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Preferred Drug List (PDL) Florida Healthy Kids Effective Date: 10/1/19

© 2019 United HealthCare Services, Inc. All rights reserved.

UnitedHealthcare Community Plan does not treat members diferently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 8:00 p.m. You can also fle a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/ofce/fle/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 8:00 p.m.

CSEX15MC3944283_001 UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad o nacionalidad. Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o nacionalidad, puede enviar una queja a: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enter de ella. Se le enviará la decisin en un plazo de 30 días. Si no está de acuerdo con la decisin, tiene 15 días para solicitar que la consideremos de nuevo. Si usted necesita ayuda con su queja, por favor llame al nmero de teléfono gratuito para miembros que aparece en su tarjeta de identifcacin del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/ofce/fle/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al nmero gratuito para miembros anotado en su tarjeta de identifcacin como miembro. Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al nmero de teléfono gratuito para miembros que aparece en su tarjeta de identifcacin del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 8:00 p.m.

Preferred Drug List

This PDL is not intended to be a substitute for the INTRODUCTION knowledge, expertise, skill and judgment of the medical UnitedHealthcare Community Plan is pleased to provide provider in their choice of prescription drugs. this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered UnitedHealthcare Community Plan assumes no by UnitedHealthcare Community Plan. The drugs listed in responsibility for the actions or omissions of any medical this PDL are intended to provide sufficient options to treat provider based upon reliance, in whole or in part, on the patients who require treatment with a drug from that information contained herein. The medical provider should pharmacologic or therapeutic class. The drugs listed in the consult the drug manufacturer’s product literature or UnitedHealthcare Community Plan PDL have been standard references for more detailed information. reviewed and approved by the UnitedHealthcare Community Plan Pharmacy and Therapeutics Committee. National guidelines can be found on the Web sites listed in The drugs have been selected to provide the most clinically the Web site section or go to the National Guideline appropriate and cost-effective for patients who Clearinghouse site at http://www.guideline.gov. have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized The PDL and quarterly updates are also available on our there may be occasions where an unlisted drug is desired web site at www.uhccommunityplan.com. for proper medical management of a specific patient. In those infrequent instances, the unlisted may be requested through the Medical prior authorization process. PREFACE The UnitedHealthcare Community Plan PDL is organized The drugs represented have been reviewed by the by sections. Each section includes therapeutic groups UnitedHealthcare Community Plan Pharmacy and identified by either a drug class or disease state. Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice Products are listed by generic name. Brand names are as of the date of review. included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable This edition incorporates drugs added to the PDL since the dosage forms and strengths of the drug cited are included in last edition as well as numerous revisions to the prescribing the PDL. Generics should be considered the first line of information based on changes in pharmacotherapy. prescribing. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare The UnitedHealthcare Community Plan PDL covers Community Plan PDL is reflective of current medical selected over-the-counter (OTC) products. Many are noted practice. in the drug lists; a complete list is included on page 44. You are encouraged to prescribe OTC medications when NOTICE clinically appropriate. The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature.

i PHARMACY AND THERAPEUTICS (P&T) PDL, examples are noted below. The general principles COMMITTEE shown in the examples can then usually be extended to The UnitedHealthcare Community Plan P&T Committee other entries in the book. Any exceptions are noted in the includes physicians and pharmacists who are not employees drug list. There may also be a statement associated with a or agents of UnitedHealthcare Community Plan or its drug list that gives additional information about which affiliates. They must adhere to the Ethics Policy standards specific products or dosage forms are covered. of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the Products covered include all strengths associated P&T Committee. UnitedHealthcare Community Plan’s with the dosage form of the cited brand name P&T Committee meets quarterly to discuss a variety of product. issues. Those issues pertaining to pharmaceutical selection carvedilol Coreg and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating All strengths of Coreg would be covered by this listing. physicians who have received UnitedHealthcare Community Plan’s PDL. PDL decisions are also Extended-release and delayed-release products communicated quarterly on the UnitedHealthcare require their own entry. Community Plan internet site. diltiazem sustained release CARDIZEM SR

OUTPATIENT PRESCRIPTION DRUG Dosage forms covered will be consistent with the BENEFIT-COVERED MEDICATIONS category and use where listed. Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to Neomycin/polymyxin B/ Cortisporin prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the As listed in the OTIC section, this is limited to the otic individual member’s benefit plan. solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be PRODUCT SELECTION CRITERIA assumed to be on the list unless there are entries for these The UnitedHealthcare Community Plan P&T Committee products in the OPHTHALMIC and DERMATOLOGY considers clinical information on new-to-market drugs that sections of the PDL. are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: When a strength or dosage form is specified, only the • Safety specified strength and dosage form is on the PDL. • Efficacy Other strengths/dosage forms of the reference product • Comparison studies are not •Approved indications • Adverse effects citalopram 40 mg tabs Celexa tabs • Contraindications/Warnings/Precautions • Pharmacokinetics DRUG TIERS • Patient administration/compliance considerations • Medical outcome and pharmacoeconomic The drugs listed in the PDL have different tiers. The tiers studies are listed in the grid below. When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in Tier Name Drug Tier the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular Tier 1 Generic therapeutic class in an effort to continually promote the Tier 2 Brand most clinically useful and cost-effective agents. GENERIC SUBSTITUTION All the information in the PDL is provided as a reference The UnitedHealthcare Community Plan PDL requires for drug therapy selection. Specific drug selection for an generic substitution on the majority of products when a individual patient rests solely with the prescriber. generic equivalent is available.

PDL PRODUCT DESCRIPTIONS Generic substitution is a pharmacy action whereby a To assist in understanding which specific strengths and generic equivalent is dispensed rather than the brand name dosage forms are covered on the product. The PDL indicates generic availability in the “Covered Drug” column.

ii If a brand name drug is medically necessary, please submit indications, and a determination of “fully effective” was a prior authorization request. made for most of these products and they remain in the marketplace. A few DESI products remain classified as The UnitedHealthcare Community Plan MAC list sets a “less than fully effective” while awaiting final ceiling price for the reimbursement of certain multisource administrative disposition. Also, classified as DESI are prescription drugs. This price will typically cover the many products listed as identical, similar, or related to acquisition of most generics but not branded versions of the actual DESI products. UnitedHealthcare Community same drug. The products selected for inclusion on the Plan’s PDL does not cover DESI “less than fully effective” MAC list are commonly prescribed and dispensed and have drug products. usually gone through the FDA’s review and approval process. An important consideration for generic PLAN EXCLUSIONS substitution is the knowledge that all approvals of generic The following drug categories are excluded from coverage drugs by the FDA since 1984, and many generic approvals under the outpatient pharmacy benefit and are not part of prior to 1984, have a showing of bioequivalence between the UnitedHealthcare Community Plan PDL. the generic versions and the reference brand product. To gain FDA approval: • DESI drugs • Anti-obesity agents 1. The generic drug must contain the same active • Experimental / research drugs ingredient(s), be the same strength and the same dosage • Cosmetic drugs form as the brand name product. • Nutritional / diet supplements • Blood and blood plasma products 2. The FDA has given the generic an “A” rating compared • Agents used to promote fertility to the branded product indicating bioequivalence, and • Agents used for erectile dysfunction has determined the generic is therapeutically equivalent • Agents used for cosmetic hair growth to the reference brand. The ratings of generic drugs are • Drugs from manufacturers that do not participate available by referring to the FDA reference, Approved in the FFS Medicaid Drug Rebate Program Drug Products with Therapeutic Equivalence • Diagnostic products Evaluations (Orange Book). • Medical supplies and DME except as listed: insulin syringes, insulin needles, lancets, When the above two criteria are met, a generic can be swabs, spacers, preferred diabetes test strips, peak substituted with the full expectation that the substituted flow meters (Astech, Assess, Peak Air brands, product will produce the same clinical effect and safety max two per year), vaporizer (limit of 1 per 3 profile as the prescribed product. Drug products that have a years), humidifier (limit of 1 per 3 years) narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to DAYS SUPPLY DISPENSING LIMITATIONS approach any one therapeutic class of drug products (e.g., UnitedHealthcare Community Plan members may receive NTI drugs) differently from any other class, when there has up to a one month supply of a specific medication per been a determination of therapeutic equivalence by the prescription order or prescription refill. A medication may FDA for the drug products under consideration. Also, be reordered or refilled when eighty-five percent (85%) of additional clinical tests or examinations by the physician the medication has been utilized. If a claim is submitted are not needed when a therapeutically equivalent generic before 85% of the medication has been used, based on the drug product is substituted for the brand name product. original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the There are now many brand name products that are UnitedHealthcare Community Plan Pharmacy Department repackaged or distributed under a generic label. The generic at 800-310-6826 with questions or for help with dosage label version should always be considered therapeutically change authorization. equivalent and substitutable for the source branded product. MANDATORY GENERIC SUBSTITUTION DRUG EFFICACY STUDY IMPLEMENTATION The UnitedHealthcare Community Plan PDL requires (DESI) DRUGS mandatory generic substitution on the vast majority of Drugs first marketed between 1938 and 1962 were products when a generic equivalent is available; however, approved as safe but required no showing of effectiveness brand name drugs may be covered in certain situations by for FDA approval. Beginning in 1962, all new drugs were requesting a prior authorization. required to be both safe and effective before they could be The UnitedHealthcare Community Plan PDL prior marketed. This legislation also applied retroactively to all authorization (PA) list does not include branded items drugs approved as safe from 1938-1962. The DESI where a generic equivalent is covered. program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled

iii PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS Pharmacies may dispense a one-time, 15-day supply to The drugs in the UnitedHealthcare Community Plan PDL members requiring an immediate supply of an ongoing have been selected to provide the most clinically medication. The pharmacist must contact the plan to appropriate and cost-effective medications for patients who obtain a manual 15-day override. Before the next have their drug benefit administered through dispensing, the pharmacy must contact the physician to UnitedHealthcare Community Plan. It is also recognized discuss a PDL drug or if a prior authorization request is that there may be occasions where an unlisted drug is warranted. If the prescribing physician feels a drug is desired for the proper medical management of a specific medically necessary, the physician may fax a request for patient. In those infrequent instances, the prior prior authorization to UnitedHealthcare Community Plan at authorization process reviews requests for unlisted 866-940-7328, Attn: Pharmacy Department. medications the physician may consider medically necessary for patient management. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the Requests for these exceptions should be made in writing by indicated limit require a prior authorization request. the physician and faxed or mailed to: Quantity limits based on Efficient Medication Dosing UnitedHealthcare Community Plan The Efficient Medication Dosing Program is designed to Pharmacy Services Department consolidate medication dosage to the most efficient daily Fax 866-940-7328 quantity to increase adherence to therapy and also promote Phone 800-310-6826 the efficient use of health care dollars. The limits for the program are established based on FDA A prior authorization request form is available in the approval for dosing and the availability of the total daily UnitedHealthcare Community Plan provider manual and dose in the least amount of tablets or capsules daily. should be used for all prior authorization requests if Quantity Limits in the prescription claims processing possible. Appropriate documentation must be provided to system will limit the dispensing to consolidate dosing. The support the medical necessity of the non-PDL request. The pharmacy claims processing system will prompt the UnitedHealthcare Community Plan Pharmacy Department pharmacist to request a new prescription order from the will respond to all requests in accordance with state physician. requirements. Controlled Substances Physicians are requested to adhere to this PDL when You may fill any FOUR medications from the following prescribing for patients covered by their pharmacy benefit classes in a 30-day period: plan offered by UnitedHealthcare Community Plan. If a • benzodiazepines pharmacist receives a prescription for a non-PDL drug, the • sedative hypnotic agents pharmacist should contact the prescribing physician and • request that the prescription be changed to a medication • select muscle relaxants included in this PDL. If a PDL alternative is not Additional fills will require prior authorization. appropriate the physician should then be instructed to Medications in these classes may also be subject to contact the Plan for a prior authorization. individual quantity limits. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions Additions to the QL program drug list will be made from concerning the prior authorization process. time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables NON-PDL DRUGS 7-DAY AND 15-DAY OVERRIDES must be taken into consideration when drug therapy is To ensure the use of PDL drugs, all non- PDL drugs should prescribed and therefore overrides will be available through be discussed with the prescribing physician. If you cannot the medical exception (prior authorization) process. Please speak to the physician immediately, and there is an contact the UnitedHealthcare Community Plan Pharmacy immediate need for the medication, the claim processing Department at 800-310-6826 with questions. system will accept an override to permit a one-time dispensing of a 7-day supply of the newly prescribed Specialty Pharmaceutical Management Program non-PDL drug. The pharmacy should submit a claim for a UnitedHealthcare Community Plan is continuously looking 7 day supply, with a PA Type of 8 and Prior Authorization for ways to provide high quality cost effective care for Plan number of “00000000120”. members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to Please note that non-preferred drugs are available for a 7- achieve these goals. day supply, however availability is subject to the benefit Injectable medications that are part of this program require design. For assistance, pharmacies may call 800-310- plan authorization and are not available through the retail 6826. pharmacy network.

iv To obtain authorization, the provider must submit the appropriate Prior Authorization form to the calcipotriene trial of two medium to high potency UnitedHealthcare Community Plan Pharmacy Department cream & oint via fax at 866-940-7328. 0.005% The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in calcitriol trial of two medium to high potency accordance with state requirements, and if authorized for 3mcg/gm corticosteroids payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or DPP4 Inhibitors At least a 90 day trial of 1500mg/day of provider. (Nesina, metformin. Drugs that are part of this program and are on the PDL are Kazano, Oseni) identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by Elidel Minimum age of 2. Trial of one topical calling the UnitedHealthcare Community Plan Pharmacy . Department 800-310-6826. Eucrisa Trial of a topical corticosteroid AND one MEDICATIONS REQUIRING DIAGNOSIS of the following: Elidel or tacrolimus UnitedHealthcare Community Plan requires that the ointment. diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published fenofibrate Fill of a statin or 90 days of gemfibrozil evidence. Drugs in scope will list “Diagnosis required” in within the previous 180 days. the Requirements and Limits section on the PDL. GLP-1 At least a 90 day trial of 1500mg/day of The diagnosis will be verified at the point-of-sale by the (Adlyxin, metformin. pharmacy claims processing system. If a matching Trulicity) diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the GLP-1/Insulin Trial of one drug from the following prescriber to verify the diagnosis and submit it on the Combinations classes: GLP-1 or Basal Insulin claim. (Soliqua)

If the diagnosis provided still does not match the approved Optivar 14 day trial of within previous use, prior authorization may be requested through the 90 days required first. standard process by faxing a request to 866-940-7328. Ranexa Trial of one drug from the following STEP THERAPY (ST) classes: beta blockers, calcium channel The following PDL drugs are routinely covered only after a blockers, long acting nitrates sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be Renvela 8 week trial of calcium acetate. requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in SGLT-2 At least a 90 day trial of 1500mg/day of many instances, other non- PDL alternatives are available Inhibitors metformin with prior authorization (PA). (Jardiance, Invokana, Invokamet, Invokamet XR, STEP Drug First-Line Agent(s) Synjardy, Synjardy XR)

Amerge Trial at a minimum dose of 50mg of tacrolimus 0.03% Minimum age of 2. Trial of tablets. one topical corticosteroid.

Aricept 23mg 90 day trial of Aricept 10mg daily tacrolimus 0.1% Minimum age of 16. Trial of one topical corticosteroid.

30 day trial of immediate release. Step Therapy only applies to members less than 65 years of age.

tretinoin cream Trial of Differin OTC Gel 0.1%. (tretinoin cream

v 0.025%, 0.05%, 0.1%, LEGEND and Avita cream 0.025%) # Only the dosage forms/strengths of the brand name products noted are on the PDL OTC over-the-counter trospium 30 day trial of oxybutynin immediate or extended release. Step Therapy only delayed-rel delayed-release (also known as enteric coated) applies to members less than 65 years enteric-coated EC of age. extended-release (also known as sustained- ext-rel release) Uloric 8 week trial of up to 600mg of PA Prior Authorization required allopurinol required first. QL Quantity Limits apply ST Step Therapy, see pages V-VI for details Xopenex Specialty Pharmaceuticals, see page V for 30 day trial of Albuterol .083% or .5% SP Respules details respules. PDL SUGGESTIONS NOTICE Providers who wish to propose PDL suggestions should The information contained in this document is proprietary forward the information to the UnitedHealthcare information. The information may not be copied in whole Community Plan Director of Pharmacy Services by either or in part without the written permission of mail or fax. UnitedHealthcare Community Plan. All rights reserved.

Attn: Director of Pharmacy Services The drug names listed here are the registered and/or UnitedHealthcare Community Plan unregistered trademarks of third-party pharmaceutical 2 Allegheny Center companies unrelated to and unaffiliated with Suite 600 UnitedHealthcare Community Plan. These trademarked Pittsburgh, PA 15212 brand names are included here for informational purposes Fax: 866-940-7328 only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and Providers should furnish adequate documentation, such as such third-party pharmaceutical companies. clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature If viewing this PDL via the Internet, please be advised that should include information documenting clinical necessity the PDL is updated periodically and changes may appear as well as therapeutic advantages over current PDL prior to their effective date to allow for notification. products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting.

EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to: UnitedHealthcare Community Plan Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826 Email: [email protected] Internet: http://www.uhccommunityplan.com

vi Table of Contents

Antineoplastics & Immunosuppressants . .4 Dermatology ...... 21 Antineoplastic Agents ...... 4 Acne Vulgaris ...... 21 Hormonal Antineoplastic Agents ...... 5 Bacterial Infections ...... 22 Immunomodulators ...... 6 Corticosteroids ...... 22 Immunosuppressants ...... 6 Fungal Infections ...... 23 Miscellaneous ...... 6 Psoriasis ...... 24 Blood Modifiers - Anticoagulants . . . . .7 Rosacea ...... 24 Anticoagulants ...... 7 Scabies and Pediculosis ...... 24 Hematopoietic Agents ...... 8 Viral Infections ...... 24 Platelet Inhibitors ...... 8 Miscellaneous ...... 25 Miscellaneous ...... 8 Ear, Nose & Throat ...... 26 Cardiovascular Agents ...... 8 Ear ...... 26 Ace Inhibitors ...... 8 Ace Inhibitor/Diuretic Combinations . . . . .9 Nose ...... 27 Adrenolytics, Central ...... 9 Throat and Mouth ...... 28 Alpha Blockers ...... 9 Endocrinology ...... 28 Angiotensin II Receptor Blockers (Antagonists) 9 Adrenal Corticosteroids ...... 28 Angiotensin II Receptor Blocker Combinations 10 Androgens ...... 29 Antiarrhythmics and Cardiac Glycosides . . 10 Beta Blockers and /Diuretic Diabetes Mellitus ...... 29 Combinations ...... 10 Growth Stimulating Agents ...... 32 Calcium Channel Blockers ...... 11 Lipodystropy Agents ...... 32 and Ace Inhibitor/ ...... 32 Angiotensin II Receptor Blocker Thyroid Disease ...... 32 Combinations ...... 11 Miscellaneous ...... 33 Diuretics ...... 12 Lipid Lowering Agents ...... 12 Gastrointestinal ...... 33 Nitrates ...... 13 Constipation/Laxatives ...... 33 Potassium-Removing Agents ...... 13 Diarrhea ...... 34 Pulmonary Arterial Hypertension ...... 13 Emesis ...... 34 Miscellaneous ...... 14 Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers ...... 34 Central Nervous System ...... 14 Gastrointestinal Spasm ...... 35 Alzheimer’s Disease ...... 14 Amyotrophic Lateral Sclerosis ...... 15 Inflammatory Bowel Disease ...... 36 Analeptics ...... 15 Pancreatic Enzymes ...... 36 ...... 15 Probiotic Supplementation ...... 36 ...... 17 Miscellaneous ...... 37 Gout ...... 17 Infectious Diseases ...... 37 Migraine Acute Therapy ...... 17 Migraine Prophylactic Therapy ...... 18 Anthelmintics ...... 37 Multiple Sclerosis ...... 18 Antibacterials ...... 37 Myasthenia Gravis ...... 18 Antifungals ...... 40 Parkinson’s Disease ...... 19 Antiprotozoals ...... 41 ...... 19 Antivirals ...... 41 Miscellaneous ...... 21 Miscellaneous ...... 44

2 Musculoskeletal ...... 45 Miscellaneous ...... 81 Arthritis ...... 45 Anaphylaxis ...... 81 Gout ...... 46 Antidotes ...... 81 Skeletal Muscle Relaxants ...... 47 Caloric Agents ...... 81 Cystic Fibrosis ...... 81 OB-GYN ...... 47 Electrolyte Maintenance ...... 81 Contraceptives ...... 47 Hereditary Angioedema ...... 83 Endometriosis ...... 49 Hyperphosphatemia ...... 84 Hormone Therapy/Menopause ...... 49 Idiopathic Pulmonary Fibrosis (IPF) . . . . .84 Ovulation Stimulants ...... 50 Iron Overload ...... 84 Vaginal Infections ...... 50 Irrigating Solutions ...... 84 Miscellaneous ...... 51 Local Anesthetics ...... 85 Ophthalmic ...... 51 Medical Devices ...... 85 ...... 51 Metabolic Modifiers ...... 85 Anti-Inflammatories ...... 51 Vaccine ...... 85 ...... 52 Other ...... 87 Immunologic Agents ...... 53 OTC MEDICATIONS ...... 88 Infections ...... 53 Acne ...... 88 Miscellaneous ...... 54 Antifungals ...... 88 Antivirals ...... 88 Psychiatric ...... 54 Atopic Dermatitis ...... 88 Alcohol Deterrents ...... 54 Cough/Cold Allergy ...... 88 Anxiety ...... 54 Diabetes ...... 89 Attention Deficit Hyperactivity Disorder Earwax Removal Products ...... 89 (ADHD) ...... 55 Family Planning ...... 89 Bipolar Disorder ...... 56 First Aid ...... 89 Depression ...... 56 Gastrointestinal ...... 90 Insomnia ...... 57 Insomnia ...... 90 Narcotic Antagonists ...... 57 Lice Products ...... 90 Psychoses ...... 58 Motion Sickness ...... 90 Smoking Cessation ...... 59 Ophthalmics ...... 91 Miscellaneous ...... 59 Pain ...... 91 Respiratory Drugs ...... 59 Smoking Cessation Products ...... 91 Antitussives, Decongestants, Expectorants Urological ...... 91 and Combinations ...... 59 Vitamins/Minerals ...... 91 Asthma/COPD ...... 64 Warts ...... 91 Miscellaneous ...... 91 Urological ...... 66 Symptomatic Benign Prostatic Hypertrophy . 66 Index of Covered Drugs ...... 92 Miscellaneous ...... 66 Vitamins and Minerals ...... 67 Potassium ...... 79

3 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Antineoplastics & Immunosuppressants Antineoplastic Agents Alkylating Agents altretamine HEXALEN brand 2 busulfan MYLERAN brand 2 chlorambucil LEUKERAN brand 2 cyclophosphamide CYTOXAN generic 1 estramustine EMCYT brand 2 phosphate sodium lomustine GLEOSTINE brand 2 melphalan ALKERAN brand 2 temozolomide TEMODAR generic 1 PA, SP Antimetabolites capecitabine XELODA generic 1 SP mercaptopurine PURINETHOL generic 1 thioguanine TABLOID brand 2 QL trifluridine/tipiracil LONSURF brand 2 PA, SP Histone Deacetylase Inhibitors panobinostat FARYDAK brand 2 PA, SP vorinostat ZOLINZA brand 2 PA, SP Isocitrate Dehydrogenase (IDH) Inhibitors enasidenib IDHIFA brand 2 PA, QL, SP ivosidenib TIBSOVO brand 2 PA, QL, SP Kinase Inhibitor abemaciclib VERZENIO brand 2 PA, QL, SP acalabrutinib CALQUENCE brand 2 PA, QL, SP afatinib GILOTRIF brand 2 PA, SP alectinib ALECENSA brand 2 PA, SP axitinib INLYTA brand 2 PA, SP bosutinib BOSULIF brand 2 PA, SP brigatinib ALUNBRIG brand 2 PA, SP CABOMETYX cabozantinib brand 2 PA, SP COMETRIQ ceritinib ZYKADIA brand 2 PA, SP cobimetinib COTELLIC brand 2 PA, SP crizotinib XALKORI brand 2 PA, SP dabrafenib TAFINLAR brand 2 PA, SP SPRYCEL brand 2 PA, SP erlotinib TARCEVA brand 2 PA, SP AFINITOR everolimus brand 2 PA, SP AFINITOR DISPERZ gefitinib IRESSA brand 2 PA, SP

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 4 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug ibrutinib IMBRUVICA brand 2 PA, SP idelalisib ZYDELIG brand 2 PA, SP mesylate GLEEVEC generic 1 PA, QL, SP lapatinib ditosylate TYKERB brand 2 PA, SP larotrectinib VITRAKVI brand 2 PA, QL, SP lenvatinib LENVIMA brand 2 PA, SP midostaurin RYDAPT brand 2 PA, SP nilotinib TASIGNA brand 2 PA, SP palbociclib IBRANCE brand 2 PA, SP pazopanib VOTRIENT brand 2 PA, SP ponatinib ICLUSIG brand 2 PA, SP regorafenib STIVARGA brand 2 PA, SP ruxolitinib JAKAFI brand 2 PA, SP sorafenib NEXAVAR brand 2 PA, SP sunitinib SUTENT brand 2 PA, SP trametinib MEKINIST brand 2 PA, SP vandetanib CAPRELSA brand 2 PA, SP vemurafenib ZELBORAF brand 2 PA, SP Miscellaneous leucovorin LEUCOVORIN generic 1 QL, tabs venetoclax VENCLEXTA brand 2 PA, SP Proteasome Inhibitors ixazomib NINLARO brand 2 PA, SP Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors PA, QL, SP, 250 mg abiraterone ZYTIGA generic 1 tablets only Antiandrogens apalutamide ERLEADA brand 2 PA, QL, SP CASODEX generic 1 QL flutamide EULEXIN generic 1 QL Antiestrogens tamoxifen NOLVADEX generic 1 QL tamoxifen citrate soln SOLTAMOX brand 2 Non-Preferred, PA, QL toremifene FARESTON brand 2 QL Aromatase Inhibitors anastrozole ARIMIDEX generic 1 QL exemestane AROMASIN generic 1 QL letrozole FEMARA generic 1 QL Gonadotropin Releasing Hormone Analog leuprolide LUPRON generic 1 PA, QL, SP LUPRON DEPOT leuprolide brand 2 PA, QL, SP LUPRON DEPOT 6-MONTH

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 5 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug leuprolide acetate (cpp) (3 LUPRON DEPOT-PED brand 2 Non-Preferred, PA, QL month) kit Progestin acetate MEGACE generic 1 QL Immunomodulators Interferons interferon alfa-2b INTRON A brand 2 PA, SP interferon beta-1b kit BETASERON brand 2 Non-Preferred, PA peginterferon alfa-2b SYLATRON brand 2 PA, SP Miscellaneous lenalidomide caps REVLIMID brand 2 Non-Preferred, PA pomalidomide POMALYST brand 2 PA, SP thalidomide THALOMID brand 2 PA, QL ustekinumab sosy STELARA brand 2 Non-Preferred, PA Immunosuppressants Antimetabolites azathioprine IMURAN generic 1 mycophenolate mofetil CELLCEPT generic 1 mycophenolate mofetil HCl CELLCEPT INTRAVENOUS brand 2 solr mycophenolate sodium MYFORTIC generic 1 Calcineurin Inhibitors cyclosporine SANDIMMUNE generic 1 cyclosporine inj SANDIMMUNE INJ generic 1 NEORAL cyclosporine, modified generic 1 caps, QL GENGRAF SANDIMMUNE ORAL cyclosporine oral solution generic 1 Non-Preferred, PA SOLUTION HECORIA tacrolimus generic 1 PROGRAF Rapamycin Derivative sirolimus RAPAMUNE generic 1 tabs sirolimus RAPAMUNE brand 2 soln Miscellaneous everolimus ZORTRESS brand 2 Miscellaneous alitretinoin 1% gel PANRETIN brand 2 PA bexarotene caps and TARGRETIN brand 2 PA topical gel

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 6 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug cysteamine bitartrate CYSTAGON brand 2 docetaxel soln DOCETAXEL generic 1 Non-Preferred, PA etoposide VEPESID generic 1 glasdegib DAURISMO brand 2 PA, QL, SP hydroxyurea DROXIA brand 2 hydroxyurea HYDREA generic 1 mesna MESNEX brand 2 tabs LYSODREN brand 2 niraparib ZEJULA brand 2 PA, SP octreotide SANDOSTATIN generic 1 olaparib LYNPARZA brand 2 PA, SP pasireotide SIGNIFOR brand 2 PA, SP procarbazine MATULANE brand 2 rucaparib RUBRACA brand 2 PA, SP sonidegib ODOMZO brand 2 PA, SP topotecan HYCAMTIN brand 2 PA, SP tretinoin VESANOID generic 1 caps vismodegib ERIVEDGE brand 2 PA, SP Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS brand 2 QL betrixaban BEVYXXA brand 2 QL dabigatran etexilate PRADAXA brand 2 Non-Preferred, PA mesylate caps dalteparin sodium soln FRAGMIN brand 2 Non-Preferred, PA edoxaban SAVAYSA brand 2 QL enoxaparin LOVENOX generic 1 QL INJ 5000 UNIT/ML, PF heparin HEPARIN generic 1 INJ 5000 UNIT/0.5ML, INJ 10000 UNIT/ML heparin (porcine) in HEPARIN SODIUM/NACL generic 1 sodium chloride soln INJ heparin sod (porcine) in HEPARIN SODIUM/D5W generic 1 d5w soln heparin sodium (porcine) HEP FLUSH-10 generic 1 lock flush soln rivaroxaban XARELTO brand 2 Non-Preferred, PA warfarin COUMADIN generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 7 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Hematopoietic Agents darbepoetin alfa ARANESP brand 2 PA, SP eltrombopag PROMACTA brand 2 PA, SP epoetin alfa EPOGEN brand 2 Non-Preferred, PA, SP epoetin alfa-epbx RETACRIT brand 2 PA, SP filgrastim NEUPOGEN brand 2 Non-Preferred, PA, SP filgrastim ZARXIO brand 2 PA, SP lusutrombopag MULPLETA brand 2 PA, QL, SP pegfilgrastim NEULASTA brand 2 PA, SP plerixafor MOZOBIL brand 2 PA, SP sargramostim LEUKINE brand 2 PA, SP TBO-filgrastim GRANIX brand 2 Non-Preferred, PA, SP Platelet Inhibitors anagrelide AGRYLIN generic 1 BAYER generic 1 OTC ECOTRIN aspirin-dipyridamole cap sr AGGRENOX brand 2 Non-Preferred, PA 12hr cilostazol PLETAL generic 1 clopidogrel PLAVIX generic 1 QL dipyridamole PERSANTINE generic 1 prasugrel HCl tabs EFFIENT generic 1 Diagnosis Required, QL ticagrelor BRILINTA brand 2 Diagnosis Required, QL Miscellaneous aminocaproic acid AMICAR generic 1 tab, QL aminocaproic acid AMICAR SOLUTION brand 2 oral solution, QL aminocaproic acid soln AMINOCAPROIC ACID INJ generic 1 caplacizumab-yhdp CABLIVI brand 2 PA, SP EXJADE deferasirox brand 2 PA, SP JADENU emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SP pentoxifylline TRENTAL generic 1 extended-release Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN generic 1 captopril CAPOTEN generic 1 enalapril VASOTEC generic 1 Members ≥ 8 years of enalapril oral soln EPANED brand 2 age will require prior authorization.

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 8 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug fosinopril MONOPRIL generic 1 QL lisinopril ZESTRIL generic 1 QL quinapril ACCUPRIL generic 1 QL ramipril ALTACE generic 1 trandolapril MAVIK generic 1 Ace Inhibitor/Diuretic Combinations benazepril/ LOTENSIN HCT generic 1 hydrochlorothiazide captopril/ CAPOZIDE generic 1 hydrochlorothiazide enalapril/ VASERETIC generic 1 hydrochlorothiazide fosinopril/ MONOPRIL-HCT generic 1 QL hydrochlorothiazide lisinopril/ ZESTORETIC generic 1 QL hydrochlorothiazide quinapril/ ACCURETIC generic 1 QL hydrochlorothiazide Adrenolytics, Central CATAPRES generic 1 clonidine HCl ptwk CATAPRES -TTS generic 1 Non-Preferred, PA guanfacine TENEX generic 1 Alpha Blockers doxazosin CARDURA generic 1 prazosin MINIPRESS generic 1 terazosin HYTRIN generic 1 Angiotensin II Receptor Blockers (Antagonists) losartan COZAAR generic 1 QL olmesartan medoxomil BENICAR brand 2 Non-Preferred, PA tabs telmisartan MICARDIS brand 2 Non-Preferred, PA telmisartan- MICARDIS HCT brand 2 Non-Preferred, PA hydrochlorothiazide valsartan DIOVAN brand 2 Non-Preferred, PA valsartan- DIOVAN HCT brand 2 Non-Preferred, PA hydrochlorothiazide

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 9 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Angiotensin II Receptor Blocker Combinations losartan/HCTZ HYZAAR generic 1 QL olmesartan medoxomil- BENICAR HCT brand 2 Non-Preferred, PA hydrochlorothiazide tab sacubitril/valsartan ENTRESTO brand 2 PA, QL Antiarrhythmics and Cardiac Glycosides Non-Preferred, PA, amiodarone HCl tabs PACERONE generic 1 100mg tabs amiodarone tabs CORDARONE generic 1 200 mg and 400 mg digoxin LANOXIN generic 1 disopyramide NORPACE generic 1 disopyramide NORPACE CR brand 2 extended-release dofetilide TIKOSYN generic 1 QL flecainide TAMBOCOR generic 1 MEXITIL generic 1 propafenone RYTHMOL generic 1 IR only Non-Preferred, PA, propafenone HCl cp12 RYTHMOL SR generic 1 225mg gluconate QUINIDINE GLUCONATE generic 1 extended-release EXT-REL quinidine sulfate QUINIDINE SULFATE generic 1 quinidine sulfate QUINIDINE SULFATE generic 1 extended-release EXT-REL sotalol BETAPACE generic 1 Beta Blockers and Beta Blocker/Diuretic Combinations acebutolol SECTRAL generic 1 atenolol TENORMIN generic 1 atenolol/chlorthalidone TENORETIC generic 1 betaxolol KERLONE generic 1 bisoprolol ZEBETA generic 1 bisoprolol/ ZIAC generic 1 hydrochlorothiazide carvedilol COREG generic 1 QL labetalol TRANDATE generic 1 metoprolol LOPRESSOR generic 1 25, 50, 100mg tablets metoprolol & LOPRESS HCT generic 1 Non-Preferred, PA hydrochlorothiazide tab metoprolol succinate TOPROL XL generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 10 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug nadolol tabs NADOLOL generic 1 Non-Preferred, PA INDERAL generic 1 IR only propranolol HCl cp24 INDERAL LA generic 1 Diagnosis Required, QL propranolol/HCTZ INDERIDE generic 1 sotalol HCl AF BETAPACE AF generic 1 Calcium Channel Blockers Dihydropyridines amlodipine NORVASC generic 1 QL felodipine PLENDIL generic 1 QL extended-release nicardipine CARDENE generic 1 nifedipine PROCARDIA generic 1 nifedipine ADALAT CC generic 1 QL extended-release PROCARDIA XL nimodipine NIMOTOP generic 1 QL nimodipine oral soln NYMALIZE brand 2 Nondihydropyridines diltiazem CARDIZEM generic 1 diltiazem CARDIZEM CD generic 1 QL extended-release diltiazem HCl coated MATZIM LA, CARDIZEM LA brand 2 Non-Preferred, PA beads tb24 diltiazem CARDIZEM SR generic 1 QL sustained-release diltiazem DILACOR XR generic 1 QL extended-release TIAZAC verapamil CALAN generic 1 verapamil CALAN SR generic 1 QL extended-release Calcium Channel Blocker and Ace Inhibitor/Angiotensin II Receptor Blocker Combinations amlodipine besylate- LOTREL brand 2 Non-Preferred, PA benazepril HCl amlodipine besylate- AZOR brand 2 Non-Preferred, PA olmesartan medoxomil amlodipine besylate- EXFORGE generic 1 Non-Preferred, PA valsartan amlodipine-valsartan- EXFORGE HCT generic 1 Non-Preferred, PA hydrochlorothiazide

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 11 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Diuretics amiloride MIDAMOR generic 1 amiloride/ MODURETIC generic 1 hydrochlorothiazide bumetanide BUMEX generic 1 bumetanide soln BUMETANIDE INJ generic 1 chlorothiazide DIURIL generic 1 DIURIL ORAL chlorothiazide brand 2 QL SUSPENSION chlorthalidone CHLORTHALIDONE generic 1 furosemide LASIX generic 1 furosemide soln FUROSEMIDE INJ generic 1 hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabs hydrochlorothiazide MICROZIDE generic 1 12.5 mg caps indapamide LOZOL generic 1 methyclothiazide tabs METHYCLOTHIAZIDE generic 1 Non-Preferred, PA metolazone ZAROXOLYN generic 1 ALDACTONE generic 1 spironolactone/ ALDACTAZIDE generic 1 hydrochlorothiazide torsemide DEMADEX generic 1 torsemide soln DEMADEX generic 1 triamterene/ DYAZIDE generic 1 hydrochlorothiazide MAXZIDE Lipid Lowering Agents Bile Acid Resin CHOLESTYRAMINE PACKETS cholestyramine generic 1 Non-Preferred, PA CHOLESTYRAMINE LIGHT PACKETS Only the bulk products QUESTRAN are covered (cans). cholestyramine generic 1 QUESTRAN-LIGHT Individual packets are not covered. colestipol HCl COLESTID generic 1 Non-Preferred, PA Fibrates fenofibrate LOFIBRA generic 1 ST fenofibrate micronized ANTARA brand 2 Non-Preferred, PA caps gemfibrozil LOPID generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 12 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR generic 1 QL lovastatin MEVACOR generic 1 QL simvastatin ZOCOR generic 1 QL Lipid Lowering Agents, Other PA, QL, SP, NDC starting alirocumab PRALUENT brand 2 w/72733 pref w/PA PA, QL, SP, NDC starting evolocumab REPATHA brand 2 w/72511 pref w/PA ezetimibe tabs ZETIA generic 1 PA omega-3-acid ethyl LOVAZA generic 1 PA esters caps Niacins niacin NIACOR generic 1 niacin extended-release NIASPAN generic 1 Nitrates Oral isosorbide dinitrate ISORDIL generic 1 isosorbide dinitrate ISOSORBIDE generic 1 extended-release DINITRATE ER isosorbide mononitrate ISMO generic 1 isosorbide mononitrate IMDUR generic 1 extended-release nitroglycerin cpcr NITROGLYCERIN ER generic 1 Non-Preferred, PA Sublingual isosorbide dinitrate ISORDIL S.L. generic 1 nitroglycerin NITROLINGUAL generic 1 nitroglycerin NITROSTAT generic 1 Transdermal NITREK nitroglycerin generic 1 transdermal, QL NITRO-DUR nitroglycerin NITRO-BID generic 1 oint Potassium-Removing Agents patiromer VELTASSA brand 2 PA, QL sodium polystyrene KAYEXALATE generic 1 susp only sulfonate sodium zirconium LOKELMA brand 2 PA, QL cyclosilicate Pulmonary Arterial Hypertension ambrisentan LETAIRIS generic 1 Diagnosis Required, SP Members <12 PA bosentan susp TRACLEER brand 2 required, SP bosentan tabs TRACLEER brand 2 Diagnosis Required, QL, SP macitentan OPSUMIT brand 2 Diagnosis Required, SP

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 13 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug riociguat ADEMPAS brand 2 Diagnosis Required, SP Diagnosis Required, SP, REVATIO generic 1 tabs Diagnosis Required, SP, sildenafil REVATIO SUSPENSION brand 2 suspension Miscellaneous alteplase solr CATHFLO ACTIVASE brand 2 Non-Preferred, PA dobutamine HCl soln DOBUTAMINE HCL generic 1 dobutamine in d5w soln DOBUTAMINE HCL/D5W generic 1 epoprostenol sodium solr FLOLAN generic 1 glycine diluent for STERILE DILUENT FOR brand 2 injection FLOLAN guanabenz WYTENSIN generic 1 hydralazine APRESOLINE generic 1 methyldopa ALDOMET generic 1 methyldopa/HCTZ ALDORIL generic 1 midodrine PROAMATINE generic 1 milrinone in dextrose iv MILRINONE IN generic 1 soln DEXTROSE IV milrinone lactate soln MILRINONE LACTATE IV generic 1 minoxidil LONITEN generic 1 RANEXA generic 1 ST SODIUM CHLORIDE sodium chloride THERMOJECT brand 2 Non-Preferred, PA (diagnostic aid) soln SYSTEM sodium polystyrene KIONEX generic 1 Non-Preferred, PA sulfonate powd Central Nervous System Alzheimer’s Disease 5 mg and 10 mg, QL, Members <18 years of donepezil ARICEPT generic 1 age will require prior authorization. 23 mg, ST, Members <18 donepezil ARICEPT generic 1 years of age will require prior authorization. donepezil ODT ARICEPT ODT generic 1 Non-Preferred, PA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 14 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug QL, Members <18 years galantamine RAZADYNE generic 1 of age will require prior authorization. QL, Members <18 years memantine NAMENDA generic 1 of age will require prior authorization. QL, Members <18 years rivastigmine EXELON generic 1 of age will require prior authorization. Amyotrophic Lateral Sclerosis (ALS) riluzole RILUTEK generic 1 QL Analeptics armodafinil NUVIGIL generic 1 Diagnosis Required, QL Analgesics Non-Narcotic Analgesics butalbital/acetaminophen SEDAPAP generic 1 QL butalbital/acetaminophen/ ESGIC generic 1 QL, 50-325-40 mg caffeine ZEBUTAL butalbital-acetaminophen- Non-Preferred, PA, FIORICET brand 2 caffeine cap 50-300-40 mg butalbital/aspirin/caffeine FIORINAL generic 1 QL Non-Narcotic Analgesics acetaminophen TYLENOL generic 1 OTC aspirin/acetaminophen/ EXCEDRIN MIGRAINE generic 1 250-250-65 mg, OTC caffeine belladonna alkaloids & BELLADONNA brand 2 Non-Preferred, PA suppos ALKALOIDS & OPIUM ULTRAM generic 1 QL NSAIDS potassium CATAFLAM generic 1 diclofenac sodium delayed- VOLTAREN generic 1 release diclofenac sodium VOLTAREN XR generic 1 delayed-release LODINE generic 1 IR Only tabs, chew tabs ADVIL generic 1 and susp, OTC

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 15 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug tabs, chew tabs ibuprofen MOTRIN generic 1 and susp indomethacin INDOCIN generic 1 ORUDIS generic 1 IR only tromethamine TORADOL generic 1 QL ketorolac tromethamine KETOROLAC generic 1 soln TROMETHAMINE INJ MOBIC generic 1 QL RELAFEN generic 1 NAPROSYN generic 1 ENTERIC naproxen delayed release generic 1 COATED-NAPROSYN naproxen sodium ANAPROX generic 1 Non-Preferred, PA DAYPRO generic 1 FELDENE generic 1 CLINORIL generic 1 — Narcotic Analgesics patch BUTRANS generic 1 PA, QL Non-Preferred, PA, butalbital/apap/caff/cod FIORICET W/ generic 1 50-300-40-30 mg butalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mg butalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QL STADOL generic 1 nasal spray, QL codeine/acetaminophen TYLENOL W/CODEINE generic 1 QL codeine sulfate generic 1 QL transdermal DURAGESIC generic 1 PA, QL / HYCET generic 1 Non-Preferred, PA, QL acetaminophen LORCET LORTAB LORTAB ELIXIR hydrocodone/ NORCO generic 1 QL acetaminophen VICODIN VICODIN ES VICOPROFEN hydrocodone/ XODOL generic 1 Non-Preferred, PA acetaminophen hydrocodone/ acetaminophen soln ZAMICET generic 1 Non-Preferred, PA, QL 10-325 mg/15 ml

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 16 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug hydrocodone ER ZOHYDRO ER brand 2 PA, QL hydrocodone/ IBUDONE generic 1 Non-Preferred, PA ibuprofen VICOPROFEN DILAUDID generic 1 QL HYDROMORPHONE HCL hydromorphone HCl soln generic 1 PF INJ meperidine DEMEROL generic 1 QL MSIR generic 1 QL morphine RMS generic 1 QL morphine MS CONTIN generic 1 PA, QL extended-release morphine sulfate iv soln MORPHINE SULFATE IV generic 1 OXYFAST generic 1 soln, QL oxycodone ROXICODONE generic 1 tabs, QL Non-Preferred, PA, QL oxycodone HCl caps OXYIR generic 1 capsules oxycodone HCl tabs DAZIDOX generic 1 Non-Preferred, PA oxycodone/ 5/325 mg, 7.5/325 mg, PERCOCET generic 1 acetaminophen 10/325 mg, QL oxycodone/ Non-Preferred, PA, QL, PERCOCET generic 1 acetaminophen 2.5-325 oxycodone/aspirin PERCODAN generic 1 QL PA, QL, non-crush ER OXYMORPHONE ER generic 1 resistant /naloxone TALWIN NX generic 1 QL Antidepressant Miscellaneous Agents Non-Preferred, PA, HCl tabs TRAZODONE HCL generic 1 300mg tab Gout colchicine caps MITIGARE brand 2 Non-Preferred, PA PROBENECID/ colchicine w/probenecid generic 1 Non-Preferred, PA COLCHICINE Migraine Acute Therapy Derivatives D.H.E. 45 generic 1 inj, QL ergotamine/caffeine CAFERGOT generic 1 ergotamine tartrate/ MIGERGOT brand 2 QL caffeine SUPPOSITORIES

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 17 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Selective Agonists AMERGE generic 1 QL, ST MAXALT/MAXALT MLT generic 1 QL sumatriptan IMITREX generic 1 QL IMITREX sumatriptan generic 1 4 mg and 6 mg inj 4 MG AND 6 MG INJ Migraine Prophylactic Therapy ELAVIL generic 1 Members ≥ 8 years of divalproex sodium DEPAKOTE SPRINKLE generic 1 age will require prior cap sprinkle authorization. divalproex sodium DEPAKOTE generic 1 Minimum age 2 delayed-release erenumab-aooe AIMOVIG brand 2 PA, QL galcanezumab-gnim EMGALITY brand 2 PA, QL propranolol INDERAL generic 1 IR only verapamil CALAN generic 1 Multiple Sclerosis Diagnosis Required, dimethyl fumarate TECFIDERA brand 2 QL, SP Diagnosis Required, fingolimod GILENYA brand 2 QL, SP Diagnosis Required, glatiramer acetate COPAXONE generic 1 QL, SP AVONEX/AVONEX PEN, interferon beta-1a brand 2 Non-preferred, PA, QL, SP REBIF Diagnosis Required, peginterferon beta-1a PLEGRIDY brand 2 QL, SP Diagnosis Required, teriflunomide AUBAGIO brand 2 QL, SP Myasthenia Gravis pyridostigmine MESTINON generic 1 pyridostigmine MESTINON TIMESPAN generic 1 extended-release

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 18 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Parkinson’s Disease SYMMETREL generic 1 except tabs amantadine tablets SYMMETREL generic 1 Non-Preferred, PA, tablets benztropine COGENTIN generic 1 CABERGOLINE generic 1 Non-Preferred, PA carbidopa & levodopa ODT PARCOPA generic 1 Non-Preferred, PA carbidopa/levodopa SINEMET generic 1 carbidopa/levodopa SINEMET CR generic 1 extended-release carbidopa-levodopa- STALEVO generic 1 Non-Preferred, PA entacapone entacapone COMTAN generic 1 pramipexole MIRAPEX generic 1 pramipexole MIRAPEX ER generic 1 Non-Preferred, PA dihydrochloride tb24 ropinirole REQUIP generic 1 selegiline ELDEPRYL generic 1 tolcapone TASMAR generic 1 ARTANE generic 1 Seizures TEGRETOL generic 1 carbamazepine CARBATROL generic 1 extended-release TEGRETOL-XR clobazam ONFI generic 1 Diagnosis Required, QL clonazepam KLONOPIN generic 1 tabs clonazepam ODT CLONAZEPAM ODT generic 1 Non-Preferred, PA corticotropin gel H.P. ACTHAR brand 2 Non-Preferred, PA diazepam DIASTAT ACUDIAL generic 1 rectal gel, QL Members ≥ 8 years of divalproex sodium DEPAKOTE SPRINKLE generic 1 age will require prior cap sprinkle authorization. divalproex sodium DEPAKOTE generic 1 Minimum age 2 delayed-release divalproex sodium tb24 DEPAKOTE ER generic 1 Non-Preferred, PA ethosuximide ZARONTIN generic 1 ethotoin tabs PEGANONE brand 2 Non-Preferred, PA exogabine POTIGA brand 2 Age Limits Apply felbamate FELBATOL generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 19 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug QL, Members ≥ 8 years felbamate oral susp FELBATOL ORAL SUSP generic 1 of age will require prior authorization. NEURONTIN generic 1 caps and tabs only Non-Preferred, PA, oral gabapentin soln NEURONTIN generic 1 solution VIMPAT brand 2 Age Limits Apply, PA lacosamide soln VIMPAT brand 2 Non-Preferred, PA lamotrigine LAMICTAL generic 1 QL lamotrigine ODT LAMICTAL ODT generic 1 Non-Preferred, PA Members ≥ 8 years of lamotrigine chew LAMICTAL CD CHEW TAB generic 1 age will require prior dispersable tab authorization. lamotrigine starter kit LAMICTAL STARTER KIT generic 1 QL, Maximum age of 9 levetiracetam KEPPRA generic 1 for solution levetiracetam oral solution KEPPRA generic 1 levetiracetam tb24 KEPPRA XR generic 1 Non-Preferred, PA methsuximide CELONTIN brand 2 QL, Maximum age of 9 oxcarbazepine TRILEPTAL generic 1 for suspension phenobarbital PHENOBARBITAL generic 1 phenytoin DILANTIN INFATABS generic 1 phenytoin sodium DILANTIN generic 1 extended PHENYTEK Diagnosis required for LYRICA generic 1 seizures only, other diagnoses require PA oral solution, Diagnosis pregabalin LYRICA SOLUTION generic 1 required for seizures only, other diagnoses require PA primidone MYSOLINE generic 1 rufinamide BANZEL brand 2 Diagnosis Required, QL Age Limits Apply, PA, tiagabine GABITRIL generic 1 2mg & 4mg Age Limits Apply, PA, tiagabine GABITRIL brand 2 12mg & 16mg topiramate TOPAMAX generic 1 QL QL, Members ≥ 8 years topiramate sprinkle caps TOPAMAX SPRINKLE generic 1 of age will require prior authorization. valproic acid DEPAKENE generic 1 vigabatrin oral solution SABRIL SOLUTION generic 1 PA, SP zonisamide ZONEGRAN generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 20 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Miscellaneous guanidine HCl tabs GUANIDINE HCL brand 2 Non-Preferred, PA inotersen inj TEGSEDI brand 2 PA, QL, SP pt72 TRANSDERM-SCOP brand 2 Non-Preferred, PA tetrabenazine XENAZINE generic 1 Diagnosis Required, SP valbenazine INGREZZA brand 2 PA, QL Dermatology Acne Vulgaris Oral AMNESTEEM CLARAVIS isotretinoin generic 1 PA MYORISAN ZENTANE Topical Non-Preferred, PA, cream, adapalene DIFFERIN brand 2 lotion adapalene gel DIFFERIN OTC GEL 0.1% generic 1 azelaic acid FINACEA brand 2 gel azelaic acid (acne) AZELEX brand 2 Non-Preferred, PA benzoyl peroxide BENZAC AC generic 1 benzoyl peroxide foam BENZEFOAMULTRA generic 1 Non-Preferred, PA clindamycin CLEOCIN T generic 1 gel clindamycin CLEOCIN T generic 1 lotion clindamycin CLEOCIN T generic 1 soln erythromycin ERYGEL generic 1 gel 2% erythromycin T- STAT generic 1 soln Non-Preferred, PA, cream, SALICYLIC ACID generic 1 lotion NEUTROGENA OIL FREE salicylic acid generic 1 liquid 2%, OTC ACNE WASH sulfacetamide/sulfur SULFACET-R generic 1 lotion sulfacetamide/sulfur SUMADAN WASH generic 1 AVITA tretinoin generic 1 cream, ST RETIN-A

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 21 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Bacterial Infections bacitracin BACITRACIN generic 1 OTC bacitracin-polymyxin- CORTISPORIN brand 2 Non-Preferred, PA neomycin hc oint gentamicin GENTAK generic 1 mafenide acetate cream SULFAMYLON brand 2 Non-Preferred, PA ointment, 22 gram tube mupirocin BACTROBAN generic 1 only mupirocin calcium oint BACTROBAN NASAL brand 2 Non-Preferred, PA neomycin/polymyxin B/ NEOSPORIN generic 1 OTC bacitracin neomycin/polymyxin-HC CORTISPORIN brand 2 Non-Preferred, PA cream 0.5% silver nitrate soln SILVER NITRATE generic 1 silver sulfadiazine SILVADENE generic 1 Corticosteroids Low Potency ACLOVATE generic 1 0.05% oint DERMA-SMOOTHE acetonide generic 1 oil 0.01% OIL/FS SYNALAR generic 1 soln 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTC hydrocortisone HYTONE generic 1 lotion 1% & 2.5% hydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5% HEMORRHOIDAL generic 1 Non-Preferred, PA (rectal) supp SUP -HC 25MG hydrocortisone acetate w/ ANALPRAM-HC, HC generic 1 Non-Preferred, PA pramoxine rectal cream PRAMOXINE hydrocortisone acetate w/ PROCTOFOAM HC brand 2 Non-Preferred, PA pramoxine rectal foam hydrocortisone (rectal) PROCTO-PAK generic 1 Non-Preferred, PA cream WESTCORT generic 1 Non-Preferred, PA oint CORTIZONE-10 INTENSIVE hydrocortisone/aloe generic 1 crm 0.5% & 1%, OTC HEALING

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 22 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Medium Potency val BETA-VAL generic 1 crm/oint/lotion 0.1% fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025% propionate CUTIVATE generic 1 crm 0.05%, oint 0.005% LOCOID generic 1 oint/soln 0.1% furoate ELOCON generic 1 crm/oint/soln 0.1% DERMATOP generic 1 crm 0.1% acetonide KENALOG generic 1 crm/lot/oint 0.025% KENALOG generic 1 crm/oint/lotion 0.1% High Potency betamethasone DIPROLENE generic 1 lotion 0.05% augmented dip betamethasone DIPROLENE AF generic 1 crm 0.05% augmented dip betamethasone generic 1 lotion/oint 0.05% dipropionate betamethasone generic 1 Non-Preferred, crm 0.05% dipropionate LIDEX generic 1 soln 0.05% fluocinonide emulsified LIDEX E generic 1 crm 0.05% base triamcinolone acetonide KENALOG generic 1 crm 0.5% Very High Potency betamethasone dip DIPROLENE generic 1 gel 0.05% augmented betamethasone dip DIPROLENE generic 1 oint 0.05% augmented propionate TEMOVATE generic 1 soln 0.05% Non-Preferred, PA, TEMOVATE generic 1 crm/gel/oint 0.05% halobetasol ULTRAVATE generic 1 cream Non-Preferred, PA, halobetasol propionate ULTRAVATE generic 1 ointment Fungal Infections ciclopirox PENLAC SOLUTION 8% generic 1 Non-Preferred, PA, cream, ciclopirox olamine crea CICLOPIROX OLAMINE brand 2 suspension clotrimazole MYCELEX generic 1 clotrimazole LOTRIMIN AF generic 1 OTC clotrimazole with LOTRISONE generic 1 betamethasone NIZORAL generic 1 ketoconazole (topical) foam EXTINA generic 1 Non-Preferred, PA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 23 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug DESENEX generic 1 2% OTC miconazole MICATIN generic 1 OTC miconazole MONISTAT-DERM generic 1 miconazole nitrate MICONAZOLE 1 brand 2 Non-Preferred, PA vaginal kit nystatin MYCOSTATIN generic 1 terbinafine LAMISIL AT generic 1 OTC tolnaftate TINACTIN generic 1 OTC Psoriasis acitretin SORIATANE generic 1 oral caps, PA calcipotriene DOVONEX generic 1 crm/oint, ST calcipotriene DOVONEX generic 1 soln calcitriol VECTICAL generic 1 ST methoxsalen OXSORALEN-ULTRA generic 1 methoxsalen (topical) OXSORALEN brand 2 Non-Preferred, PA lotion salicylic acid SCALPICIN generic 1 liquid 3% Rosacea brimonidine MIRVASO brand 2 PA METROCREAM metronidazole METROGEL generic 1 METROLOTION sulfacetamide sodium CLARIFOAM EF generic 1 Non-Preferred, PA w/sulfur foam Scabies and Pediculosis benzyl alcohol ULESFIA brand 2 Non-Preferred, PA (pediculicide) lotn crotamiton EURAX brand 2 (pediculicide) SKLICE brand 2 Non-Preferred, PA lotn malathion OVIDE generic 1 permethrin ELIMITE generic 1 5%, QL permethrin NIX CREME RINSE generic 1 1%, OTC pyrethrins/piperonyl RID SHAMPOO generic 1 4% OTC butoxide shampoo spinosad NATROBA generic 1 QL Viral Infections penciclovir cream DENAVIR brand 2 Non-Preferred, PA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 24 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug podofilox CONDYLOX SOL generic 1 sol salicylic acid 17%/ DUOFILM generic 1 OTC collodion Miscellaneous aluminum acetate brand 2 soln/cream, OTC aluminum chloride topical HYPERCARE 15% brand 2 solution crm 12%, lotion 5% & ammonium lactate LAC-HYDRIN generic 1 12% ammonium lactate LACTINOL generic 1 lotion 10% becaplermin gel REGRANEX brand 2 Diagnosis Required, QL REMEDY benzalkonium chloride liqd ANTIMICROBIAL brand 2 Non-Preferred, PA CLEANSER calamine brand 2 lotion/ointment, OTC collagenase oint SANTYL brand 2 QL crisaborole EUCRISA brand 2 2% ointment, QL, ST HCl (antipruritic) ZONALON generic 1 Non-Preferred, PA cream Non-Preferred, 0.5% fluorouracil CARAC generic 1 cream fluorouracil EFUDEX generic 1 PROCTOSOL HC CREAM 2.5% hydrocortisone PROCTOZONE generic 1 CREAM-HC 2.5% ANUSOL HC 2.5% hydroquinone cream LUSTRA generic 1 hydroquinone soln MELQUIN 3 generic 1 Non-Preferred, PA imiquimod 5% cream ALDARA generic 1 ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2% lactic acid w/vitamin E cream 10%-3500 LACTIC ACID E generic 1 Non-Preferred, PA unit/30gm LIDAMANTEL generic 1 3% cream Non-Preferred, PA, lotion, lidocaine LIDOCAINE HCL generic 1 solution 4% cream (15 gm tubes), lidocaine LMX-4 generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 25 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug lidocaine XYLOCAINE generic 1 jelly 2% lidocaine XYLOCAINE generic 1 Non-Preferred, oint 5% LIDOCAINE HCL/ lidocaine/hydrocortisone HYDROCORTISONE generic 1 Non-Preferred, PA acetate rectal cream kit ACETATE LIDOCAINE HCL/ lidocaine/hydrocortisone HYDROCORTISONE generic 1 Non-Preferred, PA acetate rectal gel ACETATE WITH ALOE lidocaine patch LIDODERM generic 1 Diagnosis Required, QL lidocaine/prilocaine EMLA generic 1 2.5% cream lidocaine/tetracaine cream PLIAGLIS brand 2 Non-Preferred, PA Diagnosis Required, QL, nitroglycerin RECTIV brand 2 0.4% rectal ointment cream QL, ST, not covered pimecrolimus ELIDEL brand 2 for members less than 2 years of age selenium sulfide SELSUN generic 1 lotion 2.5% selenium sulfide- pyrithione zinc in urea SELENIUM SULFIDE generic 1 Non-Preferred, PA shampoo ointment 0.03%, QL, ST; tacrolimus PROTOPIC 0.03% generic 1 not covered for members less than 2 years of age ointment 0.1%, ST tacrolimus PROTOPIC 0.1% generic 1 (minimum age 16) UREA 10% CREAM, urea 10%, urea 20% UREA 20% CREAM, brand 2 UREA 10% LOTION urea 40% UREA 40% LOTION generic 1 lotion urea crea ALUVEA generic 1 Non-Preferred, PA Ear, Nose & Throat Ear acetic acid VOSOL OTIC generic 1 otic acetic acid/ DOMEBORO OTIC generic 1 aluminum acetate acetic acid/ VOSOL HC OTIC generic 1 hydrocortisone

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 26 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug benzocaine/antipyrine BENZOTIC generic 1 carbamide peroxide DEBROX generic 1 6.5%, OTC / CIPRODEX brand 2 Diagnosis Required, QL fluocinolone acetonide DERMOTIC OIL generic 1 Non-Preferred, PA (otic) oil neomycin/polymyxin B/ CORTISPORIN OTIC generic 1 otic hydrocortisone ofloxacin FLOXIN OTIC generic 1 Nose - First Generation, Sedating CHLOR-TRIMETON chlorpheniramine maleate generic 1 2 mg/5 ml, OTC SYRUP chlorpheniramine CHLOR-TRIMETON generic 1 12 mg, OTC extended-release ALLERGY CLEMASTINE generic 1 CYPROHEPTADINE generic 1 generic 1 diphenhydramine BENADRYL generic 1 OTC DIPHENHYDRAMINE HCL diphenhydramine HCl soln generic 1 INJ HCl ATARAX generic 1 hydroxyzine pamoate VISTARIL generic 1 Antihistamines - Second Generation, Nonsedating ZYRTEC generic 1 OTC OTC, Members ≥ 8 years ZYRTEC CHEWABLE cetirizine chew tab generic 1 of age will require prior TABLET authorization. XYZAL generic 1 tabs ALAVERT generic 1 OTC CLARITIN Antihistamines - Others /Decongestant Combinations ASTELIN generic 1 spray azelastine HCl soln ASTEPRO generic 1 Non-Preferred, PA Antihistamine/Decongestant Combinations - First Generation chlorpheniramine/ / TRIOTANN generic 1 pyrilamine chlorpheniramine/ ACTIFED generic 1 OTC pseudoephedrine

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 27 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride ZYRTEC-D generic 1 5 mg-120 mg tablet 12 hours extended-release ALAVERT-D loratadine/ ALAVERT ALRG pseudoephedrine generic 1 OTC TAB/SINUS extended-release ALLERY/CONG saline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTC Nasal fluticasone FLONASE generic 1 mometasone furoate NASONEX brand 2 Non-Preferred, PA (nasal) susp NASACORT ALLERGY triamcinolone nasal spray brand 2 OTC 24 HOUR Miscellaneous Nasal cromolyn sodium NASALCROM generic 1 OTC ipratropium nasal ATROVENT NASAL SPRAY generic 1 QL HCl (nasal) PATANASE generic 1 Non-Preferred, PA soln Miscellaneous Nasal Decongestants oxymetazoline AFRIN generic 1 OTC NEO-SYNEPHRINE phenylephrine DIMEATAPP DRO generic 1 OTC DECONGES Throat and Mouth chlorhexidine gluconate PERIDEX generic 1 lidocaine viscous XYLOCAINE generic 1 SALAGEN generic 1 triamcinolone KENALOG IN ORABASE generic 1 paste Endocrinology Adrenal Corticosteroids betamethasone sod phosphate & acetate inj CELESTONE-SOLUSPAN generic 1 susp acetate generic 1 dexamethasone DECADRON generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 28 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug dexamethasone sodium DEXAMETHASONE generic 1 phosphate soln SODIUM PHOSPHATE FLORINEF generic 1 hydrocortisone CORTEF generic 1 hydrocortisone sod SOLU-CORTEF INJ brand 2 succinate solr MEDROL generic 1 4mg, 8mg, 16mg, 32mg methylprednisolone MEDROL brand 2 2mg methylprednisolone DEPO-MEDROL brand 2 acetate susp methylprednisolone sod SOLU-MEDROL generic 1 succ solr pegademase bovine soln ADAGEN brand 2 Non-Preferred, PA prednisolone PRELONE generic 1 syrup prednisolone sodium ORAPRED generic 1 phosphate PEDIAPRED prednisolone sodium PREDNISOLONE SODIUM generic 1 Non-Preferred, PA phosphate soln PHOSPHATE prednisolone sodium ORAPRED ODT brand 2 Non-Preferred, PA phosphate tbdp DELTASONE generic 1 triamcinolone acetonide KENALOG-10 INJ brand 2 susp Androgens testosterone cypionate DEPO-TESTOSTERONE generic 1 Vials only. Disposable testosterone enanthate DELATESTRYL generic 1 syringes not covered. ANDROGEL, ANDROGEL testosterone gel brand 2 Non-Preferred, PA PUMP testosterone gel TESTOSTERONE 1% topical tube, packet, generic 1 PA TOPICAL GEL and pump bottle Diabetes Mellitus Glucose Elevating Agents diazoxide susp PROGLYCEM brand 2 Non-Preferred, PA glucagon HCl (diagnostic) GLUCAGON HCL brand 2 Non-Preferred, PA solr DIAGNOSTIC glucagon HCL rdna GLUCAGEN DIAGNOSTIC brand 2 Non-Preferred, PA (diagnostic) solr

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 29 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug glucagon, human GLUCAGON brand 2 QL recombinant Insulins insulin aspart NOVOLOG brand 2 Non-Preferred, PA, vials NOVOLOG PENFILL insulin aspart brand 2 Non-Preferred, PA NOVOLOG FLEXPEN insulin aspart protamine & NOVOLOG MIX 70/30 brand 2 Non-Preferred, PA aspart (human) supn PREFILLED FLEXPEN insulin aspart protamine 70%/ NOVOLOG MIX 70/30 brand 2 QL, vials insulin aspart 30% insulin detemir LEVEMIR brand 2 Non-preferred, vials insulin detemir sopn LEVEMIR FLEXTOUCH brand 2 Non-Preferred, PA insulin glargine BASAGLAR brand 2 Non-Preferred, PA, QL, insulin glargine LANTUS brand 2 vials insulin glargine sopn LANTUS SOLOSTAR brand 2 Non-Preferred, PA insulin human NOVOLIN R brand 2 OTC, QL, vials insulin human RELION R brand 2 OTC, QL, vials insulin isophane HUMULIN N brand 2 OTC, QL, vials insulin isophane human NOVOLIN N brand 2 OTC, QL, vials insulin isophane human RELION N brand 2 OTC, QL, vials insulin isophane human NOVOLIN 70/30 brand 2 OTC, QL, vials 70%/regular 30% insulin isophane human RELION 70/30 brand 2 OTC, QL, vials 70%/regular 30% insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vials insulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vials insulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vials insulin lispro ADMELOG SOLOSTAR brand 2 PA, QL insulin lispro ADMELOG VIALS brand 2 insulin lispro HUMALOG brand 2 Non-Preferred, PA insulin lispro (human) soct HUMALOG KWIKPEN brand 2 Non-Preferred, PA insulin nph (human) HUMULIN N KWIKPEN brand 2 Non-Preferred, PA (isophane) supn insulin nph isophane & reg HUMULIN 70/30 brand 2 Non-Preferred, PA (human) supn KWIKPEN insulin regular HUMULIN R brand 2 OTC, QL, U-100 vials

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 30 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Insulin Combinations insulin glargine/lixisenatide SOLIQUA brand 2 QL, ST Monitoring- Strips and Kits/Diabetic Supplies QL for insulin dependent ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, or pregnant members: brand 2 VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) allow testing up to 6 times per day QL for non-insulin ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2 dependent members: allow twice daily testing Oral Agents alogliptin NESINA generic 1 ST alogliptin/metformin KAZANO generic 1 ST alogliptin/pioglitazone OSENI generic 1 ST acarbose PRECOSE generic 1 QL canagliflozin INVOKANA brand 2 Non-Preferred, PA ertugliflozin STEGLATRO brand 2 QL, ST ertugliflozin/metformin SEGLUROMET brand 2 QL, ST glimepiride AMARYL generic 1 QL glipizide GLUCOTROL generic 1 QL glipizide extended-release GLUCOTROL XL generic 1 QL glipizide-metformin METAGLIP generic 1 Non-Preferred, PA, QL glyburide MICRONASE generic 1 QL glyburide, micronized GLYNASE generic 1 QL linagliptin TRADJENTA brand 2 Non-Preferred, PA, QL metformin GLUCOPHAGE generic 1 QL PA, only generic is metformin ER FORTAMET generic 1 preferred metformin ER GLUCOPHAGE ER generic 1 QL metformin/glyburide GLUCOVANCE generic 1 QL miglitol GLYSET brand 2 Non-Preferred, PA, QL nateglinide STARLIX generic 1 QL pioglitazone ACTOS generic 1 QL pioglitazone/metformin ACTOPLUSMET generic 1 Non-Preferred, PA, QL repaglinide PRANDIN generic 1 QL saxagliptin ONGLYZA brand 2 Non-Preferred, PA, QL sitagliptin-metformin JANUMET brand 2 Non-Preferred, PA, QL sitagliptin-metformin HCL JANUMET XR brand 2 Non-Preferred, PA, QL sr 24hr sitagliptin phosphate JANUVIA brand 2 Non-Preferred, PA, QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 31 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Miscellaneous Antidiabetic Agents dulaglutide TRULICITY brand 2 ST exenatide BYDUREON brand 2 Non-Preferred, PA exenatide pen BYDUREON brand 2 Non-Preferred, PA exenatide sopn BYETTA brand 2 Non-Preferred, PA liraglutide VICTOZA 2 PEN PACK brand 2 ST lixisenatide ADLYXIN brand 2 ST pramlintide SYMLIN brand 2 PA Growth Stimulating Agents mecasermin INCRELEX brand 2 PA, SP GENOTROPIN somatropin SEROSTIM brand 2 Non-Preferred, PA SAIZEN somatropin NUTROPIN AQ NUSPIN brand 2 PA, SP Lipodystropy Agents tesamorelin EGRIFTA brand 2 Diagnosis Required, SP Osteoporosis abaloparatide inj TYMLOS brand 2 PA, SP alendronate FOSAMAX generic 1 QL calcitonin-salmon MIACALCIN brand 2 inj, Non-Preferred calcitonin-salmon MIACALCIN generic 1 nasal spray, QL calcitonin-salmon FORTICAL brand 2 nasal spray, QL etidronate DIDRONEL generic 1 PAMIDRONATE pamidronate disodium inj generic 1 DISODIUM raloxifene EVISTA generic 1 ZOMETA INJ zoledronic acid soln generic 1 RECLAST INJ Thyroid Disease levothyroxine LEVOXYL generic 1 levothyroxine SYNTHROID generic 1 levothyroxine sodium LEVOTHYROXINE generic 1 solr iv SODIUM IV liothyronine CYTOMEL generic 1 methimazole TAPAZOLE generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 32 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug propylthiouracil PROPYLTHIOURACIL generic 1 thyroid ARMOUR THYROID brand 2 Non-Preferred, PA Miscellaneous asfotase alfa STRENSIQ brand 2 PA, SP cabergoline DOSTINEX generic 1 cholic acid CHOLBAM brand 2 PA, SP desmopressin DDAVP generic 1 QL desmopressin NOCDURNA brand 2 PA desmopressin acetate soln STIMATE brand 2 Non-Preferred, PA methylergonovine METHERGINE generic 1 KORLYM brand 2 PA, SP Diagnosis Required, nitisinone NITYR brand 2 QL, SP nitisinone ORFADIN brand 2 Non-Preferred, PA pegvisomant SOMAVERT brand 2 PA, SP sapropterin KUVAN brand 2 Diagnosis Required, SP KUVAN POWDER FOR sapropterin powder brand 2 Diagnosis Required, SP SOLUTION taliglucerase alfa solr ELELYSO brand 2 Non-Preferred, PA uridine VISTOGARD brand 2 SP velaglucerase alfa solr VPRIV brand 2 Non-Preferred, PA Gastrointestinal Constipation/Laxatives casanthranol-docusate generic 1 OTC sodium docusate calcium plus generic 1 OTC docusate potasssium generic 1 OTC docusate sodium COLACE generic 1 OTC lactulose ENULOSE generic 1 Non-Preferred, Diagnosis linaclotide LINZESS brand 2 Required, QL glycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTC MAGNESIUM CITRATE magnesium citrate soln generic 1 SOLN naloxegol MOVANTIK brand 2 Diagnosis Required, QL peg 3350/electrolytes COLY TE generic 1 peg 3350/sodium bicarbonate/sodium TRILYTE generic 1 chloride

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 33 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug peg 3350/sodium bicarbonate/sodium NULYTELY generic 1 chloride/potassium chloride plecanatide TRULANCE brand 2 Diagnosis Required, QL polyethylene glycol 3350 MIRALAX generic 1 ONLY powder bottle MOTEGRITY brand 2 Diagnosis Required sennosides SENOKOT generic 1 8.6 mg tab, OTC Diarrhea HCL LOTRONEX brand 2 Non-Preferred, PA crofelemer MYTESI brand 2 Diagnosis Required, QL diphenoxylate/ LOMOTIL generic 1 loperamide IMODIUM A-D generic 1 OTC loperamide LOPERAMIDE generic 1 OPIUM TINCTURE tinc generic 1 Non-Preferred, PA (PAREGORIC) Emesis QL applies to 40 mg, 80 EMEND generic 1 mg and 80-125 mg MARINOL generic 1 PA soln DROPERIDOL generic 1 ANTIVERT generic 1 REGLAN generic 1 ZOFRAN generic 1 QL ZOFRAN ODT ondansetron HCL soln ZOFRAN INJ generic 1 Non-Preferred, PA COMPAZINE generic 1 PHENERGAN generic 1 PROMETHAZINE HCL promethazine HCL inj soln generic 1 INJ VARUBI brand 2 TIGAN generic 1 300 mg caps Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers alginic acid/sodium brand 2 OTC bicarbonate alumina/magnesia MAALOX generic 1 OTC alumina/magnesia/ MYLANTA generic 1 OTC simethicone TAGAMET generic 1 clidinium & LIBRAX generic 1 Non-Preferred, PA chlordiazepoxide generic/ esomeprazole NEXIUM 24HR OTC 1/2 PA brand

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 34 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Members ≥ 2 years NEXIUM DELAYED- esomeprazole granules brand 2 of age will require prior RELEASE PACKET authorization OTC Pepcid AC 10 mg PEPCID and 20 mg also covered/ generic 1 PEPCID AC encouraged with written prescription. famotidine in nacl soln FAMOTIDINE PREMIXED IV generic 1 famotidine oral PEPCID brand 2 Non-Preferred, PA suspension famotidine soln FAMOTIDINE INJ generic 1 lansoprazole PREVACID generic 1 orally disintegrating tabs, lansoprazole Members ≥ 2 years PREVACID SOLUTAB generic 1 delayed-release of age will require prior authorization, QL methscopolamine METHSCOPOLAMINE generic 1 Non-Preferred, PA bromide tabs BROMIDE omeprazole PRILOSEC generic 1 Capsules only, QL delayed-release pantoprazole PROTONIX generic 1 pantoprazole sodium pack PROTONIX PACKET brand 2 Non-Preferred, PA ZANTAC generic 1 150 mg tabs ranitidine HCL soln ZANTAC INJ generic 1 Non-Preferred, PA, 75mg, ranitidine HCL tabs RANITIDINE HCL generic 1 300mg tabs ranitidine syrup ZANTAC generic 1 sodium bicarbonate SODIUM BIARBONATE generic 1 tablets sucralfate CARAFATE generic 1 suspension, Members 10 years of age up to 65 sulcralfate CARAFATE SUSPENSION brand 2 years of age will require prior authorization Gastrointestinal Spasm dicyclomine BENTYL generic 1 tablets only glycopyrrolate ROBINUL generic 1 sulfate LEVSIN generic 1 hyoscyamine sulfate LEVSINEX generic 1 extended-release

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 35 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Inflammatory Bowel Disease balsalazide COLAZAL generic 1 ENTOCORT EC generic 1 Diagnosis Required, QL hydrocortisone COLOCORT generic 1 enema mesalamine ROWASA generic 1 enema only mesalamine extended- APRISO brand 2 release mesalamine extended- DELZICOL generic 1 release mesalamine supp CANASA generic 1 olsalazine sodium DIPENTUM brand 2 sulfasalazine AZULFIDINE generic 1 sulfasalazine AZULFIDINE EN-TABS generic 1 delayed-release Pancreatic Enzymes CREON pancrelipase brand 2 CREON 3000 UNIT pancrelipase ZENPEP brand 2 Non-Preferred pancrelipase (lipase- PANCREAZE protease-amylase) PERTZYE brand 2 Non-Preferred, PA cpep ULTRESA pancrelipase (lipase- VIOKACE brand 2 Non-Preferred, PA protease-amylase) tabs Probiotic Supplementation acidophilus ACIDOPHILUS XTRA brand 2 OTC acidophilus ACIDOPHILUS brand 2 caps and tabs, OTC ACIDOPHILUS/BIFIDUS acidophilus/bifidus generic 1 OTC WAFER ACIDOPHILUS/CITRUS acidophilus/citrus pectin generic 1 tabs, OTC PECTIN acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 36 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug ALIGN BACID BIOGAIA CULTURELLE DIGESTIVE PROBIOTIC FLORAJEN probiotics brand 2 OTC FLORANEX FLORASTOR LACTINEX PHILLIPS COLON HEALTH RISA-BID RISAQUAD Miscellaneous atropine sulfate SAL-TROPINE brand 2 misoprostol CYTOTEC generic 1 natalizumab conc TYSABRI brand 2 Non-Preferred, PA teduglutide GATTEX brand 2 PA, SP URSO ursodiol URSO FORTE generic 1 ACTIGALL Infectious Diseases Anthelmintics albendazole ALBENZA generic 1 PA ivermectin STROMECTOL brand 2 praziquantel BILTRICIDE brand 2 Diagnosis Required, QL chewable tablets, pamoate PIN-X brand 2 suspension REESE'S PINWORM pyrantel pamoate brand 2 tablets, suspension MEDICINE Antibacterials Antituberculosis Agents aminosalicyclic acid PASER brand 2 cycloserine SEROMYCIN generic 1 ethambutol MYAMBUTOL generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 37 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug ethionamide TRECATOR brand 2 isoniazid ISONIAZID generic 1 pyrazinamide PYRAZINAMIDE generic 1 rifabutin MYCOBUTIN generic 1 rifampin RIFADIN generic 1 rifapentine PRIFTIN brand 2 Cephalosporins - First Generation cefadroxil DURICEF generic 1 cefazolin in d5w soln CEFAZOLIN IN D5W SOLN generic 1 cefazolin sodium and CEFAZOLIN SODIUM/ generic 1 dextrose solr DEXTROSE cefazolin sodium solr CEFAZOLIN SODIUM generic 1 cephalexin KEFLEX generic 1 tabs are not covered cephalexin tabs KEFLET generic 1 Non-Preferred, PA Cephalosporins - Second Generation cefaclor CECLOR generic 1 cefotetan disodium and CEFOTETAN/DEXTROSE generic 1 dextrose solr cefotetan disodium solr CEFOTETAN brand 2 cefoxitin sodium and CEFOXITIN SODIUM generic 1 dextrose solr cefoxitin sodium solr MEFOXIN generic 1 cefprozil CEFZIL generic 1 cefuroxime axetil CEFTIN brand 2 suspension cefuroxime axetil CEFTIN generic 1 tabs cefuroxime sodium solr ZINACEF generic 1 Cephalosporins - Third Generation cefdinir OMNICEF generic 1 cefixime SUPRAX brand 2 400 mg caps only, QL cefixime susr SUPRAX SUSPENSION generic 1 Non-Preferred, PA cefotaxime sodium solr CLAFORAN generic 1 ceftazidime solr TAZICEF generic 1 ceftriaxone sodium and CEFTRIAXONE/ generic 1 dextrose solr DEXTROSE ceftriaxone sodium solr ROCEPHIN generic 1 Cephalosporins - Fourth Generation cefepime HCL solr CEFEPIME brand 2

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 38 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Fluoroquinolones ciprofloxacin CIPRO generic 1 ciprofloxacin in d5w soln CIPRO I.V.-IN D5W generic 1 ciprofloxacin soln CIPROFLOXACIN IV generic 1 levofloxacin LEVAQUIN generic 1 tablets only levofloxacin in d5w soln LEVAQUIN INJ brand 2 ofloxacin FLOXIN generic 1 tabs Macrolides azithromycin ZITHROMAX generic 1 QL ZITHROMAX POWDER FOR azithromycin pack generic 1 Non-Preferred, PA SUSP azithromycin solr ZITHROMAX IV generic 1 clarithromycin BIAXIN generic 1 clarithromycin ER BIAXIN XL generic 1 erythromycin E.E.S. generic 1 ethylsuccinate erythromycin ERYC generic 1 delayed-release erythromycin ERY-TAB brand 2 delayed-release erythromycin stearate ERYTHROCIN generic 1 erythromycin/sulfisoxazole PEDIAZOLE generic 1 fidaxomicin DIFICID brand 2 PA Penicillins AMOXICILLIN CAPSULES Except 500 mg and 875 amoxicillin generic 1 AND CHEWABLES mg film-coated tabs. amoxicillin AMOXIL SUSP generic 1 suspension amoxicillin/clavulanate AUGMENTIN generic 1 amoxicillin tabs AMOXICILLIN generic 1 Non-Preferred, PA ampicillin PRINCIPEN generic 1 ampicillin & sulbactam UNASYN generic 1 sodium for inj ampicillin sodium solr AMPICILLIN SODIUM INJ generic 1 dicloxacillin DICLOXACILLIN generic 1 penicillin g benzathine & BICILLIN C-R brand 2 procaine inj penicillin g benzathine BICILLIN L-A brand 2 susp im penicillin g potassium solr PFIZERPEN-G generic 1 inj

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 39 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug penicillin g procaine susp PENICILLIN G PROCAINE brand 2 penicillin g sodium solr inj PENICILLIN G SODIUM generic 1 penicillin VK VEETIDS generic 1 piperacillin sodium- tazobactam sodium for ZOSYN brand 2 inj Sulfonamides sulfadiazine SULFADIAZINE generic 1 Non-Preferred, PA sulfamethoxazole/ BACTRIM generic 1 trimethoprim, DS BACTRIM DS Tetracyclines doxycycline hyclate DOXY-100 generic 1 Non-Preferred, PA DOXYCYCLINE doxycycline monohydrate generic 1 50mg & 100mg caps MONOHYDRATE minocycline MINOCIN generic 1 capsules, except 75 mg Non-Preferred, PA, minocycline MINOCIN generic 1 tablets, 75mg capsules omadacycline NUZYRA brand 2 PA tetracycline SUMYCIN generic 1 Non-Preferred, PA Miscellaneous COLISTIMETHATE colistimethate sodium solr generic 1 SODIUM INJ ertapenem sodium solr INVANZ INJ brand 2 Non-Preferred, PA GENTAMICIN gentamicin in saline soln SULFATE/0.9% SODIUM brand 2 CHLORIDE imipenem-cilastatin PRIMAXIN IV generic 1 intravenous for soln meropenem solr MERREM brand 2 polymyxin b sulfate solr POLYMYXIN B SULFATE INJ brand 2 tobramycin sulfate in TOBRAMYCIN SULFATE/ brand 2 saline soln SODIUM CHLORIDE INJ tobramycin sulfate soln TOBRAMYCIN SULFATE INJ generic 1 trimethoprim HCL soln PRIMSOL generic 1 Non-Preferred, PA vancomycin HCl VANCOCIN HCL generic 1 Non-Preferred vancomycin HCl solr inj VANCOMYCIN HCL generic 1 vancomycin powder for FIRVANQ brand 2 Diagnosis Required, QL oral solution Antifungals anidulafungin solr ERAXIS brand 2 Non-Preferred, PA clotrimazole MYCELEX generic 1 troches fluconazole DIFLUCAN generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 40 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug fluconazole in dextrose FLUCONAZOLE IN generic 1 soln DEXTROSE fluconazole in nacl soln FLUCONAZOLE IN NACL generic 1 griseofulvin microsize GRIFULVIN V generic 1 griseofulvin ultramicrosize GRIS-PEG generic 1 SPORANOX generic 1 caps, PA, QL itraconazole SPORANOX brand 2 soln, PA, QL ketoconazole NIZORAL generic 1 nystatin MYCOSTATIN generic 1 terbinafine LAMISIL generic 1 QL tinidazole TINDAMAX brand 2 Non-Preferred, PA voriconazole VFEND generic 1 PA, tablets Antiprotozoals atovaquone MEPRON generic 1 PA benznidazole BENZNIDAZOLE brand 2 PA Members ≥ 8 years of nitazoxanide suspension ALINIA SUSPENSION brand 2 age will require prior authorization. nitazoxanide tablet ALINIA brand 2 PA miltefosine IMPAVIDO brand 2 PA pentamidine isethionate for NEBUPENT brand 2 nebulization Antivirals Cytomegalovirus Treatment ganciclovir CYTOVENE generic 1 valganciclovir VALCYTE generic 1 tabs only Hepatitis Treatment elbasvir/grazoprevir ZEPATIER brand 2 PA, QL, SP entecavir BARACLUDE generic 1 QL PA, SP, preferred for glecaprevir/pibrentasvir MAVYRET brand 2 Genotypes 1, 2, 3, 4, 5, & 6 interferon alfa-2b INTRON A brand 2 PA, SP lamivudine EPIVIR HBV generic 1 QL ombitas-paritapre-riton & VIEKIRA PAK brand 2 Non-Preferred, PA, QL dasab tab pak peginterferon alfa-2a PEGASYS brand 2 PA, QL, SP peginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, QL, SP peginterferon alfa-2b PEG-INTRON brand 2 Non-Preferred, PA, QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 41 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug 200 mg caps and tabs ribavirin REBETOL/COPEGUS generic 1 only, QL, SP RIBASPHERE RIBAPAK ribavirin generic 1 Non-Preferred, PA, QL RIBATAB sofosbuvir/velpatasvir EPCLUSA generic 1 PA, SP telbivudine tabs TYZEKA brand 2 Non-Preferred, PA, QL Herpes Treatment acyclovir ZOVIRAX generic 1 caps, tabs, suspension Non-Preferred, PA, cream, acyclovir topical ZOVIRAX brand 2 ointment docosanol ABREVA OTC CREAM brand 2 valacyclovir VALTREX generic 1 Influenza Treatment amantadine SYMMETREL generic 1 except tabs Non-Preferred, oseltamivir TAMIFLU brand 2 suspension, QL oseltamivir TAMIFLU generic 1 capsules, QL rimantadine FLUMADINE generic 1 zanamivir RELENZA brand 2 QL Intergrase Inhibitors – Diagnosis Required dolutegravir TIVICAY brand 2 10mg and 25mg elvitegravir VITEKTA brand 2 Non-Preferred, PA raltegravir ISENTRESS brand 2 raltegravir ISENTRESS CHEWABLE brand 2 chewable tablet raltegravir ISENTRESS HD brand 2 Members ≥ 2 years of raltegravir susp ISENTRESS SUSP brand 2 age will require prior authorization. Non-Nucleoside Reverse Transcriptase Inhibitors – Diagnosis Required RESCRIPTOR brand 2 SUSTIVA brand 2 etravirine INTELENCE brand 2 nevirapine VIRAMUNE generic 1 nevirapine ER VIRAMUNE XR generic 1 rilpivirine EDURANT brand 2

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 42 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations – Diagnosis Required abacavir ZIAGEN generic 1 abacavir/lamivudine EPZICOM generic 1 abacavir/lamivudine/ TRIZIVIR generic 1 zidovudine didanosine VIDEX brand 2 didanosine VIDEX EC generic 1 delayed-release doravirine/lamivudine/ DELSTRIGO brand 2 QL tenofovir disoproxil efavirenz/lamivudine/ tenofovir disoproxil SYMFI, SYMFI LO brand 2 QL fumarate emtricitabine EMTRIVA brand 2 emtricitabine/rilpivirine/ COMPLERA brand 2 PA tenofovir lamivudine EPIVIR generic 1 lamivudine/tenofovir CIMDUO brand 2 QL disoproxil fumarate lamivudine/zidovudine COMBIVIR generic 1 stavudine ZERIT generic 1 zidovudine RETROVIR generic 1 zidovudine soln RETROVIR IV INFUSION brand 2 Non-Preferred, PA Nucleoside/Nucleotide Reverse-Transcriptase Inhibitor Combination – Diagnosis Required efavirenz/emtricitabine/ ATRIPLA brand 2 Non-Preferred, PA tenofovir emtricitabine/rilpivirine/ ODEFSEY brand 2 tenofovir emtricitabine/tenofovir TRUVADA brand 2 disoproxil emtricitabine/tenofovir DESCOVY brand 2 QL alafenamide Nucleotide Analogues Nucleotide Reverse - Transcriptase Inhibitor – Diagnosis Required tenofovir VIREAD generic 1 Protease Inhibitors – Diagnosis Required atazanavir REYATAZ brand 2 Members ≥ 8 years of REYATAZ POWDER atazanavir brand 2 age will require prior PACKET authorization darunavir PREZISTA brand 2

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 43 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug fosamprenavir LEXIVA brand 2 CRIXIVAN brand 2 lopinavir/ritonavir KALETRA brand 2 tablets lopinavir/ritonavir KALETRA generic 1 solution nelfinavir VIRACEPT brand 2 ritonavir NORVIR brand 2 saquinavir mesylate INVIRASE brand 2 tipranavir APTIVUS brand 2 Miscellaneous – Diagnosis Required abacavir/dolutegravir/ TRIUMEQ brand 2 lamivudine atazanavir/cobicistat EVOTAZ brand 2 QL bictegravir/emtricitabine/ BIKTARVY brand 2 PA, QL tenofovir alafenamide cobicistat TYBOST brand 2 cobicistat/elvitegravir/ STRIBILD brand 2 PA emtricitabine/tenofovir darunavir/cobicistat PREZCOBIX brand 2 dolutegravir/rilpivirine JULUCA brand 2 QL elvitegravir/cobicistat/ emtricitabine/tenofovir GENVOYA brand 2 PA alafenamide fumarate enfuvirtide FUZEON brand 2 25 mg and 75 mg tab, maraviroc SELZENTRY brand 2 solution Miscellaneous AZACTAM IN aztreonam in dextrose soln ISO-OSMOTIC brand 2 DEXTROSE INJ aztreonam solr AZACTAM INJ brand 2 bedaquiline SIRTURO brand 2 chloroquine phosphate ARALEN generic 1 clindamycin CLEOCIN generic 1 150 mg and 300 mg only clindamycin CLEOCIN generic 1 Non-Preferred, PA, 75 mg clindamycin phosphate CLEOCIN PHOSPHATE INJ generic 1 soln dapsone DAPSONE brand 2 hydroxychloroquine PLAQUENIL generic 1 QL linezolid ZYVOX generic 1 PA maraviroc SELZENTRY brand 2 mefloquine LARIAM generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 44 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug metronidazole FLAGYL generic 1 tabs only METRONIDAZOLE IN NACL metronidazole in nacl soln generic 1 0.79% neomycin sulfate brand 2 nitrofurantoin MACROBID generic 1 extended-release nitrofurantoin MACRODANTIN generic 1 macrocrystals Members ≥ 8 years of FURADANTIN SUSP nitrofurantoin susp generic 1 age will require prior 25 MG/5 ML authorization. palivizumab SYNAGIS brand 2 PA paromomycin HUMATIN generic 1 povidone-iodine generic 1 OTC primaquine generic 1 pyrimethamine DARAPRIM brand 2 PA tafenoquine KRINTAFEL brand 2 QL trimethoprim TRIMETHOPRIM generic 1 tabs only Musculoskeletal Arthritis Disease Modifying Anti-Rheumatic Drugs adalimumab HUMIRA brand 2 PA, QL, SP anakinra KINERET brand 2 PA, QL, SP apremilast OTEZLA brand 2 PA, SP auranofin RIDAURA brand 2 QL azathioprine IMURAN generic 1 QL baricitinib OLUMIANT brand 2 PA, QL, SP canakinumab ILARIS brand 2 PA, SP certolizumab pegol CIMZIA brand 2 PA, QL, SP etanercept ENBREL brand 2 PA, QL, SP hydroxychloroquine PLAQUENIL generic 1 QL leflunomide ARAVA generic 1 QL methotrexate generic 1 QL penicillamine DEPEN TITRATAB brand 2 Diagnosis Required, SP sarilumab KEVZARA brand 2 PA, SP secukinumab COSENTYX brand 2 PA, SP sulfasalazine AZULFIDINE generic 1 QL sulfasalazine AZULFIDINE EN-TABS generic 1 QL delayed-release ustekinumab prefilled STELARA brand 2 PA, QL, SP syring 90mg/ml

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 45 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug NSAIDs and Other Analgesics acetaminophen TYLENOL generic 1 OTC BAYER aspirin generic 1 OTC ECOTRIN CAPSAGEL OTC, gel, lotion, 0.035% CAPZASIN-P brand 2 cream CASTIVA OTC, 0.025%, 0.075%, & capsaicin generic 1 0.1% cream CELEBREX generic 1 PA, QL VOLTAREN 1% TOPICAL diclofenac 1% gel generic 1 PA GEL diclofenac potassium CATAFLAM generic 1 diclofenac sodium delayed- VOLTAREN generic 1 release diclofenac sodium VOLTAREN XR generic 1 extended-release diclofenac w/misoprostol ARTHROTEC generic 1 Non-Preferred, PA etodolac LODINE generic 1 IR only tabs, chew tabs ibuprofen ADVIL generic 1 and susp, OTC ibuprofen MOTRIN generic 1 tabs, chew tabs and susp indomethacin INDOCIN generic 1 ketoprofen ORUDIS generic 1 IR only meloxicam MOBIC generic 1 QL naproxen NAPROSYN generic 1 ENTERIC COATED- naproxen delayed release generic 1 NAPROSYN naproxen sodium ANAPROX generic 1 Non-Preferred, PA naproxen sodium tb24 NAPRELAN brand 2 Non-Preferred, PA oxaprozin DAYPRO generic 1 piroxicam FELDENE generic 1 DISALCID generic 1 QL sulindac CLINORIL generic 1 Gout allopurinol ZYLOPRIM generic 1 colchicine MITIGARE brand 2 febuxostat ULORIC brand 2 ST probenecid PROBENECID generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 46 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Skeletal Muscle Relaxants Muscle Spasm PARAFON FORTE DSC generic 1 FLEXERIL generic 1 5mg & 10mg ROBAXIN generic 1 NORFLEX generic 1 extended-release Spasticity baclofen BACLOFEN generic 1 dantrolene DANTRIUM generic 1 diazepam VALIUM generic 1 QL tizanidine ZANAFLEX generic 1 tabs only, QL OB-GYN Contraceptives Biphasic /EE MIRCETTE generic 1 QL norethindrone acetate- FEMHRT LOW DOSE generic 1 Non-Preferred, PA ethinyl estradiol tab JINTELI norethindrone/EE ORTHO-NOVUM 10/11 generic 1 QL norethindrone/ethinyl estradiol/ferrous LO MINASTRIN PAK FE brand 2 Non-Preferred, PA fumarate Emergency Contraception PLAN B ONE STEP generic 1 ELLA brand 2 Non-Preferred, PA Extended Cycle levonorgestrel/EE SEASONALE generic 1 QL Four-Phasic estradiol valerate- NATAZIA brand 2 estradiol valerate- NATAZIA brand 2 Non-Preferred, PA dienogest Injectable DEPO-PROVERA generic 1 QL acetate medroxyprogesterone DEPO-SUBQ PROVERA acetate brand 2 Non-Preferred, PA 104 (contraceptive) susp

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 47 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Intravaginal /EE NUVARING brand 2 ring, QL ORTHO COIL ortho diaphragm ORTHO FLAT brand 2 QL ORTHO FLEX Monophasic - 20 mcg Estrogen -ethinyl BEYAZ, SAFYRAL brand 2 Non-Preferred, PA estrad-levomefolate tab drospirenon-ethinyl YAZ, YASMIN generic 1 Non-Preferred, PA estradiol tab levomefolate glucosamine FALESSA brand 2 Non-Preferred, PA tabs levonorgestrel/EE ALESSE generic 1 0.1/20, QL norethin-eth estradiol-fe LO LOESTRIN FE brand 2 Non-Preferred, PA norethindrone ace & LOMEDIA 24 FE generic 1 Non-Preferred, PA ethinyl estradiol-fe norethindrone ace-eth MINASTRIN 24 FE brand 2 Non-Preferred, PA estradiol-fe chew tab norethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QL norethindrone acetate/EE/ LOESTRIN FE 1/20 generic 1 1/20, QL iron Monophasic - 30 mcg Estrogen desogestrel/EE ORTHO-CEPT generic 1 0.15/30, QL LOSEASONIQUE levonorgestrel/EE SEASONIQUE generic 1 Non-Preferred, PA QUARTETTE levonorgestrel/EE NORDETTE generic 1 0.15/30, QL levonorgestrel-ethinyl AMETHYST generic 1 Non-Preferred, PA estradiol norethindrone acetate/EE/ LOESTRIN FE 1.5/30 generic 1 1.5/30, QL iron norethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QL /EE LO/OVRAL generic 1 0.3/30, QL Monophasic - 35 mcg Estrogen ethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 48 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug norethindrone & ethinyl FEMCON FE brand 2 Non-Preferred, PA estradiol-fe chew tab GENERESS FE norethindrone/EE BALZIVA generic 1 0.4/35, QL norethindrone/EE MODICON generic 1 0.5/35, QL norethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QL /EE ORTHO-CYCLEN generic 1 0.25/35, QL Monophasic - 50 mcg Estrogen ethynodiol diacetate/EE ZOVIA 1/50 generic 1 1/50, QL norethindrone/EE OVCON 50 generic 1 1/50, QL norethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QL norgestrel/EE OVRAL generic 1 0.5/50, QL Progestin norethindrone ORTHO MICRONOR generic 1 Transdermal ORTHO EVRA /EE generic 1 XULANE Triphasic desogestrel/EE CYCLESSA generic 1 QL levonorgestrel/EE TRIVORA generic 1 QL norethindrone ESTROSTEP FE generic 1 QL acetate/EE/iron norethindrone/EE TRI-NORINYL generic 1 QL norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QL norgestimate/EE ORTHO TRI-CYCLEN generic 1 QL norgestimate-eth estrad ORTHO TRI-CYCLEN LO brand 2 Non-Preferred, PA Endometriosis DANOCRINE generic 1 Hormone Therapy/Menopause Estrogens - Intramuscular estradiol valerate oil DELESTROGEN INJ brand 2 Estrogens - Intravaginal estradiol ESTRADIOL brand 2 estradiol vaginal ring ESTRING brand 2 Non-Preferred, PA estrogens, conjugated PREMARIN brand 2 Non-Preferred, crm yuvafem or estradiol VAGIFEM generic 1 QL vaginal tablet Estrogens - Oral esterified estrogens MENEST brand 2 Non-Preferred, PA estradiol ESTRACE generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 49 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug estrogens, conjugated PREMARIN brand 2 estropipate OGEN generic 1 Estrogens - Transdermal estradiol CLIMARA generic 1 QL estradiol patch twice VIVELLE-DOT brand 2 Non-Preferred, PA weekly Estrogen/Progestin estradiol & norethindrone ACTIVELLA generic 1 Non-Preferred, PA acetate estradiol-levonorgestrel td CLIMARA PRO brand 2 Non-Preferred, PA patch weekly estradiol-norethindrone ace COMBIPATCH brand 2 Non-Preferred, PA td patch twice weekly estrogens, conjugated/ PREMPHASE brand 2 medroxyprogesterone PREMPRO Progestins hydroxyprogesterone MAKENA generic 1 Non-Preferred, PA caproate oil medroxyprogesterone PROVERA generic 1 acetate norethindrone acetate AYGESTIN generic 1 micronized PROMETRIUM generic 1 Diagnosis Required, QL caps progesterone oil PROGESTERONE generic 1 Non-Preferred, PA Ovulation Stimulants choriogonadotropin alfa OVIDREL brand 2 Diagnosis Required chorionic gonadotropin NOVAREL brand 2 Diagnosis Required Vaginal Infections Oral fluconazole DIFLUCAN generic 1 QL metronidazole FLAGYL generic 1 tabs Vaginal acetic acid-oxyquinoline FEM PH brand 2 Non-Preferred, PA vaginal gel clindamycin CLEOCIN generic 1 crm clindamycin phosphate CLEOCIN generic 1 Non-Preferred, PA, supp vaginal supp clotrimazole GYNE-LOTRIMIN generic 1 OTC

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 50 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug METROGEL-VAGINAL metronidazole generic 1 METROGEL 1% miconazole MONISTAT generic 1 OTC miconazole MONISTAT 3 generic 1 terconazole TERAZOL 3/7 generic 1 crm tioconazole vaginal oint TIOCONAZOLE-1 generic 1 Non-Preferred, PA Miscellaneous conjugated estrogen/ DUAVEE brand 2 bazedoxifene elagolix ORILISSA brand 2 PA, QL methylergonovine METHERGINE generic 1 tranexamic acid LYSTEDA generic 1 PA tranexamic acid soln CYKLOKAPRON generic 1 Ophthalmic Allergy azelastine OPTIVAR generic 1 ST cromolyn sodium CROLOM generic 1 QL ketotifen ALAWAY OTC generic 1 ketotifen ZADITOR generic 1 QL CLEAR EYES REDNESS naphazoline/glycerin generic 1 RELIEF naphazoline HCL VASOCLEAR generic 1 soln 0.02% naphazoline/zinc sulfate VASOCLEAR A brand 2 OTC olopatadine HCL soln PATADAY brand 2 Non-Preferred, PA tetrahydrozoline/ VISINE-AC generic 1 zinc sulfate Anti-Inflammatories Anti-Infective/Anti-Inflammatory Combinations gentamicin/prednisolone PRED-G brand 2 acetate etabonate- ZYLET brand 2 Non-Preferred, PA tobramycin bacitracin/polymyxin/ CORTISPORIN generic 1 ointment neomycin/hc neomycin/polymyxin B/ MAXITROL generic 1 dexamethasone neomycin/polymyxin B/ CORTISPORIN generic 1 suspension hydrocortisone sulfacetamide/pred phos VASOCIDIN generic 1 10%/0.25%

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 51 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug tobramycin/ TOBRADEX generic 1 dexamethasone diclofenac sodium VOLTAREN generic 1 OCUFEN generic 1 ketorolac ACULAR/ACULAR LS generic 1 nepafenac susp ILEVRO brand 2 Non-Preferred, PA Steroidal dexamethasone sodium DEXASOL generic 1 phosphate dexamethasone (ophth) MAXIDEX brand 2 Non-Preferred, PA susp FML brand 2 Non-Preferred, oint 0.1% Non-Preferred, susp fluorometholone FML FORTE brand 2 0.25% fluorometholone FML LIQUIFILM generic 1 susp 0.1% fluorometholone acetate FLAREX brand 2 Non-Preferred, PA opth susp LOTEMAX loteprednol etabonate brand 2 Non-Preferred, PA ALREX PRED FORTE generic 1 1% prednisolone acetate PRED MILD brand 2 0.12% prednisolone phosphate INFLAMASE FORTE generic 1 1% Glaucoma Beta-Blockers generic 1 levobunolol BETAGAN generic 1 ophthalmic solution metipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solution METIPRANOLOL OTH metipranolol soln generic 1 Non-Preferred, PA SOLN timolol TIMOPTIC XE generic 1 gel forming solution timolol maleate TIMOPTIC generic 1 Carbonic Anhydrase Inhibitors brinzolamide-brimonidine SIMBRINZA brand 2 Non-Preferred, PA tartrate ophth susp brinzolamide susp AZOPT brand 2 Non-Preferred, PA dorzolamide TRUSOPT generic 1 Carbonic Anhydrase Inhibitor/Beta-Blocker Combination dorzolamide/ COSOPT generic 1 timolol maleate

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 52 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Inhibitor ecothiophate PHOSPHOLINE IODINE brand 2 Mydriatics atropine ISOPTO ATROPINE generic 1 CYCLOGYL generic 1 1% ISOPTO HOMATROPINE generic 1 5% homatropine ISOPTO HOMATROPINE brand 2 2% scopolamine ISOPTO HYOSCINE brand 2 Oral acetazolamide ACETAZOLAMIDE generic 1 acetazolamide DIAMOX SEQUELS generic 1 extended-release methazolamide NEPTAZANE generic 1 Parasympathomimetics pilocarpine PILOPINE HS GEL brand 2 pilocarpine ISOPTO CARPINE generic 1 Prostaglandins latanoprost XALATAN generic 1 QL travoprost soln TRAVATAN Z brand 2 Non-Preferred, PA Sympathomimetics brimonidine ALPHAGAN P brand 2 0.1% brimonidine ALPHAGAN P generic 1 0.15% brimonidine ALPHAGAN generic 1 0.2% brimonidine tartrate- timolol maleate COMBIGAN brand 2 Non-Preferred, PA ophth soln Immunologic Agents cyclosporine (ophth) emul RESTASIS brand 2 Non-Preferred, PA lifitegrast XIIDRA brand 2 PA Infections Bacterial bacitracin generic 1 ciprofloxacin CILOXAN generic 1 solution ciprofloxacin CILOXAN brand 2 ointment erythromycin ERYTHROMYCIN generic 1 gentamicin GENTAK generic 1 moxifloxacin HCL (ophth) MOXEZA brand 2 Non-Preferred, PA soln VIGAMOX

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 53 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug neomycin/bacitracin/ NEOSPORIN generic 1 ointment polymyxin neomycin/polymyxin B/ NEOSPORIN generic 1 solution gramicidin ofloxacin OCUFLOX generic 1 polymyxin B/bacitracin POLYSPORIN generic 1 polymyxin B/trimethoprim POLYTRIM generic 1 sulfacetamide BLEPH-10 generic 1 oint/soln tobramycin TOBREX generic 1 Fungal natamycin susp NATACYN brand 2 Non-Preferred, PA Viral trifluridine VIROPTIC generic 1 Miscellaneous apraclonidin ophthalmic LOPIDINE generic 1 QL solution cysteamine 0.44% CYSTARAN brand 2 Diagnosis Required, SP ophthalmic solution ophthalmic irrigation solution - intraocular BSS generic 1 Non-Preferred, PA soln sodium chloride MURO 128 generic 1 soln 5% hypertonic Psychiatric Alcohol Deterrents acamprosate CAMPRAL brand 2 disulfiram ANTABUSE generic 1 naltrexone REVIA generic 1 Anxiety Benzodiazepines alprazolam XANAX generic 1 QL, IR only alprazolam conc ALPRAZOLAM INTENSOL generic 1 Non-Preferred, PA chlordiazepoxide LIBRIUM generic 1 clonazepam KLONOPIN generic 1 not wafers clorazepate TRANXENE generic 1 diazepam VALIUM generic 1 QL diazepam conc DIAZEPAM INTENSOL generic 1 Non-Preferred, PA ATIVAN generic 1 QL lorazepam conc LORAZEPAM INTENSOL generic 1 Non-Preferred, PA lorazepam inj soln LORAZEPAM INJ generic 1 oxazepam SERAX generic 1 QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 54 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Miscellaneous BUSPAR generic 1 fluvoxamine LUVOX generic 1 Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis required / dextroamphetamine ADDERALL generic 1 QL mixed salts amphetamine/ ADDERALL XR dextroamphetamine (BRAND ADDERALL XR brand 2 QL mixed salts IS PREFERRED) extended-release atomoxetine STRATTERA generic 1 QL desvenlafaxine succinate PRISTIQ generic 1 tb24 dexmethylphenidate HCL FOCALIN XR generic 1 Non-Preferred, PA cp24 dexmethylphenidate HCL FOCALIN generic 1 Non-Preferred, PA tabs dextroamphetamine DEXEDRINE generic 1 Non-Preferred, PA, QL guanfacine ER INTUNIV generic 1 lisdexamfetamine VYVANSE brand 2 QL lisdexamfetamine VYVANSE CHEWABLE brand 2 Diagnosis Required chewable tab methylphenidate RITALIN generic 1 tabs only, QL methylphenidate CONCERTA generic 1 Age Limit Applies, QL extended-release methylphenidate METADATE CD generic 1 QL extended-release METADATE ER methylphenidate Age Limit Applies, QL, RITALIN LA generic 1 extended-release 20 mg, 30 mg, 40 mg caps methylphenidate HCL METHYLIN brand 2 Non-Preferred, PA chew Age Limit Applies, PA, QL, 18mg, 27mg, methylphenidate HCL ER generic 1 36mg, 54mg tablets, 24hr Mallinckrodt and Kremers Urban labelers

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 55 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug methylphenidate HCL oral QUILLIVANT XR brand 2 Non-Preferred, PA susr methylphenidate patch DAYTRANA brand 2 Non-Preferred, PA Bipolar Disorder Members ≥ 8 years of divalproex sodium DEPAKOTE SPRINKLE generic 1 age will require prior cap sprinkle authorization. divalproex sodium DEPAKOTE generic 1 Minimum age 2 delayed-release lithium carbonate LITHIUM CARBONATE generic 1 lithium carbonate ESKALITH CR generic 1 extended-release LITHOBID Depression Monoamine Oxidase Inhibitor (MAOI) isocarboxazid tabs MARPLAN brand 2 Non-Preferred, PA tranylcypromine PARNATE generic 1 Selective Serotonin Reuptake Inhibitor (SSRIs) citalopram CELEXA generic 1 QL escitalopram LEXAPRO generic 1 tablets, QL 10 mg and 20 mg caps PROZAC generic 1 and 20 mg soln only Non-Preferred, PA, 10 mg fluoxetine HCL caps PROZAC generic 1 and 40 mg capsule fluoxetine HCL tabs FLUOXETINE HCL generic 1 Non-Preferred, PA, tablets fluoxetine HCL (pmdd) SARAFEM brand 2 Non-Preferred, PA caps PAXIL generic 1 tablets sertraline ZOLOFT generic 1 tablets, QL Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine CYMBALTA generic 1 QL duloxetine HCL cpep IRENKA brand 2 Non-Preferred, PA venlafaxine EFFEXOR generic 1 QL venlafaxine XR EFFEXOR XR generic 1 QL (TCAs) amitriptyline ELAVIL generic 1 tablets generic 1 HCL caps CLOMIPRAMINE HCL generic 1 Non-Preferred, PA NORPRAMIN generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 56 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug doxepin SINEQUAN generic 1 HCL TOFRANIL generic 1 tablets imipramine pamoate caps TOFRANIL-PM brand 2 Non-Preferred, PA PAMELOR generic 1 HCL tabs VIVACTIL brand 2 Non-Preferred, PA / Combination amitriptyline/ TRIAVIL generic 1 Miscellaneous Agents WELLBUTRIN generic 1 bupropion WELLBUTRIN SR generic 1 QL extended-release bupropion WELLBUTRIN XL generic 1 150 mg and 300 mg extended-release LUDIOMIL generic 1 REMERON generic 1 tabs (not soltabs) 50mg, 100mg, & 150mg trazodone DESYREL generic 1 only HBR TRINTELLIX brand 2 Non-Preferred, PA Insomnia Benzodiazepines flurazepam DALMANE generic 1 QL 15 mg and 30 mg only, temazepam RESTORIL generic 1 QL triazolam HALCION generic 1 QL Non-Benzodiazepines chloral hydrate CHLORAL HYDRATE generic 1 diphenhydramine NYTOL QUICK CAPS generic 1 OTC succinate UNISOM generic 1 25mg, OTC, QL zaleplon SONATA generic 1 QL zolpidem AMBIEN generic 1 QL Narcotic Antagonists buprenorphine SUBUTEX generic 1 PA, QL 2 mg and 8 mg film only, buprenorphine/naloxone SUBOXONE brand 2 PA, QL buprenorphine/naloxone 2 mg and 8 mg tab only, SUBOXONE generic 1 SL tab PA, QL naloxone NALOXONE INJ generic 1 QL naloxone NARCAN NASAL SPRAY brand 2 naltrexone REVIA generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 57 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Psychoses – Diagnosis required Atypicals Age Limit Applies, ABILIFY TABLETS generic 1 tablets, QL aripiprazole injection ARISTADA brand 2 PA, QL aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QL Non-Preferred, PA, QL, aripiprazole ODT ABILIFY DISC TAB brand 2 Age Limit Applies Non-Preferred, PA, QL, aripiprazole soln ABILIFY SOL brand 2 Age Limit Applies 25mg, 50mg, 100mg CLOZARIL generic 1 only, Age Limit Applies, QL Non-Preferred, PA, QL, clozapine CLOZARIL generic 1 200mg only, Age Limit Applies clozapine ODT FAZACLO brand 2 Non-Preferred, PA FANAPT brand 2 Non-Preferred, PA, QL FANAPT TITRATION PACK HCL tabs LATUDA brand 2 Non-Preferred, PA, QL Age Limit Applies, ZYPREXA generic 1 tablets, QL Non-Preferred, PA, QL, olanzapine ODT ZYPREXA ZYDIS generic 1 Age Limit Applies INVEGA SUSTENNA brand 2 Age Limit Applies, PA, QL paliperidone INVEGA TRINZA brand 2 Age Limit Applies, PA, QL SEROQUEL generic 1 Age Limit Applies, QL Non-Preferred, PA, QL, quetiapine fumarate tb24 SEROQUEL XR generic 1 Age Limit Applies Age Limit Applies, QL, RISPERDAL generic 1 (Not M-Tabs) risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QL Age Limit Applies, PA, risperidone inj PERSERIS brand 2 QL, SP Non-Preferred, Age Limit risperidone ODT RISPERDAL M-TAB generic 1 Applies, PA, QL QL, Members ≥ 8 years risperidone oral soln RISPERDAL SOLUTION generic 1 of age will require prior authorization. GEODON generic 1 Age Limit Applies, QL

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 58 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Smoking Cessation bupropion HCL (smoking ZYBAN generic 1 Non-Preferred, PA deterrent) NICODERM CQ generic 1 patches, QL NICOTINE nicotine kit TRANSDERMAL brand 2 Non-Preferred, PA SYSTEM nicotine polacrilex gum NICORETTE OTC generic 1 QL nicotine polacrilex lozenge COMMITT OTC generic 1 QL CHANTIX brand 2 PA Miscellaneous THORAZINE generic 1 CHLORPROMAZINE HCL chlorpromazine HCL soln generic 1 INJ / NUEDEXTA brand 2 Diagnosis Required, QL quinidine PROLIXIN generic 1 fluphenazine decanoate PROLIXIN DECANOATE generic 1 HALDOL generic 1 tab, inj, & decanoate only haloperidol lactate oral HALOPERIDOL generic 1 Non-Preferred, PA conc LOXITANE generic 1 olanzapine-fluoxetine SYMBYAX generic 1 Non-Preferred, PA perphenazine TRILAFON generic 1 ORAP generic 1 MELLARIL generic 1 thiothixene NAVANE generic 1 STELAZINE generic 1 Respiratory Drugs Antitussives, Decongestants, Expectorants and Combinations benzonatate TESSALON generic 1 benzonatate caps ZONATUSS brand 2 Non-Preferred, PA & DIMETAPP CLD ELX/ generic 1 phenylephrine ALLERGY brompheniramine & pseudoephedrine J-TAN D PD generic 1 Non-Preferred, PA liquid 1-7.5 mg/ml brompheniramine/ ACCUHIST DROPS generic 1 pseudoephedrine UNI-HIST DROPS

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 59 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug brompheniramine/ pseudoephedrine/ BROMFED DM generic 1 syrup dextromethorphan maleate PALGIC generic 1 Non-Preferred, PA carbinoxamine maleate KARBINAL ER brand 2 Non-Preferred, PA extended-release chlordiazepoxide- LIMBITROL generic 1 Non-Preferred, PA amitriptyline TRIOTANN PEDIATRIC chlorphen tan/pyrilamine SUSP generic 1 susp tan/PE tan R-TANNAMINE chlorphen tan/ TUSSI-12 S generic 1 susp carbetapentane tan chlorpheniramine & DALLERGY, NASOHIST generic 1 Non-Preferred, PA phenylephrine liquid ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN LIQ chlorpheniramine/ CGH/CLD generic 1 dextromethorphan DIMETAPP SYP CGH/CLD CORICIDIN TAB CGH/CLD chlorpheniramine maleate ED A-HIST TABLETS AND generic 1 phenylephrine HCL LIQUID chlorpheniramine/ RONDEC DROPS generic 1 liquid phenylephrine CARDEC DRO chlorpheniramine/ RONDEC SYRUP generic 1 syrup phenylephrine CARDEC SYP chlorpheniramine/ CPM/PSE generic 1 pseudoephedrine LOHIST-D chlorpheniramine tan/ RYNATAN PEDIATRIC SUSP generic 1 susp phenylephrine tan chlorpheniramine LEXUSS 210 generic 1 Non-Preferred, PA w/codeine liquid codeine- POLY-TUSSIN brand 2 Non-Preferred, PA liquid

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 60 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug codeine/ DIHISTINE DH chlorpheniramine/ generic 1 Age Limits Apply, QL PHENYLHIST LIQ DH pseudoephedrine GUIATUSS AC codeine/guaifenesin GG/CODEINE generic 1 Age Limits Apply, QL M-CLEAR WC codeine/guaifenesin/ GUIATUSS DAC generic 1 pseudoephedrine PROMETHAZINE codeine/promethazine generic 1 Age Limits Apply, QL W/CODEINE codeine/promethazine/ PROMETHAZINE VC generic 1 Age Limits Apply, QL phenylephrine W/CODEINE codeine- pseudoephedrine- POLY-TUSSIN D brand 2 Non-Preferred, PA chlorcyclizine liq codeine-pyrilamine syrup PRO-CLEAR AC brand 2 Non-Preferred, PA dextromethorphan/ brompheniramine/ BROMETANE DX generic 1 pseudoephedrine dextromethorphan- DURATUSS DM ELX generic 1 soln 25-225 mg/5 ml guaifenesin GG/DM CR dextromethorphan/ MUCINEX DM generic 1 OTC guaifenesin ROBITUSSIN DM TUSSIN DM dextromethorphan- ROBITUSSIN LIQ CGH/ generic 1 liq 10-200 mg/ 5 ml guaifenesin CONG TRIAMINIC COUGH & dextromethorphan- CONGESTION generic 1 Non-Preferred, PA guaifenesin syrup CHILDRENS ROBITUSSIN SYP MAX-ST dextromethorphan hbr generic 1 syrup ROBITUSSIN PED SYP dextromethorphan polistirex DELSYM brand 2 OTC extended-release dextromethorphan/ PHENERGAN DM generic 1 promethazine PROMETHAZINE SYP DM guaifenesin ROBITUSSIN generic 1 OTC

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 61 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug ROBITUSSIN SYP guaifenesin generic 1 syrup 100 mg/5 ml CHST CNG CODAR GF guaifenesin-codeine liquid MAR-COF CG generic 1 Non-Preferred, PA EXPECTORANT guaifenesin MUCINEX generic 1 OTC extended-release YODEFAN-NF CHEST guaifenesin liqd generic 1 Non-Preferred, PA CONGESTION guaifenesin pack MUCINEX FOR KIDS brand 2 Non-Preferred, PA guaifenesin/ ROBITUSSIN PE generic 1 syrup, OTC pseudoephedrine PSE/GG guaifenesin/ pseudoephedrine MUCINEX D generic 1 OTC extended-release guaifenesin/ pseudoephedrine/ ROBITUSSIN CF generic 1 dextromethorphan hydrocod polst-chlorphen TUSSICAPS brand 2 Non-Preferred, PA polst cap sr 12hr TUSSIONEX hydrocod polst-chlorphen PENNKINETIC generic 1 Non-Preferred, PA polst cr susp EXTENDED-RELEASE HYCODAN HYDROMET SYP hydrocodone/homatropine generic 1 Age Limits Apply, QL HYDROCODONE/ TAB HOMATROP loratadine & pseudoephedrine SR CLARITIN-D generic 1 24hr phenylephrine-bromphen M-END PE brand 2 Non-Preferred, PA w/codeine liqd POLY-TUSSIN AC phenylephrine/ brompheniramine/ generic 1 OTC dextromethorphan

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 62 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug phenylephrine- brompheniramine- ALAHIST DM generic 1 Non-Preferred, PA dm liquid phenylephrine-chlorphen CAPCOF brand 2 Non-Preferred, PA w/codeine syrup RONDEC DM DROPS phenylephrine/ CARDEC DM DRO chlorpheniramine/ generic 1 liquid dextromethorphan ROBITUSSIN LIQ CGH/ALRG RONDEC DM phenylephrine/ STATUSS DM SYP chlorpheniramine/ generic 1 syrup CARDEC DM SYP dextromethorphan MINUTUSS DR SYP phenylephrine/ chlorpheniramine/ DIHYDRO-PE SYP generic 1 phenylephrine- dexchlorphenir- PRO-RED AC brand 2 Non-Preferred, PA codeine syrup phenylephrine/ DIMETAPP DRO generic 1 dextromethorphan DCON/CGH phenylephrine/ ROBITUSSIN LIQ dextromethorphan/ generic 1 CGH/CLD guaifenesin phenylephrine/ephed/ RYNATUSS PEDIATRIC CPM w/ generic 1 susp SUSP carbetapentane ROBITUSSIN LIQ phenylephrine/guaifenesin generic 1 HD/CHST phenylephrine/pyrilamine CODIMAL DH generic 1 syrup w/hydrocodone promethazine & PROMETH VC SYP generic 1 syrup 6.25-5 mg/ 5 mg phenylephrine 6.25-5/5 pseudoeph-chlorphen ZUTRIPRO generic 1 Non-Preferred, PA w/hydrocodone soln pseudoephed- M-END DM LIQ generic 1 Non-Preferred, PA chlorphen-dm liq pseudoephed-- PEDIATEX TDM brand 2 Non-Preferred, PA dm susp

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 63 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug pseudoephedrine/ acetaminophen/ MAPAP COLD TAB generic 1 dextromethorphan pseudoephedrine- M-END WC generic 1 Non-Preferred, PA bromphen-codeine liq MAR-COF BP PEDIACARE LIQ pseudoephedrine/ MULTI-SY chlorpheniramine/ generic 1 dextromethorphan ROBITUSSIN LIQ PED NGHT pseudoephedrine- dexbromphen-codeine M-END MAX D generic 1 Non-Preferred, PA liqd pseudoephedrine/ MULTI SYMPTOM TAB dextromethorphan/ generic 1 COLD RLF guaifenesin pseudoephedrine- RESPAIRE-30 brand 2 OTC, Non-Preferred, PA guaifenesin cap CHILD IBUPRO pseudoephedrine/ SUS COLD generic 1 iburprofen IBUOROFEN TAB COLD/SIN pseudoephedrine tan/ TANAFED DMX dexchlorphen tan/ SUSPENSION generic 1 susp DM tan TRI-FED X pseudoephedrine LORTUSS EX brand 2 Non-Preferred, PA w/cod-gg SUTTAR-SF pseudoephedrine REZIRA generic 1 Non-Preferred, PA w/hydrocodone soln pyrilamine-phenylephrine POLY HIST brand 2 Non-Preferred, PA tab pyrilamine tan/phenyleph RYNA-12 S generic 1 susp tan tripolidine/ TRIPROL/PSE SYP generic 1 pseudoephedrine APHEDRID TAB Asthma/COPD Inhalers - Beta Agonists generic/ albuterol sulfate VENTOLIN HFA 1/2 QL brand indacaterol ARCAPTA NEOHALER brand 2 olodaterol STRIVERDI RESPIMAT brand 2

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 64 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Inhalers - Corticosteroids beclomethasone QVAR REDIHALER brand 2 QL ARNUITY ELLIPTA brand 2 QL fluticasone HFA FLOVENT HFA brand 2 Non-Preferred, QL FLOVENT DISKUS brand 2 Non-Preferred, QL mometasone ASMANEX TWISTHALER brand 2 QL mometasone inhalation ASMANEX HFA brand 2 QL Inhalers - Corticosteroid/Beta Combinations budesonide/formoterol SYMBICORT brand 2 Non-Preferred fluticasone/salmeterol ADVAIR DISKUS generic 1 PA fluticasone/salmeterol ADVAIR HFA brand 2 Non-Preferred, QL fluticasone/salmeterol AIRDUO RESPICLICK generic 1 QL fluticasone/salmeterol WIXELA INHUB brand 2 PA mometasone/formoterol DULERA brand 2 Non-Preferred, ST Inhalers - Others ipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaler ipratropium HFA ATROVENT HFA brand 2 tiotropium SPIRIVA brand 2 Non-Preferred tiotropium/olodaterol STIOLTO RESPIMAT brand 2 QL umeclidinium inhalation INCRUSE ELLIPTA brand 2 Inhalers for Nebulization 0.63 mg/3 ml and 1.25 mg /3 ml, Covered for members less than 8 albuterol ACCUNEB generic 1 years of age. Members ≥ 8 years of age will require prior authorization. albuterol PROVENTIL generic 1 soln 0.083%, 0.5% susp, Members ≥ 5 years budesonide PULMICORT RESPULES generic 1 of age will require prior authorization, QL cromolyn INTAL generic 1 soln, QL ipratropium ATROVENT generic 1 soln, QL ipratropium/albuterol DUONEB generic 1 soln levalbuterol HCl XOPENEX RESPULES generic 1 QL, ST Oral Agents - Beta Agonists albuterol sulfate tabs PROVENTIL generic 1 Non-Preferred, PA METAPROTERENOL metaproterenol generic 1 SYRUP terbutaline BRETHINE generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 65 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Oral Agents - Leukotriene Modifiers montelukast SINGULAIR generic 1 QL zafirlukast ACCOLATE brand 2 Non-Preferred, PA Oral Agents - Theophylline dyphylline tabs LUFYLLIN brand 2 Non-Preferred, PA theophylline THEOPHYLLINE generic 1 liquid theophylline THEO-24 brand 2 caps extended-release theophylline THEOCHRON generic 1 tabs extended-release UNIPHYL theophylline soln THEOPHYLLINE SOLN generic 1 Non-Preferred, PA Miscellaneous roflumilast DALIRESP brand 2 Non-Preferred, PA terbutaline sulfate inj soln TERBUTALINE SULFATE INJ generic 1 Urological Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL generic 1 doxazosin CARDURA generic 1 dutasteride caps AVODART brand 2 Non-Preferred, PA finasteride PROSCAR generic 1 tamsulosin FLOMAX generic 1 terazosin HYTRIN generic 1 Miscellaneous URECHOLINE generic 1 fumarate tb24 TOVIAZ brand 2 Non-Preferred, PA hyoscyamine, methenamine, phenyl salicylate, sodium UTIRA C brand 2 phosphate monobasic, methylene blue HIPREX methenamine hippurate generic 1 UREX methenamine mandelate METHENAMINE generic 1 Non-Preferred, PA tabs MANDELATE neomycin/polymyxin b gu NEOSPORIN GU generic 1 soln IRRIGANT oxybutynin chloride DITROPAN XL generic 1 QL oxybutynin IR DITROPAN generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 66 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug OXYTROL FOR WOMEN oxybutynin patch brand 2 OTC PATCH pentosan polysulfate ELMIRON brand 2 Diagnosis Required, QL sodium potassium citrate UROCIT-K generic 1 propantheline generic 1 PYRIDIUM generic 1 sevelamer HCl tabs RENAGEL brand 2 Non-Preferred, PA sodium citrate & citric acid ORACIT brand 2 Non-Preferred, PA soln sodium citrate/citric acid BICITRA generic 1 succinate tabs VESICARE brand 2 Non-Preferred, PA tiopronin THIOLA brand 2 Non-Preferred, PA tolterodine DETROL generic 1 ST trospium SANCTURA generic 1 ST Vitamins and Minerals ascorbic acid soln ASCORBIC ACID INJ generic 1 b-complex B-COMPLEX VITAMIN TAB generic 1 OTC, QL b-complex w/c-biotin-d-zinc VITAL-D RX brand 2 Non-Preferred, PA & folic acid b-complex w/c-biotin-e- DIALYVITE 3000 brand 2 Non-Preferred, PA minerals & folic acid DIALYVITE 5000 b-complex w/c-biotin-fe DIALYVITE 800/IRON brand 2 Non-Preferred, PA & folic acid b-complex w/c-zn & folic NEPHPLEX RX brand 2 Non-Preferred, PA acid calcitriol ROCALTROL generic 1 Members ≥ 8 years of calcitriol oral soln ROCALTROL SOLUTION generic 1 age will require prior authorization. calcitriol soln CALCITRIOL INJ generic 1 calcium OS-CAL generic 1 OTC calcium carbonate chew CALCIUM generic 1 Non-Preferred, PA calcium chloride CALCIUM CHLORIDE INJ generic 1 (dihydrate) soln calcium gluconate soln CALCIUM GLUCONATE INJ generic 1 carbonyl iron susp ICAR PEDIATRIC brand 2 Non-Preferred, PA drops 400 unit/0.03 ml, cholecalciferol BIO-D DRO-MULSION generic 1 OTC

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 67 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug BIO-D-MULSIO drops 2000 unit/0.03 ml, cholecalciferol generic 1 DRO FORTE OTC cholecalciferol D3-50 CAP brand 2 cap 50000 unit, OTC caps & tabs 400 unit, cholecalciferol VITAMIN D 400 UNIT generic 1 OTC caps & tabs 2000 unit, cholecalciferol VITAMIN D 2000 UNIT generic 1 OTC caps & tabs 1000 unit, cholecalciferol VITAMIN D 1000 UNIT generic 1 OTC chromic chloride soln CHROMIUM CHLORIDE generic 1 cobalamine combination FOLTRATE brand 2 Non-Preferred, PA tab cupric chloride soln COPPER TRACE METAL brand 2 cyanocobalamin VITAMIN B-12 generic 1 inj doxercalciferol caps HECTOROL brand 2 Non-Preferred, PA electrolyte PEDIALYTE generic 1 soln, oral, OTC ergocalciferol (D2) DRISDOL generic 1 fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab IROSPAN 24/6 brand 2 Non-Preferred, PA ther pk fe asparto gly-b12-fa-c-dss- succinic acid-zn tab FERIVA 21/7 brand 2 Non-Preferred, PA 75-1 mg fe bisglycinate-fe polysacch-vit c-vit b12- TARON FORTE brand 2 Non-Preferred, PA fa cap fe carbonyl-fa-b complex-a- c-d-e-min tab 75-1.25 ACTIVE FE generic 1 Non-Preferred, PA mg fe carbonyl-fe gluconate- fa-vit b12-vit c-dss tab FERRALET 90 generic 1 Non-Preferred, PA 90-1 mg fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40- INTEGRA F brand 2 Non-Preferred, PA 3mg(125 mg fe) fe fum-iron poly cmplx-fa-b cmplx-c-biotin-probiotic FUSION PLUS brand 2 Non-Preferred, PA cap

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 68 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug fe fum-iron polysacch complex-fa-b cmplx-c- TANDEM PLUS generic 1 Non-Preferred, PA zn-mn-cu cap fe fum-iron polysacch complex-fa-b INTEGRA PLUS brand 2 Non-Preferred, PA complex-c-biotin cap fe fumarate-vit c-vit b12-fa HEMATOGEN FA generic 1 Non-Preferred, PA cap FERROGELS FORTE ferrous fumarate-fa-b complex-c-zn-mg-mn-cu HEMOCYTE PLUS brand 2 Non-Preferred, PA cap ferrous fumarate-folic acid HEMOCYTE-F generic 1 Non-Preferred, PA tab ferrous fumarate tabs FERRIMIN 150 brand 2 Non-Preferred, PA ferrous fumarate w/fa-dss-b complex-vit NEPHRON FA brand 2 Non-Preferred, PA c tab ferrous gluconate tabs FERGON generic 1 Non-Preferred, PA ferrous sulfate FEOSOL generic 1 OTC ferrous sulfate dried tabs GNP IRON generic 1 Non-Preferred, PA ferrous sulfate dried tbcr SM SLOW RELEASE IRON generic 1 Non-Preferred, PA ferrous sulfate extended- SLOW FE generic 1 Non-Preferred, PA release tablets ferrous sulfate liquid FERROUS SULFATE generic 1 Non-Preferred, PA ferrous sulfate syrup FERROUS SULFATE generic 1 Non-Preferred, PA GEL-KAM LURIDE fluoride LURIDE LOZI-TABS generic 1 PREVIDENT PHOS-FLUR folic acid FOLIC ACID generic 1 folic acid-b6-b12-d- omega 3-phytosterols ANIMI-3/VITAMIN D brand 2 Non-Preferred, PA cap 1 mg folic acid soln FOLIC ACID INJ generic 1 folic acid-vitamin b6- FOLGARD RX generic 1 Non-Preferred, PA vitamin b12 tab genistein-zinc amino acid FOSTEUM generic 1 Non-Preferred, PA chelate-vitamin d cap

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 69 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug HEMATOGEN iron combination generic 1 Non-Preferred, PA FE PLUS PROTEIN iron-docusate-b12-folic HEMATRON-AF generic 1 Non-Preferred, PA acid-c-e-cu-biotin tab iron-folic acid-vit b12-vit FERRAPLUS 90 generic 1 Non-Preferred, PA c-docusate sod tab iron-folic acid-vit c-vit b6-vit CORVITE 150 generic 1 Non-Preferred, PA b12-zinc tab iron-vit c-vit b12-folic acid ICAR-C PLUS generic 1 Non-Preferred, PA tab iron w/vitamins tabs IROMIN-G generic 1 Non-Preferred, PA l-methylfolate- methylcobalamin- CEREFOLIN NAC generic 1 Non-Preferred, PA acetylcyst tab 6-2-600 mg l-methylfolate tabs L-METHYLFOLATE generic 1 Non-Preferred, PA l-methylfolate w/vit b12-vit b6-vit b2 tab CEREFOLIN generic 1 Non-Preferred, PA 6-1-50-5 mg magnesium chloride inj MAGNESIUM CHLORIDE generic 1 soln INJ manganese chloride inj MANGANESE TRACE brand 2 soln METAL INJ magnesium oxide MAG-OX generic 1 OTC magnesium sulfate inj soln MAGNESIUM SULFATE INJ brand 2 multiple vitamin chewable AQUADEKS brand 2 Diagnosis Required, QL tablet and drops multiple vitamin inj INFUVITE PEDIATRIC brand 2 multiple vitamins ADVANCED AM/PM brand 2 Non-Preferred, PA w/calcium misc multiple vitamins w/minerals & calcium- FOLGARD OS brand 2 Non-Preferred, PA folic acid tabs UDAMIN SP multiple vitamins CORVITE brand 2 Non-Preferred, PA w/minerals & folic acid DIALYVITE SUPREME D multiple vitamins w/minerals & folic acid MULTICHEW CHW brand 2 Non-Preferred, PA chew

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 70 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug multivitamins/ POLY-VI-FLOR generic 1 fluoride/±iron multivitamins/minerals CENTRUM generic 1 OTC niacinamide w/zinc- copper & NICOMIDE brand 2 Non-Preferred, PA l-methylfolate tabs niacinamide w/zinc- copper-methylfolate-se- NICOMIDE brand 2 Non-Preferred, PA cr tabs nutritional supplements SENTRA AM brand 2 Non-Preferred, PA caps paricalcitol caps ZEMPLAR generic 1 Non-Preferred, PA paricalcitol iv soln ZEMPLAR IV brand 2 ped multivitamins ESCAVITE LQ brand 2 Non-Preferred, PA w/fl & iron liqd ped multivitamins POLY-VI-FLOR/IRON brand 2 Non-Preferred, PA w/fl & iron susp pediatric multiple vitamin VITAMAX PEDIATRIC brand 2 Non-Preferred, PA w/minerals & c soln pediatric multivitamins Non-Preferred, PA, chew, POLY-VI-FLOR brand 2 w/fl suspension ESCAVITE D pediatric multivitamins ESCAVITE brand 2 Non-Preferred, PA w/fl & iron chew POLY-VI-FLOR/IRON pediatric vitamins acd & l-methylfolate TRI-VI-FLOR brand 2 Non-Preferred, PA w/fluoride susp phytonadione MEPHYTON brand 2 phytonadione soln VITAMIN K1 generic 1 polysacch fe cmplx-fe HEMETAB brand 2 Non-Preferred, PA heme poly-fa-b12 tab NOVAFERRUM 50 polysaccharide iron Non-Preferred, PA, caps, NOVAFERRUM brand 2 complex liquid PEDIATRIC DROPS pot & sod citrates TRICITRATES generic 1 Non-Preferred, PA w/citric ac CYTRA-3 prenat-FE Bis-FE COMPLETE NATALCARE prot succ-FA-CA brand 2 PAK DHA & omega 3

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 71 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug prenat-FE Bis-FE PRUET DHA PAK prot succ-FA-CA brand 2 SETONET PAK & omega 3 prenat-FE Bis-FE TRUST NATALCARE prot succ-FA-CA brand 2 PAK DHA & omega 3 prenat-FE bis-FE prot succ-FA-CA PRUET DHAEC PAK brand 2 & omega DR prenat vit w/iron carbonyl-fe asp OB COMPLETE/DHA brand 2 Non-Preferred, PA glyc-fa-omega fatty acid prenat w/o A w/fecbn-fegl- FOLTABS PAK PLUS DHA brand 2 DSS-FA & DHA RE OB + DHA PAK prenatal multivitamins & minerals PRENATE CHEW brand 2 Non-Preferred, PA w/l-methylfolate-fa chew prenatal mv & min w/fe bisglyc-fe prot PR NATAL 400 generic 1 Non-Preferred, PA succ-fa-ca-omega 3 m prenatal mv & min w/fe carbonyl-docusate-folic PREQUE 10 brand 2 Non-Preferred, PA acid-dha tab GESTICARE PAK DHA CENTRUM SPECIALIST PRENATAL SIMILAC PRENATAL EARLY prenatal mv & min w/fe SHIELD brand 2 Non-Preferred, PA fumarate-fa-dha misc THERANATAL COMPLETE THERANATAL PLUS ENFAMIL EXPECTA VITAFOL-OB+DHA PNV-OB/DHA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 72 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug VITAFOL-ONE prenatal mv & min w/fe SELECT-OB+DHA polysaccharide PNV-FIRST SOFTGEL brand 2 Non-Preferred, PA complex-fa-dha CHOICE-OB + DHA COMBO PACK prenatal mv & min w/o vit a w/fe polysac cmplx-fa- NESTABS ABC brand 2 Non-Preferred, PA ca-omega prenatal vit w/FE bisglycinate VINATE II brand 2 chelate-FA prenatal vit w/FE bisglycinate GENTEX ADE 28-1 MG brand 2 chelate-FA prenatal vit w/FE bisglycinate VINATE AZ EX brand 2 chelate-FA prenatal vit w/fe carbonyl-fe PNV-TOTAL brand 2 Non-Preferred, PA bisglycinate-fa-fish oil cap SE-TAN DHA prenatal vit w/fe fum-iron TARON-C DHA polysacch complex- generic 1 Non-Preferred, PA CONCEPT DHA fa-omega 3 VIRT-C DHA prenatal vit w/fe glycine cysteinate-fa-omega ENBRACE HR brand 2 Non-Preferred, PA 3 fatty acid prenatal vit w/fe poly cmplx-fe heme HEMENATAL OB + DHA brand 2 Non-Preferred, PA polypept-fa & omega 3 prenatal vit w/fe polysacch cmplx-fe PAIRE OB brand 2 Non-Preferred, PA asp-fe glyc-fa & dha prenatal vit w/fe polysacch cmplx-fe VP-HEME ONE brand 2 Non-Preferred, PA heme polypept-fa & PREFERAOB +DHA dha

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 73 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug PREFERA OB prenatal vit w/fe HEMNATAL OB polysacch complex-fe brand 2 Non-Preferred, PA VP-HEME-OB heme polypeptide-fa VP-ERA OB prenatal vit w/fe polysacch complex-l VITAFOL ULTRA brand 2 Non-Preferred, PA methylfolate-fa-dha VIVA DHA prenatal vit w/ferrous VP-PNV-DHA fumarate-fa-omega 3 brand 2 Non-Preferred, PA C-NATE DHA fatty acids RELNATE DHA prenatal vit w/ferrous NATALVIT brand 2 Non-Preferred, PA fumarate-folic acid tabs TL FOLATE prenatal vit w/ferrous PNV-SELECT fumarate-l brand 2 Non-Preferred, PA ZATEAN-PN methylfolate-folic acid VIRT-PN prenatal vit w/FE polysac EDGE OB CHW brand 2 cmplx-FA prenatal vit w iron ATABEX PRENATAL brand 2 carbonyl-FA prenatal vit w/iron ULTIMATECARE ONE carbonyl-fe aspart glyc- FOLCAPS OMEGA-3 brand 2 Non-Preferred, PA fa-omega 3 cap CAPSULE prenatal vit w/iron carbonyl-fe aspart OB COMPLETE PREMIER brand 2 Non-Preferred, PA glycinate-fa tabs prenatal vit w/iron OB COMPLETE brand 2 Non-Preferred, PA carbonyl-folic acid tabs prenatal vit w/iron polysaccharide SELECT-OB brand 2 Non-Preferred, PA cmplx-l methylfolate-fa prenatal vit without vit a w/ fe bisglycinate- NESTABS DHA brand 2 Non-Preferred, PA fa-omeg 3 mis prenatal vitamins w/fe asparto glycinate-folic PRENATE STAR brand 2 Non-Preferred, PA acid tabs

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 74 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug PRENAISSANCE NEXT prenatal w/calcium-vit PRENAISSANCE NEXT-B brand 2 Non-Preferred, PA b6-folic acid-ginger ZINGIBER FOCALGIN-B prenatal w/calcium-vit b6- vit b12-folic PRENATE AM brand 2 Non-Preferred, PA acid-ginger tabs prenatal w/fe asparto glycinate-l PRENATE ELITE brand 2 Non-Preferred, PA methylfolate-folic acid prenatal w/fe cbnyl-fe asparto glyc-fa-dss- ULTIMATECARE ONE NF generic 1 Non-Preferred, PA omega 3 caps prenatal w/fe fumarate-fa- TRICARE PRENATAL DHA brand 2 Non-Preferred, PA dss-fish oil caps ONE DUET DHA BAL-CARE DHA PRENAISSANCE HA prenatal w/fe polysacch VENA-BAL DHA cmplx-sod PRENAISSANCE brand 2 Non-Preferred, PA feredetate-fa-omega 3 HARMONY DHA VENA-BAL DHA VIRT-BAL DHA COMBO PACK prenatal w/o a vit w/fe fumarate-l VITAFOL-NANO brand 2 Non-Preferred, PA methylfolate-folic acid prenatal w/o a w/ fe PRENATE PIXIE asparto glyc-l brand 2 Non-Preferred, PA PRENATE DHA methylfolate-fa-dha

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 75 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug ZATEAN-CH CAPSULE MACNATAL CN DHA prenatal w/o vit a w/fe SOFTGEL carbonyl-dss-fa-dha INFANATE BALANCE generic 1 Non-Preferred, PA caps SOFTGEL PRENAISSANCE BALANCE SOFTGEL prenatal w/o vit a w/fe carbonyl-fe asp PRENATE MINI brand 2 Non-Preferred, PA glyc-methfol-fa-dh prenatal w/o vit a w/fe carbonyl-fe aspart glyc- OB COMPLETE ONE brand 2 Non-Preferred, PA fa-fish oi prenatal w/o vit a w/fe carbonyl-fe aspart glyc- OB COMPLETE PETITE brand 2 Non-Preferred, PA fa-omega 3 PRENAISSANCE PROMISE prenatal w/o vit a w/fe PRENAISSANCE 90 DHA carbonyl-fe brand 2 Non-Preferred, PA CITRANATAL ASSURE gluconate-dss-fa-dha COMBO PACK CITRANATAL 90 DHA PACK prenatal w/o vit a w/fe carbonyl-fe CITRANATAL B-CALM brand 2 Non-Preferred, PA gluconate-fa & vit b6 prenatal w/o vit a w/fe carbonyl-folic ACTIVE OB brand 2 Non-Preferred, PA acid-dha caps

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 76 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug PRENEXA, TRIVEEN-PRX RNF PREFOL-DHA VIRTPREX VEMAVITE-PRX 2 prenatal w/o vit a w/fe PNV-DHA+DOCUSATE brand 2 Non-Preferred, PA fumarate-dss-fa-dha FOLCAL DHA TARON-PREX FOLIVANE-PRX DHA NF TL-SELECT PRENAISSANCE VIRT-SELECT prenatal w/o vit a w/fe fumarate-fe carbonyl- CITRANATAL HARMONY brand 2 Non-Preferred, PA dss-fa-dha ca prenatal w/o vit a w/fe EXTRA-VIRT PLUS DHA fumarate-docusate ca- brand 2 Non-Preferred, PA NEXA PLUS SOFTGEL folic acid-dha prenatal without a vit w/fe fumarate-folic acid PRENATA brand 2 Non-Preferred, PA chew PROVIDA OB prenatal without a vit CONCEPT OB w/fe fum-iron FOLIVANE-OB brand 2 Non-Preferred, PA polysacch complex -fa VINATE IC PUREFE OB prenatal without a w/fe asp glyc-l PRENATE ESSENTIAL brand 2 Non-Preferred, PA methylfolate-fa- omega 3 PRENATE MINI TRISTART DHA prenatal without a w/fe PNV-DHA carbonyl-l brand 2 Non-Preferred, PA PRENATE RESTORE methylfolate-fa-dha PRENATE DHA PRENATE ENHANCE

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 77 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug prenatal without a w/fe fumarate-l ZATEAN-PN PLUS brand 2 Non-Preferred, PA methylfolate-fa- PNV-OMEGA SOFTGEL omega 3 prenatal without a w/fe fum-fe polysacch PROVIDA DHA brand 2 Non-Preferred, PA complex-fa-dha cap prenatal without vit a TRICARE PRENATAL w/fe fumarate-fa-fish oil brand 2 Non-Preferred, PA COMPLEAT misc prenatal without vit a NEEVO DHA w/fe fumarate-l brand 2 Non-Preferred, PA VINATE DHA RF GELCAP methylfolate-omegas prenatal without vit a w/fe fum-fa-omega fatty CALCIUM PNV brand 2 Non-Preferred, PA acids caps prenatal without vit a w/iron carbonyl-folic TARON-BC brand 2 Non-Preferred, PA acid & vit b6 prenatal without vit a w/iron polysaccharide MARNATAL-F brand 2 Non-Preferred, PA complex-fa ca pyridoxine HCL inj soln PYRIDOXINE HCL INJ generic 1 selenious acid inj soln SELENIUM INJ generic 1 sodium ferric gluconate complex in sucrose FERRLECIT brand 2 soln sodium iodide soln IODOPEN brand 2 thiamine HCL inj soln THIAMINE HCL INJ generic 1

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 78 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug MULTITRACE-5 CONCENTRATE MULTITRACE-5 MULTITRACE-4 CONCENTRATE trace min MULTITRACE-4 generic 1 (cr-cu-mn-se-zn) inj NEONATAL MULTITRACE-4 PEDIATRIC TRACE ELEMENTS 4/ PEDIATRIC MULTITRACE-4 vitamin A generic 1 OTC vitamin ADC/fluoride/±iron TRI-VI-FLOR generic 1 drops vitamin B complex/vitamin DIALYVITE generic 1 Non-Preferred, PA C/folic acid FOLBEE PLUS vitamin B complex/ NEPHROCAPS generic 1 vitamin C/folic acid vitamin B-1 generic 1 OTC vitamin B-6 generic 1 OTC vitamin C generic 1 OTC members <3 years old, vitamins pediatric TRI-VI-SOL generic 1 OTC zinc generic 1 OTC zinc chloride inj soln ZINC TRACE METAL INJ generic 1 zinc sulfate inj soln ZINC SULFATE INJ brand 2 Potassium POTASSIUM CHLORIDE/ kcl in dextrose & nacl inj generic 1 D5W/NACL POTASSIUM CHLORIDE/ kcl in nacl inj generic 1 NACL INJ phosphorus K-PHOS NEUTRAL generic 1 tabs pot bicarbonate & EFFERVESCENT POT generic 1 Non-Preferred, PA chloride effer tab CHLORIDE

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 79 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug potassium & sodium acid K-PHOS NO 2 brand 2 Non-Preferred, PA phosphates tabs potassium acetate inj soln POTASSIUM ACETATE INJ generic 1 potassium acid phosphate K-PHOS ORIGINAL brand 2 potassium bicarbonate/ potassium citrate K-LY TE generic 1 tabs effervescent potassium chloride K-LOR generic 1 powder potassium chloride POTASSIUM CHLORIDE generic 1 liquid potassium chloride cpcr MICRO-K 8 brand 2 Non-Preferred, PA K-DUR 10 potassium chloride K-DUR 20 generic 1 tabs extended-release KLOR-CON 8 KLOR-CON 10 potassium chloride K-TAB 20 generic 1 QL extended-release potassium chloride MICRO-K 8 generic 1 Non-Preferred, PA extended-release potassium chloride MICRO-K 10 generic 1 caps extended-release potassium chloride in KCL/D5W/LR IV LAC RING generic 1 d5w lactated ringer potassium chloride in POTASSIUM CHLORIDE/ generic 1 dextrose inj D5W potassium chloride microencapsulated KLOR-CON M15 brand 2 Non-Preferred, PA crystals cr tbcr potassium chloride soln POTASSIUM CHLORIDE INJ generic 1 potassium citrate UROCIT-K 15 generic 1 Non-Preferred, PA (alkalinizer) tbcr potassium citrate-citric acid CYTRA K CRYSTALS generic 1 Non-Preferred, PA pack potassium iodide soln SSKI generic 1 Non-Preferred, PA potassium phosphates inj POTASSIUM generic 1 soln PHOSPHATES

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 80 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Miscellaneous Anaphylaxis EPIPEN epinephrine generic 1 QL EPIPEN JR. epinephrine SYMJEPI brand 2 Antidotes acetylcysteine CETYLEV brand 2 acetylcysteine (antidote) ACETADOTE INJ generic 1 Non-Preferred, PA soln succimer CHEMET brand 2 QL Caloric Agents alcohol soln DEHYDRATED ALCOHOL generic 1 amino acids-dextrose-lipids PERIKABIVEN brand 2 Non-Preferred, PA with electrolytes emul KABIVEN cysteine HCL soln L-CYSTEINE HCL generic 1 dietary management DERMANIC brand 2 Non-Preferred, PA product - tab cr Cystic Fibrosis acetylcysteine MUCOMYST generic 1 aztreonam CAYSTON brand 2 Diagnosis Required, SP dornase alfa PULMOZYME brand 2 Diagnosis Required, SP KALYDECO ivacaftor brand 2 PA, SP KALYDECO GRANULES lumacaftor/ivacaftor ORKAMBI brand 2 PA, SP sodium chloride for HYPERSAL generic 1 nebulizer NEBUSAL tezacaftor/ivcaftor SYMDEKO brand 2 PA, QL, SP tobramycin neb soln BETHKIS brand 2 Diagnosis Required, SP tobramycin neb soln TOBI brand 2 Non-Preferred, PA Electrolyte Maintenance PROCALAMINE amino acid electrolyte AMINOSYN M brand 2 infusion soln inj AMINOSYN AMINOSYN II amino acid electrolyte w/calcium infusion in CLINIMIX E/DEXTROSE 5% brand 2 d5w soln

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 81 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug amino acid electrolyte CLINIMIX E/DEXTROSE w/calcium infusion in brand 2 10% d10w soln amino acid electrolyte CLINIMIX E/DEXTROSE w/calcium infusion in brand 2 15% d15w soln amino acid electrolyte CLINIMIX E/DEXTROSE w/calcium infusion in brand 2 20% d20w soln amino acid electrolyte CLINIMIX E/DEXTROSE w/calcium infusion in brand 2 25% d25w soln amino acid infusion in d5w CLINIMIX/DEXTROSE brand 2 soln 5% amino acid infusion in CLINIMIX/DEXTROSE 10% brand 2 d10w soln amino acid infusion in CLINIMIX/DEXTROSE 15% brand 2 d15w soln amino acid infusion in CLINIMIX/DEXTROSE 20% brand 2 d20w soln amino acid infusion in CLINIMIX/DEXTROSE 25% brand 2 d25w soln AMINOSYN AMINOSYN-RF NEPHRAMINE TROPHAMINE FREAMINE HBC amino acid infusion soln brand 2 AMINOSYN II HEPATAMINE FREAMINE III CLINISOL SF PROSOL dextrose 5% in lactated DEXTROSE 5%/ generic 1 ringers LACTATED RINGERS dextrose iv soln DEXTROSE generic 1 dextrose w/sodium DEXTROSE/NACL generic 1 chloride

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 82 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug DEXTROSE 5%/ electrolyte-48 in d5w soln ELECTROLYTE #48 brand 2 VIAFLEX electrolyte-56 in d5w soln PLASMA-LYTE-56/D5W brand 2 electrolyte-148 solution PLASMA-LYTE-148 generic 1 electrolyte-a solution PLASMA-LYTE A brand 2 IONOSOL-B/DEXTROSE electrolyte-b in d5w soln brand 2 5% electrolyte-m in d5w soln NORMOSOL-M IN D5W generic 1 IONOSOL-MB/ electrolyte-mb in d5w soln brand 2 DEXTROSE 5% electrolyte-p in d5w soln ISOLYTE-P/DEXTROSE 5% brand 2 electrolyte-r solution NORMOSOL-R generic 1 electrolyte-r (ph 7.4) NORMOSOL-R generic 1 solution electrolyte-r in d5w soln NORMOSOL-R IN D5W generic 1 electrolyte-s solution ISOLYTE-S brand 2 electrolyte-s (ph 7.4) ISOLYTE-S PH 7.4 brand 2 solution LIPOSYN III fat emulsion iv generic 1 INTRALIPID lactated ringer's solution LACTATED RINGERS generic 1 parenteral electrolyte conc NUTRILYTE generic 1 parenteral electrolyte soln HYPERLYTE-CR generic 1 ringer's solution RINGERS INJECTION generic 1 sodium acetate inj soln SODIUM ACETATE INJ generic 1 sodium bicarbonate inj SODIUM BICARBONATE generic 1 soln INJ sodium chloride soln SODIUM CHLORIDE INJ generic 1 sodium chloride SODIUM CHLORIDE 0.9% generic 1 (gu irrigant) soln INJ sodium lactate inj soln SODIUM LACTATE INJ generic 1 sodium phosphate inj soln SODIUM PHOSPHATE INJ generic 1 Hereditary Angioedema icatibant FIRAZYR brand 2 PA, SP c1 esterase inhibitor RUCONEST brand 2 Non-Preferred, PA (recombinant) c1 inhibitor, human CINRYZE brand 2 Non-Preferred, PA c1 esterase inhibitor, BERINERT brand 2 PA, SP human HAEGARDA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 83 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Hyperphosphatemia calcium acetate generic 1 667 mg tablet only calcium acetate PHOSLO generic 1 Non-Preferred, PA (phosphate binder) cinacalcet SENSIPAR generic 1 PA sevelamer RENVELA generic 1 ST, tablets Idiopathic Pulmonary Fibrosis (IPF) nintedanib OFEV brand 2 PA, SP pirfenidone capsule ESBRIET brand 2 PA, SP Iron Overload deferoxamine mesylate solr DESFERAL INJ generic 1 Irrigating Solutions acetic acid irrigation soln ACETIC ACID 0.25% generic 1 citric acid & d-gluconic RENACIDIN brand 2 Non-Preferred, PA acid soln lactated ringer's LACTATED RINGERS generic 1 (irrigation) soln IRRIGATION ringer's irrigation soln RINGERS IRRIGATION generic 1 saline injection BACTERIOSTATIC generic 1 bacteriostatic SODIUM CHLORIDE SODIUM CHLORIDE saline injection w/benzyl BACTERIOSTATIC/ generic 1 alcohol BENZYL ALCOHOL sorbitol irrigation soln SORBITOL brand 2 sorbitol-mannitol irrig soln SORBITOL-MANNITOL brand 2 water for inject, BACTERIOSTATIC WATER bacteriostatic benzyl FOR INJECTION/ generic 1 alcohol BENZYL ALCOHOL water for inject, BACTERIOSTATIC WATER bacteriostatic generic 1 PARABENS parabens STERILE WATER FOR water for injection generic 1 INJECTION water for irrigation, sterile STERILE WATER generic 1 soln IRRIGATION STERILE WATER FOR water for iv injection generic 1 INJECTION

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 84 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug Local Anesthetics bupivacaine HCl soln MARCAINE generic 1 bupivacaine in dextrose BUPIVACAINE SPINAL generic 1 soln bupivacaine inj 0.25% BUPIVACAINE/ w/epinephrine generic 1 EPINEPHRINE preservative free (pf) chloroprocaine HCl soln NESACAINE-MPF generic 1 lidocaine HCl LIDOCAINE HCL MDV generic 1 (local anesth.) soln lidocaine in dextrose iv LIDOCAINE HCL/ brand 2 soln DEXTROSE IV lidocaine inj LIDOCAINE/ generic 1 w/epinephrine EPINEPHRINE mepivacaine HCl inj soln MEPIVACAINE HCL INJ brand 2 Medical Devices insulin pen needle QL, BD brand only insulin syringes QL, BD brand only lancets QL spacers QL Metabolic Modifiers carglumic acid CARBAGLU brand 2 PA, SP glycerol phenylbutyrate RAVICTI brand 2 PA, SP BUPHENYL ORAL sodium phenylbutyrate generic 1 PA, SP POWDER Vaccine diphtheria-tetanus tox DIP/TET PED INJ brand 2 QL adsorbed (dt) im HAVRIX hepatitis a vaccine susp brand 2 QL VAQTA hepatitis b vaccine ENGERIX-B brand 2 QL (recombinant) RECOMBIVAX HB hepatitis b vaccine recombinant HEPLISAV-B brand 2 Age Limits Apply adjuvanted human papillomavirus (hpv) GARDASIL 9 brand 2 QL 9-valent recomb vac

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 85 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug human papillomavirus (hpv) quadrivalent GARDASIL brand 2 QL recombinant vac influenza virus vaccine recombinant FLUBLOK brand 2 QL hemagglutinin (ha) influenza virus vaccine AFLURIA brand 2 QL split FLUZONE SPLT influenza virus vaccine split FLUZONE HD PF brand 2 QL high-dose pf influenza virus vaccine split pf AFLURIA PF brand 2 QL FLUARIX QUAD influenza virus vaccine FLULAVAL QUAD brand 2 QL split quadrivalent FLUZONE QUAD influenza virus vaccine FLUCELVAX brand 2 QL tiss-cult subunit influenza virus vaccine types FLUVIRIN brand 2 QL a&b surface antigen measles, mumps & rubella M-M-R II brand 2 QL virus vaccines for inj meningococcal (a, c, y, and MENOMUNE brand 2 QL w-135) meningococcal (a, c, y, and w-135) conjugate MENACTRA brand 2 QL vaccine meningococcal (a, c, y, and w-135) oligo conj vac MENVEO brand 2 QL for inj pneumococcal 13-valent PREVNAR 13 brand 2 QL conjugate pneumococcal vaccine PNEUMOVAX brand 2 QL polyvalent PNEUMOVAX 23 tet tox-diph-acell pertuss ad ADACEL, BOOSTRIX brand 2 QL tetanus-diphtheria toxoids TENIVAC brand 2 QL (td) TET/DIP TOX INJ tetanus immune globulin HYPERTET S/D brand 2 QL (human) typhoid vaccine VIVOTIF BERNA brand 2 capsules

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 86 Covered Generic Drug Name Brand Drug Name Tier Requirements & Limits Drug varicella virus vac live for VARIVAX brand 2 QL subcutaneous zoster vaccine live ZOSTAVAX brand 2 QL, Age Limits Apply zoster vaccine recombinant SHINGRIX brand 2 Minimum Age 50 adjuvanted Other betaine powd CYSTADANE brand 2 Non-Preferred, PA cromolyn sodium GASTROCROM brand 2 Non-Preferred, PA (mastocytosis) conc DEXTROSE dextrose (diagnostic aid) THERMOJECT brand 2 Non-Preferred, PA soln SYSTEM eliglustat tartrate caps CERDELGA brand 2 Non-Preferred, PA glycopyrrolate soln GLYCOPYRROLATE INJ generic 1 imiglucerase solr CEREZYME brand 2 Non-Preferred, PA levocarnitine (metabolic CARNITOR generic 1 Non-Preferred, PA modifiers) oral solution levocarnitine (metabolic CARNITOR generic 1 Non-Preferred, PA modifiers) tabs miglustat caps ZAVESCA brand 2 Non-Preferred, PA

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 87 Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS The following is a list of OTC products on the PDL. Some OTC products are listed on the drug list. OTC products covered are restricted to generics when available. Brand names are provided as reference only. Acne adapalene gel DIFFERIN OTC GEL 0.1% benzoyl peroxide crm, gel, lotion CLEARASIL Antifungals clotrimazole MICATIN miconazole crm LOTRIMIN AF tolnaftate TINACTIN MONISTAT vaginal products GYNE-LOTRIMIN Antivirals docosanol ABREVA OTC CREAM Atopic Dermatitis BETACARE CREAM AND LOTION CETAPHIL CREAM AND LOTION emollients DERMAPHOR OINTMENT E-OINTMENT GLYCERIN TOPICAL Cough/Cold Allergy Antihistamines CHLOR-TRIMETON BENADRYL antihistamines CLARITIN ALAVERT ZYRTEC Antihistamine/Decongestant Combinations brompheniramine/pseudoephedrine DIMETAPP cetirizine/pseudoephedrine OTC ZYRTEC D chlorpheniramine/pseudoephedrine ACTIFED

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 88 Generic Drug Name Brand Drug Name Examples ALAVERT ALRG TAB/SINUS loratadine/pseudoephedrine ALAVERT D ALLERGY/CONG Cough/Cold ROBITUSSIN antitussives ROBITUSSIN DM Age edit applied. Not covered for ROBITUSSIN PE members under the age 2. ROBITUSSIN CF DELSYM NEO-SYNEPHRINE nasal sprays AFRIN DIMETAPP DRO DECONGES Diabetes alcohol swabs CURITY ALCOHOL PADS glucose oral tablets HUMULIN insulin (vials only) NOVOLIN Earwax Removal Products carbamide peroxide DEBROX Family Planning TROJAN KIMONO LIFESTYLES condoms-male TRUSTEX DUREX FANTASY contraceptive foam DELFEN contraceptive gel GYNOL II First Aid Burow’s soln, wet dressings DOMEBORO dermatological baths COLLOIDAL OATMEAL BATHS hydrocortisone crm, oint CORTAID NEOSPORIN topical antibacterials BACITRACIN

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 89 Generic Drug Name Brand Drug Name Examples Gastrointestinal MYLANTA LIQUID antacids liquids, chew tabs MAALOX LIQUID TUMS IMODIUM A-D antidiarrheals KAOPECTATE electrolyte rehydrating soln PEDIALYTE famotidine PEPCID AC laxative enemas FLEET ENEMA DULCOLAX laxatives FLEET PHOSPHO-SODA ALIGN BACID BIOGAIA CULTURELLE DIGESTIVE PROBIOTIC FLORAJEN probiotics FLORANEX FLORASTOR LACTINEX PHILLIPS COLON HEALTH RISA-BID RISAQUAD psyllium METAMUCIL rectal crm, suppositories PREPARATION H simethicone MYLICON stool softeners COLACE sugar+orthophosphoric acid EMETROL Insomnia doxylamine succinate UNISOM Lice Products permethrin NIX pyrethrins/piperonyl butoxide shampoo RID SHAMPOO Motion Sickness DRAMAMINE meclizine BONINE

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 90 Generic Drug Name Brand Drug Name Examples Ophthalmics ALAWAY allergic ZADITOR artificial tears HYPOTEARS VISINE decongestants MURINE NAPHCON A Pain acetaminophen tabs, liquid, drops, TYLENOL suppositories, chew tabs BAYER aspirin tabs, EC tabs, chew tabs ECOTRIN aspirin with buffers tabs ADVIL ibuprofen tabs, chew tabs, susp, and drops MOTRIN IB Smoking Cessation Products COMMIT LOZENGES (QUANTITY LIMIT) NICODERM CQ (QUANTITY LIMIT) nicotine NICOTINE GUM (QUANTITY LIMIT) NICOTROL (QUANTITY LIMIT) Urological oxybutynin patch OXYTROL FOR WOMEN OTC PATCH Vitamins/Minerals b-complex B-COMPLEX VITAMIN TAB OS-CAL CALTRATE calcium TUMS iron ferrous fumarate, ferrous gluconate, FERGON ferrous sulfate, ferrous bis-glycinate FEOSOL chelate and polysaccharide iron caps magnesium oxide MAG-OX vitamin D 400 IU VITAMIN D 400 IU VI-DAYLIN vitamins pediatric members <3 years old POLY-VI-SOL TRI-VI-SOL vitamins prenatal STUART PRENATAL Warts salicylic acid 17%/collodion DUOFILM Miscellaneous fluoride dental rinse PHOS-FLUR

OTC = Over the Counter ST = Step Therapy PA = Prior Authorization required SP = Specialty Pharmacy QL = Quantity Limit 91 Index of of Covered Covered Drugs Drugs A acidophilus/bifidus. . . . . 36 ALAVERT ALRG TAB/ abacavir...... 43, 44 ACIDOPHILUS/BIFIDUS SINUS...... 28, 89 abacavir/dolutegravir/ WAFER...... 36 ALAVERT D...... 89 ALAVERT-D...... 28 lamivudine...... 44 acidophilus/citrus pectin. . .36 ALAWAY...... 51, 91 abacavir/lamivudine. . . . .43 acidophilus/pectin. . . . . 36 ALAWAY OTC...... 51 abacavir/lamivudine/ acitretin...... 24 albendazole...... 37 zidovudine...... 43 ACLOVATE...... 22 ALBENZA ...... 37 abaloparatide inj...... 32 ACTIFED ...... 27, 88 albuterol...... 64, 65 abemaciclib...... 4 ACTIGALL...... 37 albuterol sulfate. . . . . 64, 65 ABILIFY DISC TAB. . . . . 58 ACTIVE FE...... 68 albuterol sulfate tabs . . . . 65 ABILIFY MAINTENA. . . . .58 ACTIVE OB...... 76 alclometasone...... 22 ABILIFY SOL...... 58 ACTIVELLA...... 50 alcohol soln...... 81 ABILIFY TABLETS. . . . . 58 ACTOPLUSMET...... 31 alcohol swabs...... 89 abiraterone...... 5 ACTOS...... 31 ACULAR/ACULAR LS. . . .52 ALDACTAZIDE ...... 12 ABREVA OTC CREAM. . 42, 88 ALDACTONE...... 12 acalabrutinib...... 4 acyclovir...... 42 acyclovir topical...... 42 ALDARA...... 25 acamprosate...... 54 ALDOMET...... 14 acarbose ...... 31 ADACEL, BOOSTRIX. . . . 86 ADAGEN ...... 29 ALDORIL...... 14 ACCOLATE...... 66 ALECENSA...... 4 ADALAT CC...... 11 ACCUHIST DROPS. . . . .59 alectinib...... 4 adalimumab...... 45 ACCUNEB...... 65 alendronate...... 32 adapalene...... 21, 88 ACCUPRIL...... 9 ALESSE...... 48 adapalene gel...... 21, 88 ACCURETIC...... 9 alfuzosin ER...... 66 ADDERALL...... 55 acebutolol ...... 10 alginic acid/sodium ADDERALL XR...... 55 ACETADOTE INJ...... 81 bicarbonate...... 34 acetaminophen ADEMPAS...... 14 ALIGN...... 37, 90 . . . . . 15-17, 46, 64, 91 ADLYXIN ...... 32 ALINIA ...... 41 acetaminophen tabs, liquid, ADMELOG SOLOSTAR. . . 30 ALINIA SUSPENSION. . . .41 drops, suppositories, chew ADMELOG VIALS...... 30 alirocumab...... 13 tabs...... 91 ADVAIR DISKUS...... 65 alitretinoin 1% gel...... 6 acetazolamide...... 53 ADVAIR HFA...... 65 ALKERAN...... 4 acetazolamide ADVANCED AM/PM...... 70 allergic conjunctivitis . . . . 91 extended-release . . . . 53 ADVIL...... 15, 46, 91 ALLERGY/CONG...... 89 acetic acid...... 26, 84 afatinib...... 4 ALLERY/CONG ...... 28 ACETIC ACID 0.25%. . . . 84 AFINITOR...... 4 allopurinol ...... 46 acetic acid irrigation soln. . .84 AFINITOR DISPERZ. . . . . 4 alogliptin...... 31 acetic acid-oxyquinoline AFLURIA ...... 86 alogliptin/metformin. . . . .31 vaginal gel...... 50 AFLURIA PF...... 86 alogliptin/pioglitazone. . . .31 acetic acid/aluminum AFRIN...... 28, 89 alosetron HCL...... 34 acetate...... 26 AGGRENOX ...... 8 ALPHAGAN...... 53 acetic acid/hydrocortisone. .26 AGRYLIN...... 8 ALPHAGAN P...... 53 acetylcysteine...... 81 AIMOVIG ...... 18 alprazolam...... 54 acetylcysteine (antidote) soln.81 AIRDUO RESPICLICK. . . .65 alprazolam conc...... 54 acidophilus ...... 36 ALAHIST DM...... 63 ALPRAZOLAM INTENSOL. .54 ACIDOPHILUS XTRA. . . . 36 ALAVERT. . . . 27, 28, 88, 89 ALREX...... 52

ALL CAPS = Brand-name drug lower case = Generic drug 92 Index of Covered Drugs ALTACE ...... 9 amino acid infusion in d20w ampicillin...... 39 alteplase solr...... 14 soln...... 82 ampicillin & sulbactam sodium altretamine...... 4 amino acid infusion in d25w for inj...... 39 alumina/magnesia. . . . . 34 soln...... 82 AMPICILLIN SODIUM INJ. . 39 alumina/magnesia/ amino acid infusion in d5w ampicillin sodium solr . . . .39 simethicone...... 34 soln...... 82 anagrelide...... 8 aluminum acetate. . . . 25, 26 amino acid infusion soln. . .82 anakinra...... 45 aluminum chloride topical amino acids-dextrose-lipids with ANALPRAM-HC, HC solution ...... 25 electrolytes emul. . . . .81 PRAMOXINE...... 22 ALUNBRIG...... 4 aminocaproic acid...... 8 ANAPROX...... 16, 46 ALUVEA...... 26 AMINOCAPROIC ACID INJ. . 8 anastrozole...... 5 ANDROGEL, ANDROGEL amantadine...... 19, 42 aminocaproic acid soln. . . .8 PUMP...... 29 amantadine tablets. . . . . 19 aminosalicyclic acid. . . . .37 anidulafungin solr...... 40 AMARYL ...... 31 AMINOSYN...... 81, 82 AMINOSYN II...... 81, 82 ANIMI-3/VITAMIN D. . . . .69 AMBIEN...... 57 AMINOSYN M...... 81 ANTABUSE...... 54 ambrisentan...... 13 AMINOSYN-RF...... 82 antacids liquids, chew tabs. .90 AMERGE...... 18 amiodarone HCl tabs. . . . 10 ANTARA...... 12 AMETHYST...... 48 amiodarone tabs...... 10 antidiarrheals...... 90 AMICAR...... 8 amitriptyline. . . . .18, 56, 57 antihistamines...... 27, 88 AMICAR SOLUTION . . . . .8 amitriptyline/perphenazine. .57 antitussives . . . . . 3, 59, 89 amiloride ...... 12 amlodipine...... 11 ANTIVERT...... 34 amiloride/ amlodipine besylate-benazepril ANUSOL HC 2.5%. . . . . 25 hydrochlorothiazide. . . 12 HCl...... 11 apalutamide 5 amino acid electrolyte infusion amlodipine besylate-olmesartan APHEDRID TAB ...... 64 soln inj...... 81 medoxomil...... 11 apixaban ...... 7 amino acid electrolyte w/ amlodipine besylate- apraclonidin ophthalmic calcium infusion in d10w valsartan ...... 11 solution ...... 54 soln...... 82 amlodipine-valsartan- apremilast ...... 45 amino acid electrolyte w/ hydrochlorothiazide. . . 11 aprepitant...... 34 calcium infusion in d15w ammonium lactate. . . . . 25 APRESOLINE...... 14 soln...... 82 AMNESTEEM...... 21 APRISO ...... 36 amino acid electrolyte w/ amoxapine...... 56 APTIVUS ...... 44 calcium infusion in d20w amoxicillin ...... 39 AQUADEKS ...... 70 soln...... 82 AMOXICILLIN CAPSULES AND ARALEN...... 44 amino acid electrolyte w/ CHEWABLES...... 39 ARANESP...... 8 ARAVA...... 45 calcium infusion in d25w amoxicillin tabs...... 39 ARCAPTA NEOHALER. . . 64 soln...... 82 amoxicillin/clavulanate. . . .39 ARICEPT...... 14 amino acid electrolyte w/ AMOXIL SUSP...... 39 ARICEPT ODT...... 14 calcium infusion in amphetamine/ ARIMIDEX...... 5 d5w soln...... 81 dextroamphetamine mixed salts ...... 55 aripiprazole...... 58 amino acid infusion in d10w aripiprazole ER injection. . .58 amphetamine/ soln...... 82 aripiprazole injection . . . . 58 dextroamphetamine mixed amino acid infusion in d15w aripiprazole ODT...... 58 salts extended-release. . 55 soln...... 82 aripiprazole soln...... 58

ALL CAPS = Brand-name drug lower case = Generic drug 93 Index of Covered Drugs ARISTADA...... 58 axitinib...... 4 BACTERIOSTATIC WATER armodafinil...... 15 AYGESTIN...... 50 PARABENS...... 84 ARMOUR THYROID. . . . .33 AZACTAM IN ISO-OSMOTIC BACTRIM...... 40 ARNUITY ELLIPTA. . . . . 65 DEXTROSE INJ . . . . .44 BACTRIM DS...... 40 AROMASIN...... 5 AZACTAM INJ...... 44 BACTROBAN ...... 22 ARTANE...... 19 azathioprine...... 6, 45 BACTROBAN NASAL . . . .22 ARTHROTEC...... 46 azelaic acid...... 21 BAL-CARE DHA ...... 75 artificial tears...... 91 azelaic acid (acne). . . . . 21 balsalazide...... 36 ASCORBIC ACID INJ. . . . 67 azelastine...... 27, 51 BALZIVA...... 49 ascorbic acid soln...... 67 azelastine HCl soln. . . . . 27 BANZEL...... 20 asfotase alfa...... 33 AZELEX...... 21 BARACLUDE...... 41 ASMANEX HFA...... 65 azithromycin ...... 39 baricitinib ...... 45 ASMANEX TWISTHALER. . 65 azithromycin pack...... 39 BASAGLAR...... 30 aspirin. . . . .8, 15, 17, 46, 91 azithromycin solr...... 39 BAYER...... 8, 46, 91 aspirin tabs, EC tabs, chew AZOPT...... 52 becaplermin gel...... 25 tabs...... 91 AZOR...... 11 beclomethasone...... 65 aspirin with buffers tabs. . . 91 aztreonam...... 44, 81 bedaquiline...... 44 aspirin-dipyridamole cap sr aztreonam in dextrose soln. .44 BELLADONNA ALKALOIDS & 12hr...... 8 aztreonam solr...... 44 OPIUM...... 15 aspirin/acetaminophen/ AZULFIDINE...... 36, 45 belladonna alkaloids & opium caffeine ...... 15 AZULFIDINE EN-TABS. . 36, 45 suppos...... 15 ASTELIN...... 27 BENADRYL...... 27, 88 ASTEPRO ...... 27 B benazepril ...... 8, 9 ATABEX PRENATAL. . . . .74 b-complex ...... 67, 91 benazepril/ ATARAX...... 27 B-COMPLEX VITAMIN hydrochlorothiazide. . . .9 atazanavir...... 43, 44 TAB...... 67, 91 BENICAR...... 9, 10 atazanavir/cobicistat . . . . 44 b-complex w/c-biotin-d-zinc & BENICAR HCT ...... 10 atenolol...... 10 folic acid...... 67 BENTYL...... 35 atenolol/chlorthalidone. . . 10 b-complex w/c-biotin-e-minerals BENZAC AC ...... 21 ATIVAN...... 54 & folic acid...... 67 benzalkonium chloride liqd. .25 atomoxetine...... 55 b-complex w/c-biotin-fe & folic BENZEFOAMULTRA. . . . 21 atorvastatin ...... 13 acid...... 67 benznidazole...... 41 atovaquone...... 41 b-complex w/c-zn & folic acid.67 benzocaine/antipyrine. . . .27 ATRIPLA...... 43 BACID...... 37, 90 benzonatate...... 59 atropine ...... 34, 37, 53 bacitracin. . 22, 51, 53, 54, 89 benzonatate caps...... 59 atropine sulfate...... 37 bacitracin-polymyxin-neomycin BENZOTIC...... 27 ATROVENT...... 28, 65 hc oint ...... 22 benzoyl peroxide. . . . .21, 88 ATROVENT HFA...... 65 bacitracin/polymyxin/ benzoyl peroxide crm, gel, ATROVENT NASAL SPRAY . 28 neomycin/hc...... 51 lotion...... 88 AUBAGIO...... 18 baclofen...... 47 benzoyl peroxide foam. . . .21 AUGMENTIN...... 39 BACTERIOSTATIC SODIUM benztropine...... 19 auranofin...... 45 AVITA ...... 21 CHLORIDE ...... 84 benzyl alcohol (pediculicide) AVODART ...... 66 BACTERIOSTATIC WATER lotn...... 24 AVONEX/AVONEX PEN, FOR INJECTION/BENZYL BERINERT...... 83 REBIF...... 18 ALCOHOL...... 84 BETA-VAL ...... 23

ALL CAPS = Brand-name drug lower case = Generic drug 94 Index of Covered Drugs BETACARE CREAM AND bosutinib ...... 4 bupropion extended-release. 57 LOTION...... 88 BRETHINE...... 65 bupropion HCL (smoking BETAGAN ...... 52 brigatinib ...... 4 deterrent)...... 59 betaine powd...... 87 BRILINTA...... 8 Burow’s soln, wet dressings. 89 betamethasone augmented brimonidine...... 24, 53 BUSPAR...... 55 dip...... 23 brimonidine tartrate-timolol buspirone...... 55 betamethasone dip maleate ophth soln . . . 53 busulfan...... 4 augmented...... 23 brinzolamide susp . . . . . 52 butalbital-acetaminophen- betamethasone dipropionate.23 brinzolamide-brimonidine caffeine cap...... 15 betamethasone sod phosphate tartrate ophth susp. . . .52 butalbital/acetaminophen. . 15 & acetate inj susp. . . . 28 BROMETANE DX...... 61 butalbital/acetaminophen/ betamethasone val. . . . . 23 BROMFED DM...... 60 caffeine ...... 15 BETAPACE ...... 10, 11 brompheniramine & butalbital/apap/caff/cod. . .16 BETAPACE AF...... 11 phenylephrine...... 59 butalbital/asa/caff/cod . . . 16 BETASERON...... 6 brompheniramine & butalbital/aspirin/caffeine. . 15 betaxolol...... 10 pseudoephedrine liquid butorphanol...... 16 bethanechol...... 66 1-7.5 mg/ml ...... 59 BUTRANS ...... 16 BETHKIS...... 81 brompheniramine/ BYDUREON...... 32 betrixaban...... 7 pseudoephedrine BYETTA...... 32 BEVYXXA ...... 7 ...... 59-61, 88 bexarotene caps and topical brompheniramine/ C gel...... 6 pseudoephedrine/ C-NATE DHA...... 74 BEYAZ, SAFYRAL . . . . . 48 dextromethorphan. . . .60 c1 esterase inhibitor BIAXIN...... 39 BSS...... 54 (recombinant)...... 83 BIAXIN XL...... 39 budesonide...... 36, 65 c1 esterase inhibitor, human. 83 bicalutamide...... 5 budesonide/formoterol. . . 65 c1 inhibitor, human. . . . . 83 BICILLIN C-R...... 39 bumetanide...... 12 cabergoline...... 19, 33 BICILLIN L-A ...... 39 BUMETANIDE INJ . . . . . 12 CABLIVI ...... 8 BICITRA...... 67 bumetanide soln...... 12 CABOMETYX...... 4 BUMEX...... 12 bictegravir/emtricitabine/ cabozantinib...... 4 BUPHENYL ORAL tenofovir alafenamide. . .44 CAFERGOT...... 17 POWDER...... 85 BIKTARVY...... 44 calamine...... 25 bupivacaine HCl soln. . . . 85 BILTRICIDE...... 37 CALAN...... 11, 18 bupivacaine in dextrose soln. 85 BIO-D DRO-MULSION. . . .67 CALAN SR...... 11 bupivacaine inj 0.25% w/ BIO-D-MULSIO DRO FORTE. 68 calcipotriene...... 24 epinephrine preservative BIOGAIA...... 37, 90 calcitonin-salmon...... 32 free (pf)...... 85 bisoprolol...... 10 calcitriol...... 24, 67 BUPIVACAINE SPINAL . . . 85 bisoprolol/ CALCITRIOL INJ...... 67 BUPIVACAINE/ hydrochlorothiazide. . . 10 calcitriol oral soln...... 67 EPINEPHRINE . . . . . 85 BLEPH-10...... 54 calcitriol soln...... 67 buprenorphine ...... 57 BONINE...... 90 buprenorphine/naloxone. . .57 calcium. . 2, 11, 22, 33, 67, 70, bosentan susp ...... 13 buprenorphine/naloxone 78, 81, 82, 84, 91 bosentan tabs...... 13 SL tab ...... 57 calcium acetate...... 84 BOSULIF...... 4 buprenorphine patch . . . .16 calcium acetate (phosphate bupropion ...... 57, 59 binder)...... 84

ALL CAPS = Brand-name drug lower case = Generic drug 95 Index of Covered Drugs calcium carbonate chew. . .67 CARDEC SYP...... 60 ceftazidime solr...... 38 calcium chloride (dihydrate) CARDENE...... 11 CEFTIN...... 38 soln...... 67 CARDIZEM ...... 11 ceftriaxone sodium and CALCIUM CHLORIDE INJ. . 67 CARDIZEM CD...... 11 dextrose solr...... 38 CALCIUM GLUCONATE INJ. 67 CARDIZEM SR...... 11 ceftriaxone sodium solr. . . 38 calcium gluconate soln. . . 67 CARDURA...... 9, 66 CEFTRIAXONE/DEXTROSE. 38 CALCIUM PNV...... 78 carglumic acid...... 85 cefuroxime axetil...... 38 CALQUENCE ...... 4 CARNITOR ...... 87 cefuroxime sodium solr. . . 38 CAMPRAL...... 54 carteolol...... 52 CEFZIL...... 38 canagliflozin...... 31 carvedilol...... 10 CELEBREX...... 46 canakinumab ...... 45 casanthranol-docusate celecoxib...... 46 CANASA...... 36 sodium...... 33 CELESTONE-SOLUSPAN. . 28 CAPCOF ...... 63 CASODEX...... 5 CELEXA...... 56 capecitabine...... 4 CASTIVA ...... 46 CELLCEPT...... 6 caplacizumab-yhdp . . . . . 8 CATAFLAM ...... 15, 46 CELLCEPT INTRAVENOUS. .6 CAPOTEN...... 8 CATAPRES...... 9 CELONTIN...... 20 CAPOZIDE...... 9 CATAPRES -TTS ...... 9 CENTRUM...... 71, 72 CAPRELSA...... 5 CATHFLO ACTIVASE. . . . 14 CENTRUM SPECIALIST CAPSAGEL...... 46 CAYSTON ...... 81 PRENATAL ...... 72 capsaicin...... 46 CECLOR ...... 38 cephalexin...... 38 captopril...... 8, 9 cefaclor...... 38 cephalexin tabs...... 38 captopril/ cefadroxil...... 38 CERDELGA...... 87 hydrochlorothiazide. . . .9 cefazolin in d5w soln. . . . 38 CEREFOLIN...... 70 CAPZASIN-P...... 46 CEFAZOLIN SODIUM. . . . 38 CEREFOLIN NAC...... 70 CARAC...... 25 cefazolin sodium and dextrose CEREZYME...... 87 CARAFATE...... 35 solr...... 38 ceritinib...... 4 CARAFATE SUSPENSION . .35 cefazolin sodium solr. . . . 38 certolizumab pegol. . . . . 45 CARBAGLU...... 85 CEFAZOLIN SODIUM/ CETAPHIL CREAM AND carbamazepine...... 19 DEXTROSE...... 38 LOTION...... 88 carbamazepine extended- cefdinir...... 38 cetirizine...... 27, 28, 88 release...... 19 CEFEPIME...... 38 cetirizine chew tab. . . . . 27 carbamide peroxide. . . 27, 89 cefepime HCL solr. . . . . 38 cetirizine hydrochloride/ pseudoephedrine CARBATROL...... 19 cefixime...... 38 hydrochloride 12 hours carbidopa & levodopa ODT. .19 cefixime susr...... 38 extended-release . . . . 28 carbidopa-levodopa- cefotaxime sodium solr. . . 38 cetirizine/pseudoephedrine entacapone ...... 19 CEFOTETAN...... 38 OTC ...... 88 carbidopa/levodopa. . . . .19 cefotetan disodium and CETYLEV...... 81 carbidopa/levodopa extended- dextrose solr...... 38 CHANTIX...... 59 release...... 19 cefotetan disodium solr. . . 38 CHEMET...... 81 carbinoxamine maleate. . . 60 CEFOTETAN/DEXTROSE. . 38 CHILD IBUPRO SUS COLD. 64 carbinoxamine maleate CEFOXITIN SODIUM. . . . 38 CHLOR-TRIMETON. . . 27, 88 extended-release . . . . 60 cefoxitin sodium and dextrose CHLOR-TRIMETON carbonyl iron susp . . . . . 67 solr...... 38 ALLERGY ...... 27 CARDEC DM DRO. . . . . 63 cefoxitin sodium solr. . . . .38 CHLOR-TRIMETON SYRUP. 27 CARDEC DM SYP . . . . . 63 cefprozil...... 38 CARDEC DRO...... 60 ALL CAPS = Brand-name drug lower case = Generic drug 96 Index of Covered Drugs chloral hydrate...... 57 CHOLESTYRAMINE LIGHT clemastine...... 27 chlorambucil...... 4 PACKETS ...... 12 CLEOCIN...... 21, 44, 50 chlordiazepoxide...... 34, 54 CHOLESTYRAMINE CLEOCIN PHOSPHATE INJ. 44 chlordiazepoxide- PACKETS ...... 12 CLEOCIN T...... 21 amitriptyline ...... 60 cholic acid...... 33 clidinium & chlordiazepoxide.34 chlorhexidine gluconate. . . . . 28 choriogonadotropin alfa. . . 50 CLIMARA...... 50 chloroprocaine HCl soln. . .85 chorionic gonadotropin. . . 50 CLIMARA PRO...... 50 chloroquine phosphate. . . 44 chromic chloride soln. . . . 68 clindamycin. . . . .21, 44, 50 chlorothiazide...... 12 CHROMIUM CHLORIDE. . .68 clindamycin phosphate soln. 44 chlorphen tan/carbetapentane ciclopirox...... 23 clindamycin phosphate tan...... 60 CICLOPIROX OLAMINE . . .23 vaginal supp...... 50 chlorphen tan/pyrilamine tan/ ciclopirox olamine crea. . . 23 CLINIMIX E/DEXTROSE PE tan...... 60 cilostazol ...... 8 10% ...... 82 chlorpheniramine & CILOXAN...... 53 CLINIMIX E/DEXTROSE phenylephrine liquid . . .60 CIMDUO...... 43 15% ...... 82 chlorpheniramine extended- cimetidine ...... 34 CLINIMIX E/DEXTROSE release...... 27 CIMZIA...... 45 20% ...... 82 chlorpheniramine cinacalcet...... 84 CLINIMIX E/DEXTROSE maleate ...... 27, 60 CINRYZE...... 83 25% ...... 82 chlorpheniramine maleate CIPRO ...... 39 CLINIMIX E/DEXTROSE 5%. 81 phenylephrine HCL. . . 60 CIPRO I.V.-IN D5W. . . . . 39 CLINIMIX/DEXTROSE 10%. 82 chlorpheniramine tan/ CIPRODEX...... 27 CLINIMIX/DEXTROSE 15%. 82 phenylephrine tan...... 60 ciprofloxacin . . . . 27, 39, 53 CLINIMIX/DEXTROSE 20%. 82 chlorpheniramine w/codeine ciprofloxacin in d5w soln. . .39 CLINIMIX/DEXTROSE 25%. 82 liquid...... 60 CIPROFLOXACIN IV. . . . .39 CLINIMIX/DEXTROSE 5% . .82 chlorpheniramine/ ciprofloxacin soln...... 39 CLINISOL SF...... 82 dextromethorphan ciprofloxacin/dexamethasone.27 CLINORIL...... 16, 46 ...... 60, 63, 64 citalopram...... 56 clobazam...... 19 chlorpheniramine/ CITRANATAL 90 DHA clobetasol propionate...... 23 phenylephrine. . . . 27, 60 PACK...... 76 CLOMIPRAMINE HCL. . . .56 chlorpheniramine/ CITRANATAL ASSURE clomipramine HCL caps. . .56 phenylephrine/pyrilamine.27 COMBO PACK. . . . . 76 clonazepam...... 19, 54 chlorpheniramine/ CITRANATAL B-CALM. . . .76 clonazepam ODT...... 19 pseudoephedrine. . . . . CITRANATAL HARMONY. . 77 clonidine...... 9 27, 60, 61, 88 citric acid & d-gluconic acid clonidine HCl ptwk...... 9 chlorpromazine...... 59 soln...... 84 clopidogrel...... 8 CHLORPROMAZINE HCL I CLAFORAN...... 38 clorazepate ...... 54 NJ...... 59 CLARAVIS...... 21 clotrimazole. . . 23, 40, 50, 88 chlorpromazine HCL soln. . 59 CLARIFOAM EF...... 24 clotrimazole with chlorthalidone...... 10, 12 clarithromycin...... 39 betamethasone. . . . . 23 chlorzoxazone...... 47 clarithromycin ER...... 39 clozapine...... 58 CHOICE-OB + DHA COMBO CLARITIN...... 27, 88 clozapine ODT...... 58 PACK...... 73 CLARITIN-D...... 62 CHOLBAM...... 33 CLEAR EYES REDNESS CLOZARIL...... 58 cholecalciferol...... 67, 68 RELIEF...... 51 cobalamine combination tab. 68 cholestyramine...... 12 CLEARASIL...... 88 cobicistat...... 44

ALL CAPS = Brand-name drug lower case = Generic drug 97 Index of Covered Drugs cobicistat/elvitegravir/ COMTAN...... 19 CURITY ALCOHOL PADS. . 89 emtricitabine/tenofovir. . 44 CONCEPT DHA...... 73 CUTIVATE ...... 23 cobimetinib...... 4 CONCEPT OB...... 77 cyanocobalamin...... 68 CODAR GF ...... 62 CONCERTA...... 55 CYCLESSA ...... 49 codeine sulfate...... 16 condoms-male ...... 89 cyclobenzaprine...... 47 codeine-chlorcyclizine liquid. 60 CONDYLOX SOL ...... 25 CYCLOGYL...... 53 codeine-pseudoephedrine- conjugated estrogen/ cyclopentolate...... 53 chlorcyclizine liq . . . . 61 bazedoxifene...... 51 cyclophosphamide...... 4 codeine-pyrilamine syrup . . 61 contraceptive foam. . . . . 89 cycloserine...... 37 codeine/acetaminophen. . .16 contraceptive gel...... 89 cyclosporine ...... 6, 53 codeine/chlorpheniramine/ COPAXONE...... 18 cyclosporine (ophth) emul. . 53 pseudoephedrine. . . . 61 COPPER TRACE METAL . . 68 cyclosporine inj...... 6 codeine/guaifenesin...... 61 CORDARONE...... 10 cyclosporine oral solution. . .6 codeine/guaifenesin/ COREG ...... 10 cyclosporine, modified. . . . 6 pseudoephedrine. . . . 61 CORICIDIN TAB CGH/CLD. .60 CYKLOKAPRON...... 51 codeine/promethazine...... 61 CORTAID...... 89 CYMBALTA...... 56 codeine/promethazine/ CORTEF...... 29 cyproheptadine...... 27 phenylephrine...... 61 corticotropin gel...... 19 CYSTADANE...... 87 CODIMAL DH...... 63 ...... 28 CYSTAGON...... 7 COGENTIN...... 19 CORTISPORIN. . . 22, 27, 51 CYSTARAN...... 54 COLACE ...... 33, 90 CORTISPORIN OTIC. . . . 27 cysteamine 0.44% ophthalmic COLAZAL...... 36 CORTIZONE...... 22 solution ...... 54 colchicine...... 17, 46 CORTIZONE-10 INTENSIVE cysteamine bitartrate. . . . .7 colchicine caps...... 17 HEALING...... 22 cysteine HCL soln...... 81 colchicine w/probenecid. . .17 CORVITE...... 70 CYTOMEL...... 32 COLESTID...... 12 CORVITE 150...... 70 CYTOTEC ...... 37 colestipol HCl...... 12 COSENTYX...... 45 CYTOVENE...... 41 COLISTIMETHATE SODIUM COSOPT ...... 52 CYTOXAN...... 4 INJ ...... 40 COTELLIC...... 4 CYTRA K CRYSTALS. . . . 80 colistimethate sodium solr. . 40 COUMADIN...... 7 CYTRA-3...... 71 collagenase oint...... 25 COZAAR ...... 9 COLLOIDAL OATMEAL CPM/PSE...... 60 D BATHS...... 89 CREON...... 36 D3-50 CAP...... 68 COLOCORT...... 36 CREON 3000 UNIT. . . . .36 D.H.E. 45...... 17 COLY TE...... 33 crisaborole...... 25 dabigatran etexilate mesylate COMBIGAN...... 53 CRIXIVAN...... 44 caps...... 7 COMBIPATCH...... 50 crizotinib...... 4 dabrafenib...... 4 COMBIVENT RESPIMAT. . .65 crofelemer...... 34 DALIRESP...... 66 COMBIVIR...... 43 CROLOM...... 51 DALLERGY, NASOHIST. . . 60 COMETRIQ...... 4 cromolyn . . . . 28, 51, 65, 87 DALMANE...... 57 COMMIT LOZENGES. . . . 91 cromolyn sodium. . 28, 51, 87 dalteparin sodium soln. . . . 7 COMMITT OTC...... 59 cromolyn sodium (mastocytosis) danazol...... 49 COMPAZINE...... 34 conc...... 87 DANOCRINE...... 49 COMPLERA ...... 43 crotamiton...... 24 DANTRIUM...... 47 COMPLETE NATALCARE PAK CULTURELLE...... 37, 90 dantrolene...... 47 DHA...... 71 cupric chloride soln. . . . .68 dapsone...... 44

ALL CAPS = Brand-name drug lower case = Generic drug 98 Index of Covered Drugs DARAPRIM...... 45 DESFERAL INJ...... 84 DEXTROSE 5%/ELECTROLYTE darbepoetin alfa...... 8 desipramine...... 56 #48 VIAFLEX ...... 83 darunavir ...... 43, 44 desmopressin...... 33 DEXTROSE 5%/LACTATED darunavir/cobicistat. . . . .44 desmopressin acetate soln. .33 RINGERS...... 82 dasatinib...... 4 desogestrel/EE. . . . . 47-49 dextrose iv soln. . . 14, 82, 85 DAURISMO ...... 7 desvenlafaxine DEXTROSE THERMOJECT DAYPRO...... 16, 46 succinate tb24. . . . . 55 SYSTEM...... 87 DAYTRANA...... 56 DESYREL...... 57 dextrose w/sodium chloride. 82 DAZIDOX...... 17 DETROL...... 67 DEXTROSE/NACL. . . .79, 82 DDAVP...... 33 dexamethasone . 27-29, 51, 52 DIALYVITE. . . . . 67, 70, 79 DEBROX ...... 27, 89 dexamethasone (ophth) susp.52 DIALYVITE 3000...... 67 DECADRON ...... 28 DEXAMETHASONE SODIUM DIALYVITE 5000...... 67 DIALYVITE 800/IRON. . . .67 decongestants . . 3, 28, 59, 91 PHOSPHATE. . . . .29, 52 DIALYVITE SUPREME D. . .70 deferasirox...... 8 dexamethasone sodium DIAMOX SEQUELS . . . . .53 deferoxamine mesylate solr. .84 phosphate soln. . . . . 29 DIASTAT ACUDIAL. . . . . 19 DEHYDRATED ALCOHOL . .81 DEXASOL ...... 52 DELATESTRYL...... 29 diazepam...... 19, 47, 54 DEXEDRINE ...... 55 diazepam conc...... 54 delavirdine...... 42 dexmethylphenidate HCL DELESTROGEN INJ. . . . .49 DIAZEPAM INTENSOL . . . 54 cp24...... 55 DELFEN...... 89 diazoxide susp ...... 29 dexmethylphenidate HCL DELSTRIGO ...... 43 diclofenac 1% gel...... 46 tabs...... 55 DELSYM...... 61, 89 diclofenac potassium. . .15, 46 dextroamphetamine. . . . .55 DELTASONE...... 29 diclofenac sodium . .15, 46, 52 dextromethorphan hbr. . . .61 DELZICOL...... 36 diclofenac sodium delayed- dextromethorphan polistirex DEMADEX...... 12 release...... 15, 46 extended-release . . . . 61 DEMEROL...... 17 diclofenac sodium extended- DENAVIR...... 24 dextromethorphan- release...... 46 DEPAKENE...... 20 guaifenesin ...... 61 diclofenac w/misoprostol . . 46 DEPAKOTE. . . . .18, 19, 56 dextromethorphan- dicloxacillin ...... 39 DEPAKOTE ER...... 19 guaifenesin syrup 61 dicyclomine...... 35 DEPAKOTE dextromethorphan/ didanosine...... 43 SPRINKLE. . . .18, 19, 56 brompheniramine/ didanosine delayed-release. .43 DIDRONEL...... 32 DEPEN TITRATAB. . . . . 45 pseudoephedrine. . . . 61 dietary management product - DEPO-MEDROL...... 29 dextromethorphan/ tab cr ...... 81 DEPO-PROVERA...... 47 guaifenesin. . . 61, 63, 64 DIFFERIN...... 21, 88 DEPO-SUBQ PROVERA 104.47 dextromethorphan/ DIFFERIN OTC GEL DEPO-TESTOSTERONE. . .29 promethazine...... 61 0.1%...... 21, 88 DERMA-SMOOTHE OIL/FS. 22 dextromethorphan/ DIFICID...... 39 DERMANIC...... 81 quinidine...... 59 DIFLUCAN...... 40, 50 DERMAPHOR OINTMENT. .88 DEXTROSE. . . 14, 38, 41, 44, DIGESTIVE PROBIOTIC . 37, 90 dermatological baths. . . . 89 79-83, 85, 87 digoxin...... 10 DERMATOP...... 23 dextrose (diagnostic aid) DIHISTINE DH...... 61 DERMOTIC OIL...... 27 soln...... 87 DIHYDRO-PE SYP . . . . . 63 dextrose 5% in lactated DESCOVY...... 43 dihydroergotamine. . . . . 17 DESENEX ...... 24 ringers...... 82 DILACOR XR...... 11

ALL CAPS = Brand-name drug lower case = Generic drug 99 Index of Covered Drugs DILANTIN...... 20 divalproex sodium delayed- DROXIA...... 7 DILANTIN INFATABS. . . . 20 release. . . . . 18, 19, 56 DUAVEE...... 51 DILAUDID ...... 17 divalproex sodium tb24. . . 19 DUET DHA...... 75 diltiazem...... 11 DOBUTAMINE HCL. . . . .14 dulaglutide ...... 32 diltiazem extended-release. .11 dobutamine HCl soln. . . . 14 DULCOLAX...... 90 diltiazem HCl coated beads DOBUTAMINE HCL/D5W. . 14 DULERA...... 65 tb24...... 11 dobutamine in d5w soln. . .14 duloxetine ...... 56 diltiazem sustained-release. .11 DOCETAXEL...... 7 duloxetine HCL cpep. . . . 56 DIMEATAPP DRO docetaxel soln...... 7 DUOFILM...... 25, 91 DECONGES ...... 28 docosanol...... 42, 88 DUONEB...... 65 dimenhydrinate...... 90 docusate calcium plus. . . .33 DURAGESIC...... 16 DIMETAPP. . 59, 60, 63, 88, 89 docusate potasssium. . . . 33 DURATUSS DM ELX. . . . 61 docusate sodium ...... 33 DIMETAPP CLD ELX/ DUREX...... 89 dofetilide...... 10 ALLERGY ...... 59 DURICEF...... 38 dolutegravir...... 42, 44 DIMETAPP DRO DCON/ dutasteride caps...... 66 dolutegravir/rilpivirine. . . . 44 CGH...... 63 DYAZIDE ...... 12 DOMEBORO...... 26, 89 dyphylline tabs ...... 66 DIMETAPP DRO DOMEBORO OTIC. . . . . 26 DECONGES ...... 89 donepezil...... 14 E DIMETAPP SYP CGH/CLD. .60 donepezil ODT ...... 14 E-OINTMENT ...... 88 dimethyl fumarate...... 18 doravirine/lamivudine/ E.E.S...... 39 DIOVAN...... 9 tenofovir disoproxil . . . 43 ecothiophate...... 53 DIOVAN HCT...... 9 dornase alfa...... 81 ECOTRIN...... 8, 46, 91 DIP/TET PED INJ...... 85 dorzolamide...... 52 ED A-HIST TABLETS AND DIPENTUM ...... 36 dorzolamide/timolol maleate. 52 LIQUID...... 60 diphenhydramine. . . . 27, 57 DOSTINEX...... 33 EDGE OB CHW ...... 74 DIPHENHYDRAMINE DOVONEX...... 24 edoxaban...... 7 HCL INJ...... 27 doxazosin...... 9, 66 EDURANT...... 42 diphenhydramine HCl soln. .27 doxepin ...... 25, 57 efavirenz...... 42, 43 diphenoxylate/atropine. . . 34 doxepin HCl (antipruritic) efavirenz/emtricitabine/ diphtheria-tetanus tox cream...... 25 tenofovir...... 43 adsorbed (dt) im. . . . .85 doxercalciferol caps. . . . .68 efavirenz/lamivudine/ DIPROLENE ...... 23 DOXY-100...... 40 tenofovir disoproxil DIPROLENE AF ...... 23 doxycycline hyclate. . . . . 40 fumarate...... 43 dipyridamole...... 8 doxycycline monohydrate. . 40 EFFERVESCENT POT DISALCID...... 46 doxylamine succinate. . .57, 90 CHLORIDE ...... 79 disopyramide...... 10 DRAMAMINE ...... 90 EFFEXOR...... 56 disopyramide DRISDOL...... 68 EFFEXOR XR...... 56 dronabinol...... 34 extended-release . . . . 10 EFFIENT...... 8 DROPERIDOL...... 34 disulfiram...... 54 EFUDEX...... 25 droperidol soln...... 34 DITROPAN...... 66 EGRIFTA ...... 32 drospirenon-ethinyl estradiol DITROPAN XL...... 66 elagolix ...... 51 tab...... 48 ELAVIL...... 18, 56 DIURIL...... 12 drospirenone-ethinyl estrad- elbasvir/grazoprevir . . . . .41 DIURIL ORAL SUSPENSION.12 levomefolate tab. . . . .48 divalproex sodium cap ELDEPRYL...... 19 sprinkle . . . . .18, 19, 56 electrolyte. . . 3, 68, 81-83, 90 ALL CAPS = Brand-name drug lower case = Generic drug 100 Index of Covered Drugs electrolyte rehydrating soln. .90 ENBRACE HR...... 73 ESCAVITE ...... 71 electrolyte-148 solution. . . 83 ENBREL...... 45 ESCAVITE D ...... 71 electrolyte-48 in d5w soln. . 83 ENFAMIL EXPECTA. . . . .72 ESCAVITE LQ...... 71 electrolyte-56 in d5w soln. . 83 enfuvirtide...... 44 escitalopram...... 56 electrolyte-a solution. . . . .83 ENGERIX-B...... 85 ESGIC...... 15 electrolyte-b in d5w soln. . .83 enoxaparin...... 7 ESKALITH CR...... 56 electrolyte-m in d5w soln. . .83 entacapone...... 19 esomeprazole...... 34, 35 electrolyte-mb in d5w soln. . . 83 entecavir...... 41 esomeprazole granules. . . 35 electrolyte-p in d5w soln. . .83 ENTERIC COATED- esterified estrogens . . . . .49 electrolyte-r (ph 7.4) solution. 83 NAPROSYN. . . . . 16, 46 ESTRACE...... 49 electrolyte-r in d5w soln. . . 83 ENTOCORT EC...... 36 estradiol...... 47-50 electrolyte-r solution. . . . .83 ENTRESTO...... 10 estradiol & norethindrone electrolyte-s (ph 7.4) solution.83 ENULOSE ...... 33 acetate...... 50 electrolyte-s solution. . . . .83 EPANED...... 8 estradiol patch twice weekly. 50 ELELYSO...... 33 EPCLUSA...... 42 estradiol vaginal ring . . . . 49 ELIDEL...... 26 epinephrine...... 81, 85 estradiol valerate oil. . . . .49 eliglustat tartrate caps. . . .87 EPIPEN...... 81 estradiol valerate-dienogest . 47 ELIMITE...... 24 EPIPEN JR...... 81 estradiol-levonorgestrel td ELIQUIS...... 7 EPIVIR ...... 41, 43 patch weekly...... 50 ELLA...... 47 EPIVIR HBV...... 41 estradiol-norethindrone ace td ELMIRON...... 67 epoetin alfa ...... 8 patch twice weekly. . . .50 ELOCON...... 23 epoetin alfa-epbx ...... 8 estramustine phosphate eltrombopag...... 8 EPOGEN...... 8 sodium...... 4 elvitegravir...... 42, 44 epoprostenol sodium solr. . 14 ESTRING...... 49 elvitegravir/cobicistat/ EPZICOM...... 43 estrogens, conjugated. . 49, 50 emtricitabine/tenofovir ERAXIS...... 40 estrogens, conjugated/ alafenamide fumarate . . 44 erenumab-aooe ...... 18 medroxyprogesterone. . 50 EMCYT...... 4 ergocalciferol (D2) . . . . . 68 estropipate...... 50 EMEND ...... 34 ergotamine tartrate/ caffeine. 17 ESTROSTEP FE...... 49 EMETROL...... 90 ergotamine/caffeine. . . . .17 etanercept...... 45 EMGALITY ...... 18 ERIVEDGE...... 7 ethambutol...... 37 emicizumab-kxwh...... 8 ERLEADA ...... 5 ethionamide...... 38 EMLA...... 26 erlotinib ...... 4 ethosuximide...... 19 emollients...... 88 ertapenem sodium solr. . . 40 ethotoin tabs...... 19 emtricitabine...... 43, 44 ertugliflozin ...... 31 ethynodiol diacetate/EE. .48, 49 emtricitabine/rilpivirine/ ertugliflozin/metformin. . . .31 etidronate...... 32 tenofovir...... 43 ERY-TAB...... 39 etodolac...... 15, 46 emtricitabine/tenofovir ERYC ...... 39 etonogestrel/EE ...... 48 alafenamide. . . . . 43, 44 ERYGEL...... 21 etoposide...... 7 emtricitabine/tenofovir ERYTHROCIN...... 39 etravirine...... 42 disoproxil...... 43 erythromycin. . . . 21, 39, 53 EUCRISA...... 25 EMTRIVA...... 43 erythromycin delayed-release.39 EULEXIN ...... 5 enalapril...... 8, 9 erythromycin ethylsuccinate. 39 EURAX...... 24 enalapril oral soln...... 8 erythromycin stearate. . . . 39 everolimus...... 4, 6 enalapril/hydrochlorothiazide. 9 erythromycin/sulfisoxazole. .39 EVISTA...... 32 enasidenib ...... 4 ESBRIET ...... 84 evolocumab ...... 13 ALL CAPS = Brand-name drug lower case = Generic drug 101 Index of Covered Drugs evotaz...... 44 fe fum-fe poly-fa-c-b3 cap ferrous fumarate-folic acid EXCEDRIN MIGRAINE. . . .15 62.5-62.5-1-40-3mg tab...... 69 EXELON...... 15 (125 mg fe)...... 68 ferrous gluconate. . . . 69, 91 exemestane...... 5 fe fum-iron poly cmplx-fa-b ferrous gluconate tabs. . . .69 exenatide...... 32 cmplx-c-biotin-probiotic ferrous sulfate...... 69, 91 exenatide pen...... 32 cap...... 68 ferrous sulfate dried tabs. . .69 exenatide sopn...... 32 fe fum-iron polysacch complex- ferrous sulfate dried tbcr. . .69 EXFORGE...... 11 fa-b cmplx-c-zn-mn-cu ferrous sulfate extended-release EXFORGE HCT...... 11 cap...... 69 tablets...... 69 ferrous sulfate liquid. . . . .69 EXJADE...... 8 fe fum-iron polysacch complex- ferrous sulfate syrup. . . . .69 exogabine ...... 19 fa-b complex-c-biotin fesoterodine fumarate tb24. .66 EXTINA...... 23 cap...... 69 fe fumarate-vit c-vit b12-fa fidaxomicin ...... 39 EXTRA-VIRT PLUS DHA. . .77 filgrastim...... 8 ezetimibe tabs...... 13 cap...... 69 FE PLUS PROTEIN. . . . . 70 FINACEA...... 21 finasteride ...... 66 F febuxostat ...... 46 fingolimod...... 18 felbamate...... 19, 20 FALESSA...... 48 FIORICET...... 15, 16 felbamate oral susp . . . . .20 famotidine...... 35, 90 FIORICET W/CODEINE. . . 16 FELBATOL...... 19, 20 famotidine in nacl soln. . . .35 FIORINAL...... 15, 16 FELBATOL ORAL SUSP. . .20 FAMOTIDINE INJ ...... 35 FIORINAL W/CODEINE. . . 16 FELDENE...... 16, 46 famotidine oral suspension. .35 FIRAZYR...... 83 felodipine extended-release . 11 FAMOTIDINE PREMIXED IV. 35 FIRVANQ ...... 40 FEM PH...... 50 famotidine soln...... 35 FLAGYL...... 45, 50 FEMARA ...... 5 FANAPT...... 58 FLAREX...... 52 FEMCON FE...... 49 FANAPT TITRATION PACK. .58 flecainide...... 10 FEMHRT LOW DOSE. . . . 47 FANTASY...... 89 FLEET ENEMA...... 90 fenofibrate...... 12 FARESTON...... 5 FLEET PHOSPHO-SODA. . 90 fenofibrate micronized caps. 12 FLEXERIL...... 47 FARYDAK...... 4 fentanyl transdermal. . . . .16 FLOLAN...... 14 fat emulsion iv...... 83 FEOSOL...... 69, 91 FLOMAX...... 66 FAZACLO...... 58 FERGON...... 69, 91 FLONASE...... 28 fe asp gly-fe polys-succ acd-b FERIVA 21/7...... 68 FLORAJEN ...... 37, 90 cmplx-c-ca-fa tab ther FERRALET 90...... 68 FLORANEX...... 37, 90 pk...... 68 FERRAPLUS 90...... 70 FLORASTOR...... 37, 90 fe asparto gly-b12-fa-c-dss- FERRIMIN 150...... 69 FLORINEF...... 29 succinic acid-zn tab FERRLECIT...... 78 FLOVENT DISKUS. . . . . 65 75-1 mg...... 68 FERROGELS FORTE. . . . 69 FLOVENT HFA ...... 65 fe bisglycinate-fe polysacch-vit ferrous bis-glycinate chelate. 91 FLOXIN...... 27, 39 c-vit b12-fa cap. . . . . 68 ferrous fumarate. . .47, 69, 91 FLOXIN OTIC...... 27 fe carbonyl-fa-b complex- ferrous fumarate tabs. . . . 69 FLUARIX QUAD ...... 86 a-c-d-e-min tab ferrous fumarate w/fa-dss-b FLUBLOK...... 86 75-1.25 mg...... 68 complex-vit c tab. . . . .69 FLUCELVAX...... 86 fe carbonyl-fe gluconate-fa-vit ferrous fumarate-fa-b fluconazole . . . . .40, 41, 50 b12-vit c-dss tab complex-c-zn-mg-mn-cu cap. FLUCONAZOLE IN 90-1 mg...... 68 69 DEXTROSE...... 41

ALL CAPS = Brand-name drug lower case = Generic drug 102 Index of Covered Drugs fluconazole in dextrose soln. 41 FOLCAPS OMEGA-3 GATTEX...... 37 FLUCONAZOLE IN NACL. . 41 CAPSULE ...... 74 gefitinib...... 4 fluconazole in nacl soln. . . 41 FOLGARD OS...... 70 GEL-KAM...... 69 fludrocortisone...... 29 FOLGARD RX...... 69 gemfibrozil...... 12 FLULAVAL QUAD...... 86 folic acid. . . . .67, 69, 70, 79 GENERESS FE...... 49 FLUMADINE ...... 42 FOLIC ACID INJ ...... 69 GENGRAF...... 6 fluocinolone folic acid soln...... 69 genistein-zinc amino acid acetonide. . . . 22, 23, 27 folic acid-b6-b12-d-omega chelate-vitamin d cap. . .69 fluocinolone acetonide 3-phytosterols cap 1 mg . 69 GENOTROPIN...... 32 (otic) oil ...... 27 folic acid-vitamin b6-vitamin GENTAK...... 22, 53 fluocinonide...... 23 b12 tab ...... 69 gentamicin. . . .22, 40, 51, 53 fluocinonide emulsified base. 23 FOLIVANE-OB...... 77 gentamicin in saline soln. . .40 fluoride. . . . . 69, 71, 79, 91 FOLIVANE-PRX DHA NF. . .77 GENTAMICIN SULFATE/0.9% fluoride dental rinse. . . . .91 FOLTABS PAK PLUS DHA RE SODIUM CHLORIDE. . .40 fluorometholone...... 52 OB + DHA PAK. . . . . 72 gentamicin/prednisolone fluorometholone acetate opth FOLTRATE...... 68 acetate...... 51 susp...... 52 FORTAMET...... 31 GENTEX ADE 28-1 MG. . . 73 fluorouracil...... 25 FORTICAL...... 32 GENVOYA...... 44 fluoxetine...... 56 FOSAMAX...... 32 GEODON...... 58 FLUOXETINE HCL. . . . . 56 fosamprenavir...... 44 GESTICARE PAK DHA. . . .72 fluoxetine HCL (pmdd) caps. 56 fosinopril...... 9 GG/CODEINE...... 61 fluoxetine HCL caps. . . . .56 fosinopril/hydrochlorothiazide. 9 GG/DM CR...... 61 fluoxetine HCL tabs. . . . .56 FOSTEUM...... 69 GILENYA ...... 18 fluphenazine...... 59 FRAGMIN...... 7 GILOTRIF...... 4 fluphenazine decanoate . . .59 FREAMINE HBC...... 82 glasdegib ...... 7 flurazepam...... 57 FREAMINE III...... 82 glatiramer acetate...... 18 flurbiprofen ...... 52 FURADANTIN SUSP glecaprevir/pibrentasvir. . . 41 flutamide ...... 5 25 MG/5 ML...... 45 GLEEVEC ...... 5 fluticasone. . . . . 23, 28, 65 furosemide...... 12 GLEOSTINE...... 4 fluticasone furoate . . . . . 65 FUROSEMIDE INJ . . . . . 12 glimepiride...... 31 fluticasone HFA...... 65 furosemide soln ...... 12 glipizide...... 31 fluticasone propionate. . 23, 65 FUSION PLUS...... 68 glipizide extended-release. . 31 fluticasone/salmeterol. . . .65 FUZEON...... 44 glipizide-metformin. . . . . 31 FLUVIRIN...... 86 GLUCAGEN DIAGNOSTIC. .29 fluvoxamine...... 55 G GLUCAGON ...... 29, 30 FLUZONE HD PF ...... 86 gabapentin...... 20 glucagon HCl (diagnostic) FLUZONE QUAD...... 86 gabapentin soln ...... 20 solr...... 29 FLUZONE SPLT ...... 86 GABITRIL...... 20 GLUCAGON HCL FML...... 52 ...... 15 DIAGNOSTIC ...... 29 FML FORTE...... 52 galcanezumab-gnim . . . . 18 glucagon HCL rdna FML LIQUIFILM...... 52 ganciclovir...... 41 (diagnostic) solr . . . . .29 FOCALGIN-B...... 75 GARDASIL...... 85, 86 glucagon, human FOCALIN...... 55 GARDASIL 9...... 85 recombinant...... 30 FOCALIN XR...... 55 GASTROCROM ...... 87 GLUCOPHAGE...... 31 FOLBEE PLUS ...... 79 GLUCOPHAGE ER. . . . . 31 FOLCAL DHA...... 77 ALL CAPS = Brand-name drug lower case = Generic drug 103 Index of Covered Drugs glucose oral tablets . . . . .89 HALCION...... 57 human papillomavirus (hpv) GLUCOTROL ...... 31 HALDOL...... 59 quadrivalent recombinant GLUCOTROL XL...... 31 halobetasol ...... 23 vac ...... 86 GLUCOVANCE...... 31 halobetasol propionate . . . 23 HUMATIN...... 45 glyburide ...... 31 haloperidol...... 59 HUMIRA...... 45 glyburide, micronized. . . . 31 haloperidol lactate oral conc. 59 HUMULIN...... 30, 89 glycerin...... 33, 51, 88 HAVRIX...... 85 HUMULIN 70/30 ...... 30 GLYCERIN SUPPOSITORY. .33 HECORIA...... 6 HUMULIN 70/30 KWIKPEN. 30 GLYCERIN TOPICAL. . . . 88 HECTOROL...... 68 HUMULIN N...... 30 glycerol phenylbutyrate. . . 85 HEMATOGEN...... 69, 70 HUMULIN N KWIKPEN. . . 30 glycine diluent for injection. .14 HEMATOGEN FA...... 69 HUMULIN R...... 30 glycopyrrolate...... 35, 87 HEMATRON-AF ...... 70 HYCAMTIN ...... 7 GLYCOPYRROLATE INJ. . .87 HEMENATAL OB + DHA. . .73 HYCET...... 16 glycopyrrolate soln. . . . . 87 HEMETAB...... 71 HYCODAN...... 62 GLYNASE...... 31 HEMLIBRA ...... 8 hydralazine...... 14 GLYSET...... 31 HEMNATAL OB...... 74 HYDREA ...... 7 GNP IRON...... 69 HEMOCYTE PLUS. . . . . 69 hydrochlorothiazide. . 9, 10, 12 GRANIX...... 8 HEMOCYTE-F...... 69 hydrocod polst-chlorphen polst GRIFULVIN V...... 41 HEMORRHOIDAL SUP -HC cap sr 12hr...... 62 GRIS-PEG...... 41 25MG...... 22 hydrocod polst-chlorphen polst griseofulvin microsize. . . . 41 HEP FLUSH-10...... 7 cr susp...... 62 griseofulvin ultramicrosize. . 41 heparin...... 7 hydrocodone ER...... 17 guaifenesin ...... 61-64 heparin (porcine) in sodium hydrocodone/ guaifenesin extended-release.62 chloride soln...... 7 acetaminophen. . . . . 16 guaifenesin liqd...... 62 heparin sod (porcine) in d5w hydrocodone/acetaminophen guaifenesin pack...... 62 soln...... 7 soln 10-325 mg/15 ml . .16 guaifenesin-codeine liquid. . 62 heparin sodium (porcine) lock hydrocodone/homatropine. .62 guaifenesin/ flush soln...... 7 hydrocodone/ibuprofen. . . 17 pseudoephedrine. . .61, 62 HEPARIN SODIUM/D5W . . .7 HYDROCODONE/TAB guaifenesin/pseudoephedrine HEPARIN SODIUM/NACL INJ. 7 HOMATROP...... 62 extended-release . . . . 62 HEPATAMINE ...... 82 hydrocortisone . .22, 23, 25-27, guaifenesin/pseudoephedrine/ hepatitis a vaccine susp. . . 85 29, 36, 51, 89 dextromethorphan. . . .62 hepatitis b vaccine hydrocortisone (rectal) cream.22 guanabenz...... 14 (recombinant)...... 85 hydrocortisone acetate (rectal) guanfacine...... 9, 55 hepatitis b vaccine recombinant supp...... 22 guanfacine ER...... 55 adjuvanted...... 85 hydrocortisone acetate w/ GUANIDINE HCL ...... 21 HEPLISAV-B ...... 85 pramoxine rectal cream. .22 guanidine HCl tabs. . . . . 21 HEXALEN ...... 4 hydrocortisone acetate w/ GUIATUSS AC...... 61 HIPREX ...... 66 pramoxine rectal foam. . 22 GUIATUSS DAC ...... 61 homatropine ...... 53, 62 hydrocortisone butyrate. . . 23 GYNE-LOTRIMIN . . . . 50, 88 HUMALOG...... 30 hydrocortisone crm, oint. . .89 GYNOL II...... 89 HUMALOG KWIKPEN. . . .30 hydrocortisone sod succinate HUMALOG MIX 50/50...... 30 solr...... 29 H HUMALOG MIX 75/25...... 30 hydrocortisone valerate oint. 22 H.P. ACTHAR...... 19 human papillomavirus (hpv) hydrocortisone/aloe. . . . .22 HAEGARDA...... 83 9-valent recomb vac. . . 85 HYDROMET SYP...... 62

ALL CAPS = Brand-name drug lower case = Generic drug 104 Index of Covered Drugs hydromorphone ...... 17 imiglucerase solr...... 87 insulin aspart protamine & HYDROMORPHONE HCL PF imipenem-cilastatin aspart (human) supn. . .30 INJ ...... 17 intravenous for soln. . . 40 insulin aspart protamine 70%/ hydromorphone HCl soln . . 17 imipramine HCL...... 57 insulin aspart 30%. . . .30 hydroquinone cream. . . . 25 imipramine pamoate caps. . 57 insulin detemir...... 30 hydroquinone soln. . . . . 25 imiquimod 5% cream. . . . 25 insulin detemir sopn. . . . .30 hydroxychloroquine. . . 44, 45 IMITREX...... 18 insulin glargine. . . . . 30, 31 hydroxyprogesterone caproate IMITREX 4 MG AND insulin glargine sopn . . . . 30 oil ...... 50 6 MG INJ...... 18 insulin glargine/lixisenatide. .31 hydroxyurea...... 7 IMODIUM A-D...... 34, 90 insulin human...... 30 hydroxyzine HCl...... 27 IMPAVIDO...... 41 insulin isophane...... 30 hydroxyzine pamoate. . . . 27 IMURAN...... 6, 45 insulin isophane human. . . 30 hyoscyamine...... 35, 66 INCRELEX...... 32 insulin isophane human 70%/ hyoscyamine sulfate. . . . .35 regular 30%...... 30 INCRUSE ELLIPTA. . . . . 65 hyoscyamine sulfate extended- insulin isophane/regular. . .30 indacaterol...... 64 release...... 35 insulin lisopro pro/lispro . . .30 indapamide...... 12 HYPERCARE 15%. . . . . 25 insulin lisopro prot/lispro. . .30 INDERAL...... 11, 18 HYPERLYTE-CR...... 83 insulin lispro...... 30 HYPERSAL...... 81 INDERAL LA...... 11 insulin lispro (human) soct . .30 HYPERTET S/D...... 86 INDERIDE ...... 11 insulin nph (human) (isophane) HYPOTEARS...... 91 indinavir...... 44 supn...... 30 HYTONE ...... 22 INDOCIN...... 16, 46 insulin nph isophane & reg HYTRIN...... 9, 66 indomethacin ...... 16, 46 (human) supn...... 30 HYZAAR ...... 10 INFANATE BALANCE insulin pen needle . . . . . 85 SOFTGEL ...... 76 insulin regular...... 30 I INFLAMASE FORTE. . . . .52 insulin syringes...... 85 IBRANCE...... 5 influenza virus vaccine INTAL...... 65 ibrutinib ...... 5 recombinant hemagglutinin INTEGRA F...... 68 IBUDONE...... 17 (ha)...... 86 INTEGRA PLUS ...... 69 IBUOROFEN TAB influenza virus vaccine split. .86 INTELENCE...... 42 COLD/SIN...... 64 influenza virus vaccine split interferon alfa-2b. . . . . 6, 41 ibuprofen. . . . 15-17, 46, 91 high-dose pf ...... 86 interferon beta-1a...... 18 ibuprofen tabs, chew tabs, influenza virus vaccine interferon beta-1b kit. . . . .6 susp, and drops. . . . .91 split pf...... 86 INTRALIPID...... 83 ICAR PEDIATRIC ...... 67 influenza virus vaccine split INTRON A...... 6, 41 ICAR-C PLUS ...... 70 quadrivalent...... 86 INTUNIV...... 55 icatibant...... 83 influenza virus vaccine tiss-cult INVANZ INJ...... 40 ICLUSIG...... 5 subunit...... 86 INVEGA SUSTENNA. . . . 58 idelalisib...... 5 influenza virus vaccine types INVEGA TRINZA...... 58 IDHIFA ...... 4 a&b surface antigen. . . 86 INVIRASE...... 44 ILARIS ...... 45 INFUVITE PEDIATRIC . . . .70 INVOKANA ...... 31 ILEVRO ...... 52 INGREZZA...... 21 IODOPEN...... 78 iloperidone...... 58 IONOSOL-B/DEXTROSE INLYTA...... 4 imatinib mesylate ...... 5 5%...... 83 inotersen inj ...... 21 IMBRUVICA...... 5 IONOSOL-MB/DEXTROSE insulin (vials only)...... 89 IMDUR...... 13 5%...... 83 insulin aspart...... 30 ALL CAPS = Brand-name drug lower case = Generic drug 105 Index of Covered Drugs ipratropium ...... 28, 65 ivermectin ...... 24, 37 ketorolac ...... 16, 52 ipratropium HFA...... 65 ivermectin (pediculicide) lotn. 24 ketorolac tromethamine. . . 16 ipratropium nasal...... 28 ivosidenib ...... 4 KETOROLAC TROMETHAMINE ipratropium/albuterol. . . . 65 ixazomib...... 5 INJ ...... 16 IRENKA...... 56 ketorolac tromethamine soln. 16 IRESSA...... 4 J ketotifen...... 51 IROMIN-G ...... 70 J-TAN D PD...... 59 KEVZARA ...... 45 iron...... 3, 48, 49, 67, JADENU...... 8 KIMONO...... 89 69-72, 74, 78, 79, 84, 91 JAKAFI...... 5 KINERET...... 45 iron combination...... 70 JANUMET...... 31 KIONEX...... 14 iron w/vitamins tabs. . . . .70 JANUMET XR...... 31 KLONOPIN ...... 19, 54 iron-docusate-b12-folic acid-c-e- JANUVIA ...... 31 KLOR-CON 10...... 80 cu-biotin tab...... 70 JINTELI...... 47 KLOR-CON 8 ...... 80 iron-folic acid-vit b12-vit JULUCA...... 44 KLOR-CON M15...... 80 c-docusate sod tab. . . .70 KORLYM ...... 33 iron-folic acid-vit c-vit b6-vit b12- K KRINTAFEL ...... 45 zinc tab ...... 70 K-DUR 10...... 80 KUVAN...... 33 iron-vit c-vit b12-folic acid tab.70 K-DUR 20...... 80 KUVAN POWDER FOR IROSPAN 24/6...... 68 K-LOR...... 80 SOLUTION ...... 33 ISENTRESS...... 42 K-LY TE...... 80 ISENTRESS CHEWABLE . . 42 K-PHOS NEUTRAL. . . . . 79 L ISENTRESS HD ...... 42 K-PHOS NO 2...... 80 L-CYSTEINE HCL...... 81 ISENTRESS SUSP. . . . . 42 K-PHOS ORIGINAL . . . . .80 L-METHYLFOLATE. . . .70, 71 ISMO...... 13 K-TAB 20...... 80 l-methylfolate tabs. . . . 70, 71 isocarboxazid tabs. . . . . 56 KABIVEN...... 81 l-methylfolate w/vit b12-vit b6-vit ISOLYTE-P/DEXTROSE 5%. 83 KALETRA ...... 44 b2 tab 6-1-50-5 mg . . . 70 ISOLYTE-S...... 83 KALYDECO...... 81 l-methylfolate-methylcobalamin- ISOLYTE-S PH 7.4. . . . . 83 KALYDECO GRANULES. . .81 acetylcyst tab isoniazid...... 38 KAOPECTATE...... 90 6-2-600 mg ...... 70 ISOPTO ATROPINE. . . . .53 KARBINAL ER...... 60 labetalol...... 10 ISOPTO CARPINE . . . . . 53 KAYEXALATE...... 13 LAC-HYDRIN...... 25 ISOPTO HOMATROPINE. . . . 53 KAZANO...... 31 lacosamide ...... 20 ISOPTO HYOSCINE. . . . .53 kcl in dextrose & nacl inj . . .79 lacosamide soln...... 20 ISORDIL...... 13 kcl in nacl inj...... 79 lactated ringer’s (irrigation) ISORDIL S.L...... 13 KCL/D5W/LR IV LAC RING. 80 soln...... 84 isosorbide dinitrate. . . . . 13 KEFLET...... 38 lactated ringer’s solution. . .83 ISOSORBIDE DINITRATE ER.13 KEFLEX...... 38 LACTATED RINGERS . . 82-84 isosorbide dinitrate extended- KENALOG...... 23, 28 LACTATED RINGERS KENALOG IN ORABASE. . .28 release...... 13 IRRIGATION ...... 84 KENALOG-10 INJ...... 29 isosorbide mononitrate. . . 13 LACTIC ACID E...... 25 KEPPRA...... 20 isosorbide mononitrate lactic acid w/vitamin E cream KEPPRA XR...... 20 extended-release . . . . 13 10%-3500 unit/30gm. . 25 KERLONE...... 10 isotretinoin...... 21 LACTINEX...... 37, 90 ketoconazole. . . . 23, 25, 41 itraconazole...... 41 LACTINOL...... 25 ketoconazole (topical) foam . 23 ivacaftor...... 81 lactulose...... 33 ketoprofen...... 16, 46 LAMICTAL...... 20 ALL CAPS = Brand-name drug lower case = Generic drug 106 Index of Covered Drugs LAMICTAL CD CHEW TAB. .20 levetiracetam...... 20 lidocaine inj w/epinephrine. .85 LAMICTAL ODT ...... 20 levetiracetam oral solution. . 20 lidocaine patch...... 26 LAMICTAL STARTER KIT. . 20 levetiracetam tb24. . . . . 20 lidocaine viscous ...... 28 LAMISIL...... 24, 41 levobunolol ...... 52 LIDOCAINE/EPINEPHRINE . 85 LAMISIL AT...... 24 levocarnitine (metabolic lidocaine/hydrocortisone lamivudine. . . . . 41, 43, 44 modifiers) oral solution . .87 acetate rectal cream kit. .26 lamivudine/tenofovir disoproxil levocarnitine (metabolic lidocaine/hydrocortisone fumarate...... 43 modifiers) tabs. . . . . 87 acetate rectal gel . . . . 26 lamivudine/zidovudine. . . .43 levocetirizine...... 27 lidocaine/prilocaine. . . . .26 lamotrigine...... 20 levofloxacin...... 39 lidocaine/tetracaine cream. .26 lamotrigine chew dispersable levofloxacin in d5w soln. . . 39 LIDODERM...... 26 tab...... 20 levomefolate glucosamine LIFESTYLES...... 89 lamotrigine ODT...... 20 tabs...... 48 lifitegrast...... 53 lamotrigine starter kit. . . . 20 levonorgestrel...... 47-49 LIMBITROL...... 60 lancets...... 85 levonorgestrel-ethinyl linaclotide...... 33 LANOXIN...... 10 estradiol...... 48 linagliptin...... 31 lansoprazole ...... 35 levonorgestrel/EE. . . . 47-49 linezolid ...... 44 lansoprazole delayed-release.35 levothyroxine...... 32 LINZESS...... 33 LANTUS...... 30 LEVOTHYROXINE liothyronine ...... 32 LANTUS SOLOSTAR. . . . 30 SODIUM IV ...... 32 LIPITOR...... 13 lapatinib ditosylate ...... 5 levothyroxine sodium solr iv . 32 LIPOSYN III...... 83 LARIAM...... 44 LEVOXYL...... 32 liraglutide ...... 32 larotrectinib ...... 5 LEVSIN...... 35 lisdexamfetamine...... 55 LASIX...... 12 LEVSINEX...... 35 lisdexamfetamine chewable latanoprost...... 53 LEXAPRO ...... 56 tab...... 55 LATUDA...... 58 LEXIVA...... 44 lisinopril...... 9, 124 laxative enemas ...... 90 LEXUSS 210...... 60 lisinopril/hydrochlorothiazide. 9 laxatives...... 2, 33, 90 LIBRAX...... 34 lithium carbonate...... 56 LIBRIUM...... 54 leflunomide...... 45 lithium carbonate extended- LIDAMANTEL...... 25 lenalidomide caps ...... 6 release...... 56 LIDEX...... 23 lenvatinib...... 5 LITHOBID...... 56 LIDEX E...... 23 LENVIMA...... 5 lixisenatide...... 31, 32 lidocaine. . . . .25, 26, 28, 85 LETAIRIS...... 13 LMX-4...... 25 LIDOCAINE HCL. . .25, 26, 85 letrozole...... 5 LO LOESTRIN FE...... 48 lidocaine HCl (local anesth.) leucovorin ...... 5 LO MINASTRIN PAK FE. . . 47 soln...... 85 LEUKERAN...... 4 LO/OVRAL...... 48 LIDOCAINE HCL MDV. . . .85 LEUKINE...... 8 LOCOID...... 23 LIDOCAINE HCL/ LODINE ...... 15, 46 leuprolide...... 5, 6 DEXTROSE IV...... 85 LOESTRIN 1/20...... 48 leuprolide acetate (cpp) LIDOCAINE HCL/ LOESTRIN 1.5/30 . . . . . 48 (3 month) kit...... 6 HYDROCORTISONE LOESTRIN FE 1/20. . . . .48 levalbuterol HCl...... 65 ACETATE...... 26 LOESTRIN FE 1.5/30. . . . 48 LEVAQUIN...... 39 LIDOCAINE HCL/ LOFIBRA...... 12 LEVAQUIN INJ ...... 39 HYDROCORTISONE LOHIST-D...... 60 LEVEMIR...... 30 ACETATE WITH ALOE. . 26 LOKELMA ...... 13 LEVEMIR FLEXTOUCH. . . 30 lidocaine in dextrose iv soln . 85 LOMEDIA 24 FE...... 48 ALL CAPS = Brand-name drug lower case = Generic drug 107 Index of Covered Drugs LOMOTIL...... 34 LUDIOMIL ...... 57 MANGANESE TRACE METAL lomustine...... 4 LUFYLLIN ...... 66 INJ ...... 70 LONITEN...... 14 lumacaftor/ivacaftor. . . . .81 MAPAP COLD TAB . . . . .64 LONSURF ...... 4 LUPRON ...... 5, 6 maprotiline...... 57 loperamide...... 34 LUPRON DEPOT ...... 5 MAR-COF BP...... 64 LOPID...... 12 LUPRON DEPOT 6-MONTH. .5 MAR-COF CG LOPIDINE ...... 54 LUPRON DEPOT-PED. . . . 6 EXPECTORANT. . . . .62 lopinavir/ritonavir ...... 44 lurasidone HCL tabs...... 58 maraviroc...... 44 LOPRESS HCT...... 10 LURIDE...... 69 MARCAINE...... 85 LOPRESSOR...... 10 LURIDE LOZI-TABS...... 69 MARINOL...... 34 loratadine. . . . 27, 28, 62, 89 LUSTRA...... 25 MARNATAL-F...... 78 loratadine & pseudoephedrine lusutrombopag ...... 8 MARPLAN...... 56 SR 24hr...... 62 LUVOX...... 55 MATULANE...... 7 loratadine/ LYNPARZA ...... 7 MATZIM LA, CARDIZEM LA. 11 pseudoephedrine.28, 62, 89 LYRICA...... 20 MAVIK...... 9 loratadine/pseudoephedrine LYRICA SOLUTION . . . . .20 MAVYRET...... 41 extended-release . . . . 28 LYSODREN...... 7 MAXALT/MAXALT MLT. . . 18 lorazepam...... 54 LYSTEDA...... 51 MAXIDEX...... 52 lorazepam conc ...... 54 MAXITROL...... 51 LORAZEPAM INJ...... 54 M MAXZIDE...... 12 lorazepam inj soln...... 54 M-CLEAR WC...... 61 measles, mumps & rubella LORAZEPAM INTENSOL . . 54 M-END DM LIQ...... 63 virus vaccines for inj. . . 86 LORCET...... 16 M-END MAX D ...... 64 mecasermin...... 32 LORTAB...... 16 M-END PE...... 62 meclizine...... 34, 90 LORTAB ELIXIR ...... 16 M-END WC ...... 64 MEDROL...... 29 LORTUSS EX ...... 64 M-M-R II...... 86 medroxyprogesterone losartan ...... 9, 10 MAALOX ...... 34, 90 acetate...... 47, 50 losartan/HCTZ...... 10 MAALOX LIQUID ...... 90 medroxyprogesterone acetate LOSEASONIQUE...... 48 macitentan...... 13 (contraceptive) susp. . . 47 LOTEMAX ...... 52 MACNATAL CN DHA mefloquine...... 44 LOTENSIN...... 8, 9 SOFTGEL ...... 76 MEFOXIN...... 38 LOTENSIN HCT ...... 9 MACROBID...... 45 MEGACE...... 6 loteprednol etabonate. . . .52 MACRODANTIN...... 45 ...... 6 loteprednol etabonate- mafenide acetate cream . . .22 MEKINIST ...... 5 tobramycin...... 51 MAG-OX...... 70, 91 MELLARIL...... 59 LOTREL...... 11 MAGNESIUM CHLORIDE meloxicam...... 16, 46 LOTRIMIN AF ...... 23, 88 INJ ...... 70 melphalan...... 4 LOTRISONE...... 23 magnesium chloride inj soln. 70 LOTRONEX...... 34 MELQUIN 3...... 25 magnesium citrate soln. . . 33 ...... 15 lovastatin ...... 13 magnesium oxide. . . . 70, 91 LOVAZA...... 13 MENACTRA...... 86 MAGNESIUM SULFATE INJ. 70 MENEST ...... 49 LOVENOX ...... 7 magnesium sulfate inj soln. .70 loxapine...... 59 meningococcal (a, c, y, and MAKENA...... 50 w-135)...... 86 LOXITANE...... 59 malathion...... 24 LOZOL ...... 12 manganese chloride inj soln. 70

ALL CAPS = Brand-name drug lower case = Generic drug 108 Index of Covered Drugs meningococcal (a, c, y, and METHSCOPOLAMINE mexiletine...... 10 w-135) conjugate BROMIDE...... 35 MEXITIL...... 10 vaccine...... 86 methscopolamine bromide MIACALCIN...... 32 meningococcal (a, c, y, and tabs...... 35 MICARDIS...... 9 w-135) oligo conj vac methsuximide...... 20 MICARDIS HCT...... 9 for inj...... 86 METHYCLOTHIAZIDE. . . .12 MICATIN...... 24, 88 MENOMUNE...... 86 methyclothiazide tabs . . . .12 miconazole . . . . .24, 51, 88 MENVEO...... 86 methyldopa...... 14 MICONAZOLE 1...... 24 meperidine...... 17 methyldopa/HCTZ. . . . . 14 miconazole crm ...... 88 MEPHYTON ...... 71 methylene blue...... 66 miconazole nitrate vaginal kit.24 MEPIVACAINE HCL INJ. . . 85 methylergonovine. . . . 33, 51 MICRO-K 10...... 80 mepivacaine HCl inj soln. . .85 METHYLIN...... 55 MICRO-K 8 ...... 80 MEPRON...... 41 methylphenidate. . . . .55, 56 MICRONASE...... 31 mercaptopurine...... 4 methylphenidate extended- MICROZIDE...... 12 meropenem solr...... 40 release...... 55 MIDAMOR...... 12 MERREM...... 40 methylphenidate HCL chew. 55 midodrine...... 14 mesalamine...... 36 methylphenidate HCL ER midostaurin...... 5 mesalamine 24hr...... 55 mifepristone...... 33 extended-release . . . . 36 methylphenidate HCL oral MIGERGOT mesalamine supp...... 36 susr...... 56 SUPPOSITORIES. . . . 17 mesna...... 7 methylphenidate patch...... 56 miglitol...... 31 MESNEX ...... 7 methylprednisolone. . . . .29 miglustat caps...... 87 MESTINON...... 18 methylprednisolone acetate MILRINONE IN MESTINON TIMESPAN. . . 18 susp...... 29 DEXTROSE IV...... 14 METADATE CD...... 55 methylprednisolone sod succ milrinone in dextrose iv soln. 14 METADATE ER...... 55 solr...... 29 MILRINONE LACTATE IV . . 14 METAGLIP...... 31 metipranolol...... 52 milrinone lactate soln. . . . 14 METAMUCIL...... 90 METIPRANOLOL OTH miltefosine...... 41 metaproterenol...... 65 SOLN...... 52 MINASTRIN 24 FE. . . . . 48 METAPROTERENOL metipranolol soln ...... 52 MINIPRESS...... 9 SYRUP...... 65 metoclopramide...... 34 MINOCIN...... 40 metformin...... 31 metolazone...... 12 minocycline...... 40 metformin ER ...... 31 metoprolol...... 10 minoxidil...... 14 metformin/glyburide. . . . .31 metoprolol & MINUTUSS DR SYP. . . . .63 methazolamide...... 53 hydrochlorothiazide tab. .10 MIRALAX...... 34 methenamine ...... 66 metoprolol succinate. . . . 10 MIRAPEX...... 19 methenamine hippurate. . . 66 METROCREAM ...... 24 MIRAPEX ER...... 19 METHENAMINE METROGEL...... 24, 51 MIRCETTE...... 47 MANDELATE ...... 66 METROGEL 1%...... 51 mirtazapine...... 57 methenamine mandelate tabs.66 METROGEL-VAGINAL. . . .51 MIRVASO...... 24 METHERGINE...... 33, 51 METROLOTION...... 24 misoprostol...... 37, 46 methimazole...... 32 metronidazole. . 24, 45, 50, 51 MITIGARE...... 17, 46 methocarbamol...... 47 METRONIDAZOLE IN NACL mitotane...... 7 methotrexate...... 45 0.79%...... 45 MOBIC...... 16, 46 methoxsalen ...... 24 metronidazole in nacl soln. . 45 MODICON...... 49 methoxsalen (topical) lotion. . 24 MEVACOR...... 13 ALL CAPS = Brand-name drug lower case = Generic drug 109 Index of Covered Drugs MODURETIC...... 12 multiple vitamins w/minerals & NAPHCON A...... 91 mometasone. . . . 23, 28, 65 folic acid chew. . . . . 70 NAPRELAN...... 46 mometasone furoate . . .23, 28 MULTITRACE-4...... 79 NAPROSYN...... 16, 46 mometasone furoate (nasal) MULTITRACE-4 naproxen...... 16, 46 susp...... 28 CONCENTRATE. . . . .79 naproxen delayed release.16, 46 mometasone inhalation. . . 65 MULTITRACE-4 NEONATAL. 79 naproxen sodium. . . . 16, 46 mometasone/formoterol. . .65 MULTITRACE-4 PEDIATRIC. 79 naproxen sodium tb24. . . .46 MONISTAT...... 51, 88 MULTITRACE-5...... 79 naratriptan...... 18 MONISTAT 3...... 51 MULTITRACE-5 NARCAN NASAL SPRAY . . 57 MONISTAT-DERM...... 24 CONCENTRATE. . . . .79 NASACORT ALLERGY 24 MONOPRIL...... 9 multivitamins/fluoride/±iron. 71 HOUR...... 28 MONOPRIL-HCT...... 9 multivitamins/minerals. . 71, 72 nasal sprays...... 89 montelukast...... 66 mupirocin...... 22 NASALCROM...... 28 morphine...... 17 mupirocin calcium oint . . . 22 NASONEX...... 28 morphine extended-release. .17 MURINE...... 91 NATACYN...... 54 MORPHINE SULFATE IV. . .17 MURO 128 ...... 54 natalizumab conc...... 37 morphine sulfate iv soln. . . 17 MYAMBUTOL...... 37 NATALVIT...... 74 MOTEGRITY ...... 34 MYCELEX ...... 23, 40 natamycin susp...... 54 MOTRIN...... 16, 46, 91 MYCOBUTIN...... 38 NATAZIA...... 47 MOTRIN IB ...... 91 mycophenolate mofetil. . . . 6 nateglinide...... 31 mycophenolate mofetil HCl MOVANTIK ...... 33 NATROBA...... 24 solr...... 6 MOXEZA...... 53 NAVANE...... 59 mycophenolate sodium. . . .6 moxifloxacin HCL (ophth) NEBUPENT...... 41 MYCOSTATIN ...... 24, 41 soln...... 53 NEBUSAL ...... 81 MYFORTIC...... 6 MOZOBIL...... 8 NEEVO DHA...... 78 MYLANTA...... 34, 90 MS CONTIN...... 17 nelfinavir...... 44 MYLANTA LIQUID . . . . . 90 NEO-SYNEPHRINE. . . 28, 89 MSIR...... 17 MYLERAN...... 4 MUCINEX...... 61, 62 neomycin sulfate...... 45 MYLICON...... 90 neomycin/bacitracin/ MUCINEX D...... 62 MYORISAN...... 21 MUCINEX DM...... 61 polymyxin...... 54 MYSOLINE...... 20 neomycin/polymyxin b gu MUCINEX FOR KIDS. . . . 62 MYTESI ...... 34 MUCOMYST...... 81 soln...... 66 MULPLETA ...... 8 N neomycin/polymyxin B/ bacitracin...... 22 MULTI SYMPTOM TAB COLD nabumetone ...... 16 RLF...... 64 neomycin/polymyxin B/ NADOLOL...... 11 dexamethasone. . . . .51 MULTICHEW CHW. . . . . 70 nadolol tabs...... 11 multiple vitamin chewable tablet neomycin/polymyxin B/ naloxegol...... 33 gramicidin...... 54 and drops ...... 70 naloxone...... 17, 57 neomycin/polymyxin B/ multiple vitamin inj. . . . . 70 NALOXONE INJ ...... 57 hydrocortisone. . . .27, 51 multiple vitamins w/calcium naltrexone ...... 54, 57 neomycin/polymyxin-HC misc...... 70 NAMENDA...... 15 cream 0.5%...... 22 multiple vitamins w/minerals & naphazoline HCL...... 51 NEORAL ...... 6 calcium-folic acid tabs. . 70 naphazoline/glycerin. . . . 51 NEOSPORIN. . .22, 54, 66, 89 multiple vitamins w/minerals & naphazoline/zinc sulfate. . .51 NEOSPORIN GU IRRIGANT. 66 folic acid...... 70 nepafenac susp...... 52 ALL CAPS = Brand-name drug lower case = Generic drug 110 Index of Covered Drugs NEPHPLEX RX...... 67 NIMOTOP...... 11 norethindrone/ethinyl estradiol/ NEPHRAMINE...... 82 NINLARO...... 5 ferrous fumarate. . . . .47 NEPHROCAPS...... 79 nintedanib...... 84 norethindrone/ME . . . . . 49 NEPHRON FA...... 69 niraparib...... 7 NORFLEX ...... 47 NEPTAZANE...... 53 nitazoxanide suspension. . .41 norgestimate-eth estrad. . . 49 NESACAINE-MPF...... 85 nitazoxanide tablet. . . . . 41 norgestimate/EE...... 49 NESINA ...... 31 nitisinone...... 33 norgestrel/EE ...... 48, 49 NESTABS ABC...... 73 NITREK ...... 13 NORMOSOL-M IN D5W. . . 83 NESTABS DHA...... 74 NITRO-BID...... 13 NORMOSOL-R ...... 83 NEULASTA ...... 8 NITRO-DUR...... 13 NORMOSOL-R IN D5W. . . 83 NEUPOGEN ...... 8 nitrofurantoin NORPACE...... 10 NEURONTIN...... 20 extended-release . . . . 45 NORPACE CR...... 10 NEUTROGENA OIL FREE nitrofurantoin macrocrystals. 45 NORPRAMIN...... 56 ACNE WASH...... 21 nitrofurantoin susp. . . . . 45 nortriptyline...... 57 nevirapine ...... 42 nitroglycerin...... 13, 26 NORVASC...... 11 nevirapine ER...... 42 nitroglycerin cpcr ...... 13 NORVIR...... 44 NEXA PLUS SOFTGEL. . . 77 NITROGLYCERIN ER. . . . 13 NOVAFERRUM 50. . . . . 71 NEXAVAR ...... 5 NITROLINGUAL...... 13 NOVAFERRUM PEDIATRIC NEXIUM 24HR OTC. . . . .34 NITROSTAT...... 13 DROPS...... 71 NEXIUM DELAYED-RELEASE NITYR...... 33 NOVAREL ...... 50 PACKET ...... 35 NIX 24, 90 NOVOLIN...... 30, 89 niacin...... 13 NIX CREME RINSE. . . . . 24 NOVOLIN 70/30...... 30 niacin extended-release. . . 13 NIZORAL...... 23, 25, 41 NOVOLIN N...... 30 niacinamide w/zinc-copper & NIZORAL SHAMPOO...... 25 NOVOLIN R...... 30 l-methylfolate tabs . . . .71 NOCDURNA ...... 33 NOVOLOG...... 30 niacinamide w/zinc-copper- NOLVADEX...... 5 NOVOLOG FLEXPEN. . . . 30 methylfolate-se-cr tabs . .71 NORCO...... 16 NOVOLOG MIX 70/30. . . .30 NIACOR...... 13 NOVOLOG MIX 70/30 NORDETTE...... 48 NIASPAN...... 13 PREFILLED FLEXPEN. . 30 norelgestromin/EE. . . . . 49 nicardipine...... 11 NOVOLOG PENFILL . . . . 30 norethin-eth estradiol-fe. . . 48 NICODERM CQ . . . . .59, 91 NUEDEXTA...... 59 norethindrone...... 47-50 NICOMIDE...... 71 NULYTELY...... 34 norethindrone & ethinyl NICORETTE OTC...... 59 NUTRILYTE...... 83 estradiol-fe chew tab. . .49 nicotine...... 59, 91 nutritional supplements caps.71 norethindrone ace & ethinyl NICOTINE GUM...... 91 NUTROPIN AQ NUSPIN. . .32 estradiol-fe...... 48 nicotine kit...... 59 NUVARING ...... 48 norethindrone ace-eth nicotine polacrilex gum. . . 59 NUVIGIL...... 15 estradiol-fe chew tab. . .48 nicotine polacrilex lozenge. .59 NUZYRA ...... 40 NICOTINE TRANSDERMAL norethindrone acetate. . 48-50 NYMALIZE...... 11 SYSTEM...... 59 norethindrone acetate-ethinyl nystatin...... 24, 41 NICOTROL ...... 91 estradiol tab...... 47 NYTOL QUICK CAPS. . . . 57 nifedipine...... 11 norethindrone acetate/ nifedipine extended-release . 11 EE...... 48, 49 O nilotinib...... 5 norethindrone acetate/ OB COMPLETE . . .72, 74, 76 nimodipine...... 11 EE/iron...... 48, 49 OB COMPLETE ONE. . . . 76 nimodipine oral soln. . . . .11 norethindrone/EE. . . . 47, 49 ALL CAPS = Brand-name drug lower case = Generic drug 111 Index of Covered Drugs OB COMPLETE PETITE. . .76 OPSUMIT...... 13 oxycodone HCl caps. . . . 17 OB COMPLETE PREMIER. .74 OPTIPRANOLOL ...... 52 oxycodone HCl tabs. . . . .17 OB COMPLETE/DHA . . . .72 OPTIVAR...... 51 oxycodone/acetaminophen. 17 OCEAN NASAL SPRAY. . . 28 ORACIT...... 67 oxycodone/aspirin. . . . . 17 octreotide...... 7 ORAP...... 59 OXYFAST...... 17 OCUFEN ...... 52 ORAPRED...... 29 OXYIR...... 17 OCUFLOX ...... 54 ORAPRED ODT ...... 29 oxymetazoline...... 28 ODEFSEY...... 43 ORFADIN...... 33 oxymorphone ER...... 17 ODOMZO...... 7 ORKAMBI ...... 81 OXYTROL FOR WOMEN OTC OFEV ...... 84 ORILISSA ...... 51 PATCH...... 67, 91 ofloxacin...... 27, 39, 54 orphenadrine OGEN...... 50 extended-release . . . . 47 P olanzapine...... 58 ORTHO COIL ...... 48 PACERONE...... 10 olanzapine ODT ...... 58 ortho diaphragm...... 48 PAIRE OB...... 73 olanzapine-fluoxetine. . . . 59 ORTHO EVRA...... 49 palbociclib...... 5 olaparib ...... 7 ORTHO FLAT...... 48 PALGIC...... 60 olmesartan medoxomil tabs. .9 ORTHO FLEX...... 48 paliperidone...... 58 olmesartan medoxomil- ORTHO MICRONOR. . . . 49 palivizumab...... 45 hydrochlorothiazide tab . 10 ORTHO TRI-CYCLEN. . . . 49 PAMELOR...... 57 olodaterol...... 64, 65 ORTHO TRI-CYCLEN LO . . 49 PAMIDRONATE DISODIUM . 32 olopatadine HCl (nasal) soln. 28 ORTHO-CEPT...... 48 pamidronate disodium inj. . 32 olopatadine HCL soln . . . .51 ORTHO-CYCLEN...... 49 PANCREAZE...... 36 olsalazine sodium...... 36 ORTHO-NOVUM 1/35. . . .49 pancrelipase...... 36 OLUMIANT ...... 45 ORTHO-NOVUM 1/50. . . .49 pancrelipase (lipase-protease- omadacycline ...... 40 ORTHO-NOVUM 10/11 . . .47 amylase) cpep . . . . . 36 ombitas-paritapre-riton & dasab ORTHO-NOVUM 7/7/7. . . 49 pancrelipase (lipase-protease- tab pak...... 41 ORUDIS...... 16, 46 amylase) tabs ...... 36 omega-3-acid ethyl esters OS-CAL...... 67, 91 panobinostat...... 4 caps...... 13 OS-CAL CALTRATE. . . . .91 PANRETIN...... 6 omeprazole delayed-release. 35 oseltamivir...... 42 pantoprazole...... 35 OMNICEF...... 38 OSENI...... 31 pantoprazole sodium pack. .35 ondansetron ...... 34 OTEZLA...... 45 PARAFON FORTE DSC. . . 47 ondansetron HCL soln. . . .34 OVCON 50...... 49 PARCOPA ...... 19 ONE TOUCH SYSTEMS (ULTRA OVIDE...... 24 paregoric tinc ...... 34 2, ULTRAMINI, VERIO, OVIDREL...... 50 parenteral electrolyte conc . .83 VERIO FLEX, VERIO IQ, OVRAL...... 48, 49 parenteral electrolyte soln. . 83 Ovulation Stimulants . . . 3, 50 VERIO SYNC)...... 31 paricalcitol caps...... 71 oxaprozin...... 16, 46 ONE TOUCH TEST STRIPS paricalcitol iv soln...... 71 oxazepam ...... 54 (ULTRA, VERIO). . . . .31 PARNATE...... 56 oxcarbazepine...... 20 ONFI...... 19 paromomycin ...... 45 OXSORALEN...... 24 ONGLYZA...... 31 paroxetine ...... 56 OXSORALEN-ULTRA. . . . 24 ophthalmic irrigation solution - PASER...... 37 oxybutynin chloride. . . . .66 intraocular soln. . . . . 54 pasireotide...... 7 oxybutynin IR...... 66 OPIUM TINCTURE PATADAY ...... 51 oxybutynin patch...... 67, 91 (PAREGORIC)...... 34 PATANASE...... 28 oxycodone...... 17 patiromer...... 13 ALL CAPS = Brand-name drug lower case = Generic drug 112 Index of Covered Drugs PAXIL...... 56 penicillin VK...... 40 phenylephrine/ pazopanib...... 5 PENLAC SOLUTION 8%. . .23 dextromethorphan/ ped multivitamins w/fl & iron pentamidine isethionate for guaifenesin...... 63 liqd...... 71 nebulization...... 41 phenylephrine/ephed/CPM ped multivitamins w/fl & iron pentazocine/naloxone. . . .17 w/carbetapentane. . . .63 susp...... 71 pentosan polysulfate sodium. 67 phenylephrine/guaifenesin. .63 PEDIACARE LIQ MULTI-SY. .64 pentoxifylline extended-release.8 phenylephrine/pyrilamine w/ PEDIALYTE...... 68, 90 PEPCID ...... 35, 90 hydrocodone...... 63 PEDIAPRED...... 29 PEPCID AC...... 35, 90 PHENYLHIST LIQ DH . . . .61 PEDIATEX TDM ...... 63 PERSERIS ...... 58 PHENYTEK...... 20 pediatric multiple vitamin w/ PERCOCET...... 17 phenytoin...... 20 phenytoin sodium extended. 20 minerals & c soln . . . . 71 PERCODAN...... 17 PHILLIPS COLON pediatric multivitamins w/fl. .71 PERIDEX...... 28 HEALTH...... 37, 90 pediatric multivitamins w/fl & PERIKABIVEN...... 81 PHOS-FLUR ...... 69, 91 iron chew...... 71 permethrin...... 24, 90 pediatric vitamins acd & PHOSLO ...... 84 perphenazine ...... 57, 59 PHOSPHOLINE IODINE . . .53 l-methylfolate w/fluoride PERSANTINE...... 8 susp...... 71 phosphorus...... 79 PERTZYE...... 36 phytonadione...... 71 PEDIAZOLE...... 39 PFIZERPEN-G...... 39 peg 3350/electrolytes. . . .33 phytonadione soln . . . . . 71 phenazopyridine...... 67 peg 3350/sodium bicarbonate/ pilocarpine...... 28, 53 PHENERGAN...... 34, 61 sodium chloride. . . 33, 34 PILOPINE HS GEL. . . . . 53 PHENERGAN DM...... 61 peg 3350/sodium bicarbonate/ pimecrolimus...... 26 phenobarbital...... 20 sodium chloride/potassium pimozide ...... 59 phenyl salicylate...... 66 chloride...... 34 PIN-X...... 37 phenylephrine. . 27, 28, 59-63 PEG-INTRON ...... 41 pioglitazone...... 31 pegademase bovine soln . . 29 phenylephrine-bromphen w/ pioglitazone/metformin. . . 31 PEGANONE...... 19 codeine liqd ...... 62 piperacillin sodium-tazobactam sodium for inj ...... 40 PEGASYS...... 41 phenylephrine- pirfenidone capsule. . . . .84 PEGASYS PROCLICK. . . .41 brompheniramine-dm piroxicam...... 16, 46 pegfilgrastim...... 8 liquid ...... 63 PLAN B ONE STEP. . . . .47 peginterferon alfa-2a . . . . 41 phenylephrine-chlorphen PLAQUENIL...... 44, 45 peginterferon alfa-2b. . . 6, 41 w/codeine syrup. . . . .63 PLASMA-LYTE A ...... 83 peginterferon beta-1a. . . . 18 phenylephrine-dexchlorphenir- PLASMA-LYTE-148. . . . .83 pegvisomant...... 33 codeine syrup . . . . . 63 PLASMA-LYTE-56/D5W. . .83 penciclovir cream...... 24 phenylephrine/ PLAVIX...... 8 penicillamine...... 45 brompheniramine/ dextromethorphan. . . .62 plecanatide...... 34 penicillin g benzathine & PLEGRIDY...... 18 phenylephrine/ procaine inj...... 39 PLENDIL ...... 11 chlorpheniramine/ penicillin g benzathine plerixafor ...... 8 dextromethorphan. . . .63 susp im ...... 39 PLETAL ...... 8 penicillin g potassium solr inj.39 phenylephrine/ PLIAGLIS...... 26 PENICILLIN G PROCAINE . .40 chlorpheniramine/ pneumococcal 13-valent penicillin g procaine susp. . 40 dihydrocodeine. . . . . 63 conjugate...... 86 PENICILLIN G SODIUM. . . 40 phenylephrine/ penicillin g sodium solr inj. . 40 dextromethorphan. . . .63 ALL CAPS = Brand-name drug lower case = Generic drug 113 Index of Covered Drugs pneumococcal vaccine potassium chloride extended- prednisolone. . . . 29, 51, 52 polyvalent...... 86 release...... 80 prednisolone acetate. . .51, 52 PNEUMOVAX...... 86 potassium chloride in d5w prednisolone phosphate. . .52 PNEUMOVAX 23 ...... 86 lactated ringer...... 80 prednisolone sodium PNV-DHA...... 77 potassium chloride in dextrose phosphate...... 29 PNV-DHA+DOCUSATE. . . 77 inj ...... 80 prednisolone sodium phosphate PNV-FIRST SOFTGEL. . . .73 POTASSIUM CHLORIDE INJ. 80 soln...... 29 PNV-OB/DHA...... 72 potassium chloride prednisolone sodium phosphate PNV-OMEGA SOFTGEL. . .78 microencapsulated crystals tbdp...... 29 PNV-SELECT...... 74 cr tbcr...... 80 prednisone...... 29 PNV-TOTAL...... 73 potassium chloride soln. . . 80 PREFERA OB...... 74 podofilox ...... 25 POTASSIUM CHLORIDE/ PREFERAOB +DHA. . . . .73 POLY HIST...... 64 D5W...... 79, 80 PREFOL-DHA ...... 77 POLY-TUSSIN...... 60-62 POTASSIUM CHLORIDE/D5W/ pregabalin...... 20 POLY-TUSSIN AC...... 62 NACL...... 79 PRELONE ...... 29 POLY-TUSSIN D...... 61 POTASSIUM CHLORIDE/NACL PREMARIN...... 49, 50 POLY-VI-FLOR...... 71 INJ ...... 79 PREMPHASE ...... 50 POLY-VI-FLOR/IRON. . . . 71 potassium citrate. . . . .67, 80 PREMPRO...... 50 POLY-VI-SOL...... 91 potassium citrate (alkalinizer) PRENAISSANCE . . . . 75-77 polyethylene glycol 3350. . .34 tbcr...... 80 PRENAISSANCE 90 DHA. . 76 POLYMYXIN B SULFATE INJ.40 potassium citrate-citric acid PRENAISSANCE BALANCE polymyxin b sulfate solr. . . 40 pack...... 80 SOFTGEL ...... 76 polymyxin B/bacitracin . .22, 54 potassium iodide soln. . . .80 PRENAISSANCE HA. . . . 75 polymyxin B/trimethoprim. . 54 POTASSIUM PHOSPHATES. 80 PRENAISSANCE HARMONY polysacch fe cmplx-fe heme potassium phosphates DHA...... 75 poly-fa-b12 tab. . . . . 71 inj soln...... 80 PRENAISSANCE NEXT. . . 75 polysaccharide iron caps. . .91 POTIGA ...... 19 PRENAISSANCE NEXT-B. . 75 polysaccharide iron complex.71 povidone-iodine ...... 45 PRENAISSANCE PROMISE. 76 POLYSPORIN...... 54 PR NATAL 400...... 72 prenat vit w/iron carbonyl-fe asp POLYTRIM...... 54 PRADAXA...... 7 glyc-fa-omega fatty acid. .72 pomalidomide...... 6 PRALUENT...... 13 prenat w/o A w/fecbn-fegl-DSS- POMALYST...... 6 pramipexole...... 19 FA & DHA...... 72 ponatinib...... 5 pramipexole dihydrochloride prenat-FE Bis-FE prot succ-FA- pot & sod citrates w/citric ac. 71 tb24...... 19 CA & omega 3 . . . .71, 72 pot bicarbonate & chloride effer pramlintide...... 32 prenat-FE bis-FE prot succ-FA- tab...... 79 PRANDIN...... 31 CA & omega DR. . . . .72 potassium & sodium acid prasugrel HCl tabs...... 8 PRENATA...... 77 phosphates tabs. . . . .80 praziquantel...... 37 prenatal multivitamins & POTASSIUM ACETATE INJ. .80 prazosin...... 9 minerals w/l-methylfolate-fa potassium acetate inj soln. . 80 PRECOSE...... 31 chew...... 72 potassium acid phosphate. .80 PRED FORTE...... 52 prenatal mv & min w/fe bisglyc- potassium bicarbonate/ PRED MILD...... 52 fe prot succ-fa-ca-omega 3 potassium citrate PRED-G...... 51 m...... 72 effervescent...... 80 prednicarbate...... 23 prenatal mv & min w/fe carbonyl- potassium chloride. .34, 79, 80 docusate-folic acid-dha potassium chloride cpcr. . .80 tab...... 72 ALL CAPS = Brand-name drug lower case = Generic drug 114 Index of Covered Drugs prenatal mv & min w/fe prenatal vit w/iron carbonyl-fe prenatal w/o vit a w/fe fumarate- fumarate-fa-dha misc. . .72 aspart glycinate-fa tabs. .74 dss-fa-dha...... 77 prenatal mv & min w/fe prenatal vit w/iron carbonyl-folic prenatal w/o vit a w/fe fumarate- polysaccharide complex-fa- acid tabs ...... 74 fe carbonyl-dss-fa- dha...... 73 prenatal vit w/iron dha ca ...... 77 prenatal mv & min w/o vit a w/fe polysaccharide cmplx-l prenatal without a vit w/fe fum- polysac cmplx-fa-ca- methylfolate-fa...... 74 iron polysacch complex - omega...... 73 prenatal vit without vit a w/fe fa...... 77 prenatal vit w iron carbonyl-FA. bisglycinate-fa-omeg prenatal without a vit w/fe 74 3 mis...... 74 fumarate-folic acid chew. 77 prenatal vit w/FE bisglycinate prenatal vitamins w/fe asparto prenatal without a w/fe asp chelate-FA...... 73 glycinate-folic acid tabs. .74 glyc-l methylfolate-fa- prenatal vit w/fe carbonyl-fe prenatal w/calcium-vit b6-folic omega 3 ...... 77 bisglycinate-fa-fish oil cap.73 acid-ginger ...... 75 prenatal without a w/fe prenatal vit w/fe fum-iron prenatal w/calcium-vit b6-vit carbonyl-l methylfolate- polysacch complex-fa- b12-folic acid-ginger tabs.75 fa-dha...... 77 omega 3 ...... 77 prenatal w/fe asparto glycinate-l prenatal without a w/fe fum-fe prenatal vit w/fe glycine methylfolate-folic acid . . 75 polysacch complex-fa-dha cysteinate-fa-omega 3 fatty prenatal w/fe cbnyl-fe asparto cap...... 78 acid...... 73 glyc-fa-dss-omega 3 caps.75 prenatal without a w/fe prenatal vit w/fe poly cmplx-fe prenatal w/fe fumarate-fa-dss- fumarate-l methylfolate-fa- heme polypept-fa & fish oil caps...... 75 omega 3 ...... 77 omega 3 ...... 73 prenatal w/fe polysacch cmplx- prenatal without vit a w/fe fum- prenatal vit w/FE polysac cmplx- sod feredetate-fa- fa-omega fatty acids caps.78 FA...... 74 omega 3 ...... 75 prenatal without vit a w/fe prenatal vit w/fe polysacch prenatal w/o a vit w/fe fumarate-l fumarate-fa-fish oil misc. .78 cmplx-fe asp-fe glyc-fa & methylfolate-folic acid . . 75 prenatal without vit a w/fe dha...... 73 prenatal w/o a w/ fe asparto fumarate-l methylfolate- prenatal vit w/fe polysacch glyc-l methylfolate-fa-dha. 75 omegas...... 78 cmplx-fe heme polypept-fa & prenatal w/o vit a w/fe carbonyl- prenatal without vit a w/iron dha...... 73 dss-fa-dha caps . . . . .76 carbonyl-folic acid & vit b6.78 prenatal vit w/fe polysacch prenatal w/o vit a w/fe carbonyl- prenatal without vit a w/iron complex-fe heme fe asp glyc-methfol-fa-dh. 76 polysaccharide complex-fa polypeptide-fa...... 74 prenatal w/o vit a w/fe carbonyl- prenatal vit w/fe polysacch fe aspart glyc-fa-fish oi. . 76 ca...... 78 complex-l methylfolate- prenatal w/o vit a w/fe carbonyl- PRENATE AM...... 75 fa-dha...... 74 fe aspart glyc-fa PRENATE CHEW...... 72 prenatal vit w/ferrous fumarate- omega 3 ...... 76 PRENATE DHA. . . . . 75, 77 fa-omega 3 fatty acids. . 74 prenatal w/o vit a w/fe carbonyl- PRENATE ELITE...... 75 prenatal vit w/ferrous fumarate- fe gluconate-dss-fa-dha. .76 PRENATE ENHANCE...... 77 folic acid tabs...... 74 prenatal w/o vit a w/fe carbonyl- PRENATE ESSENTIAL. . . .77 prenatal vit w/ferrous fumarate-l fe gluconate-fa & vit b6. .76 PRENATE MINI. . . . . 76, 77 methylfolate-folic acid . . 74 prenatal w/o vit a w/fe carbonyl- PRENATE PIXIE ...... 75 prenatal vit w/iron carbonyl-fe folic acid-dha caps. . . .76 PRENATE RESTORE. . . . 77 aspart glyc-fa-omega prenatal w/o vit a w/fe fumarate- PRENATE STAR...... 74 3 cap ...... 74 docusate ca-folic acid-dha.77 ALL CAPS = Brand-name drug lower case = Generic drug 115 Index of Covered Drugs PRENEXA, TRIVEEN-PRX promethazine & pseudoephedrine-bromphen- RNF ...... 77 phenylephrine. . . . 61, 63 codeine liq ...... 64 PREPARATION H...... 90 PROMETHAZINE HCL INJ. .34 pseudoephedrine- PREQUE 10...... 72 promethazine HCL inj soln. .34 dexbromphen-codeine PREVACID...... 35 PROMETHAZINE SYP DM. .61 liqd ...... 64 PREVACID SOLUTAB . . . .35 PROMETHAZINE VC pseudoephedrine-guaifenesin PREVIDENT...... 69 W/CODEINE...... 61 cap ...... 64 PREVNAR 13...... 86 PROMETHAZINE pseudoephedrine/ PREZCOBIX ...... 44 W/CODEINE...... 61 acetaminophen/ PREZISTA ...... 43 PROMETRIUM...... 50 dextromethorphan. . . .64 PRIFTIN...... 38 propafenone...... 10 pseudoephedrine/ PRILOSEC...... 35 propafenone HCl cp12. . . 10 chlorpheniramine/ primaquine...... 45 propantheline ...... 67 dextromethorphan. . . .64 PRIMAXIN IV...... 40 propranolol ...... 11, 18 pseudoephedrine/ primidone...... 20 propranolol HCl cp24 . . . .11 dextromethorphan/ PRIMSOL...... 40 propranolol/HCTZ. . . . . 11 guaifenesin...... 64 PRINCIPEN...... 39 propylthiouracil...... 33 pseudoephedrine/iburprofen.64 PRISTIQ...... 55 PROSCAR...... 66 psyllium ...... 90 PRO-CLEAR AC...... 61 PROSOL ...... 82 PULMICORT RESPULES . . 65 PRO-RED AC...... 63 PROTONIX...... 35 PULMOZYME...... 81 PROAMATINE...... 14 PROTONIX PACKET . . . . 35 PUREFE OB ...... 77 probenecid ...... 17, 46 PROTOPIC 0.03% . . . . . 26 PURINETHOL...... 4 PROBENECID/COLCHICINE.17 PROTOPIC 0.1%...... 26 pyrantel pamoate ...... 37 probiotics...... 37, 90 protriptyline HCL tabs . . . .57 pyrazinamide...... 38 PROCALAMINE...... 81 PROVENTIL...... 65 pyrethrins/piperonyl butoxide procarbazine...... 7 PROVERA...... 47, 50 shampoo...... 24, 90 PROCARDIA...... 11 PROVIDA DHA...... 78 PYRIDIUM...... 67 pyridostigmine...... 18 PROCARDIA XL...... 11 PROVIDA OB...... 77 pyridostigmine prochlorperazine...... 34 PROZAC ...... 56 extended-release . . . . 18 PROCTO-PAK...... 22 prucalopride ...... 34 PYRIDOXINE HCL INJ. . . .78 PROCTOFOAM HC. . . . .22 PRUET DHA PAK SETONET pyridoxine HCL inj soln. . . 78 PROCTOSOL HC CREAM PAK...... 72 pyrilamine tan/phenyleph tan.64 2.5%...... 25 PRUET DHAEC PAK . . . . 72 pyrilamine-phenylephrine tab.64 PROCTOZONE CREAM-HC PSE/GG...... 62 pyrimethamine ...... 45 2.5%...... 25 pseudoeph-chlorphen w/ PROGESTERONE . . . . . 50 hydrocodone soln . . . .63 Q progesterone micronized pseudoephed-chlorphen- QUARTETTE...... 48 dm liq ...... 63 caps...... 50 QUESTRAN...... 12 pseudoephed-triprolidine-dm progesterone oil...... 50 QUESTRAN-LIGHT. . . . . 12 PROGLYCEM ...... 29 susp...... 63 quetiapine...... 58 PROGRAF...... 6 pseudoephedrine tan/ quetiapine fumarate tb24 . . 58 PROLIXIN...... 59 dexchlorphen tan/ QUILLIVANT XR...... 56 PROLIXIN DECANOATE. . .59 DM tan...... 64 quinapril...... 9 PROMACTA...... 8 pseudoephedrine w/cod-gg. 64 quinapril/hydrochlorothiazide. 9 PROMETH VC SYP 6.25-5/5.63 pseudoephedrine w/ promethazine . . . .34, 61, 63 hydrocodone soln . . . .64 ALL CAPS = Brand-name drug lower case = Generic drug 116 Index of Covered Drugs QUINIDINE GLUCONATE RENACIDIN...... 84 risperidone inj ...... 58 EXT-REL ...... 10 RENAGEL...... 67 risperidone ODT...... 58 quinidine gluconate extended- RENVELA ...... 84 risperidone oral soln. . . . .58 release...... 10 repaglinide...... 31 RITALIN...... 55 quinidine sulfate...... 10 REPATHA ...... 13 RITALIN LA...... 55 QUINIDINE SULFATE REQUIP...... 19 ritonavir...... 44 EXT-REL ...... 10 RESCRIPTOR...... 42 rivaroxaban ...... 7 quinidine sulfate extended- RESPAIRE-30...... 64 rivastigmine...... 15 release...... 10 RESTASIS ...... 53 rizatriptan...... 18 QVAR REDIHALER. . . . . 65 RESTORIL...... 57 RMS...... 17 RETACRIT ...... 8 ROBAXIN...... 47 R RETIN-A...... 21 ROBINUL...... 35 R-TANNAMINE...... 60 RETROVIR...... 43 ROBITUSSIN. . . . .60-64, 89 raloxifene...... 32 RETROVIR IV INFUSION. . .43 ROBITUSSIN CF. . . . .62, 89 raltegravir...... 42 REVATIO ...... 14 ROBITUSSIN DM. . . . 61, 89 raltegravir susp...... 42 REVATIO SUSPENSION . . .14 ROBITUSSIN LIQ ramipril...... 9 REVIA...... 54, 57 CGH/ALRG...... 63 RANEXA ...... 14 REVLIMID ...... 6 ROBITUSSIN LIQ ranitidine ...... 35 REYATAZ...... 43 CGH/CLD...... 60, 63 RANITIDINE HCL...... 35 REYATAZ POWDER PACKET.43 ROBITUSSIN LIQ ranitidine HCL soln. . . . . 35 REZIRA ...... 64 CGH/CONG...... 61 ranitidine HCL tabs. . . . . 35 RIBASPHERE RIBAPAK . . .42 ROBITUSSIN LIQ HD/CHST. 63 ranitidine syrup...... 35 RIBATAB ...... 42 ROBITUSSIN LIQ PED ranolazine ...... 14 ribavirin...... 42 NGHT...... 64 RAPAMUNE...... 6 RID SHAMPOO. . . . . 24, 90 ROBITUSSIN PE. . . . .62, 89 RAVICTI...... 85 RIDAURA...... 45 ROBITUSSIN PED LIQ CGH/ RAZADYNE...... 15 rifabutin ...... 38 COLD...... 60 REBETOL/COPEGUS. . . .42 RIFADIN...... 38 ROBITUSSIN PED SYP. . . 61 RECLAST INJ...... 32 rifampin ...... 38 ROBITUSSIN SYP CHST RECOMBIVAX HB . . . . . 85 rifapentine...... 38 CNG...... 62 rectal crm, suppositories. . .90 rilpivirine...... 42-44 ROBITUSSIN SYP MAX-ST. .61 RECTIV...... 26 RILUTEK ...... 15 ROCALTROL...... 67 REESE’S PINWORM riluzole ...... 15 ROCALTROL SOLUTION . . 67 MEDICINE...... 37 rimantadine...... 42 ROCEPHIN ...... 38 REGLAN ...... 34 ringer’s irrigation soln. . . . 84 roflumilast ...... 66 regorafenib ...... 5 ringer’s solution...... 83 rolapitant ...... 34 REGRANEX...... 25 RINGERS INJECTION. . . .83 RONDEC DM ...... 63 RELAFEN...... 16 RINGERS IRRIGATION. . . 84 RONDEC DM DROPS. . . .63 RELENZA...... 42 riociguat...... 14 RONDEC DROPS...... 60 RELION 70/30...... 30 RISA-BID ...... 37, 90 RONDEC SYRUP...... 60 RELION N ...... 30 RISAQUAD...... 37, 90 ropinirole...... 19 RELION R ...... 30 RISPERDAL...... 58 ROWASA...... 36 RELNATE DHA...... 74 RISPERDAL CONSTA. . . .58 ROXICODONE ...... 17 REMEDY ANTIMICROBIAL RISPERDAL M-TAB . . . . .58 RUBRACA...... 7 CLEANSER...... 25 RISPERDAL SOLUTION . . .58 rucaparib...... 7 REMERON...... 57 risperidone...... 58 RUCONEST...... 83

ALL CAPS = Brand-name drug lower case = Generic drug 117 Index of Covered Drugs rufinamide...... 20 secukinumab...... 45 sitagliptin-metformin HCL sr ruxolitinib...... 5 SEDAPAP...... 15 24hr...... 31 RYDAPT...... 5 SEGLUROMET...... 31 SKLICE...... 24 RYNA-12 S ...... 64 SELECT-OB...... 73, 74 SLOW FE...... 69 RYNATAN PEDIATRIC SUSP. 60 SELECT-OB+DHA . . . . . 73 SM SLOW RELEASE IRON. .69 RYNATUSS PEDIATRIC selegiline...... 19 SODIUM ACETATE INJ. . . 83 SUSP...... 63 selenious acid inj soln. . . .78 sodium acetate inj soln . . . 83 RYTHMOL...... 10 SELENIUM INJ...... 78 sodium bicarbonate . . . . 35 RYTHMOL SR...... 10 selenium sulfide...... 26 SODIUM BICARBONATE INJ.83 selenium sulfide-pyrithione zinc sodium bicarbonate inj soln. 83 S in urea shampoo . . . . 26 sodium chloride (diagnostic aid) SABRIL SOLUTION. . . . .20 SELSUN...... 26 soln...... 14 sacubitril/valsartan. . . . . 10 SELZENTRY...... 44 sodium chloride (gu irrigant) SAIZEN...... 32 sennosides ...... 34 soln...... 83 SAL-TROPINE...... 37 SENOKOT...... 34 SODIUM CHLORIDE 0.9% SALAGEN ...... 28 SENSIPAR...... 84 INJ ...... 83 salicylic acid . . .21, 24, 25, 91 SENTRA AM...... 71 SODIUM CHLORIDE salicylic acid 17%/ SERAX...... 54 BACTERIOSTATIC/BENZYL collodion...... 25, 91 SEROMYCIN...... 37 ALCOHOL...... 84 saline injection bacteriostatic.84 SEROQUEL...... 58 sodium chloride for nebulizer.81 saline injection w/benzyl SEROQUEL XR...... 58 sodium chloride hypertonic . 54 alcohol...... 84 SEROSTIM...... 32 SODIUM CHLORIDE INJ. 40, 83 saline nasal spray 0.65%. . .28 sertraline ...... 56 sodium chloride soln. . . 7, 83 salsalate...... 46 sevelamer...... 67, 84 SODIUM CHLORIDE SANCTURA...... 67 sevelamer HCl tabs . . . . .67 THERMOJECT SYSTEM. 14 SANDIMMUNE...... 6 SHINGRIX...... 87 sodium citrate & citric SANDIMMUNE INJ...... 6 SIGNIFOR ...... 7 acid soln ...... 67 SANDIMMUNE ORAL sildenafil...... 14 sodium citrate/citric acid. . .67 SOLUTION ...... 6 SILVADENE...... 22 sodium ferric gluconate complex SANDOSTATIN...... 7 SILVER NITRATE ...... 22 in sucrose soln. . . . . 78 SANTYL...... 25 silver nitrate soln...... 22 sodium iodide soln. . . . . 78 sapropterin...... 33 silver sulfadiazine...... 22 SODIUM LACTATE INJ . . . 83 sapropterin powder . . . . .33 SIMBRINZA...... 52 sodium lactate inj soln. . . .83 saquinavir mesylate . . . . .44 simethicone...... 34, 90 sodium phenylbutyrate . . . 85 SARAFEM...... 56 SIMILAC PRENATAL EARLY SODIUM PHOSPHATE INJ. .83 sargramostim...... 8 SHIELD ...... 72 sodium phosphate inj soln . .83 sarilumab...... 45 simvastatin...... 13 sodium phosphate SAVAYSA...... 7 SINEMET...... 19 monobasic...... 66 saxagliptin...... 31 SINEMET CR...... 19 sodium polystyrene SCALPICIN ...... 24 SINEQUAN ...... 57 sulfonate...... 13, 14 scopolamine...... 21, 53 SINGULAIR...... 66 sodium polystyrene sulfonate scopolamine pt72...... 21 sirolimus...... 6 powd ...... 14 SE-TAN DHA...... 73 SIRTURO...... 44 sodium zirconium SEASONALE...... 47 sitagliptin phosphate . . . . 31 cyclosilicate ...... 13 SEASONIQUE...... 48 sitagliptin-metformin. . . . .31 sofosbuvir/velpatasvir...... 42 SECTRAL...... 10 solifenacin succinate tabs. . 67

ALL CAPS = Brand-name drug lower case = Generic drug 118 Index of Covered Drugs SOLIQUA...... 31 STRIVERDI RESPIMAT . . . 64 T SOLTAMOX...... 5 STROMECTOL...... 37 T- STAT ...... 21 SOLU-CORTEF INJ . . . . .29 STUART PRENATAL . . . . 91 TABLOID ...... 4 SOLU-MEDROL ...... 29 SUBOXONE...... 57 tacrolimus ...... 6, 26 somatropin...... 32 SUBUTEX ...... 57 tafenoquine ...... 45 SOMAVERT...... 33 succimer ...... 81 TAFINLAR...... 4 SONATA...... 57 sucralfate...... 35 TAGAMET...... 34 sonidegib...... 7 sugar+orthophosphoric taliglucerase alfa solr. . . . 33 sorafenib ...... 5 acid...... 90 TALWIN NX...... 17 SORBITOL...... 84 sulcralfate...... 35 TAMBOCOR...... 10 sorbitol irrigation soln. . . . 84 SULFACET-R...... 21 TAMIFLU ...... 42 SORBITOL-MANNITOL . . . 84 sulfacetamide. . 21, 24, 51, 54 tamoxifen...... 5 sorbitol-mannitol irrig soln. . 84 sulfacetamide sodium w/sulfur tamoxifen citrate soln. . . . .5 SORIATANE...... 24 foam...... 24 tamsulosin...... 66 sotalol...... 10, 11 sulfacetamide/pred phos . . 51 TANAFED DMX sotalol HCl AF...... 11 sulfacetamide/sulfur. . . . .21 SUSPENSION...... 64 spacers...... 85 sulfadiazine...... 22, 40 TANDEM PLUS...... 69 spinosad ...... 24 sulfamethoxazole/trimethoprim, TAPAZOLE...... 32 SPIRIVA...... 65 DS...... 40 TARCEVA...... 4 spironolactone...... 12 SULFAMYLON ...... 22 TARGRETIN...... 6 spironolactone/ sulfasalazine...... 36, 45 TARON FORTE...... 68 hydrochlorothiazide. . . 12 sulfasalazine TARON-BC...... 78 SPORANOX...... 41 delayed-release. . . .36, 45 TARON-C DHA...... 73 SPRYCEL...... 4 sulindac...... 16, 46 TARON-PREX...... 77 SSKI...... 80 SUMADAN WASH . . . . . 21 TASIGNA...... 5 STADOL...... 16 sumatriptan...... 18 TASMAR...... 19 STALEVO...... 19 SUMYCIN...... 40 TAZICEF...... 38 STARLIX...... 31 sunitinib...... 5 TBO-filgrastim...... 8 STATUSS DM SYP. . . . . 63 SUPRAX...... 38 TECFIDERA...... 18 stavudine...... 43 SUPRAX SUSPENSION. . . 38 teduglutide...... 37 STEGLATRO...... 31 SUSTIVA...... 42 TEGRETOL...... 19 STELARA...... 6, 45 SUTENT...... 5 TEGRETOL-XR ...... 19 STELAZINE...... 59 SUTTAR-SF...... 64 TEGSEDI ...... 21 STERILE DILUENT FOR SYLATRON...... 6 telbivudine tabs...... 42 FLOLAN...... 14 SYMBICORT...... 65 telmisartan...... 9 STERILE WATER FOR SYMBYAX ...... 59 telmisartan- INJECTION...... 84 SYMDEKO...... 81 hydrochlorothiazide ...... 9 STERILE WATER SYMFI, SYMFI LO...... 43 temazepam...... 57 IRRIGATION ...... 84 SYMJEPI ...... 81 TEMODAR...... 4 STIMATE ...... 33 SYMLIN ...... 32 TEMOVATE...... 23 STIOLTO RESPIMAT . . . . 65 SYMMETREL ...... 19, 42 temozolomide...... 4 STIVARGA...... 5 SYNAGIS...... 45 TENEX...... 9 stool softeners...... 90 SYNALAR ...... 22, 23 TENIVAC ...... 86 STRATTERA...... 55 SYNTHROID...... 32 tenofovir...... 43, 44 STRENSIQ...... 33 TENORETIC ...... 10 STRIBILD...... 44 TENORMIN...... 10

ALL CAPS = Brand-name drug lower case = Generic drug 119 Index of Covered Drugs TERAZOL 3/7...... 51 TIAZAC...... 11 TORADOL...... 16 terazosin...... 9, 66 TIBSOVO ...... 4 toremifene...... 5 terbinafine...... 24, 41 ticagrelor ...... 8 torsemide...... 12 terbutaline...... 65, 66 TIGAN...... 34 torsemide soln...... 12 TERBUTALINE SULFATE INJ.66 TIKOSYN...... 10 TOVIAZ...... 66 terbutaline sulfate inj soln . . 66 timolol...... 52 TRACE ELEMENTS 4/ terconazole ...... 51 timolol maleate...... 52 PEDIATRIC ...... 79 teriflunomide...... 18 TIMOPTIC...... 52 trace min (cr-cu-mn-se-zn) inj. 79 tesamorelin ...... 32 TIMOPTIC XE...... 52 TRACLEER...... 13 TESSALON...... 59 TINACTIN...... 24, 88 TRADJENTA...... 31 TESTOSTERONE 1% TOPICAL TINDAMAX ...... 41 tramadol...... 15 GEL ...... 29 tinidazole...... 41 trametinib...... 5 testosterone cypionate. . . .29 tioconazole vaginal oint. . . 51 TRANDATE...... 10 testosterone enanthate. . . .29 TIOCONAZOLE-1...... 51 trandolapril...... 9 testosterone gel...... 29 tiopronin...... 67 tranexamic acid...... 51 testosterone gel topical tube, tiotropium...... 65 tranexamic acid soln . . . . 51 packet, and pump bottle. 29 tiotropium/olodaterol. . . . 65 TRANSDERM-SCOP. . . . 21 tet tox-diph-acell pertuss ad . 86 tipranavir ...... 44 TRANXENE...... 54 TET/DIP TOX INJ...... 86 TIVICAY ...... 42 tranylcypromine...... 56 tetanus immune globulin tizanidine...... 47 TRAVATAN Z...... 53 (human)...... 86 TL FOLATE...... 74 travoprost soln...... 53 tetanus-diphtheria toxoids TL-SELECT ...... 77 trazodone...... 17, 57 (td) ...... 86 TOBI...... 81 TRAZODONE HCL. . . . . 17 tetrabenazine...... 21 TOBRADEX...... 52 trazodone HCl tabs. . . . . 17 tetracycline...... 40 tobramycin. . . .40, 52, 54, 81 TRECATOR...... 38 tetrahydrozoline/zinc sulfate. 51 tobramycin neb soln. . . . .81 TRENTAL...... 8 tezacaftor/ivcaftor...... 81 tobramycin sulfate in tretinoin ...... 7, 21 thalidomide...... 6 saline soln...... 40 TRI-FED X...... 64 THALOMID ...... 6 TOBRAMYCIN SULFATE INJ.40 TRI-NORINYL ...... 49 THEO-24...... 66 tobramycin sulfate soln . . . 40 TRI-VI-FLOR...... 71, 79 THEOCHRON...... 66 TOBRAMYCIN SULFATE/ TRI-VI-SOL...... 79, 91 theophylline...... 66 SODIUM CHLORIDE INJ. 40 triamcinolone. . . . 23, 28, 29 theophylline tobramycin/dexamethasone. 52 triamcinolone acetonide . 23, 29 extended-release . . . . 66 TOBREX...... 54 triamcinolone acetonide susp.29 theophylline soln...... 66 TOFRANIL...... 57 triamcinolone nasal spray. . 28 THERANATAL COMPLETE. .72 TOFRANIL-PM...... 57 TRIAMINIC COUGH & THERANATAL PLUS . . . . 72 tolcapone...... 19 CONGESTION THIAMINE HCL INJ. . . . .78 tolnaftate ...... 24, 88 CHILDRENS...... 61 thiamine HCL inj soln. . . . 78 tolterodine...... 67 triamterene/ thioguanine...... 4 TOPAMAX...... 20 hydrochlorothiazide. . . 12 THIOLA ...... 67 TOPAMAX SPRINKLE. . . .20 TRIAVIL ...... 57 thioridazine ...... 59 topical antibacterials. . . . .89 triazolam...... 57 thiothixene...... 59 topiramate...... 20 TRICARE PRENATAL THORAZINE...... 59 topiramate sprinkle caps. . .20 COMPLEAT...... 78 thyroid...... 2, 32, 33 topotecan...... 7 TRICARE PRENATAL DHA tiagabine ...... 20 TOPROL XL...... 10 ONE...... 75

ALL CAPS = Brand-name drug lower case = Generic drug 120 Index of Covered Drugs TRICITRATES...... 71 U valsartan-hydrochlorothiazide . 9 trifluoperazine...... 59 UDAMIN SP...... 70 VALTREX...... 42 trifluridine...... 4, 54 ULESFIA...... 24 VANCOCIN HCL...... 40 trifluridine/tipiracil...... 4 ulipristal acetate ...... 47 vancomycin HCl...... 40 trihexyphenidyl...... 19 ULORIC...... 46 vancomycin HCl solr inj. . . 40 TRILAFON...... 59 ULTIMATECARE ONE. . 74, 75 vancomycin powder for oral TRILEPTAL ...... 20 ULTIMATECARE ONE NF. . 75 solution ...... 40 TRILYTE...... 33 ULTRAM...... 15 vandetanib...... 5 trimethobenzamide . . . . .34 ULTRAVATE...... 23 VAQTA ...... 85 trimethoprim. . . . 40, 45, 54 ULTRESA...... 36 varenicline...... 59 trimethoprim HCL soln. . . .40 umeclidinium inhalation. . . 65 varicella virus vac live for TRINTELLIX...... 57 UNASYN ...... 39 subcutaneous...... 87 TRIOTANN...... 27, 60 UNI-HIST DROPS...... 59 VARIVAX ...... 87 TRIOTANN PEDIATRIC UNIPHYL...... 66 VARUBI ...... 34 SUSP...... 60 UNISOM...... 57, 90 VASERETIC...... 9 tripolidine/pseudoephedrine. 64 UREA 10% CREAM, UREA VASOCIDIN...... 51 TRIPROL/PSE SYP . . . . .64 20% CREAM, UREA 10% VASOCLEAR...... 51 TRISTART DHA...... 77 LOTION...... 26 VASOCLEAR A...... 51 TRIUMEQ...... 44 urea 10%, urea 20%. . . . .26 VASOTEC...... 8 TRIVORA...... 49 urea 40%...... 26 VECTICAL...... 24 TRIZIVIR...... 43 UREA 40% LOTION. . . . .26 VEETIDS ...... 40 TROJAN...... 89 urea crea...... 26 velaglucerase alfa solr. . . .33 TROPHAMINE...... 82 URECHOLINE...... 66 VELTASSA...... 13 trospium...... 67 UREX...... 66 VEMAVITE-PRX 2...... 77 TRULANCE...... 34 uridine ...... 33 vemurafenib...... 5 TRULICITY ...... 32 UROCIT-K ...... 67, 80 VENA-BAL DHA...... 75 TRUSOPT...... 52 UROCIT-K 15...... 80 VENCLEXTA...... 5 TRUST NATALCARE PAK UROXATRAL...... 66 venetoclax...... 5 DHA...... 72 URSO...... 37 venlafaxine...... 56 TRUSTEX...... 89 URSO FORTE...... 37 venlafaxine XR...... 56 TRUVADA ...... 43 ursodiol ...... 37 VENTOLIN HFA...... 64 TUMS...... 90, 91 ustekinumab prefilled syring VEPESID ...... 7 TUSSI-12 S...... 60 90mg/ml ...... 45 verapamil...... 11, 18 TUSSICAPS...... 62 ustekinumab sosy...... 6 verapamil extended-release. .11 TUSSIN DM...... 61 UTIRA C...... 66 VERZENIO...... 4 TUSSIONEX PENNKINETIC VESANOID...... 7 EXTENDED-RELEASE . .62 V VESICARE...... 67 TYBOST...... 44 VAGIFEM...... 49 VFEND...... 41 TYKERB...... 5 vaginal products...... 88 VI-DAYLIN...... 91 TYLENOL. . . . 15, 16, 46, 91 valacyclovir...... 42 VICODIN...... 16 TYLENOL W/CODEINE. . . 16 valbenazine...... 21 VICODIN ES...... 16 TYMLOS ...... 32 VALCYTE...... 41 VICOPROFEN...... 16, 17 typhoid vaccine...... 86 valganciclovir...... 41 VICTOZA 2 PEN PACK . . . 32 TYSABRI...... 37 VALIUM ...... 47, 54 VIDEX...... 43 TYZEKA...... 42 valproic acid ...... 20 VIDEX EC...... 43 valsartan...... 9, 10 VIEKIRA PAK...... 41

ALL CAPS = Brand-name drug lower case = Generic drug 121 Index of Covered Drugs vigabatrin oral solution. . . .20 vitamins pediatric members XANAX...... 54 VIGAMOX...... 53 <3 years old...... 91 XARELTO...... 7 VIMPAT...... 20 vitamins prenatal...... 91 XELODA...... 4 VINATE AZ EX...... 73 VITEKTA...... 42 XENAZINE...... 21 VINATE DHA RF GELCAP. . 78 VITRAKVI ...... 5 XIIDRA...... 53 VINATE IC ...... 77 VIVA DHA...... 74 XODOL...... 16 VINATE II...... 73 VIVACTIL...... 57 XOPENEX RESPULES. . . .65 VIOKACE...... 36 VIVELLE-DOT...... 50 XULANE...... 49 VIRACEPT...... 44 VIVOTIF BERNA...... 86 XYLOCAINE...... 26, 28 VIRAMUNE...... 42 VOLTAREN . . . . .15, 46, 52 XYZAL...... 27 VIRAMUNE XR...... 42 VOLTAREN 1% TOPICAL VIREAD ...... 43 GEL ...... 46 Y VIROPTIC...... 54 VOLTAREN XR . . . . . 15, 46 YASMIN...... 48 VIRT-BAL DHA COMBO voriconazole ...... 41 YAZ...... 48 PACK...... 75 vorinostat...... 4 YODEFAN-NF CHEST VIRT-C DHA...... 73 vortioxetine HBR...... 57 CONGESTION . . . . . 62 VIRT-PN...... 74 VOSOL HC OTIC ...... 26 yuvafem or estradiol vaginal VIRT-SELECT ...... 77 VOSOL OTIC...... 26 tablet ...... 49 VIRTPREX...... 77 VOTRIENT...... 5 VISINE ...... 91 VP-ERA OB...... 74 Z VISINE-AC...... 51 VP-HEME ONE...... 73 ZADITOR ...... 51, 91 vismodegib ...... 7 VP-HEME-OB ...... 74 zafirlukast...... 66 VISTARIL...... 27 VP-PNV-DHA...... 74 zaleplon...... 57 VISTOGARD...... 33 VPRIV...... 33 ZAMICET...... 16 VITAFOL ULTRA...... 74 VYVANSE ...... 55 ZANAFLEX ...... 47 VITAFOL-NANO...... 75 VYVANSE CHEWABLE. . . 55 zanamivir...... 42 VITAFOL-OB+DHA. . . . . 72 ZANTAC...... 35 VITAFOL-ONE...... 73 W ZANTAC INJ ...... 35 VITAL-D RX...... 67 warfarin ...... 7 ZARONTIN ...... 19 VITAMAX PEDIATRIC. . . . 71 water for inject, bacteriostatic ZAROXOLYN...... 12 vitamin A ...... 79 benzyl alcohol...... 84 ZARXIO...... 8 vitamin ADC/fluoride/±iron water for inject, bacteriostatic ZATEAN-CH CAPSULE. . . 76 drops...... 79 parabens...... 84 ZATEAN-PN...... 74, 78 vitamin B complex/vitamin C/ water for injection...... 84 ZATEAN-PN PLUS. . . . . 78 folic acid...... 79 water for irrigation, sterile soln.84 ZAVESCA...... 87 vitamin B-1...... 79 water for iv injection. . . . .84 ZEBETA...... 10 VITAMIN B-12...... 68 WELLBUTRIN...... 57 ZEBUTAL...... 15 vitamin B-6...... 79 WELLBUTRIN SR...... 57 ZEJULA...... 7 vitamin C ...... 79 WELLBUTRIN XL...... 57 ZELBORAF...... 5 VITAMIN D 1000 UNIT. . . .68 WESTCORT...... 22 ZEMPLAR...... 71 VITAMIN D 2000 UNIT. . . .68 WIXELA INHUB ...... 65 ZEMPLAR IV...... 71 vitamin D 400 IU...... 91 WYTENSIN...... 14 ZENPEP...... 36 VITAMIN D 400 UNIT. . . . 68 ZENTANE...... 21 VITAMIN K1...... 71 X ZEPATIER ...... 41 vitamins pediatric. . . . 79, 91 XALATAN...... 53 ZERIT...... 43 XALKORI...... 4

ALL CAPS = Brand-name drug lower case = Generic drug 122 Index of Covered Drugs ZESTORETIC ...... 9 ZYKADIA...... 4 ZESTRIL...... 9 ZYLET ...... 51 ZETIA...... 13 ZYLOPRIM...... 46 ZIAC...... 10 ZYPREXA ...... 58 ZIAGEN ...... 43 ZYPREXA ZYDIS ...... 58 zidovudine...... 43 ZYRTEC...... 27, 88 zidovudine soln...... 43 ZYRTEC CHEWABLE ZINACEF ...... 38 TABLET...... 27 zinc...... 26, 51, 79 ZYRTEC D...... 88 zinc chloride inj soln. . . . .79 ZYRTEC-D...... 28 ZINC SULFATE INJ. . . . . 79 ZYTIGA ...... 5 zinc sulfate inj soln. . . . . 79 ZYVOX...... 44 ZINC TRACE METAL INJ. . . . 79 ZINGIBER ...... 75 ziprasidone ...... 58 ZITHROMAX...... 39 ZITHROMAX IV...... 39 ZITHROMAX POWDER FOR SUSP...... 39 ZOCOR...... 13 ZOFRAN...... 34 ZOFRAN INJ...... 34 ZOFRAN ODT...... 34 ZOHYDRO ER...... 17 zoledronic acid soln. . . . .32 ZOLINZA...... 4 ZOLOFT...... 56 zolpidem ...... 57 ZOMETA INJ...... 32 ZONALON...... 25 ZONATUSS ...... 59 ZONEGRAN ...... 20 zonisamide ...... 20 ZORTRESS...... 6 ZOSTAVAX...... 87 zoster vaccine live...... 87 zoster vaccine recombinant adjuvanted...... 87 ZOSYN...... 40 ZOVIA 1/35...... 48 ZOVIA 1/50...... 49 ZOVIRAX...... 42 ZUTRIPRO...... 63 ZYBAN...... 59 ZYDELIG...... 5

ALL CAPS = Brand-name drug lower case = Generic drug 123 Notes ______

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124 “My Medications” worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine Drug I Take This Directions Doctor and Strength Tier Medicine For

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

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