Unitedhealthcare Community Plan of Indiana Preferred Drug List (PDL

Preferred Drug List (PDL) Lista de Medicamentos Preferidos (PDL)

Indiana Effective Date/Vigencia: 7/15/2021

Contract services are funded under contract with the State of Indiana. UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected]

You must send the complaint within 60 calendar days of when you found out about it. A decision will be sent to you within 30 calendar days. If you disagree with the decision, you have 15 calendar days to ask us to look at it again.

If you need help with your complaint, please call Member Services at 1-800-832-4643, TTY 711, 8 a.m. – 8 p.m. EST, Monday – Friday.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

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

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

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

If you need help with your complaint, please call Member Services at 1-800-832-4643, TTY 711. Services to help you communicate with us are provided at no cost to members, such as other languages or large print. Or, you can ask for an interpreter. To ask for help, please call Member Services at 1-800-832-4643, TTY 711, 8 a.m. – 8 p.m. EST, Monday – Friday. CSIN20MC4852856_000 Los servicios por contrato se financian bajo contrato con el Estado de Indiana. UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad u origen nacional.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad u origen nacional, puede enviar una queja a: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected] Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al 1-800-832-4643, TTY 711, de 8 a.m. a 8 p.m. EST, de lunes a viernes.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos. Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Los formularios para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD) Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame a Servicios para Miembros al 1-800-832-4643, TTY 711. Se proporcionan servicios para ayudarle a comunicarse con nosotros, tales como otros idiomas o letra grande, sin costo para los miembros. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame a Servicios para Miembros del 1-800-832-4643, TTY 711, de 8 a.m. a 8 p.m. EST, de lunes a viernes. ATTENTION: If you speak English language assistance services, free of charge, are available to you. Call 1-800-832-4643, TTY 711.

ATENCIÓN: Si habla español (Spanish), tiene a su disposición servicios de asistencia gratuitos en su idioma. Llame al 1-800-832-4643, TTY 711.

Chinese 1-800-832-4643注意：如果您說中文 ( (TTY))，您可獲得免費語言協助服務。請致電 711 ，聽障專線。 HINWEIS: Wenn du Deutsch (German) sprichst, stehen dir kostenlose Sprachdienste zur Verfügung. Anrufe unter 1-800-832-4643, TTY 711.

Attention: Vann du Pennsylvania Deitsh (Pennsylvania Dutch) shvetsht, dann kansht du hilf greeya funn ebbah es deitsh shvetzt, un’s kosht dich nix. Call 1-800-832-4643, TTY 711.

သ䀭ိ搰ူရ倹္- သ္္သ⠹္ ျ搰倹္搰ာ (Burmese) စကာျ ျ听ာ䀭䀭္လွ်် ္္၊ 怬ာသာစကာျအကူအ⠹ီအာျ အခ搰့ ရယူႏိုူ ိ ္္听ါသ⠹္။ ခၚဆိုိ1-800-832-4643, ရ倹္ TTY 711.

تنبيه: إذا كنت تتحدث العربية (Arabic(، فتتوفر لك خدمات المساعدة اللغوية ًمجانا. اتصل على الرقم 1-800-383-2464، الهاتف النصي TTY 711.

(Korean) 1-800-832-4643(TTY참고: 한국어 를 구사하시는 711) 경우, 통역 서비스를 무료로 이용하실 수 있습니다. 는 번으로 문의하십시오. LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), chúng tôi có dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Gọi số 1-800-832-4643, TTY 711.

ATTENTION : si vous parlez français (French), vous pouvez obtenir une assistance linguistique gratuite. Appelez le 1-800-832-4643, TTY 711.

(Japanese) 注意：日本語 1-800-832-4643 をお話しになる場合は、言語支援サービスを無料でご利用いTTY 711 ただけます。電話番号、またはまでご連絡ください。 LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel 1-800-832-4643, TTY 711.

ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo na pantulong sa wika na walang bayad. Tumawag sa 1-800-832-4643, TTY 711.

ВНИМАНИЕ: Если Вы говорите по-русски (Russian), Вы можете бесплатно воспользоваться помощью переводчика. Позвоните: 1-800-832-4643, TTY 711.

ਸਾਵਧਾਨ: ਜੇ ਤੁਸȂ ਪੰਜਾਬੀ (Punjabi) ਬੋਲਦੇ ਹੋ ਤਾਂ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਸੇਵਾਵਾ ਂ ਤੁਹਾਡੇ ਲਈ ਮੁ긼ਤ ਉਪਲਬਧ ਹਨ। 1-800-832-4643, TTY 711 ਤੇ ਕਾਲ ਕਰੋ।.

鵍봾न दᴂ: यदद आप हिदीं (Hindi) बोलते ि,ℂ तो आपके ललए दनःशल्क ु भ봾ष봾 सि봾यत봾 सेव봾एं उपलब्धℂ ि। 1-800-832-4643, TTY 711 पर कॉल कर।.ᴂ

Preferred Drug List

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

i OUTPATIENT PRESCRIPTION DRUG Dosage forms covered will be consistent with the BENEFIT-COVERED MEDICATIONS category and use where listed. Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to Neomycin/polymyxin B/ Cortisporin prescribe federal legend drugs or medicines. Some items Hydrocortisone are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the As listed in the OTIC section, this is limited to the otic individual member’s benefit plan. solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be PRODUCT SELECTION CRITERIA assumed to be on the list unless there are entries for these The P&T Committee considers clinical information on products in the OPHTHALMIC and DERMATOLOGY new-to-market drugs that are typically included in an sections of the PDL. outpatient pharmacy benefit. The evaluation includes all or part of the following: When a strength or dosage form is specified, only the • Safety specified strength and dosage form is on the PDL. • Efficacy Other strengths/dosage forms of the reference product • Comparison studies are not • Approved indications • Adverse effects citalopram 40 mg tabs Celexa tabs • Contraindications/Warnings/Precautions • Pharmacokinetics DRUG TIERS • Patient administration/compliance considerations • Medical outcome and pharmacoeconomic The drugs listed in the PDL have different tiers. The tiers studies are listed in the grid below.

When a new drug is considered for PDL inclusion, it will Tier Name Drug Tier be reviewed relative to similar drugs currently included in Tier 1 Generic the UnitedHealthcare Community Plan PDL. This review Tier 2 Brand process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the GENERIC SUBSTITUTION most clinically useful and cost-effective agents. The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a All the information in the PDL is provided as a reference generic equivalent is available. for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name PDL PRODUCT DESCRIPTIONS product. The PDL indicates generic availability in the To assist in understanding which specific strengths and “Covered Drug” column. dosage forms are covered on the PDL, examples are noted below. The general principles If a brand name drug is medically necessary, please submit shown in the examples can then usually be extended to a prior authorization request. other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a The UnitedHealthcare Community Plan MAC list sets a drug list that gives additional information about which ceiling price for the reimbursement of certain multisource specific products or dosage forms are covered. prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the Products covered include all strengths associated MAC list are commonly prescribed and dispensed and have with the dosage form of the cited brand name usually gone through the FDA’s review and approval product. process. An important consideration for generic carvedilol Coreg substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals All strengths of Coreg would be covered by this listing. prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To Extended-release and delayed-release products gain FDA approval: require their own entry. diltiazem sustained release CARDIZEM SR

ii 1. The generic drug must contain the same active • Cosmetic drugs ingredient(s), be the same strength and the same dosage • Nutritional / diet supplements form as the brand name product. • Blood and blood plasma products • Agents used to promote fertility 2. The FDA has given the generic an “A” rating compared • Agents used for erectile dysfunction to the branded product indicating bioequivalence, and • Agents used for cosmetic hair growth has determined the generic is therapeutically equivalent • Drugs from manufacturers that do not participate to the reference brand. The ratings of generic drugs are in the FFS Medicaid Drug Rebate Program available by referring to the FDA reference, Approved • Diagnostic products Drug Products with Therapeutic Equivalence • Medical supplies and DME except as listed: Evaluations (Orange Book). insulin syringes, insulin needles, lancets, alcohol When the above two criteria are met, a generic can be swabs, spacers, preferred diabetes test strips, peak substituted with the full expectation that the substituted flow meters (Astech, Assess, Peak Air brands, product will produce the same clinical effect and safety max two per year), vaporizer (limit of 1 per 3 profile as the prescribed product. Drug products that have a years), humidifier (limit of 1 per 3 years) narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to DAYS SUPPLY DISPENSING LIMITATIONS approach any one therapeutic class of drug products (e.g., UnitedHealthcare Community Plan members may NTI drugs) differently from any other class, when there has receive up to a one- month supply of a specific been a determination of therapeutic equivalence by the medication per prescription order or prescription FDA for the drug products under consideration. Also, refill. A medication may be reordered or refilled additional clinical tests or examinations by the physician when ninety percent (90%) of the medication has are not needed when a therapeutically equivalent generic been utilized for a controlled substance and eighty-five drug product is substituted for the brand name product. percent (85%) of the medication has been utilized for a non-controlled substance. If a claim is submitted There are now many brand name products that are before 90% of the medication has been used for a repackaged or distributed under a generic label. The generic controlled substance or submitted before 85% of label version should always be considered therapeutically the medication has been used for a non-controlled equivalent and substitutable for the source branded product. substance, based on the original day supply submitted on the claim, the claim will reject with a DRUG EFFICACY STUDY IMPLEMENTATION “refill too soon” message. (DESI) DRUGS Drugs first marketed between 1938 and 1962 were MANDATORY GENERIC SUBSTITUTION approved as safe but required no showing of effectiveness The UnitedHealthcare Community Plan PDL requires for FDA approval. Beginning in 1962, all new drugs were mandatory generic substitution on the vast majority of required to be both safe and effective before they could be products when a generic equivalent is available; however, marketed. This legislation also applied retroactively to all brand name drugs may be covered in certain situations by drugs approved as safe from 1938-1962. The DESI requesting a prior authorization. The UnitedHealthcare program was established by the FDA to review the Community Plan PDL prior authorization (PA) list does not effectiveness of these pre-1962 drugs for their labeled include branded items where a generic equivalent is indications, and a determination of “fully effective” was covered. made for most of these products and they remain in the marketplace. A few DESI products remain classified as PRIOR AUTHORIZATION OF NON-PDL “less than fully effective” while awaiting final MEDICATIONS administrative disposition. Also, classified as DESI are The drugs in the UnitedHealthcare Community Plan PDL many products listed as identical, similar, or related to have been selected to provide the most clinically actual DESI products. UnitedHealthcare Community appropriate and cost-effective medications for patients who Plan’s PDL does not cover DESI “less than fully effective” have their drug benefit administered through drug products. UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific PLAN EXCLUSIONS patient. In those infrequent instances, the prior The following drug categories are excluded from coverage authorization process reviews requests for unlisted under the outpatient pharmacy benefit and are not part of medications the physician may consider medically the UnitedHealthcare Community Plan PDL. necessary for patient management.

• DESI drugs • Anti-obesity agents Requests for these exceptions should be either made in • Experimental / research drugs writing by the physician and faxed or called into:

iii UnitedHealthcare Community Plan The limits for the program are established based on FDA Pharmacy Services Department approval for dosing and the availability of the total daily Fax 866-940-7328 dose in the least amount of tablets or capsules daily. Phone 800-310-6826 Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The A prior authorization request form is available in the pharmacy claims processing system will prompt the UnitedHealthcare Community Plan provider manual and pharmacist to request a new prescription order from the should be used for all prior authorization requests if physician. possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan Pharmacy Department UnitedHealthcare Community Plan is continuously looking will respond to all requests in accordance with state for ways to provide high quality cost effective care for Plan requirements. members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to Physicians are requested to adhere to this PDL when achieve these goals. Injectable medications that are part of prescribing for patients covered by their pharmacy benefit this program require plan authorization and are not plan offered by UnitedHealthcare Community Plan. If a available through the retail pharmacy network. pharmacist receives a prescription for a non-PDL drug, the To obtain authorization, the provider must submit the pharmacist should contact the prescribing physician and appropriate Prior Authorization form to the request that the prescription be changed to a medication UnitedHealthcare Community Plan Pharmacy Department included in this PDL. If a PDL alternative is not via fax at 866-940-7328. appropriate the physician should then be instructed to The UnitedHealthcare Community Plan Pharmacy contact the Plan for a prior authorization. Department will review and respond to all requests in accordance with state requirements, and if authorized for Please contact the UnitedHealthcare Community Plan payment, UnitedHealthcare Community Plan will Pharmacy Prior Notification Service at 800-310-6826 with coordinate the delivery of the product to the member or questions concerning the prior authorization process. provider. Drugs that are part of this program and are on the PDL are NON-PDL DRUGS 3-DAY TEMPORARY SUPPLY identified in this booklet by the designation "SP". OVERRIDES Prior Authorization request forms can be requested by To ensure the use of PDL drugs, all non- PDL drugs should calling the UnitedHealthcare Community Plan Pharmacy be discussed with the prescribing physician. If you cannot Department at 800-310-6826. speak to the physician immediately, and there is an immediate need for the medication, the claim processing STEP THERAPY (ST) system will accept an override to permit a one-time The following PDL drugs are routinely covered only after a dispensing of a 3-day supply of the newly prescribed sufficient trial of an indicated first-line agent has been non-PDL drug. The pharmacy should submit a claim for a adequately tried and failed. These medications may also be 3 day supply, with a PA Type of 8 and Prior Authorization requested through the Prior authorization process. number of “0000000072”. Please note that non-preferred While lower cost PDL alternatives may be appropriate in drugs are available for a 3-day supply, however availability many instances, other non- PDL alternatives are available is subject to the benefit design. For assistance, pharmacies with prior authorization (PA). may call 800-310-6826. STEP Drug First-Line Agent(s) The pharmacy should contact the physician to discuss a PDL drug or if a prior authorization request is warranted. .Amerge Trial at a minimum dose of 50mg of If the prescribing physician feels a drug is medically sumatriptan tablets. necessary, the physician may fax a request for prior authorization to UnitedHealthcare Community Plan at 800- calcipotriene Trial of two medium to high potency 310-6826. cream & oint corticosteroids 0.005% QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the calcitriol Trial of two medium to high potency indicated limit require a prior authorization request. 3mcg/gm corticosteroids

Quantity limits based on Efficient Medication Dosing DPP4 Inhibitors At least a 90 day trial of 1500mg/day of The Efficient Medication Dosing Program is designed to (Nesina, metformin. consolidate medication dosage to the most efficient daily Kazano, Oseni) quantity to increase adherence to therapy and also promote the efficient use of health care dollars.

iv Elidel Minimum age of 2. Trial of one topical tretinoin Cream Trial of Differin OTC Gel 0.1%. corticosteroid. (tretinoin cream 0.025%, 0.05%, 0.1%, Eucrisa Trial of a topical steroid AND one of the and Avita cream 0.025%) following: Elidel cream or tacrolimus ointment trospium 30 day trial of oxybutynin immediate or extended release. Step Therapy only fenofibrate Fill of a statin or 90 days of gemfibrozil applies to members less than 65 years of within the previous 180 days. age. fexofenadine Trial of cetirizine and loratadine within Trulance For chronic idiopathic constipation or past 90 days irritable bowel syndrome- constipation, trial of lactulose or polyethylene glycol GLP-1 Agonists At least a 90 day trial of 1500mg/day of and trial of lubiprostone (authorized (Adlyxin, metformin generic of Amitiza) Trulicity, Victoza 2 pen pack) Uloric 8 week trial of up to 600mg of GLP-1/Insulin Trial of one drug from the following allopurinol required first. Combinations classes: GLP-1 or Basal Insulin (Soliqua) Xopenex Respules 30 day trial of Albuterol .083% or .5% lubiprostone For opioid-induced constipation or respules. chronic idiopathic constipation, trial of lactulose or polyethylene glycol PDL SUGGESTIONS Providers who wish to propose PDL suggestions should Motegrity For chronic idiopathic constipation, trial forward the information to the UnitedHealthcare of lactulose or polyethylene glycol and Community Plan Director of Pharmacy Services by either trial of lubiprostone (authorized generic mail or fax.

of Amitiza) Attn: Director of Pharmacy Services UnitedHealthcare Community Plan Movantik For opioid-induced constipation, trial of 2 Allegheny Center lactulose or polyethylene glycol and trial Suite 600 of lubiprostone (authorized generic of Pittsburgh, PA 15212 Amitiza) Phone: 800-310-6826 Email: [email protected] Optivar 14 day trial of ketotifen within previous 90 days required first. Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the ranolazine Trial of one drug from the following request to be considered for PDL addition. This literature classes: beta blockers, calcium channel should include information documenting clinical necessity blockers, long acting nitrates as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Renvela 8 week trial of calcium acetate Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee SGLT-2 At least a 90 day trial of 1500mg/day of meeting. Inhibitors metformin (Steglatro, Segluromet) EDITOR Your comments and suggestions regarding the tacrolimus 0.03% Minimum age of 2.Trial of one UnitedHealthcare Community Plan PDL are encouraged. topical corticosteroid. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send tacrolimus 0.1% Minimum age of 16. Trial of one your comments to: topical corticosteroid. UnitedHealthcare Community Plan by tolterodine 30 day trial of oxybutynin immediate or UnitedHealthcare extended release. Step Therapy only Director of Pharmacy Services applies to members less than 65 years of age.

v 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826

LEGEND # Only the dosage forms/strengths of the brand name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustained- release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V-VI for details SP Specialty Pharmaceuticals, see pages IV-V for details

NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies.

If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

vi Table of Contents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions ...... 3 Anesthetics - Drugs for Numbing ...... 11 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence ...... 12 Antibacterials ...... 14 Antibacterials - Drugs to Treat Bacterial Infections ...... 14 Anticonvulsants - Drugs to Treat Seizures ...... 17 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia ...... 19 Antidepressants - Drugs to Treat Depression ...... 20 Antiemetics - Drugs to Treat Nausea and Vomiting ...... 22 Antifungals - Drugs to Treat Fungal Infections ...... 23 Antigout Agents - Drugs to Treat Gout ...... 26 Antimigraine Agents - Drugs to Treat Migraines...... 26 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis ...... 26 Antimycobacterials - Drugs to Treat Infections ...... 27 Antineoplastics - Drugs to Treat Cancer ...... 27 Antiparasitics - Drugs to Treat Parasitic Infections ...... 31 Antiparkinson Agents - Drugs to Treat Parkinson's Disease ...... 33 Antipsychotics - Drugs to Treat Mood Disorders ...... 34 Antivirals - Drugs to Treat Viral Infections ...... 35 Anxiolytics - Drugs to Treat Anxiety ...... 38 Bipolar Agents - Drugs to Treat Mood Disorders ...... 39 Blood Glucose Regulators - Drugs to Regulate Blood Sugar ...... 40 Blood Products and Modifiers ...... 42 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders ...... 42 Cardiovascular Agents ...... 44 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions ...... 44

1 Central Nervous System Agents ...... 49 Central Nervous System Agents - Drugs to Treat Nerve Conditions ...... 49 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions ...... 52 Dermatological Agents - Drugs to Treat Skin Conditions ...... 52 Electrolytes/Minerals/Metals/Vitamins ...... 58 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions ...... 73 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ...... 88 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions ...... 89 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones ...... 90 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones ...... 91 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones ...... 91 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones ...... 91 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones ...... 97 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones ...... 98 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones ...... 98 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones ...... 99 Immunological Agents - Drugs that Stimulate or Suppress the Immune System ...... 99 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease ...... 101 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions ...... 102 Metabolic Bone Disease Agents - Other ...... 102 Miscellaneous Therapeutic Agents ...... 102 Ophthalmic Agents - Drugs to Treat Eye Conditions ...... 106 Otic Agents - Drugs to Treat Ear Conditions ...... 112 Regulators - Drugs to Regulate Blood Sugar ...... 113 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions ...... 113 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm ...... 133 Sleep Disorder Agents - Drugs for Sedation and Sleep ...... 133 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies ...... 134 2 Preferred Agents Non-Preferred Agents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen childrens oral solution - Tier 1; QL acetaminophen childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen childrens oral tablet chewable (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 3 Preferred Agents Non-Preferred Agents acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic for PANADOL CHILDRENS) - Tier 1 acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1 acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1 acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1; AL apra (generic for MEDI-TABS CHILDRENS) - Tier 1; QL arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1 bac (generic for BAC) - Tier 1; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1 butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1; QL butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1; QL butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL butalbital-aspirin-caffeine - Tier 1; QL capsaicin external cream 0.025 % (generic for DERMACINRX PENETRAL) - Tier 1 CASTIVA WARMING - Tier 2; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1 childrens apap (generic for MAPAP CHILDRENS) - Tier 1; AL childrens non-aspirin oral suspension (generic for PANADOL CHILDRENS) - Tier 1 childrens non-aspirin oral tablet chewable (generic for MAPAP CHILDRENS) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; AL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for sm migraine relief) - Tier 2; QL; AL EXCEDRIN MIGRAINE (brand for sm migraine relief) - Tier 2; QL; AL fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1 fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1 feverall adults (generic for FEVERALL ADULTS) - Tier 1; AL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1 FEVERALL INFANTS - Tier 2; AL FEVERALL JUNIOR STRENGTH - Tier 2 headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1 infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1 infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1 liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL mapap childrens oral tablet chewable 80 mg (generic for MAPAP CHILDRENS) - Tier 1; AL mapap oral capsule - Tier 1 migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1 non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL non-aspirin childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 non-aspirin childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin childrens oral tablet chewable 80 mg (generic for MAPAP CHILDRENS) - Tier 1; AL non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1 pain & fever child (generic for PANADOL CHILDRENS) - Tier 1 pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain & fever childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain & fever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain relief childrens oral elixir 160 mg/5ml (generic for MEDI-TABS CHILDRENS) - Tier 1; QL pain relief childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1 pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1 pain relief regular strength (generic for PHARBETOL) - Tier 1 pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1 pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL pain reliever extra strength oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1 pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1 pain reliever oral tablet (generic for PHARBETOL) - Tier 1 pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL; AL PANADOL CHILDRENS (brand for qc pain relief childrens) - Tier 2 PANADOL EXTRA STRENGTH (brand for cvs non-aspirin extra strength) - Tier 2 PANADOL INFANTS (brand for qc pain relief childrens) - Tier 2 PHARBETOL EXTRA STRENGTH (brand for cvs non-aspirin extra strength) - Tier 2 PHARBETOL ORAL TABLET 325 MG (brand for acetaminophen) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 7 Preferred Agents Non-Preferred Agents sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1 sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1 sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1 TENCON (brand for butalbital-acetaminophen) - Tier 2; QL TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for qc pain relief childrens) - Tier 2 TYLENOL ORAL TABLET 325 MG (brand for acetaminophen) - Tier 2 TYLENOL ORAL TABLET 500 MG (brand for cvs non-aspirin extra strength) - Tier 2 TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for non-aspirin jr strength) - Tier 2; QL TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for acetaminophen er) - Tier 2; QL

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs addaprin (generic for ADDAPRIN) - Tier 1 ADVIL JUNIOR STRENGTH ORAL TABLET (brand for sm ibuprofen jr) - Tier 2; QL ADVIL JUNIOR STRENGTH ORAL TABLET CHEWABLE (brand for ibuprofen) - Tier 2; AL ADVIL ORAL TABLET (brand for kls ibuprofen) - Tier 2 ALEVE ORAL TABLET (brand for sb naproxen sodium) - Tier 2 all day pain relief (generic for MEDIPROXEN) - Tier 1 all day relief (generic for MEDIPROXEN) - Tier 1 aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1 aspirin ec (generic for BAYER ASPIRIN) - Tier 1 aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1 aspirin oral (generic for ST JOSEPH LOW DOSE) - Tier 1 ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for aspirin adult low dose) - Tier 2 aspirin rectal - Tier 1 BAYER ASPIRIN (brand for ra aspirin) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents celecoxib oral (generic for CELEBREX) - Tier 1; PA; QL childrens aspirin oral tablet chewable 81 mg (generic for ST JOSEPH LOW DOSE) - Tier 1 diclofenac potassium (generic for CATAFLAM) - Tier 1; QL diclofenac sodium er - Tier 1; QL diclofenac sodium external gel 1 % (generic for ASPERCREME ARTHRITIS PAIN) - Tier 1; QL diclofenac sodium oral - Tier 1; QL ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL enteric aspirin (generic for BAYER ASPIRIN) - Tier 1 etodolac - Tier 1; QL h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1 ibu (generic for IBU) - Tier 1; QL ibu-200 (generic for ADDAPRIN) - Tier 1 ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; AL ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier 1; AL ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; AL ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS ADVIL) - Tier 1 ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; AL ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier 1; AL ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS ADVIL) - Tier 1 ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1; QL indomethacin oral capsule 25 mg, 50 mg - Tier 1; QL INFANTS ADVIL (brand for eql ibuprofen infants) - Tier 2 infants ibuprofen (generic for INFANTS ADVIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents ketoprofen oral - Tier 1; QL ketorolac tromethamine oral - Tier 1; QL mediproxen (generic for MEDIPROXEN) - Tier 1 meloxicam oral tablet (generic for MOBIC) - Tier 1; QL MOTRIN CHILDRENS (brand for ibuprofen) - Tier 2; AL MOTRIN IB ORAL TABLET (brand for kls ibuprofen) - Tier 2 MOTRIN INFANTS DROPS (brand for eql ibuprofen infants) - Tier 2 nabumetone oral (generic for RELAFEN) - Tier 1; QL naproxen oral - Tier 1; QL naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier 1 oxaprozin (generic for DAYPRO) - Tier 1; QL piroxicam oral (generic for FELDENE) - Tier 1; QL salsalate oral - Tier 1; QL sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1 ST JOSEPH LOW DOSE (brand for cvs aspirin adult low dose) - Tier 2 sulindac oral - Tier 1; QL

Opioid Analgesics, Long-acting - Opioid Pain Relievers buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 100 mcg/hr (generic for NUCYNTA ER - Tier 2; PA; QL DURAGESIC-100) - Tier 1; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr (generic for DURAGESIC- ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL 12) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr (generic for DURAGESIC- 25) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr (generic for DURAGESIC- 50) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 75 mcg/hr (generic for DURAGESIC- 75) - Tier 1; PA; QL morphine sulfate er oral tablet extended release (generic for MS CONTIN) - Tier 1; PA; QL oxymorphone hcl er - Tier 1; PA; QL

Opioid Analgesics, Short-acting - Opioid Pain Relievers

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents acetaminophen-codeine - Tier 1; QL apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA; acetaminophen-codeine #2 - Tier 1; QL QL acetaminophen-codeine #3 - Tier 1; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL acetaminophen-codeine #4 - Tier 1; QL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butorphanol tartrate nasal - Tier 1; QL codeine sulfate - Tier 1; QL endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg - Tier 1; QL hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL hydromorphone hcl rectal - Tier 1; QL morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier 1; QL morphine sulfate oral - Tier 1; QL morphine sulfate rectal - Tier 1; QL OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL oxycodone hcl oral solution - Tier 1; QL oxycodone hcl oral tablet - Tier 1; QL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL oxycodone-aspirin - Tier 1; QL pentazocine-naloxone hcl - Tier 1; QL tramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL

Anesthetics - Drugs for Numbing Local Anesthetics 7T LIDO - Tier 2; QL anecream external cream (generic for ANECREAM) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents blue tube/ aloe (generic for ANECREAM) - Tier 1; QL glydo (generic for GLYDO) - Tier 1; QL lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; PA; QL lidocaine hcl external cream 3 % - Tier 1; QL lidocaine hcl urethral/mucosal - Tier 1; QL lidocaine viscous hcl - Tier 1; QL lidocaine-prilocaine external cream - Tier 1; QL lidopin external cream 3 % - Tier 1; QL LMX 4 (brand for blue tube/ aloe) - Tier 2; QL

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium - Tier 1; QL disulfiram oral tablet 250 mg - Tier 1; QL disulfiram oral tablet 500 mg - Tier 1 naltrexone hcl oral - Tier 1

Opioid Dependence Treatments - Antidotes/Deterrents/Protectants buprenorphine hcl sublingual - Tier 1; QL BUNAVAIL - Tier 2; PA; QL buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1; PA; QL (generic for SUBOXONE) - Tier 1; QL SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML - Tier 2; PA SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; PA; QL ZUBSOLV - Tier 2; PA; QL

Opioid Reversal Agents - Antidotes/Deterrents/Protectants naloxone hcl injection - Tier 1; QL NARCAN - Tier 2; QL

Smoking Cessation Agents - Deterrents

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 12 Preferred Agents Non-Preferred Agents bupropion hcl er (smoking det) - Tier 1 CHANTIX - Tier 2; AL CHANTIX CONTINUING MONTH PAK - Tier 2; AL CHANTIX STARTING MONTH PAK - Tier 2; AL habitrol (generic for HABITROL) - Tier 1; QL; AL mini nicotine (generic for KLS QUIT2) - Tier 1; AL NICODERM CQ (brand for sm nicotine) - Tier 2; QL; AL NICORETTE (brand for nicotine polacrilex) - Tier 2; AL NICORETTE MINI (brand for cvs nicotine) - Tier 2; AL NICORETTE STARTER KIT (brand for nicotine polacrilex) - Tier 2; AL nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; AL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; AL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; AL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; AL nicotine mini (generic for KLS QUIT2) - Tier 1; AL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; AL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; AL nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; AL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; AL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; AL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; AL nicotine step 1 (generic for HABITROL) - Tier 1; QL; AL nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL; AL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL; AL nicotine transdermal kit 21-14-7 mg/24hr - Tier 1; QL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; QL; AL nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; QL; AL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; QL; AL quit2 (generic for KLS QUIT2) - Tier 1; AL

Antibacterials Antibacterials, Other methenamine hippurate (generic for HIPREX) - Tier 1; QL nitrofurantoin - Tier 1; QL; AL nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - Tier 1; QL

Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics gentamicin sulfate external - Tier 1; QL neomycin sulfate oral - Tier 1; QL paromomycin sulfate oral (generic for HUMATIN) - Tier 1; QL

Antibacterials, Other - Antibiotics antibiotic external ointment 3.5-400-5000 (generic for NEOSPORIN CLEOCIN VAGINAL SUPPOSITORY - Tier 2; PA; QL ORIGINAL) - Tier 1 CLINDESSE - Tier 2; PA; QL antibiotic external ointment 500 unit/gm - Tier 1; QL FLAGYL (brand for metronidazole) - Tier 2; PA; QL antiseptic (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 METROGEL (brand for metronidazole) - Tier 2; PA; QL bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1 NORITATE - Tier 2; PA bacitracin external ointment 500 unit/gm - Tier 1; QL VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL bacitracin zinc external - Tier 1; QL XENLETA ORAL - Tier 2; PA; QL bacitracin zinc first aid - Tier 1; QL clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) - Tier 1; QL clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL double antibiotic (generic for POLYSPORIN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg-unit (generic for NEOSPORIN ORIGINAL) - Tier 1 first aid antiseptic external solution 10 % (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 FIRVANQ (brand for vancomycin hcl) - Tier 2; PA; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA; QL linezolid oral tablet (generic for ZYVOX) - Tier 1 medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1 metronidazole external (generic for ROSADAN) - Tier 1; QL metronidazole oral tablet - Tier 1; QL metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL mupirocin external (generic for CENTANY) - Tier 1; QL NEOSPORIN ORIGINAL (brand for gnp triple antibiotic) - Tier 2 poly bacitracin (generic for POLYSPORIN) - Tier 1 POLYSPORIN (brand for bacitracin-polymyxin b) - Tier 2 povidone iodine (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 povidone-iodine external solution (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 rosadan external cream (generic for ROSADAN) - Tier 1; QL rosadan external gel (generic for ROSADAN) - Tier 1; QL SCRUB CARE POVIDONE-IODINE (brand for gnp povidone-iodine) - Tier 2 trimethoprim oral - Tier 1; QL triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1 triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1 vandazole (generic for VANDAZOLE) - Tier 1; QL

Beta-Lactam, Cephalosporins - Antibiotics cefaclor - Tier 1; QL cefadroxil - Tier 1; QL cefdinir - Tier 1; QL cefixime oral capsule (generic for SUPRAX) - Tier 1; QL cefprozil - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents cefuroxime axetil - Tier 1; QL cephalexin oral capsule - Tier 1; QL cephalexin oral suspension reconstituted - Tier 1; QL

Beta-Lactam, Penicillins - Antibiotics amoxicillin oral capsule - Tier 1; QL amoxicillin oral suspension reconstituted - Tier 1; QL amoxicillin oral tablet 875 mg - Tier 1; QL amoxicillin oral tablet chewable - Tier 1; QL amoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier 1; QL ampicillin - Tier 1; QL dicloxacillin sodium - Tier 1; QL penicillin v potassium - Tier 1; QL

Macrolides - Antibiotics azithromycin oral suspension reconstituted (generic for ZITHROMAX) - Tier 1; QL azithromycin oral tablet - Tier 1; QL clarithromycin er - Tier 1; QL clarithromycin oral - Tier 1; QL DIFICID - Tier 2; PA; QL E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; QL erythromycin base - Tier 1; QL erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QL erythromycin oral (generic for ERY-TAB) - Tier 1; QL

Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents ciprofloxacin hcl oral - Tier 1; QL VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QL XEPI - Tier 2; PA; QL ofloxacin oral - Tier 1; QL

Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1; QL ssd (generic for SSD) - Tier 1; QL sulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1; QL sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1; QL sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL

Tetracyclines - Antibiotics doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; QL ORACEA (brand for doxycycline) - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL SOLODYN (brand for minocycline hcl er) - Tier 2; PA doxycycline monohydrate oral capsule 100 mg (generic for XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL MONDOXYNE NL) - Tier 1; QL doxycycline monohydrate oral capsule 50 mg - Tier 1; QL minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1; QL minocycline hcl oral capsule 50 mg - Tier 1; QL mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL morgidox oral (generic for MORGIDOX) - Tier 1; QL NUZYRA ORAL - Tier 2; PA; QL

Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other - Seizure Control Drugs levetiracetam oral solution (generic for KEPPRA) - Tier 1; QL; AL BRIVIACT ORAL - Tier 2; PA; QL levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL EPIDIOLEX - Tier 2; PA; SP; QL NAYZILAM - Tier 2; PA; QL XCOPRI - Tier 2; PA; QL phenobarbital oral tablet - Tier 1 XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & roweepra (generic for ROWEEPRA) - Tier 1; QL 200 MG - Tier 2; PA; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents Calcium Channel Modifying Agents - Seizure Control Drugs CELONTIN - Tier 2; QL ethosuximide oral (generic for ZARONTIN) - Tier 1; QL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL

Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs clobazam (generic for ONFI) - Tier 1; QL VALTOCO 10 MG DOSE - Tier 2; PA; QL diazepam rectal (generic for DIASTAT PEDIATRIC) - Tier 1; QL VALTOCO 15 MG DOSE - Tier 2; PA; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL VALTOCO 20 MG DOSE - Tier 2; PA; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL VALTOCO 5 MG DOSE - Tier 2; PA; QL phenobarbital oral elixir - Tier 1 primidone oral (generic for MYSOLINE) - Tier 1; QL SYMPAZAN - Tier 2; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; AL valproic acid oral - Tier 1 vigabatrin oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL

Glutamate Reducing Agents - Seizure Control Drugs felbamate oral suspension (generic for FELBATOL) - Tier 1; QL; AL FYCOMPA - Tier 2; PA; QL felbamate oral tablet (generic for FELBATOL) - Tier 1; QL LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 42 X 50 MG & 14X100 MG - Tier 2 LAMICTAL XR ORAL KIT - Tier 2 lamotrigine er (generic for LAMICTAL XR) - Tier 1 lamotrigine oral (generic for SUBVENITE) - Tier 1 lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1 lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1 lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1 subvenite (generic for SUBVENITE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 18 Preferred Agents Non-Preferred Agents subvenite starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1 subvenite starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1 subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1 topiramate er (generic for QUDEXY XR) - Tier 1; QL topiramate oral (generic for TOPAMAX) - Tier 1 TROKENDI XR - Tier 2; QL

Sodium Channel Agents - Seizure Control Drugs carbamazepine er (generic for CARBATROL) - Tier 1 APTIOM - Tier 2; PA; QL carbamazepine oral - Tier 1 VIMPAT ORAL - Tier 2; PA; QL; AL DILANTIN ORAL CAPSULE 30 MG - Tier 2 epitol (generic for EPITOL) - Tier 1 oxcarbazepine (generic for TRILEPTAL) - Tier 1 OXTELLAR XR - Tier 2 phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; QL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL rufinamide (generic for BANZEL) - Tier 1; PA; QL

Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl (generic for ARICEPT) - Tier 1; QL galantamine hydrobromide - Tier 1; QL galantamine hydrobromide er (generic for RAZADYNE ER) - Tier 1; QL rivastigmine (generic for EXELON) - Tier 1; QL rivastigmine tartrate - Tier 1; QL

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl er (generic for NAMENDA XR) - Tier 1; QL memantine hcl oral solution 2 mg/ml - Tier 1; QL memantine hcl oral tablet (generic for NAMENDA) - Tier 1; QL NAMENDA XR TITRATION PACK - Tier 2; QL

Antidepressants - Drugs to Treat Depression Antidepressants, Other - Antidepressants APLENZIN - Tier 2; QL bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg (generic for WELLBUTRIN XL) - Tier 1; QL BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG - Tier 2; QL bupropion hcl oral - Tier 1; QL chlordiazepoxide-amitriptyline - Tier 1 FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; QL mirtazapine oral (generic for REMERON) - Tier 1; QL olanzapine-fluoxetine hcl (generic for SYMBYAX) - Tier 1; QL; AL perphenazine-amitriptyline - Tier 1 SPRAVATO (56 MG DOSE) - Tier 2; QL; AL SPRAVATO (84 MG DOSE) - Tier 2; QL; AL ZULRESSO - Tier 2; PA

Monoamine Oxidase Inhibitors - Antidepressants EMSAM - Tier 2; QL MARPLAN - Tier 2; QL phenelzine sulfate oral (generic for NARDIL) - Tier 1; QL tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 20 Preferred Agents Non-Preferred Agents SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide (generic for CELEXA) - Tier 1; QL CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL DESVENLAFAXINE ER - Tier 2; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL desvenlafaxine succinate er (generic for PRISTIQ) - Tier 1; QL DRIZALMA SPRINKLE - Tier 2; QL duloxetine hcl oral (generic for CYMBALTA) - Tier 1; QL escitalopram oxalate (generic for LEXAPRO) - Tier 1; QL FETZIMA - Tier 2; QL FETZIMA TITRATION - Tier 2; QL fluoxetine hcl (pmdd) - Tier 1; QL fluoxetine hcl oral (generic for PROZAC) - Tier 1; QL fluvoxamine maleate - Tier 1; QL fluvoxamine maleate er - Tier 1; QL maprotiline hcl - Tier 1; QL nefazodone hcl - Tier 1; QL paroxetine hcl (generic for PAXIL) - Tier 1; QL; AL paroxetine hcl er (generic for PAXIL CR) - Tier 1; QL; AL PAXIL ORAL SUSPENSION - Tier 2; QL; AL PEXEVA - Tier 2; QL; AL sertraline hcl oral (generic for ZOLOFT) - Tier 1; QL trazodone hcl oral - Tier 1; QL TRINTELLIX - Tier 2; QL venlafaxine hcl - Tier 1; QL venlafaxine hcl er (generic for EFFEXOR XR) - Tier 1; QL VIIBRYD - Tier 2; QL VIIBRYD STARTER PACK - Tier 2

Tricyclics - Antidepressants amitriptyline hcl oral - Tier 1; QL amoxapine - Tier 1; QL clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; QL desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL doxepin hcl oral capsule - Tier 1; QL doxepin hcl oral concentrate - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents imipramine hcl oral - Tier 1; QL imipramine pamoate - Tier 1; QL nortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL protriptyline hcl - Tier 1; QL trimipramine maleate oral - Tier 1; QL

Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea - Tier 1 BONINE (brand for ra motion sickness relief) - Tier 2 compro (generic for COMPRO) - Tier 1 driminate (generic for DRIMINATE) - Tier 1 meclizine hcl oral tablet 12.5 mg - Tier 1; QL meclizine hcl oral tablet 25 mg (generic for TRAVEL-EASE) - Tier 1 meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 metoclopramide hcl oral solution - Tier 1; QL motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet chewable 25 mg (generic for BONINE) - Tier 1 motion-time (generic for BONINE) - Tier 1 nausea control - Tier 1 nausea relief - Tier 1 perphenazine oral - Tier 1; QL; AL prochlorperazine (generic for COMPRO) - Tier 1 travel ease (generic for BONINE) - Tier 1 trimethobenzamide hcl oral - Tier 1; QL

Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs aprepitant (generic for EMEND) - Tier 1; QL AKYNZEO ORAL - Tier 2; PA; QL dronabinol (generic for MARINOL) - Tier 1; PA; QL EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL ondansetron hcl oral tablet (generic for ZOFRAN) - Tier 1; QL ondansetron odt - Tier 1; QL

Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day (generic for MONISTAT 3) - Tier 1 DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 GYNAZOLE-1 - Tier 2; PA; QL 3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - Tier 1 ALOE VESTA CLEAR ANTIFUNGAL - Tier 2 antifungal (tolnaftate) (generic for TINACTIN) - Tier 1 antifungal external cream (generic for TINACTIN) - Tier 1 antifungal foot care (generic for LAMISIL AT) - Tier 1 antifungal miconazole (generic for CAVILON) - Tier 1 antifungal tolnaftate (generic for TINACTIN) - Tier 1 atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1 athletes foot (tolnaftate) external aerosol powder 1 % (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) - Tier 1 athletes foot external aerosol powder 2 % (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1 athletes foot powder spray (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot spray (generic for TINACTIN) - Tier 1 athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) - Tier 1 CAVILON (brand for sm antifungal miconazole) - Tier 2 ciclodan (generic for CICLODAN) - Tier 1; QL ciclopirox external solution (generic for CICLODAN) - Tier 1; QL clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole external cream (generic for DESENEX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents clotrimazole external solution (generic for FUNGICURE INTENSIVE/NAILGUARD) - Tier 1; QL clotrimazole mouth/throat - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL CRUEX PRESCRIPTION STRENGTH (brand for ra atheletes foot) - Tier 2 DESENEX JOCK ITCH (brand for ra atheletes foot) - Tier 2 fluconazole oral (generic for DIFLUCAN) - Tier 1; QL foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 foot care (terbinafine) (generic for LAMISIL AT) - Tier 1 FORMULA 3 THE TREATMENT (brand for tinaspore) - Tier 2 FORMULA 7 THE SOLUTION (brand for tinaspore) - Tier 2 fungi-guard (generic for TINACTIN) - Tier 1 griseofulvin microsize oral - Tier 1; QL griseofulvin ultramicrosize - Tier 1; QL GYNE-LOTRIMIN (brand for sm clotrimazole vaginal) - Tier 2; QL GYNE-LOTRIMIN 3 (brand for gnp clotrimazole 3) - Tier 2 itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1 jock itch max st (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 ketoconazole external cream - Tier 1; QL ketoconazole external shampoo - Tier 1; QL ketoconazole oral - Tier 1; QL LAMISIL AT EXTERNAL CREAM (brand for cvs jock itch) - Tier 2 LAMISIL AT JOCK ITCH (brand for cvs jock itch) - Tier 2 micaderm (generic for CAVILON) - Tier 1 miconazole 1 (generic for MONISTAT 1 COMBO PACK) - Tier 1 miconazole 1 combo pack (generic for MONISTAT 1 COMBO PACK) - Tier 1 miconazole 3 - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBO PACK APP) - Tier 1 miconazole 3 combo pack app (generic for MONISTAT 3 COMBO PACK APP) - Tier 1 miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBINATION PACK) - Tier 1 miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 miconazole 7 vaginal suppository 100 mg - Tier 1 miconazole antifungal (generic for CAVILON) - Tier 1 miconazole nitrate external (generic for CAVILON) - Tier 1 miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 nyamyc (generic for NYAMYC) - Tier 1; QL nystatin external - Tier 1; QL nystatin mouth/throat - Tier 1; QL nystatin oral - Tier 1; QL nystop (generic for NYAMYC) - Tier 1; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1 terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1 terconazole vaginal cream - Tier 1; QL TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2 TINACTIN EXTERNAL CREAM (brand for eq athletes foot (tolnaftate)) - Tier 2 tinaspore (generic for FORMULA 3 THE TREATMENT) - Tier 1 tioconazole 1 vaginal ointment 6.5 % (generic for MONISTAT 1-DAY) - Tier 1 tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1 tolnaftate antifungal (generic for TINACTIN) - Tier 1 tolnaftate external cream (generic for TINACTIN) - Tier 1 voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 25 Preferred Agents Non-Preferred Agents Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL COLCHICINE ORAL CAPSULE - Tier 2; PA; QL febuxostat (generic for ULORIC) - Tier 1; PA; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL MITIGARE (brand for colchicine) - Tier 2; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL probenecid - Tier 1; QL

Antimigraine Agents - Drugs to Treat Migraines Ergot Alkaloids - Migraine Drugs dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; QL ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL MIGERGOT - Tier 2; QL

Prophylactic - Migraine Drugs AIMOVIG - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; QL EMGALITY - Tier 2; PA; QL REYVOW - Tier 2; PA; QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL UBRELVY - Tier 2; PA; QL NURTEC - Tier 2; PA; QL

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs naratriptan hcl (generic for AMERGE) - Tier 1; ST; QL rizatriptan benzoate - Tier 1; QL sumatriptan nasal (generic for IMITREX) - Tier 1; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - Tier 1; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL

Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 26 Preferred Agents Non-Preferred Agents Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL

Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1; QL rifabutin (generic for MYCOBUTIN) - Tier 1; QL

Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL ethambutol hcl oral tablet 100 mg - Tier 1 ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QL isoniazid oral - Tier 1; QL PASER - Tier 2; QL PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1; QL rifampin oral - Tier 1; QL SIRTURO - Tier 2; QL TRECATOR - Tier 2; QL

Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide oral capsule - Tier 1 CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 GLEOSTINE - Tier 2 LEUKERAN - Tier 2 MATULANE - Tier 2; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 27 Preferred Agents Non-Preferred Agents melphalan (generic for ALKERAN) - Tier 1 MYLERAN - Tier 2 temozolomide oral capsule 100 mg, 140 mg (generic for TEMODAR) - Tier 1; PA; SP temozolomide oral capsule 180 mg, 250 mg (generic for TEMODAR) - Tier 1; PA; SP; QL temozolomide oral capsule 20 mg, 5 mg - Tier 1; PA; SP; QL

Antiandrogens - Hormone Suppressants abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL XTANDI ORAL CAPSULE - Tier 2; PA; SP; QL bicalutamide (generic for CASODEX) - Tier 1; QL YONSA - Tier 2; PA; SP; QL ERLEADA - Tier 2; PA; SP; QL ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL flutamide - Tier 1; QL NUBEQA - Tier 2; PA; QL

Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL

Antiestrogens/Modifiers - Chemotherapy Agents tamoxifen citrate oral - Tier 1; QL toremifene citrate (generic for FARESTON) - Tier 1; QL

Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; PA; SP XELODA (brand for capecitabine) - Tier 2; PA; SP DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2 DROXIA ORAL CAPSULE 400 MG - Tier 2; QL hydroxyurea oral (generic for HYDREA) - Tier 1; QL mercaptopurine oral - Tier 1; QL TABLOID - Tier 2; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 28 Preferred Agents Non-Preferred Agents Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral tablet 10 mg - Tier 1 KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; QL KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL LONSURF - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL NINLARO - Tier 2; PA; SP; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL ROZLYTREK - Tier 2; PA; SP; QL VERZENIO - Tier 2; PA; SP; QL ZOLINZA - Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1; QL exemestane (generic for AROMASIN) - Tier 1; QL letrozole oral (generic for FEMARA) - Tier 1; QL

Enzyme Inhibitors - Chemotherapy Agents BALVERSA - Tier 2; PA; SP; QL etoposide oral - Tier 1 HYCAMTIN ORAL - Tier 2; PA; SP RUBRACA - Tier 2; PA; SP; QL ZEJULA - Tier 2; PA; SP; QL

Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL AFINITOR ORAL TABLET 10 MG - Tier 2; PA; SP; QL ALECENSA - Tier 2; PA; SP; QL ALUNBRIG - Tier 2; PA; SP; QL BOSULIF - Tier 2; PA; SP; QL BRUKINSA - Tier 2; PA; SP; QL CABOMETYX - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 29 Preferred Agents Non-Preferred Agents CALQUENCE - Tier 2; PA; SP; QL CAPRELSA - Tier 2; PA; SP; QL COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL COTELLIC - Tier 2; PA; SP; QL DAURISMO - Tier 2; PA; SP; QL ERIVEDGE - Tier 2; PA; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg (generic for AFINITOR) - Tier 1; PA; SP; QL everolimus oral tablet 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP FARYDAK - Tier 2; PA; SP; QL GILOTRIF - Tier 2; PA; SP; QL IBRANCE - Tier 2; PA; SP; QL ICLUSIG ORAL TABLET 15 MG, 45 MG - Tier 2; PA; SP; QL IDHIFA - Tier 2; PA; SP; QL imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL IMBRUVICA - Tier 2; PA; SP; QL INLYTA - Tier 2; PA; SP; QL IRESSA - Tier 2; PA; SP; QL JAKAFI - Tier 2; PA; SP; QL lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL LYNPARZA - Tier 2; PA; SP; QL MEKINIST - Tier 2; PA; SP; QL NEXAVAR - Tier 2; PA; SP; QL ODOMZO - Tier 2; PA; SP; QL RYDAPT - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 30 Preferred Agents Non-Preferred Agents SPRYCEL - Tier 2; PA; SP; QL STIVARGA - Tier 2; PA; SP; QL SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG - Tier 2; PA; SP; QL SUTENT ORAL CAPSULE 37.5 MG - Tier 2; PA; SP TAFINLAR - Tier 2; PA; SP; QL TASIGNA - Tier 2; PA; SP; QL TIBSOVO - Tier 2; PA; SP; QL TURALIO - Tier 2; PA; SP; QL VENCLEXTA - Tier 2; PA; SP; QL VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL VITRAKVI - Tier 2; PA; SP; QL VOTRIENT - Tier 2; PA; SP; QL XALKORI - Tier 2; PA; SP; QL ZELBORAF - Tier 2; PA; SP; QL ZYDELIG - Tier 2; PA; SP; QL

Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP PANRETIN - Tier 2; PA TARGRETIN EXTERNAL - Tier 2; PA; SP tretinoin oral - Tier 1; SP

Treatment Adjuncts - Supportive Chemotherapy Drugs MESNEX ORAL - Tier 2; SP

Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; Members > = ARAKODA - Tier 2; PA; QL 8 years of age will require PA; QL; AL atovaquone oral (generic for MEPRON) - Tier 1; PA; QL BENZNIDAZOLE - Tier 2; QL chloroquine phosphate oral - Tier 1; QL hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; QL IMPAVIDO - Tier 2; PA; QL KRINTAFEL - Tier 2; QL mefloquine hcl - Tier 1; QL nitazoxanide (generic for ALINIA) - Tier 1; QL pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1 primaquine phosphate oral tablet 26.3 mg - Tier 1 pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL

Pediculicides/Scabicides - Scabies and Lice Drugs crotan - Tier 1; QL lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice treatment - Tier 1 lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1 lice treatment external liquid 1 % (generic for NIX CREME RINSE) - Tier 1 lice treatment external shampoo 0.33-4 % (generic for RID LICE KILLING SHAMPOO) - Tier 1 malathion (generic for OVIDE) - Tier 1; QL permethrin external (generic for ELIMITE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for hm lice killing max st) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1

Antiparkinson Agents - Drugs to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease Drugs benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL

Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral capsule - Tier 1; QL amantadine hcl oral syrup - Tier 1; QL entacapone (generic for COMTAN) - Tier 1; QL tolcapone (generic for TASMAR) - Tier 1; QL

Dopamine Agonists - Parkinson's Disease Drugs pramipexole dihydrochloride oral tablet 0.125 mg, 0.5 mg, 1 mg (generic for MIRAPEX) - Tier 1; QL pramipexole dihydrochloride oral tablet 0.25 mg, 1.5 mg - Tier 1; QL pramipexole dihydrochloride oral tablet 0.75 mg (generic for MIRAPEX) - Tier 1 ropinirole hcl - Tier 1; QL

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa er - Tier 1; QL carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs selegiline hcl oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs ADASUVE - Tier 2 chlorpromazine hcl injection - Tier 1 chlorpromazine hcl oral - Tier 1; QL fluphenazine decanoate injection - Tier 1; AL fluphenazine hcl injection - Tier 1; AL fluphenazine hcl oral concentrate - Tier 1; AL fluphenazine hcl oral elixir - Tier 1; AL fluphenazine hcl oral tablet - Tier 1; QL; AL haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; AL haloperidol lactate oral - Tier 1 haloperidol oral - Tier 1; QL loxapine succinate - Tier 1; QL; AL molindone hcl - Tier 1; QL pimozide - Tier 1; QL prochlorperazine maleate oral - Tier 1 thioridazine hcl oral - Tier 1; QL thiothixene - Tier 1; QL trifluoperazine hcl - Tier 1; QL

2nd Generation/Atypical - Mood Disorder Drugs ABILIFY MAINTENA - Tier 2; QL; AL ABILIFY (brand for aripiprazole) - Tier 2; PA; QL ABILIFY MYCITE - Tier 2; QL; AL GEODON INTRAMUSCULAR (brand for ziprasidone mesylate) - Tier 2; ABILIFY MYCITE MAINTENANCE KIT - Tier 2; QL PA; AL ABILIFY MYCITE STARTER KIT - Tier 2; QL GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; QL; AL aripiprazole (generic for ABILIFY) - Tier 1; QL INVEGA (brand for paliperidone er) - Tier 2; PA; QL ARISTADA - Tier 2; QL; AL RISPERDAL (brand for risperidone) - Tier 2; PA; QL ARISTADA INITIO - Tier 2; QL; AL SAPHRIS (brand for asenapine maleate) - Tier 2; PA; QL asenapine maleate (generic for SAPHRIS) - Tier 1; QL SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; QL CAPLYTA - Tier 2; QL; AL SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL FANAPT - Tier 2; QL; AL ZYPREXA INTRAMUSCULAR (brand for olanzapine) - Tier 2; PA FANAPT TITRATION PACK - Tier 2; QL; AL ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents INVEGA SUSTENNA - Tier 2; QL; AL ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; QL INVEGA TRINZA - Tier 2; QL; AL LATUDA - Tier 2; QL; AL NUPLAZID - Tier 2; QL olanzapine intramuscular (generic for ZYPREXA) - Tier 1 olanzapine oral (generic for ZYPREXA) - Tier 1; QL paliperidone er (generic for INVEGA) - Tier 1; QL PERSERIS - Tier 2; QL; AL quetiapine fumarate (generic for SEROQUEL) - Tier 1; QL quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; QL REXULTI - Tier 2; QL; AL RISPERDAL CONSTA - Tier 2; QL; AL risperidone (generic for RISPERDAL) - Tier 1; QL SECUADO - Tier 2; QL; AL VRAYLAR ORAL CAPSULE - Tier 2; QL; AL VRAYLAR ORAL CAPSULE THERAPY PACK - Tier 2; QL ziprasidone hcl (generic for GEODON) - Tier 1; QL; AL ziprasidone mesylate (generic for GEODON) - Tier 1; AL ZYPREXA RELPREVV - Tier 2; QL; AL

Treatment-Resistant - Mood Disorder Drugs clozapine (generic for CLOZARIL) - Tier 1; QL; AL CLOZARIL (brand for clozapine) - Tier 2; PA; QL; AL VERSACLOZ - Tier 2; QL; AL

Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL

Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs BARACLUDE ORAL SOLUTION - Tier 2; SP; QL VEMLIDY - Tier 2; PA; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; SP; QL

Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP

Antiherpetic Agents - Herpes Drugs acyclovir 5% ointment (generic for ZOVIRAX) - Tier 1; QL acyclovir oral - Tier 1; QL trifluridine - Tier 1; QL valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs DOVATO - Tier 2; QL GENVOYA - Tier 2; PA; QL ISENTRESS HD - Tier 2; QL ISENTRESS ORAL PACKET - Tier 2; Members > = 2 years of age will require PA; QL; AL ISENTRESS ORAL TABLET - Tier 2; QL ISENTRESS ORAL TABLET CHEWABLE - Tier 2; QL STRIBILD - Tier 2; PA; QL TIVICAY - Tier 2; QL TIVICAY PD - Tier 2; QL; AL TRIUMEQ - Tier 2; QL TYBOST - Tier 2; QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs COMPLERA - Tier 2; PA; QL ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; PA; QL DELSTRIGO - Tier 2; QL efavirenz-emtricitab-tenofovir (generic for ATRIPLA) - Tier 1; PA; QL EDURANT - Tier 2; QL INTELENCE ORAL TABLET 200 MG (brand for etravirine) - Tier 2; PA; QL efavirenz (generic for SUSTIVA) - Tier 1; QL PIFELTRO - Tier 2; PA; QL efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; QL SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 36 Preferred Agents Non-Preferred Agents etravirine (generic for INTELENCE) - Tier 1; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL INTELENCE ORAL TABLET 25 MG - Tier 2; QL JULUCA - Tier 2; QL nevirapine - Tier 1; QL nevirapine er (generic for VIRAMUNE XR) - Tier 1; QL ODEFSEY - Tier 2; QL VIRAMUNE (brand for nevirapine) - Tier 2; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs abacavir sulfate (generic for ZIAGEN) - Tier 1; QL CIMDUO - Tier 2; PA; QL abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL DESCOVY - Tier 2; PA; QL abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; QL TRUVADA ORAL TABLET 200-300 MG (brand for emtricitabine-tenofovir BIKTARVY - Tier 2; PA; QL df) - Tier 2; PA; QL emtricitabine (generic for EMTRIVA) - Tier 1; QL emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL EMTRIVA ORAL SOLUTION - Tier 2; QL lamivudine oral solution (generic for EPIVIR) - Tier 1; QL lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; QL lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; QL stavudine - Tier 1; QL TEMIXYS - Tier 2; QL tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL VIREAD ORAL POWDER - Tier 2; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; QL zidovudine (generic for RETROVIR) - Tier 1; QL

Anti-HIV Agents, Other - HIV Drugs FUZEON - Tier 2; QL SELZENTRY - Tier 2; QL

Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS - Tier 2; QL KALETRA (brand for lopinavir-ritonavir) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents atazanavir sulfate (generic for REYATAZ) - Tier 1; QL REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA; QL CRIXIVAN - Tier 2; QL SYMTUZA - Tier 2; PA; QL EVOTAZ - Tier 2; QL fosamprenavir calcium (generic for LEXIVA) - Tier 1; QL INVIRASE - Tier 2; QL LEXIVA ORAL SUSPENSION - Tier 2; QL lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL NORVIR ORAL PACKET - Tier 2; QL NORVIR ORAL SOLUTION - Tier 2; QL PREZCOBIX - Tier 2; QL PREZISTA - Tier 2; QL REYATAZ ORAL PACKET - Tier 2; Members > = 8 years of age will require PA; QL; AL ritonavir (generic for NORVIR) - Tier 1; QL VIRACEPT - Tier 2; QL

Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA; oseltamivir phosphate oral suspension reconstituted (generic for QL TAMIFLU) - Tier 1; QL; AL TAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir RELENZA DISKHALER - Tier 2; QL phosphate) - Tier 2; PA; QL; AL rimantadine hcl - Tier 1; QL XOFLUZA (40 MG DOSE) - Tier 2; PA; QL XOFLUZA (80 MG DOSE) - Tier 2; PA; QL

Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs buspirone hcl oral - Tier 1; QL hydroxyzine hcl oral - Tier 1; QL meprobamate - Tier 1; QL

Benzodiazepines - Anxiety Drugs alprazolam er (generic for XANAX XR) - Tier 1; QL alprazolam intensol - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents alprazolam oral (generic for XANAX) - Tier 1; QL alprazolam xr (generic for XANAX XR) - Tier 1; QL chlordiazepoxide hcl - Tier 1; QL clonazepam oral (generic for KLONOPIN) - Tier 1; QL clorazepate dipotassium - Tier 1; QL diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; QL diazepam oral concentrate (generic for DIAZEPAM INTENSOL) - Tier 1; QL diazepam oral solution - Tier 1 diazepam oral tablet (generic for VALIUM) - Tier 1; QL estazolam - Tier 1; QL lorazepam injection (generic for ATIVAN) - Tier 1 lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1 lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM INTENSOL) - Tier 1 lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL midazolam hcl oral - Tier 1 MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION - Tier 2 MIDAZOLAM+SYRSPEND SF - Tier 2 oxazepam - Tier 1; QL quazepam (generic for DORAL) - Tier 1; QL temazepam oral capsule 22.5 mg (generic for RESTORIL) - Tier 1; QL triazolam - Tier 1; QL

Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs divalproex sodium er (generic for DEPAKOTE ER) - Tier 1 divalproex sodium oral (generic for DEPAKOTE) - Tier 1 EQUETRO - Tier 2; QL lithium - Tier 1 lithium carbonate er (generic for LITHOBID) - Tier 1 lithium carbonate oral - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 39 Preferred Agents Non-Preferred Agents Blood Glucose Regulators - Drugs to Regulate Blood Sugar Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL ADLYXIN - Tier 2; PA; QL BYETTA 10 MCG PEN - Tier 2; PA; QL ADLYXIN STARTER PACK - Tier 2; PA; QL BYETTA 5 MCG PEN - Tier 2; PA; QL ALOGLIPTIN BENZOATE - Tier 2; PA; QL GLYXAMBI - Tier 2; PA ALOGLIPTIN-METFORMIN HCL - Tier 2; PA; QL INVOKAMET - Tier 2; PA; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; PA; QL INVOKAMET XR - Tier 2; PA; QL FARXIGA - Tier 2; PA; QL INVOKANA - Tier 2; PA; QL glimepiride (generic for AMARYL) - Tier 1; QL JANUMET - Tier 2; PA; QL glipizide er (generic for GLUCOTROL XL) - Tier 1; QL JANUMET XR - Tier 2; PA; QL glipizide ir - Tier 1; QL JANUVIA - Tier 2; PA; QL glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL JARDIANCE - Tier 2; PA; QL glyburide micronized (generic for GLYNASE) - Tier 1; QL JENTADUETO - Tier 2; PA; QL glyburide oral - Tier 1; QL JENTADUETO XR - Tier 2; PA; QL glyburide-metformin - Tier 1; QL KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; QL metformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA; QL KOMBIGLYZE XR - Tier 2; PA; QL metformin hcl er oral tablet extended release 24 hour 500 mg - Tier 1; NESINA (brand for alogliptin benzoate) - Tier 2; PA; QL QL ONGLYZA - Tier 2; PA; QL metformin hcl er oral tablet extended release 24 hour 750 mg - Tier 1 OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; QL metformin hcl oral tablet - Tier 1; QL OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML - nateglinide - Tier 1; QL Tier 2; PA; QL pioglitazone hcl (generic for ACTOS) - Tier 1; QL QTERN - Tier 2; PA; QL repaglinide - Tier 1; QL RYBELSUS - Tier 2; PA; QL SEGLUROMET - Tier 2; PA; QL STEGLUJAN - Tier 2; PA; QL SOLIQUA - Tier 2; PA; QL SYNJARDY - Tier 2; PA; QL STEGLATRO - Tier 2; PA; QL SYNJARDY XR - Tier 2; PA; QL SYMLINPEN 120 - Tier 2; PA; QL TRADJENTA - Tier 2; PA; QL SYMLINPEN 60 - Tier 2; PA; QL TRIJARDY XR - Tier 2; PA; QL TRULICITY - Tier 2; PA; QL XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 VICTOZA - Tier 2; PA; QL MG, 10-500 MG - Tier 2; PA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG - Tier 2; PA; QL XULTOPHY - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; PA; QL BAQSIMI TWO PACK - Tier 2; QL GLUCAGEN HYPOKIT - Tier 2; QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - Tier 2; QL glucagon emergency kit 1 mg injection - Tier 1; QL glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL GVOKE HYPOPEN 1-PACK - Tier 2; QL GVOKE HYPOPEN 2-PACK - Tier 2; QL GVOKE PFS - Tier 2; QL soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL

Insulins - Diabetic Drugs ADMELOG (brand for insulin lispro) - Tier 2; QL AFREZZA - Tier 2; PA; QL ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; APIDRA SOLOSTAR - Tier 2; PA; QL PA; QL APIDRA VIAL - Tier 2; PA; QL BASAGLAR KWIKPEN - Tier 2; QL FIASP - Tier 2; PA; QL HUMALOG MIX 50/50 - Tier 2; QL FIASP FLEXTOUCH - Tier 2; PA; QL HUMALOG MIX 75/25 - Tier 2; QL HUMALOG (brand for insulin lispro) - Tier 2; PA; QL HUMULIN 70/30 VIAL - Tier 2; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - HUMULIN N VIAL - Tier 2; QL Tier 2; PA; QL HUMULIN R VIAL - Tier 2; QL HUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QL INSULIN ASPART PROT & ASPART - Tier 2; QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL NOVOLIN 70/30 RELION - Tier 2; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - NOVOLIN 70/30 VIAL - Tier 2; QL Tier 2; PA; QL NOVOLIN N RELION - Tier 2; QL HUMULIN 70/30 KWIKPEN - Tier 2; PA; QL NOVOLIN N VIAL - Tier 2; QL HUMULIN N KWIKPEN - Tier 2; PA; QL NOVOLIN R RELION - Tier 2; QL HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL NOVOLIN R VIAL - Tier 2; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL SEMGLEE - Tier 2; QL INSULIN ASP PROT & ASP FLEXPEN - Tier 2; PA; QL INSULIN ASPART - Tier 2; PA; QL INSULIN LISPRO - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents INSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QL LANTUS SOLOSTAR - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; PA; QL LEVEMIR U-100 FLEXTOUCH - Tier 2; PA; QL LEVEMIR U-100 VIAL - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL NOVOLIN N FLEXPEN - Tier 2; PA; QL NOVOLIN R FLEXPEN - Tier 2; PA; QL NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; PA; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL TOUJEO SOLOSTAR - Tier 2; PA; QL TRESIBA - Tier 2; PA; QL TRESIBA FLEXTOUCH - Tier 2; PA; QL

Blood Products and Modifiers Blood Products and Modifiers, Other NYVEPRIA - Tier 2; PA; SP

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2; QL PRADAXA - Tier 2; PA; QL ELIQUIS DVT/PE STARTER PACK - Tier 2; QL XARELTO - Tier 2; PA; QL enoxaparin sodium (generic for LOVENOX) - Tier 1; QL XARELTO STARTER PACK - Tier 2; PA; QL heparin sodium (porcine) - Tier 1 heparin sodium (porcine) pf - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1 SAVAYSA - Tier 2; QL warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1

Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 DOPTELET - Tier 2; PA; SP; QL ARANESP (ALBUMIN FREE) INJECTION SOLUTION - Tier 2; PA; SP EPOGEN - Tier 2; PA; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED FULPHILA - Tier 2; PA; SP SYRINGE 10 MCG/0.4ML - Tier 2; PA; SP; QL GRANIX - Tier 2; PA; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED LEUKINE - Tier 2; PA; SP SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2; MCG/0.3ML - Tier 2; PA; SP PA; SP; QL MOZOBIL - Tier 2; PA; SP; QL NEUPOGEN INJECTION SOLUTION 300 MCG/ML - Tier 2; PA; SP MULPLETA - Tier 2; PA; SP; QL NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML - Tier 2; PA; SP; QL NEULASTA - Tier 2; PA; SP NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE - Tier 2; PA; NEULASTA ONPRO - Tier 2; PA; SP SP PROMACTA ORAL PACKET 25 MG - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP PROMACTA ORAL TABLET - Tier 2; PA; SP; QL PROCRIT - Tier 2; PA; SP RETACRIT - Tier 2; PA; SP UDENYCA - Tier 2; PA; SP ZARXIO - Tier 2; PA; SP ZIEXTENZO - Tier 2; PA; SP

Hemostasis Agents - Drugs to Stop Bleeding aminocaproic acid oral (generic for AMICAR) - Tier 1; QL tranexamic acid oral (generic for LYSTEDA) - Tier 1; QL

Platelet Modifying Agents - Platelet Modifying Drugs BRILINTA - Tier 2; PA; QL CABLIVI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 43 Preferred Agents Non-Preferred Agents cilostazol - Tier 1; QL clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL dipyridamole oral - Tier 1; QL prasugrel hcl (generic for EFFIENT) - Tier 1; PA; QL

Cardiovascular Agents Cardiovascular Agents, Other NEXLIZET - Tier 2; PA; QL

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs clonidine (generic for CATAPRES-TTS-1) - Tier 1; QL clonidine hcl oral - Tier 1; QL; AL guanfacine hcl - Tier 1 methyldopa - Tier 1; QL midodrine hcl - Tier 1; QL

Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL prazosin hcl oral (generic for MINIPRESS) - Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs losartan potassium oral (generic for COZAAR) - Tier 1; QL EDARBI - Tier 2; PA; QL

Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL captopril oral - Tier 1; QL enalapril maleate oral (generic for VASOTEC) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 44 Preferred Agents Non-Preferred Agents EPANED - Tier 2; Members > = 8 years of age will require PA; QL; AL fosinopril sodium - Tier 1; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL ramipril (generic for ALTACE) - Tier 1; QL trandolapril - Tier 1; QL

Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL disopyramide phosphate (generic for NORPACE) - Tier 1; QL MULTAQ - Tier 2; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL flecainide acetate - Tier 1; QL PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL mexiletine hcl oral - Tier 1; QL RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 NORPACE CR - Tier 2 MG, 325 MG (brand for propafenone hcl er) - Tier 2; PA; QL propafenone hcl - Tier 1; QL RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 425 quinidine gluconate er - Tier 1; QL MG (brand for propafenone hcl er) - Tier 2; PA quinidine sulfate - Tier 1; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

Beta-adrenergic Blocking Agents - Blood Pressure Drugs acebutolol hcl oral - Tier 1; QL atenolol oral (generic for TENORMIN) - Tier 1; QL betaxolol hcl oral - Tier 1; QL bisoprolol fumarate oral - Tier 1; QL carvedilol (generic for COREG) - Tier 1; QL HEMANGEOL - Tier 2 INDERAL XL - Tier 2 INNOPRAN XL - Tier 2 labetalol hcl oral - Tier 1; QL metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL metoprolol tartrate oral tablet 100 mg, 50 mg (generic for LOPRESSOR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents metoprolol tartrate oral tablet 25 mg - Tier 1; QL propranolol hcl er (generic for INDERAL LA) - Tier 1 propranolol hcl oral - Tier 1

Calcium Channel Blocking Agents - Blood Pressure Drugs amlodipine besylate oral (generic for NORVASC) - Tier 1; QL cartia xt (generic for CARTIA XT) - Tier 1; QL diltiazem hcl er - Tier 1; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL diltiazem hcl er coated beads oral capsule extended release 24 hour (generic for CARTIA XT) - Tier 1; QL diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL dilt-xr - Tier 1; QL felodipine er - Tier 1; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; QL nifedipine oral - Tier 1; QL nimodipine oral - Tier 1; QL NYMALIZE - Tier 2; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QL verapamil hcl er oral tablet extended release (generic for CALAN SR) - Tier 1; QL verapamil hcl oral - Tier 1; QL

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL BIDIL - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL CORLANOR - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL digitek (generic for DIGITEK) - Tier 1; QL digox (generic for DIGITEK) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 46 Preferred Agents Non-Preferred Agents digoxin oral solution - Tier 1 digoxin oral tablet (generic for DIGITEK) - Tier 1; QL enalapril-hydrochlorothiazide - Tier 1; QL ENTRESTO - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL isoxsuprine hcl oral - Tier 1 lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL methyldopa-hydrochlorothiazide - Tier 1; QL pentoxifylline er - Tier 1; QL propranolol-hctz - Tier 1; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL ranolazine er (generic for RANEXA) - Tier 1; PA; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL VYNDAMAX - Tier 2; PA; SP; QL VYNDAQEL - Tier 2; PA; SP; QL

Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral - Tier 1; QL

Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1; QL furosemide oral solution 10 mg/ml - Tier 1; QL furosemide oral tablet (generic for LASIX) - Tier 1; QL torsemide - Tier 1; QL

Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL

Diuretics, Thiazide - Cardiac Drugs

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 47 Preferred Agents Non-Preferred Agents chlorthalidone - Tier 1; QL DIURIL - Tier 2; QL hydrochlorothiazide oral capsule - Tier 1; QL hydrochlorothiazide oral tablet 12.5 mg - Tier 1 hydrochlorothiazide oral tablet 25 mg, 50 mg - Tier 1; QL indapamide - Tier 1; QL metolazone - Tier 1; QL

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; PA; QL fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; PA; QL fenofibrate oral tablet 160 mg, 54 mg - Tier 1; PA; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL lovastatin oral - Tier 1; QL; AL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL simvastatin oral (generic for ZOCOR) - Tier 1; QL

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light oral powder (generic for PREVALITE) - Tier 1; QL NEXLETOL - Tier 2; PA; QL cholestyramine oral powder (generic for QUESTRAN) - Tier 1; QL PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL ezetimibe (generic for ZETIA) - Tier 1; QL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QL niacor (generic for NIACOR) - Tier 1; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL prevalite oral powder (generic for PREVALITE) - Tier 1; QL REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 48 Preferred Agents Non-Preferred Agents Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate - Tier 1; QL isosorbide mononitrate - Tier 1; QL isosorbide mononitrate er - Tier 1; QL minitran (generic for MINITRAN) - Tier 1; QL NITRO-BID - Tier 2; QL NITRO-DUR (brand for nitroglycerin) - Tier 2; QL nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL RECTIV - Tier 2; PA; QL

Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL

Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA; SP; QL KESIMPTA - Tier 2; PA; SP; QL

Central Nervous System Agents - Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs ADZENYS ER (brand for amphetamine er) - Tier 2; QL; AL EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL; AL ADZENYS XR-ODT - Tier 2; QL; AL ZENZEDI ORAL TABLET 10 MG, 5 MG (brand for dextroamphetamine AMPHETAMINE ER - Tier 2; QL; AL sulfate) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents amphetamine sulfate (generic for EVEKEO) - Tier 1; QL; AL amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; QL; AL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - Tier 1; QL; AL dextroamphetamine sulfate (generic for ZENZEDI) - Tier 1; QL; AL dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1; QL; AL DYANAVEL XR - Tier 2; QL; AL EVEKEO ODT - Tier 2; QL; AL methamphetamine hcl (generic for DESOXYN) - Tier 1; AL MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG - Tier 2; QL; AL VYVANSE - Tier 2; QL; AL ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG - Tier 2; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs ADHANSIA XR - Tier 2; QL; AL APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; PA; QL; AL atomoxetine hcl (generic for STRATTERA) - Tier 1; QL; AL CONCERTA (brand for methylphenidate hcl er) - Tier 2; PA; QL; AL clonidine hcl er (generic for KAPVAY) - Tier 1; QL FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL; AL COTEMPLA XR-ODT - Tier 2; QL; AL KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL DAYTRANA - Tier 2; QL; AL METHYLIN (brand for methylphenidate hcl) - Tier 2; PA; QL; AL dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; QL; AL RITALIN (brand for methylphenidate hcl) - Tier 2; PA; QL; AL dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; QL; AL STRATTERA (brand for atomoxetine hcl) - Tier 2; PA; QL; AL guanfacine hcl er (generic for INTUNIV) - Tier 1; QL; AL JORNAY PM - Tier 2; QL; AL methylphenidate hcl er - Tier 1; QL; AL methylphenidate hcl er (cd) - Tier 1; QL; AL methylphenidate hcl er (la) (generic for RITALIN LA) - Tier 1; QL; AL methylphenidate hcl er (xr) (generic for APTENSIO XR) - Tier 1; QL; AL methylphenidate hcl oral (generic for RITALIN) - Tier 1; QL; AL QELBREE - Tier 2; QL; AL QUILLICHEW ER - Tier 2; QL; AL

Central Nervous System, Other - Miscellaneous Central Nervous System Drugs AUSTEDO - Tier 2; PA; SP; QL caffeine citrate oral - Tier 1; QL; AL INGREZZA - Tier 2; PA; SP; QL NAMZARIC - Tier 2; QL NUEDEXTA - Tier 2; PA; QL riluzole (generic for RILUTEK) - Tier 1; QL tetrabenazine (generic for XENAZINE) - Tier 1; PA; SP; QL

Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain pregabalin oral (generic for LYRICA) - Tier 1; QL SAVELLA - Tier 2 SAVELLA TITRATION PACK - Tier 2

Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO - Tier 2; PA; SP; QL AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; PA; SP; QL AVONEX PEN - Tier 2; PA; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; PA; AVONEX PREFILLED - Tier 2; PA; SP; QL SP; QL BETASERON - Tier 2; PA; SP GILENYA - Tier 2; PA; SP; QL COPAXONE (brand for glatiramer acetate) - Tier 2; PA; SP; QL glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP; QL EXTAVIA - Tier 2; PA; SP glatopa (generic for GLATOPA) - Tier 1; PA; SP; QL MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL PLEGRIDY - Tier 2; PA; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; PA; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL REBIF - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents REBIF REBIDOSE - Tier 2; PA; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; PA; SP; QL TECFIDERA (brand for dimethyl fumarate) - Tier 2; PA; SP; QL VUMERITY - Tier 2; PA; SP; QL

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier 1; QL DENTA 5000 PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; QL DENTAGEL (brand for sf) - Tier 2 easygel - Tier 1 fluoridex daily renewal - Tier 1 oralone (generic for ORALONE) - Tier 1; QL periogard (generic for PERIOGARD) - Tier 1; QL pilocarpine hcl oral tablet 5 mg (generic for SALAGEN) - Tier 1; QL pilocarpine hcl oral tablet 7.5 mg (generic for SALAGEN) - Tier 1 PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2 PREVIDENT 5000 PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; QL PREVIDENT DENTAL (brand for sf) - Tier 2 sf (generic for CAVAREST) - Tier 1 sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental gel (generic for CAVAREST) - Tier 1 triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL

Dermatological Agents - Drugs to Treat Skin Conditions

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents accutane (generic for ACCUTANE) - Tier 1; PA; QL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL acitretin (generic for SORIATANE) - Tier 1; PA; QL ABSORICA LD - Tier 2; PA; QL acne (generic for CLEARSKIN) - Tier 1 ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL acne control cleanser (generic for CLEARSKIN) - Tier 1 ACZONE EXTERNAL GEL 7.5 % (brand for dapsone) - Tier 2; PA; QL acne medication 10 external lotion - Tier 1; QL ALDARA (brand for imiquimod) - Tier 2; PA; QL acne medication 5 external lotion - Tier 1 AMZEEQ - Tier 2; PA; QL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE ATRALIN (brand for tretinoin) - Tier 2; PA; QL; AL WASH) - Tier 1 BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL advanced acne spot treat (generic for CLEAN & CLEAR ACNE SCRUB) BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - - Tier 1 Tier 2; PA; QL advanced healing external ointment (generic for FLANDERS BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL BUTTOCKS) - Tier 1 CARAC (brand for fluorouracil) - Tier 2; PA; QL ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL alclometasone dipropionate external ointment - Tier 1; QL CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL alum sulfate-ca acetate (generic for DOMEBORO) - Tier 1 DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL amcinonide external ointment - Tier 1 DIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QL ammonium lactate external cream - Tier 1; QL DIFFERIN EXTERNAL LOTION - Tier 2; PA; QL ammonium lactate external lotion (generic for AL12) - Tier 1 DOVONEX (brand for calcipotriene) - Tier 2; PA; ST; QL amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL DUPIXENT - Tier 2; PA; SP; QL arthritis pain relieving - Tier 1 EFUDEX (brand for fluorouracil) - Tier 2; PA; QL astringent solution (generic for DOMEBORO) - Tier 1 ELIDEL (brand for pimecrolimus) - Tier 2; PA; ST; Minimum age of 2 years; AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2 QL; AL AVAR-E GREEN (brand for sss 10-5) - Tier 2 ENSTILAR - Tier 2; PA; QL AVITA EXTERNAL CREAM (brand for tretinoin) - Tier 2; ST; QL; AL EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL azelaic acid external (generic for FINACEA) - Tier 1; QL EPIDUO FORTE - Tier 2; PA; QL baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - FABIOR (brand for tazarotene) - Tier 2; PA; QL Tier 1; QL FINACEA (brand for azelaic acid) - Tier 2; PA; QL beauty 360 pure glycerin - Tier 1 LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL beauty 360 soothing bath (generic for AVEENO BABY BATH MIRVASO - Tier 2; PA; QL TREATMENT) - Tier 1 OLUX (brand for clobetasol propionate) - Tier 2; PA; QL BENZAC AC WASH (brand for bp wash) - Tier 2 OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL BENZEPRO CREAMY WASH (brand for bp wash) - Tier 2 ONEXTON - Tier 2; PA; QL BENZEPRO EXTERNAL LIQUID - Tier 2 PROTOPIC EXTERNAL OINTMENT 0.03 % (brand for tacrolimus) - Tier 2; betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier 1; PA; ST; Minimum age of 2 years; QL; AL QL PROTOPIC EXTERNAL OINTMENT 0.1 % (brand for tacrolimus) - Tier 2; betamethasone dipropionate external lotion - Tier 1 PA; ST; Minimum age of 16 years; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents betamethasone dipropionate external ointment - Tier 1; QL QBREXZA - Tier 2; PA; QL betamethasone valerate external cream - Tier 1; QL RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL; AL betamethasone valerate external lotion - Tier 1 RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL; AL betamethasone valerate external ointment - Tier 1; QL RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere boro-packs (generic for DOMEBORO) - Tier 1 pump) - Tier 2; PA; QL; AL BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % (brand for RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; AL zinc oxide) - Tier 2; QL RHOFADE - Tier 2; PA; QL bp 10-1 - Tier 1 SERNIVO - Tier 2; PA; QL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 SILIQ - Tier 2; PA; SP; QL bp wash external liquid 7 % (generic for BENZEPRO CREAMY WASH) - SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL Tier 1 SORILUX (brand for calcipotriene) - Tier 2; PA; QL calamine external lotion , 8-8 % - Tier 1 TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL calamine-zinc oxide external lotion - Tier 1 TALTZ - Tier 2; PA; SP; QL calcipotriene external cream (generic for DOVONEX) - Tier 1; ST; QL TAZORAC EXTERNAL CREAM - Tier 2; PA; QL calcipotriene external ointment (generic for CALCITRENE) - Tier 1; ST; TAZORAC EXTERNAL GEL 0.1 % - Tier 2; PA; QL QL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL calcipotriene external solution - Tier 1; QL TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL calcitriol external (generic for VECTICAL) - Tier 1; ST; QL TREMFYA - Tier 2; PA; SP; QL capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; QL VANOS (brand for fluocinonide) - Tier 2; PA; QL capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL VECTICAL (brand for calcitriol) - Tier 2; PA; ST; QL capzix (generic for ZOSTRIX HP) - Tier 1; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL cerovel (generic for CEROVEL) - Tier 1; QL ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL claravis (generic for AMNESTEEM) - Tier 1; PA; QL ZYCLARA (brand for imiquimod) - Tier 2; PA; QL clearskin (generic for CLEARSKIN) - Tier 1 clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1; QL clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; QL clindamycin phosphate external solution - Tier 1; QL clindamycin phosphate external swab (generic for CLINDACIN ETZ) - Tier 1; QL clobetasol prop emollient base - Tier 1; QL clobetasol propionate e - Tier 1; QL clobetasol propionate external solution - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents clotrimazole-betamethasone - Tier 1; QL corn & callus remover (generic for COMPOUND W) - Tier 1 COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML - Tier 2; PA; SP; QL COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML - Tier 2; PA; SP; QL daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1 DERMAPHOR (brand for ra advanced healing) - Tier 2; QL diaper rash external ointment (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL dibucaine (perianal) (generic for NUPERCAINAL) - Tier 1 DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene treatment) - Tier 2; QL DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL DR SMITHS DIAPER - Tier 2; QL erythromycin external (generic for ERYGEL) - Tier 1; QL EUCRISA - Tier 2; ST; QL flanders buttocks (generic for FLANDERS BUTTOCKS) - Tier 1 fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; QL fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; QL fluocinonide emulsified base - Tier 1; QL fluocinonide external solution - Tier 1; QL fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL fluorouracil external solution - Tier 1 fluticasone propionate external cream - Tier 1; QL fluticasone propionate external ointment - Tier 1; QL glycerin external - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents glycerin external liquid 99.5 % - Tier 1 gormel - Tier 1; QL gormel 10 (generic for NUTRAPLUS) - Tier 1; QL halobetasol propionate external cream - Tier 1; QL hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 hydrocortisone acetate external (generic for GYNECORT 10) - Tier 1 hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL hydrocortisone butyrate external ointment - Tier 1; QL hydrocortisone butyrate external solution - Tier 1; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL hydrocortisone external lotion 2.5 % - Tier 1; QL hydrocortisone external ointment 0.5 % - Tier 1 hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH RELIEF MAX STR) - Tier 1; QL hydrocortisone external ointment 2.5 % - Tier 1; QL hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone-aloe - Tier 1 hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrolatum (generic for FLANDERS BUTTOCKS) - Tier 1 ILUMYA - Tier 2; PA; SP; QL imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL instacort 5 - Tier 1; QL isotretinoin oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; QL isotretinoin oral capsule 20 mg, 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; PA; QL LAC-HYDRIN FIVE - Tier 2; QL lactic acid external - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1 methoxsalen rapid - Tier 1 mometasone furoate external - Tier 1; QL myorisan (generic for AMNESTEEM) - Tier 1; PA; QL NEUTROGENA OIL-FREE ACNE WASH (brand for eql acne scrub pink grapefruit) - Tier 2 NUPERCAINAL (brand for dibucaine (perianal)) - Tier 2 NUTRAPLUS (brand for urea 10 hydrating) - Tier 2; QL ointment base (generic for FLANDERS BUTTOCKS) - Tier 1 OVACE PLUS WASH EXTERNAL LIQUID (brand for sulfacetamide sodium) - Tier 2 OVACE WASH (brand for sulfacetamide sodium) - Tier 2 PANOXYL (brand for bp wash) - Tier 2 pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2 years; QL; AL podofilox external - Tier 1; QL PR BENZOYL PEROXIDE - Tier 2 PR BENZOYL PEROXIDE WASH (brand for bp wash) - Tier 2 REGRANEX - Tier 2; PA; QL renewal soothing bath (generic for AVEENO BABY BATH TREATMENT) - Tier 1 SANTYL - Tier 2; QL selenium sulfide external lotion - Tier 1; QL selenium sulfide external shampoo - Tier 1 SELRX (brand for selenium sulfide) - Tier 2 sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1 sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1 sulfacetamide sodium external liquid (generic for OVACE PLUS WASH) - Tier 1 sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR- E EMOLLIENT) - Tier 1 sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1 sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfamez wash - Tier 1 SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; QL tacrolimus external ointment 0.03 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 2 years; QL; AL tacrolimus external ointment 0.1 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 16 years; QL; AL tretinoin external cream (generic for AVITA) - Tier 1; ST; QL; AL triamcinolone acetonide external cream - Tier 1; QL triamcinolone acetonide external lotion 0.025 % - Tier 1 triamcinolone acetonide external lotion 0.1 % - Tier 1; QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier 1; QL triderm (generic for TRIDERM) - Tier 1; QL urea 20 intensive hydrating - Tier 1; QL urea external lotion (generic for CEROVEL) - Tier 1; QL ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL ureacin-20 - Tier 1; QL wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1 wart remover maximum strength external liquid (generic for COMPOUND W) - Tier 1 zaclir cleansing - Tier 1 zenatane (generic for ACCUTANE) - Tier 1; PA; QL zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL ZOSTRIX HP (brand for capsaicin hp) - Tier 2; QL

Dermatological Agents - Skin Agents ZILXI - Tier 2; PA; QL

Electrolytes/Minerals/Metals/Vitamins

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 58 Preferred Agents Non-Preferred Agents Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs BPROTECTED PEDIA IRON (brand for fe-vite iron) - Tier 2; QL cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1; QL calcium 500/d oral tablet (generic for RA HI CAL) - Tier 1; QL calcium 500/vitamin d3 - Tier 1 calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL calcium 600/vit d/minerals oral tablet 600-200 mg-unit - Tier 1; QL calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit - Tier 1 calcium 600/vitamin d - Tier 1 calcium 600/vitamin d-3 - Tier 1; QL calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1; QL calcium 600+d oral tablet 600-400 mg-unit - Tier 1 calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1; QL calcium carbonate-vitamin d oral tablet 600-200 mg-unit - Tier 1; QL calcium carbonate-vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium carbonate-vitamin d3 - Tier 1; QL calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1 calcium citrate + d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1 calcium citrate +d3 (generic for CALCITRATE) - Tier 1 calcium citrate plus vit d - Tier 1; QL calcium citrate+d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 w/magne (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1; QL calcium citrate-vit d - Tier 1; QL calcium citrate-vitamin d oral tablet 315-200 mg-unit - Tier 1; QL calcium fast dissolution - Tier 1; QL calcium high potency - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents calcium high potency/vitamin d - Tier 1; QL calcium oral tablet 1500 (600 ca) mg - Tier 1; QL calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1 calcium plus 600 +d - Tier 1; QL calcium plus vitamin d oral tablet 500-5 mg-mcg (generic for OYSCO 500+D) - Tier 1; QL calcium plus vitamin d oral tablet 600-200 mg-unit - Tier 1; QL calcium plus vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium plus vitamin d3 - Tier 1; QL calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier 1 calcium/minerals/vitamin d - Tier 1 calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5 mg - Tier 1 calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL CARBAGLU - Tier 2; PA; SP effer-k oral tablet effervescent 25 meq - Tier 1; QL electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL ENFAMIL ENFALYTE (brand for hm pediatric electrolyte) - Tier 2; QL EZFE 200 - Tier 2 ferate (generic for FERATE) - Tier 1 FER-IN-SOL (brand for fe-vite iron) - Tier 2; QL ferocon (generic for TRICON) - Tier 1 ferosul (generic for FEROSUL) - Tier 1; QL ferotrinsic (generic for TRICON) - Tier 1 ferretts - Tier 1 ferrex 150 (generic for FERREX 150) - Tier 1 ferric x-150 (generic for FERREX 150) - Tier 1 ferrous fumarate oral tablet 324 (106 fe) mg (generic for FERROCITE) - Tier 1 ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1 ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL ferrous sulfate oral elixir - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for BPROTECTED PEDIA IRON) - Tier 1; QL ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL ferrous sulfate oral tablet delayed release - Tier 1; QL fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL fluoritab (generic for NAFRINSE DROPS) - Tier 1; QL folic acid oral tablet 1 mg - Tier 1; QL folic acid oral tablet 400 mcg, 800 mcg - Tier 1 foltrin (generic for TRICON) - Tier 1 hi cal (generic for RA HI CAL) - Tier 1; QL iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1 iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL iron supplement - Tier 1 iron supplement childrens (generic for BPROTECTED PEDIA IRON) - Tier 1; QL klor-con (generic for KLOR-CON) - Tier 1; QL klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL klor-con/ef - Tier 1; QL K-PHOS - Tier 2; QL K-PHOS-NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL k-prime - Tier 1; QL MAGNEBIND 300 - Tier 2 magnesium oral tablet 500 mg - Tier 1 magnesium oxide oral tablet 400 (241.3 mg) mg (generic for MAGNESIUM-OXIDE) - Tier 1 magnesium oxide oral tablet 500 mg - Tier 1 magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 myferon 150 (generic for FERREX 150) - Tier 1 myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 nafrinse (generic for NAFRINSE) - Tier 1; QL nafrinse drops (generic for NAFRINSE DROPS) - Tier 1; QL NU-IRON (brand for polysaccharide-iron complex) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL OS-CAL CALCIUM + D3 (brand for calcium 500 + d) - Tier 2; QL oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium 500 + d - Tier 1; QL oyster shell calcium oral tablet 500 mg (generic for OYSTERCAL) - Tier 1; QL oyster shell calcium plus d oral tablet 500-200 mg-unit (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium/d oral tablet 250-125 mg-unit - Tier 1; QL oyster shell calcium/d oral tablet 250-250 mg-unit, 500-400 mg-unit - Tier 1 oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1; QL oyster shell calcium/vit d - Tier 1 oyster shell calcium/vitamin d oral tablet (generic for OYSCO 500+D) - Tier 1; QL ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - Tier 1; QL ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL PEDIALYTE FREEZER POPS (brand for hm pediatric electrolyte) - Tier 2; QL PEDIALYTE ORAL SOLUTION (brand for hm pediatric electrolyte) - Tier 2; QL PEDIALYTE SINGLES (brand for hm pediatric electrolyte) - Tier 2; QL pediatric electrolyte oral solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL PHOSPHA 250 NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL poly-iron 150 (generic for FERREX 150) - Tier 1 poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents polysaccharide-iron complex (generic for FERREX 150) - Tier 1 potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL potassium chloride er oral capsule extended release 10 meq - Tier 1; QL potassium chloride er oral tablet extended release (generic for KLOR- CON 10) - Tier 1; QL potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) - Tier 1; QL potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL potassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1 potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 potassium citrate-citric acid - Tier 1 PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2 REHYDRALYTE (brand for hm pediatric electrolyte) - Tier 2; QL sod citrate-citric acid - Tier 1 sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1; QL sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1 sodium fluoride oral tablet chewable - Tier 1; QL TRICON (brand for ferocon) - Tier 2 virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL zinc chelated oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL

Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL deferasirox oral packet (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL deferasirox oral tablet (generic for JADENU) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; PA; SP LOKELMA - Tier 2; PA; QL sps - Tier 1; QL VELTASSA - Tier 2; PA; QL

Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) oral tablet (generic for CALPHRON) - Tier AURYXIA - Tier 2; PA; QL 1; QL VELPHORO - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; QL sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; PA; QL

Vitamins a-25 - Tier 1; QL adc/f (0.5mg/ml) - Tier 1 animal shapes complete (generic for CEROVITE JR) - Tier 1; QL animal shapes kids first (generic for DINO-LIFE) - Tier 1; QL animal shapes/iron (generic for CEROVITE JR) - Tier 1; QL AQUADEKS - Tier 2; QL aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL ATABEX OB - Tier 2; QL b complex oral capsule - Tier 1; QL b complex vitamins - Tier 1; QL b-1 - Tier 1; QL b6 - Tier 1; QL b-complex oral tablet - Tier 1 b-complex with b-12 - Tier 1 b-complex/b-12 oral - Tier 1 biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL BPROTECTED PEDIA D-VITE (brand for vitamin d3) - Tier 2; QL BPROTECTED PEDIA POLY-VITE (brand for poly-vita) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 64 Preferred Agents Non-Preferred Agents BPROTECTED PEDIA POLY-VITE/FE (brand for poly-vita/iron) - Tier 2; QL BPROTECTED VITAMIN C (brand for vitamin c) - Tier 2; QL c 250 oral tablet - Tier 1; QL c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL c-1000/rose hips - Tier 1; QL calcidol (generic for CALCIDOL) - Tier 1; QL CENTRUM FLAVOR BURST KIDS (brand for zoo friends complete) - Tier 2; QL CENTRUM KIDS (brand for zoo friends complete) - Tier 2; QL cerovite jr (generic for CEROVITE JR) - Tier 1; QL chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL childrens chewable vitamins (generic for DINO-LIFE) - Tier 1; QL childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL childrens chewables/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL childrens complete oral tablet chewable 18 mg (generic for CEROVITE JR) - Tier 1; QL childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL childrens vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL classic prenatal - Tier 1; QL COMPLETE NATAL DHA - Tier 2; QL CO-NATAL FA (brand for neonatal complete) - Tier 2; QL cyanocobalamin injection solution 1000 mcg/ml - Tier 1; QL CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML - Tier 2; QL d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1 d 400 oral tablet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents d 400 oral tablet chewable (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 d 5000 oral tablet (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 d3 high potency oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; QL d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 super strength - Tier 1; QL d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3-50 (generic for D3-50) - Tier 1; QL daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3) - Tier 2; QL DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for d 10000) - Tier 2 DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2 DIALYVITE 800 ORAL TABLET (brand for rena-vite) - Tier 2; QL DIALYVITE VITAMIN D 5000 (brand for d3 high potency) - Tier 2 dino-life (generic for DINO-LIFE) - Tier 1; QL dino-life w/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL D-VI-SOL (brand for vitamin d3) - Tier 2; QL d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL e - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 66 Preferred Agents Non-Preferred Agents e-400-clear - Tier 1; QL ENFAMIL EXPECTA - Tier 2; QL ergocalciferol oral (generic for DRISDOL) - Tier 1; QL essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 essentials (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 fruity c - Tier 1; QL full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL gummy multivitamin kids (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL healthy hair/skin/nails (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 INATAL GT - Tier 2; QL little ones childrens (generic for DINO-LIFE) - Tier 1; QL lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL M-NATAL PLUS - Tier 2; QL multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamin-folic acid (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins essential (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL MULTIPRO - Tier 2 multi-vit/iron/fluoride - Tier 1; QL multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL multivitamin/fluoride oral solution (generic for FLORIVA PLUS) - Tier 1; QL multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg (generic for QUFLORA PEDIATRIC) - Tier 1; QL multi-vitamin/fluoride/iron - Tier 1; QL multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 67 Preferred Agents Non-Preferred Agents mynephrocaps (generic for MYNEPHRON) - Tier 1 MYNEPHRON (brand for mynephrocaps) - Tier 2 natural vitamin e - Tier 1; QL NEOMULTIVITE (brand for sm multiple vitamins essential) - Tier 2 NEONATAL COMPLETE - Tier 2; QL NEONATAL PLUS (brand for prenatal plus) - Tier 2; QL NEONATAL VITAMIN (brand for multi prenatal) - Tier 2; QL nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL NEPHRO-VITE (brand for rena-vite) - Tier 2; QL niacin er oral capsule extended release 250 mg - Tier 1; QL niacin er oral capsule extended release 500 mg - Tier 1 niacin er oral tablet extended release - Tier 1 niacin oral tablet 100 mg, 250 mg, 50 mg - Tier 1 NIVA-PLUS (brand for prenatal plus) - Tier 2; QL NOVAMV PEDIATRIC MULTI-VITAMIN - Tier 2; QL nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL O-CAL PRENATAL - Tier 2; QL once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 ONE VITE WOMENS - Tier 2; QL ONE VITE WOMENS PLUS - Tier 2; QL one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONEVITE - Tier 2; QL pediavit - Tier 1; QL phytonadione oral (generic for MEPHYTON) - Tier 1; QL pnv tabs 29-1 (generic for PRENATABS RX) - Tier 1; QL POLY-VI-SOL (brand for poly-vita) - Tier 2; QL POLY-VITE PEDIATRIC - Tier 2; QL PRENATABS RX (brand for pnv tabs 29-1) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents prenatal formula oral tablet 28-0.8 mg - Tier 1; QL prenatal multi+dha - Tier 1; QL prenatal multivitamins - Tier 1; QL prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier 1; QL prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; QL prenatal oral tablet 28-0.8 mg - Tier 1; QL prenatal plus iron (generic for PRENATABS RX) - Tier 1; QL prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; QL prenatal vitamins oral tablet 28-0.8 mg - Tier 1; QL prenatal/iron - Tier 1; QL PRENATAL-U - Tier 2; QL PRENATVITE RX - Tier 2; QL preplus (generic for NEONATAL PLUS) - Tier 1; QL PRETAB - Tier 2; QL PRONUTRIENTS VITAMIN D3 (brand for vitamin d high potency) - Tier 2 pyridoxine hcl oral - Tier 1; QL QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML (brand for poly- vitamin/fluoride) - Tier 2; QL radiance platinum vitamin d3 (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 RENAL (brand for mynephrocaps) - Tier 2 RENAL MULTIVITAMIN FORMULA (brand for rena-vite) - Tier 2; QL renal-vite (generic for DIALYVITE 800) - Tier 1; QL rena-vite (generic for DIALYVITE 800) - Tier 1; QL SLO-NIACIN (brand for niacin er) - Tier 2 stress formula - Tier 1 stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL tab-a-vite (generic for LYSIPLEX PLUS) - Tier 1 tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thiamine hcl oral - Tier 1; QL thiamine mononitrate oral - Tier 1; QL THRIVITE 19 - Tier 2; QL THRIVITE RX - Tier 2; QL TRINATAL RX 1 - Tier 2; QL TRINATE - Tier 2; QL triphrocaps (generic for MYNEPHRON) - Tier 1 tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1; QL tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QL tri-vite/fluoride oral solution 0.5 mg/ml - Tier 1 UDAMIN SP (brand for onevite) - Tier 2; QL v-c forte (generic for VIC-FORTE) - Tier 1 VENTRIXYL (brand for onevite) - Tier 2; QL vic-forte (generic for VIC-FORTE) - Tier 1 VINATE II - Tier 2; QL VINATE ONE (brand for trinatal rx 1) - Tier 2; QL virt-caps (generic for MYNEPHRON) - Tier 1 vit c/rose hips - Tier 1; QL vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1; QL vitamin b-1 oral tablet 100 mg, 250 mg - Tier 1; QL vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1 vitamin b12 oral tablet extended release 1000 mcg - Tier 1 vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1 vitamin b-6 - Tier 1; QL vitamin b-6 er - Tier 1; QL vitamin c cr oral tablet extended release 500 mg (generic for ENDUR-C) - Tier 1; QL vitamin c er oral tablet extended release 1500 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN C) - Tier 1; QL vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; QL vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/rose hips oral tablet 1000 mg - Tier 1; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; QL vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit) - Tier 1; QL vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QL vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1; QL vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; QL vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 oral tablet chewable 25 mcg, 25 mcg (1000 ut) (generic for KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1 vitamin d-400 - Tier 1; QL vitamin e natural - Tier 1 vitamin e oral capsule 100 unit, 1000 unit, 200 unit, 450 mg - Tier 1 vitamin e oral capsule 400 unit - Tier 1; QL vitamin-b complex - Tier 1 vitamins acd-fluoride - Tier 1; QL vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL VITATHELY WITH GINGER (brand for prenatal plus) - Tier 2; QL weekly-d (generic for D3-50) - Tier 1; QL WESTAB PLUS - Tier 2; QL WEST-VITE W/FOLIC ACID - Tier 2; QL womens prenatal+dha - Tier 1; QL zoo friends (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL zoo friends complete (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL zoo friends gummies (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL ZYVANA - Tier 2

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs ANASPAZ (brand for ed-spaz) - Tier 2; QL dicyclomine hcl oral capsule - Tier 1; QL dicyclomine hcl oral solution - Tier 1 dicyclomine hcl oral tablet - Tier 1; QL ED-SPAZ - Tier 2; QL glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL hyoscyamine sulfate oral - Tier 1; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL hyosyne - Tier 1; QL LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL NULEV (brand for ed-spaz) - Tier 2; QL oscimin (generic for LEVSIN) - Tier 1; QL oscimin sr (generic for LEVBID) - Tier 1; QL SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex (generic for ABATINEX) - Tier 1 OMECLAMOX-PAK - Tier 2; PA; QL acid gone oral suspension - Tier 1 PYLERA - Tier 2; PA acid gone oral tablet chewable (generic for ACID GONE) - Tier 1; AL RELISTOR - Tier 2; PA; QL acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1 SYMPROIC - Tier 2; PA; QL acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier 1 acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) - Tier 1 acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1 adult 50+ probiotic (generic for RESTORA) - Tier 1; QL adult probiotic (generic for RESTORA) - Tier 1; QL advanced antacid max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL almacone double strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid & gas relief (generic for MINTOX) - Tier 1; QL antacid advanced (generic for MINTOX) - Tier 1; QL antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas (generic for MINTOX) - Tier 1; QL antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas max strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL antacid extra strength oral suspension (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents antacid extra strength oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL antacid fast relief (generic for MINTOX) - Tier 1; QL antacid i (generic for MINTOX) - Tier 1; QL antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL antacid liquid (generic for MINTOX) - Tier 1; QL antacid m (generic for MINTOX) - Tier 1; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1; AL antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid maximum strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1; AL antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1; QL antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1; AL antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid regular strength oral suspension (generic for MINTOX) - Tier 1; QL antacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 antacid supreme - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1; AL antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 75 Preferred Agents Non-Preferred Agents antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1; QL anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1; AL anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1; QL anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 biotinex (generic for ABATINEX) - Tier 1 bismatrol maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; AL bismuth (generic for SOOTHE) - Tier 1; AL bismuth subsalicylate oral (generic for SOOTHE) - Tier 1; AL calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL calcium carbonate antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium carbonate oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL childrens soothe - Tier 1 comfort gel (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL diamode (generic for IMODIUM A-D) - Tier 1; QL diarrhea (generic for SOOTHE) - Tier 1; AL diarrhea relief (generic for SOOTHE) - Tier 1; AL digestive probiotic oral capsule (generic for RESTORA) - Tier 1; QL digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 diotame instydose (generic for SOOTHE) - Tier 1; AL diphenoxylate-atropine - Tier 1; QL floranex tablet oral (generic for FLORANEX) - Tier 1 FLORANEX TABLET ORAL (brand for cvs acidophilus probiotic) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1 gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension 20 mg/0.3ml (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral tablet chewable 80 mg - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for ra gas relief) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 77 Preferred Agents Non-Preferred Agents GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for sm gas relief) - Tier 2 GAS-X ULTRA STRENGTH (brand for cvs gas relief ultra strength) - Tier 2 GATTEX - Tier 2; PA; SP; QL GAVISCON EXTRA RELIEF FORMULA (brand for heartburn relief ex st) - Tier 2; AL GAVISCON EXTRA STRENGTH (brand for heartburn antacid ex st) - Tier 2; AL GAVISCON ORAL SUSPENSION - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1; QL geri-lanta supreme - Tier 1 geri-mox (generic for MINTOX) - Tier 1; QL geri-pectate (generic for SOOTHE) - Tier 1; AL heartburn antacid (generic for ACID GONE) - Tier 1; AL heartburn antacid ex st (generic for ACID GONE) - Tier 1; AL heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1; AL heartburn relief oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1; AL HELIDAC THERAPY - Tier 2 high potency probiotic (generic for RESTORA) - Tier 1; QL IMODIUM A-D ORAL TABLET (brand for ra anti-diarrheal) - Tier 2; QL IMODIUM MULTI-SYMPTOM RELIEF (brand for goodsense anti- diarr/ant-gas) - Tier 2 infant gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL infants gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL infants simethicone (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL lactobacillus oral tablet (generic for FLORANEX) - Tier 1 lacto-pectin (generic for RESTORA) - Tier 1; QL long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1; QL MAALOX - Tier 2 MAALOX CHILDRENS (brand for childrens pepto) - Tier 2 MAALOX MAX ORAL SUSPENSION (brand for px antacid maximum strength) - Tier 2; QL MAALOX MULTI SYMPTOM MAX ST (brand for px antacid maximum strength) - Tier 2; QL mag-al plus (generic for MINTOX) - Tier 1; QL mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL magnesium oxide oral tablet 400 mg - Tier 1 magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1 MAOX (brand for magnesium oxide) - Tier 2 mega probiotic (generic for RESTORA) - Tier 1; QL meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1; QL metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL mi-acid gas relief - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mintox plus - Tier 1 mood support probiotic (generic for RESTORA) - Tier 1; QL MOTEGRITY - Tier 2; PA; QL MOVANTIK - Tier 2; PA; QL MYTESI - Tier 2; PA; QL peptic relief (generic for SOOTHE) - Tier 1; AL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for hm stomach relief) - Tier 2; AL PHAZYME (brand for sm gas relief) - Tier 2 PHAZYME ULTRA STRENGTH (brand for cvs gas relief ultra strength) - Tier 2 pink bismuth (generic for SOOTHE) - Tier 1; AL pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; AL pink-bismuth (generic for SOOTHE) - Tier 1; AL pro-biotic blend (generic for RESTORA) - Tier 1; QL probiotic colon care (generic for RESTORA) - Tier 1; QL probiotic complex (generic for RESTORA) - Tier 1; QL probiotic maximum strength (generic for RESTORA) - Tier 1; QL probiotic oral capsule (generic for RESTORA) - Tier 1; QL probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 probiotic pearls ex st (generic for RESTORA) - Tier 1; QL RESTORA (brand for cvs mood support probiotic) - Tier 2; QL RESTORA RX - Tier 2 RISAQUAD (brand for cvs mood support probiotic) - Tier 2; QL RISAQUAD-2 (brand for cvs mood support probiotic) - Tier 2; QL saccharomyces boulardii (generic for FLORASTOR) - Tier 1 senior probiotic (generic for RESTORA) - Tier 1; QL simeped (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL simethicone oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier 1 simethicone oral suspension (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1; AL simethicone oral tablet chewable (generic for GAS-X EXTRA STRENGTH) - Tier 1 simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 smooth antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1; AL sodium bicarbonate oral tablet - Tier 1 soothe maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 soothe oral (generic for SOOTHE) - Tier 1; AL stomach relief extra strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents stomach relief max st oral suspension 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527 mg/30ml (generic for SOOTHE) - Tier 1; AL stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1; AL stomach relief oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; AL stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 TRULANCE - Tier 2; PA; QL TUMS (brand for goodsense antacid) - Tier 2 TUMS CHEWY BITES (brand for sm calcium antacid ex st) - Tier 2; AL TUMS E-X 750 (brand for sm calcium antacid ex st) - Tier 2; AL TUMS EXTRA STRENGTH 750 (brand for sm calcium antacid ex st) - Tier 2; AL TUMS LASTING EFFECTS (brand for goodsense antacid) - Tier 2 TUMS SMOOTHIES (brand for sm calcium antacid ex st) - Tier 2; AL TUMS ULTRA 1000 (brand for antacid ultra strength) - Tier 2; AL ursodiol oral capsule - Tier 1; QL ursodiol oral tablet (generic for URSO 250) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs mood support probiotic) - Tier 2; QL ZELAC - Tier 2; QL

Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 81 Preferred Agents Non-Preferred Agents cimetidine hcl - Tier 1 cimetidine oral (generic for TAGAMET HB) - Tier 1; QL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL famotidine oral tablet 20 mg (generic for MM ACID-PEP MAXIMUM STRENGTH) - Tier 1; QL famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL famotidine orig st (generic for PEPCID AC) - Tier 1; QL heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LUBIPROSTONE - Tier 1; QL AMITIZA (brand for lubiprostone) - Tier 2; PA; QL LINZESS - Tier 2; PA; QL

Laxatives - Drugs to treat Constipation bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1 bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1 bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1 citrate of magnesia (generic for CITROMA) - Tier 1 citroma (generic for CITROMA) - Tier 1 CITRUCEL - Tier 2 c-lax laxative (generic for EX-LAX ULTRA) - Tier 1 clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL COLACE (brand for qc stool softener) - Tier 2 col-rite oral capsule 250 mg - Tier 1; QL constulose - Tier 1; QL daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 docu (generic for DOCU LIQUID) - Tier 1 docu liquid (generic for DOCU LIQUID) - Tier 1 docusate calcium (generic for SURFAK) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents docusate mini (generic for DOCUSOL MINI) - Tier 1; QL docusate sodium oral capsule 100 mg (generic for DOK) - Tier 1 docusate sodium oral capsule 250 mg - Tier 1; QL docusate sodium oral liquid 50 mg/5ml (generic for DOCU LIQUID) - Tier 1 docusate sodium oral syrup - Tier 1; AL docusate sodium oral tablet (generic for DOK) - Tier 1 DOCUSOL MINI (brand for docusate mini) - Tier 2; QL docuzen (generic for SENEXON-S) - Tier 1 dok (generic for DOK) - Tier 1 dss oral capsule 100 mg (generic for DOK) - Tier 1 dss oral capsule 250 mg - Tier 1; QL easy-lax plus (generic for SENEXON-S) - Tier 1 enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL enulose - Tier 1; QL EVAC (brand for cvs natural fiber supplement) - Tier 2 EX-LAX ULTRA (brand for gentle laxative) - Tier 2 fast relief laxative (generic for THE MAGIC BULLET) - Tier 1 fiber laxative - Tier 1 fiber laxative + calcium - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber oral powder 30.9 % - Tier 1 fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 625 mg - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 625 mg - Tier 1 fiber-caps - Tier 1 fiber-lax - Tier 1 FLEET BISACODYL - Tier 2; QL FLEET ENEMA (brand for sm enema) - Tier 2 FLEET OIL (brand for sm mineral oil) - Tier 2 FLEET PEDIATRIC (brand for enema pediatric) - Tier 2; AL gavilax oral powder (generic for CLEARLAX) - Tier 1; QL gavilyte-c - Tier 1; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL generlac - Tier 1; QL gentle laxative (generic for EX-LAX ULTRA) - Tier 1 gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1 gentlelax (generic for CLEARLAX) - Tier 1; QL geri-kot (generic for SENOKOT) - Tier 1 glycerin (adult) rectal suppository 2 gm - Tier 1; AL glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA- LAX) - Tier 1; AL glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1; AL glycerin adult rectal suppository 2 gm - Tier 1; AL glycerin child rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1; AL glycerin child rectal suppository 1.2 gm - Tier 1; AL glycerin childrens (generic for PEDIA-LAX) - Tier 1; AL glycerin pediatric rectal suppository 1.2 gm - Tier 1; AL glycolax (generic for CLEARLAX) - Tier 1; QL KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL lactulose encephalopathy - Tier 1; QL lactulose oral solution - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents laxacin (generic for SENEXON-S) - Tier 1 laxaclear (generic for CLEARLAX) - Tier 1; QL laxative max str - Tier 1 laxative maximum strength oral tablet 25 mg - Tier 1 laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) - Tier 1 laxative pills (generic for SENNA SMOOTH) - Tier 1 laxative pills max st - Tier 1 laxative pills oral tablet 25 mg - Tier 1 laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1 laxative regular strength (generic for SENNA SMOOTH) - Tier 1 magnesium citrate oral solution (generic for CITROMA) - Tier 1 milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for qc natura-lax) - Tier 2; QL mm clearlax (generic for CLEARLAX) - Tier 1; QL mm stool softener laxative (generic for DOK) - Tier 1 natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL natural fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber supplement (generic for EVAC) - Tier 1 natural laxative (generic for SENOKOT) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENOKOT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natural vegetable laxative (generic for SENOKOT) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; QL p col-rite (generic for SENEXON-S) - Tier 1 PEDIA-LAX ORAL LIQUID - Tier 2 PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for glycerin childrens) - Tier 2; AL peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL PERDIEM OVERNIGHT RELIEF (brand for laxative regular strength) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for eql milk of magnesia) - Tier 2 polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; QL psyldex - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; QL ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 saline enema (generic for FLEET ENEMA) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENOKOT) - Tier 1 senna laxative (generic for SENOKOT) - Tier 1 senna oral liquid - Tier 1; AL senna oral syrup - Tier 1; AL senna oral tablet (generic for SENOKOT) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1 senna-lax (generic for SENOKOT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 86 Preferred Agents Non-Preferred Agents senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENOKOT) - Tier 1 senna-time (generic for SENOKOT) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1; AL SENOKOT (brand for senna-time) - Tier 2 SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2 SENOKOT S (brand for senna-docusate sodium) - Tier 2 silace oral liquid (generic for DOCU LIQUID) - Tier 1 silace oral syrup - Tier 1; AL smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL soluble fiber therapy - Tier 1 sorbitol oral - Tier 1 stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener laxative oral capsule 100 mg (generic for DOK) - Tier 1 stool softener laxative oral capsule 250 mg - Tier 1; QL stool softener oral capsule 100 mg (generic for DOK) - Tier 1 stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1; AL stool softener oral capsule 250 mg - Tier 1; QL stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1; AL stool softener oral tablet 100 mg (generic for DOK) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 the magic bullet (generic for THE MAGIC BULLET) - Tier 1 vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 womans laxative (generic for EX-LAX ULTRA) - Tier 1 womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1 womens laxative (generic for EX-LAX ULTRA) - Tier 1

Protectants - Ulcer and Stomach Acid Drugs

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents misoprostol oral (generic for CYTOTEC) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members 10 years of age up to 65 years of age will require PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL

Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs acid reducer oral capsule delayed release - Tier 1; QL ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; DEXILANT - Tier 2; PA; QL Members > = 2 years of age will require PA; QL; AL esomeprazole magnesium oral capsule delayed release (generic for lansoprazole oral capsule delayed release 15 mg (generic for NEXIUM) - Tier 1; PA; QL PREVACID 24HR) - Tier 1; QL NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for hm lansoprazole oral capsule delayed release 30 mg (generic for esomeprazole magnesium dr) - Tier 2; PA; QL PREVACID) - Tier 1; QL NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG (brand for esomeprazole lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg magnesium) - Tier 2; PA; Members > = 2 years of age will require PA; QL; (generic for PREVACID SOLUTAB) - Tier 1; QL; AL AL NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members > = 2 years omeprazole magnesium oral tablet delayed release (generic for PRILOSEC of age will require PA; QL; AL OTC) - Tier 1; PA; QL omeprazole magnesium oral capsule delayed release - Tier 1; QL omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20 base) pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA; QL mg, 40 mg - Tier 1; QL PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG (brand for pantoprazole sodium oral tablet delayed release (generic for lansoprazole) - Tier 2; PA; QL PROTONIX) - Tier 1; QL PRILOSEC - Tier 2; PA; QL PREVACID 24HR (brand for sm lansoprazole) - Tier 2; QL ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CHOLBAM - Tier 2; PA; SP; QL CERDELGA - Tier 2; PA; SP; QL CREON - Tier 2 ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL CYSTAGON - Tier 2; QL PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500- NITYR - Tier 2; PA; SP; QL 35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 4200-14200 UNIT - RAVICTI - Tier 2; PA; SP; QL Tier 2; PA sapropterin dihydrochloride (generic for KUVAN) - Tier 1; PA; SP; QL SUCRAID - Tier 2; PA; SP sodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1; ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL PA; SP ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 3000-10000 STRENSIQ - Tier 2; PA; SP UNIT - Tier 2; PA

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; QL oxybutynin chloride oral - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL OXYTROL FOR WOMEN - Tier 2; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL tolterodine tartrate (generic for DETROL) - Tier 1; PA; QL MYRBETRIQ - Tier 2; PA; QL trospium chloride - Tier 1; PA; QL TOVIAZ - Tier 2; PA; QL VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL tamsulosin hcl (generic for FLOMAX) - Tier 1; QL terazosin hcl - Tier 1; QL

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP azo tabs (generic for PHENAZO) - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL bethanechol chloride oral - Tier 1 ELMIRON - Tier 2; PA; QL penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1; PA; SP; QL phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1; QL phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 89 Preferred Agents Non-Preferred Agents SHUR-SEAL CONTRACEPTIVE - Tier 2; GE urin ds (generic for UTIRA-C) - Tier 1; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 UTIRA-C (brand for urin ds) - Tier 2; QL VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2; GE

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs DECADRON ORAL TABLET 0.5 MG, 0.75 MG (brand for EMFLAZA ORAL TABLET 6 MG - Tier 2; PA; SP; QL dexamethasone) - Tier 2 DECADRON ORAL TABLET 4 MG, 6 MG (brand for dexamethasone) - Tier 2; QL dexamethasone intensol - Tier 1 dexamethasone oral elixir - Tier 1; QL dexamethasone oral solution - Tier 1; QL dexamethasone oral tablet 0.5 mg, 0.75 mg (generic for DECADRON) - Tier 1 dexamethasone oral tablet 1 mg, 2 mg - Tier 1 dexamethasone oral tablet 1.5 mg - Tier 1; QL dexamethasone oral tablet 4 mg, 6 mg (generic for DECADRON) - Tier 1; QL fludrocortisone acetate oral - Tier 1; QL hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - Tier 1; QL MEDROL ORAL TABLET 2 MG - Tier 2 methylprednisolone oral (generic for MEDROL) - Tier 1; QL prednisolone oral solution - Tier 1; QL prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml (generic for PEDIAPRED) - Tier 1; QL prednisone oral solution - Tier 1; QL prednisone oral tablet - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; GENOTROPIN - Tier 2; PA; SP PA HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, desmopressin ace spray refrig - Tier 1; QL 6 MG - Tier 2; PA; SP desmopressin acetate oral (generic for DDAVP) - Tier 1; QL NORDITROPIN FLEXPRO - Tier 2; PA; SP desmopressin acetate spray - Tier 1; QL NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP INCRELEX - Tier 2; PA; SP NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP NOCDURNA - Tier 2; PA; QL NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP novarel intramuscular solution reconstituted 10000 unit (generic for OMNITROPE - Tier 2; PA; SP NOVAREL) - Tier 1; PA SAIZEN - Tier 2; PA; SP NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT - Tier 2; PA OVIDREL - Tier 2; PA pregnyl (generic for NOVAREL) - Tier 1; PA ZOMACTON - Tier 2; PA; SP ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 91 Preferred Agents Non-Preferred Agents Androgens - Hormone Replacement/Modifying Drugs danazol oral - Tier 1; QL testosterone cypionate intramuscular (generic for DEPO- TESTOSTERONE) - Tier 1; QL testosterone enanthate intramuscular - Tier 1; QL testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; QL testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; QL

Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL; GE ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE ANGELIQ - Tier 2; PA alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE CLIMARA (brand for estradiol) - Tier 2; PA; QL apri (generic for APRI) - Tier 1; QL; GE CLIMARA PRO - Tier 2; PA aranelle - Tier 1; QL; GE COMBIPATCH - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1; QL; GE DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25 aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE MG/1.25GM - Tier 2; PA; QL aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM - Tier 2; PA aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE ELESTRIN - Tier 2; PA aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE ESTRACE (brand for estradiol) - Tier 2; PA; QL aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE estradiol transdermal patch twice weekly (generic for ALORA) - Tier 1; PA; aviane (generic for AFIRMELLE) - Tier 1; QL; GE QL ayuna (generic for ALTAVERA) - Tier 1; QL; GE estradiol-norethindrone acet oral tablet 1-0.5 mg (generic for MIMVEY) - azurette (generic for AZURETTE) - Tier 1; QL; GE Tier 1; PA; QL balziva (generic for BALZIVA) - Tier 1; QL; GE ESTRING - Tier 2; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL; GE ESTROGEL - Tier 2; PA blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE EVAMIST - Tier 2; PA blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE FEMRING - Tier 2; PA; QL briellyn (generic for BALZIVA) - Tier 1; QL; GE fyavolv oral tablet 0.5-2.5 mg-mcg - Tier 1; PA caziant - Tier 1; QL fyavolv oral tablet 1-5 mg-mcg - Tier 1; PA; QL chateal (generic for ALTAVERA) - Tier 1; QL; GE jinteli - Tier 1; PA; QL chateal eq (generic for ALTAVERA) - Tier 1; QL; GE MENEST - Tier 2; PA; QL cryselle-28 - Tier 1; QL; GE MENOSTAR - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 92 Preferred Agents Non-Preferred Agents cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE mimvey (generic for MIMVEY) - Tier 1; PA; QL cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE MINIVELLE (brand for estradiol) - Tier 2; PA; QL cyred (generic for APRI) - Tier 1; QL; GE PREFEST - Tier 2; PA; QL cyred eq (generic for APRI) - Tier 1; QL; GE PREMARIN VAGINAL - Tier 2; PA; QL dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE VAGIFEM (brand for estradiol) - Tier 2; PA; QL dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL delyla (generic for AFIRMELLE) - Tier 1; QL; GE DEPO-ESTRADIOL - Tier 2; QL desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GE DUAVEE - Tier 2; QL elinest - Tier 1; QL; GE eluryng (generic for ELURYNG) - Tier 1; QL; GE emoquette (generic for APRI) - Tier 1; QL; GE enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GE enskyce (generic for APRI) - Tier 1; QL; GE estarylla (generic for ESTARYLLA) - Tier 1; QL; GE estradiol oral (generic for ESTRACE) - Tier 1; QL estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL estradiol vaginal (generic for ESTRACE) - Tier 1; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL; GE etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE falmina (generic for AFIRMELLE) - Tier 1; QL; GE femynor (generic for ESTARYLLA) - Tier 1; QL; GE hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE iclevia (generic for ICLEVIA) - Tier 1; QL introvale (generic for ICLEVIA) - Tier 1; QL isibloom (generic for APRI) - Tier 1; QL; GE jolessa (generic for ICLEVIA) - Tier 1; QL juleber (generic for APRI) - Tier 1; QL; GE junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 93 Preferred Agents Non-Preferred Agents junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) - Tier 1; QL; GE kalliga (generic for APRI) - Tier 1; QL; GE kariva (generic for AZURETTE) - Tier 1; QL; GE kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GE kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GE kurvelo (generic for ALTAVERA) - Tier 1; QL; GE larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE larissia (generic for AFIRMELLE) - Tier 1; QL; GE leena - Tier 1; QL; GE lessina (generic for AFIRMELLE) - Tier 1; QL; GE levonest (generic for ENPRESSE-28) - Tier 1; QL; GE levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg (generic for ICLEVIA) - Tier 1; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1; QL; GE levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1; QL; GE levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL; GE levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GE lillow (generic for ALTAVERA) - Tier 1; QL; GE low-ogestrel - Tier 1; QL; GE lutera (generic for AFIRMELLE) - Tier 1; QL; GE marlissa (generic for ALTAVERA) - Tier 1; QL; GE microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE mili (generic for ESTARYLLA) - Tier 1; QL; GE mono-linyah (generic for ESTARYLLA) - Tier 1; QL; GE necon 0.5/35 (28) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 94 Preferred Agents Non-Preferred Agents norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL; GE norethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL; GE norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GE norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg (generic for TRI FEMYNOR) - Tier 1; QL; GE nortrel 0.5/35 (28) - Tier 1; QL; GE nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nylia 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nymyo (generic for ESTARYLLA) - Tier 1; QL; GE orsythia (generic for AFIRMELLE) - Tier 1; QL; GE philith (generic for BALZIVA) - Tier 1; QL; GE pimtrea (generic for AZURETTE) - Tier 1; QL; GE pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE portia-28 (generic for ALTAVERA) - Tier 1; QL; GE PREMARIN ORAL - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1; QL; GE reclipsen (generic for APRI) - Tier 1; QL; GE setlakin (generic for ICLEVIA) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1; QL; GE sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GE sronyx (generic for AFIRMELLE) - Tier 1; QL; GE tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tilia fe - Tier 1; QL; GE tri femynor (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-legest fe - Tier 1; QL; GE tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-mili (generic for TRI FEMYNOR) - Tier 1; QL; GE

Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL; GE DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL camila (generic for CAMILA) - Tier 1; QL; GE deblitane (generic for CAMILA) - Tier 1; QL; GE econtra ez (generic for AFTERA) - Tier 1; QL; GE econtra one-step (generic for AFTERA) - Tier 1; QL; GE errin (generic for CAMILA) - Tier 1; QL; GE heather (generic for CAMILA) - Tier 1; QL; GE incassia (generic for CAMILA) - Tier 1; QL; GE jencycla (generic for CAMILA) - Tier 1; QL; GE levonorgestrel (generic for AFTERA) - Tier 1; QL; GE lyleq (generic for CAMILA) - Tier 1; QL; GE lyza (generic for CAMILA) - Tier 1; QL; GE medroxyprogesterone acetate intramuscular (generic for DEPO- PROVERA) - Tier 1; QL; GE medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 96 Preferred Agents Non-Preferred Agents megestrol acetate oral suspension 40 mg/ml - Tier 1; QL megestrol acetate oral tablet 20 mg - Tier 1 megestrol acetate oral tablet 40 mg - Tier 1; QL my choice (generic for AFTERA) - Tier 1; QL; GE my way (generic for AFTERA) - Tier 1; QL; GE new day (generic for AFTERA) - Tier 1; QL; GE nora-be (generic for CAMILA) - Tier 1; QL; GE norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1; QL; GE norlyda (generic for CAMILA) - Tier 1; QL; GE norlyroc (generic for CAMILA) - Tier 1; QL; GE opcicon one-step (generic for AFTERA) - Tier 1; QL; GE option 2 (generic for AFTERA) - Tier 1; QL; GE PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GE progesterone oral (generic for PROMETRIUM) - Tier 1; PA; QL react (generic for AFTERA) - Tier 1; QL; GE sharobel (generic for CAMILA) - Tier 1; QL; GE take action (generic for AFTERA) - Tier 1; QL; GE tulana (generic for CAMILA) - Tier 1; QL; GE

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs raloxifene hcl (generic for EVISTA) - Tier 1; QL OSPHENA - Tier 2; PA; QL; GE

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs euthyrox (generic for EUTHYROX) - Tier 1; QL levo-t (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL levoxyl (generic for EUTHYROX) - Tier 1; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL unithroid (generic for EUTHYROX) - Tier 1; QL

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2; QL

Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL leuprolide acetate injection - Tier 1; PA; SP LUPANETA PACK COMBINATION KIT 11.25 & 5 MG - Tier 2; PA; SP; QL LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL LUPANETA PACK COMBINATION KIT 3.75 & 5 MG - Tier 2; PA LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL ORIAHNN - Tier 2; PA; QL LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; SYNAREL - Tier 2; PA PA; SP; QL TRIPTODUR - Tier 2; PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml (generic for SANDOSTATIN) - Tier 1; SP octreotide acetate injection solution 1000 mcg/ml - Tier 1; SP; QL octreotide acetate injection solution 200 mcg/ml - Tier 1; SP octreotide acetate injection solution 500 mcg/ml (generic for SANDOSTATIN) - Tier 1; SP; QL ORILISSA - Tier 2; PA; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1; QL propylthiouracil oral - Tier 1; QL

Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin HAEGARDA - Tier 2; PA; SP; QL BERINERT - Tier 2; PA; SP icatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL RUCONEST - Tier 2; PA; SP; QL

Immune Suppressants - Immune System Drugs azathioprine oral (generic for IMURAN) - Tier 1; QL ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG - CIMZIA - Tier 2; PA; SP; QL Tier 2; PA; QL cyclosporine modified (generic for GENGRAF) - Tier 1; QL ORENCIA CLICKJECT - Tier 2; PA; SP; QL cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL ENBREL - Tier 2; PA; SP; QL OTREXUP - Tier 2; PA; QL everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for RASUVO - Tier 2; PA; QL ZORTRESS) - Tier 1 REDITREX - Tier 2; PA; QL gengraf oral capsule (generic for GENGRAF) - Tier 1; QL SIMPONI - Tier 2; PA; SP; QL HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 XELJANZ ORAL TABLET - Tier 2; PA; SP; QL MG/0.8ML - Tier 2; PA; SP; QL XELJANZ XR - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents KINERET - Tier 2; PA; SP; QL methotrexate oral - Tier 1 methotrexate sodium - Tier 1 methotrexate sodium (pf) - Tier 1 mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL OLUMIANT - Tier 2; PA; SP; QL sirolimus oral solution (generic for RAPAMUNE) - Tier 1; QL sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; QL sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1 tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1 tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL ZORTRESS ORAL TABLET 1 MG - Tier 2

Immunomodulators - Immune System Drugs ACTIMMUNE - Tier 2; PA; SP ACTEMRA ACTPEN - Tier 2; PA; SP; QL ILARIS - Tier 2; PA; SP; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; leflunomide oral (generic for ARAVA) - Tier 1; QL SP; QL OTEZLA - Tier 2; PA; SP; QL RINVOQ - Tier 2; PA; SP; QL SYNAGIS - Tier 2; PA; SP XOLAIR - Tier 2; PA; SP; QL

Vaccines ADACEL - Tier 2; QL BEXSERO - Tier 2; QL BOOSTRIX - Tier 2; QL DAPTACEL - Tier 2; QL DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QL ENGERIX-B - Tier 2; QL GARDASIL 9 - Tier 2; QL HAVRIX - Tier 2; QL HEPLISAV-B - Tier 2; QL; AL HYPERTET S/D - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents INFANRIX - Tier 2; QL MENACTRA - Tier 2; QL MENQUADFI - Tier 2; QL MENVEO - Tier 2; QL M-M-R II - Tier 2; QL PNEUMOVAX 23 - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL; AL TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL TENIVAC - Tier 2; QL TETANUS-DIPHTHERIA TOXOIDS TD - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL

Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs balsalazide disodium (generic for COLAZAL) - Tier 1; QL APRISO (brand for mesalamine er) - Tier 2; PA; QL mesalamine oral capsule delayed release 400 mg (generic for ASACOL HD (brand for mesalamine) - Tier 2; PA; QL DELZICOL) - Tier 1; QL COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL mesalamine rectal (generic for CANASA) - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL SFROWASA - Tier 2; QL DIPENTUM - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; PA; QL PENTASA - Tier 2; PA; QL

Glucocorticoids - Drugs to Treat Inflammation budesonide oral (generic for ENTOCORT EC) - Tier 1; PA; QL CORTIFOAM - Tier 2; PA; QL hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO- PROCTOFOAM HC - Tier 2; PA MED HC) - Tier 1; QL hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL

Sulfonamides - Antibiotics sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL

Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium - Tier 1; QL FORTEO (brand for teriparatide (recombinant)) - Tier 2; PA; SP; QL calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL TYMLOS - Tier 2; PA; SP; QL

Metabolic Bone Disease Agents - Other calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members > = 8 years of age will require PA; AL

Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA DEVICE (brand for verasens glucose control) - Tier ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for glucose meter test) - 2; QL Tier 2; PA; QL ACCU-CHEK COMPACT PLUS CONTROL (brand for verasens glucose ACCU-CHEK COMPACT PLUS (brand for glucose meter test) - Tier 2; PA; control) - Tier 2; QL QL ACCU-CHEK GUIDE CONTROL (brand for verasens glucose control) - ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite device/lancets) Tier 2; QL - Tier 2; PA; QL ACCU-CHEK GUIDE STRIP IN VITRO (brand for glucose meter test) - ACCU-CHEK GUIDE TEST STRIPS (brand for goodsense blood glucose) - Tier 2; QL Tier 2; PA; QL ACCU-CHEK MULTICLIX LANCETS (brand for lite touch lancets) - Tier ACCU-CHEK GUIDE STRIP IN VITRO (brand for glucose meter test) - Tier 2; QL 2; PA; QL ACCU-CHEK SMARTVIEW CONTROL (brand for verasens glucose ACCU-CHEK MULTICLIX LANCETS (brand for lite touch lancets) - Tier 2; control) - Tier 2; QL PA; QL ACCU-CHEK SMARTVIEW (brand for glucose meter test) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents ACCUTREND GLUCOSE CONTROL (brand for verasens glucose ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite control) - Tier 2; QL device/lancets) - Tier 2; PA; QL ALCOHOL PREP PADS PAD - Tier 2; QL AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; ALCOHOL PREP PADS PAD 70 % - Tier 2; QL QL antifungal external powder (generic for DESENEX) - Tier 1 CONTOUR NEXT TEST STRIPS (brand for glucose meter test) - Tier 2; anti-fungal external powder (generic for ODOR EATERS ANTIFUNGAL) PA; QL - Tier 1 CONTOUR TEST STRIPS (brand for glucose meter test) - Tier 2; PA; QL athletes foot (generic for DESENEX) - Tier 1 FREESTYLE PRECISION NEO TEST (brand for glucose meter test) - Tier BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier 2; PA; QL 2; QL INSULIN PEN NEEDLES 30G X 8 MM , 32G X 6 MM (brand for pen BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL needles) - Tier 2; PA; QL BD ULTRA-FINE PEN NEEDLES (brand for pen needles) - Tier 2; QL INSULIN PEN NEEDLES 32G X 4 MM (brand for pro comfort pen needles) BLOOD GLUCOSE TEST STRIPS (brand for glucose meter test) - Tier - Tier 2; PA; QL 2; QL NOVOTWIST PEN NEEDLE (brand for pen needles) - Tier 2; PA; QL CARETOUCH CONTROL SOL LEVEL 2 (brand for verasens glucose ONETOUCH ULTRA (brand for glucose meter test) - Tier 2; PA; QL control) - Tier 2; QL ONETOUCH ULTRA 2 KIT W/DEVICE (brand for goodsense blood CAYA - Tier 2; QL glucose) - Tier 2; PA; QL CHEMSTRIP 10 MD - Tier 2 ONETOUCH ULTRA MINI KIT W/DEVICE (brand for goodsense blood CHEMSTRIP 10/SG - Tier 2 glucose) - Tier 2; PA; QL CHEMSTRIP 2 GP - Tier 2 ONETOUCH VERIO KIT W/DEVICE (brand for goodsense blood glucose) - CHEMSTRIP 5 OB - Tier 2 Tier 2; PA; QL CHEMSTRIP 7 - Tier 2 ONETOUCH VERIO FLEX SYSTEM (brand for goodsense blood glucose) - CHEMSTRIP 9 - Tier 2 Tier 2; PA; QL CHEMSTRIP K (brand for ketone test) - Tier 2; QL ONETOUCH VERIO TEST STRIPS (brand for glucose meter test) - Tier 2; CHEMSTRIP UGK - Tier 2; QL PA; QL CONDOMS - Tier 2; QL ONETOUCH VERIO IQ SYSTEM (brand for goodsense blood glucose) - COOL MIST HUMIDIFER - Tier 2; QL Tier 2; PA; QL DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2 ONETOUCH VERIO REFLECT (brand for goodsense blood glucose) - Tier EASIVENT (brand for breathe ease medium) - Tier 2; QL 2; PA; QL EASIVENT MASK LARGE (brand for breathe ease medium) - Tier 2; QL PRECISION LINK (brand for goodsense blood glucose) - Tier 2; PA; QL EASIVENT MASK MEDIUM (brand for breathe ease medium) - Tier 2; PRECISION PCX PLUS TEST (brand for glucose meter test) - Tier 2; PA; QL QL EASIVENT MASK SMALL (brand for breathe ease medium) - Tier 2; QL PRECISION POINT OF CARE TEST (brand for glucose meter test) - Tier 2; EASYMAX 15 LEVEL 2 CONTROL (brand for verasens glucose control) PA; QL - Tier 2; QL PRECISION QID MONITOR (brand for easy trak blood glucose system) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents ONETOUCH VERIO IN VITRO SOLUTION (brand for verasens glucose control) - Tier 2; QL PRECISION GLUCOSE CONTROL (brand for verasens glucose control) - Tier 2; QL PRECISION GLUCOSE CONTROL SOLN (brand for verasens glucose control) - Tier 2; QL PRECISION GLUCOSE KETONE CONTR (brand for verasens glucose control) - Tier 2; QL PRECISION GLUCOSE/KETONE CONTR (brand for verasens glucose control) - Tier 2; QL PREMIUM CONDOMS LUBRICATED - Tier 2; QL QUINTET CONTROL HIGH/NORMAL (brand for verasens glucose control) - Tier 2; QL RELION TRUE MET AIR GLUC METER (brand for goodsense blood glucose) - Tier 2; QL RELION TRUE METRIX TEST STRIPS (brand for glucose meter test) - Tier 2; ST; QL RUZURGI - Tier 2; PA; SP; QL SOLARTEK GLUCOSE CONTROL (brand for verasens glucose control) - Tier 2; QL tolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) - Tier 1 TRUE METRIX AIR GLUCOSE METER KIT (brand for goodsense blood glucose) - Tier 2; QL TRUE METRIX METER KIT (brand for goodsense blood glucose) - Tier 2; QL TRUECONTROL GLUCOSE CONT LEV 0 (brand for verasens glucose control) - Tier 2; QL TRUECONTROL GLUCOSE CONT LEV 1 (brand for verasens glucose control) - Tier 2; QL VAPORIZER WARM STEAM - Tier 2; QL VISTOGARD - Tier 2; QL WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL ZEASORB-AF (brand for antifungal) - Tier 2

Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1; QL CEQUA - Tier 2; PA; QL altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 RESTASIS - Tier 2; PA; QL altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL RESTASIS MULTIDOSE - Tier 2; PA; QL altafrin (generic for ALTAFRIN) - Tier 1 TOBRADEX ST - Tier 2; PA; QL altalube (generic for ALTALUBE) - Tier 1; QL ZYLET - Tier 2; PA; QL artificial eye (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic solution (generic for GENTEAL TEARS) - Tier 1 artificial tears ophthalmic solution 1.4 % - Tier 1 astringent eye drops (generic for VISINE-AC) - Tier 1; QL atropine sulfate ophthalmic ointment - Tier 1 atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE) - Tier 1; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1; QL bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; QL BIOLLE TEARS (brand for sm lubricating plus) - Tier 2 carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) - Tier 1; QL cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - Tier 1; QL CYSTARAN - Tier 2; PA; SP; QL dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents eye drops long lasting (generic for SYSTANE) - Tier 1; QL eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye lubricant (generic for ALTALUBE) - Tier 1; QL for sty relief (generic for ALTALUBE) - Tier 1; QL GENTEAL SEVERE - Tier 2; QL GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) - Tier 2 GENTEAL TEARS NIGHT-TIME (brand for lubricant eye nighttime) - Tier 2; QL GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 % (brand for sm artificial tears) - Tier 2 GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2 GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL HYPOTEARS (brand for lubricant eye nighttime) - Tier 2; QL ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL lubricant drops fast act (generic for SYSTANE) - Tier 1; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for SYSTANE HYDRATION PF) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - Tier 1; QL lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye pm (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 107 Preferred Agents Non-Preferred Agents lubricant pm (generic for ALTALUBE) - Tier 1; QL lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 MURO 128 OPHTHALMIC OINTMENT (brand for cvs sodium chloride) - Tier 2 MURO 128 OPHTHALMIC SOLUTION 5 % (brand for cvs sodium chloride) - Tier 2; QL natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-gramicidin - Tier 1 neo-polycin (generic for NEO-POLYCIN) - Tier 1 neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1 polycin (generic for POLYCIN) - Tier 1; QL polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QL polyvinyl alcohol ophthalmic - Tier 1 PRED-G S.O.P. - Tier 2 PURALUBE (brand for lubricant eye nighttime) - Tier 2; QL pure & gentle lubricant - Tier 1 REFRESH LACRI-LUBE (brand for lubricant eye nighttime) - Tier 2; QL REFRESH P.M. (brand for lubricant eye nighttime) - Tier 2; QL REFRESH PLUS (brand for sm lubricating plus) - Tier 2 REFRESH TEARS (brand for ra lubricant eye drops) - Tier 2; QL relief eye drops (generic for VISINE-AC) - Tier 1; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents restore pm (generic for ALTALUBE) - Tier 1; QL sodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1 sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) - Tier 1 sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - Tier 1; QL sulfacetamide-prednisolone ophthalmic solution - Tier 1 SYSTANE (brand for eq lubricant eye drops) - Tier 2; QL SYSTANE COMPLETE (brand for lubricant eye drops) - Tier 2; QL SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2 SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE NIGHTTIME (brand for lubricant eye nighttime) - Tier 2; QL SYSTANE OVERNIGHT THERAPY - Tier 2; QL SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE ULTRA (brand for eq lubricant eye drops) - Tier 2; QL SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL TEARS AGAIN (brand for lubricant eye nighttime) - Tier 2; QL TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for sm artificial tears) - Tier 2 tears pure (generic for GENTEAL TEARS) - Tier 1 TOBRADEX OPHTHALMIC OINTMENT - Tier 2; QL tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; QL ultra fresh (generic for ULTRA FRESH) - Tier 1; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL VISINE ADVANCED RELIEF (brand for eql advanced relief) - Tier 2; QL VISTA GEL DRY EYE RELIEF - Tier 2; QL VISTA MEIBO TEARS (brand for lubricant eye drops) - Tier 2; QL VISTA TEARS (brand for eq lubricant eye drops) - Tier 2; QL

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs azelastine hcl ophthalmic - Tier 1; ST cromolyn sodium ophthalmic - Tier 1; QL eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1 NAPHCON-A (brand for allergy eye) - Tier 2; AL olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL PATADAY OPHTHALMIC SOLUTION 0.1 % (brand for eye allergy itch/redness rel) - Tier 2; QL PATADAY OPHTHALMIC SOLUTION 0.2 % (brand for eye allergy itch relief) - Tier 2; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; AL VASOCLEAR-A - Tier 2; QL VISINE (brand for allergy eye) - Tier 2; AL

Ophthalmic Antibiotics - Drugs to treat Eye Infections bacitracin ophthalmic - Tier 1; QL AZASITE - Tier 2; PA; QL ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QL BESIVANCE - Tier 2; PA; QL erythromycin ophthalmic - Tier 1; QL CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA; QL gentak - Tier 1; QL ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL gentamicin sulfate ophthalmic - Tier 1; QL ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL

Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL acetazolamide oral - Tier 1; QL AZOPT (brand for brinzolamide) - Tier 2; PA apraclonidine hcl - Tier 1; QL BETIMOL - Tier 2; PA; QL betaxolol hcl ophthalmic - Tier 1; QL BETOPTIC-S - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 110 Preferred Agents Non-Preferred Agents brimonidine tartrate ophthalmic - Tier 1; QL COMBIGAN - Tier 2; PA; QL carteolol hcl - Tier 1 COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISTALOL (brand for timolol maleate) - Tier 2; PA; QL 1; QL SIMBRINZA - Tier 2; PA; QL dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL levobunolol hcl - Tier 1; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1 TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for TIMOPTIC) - Tier 1; QL

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALAWAY (brand for hm eye itch relief) - Tier 2 ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA ALAWAY CHILDRENS ALLERGY (brand for hm eye itch relief) - Tier 2 ACUVAIL - Tier 2; PA; QL allergy eye drops (generic for ALAWAY) - Tier 1 ILEVRO - Tier 2; PA; QL CLARITIN EYE (brand for hm eye itch relief) - Tier 2 NEVANAC - Tier 2; PA; QL dexamethasone sodium phosphate ophthalmic - Tier 1 PROLENSA - Tier 2; PA; QL diclofenac sodium ophthalmic - Tier 1; QL eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - Tier 1 fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL flurbiprofen sodium - Tier 1; QL ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1 ketorolac tromethamine ophthalmic solution 0.5 % (generic for ACULAR) - Tier 1; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1 prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; QL prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL prednisolone sodium phosphate ophthalmic - Tier 1 ZADITOR (brand for hm eye itch relief) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL ZIOPTAN - Tier 2; PA; QL

Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1; QL

Otic Agents - Drugs for the Ear acetic acid otic - Tier 1; QL ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; PA; QL CLEARCANAL EARWAX SOFTENER (brand for earwax removal aid) - Tier 2; AL ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear drops earwax aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents earwax removal kit otic solution 6.5 % (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; AL hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1; QL neomycin-polymyxin-hc otic - Tier 1; QL

Regulators - Drugs to Regulate Blood Sugar Insulins - Diabetic Drugs LYUMJEV - Tier 2; PA; QL

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1; QL CHLOR-TRIMETON ALLERGY (brand for chlorpheniramine maleate er) - Tier 2; QL CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2; AL ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; AL

Antihistamines - Drugs to Treat Allergies 24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; PA ALAVERT (brand for cvs allergy relief) - Tier 2 all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL ALLEGRA ALLERGY (brand for sm fexofenadine hcl) - Tier 2; PA aller-chlor (generic for CHLOR-TRIMETON) - Tier 1; AL allerclear (generic for KLS ALLERCLEAR) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 113 Preferred Agents Non-Preferred Agents aller-ease (generic for KLS ALLER-FEX) - Tier 1; PA aller-fex (generic for KLS ALLER-FEX) - Tier 1; PA allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1; QL allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; PA allergy 4 hour (generic for CHLOR-TRIMETON) - Tier 1; AL allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) - Tier 1 allergy childrens oral syrup (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL allergy medication oral capsule 25 mg (generic for BANOPHEN) - Tier 1; AL allergy medication oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1 allergy medication oral tablet 25 mg (generic for BANOPHEN) - Tier 1; AL allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; AL allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1 allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; AL allergy oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; AL allergy rel child (loratadine) (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief 4-hour (generic for CHLOR-TRIMETON) - Tier 1; AL allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1 allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1 allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; AL allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 114 Preferred Agents Non-Preferred Agents allergy relief oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; PA allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; AL allergy relief oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; AL allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier 1; PA allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1 allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS ALLER- FEX) - Tier 1; PA aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL anti-hist allergy (generic for BANOPHEN) - Tier 1; AL aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1 azelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1; QL banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; AL banophen oral tablet (generic for BANOPHEN) - Tier 1; AL BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for sm allergy relief) - Tier 2 BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE (brand for gnp allergy relief) - Tier 2; QL BENADRYL ALLERGY ORAL TABLET (brand for complete allergy relief) - Tier 2; AL BENADRYL ALLERGY ULTRATABS (brand for complete allergy relief) - Tier 2; AL cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 115 Preferred Agents Non-Preferred Agents cetirizine hcl oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL cetirizine hcl oral tablet 5 mg - Tier 1; QL; AL childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1 childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL chlor-pheniramine (generic for CHLOR-TRIMETON) - Tier 1; AL chlorpheniramine maleate oral (generic for CHLOR-TRIMETON) - Tier 1; AL chlortabs (generic for CHLOR-TRIMETON) - Tier 1; AL CHLOR-TRIMETON ORAL TABLET (brand for gnp allergy relief) - Tier 2; AL CLARITIN ALLERGY CHILDRENS (brand for sm loratadine) - Tier 2; QL; AL CLARITIN ORAL TABLET (brand for sm loratadine) - Tier 2 CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for cvs allergy relief) - Tier 2 clemastine fumarate oral syrup - Tier 1; QL clemastine fumarate oral tablet 2.68 mg - Tier 1; QL complete allergy (generic for BANOPHEN) - Tier 1; AL complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1; AL complete allergy relief (generic for BANOPHEN) - Tier 1; AL cyproheptadine hcl oral - Tier 1 DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2; QL diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1 di-phen - Tier 1 diphen oral elixir - Tier 1 diphen oral tablet (generic for BANOPHEN) - Tier 1; AL diphenhist (generic for BANOPHEN) - Tier 1; AL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; AL diphenhydramine hcl oral elixir - Tier 1 diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; AL diphenhydramine hcl oral tablet chewable (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL dye-free allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1 fexofenadine hcl oral (generic for ALLEGRA ALLERGY) - Tier 1; PA fexofenadine hydrochloride (generic for KLS ALLER-FEX) - Tier 1; PA geri-dryl oral liquid (generic for RA DIPHEDRYL ALLERGY) - Tier 1 geri-dryl oral tablet (generic for BANOPHEN) - Tier 1; AL h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1 hydroxyzine pamoate oral - Tier 1; QL indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1; QL liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1 loradamed (generic for KLS ALLERCLEAR) - Tier 1 loratadine allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 loratadine allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1 loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL loratadine childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL loratadine oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL; AL loratadine oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 loratadine oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1 m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1 mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1; QL NARAMIN (brand for sm allergy relief) - Tier 2 nighttime sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1 pharbechlor (generic for CHLOR-TRIMETON) - Tier 1; AL pharbedryl (generic for BANOPHEN) - Tier 1; AL promethazine hcl oral - Tier 1; QL promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL promethegan - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 117 Preferred Agents Non-Preferred Agents sb allergy medicine oral tablet (generic for BANOPHEN) - Tier 1; AL siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1 sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1 sleep aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1 sleep aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1 sleep-aid max st (generic for UNISOM SLEEPGELS) - Tier 1 sleep-aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1 sleep-aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1 total allergy (generic for BANOPHEN) - Tier 1; AL total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1 TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2 ZYRTEC ALLERGY ORAL TABLET (brand for goodsense all day allergy) - Tier 2; QL

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL ALVESCO - Tier 2; PA aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL ASMANEX (120 METERED DOSES) - Tier 2; PA; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - ASMANEX (14 METERED DOSES) - Tier 2; PA; QL Tier 1; QL ASMANEX (30 METERED DOSES) - Tier 2; PA; QL ARNUITY ELLIPTA - Tier 2; QL ASMANEX (60 METERED DOSES) - Tier 2; PA; QL ASMANEX HFA - Tier 2; Members > = 8 years of age will require PA; ASMANEX (7 METERED DOSES) - Tier 2; PA; QL QL; AL FLOVENT DISKUS - Tier 2; PA; QL budesonide inhalation (generic for PULMICORT) - Tier 1; Members > = FLOVENT HFA - Tier 2; PA; QL 5 years of age will require PA; QL; AL OMNARIS - Tier 2; PA; QL fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL PULMICORT FLEXHALER - Tier 2; PA; QL NASACORT ALLERGY 24HR (brand for eq nasal allergy) - Tier 2; QL ZETONNA - Tier 2; PA; QL NASACORT ALLERGY 24HR CHILDREN (brand for eq nasal allergy) - Tier 2; QL nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER-CORT) - Tier 1; QL

Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL SPIRIVA HANDIHALER - Tier 2; PA; QL INCRUSE ELLIPTA - Tier 2; QL SPIRIVA RESPIMAT - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL TUDORZA PRESSAIR - Tier 2; PA; QL ipratropium bromide nasal - Tier 1; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL SULFATE HFA - Tier 2; QL AUVI-Q (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL 2.5 mg/0.5ml - Tier 1; QL EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL mg/3ml - Tier 1; Members > = 8 years of age will require PA; QL; AL PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL INHALATION - Tier 2; QL PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier 1; SEREVENT DISKUS - Tier 2; PA; QL QL VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL albuterol sulfate oral syrup - Tier 1; QL XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier 1; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; ST; QL STRIVERDI RESPIMAT - Tier 2; QL SYMJEPI - Tier 2; QL

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis tobramycin inhalation nebulization solution 300 mg/4ml (generic for BETHKIS (brand for tobramycin) - Tier 2; PA; SP; QL BETHKIS) - Tier 1; PA; SP; QL BRONCHITOL - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents CAYSTON - Tier 2; PA; SP; QL KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL TOBI PODHALER - Tier 2; PA; SP; QL tobramycin nebulization solution 300 mg/5ml inhalation (generic for KITABIS PAK) - Tier 1; PA; SP; QL TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP; QL

Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1; QL cromolyn sodium nasal (generic for NASALCROM) - Tier 1; AL NASALCROM (brand for cromolyn sodium) - Tier 2; AL

Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN - Tier 2; QL THEO-24 - Tier 2 theophylline - Tier 1; QL theophylline er oral tablet extended release 12 hour 300 mg - Tier 1; QL theophylline er oral tablet extended release 12 hour 450 mg - Tier 1 theophylline er oral tablet extended release 24 hour 400 mg - Tier 1; QL theophylline er oral tablet extended release 24 hour 600 mg - Tier 1

Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS - Tier 2; PA; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP; QL sildenafil citrate oral suspension reconstituted (generic for REVATIO) - Tier bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL 1; PA; SP; QL OPSUMIT - Tier 2; PA; SP; QL tadalafil (pah) (generic for ADCIRCA) - Tier 1; PA; SP; QL sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA; TRACLEER (brand for bosentan) - Tier 2; PA; SP; QL SP; QL

Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis

Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL 12 hour decongestant nasal (generic for GILTUSS SEVERE SINUS) - ADVAIR HFA - Tier 2; PA; QL Tier 1 AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour decongestant oral (generic for SUDAFED SINUS PA; QL CONGESTION 12HR) - Tier 1; AL AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour mucus relief oral tablet extended release 12 hour 1200 mg PA; QL (generic for EQ MUCUS ER) - Tier 1; QL; AL AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; PA; 12 hour nasal decongestant (generic for SUDAFED SINUS QL CONGESTION 12HR) - Tier 1; AL ANORO ELLIPTA - Tier 2; PA; QL 12 hour nasal decongestant nasal (generic for GILTUSS SEVERE BEVESPI AEROSPHERE - Tier 2; PA; QL SINUS) - Tier 1 BREO ELLIPTA - Tier 2; PA; QL 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - Tier DULERA - Tier 2; PA; QL 1 SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA; QL; 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 AL 4-WAY FAST ACTING (brand for eq nasal spray fast acting) - Tier 2 TRELEGY ELLIPTA - Tier 2; PA; QL 4-WAY MENTHOL (brand for eq nasal spray fast acting) - Tier 2 acetylcysteine inhalation solution 10 % - Tier 1; QL acetylcysteine inhalation solution 20 % - Tier 1 adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL ADVIL COLD/SINUS (brand for qc ibuprofen cold/sinus) - Tier 2; AL AFRIN NODRIP ORIGINAL (brand for sm nasal spray) - Tier 2 AFRIN SALINE NASAL MIST (brand for deep sea nasal spray) - Tier 2 AFRIN SINUS (brand for sm nasal spray) - Tier 2 ALAVERT ALLERGY/SINUS (brand for loratadine-d 12hr) - Tier 2; AL all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents allergy & congestion (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief/nasal decongest oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decongest oral tablet extended release 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy/congestion relief (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 altarussin (generic for DIABETIC TUSSIN EX) - Tier 1; AL altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL altarussin-pe - Tier 1; AL anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1 aprodine - Tier 1; AL AYR (brand for deep sea nasal spray) - Tier 2 AYR NASAL MIST ALLERGY/SINUS - Tier 2 AYR SALINE NASAL DROPS - Tier 2 BABY AYR SALINE (brand for deep sea nasal spray) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; AL benzonatate oral capsule 200 mg - Tier 1; QL; AL cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; QL; AL chest congest/cough child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL chest congestion relief dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL chest congestion relief oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL chest congestion relief oral tablet (generic for XPECT) - Tier 1 childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL childrens cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL CLARITIN-D 12 HOUR (brand for loratadine-d 12hr) - Tier 2; AL CLARITIN-D 24 HOUR (brand for ra lorata-d) - Tier 2; AL cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL cold & sinus relief oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents COMBIVENT RESPIMAT - Tier 2; QL CORICIDIN HBP COUGH/COLD (brand for cough & cold hbp) - Tier 2; AL cough & chest congestion (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL cough dm (generic for DELSYM) - Tier 1 cough dm childrens (generic for DELSYM) - Tier 1 cough dm er (generic for DELSYM) - Tier 1 cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH) - Tier 1; AL cough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL decongestant 12hour max st (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 DELSYM (brand for eql cough dm) - Tier 2 DELSYM CGH/CHEST CONG DM CHILD (brand for mucus relief dm max) - Tier 2; AL DELSYM COUGH CHILDRENS (brand for eql cough dm) - Tier 2 DELSYM COUGH/CHEST CONGEST DM (brand for mucus relief dm max) - Tier 2; AL desgen dm oral liquid (generic for DESGEN DM) - Tier 1; AL dextromethorphan polistirex er (generic for DELSYM) - Tier 1 dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL DIABETIC TUSSIN MAX ST (brand for ra tussin cough/chest dm max) - Tier 2; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL DIMETAPP COLD RELIEF CHILDRENS (brand for eq cold/cough dm childrens) - Tier 2; QL DIMETAPP COLD/ALLERGY (brand for px dibromm cold/allergy child) - Tier 2; AL DIMETAPP DM COLD/COUGH (brand for eq cold/cough dm childrens) - Tier 2; QL dm maximum adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL; AL ed bron gp - Tier 1; AL ENDACOF-DM (brand for eq cold/cough dm childrens) - Tier 2; QL ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 FASENRA PEN - Tier 2; PA; QL fluticasone-salmeterol inhalation aerosol powder breath activated 100- 50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; QL g tussin ac - Tier 1; QL; AL genaphed (generic for SUDOGEST) - Tier 1; AL geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 guaiatussin ac - Tier 1; QL; AL guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL guaifenesin ac - Tier 1; QL; AL guaifenesin er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1 guaifenesin-codeine - Tier 1; QL; AL guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL hydrocodone-homatropine (generic for HYCODAN) - Tier 1; QL; AL hydromet (generic for HYCODAN) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 125 Preferred Agents Non-Preferred Agents HYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for sodium chloride) - Tier 2 ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; AL ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ipratropium-albuterol - Tier 1; QL liquibid (generic for XPECT) - Tier 1 long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL maxi-tuss ac - Tier 1; QL; AL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL maxi-tuss pe max - Tier 1; AL m-clear wc - Tier 1; QL; AL medifin 400 (generic for XPECT) - Tier 1 meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for mucus relief dm max) - Tier 2; AL MUCINEX CHILDRENS STUFFY NOSE (brand for sm nasal spray) - Tier 2 MUCINEX COUGH CHILDRENS (brand for mucus relief dm max) - Tier 2; AL MUCINEX D (brand for sm mucus relief d) - Tier 2; AL MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) - Tier 2; AL MUCINEX DM (brand for mucus-dm) - Tier 2; QL; AL MUCINEX FAST-MAX DM MAX (brand for mucus relief dm max) - Tier 2; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents MUCINEX MAXIMUM STRENGTH (brand for sm mucus relief max strength) - Tier 2; QL; AL MUCINEX SINUS-MAX CLEAR & COOL (brand for sm nasal spray) - Tier 2 MUCINEX SINUS-MAX SINUS/ALLRGY (brand for sm nasal spray) - Tier 2 mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus d (generic for MUCINEX D) - Tier 1; AL mucus d extended release (generic for MUCINEX D) - Tier 1; AL mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1 mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; AL mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; QL; AL mucus relief er (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 127 Preferred Agents Non-Preferred Agents mucus relief max strength oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief oral tablet (generic for XPECT) - Tier 1 mucus-d (generic for MUCINEX D) - Tier 1; AL mucus-dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL nasal decongestant 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL nasal decongestant max st (generic for SUDOGEST) - Tier 1; AL nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1; AL nasal decongestant oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal four (generic for 4-WAY FAST ACTING) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for deep sea nasal spray) - Tier 2 nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray anti-drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 128 Preferred Agents Non-Preferred Agents nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1 nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for eq nasal spray fast acting) - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2 no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nohist-lq (generic for ED A-HIST) - Tier 1; QL; AL non-pseudo sinus decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal decongest (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal solution 1 % (generic for 4-WAY FAST ACTING) - Tier 1 NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; SP; QL NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP; QL OCEAN FOR KIDS (brand for deep sea nasal spray) - Tier 2 OCEAN NASAL SPRAY (brand for deep sea nasal spray) - Tier 2 pharbinex (generic for XPECT) - Tier 1 phenylephrine hcl oral (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 promethazine vc - Tier 1; QL; AL promethazine vc/codeine - Tier 1; QL; AL promethazine-codeine - Tier 1; QL; AL promethazine-dm - Tier 1; QL; AL promethazine-phenyleph-codeine - Tier 1; QL; AL promethazine-phenylephrine - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1; AL pseudoephedrine-bromphen-dm - Tier 1; QL; AL pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1; AL PULMOZYME - Tier 2; PA; SP; QL refenesen 400 (generic for XPECT) - Tier 1 robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL ROBITUSSIN 12 HOUR COUGH (brand for eql cough dm) - Tier 2 ROBITUSSIN 12 HOUR COUGH CHILD (brand for eql cough dm) - Tier 2 ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; AL ROBITUSSIN CHILDRENS COUGH LA - Tier 2; AL ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for mucus relief dm max) - Tier 2; AL ROBITUSSIN NIGHTTIME COUGH - Tier 2; AL ROBITUSSIN PEAK COLD MULTI-SYM (brand for qc tussin cf) - Tier 2; AL rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL rynex pse - Tier 1; AL saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 sb mucus relief (generic for XPECT) - Tier 1 siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1; AL siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL sinus congestion max strength (generic for SUDOGEST) - Tier 1; AL sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 sinus pe decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 130 Preferred Agents Non-Preferred Agents sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1 sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1 sinus/congestion relief pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 % - Tier 1 sodium chloride inhalation nebulization solution 7 % (generic for HYPERSAL) - Tier 1 STIOLTO RESPIMAT - Tier 2; QL SUDAFED (brand for ra suphedrine) - Tier 2; AL SUDAFED CHILDRENS - Tier 2; AL SUDAFED CONGESTION (brand for ra suphedrine) - Tier 2; AL SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for cvs nasal decongestant pe) - Tier 2 SUDAFED PE SINUS CONGESTION (brand for cvs nasal decongestant pe) - Tier 2 SUDAFED SINUS CONGESTION (brand for ra suphedrine) - Tier 2; AL SUDAFED SINUS CONGESTION 12HR (brand for gnp pseudoephedrine hcl 12 hr) - Tier 2; AL sudogest 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL sudogest maximum strength (generic for SUDOGEST) - Tier 1; AL sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; AL suphedrine maximum strength (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; AL suphedrine oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; AL tab tussin (generic for XPECT) - Tier 1 tussin adult dm oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin adult multi-symptom (generic for DESGEN DM) - Tier 1; AL tussin cf cough & cold oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL tussin cf oral liquid 30-10-100 mg/5ml - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 131 Preferred Agents Non-Preferred Agents tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin chest congestion oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin cough dm sugar free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL tussin cough long acting (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm cough/chest cong (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL tussin dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL tussin dm max st (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; AL tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; AL tussin maximum strength oral syrup 15 mg/5ml (generic for WAL- TUSSIN COUGH) - Tier 1; AL tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; AL tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL virtussin a/c - Tier 1; QL; AL virtussin ac w/alc - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 132 Preferred Agents Non-Preferred Agents virtussin dac - Tier 1; QL; AL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL XPECT (brand for kls mucus relief chest) - Tier 2 ZYRTEC-D ALLERGY & CONGESTION (brand for hm allergy complete- d) - Tier 2; QL; AL

Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1; QL chlorzoxazone oral tablet 500 mg - Tier 1; QL cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL dantrolene sodium oral - Tier 1; QL methocarbamol oral - Tier 1; QL orphenadrine citrate er - Tier 1; QL tizanidine hcl oral tablet - Tier 1; QL

Sleep Disorder Agents - Drugs for Sedation and Sleep GABA Receptor Modulators - Drugs for Sleeping EDLUAR - Tier 2; QL AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL eszopiclone (generic for LUNESTA) - Tier 1; QL AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA; QL flurazepam hcl - Tier 1; QL LUNESTA (brand for eszopiclone) - Tier 2; PA; QL temazepam oral capsule 15 mg, 30 mg, 7.5 mg (generic for RESTORIL) - Tier 1; QL zaleplon - Tier 1; QL zolpidem tartrate (generic for AMBIEN) - Tier 1; QL zolpidem tartrate er (generic for AMBIEN CR) - Tier 1; QL ZOLPIMIST - Tier 2; QL

Sleep Disorders, Other - Drugs for Sleeping armodafinil (generic for NUVIGIL) - Tier 1; QL; AL ROZEREM (brand for ramelteon) - Tier 2; PA; QL BELSOMRA - Tier 2; QL SILENOR (brand for doxepin hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 133 Preferred Agents Non-Preferred Agents DAYVIGO - Tier 2; QL; AL doxepin hcl oral tablet (generic for SILENOR) - Tier 1; QL HETLIOZ - Tier 2; QL; AL HETLIOZ LQ - Tier 2; QL; AL modafinil (generic for PROVIGIL) - Tier 1; QL; AL night time sleep aid (generic for SIMPLY SLEEP) - Tier 1 nighttime sleep aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 nighttime sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1 ramelteon (generic for ROZEREM) - Tier 1; QL rest simply (generic for SIMPLY SLEEP) - Tier 1 SIMPLY SLEEP (brand for qc rest simply) - Tier 2 sleep aid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1 sleep aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleep aid nighttime oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1 sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1 sleep ii (generic for SIMPLY SLEEP) - Tier 1 sleep tabs (generic for SIMPLY SLEEP) - Tier 1 sleepaid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1 sleep-aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleep-aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1 sleeptime oral capsule (generic for WAL-SLEEP Z) - Tier 1 SUNOSI - Tier 2; QL; AL WAKIX - Tier 2; QL; AL XYREM - Tier 2; QL; AL z-sleep oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs

Title Drugs Impacted Prior Authorization Criteria / Class Criteria

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 136 Index of Drugs

1 ABILIFY MAINTENA ...... acetaminophen ex st oral tablet 500 mg ...... 12 hour allergy-d ...... ABILIFY MYCITE ...... acetaminophen extra strength ...... 12 hour decongestant nasal ...... ABILIFY MYCITE MAINTENANCE KIT ...... acetaminophen infants oral suspension 160 12 hour decongestant oral ...... ABILIFY MYCITE STARTER KIT ...... mg/5ml ...... 12 hour mucus relief oral tablet extended abiraterone acetate ...... acetaminophen oral liquid 500 mg/15ml ...... release 12 hour 1200 mg ...... ABSORICA ...... acetaminophen oral solution 160 mg/5ml, 12 hour nasal decongestant ...... ABSORICA LD ...... 325 mg/10.15ml, 650 mg/20.3ml ...... 12 hour nasal decongestant nasal ...... acamprosate calcium ...... acetaminophen oral suspension 160 12 hour nasal relief spray ...... ACANYA ...... mg/5ml, 650 mg/20.3ml ...... 12 hour nasal spray ...... acarbose oral ...... acetaminophen oral tablet 325 mg ...... 2 ACCU-CHEK AVIVA DEVICE ...... acetaminophen oral tablet 500 mg ...... 24 hour nasal allergy ...... ACCU-CHEK AVIVA PLUS TEST STRIPS .. acetaminophen oral tablet chewable 160 mg 24hr allergy relief ...... ACCU-CHEK COMPACT PLUS ...... acetaminophen rectal suppository 120 mg .... 3 ACCU-CHEK COMPACT PLUS CONTROL. acetaminophen rectal suppository 650 mg .... 3 day ...... ACCU-CHEK FASTCLIX LANCET KIT...... acetaminophen-codeine ...... 3 day vaginal ...... ACCU-CHEK GUIDE CONTROL ...... acetaminophen-codeine #2 ...... 3-day vaginal vaginal cream 2 % ...... ACCU-CHEK GUIDE STRIP IN VITRO ...... , acetaminophen-codeine #3 ...... 4 ACCU-CHEK GUIDE TEST STRIPS ...... acetaminophen-codeine #4 ...... 4-WAY FAST ACTING ...... ACCU-CHEK MULTICLIX LANCETS ...... , acetazolamide er ...... 4-WAY MENTHOL ...... ACCU-CHEK SMARTVIEW ...... acetazolamide oral ...... 7 ACCU-CHEK SMARTVIEW CONTROL ...... acetic acid otic ...... 7T LIDO ...... ACCU-CHEK SOFTCLIX LANCET DEVICE acetylcysteine inhalation solution 10 % ...... 8 KIT ...... acetylcysteine inhalation solution 20 % ...... 8 hour arthritis pain reliever...... accutane ...... acid controller ...... 8 hour arthritis relief ...... ACCUTREND GLUCOSE CONTROL ...... acid gone oral suspension ...... 8 hour pain relief oral tablet extended acebutolol hcl oral ...... acid gone oral tablet chewable ...... release 650 mg ...... acetaminophen 8 hour ...... acid reducer oral capsule delayed release .... 8 hour pain reliever ...... acetaminophen 8 hours ...... acid reducer oral tablet 10 mg ...... 8 hr arthritis pain relief ...... acetaminophen 8hr arth pain ...... acid reducer oral tablet 200 mg ...... 8hr arthritis pain relief ...... acetaminophen 8hr musc ache ...... acidophilus lactobacillus oral ...... 8hr muscle aches & pain ...... acetaminophen childrens oral solution ...... acidophilus oral capsule , 10 mg ...... A acetaminophen childrens oral suspension acidophilus probiotic oral capsule 10 mg ...... a-25 ...... 160 mg/5ml ...... acidophilus probiotic oral tablet , 0.5 mg ...... abacavir sulfate ...... acetaminophen childrens oral tablet acidophilus/l-sporogenes ...... abacavir sulfate-lamivudine ...... chewable ...... ACIPHEX ...... abacavir-lamivudine-zidovudine ...... acetaminophen er ...... acitretin ...... abatinex ...... acetaminophen ex st oral liquid 500 mg/15ml acne ...... ABILIFY ...... acne control cleanser ......

137 acne medication 10 external lotion...... AFRIN NODRIP ORIGINAL ...... alfuzosin hcl er ...... acne medication 5 external lotion...... AFRIN SALINE NASAL MIST ...... ALINIA ORAL SUSPENSION ACTEMRA ACTPEN ...... AFRIN SINUS ...... RECONSTITUTED ...... ACTEMRA SUBCUTANEOUS ...... aftera ...... all day allergy d ...... ACTIMMUNE ...... AIMOVIG ...... all day allergy d-12 ...... ACTIVELLA ...... AIRDUO RESPICLICK 113/14 ...... all day allergy oral tablet 10 mg ...... ACULAR LS ...... AIRDUO RESPICLICK 232/14 ...... all day allergy-d oral tablet extended release ACUVAIL ...... AIRDUO RESPICLICK 55/14 ...... 12 hour 5-120 mg ...... acyclovir oral ...... AJOVY SUBCUTANEOUS SOLUTION all day pain relief ...... ACZONE EXTERNAL GEL 7.5 % ...... AUTO-INJECTOR ...... all day relief ...... ADACEL ...... AJOVY SUBCUTANEOUS SOLUTION ALLEGRA ALLERGY ...... ADASUVE ...... PREFILLED SYRINGE ...... aller-chlor ...... adc/f (0.5mg/ml) ...... ak-poly-bac ...... allerclear ...... addaprin ...... AKYNZEO ORAL ...... allerclear d-12hr ...... ADEMPAS ...... ala-cort ...... allerclear d-24hr ...... ADHANSIA XR ...... ALAVERT ...... aller-cort ...... ADLYXIN ...... ALAVERT ALLERGY/SINUS ...... aller-ease ...... ADLYXIN STARTER PACK ...... ALAWAY ...... aller-fex ...... ADMELOG ...... ALAWAY CHILDRENS ALLERGY ...... allergy & congestion ...... ADMELOG SOLOSTAR...... albendazole oral ...... allergy 24hour indoor/outdoor ...... adult 50+ probiotic ...... ALBUTEROL SULFATE HFA ...... allergy 24-hr ...... adult probiotic ...... albuterol sulfate inhalation nebulization allergy 4 hour ...... adult tussin cough & chest ...... solution (2.5 mg/3ml) 0.083%, 2.5 allergy childrens oral liquid ...... adv acne spot treatment ...... mg/0.5ml ...... allergy childrens oral syrup ...... ADVAIR DISKUS ...... albuterol sulfate inhalation nebulization allergy complete-d ...... ADVAIR HFA ...... solution 0.63 mg/3ml, 1.25 mg/3ml ...... allergy eye drops ...... advanced acne spot treat ...... albuterol sulfate nebulization solution (5 allergy medication oral capsule 25 mg ...... advanced antacid max st ...... mg/ml) 0.5% inhalation ...... allergy medication oral liquid 12.5 mg/5ml .... advanced healing external ointment ...... ALBUTEROL SULFATE NEBULIZATION allergy medication oral tablet 25 mg ...... ADVIL COLD/SINUS ...... SOLUTION (5 MG/ML) 0.5% allergy oral capsule 25 mg ...... ADVIL JUNIOR STRENGTH ORAL TABLET INHALATION ...... allergy oral liquid 12.5 mg/5ml ...... ADVIL JUNIOR STRENGTH ORAL TABLET albuterol sulfate oral syrup ...... allergy oral tablet 25 mg ...... CHEWABLE ...... alclometasone dipropionate external allergy oral tablet 4 mg ...... ADVIL ORAL TABLET ...... ointment ...... allergy oral tablet extended release 12 mg .... ADZENYS ER ...... ALCOHOL PREP PADS PAD ...... allergy rel child (loratadine) ...... ADZENYS XR-ODT ...... ALCOHOL PREP PADS PAD 70 % ...... allergy relief (cetirizine) oral tablet 10 mg ...... AFINITOR DISPERZ ...... ALDARA ...... allergy relief 4-hour ...... AFINITOR ORAL TABLET 10 MG ...... ALECENSA ...... allergy relief adult ...... afirmelle ...... alendronate sodium ...... allergy relief cetirizine ...... AFREZZA ...... ALEVE ORAL TABLET ...... allergy relief child ......

138 allergy relief childrens oral liquid 12.5 allopurinol oral ...... amlodipine besylate oral ...... mg/5ml ...... almacone double strength ...... ammonium lactate external cream ...... allergy relief childrens oral syrup 5 mg/5ml ... ALOE VESTA CLEAR ANTIFUNGAL ...... ammonium lactate external lotion ...... allergy relief d oral tablet extended release ALOGLIPTIN BENZOATE ...... amnesteem ...... 12 hour ...... ALOGLIPTIN-METFORMIN HCL ...... amoxapine ...... allergy relief d-12 ...... ALOGLIPTIN-PIOGLITAZONE ...... amoxicillin oral capsule ...... allergy relief d-24 ...... ALORA ...... amoxicillin oral suspension reconstituted ...... allergy relief oral capsule 25 mg ...... ALPHAGAN P ...... amoxicillin oral tablet 875 mg ...... allergy relief oral liquid 12.5 mg/5ml, 25 alprazolam er ...... amoxicillin oral tablet chewable ...... mg/10ml ...... alprazolam intensol ...... amoxicillin-potassium clavulanate oral ...... allergy relief oral tablet 10 mg ...... , alprazolam oral ...... AMPHETAMINE ER ...... allergy relief oral tablet 180 mg ...... alprazolam xr ...... amphetamine sulfate ...... allergy relief oral tablet 25 mg ...... altachlore ophthalmic ointment ...... amphetamine-dextroamphetamine ...... allergy relief oral tablet 4 mg ...... altachlore ophthalmic solution ...... amphetamine-dextroamphetamine er ...... allergy relief oral tablet 60 mg ...... altafrin ...... ampicillin ...... allergy relief oral tablet chewable 12.5 mg .... altalube ...... AMPYRA ...... allergy relief oral tablet dispersible 10 mg ..... altamist spray ...... AMZEEQ ...... allergy relief oral tablet extended release 12 altarussin ...... anagrelide hcl ...... hour 5-120 mg ...... altarussin dm ...... ANASPAZ ...... allergy relief oral tablet extended release 12 altarussin-pe ...... anastrozole oral ...... mg ...... altavera ...... anecream external cream ...... allergy relief(cetirizine) ...... alum & mag hydroxide-simeth ...... anefrin spray ...... allergy relief/indoor/outdoor oral tablet 10 mg alum sulfate-ca acetate ...... ANGELIQ ...... alumina-magnesia-simethicone ...... animal shapes complete ...... allergy relief/indoor/outdoor oral tablet 180 ALUNBRIG ...... animal shapes kids first ...... mg ...... ALVESCO ...... animal shapes/iron ...... allergy relief/nasal decong ...... alyacen 1/35 ...... ANORO ELLIPTA ...... allergy relief/nasal decongest oral tablet alyacen 7/7/7 ...... antacid & anti-gas oral suspension 200-200- extended release 12 hour ...... amantadine hcl oral capsule ...... 20 mg/5ml ...... allergy relief/nasal decongest oral tablet amantadine hcl oral syrup ...... antacid & anti-gas oral suspension 400-400- extended release 24 hour ...... AMBIEN ...... 40 mg/5ml ...... allergy relief-d oral tablet extended release AMBIEN CR ...... antacid & gas relief ...... 12 hour 5-120 mg ...... , ambrisentan ...... antacid advanced ...... allergy relief-d oral tablet extended release amcinonide external ointment ...... antacid advanced max st ...... 24 hour 10-240 mg ...... amiloride hcl oral ...... antacid anti-gas ...... allergy relief-d12 ...... amiloride-hydrochlorothiazide ...... antacid anti-gas ex st oral suspension 400- allergy spray 24 hour nasal aerosol ...... aminocaproic acid oral ...... 400-40 mg/5ml ...... allergy/congestion relief ...... amiodarone hcl oral tablet 200 mg, 400 mg . antacid anti-gas max strength ...... aller-tec ...... AMITIZA ...... antacid anti-gas reg strength ...... aller-tec d ...... amitriptyline hcl oral ...... antacid calcium ......

139 antacid calcium rich ...... anti-diarrheal oral tablet 2 mg ...... aripiprazole ...... antacid extra ...... antifungal (tolnaftate) ...... ARISTADA ...... antacid extra strength oral suspension ...... antifungal external cream ...... ARISTADA INITIO ...... antacid extra strength oral tablet chewable antifungal external powder ...... armodafinil ...... 160-105 mg ...... anti-fungal external powder ...... ARNUITY ELLIPTA ...... antacid extra strength oral tablet chewable antifungal foot care ...... arthritis pain oral tablet extended release 750 mg ...... antifungal miconazole ...... 650 mg ...... antacid fast relief ...... antifungal tolnaftate ...... arthritis pain relief oral tablet extended antacid i ...... anti-gas oral capsule 180 mg ...... release 650 mg ...... antacid iii ...... anti-hist allergy ...... arthritis pain reliever oral ...... antacid kids ...... anti-nausea ...... arthritis pain relieving ...... antacid liquid ...... antiseptic ...... artificial eye ...... antacid m ...... apap-caff-dihydrocodeine oral capsule ...... artificial tears ophthalmic ointment ...... antacid maximum ...... APIDRA SOLOSTAR ...... artificial tears ophthalmic solution ...... antacid maximum strength ...... APIDRA VIAL ...... artificial tears ophthalmic solution 1.4 % ...... antacid maximum strength oral tablet APLENZIN ...... ASACOL HD ...... chewable 1000 mg ...... apra ...... ascomp-codeine ...... antacid oral suspension 200-200-20 mg/5ml, apraclonidine hcl ...... ascorbic acid oral tablet 500 mg ...... 400-400-40 mg/10ml ...... aprepitant ...... asenapine maleate ...... antacid oral tablet chewable 1000 mg...... apri ...... ASMANEX (120 METERED DOSES)...... antacid oral tablet chewable 500 mg...... APRISO ...... ASMANEX (14 METERED DOSES) ...... antacid oral tablet chewable 750 mg...... aprodine ...... ASMANEX (30 METERED DOSES) ...... antacid plus antigas ...... APTENSIO XR ...... ASMANEX (60 METERED DOSES) ...... antacid plus anti-gas relief ...... APTIOM ...... ASMANEX (7 METERED DOSES) ...... antacid regular strength oral suspension ...... APTIVUS ...... ASMANEX HFA ...... antacid regular strength oral tablet chewable AQUADEKS ...... aspirin childrens ...... antacid supreme ...... aqueous vitamin d ...... aspirin ec ...... antacid ultra strength oral tablet chewable ARAKODA ...... aspirin ec oral tablet 325 mg ...... 1000 mg ...... aranelle ...... aspirin oral ...... antacid/anti-gas ...... ARANESP (ALBUMIN FREE) INJECTION ASPIRIN ORAL TABLET DELAYED antacid/anti-gas max st ...... SOLUTION ...... RELEASE 81 MG ...... antacid/antigas oral suspension 200-200-20 ARANESP (ALBUMIN FREE) INJECTION aspirin rectal ...... mg/5ml ...... SOLUTION PREFILLED SYRINGE 10 astringent eye drops ...... antacid/gas relief max st ...... MCG/0.4ML ...... astringent solution ...... antibiotic external ointment 3.5-400-5000 ..... ARANESP (ALBUMIN FREE) INJECTION ATABEX OB ...... antibiotic external ointment 500 unit/gm...... SOLUTION PREFILLED SYRINGE 100 atazanavir sulfate ...... anti-diarr/ant-gas ...... MCG/0.5ML, 150 MCG/0.3ML, 200 atenolol oral ...... anti-diarrheal anti-gas ...... MCG/0.4ML, 25 MCG/0.42ML, 300 atenolol-chlorthalidone ...... anti-diarrheal oral liquid 1 mg/5ml ...... MCG/0.6ML, 40 MCG/0.4ML, 500 atheletes foot ...... anti-diarrheal oral suspension 262 mg/15ml . MCG/ML, 60 MCG/0.3ML ...... athletes foot ......

140 athletes foot (terbinafine) ...... azathioprine oral ...... b-complex/b-12 oral ...... athletes foot (tolnaftate) external aerosol azelaic acid external ...... BD AUTOSHIELD DUO PEN NEEDLES ...... powder 1 % ...... azelastine hcl nasal solution 0.1 %, 137 BD ULTRA-FINE INSULIN SYRINGES ...... athletes foot (tolnaftate) external cream 1 % mcg/spray ...... BD ULTRA-FINE PEN NEEDLES ...... athletes foot external aerosol powder 2 % .... azelastine hcl ophthalmic ...... beauty 360 pure glycerin ...... athletes foot external cream 1 % ...... azithromycin oral suspension reconstituted .. beauty 360 soothing bath ...... athletes foot powder spray ...... azithromycin oral tablet ...... bekyree ...... athletes foot spray ...... azo ...... BELSOMRA ...... athletes foot spray external aerosol 2 % ...... azo tabs ...... BENADRYL ALLERGY CHILDRENS ORAL atomoxetine hcl ...... AZOPT ...... LIQUID ...... atorvastatin calcium oral ...... azurette ...... BENADRYL ALLERGY CHILDRENS ORAL atovaquone oral ...... B TABLET CHEWABLE ...... ATRALIN ...... b complex oral capsule ...... BENADRYL ALLERGY ORAL TABLET ...... ATRIPLA ...... b complex vitamins ...... BENADRYL ALLERGY ULTRATABS ...... atropine sulfate ophthalmic ointment ...... b-1 ...... benazepril hcl oral ...... atropine sulfate ophthalmic solution 1 %...... b6 ...... benazepril-hydrochlorothiazide ...... ATROVENT HFA ...... BABY AYR SALINE ...... BENLYSTA SUBCUTANEOUS SOLUTION AUBAGIO ...... baby basics diaper rash ...... AUTO-INJECTOR ...... aubra ...... bac ...... BENZAC AC WASH ...... aubra eq ...... bacitracin external ...... BENZACLIN ...... aurodryl allergy childrens ...... bacitracin external ointment 500 unit/gm ...... BENZACLIN WITH PUMP ...... aurophen childrens ...... bacitracin ophthalmic ...... BENZAMYCIN ...... aurovela 1.5/30 ...... bacitracin zinc external ...... BENZEPRO CREAMY WASH ...... aurovela 1/20 ...... bacitracin zinc first aid ...... BENZEPRO EXTERNAL LIQUID ...... aurovela fe 1.5/30 ...... bacitracin-polymyxin b ophthalmic ...... BENZNIDAZOLE ...... aurovela fe 1/20 ...... bacitra-neomycin-polymyxin-hc ...... benzonatate oral capsule 100 mg ...... AURYXIA ...... baclofen oral ...... benzonatate oral capsule 200 mg ...... AUSTEDO ...... BAFIERTAM ...... benztropine mesylate oral ...... AUVI-Q ...... balsalazide disodium ...... BERINERT ...... AVAR-E EMOLLIENT ...... BALVERSA ...... BESIVANCE ...... AVAR-E GREEN ...... balziva ...... betamethasone dipropionate aug ...... aviane ...... banophen oral capsule 25 mg ...... betamethasone dipropionate external lotion .. AVITA EXTERNAL CREAM ...... banophen oral tablet ...... betamethasone dipropionate external AVONEX PEN ...... BAQSIMI ONE PACK ...... ointment ...... AVONEX PREFILLED...... BAQSIMI TWO PACK ...... betamethasone valerate external cream ...... AYR ...... BARACLUDE ORAL SOLUTION ...... betamethasone valerate external lotion ...... AYR NASAL MIST ALLERGY/SINUS ...... BASAGLAR KWIKPEN ...... betamethasone valerate external ointment ... AYR SALINE NASAL DROPS ...... BAYER ASPIRIN ...... BETAPACE ...... ayuna ...... b-complex oral tablet ...... BETAPACE AF ...... AZASITE ...... b-complex with b-12 ...... BETASERON ......

141 betatemp childrens ...... BPROTECTED PEDIA D-VITE ...... butalbital-aspirin-caffeine ...... betaxolol hcl ophthalmic ...... BPROTECTED PEDIA IRON ...... butorphanol tartrate nasal ...... betaxolol hcl oral ...... BPROTECTED PEDIA POLY-VITE ...... BYDUREON BCISE AUTOINJECTOR ...... bethanechol chloride oral ...... BPROTECTED PEDIA POLY-VITE/FE ...... BYETTA 10 MCG PEN ...... BETHKIS ...... BPROTECTED VITAMIN C ...... BYETTA 5 MCG PEN ...... BETIMOL ...... BREO ELLIPTA ...... C BETOPTIC-S ...... briellyn ...... c 250 oral tablet ...... BEVESPI AEROSPHERE ...... BRILINTA ...... c 500/rose hips ...... bexarotene ...... brimonidine tartrate ophthalmic ...... c-1000/rose hips ...... BEXSERO ...... BRIVIACT ORAL ...... cabergoline ...... bicalutamide ...... BRONCHITOL ...... CABLIVI ...... BIDIL ...... BROVANA ...... CABOMETYX ...... BIKTARVY ...... BRUKINSA ...... caffeine citrate oral ...... biocel ...... budesonide inhalation ...... cal mag zinc +d3 ...... BIOLLE TEARS ...... budesonide oral ...... calamine external lotion , 8-8 % ...... biotinex ...... bumetanide oral ...... calamine-zinc oxide external lotion ...... bisacodyl ec ...... BUNAVAIL ...... calcidol ...... bisacodyl laxative ...... buprenorphine hcl sublingual ...... calcipotriene external cream ...... bisacodyl rectal ...... buprenorphine hcl-naloxone hcl sublingual calcipotriene external ointment ...... bismatrol maximum strength ...... film 2-0.5 mg, 8-2 mg ...... calcipotriene external solution ...... bismatrol oral tablet chewable ...... buprenorphine hcl-naloxone hcl sublingual calcitonin (salmon) nasal ...... bismuth ...... tablet sublingual ...... calcitriol external ...... bismuth subsalicylate oral ...... buprenorphine transdermal ...... calcitriol oral capsule ...... bisoprolol fumarate oral ...... bupropion hcl er (smoking det) ...... calcitriol oral solution ...... bisoprolol-hydrochlorothiazide ...... bupropion hcl er (sr) ...... calcium 500/d oral tablet ...... blisovi fe 1.5/30 ...... bupropion hcl er (xl) oral tablet extended calcium 500/vitamin d3 ...... blisovi fe 1/20 ...... release 24 hour 150 mg, 300 mg ...... calcium 600 oral tablet 1500 (600 ca) mg ..... BLOOD GLUCOSE TEST STRIPS ...... BUPROPION HCL ER (XL) ORAL TABLET calcium 600/vit d/minerals oral tablet 600- blue tube/ aloe ...... EXTENDED RELEASE 24 HOUR 450 MG 200 mg-unit ...... BONINE ...... calcium 600/vit d/minerals oral tablet BOOSTRIX ...... bupropion hcl oral ...... chewable 600-400 mg-unit ...... boro-packs ...... buspirone hcl oral ...... calcium 600/vitamin d ...... bosentan ...... butalbital-acetaminophen oral tablet 50-325 calcium 600/vitamin d-3 ...... BOSULIF ...... mg ...... calcium 600+d oral tablet 600-200 mg-unit, BOUDREAUXS BUTT PASTE EXTERNAL butalbital-apap-caff-cod oral capsule 50-325- 600-400 mg-unit...... OINTMENT 40 % ...... 40-30 mg ...... calcium 600+d oral tablet 600-400 mg-unit ... bp 10-1 ...... butalbital-apap-caffeine oral capsule 50-325- calcium acetate (phos binder) oral tablet ...... bp wash external liquid 2.5 % ...... 40 mg ...... calcium acetate oral tablet 667 mg ...... bp wash external liquid 7 % ...... butalbital-apap-caffeine oral tablet ...... calcium antacid ...... b-plex plus ...... butalbital-asa-caff-codeine ...... calcium antacid ex st ......

142 calcium antacid extra strength ...... calcium plus vitamin d oral tablet 600-400 cefaclor ...... calcium carb-cholecalciferol oral tablet 600- mg-unit ...... cefadroxil ...... 400 mg-unit ...... calcium plus vitamin d3 ...... cefdinir ...... calcium carbonate antacid ...... calcium soft chews oral tablet chewable 500- cefixime oral capsule ...... calcium carbonate oral tablet 1500 (600 ca) 200-40 mg-unt-mcg ...... cefprozil ...... mg ...... calcium/minerals/vitamin d ...... cefuroxime axetil ...... calcium carbonate oral tablet chewable 1250 calcium-magnesium-zinc oral tablet 333- celecoxib oral ...... (500 ca) mg ...... 133-5 mg, 333.33-133.33-5 mg ...... CELONTIN ...... calcium carbonate oral tablet chewable 500 calcium-vitamin d oral tablet 600-400 mg- CENTRUM FLAVOR BURST KIDS ...... mg ...... unit ...... CENTRUM KIDS ...... calcium carbonate-vitamin d oral tablet 600- calcium-vitamin d3 oral tablet 600-400 mg- cephalexin oral capsule ...... 200 mg-unit ...... unit ...... cephalexin oral suspension reconstituted ...... calcium carbonate-vitamin d oral tablet 600- cal-gest antacid ...... CEQUA ...... 400 mg-unit ...... CALQUENCE ...... CERDELGA ...... calcium carbonate-vitamin d3 ...... camila ...... cerovel ...... calcium cit plus vit d-3 ...... capecitabine ...... cerovite jr ...... calcium citrate + d oral tablet 315-250 mg- CAPLYTA ...... cetiri-d ...... unit ...... CAPRELSA ...... cetirizine hcl oral solution ...... calcium citrate + d3 maximum ...... capsaicin external cream 0.025 % ...... cetirizine hcl oral tablet 10 mg ...... calcium citrate +d3 ...... capsaicin external cream 0.1 % ...... cetirizine hcl oral tablet 5 mg ...... calcium citrate plus vit d ...... capsaicin hp ...... cetirizine-pseudoephedrine er ...... calcium citrate+d oral tablet 315-250 mg-unit captopril oral ...... CHANTIX ...... calcium citrate+d3 oral tablet 315-250 mg- capzix ...... CHANTIX CONTINUING MONTH PAK ...... unit ...... CARAC ...... CHANTIX STARTING MONTH PAK ...... calcium citrate+d3 w/magne ...... CARBAGLU ...... chateal ...... calcium citrate-vit d ...... carbamazepine er ...... chateal eq ...... calcium citrate-vitamin d oral tablet 315-200 carbamazepine oral ...... CHEMET ...... mg-unit ...... carbidopa-levodopa er ...... CHEMSTRIP 10 MD ...... calcium fast dissolution ...... carbidopa-levodopa oral tablet ...... CHEMSTRIP 10/SG ...... calcium high potency ...... carboxymethylcellulose sodium ophthalmic .. CHEMSTRIP 2 GP ...... calcium high potency/vitamin d ...... CARETOUCH CONTROL SOL LEVEL 2 ..... CHEMSTRIP 5 OB ...... calcium oral tablet 1500 (600 ca) mg ...... carteolol hcl ...... CHEMSTRIP 7 ...... calcium oyster shell oral tablet 1250 (500 ca) cartia xt ...... CHEMSTRIP 9 ...... mg ...... carvedilol ...... CHEMSTRIP K ...... calcium plus 600 +d ...... CASTIVA WARMING ...... CHEMSTRIP UGK ...... calcium plus vitamin d oral tablet 500-5 mg- cavarest ...... chest congest/cough child ...... mcg ...... CAVILON ...... chest congestion relief dm ...... calcium plus vitamin d oral tablet 600-200 CAYA ...... chest congestion relief oral syrup ...... mg-unit ...... CAYSTON ...... chest congestion relief oral tablet ...... caziant ...... chewable c ......

143 chewable c with rose hips ...... cholestyramine light oral powder ...... CLIMARA PRO ...... chewable childrens vitamin ...... cholestyramine oral powder ...... clindacin etz external swab ...... chewy not chalky flavor ...... chorionic gonadotropin intramuscular ...... clindacin-p ...... childrens acetaminophen ...... ciclodan ...... clindamycin hcl oral capsule 150 mg, 300 childrens allergy oral liquid 12.5 mg/5ml ...... ciclopirox external solution ...... mg ...... childrens animal shapes ...... cilostazol ...... clindamycin palmitate hcl ...... childrens apap ...... CILOXAN ...... clindamycin phosphate external gel ...... childrens aspirin oral tablet chewable 81 mg CIMDUO ...... clindamycin phosphate external lotion ...... childrens chewable vitamins ...... cimetidine hcl ...... clindamycin phosphate external solution ...... childrens chewables/ex c ...... cimetidine oral ...... clindamycin phosphate external swab ...... childrens chewables/iron ...... CIMZIA ...... clindamycin phosphate vaginal ...... childrens cold & allergy ...... cinacalcet hcl ...... CLINDESSE ...... childrens complete oral tablet chewable 18 CIPRO ORAL SUSPENSION clobazam ...... mg ...... RECONSTITUTED ...... clobetasol prop emollient base ...... childrens cough ...... ciprofloxacin hcl ophthalmic ...... clobetasol propionate e ...... childrens loratadine ...... ciprofloxacin hcl oral ...... clobetasol propionate external solution ...... childrens mucus relief cough...... ciprofloxacin-dexamethasone ...... CLOBEX ...... childrens non-aspirin oral suspension ...... citalopram hydrobromide ...... CLOBEX SPRAY ...... childrens non-aspirin oral tablet chewable .... citrate of magnesia ...... clomipramine hcl oral ...... childrens silapap ...... citroma ...... clonazepam oral ...... childrens soothe ...... CITRUCEL ...... clonidine ...... childrens vitamins/extra c ...... claravis ...... clonidine hcl er ...... childrens vitamins/iron ...... clarithromycin er ...... clonidine hcl oral ...... childs non-aspirin ...... clarithromycin oral ...... clopidogrel bisulfate oral ...... chlordiazepoxide hcl ...... CLARITIN ALLERGY CHILDRENS ...... clorazepate dipotassium ...... chlordiazepoxide-amitriptyline ...... CLARITIN EYE ...... clotrimazole 3 ...... chlorhexidine gluconate mouth/throat ...... CLARITIN ORAL TABLET ...... clotrimazole 7 ...... chloroquine phosphate oral ...... CLARITIN REDITABS ORAL TABLET clotrimazole external cream ...... chlor-pheniramine ...... DISPERSIBLE 10 MG ...... clotrimazole external solution ...... chlorpheniramine maleate er ...... CLARITIN-D 12 HOUR ...... clotrimazole mouth/throat ...... chlorpheniramine maleate oral ...... CLARITIN-D 24 HOUR ...... clotrimazole vaginal ...... , chlorpromazine hcl injection ...... classic prenatal ...... clotrimazole-betamethasone ...... chlorpromazine hcl oral ...... c-lax laxative ...... clozapine ...... chlortabs ...... CLEARCANAL EARWAX SOFTENER ...... CLOZARIL ...... chlorthalidone ...... clearlax oral powder 17 gm/scoop ...... codeine sulfate ...... CHLOR-TRIMETON ALLERGY ...... clearskin ...... COLACE ...... CHLOR-TRIMETON ORAL SYRUP ...... clemastine fumarate oral syrup ...... COLAZAL ...... CHLOR-TRIMETON ORAL TABLET ...... clemastine fumarate oral tablet 2.68 mg ...... COLCHICINE ORAL CAPSULE ...... chlorzoxazone oral tablet 500 mg ...... CLEOCIN VAGINAL SUPPOSITORY ...... colchicine oral tablet ...... CHOLBAM ...... CLIMARA ...... COLCRYS ......

144 cold & allergy ...... CORTIFOAM ...... cyclosporine modified ...... cold & allergy childrens oral elixir 1-15 COSENTYX SUBCUTANEOUS SOLUTION cyclosporine oral ...... mg/5ml ...... AUTO-INJECTOR 150 MG/ML ...... CYMBALTA ...... cold & cough childrens oral liquid 2.5-1-5 COSENTYX SUBCUTANEOUS SOLUTION cyproheptadine hcl oral ...... mg/5ml ...... PREFILLED SYRINGE 150 MG/ML ...... cyred ...... cold & cough dm childrens oral liquid 2.5-1-5 COSOPT ...... cyred eq ...... mg/5ml ...... COSOPT PF ...... CYSTAGON ...... cold & sinus relief oral tablet 30-200 mg ...... COTELLIC ...... CYSTARAN ...... cold/cough ...... COTEMPLA XR-ODT ...... D cold/cough childrens ...... cough & chest congestion ...... d 1000 oral tablet ...... cold/cough dm childrens oral liquid 2.5-1-5 cough & cold ...... d 400 oral tablet ...... mg/5ml ...... cough & cold hbp ...... d 400 oral tablet chewable ...... cold/cough dm oral liquid 2.5-1-5 mg/5ml ..... cough childrens ...... d 5000 oral tablet ...... col-rite oral capsule 250 mg ...... cough dm ...... d3 high potency oral capsule 25 mcg (1000 COMBIGAN ...... cough dm childrens ...... ut) ...... COMBIPATCH ...... cough dm er ...... d3 oral capsule 10 mcg (400 unit), 50 mcg COMBIVENT RESPIMAT ...... cough relief oral syrup 15 mg/5ml ...... (2000 ut) ...... COMETRIQ (100 MG DAILY DOSE) ...... cough/chest congestion dm ...... d3 oral capsule 125 mcg (5000 ut) ...... COMETRIQ (140 MG DAILY DOSE) ...... cough/chest dm childrens oral liquid ...... d3 oral capsule 25 mcg (1000 ut) ...... COMETRIQ (60 MG DAILY DOSE) ...... cough/cold hbp ...... d3 super strength ...... comfort gel ...... CREON ...... d-3-5 ...... comfort gel antacid anti-gas oral suspension CRIXIVAN ...... d3-50 ...... 400-400-40 mg/5ml ...... cromolyn sodium inhalation ...... daily acne wash ...... COMPLERA ...... cromolyn sodium nasal ...... daily fiber oral capsule 0.52 gm ...... complete allergy ...... cromolyn sodium ophthalmic ...... daily multiple vitamins ...... complete allergy medicine oral capsule ...... crotan ...... daily multivitamins/iron ...... complete allergy relief ...... CRUEX PRESCRIPTION STRENGTH ...... daily vitamin formula+iron ...... COMPLETE NATAL DHA ...... cryselle-28 ...... daily vitamins ...... compro ...... CUPRIMINE ...... daily vite ...... CO-NATAL FA ...... cyanocobalamin injection solution 1000 daily vites ...... CONCERTA ...... mcg/ml ...... daily-vite ...... CONDOMS ...... CYANOCOBALAMIN INJECTION danazol oral ...... constulose ...... SOLUTION 2000 MCG/ML ...... dantrolene sodium oral ...... CONTOUR NEXT TEST STRIPS ...... cyclafem 1/35 ...... dapsone oral ...... CONTOUR TEST STRIPS ...... cyclafem 7/7/7 ...... DAPTACEL ...... COOL MIST HUMIDIFER ...... cyclobenzaprine hcl oral tablet 10 mg, 5 mg dasetta 1/35 ...... COPAXONE ...... cyclopentolate hcl ophthalmic solution 1 % .. dasetta 7/7/7 ...... CORICIDIN HBP COUGH/COLD ...... cyclophosphamide oral capsule ...... DAURISMO ...... CORLANOR ...... CYCLOPHOSPHAMIDE ORAL TABLET...... DAYHIST ALLERGY 12 HOUR RELIEF ...... corn & callus remover ...... cycloserine oral ...... DAYTRANA ......

145 DAYVIGO ...... desvenlafaxine succinate er ...... dicyclomine hcl oral tablet ...... deblitane ...... DETROL ...... DIFFERIN EXTERNAL CREAM ...... DECADRON ORAL TABLET 0.5 MG, 0.75 DETROL LA ...... DIFFERIN EXTERNAL GEL 0.1 % ...... MG ...... dexamethasone intensol ...... DIFFERIN EXTERNAL GEL 0.3 % ...... DECADRON ORAL TABLET 4 MG, 6 MG .... dexamethasone oral elixir ...... DIFFERIN EXTERNAL LOTION ...... DECARA ORAL CAPSULE 1.25 MG (50000 dexamethasone oral solution ...... DIFICID ...... UT) ...... dexamethasone oral tablet 0.5 mg, 0.75 mg DIFLUCAN ...... DECARA ORAL CAPSULE 250 MCG dexamethasone oral tablet 1 mg, 2 mg ...... digestive probiotic oral capsule ...... (10000 UT) ...... dexamethasone oral tablet 1.5 mg ...... digestive probiotic oral capsule 250 mg ...... DECARA ORAL CAPSULE 625 MCG dexamethasone oral tablet 4 mg, 6 mg ...... digitek ...... (25000 UT) ...... dexamethasone sodium phosphate digox ...... decongestant 12hour max st ...... ophthalmic...... digoxin oral solution ...... deep sea nasal spray ...... DEXILANT ...... digoxin oral tablet ...... deferasirox granules ...... dexmethylphenidate hcl ...... dihydroergotamine mesylate injection ...... deferasirox oral packet ...... dexmethylphenidate hcl er ...... DILANTIN ORAL CAPSULE 30 MG ...... deferasirox oral tablet ...... dextroamphetamine sulfate ...... diltiazem hcl er ...... deferasirox oral tablet soluble ...... dextroamphetamine sulfate er ...... diltiazem hcl er beads ...... DELSTRIGO ...... dextromethorphan polistirex er ...... diltiazem hcl er coated beads oral capsule DELSYM ...... dextromethorphan-guaifenesin oral syrup .... extended release 24 hour ...... DELSYM CGH/CHEST CONG DM CHILD ... DIABETIC TUSSIN MAX ST ...... diltiazem hcl oral ...... DELSYM COUGH CHILDRENS ...... DIALYVITE 800 ORAL TABLET ...... dilt-xr ...... DELSYM COUGH/CHEST CONGEST DM .. DIALYVITE VITAMIN D 5000 ...... dimaphen dm cold/cough ...... delyla ...... diamode ...... DIMETAPP COLD RELIEF CHILDRENS ...... DELZICOL ...... diaper rash external ointment ...... DIMETAPP COLD/ALLERGY ...... DENTA 5000 PLUS ...... diarrhea ...... DIMETAPP DM COLD/COUGH ...... DENTAGEL ...... diarrhea relief ...... dimethyl fumarate oral ...... DEPEN TITRATABS ...... diazepam intensol ...... dimethyl fumarate starter pack ...... DEPO-ESTRADIOL ...... diazepam oral concentrate ...... dino-life ...... DEPO-SUBQ PROVERA 104 ...... diazepam oral solution ...... dino-life w/extra c ...... DERMAPHOR ...... diazepam oral tablet ...... diotame instydose ...... DESCOVY ...... diazepam rectal ...... DIPENTUM ...... DESENEX EXTERNAL POWDER ...... dibucaine (perianal) ...... diphedryl allergy ...... DESENEX JOCK ITCH ...... diclofenac potassium ...... di-phen ...... desgen dm oral liquid ...... diclofenac sodium er ...... diphen oral elixir ...... desipramine hcl oral ...... diclofenac sodium external gel 1 % ...... diphen oral tablet ...... desmopressin ace spray refrig ...... diclofenac sodium ophthalmic ...... diphenhist ...... desmopressin acetate oral ...... diclofenac sodium oral ...... diphenhydramine hcl oral capsule ...... desmopressin acetate spray ...... dicloxacillin sodium ...... diphenhydramine hcl oral elixir ...... desogestrel-ethinyl estradiol ...... dicyclomine hcl oral capsule ...... diphenhydramine hcl oral liquid 12.5 mg/5ml DESVENLAFAXINE ER ...... dicyclomine hcl oral solution ...... diphenhydramine hcl oral tablet ......

146 diphenhydramine hcl oral tablet chewable .... doxepin hcl oral capsule ...... earwax removal drops ...... diphenoxylate-atropine ...... doxepin hcl oral concentrate ...... earwax removal kit otic solution 6.5 % ...... DIPHTHERIA-TETANUS TOXOIDS DT ...... doxepin hcl oral tablet ...... EASIVENT ...... dipyridamole oral ...... doxycycline hyclate oral capsule ...... EASIVENT MASK LARGE ...... disopyramide phosphate ...... doxycycline hyclate oral tablet 100 mg ...... EASIVENT MASK MEDIUM ...... disulfiram oral tablet 250 mg ...... doxycycline monohydrate oral capsule 100 EASIVENT MASK SMALL ...... disulfiram oral tablet 500 mg ...... mg ...... easygel ...... DITROPAN XL ...... doxycycline monohydrate oral capsule 50 easy-lax plus ...... DIURIL ...... mg ...... EASYMAX 15 LEVEL 2 CONTROL ...... divalproex sodium er ...... DR SMITHS ADULT BARRIER EXTERNAL EASYMAX 15 LEVEL 2-3 CONTROL ...... divalproex sodium oral ...... OINTMENT ...... ec-naproxen ...... DIVIGEL TRANSDERMAL GEL 0.25 DR SMITHS DIAPER ...... econtra ez ...... MG/0.25GM, 0.75 MG/0.75GM, 1.25 driminate ...... econtra one-step ...... MG/1.25GM ...... DRIZALMA SPRINKLE ...... ED A-HIST ORAL LIQUID ...... DIVIGEL TRANSDERMAL GEL 0.5 dronabinol ...... ed bron gp ...... MG/0.5GM, 1 MG/GM ...... DROXIA ORAL CAPSULE 200 MG, 300 MG ed chlorped jr ...... dm maximum adult ...... DROXIA ORAL CAPSULE 400 MG ...... ed-apap ...... docu ...... dry-eye relief nighttime ...... EDARBI ...... docu liquid ...... dss oral capsule 100 mg ...... EDARBYCLOR ...... docusate calcium ...... dss oral capsule 250 mg ...... EDLUAR ...... docusate mini ...... DUAVEE ...... ED-SPAZ ...... docusate sodium oral capsule 100 mg ...... DULERA ...... EDURANT ...... docusate sodium oral capsule 250 mg ...... duloxetine hcl oral ...... efavirenz ...... docusate sodium oral liquid 50 mg/5ml ...... DUPIXENT ...... efavirenz-emtricitab-tenofovir ...... docusate sodium oral syrup ...... D-VI-SOL ...... efavirenz-lamivudine-tenofovir ...... docusate sodium oral tablet ...... d-vite pediatric ...... effer-k oral tablet effervescent 25 meq ...... DOCUSOL MINI ...... DYANAVEL XR ...... EFUDEX ...... docuzen ...... dye-free allergy relief ...... electrolyte solution ...... dofetilide ...... E ELESTRIN ...... dok ...... e ELIDEL ...... donepezil hcl ...... E.E.S. GRANULES ...... elinest ...... DOPTELET ...... e-400-clear ...... ELIQUIS ...... dorzolamide hcl solution 2 % ophthalmic ...... ear drops ...... ELIQUIS DVT/PE STARTER PACK ...... DORZOLAMIDE HCL SOLUTION 2 % ear drops earwax aid ...... ELIXOPHYLLIN ...... OPHTHALMIC ...... ear wax kit ...... ELMIRON ...... dorzolamide hcl-timolol mal...... ear wax removal ...... eluryng ...... double antibiotic ...... ear wax removal drops ...... EMEND ORAL ...... DOVATO ...... ear wax removal kit ...... EMFLAZA ORAL TABLET 6 MG ...... DOVONEX ...... ear wax removal system ...... EMGALITY ...... doxazosin mesylate oral ...... earwax removal ...... EMGALITY (300 MG DOSE) ......

147 emoquette ...... epitol ...... ethynodiol diac-eth estradiol ...... EMSAM ...... EPIVIR HBV ORAL SOLUTION ...... etodolac ...... emtricitabine ...... EPOGEN ...... etonogestrel-ethinyl estradiol ...... emtricitabine-tenofovir df ...... EQUETRO ...... etoposide oral ...... EMTRIVA ORAL SOLUTION ...... ergocalciferol oral ...... etravirine ...... enalapril maleate oral ...... ergoloid mesylates oral ...... EUCRISA ...... enalapril-hydrochlorothiazide ...... ergotamine-caffeine ...... euthyrox ...... ENBREL ...... ERIVEDGE ...... EVAC ...... ENDACOF-DM ...... ERLEADA ...... EVAMIST ...... endocet oral tablet 10-325 mg, 5-325 mg, erlotinib hcl ...... EVEKEO ...... 7.5-325 mg ...... errin ...... EVEKEO ODT ...... enema ...... ERYPED 200 ...... everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 enema disposable ...... ERYTHROCIN STEARATE ...... mg ...... enema mineral oil ...... erythromycin base ...... everolimus oral tablet 2.5 mg, 5 mg ...... enema ready-to-use ...... erythromycin ethylsuccinate oral ...... everolimus oral tablet 7.5 mg ...... enema rectal enema 16-6 gm/133ml, 19-7 erythromycin external ...... EVOTAZ ...... gm/118ml ...... erythromycin ophthalmic ...... EXCEDRIN EXTRA STRENGTH ...... ENEMEEZ MINI ...... erythromycin oral ...... EXCEDRIN MIGRAINE ...... ENFAMIL ENFALYTE ...... ESBRIET ...... exemestane ...... ENFAMIL EXPECTA ...... escitalopram oxalate ...... EX-LAX ULTRA ...... ENGERIX-B ...... esomeprazole magnesium oral capsule EXTAVIA ...... enoxaparin sodium ...... delayed release...... eye drops advanced relief ...... enpresse-28 ...... esomeprazole magnesium oral packet ...... eye drops allergy relief ...... enskyce ...... essential one daily ...... eye drops long lasting ...... ENSTILAR ...... essentials ...... eye drops ophthalmic solution 0.05 % ...... entacapone ...... estarylla ...... eye drops ophthalmic solution 0.05-0.1-1-1 entecavir ...... estazolam ...... % ...... enteric aspirin ...... ESTRACE ...... eye itch relief ophthalmic solution 0.025 % ... ENTRESTO ...... estradiol oral ...... eye lubricant ...... enulose ...... estradiol transdermal patch twice weekly ..... ezetimibe ...... ENVARSUS XR ORAL TABLET estradiol transdermal patch weekly ...... EZFE 200 ...... EXTENDED RELEASE 24 HOUR 1 MG ... estradiol vaginal ...... F EPANED ...... estradiol-norethindrone acet oral tablet 1-0.5 FABIOR ...... ephrine nose drops ...... mg ...... falmina ...... EPIDIOLEX ...... ESTRING ...... famotidine oral suspension reconstituted 40 EPIDUO ...... ESTROGEL ...... mg/5ml ...... EPIDUO FORTE ...... eszopiclone ...... famotidine oral tablet 10 mg ...... epinephrine injection solution auto-injector ... ethambutol hcl oral tablet 100 mg ...... famotidine oral tablet 20 mg ...... EPIPEN 2-PAK ...... ethambutol hcl oral tablet 400 mg ...... famotidine oral tablet 40 mg ...... EPIPEN JR 2-PAK ...... ethosuximide oral ...... famotidine orig st ......

148 FANAPT ...... ferrous gluconate oral tablet 324 (38 fe) mg . first aid antiseptic external solution 10 % ...... FANAPT TITRATION PACK ...... ferrous sulfate oral elixir ...... FIRVANQ ...... FARXIGA ...... ferrous sulfate oral solution 75 (15 fe) mg/ml FLAGYL ...... FARYDAK ...... ferrous sulfate oral tablet 325 (65 fe) mg ...... flanders buttocks ...... FASENRA PEN ...... ferrous sulfate oral tablet delayed release .... flecainide acetate ...... fast relief laxative ...... FETZIMA ...... FLEET BISACODYL ...... febuxostat ...... FETZIMA TITRATION ...... FLEET ENEMA ...... felbamate oral suspension ...... fever reducer/pain reliever ...... FLEET OIL ...... felbamate oral tablet ...... fever reducing childrens ...... FLEET PEDIATRIC ...... felodipine er ...... feverall adults ...... floranex tablet oral ...... FEMRING ...... feverall childrens ...... FLORANEX TABLET ORAL ...... femynor ...... FEVERALL INFANTS ...... FLOVENT DISKUS ...... fenofibrate micronized oral capsule 134 mg, FEVERALL JUNIOR STRENGTH ...... FLOVENT HFA ...... 200 mg, 67 mg ...... fe-vite iron ...... fluconazole oral ...... fenofibrate oral capsule 134 mg, 200 mg, 67 fexofenadine hcl oral ...... fludrocortisone acetate oral ...... mg ...... fexofenadine hydrochloride ...... fluocinolone acetonide body ...... fenofibrate oral tablet 160 mg, 54 mg ...... FIASP ...... fluocinolone acetonide external cream 0.025 FENSOLVI (6 MONTH) ...... FIASP FLEXTOUCH ...... % ...... fentanyl transdermal patch 72 hour 100 fiber laxative ...... fluocinolone acetonide external ointment ...... mcg/hr ...... fiber laxative + calcium ...... fluocinolone acetonide external solution ...... fentanyl transdermal patch 72 hour 12 fiber laxative oral capsule 0.52 gm ...... fluocinolone acetonide scalp ...... mcg/hr ...... fiber laxative oral tablet 500 mg ...... fluocinonide emulsified base ...... fentanyl transdermal patch 72 hour 25 fiber oral capsule 0.52 gm ...... fluocinonide external solution ...... mcg/hr ...... fiber oral powder 28.3 % ...... fluoridex daily renewal ...... fentanyl transdermal patch 72 hour 50 fiber oral powder 30.9 % ...... fluoritab ...... mcg/hr ...... fiber oral powder 48.57 % ...... fluorometholone ...... fentanyl transdermal patch 72 hour 75 fiber oral powder 58.6 % ...... fluorouracil external cream 5 % ...... mcg/hr ...... fiber oral tablet 500 mg ...... fluorouracil external solution ...... ferate ...... fiber oral tablet 625 mg ...... fluoxetine hcl (pmdd) ...... FER-IN-SOL ...... fiber therapy oral capsule 0.52 gm ...... fluoxetine hcl oral ...... ferocon ...... fiber therapy oral powder 28.3 % ...... fluphenazine decanoate injection ...... ferosul ...... fiber therapy oral tablet 500 mg ...... fluphenazine hcl injection ...... ferotrinsic ...... fiber therapy oral tablet 625 mg ...... fluphenazine hcl oral concentrate ...... ferretts ...... fiber-caps ...... fluphenazine hcl oral elixir ...... ferrex 150 ...... fiber-lax ...... fluphenazine hcl oral tablet ...... ferric x-150 ...... FINACEA ...... flurazepam hcl ...... ferrous fumarate oral tablet 324 (106 fe) mg . finasteride oral tablet 5 mg ...... flurbiprofen sodium ...... ferrous gluconate oral tablet 240 (27 fe) mg . FIRAZYR ...... flutamide ...... ferrous gluconate oral tablet 324 (37.5 fe) first aid antibiotic external ointment 3.5-400- fluticasone propionate external cream ...... mg ...... 5000 , 3.5-400-5000 mg-unit ...... fluticasone propionate external ointment ......

149 fluticasone propionate nasal ...... G GENTEAL SEVERE ...... fluticasone-salmeterol inhalation aerosol g tussin ac ...... GENTEAL TEARS MODERATE PF ...... powder breath activated 100-50 gabapentin oral capsule ...... GENTEAL TEARS NIGHT-TIME ...... mcg/dose, 250-50 mcg/dose, 500-50 gabapentin oral tablet ...... GENTEAL TEARS OPHTHALMIC mcg/dose ...... galantamine hydrobromide ...... SOLUTION 0.1-0.2-0.3 % ...... FLUTICASONE-SALMETEROL galantamine hydrobromide er ...... GENTEAL TEARS PF ...... INHALATION AEROSOL POWDER GARDASIL 9 ...... GENTEAL TEARS SEVERE DAY/NIGHT ..... BREATH ACTIVATED 113-14 MCG/ACT, gas relief antiflatuent ...... gentle laxative ...... 232-14 MCG/ACT, 55-14 MCG/ACT ...... gas relief drops infants ...... gentle laxative womens ...... fluvoxamine maleate ...... gas relief extra strength ...... gentlelax ...... fluvoxamine maleate er ...... gas relief extstrength ...... GENVOYA ...... foaming antacid oral tablet chewable 80-20 gas relief infants ...... GEODON INTRAMUSCULAR ...... mg ...... gas relief infants drops ...... GEODON ORAL ...... FOCALIN ...... gas relief oral capsule 125 mg ...... geri-dryl oral liquid ...... folic acid oral tablet 1 mg ...... gas relief oral suspension 20 mg/0.3ml ...... geri-dryl oral tablet ...... folic acid oral tablet 400 mcg, 800 mcg ...... gas relief oral tablet chewable 125 mg ...... geri-kot ...... foltrin ...... gas relief oral tablet chewable 80 mg ...... geri-lanta ...... foot & sneaker ...... gas relief ultra strength ...... geri-lanta supreme ...... foot care (terbinafine) ...... gas relief ultstrength ...... geri-mox ...... for sty relief ...... GAS-X EXTRA STRENGTH ORAL geri-pectate ...... FORFIVO XL ...... CAPSULE ...... geri-tussin dm ...... FORMULA 3 THE TREATMENT ...... GAS-X EXTRA STRENGTH ORAL TABLET GILENYA ...... FORMULA 7 THE SOLUTION ...... CHEWABLE ...... GILOTRIF ...... FORTEO ...... GAS-X ULTRA STRENGTH ...... giltuss severe sinus ...... fosamprenavir calcium ...... GATTEX ...... glatiramer acetate ...... fosinopril sodium ...... gavilax oral powder ...... glatopa ...... fosinopril sodium-hctz ...... gavilyte-c ...... GLEOSTINE ...... FREESTYLE PRECISION NEO TEST ...... gavilyte-n with flavor pack ...... glimepiride ...... freeze dried acidophilus ...... GAVISCON EXTRA RELIEF FORMULA ...... glipizide er ...... fruity c ...... GAVISCON EXTRA STRENGTH ...... glipizide ir ...... full spectrum b/vitamin c...... GAVISCON ORAL SUSPENSION ...... glipizide xl ...... FULPHILA ...... GELUSIL ...... GLUCAGEN HYPOKIT ...... fungi-guard ...... gemfibrozil oral ...... GLUCAGON EMERGENCY INJECTION furosemide oral solution 10 mg/ml ...... genaphed ...... SOLUTION RECONSTITUTED ...... furosemide oral tablet ...... generlac ...... glucagon emergency kit 1 mg injection ...... FUZEON ...... gengraf oral capsule ...... GLUCAGON EMERGENCY KIT 1 MG fyavolv oral tablet 0.5-2.5 mg-mcg ...... GENOTROPIN ...... INJECTION ...... fyavolv oral tablet 1-5 mg-mcg ...... gentak ...... GLUCOSE CONTROL SOLUTION IN FYCOMPA ...... gentamicin sulfate external ...... VITRO SOLUTION ...... gentamicin sulfate ophthalmic ...... GLUCOSE CONTROL SOLUTIONS ......

150 glucose oral tablet chewable 4 gm ...... GYNE-LOTRIMIN ...... HUMALOG JUNIOR KWIKPEN ...... glyburide micronized ...... GYNE-LOTRIMIN 3 ...... HUMALOG KWIKPEN ...... glyburide oral ...... H HUMALOG MIX 50/50 ...... glyburide-metformin ...... habitrol ...... HUMALOG MIX 50/50 KWIKPEN ...... glycerin (adult) rectal suppository 2 gm ...... HAEGARDA ...... HUMALOG MIX 75/25 ...... glycerin (infants & children) rectal hailey 1.5/30 ...... HUMALOG MIX 75/25 KWIKPEN ...... suppository 1 gm ...... hailey fe 1.5/30 ...... HUMATROPE INJECTION SOLUTION glycerin (pediatric) rectal suppository 1 gm ... hailey fe 1/20 ...... RECONSTITUTED 12 MG, 24 MG, 6 MG . glycerin adult rectal suppository 2 gm ...... halobetasol propionate external cream ...... HUMIRA PEN-PEDIATRIC UC START ...... glycerin child rectal suppository 1 gm ...... haloperidol decanoate intramuscular ...... HUMIRA PEN-PSOR/UVEIT STARTER ...... glycerin child rectal suppository 1.2 gm ...... haloperidol lactate oral ...... HUMIRA SUBCUTANEOUS PEN- glycerin childrens ...... haloperidol oral ...... INJECTOR KIT 40 MG/0.4ML, 40 glycerin external ...... HAVRIX ...... MG/0.8ML ...... glycerin external liquid 99.5 % ...... headache formula ...... HUMIRA SUBCUTANEOUS PEN- glycerin pediatric rectal suppository 1.2 gm .. headache relief ...... INJECTOR KIT 80 MG/0.8ML ...... glycolax ...... headache relief extra str ...... HUMIRA SUBCUTANEOUS PREFILLED glycopyrrolate oral tablet 1 mg, 2 mg ...... healthy hair/skin/nails ...... SYRINGE KIT 10 MG/0.1ML, 20 glydo ...... heartburn antacid ...... MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, GLYXAMBI ...... heartburn antacid ex st ...... 80 MG/0.8ML, 80 MG/0.8ML & gormel ...... heartburn prevention oral tablet 10 mg ...... 40MG/0.4ML ...... gormel 10 ...... heartburn relief ex st ...... HUMULIN 70/30 KWIKPEN ...... GRANIX ...... heartburn relief oral tablet 10 mg ...... HUMULIN 70/30 VIAL ...... griseofulvin microsize oral ...... heartburn relief oral tablet 200 mg ...... HUMULIN N KWIKPEN ...... griseofulvin ultramicrosize ...... heartburn relief oral tablet chewable 160-105 HUMULIN N VIAL ...... guaiatussin ac ...... mg ...... HUMULIN R U-500 KWIKPEN ...... guaicon dms ...... heather ...... HUMULIN R U-500 VIAL guaifenesin ac ...... h-e-b aspirin ...... (CONCENTRATED) ...... guaifenesin er oral tablet extended release h-e-b childrens allergy ...... HUMULIN R VIAL ...... 12 hour 1200 mg ...... HELIDAC THERAPY ...... HYCAMTIN ORAL ...... guaifenesin oral tablet 400 mg ...... HEMANGEOL ...... hydralazine hcl oral ...... guaifenesin-codeine ...... hemorrhoidal rectal suppository 0.25-3-85.5 hydrochlorothiazide oral capsule ...... guaifenesin-dm oral syrup ...... % ...... hydrochlorothiazide oral tablet 12.5 mg ...... guanfacine hcl ...... heparin sodium (porcine) ...... hydrochlorothiazide oral tablet 25 mg, 50 mg guanfacine hcl er ...... heparin sodium (porcine) pf ...... hydrocodone-acetaminophen oral solution gummy dinos ...... HEPLISAV-B ...... 7.5-325 mg/15ml ...... gummy multivitamin kids ...... HETLIOZ ...... hydrocodone-acetaminophen oral tablet 10- GVOKE HYPOPEN 1-PACK ...... HETLIOZ LQ ...... 325 mg, 5-325 mg, 7.5-325 mg ...... GVOKE HYPOPEN 2-PACK ...... hi cal ...... hydrocodone-homatropine ...... GVOKE PFS ...... high potency probiotic ...... hydrocortisone (perianal) external cream 2.5 GYNAZOLE-1 ...... HUMALOG ...... % ......

151 hydrocortisone acetate external ...... ibu ...... INDERAL XL ...... hydrocortisone anti-itch external cream 0.5 ibu-200 ...... indomethacin oral capsule 25 mg, 50 mg ...... % ...... ibuprofen childrens oral tablet chewable 100 indoor/outdoor allergy rlf ...... hydrocortisone butyrate external ointment .... mg ...... INFANRIX ...... hydrocortisone butyrate external solution ..... ibuprofen cold & sinus ...... infant gas relief ...... hydrocortisone external cream 0.5 %, 2.5 % ibuprofen cold/sinus oral tablet 30-200 mg ... INFANTS ADVIL ...... hydrocortisone external cream 1 %...... ibu-profen cold/sinus oral tablet 30-200 mg .. infants gas relief ...... hydrocortisone external lotion 2.5 % ...... ibuprofen ib childrens ...... infants ibuprofen ...... hydrocortisone external ointment 0.5 % ...... ibuprofen ib oral tablet 200 mg ...... infants pain & fever ...... hydrocortisone external ointment 1 % ...... ibuprofen ib oral tablet chewable 100 mg ..... infants pain relief drops ...... hydrocortisone external ointment 2.5 % ...... ibuprofen infants oral suspension 50 infants pain/fever ...... hydrocortisone oral tablet 10 mg, 20 mg, 5 mg/1.25ml ...... infants simethicone ...... mg ...... ibuprofen jr oral tablet 100 mg ...... INGREZZA ...... hydrocortisone plus external cream 1 % ...... ibuprofen junior ...... INLYTA ...... hydrocortisone rectal enema 100 mg/60ml ... ibuprofen junior strength ...... INNOPRAN XL ...... hydrocortisone/aloe ...... ibuprofen oral suspension 100 mg/5ml ...... INSPIREASE ...... hydrocortisone/aloe max str ...... ibuprofen oral tablet 200 mg ...... INSPIREASE RESERVOIR BAGS ...... hydrocortisone-acetic acid ...... ibuprofen oral tablet 400 mg, 600 mg, 800 instacort 5 ...... hydrocortisone-aloe ...... mg ...... INSULIN ASP PROT & ASP FLEXPEN ...... hydrocortisone-aloe max st ...... icatibant acetate ...... INSULIN ASPART ...... hydrolatum ...... iclevia ...... INSULIN ASPART PROT & ASPART ...... hydromet ...... ICLUSIG ORAL TABLET 15 MG, 45 MG...... INSULIN LISPRO ...... hydromorphone hcl oral ...... IDHIFA ...... INSULIN LISPRO (1 UNIT DIAL) ...... hydromorphone hcl rectal ...... iferex 150 forte ...... INSULIN PEN NEEDLES 30G X 8 MM , 32G hydroxychloroquine sulfate oral ...... ILARIS ...... X 6 MM ...... hydroxyurea oral ...... ILEVRO ...... INSULIN PEN NEEDLES 32G X 4 MM ...... hydroxyzine hcl oral ...... ILUMYA ...... INTELENCE ORAL TABLET 200 MG ...... hydroxyzine pamoate oral ...... imatinib mesylate ...... INTELENCE ORAL TABLET 25 MG ...... hyoscyamine sulfate er ...... IMBRUVICA ...... INTRON A ...... hyoscyamine sulfate oral ...... imipramine hcl oral ...... introvale ...... hyoscyamine sulfate sl ...... imipramine pamoate ...... INVEGA ...... hyoscyamine sulfate sublingual ...... imiquimod external cream 5 % ...... INVEGA SUSTENNA ...... hyosyne ...... IMODIUM A-D ORAL TABLET ...... INVEGA TRINZA ...... HYPERSAL INHALATION NEBULIZATION IMODIUM MULTI-SYMPTOM RELIEF ...... INVIRASE ...... SOLUTION 7 % ...... IMPAVIDO ...... INVOKAMET ...... HYPERTET S/D ...... INATAL GT ...... INVOKAMET XR ...... HYPOTEARS ...... incassia ...... INVOKANA ...... HYSINGLA ER ...... INCRELEX ...... ipratropium bromide inhalation ...... I INCRUSE ELLIPTA ...... ipratropium bromide nasal ...... IBRANCE ...... indapamide ...... ipratropium-albuterol ......

152 IRESSA ...... juleber ...... KOMBIGLYZE XR ...... iron oral tablet 240 (27 fe) mg ...... JULUCA ...... KONSYL DAILY FIBER ORAL POWDER iron oral tablet 325 (65 fe) mg ...... junel 1.5/30 ...... 100 % ...... iron supplement ...... junel 1/20 ...... konsyl daily fiber oral powder 28.3 % ...... iron supplement childrens ...... junel fe oral tablet 1.5-30 mg-mcg ...... KORLYM ...... ISENTRESS HD ...... junel fe oral tablet 1-20 mg-mcg ...... K-PHOS ...... ISENTRESS ORAL PACKET...... K K-PHOS-NEUTRAL ...... ISENTRESS ORAL TABLET ...... KALETRA ...... k-prime ...... ISENTRESS ORAL TABLET CHEWABLE ... kalliga ...... KRINTAFEL ...... isibloom ...... KAPVAY ...... kurvelo ...... isoniazid oral ...... kariva ...... L ISOPTO ATROPINE ...... KAZANO ...... labetalol hcl oral ...... isosorbide dinitrate ...... kelnor 1/35 ...... LAC-HYDRIN FIVE ...... isosorbide mononitrate ...... kelnor 1/50 ...... lactic acid external ...... isosorbide mononitrate er ...... KESIMPTA ...... lactobacillus oral tablet ...... isotretinoin oral capsule 10 mg ...... ketoconazole external cream ...... lacto-pectin ...... isotretinoin oral capsule 20 mg, 30 mg, 40 ketoconazole external shampoo ...... lactulose encephalopathy ...... mg ...... ketoconazole oral ...... lactulose oral solution ...... isoxsuprine hcl oral ...... KETO-DIASTIX ...... LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 ISTALOL ...... KETONE CARE ...... X 50 MG, 42 X 50 MG & 14X100 MG ...... itraconazole oral ...... KETONE TEST ...... LAMICTAL XR ORAL KIT ...... ivermectin oral ...... ketoprofen oral ...... LAMISIL AT EXTERNAL CREAM ...... J ketorolac tromethamine ophthalmic solution LAMISIL AT JOCK ITCH ...... JAKAFI ...... 0.4 % ...... lamivudine oral solution ...... jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 ketorolac tromethamine ophthalmic solution lamivudine oral tablet 100 mg ...... mg, 3 mg, 4 mg, 5 mg, 7.5 mg ...... 0.5 % ...... lamivudine oral tablet 150 mg, 300 mg ...... jantoven oral tablet 6 mg ...... ketorolac tromethamine oral ...... lamivudine-zidovudine ...... JANUMET ...... KETOSTIX ...... lamotrigine er ...... JANUMET XR ...... ketotifen fumarate ophthalmic ...... lamotrigine oral ...... JANUVIA ...... KEVZARA ...... lamotrigine starter kit-blue ...... JARDIANCE ...... KINERET ...... lamotrigine starter kit-green ...... jencycla ...... KISQALI (200 MG DOSE) ...... lamotrigine starter kit-orange ...... JENTADUETO ...... KISQALI (400 MG DOSE) ...... LANCETS ...... JENTADUETO XR ...... KISQALI (600 MG DOSE) ...... lansoprazole oral capsule delayed release jinteli ...... KITABIS PAK ...... 15 mg ...... jock itch external cream 1 % ...... klor-con ...... lansoprazole oral capsule delayed release jock itch max st ...... klor-con 10 ...... 30 mg ...... jock itch spray powder ...... klor-con m10 ...... lansoprazole oral tablet delayed release jolessa ...... klor-con m20 ...... dispersible 15 mg, 30 mg ...... JORNAY PM ...... klor-con/ef ...... LANTUS SOLOSTAR ......

153 LANTUS U-100 VIAL ...... LEVBID ...... linezolid oral suspension reconstituted ...... lapatinib ditosylate ...... LEVEMIR U-100 FLEXTOUCH ...... linezolid oral tablet ...... larin 1.5/30 ...... LEVEMIR U-100 VIAL ...... LINZESS ...... larin 1/20 ...... levetiracetam oral solution ...... liothyronine sodium oral ...... larin fe 1.5/30 ...... levetiracetam oral tablet ...... liquibid ...... larin fe 1/20 ...... levobunolol hcl ...... liquid acetaminophen ...... larissia ...... levocetirizine dihydrochloride oral tablet ...... liquid allergy relief ...... latanoprost ophthalmic ...... levofloxacin oral tablet ...... liquid pain relief ...... LATUDA ...... levonest ...... lisinopril oral ...... laxacin ...... levonorgest-eth estrad 91-day oral tablet lisinopril-hydrochlorothiazide ...... laxaclear ...... 0.15-0.03 mg ...... lithium ...... laxative max str ...... levonorgestrel ...... lithium carbonate er ...... laxative maximum strength oral tablet 25 mg levonorgestrel-ethinyl estrad oral tablet 0.1- lithium carbonate oral ...... laxative oral powder 17 gm/scoop...... 20 mg-mcg ...... little ones childrens ...... laxative oral tablet delayed release 5 mg ...... levonorgestrel-ethinyl estrad oral tablet 0.15- LMX 4 ...... laxative pills ...... 30 mg-mcg ...... LOKELMA ...... laxative pills max st ...... levonorg-eth estrad triphasic ...... long acting nasal spray ...... laxative pills oral tablet 25 mg ...... levora 0.15/30 (28) ...... long lasting antacid ...... laxative rectal suppository 10 mg ...... levo-t ...... long lasting nasal spray ...... laxative regular strength ...... levothyroxine sodium oral tablet ...... LONSURF ...... leena ...... levoxyl ...... loperamide hcl oral capsule ...... leflunomide oral ...... LEXIVA ORAL SUSPENSION ...... loperamide hcl oral tablet ...... LENVIMA (10 MG DAILY DOSE)...... LIALDA ...... lopinavir-ritonavir ...... LENVIMA (12 MG DAILY DOSE)...... lice killing ...... loradamed ...... LENVIMA (14 MG DAILY DOSE)...... lice killing max st ...... lorata-d ...... LENVIMA (18 MG DAILY DOSE)...... lice killing max strength ...... loratadine allergy relief oral tablet 10 mg ...... LENVIMA (20 MG DAILY DOSE)...... lice killing maximum strength ...... loratadine allergy relief oral tablet dispersible LENVIMA (24 MG DAILY DOSE)...... lice maximum strength ...... 10 mg ...... LENVIMA (4 MG DAILY DOSE)...... lice treatment ...... loratadine childrens oral solution 5 mg/5ml ... LENVIMA (8 MG DAILY DOSE)...... lice treatment creme rinse ...... loratadine childrens oral syrup 5 mg/5ml ...... lessina ...... lice treatment external liquid 1 % ...... lorata-dine d ...... LETAIRIS ...... lice treatment external shampoo 0.33-4 % ... loratadine d 12hr ...... letrozole oral ...... lidocaine external cream 4 % ...... loratadine oral syrup 5 mg/5ml ...... leucovorin calcium oral tablet 10 mg ...... lidocaine external patch 5 % ...... loratadine oral tablet 10 mg ...... leucovorin calcium oral tablet 15 mg, 25 mg, lidocaine hcl external cream 3 % ...... loratadine oral tablet dispersible 10 mg ...... 5 mg ...... lidocaine hcl urethral/mucosal ...... loratadine-d ...... LEUKERAN ...... lidocaine viscous hcl ...... loratadine-d 12hr ...... LEUKINE ...... lidocaine-prilocaine external cream ...... loratadine-d 24hr ...... leuprolide acetate injection ...... lidopin external cream 3 % ...... lorazepam injection ...... levalbuterol hcl inhalation ...... lillow ...... lorazepam intensol ......

154 lorazepam oral concentrate 2 mg/ml ...... LUPANETA PACK COMBINATION KIT mapap childrens oral tablet chewable 160 lorazepam oral tablet ...... 11.25 & 5 MG ...... mg ...... LORBRENA ...... LUPANETA PACK COMBINATION KIT 3.75 mapap childrens oral tablet chewable 80 mg losartan potassium oral ...... & 5 MG ...... mapap oral capsule ...... losartan potassium-hctz ...... LUPRON DEPOT (1-MONTH) ...... maprotiline hcl ...... LOTRIMIN AF EXTERNAL POWDER ...... LUPRON DEPOT (3-MONTH) ...... marlissa ...... lovastatin oral ...... LUPRON DEPOT (4-MONTH) MARPLAN ...... low-ogestrel ...... INTRAMUSCULAR KIT 30MG ...... MASK VORTEX/CHILD/FROG ...... loxapine succinate ...... LUPRON DEPOT (6-MONTH) MASK VORTEX/TODDLER/LADYBUG ...... LUBIPROSTONE ...... INTRAMUSCULAR KIT 45MG ...... MATULANE ...... lubricant drops fast act ...... LUPRON DEPOT-PED (1-MONTH) ...... MAVENCLAD (10 TABS) ...... lubricant drops long last ...... LUPRON DEPOT-PED (3-MONTH) ...... MAVENCLAD (4 TABS) ...... lubricant drops ophthalmic gel 0.25-0.3 % .... lutera ...... MAVENCLAD (5 TABS) ...... lubricant drops ophthalmic solution ...... LUXIQ ...... MAVENCLAD (6 TABS) ...... lubricant eye drops (pf) ophthalmic solution lyleq ...... MAVENCLAD (7 TABS) ...... 0.4-0.3 % ...... LYNPARZA ...... MAVENCLAD (8 TABS) ...... lubricant eye drops (pf) ophthalmic solution lysiplex plus oral tablet ...... MAVENCLAD (9 TABS) ...... 0.5 % ...... LYSODREN ...... maxi-tuss ac ...... lubricant eye drops ophthalmic solution 0.4- LYUMJEV ...... maxi-tuss gmx ...... 0.3 % ...... lyza ...... maxi-tuss pe max ...... lubricant eye drops ophthalmic solution 0.5 M MAYZENT ...... % ...... MAALOX ...... m-clear wc ...... lubricant eye drops ophthalmic solution 0.6 MAALOX CHILDRENS ...... m-dryl ...... % ...... MAALOX MAX ORAL SUSPENSION ...... meclizine hcl oral tablet 12.5 mg ...... lubricant eye drops pf ...... MAALOX MULTI SYMPTOM MAX ST...... meclizine hcl oral tablet 25 mg ...... lubricant eye nighttime ...... mag-al plus ...... meclizine hcl oral tablet chewable ...... lubricant eye ophthalmic solution 0.4-0.3 % .. mag-al plus xs ...... medicated spot ...... lubricant eye pm ...... MAGNEBIND 300 ...... medifin 400 ...... lubricant pm ...... magnesium citrate oral solution ...... medi-first triple antibiotic ...... lubricating eye drop ...... magnesium oral tablet 500 mg ...... mediproxen ...... lubricating eye drops ophthalmic solution magnesium oxide oral tablet 400 (241.3 mg) MEDISENSE GLUCOSE KETONE CONTR . 0.4-0.3 % ...... mg ...... MEDISENSE HI/MID/LOW CONTROL ...... lubricating eye/overnight ...... magnesium oxide oral tablet 400 mg ...... MEDISENSE HIGH/LOW CONTROL ...... lubricating plus ...... magnesium oxide oral tablet 420 mg ...... MEDISENSE MID CONTROL ...... lubricating plus eye drops ...... magnesium oxide oral tablet 500 mg ...... MEDROL ORAL TABLET 2 MG ...... lubricating tears ...... magnesium-oxide ...... medroxyprogesterone acetate intramuscular lubricating tears eye drops ...... malathion ...... medroxyprogesterone acetate oral ...... LUMIGAN ...... MAOX ...... mefloquine hcl ...... LUNESTA ...... mapap acetaminophen extra str ...... mega probiotic ...... mapap arthritis pain ...... megestrol acetate oral suspension 40 mg/ml

155 megestrol acetate oral tablet 20 mg ...... methylergonovine maleate oral ...... midazolam hcl oral ...... megestrol acetate oral tablet 40 mg ...... METHYLIN ...... MIDAZOLAM HCL-SODIUM CHLORIDE meijer allergy relief-d ...... methylphenidate hcl er ...... INTRAVENOUS SOLUTION ...... meijer antacid ...... methylphenidate hcl er (cd) ...... MIDAZOLAM+SYRSPEND SF ...... meijer anti-diarrheal ...... methylphenidate hcl er (la) ...... midodrine hcl ...... MEKINIST ...... methylphenidate hcl er (xr) ...... MIGERGOT ...... meloxicam oral tablet ...... methylphenidate hcl oral ...... migraine formula ...... melphalan ...... methylprednisolone oral ...... migraine relief ...... memantine hcl er ...... metoclopramide hcl oral solution ...... mili ...... memantine hcl oral solution 2 mg/ml ...... metoclopramide hcl oral tablet ...... milk of magnesia ...... memantine hcl oral tablet ...... metolazone ...... mimvey ...... MENACTRA ...... metoprolol succinate er ...... mineral oil enema ...... MENEST ...... metoprolol tartrate oral tablet 100 mg, 50 mg mineral oil heavy oral ...... MENOSTAR ...... metoprolol tartrate oral tablet 25 mg ...... mineral oil oral oil ...... MENQUADFI ...... METROGEL ...... MINERAL OIL ORAL OIL ...... MENVEO ...... metronidazole external ...... mineral oil rectal enema ...... meprobamate ...... metronidazole oral tablet ...... mini nicotine ...... mercaptopurine oral ...... metronidazole vaginal ...... minitran ...... mesalamine oral capsule delayed release mexiletine hcl oral ...... MINIVELLE ...... 400 mg ...... mi-acid gas relief ...... minocycline hcl oral capsule 100 mg ...... mesalamine rectal ...... micaderm ...... minocycline hcl oral capsule 50 mg ...... MESNEX ORAL ...... miconazole 1 ...... minoxidil oral ...... metformin hcl er (osm) ...... miconazole 1 combo pack ...... mintox maximum strength ...... metformin hcl er oral tablet extended release miconazole 3 ...... mintox plus ...... 24 hour 500 mg ...... miconazole 3 applicator vaginal kit 200 & 2 MIRALAX ORAL POWDER ...... metformin hcl er oral tablet extended release mg-% (9gm) ...... MIRCERA INJECTION SOLUTION 24 hour 750 mg ...... miconazole 3 combo pack app ...... PREFILLED SYRINGE 100 MCG/0.3ML, metformin hcl oral tablet ...... miconazole 3 combo pack vaginal kit 200 & 200 MCG/0.3ML, 50 MCG/0.3ML, 75 methamphetamine hcl ...... 2 mg-% (9gm) ...... MCG/0.3ML ...... methazolamide oral ...... miconazole 7 ...... mirtazapine oral ...... methenamine hippurate ...... miconazole 7 day treatment ...... MIRVASO ...... methergine ...... miconazole 7 vaginal suppository 100 mg .... misoprostol oral ...... methimazole oral ...... miconazole antifungal ...... MITIGARE ...... methocarbamol oral ...... miconazole nitrate external ...... mm arthritis pain ...... methotrexate oral ...... miconazole nitrate vaginal ...... mm cetirizine hcl ...... methotrexate sodium ...... miconazorb af ...... mm clearlax ...... methotrexate sodium (pf) ...... microgestin 1.5/30 ...... mm stool softener laxative ...... methoxsalen rapid ...... microgestin 1/20 ...... M-M-R II ...... methyldopa ...... microgestin fe 1.5/30 ...... M-NATAL PLUS ...... methyldopa-hydrochlorothiazide ...... microgestin fe 1/20 ...... modafinil ......

156 molindone hcl ...... mucus d extended release ...... multi-vitamin/fluoride/iron ...... mometasone furoate external ...... mucus d max st er ...... multi-vitamin/iron ...... mondoxyne nl oral capsule 100 mg ...... mucus dm ...... mupirocin external ...... mono-linyah ...... mucus er oral tablet extended release 12 MURO 128 OPHTHALMIC OINTMENT ...... montelukast sodium oral ...... hour 1200 mg ...... MURO 128 OPHTHALMIC SOLUTION 5 % . mood support probiotic ...... mucus extended release oral tablet my choice ...... morgidox oral ...... extended release 12 hour 1200 mg ...... my way ...... morphine sulfate (concentrate) oral solution mucus relief chest oral tablet 400 mg ...... mycophenolate mofetil oral ...... 100 mg/5ml, 20 mg/ml ...... mucus relief cough children ...... mycophenolate sodium ...... morphine sulfate er oral tablet extended mucus relief cough childrens ...... MYCOZYL AP ...... release ...... mucus relief d max strength ...... MYDAYIS ORAL CAPSULE EXTENDED morphine sulfate oral ...... mucus relief d oral tablet extended release RELEASE 24 HOUR 12.5 MG, 25 MG, morphine sulfate rectal ...... 12 hour 60-600 mg ...... 37.5 MG, 50 MG ...... MOTEGRITY ...... mucus relief dm max oral liquid ...... myferon 150 ...... motion sickness oral tablet 50 mg ...... mucus relief dm oral liquid ...... myferon 150 forte ...... motion sickness relief oral tablet 50 mg ...... mucus relief dm oral tablet extended release MYLERAN ...... motion sickness relief oral tablet chewable 12 hour 30-600 mg ...... mynephrocaps ...... 25 mg ...... mucus relief er ...... MYNEPHRON ...... motion-time ...... mucus relief max st ...... myorisan ...... MOTRIN CHILDRENS ...... mucus relief max strength oral tablet MYRBETRIQ ...... MOTRIN IB ORAL TABLET ...... extended release 12 hour 1200 mg ...... MYTESI ...... MOTRIN INFANTS DROPS ...... mucus relief oral tablet ...... N MOVANTIK ...... mucus-d ...... nabumetone oral ...... MOXEZA ...... mucus-dm ...... nafrinse ...... MOZOBIL ...... mucus-er oral tablet extended release 12 nafrinse drops ...... m-pap ...... hour 1200 mg ...... naloxone hcl injection ...... MUCINEX CHILDRENS FREEFROM ORAL MULPLETA ...... naltrexone hcl oral ...... LIQUID 5-100 MG/5ML ...... MULTAQ ...... NAMENDA XR TITRATION PACK ...... MUCINEX CHILDRENS STUFFY NOSE ...... multi vitamin ...... NAMZARIC ...... MUCINEX COUGH CHILDRENS ...... multi vitamin w/d-3 ...... NAPHCON-A ...... MUCINEX D ...... multiple vitamin-folic acid ...... naproxen oral ...... MUCINEX D MAX STRENGTH ...... multiple vitamins essential ...... naproxen sodium oral tablet 220 mg ...... MUCINEX DM ...... multiple vitamins/iron ...... NARAMIN ...... MUCINEX FAST-MAX DM MAX ...... MULTIPRO ...... naratriptan hcl ...... MUCINEX MAXIMUM STRENGTH ...... multi-vit/iron/fluoride ...... NARCAN ...... MUCINEX SINUS-MAX CLEAR & COOL ..... multi-vitamin ...... NASACORT ALLERGY 24HR ...... MUCINEX SINUS-MAX SINUS/ALLRGY ..... multi-vitamin/fluoride ...... NASACORT ALLERGY 24HR CHILDREN ... mucus & cough relief child ...... multivitamin/fluoride oral solution ...... nasal allergy 24 hour ...... mucus & cough relief childrens ...... multivitamin/fluoride oral tablet chewable nasal allergy nasal aerosol 55 mcg/act ...... mucus d ...... 0.25 mg, 0.5 mg, 1 mg ...... nasal allergy spray ......

157 nasal decongestant 12 hour ...... natural vegetable laxative ...... NEVANAC ...... nasal decongestant 12hr ...... natural vitamin e ...... nevirapine ...... nasal decongestant max st ...... natura-lax ...... nevirapine er ...... nasal decongestant oral tablet 30 mg ...... nausea control ...... new day ...... nasal decongestant oral tablet extended nausea relief ...... NEXAVAR ...... release 12 hour 120 mg ...... NAYZILAM ...... NEXIUM ORAL CAPSULE DELAYED nasal decongestant pe max st ...... necon 0.5/35 (28) ...... RELEASE ...... nasal decongestant pe oral tablet 10 mg ...... nefazodone hcl ...... NEXIUM ORAL PACKET 10 MG, 20 MG, 40 nasal decongestant spray ...... NEODOT THERMOMETER ...... MG ...... nasal four ...... NEOMULTIVITE ...... NEXIUM ORAL PACKET 2.5 MG, 5 MG ...... nasal mist nasal solution ...... neomycin sulfate oral ...... NEXLETOL ...... NASAL MOIST NASAL SOLUTION ...... neomycin-bacitracin zn-polymyx ...... NEXLIZET ...... nasal moisturizing spray ...... neomycin-polymyxin-dexameth ophthalmic niacin (antihyperlipidemic) ...... nasal relief ...... ointment ...... niacin er (antihyperlipidemic) ...... nasal relief moisturizing...... neomycin-polymyxin-dexameth ophthalmic niacin er oral capsule extended release 250 nasal spray ...... suspension 3.5-10000-0.1 ...... mg ...... nasal spray 12 hour ...... neomycin-polymyxin-gramicidin ...... niacin er oral capsule extended release 500 nasal spray anti-drip ...... neomycin-polymyxin-hc otic ...... mg ...... nasal spray extra moist ...... NEONATAL COMPLETE ...... niacin er oral tablet extended release ...... nasal spray extra moisturizing ...... NEONATAL PLUS ...... niacin oral tablet 100 mg, 250 mg, 50 mg ..... nasal spray fast acting ...... NEONATAL VITAMIN ...... niacor ...... nasal spray moisturizing...... neo-polycin ...... NICODERM CQ ...... nasal spray no drip ...... neo-polycin hc ...... NICORETTE ...... nasal spray saline ...... NEOSPORIN ORIGINAL ...... NICORETTE MINI ...... nasal spray sinus ...... NEO-SYNEPHRINE COLD/ALLRG MILD .... NICORETTE STARTER KIT ...... NASALCROM ...... NEO-SYNEPHRINE COLD/ALLRGY EXT ... nicotine gum mouth/throat gum 2 mg ...... nateglinide ...... NEO-SYNEPHRINE COLD/ALLRGY REG .. nicotine gum mouth/throat gum 4 mg ...... natural daily fiber ...... nephro vitamins ...... nicotine gum mouth/throat lozenge 2 mg ...... natural fiber laxative oral powder 58.6 % ...... NEPHRO-VITE ...... nicotine gum mouth/throat lozenge 4 mg ...... natural fiber oral capsule 0.52 gm ...... NESINA ...... nicotine mini ...... natural fiber oral powder 28.3 % ...... NEULASTA ...... nicotine mouth/throat gum 2 mg ...... natural fiber oral powder 48.57 % ...... NEULASTA ONPRO ...... nicotine mouth/throat gum 4 mg ...... natural fiber oral powder 58.6 % ...... NEUPOGEN INJECTION SOLUTION 300 nicotine mouth/throat lozenge 2 mg ...... natural fiber supplement ...... MCG/ML ...... nicotine mouth/throat lozenge 4 mg ...... natural laxative ...... NEUPOGEN INJECTION SOLUTION 480 nicotine polacrilex mini ...... natural laxative/stool soft ...... MCG/1.6ML ...... nicotine polacrilex mouth/throat ...... natural senna laxative ...... NEUPOGEN INJECTION SOLUTION nicotine step 1 ...... natural tears pf ...... PREFILLED SYRINGE ...... nicotine step 2 ...... natural vegetable ...... NEUTEK 2TEK CONTROL ...... nicotine step 3 ...... natural vegetable fiber ...... NEUTROGENA OIL-FREE ACNE WASH .... nicotine transdermal kit 21-14-7 mg/24hr ......

158 nicotine transdermal patch 24 hour 14 non-aspirin jr strength ...... NOVOLIN R VIAL ...... mg/24hr, 7 mg/24hr ...... non-aspirin pain relief ...... NOVOLOG FLEXPEN ...... nicotine transdermal patch 24 hour 21 non-pseudo sinus decongestant ...... NOVOLOG MIX 70/30 FLEXPEN ...... mg/24hr ...... nora-be ...... NOVOLOG MIX 70/30 VIAL ...... nicotine transdermal system ...... NORDITROPIN FLEXPRO ...... NOVOLOG PENFILL ...... nifedipine er ...... norethin ace-eth estrad-fe oral tablet ...... NOVOLOG U-100 VIAL ...... nifedipine er osmotic release ...... norethindrone acetate oral ...... NOVOTWIST PEN NEEDLE ...... nifedipine oral ...... norethindrone acet-ethinyl est ...... NUBEQA ...... night time sleep aid ...... norethindrone oral ...... NUCALA SUBCUTANEOUS SOLUTION nighttime dry-eye relief ...... norgestimate-eth estradiol ...... AUTO-INJECTOR ...... nighttime sleep aid max st ...... norgestimate-ethinyl estradiol triphasic oral NUCALA SUBCUTANEOUS SOLUTION nighttime sleep aid oral capsule 25 mg ...... tablet 0.18/0.215/0.25 mg-35 mcg ...... PREFILLED SYRINGE ...... nighttime sleep aid oral tablet 25 mg ...... NORITATE ...... NUCYNTA ER ...... nimodipine oral ...... norlyda ...... NUEDEXTA ...... NINLARO ...... norlyroc ...... NU-IRON ...... nitazoxanide ...... NORPACE ...... NULEV ...... NITRO-BID ...... NORPACE CR ...... NUPERCAINAL ...... NITRO-DUR ...... nortrel 0.5/35 (28) ...... NUPLAZID ...... nitrofurantoin ...... nortrel 1/35 (21) ...... NURTEC ...... nitrofurantoin macrocrystal ...... nortrel 1/35 (28) ...... NUTRAPLUS ...... nitrofurantoin monohydrate macrocrystals .... nortrel 7/7/7 ...... nutrifac zx ...... nitroglycerin sublingual ...... nortriptyline hcl oral ...... NUTROPIN AQ NUSPIN 10 ...... nitroglycerin transdermal ...... NORVIR ORAL PACKET ...... NUTROPIN AQ NUSPIN 20 ...... nitroglycerin translingual ...... NORVIR ORAL SOLUTION ...... NUTROPIN AQ NUSPIN 5 ...... NITYR ...... nose drops extstrength ...... NUZYRA ORAL ...... NIVA-PLUS ...... nose drops nasal decongest ...... nyamyc ...... NIVESTYM ...... nose drops nasal solution 1 % ...... nylia 7/7/7 ...... no drip nasal relief ...... NOVAMV PEDIATRIC MULTI-VITAMIN...... NYMALIZE ...... no drip nasal spray ...... novarel intramuscular solution reconstituted nymyo ...... NOCDURNA ...... 10000 unit ...... nystatin external ...... nohist-lq ...... NOVAREL INTRAMUSCULAR SOLUTION nystatin mouth/throat ...... non-aspirin ...... RECONSTITUTED 5000 UNIT ...... nystatin oral ...... non-aspirin 8 hour ...... NOVOLIN 70/30 FLEXPEN ...... nystop ...... non-aspirin childrens oral suspension 160 NOVOLIN 70/30 RELION ...... NYVEPRIA ...... mg/5ml ...... NOVOLIN 70/30 VIAL ...... O non-aspirin childrens oral tablet chewable NOVOLIN N FLEXPEN ...... O-CAL PRENATAL ...... 160 mg ...... NOVOLIN N RELION ...... OCEAN FOR KIDS ...... non-aspirin childrens oral tablet chewable 80 NOVOLIN N VIAL ...... OCEAN NASAL SPRAY ...... mg ...... NOVOLIN R FLEXPEN ...... octreotide acetate injection solution 100 non-aspirin extra strength ...... NOVOLIN R RELION ...... mcg/ml, 50 mcg/ml ......

159 octreotide acetate injection solution 1000 one-daily multi-vitamin oral tablet ...... OVACE WASH ...... mcg/ml ...... one-daily multi-vitamin/iron ...... OVIDREL ...... octreotide acetate injection solution 200 one-daily/iron ...... oxaprozin ...... mcg/ml ...... ONETOUCH ULTRA ...... OXAYDO ORAL TABLET 5 MG ...... octreotide acetate injection solution 500 ONETOUCH ULTRA 2 KIT W/DEVICE ...... oxazepam ...... mcg/ml ...... ONETOUCH ULTRA CONTROL ...... oxcarbazepine ...... ODEFSEY ...... ONETOUCH ULTRA MINI KIT W/DEVICE... OXTELLAR XR ...... ODOMZO ...... ONETOUCH VERIO FLEX SYSTEM ...... oxybutynin chloride er ...... OFEV ...... ONETOUCH VERIO IN VITRO SOLUTION . oxybutynin chloride oral ...... ofloxacin ophthalmic ...... ONETOUCH VERIO IQ SYSTEM ...... oxycodone hcl oral concentrate 100 mg/5ml . ofloxacin oral ...... ONETOUCH VERIO KIT W/DEVICE ...... oxycodone hcl oral solution ...... ofloxacin otic ...... ONETOUCH VERIO REFLECT ...... oxycodone hcl oral tablet ...... ointment base ...... ONETOUCH VERIO TEST STRIPS ...... oxycodone-acetaminophen oral tablet 10- olanzapine intramuscular ...... ONEVITE ...... 325 mg, 5-325 mg, 7.5-325 mg ...... olanzapine oral ...... ONEXTON ...... oxycodone-aspirin ...... olanzapine-fluoxetine hcl ...... ONGLYZA ...... OXYCONTIN ...... olopatadine hcl ophthalmic ...... opcicon one-step ...... oxymorphone hcl er ...... OLUMIANT ...... OPSUMIT ...... OXYTROL FOR WOMEN ...... OLUX ...... option 2 ...... oysco 500+d ...... OLUX-E ...... ORACEA ...... oyster shell calcium 500 + d ...... OMECLAMOX-PAK ...... oralone ...... oyster shell calcium oral tablet 500 mg ...... omega-3-acid ethyl esters ...... oralyte freezer pops ...... oyster shell calcium plus d oral tablet 500- omeprazole magnesium oral capsule ORENCIA CLICKJECT ...... 200 mg-unit ...... delayed release ...... ORENCIA SUBCUTANEOUS...... oyster shell calcium/d oral tablet 250-125 omeprazole magnesium oral tablet delayed ORFADIN ...... mg-unit ...... release ...... ORIAHNN ...... oyster shell calcium/d oral tablet 250-250 omeprazole oral capsule delayed release 10 ORILISSA ...... mg-unit, 500-400 mg-unit ...... mg, 20 mg, 20.6 (20 base) mg, 40 mg ...... orphenadrine citrate er ...... oyster shell calcium/d oral tablet 500-200 omeprazole oral tablet delayed release 20 orsythia ...... mg-unit ...... mg ...... OS-CAL CALCIUM + D3 ...... oyster shell calcium/vit d ...... OMNARIS ...... oscimin ...... oyster shell calcium/vitamin d oral tablet ...... OMNIFLEX DIAPHRAGM ...... oscimin sr ...... OZEMPIC SUBCUTANEOUS SOLUTION OMNITROPE ...... oseltamivir phosphate oral capsule ...... PEN-INJECTOR 2 MG/1.5ML ...... once daily ...... oseltamivir phosphate oral suspension P ondansetron hcl oral tablet ...... reconstituted ...... p col-rite ...... ondansetron odt ...... OSENI ...... PACERONE ...... one daily ...... OSPHENA ...... pain & fever child ...... ONE VITE WOMENS ...... OTEZLA ...... pain & fever childrens oral suspension 160 ONE VITE WOMENS PLUS ...... OTREXUP ...... mg/5ml ...... one-daily multi vitamins ...... OVACE PLUS WASH EXTERNAL LIQUID ..

160 pain & fever childrens oral tablet chewable PANADOL INFANTS ...... permethrin external ...... 160 mg ...... PANCREAZE ORAL CAPSULE DELAYED perphenazine oral ...... pain & fever infants oral suspension 160 RELEASE PARTICLES 10500-35500 perphenazine-amitriptyline ...... mg/5ml ...... UNIT, 16800-56800 UNIT, 21000-54700 PERSERIS ...... pain relief childrens oral elixir 160 mg/5ml .... UNIT, 4200-14200 UNIT ...... PEXEVA ...... pain relief childrens oral suspension 160 PANOXYL ...... pharbechlor ...... mg/5ml ...... PANRETIN ...... pharbedryl ...... pain relief childrens oral tablet chewable 160 pantoprazole sodium oral packet ...... PHARBETOL EXTRA STRENGTH ...... mg ...... pantoprazole sodium oral tablet delayed PHARBETOL ORAL TABLET 325 MG ...... pain relief extra st ...... release ...... pharbinex ...... pain relief extra strength ...... paromomycin sulfate oral ...... PHAZYME ...... pain relief infants oral suspension 160 paroxetine hcl ...... PHAZYME ULTRA STRENGTH ...... mg/5ml ...... paroxetine hcl er ...... phenazo oral tablet 200 mg ...... pain relief oral liquid 500 mg/15ml ...... PASER ...... phenazo oral tablet 95 mg ...... pain relief oral tablet 325 mg ...... PATADAY OPHTHALMIC SOLUTION 0.1 % phenazopyridine hcl oral tablet 100 mg ...... pain relief oral tablet 500 mg ...... PATADAY OPHTHALMIC SOLUTION 0.2 % phenazopyridine hcl oral tablet 200 mg ...... pain relief oral tablet extended release 650 PAXIL ORAL SUSPENSION ...... phenelzine sulfate oral ...... mg ...... ped electrolyte freeze pop ...... phenobarbital oral elixir ...... pain relief regular st ...... ped electrolyte freezer pops ...... phenobarbital oral tablet ...... pain relief regular strength ...... PEDIA-LAX ORAL LIQUID ...... phenylephrine hcl ophthalmic ...... pain relief/rapid burst ...... PEDIA-LAX RECTAL SUPPOSITORY 1 GM phenylephrine hcl oral ...... pain relieve child dye-free ...... PEDIALYTE FREEZER POPS ...... phenytoin infatabs ...... pain reliever childrens oral suspension 160 PEDIALYTE ORAL SOLUTION ...... phenytoin oral suspension 125 mg/5ml ...... mg/5ml ...... PEDIALYTE SINGLES ...... phenytoin oral tablet chewable ...... pain reliever ex st oral liquid 500 mg/15ml .... pediatric electrolyte oral solution ...... phenytoin sodium extended ...... pain reliever ex st oral tablet 500 mg ...... pediavit ...... philith ...... pain reliever ex st oral tablet extended peg 3350 oral powder ...... PHILLIPS MILK OF MAGNESIA ORAL release 650 mg ...... peg 3350-kcl-na bicarb-nacl ...... SUSPENSION 400 MG/5ML ...... pain reliever extra strength oral tablet 250- penicillamine oral tablet ...... PHOSPHA 250 NEUTRAL ...... 250-65 mg ...... penicillin v potassium ...... phosphorous ...... pain reliever extra strength oral tablet 500 pentamidine isethionate inhalation ...... phospho-trin 250 neutral ...... mg ...... PENTASA ...... phytonadione oral ...... pain reliever infants oral suspension 160 pentazocine-naloxone hcl ...... PIFELTRO ...... mg/5ml ...... pentoxifylline er ...... pilocarpine hcl ophthalmic ...... pain reliever oral tablet ...... peptic relief ...... pilocarpine hcl oral tablet 5 mg ...... pain reliever plus ...... PEPTO-BISMOL ORAL SUSPENSION 524 pilocarpine hcl oral tablet 7.5 mg ...... pain-off ...... MG/30ML ...... pimecrolimus ...... paliperidone er ...... PERDIEM OVERNIGHT RELIEF ...... pimozide ...... PANADOL CHILDRENS ...... PERFOROMIST ...... pimtrea ...... PANADOL EXTRA STRENGTH ...... periogard ...... pink bismuth ......

161 pink bismuth maximum strength ...... potassium chloride oral solution 20 prednisolone oral solution ...... pink bismuth oral tablet 262 mg ...... meq/15ml (10%), 40 meq/15ml (20%) ...... prednisolone sodium phosphate ophthalmic . pink bismuth oral tablet chewable 262 mg .... potassium citrate er oral tablet extended prednisolone sodium phosphate oral solution pink-bismuth ...... release 10 meq (1080 mg) ...... 15 mg/5ml ...... pioglitazone hcl ...... potassium citrate er oral tablet extended prednisolone sodium phosphate oral solution PIQRAY (200 MG DAILY DOSE) ...... release 15 meq (1620 mg) ...... 6.7 (5 base) mg/5ml ...... PIQRAY (250 MG DAILY DOSE) ...... potassium citrate er oral tablet extended prednisone oral solution ...... PIQRAY (300 MG DAILY DOSE) ...... release 5 meq (540 mg) ...... prednisone oral tablet ...... pirmella 1/35 ...... potassium citrate-citric acid ...... prednisone oral tablet therapy pack 10 mg pirmella 7/7/7 ...... povidone iodine ...... (21) ...... piroxicam oral ...... povidone-iodine external solution ...... prednisone oral tablet therapy pack 10 mg PLAN B ONE-STEP ...... PR BENZOYL PEROXIDE ...... (48), 5 mg (21), 5 mg (48) ...... PLEGRIDY ...... PR BENZOYL PEROXIDE WASH ...... PREFEST ...... PLEGRIDY STARTER PACK ...... PRADAXA ...... pregabalin oral ...... PNEUMOVAX 23 ...... PRALUENT ...... pregnyl ...... pnv tabs 29-1 ...... pramipexole dihydrochloride oral tablet PREMARIN ORAL ...... podofilox external ...... 0.125 mg, 0.5 mg, 1 mg ...... PREMARIN VAGINAL ...... poly bacitracin ...... pramipexole dihydrochloride oral tablet 0.25 PREMIUM CONDOMS LUBRICATED ...... polycin ...... mg, 1.5 mg ...... PREMPHASE ...... polyethylene glycol 3350 oral powder ...... pramipexole dihydrochloride oral tablet 0.75 PREMPRO ...... polyethylene glycol 3350-grx oral powder ..... mg ...... PRENATABS RX ...... poly-iron 150 ...... prasugrel hcl ...... prenatal formula oral tablet 28-0.8 mg ...... poly-iron 150 forte ...... praziquantel oral ...... prenatal gummy oral tablet chewable 0.4-25 polymyxin b-trimethoprim ...... prazosin hcl oral ...... mg ...... polysaccharide iron complex ...... PRECISION GLUCOSE CONTROL ...... prenatal multi+dha ...... polysaccharide iron forte ...... PRECISION GLUCOSE CONTROL SOLN .. prenatal multivitamins ...... polysaccharide-iron complex...... PRECISION GLUCOSE KETONE CONTR .. prenatal oral tablet 27-0.8 mg ...... POLYSPORIN ...... PRECISION GLUCOSE/KETONE CONTR .. prenatal oral tablet 27-1 mg ...... polyvinyl alcohol ophthalmic...... PRECISION LINK ...... prenatal oral tablet 28-0.8 mg ...... POLY-VI-SOL ...... PRECISION PCX PLUS TEST ...... prenatal plus iron ...... POLY-VITE PEDIATRIC ...... PRECISION POINT OF CARE TEST ...... prenatal vitamin plus low iron ...... POMALYST ...... PRECISION QID MONITOR ...... prenatal vitamins oral tablet 28-0.8 mg ...... portia-28 ...... PRECISION QID TEST ...... prenatal/iron ...... potassium chloride crys er ...... PRECISION SOF-TACT MONITOR ...... PRENATAL-U ...... potassium chloride er oral capsule extended PRECISION XTRA BLOOD GLUCOSE ...... PRENATVITE RX ...... release 10 meq ...... PRECISION XTRA DEVICE ...... preplus ...... potassium chloride er oral tablet extended PRECISION XTRA MONITOR...... PRETAB ...... release ...... PRED-G S.O.P...... PREVACID 24HR ...... potassium chloride oral packet...... prednisolone acetate ophthalmic ...... PREVACID ORAL CAPSULE DELAYED prednisolone acetate p-f ...... RELEASE 30 MG ......

162 prevalite oral powder ...... promethazine-phenylephrine ...... QUILLICHEW ER ...... PREVIDENT 5000 DRY MOUTH ...... promethegan ...... QUILLIVANT XR ...... PREVIDENT 5000 PLUS ...... PRONUTRIENTS VITAMIN D3 ...... quinapril hcl ...... PREVIDENT DENTAL ...... propafenone hcl ...... quinapril-hydrochlorothiazide ...... PREVIDENT MOUTH/THROAT ...... propranolol hcl er ...... quinidine gluconate er ...... previfem ...... propranolol hcl oral ...... quinidine sulfate ...... PREVNAR 13 ...... propranolol-hctz ...... QUINTET CONTROL HIGH/NORMAL ...... PREZCOBIX ...... propylthiouracil oral ...... quit2 ...... PREZISTA ...... PROTOPIC EXTERNAL OINTMENT 0.03 % quit4 ...... PRIFTIN ...... PROTOPIC EXTERNAL OINTMENT 0.1 % . QVAR REDIHALER ...... PRILOSEC ...... protriptyline hcl ...... R primaquine phosphate oral tablet 26.3 mg .... PROVENTIL HFA ...... radiance platinum vitamin d3 ...... primidone oral ...... pseudoephedrine hcl 12 hr ...... raloxifene hcl ...... PRISTIQ ...... pseudoephedrine hcl er ...... ramelteon ...... PROAIR HFA ...... pseudoephedrine hcl oral tablet 30 mg ...... ramipril ...... probenecid ...... pseudoephedrine-bromphen-dm ...... ranolazine er ...... pro-biotic blend ...... pseudoephedrine-guaifenesin er ...... RASUVO ...... probiotic colon care ...... psyldex ...... RAVICTI ...... probiotic complex ...... PULMICORT FLEXHALER ...... react ...... probiotic maximum strength ...... PULMOZYME ...... ready-to-use enema rectal enema ...... probiotic oral capsule ...... PURALUBE ...... REBIF ...... probiotic oral capsule 250 mg ...... pure & gentle lubricant ...... REBIF REBIDOSE ...... probiotic pearls ex st ...... purelax oral powder ...... REBIF REBIDOSE TITRATION PACK ...... prochlorperazine ...... PYLERA ...... REBIF TITRATION PACK ...... prochlorperazine maleate oral ...... pyrazinamide oral ...... reclipsen ...... PROCRIT ...... PYRIDIUM ...... RECOMBIVAX HB ...... PROCTOFOAM HC ...... pyridostigmine bromide er ...... RECTIV ...... procto-med hc ...... pyridostigmine bromide oral solution ...... REDITREX ...... proctozone-hc ...... pyridostigmine bromide oral tablet 60 mg ..... redness relief ophthalmic solution 0.012-0.2 progesterone oral ...... pyridoxine hcl oral ...... % ...... PROLENSA ...... pyrimethamine oral ...... refenesen 400 ...... PROMACTA ORAL PACKET 25 MG ...... Q REFRESH LACRI-LUBE ...... PROMACTA ORAL TABLET ...... QBREXZA ...... REFRESH P.M...... promethazine hcl oral ...... QELBREE ...... REFRESH PLUS ...... promethazine hcl rectal ...... QTERN ...... REFRESH TEARS ...... promethazine vc ...... quazepam ...... REGRANEX ...... promethazine vc/codeine ...... quetiapine fumarate ...... REHYDRALYTE ...... promethazine-codeine ...... quetiapine fumarate er ...... RELENZA DISKHALER ...... promethazine-dm ...... QUFLORA PEDIATRIC ORAL SOLUTION relexxii ...... promethazine-phenyleph-codeine ...... 0.5 MG/ML ...... relief eye drops ......

163 RELION TRUE MET AIR GLUC METER ...... RITALIN ...... saline mist spray ...... RELION TRUE METRIX TEST STRIPS ...... ritonavir ...... saline nasal spray ...... RELISTOR ...... rivastigmine ...... salsalate oral ...... RENAL ...... rivastigmine tartrate ...... SANTYL ...... RENAL MULTIVITAMIN FORMULA ...... rizatriptan benzoate ...... SAPHRIS ...... renal-vite ...... robafen cf multi-symptom cold ...... sapropterin dihydrochloride ...... rena-vite ...... ROBITUSSIN 12 HOUR COUGH ...... SAVAYSA ...... renewal soothing bath ...... ROBITUSSIN 12 HOUR COUGH CHILD ..... SAVELLA ...... repaglinide ...... ROBITUSSIN CHILD COUGH/COLD LA ..... SAVELLA TITRATION PACK ...... REPATHA ...... ROBITUSSIN CHILDRENS COUGH LA ...... sb allergy medicine oral tablet ...... rest simply ...... ROBITUSSIN COUGH+CHEST CONG DM sb arthritis pain relief ...... RESTASIS ...... ORAL LIQUID 20-400 MG/20ML ...... sb aspirin oral tablet delayed release ...... RESTASIS MULTIDOSE ...... ROBITUSSIN NIGHTTIME COUGH ...... sb docusate sodium/senna ...... RESTORA ...... ROBITUSSIN PEAK COLD MULTI-SYM...... sb lice killing max st ...... RESTORA RX ...... ropinirole hcl ...... sb mucus relief ...... restore plus lubricant eye ...... rosadan external cream ...... sb pain reliever childrens ...... restore pm ...... rosadan external gel ...... sb pain reliever ex st ...... RETACRIT ...... rosuvastatin calcium ...... SCRUB CARE POVIDONE-IODINE ...... RETIN-A EXTERNAL CREAM ...... roweepra ...... SECUADO ...... RETIN-A EXTERNAL GEL...... ROZEREM ...... SEGLUROMET ...... RETIN-A MICRO GEL 0.04 %, 0.1 % ...... ROZLYTREK ...... selegiline hcl oral ...... RETIN-A MICRO PUMP EXTERNAL GEL RUBRACA ...... selenium sulfide external lotion ...... 0.06 % ...... RUCONEST ...... selenium sulfide external shampoo ...... REVLIMID ...... rufinamide ...... SELRX ...... REXULTI ...... RUZURGI ...... SELZENTRY ...... REYATAZ ORAL CAPSULE ...... RYBELSUS ...... SEMGLEE ...... REYATAZ ORAL PACKET ...... RYDAPT ...... senexon-s ...... REYVOW ...... rynex dm ...... senior probiotic ...... RHOFADE ...... rynex pe ...... senna lax ...... RID LICE KILLING SHAMPOO ...... rynex pse ...... senna laxative ...... rifabutin ...... RYTHMOL SR ORAL CAPSULE senna oral liquid ...... rifampin oral ...... EXTENDED RELEASE 12 HOUR 225 senna oral syrup ...... riluzole ...... MG, 325 MG ...... senna oral tablet ...... rimantadine hcl ...... RYTHMOL SR ORAL CAPSULE senna plus oral tablet ...... RINVOQ ...... EXTENDED RELEASE 12 HOUR 425 MG senna s ...... RISAQUAD ...... senna smooth ...... RISAQUAD-2 ...... S senna-docusate sodium ...... RISPERDAL ...... saccharomyces boulardii ...... senna-extra ...... RISPERDAL CONSTA ...... SAIZEN ...... senna-lax ...... risperidone ...... saline enema ...... senna-plus ......

164 senna-s ...... SIMPLY SLEEP ...... sodium chloride (hypertonic) ophthalmic senna-tabs ...... SIMPONI ...... solution ...... senna-time ...... simvastatin oral ...... sodium chloride inhalation nebulization senna-time s ...... sinus 12 hour ...... solution 0.9 %, 10 %, 3 % ...... sennazon ...... sinus congestion max strength ...... sodium chloride inhalation nebulization SENOKOT ...... sinus nasal spray ...... solution 7 % ...... SENOKOT EXTRA STRENGTH ...... sinus pe decongestant ...... sodium chloride ophthalmic ointment 5 % ..... SENOKOT S ...... sinus relief ext st ...... sodium chloride ophthalmic solution 5 % ...... SEREVENT DISKUS ...... sinus relief extra strength ...... sodium fluoride 5000 plus ...... SERNIVO ...... sinus/congestion relief pe ...... sodium fluoride 5000 ppm dental cream ...... SEROQUEL ...... sirolimus oral solution ...... sodium fluoride dental cream ...... SEROQUEL XR ...... sirolimus oral tablet 0.5 mg, 1 mg ...... sodium fluoride dental gel ...... sertraline hcl oral ...... sirolimus oral tablet 2 mg ...... sodium fluoride mouth/throat ...... setlakin ...... SIRTURO ...... sodium fluoride oral solution 1.1 (0.5 f) sevelamer carbonate oral tablet ...... SKYRIZI (150 MG DOSE) ...... mg/ml ...... sf sleep aid (diphenhydramine) ...... sodium fluoride oral tablet 1.1 (0.5 f) mg ...... sf 5000 plus ...... sleep aid max st ...... sodium fluoride oral tablet chewable ...... SFROWASA ...... sleep aid nighttime oral capsule 25 mg ...... sodium phenylbutyrate oral powder ...... sharobel ...... sleep aid nighttime oral capsule 50 mg ...... sodium sulfacetamide wash ...... SHINGRIX ...... sleep aid nighttime oral tablet 25 mg ...... soft glucose ...... SHUR-SEAL CONTRACEPTIVE ...... sleep aid oral capsule 50 mg ...... SOLARTEK GLUCOSE CONTROL ...... SIGNIFOR ...... sleep aid oral tablet 25 mg ...... SOLIQUA ...... silace oral liquid ...... sleep ii ...... SOLODYN ...... silace oral syrup ...... sleep tabs ...... soluble fiber therapy ...... siladryl allergy ...... sleepaid (diphenhydramine) ...... SOMAVERT ...... sildenafil citrate oral suspension sleep-aid max st ...... SOOLANTRA ...... reconstituted ...... sleep-aid nighttime oral capsule 25 mg ...... soothe maximum strength ...... sildenafil citrate oral tablet 20 mg...... sleep-aid nighttime oral capsule 50 mg ...... soothe oral ...... SILENOR ...... sleep-aid oral capsule 25 mg ...... sorbitol oral ...... SILIQ ...... sleep-aid oral capsule 50 mg ...... SORILUX ...... siltussin sa ...... sleeptime oral capsule ...... sotalol hcl (af) ...... siltussin-dm alcohol free ...... SLO-NIACIN ...... sotalol hcl oral ...... silver sulfadiazine external ...... smooth antacid ex st oral tablet chewable spinosad ...... SIMBRINZA ...... 750 mg ...... SPIRIVA HANDIHALER ...... simeped ...... smooth antacid extra st ...... SPIRIVA RESPIMAT ...... simethicone oral capsule...... smooth lax oral powder ...... spironolactone oral ...... simethicone oral suspension ...... sod citrate-citric acid ...... spironolactone-hctz ...... simethicone oral tablet chewable ...... sodium bicarbonate oral tablet ...... SPRAVATO (56 MG DOSE) ...... simethicone ultra strength ...... sodium chloride (hypertonic) ophthalmic SPRAVATO (84 MG DOSE) ...... simliya ...... ointment ...... sprintec 28 ......

165 SPRYCEL ...... stress formula/iron ...... sulfamez wash ...... sps ...... STRIBILD ...... sulfasalazine oral ...... sronyx ...... STRIVERDI RESPIMAT ...... sulfatrim pediatric ...... ssd ...... SUBLOCADE SUBCUTANEOUS sulindac oral ...... sss 10-5 external cream ...... SOLUTION PREFILLED SYRINGE 100 SUMADAN WASH ...... ST JOSEPH LOW DOSE ...... MG/0.5ML ...... sumatriptan nasal ...... stavudine ...... SUBOXONE ...... sumatriptan succinate oral ...... STEGLATRO ...... subvenite ...... sumatriptan succinate refill ...... STEGLUJAN ...... subvenite starter kit-blue ...... sumatriptan succinate subcutaneous ...... STELARA SUBCUTANEOUS ...... subvenite starter kit-green ...... SUNOSI ...... stimulant laxative oral tablet 8.6-50 mg...... subvenite starter kit-orange ...... suphedrine maximum strength ...... STIOLTO RESPIMAT ...... SUCRAID ...... suphedrine oral tablet 30 mg ...... STIVARGA ...... sucralfate oral suspension ...... suphedrine oral tablet extended release 12 stomach relief extra strength ...... sucralfate oral tablet ...... hour 120 mg...... stomach relief max st oral suspension 525 SUDAFED ...... sure result sr relief ...... mg/15ml ...... SUDAFED CHILDRENS ...... SUTENT ORAL CAPSULE 12.5 MG, 25 stomach relief max strength ...... SUDAFED CONGESTION ...... MG, 50 MG ...... stomach relief oral suspension 1050 SUDAFED PE CONGESTION ORAL SUTENT ORAL CAPSULE 37.5 MG ...... mg/30ml, 525 mg/15ml ...... TABLET 10 MG ...... SYMAX-SR ...... stomach relief oral suspension 262 mg/15ml, SUDAFED PE SINUS CONGESTION ...... SYMBICORT ...... 525 mg/30ml, 527 mg/30ml ...... SUDAFED SINUS CONGESTION ...... SYMFI ...... stomach relief oral tablet 262 mg ...... SUDAFED SINUS CONGESTION 12HR ..... SYMFI LO ...... stomach relief oral tablet chewable 262 mg .. sudogest 12 hour ...... SYMJEPI ...... stomach relief plus ...... sudogest maximum strength ...... SYMLINPEN 120 ...... stomach relief ultra ...... sudogest oral tablet 30 mg ...... SYMLINPEN 60 ...... stool softener laxative oral capsule 100 mg .. sulfacetamide sodium external liquid ...... SYMPAZAN ...... stool softener laxative oral capsule 250 mg .. sulfacetamide sodium ophthalmic ...... SYMPROIC ...... stool softener oral capsule 100 mg ...... sulfacetamide sodium-sulfur external cream SYMTUZA ...... stool softener oral capsule 240 mg ...... 10-5 %...... SYNAGIS ...... stool softener oral capsule 250 mg ...... sulfacetamide sodium-sulfur external liquid SYNAREL ...... stool softener oral capsule 50 mg ...... 9-4.5 %...... SYNJARDY ...... stool softener oral tablet 100 mg ...... sulfacetamide sodium-sulfur external lotion SYNJARDY XR ...... stool softener oral tablet 8.6-50 mg...... 10-5 %...... SYSTANE ...... stool softener pls laxative ...... sulfacetamide sodium-sulfur external SYSTANE COMPLETE ...... stool softener plus laxative ...... suspension 10-5 % ...... SYSTANE CONTACTS ...... stool softener/laxative ...... sulfacetamide sod-sulfur wash external SYSTANE HYDRATION PF ...... stool softener/stimulant ...... liquid 9-4.5 % ...... SYSTANE NIGHTTIME ...... STRATTERA ...... sulfacetamide-prednisolone ophthalmic SYSTANE OVERNIGHT THERAPY ...... STRENSIQ ...... solution...... SYSTANE PRESERVATIVE FREE ...... stress formula ...... sulfamethoxazole-trimethoprim oral ...... SYSTANE ULTRA ......

166 SYSTANE ULTRA PF ...... temozolomide oral capsule 100 mg, 140 mg THRIVITE 19 ...... T temozolomide oral capsule 180 mg, 250 mg THRIVITE RX ...... tab tussin ...... temozolomide oral capsule 20 mg, 5 mg ...... tiadylt er ...... tab-a-vite ...... TENCON ...... tiagabine hcl ...... tab-a-vite/beta carotene ...... TENIVAC ...... TIBSOVO ...... tab-a-vite/iron ...... tenofovir disoproxil fumarate ...... TIKOSYN ...... TABLOID ...... terazosin hcl ...... tilia fe ...... TACLONEX ...... terbinafine hcl external ...... timolol maleate ophthalmic solution 0.25 %, tacrolimus external ointment 0.03 % ...... terbinafine hcl oral ...... 0.5 % ...... tacrolimus external ointment 0.1 % ...... terbinafine hydrochloride external cream 1 % TIMOPTIC ...... tacrolimus oral capsule 0.5 mg, 5 mg ...... TIMOPTIC-XE ...... tacrolimus oral capsule 1 mg ...... terconazole vaginal cream ...... TINACTIN EXTERNAL AEROSOL ...... tadalafil (pah) ...... TERIPARATIDE (RECOMBINANT) ...... TINACTIN EXTERNAL CREAM ...... TAFINLAR ...... testosterone cypionate intramuscular ...... tinaspore ...... take action ...... testosterone enanthate intramuscular ...... tioconazole 1 vaginal ointment 6.5 % ...... TALTZ ...... testosterone transdermal gel 12.5 mg/act tioconazole-1 ...... TAMIFLU ORAL CAPSULE ...... (1%) ...... TIVICAY ...... TAMIFLU ORAL SUSPENSION testosterone transdermal gel 25 mg/2.5gm TIVICAY PD ...... RECONSTITUTED ...... (1%), 50 mg/5gm (1%) ...... tizanidine hcl oral tablet ...... tamoxifen citrate oral ...... TETANUS-DIPHTHERIA TOXOIDS TD ...... TOBI NEBULIZER ...... tamsulosin hcl ...... tetrabenazine ...... TOBI PODHALER ...... TARGRETIN EXTERNAL ...... THALOMID ...... TOBRADEX OPHTHALMIC OINTMENT ...... tarina fe 1/20 ...... the magic bullet ...... TOBRADEX ST ...... tarina fe 1/20 eq ...... THEO-24 ...... tobramycin inhalation nebulization solution TASIGNA ...... theophylline ...... 300 mg/4ml ...... TAZORAC EXTERNAL CREAM ...... theophylline er oral tablet extended release tobramycin nebulization solution 300 mg/5ml TAZORAC EXTERNAL GEL 0.1 %...... 12 hour 300 mg ...... inhalation ...... taztia xt ...... theophylline er oral tablet extended release TOBRAMYCIN NEBULIZATION SOLUTION TDVAX ...... 12 hour 450 mg ...... 300 MG/5ML INHALATION ...... TEARS AGAIN ...... theophylline er oral tablet extended release tobramycin ophthalmic ...... TEARS AGAIN ADVANCED EYELID 24 hour 400 mg ...... tobramycin-dexamethasone ...... OPHTHALMIC ...... theophylline er oral tablet extended release tolcapone ...... tears pure ...... 24 hour 600 mg ...... tolnaftate antifungal ...... TECFIDERA ...... thera ...... tolnaftate external cream ...... TEGSEDI ...... thera-tabs ...... tolnaftate external powder ...... temazepam oral capsule 15 mg, 30 mg, 7.5 thiamine hcl oral ...... tolterodine tartrate ...... mg ...... thiamine mononitrate oral ...... TOPICORT SPRAY ...... temazepam oral capsule 22.5 mg ...... thioridazine hcl oral ...... topiramate er ...... TEMIXYS ...... thiothixene ...... topiramate oral ...... TEMOVATE ...... THRIVE ...... toremifene citrate ......

167 torsemide ...... trihexyphenidyl hcl ...... TUMS E-X 750 ...... total allergy ...... TRIJARDY XR ...... TUMS EXTRA STRENGTH 750 ...... total allergy medicine ...... tri-legest fe ...... TUMS LASTING EFFECTS ...... TOUJEO MAX SOLOSTAR ...... tri-linyah ...... TUMS SMOOTHIES ...... TOUJEO SOLOSTAR ...... trimethobenzamide hcl oral ...... TUMS ULTRA 1000 ...... TOVIAZ ...... trimethoprim oral ...... TURALIO ...... TRACLEER ...... tri-mili ...... tussin adult dm oral liquid 10-200 mg/5ml ..... TRADJENTA ...... trimipramine maleate oral ...... tussin adult multi-symptom ...... tramadol hcl oral tablet 50 mg ...... TRINATAL RX 1 ...... tussin cf cough & cold oral liquid 5-10-100 trandolapril ...... TRINATE ...... mg/5ml ...... tranexamic acid oral ...... TRINTELLIX ...... tussin cf multi-symptom cold ...... tranylcypromine sulfate ...... tri-nymyo ...... tussin cf oral liquid 30-10-100 mg/5ml ...... TRAVATAN Z ...... triphrocaps ...... tussin cf oral liquid 5-10-100 mg/5ml ...... travel ease ...... triple antibiotic ...... tussin chest congestion oral syrup 100 trazodone hcl oral ...... triple antibiotic original ...... mg/5ml ...... TRECATOR ...... tri-previfem ...... tussin cough dm sugar free ...... TRELEGY ELLIPTA ...... TRIPTODUR ...... tussin cough long acting ...... TREMFYA ...... tri-sprintec ...... tussin cough long-acting ...... TRESIBA ...... TRIUMEQ ...... tussin cough oral syrup ...... TRESIBA FLEXTOUCH ...... tri-vite pediatric ...... tussin cough/chest congest oral syrup 100- tretinoin external cream ...... tri-vite/fluoride oral solution 0.25 mg/ml ...... 10 mg/5ml ...... tretinoin oral ...... tri-vite/fluoride oral solution 0.5 mg/ml ...... tussin cough/chest dm max oral liquid 10- TREZIX ...... trivora (28) ...... 200 mg/5ml ...... tri femynor ...... tri-vylibra ...... tussin dm cough/chest cong ...... triamcinolone acetonide external cream ...... TROKENDI XR ...... tussin dm cough/chest oral syrup 10-100 triamcinolone acetonide external lotion 0.025 trospium chloride ...... mg/5ml ...... % ...... TRUE METRIX AIR GLUCOSE METER KIT tussin dm max ...... triamcinolone acetonide external lotion 0.1 TRUE METRIX METER KIT ...... tussin dm max adult ...... % ...... TRUECONTROL GLUCOSE CONT LEV 0 .. tussin dm max daytime ...... triamcinolone acetonide external ointment TRUECONTROL GLUCOSE CONT LEV 1 .. tussin dm max st ...... 0.025 %, 0.1 %, 0.5 % ...... TRUETRACK TEST ...... tussin dm oral syrup 100-10 mg/5ml ...... triamcinolone acetonide mouth/throat ...... TRULANCE ...... tussin maximum strength oral syrup 15 TRIAMINIC ALLERCHEWS ...... TRULICITY ...... mg/5ml ...... triamterene-hctz ...... TRUMENBA ...... tussin mucus+chest congestion oral syrup .... triazolam ...... TRUSOPT ...... tussin multi-symptom cold cf ...... TRICON ...... TRUVADA ORAL TABLET 200-300 MG ...... tussin oral syrup 100 mg/5ml ...... triderm ...... TUDORZA PRESSAIR ...... TWINRIX ...... tri-estarylla ...... tulana ...... tyblume ...... trifluoperazine hcl ...... TUMS ...... TYBOST ...... trifluridine ...... TUMS CHEWY BITES ......

168 TYLENOL ORAL SUSPENSION 160 VAQTA ...... VIRACEPT ...... MG/5ML ...... VARIVAX ...... VIRAMUNE ...... TYLENOL ORAL TABLET 325 MG ...... VARUBI (180 MG DOSE) ...... VIREAD ORAL POWDER ...... TYLENOL ORAL TABLET 500 MG ...... VASOCLEAR-A ...... VIREAD ORAL TABLET 150 MG, 200 MG, TYLENOL ORAL TABLET CHEWABLE 160 v-c forte ...... 250 MG ...... MG ...... VCF VAGINAL CONTRACEPTIVE virt-caps ...... TYLENOL ORAL TABLET EXTENDED VAGINAL FOAM ...... virt-phos 250 neutral ...... RELEASE 650 MG ...... VECTICAL ...... virtussin a/c ...... TYMLOS ...... vegetable lax+stool softener ...... virtussin ac w/alc ...... U velivet ...... virtussin dac ...... UBRELVY ...... VELPHORO ...... VISBIOME HIGH POTENCY ORAL UDAMIN SP ...... VELTASSA ...... CAPSULE ...... UDENYCA ...... VELTIN ...... VISINE ...... ultra fresh ...... VEMLIDY ...... VISINE ADVANCED RELIEF ...... ultra fresh pm ...... VENCLEXTA ...... VISTA GEL DRY EYE RELIEF ...... ultra lubricant drop ...... VENCLEXTA STARTING PACK ...... VISTA MEIBO TEARS ...... ultra lubricating eye drops ...... venlafaxine hcl ...... VISTA TEARS ...... unithroid ...... venlafaxine hcl er ...... VISTOGARD ...... urea 20 intensive hydrating ...... VENTOLIN HFA ...... vit c/rose hips ...... urea external lotion ...... VENTRIXYL ...... vita s forte ...... ureacin-10 ...... verapamil hcl er oral capsule extended vitacel ...... ureacin-20 ...... release 24 hour 120 mg, 180 mg, 240 mg, vitachew multiple vitamin ...... urin ds ...... 360 mg ...... vitamin a oral capsule 2400 mcg (8000 ut), 3 urinary pain relief oral tablet 95 mg ...... verapamil hcl er oral tablet extended release mg (10000 ut) ...... ursodiol oral capsule ...... verapamil hcl oral ...... vitamin b-1 oral tablet 100 mg, 250 mg ...... ursodiol oral tablet ...... VERSACLOZ ...... vitamin b-12 er oral tablet extended release UTIRA-C ...... VERZENIO ...... 1000 mcg ...... V VESICARE ...... vitamin b12 oral tablet extended release VAGIFEM ...... vic-forte ...... 1000 mcg ...... valacyclovir hcl oral ...... VICTOZA ...... vitamin b-12 tr oral tablet extended release valganciclovir hcl oral tablet ...... vienva ...... 1000 mcg ...... valproic acid oral ...... vigabatrin oral packet ...... vitamin b-6 ...... VALTOCO 10 MG DOSE ...... vigadrone ...... vitamin b-6 er ...... VALTOCO 15 MG DOSE ...... VIGAMOX ...... vitamin c cr oral tablet extended release 500 VALTOCO 20 MG DOSE ...... VIIBRYD ...... mg ...... VALTOCO 5 MG DOSE ...... VIIBRYD STARTER PACK ...... vitamin c er oral tablet extended release VANCOCIN ...... VIMPAT ORAL ...... 1500 mg ...... vandazole ...... VINATE II ...... vitamin c oral liquid 500 mg/5ml ...... VANOS ...... VINATE ONE ...... vitamin c oral tablet 1000 mg, 250 mg ...... VAPORIZER WARM STEAM ...... viorele ...... vitamin c oral tablet 500 mg ......

169 vitamin c oral tablet chewable 100 mg, 250 vitamin e oral capsule 400 unit ...... womans laxative ...... mg ...... vitamin-b complex ...... womens gentle laxative ...... vitamin c oral tablet chewable 500 mg ...... vitamins acd-fluoride ...... womens laxative ...... vitamin c/acerola ...... vitamins complete childrens ...... womens prenatal+dha ...... vitamin c/rose hips oral tablet 1000 mg ...... VITATHELY WITH GINGER ...... X vitamin c/rose hips oral tablet 500 mg ...... VITRAKVI ...... XALATAN ...... vitamin c-rose hips oral tablet ...... VIVELLE-DOT ...... XALKORI ...... vitamin d (cholecalciferol) oral tablet 10 mcg volnea ...... XARELTO ...... (400 unit) ...... voriconazole oral tablet ...... XARELTO STARTER PACK ...... vitamin d (cholecalciferol) oral tablet 25 mcg VOTRIENT ...... XCOPRI ...... (1000 ut) ...... VRAYLAR ORAL CAPSULE ...... XCOPRI (250 MG DAILY DOSE) ORAL vitamin d (ergocalciferol) oral capsule 1.25 VRAYLAR ORAL CAPSULE THERAPY TABLET THERAPY PACK 50 & 200 MG .. mg (50000 ut) ...... PACK ...... XCOPRI (350 MG DAILY DOSE) ...... vitamin d oral capsule 25 mcg (1000 ut) ...... VUMERITY ...... XELJANZ ORAL TABLET ...... vitamin d oral liquid ...... vyfemla ...... XELJANZ XR ...... vitamin d oral tablet 25 mcg (1000 ut) ...... vylibra ...... XELODA ...... vitamin d oral tablet 50 mcg (2000 ut) ...... VYNDAMAX ...... XENLETA ORAL ...... vitamin d oral tablet chewable 10 mcg (400 VYNDAQEL ...... XEPI ...... unit) ...... VYVANSE ...... XIGDUO XR ORAL TABLET EXTENDED vitamin d3 oral capsule 1.25 mg (50000 ut) .. W RELEASE 24 HOUR 10-1000 MG, 10-500 vitamin d3 oral capsule 125 mcg (5000 ut) ... WAKIX ...... MG ...... vitamin d-3 oral capsule 125 mcg (5000 ut) .. warfarin sodium oral tablet 1 mg, 10 mg, 2 XIGDUO XR ORAL TABLET EXTENDED vitamin d3 oral capsule 25 mcg (1000 ut) ..... mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg ..... RELEASE 24 HOUR 2.5-1000 MG, 5- vitamin d3 oral capsule 250 mcg (10000 ut) . warfarin sodium oral tablet 6 mg ...... 1000 MG, 5-500 MG ...... vitamin d3 oral capsule 50 mcg (2000 ut) ..... wart remover external liquid 17 % ...... XIIDRA ...... vitamin d-3 oral capsule 50 mcg (2000 ut) .... wart remover maximum strength external XIMINO ...... vitamin d3 oral liquid 10 mcg/ml ...... liquid...... XOFLUZA (40 MG DOSE) ...... vitamin d3 oral tablet 10 mcg (400 unit) ...... weekly-d ...... XOFLUZA (80 MG DOSE) ...... vitamin d3 oral tablet 125 mcg (5000 ut) ...... wera ...... XOLAIR ...... vitamin d3 oral tablet 25 mcg (1000 ut) ...... WESTAB PLUS ...... XOPENEX HFA ...... vitamin d-3 oral tablet 25 mcg (1000 ut)...... WEST-VITE W/FOLIC ACID ...... XPECT ...... vitamin d3 oral tablet 50 mcg (2000 ut) ...... WIDE-SEAL DIAPHRAGM 60 ...... XTANDI ORAL CAPSULE ...... vitamin d3 oral tablet chewable 10 mcg (400 WIDE-SEAL DIAPHRAGM 65 ...... xulane ...... unit) ...... WIDE-SEAL DIAPHRAGM 70 ...... XULTOPHY ...... vitamin d3 oral tablet chewable 25 mcg, 25 WIDE-SEAL DIAPHRAGM 75 ...... XYREM ...... mcg (1000 ut) ...... WIDE-SEAL DIAPHRAGM 80 ...... Y vitamin d-400 ...... WIDE-SEAL DIAPHRAGM 85 ...... YONSA ...... vitamin e natural ...... WIDE-SEAL DIAPHRAGM 90 ...... yuvafem ...... vitamin e oral capsule 100 unit, 1000 unit, WIDE-SEAL DIAPHRAGM 95 ...... Z 200 unit, 450 mg ...... wixela inhub ...... zaclir cleansing ......

170 ZADITOR ...... ZILXI ...... ZOSTRIX HP ...... zafemy ...... zinc chelated oral tablet 50 mg ...... zovia 1/35 (28) ...... zaleplon ...... zinc oral tablet 50 mg ...... zovia 1/35e (28) ...... ZARXIO ...... zinc oxide external ointment 40 % ...... z-sleep oral capsule 25 mg ...... ZAVESCA ...... ZIOPTAN ...... ZUBSOLV ...... ZEASORB-AF ...... ziprasidone hcl ...... ZULRESSO ...... ZEGERID ...... ziprasidone mesylate ...... ZYCLARA ...... ZEJULA ...... ZOHYDRO ER ...... ZYDELIG ...... ZELAC ...... ZOLINZA ...... ZYKADIA ...... ZELBORAF ...... zolpidem tartrate ...... ZYLET ...... zenatane ...... zolpidem tartrate er ...... ZYMAXID ...... ZENPEP ORAL CAPSULE DELAYED ZOLPIMIST ...... ZYPREXA INTRAMUSCULAR ...... RELEASE PARTICLES 3000-10000 UNIT ZOMACTON ...... ZYPREXA ORAL ...... ZENZEDI ORAL TABLET 10 MG, 5 MG ...... ZOMACTON (FOR ZOMA-JET 10) ...... ZYPREXA RELPREVV ...... ZENZEDI ORAL TABLET 15 MG, 2.5 MG, zonisamide oral ...... ZYPREXA ZYDIS ...... 20 MG, 30 MG, 7.5 MG ...... zoo friends ...... ZYRTEC ALLERGY ORAL TABLET ...... ZEPOSIA ...... zoo friends complete ...... ZYRTEC-D ALLERGY & CONGESTION ...... ZETONNA ...... zoo friends gummies ...... ZYTIGA ...... ZIANA ...... zoo friends plus extra c ...... ZYVANA ...... zidovudine ...... zoo friends plus iron ...... ZIEXTENZO ...... ZORTRESS ORAL TABLET 1 MG ......

171