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Washington Essential Rx Drug List

The Essential Rx Drug List includes a list of drugs covered by Health Net. This drug list is for Washington. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/wadruglistpdf or call us at the toll-free telephone number on your Health Net ID card.

WA Essential Drug List Updated: January 1, 2021

Welcome to Health Net

What is the Essential Rx Drug List? The Essential Rx Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)

How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents.

Abbreviation Copayment/Coinsurance Description 1 Tier 1 copayment or Generic drugs coinsurance 2 Tier 2 copayment or Preferred brand drugs coinsurance 3 Tier 3 copayment or Non-preferred brand drugs coinsurance SP Specialty copayment or Specialty drugs. This category includes self- coinsurance administered injectable and some oral high cost drugs. You may be required to get these drugs from a Specialty pharmacy. AC Anticancer drug copayment Self-administered anticancer drugs. You or coinsurance may be required to get these drugs from a Specialty pharmacy. PV $0 Preventive benefit drugs. These drugs must be covered at no cost to enrollees under the Affordable Care Act. A deductible does not apply. GP Generic Preferred This includes most brand name drugs with a generic equivalent. Depending on your plan, these drugs are either not covered (non- formulary), covered at Tier 3 or covered at a copayment plus the difference in cost between the brand and generic drug. Refer to your Summary of Benefits or other plan documents.

ii How do I use the drug list? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

What if my drug is not on the drug list? If your drug is not on the drug list, call us at the telephone number on your Health Net ID card and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. Your doctor can ask us to make an exception if he or she feels you need the drug that is not covered. If we approve an exception request for a drug not on the drug list, the non-preferred brand tier (Tier 3) copayment will apply.

What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less.

Generic drugs are available on the drug list at Tier 1. Brand name drugs with a generic equivalent are either non-formulary or non-preferred, depending on your plan benefits. If your doctor determines that you need a brand name drug instead of its generic equivalent, your doctor can submit a prior authorization request for a formulary exception with documentation of medical necessity.

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA or clinical recommendations. PA Prior Authorization These drugs require prior authorization for coverage, effectiveness or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. RX/OTC Prescription & Over- Certain drugs are available both in a prescription the-Counter (OTC) form and in an OTC form. Only prescription drugs are covered by your plan with the exception of some , supplies and some covered preventive drugs. ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.

iii How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage. • Your doctor can ask us to cover your drug even if it is not on the drug list. • Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198.

Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” and, in most cases, must be obtained from one of Health Net’s approved Specialty Pharmacies.

Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies.

Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your Health Net ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online, so you may have to pay the full cost of your drug. If you do pay out-of-pocket for your drug, you may be able to send us your pharmacy receipt and ask for reimbursement of our share of the cost. Please refer to your plan documents for more information.

Some injectable and high cost drugs (including anticancer drugs) may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s approved Specialty pharmacies.

Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition.

To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com or you may call us at the telephone number on your Health Net ID card to request a form.

How often can I refill my prescription? • For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as directed. • For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used as directed.

If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.

iv How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at Health Net participating pharmacies. • Be sure your doctor prescribes drugs on the drug list • Fill your maintenance drugs through our mail order pharmacy program.

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Nondiscrimination Notice Health Net Health Plan of Oregon, Inc. (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex. Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at 1-888-802-7001 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Nondiscrimination Notice FLY029224ER00 (1/20)

OR WA Commercial Notice of Language Assistance

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Notice of Language Assistance FLY029225ER00 (1/20) Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine ADHD, Sleep and Eating Disorders tabs 1.25 mg-1.25 mg- Amphetamines 1.25 mg-1.25 mg, (Dextroamphetamine 1.875 mg-1.875 mg- Sulfate) PROCENTRA 1 1.875 mg-1.875 mg, SOLN 2.5 mg-2.5 mg-2.5 mg- 1 (Dextroamphetamine 2.5 mg, 3.125 mg- Sulfate) ZENZEDI TABS 10 1 3.125 mg-3.125 mg- MG, 2.5 MG, 5 MG, 7.5 MG 3.125 mg, 3.75 mg- ADDERALL TABS 1.25 3.75 mg-3.75 mg-3.75 MG-1.25 MG-1.25 MG-1.25 mg, 5 mg-5 mg-5 mg-5 MG, 1.875 MG-1.875 MG- 1.875 MG-1.875 MG, 2.5 mg, 7.5 mg-7.5 mg-7.5 MG-2.5 MG-2.5 MG-2.5 mg-7.5 mg MG, 3.125 MG-3.125 MG- GP DESOXYN TABS PA GP 3.125 MG-3.125 MG, 3.75 (methamphetamine hcl) MG-3.75 MG-3.75 MG-3.75 DEXEDRINE CP24 MG ( amphetamine- (dextroamphetamine GP ) dextroamphetamine sulfate) ADDERALL XR CP24 1.25 QL(1 ea daily) MG-1.25 MG-1.25 MG-1.25 dextroamphetamine 1 MG, 2.5 MG-2.5 MG-2.5 sulfate cp24 MG-2.5 MG, 3.75 MG-3.75 GP dextroamphetamine 1 MG-3.75 MG-3.75 MG sulfate soln (amphetamine- dextroamphetamine dextroamphetamine) 1 sulfate tabs amphetamine- QL(1 ea daily) methamphetamine hcl PA dextroamphetamine 1 cp24 1.25 mg-1.25 mg- tabs 1.25 mg-1.25 mg, 2.5 VYVANSE CAPS QL(1 ea daily) mg-2.5 mg-2.5 mg-2.5 (lisdexamfetamine 2 mg, 3.75 mg-3.75 mg- 1 dimesylate) 3.75 mg-3.75 mg, 5 VYVANSE CHEW QL(1 ea daily) mg-5 mg-5 mg-5 mg, (lisdexamfetamine 2 6.25 mg-6.25 mg-6.25 dimesylate) mg-6.25 mg, 7.5 mg- Analeptics 7.5 mg-7.5 mg-7.5 mg caffeine citrate soln 1 Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps QL(2 ea daily) 10 mg, 18 mg, 25 mg, 1 40 mg QL(1 ea daily) atomoxetine hcl caps 1 100 mg, 60 mg, 80 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea daily) METHYLIN SOLN clonidine hcl (adhd) 1 GP tb12 (methylphenidate hcl) QL(1 ea daily) methylphenidate hcl guanfacine hcl (adhd) 1 tb24 chew 10 mg, 2.5 mg, 5 1 INTUNIV TB24 QL(1 ea daily) mg GP (guanfacine hcl (adhd)) methylphenidate hcl QL(1 ea daily) KAPVAY TB12 ( QL(4 ea daily) cp24 10 mg, 20 mg, 30 1 clonidine GP hcl (adhd)) mg, 40 mg STRATTERA CAPS 100 QL(1 ea daily) methylphenidate hcl MG, 60 MG, 80 MG GP cpcr 10 mg, 40 mg, 50 1 (atomoxetine hcl) mg, 60 mg STRATTERA CAPS 18 MG QL(2 ea daily) QL(2 ea daily) GP methylphenidate hcl 1 (atomoxetine hcl) cpcr 20 mg, 30 mg Stimulants - Misc. methylphenidate hcl soln 10 mg/5ml, 5 1 (Methylphenidate Hcl) 1 QL(1 ea daily) METADATE ER TBCR mg/5ml armodafinil tabs 1 PA methylphenidate hcl tabs 10 mg, 20 mg, 5 1 CONCERTA TBCR 27 MG QL(1 ea daily) GP mg (methylphenidate hcl) methylphenidate hcl QL(1 ea daily) DAYTRANA PTCH QL(1 ea daily) 3 tb24 18 mg, 27 mg, 54 1 (methylphenidate) mg QL(1 ea daily) dexmethylphenidate hcl QL(2 ea daily) methylphenidate hcl 1 cp24 10 mg, 15 mg, 20 1 mg, 30 mg, 40 mg, 5 tb24 36 mg mg methylphenidate hcl QL(1 ea daily) tbcr 10 mg, 18 mg, 20 1 dexmethylphenidate hcl 1 cp24 25 mg, 35 mg mg, 27 mg, 54 mg methylphenidate hcl QL(2 ea daily) dexmethylphenidate hcl QL(2 ea daily) 1 tabs 10 mg, 2.5 mg, 5 1 tbcr 36 mg mg METHYLPHENIDATE QL(1 ea daily) HYDROCHLORIDE ER FOCALIN TABS QL(2 ea daily) TBCR (methylphenidate 3 (dexmethylphenidate GP hcl) hcl) 1 ST; QL(1 ea FOCALIN XR CP24 10 QL(1 ea daily) modafinil tabs daily) MG, 20 MG, 30 MG, 40 NUVIGIL TABS PA MG, 5 MG GP GP (dexmethylphenidate (armodafinil) hcl) PROVIGIL TABS ST; QL(1 ea GP daily) FOCALIN XR CP24 35 MG (modafinil) QUILLIVANT XR SRER PA; QL(12 ml (dexmethylphenidate GP 3 hcl) (methylphenidate hcl) daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELEXXII TBCR QL(1 ea daily) ARIKAYCE SUSP PA 3 (methylphenidate hcl) (amikacin sulfate SP RITALIN LA CP24 QL(1 ea daily) liposome) GP (methylphenidate hcl) BETHKIS NEBU PA SP RITALIN TABS (tobramycin) GP (methylphenidate hcl) PA gentamicin in saline SP soln ALLERGENIC EXTRACTS/BIOLOGICALS MISC gentamicin sulfate soln SP PA Allergenic Extracts KITABIS PAK NEBU GRASTEK SUBL PA SP (timothy grass pollen 3 (tobramycin) allergen extract) neomycin sulfate tabs 1 ODACTRA SUBL (dust PA mite mixed allergen 3 paromomycin sulfate 1 extract) caps PA ORALAIR ADULT SAMPLE PA streptomycin sulfate SP KIT SUBL (grass mixed solr 3 pollens allergen TOBI NEBU (tobramycin) SP extract) TOBI PODHALER CAPS PA ORALAIR ADULT PA SP STARTER PACK SUBL (tobramycin) 3 PA (grass mixed pollens tobramycin nebu 300 SP allergen extract) mg/4ml ORALAIR SUBL (grass PA tobramycin nebu 300 SP mixed pollens allergen 3 mg/5ml extract) tobramycin sulfate soln SP PA RAGWITEK SUBL (short PA ragweed pollen 3 ANALGESICS - ANTI-INFLAMMATORY - Drugs allergen extract) to Treat Pain, Swelling, Muscle and Joint Conditions Biologicals Misc Anti-TNF-alpha - Monoclonal Antibodies ADAGEN SOLN PA SP HUMIRA PEDIATRIC PA (pegademase bovine) CROHNS DISEASE SP AMINOGLYCOSIDES - Drugs to Treat Bacterial STARTER PACK PSKT Infections (adalimumab) HUMIRA PEN PNKT PA Aminoglycosides SP (Tobramycin) (adalimumab) HUMIRA PEN-CD/UC/HS PA TOBRAMYCIN SP INHALATION SOLUTION STARTER PNKT SP PAK NEBU (adalimumab) amikacin sulfate soln SP PA HUMIRA PEN-PS/UV PA STARTER PNKT SP (adalimumab)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMIRA PSKT PA KEVZARA SOAJ 150 PA; SP SP (adalimumab) MG/1.14ML, 200 SP SIMPONI ARIA SOLN PA MG/1.14ML (sarilumab) SP (golimumab) KEVZARA SOSY 150 PA SIMPONI SOAJ PA MG/1.14ML, 200 SP SP (golimumab) MG/1.14ML (sarilumab) SIMPONI SOSY PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) SP (golimumab) (Fenoprofen Calcium) 1 PROFENO TABS Antirheumatic - Enzyme Inhibitors (Ibuprofen) CHILDRENS RX/OTC RINVOQ TB24 PA SP IBUPROFEN, CHILDRENS (upadacitinib) IBUPROFEN 100, XELJANZ TABS PA CHILDRENS MEDI- SP (tofacitinib citrate) PROFEN, CVS CHILDRENS IBUPROFEN, XELJANZ XR TB24 PA SP CVS IBUPROFEN (tofacitinib citrate) CHILDRENS, EQ Antirheumatic Antimetabolites IBUPROFEN CHILDRENS, EQL CHILDRENS TABS IBUPROFEN, GNP (methotrexate sodium 2 CHILDRENS IBUPROFEN, (antirheumatic)) GOODSENSE OTREXUP SOAJ PA IBUPROFEN CHILDRENS, 1 (methotrexate SP HM IBUPROFEN CHILDRENS, HYVEE (antirheumatic)) IBUPROFEN CHILDRENS, RASUVO SOAJ PA IBUPROFEN CHILDRENS, (methotrexate SP PX CHILDRENS PROFEN (antirheumatic)) IB, QC CHILDRENS IBUPROFEN, RA Gold Compounds IBUPROFEN, RA RIDAURA CAPS IBUPROFEN CHILDRENS, 2 (auranofin) SM CHILDRENS IBUPROFEN, TGT -1 Blockers CHILDRENS IBUPROFEN, ARCALYST SOLR PA TGT IBUPROFEN SP (rilonacept) CHILDRENS SUSP Interleukin-1 Receptor Antagonist (IL-1Ra) (Ibuprofen) IBU TABS 1 KINERET SOSY PA SP (Nabumetone) RELAFEN 1 QL(4 ea daily) (anakinra) TABS 500 MG Interleukin-6 Receptor Inhibitors (Nabumetone) RELAFEN 1 QL(3 ea daily) ACTEMRA SOLN PA TABS 750 MG SP (tocilizumab) (Naproxen) EC- NAPROXEN, NAPROXEN 1 ACTEMRA SOSY PA SP DR TBEC (tocilizumab)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARTHROTEC 50 TBEC QL(2 ea daily) etodolac tb24 400 mg, 1 (diclofenac w/ GP 500 mg, 600 mg misoprostol) FELDENE CAPS GP ARTHROTEC 75 TBEC (piroxicam) (diclofenac w/ GP FENOPROFEN CALCIUM misoprostol) CAPS 200 MG 3 CELEBREX CAPS 100 ST; QL(2 ea (fenoprofen calcium) GP MG, 50 MG (celecoxib) daily) fenoprofen calcium 1 ST; QL(2 ea caps 200 mg, 400 mg CELEBREX CAPS 400 MG GP daily); AL(At fenoprofen calcium (celecoxib) least 60 yrs 1 old) tabs 600 mg ST; QL(2 ea FENORTHO CAPS celecoxib caps 100 mg, 1 3 200 mg, 50 mg daily) (fenoprofen calcium) ST; QL(2 ea flurbiprofen tabs 1 daily); AL(At celecoxib caps 400 mg 1 RX/OTC least 60 yrs ibuprofen susp 100 1 old) mg/5ml CHILDRENS ADVIL SUSP RX/OTC GP ibuprofen tabs 400 mg, 1 (ibuprofen) 600 mg, 800 mg CHILDRENS MOTRIN RX/OTC INDOCIN SUPP RE 50 MG GP 3 SUSP (ibuprofen) (indomethacin) DAYPRO TABS INDOCIN SUSP OR 25 GP 2 (oxaprozin) MG/5ML (indomethacin) DICLOFENAC CAPS ST; QL(3 ea ST; QL(3 ea 3 indomethacin caps 20 1 (diclofenac) daily) mg daily) diclofenac potassium 1 indomethacin caps 25 1 tabs mg, 50 mg diclofenac sodium tb24 1 indomethacin cpcr 75 1 mg diclofenac sodium tbec 1 ketoprofen caps 1 diclofenac w/ 1 misoprostol tbec ketoprofen cp24 1 DUEXIS TABS PA 3 KETOROLAC QL(1 ea daily,5 (ibuprofen-famotidine) TROMETHAMINE SOLN day(s) limit) EC-NAPROSYN TBEC NA 15.75 MG/SPRAY 3 GP (naproxen) (ketorolac etodolac caps 200 mg, tromethamine) 1 QL(0.67 ea 300 mg ketorolac tromethamine 1 tabs or 10 mg daily) etodolac tabs 400 mg, 1 500 mg LODINE TABS (etodolac) GP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPRIX SOLN ( QL(1 ea daily,5 meclofenamate sodium 1 ketorolac 3 caps tromethamine) day(s) limit) mefenamic acid caps 1 sulindac tabs 1 QL(1 ea daily) TIVORBEX CAPS ST; QL(3 ea meloxicam tabs 15 mg 1 3 (indomethacin) daily) QL(2 ea daily) meloxicam tabs 7.5 mg 1 tolmetin sodium caps 1 MOBIC TABS 15 MG QL(1 ea daily) GP (meloxicam) tolmetin sodium tabs 1 MOBIC TABS 7.5 MG QL(2 ea daily) VIMOVO TBEC PA GP (meloxicam) (naproxen- GP QL(4 ea daily) esomeprazole nabumetone tabs 500 1 mg magnesium) QL(3 ea daily) ZIPSOR CAPS ST nabumetone tabs 750 1 3 mg (diclofenac potassium) NALFON CAPS 400 MG ZORVOLEX CAPS 18 MG, ST; QL(3 ea 3 3 daily) (fenoprofen calcium) 35 MG (diclofenac) NALFON TABS 600 MG Phosphodiesterase 4 (PDE4) Inhibitors GP (fenoprofen calcium) OTEZLA TABS PA SP NAPRELAN TB24 375 MG, (apremilast) 500 MG (naproxen GP OTEZLA TBPK PA SP sodium) (apremilast) NAPRELAN TB24 750 MG 3 Pyrimidine Synthesis Inhibitors (naproxen sodium) ARAVA TABS 10 MG QL(2 ea daily) NAPROSYN SUSP GP GP (leflunomide) (naproxen) ARAVA TABS 20 MG QL(1 ea daily) GP naproxen sodium tabs 1 (leflunomide) leflunomide tabs 10 mg 1 QL(2 ea daily) naproxen sodium tb24 1 leflunomide tabs 20 mg 1 QL(1 ea daily) naproxen susp 1 Selective Costimulation Modulators naproxen tabs 1 ORENCIA CLICKJECT PA SP naproxen tbec 1 SOAJ (abatacept) ORENCIA SOLR PA SP naproxen- PA (abatacept) esomeprazole 1 ORENCIA SOSY PA SP magnesium tbec (abatacept) oxaprozin tabs 1 Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT PA 1 SP piroxicam caps (etanercept)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBREL SOLN 25 PA FIORICET CAPS 3 MG/0.5ML (etanercept) (butalbital- GP ENBREL SOLR 25 MG PA acetaminophen- SP (etanercept) caffeine) ENBREL SOSY 25 PA FIORINAL CAPS MG/0.5ML, 50 MG/ML SP (butalbital-aspirin- GP (etanercept) caffeine) ENBREL SURECLICK PA VTOL LQ SOLN SP SOAJ (etanercept) (butalbital- 3 ANALGESICS - NonNarcotic - Drugs to Treat acetaminophen- Pain, Muscle and Joint Conditions caffeine) Analgesic Combinations Salicylates (Acetaminophen- Salicylamide- 1 Phenyltoloxamine) DURAXIN CAPS (Butalbital-Acetaminophen) 1 BUPAP, TENCON TABS (Butalbital-Acetaminophen- Caffeine) ESGIC, 1 PHRENILIN FORTE, ZEBUTAL CAPS (Butalbital-Acetaminophen- Caffeine) VANATOL LQ, 1 VANATOL S SOLN butalbital- acetaminophen tabs 1 300 mg-50 mg, 325 mg-50 mg butalbital- acetaminophen- 1 caffeine caps butalbital- acetaminophen- 1 caffeine tabs butalbital-aspirin- 1 caffeine caps BUTALBITAL/ASPIRIN/CA FFEINE TABS (butalbital-aspirin- 2 caffeine) ESGIC TABS (butalbital- acetaminophen- GP caffeine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN PV EC, SM ASPIRIN ADULT REGIMEN, ASPIR-LOW, LOW STRENGTH, SM ASPIRIN 81, ASPIRIN ASPIRIN EC LOW ADULT LOW DOSE, STRENGTH, SM ASPIRIN ASPIRIN ADULT LOW ENTERIC COATED, ST STRENGTH, ASPIRIN EC JOSEPH ASPIRIN, TGT LOW DOSE, ASPIRIN ASPIRIN, TGT ASPIRIN ENTERIC COATED LOW DOSE, TGT ADULT LOW STRENGTH, ENTERIC-COATED ASPIRIN LOW DOSE, ASPIRIN TBEC ASPIRTAB, BAYER (Aspirin) ASPIRIN 81 LOW PV ASPIRIN, BAYER ASPIRIN DOSE, ASPIRIN ADULT EC LOW DOSE, BAYER LOW STRENGTH, ASPIRIN REGIMEN, ASPIRIN CHILDRENS, BAYER LOW DOSE, CVS ASPIRIN LOW DOSE, ASPIRIN, CVS ASPIRIN ASPIRIN LOW ADULT LOW STRENGTH, STRENGTH, BAYER CVS ASPIRIN EC, CVS CHEWABLE LOW DOSE, ASPIRIN LOW DOSE, CVS CHILDRENS ASPIRIN, ASPIRIN LOW CHILDRENS ASPIRIN STRENGTH, EC-81 LOW STRENGTH, CVS ASPIRIN, ECOTRIN LOW ASPIRIN ADULT LOW STRENGTH, ECPIRIN, EQ DOSE, EQ ASPIRIN LOW ADULT ASPIRIN LOW DOSE, EQ CHILDRENS STRENGTH, EQ ASPIRIN, ASPIRIN, EQL ASPIRIN EQ ASPIRIN ADULT LOW PV LOW DOSE, GNP ADULT DOSE, EQ ASPIRIN EC, ASPIRIN LOW EQ ASPIRIN LOW DOSE, STRENGTH, EQL ASPIRIN EC, EQL GOODSENSE ASPIRIN, ASPIRIN LOW DOSE, GOODSENSE ASPIRIN PV GNP ASPIRIN, GNP ADULT LOW STRENGTH, ASPIRIN LOW DOSE, HM ASPIRIN, PX ASPIRIN, GOODSENSE ASPIRIN, QC ASPIRIN LOW DOSE, GOODSENSE ASPIRIN QC CHEWABLE ASPIRIN LOW DOSE, H-E-B LOW DOSE, QC ASPIRIN, HM ASPIRIN, CHILDRENS ASPIRIN, RA HM ASPIRIN EC, HM ASPIRIN ADULT LOW ASPIRIN EC LOW DOSE, DOSE, RA ASPIRIN KLS ASPIRIN EC, KLS ADULT LOW STRENGTH, ASPIRIN LOW DOSE, KP RA ASPIRIN CHILDRENS, ASPIRIN, MEIJER RA CHILDRENS ASPIRIN, ASPIRIN EC, MINIPRIN SB CHILDRENS ASPIRIN, LOW DOSE, PX ENTERIC SM ASPIRIN ADULT LOW ASPIRIN, QC ASPIRIN, STRENGTH, SM ASPIRIN QC ASPIRIN LOW DOSE, LOW DOSE, SM QC ENTERIC ASPIRIN, CHILDRENS ASPIRIN, ST RA ASPIRIN EC, RA JOSEPH LOW DOSE ASPIRIN EC ADULT LOW ASPIRIN, TGT ASPIRIN, STRENGTH, SB ASPIRIN, TGT CHILDRENS SB ASPIRIN ADULT LOW ASPIRIN CHEW STRENGTH, SB ASPIRIN EC, SB LOW DOSE ASA You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT, PV (Methadone Hcl) BAYER ADVANCED METHADONE HCL ASPIRIN REGULAR INTENSOL, METHADOSE, 1 STRENGTH, BAYER METHADOSE SUGAR- ASPIRIN, CVS ASPIRIN, FREE CONC EQ ASPIRIN, EQL (Methadone Hcl) 1 ASPIRIN, GNP ASPIRIN, METHADOSE TBSO GOODSENSE ASPIRIN, HM ADULT ASPIRIN, HM PV (Morphine Sulfate) SP PA ASPIRIN, MEDIQUE DURAMORPH SOLN ABSTRAL SUBL PA ASPIRIN, MM ASPIRIN, 3 NORWICH ASPIRIN, PX (fentanyl citrate) ASPIRIN, QC ASPIRIN, RA ACTIQ LPOP (fentanyl PA ASPIRIN, RA PAIN GP RELIEF ASPIRIN, SB citrate) ASPIRIN, SM ASPIRIN, codeine sulfate tabs 1 TGT ASPIRIN TABS CONZIP CP24 ( ASCRIPTIN TABS PV tramadol 3 (aspirin buffered (al hcl) PV hydrox-mg hydrox-ca DILAUDID LIQD OR 1 carb)) MG/ML (hydromorphone GP hcl) aspirin chew PV PV DILAUDID TABS OR 2 aspirin tabs PV PV MG, 4 MG, 8 MG GP (hydromorphone hcl) aspirin tbec PV PV DOLOPHINE TABS QL(12 ea daily) GP (methadone hcl) diflunisal tabs 1 DURAGESIC PT72 100 Limit 15 MCG/HR, 12 MCG/HR, 25 patches per ECOTRIN REGULAR PV GP STRENGTH TBEC GP MCG/HR, 50 MCG/HR month;QL(0.5 (aspirin) (fentanyl) ea daily) EMBEDA CPCR PA GP PV 3 ECOTRIN TBEC (aspirin) (morphine-naltrexone) salsalate tabs 1 EXALGO TB24 12 MG, 16 QL(4 ea daily) MG, 8 MG GP ST JOSEPH ADULT PV (hydromorphone hcl) ANALGESICLOW DOSE GP EXALGO TB24 32 MG QL(2 ea daily) BITE SIZE CHEW 3 (aspirin) (hydromorphone hcl) ST JOSEPH ADULT PV fentanyl citrate lpop bu PA GP CHEW (aspirin) 1200 mcg, 1600 mcg, 1 200 mcg, 400 mcg, 600 ANALGESICS - OPIOID - Drugs to Treat Pain, mcg, 800 mcg Muscle and Joint Conditions fentanyl citrate tabs bu PA; QL(3 ea Opioid Agonists daily) 100 mcg, 200 mcg, 400 1 mcg, 600 mcg, 800 mcg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 15 fentanyl pt72 100 methadone hcl tbso or 1 mcg/hr, 12 mcg/hr, 25 patches per 40 mg 1 month;QL(0.5 mcg/hr, 50 mcg/hr, 75 QL(1 ea daily) ea daily) morphine sulfate beads 1 mcg/hr cp24 FENTORA TABS PA; QL(3 ea QL(1 ea daily) 3 morphine sulfate cp24 1 (fentanyl citrate) daily) or 10 mg hydromorphone hcl liqd 1 morphine sulfate cp24 QL(2 ea daily) 1 mg/ml or 100 mg, 20 mg, 30 1 hydromorphone hcl 1 mg, 50 mg, 60 mg, 80 tabs 2 mg, 4 mg, 8 mg mg hydromorphone hcl QL(4 ea daily) MORPHINE SULFATE ER QL(2 ea daily) tb24 12 mg, 16 mg, 8 1 CP24 (morphine 3 mg sulfate) QL(2 ea daily) PA hydromorphone hcl 1 morphine sulfate soln ij SP tb24 32 mg 0.5 mg/ml, 1 mg/ml KADIAN CP24 10 MG QL(1 ea daily) GP morphine sulfate soln (morphine sulfate) or 10 mg/5ml, 100 1 KADIAN CP24 100 MG, 20 QL(2 ea daily) mg/5ml, 20 mg/5ml, 20 MG, 30 MG, 40 MG, 50 GP mg/ml MG, 60 MG, 80 MG morphine sulfate supp (morphine sulfate) re 10 mg, 20 mg, 30 1 KADIAN CP24 200 MG QL(2 ea daily) 3 mg, 5 mg (morphine sulfate) morphine sulfate tabs 1 LAZANDA SOLN 100 PA or 15 mg, 30 mg MCG/ACT, 400 MCG/ACT 3 (fentanyl citrate) morphine sulfate tbcr or QL(3 ea daily) 100 mg, 15 mg, 200 1 meperidine hcl soln 1 mg, 30 mg, 60 mg MS CONTIN TBCR QL(3 ea daily) meperidine hcl tabs 1 GP (morphine sulfate) methadone hcl conc or NUCYNTA ER TB12 QL(2 ea daily) 1 2 10 mg/ml (tapentadol hcl) methadone hcl soln ij PA NUCYNTA TABS SP 2 10 mg/ml (tapentadol hcl) METHADONE HCL SOLN PA OPANA TABS GP IJ 10 MG/ML (methadone SP (oxymorphone hcl) hcl) OXAYDO TABS 5 MG 2 methadone hcl soln or 1 (oxycodone hcl) 10 mg/5ml, 5 mg/5ml OXAYDO TABS 7.5 MG QL(4 ea daily) 3 QL(12 ea daily) (oxycodone hcl) methadone hcl tabs or 1 10 mg, 5 mg oxycodone hcl caps 5 1 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Oxycodone W/ oxycodone hcl conc 1 100 mg/5ml Acetaminophen) 1 ENDOCET TABS oxycodone hcl soln 5 1 mg/5ml acetaminophen w/ 1 codeine soln oxycodone hcl tabs 10 mg, 15 mg, 20 mg, 30 1 acetaminophen w/ 1 mg, 5 mg codeine tabs butalbital- oxymorphone hcl tabs 1 10 mg, 5 mg acetaminophen- 1 caffeine w/ codeine oxymorphone hcl tb12 QL(2 ea daily) caps 10 mg, 15 mg, 20 mg, 1 30 mg, 40 mg, 5 mg, butalbital-aspirin- 1 7.5 mg caffeine w/cod caps FIORICET/CODEINE QDOLO SOLN (tramadol 3 CAPS (butalbital- hcl) acetaminophen- GP ROXICODONE TABS GP caffeine w/ codeine) (oxycodone hcl) FIORINAL/CODEINE #3 ROXYBOND TABA 5 MG QL(4 ea daily) 3 CAPS (butalbital-aspirin- GP (oxycodone hcl) caffeine w/cod) SUBSYS LIQD (fentanyl) 3 PA hydrocodone- 1 tramadol hcl cp24 100 acetaminophen soln mg, 150 mg, 200 mg, 1 hydrocodone- 1 300 mg acetaminophen tabs hydrocodone-ibuprofen tramadol hcl tabs 100 1 1 mg tabs QL(8 ea daily) LORTAB ELIX tramadol hcl tabs 50 1 mg (hydrocodone- 3 acetaminophen) tramadol hcl tb24 100 1 mg, 200 mg, 300 mg NALOCET TABS (oxycodone w/ 3 ULTRAM TABS ( QL(8 ea daily) tramadol GP acetaminophen) hcl) NORCO TABS Opioid Combinations (hydrocodone- GP (Butalbital-Aspirin-Caffeine acetaminophen) W/Cod) 1 ASCOMP/CODEINE CAPS oxycodone w/ 1 acetaminophen tabs (Hydrocodone- Acetaminophen) LORCET, 1 oxycodone-aspirin tabs 1 LORCET HD, LORCET QL(4 ea daily) PLUS TABS oxycodone-ibuprofen 1 tabs (Hydrocodone-Ibuprofen) 1 IBUDONE TABS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYCODONE/ACETAMIN buprenorphine hcl subl PA; QL(4 ea OPHEN TABS 1 daily) 3 sl 8 mg (oxycodone w/ buprenorphine hcl- PA acetaminophen) naloxone hcl dihydrate PERCOCET TABS 2.5 film 0.5 mg-2 mg, 1 mg- 1 MG-325 MG, 325 MG-5 4 mg, 12 mg-3 mg, 2 MG, 325 MG-7.5 MG GP (oxycodone w/ mg-8 mg acetaminophen) buprenorphine hcl- PA; QL(3 ea daily) PRIMLEV TABS naloxone hcl dihydrate 1 (oxycodone w/ 3 subl 0.5 mg-2 mg acetaminophen) buprenorphine hcl- PA; QL(4 ea PROLATE TABS 10 MG- naloxone hcl dihydrate 1 daily) 300 MG, 300 MG-5 MG, subl 2 mg-8 mg 300 MG-7.5 MG 3 buprenorphine ptwk td Limit 4 per (oxycodone w/ month;QL(0.15 10 mcg/hr, 15 mcg/hr, 1 acetaminophen) 20 mcg/hr, 5 mcg/hr, ea daily) ROXICET SOLN 7.5 mcg/hr (oxycodone w/ 2 Limit 7.5mls acetaminophen) butorphanol tartrate 1 per soln month;QL(0.25 tramadol- 1 acetaminophen tabs ml daily) TYLENOL/CODEINE #3 BUTRANS PTWK Limit 4 per GP month;QL(0.15 TABS (acetaminophen GP (buprenorphine) ea daily) w/ codeine) pentazocine w/ 1 TYLENOL/CODEINE #4 naloxone tabs TABS (acetaminophen GP w/ codeine) SUBOXONE FILM PA (buprenorphine hcl- GP ULTRACET TABS naloxone hcl dihydrate) (tramadol- GP acetaminophen) ZUBSOLV SUBL PA (buprenorphine hcl- 3 Opioid Partial Agonists naloxone hcl dihydrate) BELBUCA FILM QL(2 ea daily) 3 ANDROGENS-ANABOLIC - Drugs to Regulate (buprenorphine hcl) Hormones BUNAVAIL FILM PA Anabolic Steroids (buprenorphine hcl- 3 ANADROL-50 TABS naloxone hcl dihydrate) 3 (oxymetholone) BUPRENEX SOLN PA SP (buprenorphine hcl) oxandrolone tabs 1 PA buprenorphine hcl soln SP Androgens ij 0.3 mg/ml ANDRODERM PT24 ST; QL(1 ea PA; QL(3 ea 3 buprenorphine hcl subl 1 () daily) sl 2 mg daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANDROGEL GEL 20.25 QL(10 gm Intrarectal Steroids MG/1.25GM daily) GP (Hydrocortisone (testosterone) (Intrarectal)) COLOCORT 1 ANDROGEL GEL 25 QL(10 gm ENEM MG/2.5GM, 50 MG/5GM 2 daily) CORTENEMA ENEM (testosterone) (hydrocortisone GP ANDROGEL GEL 40.5 GP (intrarectal)) MG/2.5GM (testosterone) CORTIFOAM FOAM ANDROGEL PUMP GEL QL(10 gm GP (hydrocortisone acetate 2 (testosterone) daily) (intrarectal)) danazol caps 1 hydrocortisone 1 (intrarectal) enem DEPO-TESTOSTERONE UCERIS FOAM RE 2 PA SOLN (testosterone GP cypionate) MG/ACT (budesonide 3 (intrarectal)) FORTESTA GEL QL(4 gm daily) GP (testosterone) Rectal Combinations METHITEST TABS ANALPRAM-HC CREA 1 2 (methyltestosterone) %-1 % (hydrocortisone GP acetate w/ pramoxine) methyltestosterone 1 caps ANALPRAM-HC LOTN 1 %-2.5 % (hydrocortisone 3 STRIANT MISC QL(2 ea daily) 3 acetate w/ pramoxine) (testosterone) TESTIM GEL PA; QL(10 gm hydrocortisone acetate 1 3 (testosterone) daily) w/ pramoxine crea testosterone cypionate lidocaine- soln im 100 mg/ml, 200 1 hydrocortisone acetate 1 mg/ml (rectal) PROCORT CREA testosterone enanthate 1 soln im (hydrocortisone acetate 3 w/ pramoxine) testosterone gel td 1 %, QL(10 gm daily) PROCTOFOAM HC FOAM 1.62 %, 20.25 1 (hydrocortisone acetate 2 mg/1.25gm, 25 w/ pramoxine) mg/2.5gm, 50 mg/5gm QL(4 gm daily) Rectal Steroids testosterone gel td 10 1 mg/act (Hydrocortisone (Rectal)) PROCTO-MED HC, 1 testosterone gel td 40.5 1 PROCTOSOL HC, mg/2.5gm PROCTOZONE-HC CREA QL(6 ml daily) (Hydrocortisone Acetate testosterone soln td 30 1 mg/act (Rectal)) ANUCORT-HC, 1 HEMMOREX-HC SUPP ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone Acetate bacitracin solr SP PA (Rectal)) ANUSOL-HC 1 SUPP RE 25 MG FLAGYL CAPS GP ANUSOL-HC CREA EX 2.5 (metronidazole) % (hydrocortisone GP FLAGYL TABS GP (rectal)) (metronidazole) hydrocortisone (rectal) IMPAVIDO CAPS 1 SP crea (miltefosine) hydrocortisone acetate 1 metronidazole caps 1 (rectal) supp PA PROCTOCORT SUPP metronidazole in nacl SP (hydrocortisone acetate GP soln (rectal)) metronidazole tabs 1 Vasodilating Agents NEBUPENT SOLR RECTIV OINT (pentamidine GP (nitroglycerin (intra- 3 isethionate) anal)) pentamidine isethionate 1 ANTHELMINTICS - Drugs to Treat Worm solr Infections PRIMSOL SOLN 3 Anthelmintics (trimethoprim hcl) albendazole tabs 1 tinidazole tabs 1 ALBENZA TABS GP trimethoprim tabs 1 (albendazole) AL(At least 2 XIFAXAN TABS 200 MG PA; QL(9 ea BENZNIDAZOLE TABS 3 per fill retail,9 3 yrs old - Up to (rifaximin) (benznidazole) 12 yrs old) ea per fill mail) BILTRICIDE TABS XIFAXAN TABS 550 MG PA; QL(2 ea GP 3 (praziquantel) (rifaximin) daily) EMVERM CHEW QL(6 ea per fill Anti-infective Misc. - Combinations 3 retail,6 ea per (Methenamine-Hyosc- (mebendazole) fill mail) Methylene Blue-Benzoic 1 1 Acid-Phenyl Sal) ivermectin tabs HYOPHEN TABS praziquantel tabs 1 (Methenamine-Hyosc- Methylene Blue-Sod Phos- STROMECTOL TABS Phenyl Sal) GP (ivermectin) PHOSPHASAL, URELLE, 1 URETRON D/S, URIN D/S, ANTI-INFECTIVE AGENTS - MISC. - Drugs to URO-458, UROAV-81, Treat Bacterial Infections UTIRA-C, UTRONA-C, Anti-infective Agents - Misc. VILEVEV MB TABS (Bacitracin) BACIIM SOLR SP PA

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Methenamine-Hyosc- Chloramphenicols Methylene Blue-Sod Phos- chloramphenicol PA Phenyl Sal) URIBEL, URO- 1 SP MP, UROAV-B, USTELL, sodium succinate solr UTICAP, VILAMIT MB Cyclic Lipopeptides CAPS CUBICIN RF SOLR PA SP (Sulfamethoxazole- ( ) Trimethoprim) SULFATRIM 1 daptomycin CUBICIN SOLR PA PEDIATRIC SUSP SP BACTRIM DS TABS (daptomycin) (sulfamethoxazole- GP daptomycin solr SP PA trimethoprim) BACTRIM TABS Glycopeptides FIRVANQ SOLR PA (sulfamethoxazole- GP 3 trimethoprim) (vancomycin hcl) VANCOCIN CAPS PA sulfamethoxazole- 1 GP trimethoprim susp (vancomycin hcl) VANCOCIN HCL CAPS PA sulfamethoxazole- 1 GP trimethoprim tabs (vancomycin hcl) PA Antiprotozoal Agents vancomycin hcl caps 1 ALINIA SUSR 100 3 Leprostatics MG/5ML (nitazoxanide) ALINIA TABS 500 MG dapsone tabs 1 GP (nitazoxanide) Lincosamides atovaquone susp 1 CLEOCIN CAPS OR 150 MG, 300 MG, 75 MG GP MEPRON SUSP GP (clindamycin hcl) (atovaquone) CLEOCIN PEDIATRIC nitazoxanide tabs 1 GRANULES SOLR (clindamycin palmitate GP Carbapenems hydrochloride) doripenem solr SP PA CLEOCIN PHOSPHATE PA SOLN IJ 900 MG/6ML SP ertapenem sodium solr SP PA (clindamycin phosphate) PA imipenem-cilastatin solr SP CLEOCIN PHOSPHATE PA INVANZ SOLR PA SOLN IV 600 MG/4ML SP SP (ertapenem sodium) (clindamycin phosphate) meropenem solr SP PA clindamycin hcl caps 1 MERREM SOLR PA SP (meropenem) clindamycin palmitate 1 PRIMAXIN IV SOLR PA hydrochloride solr SP (imipenem-cilastatin) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA clindamycin phosphate SP methenamine in d5w soln mandelate tabs 0.5 gm, 1 PA 1 gm clindamycin phosphate SP soln MONUROL PACK LINCOCIN SOLN PA (fosfomycin GP SP (lincomycin hcl) tromethamine) nitrofurantoin lincomycin hcl soln SP PA 1 macrocrystal caps Oxazolidinones nitrofurantoin monohyd 1 macro caps linezolid susr 100 1 mg/5ml nitrofurantoin susp 1 QL(20 ea per linezolid tabs 600 mg 1 90 days ANTIANGINAL AGENTS - Drugs to Treat Chest retail,20 ea per Pain 90 days mail) Antianginals-Other SIVEXTRO TABS QL(6 ea per 90 2 RANEXA TB12 1000 MG (tedizolid phosphate) days retail) GP (ranolazine) ZYVOX SUSR 100 GP RANEXA TB12 500 MG QL(4 ea daily) MG/5ML (linezolid) GP (ranolazine) QL(20 ea per ZYVOX TABS 600 MG ranolazine tb12 1000 GP 90 days 1 (linezolid) retail,20 ea per mg 90 days mail) ranolazine tb12 500 mg 1 QL(4 ea daily) Polymyxins Nitrates polymyxin b sulfate solr SP PA (Nitroglycerin) MINITRAN 1 QL(1 ea daily) Urinary Anti-infectives PT24 (Nitroglycerin) NITRO- fosfomycin 1 1 tromethamine pack TIME CPCR DILATRATE SR CPCR FURADANTIN SUSP 3 GP (isosorbide dinitrate) (nitrofurantoin) GONITRO PACK PA HIPREX TABS 3 (nitroglycerin) (methenamine GP ISORDIL TITRADOSE hippurate) TABS (isosorbide GP MACROBID CAPS dinitrate) (nitrofurantoin monohyd GP macro) isosorbide dinitrate tabs 1 MACRODANTIN CAPS 1 (nitrofurantoin GP isosorbide dinitrate tbcr macrocrystal) isosorbide mononitrate 1 tabs methenamine hippurate 1 tabs isosorbide mononitrate 1 tb24 You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITRO-BID OINT 2 Benzodiazepines (nitroglycerin) (Alprazolam) 1 NITRO-DUR PT24 0.1 QL(1 ea daily) ALPRAZOLAM XR TB24 MG/HR, 0.2 MG/HR, 0.4 GP (Diazepam) DIAZEPAM 1 MG/HR, 0.6 MG/HR INTENSOL CONC (nitroglycerin) (Lorazepam) LORAZEPAM 1 NITRO-DUR PT24 0.3 QL(1 ea daily) INTENSOL CONC MG/HR, 0.8 MG/HR 2 ALPRAZOLAM INTENSOL 3 (nitroglycerin) CONC (alprazolam) nitroglycerin cpcr or 2.5 1 mg, 9 mg alprazolam tabs 1 nitroglycerin pt24 td 0.1 QL(1 ea daily) alprazolam tb24 1 mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr alprazolam tbdp 1 nitroglycerin soln tl 0.4 ATIVAN TABS 0.5 MG, 2 1 GP mg/spray MG (lorazepam) nitroglycerin subl sl 0.3 1 chlordiazepoxide hcl 1 mg, 0.4 mg, 0.6 mg caps NITROLINGUAL clorazepate 1 PUMPSPRAY SOLN GP dipotassium tabs (nitroglycerin) NITROMIST AERS diazepam conc 1 3 (nitroglycerin) diazepam soln 1 NITROSTAT SUBL GP (nitroglycerin) diazepam tabs 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety lorazepam conc 1 Antianxiety Agents - Misc. lorazepam tabs 1 buspirone hcl tabs 1 oxazepam caps 10 mg, PA 1 hydroxyzine hcl soln im SP 15 mg, 30 mg 25 mg/ml, 50 mg/ml TRANXENE T TABS hydroxyzine hcl syrp or 1 (clorazepate GP 10 mg/5ml dipotassium) hydroxyzine hcl tabs or VALIUM TABS 10 MG, 2 1 GP 10 mg, 25 mg, 50 mg MG (diazepam) XANAX TABS hydroxyzine pamoate 1 GP caps (alprazolam) XANAX XR TB24 meprobamate tabs 1 GP (alprazolam) VISTARIL CAPS GP ANTIARRHYTHMICS - Drugs to treat abnormal (hydroxyzine pamoate) heart rhythms

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTAQ TABS Antiarrhythmics Type I-A 2 disopyramide (dronedarone hcl) 1 TIKOSYN CAPS phosphate caps GP NORPACE CAPS (dofetilide) (disopyramide GP ANTIASTHMATIC AND BRONCHODILATOR phosphate) AGENTS - Drugs to Treat Lung Conditions NORPACE CR CP12 100 Anti-Inflammatory Agents MG (disopyramide 2 cromolyn sodium nebu 1 phosphate) NORPACE CR CP12 150 CROMOLYN SODIUM MG (disopyramide 3 NEBU (cromolyn 2 phosphate) sodium) procainamide hcl soln SP PA Antiasthmatic - Monoclonal Antibodies XOLAIR SOLR PA SP quinidine gluconate 1 (omalizumab) tbcr XOLAIR SOSY PA SP quinidine sulfate tabs 1 (omalizumab) Bronchodilators - Anticholinergics Antiarrhythmics Type I-B Limit 2 inhalers mexiletine hcl caps 150 ATROVENT HFA AERS 1 ( 2 per mg, 200 mg, 250 mg ipratropium bromide month;QL(0.86 hfa) Antiarrhythmics Type I-C gm daily) INCRUSE ELLIPTA AEPB Limit 1 inhaler flecainide acetate tabs 1 2 per month;QL(1 (umeclidinium bromide) ea daily) propafenone hcl cp12 225 mg, 325 mg, 425 1 ipratropium bromide 1 mg soln QL(6 ea daily) SPIRIVA HANDIHALER QL(1 ea daily) propafenone hcl tabs 1 150 mg CAPS (tiotropium 2 bromide monohydrate) QL(3 ea daily) propafenone hcl tabs 1 Limit 1 inhaler 225 mg, 300 mg SPIRIVA RESPIMAT AERS ( 2 per RYTHMOL SR CP12 tiotropium month;QL(0.14 GP ) (propafenone hcl) bromide monohydrate gm daily) Antiarrhythmics Type III Leukotriene Modulators ACCOLATE TABS (Amiodarone Hcl) 1 GP PACERONE TABS (zafirlukast) QL(1 ea daily) amiodarone hcl tabs 1 montelukast sodium 1 chew CORDARONE TABS GP montelukast sodium QL(1 ea daily) (amiodarone hcl) 1 pack dofetilide caps 1 QL(1 ea daily) montelukast sodium 1 tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SINGULAIR CHEW 4 MG, QL(1 ea daily) FLOVENT DISKUS AEPB QL(8 ea daily) 5 MG ( 250 MCG/BLIST montelukast GP 2 sodium) (fluticasone propionate SINGULAIR PACK 4 MG QL(1 ea daily) (inhalation)) GP (montelukast sodium) FLOVENT DISKUS AEPB QL(40 ea daily) 50 MCG/BLIST zafirlukast tabs 1 (fluticasone propionate 2 (inhalation)) zileuton tb12 1 ST FLOVENT HFA AERO 110 Limit 2 inhalers ZYFLO TABS (zileuton) 3 ST MCG/ACT, 220 MCG/ACT per (fluticasone propionate 2 month;QL(0.8 Selective Phosphodiesterase 4 (PDE4) Inhibitors hfa) gm daily) DALIRESP TABS QL(1 ea daily) Limit 1 inhaler 3 FLOVENT HFA AERO 44 (roflumilast) MCG/ACT ( 2 per fluticasone month;QL(0.36 Steroid Inhalants propionate hfa) gm daily) ARMONAIR DIGIHALER QL(0.04 ea PULMICORT FLEXHALER Limit 2 inhalers AEPB (fluticasone 3 daily) AEPB 180 MCG/ACT per propionate (inhalation)) (budesonide 2 month;QL(0.07 ARMONAIR RESPICLICK QL(0.04 ea (inhalation)) ea daily) 113 AEPB (fluticasone 3 daily) PULMICORT FLEXHALER Limit 8 inhalers propionate (inhalation)) AEPB 90 MCG/ACT per 2 ARMONAIR RESPICLICK QL(0.04 ea (budesonide month;QL(0.27 232 AEPB (fluticasone 3 daily) (inhalation)) ea daily) propionate (inhalation)) PULMICORT SUSP 0.5 QL(4 ml daily) ARMONAIR RESPICLICK QL(0.04 ea MG/2ML (budesonide GP 55 AEPB (fluticasone 3 daily) (inhalation)) propionate (inhalation)) PULMICORT SUSP 1 QL(2 ml daily) ARNUITY ELLIPTA AEPB QL(1 ea daily) MG/2ML (budesonide GP (fluticasone furoate 2 (inhalation)) (inhalation)) QVAR REDIHALER AERB Limit 1 inhaler QL(8 ml daily) 40 MCG/ACT per budesonide (inhalation) 1 2 susp 0.25 mg/2ml (beclomethasone month;QL(0.36 dipropionate hfa) gm daily) budesonide (inhalation) QL(4 ml daily) 1 QVAR REDIHALER AERB Limit 2 Inhalers susp 0.5 mg/2ml 80 MCG/ACT per QL(2 ml daily) 2 budesonide (inhalation) 1 (beclomethasone month;QL(0.72 susp 1 mg/2ml dipropionate hfa) gm daily) FLOVENT DISKUS AEPB QL(20 ea daily) Sympathomimetics 100 MCG/BLIST 2 (fluticasone propionate (Fluticasone-Salmeterol) 1 QL(2 ea daily) WIXELA INHUB AEPB (inhalation)) ADVAIR DISKUS AEPB QL(2 ea daily) GP (fluticasone-salmeterol)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 inhaler SP PA ADVAIR HFA AERO epinephrine hcl soln 2 per (fluticasone-salmeterol) month;QL(0.4 fluticasone-salmeterol QL(2 ea daily) gm daily) aepb 100 mcg/dose-50 Limit 2 inhalers mcg/dose, 250 albuterol sulfate aers in 1 per mcg/dose-50 1 108 mcg/act month;QL(0.57 gm daily) mcg/dose, 50 mcg/dose-500 albuterol sulfate aers in QL(1.2 gm 1 mcg/dose 108 mcg/act daily) ipratropium-albuterol albuterol sulfate aers in QL(0.45 gm 1 1 soln 108 mcg/act daily) albuterol sulfate nebu levalbuterol hcl nebu 1 in 0.083 %, 0.5 %, 0.63 1 levalbuterol tartrate Limit 2 inhalers mg/3ml, 1.25 mg/3ml, 1 per month;QL(1 2.5 mg/0.5ml aero gm daily) ALBUTEROL SULFATE metaproterenol sulfate 1 NEBU IN 0.5 % (albuterol 2 tabs sulfate) PERFOROMIST NEBU QL(4 ml daily) 3 (formoterol fumarate) albuterol sulfate syrp or 1 2 mg/5ml Limit 2 inhalers PROAIR HFA AERS albuterol sulfate tabs or 1 per 1 (albuterol sulfate) month;QL(0.57 2 mg, 4 mg gm daily) QL(2 ea daily) albuterol sulfate tb12 or 1 Limit 2 inhalers PROAIR RESPICLICK 4 mg, 8 mg 3 per ANORO ELLIPTA AEPB QL(2 ea daily) AEPB (albuterol sulfate) month;QL(0.07 (umeclidinium- 2 ea daily) vilanterol) Limit 2 inhalers PROVENTIL HFA AERS 1 per ARCAPTA NEOHALER QL(1 ea daily) (albuterol sulfate) month;QL(0.45 CAPS (indacaterol 3 gm daily) maleate) SEREVENT DISKUS QL(2 ea daily) BREO ELLIPTA AEPB QL(2 ea daily) AEPB (salmeterol 2 (fluticasone furoate- 2 xinafoate) vilanterol) STIOLTO RESPIMAT Limit 1 inhaler BROVANA NEBU per 3 AERS (tiotropium 2 (arformoterol tartrate) month;QL(0.14 bromide-olodaterol hcl) gm daily) budesonide-formoterol Limit 1 inhaler per Limit 1 inhaler fumarate dihydrate 1 STRIVERDI RESPIMAT month;QL(0.34 2 per aero gm daily) AERS (olodaterol hcl) month;QL(0.14 gm daily) COMBIVENT RESPIMAT Limit 1 inhaler AERS ( 3 per ipratropium- month;QL(0.2 albuterol) gm daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYMBICORT AERO Limit 1 inhaler Coumarin Anticoagulants ( 2 per budesonide-formoterol month;QL(0.34 (Warfarin Sodium) 1 JANTOVEN TABS fumarate dihydrate) gm daily) COUMADIN TABS GP terbutaline sulfate tabs 1 (warfarin sodium) TRELEGY ELLIPTA AEPB QL(2 ea daily) warfarin sodium tabs 1 100 MCG/INH-25 MCG/INH-62.5 MCG/INH 2 Direct Factor Xa Inhibitors (fluticasone- BEVYXXA CAPS QL(42 ea per 3 umeclidinium-vilanterol) (betrixaban maleate) 42 days retail) TRELEGY ELLIPTA AEPB 1 inhaler per ELIQUIS STARTER PACK 2 200 MCG/INH-25 month;QL(2 ea TBPK (apixaban) MCG/INH-62.5 MCG/INH 2 daily) ELIQUIS TABS (fluticasone- 2 umeclidinium-vilanterol) (apixaban) Limit 2 inhalers XARELTO STARTER VENTOLIN HFA AERS PACK TBPK 2 1 per (albuterol sulfate) month;QL(0.54 (rivaroxaban) gm daily) XARELTO TABS 10 MG, Limit 2 inhalers 15 MG, 20 MG 2 VENTOLIN HFA AERS ( ) 1 per rivaroxaban (albuterol sulfate) month;QL(1.2 gm daily) Heparins And Heparinoid-Like Agents ARIXTRA SOLN PA; XOPENEX SP CONCENTRATE NEBU GP (fondaparinux sodium) QL(3 ml per 10 (levalbuterol hcl) enoxaparin sodium SP soln ij 300 mg/3ml days retail) XOPENEX HFA AERO Limit 2 inhalers 1 per month;QL(1 (levalbuterol tartrate) enoxaparin sodium QL(20 ml per gm daily) soln sc 100 mg/ml, 150 SP 10 days retail) XOPENEX NEBU GP mg/ml (levalbuterol hcl) enoxaparin sodium QL(16 ml per Xanthines soln sc 120 mg/0.8ml, SP 10 days retail) aminophylline soln SP PA 80 mg/0.8ml enoxaparin sodium QL(6 ml per 10 ELIXOPHYLLIN ELIX SP 3 soln sc 30 mg/0.3ml days retail) (theophylline) QL(8 ml per 10 THEO-24 CP24 enoxaparin sodium SP 2 days retail) (theophylline) soln sc 40 mg/0.4ml QL(12 ml per enoxaparin sodium SP theophylline soln 1 soln sc 60 mg/0.6ml 10 days retail) PA; theophylline tb12 1 fondaparinux sodium SP soln theophylline tb24 1 FRAGMIN SOLN 10000 QL(20 ml per UNIT/ML (dalteparin SP 365 days retail) ANTICOAGULANTS - Blood Thinners sodium) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FRAGMIN SOLN 12500 QL(10 ml per LOVENOX SOLN IJ 300 QL(3 ml per 10 UNIT/0.5ML (dalteparin SP 365 days retail) MG/3ML (enoxaparin SP days retail) sodium) sodium) FRAGMIN SOLN 15000 QL(12 ml per LOVENOX SOLN SC 100 QL(20 ml per UNIT/0.6ML (dalteparin SP 365 days retail) MG/ML, 150 MG/ML SP 10 days retail) sodium) (enoxaparin sodium) FRAGMIN SOLN 18000 QL(14 ml per LOVENOX SOLN SC 120 QL(16 ml per UNT/0.72ML (dalteparin SP 365 days retail) MG/0.8ML, 80 MG/0.8ML SP 10 days retail) sodium) (enoxaparin sodium) FRAGMIN SOLN 2500 QL(4 ml per LOVENOX SOLN SC 30 QL(6 ml per 10 UNIT/0.2ML, 5000 365 days retail) MG/0.3ML (enoxaparin SP days retail) UNIT/0.2ML (dalteparin SP sodium) sodium) LOVENOX SOLN SC 40 QL(8 ml per 10 FRAGMIN SOLN 7500 QL(6 ml per MG/0.4ML (enoxaparin SP days retail) UNIT/0.3ML (dalteparin SP 365 days retail) sodium) sodium) LOVENOX SOLN SC 60 QL(12 ml per FRAGMIN SOLN 95000 PA MG/0.6ML (enoxaparin SP 10 days retail) UNIT/3.8ML (dalteparin SP sodium) ) sodium ANTICONVULSANTS - Drugs to Treat Seizures heparin (porcine) in SP sodium chloride soln AMPA Glutamate Receptor Antagonists FYCOMPA SUSP heparin sod (porcine) in SP 3 d5w soln (perampanel) FYCOMPA TABS heparin sodium 3 SP (perampanel) (porcine) soln HEPARIN SODIUM/NACL Anticonvulsants - Benzodiazepines 0.45% SOLN (heparin SP clobazam susp 1 (porcine) in sodium chloride) clobazam tabs 1 HEPARIN SODIUM/SODIUM clonazepam tabs 1 CHLORIDE 0.9% SOLN SP (heparin (porcine) in clonazepam tbdp 1 sodium chloride) DIASTAT ACUDIAL GEL Limit 4 per HEPARIN (diazepam 3 month;QL(0.14 SODIUM/SODIUM ea daily) CHLORIDE SOLN 0.45 %- (anticonvulsant)) 25000 UNIT/250ML, 0.45 DIASTAT PEDIATRIC GEL Limit 4 per %-25000 UNIT/500ML, 0.9 SP (diazepam 3 month;QL(0.14 %-1000 UNIT/500ML, 0.9 (anticonvulsant)) ea daily) %-2000 UNIT/L (heparin diazepam Limit 4 per (porcine) in sodium (anticonvulsant) gel 10 3 month;QL(0.14 chloride) mg ea daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 4 per BRIVIACT SOLN PA diazepam 3 (anticonvulsant) gel 2.5 1 month;QL(0.14 (brivaracetam) mg, 20 mg ea daily) BRIVIACT TABS PA 3 KLONOPIN TABS (brivaracetam) GP (clonazepam) carbamazepine chew 1 NAYZILAM SOLN PA; QL(10 ea (midazolam SP per 30 days carbamazepine cp12 1 (anticonvulsant)) retail) carbamazepine susp 1 ONFI SUSP (clobazam) GP carbamazepine tabs 1 ONFI TABS (clobazam) GP VALTOCO LIQD PA; QL(10 ea carbamazepine tb12 1 (diazepam SP per 30 days CARBATROL CP12 3 (anticonvulsant)) retail) (carbamazepine) VALTOCO LQPK PA; QL(10 ea DIACOMIT CAPS 250 MG PA; QL(12 ea SP (diazepam SP per 30 days (stiripentol) daily) retail) (anticonvulsant)) DIACOMIT CAPS 500 MG PA; QL(6 ea SP Anticonvulsants - Misc. (stiripentol) daily) (Carbamazepine) EPITOL DIACOMIT PACK 250 MG PA; QL(12 ea 1 SP TABS (stiripentol) daily) (Lamotrigine) SUBVENITE DIACOMIT PACK 500 MG PA; QL(6 ea SP STARTER KIT/BLUE, (stiripentol) daily) SUBVENITE STARTER 1 EPIDIOLEX SOLN PA KIT/GREEN, SUBVENITE SP STARTER KIT/ORANGE (cannabidiol) KIT gabapentin caps 1 (Lamotrigine) SUBVENITE 1 TABS gabapentin soln 1 (Levetiracetam) 1 ROWEEPRA TABS gabapentin tabs 1 (Levetiracetam) 1 KEPPRA SOLN IV 500 PA ROWEEPRA XR TB24 SP MG/5ML (levetiracetam) APTIOM TABS 200 MG, QL(2 ea daily) KEPPRA SOLN OR 100 400 MG, 600 MG 3 (eslicarbazepine 3 MG/ML (levetiracetam) acetate) KEPPRA TABS OR 1000 APTIOM TABS 800 MG QL(1 ea daily) MG, 250 MG, 500 MG, 750 3 (eslicarbazepine 3 MG (levetiracetam) KEPPRA XR TB24 acetate) 3 BANZEL SUSP 40 MG/ML (levetiracetam) GP (rufinamide) LAMICTAL CHEWABLE DISPERSIBLE CHEW BANZEL TABS 200 MG, 3 2 (lamotrigine) 400 MG (rufinamide)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL ODT KIT PA PA 3 lamotrigine tb24 250 1 (lamotrigine) mg LAMICTAL ODT KIT PA GP lamotrigine tb24 300 1 (lamotrigine) mg LAMICTAL ODT TBDP 100 PA lamotrigine tbdp 100 PA MG, 200 MG, 25 MG, 50 3 mg, 200 mg, 25 mg, 50 1 MG (lamotrigine) mg LAMICTAL STARTER/NOT PA TAKING levetiracetam soln iv SP CARBAMAZEPINE KIT GP 500 mg/5ml (lamotrigine) levetiracetam soln or 1 LAMICTAL 100 mg/ml, 500 mg/5ml STARTER/TAKING levetiracetam tabs or CARBAMAZEPINE/NOT GP 1 TAKING VALPROATE KIT 1000 mg, 250 mg, 500 (lamotrigine) mg, 750 mg LAMICTAL levetiracetam tb24 or 1 STARTER/TAKING 500 mg, 750 mg GP VALPROATE KIT LYRICA CAPS 100 MG, PA; QL(3 ea (lamotrigine) 200 MG, 25 MG, 50 MG, 3 daily) LAMICTAL TABS 75 MG (pregabalin) 3 (lamotrigine) LYRICA CAPS 150 MG, PA; QL(2 ea LAMICTAL XR KIT PA 225 MG, 300 MG 3 daily) 3 (lamotrigine) (pregabalin) LYRICA SOLN 20 MG/ML PA LAMICTAL XR TB24 100 PA; QL(1 ea 3 MG, 200 MG, 25 MG, 50 3 daily) (pregabalin) MG (lamotrigine) MYSOLINE TABS 3 LAMICTAL XR TB24 250 PA (primidone) 3 MG (lamotrigine) NEURONTIN CAPS 3 LAMICTAL XR TB24 300 (gabapentin) 3 MG (lamotrigine) NEURONTIN SOLN 3 lamotrigine chew 25 (gabapentin) 1 NEURONTIN TABS mg, 5 mg 3 (gabapentin) lamotrigine kit 1 PA oxcarbazepine susp 1 lamotrigine kit 25 mg, 1 oxcarbazepine tabs 1 lamotrigine tabs 100 OXTELLAR XR TB24 mg, 150 mg, 200 mg, 1 3 25 mg (oxcarbazepine) lamotrigine tb24 100 PA; QL(1 ea pregabalin caps 100 PA; QL(3 ea daily) mg, 200 mg, 25 mg, 50 1 daily) mg, 200 mg, 25 mg, 50 1 mg mg, 75 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea ZONEGRAN CAPS pregabalin caps 150 1 3 mg, 225 mg, 300 mg daily) (zonisamide) PA pregabalin soln 20 1 zonisamide caps 1 mg/ml Carbamates primidone tabs 1 felbamate susp 1 QUDEXY XR CS24 PA 3 (topiramate) felbamate tabs 1 rufinamide susp 1 FELBATOL SUSP 3 TEGRETOL SUSP (felbamate) 3 FELBATOL TABS (carbamazepine) 3 TEGRETOL TABS (felbamate) 3 (carbamazepine) GABA Modulators TEGRETOL-XR TB12 100 (Vigabatrin) VIGADRONE GP 1 MG (carbamazepine) PACK GABITRIL TABS 12 MG, TEGRETOL-XR TB12 200 3 MG, 400 MG 3 16 MG (tiagabine hcl) (carbamazepine) GABITRIL TABS 2 MG, 4 GP TOPAMAX SPRINKLE MG (tiagabine hcl) 3 CPSP (topiramate) SABRIL PACK GP TOPAMAX TABS (vigabatrin) 3 (topiramate) SABRIL TABS GP (vigabatrin) topiramate cpsp 15 mg, 1 25 mg tiagabine hcl tabs 1 topiramate cs24 100 PA mg, 150 mg, 200 mg, 1 vigabatrin pack 1 25 mg, 50 mg vigabatrin tabs 1 topiramate tabs 100 mg, 200 mg, 25 mg, 50 1 Hydantoins mg (Phenytoin) PHENYTOIN 1 TRILEPTAL SUSP INFATABS CHEW 3 ) CEREBYX SOLN PA (oxcarbazepine SP TRILEPTAL TABS (fosphenytoin sodium) 3 (oxcarbazepine) DILANTIN CAPS 100 MG TROKENDI XR CP24 PA (phenytoin sodium 3 3 (topiramate) extended) VIMPAT SOLN DILANTIN CAPS 30 MG 2 (lacosamide) (phenytoin sodium 2 VIMPAT TABS extended) 2 DILANTIN INFATABS (lacosamide) 3 CHEW (phenytoin)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILANTIN-125 SUSP 3 valproic acid caps or 1 (phenytoin) PA ANTIDEPRESSANTS - Drugs to Treat fosphenytoin sodium SP soln Depression PEGANONE TABS Alpha-2 Receptor Antagonists (Tetracyclics) 3 (ethotoin) mirtazapine tabs 1 PHENYTEK CAPS (phenytoin sodium 3 mirtazapine tbdp 1 extended) REMERON SOLTAB TBDP GP phenytoin chew 1 (mirtazapine) REMERON TABS phenytoin sodium GP 1 (mirtazapine) extended caps PA Antidepressants - Misc. phenytoin sodium soln SP APLENZIN TB24 ST; QL(1 ea daily) phenytoin susp 1 (bupropion 3 hydrobromide) Succinimides bupropion hcl tabs 100 1 CELONTIN CAPS 2 mg, 75 mg (methsuximide) bupropion hcl tb12 100 1 ethosuximide caps 1 mg, 150 mg, 200 mg QL(1 ea daily) bupropion hcl tb24 150 1 ethosuximide soln 1 mg, 300 mg ZARONTIN CAPS ST; QL(1 ea 3 bupropion hcl tb24 450 1 (ethosuximide) mg daily) ZARONTIN SOLN FORFIVO XL TB24 ST; QL(1 ea 3 3 (ethosuximide) (bupropion hcl) daily) Valproic Acid maprotiline hcl tabs 1 DEPAKENE CAPS 250 MG 3 WELLBUTRIN SR TB12 (valproic acid) GP 100 MG (bupropion hcl) DEPAKOTE ER TB24 3 WELLBUTRIN XL TB24 QL(1 ea daily) (divalproex sodium) GP 300 MG (bupropion hcl) DEPAKOTE SPRINKLES CSDR (divalproex 3 Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 QL(1 ea daily) sodium) 3 DEPAKOTE TBEC () 3 MARPLAN TABS (divalproex sodium) 3 (isocarboxazid) divalproex sodium csdr 1 NARDIL TABS GP divalproex sodium tb24 1 (phenelzine sulfate) divalproex sodium tbec 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARNATE TABS ST; QL(1 ea fluoxetine hcl tabs 60 1 (tranylcypromine GP mg daily) sulfate) FLUOXETINE ST; QL(1 ea phenelzine sulfate tabs 1 HYDROCHLORIDE TABS 3 daily) 60 MG (fluoxetine hcl) tranylcypromine sulfate 1 fluvoxamine maleate 1 tabs cp24 Selective Serotonin Reuptake Inhibitors (SSRIs) fluvoxamine maleate 1 CELEXA TABS 10 MG QL(4 ea daily) tabs (citalopram GP LEXAPRO TABS 5 MG GP hydrobromide) (escitalopram oxalate) CELEXA TABS 20 MG QL(2 ea daily) 1 (citalopram GP paroxetine hcl tabs hydrobromide) paroxetine hcl tb24 1 CELEXA TABS 40 MG QL(1 ea daily) PAXIL CR TB24 12.5 MG, (citalopram GP GP hydrobromide) 25 MG (paroxetine hcl) citalopram QL(20 ml daily) PAXIL TABS 10 MG, 30 hydrobromide soln 10 1 MG, 40 MG (paroxetine GP mg/5ml hcl) PEXEVA TABS citalopram QL(4 ea daily) 3 (paroxetine mesylate) hydrobromide tabs 10 1 PROZAC CAPS mg GP (fluoxetine hcl) citalopram QL(2 ea daily) hydrobromide tabs 20 1 sertraline hcl conc 1 mg sertraline hcl tabs 1 citalopram QL(1 ea daily) ZOLOFT CONC 20 MG/ML hydrobromide tabs 40 1 GP mg (sertraline hcl) ZOLOFT TABS 25 MG, 50 escitalopram oxalate 1 GP soln MG (sertraline hcl) Serotonin Modulators escitalopram oxalate 1 tabs nefazodone hcl tabs 1 fluoxetine hcl caps 10 1 mg, 20 mg, 40 mg trazodone hcl tabs 1 fluoxetine hcl cpdr 90 TRINTELLIX TABS ST; QL(1 ea 1 3 mg (vortioxetine hbr) daily) VIIBRYD STARTER PACK ST fluoxetine hcl soln 20 1 3 mg/5ml KIT (vilazodone hcl) VIIBRYD TABS ST fluoxetine hcl tabs 10 1 3 mg, 20 mg (vilazodone hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Serotonin-Norepinephrine Reuptake Inhibitors desipramine hcl tabs 1 CYMBALTA CPEP 20 MG QL(2 ea daily) GP (duloxetine hcl) doxepin hcl caps 1 DESVENLAFAXINE ER ST; QL(1 ea 3 doxepin hcl conc 1 TB24 (desvenlafaxine) daily) desvenlafaxine 1 imipramine hcl tabs 1 succinate tb24 imipramine pamoate 1 1 ST; QL(1 ea desvenlafaxine tb24 daily) caps QL(2 ea daily) NORPRAMIN TABS duloxetine hcl cpep 20 1 GP mg, 30 mg, 60 mg (desipramine hcl) EFFEXOR XR CP24 37.5 QL(1 ea daily) nortriptyline hcl caps 10 MG, 75 MG (venlafaxine GP mg, 25 mg, 50 mg, 75 1 hcl) mg PAMELOR CAPS FETZIMA CP24 120 MG, ST; QL(1 ea GP 40 MG, 80 MG 3 daily) (nortriptyline hcl) (levomilnacipran hcl) protriptyline hcl tabs 10 1 FETZIMA CP24 20 MG ST; QL(2 ea mg, 5 mg 3 (levomilnacipran hcl) daily) SURMONTIL CAPS GP FETZIMA TITRATION ST (trimipramine maleate) PACK C4PK 3 TOFRANIL TABS GP (levomilnacipran hcl) (imipramine hcl) KHEDEZLA TB24 ST; QL(1 ea 3 trimipramine maleate 1 (desvenlafaxine) daily) caps QL(2 ea daily) venlafaxine hcl cp24 1 ANTIDIABETICS - Drugs to Regulate Blood 150 mg Sugar QL(1 ea daily) venlafaxine hcl cp24 1 Alpha-Glucosidase Inhibitors 37.5 mg, 75 mg venlafaxine hcl tabs acarbose tabs 1 100 mg, 25 mg, 37.5 1 GLYSET TABS (miglitol) GP mg, 50 mg, 75 mg MIGLITOL TABS venlafaxine hcl tb24 3 (miglitol) 150 mg, 225 mg, 37.5 1 PRECOSE TABS mg, 75 mg GP (acarbose) Tricyclic Agents Antidiabetic - Amylin Analogs hcl tabs 1 SYMLINPEN 120 SOPN PA 3 (pramlintide acetate) amoxapine tabs 1 SYMLINPEN 60 SOPN PA ANAFRANIL CAPS SP GP (pramlintide acetate) (clomipramine hcl) Antidiabetic Combinations clomipramine hcl caps 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTOPLUS MET TABS XULTOPHY 100/3.6 SOPN PA (pioglitazone hcl- GP (insulin degludec- SP metformin hcl) liraglutide) ACTOPLUS MET XR TB24 Biguanides (pioglitazone hcl- 3 GLUCOPHAGE TABS GP metformin hcl) (metformin hcl) DUETACT TABS GLUCOPHAGE XR TB24 GP (pioglitazone hcl- GP (metformin hcl) glimepiride) GLUMETZA TB24 PA SP glipizide-metformin hcl 1 (metformin hcl) tabs metformin hcl soln 500 1 glyburide-metformin 1 mg/5ml tabs metformin hcl tabs GLYXAMBI TABS 1000 mg, 500 mg, 850 1 (empagliflozin- 2 mg linagliptin) PA metformin hcl tb24 SP JANUMET TABS 1000 mg, 500 mg (sitagliptin-metformin 2 hcl) metformin hcl tb24 500 1 mg, 750 mg JANUMET XR TB24 (sitagliptin-metformin 2 METFORMIN HYDROCHLORIDE SOLN 1 hcl) (metformin hcl) pioglitazone hcl- RIOMET SOLN 1 3 glimepiride tabs (metformin hcl) pioglitazone hcl- 1 metformin hcl tabs Diabetic Other BAQSIMI ONE PACK QL(0.069 ea 2 repaglinide-metformin 1 POWD (glucagon) daily) hcl tabs BAQSIMI TWO PACK QL(0.069 ea 2 SOLIQUA 100/33 SOPN PA POWD (glucagon) daily) (insulin glargine- SP lixisenatide) diazoxide susp 1 SYNJARDY TABS GLUCAGEN HYPOKIT (empagliflozin- 2 SOLR (glucagon hcl 2 metformin hcl) (rdna)) SYNJARDY XR TB24 GLUCAGON (empagliflozin- 2 EMERGENCY KIT FOR 2 metformin hcl) LOW BLOOD SUGAR XIGDUO XR TB24 SOLR (glucagon hcl) (dapagliflozin- 2 GLUCAGON metformin hcl) EMERGENCY KIT KIT 2 (glucagon (rdna))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GVOKE PFS SOSY QL(0.02 ml (Insulin Lispro) HUMALOG Limit 3 boxes 2 daily) per (glucagon) KWIKPEN SOPN 100 1 KORLYM TABS PA UNIT/ML month;QL(1.5 ml daily) (mifepristone SP Limit 4 boxes (hyperglycemia)) (Insulin Lispro) HUMALOG per PROGLYCEM SUSP KWIKPEN SOPN 200 1 GP UNIT/ML month;QL(0.8 (diazoxide) ml daily) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Limit 4 vials per (Insulin Lispro) HUMALOG 1 month;QL(1.5 JANUVIA TABS SOLN 2 ml daily) (sitagliptin phosphate) Limit 3 boxes Dopamine Receptor Agonists - Antidiabetic (Insulin Nph (Human) 1 per (Isophane)) HUMULIN N month;QL(1.5 CYCLOSET TABS KWIKPEN SUPN (bromocriptine 3 ml daily) mesylate (diabetes)) (Insulin Nph (Human) Limit 4 vials per (Isophane)) HUMULIN N 1 month;QL(1.5 Incretin Mimetic Agents (GLP-1 Receptor SUSP ml daily) OZEMPIC SOPN PA SP (Insulin Nph Isophane & Limit 45mls per (semaglutide) Reg (Human)) HUMULIN 1 month;QL(1.5 TANZEUM PEN PA 70/30 KWIKPEN SUPN ml daily) SP (albiglutide) (Insulin Nph Isophane & Limit 4 vials per Reg (Human)) HUMULIN 1 month;QL(1.5 TRULICITY SOPN PA SP 70/30 SUSP ml daily) (dulaglutide) Limit 3 boxes VICTOZA SOPN PA (Insulin Regular (Human)) SP 1 per (liraglutide) HUMULIN R U-500 month;QL(1.5 KWIKPEN SOPN Insulin Sensitizing Agents ml daily) ACTOS TABS (Insulin Regular (Human)) Limit 4 vials per GP HUMULIN R, HUMULIN R 1 month;QL(1.5 (pioglitazone hcl) U-500 (CONCENTRATED) ml daily) AVANDIA TABS 2 SOLN (rosiglitazone maleate) (Insulin Regular (Human)) Limit 2 vials per 1 HUMULIN R, HUMULIN R 1 month;QL(1.5 pioglitazone hcl tabs U-500 (CONCENTRATED) ml daily) Insulin SOLN (Insulin Lispro Protamine & Limit 3 boxes HUMALOG SOCT (insulin Limit 45mls per 2 month;QL(1.5 Lispro) HUMALOG MIX per lispro) 50/50 KWIKPEN, 1 month;QL(1.5 ml daily) HUMALOG MIX 75/25 ml daily) HUMULIN N SUSP Limit 45mls per KWIKPEN SUPN (insulin nph (human) 2 month;QL(1.5 (Insulin Lispro Protamine & Limit 4 vials per (isophane)) ml daily) Lispro) HUMALOG MIX 1 month;QL(1.5 LANTUS SOLN (insulin Limit 45mls per 50/50, HUMALOG MIX ml daily) 2 month;QL(1.5 75/25 SUSP glargine) ml daily) LANTUS SOLOSTAR Limit 45mls per 2 month;QL(1.5 SOPN (insulin glargine) ml daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 3 boxes 1 LEVEMIR FLEXTOUCH glimepiride tabs 2 per SOPN (insulin detemir) month;QL(1.5 1 ml daily) glipizide tabs LEVEMIR SOLN (insulin Limit 4 vials per glipizide tb24 1 2 month;QL(1.5 detemir) ml daily) GLUCOTROL TABS GP Limit 3 boxes (glipizide) TOUJEO MAX SOLOSTAR per GLUCOTROL XL TB24 2.5 2 GP SOPN (insulin glargine) month;QL(0.6 MG, 5 MG (glipizide) ml daily) Limit 3 boxes glyburide micronized 1 TOUJEO SOLOSTAR tabs 2 per SOPN (insulin glargine) month;QL(0.6 glyburide tabs 1 ml daily) GLYNASE TABS TRESIBA FLEXTOUCH Limit 3 boxes GP (glyburide micronized) SOPN 100 UNIT/ML 2 per month;QL(1.5 (insulin degludec) ml daily) tolazamide tabs 1 TRESIBA FLEXTOUCH Limit 3 boxes tolbutamide tabs 1 SOPN 200 UNIT/ML 2 per month;QL(0.9 (insulin degludec) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs ml daily) to Treat Diarrhea TRESIBA SOLN (insulin 2 Antidiarrheal - Chloride Channel Antagonists degludec) MYTESI TBEC PA; QL(2 ea 3 Meglitinide Analogues (crofelemer) daily) nateglinide tabs 1 Antiperistaltic Agents PRANDIN TABS (Loperamide Hcl) ANTI- RX/OTC GP (repaglinide) DIARRHEAL, CVS ANTI- DIARRHEAL, EQ ANTI- repaglinide tabs 1 DIARRHEAL, GNP ANTI- DIARRHEAL, HM ANTI- STARLIX TABS GP DIARRHEAL, HM 1 (nateglinide) LOPERAMIDE HCL, QC ANTI-DIARRHEAL, RA Sodium-Glucose Co-Transporter 2 (SGLT2) ANTI-DIARRHEAL, SM FARXIGA TABS ANTI-DIARRHEAL, TGT (dapagliflozin 2 LOPERAMIDE HCL CAPS propanediol) diphenoxylate w/ 1 JARDIANCE TABS 2 atropine liqd (empagliflozin) diphenoxylate w/ 1 Sulfonylureas atropine tabs (Glipizide) GLIPIZIDE XL IMODIUM A-D CAPS RX/OTC 1 GP TB24 (loperamide hcl) AMARYL TABS GP (glimepiride)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOMOTIL TABS VISTOGARD PACK (diphenoxylate w/ GP (uridine triacetate SP atropine) (emergency treatment)) loperamide hcl caps 1 RX/OTC Opioid Antagonists EVZIO SOAJ ( PA MOTOFEN TABS naloxone SP 2 (difenoxin w/ atropine) hcl) PA naloxone hcl soaj 2 SP opium tincture tinc 1 mg/0.4ml paregoric tinc 1 naloxone hcl sosy 2 SP mg/2ml ANTIDOTES AND SPECIFIC ANTAGONISTS naltrexone hcl tabs 1 Antidotes - Chelating Agents Limit 2 boxes CHEMET CAPS NARCAN LIQD per month;QL(4 3 3 (succimer) (naloxone hcl) ea per 30 days retail) deferasirox pack SP PA ANTIEMETICS - Drugs to Treat Nausea and deferasirox tabs SP PA Vomiting 5-HT3 Receptor Antagonists PA deferasirox tbso SP ALOXI SOLN PA SP (palonosetron hcl) deferiprone tabs SP PA ANZEMET TABS PA; QL(0.07 ea EXJADE TBSO PA 3 daily) SP (dolasetron mesylate) (deferasirox) granisetron hcl tabs 1 QL(2 ea daily) FERRIPROX SOLN 100 PA SP MG/ML (deferiprone) PA; Limit 1 FERRIPROX TABS 1000 PA ondansetron hcl soln 4 1 bottle per SP mg/5ml month;QL(1.67 MG (deferiprone) ml daily) FERRIPROX TABS 500 PA SP ondansetron hcl tabs 4 QL(20 ea per MG (deferiprone) 1 fill retail,60 ea FERRIPROX TWICE-A- PA mg, 8 mg per fill mail) SP DAY TABS (deferiprone) QL(20 ea per JADENU SPRINKLE PACK PA ondansetron tbdp 1 fill retail,60 ea SP (deferasirox) per fill mail) JADENU TABS PA palonosetron hcl soln SP PA SP (deferasirox) PALONOSETRON PA Antidotes and Specific Antagonists HYDROCHLORIDE SOLN SP RADIOGARDASE CAPS (palonosetron hcl) (prussian blue insoluble SANCUSO PTCH PA 3 3 (ferric (granisetron) hexacyanoferrate ii))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Limit 1 CESAMET CAPS PA; QL(2 ea ZOFRAN SOLN 4 MG/5ML 3 GP bottle per (nabilone) daily) (ondansetron hcl) month;QL(1.67 DICLEGIS TBEC QL(4 ea daily) ml daily) GP (doxylamine-pyridoxine) QL(20 ea per ZOFRAN TABS 4 MG, 8 QL(4 ea daily) GP fill retail,60 ea doxylamine-pyridoxine 1 MG (ondansetron hcl) per fill mail) tbec ZUPLENZ FILM QL(20 ea per dronabinol caps 1 3 fill retail,60 ea ( ) ondansetron per fill mail) MARINOL CAPS GP Antiemetics - Anticholinergic (dronabinol) (Meclizine Hcl) CVS RX/OTC Substance P/Neurokinin 1 (NK1) Receptor MOTION SICKNESS II, QL(3 ea per fill DRAMAMINE LESS aprepitant caps 1 retail,9 ea per DROWSY, EQ MOTION fill mail) SICKNESS RELIEF, EQL MOTION SICKNESS aprepitant caps 125 QL(1 ea per fill 1 retail,3 ea per RELIEF, GNP MOTION mg, 80 mg SICKNESS RELIEF, HM 1 fill mail) MOTION RELIEF, HM QL(2 ea per fill MOTION SICKNESS aprepitant caps 40 mg 1 retail,6 ea per RELIEF, RA MOTION fill mail) SICKNESS RELIEF, SM EMEND CAPS 125 MG, 80 QL(1 ea per fill MOTION SICKNESS, GP retail,3 ea per TRAVEL-EASE, WAL- MG (aprepitant) fill mail) DRAM II TABS EMEND CAPS 40 MG QL(2 ea per fill meclizine hcl tabs 1 RX/OTC GP retail,6 ea per (aprepitant) fill mail) MECLIZINE EMEND TRIPACK CAPS QL(3 ea per fill HYDROCHLORIDE TABS 3 GP retail,9 ea per (meclizine hcl) (aprepitant) fill mail) VARUBI TBPK ( QL(4 ea per fill scopolamine pt72 1 rolapitant 3 hcl) retail) TIGAN CAPS (trimethobenzamide GP ANTIFUNGALS - Drugs to Treat Fungal Infections hcl) Antifungal - Glucan Synthesis Inhibitors trimethobenzamide hcl CANCIDAS SOLR PA 1 SP caps (caspofungin acetate) Antiemetics - Miscellaneous PA caspofungin acetate SP AKYNZEO CAPS QL(2 ea per 28 solr 50 mg, 70 mg days retail) (netupitant- 3 CASPOFUNGIN ACETATE PA palonosetron) SOLR 50 MG, 70 MG SP BONJESTA TBCR QL(2 ea daily) (caspofungin acetate) (doxylamine- 3 ERAXIS SOLR PA SP pyridoxine) (anidulafungin)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA micafungin sodium solr SP fluconazole tabs 1 100 mg, 50 mg PA MYCAMINE SOLR PA itraconazole caps 1 SP (micafungin sodium) itraconazole soln 1 PA Antifungals (Nystatin) BIO-STATIN 1 ketoconazole tabs 1 POWD NOXAFIL SUSP 40 MG/ML ABELCET SUSP PA 3 SP ( ) (amphotericin b lipid) posaconazole NOXAFIL TBEC 100 MG AMBISOME SUSR PA GP ( ) (amphotericin b SP posaconazole liposome) posaconazole tbec 1 amphotericin b solr SP PA SPORANOX CAPS PA GP ( ) ANCOBON CAPS itraconazole GP SPORANOX PULSEPAK PA (flucytosine) GP CAPS ( ) BIO-STATIN CAPS itraconazole SPORANOX SOLN PA 1000000 UNIT, 500000 3 GP UNIT (nystatin) (itraconazole) TOLSURA CAPS PA flucytosine caps 1 SP (itraconazole) griseofulvin microsize VFEND SUSR 1 GP susp (voriconazole) griseofulvin microsize VFEND TABS 1 GP tabs (voriconazole) voriconazole susr or 40 griseofulvin 1 1 ultramicrosize tabs mg/ml nystatin tabs 1 voriconazole tabs or 1 200 mg, 50 mg QL(90 ea per ANTIHISTAMINES - Drugs to Treat Allergies 1 365 days terbinafine hcl tabs retail,90 ea per 365 days mail) Antihistamines - Alkylamines Imidazole-Related Antifungals (Dexchlorpheniramine 1 Maleate) RYCLORA SOLN CRESEMBA CAPS dexchlorpheniramine (isavuconazonium 3 1 sulfate) maleate soln DIFLUCAN SUSR Antihistamines - Ethanolamines GP (fluconazole) (Diphenhydramine Hcl) DIFLUCAN TABS BANOPHEN, KP GP DIPHENHYDRAMINE 1 (fluconazole) HCL, PHARBEDRYL fluconazole susr 1 CAPS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) RX/OTC (Cetirizine Hcl) ALL DAY RX/OTC DIPHEN, EQ ALLERGY 1 ALLERGY CHILDRENS, RELIEF CHILDRENS ELIX ALL-DAY ALLERGY carbinoxamine maleate CHILDRENS, ALLERGY 1 RELIEF CHILDRENS, soln 4 mg/5ml CETIRIZINE HCL ALLERGY CHILDRENS, carbinoxamine maleate 1 tabs 4 mg CETIRIZINE HCL CHILDRENS, CETIRIZINE clemastine fumarate 1 HCL tabs CHILDRENSALLERGY, CETIRIZINE diphenhydramine hcl 1 caps or 50 mg HYDROCHLORIDECHILD RENS ALLERGY, CVS RX/OTC diphenhydramine hcl 1 ALLERGY RELIEF elix or 12.5 mg/5ml CHILDRENS, EQ diphenhydramine hcl PA ALLERGY RELIEF SP CHILDRENS, EQL ALL soln ij 50 mg/ml DAY ALLERGY KARBINAL ER SUER CHILDRENS, GNP ALL (carbinoxamine 3 DAY ALLERGY maleate) CHILDRENS, GOODSENSE ALL DAY Antihistamines - Non-Sedating ALLERGYCHILDRENS, 1 HM ALL DAY ALLERGY CHILDRENS, HM CETIRIZINE HCL CHILDRENS, KLS ALLER- TEC CHILDRENS, PX CHILDRENS ALLERGY, QC CHILDRENS ALLERGY, RA ALLERGY RELIEF CHILDRENS, RA CETIRIZINE HCL CHILDRENS ALLERGY, SB CETIRIZINE HCL CHILDRENS, SM ALL DAY ALLERGY CHILDRENS, TGT ALL DAY ALLERGY RELIEF CHILDRENS, WAL-ZYR, WAL-ZYR ALL DAY ALLERGY CHILDRENS, WAL-ZYR ALL DAY ALLERGYCHILDRENS, WAL-ZYR CHILDRENS SOLN (Cetirizine Hcl) EQ RX/OTC ALLERGY RELIEF SOLN 1 OR 1 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) QC RX/OTC promethazine hcl tabs ALLERGY RELIEF or 12.5 mg, 25 mg, 50 1 CHILDRENS, RA 1 mg ALLERGY RELIEF CHILDRENS SYRP Antihistamines - Piperidines (Levocetirizine RX/OTC cyproheptadine hcl syrp 1 Dihydrochloride) ALLERGY 1 RELIEF 24HR, CVS 1 ALLERGY RELIEF TABS cyproheptadine hcl tabs cetirizine hcl soln 1 RX/OTC ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol CLARINEX SYRP 0.5 3 Antihyperlipidemics - Combinations MG/ML (desloratadine) ezetimibe-simvastatin QL(1 ea daily) CLARINEX TABS 5 MG PA; QL(1 ea 1 GP tabs (desloratadine) daily) VYTORIN TABS 10 MG-20 QL(1 ea daily) desloratadine tabs 5 PA; QL(1 ea MG, 10 MG-40 MG, 10 1 daily) mg MG-80 MG (ezetimibe- GP desloratadine tbdp 2.5 1 simvastatin) mg, 5 mg Antihyperlipidemics - Misc. RX/OTC levocetirizine 1 ST dihydrochloride tabs or icosapent ethyl caps 1 XYZAL ALLERGY 24HR RX/OTC LOVAZA CAPS ( omega- GP TABS (levocetirizine GP 3-acid ethyl esters) dihydrochloride) omega-3-acid ethyl 1 ZYRTEC CHILDRENS RX/OTC esters caps ALLERGY SOLN GP VASCEPA CAPS 0.5 GM ST 3 (cetirizine hcl) (icosapent ethyl) Antihistamines - Phenothiazines VASCEPA CAPS 1 GM ST GP (Promethazine Hcl) (icosapent ethyl) PHENADOZ, 1 PROMETHEGAN SUPP Bile Acid Sequestrants PHENERGAN SOLN PA (Cholestyramine Light) 1 SP PREVALITE PACK (promethazine hcl) (Cholestyramine Light) PA 1 promethazine hcl soln ij SP PREVALITE POWD 25 mg/ml, 50 mg/ml cholestyramine light 1 promethazine hcl soln 1 pack or 6.25 mg/5ml cholestyramine light 1 promethazine hcl supp powd re 12.5 mg, 25 mg, 50 1 mg cholestyramine pack 1 promethazine hcl syrp 1 cholestyramine powd 1 or 6.25 mg/5ml colesevelam hcl pack 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENOFIBRIC ACID TABS colesevelam hcl tabs 1 3 105 MG (fenofibric acid) COLESTID FLAVORED GP fenofibric acid tabs 105 1 GRAN (colestipol hcl) mg, 35 mg COLESTID FLAVORED GP FIBRICOR TABS 105 MG, PACK ( ) 3 colestipol hcl 35 MG (fenofibric acid) COLESTID GRAN GP FIBRICOR TABS 105 MG, ( ) 3 colestipol hcl 35 MG (fenofibric acid) COLESTID PACK GP (colestipol hcl) gemfibrozil tabs 1 COLESTID TABS LIPOFEN CAPS GP 3 (colestipol hcl) (fenofibrate) LOPID TABS colestipol hcl gran 1 GP (gemfibrozil) colestipol hcl pack 1 TRICOR TABS GP (fenofibrate) 1 colestipol hcl tabs TRIGLIDE TABS 3 QUESTRAN LIGHT POWD (fenofibrate) GP (cholestyramine light) TRILIPIX CPDR ( choline GP QUESTRAN PACK GP fenofibrate) ( ) cholestyramine HMG CoA Reductase Inhibitors QUESTRAN POWD ADVICOR TB24 1000 MG- GP 2 (cholestyramine) 20 MG (niacin-lovastatin) WELCHOL PACK ADVICOR TB24 1000 MG- QL(1 ea daily) GP 2 (colesevelam hcl) 40 MG (niacin-lovastatin) WELCHOL TABS ALTOPREV TB24 GP 3 (colesevelam hcl) (lovastatin) Fibric Acid Derivatives atorvastatin calcium QL(1 ea daily) ANTARA CAPS 1 3 tabs (fenofibrate micronized) fluvastatin sodium caps 1 QL(1 ea daily) choline fenofibrate cpdr 1 fluvastatin sodium tb24 1 QL(1 ea daily) fenofibrate caps 150 1 LESCOL XL TB24 QL(1 ea daily) mg, 50 mg GP (fluvastatin sodium) fenofibrate micronized 1 caps LIVALO TABS ST; QL(1 ea 3 daily) fenofibrate tabs 145 (pitavastatin calcium) mg, 160 mg, 48 mg, 54 1 lovastatin tabs 1 $0 copay, age mg 40 to 76;PV PRAVACHOL TABS 20 QL(1 ea daily) FENOFIBRATE TABS 160 3 MG, 80 MG (pravastatin GP MG (fenofibrate) sodium)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRAVACHOL TABS 40 QL(2 ea daily) ANTIHYPERTENSIVES - Drugs to Treat High MG (pravastatin GP Blood Pressure sodium) ACE Inhibitors pravastatin sodium QL(1 ea daily) ACCUPRIL TABS 20 MG, tabs 10 mg, 20 mg, 80 1 40 MG, 5 MG (quinapril GP mg hcl) pravastatin sodium QL(2 ea daily) ALTACE CAPS 1.25 MG, 5 QL(1 ea daily) 1 GP tabs 40 mg MG (ramipril) rosuvastatin calcium QL(1 ea daily) ALTACE CAPS 10 MG QL(2 ea daily) 1 GP tabs (ramipril) SIMCOR TB24 ( niacin- 2 benazepril hcl tabs 1 simvastatin) simvastatin tabs 10 mg, QL(1 ea daily) captopril tabs 1 20 mg, 40 mg, 5 mg, 1 QL(2 ea daily) 80 mg enalapril maleate tabs 1 ZOCOR TABS QL(1 ea daily) EPANED SOLN QL(5 ml daily) GP 3 (simvastatin) (enalapril maleate) Intestinal Cholesterol Absorption Inhibitors fosinopril sodium tabs 1 ezetimibe tabs 1 lisinopril tabs 1 ZETIA TABS (ezetimibe) GP LOTENSIN TABS GP (benazepril hcl) Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS PA moexipril hcl tabs 1 SP (lomitapide mesylate) perindopril erbumine 1 Nicotinic Acid Derivatives tabs niacin PRINIVIL TABS (lisinopril) GP (antihyperlipidemic) 1 tbcr Limited to 1 QBRELIS SOLN bottle per NIASPAN TBCR ( 3 niacin GP (lisinopril) month.;QL(5 ml (antihyperlipidemic)) daily) Proprotein Convertase Subtilisin/Kexin Type 9 quinapril hcl tabs 1 PRALUENT SOAJ PA SP QL(1 ea daily) (alirocumab) ramipril caps 1.25 mg, 1 REPATHA PUSHTRONEX PA 2.5 mg, 5 mg SYSTEM SOCT SP ramipril caps 10 mg 1 QL(2 ea daily) (evolocumab) REPATHA SOSY PA trandolapril tabs 1 SP (evolocumab) VASOTEC TABS QL(2 ea daily) REPATHA SURECLICK PA GP SP (enalapril maleate) SOAJ (evolocumab) ZESTRIL TABS (lisinopril) GP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CATAPRES-TTS-1 PTWK Agents for Pheochromocytoma GP DEMSER CAPS (clonidine) GP CATAPRES-TTS-2 PTWK (metyrosine) GP DIBENZYLINE CAPS (clonidine) CATAPRES-TTS-3 PTWK (phenoxybenzamine GP GP hcl) (clonidine) metyrosine caps 1 clonidine hcl tabs 1 phenoxybenzamine hcl 1 clonidine ptwk 1 caps doxazosin mesylate 1 Angiotensin II Receptor Antagonists tabs ATACAND TABS GP (candesartan cilexetil) guanfacine hcl tabs 1 AVAPRO TABS GP methyldopa tabs 1 (irbesartan) MINIPRESS CAPS candesartan cilexetil 1 GP tabs (prazosin hcl) COZAAR TABS ( prazosin hcl caps 1 losartan GP potassium) terazosin hcl caps 1 DIOVAN TABS GP (valsartan) Antihypertensive Combinations EDARBI TABS ACCURETIC TABS 3 (azilsartan medoxomil) (quinapril- GP hydrochlorothiazide) eprosartan mesylate 1 tabs amlodipine besylate- 1 irbesartan tabs 1 benazepril hcl caps amlodipine besylate- losartan potassium 1 olmesartan medoxomil 1 tabs tabs MICARDIS TABS GP amlodipine besylate- 1 (telmisartan) valsartan tabs olmesartan medoxomil 1 amlodipine-valsartan- tabs hydrochlorothiazide 1 telmisartan tabs 1 tabs ATACAND HCT TABS valsartan tabs 1 (candesartan cilexetil- GP Antiadrenergic Antihypertensives hydrochlorothiazide) CARDURA TABS atenolol & GP 1 (doxazosin mesylate) chlorthalidone tabs CATAPRES TABS GP (clonidine hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVALIDE TABS enalapril maleate & (irbesartan- GP hydrochlorothiazide 1 hydrochlorothiazide) tabs AZOR TABS 10 MG-20 EXFORGE HCT TABS MG, 20 MG-5 MG, 40 MG- (amlodipine-valsartan- GP 5 MG (amlodipine GP hydrochlorothiazide) besylate-olmesartan EXFORGE TABS medoxomil) (amlodipine besylate- GP benazepril & valsartan) hydrochlorothiazide 1 fosinopril sodium & tabs hydrochlorothiazide 1 BENICAR HCT TABS 12.5 tabs MG-20 MG (olmesartan HYZAAR TABS (losartan medoxomil- GP potassium & GP hydrochlorothiazide) hydrochlorothiazide) bisoprolol & irbesartan- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs BYVALSON TABS 3 (nebivolol-valsartan) lisinopril & hydrochlorothiazide 1 candesartan cilexetil- tabs hydrochlorothiazide 1 tabs LOPRESSOR HCT TABS (metoprolol & GP captopril & hydrochlorothiazide) hydrochlorothiazide 1 losartan potassium & tabs hydrochlorothiazide 1 CORZIDE TABS 40 MG-5 tabs MG (nadolol & 3 LOTENSIN HCT TABS bendroflumethiazide) (benazepril & GP CORZIDE TABS 5 MG-80 hydrochlorothiazide) MG (nadolol & 3 LOTREL CAPS bendroflumethiazide) (amlodipine besylate- GP DIOVAN HCT TABS 12.5 benazepril hcl) MG-160 MG, 12.5 MG-320 MG, 12.5 MG-80 MG, 160 GP methyldopa & MG-25 MG (valsartan- hydrochlorothiazide 1 hydrochlorothiazide) tabs DUTOPROL TB24 metoprolol & (metoprolol & 3 hydrochlorothiazide 1 hydrochlorothiazide) tabs EDARBYCLOR TABS (azilsartan medoxomil- 3 chlorthalidone)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METOPROLOL trandolapril-verapamil 1 SUCCINATE hcl tbcr ER/HYDROCHLOROTHIA 3 TRIBENZOR TABS ZIDE TB24 (metoprolol (olmesartan & hydrochlorothiazide) GP medoxomil-amlodipine- MICARDIS HCT TABS hydrochlorothiazide) (telmisartan- GP TWYNSTA TABS hydrochlorothiazide) (telmisartan- GP nadolol & amlodipine) bendroflumethiazide 1 tabs valsartan- hydrochlorothiazide 1 olmesartan medoxomil- tabs amlodipine- 1 VASERETIC TABS hydrochlorothiazide (enalapril maleate & GP tabs hydrochlorothiazide) olmesartan medoxomil- ZESTORETIC TABS hydrochlorothiazide 1 (lisinopril & GP tabs hydrochlorothiazide) propranolol & ZIAC TABS ( bisoprolol & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs Antihypertensives - Misc. quinapril- VECAMYL TABS PA hydrochlorothiazide 1 SP (mecamylamine hcl) tabs TARKA TBCR Direct Renin Inhibitors (trandolapril-verapamil GP aliskiren fumarate tabs 1 hcl) TEKTURNA TABS TEKTURNA HCT TABS 3 (aliskiren fumarate) (aliskiren- 3 hydrochlorothiazide) Selective Aldosterone Receptor Antagonists 1 telmisartan-amlodipine 1 eplerenone tabs tabs INSPRA TABS GP telmisartan- (eplerenone) hydrochlorothiazide 1 tabs Vasodilators PA TENORETIC 100 TABS hydralazine hcl soln ij SP (atenolol & GP 20 mg/ml chlorthalidone) hydralazine hcl tabs or TENORETIC 50 TABS 10 mg, 100 mg, 25 mg, 1 (atenolol & GP 50 mg chlorthalidone) minoxidil tabs 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUANIDINE HCL TABS ANTIMALARIALS - Drugs to Treat Malaria 2 (Parasitic Infections) (guanidine hcl) Antimalarial Combinations MESTINON SOLN 60 PA MG/5ML (pyridostigmine GP atovaquone-proguanil 1 hcl tabs bromide) MESTINON TABS 60 MG COARTEM TABS QL(0.8 ea ( GP (artemether- 2 daily) pyridostigmine ) lumefantrine) bromide MESTINON TIMESPAN MALARONE TABS TBCR ( GP (atovaquone-proguanil GP pyridostigmine ) hcl) bromide PA pyridostigmine bromide 1 Antimalarials soln 60 mg/5ml chloroquine phosphate 1 pyridostigmine bromide tabs 1 tabs 60 mg DARAPRIM TABS PA 3 (pyrimethamine) pyridostigmine bromide 1 tbcr 180 mg KRINTAFEL TABS QL(2 ea per 30 2 RUZURGI TABS PA; QL(10 ea (tafenoquine succinate) days retail) SP (amifampridine) daily) 1 QL(6 ea per fill mefloquine hcl tabs retail) ANTIMYCOBACTERIAL AGENTS - Drugs to PLAQUENIL TABS Treat Tuberculosis (Bacterial Infections) (hydroxychloroquine 1 Anti TB Combinations sulfate) RIFAMATE CAPS 2 (isoniazid & rifampin) primaquine phosphate 1 tabs RIFATER TABS PRIMAQUINE (isoniazid-rifampin w/ 3 PHOSPHATE TABS GP pyrazinamide) (primaquine phosphate) Antimycobacterial Agents pyrimethamine tabs 1 PA CAPASTAT SULFATE PA SOLR (capreomycin SP QUALAQUIN CAPS PA; QL(42 ea GP per 7 days sulfate) (quinine sulfate) retail) cycloserine caps 1 PA; QL(42 ea quinine sulfate caps 1 per 7 days ethambutol hcl tabs 1 retail) PA isoniazid soln ij 100 SP ANTIMYASTHENIC/CHOLINERGIC AGENTS mg/ml Antimyasthenic/Cholinergic Agents isoniazid syrp or 50 1 FIRDAPSE TABS PA mg/5ml (amifampridine SP isoniazid tabs or 100 1 phosphate) mg, 300 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYAMBUTOL TABS PA GP melphalan hcl solr AC (ethambutol hcl) MYCOBUTIN CAPS melphalan tabs AC GP ( ) rifabutin MYLERAN TABS PASER PACK AC 3 (busulfan) ( ) aminosalicylic acid TEMODAR CAPS PRIFTIN TABS AC 3 (temozolomide) (rifapentine) temozolomide caps AC pyrazinamide tabs 1 TEPADINA SOLR AC rifabutin caps 1 (thiotepa) RIFADIN CAPS OR 150 thiotepa solr AC GP MG, 300 MG ( ) rifampin ZANOSAR SOLR PA RIFADIN SOLR IV 600 MG PA AC SP (streptozocin) (rifampin) Antimetabolites rifampin caps or 150 1 (Fluorouracil) ADRUCIL AC PA mg, 300 mg SOLN rifampin solr iv 600 mg SP PA ALIMTA SOLR PA AC ( ) SIRTURO TABS 100 MG pemetrexed disodium SP ARRANON SOLN PA (bedaquiline fumarate) AC ( ) SIRTURO TABS 20 MG nelarabine 3 (bedaquiline fumarate) azacitidine susr AC PA TRECATOR TABS 2 (ethionamide) capecitabine tabs AC ANTINEOPLASTICS AND ADJUNCTIVE cladribine soln AC PA THERAPIES - Drugs to Treat Cancer PA Alkylating Agents clofarabine soln AC ALKERAN SOLR IV 50 MG PA CLOLAR SOLN PA AC AC (melphalan hcl) (clofarabine) ALKERAN TABS OR 2 MG PA AC cytarabine soln 100 AC (melphalan) mg/ml AC PA PA busulfan soln cytarabine soln 20 SP BUSULFEX SOLN PA mg/ml AC DACOGEN SOLR PA (busulfan) AC (decitabine) cyclophosphamide AC caps decitabine solr AC PA GLEOSTINE CAPS PA AC PA (lomustine) floxuridine solr AC LEUKERAN TABS fludarabine phosphate PA AC AC (chlorambucil) soln You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA ARZERRA CONC PA fludarabine phosphate AC AC solr (ofatumumab) CAMPATH SOLN PA fluorouracil soln AC PA AC (alemtuzumab) PA ERBITUX SOLN PA gemcitabine hcl soln AC AC () PA gemcitabine hcl solr AC RITUXAN SOLN PA AC GEMCITABINE PA (rituximab) HYDROCHLORIDE SOLN YERVOY SOLN PA AC 1 GM/10ML, 2 GM/20ML, AC (ipilimumab) 200 MG/2ML (gemcitabine hcl) Antineoplastic - BCL-2 Inhibitors GEMCITABINE PA VENCLEXTA STARTING PA HYDROCHLORIDE SOLN PACK TBPK AC 1.5 GM/15ML AC (venetoclax) VENCLEXTA TABS PA (gemcitabine hcl) AC GEMZAR SOLR PA (venetoclax) AC (gemcitabine hcl) Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS PA mercaptopurine tabs AC AC (glasdegib maleate) methotrexate sodium ERIVEDGE CAPS PA AC soln ij 1 gm/40ml, 25 SP (vismodegib) mg/ml, 250 mg/10ml, ODOMZO CAPS PA AC 50 mg/2ml (sonidegib phosphate) methotrexate sodium SP solr ij 1 gm Antineoplastic - Hormonal and Related Agents abiraterone acetate PA methotrexate sodium AC 1 tabs tabs or 2.5 mg ONUREG TABS PA anastrozole tabs AC AC (azacitidine) ARIMIDEX TABS PURIXAN SUSP PA; AL(Up to AC AC (anastrozole) (mercaptopurine) 13 yrs old ) AROMASIN TABS TABLOID TABS AC AC (exemestane) (thioguanine) bicalutamide tabs AC TREXALL TABS 3 CASODEX TABS (methotrexate sodium) AC VIDAZA SUSR PA (bicalutamide) AC (azacitidine) DEPO-PROVERA SUSP PA XATMEP SOLN PA (medroxyprogesterone AC SP (methotrexate) acetate XELODA TABS (antineoplastic)) AC ELIGARD KIT ( PA (capecitabine) leuprolide AC ) Antineoplastic - Antibodies acetate (3 month) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIGARD KIT ( PA LUPRON DEPOT ( PA leuprolide AC 4- acetate (4 month)) MONTH) KIT (leuprolide AC ELIGARD KIT ( PA acetate (4 month)) leuprolide AC acetate (6 month)) LUPRON DEPOT (6- PA AC ELIGARD KIT ( PA MONTH) KIT (leuprolide leuprolide AC acetate (6 month)) acetate) LYSODREN TABS AC EMCYT CAPS (mitotane) (estramustine AC phosphate sodium) megestrol acetate susp 1 40 mg/ml, 400 mg/10ml ERLEADA TABS PA AC (apalutamide) megestrol acetate tabs AC 20 mg, 40 mg exemestane tabs AC NILANDRON TABS AC FARESTON TABS (nilutamide) AC (toremifene citrate) nilutamide tabs AC FEMARA TABS AC NUBEQA TABS PA (letrozole) AC FIRMAGON SOLR PA (darolutamide) AC SOLTAMOX SOLN (degarelix acetate) AC (tamoxifen citrate) flutamide caps AC tamoxifen citrate tabs PV PV letrozole tabs AC toremifene citrate tabs AC PA leuprolide acetate kit AC TRELSTAR MIXJECT PA LEUPROLIDE PA SUSR (triptorelin AC ACETATE/BUPIVACAINE pamoate) HYDROCHLORIDE SOLN AC XTANDI CAPS PA AC (leuprolide acetate- (enzalutamide) bupivacaine hcl) YONSA TABS PA AC LUPRON DEPOT (1- PA (abiraterone acetate) SP MONTH) KIT 3.75 MG ZYTIGA TABS 250 MG PA (leuprolide acetate) AC (abiraterone acetate) LUPRON DEPOT (1- PA ZYTIGA TABS 500 MG PA MONTH) KIT 7.5 MG AC AC (leuprolide acetate) (abiraterone acetate) LUPRON DEPOT (3- PA Antineoplastic - Immunomodulators POMALYST CAPS PA MONTH) KIT 11.25 MG SP AC (leuprolide acetate (3 (pomalidomide) month)) Antineoplastic - XPO1 Inhibitors LUPRON DEPOT (3- PA XPOVIO 100 MG ONCE PA MONTH) KIT 22.5 MG AC WEEKLY TBPK AC (leuprolide acetate (3 (selinexor) month))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XPOVIO 40 MG ONCE PA ALECENSA CAPS PA AC WEEKLY TBPK AC ( hcl) (selinexor) ALUNBRIG TABS PA AC XPOVIO 40 MG TWICE PA () WEEKLY TBPK AC ALUNBRIG TBPK PA AC (selinexor) (brigatinib) XPOVIO 60 MG ONCE PA AYVAKIT TABS PA; QL(1 ea WEEKLY TBPK AC AC () daily) (selinexor) BALVERSA TABS PA XPOVIO 60 MG TWICE PA AC WEEKLY TBPK AC (erdafitinib) BOSULIF TABS PA (selinexor) AC XPOVIO 80 MG ONCE PA () WEEKLY TBPK BRAFTOVI CAPS PA AC AC (selinexor) () XPOVIO 80 MG TWICE PA BRUKINSA CAPS PA AC WEEKLY TBPK AC (zanubrutinib) (selinexor) CABOMETYX TABS PA AC Antineoplastic Antibiotics ( s-malate) PA CALQUENCE CAPS PA mitoxantrone hcl conc SP AC (acalabrutinib) Antineoplastic Combinations CAPRELSA TABS AC KISQALI FEMARA 200 PA () DOSE TBPK (ribociclib AC COMETRIQ KIT AC succinate-letrozole) (cabozantinib s-malate) KISQALI FEMARA 400 PA COPIKTRA CAPS PA AC DOSE TBPK (ribociclib AC (duvelisib) succinate-letrozole) COTELLIC TABS PA AC KISQALI FEMARA 600 PA ( fumarate) DOSE TBPK (ribociclib AC AC PA succinate-letrozole) hcl tabs LONSURF TABS PA PA; QL(1 ea AC everolimus tabs AC (trifluridine-tipiracil) daily) FARYDAK CAPS PA RITUXAN HYCELA SOLN PA AC (rituximab- AC (panobinostat lactate) GILOTRIF TABS ( PA hyaluronidase human) AC Antineoplastic Enzyme Inhibitors dimaleate) AFINITOR DISPERZ TBSO PA; QL(1 ea GLEEVEC TABS ( PA AC AC (everolimus) daily) mesylate) AFINITOR TABS 10 MG PA; QL(1 ea IBRANCE CAPS PA AC AC (everolimus) daily) (palbociclib) AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea IBRANCE TABS PA AC AC MG, 7.5 MG (everolimus) daily) (palbociclib)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ICLUSIG TABS 15 MG, 45 PA LENVIMA 4 MG DAILY PA AC MG ( hcl) DOSE CPPK ( AC IDHIFA TABS PA mesylate) AC ( mesylate) LENVIMA 8 MG DAILY PA DOSE CPPK (lenvatinib AC imatinib mesylate tabs AC PA mesylate) IMBRUVICA CAPS PA LORBRENA TABS PA AC AC (ibrutinib) () IMBRUVICA TABS PA LYNPARZA TABS PA AC AC (ibrutinib) (olaparib) INLYTA TABS () AC PA MEKINIST TABS PA ( dimethyl AC INREBIC CAPS PA AC sulfoxide) (fedratinib hcl) MEKTOVI TABS PA PA AC IRESSA TABS () AC () PA NERLYNX TABS PA ISTODAX (OVERFILL) AC AC SOLR (romidepsin) ( maleate) JAKAFI TABS ( PA NEXAVAR TABS PA ruxolitinib AC AC phosphate) ( tosylate) KISQALI TBPK ( PA NINLARO CAPS PA ribociclib AC AC succinate) (ixazomib citrate) PEMAZYRE TABS PA; QL(1 ea PA AC ditosylate tabs AC () daily) LENVIMA 10 MG DAILY PA PIQRAY 200MG DAILY PA AC DOSE CPPK (lenvatinib AC DOSE TBPK (alpelisib) mesylate) PIQRAY 250MG DAILY PA AC LENVIMA 12MG DAILY PA DOSE TBPK (alpelisib) DOSE CPPK (lenvatinib AC PIQRAY 300MG DAILY PA AC mesylate) DOSE TBPK (alpelisib) LENVIMA 14 MG DAILY PA QINLOCK TABS PA AC DOSE CPPK (lenvatinib AC () mesylate) RETEVMO CAPS PA AC LENVIMA 18 MG DAILY PA () DOSE CPPK (lenvatinib AC ROMIDEPSIN SOLR PA AC mesylate) (romidepsin) LENVIMA 20 MG DAILY PA ROZLYTREK CAPS PA AC DOSE CPPK (lenvatinib AC () mesylate) RUBRACA TABS PA AC LENVIMA 24 MG DAILY PA (rucaparib camsylate) DOSE CPPK (lenvatinib AC RYDAPT CAPS PA AC mesylate) (midostaurin)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPRYCEL TABS PA VOTRIENT TABS PA AC AC () ( hcl) STIVARGA TABS PA; SP XALKORI CAPS PA AC AC () () SUTENT CAPS ( PA XOSPATA TABS PA AC AC malate) (gilteritinib fumarate) TABRECTA TABS PA ZEJULA CAPS (niraparib PA AC AC ( hcl) tosylate) TAFINLAR CAPS PA ZELBORAF TABS PA AC AC ( mesylate) () TAGRISSO TABS PA ZOLINZA CAPS PA AC AC ( mesylate) (vorinostat) TALZENNA CAPS PA ZYDELIG TABS PA AC AC (talazoparib tosylate) (idelalisib) TARCEVA TABS PA ZYKADIA CAPS PA AC AC (erlotinib hcl) () TASIGNA CAPS ( PA ZYKADIA TABS PA AC AC hcl) (ceritinib) TAZVERIK TABS PA AC Antineoplastics Misc. (tazemetostat hbr) ACTIMMUNE SOLN PA SP temsirolimus soln AC PA (interferon gamma-1b) ALFERON N SOLN PA TIBSOVO TABS PA AC AC (interferon alfa-n3) (ivosidenib) PA TORISEL SOLN PA bexarotene caps AC AC (temsirolimus) HYDREA CAPS AC TUKYSA TABS PA ( ) AC hydroxyurea () hydroxyurea caps AC TURALIO CAPS PA AC INTRON A SOLN PA (pexidartinib hcl) AC TYKERB TABS (lapatinib PA (interferon alfa-2b) AC INTRON A SOLR PA ditosylate) AC VELCADE SOLR PA (interferon alfa-2b) AC MATULANE CAPS (bortezomib) AC VERZENIO TABS PA (procarbazine hcl) AC (abemaciclib) SYLATRON KIT PA VITRAKVI CAPS PA (peginterferon alfa-2b AC AC ( sulfate) (antineoplastic)) VITRAKVI SOLN PA TARGRETIN CAPS OR 75 PA AC AC (larotrectinib sulfate) MG (bexarotene) VIZIMPRO TABS PA tretinoin AC AC () () caps

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Chemotherapy Adjuncts ANTIPARKINSON AND RELATED THERAPY KEPIVANCE SOLR PA AGENTS - Drugs to Treat Parkinson's Disease SP (palifermin) Antiparkinson Adjunctive Therapy Chemotherapy Rescue/Antidote Agents carbidopa tabs 1 ETHYOL SOLR PA SP LODOSYN TABS ( crystalline) GP (carbidopa) PA leucovorin calcium soln AC ij 500 mg/50ml Antiparkinson Anticholinergics PA benztropine mesylate PA leucovorin calcium solr AC SP ij 100 mg, 350 mg soln ij 1 mg/ml leucovorin calcium tabs benztropine mesylate or 10 mg, 15 mg, 25 AC tabs or 0.5 mg, 1 mg, 2 1 mg, 5 mg mg COGENTIN SOLN PA SP MESNEX TABS () AC (benztropine mesylate) Mitotic Inhibitors trihexyphenidyl hcl soln 1 (Etoposide) TOPOSAR AC PA SOLN trihexyphenidyl hcl tabs 1 ETOPOPHOS SOLR PA AC Antiparkinson COMT Inhibitors (etoposide phosphate) COMTAN TABS GP etoposide caps or 50 AC (entacapone) mg etoposide soln iv 1 PA entacapone tabs 1 gm/50ml, 100 mg/5ml, AC TASMAR TABS GP 500 mg/25ml (tolcapone) Topoisomerase I Inhibitors tolcapone tabs 1 HYCAMTIN CAPS OR 0.25 PA MG, 1 MG (topotecan AC Antiparkinson Dopaminergics hcl) amantadine hcl caps 1 HYCAMTIN SOLR IV 4 MG PA AC (topotecan hcl) amantadine hcl syrp 1 PA topotecan hcl soln 4 AC amantadine hcl tabs 1 mg/4ml TOPOTECAN HCL SOLN PA bromocriptine mesylate 1 4 MG/4ML (topotecan AC caps hcl) bromocriptine mesylate 1 TOPOTECAN HCL SOLN PA tabs 4 MG/4ML (topotecan AC carbidopa-levodopa 1 hcl) tabs PA topotecan hcl solr 4 mg AC carbidopa-levodopa 1 tbcr

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbidopa-levodopa 1 ropinirole hydrochloride 1 tbdp tabs carbidopa-levodopa- 1 ropinirole hydrochloride 1 entacapone tabs tb24 DUOPA SUSP RYTARY CPCR PA SP 3 (carbidopa-levodopa) (carbidopa-levodopa) GOCOVRI CP24 PA SINEMET CR TBCR 3 GP (amantadine hcl) (carbidopa-levodopa) MIRAPEX ER TB24 SINEMET TABS GP (pramipexole GP (carbidopa-levodopa) dihydrochloride) STALEVO 100 TABS MIRAPEX TABS (carbidopa-levodopa- 2 (pramipexole GP entacapone) dihydrochloride) STALEVO 125 TABS NEUPRO PT24 1 (carbidopa-levodopa- 2 MG/24HR, 3 MG/24HR, 8 3 entacapone) MG/24HR (rotigotine) STALEVO 150 TABS NEUPRO PT24 2 QL(3 ea daily) 3 (carbidopa-levodopa- 2 MG/24HR (rotigotine) entacapone) NEUPRO PT24 4 QL(1 ea daily) STALEVO 200 TABS MG/24HR, 6 MG/24HR 3 (carbidopa-levodopa- 2 (rotigotine) entacapone) OSMOLEX ER T4PK PA 3 STALEVO 50 TABS (amantadine hcl) (carbidopa-levodopa- 2 OSMOLEX ER TB24 PA 3 entacapone) (amantadine hcl) STALEVO 75 TABS PARLODEL CAPS (carbidopa-levodopa- 2 (bromocriptine GP entacapone) mesylate) Antiparkinson Monoamine Oxidase Inhibitors PARLODEL TABS AZILECT TABS (bromocriptine GP GP (rasagiline mesylate) mesylate) rasagiline mesylate pramipexole 1 1 tabs dihydrochloride tabs selegiline hcl caps 1 pramipexole 1 dihydrochloride tb24 selegiline hcl tabs 1 REQUIP TABS (ropinirole GP ZELAPAR TBDP hydrochloride) 3 ( ) REQUIP XL TB24 selegiline hcl (ropinirole GP ANTIPSYCHOTICS/ANTIMANIC AGENTS - hydrochloride) Drugs to Treat Mood Disorders Antimanic Agents

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lithium carbonate caps 1 FANAPT TITRATION PA PACK TABS 3 lithium carbonate tabs 1 (iloperidone) INVEGA SUSTENNA PA lithium carbonate tbcr 1 SUSY (paliperidone SP palmitate) LITHIUM SOLN (lithium) 3 INVEGA TB24 GP LITHOBID TBCR ( (paliperidone) lithium 3 carbonate) INVEGA TRINZA SUSY PA SP Antipsychotics - Misc. (paliperidone palmitate) CAPLYTA CAPS PA; QL(1 ea 1 3 paliperidone tb24 (lumateperone tosylate) daily) PERSERIS PRSY PA SP EQUETRO CP12 (risperidone) (carbamazepine 3 RISPERDAL CONSTA PA (antipsychotic)) SRER (risperidone SP GEODON CAPS OR 20 microspheres) MG, 40 MG, 60 MG, 80 MG GP RISPERDAL SOLN (ziprasidone hcl) GP (risperidone) GEODON SOLR IM 20 MG PA SP RISPERDAL TABS (ziprasidone mesylate) GP (risperidone) LATUDA TABS PA 3 (lurasidone hcl) risperidone soln 1 NUPLAZID CAPS 34 MG PA; QL(1 ea SP (pimavanserin tartrate) daily) risperidone tabs 1 NUPLAZID TABS 10 MG PA; QL(1 ea SP risperidone tbdp 1 (pimavanserin tartrate) daily) NUPLAZID TABS 17 MG PA Butyrophenones SP (pimavanserin tartrate) haloperidol lactate conc 1 VRAYLAR CAPS PA 3 (cariprazine hcl) haloperidol tabs 1 VRAYLAR CPPK PA 3 Dibenzapines (cariprazine hcl) clozapine tabs 100 mg, 1 ziprasidone hcl caps 1 200 mg, 25 mg, 50 mg PA clozapine tbdp 100 mg, ziprasidone mesylate SP solr 12.5 mg, 150 mg, 200 1 mg, 25 mg Benzisoxazoles CLOZARIL TABS (Risperidone) GP RISPERIDONE M-TAB 1 (clozapine) TBDP FAZACLO TBDP 100 MG, GP FANAPT TABS PA 25 MG (clozapine) 3 (iloperidone)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FAZACLO TBDP 12.5 MG, molindone hcl tabs 1 150 MG, 200 MG 3 (clozapine) Phenothiazines (Prochlorperazine) loxapine succinate 1 1 caps COMPRO SUPP PA olanzapine solr im 10 SP chlorpromazine hcl tabs 1 mg fluphenazine hcl conc 5 1 olanzapine tabs or 10 mg/ml mg, 15 mg, 2.5 mg, 20 1 mg, 5 mg, 7.5 mg fluphenazine hcl elix 1 2.5 mg/5ml olanzapine tbdp or 10 mg, 15 mg, 20 mg, 5 1 fluphenazine hcl tabs 1 mg mg, 10 mg, 2.5 mg, 5 1 mg quetiapine fumarate perphenazine tabs 1 tabs 100 mg, 200 mg, 1 25 mg, 300 mg, 400 prochlorperazine 1 mg, 50 mg maleate tabs quetiapine fumarate PA prochlorperazine supp 1 tb24 150 mg, 200 mg, 1 300 mg, 400 mg, 50 thioridazine hcl tabs 1 mg SAPHRIS SUBL PA 1 3 trifluoperazine hcl tabs (asenapine maleate) SECUADO PT24 PA; QL(1 ea Quinolinone Derivatives 3 ABILIFY TABS 10 MG, 2 (asenapine) daily) GP MG, 30 MG ( ) SEROQUEL TABS aripiprazole GP (quetiapine fumarate) aripiprazole soln 1 1 SEROQUEL XR TB24 150 PA mg/ml MG, 200 MG, 400 MG, 50 aripiprazole tabs 10 MG (quetiapine GP mg, 15 mg, 2 mg, 20 1 fumarate) mg, 30 mg, 5 mg VERSACLOZ SUSP QL(18 ml daily) PA 3 aripiprazole tbdp 10 1 (clozapine) mg, 15 mg ZYPREXA SOLR IM 10 PA REXULTI TABS PA SP 3 MG (olanzapine) (brexpiprazole) ZYPREXA TABS OR 10 Thioxanthenes MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG GP thiothixene caps 1 (olanzapine) ZYPREXA ZYDIS TBDP ANTISEPTICS & DISINFECTANTS GP (olanzapine) Antiseptics & Disinfectants Dihydroindolones

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52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Formaldehyde) 1 DOVATO TABS FORMADON SOLN (dolutegravir sodium- 2 formaldehyde soln 1 lamivudine) EDURANT TABS 2 ANTIVIRALS - Drugs to Treat Viral Infections (rilpivirine hcl) Antiretrovirals efavirenz caps 1 abacavir sulfate soln 1 efavirenz tabs 1 abacavir sulfate tabs 1 efavirenz-emtricitabine- ST tenofovir disoproxil 1 abacavir sulfate- 1 fumarate tabs lamivudine tabs abacavir sulfate- emtricitabine caps 1 lamivudine-zidovudine 1 emtricitabine-tenofovir tabs disoproxil fumarate 1 APTIVUS CAPS 2 tabs (tipranavir) EMTRIVA CAPS 200 MG APTIVUS SOLN GP 2 (emtricitabine) (tipranavir) EMTRIVA SOLN 10 2 atazanavir sulfate caps 1 MG/ML (emtricitabine) EPIVIR SOLN ATRIPLA TABS ST GP (lamivudine) (efavirenz- GP EPIVIR TABS emtricitabine-tenofovir GP ( ) disoproxil fumarate) lamivudine EPZICOM TABS COMBIVIR TABS GP (abacavir sulfate- GP (lamivudine-zidovudine) lamivudine) COMPLERA TABS ST EVOTAZ TABS (emtricitabine- rilpivirine-tenofovir 2 (atazanavir sulfate- 2 ) disoproxil fumarate) cobicistat CRIXIVAN CAPS fosamprenavir calcium 2 1 (indinavir sulfate) tabs FUZEON SOLR PA DELSTRIGO TABS ST SP (doravirine-lamivudine- (enfuvirtide) tenofovir disoproxil 3 GENVOYA TABS (elvitegravir-cobicistat- fumarate) 2 DESCOVY TABS PA emtricitabine-tenofovir (emtricitabine-tenofovir 2 alafenamide) INTELENCE TABS alafenamide fumarate) 2 (etravirine) 1 didanosine cpdr INVIRASE CAPS 2 (saquinavir mesylate)

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53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INVIRASE TABS ODEFSEY TABS ST 2 (saquinavir mesylate) (emtricitabine- 2 ISENTRESS CHEW rilpivirine-tenofovir 2 (raltegravir potassium) alafenamide fumarate) ISENTRESS HD TABS PIFELTRO TABS 2 2 (raltegravir potassium) (doravirine) ISENTRESS PACK PREZCOBIX TABS 2 2 (raltegravir potassium) (darunavir-cobicistat) ISENTRESS TABS PREZISTA SUSP 2 2 (raltegravir potassium) (darunavir ethanolate) PREZISTA TABS JULUCA TABS 2 (dolutegravir sodium- 2 (darunavir ethanolate) rilpivirine hcl) RESCRIPTOR TABS 2 KALETRA SOLN 100 (delavirdine mesylate) MG/5ML-400 MG/5ML GP RETROVIR CAPS GP (lopinavir-ritonavir) (zidovudine) KALETRA TABS 100 MG- RETROVIR SYRP GP 25 MG, 200 MG-50 MG 2 (zidovudine) (lopinavir-ritonavir) REYATAZ CAPS 150 MG, lamivudine soln 1 200 MG (atazanavir GP sulfate) lamivudine tabs 1 REYATAZ PACK 50 MG 2 (atazanavir sulfate) lamivudine-zidovudine 1 tabs ritonavir tabs 1 LEXIVA SUSP 50 MG/ML SELZENTRY SOLN (fosamprenavir 2 2 (maraviroc) calcium) SELZENTRY TABS LEXIVA TABS 700 MG 2 (maraviroc) (fosamprenavir GP calcium) stavudine caps 1 lopinavir-ritonavir soln 1 STRIBILD TABS (elvitegravir-cobicistat- nevirapine susp 1 emtricitabine-tenofovir 2 df) nevirapine tabs 1 SUSTIVA CAPS GP nevirapine tb24 1 (efavirenz) SUSTIVA TABS NORVIR SOLN 80 MG/ML GP 2 (efavirenz) (ritonavir) SYMTUZA TABS ST NORVIR TABS 100 MG GP (darunavir-cobicistat- (ritonavir) emtricitabine-tenofovir 3 alafenamide)

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54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tenofovir disoproxil 1 ZERIT CAPS (stavudine) GP fumarate tabs TIVICAY TABS 50 MG ZIAGEN SOLN (abacavir 2 GP (dolutegravir sodium) sulfate) ZIAGEN TABS ( TRIUMEQ TABS abacavir GP (abacavir-dolutegravir- 2 sulfate) lamivudine) zidovudine caps 1 TRIZIVIR TABS (abacavir sulfate-lamivudine- GP zidovudine syrp 1 zidovudine) zidovudine tabs 1 TRUVADA TABS 100 MG- 150 MG, 133 MG-200 MG, CMV Agents 167 MG-250 MG 2 PA (emtricitabine-tenofovir cidofovir soln SP disoproxil fumarate) FOSCAVIR SOLN PA SP TRUVADA TABS 200 MG- (foscarnet sodium) 300 MG (emtricitabine- PREVYMIS TABS PA; SP GP SP tenofovir disoproxil (letermovir) fumarate) VALCYTE SOLR 50 QL(21 ml daily) TYBOST TABS 2 MG/ML (valganciclovir GP (cobicistat) hcl) VIDEX EC CPDR 125 MG VALCYTE TABS 450 MG 2 GP (didanosine) (valganciclovir hcl) VIDEX EC CPDR 200 MG, QL(21 ml daily) valganciclovir hcl solr 1 250 MG, 400 MG 3 50 mg/ml (didanosine) VIDEXPEDIATRIC SOLR valganciclovir hcl tabs 1 2 (didanosine) 450 mg VIRACEPT TABS Hepatitis Agents 2 (nelfinavir mesylate) (Ribavirin (Hepatitis C)) PA VIRAMUNE SUSP MODERIBA, 1 GP RIBASPHERE TABS (nevirapine) (Ribavirin (Hepatitis C)) PA VIRAMUNE TABS 1 GP RIBASPHERE CAPS (nevirapine) (Ribavirin (Hepatitis C)) PA VIRAMUNE XR TB24 GP RIBASPHERE RIBAPAK 1 (nevirapine) TBPK 400 MG, 600 MG VIREAD POWD 40 MG/GM adefovir dipivoxil tabs 1 (tenofovir disoproxil 2 BARACLUDE SOLN 0.05 fumarate) 2 VIREAD TABS 150 MG, MG/ML (entecavir) BARACLUDE TABS 0.5 200 MG, 250 MG GP (tenofovir disoproxil 2 MG, 1 MG (entecavir) fumarate)

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55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DAKLINZA TABS PA PA ribavirin (hepatitis c) 1 (daclatasvir SP caps dihydrochloride) PA ribavirin (hepatitis c) 1 entecavir tabs 1 tabs SOFOSBUVIR/VELPATAS PA EPCLUSA TABS 100 MG- PA 400 MG, 200 MG-50 MG SP VIR TABS (sofosbuvir- SP (sofosbuvir-velpatasvir) velpatasvir) SOVALDI TABS 200 MG, PA EPIVIR HBV SOLN 5 SP MG/ML (lamivudine 3 400 MG (sofosbuvir) (hbv)) VEMLIDY TABS PA EPIVIR HBV TABS 100 (tenofovir alafenamide SP GP MG (lamivudine (hbv)) fumarate) HARVONI TABS 200 MG- PA VIEKIRA PAK TBPK PA 45 MG, 400 MG-90 MG SP (ombitasvir-paritaprevir- SP (ledipasvir-sofosbuvir) ritonavir-dasabuvir) VOSEVI TABS PA lamivudine (hbv) tabs 1 (sofosbuvir-velpatasvir- SP LEDIPASVIR/SOFOSBUVI PA voxilaprevir) R TABS (ledipasvir- SP ZEPATIER TABS PA SP sofosbuvir) (elbasvir-grazoprevir) MAVYRET TABS PA Herpes Agents (glecaprevir- SP pibrentasvir) acyclovir caps 1 MODERIBA 1200 DOSE PA acyclovir susp 1 PACK TBPK (ribavirin 3 (hepatitis c)) acyclovir tabs 1 PEGASYS PROCLICK PA SOLN (peginterferon SP famciclovir tabs 1 alfa-2a) 1 PEGASYS SOLN PA valacyclovir hcl tabs SP (peginterferon alfa-2a) VALTREX TABS 1 GM GP PEGINTRON KIT PA (valacyclovir hcl) SP (peginterferon alfa-2b) ZOVIRAX CAPS OR 200 GP REBETOL CAPS 200 MG PA MG (acyclovir) GP (ribavirin (hepatitis c)) ZOVIRAX SUSP OR 200 GP REBETOL SOLN 40 PA MG/5ML (acyclovir) MG/ML (ribavirin 2 ZOVIRAX TABS OR 400 GP (hepatitis c)) MG, 800 MG (acyclovir) RIBASPHERE RIBAPAK PA Influenza Agents TBPK (ribavirin 3 FLUMADINE TABS (hepatitis c)) (rimantadine 3 hydrochloride)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ea per oseltamivir phosphate 1 Beta Blockers Cardio-Selective caps or 30 mg, 45 mg 180 days retail) acebutolol hcl caps 1 oseltamivir phosphate 1 caps or 75 mg atenolol tabs 1 QL(180 ml per betaxolol hcl tabs 1 oseltamivir phosphate 1 180 days retail); AL(At susr or 6 mg/ml QL(1 ea daily) least 1 yrs old) bisoprolol fumarate 1 Limit 1 inhaler tabs RELENZA DISKHALER BYSTOLIC TABS 3 per 3 AEPB (zanamivir) month;QL(0.67 (nebivolol hcl) ea daily) LOPRESSOR TABS GP rimantadine 1 (metoprolol tartrate) hydrochloride tabs metoprolol succinate 1 TAMIFLU CAPS 30 MG, 45 QL(10 ea per tb24 MG (oseltamivir GP 180 days retail) phosphate) metoprolol tartrate tabs 1 QL(180 ml per TENORMIN TABS TAMIFLU SUSR 6 MG/ML GP GP 180 days (atenolol) (oseltamivir phosphate) retail); AL(At TOPROL XL TB24 100 least 1 yrs old) MG, 200 MG, 25 MG GP Respiratory Syncytial Virus (RSV) Agents (metoprolol succinate) ribavirin solr 1 Beta Blockers Non-Selective VIRAZOLE SOLR (Sotalol Hcl) SORINE 1 GP TABS (ribavirin) BETAPACE AF TABS GP BETA BLOCKERS - Drugs to Treat High Blood (sotalol hcl (afib/afl)) Pressure BETAPACE TABS ( sotalol GP Alpha-Beta Blockers hcl) carvedilol phosphate CORGARD TABS 1 GP cp24 (nadolol) carvedilol tabs 12.5 HEMANGEOL SOLN AL(Up to 1 yrs 1 3 mg, 25 mg, 6.25 mg (propranolol hcl) old ) carvedilol tabs 3.125 QL(2 ea daily) INDERAL LA CP24 1 GP mg (propranolol hcl) COREG CR CP24 INDERAL XL CP24 GP (carvedilol phosphate) (propranolol hcl 3 COREG TABS 12.5 MG, sustained-release GP 25 MG (carvedilol) beads) COREG TABS 3.125 MG QL(2 ea daily) INNOPRAN XL CP24 GP (carvedilol) (propranolol hcl sustained-release 3 1 labetalol hcl tabs beads)

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57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nadolol tabs 1 CARDIZEM LA TB24 120 MG (diltiazem hcl 2 pindolol tabs 1 coated beads) CARDIZEM LA TB24 180 propranolol hcl cp24 1 MG, 240 MG, 300 MG, 360 MG, 420 MG (diltiazem GP propranolol hcl soln 1 hcl coated beads) CARDIZEM TABS propranolol hcl tabs 1 GP (diltiazem hcl) sotalol hcl (afib/afl) tabs 1 diltiazem hcl coated 1 beads cp24 sotalol hcl tabs 1 diltiazem hcl coated 1 SOTYLIZE SOLN ( beads tb24 sotalol 3 hcl) diltiazem hcl cp12 120 1 QL(2 ea daily) mg, 60 mg, 90 mg timolol maleate tabs 10 1 mg, 20 mg, 5 mg diltiazem hcl cp24 120 1 CALCIUM CHANNEL BLOCKERS - Drugs to mg, 180 mg, 240 mg Treat High Blood Pressure diltiazem hcl extended 1 Calcium Channel Blockers release beads cp24 (Diltiazem Hcl Coated 1 diltiazem hcl tabs 120 Beads) CARTIA XT CP24 mg, 30 mg, 60 mg, 90 1 (Diltiazem Hcl Coated 1 mg Beads) MATZIM LA TB24 (Diltiazem Hcl Extended felodipine tb24 1 Release Beads) TAZTIA 1 XT, TIADYLT ER CP24 isradipine caps 1 (Diltiazem Hcl) DILT-XR 1 1 CP24 nicardipine hcl caps ADALAT CC TB24 30 MG, nifedipine caps 10 mg, GP 1 60 MG (nifedipine) 20 mg ADALAT CC TB24 90 MG QL(1 ea daily) GP nifedipine tb24 30 mg, 1 (nifedipine) 60 mg amlodipine besylate QL(2 ea daily) QL(1 ea daily) 1 nifedipine tb24 30 mg, 1 tabs 60 mg, 90 mg CALAN SR TBCR GP nimodipine caps 1 (verapamil hcl) CALAN TABS ( 1 verapamil GP nisoldipine tb24 ) hcl NORVASC TABS QL(2 ea daily) GP CARDIZEM CD CP24 (amlodipine besylate) ( GP diltiazem hcl coated NYMALIZE SOLN 30 beads) MG/10ML, 60 MG/20ML 3 (nimodipine)

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58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCARDIA CAPS GP amlodipine besylate- (nifedipine) atorvastatin calcium 1 PROCARDIA XL TB24 QL(1 ea daily) tabs GP (nifedipine) BIDIL TABS (isosorbide SULAR TB24 3 GP dinitrate-hydralazine (nisoldipine) hcl) TIAZAC CP24 (diltiazem CADUET TABS hcl extended release GP (amlodipine besylate- GP beads) atorvastatin calcium) ENTRESTO TABS PA verapamil hcl cp24 1 3 (sacubitril-valsartan) verapamil hcl tabs 1 Impotence Agents GP PA; QL(1 ea verapamil hcl tbcr 1 CIALIS TABS (tadalafil) daily) VERELAN CP24 120 MG, tadalafil tabs 1 PA; QL(1 ea 180 MG, 240 MG GP daily) (verapamil hcl) Peripheral Vasodilators VERELAN CP24 360 MG 2 (verapamil hcl) isoxsuprine hcl tabs 1 VERELAN PM CP24 3 Prostaglandin Vasodilators (verapamil hcl) ORENITRAM TBCR PA SP CARDIOTONICS - Drugs to Treat Heart Failure (treprostinil diolamine) and Abnormal Heart Rhythm REMODULIN SOLN PA SP Cardiac Glycosides (treprostinil) PA (Digoxin) DIGITEK, DIGOX 1 treprostinil soln SP TABS VENTAVIS SOLN PA SP digoxin soln 1 (iloprost) digoxin tabs 1 Pulmonary Hypertension - Endothelin Receptor PA LANOXIN PEDIATRIC PA ambrisentan tabs SP SP SOLN (digoxin) SP PA LANOXIN SOLN IJ 0.25 bosentan tabs GP MG/ML (digoxin) LETAIRIS TABS PA SP LANOXIN TABS OR 125 (ambrisentan) 3 MCG, 250 MCG (digoxin) OPSUMIT TABS PA SP LANOXIN TABS OR 62.5 (macitentan) 3 MCG (digoxin) TRACLEER TABS 125 PA SP CARDIOVASCULAR AGENTS - MISC. - Drugs to MG, 62.5 MG (bosentan) Treat Heart and Circulation Conditions TRACLEER TBSO 32 MG PA; SP- Acaria SP Health;SP Cardiovascular Agents Misc. - Combinations (bosentan) Pulmonary Hypertension - Phosphodiesterase

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59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tadalafil (Pulmonary PA ADEMPAS TABS PA SP Hypertension)) ALYQ SP (riociguat) TABS Sinus Node Inhibitors ADCIRCA TABS (tadalafil PA CORLANOR SOLN 5 ST; QL(15 ml (pulmonary SP 3 MG/5ML (ivabradine hcl) daily) hypertension)) CORLANOR TABS 5 MG, ST REVATIO SOLN IV 10 PA 3 7.5 MG (ivabradine hcl) MG/12.5ML (sildenafil citrate (pulmonary SP Transthyretin Stabilizers VYNDAMAX CAPS PA; QL(1 ea hypertension)) SP REVATIO SUSR OR 10 PA (tafamidis) daily) MG/ML (sildenafil citrate VYNDAQEL CAPS PA; QL(4 ea (pulmonary SP (tafamidis meglumine SP daily) hypertension)) (cardiac)) REVATIO TABS OR 20 PA; PAH Only CEPHALOSPORINS - Drugs to Treat Bacterial MG (sildenafil citrate Infections SP (pulmonary Cephalosporins - 1st Generation hypertension)) 1 sildenafil citrate PA cefadroxil caps (pulmonary SP cefadroxil susr 1 hypertension) soln iv 10 mg/12.5ml cefadroxil tabs 1 sildenafil citrate PA cefazolin sodium solr SP PA (pulmonary SP hypertension) susr or cephalexin caps 1 10 mg/ml SILDENAFIL CITRATE PA cephalexin susr 1 TABS (sildenafil citrate (pulmonary 2 cephalexin tabs 1 hypertension)) KEFLEX CAPS GP SILDENAFIL CITRATE PA; PAH Only (cephalexin) TABS (sildenafil citrate (pulmonary 2 Cephalosporins - 2nd Generation hypertension)) cefaclor caps 1 tadalafil (pulmonary PA CEFACLOR ER TB12 SP 3 hypertension) tabs (cefaclor monohydrate) Pulmonary Hypertension - Prostacyclin Receptor cefaclor susr 1 UPTRAVI TABS PA SP CEFOTAN SOLR PA (selexipag) SP (cefotetan disodium) UPTRAVI TBPK PA SP (selexipag) cefotetan disodium solr SP PA Pulmonary Hypertension - Sol Guanylate Cyclase

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60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA SUPRAX CHEW 100 MG, cefoxitin sodium solr ij SP 3 10 gm 200 MG (cefixime) PA SUPRAX SUSR 100 cefoxitin sodium solr iv SP 1 gm, 2 gm MG/5ML, 200 MG/5ML GP (cefixime) CEFOXITIN SODIUM PA SUPRAX SUSR 500 SOLR IV 1 GM-4 %, 2 GM- 3 2.2 % (cefoxitin sodium SP MG/5ML (cefixime) and dextrose) Cephalosporins - 4th Generation cefprozil susr 1 cefepime hcl solr SP PA CEFEPIME SOLN PA cefprozil tabs 1 SP (cefepime hcl) cefuroxime axetil tabs 1 CEFEPIME/DEXTROSE PA PA SOLR (cefepime hcl- SP cefuroxime sodium solr SP dextrose) MAXIPIME SOLR PA Cephalosporins - 3rd Generation SP (cefepime hcl) (Ceftazidime) TAZICEF SP PA SOLR Cephalosporins - 5th Generation TEFLARO SOLR PA cefdinir caps 1 SP (ceftaroline fosamil) cefdinir susr 1 CONTRACEPTIVES - Drugs to Prevent Pregnancy cefditoren pivoxil tabs 1 Combination Contraceptives - Oral cefixime caps 1 (Desogestrel & Ethinyl PV Estradiol) APRI, CYRED, cefixime susr 1 CYRED EQ, EMOQUETTE, ENSKYCE, PV cefotaxime sodium solr SP PA ISIBLOOM, JULEBER, KALLIGA, RECLIPSEN TABS cefpodoxime proxetil 1 susr (Desogestrel-Ethinyl PV Estradiol (Biphasic)) cefpodoxime proxetil 1 tabs AZURETTE, BEKYREE, PV KARIVA, PIMTREA, ceftazidime solr SP PA SIMLIYA, VIORELE, VOLNEA TABS ceftriaxone sodium solr SP PA (Desogestrel-Ethinyl PV Estradiol (Triphasic)) PV CLAFORAN SOLR PA SP CAZIANT, VELIVET TABS (cefotaxime sodium) FORTAZ SOLR IJ 1 GM PA SP (ceftazidime) SUPRAX CAPS 400 MG GP (cefixime)

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61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Drospirenone-Ethinyl PV (Norethin Acet & Estrad- PV Estradiol) GIANVI, Fe) AUROVELA 24 FE, JASMIEL, LO- AUROVELA FE 1.5/30, ZUMANDIMINE, LORYNA, PV AUROVELA FE 1/20, NIKKI, OCELLA, SYEDA, BLISOVI 24 FE, BLISOVI ZARAH, ZUMANDIMINE FE 1.5/30, BLISOVI FE TABS 1/20, HAILEY 24 FE, (Drospirenone-Ethinyl PV HAILEY FE 1.5/30, HAILEY FE 1/20, JUNEL FE 1.5/30, Estradiol-Levomefolate PV Calcium) RAJANI, JUNEL FE 1/20, JUNEL FE PV TYDEMY TABS 24, LARIN 24 FE, LARIN FE 1.5/30, LARIN FE 1/20, (Ethynodiol Diacet & Eth PV LOESTRIN FE 1.5/30, Estrad) KELNOR 1/35, PV LOESTRIN FE 1/20, KELNOR 1/50, ZOVIA MICROGESTIN 24 FE, 1/35, ZOVIA 1/35E TABS MICROGESTIN FE 1.5/30, (Levonorgestrel & Eth PV MICROGESTIN FE 1/20, Estradiol) AFIRMELLE, TARINA 24 FE, TARINA ALTAVERA, AUBRA, FE 1/20, TARINA FE 1/20 AUBRA EQ, AVIANE, EQ TABS AYUNA, CHATEAL, (Norethin Acet & Estrad- PV CHATEAL EQ, DELYLA, Fe) CHARLOTTE 24 FE, PV FALMINA, KURVELO, PV MELODETTA 24 FE, LARISSIA, LESSINA, MIBELAS 24 FE CHEW LEVORA 0.15/30-28, LILLOW, LUTERA, (Norethin Acet & Estrad- PV PA; PV MARLISSA, ORSYTHIA, Fe) GEMMILY CAPS PORTIA-28, SRONYX, (Norethindrone & Eth PV VIENVA TABS Estradiol) ALYACEN 1/35, (Levonorgestrel-Eth PV BALZIVA, BRIELLYN, Estradiol (Triphasic)) CYCLAFEM 1/35, ENPRESSE-28, PV DASETTA 1/35, NECON PV LEVONEST, MYZILRA, 0.5/35-28, NORTREL TRIVORA-28 TABS 0.5/35 (28), NORTREL 1/35, PHILITH, PIRMELLA (Levonorgestrel-Ethinyl PV 1/35, VYFEMLA, WERA Estradiol (91-Day)) TABS AMETHIA, AMETHIA LO, ASHLYNA, CAMRESE, (Norethindrone & Ethinyl PV CAMRESE LO, DAYSEE, Estradiol-Fe) KAITLIB FE, PV FAYOSIM, ICLEVIA, PV LAYOLIS FE, WYMZYA FE INTROVALE, JAIMIESS, CHEW JOLESSA, LOJAIMIESS, (Norethindrone Acet & Eth PV QUASENSE, RIVELSA, Estra) AUROVELA 1.5/30, SETLAKIN, SIMPESSE AUROVELA 1/20, HAILEY TABS 1.5/30, JUNEL 1.5/30, (Levonorgestrel-Ethinyl PV JUNEL 1/20, LARIN 1.5/30, PV Estradiol (Continuous)) PV LARIN 1/20, LOESTRIN AMETHYST TABS 1.5/30-21, LOESTRIN 1/20-21, MICROGESTIN 1.5/30, MICROGESTIN 1/20 TABS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone Acetate- PV drospirenone-ethinyl PV Ethinyl Estradiol-Fe) TILIA PV estradiol-levomefolate PV FE, TRI-LEGEST FE TABS calcium tabs (Norethindrone-Eth PV ESTROSTEP FE TABS PV Estradiol (Triphasic)) ALYACEN 7/7/7, (norethindrone acetate- GP ARANELLE, CYCLAFEM PV ethinyl estradiol-fe) 7/7/7, DASETTA 7/7/7, ethynodiol diacet & eth PV LEENA, NORTREL 7/7/7, estrad tabs 1 mg-35 PV PIRMELLA 7/7/7 TABS mcg, 1 mg-50 mcg (Norgestimate-Ethinyl PV Estradiol (Triphasic)) TRI FALESSA KIT PA; PV FEMYNOR, TRI- (levonorgestrel-ethinyl PV ESTARYLLA, TRI-LINYAH, estradiol & folic acid) TRI-LO-ESTARYLLA, TRI- PV GENERESS FE CHEW PV LO-MARZIA, TRI-LO-MILI, (norethindrone & GP TRI-LO-SPRINTEC, TRI- MILI, TRI-PREVIFEM, TRI- ethinyl estradiol-fe) SPRINTEC, TRI-VYLIBRA, PV levonorgestrel & eth PV TRI-VYLIBRA LO TABS estradiol tabs (Norgestimate-Ethinyl PV levonorgestrel-eth PV Estradiol) ESTARYLLA, PV FEMYNOR, MILI, MONO- estradiol (triphasic) LINYAH, MONONESSA, PV tabs NYMYO, PREVIFEM, PV levonorgestrel-ethinyl PV SPRINTEC 28, VYLIBRA estradiol (91-day) tabs TABS levonorgestrel-ethinyl PV (Norgestrel & Ethinyl PV Estradiol) CRYSELLE-28, estradiol (continuous) PV ELINEST, LOW- PV tabs OGESTREL, OGESTREL LO LOESTRIN FE TABS PV TABS (norethindrone acetate- BALCOLTRA TABS QL(1 ea daily); ethinyl estradiol-fe fum PV (levonorgestrel-ethinyl PV PV (biphasic)) estradiol-ferrous LOSEASONIQUE TABS PV bisglycinate) (levonorgestrel-ethinyl GP BEYAZ TABS PV estradiol (91-day)) (drospirenone-ethinyl GP MINASTRIN 24 FE CHEW PV estradiol-levomefolate (norethin acet & estrad- PV calcium) fe) PV desogestrel & ethinyl PV MINASTRIN 24 FE CHEW PV estradiol tabs (norethin acet & estrad- GP desogestrel-ethinyl PV fe) estradiol (biphasic) PV MIRCETTE TABS PV tabs (desogestrel-ethinyl GP PV estradiol (biphasic)) drospirenone-ethinyl PV estradiol tabs

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATAZIA TABS PV SAFYRAL TABS PV (estradiol valerate- PV (drospirenone-ethinyl GP dienogest) estradiol-levomefolate norethin acet & estrad- PA; PV calcium) fe caps 1 mg-20 mcg- PV SEASONIQUE TABS PV 75 mg (levonorgestrel-ethinyl GP norethin acet & estrad- PV estradiol (91-day)) fe chew 1 mg-20 mcg- PV TAYTULLA CAPS PA; PV 75 mg (norethin acet & estrad- GP norethin acet & estrad- PV fe) TRI-NORINYL 28 TABS PV fe tabs 1 mg-20 mcg- PV 75 mg, 1.5 mg-30 mcg- (norethindrone-eth GP 75 mg estradiol (triphasic)) PV TYBLUME TABS PV norethindrone & ethinyl PV estradiol-fe chew (levonorgestrel & eth PV estradiol) PV norethindrone acet & PV eth estra tabs YASMIN 28 TABS PV (drospirenone-ethinyl GP norgestimate-ethinyl PV estradiol) estradiol (triphasic) PV YAZ TABS PV tabs (drospirenone-ethinyl GP PV norgestimate-ethinyl PV estradiol) estradiol tabs Combination Contraceptives - Transdermal ORTHO TRI-CYCLEN LO PV (Norelgestromin-Ethinyl PV TABS (norgestimate- PV GP Estradiol) XULANE PTWK ethinyl estradiol TWIRLA PTWK QL(3 ea per 28 (triphasic)) (levonorgestrel-ethinyl PV days retail); PV ORTHO TRI-CYCLEN PV estradiol) TABS (norgestimate- ethinyl estradiol GP Combination Contraceptives - Vaginal (triphasic)) (Etonogestrel-Ethinyl PV PV Estradiol) ELURYNG RING ORTHO-CYCLEN TABS PV ANNOVERA RING PV (norgestimate-ethinyl GP (segesterone acetate- PV estradiol) ethinyl estradiol) ORTHO-NOVUM 1/35 PV PV TABS (norethindrone & GP etonogestrel-ethinyl PV eth estradiol) estradiol ring ORTHO-NOVUM 7/7/7 PV NUVARING RING PV TABS (norethindrone- GP (etonogestrel-ethinyl GP eth estradiol (triphasic)) estradiol) QUARTETTE TABS PV Copper Contraceptives - IUD (levonorgestrel-ethinyl GP estradiol (91-day))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARAGARD PV DEPO-SUBQ PROVERA PV INTRAUTERINE COPPER 104 SUSY PV CONTRACEPTIVE T380A (medroxyprogesterone PV IUD (copper (iud)) acetate (contraceptive)) Emergency Contraceptives medroxyprogesterone PV (Levonorgestrel PV acetate (contraceptive) PV (Emergency Oc)) AFTERA, susp ECONTRA EZ, ECONTRA PV ONE-STEP, MY CHOICE, medroxyprogesterone MY WAY, NEW DAY, PV acetate (contraceptive) PV OPCICON ONE-STEP, susy OPTION 2, PREVENTEZA, Progestin Contraceptives - Oral REACT, TAKE ACTION TABS (Norethindrone PV (Contraceptive)) CAMILA, ELLA TABS ( PV ulipristal PV DEBLITANE, ERRIN, acetate) HEATHER, INCASSIA, PV JENCYCLA, JOLIVETTE, PV levonorgestrel PV (emergency oc) tabs LYZA, NORA-BE, NORLYDA, NORLYROC, PLAN B ONE-STEP TABS PV SHAROBEL, TULANA (levonorgestrel GP TABS (emergency oc)) PV norethindrone PV Progestin Contraceptives - IUD (contraceptive) tabs KYLEENA IUD PV ORTHO MICRONOR PV PV (levonorgestrel (iud)) TABS (norethindrone GP LILETTA IUD PV (contraceptive)) PV (levonorgestrel (iud)) SLYND TABS PV PV MIRENA IUD PV (drospirenone) PV (levonorgestrel (iud)) CORTICOSTEROIDS - Steroid Hormone Drugs to SKYLA IUD PV Treat Systemic Swelling Conditions PV (levonorgestrel (iud)) Glucocorticosteroids Progestin Contraceptives - Implants () 1 NEXPLANON IMPL PV DECADRON ELIX PV (etonogestrel) (Dexamethasone) 1 DECADRON TABS Progestin Contraceptives - Injectable (Dexamethasone) DEXPAK DEPO-PROVERA PV 10 DAY, DEXPAK 13 DAY, CONTRACEPTIVE SUSP GP DEXPAK 6 DAY, HIDEX 6- 1 (medroxyprogesterone DAY, TAPERDEX 6-DAY acetate (contraceptive)) TBPK DEPO-PROVERA PV budesonide cpep 3 mg 1 CONTRACEPTIVE SUSY GP (medroxyprogesterone budesonide tb24 9 mg 1 PA acetate (contraceptive)) CORTEF TABS GP (hydrocortisone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cortisone acetate tabs 1 ORAPRED ODT TBDP (prednisolone sodium GP dexamethasone elix 1 phosphate) DEXAMETHASONE prednisolone sodium INTENSOL CONC 2 phosphate soln or 10 1 (dexamethasone) mg/5ml, 15 mg/5ml, 20 dexamethasone PA mg/5ml, 25 mg/5ml sodium phosphate soln prednisolone sodium 10 mg/ml, 100 SP phosphate tbdp or 10 1 mg/10ml, 120 mg/30ml, mg, 15 mg, 30 mg 20 mg/5ml, 4 mg/ml prednisolone soln 1 DEXAMETHASONE PA PREDNISONE INTENSOL SODIUM PHOSPHATE 2 SOLN 4 MG/ML SP CONC (prednisone) (dexamethasone prednisone soln 5 1 sodium phosphate) mg/5ml dexamethasone soln 1 prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 1 dexamethasone tabs 1 5 mg, 50 mg prednisone tbpk 10 mg, 1 dexamethasone tbpk 1 5 mg ENTOCORT EC CPEP RAYOS TBEC PA GP 3 (budesonide) (prednisone) UCERIS TB24 OR 9 MG PA hydrocortisone tabs 1 GP (budesonide) MEDROL DOSEPAK TBPK GP VERIPRED 20 SOLN (methylprednisolone) (prednisolone sodium GP MEDROL TABS 16 MG, 32 phosphate) MG, 4 MG, 8 MG GP (methylprednisolone) Mineralocorticoids MEDROL TABS 2 MG fludrocortisone acetate 2 1 (methylprednisolone) tabs methylprednisolone 1 COUGH/COLD/ALLERGY - Drugs to Treat tabs Cough, Cold and Allergy Symptoms Antitussives methylprednisolone 1 tbpk (Hydrocodone W/ MILLIPRED DP TBPK Homatropine) HYDROMET 1 3 (prednisolone) SYRP MILLIPRED SOLN 10 benzonatate caps 1 MG/5ML (prednisolone GP HYCODAN SYRP sodium phosphate) (hydrocodone w/ GP MILLIPRED TABS 5 MG 2 homatropine) (prednisolone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DOCTOR MANZANILLA hydrocodone w/ 1 homatropine syrp PE SYRUP ANTIHISTAMINE/DECON 3 hydrocodone w/ 1 GESTANT LIQD homatropine tabs (triprolidine- TESSALON PERLES GP phenylephrine) CAPS (benzonatate) DOMETUSS-DMX LIQD Cough/Cold/Allergy Combinations (phenylephrine w/ dm- 3 (Guaifenesin-Codeine) gg) CHERATUSSIN AC, 1 EXACTUSS LIQD RX/OTC GUAIATUSSIN AC, (phenylephrine w/ dm- GP GUAIFENESIN AC SYRP gg) (Guaifenesin-Codeine) G EXACTUSS TR TABS RX/OTC TUSSIN AC, MAXI-TUSS 1 AC, ROBAFEN AC, (phenylephrine w/ dm- 3 VIRTUSSIN A/C SOLN gg) EXAPHEX TR TABS RX/OTC (Guaifenesin-Codeine) 1 VIRTUSSIN AC/ALC LIQD (phenylephrine- 3 (Phenylephrine W/ Dm-Gg) RX/OTC guaifenesin) BIOGTUSS, GILTUSS 1 GILPHEX TR TABS RX/OTC PEDIATRIC LIQD (phenylephrine- 3 (Pseudoephedrine W/ guaifenesin) Codeine-Gg) 1 GUAIFENESIN DAC, GILTUSS COUGH & COLD RX/OTC VIRTUSSIN DAC SOLN TABS (phenylephrine w/ 3 ACTIDOM DMX LIQD dm-gg) (phenylephrine w/ dm- 3 GILTUSS LIQD RX/OTC gg) (phenylephrine w/ dm- GP BIO-DTUSS DMX LIQD gg) (pseudoephed- 3 GILTUSS SINUS & RX/OTC bromphen-dm) CONGESTION TABS ( 3 CARBAPHEN 12 LIQD phenylephrine- ) (phenylephrine- guaifenesin chlorpheniramine- 3 GILTUSS TR TABS RX/OTC carbetapentane) (phenylephrine w/ dm- 3 ) CARBAPHEN 12 PED gg SUSP (phenylephrine- guaifenesin-codeine 1 chlorpheniramine- 3 soln carbetapentane) HISTEX-PE SYRP CLARINEX-D 12 HOUR PA (triprolidine- GP TB12 (desloratadine- 3 phenylephrine) pseudoephedrine) hydrocodone polistirex- CODITUSSIN AC LIQD chlorpheniramine 1 3 (guaifenesin-codeine) polistirex suer

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOTUSS PLUS LIQD (Sodium Chloride (phenylephrine- 3 (Inhalant)) PULMOSAL 1 chlorphen-dm) NEBU HYPER-SAL NEBU promethazine & 1 phenylephrine syrp (sodium chloride GP (inhalant)) promethazine 1 w/codeine soln HYPERSAL NEBU 3.5 % (sodium chloride 3 promethazine 1 (inhalant)) w/codeine syrp HYPERSAL NEBU 7 % promethazine-dm soln 1 (sodium chloride GP (inhalant)) promethazine-dm syrp 1 NEBUSAL NEBU 6 % promethazine- (sodium chloride 3 phenylephrine-codeine 1 (inhalant)) syrp sodium chloride 1 (inhalant) nebu pseudoephed-cpm w/ 1 hydrocod soln Mucolytics SEMPREX-D CAPS acetylcysteine soln 1 (acrivastine & 3 pseudoephedrine) DERMATOLOGICALS - Drugs to Treat Skin TUSSICAPS CP12 Conditions (hydrocodone Acne Products polistirex- 3 (Benzoyl Peroxide) chlorpheniramine BENZEPRO CREAMY polistirex) WASH, BP WASH, PR 1 BENZOYL PEROXIDE TUSSIONEX WASH LIQD PENNKINETIC EXTENDED RELEASE (Clindamycin Phosphate SUER (hydrocodone (Topical)) CLINDACIN ETZ 1 GP PLEDGETS, CLINDACIN-P polistirex- SWAB chlorpheniramine (Clindamycin Phosphate- polistirex) Benzoyl Peroxide 1 TUSSLIN LIQD RX/OTC (Refrigerate)) NEUAC GEL (phenylephrine w/ dm- 3 (Erythromycin (Acne Aid)) 1 gg) ERY PADS TUSSLIN PEDIATRIC RX/OTC (Isotretinoin) Greater than 5 LIQD (phenylephrine w/ 3 months AMNESTEEM, 1 requires dm-gg) MYORISAN, ZENATANE CAPS PA;QL(2 ea Misc. Respiratory Inhalants daily) (Sodium Chloride (Inhalant)) NEBUSAL 1 NEBU 3 %

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Greater than 5 Limit 45gms (Isotretinoin) CLARAVIS months 1 per CAPS 10 MG, 20 MG, 30 1 requires adapalene gel 0.3 % month;QL(1.5 MG, 40 MG PA;QL(2 ea gm daily) daily) adapalene lotn 0.1 % 1 (Sulfacetamide Sodium W/ Sulfur) AVAR CLEANSER, adapalene-benzoyl 1 BP 10-1, ROSANIL 1 peroxide gel CLEANSER, SULFAMEZ WASH EMUL ATRALIN GEL (tretinoin) GP (Sulfacetamide Sodium W/ AVAR LS CLEANSER Sulfur) AVAR-E EMOLLIENT, AVAR-E 1 LIQD (sulfacetamide GP GREEN, SSS 10%-5% sodium w/ sulfur) CREA AVAR LS PADS (Sulfacetamide Sodium W/ 1 (sulfacetamide sodium 3 Sulfur) SSS 10-5 FOAM w/ sulfur) (Sulfacetamide Sodium W/ AVAR PADS Sulfur) SULFACLEANSE 1 (sulfacetamide sodium 3 8/4 SUSP w/ sulfur) (Sulfacetamide Sodium- Sulfur In Urea Vehicle) BP 1 AVAR-E LS CREA CLEANSING WASH EMUL (sulfacetamide sodium GP w/ sulfur) (Tretinoin) AVITA CREA 1 AZELEX CREA ( azelaic 3 (Tretinoin) AVITA GEL 1 acid (acne)) BENZACLIN GEL PA; Limited to ABSORICA CAPS (clindamycin 3 5 months of GP (isotretinoin) treatment;QL(2 phosphate-benzoyl ea daily) peroxide) PA; Limited to BENZACLIN WITH PUMP ABSORICA LD CAPS 3 5 months of GEL (clindamycin (isotretinoin micronized) treatment;QL(2 phosphate-benzoyl GP ea daily) peroxide) ACZONE GEL 5 % PA GP BENZAMYCIN GEL (dapsone (topical)) (benzoyl peroxide- GP ACZONE GEL 7.5 % PA; QL(2 gm GP erythromycin) (dapsone (topical)) daily) benzoyl peroxide- 1 Limit 45gms erythromycin gel 1 per adapalene crea 0.1 % month;QL(1.5 CLEOCIN-T GEL gm daily) (clindamycin phosphate 3 Limit 45gms (topical)) per CLEOCIN-T LOTN adapalene gel 0.1 % 1 month;QL(1.5 (clindamycin phosphate GP gm daily); (topical)) RX/OTC

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN-T SOLN Limit 45gms (clindamycin phosphate GP DIFFERIN GEL 0.1 % per (topical)) GP month;QL(1.5 (adapalene) gm daily); CLEOCIN-T SWAB RX/OTC (clindamycin phosphate GP Limit 45gms (topical)) DIFFERIN GEL 0.3 % GP per CLINDACIN ETZ KIT (adapalene) month;QL(1.5 (clindamycin phosphate 3 gm daily) ) DIFFERIN LOTN 0.1 % & cleanser 3 CLINDACIN PAC KIT (adapalene) (clindamycin phosphate 3 DUAC GEL (clindamycin & cleanser) phosphate-benzoyl GP CLINDAGEL GEL peroxide (refrigerate)) (clindamycin phosphate 3 ERYGEL GEL (topical)) (erythromycin (acne GP aid)) clindamycin phosphate 1 (topical) foam erythromycin (acne aid) 1 gel clindamycin phosphate 1 (topical) gel erythromycin (acne aid) 1 pads clindamycin phosphate 1 (topical) lotn erythromycin (acne aid) 1 soln clindamycin phosphate 1 (topical) soln EVOCLIN FOAM (clindamycin phosphate GP clindamycin phosphate 1 (topical) swab (topical)) Limit 50gms clindamycin phosphate- FABIOR FOAM 3 per benzoyl peroxide 1 (tazarotene (acne)) month;QL(1.67 (refrigerate) gel gm daily) clindamycin phosphate- Greater than 5 benzoyl peroxide gel 1 1 months %-5 % requires isotretinoin caps 1 PA;QL(2 ea clindamycin phosphate- 1 daily)150 rtl tretinoin gel MAX day(s) PA supply,365 rtl dapsone (topical) gel 5 1 % lmt day(s), KLARON LOTN dapsone (topical) gel PA; QL(2 gm 1 (sulfacetamide sodium GP 7.5 % daily) (acne)) Limit 45gms DIFFERIN CREA 0.1 % per NEUTROGENA CLEAR GP PORE CLEANSER/MASK (adapalene) month;QL(1.5 3 gm daily) LIQD (benzoyl peroxide)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEXION CLEANSER sulfacetamide sodium LIQD (sulfacetamide GP w/ sulfur liqd 10 %-2 %, 1 sodium w/ sulfur) 4 %-9 %, 4.5 %-9 %, PLEXION CLEANSING 4.8 %-9.8 % CLOTHS PADS QL(1 gm daily) 3 sulfacetamide sodium 1 (sulfacetamide sodium w/ sulfur lotn 10 %-5 % w/ sulfur) sulfacetamide sodium PLEXION CREA w/ sulfur lotn 4.8 %-9.8 1 (sulfacetamide sodium GP % w/ sulfur) PLEXION LOTN sulfacetamide sodium w/ sulfur pads 10 %-10 1 (sulfacetamide sodium GP w/ sulfur) %-4 %-4 %, 10 %-4 % sulfacetamide sodium 1 RETIN-A CREA (tretinoin) GP w/ sulfur susp 4 %-8 % RETIN-A GEL (tretinoin) GP SUMADAN WASH LIQD (sulfacetamide sodium GP RETIN-A MICRO GEL 0.04 w/ sulfur) %, 0.1 % (tretinoin GP SUMAXIN PADS microsphere) (sulfacetamide sodium GP RETIN-A MICRO PUMP w/ sulfur) GEL 0.04 %, 0.1 % GP SUMAXIN WASH LIQD (tretinoin microsphere) (sulfacetamide sodium GP RIAX FOAM ( benzoyl 3 w/ sulfur) peroxide) SODIUM tretinoin crea 1 SULFACETAMIDE/SULFU R CLEANSER IN UREA tretinoin gel 1 EMUL (sulfacetamide 3 tretinoin microsphere 1 sodium-sulfur in urea gel vehicle) VELTIN GEL SODIUM (clindamycin 3 SULFACETAMIDE/SULFU phosphate-tretinoin) R SUSP (sulfacetamide 3 ZIANA GEL ( sodium w/ sulfur) clindamycin GP phosphate-tretinoin) sulfacetamide sodium 1 (acne) lotn Agents for External Genital and Perianal Warts VEREGEN OINT Limit 30gms sulfacetamide sodium 3 per month;QL(1 (sinecatechins) w/ sulfur crea 10 %-2 1 gm daily) %, 10 %-5 %, 4.8 %- 9.8 % Anti-inflammatory Agents - Topical sulfacetamide sodium w/ sulfur emul 10 %-5 1 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diclofenac Sodium RX/OTC Antifungals - Topical (Topical)) ARTHRITIS (Ciclopirox) CICLOPIROX 1 PAIN RELIEVER, GNP TREATMENT KIT ARTHRITIS PAIN, 1 GOODSENSE ARTHRITIS (Clotrimazole (Topical)) RX/OTC PAIN, QC DICLOFENAC CVS CLOTRIMAZOLE SODIIUM GEL MAXIMUMSTRENGTH, 1 FUNGICURE INTENSIVE (Diclofenac Sodium QL(5 ml daily) WITHNAILGUARD SOLN (Topical)) KLOFENSAID II 1 SOLN (Iodoquinol-Hc) 1 diclofenac epolamine DERMAZENE CREA 1 (Iodoquinol-Hydrocortisone ptch In Aloe Vehicle) 1 RX/OTC diclofenac sodium 1 IODOQUIMEZ-HC CREA (topical) gel 1 % (Ketoconazole (Topical)) 1 diclofenac sodium QL(5 ml daily) KETODAN FOAM 1 ALA-QUIN CREA (topical) soln 1.5 % 3 FLECTOR PTCH (clioquinol-hc) 3 (diclofenac epolamine) ALCORTIN A GEL PA; Limit 1 (iodoquinol- PENNSAID SOLN hydrocortisone-aloe GP (diclofenac sodium 3 bottle per month;QL(4 gm polysaccharide) (topical)) daily) CICLODAN SOLUTION 3 Antibiotics - Topical KIT KIT (ciclopirox) ALTABAX OINT 3 ciclopirox gel 1 (retapamulin) CENTANY AT KIT 1 3 ciclopirox olamine crea (mupirocin) CENTANY OINT ciclopirox olamine susp 1 2 (mupirocin) ciclopirox sham 1 CORTISPORIN CREA RX/OTC (neomycin-polymyxin- 3 clotrimazole (topical) 1 hc) soln CORTISPORIN OINT Limit 45gms (bacitracin-polymyxin- 3 clotrimazole w/ 1 per neomycin hc) betamethasone crea month;QL(1.5 gm daily) gentamicin sulfate 1 QL(2 ml daily) clotrimazole w/ 1 (topical) crea betamethasone lotn gentamicin sulfate 1 (topical) oint econazole nitrate crea 1 ERTACZO CREA PA mupirocin oint 1 3 (sertaconazole nitrate) NEO-SYNALAR CREA EXELDERM CREA 3 (neomycin sulfate- 3 (sulconazole nitrate) fluocinolone acetonide) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXELDERM SOLN NAFTIN GEL 1 % 2 GP (sulconazole nitrate) (naftifine hcl) EXODERM LOTN NAFTIN GEL 2 % 3 (sodium thiosulfate- 3 (naftifine hcl) salicylic acid) NIZORAL SHAM GP EXTINA FOAM (ketoconazole (topical)) GP (ketoconazole (topical)) nystatin (topical) crea 1 iodoquinol-hc crea 1 nystatin (topical) oint 1 iodoquinol- hydrocortisone in aloe 1 nystatin-triamcinolone 1 vehicle crea crea iodoquinol- nystatin-triamcinolone 1 hydrocortisone-aloe 1 oint polysaccharide gel oxiconazole nitrate crea 1 ketoconazole (topical) QL(2 gm daily) 1 OXISTAT LOTN crea 3 (oxiconazole nitrate) ketoconazole (topical) 1 QUINJA GEL foam (iodoquinol-aloe 3 ketoconazole (topical) 1 polysaccharides) sham sulconazole nitrate crea 1 LOPROX CREA GP (ciclopirox olamine) sulconazole nitrate soln 1 LOPROX SHAMPOO GP SHAM (ciclopirox) VUSION OINT (miconazole-zinc oxide- 3 LOPROX SUSP GP white petrolatum) (ciclopirox olamine) VYTONE CREA Limit 45gms LOTRISONE CREA (iodoquinol- ( GP per GP clotrimazole w/ month;QL(1.5 hydrocortisone in aloe betamethasone) gm daily) vehicle) XOLEGEL GEL luliconazole crea 1 3 (ketoconazole (topical)) LUZU CREA 3 Antineoplastic or Premalignant Lesion Agents - (luliconazole) CARAC CREA GP miconazole-zinc oxide- 1 (fluorouracil (topical)) white petrolatum oint PA diclofenac sodium 1 naftifine hcl crea 1 (actinic keratoses) gel EFUDEX CREA AC naftifine hcl gel 1 (fluorouracil (topical)) NAFTIN CREA 2 % FLUOROPLEX CREA GP 2 (naftifine hcl) (fluorouracil (topical))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited 100 fluorouracil (topical) 1 crea 0.5 % 1 gms per calcitriol (topical) oint month;QL(3.4 fluorouracil (topical) AC gm daily) crea 5 % COSENTYX PA SENSOREADY PEN SOAJ fluorouracil (topical) 1 SP soln 2 % (secukinumab) COSENTYX SOSY PA fluorouracil (topical) AC SP soln 5 % (secukinumab) PANRETIN GEL PA DOVONEX CREA QL(5 gm daily) AC GP (alitretinoin) (calcipotriene) PICATO GEL ( ILUMYA SOSY PA ingenol AC SP mebutate) (tildrakizumab-asmn) TARGRETIN GEL EX 1 % AC methoxsalen rapid caps 1 (bexarotene (topical)) OXSORALEN ULTRA TOLAK CREA PA AC CAPS (methoxsalen GP (fluorouracil (topical)) rapid) VALCHLOR GEL PA SILIQ SOSY PA SP (mechlorethamine hcl AC (brodalumab) (topical)) SKYRIZI PSKT PA SP Antipruritics - Topical (risankizumab-rzaa) doxepin hcl SORIATANE CAPS 3 GP (antipruritic) crea (acitretin) PRUDOXIN CREA SORILUX FOAM PA 3 (doxepin hcl 3 (calcipotriene) (antipruritic)) STELARA SOLN PA SP Antipsoriatics (ustekinumab) (Calcipotriene) QL(5 gm daily) STELARA SOSY PA 1 SP CALCITRENE OINT (ustekinumab) TALTZ SOAJ PA acitretin caps 1 SP (ixekizumab) QL(5 gm daily) calcipotriene crea 1 TALTZ SOSY PA SP (ixekizumab) calcipotriene foam 1 PA tazarotene crea 1 CALCIPOTRIENE FOAM PA 3 TAZORAC CREA 0.05 % (calcipotriene) 2 (tazarotene) 1 QL(5 gm daily) calcipotriene oint TAZORAC GEL 0.05 %, 2 calcipotriene soln 1 0.1 % (tazarotene) TREMFYA SOPN PA SP (guselkumab)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TREMFYA SOSY PA SP Burn Products (guselkumab) (Silver Sulfadiazine) SSD 1 Limited 100 CREA VECTICAL OINT 3 gms per (calcitriol (topical)) month;QL(3.4 mafenide acetate pack 1 gm daily) SILVADENE CREA ( silver GP Antiseborrheic Products sulfadiazine) (Sulfacetamide Sodium) silver sulfadiazine crea 1 SODIUM 1 SULFACETAMIDE WASH SULFAMYLON CREA 85 LIQD 10 % MG/GM (mafenide 3 OVACE PLUS SHAM 10 % GP acetate) (sulfacetamide sodium) SULFAMYLON PACK 5 % OVACE PLUS WASH LIQD GP GP (mafenide acetate) (sulfacetamide sodium) Corticosteroids - Topical OVACE WASH LIQD GP ( ) (Clobetasol Propionate sulfacetamide sodium Emollient Base) selenium sulfide lotn 1 CLOBETASOL PROPIONATE E, 1 selenium sulfide sham 1 CLOBETASOL PROPIONATE SODIUM EMOLLIENT CREA SULFACETAMIDE WASH (Clobetasol Propionate 1 LIQD 0.5 %-10 % 3 Emulsion) TOVET FOAM (sulfacetamide sodium (Clobetasol Propionate) 1 in bakuchiol vehicle) CLODAN SHAM sulfacetamide sodium 1 (Flurandrenolide) NOLIX 1 liqd CREA (Fluticasone Propionate) sulfacetamide sodium 1 1 sham BESER LOTN (Hydrocortisone (Topical)) 1 Antivirals - Topical ALA-CORT CREA acyclovir topical crea 1 acyclovir topical oint 1 QL(1 gm daily) DENAVIR CREA Limit 5gms per 3 month;QL(0.17 (penciclovir) gm daily) XERESE CREA Limit 5gms per (acyclovir- 3 month;QL(0.17 hydrocortisone) gm daily) ZOVIRAX CREA EX 5 % GP (acyclovir topical) ZOVIRAX OINT EX 5 % QL(1 gm daily) GP (acyclovir topical) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC betamethasone CORTIZONE-10, CVS dipropionate (topical) 1 CORTISONE MAXIMUM crea STRENGTH, EQL ANTI- ITCH MAXIMUM betamethasone STRENGTH, GNP dipropionate (topical) 1 HYDROCORTISONE lotn MAXIMUM STRENGTH, HYDROCORTISONE 1% betamethasone IN ABSORBASE, dipropionate (topical) 1 HYDROCORTISONE IN 1 oint ABSORBASE, KP betamethasone HYDROCORTISONE MAXIMUM STRENGTH, dipropionate 1 RA ANTI-ITCH/MAXIMUM augmented crea STRENGTH, SB betamethasone HYDROCORTISONE dipropionate 1 MAXIMUM STRENGTH, SM HYDROCORTISONE augmented gel MAXIMUM STRENGTH betamethasone OINT dipropionate 1 (Pramoxine-Hc) 1 augmented lotn MEZPAROX-HC CREA betamethasone (Triamcinolone Acetonide 1 dipropionate 1 (Topical)) TRIANEX OINT augmented oint (Triamcinolone Acetonide 1 (Topical)) TRIDERM CREA betamethasone 1 ALA SCALP LOTN valerate crea (hydrocortisone 3 betamethasone 1 (topical)) valerate foam ALA-SCALP LOTN betamethasone 1 (hydrocortisone 3 valerate lotn (topical)) betamethasone 1 valerate oint alclometasone 1 dipropionate crea calcipotriene- ST betamethasone 1 alclometasone 1 dipropionate oint dipropionate oint amcinonide crea 1 calcipotriene- ST; QL(2 gm betamethasone 1 daily) amcinonide lotn 1 dipropionate susp AMCINONIDE OINT CAPEX SHAM 3 2 (amcinonide) (fluocinolone acetonide) APEXICON E CREA clobetasol propionate 1 (diflorasone diacetate 2 crea emollient base) clobetasol propionate 1 emollient base crea

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMA-SMOOTHE/FS clobetasol propionate 1 emulsion foam BODY OIL (fluocinolone GP acetonide) clobetasol propionate 1 foam DERMA-SMOOTHE/FS SCALP OIL (fluocinolone GP clobetasol propionate 1 gel acetonide) clobetasol propionate DERMASORB TA KIT 1 (triamcinolone 3 liqd acetonide & emollient) clobetasol propionate DESONATE GEL 1 GP lotn (desonide) clobetasol propionate 1 oint desonide crea 1 clobetasol propionate 1 desonide gel 1 sham desonide lotn 1 clobetasol propionate 1 soln desonide oint 1 CLOBEX LIQD GP DESOWEN CREA (clobetasol propionate) GP CLOBEX LOTN (desonide) GP DESOWEN LOTN (clobetasol propionate) GP CLOBEX SHAM (desonide) GP (clobetasol propionate) DESOXIMETASONE CREA 0.05 % clocortolone pivalate 2 1 (desoximetasone) crea CLODERM CREA desoximetasone crea 1 3 (clocortolone pivalate) 0.05 %, 0.25 % CLODERM CREA desoximetasone gel 3 1 (clocortolone pivalate) 0.05 % CLODERM PUMP CREA desoximetasone liqd 3 1 (clocortolone pivalate) 0.25 % CORDRAN CREA 0.05 % desoximetasone oint GP 1 (flurandrenolide) 0.05 %, 0.25 % CORDRAN TAPE 4 diflorasone diacetate 1 MCG/SQCM 3 crea (flurandrenolide) diflorasone diacetate 1 CORTANE-B LOTN oint (hydrocortisone- 3 DIPROLENE AF CREA pramoxine- (betamethasone chloroxylenol) dipropionate GP CUTIVATE LOTN GP augmented) (fluticasone propionate)

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77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIPROLENE OINT HALOG CREA GP (betamethasone (halcinonide) GP dipropionate HALOG OINT 3 augmented) (halcinonide) ELOCON CREA HALOG SOLN GP 3 (mometasone furoate) (halcinonide) ELOCON OINT GP hydrocortisone (topical) 1 (mometasone furoate) crea 2.5 % EPIFOAM FOAM 3 hydrocortisone (topical) 1 (pramoxine-hc) lotn 2.5 % fluocinolone acetonide RX/OTC 1 hydrocortisone (topical) 1 crea oint 1 % fluocinolone acetonide 1 hydrocortisone (topical) 1 oil oint 2.5 % fluocinolone acetonide 1 hydrocortisone butyrate 1 oint crea fluocinolone acetonide 1 hydrocortisone butyrate soln hydrophilic lipo base 1 fluocinonide crea 1 crea hydrocortisone butyrate 1 fluocinonide emulsified 1 base crea lotn hydrocortisone butyrate 1 fluocinonide gel 1 oint fluocinonide oint 1 hydrocortisone butyrate 1 soln fluocinonide soln 1 hydrocortisone valerate 1 crea flurandrenolide crea 1 hydrocortisone valerate 1 fluticasone propionate 1 oint crea IMPEKLO LOTN 2 (clobetasol propionate) fluticasone propionate 1 lotn KENALOG AERS (triamcinolone GP fluticasone propionate 1 oint acetonide (topical)) LOCOID CREA halcinonide crea 1 (hydrocortisone GP butyrate) halobetasol propionate 1 crea LOCOID LIPOCREAM CREA (hydrocortisone halobetasol propionate 1 GP oint butyrate hydrophilic lipo base)

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78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOCOID LOTN prednicarbate oint 1 (hydrocortisone GP PSORCON CREA butyrate) 3 LOCOID SOLN (diflorasone diacetate) SYNALAR CREA (hydrocortisone GP GP butyrate) (fluocinolone acetonide) SYNALAR OINT LUXIQ FOAM GP (betamethasone GP (fluocinolone acetonide) SYNALAR SOLN valerate) GP (fluocinolone acetonide) mometasone furoate 1 crea TACLONEX OINT ST (calcipotriene- mometasone furoate 1 GP oint betamethasone dipropionate) mometasone furoate 1 soln TACLONEX SUSP ST; QL(2 gm (calcipotriene- daily) NUCORT LOTN betamethasone 3 (hydrocortisone acetate 3 dipropionate) (topical)) TEMOVATE CREA OLUX FOAM ( GP clobetasol GP (clobetasol propionate) propionate) TEMOVATE OINT GP OLUX-E FOAM (clobetasol propionate) (clobetasol propionate GP TEXACORT SOLN emulsion) (hydrocortisone 3 PANDEL CREA (topical)) (hydrocortisone 3 TOPICORT CREA GP probutate) (desoximetasone) PRAMOSONE CREA 1 %- TOPICORT GEL 3 GP 1 % (pramoxine-hc) (desoximetasone) PRAMOSONE CREA 1 %- TOPICORT LIQD GP GP 2.5 % (pramoxine-hc) (desoximetasone) PRAMOSONE E CREA TOPICORT OINT GP (pramoxine-hc 3 (desoximetasone) emollient base) triamcinolone acetonide PRAMOSONE LOTN 1 %- (topical) aers 0.147 1 1 %, 1 %-2.5 % 3 (pramoxine-hc) mg/gm PRAMOSONE OINT 1 %-1 triamcinolone acetonide %, 1 %-2.5 % 3 (topical) crea 0.025 %, 1 (pramoxine-hc) 0.1 %, 0.5 % pramoxine-hc crea 1 triamcinolone acetonide (topical) lotn 0.025 %, 1 prednicarbate crea 1 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDRO 40 FOAM FOAM triamcinolone GP acetonide (topical) oint 1 (urea) 0.025 %, 0.1 %, 0.5 % KERALAC CREA (urea) GP TRIDESILON CREA GP (desonide) URAMAXIN GEL (urea) GP ULTRAVATE CREA (halobetasol GP URE-K CREA (urea) 3 propionate) urea crea 39 %, 41 %, 1 ULTRAVATE OINT 45 %, 47 % (halobetasol GP RX/OTC propionate) urea crea 40 % 1 VANOS CREA GP urea lotn 40 % 1 (fluocinonide) VERDESO FOAM urea susp 40 % 1 3 (desonide) UTOPIC CREA (urea) GP Eczema Agents DUPIXENT SOPN PA Emollients SP (dupilumab) (Lactic Acid (Ammonium RX/OTC DUPIXENT SOSY PA Lactate)) AL12, SP (dupilumab) AMLACTIN, AMLACTIN DAILY, CVS HYDRATING Emollient/Keratolytic Agents SKIN TREATMENT, CVS 1 (Urea In Lactic Acid SKIN TREATMENT, CVS Vehicle) UREA 1 SKIN TREATMENT BODY HYDRATING FOAM LOTION, GERI- HYDROLAC 12 LOTN (Urea) CEROVEL, UREA- 1 C40 LOTN (Lactic Acid (Ammonium RX/OTC Lactate)) GERI- 1 (Urea) GORDONS UREA, RX/OTC HYDROLAC 12 CREA METOPIC, UREDEB, 1 UREMEZ-40, XUREA hyaluronate sodium 1 CREA (emollient) gel (Urea) GORDONS UREA, HYLINATE LOTN METOPIC, UREDEB, 1 (hyaluronate sodium 3 UREMEZ-40, XUREA (emollient)) CREA LAC-HYDRIN CREA RX/OTC (Urea) UMECTA MOUSSE 1 FOAM (lactic acid (ammonium GP lactate)) (Urea) UREA NAIL GEL 1 LAC-HYDRIN TWELVE RX/OTC LOTN (lactic acid GP CEM-UREA SOLN (urea) 3 (ammonium lactate)) GORDONS UREA OINT RX/OTC 3 lactic acid (ammonium 1 (urea) lactate) crea 12 % HYDRO 35 FOAM (urea 3 lactic acid (ammonium 1 in lactic acid vehicle) lactate) lotn 10 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC PODOCON 25 IN lactic acid (ammonium 1 lactate) lotn 12 % BENZOIN TINCTURE SOLN (podophyllum 3 Enzymes - Topical resin) SANTYL OINT 3 (collagenase) podofilox soln 1 Immunomodulating Agents - Topical SALEX LOTION KIT ALDARA CREA (salicylic acid w/ 3 GP (imiquimod) cleanser) SALEX SHAM (salicylic imiquimod crea 3.75 % 1 QL(1 gm daily) GP acid) imiquimod crea 5 % 1 salicylic acid crea 1 ZYCLARA CREA QL(1 ea daily) 3 (imiquimod) salicylic acid foam 1 ZYCLARA PUMP CREA Limit 2 per salicylic acid in 3 month;QL(0.6 2.5 % (imiquimod) ammonium lactate 1 gm daily) vehicle foam ZYCLARA PUMP CREA QL(1 gm daily) 3 3.75 % (imiquimod) salicylic acid liqd 1 Immunosuppressive Agents - Topical salicylic acid lotn 1 ELIDEL CREA QL(2 gm daily) GP (pimecrolimus) salicylic acid sham 1 QL(2 gm daily) pimecrolimus crea 1 salicylic acid soln 1 PROTOPIC OINT GP salicylic acid w/ 1 (tacrolimus (topical)) cleanser kit tacrolimus (topical) oint 1 SALISOL SOLN ( salicylic 3 acid) Keratolytic/Antimitotic Agents SALITECH LOTN (Salicylic Acid) SALICYLIC 3 ACID WART REMOVER 1 (salicylic acid) SALVAX FOAM ( LIQD salicylic GP acid) (Salicylic Acid) SALIMEZ 1 CREA ULTRASAL-ER SOLN GP (Salicylic Acid) SALISOL 1 (salicylic acid) FORTE SOLN VIRASAL LIQD ( salicylic GP (Salicylic Acid) SALITECH 1 acid) FORTE LOTN BENSAL HP OINT Liniments (salicylic acid & benzoic 3 MEDROX-RX OINT PA acid) (capsaicin-menthol- 3 CONDYLOX GEL methyl salicylate) 2 (podofilox) Local Anesthetics - Topical

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cocaine Hcl) C-TOPICAL 1 lidocaine hcl soln 4 % 1 SOLN (Lidocaine Hcl) 7T LIDO RX/OTC lidocaine oint 5 % 1 GEL, REGENECARE HA 1 GEL lidocaine ptch 5 % 1 QL(3 ea daily) (Lidocaine Hcl) GLYDO 1 PRSY lidocaine-prilocaine 1 (Lidocaine Hcl) LIDO-K, crea LIDO-SORB, LIDOZION, LIDODERM PTCH QL(3 ea daily) 1 GP ZIONODIL, ZIONODIL 100 (lidocaine) LOTN LIDODOSE GEL RX/OTC 3 (Lidocaine Hcl) LIDOPIN 1 RX/OTC (lidocaine hcl) CREA 3 % LIDODOSE PEDIATRIC RX/OTC (Lidocaine) LIDOCAINE BULK PACK GEL PAK, PREMIUM 1 3 LIDOCAINE OINT (lidocaine hcl) LIDORX GEL (lidocaine RX/OTC 1 3 ethyl chloride aero hcl) ETHYL CHLORIDE/FINE PRAMOX GEL GEL 3 STREAM AERO (ethyl 3 (pramoxine hcl) chloride) SYNERA PTCH 3 ETHYL (lidocaine-tetracaine) CHLORIDE/MEDIUM STREAM AERO (ethyl 3 Misc. Dermatological Products chloride) 7TOPIC EMUL ( 3 GEBAUERS INSTANT ICE RX/OTC dermatological AERO products, misc.) (pentafluoropropane- 3 CERACADE EMUL tetrafluoroethane) (dermatological 3 GEBAUERS PAIN EASE RX/OTC products, misc.) AERO EMULSION SB EMUL (pentafluoropropane- 3 (dermatological 3 tetrafluoroethane) products, misc.) GEBAUERS SPRAY AND RX/OTC ENTTY SPRAY EMUL STRETCH AERO (dermatological 3 3 (pentafluoropropane- products, misc.) tetrafluoroethane) EPICERAM EMUL lidocaine crea 3 % 1 (dermatological 3 products, misc.) RX/OTC lidocaine hcl crea 3 % 1 ILIDERM EMUL (dermatological 3 lidocaine hcl gel 2 % 1 products, misc.) lidocaine hcl lotn 3 % 1 KAMDOY EMUL (dermatological 3 lidocaine hcl prsy 2 % 1 products, misc.)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIVIK EMUL METROCREAM CREA (dermatological 3 (metronidazole GP products, misc.) (topical)) PENLEN EMUL METROLOTION LOTN QL(2 ml daily) (dermatological 3 (metronidazole GP products, misc.) (topical)) PHLAG SPRAY EMUL metronidazole (topical) 1 (dermatological 3 crea 0.75 % products, misc.) Limit 45gms SUVICORT EMUL metronidazole (topical) 1 per (dermatological 3 gel 0.75 % month;QL(1.5 products, misc.) gm daily) SYNERDERM EMUL metronidazole (topical) 1 (dermatological 3 gel 1 % ) QL(2 ml daily) products, misc. metronidazole (topical) 1 Misc. Topical lotn 0.75 % DRYSOL SOLN MIRVASO GEL PA 2 (aluminum chloride) (brimonidine tartrate 3 ) XERAC AC SOLN (topical) (aluminum chloride in 3 NORITATE CREA PA alcohol) (metronidazole 3 (topical)) Phosphodiesterase 4 (PDE4) Inhibitors - Topical ORACEA CPDR PA EUCRISA OINT PA 3 3 (doxycycline (rosacea)) (crisaborole) RHOFADE CREA PA Rosacea Agents (oxymetazoline hcl 3 (Metronidazole (Topical)) 1 (topical)) ROSADAN CREA SOOLANTRA CREA PA; QL(1 gm 3 Limit 45gms (ivermectin (rosacea)) daily) (Metronidazole (Topical)) 1 per ROSADAN GEL month;QL(1.5 Scabicides & Pediculicides gm daily) (Crotamiton) CROTAN 1 LOTN azelaic acid gel 1 Limit 2 per PA ELIMITE CREA month;QL(60 doxycycline (rosacea) 1 GP cpdr (permethrin) gm per 14 days retail) FINACEA FOAM (azelaic 3 EURAX CREA acid) 2 (crotamiton) FINACEA GEL ( azelaic GP EURAX LOTN 3 acid) (crotamiton) ivermectin (rosacea) PA; QL(1 gm 1 daily) ivermectin 1 crea (pediculicide) lotn

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lindane sham 1 FREESTYLE TEST Limit 200 per STRIPS STRP (glucose 2 month;QL(6.67 1 ea daily); malathion lotn blood) RX/OTC NATROBA SUSP AL(At least 4 3 NON PREFERRED TEST 3 PA (spinosad) yrs old) STRIPS Limit 200 per OVIDE LOTN (malathion) GP ONETOUCH ULTRA STRP 2 month;QL(6.67 Limit 2 per (glucose blood) ea daily); RX/OTC permethrin crea 1 month;QL(60 gm per 14 days ONETOUCH VERIO TEST Limit 200 per retail) STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); SKLICE LOTN blood) (ivermectin GP RX/OTC (pediculicide)) PRECISION XTRA BLOOD Limit 200 per GLUCOSE TEST STRIPS 2 month;QL(6.67 spinosad susp 1 AL(At least 4 ea daily); yrs old) STRP (glucose blood) RX/OTC ULESFIA LOTN (benzyl 3 PRECISION XTRA STRP Limit 200 per alcohol (pediculicide)) 2 month;QL(6.67 VI (ketone blood test) Wound Care Products ea daily) Limit 15gms DIETARY PRODUCTS/DIETARY MANAGEMENT REGRANEX GEL PRODUCTS 3 per () month;QL(0.5 Dietary Management Products gm daily) (Folic Acid-Pyridoxine- RX/OTC DIAGNOSTIC PRODUCTS Cyanocobalamin) AV-VITE FB FORTE, FOLBIC, 1 Diagnostic Drugs NIVA-FOL, WESTAB MAX GLUCAGEN DIAGNOSTIC TABS SOLR (glucagon hcl 2 DEPLIN 15 CAPS ( l- 3 rdna (diagnostic)) methylfolate-algae) METOPIRONE CAPS DEPLIN 7.5 CAPS ( 3 l- 3 (metyrapone) methylfolate-algae) Diagnostic Tests ELFOLATE TABS ( l- 3 FREESTYLE INSULINX Limit 200 per methylfolate) BLOODGLUCOSE TEST month;QL(6.67 2 FOLBIC RF TABS (l- STRIPS STRP (glucose ea daily); 3 RX/OTC methylfolate w/ vitamin blood) b6-vitamin b12) FREESTYLE INSULINX Limit 200 per FOLTX TABS (l- BLOODGLUCOSE TEST 2 month;QL(6.67 ea daily); methylfolate w/ vitamin 3 STRP (glucose blood) RX/OTC b6-vitamin b12) FREESTYLE LITE TEST Limit 200 per L-METHYLFOLATE CA/S- STRIPS STRP (glucose 2 month;QL(6.67 ALGAL CAPS (l- 3 ea daily); methylfolate-algae) blood) RX/OTC

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits L-METHYLFOLATE ALDACTAZIDE TABS 25 FORTE CAPS ( MG-25 MG l- 3 GP methylfolate-algae) (spironolactone & hydrochlorothiazide) l-methylfolate tabs 1 ALDACTAZIDE TABS 50 LEVOMEFOLATE MG-50 MG CALCIUM ALGAL (spironolactone & 2 3 POWDER CAPS (l- hydrochlorothiazide) methylfolate-algae) amiloride & DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide 1 Enzymes tabs Digestive Enzymes DYAZIDE CAPS CREON CPEP (triamterene & GP (pancrelipase (lipase- 2 hydrochlorothiazide) protease-amylase)) MAXZIDE TABS PANCREAZE CPEP (triamterene & GP (pancrelipase (lipase- 3 hydrochlorothiazide) protease-amylase)) MAXZIDE-25 TABS PERTZYE CPEP (triamterene & GP (pancrelipase (lipase- 3 hydrochlorothiazide) protease-amylase)) spironolactone & SUCRAID SOLN PA hydrochlorothiazide 1 3 (sacrosidase) tabs VIOKACE TABS triamterene & (pancrelipase (lipase- 3 hydrochlorothiazide 1 protease-amylase)) caps ZENPEP CPEP triamterene & (pancrelipase (lipase- 2 hydrochlorothiazide 1 protease-amylase)) tabs DIURETICS - Drugs to Treat Heart, Circulation Loop Diuretics Conditions and Blood Pressure bumetanide tabs 1 Carbonic Anhydrase Inhibitors BUMEX TABS 1 GP acetazolamide cp12 (bumetanide) DEMADEX TABS acetazolamide tabs 1 GP (torsemide) KEVEYIS TABS PA SP EDECRIN TABS ST (dichlorphenamide) GP (ethacrynic acid) methazolamide tabs 1 PA ethacrynate sodium SP Diuretic Combinations solr ethacrynic acid tabs 1 ST

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTONEL TABS 150 MG ST; QL(0.04 ea furosemide soln 1 GP (risedronate sodium) daily) furosemide tabs 1 ACTONEL TABS 35 MG ST; QL(0.15 ea GP ( ) daily) LASIX TABS risedronate sodium GP ACTONEL TABS 5 MG ST; QL(1 ea (furosemide) GP ( ) daily) SODIUM EDECRIN SOLR PA risedronate sodium SP (ethacrynate sodium) alendronate sodium 1 soln 70 mg/75ml 1 torsemide tabs alendronate sodium Potassium Sparing Diuretics tabs 10 mg, 40 mg, 5 1 ALDACTONE TABS mg GP (spironolactone) QL(0.15 ea alendronate sodium 1 tabs 35 mg, 70 mg daily) amiloride hcl tabs 1 Limit 4 per DYRENIUM CAPS ATELVIA TBEC GP GP month;QL(0.15 (triamterene) (risedronate sodium) ea daily) 1 BINOSTO TBEF Limit 4 per spironolactone tabs 3 month;QL(0.15 (alendronate sodium) ea daily) triamterene caps 1 BONIVA SOLN IV 3 PA Thiazides and Thiazide-Like Diuretics MG/3ML (ibandronate SP sodium) chlorothiazide tabs 1 BONIVA TABS OR 150 MG QL(0.04 ea GP chlorthalidone tabs 1 (ibandronate sodium) daily) DIURIL SUSP calcitonin (salmon) soln 1 3 (chlorothiazide) etidronate disodium 1 hydrochlorothiazide 1 tabs caps FORTEO SOPN PA hydrochlorothiazide 1 (teriparatide SP tabs (recombinant)) indapamide tabs 1 FOSAMAX PLUS D TABS PA; QL(0.15 ea (alendronate sodium- 3 daily) methyclothiazide tabs 1 cholecalciferol) FOSAMAX TABS QL(0.15 ea GP metolazone tabs 1 (alendronate sodium) daily) MICROZIDE CAPS PA GP ibandronate sodium SP (hydrochlorothiazide) soln iv 3 mg/3ml ENDOCRINE AND METABOLIC AGENTS - QL(0.04 ea ibandronate sodium 1 MISC. - Drugs to Treat Bone Disease and tabs or 150 mg daily) Regulate Hormones MIACALCIN SOLN PA SP Bone Density Regulators (calcitonin (salmon))

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86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATPARA CART PA Limit 15 per (parathyroid hormone SP clomiphene citrate tabs 1 month;QL(0.5 (recombinant)) ea daily) pamidronate disodium PA GnRH/LHRH Antagonists CETROTIDE KIT PA soln 30 mg/10ml, 90 SP SP mg/10ml (cetrorelix acetate) PAMIDRONATE PA Growth Hormone Receptor Antagonists DISODIUM SOLN 6 SOMAVERT SOLR PA SP SP MG/ML (pamidronate (pegvisomant) disodium) Growth Hormones PROLIA SOSY PA SP ( ) PA; Use denosumab GENOTROPIN MINIQUICK preferred RECLAST SOLN PA SP SP SOLR (somatropin) Humatrope or (zoledronic acid) Norditropin risedronate sodium ST; QL(0.04 ea PA; Use 1 GENOTROPIN SOLR tabs 150 mg daily) SP preferred (somatropin) Humatrope or risedronate sodium ST; QL(1 ea Norditropin 1 daily) tabs 30 mg, 5 mg HUMATROPE COMBO PA ST; QL(0.15 ea PACK SOLR risedronate sodium 1 SP tabs 35 mg daily) (somatropin) risedronate sodium Limit 4 per HUMATROPE SOLR PA 1 month;QL(0.15 SP tbec 35 mg (somatropin) ea daily) NORDITROPIN FLEXPRO PA TYMLOS SOPN PA SP SP SOPN (somatropin) (abaloparatide) PA; Use XGEVA SOLN PA NUTROPIN AQ NUSPIN SP SP preferred (denosumab) 10 SOPN (somatropin) Humatrope or PA Norditropin zoledronic acid conc 4 SP mg/5ml PA; Use NUTROPIN AQ NUSPIN SP preferred ZOLEDRONIC ACID SOLN PA 20 SOPN (somatropin) Humatrope or 4 MG/100ML (zoledronic SP Norditropin acid) PA; Use PA NUTROPIN AQ NUSPIN 5 preferred zoledronic acid soln 4 SP SP mg/100ml, 5 mg/100ml SOPN (somatropin) Humatrope or Norditropin ZOMETA CONC 4 PA PA; Use MG/5ML (zoledronic SP OMNITROPE SOLR SP preferred acid) (somatropin) Humatrope or ZOMETA SOLN 4 PA Norditropin MG/100ML (zoledronic SP SEROSTIM SOLR PA; Use acid) ( SP preferred somatropin (non- Humatrope or Fertility Regulators refrigerated)) Norditropin

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87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Use calcitriol soln or 1 ZOMACTON SOLR 1 SP preferred mcg/ml (somatropin) Humatrope or CARBAGLU TABS PA Norditropin SP (carglumic acid) Hormone Receptor Modulators CARNITOR SF SOLN EVISTA TABS (raloxifene QL(1 ea daily); (levocarnitine GP GP PV hcl) (metabolic modifiers)) OSPHENA TABS 3 CARNITOR SOLN (ospemifene) (levocarnitine GP PV QL(1 ea daily); (metabolic modifiers)) raloxifene hcl tabs PV CARNITOR TABS Insulin-Like Growth Factors (Somatomedins) (levocarnitine GP INCRELEX SOLN PA ) SP (metabolic modifiers) () cinacalcet hcl tabs 1 LHRH/GnRH Agonist Analog Pituitary CYSTADANE POWD PA FENSOLVI KIT PA SP (betaine) (leuprolide acetate AC (cpp) (6 month)) doxercalciferol caps or LUPANETA PACK KIT PA 0.5 mcg, 1 mcg, 2.5 1 (leuprolide acetate & SP mcg PA norethindrone acetate) doxercalciferol soln iv 4 SP LUPRON DEPOT-PED (1- PA mcg/2ml ELAPRASE SOLN PA MONTH) KIT (leuprolide SP SP acetate (cpp)) (idursulfase) PA FABRAZYME SOLR PA LUPRON DEPOT-PED (3- SP MONTH) KIT (leuprolide SP (agalsidase beta) acetate (cpp) (3 month)) GALAFOLD CAPS PA; QL(0.5 ea SP SYNAREL SOLN (migalastat hcl) daily) 2 (nafarelin acetate) HECTOROL SOLN 2 PA Metabolic Modifiers MCG/ML SP ALDURAZYME SOLN PA (doxercalciferol) SP (laronidase) HECTOROL SOLN 4 PA MCG/2ML SP BUPHENYL POWD PA (doxercalciferol) (sodium SP phenylbutyrate) KUVAN PACK PA (sapropterin SP BUPHENYL TABS PA dihydrochloride) (sodium SP phenylbutyrate) KUVAN TBSO PA (sapropterin SP calcitriol caps or 0.25 1 dihydrochloride) mcg, 0.5 mcg levocarnitine (metabolic PA 1 calcitriol soln iv 1 SP modifiers) soln mcg/ml

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88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRENSIQ SOLN PA levocarnitine (metabolic 1 SP modifiers) tabs (asfotase alfa) LUMIZYME SOLR PA XURIDEN PACK (uridine SP SP (alglucosidase alfa) triacetate) MYALEPT SOLR PA ZEMPLAR CAPS OR 1 SP (metreleptin) MCG, 2 MCG GP NAGLAZYME SOLN PA (paricalcitol) SP (galsulfase) ZEMPLAR SOLN IV 2 PA PA MCG/ML, 5 MCG/ML SP nitisinone caps SP (paricalcitol) NITYR TABS (nitisinone) SP PA Posterior Pituitary Hormones DDAVP SOLN NA 0.01 % ORFADIN CAPS 10 MG, 2 PA SP (desmopressin acetate 2 MG, 5 MG (nitisinone) refrigerated) ORFADIN CAPS 20 MG PA SP DDAVP SOLN NA 0.01 % ( ) nitisinone (desmopressin acetate GP ORFADIN SUSP 4 MG/ML PA SP spray) ( ) nitisinone DDAVP TABS OR 0.1 MG, PALYNZIQ SOSY PA SP 0.2 MG (desmopressin GP (pegvaliase-pqpz) acetate) paricalcitol caps or 1 1 desmopressin acetate 1 mcg, 2 mcg, 4 mcg spray refrigerated soln paricalcitol soln iv 2 PA SP desmopressin acetate 1 mcg/ml, 5 mcg/ml spray soln RAVICTI LIQD (glycerol PA SP desmopressin acetate 1 phenylbutyrate) tabs RAYALDEE CPCR PA NOCTIVA EMUL PA SP 3 (calcifediol) (desmopressin acetate) ROCALTROL CAPS STIMATE SOLN PA GP 3 (calcitriol) (desmopressin acetate) ROCALTROL SOLN GP Prolactin Inhibitors (calcitriol) PA cabergoline tabs 1 sapropterin SP dihydrochloride pack Somatostatic Agents PA sapropterin SP PA dihydrochloride tbso octreotide acetate soln SP SENSIPAR TABS SANDOSTATIN LAR PA GP (cinacalcet hcl) DEPOT KIT (octreotide SP sodium phenylbutyrate PA acetate) SP SANDOSTATIN SOLN PA powd SP PA (octreotide acetate) sodium phenylbutyrate SP tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIGNIFOR SOLN PA ACTIVELLA TABS (pasireotide SP (estradiol & GP diaspartate) norethindrone acetate) SOMATULINE DEPOT PA ANGELIQ TABS 3 SOLN (lanreotide SP (drospirenone-estradiol) acetate) CLIMARA PRO PTWK Vasopressin Receptor Antagonists (estradiol- 2 JYNARQUE TABS 15 MG, PA; QL(1 ea levonorgestrel) SP 30 MG (tolvaptan) daily) COMBIPATCH PTTW JYNARQUE TBPK PA; SP (estradiol & 3 SP (tolvaptan) norethindrone acetate) SAMSCA TABS PA; QL(1 ea DUAVEE TABS SP (tolvaptan) daily) (conjugated estrogens- 3 bazedoxifene) SP PA; QL(1 ea tolvaptan tabs daily) esterified estrogens & QL(1 ea daily) ESTROGENS - Hormone Replacement/Modifying methyltestosterone 1 Drugs tabs Estrogen Combinations estradiol & (Esterified Estrogens & QL(1 ea daily) norethindrone acetate 1 Methyltestosterone) tabs COVARYX, COVARYX HS, norethindrone acetate- EEMT, EEMT HS, ethinyl estradiol tabs 1 ESTERIFIED 1 ESTROGENS/METHYLTE 0.5 mg-2.5 mcg STOSTERONE DS, norethindrone acetate- QL(84 ea per ESTERIFIED ethinyl estradiol tabs 1 1 fill retail,112 ea ESTROGENS/METHYLTE mg-5 mcg per fill mail) STOSTERONE HS TABS PREFEST TABS 3 (Estradiol & Norethindrone (estradiol-norgestimate) Acetate) AMABELZ, 1 LOPREEZA, MIMVEY, PREMPHASE TABS MIMVEY LO TABS (conjugated estrogens- 2 (Norethindrone Acetate- medroxyprogesterone Ethinyl Estradiol) 1 acetate) FYAVOLV TABS 0.5 MG- PREMPRO TABS 2.5 MCG (conjugated estrogens- (Norethindrone Acetate- QL(84 ea per medroxyprogesterone 2 Ethinyl Estradiol) 1 fill retail,112 ea FYAVOLV TABS 1 MG-5 per fill mail) acetate) MCG Estrogens (Norethindrone Acetate- QL(84 ea per Limit 8 patches Ethinyl Estradiol) JINTELI 1 fill retail,112 ea (Estradiol) DOTTI, 1 per TABS per fill mail) LYLLANA PTTW month;QL(0.29 ea daily)

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90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALORA PTTW 0.025 Limit 8 patches Limit 50gms ESTROGEL GEL MG/24HR, 0.075 per 3 per MG/24HR, 0.1 MG/24HR 3 month;QL(0.29 (estradiol) month;QL(1.67 (estradiol) ea daily) gm daily) EVAMIST SOLN CLIMARA PTWK 0.025 Limit 4 per 3 MG/24HR, 0.06 MG/24HR, month;QL(0.15 (estradiol) 0.075 MG/24HR, 0.1 GP ea daily) MENEST TABS 2 MG/24HR, 37.5 (esterified estrogens) MCG/24HR (estradiol) MENOSTAR PTWK Limit 4 per DELESTROGEN OIL 10 PA 3 month;QL(0.14 MG/ML (estradiol SP (estradiol) ea daily) valerate) Limit 8 patches MINIVELLE PTTW 0.0375 DELESTROGEN OIL 20 PA GP per MG/ML, 40 MG/ML SP MG/24HR (estradiol) month;QL(0.29 (estradiol valerate) ea daily) DEPO-ESTRADIOL OIL PA PREMARIN SOLR IJ 25 PA SP (estradiol cypionate) MG (estrogens, SP DIVIGEL GEL 0.25 conjugated) MG/0.25GM, 0.5 PREMARIN TABS OR 0.3 3 MG, 0.45 MG, 0.625 MG, MG/0.5GM, 1 MG/GM, 1.25 2 MG/1.25GM (estradiol) 0.9 MG, 1.25 MG ELESTRIN GEL (estrogens, conjugated) 3 (estradiol) VIVELLE-DOT PTTW Limit 8 patches per ESTRACE TABS 0.0375 MG/24HR GP GP month;QL(0.29 (estradiol) (estradiol) ea daily) estradiol pttw td 0.025 Limit 8 patches FLUOROQUINOLONES - Drugs to Treat Bacterial mg/24hr, 0.0375 per Infections 1 month;QL(0.29 mg/24hr, 0.05 mg/24hr, Fluoroquinolones 0.075 mg/24hr, 0.1 ea daily) AVELOX TABS mg/24hr GP (moxifloxacin hcl) estradiol ptwk td 0.025 Limit 4 per month;QL(0.15 BAXDELA TABS ST mg/24hr, 0.06 mg/24hr, (delafloxacin 3 1 ea daily) 0.075 mg/24hr, 0.1 meglumine) mg/24hr, 37.5 mcg/24hr CIPRO SUSR 5 GM/100ML, 500 MG/5ML 2 estradiol ptwk td 0.05 Limit 4 per 28 (ciprofloxacin) 1 days;QL(0.15 mg/24hr CIPRO TABS 250 MG, 500 ea daily) GP MG (ciprofloxacin hcl) estradiol tabs or 0.5 1 mg, 1 mg, 2 mg ciprofloxacin hcl tabs 1 PA estradiol valerate oil SP ciprofloxacin susr 1 QL(14 ea per ciprofloxacin- 1 ciprofloxacin hcl tb24 fill retail)

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91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVAQUIN TABS QL(14 ea per AMITIZA CAPS GP 2 (levofloxacin) fill retail) (lubiprostone) levofloxacin soln 25 1 Gastrointestinal Stimulants mg/ml metoclopramide hcl QL(14 ea per 1 levofloxacin tabs 250 1 soln mg, 500 mg, 750 mg fill retail) metoclopramide hcl 1 moxifloxacin hcl tabs 1 tabs metoclopramide hcl 1 ofloxacin tabs 1 tbdp GASTROINTESTINAL AGENTS - MISC. - METOCLOPRAMIDE ODT Miscellaneous Gastrointestinal Drugs TBDP (metoclopramide 3 ) Agents for Chronic Idiopathic Constipation (CIC) hcl TRULANCE TABS PA REGLAN TABS 3 GP (plecanatide) (metoclopramide hcl) Bile Acid Synthesis Disorder Agents Inflammatory Bowel Agents ASACOL HD TBEC PA CHOLBAM CAPS (cholic PA 3 SP (mesalamine) acid) AZULFIDINE EN-TABS GP Farnesoid X Receptor (FXR) Agonists TBEC (sulfasalazine) OCALIVA TABS PA AZULFIDINE TABS SP GP (obeticholic acid) (sulfasalazine) Gallstone Solubilizing Agents Limit 282 caps ACTIGALL CAPS balsalazide disodium per GP 1 (ursodiol) caps month;QL(9.4 ea daily) CHENODAL TABS PA 3 CANASA SUPP (chenodiol) GP (mesalamine) URSO 250 TABS GP CIMZIA KIT PA (ursodiol) SP (certolizumab pegol) URSO FORTE TABS GP CIMZIA STARTER KIT KIT PA (ursodiol) SP (certolizumab pegol) ursodiol caps 1 Limit 282 caps COLAZAL CAPS GP per ursodiol tabs 1 (balsalazide disodium) month;QL(9.4 ea daily) Gastrointestinal Antiallergy Agents DIPENTUM CAPS 3 cromolyn sodium 1 (olsalazine sodium) (mastocytosis) conc INFLECTRA SOLR PA SP GASTROCROM CONC (infliximab-dyyb) (cromolyn sodium GP mesalamine cp24 or (mastocytosis)) 1 0.375 gm Gastrointestinal Chloride Channel Activators

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92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea daily) mesalamine cpdr or 1 alvimopan caps 1 400 mg ENTEREG CAPS mesalamine enem re 4 GP 1 (alvimopan) gm MOVANTIK TABS 3 mesalamine supp re 1 (naloxegol oxalate) 1000 mg RELISTOR SOLN PA mesalamine tbec or 1.2 1 (methylnaltrexone SP gm bromide) mesalamine w/ 1 RELISTOR TABS PA cleanser kit (methylnaltrexone SP PENTASA CPCR PA bromide) 3 (mesalamine) SYMPROIC TABS PA 3 REMICADE SOLR PA (naldemedine tosylate) SP (infliximab) Phosphate Binder Agents ROWASA KIT calcium acetate (mesalamine w/ GP (phosphate binder) 1 cleanser) caps SFROWASA ENEM 2 FOSRENOL CHEW 1000 (mesalamine) MG, 500 MG, 750 MG GP STELARA SOLN PA SP (lanthanum carbonate) (ustekinumab (iv)) lanthanum carbonate 1 sulfasalazine tabs 1 chew PHOSLYRA SOLN sulfasalazine tbec 1 (calcium acetate 3 Intestinal Acidifiers (phosphate binder)) RENAGEL TABS PA (Lactulose GP (sevelamer hcl) (Encephalopathy)) 1 ENULOSE, GENERLAC RENVELA PACK GP SOLN (sevelamer carbonate) lactulose RENVELA TABS 1 GP (encephalopathy) soln (sevelamer carbonate) Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate 1 alosetron hcl tabs 1 PA pack sevelamer carbonate LINZESS CAPS 1 2 tabs (linaclotide) PA LOTRONEX TABS PA sevelamer hcl tabs 1 GP (alosetron hcl) VELPHORO CHEW PA VIBERZI TABS PA (sucroferric 3 3 (eluxadoline) oxyhydroxide) Peripheral Opioid Receptor Antagonists Short Bowel Syndrome (SBS) Agents

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93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GATTEX KIT PA UROCIT-K 5 TBCR SP (teduglutide (rdna)) (potassium citrate GP Tryptophan Hydroxylase Inhibitors (alkalinizer)) XERMELO TABS PA Cystinosis Agents SP (telotristat etiprate) CYSTAGON CAPS 3 GENITOURINARY AGENTS - MISCELLANEOUS (cysteamine bitartrate) - Miscellaneous Drugs to Treat Reproductive PROCYSBI CPDR 25 MG, Organs and Urinary System 75 MG (cysteamine 3 Acidifiers bitartrate) K-PHOS NO 2 TABS Genitourinary Irrigants (potassium & sodium 2 (Sodium Chloride (Gu acid phosphates) Irrigant)) ARGYLE STERILE SALINE 100ML, 1 Alkalinizers CURITY STERILE SALINE (Pot & Sod Citrates SOLN W/Citric Ac) CYTRA-3 1 SYRP neomycin/polymyxin b 1 gu soln (Potassium Citrate-Citric sodium chloride (gu Acid) CYTRA K 1 1 CRYSTALS, TARON- irrigant) soln CRYSTALS PACK Interstitial Cystitis Agents (Potassium Citrate-Citric 1 RX/OTC Acid) CYTRA-K SOLN ELMIRON CAPS QL(3 ea daily) (pentosan polysulfate 3 (Sodium Citrate & Citric 1 RX/OTC Acid) CYTRA-2 SOLN sodium) ORACIT SOLN ( Prostatic Hypertrophy Agents sodium 3 citrate & citric acid) alfuzosin hcl tb24 1 pot & sod citrates 1 AVODART CAPS AL(At least 40 w/citric ac soln GP (dutasteride) yrs old) potassium citrate 1 CARDURA XL TB24 (alkalinizer) tbcr (doxazosin mesylate 3 RX/OTC potassium citrate-citric 1 (bph)) acid soln 1 AL(At least 40 RX/OTC dutasteride caps yrs old) sodium citrate & citric 1 acid soln dutasteride-tamsulosin 1 UROCIT-K 10 TBCR hcl caps (potassium citrate GP QL(1 ea daily); (alkalinizer)) finasteride tabs 1 AL(At least 40 UROCIT-K 15 TBCR yrs old) FLOMAX CAPS QL(2 ea daily) (potassium citrate GP GP (alkalinizer)) (tamsulosin hcl) JALYN CAPS (dutasteride-tamsulosin GP hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROSCAR TABS QL(1 ea daily); ULORIC TABS GP AL(At least 40 GP (finasteride) (febuxostat) yrs old) ZURAMPIC TABS PA RAPAFLO CAPS 4 MG 3 3 (lesinurad) ( ) silodosin ZYLOPRIM TABS RAPAFLO CAPS 8 MG GP GP (allopurinol) (silodosin) Uricosurics silodosin caps 4 mg, 8 1 mg probenecid tabs 1 tamsulosin hcl caps 1 QL(2 ea daily) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders UROXATRAL TB24 GP (alfuzosin hcl) Bradykinin B2 Receptor Antagonists FIRAZYR SOLN ( PA Urinary Analgesics icatibant SP acetate) (Phenazopyridine Hcl) 1 PHENAZO TABS icatibant acetate soln SP PA phenazopyridine hcl 1 tabs Complement Inhibitors PA; SP PYRIDIUM TABS BERINERT KIT (c1 GP (phenazopyridine hcl) esterase inhibitor SP (human)) Urinary Stone Agents HAEGARDA SOLR (c1 PA LITHOSTAT TABS 3 esterase inhibitor SP (acetohydroxamic acid) (human)) THIOLA EC TBEC SP RUCONEST SOLR ( PA (tiopronin) c1 esterase inhibitor SP THIOLA TABS (tiopronin) SP (recombinant)) Hemataologic - Inhibitors GOUT AGENTS - Drugs to Treat Gout TAVALISSE TABS PA; SP SP Gout Agent Combinations (fostamatinib disodium) colchicine w/ 1 Hematorheologic Agents probenecid tabs 1 DUZALLO TABS PA pentoxifylline tbcr 3 (lesinurad-allopurinol) Plasma Kallikrein Inhibitors TAKHZYRO SOLN PA Gout Agents SP (lanadelumab-flyo) allopurinol tabs 1 Platelet Aggregation Inhibitors colchicine caps 1 AGGRENOX CP12 GP (aspirin-dipyridamole) 1 febuxostat tabs AGRYLIN CAPS GP MITIGARE CAPS (anagrelide hcl) 3 (colchicine)

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95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits anagrelide hcl caps 1 SIKLOS TABS PA (hydroxyurea (sickle SP aspirin-dipyridamole 1 cell anemia)) cp12 Folic Acid/ BRILINTA TABS 2 (Folic Acid) CVS FOLIC PV (ticagrelor) ACID, FA-8, , GNP CABLIVI KIT PA FOLIC ACID, HM FOLIC SP (caplacizumab-yhdp) ACID, PX FOLIC ACID, QC PV QL(2 ea daily) FOLIC ACID, RA FOLIC cilostazol tabs 1 ACID, SM FOLIC ACID, YL FOLIC ACID TABS QL(2 ea daily) clopidogrel bisulfate 1 (Folic Acid) KP FOLIC PV RX/OTC; PV tabs ACID TABS 1 MG dipyridamole tabs 1 (Folic Acid) KP FOLIC PV PV ACID TABS 800 MCG EFFIENT TABS 5 MG GP PV (prasugrel hcl) folic acid soln ij 5 mg/ml PV PLAVIX TABS QL(2 ea daily) GP folic acid tabs or 1 mg PV RX/OTC; PV (clopidogrel bisulfate) folic acid tabs or 400 PV prasugrel hcl tabs 1 PV mcg, 800 mcg ZONTIVITY TABS 2 Hematopoietic Growth Factors (vorapaxar sulfate) ARANESP ALBUMIN PA HEMATOPOIETIC AGENTS - Drugs to Treat FREE SOLN SP Blood Disorders (darbepoetin alfa) Agents for Gaucher Disease ARANESP ALBUMIN PA CERDELGA CAPS PA FREE SOSY SP SP (eliglustat tartrate) (darbepoetin alfa) ELELYSO SOLR PA DOPTELET TABS PA SP (taliglucerase alfa) (avatrombopag SP maleate) miglustat caps SP PA EPOGEN SOLN (epoetin PA VPRIV SOLR PA SP SP alfa) (velaglucerase alfa) GRANIX SOSY 300 PA ZAVESCA CAPS PA MCG/0.5ML, 480 SP SP (miglustat) MCG/0.8ML (tbo- Agents for Sickle Cell Disease ) LEUKINE SOLR PA DROXIA CAPS SP (hydroxyurea (sickle 3 () cell anemia)) MIRCERA SOSY PA ENDARI PACK PA (methoxy polyethylene SP SP (glutamine (sickle cell)) glycol-epoetin beta) MULPLETA TABS PA SP (lusutrombopag)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEULASTA ONPRO KIT PA SP FUSION PLUS CAPS (fe PSKT () fum-iron polysacch 3 NEULASTA SOSY PA complex-fa-b cmplx-c- SP (pegfilgrastim) biotin-probiotic) NEUPOGEN SOLN PA INTEGRA F CAPS SP (filgrastim) (ferrous fumarate-iron 2 NEUPOGEN SOSY PA polysaccharide SP (filgrastim) complex-folic acid-c-b3) NIVESTYM SOSY 300 PA Iron MCG/0.5ML, 480 SP (Carbonyl Iron) WEE CARE PV PV MCG/0.8ML (filgrastim- SUSP aafi) (Ferrous Sulfate) PV PROCRIT SOLN 10000 PA BPROTECTED PEDIA UNIT/ML, 2000 UNIT/ML, IRON, IRON 20000 UNIT/ML, 3000 SUPPLEMENT PV UNIT/ML, 4000 UNIT/ML, SP CHILDRENS, PC 40000 UNIT/ML (epoetin PEDIATRIC IRON DROPS alfa) SOLN PROMACTA PACK 12.5 PA (Ferrous Sulfate) PV FEROSUL, IRON PV MG, 25 MG (eltrombopag SP SUPPLEMENT ELIX olamine) FER-IN-SOL SOLN PV GP PROMACTA TABS 12.5 PA (ferrous sulfate) MG, 25 MG, 50 MG SP (eltrombopag olamine) ferrous sulfate elix PV PV PROMACTA TABS 75 MG PA; QL(1 ea SP PV (eltrombopag olamine) daily) ferrous sulfate soln PV RETACRIT SOLN 10000 PA ferrous sulfate syrp PV PV UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 3000 ICAR PEDIATRIC SUSP PV SP GP UNIT/ML, 4000 UNIT/ML, (carbonyl iron) 40000 UNIT/ML (epoetin MYKIDZ IRON 10 SUSP PV PV alfa-epbx) (iron) ZARXIO SOSY PA SP Stem Cell Mobilizers (filgrastim-sndz) MOZOBIL SOLN PA ZIEXTENZO SOSY PA SP SP (plerixafor) (pegfilgrastim-bmez) HEMOSTATICS - Drugs to Stop Bleeding/Treat Hematopoietic Mixtures Blood Disorders FOLIVANE-F CAPS Hemostatics - Systemic (ferrous fumarate-iron polysaccharide 2 AMICAR TABS 1000 MG, complex-folic acid-c-b3) 500 MG (aminocaproic GP acid) aminocaproic acid tabs 1 1000 mg, 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYKLOKAPRON SOLN PA SP phenobarbital soln 20 1 (tranexamic acid) mg/5ml LYSTEDA TABS QL(6 ea daily,5 GP phenobarbital tabs 100 (tranexamic acid) day(s) limit) mg, 15 mg, 16.2 mg, 30 1 PA mg, 32.4 mg, 60 mg, tranexamic acid soln iv SP 1000 mg/10ml 64.8 mg, 97.2 mg QL(6 ea daily,5 SECONAL SODIUM CAPS tranexamic acid tabs or 1 3 650 mg day(s) limit) (secobarbital sodium) HYPNOTICS/SEDATIVES/SLEEP DISORDER Hypnotics - Tricyclic Agents AGENTS doxepin hcl (sleep) tabs 1 ST; QL(1 ea Antihistamine Hypnotics daily) SILENOR TABS ( ST; QL(1 ea (Diphenhydramine Hcl doxepin GP (Sleep)) COMPOZ, CVS hcl (sleep)) daily) SLEEP AID Non-Barbiturate Hypnotics NIGHTTIME/MAXIMUM AMBIEN CR TBCR QL(1 ea daily) STRENGTH, CVS SLEEP- GP AID NIGHTTIME, EQ (zolpidem tartrate) NIGHTTIME SLEEP AID AMBIEN TABS 10 MG QL(1 ea daily) GP MAXIMUM STRENGTH, (zolpidem tartrate) EQL SLEEP AID DORAL TABS MAXIMUM STRENGTH, 3 GOODSENSE SLEEP AID, (quazepam) ORMIR, QC SLEEP AID EDLUAR SUBL ST; QL(1 ea 3 MAXIMUM STRENGTH, 1 (zolpidem tartrate) daily) QC SLEEP-AID MAXIMUM STRENGTH, RA estazolam tabs 1 NIGHTTIME SLEEP AID, RA SLEEP AID MAXIMUM eszopiclone tabs 1 QL(1 ea daily) STRENGTH, SLEEP AID, SLEEP-AID, SM SLEEP flurazepam hcl caps 1 AID MAXIMUM HALCION TABS STRENGTH, TGT SLEEP GP AID MAXIMUM (triazolam) STRENGTH, WAL-SOM INTERMEZZO SUBL PA GP MAXIMUM STRENGTH ( ) CAPS zolpidem tartrate LUNESTA TABS 3 MG QL(1 ea daily) UNISOM SLEEPGELS GP CAPS (eszopiclone) GP (diphenhydramine hcl midazolam hcl syrp 1 (sleep)) Barbiturate Hypnotics quazepam tabs 1 BUTISOL SODIUM TABS RESTORIL CAPS 3 GP (butabarbital sodium) (temazepam) phenobarbital elix 20 1 temazepam caps 1 mg/5ml triazolam tabs 1

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98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zaleplon caps 1 QL(1 ea daily) CLENPIQ SOLN (sodium PV picosulfate-magnesium PA PV zolpidem tartrate subl 1 oxide-anhydrous citric sl 1.75 mg, 3.5 mg acid) QL(1 ea daily) zolpidem tartrate tabs 1 COLYTE-FLAVOR PACKS PV or 10 mg, 5 mg SOLR (peg 3350-kcl-sod 3 QL(1 ea daily) bicarb-sod chloride-sod zolpidem tartrate tbcr 1 or 12.5 mg, 6.25 mg sulfate) ST; Limit 1 GOLYTELY SOLR 2.82 PA; PV ZOLPIMIST SOLN GM-21.5 GM-227.1 GM- 3 bottle per (zolpidem tartrate) month;QL(0.26 5.53 GM-6.36 GM (peg ml daily) 3350-kcl-sod bicarb- PV Orexin Receptor Antagonists sod chloride-sod BELSOMRA TABS ST; QL(1 ea sulfate) 2 (suvorexant) daily) GOLYTELY SOLR 2.97 PV GM-22.74 GM-236 GM- Selective Melatonin Receptor Agonists 5.86 GM-6.74 GM (peg HETLIOZ CAPS PA GP SP 3350-kcl-sod bicarb- (tasimelteon) sod chloride-sod 1 ST; QL(1 ea sulfate) ramelteon tabs daily) MOVIPREP SOLR (peg PA; PV ROZEREM TABS ST; QL(1 ea GP 3350-kcl-nacl-na (ramelteon) daily) GP sulfate-na ascorbate- LAXATIVES - Bowel Treatment Drugs ascorbic acid) PV Laxative Combinations NULYTELY SOLR (peg (Bisacodyl-Peg 3350-Pot PV 3350-potassium chloride-sod GP Chloride-Sod Bicarb-Sod PV Chloride) GAVILYTE-H, bicarbonate-sod PEG-PREP KIT chloride) (Peg 3350-Kcl-Nacl-Na PA; PV NULYTELY/FLAVOR PV Sulfate-Na Ascorbate- PACKS SOLR (peg 3350- Ascorbic Acid) PEG- PV potassium chloride-sod GP 3350/ELECTROLYTES/AS CORBATE SOLR bicarbonate-sod chloride) (Peg 3350-Kcl-Sod Bicarb- PV peg 3350-kcl-nacl-na PA; PV Sod Chloride-Sod Sulfate) PV GAVILYTE-C, GAVILYTE- sulfate-na ascorbate- PV G SOLR ascorbic acid solr (Peg 3350-Potassium PV peg 3350-kcl-sod PV Chloride-Sod Bicarbonate- PV Sod Chloride) GAVILYTE- PV bicarb-sod chloride-sod N/FLAVOR PACK, sulfate solr TRILYTE SOLR

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99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits peg 3350-potassium PV MIRALAX POWD Limit 510gms chloride-sod ( GP per PV polyethylene glycol month;QL(17.6 bicarbonate-sod 3350) chloride solr gm daily) Limit 510gms PLENVU SOLR (peg PA; PV polyethylene glycol 1 per 3350-kcl-nacl-na PV 3350 powd month;QL(17.6 sulfate-na ascorbate- gm daily) ascorbic acid) Saline Laxatives PREPOPIK PACK PA; PV OSMOPREP TABS PA; PV (sodium picosulfate- PV (sodium phosphate magnesium oxide- monobasic-sodium PV anhydrous citric acid) phosphate dibasic) SUPREP BOWEL PREP PV MACROLIDES - Drugs to Treat Bacterial KIT SOLN (sodium Infections sulfate-potassium PV sulfate-magnesium Azithromycin sulfate) azithromycin pack 1 gm 1 Laxatives - Miscellaneous azithromycin susr 100 1 (Lactulose) CONSTULOSE 1 mg/5ml, 200 mg/5ml SOLN QL(6 ea per fill azithromycin tabs 250 1 (Polyethylene Glycol 3350) Limit 510gms mg retail) CLEARLAX, CVS per QL(3 ea per fill PURELAX, EQ month;QL(17.6 azithromycin tabs 500 1 CLEARLAX, EQL gm daily) mg retail) CLEARLAX, GAVILAX, azithromycin tabs 600 QL(10 ea per GENTLELAX, GLYCOLAX, 1 fill retail) GNP CLEARLAX, mg GOODSENSE CLEARLAX, ZITHROMAX PACK 1 GM 1 2 HM CLEARLAX, KLS (azithromycin) LAXACLEAR, QC ZITHROMAX SUSR 100 NATURA-LAX, RA MG/5ML, 200 MG/5ML GP LAXATIVE, SB POLYETHYLENE GLYCOL (azithromycin) ZITHROMAX TABS 250 QL(6 ea per fill 3350, SM CLEARLAX, GP SMOOTH LAX, TGT MG (azithromycin) retail) POWDERLAX POWD ZITHROMAX TABS 500 QL(3 ea per fill KRISTALOSE PACK 10 GP retail) 3 MG (azithromycin) GM, 20 GM (lactulose) ZITHROMAX TABS 600 QL(10 ea per LACTULOSE PACK 10 GM GP fill retail) 3 MG (azithromycin) (lactulose) ZITHROMAX TRI-PAK QL(3 ea per fill GP retail) lactulose soln 10 1 TABS (azithromycin) gm/15ml, 20 gm/30ml ZITHROMAX Z-PAK TABS QL(6 ea per fill GP (azithromycin) retail) Clarithromycin

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin susr 125 1 DIAPHRAGMS PV mg/5ml, 250 mg/5ml DUREX EXTRA PV clarithromycin tabs 250 1 SENSITIVE DEVI mg, 500 mg (condoms latex PV clarithromycin tb24 500 QL(14 ea per lubricated - male) 1 fill retail) mg FANTASY LUBRICATED PV Erythromycins MISC (condoms latex PV lubricated - male) (Erythromycin Base) ERY- 1 TAB TBEC FANTASY PV LUBRICATED/SPERMICID (Erythromycin PV Ethylsuccinate) E.E.S. 400 1 E MISC (condoms latex TABS lubricated - male) (Erythromycin Stearate) FC FEMALE CONDOM PV ERYTHROCIN STEARATE 1 MISC (condoms - PV TABS female) E.E.S. GRANULES SUSR FC2 FEMALE CONDOM PV (erythromycin GP MISC (condoms - PV ethylsuccinate) female) ERYPED 200 SUSR FEMCAP DEVI ( PV (erythromycin GP cervical PV ) ethylsuccinate) caps K-Y ME & YOU EXTRA PV ERYPED 400 SUSR LUBRICATED DEVI (erythromycin GP (condoms latex PV ethylsuccinate) lubricated - male) erythromycin base 1 K-Y ME & YOU INTENSE PV cpep DEVI (condoms latex PV erythromycin base tabs 1 lubricated - male) KAMELEON LUBRICATED PV erythromycin base tbec 1 MISC (condoms latex PV lubricated - male) erythromycin 1 ethylsuccinate susr KIMONO COLORS DEVI PV (condoms latex PV erythromycin 1 ethylsuccinate tabs lubricated - male) KIMONO LUBRICATED PV Fidaxomicin MISC (condoms latex PV DIFICID TABS 200 MG 3 lubricated - male) (fidaxomicin) KIMONO MICRO THIN PV MEDICAL DEVICES AND SUPPLIES MISC (condoms latex PV non-lubricated - male) Contraceptives AIMSCO LUBRICATED PV MISC (condoms latex PV lubricated - male) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO MICRO THIN PV REALITY LATEX PV PLUS SPERMICIDE CONDOMS/LUBRICATED LUBRICATED MISC PV MISC (condoms latex PV (condoms latex lubricated - male) lubricated - male) REALITY LATEX/ULTRA PV KIMONO PLUS PV TEXTURED DEVI SPERMICIDE (condoms latex PV LUBRICATED MISC PV lubricated - male) (condoms latex REALITY LATEX/ULTRA PV lubricated - male) THIN DEVI (condoms PV KIMONO PLUS PV latex lubricated - male) SPERMICIDE/LUBRICATE PV TRUSTEX COLOR PV D MISC (condoms latex CONDOMS + LUBE MISC lubricated - male) (condoms latex PV KIMONO PS LUBRICATED PV lubricated - male) MISC (condoms latex PV TRUSTEX LUBRICATED PV lubricated - male) EXTRALARGE MISC KIMONO PS PLUS PV (condoms latex PV SPERMICIDE/LUBRICATE PV lubricated - male) D MISC (condoms latex TRUSTEX LUBRICATED PV lubricated - male) EXTRASTRENGTH MISC KIMONO SENSATION PV (condoms latex PV LUBRICATED MISC PV lubricated - male) (condoms latex TRUSTEX LUBRICATED PV lubricated - male) MISC (condoms latex PV KIMONO SENSATION PV lubricated - male) PLUS SPERMICIDE LUBRICATED MISC TRUSTEX PV PV LUBRICATED/RIBBED/ST (condoms latex UDDED MISC (condoms PV lubricated - male) latex lubricated - male) KIMONO SPECIAL DEVI PV TRUSTEX PV (condoms latex PV LUBRICATED/SPERMICID lubricated - male) E EXTRA LARGE MISC PV MAXX LUBRICATED MISC PV (condoms latex (condoms latex PV lubricated - male) lubricated - male) TRUSTEX PV MAXX PLUS SPERMICIDE PV LUBRICATED/SPERMICID LUBRICATED MISC E EXTRA STRENGTH PV (condoms latex PV MISC (condoms latex lubricated - male) lubricated - male) PREMIUM CONDOMS PV TRUSTEX PV LUBRICATED MISC LUBRICATED/SPERMICID (condoms latex PV E MISC (condoms latex PV lubricated - male) lubricated - male)

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102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX NATURAL PV LANCET 2 CONDOMS +LUBE/LUBRICATED PV ONETOUCH ULTRA 2 KIT QL(1 ea per MISC (condoms latex (blood glucose 2 365 days lubricated - male) monitoring supplies) retail); RX/OTC TRUSTEX NON- PV ONETOUCH ULTRA MINI QL(1 ea per LUBRICATED MISC 365 days PV KIT (blood glucose 2 (condoms latex non- monitoring supplies) retail); RX/OTC lubricated - male) ONETOUCH VERIO FLEX Limit 1 per TRUSTEX WITH PV BLOOD GLUCOSE year;QL(1 ea NONOXYNOL- MONITORING SYSTEM 2 per 365 days 9/RIBBED/STUDDED PV KIT (blood glucose retail); RX/OTC MISC (condoms latex monitoring supplies) lubricated - male) ONETOUCH VERIO IQ QL(1 ea per TRUSTEX/RIA PV BLOOD GLUCOSE 365 days LUBRICATED MISC MONITORING SYSTEM retail); RX/OTC PV 2 (condoms latex KIT (blood glucose lubricated - male) monitoring supplies) TRUSTEX/RIA PV ONETOUCH VERIO KIT Limited to 1 per LUBRICATED (blood glucose 2 year;QL(1 ea SPERMICIDE MISC PV per 365 days (condoms latex monitoring supplies) retail); RX/OTC lubricated - male) ONETOUCH VERIO SYNC Limited to 1 per TRUSTEX/RIA PV BLOODGLUCOSE year;QL(1 ea LUBRICATED/SPERMICID MONITORING SYSTEM 2 per 365 days E MISC (condoms latex PV KIT (blood glucose retail); RX/OTC lubricated - male) monitoring supplies) TRUSTEX/RIA NON- PV PRECISION XTRA DEVI QL(1 ea per LUBRICATED MISC XX (blood glucose 2 365 days retail) (condoms latex non- PV monitoring supplies) lubricated - male) Parenteral Therapy Supplies Diabetic Supplies INSULIN SYRINGES AND 2 MO FREESTYLE FREEDOM QL(1 ea per PEN NEEDLES LITE KIT (blood glucose 2 365 days Respiratory Therapy Supplies monitoring supplies) retail); RX/OTC INHALER SPACERS 2 MO FREESTYLE INSULINX QL(1 ea per BLOODGLUCOSE 365 days MIGRAINE PRODUCTS - Drugs to Treat Migraine MONITORING SYSTEM 2 retail); RX/OTC Headaches KIT (blood glucose Calcitonin Gene-Related Peptide (CGRP) monitoring supplies) AIMOVIG SOAJ 140 PA FREESTYLE LITE BLOOD QL(1 ea per MG/ML ( SP GLUCOSE MONITORING 365 days retail) erenumab- aooe) SYSTEM DEVI (blood 2 AIMOVIG SOAJ 70 MG/ML PA; SP glucose monitoring SP supplies) (erenumab-aooe)

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103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMGALITY SOAJ 120 PA ERGOMAR SUBL 2 MG/ML (galcanezumab- SP (ergotamine tartrate) gnlm) MIGRANAL SOLN QL(8 ml per fill EMGALITY SOSY 120 PA (dihydroergotamine 3 retail,24 ml per MG/ML (galcanezumab- SP mesylate) fill mail) gnlm) Serotonin Agonists Migraine Combinations 1 QL(6 ea per 30 almotriptan malate tabs days retail) (Ergotamine W/ Caffeine) 1 MIGERGOT SUPP AMERGE TABS QL(9 ea per 30 GP CAFERGOT TABS (naratriptan hcl) days retail) (ergotamine w/ GP QL(0.2 ea eletriptan hydrobromide 1 caffeine) tabs daily) ergotamine w/ caffeine FROVA TABS QL(0.3 ea 1 GP tabs (frovatriptan succinate) daily) sumatriptan-naproxen PA; QL(0.3 ea QL(0.3 ea 1 frovatriptan succinate 1 sodium tabs daily) tabs daily) TREXIMET TABS 10 MG- PA; Limit 9 per IMITREX SOLN NA 20 Limited to 6 per 60 MG (sumatriptan- 3 month;QL(0.3 GP month;QL(0.2 MG/ACT (sumatriptan) naproxen sodium) ea daily) ea daily) TREXIMET TABS 500 MG- PA; QL(0.3 ea IMITREX SOLN NA 5 Limit 6 per 85 MG (sumatriptan- GP daily) GP month;QL(0.2 MG/ACT (sumatriptan) ea daily) naproxen sodium) QL(2 ml per fill Migraine Products - NSAIDs IMITREX SOLN SC 6 retail,6 ml per CAMBIA PACK PA; Limit 9 per MG/0.5ML (sumatriptan GP fill mail,4 ml per month;QL(0.3 30 days (diclofenac potassium 3 succinate) (migraine)) ea daily) retail,12 ml per 90 days mail) Migraine Products QL(2 ml per fill QL(10 ml per IMITREX STATDOSE retail,6 ml per fill retail,30 ml D.H.E. 45 SOLN REFILL SOCT GP fill mail,4 ml per (dihydroergotamine GP per fill mail,20 30 days ml per 30 days (sumatriptan succinate) retail,12 ml per mesylate) retail,60 ml per 90 days mail) 90 days mail) QL(2 ml per fill QL(10 ml per IMITREX STATDOSE retail,6 ml per fill retail,30 ml dihydroergotamine SYSTEM SOAJ GP fill mail,4 ml per 1 per fill mail,20 30 days mesylate soln ij 1 ml per 30 days (sumatriptan succinate) retail,12 ml per mg/ml retail,60 ml per 90 days mail) 90 days mail) QL(9 ea per fill dihydroergotamine QL(8 ml per fill retail,27 ea per retail,24 ml per IMITREX TABS OR 25 MG mesylate soln na 4 3 GP fill mail,18 ea mg/ml fill mail) (sumatriptan succinate) per 30 days retail,54 ea per 90 days mail)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per QL(9 ea per fill fill retail,36 ea retail,27 ea per MAXALT-MLT TBDP 5 MG sumatriptan succinate GP per fill mail,24 tabs or 100 mg, 25 mg, 1 fill mail,18 ea (rizatriptan benzoate) ea per 30 days per 30 days retail,72 ea per 50 mg retail,54 ea per 90 days mail) 90 days mail) naratriptan hcl tabs 1 QL(9 ea per 30 ZEMBRACE SYMTOUCH PA days retail) SOAJ (sumatriptan 3 RELPAX TABS 20 MG QL(0.2 ea succinate) (eletriptan GP daily) QL(9 ea per fill hydrobromide) retail,27 ea per QL(12 ea per zolmitriptan tabs 1 fill mail,18 ea fill retail,36 ea per 30 days retail,54 ea per rizatriptan benzoate 1 per fill mail,24 tabs ea per 30 days 90 days mail) retail,72 ea per QL(9 ea per fill 90 days mail) retail,27 ea per QL(12 ea per zolmitriptan tbdp 1 fill mail,18 ea fill retail,36 ea per 30 days retail,54 ea per rizatriptan benzoate 1 per fill mail,24 tbdp ea per 30 days 90 days mail) retail,72 ea per QL(9 ea per fill 90 days mail) retail,27 ea per ZOMIG SOLN NA 2.5 MG fill mail,18 ea sumatriptan soln 20 Limited to 6 per 3 1 month;QL(0.2 (zolmitriptan) per 30 days mg/act ea daily) retail,54 ea per 90 days mail) sumatriptan soln 5 Limit 6 per 1 month;QL(0.2 QL(6 ea per 30 mg/act ZOMIG SOLN NA 5 MG ea daily) 3 days retail,18 (zolmitriptan) ea per 90 days QL(2 ml per fill mail) retail,6 ml per sumatriptan succinate QL(9 ea per fill 1 fill mail,4 ml per soaj sc 4 mg/0.5ml, 6 30 days retail,27 ea per ZOMIG TABS OR 2.5 MG, mg/0.5ml retail,12 ml per GP fill mail,18 ea 90 days mail) 5 MG (zolmitriptan) per 30 days retail,54 ea per QL(2 ml per fill 90 days mail) retail,6 ml per sumatriptan succinate QL(9 ea per fill 1 fill mail,4 ml per soct sc 4 mg/0.5ml, 6 30 days retail,27 ea per ZOMIG ZMT TBDP mg/0.5ml retail,12 ml per GP fill mail,18 ea 90 days mail) (zolmitriptan) per 30 days retail,54 ea per QL(2 ml per fill 90 days mail) retail,6 ml per sumatriptan succinate 1 fill mail,4 ml per MINERALS & ELECTROLYTES soln sc 6 mg/0.5ml 30 days retail,12 ml per Calcium 90 days mail)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCIFOL WAFR PA magnesium sulfate soln SP (calcium carbonate-folic 3 ij 50 % acid-vit d-b6-b12- magnesium sulfate soln PA boron-magnesium) iv 2 gm/50ml, 20 CALCIUM-FOLIC ACID gm/500ml, 4 gm/100ml, SP PLUS D WAFR (calcium 4 gm/50ml, 40 carbonate-folic acid-vit 3 gm/1000ml d-b6-b12-boron- MAGNESIUM SULFATE PA magnesium) SOLN IV 2 GM/50ML, 20 Electrolyte Mixtures GM/500ML, 4 GM/100ML, 4 GM/50ML, 40 SP ISOLYTE-S SOLN PA SP GM/1000ML (magnesium (electrolyte-s) sulfate) NORMOSOL-R SOLN PA SP (electrolyte-r (ph 7.4)) Phosphate PLASMA-LYTE A SOLN PA (Pot Phosphate Monobasic SP W/ Sod Phosphate Dibasic (electrolyte-a) & Monobasic) AV-PHOS PLASMA-LYTE-148 SOLN PA SP 250 NEUTRAL, PHOSPHA 1 (electrolyte-148) 250 NEUTRAL, potassium chloride in PA PHOSPHO-TRIN 250 NEUTRAL, VIRT-PHOS nacl soln 0.15 %-0.9 %, 250 NEUTRAL TABS SP 0.45 %-20 meq/l, 0.9 K-PHOS NEUTRAL TABS %-20 meq/l, 0.9 %-40 (pot phosphate meq/l monobasic w/ sod GP Fluoride phosphate dibasic & (Sodium Fluoride) PV monobasic) FLUORITAB, FLURA- PV K-PHOS TABS DROPS, NAFRINSE ( 2 DROPS SOLN potassium phosphate monobasic) (Sodium Fluoride) PV FLUORITAB, NAFRINSE PV pot phosphate CHEW monobasic w/ sod 1 FLUORABON SOLN PV phosphate dibasic & PV (sodium fluoride) monobasic tabs sodium fluoride chew PV PV Potassium (Potassium Bicarb & PV sodium fluoride soln PV Chloride) 1 EFFERVESCENT POT sodium fluoride tabs PV PV CHLORIDE TBEF (Potassium Bicarbonate) 1 Magnesium EFFER-K TBEF 25 MEQ MAGNEBIND 400 TABS (Potassium Bicarbonate) K- (magnesium-calcium- 3 EFFERVESCENT, K- 1 folic acid) PRIME, K-VESCENT, KLOR-CON/EF TBEF

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Potassium Chloride POTASSIUM CHLORIDE PA Microencapsulated SOLN IV 0.4 MEQ/ML, 10 Crystals Er) KLOR-CON 1 MEQ/100ML, 10 M10, KLOR-CON M15, MEQ/50ML, 20 SP KLOR-CON M20 TBCR MEQ/100ML, 20 (Potassium Chloride) K- MEQ/50ML (potassium SOL, POTASSIUM 1 chloride) CHLORIDE PROAMP PA SOLN potassium chloride soln SP iv 2 meq/ml (Potassium Chloride) K- PA potassium chloride soln SOL, POTASSIUM SP 1 CHLORIDE PROAMP or 10 %, 20 % SOLN potassium chloride tbcr (Potassium Chloride) or 10 meq, 20 meq, 8 1 KLOR-CON 10, KLOR- 1 meq CON 8 TBCR Sodium (Potassium Chloride) 1 KLOR-CON PACK PA sodium chloride soln ij SP (Potassium Chloride) 2.5 meq/ml KLOR-CON SPRINKLE 1 sodium chloride soln iv PA CPCR 0.45 %, 0.9 %, 3 %, 5 SP EFFER-K TBEF 0.84 GM-1 GM, 1.68 GM-2 GM % (potassium 3 Zinc bicarbonate-citric acid) (Zinc Sulfate) ORAZINC, 1 K-TAB TBCR 10 MEQ ZINC-220 CAPS GP GALZIN CAPS ( (potassium chloride) zinc 3 K-TAB TBCR 8 MEQ acetate (oral)) 2 (potassium chloride) zinc sulfate caps 1 potassium bicarb & 1 chloride tbef MISCELLANEOUS THERAPEUTIC CLASSES potassium bicarbonate 1 Chelating Agents tbef (Trientine Hcl) CLOVIQUE SP PA CAPS potassium chloride cpcr 1 or 10 meq, 8 meq CUPRIMINE CAPS PA GP potassium chloride (penicillamine) 1 DEPEN TITRATABS TABS microencapsulated GP crystals er tbcr (penicillamine) PA potassium chloride 1 penicillamine caps 1 pack or 20 meq penicillamine tabs 1 SYPRINE CAPS ( PA trientine SP hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trientine hcl caps SP PA CELLCEPT TABS (mycophenolate GP Enzymes mofetil) XIAFLEX SOLR PA cyclosporine caps or (collagenase 1 SP 100 mg, 25 mg clostridium cyclosporine modified histolyticum) (for microemulsion) 1 Immunomodulators caps 100 mg, 25 mg, REVLIMID CAPS PA 50 mg AC (lenalidomide) cyclosporine modified THALOMID CAPS 1 AC (for microemulsion) (thalidomide) soln 100 mg/ml PA Immunosuppressive Agents cyclosporine soln iv 50 SP (Cyclosporine Modified mg/ml (For Microemulsion)) 1 ENVARSUS XR TB24 PA 3 GENGRAF CAPS (tacrolimus) (Cyclosporine Modified (For Microemulsion)) 1 everolimus GENGRAF SOLN (immunosuppressant) 1 ASTAGRAF XL CP24 PA tabs 3 IMURAN TABS (tacrolimus) GP (azathioprine) ATGAM INJ (lymphocyte PA mycophenolate mofetil immune globulin,anti- SP 1 thymocyte globulin caps ) PA (equine) mycophenolate mofetil SP AZASAN TABS hcl solr 3 (azathioprine) mycophenolate mofetil 1 AZATHIOPRINE SOLR IJ PA susr 100 MG (azathioprine SP mycophenolate mofetil 1 sodium) tabs azathioprine tabs or 50 1 mycophenolate sodium 1 mg tbec CELLCEPT CAPS MYFORTIC TBEC (mycophenolate GP (mycophenolate GP mofetil) sodium) CELLCEPT PA NEORAL CAPS INTRAVENOUS SOLR SP (cyclosporine modified GP (mycophenolate mofetil (for microemulsion)) ) hcl NEORAL SOLN CELLCEPT SUSR (cyclosporine modified GP (mycophenolate GP (for microemulsion)) mofetil)

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108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NULOJIX SOLR PA SP lactated ringer's 1 (belatacept) (irrigation) soln PROGRAF CAPS OR 0.5 1 MG, 1 MG, 5 MG GP ringer's irrigation soln (tacrolimus) water for irrigation, 1 PROGRAF PACK OR 0.2 PA sterile soln SP MG, 1 MG (tacrolimus) Potassium Removing Agents PROGRAF SOLN IV 5 PA SP (Sodium Polystyrene MG/ML (tacrolimus) Sulfonate) KIONEX, SPS 1 RAPAMUNE SOLN SUSP GP (sirolimus) LOKELMA PACK ST RAPAMUNE TABS (sodium zirconium 3 GP (sirolimus) cyclosilicate) SANDIMMUNE CAPS OR sodium polystyrene 1 100 MG, 25 MG GP sulfonate powd (cyclosporine) sodium polystyrene SANDIMMUNE SOLN IV PA 1 SP sulfonate susp 50 MG/ML (cyclosporine) VELTASSA PACK ST SIMULECT SOLR PA SP (patiromer sorbitex 3 (basiliximab) calcium) sirolimus soln 1 Systemic Lupus Erythematosus Agents BENLYSTA SOAJ PA SP sirolimus tabs 1 (belimumab) BENLYSTA SOLR PA tacrolimus caps 1 SP (belimumab) THYMOGLOBULIN SOLR PA BENLYSTA SOSY PA SP (anti-thymocyte globulin SP (belimumab) (rabbit), lymphocyte immune globulin) MOUTH/THROAT/DENTAL AGENTS ZORTRESS TABS 0.25 MG, 0.5 MG, 0.75 MG Anesthetics Topical Oral (everolimus GP FIRST-MOUTHWASH BLM (immunosuppressant)) SUSP (diphenhydramine- Irrigation Solutions lidocaine-alum 3 (Irrigation Solutions, hydroxide-mg Physiological) hydroxide-simeth) PHYSIOLYTE, 1 PHYSIOSOL IRRIGATION lidocaine hcl (mouth- 1 SOLN throat) soln (Ringer'S Irrigation) TIS-U- 1 Anti-infectives - Throat SOL SOLN (Water For Irrigation, clotrimazole troc 1 Sterile) ARGYLE STERILE 1 WATER 100ML SOLN

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109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nystatin (mouth-throat) 1 Multiple Vitamins & Fluoride-Folic Acid susp MULTIVITAMIN WITH AL(Up to 6 yrs ORAVIG TABS FLUORIDE CHEW 0.25 old ) (miconazole (mouth- 3 MG-0.3 MG-1.05 MG-1.05 throat)) MG-1.2 MG-13.5 MG-15 UNIT-2500 UNIT-4.5 MCG- Antiseptics - Mouth/Throat 400 UNIT-60 MG, 0.3 MG- (Chlorhexidine Gluconate 0.5 MG-1.05 MG-1.05 MG- (Mouth-Throat)) PAROEX, 1 1.2 MG-13.5 MG-15 UNIT- PERIOGARD SOLN 2500 UNIT-4.5 MCG-400 2 UNIT-60 MG, 0.3 MG-1 chlorhexidine gluconate 1 MG-1.05 MG-1.05 MG-1.2 (mouth-throat) soln MG-13.5 MG-15 UNIT- PERIDEX SOLN 2500 UNIT-4.5 MCG-400 (chlorhexidine UNIT-60 MG (multiple gluconate (mouth- GP vitamins & fluoride-folic throat)) acid) Steroids - Mouth/Throat/Dental Multiple Vitamins w/ Minerals (Triamcinolone Acetonide ONEVITE TABS (multiple (Mouth)) ORALONE 1 vitamins w/ minerals & 3 DENTAL PASTE PSTE folic acid) triamcinolone 1 THRIVITE 19 TABS acetonide (mouth) pste (multiple vitamins w/ 3 Throat Products - Misc. minerals & folic acid) cevimeline hcl caps 1 UDAMIN SP TABS (multiple vitamins w/ 3 EVOXAC CAPS GP minerals & folic acid) (cevimeline hcl) Ped MV w/ Fluoride GELCLAIR GEL (Pediatric Multivitamins AL(Up to 6 yrs (povidone-sodium 3 W/Fl) MULTI- 1 old ) hyaluronate- VITAMIN/FLUORIDE glycyrrhetinic acid) DROPS SOLN MUCOTROL WAFR ( (Pediatric Multivitamins AL(Up to 6 yrs oral 3 wound care products) W/Fl) MULTIVITAMIN old ) WITH FLUORIDE SOLN ORAFATE PSTE 3 0.25 MG/ML-0.4 MG/ML- (sucralfate-malate) 0.5 MG/ML-0.6 MG/ML- 1500 UNIT/ML-2 MCG/ML- pilocarpine hcl (oral) 1 tabs 35 MG/ML-400 UNIT/ML-5 1 UNIT/ML-8 MG/ML, 0.4 PROTHELIAL PSTE 3 MG/ML-0.5 MG/ML-0.5 (sucralfate-malate) MG/ML-0.6 MG/ML-1500 SALAGEN TABS UNIT/ML-2 MCG/ML-35 GP (pilocarpine hcl (oral)) MG/ML-400 UNIT/ML-5 UNIT/ML-8 MG/ML MULTIVITAMINS

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110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins AL(Up to 6 yrs (Ped Multivitamins W/Fl & W/Fl) old ) Iron) MULTI- MULTIVITAMIN/FLUORID 1 VIT/IRON/FLUORIDE, 1 E, MULTI- MULTIVITAMINS/FLUORI VITAMIN/FLUORIDE/IRON DE CHEW SOLN (Pediatric Vitamins Acd W/ AL(Up to 6 yrs POLY-VI-FLOR/IRON AL(Up to 6 yrs Fluoride) TRI- old ) CHEW 0.5 MG-10 MG-15 old ) VITE/FLUORIDE, 1 UNIT-200 MCG-400 UNIT 3 VITAMINS (ped multivitamins w/fl A/C/D/FLUORIDE SOLN & iron) FLORIVA PLUS SOLN AL(Up to 6 yrs POLY-VI-FLOR/IRON (pediatric multivitamins 2 old ) SUSP 0.25 MG/ML-200 w/fl) MCG/ML-7 MG/ML (ped 3 AL(Up to 6 yrs multivitamins w/fl & pediatric vitamins acd 1 w/ fluoride soln old ) iron) POLY-VI-FLOR CHEW AL(Up to 6 yrs Prenatal Vitamins 0.25 MG-15 UNIT-200 old ) (Prenatal Vit W/ Docusate- RX/OTC MCG-400 UNIT, 0.5 MG-15 Fe Fumarate-Folic Acid) UNIT-200 MCG-400 UNIT, 3 PRENATAL 19 TABS 1 1 MG-15 UNIT-200 MCG- MG-100 MG-1000 UNIT-12 1 400 UNIT (pediatric MCG-15 MG-20 MG-20 multivitamins w/fl) MG-200 MG-25 MG-29 POLY-VI-FLOR SUSP 0.25 MG-3 MG-3 MG-30 UNIT- MG/ML-200 MCG/ML 400 UNIT-7 MG (pediatric multivitamins 3 (Prenatal Vit W/ Docusate- w/fl) Iron Carbonyl-Folic Acid) 1 INATAL GT TABS QUFLORA GUMMIES AL(Up to 6 yrs CHEW (pediatric 2 old ) (Prenatal Vit W/ Ferrous Fumarate-Folic Acid) multivitamins w/fl) PRENATAL 19 CHEW 1 QUFLORA PEDIATRIC AL(Up to 6 yrs MG-100 MG-1000 UNIT-12 1 CHEW (pediatric 2 old ) MCG-20 MG-20 MG-200 multivitamins w/fl) MG-25 MG-29 MG-3 MG-3 MG-30 UNIT-400 UNIT-6 QUFLORA PEDIATRIC AL(Up to 6 yrs MG-7 MG SOLN ( 2 old ) pediatric (Prenatal Vit W/ Ferrous multivitamins w/fl) Fumarate-L Methylfolate- 1 TRI-VI-FLOR SUSP Folic Acid) PNV-SELECT (pediatric vitamins acd TABS 3 & l-methylfolate w/ (Prenatal Vit W/ Iron fluoride) Carbonyl-Folic Acid) 1 TRI-VI-FLORO SUSP PRENATABS RX TABS (pediatric vitamins acd (Prenatal Without A W/ Fe 3 Fumarate-L Methylfolate- 1 & l-methylfolate w/ Fa-Dha) PNV-DHA CAPS fluoride) Ped Multi Vitamins w/Fl & FE You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATABEX EC TBEC CITRANATAL ESSENCE (prenatal vit w/ THPK (prenatal w/o vit docusate-iron carbonyl- 2 a w/ fe carbonyl-fe 2 folic acid) gluconate-fa-dha) ATABEX OB TABS CITRANATAL HARMONY (prenatal vit w/ fe CAPS (prenatal w/o vit bisglycinate chelate- 2 a w/ fe fumarate-fe 3 folic acid) carbonyl-dss-fa-dha) BAL-CARE DHA MISC CITRANATAL MEDLEY (prenatal w/fe CAPS (prenatal w/o vit polysacch cmplx-sod 2 a w/ fe fumarate-fe 3 feredetate-fa-omega 3) carbonyl-fa-dha) C-NATE DHA CAPS CITRANATAL RX TABS (prenatal vit w/ ferrous (prenatal without vit a fumarate-fa-omega 3 3 w/ fe carbonyl-fe gluc- 3 fatty acids) docusate-fa) CITRANATAL 90 DHA COMPLETENATE CHEW MISC (prenatal w/o vit a (prenatal vit w/ ferrous 2 2 w/ fe carbonyl-fe fumarate-folic acid) gluconate-dss-fa-dha) CONCEPT DHA CAPS CITRANATAL ASSURE (prenatal vit w/ fe fum- 2 MISC (prenatal w/o vit a iron polysacch complex 2 w/ fe carbonyl-fe -fa-omega 3) gluconate-dss-fa-dha) CONCEPT OB CAPS CITRANATAL B-CALM (prenatal without a vit 2 MISC (prenatal w/o vit a w/ fe fum-iron 3 w/ fe carbonyl-fe polysacch complex -fa) gluconate-fa & vit b6) CVS PRENATAL TABS CITRANATAL BLOOM (prenatal vit w/ ferrous 2 DHA MISC (prenatal w/o fumarate-folic acid) 2 vit a w/ fe carbonyl-fe DOTHELLE DHA CAPS gluconate-dss-fa-dha) (prenatal vit w/ fe fum- 2 CITRANATAL BLOOM iron polysacch complex TABS (prenatal vit w/ -fa-omega 3) 3 docusate-fe carbonyl-fe DUET DHA 400 MISC gluconate-folic acid) (prenatal w/fe 3 CITRANATAL DHA MISC polysacch cmplx-sod (prenatal w/o vit a w/ fe feredetate-fa-omega 3) 2 carbonyl-fe gluconate- DUET DHA BALANCED dss-fa-dha) MISC (prenatal w/fe polysacch cmplx-sod 3 feredetate-fa-omega 3)

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112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBRACE HR CAPS MYNATAL ULTRACAPLET (prenatal vit w/ fe TABS (prenatal vit w/ glycine cysteinate-fa- 3 docusate-iron carbonyl- 2 omega 3 fatty acids) folic acid) FOLET DHA THPK MYNATE 90 PLUS TBCR (prenatal vit w/fe (prenatal vit w/ carbonyl-fe bisglyc- 3 docusate-fe fumarate- 2 methylfol-dss & dha) folic acid) FOLET ONE CAPS NATACHEW CHEW (prenatal w/o a w/fe (prenatal vit w/ fe fum- carbonyl-fe bisglyc-l 3 fe bisglycinate chelate- 3 methylfol-dss-dha) folic acid) FOLIVANE-OB CAPS NATELLE ONE CAPS (prenatal without a vit (prenatal without vit a w/ fe fum-iron 2 w/ fe fum-fa-omega 3 polysacch complex -fa) fatty acids) HEMENATAL OB + DHA NEEVO DHA CAPS MISC (prenatal vit w/ fe (prenatal without vit a poly cmplx-fe heme 2 w/ fe fumarate-l 3 polypept-fa & omega 3) methylfolate-omegas) HEMENATAL OB TABS NEONATAL 19 TABS (prenatal vit w/ fe (prenatal vitamin-folic 2 3 polysacch complex-fe acid) heme polypeptide-fa) NEONATAL COMPLETE RX/OTC KOSHER PRENATAL TABS (prenatal vit w/ PLUS IRON TABS 2 3 ferrous fumarate-folic (prenatal vit w/ iron acid) carbonyl-folic acid) NEONATAL FE TABS M-NATAL PLUS TABS RX/OTC (prenatal multivitamins 2 (prenatal vit w/ ferrous 2 w/ iron-folic acid) fumarate-folic acid) NEONATAL PLUS TABS RX/OTC MARNATAL-F CAPS (prenatal vit w/ ferrous 2 (prenatal without vit a 2 fumarate-folic acid) w/ iron polysaccharide NEONATAL VITAMIN complex-fa) TABS (prenatal vit w/ MULTI PRENATAL TABS ferrous fumarate-folic 2 (prenatal vit w/ ferrous 2 acid) fumarate-folic acid) NEONATAL/DHA MISC PV MYNATAL ADVANCE (prenatal mv & min w/fe PV TABS (prenatal vit w/ fumarate-fa-dha) docusate-iron carbonyl- 2 folic acid)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NESTABS ABC MISC OBSTETRIX ONE CAPS (prenatal mv & min w/o (prenatal w/o a w/fe vit a w/fe polysac 3 carbonyl-fe bisglyc-l 3 cmplx-fa-ca-omega 3) methylfol-dss-dha) NESTABS DHA MISC ONE VITE WOMENS RX/OTC (prenatal vit without vit PRENATALVITAMIN PLUS a w/ fe bisglycinate-fa- 2 TABS (prenatal vit w/ 2 omeg 3) ferrous fumarate-folic NESTABS ONE CAPS acid) (prenatal w/o a w/fe ONE VITE WOMENS 3 PRENATALVITAMIN TABS carbonyl-fe bisglyc-l 2 methylfol-dha) (prenatal vit w/ ferrous NESTABS TABS fumarate-folic acid) (prenatal vit without vit PNV OB+DHA MISC 3 (prenatal w/o vit a w/ fe a w/ fe bisglycinate- 2 folic acid) carbonyl-fe gluconate- NEXA PLUS CAPS dss-fa-dha) (prenatal w/o vit a w/fe PNV TABS 29-1 TABS fumarate-docusate ca- 3 (prenatal vit w/ iron 3 folic acid-dha) carbonyl-folic acid) NIVA-PLUS TABS RX/OTC PNV-DHA+DOCUSATE CAPS (prenatal w/o vit (prenatal vit w/ ferrous 2 3 fumarate-folic acid) a w/ fe fumarate-dss-fa- O-CAL FA TABS RX/OTC dha) (prenatal vit w/ ferrous 2 PNV-OMEGA CAPS fumarate-folic acid) (prenatal without a w/ OB COMPLETE ONE fe fumarate-l 3 CAPS (prenatal w/o vit methylfolate-fa-omega a w/ fe carbonyl-fe 3 3) aspart glyc-fa-fish oil) PR NATAL 400 EC MISC (prenatal mv & min w/fe OB COMPLETE PETITE 2 CAPS (prenatal w/o vit bisglyc-fe prot succ-fa- a w/ fe carbonyl-fe 3 ca-omega 3) aspart glyc-fa-omega 3) PR NATAL 430 EC MISC (prenatal mv & min w/fe OB COMPLETE PREMIER 3 TABS (prenatal vit w/ bisglyc-fe prot succ-fa- iron carbonyl-fe aspart 3 ca-omega 3) glycinate-fa) PR NATAL 430 MISC (prenatal mv & min w/fe OB COMPLETE/DHA 3 CAPS (prenat vit w/ iron bisglyc-fe prot succ-fa- carbonyl-fe asp glyc-fa- 3 ca-omega 3) omega fatty acid)

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114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMESISRX TABS PRENATAL PLUS IRON (prenatal w/ calcium-vit TABS (prenatal vit w/ 3 3 b6-vit b12-folic acid- iron carbonyl-folic acid) ginger) PRENATAL PLUS TABS RX/OTC PRENA 1 TRUE MISC (prenatal vit w/ ferrous 2 (prenatal without a w/ fumarate-folic acid) 3 fe amino acid chelate- PRENATAL TABS 0.8 MG- fa-dha) 1.5 MG-1.7 MG-100 MG-11 PRENA1 PEARL CPCR UNIT-18 MG-2.6 MG-25 MG-263 MG-27 MG-4 (prenatal without a w/ 3 MCG-400 UNIT-4000 fe fumarate-sod UNIT, 1.7 MG-1.84 MG- feredetate-fa-dha) 100 MG-11 UNIT-160 MG- 2 PRENAISSANCE CAPS 18 MG-2.6 MG-200 MG-25 (prenatal w/o vit a w/ fe 3 MG-27 MG-4 MCG-400 fumarate-dss-fa-dha) UNIT-4000 UNIT-800 MCG (prenatal vit w/ ferrous PRENAISSANCE PLUS fumarate-folic acid) CAPS (prenatal w/o vit 3 PRENATAL TABS 1 MG- RX/OTC a w/ fe carbonyl-dss-fa- 1.84 MG-10 MG-12 MCG- dha) 120 MG-2 MG-20 MG-200 PRENATAL 19 CHEW 1 MG-22 MG-25 MG-27 MG- 2 MG-100 MG-1000 UNIT-12 3 MG-400 UNIT-4000 UNIT MCG-15 MG-20 MG-20 (prenatal vit w/ ferrous MG-200 MG-29 MG-3 MG- fumarate-folic acid) 3 MG-30 UNIT-400 UNIT-7 2 MG (prenatal vit w/ PRENATAL VITAMIN TABS (prenatal vit w/ ferrous fumarate-folic 2 acid) ferrous fumarate-folic acid) PRENATAL 19 TABS 1 RX/OTC MG-100 MG-1000 UNIT-12 PRENATAL VITAMINS RX/OTC PLUS LOW IRON TABS MCG-15 MG-20 MG-20 2 MG-200 MG-25 MG-29 (prenatal vit w/ ferrous MG-3 MG-3 MG-30 UNIT- 3 fumarate-folic acid) 400 UNIT-7 MG (prenatal PRENATAL-U CAPS vit w/ docusate-fe (prenatal without a vit fumarate-folic acid) w/ fe fumarate-folic 2 PRENATAL LOW IRON acid) TABS (prenatal vit w/ 2 PRENATE AM TABS ferrous fumarate-folic (prenatal w/ calcium-vit acid) b6-vit b12-folic acid- 3 PRENATAL ONE DAILY ginger) TABS (prenatal vit w/ 2 PRENATE CHEW ferrous fumarate-folic (prenatal multivitamins acid) & minerals w/ l- 3 methylfolate-fa)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATE DHA CAPS R-NATAL OB CAPS (prenatal w/o a w/ fe (prenatal w/o vit a w/ fe 3 3 asparto glyc-l carbonyl-folic acid-dha) methylfolate-fa-dha) RELNATE DHA CAPS PRENATE ELITE TABS (prenatal vit w/ ferrous 3 (prenatal w/ fe asparto fumarate-fa-omega 3 3 glycinate-l methylfolate- fatty acids) folic acid) RIGHT STEP PRENATAL PRENATE ESSENTIAL TABS (prenatal vit w/ 2 CAPS (prenatal w/o a ferrous fumarate-folic 3 w/ fe asparto glyc-l acid) methylfolate-fa-dha) SE-NATAL 19 CHEW PRENATE MINI CAPS (prenatal vit w/ ferrous 2 (prenatal w/o vit a w/ fe fumarate-folic acid) 3 carbonyl-fe asp glyc- SE-NATAL 19 TABS RX/OTC methfol-fa-dha) (prenatal vit w/ 3 PRENATE PIXIE CAPS docusate-fe fumarate- (prenatal w/o a w/ fe folic acid) 3 asparto glyc-l SELECT-OB CHEW 1 MG- methylfolate-fa-dha) 1.6 MG-1.8 MG-15 MG-15 PRENATRIX TABS RX/OTC MG-1700 UNIT-2.5 MG-25 MG-29 MG-30 UNIT-400 ( prenatal vit w/ ferrous 2 UNIT-5 MCG-60 MG 3 ) fumarate-folic acid (prenatal vit w/ iron PRENATRYL TABS RX/OTC polysaccharide (prenatal vit w/ ferrous 2 complex-folic acid) ) fumarate-folic acid SELECT-OB+DHA MISC PREPLUS TABS RX/OTC (prenatal mv & min w/fe (prenatal vit w/ ferrous 2 polysaccharide 3 fumarate-folic acid) complex-fa-dha) PRIMACARE CAPS TARON-BC MISC (prenatal without a w/ (prenatal without vit a fe asp glyc-l 3 w/ iron carbonyl-folic 3 methylfolate-fa-omega acid & vit b6) ) 3 TARON-C DHA CAPS PROVIDA DHA CAPS (prenatal vit w/ fe fum- (prenatal without a w/fe 2 3 iron polysacch complex fum-fe polysacch -fa-omega 3) ) complex-fa-dha TARON-PREX CAPS PROVIDA OB CAPS (prenatal w/o vit a w/ fe 3 (prenatal without a vit fumarate-dss-fa-dha) w/ fe fum-iron 2 polysacch complex -fa)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THERANATAL CORE RX/OTC ULTIMATECARE ONE NUTRITION TABS CAPS ( 2 prenatal vit w/ (prenatal vit w/ ferrous iron carbonyl-fe aspart 3 fumarate-folic acid) glyc-fa-omega 3) THRIVITE RX TABS VENA-BAL DHA MISC (prenatal vit w/ iron 3 (prenatal w/fe carbonyl-folic acid) polysacch cmplx-sod 2 TL FOLATE TABS feredetate-fa-omega 3) (prenatal vit w/ ferrous 2 VIL-RX TABS (prenatal fumarate-l methylfolate- vit w/ iron carbonyl-folic 3 folic acid) acid) TL-CARE DHA CAPS VINATE DHA RF CAPS (prenatal w/fe 3 (prenatal without vit a fumarate-fa-dss-fish oil) w/ fe fumarate-l 3 TL-SELECT CAPS methylfolate-omegas) (prenatal w/o vit a w/ fe 3 VINATE II TABS fumarate-dss-fa-dha) (prenatal vit w/ fe TRI-TABS DHA MISC bisglycinate chelate- 2 (prenatal vit without vit 2 folic acid) a w/ fe bisglycinate-fa- VIRT-C DHA CAPS omeg 3) (prenatal vit w/ fe fum- TRICARE PRENATAL iron polysacch complex 2 DHA ONE CAPS 3 -fa-omega 3) (prenatal w/fe VIRT-NATE DHA CAPS fumarate-fa-dss-fish oil) (prenatal vit w/ ferrous TRICARE PRENATAL fumarate-fa-omega 3 3 DHA ONE/FOLATE CAPS fatty acids) (prenatal multivit-min 2 VIRT-PN DHA CAPS w/fe-fa) (prenatal without a w/ TRICARE TABS RX/OTC fe fumarate-l 3 (prenatal vit w/ ferrous 2 methylfolate-fa-dha) fumarate-folic acid) VIRT-PN PLUS CAPS TRISTART DHA CAPS (prenatal without a w/ (prenatal without a w/ 3 fe fumarate-l 3 fe carbonyl-l methylfolate-fa-omega methylfolate-fa-dha) 3) TRISTART ONE CAPS VIRT-PN TABS (prenatal (prenatal without a w/ fe carbonyl-l 3 vit w/ ferrous fumarate-l 3 methylfolate-folic acid) methylfolate-fa-dha)

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117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAFOL FE+ CPPK 0.4 VIVA DHA CAPS MG-0.6 MG-1.6 MG-1.8 (prenatal vit w/ ferrous MG-1000 UNIT-1100 fumarate-fa-omega 3 3 UNIT-15 MG-150 MCG-2 ) MG-2.5 MG-20 MG-20 fatty acids VOL-PLUS TABS RX/OTC UNIT-200 MG-25 MCG-25 3 MG-415 MG-50 MG-60 (prenatal vit w/ ferrous 2 MG-90 MG (prenatal vit fumarate-folic acid) w/ fe polysacch VOL-TAB RX TABS complex-l methylfol-fa- (prenatal vit w/ iron 3 dha-dss) carbonyl-folic acid) VITAFOL GUMMIES VP-HEME OB + DHA MISC CHEW (prenatal vit w/ 3 (prenatal vit w/ fe poly ferric phosphate-fa- cmplx-fe heme 2 omega 3 fatty acids) polypept-fa & omega 3) VITAFOL ULTRA CAPS VP-PNV-DHA CAPS (prenatal vit w/ fe 2 (prenatal vit w/ ferrous polysacch complex-l fumarate-fa-omega 3 3 methylfolate-fa-dha) fatty acids) VITAFOL-NANO TABS WESTAB PLUS TABS RX/OTC (prenatal w/o a vit w/ fe 3 (prenatal vit w/ ferrous 2 fumarate-l methylfolate- fumarate-folic acid) folic acid) WESTGEL DHA CAPS VITAFOL-ONE CAPS (prenatal without a w/ (prenatal mv & min w/fe 3 3 fe carbonyl-l polysaccharide methylfolate-fa-dha) complex-fa-dha) ZATEAN-PN DHA CAPS VITAMEDMD ONE (prenatal without a w/ RX/QUATREFOLIC CAPS fe fumarate-l 3 (prenatal without a w/ 3 methylfolate-fa-dha) fe fumarate-l ZATEAN-PN PLUS CAPS methylfolate-fa-dha) (prenatal without a w/ VITAPEARL CPCR fe fumarate-l 3 (prenatal without a w/ 3 methylfolate-fa-omega fe fumarate-sod 3) feredetate-fa-dha) MUSCULOSKELETAL THERAPY AGENTS - VITATHELY/GINGER RX/OTC Drugs to Treat Spasms TABS (prenatal vit w/ ferrous fumarate-folic 2 Central Muscle Relaxants acid) (Carisoprodol) VANADOM 1 TABS VITATRUE MISC (Chlorzoxazone) 1 (prenatal without a w/ LORZONE TABS fe amino acid chelate- 3 (Cyclobenzaprine Hcl) 1 fa-dha) FEXMID TABS

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118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Metaxalone) METAXALL 1 tizanidine hcl caps 1 TABS AMRIX CP24 ST; QL(1 ea GP tizanidine hcl tabs 1 (cyclobenzaprine hcl) daily) ZANAFLEX CAPS PA GP baclofen soln it 500 SP (tizanidine hcl) mcg/ml ZANAFLEX TABS GP baclofen tabs or 10 mg, 1 (tizanidine hcl) 20 mg, 5 mg Direct Muscle Relaxants carisoprodol tabs 1 DANTRIUM CAPS GP CHLORZOXAZONE TABS (dantrolene sodium) 3 250 MG (chlorzoxazone) dantrolene sodium 1 chlorzoxazone tabs caps 375 mg, 500 mg, 750 1 Muscle Relaxant Combinations mg carisoprodol w/ aspirin ST; QL(1 ea 1 cyclobenzaprine hcl 1 & codeine tabs cp24 15 mg, 30 mg daily) carisoprodol w/ aspirin 1 cyclobenzaprine hcl tabs tabs 10 mg, 5 mg, 7.5 1 orphenadrine w/ aspirin mg & caff tabs 25 mg-30 1 GABLOFEN SOLN PA SP mg-385 mg (baclofen) NASAL AGENTS - SYSTEMIC AND TOPICAL - LIORESAL INTRATHECAL PA Drugs to treat the Nose or Sinus SOLN 0.05 MG/ML, 10 SP MG/5ML (baclofen) Nasal Agent Combinations LIORESAL INTRATHECAL PA azelastine hcl- Limit 1 per SOLN 10 MG/20ML SP fluticasone propionate 1 month;QL(0.77 gm daily) (baclofen) susp DYMISTA SUSP Limit 1 per metaxalone tabs 1 (azelastine hcl- GP month;QL(0.77 gm daily) methocarbamol tabs 1 fluticasone propionate) Nasal Anti-infectives orphenadrine citrate 1 tb12 BACTROBAN NASAL OINT (mupirocin 2 ROBAXIN TABS GP calcium) (methocarbamol) ROBAXIN-750 TABS Nasal Antiallergy GP (methocarbamol) Limit 1 inhaler azelastine hcl soln 0.1 per SKELAXIN TABS 1 GP %, 137 mcg/spray month;QL(1.2 (metaxalone) ml daily) SOMA TABS GP azelastine hcl soln 0.15 Limit 1 inhaler (carisoprodol) 1 per month;QL(1 % ml daily)

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119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers olopatadine hcl (nasal) 1 (Fluticasone Propionate soln per (Nasal)) EQ ALLERGY 1 month;QL(1.1 PATANASE SOLN RELIEF SUSP NA 50 MCG/ACT ml daily); (olopatadine hcl GP RX/OTC (nasal)) BECONASE AQ SUSP Limit 2 inhalers Nasal Anticholinergics ( 3 per beclomethasone month;QL(1.67 ipratropium bromide 1 diprop monohyd) gm daily) (nasal) soln Limit 2 inhalers Nasal Steroids budesonide (nasal) 1 per (Budesonide (Nasal)) CVS Limit 2 inhalers susp month;QL(0.6 BUDESONIDE NASAL per ml daily) SPRAY, EQ BUDESONIDE month;QL(0.6 FLONASE ALLERGY Limit 2 inhalers NASAL SPRAY, GNP ml daily) RELIEF CHILDRENS per BUDESONIDE NASAL 1 SUSP (fluticasone GP month;QL(1.1 SPRAY, RA BUDESONIDE ml daily); NASAL SPRAY, propionate (nasal)) RX/OTC RHINOCORT ALLERGY Limit 2 inhalers SUSP FLONASE ALLERGY RELIEF SUSP per (Fluticasone Propionate Limit 2 inhalers ( GP month;QL(1.1 (Nasal)) ALLERGY NASAL per fluticasone propionate ml daily); SPRAY 24 HOUR, month;QL(1.1 (nasal)) RX/OTC ALLERGY RELIEF, ml daily); Limit 1 inhaler CLARISPRAY, CVS RX/OTC FLONASE SENSIMIST SUSP ( 3 per FLUTICASONE fluticasone month;QL(0.34 PROPRIONATE NASAL furoate) ml daily) SPRAY, EQL FLUTICASONE flunisolide (nasal) soln 1 PROPIONATE, EQL FLUTICASONE Limit 2 inhalers PROPIONATE fluticasone propionate per CHILDRENS, GNP 1 month;QL(1.1 (nasal) susp ml daily); FLUTICASONE 1 PROPIONATE, GNP RX/OTC FLUTICASONE Limit 2 inhalers PROPIONATE mometasone furoate 1 per CHILDRENS, HM (nasal) susp month;QL(1.14 ALLERGY RELIEF NASAL gm daily) SPRAY 24HR, KLS NASONEX SUSP Limit 2 inhalers ALLER-FLO, KP ( GP per FLUTICASONE mometasone furoate month;QL(1.14 PROPIONATE, QC (nasal)) gm daily) ALLERGY RELIEF, QC Limit 1 inhaler FLUTICASONE OMNARIS SUSP 3 per PROPIONATE, SM (ciclesonide (nasal)) month;QL(0.42 ALLERGY RELIEF NASAL gm daily) SPRAY SUSP

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120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QNASL AERS Limit 1 inhaler COSOPT SOLN (beclomethasone 3 per (dorzolamide hcl-timolol 3 month;QL(0.29 maleate) dipropionate (nasal)) gm daily) Limit 1 inhaler dorzolamide hcl-timolol QNASL CHILDRENS maleate soln 0.5 %-2 AERS ( 3 per 1 beclomethasone month;QL(0.17 %, 20 mg/ml-5 mg/ml, dipropionate (nasal)) gm daily) 22.3 mg/ml-6.8 mg/ml Limit 1 inhaler ISTALOL SOLN (timolol ZETONNA AERS GP 3 per maleate (ophth)) (ciclesonide (nasal)) month;QL(0.3 gm daily) levobunolol hcl soln 1 NEUROMUSCULAR AGENTS - Drugs to timolol maleate (ophth) 1 Relax/Paralyze Muscles solg 0.25 %, 0.5 % ALS Agents timolol maleate (ophth) 1 RILUTEK TABS (riluzole) GP soln 0.25 %, 0.5 % TIMOPTIC OCUDOSE riluzole tabs 1 SOLN 0.25 % (timolol 3 Neuromuscular Blocking Agent - Neurotoxins maleate (ophth)) BOTOX SOLR PA TIMOPTIC OCUDOSE SP (onabotulinumtoxina) SOLN 0.5 % (timolol GP maleate (ophth)) OPHTHALMIC AGENTS - Drugs to Treat the Eye TIMOPTIC SOLN ( timolol GP Artificial Tears and Lubricants maleate (ophth)) LACRISERT INST TIMOPTIC-XE SOLG 3 (artificial tear insert) (timolol maleate 2 (ophth)) Beta-blockers - Ophthalmic BETAGAN SOLN Cycloplegic Mydriatics 3 (levobunolol hcl) (Homatropine Hbr) 1 HOMATROPAIRE SOLN betaxolol hcl (ophth) 1 (Phenylephrine Hcl soln (Mydriatic)) ALTAFRIN 1 BETIMOL SOLN (timolol) 2 SOLN ATROPINE SULFATE BETOPTIC-S SUSP 2 SOLN OP 1 % (atropine 2 (betaxolol hcl (ophth)) sulfate (ophthalmic)) carteolol hcl (ophth) CYCLOGYL SOLN 1 GP soln (cyclopentolate hcl) COMBIGAN SOLN CYCLOMYDRIL SOLN (brimonidine tartrate- 3 (cyclopentolate w/ 3 timolol maleate) phenylephrine) COSOPT PF SOLN (dorzolamide hcl-timolol GP cyclopentolate hcl soln 1 maleate)

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121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits homatropine hbr soln 1 (Neomycin-Bacitracin Zn- Polymyxin) NEO-POLYCIN 1 ISOPTO ATROPINE SOLN OINT (atropine sulfate 2 AZASITE SOLN Limit 5mls per 3 month;QL(0.17 (ophthalmic)) (azithromycin (ophth)) MYDRIACYL SOLN ml daily) GP (tropicamide) bacitracin (ophthalmic) 1 oint phenylephrine hcl 1 (mydriatic) soln bacitracin-polymyxin b 1 (ophth) oint 1 tropicamide soln BESIVANCE SUSP 3 Miotics (besifloxacin hcl) ISOPTO CARPINE SOLN BETADINE OPHTHALMIC GP (pilocarpine hcl) PREP SOLN (povidone- 3 PHOSPHOLINE IODIDE iodine (ophth)) SOLR (echothiophate 2 BLEPH-10 SOLN iodide) (sulfacetamide sodium GP (ophth)) pilocarpine hcl soln 1 CILOXAN OINT Ophthalmic Adrenergic Agents (ciprofloxacin hcl 2 ALPHAGAN P SOLN 0.1 % (ophth)) 2 (brimonidine tartrate) CILOXAN SOLN ALPHAGAN P SOLN 0.15 (ciprofloxacin hcl GP GP % (brimonidine tartrate) (ophth)) ciprofloxacin hcl (ophth) apraclonidine hcl soln 1 1 soln brimonidine tartrate 1 erythromycin (ophth) 1 soln oint IOPIDINE SOLN 0.5 % GP 1 (apraclonidine hcl) gatifloxacin (ophth) soln IOPIDINE SOLN 1 % gentamicin sulfate 3 1 (apraclonidine hcl) (ophth) soln SIMBRINZA SUSP KLARITY-A SOLN Limit 5mls per 3 month;QL(0.17 (brinzolamide- 3 (azithromycin (ophth)) brimonidine tartrate) ml daily) Ophthalmic Anti-infectives levofloxacin (ophth) 1 soln (Bacitracin-Polymyxin B (Ophth)) AK-POLY-BAC, 1 MOXEZA SOLN POLYCIN OINT (moxifloxacin hcl GP (ophth)) (Erythromycin (Ophth)) 1 ILOTYCIN OINT moxifloxacin hcl (ophth) 1 (Gentamicin Sulfate 1 soln (Ophth)) GENTAK OINT

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122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATACYN SUSP RESTASIS MULTIDOSE QL(2.14 ml 2 (natamycin) EMUL (cyclosporine 3 daily) (ophth)) neomycin-bacitracin 1 zn-polymyxin oint Ophthalmic Antagonists PA neomycin-polymyxin- 1 XIIDRA SOLN (lifitegrast) 3 gramicidin soln NEOSPORIN SOLN Ophthalmic Local Anesthetics (neomycin-polymyxin- 3 (Tetracaine Hcl (Ophth)) gramicidin) ALTACAINE, TETCAINE, 1 TETRAVISC, TETRAVISC OCUFLOX SOLN GP FORTE SOLN (ofloxacin (ophth)) AKTEN GEL ( lidocaine 3 ofloxacin (ophth) soln 1 hcl (ophth)) ALCAINE SOLN polymyxin b- 1 GP trimethoprim soln (proparacaine hcl) POLYTRIM SOLN proparacaine hcl soln 1 (polymyxin b- GP tetracaine hcl (ophth) trimethoprim) 1 soln POVIDONE IODINE SOLN (povidone-iodine 3 Ophthalmic Nerve Growth Factors OXERVATE SOLN PA (ophth)) SP (-bkbj) sulfacetamide sodium 1 (ophth) oint Ophthalmic Steroids (Bacitracin-Poly-Neomycin- QL(4 gm per fill sulfacetamide sodium 1 (ophth) soln Hc) NEO-POLYCIN HC 1 retail) OINT tobramycin (ophth) soln 1 ALREX SUSP 3 TOBREX OINT (loteprednol etabonate) 2 (tobramycin (ophth)) bacitracin-poly- QL(4 gm per fill 1 retail) TOBREX SOLN neomycin-hc oint GP (tobramycin (ophth)) BLEPHAMIDE S.O.P. OINT (sulfacetamide 2 1 trifluridine soln sod-prednisolone) VIROPTIC SOLN 3 BLEPHAMIDE SUSP (trifluridine) (sulfacetamide sod- 2 ZIRGAN GEL prednisolone) 3 (ganciclovir ophthalmic) dexamethasone ZYMAXID SOLN 1 GP sodium phosphate (gatifloxacin (ophth)) (ophth) soln DUREZOL EMUL Ophthalmic Immunomodulators 3 RESTASIS EMUL QL(2.14 ml (difluprednate) 3 (cyclosporine (ophth)) daily)

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123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLAREX SUSP PRED-G S.O.P. OINT (fluorometholone 2 (gentamicin- 3 acetate) prednisolone acetate) PRED-G SUSP fluorometholone 1 (ophth) susp (gentamicin- 3 FML FORTE SUSP prednisolone acetate) ( 2 fluorometholone prednisolone acetate 1 (ophth)) (ophth) susp FML LIQUIFILM SUSP PREDNISOLONE SODIUM ( PHOSPHATE SOLN OP 1 fluorometholone GP 2 (ophth)) % (prednisolone sodium FML OINT phosphate (ophth)) (fluorometholone 2 sulfacetamide sod- 1 (ophth)) prednisolone soln LOTEMAX GEL TOBRADEX OINT 3 (loteprednol etabonate) (tobramycin- 3 LOTEMAX OINT dexamethasone) 3 (loteprednol etabonate) TOBRADEX ST SUSP LOTEMAX SUSP (tobramycin- 3 GP (loteprednol etabonate) dexamethasone) TOBRADEX SUSP QL(5 ml per fill loteprednol etabonate 1 susp (tobramycin- GP retail) MAXIDEX SUSP dexamethasone) QL(5 ml per fill (dexamethasone 2 tobramycin- 1 (ophth)) dexamethasone susp retail) MAXITROL OINT ZYLET SUSP Limit 5mls per (neomycin-polymy- GP (loteprednol etabonate- 3 fill;QL(5 ml per fill retail) dexameth) tobramycin) MAXITROL SUSP Ophthalmic Surgical Aids (neomycin-polymy- GP GELFILM OP FILM dexameth) (gelatin adsorbable 3 (ophth)) neomycin-polymy- 1 dexameth oint Ophthalmics - Misc. neomycin-polymy- 1 ACULAR LS SOLN dexameth susp (ketorolac GP tromethamine (ophth)) neomycin-polymyxin-hc 1 (ophth) susp ACULAR SOLN PRED MILD SUSP (ketorolac GP (prednisolone acetate 2 tromethamine (ophth)) (ophth)) ACUVAIL SOLN (ketorolac 3 tromethamine (ophth))

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124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALOCRIL SOLN ILEVRO SUSP 3 (nedocromil sodium 3 (nepafenac) (ophth)) ketorolac tromethamine 1 ALOMIDE SOLN (ophth) soln (lodoxamide 2 LASTACAFT SOLN ST 3 tromethamine) (alcaftadine) azelastine hcl (ophth) NEVANAC SUSP 1 3 soln (nepafenac) AZOPT SUSP Limit 10mls per Limit 10mls per 2 month;QL(0.4 (brinzolamide) olopatadine hcl soln 0.1 1 month;QL(0.34 ml daily) % ml daily); ST; Limit 10mls RX/OTC BEPREVE SOLN per QL(0.09 ml 3 olopatadine hcl soln 0.2 1 (bepotastine besilate) month;QL(0.34 % daily); RX/OTC ml daily) PAREMYD SOLN bromfenac sodium 1 (hydroxyamphetamine- 3 (ophth) soln tropicamide) BROMSITE SOLN PATADAY SOLN 0.2 % QL(0.09 ml ( GP bromfenac sodium 3 (olopatadine hcl) daily); RX/OTC (ophth)) PROLENSA SOLN cromolyn sodium 1 (bromfenac sodium 3 (ophth) soln (ophth)) CYSTADROPS SOLN QL(0.34 ml SP TRUSOPT SOLN Limit 10mls per (cysteamine hcl) daily) GP month;QL(0.34 ( ) CYSTARAN SOLN dorzolamide hcl ml daily) SP (cysteamine hcl) Prostaglandins - Ophthalmic diclofenac sodium 1 Limit 2.5mls (ophth) soln bimatoprost soln 1 per Limit 10mls per month;QL(0.09 dorzolamide hcl soln 1 month;QL(0.34 ml daily) ml daily) latanoprost soln 1 Limit 10mls per DORZOLAMIDE HCL LUMIGAN SOLN 2 month;QL(0.34 2 SOLN (dorzolamide hcl) ml daily) (bimatoprost) ELESTAT SOLN Limit 2.5mls GP TRAVATAN Z SOLN (epinastine hcl (ophth)) GP per (travoprost) month;QL(0.09 EMADINE SOLN ml daily) (emedastine 3 Limit 2.5mls difumarate) 1 per travoprost soln month;QL(0.09 epinastine hcl (ophth) 1 soln ml daily) XALATAN SOLN flurbiprofen sodium 1 3 soln (latanoprost)

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125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZIOPTAN SOLN CORTISPORIN-TC SUSP 3 (tafluprost) (neomycin-colistin-hc- 3 thonzonium) OTIC AGENTS - Drugs to Treat the Ear neomycin-polymyxin-hc 1 Otic Agents - Miscellaneous (otic) soln acetic acid (otic) soln 1 neomycin-polymyxin-hc 1 (otic) susp Otic Anti-infectives OTICIN HC NR SOLN CETRAXAL SOLN 3 (pramoxine-hc- GP (ciprofloxacin hcl (otic)) chloroxylenol) ciprofloxacin hcl (otic) 1 Limit 1 bottle soln OTOVEL SOLN (ciprofloxacin- 3 per FLOXIN OTIC SOLN month;QL(0.5 GP fluocinolone acetonide) (ofloxacin (otic)) ea daily) PRAMOTIC LIQD ofloxacin (otic) soln 1 (pramoxine- 3 Otic Combinations chloroxylenol) (Pramoxine-Hc- Otic Steroids Chloroxylenol) CORTIC- 1 (Fluocinolone Acetonide 1 ND, EXOTIC-HC SOLN (Otic)) FLAC OIL CIPRO HC SUSP DERMOTIC OIL (ciprofloxacin- 3 (fluocinolone acetonide GP hydrocortisone) (otic)) CIPRODEX SUSP fluocinolone acetonide 1 (ciprofloxacin- GP (otic) oil dexamethasone) hydrocortisone w/acetic QL(10 ml per ciprofloxacin- 1 fill retail,30 ml 1 acid soln dexamethasone susp per fill mail) ciprofloxacin- Limit 1 bottle OXYTOCICS - Drugs to Prevent/Control Uterine 1 per Bleeding fluocinolone acetonide month;QL(0.5 soln ea daily) Oxytocics (Methylergonovine COLY-MYCIN S SUSP Maleate) METHERGINE 1 (neomycin-colistin-hc- 3 TABS thonzonium) methylergonovine 1 CORTANE-B AQUEOUS maleate tabs SOLN (pramoxine-hc- 3 chloroxylenol aqueous) PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune CORTANE-B-OTIC SOLN System (pramoxine-hc- GP chloroxylenol) Immune Serums BIVIGAM SOLN ( PA immune SP globulin (human) iv)

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126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CUVITRU SOLN PA amoxicillin caps 1 (immune globulin SP (human) subcutaneous) amoxicillin chew 1 FLEBOGAMMA DIF SOLN PA (immune globulin SP amoxicillin susr 1 (human) iv) amoxicillin tabs 1 GAMASTAN INJ PA (immune globulin SP ampicillin caps 1 (human) im) PA GAMMAGARD LIQUID PA ampicillin sodium solr SP SOLN (immune globulin SP MOXATAG TB24 PA; QL(1 ea (human) iv or 3 daily,10 ea per subcutaneous) (amoxicillin) fill retail) GAMMAKED SOLN PA Natural Penicillins (immune globulin SP (Penicillin G Potassium) SP PA (human) iv or PFIZERPEN SOLR subcutaneous) BICILLIN L-A SUSP PA GAMMAPLEX SOLN PA SP (penicillin g benzathine) (immune globulin SP (human) iv) PENICILLIN G PA POTASSIUM IN ISO- GAMUNEX-C SOLN PA OSMOTIC DEXTROSE SP (immune globulin SP SOLN (penicillin g pot in (human) iv or dextrose) subcutaneous) PA penicillin g potassium SP HIZENTRA SOLN PA solr (immune globulin SP (human) subcutaneous) PENICILLIN G PROCAINE PA SUSP (penicillin g SP OCTAGAM SOLN 1 PA GM/20ML, 10 GM/200ML, procaine) 2 GM/20ML, 20 penicillin g sodium solr SP PA GM/200ML, 5 GM/50ML SP (immune globulin penicillin v potassium 1 (human) iv) solr PRIVIGEN SOLN PA penicillin v potassium 1 (immune globulin SP tabs (human) iv) Penicillin Combinations Passive Immunizing Agents - Combinations amoxicillin & pot 1 HYQVIA KIT (immune PA clavulanate chew globulin (human)- SP amoxicillin & pot hyaluronidase (human 1 recombinant)) clavulanate susr amoxicillin & pot 1 PENICILLINS - Drugs to Treat Bacterial Infections clavulanate tabs Aminopenicillins

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127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOSYN SOLR 0.25 GM-2 PA amoxicillin & pot 1 clavulanate tb12 GM, 0.375 GM-3 GM, 0.5 PA GM-4 GM (piperacillin SP ampicillin & sulbactam SP sodium solr sodium-tazobactam sodium) AUGMENTIN ES-600 SUSR (amoxicillin & pot GP Penicillinase-Resistant Penicillins clavulanate) dicloxacillin sodium 1 AUGMENTIN SUSR 125 caps MG/5ML-31.25 MG/5ML PA 2 nafcillin sodium solr ij 1 SP (amoxicillin & pot gm clavulanate) NAFCILLIN SODIUM PA AUGMENTIN SUSR 250 SOLR IJ 10 GM (nafcillin SP MG/5ML-62.5 MG/5ML sodium) (amoxicillin & pot GP nafcillin sodium solr iv 2 PA clavulanate) SP gm AUGMENTIN TABS 125 MG-500 MG, 125 MG-875 NAFCILLIN SOLN PA MG (amoxicillin & pot GP (nafcillin sodium in SP clavulanate) dextrose) AUGMENTIN XR TB12 OXACILLIN SODIUM PA SOLN IV 1 GM/50ML-1.5 (amoxicillin & pot 3 GM/50ML, 2 GM/50ML-300 SP clavulanate) MG/50ML (oxacillin BICILLIN C-R SUSP PA sodium in dextrose) (penicillin g benzathine SP oxacillin sodium solr ij 1 PA & procaine) SP gm piperacillin sodium- PA oxacillin sodium solr iv PA tazobactam sodium SP SP 10 gm solr UNASYN BULK PACK PA PROGESTINS - Hormone Replacement/Modifying Drugs SOLR (ampicillin & SP sulbactam sodium) Progestins AYGESTIN TABS UNASYN SOLR PA GP (ampicillin & sulbactam SP (norethindrone acetate) sodium) PA hydroxyprogesterone SP ZOSYN SOLN 0.25 PA caproate oil GM/50ML-2 GM/50ML-5 MAKENA OIL IM 250 PA %, 0.375 GM/50ML-3 MG/ML GM/50ML-5 % SP (hydroxyprogesterone SP (piperacillin sodium- caproate) tazobactam sodium in MAKENA SOAJ SC 275 PA dextrose) MG/1.1ML (hydroxyprogesterone SP caproate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) medroxyprogesterone 1 galantamine acetate tabs hydrobromide cp24 16 1 MEGACE ES SUSP mg, 24 mg, 8 mg (megestrol acetate GP galantamine (appetite)) hydrobromide soln 4 1 mg/ml megestrol acetate 1 (appetite) susp galantamine hydrobromide tabs 12 1 norethindrone acetate 1 tabs mg, 4 mg, 8 mg QL(2 ea daily) memantine hcl cp24 14 PA progesterone 1 micronized caps mg, 21 mg, 28 mg, 7 1 mg progesterone oil 1 memantine hcl soln 10 1 PROMETRIUM CAPS QL(2 ea daily) mg/5ml, 2 mg/ml (progesterone GP memantine hcl tabs 10 1 micronized) mg, 5 mg, PROVERA TABS NAMENDA TABS GP (medroxyprogesterone GP (memantine hcl) acetate) NAMENDA TITRATION PSYCHOTHERAPEUTIC AND NEUROLOGICAL PAK TABS (memantine GP AGENTS - MISC. - Drugs to Treat Mental and hcl) Emotional Conditions NAMENDA XR CP24 PA GP Agents for Chemical Dependency (memantine hcl) acamprosate calcium 1 NAMENDA XR TITRATION PA tbec PACK CP24 (memantine 3 ANTABUSE TABS GP hcl) (disulfiram) RAZADYNE ER CP24 QL(1 ea daily) disulfiram tabs 1 (galantamine GP hydrobromide) Anti-Cataplectic Agents RAZADYNE TABS XYREM SOLN ( PA sodium SP (galantamine GP oxybate) hydrobromide) Antidementia Agents rivastigmine pt24 1 ARICEPT TABS QL(1 ea daily) (donepezil GP rivastigmine tartrate 1 hydrochloride) caps QL(1 ea daily) Combination Psychotherapeutics donepezil 1 hydrochloride tabs chlordiazepoxide- 1 QL(1 ea daily) amitriptyline tabs donepezil 1 hydrochloride tbdp olanzapine-fluoxetine 1 EXELON PT24 hcl caps GP (rivastigmine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA perphenazine- 1 dimethyl fumarate cpdr 1 amitriptyline tabs PA SYMBYAX CAPS dimethyl fumarate misc 1 (olanzapine-fluoxetine GP EXTAVIA KIT (interferon PA hcl) SP beta-1b) Fibromyalgia Agents GILENYA CAPS PA SAVELLA TABS PA; QL(2 ea 3 3 (fingolimod hcl) (milnacipran hcl) daily) SP PA SAVELLA TITRATION PA; QL(2 ea glatiramer acetate sosy PACK MISC 3 daily) MAVENCLAD TBPK PA (milnacipran hcl) (cladribine (multiple SP Movement Disorder Drug Therapy sclerosis)) AUSTEDO TABS PA MAYZENT STARTER PA 3 (deutetrabenazine) PACK TBPK (siponimod 3 INGREZZA CAPS PA fumarate) 3 MAYZENT TABS PA (valbenazine tosylate) 3 INGREZZA CPPK PA (siponimod fumarate) 3 PLEGRIDY SOPN PA (valbenazine tosylate) SP (peginterferon beta-1a) SP tetrabenazine tabs PLEGRIDY SOSY PA SP XENAZINE TABS (peginterferon beta-1a) SP (tetrabenazine) PLEGRIDY STARTER PA Multiple Sclerosis Agents PACK SOPN SP (Glatiramer Acetate) PA (peginterferon beta-1a) GLATOPA SOSY 20 1 PLEGRIDY STARTER PA MG/ML PACK SOSY SP (Glatiramer Acetate) PA (peginterferon beta-1a) GLATOPA SOSY 40 SP REBIF REBIDOSE SOAJ PA SP MG/ML (interferon beta-1a) AMPYRA TB12 PA GP REBIF REBIDOSE PA (dalfampridine) TITRATIONPACK SOAJ SP AUBAGIO TABS PA (interferon beta-1a) 3 (teriflunomide) REBIF SOSY ( PA interferon SP AVONEX PEN AJKT PA beta-1a) SP (interferon beta-1a) REBIF TITRATION PACK PA AVONEX PSKT PA SOSY (interferon beta- SP SP (interferon beta-1a) 1a) BETASERON KIT PA TECFIDERA CPDR PA SP GP (interferon beta-1b) (dimethyl fumarate) COPAXONE SOSY PA TECFIDERA STARTER PA SP (glatiramer acetate) PACK MISC (dimethyl GP dalfampridine tb12 1 PA fumarate)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYSABRI CONC PA (Nicotine Polacrilex) CVS PV SP (natalizumab) NICOTINE POLACRILEX STARTER, EQ NICOTINE Postherpetic Neuralgia (PHN)/Neuropathic Pain GUM REFILL, EQ GRALISE TABS PA NICOTINE GUM (gabapentin (once- 3 STARTER, EQL NICOTINE daily)) POLACRILEX REFILL, EQL NICOTINE PV Premenstrual Dysphoric Disorder (PMDD) Agents POLACRILEX STARTER, GNP NICOTINE GUM, fluoxetine hcl (pmdd) 1 caps GOODSENSE NICOTINE GUM, KLS QUIT2, KLS FLUOXETINE QUIT4, NICORELIEF, SR HYDROCHLORIDE TABS 3 NICOTINE GUM, THRIVE 10 MG, 20 MG (fluoxetine GUM hcl (pmdd)) (Nicotine Polacrilex) CVS PV SARAFEM TABS NICOTINE POLACRILEX GP (fluoxetine hcl (pmdd)) STARTER, EQ NICOTINE GUM REFILL, EQ Pseudobulbar Affect (PBA) Agents NICOTINE GUM NUEDEXTA CAPS PA STARTER, EQL NICOTINE (dextromethorphan hbr- 3 POLACRILEX REFILL, quinidine sulfate) EQL NICOTINE 1 POLACRILEX STARTER, Psychotherapeutic and Neurological Agents - GNP NICOTINE GUM, GOODSENSE NICOTINE ergoloid mesylates tabs 1 GUM, KLS QUIT2, KLS QUIT4, NICORELIEF, SR ORAP TABS (pimozide) 3 NICOTINE GUM, THRIVE GUM 1 pimozide tabs (Nicotine Polacrilex) CVS PV Restless Leg Syndrome (RLS) Agents NICOTINE POLACRILEX, EQ NICOTINE HORIZANT TBCR QL(1 ea daily) 3 POLACRILEX, EQL (gabapentin enacarbil) NICOTINE POLACRILEX, Smoking Deterrents GNP NICOTINE POLACRILEX, HM PV (Nicotine Polacrilex) CVS PV NICOTINE POLACRILEX, NICOTINE LOZENGE, EQ PX STOP SMOKING AID, NICOTINE LOZENGES, RA NICOTINE GNP NICOTINE MINI POLACRILEX, TGT LOZENGE, GNP NICOTINE POLACRILEX NICOTINE POLACRILEX LOZG 2 MG, 4 MG MINI, GOODSENSE PV NICOTINE, GOODSENSE NICOTINE POLACRILEX, KLS QUIT2, KLS QUIT4, NICOTINE MINI LOZENGE, RA MINI NICOTINE LOZG

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine Polacrilex) CVS PV NICOTINE, CVS NICOTINE, CVS NICOTINE POLACRILEX, NICOTINE POLACRILEX, EQ NICOTINE EQ NICOTINE POLACRILEX, EQL POLACRILEX, EQL NICOTINE POLACRILEX, NICOTINE POLACRILEX, GNP NICOTINE GNP NICOTINE POLACRILEX, POLACRILEX, GOODSENSE NICOTINE GOODSENSE NICOTINE POLACRILEX GUM, HM PV POLACRILEX GUM, HM 1 NICOTINE POLACRILEX, NICOTINE POLACRILEX, PX STOP SMOKING AID, PX STOP SMOKING AID, RA NICOTINE, RA RA NICOTINE, RA NICOTINE GUM, RA NICOTINE GUM, RA NICOTINE POLACRILEX, NICOTINE POLACRILEX, SM NICOTINE SM NICOTINE, SM POLACRILEX, TGT NICOTINE POLACRILEX, NICOTINE GUM, TGT TGT NICOTINE GUM, TGT NICOTINE POLACRILEX NICOTINE POLACRILEX GUM 2 MG GUM 4 MG (Nicotine Polacrilex) CVS PV (Nicotine Polacrilex) CVS PV NICOTINE, CVS NICOTINE, CVS NICOTINE POLACRILEX, NICOTINE POLACRILEX, EQ NICOTINE EQ NICOTINE POLACRILEX, EQL POLACRILEX, EQL NICOTINE POLACRILEX, NICOTINE POLACRILEX, GNP NICOTINE GNP NICOTINE POLACRILEX, POLACRILEX, GOODSENSE NICOTINE GOODSENSE NICOTINE POLACRILEX GUM, HM PV POLACRILEX GUM, HM 1 NICOTINE POLACRILEX, NICOTINE POLACRILEX, PX STOP SMOKING AID, PX STOP SMOKING AID, RA NICOTINE, RA RA NICOTINE, RA NICOTINE GUM, RA NICOTINE GUM, RA NICOTINE POLACRILEX, NICOTINE POLACRILEX, SM NICOTINE SM NICOTINE, SM POLACRILEX, TGT NICOTINE POLACRILEX, NICOTINE GUM, TGT TGT NICOTINE GUM, TGT NICOTINE POLACRILEX NICOTINE POLACRILEX GUM MT 2 MG GUM MT 4 MG (Nicotine Polacrilex) EQ PV NICOTINE, SM NICOTINE PV POLACRILEX LOZG 4 MG (Nicotine Polacrilex) EQ PV NICOTINE, SM NICOTINE PV POLACRILEX LOZG MT 4 MG (Nicotine Polacrilex) SM PV PV NICOTINE LOZG 2 MG

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132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine) CVS NICOTINE PV SYSTEM/STEP 3/CLEAR, TRANSDERMALSYSTEM, TGT NICOTINE STEP CVS NICOTINE ONE, TGT NICOTINE TRANSDERMALSYSTEM STEP THREE, TGT STEP 1, CVS NICOTINE NICOTINE STEP TWO TRANSDERMALSYSTEM PT24 STEP 2, CVS NICOTINE TRANSDERMALSYSTEM/ STEP 3, EQ NICOTINE STEP 3, GNP NICOTINE TRANSDERMALSYSTEM, GNP NICOTINE TRANSDERMALSYSTEM STEP 2, HM NICOTINE TRANSDERMAL SYSTEM, HM NICOTINE TRANSDERMAL SYSTEM STEP 1, HM NICOTINE TRANSDERMAL SYSTEM STEP 2, HM NICOTINE TRANSDERMAL SYSTEM STEP 3, HM NICOTINE TRANSDERMALSYSTEM, NICOTINE STEP 1, NICOTINE STEP 3, NICOTINE 1 TRANSDERMAL SYSTEM STEP 1, NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 2, NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 3, NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR, RA NICOTINE TRANSDERMAL SYSTEM, RA NICOTINE TRANSDERMAL SYSTEM STEP 3, SM NICOTINE TRANSDERMAL SYSTEM/STEP 1/CLEAR, SM NICOTINE TRANSDERMAL SYSTEM/STEP 2/CLEAR, SM NICOTINE TRANSDERMAL You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine) CVS NICOTINE PV SYSTEM/STEP 3/CLEAR, TRANSDERMALSYSTEM, TGT NICOTINE STEP CVS NICOTINE ONE, TGT NICOTINE TRANSDERMALSYSTEM STEP THREE, TGT STEP 1, CVS NICOTINE NICOTINE STEP TWO TRANSDERMALSYSTEM PT24 STEP 2, CVS NICOTINE (Nicotine) EQ NICOTINE, PV TRANSDERMALSYSTEM/ RA NICOTINE PT24 TD 21 PV STEP 3, EQ NICOTINE MG/24HR, 7 MG/24HR STEP 3, GNP NICOTINE (Nicotine) EQ NICOTINE, PV TRANSDERMALSYSTEM, RA NICOTINE, SM GNP NICOTINE NICOTINE 1 TRANSDERMALSYSTEM TRANSDERMAL SYSTEM STEP 2, HM NICOTINE PT24 14 MG/24HR TRANSDERMAL SYSTEM, HM NICOTINE (Nicotine) EQ NICOTINE, PV TRANSDERMAL SYSTEM RA NICOTINE, SM STEP 1, HM NICOTINE NICOTINE 1 TRANSDERMAL SYSTEM TRANSDERMAL SYSTEM STEP 2, HM NICOTINE PT24 TD 14 MG/24HR TRANSDERMAL SYSTEM (Nicotine) SM NICOTINE PV STEP 3, HM NICOTINE TRANSDERMAL SYSTEM PV TRANSDERMALSYSTEM, PT24 21 MG/24HR NICOTINE STEP 1, PV bupropion hcl (smoking PV NICOTINE STEP 3, deterrent) tb12 NICOTINE PV TRANSDERMAL SYSTEM CHANTIX CONTINUING PV STEP 1, NICOTINE MONTHPAK TABS PV TRANSDERMAL SYSTEM (varenicline tartrate) STEP 1/CLEAR, CHANTIX STARTING PV NICOTINE MONTH PAK TABS PV TRANSDERMAL SYSTEM ( ) STEP 2, NICOTINE varenicline tartrate CHANTIX TABS PV TRANSDERMAL SYSTEM PV STEP 2/CLEAR, (varenicline tartrate) NICOTINE NICODERM CQ PT24 21 PV TRANSDERMAL SYSTEM MG/24HR, 7 MG/24HR GP STEP 3, NICOTINE (nicotine) TRANSDERMAL NICORETTE GUM 2 MG PV SYSTSTEM STEP GP 3/CLEAR, RA NICOTINE (nicotine polacrilex) TRANSDERMAL SYSTEM, NICORETTE LOZG 2 MG, PV RA NICOTINE 4 MG (nicotine GP TRANSDERMAL SYSTEM STEP 3, SM NICOTINE polacrilex) NICORETTE MINI LOZG PV TRANSDERMAL GP SYSTEM/STEP 1/CLEAR, (nicotine polacrilex) SM NICOTINE NICORETTE STARTER PV TRANSDERMAL KIT GUM 2 MG ( SYSTEM/STEP 2/CLEAR, nicotine GP SM NICOTINE polacrilex) TRANSDERMAL You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PV PROLASTIN-C SOLR PA nicotine polacrilex gum PV 2 mg (alpha1-proteinase SP PV inhibitor (human)) nicotine polacrilex gum 1 4 mg ZEMAIRA SOLR (alpha1- PA PV proteinase inhibitor SP nicotine polacrilex lozg PV 2 mg, 4 mg (human)) nicotine pt24 14 PV Cystic Fibrosis Agents 1 KALYDECO PACK PA mg/24hr SP nicotine pt24 21 PV (ivacaftor) PV KALYDECO TABS PA mg/24hr, 7 mg/24hr SP NICOTINE PV (ivacaftor) ORKAMBI PACK PA TRANSDERMAL SYSTEM PV SP KIT (nicotine) (lumacaftor-ivacaftor) NICOTROL INHALER PV ORKAMBI TABS PA PV SP INHA (nicotine) (lumacaftor-ivacaftor) NICOTROL NS SOLN PV PA; Limited to PV PULMOZYME SOLN (nicotine) 2 75mls per (dornase alfa) month;QL(2.5 ZYBAN TB12 ( PV bupropion GP ml daily) hcl (smoking deterrent)) SYMDEKO TBPK PA SP Transthyretin Amyloidosis Agents (tezacaftor-ivacaftor) TEGSEDI SOSY PA TRIKAFTA TBPK PA; QL(3 ea SP (inotersen sodium) (elexacaftor-tezacaftor- SP daily) Vasomotor Symptom Agents ivacaftor) BRISDELLE CAPS Pulmonary Fibrosis Agents (paroxetine mesylate GP ESBRIET CAPS PA SP (vasomotor)) (pirfenidone) ESBRIET TABS PA paroxetine mesylate 1 SP (vasomotor) caps (pirfenidone) OFEV CAPS ( PA RESPIRATORY AGENTS - MISC. - Drugs to SP Treat Lung Conditions esylate) Alpha-Proteinase Inhibitor (Human) SULFONAMIDES - Drugs to Treat Bacterial ARALAST NP SOLR PA Infections (alpha1-proteinase SP Sulfonamides inhibitor (human)) SULFADIAZINE TABS 3 GLASSIA SOLN (alpha1- PA (sulfadiazine) proteinase inhibitor SP TETRACYCLINES - Drugs to Treat Bacterial (human)) Infections PROLASTIN-C SOLN PA Glycylcyclines (alpha1-proteinase SP PA inhibitor (human)) tigecycline solr SP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIGECYCLINE SOLR PA SP minocycline hcl caps 1 (tigecycline) 100 mg, 50 mg, 75 mg TYGACIL SOLR PA SP minocycline hcl tabs 1 (tigecycline) 100 mg, 50 mg Tetracyclines PA minocycline hcl tabs 75 1 (Doxycycline mg (Monohydrate)) AVIDOXY 1 minocycline hcl tb24 ST TABS 105 mg, 115 mg, 135 1 (Doxycycline mg, 45 mg, 55 mg, 65 (Monohydrate)) 1 MONDOXYNE NL, OKEBO mg, 80 mg, 90 mg CAPS SOLODYN TB24 ST GP (Doxycycline Hyclate) (minocycline hcl) MORGIDOX 1X100MG, tetracycline hcl caps MORGIDOX 1X50MG, 1 1 MORGIDOX 2X100MG 250 mg, 500 mg CAPS VIBRAMYCIN CAPS 100 MG (doxycycline GP (Minocycline Hcl) 1 ST COREMINO TB24 hyclate) VIBRAMYCIN SUSR 25 demeclocycline hcl 1 tabs MG/5ML (doxycycline GP doxycycline (monohydrate)) VIBRAMYCIN SYRP 50 (monohydrate) caps 1 100 mg, 150 mg, 50 MG/5ML (doxycycline 2 mg, 75 mg calcium) doxycycline THYROID AGENTS - Drugs to Regulate Thyroid (monohydrate) susr 25 1 Hormones mg/5ml Antithyroid Agents doxycycline methimazole tabs 1 (monohydrate) tabs 1 100 mg, 50 mg propylthiouracil tabs 1 doxycycline ST TAPAZOLE TABS GP (monohydrate) tabs 1 (methimazole) 150 mg, 75 mg Thyroid Hormones doxycycline hyclate 1 (Levothyroxine Sodium) caps 100 mg, 50 mg EUTHYROX, LEVO-T, 1 LEVOXYL, UNITHROID doxycycline hyclate 1 tabs 100 mg, 20 mg TABS ST (Thyroid) NP THYROID doxycycline hyclate 120, NP THYROID 15 1 tbec 100 mg, 150 mg, 1 TABS 75 mg ARMOUR THYROID TABS MINOCIN CAPS GP GP 120 MG, 15 MG (thyroid) (minocycline hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARMOUR THYROID TABS WP THYROID TABS 2 180 MG, 240 MG, 30 MG, (thyroid) 300 MG, 60 MG, 90 MG 2 (thyroid) ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions CYTOMEL TABS 3 (liothyronine sodium) Antispasmodics LEVOTHYROXINE (Hyoscyamine Sulfate) ED- SODIUM CAPS OR 100 SPAZ, NULEV, OSCIMIN 1 MCG, 112 MCG, 125 TBDP MCG, 13 MCG, 137 MCG, 3 (Hyoscyamine Sulfate) 150 MCG, 25 MCG, 50 OSCIMIN SR, SYMAX-SR 1 MCG, 75 MCG, 88 MCG TB12 (levothyroxine sodium) (Hyoscyamine Sulfate) 1 levothyroxine sodium OSCIMIN TABS tabs or 100 mcg, 112 (Hyoscyamine Sulfate) OSCIMIN, SYMAX-SL 1 mcg, 125 mcg, 137 SUBL mcg, 150 mcg, 175 1 ANASPAZ TBDP mcg, 200 mcg, 25 mcg, GP (hyoscyamine sulfate) 300 mcg, 50 mcg, 75 mcg, 88 mcg BELLADONNA/OPIUM SUPP (belladonna 3 liothyronine sodium 1 alkaloids & opium) tabs chlordiazepoxide hcl- NATURE-THROID NT-2.5 1 2 clidinium bromide caps TABS (thyroid) CUVPOSA SOLN NATURE-THROID TABS 2 2 (glycopyrrolate) (thyroid) SYNTHROID TABS dicyclomine hcl caps 1 3 (levothyroxine sodium) dicyclomine hcl soln 1 thyroid tabs 1 dicyclomine hcl tabs 1 TIROSINT CAPS 100 MCG, 112 MCG, 125 GLYCATE TABS 3 MCG, 13 MCG, 137 MCG, (glycopyrrolate) 150 MCG, 25 MCG, 50 3 MCG, 75 MCG, 88 MCG glycopyrrolate tabs or 1 1 (levothyroxine sodium) mg, 2 mg TIROSINT-SOL SOLN 100 GLYCOPYRROLATE MCG/ML, 112 MCG/ML, TABS OR 1.5 MG 3 125 MCG/ML, 13 MCG/ML, (glycopyrrolate) 137 MCG/ML, 150 3 hyoscyamine sulfate 1 MCG/ML, 200 MCG/ML, 25 subl MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML hyoscyamine sulfate 1 (levothyroxine sodium) tabs WESTHROID TABS hyoscyamine sulfate 2 1 (thyroid) tb12 You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC hyoscyamine sulfate 1 tbdp CONTROL MAXIMUM STRENGTH, ACID LEVBID TB12 GP CONTROLLER MAXIMUM (hyoscyamine sulfate) STRENGTH, ACID LEVSIN TABS REDUCER MAXIMUM GP (hyoscyamine sulfate) STRENGTH, CVS ACID CONTROLLER MAXIMUM LEVSIN/SL SUBL GP STRENGTH, EQ ACID (hyoscyamine sulfate) REDUCER MAXIMUM LIBRAX CAPS STRENGTH, EQ (chlordiazepoxide hcl- GP FAMOTIDINE MAXIMUM clidinium bromide) STRENGTH, EQL HEARTBURN methscopolamine 1 PREVENTION/MAXIMUM bromide tabs STRENGTH, FAMOTIDINE MAXIMUM STRENGTH, propantheline bromide 1 GNP ACID REDUCER 1 tabs MAXIMUMSTRENGTH, H-2 Antagonists HEARTBURN RELIEF (Cimetidine) CIMETIDINE RX/OTC MAXIMUMSTRENGTH, 200, CIMETIDINE ACID HM FAMOTIDINE, KLS REDUCER, CVS ACID CONTROLLER HEARTBURN RELIEF, EQ MAXIMUM STRENGTH, ACID REDUCER, EQ MM FAMOTIDINE, PX CIMETIDINE ACID ACID REDUCER REDUCER, EQ MAXIMUM STRENGTH, QC ACID CONTROLLER HEARTBURN RELIEF, 1 GNP HEARTBURN MAXIMUM STRENGTH, RELIEF, GNP RA ACID REDUCER HEARTBURN RELIEF 200, MAXIMUM STRENGTH, HEARTBURN RELIEF, PX SB ACID CONTROLLER ACID REDUCER, RA ACID MAXIMUM STRENGTH, REDUCER, SB SM ACID REDUCER CIMETIDINE, SM ACID MAXIMUM STRENGTH REDUCER TABS TABS

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138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID RX/OTC nizatidine caps 1 CONTROL MAXIMUM STRENGTH, ACID 1 REDUCER, ACID nizatidine soln REDUCER MAXIMUM PEPCID AC MAXIMUM RX/OTC STRENGTH, CVS ACID STRENGTH TABS GP REDUCER (famotidine) MAXIMUMSTRENGTH, PEPCID SUSR 40 MG/5ML EQ ACID REDUCER, EQL GP ACID REDUCER (famotidine) MAXIMUMSTRENGTH, PEPCID TABS 20 MG RX/OTC GP EQL HEARTBURN RELIEF (famotidine) MAXIMUM STRENGTH, PEPCID TABS 40 MG QL(2 ea daily) GNP ACID CONTROL 150 GP MAXIMUM STRENGTH, (famotidine) GOODSENSE ACID ranitidine hcl caps 150 1 REDUCER, HEARTBURN mg, 300 mg RELIEF 150 MAXIMUM 1 STRENGTH, HM ACID ranitidine hcl syrp 15 REDUCER, HM ACID mg/ml, 150 mg/10ml, 1 REDUCER MAXIMUM 75 mg/5ml STRENGTH, KLS ACID RX/OTC REDUCER ranitidine hcl tabs 150 1 MAXIMUMSTRENGTH, PX mg ACID REDUCER ranitidine hcl tabs 300 1 MAXIMUM STRENGTH, mg RA ACID REDUCER TAGAMET HB TABS RX/OTC MAXIMUM STRENGTH, GP RANITIDINE 150 (cimetidine) MAXIMUM STRENGTH, ZANTAC 150 MAXIMUM RX/OTC SB ACID REDUCER, SM STRENGTH TABS GP ACID REDUCER (ranitidine hcl) MAXIMUM STRENGTH, WAL-ZAN 150 MAXIMUM Misc. Anti-Ulcer STRENGTH TABS CARAFATE SUSP GP cimetidine hcl soln 1 (sucralfate) CARAFATE TABS GP cimetidine tabs 200 mg 1 RX/OTC (sucralfate) sucralfate susp 1 cimetidine tabs 300 1 mg, 400 mg, 800 mg sucralfate tabs 1 famotidine susr 40 1 mg/5ml Proton Pump Inhibitors famotidine tabs 20 mg 1 RX/OTC famotidine tabs 40 mg 1 QL(2 ea daily) GNP ACID CONTROL 150 RX/OTC MAXIMUM STRENGTH 3 TABS (ranitidine hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. WA Essential Drug List Updated: January 1, 2021

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Esomeprazole PA; QL(1 ea PA; QL(1 ea esomeprazole 1 Magnesium) CVS daily); RX/OTC magnesium cpdr 40 mg daily) ESOMEPRAZOLE MAGNESIUM, GNP esomeprazole PA ESOMEPRAZOLE magnesium pack 10 1 MAGNESIUM, mg, 20 mg, 40 mg GOODSENSE ESOMEPRAZOLE PA; QL(1 ea ESOMEPRAZOLE STRONTIUM CPDR daily) MAGNESIUM, HM (esomeprazole 3 ESOMEPRAZOLE 1 MAGNESIUM DELAYED strontium) RELEASE, KLS FIRST-LANSOPRAZOLE PA 3 ESOMEPRAZOLE SUSP (lansoprazole) MAGNESIUM, QC FIRST-OMEPRAZOLE ESOMEPRAZOLE 3 MAGNESIUM, RA SUSP (omeprazole) ESOMEPRAZOLE RX/OTC lansoprazole cpdr 15 1 MAGNESIUM, SM mg ESOMEPRAZOLE MAGNESIUM CPDR lansoprazole cpdr 30 1 (Esomeprazole PA; QL(1 ea mg QL(1 ea daily); Magnesium) HEARTBURN 1 daily); RX/OTC lansoprazole tbdd 15 TREATMENT 24 HOUR 1 AL(Up to 12 yrs CPDR 20 MG mg old ); RX/OTC QL(1 ea daily); lansoprazole tbdd 30 QL(1 ea daily); (Lansoprazole) CVS 1 1 AL(Up to 12 yrs LANSOPRAZOLE TBDD AL(Up to 12 yrs old ); RX/OTC mg old ) (Lansoprazole) CVS RX/OTC NEXIUM 24HR CLEAR PA; QL(1 ea LANSOPRAZOLE, EQ MINIS CPDR daily); RX/OTC LANSOPRAZOLE, GNP (esomeprazole GP LANSOPRAZOLE, magnesium) GOODSENSE LANSOPRAZOLE, HM 1 NEXIUM 24HR CPDR PA; QL(1 ea daily); RX/OTC LANSOPRAZOLE, KLS (esomeprazole GP LANSOPRAZOLE, QC magnesium) LANSOPRAZOLE, RA NEXIUM CPDR 20 MG PA; QL(1 ea LANSOPRAZOLE, SM (esomeprazole GP daily); RX/OTC LANSOPRAZOLE CPDR magnesium) (Lansoprazole) RX/OTC HEARTBURN NEXIUM PACK 10 MG, 20 PA 1 MG, 40 MG TREATMENT 24 HOUR GP CPDR 15 MG (esomeprazole ACIPHEX SPRINKLE PA magnesium) CPSP 10 MG, 5 MG 3 NEXIUM PACK 2.5 MG, 5 PA (rabeprazole sodium) MG (esomeprazole 3 DEXILANT CPDR PA; QL(1 ea magnesium) 3 (dexlansoprazole) daily) OMEPRAZOLE + PA; QL(1 ea SYRSPEND SFALKA 3 esomeprazole 1 magnesium cpdr 20 mg daily); RX/OTC SUSP (omeprazole)

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140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HELIDAC THERAPY MISC omeprazole cpdr 10 1 mg, 40 mg (metronidazole- tetracycline w/ bismuth 3 1 RX/OTC omeprazole cpdr 20 mg subsalicylate) OMECLAMOX-PAK MISC pantoprazole sodium 1 pack (amoxicillin- clarithromycin w/ 3 pantoprazole sodium 1 tbec omeprazole) PREVACID CPDR 30 MG omeprazole-sodium PA GP (lansoprazole) bicarbonate caps 1100 1 PREVACID SOLUTAB QL(1 ea daily); mg-40 mg TBDD 15 MG GP AL(Up to 12 yrs omeprazole-sodium (lansoprazole) old ); RX/OTC bicarbonate pack 1680 1 PREVACID SOLUTAB QL(1 ea daily); mg-20 mg, 1680 mg-40 TBDD 30 MG GP AL(Up to 12 yrs mg old ) (lansoprazole) PYLERA CAPS (bismuth PRILOSEC PACK PA subcitrate potassium- 3 (omeprazole 3 metronidazole- magnesium) tetracycline) PROTONIX PACK 40 MG GP ZEGERID CAPS 1100 MG- PA (pantoprazole sodium) 40 MG (omeprazole- GP PROTONIX TBEC 20 MG GP sodium bicarbonate) (pantoprazole sodium) ZEGERID PACK 1680 MG- RABEPRAZOLE SODIUM PA 20 MG, 1680 MG-40 MG DR SPRINKLE CPSP 3 (omeprazole-sodium GP (rabeprazole sodium) bicarbonate) PA; QL(2 ea rabeprazole sodium 1 URINARY ANTI-INFECTIVES - Drugs to Treat tbec daily) Bladder/Kidney Infections Ulcer Drugs - Prostaglandins Urinary Anti-infective Combinations CYTOTEC TABS (Methenamine-Hyosc- GP (misoprostol) Methylene Blue-Sod Phos- Phenyl Sal) misoprostol tabs 1 PHOSPHASAL, URELLE, 1 URETRON D/S, URIN D/S, Ulcer Therapy Combinations URO-458, UROAV-81, (Omeprazole-Sodium PA UTIRA-C, UTRONA-C, Bicarbonate) OMEPPI 1 VILEVEV MB TABS CAPS (Methenamine-Hyosc- amoxicillin- Methylene Blue-Sod Phos- clarithromycin w/ 1 Phenyl Sal) URIBEL, URO- 1 lansoprazole misc MP, UROAV-B, USTELL, UTICAP, VILAMIT MB CAPS Urinary Anti-infectives

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141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOVIAZ TB24 QL(1 ea daily) nitrofurantoin monohyd 1 2 macro caps (fesoterodine fumarate) URINARY ANTISPASMODICS - Drugs to Treat trospium chloride cp24 1 Miscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics trospium chloride tabs 1 VESICARE TABS darifenacin 1 GP hydrobromide tb24 (solifenacin succinate) DETROL LA CP24 2 MG QL(1 ea daily) GP Urinary Antispasmodics - Beta-3 Adrenergic (tolterodine tartrate) MYRBETRIQ TB24 QL(1 ea daily) 3 DETROL TABS 1 MG QL(2 ea daily) ) GP (mirabegron (tolterodine tartrate) Urinary Antispasmodics - Cholinergic Agonists DETROL TABS 2 MG GP bethanechol chloride 1 (tolterodine tartrate) tabs DITROPAN XL TB24 GP URECHOLINE TABS (oxybutynin chloride) GP (bethanechol chloride) ENABLEX TB24 7.5 MG (darifenacin GP Urinary Antispasmodics - Direct Muscle Relaxants hydrobromide) flavoxate hcl tabs 1 GELNIQUE GEL 3 (oxybutynin chloride) VACCINES GELNIQUE PUMP GEL 3 Bacterial Vaccines (oxybutynin chloride) VIVOTIF BERNA CPDR QL(4 ea per fill oxybutynin chloride 3 retail,4 ea per 1 (typhoid vaccine) syrp fill mail) oxybutynin chloride VIVOTIF CPDR (typhoid QL(4 ea per fill 1 3 retail,4 ea per tabs vaccine) fill mail) oxybutynin chloride 1 tb24 Viral Vaccines FLUCELVAX PV OXYTROL FOR WOMEN RX/OTC 3 QUADRIVALENT 2018- PTTW (oxybutynin) 2019 SUSY (influenza OXYTROL PTTW RX/OTC PV 3 virus vaccine tissue- (oxybutynin) cultured subunit quadrivalent) solifenacin succinate 1 tabs FLUCELVAX PV tolterodine tartrate QL(1 ea daily) QUADRIVALENT 2019- 1 2020 SUSY (influenza cp24 2 mg, 4 mg PV QL(2 ea daily) virus vaccine tissue- tolterodine tartrate tabs 1 1 mg cultured subunit quadrivalent) tolterodine tartrate tabs 1 2 mg

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142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUCELVAX PV SHUR-SEAL GEL PV PV QUADRIVALENT 2020- (nonoxynol-9) 2021 SUSY (influenza TODAY SPONGE MISC PV PV PV virus vaccine tissue- (nonoxynol-9) cultured subunit VCF VAGINAL PV quadrivalent) CONTRACEPTIVE FILM PV GARDASIL 9 SUSP PV FILM (nonoxynol-9) (human papillomavirus PV VCF VAGINAL PV (hpv) 9-valent recombinant CONTRACEPTIVE FOAM PV vaccine) FOAM (nonoxynol-9) GARDASIL 9 SUSY PV Vaginal Anti-infectives (human papillomavirus PV (Metronidazole Vaginal) 1 (hpv) 9-valent recombinant VANDAZOLE GEL vaccine) (Miconazole Nitrate RECOMBIVAX HB SUSP Vaginal) MICONAZOLE 3 1 (hepatitis b vaccine 3 SUPP (recomb)) AVC CREA 3 ROTATEQ SOLN (sulfanilamide vaginal) (rotavirus vaccine, live 3 CLEOCIN CREA VA 2 % oral pentavalent) (clindamycin phosphate GP VAGINAL AND RELATED PRODUCTS vaginal) CLEOCIN SUPP VA 100 Miscellaneous Vaginal Products MG (clindamycin 3 (Acetic Acid-Oxyquinoline 3 phosphate vaginal) Vaginal) RELAGARD GEL clindamycin phosphate 1 FEM PH GEL (acetic vaginal crea acid-oxyquinoline 3 vaginal) CLINDESSE CREA (clindamycin phosphate 3 INTRAROSA INST 3 (one dose)) ( vaginal) GYNAZOLE-1 CREA Spermicides (butoconazole nitrate 3 (Nonoxynol-9) VCF PV (one dose)) VAGINAL PV CONTRACEPTIVEGEL METROGEL-VAGINAL GEL GEL (metronidazole GP ENCARE SUPP PV vaginal) PV (nonoxynol-9) metronidazole vaginal 1 OPTIONS CONCEPTROL PV gel VAGINAL GP terconazole vaginal 1 CONTRACEPTIVE GEL crea (nonoxynol-9) terconazole vaginal 1 OPTIONS GYNOL II PV supp VAGINALCONTRACEPTIV PV E GEL (nonoxynol-9) Vaginal Estrogens

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143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Estradiol Vaginal) 1 Neurogenic Orthostatic Hypotension (NOH) - YUVAFEM TABS NORTHERA CAPS PA ESTRACE CREA SP GP (droxidopa) (estradiol vaginal) Vasopressors estradiol vaginal crea 1 EPINEPHRINE HCL SOLN PA SP (epinephrine) estradiol vaginal tabs 1 epinephrine soln 1 PA ESTRING RING SP 3 mg/ml (estradiol vaginal) FEMRING RING QL(1 ea per 90 midodrine hcl tabs 1 (estradiol acetate 3 days retail) VITAMINS vaginal) PREMARIN CREA VA Oil Soluble Vitamins 0.625 MG/GM 2 (Cholecalciferol) AL(At least 65 (estrogens, conjugated AQUEOUS VITAMIN D yrs old); PV vaginal) INFANTS, BPROTECTED PEDIA D-VITE, D-VITE Vaginal Progestins PEDIATRIC, D3 VITAMIN, PV CRINONE GEL 4 % JUST D, PHARMACIST (progesterone 3 CHOICE D-VITAMIN (vaginal)) PEDIATRIC DROPS, VITAMIN D INFANT LIQD CRINONE GEL 8 % PA (Cholecalciferol) CVS D3, AL(At least 65 ( 3 PV progesterone EQL VITAMIN D3 CAPS yrs old); PV (vaginal)) (Cholecalciferol) D 400, D- AL(At least 65 ENDOMETRIN INST PA 400, D3 HIGH POTENCY, yrs old); PV (progesterone 3 DELTA D3, GNP VITAMIN PV (vaginal)) D-400, HM VITAMIN D, QC VITAMIN D3, SM VITAMIN VASOPRESSORS - Drugs to Treat Heart and D, VITAMIN D-400 TABS Circulation Conditions (Cholecalciferol) D 400, D3 AL(At least 65 Anaphylaxis Therapy Agents KIDS, GNP VITAMIN D, yrs old); PV epinephrine QL(4 ea per fill HEALTHY KIDS VITAMIN PV (anaphylaxis) soaj 0.15 retail) D3, KP VITAMIN D, PA 2 VITAMIN D-3 GUMMY mg/0.15ml, 0.15 CHEW mg/0.3ml, 0.3 mg/0.3ml BABY DDROPS LIQD AL(At least 65 PV EPINEPHRINE SOAJ 0.3 QL(4 ea per fill (cholecalciferol) yrs old); PV MG/0.3ML (epinephrine 2 retail) PV AL(At least 65 (anaphylaxis)) cholecalciferol caps yrs old); PV EPIPEN 2-PAK SOAJ PA; QL(4 ea PV AL(At least 65 (epinephrine 2 per fill retail) cholecalciferol chew yrs old); PV (anaphylaxis)) PV AL(At least 65 EPIPEN-JR 2-PAK SOAJ PA; QL(4 ea cholecalciferol liqd yrs old); PV (epinephrine 2 per fill retail) cholecalciferol tabs PV AL(At least 65 (anaphylaxis)) yrs old); PV

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144 Drug Requirements/ Drug Name Tier Limits D-VI-SOL LIQD AL(At least 65 GP (cholecalciferol) yrs old); PV DRISDOL CAPS GP (ergocalciferol) ergocalciferol caps 1 MEPHYTON TABS GP (phytonadione) phytonadione tabs 1 VITAMIN D2 TABS AL(At least 65 PV (ergocalciferol) yrs old); PV VITAMIN D3 IMMUNE AL(At least 65 HEALTH LIQD PV yrs old); PV (cholecalciferol) VITAMIN D3 LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV Water Soluble Vitamins POTABA CAPS (potassium 3 aminobenzoate) potassium 1 aminobenzoate pack

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145 Index 7t lido gel 82 ADDERALL 1 all day allergy childrens 35 7TOPIC 82 ADDERALL XR 1 allergy relief 24hr 36 abacavir sulfate 53 adefovir dipivoxil 55 allopurinol 95 abacavir sulfate-lamivudine 53 ADEMPAS 60 almotriptan malate 104 abacavir sulfate-lamivudine- adrucil 43 ALOCRIL 125 zidovudine 53 adult aspirin regimen 8 ALOMIDE 125 ABELCET 34 ADVAIR DISKUS 19 ALORA 91 ABILIFY 52 ADVAIR HFA 20 alosetron hcl 93 abiraterone acetate 44 ADVICOR 37 ALOXI 32 ABSORICA 69 AFINITOR 46 ALPHAGAN P 122 ABSORICA LD 69 AFINITOR DISPERZ 46 alprazolam 17 ABSTRAL 9 afirmelle 62 ALPRAZOLAM INTENSOL 17 acamprosate calcium 129 aftera 65 alprazolam xr 17 acarbose 28 AGGRENOX 95 ALREX 123 ACCOLATE 18 AGRYLIN 95 ALTABAX 72 ACCUPRIL 38 AIMOVIG 103 altacaine 123 ACCURETIC 39 AIMSCO LUBRICATED 101 ALTACE 38 acebutolol hcl 57 ak-poly-bac 122 altafrin 121 acetaminophen w/ codeine 11 AKTEN 123 ALTOPREV 37 acetazolamide 85 AKYNZEO 33 ALUNBRIG 46 acetic acid (otic) 126 al12 80 alvimopan 93 acetylcysteine 68 ALA SCALP 76 alyacen 1/35 62 acid control maximum strength 138 ala-cort 75 alyacen 7/7/7 63 ACIPHEX SPRINKLE 140 ALA-QUIN 72 alyq 60 acitretin 74 ALA-SCALP 76 amabelz 90 ACTEMRA 4 albendazole 14 amantadine hcl 49 ACTIDOM DMX 67 ALBENZA 14 AMARYL 31 ACTIGALL 92 albuterol sulfate 20 AMBIEN 98 ACTIMMUNE 48 ALBUTEROL SULFATE 20 AMBIEN CR 98 ACTIQ 9 albuterol sulfate 20 AMBISOME 34 ACTIVELLA 90 ALCAINE 123 ambrisentan 59 ACTONEL 86 alclometasone amcinonide 76 dipropionate 76 ACTOPLUS MET 29 AMCINONIDE 76 ALCORTIN A 72 ACTOPLUS MET XR 29 AMERGE 104 ALDACTAZIDE 85 ACTOS 30 amethia 62 ALDACTONE 86 ACULAR 124 amethyst 62 ALDARA 81 ACULAR LS 124 AMICAR 97 ALDURAZYME 88 ACUVAIL 124 amikacin sulfate 3 ALECENSA 46 acyclovir 56 amiloride & alendronate sodium 86 hydrochlorothiazide 85 acyclovir topical 75 ALFERON N 48 amiloride hcl 86 ACZONE 69 alfuzosin hcl 94 aminocaproic acid 97 ADAGEN 3 ALIMTA 43 aminophylline 21 ADALAT CC 58 ALINIA 15 amiodarone hcl 18 adapalene 69 aliskiren fumarate 41 AMITIZA 92 adapalene-benzoyl peroxide 69 ALKERAN 43 amitriptyline hcl 28 ADCIRCA 60

Index 1 amlodipine besylate 58 aprepitant 33 atenolol 57 amlodipine besylate-atorvastatin apri 61 atenolol & chlorthalidone 39 calcium 59 APTIOM 23 ATGAM 108 amlodipine besylate-benazepril hcl 39 APTIVUS 53 ATIVAN 17 amlodipine besylate-olmesartan aqueous vitamin d infants 144 atomoxetine hcl 1 medoxomil 39 ARALAST NP 135 atorvastatin calcium 37 amlodipine besylate- ARANESP ALBUMIN atovaquone 15 valsartan 39 FREE 96 amlodipine-valsartan- atovaquone-proguanil hcl 42 ARAVA 6 hydrochlorothiazide 39 ATRALIN 69 ARCALYST 4 amnesteem 68 ATRIPLA 53 ARCAPTA NEOHALER 20 amoxapine 28 ATROPINE SULFATE 121 argyle sterile saline 100ml 94 amoxicillin 127 ATROVENT HFA 18 argyle sterile water 100ml109 amoxicillin & pot AUBAGIO 130 clavulanate 127 ARICEPT 129 AUGMENTIN 128 amoxicillin-clarithromycin w/ ARIKAYCE 3 lansoprazole 141 AUGMENTIN ES-600 128 ARIMIDEX 44 amphetamine- AUGMENTIN XR 128 dextroamphetamine 1 aripiprazole 52 aurovela 1.5/30 62 amphotericin b 34 ARIXTRA 21 aurovela 24 fe 62 ampicillin 127 armodafinil 2 AUSTEDO 130 ampicillin & sulbactam ARMONAIR DIGIHALER 19 av-phos 250 neutral 106 sodium 128 ARMONAIR RESPICLICK ampicillin sodium 127 113 19 av-vite fb forte 84 AMPYRA 130 ARMONAIR RESPICLICK AVALIDE 40 AMRIX 119 232 19 AVANDIA 30 ARMONAIR RESPICLICK ANADROL-50 12 55 19 AVAPRO 39 ANAFRANIL 28 ARMOUR THYROID 136,137 AVAR 69 anagrelide hcl 96 ARNUITY ELLIPTA 19 avar cleanser 69 ANALPRAM-HC 13 AROMASIN 44 AVAR LS 69 ANASPAZ 137 ARRANON 43 AVAR LS CLEANSER 69 anastrozole 44 arthritis pain reliever 72 avar-e emollient 69 ANCOBON 34 ARTHROTEC 50 5 AVAR-E LS 69 ANDRODERM 12 ARTHROTEC 75 5 AVC 143 ANDROGEL 13 ARZERRA 44 AVELOX 91 ANDROGEL PUMP 13 ASACOL HD 92 avidoxy 136 ANGELIQ 90 ascomp/codeine 11 avita 69 ANNOVERA 64 ASCRIPTIN 9 AVODART 94 ANORO ELLIPTA 20 aspirin 9 AVONEX 130 ANTABUSE 129 aspirin 81 low dose 8 AVONEX PEN 130 ANTARA 37 aspirin adult 9 AYGESTIN 128 anti-diarrheal 31 aspirin-dipyridamole 96 AYVAKIT 46 anucort-hc 13 ASTAGRAF XL 108 azacitidine 43 anusol-hc 14 ATABEX EC 112 AZASAN 108 ANUSOL-HC 14 ATABEX OB 112 AZASITE 122 ANZEMET 32 ATACAND 39 AZATHIOPRINE 108 APEXICON E 76 ATACAND HCT 39 azathioprine 108 APLENZIN 26 atazanavir sulfate 53 azelaic acid 83 apraclonidine hcl 122 ATELVIA 86 azelastine hcl 119

Index 2 azelastine hcl (ophth) 125 benzonatate 66 bosentan 59 azelastine hcl-fluticasone benzoyl peroxide- BOSULIF 46 propionate 119 erythromycin 69 BOTOX 121 AZELEX 69 benztropine mesylate 49 bp cleansing wash 69 AZILECT 50 BEPREVE 125 bprotected pedia iron 97 azithromycin 100 BERINERT 95 BRAFTOVI 46 AZOPT 125 beser 75 BREO ELLIPTA 20 AZOR 40 BESIVANCE 122 BRILINTA 96 AZULFIDINE 92 BETADINE OPHTHALMIC brimonidine tartrate 122 AZULFIDINE EN-TABS 92 PREP 122 BETAGAN 121 BRISDELLE 135 azurette 61 betamethasone dipropionate BRIVIACT 23 BABY DDROPS 144 (topical) 76 bromfenac sodium (ophth) 125 baciim 14 betamethasone dipropionate bromocriptine mesylate 49 bacitracin 14 augmented 76 BROMSITE 125 bacitracin (ophthalmic) 122 betamethasone valerate 76 BROVANA 20 bacitracin-poly-neomycin-hc BETAPACE 57 123 BETAPACE AF 57 BRUKINSA 46 bacitracin-polymyxin b BETASERON 130 budesonide 65 (ophth) 122 betaxolol hcl 57 budesonide (inhalation) 19 baclofen 119 betaxolol hcl (ophth) 121 budesonide (nasal) 120 BACTRIM 15 bethanechol chloride 142 budesonide-formoterol fumarate BACTRIM DS 15 dihydrate 20 BETHKIS 3 BACTROBAN NASAL 119 bumetanide 85 BETIMOL 121 BAL-CARE DHA 112 BUMEX 85 BETOPTIC-S 121 BALCOLTRA 63 BUNAVAIL 12 BEVYXXA 21 balsalazide disodium 92 bupap 7 bexarotene 48 BALVERSA 46 BUPHENYL 88 BEYAZ 63 banophen 34 BUPRENEX 12 bicalutamide 44 BANZEL 23 buprenorphine 12 BICILLIN C-R 128 BAQSIMI ONE PACK 29 buprenorphine hcl 12 BICILLIN L-A 127 BAQSIMI TWO PACK 29 buprenorphine hcl-naloxone hcl BIDIL 59 dihydrate 12 BARACLUDE 55 BILTRICIDE 14 bupropion hcl 26 BAXDELA 91 bimatoprost 125 bupropion hcl (smoking BECONASE AQ 120 deterrent) 134 BINOSTO 86 BELBUCA 12 buspirone hcl 17 BIO-DTUSS DMX 67 BELLADONNA/OPIUM 137 busulfan 43 bio-statin 34 BELSOMRA 99 BUSULFEX 43 BIO-STATIN 34 benazepril & butalbital-acetaminophen 7 hydrochlorothiazide 40 biogtuss 67 butalbital-acetaminophen- benazepril hcl 38 bisoprolol & caffeine 7 BENICAR HCT 40 hydrochlorothiazide 40 butalbital-acetaminophen- bisoprolol fumarate 57 BENLYSTA 109 caffeine w/ codeine 11 BIVIGAM 126 butalbital-aspirin-caffeine 7 BENSAL HP 81 BLEPH-10 122 butalbital-aspirin-caffeine BENZACLIN 69 BLEPHAMIDE 123 w/cod 11 BENZACLIN WITH PUMP 69 BUTALBITAL/ASPIRIN/CAFFEIN BLEPHAMIDE S.O.P. 123 BENZAMYCIN 69 E 7 BONIVA 86 benzepro creamy wash 68 BUTISOL SODIUM 98 BONJESTA 33 BENZNIDAZOLE 14 butorphanol tartrate 12

Index 3 BUTRANS 12 CARBAPHEN 12 PED 67 cefprozil 61 BYSTOLIC 57 CARBATROL 23 ceftazidime 61 BYVALSON 40 carbidopa 49 ceftriaxone sodium 61 C-NATE DHA 112 carbidopa-levodopa 49 cefuroxime axetil 61 c-topical 82 carbidopa-levodopa- cefuroxime sodium 61 cabergoline 89 entacapone 50 CELEBREX 5 carbinoxamine maleate 35 CABLIVI 96 celecoxib 5 CARDIZEM 58 CABOMETYX 46 CELEXA 27 CARDIZEM CD 58 CADUET 59 CELLCEPT 108 CARDIZEM LA 58 CAFERGOT 104 CELLCEPT CARDURA 39 caffeine citrate 1 INTRAVENOUS 108 CARDURA XL 94 CELONTIN 26 CALAN 58 carisoprodol 119 CEM-UREA 80 CALAN SR 58 carisoprodol w/ aspirin 119 CENTANY 72 CALCIFOL 106 carisoprodol w/ aspirin & CENTANY AT 72 calcipotriene 74 codeine 119 cephalexin 60 CALCIPOTRIENE 74 CARNITOR 88 CERACADE 82 calcipotriene-betamethasone CARNITOR SF 88 dipropionate 76 CERDELGA 96 carteolol hcl (ophth) 121 calcitonin (salmon) 86 CEREBYX 25 cartia xt 58 calcitrene 74 cerovel 80 carvedilol 57 calcitriol 88 CESAMET 33 carvedilol phosphate 57 calcitriol (topical) 74 cetirizine hcl 36 CASODEX 44 calcium acetate (phosphate CETRAXAL 126 caspofungin acetate 33 binder) 93 CETROTIDE 87 CALCIUM-FOLIC ACID PLUS CASPOFUNGIN D 106 ACETATE 33 cevimeline hcl 110 CALQUENCE 46 CATAPRES 39 CHANTIX 134 CAMBIA 104 CATAPRES-TTS-1 39 CHANTIX CONTINUING MONTHPAK 134 camila 65 CATAPRES-TTS-2 39 CHANTIX STARTING MONTH CAMPATH 44 CATAPRES-TTS-3 39 PAK 134 CANASA 92 caziant 61 charlotte 24 fe 62 CANCIDAS 33 cefaclor 60 CHEMET 32 candesartan cilexetil 39 CEFACLOR ER 60 CHENODAL 92 candesartan cilexetil- cefadroxil 60 cheratussin ac 67 hydrochlorothiazide 40 cefazolin sodium 60 CHILDRENS ADVIL 5 CAPASTAT SULFATE 42 cefdinir 61 childrens ibuprofen 4 capecitabine 43 cefditoren pivoxil 61 CHILDRENS MOTRIN 5 CAPEX 76 CEFEPIME 61 chloramphenicol sodium CAPLYTA 51 cefepime hcl 61 succinate 15 CAPRELSA 46 chlordiazepoxide hcl 17 CEFEPIME/DEXTROSE 61 captopril 38 chlordiazepoxide hcl-clidinium cefixime 61 captopril & bromide 137 hydrochlorothiazide 40 CEFOTAN 60 chlordiazepoxide-amitriptyline CARAC 73 cefotaxime sodium 61 129 chlorhexidine gluconate (mouth- CARAFATE 139 cefotetan disodium 60 throat) 110 CARBAGLU 88 cefoxitin sodium 61 chloroquine phosphate 42 carbamazepine 23 CEFOXITIN SODIUM 61 chlorothiazide 86 CARBAPHEN 12 67 cefpodoxime proxetil 61 chlorpromazine hcl 52

Index 4 chlorthalidone 86 CLAFORAN 61 clomiphene citrate 87 CHLORZOXAZONE 119 claravis 69 clomipramine hcl 28 chlorzoxazone 119 CLARINEX 36 clonazepam 22 CHOLBAM 92 CLARINEX-D 12 HOUR 67 clonidine 39 cholecalciferol 144 clarithromycin 101 clonidine hcl 39 cholestyramine 36 clearlax 100 clonidine hcl (adhd) 2 cholestyramine light 36 clemastine fumarate 35 clopidogrel bisulfate 96 choline fenofibrate 37 CLENPIQ 99 clorazepate dipotassium 17 CIALIS 59 CLEOCIN 15,143 clotrimazole 109 CICLODAN SOLUTION KIT 72 CLEOCIN PEDIATRIC clotrimazole (topical) 72 ciclopirox 72 GRANULES 15 clotrimazole w/ CLEOCIN PHOSPHATE 15 ciclopirox olamine 72 betamethasone 72 CLEOCIN-T 69 clovique 107 ciclopirox treatment 72 CLIMARA 91 clozapine 51 cidofovir 55 CLIMARA PRO 90 CLOZARIL 51 cilostazol 96 CLINDACIN ETZ 70 COARTEM 42 CILOXAN 122 clindacin etz pledgets 68 codeine sulfate 9 cimetidine 139 CLINDACIN PAC 70 CODITUSSIN AC 67 cimetidine 200 138 CLINDAGEL 70 COGENTIN 49 cimetidine hcl 139 clindamycin hcl 15 COLAZAL 92 CIMZIA 92 clindamycin palmitate colchicine 95 CIMZIA STARTER KIT 92 hydrochloride 15 colchicine w/ probenecid 95 cinacalcet hcl 88 clindamycin phosphate 16 colesevelam hcl 36 CIPRO 91 clindamycin phosphate COLESTID 37 CIPRO HC 126 (topical) 70 clindamycin phosphate in COLESTID FLAVORED 37 CIPRODEX 126 d5w 16 colestipol hcl 37 ciprofloxacin 91 clindamycin phosphate colocort 13 ciprofloxacin hcl 91 vaginal 143 COLY-MYCIN S 126 ciprofloxacin hcl (ophth) 122 clindamycin phosphate-benzoyl peroxide 70 COLYTE-FLAVOR PACKS 99 ciprofloxacin hcl (otic) 126 clindamycin phosphate-benzoyl COMBIGAN 121 ciprofloxacin-ciprofloxacin peroxide (refrigerate) 70 hcl 91 clindamycin phosphate- COMBIPATCH 90 ciprofloxacin-dexamethasone tretinoin 70 COMBIVENT RESPIMAT 20 126 CLINDESSE 143 COMBIVIR 53 ciprofloxacin-fluocinolone acetonide 126 clobazam 22 COMETRIQ 46 citalopram hydrobromide 27 clobetasol propionate 76 COMPLERA 53 CITRANATAL 90 DHA 112 clobetasol propionate e 75 COMPLETENATE 112 CITRANATAL ASSURE 112 clobetasol propionate emollient compoz 98 base 76 CITRANATAL B-CALM 112 clobetasol propionate compro 52 CITRANATAL BLOOM 112 emulsion 77 COMTAN 49 CITRANATAL BLOOM CLOBEX 77 CONCEPT DHA 112 DHA 112 clocortolone pivalate 77 CONCEPT OB 112 CITRANATAL DHA 112 clodan 75 CONCERTA 2 CITRANATAL ESSENCE 112 CLODERM 77 CONDYLOX 81 CITRANATAL HARMONY 112 CLODERM PUMP 77 constulose 100 CITRANATAL MEDLEY 112 clofarabine 43 CONZIP 9 CITRANATAL RX 112 CLOLAR 43 COPAXONE 130 cladribine 43

Index 5 COPIKTRA 46 cvs budesonide nasal dalfampridine 130 CORDARONE 18 spray 120 DALIRESP 19 cvs clotrimazole CORDRAN 77 maximumstrength 72 danazol 13 COREG 57 cvs d3 144 DANTRIUM 119 COREG CR 57 cvs esomeprazole dantrolene sodium 119 coremino 136 magnesium 140 dapsone 15 CORGARD 57 cvs folic acid 96 dapsone (topical) 70 CORLANOR 60 cvs lansoprazole 140 daptomycin 15 CORTANE-B 77 cvs motion sickness ii 33 DARAPRIM 42 CORTANE-B AQUEOUS 126 cvs nicotine 132 darifenacin hydrobromide 142 CORTANE-B-OTIC 126 cvs nicotine lozenge 131 DAURISMO 44 CORTEF 65 cvs nicotine polacrilex 131 DAYPRO 5 cvs nicotine polacrilex CORTENEMA 13 starter 131 DAYTRANA 2 cortic-nd 126 cvs nicotine DDAVP 89 CORTIFOAM 13 transdermalsystem 133 decadron 65 cortisone acetate 66 cvs nicotine transdermalsystem decitabine 43 step 1 134 CORTISPORIN 72 CVS PRENATAL 112 deferasirox 32 CORTISPORIN-TC 126 cyclobenzaprine hcl 119 deferiprone 32 cortizone-10 76 CYCLOGYL 121 DELESTROGEN 91 CORZIDE 40 CYCLOMYDRIL 121 DELSTRIGO 53 COSENTYX 74 cyclopentolate hcl 121 DEMADEX 85 COSENTYX SENSOREADY cyclophosphamide 43 demeclocycline hcl 136 PEN 74 DEMSER 39 COSOPT 121 cycloserine 42 DENAVIR 75 COSOPT PF 121 CYCLOSET 30 DEPAKENE 26 COTELLIC 46 cyclosporine 108 DEPAKOTE 26 COUMADIN 21 cyclosporine modified (for microemulsion) 108 DEPAKOTE ER 26 covaryx 90 CYKLOKAPRON 98 DEPAKOTE SPRINKLES 26 COZAAR 39 CYMBALTA 28 DEPEN TITRATABS 107 CREON 85 cyproheptadine hcl 36 DEPLIN 15 84 CRESEMBA 34 CYSTADANE 88 DEPLIN 7.5 84 CRINONE 144 CYSTADROPS 125 DEPO-ESTRADIOL 91 CRIXIVAN 53 CYSTAGON 94 DEPO-PROVERA 44 cromolyn sodium 18 CYSTARAN 125 DEPO-PROVERA CROMOLYN SODIUM 18 cytarabine 43 CONTRACEPTIVE 65 cromolyn sodium DEPO-SUBQ PROVERA (mastocytosis) 92 CYTOMEL 137 104 65 cromolyn sodium (ophth) 125 CYTOTEC 141 DEPO-TESTOSTERONE 13 crotan 83 cytra k crystals 94 DERMA-SMOOTHE/FS cryselle-28 63 cytra-2 94 BODY 77 cytra-3 94 DERMA-SMOOTHE/FS CUBICIN 15 SCALP 77 CUBICIN RF 15 cytra-k 94 DERMASORB TA 77 CUPRIMINE 107 d 400 144 dermazene 72 CUTIVATE 77 D-VI-SOL 145 DERMOTIC 126 CUVITRU 127 D.H.E. 45 104 DESCOVY 53 CUVPOSA 137 DACOGEN 43 desipramine hcl 28 DAKLINZA 56 desloratadine 36

Index 6 desmopressin acetate 89 diclofenac sodium (actinic DOLOPHINE 9 desmopressin acetate spray 89 keratoses) 73 DOMETUSS-DMX 67 diclofenac sodium (ophth)125 desmopressin acetate spray donepezil hydrochloride 129 diclofenac sodium (topical) 72 refrigerated 89 DOPTELET 96 desogestrel & ethinyl diclofenac w/ misoprostol 5 DORAL 98 estradiol 63 dicloxacillin sodium 128 desogestrel-ethinyl estradiol doripenem 15 dicyclomine hcl 137 (biphasic) 63 dorzolamide hcl 125 didanosine 53 DESONATE 77 DORZOLAMIDE HCL 125 desonide 77 DIFFERIN 70 dorzolamide hcl-timolol DESOWEN 77 DIFICID 101 maleate 121 DESOXIMETASONE 77 diflorasone diacetate 77 DOTHELLE DHA 112 desoximetasone 77 DIFLUCAN 34 dotti 90 DESOXYN 1 diflunisal 9 DOVATO 53 desvenlafaxine 28 digitek 59 DOVONEX 74 DESVENLAFAXINE ER 28 digoxin 59 doxazosin mesylate 39 desvenlafaxine succinate 28 dihydroergotamine doxepin hcl 28 mesylate 104 DETROL 142 doxepin hcl (antipruritic) 74 DILANTIN 25 DETROL LA 142 doxepin hcl (sleep) 98 DILANTIN INFATABS 25 dexamethasone 66 doxercalciferol 88 DILANTIN-125 26 DEXAMETHASONE doxycycline (monohydrate) 136 DILATRATE SR 16 INTENSOL 66 doxycycline (rosacea) 83 dexamethasone sodium DILAUDID 9 doxycycline hyclate 136 phosphate 66 dilt-xr 58 DEXAMETHASONE SODIUM doxylamine-pyridoxine 33 diltiazem hcl 58 PHOSPHATE 66 DRISDOL 145 diltiazem hcl coated beads 58 dexamethasone sodium dronabinol 33 phosphate (ophth) 123 diltiazem hcl extended release dexchlorpheniramine beads 58 drospirenone-ethinyl maleate 34 estradiol 63 dimethyl fumarate 130 drospirenone-ethinyl estradiol- DEXEDRINE 1 DIOVAN 39 levomefolate calcium 63 DEXILANT 140 DIOVAN HCT 40 DROXIA 96 dexmethylphenidate hcl 2 DIPENTUM 92 DRYSOL 83 dexpak 10 day 65 diphen 35 DUAC 70 dextroamphetamine sulfate 1 diphenhydramine hcl 35 DUAVEE 90 DIACOMIT 23 diphenoxylate w/ atropine 31 DUET DHA 400 112 DIAPHRAGMS 101 DIPROLENE 78 DUET DHA BALANCED 112 DIASTAT ACUDIAL 22 DIPROLENE AF 77 DUETACT 29 DIASTAT PEDIATRIC 22 dipyridamole 96 DUEXIS 5 diazepam 17 disopyramide phosphate 18 duloxetine hcl 28 diazepam disulfiram 129 DUOPA 50 (anticonvulsant) 22,23 diazepam intensol 17 DITROPAN XL 142 DUPIXENT 80 diazoxide 29 DIURIL 86 DURAGESIC 9 DIBENZYLINE 39 divalproex sodium 26 duramorph 9 DICLEGIS 33 DIVIGEL 91 duraxin 7 DOCTOR MANZANILLA PE DUREX EXTRA DICLOFENAC 5 SYRUP SENSITIVE 101 diclofenac epolamine 72 ANTIHISTAMINE/DECONGES DUREZOL 123 diclofenac potassium 5 TANT 67 dutasteride 94 dofetilide 18 diclofenac sodium 5 dutasteride-tamsulosin hcl 94

Index 7 DUTOPROL 40 EMEND 33 EPIVIR HBV 56 DUZALLO 95 EMEND TRIPACK 33 eplerenone 41 DYAZIDE 85 EMGALITY 104 EPOGEN 96 DYMISTA 119 EMSAM 26 eprosartan mesylate 39 DYRENIUM 86 emtricitabine 53 EPZICOM 53 e.e.s. 400 101 emtricitabine-tenofovir eq allergy relief 35,120 E.E.S. GRANULES 101 disoproxil fumarate 53 eq nicotine 132,134 EMTRIVA 53 EC-NAPROSYN 5 eq nicotine gum refill 131 EMULSION SB 82 ec-naproxen 4 EQUETRO 51 EMVERM 14 econazole nitrate 72 ERAXIS 33 ENABLEX 142 ECOTRIN 9 ERBITUX 44 enalapril maleate 38 ECOTRIN REGULAR ergocalciferol 145 enalapril maleate & STRENGTH 9 ergoloid mesylates 131 ed-spaz 137 hydrochlorothiazide 40 ENBRACE HR 113 ERGOMAR 104 EDARBI 39 ENBREL 7 ergotamine w/ caffeine 104 EDARBYCLOR 40 ENBREL MINI 6 ERIVEDGE 44 EDECRIN 85 ENBREL SURECLICK 7 ERLEADA 45 EDLUAR 98 ENCARE 143 erlotinib hcl 46 EDURANT 53 ENDARI 96 ERTACZO 72 efavirenz 53 ertapenem sodium 15 efavirenz-emtricitabine-tenofovir endocet 11 disoproxil fumarate 53 ENDOMETRIN 144 ery 68 effer-k 106 enoxaparin sodium 21 ery-tab 101 EFFER-K 107 enpresse-28 62 ERYGEL 70 effervescent pot chloride 106 entacapone 49 ERYPED 200 101 EFFEXOR XR 28 entecavir 56 ERYPED 400 101 EFFIENT 96 ENTEREG 93 erythrocin stearate 101 EFUDEX 73 ENTOCORT EC 66 erythromycin (acne aid) 70 ELAPRASE 88 ENTRESTO 59 erythromycin (ophth) 122 ELELYSO 96 ENTTY SPRAY 82 erythromycin base 101 ELESTAT 125 enulose 93 erythromycin ethylsuccinate 101 ELESTRIN 91 ENVARSUS XR 108 ESBRIET 135 eletriptan hydrobromide 104 EPANED 38 escitalopram oxalate 27 ELFOLATE 84 EPCLUSA 56 esgic 7 ELIDEL 81 EPICERAM 82 ESGIC 7 ELIGARD 44 EPIDIOLEX 23 esomeprazole magnesium 140 ELIMITE 83 EPIFOAM 78 ESOMEPRAZOLE ELIQUIS 21 epinastine hcl (ophth) 125 STRONTIUM 140 ELIQUIS STARTER PACK 21 EPINEPHRINE 144 estarylla 63 ELIXOPHYLLIN 21 epinephrine 144 estazolam 98 ELLA 65 epinephrine (anaphylaxis)144 esterified estrogens & ELMIRON 94 epinephrine hcl 20 methyltestosterone 90 ESTRACE 91 ELOCON 78 EPINEPHRINE HCL 144 estradiol 91 eluryng 64 EPIPEN 2-PAK 144 estradiol & norethindrone EMADINE 125 EPIPEN-JR 2-PAK 144 acetate 90 EMBEDA 9 epitol 23 estradiol vaginal 144 EMCYT 45 EPIVIR 53 estradiol valerate 91

Index 8 ESTRING 144 FABIOR 70 fexmid 118 ESTROGEL 91 FABRAZYME 88 FIBRICOR 37 ESTROSTEP FE 63 FALESSA 63 FINACEA 83 eszopiclone 98 famciclovir 56 finasteride 94 ethacrynate sodium 85 famotidine 139 FIORICET 7 ethacrynic acid 85 FANAPT 51 FIORICET/CODEINE 11 ethambutol hcl 42 FANAPT TITRATION FIORINAL 7 ethosuximide 26 PACK 51 FIORINAL/CODEINE #3 11 FANTASY LUBRICATED 101 ethyl chloride 82 FIRAZYR 95 FANTASY ETHYL CHLORIDE/FINE LUBRICATED/SPERMICIDE FIRDAPSE 42 STREAM 82 101 FIRMAGON 45 ETHYL CHLORIDE/MEDIUM STREAM 82 FARESTON 45 FIRST-LANSOPRAZOLE 140 ethynodiol diacet & eth FARXIGA 31 FIRST-MOUTHWASH BLM 109 estrad 63 FARYDAK 46 FIRST-OMEPRAZOLE 140 ETHYOL 49 FAZACLO 51,52 FIRVANQ 15 etidronate disodium 86 FC FEMALE CONDOM 101 flac 126 etodolac 5 FC2 FEMALE CONDOM 101 FLAGYL 14 etonogestrel-ethinyl estradiol64 febuxostat 95 FLAREX 124 ETOPOPHOS 49 felbamate 25 flavoxate hcl 142 etoposide 49 FELBATOL 25 FLEBOGAMMA DIF 127 EUCRISA 83 FELDENE 5 flecainide acetate 18 EURAX 83 felodipine 58 FLECTOR 72 euthyrox 136 FEM PH 143 FLOMAX 94 EVAMIST 91 FEMARA 45 FLONASE ALLERGY everolimus 46 FEMCAP 101 RELIEF 120 FLONASE ALLERGY RELIEF everolimus FEMRING 144 (immunosuppressant) 108 CHILDRENS 120 EVISTA 88 fenofibrate 37 FLONASE SENSIMIST 120 EVOCLIN 70 FENOFIBRATE 37 FLORIVA PLUS 111 EVOTAZ 53 fenofibrate micronized 37 FLOVENT DISKUS 19 EVOXAC 110 FENOFIBRIC ACID 37 FLOVENT HFA 19 EVZIO 32 fenofibric acid 37 FLOXIN OTIC 126 EXACTUSS 67 FENOPROFEN CALCIUM 5 floxuridine 43 EXACTUSS TR 67 fenoprofen calcium 5 FLUCELVAX QUADRIVALENT 2018-2019 142 EXALGO 9 FENORTHO 5 FENSOLVI 88 FLUCELVAX QUADRIVALENT EXAPHEX TR 67 2019-2020 142 EXELDERM 72 fentanyl 10 FLUCELVAX QUADRIVALENT EXELON 129 fentanyl citrate 9 2020-2021 143 fluconazole 34 exemestane 45 FENTORA 10 flucytosine 34 EXFORGE 40 FER-IN-SOL 97 fludarabine phosphate 43 EXFORGE HCT 40 ferosul 97 fludrocortisone acetate 66 EXJADE 32 FERRIPROX 32 FERRIPROX TWICE-A- FLUMADINE 56 EXODERM 73 DAY 32 flunisolide (nasal) 120 EXTAVIA 130 ferrous sulfate 97 fluocinolone acetonide 78 EXTINA 73 FETZIMA 28 fluocinolone acetonide ezetimibe 38 FETZIMA TITRATION (otic) 126 ezetimibe-simvastatin 36 PACK 28 fluocinonide 78

Index 9 fluocinonide emulsified base 78 fosinopril sodium 38 GEBAUERS INSTANT ICE 82 FLUORABON 106 fosinopril sodium & GEBAUERS PAIN EASE 82 fluoritab 106 hydrochlorothiazide 40 GEBAUERS SPRAY AND fosphenytoin sodium 26 fluorometholone (ophth) 124 STRETCH 82 FOSRENOL 93 GELCLAIR 110 FLUOROPLEX 73 FRAGMIN 21,22 GELFILM OP 124 fluorouracil 44 FREESTYLE FREEDOM GELNIQUE 142 fluorouracil (topical) 74 LITE 103 GELNIQUE PUMP 142 fluoxetine hcl 27 FREESTYLE INSULINX gemcitabine hcl 44 fluoxetine hcl (pmdd) 131 BLOODGLUCOSE MONITORING SYSTEM 103 GEMCITABINE FLUOXETINE HYDROCHLORIDE 44 HYDROCHLORIDE 27,131 FREESTYLE INSULINX BLOODGLUCOSE TEST 84 gemfibrozil 37 fluphenazine hcl 52 FREESTYLE INSULINX gemmily 62 flurandrenolide 78 BLOODGLUCOSE TEST GEMZAR 44 flurazepam hcl 98 STRIPS 84 GENERESS FE 63 flurbiprofen 5 FREESTYLE LITE BLOOD GLUCOSE MONITORING gengraf 108 flurbiprofen sodium 125 SYSTEM 103 GENOTROPIN 87 flutamide 45 FREESTYLE LITE TEST GENOTROPIN MINIQUICK 87 fluticasone propionate 78 STRIPS 84 fluticasone propionate FREESTYLE TEST gentak 122 (nasal) 120 STRIPS 84 gentamicin in saline 3 fluticasone-salmeterol 20 FROVA 104 gentamicin sulfate 3 fluvastatin sodium 37 frovatriptan succinate 104 gentamicin sulfate (ophth) 122 fluvoxamine maleate 27 FURADANTIN 16 gentamicin sulfate (topical) 72 FML 124 furosemide 86 GENVOYA 53 FML FORTE 124 FUSION PLUS 97 GEODON 51 FML LIQUIFILM 124 FUZEON 53 geri-hydrolac 12 80 FOCALIN 2 fyavolv 90 gianvi 62 FOCALIN XR 2 FYCOMPA 22 GILENYA 130 FOLBIC RF 84 g tussin ac 67 GILOTRIF 46 FOLET DHA 113 gabapentin 23 GILPHEX TR 67 FOLET ONE 113 GABITRIL 25 GILTUSS 67 folic acid 96 GABLOFEN 119 GILTUSS COUGH & COLD 67 FOLIVANE-F 97 GALAFOLD 88 GILTUSS SINUS & galantamine FOLIVANE-OB 113 CONGESTION 67 hydrobromide 129 GILTUSS TR 67 FOLTX 84 GALZIN 107 GLASSIA 135 fondaparinux sodium 21 GAMASTAN 127 glatiramer acetate 130 FORFIVO XL 26 GAMMAGARD LIQUID 127 glatopa 130 formadon 53 GAMMAKED 127 GLEEVEC 46 formaldehyde 53 GAMMAPLEX 127 GLEOSTINE 43 FORTAZ 61 GAMUNEX-C 127 glimepiride 31 FORTEO 86 GARDASIL 9 143 glipizide 31 FORTESTA 13 GASTROCROM 92 glipizide xl 31 FOSAMAX 86 gatifloxacin (ophth) 122 glipizide-metformin hcl 29 FOSAMAX PLUS D 86 GATTEX 94 GLUCAGEN DIAGNOSTIC 84 fosamprenavir calcium 53 gavilyte-c 99 GLUCAGEN HYPOKIT 29 FOSCAVIR 55 gavilyte-h 99 GLUCAGON EMERGENCY fosfomycin tromethamine 16 gavilyte-n/flavor pack 99 KIT 29

Index 10 GLUCAGON EMERGENCY KIT heartburn treatment 24 hyaluronate sodium FOR LOW BLOOD SUGAR 29 hour 140 (emollient) 80 GLUCOPHAGE 29 HECTOROL 88 HYCAMTIN 49 GLUCOPHAGE XR 29 HELIDAC THERAPY 141 HYCODAN 66 GLUCOTROL 31 HEMANGEOL 57 hydralazine hcl 41 GLUCOTROL XL 31 HEMENATAL OB 113 HYDREA 48 GLUMETZA 29 HEMENATAL OB + DHA 113 HYDRO 35 80 glyburide 31 heparin (porcine) in sodium HYDRO 40 FOAM 80 glyburide micronized 31 chloride 22 hydrochlorothiazide 86 heparin sod (porcine) in glyburide-metformin 29 d5w 22 hydrocodone polistirex- GLYCATE 137 chlorpheniramine polistirex 67 heparin sodium (porcine) 22 hydrocodone w/ glycopyrrolate 137 HEPARIN SODIUM/NACL homatropine 67 GLYCOPYRROLATE 137 0.45% 22 hydrocodone- HEPARIN SODIUM/SODIUM glydo 82 acetaminophen 11 CHLORIDE 22 hydrocodone-ibuprofen 11 GLYNASE 31 HEPARIN SODIUM/SODIUM GLYSET 28 CHLORIDE 0.9% 22 hydrocortisone 66 GLYXAMBI 29 HETLIOZ 99 hydrocortisone (intrarectal) 13 GNP ACID CONTROL 150 HIPREX 16 hydrocortisone (rectal) 14 MAXIMUM STRENGTH 139 HISTEX-PE 67 hydrocortisone (topical) 78 gnp fluticasone propionate 120 HIZENTRA 127 hydrocortisone acetate GOCOVRI 50 (rectal) 14 homatropaire 121 hydrocortisone acetate w/ GOLYTELY 99 homatropine hbr 122 pramoxine 13 GONITRO 16 HORIZANT 131 hydrocortisone butyrate 78 gordons urea 80 humalog 30 hydrocortisone butyrate GORDONS UREA 80 HUMALOG 30 hydrophilic lipo base 78 hydrocortisone valerate 78 GRALISE 131 humalog kwikpen 30 granisetron hcl 32 hydrocortisone w/acetic humalog mix 50/50 30 acid 126 GRANIX 96 humalog mix 50/50 hydromet 66 kwikpen 30 GRASTEK 3 hydromorphone hcl 10 HUMATROPE 87 griseofulvin microsize 34 hydroxyprogesterone griseofulvin ultramicrosize 34 HUMATROPE COMBO caproate 128 PACK 87 hydroxyurea 48 guaifenesin dac 67 HUMIRA 4 guaifenesin-codeine 67 HUMIRA PEDIATRIC CROHNS hydroxyzine hcl 17 guanfacine hcl 39 DISEASE STARTER PACK 3 hydroxyzine pamoate 17 guanfacine hcl (adhd) 2 HUMIRA PEN 3 HYLINATE 80 GUANIDINE HCL 42 HUMIRA PEN-CD/UC/HS hyophen 14 STARTER 3 hyoscyamine sulfate 137 GVOKE PFS 30 HUMIRA PEN-PS/UV GYNAZOLE-1 143 STARTER 3 HYPER-SAL 68 HAEGARDA 95 humulin 70/30 30 HYPERSAL 68 halcinonide 78 humulin 70/30 kwikpen 30 HYQVIA 127 HALCION 98 humulin n 30 HYZAAR 40 halobetasol propionate 78 HUMULIN N 30 ibandronate sodium 86 HALOG 78 humulin n kwikpen 30 IBRANCE 46 haloperidol 51 humulin r 30 ibu 4 haloperidol lactate 51 humulin r u-500 ibudone 11 HARVONI 56 (concentrated) 30 ibuprofen 5 humulin r u-500 kwikpen 30 ICAR PEDIATRIC 97

Index 11 icatibant acetate 95 INVEGA 51 JUXTAPID 38 ICLUSIG 47 INVEGA SUSTENNA 51 JYNARQUE 90 icosapent ethyl 36 INVEGA TRINZA 51 k-effervescent 106 IDHIFA 47 INVIRASE 53 K-PHOS 106 ILEVRO 125 iodoquimez-hc 72 K-PHOS NEUTRAL 106 ILIDERM 82 iodoquinol-hc 73 K-PHOS NO 2 94 ilotycin 122 iodoquinol-hydrocortisone in k-sol 107 ILUMYA 74 aloe vehicle 73 K-TAB 107 iodoquinol-hydrocortisone-aloe imatinib mesylate 47 polysaccharide 73 K-Y ME & YOU EXTRA LUBRICATED 101 IMBRUVICA 47 IOPIDINE 122 K-Y ME & YOU INTENSE 101 imipenem-cilastatin 15 ipratropium bromide 18 KADIAN 10 imipramine hcl 28 ipratropium bromide kaitlib fe 62 imipramine pamoate 28 (nasal) 120 KALETRA 54 imiquimod 81 ipratropium-albuterol 20 KALYDECO 135 IMITREX 104 irbesartan 39 IMITREX STATDOSE irbesartan-hydrochlorothiazide KAMDOY 82 REFILL 104 40 KAMELEON LUBRICATED 101 IMITREX STATDOSE IRESSA 47 KAPVAY 2 SYSTEM 104 ISENTRESS 54 KARBINAL ER 35 IMODIUM A-D 31 ISENTRESS HD 54 KEFLEX 60 IMPAVIDO 14 ISOLYTE-S 106 kelnor 1/35 62 IMPEKLO 78 isoniazid 42 KENALOG 78 IMURAN 108 ISOPTO ATROPINE 122 KEPIVANCE 49 inatal gt 111 ISOPTO CARPINE 122 KEPPRA 23 INCRELEX 88 ISORDIL TITRADOSE 16 KEPPRA XR 23 INCRUSE ELLIPTA 18 isosorbide dinitrate 16 KERALAC 80 indapamide 86 isosorbide mononitrate 16 ketoconazole 34 INDERAL LA 57 isotretinoin 70 ketoconazole (topical) 73 INDERAL XL 57 isoxsuprine hcl 59 ketodan 72 INDOCIN 5 isradipine 58 ketoprofen 5 indomethacin 5 ISTALOL 121 KETOROLAC INFLECTRA 92 ISTODAX (OVERFILL) 47 TROMETHAMINE 5 INGREZZA 130 itraconazole 34 ketorolac tromethamine 5 INHALER SPACERS 103 ivermectin 14 ketorolac tromethamine (ophth) 125 INLYTA 47 ivermectin (pediculicide) 83 KEVEYIS 85 INNOPRAN XL 57 ivermectin (rosacea) 83 KEVZARA 4 INREBIC 47 JADENU 32 KHEDEZLA 28 INSPRA 41 JADENU SPRINKLE 32 KIMONO COLORS 101 INSULIN SYRINGES AND PEN JAKAFI 47 NEEDLES 103 KIMONO LUBRICATED 101 JALYN 94 INTEGRA F 97 KIMONO MICRO THIN 101 jantoven 21 INTELENCE 53 KIMONO MICRO THIN PLUS JANUMET 29 INTERMEZZO 98 SPERMICIDE JANUMET XR 29 LUBRICATED 102 INTRAROSA 143 JANUVIA 30 KIMONO PLUS SPERMICIDE INTRON A 48 LUBRICATED 102 JARDIANCE 31 INTUNIV 2 KIMONO PLUS jinteli 90 SPERMICIDE/LUBRICATED INVANZ 15 JULUCA 54 102

Index 12 KIMONO PS LUBRICATED102 lactulose (encephalopathy)93 letrozole 45 KIMONO PS PLUS LAMICTAL 24 leucovorin calcium 49 SPERMICIDE/LUBRICATED LAMICTAL CHEWABLE LEUKERAN 43 102 DISPERSIBLE 23 LEUKINE 96 KIMONO SENSATION LAMICTAL ODT 24 LUBRICATED 102 leuprolide acetate 45 KIMONO SENSATION PLUS LAMICTAL STARTER/NOT TAKING LEUPROLIDE SPERMICIDE ACETATE/BUPIVACAINE 102 CARBAMAZEPINE 24 LUBRICATED LAMICTAL STARTER/TAKING HYDROCHLORIDE 45 KIMONO SPECIAL 102 CARBAMAZEPINE/NOT levalbuterol hcl 20 KINERET 4 TAKING VALPROATE 24 levalbuterol tartrate 20 kionex 109 LAMICTAL STARTER/TAKING LEVAQUIN 92 VALPROATE 24 KISQALI 47 LEVBID 138 LAMICTAL XR 24 KISQALI FEMARA 200 LEVEMIR 31 DOSE 46 lamivudine 54 LEVEMIR FLEXTOUCH 31 KISQALI FEMARA 400 lamivudine (hbv) 56 levetiracetam 24 DOSE 46 lamivudine-zidovudine 54 KISQALI FEMARA 600 levobunolol hcl 121 lamotrigine 24 DOSE 46 levocarnitine (metabolic KITABIS PAK 3 LANCET 103 modifiers) 88 KIVIK 83 LANOXIN 59 levocetirizine dihydrochloride36 KLARITY-A 122 LANOXIN PEDIATRIC 59 levofloxacin 92 KLARON 70 lansoprazole 140 levofloxacin (ophth) 122 klofensaid ii 72 lanthanum carbonate 93 LEVOMEFOLATE CALCIUM KLONOPIN 23 LANTUS 30 ALGAL POWDER 85 levonorgestrel & eth klor-con 107 LANTUS SOLOSTAR 30 estradiol 63 klor-con 10 107 lapatinib ditosylate 47 levonorgestrel (emergency klor-con m10 107 LASIX 86 oc) 65 LASTACAFT 125 levonorgestrel-eth estradiol klor-con sprinkle 107 (triphasic) 63 KORLYM 30 latanoprost 125 levonorgestrel-ethinyl estradiol KOSHER PRENATAL PLUS LATUDA 51 (91-day) 63 IRON 113 LAZANDA 10 levonorgestrel-ethinyl estradiol kp folic acid 96 LEDIPASVIR/SOFOSBUVIR (continuous) 63 KRINTAFEL 42 56 LEVOTHYROXINE SODIUM 137 leflunomide 6 KRISTALOSE 100 levothyroxine sodium 137 KUVAN 88 LENVIMA 10 MG DAILY DOSE 47 LEVSIN 138 KYLEENA 65 LENVIMA 12MG DAILY LEVSIN/SL 138 l-methylfolate 85 DOSE 47 LEXAPRO 27 L-METHYLFOLATE CA/S- LENVIMA 14 MG DAILY ALGAL 84 DOSE 47 LEXIVA 54 L-METHYLFOLATE FORTE 85 LENVIMA 18 MG DAILY LIBRAX 138 labetalol hcl 57 DOSE 47 lido-k 82 LENVIMA 20 MG DAILY lidocaine 82 LAC-HYDRIN 80 DOSE 47 LAC-HYDRIN TWELVE 80 LENVIMA 24 MG DAILY lidocaine hcl 82 LACRISERT 121 DOSE 47 lidocaine hcl (mouth-throat) 109 LENVIMA 4 MG DAILY lidocaine pak 82 lactated ringer's (irrigation) 109 DOSE 47 lactic acid (ammonium lidocaine-hydrocortisone acetate LENVIMA 8 MG DAILY (rectal) 13 lactate) 80 DOSE 47 lidocaine-prilocaine 82 LACTULOSE 100 LESCOL XL 37 LIDODERM 82 lactulose 100 LETAIRIS 59 LIDODOSE 82

Index 13 LIDODOSE PEDIATRIC BULK LOTENSIN 38 MAVENCLAD 130 PACK 82 LOTENSIN HCT 40 MAVYRET 56 lidopin 82 loteprednol etabonate 124 MAXALT-MLT 105 LIDORX 82 LOTREL 40 MAXIDEX 124 LILETTA 65 LOTRISONE 73 MAXIPIME 61 LINCOCIN 16 LOTRONEX 93 MAXITROL 124 lincomycin hcl 16 lovastatin 37 MAXX LUBRICATED 102 lindane 84 LOVAZA 36 MAXX PLUS SPERMICIDE linezolid 16 LOVENOX 22 LUBRICATED 102 LINZESS 93 MAXZIDE 85 loxapine succinate 52 LIORESAL INTRATHECAL 119 MAXZIDE-25 85 luliconazole 73 liothyronine sodium 137 MAYZENT 130 LUMIGAN 125 LIPOFEN 37 MAYZENT STARTER LUMIZYME 89 lisinopril 38 PACK 130 LUNESTA 98 lisinopril & meclizine hcl 33 hydrochlorothiazide 40 LUPANETA PACK 88 MECLIZINE LITHIUM 51 LUPRON DEPOT (1- HYDROCHLORIDE 33 MONTH) 45 meclofenamate sodium 6 lithium carbonate 51 LUPRON DEPOT (3- MEDROL 66 LITHOBID 51 MONTH) 45 MEDROL DOSEPAK 66 LITHOSTAT 95 LUPRON DEPOT (4- MEDROX-RX 81 LIVALO 37 MONTH) 45 LUPRON DEPOT (6- medroxyprogesterone LO LOESTRIN FE 63 MONTH) 45 acetate 129 LOCOID 78 LUPRON DEPOT-PED (1- medroxyprogesterone acetate LOCOID LIPOCREAM 78 MONTH) 88 (contraceptive) 65 LUPRON DEPOT-PED (3- LODINE 5 mefenamic acid 6 MONTH) 88 mefloquine hcl 42 LODOSYN 49 LUXIQ 79 MEGACE ES 129 LOKELMA 109 LUZU 73 LOMOTIL 32 megestrol acetate 45 LYNPARZA 47 megestrol acetate LONSURF 46 LYRICA 24 (appetite) 129 loperamide hcl 32 LYSODREN 45 MEKINIST 47 LOPID 37 LYSTEDA 98 MEKTOVI 47 lopinavir-ritonavir 54 M-NATAL PLUS 113 meloxicam 6 LOPRESSOR 57 MACROBID 16 melphalan 43 LOPRESSOR HCT 40 MACRODANTIN 16 melphalan hcl 43 LOPROX 73 mafenide acetate 75 memantine hcl 129 LOPROX SHAMPOO 73 MAGNEBIND 400 106 MENEST 91 lorazepam 17 magnesium sulfate 106 MENOSTAR 91 lorazepam intensol 17 MAGNESIUM SULFATE 106 meperidine hcl 10 LORBRENA 47 MAKENA 128 MEPHYTON 145 lorcet 11 MALARONE 42 meprobamate 17 LORTAB 11 malathion 84 MEPRON 15 lorzone 118 maprotiline hcl 26 mercaptopurine 44 losartan potassium 39 MARINOL 33 meropenem 15 losartan potassium & MARNATAL-F 113 MERREM 15 hydrochlorothiazide 40 LOSEASONIQUE 63 MARPLAN 26 mesalamine 92,93 LOTEMAX 124 MATULANE 48 mesalamine w/ cleanser 93 matzim la 58 MESNEX 49

Index 14 MESTINON 42 metoprolol tartrate 57 modafinil 2 MESTINON TIMESPAN 42 METROCREAM 83 moderiba 55 metadate er 2 METROGEL-VAGINAL 143 MODERIBA 1200 DOSE metaproterenol sulfate 20 METROLOTION 83 PACK 56 moexipril hcl 38 metaxall 119 metronidazole 14 molindone hcl 52 metaxalone 119 metronidazole (topical) 83 mometasone furoate 79 metformin hcl 29 metronidazole in nacl 14 mometasone furoate METFORMIN metronidazole vaginal 143 (nasal) 120 HYDROCHLORIDE 29 metyrosine 39 mondoxyne nl 136 methadone hcl 10 mexiletine hcl 18 montelukast sodium 18 METHADONE HCL 10 mezparox-hc 76 MONUROL 16 methadone hcl 10 MIACALCIN 86 morgidox 1x100mg 136 methadone hcl intensol 9 micafungin sodium 34 morphine sulfate 10 methadose 9 MICARDIS 39 morphine sulfate beads 10 methamphetamine hcl 1 MICARDIS HCT 41 MORPHINE SULFATE ER 10 methazolamide 85 miconazole 3 143 MOTOFEN 32 methenamine hippurate 16 miconazole-zinc oxide-white MOVANTIK 93 methenamine mandelate 16 petrolatum 73 MOVIPREP 99 methergine 126 MICROZIDE 86 MOXATAG 127 methimazole 136 midazolam hcl 98 MOXEZA 122 METHITEST 13 midodrine hcl 144 moxifloxacin hcl 92 methocarbamol 119 migergot 104 moxifloxacin hcl (ophth) 122 METHOTREXATE 4 MIGLITOL 28 MOZOBIL 97 methotrexate sodium 44 miglustat 96 MS CONTIN 10 methoxsalen rapid 74 MIGRANAL 104 MUCOTROL 110 methscopolamine bromide 138 MILLIPRED 66 MULPLETA 96 methyclothiazide 86 MILLIPRED DP 66 MULTAQ 18 methyldopa 39 MINASTRIN 24 FE 63 MULTI PRENATAL 113 methyldopa & MINIPRESS 39 multi-vit/iron/fluoride 111 hydrochlorothiazide 40 minitran 16 methylergonovine maleate 126 multi-vitamin/fluoride drops 110 MINIVELLE 91 METHYLIN 2 MULTIVITAMIN WITH MINOCIN 136 methylphenidate hcl 2 FLUORIDE 110 minocycline hcl 136 METHYLPHENIDATE multivitamin with fluoride 110 HYDROCHLORIDE ER 2 minoxidil 41 multivitamin/fluoride 111 methylprednisolone 66 MIRALAX 100 mupirocin 72 methyltestosterone 13 MIRAPEX 50 MYALEPT 89 metoclopramide hcl 92 MIRAPEX ER 50 MYAMBUTOL 43 METOCLOPRAMIDE ODT 92 MIRCERA 96 MYCAMINE 34 metolazone 86 MIRCETTE 63 MYCOBUTIN 43 metopic 80 MIRENA 65 mycophenolate mofetil 108 METOPIRONE 84 mirtazapine 26 mycophenolate mofetil hcl 108 metoprolol & MIRVASO 83 mycophenolate sodium 108 hydrochlorothiazide 40 misoprostol 141 MYDRIACYL 122 metoprolol succinate 57 MITIGARE 95 MYFORTIC 108 METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE mitoxantrone hcl 46 MYKIDZ IRON 10 97 41 MOBIC 6 MYLERAN 43

Index 15 MYNATAL ADVANCE 113 nebusal 68 NEXPLANON 65 MYNATAL ULTRACAPLET 113 NEBUSAL 68 niacin (antihyperlipidemic) 38 MYNATE 90 PLUS 113 NEEVO DHA 113 NIASPAN 38 MYRBETRIQ 142 nefazodone hcl 27 nicardipine hcl 58 MYSOLINE 24 neo-polycin 122 NICODERM CQ 134 MYTESI 31 neo-polycin hc 123 NICORETTE 134 nabumetone 6 NEO-SYNALAR 72 NICORETTE MINI 134 nadolol 58 neomycin sulfate 3 NICORETTE STARTER nadolol & neomycin-bacitracin zn- KIT 134 bendroflumethiazide 41 polymyxin 123 nicotine 135 NAFCILLIN 128 neomycin-polymy- nicotine polacrilex 135 nafcillin sodium 128 dexameth 124 NICOTINE TRANSDERMAL neomycin-polymyxin-gramicidin NAFCILLIN SODIUM 128 SYSTEM 135 123 NICOTROL INHALER 135 nafcillin sodium 128 neomycin-polymyxin-hc NICOTROL NS 135 naftifine hcl 73 (ophth) 124 neomycin-polymyxin-hc nifedipine 58 NAFTIN 73 (otic) 126 NILANDRON 45 NAGLAZYME 89 neomycin/polymyxin b gu 94 nilutamide 45 NALFON 6 NEONATAL 19 113 nimodipine 58 NALOCET 11 NEONATAL COMPLETE 113 NINLARO 47 naloxone hcl 32 NEONATAL FE 113 nisoldipine 58 naltrexone hcl 32 NEONATAL PLUS 113 nitazoxanide 15 NAMENDA 129 NEONATAL VITAMIN 113 nitisinone 89 NAMENDA TITRATION NEONATAL/DHA 113 PAK 129 NITRO-BID 17 NAMENDA XR 129 NEORAL 108 NITRO-DUR 17 NAMENDA XR TITRATION NEOSPORIN 123 nitro-time 16 PACK 129 NEOTUSS PLUS 68 nitrofurantoin 16 NAPRELAN 6 NERLYNX 47 nitrofurantoin macrocrystal 16 NAPROSYN 6 NESTABS 114 nitrofurantoin monohyd naproxen 6 NESTABS ABC 114 macro 16 naproxen sodium 6 NESTABS DHA 114 nitroglycerin 17 naproxen-esomeprazole NESTABS ONE 114 NITROLINGUAL magnesium 6 PUMPSPRAY 17 neuac 68 naratriptan hcl 105 NITROMIST 17 NEULASTA 97 NARCAN 32 NITROSTAT 17 NEULASTA ONPRO KIT 97 NARDIL 26 NITYR 89 NEUPOGEN 97 NASONEX 120 NIVA-PLUS 114 NEUPRO 50 NATACHEW 113 NIVESTYM 97 NEURONTIN 24 NATACYN 123 nizatidine 139 NEUTROGENA CLEAR PORE NATAZIA 64 CLEANSER/MASK 70 NIZORAL 73 nateglinide 31 NEVANAC 125 NOCTIVA 89 NATELLE ONE 113 nevirapine 54 nolix 75 NATPARA 87 NEXA PLUS 114 NON PREFERRED TEST STRIPS 84 NATROBA 84 NEXAVAR 47 NORCO 11 NATURE-THROID 137 NEXIUM 140 NORDITROPIN FLEXPRO 87 NATURE-THROID NT-2.5 137 NEXIUM 24HR 140 norethin acet & estrad-fe 64 NAYZILAM 23 NEXIUM 24HR CLEAR MINIS 140 norethindrone & ethinyl estradiol- NEBUPENT 14 fe 64

Index 16 norethindrone OCTAGAM 127 ONETOUCH VERIO SYNC (contraceptive) 65 octreotide acetate 89 BLOODGLUCOSE norethindrone acet & eth MONITORING SYSTEM 103 estra 64 OCUFLOX 123 ONETOUCH VERIO TEST norethindrone acetate 129 ODACTRA 3 STRIPS 84 norethindrone acetate-ethinyl ODEFSEY 54 ONEVITE 110 estradiol 90 ODOMZO 44 ONFI 23 norgestimate-ethinyl ONUREG 44 estradiol 64 OFEV 135 norgestimate-ethinyl estradiol ofloxacin 92 OPANA 10 (triphasic) 64 ofloxacin (ophth) 123 opium tincture 32 NORITATE 83 ofloxacin (otic) 126 OPSUMIT 59 NORMOSOL-R 106 olanzapine 52 OPTIONS CONCEPTROL NORPACE 18 VAGINAL olanzapine-fluoxetine hcl 129 CONTRACEPTIVE 143 NORPACE CR 18 olmesartan medoxomil 39 OPTIONS GYNOL II NORPRAMIN 28 olmesartan medoxomil- VAGINALCONTRACEPTIVE NORTHERA 144 amlodipine-hydrochlorothiazide 143 nortriptyline hcl 28 41 ORACEA 83 olmesartan medoxomil- ORACIT 94 NORVASC 58 hydrochlorothiazide 41 NORVIR 54 olopatadine hcl 125 ORAFATE 110 NOXAFIL 34 olopatadine hcl (nasal) 120 ORALAIR 3 np thyroid 120 136 ORALAIR ADULT SAMPLE OLUX 79 KIT 3 NUBEQA 45 OLUX-E 79 ORALAIR ADULT STARTER NUCORT 79 OMECLAMOX-PAK 141 PACK 3 NUCYNTA 10 omega-3-acid ethyl esters 36 oralone dental paste 110 NUCYNTA ER 10 omeppi 141 ORAP 131 NUEDEXTA 131 omeprazole 141 ORAPRED ODT 66 NULOJIX 109 OMEPRAZOLE + SYRSPEND ORAVIG 110 NULYTELY 99 SFALKA 140 orazinc 107 NULYTELY/FLAVOR omeprazole-sodium ORENCIA 6 bicarbonate 141 PACKS 99 ORENCIA CLICKJECT 6 NUPLAZID 51 OMNARIS 120 ORENITRAM 59 NUTROPIN AQ NUSPIN 10 87 OMNITROPE 87 ORFADIN 89 NUTROPIN AQ NUSPIN 20 87 ondansetron 32 ORKAMBI 135 NUTROPIN AQ NUSPIN 5 87 ondansetron hcl 32 ONE VITE WOMENS orphenadrine citrate 119 NUVARING 64 PRENATALVITAMIN 114 orphenadrine w/ aspirin & NUVIGIL 2 ONE VITE WOMENS caff 119 NYMALIZE 58 PRENATALVITAMIN ORTHO MICRONOR 65 nystatin 34 PLUS 114 ORTHO TRI-CYCLEN 64 ONETOUCH ULTRA 84 nystatin (mouth-throat) 110 ORTHO TRI-CYCLEN LO 64 ONETOUCH ULTRA 2 103 nystatin (topical) 73 ORTHO-CYCLEN 64 ONETOUCH ULTRA nystatin-triamcinolone 73 MINI 103 ORTHO-NOVUM 1/35 64 O-CAL FA 114 ONETOUCH VERIO 103 ORTHO-NOVUM 7/7/7 64 OB COMPLETE ONE 114 ONETOUCH VERIO FLEX oscimin 137 OB COMPLETE PETITE 114 BLOOD GLUCOSE oscimin sr 137 MONITORING SYSTEM 103 oseltamivir phosphate 57 OB COMPLETE PREMIER 114 ONETOUCH VERIO IQ OB COMPLETE/DHA 114 BLOOD GLUCOSE OSMOLEX ER 50 OBSTETRIX ONE 114 MONITORING SYSTEM 103 OSMOPREP 100 OCALIVA 92 OSPHENA 88

Index 17 OTEZLA 6 paregoric 32 PERFOROMIST 20 OTICIN HC NR 126 PAREMYD 125 PERIDEX 110 OTOVEL 126 paricalcitol 89 perindopril erbumine 38 OTREXUP 4 PARLODEL 50 permethrin 84 OVACE PLUS 75 PARNATE 27 perphenazine 52 OVACE PLUS WASH 75 paroex 110 perphenazine-amitriptyline 130 OVACE WASH 75 paromomycin sulfate 3 PERSERIS 51 OVIDE 84 paroxetine hcl 27 PERTZYE 85 OXACILLIN SODIUM 128 paroxetine mesylate PEXEVA 27 oxacillin sodium 128 (vasomotor) 135 pfizerpen 127 PASER 43 oxandrolone 12 phenadoz 36 PATADAY 125 oxaprozin 6 phenazo 95 PATANASE 120 OXAYDO 10 phenazopyridine hcl 95 PAXIL 27 oxazepam 17 phenelzine sulfate 27 PAXIL CR 27 oxcarbazepine 24 PHENERGAN 36 pediatric vitamins acd w/ OXERVATE 123 fluoride 111 phenobarbital 98 oxiconazole nitrate 73 peg 3350-kcl-nacl-na sulfate-na phenoxybenzamine hcl 39 OXISTAT 73 ascorbate-ascorbic acid 99 phenylephrine hcl peg 3350-kcl-sod bicarb-sod OXSORALEN ULTRA 74 (mydriatic) 122 chloride-sod sulfate 99 PHENYTEK 26 OXTELLAR XR 24 peg 3350-potassium chloride- phenytoin 26 oxybutynin chloride 142 sod bicarbonate-sod phenytoin infatabs 25 oxycodone hcl 10,11 chloride 100 peg- oxycodone w/ phenytoin sodium 26 3350/electrolytes/ascorbate phenytoin sodium extended 26 acetaminophen 11 99 oxycodone-aspirin 11 PEGANONE 26 PHLAG SPRAY 83 oxycodone-ibuprofen 11 PEGASYS 56 PHOSLYRA 93 OXYCODONE/ACETAMINOPHE PEGASYS PROCLICK 56 phosphasal 14 N 12 PHOSPHOLINE IODIDE 122 oxymorphone hcl 11 PEGINTRON 56 physiolyte 109 OXYTROL 142 PEMAZYRE 47 phytonadione 145 OXYTROL FOR WOMEN 142 penicillamine 107 PICATO 74 OZEMPIC 30 penicillin g potassium 127 PIFELTRO 54 pacerone 18 PENICILLIN G POTASSIUM IN ISO-OSMOTIC pilocarpine hcl 122 paliperidone 51 DEXTROSE 127 pilocarpine hcl (oral) 110 palonosetron hcl 32 PENICILLIN G pimecrolimus 81 PALONOSETRON PROCAINE 127 HYDROCHLORIDE 32 penicillin g sodium 127 pimozide 131 PALYNZIQ 89 penicillin v potassium 127 pindolol 58 PAMELOR 28 PENLEN 83 pioglitazone hcl 30 pamidronate disodium 87 PENNSAID 72 pioglitazone hcl-glimepiride 29 PAMIDRONATE DISODIUM 87 pentamidine isethionate 14 pioglitazone hcl-metformin hcl 29 PANCREAZE 85 PENTASA 93 piperacillin sodium-tazobactam PANDEL 79 pentazocine w/ naloxone 12 sodium 128 PANRETIN 74 pentoxifylline 95 PIQRAY 200MG DAILY pantoprazole sodium 141 DOSE 47 PEPCID 139 PIQRAY 250MG DAILY PARAGARD INTRAUTERINE PEPCID AC MAXIMUM DOSE 47 COPPER CONTRACEPTIVE STRENGTH 139 PIQRAY 300MG DAILY T380A 65 PERCOCET 12 DOSE 47

Index 18 piroxicam 6 potassium citrate-citric acid94 PRENATAL 115 PLAN B ONE-STEP 65 POVIDONE IODINE 123 prenatal 19 111 PLAQUENIL 42 PR NATAL 400 EC 114 PRENATAL 19 115 PLASMA-LYTE A 106 PR NATAL 430 114 PRENATAL LOW IRON 115 PLASMA-LYTE-148 106 PR NATAL 430 EC 114 PRENATAL ONE DAILY 115 PLAVIX 96 PRALUENT 38 PRENATAL PLUS 115 PLEGRIDY 130 pramipexole PRENATAL PLUS IRON 115 PLEGRIDY STARTER dihydrochloride 50 PRENATAL VITAMIN 115 PACK 130 PRAMOSONE 79 PRENATAL VITAMINS PLUS PLENVU 100 PRAMOSONE E 79 LOW IRON 115 PLEXION 71 PRAMOTIC 126 PRENATAL-U 115 PLEXION CLEANSER 71 PRAMOX GEL 82 PRENATE 115 PLEXION CLEANSING pramoxine-hc 79 PRENATE AM 115 CLOTHS 71 PRANDIN 31 PRENATE DHA 116 PNV OB+DHA 114 prasugrel hcl 96 PRENATE ELITE 116 PNV TABS 29-1 114 PRAVACHOL 37,38 PRENATE ESSENTIAL 116 pnv-dha 111 pravastatin sodium 38 PRENATE MINI 116 PNV-DHA+DOCUSATE 114 praziquantel 14 PRENATE PIXIE 116 PNV-OMEGA 114 prazosin hcl 39 PRENATRIX 116 pnv-select 111 PRECISION XTRA 84 PRENATRYL 116 PODOCON 25 IN BENZOIN TINCTURE 81 PRECISION XTRA BLOOD PREPLUS 116 GLUCOSE TEST STRIPS 84 podofilox 81 PREPOPIK 100 PRECOSE 28 POLY-VI-FLOR 111 PREVACID 141 PRED MILD 124 POLY-VI-FLOR/IRON 111 PREVACID SOLUTAB 141 PRED-G 124 polyethylene glycol 3350 100 prevalite 36 PRED-G S.O.P. 124 polymyxin b sulfate 16 PREVYMIS 55 prednicarbate 79 polymyxin b-trimethoprim 123 PREZCOBIX 54 prednisolone 66 PREZISTA 54 POLYTRIM 123 prednisolone acetate POMALYST 45 (ophth) 124 PRIFTIN 43 posaconazole 34 prednisolone sodium PRILOSEC 141 pot & sod citrates w/citric ac 94 phosphate 66 PRIMACARE 116 PREDNISOLONE SODIUM pot phosphate monobasic w/ sod PHOSPHATE 124 primaquine phosphate 42 phosphate dibasic & PRIMAQUINE PHOSPHATE 42 monobasic 106 prednisone 66 PRIMAXIN IV 15 POTABA 145 PREDNISONE INTENSOL 66 primidone 25 potassium aminobenzoate 145 PREFEST 90 PRIMLEV 12 potassium bicarb & chloride107 pregabalin 24,25 PRIMSOL 14 potassium bicarbonate 107 PREMARIN 91,144 PRINIVIL 38 potassium chloride 107 PREMESISRX 115 PRIVIGEN 127 POTASSIUM CHLORIDE 107 PREMIUM CONDOMS LUBRICATED 102 PROAIR HFA 20 potassium chloride 107 PREMPHASE 90 PROAIR RESPICLICK 20 potassium chloride in nacl 106 PREMPRO 90 potassium chloride probenecid 95 microencapsulated crystals PRENA 1 TRUE 115 procainamide hcl 18 er 107 PRENA1 PEARL 115 PROCARDIA 59 potassium chloride proamp 107 PRENAISSANCE 115 PROCARDIA XL 59 potassium citrate PRENAISSANCE PLUS 115 procentra 1 (alkalinizer) 94 prenatabs rx 111

Index 19 prochlorperazine 52 PULMICORT 19 ranolazine 16 prochlorperazine maleate 52 PULMICORT FLEXHALER19 RAPAFLO 95 PROCORT 13 pulmosal 68 RAPAMUNE 109 PROCRIT 97 PULMOZYME 135 rasagiline mesylate 50 procto-med hc 13 PURIXAN 44 RASUVO 4 PROCTOCORT 14 PYLERA 141 RAVICTI 89 PROCTOFOAM HC 13 pyrazinamide 43 RAYALDEE 89 PROCYSBI 94 PYRIDIUM 95 RAYOS 66 profeno 4 pyridostigmine bromide 42 RAZADYNE 129 progesterone 129 pyrimethamine 42 RAZADYNE ER 129 progesterone micronized 129 QBRELIS 38 REALITY LATEX PROGLYCEM 30 qc allergy relief childrens 36 CONDOMS/LUBRICATED 102 REALITY LATEX/ULTRA PROGRAF 109 QDOLO 11 TEXTURED 102 PROLASTIN-C 135 QINLOCK 47 REALITY LATEX/ULTRA PROLATE 12 QNASL 121 THIN 102 PROLENSA 125 QNASL CHILDRENS 121 REBETOL 56 PROLIA 87 QUALAQUIN 42 REBIF 130 PROMACTA 97 QUARTETTE 64 REBIF REBIDOSE 130 promethazine & REBIF REBIDOSE quazepam 98 TITRATIONPACK 130 phenylephrine 68 QUDEXY XR 25 promethazine hcl 36 REBIF TITRATION PACK 130 QUESTRAN 37 promethazine w/codeine 68 RECLAST 87 QUESTRAN LIGHT 37 promethazine-dm 68 RECOMBIVAX HB 143 quetiapine fumarate 52 promethazine-phenylephrine- RECTIV 14 codeine 68 QUFLORA GUMMIES 111 REGLAN 92 PROMETRIUM 129 QUFLORA PEDIATRIC 111 REGRANEX 84 propafenone hcl 18 QUILLIVANT XR 2 relafen 4 propantheline bromide 138 quinapril hcl 38 relagard 143 proparacaine hcl 123 quinapril-hydrochlorothiazide RELENZA DISKHALER 57 41 propranolol & RELEXXII 3 hydrochlorothiazide 41 quinidine gluconate 18 RELISTOR 93 propranolol hcl 58 quinidine sulfate 18 RELNATE DHA 116 propylthiouracil 136 quinine sulfate 42 RELPAX 105 PROSCAR 95 QUINJA 73 REMERON 26 PROTHELIAL 110 QVAR REDIHALER 19 REMERON SOLTAB 26 PROTONIX 141 R-NATAL OB 116 REMICADE 93 PROTOPIC 81 ra nicotine 132 REMODULIN 59 protriptyline hcl 28 rabeprazole sodium 141 RENAGEL 93 PROVENTIL HFA 20 RABEPRAZOLE SODIUM DR SPRINKLE 141 RENVELA 93 PROVERA 129 RADIOGARDASE 32 repaglinide 31 PROVIDA DHA 116 RAGWITEK 3 repaglinide-metformin hcl 29 PROVIDA OB 116 rajani 62 REPATHA 38 PROVIGIL 2 raloxifene hcl 88 REPATHA PUSHTRONEX PROZAC 27 ramelteon 99 SYSTEM 38 PRUDOXIN 74 ramipril 38 REPATHA SURECLICK 38 pseudoephed-cpm w/ REQUIP 50 hydrocod 68 RANEXA 16 REQUIP XL 50 PSORCON 79 ranitidine hcl 139

Index 20 RESCRIPTOR 54 rizatriptan benzoate 105 SANDOSTATIN LAR RESTASIS 123 ROBAXIN 119 DEPOT 89 SANTYL 81 RESTASIS MULTIDOSE 123 ROBAXIN-750 119 SAPHRIS 52 RESTORIL 98 ROCALTROL 89 sapropterin dihydrochloride 89 RETACRIT 97 ROMIDEPSIN 47 SARAFEM 131 RETEVMO 47 ropinirole hydrochloride 50 SAVELLA 130 RETIN-A 71 rosadan 83 SAVELLA TITRATION RETIN-A MICRO 71 rosuvastatin calcium 38 PACK 130 RETIN-A MICRO PUMP 71 ROTATEQ 143 scopolamine 33 RETROVIR 54 ROWASA 93 SE-NATAL 19 116 REVATIO 60 roweepra 23 SEASONIQUE 64 REVLIMID 108 roweepra xr 23 SECONAL SODIUM 98 REXULTI 52 ROXICET 12 SECUADO 52 REYATAZ 54 ROXICODONE 11 SELECT-OB 116 RHOFADE 83 ROXYBOND 11 SELECT-OB+DHA 116 RIAX 71 ROZEREM 99 selegiline hcl 50 ribasphere 55 ROZLYTREK 47 selenium sulfide 75 ribasphere ribapak 55 RUBRACA 47 SELZENTRY 54 RIBASPHERE RIBAPAK 56 RUCONEST 95 SEMPREX-D 68 ribavirin 57 rufinamide 25 SENSIPAR 89 ribavirin (hepatitis c) 56 RUZURGI 42 SEREVENT DISKUS 20 RIDAURA 4 ryclora 34 SEROQUEL 52 rifabutin 43 RYDAPT 47 SEROQUEL XR 52 RIFADIN 43 RYTARY 50 SEROSTIM 87 RIFAMATE 42 RYTHMOL SR 18 sertraline hcl 27 rifampin 43 SABRIL 25 sevelamer carbonate 93 RIFATER 42 SAFYRAL 64 sevelamer hcl 93 RIGHT STEP PRENATAL 116 SALAGEN 110 SFROWASA 93 RILUTEK 121 SALEX 81 SHUR-SEAL 143 riluzole 121 SALEX LOTION 81 SIGNIFOR 90 rimantadine hydrochloride 57 salicylic acid 81 SIKLOS 96 ringer's irrigation 109 salicylic acid in ammonium SILDENAFIL CITRATE 60 RINVOQ 4 lactate vehicle 81 sildenafil citrate (pulmonary salicylic acid w/ cleanser 81 RIOMET 29 hypertension) 60 salicylic acid wart remover 81 risedronate sodium 87 SILENOR 98 salimez 81 RISPERDAL 51 SILIQ 74 SALISOL 81 RISPERDAL CONSTA 51 silodosin 95 salisol forte 81 risperidone 51 SILVADENE 75 SALITECH 81 risperidone m-tab 51 silver sulfadiazine 75 salitech forte 81 RITALIN 3 SIMBRINZA 122 salsalate 9 RITALIN LA 3 SIMCOR 38 SALVAX 81 ritonavir 54 SIMPONI 4 SAMSCA 90 RITUXAN 44 SIMPONI ARIA 4 SANCUSO 32 RITUXAN HYCELA 46 SIMULECT 109 SANDIMMUNE 109 rivastigmine 129 simvastatin 38 SANDOSTATIN 89 rivastigmine tartrate 129 SINEMET 50

Index 21 SINEMET CR 50 spinosad 84 sulfacetamide sodium SINGULAIR 19 SPIRIVA HANDIHALER 18 (ophth) 123 sulfacetamide sodium w/ sirolimus 109 SPIRIVA RESPIMAT 18 sulfur 71 SIRTURO 43 spironolactone 86 sulfacleanse 8/4 69 SIVEXTRO 16 spironolactone & SULFADIAZINE 135 SKELAXIN 119 hydrochlorothiazide 85 sulfamethoxazole-trimethoprim SPORANOX 34 SKLICE 84 15 SPORANOX PULSEPAK 34 SKYLA 65 SULFAMYLON 75 SPRIX 6 SKYRIZI 74 sulfasalazine 93 SPRYCEL 48 SLYND 65 sulfatrim pediatric 15 ssd 75 sm nicotine 132 sulindac 6 sss 10-5 69 sm nicotine polacrilex 132 SUMADAN WASH 71 sm nicotine transdermal ST JOSEPH ADULT 9 sumatriptan 105 system 134 ST JOSEPH ADULT sumatriptan succinate 105 sodium chloride 107 ANALGESICLOW DOSE BITE sumatriptan-naproxen SIZE 9 sodium 104 sodium chloride (gu irrigant) 94 STALEVO 100 50 sodium chloride (inhalant) 68 SUMAXIN 71 STALEVO 125 50 SUMAXIN WASH 71 sodium citrate & citric acid 94 STALEVO 150 50 SODIUM EDECRIN 86 SUPRAX 61 STALEVO 200 50 SUPREP BOWEL PREP sodium fluoride 106 STALEVO 50 50 KIT 100 sodium phenylbutyrate 89 STALEVO 75 50 SURMONTIL 28 sodium polystyrene SUSTIVA 54 sulfonate 109 STARLIX 31 sodium sulfacetamide wash 75 stavudine 54 SUTENT 48 SODIUM SULFACETAMIDE STELARA 74 SUVICORT 83 WASH 75 STIMATE 89 SYLATRON 48 SODIUM STIOLTO RESPIMAT 20 SYMBICORT 21 SULFACETAMIDE/SULFUR 71 STIVARGA 48 SYMBYAX 130 SODIUM STRATTERA 2 SYMDEKO 135 SULFACETAMIDE/SULFUR STRENSIQ 89 SYMLINPEN 120 28 CLEANSER IN UREA 71 SYMLINPEN 60 28 SOFOSBUVIR/VELPATASVIR streptomycin sulfate 3 56 STRIANT 13 SYMPROIC 93 solifenacin succinate 142 STRIBILD 54 SYMTUZA 54 SOLIQUA 100/33 29 STRIVERDI RESPIMAT 20 SYNALAR 79 SOLODYN 136 STROMECTOL 14 SYNAREL 88 SOLTAMOX 45 SUBOXONE 12 SYNERA 82 SOMA 119 SUBSYS 11 SYNERDERM 83 SOMATULINE DEPOT 90 subvenite 23 SYNJARDY 29 SOMAVERT 87 subvenite starter kit/blue 23 SYNJARDY XR 29 SOOLANTRA 83 SUCRAID 85 SYNTHROID 137 SORIATANE 74 sucralfate 139 SYPRINE 107 SORILUX 74 SULAR 59 TABLOID 44 sorine 57 sulconazole nitrate 73 TABRECTA 48 sotalol hcl 58 sulfacetamide sod- TACLONEX 79 sotalol hcl (afib/afl) 58 prednisolone 124 tacrolimus 109 sulfacetamide sodium 75 SOTYLIZE 58 tacrolimus (topical) 81 sulfacetamide sodium SOVALDI 56 (acne) 71 tadalafil 59

Index 22 tadalafil (pulmonary TENORETIC 100 41 TIROSINT-SOL 137 hypertension) 60 TENORETIC 50 41 tis-u-sol 109 TAFINLAR 48 TENORMIN 57 TIVICAY 55 TAGAMET HB 139 TEPADINA 43 TIVORBEX 6 TAGRISSO 48 terazosin hcl 39 tizanidine hcl 119 TAKHZYRO 95 terbinafine hcl 34 TL FOLATE 117 TALTZ 74 terbutaline sulfate 21 TL-CARE DHA 117 TALZENNA 48 terconazole vaginal 143 TL-SELECT 117 TAMIFLU 57 TESSALON PERLES 67 TOBI 3 tamoxifen citrate 45 TESTIM 13 TOBI PODHALER 3 tamsulosin hcl 95 testosterone 13 TOBRADEX 124 TANZEUM 30 testosterone cypionate 13 TOBRADEX ST 124 TAPAZOLE 136 testosterone enanthate 13 tobramycin 3 TARCEVA 48 tetrabenazine 130 tobramycin (ophth) 123 TARGRETIN 48,74 tetracaine hcl (ophth) 123 tobramycin inhalation solution TARKA 41 tetracycline hcl 136 pak 3 TARON-BC 116 tobramycin sulfate 3 TEXACORT 79 TARON-C DHA 116 tobramycin- THALOMID 108 TARON-PREX 116 dexamethasone 124 THEO-24 21 TOBREX 123 TASIGNA 48 theophylline 21 TODAY SPONGE 143 TASMAR 49 THERANATAL CORE TOFRANIL 28 TAVALISSE 95 NUTRITION 117 TOLAK 74 TAYTULLA 64 THIOLA 95 tolazamide 31 tazarotene 74 THIOLA EC 95 tolbutamide 31 tazicef 61 thioridazine hcl 52 tolcapone 49 TAZORAC 74 thiotepa 43 tolmetin sodium 6 taztia xt 58 thiothixene 52 TOLSURA 34 TAZVERIK 48 THRIVITE 19 110 tolterodine tartrate 142 TECFIDERA 130 THRIVITE RX 117 tolvaptan 90 TECFIDERA STARTER THYMOGLOBULIN 109 TOPAMAX 25 PACK 130 thyroid 137 TEFLARO 61 TOPAMAX SPRINKLE 25 tiagabine hcl 25 TEGRETOL 25 TOPICORT 79 TIAZAC 59 TEGRETOL-XR 25 topiramate 25 TIBSOVO 48 TEGSEDI 135 toposar 49 TIGAN 33 TEKTURNA 41 topotecan hcl 49 tigecycline 135 TEKTURNA HCT 41 TOPOTECAN HCL 49 TIGECYCLINE 136 telmisartan 39 topotecan hcl 49 TIKOSYN 18 telmisartan-amlodipine 41 TOPROL XL 57 tilia fe 63 telmisartan-hydrochlorothiazide toremifene citrate 45 timolol maleate 58 41 TORISEL 48 temazepam 98 timolol maleate (ophth) 121 torsemide 86 TEMODAR 43 TIMOPTIC 121 TOUJEO MAX SOLOSTAR 31 TEMOVATE 79 TIMOPTIC OCUDOSE 121 TOUJEO SOLOSTAR 31 temozolomide 43 TIMOPTIC-XE 121 tovet 75 temsirolimus 48 tinidazole 14 TOVIAZ 142 tenofovir disoproxil fumarate 55 TIROSINT 137 TRACLEER 59

Index 23 tramadol hcl 11 trifluridine 123 TRUSTEX/RIA tramadol-acetaminophen 12 TRIGLIDE 37 LUBRICATED/SPERMICIDE 103 trandolapril 38 trihexyphenidyl hcl 49 TRUSTEX/RIA NON- trandolapril-verapamil hcl 41 TRIKAFTA 135 LUBRICATED 103 tranexamic acid 98 TRILEPTAL 25 TRUVADA 55 TRANXENE T 17 TRILIPIX 37 TUKYSA 48 tranylcypromine sulfate 27 trimethobenzamide hcl 33 TURALIO 48 TRAVATAN Z 125 trimethoprim 14 TUSSICAPS 68 travoprost 125 trimipramine maleate 28 TUSSIONEX PENNKINETIC EXTENDED RELEASE 68 trazodone hcl 27 TRINTELLIX 27 TUSSLIN 68 TRECATOR 43 TRISTART DHA 117 TUSSLIN PEDIATRIC 68 TRELEGY ELLIPTA 21 TRISTART ONE 117 TWIRLA 64 TRELSTAR MIXJECT 45 TRIUMEQ 55 TWYNSTA 41 TREMFYA 74 TRIZIVIR 55 TYBLUME 64 treprostinil 59 TROKENDI XR 25 TYBOST 55 TRESIBA 31 tropicamide 122 TYGACIL 136 TRESIBA FLEXTOUCH 31 trospium chloride 142 TYKERB 48 tretinoin 71 TRULANCE 92 TYLENOL/CODEINE #3 12 tretinoin (chemotherapy) 48 TRULICITY 30 TYLENOL/CODEINE #4 12 tretinoin microsphere 71 TRUSOPT 125 TYMLOS 87 TREXALL 44 TRUSTEX COLOR CONDOMS TYSABRI 131 TREXIMET 104 + LUBE 102 TRUSTEX LUBRICATED 102 UCERIS 13,66 tri femynor 63 TRUSTEX LUBRICATED UDAMIN SP 110 TRI-NORINYL 28 64 EXTRALARGE 102 ULESFIA 84 TRI-TABS DHA 117 TRUSTEX LUBRICATED ULORIC 95 TRI-VI-FLOR 111 EXTRASTRENGTH 102 TRUSTEX ULTIMATECARE ONE 117 TRI-VI-FLORO 111 LUBRICATED/RIBBED/STUDD ULTRACET 12 tri-vite/fluoride 111 ED 102 ULTRAM 11 triamcinolone acetonide TRUSTEX (mouth) 110 LUBRICATED/SPERMICIDE ULTRASAL-ER 81 triamcinolone acetonide 102 ULTRAVATE 80 (topical) 79 TRUSTEX umecta mousse 80 LUBRICATED/SPERMICIDE triamterene 86 UNASYN 128 triamterene & EXTRA LARGE 102 hydrochlorothiazide 85 TRUSTEX UNASYN BULK PACK 128 trianex 76 LUBRICATED/SPERMICIDE UNISOM SLEEPGELS 98 EXTRA STRENGTH 102 UPTRAVI 60 triazolam 98 TRUSTEX NATURAL TRIBENZOR 41 CONDOMS URAMAXIN 80 TRICARE 117 +LUBE/LUBRICATED 103 URE-K 80 TRICARE PRENATAL DHA TRUSTEX NON- urea 80 ONE 117 LUBRICATED 103 TRUSTEX WITH urea hydrating 80 TRICARE PRENATAL DHA urea nail 80 ONE/FOLATE 117 NONOXYNOL- TRICOR 37 9/RIBBED/STUDDED 103 URECHOLINE 142 TRUSTEX/RIA uribel 15 triderm 76 LUBRICATED 103 TRIDESILON 80 TRUSTEX/RIA LUBRICATED uroav-81 141 trientine hcl 108 SPERMICIDE 103 uroav-b 141 trifluoperazine hcl 52 UROCIT-K 10 94 UROCIT-K 15 94

Index 24 UROCIT-K 5 94 VERDESO 80 VITAMEDMD ONE UROXATRAL 95 VEREGEN 71 RX/QUATREFOLIC 118 VITAMIN D2 145 URSO 250 92 VERELAN 59 VITAMIN D3 145 URSO FORTE 92 VERELAN PM 59 VITAMIN D3 IMMUNE ursodiol 92 VERIPRED 20 66 HEALTH 145 UTOPIC 80 VERSACLOZ 52 VITAPEARL 118 valacyclovir hcl 56 VERZENIO 48 VITATHELY/GINGER 118 VALCHLOR 74 VESICARE 142 VITATRUE 118 VALCYTE 55 VFEND 34 VITRAKVI 48 valganciclovir hcl 55 VIBERZI 93 VIVA DHA 118 VALIUM 17 VIBRAMYCIN 136 VIVELLE-DOT 91 valproic acid 26 VICTOZA 30 VIVOTIF 142 valsartan 39 VIDAZA 44 VIVOTIF BERNA 142 valsartan-hydrochlorothiazide VIDEX EC 55 VIZIMPRO 48 41 VIDEXPEDIATRIC 55 VOL-PLUS 118 VALTOCO 23 VIEKIRA PAK 56 VOL-TAB RX 118 VALTREX 56 vigabatrin 25 voriconazole 34 vanadom 118 vigadrone 25 VOSEVI 56 vanatol lq 7 VIIBRYD 27 VOTRIENT 48 VANCOCIN 15 VIIBRYD STARTER PACK 27 VP-HEME OB + DHA 118 VANCOCIN HCL 15 VIL-RX 117 VP-PNV-DHA 118 vancomycin hcl 15 VIMOVO 6 VPRIV 96 vandazole 143 VIMPAT 25 VRAYLAR 51 VANOS 80 VINATE DHA RF 117 VTOL LQ 7 VARUBI 33 VINATE II 117 VUSION 73 VASCEPA 36 VIOKACE 85 VYNDAMAX 60 VASERETIC 41 VIRACEPT 55 VYNDAQEL 60 VASOTEC 38 VIRAMUNE 55 VCF VAGINAL VYTONE 73 CONTRACEPTIVE FILM 143 VIRAMUNE XR 55 VYTORIN 36 VCF VAGINAL VIRASAL 81 VYVANSE 1 CONTRACEPTIVE FOAM 143 VIRAZOLE 57 warfarin sodium 21 vcf vaginal contraceptivegel143 VIREAD 55 water for irrigation, sterile 109 VECAMYL 41 VIROPTIC 123 wee care 97 VECTICAL 75 VIRT-C DHA 117 WELCHOL 37 VELCADE 48 VIRT-NATE DHA 117 WELLBUTRIN SR 26 VELPHORO 93 VIRT-PN 117 WELLBUTRIN XL 26 VELTASSA 109 VIRT-PN DHA 117 WESTAB PLUS 118 VELTIN 71 VIRT-PN PLUS 117 WESTGEL DHA 118 VEMLIDY 56 virtussin ac/alc 67 WESTHROID 137 VENA-BAL DHA 117 VISTARIL 17 wixela inhub 19 VENCLEXTA 44 VISTOGARD 32 WP THYROID 137 VENCLEXTA STARTING PACK 44 VITAFOL FE+ 118 XALATAN 125 venlafaxine hcl 28 VITAFOL GUMMIES 118 XALKORI 48 VENTAVIS 59 VITAFOL ULTRA 118 XANAX 17 VENTOLIN HFA 21 VITAFOL-NANO 118 XANAX XR 17 verapamil hcl 59 VITAFOL-ONE 118 XARELTO 21

Index 25 XARELTO STARTER PACK 21 ZANTAC 150 MAXIMUM ZOLPIMIST 99 XATMEP 44 STRENGTH 139 ZOMACTON 88 ZARONTIN 26 XELJANZ 4 ZOMETA 87 ZARXIO 97 XELJANZ XR 4 ZOMIG 105 ZATEAN-PN DHA 118 XELODA 44 ZOMIG ZMT 105 ZATEAN-PN PLUS 118 XENAZINE 130 ZONEGRAN 25 ZAVESCA 96 XERAC AC 83 zonisamide 25 ZEGERID 141 XERESE 75 ZONTIVITY 96 ZEJULA 48 XERMELO 94 ZORTRESS 109 ZELAPAR 50 XGEVA 87 ZORVOLEX 6 ZELBORAF 48 XIAFLEX 108 ZOSYN 128 ZEMAIRA 135 XIFAXAN 14 ZOVIRAX 56,75 ZEMBRACE XIGDUO XR 29 SYMTOUCH 105 ZUBSOLV 12 XIIDRA 123 ZEMPLAR 89 ZUPLENZ 33 XOLAIR 18 ZENPEP 85 ZURAMPIC 95 XOLEGEL 73 zenzedi 1 ZYBAN 135 XOPENEX 21 ZEPATIER 56 ZYCLARA 81 XOPENEX CONCENTRATE 21 ZERIT 55 ZYCLARA PUMP 81 XOPENEX HFA 21 ZESTORETIC 41 ZYDELIG 48 XOSPATA 48 ZESTRIL 38 ZYFLO 19 XPOVIO 100 MG ONCE ZETIA 38 ZYKADIA 48 WEEKLY 45 ZYLET 124 XPOVIO 40 MG ONCE ZETONNA 121 WEEKLY 46 ZIAC 41 ZYLOPRIM 95 XPOVIO 40 MG TWICE ZIAGEN 55 ZYMAXID 123 WEEKLY 46 ZIANA 71 ZYPREXA 52 XPOVIO 60 MG ONCE WEEKLY 46 zidovudine 55 ZYPREXA ZYDIS 52 XPOVIO 60 MG TWICE ZIEXTENZO 97 ZYRTEC CHILDRENS ALLERGY 36 WEEKLY 46 zileuton 19 XPOVIO 80 MG ONCE ZYTIGA 45 zinc sulfate 107 WEEKLY 46 ZYVOX 16 XPOVIO 80 MG TWICE ZIOPTAN 126 WEEKLY 46 ziprasidone hcl 51 XTANDI 45 ziprasidone mesylate 51 xulane 64 ZIPSOR 6 XULTOPHY 100/3.6 29 ZIRGAN 123 XURIDEN 89 ZITHROMAX 100 XYREM 129 ZITHROMAX TRI-PAK 100 XYZAL ALLERGY 24HR 36 ZITHROMAX Z-PAK 100 YASMIN 28 64 ZOCOR 38 YAZ 64 ZOFRAN 33 YERVOY 44 zoledronic acid 87 YONSA 45 ZOLEDRONIC ACID 87 yuvafem 144 zoledronic acid 87 zafirlukast 19 ZOLINZA 48 zaleplon 99 zolmitriptan 105 ZANAFLEX 119 ZOLOFT 27 ZANOSAR 43 zolpidem tartrate 99

Index 26