sign in sign up
<<
Home , Ergoloid, Phenoxybenzamine

2019 Essential Health Benefits Base Formulary

Effective July 1, 2019

For the most current list of covered medications or if you have questions:

Call the number on your member ID card.

Visit your plan’s website on your member ID card to: • Find a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

EHB Base Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost, and effectiveness. Where differences between this Medications are listed by categories or classes and are formulary and your benefit plan placed into cost levels known as tiers. It includes both brand exist, the benefit plan documents and generic prescription medications approved by the rule. This may not be a complete U.S. Food and Drug Administration (FDA). list of medications that are covered by your plan. Please review your OptumRx® is guided by the Pharmacy and Therapeutics benefit plan for full details. Committee (a group of doctors, nurses, and pharmacists) who reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

How do I use my formulary? You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the number on your member ID card.

Some medications on your formulary have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST) and quantity limits (QL). We use programs like these to help make sure the medication you take is safe and effective. Check your plan documents for more information. SomeAffordable CareAct (ACA) preventive medication may have coverage restrictions. If you want to learn more about these programs or to see if you take a medication in one of these programs, please visit your plan’s member website or call the number on your member ID card.

2 Understanding your formulary

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equal becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID card.

3 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter medications Generic medications contain the same active ingredients (what An over-the-counter (OTC) makes the medication work) as brand-name medications, medication may be the right but they often cost less. Once the patent for a brand-name treatment for some conditions. medication ends, the FDA can approve a generic version with Talk to your doctor about the same active ingredients. available OTC options. Even though OTC medications may What if my doctor writes a brand-name prescription? not be covered by your pharmacy If your doctor gives you a prescription for a brand-name benefit, they may cost less than medication, ask if a generic or lower-cost option could be right a prescription medication. for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication? Specialty medications are for rare or complex conditions and are usually higher-cost medications. Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered right to your home or doctor’s office.

4 Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) Generic medications are shown in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers.

Drug Tier Includes Helpful Tips Tier 1 $ Generic Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs. Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you. Tier 4 $$$$ Specialty Tier 4 is generally highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring and handling.

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

M Authorized generic or cobranded product PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.

PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met.

PV* Preventive drugs – Available at $0 if prior authorization is approved. QL Quantity Limit – Medication may be limited to a certain quantity. ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

5 Table of Contents

Analgesics...... 12 Antimycobacterials...... 25 Nonsteroidal Anti-inflammatory Drugs...... 12 Antimycobacterials, Other...... 25 Opioid Analgesics, Long-acting...... 13 Antituberculars...... 25 Opioid Analgesics, Short-acting...... 13 Antineoplastics...... 25 Anesthetics...... 15 Alkylating Agents...... 25 Local Anesthetics...... 15 Antiandrogens...... 26 Anti-Addiction/Substance Abuse Antiangiogenic Agents...... 26 Treatment Agents...... 16 Antiestrogens/Modifiers...... 26 Deterrents/Anti-craving...... 16 Antimetabolites...... 26 Opioid Dependence Treatments...... 16 Antineoplastics, Other...... 27 Opioid Reversal Agents...... 16 Aromatase Inhibitors, 3rd Generation...... 28 Smoking Cessation Agents...... 16 Enzyme Inhibitors...... 28 Antibacterials...... 16 Molecular Target Inhibitors...... 28 Aminoglycosides...... 16 Monoclonal Antibody/Antibody-Drug Antibacterials, Other...... 16 Conjugate...... 29 Beta-lactam, Cephalosporins...... 18 Retinoids...... 30 Beta-lactam, Other...... 19 Antiparasitics...... 30 Beta-lactam, ...... 19 Anthelmintics...... 30 Macrolides...... 19 Antiprotozoals...... 30 Quinolones...... 20 Pediculicides/Scabicides...... 30 Sulfonamides...... 20 Antiparkinson Agents...... 30 Tetracyclines...... 20 Anticholinergics...... 30 Anticonvulsants...... 20 Antiparkinson Agents, Other...... 30 Anticonvulsants, Other...... 20 Agonists...... 30 Calcium Channel Modifying Agents...... 21 Dopamine Precursors/L- Amino Acid Gamma-aminobutyric Acid (GABA) Decarboxylase Inhibitors...... 31 Augmenting Agents...... 21 B (MAO-B) Inhibitors 31 Glutamate Reducing Agents...... 21 Antipsychotics...... 31 Sodium Channel Agents...... 21 1st Generation/Typical...... 31 Antidementia Agents...... 22 2nd Generation/Atypical...... 31 Antidementia Agents, Other...... 22 Treatment-Resistant...... 31 Cholinesterase Inhibitors...... 22 Antispasticity Agents...... 32 N-methyl-D-aspartate (NMDA) Receptor Antivirals...... 32 Antagonist...... 22 Anti-cytomegalovirus (CMV) Agents...... 32 ...... 22 Anti-hepatitis B (HBV) Agents...... 32 Antidepressants, Other...... 22 Anti-hepatitis C (HBV) Agents...... 32 Monoamine Oxidase Inhibitors...... 22 Antiherpetic Agents...... 32 SSRI/SNRI (Selective Reuptake Anti-HIV Agents, Integrase Inhibitors Inhibitors/Serotonin and (INSTI)...... 33 Reuptake Inhibitors)...... 22 Anti-HIV Agents, Non-nucleoside Reverse Tricyclics...... 23 Transcriptase Inhibitors (NNRTI)...... 33 Antiemetics...... 23 Anti-Hiv Agents, Nucleoside And Antiemetics, Other...... 23 Nucleotide Reverse Transcriptase Emetogenic Therapy Adjuncts...... 23 Inhibitors (Nrti)...... 33 Antifungals...... 24 Anti-HIV Agents, Other...... 33 Antigout Agents...... 24 Anti-HIV Agents, Protease Inhibitors...... 33 Antimigraine Agents...... 25 Anti-influenza Agents...... 34 ...... 25 Anxiolytics...... 34 Serotonin (5-HT) 1b/1d Receptor Agonists 25 Anxiolytics, Other...... 34 Antimyasthenic Agents...... 25 ...... 34 Parasympathomimetics...... 25 Bipolar Agents...... 34 9

Mood Stabilizers...... 34 Genetic or Enzyme Disorder: Blood Glucose Monitoring...... 34 Replacement, Modifiers, Treatment...... 52 Blood Glucose Regulators...... 35 Genitourinary Agents...... 53 Antidiabetic Agents...... 35 Antispasmodics, Urinary...... 53 Glycemic Agents...... 36 Benign Prostatic Hypertrophy Agents...... 53 Insulins...... 36 Genitourinary Agents, Other...... 53 Blood Products/Modifiers/Volume Phosphate Binders...... 53 Expanders...... 37 Hormonal Agents, Anticoagulants...... 37 Stimulant/Replacement/Modifying Blood Formation Modifiers...... 38 (Adrenal)...... 54 Hemostasis Agents...... 38 Hormonal Agents, Platelet Modifying Agents...... 39 Stimulant/Replacement/Modifying Cardiovascular Agents...... 39 (Pituitary)...... 55 Alpha- Agonists...... 39 Hormonal Agents, Suppressant (Pituitary).56 Alpha-adrenergic Blocking Agents...... 39 Hormonal Agents, Angiotensin II Receptor Antagonists...... 39 Stimulant/Replacement/Modifying Angiotensin-converting Enzyme (ACE) (Prostaglandins)...... 56 Inhibitors...... 40 Hormonal Agents, Antiarrhythmics...... 40 Stimulant/Replacement/Modifying (Sex Beta-adrenergic Blocking Agents...... 40 Hormones/Modifiers)...... 56 Calcium Channel Blocking Agents...... 41 Anabolic Steroids...... 56 Cardiovascular Agents, Other...... 42 Androgens...... 56 Diuretics, Loop...... 42 Estrogens...... 56 Diuretics, Potassium-sparing...... 42 Agonists/Antagonists...... 59 Diuretics, Thiazide...... 42 Progestins...... 59 Dyslipidemics, Fibric Acid Derivatives...... 42 Selective Estrogen Receptor Modifying Dyslipidemics, HMG CoA Reductase Agents...... 60 Inhibitors...... 43 Hormonal Agents, Dyslipidemics, Other...... 43 Stimulant/Replacement/Modifying Vasodilators, Direct-acting Arterial...... 43 (Thyroid)...... 60 Vasodilators, Direct-acting Arterial/Venous43 Hormonal Agents, Suppressant (Adrenal). 60 Central Nervous System Agents...... 43 Hormonal Agents, Suppressant (pituitary) 60 Attention Deficit Hyperactivity Disorder Hormonal Agents, Suppressant (Thyroid). 60 Agents, ...... 43 Antithyroid Agents...... 60 Attention Deficit Hyperactivity Disorder Immunological Agents...... 61 Agents, Non-amphetamines...... 44 Angioedema Agents...... 61 Central Nervous System, Other...... 44 Immune Suppressants...... 61 Fibromyalgia Agents...... 44 Immunizing Agents, Passive...... 62 Multiple Sclerosis Agents...... 44 Immunomodulators...... 63 Dental and Oral Agents...... 44 Vaccines...... 63 Dermatological Agents...... 45 Inflammatory Bowel Disease Agents...... 65 Electrolytes/Minerals/Metals/Vitamins...... 47 Aminosalicylates...... 65 Electrolyte/Mineral Replacement...... 47 Glucocorticoids...... 65 Electrolyte/Mineral/Metal Modifiers...... 48 Sulfonamides...... 65 Vitamins...... 49 Metabolic Bone Disease Agents...... 65 Gastrointestinal Agents...... 50 Miscellaneous Therapeutic Agents...... 65 Antispasmodics, Gastrointestinal...... 50 Ophthalmic Agents...... 68 Gastrointestinal Agents, Other...... 51 Aminoglycosides...... 68 Histamine2 (H2) receptor Antagonists...... 51 Antibacterials, Other...... 68 Irritable Bowel Syndrome Agents...... 51 Anti-cytomegalovirus (CMV) Agents...... 68 Laxatives...... 51 Antifungals...... 68 Protectants...... 52 Antiherpetic Agents...... 68 Proton Pump Inhibitors...... 52 Macrolides...... 68

10

Ophthalmic Prostaglandin and Prostamide Analogs...... 68 Ophthalmic Agents, Other...... 68 Ophthalmic Anti-allergy Agents...... 69 Ophthalmic Antiglaucoma Agents...... 69 Ophthalmic Anti-inflammatories...... 69 Quinolones...... 70 Sulfonamides...... 70 Otic Agents...... 70 Respiratory Tract/Pulmonary Agents...... 70 ...... 70 Anti-inflammatories, Inhaled Corticosteroids...... 71 Antileukotrienes...... 71 Bronchodilators, Anticholinergic...... 71 Bronchodilators, Sympathomimetic...... 72 Cystic Fibrosis Agents...... 72 Mast Cell Stabilizers...... 72 Phosphodiesterase Inhibitors, Airways Disease...... 72 Pulmonary Antihypertensives...... 73 Pulmonary Fibrosis Agents...... 73 Respiratory Tract Agents, Other...... 73 Skeletal Muscle Relaxants...... 73 Sleep Disorder Agents...... 74 GABA Receptor Modulators...... 74 Sleep Disorders, Other...... 74 Index of Drugs...... 75

11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics diclofenac-misoprostol oral tablet delayed 1 -acetaminophen 1 oral tablet release butalbital-apap 1 DICLOFONO 2 diflunisal oral 1 butalbital-apap-caffeine 1 oral capsule etodolac er 1 1 butalbital-apap-caffeine 1 etodolac oral oral tablet 50-325-40 mg fenoprofen calcium oral 1 butalbital-aspirin-caffeine 1 fenortho oral capsule 200 1 duraxin 1 mg esgic oral capsule 1 flurbiprofen oral 1 phrenilin forte oral ibu oral tablet 600 mg, 1 1 capsule 50-300-40 mg 800 mg tencon oral tablet 50-325 1 1 mg ibuprofen oral 1 zebutal oral capsule 50- 1 suspension 325-40 mg ibuprofen oral tablet 400 1 Nonsteroidal Anti-inflammatory Drugs mg, 600 mg, 800 mg aspirin adult 1 PV indomethacin er 1 aspirin childrens 1 PV indomethacin oral 1 aspirin ec low dose 1 PV indomethacin sodium 1 1 aspirin low dose oral 1 PV ketoprofen er tablet chewable ketoprofen oral capsule 1 aspirin oral tablet 325 mg 1 PV 25 mg aspirin oral tablet 1 PV ketorolac tromethamine delayed release 325 mg injection solution 15 1 bayer aspirin ec low dose 1 PV mg/ml, 30 mg/ml bayer aspirin oral tablet 1 PV ketorolac tromethamine intramuscular solution 60 1 1 QL celecoxib oral mg/2ml 1 diclofenac potassium ketorolac tromethamine 1 QL diclofenac sodium er 1 oral diclofenac sodium oral 1 klofensaid ii 1 PA diclofenac sodium 1 QL meclofenamate sodium 1 transdermal gel 1 % oral diclofenac sodium 1 PV 1 PA medique aspirin transdermal solution meloxicam oral tablet 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nabumetone oral 1 methadose oral tablet 1 dr 1 soluble naproxen oral tablet 1 mitigo 1 morphine sulfate er naproxen sodium oral 1 1 PA; QL tablet 275 mg, 550 mg beads oxaprozin 1 morphine sulfate er oral capsule extended 1 PA; QL piroxicam oral 1 release 24 hour SPRIX 3 PA; QL morphine sulfate er oral 1 PA; QL sulindac oral 1 tablet extended release 1 morphine sulfate tolmetin sodium 1 Opioid Analgesics, Long-acting intramuscular buprenorphine hcl OXYCODONE HCL ER injection solution 0.3 1 ORAL TABLET ER 12 3 PA; QL mg/ml HOUR ABUSE- DETERRENT buprenorphine transdermal patch weekly OXYCONTIN ORAL 1 PA; QL 10 mcg/hr, 15 mcg/hr, 20 TABLET ER 12 HOUR 2 PA; QL mcg/hr, 5 mcg/hr ABUSE-DETERRENT BUPRENORPHINE oxymorphone hcl er 1 PA; QL TRANSDERMAL PATCH 3 PA; QL hcl er (biphasic) WEEKLY 7.5 MCG/HR oral tablet extended 1 QL BUTRANS release 24 hour 100 mg, TRANSDERMAL PATCH 3 PA; QL 200 mg, 300 mg WEEKLY 7.5 MCG/HR tramadol hcl er oral EMBEDA 2 PA; QL capsule extended 1 PA; QL release 24 hour 150 mg fentanyl 1 PA; QL tramadol hcl er oral tablet 1 PA; QL 1 QL hydromorphone hcl er extended release 24 hour HYSINGLA ER 2 PA; QL Opioid Analgesics, Short-acting methadone hcl injection 1 acetaminophen-codeine 1 QL methadone hcl intensol 1 acetaminophen-codeine 1 QL methadone hcl oral #2 1 concentrate acetaminophen-codeine 1 QL methadone hcl oral #3 1 solution acetaminophen-codeine 1 QL methadone hcl oral tablet 1 PA #4 alfentanil hcl intravenous 1 methadone hcl oral tablet 1 soluble

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier apap-caff-dihydrocodeine lorcet hd 1 QL 1 QL oral tablet 325-30-16 mg lorcet plus oral tablet 7.5- 1 QL ascomp-codeine 1 325 mg butalbital-apap-caff-cod 1 meperidine hcl injection solution 100 mg/ml, 25 1 butalbital-asa-caff- 1 codeine mg/ml, 50 mg/ml meperidine hcl oral 1 QL butorphanol tartrate 1 injection morphine sulfate (concentrate) oral butorphanol tartrate 1 QL 1 QL nasal solution 100 mg/5ml, 20 mg/ml codeine sulfate oral 1 QL morphine sulfate (pf) tablet 30 mg, 60 mg 1 injection duramorph 1 morphine sulfate (pf) endocet oral tablet 10- intravenous solution 10 1 325 mg, 2.5-325 mg, 5- 1 QL mg/ml, 2 mg/ml, 4 mg/ml, 325 mg, 7.5-325 mg 8 mg/ml fentanyl citrate buccal 1 PA; QL morphine sulfate injection hydrocodone- solution 10 mg/ml, 2 1 acetaminophen oral mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml solution 10-325 mg/15ml, 1 QL 2.5-108 mg/5ml, 5-217 morphine sulfate mg/10ml, 7.5-325 intravenous solution 1 1 mg/15ml mg/ml, 150 mg/30ml hydrocodone- morphine sulfate oral 1 QL acetaminophen oral tablet 10-300 mg, 10-325 1 QL nalbuphine hcl injection 1 mg, 5-300 mg, 5-325 mg, oxycodone hcl oral 1 QL 7.5-300 mg, 7.5-325 mg capsule hydrocodone-ibuprofen oxycodone hcl oral 1 QL oral tablet 10-200 mg, 5- 1 QL concentrate 100 mg/5ml 200 mg, 7.5-200 mg oxycodone hcl oral 1 QL hydromorphone hcl solution injection solution 1 1 oxycodone hcl oral tablet 1 QL mg/ml, 2 mg/ml, 4 mg/ml oxycodone- hydromorphone hcl oral 1 QL acetaminophen oral hydromorphone hcl pf 1 tablet 10-325 mg, 2.5- 1 QL tartrate oral 325 mg, 5-325 mg, 7.5- 1 QL tablet 2 mg 325 mg lorcet 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier oxycodone-aspirin oral lidocaine external patch 5 1 QL 1 tablet 4.8355-325 mg % 1 QL oxycodone-ibuprofen lidocaine hcl (pf) injection 1 oxymorphone hcl 1 QL solution pentazocine-naloxone hcl 1 QL lidocaine hcl external gel 1 2 % remifentanil hcl 1 lidocaine hcl external 1 tramadol hcl ir 1 QL solution tramadol-acetaminophen 1 QL lidocaine hcl injection 1 verdrocet 1 QL solution 0.5 %, 1 %, 2 % lidocaine hcl vicodin es oral tablet 7.5- 1 QL 1 300 mg mouth/throat lidocaine viscous 1 vicodin hp oral tablet 10- 1 QL 300 mg lidocaine-epinephrine vicodin oral tablet 5-300 injection solution 0.5 %- 1 QL mg 1:200000, 1 %-1:100000, 1 Anesthetics 1.5 %-1:200000, 2 %- 1:100000, 2 %-1:200000, Local Anesthetics 2 %-1:50000 1 bupivacaine hcl (pf) lidocaine-prilocaine 1 bupivacaine hcl injection 1 external cream solution 0.25 %, 0.5 % polocaine 1 bupivacaine in dextrose 1 polocaine-mpf 1 intrathecal ropivacaine hcl injection 1 bupivacaine spinal solution 10 mg/ml, 2 1 bupivacaine-epinephrine mg/ml, 5 mg/ml, 7.5 (pf) injection solution 1 mg/ml 0.25% -1:200000, 0.5% - sensorcaine 1 1:200000 sensorcaine/epinephrine 1 bupivacaine-epinephrine injection solution 0.25% - sensorcaine-mpf 1 1 1:200000, 0.5% - sensorcaine- 1:200000 mpf/epinephrine injection chloroprocaine hcl (pf) 1 solution 0.25% - 1 1:200000, 0.5% - 1 ethyl chloride 1:200000 1 glydo xylocaine dental 1 lidocaine external 1 ointment

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Anti-Addiction/Substance Abuse Treatment NICOTROL 3 ST; PV; QL Agents NICOTROL NS 3 ST; PV; QL Alcohol Deterrents/Anti-craving Antibacterials acamprosate calcium 1 Aminoglycosides disulfiram oral 1 amikacin sulfate injection VIVITROL 4 solution 1 gm/4ml, 500 1 Opioid Dependence Treatments mg/2ml gentamicin in saline buprenorphine hcl 1 QL sublingual intravenous solution 0.8- 0.9 mg/ml-%, 1-0.9 1 buprenorphine hcl- 1 QL mg/ml-%, 1.2-0.9 mg/ml- naloxone hcl %, 1.6-0.9 mg/ml-%, 2- naltrexone hcl oral 1 0.9 mg/ml-% Opioid Reversal Agents gentamicin sulfate 1 naloxone hcl injection external solution 0.4 mg/ml, 4 1 gentamicin sulfate 1 mg/10ml injection naloxone hcl injection 1 1 neomycin sulfate oral solution cartridge paromomycin sulfate oral 1 naloxone hcl injection 1 streptomycin sulfate 1 solution prefilled syringe intramuscular NARCAN 2 tobramycin sulfate 1 Smoking Cessation Agents injection Antibacterials, Other hcl er 1 PV; QL (smoking det) ALTABAX 3 3 ST; PV; QL CHANTIX baciim 1 CHANTIX CONTINUING 3 ST; PV; QL bacitracin intramuscular 1 MONTH PAK chloramphenicol sod CHANTIX STARTING 1 3 ST; PV; QL succinate MONTH PAK clindamycin hcl oral 1 nicotine polacrilex 1 PV; QL mouth/throat gum clindamycin palmitate hcl 1 nicotine polacrilex clindamycin phosphate in 1 mouth/throat lozenge 2 1 PV; QL d5w mg clindamycin phosphate 1 nicotine step 1 1 PV; QL injection nicotine step 2 1 PV; QL nicotine step 3 1 PV; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clindamycin phosphate nitrofurantoin 1 intravenous solution 300 1 monohydrate mg/2ml, 600 mg/4ml, 900 macrocrystals mg/6ml nitrofurantoin oral 1 clindamycin phosphate 1 suspension vaginal polymyxin b sulfate 1 colistimethate sodium 1 injection (cba) PRIMSOL 3 CORTISPORIN silver sulfadiazine 3 1 EXTERNAL external daptomycin intravenous ssd 1 solution reconstituted 1 SULFAMYLON 500 mg 3 EXTERNAL CREAM IMPAVIDO 3 tigecycline 1 iodine tincture external 1 tincture 2 % trimethoprim oral 1 lincomycin hcl injection 1 vancomycin hcl in dextrose intravenous linezolid in sodium 1 solution 1-5 gm/200ml-%, 1 chloride 500-5 mg/100ml-%, 750- linezolid intravenous 1 5 mg/150ml-% solution 600 mg/300ml vancomycin hcl in nacl linezolid oral 1 QL intravenous solution 1- 1 mafenide acetate 0.9 gm/200ml-%, 500-0.9 1 external mg/100ml-% methenamine hippurate 1 VANCOMYCIN HCL IN NACL SOLUTION 750- 3 metronidazole in nacl 0.9 MG/150ML-% intravenous solution 5- 1 INTRAVENOUS 0.79 mg/ml-%, 500-0.79 mg/100ml-% vancomycin hcl in nacl solution 750-0.9 1 metronidazole oral 1 mg/150ml-% intravenous metronidazole vaginal 1 vancomycin hcl MONUROL 3 intravenous solution reconstituted 1 gm, 1.25 mupirocin calcium 1 1 gm, 1.5 gm, 10 gm, 100 mupirocin external 1 gm, 250 mg, 5 gm, 500 mg, 750 mg NEO-SYNALAR 3 EXTERNAL CREAM vancomycin hcl oral 1 nitrofurantoin 1 vandazole 1 macrocrystal oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XIFAXAN 3 PA cefotetan disodium- ZYVOX INTRAVENOUS dextrose intravenous SOLUTION 200 3 solution reconstituted 1- 1 MG/100ML 3.58 gm-%(50ml), 2-2.08 gm-%(50ml) Beta-lactam, Cephalosporins cefoxitin sodium 1 cefaclor 1 cefoxitin sodium-dextrose 1 cefaclor er intravenous solution cefadroxil 1 reconstituted 1-4 gm- 1 %(50ml), 2-2.2 gm- cefazolin sodium 1 injection %(50ml) cefazolin sodium cefpodoxime proxetil 1 intravenous solution 1 cefprozil 1 reconstituted ceftazidime and dextrose cefazolin sodium- intravenous solution dextrose intravenous 1 1 reconstituted 1-5 gm- solution 1-4 gm/50ml-%, %(50ml), 2-5 gm- 2-4 gm/100ml-% %(50ml) cefazolin sodium- ceftazidime injection dextrose intravenous solution reconstituted 1 1 solution reconstituted 1-4 1 gm, 2 gm, 6 gm gm-%(50ml), 2-3 gm- ceftriaxone sodium in 1 %(50ml) dextrose cefdinir 1 ceftriaxone sodium 1 cefditoren pivoxil 1 injection cefepime hcl 1 ceftriaxone sodium 1 cefepime-dextrose intravenous intravenous solution ceftriaxone sodium- reconstituted 1-5 gm- 1 dextrose intravenous %(50ml), 2-5 gm- solution reconstituted 1- 1 %(50ml) 3.74 gm-%(50ml), 2-2.22 cefixime 1 gm-%(50ml) cefuroxime axetil oral cefotaxime sodium 1 tablet injection solution 1 reconstituted 1 gm, 500 cefuroxime sodium mg injection solution 1 cefotetan disodium 1 reconstituted 7.5 gm, 750 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cefuroxime sodium ampicillin-sulbactam 1 intravenous solution 1 sodium injection reconstituted 1.5 gm ampicillin-sulbactam 1 cephalexin sodium intravenous 1 MAXIPIME solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm INTRAVENOUS 3 SOLUTION AUGMENTIN ORAL RECONSTITUTED 2 GM SUSPENSION 3 tazicef injection 1 RECONSTITUTED 125- 31.25 MG/5ML tazicef intravenous 1 solution reconstituted BICILLIN L-A 3 Beta-lactam, Other dicloxacillin sodium 1 AZACTAM IN nafcillin sodium injection solution reconstituted 1 1 DEXTROSE 3 INTRAVENOUS gm, 2 gm SOLUTION 1 GM/50ML nafcillin sodium 1 aztreonam 1 intravenous ertapenem sodium 1 oxacillin sodium 1 -cilastatin 1 g potassium 1 meropenem 1 penicillin g procaine 1 Beta-lactam, Penicillins penicillin g sodium 1 amoxicillin oral capsule 1 penicillin v potassium 1 piperacillin sod- amoxicillin oral 1 1 suspension reconstituted tazobactam so amoxicillin oral tablet 1 Macrolides amoxicillin oral tablet azithromycin intravenous chewable 125 mg, 250 1 solution reconstituted 1 mg 500 mg amoxicillin-potassium azithromycin oral packet 1 1 clavulanate er azithromycin oral 1 suspension reconstituted amoxicillin-potassium 1 clavulanate oral azithromycin oral tablet 1 250 mg, 500 mg, 600 mg ampicillin oral capsule 1 500 mg clarithromycin er 1 1 ampicillin sodium 1 clarithromycin oral injection DIFICID 3 ampicillin sodium 1 e.e.s. 400 oral tablet 1 intravenous

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ERY-TAB ORAL sulfamethoxazole- 3 TABLET DELAYED trimethoprim oral 1 RELEASE 333 MG suspension 200-40 erythromycin base oral mg/5ml 1 capsule delayed release sulfamethoxazole- 1 particles trimethoprim oral tablet 1 erythromycin base oral 1 sulfatrim pediatric tablet Tetracyclines erythromycin 1 avidoxy 1 ethylsuccinate oral coremino 1 ZITHROMAX ORAL 2 1 PACKET demeclocycline hcl oral Quinolones doxy 100 1 doxycycline hyclate AVELOX 3 1 INTRAVENOUS intravenous doxycycline hyclate oral CIPRO ORAL 1 capsule SUSPENSION 3 RECONSTITUTED 250 doxycycline hyclate oral MG/5ML (5%) tablet 100 mg, 150 mg, 1 hcl oral 1 20 mg, 50 mg, 75 mg ciprofloxacin in d5w 1 doxycycline hyclate oral 1 tablet delayed release ciprofloxacin oral suspension reconstituted 1 doxycycline monohydrate 1 500 mg/5ml (10%) oral ciprofloxacin-ciproflox hcl minocycline hcl er 1 1 er minocycline hcl oral 1 in d5w 1 mondoxyne nl 1 levofloxacin intravenous 1 morgidox oral 1 levofloxacin oral 1 okebo oral capsule 75 1 moxifloxacin hcl in nacl 1 mg moxifloxacin hcl oral 1 soloxide 1 tetracycline hcl oral 1 oral tablet 300 1 mg, 400 mg Anticonvulsants Sulfonamides Anticonvulsants, Other sulfadiazine oral 1 BRIVIACT ORAL 3 FYCOMPA 3 sulfamethoxazole- 1 trimethoprim intravenous levetiracetam er 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier levetiracetam in nacl 1 valproic acid oral solution 1 4 PA levetiracetam 1 vigabatrin intravenous vigadrone 4 PA levetiracetam oral 1 Glutamate Reducing Agents roweepra 1 1 roweepra xr 1 lamotrigine er 1 Calcium Channel Modifying Agents lamotrigine oral tablet 1 CELONTIN 3 lamotrigine oral tablet 1 ethosuximide oral 1 chewable

LYRICA ORAL 2 QL lamotrigine oral tablet 1 CAPSULE dispersible

LYRICA ORAL 3 QL lamotrigine starter kit- 1 SOLUTION blue zonisamide oral 1 lamotrigine starter kit- 1 Gamma-aminobutyric Acid (GABA) green Augmenting Agents lamotrigine starter kit- 1 1 PA orange oral 1 QL subvenite 1 rectal 1 QL subvenite starter kit-blue 1 divalproex sodium er oral subvenite starter kit- 1 tablet extended release 1 green 24 hour subvenite starter kit- 1 divalproex sodium oral orange capsule delayed release 1 er 1 sprinkle topiramate oral 1 divalproex sodium oral 1 Sodium Channel Agents tablet delayed release BANZEL 3 gabapentin oral 1 er 1 oral 1 carbamazepine oral 1 oral 1 DILANTIN ORAL 3 tiagabine hcl 1 CAPSULE 30 MG valproate sodium 1 epitol 1 intravenous fosphenytoin sodium 1 valproate sodium oral 1 solution oxcarbazepine 1 valproic acid oral capsule 1 PEGANONE 3 infatabs 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier phenytoin oral oral 1 1 suspension 125 mg/5ml Monoamine Oxidase Inhibitors phenytoin oral tablet 1 EMSAM 3 QL chewable MARPLAN 3 phenytoin sodium 1 1 extended phenelzine sulfate oral tranylcypromine sulfate 1 phenytoin sodium 1 injection SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine VIMPAT ORAL 3 Reuptake Inhibitors) Antidementia Agents citalopram hydrobromide 1 Antidementia Agents, Other desvenlafaxine succinate 1 QL mesylates oral 1 er Cholinesterase Inhibitors duloxetine hcl oral 1 QL 1 hcl escitalopram oxalate 1 1 FETZIMA 3 ST; QL hydrobromide FETZIMA TITRATION 3 ST; QL galantamine 1 hydrobromide er hcl (pmdd) 1 fluoxetine hcl oral 1 1 capsule rivastigmine tartrate 1 fluoxetine hcl oral N-methyl-D-aspartate (NMDA) Receptor 1 QL capsule delayed release Antagonist fluoxetine hcl oral 1 QL 1 hcl er solution 1 memantine hcl oral fluoxetine hcl oral tablet 1 NAMENDA XR 2 QL fluvoxamine maleate 1 TITRATION PACK fluvoxamine maleate er 1 QL NAMZARIC ORAL CAPSULE EXTENDED 2 QL hcl 1 RELEASE 24 HOUR hcl 1 Antidepressants -fluoxetine hcl 1 QL Antidepressants, Other paroxetine hcl er 1 APLENZIN 3 ST; QL paroxetine hcl oral tablet 1 bupropion hcl er (sr) 1 QL paroxetine mesylate 1 QL bupropion hcl er (xl) oral PAXIL ORAL 2 tablet extended release 1 QL SUSPENSION 24 hour 150 mg, 300 mg sertraline hcl oral 1 bupropion hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hcl oral 1 1 3 ST; QL TRINTELLIX prochlorperazine 1 venlafaxine hcl 1 edisylate injection venlafaxine hcl er oral prochlorperazine maleate 1 capsule extended 1 oral release 24 hour hcl 1 venlafaxine hcl er oral injection tablet extended release 1 promethazine hcl oral 1 24 hour 225 mg promethazine hcl rectal 1 3 QL VIIBRYD ORAL TABLET promethegan 1 VIIBRYD STARTER 3 QL TIGAN 3 PACK INTRAMUSCULAR Tricyclics TRANSDERM-SCOP 3 hcl oral 1 (1.5 MG) 1 hcl 1 - oral 1 amitriptyline Emetogenic Therapy Adjuncts hcl oral 1 ANZEMET ORAL 3 QL hcl oral 1 aprepitant 1 QL hcl oral 1 CESAMET 3 PA; QL hcl oral 1 dronabinol 1 PA; QL imipramine pamoate 1 hcl hcl oral 1 intravenous solution 1 1 mg/ml, 4 mg/4ml - 1 amitriptyline granisetron hcl oral 1 QL hcl 1 hcl injection solution 4 mg/2ml, 40 1 maleate oral 1 mg/20ml Antiemetics ondansetron hcl oral 1 QL Antiemetics, Other solution AKYNZEO ORAL 3 QL ondansetron hcl oral 1 QL compro 1 tablet 24 mg dimenhydrinate injection 1 ondansetron hcl oral 1 tablet 4 mg, 8 mg injection 1 ondansetron odt 1 meclizine hcl oral tablet 1 hcl 1 phenadoz 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Antifungals ketoconazole external 1 ABELCET 3 shampoo AMBISOME 3 ketoconazole oral 1 amphotericin b injection 1 MENTAX 3 caspofungin acetate 1 miconazole 3 vaginal 1 suppository ciclodan external solution 1 MYCAMINE 3 ciclopirox 1 naftifine hcl 1 ciclopirox olamine 1 external NOXAFIL ORAL TABLET 3 DELAYED RELEASE clotrimazole external 1 nyamyc 1 clotrimazole mouth/throat 1 nystatin external 1 clotrimazole- 1 betamethasone nystatin mouth/throat 1 CRESEMBA 3 nystatin oral tablet 1 econazole nitrate nystatin-triamcinolone 1 1 external nystop 1 ERAXIS INTRAVENOUS OXISTAT EXTERNAL 3 SOLUTION 3 LOTION RECONSTITUTED 50 terbinafine hcl oral 1 QL MG terconazole 1 fluconazole in sodium chloride intravenous voriconazole intravenous 1 solution 200-0.9 1 voriconazole oral 1 mg/100ml-%, 400-0.9 XOLEGEL 3 mg/200ml-% Antigout Agents fluconazole oral 1 allopurinol oral 1 flucytosine oral 1 allopurinol sodium 1 griseofulvin microsize 1 oral COLCHICINE ORAL 3 TABLET griseofulvin 1 ultramicrosize colchicine-probenecid 1 GYNAZOLE-1 3 COLCRYS 2 itraconazole oral 1 PA probenecid oral 1 JUBLIA 3 PA ULORIC 2 ST KERYDIN 3 PA ZURAMPIC 3 ST ketoconazole external 1 cream

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Antimigraine Agents MESTINON ORAL 2 Ergot Alkaloids SYRUP neostigmine 1 mesylate injection methylsulfate intravenous 1 solution dihydroergotamine 1 QL mesylate nasal pyridostigmine 1 er -caffeine 1 pyridostigmine bromide Serotonin (5-HT) 1b/1d Receptor Agonists 1 oral tablet malate 1 QL Antimycobacterials hydrobromide 1 QL Antimycobacterials, Other 1 QL hcl dapsone oral 1 1 QL benzoate rifabutin 1 nasal 1 QL Antituberculars sumatriptan succinate 1 QL CAPASTAT SULFATE 3 oral cycloserine oral 1 sumatriptan succinate refill subcutaneous 1 QL ethambutol hcl oral 1 solution cartridge isoniazid injection 1 sumatriptan succinate isoniazid oral 1 subcutaneous solution 6 1 QL PASER 3 mg/0.5ml PRIFTIN 3 sumatriptan succinate pyrazinamide oral 1 subcutaneous solution 1 QL auto-injector 4 mg/0.5ml, rifampin intravenous 1 6 mg/0.5ml rifampin oral 1 sumatriptan succinate RIFATER 3 subcutaneous solution 1 QL prefilled syringe 6 SIRTURO 3 mg/0.5ml TRECATOR 3 Antineoplastics sumatriptan-naproxen 1 QL sodium Alkylating Agents oral 1 QL busulfan 4 ZOMIG NASAL 3 QL carboplatin intravenous 4 Antimyasthenic Agents solution Parasympathomimetics carmustine 4 GUANIDINE HCL ORAL 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cisplatin intravenous flutamide 1 solution 100 mg/100ml, 4 nilutamide 4 200 mg/200ml, 50 mg/50ml XTANDI 4 PA ZYTIGA ORAL TABLET cyclophosphamide 4 4 PA injection 500 MG Antiangiogenic Agents cyclophosphamide oral 1 capsule POMALYST 4 PA dacarbazine intravenous 4 REVLIMID 4 PA GLEOSTINE ORAL THALOMID 4 PA CAPSULE 10 MG, 100 4 Antiestrogens/Modifiers MG, 40 MG EMCYT 2 ifosfamide 4 FASLODEX LEUKERAN 4 INTRAMUSCULAR 4 MATULANE 4 SOLUTION 250 MG/5ML melphalan 1 SOLTAMOX 3 melphalan hcl 4 tamoxifen citrate oral 1 PV* MYLERAN 4 toremifene citrate 1 oxaliplatin 4 Antimetabolites adrucil 4 TEMODAR 4 INTRAVENOUS ALIMTA 4 temozolomide 4 PA ARRANON 4 TEPADINA 4 capecitabine 4 PA thiotepa injection 4 cladribine intravenous 4 TREANDA solution 10 mg/10ml INTRAVENOUS 4 clofarabine 4 SOLUTION 4 RECONSTITUTED cytarabine (pf) VYXEOS cytarabine injection 4 INTRAVENOUS solution SUSPENSION 4 PA decitabine 4 PA RECONSTITUTED 44- DROXIA 3 100 MG ELITEK 3 ZANOSAR 4 floxuridine injection 4 Antiandrogens fludarabine phosphate 4 abiraterone acetate 4 PA fluorouracil intravenous 4 bicalutamide 1 FOLOTYN 4 PA

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier gemcitabine hcl 4 epirubicin hcl intravenous hydroxyurea oral 1 solution 200 mg/100ml, 4 50 mg/25ml KEPIVANCE 4 ERWINAZE INJECTION 4 LONSURF 4 PA ETHYOL 4 mercaptopurine oral 4 FARYDAK 4 PA NIPENT 4 FLUOROPLEX 3 TABLOID 4 fluorouracil external Antineoplastics, Other 1 cream 5 % ABRAXANE 4 fluorouracil external 4 adriamycin intravenous 4 solution solution HALAVEN 4 PA adriamycin intravenous IBRANCE 4 PA solution reconstituted 10 4 mg, 50 mg idarubicin hcl 4 arsenic trioxide ISTODAX (OVERFILL) 4 PA 4 intravenous IXEMPRA KIT 4 azacitidine 4 JEVTANA 4 PA bleomycin sulfate 4 KYPROLIS COTELLIC 4 PA INTRAVENOUS SOLUTION 4 PA 4 dactinomycin RECONSTITUTED 10 daunorubicin hcl 4 MG intravenous solution leucovorin calcium 1 dexrazoxane 4 injection 1 diclofenac sodium 1 ST; QL leucovorin calcium oral transdermal gel 3 % levoleucovorin calcium 4 docetaxel (non-alcohol) 4 intravenous solution docetaxel intravenous LEVOLEUCOVORIN concentrate 160 mg/8ml, 4 CALCIUM 20 mg/ml, 200 mg/10ml, INTRAVENOUS 4 80 mg/4ml SOLUTION docetaxel intravenous RECONSTITUTED 175 solution 160 mg/16ml, 20 4 MG mg/2ml, 80 mg/8ml levoleucovorin calcium doxorubicin hcl intravenous solution 4 4 intravenous solution reconstituted 50 mg doxorubicin hcl liposomal 4 levoleucovorin calcium pf 4 lipodox 50 4

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LYNPARZA ORAL exemestane 1 4 PA TABLET letrozole oral 1 MARQIBO 4 Enzyme Inhibitors mesna 4 CAMPTOSAR 4 MESNEX ORAL INTRAVENOUS 4 mitomycin intravenous 4 SOLUTION 300 MG/15ML mitoxantrone hcl 4 PA etoposide intravenous mutamycin 4 solution 1 gm/50ml, 100 4 NINLARO 4 PA mg/5ml, 500 mg/25ml ONCASPAR INJECTION 4 etoposide oral 4 paclitaxel 4 HYCAMTIN ORAL 4 PICATO 3 ST irinotecan hcl 4 PROLEUKIN 4 KYPROLIS ROMIDEPSIN 4 PA INTRAVENOUS SOLUTION 4 PA RUBRACA 4 PA RECONSTITUTED 30 SYLATRON MG, 60 MG SUBCUTANEOUS KIT 4 PA ONIVYDE 4 200 MCG, 300 MCG, 600 MCG toposar intravenous solution 1 gm/50ml, 100 4 SYNRIBO 4 PA mg/5ml, 500 mg/25ml teniposide 4 topotecan hcl 4 TOTECT 4 ZYDELIG 4 PA TRISENOX Molecular Target Inhibitors INTRAVENOUS 4 4 PA; QL SOLUTION 12 MG/6ML AFINITOR 4 PA VELCADE INJECTION 4 PA AFINITOR DISPERZ BOSULIF 4 PA vinblastine sulfate 4 intravenous solution CABOMETYX 4 PA 4 CAPRELSA ORAL vincasar pfs 4 PA; QL TABLET 100 MG vincristine sulfate 4 intravenous CAPRELSA ORAL 4 PA vinorelbine tartrate 4 TABLET 300 MG ZALTRAP 4 PA COMETRIQ (100 MG 4 PA DAILY DOSE) ZOLINZA 4 PA COMETRIQ (140 MG 4 PA Aromatase Inhibitors, 3rd Generation DAILY DOSE) anastrozole oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier COMETRIQ (60 MG SUTENT 4 PA 4 PA DAILY DOSE) TAFINLAR 4 PA ERIVEDGE 4 PA TAGRISSO ORAL 4 PA; QL GILOTRIF 4 PA; QL TABLET 40 MG

ICLUSIG ORAL TABLET 4 PA; QL TAGRISSO ORAL 4 PA 15 MG TABLET 80 MG 4 PA ICLUSIG ORAL TABLET 4 PA TARCEVA 45 MG TASIGNA 4 PA imatinib mesylate 4 PA temsirolimus 4 IMBRUVICA 4 PA TYKERB 4 PA INLYTA 4 PA VENCLEXTA 4 PA JAKAFI ORAL TABLET 4 PA; QL VENCLEXTA STARTING 4 PA 10 MG PACK JAKAFI ORAL TABLET VOTRIENT 4 PA 15 MG, 20 MG, 25 MG, 5 4 PA MG XALKORI 4 PA ZELBORAF 4 PA LENVIMA 10 MG DAILY 4 PA DOSE ZYKADIA 4 PA Monoclonal Antibody/Antibody-Drug Conjugate LENVIMA 12 MG DAILY 4 PA DOSE ADCETRIS 4 PA LENVIMA 14 MG DAILY 4 PA ARZERRA 4 PA DOSE AVASTIN 4 LENVIMA 18 MG DAILY 4 PA 4 PA DOSE BAVENCIO 4 PA LENVIMA 20 MG DAILY BLINCYTO 4 PA DOSE DARZALEX 4 PA LENVIMA 24 MG DAILY EMPLICITI 4 PA 4 PA DOSE ERBITUX 4 PA LENVIMA 4 MG DAILY 4 PA GAZYVA 4 PA DOSE HERCEPTIN 4 PA LENVIMA 8 MG DAILY 4 PA 4 PA DOSE KADCYLA 4 PA MEKINIST 4 PA LARTRUVO 4 PA NEXAVAR 4 PA OPDIVO 4 PA RYDAPT 4 PA PERJETA SPRYCEL 4 PA RITUXAN INTRAVENOUS 4 PA STIVARGA 4 PA SOLUTION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TECENTRIQ Pediculicides/Scabicides INTRAVENOUS 4 PA crotan 1 SOLUTION 1200 MG/20ML EURAX EXTERNAL 2 CREAM UNITUXIN 4 PA external 1 YERVOY 4 PA shampoo Retinoids malathion external 1 bexarotene 4 PA permethrin external 1 PANRETIN 3 cream TARGRETIN EXTERNAL 3 PA SKLICE 3 tretinoin oral 4 spinosad 1 Antiparasitics sulfurated lime 1 Anthelmintics ULESFIA 3 albendazole oral 1 PA Antiparkinson Agents EMVERM 2 Anticholinergics oral 1 benztropine mesylate 1 praziquantel oral 1 injection benztropine mesylate Antiprotozoals 1 oral ALINIA 2 trihexyphenidyl hcl 1 atovaquone oral 1 Antiparkinson Agents, Other atovaquone-proguanil hcl 1 entacapone 1 BENZNIDAZOLE 3 tolcapone 1 chloroquine phosphate 1 Dopamine Agonists oral COARTEM 3 APOKYN SUBCUTANEOUS 4 PA; QL DARAPRIM 4 PA SOLUTION CARTRIDGE hydroxychloroquine 1 mesylate 1 sulfate oral oral mefloquine hcl 1 NEUPRO 3 NEBUPENT 2 1 dihydrochloride primaquine phosphate 1 oral pramipexole 1 quinine sulfate oral 1 PA dihydrochloride er tinidazole oral 1 hcl 1 ropinirole hcl er 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Dopamine Precursors/L- Amino Acid 2nd Generation/Atypical Decarboxylase Inhibitors ABILIFY MAINTENA carbidopa oral 1 INTRAMUSCULAR 3 carbidopa-levodopa 1 PREFILLED SYRINGE carbidopa-levodopa er ABILIFY MAINTENA INTRAMUSCULAR oral tablet extended 1 3 release 25-100 mg, 50- SUSPENSION 200 mg RECONSTITUTED ER carbidopa-levodopa- 1 QL 1 entacapone FANAPT 3 ST; QL Monoamine Oxidase B (MAO-B) Inhibitors FANAPT TITRATION 3 ST; QL rasagiline mesylate oral 1 PACK GEODON selegiline hcl oral 1 3 INTRAMUSCULAR Antipsychotics INVEGA SUSTENNA 3 1st Generation/Typical INVEGA TRINZA 3 hcl 1 injection LATUDA 3 QL chlorpromazine hcl oral 1 olanzapine intramuscular 1 olanzapine oral 1 QL decanoate 1 injection er 1 QL fluphenazine hcl injection 1 fumarate 1 QL fluphenazine hcl oral 1 quetiapine fumarate er 1 QL decanoate REXULTI 3 QL 1 intramuscular solution RISPERDAL CONSTA 3 100 mg/ml, 50 mg/ml 1 QL haloperidol lactate 1 injection solution 5 mg/ml risperidone m-tab oral tablet dispersible 0.5 mg, 1 QL 1 haloperidol lactate oral 1 mg, 2 mg 1 haloperidol oral SAPHRIS 2 QL 1 succinate oral hcl 1 QL 1 hcl ZYPREXA RELPREVV 3 perphenazine oral 1 Treatment-Resistant 1 oral tablet 1 QL 1 hcl oral clozapine oral tablet thiothixene oral 1 dispersible 100 mg, 150 1 QL hcl oral 1 mg, 200 mg, 25 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clozapine oral tablet moderiba oral tablet 200 1 PA; QL 4 dispersible 12.5 mg mg Antispasticity Agents PEGASYS PROCLICK intrathecal 1 SUBCUTANEOUS 4 PA SOLUTION 180 1 baclofen oral MCG/0.5ML PA; Non- 4 PEGASYS Cosmetic BOTOX SUBCUTANEOUS 4 PA dantrolene sodium oral 1 SOLUTION revonto 1 PEGINTRON hcl oral 1 SUBCUTANEOUS KIT 4 PA 50 MCG/0.5ML Antivirals REBETOL ORAL Anti-cytomegalovirus (CMV) Agents 4 SOLUTION 1 cidofovir intravenous ribasphere 4 ganciclovir sodium 1 ribasphere ribapak oral 4 valganciclovir hcl 1 tablet 400 mg, 600 mg Anti-hepatitis B (HBV) Agents RIBASPHERE RIBAPAK adefovir dipivoxil 4 ORAL TABLET 4 THERAPY PACK 200 & BARACLUDE ORAL 4 QL 400 MG SOLUTION ribasphere ribapak oral 4 QL entecavir tablet therapy pack 400 & 4 EPIVIR HBV ORAL 4 600 mg SOLUTION ribavirin oral capsule 4 INTRON A 4 PA ribavirin oral tablet 200 4 lamivudine oral tablet 4 mg 100 mg SOFOSBUVIR- 4 PA; M; QL VEMLIDY 4 VELPATASVIR Anti-hepatitis C (HBV) Agents SOVALDI 4 PA; QL DAKLINZA ORAL 4 PA; QL TECHNIVIE 4 PA; QL TABLET 30 MG, 60 MG VIEKIRA PAK 4 PA; QL EPCLUSA 4 PA; QL ZEPATIER 4 PA; QL HARVONI 4 PA; QL Antiherpetic Agents LEDIPASVIR- 4 PA; M; QL acyclovir external 1 SOFOSBUVIR acyclovir oral 1 MAVYRET 4 PA; QL acyclovir sodium MODERIBA 1200 DOSE 1 4 intravenous solution PACK

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DENAVIR 3 didanosine oral capsule famciclovir oral 1 delayed release 200 mg, 1 250 mg, 400 mg valacyclovir hcl oral 1 QL EMTRIVA 2 Anti-HIV Agents, Integrase Inhibitors (INSTI) lamivudine oral solution 1 BIKTARVY 3 lamivudine oral tablet 2 1 GENVOYA 150 mg, 300 mg 2 ISENTRESS lamivudine-zidovudine 1 ISENTRESS HD 2 RETROVIR 2 JULUCA 2 INTRAVENOUS STRIBILD 2 stavudine oral capsule 1 TIVICAY 2 tenofovir disoproxil 1 TRIUMEQ 2 fumarate Anti-HIV Agents, Non-nucleoside Reverse TRUVADA 2 Transcriptase Inhibitors (NNRTI) VIDEX 2 ATRIPLA 2 VIDEX EC ORAL COMPLERA 2 CAPSULE DELAYED 2 RELEASE 125 MG EDURANT 2 VIREAD ORAL 1 2 POWDER 2 INTELENCE VIREAD ORAL TABLET nevirapine 1 150 MG, 200 MG, 250 2 nevirapine er 1 MG ODEFSEY 2 zidovudine 1 RESCRIPTOR ORAL Anti-HIV Agents, Other 2 TABLET 200 MG FUZEON SUBCUTANEOUS SYMFI 2 2 QL SOLUTION 2 SYMFI LO RECONSTITUTED Anti-Hiv Agents, Nucleoside And Nucleotide SELZENTRY 2 PA Reverse Transcriptase Inhibitors (Nrti) TYBOST 2 abacavir sulfate 1 Anti-HIV Agents, Protease Inhibitors abacavir sulfate- 1 lamivudine APTIVUS 2 atazanavir sulfate 1 abacavir-lamivudine- 1 zidovudine CRIXIVAN ORAL CIMDUO 2 CAPSULE 200 MG, 400 2 MG DESCOVY 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EVOTAZ 2 xr 1 QL fosamprenavir calcium 1 chlordiazepoxide hcl 1 QL 1 QL INVIRASE ORAL 2 dipotassium TABLET diazepam injection 1 KALETRA ORAL 2 diazepam intensol 1 TABLET diazepam intramuscular 1 LEXIVA ORAL 2 solution auto-injector SUSPENSION diazepam oral 1 lopinavir-ritonavir 1 concentrate NORVIR ORAL PACKET 2 diazepam oral solution 5 1 NORVIR ORAL 2 mg/5ml SOLUTION diazepam oral tablet 1 PREZCOBIX 2 1 QL PREZISTA ORAL 2 hcl 1 PA; QL SUSPENSION injection 1 PREZISTA ORAL TABLET 150 MG, 600 2 lorazepam intensol 1 QL MG, 75 MG, 800 MG lorazepam oral 1 QL 1 QL REYATAZ ORAL 2 PACKET 1 QL 1 ritonavir 1 QL VIRACEPT ORAL 2 1 QL TABLET Bipolar Agents Anti-influenza Agents Mood Stabilizers hcl oral 1 lithium 1 oseltamivir phosphate 1 QL 1 oral lithium carbonate er 1 RELENZA DISKHALER 3 QL lithium carbonate oral Blood Glucose Monitoring hcl 1 Anxiolytics ACCU-CHEK FASTCLIX 2 LANCET KIT Anxiolytics, Other ACCU-CHEK FASTCLIX 1 2 hcl oral LANCETS 1 ACCU-CHEK Benzodiazepines MULTICLIX LANCET 2 alprazolam er 1 QL DEVICE KIT ACCU-CHEK alprazolam oral 1 QL 2 MULTICLIX LANCETS

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACCU-CHEK SOFT ONETOUCH VERIO IQ 2 3 TOUCH LANCETS SYSTEM KIT W/DEVICE

ACCU-CHEK SOFTCLIX 2 ONETOUCH VERIO IQ 2 LANCET DEVICE KIT SYSTEM KIT W/DEVICE

ACCU-CHEK SOFTCLIX 2 ONETOUCH VERIO 3 QL LANCETS STRIP IN VITRO 3 CHEMSTRIP UGK ONETOUCH VERIO 2 QL INPEN 100-BLUE-LILLY 3 STRIP IN VITRO INPEN 100-BLUE-NOVO 3 ONETOUCH VERIO SYNC SYSTEM KIT 2 INPEN 100-GRAY-LILLY 3 W/DEVICE INPEN 100-GREY- SURESTEP PRO HIGH 3 3 NOVO GLUCOSE INPEN 100-PINK-LILLY 3 SURESTEP PRO LOW 3 INPEN 100-PINK-NOVO 3 GLUCOSE 3 KETOCARE SURESTEP PRO 3 KETOSTIX 3 NORMAL GLUCOSE Blood Glucose Regulators LANCETS 2 Antidiabetic Agents NOVOPEN ECHO 3 1 ONETOUCH DELICA acarbose 3 LANCING DEV ACTOPLUS MET XR 3 ST AVANDIA ORAL ONETOUCH ULTRA 2 3 3 ST KIT W/DEVICE TABLET 2 MG, 4 MG BYDUREON BCISE ONETOUCH ULTRA 2 2 2 ST; QL KIT W/DEVICE AUTOINJECTOR BYDUREON PEN 2 ST; QL ONETOUCH ULTRA 2 QL BLUE TEST STRIPS BYETTA 10 MCG PEN 2 ST; QL ONETOUCH ULTRA 3 BYETTA 5 MCG PEN 2 ST; QL MINI KIT W/DEVICE chlorpropamide 1 ONETOUCH ULTRA 2 3 ST MINI KIT W/DEVICE CYCLOSET 1 ONETOUCH VERIO 2 glimepiride 1 ONETOUCH VERIO glipizide er FLEX SYSTEM KIT 2 glipizide ir 1 W/DEVICE glipizide xl 1 ONETOUCH VERIO IN 3 glipizide-metformin hcl 1 VITRO SOLUTION HIGH glyburide micronized 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier glyburide oral 1 TRADJENTA 2 ST glyburide-metformin 1 TRULICITY 2 ST; QL GLYXAMBI 2 ST VICTOZA 2 ST; QL INVOKAMET 2 ST Glycemic Agents INVOKAMET XR 2 ST GLUCAGEN HYPOKIT 2 2 ST INVOKANA GLUCAGON 2 JANUMET 2 ST EMERGENCY 2 JANUMET XR 2 ST PROGLYCEM Insulins JANUVIA 2 ST JARDIANCE 2 ST HUMALOG U-100 AND 2 U-200 KWIKPEN JENTADUETO 2 ST HUMALOG MIX 50/50 2 JENTADUETO XR 2 ST KWIKPEN metformin hcl er 1 HUMALOG MIX 50/50 2 VIAL METFORMIN HCL ORAL 3 SOLUTION HUMALOG MIX 75/25 2 metformin hcl oral tablet 1 KWIKPEN 1 HUMALOG MIX 75/25 miglitol 2 nateglinide 1 VIAL OZEMPIC 2 ST; QL HUMALOG U-100 2 JUNIOR KWIKPEN pioglitazone hcl 1 HUMALOG U-100 VIAL pioglitazone hcl- 2 1 AND CARTRIDGE glimepiride HUMULIN 70/30 pioglitazone hcl- 2 1 KWIKPEN metformin hcl HUMULIN 70/30 VIAL 2 QTERN 3 ST HUMULIN N KWIKPEN 2 repaglinide 1 HUMULIN N VIAL 2 repaglinide-metformin hcl 1 HUMULIN R U-500 2 RIOMET 3 KWIKPEN SYMLINPEN 120 3 PA HUMULIN R U-500 VIAL 2 SYMLINPEN 60 3 PA (CONCENTRATED) SYNJARDY 2 ST HUMULIN R VIAL 2 2 ST LANTUS U-100 SYNJARDY XR 2 tolazamide 1 SOLOSTAR 2 tolbutamide 1 LANTUS U-100 VIAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LEVEMIR U-100 argatroban in sodium 2 FLEXTOUCH chloride intravenous 1 LEVEMIR U-100 VIAL 2 solution 50 mg/50ml NOVOLIN 70/30 RELION 3 BEVYXXA 3 QL NOVOLIN 70/30 VIAL 3 bivalirudin 1 trifluoroacetate NOVOLIN N RELION 3 CEPROTIN 4 NOVOLIN N VIAL 3 ELIQUIS 2 QL NOVOLIN R RELION 3 ELIQUIS STARTER 2 QL NOVOLIN R VIAL 3 PACK NOVOLOG U-100 3 enoxaparin sodium 1 QL FLEXPEN fondaparinux sodium 1 QL NOVOLOG MIX 70/30 3 FLEXPEN FRAGMIN SUBCUTANEOUS NOVOLOG MIX 70/30 3 SOLUTION 10000 VIAL UNIT/ML, 12500 NOVOLOG U-100 UNIT/0.5ML, 15000 3 PENFILL UNIT/0.6ML, 18000 3 QL NOVOLOG U-100 VIAL 3 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 TOUJEO MAX 2 UNIT/0.2ML, 7500 SOLOSTAR UNIT/0.3ML, 95000 TOUJEO SOLOSTAR 2 UNIT/3.8ML TRESIBA 3 heparin (porcine) in d5w 1 3 TRESIBA FLEXTOUCH heparin (porcine) in nacl 1 Blood Products/Modifiers/Volume injection Expanders heparin (porcine) in nacl SOLIRIS intravenous solution 1 25000-0.45 ut/250ml-%, INTRAVENOUS 4 PA SOLUTION 300 25000-0.45 ut/500ml-% MG/30ML heparin sod (porcine) in Anticoagulants d5w intravenous solution 1 100 unit/ml anticoagulant cit dext 1 soln a heparin sodium (porcine) injection solution 1000 anticoagulant sodium 1 unit/ml, 10000 unit/ml, 1 citrate 20000 unit/ml, 5000 argatroban 1 unit/ml

heparin sodium (porcine) 1 pf

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier jantoven 1 COAGADEX 4 PRADAXA 2 QL CORIFACT 4 SAVAYSA 3 QL ELOCTATE 4 THROMBATE III 4 FEIBA 4 warfarin sodium oral 1 FIBRYGA 4 XARELTO 2 QL HELIXATE FS 4 4 XARELTO STARTER 2 QL HEMLIBRA PACK hemofil m intravenous Blood Formation Modifiers solution reconstituted 4 anagrelide hcl 1 1000 unit, 250 unit, 500 unit MOZOBIL 4 PA; QL HEMOFIL M 4 PA NEULASTA ONPRO INTRAVENOUS NEULASTA SOLUTION 4 SUBCUTANEOUS 4 PA RECONSTITUTED 1700 SOLUTION PREFILLED UNIT SYRINGE HUMATE-P NEUPOGEN INJECTION INTRAVENOUS SOLUTION 300 4 PA SOLUTION 4 MCG/ML, 480 RECONSTITUTED 1000- MCG/1.6ML 2400 UNIT, 250-600 NEUPOGEN INJECTION UNIT, 500-1200 UNIT SOLUTION PREFILLED 4 PA KOATE 4 SYRINGE KOATE-DVI 4 4 PA NPLATE KOGENATE FS 4 4 PA PROCRIT MONOCLATE-P PROMACTA 4 PA INTRAVENOUS KIT 4 Hemostasis Agents 1000 UNIT ADVATE 4 MONONINE INTRAVENOUS ALPHANATE/VWF 4 SOLUTION 4 COMPLEX/HUMAN RECONSTITUTED 1000 ALPHANINE SD 4 UNIT aminocaproic acid 4 1 NOVOSEVEN RT intravenous OBIZUR 4 aminocaproic acid oral 1 PROFILNINE 4 tablet PROFILNINE SD 4 BENEFIX 4 INTRAVENOUS KIT

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

38 Drug Drug Drug Name Notes Drug Name Notes Tier Tier protamine sulfate hcl oral 1 1 intravenous hcl oral 1 RECOMBINATE 4 oral 1 RIASTAP 4 methyldopa- 1 RIXUBIS 4 hydrochlorothiazide tranexamic acid hcl 1 intravenous solution 1 injection 1000 mg/10ml phenylephrine hcl 1 tranexamic acid oral 1 intravenous solution VONVENDI 4 Alpha-adrenergic Blocking Agents

XYNTHA hcl 1 INTRAVENOUS KIT oral 4 1000 UNIT, 2000 UNIT, mesylate 250 UNIT, 500 UNIT injection solution 1 XYNTHA SOLOFUSE 4 reconstituted Platelet Modifying Agents hcl oral 1 AGGRASTAT Angiotensin II Receptor Antagonists INTRAVENOUS 3 amlodipine besylate- 1 CONCENTRATE valsartan AGGRASTAT amlodipine-olmesartan 1 INTRAVENOUS SOLUTION 12.5-0.9 3 amlodipine-valsartan- 1 MG/250ML-%, 5-0.9 hctz MG/100ML-% BYVALSON 2 aspirin-dipyridamole er 1 candesartan cilexetil 1 BRILINTA 2 candesartan cilexetil-hctz 1 cilostazol 1 eprosartan mesylate 1 clopidogrel bisulfate oral 1 irbesartan 1 1 dipyridamole oral irbesartan- 1 eptifibatide intravenous hydrochlorothiazide solution 20 mg/10ml, 200 1 losartan potassium 1 mg/100ml, 75 mg/100ml losartan potassium-hctz 1 prasugrel hcl 1 olmesartan medoxomil 1 ZONTIVITY 3 oral Cardiovascular Agents olmesartan medoxomil- 1 Alpha-adrenergic Agonists hctz clonidine 1 olmesartan-amlodipine- 1 hctz

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

39 Drug Drug Drug Name Notes Drug Name Notes Tier Tier telmisartan 1 Antiarrhythmics telmisartan-amlodipine 1 adenosine intravenous 1 telmisartan-hctz 1 solution 12 mg/4ml, 6 mg/2ml valsartan 1 amiodarone hcl 1 valsartan- 1 intravenous hydrochlorothiazide amiodarone hcl oral 1 Angiotensin-converting Enzyme (ACE) Inhibitors disopyramide phosphate 1 oral amlodipine besylate- 1 1 benazepril hcl dofetilide 1 benazepril hcl oral 1 flecainide acetate benazepril- ibutilide fumarate 1 1 hydrochlorothiazide lidocaine hcl (cardiac) 1 captopril oral 1 lidocaine in d5w 1 captopril- mexiletine hcl oral 1 1 hydrochlorothiazide MULTAQ 3 enalapril maleate oral 1 NORPACE CR ORAL enalaprilat 1 CAPSULE EXTENDED 2 enalapril- RELEASE 12 HOUR 100 1 hydrochlorothiazide MG fosinopril sodium 1 pacerone oral tablet 100 1 mg, 200 mg, 400 mg fosinopril sodium-hctz 1 procainamide hcl 1 lisinopril oral 1 injection lisinopril- 1 hcl 1 hydrochlorothiazide propafenone hcl er 1 moexipril hcl 1 gluconate er 1 perindopril erbumine 1 quinidine sulfate oral 1 quinapril hcl 1 sorine 1 quinapril- 1 hydrochlorothiazide hcl (af) 1 ramipril 1 sotalol hcl oral 1 Beta-adrenergic Blocking Agents trandolapril 1 1 trandolapril-verapamil hcl hcl oral 1 er oral 1 atenolol-chlorthalidone 1 hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

40 Drug Drug Drug Name Notes Drug Name Notes Tier Tier fumarate 1 cartia xt 1 1 bisoprolol- 1 diltiazem hcl er beads hydrochlorothiazide diltiazem hcl er coated 1 BYSTOLIC 2 beads 1 diltiazem hcl er oral carvedilol phosphate er 1 capsule extended 1 release 12 hour esmolol hcl intravenous 1 solution 100 mg/10ml diltiazem hcl er oral capsule extended 1 esmolol hcl-sodium 1 release 24 hour 120 mg, chloride 180 mg, 240 mg hcl intravenous diltiazem hcl intravenous 1 1 solution solution labetalol hcl oral 1 diltiazem hcl intravenous 1 succinate er 1 solution reconstituted metoprolol tartrate diltiazem hcl oral 1 intravenous solution 5 1 dilt-xr 1 mg/5ml felodipine er 1 metoprolol tartrate intravenous solution 1 isradipine 1 cartridge matzim la 1 1 metoprolol tartrate oral hcl 1 intravenous metoprolol- 1 hydrochlorothiazide nicardipine hcl oral 1 1 nifedipine er 1 1 hcl er nifedipine er osmotic 1 propranolol hcl release 1 intravenous nifedipine oral 1 propranolol hcl oral 1 nimodipine oral 1 propranolol-hctz 1 nisoldipine er 1 maleate oral 1 taztia xt 1 Calcium Channel Blocking Agents verapamil hcl er oral amlodipine besylate oral 1 capsule extended 1 release 24 hour amlodipine-atorvastatin 1 verapamil hcl er oral CARDIZEM LA ORAL tablet extended release 1 TABLET EXTENDED 3 120 mg, 180 mg, 240 mg RELEASE 24 HOUR 120 MG verapamil hcl intravenous 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

41 Drug Drug Drug Name Notes Drug Name Notes Tier Tier verapamil hcl oral 1 bumetanide oral 1 Cardiovascular Agents, Other ethacrynate sodium 1 DEMSER 3 ethacrynic acid oral 1 digitek 1 injection 1 digox 1 solution 10 mg/ml digoxin injection 1 furosemide oral solution 1 10 mg/ml, 8 mg/ml digoxin oral 1 furosemide oral tablet 1 hcl 1 intravenous torsemide oral 1 dobutamine in d5w 1 Diuretics, Potassium-sparing amiloride hcl oral 1 dopamine hcl 1 intravenous amiloride- 1 dopamine in d5w 1 hydrochlorothiazide DYRENIUM ORAL ENTRESTO 2 QL 3 CAPSULE 100 MG sulfate 1 intravenous solution eplerenone 1 epinephrine pf 1 spironolactone oral 1 mannitol intravenous spironolactone-hctz 1 1 solution 20 %, 25 % triamterene-hctz oral 1 hcl 1 capsule 37.5-25 mg milrinone lactate in triamterene-hctz oral 1 1 dextrose tablet Diuretics, Thiazide milrinone lactate chlorothiazide oral 1 intravenous solution 10 1 mg/10ml, 20 mg/20ml, 50 chlorothiazide sodium 1 mg/50ml chlorthalidone oral tablet 1 norepinephrine bitartrate 1 25 mg, 50 mg intravenous hydrochlorothiazide oral 1 osmitrol intravenous 1 1 solution 15 %, 20 % indapamide oral 1 er 1 methyclothiazide oral 1 ranolazine er 1 ST metolazone Dyslipidemics, Fibric Acid Derivatives TEKTURNA 2 ST 1 VECAMYL 3 choline fenofibrate Diuretics, Loop fenofibrate micronized 1 1 bumetanide injection 1 fenofibrate oral capsule

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

42 Drug Drug Drug Name Notes Drug Name Notes Tier Tier fenofibrate oral tablet 145 ezetimibe-simvastatin 1 PA mg, 160 mg, 48 mg, 54 1 oral tablet 10-80 mg mg JUXTAPID 4 PA; QL fenofibric acid 1 er 1 gemfibrozil oral 1 (antihyperlipidemic) Dyslipidemics, HMG CoA Reductase Inhibitors omega-3-acid ethyl 1 esters atorvastatin calcium oral 1 PV* tablet 10 mg, 20 mg prevalite 1 Vasodilators, Direct-acting Arterial atorvastatin calcium oral 1 tablet 40 mg, 80 mg hydralazine hcl injection 1 3 fluvastatin sodium hydralazine hcl oral 1 fluvastatin sodium er 3 minoxidil oral 1 LIVALO 3 ST Vasodilators, Direct-acting Arterial/Venous lovastatin 1 PV DILATRATE-SR 3 PRALUENT isosorbide dinitrate er 1 SUBCUTANEOUS 4 PA; QL 1 SOLUTION PEN- isosorbide dinitrate oral INJECTOR isosorbide mononitrate 1 pravastatin sodium 1 isosorbide mononitrate er 1 REPATHA 4 PA; QL minitran 1 NITRO-BID 3 REPATHA 4 PA; QL PUSHTRONEX SYSTEM nitroglycerin er oral REPATHA SURECLICK 4 PA; QL capsule extended 1 rosuvastatin calcium 1 release 2.5 mg nitroglycerin in d5w 1 simvastatin oral tablet 10 1 PV* mg, 20 mg, 40 mg, 5 mg nitroglycerin intravenous 1 simvastatin oral tablet 80 nitroglycerin sublingual 1 1 PA mg nitroglycerin transdermal 1 Dyslipidemics, Other patch 24 hour cholestyramine light 1 nitroglycerin translingual 1 cholestyramine oral 1 solution colesevelam hcl 1 NITROMIST 3 colestipol hcl 1 nitroprusside sodium 1 Central Nervous System Agents ezetimibe 1 Attention Deficit Hyperactivity Disorder Agents, ezetimibe-simvastatin Amphetamines oral tablet 10-10 mg, 10- 1 20 mg, 10-40 mg sulfate 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

43 Drug Drug Drug Name Notes Drug Name Notes Tier Tier amphetamine- PRIALT 4 1 PA; QL dextroamphetamine riluzole 1 PA; QL amphetamine- 1 PA; QL TEGSEDI 4 PA dextroamphetamine er tetrabenazine 4 PA dextroamphetamine 1 PA; QL Fibromyalgia Agents sulfate er SAVELLA 3 ST; QL dextroamphetamine 1 PA; QL sulfate oral SAVELLA TITRATION 3 ST; QL methamphetamine hcl 3 PA; QL PACK Multiple Sclerosis Agents VYVANSE 2 PA; QL 4 PA; QL zenzedi oral tablet 10 AUBAGIO 1 PA; QL mg, 5 mg AVONEX PEN Attention Deficit Hyperactivity Disorder Agents, INTRAMUSCULAR 4 PA; QL Non-amphetamines AUTO-INJECTOR KIT atomoxetine hcl 1 QL AVONEX PREFILLED INTRAMUSCULAR 4 PA; QL clonidine hcl er 1 PREFILLED SYRINGE DAYTRANA 3 ST; PA; QL KIT 1 PA; QL dexmethylphenidate hcl AVONEX VIAL 4 PA; QL INTRAMUSCULAR KIT dexmethylphenidate hcl 1 PA; QL er BETASERON 4 PA; QL guanfacine hcl er 1 SUBCUTANEOUS KIT COPAXONE metadate er oral tablet 1 PA; QL extended release 20 mg SUBCUTANEOUS 4 PA; QL SOLUTION PREFILLED methylphenidate hcl er 1 PA; QL SYRINGE methylphenidate hcl er 1 PA; QL dalfampridine er 4 PA; QL (cd) GILENYA 4 PA; QL methylphenidate hcl er 1 PA; QL 4 PA; QL (la) glatiramer acetate 4 PA; QL methylphenidate hcl oral 1 PA; QL glatopa 4 PA; QL QUILLIVANT XR 3 ST; PA; QL TECFIDERA 4 PA; QL relexxii 1 PA; QL TYSABRI Central Nervous System, Other Dental and Oral Agents 1 caffeine citrate 1 cavarest 1 intravenous 1 cevimeline hcl GRALISE 3 ST; QL chlorhexidine gluconate 1 mouth/throat GRALISE STARTER 3 ST; QL clinpro 5000 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

44 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEBACTEROL 3 benzoyl peroxide- 1 denta 5000 plus 1 erythromycin dentagel 1 calcipotriene external 1 fluoridex 1 calcitrene 1 fluoridex daily renewal 1 calcitriol external 1 claravis 1 PA fluoridex enhanced 1 whitening dental paste clindacin etz external 1 swab fluoridex sensitivity relief 1 dental paste clindacin-p 1 1 neutral sodium fluoride clindamycin phosphate- 1 oralone 1 benzoyl peroxide clindamycin phosphate paroex 1 1 external foam periogard 1 clindamycin phosphate 1 pilocarpine hcl oral 1 external lotion prevident mouth/throat 1 clindamycin phosphate 1 sf 1 external solution 1 sf 5000 plus clindamycin phosphate 1 topex topical anesthetic external swab 1 mouth/throat aerosol clindamycin phosphate 1 triamcinolone acetonide gel 1 % external 1 mouth/throat clindamycin-tretinoin 1 Dermatological Agents coal tar external solution 1 acitretin 1 colocort 1 adapalene external 1 PA CONDYLOX EXTERNAL 3 cream GEL adapalene external gel 1 PA CORTIFOAM 3 4 PA adapalene-benzoyl 1 COSENTYX 150 MG/ML peroxide COSENTYX 300 DOSE 4 PA ammonium lactate 1 COSENTYX external SENSOREADY 300 4 PA amnesteem 1 PA DOSE ana-lex 1 COSENTYX avita 1 PA SENSOREADY PEN SUBCUTANEOUS 4 PA 1 azelaic acid external SOLUTION AUTO- AZELEX 3 INJECTOR 150 MG/ML

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

45 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dapsone external 1 rosadan external gel 1 3 doxepin hcl external salicylic acid external 1 doxycycline 1 cream DUPIXENT SANTYL 3 SUBCUTANEOUS 4 PA; QL selenium sulfide external 1 SOLUTION PREFILLED lotion SYRINGE 300 MG/2ML silver nitrate external 1 EPIDUO FORTE 3 ointment ery 1 STELARA SUBCUTANEOUS erythromycin external 1 4 PA SOLUTION 45 FINACEA EXTERNAL 3 MG/0.5ML FOAM STELARA hydrocortisone rectal 1 SUBCUTANEOUS 4 PA imiquimod external 1 SOLUTION PREFILLED isotretinoin oral 1 PA SYRINGE lactic acid e 1 sulfacetamide sodium 1 (acne) lactic acid external lotion 1 TACLONEX EXTERNAL lidocaine-hydrocortisone 3 QL 1 SUSPENSION ace rectal cream tacrolimus external 1 methoxsalen oral 1 tazarotene external 1 methoxsalen rapid 1 TAZORAC EXTERNAL 3 metronidazole external 1 CREAM 0.05 % MIRVASO 2 TAZORAC EXTERNAL 3 myorisan 1 PA GEL neuac external gel 1 TREMFYA pimecrolimus 1 SUBCUTANEOUS 4 PA SOLUTION PREFILLED podofilox external 1 SYRINGE procto-med hc 1 tretinoin external 1 PA procto-pak 1 tretinoin microsphere 1 PA proctosol hc 1 tretinoin microsphere 1 PA proctozone-hc rectal 1 pump 1 urea external cream 40 pyrogallic acid 1 RECTIV 3 % 1 PA REGRANEX 3 PA zenatane rosadan external cream 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

46 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Electrolytes/Minerals/Metals/Vitamins hemocyte-plus oral tablet 1 Electrolyte/Mineral Replacement 106-1 mg calcium chloride 1 iferex 150 forte 1 iodine strong oral 1 calcium gluconate 1 intravenous solution ISOLYTE-S 3 chromagen oral capsule 1 kcl in d5w lactated 1 ringers chromic chloride 1 intravenous kcl in dextrose-nacl corvita 150 1 intravenous solution 10- 5-0.45 meq/l-%-%, 20-5- dehydrated alcohol 1 0.2 meq/l-%-%, 20-5- injection 0.225 meq/l-%-%, 20-5- dextrose in lactated 1 1 0.33 meq/l-%-%, 20-5- ringers 0.45 meq/l-%-%, 20-5- dextrose intravenous 0.9 meq/l-%-%, 30-5- solution 10 %, 20 %, 250 0.45 meq/l-%-%, 40-5- 1 mg/ml, 30 %, 40 %, 5 %, 0.45 meq/l-%-%, 40-5- 50 %, 70 % 0.9 meq/l-%-% dextrose-nacl kcl-lactated ringers-d5w 1 intravenous solution 10- klor-con 10 1 0.2 %, 10-0.225 %, 10- klor-con m10 1 0.45 %, 2.5-0.45 %, 5-0.2 1 %, 5-0.225 %, 5-0.3 %, KLOR-CON M15 3 5-0.33 %, 5-0.45 %, 5- klor-con m20 1 0.9 % klor-con oral packet 20 1 effer-k oral tablet 1 meq effervescent 25 meq klor-con oral tablet 1 ferocon 1 extended release ferotrinsic 1 klor-con sprinkle 1 ferrocite plus oral tablet 1 klor-con/ef 1 foltrin 1 k-prime 1 glucose intravenous 1 k-tan plus 1 hematinic plus 1 lactated ringers 1 vit/minerals intravenous hematinic/folic acid 1 magnesium chloride 1 hematogen 1 injection hematogen forte 1 magnesium sulfate in d5w intravenous solution 1 1 hemocyte-f oral tablet 1-5 gm/100ml-%

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

47 Drug Drug Drug Name Notes Drug Name Notes Tier Tier magnesium sulfate potassium chloride oral 1 injection solution 50 % solution 20 meq/15ml 1 magnesium sulfate (10%), 40 meq/15ml intravenous solution 2 (20%) 1 gm/50ml, 20 gm/500ml, 4 potassium chloride 1 gm/100ml, 4 gm/50ml, 40 proamp gm/1000ml potassium citrate er 1 na ferric gluc cplx in 1 purevit dualfe plus 1 sucrose ringers 1 phosphorous 1 se-tan plus 1 PLASMA-LYTE 148 3 sod citrate-citric acid 1 PLASMA-LYTE A 3 sodium bicarbonate poly-iron 150 forte 1 intravenous solution 4.2 1 polysaccharide iron forte 1 %, 7.5 %, 8.4 % pot bicarb-pot chloride 1 sodium chloride injection 1 potassium acetate sodium chloride 1 intravenous solution 2 intravenous solution 0.45 1 meq/ml %, 0.9 %, 3 %, 4 meq/ml, 5 % potassium chloride crys 1 er sodium fluoride oral 1 PV potassium chloride er 1 sodium lactate potassium chloride in intravenous solution 5 1 dextrose intravenous meq/ml 1 solution 20-5 meq/l-%, sodium phosphates 40-5 meq/l-% intravenous solution 45 1 potassium chloride in mmole/15ml nacl intravenous solution tl icon 1 1 20-0.45 meq/l-%, 20-0.9 tl-hem 150 1 meq/l-%, 40-0.9 meq/l-% tpn electrolytes 1 potassium chloride intravenous solution intravenous solution 0.4 tricon 1 meq/ml, 10 meq/100ml, 1 10 meq/50ml, 2 meq/ml, trigels-f forte 1 20 meq/100ml, 20 virt-phos 250 neutral 1 meq/50ml, 40 meq/100ml Electrolyte/Mineral/Metal Modifiers potassium chloride oral 1 3 packet CHEMET CUPRIMINE ORAL 4 PA CAPSULE 250 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

48 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEPEN TITRATABS 2 fabb 1 3 PA EXJADE fa-vitamin b-6-vitamin b- 1 12 FERRIPROX ORAL 4 PA TABLET folbee 1 JADENU 3 PA folbee plus 1 JADENU SPRINKLE 3 PA folic acid injection 1 kionex oral suspension 1 folic acid oral tablet 1 mg 1 2 QL SAMSCA folic acid oral tablet 400 1 PV mcg, 800 mcg sodium polystyrene 1 sulfonate oral folplex 2.2 1 1 PV sodium polystyrene 1 gnp folic acid sulfonate rectal hydroxocobalamin 1 sps 1 acetate trientine hcl 4 PA lysiplex plus oral tablet 1 VELTASSA 3 multi prenatal 1 PV Vitamins multi-vit/iron/fluoride 1 adc/f (0.5mg/ml) 1 multivitamin/fluoride oral 1 airavite 1 solution multi-vitamin/fluoride oral ascorbic acid injection 1 1 solution b-6 folic acid 1 multivitamin/fluoride oral 1 biocel tablet chewable 0.25 mg, 1 bp vit 3 1 0.5 mg, 1 mg b-plex 1 multivitamin/fluoride/iron 1 b-plex plus 1 multi-vitamin/fluoride/iron 1 cod liver oil oral oil 1 multivitamins/fluoride oral 1 corvita 1 tablet chewable 0.5 mg corvite free 1 mvc-fluoride 1 mynephron 1 cyanocobalamin injection 1 solution 1000 mcg/ml NASCOBAL 3 1 decara oral capsule 1 nephronex oral tablet 50000 unit nufol 1 1 dexifol nutrifac zx 1 1 dialyvite ONE-A-DAY WOMENS 3 PV ergocalciferol oral 1 PRENATAL 1 capsule

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

49 Drug Drug Drug Name Notes Drug Name Notes Tier Tier phytonadione injection vitamin b complex 100 1 1 solution 1 mg/0.5ml vitamin d (ergocalciferol) 1 phytonadione oral 1 oral capsule 50000 unit pnv prenatal plus 1 vitamin k1 injection multivit+dha solution 1 mg/0.5ml, 10 1 prenatal multi +dha 1 PV mg/ml vitamins acd-fluoride 1 prenatal oral tablet 27- 1 PV 0.8 mg vol-care rx 1 1 prenatal oral tablet 27-1 1 vp-vite rx mg Gastrointestinal Agents prenatal plus iron 1 Antispasmodics, Gastrointestinal pyridoxine hcl injection 1 ATROPEN quflora pediatric oral INTRAMUSCULAR 1 solution 0.25 mg/ml SOLUTION AUTO- 3 quflora pediatric oral INJECTOR 0.5 tablet chewable 0.5 mg, 1 MG/0.7ML 1 mg atropine sulfate injection 1 RAYALDEE 3 solution 8 mg/20ml renal oral capsule 1 atropine sulfate injection 1 solution prefilled syringe sodium acetate intravenous solution 2 1 chlordiazepoxide- 1 meq/ml clidinium 3 thiamine hcl injection 1 CUVPOSA dicyclomine hcl tl gard rx 1 1 intramuscular triphrocaps 1 dicyclomine hcl oral 1 tri-vitamin/fluoride 1 ed-spaz 1 tri-vite/fluoride 1 glycopyrrolate injection 1 urosex 1 solution v-c forte 1 glycopyrrolate oral tablet 1 vic-forte 1 1 mg, 2 mg virt-caps 1 hyoscyamine sulfate oral 1 virt-gard 1 hyoscyamine sulfate sl 1 1 vita s forte hyoscyamine sulfate 1 vitacel 1 sublingual vitamax pediatric 1 methscopolamine 1 bromide oral vita-min 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

50 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nulev 1 famotidine intravenous oscimin 1 solution 20 mg/2ml, 200 1 mg/20ml, 40 mg/4ml propantheline bromide 1 oral famotidine oral 1 suspension reconstituted Gastrointestinal Agents, Other famotidine oral tablet 20 1 amoxicill-clarithro- 1 mg, 40 mg lansopraz famotidine premixed 1 CHOLBAM 4 PA nizatidine 1 cromolyn sodium oral 1 ranitidine hcl injection 1 diphenoxylate-atropine solution 150 mg/6ml, 50 1 GATTEX 4 PA mg/2ml 1 loperamide hcl oral 1 ranitidine hcl oral capsule capsule ranitidine hcl oral syrup 1 hcl ranitidine hcl oral tablet 1 1 injection 150 mg, 300 mg metoclopramide hcl oral Irritable Bowel Syndrome Agents solution 10 mg/10ml, 5 1 mg/5ml hcl 1 PA AMITIZA 2 ST; QL metoclopramide hcl oral 1 tablet LINZESS 2 ST; QL Laxatives metoclopramide hcl oral 1 tablet dispersible bisacodyl ec 1 PV; QL OCALIVA 4 PA; QL cascara sagrada oral 1 OMECLAMOX-PAK 2 fluid extract PYLERA 2 clearlax oral powder 1 PV; QL RELISTOR ORAL 3 PA; QL constulose 1 RELISTOR enulose 1 SUBCUTANEOUS 3 PA; QL ex-lax ultra 1 PV; QL SOLUTION 12 1 PV; QL MG/0.6ML, 8 MG/0.4ML gavilax oral powder 1 PV; QL sodium bicarbonate oral gavilyte-c 1 powder gavilyte-g 1 PV; QL ursodiol oral 1 gavilyte-h 1 Histamine2 (H2) receptor Antagonists gavilyte-n with flavor 1 PV; QL cimetidine hcl oral 1 pack cimetidine oral 1 generlac 1 gentle laxative oral 1 PV; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

51 Drug Drug Drug Name Notes Drug Name Notes Tier Tier glycolax 1 PV; QL Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment lactulose encephalopathy 1 4 PA lactulose oral 1 ALDURAZYME CARBAGLU 4 magnesium citrate oral 1 PV; QL solution 1.745 gm/30ml CERDELGA 4 PA mineral oil heavy oral 1 CEREZYME MOVIPREP 3 INTRAVENOUS SOLUTION 4 PA OSMOPREP 3 RECONSTITUTED 400 peg 3350/electrolytes 1 PV; QL UNIT CREON 2 peg 3350-kcl-na bicarb- 1 PV; QL nacl CYSTADANE 4 peg-3350/electrolytes 1 PV; QL ELAPRASE 4 PA peg-prep 1 KANUMA 4 PA PREPOPIK 3 KUVAN 4 PA SUPREP BOWEL PREP 3 LUMIZYME 4 PA KIT MEPSEVII 4 PA trilyte 1 PV; QL miglustat 4 PA Protectants MYALEPT 4 PA CARAFATE ORAL 3 SUSPENSION NAGLAZYME 4 PA misoprostol oral 1 ORFADIN 4 PA sucralfate oral tablet 1 RAVICTI 4 PA Proton Pump Inhibitors sod benz-sod phenylacet 1 DEXILANT ORAL sodium phenylbutyrate 4 CAPSULE DELAYED 2 QL oral powder 3 gm/tsp RELEASE 60 MG sodium phenylbutyrate 4 esomeprazole sodium 1 oral tablet lansoprazole oral 1 QL STRENSIQ 4 PA SUCRAID 4 omeprazole oral capsule 1 QL delayed release VIMIZIM 4 PA 4 PA pantoprazole sodium 1 QL XIAFLEX intravenous pantoprazole sodium oral 1 QL rabeprazole sodium 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

52 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZENPEP ORAL finasteride oral tablet 5 1 CAPSULE DELAYED mg RELEASE PARTICLES 1 10000-32000 UNIT, tadalafil oral tablet 2.5 15000-47000 UNIT, 2 1 PA; QL 20000-63000 UNIT, mg, 5 mg 25000-79000 UNIT, hcl 1 3000-14000 UNIT, hcl oral 1 40000-126000 UNIT, Genitourinary Agents, Other 5000-24000 UNIT Genitourinary Agents acetic acid irrigation 1 Antispasmodics, Urinary aminoacetic acid 1 argyle sterile saline 1 darifenacin hydrobromide 1 er bethanechol chloride oral 1 flavoxate hcl 1 CYSTAGON 4 GELNIQUE PUMP 3 ELMIRON 2 GELNIQUE glycine irrigation 1 3 TRANSDERMAL GEL 10 glycine urologic 1 % neomycin-polymyxin b gu 1 MYRBETRIQ 2 phenazo oral tablet 200 1 1 oxybutynin chloride er mg 1 oxybutynin chloride oral phenazopyridine hcl oral 1 tolterodine tartrate 1 tablet 100 mg, 200 mg tolterodine tartrate er 1 RENACIDIN 3 TOVIAZ 3 sodium chloride irrigation 1 trospium chloride 1 solution 0.9 % trospium chloride er 1 sorbitol irrigation solution 1 3.3 % VESICARE 2 sorbitol-mannitol 1 Benign Prostatic Hypertrophy Agents vcf vaginal contraceptive 1 1 PV; QL hcl er vaginal gel CARDURA XL ORAL Phosphate Binders TABLET EXTENDED 3 ST RELEASE 24 HOUR 4 calcium acetate (phos 1 MG binder) FOSRENOL ORAL mesylate oral 1 3 PACKET dutasteride oral 1 lanthanum carbonate 1 dutasteride-tamsulosin 1 hcl PHOSLYRA 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

53 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sevelamer carbonate 1 DEPO-MEDROL sevelamer hcl 1 INJECTION 3 SUSPENSION 20 VELPHORO 3 MG/ML Hormonal Agents, desonide external 1 Stimulant/Replacement/Modifying (Adrenal) desoximetasone external 1 ala-cort external cream 1 DEXAMETHASONE 3 alclometasone 1 INTENSOL dipropionate dexamethasone oral 1 amcinonide 1 dexamethasone sod 1 betamethasone 1 phosphate pf dipropionate aug dexamethasone sodium betamethasone 1 1 phosphate injection dipropionate external diflorasone diacetate 1 betamethasone sod phos external & acet injection 1 suspension 6 (3-3) mg/ml fludrocortisone acetate 1 oral betamethasone valerate 1 external fluocinolone acetonide 1 body CAPEX 3 fluocinolone acetonide 1 clobetasol prop emollient 1 external base fluocinolone acetonide 1 1 clobetasol propionate e scalp clobetasol propionate fluocinonide emulsified 1 1 emulsion base clobetasol propionate 1 fluocinonide external 1 external fluticasone propionate 1 1 clocortolone pivalate external clocortolone pivalate halobetasol propionate 1 1 pump external cream clodan external shampoo 1 halobetasol propionate 1 CORDRAN EXTERNAL 3 external ointment TAPE hydrocortisone butyr lipo 1 cortisone acetate oral 1 base deltasone 1 hydrocortisone butyrate 1 external hydrocortisone external 1 cream 1 %, 2.5 %

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

54 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydrocortisone external triamcinolone acetonide 1 lotion 2.5 % injection suspension 40 1 mg/ml hydrocortisone external 1 ointment 1 %, 2.5 % triderm external cream 1 hydrocortisone oral 1 Hormonal Agents, Stimulant/Replacement/Modifying hydrocortisone valerate 1 (Pituitary) methylprednisolone 1 acetate injection 1 chorionic gonadotropin suspension 40 mg/ml, 80 4 PA mg/ml intramuscular 1 desmopressin ace spray methylprednisolone oral 1 methylprednisolone refrig sodium succ injection desmopressin acetate 1 1 solution reconstituted injection 1000 mg, 125 mg, 40 mg desmopressin acetate 1 oral mometasone furoate 1 external desmopressin acetate 1 prednicarbate 1 spray HP ACTHAR 4 PA prednisolone oral 1 solution INCRELEX 4 PA prednisolone sodium NORDITROPIN phosphate oral solution FLEXPRO 10 mg/5ml, 15 mg/5ml, 1 SUBCUTANEOUS 4 PA 20 mg/5ml, 25 mg/5ml, SOLUTION 10 6.7 (5 base) mg/5ml MG/1.5ML, 30 MG/3ML, prednisolone sodium 5 MG/1.5ML phosphate oral tablet 1 novarel intramuscular dispersible solution reconstituted 4 PA 10000 unit PREDNISONE 2 INTENSOL NUTROPIN AQ NUSPIN 4 PA prednisone oral 1 10

SOLU-CORTEF NUTROPIN AQ NUSPIN 4 PA INJECTION SOLUTION 20 3 RECONSTITUTED 1000 NUTROPIN AQ NUSPIN 4 PA MG 5 TEXACORT 3 oxytocin injection 1 triamcinolone acetonide 1 pregnyl 4 PA external

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

55 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Hormonal Agents, Suppressant (Pituitary) enanthate 1 PA intramuscular solution leuprolide acetate 4 PA injection testosterone transdermal gel 12.5 mg/act (1%), LUPRON DEPOT (1- 4 PA MONTH) 20.25 mg/1.25gm (1.62%), 20.25 mg/act 1 PA LUPRON DEPOT (3- 4 PA (1.62%), 25 mg/2.5gm MONTH) (1%), 40.5 mg/2.5gm LUPRON DEPOT (4- (1.62%), 50 mg/5gm MONTH) 4 PA (1%) INTRAMUSCULAR KIT testosterone transdermal 1 PA 30MG solution LUPRON DEPOT (6- Estrogens MONTH) 4 PA INTRAMUSCULAR KIT altavera 1 PV 45MG alyacen 1/35 1 PV ZOLADEX alyacen 7/7/7 1 PV SUBCUTANEOUS 4 QL amabelz 1 IMPLANT 3.6 MG amethia 1 PV; QL Hormonal Agents, Stimulant/Replacement/Modifying amethia lo 1 PV; QL (Prostaglandins) apri 1 PV alprostadil injection 1 aranelle 1 PV KORLYM 4 PA; QL ashlyna 1 PV; QL Hormonal Agents, aubra 1 PV Stimulant/Replacement/Modifying (Sex aubra eq 1 PV Hormones/Modifiers) aviane 1 PV Anabolic Steroids azurette 1 PV ANADROL-50 3 PA balziva 1 PV oxandrolone oral 1 PA; QL bekyree 1 PV Androgens blisovi 24 fe 1 PV danazol oral 1 blisovi fe 1.5/30 1 PV METHITEST 3 PA blisovi fe 1/20 1 PV methyltestosterone oral 1 PA briellyn 1 PV STRIANT 3 PA camrese 1 PV; QL testosterone cypionate intramuscular solution 1 PA camrese lo 1 PV; QL 100 mg/ml, 200 mg/ml caziant 1 PV chateal 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

56 Drug Drug Drug Name Notes Drug Name Notes Tier Tier chateal eq 1 PV fayosim 1 PV; QL COMBIPATCH 3 femynor 1 PV cryselle-28 1 PV fyavolv 1 cyclafem 1/35 1 PV gianvi 1 PV cyclafem 7/7/7 1 PV hailey 24 fe 1 PV cyred 1 PV introvale 1 PV; QL cyred eq 1 PV isibloom 1 PV dasetta 1/35 1 PV jasmiel 1 PV dasetta 7/7/7 1 PV jinteli 1 daysee 1 PV; QL jolessa 1 PV; QL delyla 1 PV juleber 1 PV 1 PV desogestrel-ethinyl 1 PV junel 1.5/30 estradiol junel 1/20 1 PV drospiren-eth estrad- 1 PV junel fe 1.5/30 1 PV levomefol junel fe 1/20 1 PV drospirenone-ethinyl 1 PV estradiol junel fe 24 1 PV DUAVEE 2 kaitlib fe 1 PV elinest 1 PV kariva 1 PV emoquette 1 PV kelnor 1/35 1 PV enpresse-28 1 PV kelnor 1/50 1 PV enskyce oral tablet 0.15- kurvelo 1 PV 1 PV 30 mg-mcg larin 1.5/30 1 PV estarylla 1 PV larin 1/20 1 PV estradiol oral 1 larin 24 fe 1 PV estradiol transdermal 1 larin fe 1.5/30 1 PV estradiol vaginal 1 larin fe 1/20 1 PV estradiol valerate larissia 1 PV 1 intramuscular oil 20 layolis fe 1 PV mg/ml, 40 mg/ml leena 1 PV estradiol-norethindrone 1 acet lessina 1 PV ethynodiol diac-eth levonest 1 PV 1 PV estradiol levonorgest-eth est & eth 1 PV; QL EVAMIST 3 est falmina 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

57 Drug Drug Drug Name Notes Drug Name Notes Tier Tier levonorgest-eth estrad norethindrone acet- 1 PV; QL 1 PV 91-day ethinyl est levonorgestrel-ethinyl 1 PV norethindrone-eth 1 estrad estradiol 1 PV levonorg-eth estrad 1 PV norethin-eth estradiol-fe triphasic norgestimate-eth levora 0.15/30 (28) 1 PV estradiol oral tablet 0.25- 1 PV lillow 1 PV 35 mg-mcg norgestimate-ethinyl LO LOESTRIN FE 3 1 PV estradiol triphasic lopreeza 1 nortrel 0.5/35 (28) 1 PV loryna 1 PV nortrel 1/35 (21) 1 PV low-ogestrel 1 PV nortrel 1/35 (28) 1 PV lutera 1 PV nortrel 7/7/7 1 PV marlissa 1 PV NUVARING 2 PV melodetta 24 fe 1 PV ocella 1 PV MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 2 ogestrel 1 PV MG orsythia 1 PV mibelas 24 fe 1 PV philith 1 PV microgestin 1.5/30 1 PV pimtrea 1 PV microgestin 1/20 1 PV pirmella 1/35 1 PV microgestin fe 1.5/30 1 PV pirmella 7/7/7 1 PV microgestin fe 1/20 1 PV portia-28 1 PV mili 1 PV PREMARIN ORAL 2 mimvey 1 PREMPHASE 2 mimvey lo 1 PREMPRO 2 mono-linyah 1 PV previfem 1 PV mononessa 1 PV reclipsen 1 PV myzilra 1 PV rivelsa 1 PV; QL NATAZIA 2 PV setlakin 1 PV; QL necon 0.5/35 (28) 1 PV sprintec 28 1 PV nikki 1 PV sronyx 1 PV 1 PV norethin ace-eth estrad- 1 PV syeda fe tarina fe 1/20 1 PV tarina fe 1/20 eq 1 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

58 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tilia fe 1 PV DEPO-PROVERA tri femynor 1 PV INTRAMUSCULAR 3 SUSPENSION 400 tri-estarylla 1 PV MG/ML tri-legest fe 1 PV DEPO-SUBQ PROVERA 1 PV tri-linyah 104 SUBCUTANEOUS 3 QL tri-lo-estarylla 1 PV SUSPENSION PREFILLED SYRINGE tri-lo-marzia 1 PV errin 1 PV tri-lo-sprintec 1 PV heather 1 PV tri-mili 1 PV hydroxyprogesterone tri-previfem 1 PV caproate intramuscular 4 PA tri-sprintec 1 PV oil trivora (28) 1 PV incassia 1 PV tri-vylibra 1 PV jencycla 1 PV tri-vylibra lo 1 PV jolivette 1 PV tydemy 1 PV KYLEENA 4 PV 1 PV velivet levonorgestrel oral tablet 1 PV vienva 1 PV 1.5 mg viorele 1 PV LILETTA (52 MG) INTRAUTERINE 4 PV vyfemla 1 PV INTRAUTERINE vylibra 1 PV DEVICE 19.5 MCG/DAY wera 1 PV lyza 1 PV 1 PV MAKENA wymzya fe 4 PA xulane 1 PV SUBCUTANEOUS medroxyprogesterone yuvafem 1 1 PV; QL acetate intramuscular zarah 1 PV medroxyprogesterone 1 zovia 1/35e (28) 1 PV acetate oral Progesterone Agonists/Antagonists megestrol acetate oral ELLA 3 PV suspension 40 mg/ml, 1 Progestins 400 mg/10ml, 625 mg/5ml camila 1 PV megestrol acetate oral 1 PV 1 deblitane tablet MIRENA (52 MG) 3 PV NEXPLANON 3 PV

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

59 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nora-be 1 PV THYROLAR-1/2 ORAL TABLET 30 (6.25-25) 3 norethindrone acetate 1 oral MG (MCG) norethindrone oral 1 PV THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) 3 norlyda 1 PV MG (MCG) norlyroc 1 PV THYROLAR-2 ORAL preventeza 1 PV TABLET 120 (25-100) 3 MG (MCG) progesterone 1 intramuscular THYROLAR-3 ORAL TABLET 180 (37.5-150) 3 progesterone micronized 1 oral MG (MCG) 1 sharobel 1 PV unithroid 3 SKYLA 3 PV WP THYROID Hormonal Agents, Suppressant (Adrenal) tulana 1 PV Selective Estrogen Receptor Modifying Agents LYSODREN 2 Hormonal Agents, Suppressant (pituitary) OSPHENA 3 4 PA; QL raloxifene hcl 1 PV* LUPANETA PACK Hormonal Agents, LUPRON DEPOT-PED 4 PA Stimulant/Replacement/Modifying (Thyroid) (1-MONTH) ARMOUR THYROID 3 LUPRON DEPOT-PED 4 PA (3-MONTH) euthyrox 1 octreotide acetate levo-t 1 injection solution 100 mcg/ml, 1000 mcg/ml, 4 PA levothyroxine sodium 1 intravenous 200 mcg/ml, 50 mcg/ml, levothyroxine sodium oral 1 500 mcg/ml 4 PA; QL levothyroxine-liothyronine 1 SIGNIFOR 4 PA levoxyl 1 SOMATULINE DEPOT SOMAVERT 4 PA liothyronine sodium 1 intravenous SUPPRELIN LA 4 PA; QL liothyronine sodium oral 1 SYNAREL 2 np thyroid 1 Hormonal Agents, Suppressant (Thyroid) THYROLAR-1 ORAL Antithyroid Agents TABLET 60 (12.5-50) 3 methimazole oral 1 MG (MCG) propylthiouracil oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

60 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Immunological Agents HUMIRA PEN Angioedema Agents SUBCUTANEOUS PEN- 4 PA INJECTOR KIT BERINERT 4 PA HUMIRA PEN- 4 PA 4 PA CINRYZE CD/UC/HS STARTER FIRAZYR 4 PA HUMIRA PEN- 4 PA Immune Suppressants PS/UV/ADOL HS START AZASAN 3 HUMIRA SUBCUTANEOUS azathioprine oral 1 4 PA PREFILLED SYRINGE 1 azathioprine sodium KIT 4 PA CIMZIA PREFILLED KIT KINERET CIMZIA STARTER KIT 4 PA SUBCUTANEOUS 4 PA CIMZIA VIAL KIT 4 PA SOLUTION PREFILLED SYRINGE cyclosporine intravenous 1 methotrexate (anti- 1 1 cyclosporine modified rheumatic) 1 cyclosporine oral capsule methotrexate oral 1 4 PA ENBREL MINI methotrexate sodium (pf) ENBREL injection solution 1 1 SUBCUTANEOUS 4 PA gm/40ml, 250 mg/10ml, SOLUTION PREFILLED 50 mg/2ml SYRINGE methotrexate sodium ENBREL injection solution 250 1 SUBCUTANEOUS 4 PA mg/10ml, 50 mg/2ml SOLUTION methotrexate sodium RECONSTITUTED injection solution 1 ENBREL SURECLICK reconstituted SUBCUTANEOUS 4 PA methotrexate sodium oral 1 SOLUTION AUTO- INJECTOR mycophenolate mofetil 1 gengraf oral capsule 100 mycophenolate mofetil 1 1 mg, 25 mg hcl gengraf oral solution 1 mycophenolate sodium 1 HUMIRA PEDIATRIC ORENCIA CLICKJECT 4 PA CROHNS START ORENCIA 4 PA SUBCUTANEOUS INTRAVENOUS PREFILLED SYRINGE 4 PA KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

61 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORENCIA carimune nf solution 4 PA SUBCUTANEOUS 4 PA reconstituted 6 gm SOLUTION PREFILLED intravenous SYRINGE CUVITRU 4 PA PROGRAF 3 CYTOGAM 4 PA INTRAVENOUS FLEBOGAMMA DIF 4 PA REMICADE 4 PA GAMASTAN 4 PA SANDIMMUNE ORAL 2 SOLUTION GAMASTAN S/D INTRAMUSCULAR 4 PA SIMPONI ARIA 4 PA INJECTABLE SIMPONI GAMMAGARD 4 PA SUBCUTANEOUS 4 PA GAMMAGARD S/D SOLUTION AUTO- 4 PA INJECTOR LESS IGA SIMPONI GAMMAKED 4 PA SUBCUTANEOUS 4 PA GAMMAPLEX SOLUTION PREFILLED INTRAVENOUS SYRINGE SOLUTION 10 sirolimus oral 1 GM/100ML, 10 4 PA GM/200ML, 20 STELARA 4 PA GM/200ML, 20 INTRAVENOUS GM/400ML, 5 tacrolimus oral 1 GM/100ML, 5 GM/50ML TREXALL 3 GAMUNEX-C 4 PA ZORTRESS 3 PA HEPAGAM B 4 Immunizing Agents, Passive HIZENTRA ATGAM 4 SUBCUTANEOUS SOLUTION 1 GM/5ML, 4 PA 4 PA BIVIGAM 10 GM/50ML, 2 CARIMUNE NF GM/10ML, 4 GM/20ML SOLUTION 4 PA HYPERHEP B S/D 4 RECONSTITUTED 12 GM INTRAVENOUS HYPERRHO S/D INTRAMUSCULAR 4 carimune nf solution SOLUTION PREFILLED 4 PA reconstituted 12 gm SYRINGE intravenous HYQVIA 4 PA CARIMUNE NF SOLUTION 4 PA RECONSTITUTED 6 GM INTRAVENOUS

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

62 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MICRHOGAM ULTRA- XELJANZ 4 PA FILTERED PLUS XELJANZ XR 4 PA INTRAMUSCULAR 4 Vaccines SOLUTION PREFILLED SYRINGE ACTHIB 2 PV NABI-HB 4 ADACEL OCTAGAM 4 PA INTRAMUSCULAR 2 PV SUSPENSION 5-2-15.5 PRIVIGEN 4 PA LF-MCG/0.5 RHOGAM ULTRA- AFLURIA 2 PV FILTERED PLUS INTRAMUSCULAR 4 AFLURIA SOLUTION PREFILLED PRESERVATIVE FREE 2 PV SYRINGE INTRAMUSCULAR SUSPENSION RHOPHYLAC PREFILLED SYRINGE INJECTION SOLUTION 4 PREFILLED SYRINGE AFLURIA 2 PV QUADRIVALENT SYNAGIS 4 PA BEXSERO 2 PV THYMOGLOBULIN 3 BOOSTRIX WINRHO SDF 4 INTRAMUSCULAR 2 PV Immunomodulators SUSPENSION 5-2.5- ACTEMRA 4 PA 18.5 LF-MCG/0.5 ACTEMRA ACTPEN 4 PA DAPTACEL INTRAMUSCULAR 2 PV ACTIMMUNE 4 PA SUSPENSION 23-15-5 ALFERON N 4 DIPHTHERIA-TETANUS 2 PV ARCALYST 4 PA TOXOIDS DT ILARIS ENGERIX-B INJECTION SUBCUTANEOUS 4 PA; QL SUSPENSION 10 2 PV SOLUTION MCG/0.5ML, 20 MCG/ML 4 PA KEVZARA ENGERIX-B 2 PV leflunomide oral 1 INTRAMUSCULAR OTEZLA ORAL TABLET 4 PA EZ FLU SHOT- 2 PV FLUCELVAX QUAD OTEZLA ORAL TABLET 4 PA 2 PV THERAPY PACK FLUAD SIMULECT FLUARIX INTRAVENOUS QUADRIVALENT 2 PV SOLUTION 3 INTRAMUSCULAR RECONSTITUTED 20 SUSPENSION MG PREFILLED SYRINGE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

63 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLUBLOK KINRIX 2 PV QUADRIVALENT INTRAMUSCULAR 2 PV SUSPENSION FLUCELVAX 2 PV QUADRIVALENT MENACTRA 2 PV FLULAVAL MENVEO 2 PV QUADRIVALENT 2 PV M-M-R II 2 PV INTRAMUSCULAR SUSPENSION PEDIARIX 2 PV FLULAVAL PEDVAX HIB QUADRIVALENT INTRAMUSCULAR 2 PV INTRAMUSCULAR 2 PV SUSPENSION SUSPENSION PENTACEL 2 PV PREFILLED SYRINGE PNEUMOVAX 23 2 PV FLUMIST 2 PREVNAR 13 2 PV QUADRIVALENT PROQUAD FLUZONE HIGH-DOSE SUBCUTANEOUS 2 PV INTRAMUSCULAR 2 PV SUSPENSION SUSPENSION RECONSTITUTED PREFILLED SYRINGE QUADRACEL 2 PV FLUZONE QUADRIVALENT RECOMBIVAX HB 2 PV INTRAMUSCULAR INJECTION SUSPENSION , 0.5 ML SUSPENSION 10 2 PV MCG/ML, 40 MCG/ML, 5 FLUZONE MCG/0.5ML QUADRIVALENT INTRAMUSCULAR 2 PV ROTARIX 2 PV SUSPENSION ROTATEQ ORAL 2 PV PREFILLED SYRINGE SOLUTION GARDASIL 9 2 PV SHINGRIX HAVRIX INTRAMUSCULAR INTRAMUSCULAR SUSPENSION 2 PV 2 PV SUSPENSION 1440 EL RECONSTITUTED 50 U/ML, 720 EL U/0.5ML MCG/0.5ML HEPLISAV-B 2 PV TDVAX 2 PV HIBERIX INJECTION 2 PV TENIVAC 2 PV INFANRIX 2 PV TRUMENBA 2 PV TWINRIX 2 PV IPOL INJECTION 2 PV INJECTABLE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

64 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VAQTA doxercalciferol 1 INTRAMUSCULAR 2 PV intravenous SUSPENSION 25 etidronate disodium 1 UNIT/0.5ML, 50 UNIT/ML FORTEO VARIVAX 2 PV SUBCUTANEOUS 4 PA ZOSTAVAX SOLUTION 600 SUBCUTANEOUS 2 PV MCG/2.4ML SUSPENSION FOSAMAX PLUS D 3 QL RECONSTITUTED HECTOROL Inflammatory Bowel Disease Agents INTRAVENOUS 3 Aminosalicylates SOLUTION 2 MCG/ML APRISO 2 ibandronate sodium balsalazide disodium 1 intravenous solution 3 1 QL mg/3ml DIPENTUM 3 ibandronate sodium oral 1 QL mesalamine oral tablet 1 delayed release 1.2 gm MIACALCIN INJECTION 3 mesalamine rectal 1 pamidronate disodium 1 mesalamine-cleanser 1 paricalcitol 1 PENTASA 3 PROLIA 4 PA; QL Glucocorticoids risedronate sodium oral 1 QL tablet 150 mg, 35 mg budesonide er oral tablet 1 extended release 24 hour risedronate sodium oral 1 tablet 30 mg, 5 mg budesonide oral 1 risedronate sodium oral Sulfonamides 1 QL tablet delayed release 1 sulfasalazine oral SENSIPAR 3 PA Metabolic Bone Disease Agents XGEVA 4 PA alendronate sodium oral 1 zoledronic acid solution 4 intravenous concentrate alendronate sodium oral zoledronic acid tablet 10 mg, 40 mg, 5 1 4 intravenous solution mg Miscellaneous Therapeutic Agents alendronate sodium oral 1 QL tablet 35 mg, 70 mg albumin human 1 calcitonin (salmon) 1 QL albumin-zlb 1 alburx 1 calcitriol intravenous 1 solution 1 mcg/ml albutein intravenous 1 calcitriol oral 1 solution 25 %

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

65 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ALCOHOL PREP PADS FLEXICHAMBER CHILD 3 2 PAD , 70 % MASK/SMALL 1 aminosyn ii/electrolytes fomepizole intravenous 1 aminosyn/electrolytes solution 1.5 gm/1.5ml intravenous solution 8.5 1 GOODSENSE % CLICKFINE PEN 2 argyle sterile water 1 NEEDLE GOODSENSE PEN asilnasal rms 1 2 NEEDLE PENFINE bacteriostatic water(benz 1 alc) heparin lock flush intravenous solution 1 1 bal in oil 1 unit/ml, 10 unit/ml, 100 bd posiflush intravenous 1 unit/ml benzalkonium chloride heparin sodium flush 1 external solution , 50 % intravenous kit 100-0.9 1 BREATHE EASE LARGE 2 unit/ml-% BREATHE EASE heparin sodium lock flush 2 1 MEDIUM intravenous solution 100 unit/ml BREATHE EASE SMALL 2 hetastarch-nacl 1 BREATHERITE 2 INSPIREASE 2 CAYA 3 PV; QL RESERVOIR BAGS chlorhexidine gluconate 1 INSULIN PEN NEEDLES solution 20 % 29G X 12.7MM , 29G X 1 clinisol sf 12MM , 30G X 8 MM , 2 31G X 5 MM , 31G X 6 COMFORT EZ MICRO 2 PEN NEEDLES MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM COMFORT EZ SHORT 2 PEN NEEDLES INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G deferoxamine mesylate 1 X 1/2" 1 ML, 29G 0.3 ML, EASIVENT 2 29G X 1/2" 1 ML, 30G X EASY TOUCH SAFETY 1/2" 0.5 ML, 30G X 1/2" 1 2 PEN NEEDLES ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G 2 FEMCAP 3 PV; QL X 5/16" 1 ML, 31G X FLEXICHAMBER ADULT 15/64" 0.3 ML, 31G X 2 MASK/SMALL 15/64" 0.5 ML, 31G X FLEXICHAMBER CHILD 5/16" 0.3 ML, 31G X 2 MASK/LARGE 5/16" 0.5 ML, 31G X 5/16" 1 ML

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

66 Drug Drug Drug Name Notes Drug Name Notes Tier Tier intralipid intravenous PARAGARD 1 emulsion 20 % INTRAUTERINE 3 PV COPPER J-TIP KIT W/VIAL 3 ADAPTERS PEDIATRIC PANDA 2 kedbumin 1 MASK lactated ringers irrigation 1 physiolyte 1 levocarnitine oral solution 1 physiosol irrigation 1 levocarnitine oral tablet 1 plenamine 1 MASK VORTEX 2 POCKET SPACER 2 MAXI-COMFORT pralidoxime chloride 2 1 SAFETY PEN NEEDLE intramuscular solution auto-injector methergine oral 1 premasol intravenous methylergonovine 1 1 solution 6 % maleate injection PRO COMFORT monoject flush syringe 2 1 SPACER ADULT intravenous PRO COMFORT monoject sodium chloride 2 1 SPACER CHILD flush intravenous ringers irrigation 1 n-acetyl-l-cysteine oral 1 saline flush intravenous 1 normal saline flush 1 intravenous saline flush zr 1 NOVOFINE saline-benzyl alcohol 1 2 AUTOCOVER PEN sash kit intravenous kit 1 NEEDLE 100-0.9 unit/ml-%

NOVOFINE PEN 2 sodium chloride 1 NEEDLE 32G X 6 MM bacteriostatic NOVOFINE PLUS PEN sodium chloride flush 1 2 NEEDLE sodium nitrite 1 NOVOTWIST PEN intravenous 2 NEEDLE 32G X 5 MM sodium saccharin powder 1 nutrilipid intravenous 1 sodium thiosulfate emulsion 20 % intravenous solution 25 1 PANDA MASK LARGE 2 % 2 PANDA MASK MEDIUM sterile 1 PANDA MASK SMALL 2 diluent/epoprostenol sterile water for injection 1 sterile water for irrigation 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

67 Drug Drug Drug Name Notes Drug Name Notes Tier Tier swabflush saline flush 1 neomycin-bacitracin zn- 1 tis-u-sol 1 polymyx neomycin-polymyxin- TRUE COMFORT 3 ALCOHOL PREP PADS dexameth ophthalmic 1 ointment TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 2 neomycin-polymyxin- 12.7MM dexameth ophthalmic 1 suspension 3.5-10000- ULTRACARE PEN 2 0.1 NEEDLES neomycin-polymyxin-hc VISTOGARD 3 ophthalmic suspension 1 WIDE-SEAL 3.5-10000-1 3 PV; QL DIAPHRAGM 60 neo-polycin 1 Ophthalmic Agents neo-polycin hc 1 Aminoglycosides polycin 1 gentak ophthalmic 1 polymyxin b-trimethoprim 1 ointment Anti-cytomegalovirus (CMV) Agents gentamicin sulfate 1 ophthalmic solution ZIRGAN 3 neomycin-polymyxin- Antifungals gramicidin ophthalmic 1 NATACYN 2 solution 1.75-10000-.025 Antiherpetic Agents TOBRADEX trifluridine ophthalmic 1 OPHTHALMIC 3 Macrolides OINTMENT 3 TOBRADEX ST 3 AZASITE 1 tobramycin ophthalmic 1 erythromycin ophthalmic Ophthalmic Prostaglandin and Prostamide tobramycin- 1 Analogs dexamethasone 1 QL TOBREX OPHTHALMIC bimatoprost ophthalmic 3 OINTMENT latanoprost ophthalmic 1 QL Antibacterials, Other LUMIGAN 2 QL bacitracin ophthalmic 1 OPHTHALMIC SOLUTION 0.01 % bacitracin-polymyxin b 2 QL ophthalmic ointment 500- 1 TRAVATAN Z 10000 unit/gm ZIOPTAN 3 QL Ophthalmic Agents, Other bacitra-neomycin- 1 polymyxin-hc altacaine 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

68 Drug Drug Drug Name Notes Drug Name Notes Tier Tier atropine sulfate Ophthalmic Antiglaucoma Agents 1 ophthalmic acetazolamide er 1 cyclopentolate hcl 1 acetazolamide oral 1 ophthalmic acetazolamide sodium 1 CYSTARAN 4 PA; QL ALPHAGAN P homatropaire 1 OPHTHALMIC 2 SOLUTION 0.1 % homatropine hbr 1 ophthalmic hcl 1 OMIDRIA 3 AZOPT 2 proparacaine hcl 1 betaxolol hcl ophthalmic 1 ophthalmic BETIMOL 3 RESTASIS 2 PA tartrate 1 RESTASIS MULTIDOSE 2 PA ophthalmic tetcaine 1 hcl 1 tetracaine hcl ophthalmic 1 COMBIGAN 2 tropicamide ophthalmic dorzolamide hcl 1 1 solution 0.5 % ophthalmic XIIDRA 2 PA dorzolamide hcl-timolol 1 Ophthalmic Anti-allergy Agents mal 3 ALOCRIL dorzolamide hcl-timolol 1 ALOMIDE 3 mal pf IOPIDINE OPHTHALMIC altafrin ophthalmic 1 3 solution 10 %, 2.5 % SOLUTION 1 % azelastine hcl ophthalmic 1 KEVEYIS 4 PA; QL BEPREVE 3 ST hcl ophthalmic solution 0.5 1 cromolyn sodium 1 % ophthalmic methazolamide oral 1 EMADINE 3 PHOSPHOLINE IODIDE 2 epinastine hcl 1 pilocarpine hcl LASTACAFT 3 ST ophthalmic solution 1 %, 1 2 %, 4 % olopatadine hcl 1 ophthalmic SIMBRINZA 2 PAZEO 2 timolol maleate 1 phenylephrine hcl ophthalmic ophthalmic solution 10 1 Ophthalmic Anti-inflammatories %, 2.5 % ACUVAIL 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

69 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ALREX 3 CILOXAN OPHTHALMIC 3 OINTMENT bromfenac sodium (once- 1 QL daily) ciprofloxacin hcl 1 ophthalmic dexamethasone sodium 1 phosphate ophthalmic gatifloxacin ophthalmic 1 1 diclofenac sodium 1 levofloxacin ophthalmic ophthalmic MOXEZA 2 DUREZOL 3 moxifloxacin hcl 1 FLAREX 3 ophthalmic 1 fluorometholone 1 ofloxacin ophthalmic ophthalmic Sulfonamides flurbiprofen sodium 1 sulfacetamide sodium 1 FML 2 ophthalmic ILEVRO 3 QL Otic Agents ILUVIEN INTRAVITREAL 4 acetic acid otic 1 ketorolac tromethamine CIPRO HC 3 1 ophthalmic CIPRODEX 2 LOTEMAX 3 QL ciprofloxacin hcl otic 1 OPHTHALMIC GEL COLY-MYCIN S 3 LOTEMAX 1 OPHTHALMIC 3 QL flac fluocinolone acetonide OINTMENT 1 LOTEMAX otic 3 OPHTHALMIC hydrocortisone-acetic 1 SUSPENSION acid 3 LOTEMAX SM neomycin-polymyxin-hc 1 NEVANAC 3 QL otic 1 PRED MILD 2 ofloxacin otic Respiratory Tract/Pulmonary Agents prednisolone acetate 1 ophthalmic Antihistamines prednisolone sodium azelastine hcl nasal 1 QL 1 phosphate ophthalmic brompheniramine sulfacetamide- tannate oral tablet 1 prednisolone ophthalmic 1 chewable solution carbinoxamine maleate 1 Quinolones oral solution BESIVANCE 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

70 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carbinoxamine maleate flunisolide nasal solution 1 1 QL oral tablet 4 mg 25 mcg/act (0.025%) 1 cetirizine hcl oral solution fluticasone propionate 1 nasal clemastine fumarate oral 3 tablet 2.68 mg fluticasone- hcl oral 1 inhalation aerosol powder breath activated 1 QL desloratadine 1 100-50 mcg/dose, 250- 50 mcg/dose, 500-50 hcl 1 injection mcg/dose FLUTICASONE- diphenhydramine hcl oral 1 elixir SALMETEROL hcl INHALATION AEROSOL 1 intramuscular POWDER BREATH 1 QL ACTIVATED 113-14 hydroxyzine hcl oral 1 MCG/ACT, 232-14 syrup MCG/ACT, 55-14 hydroxyzine hcl oral MCG/ACT 1 tablet mometasone furoate 1 QL nasal hydroxyzine pamoate 1 oral OMNARIS 3 QL levocetirizine 1 PULMICORT 2 QL dihydrochloride oral FLEXHALER olopatadine hcl nasal 1 QL SYMBICORT 2 QL ryvent 1 wixela inhub 1 QL TUZISTRA XR ORAL Antileukotrienes SUSPENSION 3 PA; QL 1 EXTENDED RELEASE montelukast sodium oral Anti-inflammatories, Inhaled Corticosteroids zafirlukast 1 1 ST ADVAIR HFA 2 QL zileuton er Bronchodilators, Anticholinergic ARNUITY ELLIPTA 2 QL 2 QL BECONASE AQ 3 QL ANORO ELLIPTA 3 QL BEVESPI ATROVENT HFA 3 ST; QL AEROSPHERE COMBIVENT RESPIMAT 2 QL BREO ELLIPTA 2 QL INCRUSE ELLIPTA 2 QL 1 QL budesonide inhalation ipratropium bromide 1 QL DYMISTA 2 QL inhalation ipratropium bromide FLOVENT DISKUS 2 QL 1 nasal FLOVENT HFA 2 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

71 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ipratropium-albuterol 1 QL isoproterenol hcl injection 1 SPIRIVA HANDIHALER 2 QL levalbuterol hcl inhalation SPIRIVA RESPIMAT nebulization solution 0.31 INHALATION AEROSOL mg/3ml, 0.63 mg/3ml, 1 QL SOLUTION 1.25 2 QL 1.25 mg/0.5ml, 1.25 MCG/ACT, 2.5 mg/3ml MCG/ACT metaproterenol sulfate 1 STIOLTO RESPIMAT oral INHALATION AEROSOL PERFOROMIST 3 QL 2 QL SOLUTION 2.5-2.5 PROAIR HFA 2 M; QL MCG/ACT PROAIR RESPICLICK 2 QL Bronchodilators, Sympathomimetic SEREVENT DISKUS 2 QL albuterol sulfate er 1 STRIVERDI RESPIMAT 3 ST; QL albuterol sulfate 1 QL sulfate inhalation 1 injection albuterol sulfate oral 1 terbutaline sulfate oral 1 ARCAPTA NEOHALER 3 ST; QL VENTOLIN HFA 2 M; QL AUVI-Q INJECTION Cystic Fibrosis Agents SOLUTION AUTO- 3 QL INJECTOR 0.1 BETHKIS 4 MG/0.1ML CAYSTON 4 PA 3 QL BROVANA KALYDECO 4 PA EPINEPHRINE Made by ORKAMBI 4 PA; QL INJECTION SOLUTION 1 Impax; M 0.3 MG/0.3ML PULMOZYME 4 PA EPINEPHRINE tobramycin nebulization Made by solution 300 mg/5ml 4 ST INJECTION SOLUTION 1 AUTO-INJECTOR 0.15 Impax; M inhalation MG/0.15ML Mast Cell Stabilizers

EPINEPHRINE cromolyn sodium 1 Made by inhalation INJECTION SOLUTION 1 AUTO-INJECTOR 0.15 Mylan Phosphodiesterase Inhibitors, Airways Disease MG/0.3ML aminophylline 1 EPINEPHRINE intravenous SOLUTION AUTO- Made by 1 DALIRESP ORAL INJECTOR 0.3 Mylan 3 PA MG/0.3ML INJECTION TABLET 500 MCG 1 epinephrine solution difil-g forte auto-injector 0.3 1 ELIXOPHYLLIN 2 mg/0.3ml injection

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

72 Drug Drug Drug Name Notes Drug Name Notes Tier Tier THEO-24 3 acetylcysteine 1 theochron oral tablet intravenous extended release 12 hour 1 ARALAST NP 100 mg, 200 mg, 300 mg INTRAVENOUS theophylline 1 SOLUTION 4 PA RECONSTITUTED 1000 theophylline er 1 MG, 500 MG theophylline in d5w benzonatate 1 intravenous solution 0.8- 1 5 mg/ml-% DUPIXENT SUBCUTANEOUS Pulmonary Antihypertensives SOLUTION PREFILLED 4 PA; QL ADEMPAS 4 PA; QL SYRINGE 200 alyq 4 PA; QL MG/1.14ML epoprostenol sodium 4 PA GLASSIA 4 PA LETAIRIS 4 PA; QL HYDROCODONE- 3 PA; QL GUAIFENESIN OPSUMIT 4 PA; QL hydrocodone- 4 PA 1 PA; QL ORENITRAM homatropine 4 PA REMODULIN hydromet 1 PA; QL sildenafil citrate nebusal inhalation 4 PA 1 intravenous nebulization solution 3 % sildenafil citrate oral 4 PA; QL NUCALA 4 PA; QL tablet 20 mg PROLASTIN-C 4 PA; QL tadalafil (pah) INTRAVENOUS TRACLEER 4 PA; QL SOLUTION 4 PA treprostinil sodium 4 PA RECONSTITUTED 1000 MG TYVASO 4 PA; QL pulmosal 1 TYVASO REFILL 4 PA; QL ribavirin inhalation 4 TYVASO STARTER 4 PA; QL sodium chloride UPTRAVI 4 PA; QL inhalation nebulization 1 VELETRI 4 PA solution 0.9 %, 10 %, 3 VENTAVIS 4 PA; QL %, 7 % Pulmonary Fibrosis Agents XOLAIR 4 PA ESBRIET 4 PA ZEMAIRA 4 PA OFEV 4 PA Skeletal Muscle Relaxants Respiratory Tract Agents, Other atracurium besylate intravenous solution 100 1 1 acetylcysteine inhalation mg/10ml, 50 mg/5ml

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

73 Drug Drug Drug Name Notes Drug Name Notes Tier Tier oral 1 hcl in 1 nacl chlorzoxazone oral tablet 1 500 mg dexmedetomidine hcl intravenous solution 200 1 cisatracurium besylate 1 (pf) mcg/2ml cisatracurium besylate HETLIOZ 4 PA; QL intravenous solution 20 1 1 PA; QL mg/10ml sodium 1 hcl er 1 injection cyclobenzaprine hcl oral 1 ROZEREM 3 QL metaxall 1 SILENOR 3 QL metaxalone 1 methocarbamol injection 1 solution 1000 mg/10ml methocarbamol oral 1 orphenadrine citrate er 1 orphenadrine citrate 1 injection pancuronium bromide intravenous solution 1 1 mg/ml rocuronium bromide 1 intravenous solution succinylcholine chloride 1 injection vecuronium bromide intravenous solution 1 reconstituted Sleep Disorder Agents GABA Receptor Modulators 1 QL 1 QL tartrate 1 QL zolpidem tartrate er 1 QL Sleep Disorders, Other 1 PA; QL BELSOMRA 3 ST; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

74 Index of Drugs abacavir sulfate...... 33 adrucil...... 26 amabelz...... 56 abacavir sulfate-lamivudine 33 ADVAIR HFA...... 71 amantadine hcl...... 34 abacavir-lamivudine- ADVATE...... 38 AMBISOME...... 24 zidovudine...... 33 AFINITOR...... 28 amcinonide...... 54 ABELCET...... 24 AFINITOR DISPERZ...... 28 amethia...... 56 ABILIFY MAINTENA...... 31 AFLURIA...... 63 amethia lo...... 56 abiraterone acetate...... 26 AFLURIA amikacin sulfate...... 16 ABRAXANE...... 27 PRESERVATIVE FREE...... 63 amiloride hcl...... 42 acamprosate calcium...... 16 AFLURIA amiloride- acarbose...... 35 QUADRIVALENT...... 63 hydrochlorothiazide...... 42 ACCU-CHEK FASTCLIX AGGRASTAT...... 39 aminoacetic acid...... 53 LANCET KIT...... 34 airavite...... 49 aminocaproic acid...... 38 ACCU-CHEK FASTCLIX AKYNZEO...... 23 aminophylline...... 72 LANCETS...... 34 ala-cort...... 54 aminosyn ii/electrolytes...... 66 ACCU-CHEK MULTICLIX albendazole...... 30 aminosyn/electrolytes...... 66 LANCET DEVICE KIT...... 34 albumin human...... 65 amiodarone hcl...... 40 ACCU-CHEK MULTICLIX albumin-zlb...... 65 AMITIZA...... 51 LANCETS...... 34 alburx...... 65 amitriptyline hcl...... 23 ACCU-CHEK SOFT albutein...... 65 amlodipine besylate...... 41 TOUCH LANCETS...... 35 albuterol sulfate...... 72 amlodipine besylate- ACCU-CHEK SOFTCLIX albuterol sulfate er...... 72 benazepril hcl...... 40 LANCET DEVICE KIT...... 35 alclometasone amlodipine besylate- ACCU-CHEK SOFTCLIX dipropionate...... 54 valsartan...... 39 LANCETS...... 35 ALCOHOL PREP PADS..... 66 amlodipine-atorvastatin...... 41 acebutolol hcl...... 40 ALDURAZYME...... 52 amlodipine-olmesartan...... 39 acetaminophen-codeine..... 13 alendronate sodium...... 65 amlodipine-valsartan-hctz...39 acetaminophen-codeine #2 13 alfentanil hcl...... 13 ammonium lactate...... 45 acetaminophen-codeine #3 13 ALFERON N...... 63 amnesteem...... 45 acetaminophen-codeine #4 13 alfuzosin hcl er...... 53 amoxapine...... 23 acetazolamide...... 69 ALIMTA...... 26 amoxicill-clarithro- acetazolamide er...... 69 ALINIA...... 30 lansopraz...... 51 acetazolamide sodium...... 69 allopurinol...... 24 amoxicillin...... 19 acetic acid...... 53, 70 allopurinol sodium...... 24 amoxicillin-potassium acetylcysteine...... 73 almotriptan malate...... 25 clavulanate...... 19 acitretin...... 45 ALOCRIL...... 69 amoxicillin-potassium ACTEMRA...... 63 ALOMIDE...... 69 clavulanate er...... 19 ACTEMRA ACTPEN...... 63 alosetron hcl...... 51 amphetamine sulfate...... 43 ACTHIB...... 63 ALPHAGAN P...... 69 amphetamine- ACTIMMUNE...... 63 ALPHANATE/VWF dextroamphetamine...... 44 ACTOPLUS MET XR...... 35 COMPLEX/HUMAN...... 38 amphetamine- ACUVAIL...... 69 ALPHANINE SD...... 38 dextroamphetamine er...... 44 acyclovir...... 32 alprazolam...... 34 amphotericin b...... 24 acyclovir sodium...... 32 alprazolam er...... 34 ampicillin...... 19 ADACEL...... 63 alprazolam xr...... 34 ampicillin sodium...... 19 adapalene...... 45 alprostadil...... 56 ampicillin-sulbactam adapalene-benzoyl ALREX...... 70 sodium...... 19 peroxide...... 45 ALTABAX...... 16 ANADROL-50...... 56 adc/f (0.5mg/ml)...... 49 altacaine...... 68 anagrelide hcl...... 38 ADCETRIS...... 29 altafrin...... 69 ana-lex...... 45 adefovir dipivoxil...... 32 altavera...... 56 anastrozole...... 28 ADEMPAS...... 73 alyacen 1/35...... 56 ANORO ELLIPTA...... 71 adenosine...... 40 alyacen 7/7/7...... 56 anticoagulant cit dext soln adriamycin...... 27 alyq...... 73 a...... 37 75 anticoagulant sodium AUGMENTIN...... 19 benzoyl peroxide- citrate...... 37 AUVI-Q...... 72 erythromycin...... 45 ANZEMET...... 23 AVANDIA...... 35 benztropine mesylate...... 30 apap-caff-dihydrocodeine... 14 AVASTIN...... 29 BEPREVE...... 69 APLENZIN...... 22 AVELOX...... 20 BERINERT...... 61 APOKYN...... 30 aviane...... 56 BESIVANCE...... 70 apraclonidine hcl...... 69 avidoxy...... 20 betamethasone aprepitant...... 23 avita...... 45 dipropionate...... 54 apri...... 56 AVONEX PEN...... 44 betamethasone APRISO...... 65 AVONEX PREFILLED...... 44 dipropionate aug...... 54 APTIVUS...... 33 AVONEX VIAL betamethasone sod phos ARALAST NP...... 73 INTRAMUSCULAR KIT..... 44 & acet...... 54 aranelle...... 56 azacitidine...... 27 betamethasone valerate..... 54 ARCALYST...... 63 AZACTAM IN DEXTROSE. 19 BETASERON...... 44 ARCAPTA NEOHALER...... 72 AZASAN...... 61 betaxolol hcl...... 40, 69 argatroban...... 37 AZASITE...... 68 bethanechol chloride...... 53 argatroban in sodium azathioprine...... 61 BETHKIS...... 72 chloride...... 37 azathioprine sodium...... 61 BETIMOL...... 69 argyle sterile saline...... 53 azelaic acid...... 45 BEVESPI AEROSPHERE.. 71 argyle sterile water...... 66 azelastine hcl...... 69, 70 BEVYXXA...... 37 aripiprazole...... 31 AZELEX...... 45 bexarotene...... 30 armodafinil...... 74 azithromycin...... 19 BEXSERO...... 63 ARMOUR THYROID...... 60 AZOPT...... 69 bicalutamide...... 26 ARNUITY ELLIPTA...... 71 aztreonam...... 19 BICILLIN L-A...... 19 ARRANON...... 26 azurette...... 56 BIKTARVY...... 33 arsenic trioxide...... 27 b-6 folic acid...... 49 bimatoprost...... 68 ARZERRA...... 29 baciim...... 16 biocel...... 49 ascomp-codeine...... 14 bacitracin...... 16, 68 bisacodyl ec...... 51 ascorbic acid...... 49 bacitracin-polymyxin b...... 68 bisoprolol fumarate...... 41 ashlyna...... 56 bacitra-neomycin- bisoprolol- asilnasal rms...... 66 polymyxin-hc...... 68 hydrochlorothiazide...... 41 aspirin...... 12 baclofen...... 32 bivalirudin trifluoroacetate...37 aspirin adult...... 12 bacteriostatic water(benz BIVIGAM...... 62 aspirin childrens...... 12 alc)...... 66 bleomycin sulfate...... 27 aspirin ec low dose...... 12 bal in oil...... 66 BLINCYTO...... 29 aspirin low dose...... 12 balsalazide disodium...... 65 blisovi 24 fe...... 56 aspirin-dipyridamole er...... 39 balziva...... 56 blisovi fe 1.5/30...... 56 atazanavir sulfate...... 33 BANZEL...... 21 blisovi fe 1/20...... 56 atenolol...... 40 BARACLUDE...... 32 BOOSTRIX...... 63 atenolol-chlorthalidone...... 40 BAVENCIO...... 29 BOSULIF...... 28 ATGAM...... 62 bayer aspirin...... 12 BOTOX...... 32 atomoxetine hcl...... 44 bayer aspirin ec low dose... 12 bp vit 3...... 49 atorvastatin calcium...... 43 bd posiflush...... 66 b-plex...... 49 atovaquone...... 30 BECONASE AQ...... 71 b-plex plus...... 49 atovaquone-proguanil hcl... 30 bekyree...... 56 BREATHE EASE LARGE... 66 atracurium besylate...... 73 BELSOMRA...... 74 BREATHE EASE MEDIUM.66 ATRIPLA...... 33 benazepril hcl...... 40 BREATHE EASE SMALL... 66 ATROPEN...... 50 benazepril- BREATHERITE...... 66 atropine sulfate...... 50, 69 hydrochlorothiazide...... 40 BREO ELLIPTA...... 71 ATROVENT HFA...... 71 BENEFIX...... 38 briellyn...... 56 AUBAGIO...... 44 benzalkonium chloride...... 66 BRILINTA...... 39 aubra...... 56 BENZNIDAZOLE...... 30 brimonidine tartrate...... 69 aubra eq...... 56 benzonatate...... 73 BRIVIACT...... 20

76 bromfenac sodium (once- camila...... 59 cefotetan disodium- daily)...... 70 CAMPTOSAR...... 28 dextrose...... 18 bromocriptine mesylate...... 30 camrese...... 56 cefoxitin sodium...... 18 brompheniramine tannate...70 camrese lo...... 56 cefoxitin sodium-dextrose... 18 BROVANA...... 72 candesartan cilexetil...... 39 cefpodoxime proxetil...... 18 budesonide...... 65, 71 candesartan cilexetil-hctz... 39 cefprozil...... 18 budesonide er...... 65 CAPASTAT SULFATE...... 25 ceftazidime...... 18 bumetanide...... 42 capecitabine...... 26 ceftazidime and dextrose....18 bupivacaine hcl...... 15 CAPEX...... 54 ceftriaxone sodium...... 18 bupivacaine hcl (pf)...... 15 CAPRELSA...... 28 ceftriaxone sodium in bupivacaine in dextrose...... 15 captopril...... 40 dextrose...... 18 bupivacaine spinal...... 15 captopril- ceftriaxone sodium- bupivacaine-epinephrine.....15 hydrochlorothiazide...... 40 dextrose...... 18 bupivacaine-epinephrine CARAFATE...... 52 cefuroxime axetil...... 18 (pf)...... 15 CARBAGLU...... 52 cefuroxime sodium...... 18, 19 buprenorphine...... 13 carbamazepine...... 21 celecoxib...... 12 BUPRENORPHINE...... 13 carbamazepine er...... 21 CELONTIN...... 21 buprenorphine hcl...... 13, 16 carbidopa...... 31 cephalexin...... 19 buprenorphine hcl- carbidopa-levodopa...... 31 CEPROTIN...... 37 naloxone hcl...... 16 carbidopa-levodopa er...... 31 CERDELGA...... 52 bupropion hcl...... 22 carbidopa-levodopa- CEREZYME...... 52 bupropion hcl er (smoking entacapone...... 31 CESAMET...... 23 det)...... 16 carbinoxamine maleate.70, 71 cetirizine hcl...... 71 bupropion hcl er (sr)...... 22 carboplatin...... 25 cevimeline hcl...... 44 bupropion hcl er (xl)...... 22 CARDIZEM LA...... 41 CHANTIX...... 16 buspirone hcl...... 34 CARDURA XL...... 53 CHANTIX CONTINUING busulfan...... 25 CARIMUNE NF...... 62 MONTH PAK...... 16 butalbital-acetaminophen....12 carimune nf...... 62 CHANTIX STARTING butalbital-apap...... 12 carisoprodol...... 74 MONTH PAK...... 16 butalbital-apap-caff-cod...... 14 carmustine...... 25 chateal...... 56 butalbital-apap-caffeine...... 12 carteolol hcl...... 69 chateal eq...... 57 butalbital-asa-caff-codeine..14 cartia xt...... 41 CHEMET...... 48 butalbital-aspirin-caffeine....12 carvedilol...... 41 CHEMSTRIP UGK...... 35 butorphanol tartrate...... 14 carvedilol phosphate er...... 41 chloramphenicol sod BUTRANS...... 13 cascara sagrada...... 51 succinate...... 16 BYDUREON...... 35 caspofungin acetate...... 24 chlordiazepoxide hcl...... 34 BYDUREON BCISE cavarest...... 44 chlordiazepoxide- AUTOINJECTOR...... 35 CAYA...... 66 amitriptyline...... 23 BYETTA 10 MCG PEN...... 35 CAYSTON...... 72 chlordiazepoxide-clidinium..50 BYETTA 5 MCG PEN...... 35 caziant...... 56 chlorhexidine gluconate 44, 66 BYSTOLIC...... 41 cefaclor...... 18 chloroprocaine hcl (pf)...... 15 BYVALSON...... 39 cefaclor er...... 18 chloroquine phosphate...... 30 cabergoline...... 55 cefadroxil...... 18 chlorothiazide...... 42 CABOMETYX...... 28 cefazolin sodium...... 18 chlorothiazide sodium...... 42 caffeine citrate...... 44 cefazolin sodium-dextrose.. 18 chlorpromazine hcl...... 31 calcipotriene...... 45 cefdinir...... 18 chlorpropamide...... 35 calcitonin (salmon)...... 65 cefditoren pivoxil...... 18 chlorthalidone...... 42 calcitrene...... 45 cefepime hcl...... 18 chlorzoxazone...... 74 calcitriol...... 45, 65 cefepime-dextrose...... 18 CHOLBAM...... 51 calcium acetate (phos cefixime...... 18 cholestyramine...... 43 binder)...... 53 cefotaxime sodium...... 18 cholestyramine light...... 43 calcium chloride...... 47 cefotetan disodium...... 18 choline fenofibrate...... 42 calcium gluconate...... 47 chorionic gonadotropin...... 55

77 chromagen...... 47 clocortolone pivalate...... 54 corvita...... 49 chromic chloride...... 47 clocortolone pivalate pump. 54 corvita 150...... 47 ciclodan...... 24 clodan...... 54 corvite free...... 49 ciclopirox...... 24 clofarabine...... 26 COSENTYX 150 MG/ML.... 45 ciclopirox olamine...... 24 clomipramine hcl...... 23 COSENTYX 300 DOSE...... 45 cidofovir...... 32 clonazepam...... 21 COSENTYX cilostazol...... 39 clonidine...... 39 SENSOREADY 300 DOSE.45 CILOXAN...... 70 clonidine hcl...... 39 COSENTYX CIMDUO...... 33 clonidine hcl er...... 44 SENSOREADY PEN...... 45 cimetidine...... 51 clopidogrel bisulfate...... 39 COTELLIC...... 27 cimetidine hcl...... 51 clorazepate dipotassium..... 34 CREON...... 52 CIMZIA...... 61 clotrimazole...... 24 CRESEMBA...... 24 CIMZIA PREFILLED KIT.... 61 clotrimazole- CRIXIVAN...... 33 CIMZIA STARTER KIT...... 61 betamethasone...... 24 cromolyn sodium.....51, 69, 72 CINRYZE...... 61 clozapine...... 31, 32 crotan...... 30 CIPRO...... 20 COAGADEX...... 38 cryselle-28...... 57 CIPRO HC...... 70 coal tar...... 45 CUPRIMINE...... 48 CIPRODEX...... 70 COARTEM...... 30 CUVITRU...... 62 ciprofloxacin...... 20 cod liver oil...... 49 CUVPOSA...... 50 ciprofloxacin hcl...... 20, 70 codeine sulfate...... 14 cyanocobalamin...... 49 ciprofloxacin in d5w...... 20 COLCHICINE...... 24 cyclafem 1/35...... 57 ciprofloxacin-ciproflox hcl colchicine-probenecid...... 24 cyclafem 7/7/7...... 57 er...... 20 COLCRYS...... 24 cyclobenzaprine hcl...... 74 cisatracurium besylate...... 74 colesevelam hcl...... 43 cyclobenzaprine hcl er...... 74 cisatracurium besylate (pf)..74 colestipol hcl...... 43 cyclopentolate hcl...... 69 cisplatin...... 26 colistimethate sodium cyclophosphamide...... 26 citalopram hydrobromide.... 22 (cba)...... 17 cycloserine...... 25 cladribine...... 26 colocort...... 45 CYCLOSET...... 35 claravis...... 45 COLY-MYCIN S...... 70 cyclosporine...... 61 clarithromycin...... 19 COMBIGAN...... 69 cyclosporine modified...... 61 clarithromycin er...... 19 COMBIPATCH...... 57 cyproheptadine hcl...... 71 clearlax...... 51 COMBIVENT RESPIMAT... 71 cyred...... 57 clemastine fumarate...... 71 COMETRIQ (100 MG cyred eq...... 57 clindacin etz...... 45 DAILY DOSE)...... 28 CYSTADANE...... 52 clindacin-p...... 45 COMETRIQ (140 MG CYSTAGON...... 53 clindamycin hcl...... 16 DAILY DOSE)...... 28 CYSTARAN...... 69 clindamycin palmitate hcl....16 COMETRIQ (60 MG cytarabine...... 26 clindamycin phosphate DAILY DOSE)...... 29 cytarabine (pf)...... 26 ...... 16, 17, 45 COMFORT EZ MICRO CYTOGAM...... 62 clindamycin phosphate in PEN NEEDLES...... 66 dacarbazine...... 26 d5w...... 16 COMFORT EZ SHORT dactinomycin...... 27 clindamycin phosphate- PEN NEEDLES...... 66 DAKLINZA...... 32 benzoyl peroxide...... 45 COMPLERA...... 33 dalfampridine er...... 44 clindamycin-tretinoin...... 45 compro...... 23 DALIRESP...... 72 clinisol sf...... 66 CONDYLOX...... 45 danazol...... 56 clinpro 5000...... 44 constulose...... 51 dantrolene sodium...... 32 clobazam...... 21 COPAXONE...... 44 dapsone...... 25, 46 clobetasol prop emollient CORDRAN...... 54 DAPTACEL...... 63 base...... 54 coremino...... 20 daptomycin...... 17 clobetasol propionate...... 54 CORIFACT...... 38 DARAPRIM...... 30 clobetasol propionate e...... 54 CORTIFOAM...... 45 darifenacin hydrobromide clobetasol propionate cortisone acetate...... 54 er...... 53 emulsion...... 54 CORTISPORIN...... 17 DARZALEX...... 29

78 dasetta 1/35...... 57 dextroamphetamine sulfate dorzolamide hcl-timolol mal 69 dasetta 7/7/7...... 57 er...... 44 dorzolamide hcl-timolol mal daunorubicin hcl...... 27 dextrose...... 47 pf...... 69 daysee...... 57 dextrose in lactated ringers.47 doxazosin mesylate...... 53 DAYTRANA...... 44 dextrose-nacl...... 47 doxepin hcl...... 23, 46 DEBACTEROL...... 45 dialyvite...... 49 doxercalciferol...... 65 deblitane...... 59 diazepam...... 21, 34 doxorubicin hcl...... 27 decara...... 49 diazepam intensol...... 34 doxorubicin hcl liposomal....27 decitabine...... 26 diclofenac potassium...... 12 doxy 100...... 20 deferoxamine mesylate...... 66 diclofenac sodium... 12, 27, 70 doxycycline...... 46 dehydrated alcohol...... 47 diclofenac sodium er...... 12 doxycycline hyclate...... 20 deltasone...... 54 diclofenac-misoprostol...... 12 doxycycline monohydrate... 20 delyla...... 57 DICLOFONO...... 12 dronabinol...... 23 demeclocycline hcl...... 20 dicloxacillin sodium...... 19 droperidol...... 23 DEMSER...... 42 dicyclomine hcl...... 50 drospiren-eth estrad- DENAVIR...... 33 didanosine...... 33 levomefol...... 57 denta 5000 plus...... 45 DIFICID...... 19 drospirenone-ethinyl dentagel...... 45 difil-g forte...... 72 estradiol...... 57 DEPEN TITRATABS...... 49 diflorasone diacetate...... 54 DROXIA...... 26 DEPO-MEDROL...... 54 diflunisal...... 12 DUAVEE...... 57 DEPO-PROVERA...... 59 digitek...... 42 duloxetine hcl...... 22 DEPO-SUBQ PROVERA digox...... 42 DUPIXENT...... 46, 73 104...... 59 digoxin...... 42 duramorph...... 14 DESCOVY...... 33 dihydroergotamine duraxin...... 12 desipramine hcl...... 23 mesylate...... 25 DUREZOL...... 70 desloratadine...... 71 DILANTIN...... 21 dutasteride...... 53 desmopressin ace spray DILATRATE-SR...... 43 dutasteride-tamsulosin hcl.. 53 refrig...... 55 diltiazem hcl...... 41 DYMISTA...... 71 desmopressin acetate...... 55 diltiazem hcl er...... 41 DYRENIUM...... 42 desmopressin acetate diltiazem hcl er beads...... 41 e.e.s. 400...... 19 spray...... 55 diltiazem hcl er coated EASIVENT...... 66 desogestrel-ethinyl beads...... 41 EASY TOUCH SAFETY estradiol...... 57 dilt-xr...... 41 PEN NEEDLES...... 66 desonide...... 54 dimenhydrinate...... 23 econazole nitrate...... 24 desoximetasone...... 54 DIPENTUM...... 65 ed-spaz...... 50 desvenlafaxine succinate diphenhydramine hcl...... 71 EDURANT...... 33 er...... 22 diphenoxylate-atropine...... 51 efavirenz...... 33 dexamethasone...... 54 DIPHTHERIA-TETANUS effer-k...... 47 DEXAMETHASONE TOXOIDS DT...... 63 ELAPRASE...... 52 INTENSOL...... 54 dipyridamole...... 39 eletriptan hydrobromide...... 25 dexamethasone sod disopyramide phosphate.....40 elinest...... 57 phosphate pf...... 54 disulfiram...... 16 ELIQUIS...... 37 dexamethasone sodium divalproex sodium...... 21 ELIQUIS STARTER PACK. 37 phosphate...... 54, 70 divalproex sodium er...... 21 ELITEK...... 26 dexifol...... 49 dobutamine hcl...... 42 ELIXOPHYLLIN...... 72 DEXILANT...... 52 dobutamine in d5w...... 42 ELLA...... 59 dexmedetomidine hcl...... 74 docetaxel...... 27 ELMIRON...... 53 dexmedetomidine hcl in docetaxel (non-alcohol)...... 27 ELOCTATE...... 38 nacl...... 74 dofetilide...... 40 EMADINE...... 69 dexmethylphenidate hcl...... 44 donepezil hcl...... 22 EMBEDA...... 13 dexmethylphenidate hcl er..44 dopamine hcl...... 42 EMCYT...... 26 dexrazoxane...... 27 dopamine in d5w...... 42 emoquette...... 57 dextroamphetamine sulfate 44 dorzolamide hcl...... 69 EMPLICITI...... 29

79 EMSAM...... 22 esmolol hcl-sodium fenoprofen calcium...... 12 EMTRIVA...... 33 chloride...... 41 fenortho...... 12 EMVERM...... 30 esomeprazole sodium...... 52 fentanyl...... 13 enalapril maleate...... 40 estarylla...... 57 fentanyl citrate...... 14 enalaprilat...... 40 estazolam...... 34 ferocon...... 47 enalapril- estradiol...... 57 ferotrinsic...... 47 hydrochlorothiazide...... 40 estradiol valerate...... 57 FERRIPROX...... 49 ENBREL...... 61 estradiol-norethindrone ferrocite plus...... 47 ENBREL MINI...... 61 acet...... 57 FETZIMA...... 22 ENBREL SURECLICK...... 61 eszopiclone...... 74 FETZIMA TITRATION...... 22 endocet...... 14 ethacrynate sodium...... 42 FIBRYGA...... 38 ENGERIX-B...... 63 ethacrynic acid...... 42 FINACEA...... 46 enoxaparin sodium...... 37 ethambutol hcl...... 25 finasteride...... 53 enpresse-28...... 57 ethosuximide...... 21 FIRAZYR...... 61 enskyce...... 57 ethyl chloride...... 15 flac...... 70 entacapone...... 30 ethynodiol diac-eth FLAREX...... 70 entecavir...... 32 estradiol...... 57 flavoxate hcl...... 53 ENTRESTO...... 42 ETHYOL...... 27 FLEBOGAMMA DIF...... 62 enulose...... 51 etidronate disodium...... 65 flecainide acetate...... 40 EPCLUSA...... 32 etodolac...... 12 FLEXICHAMBER ADULT ephedrine sulfate...... 42 etodolac er...... 12 MASK/SMALL...... 66 EPIDUO FORTE...... 46 etoposide...... 28 FLEXICHAMBER CHILD epinastine hcl...... 69 EURAX...... 30 MASK/LARGE...... 66 EPINEPHRINE...... 72 euthyrox...... 60 FLEXICHAMBER CHILD epinephrine...... 72 EVAMIST...... 57 MASK/SMALL...... 66 epinephrine pf...... 42 EVOTAZ...... 34 FLOVENT DISKUS...... 71 epirubicin hcl...... 27 exemestane...... 28 FLOVENT HFA...... 71 epitol...... 21 EXJADE...... 49 floxuridine...... 26 EPIVIR HBV...... 32 ex-lax ultra...... 51 FLUAD...... 63 eplerenone...... 42 EZ FLU SHOT- FLUARIX epoprostenol sodium...... 73 FLUCELVAX QUAD...... 63 QUADRIVALENT...... 63 eprosartan mesylate...... 39 ezetimibe...... 43 FLUBLOK eptifibatide...... 39 ezetimibe-simvastatin...... 43 QUADRIVALENT...... 64 ERAXIS...... 24 fabb...... 49 FLUCELVAX ERBITUX...... 29 falmina...... 57 QUADRIVALENT...... 64 ergocalciferol...... 49 famciclovir...... 33 fluconazole...... 24 ergoloid mesylates...... 22 famotidine...... 51 fluconazole in sodium ergotamine-caffeine...... 25 famotidine premixed...... 51 chloride...... 24 ERIVEDGE...... 29 FANAPT...... 31 flucytosine...... 24 errin...... 59 FANAPT TITRATION fludarabine phosphate...... 26 ertapenem sodium...... 19 PACK...... 31 fludrocortisone acetate...... 54 ERWINAZE...... 27 FARYDAK...... 27 FLULAVAL ery...... 46 FASLODEX...... 26 QUADRIVALENT...... 64 ERY-TAB...... 20 fa-vitamin b-6-vitamin b-12. 49 flumazenil...... 44 erythromycin...... 46, 68 fayosim...... 57 FLUMIST erythromycin base...... 20 FEIBA...... 38 QUADRIVALENT...... 64 erythromycin felbamate...... 21 flunisolide...... 71 ethylsuccinate...... 20 felodipine er...... 41 fluocinolone acetonide.. 54, 70 ESBRIET...... 73 FEMCAP...... 66 fluocinolone acetonide escitalopram oxalate...... 22 femynor...... 57 body...... 54 esgic...... 12 fenofibrate...... 42, 43 fluocinolone acetonide esmolol hcl...... 41 fenofibrate micronized...... 42 scalp...... 54 fenofibric acid...... 43 fluocinonide...... 54

80 fluocinonide emulsified galantamine hydrobromide glycolax...... 52 base...... 54 er...... 22 glycopyrrolate...... 50 fluoridex...... 45 GAMASTAN...... 62 glydo...... 15 fluoridex daily renewal...... 45 GAMASTAN S/D...... 62 GLYXAMBI...... 36 fluoridex enhanced GAMMAGARD...... 62 gnp folic acid...... 49 whitening...... 45 GAMMAGARD S/D LESS GOODSENSE CLICKFINE fluoridex sensitivity relief.....45 IGA...... 62 PEN NEEDLE...... 66 fluorometholone...... 70 GAMMAKED...... 62 GOODSENSE PEN FLUOROPLEX...... 27 GAMMAPLEX...... 62 NEEDLE PENFINE...... 66 fluorouracil...... 26, 27 GAMUNEX-C...... 62 GRALISE...... 44 fluoxetine hcl...... 22 ganciclovir sodium...... 32 GRALISE STARTER...... 44 fluoxetine hcl (pmdd)...... 22 GARDASIL 9...... 64 granisetron hcl...... 23 fluphenazine decanoate...... 31 gatifloxacin...... 70 griseofulvin microsize...... 24 fluphenazine hcl...... 31 GATTEX...... 51 griseofulvin ultramicrosize.. 24 flurazepam hcl...... 34 gavilax...... 51 guanfacine hcl...... 39 flurbiprofen...... 12 gavilyte-c...... 51 guanfacine hcl er...... 44 flurbiprofen sodium...... 70 gavilyte-g...... 51 GUANIDINE HCL...... 25 flutamide...... 26 gavilyte-h...... 51 GYNAZOLE-1...... 24 fluticasone propionate...54, 71 gavilyte-n with flavor pack...51 hailey 24 fe...... 57 fluticasone-salmeterol...... 71 GAZYVA...... 29 HALAVEN...... 27 FLUTICASONE- GELNIQUE...... 53 halobetasol propionate...... 54 SALMETEROL...... 71 GELNIQUE PUMP...... 53 haloperidol...... 31 fluvastatin sodium...... 43 gemcitabine hcl...... 27 ...... 31 fluvastatin sodium er...... 43 gemfibrozil...... 43 haloperidol lactate...... 31 fluvoxamine maleate...... 22 generlac...... 51 HARVONI...... 32 fluvoxamine maleate er...... 22 gengraf...... 61 HAVRIX...... 64 FLUZONE HIGH-DOSE...... 64 gentak...... 68 heather...... 59 FLUZONE gentamicin in saline...... 16 HECTOROL...... 65 QUADRIVALENT...... 64 gentamicin sulfate...... 16, 68 HELIXATE FS...... 38 FML...... 70 gentle laxative...... 51 hematinic plus vit/minerals..47 folbee...... 49 GENVOYA...... 33 hematinic/folic acid...... 47 folbee plus...... 49 GEODON...... 31 hematogen...... 47 folic acid...... 49 gianvi...... 57 hematogen forte...... 47 FOLOTYN...... 26 GILENYA...... 44 HEMLIBRA...... 38 folplex 2.2...... 49 GILOTRIF...... 29 hemocyte-f...... 47 foltrin...... 47 GLASSIA...... 73 hemocyte-plus...... 47 fomepizole...... 66 glatiramer acetate...... 44 hemofil m...... 38 fondaparinux sodium...... 37 glatopa...... 44 HEMOFIL M...... 38 FORTEO...... 65 GLEOSTINE...... 26 HEPAGAM B...... 62 FOSAMAX PLUS D...... 65 glimepiride...... 35 heparin (porcine) in d5w..... 37 fosamprenavir calcium...... 34 glipizide er...... 35 heparin (porcine) in nacl..... 37 fosinopril sodium...... 40 glipizide ir...... 35 heparin lock flush...... 66 fosinopril sodium-hctz...... 40 glipizide xl...... 35 heparin sod (porcine) in fosphenytoin sodium...... 21 glipizide-metformin hcl...... 35 d5w...... 37 FOSRENOL...... 53 GLUCAGEN HYPOKIT...... 36 heparin sodium (porcine).... 37 FRAGMIN...... 37 GLUCAGON heparin sodium (porcine) furosemide...... 42 EMERGENCY...... 36 pf...... 37 FUZEON...... 33 glucose...... 47 heparin sodium flush...... 66 fyavolv...... 57 glyburide...... 36 heparin sodium lock flush... 66 FYCOMPA...... 20 glyburide micronized...... 35 HEPLISAV-B...... 64 gabapentin...... 21 glyburide-metformin...... 36 HERCEPTIN...... 29 galantamine hydrobromide. 22 glycine...... 53 hetastarch-nacl...... 66 glycine urologic...... 53 HETLIOZ...... 74

81 HIBERIX...... 64 hydromorphone hcl...... 14 INSULIN PEN NEEDLES... 66 HIZENTRA...... 62 hydromorphone hcl er...... 13 INSULIN SYRINGES...... 66 homatropaire...... 69 hydromorphone hcl pf...... 14 INTELENCE...... 33 homatropine hbr...... 69 hydroxocobalamin acetate..49 intralipid...... 67 HP ACTHAR...... 55 hydroxychloroquine sulfate. 30 INTRON A...... 32 HUMALOG KWIKPEN...... 36 hydroxyprogesterone introvale...... 57 HUMALOG MIX 50/50 caproate...... 59 INVEGA SUSTENNA...... 31 KWIKPEN...... 36 hydroxyurea...... 27 INVEGA TRINZA...... 31 HUMALOG MIX 50/50 hydroxyzine hcl...... 71 INVIRASE...... 34 VIAL...... 36 hydroxyzine pamoate...... 71 INVOKAMET...... 36 HUMALOG MIX 75/25 hyoscyamine sulfate...... 50 INVOKAMET XR...... 36 KWIKPEN...... 36 hyoscyamine sulfate sl...... 50 INVOKANA...... 36 HUMALOG MIX 75/25 HYPERHEP B S/D...... 62 iodine strong...... 47 VIAL...... 36 HYPERRHO S/D...... 62 iodine tincture...... 17 HUMALOG U-100 JUNIOR HYQVIA...... 62 IOPIDINE...... 69 KWIKPEN...... 36 HYSINGLA ER...... 13 IPOL...... 64 HUMALOG U-100 VIAL ibandronate sodium...... 65 ipratropium bromide...... 71 AND CARTRIDGE...... 36 IBRANCE...... 27 ipratropium-albuterol...... 72 HUMATE-P...... 38 ibu...... 12 irbesartan...... 39 HUMIRA...... 61 ibuprofen...... 12 irbesartan- HUMIRA PEDIATRIC ibuprofen lysine...... 12 hydrochlorothiazide...... 39 CROHNS START...... 61 ibutilide fumarate...... 40 irinotecan hcl...... 28 HUMIRA PEN...... 61 ICLUSIG...... 29 ISENTRESS...... 33 HUMIRA PEN-CD/UC/HS idarubicin hcl...... 27 ISENTRESS HD...... 33 STARTER...... 61 iferex 150 forte...... 47 isibloom...... 57 HUMIRA PEN- ifosfamide...... 26 ISOLYTE-S...... 47 PS/UV/ADOL HS START... 61 ILARIS...... 63 isoniazid...... 25 HUMULIN 70/30 ILEVRO...... 70 isoproterenol hcl...... 72 KWIKPEN...... 36 ILUVIEN...... 70 isosorbide dinitrate...... 43 HUMULIN 70/30 VIAL...... 36 imatinib mesylate...... 29 isosorbide dinitrate er...... 43 HUMULIN N KWIKPEN...... 36 IMBRUVICA...... 29 isosorbide mononitrate...... 43 HUMULIN N VIAL...... 36 imipenem-cilastatin...... 19 isosorbide mononitrate er... 43 HUMULIN R U-500 imipramine hcl...... 23 isotretinoin...... 46 KWIKPEN...... 36 imipramine pamoate...... 23 isradipine...... 41 HUMULIN R U-500 VIAL imiquimod...... 46 ISTODAX (OVERFILL)...... 27 (CONCENTRATED)...... 36 IMPAVIDO...... 17 itraconazole...... 24 HUMULIN R VIAL...... 36 incassia...... 59 ivermectin...... 30 HYCAMTIN...... 28 INCRELEX...... 55 IXEMPRA KIT...... 27 hydralazine hcl...... 43 INCRUSE ELLIPTA...... 71 JADENU...... 49 hydrochlorothiazide...... 42 indapamide...... 42 JADENU SPRINKLE...... 49 hydrocodone- indomethacin...... 12 JAKAFI...... 29 acetaminophen...... 14 indomethacin er...... 12 jantoven...... 38 HYDROCODONE- indomethacin sodium...... 12 JANUMET...... 36 GUAIFENESIN...... 73 INFANRIX...... 64 JANUMET XR...... 36 hydrocodone-homatropine..73 INLYTA...... 29 JANUVIA...... 36 hydrocodone-ibuprofen...... 14 INPEN 100-BLUE-LILLY.....35 JARDIANCE...... 36 hydrocortisone...... 46, 54, 55 INPEN 100-BLUE-NOVO... 35 jasmiel...... 57 hydrocortisone butyr lipo INPEN 100-GRAY-LILLY....35 jencycla...... 59 base...... 54 INPEN 100-GREY-NOVO...35 JENTADUETO...... 36 hydrocortisone butyrate...... 54 INPEN 100-PINK-LILLY...... 35 JENTADUETO XR...... 36 hydrocortisone valerate...... 55 INPEN 100-PINK-NOVO.... 35 JEVTANA...... 27 hydrocortisone-acetic acid.. 70 INSPIREASE jinteli...... 57 hydromet...... 73 RESERVOIR BAGS...... 66 jolessa...... 57

82 jolivette...... 59 KYLEENA...... 59 lessina...... 57 J-TIP KIT W/VIAL KYPROLIS...... 27, 28 LETAIRIS...... 73 ADAPTERS...... 67 labetalol hcl...... 41 letrozole...... 28 JUBLIA...... 24 lactated ringers...... 47, 67 leucovorin calcium...... 27 juleber...... 57 lactic acid...... 46 LEUKERAN...... 26 JULUCA...... 33 lactic acid e...... 46 leuprolide acetate...... 56 junel 1.5/30...... 57 lactulose...... 52 levalbuterol hcl...... 72 junel 1/20...... 57 lactulose encephalopathy... 52 LEVEMIR U-100 junel fe 1.5/30...... 57 lamivudine...... 32, 33 FLEXTOUCH...... 37 junel fe 1/20...... 57 lamivudine-zidovudine...... 33 LEVEMIR U-100 VIAL...... 37 junel fe 24...... 57 lamotrigine...... 21 levetiracetam...... 21 JUXTAPID...... 43 lamotrigine er...... 21 levetiracetam er...... 20 KADCYLA...... 29 lamotrigine starter kit-blue.. 21 levetiracetam in nacl...... 21 kaitlib fe...... 57 lamotrigine starter kit- levobunolol hcl...... 69 KALETRA...... 34 green...... 21 levocarnitine...... 67 KALYDECO...... 72 lamotrigine starter kit- levocetirizine KANUMA...... 52 orange...... 21 dihydrochloride...... 71 kariva...... 57 LANCETS...... 35 levofloxacin...... 20, 70 kcl in d5w lactated ringers.. 47 lansoprazole...... 52 levofloxacin in d5w...... 20 kcl in dextrose-nacl...... 47 lanthanum carbonate...... 53 levoleucovorin calcium...... 27 kcl-lactated ringers-d5w...... 47 LANTUS SOLOSTAR...... 36 LEVOLEUCOVORIN kedbumin...... 67 LANTUS U-100 VIAL...... 36 CALCIUM...... 27 kelnor 1/35...... 57 larin 1.5/30...... 57 levoleucovorin calcium pf....27 kelnor 1/50...... 57 larin 1/20...... 57 levonest...... 57 KEPIVANCE...... 27 larin 24 fe...... 57 levonorgest-eth est & eth KERYDIN...... 24 larin fe 1.5/30...... 57 est...... 57 KETOCARE...... 35 larin fe 1/20...... 57 levonorgest-eth estrad 91- ketoconazole...... 24 larissia...... 57 day...... 58 ketoprofen...... 12 LARTRUVO...... 29 levonorgestrel...... 59 ketoprofen er...... 12 LASTACAFT...... 69 levonorgestrel-ethinyl ketorolac tromethamine 12, 70 latanoprost...... 68 estrad...... 58 KETOSTIX...... 35 LATUDA...... 31 levonorg-eth estrad KEVEYIS...... 69 layolis fe...... 57 triphasic...... 58 KEVZARA...... 63 LEDIPASVIR- levora 0.15/30 (28)...... 58 KINERET...... 61 SOFOSBUVIR...... 32 levorphanol tartrate...... 14 KINRIX...... 64 leena...... 57 levo-t...... 60 kionex...... 49 leflunomide...... 63 levothyroxine sodium...... 60 klofensaid ii...... 12 LENVIMA 10 MG DAILY levothyroxine-liothyronine... 60 klor-con...... 47 DOSE...... 29 levoxyl...... 60 klor-con 10...... 47 LENVIMA 12 MG DAILY LEXIVA...... 34 klor-con m10...... 47 DOSE...... 29 lidocaine...... 15 KLOR-CON M15...... 47 LENVIMA 14 MG DAILY lidocaine hcl...... 15 klor-con m20...... 47 DOSE...... 29 lidocaine hcl (cardiac)...... 40 klor-con sprinkle...... 47 LENVIMA 18 MG DAILY lidocaine hcl (pf)...... 15 klor-con/ef...... 47 DOSE...... 29 lidocaine in d5w...... 40 KOATE...... 38 LENVIMA 20 MG DAILY lidocaine viscous...... 15 KOATE-DVI...... 38 DOSE...... 29 lidocaine-epinephrine...... 15 KOGENATE FS...... 38 LENVIMA 24 MG DAILY lidocaine-hydrocortisone KORLYM...... 56 DOSE...... 29 ace...... 46 k-prime...... 47 LENVIMA 4 MG DAILY lidocaine-prilocaine...... 15 k-tan plus...... 47 DOSE...... 29 LILETTA (52 MG)...... 59 kurvelo...... 57 LENVIMA 8 MG DAILY lillow...... 58 KUVAN...... 52 DOSE...... 29 lincomycin hcl...... 17

83 lindane...... 30 lysiplex plus...... 49 metaxalone...... 74 linezolid...... 17 LYSODREN...... 60 metformin hcl er...... 36 linezolid in sodium chloride.17 lyza...... 59 METFORMIN HCL IR...... 36 LINZESS...... 51 mafenide acetate...... 17 metformin hcl ir...... 36 liothyronine sodium...... 60 magnesium chloride...... 47 methadone hcl...... 13 lipodox 50...... 27 magnesium citrate...... 52 methadone hcl intensol...... 13 lisinopril...... 40 magnesium sulfate...... 48 methadose...... 13 lisinopril- magnesium sulfate in d5w.. 47 methamphetamine hcl...... 44 hydrochlorothiazide...... 40 MAKENA...... 59 methazolamide...... 69 lithium...... 34 malathion...... 30 methenamine hippurate...... 17 lithium carbonate...... 34 mannitol...... 42 methergine...... 67 lithium carbonate er...... 34 maprotiline hcl...... 22 methimazole...... 60 LIVALO...... 43 marlissa...... 58 METHITEST...... 56 LO LOESTRIN FE...... 58 MARPLAN...... 22 methocarbamol...... 74 LONSURF...... 27 MARQIBO...... 28 methotrexate...... 61 loperamide hcl...... 51 MASK VORTEX...... 67 methotrexate (anti- lopinavir-ritonavir...... 34 MATULANE...... 26 rheumatic)...... 61 lopreeza...... 58 matzim la...... 41 methotrexate sodium...... 61 lorazepam...... 34 MAVYRET...... 32 methotrexate sodium (pf)....61 lorazepam intensol...... 34 MAXI-COMFORT SAFETY methoxsalen...... 46 lorcet...... 14 PEN NEEDLE...... 67 methoxsalen rapid...... 46 lorcet hd...... 14 MAXIPIME...... 19 methscopolamine bromide..50 lorcet plus...... 14 meclizine hcl...... 23 methyclothiazide...... 42 loryna...... 58 meclofenamate sodium...... 12 methyldopa...... 39 losartan potassium...... 39 medique aspirin...... 12 methyldopa- losartan potassium-hctz...... 39 medroxyprogesterone hydrochlorothiazide...... 39 LOTEMAX...... 70 acetate...... 59 methylergonovine maleate..67 LOTEMAX SM...... 70 mefloquine hcl...... 30 methylphenidate hcl...... 44 lovastatin...... 43 megestrol acetate...... 59 methylphenidate hcl er...... 44 low-ogestrel...... 58 MEKINIST...... 29 methylphenidate hcl er (cd) 44 loxapine succinate...... 31 melodetta 24 fe...... 58 methylphenidate hcl er (la). 44 LUMIGAN...... 68 meloxicam...... 12 methylprednisolone...... 55 LUMIZYME...... 52 melphalan...... 26 methylprednisolone LUPANETA PACK...... 60 melphalan hcl...... 26 acetate...... 55 LUPRON DEPOT (1- memantine hcl...... 22 methylprednisolone MONTH)...... 56 memantine hcl er...... 22 sodium succ...... 55 LUPRON DEPOT (3- MENACTRA...... 64 methyltestosterone...... 56 MONTH)...... 56 MENEST...... 58 metoclopramide hcl...... 51 LUPRON DEPOT (4- MENTAX...... 24 metolazone...... 42 MONTH) MENVEO...... 64 metoprolol succinate er...... 41 INTRAMUSCULAR KIT meperidine hcl...... 14 metoprolol tartrate...... 41 30MG...... 56 meprobamate...... 34 metoprolol- LUPRON DEPOT (6- MEPSEVII...... 52 hydrochlorothiazide...... 41 MONTH) mercaptopurine...... 27 metronidazole...... 17, 46 INTRAMUSCULAR KIT meropenem...... 19 metronidazole in nacl...... 17 45MG...... 56 mesalamine...... 65 mexiletine hcl...... 40 LUPRON DEPOT-PED (1- mesalamine-cleanser...... 65 MIACALCIN...... 65 MONTH)...... 60 mesna...... 28 mibelas 24 fe...... 58 LUPRON DEPOT-PED (3- MESNEX...... 28 miconazole 3...... 24 MONTH)...... 60 MESTINON...... 25 MICRHOGAM ULTRA- lutera...... 58 metadate er...... 44 FILTERED PLUS...... 63 LYNPARZA...... 28 metaproterenol sulfate...... 72 microgestin 1.5/30...... 58 LYRICA...... 21 metaxall...... 74 microgestin 1/20...... 58

84 microgestin fe 1.5/30...... 58 MULTAQ...... 40 neomycin-polymyxin- microgestin fe 1/20...... 58 multi prenatal...... 49 dexameth...... 68 midodrine hcl...... 42 multi-vit/iron/fluoride...... 49 neomycin-polymyxin- miglitol...... 36 multivitamin/fluoride...... 49 gramicidin...... 68 miglustat...... 52 multi-vitamin/fluoride...... 49 neomycin-polymyxin-hc 68, 70 mili...... 58 multivitamin/fluoride/iron..... 49 neo-polycin...... 68 milrinone lactate...... 42 multi-vitamin/fluoride/iron....49 neo-polycin hc...... 68 milrinone lactate in multivitamins/fluoride...... 49 neostigmine methylsulfate.. 25 dextrose...... 42 mupirocin...... 17 NEO-SYNALAR...... 17 mimvey...... 58 mupirocin calcium...... 17 nephronex...... 49 mimvey lo...... 58 mutamycin...... 28 neuac...... 46 mineral oil heavy...... 52 mvc-fluoride...... 49 NEULASTA...... 38 minitran...... 43 MYALEPT...... 52 NEULASTA ONPRO...... 38 minocycline hcl...... 20 MYCAMINE...... 24 NEUPOGEN...... 38 minocycline hcl er...... 20 mycophenolate mofetil...... 61 NEUPRO...... 30 minoxidil...... 43 mycophenolate mofetil hcl.. 61 neutral sodium fluoride...... 45 MIRENA (52 MG)...... 59 mycophenolate sodium...... 61 NEVANAC...... 70 mirtazapine...... 22 MYLERAN...... 26 nevirapine...... 33 MIRVASO...... 46 mynephron...... 49 nevirapine er...... 33 misoprostol...... 52 myorisan...... 46 NEXAVAR...... 29 mitigo...... 13 MYRBETRIQ...... 53 NEXPLANON...... 59 mitomycin...... 28 myzilra...... 58 niacin er mitoxantrone hcl...... 28 na ferric gluc cplx in (antihyperlipidemic)...... 43 M-M-R II...... 64 sucrose...... 48 nicardipine hcl...... 41 modafinil...... 74 NABI-HB...... 63 nicotine polacrilex...... 16 moderiba...... 32 nabumetone...... 13 nicotine step 1...... 16 MODERIBA 1200 DOSE n-acetyl-l-cysteine...... 67 nicotine step 2...... 16 PACK...... 32 nafcillin sodium...... 19 nicotine step 3...... 16 moexipril hcl...... 40 naftifine hcl...... 24 NICOTROL...... 16 molindone hcl...... 31 NAGLAZYME...... 52 NICOTROL NS...... 16 mometasone furoate.....55, 71 nalbuphine hcl...... 14 nifedipine...... 41 mondoxyne nl...... 20 naloxone hcl...... 16 nifedipine er...... 41 MONOCLATE-P...... 38 naltrexone hcl...... 16 nifedipine er osmotic monoject flush syringe...... 67 NAMENDA XR release...... 41 monoject sodium chloride TITRATION PACK...... 22 nikki...... 58 flush...... 67 NAMZARIC...... 22 nilutamide...... 26 mono-linyah...... 58 naproxen...... 13 nimodipine...... 41 mononessa...... 58 naproxen dr...... 13 NINLARO...... 28 MONONINE...... 38 naproxen sodium...... 13 NIPENT...... 27 montelukast sodium...... 71 naratriptan hcl...... 25 nisoldipine er...... 41 MONUROL...... 17 NARCAN...... 16 NITRO-BID...... 43 morgidox...... 20 NASCOBAL...... 49 nitrofurantoin...... 17 morphine sulfate...... 13, 14 NATACYN...... 68 nitrofurantoin macrocrystal. 17 morphine sulfate NATAZIA...... 58 nitrofurantoin monohydrate (concentrate)...... 14 nateglinide...... 36 macrocrystals...... 17 morphine sulfate (pf)...... 14 NEBUPENT...... 30 nitroglycerin...... 43 morphine sulfate er...... 13 nebusal...... 73 nitroglycerin er...... 43 morphine sulfate er beads.. 13 necon 0.5/35 (28)...... 58 nitroglycerin in d5w...... 43 MOVIPREP...... 52 nefazodone hcl...... 22 NITROMIST...... 43 MOXEZA...... 70 neomycin sulfate...... 16 nitroprusside sodium...... 43 moxifloxacin hcl...... 20, 70 neomycin-bacitracin zn- nizatidine...... 51 moxifloxacin hcl in nacl...... 20 polymyx...... 68 nora-be...... 60 MOZOBIL...... 38 neomycin-polymyxin b gu... 53 NORDITROPIN FLEXPRO.55

85 norepinephrine bitartrate.....42 NUTROPIN AQ NUSPIN OPDIVO...... 29 norethin ace-eth estrad-fe...58 10...... 55 OPSUMIT...... 73 norethindrone...... 60 NUTROPIN AQ NUSPIN oralone...... 45 norethindrone acetate...... 60 20...... 55 ORENCIA...... 61, 62 norethindrone acet-ethinyl NUTROPIN AQ NUSPIN 5. 55 ORENCIA CLICKJECT...... 61 est...... 58 NUVARING...... 58 ORENITRAM...... 73 norethindrone-eth estradiol.58 nyamyc...... 24 ORFADIN...... 52 norethin-eth estradiol-fe...... 58 nystatin...... 24 ORKAMBI...... 72 norgestimate-eth estradiol.. 58 nystatin-triamcinolone...... 24 orphenadrine citrate...... 74 norgestimate-ethinyl nystop...... 24 orphenadrine citrate er...... 74 estradiol triphasic...... 58 OBIZUR...... 38 orsythia...... 58 norlyda...... 60 OCALIVA...... 51 oscimin...... 51 norlyroc...... 60 ocella...... 58 oseltamivir phosphate...... 34 normal saline flush...... 67 OCTAGAM...... 63 osmitrol...... 42 NORPACE CR...... 40 octreotide acetate...... 60 OSMOPREP...... 52 nortrel 0.5/35 (28)...... 58 ODEFSEY...... 33 OSPHENA...... 60 nortrel 1/35 (21)...... 58 OFEV...... 73 OTEZLA...... 63 nortrel 1/35 (28)...... 58 ofloxacin...... 20, 70 oxacillin sodium...... 19 nortrel 7/7/7...... 58 ogestrel...... 58 oxaliplatin...... 26 nortriptyline hcl...... 23 okebo...... 20 oxandrolone...... 56 NORVIR...... 34 olanzapine...... 31 oxaprozin...... 13 novarel...... 55 olanzapine-fluoxetine hcl.... 22 oxazepam...... 34 NOVOFINE AUTOCOVER olmesartan medoxomil...... 39 oxcarbazepine...... 21 PEN NEEDLE...... 67 olmesartan medoxomil- OXISTAT...... 24 NOVOFINE PEN NEEDLE. 67 hctz...... 39 oxybutynin chloride...... 53 NOVOFINE PLUS PEN olmesartan-amlodipine- oxybutynin chloride er...... 53 NEEDLE...... 67 hctz...... 39 oxycodone hcl...... 14 NOVOLIN 70/30 RELION... 37 olopatadine hcl...... 69, 71 OXYCODONE HCL ER...... 13 NOVOLIN 70/30 VIAL...... 37 OMECLAMOX-PAK...... 51 oxycodone-acetaminophen.14 NOVOLIN N RELION...... 37 omega-3-acid ethyl esters.. 43 oxycodone-aspirin...... 15 NOVOLIN N VIAL...... 37 omeprazole...... 52 oxycodone-ibuprofen...... 15 NOVOLIN R RELION...... 37 OMIDRIA...... 69 OXYCONTIN...... 13 NOVOLIN R VIAL...... 37 OMNARIS...... 71 oxymorphone hcl...... 15 NOVOLOG FLEXPEN...... 37 ONCASPAR...... 28 oxymorphone hcl er...... 13 NOVOLOG MIX 70/30 ondansetron hcl...... 23 oxytocin...... 55 FLEXPEN...... 37 ondansetron odt...... 23 OZEMPIC...... 36 NOVOLOG MIX 70/30 ONE-A-DAY WOMENS pacerone...... 40 VIAL...... 37 PRENATAL 1...... 49 paclitaxel...... 28 NOVOLOG PENFILL...... 37 ONETOUCH DELICA paliperidone er...... 31 NOVOLOG U-100 VIAL...... 37 LANCING DEV...... 35 palonosetron hcl...... 23 NOVOPEN ECHO...... 35 ONETOUCH ULTRA 2...... 35 pamidronate disodium...... 65 NOVOSEVEN RT...... 38 ONETOUCH ULTRA pancuronium bromide...... 74 NOVOTWIST PEN BLUE TEST STRIPS...... 35 PANDA MASK LARGE...... 67 NEEDLE...... 67 ONETOUCH ULTRA MINI..35 PANDA MASK MEDIUM.....67 NOXAFIL...... 24 ONETOUCH VERIO...... 35 PANDA MASK SMALL...... 67 np thyroid...... 60 ONETOUCH VERIO FLEX PANRETIN...... 30 NPLATE...... 38 SYSTEM KIT W/DEVICE....35 pantoprazole sodium...... 52 NUCALA...... 73 ONETOUCH VERIO IQ PARAGARD nufol...... 49 SYSTEM...... 35 INTRAUTERINE COPPER. 67 nulev...... 51 ONETOUCH VERIO paricalcitol...... 65 nutrifac zx...... 49 SYNC SYSTEM KIT paroex...... 45 nutrilipid...... 67 W/DEVICE...... 35 paromomycin sulfate...... 16 ONIVYDE...... 28 paroxetine hcl...... 22

86 paroxetine hcl er...... 22 physiosol irrigation...... 67 praziquantel...... 30 paroxetine mesylate...... 22 phytonadione...... 50 prazosin hcl...... 39 PASER...... 25 PICATO...... 28 PRED MILD...... 70 PAXIL...... 22 pilocarpine hcl...... 45, 69 prednicarbate...... 55 PAZEO...... 69 pimecrolimus...... 46 prednisolone...... 55 PEDIARIX...... 64 pimozide...... 31 prednisolone acetate...... 70 PEDIATRIC PANDA pimtrea...... 58 prednisolone sodium MASK...... 67 pindolol...... 41 phosphate...... 55, 70 PEDVAX HIB...... 64 pioglitazone hcl...... 36 prednisone...... 55 peg 3350/electrolytes...... 52 pioglitazone hcl-glimepiride 36 PREDNISONE INTENSOL. 55 peg 3350-kcl-na bicarb- pioglitazone hcl-metformin pregnyl...... 55 nacl...... 52 hcl...... 36 PREMARIN...... 58 peg-3350/electrolytes...... 52 piperacillin sod-tazobactam premasol...... 67 PEGANONE...... 21 so...... 19 PREMPHASE...... 58 PEGASYS...... 32 pirmella 1/35...... 58 PREMPRO...... 58 PEGASYS PROCLICK...... 32 pirmella 7/7/7...... 58 prenatal...... 50 PEGINTRON...... 32 piroxicam...... 13 prenatal multi +dha...... 50 peg-prep...... 52 PLASMA-LYTE 148...... 48 prenatal plus iron...... 50 penicillin g potassium...... 19 PLASMA-LYTE A...... 48 PREPOPIK...... 52 penicillin g procaine...... 19 plenamine...... 67 prevalite...... 43 penicillin g sodium...... 19 PNEUMOVAX 23...... 64 preventeza...... 60 penicillin v potassium...... 19 pnv prenatal plus prevident...... 45 PENTACEL...... 64 multivit+dha...... 50 previfem...... 58 PENTASA...... 65 POCKET SPACER...... 67 PREVNAR 13...... 64 pentazocine-naloxone hcl... 15 podofilox...... 46 PREZCOBIX...... 34 pentobarbital sodium...... 74 polocaine...... 15 PREZISTA...... 34 pentoxifylline er...... 42 polocaine-mpf...... 15 PRIALT...... 44 PERFOROMIST...... 72 polycin...... 68 PRIFTIN...... 25 perindopril erbumine...... 40 poly-iron 150 forte...... 48 primaquine phosphate...... 30 periogard...... 45 polymyxin b sulfate...... 17 primidone...... 21 PERJETA...... 29 polymyxin b-trimethoprim....68 PRIMSOL...... 17 permethrin...... 30 polysaccharide iron forte.....48 PRIVIGEN...... 63 perphenazine...... 31 POMALYST...... 26 PRO COMFORT SPACER perphenazine-amitriptyline..23 portia-28...... 58 ADULT...... 67 phenadoz...... 23 pot bicarb-pot chloride...... 48 PRO COMFORT SPACER phenazo...... 53 potassium acetate...... 48 CHILD...... 67 phenazopyridine hcl...... 53 potassium chloride...... 48 PROAIR HFA...... 72 phenelzine sulfate...... 22 potassium chloride crys er.. 48 PROAIR RESPICLICK...... 72 phenobarbital...... 21 potassium chloride er...... 48 probenecid...... 24 phenoxybenzamine hcl...... 39 potassium chloride in procainamide hcl...... 40 phentolamine mesylate...... 39 dextrose...... 48 prochlorperazine...... 23 phenylephrine hcl...... 39, 69 potassium chloride in nacl.. 48 prochlorperazine edisylate..23 phenytoin...... 22 potassium chloride proamp.48 prochlorperazine maleate... 23 phenytoin infatabs...... 21 potassium citrate er...... 48 PROCRIT...... 38 phenytoin sodium...... 22 PRADAXA...... 38 procto-med hc...... 46 phenytoin sodium pralidoxime chloride...... 67 procto-pak...... 46 extended...... 22 PRALUENT...... 43 proctosol hc...... 46 philith...... 58 pramipexole proctozone-hc...... 46 PHOSLYRA...... 53 dihydrochloride...... 30 PROFILNINE...... 38 PHOSPHOLINE IODIDE.... 69 pramipexole PROFILNINE SD...... 38 phosphorous...... 48 dihydrochloride er...... 30 progesterone...... 60 phrenilin forte...... 12 prasugrel hcl...... 39 progesterone micronized.... 60 physiolyte...... 67 pravastatin sodium...... 43 PROGLYCEM...... 36

87 PROGRAF...... 62 RECTIV...... 46 ropinirole hcl...... 30 PROLASTIN-C...... 73 REGRANEX...... 46 ropinirole hcl er...... 30 PROLEUKIN...... 28 RELENZA DISKHALER...... 34 ropivacaine hcl...... 15 PROLIA...... 65 relexxii...... 44 rosadan...... 46 PROMACTA...... 38 RELISTOR...... 51 rosuvastatin calcium...... 43 promethazine hcl...... 23 REMICADE...... 62 ROTARIX...... 64 promethegan...... 23 remifentanil hcl...... 15 ROTATEQ...... 64 propafenone hcl...... 40 REMODULIN...... 73 roweepra...... 21 propafenone hcl er...... 40 RENACIDIN...... 53 roweepra xr...... 21 propantheline bromide...... 51 renal...... 50 ROZEREM...... 74 proparacaine hcl...... 69 repaglinide...... 36 RUBRACA...... 28 propranolol hcl...... 41 repaglinide-metformin hcl... 36 RYDAPT...... 29 propranolol hcl er...... 41 REPATHA...... 43 ryvent...... 71 propranolol-hctz...... 41 REPATHA PUSHTRONEX salicylic acid...... 46 propylthiouracil...... 60 SYSTEM...... 43 saline flush...... 67 PROQUAD...... 64 REPATHA SURECLICK..... 43 saline flush zr...... 67 protamine sulfate...... 39 RESCRIPTOR...... 33 saline-benzyl alcohol...... 67 protriptyline hcl...... 23 RESTASIS...... 69 SAMSCA...... 49 PULMICORT FLEXHALER.71 RESTASIS MULTIDOSE.... 69 SANDIMMUNE...... 62 pulmosal...... 73 RETROVIR...... 33 SANTYL...... 46 PULMOZYME...... 72 REVLIMID...... 26 SAPHRIS...... 31 purevit dualfe plus...... 48 revonto...... 32 sash kit...... 67 PYLERA...... 51 REXULTI...... 31 SAVAYSA...... 38 pyrazinamide...... 25 REYATAZ...... 34 SAVELLA...... 44 pyridostigmine bromide...... 25 RHOGAM ULTRA- SAVELLA TITRATION pyridostigmine bromide er.. 25 FILTERED PLUS...... 63 PACK...... 44 pyridoxine hcl...... 50 RHOPHYLAC...... 63 selegiline hcl...... 31 pyrogallic acid...... 46 RIASTAP...... 39 selenium sulfide...... 46 QTERN...... 36 ribasphere...... 32 SELZENTRY...... 33 QUADRACEL...... 64 ribasphere ribapak...... 32 SENSIPAR...... 65 quazepam...... 34 RIBASPHERE RIBAPAK.... 32 sensorcaine...... 15 quetiapine fumarate...... 31 ribavirin...... 32, 73 sensorcaine/epinephrine.....15 quetiapine fumarate er...... 31 rifabutin...... 25 sensorcaine-mpf...... 15 quflora pediatric...... 50 rifampin...... 25 sensorcaine- QUILLIVANT XR...... 44 RIFATER...... 25 mpf/epinephrine...... 15 quinapril hcl...... 40 riluzole...... 44 SEREVENT DISKUS...... 72 quinapril- rimantadine hcl...... 34 sertraline hcl...... 22 hydrochlorothiazide...... 40 ringers...... 48 se-tan plus...... 48 quinidine gluconate er...... 40 ringers irrigation...... 67 setlakin...... 58 quinidine sulfate...... 40 RIOMET...... 36 sevelamer carbonate...... 54 quinine sulfate...... 30 risedronate sodium...... 65 sevelamer hcl...... 54 rabeprazole sodium...... 52 RISPERDAL CONSTA...... 31 sf...... 45 raloxifene hcl...... 60 risperidone...... 31 sf 5000 plus...... 45 ramipril...... 40 risperidone m-tab...... 31 sharobel...... 60 ranitidine hcl...... 51 ritonavir...... 34 SHINGRIX...... 64 ranolazine er...... 42 RITUXAN...... 29 SIGNIFOR...... 60 rasagiline mesylate...... 31 rivastigmine...... 22 sildenafil citrate...... 73 RAVICTI...... 52 rivastigmine tartrate...... 22 SILENOR...... 74 RAYALDEE...... 50 rivelsa...... 58 silodosin...... 53 REBETOL...... 32 RIXUBIS...... 39 silver nitrate...... 46 reclipsen...... 58 rizatriptan benzoate...... 25 silver sulfadiazine...... 17 RECOMBINATE...... 39 rocuronium bromide...... 74 SIMBRINZA...... 69 RECOMBIVAX HB...... 64 ROMIDEPSIN...... 28 SIMPONI...... 62

88 SIMPONI ARIA...... 62 sterile water for irrigation.... 67 SYNJARDY...... 36 SIMULECT...... 63 STIOLTO RESPIMAT...... 72 SYNJARDY XR...... 36 simvastatin...... 43 STIVARGA...... 29 SYNRIBO...... 28 sirolimus...... 62 STRENSIQ...... 52 TABLOID...... 27 SIRTURO...... 25 streptomycin sulfate...... 16 TACLONEX...... 46 SKLICE...... 30 STRIANT...... 56 tacrolimus...... 46, 62 SKYLA...... 60 STRIBILD...... 33 tadalafil...... 53 sod benz-sod phenylacet....52 STRIVERDI RESPIMAT..... 72 tadalafil (pah)...... 73 sod citrate-citric acid...... 48 subvenite...... 21 TAFINLAR...... 29 sodium acetate...... 50 subvenite starter kit-blue.....21 TAGRISSO...... 29 sodium bicarbonate...... 48, 51 subvenite starter kit-green.. 21 tamoxifen citrate...... 26 sodium chloride...... 48, 53, 73 subvenite starter kit-orange 21 tamsulosin hcl...... 53 sodium chloride succinylcholine chloride...... 74 TARCEVA...... 29 bacteriostatic...... 67 SUCRAID...... 52 TARGRETIN...... 30 sodium chloride flush...... 67 sucralfate...... 52 tarina fe 1/20...... 58 sodium fluoride...... 48 sulfacetamide sodium...... 70 tarina fe 1/20 eq...... 58 sodium lactate...... 48 sulfacetamide sodium TASIGNA...... 29 sodium nitrite...... 67 (acne)...... 46 tazarotene...... 46 sodium phenylbutyrate...... 52 sulfacetamide- tazicef...... 19 sodium phosphates...... 48 prednisolone...... 70 TAZORAC...... 46 sodium polystyrene sulfadiazine...... 20 taztia xt...... 41 sulfonate...... 49 sulfamethoxazole- TDVAX...... 64 sodium saccharin...... 67 trimethoprim...... 20 TECENTRIQ...... 30 sodium thiosulfate...... 67 SULFAMYLON...... 17 TECFIDERA...... 44 SOFOSBUVIR- sulfasalazine...... 65 TECHNIVIE...... 32 VELPATASVIR...... 32 sulfatrim pediatric...... 20 TEGSEDI...... 44 SOLIRIS...... 37 sulfurated lime...... 30 TEKTURNA...... 42 soloxide...... 20 sulindac...... 13 telmisartan...... 40 SOLTAMOX...... 26 sumatriptan...... 25 telmisartan-amlodipine...... 40 SOLU-CORTEF...... 55 sumatriptan succinate...... 25 telmisartan-hctz...... 40 SOMATULINE DEPOT...... 60 sumatriptan succinate refill. 25 temazepam...... 34 SOMAVERT...... 60 sumatriptan-naproxen TEMODAR...... 26 sorbitol...... 53 sodium...... 25 temozolomide...... 26 sorbitol-mannitol...... 53 SUPPRELIN LA...... 60 temsirolimus...... 29 sorine...... 40 SUPREP BOWEL PREP tencon...... 12 sotalol hcl...... 40 KIT...... 52 teniposide...... 28 sotalol hcl (af)...... 40 SURESTEP PRO HIGH TENIVAC...... 64 SOVALDI...... 32 GLUCOSE...... 35 tenofovir disoproxil spinosad...... 30 SURESTEP PRO LOW fumarate...... 33 SPIRIVA HANDIHALER..... 72 GLUCOSE...... 35 TEPADINA...... 26 SPIRIVA RESPIMAT...... 72 SURESTEP PRO terazosin hcl...... 53 spironolactone...... 42 NORMAL GLUCOSE...... 35 terbinafine hcl...... 24 spironolactone-hctz...... 42 SUTENT...... 29 terbutaline sulfate...... 72 sprintec 28...... 58 swabflush saline flush...... 68 terconazole...... 24 SPRIX...... 13 syeda...... 58 testosterone...... 56 SPRYCEL...... 29 SYLATRON...... 28 testosterone cypionate...... 56 sps...... 49 SYMBICORT...... 71 testosterone enanthate...... 56 sronyx...... 58 SYMFI...... 33 tetcaine...... 69 ssd...... 17 SYMFI LO...... 33 tetrabenazine...... 44 stavudine...... 33 SYMLINPEN 120...... 36 tetracaine hcl...... 69 STELARA...... 46, 62 SYMLINPEN 60...... 36 tetracycline hcl...... 20 sterile diluent/epoprostenol.67 SYNAGIS...... 63 TEXACORT...... 55 sterile water for injection..... 67 SYNAREL...... 60 THALOMID...... 26

89 THEO-24...... 73 tpn electrolytes...... 48 TRIUMEQ...... 33 theochron...... 73 TRACLEER...... 73 tri-vitamin/fluoride...... 50 theophylline...... 73 TRADJENTA...... 36 tri-vite/fluoride...... 50 theophylline er...... 73 tramadol hcl er...... 13 trivora (28)...... 59 theophylline in d5w...... 73 tramadol hcl er (biphasic)... 13 tri-vylibra...... 59 thiamine hcl...... 50 tramadol hcl ir...... 15 tri-vylibra lo...... 59 thioridazine hcl...... 31 tramadol-acetaminophen.... 15 tropicamide...... 69 thiotepa...... 26 trandolapril...... 40 trospium chloride...... 53 thiothixene...... 31 trandolapril-verapamil hcl trospium chloride er...... 53 THROMBATE III...... 38 er...... 40 TRUE COMFORT THYMOGLOBULIN...... 63 tranexamic acid...... 39 ALCOHOL PREP PADS..... 68 THYROLAR-1...... 60 TRANSDERM-SCOP (1.5 TRUEPLUS 5-BEVEL PEN THYROLAR-1/2...... 60 MG)...... 23 NEEDLES...... 68 THYROLAR-1/4...... 60 tranylcypromine sulfate...... 22 TRULICITY...... 36 THYROLAR-2...... 60 TRAVATAN Z...... 68 TRUMENBA...... 64 THYROLAR-3...... 60 trazodone hcl...... 23 TRUVADA...... 33 tiagabine hcl...... 21 TREANDA...... 26 tulana...... 60 TIGAN...... 23 TRECATOR...... 25 TUZISTRA XR...... 71 tigecycline...... 17 TREMFYA...... 46 TWINRIX...... 64 tilia fe...... 59 treprostinil sodium...... 73 TYBOST...... 33 timolol maleate...... 41, 69 TRESIBA...... 37 tydemy...... 59 tinidazole...... 30 TRESIBA FLEXTOUCH...... 37 TYKERB...... 29 tis-u-sol...... 68 tretinoin...... 30, 46 TYSABRI...... 44 TIVICAY...... 33 tretinoin microsphere...... 46 TYVASO...... 73 tizanidine hcl...... 32 tretinoin microsphere pump 46 TYVASO REFILL...... 73 tl gard rx...... 50 TREXALL...... 62 TYVASO STARTER...... 73 tl icon...... 48 tri femynor...... 59 ULESFIA...... 30 tl-hem 150...... 48 triamcinolone acetonide 45, 55 ULORIC...... 24 TOBRADEX...... 68 triamterene-hctz...... 42 ULTRACARE PEN TOBRADEX ST...... 68 triazolam...... 34 NEEDLES...... 68 tobramycin...... 68, 72 tricon...... 48 unithroid...... 60 tobramycin sulfate...... 16 triderm...... 55 UNITUXIN...... 30 tobramycin- trientine hcl...... 49 UPTRAVI...... 73 dexamethasone...... 68 tri-estarylla...... 59 urea...... 46 TOBREX...... 68 trifluoperazine hcl...... 31 urosex...... 50 tolazamide...... 36 trifluridine...... 68 ursodiol...... 51 tolbutamide...... 36 trigels-f forte...... 48 valacyclovir hcl...... 33 tolcapone...... 30 trihexyphenidyl hcl...... 30 valganciclovir hcl...... 32 tolmetin sodium...... 13 tri-legest fe...... 59 valproate sodium...... 21 tolterodine tartrate...... 53 tri-linyah...... 59 valproic acid...... 21 tolterodine tartrate er...... 53 tri-lo-estarylla...... 59 valsartan...... 40 topex topical anesthetic...... 45 tri-lo-marzia...... 59 valsartan- topiramate...... 21 tri-lo-sprintec...... 59 hydrochlorothiazide...... 40 topiramate er...... 21 trilyte...... 52 vancomycin hcl...... 17 toposar...... 28 trimethobenzamide hcl...... 23 vancomycin hcl in dextrose.17 topotecan hcl...... 28 trimethoprim...... 17 vancomycin hcl in nacl...... 17 toremifene citrate...... 26 tri-mili...... 59 VANCOMYCIN HCL IN torsemide...... 42 trimipramine maleate...... 23 NACL...... 17 TOTECT...... 28 TRINTELLIX...... 23 vandazole...... 17 TOUJEO MAX triphrocaps...... 50 VAQTA...... 65 SOLOSTAR...... 37 tri-previfem...... 59 VARIVAX...... 65 TOUJEO SOLOSTAR...... 37 TRISENOX...... 28 v-c forte...... 50 TOVIAZ...... 53 tri-sprintec...... 59 vcf vaginal contraceptive.... 53

90 VECAMYL...... 42 VIVITROL...... 16 ZIRGAN...... 68 vecuronium bromide...... 74 vol-care rx...... 50 ZITHROMAX...... 20 VELCADE...... 28 VONVENDI...... 39 ZOLADEX...... 56 VELETRI...... 73 voriconazole...... 24 zoledronic acid...... 65 velivet...... 59 VOTRIENT...... 29 ZOLINZA...... 28 VELPHORO...... 54 vp-vite rx...... 50 zolmitriptan...... 25 VELTASSA...... 49 vyfemla...... 59 zolpidem tartrate...... 74 VEMLIDY...... 32 vylibra...... 59 zolpidem tartrate er...... 74 VENCLEXTA...... 29 VYVANSE...... 44 ZOMIG...... 25 VENCLEXTA STARTING VYXEOS...... 26 zonisamide...... 21 PACK...... 29 warfarin sodium...... 38 ZONTIVITY...... 39 venlafaxine hcl...... 23 wera...... 59 ZORTRESS...... 62 venlafaxine hcl er...... 23 WIDE-SEAL DIAPHRAGM ZOSTAVAX...... 65 VENTAVIS...... 73 60...... 68 zovia 1/35e (28)...... 59 VENTOLIN HFA...... 72 WINRHO SDF...... 63 ZURAMPIC...... 24 verapamil hcl...... 41, 42 wixela inhub...... 71 ZYDELIG...... 28 verapamil hcl er...... 41 WP THYROID...... 60 ZYKADIA...... 29 verdrocet...... 15 wymzya fe...... 59 ZYPREXA RELPREVV...... 31 VESICARE...... 53 XALKORI...... 29 ZYTIGA...... 26 vic-forte...... 50 XARELTO...... 38 ZYVOX...... 18 vicodin...... 15 XARELTO STARTER vicodin es...... 15 PACK...... 38 vicodin hp...... 15 XELJANZ...... 63 VICTOZA...... 36 XELJANZ XR...... 63 VIDEX...... 33 XGEVA...... 65 VIDEX EC...... 33 XIAFLEX...... 52 VIEKIRA PAK...... 32 XIFAXAN...... 18 vienva...... 59 XIIDRA...... 69 vigabatrin...... 21 XOLAIR...... 73 vigadrone...... 21 XOLEGEL...... 24 VIIBRYD...... 23 XTANDI...... 26 VIIBRYD STARTER PACK.23 xulane...... 59 VIMIZIM...... 52 xylocaine dental...... 15 VIMPAT...... 22 XYNTHA...... 39 vinblastine sulfate...... 28 XYNTHA SOLOFUSE...... 39 vincasar pfs...... 28 YERVOY...... 30 vincristine sulfate...... 28 yuvafem...... 59 vinorelbine tartrate...... 28 zafirlukast...... 71 viorele...... 59 zaleplon...... 74 VIRACEPT...... 34 ZALTRAP...... 28 VIREAD...... 33 ZANOSAR...... 26 virt-caps...... 50 zarah...... 59 virt-gard...... 50 zebutal...... 12 virt-phos 250 neutral...... 48 ZELBORAF...... 29 VISTOGARD...... 68 ZEMAIRA...... 73 vita s forte...... 50 zenatane...... 46 vitacel...... 50 ZENPEP...... 53 vitamax pediatric...... 50 zenzedi...... 44 vita-min...... 50 ZEPATIER...... 32 vitamin b complex 100...... 50 zidovudine...... 33 vitamin d (ergocalciferol).....50 zileuton er...... 71 vitamin k1...... 50 ZIOPTAN...... 68 vitamins acd-fluoride...... 50 ziprasidone hcl...... 31

91 Nondiscrimination notice and access to communication services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 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

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card. Multi-language interpreter services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號 碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드 에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card. ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификаци- онной карте.

تنبيه: إذا كنت تتحدث العربية )Arabic(، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على ّمعرف العضوية. ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuite- ment. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an. 注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証 に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی )Farsi( است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. لطفا با شماره تلفن رایگانی که روی کارت شناسايی شما قید شده تماس بگيريد.

ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej. ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identi- fication card mo. DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga. optumrx.com

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com/optumrx. All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners. © 2019 Optum, Inc. All rights reserved. 68002C-072019 EHB Base