reyataz) ATRIPLA – efavirenz-emtricitabine-tenofovir df tab lamivudine oral soln 10 mg/ml (Epivir) 600-200-300 mg lamivudine tab 100 mg (hbv) (Epivir hbv) BARACLUDE – entecavir oral soln 0.05 mg/ml lamivudine tab 150 mg (Epivir) BIKTARVY – bictegravir-emtricitabine-tenofovir af tab lamivudine tab 300 mg (Epivir) 50-200-25 mg lamivudine-zidovudine tab 150-300 mg (Combivir) CIMDUO – lamivudine-tenofovir disoproxil fumarate tab lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 300-300 mg (Kaletra) DESCOVY – emtricitabine-tenofovir alafenamide MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg fumarate tab 200-25 mg nevirapine susp 50 mg/5ml (Viramune) didanosine delayed release capsule 200 mg (Videx ec) nevirapine tab er 24hr 100 mg (Viramune xr) didanosine delayed release capsule 250 mg (Videx ec) nevirapine tab er 24hr 400 mg (Viramune xr) didanosine delayed release capsule 400 mg (Videx ec) nevirapine tab 200 mg (Viramune) efavirenz cap 50 mg (Sustiva) NORVIR – ritonavir oral soln 80 mg/ml efavirenz cap 200 mg (Sustiva) NORVIR – ritonavir powder packet 100 mg efavirenz tab 600 mg (Sustiva) ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab entecavir tab 0.5 mg (Baraclude) 200-25-25 mg entecavir tab 1 mg (Baraclude) oseltamivir phosphate cap 30 mg (base equiv) EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg (Tamiflu) EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv) oseltamivir phosphate cap 45 mg (base equiv) EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (Tamiflu) (base equiv)

PrimeChoice Accord Formulary, January 2018 3 2018

Drug Name Drug Name oseltamivir phosphate cap 75 mg (base equiv) TRUVADA – emtricitabine-tenofovir disoproxil fumarate (Tamiflu) tab 167-250 mg oseltamivir phosphate for susp 6 mg/ml (base equiv) TRUVADA – emtricitabine-tenofovir disoproxil fumarate (Tamiflu) tab 200-300 mg PEGASYS – peginterferon alfa-2a inj 180 mcg/ml valacyclovir hcl tab 500 mg (Valtrex) PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml valacyclovir hcl tab 1 gm (Valtrex) PEGASYS PROCLICK – peginterferon alfa-2a inj 135 valganciclovir hcl for soln 50 mg/ml (base equiv) mcg/0.5ml (Valcyte) PEGASYS PROCLICK – peginterferon alfa-2a inj 180 valganciclovir hcl tab 450 mg (base equivalent) mcg/0.5ml (Valcyte) PREZCOBIX – darunavir-cobicistat tab 800-150 mg VIDEX – didanosine for soln 2 gm PREZISTA – darunavir ethanolate susp 100 mg/ml (base VIDEX – didanosine for soln 4 gm equiv) VIRAMUNE – nevirapine susp 50 mg/5ml PREZISTA – darunavir ethanolate tab 75 mg (base VIREAD – tenofovir disoproxil fumarate oral powder 40 equiv) mg/gm PREZISTA – darunavir ethanolate tab 150 mg (base VIREAD – tenofovir disoproxil fumarate tab 150 mg equiv) VIREAD – tenofovir disoproxil fumarate tab 200 mg PREZISTA – darunavir ethanolate tab 600 mg (base equiv) VIREAD – tenofovir disoproxil fumarate tab 250 mg PREZISTA – darunavir ethanolate tab 800 mg (base VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab equiv) 400-100-100 mg ribavirin cap 200 mg (Rebetol) zidovudine cap 100 mg (Retrovir) ribavirin tab 200 mg (Copegus) zidovudine syrup 10 mg/ml (Retrovir) ritonavir tab 100 mg (Norvir) zidovudine tab 300 mg SOVALDI – sofosbuvir tab 400 mg ANTIMALARIALS stavudine cap 15 mg (Zerit) atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) stavudine cap 20 mg (Zerit) atovaquone-proguanil hcl tab 250-100 mg (Malarone) stavudine cap 30 mg (Zerit) CHLOROQUINE PHOSPHATE – chloroquine phosphate tab 250 mg stavudine cap 40 mg (Zerit) chloroquine phosphate tab 500 mg (Aralen) SYMFI – efavirenz-lamivudine-tenofovir df tab 600-300-300 mg COARTEM – artemether-lumefantrine tab 20-120 mg SYMFI LO – efavirenz-lamivudine-tenofovir df tab DARAPRIM – pyrimethamine tab 25 mg 400-300-300 mg hydroxychloroquine sulfate tab 200 mg (Plaquenil) tenofovir disoproxil fumarate tab 300 mg (Viread) MEFLOQUINE HCL – mefloquine hcl tab 250 mg TIVICAY – dolutegravir sodium tab 10 mg (base equiv) PRIMAQUINE PHOSPHATE – primaquine phosphate tab TIVICAY – dolutegravir sodium tab 25 mg (base equiv) 26.3 mg (15 mg base) TIVICAY – dolutegravir sodium tab 50 mg (base equiv) ANTHELMINTICS TRIUMEQ – abacavir-dolutegravir-lamivudine tab albendazole tab 200 mg (Albenza) 600-50-300 mg ALBENZA – albendazole tab 200 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate BENZNIDAZOLE – benznidazole tab 12.5 mg tab 100-150 mg BENZNIDAZOLE – benznidazole tab 100 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate ivermectin tab 3 mg (Stromectol) tab 133-200 mg praziquantel tab 600 mg (Biltricide)

PrimeChoice Accord Formulary, January 2018 4 2018

Drug Name Drug Name ANTI-INFECTIVE AGENTS - MISC. AFINITOR DISPERZ – everolimus tab for oral susp 2 mg ALINIA – nitazoxanide tab 500 mg AFINITOR DISPERZ – everolimus tab for oral susp 3 mg ALINIA – nitazoxanide for susp 100 mg/5ml AFINITOR DISPERZ – everolimus tab for oral susp 5 mg clindamycin hcl cap 75 mg (Cleocin) ALECENSA – alectinib hcl cap 150 mg (base equivalent) clindamycin hcl cap 150 mg (Cleocin) ALUNBRIG – brigatinib tab initiation therapy pack 90 mg clindamycin hcl cap 300 mg (Cleocin) & 180 mg clindamycin palmitate hcl for soln 75 mg/5ml (base ALUNBRIG – brigatinib tab 30 mg equiv) (Cleocin pediatric gr) ALUNBRIG – brigatinib tab 90 mg dapsone tab 25 mg ALUNBRIG – brigatinib tab 180 mg dapsone tab 100 mg anastrozole tab 1 mg (Arimidex) IMPAVIDO – miltefosine cap 50 mg bexarotene cap 75 mg (Targretin) linezolid for susp 100 mg/5ml (Zyvox) bicalutamide tab 50 mg (Casodex) linezolid tab 600 mg (Zyvox) BOSULIF – bosutinib tab 100 mg metronidazole tab 250 mg (Flagyl) BOSULIF – bosutinib tab 400 mg metronidazole tab 500 mg (Flagyl) BOSULIF – bosutinib tab 500 mg NEBUPENT – pentamidine isethionate for nebulization capecitabine tab 150 mg (Xeloda) soln 300 mg capecitabine tab 500 mg (Xeloda) SIVEXTRO – tedizolid phosphate tab 200 mg CAPRELSA – vandetanib tab 100 mg sulfamethoxazole-trimethoprim susp 200-40 mg/5ml CAPRELSA – vandetanib tab 300 mg sulfamethoxazole-trimethoprim tab 400-80 mg COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 (Bactrim) mg dose) kit sulfamethoxazole-trimethoprim tab 800-160 mg COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 (Bactrim ds) mg (100 dose) kit trimethoprim tab 100 mg COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 vancomycin hcl cap 125 mg (base equivalent) mg (140 dose) kit (Vancocin hcl) COTELLIC – cobimetinib fumarate tab 20 mg (base vancomycin hcl cap 250 mg (base equivalent) equivalent) (Vancocin hcl) cyclophosphamide cap 25 mg (Cyclophosphamide) XIFAXAN – rifaximin tab 550 mg cyclophosphamide cap 50 mg (Cyclophosphamide) BIOLOGICALS EMCYT – estramustine phosphate sodium cap 140 mg PASSIVE IMMUNIZING AGENTS ERIVEDGE – vismodegib cap 150 mg SYNAGIS – palivizumab im soln 50 mg/0.5ml ERLEADA – apalutamide tab 60 mg SYNAGIS – palivizumab im soln 100 mg/ml ETOPOSIDE – etoposide cap 50 mg ANTINEOPLASTIC AGENTS exemestane tab 25 mg (Aromasin) ANTINEOPLASTICS FARESTON – toremifene citrate tab 60 mg (base ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml equivalent) (2000000 unit/0.5ml) FARYDAK – panobinostat lactate cap 10 mg (base AFINITOR – everolimus tab 2.5 mg equivalent) AFINITOR – everolimus tab 5 mg FARYDAK – panobinostat lactate cap 15 mg (base AFINITOR – everolimus tab 7.5 mg equivalent) AFINITOR – everolimus tab 10 mg FARYDAK – panobinostat lactate cap 20 mg (base equivalent)

PrimeChoice Accord Formulary, January 2018 5 2018

Drug Name Drug Name flutamide cap 125 mg KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & GILOTRIF – afatinib dimaleate tab 20 mg (base letrozole tab 2.5 mg therapy pack equivalent) KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg & GILOTRIF – afatinib dimaleate tab 30 mg (base letrozole tab 2.5 mg therapy pack equivalent) KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & GILOTRIF – afatinib dimaleate tab 40 mg (base letrozole tab 2.5 mg therapy pack equivalent) LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy GLEOSTINE – lomustine cap 10 mg pack 10 mg (10 mg daily dose) GLEOSTINE – lomustine cap 40 mg LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy pack 4 (3) mg (12 mg daily dose) GLEOSTINE – lomustine cap 100 mg LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) pack 10 & 4 mg (14 mg daily dose) HYCAMTIN – topotecan hcl cap 1 mg (base equiv) LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy hydroxyurea cap 500 mg (Hydrea) pack 10 & 4 (2) mg (18 mg daily dose) IBRANCE – palbociclib cap 75 mg LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy IBRANCE – palbociclib cap 100 mg pack 10 (2) mg (20 mg daily dose) IBRANCE – palbociclib cap 125 mg LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) ICLUSIG – ponatinib hcl tab 15 mg (base equiv) LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy ICLUSIG – ponatinib hcl tab 45 mg (base equiv) pack 4 mg (4 mg daily dose) imatinib mesylate tab 100 mg (base equivalent) LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy (Gleevec) pack 4 (2) mg (8 mg daily dose) imatinib mesylate tab 400 mg (base equivalent) letrozole tab 2.5 mg (Femara) (Gleevec) LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg IMBRUVICA – ibrutinib cap 70 mg LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg IMBRUVICA – ibrutinib cap 140 mg leucovorin calcium tab 5 mg IMBRUVICA – ibrutinib tab 140 mg leucovorin calcium tab 25 mg IMBRUVICA – ibrutinib tab 280 mg LEUKERAN – chlorambucil tab 2 mg IMBRUVICA – ibrutinib tab 420 mg LONSURF – trifluridine-tipiracil tab 15-6.14 mg IMBRUVICA – ibrutinib tab 560 mg LONSURF – trifluridine-tipiracil tab 20-8.19 mg INLYTA – axitinib tab 1 mg LYNPARZA – olaparib tab 100 mg INLYTA – axitinib tab 5 mg LYNPARZA – olaparib tab 150 mg IRESSA – gefitinib tab 250 mg LYSODREN – mitotane tab 500 mg JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) MATULANE – procarbazine hcl cap 50 mg JAKAFI – ruxolitinib phosphate tab 10 mg (base megestrol acetate susp 40 mg/ml (Megace oral) equivalent) megestrol acetate tab 20 mg JAKAFI – ruxolitinib phosphate tab 15 mg (base megestrol acetate tab 40 mg equivalent) MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg JAKAFI – ruxolitinib phosphate tab 20 mg (base (base equivalent) equivalent) MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent) equivalent) melphalan tab 2 mg (Alkeran) KISQALI – ribociclib succinate tab 200 mg (base equiv) mercaptopurine tab 50 mg (Purinethol)

PrimeChoice Accord Formulary, January 2018 6 2018

Drug Name Drug Name MESNEX – mesna tab 400 mg TAGRISSO – osimertinib mesylate tab 40 mg (base methotrexate sodium tab 2.5 mg (base equiv) equivalent) MYLERAN – busulfan tab 2 mg TAGRISSO – osimertinib mesylate tab 80 mg (base equivalent) NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) tamoxifen citrate tab 10 mg (base equivalent) nilutamide tab 150 mg (Nilandron) tamoxifen citrate tab 20 mg (base equivalent) NINLARO – ixazomib citrate cap 2.3 mg (base TARCEVA – erlotinib hcl tab 25 mg (base equivalent) equivalent) TARCEVA – erlotinib hcl tab 100 mg (base equivalent) NINLARO – ixazomib citrate cap 3 mg (base equivalent) TARCEVA – erlotinib hcl tab 150 mg (base equivalent) NINLARO – ixazomib citrate cap 4 mg (base equivalent) TASIGNA – nilotinib hcl cap 50 mg (base equivalent) ODOMZO – sonidegib phosphate cap 200 mg (base TASIGNA – nilotinib hcl cap 150 mg (base equivalent) equivalent) TASIGNA – nilotinib hcl cap 200 mg (base equivalent) POMALYST – pomalidomide cap 1 mg temozolomide cap 5 mg (Temodar) POMALYST – pomalidomide cap 2 mg temozolomide cap 20 mg (Temodar) POMALYST – pomalidomide cap 3 mg temozolomide cap 100 mg (Temodar) POMALYST – pomalidomide cap 4 mg temozolomide cap 140 mg (Temodar) PURIXAN – mercaptopurine susp 2000 mg/100ml (20 temozolomide cap 180 mg (Temodar) mg/ml) temozolomide cap 250 mg (Temodar) RYDAPT – midostaurin cap 25 mg tretinoin cap 10 mg SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base equivalent) TYKERB – lapatinib ditosylate tab 250 mg (base equiv) SPRYCEL – dasatinib tab 20 mg VOTRIENT – pazopanib hcl tab 200 mg (base equiv) SPRYCEL – dasatinib tab 50 mg XALKORI – crizotinib cap 200 mg SPRYCEL – dasatinib tab 70 mg XALKORI – crizotinib cap 250 mg SPRYCEL – dasatinib tab 80 mg XTANDI – enzalutamide cap 40 mg SPRYCEL – dasatinib tab 100 mg YONSA – abiraterone acetate tab 125 mg SPRYCEL – dasatinib tab 140 mg ZELBORAF – vemurafenib tab 240 mg STIVARGA – regorafenib tab 40 mg ZOLINZA – vorinostat cap 100 mg SUTENT – sunitinib malate cap 12.5 mg (base ZYDELIG – idelalisib tab 100 mg equivalent) ZYDELIG – idelalisib tab 150 mg SUTENT – sunitinib malate cap 25 mg (base equivalent) ZYKADIA – ceritinib cap 150 mg SUTENT – sunitinib malate cap 37.5 mg (base ZYTIGA – abiraterone acetate tab 250 mg equivalent) ZYTIGA – abiraterone acetate tab 500 mg SUTENT – sunitinib malate cap 50 mg (base equivalent) ENDOCRINE AND METABOLIC DRUGS SYLATRON – peginterferon alfa-2b for inj kit 200 mcg CORTICOSTEROIDS SYLATRON – peginterferon alfa-2b for inj kit 300 mcg budesonide delayed release particles cap 3 mg SYLATRON – peginterferon alfa-2b for inj kit 600 mcg (Entocort ec) TABLOID – thioguanine tab 40 mg CORTISONE ACETATE – cortisone acetate tab 25 mg TAFINLAR – dabrafenib mesylate cap 50 mg (base DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml equivalent) DEXAMETHASONE – dexamethasone tab 1 mg TAFINLAR – dabrafenib mesylate cap 75 mg (base DEXAMETHASONE – dexamethasone tab 2 mg equivalent)

PrimeChoice Accord Formulary, January 2018 7 2018

Drug Name Drug Name dexamethasone elixir 0.5 mg/5ml danazol cap 50 mg DEXAMETHASONE INTENSOL – dexamethasone conc danazol cap 100 mg 1 mg/ml danazol cap 200 mg dexamethasone tab 0.5 mg testosterone cypionate im inj in oil 100 mg/ml (Depo- dexamethasone tab 0.75 mg testosterone) dexamethasone tab 1.5 mg testosterone cypionate im inj in oil 200 mg/ml (Depo- dexamethasone tab 4 mg testosterone) dexamethasone tab 6 mg testosterone enanthate im inj in oil 200 mg/ml fludrocortisone acetate tab 0.1 mg testosterone td gel 25 mg/2.5gm (1%) (Androgel) hydrocortisone tab 5 mg (Cortef) testosterone td gel 50 mg/5gm (1%) (Androgel) hydrocortisone tab 10 mg (Cortef) testosterone td gel 12.5 mg/act (1%) (Androgel pump) hydrocortisone tab 20 mg (Cortef) testosterone td gel 20.25 mg/1.25gm (1.62%) (Androgel) methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) testosterone td gel 40.5 mg/2.5gm (1.62%) (Androgel) methylprednisolone tab 4 mg (Medrol) testosterone td gel 20.25 mg/act (1.62%) (Androgel pump) methylprednisolone tab 8 mg (Medrol) testosterone td soln 30 mg/act (Axiron) methylprednisolone tab 16 mg (Medrol) ESTROGENS methylprednisolone tab 32 mg (Medrol) CLIMARA PRO – estradiol-levonorgestrel td patch PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp weekly 0.045-0.015 mg/day solution equivalent) DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%) prednisolone sod phosphate oral soln 15 mg/5ml DIVIGEL – estradiol td gel 1 mg/gm (0.1%) (base equiv) (Orapred) estradiol & norethindrone acetate tab 0.5-0.1 mg PREDNISONE – prednisone tab 50 mg (Activella) PREDNISONE – prednisone oral soln 5 mg/5ml estradiol & norethindrone acetate tab 1-0.5 mg (Activella) PREDNISONE – prednisone tab therapy pack 5 mg (21) estradiol tab 0.5 mg (Estrace) PREDNISONE – prednisone tab therapy pack 5 mg (48) estradiol tab 1 mg (Estrace) PREDNISONE – prednisone tab therapy pack 10 mg (21) estradiol tab 2 mg (Estrace) PREDNISONE – prednisone tab therapy pack 10 mg (48) estradiol td patch twice weekly 0.025 mg/24hr (Vivelle- prednisone tab 1 mg dot) prednisone tab 2.5 mg estradiol td patch twice weekly 0.0375 mg/24hr prednisone tab 5 mg (Vivelle-dot) prednisone tab 10 mg estradiol td patch twice weekly 0.05 mg/24hr (Vivelle- dot) prednisone tab 20 mg (Vivelle- ANDROGEN-ANABOLIC estradiol td patch twice weekly 0.075 mg/24hr dot) ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%) estradiol td patch twice weekly 0.1 mg/24hr (Vivelle- dot) ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%) estradiol td patch weekly 0.025 mg/24hr (Climara) ANDROGEL PUMP – testosterone td gel 20.25 mg/act estradiol td patch weekly 0.0375 mg/24hr (1.62%) (37.5 mcg/24hr) (Climara)

PrimeChoice Accord Formulary, January 2018 8 2018

Drug Name Drug Name estradiol td patch weekly 0.05 mg/24hr (Climara) levonorgestrel & ethinyl estradiol (91-day) tab estradiol td patch weekly 0.06 mg/24hr (Climara) 0.15-0.03 mg estradiol td patch weekly 0.075 mg/24hr (Climara) levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg estradiol td patch weekly 0.1 mg/24hr (Climara) levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm levonorgestrel-eth estra tab metered-dose pump) 0.05-30/0.075-40/0.125-30mg-mcg norethindrone acetate-ethinyl estradiol tab medroxyprogesterone acetate im susp prefilled syr 0.5 mg-2.5 mcg (Femhrt low dose) 150 mg/ml (Depo-provera contrac) norethindrone acetate-ethinyl estradiol tab medroxyprogesterone acetate im susp 150 mg/ml 1 mg-5 mcg (Depo-provera contrac) PREMARIN – estrogens, conjugated tab 0.3 mg MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) PREMARIN – estrogens, conjugated tab 0.45 mg norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg PREMARIN – estrogens, conjugated tab 0.625 mg (Ovcon-35) PREMARIN – estrogens, conjugated tab 0.9 mg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg PREMARIN – estrogens, conjugated tab 1.25 mg (Brevicon-28) PREMPHASE – conj est 0.625(14)/conj est-medroxypro norethindrone & ethinyl estradiol tab 1 mg-35 mcg ac tab 0.625-5mg(14) (Norinyl 1+35) PREMPRO – conjugated estrogen-medroxyprogest norethindrone & ethinyl estradiol-fe chew tab acetate tab 0.3-1.5 mg 0.4 mg-35 mcg (Femcon fe) PREMPRO – conjugated estrogen-medroxyprogest norethindrone ac-ethinyl estrad-fe tab acetate tab 0.45-1.5 mg 1-20/1-30/1-35 mg-mcg (Estrostep fe) PREMPRO – conjugated estrogen-medroxyprogest norethindrone ace & ethinyl estradiol tab acetate tab 0.625-2.5 mg 1 mg-20 mcg (Loestrin 1/20-21) PREMPRO – conjugated estrogen-medroxyprogest norethindrone ace & ethinyl estradiol tab acetate tab 0.625-5 mg 1.5 mg-30 mcg (Loestrin 1.5/30-21) CONTRACEPTIVES norethindrone ace & ethinyl estradiol-fe tab (Loestrin fe 1/20) desogest-eth estrad & eth estrad tab 1 mg-20 mcg 0.15-0.02/0.01 mg(21/5) (Mircette) norethindrone ace & ethinyl estradiol-fe tab (Loestrin fe 1.5/30) desogest-ethin est tab 1.5 mg-30 mcg 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa) norethindrone tab 0.35 mg (Nor-qd) desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg norethindrone-eth estradiol tab (Desogen) 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7) drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg- (Tri-norinyl 28) drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin mcg 28) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ELLA – ulipristal acetate tab 30 mg (Ortho-cyclen) ethynodiol diacetate & ethinyl estradiol tab norgestimate-eth estrad tab (Ortho tri-cyclen lo) 1 mg-35 mcg 0.18-25/0.215-25/0.25-25 mg-mcg ethynodiol diacetate & ethinyl estradiol tab norgestimate-eth estrad tab (Ortho tri-cyclen) 1 mg-50 mcg (Zovia 1/50e) 0.18-35/0.215-35/0.25-35 mg-mcg levonorg-eth est tab 0.1-0.02mg(84) & eth est tab norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 0.01mg(7) (Loseasonique) NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)

PrimeChoice Accord Formulary, January 2018 9 2018

Drug Name Drug Name OGESTREL – norgestrel & ethinyl estradiol tab 0.5 GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg mg-50 mcg INVOKAMET – canagliflozin-metformin hcl tab 50-500 SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg mg total) INVOKAMET – canagliflozin-metformin hcl tab 50-1000 XULANE – norelgestromin-ethinyl estradiol td ptwk mg 150-35 mcg/24hr INVOKAMET – canagliflozin-metformin hcl tab 150-500 PROGESTINS mg medroxyprogesterone acetate tab 2.5 mg (Provera) INVOKAMET – canagliflozin-metformin hcl tab 150-1000 medroxyprogesterone acetate tab 5 mg (Provera) mg medroxyprogesterone acetate tab 10 mg (Provera) INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-500 mg norethindrone acetate tab 5 mg (Aygestin) INVOKAMET XR – canagliflozin-metformin hcl tab er progesterone micronized cap 100 mg (Prometrium) 24hr 50-1000 mg progesterone micronized cap 200 mg (Prometrium) INVOKAMET XR – canagliflozin-metformin hcl tab er ANTIDIABETICS 24hr 150-500 mg acarbose tab 25 mg (Precose) INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 150-1000 mg acarbose tab 50 mg (Precose) INVOKANA – canagliflozin tab 100 mg acarbose tab 100 mg (Precose) INVOKANA – canagliflozin tab 300 mg glimepiride tab 1 mg (Amaryl) JANUMET – sitagliptin-metformin hcl tab 50-500 mg glimepiride tab 2 mg (Amaryl) JANUMET – sitagliptin-metformin hcl tab 50-1000 mg glimepiride tab 4 mg (Amaryl) JANUMET XR – sitagliptin-metformin hcl tab er 24hr glipizide tab er 24hr 2.5 mg (Glucotrol xl) 50-500 mg glipizide tab er 24hr 5 mg (Glucotrol xl) JANUMET XR – sitagliptin-metformin hcl tab er 24hr glipizide tab er 24hr 10 mg (Glucotrol xl) 50-1000 mg glipizide tab 5 mg (Glucotrol) JANUMET XR – sitagliptin-metformin hcl tab er 24hr glipizide tab 10 mg (Glucotrol) 100-1000 mg glipizide-metformin hcl tab 2.5-250 mg JANUVIA – sitagliptin phosphate tab 25 mg (base equiv) glipizide-metformin hcl tab 2.5-500 mg JANUVIA – sitagliptin phosphate tab 50 mg (base equiv) glipizide-metformin hcl tab 5-500 mg JANUVIA – sitagliptin phosphate tab 100 mg (base equiv) GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj JARDIANCE – empagliflozin tab 10 mg kit 1 mg JARDIANCE – empagliflozin tab 25 mg glyburide micronized tab 1.5 mg (Glynase) KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr glyburide micronized tab 3 mg (Glynase) 2.5-1000 mg glyburide micronized tab 6 mg (Glynase) KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-500 mg glyburide tab 1.25 mg KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr glyburide tab 2.5 mg 5-1000 mg glyburide tab 5 mg metformin hcl tab er 24hr 500 mg (Glucophage xr) glyburide-metformin tab 1.25-250 mg (Glucovance) metformin hcl tab er 24hr 750 mg (Glucophage xr) glyburide-metformin tab 2.5-500 mg (Glucovance) metformin hcl tab 500 mg (Glucophage) glyburide-metformin tab 5-500 mg (Glucovance) metformin hcl tab 850 mg (Glucophage) GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg metformin hcl tab 1000 mg (Glucophage)

PrimeChoice Accord Formulary, January 2018 10 2018

Drug Name Drug Name nateglinide tab 60 mg (Starlix) NOVOLOG PENFILL – insulin aspart soln cartridge 100 nateglinide tab 120 mg (Starlix) unit/ml ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv) Short-Acting Insulins ONGLYZA – saxagliptin hcl tab 5 mg (base equiv) HUMULIN R U-500 (CONCENTR – insulin regular (human) inj 500 unit/ml OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/ dose (2 mg/1.5ml) HUMULIN R U-500 KWIKPEN – insulin regular (human) soln pen-injector 500 unit/ml OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) NOVOLIN R – insulin regular (human) inj 100 unit/ml pioglitazone hcl tab 15 mg (base equiv) (Actos) Intermediate-Acting Insulins pioglitazone hcl tab 30 mg (base equiv) (Actos) NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml pioglitazone hcl tab 45 mg (base equiv) (Actos) NOVOLIN 70/30 – insulin nph isophane & regular human pioglitazone hcl-metformin hcl tab 15-500 mg inj 100 unit/ml (70-30) (Actoplus met) NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp pioglitazone hcl-metformin hcl tab 15-850 mg pen-inj 100 unit/ml (70-30) (Actoplus met) NOVOLOG MIX 70/30 – insulin aspart prot & aspart repaglinide tab 0.5 mg (Prandin) (human) inj 100 unit/ml (70-30) repaglinide tab 1 mg (Prandin) NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & repaglinide tab 2 mg (Prandin) aspart sus pen-inj 100 unit/ml (70-30) SYNJARDY – empagliflozin-metformin hcl tab 5-500 mg Basal Insulins SYNJARDY – empagliflozin-metformin hcl tab 5-1000 mg LANTUS – insulin glargine inj 100 unit/ml SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 LANTUS SOLOSTAR – insulin glargine soln pen-injector mg 100 unit/ml SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000 LEVEMIR – insulin detemir inj 100 unit/ml mg LEVEMIR FLEXTOUCH – insulin detemir soln pen- SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr injector 100 unit/ml 5-1000 mg TOUJEO MAX SOLOSTAR – insulin glargine soln pen- SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr injector 300 unit/ml 10-1000 mg TOUJEO SOLOSTAR – insulin glargine soln pen-injector SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr 300 unit/ml 12.5-1000 mg TRESIBA FLEXTOUCH – insulin degludec soln pen- SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr injector 100 unit/ml 25-1000 mg TRESIBA FLEXTOUCH – insulin degludec soln pen- TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml injector 200 unit/ml TRULICITY – dulaglutide soln pen-injector 1.5 mg/0.5ml THYROID AGENTS VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ levothyroxine sodium tab 25 mcg (Synthroid) ml) levothyroxine sodium tab 50 mcg (Synthroid) Rapid-Acting Insulins levothyroxine sodium tab 75 mcg (Synthroid) FIASP – insulin aspart inj 100 unit/ml levothyroxine sodium tab 88 mcg (Synthroid) FIASP FLEXTOUCH – insulin aspart soln pen-injector levothyroxine sodium tab 100 mcg (Synthroid) 100 unit/ml levothyroxine sodium tab 112 mcg (Synthroid) NOVOLOG – insulin aspart inj 100 unit/ml levothyroxine sodium tab 125 mcg (Synthroid) NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml levothyroxine sodium tab 137 mcg (Synthroid)

PrimeChoice Accord Formulary, January 2018 11 2018

Drug Name Drug Name levothyroxine sodium tab 150 mcg (Synthroid) GONAL-F RFF – follitropin alfa for subcutaneous inj 75 levothyroxine sodium tab 175 mcg (Synthroid) unit levothyroxine sodium tab 200 mcg (Synthroid) GONAL-F RFF REDIJECT – follitropin alfa inj 300 unit/0.5ml levothyroxine sodium tab 300 mcg (Synthroid) GONAL-F RFF REDIJECT – follitropin alfa inj 450 liothyronine sodium tab 5 mcg (Cytomel) unit/0.75ml liothyronine sodium tab 25 mcg (Cytomel) GONAL-F RFF REDIJECT – follitropin alfa inj 900 liothyronine sodium tab 50 mcg (Cytomel) unit/1.5ml methimazole tab 5 mg (Tapazole) ibandronate sodium tab 150 mg (base equivalent) (Boniva) methimazole tab 10 mg (Tapazole) INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) propylthiouracil tab 50 mg (Carnitor) OXYTOCICS levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) methylergonovine maleate tab 0.2 mg levocarnitine tab 330 mg NITYR – nitisinone tab 2 mg ENDOCRINE and METABOLIC AGENTS - MISC. ALENDRONATE SODIUM – alendronate sodium tab 40 NITYR – nitisinone tab 5 mg mg NITYR – nitisinone tab 10 mg alendronate sodium tab 5 mg NOVAREL – chorionic gonadotropin for im inj 10000 unit alendronate sodium tab 10 mg octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) alendronate sodium tab 35 mg alendronate sodium tab 70 mg (Fosamax) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) cabergoline tab 0.5 mg octreotide acetate inj 200 mcg/ml (0.2 mg/ml) calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) (Sandostatin) calcitriol cap 0.25 mcg (Rocaltrol) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) calcitriol cap 0.5 mcg (Rocaltrol) (Sandostatin) calcitriol oral soln 1 mcg/ml (Rocaltrol) octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) CETROTIDE – cetrorelix acetate for inj kit 0.25 mg OMNITROPE – somatropin for inj 5.8 mg CHORIONIC GONADOTROPIN – chorionic gonadotropin for im inj 10000 unit OMNITROPE – somatropin inj 5 mg/1.5ml CLOMIPHENE CITRATE – clomiphene citrate tab 50 mg OMNITROPE – somatropin inj 10 mg/1.5ml CYSTADANE – betaine powder for oral solution ORFADIN – nitisinone susp 4 mg/ml desmopressin acetate nasal spray soln 0.01% ORFADIN – nitisinone cap 2 mg (Ddavp) ORFADIN – nitisinone cap 5 mg desmopressin acetate nasal spray soln 0.01% ORFADIN – nitisinone cap 10 mg (refrigerated) ORFADIN – nitisinone cap 20 mg desmopressin acetate tab 0.1 mg (Ddavp) OVIDREL – choriogonadotropin alfa inj 250 mcg/0.5ml desmopressin acetate tab 0.2 mg (Ddavp) paricalcitol cap 1 mcg (Zemplar) FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml paricalcitol cap 2 mcg (Zemplar) FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml paricalcitol cap 4 mcg (Zemplar) FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml PREGNYL W/DILUENT BENZYL – chorionic GONAL-F – follitropin alfa for inj 450 unit gonadotropin for im inj 10000 unit GONAL-F – follitropin alfa for inj 1050 unit PROLIA – denosumab inj 60 mg/ml

PrimeChoice Accord Formulary, January 2018 12 2018

Drug Name Drug Name raloxifene hcl tab 60 mg (Evista) nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) risedronate sodium tab 5 mg (Actonel) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) risedronate sodium tab 30 mg (Actonel) nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) risedronate sodium tab 35 mg (Actonel) nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) risedronate sodium tab 150 mg (Actonel) BETA BLOCKERS SANDOSTATIN LAR DEPOT – octreotide acetate for im acebutolol hcl cap 200 mg (Sectral) inj kit 10 mg acebutolol hcl cap 400 mg (Sectral) SANDOSTATIN LAR DEPOT – octreotide acetate for im atenolol tab 25 mg (Tenormin) inj kit 20 mg atenolol tab 50 mg (Tenormin) SANDOSTATIN LAR DEPOT – octreotide acetate for im inj kit 30 mg atenolol tab 100 mg (Tenormin) SENSIPAR – cinacalcet hcl tab 30 mg (base equiv) bisoprolol fumarate tab 5 mg (Zebeta) SENSIPAR – cinacalcet hcl tab 60 mg (base equiv) bisoprolol fumarate tab 10 mg (Zebeta) SENSIPAR – cinacalcet hcl tab 90 mg (base equiv) carvedilol tab 3.125 mg (Coreg) STIMATE – desmopressin acetate nasal soln 1.5 mg/ml carvedilol tab 6.25 mg (Coreg) STRENSIQ – asfotase alfa subcutaneous inj 18 carvedilol tab 12.5 mg (Coreg) mg/0.45ml carvedilol tab 25 mg (Coreg) STRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml labetalol hcl tab 100 mg (Trandate) STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml labetalol hcl tab 200 mg (Trandate) STRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml labetalol hcl tab 300 mg (Trandate) TYMLOS – abaloparatide subcutaneous soln pen-injector metoprolol succinate tab er 24hr 25 mg (tartrate 3120 mcg/1.56ml equiv) (Toprol xl) CARDIOVASCULAR AGENTS metoprolol succinate tab er 24hr 50 mg (tartrate CARDIOTONICS equiv) (Toprol xl) DIGOXIN – digoxin oral soln 0.05 mg/ml metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol xl) digoxin tab 125 mcg (0.125 mg) (Lanoxin) metoprolol succinate tab er 24hr 200 mg (tartrate digoxin tab 250 mcg (0.25 mg) (Lanoxin) equiv) (Toprol xl) ANTIANGINAL AGENTS metoprolol tartrate tab 25 mg isosorbide dinitrate tab 5 mg (Isordil titradose) metoprolol tartrate tab 50 mg (Lopressor) isosorbide dinitrate tab 10 mg metoprolol tartrate tab 100 mg (Lopressor) isosorbide dinitrate tab 20 mg nadolol tab 20 mg (Corgard) isosorbide dinitrate tab 30 mg nadolol tab 40 mg (Corgard) isosorbide mononitrate tab er 24hr 30 mg nadolol tab 80 mg (Corgard) isosorbide mononitrate tab er 24hr 60 mg pindolol tab 5 mg isosorbide mononitrate tab er 24hr 120 mg pindolol tab 10 mg isosorbide mononitrate tab 10 mg PROPRANOLOL HCL – propranolol hcl oral soln 20 isosorbide mononitrate tab 20 mg mg/5ml NITRO-BID – nitroglycerin oint 2% PROPRANOLOL HCL – propranolol hcl oral soln 40 nitroglycerin sl tab 0.3 mg (Nitrostat) mg/5ml nitroglycerin sl tab 0.4 mg (Nitrostat) propranolol hcl cap er 24hr 60 mg (Inderal la) nitroglycerin sl tab 0.6 mg (Nitrostat) propranolol hcl cap er 24hr 80 mg (Inderal la)

PrimeChoice Accord Formulary, January 2018 13 2018

Drug Name Drug Name propranolol hcl cap er 24hr 120 mg (Inderal la) diltiazem hcl extended release beads cap er 24hr propranolol hcl cap er 24hr 160 mg (Inderal la) 300 mg (Tiazac) propranolol hcl tab 10 mg diltiazem hcl extended release beads cap er 24hr 360 mg (Tiazac) propranolol hcl tab 20 mg diltiazem hcl extended release beads cap er 24hr propranolol hcl tab 40 mg 420 mg (Tiazac) propranolol hcl tab 60 mg diltiazem hcl tab 30 mg (Cardizem) propranolol hcl tab 80 mg diltiazem hcl tab 60 mg (Cardizem) sotalol hcl (afib/afl) tab 80 mg (Betapace af) diltiazem hcl tab 90 mg sotalol hcl (afib/afl) tab 120 mg (Betapace af) diltiazem hcl tab 120 mg (Cardizem) sotalol hcl (afib/afl) tab 160 mg (Betapace af) felodipine tab er 24hr 2.5 mg sotalol hcl tab 80 mg (Betapace) felodipine tab er 24hr 5 mg sotalol hcl tab 120 mg (Betapace) felodipine tab er 24hr 10 mg sotalol hcl tab 160 mg (Betapace) nifedipine tab er 24hr 30 mg (Adalat cc) sotalol hcl tab 240 mg nifedipine tab er 24hr 60 mg (Adalat cc) TIMOLOL MALEATE – timolol maleate tab 5 mg nifedipine tab er 24hr 90 mg (Adalat cc) TIMOLOL MALEATE – timolol maleate tab 10 mg nifedipine tab er 24hr osmotic release 30 mg TIMOLOL MALEATE – timolol maleate tab 20 mg (Procardia xl) CALCIUM CHANNEL BLOCKERS nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) amlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) amlodipine besylate tab 5 mg (base equivalent) (Norvasc) nimodipine cap 30 mg amlodipine besylate tab 10 mg (base equivalent) verapamil hcl cap er 24hr 120 mg (Verelan) (Norvasc) verapamil hcl cap er 24hr 180 mg (Verelan) diltiazem hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 240 mg (Verelan) diltiazem hcl cap er 24hr 180 mg VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 diltiazem hcl cap er 24hr 240 mg mg diltiazem hcl coated beads cap er 24hr 120 mg verapamil hcl tab er 120 mg (Calan sr) (Cardizem cd) verapamil hcl tab er 180 mg (Calan sr) diltiazem hcl coated beads cap er 24hr 180 mg verapamil hcl tab er 240 mg (Calan sr) (Cardizem cd) verapamil hcl tab 40 mg diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) verapamil hcl tab 80 mg (Calan) diltiazem hcl coated beads cap er 24hr 300 mg verapamil hcl tab 120 mg (Calan) diltiazem hcl coated beads cap er 24hr 360 mg ANTIARRHYTHMICS (Cardizem cd) amiodarone hcl tab 100 mg diltiazem hcl extended release beads cap er 24hr amiodarone hcl tab 200 mg (Cordarone) 120 mg (Tiazac) amiodarone hcl tab 400 mg diltiazem hcl extended release beads cap er 24hr disopyramide phosphate cap 100 mg (Norpace) 180 mg (Tiazac) disopyramide phosphate cap 150 mg (Norpace) diltiazem hcl extended release beads cap er 24hr 240 mg (Tiazac) flecainide acetate tab 50 mg

PrimeChoice Accord Formulary, January 2018 14 2018

Drug Name Drug Name flecainide acetate tab 100 mg amlodipine-valsartan-hydrochlorothiazide tab flecainide acetate tab 150 mg 10-320-25 mg (Exforge hct) mexiletine hcl cap 150 mg atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) mexiletine hcl cap 200 mg atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) mexiletine hcl cap 250 mg benazepril & hydrochlorothiazide tab 5-6.25 mg MULTAQ – dronedarone hcl tab 400 mg (base equivalent) benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) propafenone hcl cap er 12hr 225 mg (Rythmol sr) benazepril & hydrochlorothiazide tab 20-12.5 mg propafenone hcl cap er 12hr 325 mg (Rythmol sr) (Lotensin hct) propafenone hcl cap er 12hr 425 mg (Rythmol sr) benazepril & hydrochlorothiazide tab 20-25 mg propafenone hcl tab 150 mg (Rythmol) (Lotensin hct) propafenone hcl tab 225 mg (Rythmol) benazepril hcl tab 5 mg propafenone hcl tab 300 mg benazepril hcl tab 10 mg (Lotensin) quinidine gluconate tab er 324 mg benazepril hcl tab 20 mg (Lotensin) QUINIDINE SULFATE – quinidine sulfate tab 200 mg benazepril hcl tab 40 mg (Lotensin) QUINIDINE SULFATE – quinidine sulfate tab 300 mg bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) ANTIHYPERTENSIVES (Ziac) amlodipine besylate-benazepril hcl cap 2.5-10 mg bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Lotrel) bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) candesartan cilexetil tab 4 mg (Atacand) amlodipine besylate-benazepril hcl cap 5-20 mg candesartan cilexetil tab 8 mg (Atacand) (Lotrel) candesartan cilexetil tab 16 mg (Atacand) amlodipine besylate-benazepril hcl cap 5-40 mg candesartan cilexetil tab 32 mg (Atacand) (Lotrel) candesartan cilexetil-hydrochlorothiazide tab amlodipine besylate-benazepril hcl cap 10-20 mg 16-12.5 mg (Atacand hct) (Lotrel) candesartan cilexetil-hydrochlorothiazide tab amlodipine besylate-benazepril hcl cap 10-40 mg 32-12.5 mg (Atacand hct) (Lotrel) candesartan cilexetil-hydrochlorothiazide tab amlodipine besylate-valsartan tab 5-160 mg (Exforge) 32-25 mg (Atacand hct) amlodipine besylate-valsartan tab 5-320 mg (Exforge) captopril tab 12.5 mg amlodipine besylate-valsartan tab 10-160 mg captopril tab 25 mg (Exforge) captopril tab 50 mg amlodipine besylate-valsartan tab 10-320 mg (Exforge) captopril tab 100 mg amlodipine-valsartan-hydrochlorothiazide tab CAPTOPRIL/HYDROCHLOROTHIA – captopril & 5-160-12.5 mg (Exforge hct) hydrochlorothiazide tab 25-15 mg amlodipine-valsartan-hydrochlorothiazide tab CAPTOPRIL/HYDROCHLOROTHIA – captopril & 5-160-25 mg (Exforge hct) hydrochlorothiazide tab 25-25 mg amlodipine-valsartan-hydrochlorothiazide tab CAPTOPRIL/HYDROCHLOROTHIA – captopril & 10-160-12.5 mg (Exforge hct) hydrochlorothiazide tab 50-15 mg amlodipine-valsartan-hydrochlorothiazide tab CAPTOPRIL/HYDROCHLOROTHIA – captopril & 10-160-25 mg (Exforge hct) hydrochlorothiazide tab 50-25 mg

PrimeChoice Accord Formulary, January 2018 15 2018

Drug Name Drug Name clonidine hcl tab 0.1 mg (Catapres) lisinopril & hydrochlorothiazide tab 10-12.5 mg clonidine hcl tab 0.2 mg (Catapres) (Zestoretic) clonidine hcl tab 0.3 mg (Catapres) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1) lisinopril & hydrochlorothiazide tab 20-25 mg clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2) (Zestoretic) clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3) lisinopril tab 2.5 mg (Zestril) doxazosin mesylate tab 1 mg (Cardura) lisinopril tab 5 mg (Prinivil) doxazosin mesylate tab 2 mg (Cardura) lisinopril tab 10 mg (Prinivil) doxazosin mesylate tab 4 mg (Cardura) lisinopril tab 20 mg (Prinivil) doxazosin mesylate tab 8 mg (Cardura) lisinopril tab 30 mg (Zestril) enalapril maleate & hydrochlorothiazide tab lisinopril tab 40 mg (Zestril) 5-12.5 mg losartan potassium & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab 10-25 mg 50-12.5 mg (Hyzaar) (Vaseretic) losartan potassium & hydrochlorothiazide tab enalapril maleate tab 2.5 mg (Vasotec) 100-12.5 mg (Hyzaar) enalapril maleate tab 5 mg (Vasotec) losartan potassium & hydrochlorothiazide tab enalapril maleate tab 10 mg (Vasotec) 100-25 mg (Hyzaar) enalapril maleate tab 20 mg (Vasotec) losartan potassium tab 25 mg (Cozaar) eplerenone tab 25 mg (Inspra) losartan potassium tab 50 mg (Cozaar) eplerenone tab 50 mg (Inspra) losartan potassium tab 100 mg (Cozaar) fosinopril sodium & hydrochlorothiazide tab methyldopa tab 250 mg 10-12.5 mg methyldopa tab 500 mg fosinopril sodium & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab 50-25 mg 20-12.5 mg (Lopressor hct) fosinopril sodium tab 10 mg metoprolol & hydrochlorothiazide tab 100-25 mg fosinopril sodium tab 20 mg (Lopressor hct) fosinopril sodium tab 40 mg METOPROLOL/HYDROCHLOROTHI – metoprolol & hydrochlorothiazide tab 100-50 mg guanfacine hcl tab 1 mg (Tenex) guanfacine hcl tab 2 mg (Tenex) minoxidil tab 2.5 mg hydralazine hcl tab 10 mg minoxidil tab 10 mg (Univasc) hydralazine hcl tab 25 mg moexipril hcl tab 7.5 mg (Univasc) hydralazine hcl tab 50 mg moexipril hcl tab 15 mg hydralazine hcl tab 100 mg moexipril-hydrochlorothiazide tab 7.5-12.5 mg (Uniretic) irbesartan tab 75 mg (Avapro) moexipril-hydrochlorothiazide tab 15-12.5 mg irbesartan tab 150 mg (Avapro) (Uniretic) irbesartan tab 300 mg (Avapro) moexipril-hydrochlorothiazide tab 15-25 mg irbesartan-hydrochlorothiazide tab 150-12.5 mg olmesartan medoxomil tab 5 mg (Benicar) (Avalide) olmesartan medoxomil tab 20 mg (Benicar) irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) olmesartan medoxomil tab 40 mg (Benicar) olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg (Benicar hct)

PrimeChoice Accord Formulary, January 2018 16 2018

Drug Name Drug Name olmesartan medoxomil-hydrochlorothiazide tab trandolapril tab 1 mg (Mavik) 40-12.5 mg (Benicar hct) trandolapril tab 2 mg (Mavik) olmesartan medoxomil-hydrochlorothiazide tab trandolapril tab 4 mg (Mavik) 40-25 mg (Benicar hct) valsartan tab 40 mg (Diovan) perindopril erbumine tab 2 mg valsartan tab 80 mg (Diovan) perindopril erbumine tab 4 mg (Aceon) valsartan tab 160 mg (Diovan) perindopril erbumine tab 8 mg (Aceon) valsartan tab 320 mg (Diovan) phenoxybenzamine hcl cap 10 mg (Dibenzyline) valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan prazosin hcl cap 1 mg (Minipress) hct) prazosin hcl cap 2 mg (Minipress) valsartan-hydrochlorothiazide tab 160-12.5 mg prazosin hcl cap 5 mg (Minipress) (Diovan hct) PROPRANOLOL/HYDROCHLOROTH – propranolol & valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hydrochlorothiazide tab 40-25 mg hct) PROPRANOLOL/HYDROCHLOROTH – propranolol & valsartan-hydrochlorothiazide tab 320-12.5 mg hydrochlorothiazide tab 80-25 mg (Diovan hct) quinapril hcl tab 5 mg (Accupril) valsartan-hydrochlorothiazide tab 320-25 mg (Diovan quinapril hcl tab 10 mg (Accupril) hct) quinapril hcl tab 20 mg (Accupril) DIURETICS quinapril hcl tab 40 mg (Accupril) acetazolamide cap er 12hr 500 mg (Diamox) quinapril-hydrochlorothiazide tab 10-12.5 mg acetazolamide tab 125 mg (Accuretic) acetazolamide tab 250 mg quinapril-hydrochlorothiazide tab 20-12.5 mg amiloride & hydrochlorothiazide tab 5-50 mg (Accuretic) amiloride hcl tab 5 mg quinapril-hydrochlorothiazide tab 20-25 mg bumetanide tab 0.5 mg (Accuretic) bumetanide tab 1 mg ramipril cap 1.25 mg (Altace) bumetanide tab 2 mg ramipril cap 2.5 mg (Altace) CHLOROTHIAZIDE – chlorothiazide tab 250 mg ramipril cap 5 mg (Altace) chlorothiazide tab 500 mg ramipril cap 10 mg (Altace) chlorthalidone tab 25 mg telmisartan tab 20 mg (Micardis) chlorthalidone tab 50 mg telmisartan tab 40 mg (Micardis) furosemide oral soln 10 mg/ml telmisartan tab 80 mg (Micardis) furosemide tab 20 mg (Lasix) telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct) furosemide tab 40 mg (Lasix) telmisartan-hydrochlorothiazide tab 80-12.5 mg furosemide tab 80 mg (Lasix) (Micardis hct) hydrochlorothiazide cap 12.5 mg (Microzide) telmisartan-hydrochlorothiazide tab 80-25 mg hydrochlorothiazide tab 12.5 mg (Micardis hct) hydrochlorothiazide tab 25 mg terazosin hcl cap 1 mg (base equivalent) hydrochlorothiazide tab 50 mg terazosin hcl cap 2 mg (base equivalent) indapamide tab 1.25 mg terazosin hcl cap 5 mg (base equivalent) indapamide tab 2.5 mg terazosin hcl cap 10 mg (base equivalent) methazolamide tab 25 mg (Neptazane)

PrimeChoice Accord Formulary, January 2018 17 2018

Drug Name Drug Name methazolamide tab 50 mg (Neptazane) cholestyramine powder packets 4 gm (Questran) metolazone tab 2.5 mg (Zaroxolyn) cholestyramine powder 4 gm/dose (Questran) metolazone tab 5 mg (Zaroxolyn) choline fenofibrate cap dr 45 mg (fenofibric acid metolazone tab 10 mg equiv) (Trilipix) spironolactone & hydrochlorothiazide tab 25-25 mg choline fenofibrate cap dr 135 mg (fenofibric acid (Aldactazide) equiv) (Trilipix) spironolactone tab 25 mg (Aldactone) colesevelam hcl packet for susp 3.75 gm (Welchol) spironolactone tab 50 mg (Aldactone) colesevelam hcl tab 625 mg (Welchol) spironolactone tab 100 mg (Aldactone) colestipol hcl granule packets 5 gm (Colestid flavored) torsemide tab 5 mg (Demadex) colestipol hcl granules 5 gm (Colestid flavored) torsemide tab 10 mg (Demadex) colestipol hcl tab 1 gm (Colestid) torsemide tab 20 mg (Demadex) ezetimibe tab 10 mg (Zetia) torsemide tab 100 mg (Demadex) ezetimibe-simvastatin tab 10-10 mg (Vytorin) triamterene & hydrochlorothiazide cap 37.5-25 mg ezetimibe-simvastatin tab 10-20 mg (Vytorin) (Dyazide) ezetimibe-simvastatin tab 10-40 mg (Vytorin) triamterene & hydrochlorothiazide tab 37.5-25 mg ezetimibe-simvastatin tab 10-80 mg (Vytorin) (Maxzide-25) fenofibrate micronized cap 67 mg (Lofibra) triamterene & hydrochlorothiazide tab 75-50 mg fenofibrate micronized cap 134 mg (Lofibra) (Maxzide) fenofibrate micronized cap 200 mg (Lofibra) VASOPRESSORS fenofibrate tab 48 mg (Tricor) EPINEPHRINE (Mylan Products) – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) fenofibrate tab 54 mg (Lofibra) EPINEPHRINE (Mylan Products) – epinephrine solution fenofibrate tab 145 mg (Tricor) auto-injector 0.3 mg/0.3ml (1:1000) fenofibrate tab 160 mg (Lofibra) EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 gemfibrozil tab 600 mg (Lopid) mg/0.3ml (1:1000) lovastatin tab 10 mg EPIPEN-JR 2-PAK – epinephrine solution auto-injector lovastatin tab 20 mg (Mevacor) 0.15 mg/0.3ml (1:2000) lovastatin tab 40 mg (Mevacor) midodrine hcl tab 2.5 mg niacin tab er 500 mg (antihyperlipidemic) (Niaspan) midodrine hcl tab 5 mg niacin tab er 750 mg (antihyperlipidemic) (Niaspan) midodrine hcl tab 10 mg niacin tab er 1000 mg (antihyperlipidemic) (Niaspan) ANTIHYPERLIPIDEMICS pravastatin sodium tab 10 mg atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) pravastatin sodium tab 20 mg (Pravachol) atorvastatin calcium tab 20 mg (base equivalent) pravastatin sodium tab 40 mg (Pravachol) (Lipitor) pravastatin sodium tab 80 mg (Pravachol) atorvastatin calcium tab 40 mg (base equivalent) REPATHA – evolocumab subcutaneous soln prefilled (Lipitor) syringe 140 mg/ml atorvastatin calcium tab 80 mg (base equivalent) REPATHA PUSHTRONEX SYSTEM – evolocumab (Lipitor) subcutaneous soln cartridge/infusor 420 mg/3.5ml cholestyramine light powder packets 4 gm REPATHA SURECLICK – evolocumab subcutaneous cholestyramine light powder 4 gm/dose (Questran soln auto-injector 140 mg/ml light) rosuvastatin calcium tab 5 mg (Crestor)

PrimeChoice Accord Formulary, January 2018 18 2018

Drug Name Drug Name rosuvastatin calcium tab 10 mg (Crestor) OPSUMIT – macitentan tab 10 mg rosuvastatin calcium tab 20 mg (Crestor) sildenafil citrate tab 20 mg (Revatio) rosuvastatin calcium tab 40 mg (Crestor) tadalafil tab 20 mg (pah) (Adcirca) simvastatin tab 5 mg (Zocor) tadalafil tab 2.5 mg (Cialis) simvastatin tab 10 mg (Zocor) tadalafil tab 5 mg (Cialis) simvastatin tab 20 mg (Zocor) tadalafil tab 10 mg (Cialis) simvastatin tab 40 mg (Zocor) tadalafil tab 20 mg (Cialis) simvastatin tab 80 mg (Zocor) TRACLEER – bosentan tab for oral susp 32 mg WELCHOL – colesevelam hcl packet for susp 3.75 gm TRACLEER – bosentan tab 62.5 mg CARDIOVASCULAR AGENTS - MISC. TRACLEER – bosentan tab 125 mg ADCIRCA – tadalafil tab 20 mg (pah) UPTRAVI – selexipag tab therapy pack 200 mcg (140) & amlodipine besylate-atorvastatin calcium tab 800 mcg (60) 2.5-10 mg (Caduet) UPTRAVI – selexipag tab 200 mcg amlodipine besylate-atorvastatin calcium tab UPTRAVI – selexipag tab 400 mcg 2.5-20 mg (Caduet) UPTRAVI – selexipag tab 600 mcg amlodipine besylate-atorvastatin calcium tab UPTRAVI – selexipag tab 800 mcg 2.5-40 mg (Caduet) UPTRAVI – selexipag tab 1000 mcg amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet) UPTRAVI – selexipag tab 1200 mcg amlodipine besylate-atorvastatin calcium tab 5-20 mg UPTRAVI – selexipag tab 1400 mcg (Caduet) UPTRAVI – selexipag tab 1600 mcg amlodipine besylate-atorvastatin calcium tab 5-40 mg RESPIRATORY AGENTS (Caduet) ANTIHISTAMINES amlodipine besylate-atorvastatin calcium tab 5-80 mg cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) (Caduet) cyproheptadine hcl syrup 2 mg/5ml amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet) cyproheptadine hcl tab 4 mg amlodipine besylate-atorvastatin calcium tab DESLORATADINE ODT – desloratadine tab orally 10-20 mg (Caduet) disintegrating 2.5 mg amlodipine besylate-atorvastatin calcium tab DESLORATADINE ODT – desloratadine tab orally 10-40 mg (Caduet) disintegrating 5 mg amlodipine besylate-atorvastatin calcium tab desloratadine tab 5 mg (Clarinex) 10-80 mg (Caduet) levocetirizine dihydrochloride soln 2.5 mg/5ml CIALIS – tadalafil tab 2.5 mg (0.5 mg/ml) (Xyzal) CIALIS – tadalafil tab 5 mg levocetirizine dihydrochloride tab 5 mg (Xyzal) CIALIS – tadalafil tab 10 mg promethazine hcl suppos 12.5 mg CIALIS – tadalafil tab 20 mg promethazine hcl suppos 25 mg ENTRESTO – sacubitril-valsartan tab 24-26 mg promethazine hcl suppos 50 mg ENTRESTO – sacubitril-valsartan tab 49-51 mg promethazine hcl syrup 6.25 mg/5ml ENTRESTO – sacubitril-valsartan tab 97-103 mg promethazine hcl tab 12.5 mg LETAIRIS – ambrisentan tab 5 mg promethazine hcl tab 25 mg LETAIRIS – ambrisentan tab 10 mg promethazine hcl tab 50 mg

PrimeChoice Accord Formulary, January 2018 19 2018

Drug Name Drug Name NASAL AGENTS - SYSTEMIC and TOPICAL ARNUITY ELLIPTA – fluticasone furoate aerosol powder azelastine hcl nasal spray 0.1% (137 mcg/spray) breath activ 100 mcg/act azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ARNUITY ELLIPTA – fluticasone furoate aerosol powder (Astepro) breath activ 200 mcg/act BACTROBAN NASAL – mupirocin calcium nasal oint 2% ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act fluticasone propionate nasal susp 50 mcg/act (Flonase) ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated) ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated) ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) mometasone furoate nasal susp 50 mcg/act (Nasonex) ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) COUGH/COLD/ALLERGY ATROVENT HFA – ipratropium bromide hfa inhal aerosol acetylcysteine inhal soln 10% 17 mcg/act acetylcysteine inhal soln 20% BREO ELLIPTA – fluticasone furoate-vilanterol aero ANTIASTHMATIC and BRONCHODILATOR AGENTS powd ba 100-25 mcg/inh ADVAIR DISKUS – fluticasone-salmeterol aer powder ba BREO ELLIPTA – fluticasone furoate-vilanterol aero 100-50 mcg/dose powd ba 200-25 mcg/inh ADVAIR DISKUS – fluticasone-salmeterol aer powder ba budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 250-50 mcg/dose budesonide inhalation susp 0.5 mg/2ml (Pulmicort) ADVAIR DISKUS – fluticasone-salmeterol aer powder ba budesonide inhalation susp 1 mg/2ml (Pulmicort) 500-50 mcg/dose COMBIVENT RESPIMAT – ipratropium-albuterol inhal ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 aerosol soln 20-100 mcg/act mcg/act cromolyn sodium soln nebu 20 mg/2ml ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act DULERA – mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act DULERA – mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) FLOVENT DISKUS – fluticasone propionate aer pow ba albuterol sulfate soln nebu 0.5% (5 mg/ml) 50 mcg/blister albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) FLOVENT DISKUS – fluticasone propionate aer pow ba albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 100 mcg/blister albuterol sulfate syrup 2 mg/5ml FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister albuterol sulfate tab 2 mg FLOVENT HFA – fluticasone propionate hfa inhal aero 44 albuterol sulfate tab 4 mg mcg/act (50/valve) ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 50 mcg/act FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)

PrimeChoice Accord Formulary, January 2018 20 2018

Drug Name Drug Name FLUTICASONE PROPIONATE/SA – fluticasone- SYMBICORT – budesonide-formoterol fumarate dihyd salmeterol aer powder ba 55-14 mcg/act aerosol 80-4.5 mcg/act FLUTICASONE PROPIONATE/SA – fluticasone- SYMBICORT – budesonide-formoterol fumarate dihyd salmeterol aer powder ba 113-14 mcg/act aerosol 160-4.5 mcg/act FLUTICASONE PROPIONATE/SA – fluticasone- terbutaline sulfate tab 2.5 mg salmeterol aer powder ba 232-14 mcg/act terbutaline sulfate tab 5 mg INCRUSE ELLIPTA – umeclidinium br aero powd breath theophylline tab er 12hr 100 mg act 62.5 mcg/inh (base eq) theophylline tab er 12hr 200 mg ipratropium bromide inhal soln 0.02% theophylline tab er 12hr 300 mg ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml (Duoneb) theophylline tab er 12hr 450 mg levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base theophylline tab er 24hr 400 mg equiv) theophylline tab er 24hr 600 mg levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol (Xopenex) aepb 100-62.5-25 mcg/inh levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/ (Xopenex) act (90mcg base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) zafirlukast tab 10 mg (Accolate) (Xopenex) zafirlukast tab 20 mg (Accolate) montelukast sodium chew tab 4 mg (base equiv) RESPIRATORY AGENTS - MISC. (Singulair) KALYDECO – ivacaftor tab 150 mg montelukast sodium chew tab 5 mg (base equiv) (Singulair) KALYDECO – ivacaftor packet 50 mg montelukast sodium oral granules packet 4 mg (base KALYDECO – ivacaftor packet 75 mg equiv) (Singulair) PULMOZYME – dornase alfa inhal soln 1 mg/ml montelukast sodium tab 10 mg (base equiv) GASTROINTESTINAL AGENTS (Singulair) LAXATIVES PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act lactulose solution 10 gm/15ml (90mcg base equiv) peg 3350-kcl-sod bicarb-nacl for soln 420 gm PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 (Nulytely/flavor pack) mcg/act (90 mcg base equiv) peg 3350-kcl-na bicarb-nacl-na sulfate for soln QVAR REDIHALER – beclomethasone diprop hfa breath 236 gm (Golytely) act inh aer 40 mcg/act peg 3350-kcl-na bicarb-nacl-na sulfate for soln QVAR REDIHALER – beclomethasone diprop hfa breath 240 gm (Colyte-flavor packs) act inh aer 80 mcg/act ANTIDIARRHEALS SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) SPIRIVA HANDIHALER – tiotropium bromide DIPHENOXYLATE/ATROPINE – diphenoxylate w/ monohydrate inhal cap 18 mcg (base equiv) atropine liq 2.5-0.025 mg/5ml SPIRIVA RESPIMAT – tiotropium bromide monohydrate loperamide hcl cap 2 mg inhal aerosol 1.25 mcg/act ULCER DRUGS SPIRIVA RESPIMAT – tiotropium bromide monohydrate CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml inhal aerosol 2.5 mcg/act cimetidine tab 300 mg STIOLTO RESPIMAT – tiotropium br-olodaterol inhal cimetidine tab 400 mg aero soln 2.5-2.5 mcg/act cimetidine tab 800 mg

PrimeChoice Accord Formulary, January 2018 21 2018

Drug Name Drug Name dicyclomine hcl cap 10 mg (Bentyl) ANTIEMETICS dicyclomine hcl oral soln 10 mg/5ml aprepitant capsule therapy pack 80 & 125 mg (Emend) dicyclomine hcl tab 20 mg (Bentyl) aprepitant capsule 40 mg (Emend) esomeprazole magnesium cap delayed release 20 mg aprepitant capsule 80 mg (Emend) (base eq) (Nexium) aprepitant capsule 125 mg (Emend) esomeprazole magnesium cap delayed release 40 mg EMEND – aprepitant for oral susp 125 mg (125 mg/5ml) (base eq) (Nexium) granisetron hcl tab 1 mg famotidine tab 20 mg (Pepcid) meclizine hcl tab 12.5 mg famotidine tab 40 mg (Pepcid) meclizine hcl tab 25 mg glycopyrrolate tab 1 mg (Robinul) ondansetron hcl oral soln 4 mg/5ml (Zofran) glycopyrrolate tab 2 mg (Robinul forte) ondansetron hcl tab 4 mg (Zofran) lansoprazole cap delayed release 15 mg (Prevacid) ondansetron hcl tab 8 mg (Zofran) lansoprazole cap delayed release 30 mg (Prevacid) ondansetron hcl tab 24 mg methscopolamine bromide tab 2.5 mg (Pamine) ondansetron orally disintegrating tab 4 mg (Zofran methscopolamine bromide tab 5 mg (Pamine forte) odt) misoprostol tab 100 mcg (Cytotec) ondansetron orally disintegrating tab 8 mg (Zofran misoprostol tab 200 mcg (Cytotec) odt) NEXIUM – esomeprazole magnesium for delayed release trimethobenzamide hcl cap 300 mg (Tigan) susp pack 2.5 mg DIGESTIVE AIDS NEXIUM – esomeprazole magnesium for delayed release CREON – pancrelipase (lip-prot-amyl) dr cap susp packet 5 mg 3000-9500-15000 unit NEXIUM – esomeprazole magnesium for delayed release CREON – pancrelipase (lip-prot-amyl) dr cap susp packet 10 mg 6000-19000-30000 unit NEXIUM – esomeprazole magnesium for delayed release CREON – pancrelipase (lip-prot-amyl) dr cap susp packet 20 mg 12000-38000-60000 unit NEXIUM – esomeprazole magnesium for delayed release CREON – pancrelipase (lip-prot-amyl) dr cap susp packet 40 mg 24000-76000-120000 unit omeprazole cap delayed release 10 mg (Prilosec) CREON – pancrelipase (lip-prot-amyl) dr cap omeprazole cap delayed release 20 mg (Prilosec) 36000-114000-180000 unit omeprazole cap delayed release 40 mg (Prilosec) ZENPEP – pancrelipase (lip-prot-amyl) dr cap pantoprazole sodium ec tab 20 mg (base equiv) 3000-10000-14000 unit (Protonix) ZENPEP – pancrelipase (lip-prot-amyl) dr cap pantoprazole sodium ec tab 40 mg (base equiv) 5000-17000-24000 unit (Protonix) ZENPEP – pancrelipase (lip-prot-amyl) dr cap PROPANTHELINE BROMIDE – propantheline bromide 10000-32000-42000 unit tab 15 mg ZENPEP – pancrelipase (lip-prot-amyl) dr cap ranitidine hcl cap 150 mg 15000-47000-63000 unit ranitidine hcl cap 300 mg ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-63000-84000 unit ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ZENPEP – pancrelipase (lip-prot-amyl) dr cap ranitidine hcl tab 150 mg (Zantac) 25000-79000-105000 unit ranitidine hcl tab 300 mg (Zantac) ZENPEP – pancrelipase (lip-prot-amyl) dr cap sucralfate tab 1 gm (Carafate) 40000-126000-168000 unit

PrimeChoice Accord Formulary, January 2018 22 2018

Drug Name Drug Name GASTROINTESTINAL AGENTS- MISC. nitrofurantoin macrocrystalline cap 100 mg APRISO – mesalamine cap er 24hr 0.375 gm (Macrodantin) ASACOL HD – mesalamine tab delayed release 800 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) balsalazide disodium cap 750 mg (Colazal) nitrofurantoin susp 25 mg/5ml (Furadantin) calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) URINARY ANTISPASMODICS calcium acetate (phosphate binder) tab 667 mg oxybutynin chloride syrup 5 mg/5ml (Eliphos) oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) CANASA – mesalamine suppos 1000 mg oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) CHENODAL – chenodiol tab 250 mg oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) DELZICOL – mesalamine cap dr 400 mg oxybutynin chloride tab 5 mg lactulose (encephalopathy) solution 10 gm/15ml tolterodine tartrate cap er 24hr 2 mg (Detrol la) LINZESS – linaclotide cap 72 mcg tolterodine tartrate cap er 24hr 4 mg (Detrol la) LINZESS – linaclotide cap 145 mcg tolterodine tartrate tab 1 mg (Detrol) LINZESS – linaclotide cap 290 mcg tolterodine tartrate tab 2 mg (Detrol) mesalamine enema 4 gm VESICARE – solifenacin succinate tab 5 mg mesalamine tab delayed release 800 mg (Asacol hd) VESICARE – solifenacin succinate tab 10 mg mesalamine tab delayed release 1.2 gm (Lialda) VAGINAL PRODUCTS metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) clindamycin phosphate vaginal cream 2% (Cleocin) (base equiv) estradiol vaginal cream 0.1 mg/gm (Estrace) metoclopramide hcl tab 5 mg (base equivalent) metronidazole vaginal gel 0.75% (Metrogel-vaginal) (Reglan) TERCONAZOLE – terconazole vaginal cream 0.8% metoclopramide hcl tab 10 mg (base equivalent) (Reglan) terconazole vaginal cream 0.4% (Terazol 7) sevelamer carbonate packet 0.8 gm (Renvela) terconazole vaginal suppos 80 mg (Terazol 3) sevelamer carbonate packet 2.4 gm (Renvela) VAGIFEM – estradiol vaginal tab 10 mcg sevelamer carbonate tab 800 mg (Renvela) GENITOURINARY AGENTS - MISC. sulfasalazine tab delayed release 500 mg (Azulfidine alfuzosin hcl tab er 24hr 10 mg (Uroxatral) en-tabs) CYSTAGON – cysteamine bitartrate cap 50 mg sulfasalazine tab 500 mg (Azulfidine) CYSTAGON – cysteamine bitartrate cap 150 mg ursodiol cap 300 mg (Actigall) dutasteride cap 0.5 mg (Avodart) ursodiol tab 250 mg (Urso 250) finasteride tab 5 mg (Proscar) ursodiol tab 500 mg (Urso forte) K-PHOS NO 2 – potassium & sodium acid phosphates VELPHORO – sucroferric oxyhydroxide chew tab 500 mg tab 305-700 mg VIBERZI – eluxadoline tab 75 mg potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) VIBERZI – eluxadoline tab 100 mg potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) GENITOURINARY AGENTS potassium citrate tab er 15 meq (1620 mg) (Urocit-k URINARY ANTI-INFECTIVES 15) nitrofurantoin macrocrystalline cap 25 mg sodium citrate & citric acid soln 500-334 mg/5ml (Macrodantin) (Shohls solution modi) nitrofurantoin macrocrystalline cap 50 mg tamsulosin hcl cap 0.4 mg (Flomax) (Macrodantin)

PrimeChoice Accord Formulary, January 2018 23 2018

Drug Name Drug Name CENTRAL NERVOUS SYSTEM DRUGS bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) ANTIANXIETY AGENTS bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) alprazolam tab er 24hr 0.5 mg (Xanax xr) bupropion hcl tab 75 mg (Wellbutrin) alprazolam tab er 24hr 1 mg (Xanax xr) bupropion hcl tab 100 mg (Wellbutrin) alprazolam tab er 24hr 2 mg (Xanax xr) citalopram hydrobromide oral soln 10 mg/5ml alprazolam tab er 24hr 3 mg (Xanax xr) citalopram hydrobromide tab 10 mg (base equiv) alprazolam tab 0.25 mg (Xanax) (Celexa) alprazolam tab 0.5 mg (Xanax) citalopram hydrobromide tab 20 mg (base equiv) (Celexa) alprazolam tab 1 mg (Xanax) citalopram hydrobromide tab 40 mg (base equiv) alprazolam tab 2 mg (Xanax) (Celexa) buspirone hcl tab 5 mg clomipramine hcl cap 25 mg (Anafranil) buspirone hcl tab 10 mg clomipramine hcl cap 50 mg (Anafranil) buspirone hcl tab 15 mg clomipramine hcl cap 75 mg (Anafranil) buspirone hcl tab 30 mg desipramine hcl tab 10 mg (Norpramin) DIAZEPAM – diazepam oral soln 1 mg/ml desipramine hcl tab 25 mg (Norpramin) diazepam tab 2 mg (Valium) desipramine hcl tab 50 mg (Norpramin) diazepam tab 5 mg (Valium) desipramine hcl tab 75 mg (Norpramin) diazepam tab 10 mg (Valium) desipramine hcl tab 100 mg (Norpramin) hydroxyzine hcl syrup 10 mg/5ml desipramine hcl tab 150 mg (Norpramin) hydroxyzine hcl tab 10 mg doxepin hcl cap 10 mg hydroxyzine hcl tab 25 mg doxepin hcl cap 25 mg hydroxyzine hcl tab 50 mg doxepin hcl cap 50 mg HYDROXYZINE PAMOATE – hydroxyzine pamoate cap doxepin hcl cap 75 mg 100 mg doxepin hcl cap 100 mg hydroxyzine pamoate cap 25 mg (Vistaril) doxepin hcl conc 10 mg/ml hydroxyzine pamoate cap 50 mg (Vistaril) duloxetine hcl enteric coated pellets cap 20 mg (base lorazepam conc 2 mg/ml (Lorazepam intensol) eq) (Cymbalta) lorazepam tab 0.5 mg (Ativan) duloxetine hcl enteric coated pellets cap 30 mg (base lorazepam tab 1 mg (Ativan) eq) (Cymbalta) lorazepam tab 2 mg (Ativan) duloxetine hcl enteric coated pellets cap 60 mg (base (Cymbalta) ANTIDEPRESSANTS eq) amitriptyline hcl tab 10 mg escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) amitriptyline hcl tab 25 mg escitalopram oxalate tab 5 mg (base equiv) (Lexapro) amitriptyline hcl tab 50 mg escitalopram oxalate tab 10 mg (base equiv) (Lexapro) amitriptyline hcl tab 75 mg escitalopram oxalate tab 20 mg (base equiv) (Lexapro) amitriptyline hcl tab 100 mg fluoxetine hcl cap 10 mg (Prozac) amitriptyline hcl tab 150 mg fluoxetine hcl cap 20 mg (Prozac) bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) fluoxetine hcl cap 40 mg (Prozac) bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) fluoxetine hcl solution 20 mg/5ml bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)

PrimeChoice Accord Formulary, January 2018 24 2018

Drug Name Drug Name fluoxetine hcl tab 10 mg venlafaxine hcl cap er 24hr 150 mg (base equivalent) fluoxetine hcl tab 20 mg (Effexor xr) fluvoxamine maleate tab 25 mg venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) fluvoxamine maleate tab 50 mg venlafaxine hcl tab er 24hr 75 mg (base equivalent) fluvoxamine maleate tab 100 mg (Venlafaxine hcl er) imipramine hcl tab 10 mg (Tofranil) venlafaxine hcl tab er 24hr 150 mg (base equivalent) imipramine hcl tab 25 mg (Tofranil) (Venlafaxine hcl er) imipramine hcl tab 50 mg (Tofranil) venlafaxine hcl tab 25 mg mirtazapine tab 7.5 mg venlafaxine hcl tab 37.5 mg mirtazapine tab 15 mg (Remeron) venlafaxine hcl tab 50 mg mirtazapine tab 30 mg (Remeron) venlafaxine hcl tab 75 mg mirtazapine tab 45 mg (Remeron) venlafaxine hcl tab 100 mg NORTRIPTYLINE HCL – nortriptyline hcl soln 10 mg/5ml ANTIPSYCHOTICS nortriptyline hcl cap 10 mg (Pamelor) aripiprazole tab 2 mg (Abilify) nortriptyline hcl cap 25 mg (Pamelor) aripiprazole tab 5 mg (Abilify) nortriptyline hcl cap 50 mg (Pamelor) aripiprazole tab 10 mg (Abilify) nortriptyline hcl cap 75 mg (Pamelor) aripiprazole tab 15 mg (Abilify) paroxetine hcl tab er 24hr 12.5 mg (Paxil cr) aripiprazole tab 20 mg (Abilify) paroxetine hcl tab er 24hr 25 mg (Paxil cr) aripiprazole tab 30 mg (Abilify) paroxetine hcl tab er 24hr 37.5 mg (Paxil cr) chlorpromazine hcl tab 10 mg paroxetine hcl tab 10 mg (Paxil) chlorpromazine hcl tab 25 mg paroxetine hcl tab 20 mg (Paxil) chlorpromazine hcl tab 50 mg paroxetine hcl tab 30 mg (Paxil) chlorpromazine hcl tab 100 mg paroxetine hcl tab 40 mg (Paxil) chlorpromazine hcl tab 200 mg phenelzine sulfate tab 15 mg (Nardil) clozapine tab 25 mg (Clozaril) sertraline hcl oral concentrate for solution 20 mg/ml clozapine tab 50 mg (Zoloft) clozapine tab 100 mg (Clozaril) sertraline hcl tab 25 mg (Zoloft) clozapine tab 200 mg sertraline hcl tab 50 mg (Zoloft) fluphenazine decanoate inj 25 mg/ml sertraline hcl tab 100 mg (Zoloft) FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 tranylcypromine sulfate tab 10 mg (Parnate) mg/5ml trazodone hcl tab 50 mg FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ ml trazodone hcl tab 100 mg trazodone hcl tab 150 mg fluphenazine hcl tab 1 mg trazodone hcl tab 300 mg fluphenazine hcl tab 2.5 mg venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) fluphenazine hcl tab 5 mg (Effexor xr) fluphenazine hcl tab 10 mg venlafaxine hcl cap er 24hr 75 mg (base equivalent) haloperidol decanoate im soln 50 mg/ml (Haldol (Effexor xr) decanoate 50) haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100)

PrimeChoice Accord Formulary, January 2018 25 2018

Drug Name Drug Name haloperidol lactate oral conc 2 mg/ml prochlorperazine suppos 25 mg haloperidol tab 0.5 mg quetiapine fumarate tab er 24hr 50 mg (Seroquel xr) haloperidol tab 1 mg quetiapine fumarate tab er 24hr 150 mg (Seroquel xr) haloperidol tab 2 mg quetiapine fumarate tab er 24hr 200 mg (Seroquel xr) haloperidol tab 5 mg quetiapine fumarate tab er 24hr 300 mg (Seroquel xr) haloperidol tab 10 mg quetiapine fumarate tab er 24hr 400 mg (Seroquel xr) haloperidol tab 20 mg quetiapine fumarate tab 25 mg (Seroquel) LITHIUM – lithium oral solution 8 meq/5ml quetiapine fumarate tab 50 mg (Seroquel) LITHIUM CARBONATE – lithium carbonate cap 150 mg quetiapine fumarate tab 100 mg (Seroquel) lithium carbonate cap 150 mg (Lithium carbonate) quetiapine fumarate tab 200 mg (Seroquel) lithium carbonate cap 300 mg quetiapine fumarate tab 300 mg (Seroquel) lithium carbonate cap 600 mg (Lithium carbonate) quetiapine fumarate tab 400 mg (Seroquel) lithium carbonate tab er 300 mg (Lithobid) RISPERIDONE ODT – risperidone orally disintegrating lithium carbonate tab er 450 mg tab 0.25 mg lithium carbonate tab 300 mg risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) loxapine succinate cap 5 mg (Loxitane) risperidone orally disintegrating tab 1 mg (Risperdal loxapine succinate cap 10 mg m-tab) loxapine succinate cap 25 mg risperidone orally disintegrating tab 2 mg (Risperdal loxapine succinate cap 50 mg m-tab) olanzapine orally disintegrating tab 5 mg (Zyprexa risperidone orally disintegrating tab 3 mg (Risperdal zydis) m-tab) olanzapine orally disintegrating tab 10 mg (Zyprexa risperidone orally disintegrating tab 4 mg (Risperdal zydis) m-tab) olanzapine orally disintegrating tab 15 mg (Zyprexa risperidone soln 1 mg/ml (Risperdal) zydis) risperidone tab 0.25 mg (Risperdal) olanzapine orally disintegrating tab 20 mg (Zyprexa risperidone tab 0.5 mg (Risperdal) zydis) risperidone tab 1 mg (Risperdal) olanzapine tab 2.5 mg (Zyprexa) risperidone tab 2 mg (Risperdal) olanzapine tab 5 mg (Zyprexa) risperidone tab 3 mg (Risperdal) olanzapine tab 7.5 mg (Zyprexa) risperidone tab 4 mg (Risperdal) olanzapine tab 10 mg (Zyprexa) thiothixene cap 1 mg olanzapine tab 15 mg (Zyprexa) thiothixene cap 2 mg olanzapine tab 20 mg (Zyprexa) thiothixene cap 5 mg perphenazine tab 2 mg thiothixene cap 10 mg perphenazine tab 4 mg trifluoperazine hcl tab 1 mg (base equivalent) perphenazine tab 8 mg trifluoperazine hcl tab 2 mg (base equivalent) perphenazine tab 16 mg trifluoperazine hcl tab 5 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) (Compazine) trifluoperazine hcl tab 10 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) ziprasidone hcl cap 20 mg (Geodon) (Compazine) ziprasidone hcl cap 40 mg (Geodon)

PrimeChoice Accord Formulary, January 2018 26 2018

Drug Name Drug Name ziprasidone hcl cap 60 mg (Geodon) ADDERALL XR – amphetamine-dextroamphetamine cap ziprasidone hcl cap 80 mg (Geodon) er 24hr 30 mg HYPNOTICS amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) BELSOMRA – suvorexant tab 5 mg amphetamine-dextroamphetamine cap er 24hr 10 mg BELSOMRA – suvorexant tab 10 mg (Adderall xr) BELSOMRA – suvorexant tab 15 mg amphetamine-dextroamphetamine cap er 24hr 15 mg BELSOMRA – suvorexant tab 20 mg (Adderall xr) estazolam tab 1 mg amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderall xr) estazolam tab 2 mg eszopiclone tab 1 mg (Lunesta) amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderall xr) eszopiclone tab 2 mg (Lunesta) amphetamine-dextroamphetamine cap er 24hr 30 mg eszopiclone tab 3 mg (Lunesta) (Adderall xr) phenobarbital elixir 20 mg/5ml amphetamine-dextroamphetamine tab 5 mg (Adderall) phenobarbital tab 15 mg amphetamine-dextroamphetamine tab 7.5 mg phenobarbital tab 16.2 mg (Adderall) phenobarbital tab 30 mg amphetamine-dextroamphetamine tab 10 mg (Adderall) phenobarbital tab 32.4 mg amphetamine-dextroamphetamine tab 12.5 mg phenobarbital tab 60 mg (Adderall) phenobarbital tab 100 mg amphetamine-dextroamphetamine tab 15 mg temazepam cap 7.5 mg (Restoril) (Adderall) temazepam cap 15 mg (Restoril) amphetamine-dextroamphetamine tab 20 mg temazepam cap 22.5 mg (Restoril) (Adderall) temazepam cap 30 mg (Restoril) amphetamine-dextroamphetamine tab 30 mg (Adderall) zaleplon cap 5 mg (Sonata) armodafinil tab 50 mg (Nuvigil) zaleplon cap 10 mg (Sonata) armodafinil tab 150 mg (Nuvigil) zolpidem tartrate tab er 6.25 mg (Ambien cr) armodafinil tab 200 mg (Nuvigil) zolpidem tartrate tab er 12.5 mg (Ambien cr) armodafinil tab 250 mg (Nuvigil) zolpidem tartrate tab 5 mg (Ambien) atomoxetine hcl cap 10 mg (base equiv) (Strattera) zolpidem tartrate tab 10 mg (Ambien) atomoxetine hcl cap 18 mg (base equiv) (Strattera) ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS atomoxetine hcl cap 25 mg (base equiv) (Strattera) ADDERALL XR – amphetamine-dextroamphetamine cap atomoxetine hcl cap 40 mg (base equiv) (Strattera) er 24hr 5 mg atomoxetine hcl cap 60 mg (base equiv) (Strattera) ADDERALL XR – amphetamine-dextroamphetamine cap atomoxetine hcl cap 80 mg (base equiv) (Strattera) er 24hr 10 mg atomoxetine hcl cap 100 mg (base equiv) (Strattera) ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr 15 mg caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit) ADDERALL XR – amphetamine-dextroamphetamine cap CONCERTA – methylphenidate hcl tab er osmotic er 24hr 20 mg release (osm) 18 mg ADDERALL XR – amphetamine-dextroamphetamine cap CONCERTA – methylphenidate hcl tab er osmotic er 24hr 25 mg release (osm) 27 mg

PrimeChoice Accord Formulary, January 2018 27 2018

Drug Name Drug Name CONCERTA – methylphenidate hcl tab er osmotic VYVANSE – lisdexamfetamine dimesylate chew tab 10 release (osm) 36 mg mg CONCERTA – methylphenidate hcl tab er osmotic VYVANSE – lisdexamfetamine dimesylate chew tab 20 release (osm) 54 mg mg dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) VYVANSE – lisdexamfetamine dimesylate chew tab 30 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin mg xr) VYVANSE – lisdexamfetamine dimesylate chew tab 40 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin mg xr) VYVANSE – lisdexamfetamine dimesylate chew tab 50 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin mg xr) VYVANSE – lisdexamfetamine dimesylate chew tab 60 dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin mg xr) PSYCHOTHERAPEUTIC and NEUROLOGICAL dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin AGENTS - MISC. xr) acamprosate calcium tab delayed release 333 mg dextroamphetamine sulfate cap er 24hr 5 mg (Campral) (Dexedrine) AUBAGIO – teriflunomide tab 7 mg dextroamphetamine sulfate cap er 24hr 10 mg AUBAGIO – teriflunomide tab 14 mg (Dexedrine) AVONEX – interferon beta-1a im prefilled syringe kit 30 dextroamphetamine sulfate cap er 24hr 15 mg mcg/0.5ml (Dexedrine) AVONEX – interferon beta-1a for im inj kit 30mcg dextroamphetamine sulfate tab 5 mg (33mcg(6.6 mu)/vial) dextroamphetamine sulfate tab 10 mg AVONEX PEN – interferon beta-1a im auto-injector kit 30 guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) mcg/0.5ml guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) BETASERON – interferon beta-1b for inj kit 0.3 mg guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) methylphenidate hcl tab er 10 mg CHANTIX – varenicline tartrate tab 1 mg (base equiv) methylphenidate hcl tab er 20 mg CHANTIX CONTINUING MONTH – varenicline tartrate methylphenidate hcl tab 5 mg (Ritalin) tab 1 mg (base equiv) methylphenidate hcl tab 10 mg (Ritalin) CHANTIX STARTING MONTH PA – varenicline tartrate methylphenidate hcl tab 20 mg (Ritalin) tab 0.5 mg x 11 & tab 1 mg x 42 pack modafinil tab 100 mg (Provigil) COPAXONE – glatiramer acetate soln prefilled syringe 20 mg/ml modafinil tab 200 mg (Provigil) VYVANSE – lisdexamfetamine dimesylate cap 10 mg COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml VYVANSE – lisdexamfetamine dimesylate cap 20 mg disulfiram tab 250 mg (Antabuse) VYVANSE – lisdexamfetamine dimesylate cap 30 mg disulfiram tab 500 mg (Antabuse) VYVANSE – lisdexamfetamine dimesylate cap 40 mg donepezil hydrochloride orally disintegrating tab VYVANSE – lisdexamfetamine dimesylate cap 50 mg 5 mg (Aricept odt) VYVANSE – lisdexamfetamine dimesylate cap 60 mg donepezil hydrochloride orally disintegrating tab VYVANSE – lisdexamfetamine dimesylate cap 70 mg 10 mg (Aricept odt) donepezil hydrochloride tab 5 mg (Aricept)

PrimeChoice Accord Formulary, January 2018 28 2018

Drug Name Drug Name donepezil hydrochloride tab 10 mg (Aricept) REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 GALANTAMINE HYDROBROMIDE – galantamine mcg/0.5ml (24mu/ml) hydrobromide oral soln 4 mg/ml REBIF REBIDOSE TITRATION – interferon beta-1a auto- galantamine hydrobromide cap er 24hr 8 mg inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml (Razadyne er) REBIF TITRATION PACK – interferon beta-1a pref syr galantamine hydrobromide cap er 24hr 16 mg 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml (Razadyne er) rivastigmine tartrate cap 1.5 mg (base equivalent) galantamine hydrobromide cap er 24hr 24 mg rivastigmine tartrate cap 3 mg (base equivalent) (Razadyne er) rivastigmine tartrate cap 4.5 mg (base equivalent) galantamine hydrobromide tab 4 mg (Razadyne) rivastigmine tartrate cap 6 mg (base equivalent) galantamine hydrobromide tab 8 mg (Razadyne) TECFIDERA – dimethyl fumarate capsule delayed galantamine hydrobromide tab 12 mg (Razadyne) release 120 mg GILENYA – fingolimod hcl cap 0.5 mg (base equiv) TECFIDERA – dimethyl fumarate capsule delayed glatiramer acetate soln prefilled syringe 20 mg/ml release 240 mg (Copaxone) TECFIDERA STARTER PACK – dimethyl fumarate glatiramer acetate soln prefilled syringe 40 mg/ml capsule dr starter pack 120 mg & 240 mg (Copaxone) tetrabenazine tab 12.5 mg (Xenazine) memantine hcl oral solution 2 mg/ml (Namenda) tetrabenazine tab 25 mg (Xenazine) memantine hcl tab 5 mg (Namenda) ANALGESICS AND ANESTHETICS memantine hcl tab 10 mg (Namenda) ANALGESICS - NON-NARCOTIC memantine hcl tab 5 mg (28) & 10 mg (21) titration butalbital-acetaminophen tab 50-325 mg pak (Namenda titration pa) butalbital-acetaminophen-caffeine cap 50-325-40 mg NICOTROL INHALER – nicotine inhaler system 10 mg (4 (Esgic) mg delivered) butalbital-acetaminophen-caffeine tab 50-325-40 mg NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ (Esgic) spray) butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) NUEDEXTA – dextromethorphan hbr-quinidine sulfate TENCON – butalbital-acetaminophen tab 50-325 mg cap 20-10 mg ANALGESICS - NARCOTIC pimozide tab 1 mg (Orap) acetaminophen w/ codeine soln 120-12 mg/5ml pimozide tab 2 mg (Orap) acetaminophen w/ codeine tab 300-15 mg (Tylenol/ PLEGRIDY – peginterferon beta-1a soln pen-injector 125 codeine) mcg/0.5ml acetaminophen w/ codeine tab 300-30 mg (Tylenol/ PLEGRIDY – peginterferon beta-1a soln prefilled syringe codeine #3) 125 mcg/0.5ml acetaminophen w/ codeine tab 300-60 mg (Tylenol/ PLEGRIDY STARTER PACK – peginterferon beta-1a codeine #4) soln pen-inj 63 & 94 mcg/0.5ml pack buprenorphine hcl sl tab 2 mg (base equiv) PLEGRIDY STARTER PACK – peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack buprenorphine hcl sl tab 8 mg (base equiv) REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml butalbital-aspirin-caff w/ codeine cap (12mu/ml) 50-325-40-30 mg (Fiorinal/codeine #3) REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml codeine sulfate tab 15 mg (Codeine sulfate) (24mu/ml) codeine sulfate tab 30 mg REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 codeine sulfate tab 60 mg mcg/0.5ml (12mu/ml) fentanyl citrate lozenge on a handle 200 mcg (Actiq)

PrimeChoice Accord Formulary, January 2018 29 2018

Drug Name Drug Name fentanyl citrate lozenge on a handle 400 mcg (Actiq) MORPHINE SULFATE ER – morphine sulfate beads cap fentanyl citrate lozenge on a handle 600 mcg (Actiq) er 24hr 120 mg fentanyl citrate lozenge on a handle 800 mcg (Actiq) morphine sulfate oral soln 10 mg/5ml fentanyl citrate lozenge on a handle 1200 mcg (Actiq) morphine sulfate oral soln 20 mg/5ml fentanyl citrate lozenge on a handle 1600 mcg (Actiq) morphine sulfate oral soln 100 mg/5ml (20 mg/ml) fentanyl td patch 72hr 12 mcg/hr (Duragesic) morphine sulfate tab er 15 mg (Ms contin) fentanyl td patch 72hr 25 mcg/hr (Duragesic) morphine sulfate tab er 30 mg (Ms contin) fentanyl td patch 72hr 50 mcg/hr (Duragesic) morphine sulfate tab er 60 mg (Ms contin) fentanyl td patch 72hr 75 mcg/hr (Duragesic) morphine sulfate tab er 100 mg (Ms contin) fentanyl td patch 72hr 100 mcg/hr (Duragesic) morphine sulfate tab er 200 mg (Ms contin) hydrocodone-acetaminophen soln 7.5-325 mg/15ml NUCYNTA ER – tapentadol hcl tab er 12hr 50 mg (Hycet) NUCYNTA ER – tapentadol hcl tab er 12hr 100 mg hydrocodone-acetaminophen tab 10-325 mg (Norco) NUCYNTA ER – tapentadol hcl tab er 12hr 150 mg hydrocodone-acetaminophen tab 5-325 mg (Norco) NUCYNTA ER – tapentadol hcl tab er 12hr 200 mg hydrocodone-acetaminophen tab 7.5-325 mg (Norco) NUCYNTA ER – tapentadol hcl tab er 12hr 250 mg hydrocodone-ibuprofen tab 5-200 mg (Reprexain) oxycodone hcl cap 5 mg hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) oxycodone hcl conc 100 mg/5ml (20 mg/ml) hydrocodone-ibuprofen tab 10-200 mg (Ibudone) (Oxycodone hcl) hydromorphone hcl liqd 1 mg/ml (Dilaudid) oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) hydromorphone hcl tab 2 mg (Dilaudid) oxycodone hcl tab 5 mg (Roxicodone) hydromorphone hcl tab 4 mg (Dilaudid) oxycodone hcl tab 10 mg hydromorphone hcl tab 8 mg (Dilaudid) oxycodone hcl tab 15 mg (Roxicodone) methadone hcl conc 10 mg/ml (Methadose) oxycodone hcl tab 20 mg methadone hcl soln 5 mg/5ml (Methadone hcl) oxycodone hcl tab 30 mg (Roxicodone) methadone hcl soln 10 mg/5ml (Methadone hcl) oxycodone w/ acetaminophen tab 5-325 mg (Percocet) methadone hcl tab for oral susp 40 mg oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) methadone hcl tab 5 mg (Dolophine hcl) oxycodone w/ acetaminophen tab 10-325 mg methadone hcl tab 10 mg (Dolophine) (Percocet) MORPHINE SULFATE – morphine sulfate tab 15 mg oxycodone-aspirin tab 4.8355-325 mg (Percodan) MORPHINE SULFATE – morphine sulfate tab 30 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg MORPHINE SULFATE ER – morphine sulfate beads cap OXYCONTIN – oxycodone hcl tab er 12hr deter 15 mg er 24hr 30 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr 45 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg MORPHINE SULFATE ER – morphine sulfate beads cap OXYCONTIN – oxycodone hcl tab er 12hr deter 40 mg er 24hr 60 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg MORPHINE SULFATE ER – morphine sulfate beads cap OXYCONTIN – oxycodone hcl tab er 12hr deter 80 mg er 24hr 75 mg tramadol hcl tab er 24hr 100 mg MORPHINE SULFATE ER – morphine sulfate beads cap tramadol hcl tab er 24hr 200 mg er 24hr 90 mg tramadol hcl tab er 24hr 300 mg

PrimeChoice Accord Formulary, January 2018 30 2018

Drug Name Drug Name tramadol hcl tab 50 mg (Ultram) HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled tramadol-acetaminophen tab 37.5-325 mg (Ultracet) syringe kit 80 mg/0.8ml & 40 mg/0.4ml ANALGESICS - ANTI-INFLAMMATORY HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml celecoxib cap 50 mg (Celebrex) HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml celecoxib cap 100 mg (Celebrex) HUMIRA PEN-CD/UC/HS START – adalimumab pen- injector kit 40 mg/0.8ml celecoxib cap 200 mg (Celebrex) HUMIRA PEN-CD/UC/HS START – adalimumab pen- celecoxib cap 400 mg (Celebrex) injector kit 80 mg/0.8ml diclofenac potassium tab 50 mg (Cataflam) HUMIRA PEN-PS/UV STARTER – adalimumab pen- diclofenac sodium tab delayed release 25 mg injector kit 40 mg/0.8ml diclofenac sodium tab delayed release 50 mg HUMIRA PEN-PS/UV STARTER – adalimumab pen- injector kit 80 mg/0.8ml & 40 mg/0.4ml diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er 24hr 100 mg ibuprofen susp 100 mg/5ml ENBREL – etanercept for subcutaneous inj 25 mg ibuprofen tab 400 mg ENBREL – etanercept subcutaneous soln prefilled ibuprofen tab 600 mg syringe 25 mg/0.5ml ibuprofen tab 800 mg ENBREL – etanercept subcutaneous soln prefilled ILARIS – canakinumab subcutaneous inj 150 mg/ml syringe 50 mg/ml indomethacin cap 25 mg ENBREL MINI – etanercept subcutaneous solution indomethacin cap 50 mg cartridge 50 mg/ml leflunomide tab 10 mg (Arava) ENBREL SURECLICK – etanercept subcutaneous solution auto-injector 50 mg/ml leflunomide tab 20 mg (Arava) etodolac cap 200 mg meloxicam tab 7.5 mg (Mobic) etodolac cap 300 mg meloxicam tab 15 mg (Mobic) etodolac tab er 24hr 400 mg nabumetone tab 500 mg etodolac tab er 24hr 500 mg nabumetone tab 750 mg etodolac tab er 24hr 600 mg naproxen sodium tab 275 mg (Anaprox) etodolac tab 400 mg naproxen sodium tab 550 mg (Anaprox ds) etodolac tab 500 mg naproxen susp 125 mg/5ml (Naprosyn) flurbiprofen tab 50 mg naproxen tab ec 375 mg (Ec-naprosyn) flurbiprofen tab 100 mg naproxen tab ec 500 mg (Ec-naprosyn) HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml naproxen tab 250 mg (Naprosyn) HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml naproxen tab 375 mg (Naprosyn) HUMIRA – adalimumab prefilled syringe kit 20 mg/0.2ml naproxen tab 500 mg (Naprosyn) HUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml OTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml OTEZLA – apremilast tab 30 mg HUMIRA – adalimumab prefilled syringe kit 40 mg/0.4ml oxaprozin tab 600 mg (Daypro) HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe kit 40 mg/0.8ml piroxicam cap 10 mg (Feldene) HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled piroxicam cap 20 mg (Feldene) syringe kit 80 mg/0.8ml SIMPONI – golimumab subcutaneous soln auto-injector 50 mg/0.5ml

PrimeChoice Accord Formulary, January 2018 31 2018

Drug Name Drug Name SIMPONI – golimumab subcutaneous soln auto-injector colchicine w/ probenecid tab 0.5-500 mg 100 mg/ml COLCRYS – colchicine tab 0.6 mg SIMPONI – golimumab subcutaneous soln prefilled probenecid tab 500 mg syringe 50 mg/0.5ml NEUROMUSCULAR DRUGS SIMPONI – golimumab subcutaneous soln prefilled syringe 100 mg/ml ANTICONVULSANTS sulindac tab 150 mg BANZEL – rufinamide tab 200 mg sulindac tab 200 mg BANZEL – rufinamide tab 400 mg MIGRAINE PRODUCTS carbamazepine cap er 12hr 100 mg (Carbatrol) eletriptan hydrobromide tab 20 mg (base equivalent) carbamazepine cap er 12hr 200 mg (Carbatrol) (Relpax) carbamazepine cap er 12hr 300 mg (Carbatrol) eletriptan hydrobromide tab 40 mg (base equivalent) carbamazepine chew tab 100 mg (Relpax) carbamazepine susp 100 mg/5ml (Tegretol) MIGRANAL – dihydroergotamine mesylate nasal spray 4 carbamazepine tab er 12hr 100 mg (Tegretol-xr) mg/ml carbamazepine tab er 12hr 200 mg (Tegretol-xr) naratriptan hcl tab 1 mg (base equiv) (Amerge) carbamazepine tab er 12hr 400 mg (Tegretol-xr) naratriptan hcl tab 2.5 mg (base equiv) (Amerge) carbamazepine tab 200 mg (Tegretol) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt) CELONTIN – methsuximide cap 300 mg rizatriptan benzoate oral disintegrating tab 10 mg clonazepam tab 0.5 mg (Klonopin) (base eq) (Maxalt-mlt) clonazepam tab 1 mg (Klonopin) rizatriptan benzoate tab 5 mg (base equivalent) clonazepam tab 2 mg (Klonopin) (Maxalt) DIASTAT ACUDIAL – diazepam rectal gel delivery rizatriptan benzoate tab 10 mg (base equivalent) system 10 mg (Maxalt) DIASTAT ACUDIAL – diazepam rectal gel delivery sumatriptan nasal spray 5 mg/act (Imitrex) system 20 mg sumatriptan nasal spray 20 mg/act (Imitrex) DIASTAT PEDIATRIC – diazepam rectal gel delivery sumatriptan succinate inj 6 mg/0.5ml (Imitrex statdose system 2.5 mg ref) DILANTIN – phenytoin sodium extended cap 30 mg sumatriptan succinate solution auto-injector DILANTIN – phenytoin sodium extended cap 100 mg (Imitrex statdose sys) 4 mg/0.5ml DILANTIN-125 – phenytoin susp 125 mg/5ml sumatriptan succinate solution auto-injector divalproex sodium cap delayed release sprinkle 6 mg/0.5ml (Imitrex statdose sys) 125 mg (Depakote sprinkles) sumatriptan succinate solution cartridge 4 mg/0.5ml divalproex sodium tab delayed release 125 mg (Imitrex statdose ref) (Depakote) sumatriptan succinate solution cartridge 6 mg/0.5ml divalproex sodium tab delayed release 250 mg (Imitrex statdose ref) (Depakote) sumatriptan succinate tab 25 mg (Imitrex) divalproex sodium tab delayed release 500 mg sumatriptan succinate tab 50 mg (Imitrex) (Depakote) sumatriptan succinate tab 100 mg (Imitrex) divalproex sodium tab er 24 hr 250 mg (Depakote er) GOUT AGENTS divalproex sodium tab er 24 hr 500 mg (Depakote er) allopurinol tab 100 mg (Zyloprim) ethosuximide cap 250 mg (Zarontin) allopurinol tab 300 mg (Zyloprim) ethosuximide soln 250 mg/5ml (Zarontin)

PrimeChoice Accord Formulary, January 2018 32 2018

Drug Name Drug Name gabapentin cap 100 mg (Neurontin) primidone tab 250 mg (Mysoline) gabapentin cap 300 mg (Neurontin) SABRIL – vigabatrin tab 500 mg gabapentin cap 400 mg (Neurontin) topiramate sprinkle cap 15 mg (Topamax sprinkle) gabapentin oral soln 250 mg/5ml (Neurontin) topiramate sprinkle cap 25 mg (Topamax sprinkle) gabapentin tab 600 mg (Neurontin) topiramate tab 25 mg (Topamax) gabapentin tab 800 mg (Neurontin) topiramate tab 50 mg (Topamax) lamotrigine tab chewable dispersible 5 mg (Lamictal topiramate tab 100 mg (Topamax) chewable di) topiramate tab 200 mg (Topamax) lamotrigine tab chewable dispersible 25 mg (Lamictal valproate sodium oral soln 250 mg/5ml (base equiv) chewable di) (Depakene) lamotrigine tab 25 mg (Lamictal) valproic acid cap 250 mg (Depakene) lamotrigine tab 100 mg (Lamictal) vigabatrin powd pack 500 mg (Sabril) lamotrigine tab 150 mg (Lamictal) zonisamide cap 25 mg (Zonegran) lamotrigine tab 200 mg (Lamictal) zonisamide cap 50 mg levetiracetam oral soln 100 mg/ml (Keppra) zonisamide cap 100 mg (Zonegran) levetiracetam tab er 24hr 500 mg (Keppra xr) ANTIPARKINSON AGENTS levetiracetam tab er 24hr 750 mg (Keppra xr) amantadine hcl cap 100 mg levetiracetam tab 250 mg (Keppra) amantadine hcl syrup 50 mg/5ml levetiracetam tab 500 mg (Keppra) benztropine mesylate tab 0.5 mg levetiracetam tab 750 mg (Keppra) benztropine mesylate tab 1 mg levetiracetam tab 1000 mg (Keppra) benztropine mesylate tab 2 mg LYRICA – pregabalin soln 20 mg/ml bromocriptine mesylate cap 5 mg (base equivalent) LYRICA – pregabalin cap 25 mg (Parlodel) LYRICA – pregabalin cap 50 mg bromocriptine mesylate tab 2.5 mg (base equivalent) LYRICA – pregabalin cap 75 mg (Parlodel) LYRICA – pregabalin cap 100 mg carbidopa & levodopa orally disintegrating tab 10-100 mg (Parcopa) LYRICA – pregabalin cap 150 mg carbidopa & levodopa orally disintegrating tab LYRICA – pregabalin cap 200 mg 25-100 mg (Parcopa) LYRICA – pregabalin cap 225 mg carbidopa & levodopa orally disintegrating tab LYRICA – pregabalin cap 300 mg 25-250 mg (Parcopa) oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) carbidopa & levodopa tab er 25-100 mg (Sinemet cr) oxcarbazepine tab 150 mg (Trileptal) carbidopa & levodopa tab er 50-200 mg (Sinemet cr) oxcarbazepine tab 300 mg (Trileptal) carbidopa & levodopa tab 10-100 mg (Sinemet) oxcarbazepine tab 600 mg (Trileptal) carbidopa & levodopa tab 25-100 mg (Sinemet) phenytoin chew tab 50 mg (Dilantin infatabs) carbidopa & levodopa tab 25-250 mg (Sinemet) phenytoin sodium extended cap 100 mg (Dilantin) CARBIDOPA/LEVODOPA/ENTACA – carbidopa- levodopa-entacapone tabs 12.5-50-200 mg phenytoin sodium extended cap 200 mg (Phenytek) CARBIDOPA/LEVODOPA/ENTACA – carbidopa- phenytoin sodium extended cap 300 mg (Phenytek) levodopa-entacapone tabs 18.75-75-200 mg phenytoin susp 125 mg/5ml (Dilantin) CARBIDOPA/LEVODOPA/ENTACA – carbidopa- primidone tab 50 mg (Mysoline) levodopa-entacapone tabs 25-100-200 mg

PrimeChoice Accord Formulary, January 2018 33 2018

Drug Name Drug Name CARBIDOPA/LEVODOPA/ENTACA – carbidopa- metaxalone tab 800 mg (Skelaxin) levodopa-entacapone tabs 31.25-125-200 mg methocarbamol tab 500 mg (Robaxin) CARBIDOPA/LEVODOPA/ENTACA – carbidopa- methocarbamol tab 750 mg (Robaxin-750) levodopa-entacapone tabs 37.5-150-200 mg orphenadrine citrate tab er 12hr 100 mg CARBIDOPA/LEVODOPA/ENTACA – carbidopa- levodopa-entacapone tabs 50-200-200 mg SYNVISC – hylan intra-articular solution prefilled syringe 16 mg/2ml entacapone tab 200 mg (Comtan) SYNVISC ONE – hylan intra-articular solution prefilled pramipexole dihydrochloride tab 0.125 mg (Mirapex) syringe 48 mg/6ml pramipexole dihydrochloride tab 0.25 mg (Mirapex) tizanidine hcl tab 2 mg (base equivalent) pramipexole dihydrochloride tab 0.5 mg (Mirapex) tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) pramipexole dihydrochloride tab 0.75 mg (Mirapex) ANTIMYASTHENIC AGENTS pramipexole dihydrochloride tab 1 mg (Mirapex) pyridostigmine bromide tab 60 mg (Mestinon) pramipexole dihydrochloride tab 1.5 mg (Mirapex) NUTRITIONAL PRODUCTS rasagiline mesylate tab 0.5 mg (base equiv) (Azilect) VITAMINS rasagiline mesylate tab 1 mg (base equiv) (Azilect) ergocalciferol cap 50000 unit (Drisdol) ropinirole hydrochloride tab 0.25 mg (Requip) phytonadione tab 5 mg (Mephyton) ropinirole hydrochloride tab 0.5 mg (Requip) MULTIVITAMINS ropinirole hydrochloride tab 1 mg (Requip) KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron ropinirole hydrochloride tab 2 mg (Requip) carbonyl-fa tab 30-1 mg ropinirole hydrochloride tab 3 mg (Requip) MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonyl- ropinirole hydrochloride tab 4 mg (Requip) fa tab 90-1 mg ropinirole hydrochloride tab 5 mg (Requip) MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1 mg selegiline hcl cap 5 mg (Eldepryl) MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron selegiline hcl tab 5 mg carbonyl-fa tab 90-1 mg trihexyphenidyl hcl elixir 0.4 mg/ml MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1 mg trihexyphenidyl hcl tab 2 mg PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab trihexyphenidyl hcl tab 5 mg 29-1 mg NEUROMUSCULAR AGENTS PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa tab 29-1 mg riluzole tab 50 mg (Rilutek) PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe MUSCULOSKELETAL THERAPY AGENTS fumarate-fa tab 27-1 mg baclofen tab 10 mg PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab baclofen tab 20 mg 29-1 mg CHLORZOXAZONE – chlorzoxazone tab 500 mg PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab cyclobenzaprine hcl tab 5 mg 29-1 mg cyclobenzaprine hcl tab 10 mg PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg dantrolene sodium cap 25 mg (Dantrium) SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab dantrolene sodium cap 50 mg (Dantrium) 29-1 mg dantrolene sodium cap 100 mg (Dantrolene sodium) SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab EUFLEXXA – sodium hyaluronate intra-articular soln pref 29-1 mg syr 20 mg/2ml TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg

PrimeChoice Accord Formulary, January 2018 34 2018

Drug Name Drug Name VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab ARANESP ALBUMIN FREE – darbepoetin alfa soln 29-1 mg prefilled syringe 25 mcg/0.42ml VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 ARANESP ALBUMIN FREE – darbepoetin alfa soln mg prefilled syringe 40 mcg/0.4ml VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln MINERALS and ELECTROLYTES prefilled syringe 60 mcg/0.3ml FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f ARANESP ALBUMIN FREE – darbepoetin alfa soln (from 0.55 mg/drop naf) prefilled syringe 100 mcg/0.5ml K-PHOS – potassium phosphate monobasic tab 500 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral) ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml potassium chloride cap er 8 meq (Micro-k) ARANESP ALBUMIN FREE – darbepoetin alfa soln potassium chloride cap er 10 meq (Micro-k) prefilled syringe 300 mcg/0.6ml POTASSIUM CHLORIDE ER – potassium chloride tab er ARANESP ALBUMIN FREE – darbepoetin alfa soln 8 meq (600 mg) prefilled syringe 500 mcg/ml potassium chloride microencapsulated crys er tab 10 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 meq mcg/ml potassium chloride microencapsulated crys er tab 20 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 meq mcg/ml potassium chloride oral soln 10% (20 meq/15ml) ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 potassium chloride oral soln 20% (40 meq/15ml) mcg/ml potassium chloride powder packet 20 meq (K-lor ARANESP ALBUMIN FREE – darbepoetin alfa soln inj hospital pack) 100 mcg/ml potassium chloride tab er 8 meq (600 mg) ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200 mcg/ml potassium chloride tab er 10 meq (K-tab) SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 1.1 mg naf) 300 mcg/ml SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from cyanocobalamin inj 1000 mcg/ml 2.2 mg naf) folic acid tab 1 mg sodium fluoride chew tab 0.25 mg f (from 0.55 mg FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 naf) (Luride) mg/0.6ml sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) GRANIX – tbo-filgrastim soln prefilled syringe 300 (Luride) mcg/0.5ml sodium fluoride chew tab 1 mg f (from 2.2 mg naf) GRANIX – tbo-filgrastim soln prefilled syringe 480 (Luride) mcg/0.8ml sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop NEULASTA – pegfilgrastim soln prefilled syringe 6 naf) mg/0.6ml sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) NEULASTA ONPRO KIT – pegfilgrastim soln prefilled (Luride) syringe kit 6 mg/0.6ml HEMATOLOGICAL AGENTS NEUPOGEN – filgrastim soln prefilled syringe 300 mcg/0.5ml HEMATOPOIETIC AGENTS ARANESP ALBUMIN FREE – darbepoetin alfa soln NEUPOGEN – filgrastim soln prefilled syringe 480 prefilled syringe 10 mcg/0.4ml mcg/0.8ml (600 mcg/ml) NEUPOGEN – filgrastim inj 300 mcg/ml

PrimeChoice Accord Formulary, January 2018 35 2018

Drug Name Drug Name NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) XARELTO STARTER PACK – rivaroxaban tab starter PROCRIT – epoetin alfa inj 2000 unit/ml therapy pack 15 mg & 20 mg PROCRIT – epoetin alfa inj 3000 unit/ml HEMATOLOGICAL AGENTS - MISC. PROCRIT – epoetin alfa inj 4000 unit/ml anagrelide hcl cap 0.5 mg (Agrylin) PROCRIT – epoetin alfa inj 10000 unit/ml anagrelide hcl cap 1 mg PROCRIT – epoetin alfa inj 20000 unit/ml BRILINTA – ticagrelor tab 60 mg PROCRIT – epoetin alfa inj 40000 unit/ml BRILINTA – ticagrelor tab 90 mg RETACRIT – epoetin alfa-epbx inj 2000 unit/ml cilostazol tab 50 mg (Pletal) RETACRIT – epoetin alfa-epbx inj 3000 unit/ml cilostazol tab 100 mg (Pletal) RETACRIT – epoetin alfa-epbx inj 4000 unit/ml CINRYZE – c1 esterase inhibitor (human) for iv inj 500 unit RETACRIT – epoetin alfa-epbx inj 10000 unit/ml clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) RETACRIT – epoetin alfa-epbx inj 40000 unit/ml dipyridamole tab 25 mg (Persantine) ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml dipyridamole tab 50 mg (Persantine) ZARXIO – filgrastim-sndz soln prefilled syringe 480 dipyridamole tab 75 mg (Persantine) mcg/0.8ml FIRAZYR – icatibant acetate inj 30 mg/3ml (base ANTICOAGULANTS equivalent) ELIQUIS – apixaban tab 2.5 mg HAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj 2000 unit ELIQUIS – apixaban tab 5 mg HAEGARDA – c1 esterase inhibitor (human) for ELIQUIS STARTER PACK – apixaban tab 5 mg subcutaneous inj 3000 unit enoxaparin sodium inj 30 mg/0.3ml (Lovenox) pentoxifylline tab er 400 mg enoxaparin sodium inj 40 mg/0.4ml (Lovenox) prasugrel hcl tab 5 mg (base equiv) (Effient) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) prasugrel hcl tab 10 mg (base equiv) (Effient) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) TOPICAL PRODUCTS enoxaparin sodium inj 100 mg/ml (Lovenox) OPHTHALMIC AGENTS enoxaparin sodium inj 120 mg/0.8ml (Lovenox) ALPHAGAN P – brimonidine tartrate ophth soln 0.1% enoxaparin sodium inj 150 mg/ml (Lovenox) ALREX – loteprednol etabonate ophth susp 0.2% enoxaparin sodium inj 300 mg/3ml (Lovenox) ATROPINE SULFATE – atropine sulfate ophth soln 1% warfarin sodium tab 1 mg (Coumadin) azelastine hcl ophth soln 0.05% (Optivar) warfarin sodium tab 2 mg (Coumadin) AZOPT – brinzolamide ophth susp 1% warfarin sodium tab 2.5 mg (Coumadin) BACITRACIN – bacitracin ophth oint 500 unit/gm warfarin sodium tab 3 mg (Coumadin) bacitracin-polymyxin b ophth oint warfarin sodium tab 4 mg (Coumadin) bacitracin-polymyxin-neomycin-hc ophth oint 1% warfarin sodium tab 5 mg (Coumadin) brimonidine tartrate ophth soln 0.15% (Alphagan p) warfarin sodium tab 6 mg (Coumadin) brimonidine tartrate ophth soln 0.2% warfarin sodium tab 7.5 mg (Coumadin) CARTEOLOL HCL – carteolol hcl ophth soln 1% warfarin sodium tab 10 mg (Coumadin) CILOXAN – ciprofloxacin hcl ophth oint 0.3% XARELTO – rivaroxaban tab 10 mg ciprofloxacin hcl ophth soln 0.3% (Ciloxan) XARELTO – rivaroxaban tab 15 mg cromolyn sodium ophth soln 4% XARELTO – rivaroxaban tab 20 mg cyclopentolate hcl ophth soln 1% (Cyclogyl)

PrimeChoice Accord Formulary, January 2018 36 2018

Drug Name Drug Name DEXAMETHASONE SODIUM PHOS – dexamethasone polymyxin b-trimethoprim ophth soln 10000 unit/ sodium phosphate ophth soln 0.1% ml-0.1% (Polytrim) diclofenac sodium ophth soln 0.1% prednisolone acetate ophth susp 1% (Pred forte) dorzolamide hcl ophth soln 2% (Trusopt) SIMBRINZA – brinzolamide-brimonidine tartrate ophth dorzolamide hcl-timolol maleate ophth soln susp 1-0.2% 22.3-6.8 mg/ml (Cosopt) sulfacetamide sodium ophth soln 10% (Bleph-10) erythromycin ophth oint 5 mg/gm sulfacetamide sodium-prednisolone ophth soln fluorometholone ophth susp 0.1% (Fml liquifilm) 10-0.23(0.25)% flurbiprofen sodium ophth soln 0.03% (Ocufen) timolol maleate ophth soln 0.25% (Timoptic) GENTAK – gentamicin sulfate ophth oint 0.3% timolol maleate ophth soln 0.5% (Timoptic) gentamicin sulfate ophth soln 0.3% (Garamycin) TIMOLOL MALEATE OPHTHALMI – timolol maleate ophth gel forming soln 0.25% ketorolac tromethamine ophth soln 0.4% (Acular ls) TIMOLOL MALEATE OPHTHALMI – timolol maleate ketorolac tromethamine ophth soln 0.5% (Acular) ophth gel forming soln 0.5% latanoprost ophth soln 0.005% (Xalatan) tobramycin ophth soln 0.3% (Tobrex) levobunolol hcl ophth soln 0.5% (Betagan) tobramycin-dexamethasone ophth susp 0.3-0.1% LOTEMAX – loteprednol etabonate ophth gel 0.5% (Tobradex) LOTEMAX – loteprednol etabonate ophth oint 0.5% TRAVATAN Z – travoprost ophth soln 0.004% LOTEMAX – loteprednol etabonate ophth susp 0.5% (benzalkonium free) (bak free) LUMIGAN – bimatoprost ophth soln 0.01% trifluridine ophth soln 1% (Viroptic) METIPRANOLOL – metipranolol ophth soln 0.3% tropicamide ophth soln 0.5% (Mydriacyl) moxifloxacin hcl ophth soln 0.5% (base equiv) tropicamide ophth soln 1% (Vigamox) ZYLET – loteprednol etabonate-tobramycin ophth susp NATACYN – natamycin ophth susp 5% 0.5-0.3% neomycin-bacitrac zn-polymyx OTIC AGENTS 5(3.5)mg-400unt-10000unt op oin acetic acid otic soln 2% neomycin-polymy-gramicid op sol CIPRO HC – ciprofloxacin-hydrocortisone otic susp 1.75-10000-0.025mg-unt-mg/ml (Neosporin) 0.2-1% neomycin-polymyxin-dexamethasone ophth oint CIPRODEX – ciprofloxacin-dexamethasone otic susp 0.1% (Maxitrol) 0.3-0.1% neomycin-polymyxin-dexamethasone ophth susp hydrocortisone w/ acetic acid otic soln 1-2% (Vosol 0.1% (Maxitrol) hc) ofloxacin ophth soln 0.3% (Ocuflox) neomycin-polymyxin-hc otic soln 1% (Cortisporin) olopatadine hcl ophth soln 0.1% (base equivalent) neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 (Patanol) unit/ml-1% olopatadine hcl ophth soln 0.2% (base equivalent) ofloxacin otic soln 0.3% (Pataday) MOUTH/THROAT/DENTAL AGENTS PAZEO – olopatadine hcl ophth soln 0.7% (base cevimeline hcl cap 30 mg (Evoxac) equivalent) chlorhexidine gluconate soln 0.12% (Peridex) pilocarpine hcl ophth soln 1% (Isopto carpine) clotrimazole troche 10 mg pilocarpine hcl ophth soln 2% (Isopto carpine) lidocaine hcl viscous soln 2% pilocarpine hcl ophth soln 4% (Isopto carpine) nystatin susp 100000 unit/ml pilocarpine hcl tab 5 mg (Salagen)

PrimeChoice Accord Formulary, January 2018 37 2018

Drug Name Drug Name pilocarpine hcl tab 7.5 mg (Salagen) ciclopirox gel 0.77% (Loprox) sodium fluoride cream 1.1% (Prevident 5000 plus) ciclopirox olamine cream 0.77% (base equiv) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) ciclopirox olamine susp 0.77% (base equiv) triamcinolone acetonide dental paste 0.1% ciclopirox shampoo 1% (Loprox shampoo) ANORECTAL AGENTS ciclopirox solution 8% (Penlac nail lacquer) CORTIFOAM – hydrocortisone acetate rectal foam 10% clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (90 mg/dose) (1)-5% (Duac) hydrocortisone enema 100 mg/60ml (Cortenema) clindamycin phosphate gel 1% (Cleocin-t) hydrocortisone rectal cream 2.5% (Anusol-hc) clindamycin phosphate lotion 1% (Cleocin-t) DERMATOLOGICALS clindamycin phosphate soln 1% (Cleocin-t) acitretin cap 10 mg (Soriatane) clindamycin phosphate swab 1% (Cleocin-t) acitretin cap 17.5 mg (Soriatane) clindamycin phosphate-benzoyl peroxide gel 1-5% acitretin cap 25 mg (Soriatane) (Benzaclin) adapalene cream 0.1% (Differin) clobetasol propionate cream 0.05% (Temovate) adapalene gel 0.1% (Differin) clobetasol propionate emollient base cream 0.05% (Temovate e) adapalene gel 0.3% (Differin) clobetasol propionate foam 0.05% (Olux) adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo) clobetasol propionate gel 0.05% (Temovate) alclometasone dipropionate cream 0.05% (Aclovate) clobetasol propionate oint 0.05% (Temovate) alclometasone dipropionate oint 0.05% clobetasol propionate soln 0.05% (Temovate) AMCINONIDE – amcinonide cream 0.1% COSENTYX – secukinumab subcutaneous soln prefilled AUGMENTED BETAMETHASONE D – betamethasone syringe 150 mg/ml dipropionate augmented gel 0.05% COSENTYX SENSOREADY PEN – secukinumab benzoyl peroxide-erythromycin gel 5-3% subcutaneous soln auto-injector 150 mg/ml (Benzamycin) desonide cream 0.05% (Desowen) betamethasone dipropionate augmented cream 0.05% (Diprolene af) desonide lotion 0.05% (Desowen) betamethasone dipropionate augmented lotion 0.05% desonide oint 0.05% (Desowen) (Diprolene) desoximetasone cream 0.05% (Topicort) betamethasone dipropionate augmented oint 0.05% desoximetasone cream 0.25% (Topicort) (Diprolene) desoximetasone gel 0.05% (Topicort) betamethasone dipropionate cream 0.05% desoximetasone oint 0.25% (Topicort) betamethasone dipropionate lotion 0.05% diclofenac sodium (actinic keratoses) gel 3% betamethasone dipropionate oint 0.05% (Solaraze) betamethasone valerate cream 0.1% (base diclofenac sodium gel 1% (Voltaren) equivalent) DIFFERIN – adapalene lotion 0.1% betamethasone valerate lotion 0.1% (base equivalent) DIFLORASONE DIACETATE – diflorasone diacetate betamethasone valerate oint 0.1% (base equivalent) cream 0.05% calcipotriene cream 0.005% (Dovonex) diflorasone diacetate oint 0.05% calcipotriene oint 0.005% econazole nitrate cream 1% calcipotriene soln 0.005% (50 mcg/ml) ELIDEL – pimecrolimus cream 1% CARAC – fluorouracil cream 0.5% ENSTILAR – calcipotriene-betamethasone dipropionate foam 0.005-0.064%

PrimeChoice Accord Formulary, January 2018 38 2018

Drug Name Drug Name EPIDUO FORTE – adapalene-benzoyl peroxide gel ketoconazole cream 2% 0.3-2.5% ketoconazole shampoo 2% (Nizoral) erythromycin gel 2% (Erygel) lidocaine hcl gel 2% erythromycin pads 2% lidocaine hcl soln 4% (Xylocaine) erythromycin soln 2% lidocaine oint 5% FINACEA – azelaic acid foam 15% lidocaine patch 5% (Lidoderm) FINACEA – azelaic acid gel 15% lidocaine-prilocaine cream 2.5-2.5% (Emla) fluocinolone acetonide cream 0.01% LINDANE – lindane shampoo 1% fluocinolone acetonide cream 0.025% (Synalar) malathion lotion 0.5% (Ovide) fluocinolone acetonide oil 0.01% (body oil) (Derma- metronidazole cream 0.75% (Metrocream) smoothe/fs bod) metronidazole gel 0.75% fluocinolone acetonide oil 0.01% (scalp oil) (Derma- smoothe/fs sca) metronidazole gel 1% (Metrogel) fluocinolone acetonide oint 0.025% (Synalar) metronidazole lotion 0.75% (Metrolotion) fluocinolone acetonide soln 0.01% (Synalar) mometasone furoate cream 0.1% (Elocon) fluocinonide cream 0.05% mometasone furoate oint 0.1% (Elocon) fluocinonide emulsified base cream 0.05% mometasone furoate solution 0.1% (lotion) (Elocon) fluocinonide gel 0.05% mupirocin calcium cream 2% (Bactroban) fluocinonide oint 0.05% mupirocin oint 2% (Bactroban) fluocinonide soln 0.05% nystatin cream 100000 unit/gm FLUOROPLEX – fluorouracil cream 1% nystatin oint 100000 unit/gm FLUOROURACIL – fluorouracil soln 2% nystatin topical powder 100000 unit/gm FLUOROURACIL – fluorouracil soln 5% nystatin-triamcinolone cream 100000-0.1 unit/gm-% fluorouracil cream 5% (Efudex) nystatin-triamcinolone oint 100000-0.1 unit/gm-% fluticasone propionate cream 0.05% (Cutivate) ORACEA – doxycycline (rosacea) cap delayed release 40 mg fluticasone propionate oint 0.005% (Cutivate) permethrin cream 5% (Elimite) gentamicin sulfate cream 0.1% PICATO – ingenol mebutate gel 0.015% gentamicin sulfate oint 0.1% PICATO – ingenol mebutate gel 0.05% halobetasol propionate cream 0.05% (Ultravate) podofilox soln 0.5% (Condylox) halobetasol propionate oint 0.05% (Ultravate) selenium sulfide lotion 2.5% hydrocortisone cream 2.5% silver sulfadiazine cream 1% (Silvadene) hydrocortisone lotion 2.5% SOOLANTRA – ivermectin cream 1% hydrocortisone oint 2.5% STELARA – ustekinumab inj 45 mg/0.5ml hydrocortisone valerate cream 0.2% STELARA – ustekinumab soln prefilled syringe 45 hydrocortisone valerate oint 0.2% (Westcort) mg/0.5ml imiquimod cream 5% (Aldara) STELARA – ustekinumab soln prefilled syringe 90 mg/ml isotretinoin cap 10 mg sulfacetamide sodium lotion 10% (acne) (Klaron) isotretinoin cap 20 mg tacrolimus oint 0.03% (Protopic) isotretinoin cap 30 mg (Claravis) tacrolimus oint 0.1% (Protopic) isotretinoin cap 40 mg tazarotene cream 0.1% (Tazorac)

PrimeChoice Accord Formulary, January 2018 39 2018

Drug Name Drug Name TAZORAC – tazarotene cream 0.05% LANCET DEVICES - various TAZORAC – tazarotene gel 0.05% LANCETS - various TAZORAC – tazarotene gel 0.1% MEDICAL DEVICES tretinoin cream 0.025% (Retin-a) INHALER ASSIST DEVICES - SPACERS tretinoin cream 0.05% (Retin-a) ASSORTED CLASSES tretinoin cream 0.1% (Retin-a) azathioprine tab 50 mg (Imuran) tretinoin gel 0.01% (Retin-a) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base tretinoin gel 0.025%, NF = Avita (Retin-a) equiv) tretinoin microsphere gel 0.04% (Retin-a micro) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) tretinoin microsphere gel 0.1% (Retin-a micro) cyclosporine cap 25 mg (Sandimmune) triamcinolone acetonide cream 0.025% cyclosporine cap 100 mg (Sandimmune) triamcinolone acetonide cream 0.1% CYCLOSPORINE MODIFIED – cyclosporine modified triamcinolone acetonide cream 0.5% cap 50 mg triamcinolone acetonide lotion 0.025% cyclosporine modified cap 25 mg (Neoral) triamcinolone acetonide lotion 0.1% cyclosporine modified cap 100 mg (Neoral) triamcinolone acetonide oint 0.025% cyclosporine modified oral soln 100 mg/ml (Neoral) triamcinolone acetonide oint 0.1% DEPEN TITRATABS – penicillamine tab 250 mg triamcinolone acetonide oint 0.5% mycophenolate mofetil cap 250 mg (Cellcept) VALCHLOR – mechlorethamine hcl gel 0.016% (base mycophenolate mofetil for oral susp 200 mg/ml equivalent) (Cellcept) ZYCLARA – imiquimod cream 3.75% mycophenolate mofetil tab 500 mg (Cellcept) ZYCLARA PUMP – imiquimod cream 2.5% mycophenolate sodium tab dr 180 mg (mycophenolic ZYCLARA PUMP – imiquimod cream 3.75% acid equiv) (Myfortic) MISCELLANEOUS PRODUCTS mycophenolate sodium tab dr 360 mg (mycophenolic (Myfortic) ANTIDOTES acid equiv) CHEMET – succimer cap 100 mg RAPAMUNE – sirolimus oral soln 1 mg/ml NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml REVLIMID – lenalidomide caps 2.5 mg REVLIMID – lenalidomide cap 5 mg naloxone hcl inj 0.4 mg/ml REVLIMID – lenalidomide cap 10 mg naloxone hcl inj 4 mg/10ml REVLIMID – lenalidomide cap 15 mg naltrexone hcl tab 50 mg (Revia) NARCAN – naloxone hcl nasal spray 4 mg/0.1ml REVLIMID – lenalidomide cap 20 mg REVLIMID – lenalidomide cap 25 mg DIABETIC SUPPLIES BAYER/ASCENCIA BREEZE 2, CONTOUR, CONTOUR sirolimus tab 0.5 mg (Rapamune) NEXT calibration liquid; test strips sirolimus tab 1 mg (Rapamune) BAYER/ASCENSIA BREEZE 2, CONTOUR/LINK, sirolimus tab 2 mg (Rapamune) CONTOUR NEXT/EZ/LINK/ONE blood glucose meter sodium polystyrene sulfonate oral susp 15 gm/60ml BAYER/ASCENSIA DIASTIX, KETO-DIASTIX, (Sps) KETOSTIX urine test products sodium polystyrene sulfonate powder (Kayexalate) INSULIN PEN NEEDLES - various SUBOXONE – buprenorphine hcl-naloxone hcl sl film INSULIN SYRINGES - various 2-0.5 mg (base equiv)

PrimeChoice Accord Formulary, January 2018 40 2018

Drug Name SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv) tacrolimus cap 0.5 mg (Prograf) tacrolimus cap 1 mg (Prograf) tacrolimus cap 5 mg (Prograf) THALOMID – thalidomide cap 50 mg THALOMID – thalidomide cap 100 mg THALOMID – thalidomide cap 150 mg THALOMID – thalidomide cap 200 mg ZORTRESS – everolimus tab 0.25 mg ZORTRESS – everolimus tab 0.5 mg ZORTRESS – everolimus tab 0.75 mg

PrimeChoice Accord Formulary, January 2018 41 2018

ADDERALL XR – amphetamine-dextroamphetamine cap INDEX er 24hr 30 mg...... 27 adefovir dipivoxil tab 10 mg (Hepsera)...... 3 A ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose...... 20 abacavir sulfate-lamivudine tab 600-300 mg ADVAIR DISKUS – fluticasone-salmeterol aer powder ba (Epzicom)...... 3 250-50 mcg/dose...... 20 abacavir sulfate-lamivudine-zidovudine tab ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 300-150-300 mg (Trizivir)...... 3 500-50 mcg/dose...... 20 abacavir sulfate soln 20 mg/ml (base equiv) ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 (Ziagen)...... 3 mcg/act...... 20 abacavir sulfate tab 300 mg (base equiv) (Ziagen)...... 3 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 acamprosate calcium tab delayed release 333 mg mcg/act...... 20 (Campral)...... 28 ADVAIR HFA – fluticasone-salmeterol inhal aerosol acarbose tab 25 mg (Precose)...... 10 230-21 mcg/act...... 20 acarbose tab 50 mg (Precose)...... 10 AFINITOR DISPERZ – everolimus tab for oral susp 2 acarbose tab 100 mg (Precose)...... 10 mg...... 5 acebutolol hcl cap 200 mg (Sectral)...... 13 AFINITOR DISPERZ – everolimus tab for oral susp 3 acebutolol hcl cap 400 mg (Sectral)...... 13 mg...... 5 acetaminophen w/ codeine soln 120-12 mg/5ml...... 29 AFINITOR DISPERZ – everolimus tab for oral susp 5 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ mg...... 5 codeine)...... 29 AFINITOR – everolimus tab 2.5 mg...... 5 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ AFINITOR – everolimus tab 5 mg...... 5 codeine #3)...... 29 AFINITOR – everolimus tab 7.5 mg...... 5 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ AFINITOR – everolimus tab 10 mg...... 5 codeine #4)...... 29 albendazole tab 200 mg (Albenza)...... 4 acetazolamide cap er 12hr 500 mg (Diamox)...... 17 ALBENZA – albendazole tab 200 mg...... 4 acetazolamide tab 125 mg...... 17 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...... 20 acetazolamide tab 250 mg...... 17 albuterol sulfate soln nebu 0.5% (5 mg/ml)...... 20 acetic acid otic soln 2%...... 37 albuterol sulfate soln nebu 0.63 mg/3ml (base acetylcysteine inhal soln 10%...... 20 equiv)...... 20 acetylcysteine inhal soln 20%...... 20 albuterol sulfate soln nebu 1.25 mg/3ml (base acitretin cap 10 mg (Soriatane)...... 38 equiv)...... 20 acitretin cap 17.5 mg (Soriatane)...... 38 albuterol sulfate syrup 2 mg/5ml...... 20 acitretin cap 25 mg (Soriatane)...... 38 ...... 20 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml albuterol sulfate tab 2 mg ...... 20 (2000000 unit/0.5ml)...... 5 albuterol sulfate tab 4 mg alclometasone dipropionate cream 0.05% acyclovir cap 200 mg (Zovirax)...... 3 (Aclovate)...... 38 acyclovir susp 200 mg/5ml (Zovirax)...... 3 alclometasone dipropionate oint 0.05%...... 38 acyclovir tab 400 mg (Zovirax)...... 3 ALECENSA – alectinib hcl cap 150 mg (base acyclovir tab 800 mg (Zovirax)...... 3 equivalent)...... 5 adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)...... 38 ALENDRONATE SODIUM – alendronate sodium tab 40 adapalene cream 0.1% (Differin)...... 38 mg...... 12 adapalene gel 0.1% (Differin)...... 38 alendronate sodium tab 5 mg...... 12 adapalene gel 0.3% (Differin)...... 38 ...... 12 ADCIRCA – tadalafil tab 20 mg (pah)...... 19 alendronate sodium tab 10 mg ...... 12 ADDERALL XR – amphetamine-dextroamphetamine cap alendronate sodium tab 35 mg ...... 12 er 24hr 5 mg...... 27 alendronate sodium tab 70 mg (Fosamax) ...... 23 ADDERALL XR – amphetamine-dextroamphetamine cap alfuzosin hcl tab er 24hr 10 mg (Uroxatral) ALINIA – nitazoxanide for susp 100 mg/5ml...... 5 er 24hr 10 mg...... 27 ALINIA – nitazoxanide tab 500 mg...... 5 ADDERALL XR – amphetamine-dextroamphetamine cap ...... 32 er 24hr 15 mg...... 27 allopurinol tab 100 mg (Zyloprim) ...... 32 ADDERALL XR – amphetamine-dextroamphetamine cap allopurinol tab 300 mg (Zyloprim) ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 36 er 24hr 20 mg...... 27 ...... 24 ADDERALL XR – amphetamine-dextroamphetamine cap alprazolam tab er 24hr 0.5 mg (Xanax xr) ...... 24 er 24hr 25 mg...... 27 alprazolam tab er 24hr 1 mg (Xanax xr) alprazolam tab er 24hr 2 mg (Xanax xr)...... 24

PrimeChoice Accord Formulary, January 2018 42 2018 alprazolam tab er 24hr 3 mg (Xanax xr)...... 24 amlodipine besylate-benazepril hcl cap 10-20 mg alprazolam tab 0.25 mg (Xanax)...... 24 (Lotrel)...... 15 alprazolam tab 0.5 mg (Xanax)...... 24 amlodipine besylate-benazepril hcl cap 10-40 mg alprazolam tab 1 mg (Xanax)...... 24 (Lotrel)...... 15 alprazolam tab 2 mg (Xanax)...... 24 amlodipine besylate tab 2.5 mg (base equivalent) ALREX – loteprednol etabonate ophth susp 0.2%...... 36 (Norvasc)...... 14 ALUNBRIG – brigatinib tab initiation therapy pack 90 mg & amlodipine besylate tab 5 mg (base equivalent) 180 mg...... 5 (Norvasc)...... 14 ALUNBRIG – brigatinib tab 30 mg...... 5 amlodipine besylate tab 10 mg (base equivalent) ALUNBRIG – brigatinib tab 90 mg...... 5 (Norvasc)...... 14 ALUNBRIG – brigatinib tab 180 mg...... 5 amlodipine besylate-valsartan tab 5-160 mg amantadine hcl cap 100 mg...... 33 (Exforge)...... 15 amantadine hcl syrup 50 mg/5ml...... 33 amlodipine besylate-valsartan tab 5-320 mg AMCINONIDE – amcinonide cream 0.1%...... 38 (Exforge)...... 15 amiloride & hydrochlorothiazide tab 5-50 mg...... 17 amlodipine besylate-valsartan tab 10-160 mg amiloride hcl tab 5 mg...... 17 (Exforge)...... 15 amiodarone hcl tab 100 mg...... 14 amlodipine besylate-valsartan tab 10-320 mg amiodarone hcl tab 400 mg...... 14 (Exforge)...... 15 amiodarone hcl tab 200 mg (Cordarone)...... 14 amlodipine-valsartan-hydrochlorothiazide tab amitriptyline hcl tab 10 mg...... 24 5-160-12.5 mg (Exforge hct)...... 15 amitriptyline hcl tab 25 mg...... 24 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 amitriptyline hcl tab 50 mg...... 24 mg (Exforge hct)...... 15 amitriptyline hcl tab 75 mg...... 24 amlodipine-valsartan-hydrochlorothiazide tab amitriptyline hcl tab 100 mg...... 24 10-160-12.5 mg (Exforge hct)...... 15 amitriptyline hcl tab 150 mg...... 24 amlodipine-valsartan-hydrochlorothiazide tab amlodipine besylate-atorvastatin calcium tab 2.5-10 10-160-25 mg (Exforge hct)...... 15 mg (Caduet)...... 19 amlodipine-valsartan-hydrochlorothiazide tab amlodipine besylate-atorvastatin calcium tab 2.5-20 10-320-25 mg (Exforge hct)...... 15 mg (Caduet)...... 19 AMOXICILLIN/CLAVULANATE P – amoxicillin & k amlodipine besylate-atorvastatin calcium tab 2.5-40 clavulanate chew tab 200-28.5 mg...... 1 mg (Caduet)...... 19 AMOXICILLIN/CLAVULANATE P – amoxicillin & k amlodipine besylate-atorvastatin calcium tab 5-10 mg clavulanate chew tab 400-57 mg...... 1 (Caduet)...... 19 amoxicillin & k clavulanate for susp 200-28.5 amlodipine besylate-atorvastatin calcium tab 5-20 mg mg/5ml...... 1 (Caduet)...... 19 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amlodipine besylate-atorvastatin calcium tab 5-40 mg amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Caduet)...... 19 (Augmentin)...... 1 amlodipine besylate-atorvastatin calcium tab 5-80 mg amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Caduet)...... 19 (Augmentin es-600)...... 1 amlodipine besylate-atorvastatin calcium tab 10-10 mg amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg (Caduet)...... 19 (Augmentin xr)...... 1 amlodipine besylate-atorvastatin calcium tab 10-20 mg amoxicillin & k clavulanate tab 250-125 mg...... 1 (Caduet)...... 19 amoxicillin & k clavulanate tab 500-125 mg amlodipine besylate-atorvastatin calcium tab 10-40 mg (Augmentin)...... 1 (Caduet)...... 19 amoxicillin & k clavulanate tab 875-125 mg amlodipine besylate-atorvastatin calcium tab 10-80 mg (Augmentin)...... 1 (Caduet)...... 19 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 amlodipine besylate-benazepril hcl cap 2.5-10 mg mg...... 1 (Lotrel)...... 15 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 amlodipine besylate-benazepril hcl cap 5-10 mg mg...... 1 (Lotrel)...... 15 amoxicillin (trihydrate) cap 250 mg...... 1 amlodipine besylate-benazepril hcl cap 5-20 mg amoxicillin (trihydrate) cap 500 mg...... 1 (Lotrel)...... 15 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 amlodipine besylate-benazepril hcl cap 5-40 mg amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 (Lotrel)...... 15 amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1

PrimeChoice Accord Formulary, January 2018 43 2018 amoxicillin (trihydrate) tab 500 mg...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj amoxicillin (trihydrate) tab 875 mg...... 1 300 mcg/ml...... 35 amphetamine-dextroamphetamine cap er 24hr 5 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 10 mcg/0.4ml...... 35 amphetamine-dextroamphetamine cap er 24hr 10 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 25 mcg/0.42ml...... 35 amphetamine-dextroamphetamine cap er 24hr 15 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 40 mcg/0.4ml...... 35 amphetamine-dextroamphetamine cap er 24hr 20 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 60 mcg/0.3ml...... 35 amphetamine-dextroamphetamine cap er 24hr 25 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 100 mcg/0.5ml...... 35 amphetamine-dextroamphetamine cap er 24hr 30 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall xr)...... 27 prefilled syringe 150 mcg/0.3ml...... 35 amphetamine-dextroamphetamine tab 5 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall)...... 27 prefilled syringe 200 mcg/0.4ml...... 35 amphetamine-dextroamphetamine tab 7.5 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall)...... 27 prefilled syringe 300 mcg/0.6ml...... 35 amphetamine-dextroamphetamine tab 10 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln (Adderall)...... 27 prefilled syringe 500 mcg/ml...... 35 amphetamine-dextroamphetamine tab 12.5 mg aripiprazole tab 2 mg (Abilify)...... 25 (Adderall)...... 27 aripiprazole tab 5 mg (Abilify)...... 25 amphetamine-dextroamphetamine tab 15 mg aripiprazole tab 10 mg (Abilify)...... 25 (Adderall)...... 27 aripiprazole tab 15 mg (Abilify)...... 25 amphetamine-dextroamphetamine tab 20 mg aripiprazole tab 20 mg (Abilify)...... 25 (Adderall)...... 27 aripiprazole tab 30 mg (Abilify)...... 25 amphetamine-dextroamphetamine tab 30 mg armodafinil tab 50 mg (Nuvigil)...... 27 (Adderall)...... 27 armodafinil tab 150 mg (Nuvigil)...... 27 AMPICILLIN – ampicillin cap 500 mg...... 1 armodafinil tab 200 mg (Nuvigil)...... 27 anagrelide hcl cap 1 mg...... 36 armodafinil tab 250 mg (Nuvigil)...... 27 anagrelide hcl cap 0.5 mg (Agrylin)...... 36 ARNUITY ELLIPTA – fluticasone furoate aerosol powder anastrozole tab 1 mg (Arimidex)...... 5 breath activ 50 mcg/act...... 20 ANDROGEL PUMP – testosterone td gel 20.25 mg/act ARNUITY ELLIPTA – fluticasone furoate aerosol powder (1.62%)...... 8 breath activ 100 mcg/act...... 20 ANDROGEL – testosterone td gel 20.25 mg/1.25gm ARNUITY ELLIPTA – fluticasone furoate aerosol powder (1.62%)...... 8 breath activ 200 mcg/act...... 20 ANDROGEL – testosterone td gel 40.5 mg/2.5gm ASACOL HD – mesalamine tab delayed release 800 (1.62%)...... 8 mg...... 23 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba ASMANEX HFA – mometasone furoate inhal aerosol 62.5-25 mcg/inh...... 20 suspension 100 mcg/act...... 20 aprepitant capsule 40 mg (Emend)...... 22 ASMANEX HFA – mometasone furoate inhal aerosol aprepitant capsule 80 mg (Emend)...... 22 suspension 200 mcg/act...... 20 aprepitant capsule 125 mg (Emend)...... 22 ASMANEX TWISTHALER 120 ME – mometasone furoate aprepitant capsule therapy pack 80 & 125 mg inhal powd 220 mcg/inh (breath activated)...... 20 (Emend)...... 22 ASMANEX TWISTHALER 30 MET – mometasone furoate APRISO – mesalamine cap er 24hr 0.375 gm...... 23 inhal powd 110 mcg/inh (breath activated)...... 20 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 ASMANEX TWISTHALER 30 MET – mometasone furoate mcg/ml...... 35 inhal powd 220 mcg/inh (breath activated)...... 20 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 ASMANEX TWISTHALER 60 MET – mometasone furoate mcg/ml...... 35 inhal powd 220 mcg/inh (breath activated)...... 20 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 atazanavir sulfate cap 150 mg (base equiv) mcg/ml...... 35 (Reyataz)...... 3 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj atazanavir sulfate cap 200 mg (base equiv) 100 mcg/ml...... 35 (Reyataz)...... 3 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj atazanavir sulfate cap 300 mg (base equiv) 200 mcg/ml...... 35 (Reyataz)...... 3

PrimeChoice Accord Formulary, January 2018 44 2018 atenolol & chlorthalidone tab 50-25 mg (Tenoretic azithromycin tab 600 mg (Zithromax)...... 1 50)...... 15 AZOPT – brinzolamide ophth susp 1%...... 36 atenolol & chlorthalidone tab 100-25 mg (Tenoretic B 100)...... 15 atenolol tab 25 mg (Tenormin)...... 13 BACITRACIN – bacitracin ophth oint 500 unit/gm...... 36 atenolol tab 50 mg (Tenormin)...... 13 bacitracin-polymyxin b ophth oint...... 36 atenolol tab 100 mg (Tenormin)...... 13 bacitracin-polymyxin-neomycin-hc ophth oint 1%...... 36 atomoxetine hcl cap 10 mg (base equiv) (Strattera).....27 baclofen tab 10 mg...... 34 atomoxetine hcl cap 18 mg (base equiv) (Strattera).....27 baclofen tab 20 mg...... 34 atomoxetine hcl cap 25 mg (base equiv) (Strattera).....27 BACTROBAN NASAL – mupirocin calcium nasal oint atomoxetine hcl cap 40 mg (base equiv) (Strattera).....27 2%...... 20 atomoxetine hcl cap 60 mg (base equiv) (Strattera).....27 balsalazide disodium cap 750 mg (Colazal)...... 23 atomoxetine hcl cap 80 mg (base equiv) (Strattera).....27 BANZEL – rufinamide tab 200 mg...... 32 atomoxetine hcl cap 100 mg (base equiv) BANZEL – rufinamide tab 400 mg...... 32 (Strattera)...... 27 BARACLUDE – entecavir oral soln 0.05 mg/ml...... 3 atorvastatin calcium tab 10 mg (base equivalent) BAYER/ASCENCIA BREEZE 2, CONTOUR, CONTOUR (Lipitor)...... 18 NEXT calibrationliquid; test strips...... 40 atorvastatin calcium tab 20 mg (base equivalent) BAYER/ASCENSIA BREEZE 2, CONTOUR/LINK, (Lipitor)...... 18 CONTOUR NEXT/EZ/LINK/ONE blood glucose atorvastatin calcium tab 40 mg (base equivalent) meter...... 40 (Lipitor)...... 18 BAYER/ASCENSIA DIASTIX, KETO-DIASTIX, atorvastatin calcium tab 80 mg (base equivalent) KETOSTIXurine test products...... 40 (Lipitor)...... 18 BELSOMRA – suvorexant tab 5 mg...... 27 atovaquone-proguanil hcl tab 62.5-25 mg BELSOMRA – suvorexant tab 10 mg...... 27 (Malarone)...... 4 BELSOMRA – suvorexant tab 15 mg...... 27 atovaquone-proguanil hcl tab 250-100 mg BELSOMRA – suvorexant tab 20 mg...... 27 (Malarone)...... 4 benazepril & hydrochlorothiazide tab 5-6.25 mg...... 15 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab benazepril & hydrochlorothiazide tab 10-12.5 mg 600-200-300 mg...... 3 (Lotensin hct)...... 15 ATROPINE SULFATE – atropine sulfate ophth soln benazepril & hydrochlorothiazide tab 20-12.5 mg 1%...... 36 (Lotensin hct)...... 15 ATROVENT HFA – ipratropium bromide hfa inhal aerosol benazepril & hydrochlorothiazide tab 20-25 mg 17 mcg/act...... 20 (Lotensin hct)...... 15 AUBAGIO – teriflunomide tab 7 mg...... 28 benazepril hcl tab 5 mg...... 15 AUBAGIO – teriflunomide tab 14 mg...... 28 benazepril hcl tab 10 mg (Lotensin)...... 15 AUGMENTED BETAMETHASONE D – betamethasone benazepril hcl tab 20 mg (Lotensin)...... 15 dipropionate augmented gel 0.05%...... 38 benazepril hcl tab 40 mg (Lotensin)...... 15 AUGMENTIN – amoxicillin & k clavulanate for susp BENZNIDAZOLE – benznidazole tab 12.5 mg...... 4 125-31.25 mg/5ml...... 1 BENZNIDAZOLE – benznidazole tab 100 mg...... 4 AVONEX – interferon beta-1a for im inj kit 30mcg benzoyl peroxide-erythromycin gel 5-3% (33mcg(6.6 mu)/vial)...... 28 (Benzamycin)...... 38 AVONEX – interferon beta-1a im prefilled syringe kit 30 benztropine mesylate tab 0.5 mg...... 33 mcg/0.5ml...... 28 benztropine mesylate tab 1 mg...... 33 AVONEX PEN – interferon beta-1a im auto-injector kit 30 benztropine mesylate tab 2 mg...... 33 mcg/0.5ml...... 28 betamethasone dipropionate augmented cream 0.05% azathioprine tab 50 mg (Imuran)...... 40 (Diprolene af)...... 38 azelastine hcl nasal spray 0.1% (137 mcg/spray)...... 20 betamethasone dipropionate augmented lotion 0.05% azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Diprolene)...... 38 (Astepro)...... 20 betamethasone dipropionate augmented oint 0.05% azelastine hcl ophth soln 0.05% (Optivar)...... 36 (Diprolene)...... 38 AZITHROMYCIN – azithromycin powd pack for susp 1 betamethasone dipropionate cream 0.05%...... 38 gm...... 1 betamethasone dipropionate lotion 0.05%...... 38 azithromycin for susp 100 mg/5ml (Zithromax)...... 1 betamethasone dipropionate oint 0.05%...... 38 azithromycin for susp 200 mg/5ml (Zithromax)...... 1 betamethasone valerate cream 0.1% (base azithromycin tab 250 mg (Zithromax)...... 1 equivalent)...... 38 azithromycin tab 500 mg (Zithromax)...... 1

PrimeChoice Accord Formulary, January 2018 45 2018 betamethasone valerate lotion 0.1% (base bupropion hcl tab 75 mg (Wellbutrin)...... 24 equivalent)...... 38 bupropion hcl tab 100 mg (Wellbutrin)...... 24 betamethasone valerate oint 0.1% (base buspirone hcl tab 5 mg...... 24 equivalent)...... 38 buspirone hcl tab 10 mg...... 24 BETASERON – interferon beta-1b for inj kit 0.3 mg...... 28 buspirone hcl tab 15 mg...... 24 bexarotene cap 75 mg (Targretin)...... 5 buspirone hcl tab 30 mg...... 24 bicalutamide tab 50 mg (Casodex)...... 5 butalbital-acetaminophen-caffeine cap 50-325-40 mg BIKTARVY – bictegravir-emtricitabine-tenofovir af tab (Esgic)...... 29 50-200-25 mg...... 3 butalbital-acetaminophen-caffeine tab 50-325-40 mg bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Esgic)...... 29 (Ziac)...... 15 butalbital-acetaminophen tab 50-325 mg...... 29 bisoprolol & hydrochlorothiazide tab 5-6.25 mg butalbital-aspirin-caffeine cap 50-325-40 mg (Ziac)...... 15 (Fiorinal)...... 29 bisoprolol & hydrochlorothiazide tab 10-6.25 mg butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Ziac)...... 15 (Fiorinal/codeine #3)...... 29 ...... 13 bisoprolol fumarate tab 5 mg (Zebeta) C bisoprolol fumarate tab 10 mg (Zebeta)...... 13 BOSULIF – bosutinib tab 100 mg...... 5 cabergoline tab 0.5 mg...... 12 BOSULIF – bosutinib tab 400 mg...... 5 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base BOSULIF – bosutinib tab 500 mg...... 5 equiv) (Cafcit)...... 27 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd calcipotriene cream 0.005% (Dovonex)...... 38 ba 100-25 mcg/inh...... 20 calcipotriene oint 0.005%...... 38 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd calcipotriene soln 0.005% (50 mcg/ml)...... 38 ba 200-25 mcg/inh...... 20 calcitonin (salmon) nasal soln 200 unit/act BRILINTA – ticagrelor tab 60 mg...... 36 (Miacalcin)...... 12 BRILINTA – ticagrelor tab 90 mg...... 36 calcitriol cap 0.25 mcg (Rocaltrol)...... 12 brimonidine tartrate ophth soln 0.2%...... 36 calcitriol cap 0.5 mcg (Rocaltrol)...... 12 brimonidine tartrate ophth soln 0.15% (Alphagan calcitriol oral soln 1 mcg/ml (Rocaltrol)...... 12 p)...... 36 calcium acetate (phosphate binder) cap 667 mg (169 bromocriptine mesylate cap 5 mg (base equivalent) mg ca) (Phoslo)...... 23 (Parlodel)...... 33 calcium acetate (phosphate binder) tab 667 mg bromocriptine mesylate tab 2.5 mg (base equivalent) (Eliphos)...... 23 (Parlodel)...... 33 CANASA – mesalamine suppos 1000 mg...... 23 budesonide delayed release particles cap 3 mg candesartan cilexetil-hydrochlorothiazide tab 16-12.5 (Entocort ec)...... 7 mg (Atacand hct)...... 15 budesonide inhalation susp 0.25 mg/2ml candesartan cilexetil-hydrochlorothiazide tab 32-12.5 (Pulmicort)...... 20 mg (Atacand hct)...... 15 budesonide inhalation susp 0.5 mg/2ml candesartan cilexetil-hydrochlorothiazide tab 32-25 (Pulmicort)...... 20 mg (Atacand hct)...... 15 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 20 candesartan cilexetil tab 4 mg (Atacand)...... 15 bumetanide tab 0.5 mg...... 17 candesartan cilexetil tab 8 mg (Atacand)...... 15 bumetanide tab 1 mg...... 17 candesartan cilexetil tab 16 mg (Atacand)...... 15 bumetanide tab 2 mg...... 17 candesartan cilexetil tab 32 mg (Atacand)...... 15 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base capecitabine tab 150 mg (Xeloda)...... 5 equiv)...... 40 capecitabine tab 500 mg (Xeloda)...... 5 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base CAPRELSA – vandetanib tab 100 mg...... 5 equiv)...... 40 CAPRELSA – vandetanib tab 300 mg...... 5 buprenorphine hcl sl tab 2 mg (base equiv)...... 29 CAPTOPRIL/HYDROCHLOROTHIA – captopril & buprenorphine hcl sl tab 8 mg (base equiv)...... 29 hydrochlorothiazide tab 25-15 mg...... 15 bupropion hcl (smoking deterrent) tab er 12hr 150 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & (Zyban)...... 28 hydrochlorothiazide tab 25-25 mg...... 15 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 24 CAPTOPRIL/HYDROCHLOROTHIA – captopril & bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 24 hydrochlorothiazide tab 50-15 mg...... 15 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...... 24 CAPTOPRIL/HYDROCHLOROTHIA – captopril & bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)...... 24 hydrochlorothiazide tab 50-25 mg...... 15 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)...... 24 captopril tab 12.5 mg...... 15

PrimeChoice Accord Formulary, January 2018 46 2018 captopril tab 25 mg...... 15 cefpodoxime proxetil tab 100 mg...... 1 captopril tab 50 mg...... 15 cefpodoxime proxetil tab 200 mg...... 1 captopril tab 100 mg...... 15 cefprozil for susp 125 mg/5ml...... 1 CARAC – fluorouracil cream 0.5%...... 38 cefprozil for susp 250 mg/5ml...... 1 carbamazepine cap er 12hr 100 mg (Carbatrol)...... 32 cefprozil tab 250 mg...... 1 carbamazepine cap er 12hr 200 mg (Carbatrol)...... 32 cefprozil tab 500 mg...... 1 carbamazepine cap er 12hr 300 mg (Carbatrol)...... 32 ceftriaxone sodium for inj 2 gm...... 1 carbamazepine chew tab 100 mg...... 32 ceftriaxone sodium for inj 1 gm (Rocephin)...... 1 carbamazepine susp 100 mg/5ml (Tegretol)...... 32 ceftriaxone sodium for inj 250 mg...... 1 carbamazepine tab er 12hr 100 mg (Tegretol-xr)...... 32 ceftriaxone sodium for inj 500 mg (Rocephin)...... 1 carbamazepine tab er 12hr 200 mg (Tegretol-xr)...... 32 cefuroxime axetil tab 250 mg (Ceftin)...... 1 carbamazepine tab er 12hr 400 mg (Tegretol-xr)...... 32 cefuroxime axetil tab 500 mg (Ceftin)...... 1 carbamazepine tab 200 mg (Tegretol)...... 32 celecoxib cap 50 mg (Celebrex)...... 31 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- celecoxib cap 100 mg (Celebrex)...... 31 entacapone tabs 12.5-50-200 mg...... 33 celecoxib cap 200 mg (Celebrex)...... 31 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- celecoxib cap 400 mg (Celebrex)...... 31 entacapone tabs 18.75-75-200 mg...... 33 CELONTIN – methsuximide cap 300 mg...... 32 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- cephalexin cap 250 mg (Keflex)...... 1 entacapone tabs 25-100-200 mg...... 33 cephalexin cap 500 mg (Keflex)...... 1 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- cephalexin for susp 125 mg/5ml...... 1 entacapone tabs 31.25-125-200 mg...... 34 cephalexin for susp 250 mg/5ml...... 1 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...... 19 entacapone tabs 37.5-150-200 mg...... 34 CETROTIDE – cetrorelix acetate for inj kit 0.25 mg...... 12 CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa- cevimeline hcl cap 30 mg (Evoxac)...... 37 entacapone tabs 50-200-200 mg...... 34 CHANTIX CONTINUING MONTH – varenicline tartrate tab carbidopa & levodopa orally disintegrating tab 10-100 1 mg (base equiv)...... 28 mg (Parcopa)...... 33 CHANTIX STARTING MONTH PA – varenicline tartrate carbidopa & levodopa orally disintegrating tab 25-100 tab 0.5 mg x 11 & tab 1 mg x 42 pack...... 28 mg (Parcopa)...... 33 CHANTIX – varenicline tartrate tab 0.5 mg (base carbidopa & levodopa orally disintegrating tab 25-250 equiv)...... 28 mg (Parcopa)...... 33 CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 28 carbidopa & levodopa tab er 25-100 mg (Sinemet CHEMET – succimer cap 100 mg...... 40 cr)...... 33 CHENODAL – chenodiol tab 250 mg...... 23 carbidopa & levodopa tab er 50-200 mg (Sinemet chlorhexidine gluconate soln 0.12% (Peridex)...... 37 cr)...... 33 CHLOROQUINE PHOSPHATE – chloroquine phosphate carbidopa & levodopa tab 10-100 mg (Sinemet)...... 33 tab 250 mg...... 4 carbidopa & levodopa tab 25-100 mg (Sinemet)...... 33 chloroquine phosphate tab 500 mg (Aralen)...... 4 carbidopa & levodopa tab 25-250 mg (Sinemet)...... 33 CHLOROTHIAZIDE – chlorothiazide tab 250 mg...... 17 CARTEOLOL HCL – carteolol hcl ophth soln 1%...... 36 chlorothiazide tab 500 mg...... 17 carvedilol tab 3.125 mg (Coreg)...... 13 chlorpromazine hcl tab 10 mg...... 25 carvedilol tab 6.25 mg (Coreg)...... 13 chlorpromazine hcl tab 25 mg...... 25 carvedilol tab 12.5 mg (Coreg)...... 13 chlorpromazine hcl tab 50 mg...... 25 carvedilol tab 25 mg (Coreg)...... 13 chlorpromazine hcl tab 100 mg...... 25 cefaclor cap 250 mg...... 1 chlorpromazine hcl tab 200 mg...... 25 cefaclor cap 500 mg...... 1 chlorthalidone tab 25 mg...... 17 cefadroxil cap 500 mg...... 1 chlorthalidone tab 50 mg...... 17 cefadroxil for susp 250 mg/5ml...... 1 CHLORZOXAZONE – chlorzoxazone tab 500 mg...... 34 cefadroxil for susp 500 mg/5ml...... 1 cholestyramine light powder 4 gm/dose (Questran cefadroxil tab 1 gm...... 1 light)...... 18 cefdinir cap 300 mg...... 1 cholestyramine light powder packets 4 gm...... 18 cefdinir for susp 125 mg/5ml...... 1 cholestyramine powder 4 gm/dose (Questran)...... 18 cefdinir for susp 250 mg/5ml...... 1 cholestyramine powder packets 4 gm (Questran)...... 18 cefixime for susp 100 mg/5ml (Suprax)...... 1 choline fenofibrate cap dr 45 mg (fenofibric acid cefixime for susp 200 mg/5ml (Suprax)...... 1 equiv) (Trilipix)...... 18 cefpodoxime proxetil for susp 50 mg/5ml...... 1 choline fenofibrate cap dr 135 mg (fenofibric acid cefpodoxime proxetil for susp 100 mg/5ml...... 1 equiv) (Trilipix)...... 18

PrimeChoice Accord Formulary, January 2018 47 2018

CHORIONIC GONADOTROPIN – chorionic gonadotropin clindamycin hcl cap 300 mg (Cleocin)...... 5 for im inj 10000 unit...... 12 clindamycin palmitate hcl for soln 75 mg/5ml (base CIALIS – tadalafil tab 2.5 mg...... 19 equiv) (Cleocin pediatric gr)...... 5 CIALIS – tadalafil tab 5 mg...... 19 clindamycin phosphate-benzoyl peroxide gel 1-5% CIALIS – tadalafil tab 10 mg...... 19 (Benzaclin)...... 38 CIALIS – tadalafil tab 20 mg...... 19 clindamycin phosphate gel 1% (Cleocin-t)...... 38 ciclopirox gel 0.77% (Loprox)...... 38 clindamycin phosphate lotion 1% (Cleocin-t)...... 38 ciclopirox olamine cream 0.77% (base equiv)...... 38 clindamycin phosphate soln 1% (Cleocin-t)...... 38 ciclopirox olamine susp 0.77% (base equiv)...... 38 clindamycin phosphate swab 1% (Cleocin-t)...... 38 ciclopirox shampoo 1% (Loprox shampoo)...... 38 clindamycin phosphate vaginal cream 2% ciclopirox solution 8% (Penlac nail lacquer)...... 38 (Cleocin)...... 23 cilostazol tab 50 mg (Pletal)...... 36 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 cilostazol tab 100 mg (Pletal)...... 36 (1)-5% (Duac)...... 38 CILOXAN – ciprofloxacin hcl ophth oint 0.3%...... 36 clobetasol propionate cream 0.05% (Temovate)...... 38 CIMDUO – lamivudine-tenofovir disoproxil fumarate tab clobetasol propionate emollient base cream 0.05% 300-300 mg...... 3 (Temovate e)...... 38 CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml...... 21 clobetasol propionate foam 0.05% (Olux)...... 38 cimetidine tab 300 mg...... 21 clobetasol propionate gel 0.05% (Temovate)...... 38 cimetidine tab 400 mg...... 21 clobetasol propionate oint 0.05% (Temovate)...... 38 cimetidine tab 800 mg...... 21 clobetasol propionate soln 0.05% (Temovate)...... 38 CINRYZE – c1 esterase inhibitor (human) for iv inj 500 CLOMIPHENE CITRATE – clomiphene citrate tab 50 unit...... 36 mg...... 12 CIPRODEX – ciprofloxacin-dexamethasone otic susp clomipramine hcl cap 25 mg (Anafranil)...... 24 0.3-0.1%...... 37 clomipramine hcl cap 50 mg (Anafranil)...... 24 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 clomipramine hcl cap 75 mg (Anafranil)...... 24 mg(base eq) (Cipro xr)...... 2 clonazepam tab 0.5 mg (Klonopin)...... 32 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg clonazepam tab 1 mg (Klonopin)...... 32 (base eq) (Cipro xr)...... 2 clonazepam tab 2 mg (Klonopin)...... 32 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 clonidine hcl tab 0.1 mg (Catapres)...... 16 gm/100ml) (Cipro)...... 2 clonidine hcl tab 0.2 mg (Catapres)...... 16 CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg clonidine hcl tab 0.3 mg (Catapres)...... 16 (base equiv)...... 2 clonidine td patch weekly 0.1 mg/24hr (Catapres- ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...... 36 tts-1)...... 16 ciprofloxacin hcl tab 750 mg (base equiv)...... 2 clonidine td patch weekly 0.2 mg/24hr (Catapres- ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 2 tts-2)...... 16 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 2 clonidine td patch weekly 0.3 mg/24hr (Catapres- CIPRO HC – ciprofloxacin-hydrocortisone otic susp tts-3)...... 16 0.2-1%...... 37 clopidogrel bisulfate tab 75 mg (base equiv) citalopram hydrobromide oral soln 10 mg/5ml...... 24 (Plavix)...... 36 citalopram hydrobromide tab 10 mg (base equiv) clotrimazole troche 10 mg...... 37 (Celexa)...... 24 clozapine tab 50 mg...... 25 citalopram hydrobromide tab 20 mg (base equiv) clozapine tab 200 mg...... 25 (Celexa)...... 24 clozapine tab 25 mg (Clozaril)...... 25 citalopram hydrobromide tab 40 mg (base equiv) clozapine tab 100 mg (Clozaril)...... 25 (Celexa)...... 24 COARTEM – artemether-lumefantrine tab 20-120 mg...... 4 CLARITHROMYCIN – clarithromycin for susp 125 codeine sulfate tab 30 mg...... 29 mg/5ml...... 2 codeine sulfate tab 60 mg...... 29 CLARITHROMYCIN – clarithromycin for susp 250 codeine sulfate tab 15 mg (Codeine sulfate)...... 29 mg/5ml...... 2 colchicine w/ probenecid tab 0.5-500 mg...... 32 clarithromycin tab er 24hr 500 mg...... 2 COLCRYS – colchicine tab 0.6 mg...... 32 clarithromycin tab 250 mg (Biaxin)...... 2 colesevelam hcl packet for susp 3.75 gm clarithromycin tab 500 mg (Biaxin)...... 2 (Welchol)...... 18 CLIMARA PRO – estradiol-levonorgestrel td patch weekly colesevelam hcl tab 625 mg (Welchol)...... 18 0.045-0.015 mg/day...... 8 colestipol hcl granule packets 5 gm (Colestid clindamycin hcl cap 75 mg (Cleocin)...... 5 flavored)...... 18 clindamycin hcl cap 150 mg (Cleocin)...... 5 colestipol hcl granules 5 gm (Colestid flavored)...... 18

PrimeChoice Accord Formulary, January 2018 48 2018 colestipol hcl tab 1 gm (Colestid)...... 18 cyproheptadine hcl syrup 2 mg/5ml...... 19 COMBIVENT RESPIMAT – ipratropium-albuterol inhal cyproheptadine hcl tab 4 mg...... 19 aerosol soln 20-100 mcg/act...... 20 CYSTADANE – betaine powder for oral solution...... 12 COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 CYSTAGON – cysteamine bitartrate cap 50 mg...... 23 mg dose) kit...... 5 CYSTAGON – cysteamine bitartrate cap 150 mg...... 23 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 D mg (100 dose) kit...... 5 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 danazol cap 50 mg...... 8 mg (140 dose) kit...... 5 danazol cap 100 mg...... 8 CONCERTA – methylphenidate hcl tab er osmotic release danazol cap 200 mg...... 8 (osm) 18 mg...... 27 dantrolene sodium cap 25 mg (Dantrium)...... 34 CONCERTA – methylphenidate hcl tab er osmotic release dantrolene sodium cap 50 mg (Dantrium)...... 34 (osm) 27 mg...... 27 dantrolene sodium cap 100 mg (Dantrolene CONCERTA – methylphenidate hcl tab er osmotic release sodium)...... 34 (osm) 36 mg...... 28 dapsone tab 25 mg...... 5 CONCERTA – methylphenidate hcl tab er osmotic release dapsone tab 100 mg...... 5 (osm) 54 mg...... 28 DARAPRIM – pyrimethamine tab 25 mg...... 4 COPAXONE – glatiramer acetate soln prefilled syringe 20 DELZICOL – mesalamine cap dr 400 mg...... 23 mg/ml...... 28 demeclocycline hcl tab 150 mg...... 2 COPAXONE – glatiramer acetate soln prefilled syringe 40 demeclocycline hcl tab 300 mg...... 2 mg/ml...... 28 DEPEN TITRATABS – penicillamine tab 250 mg...... 40 CORTIFOAM – hydrocortisone acetate rectal foam 10% DESCOVY – emtricitabine-tenofovir alafenamide fumarate (90 mg/dose)...... 38 tab 200-25 mg...... 3 CORTISONE ACETATE – cortisone acetate tab 25 mg...... 7 desipramine hcl tab 10 mg (Norpramin)...... 24 COSENTYX – secukinumab subcutaneous soln prefilled desipramine hcl tab 25 mg (Norpramin)...... 24 syringe 150 mg/ml...... 38 desipramine hcl tab 50 mg (Norpramin)...... 24 COSENTYX SENSOREADY PEN – secukinumab desipramine hcl tab 75 mg (Norpramin)...... 24 subcutaneous soln auto-injector 150 mg/ml...... 38 desipramine hcl tab 100 mg (Norpramin)...... 24 COTELLIC – cobimetinib fumarate tab 20 mg (base desipramine hcl tab 150 mg (Norpramin)...... 24 equivalent)...... 5 DESLORATADINE ODT – desloratadine tab orally CREON – pancrelipase (lip-prot-amyl) dr cap disintegrating 2.5 mg...... 19 3000-9500-15000 unit...... 22 DESLORATADINE ODT – desloratadine tab orally CREON – pancrelipase (lip-prot-amyl) dr cap disintegrating 5 mg...... 19 6000-19000-30000 unit...... 22 desloratadine tab 5 mg (Clarinex)...... 19 CREON – pancrelipase (lip-prot-amyl) dr cap desmopressin acetate nasal spray soln 0.01% 12000-38000-60000 unit...... 22 (Ddavp)...... 12 CREON – pancrelipase (lip-prot-amyl) dr cap desmopressin acetate nasal spray soln 0.01% 24000-76000-120000 unit...... 22 (refrigerated)...... 12 CREON – pancrelipase (lip-prot-amyl) dr cap desmopressin acetate tab 0.1 mg (Ddavp)...... 12 36000-114000-180000 unit...... 22 desmopressin acetate tab 0.2 mg (Ddavp)...... 12 cromolyn sodium ophth soln 4%...... 36 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 cromolyn sodium soln nebu 20 mg/2ml...... 20 mg(21/5) (Mircette)...... 9 cyanocobalamin inj 1000 mcg/ml...... 35 desogest-ethin est tab cyclobenzaprine hcl tab 5 mg...... 34 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)..... 9 cyclobenzaprine hcl tab 10 mg...... 34 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 36 (Desogen)...... 9 cyclophosphamide cap 25 mg (Cyclophosphamide)..... 5 desonide cream 0.05% (Desowen)...... 38 cyclophosphamide cap 50 mg (Cyclophosphamide)..... 5 desonide lotion 0.05% (Desowen)...... 38 cyclosporine cap 25 mg (Sandimmune)...... 40 desonide oint 0.05% (Desowen)...... 38 cyclosporine cap 100 mg (Sandimmune)...... 40 desoximetasone cream 0.05% (Topicort)...... 38 cyclosporine modified cap 25 mg (Neoral)...... 40 desoximetasone cream 0.25% (Topicort)...... 38 cyclosporine modified cap 100 mg (Neoral)...... 40 desoximetasone gel 0.05% (Topicort)...... 38 CYCLOSPORINE MODIFIED – cyclosporine modified cap desoximetasone oint 0.25% (Topicort)...... 38 50 mg...... 40 DEXAMETHASONE – dexamethasone soln 0.5 cyclosporine modified oral soln 100 mg/ml mg/5ml...... 7 (Neoral)...... 40 DEXAMETHASONE – dexamethasone tab 1 mg...... 7

PrimeChoice Accord Formulary, January 2018 49 2018

DEXAMETHASONE – dexamethasone tab 2 mg...... 7 didanosine delayed release capsule 200 mg (Videx dexamethasone elixir 0.5 mg/5ml...... 8 ec)...... 3 DEXAMETHASONE INTENSOL – dexamethasone conc 1 didanosine delayed release capsule 250 mg (Videx mg/ml...... 8 ec)...... 3 DEXAMETHASONE SODIUM PHOS – dexamethasone didanosine delayed release capsule 400 mg (Videx sodium phosphate ophth soln 0.1%...... 37 ec)...... 3 dexamethasone tab 0.5 mg...... 8 DIFFERIN – adapalene lotion 0.1%...... 38 dexamethasone tab 0.75 mg...... 8 DIFLORASONE DIACETATE – diflorasone diacetate dexamethasone tab 1.5 mg...... 8 cream 0.05%...... 38 dexamethasone tab 4 mg...... 8 diflorasone diacetate oint 0.05%...... 38 dexamethasone tab 6 mg...... 8 DIGOXIN – digoxin oral soln 0.05 mg/ml...... 13 dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin digoxin tab 125 mcg (0.125 mg) (Lanoxin)...... 13 xr)...... 28 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...... 13 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin DILANTIN – phenytoin sodium extended cap 30 mg...... 32 xr)...... 28 DILANTIN – phenytoin sodium extended cap 100 mg...... 32 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin DILANTIN-125 – phenytoin susp 125 mg/5ml...... 32 xr)...... 28 diltiazem hcl cap er 24hr 120 mg...... 14 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin diltiazem hcl cap er 24hr 180 mg...... 14 xr)...... 28 diltiazem hcl cap er 24hr 240 mg...... 14 dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin diltiazem hcl coated beads cap er 24hr 300 mg...... 14 xr)...... 28 diltiazem hcl coated beads cap er 24hr 120 mg dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin (Cardizem cd)...... 14 xr)...... 28 diltiazem hcl coated beads cap er 24hr 180 mg dextroamphetamine sulfate cap er 24hr 5 mg (Cardizem cd)...... 14 (Dexedrine)...... 28 diltiazem hcl coated beads cap er 24hr 240 mg dextroamphetamine sulfate cap er 24hr 10 mg (Cardizem cd)...... 14 (Dexedrine)...... 28 diltiazem hcl coated beads cap er 24hr 360 mg dextroamphetamine sulfate cap er 24hr 15 mg (Cardizem cd)...... 14 (Dexedrine)...... 28 diltiazem hcl extended release beads cap er 24hr 120 dextroamphetamine sulfate tab 5 mg...... 28 mg (Tiazac)...... 14 dextroamphetamine sulfate tab 10 mg...... 28 diltiazem hcl extended release beads cap er 24hr 180 DIASTAT ACUDIAL – diazepam rectal gel delivery system mg (Tiazac)...... 14 10 mg...... 32 diltiazem hcl extended release beads cap er 24hr 240 DIASTAT ACUDIAL – diazepam rectal gel delivery system mg (Tiazac)...... 14 20 mg...... 32 diltiazem hcl extended release beads cap er 24hr 300 DIASTAT PEDIATRIC – diazepam rectal gel delivery mg (Tiazac)...... 14 system 2.5 mg...... 32 diltiazem hcl extended release beads cap er 24hr 360 DIAZEPAM – diazepam oral soln 1 mg/ml...... 24 mg (Tiazac)...... 14 diazepam tab 2 mg (Valium)...... 24 diltiazem hcl extended release beads cap er 24hr 420 diazepam tab 5 mg (Valium)...... 24 mg (Tiazac)...... 14 diazepam tab 10 mg (Valium)...... 24 diltiazem hcl tab 90 mg...... 14 diclofenac potassium tab 50 mg (Cataflam)...... 31 diltiazem hcl tab 30 mg (Cardizem)...... 14 diclofenac sodium (actinic keratoses) gel 3% diltiazem hcl tab 60 mg (Cardizem)...... 14 (Solaraze)...... 38 diltiazem hcl tab 120 mg (Cardizem)...... 14 diclofenac sodium gel 1% (Voltaren)...... 38 DIPHENOXYLATE/ATROPINE – diphenoxylate w/ diclofenac sodium ophth soln 0.1%...... 37 atropine liq 2.5-0.025 mg/5ml...... 21 diclofenac sodium tab delayed release 25 mg...... 31 diphenoxylate w/ atropine tab 2.5-0.025 mg diclofenac sodium tab delayed release 50 mg...... 31 (Lomotil)...... 21 diclofenac sodium tab delayed release 75 mg...... 31 dipyridamole tab 25 mg (Persantine)...... 36 diclofenac sodium tab er 24hr 100 mg...... 31 dipyridamole tab 50 mg (Persantine)...... 36 dicloxacillin sodium cap 250 mg...... 1 dipyridamole tab 75 mg (Persantine)...... 36 dicloxacillin sodium cap 500 mg...... 1 disopyramide phosphate cap 100 mg (Norpace)...... 14 dicyclomine hcl cap 10 mg (Bentyl)...... 22 disopyramide phosphate cap 150 mg (Norpace)...... 14 dicyclomine hcl oral soln 10 mg/5ml...... 22 disulfiram tab 250 mg (Antabuse)...... 28 dicyclomine hcl tab 20 mg (Bentyl)...... 22 disulfiram tab 500 mg (Antabuse)...... 28

PrimeChoice Accord Formulary, January 2018 50 2018 divalproex sodium cap delayed release sprinkle 125 duloxetine hcl enteric coated pellets cap 20 mg (base mg (Depakote sprinkles)...... 32 eq) (Cymbalta)...... 24 divalproex sodium tab delayed release 125 mg duloxetine hcl enteric coated pellets cap 30 mg (base (Depakote)...... 32 eq) (Cymbalta)...... 24 divalproex sodium tab delayed release 250 mg duloxetine hcl enteric coated pellets cap 60 mg (base (Depakote)...... 32 eq) (Cymbalta)...... 24 divalproex sodium tab delayed release 500 mg dutasteride cap 0.5 mg (Avodart)...... 23 ...... 32 (Depakote) E divalproex sodium tab er 24 hr 250 mg (Depakote er)...... 32 econazole nitrate cream 1%...... 38 divalproex sodium tab er 24 hr 500 mg (Depakote efavirenz cap 50 mg (Sustiva)...... 3 er)...... 32 efavirenz cap 200 mg (Sustiva)...... 3 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...... 8 efavirenz tab 600 mg (Sustiva)...... 3 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...... 8 eletriptan hydrobromide tab 20 mg (base equivalent) DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...... 8 (Relpax)...... 32 donepezil hydrochloride orally disintegrating tab 5 mg eletriptan hydrobromide tab 40 mg (base equivalent) (Aricept odt)...... 28 (Relpax)...... 32 donepezil hydrochloride orally disintegrating tab 10 ELIDEL – pimecrolimus cream 1%...... 38 mg (Aricept odt)...... 28 ELIQUIS – apixaban tab 2.5 mg...... 36 donepezil hydrochloride tab 5 mg (Aricept)...... 28 ELIQUIS – apixaban tab 5 mg...... 36 donepezil hydrochloride tab 10 mg (Aricept)...... 29 ELIQUIS STARTER PACK – apixaban tab 5 mg...... 36 dorzolamide hcl ophth soln 2% (Trusopt)...... 37 ELLA – ulipristal acetate tab 30 mg...... 9 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 EMCYT – estramustine phosphate sodium cap 140 mg...... 5 mg/ml (Cosopt)...... 37 EMEND – aprepitant for oral susp 125 mg (125 doxazosin mesylate tab 1 mg (Cardura)...... 16 mg/5ml)...... 22 doxazosin mesylate tab 2 mg (Cardura)...... 16 enalapril maleate & hydrochlorothiazide tab 5-12.5 doxazosin mesylate tab 4 mg (Cardura)...... 16 mg...... 16 doxazosin mesylate tab 8 mg (Cardura)...... 16 enalapril maleate & hydrochlorothiazide tab 10-25 mg doxepin hcl cap 10 mg...... 24 (Vaseretic)...... 16 doxepin hcl cap 25 mg...... 24 enalapril maleate tab 2.5 mg (Vasotec)...... 16 doxepin hcl cap 50 mg...... 24 enalapril maleate tab 5 mg (Vasotec)...... 16 doxepin hcl cap 75 mg...... 24 enalapril maleate tab 10 mg (Vasotec)...... 16 doxepin hcl cap 100 mg...... 24 enalapril maleate tab 20 mg (Vasotec)...... 16 doxepin hcl conc 10 mg/ml...... 24 ENBREL – etanercept for subcutaneous inj 25 mg...... 31 doxycycline hyclate cap 50 mg...... 2 ENBREL – etanercept subcutaneous soln prefilled syringe doxycycline hyclate cap 100 mg (Vibramycin)...... 2 25 mg/0.5ml...... 31 doxycycline hyclate tab 20 mg...... 2 ENBREL – etanercept subcutaneous soln prefilled syringe doxycycline hyclate tab 100 mg...... 2 50 mg/ml...... 31 doxycycline monohydrate cap 50 mg...... 2 ENBREL MINI – etanercept subcutaneous solution doxycycline monohydrate cap 150 mg (Adoxa)...... 2 cartridge 50 mg/ml...... 31 doxycycline monohydrate cap 75 mg (Monodox)...... 2 ENBREL SURECLICK – etanercept subcutaneous doxycycline monohydrate cap 100 mg (Monodox)...... 2 solution auto-injector 50 mg/ml...... 31 doxycycline monohydrate tab 50 mg (Adoxa)...... 2 enoxaparin sodium inj 30 mg/0.3ml (Lovenox)...... 36 doxycycline monohydrate tab 75 mg (Adoxa)...... 2 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)...... 36 doxycycline monohydrate tab 100 mg (Adoxa pak enoxaparin sodium inj 60 mg/0.6ml (Lovenox)...... 36 1/100)...... 2 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)...... 36 doxycycline monohydrate tab 150 mg (Adoxa pak enoxaparin sodium inj 100 mg/ml (Lovenox)...... 36 1/150)...... 2 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...... 36 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin enoxaparin sodium inj 150 mg/ml (Lovenox)...... 36 28)...... 9 enoxaparin sodium inj 300 mg/3ml (Lovenox)...... 36 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)...... 9 ENSTILAR – calcipotriene-betamethasone dipropionate DULERA – mometasone furoate-formoterol fumarate foam 0.005-0.064%...... 38 aerosol 100-5 mcg/act...... 20 entacapone tab 200 mg (Comtan)...... 34 DULERA – mometasone furoate-formoterol fumarate entecavir tab 0.5 mg (Baraclude)...... 3 aerosol 200-5 mcg/act...... 20 entecavir tab 1 mg (Baraclude)...... 3 ENTRESTO – sacubitril-valsartan tab 24-26 mg...... 19

PrimeChoice Accord Formulary, January 2018 51 2018

ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 19 estradiol td patch weekly 0.06 mg/24hr (Climara)...... 9 ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 19 estradiol td patch weekly 0.075 mg/24hr (Climara)...... 9 EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg...... 3 estradiol td patch weekly 0.1 mg/24hr (Climara)...... 9 EPIDUO FORTE – adapalene-benzoyl peroxide gel estradiol td patch weekly 0.0375 mg/24hr (37.5 0.3-2.5%...... 39 mcg/24hr) (Climara)...... 8 EPINEPHRINE(Mylan Products) – epinephrine solution estradiol vaginal cream 0.1 mg/gm (Estrace)...... 23 auto-injector 0.15 mg/0.3ml (1:2000)...... 18 ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm EPINEPHRINE(Mylan Products) – epinephrine solution metered-dose pump)...... 9 auto-injector 0.3 mg/0.3ml (1:1000)...... 18 eszopiclone tab 1 mg (Lunesta)...... 27 EPIPEN-JR 2-PAK – epinephrine solution auto-injector eszopiclone tab 2 mg (Lunesta)...... 27 0.15 mg/0.3ml (1:2000)...... 18 eszopiclone tab 3 mg (Lunesta)...... 27 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 ethambutol hcl tab 100 mg (Myambutol)...... 2 mg/0.3ml (1:1000)...... 18 ethambutol hcl tab 400 mg (Myambutol)...... 2 EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv)...... 3 ethosuximide cap 250 mg (Zarontin)...... 32 eplerenone tab 25 mg (Inspra)...... 16 ethosuximide soln 250 mg/5ml (Zarontin)...... 32 eplerenone tab 50 mg (Inspra)...... 16 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 ergocalciferol cap 50000 unit (Drisdol)...... 34 mcg...... 9 ERIVEDGE – vismodegib cap 150 mg...... 5 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 ERLEADA – apalutamide tab 60 mg...... 5 mcg (Zovia 1/50e)...... 9 erythromycin gel 2% (Erygel)...... 39 etodolac cap 200 mg...... 31 erythromycin ophth oint 5 mg/gm...... 37 etodolac cap 300 mg...... 31 erythromycin pads 2%...... 39 etodolac tab er 24hr 400 mg...... 31 erythromycin soln 2%...... 39 etodolac tab er 24hr 500 mg...... 31 escitalopram oxalate soln 5 mg/5ml (base equiv) etodolac tab er 24hr 600 mg...... 31 (Lexapro)...... 24 etodolac tab 400 mg...... 31 escitalopram oxalate tab 5 mg (base equiv) etodolac tab 500 mg...... 31 (Lexapro)...... 24 ETOPOSIDE – etoposide cap 50 mg...... 5 escitalopram oxalate tab 10 mg (base equiv) EUFLEXXA – sodium hyaluronate intra-articular soln pref (Lexapro)...... 24 syr 20 mg/2ml...... 34 escitalopram oxalate tab 20 mg (base equiv) EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (Lexapro)...... 24 (base equiv)...... 3 esomeprazole magnesium cap delayed release 20 mg exemestane tab 25 mg (Aromasin)...... 5 (base eq) (Nexium)...... 22 ezetimibe-simvastatin tab 10-10 mg (Vytorin)...... 18 esomeprazole magnesium cap delayed release 40 mg ezetimibe-simvastatin tab 10-20 mg (Vytorin)...... 18 (base eq) (Nexium)...... 22 ezetimibe-simvastatin tab 10-40 mg (Vytorin)...... 18 estazolam tab 1 mg...... 27 ezetimibe-simvastatin tab 10-80 mg (Vytorin)...... 18 estazolam tab 2 mg...... 27 ezetimibe tab 10 mg (Zetia)...... 18 estradiol & norethindrone acetate tab 0.5-0.1 mg F (Activella)...... 8 estradiol & norethindrone acetate tab 1-0.5 mg famciclovir tab 125 mg (Famvir)...... 3 (Activella)...... 8 famciclovir tab 250 mg (Famvir)...... 3 estradiol tab 0.5 mg (Estrace)...... 8 famciclovir tab 500 mg (Famvir)...... 3 estradiol tab 1 mg (Estrace)...... 8 famotidine tab 20 mg (Pepcid)...... 22 estradiol tab 2 mg (Estrace)...... 8 famotidine tab 40 mg (Pepcid)...... 22 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle- FARESTON – toremifene citrate tab 60 mg (base dot)...... 8 equivalent)...... 5 estradiol td patch twice weekly 0.0375 mg/24hr FARYDAK – panobinostat lactate cap 10 mg (base (Vivelle-dot)...... 8 equivalent)...... 5 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle- FARYDAK – panobinostat lactate cap 15 mg (base dot)...... 8 equivalent)...... 5 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle- FARYDAK – panobinostat lactate cap 20 mg (base dot)...... 8 equivalent)...... 5 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle- felodipine tab er 24hr 2.5 mg...... 14 dot)...... 8 felodipine tab er 24hr 5 mg...... 14 estradiol td patch weekly 0.025 mg/24hr (Climara)...... 8 felodipine tab er 24hr 10 mg...... 14 estradiol td patch weekly 0.05 mg/24hr (Climara)...... 9 fenofibrate micronized cap 67 mg (Lofibra)...... 18

PrimeChoice Accord Formulary, January 2018 52 2018 fenofibrate micronized cap 134 mg (Lofibra)...... 18 FLUNISOLIDE – flunisolide nasal soln 25 mcg/act fenofibrate micronized cap 200 mg (Lofibra)...... 18 (0.025%)...... 20 fenofibrate tab 54 mg (Lofibra)...... 18 fluocinolone acetonide cream 0.01%...... 39 fenofibrate tab 160 mg (Lofibra)...... 18 fluocinolone acetonide cream 0.025% (Synalar)...... 39 fenofibrate tab 48 mg (Tricor)...... 18 fluocinolone acetonide oil 0.01% (body oil) (Derma- fenofibrate tab 145 mg (Tricor)...... 18 smoothe/fs bod)...... 39 fentanyl citrate lozenge on a handle 200 mcg fluocinolone acetonide oil 0.01% (scalp oil) (Derma- (Actiq)...... 29 smoothe/fs sca)...... 39 fentanyl citrate lozenge on a handle 400 mcg fluocinolone acetonide oint 0.025% (Synalar)...... 39 (Actiq)...... 30 fluocinolone acetonide soln 0.01% (Synalar)...... 39 fentanyl citrate lozenge on a handle 600 mcg fluocinonide cream 0.05%...... 39 (Actiq)...... 30 fluocinonide emulsified base cream 0.05%...... 39 fentanyl citrate lozenge on a handle 800 mcg fluocinonide gel 0.05%...... 39 (Actiq)...... 30 fluocinonide oint 0.05%...... 39 fentanyl citrate lozenge on a handle 1200 mcg fluocinonide soln 0.05%...... 39 (Actiq)...... 30 fluorometholone ophth susp 0.1% (Fml liquifilm)...... 37 fentanyl citrate lozenge on a handle 1600 mcg FLUOROPLEX – fluorouracil cream 1%...... 39 (Actiq)...... 30 fluorouracil cream 5% (Efudex)...... 39 fentanyl td patch 72hr 12 mcg/hr (Duragesic)...... 30 FLUOROURACIL – fluorouracil soln 2%...... 39 fentanyl td patch 72hr 25 mcg/hr (Duragesic)...... 30 FLUOROURACIL – fluorouracil soln 5%...... 39 fentanyl td patch 72hr 50 mcg/hr (Duragesic)...... 30 fluoxetine hcl cap 10 mg (Prozac)...... 24 fentanyl td patch 72hr 75 mcg/hr (Duragesic)...... 30 fluoxetine hcl cap 20 mg (Prozac)...... 24 fentanyl td patch 72hr 100 mcg/hr (Duragesic)...... 30 fluoxetine hcl cap 40 mg (Prozac)...... 24 FIASP FLEXTOUCH – insulin aspart soln pen-injector 100 fluoxetine hcl solution 20 mg/5ml...... 24 unit/ml...... 11 fluoxetine hcl tab 10 mg...... 25 FIASP – insulin aspart inj 100 unit/ml...... 11 fluoxetine hcl tab 20 mg...... 25 FINACEA – azelaic acid foam 15%...... 39 fluphenazine decanoate inj 25 mg/ml...... 25 FINACEA – azelaic acid gel 15%...... 39 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 finasteride tab 5 mg (Proscar)...... 23 mg/5ml...... 25 FIRAZYR – icatibant acetate inj 30 mg/3ml (base FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ equivalent)...... 36 ml...... 25 flecainide acetate tab 50 mg...... 14 fluphenazine hcl tab 1 mg...... 25 flecainide acetate tab 100 mg...... 15 fluphenazine hcl tab 2.5 mg...... 25 flecainide acetate tab 150 mg...... 15 fluphenazine hcl tab 5 mg...... 25 FLOVENT DISKUS – fluticasone propionate aer pow ba fluphenazine hcl tab 10 mg...... 25 50 mcg/blister...... 20 FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f FLOVENT DISKUS – fluticasone propionate aer pow ba (from 0.55 mg/drop naf)...... 35 100 mcg/blister...... 20 flurbiprofen sodium ophth soln 0.03% (Ocufen)...... 37 FLOVENT DISKUS – fluticasone propionate aer pow ba flurbiprofen tab 50 mg...... 31 250 mcg/blister...... 20 flurbiprofen tab 100 mg...... 31 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 flutamide cap 125 mg...... 6 mcg/act (125/valve)...... 20 FLUTICASONE PROPIONATE/SA – fluticasone- FLOVENT HFA – fluticasone propionate hfa inhal aer 220 salmeterol aer powder ba 55-14 mcg/act...... 21 mcg/act (250/valve)...... 20 FLUTICASONE PROPIONATE/SA – fluticasone- FLOVENT HFA – fluticasone propionate hfa inhal aero 44 salmeterol aer powder ba 113-14 mcg/act...... 21 mcg/act (50/valve)...... 20 FLUTICASONE PROPIONATE/SA – fluticasone- fluconazole for susp 10 mg/ml (Diflucan)...... 2 salmeterol aer powder ba 232-14 mcg/act...... 21 fluconazole for susp 40 mg/ml (Diflucan)...... 2 fluticasone propionate cream 0.05% (Cutivate)...... 39 fluconazole tab 50 mg (Diflucan)...... 2 fluticasone propionate nasal susp 50 mcg/act fluconazole tab 100 mg (Diflucan)...... 2 (Flonase)...... 20 fluconazole tab 150 mg (Diflucan)...... 2 fluticasone propionate oint 0.005% (Cutivate)...... 39 fluconazole tab 200 mg (Diflucan)...... 2 fluvoxamine maleate tab 25 mg...... 25 flucytosine cap 250 mg (Ancobon)...... 2 fluvoxamine maleate tab 50 mg...... 25 flucytosine cap 500 mg (Ancobon)...... 2 fluvoxamine maleate tab 100 mg...... 25 fludrocortisone acetate tab 0.1 mg...... 8 folic acid tab 1 mg...... 35 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml...... 12

PrimeChoice Accord Formulary, January 2018 53 2018

FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml...... 12 glimepiride tab 2 mg (Amaryl)...... 10 FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml...... 12 glimepiride tab 4 mg (Amaryl)...... 10 fosinopril sodium & hydrochlorothiazide tab 10-12.5 glipizide-metformin hcl tab 2.5-250 mg...... 10 mg...... 16 glipizide-metformin hcl tab 2.5-500 mg...... 10 fosinopril sodium & hydrochlorothiazide tab 20-12.5 glipizide-metformin hcl tab 5-500 mg...... 10 mg...... 16 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 10 fosinopril sodium tab 10 mg...... 16 glipizide tab er 24hr 5 mg (Glucotrol xl)...... 10 fosinopril sodium tab 20 mg...... 16 glipizide tab er 24hr 10 mg (Glucotrol xl)...... 10 fosinopril sodium tab 40 mg...... 16 glipizide tab 5 mg (Glucotrol)...... 10 FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 glipizide tab 10 mg (Glucotrol)...... 10 mg/0.6ml...... 35 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj furosemide oral soln 10 mg/ml...... 17 kit 1 mg...... 10 furosemide tab 20 mg (Lasix)...... 17 glyburide-metformin tab 1.25-250 mg furosemide tab 40 mg (Lasix)...... 17 (Glucovance)...... 10 furosemide tab 80 mg (Lasix)...... 17 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 10 ...... 10 G glyburide-metformin tab 5-500 mg (Glucovance) glyburide micronized tab 1.5 mg (Glynase)...... 10 gabapentin cap 100 mg (Neurontin)...... 33 glyburide micronized tab 3 mg (Glynase)...... 10 gabapentin cap 300 mg (Neurontin)...... 33 glyburide micronized tab 6 mg (Glynase)...... 10 gabapentin cap 400 mg (Neurontin)...... 33 glyburide tab 1.25 mg...... 10 gabapentin oral soln 250 mg/5ml (Neurontin)...... 33 glyburide tab 2.5 mg...... 10 gabapentin tab 600 mg (Neurontin)...... 33 glyburide tab 5 mg...... 10 gabapentin tab 800 mg (Neurontin)...... 33 glycopyrrolate tab 1 mg (Robinul)...... 22 galantamine hydrobromide cap er 24hr 8 mg glycopyrrolate tab 2 mg (Robinul forte)...... 22 (Razadyne er)...... 29 GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg...... 10 galantamine hydrobromide cap er 24hr 16 mg GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg...... 10 (Razadyne er)...... 29 GONAL-F – follitropin alfa for inj 450 unit...... 12 galantamine hydrobromide cap er 24hr 24 mg GONAL-F – follitropin alfa for inj 1050 unit...... 12 (Razadyne er)...... 29 GONAL-F RFF – follitropin alfa for subcutaneous inj 75 GALANTAMINE HYDROBROMIDE – galantamine unit...... 12 hydrobromide oral soln 4 mg/ml...... 29 GONAL-F RFF REDIJECT – follitropin alfa inj 300 galantamine hydrobromide tab 4 mg (Razadyne)...... 29 unit/0.5ml...... 12 galantamine hydrobromide tab 8 mg (Razadyne)...... 29 GONAL-F RFF REDIJECT – follitropin alfa inj 450 galantamine hydrobromide tab 12 mg (Razadyne)...... 29 unit/0.75ml...... 12 gemfibrozil tab 600 mg (Lopid)...... 18 GONAL-F RFF REDIJECT – follitropin alfa inj 900 GENTAK – gentamicin sulfate ophth oint 0.3%...... 37 unit/1.5ml...... 12 gentamicin sulfate cream 0.1%...... 39 granisetron hcl tab 1 mg...... 22 gentamicin sulfate oint 0.1%...... 39 GRANIX – tbo-filgrastim soln prefilled syringe 300 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 37 mcg/0.5ml...... 35 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab GRANIX – tbo-filgrastim soln prefilled syringe 480 150-150-200-10 mg...... 3 mcg/0.8ml...... 35 GILENYA – fingolimod hcl cap 0.5 mg (base equiv)...... 29 griseofulvin microsize susp 125 mg/5ml...... 2 GILOTRIF – afatinib dimaleate tab 20 mg (base griseofulvin microsize tab 500 mg (Grifulvin v)...... 2 equivalent)...... 6 guanfacine hcl tab er 24hr 1 mg (base equiv) GILOTRIF – afatinib dimaleate tab 30 mg (base (Intuniv)...... 28 equivalent)...... 6 guanfacine hcl tab er 24hr 2 mg (base equiv) GILOTRIF – afatinib dimaleate tab 40 mg (base (Intuniv)...... 28 equivalent)...... 6 guanfacine hcl tab er 24hr 3 mg (base equiv) glatiramer acetate soln prefilled syringe 20 mg/ml (Intuniv)...... 28 (Copaxone)...... 29 guanfacine hcl tab er 24hr 4 mg (base equiv) glatiramer acetate soln prefilled syringe 40 mg/ml (Intuniv)...... 28 (Copaxone)...... 29 guanfacine hcl tab 1 mg (Tenex)...... 16 GLEOSTINE – lomustine cap 10 mg...... 6 guanfacine hcl tab 2 mg (Tenex)...... 16 GLEOSTINE – lomustine cap 40 mg...... 6 GLEOSTINE – lomustine cap 100 mg...... 6 glimepiride tab 1 mg (Amaryl)...... 10

PrimeChoice Accord Formulary, January 2018 54 2018

...... 16 H hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg...... 16 HAEGARDA – c1 esterase inhibitor (human) for hydralazine hcl tab 50 mg...... 16 subcutaneous inj 2000 unit...... 36 hydralazine hcl tab 100 mg...... 16 HAEGARDA – c1 esterase inhibitor (human) for hydrochlorothiazide cap 12.5 mg (Microzide)...... 17 subcutaneous inj 3000 unit...... 36 hydrochlorothiazide tab 12.5 mg...... 17 halobetasol propionate cream 0.05% (Ultravate)...... 39 hydrochlorothiazide tab 25 mg...... 17 halobetasol propionate oint 0.05% (Ultravate)...... 39 hydrochlorothiazide tab 50 mg...... 17 haloperidol decanoate im soln 50 mg/ml (Haldol hydrocodone-acetaminophen soln 7.5-325 mg/15ml decanoate 50)...... 25 (Hycet)...... 30 haloperidol decanoate im soln 100 mg/ml (Haldol hydrocodone-acetaminophen tab 7.5-325 mg decanoate 100)...... 25 (Norco)...... 30 haloperidol lactate oral conc 2 mg/ml...... 26 hydrocodone-acetaminophen tab 5-325 mg haloperidol tab 0.5 mg...... 26 (Norco)...... 30 haloperidol tab 1 mg...... 26 hydrocodone-acetaminophen tab 10-325 mg haloperidol tab 2 mg...... 26 (Norco)...... 30 haloperidol tab 5 mg...... 26 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)...... 30 haloperidol tab 10 mg...... 26 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 30 haloperidol tab 20 mg...... 26 hydrocodone-ibuprofen tab 7.5-200 mg HARVONI – ledipasvir-sofosbuvir tab 90-400 mg...... 3 (Vicoprofen)...... 30 HUMIRA – adalimumab prefilled syringe kit 10 hydrocortisone cream 2.5%...... 39 mg/0.1ml...... 31 hydrocortisone enema 100 mg/60ml (Cortenema)...... 38 HUMIRA – adalimumab prefilled syringe kit 10 hydrocortisone lotion 2.5%...... 39 mg/0.2ml...... 31 hydrocortisone oint 2.5%...... 39 HUMIRA – adalimumab prefilled syringe kit 20 hydrocortisone rectal cream 2.5% (Anusol-hc)...... 38 mg/0.2ml...... 31 hydrocortisone tab 5 mg (Cortef)...... 8 HUMIRA – adalimumab prefilled syringe kit 20 hydrocortisone tab 10 mg (Cortef)...... 8 mg/0.4ml...... 31 hydrocortisone tab 20 mg (Cortef)...... 8 HUMIRA – adalimumab prefilled syringe kit 40 hydrocortisone valerate cream 0.2%...... 39 mg/0.8ml...... 31 hydrocortisone valerate oint 0.2% (Westcort)...... 39 HUMIRA – adalimumab prefilled syringe kit 40 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol mg/0.4ml...... 31 hc)...... 37 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled hydromorphone hcl liqd 1 mg/ml (Dilaudid)...... 30 syringe kit 40 mg/0.8ml...... 31 hydromorphone hcl tab 2 mg (Dilaudid)...... 30 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled hydromorphone hcl tab 4 mg (Dilaudid)...... 30 syringe kit 80 mg/0.8ml...... 31 hydromorphone hcl tab 8 mg (Dilaudid)...... 30 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 4 syringe kit 80 mg/0.8ml & 40 mg/0.4ml...... 31 hydroxyurea cap 500 mg (Hydrea)...... 6 HUMIRA PEN – adalimumab pen-injector kit 40 hydroxyzine hcl syrup 10 mg/5ml...... 24 mg/0.8ml...... 31 hydroxyzine hcl tab 10 mg...... 24 HUMIRA PEN – adalimumab pen-injector kit 40 hydroxyzine hcl tab 25 mg...... 24 mg/0.4ml...... 31 hydroxyzine hcl tab 50 mg...... 24 HUMIRA PEN-CD/UC/HS START – adalimumab pen- hydroxyzine pamoate cap 25 mg (Vistaril)...... 24 injector kit 40 mg/0.8ml...... 31 hydroxyzine pamoate cap 50 mg (Vistaril)...... 24 HUMIRA PEN-CD/UC/HS START – adalimumab pen- HYDROXYZINE PAMOATE – hydroxyzine pamoate cap injector kit 80 mg/0.8ml...... 31 100 mg...... 24 HUMIRA PEN-PS/UV STARTER – adalimumab pen- injector kit 40 mg/0.8ml...... 31 I HUMIRA PEN-PS/UV STARTER – adalimumab pen- ibandronate sodium tab 150 mg (base equivalent) injector kit 80 mg/0.8ml & 40 mg/0.4ml...... 31 (Boniva)...... 12 HUMULIN R U-500 (CONCENTR – insulin regular IBRANCE – palbociclib cap 75 mg...... 6 (human) inj 500 unit/ml...... 11 IBRANCE – palbociclib cap 100 mg...... 6 HUMULIN R U-500 KWIKPEN – insulin regular (human) IBRANCE – palbociclib cap 125 mg...... 6 soln pen-injector 500 unit/ml...... 11 ibuprofen susp 100 mg/5ml...... 31 HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)...... 6 ibuprofen tab 400 mg...... 31 HYCAMTIN – topotecan hcl cap 1 mg (base equiv)...... 6 ibuprofen tab 600 mg...... 31

PrimeChoice Accord Formulary, January 2018 55 2018 ibuprofen tab 800 mg...... 31 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ICLUSIG – ponatinib hcl tab 15 mg (base equiv)...... 6 (Atrovent)...... 20 ICLUSIG – ponatinib hcl tab 45 mg (base equiv)...... 6 ipratropium bromide nasal soln 0.06% (42 mcg/spray) ILARIS – canakinumab subcutaneous inj 150 mg/ml...... 31 (Atrovent)...... 20 imatinib mesylate tab 100 mg (base equivalent) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Gleevec)...... 6 (Avalide)...... 16 imatinib mesylate tab 400 mg (base equivalent) irbesartan-hydrochlorothiazide tab 300-12.5 mg (Gleevec)...... 6 (Avalide)...... 16 IMBRUVICA – ibrutinib cap 70 mg...... 6 irbesartan tab 75 mg (Avapro)...... 16 IMBRUVICA – ibrutinib cap 140 mg...... 6 irbesartan tab 150 mg (Avapro)...... 16 IMBRUVICA – ibrutinib tab 140 mg...... 6 irbesartan tab 300 mg (Avapro)...... 16 IMBRUVICA – ibrutinib tab 280 mg...... 6 IRESSA – gefitinib tab 250 mg...... 6 IMBRUVICA – ibrutinib tab 420 mg...... 6 ISENTRESS HD – raltegravir potassium tab 600 mg (base IMBRUVICA – ibrutinib tab 560 mg...... 6 equiv)...... 3 imipramine hcl tab 10 mg (Tofranil)...... 25 ISENTRESS – raltegravir potassium chew tab 25 mg imipramine hcl tab 25 mg (Tofranil)...... 25 (base equiv)...... 3 imipramine hcl tab 50 mg (Tofranil)...... 25 ISENTRESS – raltegravir potassium chew tab 100 mg imiquimod cream 5% (Aldara)...... 39 (base equiv)...... 3 IMPAVIDO – miltefosine cap 50 mg...... 5 ISENTRESS – raltegravir potassium packet for susp 100 INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 12 mg (base equiv)...... 3 INCRUSE ELLIPTA – umeclidinium br aero powd breath ISENTRESS – raltegravir potassium tab 400 mg (base act 62.5 mcg/inh (base eq)...... 21 equiv)...... 3 indapamide tab 1.25 mg...... 17 ISONIAZID – isoniazid syrup 50 mg/5ml...... 2 indapamide tab 2.5 mg...... 17 isoniazid tab 100 mg...... 2 indomethacin cap 25 mg...... 31 isoniazid tab 300 mg...... 2 indomethacin cap 50 mg...... 31 isosorbide dinitrate tab 10 mg...... 13 INHALER ASSIST DEVICES -...... 40 isosorbide dinitrate tab 20 mg...... 13 INLYTA – axitinib tab 1 mg...... 6 isosorbide dinitrate tab 30 mg...... 13 INLYTA – axitinib tab 5 mg...... 6 isosorbide dinitrate tab 5 mg (Isordil titradose)...... 13 INSULIN PEN NEEDLES - various...... 40 isosorbide mononitrate tab er 24hr 30 mg...... 13 INSULIN SYRINGES - various...... 40 isosorbide mononitrate tab er 24hr 60 mg...... 13 INTELENCE – etravirine tab 25 mg...... 3 isosorbide mononitrate tab er 24hr 120 mg...... 13 INTELENCE – etravirine tab 100 mg...... 3 isosorbide mononitrate tab 10 mg...... 13 INTELENCE – etravirine tab 200 mg...... 3 isosorbide mononitrate tab 20 mg...... 13 INVOKAMET – canagliflozin-metformin hcl tab 50-500 isotretinoin cap 10 mg...... 39 mg...... 10 isotretinoin cap 20 mg...... 39 INVOKAMET – canagliflozin-metformin hcl tab 50-1000 isotretinoin cap 40 mg...... 39 mg...... 10 isotretinoin cap 30 mg (Claravis)...... 39 INVOKAMET – canagliflozin-metformin hcl tab 150-500 itraconazole cap 100 mg (Sporanox)...... 2 mg...... 10 itraconazole oral soln 10 mg/ml (Sporanox)...... 2 INVOKAMET – canagliflozin-metformin hcl tab 150-1000 ivermectin tab 3 mg (Stromectol)...... 4 mg...... 10 J INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr 50-500 mg...... 10 JAKAFI – ruxolitinib phosphate tab 5 mg (base INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr equivalent)...... 6 50-1000 mg...... 10 JAKAFI – ruxolitinib phosphate tab 10 mg (base INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr equivalent)...... 6 150-500 mg...... 10 JAKAFI – ruxolitinib phosphate tab 15 mg (base INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr equivalent)...... 6 150-1000 mg...... 10 JAKAFI – ruxolitinib phosphate tab 20 mg (base INVOKANA – canagliflozin tab 100 mg...... 10 equivalent)...... 6 INVOKANA – canagliflozin tab 300 mg...... 10 JAKAFI – ruxolitinib phosphate tab 25 mg (base ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml equivalent)...... 6 (Duoneb)...... 21 JANUMET – sitagliptin-metformin hcl tab 50-500 mg...... 10 ipratropium bromide inhal soln 0.02%...... 21 JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 10

PrimeChoice Accord Formulary, January 2018 56 2018

JANUMET XR – sitagliptin-metformin hcl tab er 24hr lamivudine-zidovudine tab 150-300 mg (Combivir)...... 3 50-500 mg...... 10 lamotrigine tab chewable dispersible 5 mg (Lamictal JANUMET XR – sitagliptin-metformin hcl tab er 24hr chewable di)...... 33 50-1000 mg...... 10 lamotrigine tab chewable dispersible 25 mg (Lamictal JANUMET XR – sitagliptin-metformin hcl tab er 24hr chewable di)...... 33 100-1000 mg...... 10 lamotrigine tab 25 mg (Lamictal)...... 33 JANUVIA – sitagliptin phosphate tab 25 mg (base lamotrigine tab 100 mg (Lamictal)...... 33 equiv)...... 10 lamotrigine tab 150 mg (Lamictal)...... 33 JANUVIA – sitagliptin phosphate tab 50 mg (base lamotrigine tab 200 mg (Lamictal)...... 33 equiv)...... 10 LANCET DEVICES - various...... 40 JANUVIA – sitagliptin phosphate tab 100 mg (base LANCETS - various...... 40 equiv)...... 10 lansoprazole cap delayed release 15 mg JARDIANCE – empagliflozin tab 10 mg...... 10 (Prevacid)...... 22 JARDIANCE – empagliflozin tab 25 mg...... 10 lansoprazole cap delayed release 30 mg ...... 22 K (Prevacid) LANTUS – insulin glargine inj 100 unit/ml...... 11 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 3 LANTUS SOLOSTAR – insulin glargine soln pen-injector KALETRA – lopinavir-ritonavir tab 200-50 mg...... 3 100 unit/ml...... 11 KALYDECO – ivacaftor packet 50 mg...... 21 latanoprost ophth soln 0.005% (Xalatan)...... 37 KALYDECO – ivacaftor packet 75 mg...... 21 leflunomide tab 10 mg (Arava)...... 31 KALYDECO – ivacaftor tab 150 mg...... 21 leflunomide tab 20 mg (Arava)...... 31 ketoconazole cream 2%...... 39 LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy ketoconazole shampoo 2% (Nizoral)...... 39 pack 10 & 4 mg (14 mg daily dose)...... 6 ketorolac tromethamine ophth soln 0.5% (Acular)...... 37 LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy ketorolac tromethamine ophth soln 0.4% (Acular pack 10 & 4 (2) mg (18 mg daily dose)...... 6 ls)...... 37 LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & pack 10 (2) & 4 mg (24 mg daily dose)...... 6 letrozole tab 2.5 mg therapy pack...... 6 LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg & pack 10 mg (10 mg daily dose)...... 6 letrozole tab 2.5 mg therapy pack...... 6 LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & pack 4 (3) mg (12 mg daily dose)...... 6 letrozole tab 2.5 mg therapy pack...... 6 LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy KISQALI – ribociclib succinate tab 200 mg (base equiv)..... 6 pack 10 (2) mg (20 mg daily dose)...... 6 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy 2.5-1000 mg...... 10 pack 4 mg (4 mg daily dose)...... 6 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy 5-500 mg...... 10 pack 4 (2) mg (8 mg daily dose)...... 6 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr LETAIRIS – ambrisentan tab 5 mg...... 19 5-1000 mg...... 10 LETAIRIS – ambrisentan tab 10 mg...... 19 KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron letrozole tab 2.5 mg (Femara)...... 6 carbonyl-fa tab 30-1 mg...... 34 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 K-PHOS NO 2 – potassium & sodium acid phosphates tab mg...... 6 305-700 mg...... 23 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 K-PHOS – potassium phosphate monobasic tab 500 mg...... 6 mg...... 35 leucovorin calcium tab 5 mg...... 6 L leucovorin calcium tab 25 mg...... 6 LEUKERAN – chlorambucil tab 2 mg...... 6 ...... 13 labetalol hcl tab 100 mg (Trandate) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base ...... 13 labetalol hcl tab 200 mg (Trandate) equiv)...... 21 ...... 13 labetalol hcl tab 300 mg (Trandate) levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) ...... 23 lactulose (encephalopathy) solution 10 gm/15ml (Xopenex)...... 21 ...... 21 lactulose solution 10 gm/15ml levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) ...... 3 lamivudine oral soln 10 mg/ml (Epivir) (Xopenex)...... 21 ...... 3 lamivudine tab 150 mg (Epivir) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) ...... 3 lamivudine tab 300 mg (Epivir) (Xopenex)...... 21 lamivudine tab 100 mg (hbv) (Epivir hbv)...... 3

PrimeChoice Accord Formulary, January 2018 57 2018

LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector liothyronine sodium tab 5 mcg (Cytomel)...... 12 100 unit/ml...... 11 liothyronine sodium tab 25 mcg (Cytomel)...... 12 LEVEMIR – insulin detemir inj 100 unit/ml...... 11 liothyronine sodium tab 50 mcg (Cytomel)...... 12 levetiracetam oral soln 100 mg/ml (Keppra)...... 33 lisinopril & hydrochlorothiazide tab 10-12.5 mg levetiracetam tab er 24hr 500 mg (Keppra xr)...... 33 (Zestoretic)...... 16 levetiracetam tab er 24hr 750 mg (Keppra xr)...... 33 lisinopril & hydrochlorothiazide tab 20-12.5 mg levetiracetam tab 250 mg (Keppra)...... 33 (Zestoretic)...... 16 levetiracetam tab 500 mg (Keppra)...... 33 lisinopril & hydrochlorothiazide tab 20-25 mg levetiracetam tab 750 mg (Keppra)...... 33 (Zestoretic)...... 16 levetiracetam tab 1000 mg (Keppra)...... 33 lisinopril tab 5 mg (Prinivil)...... 16 levobunolol hcl ophth soln 0.5% (Betagan)...... 37 lisinopril tab 10 mg (Prinivil)...... 16 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 12 lisinopril tab 20 mg (Prinivil)...... 16 levocarnitine tab 330 mg (Carnitor)...... 12 lisinopril tab 2.5 mg (Zestril)...... 16 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ lisinopril tab 30 mg (Zestril)...... 16 ml) (Xyzal)...... 19 lisinopril tab 40 mg (Zestril)...... 16 levocetirizine dihydrochloride tab 5 mg (Xyzal)...... 19 lithium carbonate cap 300 mg...... 26 levofloxacin oral soln 25 mg/ml (Levaquin)...... 2 lithium carbonate cap 150 mg (Lithium carbonate)...... 26 levofloxacin tab 250 mg (Levaquin)...... 2 lithium carbonate cap 600 mg (Lithium carbonate)...... 26 levofloxacin tab 500 mg (Levaquin)...... 2 LITHIUM CARBONATE – lithium carbonate cap 150 levofloxacin tab 750 mg (Levaquin)...... 2 mg...... 26 levonorgestrel & ethinyl estradiol (91-day) tab lithium carbonate tab er 450 mg...... 26 0.15-0.03 mg...... 9 lithium carbonate tab er 300 mg (Lithobid)...... 26 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 lithium carbonate tab 300 mg...... 26 mcg...... 9 LITHIUM – lithium oral solution 8 meq/5ml...... 26 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 LONSURF – trifluridine-tipiracil tab 15-6.14 mg...... 6 mcg...... 9 LONSURF – trifluridine-tipiracil tab 20-8.19 mg...... 6 levonorgestrel-eth estra tab loperamide hcl cap 2 mg...... 21 0.05-30/0.075-40/0.125-30mg-mcg...... 9 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) levonorg-eth est tab 0.1-0.02mg(84) & eth est tab (Kaletra)...... 3 0.01mg(7) (Loseasonique)...... 9 lorazepam conc 2 mg/ml (Lorazepam intensol)...... 24 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab lorazepam tab 0.5 mg (Ativan)...... 24 0.01mg(7) (Seasonique)...... 9 lorazepam tab 1 mg (Ativan)...... 24 levothyroxine sodium tab 25 mcg (Synthroid)...... 11 lorazepam tab 2 mg (Ativan)...... 24 levothyroxine sodium tab 50 mcg (Synthroid)...... 11 losartan potassium & hydrochlorothiazide tab 50-12.5 levothyroxine sodium tab 75 mcg (Synthroid)...... 11 mg (Hyzaar)...... 16 levothyroxine sodium tab 88 mcg (Synthroid)...... 11 losartan potassium & hydrochlorothiazide tab 100-12.5 levothyroxine sodium tab 100 mcg (Synthroid)...... 11 mg (Hyzaar)...... 16 levothyroxine sodium tab 112 mcg (Synthroid)...... 11 losartan potassium & hydrochlorothiazide tab 100-25 levothyroxine sodium tab 125 mcg (Synthroid)...... 11 mg (Hyzaar)...... 16 levothyroxine sodium tab 137 mcg (Synthroid)...... 11 losartan potassium tab 25 mg (Cozaar)...... 16 levothyroxine sodium tab 150 mcg (Synthroid)...... 12 losartan potassium tab 50 mg (Cozaar)...... 16 levothyroxine sodium tab 175 mcg (Synthroid)...... 12 losartan potassium tab 100 mg (Cozaar)...... 16 levothyroxine sodium tab 200 mcg (Synthroid)...... 12 LOTEMAX – loteprednol etabonate ophth gel 0.5%...... 37 levothyroxine sodium tab 300 mcg (Synthroid)...... 12 LOTEMAX – loteprednol etabonate ophth oint 0.5%...... 37 lidocaine hcl gel 2%...... 39 LOTEMAX – loteprednol etabonate ophth susp 0.5%...... 37 lidocaine hcl soln 4% (Xylocaine)...... 39 lovastatin tab 10 mg...... 18 lidocaine hcl viscous soln 2%...... 37 lovastatin tab 20 mg (Mevacor)...... 18 lidocaine oint 5%...... 39 lovastatin tab 40 mg (Mevacor)...... 18 lidocaine patch 5% (Lidoderm)...... 39 loxapine succinate cap 10 mg...... 26 lidocaine-prilocaine cream 2.5-2.5% (Emla)...... 39 loxapine succinate cap 25 mg...... 26 LINDANE – lindane shampoo 1%...... 39 loxapine succinate cap 50 mg...... 26 linezolid for susp 100 mg/5ml (Zyvox)...... 5 loxapine succinate cap 5 mg (Loxitane)...... 26 linezolid tab 600 mg (Zyvox)...... 5 LUMIGAN – bimatoprost ophth soln 0.01%...... 37 LINZESS – linaclotide cap 72 mcg...... 23 LYNPARZA – olaparib tab 100 mg...... 6 LINZESS – linaclotide cap 145 mcg...... 23 LYNPARZA – olaparib tab 150 mg...... 6 LINZESS – linaclotide cap 290 mcg...... 23 LYRICA – pregabalin cap 25 mg...... 33

PrimeChoice Accord Formulary, January 2018 58 2018

LYRICA – pregabalin cap 50 mg...... 33 methadone hcl tab 10 mg (Dolophine)...... 30 LYRICA – pregabalin cap 75 mg...... 33 methadone hcl tab 5 mg (Dolophine hcl)...... 30 LYRICA – pregabalin cap 100 mg...... 33 methazolamide tab 25 mg (Neptazane)...... 17 LYRICA – pregabalin cap 150 mg...... 33 methazolamide tab 50 mg (Neptazane)...... 18 LYRICA – pregabalin cap 200 mg...... 33 methimazole tab 5 mg (Tapazole)...... 12 LYRICA – pregabalin cap 225 mg...... 33 methimazole tab 10 mg (Tapazole)...... 12 LYRICA – pregabalin cap 300 mg...... 33 methocarbamol tab 750 mg (Robaxin-750)...... 34 LYRICA – pregabalin soln 20 mg/ml...... 33 methocarbamol tab 500 mg (Robaxin)...... 34 LYSODREN – mitotane tab 500 mg...... 6 methotrexate sodium tab 2.5 mg (base equiv)...... 7 ...... 22 M methscopolamine bromide tab 2.5 mg (Pamine) methscopolamine bromide tab 5 mg (Pamine malathion lotion 0.5% (Ovide)...... 39 forte)...... 22 MATULANE – procarbazine hcl cap 50 mg...... 6 methyldopa tab 250 mg...... 16 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg...... 3 methyldopa tab 500 mg...... 16 meclizine hcl tab 12.5 mg...... 22 methylergonovine maleate tab 0.2 mg...... 12 meclizine hcl tab 25 mg...... 22 methylphenidate hcl tab er 10 mg...... 28 medroxyprogesterone acetate im susp 150 mg/ml methylphenidate hcl tab er 20 mg...... 28 (Depo-provera contrac)...... 9 methylphenidate hcl tab 5 mg (Ritalin)...... 28 medroxyprogesterone acetate im susp prefilled syr methylphenidate hcl tab 10 mg (Ritalin)...... 28 150 mg/ml (Depo-provera contrac)...... 9 methylphenidate hcl tab 20 mg (Ritalin)...... 28 medroxyprogesterone acetate tab 2.5 mg methylprednisolone tab 4 mg (Medrol)...... 8 (Provera)...... 10 methylprednisolone tab 8 mg (Medrol)...... 8 medroxyprogesterone acetate tab 5 mg (Provera)...... 10 methylprednisolone tab 16 mg (Medrol)...... 8 medroxyprogesterone acetate tab 10 mg (Provera)..... 10 methylprednisolone tab 32 mg (Medrol)...... 8 MEFLOQUINE HCL – mefloquine hcl tab 250 mg...... 4 methylprednisolone tab therapy pack 4 mg (21) megestrol acetate susp 40 mg/ml (Megace oral)...... 6 (Medrol dosepak)...... 8 megestrol acetate tab 20 mg...... 6 METIPRANOLOL – metipranolol ophth soln 0.3%...... 37 megestrol acetate tab 40 mg...... 6 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg equiv)...... 23 (base equivalent)...... 6 metoclopramide hcl tab 5 mg (base equivalent) MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base (Reglan)...... 23 equivalent)...... 6 metoclopramide hcl tab 10 mg (base equivalent) meloxicam tab 7.5 mg (Mobic)...... 31 (Reglan)...... 23 meloxicam tab 15 mg (Mobic)...... 31 metolazone tab 10 mg...... 18 melphalan tab 2 mg (Alkeran)...... 6 metolazone tab 2.5 mg (Zaroxolyn)...... 18 memantine hcl oral solution 2 mg/ml (Namenda)...... 29 metolazone tab 5 mg (Zaroxolyn)...... 18 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak METOPROLOL/HYDROCHLOROTHI – metoprolol & (Namenda titration pa)...... 29 hydrochlorothiazide tab 100-50 mg...... 16 memantine hcl tab 5 mg (Namenda)...... 29 metoprolol & hydrochlorothiazide tab 50-25 mg memantine hcl tab 10 mg (Namenda)...... 29 (Lopressor hct)...... 16 mercaptopurine tab 50 mg (Purinethol)...... 6 metoprolol & hydrochlorothiazide tab 100-25 mg mesalamine enema 4 gm...... 23 (Lopressor hct)...... 16 mesalamine tab delayed release 1.2 gm (Lialda)...... 23 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) mesalamine tab delayed release 800 mg (Asacol (Toprol xl)...... 13 hd)...... 23 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) MESNEX – mesna tab 400 mg...... 7 (Toprol xl)...... 13 metaxalone tab 800 mg (Skelaxin)...... 34 metoprolol succinate tab er 24hr 100 mg (tartrate metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 10 equiv) (Toprol xl)...... 13 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 10 metoprolol succinate tab er 24hr 200 mg (tartrate metformin hcl tab 500 mg (Glucophage)...... 10 equiv) (Toprol xl)...... 13 metformin hcl tab 850 mg (Glucophage)...... 10 metoprolol tartrate tab 25 mg...... 13 metformin hcl tab 1000 mg (Glucophage)...... 10 metoprolol tartrate tab 50 mg (Lopressor)...... 13 methadone hcl conc 10 mg/ml (Methadose)...... 30 metoprolol tartrate tab 100 mg (Lopressor)...... 13 methadone hcl soln 5 mg/5ml (Methadone hcl)...... 30 metronidazole cream 0.75% (Metrocream)...... 39 methadone hcl soln 10 mg/5ml (Methadone hcl)...... 30 metronidazole gel 0.75%...... 39 methadone hcl tab for oral susp 40 mg...... 30 metronidazole gel 1% (Metrogel)...... 39

PrimeChoice Accord Formulary, January 2018 59 2018 metronidazole lotion 0.75% (Metrolotion)...... 39 MORPHINE SULFATE ER – morphine sulfate beads cap metronidazole tab 250 mg (Flagyl)...... 5 er 24hr 60 mg...... 30 metronidazole tab 500 mg (Flagyl)...... 5 MORPHINE SULFATE ER – morphine sulfate beads cap metronidazole vaginal gel 0.75% (Metrogel- er 24hr 75 mg...... 30 vaginal)...... 23 MORPHINE SULFATE ER – morphine sulfate beads cap mexiletine hcl cap 150 mg...... 15 er 24hr 90 mg...... 30 mexiletine hcl cap 200 mg...... 15 MORPHINE SULFATE ER – morphine sulfate beads cap mexiletine hcl cap 250 mg...... 15 er 24hr 120 mg...... 30 midodrine hcl tab 2.5 mg...... 18 MORPHINE SULFATE – morphine sulfate tab 15 mg...... 30 midodrine hcl tab 5 mg...... 18 MORPHINE SULFATE – morphine sulfate tab 30 mg...... 30 midodrine hcl tab 10 mg...... 18 morphine sulfate oral soln 10 mg/5ml...... 30 MIGRANAL – dihydroergotamine mesylate nasal spray 4 morphine sulfate oral soln 20 mg/5ml...... 30 mg/ml...... 32 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 30 minocycline hcl cap 50 mg (Minocin)...... 2 morphine sulfate tab er 15 mg (Ms contin)...... 30 minocycline hcl cap 75 mg (Minocin)...... 2 morphine sulfate tab er 30 mg (Ms contin)...... 30 minocycline hcl cap 100 mg (Minocin)...... 2 morphine sulfate tab er 60 mg (Ms contin)...... 30 minocycline hcl tab 50 mg...... 2 morphine sulfate tab er 100 mg (Ms contin)...... 30 minocycline hcl tab 75 mg...... 2 morphine sulfate tab er 200 mg (Ms contin)...... 30 minocycline hcl tab 100 mg...... 2 moxifloxacin hcl ophth soln 0.5% (base equiv) minoxidil tab 2.5 mg...... 16 (Vigamox)...... 37 minoxidil tab 10 mg...... 16 MULTAQ – dronedarone hcl tab 400 mg (base MIRENA – levonorgestrel releasing iud 20 mcg/day (52 equivalent)...... 15 mg total)...... 9 mupirocin calcium cream 2% (Bactroban)...... 39 mirtazapine tab 7.5 mg...... 25 mupirocin oint 2% (Bactroban)...... 39 mirtazapine tab 15 mg (Remeron)...... 25 mycophenolate mofetil cap 250 mg (Cellcept)...... 40 mirtazapine tab 30 mg (Remeron)...... 25 mycophenolate mofetil for oral susp 200 mg/ml mirtazapine tab 45 mg (Remeron)...... 25 (Cellcept)...... 40 misoprostol tab 100 mcg (Cytotec)...... 22 mycophenolate mofetil tab 500 mg (Cellcept)...... 40 misoprostol tab 200 mcg (Cytotec)...... 22 mycophenolate sodium tab dr 180 mg (mycophenolic modafinil tab 100 mg (Provigil)...... 28 acid equiv) (Myfortic)...... 40 modafinil tab 200 mg (Provigil)...... 28 mycophenolate sodium tab dr 360 mg (mycophenolic moexipril hcl tab 7.5 mg (Univasc)...... 16 acid equiv) (Myfortic)...... 40 moexipril hcl tab 15 mg (Univasc)...... 16 MYLERAN – busulfan tab 2 mg...... 7 moexipril-hydrochlorothiazide tab 15-25 mg...... 16 MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa moexipril-hydrochlorothiazide tab 7.5-12.5 mg tab 90-1 mg...... 34 (Uniretic)...... 16 MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1 moexipril-hydrochlorothiazide tab 15-12.5 mg mg...... 34 (Uniretic)...... 16 MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron mometasone furoate cream 0.1% (Elocon)...... 39 carbonyl-fa tab 90-1 mg...... 34 mometasone furoate nasal susp 50 mcg/act MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1 (Nasonex)...... 20 mg...... 34 ...... 39 mometasone furoate oint 0.1% (Elocon) N mometasone furoate solution 0.1% (lotion) (Elocon)...... 39 nabumetone tab 500 mg...... 31 montelukast sodium chew tab 4 mg (base equiv) nabumetone tab 750 mg...... 31 (Singulair)...... 21 nadolol tab 20 mg (Corgard)...... 13 montelukast sodium chew tab 5 mg (base equiv) nadolol tab 40 mg (Corgard)...... 13 (Singulair)...... 21 nadolol tab 80 mg (Corgard)...... 13 montelukast sodium oral granules packet 4 mg (base naloxone hcl inj 0.4 mg/ml...... 40 equiv) (Singulair)...... 21 naloxone hcl inj 4 mg/10ml...... 40 montelukast sodium tab 10 mg (base equiv) NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ (Singulair)...... 21 ml...... 40 MORPHINE SULFATE ER – morphine sulfate beads cap naltrexone hcl tab 50 mg (Revia)...... 40 er 24hr 30 mg...... 30 naproxen sodium tab 275 mg (Anaprox)...... 31 MORPHINE SULFATE ER – morphine sulfate beads cap naproxen sodium tab 550 mg (Anaprox ds)...... 31 er 24hr 45 mg...... 30 naproxen susp 125 mg/5ml (Naprosyn)...... 31

PrimeChoice Accord Formulary, January 2018 60 2018 naproxen tab ec 375 mg (Ec-naprosyn)...... 31 niacin tab er 1000 mg (antihyperlipidemic) naproxen tab ec 500 mg (Ec-naprosyn)...... 31 (Niaspan)...... 18 naproxen tab 250 mg (Naprosyn)...... 31 NICOTROL INHALER – nicotine inhaler system 10 mg (4 naproxen tab 375 mg (Naprosyn)...... 31 mg delivered)...... 29 naproxen tab 500 mg (Naprosyn)...... 31 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ naratriptan hcl tab 1 mg (base equiv) (Amerge)...... 32 spray)...... 29 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 32 nifedipine tab er 24hr 30 mg (Adalat cc)...... 14 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 40 nifedipine tab er 24hr 60 mg (Adalat cc)...... 14 NATACYN – natamycin ophth susp 5%...... 37 nifedipine tab er 24hr 90 mg (Adalat cc)...... 14 nateglinide tab 60 mg (Starlix)...... 11 nifedipine tab er 24hr osmotic release 30 mg nateglinide tab 120 mg (Starlix)...... 11 (Procardia xl)...... 14 NEBUPENT – pentamidine isethionate for nebulization nifedipine tab er 24hr osmotic release 60 mg soln 300 mg...... 5 (Procardia xl)...... 14 neomycin-bacitrac zn-polymyx nifedipine tab er 24hr osmotic release 90 mg 5(3.5)mg-400unt-10000unt op oin...... 37 (Procardia xl)...... 14 neomycin-polymy-gramicid op sol nilutamide tab 150 mg (Nilandron)...... 7 1.75-10000-0.025mg-unt-mg/ml (Neosporin)...... 37 nimodipine cap 30 mg...... 14 neomycin-polymyxin-dexamethasone ophth oint 0.1% NINLARO – ixazomib citrate cap 2.3 mg (base (Maxitrol)...... 37 equivalent)...... 7 neomycin-polymyxin-dexamethasone ophth susp NINLARO – ixazomib citrate cap 3 mg (base 0.1% (Maxitrol)...... 37 equivalent)...... 7 neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 37 NINLARO – ixazomib citrate cap 4 mg (base neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 equivalent)...... 7 unit/ml-1%...... 37 NITRO-BID – nitroglycerin oint 2%...... 13 neomycin sulfate tab 500 mg...... 2 nitrofurantoin macrocrystalline cap 25 mg NEULASTA ONPRO KIT – pegfilgrastim soln prefilled (Macrodantin)...... 23 syringe kit 6 mg/0.6ml...... 35 nitrofurantoin macrocrystalline cap 50 mg NEULASTA – pegfilgrastim soln prefilled syringe 6 (Macrodantin)...... 23 mg/0.6ml...... 35 nitrofurantoin macrocrystalline cap 100 mg NEUPOGEN – filgrastim inj 300 mcg/ml...... 35 (Macrodantin)...... 23 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ nitrofurantoin monohydrate macrocrystalline cap 100 ml)...... 36 mg (Macrobid)...... 23 NEUPOGEN – filgrastim soln prefilled syringe 300 nitrofurantoin susp 25 mg/5ml (Furadantin)...... 23 mcg/0.5ml...... 35 nitroglycerin sl tab 0.3 mg (Nitrostat)...... 13 NEUPOGEN – filgrastim soln prefilled syringe 480 nitroglycerin sl tab 0.4 mg (Nitrostat)...... 13 mcg/0.8ml (600 mcg/ml)...... 35 nitroglycerin sl tab 0.6 mg (Nitrostat)...... 13 nevirapine susp 50 mg/5ml (Viramune)...... 3 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)...... 13 nevirapine tab er 24hr 100 mg (Viramune xr)...... 3 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)...... 13 nevirapine tab er 24hr 400 mg (Viramune xr)...... 3 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)...... 13 nevirapine tab 200 mg (Viramune)...... 3 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)...... 13 NEXAVAR – sorafenib tosylate tab 200 mg (base NITYR – nitisinone tab 2 mg...... 12 equivalent)...... 7 NITYR – nitisinone tab 5 mg...... 12 NEXIUM – esomeprazole magnesium for delayed release NITYR – nitisinone tab 10 mg...... 12 susp packet 5 mg...... 22 norethindrone & ethinyl estradiol-fe chew tab 0.4 NEXIUM – esomeprazole magnesium for delayed release mg-35 mcg (Femcon fe)...... 9 susp packet 10 mg...... 22 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Brevicon-28)...... 9 susp packet 20 mg...... 22 norethindrone & ethinyl estradiol tab 1 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Norinyl 1+35)...... 9 susp packet 40 mg...... 22 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg NEXIUM – esomeprazole magnesium for delayed release (Ovcon-35)...... 9 susp pack 2.5 mg...... 22 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 niacin tab er 500 mg (antihyperlipidemic) mcg (Loestrin fe 1/20)...... 9 (Niaspan)...... 18 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 niacin tab er 750 mg (antihyperlipidemic) mcg (Loestrin fe 1.5/30)...... 9 (Niaspan)...... 18

PrimeChoice Accord Formulary, January 2018 61 2018 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap (Loestrin 1/20-21)...... 9 20-10 mg...... 29 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 NUVARING – etonogestrel-ethinyl estradiol va ring mcg (Loestrin 1.5/30-21)...... 9 0.120-0.015 mg/24hr...... 9 norethindrone acetate-ethinyl estradiol tab 1 mg-5 nystatin cream 100000 unit/gm...... 39 mcg...... 9 nystatin oint 100000 unit/gm...... 39 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 nystatin susp 100000 unit/ml...... 37 mcg (Femhrt low dose)...... 9 nystatin tab 500000 unit...... 3 norethindrone acetate tab 5 mg (Aygestin)...... 10 nystatin topical powder 100000 unit/gm...... 39 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 nystatin-triamcinolone cream 100000-0.1 unit/gm- mg-mcg (Estrostep fe)...... 9 %...... 39 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg- nystatin-triamcinolone oint 100000-0.1 unit/gm-%...... 39 ...... 9 mcg (Ortho-novum 7/7/7) O norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg- mcg (Tri-norinyl 28)...... 9 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) norethindrone tab 0.35 mg (Nor-qd)...... 9 (Sandostatin)...... 12 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Ortho-cyclen)...... 9 (Sandostatin)...... 12 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) mg-mcg (Ortho tri-cyclen)...... 9 (Sandostatin)...... 12 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) mg-mcg (Ortho tri-cyclen lo)...... 9 (Sandostatin)...... 12 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg...... 9 octreotide acetate inj 1000 mcg/ml (1 mg/ml) nortriptyline hcl cap 10 mg (Pamelor)...... 25 (Sandostatin)...... 12 nortriptyline hcl cap 25 mg (Pamelor)...... 25 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab nortriptyline hcl cap 50 mg (Pamelor)...... 25 200-25-25 mg...... 3 nortriptyline hcl cap 75 mg (Pamelor)...... 25 ODOMZO – sonidegib phosphate cap 200 mg (base NORTRIPTYLINE HCL – nortriptyline hcl soln 10 equivalent)...... 7 mg/5ml...... 25 ofloxacin ophth soln 0.3% (Ocuflox)...... 37 NORVIR – ritonavir oral soln 80 mg/ml...... 3 ofloxacin otic soln 0.3%...... 37 NORVIR – ritonavir powder packet 100 mg...... 3 ofloxacin tab 400 mg...... 2 NOVAREL – chorionic gonadotropin for im inj 10000 OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50 unit...... 12 mcg...... 10 NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp olanzapine orally disintegrating tab 5 mg (Zyprexa pen-inj 100 unit/ml (70-30)...... 11 zydis)...... 26 NOVOLIN 70/30 – insulin nph isophane & regular human olanzapine orally disintegrating tab 10 mg (Zyprexa inj 100 unit/ml (70-30)...... 11 zydis)...... 26 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ olanzapine orally disintegrating tab 15 mg (Zyprexa ml...... 11 zydis)...... 26 NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 11 olanzapine orally disintegrating tab 20 mg (Zyprexa NOVOLOG FLEXPEN – insulin aspart soln pen-injector zydis)...... 26 100 unit/ml...... 11 olanzapine tab 2.5 mg (Zyprexa)...... 26 NOVOLOG – insulin aspart inj 100 unit/ml...... 11 olanzapine tab 5 mg (Zyprexa)...... 26 NOVOLOG MIX 70/30 – insulin aspart prot & aspart olanzapine tab 7.5 mg (Zyprexa)...... 26 (human) inj 100 unit/ml (70-30)...... 11 olanzapine tab 10 mg (Zyprexa)...... 26 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & olanzapine tab 15 mg (Zyprexa)...... 26 aspart sus pen-inj 100 unit/ml (70-30)...... 11 olanzapine tab 20 mg (Zyprexa)...... 26 NOVOLOG PENFILL – insulin aspart soln cartridge 100 olmesartan medoxomil-hydrochlorothiazide tab unit/ml...... 11 20-12.5 mg (Benicar hct)...... 16 NOXAFIL – posaconazole susp 40 mg/ml...... 2 olmesartan medoxomil-hydrochlorothiazide tab NOXAFIL – posaconazole tab delayed release 100 mg...... 2 40-12.5 mg (Benicar hct)...... 17 NUCYNTA ER – tapentadol hcl tab er 12hr 50 mg...... 30 olmesartan medoxomil-hydrochlorothiazide tab 40-25 NUCYNTA ER – tapentadol hcl tab er 12hr 100 mg...... 30 mg (Benicar hct)...... 17 NUCYNTA ER – tapentadol hcl tab er 12hr 150 mg...... 30 olmesartan medoxomil tab 5 mg (Benicar)...... 16 NUCYNTA ER – tapentadol hcl tab er 12hr 200 mg...... 30 olmesartan medoxomil tab 20 mg (Benicar)...... 16 NUCYNTA ER – tapentadol hcl tab er 12hr 250 mg...... 30 olmesartan medoxomil tab 40 mg (Benicar)...... 16

PrimeChoice Accord Formulary, January 2018 62 2018 olopatadine hcl ophth soln 0.2% (base equivalent) oxycodone hcl cap 5 mg...... 30 (Pataday)...... 37 oxycodone hcl conc 100 mg/5ml (20 mg/ml) olopatadine hcl ophth soln 0.1% (base equivalent) (Oxycodone hcl)...... 30 (Patanol)...... 37 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...... 30 omeprazole cap delayed release 10 mg (Prilosec)...... 22 oxycodone hcl tab 10 mg...... 30 omeprazole cap delayed release 20 mg (Prilosec)...... 22 oxycodone hcl tab 20 mg...... 30 omeprazole cap delayed release 40 mg (Prilosec)...... 22 oxycodone hcl tab 5 mg (Roxicodone)...... 30 OMNITROPE – somatropin for inj 5.8 mg...... 12 oxycodone hcl tab 15 mg (Roxicodone)...... 30 OMNITROPE – somatropin inj 5 mg/1.5ml...... 12 oxycodone hcl tab 30 mg (Roxicodone)...... 30 OMNITROPE – somatropin inj 10 mg/1.5ml...... 12 oxycodone w/ acetaminophen tab 5-325 mg ondansetron hcl oral soln 4 mg/5ml (Zofran)...... 22 (Percocet)...... 30 ondansetron hcl tab 24 mg...... 22 oxycodone w/ acetaminophen tab 7.5-325 mg ondansetron hcl tab 4 mg (Zofran)...... 22 (Percocet)...... 30 ondansetron hcl tab 8 mg (Zofran)...... 22 oxycodone w/ acetaminophen tab 10-325 mg ondansetron orally disintegrating tab 4 mg (Zofran (Percocet)...... 30 odt)...... 22 OXYCONTIN – oxycodone hcl tab er 12hr deter 10 ondansetron orally disintegrating tab 8 mg (Zofran mg...... 30 odt)...... 22 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)...... 11 mg...... 30 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)...... 11 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 OPSUMIT – macitentan tab 10 mg...... 19 mg...... 30 ORACEA – doxycycline (rosacea) cap delayed release 40 OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg...... 39 mg...... 30 ORFADIN – nitisinone cap 2 mg...... 12 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 ORFADIN – nitisinone cap 5 mg...... 12 mg...... 30 ORFADIN – nitisinone cap 10 mg...... 12 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 ORFADIN – nitisinone cap 20 mg...... 12 mg...... 30 ORFADIN – nitisinone susp 4 mg/ml...... 12 OXYCONTIN – oxycodone hcl tab er 12hr deter 80 orphenadrine citrate tab er 12hr 100 mg...... 34 mg...... 30 oseltamivir phosphate cap 30 mg (base equiv) OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2 (Tamiflu)...... 3 mg/1.5ml)...... 11 oseltamivir phosphate cap 45 mg (base equiv) OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose (Tamiflu)...... 3 (2 mg/1.5ml)...... 11 oseltamivir phosphate cap 75 mg (base equiv) P (Tamiflu)...... 4 oseltamivir phosphate for susp 6 mg/ml (base equiv) pantoprazole sodium ec tab 20 mg (base equiv) (Tamiflu)...... 4 (Protonix)...... 22 OTEZLA – apremilast tab 30 mg...... 31 pantoprazole sodium ec tab 40 mg (base equiv) OTEZLA – apremilast tab starter therapy pack 10 mg & 20 (Protonix)...... 22 mg & 30 mg...... 31 paricalcitol cap 1 mcg (Zemplar)...... 12 OVIDREL – choriogonadotropin alfa inj 250 paricalcitol cap 2 mcg (Zemplar)...... 12 mcg/0.5ml...... 12 paricalcitol cap 4 mcg (Zemplar)...... 12 oxaprozin tab 600 mg (Daypro)...... 31 paromomycin sulfate cap 250 mg...... 2 oxcarbazepine susp 300 mg/5ml (60 mg/ml) paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)...... 25 (Trileptal)...... 33 paroxetine hcl tab er 24hr 25 mg (Paxil cr)...... 25 oxcarbazepine tab 150 mg (Trileptal)...... 33 paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)...... 25 oxcarbazepine tab 300 mg (Trileptal)...... 33 paroxetine hcl tab 10 mg (Paxil)...... 25 oxcarbazepine tab 600 mg (Trileptal)...... 33 paroxetine hcl tab 20 mg (Paxil)...... 25 oxybutynin chloride syrup 5 mg/5ml...... 23 paroxetine hcl tab 30 mg (Paxil)...... 25 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)...... 23 paroxetine hcl tab 40 mg (Paxil)...... 25 oxybutynin chloride tab er 24hr 10 mg (Ditropan PAZEO – olopatadine hcl ophth soln 0.7% (base xl)...... 23 equivalent)...... 37 oxybutynin chloride tab er 24hr 15 mg (Ditropan PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...... 4 xl)...... 23 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml...... 4 oxybutynin chloride tab 5 mg...... 23 PEGASYS PROCLICK – peginterferon alfa-2a inj 135 oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 30 mcg/0.5ml...... 4

PrimeChoice Accord Formulary, January 2018 63 2018

PEGASYS PROCLICK – peginterferon alfa-2a inj 180 pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 11 mcg/0.5ml...... 4 pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 11 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm piroxicam cap 10 mg (Feldene)...... 31 (Colyte-flavor packs)...... 21 piroxicam cap 20 mg (Feldene)...... 31 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm PLEGRIDY – peginterferon beta-1a soln pen-injector 125 (Golytely)...... 21 mcg/0.5ml...... 29 peg 3350-kcl-sod bicarb-nacl for soln 420 gm PLEGRIDY – peginterferon beta-1a soln prefilled syringe (Nulytely/flavor pack)...... 21 125 mcg/0.5ml...... 29 PENICILLIN V POTASSIUM – penicillin v potassium for PLEGRIDY STARTER PACK – peginterferon beta-1a soln soln 125 mg/5ml...... 1 pen-inj 63 & 94 mcg/0.5ml pack...... 29 PENICILLIN V POTASSIUM – penicillin v potassium for PLEGRIDY STARTER PACK – peginterferon beta-1a soln soln 250 mg/5ml...... 1 pref syr 63 & 94 mcg/0.5ml pack...... 29 penicillin v potassium tab 250 mg...... 1 podofilox soln 0.5% (Condylox)...... 39 penicillin v potassium tab 500 mg...... 1 polymyxin b-trimethoprim ophth soln 10000 unit/ pentoxifylline tab er 400 mg...... 36 ml-0.1% (Polytrim)...... 37 perindopril erbumine tab 2 mg...... 17 POMALYST – pomalidomide cap 1 mg...... 7 perindopril erbumine tab 4 mg (Aceon)...... 17 POMALYST – pomalidomide cap 2 mg...... 7 perindopril erbumine tab 8 mg (Aceon)...... 17 POMALYST – pomalidomide cap 3 mg...... 7 permethrin cream 5% (Elimite)...... 39 POMALYST – pomalidomide cap 4 mg...... 7 perphenazine tab 2 mg...... 26 potassium chloride cap er 8 meq (Micro-k)...... 35 perphenazine tab 4 mg...... 26 potassium chloride cap er 10 meq (Micro-k)...... 35 perphenazine tab 8 mg...... 26 POTASSIUM CHLORIDE ER – potassium chloride tab er perphenazine tab 16 mg...... 26 8 meq (600 mg)...... 35 phenelzine sulfate tab 15 mg (Nardil)...... 25 potassium chloride microencapsulated crys er tab 10 phenobarbital elixir 20 mg/5ml...... 27 meq...... 35 phenobarbital tab 15 mg...... 27 potassium chloride microencapsulated crys er tab 20 phenobarbital tab 16.2 mg...... 27 meq...... 35 phenobarbital tab 30 mg...... 27 potassium chloride oral soln 10% (20 meq/15ml)...... 35 phenobarbital tab 32.4 mg...... 27 potassium chloride oral soln 20% (40 meq/15ml)...... 35 phenobarbital tab 60 mg...... 27 potassium chloride powder packet 20 meq (K-lor phenobarbital tab 100 mg...... 27 hospital pack)...... 35 phenoxybenzamine hcl cap 10 mg (Dibenzyline)...... 17 potassium chloride tab er 10 meq (K-tab)...... 35 phenytoin chew tab 50 mg (Dilantin infatabs)...... 33 potassium chloride tab er 8 meq (600 mg)...... 35 phenytoin sodium extended cap 100 mg (Dilantin)...... 33 potassium citrate tab er 5 meq (540 mg) (Urocit-k phenytoin sodium extended cap 200 mg 5)...... 23 (Phenytek)...... 33 potassium citrate tab er 10 meq (1080 mg) (Urocit-k phenytoin sodium extended cap 300 mg 10)...... 23 (Phenytek)...... 33 potassium citrate tab er 15 meq (1620 mg) (Urocit-k phenytoin susp 125 mg/5ml (Dilantin)...... 33 15)...... 23 phytonadione tab 5 mg (Mephyton)...... 34 pot phos monobasic w/sod phos di & monobas tab PICATO – ingenol mebutate gel 0.015%...... 39 155-852-130mg (K-phos neutral)...... 35 PICATO – ingenol mebutate gel 0.05%...... 39 pramipexole dihydrochloride tab 0.125 mg pilocarpine hcl ophth soln 1% (Isopto carpine)...... 37 (Mirapex)...... 34 pilocarpine hcl ophth soln 2% (Isopto carpine)...... 37 pramipexole dihydrochloride tab 0.25 mg pilocarpine hcl ophth soln 4% (Isopto carpine)...... 37 (Mirapex)...... 34 pilocarpine hcl tab 5 mg (Salagen)...... 37 pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 34 pilocarpine hcl tab 7.5 mg (Salagen)...... 38 pramipexole dihydrochloride tab 0.75 mg pimozide tab 1 mg (Orap)...... 29 (Mirapex)...... 34 pimozide tab 2 mg (Orap)...... 29 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 34 pindolol tab 5 mg...... 13 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 34 pindolol tab 10 mg...... 13 prasugrel hcl tab 5 mg (base equiv) (Effient)...... 36 pioglitazone hcl-metformin hcl tab 15-500 mg prasugrel hcl tab 10 mg (base equiv) (Effient)...... 36 (Actoplus met)...... 11 pravastatin sodium tab 10 mg...... 18 pioglitazone hcl-metformin hcl tab 15-850 mg pravastatin sodium tab 20 mg (Pravachol)...... 18 (Actoplus met)...... 11 pravastatin sodium tab 40 mg (Pravachol)...... 18 pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 11 pravastatin sodium tab 80 mg (Pravachol)...... 18

PrimeChoice Accord Formulary, January 2018 64 2018 praziquantel tab 600 mg (Biltricide)...... 4 PREZISTA – darunavir ethanolate susp 100 mg/ml (base prazosin hcl cap 1 mg (Minipress)...... 17 equiv)...... 4 prazosin hcl cap 2 mg (Minipress)...... 17 PREZISTA – darunavir ethanolate tab 75 mg (base prazosin hcl cap 5 mg (Minipress)...... 17 equiv)...... 4 prednisolone acetate ophth susp 1% (Pred forte)...... 37 PREZISTA – darunavir ethanolate tab 150 mg (base PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp equiv)...... 4 solution equivalent)...... 8 PREZISTA – darunavir ethanolate tab 600 mg (base prednisolone sod phosphate oral soln 15 mg/5ml equiv)...... 4 (base equiv) (Orapred)...... 8 PREZISTA – darunavir ethanolate tab 800 mg (base prednisolone sod phosph oral soln 6.7 mg/5ml (5 equiv)...... 4 mg/5ml base) (Pediapred)...... 8 PRIFTIN – rifapentine tab 150 mg...... 2 PREDNISONE – prednisone oral soln 5 mg/5ml...... 8 PRIMAQUINE PHOSPHATE – primaquine phosphate tab PREDNISONE – prednisone tab 50 mg...... 8 26.3 mg (15 mg base)...... 4 PREDNISONE – prednisone tab therapy pack 5 mg primidone tab 50 mg (Mysoline)...... 33 (21)...... 8 primidone tab 250 mg (Mysoline)...... 33 PREDNISONE – prednisone tab therapy pack 5 mg PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (48)...... 8 (90mcg base equiv)...... 21 PREDNISONE – prednisone tab therapy pack 10 mg PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 (21)...... 8 mcg/act (90 mcg base equiv)...... 21 PREDNISONE – prednisone tab therapy pack 10 mg probenecid tab 500 mg...... 32 (48)...... 8 prochlorperazine maleate tab 5 mg (base equivalent) prednisone tab 1 mg...... 8 (Compazine)...... 26 prednisone tab 2.5 mg...... 8 prochlorperazine maleate tab 10 mg (base equivalent) prednisone tab 5 mg...... 8 (Compazine)...... 26 prednisone tab 10 mg...... 8 prochlorperazine suppos 25 mg...... 26 prednisone tab 20 mg...... 8 PROCRIT – epoetin alfa inj 2000 unit/ml...... 36 PREGNYL W/DILUENT BENZYL – chorionic gonadotropin PROCRIT – epoetin alfa inj 3000 unit/ml...... 36 for im inj 10000 unit...... 12 PROCRIT – epoetin alfa inj 4000 unit/ml...... 36 PREMARIN – estrogens, conjugated tab 0.3 mg...... 9 PROCRIT – epoetin alfa inj 10000 unit/ml...... 36 PREMARIN – estrogens, conjugated tab 0.45 mg...... 9 PROCRIT – epoetin alfa inj 20000 unit/ml...... 36 PREMARIN – estrogens, conjugated tab 0.625 mg...... 9 PROCRIT – epoetin alfa inj 40000 unit/ml...... 36 PREMARIN – estrogens, conjugated tab 0.9 mg...... 9 progesterone micronized cap 100 mg PREMARIN – estrogens, conjugated tab 1.25 mg...... 9 (Prometrium)...... 10 PREMPHASE – conj est 0.625(14)/conj est-medroxypro progesterone micronized cap 200 mg ac tab 0.625-5mg(14)...... 9 (Prometrium)...... 10 PREMPRO – conjugated estrogen-medroxyprogest PROLIA – denosumab inj 60 mg/ml...... 12 acetate tab 0.3-1.5 mg...... 9 promethazine hcl suppos 12.5 mg...... 19 PREMPRO – conjugated estrogen-medroxyprogest promethazine hcl suppos 25 mg...... 19 acetate tab 0.45-1.5 mg...... 9 promethazine hcl suppos 50 mg...... 19 PREMPRO – conjugated estrogen-medroxyprogest promethazine hcl syrup 6.25 mg/5ml...... 19 acetate tab 0.625-2.5 mg...... 9 promethazine hcl tab 12.5 mg...... 19 PREMPRO – conjugated estrogen-medroxyprogest promethazine hcl tab 25 mg...... 19 acetate tab 0.625-5 mg...... 9 promethazine hcl tab 50 mg...... 19 PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1 propafenone hcl cap er 12hr 225 mg (Rythmol sr)...... 15 mg...... 34 propafenone hcl cap er 12hr 325 mg (Rythmol sr)...... 15 PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa propafenone hcl cap er 12hr 425 mg (Rythmol sr)...... 15 tab 29-1 mg...... 34 propafenone hcl tab 300 mg...... 15 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab propafenone hcl tab 150 mg (Rythmol)...... 15 29-1 mg...... 34 propafenone hcl tab 225 mg (Rythmol)...... 15 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab PROPANTHELINE BROMIDE – propantheline bromide 29-1 mg...... 34 tab 15 mg...... 22 PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap PROPRANOLOL/HYDROCHLOROTH – propranolol & 106.5-1 mg...... 34 hydrochlorothiazide tab 40-25 mg...... 17 PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe PROPRANOLOL/HYDROCHLOROTH – propranolol & fumarate-fa tab 27-1 mg...... 34 hydrochlorothiazide tab 80-25 mg...... 17 PREZCOBIX – darunavir-cobicistat tab 800-150 mg...... 4 propranolol hcl cap er 24hr 60 mg (Inderal la)...... 13

PrimeChoice Accord Formulary, January 2018 65 2018 propranolol hcl cap er 24hr 80 mg (Inderal la)...... 13 ramipril cap 1.25 mg (Altace)...... 17 propranolol hcl cap er 24hr 120 mg (Inderal la)...... 14 ramipril cap 2.5 mg (Altace)...... 17 propranolol hcl cap er 24hr 160 mg (Inderal la)...... 14 ramipril cap 5 mg (Altace)...... 17 PROPRANOLOL HCL – propranolol hcl oral soln 20 ramipril cap 10 mg (Altace)...... 17 mg/5ml...... 13 ranitidine hcl cap 150 mg...... 22 PROPRANOLOL HCL – propranolol hcl oral soln 40 ranitidine hcl cap 300 mg...... 22 mg/5ml...... 13 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 22 propranolol hcl tab 10 mg...... 14 ranitidine hcl tab 150 mg (Zantac)...... 22 propranolol hcl tab 20 mg...... 14 ranitidine hcl tab 300 mg (Zantac)...... 22 propranolol hcl tab 40 mg...... 14 RAPAMUNE – sirolimus oral soln 1 mg/ml...... 40 propranolol hcl tab 60 mg...... 14 rasagiline mesylate tab 0.5 mg (base equiv) propranolol hcl tab 80 mg...... 14 (Azilect)...... 34 propylthiouracil tab 50 mg...... 12 rasagiline mesylate tab 1 mg (base equiv) (Azilect)..... 34 PULMOZYME – dornase alfa inhal soln 1 mg/ml...... 21 REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ (12mu/ml)...... 29 ml)...... 7 REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml pyrazinamide tab 500 mg...... 2 (24mu/ml)...... 29 pyridostigmine bromide tab 60 mg (Mestinon)...... 34 REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml)...... 29 Q REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 quetiapine fumarate tab er 24hr 50 mg (Seroquel mcg/0.5ml (24mu/ml)...... 29 xr)...... 26 REBIF REBIDOSE TITRATION – interferon beta-1a auto- quetiapine fumarate tab er 24hr 150 mg (Seroquel inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 29 xr)...... 26 REBIF TITRATION PACK – interferon beta-1a pref syr quetiapine fumarate tab er 24hr 200 mg (Seroquel 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 29 xr)...... 26 repaglinide tab 0.5 mg (Prandin)...... 11 quetiapine fumarate tab er 24hr 300 mg (Seroquel repaglinide tab 1 mg (Prandin)...... 11 xr)...... 26 repaglinide tab 2 mg (Prandin)...... 11 quetiapine fumarate tab er 24hr 400 mg (Seroquel REPATHA – evolocumab subcutaneous soln prefilled xr)...... 26 syringe 140 mg/ml...... 18 quetiapine fumarate tab 25 mg (Seroquel)...... 26 REPATHA PUSHTRONEX SYSTEM – evolocumab quetiapine fumarate tab 50 mg (Seroquel)...... 26 subcutaneous soln cartridge/infusor 420 mg/3.5ml...... 18 quetiapine fumarate tab 100 mg (Seroquel)...... 26 REPATHA SURECLICK – evolocumab subcutaneous soln quetiapine fumarate tab 200 mg (Seroquel)...... 26 auto-injector 140 mg/ml...... 18 quetiapine fumarate tab 300 mg (Seroquel)...... 26 RETACRIT – epoetin alfa-epbx inj 2000 unit/ml...... 36 quetiapine fumarate tab 400 mg (Seroquel)...... 26 RETACRIT – epoetin alfa-epbx inj 3000 unit/ml...... 36 quinapril hcl tab 5 mg (Accupril)...... 17 RETACRIT – epoetin alfa-epbx inj 4000 unit/ml...... 36 quinapril hcl tab 10 mg (Accupril)...... 17 RETACRIT – epoetin alfa-epbx inj 10000 unit/ml...... 36 quinapril hcl tab 20 mg (Accupril)...... 17 RETACRIT – epoetin alfa-epbx inj 40000 unit/ml...... 36 quinapril hcl tab 40 mg (Accupril)...... 17 REVLIMID – lenalidomide cap 5 mg...... 40 quinapril-hydrochlorothiazide tab 10-12.5 mg REVLIMID – lenalidomide cap 10 mg...... 40 (Accuretic)...... 17 REVLIMID – lenalidomide cap 15 mg...... 40 quinapril-hydrochlorothiazide tab 20-12.5 mg REVLIMID – lenalidomide cap 20 mg...... 40 (Accuretic)...... 17 REVLIMID – lenalidomide cap 25 mg...... 40 quinapril-hydrochlorothiazide tab 20-25 mg REVLIMID – lenalidomide caps 2.5 mg...... 40 (Accuretic)...... 17 ribavirin cap 200 mg (Rebetol)...... 4 quinidine gluconate tab er 324 mg...... 15 ribavirin tab 200 mg (Copegus)...... 4 QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 15 rifabutin cap 150 mg (Mycobutin)...... 2 QUINIDINE SULFATE – quinidine sulfate tab 300 mg...... 15 rifampin cap 150 mg (Rifadin)...... 2 QVAR REDIHALER – beclomethasone diprop hfa breath rifampin cap 300 mg (Rifadin)...... 2 act inh aer 40 mcg/act...... 21 riluzole tab 50 mg (Rilutek)...... 34 QVAR REDIHALER – beclomethasone diprop hfa breath risedronate sodium tab 5 mg (Actonel)...... 13 act inh aer 80 mcg/act...... 21 risedronate sodium tab 30 mg (Actonel)...... 13 R risedronate sodium tab 35 mg (Actonel)...... 13 risedronate sodium tab 150 mg (Actonel)...... 13 raloxifene hcl tab 60 mg (Evista)...... 13

PrimeChoice Accord Formulary, January 2018 66 2018

RISPERIDONE ODT – risperidone orally disintegrating tab SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 0.25 mg...... 26 mg...... 34 risperidone orally disintegrating tab 0.5 mg (Risperdal SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab m-tab)...... 26 29-1 mg...... 34 risperidone orally disintegrating tab 1 mg (Risperdal SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)...... 13 m-tab)...... 26 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)...... 13 risperidone orally disintegrating tab 2 mg (Risperdal SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)...... 13 m-tab)...... 26 SEREVENT DISKUS – salmeterol xinafoate aer pow ba risperidone orally disintegrating tab 3 mg (Risperdal 50 mcg/dose (base equiv)...... 21 m-tab)...... 26 sertraline hcl oral concentrate for solution 20 mg/ml risperidone orally disintegrating tab 4 mg (Risperdal (Zoloft)...... 25 m-tab)...... 26 sertraline hcl tab 25 mg (Zoloft)...... 25 risperidone soln 1 mg/ml (Risperdal)...... 26 sertraline hcl tab 50 mg (Zoloft)...... 25 risperidone tab 0.25 mg (Risperdal)...... 26 sertraline hcl tab 100 mg (Zoloft)...... 25 risperidone tab 0.5 mg (Risperdal)...... 26 sevelamer carbonate packet 0.8 gm (Renvela)...... 23 risperidone tab 1 mg (Risperdal)...... 26 sevelamer carbonate packet 2.4 gm (Renvela)...... 23 risperidone tab 2 mg (Risperdal)...... 26 sevelamer carbonate tab 800 mg (Renvela)...... 23 risperidone tab 3 mg (Risperdal)...... 26 sildenafil citrate tab 20 mg (Revatio)...... 19 risperidone tab 4 mg (Risperdal)...... 26 silver sulfadiazine cream 1% (Silvadene)...... 39 ritonavir tab 100 mg (Norvir)...... 4 SIMBRINZA – brinzolamide-brimonidine tartrate ophth rivastigmine tartrate cap 1.5 mg (base equivalent)...... 29 susp 1-0.2%...... 37 rivastigmine tartrate cap 3 mg (base equivalent)...... 29 SIMPONI – golimumab subcutaneous soln auto-injector rivastigmine tartrate cap 4.5 mg (base equivalent)...... 29 50 mg/0.5ml...... 31 rivastigmine tartrate cap 6 mg (base equivalent)...... 29 SIMPONI – golimumab subcutaneous soln auto-injector rizatriptan benzoate oral disintegrating tab 5 mg (base 100 mg/ml...... 32 eq) (Maxalt-mlt)...... 32 SIMPONI – golimumab subcutaneous soln prefilled rizatriptan benzoate oral disintegrating tab 10 mg syringe 50 mg/0.5ml...... 32 (base eq) (Maxalt-mlt)...... 32 SIMPONI – golimumab subcutaneous soln prefilled rizatriptan benzoate tab 5 mg (base equivalent) syringe 100 mg/ml...... 32 (Maxalt)...... 32 simvastatin tab 5 mg (Zocor)...... 19 rizatriptan benzoate tab 10 mg (base equivalent) simvastatin tab 10 mg (Zocor)...... 19 (Maxalt)...... 32 simvastatin tab 20 mg (Zocor)...... 19 ropinirole hydrochloride tab 0.25 mg (Requip)...... 34 simvastatin tab 40 mg (Zocor)...... 19 ropinirole hydrochloride tab 0.5 mg (Requip)...... 34 simvastatin tab 80 mg (Zocor)...... 19 ropinirole hydrochloride tab 1 mg (Requip)...... 34 sirolimus tab 0.5 mg (Rapamune)...... 40 ropinirole hydrochloride tab 2 mg (Requip)...... 34 sirolimus tab 1 mg (Rapamune)...... 40 ropinirole hydrochloride tab 3 mg (Requip)...... 34 sirolimus tab 2 mg (Rapamune)...... 40 ropinirole hydrochloride tab 4 mg (Requip)...... 34 SIVEXTRO – tedizolid phosphate tab 200 mg...... 5 ropinirole hydrochloride tab 5 mg (Requip)...... 34 SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 rosuvastatin calcium tab 5 mg (Crestor)...... 18 mg total)...... 10 rosuvastatin calcium tab 10 mg (Crestor)...... 19 sodium citrate & citric acid soln 500-334 mg/5ml rosuvastatin calcium tab 20 mg (Crestor)...... 19 (Shohls solution modi)...... 23 rosuvastatin calcium tab 40 mg (Crestor)...... 19 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) RYDAPT – midostaurin cap 25 mg...... 7 (Luride)...... 35 S sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)...... 35 SABRIL – vigabatrin tab 500 mg...... 33 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) SANDOSTATIN LAR DEPOT – octreotide acetate for im (Luride)...... 35 inj kit 10 mg...... 13 sodium fluoride cream 1.1% (Prevident 5000 plus)...... 38 SANDOSTATIN LAR DEPOT – octreotide acetate for im sodium fluoride gel 1.1% (0.5% f) (Prevident inj kit 20 mg...... 13 fluoride)...... 38 SANDOSTATIN LAR DEPOT – octreotide acetate for im SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from inj kit 30 mg...... 13 1.1 mg naf)...... 35 selegiline hcl cap 5 mg (Eldepryl)...... 34 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from selegiline hcl tab 5 mg...... 34 2.2 mg naf)...... 35 selenium sulfide lotion 2.5%...... 39

PrimeChoice Accord Formulary, January 2018 67 2018 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ naf)...... 35 ml...... 13 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) STRENSIQ – asfotase alfa subcutaneous inj 80 (Luride)...... 35 mg/0.8ml...... 13 sodium polystyrene sulfonate oral susp 15 gm/60ml SUBOXONE – buprenorphine hcl-naloxone hcl sl film (Sps)...... 40 2-0.5 mg (base equiv)...... 40 sodium polystyrene sulfonate powder SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 (Kayexalate)...... 40 mg (base equiv)...... 41 SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 equivalent)...... 7 mg (base equiv)...... 41 SOOLANTRA – ivermectin cream 1%...... 39 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 sotalol hcl (afib/afl) tab 80 mg (Betapace af)...... 14 mg (base equiv)...... 41 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...... 14 sucralfate tab 1 gm (Carafate)...... 22 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...... 14 sulfacetamide sodium lotion 10% (acne) (Klaron)...... 39 sotalol hcl tab 240 mg...... 14 sulfacetamide sodium ophth soln 10% (Bleph-10)...... 37 sotalol hcl tab 80 mg (Betapace)...... 14 sulfacetamide sodium-prednisolone ophth soln sotalol hcl tab 120 mg (Betapace)...... 14 10-0.23(0.25)%...... 37 sotalol hcl tab 160 mg (Betapace)...... 14 SULFADIAZINE – sulfadiazine tab 500 mg...... 2 SOVALDI – sofosbuvir tab 400 mg...... 4 sulfamethoxazole-trimethoprim susp 200-40 SPIRIVA HANDIHALER – tiotropium bromide mg/5ml...... 5 monohydrate inhal cap 18 mcg (base equiv)...... 21 sulfamethoxazole-trimethoprim tab 400-80 mg SPIRIVA RESPIMAT – tiotropium bromide monohydrate (Bactrim)...... 5 inhal aerosol 1.25 mcg/act...... 21 sulfamethoxazole-trimethoprim tab 800-160 mg SPIRIVA RESPIMAT – tiotropium bromide monohydrate (Bactrim ds)...... 5 inhal aerosol 2.5 mcg/act...... 21 sulfasalazine tab delayed release 500 mg (Azulfidine spironolactone & hydrochlorothiazide tab 25-25 mg en-tabs)...... 23 (Aldactazide)...... 18 sulfasalazine tab 500 mg (Azulfidine)...... 23 spironolactone tab 25 mg (Aldactone)...... 18 sulindac tab 150 mg...... 32 spironolactone tab 50 mg (Aldactone)...... 18 sulindac tab 200 mg...... 32 spironolactone tab 100 mg (Aldactone)...... 18 sumatriptan nasal spray 5 mg/act (Imitrex)...... 32 SPORANOX – itraconazole oral soln 10 mg/ml...... 3 sumatriptan nasal spray 20 mg/act (Imitrex)...... 32 SPRYCEL – dasatinib tab 20 mg...... 7 sumatriptan succinate inj 6 mg/0.5ml (Imitrex statdose SPRYCEL – dasatinib tab 50 mg...... 7 ref)...... 32 SPRYCEL – dasatinib tab 70 mg...... 7 sumatriptan succinate solution auto-injector 4 SPRYCEL – dasatinib tab 80 mg...... 7 mg/0.5ml (Imitrex statdose sys)...... 32 SPRYCEL – dasatinib tab 100 mg...... 7 sumatriptan succinate solution auto-injector 6 SPRYCEL – dasatinib tab 140 mg...... 7 mg/0.5ml (Imitrex statdose sys)...... 32 stavudine cap 15 mg (Zerit)...... 4 sumatriptan succinate solution cartridge 4 mg/0.5ml stavudine cap 20 mg (Zerit)...... 4 (Imitrex statdose ref)...... 32 stavudine cap 30 mg (Zerit)...... 4 sumatriptan succinate solution cartridge 6 mg/0.5ml stavudine cap 40 mg (Zerit)...... 4 (Imitrex statdose ref)...... 32 STELARA – ustekinumab inj 45 mg/0.5ml...... 39 sumatriptan succinate tab 25 mg (Imitrex)...... 32 STELARA – ustekinumab soln prefilled syringe 45 sumatriptan succinate tab 50 mg (Imitrex)...... 32 mg/0.5ml...... 39 sumatriptan succinate tab 100 mg (Imitrex)...... 32 STELARA – ustekinumab soln prefilled syringe 90 mg/ SUPRAX – cefixime cap 400 mg...... 1 ml...... 39 SUPRAX – cefixime chew tab 100 mg...... 1 STIMATE – desmopressin acetate nasal soln 1.5 mg/ SUPRAX – cefixime chew tab 200 mg...... 1 ml...... 13 SUPRAX – cefixime for susp 500 mg/5ml...... 1 STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero SUTENT – sunitinib malate cap 12.5 mg (base soln 2.5-2.5 mcg/act...... 21 equivalent)...... 7 STIVARGA – regorafenib tab 40 mg...... 7 SUTENT – sunitinib malate cap 25 mg (base STRENSIQ – asfotase alfa subcutaneous inj 18 equivalent)...... 7 mg/0.45ml...... 13 SUTENT – sunitinib malate cap 37.5 mg (base STRENSIQ – asfotase alfa subcutaneous inj 28 equivalent)...... 7 mg/0.7ml...... 13 SUTENT – sunitinib malate cap 50 mg (base equivalent)...... 7

PrimeChoice Accord Formulary, January 2018 68 2018

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg...... 7 tamsulosin hcl cap 0.4 mg (Flomax)...... 23 SYLATRON – peginterferon alfa-2b for inj kit 300 mcg...... 7 TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 7 SYLATRON – peginterferon alfa-2b for inj kit 600 mcg...... 7 TARCEVA – erlotinib hcl tab 100 mg (base equivalent)...... 7 SYMBICORT – budesonide-formoterol fumarate dihyd TARCEVA – erlotinib hcl tab 150 mg (base equivalent)...... 7 aerosol 80-4.5 mcg/act...... 21 TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 7 SYMBICORT – budesonide-formoterol fumarate dihyd TASIGNA – nilotinib hcl cap 150 mg (base equivalent)...... 7 aerosol 160-4.5 mcg/act...... 21 TASIGNA – nilotinib hcl cap 200 mg (base equivalent)...... 7 SYMFI – efavirenz-lamivudine-tenofovir df tab tazarotene cream 0.1% (Tazorac)...... 39 600-300-300 mg...... 4 TAZORAC – tazarotene cream 0.05%...... 40 SYMFI LO – efavirenz-lamivudine-tenofovir df tab TAZORAC – tazarotene gel 0.05%...... 40 400-300-300 mg...... 4 TAZORAC – tazarotene gel 0.1%...... 40 SYNAGIS – palivizumab im soln 50 mg/0.5ml...... 5 TECFIDERA – dimethyl fumarate capsule delayed release SYNAGIS – palivizumab im soln 100 mg/ml...... 5 120 mg...... 29 SYNJARDY – empagliflozin-metformin hcl tab 5-500 TECFIDERA – dimethyl fumarate capsule delayed release mg...... 11 240 mg...... 29 SYNJARDY – empagliflozin-metformin hcl tab 5-1000 TECFIDERA STARTER PACK – dimethyl fumarate mg...... 11 capsule dr starter pack 120 mg & 240 mg...... 29 SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 telmisartan-hydrochlorothiazide tab 40-12.5 mg mg...... 11 (Micardis hct)...... 17 SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000 telmisartan-hydrochlorothiazide tab 80-12.5 mg mg...... 11 (Micardis hct)...... 17 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr telmisartan-hydrochlorothiazide tab 80-25 mg 5-1000 mg...... 11 (Micardis hct)...... 17 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr telmisartan tab 20 mg (Micardis)...... 17 10-1000 mg...... 11 telmisartan tab 40 mg (Micardis)...... 17 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr telmisartan tab 80 mg (Micardis)...... 17 12.5-1000 mg...... 11 temazepam cap 7.5 mg (Restoril)...... 27 SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr temazepam cap 15 mg (Restoril)...... 27 25-1000 mg...... 11 temazepam cap 22.5 mg (Restoril)...... 27 SYNVISC – hylan intra-articular solution prefilled syringe temazepam cap 30 mg (Restoril)...... 27 16 mg/2ml...... 34 temozolomide cap 5 mg (Temodar)...... 7 SYNVISC ONE – hylan intra-articular solution prefilled temozolomide cap 20 mg (Temodar)...... 7 syringe 48 mg/6ml...... 34 temozolomide cap 100 mg (Temodar)...... 7 ...... 7 T temozolomide cap 140 mg (Temodar) temozolomide cap 180 mg (Temodar)...... 7 TABLOID – thioguanine tab 40 mg...... 7 temozolomide cap 250 mg (Temodar)...... 7 tacrolimus cap 0.5 mg (Prograf)...... 41 TENCON – butalbital-acetaminophen tab 50-325 mg...... 29 tacrolimus cap 1 mg (Prograf)...... 41 tenofovir disoproxil fumarate tab 300 mg (Viread)...... 4 tacrolimus cap 5 mg (Prograf)...... 41 terazosin hcl cap 1 mg (base equivalent)...... 17 tacrolimus oint 0.03% (Protopic)...... 39 terazosin hcl cap 2 mg (base equivalent)...... 17 tacrolimus oint 0.1% (Protopic)...... 39 terazosin hcl cap 5 mg (base equivalent)...... 17 tadalafil tab 2.5 mg (Cialis)...... 19 terazosin hcl cap 10 mg (base equivalent)...... 17 tadalafil tab 5 mg (Cialis)...... 19 terbinafine hcl tab 250 mg (Lamisil)...... 3 tadalafil tab 10 mg (Cialis)...... 19 terbutaline sulfate tab 2.5 mg...... 21 tadalafil tab 20 mg (Cialis)...... 19 terbutaline sulfate tab 5 mg...... 21 tadalafil tab 20 mg (pah) (Adcirca)...... 19 TERCONAZOLE – terconazole vaginal cream 0.8%...... 23 TAFINLAR – dabrafenib mesylate cap 50 mg (base terconazole vaginal cream 0.4% (Terazol 7)...... 23 equivalent)...... 7 terconazole vaginal suppos 80 mg (Terazol 3)...... 23 TAFINLAR – dabrafenib mesylate cap 75 mg (base testosterone cypionate im inj in oil 100 mg/ml (Depo- equivalent)...... 7 testosterone)...... 8 TAGRISSO – osimertinib mesylate tab 40 mg (base testosterone cypionate im inj in oil 200 mg/ml (Depo- equivalent)...... 7 testosterone)...... 8 TAGRISSO – osimertinib mesylate tab 80 mg (base testosterone enanthate im inj in oil 200 mg/ml...... 8 equivalent)...... 7 testosterone td gel 12.5 mg/act (1%) (Androgel tamoxifen citrate tab 10 mg (base equivalent)...... 7 pump)...... 8 tamoxifen citrate tab 20 mg (base equivalent)...... 7

PrimeChoice Accord Formulary, January 2018 69 2018 testosterone td gel 20.25 mg/act (1.62%) (Androgel torsemide tab 5 mg (Demadex)...... 18 pump)...... 8 torsemide tab 10 mg (Demadex)...... 18 testosterone td gel 25 mg/2.5gm (1%) (Androgel)...... 8 torsemide tab 20 mg (Demadex)...... 18 testosterone td gel 50 mg/5gm (1%) (Androgel)...... 8 torsemide tab 100 mg (Demadex)...... 18 testosterone td gel 20.25 mg/1.25gm (1.62%) TOUJEO MAX SOLOSTAR – insulin glargine soln pen- (Androgel)...... 8 injector 300 unit/ml...... 11 testosterone td gel 40.5 mg/2.5gm (1.62%) TOUJEO SOLOSTAR – insulin glargine soln pen-injector (Androgel)...... 8 300 unit/ml...... 11 testosterone td soln 30 mg/act (Axiron)...... 8 TRACLEER – bosentan tab for oral susp 32 mg...... 19 tetrabenazine tab 12.5 mg (Xenazine)...... 29 TRACLEER – bosentan tab 62.5 mg...... 19 tetrabenazine tab 25 mg (Xenazine)...... 29 TRACLEER – bosentan tab 125 mg...... 19 tetracycline hcl cap 250 mg (Tetracycline hcl)...... 2 tramadol-acetaminophen tab 37.5-325 mg tetracycline hcl cap 500 mg (Tetracycline hcl)...... 2 (Ultracet)...... 31 THALOMID – thalidomide cap 50 mg...... 41 tramadol hcl tab er 24hr 100 mg...... 30 THALOMID – thalidomide cap 100 mg...... 41 tramadol hcl tab er 24hr 200 mg...... 30 THALOMID – thalidomide cap 150 mg...... 41 tramadol hcl tab er 24hr 300 mg...... 30 THALOMID – thalidomide cap 200 mg...... 41 tramadol hcl tab 50 mg (Ultram)...... 31 theophylline tab er 12hr 100 mg...... 21 trandolapril tab 1 mg (Mavik)...... 17 theophylline tab er 12hr 200 mg...... 21 trandolapril tab 2 mg (Mavik)...... 17 theophylline tab er 12hr 300 mg...... 21 trandolapril tab 4 mg (Mavik)...... 17 theophylline tab er 12hr 450 mg...... 21 tranylcypromine sulfate tab 10 mg (Parnate)...... 25 theophylline tab er 24hr 400 mg...... 21 TRAVATAN Z – travoprost ophth soln 0.004% theophylline tab er 24hr 600 mg...... 21 (benzalkonium free) (bak free)...... 37 thiothixene cap 1 mg...... 26 trazodone hcl tab 50 mg...... 25 thiothixene cap 2 mg...... 26 trazodone hcl tab 100 mg...... 25 thiothixene cap 5 mg...... 26 trazodone hcl tab 150 mg...... 25 thiothixene cap 10 mg...... 26 trazodone hcl tab 300 mg...... 25 TIMOLOL MALEATE OPHTHALMI – timolol maleate ophth TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol gel forming soln 0.25%...... 37 aepb 100-62.5-25 mcg/inh...... 21 TIMOLOL MALEATE OPHTHALMI – timolol maleate ophth TRESIBA FLEXTOUCH – insulin degludec soln pen- gel forming soln 0.5%...... 37 injector 100 unit/ml...... 11 timolol maleate ophth soln 0.25% (Timoptic)...... 37 TRESIBA FLEXTOUCH – insulin degludec soln pen- timolol maleate ophth soln 0.5% (Timoptic)...... 37 injector 200 unit/ml...... 11 TIMOLOL MALEATE – timolol maleate tab 5 mg...... 14 tretinoin cap 10 mg...... 7 TIMOLOL MALEATE – timolol maleate tab 10 mg...... 14 tretinoin cream 0.025% (Retin-a)...... 40 TIMOLOL MALEATE – timolol maleate tab 20 mg...... 14 tretinoin cream 0.05% (Retin-a)...... 40 TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 4 tretinoin cream 0.1% (Retin-a)...... 40 TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 4 tretinoin gel 0.025%, NF = Avita (Retin-a)...... 40 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 4 tretinoin gel 0.01% (Retin-a)...... 40 tizanidine hcl tab 2 mg (base equivalent)...... 34 tretinoin microsphere gel 0.04% (Retin-a micro)...... 40 tizanidine hcl tab 4 mg (base equivalent) tretinoin microsphere gel 0.1% (Retin-a micro)...... 40 (Zanaflex)...... 34 triamcinolone acetonide cream 0.025%...... 40 tobramycin-dexamethasone ophth susp 0.3-0.1% triamcinolone acetonide cream 0.1%...... 40 (Tobradex)...... 37 triamcinolone acetonide cream 0.5%...... 40 tobramycin nebu soln 300 mg/5ml (Tobi)...... 2 triamcinolone acetonide dental paste 0.1%...... 38 tobramycin ophth soln 0.3% (Tobrex)...... 37 triamcinolone acetonide lotion 0.025%...... 40 tolterodine tartrate cap er 24hr 2 mg (Detrol la)...... 23 triamcinolone acetonide lotion 0.1%...... 40 tolterodine tartrate cap er 24hr 4 mg (Detrol la)...... 23 triamcinolone acetonide oint 0.025%...... 40 tolterodine tartrate tab 1 mg (Detrol)...... 23 triamcinolone acetonide oint 0.1%...... 40 tolterodine tartrate tab 2 mg (Detrol)...... 23 triamcinolone acetonide oint 0.5%...... 40 topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 33 triamterene & hydrochlorothiazide cap 37.5-25 mg topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 33 (Dyazide)...... 18 topiramate tab 25 mg (Topamax)...... 33 triamterene & hydrochlorothiazide tab 37.5-25 mg topiramate tab 50 mg (Topamax)...... 33 (Maxzide-25)...... 18 topiramate tab 100 mg (Topamax)...... 33 triamterene & hydrochlorothiazide tab 75-50 mg topiramate tab 200 mg (Topamax)...... 33 (Maxzide)...... 18

PrimeChoice Accord Formulary, January 2018 70 2018 trifluoperazine hcl tab 1 mg (base equivalent)...... 26 valproate sodium oral soln 250 mg/5ml (base equiv) trifluoperazine hcl tab 2 mg (base equivalent)...... 26 (Depakene)...... 33 trifluoperazine hcl tab 5 mg (base equivalent)...... 26 valproic acid cap 250 mg (Depakene)...... 33 trifluoperazine hcl tab 10 mg (base equivalent)...... 26 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan trifluridine ophth soln 1% (Viroptic)...... 37 hct)...... 17 trihexyphenidyl hcl elixir 0.4 mg/ml...... 34 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan trihexyphenidyl hcl tab 2 mg...... 34 hct)...... 17 trihexyphenidyl hcl tab 5 mg...... 34 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan trimethobenzamide hcl cap 300 mg (Tigan)...... 22 hct)...... 17 trimethoprim tab 100 mg...... 5 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg...... 34 hct)...... 17 TRIUMEQ – abacavir-dolutegravir-lamivudine tab valsartan-hydrochlorothiazide tab 320-25 mg (Diovan 600-50-300 mg...... 4 hct)...... 17 tropicamide ophth soln 0.5%...... 37 valsartan tab 40 mg (Diovan)...... 17 tropicamide ophth soln 1% (Mydriacyl)...... 37 valsartan tab 80 mg (Diovan)...... 17 TRULICITY – dulaglutide soln pen-injector 0.75 valsartan tab 160 mg (Diovan)...... 17 mg/0.5ml...... 11 valsartan tab 320 mg (Diovan)...... 17 TRULICITY – dulaglutide soln pen-injector 1.5 vancomycin hcl cap 125 mg (base equivalent) mg/0.5ml...... 11 (Vancocin hcl)...... 5 TRUVADA – emtricitabine-tenofovir disoproxil fumarate vancomycin hcl cap 250 mg (base equivalent) tab 100-150 mg...... 4 (Vancocin hcl)...... 5 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VELPHORO – sucroferric oxyhydroxide chew tab 500 tab 133-200 mg...... 4 mg...... 23 TRUVADA – emtricitabine-tenofovir disoproxil fumarate venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) tab 167-250 mg...... 4 (Effexor xr)...... 25 TRUVADA – emtricitabine-tenofovir disoproxil fumarate venlafaxine hcl cap er 24hr 75 mg (base equivalent) tab 200-300 mg...... 4 (Effexor xr)...... 25 TYKERB – lapatinib ditosylate tab 250 mg (base equiv)..... 7 venlafaxine hcl cap er 24hr 150 mg (base equivalent) TYMLOS – abaloparatide subcutaneous soln pen-injector (Effexor xr)...... 25 3120 mcg/1.56ml...... 13 venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) ...... 25 U (Venlafaxine hcl er) venlafaxine hcl tab er 24hr 75 mg (base equivalent) UPTRAVI – selexipag tab 200 mcg...... 19 (Venlafaxine hcl er)...... 25 UPTRAVI – selexipag tab 400 mcg...... 19 venlafaxine hcl tab er 24hr 150 mg (base equivalent) UPTRAVI – selexipag tab 600 mcg...... 19 (Venlafaxine hcl er)...... 25 UPTRAVI – selexipag tab 800 mcg...... 19 venlafaxine hcl tab 25 mg...... 25 UPTRAVI – selexipag tab 1000 mcg...... 19 venlafaxine hcl tab 37.5 mg...... 25 UPTRAVI – selexipag tab 1200 mcg...... 19 venlafaxine hcl tab 50 mg...... 25 UPTRAVI – selexipag tab 1400 mcg...... 19 venlafaxine hcl tab 75 mg...... 25 UPTRAVI – selexipag tab 1600 mcg...... 19 venlafaxine hcl tab 100 mg...... 25 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act 800 mcg (60)...... 19 (90mcg base equiv)...... 21 ursodiol cap 300 mg (Actigall)...... 23 verapamil hcl cap er 24hr 120 mg (Verelan)...... 14 ursodiol tab 250 mg (Urso 250)...... 23 verapamil hcl cap er 24hr 180 mg (Verelan)...... 14 ursodiol tab 500 mg (Urso forte)...... 23 verapamil hcl cap er 24hr 240 mg (Verelan)...... 14 V VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg...... 14 VAGIFEM – estradiol vaginal tab 10 mcg...... 23 verapamil hcl tab er 120 mg (Calan sr)...... 14 ...... 4 valacyclovir hcl tab 1 gm (Valtrex) verapamil hcl tab er 180 mg (Calan sr)...... 14 ...... 4 valacyclovir hcl tab 500 mg (Valtrex) verapamil hcl tab er 240 mg (Calan sr)...... 14 VALCHLOR – mechlorethamine hcl gel 0.016% (base verapamil hcl tab 40 mg...... 14 equivalent)...... 40 verapamil hcl tab 80 mg (Calan)...... 14 valganciclovir hcl for soln 50 mg/ml (base equiv) verapamil hcl tab 120 mg (Calan)...... 14 (Valcyte)...... 4 VESICARE – solifenacin succinate tab 5 mg...... 23 valganciclovir hcl tab 450 mg (base equivalent) VESICARE – solifenacin succinate tab 10 mg...... 23 (Valcyte)...... 4 VIBERZI – eluxadoline tab 75 mg...... 23

PrimeChoice Accord Formulary, January 2018 71 2018

VIBERZI – eluxadoline tab 100 mg...... 23 X VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml)...... 11 XALKORI – crizotinib cap 200 mg...... 7 VIDEX – didanosine for soln 2 gm...... 4 XALKORI – crizotinib cap 250 mg...... 7 VIDEX – didanosine for soln 4 gm...... 4 XARELTO – rivaroxaban tab 10 mg...... 36 vigabatrin powd pack 500 mg (Sabril)...... 33 XARELTO – rivaroxaban tab 15 mg...... 36 VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab XARELTO – rivaroxaban tab 20 mg...... 36 29-1 mg...... 35 XARELTO STARTER PACK – rivaroxaban tab starter VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 therapy pack 15 mg & 20 mg...... 36 mg...... 35 XIFAXAN – rifaximin tab 550 mg...... 5 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 XTANDI – enzalutamide cap 40 mg...... 7 mg...... 35 XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35 VIRAMUNE – nevirapine susp 50 mg/5ml...... 4 mcg/24hr...... 10 VIREAD – tenofovir disoproxil fumarate oral powder 40 Y mg/gm...... 4 VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 4 YONSA – abiraterone acetate tab 125 mg...... 7 VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 4 Z VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 4 zafirlukast tab 10 mg (Accolate)...... 21 voriconazole for susp 40 mg/ml (Vfend)...... 3 zafirlukast tab 20 mg (Accolate)...... 21 voriconazole tab 50 mg (Vfend)...... 3 zaleplon cap 5 mg (Sonata)...... 27 voriconazole tab 200 mg (Vfend)...... 3 zaleplon cap 10 mg (Sonata)...... 27 VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab ZARXIO – filgrastim-sndz soln prefilled syringe 300 400-100-100 mg...... 4 mcg/0.5ml...... 36 VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 7 ZARXIO – filgrastim-sndz soln prefilled syringe 480 VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 28 mcg/0.8ml...... 36 VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 28 ZELBORAF – vemurafenib tab 240 mg...... 7 VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 28 3000-10000-14000 unit...... 22 VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 28 5000-17000-24000 unit...... 22 VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate chew tab 10 10000-32000-42000 unit...... 22 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate chew tab 20 15000-47000-63000 unit...... 22 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate chew tab 30 20000-63000-84000 unit...... 22 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate chew tab 40 25000-79000-105000 unit...... 22 mg...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VYVANSE – lisdexamfetamine dimesylate chew tab 50 40000-126000-168000 unit...... 22 mg...... 28 zidovudine cap 100 mg (Retrovir)...... 4 VYVANSE – lisdexamfetamine dimesylate chew tab 60 zidovudine syrup 10 mg/ml (Retrovir)...... 4 mg...... 28 zidovudine tab 300 mg...... 4 W ziprasidone hcl cap 20 mg (Geodon)...... 26 ...... 26 warfarin sodium tab 1 mg (Coumadin)...... 36 ziprasidone hcl cap 40 mg (Geodon) ...... 27 warfarin sodium tab 2 mg (Coumadin)...... 36 ziprasidone hcl cap 60 mg (Geodon) ...... 27 warfarin sodium tab 2.5 mg (Coumadin)...... 36 ziprasidone hcl cap 80 mg (Geodon) ZOLINZA – vorinostat cap 100 mg...... 7 warfarin sodium tab 3 mg (Coumadin)...... 36 ...... 27 warfarin sodium tab 4 mg (Coumadin)...... 36 zolpidem tartrate tab er 6.25 mg (Ambien cr) ...... 27 warfarin sodium tab 5 mg (Coumadin)...... 36 zolpidem tartrate tab er 12.5 mg (Ambien cr) ...... 27 warfarin sodium tab 6 mg (Coumadin)...... 36 zolpidem tartrate tab 5 mg (Ambien) ...... 27 warfarin sodium tab 7.5 mg (Coumadin)...... 36 zolpidem tartrate tab 10 mg (Ambien) ...... 33 warfarin sodium tab 10 mg (Coumadin)...... 36 zonisamide cap 50 mg WELCHOL – colesevelam hcl packet for susp 3.75 zonisamide cap 25 mg (Zonegran)...... 33 gm...... 19 zonisamide cap 100 mg (Zonegran)...... 33

PrimeChoice Accord Formulary, January 2018 72 2018

ZORTRESS – everolimus tab 0.25 mg...... 41 ZORTRESS – everolimus tab 0.5 mg...... 41 ZORTRESS – everolimus tab 0.75 mg...... 41 ZYCLARA – imiquimod cream 3.75%...... 40 ZYCLARA PUMP – imiquimod cream 2.5%...... 40 ZYCLARA PUMP – imiquimod cream 3.75%...... 40 ZYDELIG – idelalisib tab 100 mg...... 7 ZYDELIG – idelalisib tab 150 mg...... 7 ZYKADIA – ceritinib cap 150 mg...... 7 ZYLET – loteprednol etabonate-tobramycin ophth susp 0.5-0.3%...... 37 ZYTIGA – abiraterone acetate tab 250 mg...... 7 ZYTIGA – abiraterone acetate tab 500 mg...... 7

PrimeChoice Accord Formulary, January 2018 73