Prescription Drug List/Formulary

Home , Amcinonide, Autoinjector, Bakuchiol, Betamethasone valerate, Ciprofloxacin, Clobetasol

2021

Effective January 1, 2021

Please read: For a complete list of covered drugs This document contains or if you have questions: information about the drugs • Call a customer care representative covered under your pharmacy toll-free at (855) 828-9834 (TTY 711). benefit plan. • Visit www.HealthSelectRx.com — Locate an OptumRx in-network pharmacy — Look up possible lower-cost medication alternatives — Compare medication pricing and options

HealthSelect of Texas

1 Your Prescription Drug List / Formulary This formulary outlines the most commonly prescribed medications covered under your plan’s prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to www.HealthSelectRx.com for complete and up-to-date drug information Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com and click on Prescription Drug List. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

2 Understanding your Prescription Drug List/formulary

What is a formulary? This document is a list of prescription Where differences exist between this medications covered by your plan for their formulary and your benefit plan documents, safety, cost and effectiveness. Medications the benefit plan documents will rule. This are listed by categories or class and may not be a complete list of medications, are placed into cost levels known as and not all medications listed may be tiers. It includes both brand and generic covered under your plan. Please look at prescription medications approved by the the Master Benefit Plan Document (MBPD) U.S. Food and Drug Administration (FDA). provided by your plan for full details.

How do I use my formulary? You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed on this document, it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program. Please visit www.HealthSelectRx.com and click on Prescription Drug List for the most up to date list of medications covered under your plan. If you have any questions, call a customer care representative toll-free at (855) 828-9834 (TTY 711).

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your plan. This is how much you will pay when you fill a prescription. The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

3 When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call a customer care representative, 24 hours a day, 7 days a week toll-free at (855) 828-9834 (TTY 711).

Why are some medications excluded from coverage? A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711).

4 Medication Tips

What is the difference between brand-name and generic medications? An OTC medication may be the right treatment option for some conditions. Talk Generic medications contain the same to your doctor about available OTC options. active ingredients (what makes the Even though these medications may not be medication work) as brand-name medications, covered under your pharmacy benefit, they but they often cost less. Once the patent of may cost less than prescription medications a brand-name medication ends, the FDA covered under your prescription drug plan. can approve a generic version with the same active ingredients.

What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always.

What if I am taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary. Optum Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services. Call Optum Specialty Pharmacy at (855) 427-4682 and have your prescriptions delivered right to your home or doctor’s office.

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

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your prescription drug plan has multiple tiers. Please note: If you have a high deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips Tier 1 Lower-cost, commonly used Use Tier 1 drugs for the lowest Lowest Cost generic drugs. Some low- out-of-pocket costs. cost brands may be included. Tier 2 Many common brand-name Use Tier 2 drugs, instead of Tier 3, to Mid-range Cost drugs, called preferred brands. help reduce your out-of-pocket costs. Tier 3 Mostly higher-cost brand Many Tier 3 drugs have lower-cost Highest Cost drugs, also known as non- options in Tier 1 or 2. Ask your doctor preferred brands. if they could work for you.

Tier E Excluded May be excluded from coverage or subject to prior authorization. Lower- cost options are available and covered.

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

PA Prior Authorization – Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan.

ST Step Therapy – Requires you to first try a cost-effective medication before the more expensive medication will be covered.

QL Quantity Limit – Limits the amount of a medication that will be covered under your prescription drug plan.

SP Specialty Medication – Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused, are high cost, have special delivery and storage requirements, or require close monitoring or care coordination with your doctor.

E Excluded – Drugs that are not covered by your health plan. Lower-cost options are available and covered. 6 Table of Contents Analgesics - Drugs for Pain...... 9 Analgesics - Drugs for Pain and Inflammation...... 14 Anesthetics...... 17 Anti-Addiction / Substance Abuse Treatment Agents...... 20 Antibacterials...... 20 Anticoagulants...... 25 Anticonvulsants - Drugs for Seizures...... 26 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia...... 28 Antidepressants...... 29 Antiemetics - Drugs for Nausea and Vomiting...... 30 Antifungals...... 31 Antigout Agents...... 34 Anti-inflammatory Agents...... 34 Antimigraine Agents...... 34 Antimyasthenic Agents...... 35 Antimycobacterials...... 35 Antineoplastics - Drugs for Cancer...... 35 Antiparasitics...... 41 Antiparkinson Agents...... 42 Antiplatelets...... 43 Antipsychotics - Drugs for Mood Disorders...... 43 Antivirals...... 44 Anxiolytics - Drugs for Anxiety...... 47 Bipolar Agents - Drugs for Mood Disorders...... 48 Blood Products and Modifiers - Drugs for Blood Disorders...... 48 Cardiovascular Agents - Drugs for Heart and Circulation Conditions...... 50 Central Nervous System Agents - Drugs for Attention Deficit Disorder...... 56 Central Nervous System Agents - Drugs for Multiple Sclerosis...... 57 Central Nervous System Agents - Miscellaneous...... 58 Dental and Oral Agents - Drugs for Mouth and Throat Conditions...... 59 Dermatological Agents - Drugs for Skin Conditions...... 60 Diabetes - Antidiabetic Agents...... 72 Diabetes - Glucose Monitoring...... 73 Diabetes - Glycemic Agents...... 75 Diabetes - Insulins...... 75 Electrolytes / Minerals / Metals / Vitamins...... 77 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...... 86 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...... 87 Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment...... 92 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions...... 93 Genitourinary Agents - Drugs for Prostate Conditions...... 95 Hormonal Agents - Adrenal...... 95 Hormonal Agents - Men's Health...... 97 Hormonal Agents - Osteoporosis...... 98 Hormonal Agents - Pituitary...... 98 Hormonal Agents - Prostaglandins...... 100 Hormonal Agents - Sex Hormones and Birth Control...... 100 Hormonal Agents - Thyroid...... 105 Immunological Agents - Drugs for Immune System Stimulation or Suppression...... 105 Immunological Agents - Drugs for Vaccination...... 109 Inflammatory Bowel Disease Agents...... 111

7 Metabolic Bone Disease Agents - Drugs for Osteoporosis...... 112 Metabolic Bone Disease Agents - Other...... 112 Miscellaneous Therapeutic Agents...... 113 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...... 121 Ophthalmic Agents - Drugs for Glaucoma...... 123 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions...... 124 Otic Agents - Drugs for Ear Conditions...... 127 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold...... 127 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...... 131 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis...... 134 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension...... 134 Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...... 135 Sleep Disorder Agents...... 135

8 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Analgesics - Drugs apap-caff- for Pain dihydrocodeine oral 1 QL 8 hour pain reliever E capsule 8 hr arthritis pain relief E apap-caff- dihydrocodeine oral 1 QL acetaminophen 8 hour tablet 325-30-16 mg oral tablet extended E release ARYMO ER E acetaminophen ascomp-codeine 1 E childrens oral solution aurophen childrens E acetaminophen BELBUCA 2 PA; QL childrens oral E BENZHYDROCODON E suspension 160 mg/5ml E-ACETAMINOPHEN acetaminophen BUPAP ORAL TABLET 3 childrens oral tablet E 50-300 MG chewable 160 mg BUPRENEX E acetaminophen er E buprenorphine hcl acetaminophen extra E injection solution 0.3 E strength oral tablet mg/ml acetaminophen oral buprenorphine solution 160 mg/5ml, 1 PA; QL E transdermal 325 mg/10.15ml, 650 mg/20.3ml butalbital- acetaminophen capsule 1 acetaminophen oral E 50-300 mg oral suspension 160 mg/5ml BUTALBITAL- acetaminophen oral ACETAMINOPHEN E E tablet CAPSULE 50-300 MG acetaminophen oral ORAL E tablet chewable 160 mg butalbital- acetaminophen rectal acetaminophen oral 1 suppository 120 mg, E tablet 650 mg butalbital-apap-caff-cod 1 acetaminophen- butalbital-apap-caffeine 1 QL 1 codeine oral capsule acetaminophen- 1 QL butalbital-apap-caffeine codeine #2 oral tablet 50-325-40 1 acetaminophen- mg 1 QL codeine #3 butalbital-asa-caff- 1 acetaminophen- codeine 1 QL codeine #4 butalbital-aspirin- 1 ACTIQ 3 PA; QL caffeine ALLZITAL E butorphanol tartrate E APADAZ E injection

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 9 Drug Name Drug Tier Notes Drug Name Drug Tier Notes butorphanol tartrate FENTANYL CITRATE 1 QL nasal INTRAVENOUS BUTRANS 3 PA; QL SOLUTION E PREFILLED SYRINGE carisoprodol-aspirin- 1 100 MCG/2ML codeine FENTANYL CITRATE- E childrens NACL INJECTION acetaminophen oral E suspension 160 mg/5ml FENTANYL CITRATE- NACL INTRAVENOUS childrens SOLUTION 1.25-0.9 E acetaminophen oral E MG/250ML-%, 2-0.9 tablet dispersible MG/100ML-% childrens apap E FENTANYL CITRATE- childrens non-aspirin NACL SOLUTION 1- E E oral tablet chewable 0.9 MG/100ML-% codeine sulfate oral INTRAVENOUS 1 QL tablet 30 mg, 60 mg FENTANYL CITRATE- NACL SOLUTION 2.5- CONZIP E E 0.9 MG/250ML-% cvs acetaminophen ex E INTRAVENOUS st oral tablet FENTANYL CITRATE- DEMEROL INJECTION E NACL SOLUTION SOLUTION 50 MG/ML PREFILLED SYRINGE E DILAUDID ORAL E 500-0.9 MCG/50ML-% DOLOPHINE 3 PA INTRAVENOUS DSUVIA E FENTANYL- BUPIVACAINE-NACL DURAGESIC-100 E EPIDURAL SOLUTION E DURAGESIC-12 E 0.2-0.1-0.9 MG/100ML- DURAGESIC-25 E %, 0.2-0.125-0.9 MG/100ML-% DURAGESIC-50 E FENTANYL- DURAGESIC-75 E BUPIVACAINE-NACL E duramorph E INJECTION endocet oral tablet 10- FENTANYL- 325 mg, 2.5-325 mg, 5- 1 QL BUPIVACAINE-NACL 325 mg, 7.5-325 mg SOLUTION 0.5-0.0625- E ESGIC 3 0.9 MG/250ML-% EPIDURAL fentanyl 1 PA; QL FENTANYL- fentanyl citrate (pf) E BUPIVACAINE-NACL fentanyl citrate buccal SOLUTION 0.5-0.1-0.9 E 1 PA; QL lozenge on a handle MG/250ML-% FENTANYL CITRATE EPIDURAL E BUCCAL TABLET

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 10 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FENTANYL- hydromorphone hcl oral 1 QL BUPIVACAINE-NACL hydromorphone hcl E SOLUTION 0.5-0.125- E rectal 0.9 MG/250ML-% EPIDURAL HYDROMORPHONE HCL-NACL FENTORA BUCCAL INTRAVENOUS TABLET 100 MCG, 200 E E SOLUTION 25-0.9 MCG, 400 MCG, 600 MG/50ML-%, 50-0.9 MCG, 800 MCG MG/50ML-% FIORICET ORAL 3 HYDROMORPHONE CAPSULE HCL-NACL FIORICET/CODEINE INTRAVENOUS E ORAL CAPSULE 50- 3 SOLUTION 300-40-30 MG PREFILLED SYRINGE FIORINAL 3 10-0.9 MG/50ML-% FIORINAL/CODEINE HYSINGLA ER 2 PA; QL 3 #3 INFUMORPH 200 E goodsense pain relief INFUMORPH 500 E E oral tablet KADIAN ORAL headache relief oral E CAPSULE EXTENDED hydrocodone bitartrate RELEASE 24 HOUR er oral capsule 10 MG, 100 MG, 20 E 1 PA; ST; QL extended release 12 MG, 200 MG, 30 MG, hour 40 MG, 50 MG, 60 MG, 80 MG hydrocodone- acetaminophen oral LAZANDA E solution 10-325 1 QL levorphanol tartrate oral E mg/15ml, 7.5-325 liquid acetaminophen E mg/15ml LORTAB ORAL ELIXIR 3 QL hydrocodone- 10-300 MG/15ML acetaminophen oral tablet 10-300 mg, 10- MEDI-DERM-RX E 1 QL 325 mg, 5-300 mg, 5- MEDROX-RX 3 325 mg, 7.5-300 mg, meperidine hcl injection E 7.5-325 mg solution 50 mg/ml hydrocodone-ibuprofen meperidine hcl oral 1 QL oral tablet 10-200 mg, 1 QL solution 5-200 mg, 7.5-200 mg meperidine hcl oral 1 QL hydromorphone hcl er tablet 50 mg oral tablet extended 1 PA; QL release 24 hour methadone hcl injection E hydromorphone hcl methadone hcl intensol 1 injection solution 2 E methadone hcl oral 1 mg/ml concentrate

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 11 Drug Name Drug Tier Notes Drug Name Drug Tier Notes methadone hcl oral morphine sulfate oral 1 QL 1 solution morphine sulfate rectal E methadone hcl oral 1 PA MORPHINE SULFATE tablet SOLUTION 1 MG/ML E methadone hcl oral INTRAVENOUS 1 tablet soluble morphine sulfate methadose oral solution 1 mg/ml E 1 concentrate 10 mg/ml intravenous methadose oral tablet MORPHINE SULFATE- 1 soluble NACL INTRAVENOUS methadose sugar-free 1 SOLUTION E PREFILLED SYRINGE migraine relief E 50-0.9 MG/50ML-% mitigo E m-pap E morphine sulfate MS CONTIN ORAL (concentrate) oral 1 QL TABLET EXTENDED E solution 100 mg/5ml, RELEASE 20 mg/ml nalbuphine hcl injection morphine sulfate (pf) 1 E solution 20 mg/ml injection NALOCET E morphine sulfate (pf) intravenous solution 10 NORCO E E mg/ml, 2 mg/ml, 4 NUCYNTA E mg/ml, 8 mg/ml NUCYNTA ER E morphine sulfate er OXAYDO ORAL 1 PA; QL E beads TABLET morphine sulfate er oral OXYCODONE HCL ER capsule extended 1 PA; QL ORAL TABLET ER 12 E release 24 hour HOUR ABUSE- morphine sulfate er oral DETERRENT 1 PA; QL tablet extended release oxycodone hcl oral 1 QL MORPHINE SULFATE capsule INJECTION E oxycodone hcl oral SOLUTION 1 MG/ML concentrate 100 1 QL morphine sulfate mg/5ml injection solution 2 oxycodone hcl oral E 1 QL mg/ml, 4 mg/ml, 5 solution mg/ml oxycodone hcl oral 1 QL MORPHINE SULFATE tablet INTRAVENOUS E SOLUTION 0.5 MG/ML OXYCODONE- ACETAMINOPHEN morphine sulfate ORAL TABLET 10-300 E intravenous solution 50 E MG, 2.5-300 MG, 5-300 mg/ml MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 12 Drug Name Drug Tier Notes Drug Name Drug Tier Notes oxycodone- PROLATE E acetaminophen oral QDOLO E tablet 10-325 mg, 2.5- 1 QL 325 mg, 5-325 mg, 7.5- ra acetaminophen rapid 325 mg melts oral tablet E dispersible 160 mg oxycodone-aspirin oral 1 QL ROXICODONE ORAL tablet 4.8355-325 mg E TABLET OXYCONTIN ORAL TABLET ER 12 HOUR 2 PA; QL SUBSYS E ABUSE-DETERRENT SYNAPRYN FUSEPAQ E oxymorphone hcl 1 QL tencon oral tablet 50- 1 oxymorphone hcl er 1 PA; QL 325 mg pain & fever childrens tramadol hcl er E oral suspension (biphasic) oral tablet extended release 24 1 ST; QL pain & fever infants E hour 100 mg, 200 mg, pain relief childrens oral 300 mg E elixir TRAMADOL HCL ER pain relief extra ORAL CAPSULE strength oral capsule E EXTENDED RELEASE E 500 mg 24 HOUR 100 MG, 200 pain relief extra MG, 300 MG strength oral tablet 500 E tramadol hcl er oral mg capsule extended 1 PA; QL pain relief oral liquid E release 24 hour 150 mg pain relief regular tramadol hcl er oral E strength tablet extended release 1 QL 24 hour PANADOL E CHILDRENS tramadol hcl ir 1 QL tramadol- PANADOL EXTRA E 1 QL acetaminophen PANADOL EXTRA E STRENGTH TREZIX ORAL CAPSULE 320.5-30-16 3 QL PANADOL INFANTS E MG pentazocine-naloxone 1 QL TYLENOL 8 HOUR E hcl TYLENOL EXTRA PERCOCET ORAL STRENGTH ORAL E TABLET 10-325 MG, E TABLET 2.5-325 MG, 5-325 MG, TYLENOL INFANTS 7.5-325 MG E PAIN+FEVER PRIALT 2 SP TYLENOL ORAL E PRIMLEV E TABLET PROBUPHINE E ULTRACET E IMPLANT KIT ULTRAM E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 13 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VANATOL LQ E aspirin ec oral tablet VTOL LQ E delayed release 325 $0 mg XTAMPZA ER 2 PA; QL aspirin low dose oral $0 ZEBUTAL ORAL tablet chewable CAPSULE 50-325-40 3 aspirin low dose oral MG $0 tablet delayed release ZOHYDRO ER ORAL aspirin oral tablet 325 CAPSULE EXTENDED E $0 RELEASE 12 HOUR mg Analgesics - Drugs aspirin oral tablet for Pain and delayed release 325 $0 Inflammation mg, 81 mg ACTIVE- aspirin rectal E KETOPROFEN suppository 300 mg, E 600 mg ACTIVE-PREP KIT I E BAYER ASPIRIN EC $0 ACTIVE-PREP KIT II E LOW DOSE ACTIVE-PREP KIT III E BAYER ASPIRIN $0 adult aspirin regimen $0 ORAL TABLET ADVIL E BAYER ASPIRIN ADVIL JUNIOR ORAL TABLET $0 E STRENGTH DELAYED RELEASE ADVIL LIQUI-GELS BIIFENAC 1000 E E MINIS BIIFENAC 500 E ADVIL MIGRAINE E CALDOLOR aif #2 drug preparation INTRAVENOUS E kit SOLUTION 800 E MG/200ML, 800 AIF #3 DRUG E MG/8ML PREPARATION KIT CAMBIA E ALEVE ORAL TABLET E CAPSFENAC PAK E ARTHROTEC ORAL TABLET DELAYED E CAPSINAC E RELEASE CELEBREX E aspirin adult $0 celecoxib oral 1 QL aspirin adult low DAYPRO 3 strength oral tablet $0 DERMACINRX delayed release ANALGESIC E aspirin childrens $0 COMBOPAK aspirin ec low dose $0 DERMACINRX aspirin ec low strength $0 LEXITRAL E PHARMAPAK

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 14 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DFS EC-NAPROSYN ORAL DR/MS/MENTH/CAP E TABLET DELAYED 3 PAK RELEASE 375 MG DFS/MS/MENTH/CAP ec-naproxen 1 E PAK ENOVARX- DICLOFENAC E DICLOFENAC E DICLOFENAC SODIUM EXTERNAL EPOLAMINE 3 QL enovarx-ibuprofen E EXTERNAL enovarx-naproxen E diclofenac potassium 1 external diclofenac sodium er 1 EQUAPAX/IBUPROFE E diclofenac sodium N/MINREX 1 QL external gel 1 % etodolac er 1 diclofenac sodium etodolac oral 1 1 PA external solution FBL KIT E diclofenac sodium oral 1 FELDENE 3 diclofenac-misoprostol fenoprofen calcium oral E oral tablet delayed 1 fenortho oral capsule release E 200 mg diclofex dc combination therapy pack 1.5-0.025 E FLEXIPAK E % flurbiprofen oral 1 DICLOFONO GEL 1.6 FROTEK E 3 % EXTERNAL GABAPENTIN- DICLOFONO GEL 1.6 NAPROXEN CMPD E E % EXTERNAL KIT DICLOPR E gnp aspirin low dose $0 diclosaicin E goodsense aspirin low $0 DICLOSTREAM E dose goodsense ibuprofen DICLOTREX E E oral capsule DICLOVIX E IBUPAK E DICLOVIX M E ibuprofen 1 DICLOZOR E EXTERNAL ibuprofen infants E diflunisal oral 1 ibuprofen oral capsule E ibuprofen oral DIMENTHO E 1 suspension DUAL COMPLEX E ibuprofen oral tablet FORMULA 1 KIT E 200 mg DUEXIS E inavix E INDOCIN ORAL 3 ST

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 15 Drug Name Drug Tier Notes Drug Name Drug Tier Notes INDOCIN RECTAL E mefenamic acid oral E indomethacin er 1 meloxicam oral tablet 1 INDOMETHACIN MOBIC ORAL TABLET E ORAL CAPSULE 20 E MOTRIN IB ORAL E MG CAPSULE indomethacin oral MOTRIN INFANTS 1 ST E capsule 25 mg, 50 mg DROPS INFLAMMACIN E nabumetone oral 1 INFLATHERM NALFON ORAL 3 COMBINATION E CAPSULE 400 MG THERAPY PACK NALFON ORAL K.B.G.L IN 3 E TABLET TERODERM NAPRELAN ORAL KETOPHENE TABLET EXTENDED E 3 RAPIDPAQ RELEASE 24 HOUR ketoprofen er 1 375 MG, 500 MG ketoprofen oral 1 NAPRELAN ORAL TABLET EXTENDED KETOROLAC E TROMETHAMINE E RELEASE 24 HOUR EXTERNAL 750 MG NAPROSYN ORAL ketorolac tromethamine 3 injection solution 15 1 SUSPENSION mg/ml naproxen dr 1 ketorolac tromethamine naproxen oral E intramuscular solution 1 suspension 60 mg/2ml naproxen oral tablet 1 KETOROLAC naproxen sodium er E TROMETHAMINE 3 PA; QL naproxen sodium oral NASAL E tablet 220 mg ketorolac tromethamine 1 QL naproxen sodium oral oral 1 tablet 275 mg, 550 mg ketorolac tromethamine naproxen- solution 30 mg/ml 1 1 PA; QL injection esomeprazole NP #2 DRUG KETOROLAC E TROMETHAMINE PREPARATION KIT 3 SOLUTION 30 MG/ML NUDICLO SOLUPAK E INJECTION NUDICLO TABPAK E LICART EXTERNAL E NUDROXIPAK E LODINE 3 NUDROXIPAK DSDR- E meclofenamate sodium 50 1 oral

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 16 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NUDROXIPAK DSDR- TORONOVA SUIK E E 75 tri-buffered aspirin oral E NUDROXIPAK E-400 E tablet 325 mg NUDROXIPAK I-800 E TRIPLE COMPLEX E NUDROXIPAK M-15 E FORMULA 3 KIT NUDROXIPAK N-500 E VAROPHEN E ORMECA E VENNGEL ONE E oxaprozin 1 VIMOVO E PENNSAID VIVLODEX E E EXTERNAL VOLTAREN E piroxicam oral 1 EXTERNAL PRASTERA E VP FC KIT E PREVIDOLRX VP GKL KIT E E ANALGESIC XRYLIX EXTERNAL E previdolrx plus ZIPSOR E E analgesic ZORVOLEX E qc aspirin low dose oral $0 Anesthetics tablet delayed release 1ST MEDX-PATCH/ QMIIZ ODT E LIDOCAINE E READYSHARP EXTERNAL PATCH 4- E KETOROLAC 0.0375-5-20 % RELAFEN E 7T LIDO E RELAFEN DS E ACCUCAINE E REXAPHENAC ACTIVE INJECTION E E EXTERNAL LM-2 salsalate oral E AGONEAZE E SPRIX 3 PA; QL ANODYNE LPT E ST JOSEPH LOW APRIZIO PAK E DOSE ORAL TABLET $0 APRIZIO PAK II E DELAYED RELEASE ASTERO E sulindac oral 1 BENZO-LIDOCAINE- sure result dss E E TETRACAINE premium pack blue tube/ aloe E TIVORBEX ORAL E bupivacaine CAPSULE 20 MG E fisiopharma tolmetin sodium oral 1 capsule bupivacaine hcl (pf) E tolmetin sodium oral BUPIVACAINE HCL 1 tablet 600 mg INJECTION E SOLUTION 0.125 % TORONOVA II SUIK E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 17 Drug Name Drug Tier Notes Drug Name Drug Tier Notes bupivacaine hcl LDO PLUS E injection solution 0.25 E lets E %, 0.5 % LEVATIO E BUPIVACAINE HCL INJECTION LIDO BDK E SOLUTION E lidocaine external E PREFILLED SYRINGE cream 4 % 0.125 % (50 ML) lidocaine external patch 1 CADIRAMD E 5 % CAPSAICIN- lidocaine hcl (pf) E 1 MENTHOL injection solution CBD4 FREEZE PUMP lidocaine hcl external 3 E MAXIMUM STR cream 3 % CETACAINE LIDOCAINE HCL E EXTERNAL AEROSOL EXTERNAL CREAM E COCAINE HCL NASAL E 4.12 % lidocaine hcl external DERMACINRX E DUOPATCH E lotion PHARMAPAK lidocaine hcl external 1 DERMACINRX solution E EMPRICAINE lidocaine hcl injection 1 DERMACINRX solution 0.5 % NEUROTRAL E LIDOCAINE HCL PHARMAPAK INJECTION SOLUTION DERMACINRX PHN E E PREFILLED SYRINGE DERMACINRX E 10 MG/ML, 100 PRIZOPAK MG/5ML, 60 MG/3ML DERMACINRX ZRM E LIDOCAINE HCL E EHA E INTRADERMAL EMPRICAINE-II E LIDOCAINE HCL enovarx-lidocaine hcl E SOLUTION 1 % 3 INJECTION ethyl chloride 1 lidocaine hcl solution 1 1 EXPAREL E % injection FLEXIN E LIDOCAINE HCL GEBAUERS PAIN SOLUTION 2 % 3 3 EASE INJECTION GEBAUERS SPRAY lidocaine hcl solution 2 3 1 AND STRETCH % injection GEN7T E lidocaine hcl 1 GEN7T PLUS E urethral/mucosal lidocaine ointment 5 % GOPRELTO E 1 QL external

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 18 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lidocaine ointment 5 % MARCAINE E E external MARCAINE lidocaine-prilocaine PRESERVATIVE E 1 external cream FREE lidocaine-prilocaine marlido E E external kit MARLIDO-25 E LIDOCAINE- E MARVONA SUIK E TETRACAINE MEDI-DERM/L-RX E LIDOCANNA E MEDI-PATCH RX E LIDODERM E NUMBRINO E LIDO-EPINEPHRINE- TETRACAINE NUVAKAAN E 3 SOLUTION 4-0.05-0.5 NUVAKAAN-II E % EXTERNAL PAINGO KFT E LIDO-EPINEPHRINE- PLIAGLIS E TETRACAINE E POINT OF CARE LM- SOLUTION 4-0.05-0.5 E % EXTERNAL 2.2 POINT OF CARE LM- LIDOMARK 2/5 E E 2.5 LIDOPAC E premium lidocaine E lidopin external cream E 3 % PREMIUM SCAR E LIDOPIN EXTERNAL PREPIV SUPPLY 3 E CREAM 3.25 % PRILO PATCH E LIDOPRIL EXTERNAL PRILO PATCH II 3 E KIT PRILOLID E LIDOPRIL XR E PRILOVIX E LIDO-PRILO CAINE E PRILOVIX LITE E PACK PRILOVIX LITE PLUS E LIDOPURE PATCH E PRILOVIX PLUS E LIDORX E prilovix ultralite E LIDO-SORB E prilovix ultralite plus E LIDOSTREAM E PRILOVIXIL E LIDOTHOL E PRIZOPAK II E LIDOTRAL E PRIZOTRAL E LIDOVIX L E PRIZOTRAL-II E LIDTOPIC MAX E READYSHARP-A E LIVIXIL PAK E RELADOR PAK E LMR PLUS E EXTERNAL KIT LYDEXA E RELADOR PAK PLUS E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 19 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RENOVO E CHANTIX $0 QL sensorcaine E CHANTIX sensorcaine-mpf E CONTINUING MONTH $0 QL PAK SOOTHEE EXTERNAL CHANTIX STARTING PATCH 0.5-0.0375-5-2 E $0 QL % MONTH PAK SX1 MEDICATED disulfiram oral 1 E POST-OPERATIVE LUCEMYRA 3 ST; QL SYNERA E naloxone hcl injection SYNVEXIA TC E solution 0.4 mg/ml, 4 E mg/10ml VENIPUNCTURE PX1 3 naloxone hcl injection PHLEBOTOMY E solution cartridge VEXATROL E naloxone hcl injection WPR PLUS WOUND E solution prefilled E HEALING SYSTEM syringe XARACOLL E naltrexone hcl oral 1 XYLOCAINE NALTREXONE 3 E INJECTION SUBCUTANEOUS XYLOCAINE-MPF NARCAN 2 INJECTION 3 SOLUTION 0.5 %, 1 %, NICORETTE 1.5 %, 2 % MOUTH/THROAT $0 QL GUM 2 MG ZERUVIA E nicotine polacrilex $0 QL ZILACAINE PATCH E mouth/throat ZINGO nicotine step 1 $0 QL INTRADERMAL JET- E INJECTOR nicotine step 2 $0 QL ZIONODIL E nicotine step 3 $0 QL ZIONODIL 100 E NICOTROL $0 QL ZTLIDO E NICOTROL NS $0 QL Anti-Addiction / SUBLOCADE 3 SP Substance Abuse SUBOXONE 2 QL Treatment Agents SUBLINGUAL FILM acamprosate calcium 1 VIVITROL 3 SP BUNAVAIL 3 QL ZUBSOLV 2 QL buprenorphine hcl Antibacterials 1 QL sublingual ACTICLATE E buprenorphine hcl- 1 QL AEMCOLO 3 PA naloxone hcl ALTABAX 3 bupropion hcl er $0 QL (smoking det)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 20 Drug Name Drug Tier Notes Drug Name Drug Tier Notes amikacin sulfate BACTRIM 3 injection solution 500 E BACTRIM DS 3 mg/2ml BAXDELA E amoxicillin oral capsule 1 INTRAVENOUS amoxicillin oral BAXDELA ORAL 3 suspension 1 reconstituted BENZALKONIUM CHLORIDE 3 amoxicillin oral tablet 1 EXTERNAL amoxicillin oral tablet SOLUTION chewable 125 mg, 250 1 benzalkonium chloride 1 mg external solution 50 % amoxicillin-potassium 1 BENZODOX E clavulanate er BICILLIN L-A E amoxicillin-potassium 1 clavulanate oral cefaclor 1 ampicillin oral capsule cefaclor er 1 1 500 mg cefadroxil 1 ampicillin-sulbactam cefazolin sodium sodium injection injection solution E E solution reconstituted 3 reconstituted 1 gm, 10 (2-1) gm gm ARIKAYCE 3 SP cefazolin sodium- dextrose intravenous AUGMENTIN ES-600 3 E solution 2-4 gm/100ml- AUGMENTIN ORAL % SUSPENSION RECONSTITUTED 3 cefdinir 1 125-31.25 MG/5ML, cefepime hcl injection 250-62.5 MG/5ML solution reconstituted 2 E AUGMENTIN ORAL gm 3 TABLET 500-125 MG cefixime 1 avidoxy 1 ST CEFOTAN E AVIDOXY DK E cefotaxime sodium azithromycin oral injection solution 1 E packet reconstituted 1 gm, 2 gm, 500 mg azithromycin oral suspension 1 cefotetan disodium injection solution reconstituted E reconstituted 1 gm, 2 azithromycin oral tablet gm 250 mg, 500 mg, 600 1 cefoxitin sodium mg E injection bacitracin external E cefpodoxime proxetil 1 bacitracin zinc external E cefprozil 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 21 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ceftazidime injection dicloxacillin sodium 1 solution reconstituted 1 E DIFICID 3 gm, 2 gm, 6 gm DORYX MPC E ceftriaxone sodium injection solution DORYX ORAL 1 TABLET DELAYED reconstituted 1 gm, 2 3 ST gm, 250 mg, 500 mg RELEASE 200 MG, 50 MG cefuroxime axetil oral 1 tablet DORYX ORAL TABLET DELAYED E CENTANY 3 RELEASE 80 MG CENTANY AT E doxy 100 E cephalexin 1 doxycycline hyclate E chloramphenicol sod intravenous E succinate doxycycline hyclate oral 1 CIPRO ORAL capsule SUSPENSION 3 doxycycline hyclate oral 1 RECONSTITUTED tablet 100 mg, 50 mg CIPRO ORAL TABLET doxycycline hyclate oral 3 1 ST 250 MG, 500 MG tablet 150 mg, 75 mg ciprofloxacin hcl oral 1 doxycycline hyclate oral E clarithromycin er 1 tablet 20 mg clarithromycin oral 1 doxycycline hyclate oral CLEOCIN ORAL 3 tablet delayed release 1 100 mg, 75 mg CLEOCIN VAGINAL 3 CREAM doxycycline hyclate oral tablet delayed release 1 ST CLEOCIN VAGINAL 2 150 mg, 200 mg, 50 mg SUPPOSITORY DOXYCYCLINE clindamycin hcl oral 1 HYCLATE ORAL E clindamycin palmitate TABLET DELAYED 1 hcl RELEASE 80 MG clindamycin phosphate doxycycline 1 vaginal monohydrate oral 1 ST CLINDESSE 3 capsule 100 mg, 150 mg, 75 mg colistimethate sodium E (cba) doxycycline monohydrate oral 1 COLY-MYCIN M E capsule 50 mg coremino E doxycycline CUBICIN E monohydrate oral 1 CUBICIN RF E suspension reconstituted daptomycin E demeclocycline hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 22 Drug Name Drug Tier Notes Drug Name Drug Tier Notes doxycycline levofloxacin oral 1 1 ST monohydrate oral tablet LINCOCIN E E.E.S. GRANULES 3 lincomycin hcl injection E ertapenem sodium E linezolid in sodium E ERYPED 200 3 chloride ERYPED 400 3 linezolid intravenous E ERY-TAB 3 solution 600 mg/300ml ERYTHROCIN linezolid oral 1 QL STEARATE ORAL 3 MACROBID 3 TABLET 250 MG MACRODANTIN 3 erythromycin base oral 1 mafenide acetate 1 erythromycin external 1 ethylsuccinate oral meropenem erythromycin oral 1 intravenous solution E FETROJA E reconstituted 500 mg FIRST- MEROPENEM- METRONIDAZOLE SODIUM CHLORIDE ORAL SUSPENSION E INTRAVENOUS RECONSTITUTED 50 SOLUTION E MG/ML RECONSTITUTED 1 GM/50ML, 500 FIRVANQ 3 MG/50ML FLAGYL ORAL 3 MERREM CAPSULE INTRAVENOUS FLAGYL ORAL SOLUTION E 3 TABLET 500 MG RECONSTITUTED 500 FORTAZ INJECTION MG SOLUTION methenamine hippurate 1 E RECONSTITUTED 1 methenamine E GM mandelate oral fosfomycin METRONIDAZOLE 1 E tromethamine BENZO+SYRSPEND gentamicin sulfate 1 metronidazole oral 1 external metronidazole vaginal 1 HIPREX 3 MINOCYCLINE HCL imipenem-cilastatin ER ORAL CAPSULE 3 intravenous solution E EXTENDED RELEASE reconstituted 250 mg 24 HOUR INVANZ INJECTION E minocycline hcl er oral iodine tincture external tablet extended release E 1 tincture 2 % 24 hour KEFLEX 3 minocycline hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 23 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MINOLIRA E penicillin g potassium mondoxyne nl oral injection solution 1 ST E capsule 100 mg, 75 mg reconstituted 5000000 unit MONUROL 3 penicillin g procaine E MORGIDOX COMBINATION KIT 1 E penicillin g sodium E X 100 MG, 2 X 100 MG penicillin v potassium 1 morgidox oral capsule PFIZERPEN 1 100 mg INJECTION moxifloxacin hcl in nacl E SOLUTION E RECONSTITUTED moxifloxacin hcl oral 1 5000000 UNIT mupirocin calcium E piperacillin sod- mupirocin external 1 tazobactam so nafcillin sodium intravenous solution E injection solution E reconstituted 4.5 (4- reconstituted 1 gm 0.5) gm polymyxin b sulfate nafcillin sodium E intravenous solution E injection reconstituted 10 gm POLYSPORIN EXTERNAL neomycin sulfate oral 1 E OINTMENT 500-10000 neomycin-polymyxin b E UNIT/GM gu PRIMSOL 3 nitrofurantoin 1 macrocrystal oral RECARBRIO E SCRUB CARE nitrofurantoin E monohydrate 1 POVIDONE-IODINE macrocrystals SEYSARA 3 ST nitrofurantoin oral SILVADENE 3 1 suspension silver nitrate external E NUTRIDOX E solution NUVESSA E silver sulfadiazine 1 NUZYRA ORAL external 3 TABLET 150 MG SIVEXTRO E ofloxacin oral tablet 300 SOLODYN ORAL 1 mg, 400 mg TABLET EXTENDED oxacillin sodium RELEASE 24 HOUR 3 injection solution E 105 MG, 115 MG, 55 reconstituted 1 gm MG, 65 MG, 80 MG oxacillin sodium SOLOSEC 3 E intravenous ssd 1 paromomycin sulfate streptomycin sulfate 1 E oral intramuscular

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 24 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sulfadiazine oral 1 vancomycin hcl in nacl sulfamethoxazole- intravenous solution 1- E trimethoprim oral 0.9 gm/200ml-% 1 suspension 200-40 vancomycin hcl mg/5ml intravenous solution sulfamethoxazole- 1000 mg/200ml, 1250 1 trimethoprim oral tablet mg/250ml, 1500 mg/300ml, 1750 E SULFAMYLON E mg/350ml, 2000 EXTERNAL CREAM mg/400ml, 500 SULFAMYLON mg/100ml, 750 3 EXTERNAL PACKET mg/150ml sulfatrim pediatric 1 vancomycin hcl oral 1 SUPRAX ORAL VANCOMYCIN+SYRS 3 E CAPSULE PEND SF SUPRAX ORAL vandazole 1 SUSPENSION 3 VIBRAMYCIN 3 ST RECONSTITUTED XENLETA SUPRAX ORAL E 3 INTRAVENOUS TABLET CHEWABLE XENLETA ORAL 3 TARGADOX E XEPI 3 tazicef injection E XIFAXAN 3 PA tazicef intravenous solution reconstituted 1 E XIMINO 3 gm ZEMDRI E TEFLARO ZITHROMAX ORAL 3 INTRAVENOUS PACKET SOLUTION E ZITHROMAX ORAL RECONSTITUTED 600 SUSPENSION 3 MG RECONSTITUTED tetracycline hcl oral 1 ZITHROMAX ORAL tigecycline E TABLET 250 MG, 500 3 tinidazole oral 1 MG trimethoprim oral 1 ZITHROMAX TRI-PAK 3 TYGACIL E ZITHROMAX Z-PAK 3 UNASYN INJECTION ZYVOX SOLUTION INTRAVENOUS E RECONSTITUTED 3 SOLUTION 200 E (2-1) GM MG/100ML, 600 MG/300ML VANCOCIN 3 ZYVOX ORAL 3 QL VANCOCIN HCL ORAL 3 CAPSULE 125 MG Anticoagulants ACD-A NOCLOT-50 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 25 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ACTIVASE E heparin sodium anticoagulant cit dext (porcine) pf injection E 1 soln a solution 5000 unit/ml ANTICOAGULANT jantoven 1 3 SODIUM CITRATE LOVENOX 3 SP; QL ARIXTRA 3 SP; QL PRADAXA 2 QL CATHFLO ACTIVASE E REGIOCIT E ELIQUIS 2 QL SAVAYSA 3 QL ELIQUIS DVT/PE THROMBATE III 3 SP STARTER PACK 2 QL TRICITRASOL 3 ORAL TABLET THERAPY PACK warfarin sodium oral 1 enoxaparin sodium 1 SP; QL XARELTO 2 QL XARELTO STARTER fondaparinux sodium 1 SP; QL 2 QL PACK FRAGMIN SUBCUTANEOUS Anticonvulsants - SOLUTION 10000 Drugs for Seizures UNIT/ML, 12500 APTIOM 3 UNIT/0.5ML, 15000 BANZEL 3 PA UNIT/0.6ML, 18000 3 SP; QL BRIVIACT UNT/0.72ML, 2500 E UNIT/0.2ML, 5000 INTRAVENOUS UNIT/0.2ML, 7500 BRIVIACT ORAL 3 ST UNIT/0.3ML, 95000 carbamazepine er 1 UNIT/3.8ML carbamazepine oral 1 heparin (porcine) in nacl intravenous CARBATROL 3 solution 1000-0.9 E CELONTIN 3 ut/500ml-%, 2000-0.9 CEREBYX INJECTION unit/l-% SOLUTION 500 MG E heparin sodium PE/10ML (porcine) injection clobazam 1 PA solution 1000 unit/ml, 1 10000 unit/ml, 20000 DEPAKOTE 3 unit/ml, 5000 unit/ml DEPAKOTE ER 3 heparin sodium DEPAKOTE (porcine) injection SPRINKLES ORAL E 3 solution prefilled CAPSULE DELAYED syringe RELEASE SPRINKLE heparin sodium DIACOMIT 3 PA; SP (porcine) pf injection 1 DIASTAT ACUDIAL 3 QL solution 5000 unit/0.5ml DIASTAT PEDIATRIC 3 QL diazepam rectal 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 26 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DILANTIN INFATABS E LAMICTAL ODT ORAL E DILANTIN ORAL KIT 25 & 50 & 100 MG E CAPSULE 100 MG LAMICTAL ODT ORAL DILANTIN ORAL TABLET 3 3 CAPSULE 30 MG DISPERSIBLE DILANTIN ORAL LAMICTAL ORAL E 3 SUSPENSION TABLET divalproex sodium er LAMICTAL ORAL oral tablet extended 1 TABLET CHEWABLE 3 release 24 hour 25 MG, 5 MG divalproex sodium oral LAMICTAL STARTER 3 capsule delayed 1 LAMICTAL XR 3 release sprinkle lamotrigine er 1 divalproex sodium oral lamotrigine oral kit 25 & 1 1 tablet delayed release 50 & 100 mg EPIDIOLEX 3 PA; SP lamotrigine oral tablet 1 epitol 1 lamotrigine oral tablet 1 ethosuximide oral 1 chewable FANATREX FUSEPAQ E lamotrigine oral tablet 1 felbamate 1 dispersible lamotrigine starter kit- FELBATOL 3 1 blue FINTEPLA 3 PA; SP lamotrigine starter kit- 1 fosphenytoin sodium green injection solution 500 E lamotrigine starter kit- mg pe/10ml 1 orange FYCOMPA 3 levetiracetam er 1 gabapentin oral 1 levetiracetam capsule E intravenous gabapentin oral 1 solution 250 mg/5ml levetiracetam oral 1 gabapentin oral tablet 1 MYSOLINE 3 GABITRIL 3 NAYZILAM 3 QL KEPPRA NEURONTIN 3 E INTRAVENOUS ONFI ORAL 3 PA KEPPRA ORAL 3 SUSPENSION ONFI ORAL TABLET KEPPRA XR 3 3 PA 10 MG, 20 MG LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X oxcarbazepine 1 2 50 MG, 42 X 50 MG & OXTELLAR XR E 14X100 MG phenobarbital oral elixir 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 27 Drug Name Drug Tier Notes Drug Name Drug Tier Notes phenobarbital oral valproic acid oral 1 1 tablet capsule PHENYTEK 3 valproic acid oral 1 phenytoin infatabs 1 solution phenytoin oral VALTOCO 10 MG 1 3 QL suspension 125 mg/5ml DOSE phenytoin oral tablet VALTOCO 15 MG 1 3 QL chewable DOSE phenytoin sodium VALTOCO 20 MG 1 3 QL extended DOSE VALTOCO 5 MG primidone oral 1 3 QL DOSE QUDEXY XR 3 vigabatrin 1 PA; SP roweepra oral tablet 1 500 mg vigadrone 1 PA; SP VIMPAT rufinamide 1 PA E INTRAVENOUS SABRIL ORAL E SP PACKET VIMPAT ORAL 3 SABRIL ORAL XCOPRI 3 ST 3 PA; SP TABLET XCOPRI (250 MG 3 ST SPRITAM E DAILY DOSE) XCOPRI (350 MG subvenite 1 3 ST DAILY DOSE) subvenite starter kit- 1 blue ZARONTIN 3 subvenite starter kit- ZONEGRAN 3 1 green zonisamide oral 1 subvenite starter kit- Antidementia Agents 1 orange - Drugs for SYMPAZAN 3 PA Alzheimer's Disease and Dementia TEGRETOL ORAL 3 SUSPENSION ARICEPT 3 TEGRETOL ORAL donepezil hcl 1 3 TABLET EXELON 3 TEGRETOL-XR 3 TRANSDERMAL galantamine tiagabine hcl 1 1 hydrobromide TOPAMAX 3 galantamine 1 TOPAMAX SPRINKLE 3 hydrobromide er topiramate er 1 memantine hcl er 1 QL topiramate oral 1 memantine hcl oral 1 TRILEPTAL 3 solution 2 mg/ml TROKENDI XR 3 ST

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 28 Drug Name Drug Tier Notes Drug Name Drug Tier Notes memantine hcl oral desvenlafaxine 1 1 QL tablet succinate er NAMENDA ORAL doxepin hcl oral 3 1 TABLET capsule NAMENDA TITRATION doxepin hcl oral 3 1 PAK concentrate NAMENDA XR 3 QL DRIZALMA SPRINKLE 3 ST; QL NAMENDA XR duloxetine hcl oral 1 QL 3 QL TITRATION PACK EFFEXOR XR E NAMZARIC 2 QL EMSAM 3 QL RAZADYNE ER 3 escitalopram oxalate 1 rivastigmine 1 FETZIMA 3 ST; QL rivastigmine tartrate 1 FETZIMA TITRATION 3 ST; QL Antidepressants FLUOXETINE HCL amitriptyline hcl oral 1 (PMDD) ORAL 3 amoxapine 1 TABLET fluoxetine hcl oral ANAFRANIL 3 1 capsule APLENZIN 3 ST; QL fluoxetine hcl oral BRISDELLE 3 ST; QL capsule delayed 1 QL bupropion hcl er (sr) 1 QL release bupropion hcl er (xl) fluoxetine hcl oral 1 oral tablet extended solution 1 QL release 24 hour 150 fluoxetine hcl oral tablet 1 mg, 300 mg fluvoxamine maleate 1 BUPROPION HCL ER (XL) ORAL TABLET fluvoxamine maleate er 1 QL E EXTENDED RELEASE FORFIVO XL E 24 HOUR 450 MG imipramine hcl oral 1 bupropion hcl oral 1 imipramine pamoate 1 CELEXA ORAL LEXAPRO ORAL 3 E TABLET TABLET chlordiazepoxide- 1 maprotiline hcl 1 amitriptyline MARPLAN 3 citalopram 1 hydrobromide mirtazapine oral 1 clomipramine hcl oral 1 NARDIL 3 CYMBALTA E nefazodone hcl 1 desipramine hcl oral 1 NORPRAMIN ORAL TABLET 10 MG, 25 3 DESVENLAFAXINE 3 ST; QL MG ER nortriptyline hcl oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 29 Drug Name Drug Tier Notes Drug Name Drug Tier Notes olanzapine-fluoxetine venlafaxine hcl er 1 1 QL hcl VIIBRYD ORAL 3 QL PAMELOR ORAL TABLET 3 CAPSULE VIIBRYD STARTER 3 QL PARNATE 3 PACK paroxetine hcl er 1 WELLBUTRIN SR E paroxetine hcl oral WELLBUTRIN XL E 1 tablet ZOLOFT E paroxetine mesylate 1 QL ZULRESSO 3 PA; SP PAXIL CR 3 Antiemetics - Drugs PAXIL ORAL for Nausea and 2 ST SUSPENSION Vomiting PAXIL ORAL TABLET 3 AKYNZEO E perphenazine- INTRAVENOUS 1 amitriptyline AKYNZEO ORAL 3 QL PEXEVA E ALOXI INTRAVENOUS phenelzine sulfate oral 1 SOLUTION 0.25 E MG/5ML PRISTIQ E ANZEMET ORAL 3 QL protriptyline hcl 1 aprepitant 1 QL PROZAC ORAL E CAPSULE BONJESTA 3 PA; QL REMERON ORAL compro 1 TABLET 15 MG, 30 3 cvs motion sickness E MG DICLEGIS 3 PA; QL REMERON SOLTAB 3 doxylamine-pyridoxine 1 PA; QL sertraline hcl oral 1 dronabinol 1 PA; QL SPRAVATO (56 MG 3 PA; SP EMEND DOSE) INTRAVENOUS SPRAVATO (84 MG SOLUTION E 3 PA; SP DOSE) RECONSTITUTED 150 SYMBYAX ORAL MG CAPSULE 12-50 MG, EMEND ORAL 3 QL 3 QL 3-25 MG, 6-25 MG, 6- CAPSULE 80 MG 50 MG EMEND ORAL tranylcypromine sulfate 1 SUSPENSION 3 trazodone hcl oral 1 RECONSTITUTED trimipramine maleate EMEND TRI-PACK 3 QL 1 oral fosaprepitant E TRINTELLIX 3 ST; QL dimeglumine venlafaxine hcl 1 GIMOTI E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 30 Drug Name Drug Tier Notes Drug Name Drug Tier Notes goodsense motion scopolamine 1 E sickness SYNDROS 3 PA; QL granisetron hcl TIGAN E intravenous solution 1 E INTRAMUSCULAR mg/ml, 4 mg/4ml TIGAN ORAL 3 granisetron hcl oral 1 QL TRANSDERM SCOP 3 MARINOL 3 PA; QL (1.5 MG) meclizine hcl oral tablet TRANSDERM-SCOP 1 3 12.5 mg, 25 mg (1.5 MG) meclizine hcl oral tablet travel sickness oral E E 50 mg tablet chewable meclizine hcl tablet trimethobenzamide hcl 1 chewable 25 mg oral E oral (otc) VARUBI (180 MG 3 QL meclizine hcl tablet DOSE) chewable 25 mg oral 1 ZOFRAN ORAL (rx) 3 TABLET 4 MG metoclopramide hcl oral solution 10 1 ZUPLENZ E mg/10ml, 5 mg/5ml Antifungals metoclopramide hcl ACTIVE-PREP KIT V E 1 oral tablet ala-quin E metoclopramide hcl 1 ALCORTIN A E oral tablet dispersible ALOE VESTA CLEAR E motion sickness relief E ANTIFUNGAL ondansetron hcl amphotericin b E injection solution 4 E intravenous mg/2ml, 40 mg/20ml ANCOBON 3 ondansetron hcl oral 1 QL athletes foot solution E (terbinafine) ondansetron hcl oral 1 QL BIO-STATIN ORAL tablet 24 mg 3 CAPSULE ondansetron hcl oral 1 tablet 4 mg, 8 mg bio-statin oral powder E ondansetron odt 1 CANCIDAS INTRAVENOUS palonosetron hcl E SOLUTION E perphenazine oral 1 RECONSTITUTED 70 prochlorperazine 1 MG prochlorperazine caspofungin acetate 1 maleate oral intravenous solution E reconstituted 70 mg REGLAN ORAL 3 SANCUSO 3 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 31 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ciclodan external ERTACZO E 1 solution EXELDERM E ciclopirox external 1 exoderm external lotion 1 ciclopirox olamine 1 EXTINA 3 external fluconazole oral 1 ciclopirox treatment E FLUCON-IBUPROF- clotrimazole external E 1 ITRACON-TERBINA cream flucytosine oral 1 clotrimazole external 1 solution FUNGIMEZ E clotrimazole griseofulvin microsize 1 1 mouth/throat troche oral clotrimazole vaginal griseofulvin E 1 cream 1 % ultramicrosize clotrimazole- GYNAZOLE-1 3 1 betamethasone hydrocortisone- CRESEMBA ORAL 3 iodoquinol external E cream 1-1 % cvs clotrimazole 3 E IMIOXIA E DERMACINRX E THERAZOLE PAK IODOQUIMEZ-HC E iodoquinol-hc-aloe dermazene E E polysacch DESENEX EXTERNAL E IODOQUINOL-HC- POWDER E KETOCONAZOLE DIFLUCAN ORAL iodoquinol- SUSPENSION 3 E RECONSTITUTED hydrocortisone-aloe DIFLUCAN ORAL itraconazole oral 1 PA TABLET 100 MG, 200 3 JUBLIA E MG, 50 MG KERYDIN 3 PA DIFMETIOXRIME E ketoconazole external 1 ECONASIL E cream econazole nitrate ketoconazole external 1 E external foam ECONAZOLE ketoconazole external 1 NITRATE- E shampoo 2 % NIACINAMIDE ketoconazole oral 1 ECOZA E KETOCONAZOLE- E ERAXIS HYDROCORTISONE INTRAVENOUS ketodan external foam E SOLUTION E KETODAN EXTERNAL RECONSTITUTED 100 E MG KIT

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 32 Drug Name Drug Tier Notes Drug Name Drug Tier Notes LOPROX EXTERNAL nystatin-triamcinolone 1 3 CREAM nystop 1 LOPROX EXTERNAL E ONYCHO-MED E KIT ORAVIG E LOPROX EXTERNAL 3 SHAMPOO oxiconazole nitrate E LOPROX EXTERNAL OXISTAT EXTERNAL 3 3 SUSPENSION CREAM LOTRIMIN AF OXISTAT EXTERNAL E E EXTERNAL POWDER LOTION LULICONAZOLE E PEDIZOLPAK E LUZU E PHEODOYO E MENTAX E PHEYO E podactin external micaderm E E cream micafungin sodium intravenous solution E posaconazole 1 reconstituted 100 mg QUINJA E miconazole 1 E RECURA E miconazole 3 vaginal SPORANOX 3 PA 1 suppository SPORANOX 3 PA miconazole 7 vaginal PULSEPAK E suppository SULCONAZOLE E miconazole nitrate NITRATE E external cream tavaborole 1 PA MICONAZOLE-ZINC E terbinafine hcl oral 1 QL OXIDE-PETROLAT terconazole 1 MYCAMINE INTRAVENOUS tolnaftate antifungal E SOLUTION E tolnaftate external E RECONSTITUTED 100 powder MG TOLSURA E naftifine hcl 1 VFEND 3 NAFTIN EXTERNAL 3 voriconazole oral 1 CREAM 2 % VUSION E NAFTIN EXTERNAL 3 GEL VYTONE E NOXAFIL ORAL 3 XOLEGEL E nyamyc 1 XOLEGEL COREPAK E XOLEGEL DUO/HEAD nystatin external 1 E & SHOULDERS nystatin mouth/throat 1 XOLEGEL E nystatin oral tablet 1 DUO/XOLEX

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 33 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ZEASORB-AF frovatriptan succinate 1 QL E EXTERNAL POWDER IMITREX 3 QL ZOLPAK E IMITREX STATDOSE Antigout Agents REFILL allopurinol oral 1 SUBCUTANEOUS 3 QL SOLUTION COLCHICINE ORAL E CARTRIDGE CAPSULE IMITREX STATDOSE colchicine oral tablet 1 SYSTEM colchicine-probenecid 1 SUBCUTANEOUS 3 QL COLCRYS E SOLUTION AUTO- INJECTOR febuxostat 1 ST MAXALT ORAL 3 QL GLOPERBA E TABLET 10 MG KRYSTEXXA 3 PA; SP MAXALT-MLT ORAL MITIGARE E TABLET 3 QL probenecid oral 1 DISPERSIBLE 10 MG ULORIC 3 ST MIGERGOT 3 ZYLOPRIM 3 MIGRAINE PACK E Anti-inflammatory MIGRANAL 3 PA; QL Agents MIGRANOW E EMFLAZA 3 PA; SP naratriptan hcl 1 QL Antimigraine Agents NURTEC 2 PA; QL AIMOVIG 2 PA; QL ONZETRA XSAIL 3 ST; QL AJOVY E RELPAX 3 QL almotriptan malate 1 QL REYVOW E AMERGE 3 QL rizatriptan benzoate 1 QL CAFERGOT 3 sumatriptan nasal 1 QL D.H.E. 45 3 PA; QL sumatriptan succinate 1 QL dihydroergotamine oral 1 PA; QL mesylate injection sumatriptan succinate dihydroergotamine refill subcutaneous 1 QL 1 PA; QL mesylate nasal solution cartridge eletriptan hydrobromide 1 QL sumatriptan succinate subcutaneous solution 1 QL EMGALITY 2 PA; QL 6 mg/0.5ml EMGALITY (300 MG 2 PA; QL sumatriptan succinate DOSE) subcutaneous solution 1 QL ERGOMAR 3 auto-injector 4 ergotamine-caffeine 1 mg/0.5ml, 6 mg/0.5ml FROVA 3 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 34 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sumatriptan succinate cycloserine oral 1 subcutaneous solution 1 QL dapsone oral 1 prefilled syringe 6 mg/0.5ml ethambutol hcl oral 1 sumatriptan-naproxen isoniazid oral 1 1 QL sodium MYAMBUTOL ORAL 3 TOSYMRA E TABLET 400 MG TREXIMET ORAL MYCOBUTIN 3 3 ST; QL TABLET 85-500 MG PASER 3 UBRELVY 2 PA; QL PRETOMANID 3 VYEPTI E PRIFTIN 3 ZEMBRACE pyrazinamide oral 1 E SYMTOUCH rifabutin 1 zolmitriptan oral 1 QL rifampin oral 1 ZOMIG NASAL 3 ST; QL RIFAMPIN+SYRSPEN E ZOMIG ORAL E D SF ZOMIG ZMT E SIRTURO 3 Antimyasthenic TRECATOR 3 Agents Antineoplastics - GUANIDINE HCL Drugs for Cancer 3 ORAL abiraterone acetate 1 PA; SP MESTINON ORAL 3 ABRAXANE 2 SP SOLUTION ADCETRIS 2 PA; SP MESTINON ORAL 3 adriamycin intravenous TABLET 1 SP solution MESTINON ORAL TABLET EXTENDED 3 adriamycin intravenous RELEASE solution reconstituted 1 SP 10 mg, 50 mg NEOSTIGMINE METHYLSULFATE AFINITOR DISPERZ 3 PA; SP SOLUTION AFINITOR ORAL E 2 PA; SP; QL PREFILLED SYRINGE TABLET 10 MG 5 MG/5ML AFINITOR ORAL INTRAVENOUS TABLET 2.5 MG, 5 E SP pyridostigmine bromide MG, 7.5 MG 1 er ALECENSA 3 PA; SP pyridostigmine bromide 1 ALIMTA 2 SP oral solution ALIQOPA 3 PA; SP pyridostigmine bromide 1 oral tablet ALKERAN 3 SP Antimycobacterials ALUNBRIG 3 PA; SP; QL CAPASTAT SULFATE E anastrozole oral $0

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 35 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ARIMIDEX E carboplatin intravenous 1 SP AROMASIN 3 solution ARRANON 2 SP carmustine 1 SP arsenic trioxide CASODEX 3 1 SP intravenous cisplatin intravenous solution 100 mg/100ml, ARZERRA 2 PA; SP 1 SP 200 mg/200ml, 50 ASPARLAS 3 SP mg/50ml AVASTIN 3 PA; SP CISPLATIN AYVAKIT 3 PA; SP; QL INTRAVENOUS 3 SP azacitidine 1 PA; SP SOLUTION RECONSTITUTED BALVERSA 3 PA; SP cladribine intravenous 1 SP BAVENCIO 3 PA; SP solution 10 mg/10ml BELEODAQ 3 PA; SP clofarabine 1 SP BELRAPZO E SP CLOLAR 3 SP BENDEKA 3 PA; SP COMETRIQ (100 MG BESPONSA 3 PA; SP DAILY DOSE) ORAL 3 PA; SP bexarotene 1 PA; SP KIT 80 & 20 MG bicalutamide 1 COMETRIQ (140 MG DAILY DOSE) ORAL 3 PA; SP BICNU 3 SP KIT 3 X 20 MG & 80 BLENREP E SP MG bleomycin sulfate 1 SP COMETRIQ (60 MG 3 PA; SP BLINCYTO 3 PA; SP DAILY DOSE) BORTEZOMIB 3 PA; SP COPIKTRA 3 PA; SP BOSULIF 3 PA; SP COSMEGEN 3 SP BRAFTOVI ORAL COTELLIC 3 PA; SP 3 PA; SP CAPSULE 75 MG cyclophosphamide 1 SP BRUKINSA 3 PA; SP injection CYCLOPHOSPHAMID busulfan 1 SP E SP E INTRAVENOUS BUSULFEX 3 SP cyclophosphamide oral 1 CABOMETYX 2 PA; SP capsule CALQUENCE 3 PA; SP CYRAMZA 3 PA; SP CAMPATH 2 SP cytarabine (pf) 1 SP CAMPTOSAR 3 SP cytarabine injection 1 SP capecitabine 1 PA; SP solution CAPRELSA ORAL dacarbazine 2 PA; SP; QL 1 SP TABLET 100 MG intravenous CAPRELSA ORAL DACOGEN 3 PA; SP 2 PA; SP TABLET 300 MG dactinomycin 1 SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 36 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DARZALEX 3 PA; SP ETOPOPHOS 3 SP DARZALEX FASPRO E SP etoposide intravenous daunorubicin hcl solution 1 gm/50ml, 1 SP 1 SP intravenous solution 100 mg/5ml, 500 mg/25ml DAURISMO 3 PA; SP etoposide oral 1 SP decitabine 1 PA; SP everolimus oral tablet 1 PA; SP; QL dexrazoxane hcl 1 SP 2.5 mg, 5 mg, 7.5 mg docetaxel intravenous EVOMELA 3 SP concentrate 160 1 SP mg/8ml, 20 mg/ml, 80 exemestane $0 mg/4ml FARESTON 3 docetaxel intravenous FARYDAK 3 PA; SP solution 160 mg/16ml, 1 SP FASLODEX 20 mg/2ml, 80 mg/8ml INTRAMUSCULAR 3 SP DOXIL 3 SP SOLUTION 250 doxorubicin hcl MG/5ML 1 SP intravenous solution FEMARA 3 doxorubicin hcl floxuridine injection 1 SP 1 SP liposomal fludarabine phosphate 1 SP DROXIA 3 fluorouracil intravenous 1 SP ELITEK 3 SP flutamide 1 ELLENCE 3 SP FOLOTYN 2 PA; SP ELZONRIS 3 PA; SP fulvestrant 1 SP EMCYT 2 GAVRETO E SP EMPLICITI 3 PA; SP GAZYVA 3 PA; SP ENHERTU 3 PA; SP gemcitabine hcl 1 SP epirubicin hcl GILOTRIF 3 PA; SP; QL intravenous solution 1 SP 200 mg/100ml, 50 GLEEVEC 3 PA; SP mg/25ml GLEOSTINE ORAL ERBITUX 2 PA; SP CAPSULE 10 MG, 100 3 SP MG, 40 MG ERIVEDGE 2 PA; SP HALAVEN 2 PA; SP ERLEADA E SP HERCEPTIN erlotinib hcl oral tablet 3 PA; SP 1 PA; SP HYLECTA 100 mg, 150 mg HERCEPTIN erlotinib hcl oral tablet 1 PA; SP; QL INTRAVENOUS 25 mg SOLUTION 3 PA; SP ERWINAZE RECONSTITUTED 150 3 SP INJECTION MG ETHYOL 3 SP HERZUMA E SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 37 Drug Name Drug Tier Notes Drug Name Drug Tier Notes HYCAMTIN 3 SP KISQALI (200 MG 3 PA; SP HYDREA 3 DOSE) KISQALI (400 MG hydroxyurea oral 1 3 PA; SP DOSE) IBRANCE 3 PA; SP KISQALI (600 MG ICLUSIG ORAL 3 PA; SP 3 PA; SP; QL DOSE) TABLET 15 MG KISQALI FEMARA ICLUSIG ORAL 3 PA; SP 3 PA; SP (400 MG DOSE) TABLET 45 MG KISQALI FEMARA 3 PA; SP IDAMYCIN PFS 3 SP (600 MG DOSE) idarubicin hcl 1 SP KISQALI FEMARA(200 3 PA; SP IDHIFA 3 PA; SP; QL MG DOSE) IFEX 3 SP KOSELUGO 3 PA; SP ifosfamide 1 SP KYPROLIS 2 PA; SP imatinib mesylate 1 PA; SP lapatinib ditosylate 1 PA; SP IMBRUVICA 3 PA; SP LARTRUVO 3 PA; SP IMFINZI 3 PA; SP LENVIMA (10 MG 3 PA; SP IMLYGIC 3 SP DAILY DOSE) LENVIMA (12 MG INFUGEM 3 SP 3 PA; SP DAILY DOSE) INLYTA 3 PA; SP LENVIMA (14 MG 3 PA; SP INQOVI E SP DAILY DOSE) INREBIC 3 PA; SP LENVIMA (18 MG 3 PA; SP IRESSA 3 PA; SP DAILY DOSE) irinotecan hcl 1 SP LENVIMA (20 MG 3 PA; SP ISTODAX (OVERFILL) 3 PA; SP DAILY DOSE) LENVIMA (24 MG IXEMPRA KIT 2 SP 3 PA; SP DAILY DOSE) JAKAFI ORAL TABLET 2 PA; SP; QL LENVIMA (4 MG 10 MG 3 PA; SP DAILY DOSE) JAKAFI ORAL TABLET LENVIMA (8 MG 15 MG, 20 MG, 25 MG, 2 PA; SP 3 PA; SP 5 MG DAILY DOSE) JELMYTO E SP letrozole oral 1 leucovorin calcium JEVTANA 2 PA; SP E injection KADCYLA 3 PA; SP leucovorin calcium oral 1 KANJINTI 2 PA; SP LEUKERAN 2 KEYTRUDA INTRAVENOUS 3 PA; SP levoleucovorin calcium SOLUTION intravenous solution 1 SP reconstituted 50 mg KHAPZORY 3 ST; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 38 Drug Name Drug Tier Notes Drug Name Drug Tier Notes levoleucovorin calcium ODOMZO 3 PA; SP 1 SP pf OGIVRI E SP LIBTAYO 3 PA; SP ONCASPAR 2 SP LONSURF 3 PA; SP INJECTION LORBRENA 3 PA; SP ONIVYDE 3 SP LUMOXITI 3 PA; SP ONTRUZANT E SP LUTATHERA E ONUREG E SP LYNPARZA ORAL OPDIVO 3 PA; SP 2 PA; SP TABLET oxaliplatin intravenous LYSODREN 2 solution 100 mg/20ml, 1 SP MARQIBO 3 SP 50 mg/10ml oxaliplatin intravenous MATULANE 2 SP E solution 200 mg/40ml MEKINIST 2 PA; SP oxaliplatin intravenous 1 SP MEKTOVI 3 PA; SP solution reconstituted melphalan 1 SP paclitaxel 1 SP melphalan hcl 1 SP PADCEV 3 PA; SP mercaptopurine oral 1 PANRETIN 3 mesna 1 SP paraplatin 1 SP MESNEX 3 SP PEMAZYRE 3 PA; SP; QL mitomycin intravenous 1 SP PERJETA 2 PA; SP MITOMYCIN E SP PHESGO E SP INTRAVESICAL PHOTOFRIN 3 SP mitoxantrone hcl 1 PA; SP PIQRAY (200 MG 3 PA; SP MONJUVI E SP DAILY DOSE) mutamycin 1 SP PIQRAY (250 MG 3 PA; SP MVASI 2 PA; SP DAILY DOSE) MYLERAN 2 PIQRAY (300 MG 3 PA; SP MYLOTARG DAILY DOSE) INTRAVENOUS POLIVY 3 PA; SP SOLUTION 3 PA; SP POMALYST 3 PA; SP RECONSTITUTED 4.5 MG PORTRAZZA 3 PA; SP NAVELBINE 3 SP POTELIGEO 3 PA; SP NERLYNX 3 PA; SP; QL PROLEUKIN 2 SP NEXAVAR 2 PA; SP PURIXAN 3 SP nilutamide 1 SP QINLOCK 3 PA; SP NINLARO 3 PA; SP RETEVMO E SP NIPENT 3 SP REVLIMID 2 PA; SP NUBEQA 3 PA; SP RITUXAN HYCELA 3 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 39 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RITUXAN TAZVERIK E SP INTRAVENOUS 3 PA; SP TECARTUS 3 PA; SP SOLUTION TECENTRIQ 3 PA; SP ROMIDEPSIN TEMODAR INTRAVENOUS 3 PA; SP 2 SP SOLUTION INTRAVENOUS ROZLYTREK 3 PA; SP TEMODAR ORAL 3 PA; SP RUBRACA 2 PA; SP temozolomide 1 PA; SP RUXIENCE 2 PA; SP teniposide 1 SP RYDAPT 3 PA; SP TEPADINA 3 SP SARCLISA 3 PA; SP THALOMID 2 PA; SP SIKLOS 3 PA thiotepa injection 1 SP SOLTAMOX $0 TIBSOVO 3 PA; SP SPRYCEL 2 PA; SP toposar intravenous solution 1 gm/50ml, 1 SP STIVARGA 3 PA; SP 100 mg/5ml, 500 SUTENT 2 PA; SP mg/25ml SYLVANT 3 PA; SP topotecan hcl 1 SP SYNRIBO 3 PA; SP toremifene citrate 1 TABLOID 2 SP TOTECT 3 SP TABRECTA E SP TRAZIMERA 2 PA; SP TAFINLAR 2 PA; SP TREANDA TAGRISSO ORAL INTRAVENOUS 3 PA; SP; QL E SP TABLET 40 MG SOLUTION RECONSTITUTED TAGRISSO ORAL 3 PA; SP TABLET 80 MG tretinoin oral 1 SP TALZENNA 3 PA; SP TRISENOX INTRAVENOUS 3 SP tamoxifen citrate oral 1 SOLUTION 12 TARCEVA ORAL MG/6ML TABLET 100 MG, 150 3 PA; SP TRODELVY 3 PA; SP MG TRUXIMA E SP TARCEVA ORAL 3 PA; SP; QL TABLET 25 MG TUKYSA 3 PA; SP TARGRETIN TURALIO 3 PA; SP 3 PA; SP EXTERNAL TYKERB 3 PA; SP TARGRETIN ORAL E SP UNITUXIN 3 PA; SP TASIGNA 3 PA; SP VALCHLOR 3 PA; SP TAXOTERE valrubicin E INTRAVENOUS 3 SP VALSTAR E CONCENTRATE 80 MG/4ML

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 40 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VECTIBIX XPOVIO (80 MG 3 PA; SP INTRAVENOUS ONCE WEEKLY) SOLUTION 100 3 SP XPOVIO (80 MG 3 PA; SP MG/5ML, 400 TWICE WEEKLY) MG/20ML XTANDI 3 PA; SP VELCADE INJECTION 2 PA; SP YERVOY 2 PA; SP VENCLEXTA 3 PA; SP YESCARTA 3 PA; SP VENCLEXTA 3 PA; SP STARTING PACK YONDELIS 3 SP VERZENIO 3 PA; SP YONSA E SP VIDAZA 3 PA; SP ZALTRAP 2 PA; SP vinblastine sulfate ZANOSAR 2 SP 1 SP intravenous solution ZEJULA 2 PA; SP vincristine sulfate ZELBORAF 3 PA; SP 1 SP intravenous ZEPZELCA 3 PA; SP vinorelbine tartrate 1 SP ZEVALIN Y-90 3 SP VITRAKVI 3 PA; SP ZIRABEV 2 PA; SP VIZIMPRO 3 PA; SP ZOLINZA 2 PA; SP VORAXAZE E ZYDELIG 3 PA; SP VOTRIENT 3 PA; SP ZYKADIA ORAL 3 PA; SP VYXEOS TABLET INTRAVENOUS ZYTIGA E SP SUSPENSION 3 PA; SP RECONSTITUTED 44- Antiparasitics 100 MG albendazole oral 1 PA XALKORI 2 PA; SP ALBENZA 3 PA XELODA 3 PA; SP ALINIA 2 XOFIGO ARAKODA 3 INTRAVENOUS E atovaquone oral 1 SOLUTION 30 atovaquone-proguanil MCCI/ML 1 hcl XOSPATA 3 PA; SP BENZNIDAZOLE 3 XPOVIO (100 MG 3 PA; SP ONCE WEEKLY) BILTRICIDE 3 XPOVIO (40 MG chloroquine phosphate 3 PA; SP 1 ONCE WEEKLY) oral XPOVIO (40 MG COARTEM 3 3 PA; SP TWICE WEEKLY) complete lice treatment E XPOVIO (60 MG crotan 1 3 PA; SP ONCE WEEKLY) DARAPRIM 3 PA; SP XPOVIO (60 MG 3 PA; SP EGATEN 3 TWICE WEEKLY)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 41 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ELIMITE 3 SKLICE 3 EMVERM 2 spinosad 1 hydroxychloroquine stop lice complete 1 E sulfate oral treatment IMPAVIDO 3 STROMECTOL 3 ivermectin external SULFURATED LIME 3 1 lotion Antiparkinson Agents ivermectin oral 1 amantadine hcl oral 1 KRINTAFEL 3 APOKYN LAMPIT E SUBCUTANEOUS 2 PA; SP; QL lice killing E SOLUTION CARTRIDGE lice treatment external E liquid 1 % AZILECT 3 lindane external benztropine mesylate 1 1 shampoo oral bromocriptine mesylate MALARONE 3 1 oral malathion external 1 carbidopa oral 1 mefloquine hcl 1 carbidopa-levodopa 1 MEPRON 3 carbidopa-levodopa er NATROBA 3 oral tablet extended 1 NEBUPENT 3 release 25-100 mg, 50- nitazoxanide 2 200 mg carbidopa-levodopa- OVIDE 3 1 entacapone PENTAM E COMTAN 3 pentamidine isethionate 1 inhalation DUOPA ENTERAL 3 PA pentamidine isethionate entacapone 1 E injection GOCOVRI E permethrin external INBRIJA 3 PA; SP 1 cream KYNMOBI E SP PLAQUENIL 3 KYNMOBI TITRATION E SP praziquantel oral 1 KIT primaquine phosphate LODOSYN 3 1 oral MIRAPEX ER 3 pyrimethamine oral 1 PA; SP MIRAPEX ORAL PYRIMETHAMINE- TABLET 0.125 MG, 0.5 3 3 LEUCOVORIN MG, 0.75 MG, 1 MG QUALAQUIN 3 PA NEUPRO 3 ST quinine sulfate oral 1 PA NOURIANZ 3 PA

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 42 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ONGENTYS E PLAVIX ORAL TABLET 3 OSMOLEX ER E 75 MG PARLODEL 3 prasugrel hcl 1 pramipexole YOSPRALA E 1 dihydrochloride ZONTIVITY 3 pramipexole Antipsychotics - 1 dihydrochloride er Drugs for Mood rasagiline mesylate oral 1 Disorders ropinirole hcl 1 ABILIFY MAINTENA INTRAMUSCULAR 3 ropinirole hcl er 1 PREFILLED SYRINGE RYTARY 3 ST ABILIFY MAINTENA selegiline hcl oral 1 INTRAMUSCULAR 3 SINEMET 3 SUSPENSION RECONSTITUTED ER STALEVO 100 3 ABILIFY MYCITE E STALEVO 125 3 ABILIFY ORAL 3 QL STALEVO 150 3 TABLET STALEVO 200 3 ADASUVE 3 PA STALEVO 50 3 aripiprazole 1 QL STALEVO 75 3 ARISTADA E TASMAR ORAL 3 ARISTADA INITIO E TABLET 100 MG CAPLYTA 3 ST; QL tolcapone 1 chlorpromazine hcl E trihexyphenidyl hcl 1 injection XADAGO 3 ST; QL chlorpromazine hcl oral 1 ZELAPAR 3 clozapine 1 QL Antiplatelets CLOZARIL 3 QL aspirin-dipyridamole er 1 FANAPT 3 ST; QL ASPIRIN- FANAPT TITRATION E 3 ST; QL OMEPRAZOLE PACK BRILINTA 2 fluphenazine E CABLIVI 3 PA; SP; QL decanoate injection cilostazol 1 fluphenazine hcl E clopidogrel bisulfate injection 1 oral fluphenazine hcl oral 1 dipyridamole oral 1 GEODON E DURLAZA E INTRAMUSCULAR EFFIENT 3 GEODON ORAL 3 QL HALDOL DECANOATE E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 43 Drug Name Drug Tier Notes Drug Name Drug Tier Notes haloperidol decanoate SAPHRIS 2 QL intramuscular solution E SECUADO E 100 mg/ml, 50 mg/ml SEROQUEL 3 QL haloperidol lactate oral 1 SEROQUEL XR 3 QL haloperidol oral 1 thioridazine hcl oral 1 INVEGA 3 QL thiothixene oral 1 INVEGA SUSTENNA INTRAMUSCULAR trifluoperazine hcl oral 1 3 SUSPENSION VERSACLOZ 3 QL PREFILLED SYRINGE VRAYLAR 3 ST; QL INVEGA TRINZA ziprasidone hcl 1 QL INTRAMUSCULAR 3 SUSPENSION ziprasidone mesylate E PREFILLED SYRINGE ZYPREXA 3 LATUDA 3 QL INTRAMUSCULAR loxapine succinate oral 1 ZYPREXA ORAL 3 QL molindone hcl 1 ZYPREXA RELPREVV E NUPLAZID ORAL ZYPREXA ZYDIS 3 QL 3 PA CAPSULE Antivirals NUPLAZID ORAL abacavir sulfate 1 3 PA TABLET 10 MG abacavir sulfate- 1 olanzapine lamivudine E intramuscular abacavir-lamivudine- 1 olanzapine oral 1 QL zidovudine paliperidone er 1 QL acyclovir external 1 PERSERIS E acyclovir oral 1 pimozide 1 adefovir dipivoxil 1 SP quetiapine fumarate 1 QL APTIVUS 2 quetiapine fumarate er 1 QL atazanavir sulfate 1 REXULTI 3 QL ATRIPLA E RISPERDAL CONSTA BARACLUDE 3 SP; QL INTRAMUSCULAR 3 BIKTARVY 3 SUSPENSION RECONSTITUTED ER cidofovir intravenous E RISPERDAL ORAL CIMDUO 2 E SOLUTION COMBIVIR 3 RISPERDAL ORAL COMPLERA 2 TABLET 0.5 MG, 1 E CRIXIVAN ORAL MG, 2 MG, 3 MG, 4 CAPSULE 200 MG, 2 MG 400 MG risperidone 1 QL DELSTRIGO 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 44 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DENAVIR E HEPSERA 3 SP DESCOVY E INTELENCE 2 didanosine oral capsule INTRON A 3 PA; SP delayed release 200 1 INVIRASE ORAL 2 mg, 250 mg, 400 mg TABLET DOVATO 2 ISENTRESS 2 EDURANT 2 ISENTRESS HD 2 efavirenz 1 JULUCA 2 efavirenz-emtricitab- KALETRA ORAL 1 3 tenofovir SOLUTION efavirenz-lamivudine- KALETRA ORAL 1 2 tenofovir TABLET emtricitabine 1 lamivudine oral solution 1 emtricitabine-tenofovir lamivudine oral tablet 1 1 SP df 100 mg EMTRIVA ORAL lamivudine oral tablet 3 1 CAPSULE 150 mg, 300 mg EMTRIVA ORAL 2 lamivudine-zidovudine 1 SOLUTION LEDIPASVIR- E SP entecavir 1 SP; QL SOFOSBUVIR EPCLUSA 2 PA; SP; QL LEXIVA ORAL 2 EPIVIR 3 SUSPENSION EPIVIR HBV ORAL LEXIVA ORAL TABLET 3 2 SP SOLUTION lopinavir-ritonavir 1 EPIVIR HBV ORAL 3 SP MAVYRET 2 PA; SP; QL TABLET nevirapine 1 EPZICOM 3 nevirapine er 1 EVOTAZ 2 NORVIR ORAL 2 famciclovir oral 1 PACKET FAVIPIRAVIR 3 NORVIR ORAL 2 fosamprenavir calcium 1 SOLUTION FOSCAVIR NORVIR ORAL 3 INTRAVENOUS TABLET E SOLUTION 6000 ODEFSEY 3 MG/250ML oseltamivir phosphate 1 QL FUZEON oral SUBCUTANEOUS E SOLUTION PEGASYS RECONSTITUTED SUBCUTANEOUS 2 PA; SP SOLUTION GENVOYA 3 HARVONI 2 PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 45 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PEGINTRON SYMTUZA 3 SUBCUTANEOUS KIT 3 PA; SP TAMIFLU ORAL E 50 MCG/0.5ML CAPSULE PIFELTRO 3 TAMIFLU ORAL PREVYMIS 3 SP SUSPENSION E PREZCOBIX 2 RECONSTITUTED 6 MG/ML PREZISTA ORAL 2 SUSPENSION TEMIXYS E tenofovir disoproxil PREZISTA ORAL 1 TABLET 150 MG, 600 2 fumarate MG, 75 MG, 800 MG TIVICAY 2 RELENZA DISKHALER 3 QL TIVICAY PD 2 RETROVIR TRIUMEQ 2 E INTRAVENOUS TRIZIVIR 3 RETROVIR ORAL 3 TROGARZO 3 PA CAPSULE TRUVADA ORAL RETROVIR ORAL TABLET 100-150 MG, 3 2 SYRUP 133-200 MG, 167-250 REYATAZ ORAL MG CAPSULE 150 MG, 3 TRUVADA ORAL E 200 MG, 300 MG TABLET 200-300 MG REYATAZ ORAL 2 TYBOST 2 PACKET valacyclovir hcl oral 1 QL ribavirin inhalation 1 VALCYTE 3 ribavirin oral capsule 1 SP valganciclovir hcl 1 ribavirin oral tablet 200 1 SP mg VALTREX 3 QL rimantadine hcl 1 VEMLIDY 3 SP ritonavir 1 VIEKIRA PAK 3 PA; SP; QL VIRACEPT ORAL RUKOBIA 3 2 TABLET SELZENTRY 2 PA VIRAMUNE ORAL 3 SITAVIG 3 QL SUSPENSION SOFOSBUVIR- E SP VIRAMUNE XR ORAL VELPATASVIR TABLET EXTENDED 3 SOVALDI 3 PA; SP; QL RELEASE 24 HOUR stavudine oral capsule 1 400 MG STRIBILD 3 VIRAZOLE 3 VIREAD ORAL SUSTIVA 3 2 POWDER SYMFI 2 SYMFI LO 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 46 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VIREAD ORAL HALCION 3 QL TABLET 150 MG, 200 2 hydroxyzine hcl oral 1 MG, 250 MG syrup VIREAD ORAL hydroxyzine hcl oral 3 1 TABLET 300 MG tablet VOSEVI 2 PA; SP; QL hydroxyzine pamoate 1 XERESE E oral XOFLUZA (40 MG KLONOPIN 3 QL 3 QL DOSE) lorazepam injection E XOFLUZA (80 MG 3 QL lorazepam intensol 1 QL DOSE) lorazepam oral 1 QL ZEPATIER 3 PA; SP; QL concentrate 2 mg/ml ZIAGEN 3 lorazepam oral tablet 1 QL zidovudine 1 meprobamate 1 ZOVIRAX EXTERNAL 3 midazolam hcl oral 1 CREAM MIDAZOLAM HCL- ZOVIRAX EXTERNAL E SODIUM CHLORIDE OINTMENT INTRAVENOUS ZOVIRAX ORAL SOLUTION 100-0.8 E E SUSPENSION MG/100ML-%, 50-0.8 Anxiolytics - Drugs MG/50ML-%, 50-0.9 for Anxiety MG/50ML-% alprazolam er 1 QL MIDAZOLAM HCL- SODIUM CHLORIDE alprazolam intensol 1 QL SOLUTION 100-0.9 E alprazolam oral 1 QL MG/100ML-% alprazolam xr 1 QL INTRAVENOUS MIDAZOLAM+SYRSP ATIVAN E E END SF buspirone hcl oral 1 oxazepam 1 QL chlordiazepoxide hcl 1 QL quazepam 1 QL clonazepam oral 1 QL TRANXENE-T ORAL clorazepate 3 QL 1 QL TABLET 7.5 MG dipotassium triazolam 1 QL diazepam intensol 1 VALIUM E diazepam oral 1 concentrate VISTARIL 3 diazepam oral solution XANAX E 1 5 mg/5ml XANAX XR E diazepam oral tablet 1 DORAL 3 QL estazolam 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 47 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Bipolar Agents - ASTRINGYN Drugs for Mood SOLUTION 259 E Disorders MG/GM EXTERNAL EQUETRO 3 BENEFIX 2 SP lithium 1 INTRAVENOUS KIT lithium carbonate er 1 CEPROTIN 3 SP lithium carbonate oral 1 COAGADEX 3 SP LITHOBID 3 CORIFACT 2 SP Blood Products and CYKLOKAPRON INTRAVENOUS Modifiers - Drugs for E Blood Disorders SOLUTION 1000 MG/10ML ADVATE 2 SP DOPTELET ORAL 3 PA; SP ADYNOVATE 3 SP TABLET 20 MG AFSTYLA 3 SP ELOCTATE 3 SP AGRYLIN 3 EPOGEN INJECTION ALPHANATE/VWF SOLUTION 10000 2 SP COMPLEX/HUMAN UNIT/ML, 2000 ALPHANINE SD 2 SP UNIT/ML, 20000 E SP UNIT/ML, 3000 ALPROLIX 3 SP UNIT/ML, 4000 AMICAR ORAL UNIT/ML 3 SOLUTION ESPEROCT E SP AMICAR ORAL 3 FEIBA INTRAVENOUS TABLET SOLUTION aminocaproic acid oral RECONSTITUTED 2 SP 1 solution 1000 UNIT, 2500 UNIT, aminocaproic acid oral 500 UNIT 1 tablet FIBRYGA 2 SP anagrelide hcl 1 FULPHILA E SP ARANESP (ALBUMIN GRANIX E SP FREE) INJECTION HEMLIBRA 3 SP SOLUTION 100 MCG/ML, 200 2 PA; SP HEMOFIL M MCG/ML, 25 MCG/ML, INTRAVENOUS SOLUTION 300 MCG/ML, 40 3 SP MCG/ML, 60 MCG/ML RECONSTITUTED 1000 UNIT, 1700 UNIT, ARANESP (ALBUMIN 250 UNIT, 500 UNIT FREE) INJECTION 2 PA; SP SOLUTION PREFILLED SYRINGE ASTRINGYN SOLUTION 259 3 MG/GM EXTERNAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 48 Drug Name Drug Tier Notes Drug Name Drug Tier Notes HUMATE-P NEUPOGEN INTRAVENOUS INJECTION E SP SOLUTION SOLUTION RECONSTITUTED 2 SP PREFILLED SYRINGE 1000-2400 UNIT, 250- NIVESTYM 2 PA; SP 600 UNIT, 500-1200 UNIT NOVOEIGHT 2 SP IDELVION 3 SP NOVOSEVEN RT 2 SP IXINITY 3 SP NPLATE 2 PA; SP JIVI 3 SP NUWIQ 2 SP KOATE 2 SP OBIZUR 3 SP KOATE-DVI 2 SP PANHEMATIN INTRAVENOUS KOGENATE FS 3 SP SOLUTION 3 SP KOVALTRY 3 SP RECONSTITUTED 350 LEUKINE INJECTION MG SOLUTION 3 PA; SP PROCRIT E SP RECONSTITUTED PROFILNINE 2 SP LYSTEDA 3 PROMACTA 3 PA; SP MIRCERA INJECTION REBINYN 3 SP SOLUTION 3 PA; SP PREFILLED SYRINGE REBLOZYL 3 PA; SP MONONINE RECOMBINATE 2 SP INTRAVENOUS RECOTHROM 3 SOLUTION 2 SP RECOTHROM SPRAY 3 RECONSTITUTED KIT 1000 UNIT RETACRIT INJECTION monsels ferric E SOLUTION 10000 subsulfate external UNIT/ML, 2000 MOZOBIL 2 PA; SP; QL UNIT/ML, 20000 2 PA; SP MULPLETA 2 PA; SP UNIT/ML, 3000 UNIT/ML, 4000 NEULASTA ONPRO 3 PA; SP UNIT/ML, 40000 NEULASTA UNIT/ML SUBCUTANEOUS 3 PA; SP RIASTAP 2 SP SOLUTION PREFILLED SYRINGE RIXUBIS 3 SP NEUPOGEN SEVENFACT E SP INJECTION SOLIRIS SOLUTION 300 E SP INTRAVENOUS 3 PA; SP MCG/ML, 480 SOLUTION 300 MCG/1.6ML MG/30ML TAVALISSE 3 PA; SP THROMBIN-JMI 3 EPISTAXIS

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 49 Drug Name Drug Tier Notes Drug Name Drug Tier Notes THROMBIN-JMI AKOVAZ SOLUTION 3 EXTERNAL KIT 50 MG/ML E THROMBOGEN 3 INTRAVENOUS tranexamic acid ALDACTAZIDE 3 intravenous solution E ALDACTONE 3 1000 mg/10ml aliskiren fumarate 1 ST tranexamic acid oral 1 ALTACE ORAL E TRANEXAMIC ACID- CAPSULE E NACL ALTOPREV E TRETTEN 3 SP amiloride hcl oral 1 UDENYCA E SP amiloride- 1 ULTOMIRIS hydrochlorothiazide INTRAVENOUS amiodarone hcl oral 1 SOLUTION 1100 3 PA; SP AMLODIPINE MG/11ML, 300 E MG/3ML BES+SYRSPEND SF amlodipine besylate ULTOMIRIS 1 INTRAVENOUS oral 2 PA; SP SOLUTION 300 amlodipine besylate- 1 MG/30ML benazepril hcl VONVENDI 3 SP amlodipine besylate- 1 WILATE valsartan 2 SP INTRAVENOUS KIT amlodipine-atorvastatin 1 XYNTHA amlodipine-olmesartan 1 INTRAVENOUS KIT amlodipine-valsartan- 2 SP 1 1000 UNIT, 2000 UNIT, hctz 250 UNIT, 500 UNIT ANTARA ORAL XYNTHA SOLOFUSE 2 SP CAPSULE 30 MG, 90 E ZARXIO 2 PA; SP MG ZIEXTENZO 3 PA; SP ATACAND E Cardiovascular ATACAND HCT 3 Agents - Drugs for atenolol oral 1 Heart and Circulation ATENOLOL+SYRSPE Conditions E ND SF ACCUPRIL 3 atenolol-chlorthalidone 1 ACCURETIC 3 atorvastatin calcium 1 acebutolol hcl oral 1 oral ADALAT CC ORAL AVALIDE ORAL TABLET EXTENDED 3 TABLET 150-12.5 MG, 3 RELEASE 24 HOUR 300-12.5 MG 60 MG AVAPRO 3 AZOR E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 50 Drug Name Drug Tier Notes Drug Name Drug Tier Notes benazepril hcl oral 1 CARDURA 3 benazepril- CAROSPIR 3 1 hydrochlorothiazide cartia xt 1 BENICAR E carvedilol 1 BENICAR HCT E carvedilol phosphate er 1 BETAPACE AF 3 CATAPRES 3 BETAPACE ORAL CATAPRES-TTS-1 3 TABLET 120 MG, 160 3 MG, 80 MG CATAPRES-TTS-2 3 betaxolol hcl oral 1 CATAPRES-TTS-3 3 chlorthalidone oral BIDIL 3 1 tablet 25 mg, 50 mg bisoprolol fumarate 1 cholestyramine light 1 bisoprolol- 1 hydrochlorothiazide cholestyramine oral 1 bumetanide oral 1 clonidine 1 BUMEX 3 clonidine hcl oral 1 BYSTOLIC 2 colesevelam hcl 1 CADUET ORAL COLESTID E TABLET 10-10 MG, 10- COLESTID E 20 MG, 10-40 MG, 10- 3 FLAVORED 80 MG, 5-10 MG, 5-20 colestipol hcl 1 MG, 5-40 MG, 5-80 MG CONJUPRI E CALAN SR 3 CONSENSI E candesartan cilexetil 1 COREG 3 candesartan cilexetil- 1 hctz COREG CR 3 captopril oral 1 CORGARD 3 captopril- CORLANOR 3 PA; QL 1 hydrochlorothiazide COZAAR 3 CARDIZEM CD 3 CRESTOR E CARDIZEM LA ORAL DEMSER 3 TABLET EXTENDED 3 DIBENZYLINE 3 RELEASE 24 HOUR 120 MG digitek 1 CARDIZEM LA ORAL digox 1 TABLET EXTENDED digoxin oral 1 RELEASE 24 HOUR E DILATRATE-SR 3 180 MG, 240 MG, 300 MG, 360 MG, 420 MG diltiazem hcl er beads 1 diltiazem hcl er coated CARDIZEM ORAL 1 TABLET 120 MG, 30 3 beads MG, 60 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 51 Drug Name Drug Tier Notes Drug Name Drug Tier Notes diltiazem hcl er oral EPHEDRINE capsule extended 1 SULFATE-NACL release 12 hour SOLUTION E diltiazem hcl er oral PREFILLED SYRINGE capsule extended 50-0.9 MG/5ML-% 1 release 24 hour 120 INTRAVENOUS mg, 180 mg, 240 mg eplerenone 1 diltiazem hcl oral 1 EQUAPAX/ATORVAST E DILTIAZEM HCL- ATIN/COQ10 DEXTROSE ethacrynic acid oral 1 SOLUTION 125-5 E EXFORGE 3 MG/125ML-% INTRAVENOUS EXFORGE HCT 3 dilt-xr 1 EZALLOR SPRINKLE 3 ST DIOVAN E ezetimibe 1 DIOVAN HCT E ezetimibe-simvastatin 1 disopyramide felodipine er 1 1 phosphate oral fenofibrate micronized DIURIL 3 oral capsule 130 mg, 1 43 mg dofetilide 1 fenofibrate micronized doxazosin mesylate 1 oral capsule 134 mg, 1 ST oral 200 mg, 67 mg DUTOPROL E fenofibrate oral capsule 1 ST DYAZIDE 3 134 mg, 200 mg, 67 mg DYRENIUM 3 fenofibrate oral capsule 1 EDARBI 3 ST 150 mg, 50 mg fenofibrate oral tablet EDARBYCLOR 3 ST E 120 mg, 40 mg EDECRIN 3 fenofibrate oral tablet 1 enalapril maleate oral 1 145 mg, 48 mg enalapril- fenofibrate oral tablet 1 1 ST hydrochlorothiazide 160 mg, 54 mg ENTRESTO 2 QL fenofibric acid oral EPANED ORAL capsule delayed 1 E SOLUTION release ephedrine sulfate fenofibric acid oral E 1 ST intravenous solution tablet EPHEDRINE FENOGLIDE 3 ST SULFATE-NACL FIBRICOR 3 ST SOLUTION E FIRST - PREFILLED SYRINGE E 50-0.9 MG/10ML-% METOPROLOL INTRAVENOUS FIRST-ATENOLOL E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 52 Drug Name Drug Tier Notes Drug Name Drug Tier Notes flecainide acetate 1 KATERZIA E FLOLIPID 3 ST labetalol hcl oral 1 fluvastatin sodium 1 LANOXIN ORAL fluvastatin sodium er 1 TABLET 125 MCG, 250 2 MCG, 62.5 MCG fosinopril sodium 1 LASIX 3 fosinopril sodium-hctz 1 LESCOL XL E furosemide oral solution 10 mg/ml, 8 1 LIPITOR E mg/ml LIPOFEN 3 furosemide oral tablet 1 lisinopril oral 1 gemfibrozil oral 1 lisinopril- 1 GONITRO 3 hydrochlorothiazide guanfacine hcl oral 1 LIVALO E HEMANGEOL 3 LOPID 3 hydralazine hcl oral 1 LOPRESSOR HCT ORAL TABLET 50-25 3 hydrochlorothiazide 1 MG oral LOPRESSOR ORAL 3 HYZAAR 3 losartan potassium oral 1 icosapent ethyl 1 PA losartan potassium-hctz 1 indapamide oral 1 LOTENSIN HCT ORAL INDERAL LA E TABLET 10-12.5 MG, 3 INDERAL XL E 20-12.5 MG, 20-25 MG INNOPRAN XL E LOTENSIN ORAL INSPRA 3 TABLET 10 MG, 20 3 MG, 40 MG irbesartan 1 LOTREL ORAL irbesartan- CAPSULE 10-20 MG, 1 3 hydrochlorothiazide 10-40 MG, 5-10 MG, 5- ISORDIL TITRADOSE 3 20 MG isosorbide dinitrate oral 1 lovastatin 1 isosorbide mononitrate 1 LOVAZA E isosorbide mononitrate matzim la 1 1 er MAXZIDE 3 isoxsuprine hcl oral E MAXZIDE-25 3 isradipine 1 methyldopa oral 1 JUXTAPID ORAL methyldopa- 1 CAPSULE 10 MG, 20 3 PA; SP; QL hydrochlorothiazide MG, 30 MG, 5 MG metolazone 1 KAPSPARGO E SPRINKLE metoprolol succinate er 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 53 Drug Name Drug Tier Notes Drug Name Drug Tier Notes metoprolol tartrate oral 1 nitroglycerin metoprolol- transdermal patch 24 1 1 hydrochlorothiazide hour nitroglycerin metyrosine 1 1 translingual solution mexiletine hcl oral 1 NITROLINGUAL 3 MICARDIS 3 NITROMIST 3 MICARDIS HCT 3 NITROSTAT E midodrine hcl 1 nitro-time oral capsule milrinone lactate in E extended release 2.5 1 dextrose mg milrinone lactate nitro-time oral capsule intravenous solution 10 E extended release 6.5 E mg/10ml, 20 mg/20ml, mg, 9 mg 50 mg/50ml NORPACE 3 MINIPRESS 3 NORPACE CR 2 minitran 1 NORTHERA 3 PA; SP minoxidil oral 1 NORVASC E moexipril hcl 1 NYMALIZE ORAL 3 MULTAQ 3 SOLUTION 6 MG/ML nadolol oral tablet 20 olmesartan medoxomil 1 1 mg, 40 mg, 80 mg oral NEXLETOL 2 PA; QL olmesartan medoxomil- 1 NEXLIZET 2 PA; QL hctz niacin olmesartan-amlodipine- 1 1 (antihyperlipidemic) hctz niacin er OMEGA-3 RX 1 3 (antihyperlipidemic) COMPLETE niacor 1 OMEGA-3/D-3 E NIASPAN 3 WELLNESS PACK omega-3-acid ethyl nicardipine hcl oral 1 1 PA esters nifedipine er 1 PACERONE ORAL nifedipine er osmotic 1 TABLET 100 MG, 400 3 release MG nifedipine oral 1 pacerone oral tablet 1 nimodipine oral 1 200 mg nisoldipine er 1 papaverine hcl injection E NITRO-BID 3 pentoxifylline er 1 NITRO-DUR 3 perindopril erbumine 1 nitroglycerin sublingual 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 54 Drug Name Drug Tier Notes Drug Name Drug Tier Notes phenoxybenzamine hcl quinapril- 1 1 oral hydrochlorothiazide phentolamine mesylate quinidine gluconate er 1 injection solution E quinidine sulfate oral 1 reconstituted ramipril 1 PHENYLEPHRINE HCL-NACL RANEXA 3 ST INTRAVENOUS ranolazine er 1 ST SOLUTION E RECTIV 3 PREFILLED SYRINGE 1-0.9 MG/10ML-%, 20- REPATHA 2 PA; QL 0.9 MG/50ML-% REPATHA pindolol 1 PUSHTRONEX 2 PA; QL SYSTEM PRALUENT SUBCUTANEOUS REPATHA 2 PA; QL 2 PA; QL SOLUTION AUTO- SURECLICK INJECTOR rosuvastatin calcium 1 PRAVACHOL ORAL RYTHMOL SR 3 TABLET 20 MG, 40 3 simvastatin oral tablet 1 MG sotalol hcl (af) 1 pravastatin sodium 1 sotalol hcl oral 1 prazosin hcl oral 1 SOTYLIZE 3 PRESTALIA 3 ST spironolactone oral 1 prevalite 1 spironolactone-hctz 1 PRINIVIL ORAL TABLET 10 MG, 20 3 SULAR ORAL TABLET EXTENDED RELEASE MG 3 24 HOUR 17 MG, 34 procainamide hcl E MG, 8.5 MG injection SURE RESULT O3D3 E PROCARDIA 3 SYSTEM PROCARDIA XL 3 TARKA ORAL TABLET propafenone hcl 1 EXTENDED RELEASE 3 propafenone hcl er 1 2-180 MG, 2-240 MG, 4-240 MG propranolol hcl er 1 taztia xt 1 propranolol hcl oral 1 TEKTURNA 2 ST propranolol-hctz 1 TEKTURNA HCT 2 ST QBRELIS E telmisartan 1 QUESTRAN E telmisartan-amlodipine 1 QUESTRAN LIGHT E ORAL POWDER telmisartan-hctz 1 quinapril hcl 1 TENORETIC 100 3 TENORETIC 50 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 55 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TENORMIN E WELCHOL 3 tiadylt er 1 ZESTORETIC 3 TIAZAC 3 ZESTRIL ORAL TIKOSYN E TABLET 10 MG, 20 3 MG, 5 MG timolol maleate oral 1 ZESTRIL ORAL TOPROL XL E TABLET 2.5 MG, 30 E torsemide oral 1 MG, 40 MG trandolapril 1 ZETIA E trandolapril-verapamil ZIAC 3 1 hcl er ZOCOR ORAL triamterene oral 1 TABLET 10 MG, 20 3 triamterene-hctz oral MG, 40 MG, 80 MG 1 capsule 37.5-25 mg ZYPITAMAG ORAL E triamterene-hctz oral TABLET 2 MG, 4 MG 1 tablet Central Nervous TRIBENZOR E System Agents - Drugs for Attention TRICOR 3 Deficit Disorder TRILIPIX 3 ADDERALL 3 PA; QL TWYNSTA 3 ADDERALL XR E valsartan 1 ADHANSIA XR E valsartan- 1 ADZENYS ER 3 PA; ST; QL hydrochlorothiazide ADZENYS XR-ODT 3 PA; ST; QL VASCEPA 2 PA AMPHETAMINE ER 3 PA; ST; QL VASERETIC 3 amphetamine sulfate 1 PA; ST; QL VASOTEC 3 amphetamine- 1 PA; QL VECAMYL 3 dextroamphetamine verapamil hcl er oral amphetamine- 1 PA; QL capsule extended 1 dextroamphetamine er release 24 hour APTENSIO XR 3 PA; ST; QL verapamil hcl er oral tablet extended release atomoxetine hcl 1 QL 1 120 mg, 180 mg, 240 clonidine hcl er 1 ST mg CONCERTA E verapamil hcl oral 1 COTEMPLA XR-ODT 3 PA; ST; QL VERELAN 3 DAYTRANA 3 PA; ST; QL VERELAN PM 3 DESOXYN 3 PA; ST; QL VYNDAMAX 3 PA; SP; QL DEXEDRINE ORAL VYNDAQEL 3 PA; SP; QL CAPSULE EXTENDED 3 PA; QL VYTORIN E RELEASE 24 HOUR

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 56 Drug Name Drug Tier Notes Drug Name Drug Tier Notes dexmethylphenidate hcl 1 PA; QL methylphenidate hcl 1 PA; ST; QL dexmethylphenidate hcl oral tablet chewable 1 PA; ST; QL er MYDAYIS 3 PA; ST; QL dextroamphetamine PROCENTRA 3 PA; ST; QL 1 PA; QL sulfate er QUILLICHEW ER 3 PA; ST; QL dextroamphetamine 1 PA; ST; QL QUILLIVANT XR ORAL sulfate oral SUSPENSION 3 PA; ST; QL DYANAVEL XR 3 PA; ST; QL RECONSTITUTED ER EVEKEO 3 PA; ST; QL relexxii 1 PA; ST; QL EVEKEO ODT 3 PA; QL RITALIN 3 PA; QL FOCALIN 3 PA; QL RITALIN LA ORAL FOCALIN XR 3 PA; ST; QL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA; ST; QL guanfacine hcl er 1 10 MG, 20 MG, 30 MG, INTUNIV 3 40 MG JORNAY PM 3 PA; ST; QL STRATTERA 3 QL KAPVAY ORAL VYVANSE 2 PA; QL TABLET EXTENDED 3 ST ZENZEDI 3 PA; ST; QL RELEASE 12 HOUR Central Nervous metadate er oral tablet System Agents - extended release 20 1 PA; ST; QL Drugs for Multiple mg Sclerosis methamphetamine hcl 1 PA; ST; QL AMPYRA 3 PA; SP; QL METHYLIN ORAL 3 PA; ST; QL AUBAGIO 3 PA; SP; QL SOLUTION AVONEX PEN methylphenidate hcl er 1 PA; ST; QL INTRAMUSCULAR 2 PA; SP; QL (cd) AUTO-INJECTOR KIT methylphenidate hcl er 1 PA; ST; QL AVONEX PREFILLED (la) INTRAMUSCULAR 2 PA; SP; QL methylphenidate hcl er PREFILLED SYRINGE 1 PA; ST; QL (xr) KIT methylphenidate hcl er BAFIERTAM 2 PA; SP; QL oral tablet extended 1 PA; ST; QL BETASERON 2 PA; SP; QL release SUBCUTANEOUS KIT methylphenidate hcl er COPAXONE oral tablet extended 1 PA; QL SUBCUTANEOUS 2 PA; SP; QL release 24 hour SOLUTION methylphenidate hcl PREFILLED SYRINGE 1 PA; ST; QL oral solution dalfampridine er 1 PA; SP; QL methylphenidate hcl 1 PA; QL dimethyl fumarate oral 1 PA; SP; QL oral tablet dimethyl fumarate 1 PA; SP; QL starter pack

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 57 Drug Name Drug Tier Notes Drug Name Drug Tier Notes EXTAVIA REBIF TITRATION E SP SUBCUTANEOUS KIT PACK GILENYA 3 PA; SP; QL SUBCUTANEOUS E SP SOLUTION glatiramer acetate 1 PA; SP; QL PREFILLED SYRINGE glatopa 1 PA; SP; QL TECFIDERA 2 PA; SP; QL KESIMPTA E SP TYSABRI 3 PA; SP; QL LEMTRADA 3 PA; SP VUMERITY 2 PA; SP; QL MAVENCLAD (10 3 PA; SP ZEPOSIA 3 PA; SP; QL TABS) ZEPOSIA 7-DAY MAVENCLAD (4 3 PA; SP; QL 3 PA; SP STARTER PACK TABS) ZEPOSIA STARTER MAVENCLAD (5 3 PA; SP; QL 3 PA; SP KIT TABS) Central Nervous MAVENCLAD (6 3 PA; SP System Agents - TABS) Miscellaneous MAVENCLAD (7 3 PA; SP ADDYI 3 PA; QL TABS) ADIPEX-P E MAVENCLAD (8 3 PA; SP TABS) AUSTEDO 3 PA; SP; QL MAVENCLAD (9 benzphetamine hcl E 3 PA; SP TABS) caffeine citrate oral 1 MAYZENT 3 PA; SP; QL CONTRAVE E MAYZENT STARTER CONVENIENCE PAK E 3 PA; SP; QL PACK diethylpropion hcl er E OCREVUS 3 PA; SP; QL diethylpropion hcl oral E PLEGRIDY E SP GABACAINE E PLEGRIDY STARTER E SP GRALISE 3 ST; QL PACK HORIZANT ORAL REBIF REBIDOSE TABLET EXTENDED 3 PA; QL SUBCUTANEOUS E SP RELEASE SOLUTION AUTO- INJECTOR INGREZZA 3 PA; SP; QL REBIF REBIDOSE LIPRITIN II COMBINATION TITRATION PACK E SUBCUTANEOUS E SP THERAPY PACK 100 SOLUTION AUTO- MG INJECTOR LOMAIRA E REBIF LYRICA CR 3 ST; QL SUBCUTANEOUS LYRICA ORAL E SP 2 QL SOLUTION CAPSULE PREFILLED SYRINGE LYRICA ORAL 3 QL SOLUTION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 58 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NEURAPTINE E chlorhexidine gluconate E NUEDEXTA 3 PA mouth/throat ONPATTRO 3 PA; SP clinpro 5000 E phendimetrazine DEBACTEROL E tartrate SOLUTION 30-50 % E MOUTH/THROAT phendimetrazine E tartrate er denta 5000 plus E phentermine hcl oral E dentagel E DERMACINRX pregabalin oral 1 QL E CLORHEXACIN QSYMIA E DERMACINRX RADICAVA 3 PA; SP SURGICAL E RILUTEK 3 PA; QL PHARMAPAK riluzole 1 PA; QL easygel dental E SAVELLA 3 ST; QL EVOXAC 3 SAVELLA TITRATION FIRST-MOUTHWASH 3 ST; QL E PACK BLM SAXENDA E fluoridex E SUCCINYLCHOLINE fluoridex daily renewal E CHLORIDE fluoridex enhanced INTRAVENOUS E E whitening dental paste SOLUTION fluoridex sensitivity PREFILLED SYRINGE E 140 MG/7ML relief dental paste TEGSEDI 3 PA; SP KEPIVANCE 2 SP lidocaine hcl tetrabenazine 1 PA; SP 1 mouth/throat TIGLUTIK 3 PA; SP; QL lidocaine viscous hcl 1 VECURONIUM MOUTH KOTE BROMIDE E INTRAVENOUS E REMINT SOLUTION MUCOSITISRX E PREFILLED SYRINGE NAFRINSE DAILY E VYLEESI 3 PA; QL ACIDULATED XENAZINE 3 PA; SP NAFRINSE E XENICAL E DAILY/NEUTRAL Dental and Oral NAFRINSE WEEKLY E Agents - Drugs for NUSURGEPAK Mouth and Throat SURGICAL E Conditions PREP/CARE ARESTIN E oralone 1 cavarest E paroex E cevimeline hcl 1 PERIDEX E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 59 Drug Name Drug Tier Notes Drug Name Drug Tier Notes periogard E Dermatological pilocarpine hcl oral 1 Agents - Drugs for Skin Conditions PREVIDENT E A.A.G.C. KIT IN PREVIDENT 5000 E E TERODERM BOOSTER PLUS ABREVA E PREVIDENT 5000 DRY MOUTH DENTAL E ABSORICA E GEL ABSORICA LD 3 PA PREVIDENT 5000 ACANYA E E ENAMEL PROTECT ACESO AG E PREVIDENT 5000 E acitretin 1 ORTHO DEFENSE ACTIVE-PREP KIT IV E PREVIDENT 5000 E PLUS active-tramadol E PREVIDENT 5000 ACZONE EXTERNAL E E SENSITIVE GEL 5 % ACZONE EXTERNAL SALAGEN 3 2 GEL 7.5 % SALIVAMAX E adapalene external 1 PA sf E cream sf 5000 plus E adapalene external gel 1 PA sodium fluoride 5000 ADAPALENE E E plus EXTERNAL PAD sodium fluoride 5000 E ADAPALENE ppm EXTERNAL 3 PA sodium fluoride 5000 SOLUTION E sensitive ADAPALENE- sodium fluoride dental BENZOYL PER- E E cream CLINDAMY sodium fluoride dental ADAPALENE- E gel 1.1 % BENZOYL PER- E TOPEX TOPICAL NIACINAM ANESTHETIC adapalene-benzoyl 3 1 MOUTH/THROAT peroxide AEROSOL ADVANCED ALLERGY E triamcinolone acetonide COLLECTION 1 mouth/throat AKLIEF E XEROSTOMIA RELIEF E ALA SCALP E SPRAY ala-cort external cream 1 alclometasone 1 dipropionate

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 60 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ALCOHOL PREP balsam peru-castor oil 1 PADS EXTERNAL 70 3 BEAU RX E % BENSAL HP E ALDARA E BENZ PER-CLIND- E ALEVAMAX E NIACIN-TRETIN ALTRENO 3 PA BENZAC AC WASH E amcinonide external EXTERNAL LIQUID E cream BENZACLIN E amcinonide external BENZACLIN WITH 1 E lotion PUMP amcinonide external 1 BENZAMYCIN E ointment benzepro creamy wash E AMELUZ E BENZEPRO ammonium lactate E 1 EXTERNAL external BENZEPRO amnesteem 1 PA EXTERNAL FOAM 5.2 E AMZEEQ 3 %, 9.7 % ANACAINE E benzepro external foam E APEXICON E E 5.3 % BENZEPRO AQUAPHILIC E E EXTERNAL LIQUID ARAZLO E benzepro foaming E ARIDA E cloths arzol silver nit BENZEPRO SHORT E E applicators CONTACT ATOPADERM E benzoin compound E ATOPICLAIR E BENZOIN EXTERNAL E ATRALIN 3 PA TINCTURE avar cleanser E BENZOYL PEROX- E AVAR LS CLEANSER E HYDROCORTISONE benzoyl peroxide AVAR-E EMOLLIENT E E external foam 9.8 % AVAR-E GREEN E BENZOYL PEROXIDE AVAR-E LS E EXTERNAL GEL 6.5 E AVEIDAOXIA E %, 8 % avita 1 PA BENZOYL PEROXIDE E AZADROX E FORTE- HC benzoyl peroxide- azelaic acid external 1 ST 1 ST erythromycin AZELAIC ACID- E BESER EXTERNAL NIACINAMIDE E KIT AZELEX 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 61 Drug Name Drug Tier Notes Drug Name Drug Tier Notes beser external lotion 1 capsaicin external E betamethasone cream 0.025 % 1 dipropionate aug capzix E betamethasone CARAC 3 1 dipropionate external CEM-UREA E BETAMETHASONE E CERACADE E DIPROP-MINOXIDIL cerovel external lotion E betamethasone 1 valerate external CHLOOXIA E CICLOPIROX- BIAFINE E E CLOBETASOL BIONECT EXTERNAL E CREAM CICLOPIROX- CLOBETASOL-SAL E blanche E ACID BOTOX COSMETIC 3 PA; SP CICLOPIROX- E bp 10-1 E SALICYLIC ACID bp cleansing wash E CIMETIDINE-LIDO- E bp wash external liquid SALICYLIC ACID E 2.5 %, 7 % claravis 1 PA BPCO 3 CLEOCIN-T 3 BRYHALI E EXTERNAL LOTION calcipotriene external CLINDACIN ETZ 1 QL E cream EXTERNAL KIT CALCIPOTRIENE clindacin etz external E 1 EXTERNAL FOAM swab calcipotriene external CLINDACIN PAC E 1 ointment clindacin-p 1 calcipotriene external CLINDAGEL E 1 solution CLINDAMY-BENZOYL E calcipotriene-betameth PER-NIACINAM diprop external E clindamycin phos- ointment benzoyl perox external 1 ST calcipotriene-betameth gel 1-5 %, 1.2-2.5 %, diprop external 1 QL 1.2-5 % suspension CLINDAMYCIN PHOS- E CALCIPOTRIENE- NIACINAMIDE E CLOBETASOL PROP clindamycin phosphate 1 CALCITRENE 3 external foam calcitriol external 1 clindamycin phosphate 1 CANTHARIDIN external lotion E EXTERNAL clindamycin phosphate 1 CAPEX E external solution

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 62 Drug Name Drug Tier Notes Drug Name Drug Tier Notes clindamycin phosphate CORDRAN 1 external swab EXTERNAL CREAM E CLINDAMYCIN 0.025 % PHOSPHATE GEL 1 % E CORDRAN EXTERNAL EXTERNAL CREAM 3 clindamycin phosphate 0.05 % 1 gel 1 % external CORDRAN 3 CLINDAMYCIN- EXTERNAL LOTION E NIACIN-TRETINOIN CORDRAN clindamycin-tretinoin 1 ST EXTERNAL 3 OINTMENT CLIND-NIACIN- E CORDRAN SPIRONOLAC-TRETIN E EXTERNAL TAPE CLINOIN E corn & callus remover E clobetasol prop 1 CORTANE-B emollient base E EXTERNAL clobetasol propionate e 1 CORTISPORIN clobetasol propionate 3 1 EXTERNAL emulsion CUTIVATE EXTERNAL clobetasol propionate 3 1 LOTION external dapsone external gel 5 CLOBETASOL PROP- 1 E % LEVOCETIRIZINE DAPSONE EXTERNAL CLOBETASOL PROP- E E GEL 7.5 % NIACINAMIDE DAPSONE- E CLOBETAVIX E NIACINAMIDE CLOBEX 3 DAPSONE- CLOBEX SPRAY 3 NIACINAMIDE- E clocortolone pivalate 1 SPIRONOLAC CLODAN EXTERNAL DELUO E E KIT DEOXIA E clodan external DERMACINRX 1 E shampoo PENETRAL CLODERM E DERMACINRX COAL TAR EXTERNAL SURGICAL E 3 SOLUTION COMBOPAK DERMA-SMOOTHE/FS COLLATYL E 3 BODY CONDYLOX 3 DERMA-SMOOTHE/FS EXTERNAL GEL 3 SCALP COPADERM E DERMULCERA 3 COPASIL EXTERNAL E DESONATE E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 63 Drug Name Drug Tier Notes Drug Name Drug Tier Notes desonide external 1 DIPROLENE DESOWEN EXTERNAL 3 3 EXTERNAL CREAM OINTMENT desoximetasone docosanol external E 1 external cream DOVONEX EXTERNAL 3 desoximetasone CREAM 1 external gel doxepin hcl external 1 PA desoximetasone doxycycline 1 E external liquid DR SMITHS ADULT desoximetasone BARRIER EXTERNAL E external ointment 0.05 E OINTMENT % DRAXACE E desoximetasone DRAXACE LOTION E external ointment 0.25 1 CLEANSER % DRITHO-CREME HP E DEXERYL E DRIXECE E DIADIMAXIA E DRYSOL 3 DIAOXIA E DUOBRII E diaper rash external E ointment DUPIXENT 2 PA; SP; QL DIASDIMAXIA E ECEOXIA E EFUDEX EXTERNAL DIASOXIA E 3 CREAM diclofenac sodium gel 3 1 ST; QL % external ELETONE E diclofenac sodium gel 3 ELIDEL 3 ST 1 PA; QL % external ELLZIA PAK E diclofenac sodium gel 3 EMULSION SB E E % external enovarx-tramadol E DICLOFENAC-NA E ENSTILAR E HYALURON-NIACIN ENTTY SPRAY E DIFFERIN EXTERNAL E CREAM ENZOCLEAR E DIFFERIN EXTERNAL EPICERAM E E GEL 0.3 % EPIDUO 3 DIFFERIN EXTERNAL EPIDUO FORTE 3 E LOTION EPIFOAM 3 diflorasone diacetate E EPIQUIN MICRO E external ery 1 DIMOXIA E ERYGEL 3 DIPROLENE AF 3 erythromycin external 1 gel

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 64 Drug Name Drug Tier Notes Drug Name Drug Tier Notes erythromycin external FLUOVIX E 1 solution FLUOVIX PLUS E ESKATA E flurandrenolide E ETHOXIA E fluticasone propionate 1 EUCRISA 2 ST external EVOCLIN 3 FORAXA E FABIOR E GENADUR E FINACEA 3 ST GORDOFILM 3 finasteride oral tablet 1 grafco silver nit E E mg applicator FINASTERIDE- halcinonide E E MINOXIDIL halobetasol propionate 1 FLUOCINOLONE external cream E ACET-NIACINAMIDE HALOBETASOL fluocinolone acetonide PROPIONATE E 1 body EXTERNAL FOAM fluocinolone acetonide halobetasol propionate 1 1 external external ointment fluocinolone acetonide HALOG EXTERNAL 1 E scalp CREAM fluocinonide cream 0.1 HALOG EXTERNAL E E % external OINTMENT fluocinonide emulsified HALOG EXTERNAL 1 3 base SOLUTION fluocinonide external HALUCORT E 1 cream 0.05 % HPR PLUS EXTERNAL E fluocinonide external CREAM 1 gel hpr plus external foam E fluocinonide external HPR PLUS 1 E ointment HYDROGEL fluocinonide external 1 HYALUCIL-4 E solution HYALURONATE- FLUOPAR E NIACINAM- E FLUOROPLEX 3 TRETINOIN FLUOROURACIL HYALURONATE- E EXTERNAL CREAM 2 NIACIN-TACROLIMUS 0.5 % HYALURONIC ACID- E fluorouracil external HYDROQUINONE 1 cream 5 % HYDRO 40 E fluorouracil external 1 solution

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 65 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hydrocortisone ace- IMIQUIMOD PUMP pramoxine external E CREAM 3.75 % E cream 2.5-1 % EXTERNAL hydrocortisone acetate IMIQUIMOD- E external cream LEVOCETIRIZIN- E hydrocortisone acetate NIACIN E external ointment 1 % IMIQUIMOD- E hydrocortisone butyr LEVOCET-TRETINOIN E lipo base IMPEKLO E hydrocortisone butyrate IMPOYZ E 1 external cream INOVA E hydrocortisone butyrate INOVA 4/1 ACNE E E external lotion CONTROL THERAPY hydrocortisone butyrate INOVA 8/2 ACNE 1 E external ointment CONTROL THERAPY hydrocortisone butyrate 1 isotretinoin oral 1 PA external solution ITHOXIA E hydrocortisone external E cream 0.5 % IVERMECTIN- METRONIDAZOL- E hydrocortisone external 1 NIACIN cream 1 %, 2.5 % KAMDOY E hydrocortisone external 1 lotion 2.5 % KATARYA E hydrocortisone external KATARYAXN E 1 ointment 1 %, 2.5 % KAXM E hydrocortisone valerate 1 KEIDO E hydroquinone external KELARX E E cream KENALOG EXTERNAL 3 HYDROQUINONE KERAGEL E EXTERNAL E KERALAC EXTERNAL EMULSION E CREAM 47 % HYDROQUINONE-HC- E KERALYT EXTERNAL TRETINOIN E GEL 6 % HYDROQUINONE- E HYDROCORTISONE KERALYT SCALP E HYLATOPIC PLUS KERAMATRIX E EXTERNAL CREAM REPLICINE 5CMX5CM 3 EXTERNAL SHEET HYLATOPIC PLUS E EXTERNAL LOTION KETARYA E imiquimod external E KEVARYA E KEXM E KEYA E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 66 Drug Name Drug Tier Notes Drug Name Drug Tier Notes KIVIK E MINOXIDIL- KLARON 3 PROGEST- E TRETINOIN KUTARYAXM E MIRVASO 3 KUTARYAXMPA E moisturel external lotion E KUTEA E 3 % KUVARYA E mometasone furoate 1 KUVARYE E external KUXM E myorisan 1 PA lactic acid e 1 NEOCERA E lactic acid external NEOSALUS E 1 lotion NEOSALUS CP E LACTIC ACID- E NEOSPORIN NIACINAMIDE ORIGINAL EXTERNAL E lavare wound wash E OINTMENT LEVULAN KERASTICK 3 NEO-SYNALAR 3 LEXETTE E EXTERNAL CREAM NEO-SYNALAR LIDOCAINE- E HYDROCORTISONE EXTERNAL KIT E ACE EXTERNAL neuac external gel 1 ST CREAM 1-1 % NEUAC EXTERNAL E LIDOTREX E KIT LOCOID EXTERNAL NIACINAMIDE- 3 E LOTION SPIRONOLACTONE LOCOID LIPOCREAM E NIACINAMIDE- E LUXIQ 3 SULFACETAMIDE NIACINAMIDE- MEDERMA E E TACROLIMUS MEDERMA FOR KIDS E NIACINAMIDE- E MEDERMA SPF 30 E TAZAROTENE MEDPURA ALCOHOL NIACINAMIDE- E E PADS TRETINOIN methoxsalen rapid 1 NIACINAMIDE- methyl salicylate TRIAMCINOLONE E E external liquid ACET METROCREAM 3 NIACIN- METROGEL SPIRONOLACTON- E E EXTERNAL GEL TRETINOIN METROLOTION 3 NIVATOPIC PLUS E metronidazole external 1 nolix E MIMYX E NORITATE E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 67 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NOVACORT PRAMOSONE E EXTERNAL GEL 1-2 % EXTERNAL CREAM 1- E NUCARACLINPAK E 2.5 % PRAMOSONE NUCARARXPAK E 3 EXTERNAL LOTION NUCORT E PRAMOSONE NUDERMRXPAK 120 E EXTERNAL E NUDERMRXPAK 60 E OINTMENT NUTRASEB E pramox E NUTRIARX PRE & POST SX E E CREAMPAK POUCH NUVAIL E prednicarbate 1 OLUX 3 PRESERA E OLUX-E 3 PROGESTERONE- E ONEXTON 3 MINOXIDIL ORACEA 3 PROMISEB E OVACE PLUS E PROPECIA E OVACE PLUS WASH E PROSILK EXTERNAL E OVACE WASH E PROTEXA E OXSORALEN ULTRA 3 PROTOPIC 3 PANDEL E PROTYL AG E PENLEN E PRUCLAIR E PHLAG SPRAY E PRUDOXIN 3 PA PICATO 3 ST PRUMYX E pimecrolimus 1 ST PSORCON E PLEXION E PYROGALLIC ACID 3 PLEXION CLEANSER QBREXZA 3 QL E EXTERNAL LIQUID QUINIXIL E PLEXION CLEANSING QUTENZA E CLOTH EXTERNAL E QUTENZA (2 PATCH) E PAD RADIAGEL E podocon E RADIAPLEXRX GEL 3 podofilox external 1 EXTERNAL PR BENZOYL RADIAPLEXRX GEL E E PEROXIDE EXTERNAL pr benzoyl peroxide E RECEDO E wash REFISSA E PR CREAM E REGENECARE 3 pramosone external 1 cream 1-1 % REGRANEX 3 PA

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 68 Drug Name Drug Tier Notes Drug Name Drug Tier Notes remergent hq E salicylic acid wart E REMIGEN E remover salicylic acid-cleanser RENOVA E E external kit 6 % (cream) RENOVA PUMP E SALICYLIC ACID- RESORCINOL- E E SULFACETAMIDE SULFUR salimez E RETIN-A 3 PA SALIMEZ FORTE E RETIN-A MICRO GEL E 0.04 %, 0.1 % SALVAX E RETIN-A MICRO SALVAX DUO PLUS E PUMP EXTERNAL E SANADERMRX SKIN E GEL 0.04 %, 0.1 % REPAIR RETIN-A MICRO SANTYL 3 PUMP EXTERNAL 2 PA SCALACORT DK E GEL 0.06 %, 0.08 % SCARCARE GEL-PAD REXASIL PATCH & E E KIT/LARGE VITAMIN E LIQ SCARCIN E RHOFADE 3 SCARSILK EXTERNAL E RIAX E SCARZEN SKIN E rosadan external cream 1 REPAIR rosadan external gel 1 SCENESSE 3 PA; SP ROSADAN EXTERNAL selenium sulfide E 1 KIT external lotion SALEX EXTERNAL selenium sulfide E E SHAMPOO external shampoo salicylic acid er E SELRX E salicylic acid external E SERNIVO 3 cream SILA III E salicylic acid external E foam SILIPAC E salicylic acid external SILVERSEAL E HYDROGEL gel E DRESSING salicylic acid external E EXTERNAL PAD 2"X3" liquid 27.5 % skarjel E salicylic acid external E sodium hyaluronate lotion E external gel salicylic acid external E sodium sulfacetamide shampoo E external shampoo salicylic acid external E solution 26 % sodium sulfacetamide wash liquid 10 % E external

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 69 Drug Name Drug Tier Notes Drug Name Drug Tier Notes SODIUM sulfacetamide sod- SULFACETAMIDE- sulfur wash external E E BAKUCHIOL LIQUID liquid 10 % EXTERNAL sulfacetamide-sulfur in E SOLARAVIX urea external emulsion E EXTERNAL sulfacleanse 8/4 E SOLOX E sulfamez wash E SOOLANTRA 3 SUMADAN E SORIATANE ORAL SUMADAN WASH E CAPSULE 10 MG, 25 3 MG SUMADAN XLT E SORILUX E SUMAXIN E sss 10-5 E SUMAXIN CP E STRATA CTX E SUMAXIN WASH E STRATA GRT E SUVICORT E STRATA MARK E SYNALAR 3 STRATA TRIZ E SYNALAR (CREAM) E SYNALAR STRATA XRT E E (OINTMENT) sulfacetamide sodium 1 (acne) SYNALAR TS E sulfacetamide sodium SYNERDERM E E external gel TACLONEX sulfacetamide sodium EXTERNAL E E external liquid OINTMENT sulfacetamide sodium- TACLONEX E sulfur external cream EXTERNAL 3 QL SUSPENSION sulfacetamide sodium- E TACROLIMUS sulfur external emulsion E EXTERNAL CREAM sulfacetamide sodium- E tacrolimus external sulfur external liquid 1 ointment sulfacetamide sodium- E sulfur external lotion TARDEOXIA E sulfacetamide sodium- TARDIMAXIA E sulfur external pad 10-4 E TAROXIA E % TASOPROL E sulfacetamide sodium- tazarotene external 1 PA sulfur external E TAZORAC EXTERNAL suspension 3 PA CREAM sulfacetamide sod- E TAZORAC EXTERNAL sulfur wash external kit 3 PA GEL 0.05 %

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 70 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TAZORAC EXTERNAL trianex E E GEL 0.1 % TRI-CHLOR 3 TEMOVATE 3 triderm external cream 1 EXTERNAL CREAM TRIDESILON 3 TEMOVATE EXTERNAL 3 TRI-LUMA E OINTMENT triple antibiotic external TETRIX EXTERNAL ointment , 3.5-400- E E CREAM 5000 , 5-400-5000 triple antibiotic+pain TEXACORT 3 E relief tl hydroquinone E TRIVIX E TOLAK 3 ST TURPENTINE TOPICORT E 3 EXTERNAL EXTERNAL CREAM ULTRASAL-ER E TOPICORT 3 ULTRAVATE EXTERNAL GEL E EXTERNAL LOTION TOPICORT EXTERNAL 3 UMECTA MOUSSE E OINTMENT URAMAXIN E TOPICORT SPRAY E EXTERNAL GEL tovet external foam 1 urea external cream 39 %, 40 %, 41 %, 45 %, E TOVET EXTERNAL E 47 % KIT UREA EXTERNAL E tretinoin (emollient) E FOAM tretinoin external 1 PA urea external lotion 40 E tretinoin microsphere 1 PA % tretinoin microsphere urea external E pump external gel 0.04 1 PA suspension 40 % % urea hydrating E triamcinolone acetonide urea nail external gel E external aerosol E 45 % solution urea-c40 E triamcinolone acetonide 1 external cream ureacin-10 E triamcinolone acetonide ureacin-20 E 1 external lotion uredeb E triamcinolone acetonide uremez-40 E 1 external ointment URESOL E TRIAMSIL COMBIPAK UTOPIC E EXTERNAL THERAPY E PACK TRIAMSIL MULTIPAK E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 71 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VANICREAM ALOGLIPTIN E EXTERNAL E BENZOATE OINTMENT ALOGLIPTIN- E VANIQA E METFORMIN HCL VANOS 3 ALOGLIPTIN- E VANOXIDE-HC E PIOGLITAZONE VARDIMAXIA E AMARYL 3 AVANDIA ORAL VAROXIA E 3 ST TABLET 2 MG, 4 MG VECTICAL E BYDUREON BCISE 2 ST; QL VELTIN E AUTOINJECTOR VENELEX 3 BYDUREON PEN 2 ST; QL VERDESO E BYETTA 10 MCG PEN 2 ST; QL VEREGEN E BYETTA 5 MCG PEN 2 ST; QL VEXASYN E CYCLOSET 3 ST VIRASAL E DUETACT 3 XALIX E FARXIGA 2 ST XERAC AC 3 FORTAMET E XERALUX E glimepiride 1 xurea E glipizide er 1 ZACARE E glipizide ir 1 zaclir cleansing E glipizide xl 1 external lotion 8 % glipizide-metformin hcl 1 ST zenatane 1 PA GLUCOTROL 3 ZIANA E GLUCOTROL XL 3 ZILXI E GLUCOVANCE ORAL 3 ZITHRANOL E TABLET 5-500 MG ZONALON 3 PA GLUMETZA E ZYCLARA E glyburide micronized 1 ZYCLARA PUMP E glyburide oral 1 Diabetes - glyburide-metformin 1 Antidiabetic Agents GLYNASE 3 acarbose oral 1 GLYSET 3 ACTOPLUS MET 3 GLYXAMBI 2 ST ACTOS 3 INVOKAMET E ADLYXIN E INVOKAMET XR E ADLYXIN STARTER E PACK INVOKANA E JANUMET 2 ST

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 72 Drug Name Drug Tier Notes Drug Name Drug Tier Notes JANUMET XR 2 ST SYNJARDY 2 ST JANUVIA 2 ST SYNJARDY XR 2 ST JARDIANCE 2 ST tolbutamide 1 ST JENTADUETO 2 ST TRADJENTA 2 ST JENTADUETO XR 2 ST TRIJARDY XR 2 ST KAZANO E TRULICITY 2 ST; QL KOMBIGLYZE XR E VICTOZA 2 ST; QL metformin hcl er 1 XIGDUO XR 2 ST metformin hcl er (mod) E XULTOPHY 3 ST; QL metformin hcl er (osm) Diabetes - Glucose oral tablet extended Monitoring E release 24 hour 1000 ACCU-CHEK AVIVA E mg, 500 mg DEVICE metformin hcl ir 1 ACCU-CHEK AVIVA miglitol 1 CONNECT KIT E nateglinide 1 W/DEVICE ACCU-CHEK AVIVA IN NESINA E E VITRO SOLUTION ONGLYZA E ACCU-CHEK AVIVA E OSENI E PLUS KIT W/DEVICE OZEMPIC 2 ST; QL ACCU-CHEK pioglitazone hcl 1 COMPACT PLUS E pioglitazone hcl- CARE KIT 1 glimepiride ACCU-CHEK pioglitazone hcl- COMPACT PLUS E 1 metformin hcl CONTROL PRECOSE 3 ACCU-CHEK COMPACT PLUS E QTERN E TEST STRIPS repaglinide 1 ACCU-CHEK RIOMET 3 ST FASTCLIX LANCET $0 RIOMET ER 3 ST KIT ACCU-CHEK GUIDE RYBELSUS 2 ST; QL E KIT W/DEVICE SEGLUROMET E ACCU-CHEK GUIDE E SOLIQUA 2 ST; QL CONTROL STARLIX 3 ACCU-CHEK STEGLATRO E MULTICLIX LANCET $0 STEGLUJAN E DEVICE KIT SYMLINPEN 120 3 PA ACCU-CHEK NANO SMARTVIEW KIT E SYMLINPEN 60 3 PA W/DEVICE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 73 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ACCU-CHEK FORTISCARE E SMARTVIEW E CONTROL CONTROL FORTISCARE ACCU-CHEK GLUCOSE SYSTEM E SMARTVIEW TEST E DEVICE STRIPS FORTISCARE T1 E ACCU-CHEK GLUCOSE SYSTEM SOFTCLIX LANCET $0 FREESTYLE LIBRE 14 E DEVICE KIT DAY READER AUTOLET II FREESTYLE LIBRE 14 $0 E CLINISAFE DAY SENSOR AUTOLET LANCING FREESTYLE LIBRE 2 $0 E DEVICE READER SYSTM BLUESTAR E FREESTYLE LIBRE 2 E CARETOUCH SENSOR SYSTM CONTROL SOL LEVEL E FREESTYLE LIBRE E 2 READER CARETOUCH FREESTYLE LIBRE $0 E LANCING/EJECTOR SENSOR SYSTEM CARETOUCH TEST E FREESTYLE CEQUR SIMPLICITY PRECISION NEO E 3 2U TEST CHEMSTRIP UGK 3 GUARDIAN CONNECT E CONTOUR CONTROL E TRANSMITTER CONTOUR NEXT GUARDIAN LINK 3 E E CONTROL TRANSMITTER GUARDIAN SENSOR CONTOUR NEXT LINK E E (3) CONTOUR NEXT E MONITOR KETONE TEST 3 CONTOUR NEXT KETOSTIX 3 E TEST LANCETS $0 CONTOUR TEST E MICRODOT TEST E EASYMAX 15 LEVEL MICROLET NEXT E $0 2-3 CONTROL LANCING DEVICE EASYMAX CONTROL NOVOPEN ECHO 3 IN VITRO SOLUTION E ONETOUCH DELICA $0 NORMAL LANCING DEV EASYMAX CONTROL ONETOUCH DELICA E $0 NORMAL/HIGH PLUS LANCING ENLITE GLUCOSE E ONETOUCH ULTRA $0 QL SENSOR ONETOUCH ULTRA 2 2 KIT W/DEVICE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 74 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ONETOUCH ULTRA SURESTEP PRO 2 3 MINI KIT W/DEVICE HIGH GLUCOSE ONETOUCH VERIO SURESTEP PRO LOW 2 3 KIT W/DEVICE GLUCOSE ONETOUCH VERIO SURESTEP PRO 3 FLEX SYSTEM KIT 2 NORMAL GLUCOSE W/DEVICE TRUE METRIX BLOOD E ONETOUCH VERIO IN GLUCOSE TEST VITRO SOLUTION 3 TRUE METRIX LEVEL E HIGH 1 ONETOUCH VERIO TRUE METRIX LEVEL $0 QL E TEST STRIPS 2 ONETOUCH VERIO IQ TRUE METRIX LEVEL 2 E SYSTEM 3 ONETOUCH VERIO TRUE METRIX PRO 2 E REFLECT BLOOD GLUCOSE ONETOUCH VERIO TRUETRACK TEST E SYNC SYSTEM KIT 2 W/DEVICE UNISTRIP CONTROL IN VITRO SOLUTION E PRECISION LINK E LOW PRECISION PCX E Diabetes - Glycemic PLUS TEST Agents PRECISION QID E BAQSIMI ONE PACK 2 MONITOR BAQSIMI TWO PACK 2 PRECISION QID TEST E diazoxide oral 1 PRECISION SOF- E TACT MONITOR GLUCAGEN HYPOKIT 3 ST PRECISION SOF- GLUCAGON E 2 Made by Lilly TACT TEST EMERGENCY KIT PRECISION XTRA GLUCAGON Made by E 2 BLOOD GLUCOSE EMERGENCY KIT Fresenius PRECISION XTRA GVOKE HYPOPEN 1- E 2 DEVICE PACK PRECISION XTRA GVOKE HYPOPEN 2- 3 2 KETONE PACK PRECISION XTRA KIT E GVOKE PFS 2 PRECISION XTRA PROGLYCEM 3 E MONITOR Diabetes - Insulins RELION BLOOD ADMELOG E E GLUCOSE TEST ADMELOG E RELION ULTIMA TEST E SOLOSTAR

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 75 Drug Name Drug Tier Notes Drug Name Drug Tier Notes AFREZZA INSULIN ASPART E INHALATION PENFILL POWDER 12 UNIT, 4 & INSULIN ASPART E 8 & 12 UNIT, 4 UNIT, 8 3 PA PROT & ASPART UNIT, 90 X 4 UNIT & INSULIN LISPRO (1 90X8 UNIT, 90 X 8 E UNIT & 90X12 UNIT UNIT DIAL) INSULIN LISPRO APIDRA SOLOSTAR E E JUNIOR KWIKPEN APIDRA VIAL E INSULIN LISPRO E BASAGLAR KWIKPEN E PROT & LISPRO FIASP E INSULIN LISPRO FIASP FLEXTOUCH E SUBCUTANEOUS E FIASP PENFILL E SOLUTION HUMALOG U-100 AND INSULIN PEN 2 U-200 KWIKPEN NEEDLES 29G X 12.7MM , 29G X 12MM HUMALOG MIX 50/50 , 29G X 5MM , 29G X 2 $0 KWIKPEN 8MM , 31G X 5 MM , HUMALOG MIX 50/50 31G X 6 MM , 31G X 8 2 VIAL MM , 32G X 4 MM , HUMALOG MIX 75/25 33G X 4 MM 2 KWIKPEN INSULIN SYRINGES $0 HUMALOG MIX 75/25 LANTUS U-100 2 2 VIAL SOLOSTAR HUMALOG U-100 LANTUS U-100 VIAL 2 2 JUNIOR KWIKPEN LEVEMIR U-100 E HUMALOG VIAL 2 FLEXTOUCH HUMULIN 70/30 LEVEMIR U-100 VIAL E 2 KWIKPEN LYUMJEV 2 HUMULIN 70/30 VIAL 2 LYUMJEV KWIKPEN 2 HUMULIN N KWIKPEN 2 MAXICOMFORT SYR $0 HUMULIN N VIAL 2 27G X 1/2" HUMULIN R U-500 MYXREDLIN 3 2 KWIKPEN NOVOFINE HUMULIN R U-500 AUTOCOVER PEN $0 2 VIAL NEEDLE HUMULIN R VIAL 2 NOVOFINE PEN $0 INSULIN ASP PROT & NEEDLE 32G X 6 MM E ASP FLEXPEN NOVOFINE PLUS PEN $0 INSULIN ASPART E NEEDLE INSULIN ASPART NOVOLIN 70/30 E E FLEXPEN FLEXPEN

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 76 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NOVOLIN 70/30 ADRENAL C E E FLEXPEN RELION FORMULA NOVOLIN 70/30 airavite E E RELION aminoamrms E NOVOLIN 70/30 VIAL E aminobenzoate E NOVOLIN N FLEXPEN E potassium oral packet NOVOLIN N FLEXPEN aminoreliefrms E E RELION animal shapes E NOVOLIN N RELION E ANIMI-3 E NOVOLIN N VIAL E ANIMI-3/VITAMIN D E NOVOLIN R FLEXPEN E AQUASOL A NOVOLIN R FLEXPEN INTRAMUSCULAR E E RELION SOLUTION 15 MG/ML NOVOLIN R RELION E ASCOR E NOVOLIN R VIAL E ASCORBIC ACID NOVOLOG U-100 SOLUTION 500 E E FLEXPEN MG/ML INJECTION NOVOLOG MIX 70/30 ascorbic acid solution E E FLEXPEN 500 mg/ml injection NOVOLOG MIX 70/30 ATABEX OB 2 E VIAL AZESCHEW NOVOLOG U-100 PRENATAL/POSTNAT E E PENFILL AL NOVOLOG U-100 VIAL E AZESCO E NOVOTWIST PEN B-12 COMPLIANCE $0 E NEEDLE 32G X 5 MM INJECTION SEMGLEE E b-6 folic acid oral capsule 8.333-100-1 E TOUJEO MAX 2 mg SOLOSTAR BACMIN E TOUJEO SOLOSTAR 2 b-complex/b-12 oral E TRESIBA E biocel E TRESIBA E FLEXTOUCH biopetit E biotin oral tablet 1000 Electrolytes / Minerals E / Metals / Vitamins mcg ABANEU-SL E bp vit 3 E ACTITROM-D E b-plex E active fe E b-plex plus E calcidol oral solution ACTIVITE E E 200 mcg/ml adc/f (0.5mg/ml) 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 77 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CALCIFOL 3 CEREFOLIN E calcitrate oral tablet cerefolin nac oral tablet E E 950 mg 6-90.314-2-600 mg calcium carb- CHEMET 3 cholecalciferol oral E childrens chewable E tablet 600-400 mg-unit vitamins calcium carbonate oral E CHOLECAL DF E tablet 600 mg chromagen oral E calcium carbonate- capsule vitamin d oral tablet E 600-400 mg-unit CIFEREX E calcium-folic acid plus d E CIFRAZOL E CARBAGLU 2 SP CITRANATAL BLOOM E CARDIOPLEGIA DEL CITRANATAL E E NIDO FORMULA ESSENCE CARDIOPLEGIA IND CITRANATAL E E PLASMA HIGH K MEDLEY CARDIOPLEGIA IND clovique 1 PA; SP E PLASMA-TROMET COD LIVER OIL ORAL E CARDIOPLEGIA OIL E INDUCTION HIGH K corvita E CARDIOPLEGIA corvita 150 E E INDUCTION LOW DEX CORVITE 150 E CARDIOPLEGIA E corvite fe E INDUCTION NON-ENR cvs vitamin e oral CARDIOPLEGIA MAIN E E capsule 1000 unit LOW DEXTROSE cyanocobalamin CARDIOPLEGIA MAIN E injection solution 1000 1 LOW TROMETHA mcg/ml CARDIOPLEGIA MAIN E CYANOCOBALAMIN PLASMA-TROME INJECTION 3 CARDIOPLEGIA SOLUTION 2000 E MAINTENANCE MCG/ML CARDIOPLEGIA cytra k crystals E E REPERFUSATE 4:1 d3 high potency oral CARNITOR capsule 25 mcg (1000 E E INTRAVENOUS ut) CARNITOR ORAL 3 d3 super strength E CARNITOR SF 3 daflonex-xl oral capsule E CENFOL E decara oral capsule CENTRATEX E 1.25 mg (50000 ut), E 250 mcg (10000 ut)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 78 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DECARA ORAL EXJADE 3 PA CAPSULE 625 MCG E fabb E (25000 UT) fa-vitamin b-6-vitamin E deferasirox 1 PA b-12 deferasirox granules 1 PA FERAHEME E deferiprone 1 PA FERIVA 21/7 E dehydrated alcohol E FERIVAFA E solution 98 % injection ferocon E DEPLIN 15 E ferotrinsic E DEPLIN 7.5 E FERRALET 90 E DERMACINRX E PUREFOLIX ferraplus 90 E dexifol E FERRIPROX 3 PA FERRIPROX TWICE- dialyvite E 3 PA A-DAY DIALYVITE 3000 E FERRLECIT E DIALYVITE 5000 E ferrocite plus oral tablet E DIALYVITE SUPREME E FERRO-PLEX D E HEMATINIC DIALYVITE/ZINC E FERROTRIN E DRISDOL ORAL 3 CAPSULE ferrous sulfate oral solution 75 (15 fe) E DURACHOL E mg/ml d-vite pediatric E ferrous sulfate oral E EFFER-K ORAL syrup TABLET ferrous sulfate oral 3 E EFFERVESCENT 10 tablet 325 (65 fe) mg MEQ, 20 MEQ ferrous sulfate oral effer-k oral tablet tablet delayed release 1 E effervescent 25 meq 324 (65 fe) mg, 325 (65 ELFOLATE E fe) mg ELFOLATE PLUS FLORIVA E ORAL TABLET 3-35-2 E FLORIVA PLUS E MG FLUORABON $0 ELITE-OB 2 fluoritab $0 ENBRACE HR E FLURA-DROPS ORAL ERGOCAL E SOLUTION 0.55 (0.25 $0 ergocalciferol oral F) MG/DROP 1 capsule folbee E ergocalciferol oral E folbee plus E solution 200 mcg/ml folbee plus cz E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 79 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FOLBIC RF E hemocyte-f oral tablet E FOLGARD OS E hemocyte-plus oral E FOLGARD RX E tablet 106-1 mg folic acid injection E HYLAVITE E folic acid oral tablet 1 HYLAZINC E 1 mg ICAR-C PLUS E folic acid oral tablet 800 iferex 150 forte E $0 mcg INFED E FOLIC D3 E INFUVITE ADULT E FOLIC-K E INFUVITE PEDIATRIC FOLI-D E INTRAVENOUS E FOLITE E SOLUTION FOLIVANE-F E INTEGRA F E FOLIVANE-PLUS E INTEGRA PLUS E IODINE STRONG FOLIXAPURE E 3 ORAL folplex 2.2 E IROSPAN 24/6 E foltanx E ISOLYTE-S E FOLTANX RF E JADENU 3 PA FOLTRATE E JADENU SPRINKLE 3 PA FOLTREXYL E JYNARQUE 3 SP; QL foltrin E KCL-LIDOCAINE- FOLTX ORAL TABLET E E NACL 1.13-25-2 MG kionex oral suspension 1 FOLVITE-D E klor-con 10 1 FOSTEUM E klor-con m10 1 FUSION PLUS E KLOR-CON M15 3 GALZIN 3 klor-con m20 1 GENICIN VITA-D E klor-con oral packet 20 1 GENICIN VITA-Q E meq GENICIN VITA-S E klor-con oral tablet 1 hematinic plus extended release E vit/minerals klor-con sprinkle 1 hematinic/folic acid E klor-con/ef 1 HEMATOGEN E K-PHOS NO 2 E HEMATOGEN FA E K-PHOS TABLET 500 3 HEMATRON-AF E MG ORAL HEMETAB E K-PHOS TABLET 500 E HEMOCYTE PLUS E MG ORAL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 80 Drug Name Drug Tier Notes Drug Name Drug Tier Notes K-PHOS-NEUTRAL 3 magnesium sulfate k-prime 1 intravenous solution 2 gm/50ml, 20 gm/500ml, E K-TAB 3 4 gm/100ml, 4 k-tan plus E gm/50ml, 40 L-CYSTINE E gm/1000ml levocarnitine oral MAGNESIUM 1 solution SULFATE SOLUTION E 50 % INJECTION levocarnitine oral tablet 1 magnesium sulfate E levocarnitine sf 1 solution 50 % injection L-ISOLEUCINE E magnesium-oxide E l-methylfolate E mag-oxide oral tablet E l-methylfolate ca me-cbl 200 mg E nac MEPHYTON 3 l-methylfolate calcium E metafolbic E oral metafolbic plus E l-methylfolate forte E metafolbic plus rf E l-methylfolate-algae METANX ORAL oral capsule 15-90.314 E E mg CAPSULE l-methylfolate-algae- methylfol-algae-b12- E E b12-b6 acetylcyst l-methylfolate-b6-b12 MICROPLEGIA MSA- E E oral tablet 3-35-2 mg MSG l-methyl-mc E MIFEPREX 3 l-methyl-mc nac E mifepristone 1 LOKELMA 3 M-NATAL PLUS 2 LORID E MULTIGEN E lysiplex plus oral tablet E MULTIGEN FOLIC E M.V.I. ADULT E MULTIGEN PLUS E multiple vitamin-folic M.V.I. PEDIATRIC E INTRAVENOUS acid E SOLUTION MULTIPRO E RECONSTITUTED multi-vit/iron/fluoride 1 MAGNEBIND 400 3 multivitamin/fluoride 1 magnesium oxide oral oral solution tablet 400 (241.3 mg) E multi-vitamin/fluoride 1 mg oral solution multivitamin/fluoride oral tablet chewable 1 0.25 mg, 0.5 mg, 1 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 81 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MULTIVITAMIN/FLUO NICOMIDE ORAL RIDE ORAL TABLET TABLET 750-27-2-0.5 E CHEWABLE 0.25-0.3 E MG MG, 0.5-0.3 MG, 1-0.3 NIFEREX ORAL E MG TABLET multi- novamv pediatric multi- 1 E vitamin/fluoride/iron vitamin multivitamins/fluoride NUFERA E oral tablet chewable 0.5 1 mg nufol E mynephrocaps capsule NUTRICAP E E 1 mg oral nutrifac zx E mynephron E NUTRIVIT E na ferric gluc cplx in OCUVEL ORAL E E sucrose CAPSULE 0.5 MG n-acetyl-l-cysteine oral 1 one daily E nafrinse $0 ONE VITE WOMENS $0 nafrinse drops $0 ONE VITE WOMENS 2 NASCOBAL 3 PLUS NEONATAL + DHA E ONEVITE E NEONATAL 19 2 ORACIT 3 NEONATAL ORTHO DF E E COMPLETE OVEEZA E NEONATAL FE E oyster shell calcium/d oral tablet 250-250 mg- NEONATAL PLUS 2 E unit, 500-200 mg-unit, NEOVITE E 500-400 mg-unit NEPHPLEX RX E oyster shell NEPHRON FA E calcium/vitamin d oral E nephronex oral tablet E tablet 500-200 mg-unit PEDIALYTE ORAL NEPHRO-VITE RX E E SOLUTION NESTABS 2 pediatric electrolyte oral E NESTABS ONE E solution NEURIN-SL E pediavit E niacin oral tablet 100 E phospha 250 neutral 1 mg phosphorous 1 NICADAN E phosphorus E NICAZEL E supplement NICAZEL FORTE E phosphorus w/sod & E potassium

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 82 Drug Name Drug Tier Notes Drug Name Drug Tier Notes phospho-trin 250 potassium chloride oral 1 neutral solution 20 meq/15ml 1 PHOXILLUM BK4/2.5 E (10%), 40 meq/15ml (20%) PHYSICIANS EZ USE E B-12 potassium citrate er 1 potassium citrate-citric PHYSIOLYTE E E acid oral solution PHYSIOSOL E IRRIGATION PREGENNA E phytonadione injection PREMESISRX E solution 1 mg/0.5ml, 10 E PRENAISSANCE E mg/ml PRENARA E phytonadione oral 1 prenatal oral tablet 27- $0 PLASMA-LYTE 148 E 0.8 mg, 28-0.8 mg PLASMA-LYTE A E prenatal plus iron 1 PODIAPN ORAL prenatal tablet 27-1 mg E 1 CAPSULE oral poly-iron 150 forte E prenatal tablet 27-1 mg E POLY-VI-FLOR FS 3 oral POLY-VI-FLOR ORAL prenatal vitamin plus 3 1 SUSPENSION low iron POLY-VI-FLOR ORAL PRENATE E E TABLET CHEWABLE PRENATE DHA ORAL POLY-VI-FLOR/IRON CAPSULE 18-0.6-0.4- E 2 ORAL SUSPENSION 300 MG POLY-VI-FLOR/IRON PRENATE ELITE ORAL TABLET E ORAL TABLET 20-0.6- E CHEWABLE 0.4 MG poly-vite pediatric E PRENATE ENHANCE E POTABA ORAL PRENATE ESSENTIAL E CAPSULE ORAL CAPSULE 18- E 0.6-0.4-300 MG potassium chloride crys 1 er PRENATE MINI ORAL CAPSULE 18-0.6-0.4- E potassium chloride er 1 350 MG potassium chloride in PRENATE PIXIE E nacl intravenous solution 20-0.45 meq/l- E PRENATE RESTORE E %, 20-0.9 meq/l-%, 40- PRENATRIX E 0.9 meq/l-% PRENATRYL E potassium chloride oral PRENATVITE 1 E packet COMPLETE PRENATVITE PLUS 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 83 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PRENATVITE RX 2 SIDEROL ORAL E preplus 1 TABLET SLOWMAG MG pretab 1 E MUSCLE/HEART PRIMACARE ORAL E CAPSULE sod citrate-citric acid 1 PROTEINEX P18 E sodium bicarbonate intravenous solution 7.5 E purevit dualfe plus E % PYRIDOXINE HCL sodium bicarbonate SOLUTION 100 E solution 4.2 % E MG/ML INJECTION intravenous pyridoxine hcl solution E sodium bicarbonate 100 mg/ml injection solution 8.4 % E QUFLORA FE E intravenous QUFLORA FE SODIUM E PEDIATRIC BICARBONATE E QUFLORA GUMMIES E SOLUTION 8.4 % INTRAVENOUS QUFLORA PEDIATRIC E sodium chloride (pf) E RELNATE DHA 2 solution 0.9 % injection REMEDIENT E sodium chloride RENAL injection solution 2.5 E MULTIVITAMIN E meq/ml FORMULA sodium chloride renal oral capsule E intravenous solution E RENATABS E 0.45 %, 0.9 %, 3 %, 5 % RENATABS WITH E IRON sodium chloride solution 4 meq/ml E rena-vite E intravenous reno caps capsule 1 E sodium fluoride oral $0 mg oral (rx) sodium polystyrene 1 REQ 49+ E sulfonate oral REVESTA E sodium polystyrene 1 ringers irrigation E sulfonate rectal SAMSCA ORAL soluvita e E 2 SP; QL TABLET 15 MG sps 1 SAMSCA ORAL 3 SP; QL STROVITE FORTE E TABLET 30 MG STROVITE ONE E SELECT-OB ORAL TABLET CHEWABLE E SUPERVITE E 29-1 MG support E se-tan plus E SUPPORT-500 E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 84 Drug Name Drug Tier Notes Drug Name Drug Tier Notes SYNAGEX E urosex E SYPRINE 3 PA; SP v-c forte E SYSTANE ICAPS VELTASSA 3 AREDS2 ORAL E VENOFER E TABLET CHEWABLE vic-forte E TALIVA E vinate one 1 TARON FORTE E virt-caps E taron-crystals E VIRT-FEFA PLUS E thiamine hcl injection E virt-gard E tis-u-sol E virt-phos 250 neutral 1 tl-hem 150 E vita s forte E TOLVAPTAN ORAL E SP TABLET 15 MG vitacel E tolvaptan oral tablet 30 VITAFOL FE+ ORAL 1 SP; QL E mg CAPSULE VITAFOL ORAL TRICARE PRENATAL E DHA ONE ORAL TABLET 2 CAPSULE 27-1-500 VITAFOL STRIPS 2 MG VITAFOL-OB+DHA E tricitrates E VITAL-D RX E tricon E VITAMAX PEDIATRIC E trientine hcl 1 PA; SP VITAMEZ E TRIFERIC vita-min E HEMODIALYSIS E PACKET vitamin b complex 100 E vitamin b-6 oral tablet trinate 1 E 100 mg, 25 mg, 50 mg TRINAZ E vitamin b-complex 100 E triphrocaps E vitamin c oral tablet E TRISTART ONE E 1000 mg TRI-VI-FLOR 3 vitamin d TRI-VI-FLORO 3 (cholecalciferol) oral E tri-vite pediatric E tablet 25 mcg (1000 ut) tri-vite/fluoride 1 vitamin d (ergocalciferol) oral 1 TRONVITE E capsule 1.25 mg TRYPTOPHAN ORAL E (50000 ut) UDAMIN SP E vitamin d3 oral capsule E UROCIT-K 10 3 250 mcg (10000 ut) UROCIT-K 15 3 UROCIT-K 5 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 85 Drug Name Drug Tier Notes Drug Name Drug Tier Notes vitamin d3 oral tablet Gastrointestinal 10 mcg (400 unit), 125 Agents - Drugs for E mcg (5000 ut), 50 mcg Acid Reflux and Ulcer (2000 ut) acid reducer oral tablet E VITAMIN DEFICIENCY 10 mg E SYSTEM-B12 acid reducer oral tablet E vitamin e oral capsule delayed release E 1000 unit ACIPHEX E vitamin k1 injection ACIPHEX SPRINKLE E solution 1 mg/0.5ml, 10 E CARAFATE ORAL mg/ml 3 SUSPENSION vitamins acd-fluoride 1 CARAFATE ORAL E VITAROCA PLUS E TABLET VITA-RX DIABETIC E cimetidine hcl oral 1 VITAMIN cimetidine oral 1 VITASURE E CYTOTEC 3 VITATHELY WITH E GINGER DEXILANT 2 QL VITREXATE E ESOMEP-EZS E VITREXATE FE E esomeprazole magnesium oral 1 QL VITREXYL E capsule delayed VITREXYL + IRON E release vp-pnv-dha 1 esomeprazole 1 QL vp-vite rx E magnesium oral packet weekly-d E ESOMEPRAZOLE STRONTIUM ORAL E westab mini E CAPSULE DELAYED westab one E RELEASE 49.3 MG WESTAB PLUS 2 famotidine oral WESTGEL DHA E suspension 1 reconstituted WHEAT GERM OIL E famotidine oral tablet ORAL OIL 1 20 mg, 40 mg XAQUIL XR E FIRST- 3 ST XVITE E LANSOPRAZOLE ZALVIT E FIRST-OMEPRAZOLE 3 ST zinc sulfate oral tablet heartburn relief oral E E 220 (50 zn) mg tablet 200 mg lansoprazole oral capsule delayed 1 ST; QL release

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 86 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lansoprazole oral tablet sucralfate oral 1 delayed release 1 QL ZEGERID E dispersible Gastrointestinal misoprostol oral 1 Agents - Drugs for NEXIUM ORAL Bowel, Intestine and CAPSULE DELAYED E Stomach Conditions RELEASE ACTIGALL 3 NEXIUM ORAL 3 QL ACTIPHLORA E PACKET alosetron hcl 1 PA nizatidine 1 alum & mag hydroxide- E omeprazole simeth magnesium oral tablet E alumina-magnesia- delayed release E simethicone omeprazole oral capsule delayed 1 ST; QL alvimopan 1 release AMITIZA E omeprazole oral tablet amoxicill-clarithro- E 1 ST delayed release lansopraz OMEPRAZOLE+SYRS ANASPAZ 3 3 ST PEND SF ALKA antacid anti-gas max E omeprazole-sodium strength E bicarbonate antacid calcium E pantoprazole sodium 1 ST; QL antacid calcium rich E oral antacid extra strength PEPCID ORAL 3 oral tablet chewable E TABLET 160-105 mg, 750 mg PREVACID E antacid maximum E PREVACID 24HR E antacid oral tablet E PREVACID SOLUTAB chewable 500 mg ORAL TABLET 3 ST; QL antacid regular strength E DELAYED RELEASE DISPERSIBLE antacid ultra strength oral tablet chewable E PRILOSEC ORAL 3 ST; QL 1000 mg PACKET anti-diarrheal oral liquid E PROTONIX ORAL 3 ST; QL anti-diarrheal oral tablet E ra omeprazole-sodium E bicarb ATROPEN INTRAMUSCULAR E RABEPRAZOLE SOLUTION AUTO- SODIUM ORAL E INJECTOR CAPSULE SPRINKLE atropine sulfate rabeprazole sodium injection solution 0.4 E oral tablet delayed 1 ST; QL mg/ml, 1 mg/ml release

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 87 Drug Name Drug Tier Notes Drug Name Drug Tier Notes atropine sulfate cvs gentle laxative E injection solution rectal E prefilled syringe 0.25 cvs stool softener oral E mg/5ml capsule 250 mg ATROPINE SULFATE dicyclomine hcl oral 1 INTRAVENOUS SOLUTION diotame instydose E E PREFILLED SYRINGE diphenoxylate-atropine 1 1 MG/2.5ML, 1.2 docusate mini E MG/3ML docusate sodium oral atropine sulfate solution E E capsule 8 mg/20ml injection docusate sodium oral E atropine sulfate solution syrup prefilled syringe 0.5 E mg/5ml injection docuzen E atropine sulfate solution dok oral tablet E prefilled syringe 1 E DONNATAL E mg/10ml injection ed-spaz 1 BACICAP E ENTEREG 3 belladonna alkaloids- E enulose 1 opium eq anti-diarrheal oral E bisacodyl ec $0 QL tablet bisacodyl rectal E EX-LAX ULTRA E bismuth subsalicylate fiber laxative oral tablet E oral suspension 525 E fiber oral powder 28.3 mg/30ml E % cascara sagrada oral 1 fluid extract FOLIKA PROBIOTIC E gas relief extra strength CHENODAL 3 PA; SP E oral capsule chlordiazepoxide- E gas relief oral tablet clidinium E chewable chocolated laxative E GASTROCROM 3 citroma $0 QL GATTEX 3 PA; SP clearlax oral powder $0 QL gavilax oral powder $0 QL CLENPIQ 3 gavilyte-c $0 QL constulose 1 gavilyte-g $0 QL cromolyn sodium oral 1 gavilyte-h 1 CUVPOSA 3 gavilyte-n with flavor $0 QL cvs antacid extra pack strength oral tablet E chewable 750 mg GELUSIL E generlac 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 88 Drug Name Drug Tier Notes Drug Name Drug Tier Notes gentle laxative oral $0 QL hyoscyamine sulfate 1 gentle laxative rectal E oral elixir hyoscyamine sulfate geri-kot E 1 oral tablet GIALAX E hyoscyamine sulfate 1 GLYCATE E oral tablet dispersible glycolax $0 QL hyoscyamine sulfate sl 1 GLYCOPYRROLATE hyoscyamine sulfate INJECTION E solution 0.125 mg/ml E SOLUTION oral PREFILLED SYRINGE hyoscyamine sulfate GLYCOPYRROLATE solution 0.125 mg/ml 1 INTRAVENOUS oral SOLUTION E PREFILLED SYRINGE hyoscyamine sulfate 0.6 MG/3ML, 1 tablet sublingual 0.125 1 MG/5ML mg sublingual glycopyrrolate oral hyoscyamine sulfate 1 tablet 1 mg, 2 mg tablet sublingual 0.125 E mg sublingual GLYCOPYRROLATE E ORAL TABLET 1.5 MG hyosyne 1 IMODIUM A-D ORAL glycopyrrolate pf E E TABLET gnp senna lax E IMODIUM MULTI- GOLYTELY ORAL SYMPTOM RELIEF E SOLUTION 3 ORAL TABLET RECONSTITUTED 236 GM infants gas relief oral suspension 20 E goodsense antacid oral mg/0.3ml tablet chewable 500 E KRISTALOSE ORAL mg, 750 mg E PACKET 20 GM goodsense anti- E diarrheal lactobacillus oral tablet E HELIDAC THERAPY 3 LACTOJEN E lactulose high potency probiotic E 1 encephalopathy hm stomach relief oral suspension 525 E lactulose oral 1 mg/30ml laxative max str E hm stool softener oral laxative regular E E capsule 100 mg strength hyoscyamine sulfate er LEVBID E oral tablet extended E LEVSIN ORAL E release 12 hour TABLET LEVSIN/SL E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 89 Drug Name Drug Tier Notes Drug Name Drug Tier Notes LIBRAX 3 NULYTELY WITH 3 LINZESS 2 ST; QL FLAVOR PACKS LOMOTIL ORAL OMECLAMOX-PAK 2 3 TABLET opium E loperamide hcl oral oscimin oral tablet 1 1 capsule oscimin sr E loperamide hcl oral E oscimin sublingual 1 solution OSMOPREP E loperamide hcl oral E pb-hyoscy-atropine- suspension E scopolamine LOTRONEX 3 PA PCP 100 E MAALOX MULTI peg 3350-kcl-na bicarb- SYMPTOM MAX ST E $0 QL ORAL SUSPENSION nacl magnesium citrate oral peg-3350/electrolytes $0 QL $0 QL solution 1.745 gm/30ml peg- magnesium oxide oral 3350/electrolytes/ascor 1 E tablet 400 mg, 420 mg bat methscopolamine peg-kcl-nacl-nasulf-na 1 1 bromide oral asc-c mi-acid maximum peg-prep 1 E strength PEPTO-BISMOL ORAL E mi-acid oral suspension E TABLET milk of magnesia oral PERDIEM E E suspension 400 mg/5ml OVERNIGHT RELIEF mineral oil heavy oral 1 phenobarbital- belladonna alk oral E mm stool softener E elixir laxative phenobarbital- MOTEGRITY 3 ST; QL belladonna alk oral 1 MOTOFEN E tablet MOVANTIK E phenohytro E MOVIPREP E pink bismuth maximum E MYTESI 3 QL strength natural fiber laxative PLENVU E E oral powder 28.3 % PROBICHEW E natural senna laxative PRODIGEN E E oral tablet 8.6 mg PROMELLA IN E NULEV 3 PREBIOTIC NULYTELY LEMON- propantheline bromide 3 1 LIME oral PYLERA 2

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 90 Drug Name Drug Tier Notes Drug Name Drug Tier Notes qc magnesium citrate $0 QL sodium bicarbonate QUAD-PROBIOTIC E oral tablet 325 mg, 650 E mg RELISTOR ORAL E soothe oral tablet E RELISTOR stimulant laxative oral SUBCUTANEOUS E SOLUTION 12 E tablet MG/0.6ML, 8 stomach relief oral MG/0.4ML suspension 525 E RESTORA RX 3 mg/30ml saccharomyces stomach relief oral E E boulardii tablet chewable stool softener laxative senexon-s E E oral capsule 100 mg senna oral liquid E stool softener oral senna oral syrup 8.8 E capsule 100 mg, 250 E mg/5ml mg senna oral tablet 8.6 stool softener plus E E mg laxative senna plus oral tablet E stool softener/laxative E senna s E oral tablet senna smooth E SUPREP BOWEL 3 senna-docusate PREP KIT E sodium SUTAB E senna-plus E SYMAX DUOTAB E SENOKOT EXTRA symax-sl E E STRENGTH symax-sr E SENOKOT S E SYMPROIC 2 ST; QL SEROSTIM TALICIA 3 SUBCUTANEOUS SOLUTION 3 PA; SP trilyte $0 QL RECONSTITUTED 4 TRULANCE E MG, 5 MG, 6 MG TUMS CHEWY BITES E simethicone oral E URSO 250 3 capsule URSO FORTE 3 simethicone oral suspension 40 E ursodiol oral 1 mg/0.6ml URSODIOL+SYRSPE E simethicone oral tablet ND SF E chewable 80 mg vegetable lax+stool E SODIUM softener BICARBONATE ORAL 3 VIBERZI 3 PA; QL POWDER VISBIOME E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 91 Drug Name Drug Tier Notes Drug Name Drug Tier Notes XERMELO 3 PA; SP; QL nitisinone 1 PA; SP ZELAC E NITYR 3 PA; SP ZELNORM 3 PA; QL OCALIVA 3 PA; SP; QL ZORBTIVE 3 PA; SP ORFADIN 3 PA; SP Genetic or Enzyme PALYNZIQ 3 PA; SP; QL Disorder - Drugs for PANCREAZE E Replacement, Modification, PERTZYE E Treatment PROCYSBI 3 PA; SP ALDURAZYME 2 PA; SP RAVICTI 3 PA; SP BRINEURA KIT 3 PA; SP REVCOVI 3 PA; SP BUPHENYL ORAL sapropterin 3 SP 1 PA; SP POWDER 3 GM/TSP dihydrochloride BUPHENYL ORAL sodium phenylbutyrate 3 SP 1 SP TABLET oral powder 3 gm/tsp CERDELGA 3 PA; SP sodium phenylbutyrate 1 SP CEREZYME oral tablet INTRAVENOUS STRENSIQ 2 PA; SP SOLUTION 2 PA; SP SUCRAID 3 SP RECONSTITUTED 400 UNIT VIMIZIM 3 PA; SP CHOLBAM 3 PA; SP VIOKACE E CREON 2 VPRIV 3 PA; SP CRYSVITA 3 PA; SP VYONDYS 53 E SP CYSTADANE 3 SP XURIDEN 3 PA; SP; QL CYSTAGON 3 SP ZAVESCA 3 PA; SP ELAPRASE 2 PA; SP ZENPEP ORAL CAPSULE DELAYED ELELYSO 3 PA; SP RELEASE PARTICLES ENZADYNE E 10000-32000 UNIT, 15000-47000 UNIT, EXONDYS 51 E SP 2 20000-63000 UNIT, FABRAZYME 2 PA; SP 25000-79000 UNIT, GALAFOLD 3 PA; SP; QL 3000-14000 UNIT, KANUMA 3 PA; SP 40000-126000 UNIT, 5000-24000 UNIT KUVAN 3 PA; SP ZOLGENSMA 10.1- 3 PA; SP LUMIZYME 2 PA; SP 10.5 KG MEPSEVII 3 PA; SP ZOLGENSMA 10.6- 3 PA; SP miglustat 1 PA; SP 11.0 KG MYALEPT 3 PA; SP ZOLGENSMA 11.1- 3 PA; SP NAGLAZYME 2 PA; SP 11.5 KG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 92 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ZOLGENSMA 11.6- Genitourinary Agents 3 PA; SP 12.0 KG - Drugs for Bladder, ZOLGENSMA 12.1- Genital and Kidney 3 PA; SP 12.5 KG Conditions ZOLGENSMA 12.6- aminoacetic acid E 3 PA; SP 13.0 KG AURYXIA 3 ZOLGENSMA 13.1- azo tabs E 3 PA; SP 13.5 KG bethanechol chloride 1 ZOLGENSMA 2.6-3.0 oral 3 PA; SP KG BI-MIX 3 ZOLGENSMA 3.1-3.5 calcium acetate (phos 3 PA; SP 1 KG binder) ZOLGENSMA 3.6-4.0 calcium acetate oral 3 PA; SP 1 KG tablet 667 mg ZOLGENSMA 4.1-4.5 CAVERJECT 3 PA; SP 3 QL KG IMPULSE ZOLGENSMA 4.6-5.0 3 PA; SP CAVERJECT KG INTRACAVERNOSAL ZOLGENSMA 5.1-5.5 SOLUTION 3 QL 3 PA; SP KG RECONSTITUTED 40 ZOLGENSMA 5.6-6.0 MCG 3 PA; SP KG CERVIDIL 3 ZOLGENSMA 6.1-6.5 CIALIS 3 QL 3 PA; SP KG CUPRIMINE ORAL 3 PA; SP ZOLGENSMA 6.6-7.0 CAPSULE 250 MG 3 PA; SP KG darifenacin 1 ZOLGENSMA 7.1-7.5 hydrobromide er 3 PA; SP KG DEPEN TITRATABS 2 SP ZOLGENSMA 7.6-8.0 3 PA; SP DETROL 3 KG DETROL LA 3 ZOLGENSMA 8.1-8.5 3 PA; SP KG DITROPAN XL ORAL TABLET EXTENDED ZOLGENSMA 8.6-9.0 3 3 PA; SP RELEASE 24 HOUR KG 10 MG, 5 MG ZOLGENSMA 9.1-9.5 3 PA; SP EDEX 3 QL KG ELMIRON 2 ZOLGENSMA 9.6-10.0 3 PA; SP KG ENABLEX ORAL TABLET EXTENDED 3 RELEASE 24 HOUR 7.5 MG FEM PH E flavoxate hcl 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 93 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FOSRENOL ORAL phosphasal E 3 PACKET PREPIDIL 3 FOSRENOL ORAL PROSTIN E2 3 TABLET CHEWABLE 3 1000 MG, 500 MG, 750 PYRIDIUM E MG QUAD-MIX 3 GELNIQUE RENACIDIN E TRANSDERMAL GEL 3 ST RENAGEL ORAL E 10 % TABLET 800 MG glycine irrigation E RENVELA 3 glycine urologic E RIMSO-50 E hyophen E sevelamer carbonate 1 INTRAROSA 3 ST sevelamer hcl 1 lanthanum carbonate 1 sildenafil citrate oral LEVITRA ORAL tablet 100 mg, 25 mg, 1 QL TABLET 10 MG, 20 E 50 mg MG solifenacin succinate 1 LITHOSTAT 3 STAXYN E me/naphos/mb/hyo1 E STENDRA E MUSE 3 QL SUPER BI-MIX 3 MYRBETRIQ 2 SUPER QUAD-MIX 3 oxybutynin chloride er 1 SUPER TRI-MIX E oxybutynin chloride oral 1 tadalafil oral 1 QL OXYTROL 3 ST; QL THIOLA 3 SP OXYTROL FOR E THIOLA EC 3 SP WOMEN tolterodine tartrate 1 penicillamine oral 1 PA; SP capsule tolterodine tartrate er 1 penicillamine oral tablet 1 SP TOVIAZ 3 PENTOSAN TRI-MIX E POLYSULFATE E trospium chloride 1 ST SODIUM ORAL trospium chloride er 1 phenazo oral tablet 200 1 URELLE E mg uretron d/s oral tablet 1 phenazopyridine hcl 81.6 mg oral tablet 100 mg, 200 1 mg URIBEL E PHENYLEPHRINE URIMAR-T E HCL E urin ds oral tablet 81.6 1 INTRACAVERNOSAL mg PHOSLYRA 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 94 Drug Name Drug Tier Notes Drug Name Drug Tier Notes urinary pain relief oral ACTIVE INJECTION E E tablet 95 mg KL-3 URO-458 E ACTIVE INJECTION E UROGESIC-BLUE E LM-DEP-2 uro-mp E ALKINDI SPRINKLE E ustell E BETA 1 KIT E uticap E BETALOAN SUIK E BETAMETHASONE utira-c E E COMBO utrona-c 1 BETAMETHASONE vardenafil hcl oral 1 QL SOD PHOS & ACET VELPHORO 3 INJECTION E VESICARE 3 SUSPENSION 7 (4-3) MG/ML VIAGRA E BETAMETHASONE vilamit mb E SOD PHOS & ACET E VILEVEV MB E SUSPENSION 6 (3-3) Genitourinary Agents MG/ML INJECTION - Drugs for Prostate betamethasone sod Conditions phos & acet E alfuzosin hcl er 1 suspension 6 (3-3) mg/ml injection AVODART 3 BSP 0820 E CARDURA XL 3 ST CELESTONE E dutasteride oral 1 SOLUSPAN dutasteride-tamsulosin CONTRAST ALLERGY 1 E hcl PREMED PACK finasteride oral tablet 5 1 CORTEF 3 mg cortisone acetate oral 1 FLOMAX E DECADRON ORAL E JALYN 3 TABLET PROSCAR 3 DEPO-MEDROL E RAPAFLO 3 DEXABLISS E silodosin 1 dexamethasone 1 tamsulosin hcl 1 intensol terazosin hcl oral 1 dexamethasone oral 1 UROXATRAL 3 dexamethasone sod E Hormonal Agents - phosphate pf Adrenal ACTIVE INJECTION D E ACTIVE INJECTION E KIT L

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 95 Drug Name Drug Tier Notes Drug Name Drug Tier Notes dexamethasone MEDROL ORAL sodium phosphate TABLET THERAPY 3 injection solution 100 E PACK mg/10ml, 120 mg/30ml, MEDROLOAN II SUIK E 20 mg/5ml MEDROLOAN SUIK E DEXAMETHASONE SODIUM PHOSPHATE METHYLPREDNISOL E SOLUTION 10 MG/ML ONE ACETATE INJECTION INJECTION E SUSPENSION 50 dexamethasone MG/ML sodium phosphate E solution 10 mg/ml METHYLPREDNISOL ONE ACETATE injection E SUSPENSION 40 DEXAMETHASONE MG/ML INJECTION SODIUM PHOSPHATE E SOLUTION 4 MG/ML methylprednisolone INJECTION acetate suspension 40 E mg/ml injection dexamethasone sodium phosphate METHYLPREDNISOL E ONE ACETATE solution 4 mg/ml E injection SUSPENSION 80 MG/ML INJECTION DEXONTO 0.4% 3 methylprednisolone DMT SUIK E acetate suspension 80 E DOUBLEDEX E mg/ml injection DXEVO 11-DAY E methylprednisolone 1 DYURAL-40 E oral DYURAL-80 E MILLIPRED DP 12- DAY ORAL TABLET 3 DYURAL-L E THERAPY PACK DYURAL-LM E MILLIPRED ORAL E fludrocortisone acetate TABLET 1 oral MULTI-SPECIALTY E HEMADY E ORAPRED ODT 3 HIDEX 6-DAY E P-CARE K40 E hydrocortisone oral 1 P-CARE K40G E KENALOG INJECTION 3 P-CARE K40MX E KENALOG-80 3 P-CARE K80 E MAS CARE-PAK E P-CARE K80G E MEDROL ORAL P-CARE K80MX E TABLET 16 MG, 32 3 MG, 4 MG, 8 MG PEDIAPRED 3 MEDROL ORAL physicians ez use 2 E TABLET 2 MG joint/tunnel

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 96 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PHYSICIANS EZ USE TRIAMCINOLONE E M-PRED ACETONIDE POD-CARE 100K E INJECTION E SUSPENSION 50 POINT OF CARE L.2 E MG/ML POINT OF CARE L.5 E triamcinolone acetonide POINT OF CARE LM suspension 40 mg/ml 1 E DEP 2 injection prednisolone oral TRIAMCINOLONE 1 solution ACETONIDE 3 prednisolone sodium SUSPENSION 40 phosphate oral solution MG/ML INJECTION 10 mg/5ml, 15 mg/5ml, 1 TRIAMCINOLONE 20 mg/5ml, 25 mg/5ml, ACETONIDE E 6.7 (5 base) mg/5ml SUSPENSION 40 prednisolone sodium MG/ML INJECTION phosphate oral tablet 1 TRILOAN II SUIK E dispersible TRILOAN SUIK E prednisone intensol 1 ZCORT 7-DAY E prednisone oral 1 ZILRETTA E PRO-C-DURE 5 E Hormonal Agents - PRO-C-DURE 6 E Men's Health RAYOS E ANADROL-50 3 PA READYSHARP ANDRODERM ANESTH + E TRANSDERMAL 2 PA METHYLPRED PATCH 24 HOUR READYSHARP ANDROGEL PUMP E BETAMETHASONE TRANSDERMAL GEL 3 PA READYSHARP 20.25 MG/ACT (1.62%) E DEXAMETHASONE ANDROGEL SOLU-CORTEF TRANSDERMAL GEL INJECTION 20.25 MG/1.25GM 3 PA SOLUTION 3 (1.62%), 40.5 RECONSTITUTED 100 MG/2.5GM (1.62%) MG ANDROGEL TRANSDERMAL GEL TAPERDEX 12-DAY E E 25 MG/2.5GM (1%), 50 TAPERDEX 6-DAY E MG/5GM (1%) TAPERDEX 7-DAY AVEED E ORAL TABLET E THERAPY PACK 1.5 danazol oral 1 MG (27) DEPO- TESTOSTERONE TOPIDEX E E INTRAMUSCULAR SOLUTION

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 97 Drug Name Drug Tier Notes Drug Name Drug Tier Notes EC-RX XYOSTED 3 PA E TESTOSTERONE Hormonal Agents - FORTESTA E Osteoporosis JATENZO E EVISTA 3 METHITEST 3 PA OSPHENA 3 methyltestosterone oral 1 PA raloxifene hcl 1 NATESTO E Hormonal Agents - oxandrolone oral 1 PA; QL Pituitary TESTIM E ACTHAR 2 PA; SP TESTONE CIK E BYNFEZIA PEN E SP TESTOPEL E cabergoline 1 TESTOSTERONE CETROTIDE E COMPOUNDING KIT SUBCUTANEOUS KIT E SP 0.25 MG TESTOSTERONE chorionic gonadotropin CYPIONATE 1 PA; SP INJECTION E intramuscular SOLUTION 200 clomiphene citrate oral 1 PA MG/ML DDAVP INJECTION 3 testosterone cypionate SOLUTION 4 MCG/ML intramuscular solution 1 PA DDAVP NASAL 3 100 mg/ml, 200 mg/ml DDAVP ORAL 3 testosterone enanthate 1 PA intramuscular solution DDAVP RHINAL TUBE 2 desmopressin ace TESTOSTERONE 1 IMPLANT PELLET 100 spray refrig E MG, 200 MG, 25 MG, desmopressin acetate 1 50 MG injection testosterone desmopressin acetate 1 transdermal gel 1.62 %, oral 10 mg/act (2%), 12.5 desmopressin acetate 1 mg/act (1%), 20.25 spray mg/1.25gm (1.62%), 1 PA 20.25 mg/act (1.62%), EGRIFTA SV 3 PA; SP; QL 25 mg/2.5gm (1%), ELIGARD 3 PA; SP; QL 40.5 mg/2.5gm FENSOLVI (6 MONTH) E SP (1.62%), 50 mg/5gm FIRMAGON (240 MG (1%) 3 PA; SP; QL DOSE) testosterone 1 PA transdermal solution FIRMAGON SUBCUTANEOUS VOGELXO PUMP E SOLUTION 3 PA; SP; QL VOGELXO RECONSTITUTED 80 TRANSDERMAL GEL E MG 50 MG/5GM (1%)

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 98 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FOLLISTIM AQ LUPRON DEPOT (6- 2 PA; SP SUBCUTANEOUS MONTH) 2 PA; SP ganirelix acetate INTRAMUSCULAR KIT solution prefilled 45MG 1 PA; SP syringe 250 mcg/0.5ml LUPRON DEPOT-PED subcutaneous (1-MONTH) 3 PA; SP ganirelix acetate INTRAMUSCULAR KIT PA; Made by solution prefilled 11.25 MG 1 Organon/Merc syringe 250 mcg/0.5ml LUPRON DEPOT-PED k; SP subcutaneous (1-MONTH) 2 PA; SP GENOTROPIN E SP INTRAMUSCULAR KIT 15 MG, 7.5 MG GENOTROPIN E SP MINIQUICK LUPRON DEPOT-PED (3-MONTH) 3 PA; SP GONAL-F E SP INTRAMUSCULAR KIT GONAL-F RFF E SP 11.25 MG (PED) GONAL-F RFF LUPRON DEPOT-PED E SP REDIJECT (3-MONTH) 2 PA; SP HUMATROPE E SP INTRAMUSCULAR KIT 30 MG (PED) INCRELEX 2 PA; SP MENOPUR 3 PA; SP ISTURISA E SP MYCAPSSA E SP leuprolide acetate 1 PA; SP injection NOCDURNA 3 LUPANETA PACK 3 PA; SP; QL NORDITROPIN FLEXPRO LUPRON DEPOT (1- SUBCUTANEOUS 2 PA; SP MONTH) 3 PA; SP SOLUTION PEN- INTRAMUSCULAR KIT INJECTOR 3.75 MG novarel intramuscular LUPRON DEPOT (1- solution reconstituted 1 PA; SP MONTH) 2 PA; SP 10000 unit INTRAMUSCULAR KIT 7.5 MG NOVAREL INTRAMUSCULAR LUPRON DEPOT (3- SOLUTION 3 PA; SP MONTH) 3 PA; SP RECONSTITUTED INTRAMUSCULAR KIT 5000 UNIT 11.25 MG NUTROPIN AQ LUPRON DEPOT (3- NUSPIN 10 MONTH) 2 PA; SP SUBCUTANEOUS 2 PA; SP INTRAMUSCULAR KIT SOLUTION PEN- 22.5 MG INJECTOR LUPRON DEPOT (4- MONTH) 2 PA; SP INTRAMUSCULAR KIT 30MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 99 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NUTROPIN AQ SIGNIFOR 3 PA; SP; QL NUSPIN 20 SIGNIFOR LAR SUBCUTANEOUS 2 PA; SP INTRAMUSCULAR 3 PA; SP; QL SOLUTION PEN- SUSPENSION INJECTOR RECONSTITUTED ER NUTROPIN AQ SOMATULINE DEPOT 3 PA; SP NUSPIN 5 SUBCUTANEOUS 2 PA; SP SOMAVERT 3 PA; SP SOLUTION PEN- STIMATE 3 INJECTOR SUPPRELIN LA 2 PA; SP; QL octreotide acetate SYNAREL 2 injection solution 100 mcg/ml, 1000 mcg/ml, 1 PA; SP TEPEZZA 3 PA; SP 200 mcg/ml, 50 TRELSTAR MIXJECT 3 PA; SP; QL mcg/ml, 500 mcg/ml TRIPTODUR 3 PA; SP; QL OMNITROPE VANTAS 3 PA; SP; QL SUBCUTANEOUS E SP SOLUTION ZOLADEX CARTRIDGE SUBCUTANEOUS 3 SP; QL IMPLANT 10.8 MG OMNITROPE SUBCUTANEOUS ZOLADEX E SP SOLUTION SUBCUTANEOUS 2 SP; QL RECONSTITUTED IMPLANT 3.6 MG ORILISSA 2 PA; QL ZOMACTON E SP ZOMACTON (FOR OVIDREL 3 PA; SP E SP ZOMA-JET 10) OXYTOCIN- LACTATED RINGERS Hormonal Agents - INTRAVENOUS E Prostaglandins SOLUTION 30 KORLYM 3 PA; SP; QL UNIT/500ML Hormonal Agents - OXYTOCIN-SODIUM Sex Hormones and CHLORIDE Birth Control INTRAVENOUS E ACTIVELLA ORAL 3 SOLUTION 20-0.9 TABLET 1-0.5 MG UNT/L-% afirmelle $0 QL pregnyl 1 PA; SP ALORA 3 ST SAIZEN E SP altavera $0 QL SAIZENPREP E SP alyacen 1/35 $0 QL SANDOSTATIN INJECTION alyacen 7/7/7 $0 QL SOLUTION 100 E SP amabelz 1 MCG/ML, 50 MCG/ML, amethia $0 QL 500 MCG/ML amethia lo $0 QL SANDOSTATIN LAR E SP DEPOT amethyst $0 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 100 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ANGELIQ 3 CLIMARA PRO 2 ANNOVERA E COMBIPATCH 3 apri $0 QL covaryx E aranelle $0 QL covaryx hs E ashlyna $0 QL CRINONE VAGINAL 3 QL aubra $0 QL GEL 4 % CRINONE VAGINAL aubra eq $0 QL 3 PA; QL GEL 8 % aurovela 1.5/30 $0 QL cryselle-28 $0 QL aurovela 1/20 $0 QL cyclafem 1/35 $0 QL aurovela 24 fe $0 QL cyclafem 7/7/7 $0 QL aurovela fe 1.5/30 $0 QL cyred $0 QL aurovela fe 1/20 $0 QL cyred eq $0 QL aviane $0 QL dasetta 1/35 $0 QL AYGESTIN 3 dasetta 7/7/7 $0 QL ayuna $0 QL daysee $0 QL azurette $0 QL deblitane $0 QL BALCOLTRA E DELESTROGEN 3 balziva $0 QL delyla $0 QL bekyree $0 QL DEPO-ESTRADIOL 3 BEYAZ E DEPO-PROVERA BI-EST 80:20 INTRAMUSCULAR E 3 QL PROGESTERONE SUSPENSION 150 BIEST/PROGESTERO MG/ML E NE DEPO-PROVERA BIJUVA 3 INTRAMUSCULAR 3 QL blisovi 24 fe $0 QL SUSPENSION PREFILLED SYRINGE blisovi fe 1.5/30 $0 QL DEPO-SUBQ blisovi fe 1/20 $0 QL PROVERA 104 briellyn $0 QL SUBCUTANEOUS $0 QL camila $0 QL SUSPENSION PREFILLED SYRINGE camrese $0 QL desogestrel-ethinyl camrese lo $0 QL estradiol oral tablet $0 QL caziant $0 QL 0.15-0.02/0.01 mg charlotte 24 fe $0 QL (21/5) chateal $0 QL DIVIGEL 3 chateal eq $0 QL dotti 1 drospiren-eth estrad- CLIMARA 3 $0 QL levomefol

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 101 Drug Name Drug Tier Notes Drug Name Drug Tier Notes drospirenone-ethinyl etonogestrel-ethinyl $0 QL $0 QL estradiol estradiol DUAVEE 2 EVAMIST 3 EC-RX ESTRADIOL E FALESSA ORAL KIT E EC-RX 20-1-0.1 MCG-MG E PROGESTERONE falmina $0 QL eemt E fayosim $0 QL eemt hs E FEMHRT LOW DOSE 3 ELESTRIN 3 FEMRING 3 ST; QL elinest $0 QL femynor $0 QL ELLA $0 QL FIRST- eluryng $0 QL PROGESTERONE VGS VAGINAL E emoquette $0 QL SUPPOSITORY 100 ENDOMETRIN 2 PA MG, 200 MG enpresse-28 $0 QL fyavolv 1 enskyce oral tablet gemmily $0 QL $0 QL 0.15-30 mg-mcg GENERESS FE 3 QL errin $0 QL gianvi $0 QL est estrogens- E hailey 1.5/30 $0 QL methyltest hailey 24 fe $0 QL est estrogens- E methyltest ds hailey fe 1.5/30 $0 QL est estrogens- hailey fe 1/20 $0 QL E methyltest hs heather $0 QL estarylla $0 QL hydroxyprogesterone 1 PA; SP ESTRACE 3 caproate intramuscular IMVEXXY estradiol oral 1 3 MAINTENANCE PACK estradiol transdermal 1 IMVEXXY STARTER 3 estradiol vaginal 1 PACK estradiol valerate incassia $0 QL intramuscular oil 20 1 mg/ml, 40 mg/ml introvale $0 QL estradiol-norethindrone isibloom $0 QL 1 acet jaimiess $0 QL ESTRING 3 QL jasmiel $0 QL ESTROGEL 3 jencycla $0 QL ESTROSTEP FE 3 QL jinteli 1 ethynodiol diac-eth jolessa $0 QL $0 QL estradiol juleber $0 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 102 Drug Name Drug Tier Notes Drug Name Drug Tier Notes junel 1.5/30 $0 QL lillow $0 QL junel 1/20 $0 QL LO LOESTRIN FE $0 QL junel fe 1.5/30 $0 QL LOESTRIN 1.5/30 (21) 3 QL junel fe 1/20 $0 QL LOESTRIN 1/20 (21) 3 QL junel fe 24 $0 QL LOESTRIN FE 1.5/30 3 QL kaitlib fe $0 QL LOESTRIN FE 1/20 3 QL kalliga $0 QL lojaimiess $0 QL kariva $0 QL loryna $0 QL kelnor 1/35 $0 QL LOSEASONIQUE 3 QL kelnor 1/50 $0 QL low-ogestrel $0 QL kurvelo $0 QL lo-zumandimine $0 QL KYLEENA E lutera $0 QL larin 1.5/30 $0 QL lyllana 1 larin 1/20 $0 QL lyza $0 QL larin 24 fe $0 QL MAKENA 2 PA; SP larin fe 1.5/30 $0 QL marlissa $0 QL larin fe 1/20 $0 QL medroxyprogesterone $0 QL larissia $0 QL acetate intramuscular medroxyprogesterone layolis fe $0 QL 1 acetate oral leena $0 QL megestrol acetate oral lessina $0 QL suspension 40 mg/ml, 1 levonest $0 QL 625 mg/5ml levonorgest-eth est & megestrol acetate oral $0 QL 1 eth est tablet levonorgest-eth estrad melodetta 24 fe $0 QL $0 QL 91-day MENEST ORAL levonorgestrel oral TABLET 0.3 MG, 0.625 2 $0 QL tablet 1.5 mg MG, 1.25 MG levonorgestrel-ethinyl MENOSTAR 3 ST $0 QL estrad mibelas 24 fe $0 QL levonorg-eth estrad microgestin 1.5/30 $0 QL triphasic oral tablet 50- $0 QL 30/75-40/ 125-30 mcg microgestin 1/20 $0 QL levora 0.15/30 (28) $0 QL microgestin fe 1.5/30 $0 QL LILETTA (52 MG) microgestin fe 1/20 $0 QL INTRAUTERINE mili $0 QL INTRAUTERINE E mimvey 1 DEVICE 19.5 MCG/DAY MINASTRIN 24 FE E MINIVELLE 3 ST

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 103 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MIRCETTE 3 QL ORTHO MICRONOR E MIRENA (52 MG) E PARAGARD mono-linyah $0 QL INTRAUTERINE E COPPER NATAZIA $0 QL philith $0 QL necon 0.5/35 (28) $0 QL pimtrea $0 QL NEXPLANON E pirmella 1/35 $0 QL nikki $0 QL pirmella 7/7/7 $0 QL nora-be $0 QL PLAN B ONE-STEP $0 QL norethin ace-eth $0 QL estrad-fe oral capsule portia-28 $0 QL norethin ace-eth PREFEST 3 estrad-fe oral tablet 1- PREMARIN ORAL 2 $0 QL 20 mg-mcg, 1.5-30 mg- PREMARIN VAGINAL 2 mcg PREMPHASE 2 norethin ace-eth estrad-fe oral tablet $0 QL PREMPRO 2 chewable previfem $0 QL norethindrone acetate PROGESTERONE 1 E oral COMPOUNDING KIT norethindrone acet- progesterone $0 QL 1 ethinyl est oral tablet intramuscular norethindrone oral $0 QL progesterone 1 norethindrone-eth micronized oral 1 estradiol PROGESTERONE norethin-eth estradiol-fe $0 QL MICRONIZED E TRANSDERMAL norgestimate-eth estradiol oral tablet $0 QL PROMETRIUM 3 0.25-35 mg-mcg PROVERA 3 norgestimate-ethinyl QUARTETTE 3 QL $0 QL estradiol triphasic reclipsen $0 QL norlyda $0 QL rivelsa $0 QL norlyroc $0 QL SAFYRAL 3 QL nortrel 0.5/35 (28) $0 QL SEASONIQUE 3 QL nortrel 1/35 (21) $0 QL setlakin $0 QL nortrel 1/35 (28) $0 QL sharobel $0 QL nortrel 7/7/7 $0 QL simliya $0 QL NUVARING 3 QL simpesse $0 QL ocella $0 QL SKYLA E ORIAHNN 2 PA; QL SLYND E orsythia $0 QL sprintec 28 $0 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 104 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sronyx $0 QL YASMIN 28 3 QL syeda $0 QL YAZ E tarina 24 fe $0 QL yuvafem 1 tarina fe 1/20 $0 QL zarah $0 QL tarina fe 1/20 eq $0 QL zovia 1/35 (28) $0 QL TAYTULLA E zovia 1/35e (28) $0 QL tilia fe $0 QL zumandimine $0 QL tri femynor $0 QL Hormonal Agents - tri-estarylla $0 QL Thyroid tri-legest fe $0 QL ARMOUR THYROID 3 ST tri-linyah $0 QL CYTOMEL E tri-lo-estarylla $0 QL euthyrox 1 tri-lo-marzia $0 QL levo-t 1 tri-lo-mili $0 QL LEVOTHYROXINE SODIUM ORAL E tri-lo-sprintec $0 QL CAPSULE tri-mili $0 QL levothyroxine sodium 1 tri-previfem $0 QL oral tablet tri-sprintec $0 QL levoxyl 1 trivora (28) $0 QL liothyronine sodium oral 1 tri-vylibra $0 QL methimazole oral 1 tri-vylibra lo $0 QL NATURE-THROID 3 ST tulana $0 QL np thyroid 1 TWIRLA 3 QL propylthiouracil oral 1 tyblume $0 QL SYNTHROID 3 tydemy $0 QL TAPAZOLE 3 VAGIFEM VAGINAL TIROSINT E E TABLET 10 MCG TIROSINT-SOL 3 velivet $0 QL unithroid 1 vienva $0 QL WESTHROID ORAL viorele $0 QL TABLET 130 MG, 195 3 ST VIVELLE-DOT E MG, 32.5 MG, 65 MG, 97.5 MG volnea $0 QL WP THYROID 3 ST vyfemla $0 QL Immunological vylibra $0 QL Agents - Drugs for wera $0 QL Immune System wymzya fe $0 QL Stimulation or Suppression xulane $0 QL ACTEMRA 3 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 105 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ACTEMRA ACTPEN 3 PA; SP COSENTYX ACTIMMUNE 2 PA; SP SENSOREADY PEN SUBCUTANEOUS E SP ALFERON N 2 SP SOLUTION AUTO- ARAVA 3 INJECTOR 150 MG/ML ARCALYST 3 PA; SP CUTAQUIG E SP ASCENIV E SP CUVITRU 3 PA; SP ASTAGRAF XL 3 SP cyclosporine 1 SP ATGAM 2 SP intravenous AVSOLA 3 PA; SP cyclosporine modified 1 SP cyclosporine oral AZASAN 3 1 SP capsule azathioprine oral 1 CYTOGAM 2 PA; SP azathioprine sodium E ENBREL MINI 3 PA; SP BENLYSTA 3 PA; SP ENBREL BERINERT 3 PA; SP; QL SUBCUTANEOUS 3 PA; SP BIVIGAM SOLUTION 25 INTRAVENOUS MG/0.5ML 3 PA; SP SOLUTION 5 ENBREL GM/50ML SUBCUTANEOUS 3 PA; SP CARIMUNE NF SOLUTION INTRAVENOUS PREFILLED SYRINGE SOLUTION 3 PA; SP ENBREL RECONSTITUTED 12 SUBCUTANEOUS 3 PA; SP GM, 6 GM SOLUTION CELLCEPT 3 SP RECONSTITUTED CELLCEPT ENBREL SURECLICK 3 SP INTRAVENOUS SUBCUTANEOUS 3 PA; SP CIMZIA PREFILLED SOLUTION AUTO- 2 PA; SP KIT INJECTOR CIMZIA STARTER KIT 2 PA; SP ENSPRYNG E SP CIMZIA VIAL KIT 2 PA; SP ENTYVIO 3 PA; SP CINRYZE 2 PA; SP ENVARSUS XR 3 SP COSENTYX (300 MG everolimus oral tablet E SP DOSE) 0.25 mg, 0.5 mg, 0.75 1 PA; SP mg COSENTYX 150 E SP MG/ML FIRAZYR 3 PA; SP; QL COSENTYX FLEBOGAMMA DIF 3 PA; SP SENSOREADY (300 E SP GAMASTAN 2 PA; SP MG) GAMIFANT 3 PA; SP GAMMAGARD 3 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 106 Drug Name Drug Tier Notes Drug Name Drug Tier Notes GAMMAGARD S/D HUMIRA PEN- 3 PA; SP LESS IGA PS/UV/ADOL HS START GAMMAKED 2 PA; SP INJECTION SUBCUTANEOUS SOLUTION 1 PEN-INJECTOR KIT GM/10ML, 10 3 PA; SP 40 MG/0.8ML GM/100ML, 20 HUMIRA PEN- GM/200ML, 5 PSOR/UVEIT 2 PA; SP GM/50ML STARTER GAMMAPLEX HUMIRA INTRAVENOUS SUBCUTANEOUS 2 PA; SP SOLUTION 10 PREFILLED SYRINGE GM/100ML, 10 KIT GM/200ML, 20 3 PA; SP HYPERHEP B S/D E GM/200ML, 20 GM/400ML, 5 HYPERRAB E GM/100ML, 5 HYPERRAB S/D E GM/50ML INJECTION GAMUNEX-C 3 PA; SP HYPERRHO S/D gengraf oral capsule INTRAMUSCULAR 1 SP 2 SP 100 mg, 25 mg SOLUTION PREFILLED SYRINGE gengraf oral solution 1 SP HYPERTET S/D E HAEGARDA 3 PA; SP HYQVIA 3 PA; SP HEPAGAM B E icatibant acetate 1 PA; SP; QL HIZENTRA SUBCUTANEOUS ILARIS SOLUTION 1 GM/5ML, 3 PA; SP SUBCUTANEOUS 2 PA; SP; QL 10 GM/50ML, 2 SOLUTION GM/10ML, 4 GM/20ML ILUMYA 3 PA; SP HIZENTRA IMOGAM RABIES-HT E SUBCUTANEOUS INJECTION 3 PA; SP SOLUTION IMURAN 3 PREFILLED SYRINGE INFLECTRA 2 PA; SP HUMIRA PEDIATRIC CROHNS START KALBITOR 3 PA; SP; QL SUBCUTANEOUS KEDRAB INJECTION E PREFILLED SYRINGE 2 PA; SP KEVZARA 3 PA; SP KIT 80 MG/0.8ML, 80 MG/0.8ML & KINERET SUBCUTANEOUS 40MG/0.4ML 3 PA; SP SOLUTION HUMIRA PEN PREFILLED SYRINGE SUBCUTANEOUS 2 PA; SP PEN-INJECTOR KIT KYMRIAH 3 PA; SP HUMIRA PEN- leflunomide oral 1 2 PA; SP CD/UC/HS STARTER methotrexate oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 107 Drug Name Drug Tier Notes Drug Name Drug Tier Notes methotrexate sodium OTREXUP (pf) injection solution 1 SUBCUTANEOUS 1 gm/40ml, 250 mg/10ml, SOLUTION AUTO- 50 mg/2ml INJECTOR 10 3 PA; QL methotrexate sodium MG/0.4ML, 15 injection solution 250 1 MG/0.4ML, 20 mg/10ml, 50 mg/2ml MG/0.4ML, 25 MG/0.4ML methotrexate sodium injection solution 1 OTREXUP reconstituted SUBCUTANEOUS SOLUTION AUTO- methotrexate sodium 1 INJECTOR 12.5 E oral MG/0.4ML, 17.5 MICRHOGAM ULTRA- MG/0.4ML, 22.5 FILTERED PLUS MG/0.4ML INTRAMUSCULAR 2 SP PANZYGA E SP SOLUTION PREFILLED SYRINGE PRIVIGEN 3 PA; SP mycophenolate mofetil 1 SP PROGRAF 3 SP mycophenolate mofetil PROVENGE 2 PA; SP 1 SP hcl RAPAMUNE 3 SP mycophenolate sodium 1 SP RASUVO MYFORTIC 3 SP SUBCUTANEOUS SOLUTION AUTO- NABI-HB E INJECTOR 10 NEORAL 3 SP MG/0.2ML, 12.5 NULOJIX 3 PA; SP MG/0.25ML, 15 MG/0.3ML, 17.5 2 PA; QL OCTAGAM 3 PA; SP MG/0.35ML, 20 OLUMIANT E SP MG/0.4ML, 22.5 ORENCIA CLICKJECT 3 PA; SP MG/0.45ML, 25 MG/0.5ML, 30 ORENCIA 3 PA; SP MG/0.6ML, 7.5 INTRAVENOUS MG/0.15ML ORENCIA REDITREX E SUBCUTANEOUS 3 PA; SP SOLUTION REMICADE E SP PREFILLED SYRINGE RENFLEXIS 2 PA; SP OTEZLA ORAL RHOGAM ULTRA- 2 PA; SP TABLET FILTERED PLUS OTEZLA ORAL INTRAMUSCULAR 2 SP TABLET THERAPY 2 PA; SP SOLUTION PACK PREFILLED SYRINGE RHOPHYLAC INJECTION E SOLUTION PREFILLED SYRINGE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 108 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RIDAURA 3 SP TREMFYA 2 PA; SP RINVOQ 2 PA; SP TREXALL 3 RUCONEST 3 PA; SP; QL UPLIZNA 3 PA; SP SANDIMMUNE VARIZIG 2 SP INTRAVENOUS INTRAMUSCULAR E SANDIMMUNE ORAL SOLUTION 3 SP CAPSULE WINRHO SDF 2 SP SANDIMMUNE ORAL XATMEP 3 2 SP SOLUTION XELJANZ 2 PA; SP SILIQ 3 PA; SP XELJANZ XR 2 PA; SP SIMPONI ARIA 2 PA; SP XEMBIFY 3 PA; SP SIMPONI ZINPLAVA E SUBCUTANEOUS 2 PA; SP SOLUTION AUTO- ZORTRESS 3 PA; SP INJECTOR Immunological SIMPONI Agents - Drugs for SUBCUTANEOUS Vaccination 2 PA; SP SOLUTION ACTHIB $0 PREFILLED SYRINGE ADACEL SIMULECT E INTRAMUSCULAR $0 sirolimus oral 1 SP SUSPENSION 5-2-15.5 LF-MCG/0.5 SKYRIZI (150 MG 2 PA; SP AFLURIA DOSE) $0 QUADRIVALENT STELARA 2 PA; SP INTRAVENOUS BCG VACCINE E STELARA BEXSERO $0 SUBCUTANEOUS BIOTHRAX E 2 PA; SP; QL SOLUTION 45 BOOSTRIX MG/0.5ML INTRAMUSCULAR $0 STELARA SUSPENSION 5-2.5- SUBCUTANEOUS 18.5 LF-MCG/0.5 2 PA; SP; QL SOLUTION DAPTACEL PREFILLED SYRINGE INTRAMUSCULAR $0 SYNAGIS 2 PA; SP SUSPENSION 23-15-5 tacrolimus oral 1 SP DIPHTHERIA- TAKHZYRO 3 PA; SP TETANUS TOXOIDS $0 DT TALTZ 3 PA; SP ENGERIX-B temsirolimus 1 SP INJECTION THYMOGLOBULIN E SUSPENSION 10 $0 TICE BCG 2 SP MCG/0.5ML, 20 MCG/ML TORISEL 3 SP FLUAD $0

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 109 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FLUAD MENVEO $0 $0 QUADRIVALENT M-M-R II INJECTION $0 FLUARIX PEDVAX HIB QUADRIVALENT INTRAMUSCULAR $0 INTRAMUSCULAR $0 SUSPENSION SUSPENSION PREFILLED SYRINGE PNEUMOVAX 23 $0 FLUCELVAX PREVNAR 13 $0 $0 QUADRIVALENT RABAVERT E FLULAVAL RECOMBIVAX HB QUADRIVALENT INJECTION INTRAMUSCULAR $0 SUSPENSION 10 $0 SUSPENSION MCG/ML, 40 MCG/ML, PREFILLED SYRINGE 5 MCG/0.5ML FLUMIST ROTARIX $0 $0 QUADRIVALENT ROTATEQ ORAL $0 FLUZONE SOLUTION QUADRIVALENT SHINGRIX INTRAMUSCULAR $0 INTRAMUSCULAR SUSPENSION , 0.5 SUSPENSION $0 ML RECONSTITUTED 50 FLUZONE MCG/0.5ML QUADRIVALENT STAMARIL E INTRAMUSCULAR $0 SUSPENSION TDVAX $0 PREFILLED SYRINGE TENIVAC $0 0.5 ML TETANUS- GARDASIL 9 $0 DIPHTHERIA $0 HAVRIX TOXOIDS TD INTRAMUSCULAR TRUMENBA $0 $0 SUSPENSION 1440 EL TWINRIX U/ML, 720 EL U/0.5ML INTRAMUSCULAR $0 HEPLISAV-B SUSPENSION INTRAMUSCULAR PREFILLED SYRINGE $0 SOLUTION TYPHIM VI PREFILLED SYRINGE INTRAMUSCULAR E HIBERIX INJECTION $0 SOLUTION 25 IMOVAX RABIES E MCG/0.5ML INFANRIX $0 VAQTA INTRAMUSCULAR IPOL INJECTION $0 SUSPENSION 25 $0 INJECTABLE UNIT/0.5ML, 50 IXIARO E UNIT/ML MENACTRA $0 VARIVAX $0 MENQUADFI $0 VAXCHORA E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 110 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VIVOTIF E hemorrhoidal-hc rectal E YF-VAX E suppository hydrocortisone Inflammatory Bowel 1 Disease Agents (perianal) ana-lex E hydrocortisone ace- pramoxine external 1 ANALPRAM HC E cream 1-1 % EXTERNAL hydrocortisone acetate ANALPRAM HC E E rectal SINGLES EXTERNAL hydrocortisone rectal ANALPRAM-HC 1 3 enema EXTERNAL CREAM hydrocort-pramoxine ANALPRAM-HC E E (perianal) EXTERNAL LOTION LIALDA E anucort-hc E lidocaine-hydrocort ANUSOL-HC E 3 (perianal) EXTERNAL LIDOCAINE- ANUSOL-HC RECTAL E HYDROCORTISONE E SUPPOSITORY ACE RECTAL GEL APRISO 2 lidocaine- ASACOL HD E hydrocortisone ace E AZULFIDINE 3 rectal kit LIDOCORT AZULFIDINE EN-TABS 3 E EXTERNAL balsalazide disodium 1 mesalamine er 1 budesonide er oral tablet extended release 1 mesalamine oral 1 24 hour mesalamine rectal 1 budesonide oral 1 mesalamine-cleanser 1 CANASA E ORTIKOS E COLAZAL 3 PENTASA 3 CORTENEMA 3 PROCORT EXTERNAL E CORTIFOAM PROCTOCORT 3 3 EXTERNAL EXTERNAL DELZICOL E PROCTOCORT DIPENTUM E RECTAL E SUPPOSITORY ENTOCORT EC ORAL PROCTOFOAM HC CAPSULE DELAYED 3 2 RELEASE PARTICLES EXTERNAL hemmorex-hc rectal procto-med hc external 1 E suppository 25 mg procto-pak external 1 proctozone-hc external 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 111 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ROWASA RECTAL 3 PROLIA SUBCUTANEOUS SFROWASA 2 2 PA; SP; QL SOLUTION sulfasalazine oral 1 PREFILLED SYRINGE UCERIS 3 RAYALDEE 3 Metabolic Bone RECLAST 3 SP Disease Agents - risedronate sodium oral Drugs for 1 QL Osteoporosis tablet 150 mg, 35 mg risedronate sodium oral ACTONEL ORAL 1 TABLET 150 MG, 35 3 QL tablet 30 mg, 5 mg MG risedronate sodium oral 1 QL alendronate sodium tablet delayed release 1 oral solution TERIPARATIDE 2 PA; SP alendronate sodium (RECOMBINANT) 1 oral tablet 10 mg, 5 mg TYMLOS 2 PA; SP alendronate sodium XGEVA 2 PA; SP oral tablet 35 mg, 70 1 QL zoledronic acid mg intravenous 1 SP ATELVIA 3 QL concentrate BINOSTO 3 QL zoledronic acid 1 SP BONIVA intravenous solution E INTRAVENOUS Metabolic Bone BONIVA ORAL Disease Agents - 3 QL TABLET 150 MG Other calcitriol intravenous calcitonin (salmon) 1 QL E solution 1 mcg/ml EVENITY 3 PA; SP; QL calcitriol oral 1 FORTEO SUBCUTANEOUS cinacalcet hcl 1 PA 2 PA; SP SOLUTION PEN- doxercalciferol oral 1 INJECTOR NATPARA 3 PA; SP; QL FOSAMAX ORAL 3 QL paricalcitol intravenous E TABLET 70 MG paricalcitol oral 1 FOSAMAX PLUS D E PARSABIV 3 SP ibandronate sodium intravenous solution 3 E ROCALTROL 3 mg/3ml SENSIPAR 3 PA ibandronate sodium ZEMPLAR 1 QL E oral INTRAVENOUS MIACALCIN ZEMPLAR ORAL 3 INJECTION CAPSULE 1 MCG, 2 3 pamidronate disodium 1 SP MCG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 112 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Miscellaneous ANTIVENIN Therapeutic Agents LATRODECTUS E 3232a infant formula E MACTANS ACACIA ANTIVENIN E SUBCUTANEOUS MICRURUS FULVIUS E INTRAVENOUS ACCU-CHEK E FLEXLINK PLUS 6MM APP SLIM RMS E ACCU-CHEK TENDER APPTRIM E E 1 INFUSION APPTRIM-D E ACCU-CHEK ARIDOL INHALATION E ULTRAFLEX INF SET KIT 0 & 5 & 10 & 20 & E ACREMONIUM E 40 MG ACTHREL 3 SP ARIZONA CYPRESS E ACTIFOAM ARTISS EXTERNAL E 3 COLLAGEN SPONGE SOLUTION ACUNOL E asilnasalrms E ADAKVEO 3 PA; SP ASPARTAME E ADULT AEROSOL ASPARTAME E E MASK (NUTRASWEET) AERIVA AUREOBASIDIUM E CONCENTRATOR E AUSTRALIAN PINE E NEBULIZER AUTOSOFT 30 E ALCOHOL PREP INFUSION SET 3 PADS PAD AUTOSOFT 90 E ALCOHOL PREP INFUSION SET 3 PADS PAD 70 % AUTOSOFT XC E ALDER E INFUSION SET ALTERNARIA E AVAILNEX E AMERICAN BEECH E AVITENE E AMERICAN AVITENE FLOUR E E COCKROACH AXONA E AMERICAN ELM E AZALGIA E AMERICAN E BAHIA E SYCAMORE BALD CYPRESS E AMINOPMRMS E BAYBERRY (WAX E ANDEXXA MYRTLE) INTRAVENOUS BERMUDA GRASS SOLUTION E E RECONSTITUTED 200 SUBCUTANEOUS MG BHI URI-CONTROL E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 113 Drug Name Drug Tier Notes Drug Name Drug Tier Notes BLACK WALNUT CARETOUCH E POLLEN UNIVERSL CPAP E BLACK WILLOW E FILTER PA; Non- CARTICEL E BOTOX 2 Cosmetic; SP CAT HAIR EXTRACT E BOTRYTIS SUBCUTANEOUS E SUBCUTANEOUS CATTLE EPITHELIUM E BOX ELDER E CAYA $0 QL BREATHE EASE CEDAR ELM E E HUMIDIFIER CLADOSPORIUM BREATHE EASE NEB CLADOSPORIOIDES E E MASK/CHILD SUBCUTANEOUS BREATHE EASE NEB CLADOSPORIUM E E MASK/INFANT SPHAEROSPERMUM BRIDION COCKLEBUR E INTRAVENOUS coenzyme q10 oral E E SOLUTION 500 capsule 50 mg MG/5ML COLCIGEL E BRIDION SOLUTION 200 MG/2ML E COLD-EEZE NATURAL MULTI- INTRAVENOUS E SYMP BROME E MOUTH/THROAT CALIFORNIA PEPPER E COLD-EEZE PLUS TREE DEFENSE E CAMINO PRO MOUTH/THROAT COMPLETE/GLYTACT E COLD-EEZE SUGAR IN FREE E CANDIDA ALBICANS MOUTH/THROAT EXTRACT E LOZENGE SUBCUTANEOUS CONDOMS E CARDIOVID PLUS E CORN POLLEN E CARETOUCH 2 CPAP E CORTROSYN E HOSE HANGER cosyntropin injection E CARETOUCH CPAP & E BIPAP HOSE CROFAB E CARETOUCH CPAP CURVULARIA E E MASK WIPES DANDELION E CARETOUCH CPAP deferoxamine mesylate E E PRE-WASH SOLN DELTEC COZMO E CARETOUCH CPAP CLEO SET 24" 6MM E TUBE BRUSH

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 114 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DESFERAL ENFAGROW INJECTION NEUROPRO E SOLUTION E TODDLER RECONSTITUTED 500 ENFAMIL MG GENTLEASE ORAL E desflurane 1 POWDER dexmedetomidine hcl in ENFAMIL INFANT E nacl intravenous ORAL POWDER E solution 200-0.9 ENFAMIL NEUROPRO E mcg/50ml-%, 400-0.9 SENSITIVE dexmedetomidine hcl in ENFAMIL nacl solution 200 E NUTRAMIGEN LIPIL E mcg/50ml intravenous ORAL LIQUID dexmedetomidine hcl in ENFAMIL nacl solution 400 E NUTRAMIGEN LIPIL E mcg/100ml intravenous ORAL POWDER dexmedetomidine hcl in ENFAMIL nacl solution 80 E NUTRAMIGEN ORAL E mcg/20ml intravenous LIQUID dexmedetomidine hcl ENGLISH PLANTAIN E intravenous solution E 200 mcg/2ml ENLYTE E DIGIFAB E enovarx-amitriptyline E DOG EPITHELIUM E ENTERAGAM E DOG FENNEL E enteric fish oil E DOJOLVI E EPICOCCUM E DRECHSLERA E EPISIL E DUROLANE INTRA- EQUACARE JR E 2 PA; SP ARTICULAR ergoloid mesylates oral 1 DUST MITE MIXED ESSENTIAL CARE JR E ALLERGEN EXT E EUFLEXXA INTRA- SUBCUTANEOUS ARTICULAR 2 PA; SP DYSPORT 3 PA; SP SOLUTION EASIVENT 2 PREFILLED SYRINGE EASTERN EVRYSDI E SP E COTTONWOOD FIRDAPSE E SP EC-RX DHEA E FIRE ANT E ECZEMOL E FLEXICHAMBER 2 ENDARI 3 PA ADULT MASK/SMALL FLEXICHAMBER ENDO AVITENE E 2 CHILD MASK/LARGE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 115 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FLEXICHAMBER GLEOLAN E 2 CHILD MASK/SMALL GLUTARALDEHYDE 3 FORANE 3 EXTERNAL formaldehyde external GLYTACTIN E E solution 10 % BETTERMILK 15 FORMALDEHYDE GLYTACTIN E SOLUTION 37 % 3 BETTERMILK DE-LITE EXTERNAL (RX) GLYTACTIN BUILD E FORMALDEHYDE 10PE SOLUTION 37 % E GLYTACTIN BUILD E EXTERNAL (RX) 20/20 FOSTEUM PLUS E GLYTACTIN BUILD E FOVEX E 20/20 PKU FUSARIUM E GLYTACTIN BURST E GABADONE E GLYTACTIN E GELCLAIR E COMPLETE 10PE GLYTACTIN GELFILM EXTERNAL E E RESTORE 10 GEL-FLOW E GLYTACTIN E GEL-FLOW NT E RESTORE 5 GELFOAM E GLYTACTIN E GELFOAM RESTORE LITE 10 COMPRESSED SIZE E GLYTACTIN E 100 RESTORE LITE 10PE GELFOAM DENTAL GLYTACTIN RTD 10 E E PACK SIZE 4 LIQUID ORAL GELFOAM SPONGE E GLYTACTIN RTD 15 E GELFOAM SPONGE GLYTACTIN RTD LITE E E SIZE 100 15 LIQUID ORAL GELFOAM SPONGE GLYTACTIN SWIRL E E SIZE 200 15PE GELFOAM SPONGE E GOLDENROD E SIZE 50 GRASTEK 3 PA; QL GELFOAM-JMI E POWDER H2Q ORAL POWDER E GELFOAM-JMI HACKBERRY E E SPONGE heparin lock flush GELSYN-3 2 PA; SP intravenous solution 10 1 unit/ml GELX E heparin sodium lock GERMAN E flush intravenous 1 COCKROACH solution 100 unit/ml GIVLAARI 3 PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 116 Drug Name Drug Tier Notes Drug Name Drug Tier Notes HEPMED E KETOVIE PEPTIDE E HIBICLENS E KOCHIA E HOMACTIN AA PLUS E LAMBS QUARTERS E HOME PAP KIT E LENSCALE E HONEY BEE VENOM LIMBREL E SUBCUTANEOUS LIMBREL250 E SOLUTION E RECONSTITUTED LIMBREL500 E 1100 MCG LISTER-V E HORSE EPITHELIUM E LORMATE E HUMATROPEN FOR MACRILEN E E 12MG MACUTEK E HUMATROPEN FOR E MASK VORTEX E 24MG MEADOW FESCUE HUMATROPEN FOR E E GRASS POLLEN 6MG MELALEUCA E HYALGAN E SP MESQUITE E HYLAFEM E METHACHOLINE HYMOVIS E SP CHLORIDE E HYPERTENSA E INHALATION INSPIREASE METHAVER E 2 RESERVOIR BAGS methergine oral 1 QL INTERCEED E METHOHEXITAL IOSAT E SODIUM INTRAVENOUS isoflurane 1 E SOLUTION ISOVACTIN AA PLUS E PREFILLED SYRINGE JOHNSON GRASS E 100 MG/10ML JUNE GRASS methylergonovine 1 QL POLLEN E maleate oral STANDARDIZED METOPIRONE E KAPOK E MINIMED PUMP E KETAMINE HCL RESERVOIR 3ML 3 SUBLINGUAL MITE (D. FARINAE) E KETAMINE HCL- SUBCUTANEOUS SODIUM CHLORIDE MITE (D. INTRAVENOUS E PTERONYSSINUS) E SOLUTION SUBCUTANEOUS PREFILLED SYRINGE 50-0.9 MG/5ML-% MIXED ASPERGILLUS E KETOVIE LIQUID MIXED FEATHERS E E ORAL MIXED RAGWEED E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 117 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MIXED VESPID ORALAIR CHILDRENS 3 PA; QL VENOM PROTEIN SAMPLE KIT SUBCUTANEOUS ORALAIR CHILDRENS E 3 PA; QL SOLUTION STARTER PACK RECONSTITUTED 1100-1100-1100 MCG ORAMAGICRX E MKO MELT DOSE ORCHARD GRASS E E PACK POLLEN mlk f1 E ORTHOVISC INTRA- ARTICULAR E SP mlk f2 E SOLUTION mlk f3 E PREFILLED SYRINGE mlk f4 E OXBRYTA E SP MONOVISC E SP PALFORZIA (12 MG E SP MORCIN E DAILY DOSE) PALFORZIA (120 MG MOUNTAIN CEDAR E E SP DAILY DOSE) MOUSE EPITHELIUM E PALFORZIA (160 MG MUCOR E SP E DAILY DOSE) SUBCUTANEOUS PALFORZIA (20 MG E SP MUCOTROL E DAILY DOSE) MUGARD E PALFORZIA (200 MG E SP MUGWORT E DAILY DOSE) MYOBLOC 3 PA; SP PALFORZIA (240 MG E SP NEODOT DAILY DOSE) E THERMOMETER PALFORZIA (3 MG E SP NEUREPA E DAILY DOSE) PALFORZIA (300 MG NICAPRIN E E SP MAINTENANCE) NICAZYME E PALFORZIA (300 MG NORDIPEN 5 E SP E TITRATION) INJECTION DEVICE PALFORZIA (40 MG E SP odorless coated fish oil E DAILY DOSE) OLIVE TREE E PALFORZIA (6 MG E SP OMNIVEX E DAILY DOSE) OPTIONS PALFORZIA (80 MG $0 QL E SP CONCEPTROL DAILY DOSE) ORALAIR 3 PA; QL PALFORZIA INITIAL E SP ORALAIR ADULT ESCALATION 3 PA; QL SAMPLE KIT PARADIGM QUICK- E ORALAIR ADULT SET 23" 9MM 3 PA; QL STARTER PACK

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 118 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PARI ALTERA PRONEB ULTRA E NEBULIZER E FILTER SET HANDSET PSORIZIDE FORTE E PARI TREK S COMBO E PSORIZIDE ULTRA E PACK PULMONA E PARI VORTEX ADULT E MASK PURAMINO DHA/ARA E PECAN POLLEN E QUEEN PALM E PENICILLIUM RABBIT EPITHELIUM E NOTATUM E RADIOGARDASE 3 SUBCUTANEOUS RAGWITEK 3 PA; QL PERCURA E RAPID GEL RX E PERENNIAL RYE RED BIRCH E GRASS POLLEN E SUBCUTANEOUS RED CEDAR E PH STRIPS E RED MAPLE E PHENACTIN AA PLUS E RED MULBERRY E RED TOP GRASS PHEXXI E E POLLEN PHOMA EXIGUA E RESECTISOL E PHOTREXA- RESOURCE PHOTREXA VISCOUS 3 E KIT THICKENUP JUICE PRAXBIND E RHEUMATE E PRECEDEX RHIZOPUS E INTRAVENOUS RIBOZEL E SOLUTION 1000 ROUGH MARSH MCG/250ML, 200 E E ELDER MCG/2ML, 200 MCG/50ML, 400 ROUGH PIGWEED E MCG/100ML, 80 RUSSIAN THISTLE E MCG/20ML RUZURGI 3 PA; SP PREMIUM CONDOMS E SACCHAROMYCES LUBRICATED CEREVISIAE E PRID E SUBCUTANEOUS PRIVET E SAGEBRUSH E PRO-CRITIC E SALICEPT PROFESSIONAL DNA MOUTH/THROAT E E COLLECTION SUSPENSION RECONSTITUTED PROLEVA E SENTRA AM E PROMACTIN AA PLUS E 20PE SENTRA PM E sevoflurane 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 119 Drug Name Drug Tier Notes Drug Name Drug Tier Notes SHAGBARK HICKORY E THYROGEN 2 PA; SP SHARPS CONTAINER E TIMOTHY GRASS SHEEP SORREL E POLLEN ALLERGEN E SUBCUTANEOUS SHORT RAGWEED E TISSEEL EXTERNAL POLLEN EXT 3 KIT SILTREX E TL-ICARE E SODIUM HYALURONATE E SP TOBAKIENT E INTRA-ARTICULAR TOXICOLOGY SALIVA E SORBITOL COLLECTION E IRRIGATION TRANZGEL E sorbitol-mannitol E TRAUMEEL SORREL/DOCK MIX E EXTERNAL E OINTMENT SPEEDGEL RX E TRAUMEEL ORAL E SPINRAZA 3 PA; SP TABLET SPINY PIGWEED E TREPADONE E STEMPHYLIUM E TRICHOPHYTON E SUPARTZ FX E SP MENTAGROPHYTES SUPRANE 3 TRICHOPHYTON E SWEET GUM E SUBCUTANEOUS SWEET VERNAL TRILURON E SP E GRASS POLLEN TRUSTEEL INFUSION E SYNVISC INTRA- SET ARTICULAR T-SUPPORT MAX E E SP SOLUTION TYLACTIN BUILD E PREFILLED SYRINGE 20PE TYR SYNVISC ONE INTRA- TYLACTIN ARTICULAR E E SP COMPLETE 15 PE SOLUTION TYLACTIN RESTORE PREFILLED SYRINGE E 10 SYRINGE AVITENE E TYLACTIN RESTORE E TACHOSIL 3 5PE TALL RAGWEED E TYLACTIN RTD 15 E terrell 1 TYROS 2 E THERAMINE E ULTANE 3 THERAMINE PLUS E ULTRAFOAM E THROMBI-GEL 10 E SPONGE 2X6.25X7CM THROMBI-GEL 100 E ULTRAFOAM E THROMBI-GEL 40 E SPONGE 8X12.5X1CM THROMBI-PAD E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 120 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ULTRAFOAM WHITE PINE E E SPONGE 8X12.5X3CM WIDE-SEAL $0 QL ULTRAFOAM DIAPHRAGM 60 E SPONGE 8X25X1CM WIDE-SEAL $0 QL ULTRAFOAM DIAPHRAGM 65 E SPONGE 8X6.25X1CM WIDE-SEAL $0 QL VARISOFT INFUSION DIAPHRAGM 70 E SET WIDE-SEAL $0 QL VASCULERA E DIAPHRAGM 75 VCF VAGINAL WIDE-SEAL $0 QL CONTRACEPTIVE $0 QL DIAPHRAGM 80 VAGINAL FILM WIDE-SEAL $0 QL vcf vaginal DIAPHRAGM 85 contraceptive vaginal $0 QL WIDE-SEAL $0 QL gel DIAPHRAGM 90 VILACTIN AA PLUS E WIDE-SEAL $0 QL VILTEPSO E SP DIAPHRAGM 95 VIRGINIA LIVE OAK E XEOMIN 3 PA; SP VISTOGARD 3 XIAFLEX 2 PA; SP VITRASE INJECTION XYZBAC E E SOLUTION XYZMUNE E VORTEX HOLDING E YELLOW DOCK E CHAMBER/MASK YELLOW HORNET WASP VENOM VENOM PROTEIN PROTEIN SUBCUTANEOUS SUBCUTANEOUS E E SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED 1100 MCG 1100 MCG YELLOW JACKET WELLMIND VERTIGO E VENOM PROTEIN E westab max E SUBCUTANEOUS WESTERN JUNIPER E ZYVEXOL E WHITE ASH E ZYVIT E WHITE BIRCH E Ophthalmic Agents - WHITE FACED Drugs for Eye Allergy, HORNET VENOM Infection and SUBCUTANEOUS Inflammation E SOLUTION ACULAR 3 RECONSTITUTED ACULAR LS 3 1100 MCG ALAWAY E WHITE MULBERRY E ALOCRIL E WHITE OAK E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 121 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ALOMIDE 3 gatifloxacin ophthalmic 1 ALREX E gentak ophthalmic 1 AZASITE 3 ointment azelastine hcl gentamicin sulfate 1 1 ophthalmic ophthalmic solution bacitracin ophthalmic 1 ILEVRO E ILUVIEN BEPREVE 3 ST E SP INTRAVITREAL BESIVANCE 3 INVELTYS 3 BETADINE 3 ketorolac tromethamine OPHTHALMIC PREP 1 ophthalmic BLEPH-10 3 KLARITY-A E bromfenac sodium 1 QL (once-daily) KLARITY-L E BROMSITE E levofloxacin ophthalmic 1 LOTEMAX CILOXAN 3 E OPHTHALMIC GEL ciprofloxacin hcl 1 ophthalmic LOTEMAX OPHTHALMIC E cromolyn sodium 1 OINTMENT ophthalmic LOTEMAX dexamethasone OPHTHALMIC 3 sodium phosphate 1 SUSPENSION ophthalmic LOTEMAX SM 3 DEXTENZA E SP loteprednol etabonate 1 DEXYCU E MAXIDEX 3 diclofenac sodium 1 ophthalmic MITOSOL 3 DUREZOL E MOXEZA 2 moxifloxacin hcl (2x epinastine hcl 1 1 day) erythromycin 1 moxifloxacin hcl ophthalmic 1 ophthalmic solution eye itch relief E NATACYN 2 EYSUVIS E NEVANAC E FLAREX 3 OCUFLOX 3 fluorometholone 1 ophthalmic ofloxacin ophthalmic 1 olopatadine hcl solution flurbiprofen sodium 1 E 0.1 % ophthalmic (otc) FML 2 olopatadine hcl solution 1 FML FORTE 3 0.1 % ophthalmic (rx) FML LIQUIFILM 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 122 Drug Name Drug Tier Notes Drug Name Drug Tier Notes olopatadine hcl solution Ophthalmic Agents - E 0.2 % ophthalmic (otc) Drugs for Glaucoma olopatadine hcl solution acetazolamide er 1 1 0.2 % ophthalmic (rx) acetazolamide oral 1 OZURDEX 3 SP ALPHAGAN P INTRAVITREAL OPHTHALMIC 2 PATADAY E SOLUTION 0.1 % POVIDONE-IODINE ALPHAGAN P 3 OPHTHALMIC OPHTHALMIC E PRED FORTE 3 SOLUTION 0.15 % PRED MILD 3 apraclonidine hcl 1 PREDNISOL ACE- AZOPT 2 E MOXIFLOX-BROMFEN betaxolol hcl 1 prednisolone acetate ophthalmic 1 ophthalmic BETIMOL 3 prednisolone acetate p- BETOPTIC-S 3 E f bimatoprost ophthalmic 1 QL prednisolone sodium brimonidine tartrate 1 1 phosphate ophthalmic ophthalmic PREDNISOLON- BRIMONIDINE- E MOXIFLOX- E DORZOLAMIDE NEPAFENAC carteolol hcl 1 PROLENSA 2 QL COMBIGAN 2 RETISERT E SP INTRAVITREAL COSOPT 3 sulfacetamide sodium COSOPT PF 1 ophthalmic OPHTHALMIC 3 SOLUTION 2-0.5 % tobramycin ophthalmic 1 DORZOLAMIDE HCL TOBREX 3 SOLUTION 2 % 3 trifluridine ophthalmic 1 OPHTHALMIC TRIPLE PMB E dorzolamide hcl 1 TRIPLE PMK E solution 2 % ophthalmic dorzolamide hcl-timolol UPNEEQ E 1 mal VIGAMOX 3 dorzolamide hcl-timolol 1 YUTIQ E SP mal pf ZADITOR E DURYSTA E ZERVIATE E IOPIDINE ZIRGAN 3 OPHTHALMIC 3 ZYMAXID 3 SOLUTION 1 % ISOPTO CARPINE 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 123 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ISTALOL 3 TRUSOPT 3 KEVEYIS 3 PA; SP; QL VYZULTA E latanoprost ophthalmic 1 XALATAN 3 LATANOPROST- XELPROS 3 ST; QL E TIMOLOL MALEATE ZIOPTAN E levobunolol hcl Ophthalmic Agents - ophthalmic solution 0.5 1 Drugs for % Miscellaneous Eye LUMIGAN Conditions OPHTHALMIC 2 QL ak-poly-bac 1 SOLUTION 0.01 % AKTEN 3 methazolamide oral 1 ALCAINE 3 PHOSPHOLINE 2 IODIDE altacaine 1 pilocarpine hcl altachlore E ophthalmic solution 1 1 altafluor benox E %, 2 %, 4 % altafrin ophthalmic 1 RHOPRESSA 3 QL solution 10 %, 2.5 % ROCKLATAN 3 QL artificial tears SIMBRINZA 2 ophthalmic solution 0.5- E 0.6 %, 1.4 % timolol maleate 1 atropine sulfate ophthalmic 1 ophthalmic ointment timolol maleate pf 1 ATROPINE SULFATE TIMOLOL-BRIMON- E OPHTHALMIC E DORZOL-LATANOPR SOLUTION 0.01 % TIMOLOL- atropine sulfate 1 BRIMONIDINE- E ophthalmic solution 1 % DORZOLAMID bacitracin-polymyxin b TIMOLOL- ophthalmic ointment 1 DORZOLAMID- E 500-10000 unit/gm LATANOPROST bacitra-neomycin- 1 TIMOPTIC E polymyxin-hc TIMOPTIC OCUDOSE BEOVU E SP OPHTHALMIC 3 SOLUTION 0.25 % BEVACIZUMAB 3 SP TIMOPTIC OCUDOSE bimatoprost external E OPHTHALMIC E bio glo E SOLUTION 0.5 % BLEPHAMIDE 3 TIMOPTIC-XE E BLEPHAMIDE S.O.P. 3 TRAVATAN Z 3 QL CEQUA E travoprost (bak free) 1 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 124 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CHONDROITIN LACRISERT 3 SULFATE E LASTACAFT 3 ST OPHTHALMIC LATISSE E cvs lubricant eye drops ophthalmic solution 0.4- E lissamine green E 0.3 % lubricant eye drops CYCLOGYL 3 ophthalmic solution 0.4- E 0.3 % CYCLOMYDRIL 3 lubricant eye drops pf E cyclopentolate hcl 1 ophthalmic lubricant eye pm E CYCLOSPORINE IN lubricant pm E E KLARITY lubricating eye drops E CYSTADROPS E SP lubricating plus eye E CYSTARAN 3 PA; SP; QL drops LUCENTIS DOUBLE PM E 2 PA; SP INTRAVITREAL EYLEA 3 PA; SP INTRAVITREAL LUXTURNA INTRAOCULAR flucaine E SUSPENSION 3 PA; SP fluorescein-benoxinate E 5000000000000 fluor-i-strips a.t. E VG/ML FLURA-SAFE E MAXITROL 3 FUL-GLO MEMBRANEBLUE 3 OPHTHALMIC STRIP E MURO 128 0.6 MG OPHTHALMIC E ful-glo ophthalmic strip OINTMENT E 1 mg MURO 128 GELFILM OPHTHALMIC E E OPHTHALMIC SOLUTION 5 % GENTEAL TEARS MYDRIACYL E E NIGHT-TIME neomycin-bacitracin zn- 1 GENTEAL TEARS polymyx OPHTHALMIC E neomycin-polymyxin- SOLUTION 0.1-0.3 % dexameth ophthalmic 1 glostrips ophthalmic ointment E strip 1 mg neomycin-polymyxin- green glo lissamine dexameth ophthalmic E 1 green suspension 3.5-10000- 0.1 homatropaire 1 neomycin-polymyxin- HYPOCYN EXTERNAL gramicidin ophthalmic E 1 SOLUTION solution 1.75-10000- ISOPTO ATROPINE 3 .025

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 125 Drug Name Drug Tier Notes Drug Name Drug Tier Notes neomycin-polymyxin-hc REFRESH RELIEVA E ophthalmic suspension 1 REFRESH RELIEVA 3.5-10000-1 PF OPHTHALMIC E neo-polycin 1 SOLUTION 0.5-0.9 % neo-polycin hc 1 RESTASIS 2 PA OXERVATE 3 PA; SP; QL RESTASIS MULTIDOSE PAREMYD E 2 PA OPHTHALMIC phenylephrine hcl EMULSION 0.05 % ophthalmic solution 10 1 %, 2.5 % ROSE GLO E sodium chloride polycin 1 E (hypertonic) polymyxin b- 1 trimethoprim sulfacetamide- prednisolone 1 POLYTRIM 3 ophthalmic solution PRED-G 3 SYSTANE COMPLETE E PRED-G S.O.P. 3 SYSTANE E PREDNISOLONE HYDRATION PF ACETATE- E SYSTANE ULTRA PF E NEPAFENAC tetracaine hcl PREDNISOLONE 1 E ophthalmic ACET-MOXIFLOXACIN TOBRADEX PREDNISOLONE- E OPHTHALMIC 3 BROMFENAC OINTMENT PREDNISOLONE- TOBRADEX GATIFLOXACIN E OPHTHALMIC E OPHTHALMIC SUSPENSION SUSPENSION TOBRADEX ST 3 PREDNISOLONE- E tobramycin- MOXIFLOXACIN 1 dexamethasone PREDNISOLON- GATIFLOX- E tropicamide ophthalmic E BROMFENAC TROPICAMIDE- PREDNISOLON- CYCLOPENTOLATE- E MOXIFLOX- PE BROMFENAC TROPICAMIDE- E E OPHTHALMIC PHENYLEPHRINE SOLUTION 1-0.5-0.075 TROPIC-CYCLOPENT- E % PE-KETOROLAC proparacaine hcl TROPIC-CYCLOP-PE- 1 E ophthalmic KETO-PROPAR proparacaine- E fluorescein

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 126 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TROPIC- Respiratory Tract / PROPARACA-PE- E Pulmonary Agents - KETOROLAC Drugs for Allergies, ultra fresh pm E Cough, Cold ultra lubricating eye 12 hour allergy-d E E drops 12 hour nasal E VISIONBLUE 3 decongestant nasal 12hr allergy & VISUDYNE 3 SP E congestion XIIDRA 2 PA 24hr allergy relief E ZYLET 3 ADRENALIN NASAL E Otic Agents - Drugs for Ear Conditions all day allergy d E acetic acid otic 1 all day allergy d-12 E allergy 24hour CETRAXAL 3 ST E indoor/outdoor CIPRO HC 3 allergy 24-hr E CIPRODEX 2 allergy childrens E ciprofloxacin hcl otic 1 ST allergy rel child ciprofloxacin- E 1 (loratadine) dexamethasone allergy relief cetirizine E CIPROFLOXACIN- E allergy relief childrens FLUOCINOLONE PF E oral liquid cortic-nd 1 allergy relief d-12 E DERMOTIC 3 allergy relief oral E exotic-hc 1 capsule 10 mg flac 1 allergy relief oral tablet fluocinolone acetonide 10 mg, 180 mg, 25 mg, E 1 otic 4 mg hydrocortisone-acetic allergy relief oral tablet 1 E acid dispersible neomycin-polymyxin-hc allergy 1 E otic relief/indoor/outdoor ofloxacin otic 1 allergy relief/nasal decongest oral tablet OTICIN HC NR 3 E extended release 12 OTIPRIO E hour OTOVEL E allergy relief-d oral PRAMOTIC 3 tablet extended release E 12 hour ALZAIR ALLERGY E NASAL SPRAY

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 127 Drug Name Drug Tier Notes Drug Name Drug Tier Notes antihistamine & nasal CLARITIN REDITABS E deconges ORAL TABLET E aurodryl allergy DISPERSIBLE 10 MG E childrens CLARITIN-D 12 HOUR E azelastine hcl nasal 1 QL clemastine fumarate 1 azelastine-fluticasone 1 QL oral tablet 2.68 mg banophen oral capsule cold & flu relief daytime E E 25 mg cold/flu daytime relief E banophen oral tablet E cough dm oral BECONASE AQ 3 QL suspension extended E release benzonatate 1 cough/chest congestion E bromfed dm 1 dm carbinoxamine maleate 1 CUROSURF oral solution INTRATRACHEAL 3 carbinoxamine maleate SUSPENSION 120 1 oral tablet 4 mg MG/1.5ML carbinoxamine maleate cyproheptadine hcl oral 1 E oral tablet 6 mg dayhist allergy 12 hour E cetirizine hcl childrens relief oral tablet chewable 5 E daytime cold & flu relief E mg oral capsule cetirizine hcl oral daytime cold/flu relief 1 E solution oral capsule cetirizine hcl oral tablet E DERMACINRX E cetirizine hcl oral tablet AZENASE PAK E chewable 10 mg DERMACINRX E chest congestion relief TICANASE PAK E dm oral syrup desloratadine oral 1 chest congestion relief tablet E oral syrup desloratadine oral 1 chlorpheniramine tablet dispersible 5 mg E maleate er dexchlorpheniramine E CHLOR-TRIMETON maleate oral solution E ORAL TABLET DICOPANOL E CINQAIR 3 PA; SP FUSEPAQ CLARINEX ORAL DICOPANOL E E TABLET RAPIDPAQ CLARINEX-D 12 dimaphen dm E E HOUR cold/cough oral liquid CLARITIN ORAL DI-PHEN E E TABLET diphen oral elixir 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 128 Drug Name Drug Tier Notes Drug Name Drug Tier Notes diphenhydramine hcl HYCODAN 3 PA; QL E injection hydrocodone polst- diphenhydramine hcl chlorphen polst er susp E 1 PA; QL oral capsule oral suspension diphenhydramine hcl extended release 1 oral elixir hydrocodone- 1 PA; QL diphenhydramine hcl homatropine E oral liquid 12.5 mg/5ml hydromet 1 PA; QL diphenhydramine hcl HYPERSAL 3 E oral tablet 25 mg INFASURF 3 DYMISTA 2 QL INTRATRACHEAL epinephrine hcl (nasal) E ipratropium bromide 1 FASENRA 2 PA; SP nasal FASENRA PEN 2 PA; SP KARBINAL ER ORAL SUSPENSION E fexofenadine hcl oral E EXTENDED RELEASE tablet 180 mg, 60 mg levocetirizine 1 fexofenadine- dihydrochloride oral pseudoephed er oral E tablet extended release loratadine oral syrup E 12 hour loratadine oral tablet E flunisolide nasal loratadine-d 12hr E solution 25 mcg/act 1 QL loratadine-d 24hr E (0.025%) maxi-tuss ac 1 PA; QL fluticasone propionate 1 nasal maxi-tuss gmx E geri-dryl oral liquid E maxi-tuss pe max E geri-dryl oral tablet E m-dryl E GILPHEX TR E MICLARA LQ E GILTUSS TR ORAL mometasone furoate E 1 QL TABLET nasal goodsense tussin dm MUCINEX E CHILDRENS max E FREEFROM ORAL guaiatussin ac 1 PA; QL LIQUID 5-100 MG/5ML guaifenesin ac 1 PA; QL MUCINEX guaifenesin oral tablet CHILDRENS STUFFY E E 400 mg NOSE guaifenesin-dm oral MUCINEX DM E E syrup MUCINEX FAST-MAX E hm adult tussin cough DM MAX E & chest mucus dm E hm loratadine E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 129 Drug Name Drug Tier Notes Drug Name Drug Tier Notes mucus relief d oral promethazine-dm oral 1 tablet extended release E syrup 12 hour promethazine- 1 PA; QL mucus relief dm oral phenyleph-codeine E liquid promethazine- 1 mucus relief max st E phenylephrine mucus-d E promethegan 1 mucus-er max E PROPEL E NASACORT ALLERGY PROPEL MINI E E 24HR pseudoephedrine hcl er E nasal decongestant E pseudoephedrine- oral tablet 30 mg bromphen-dm oral 1 nasal decongestant pe E syrup 30-2-10 mg/5ml nasal moisturizing pseudoephedrine- E E spray guaifenesin er nasal spray 12 hour E QNASL 3 QL nasal spray no drip E QNASL CHILDRENS 3 QL NASONEX E ROBITUSSIN 12 E NEO-SYNEPHRINE HOUR COUGH CHILD E COLD/ALLRG MILD ROBITUSSIN NEO-SYNEPHRINE COUGH+CHEST E COLD/ALLRGY EXT CONG DM ORAL E LIQUID 20-400 NEO-SYNEPHRINE E MG/20ML COLD/ALLRGY REG RYCLORA ORAL 3 NEOTUSS PLUS E SOLUTION NUCALA 2 PA; SP; QL ryvent E olopatadine hcl nasal 1 QL SEMPREX-D E OMNARIS 3 QL sinus 12 hour E PATANASE 3 QL SINUVA 3 pediaclear pd childrens E sodium chloride PHENERGAN inhalation nebulization E 1 INJECTION solution 0.9 %, 10 %, 3 promethazine hcl %, 7 % E injection SSKI E promethazine hcl oral 1 SUDAFED E promethazine hcl rectal CONGESTION suppository 12.5 mg, 1 sudogest 12 hour E 25 mg sudogest maximum E promethazine-codeine 1 PA; QL strength

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 130 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sudogest oral tablet 30 ADRENALIN E mg INJECTION 3 SURVANTA SOLUTION 1 MG/ML 3 INTRATRACHEAL ADVAIR DISKUS 1 QL TESSALON PERLES 3 ADVAIR HFA 2 QL triprolidine hcl oral ADYPHREN E liquid 0.313 mg/ml, E ADYPHREN AMP E 0.625 mg/ml, 0.938 mg/ml, 2.5 mg/5ml ADYPHREN AMP II E TUSSICAPS ORAL ADYPHREN II E CAPSULE EXTENDED AIRDUO DIGIHALER E E RELEASE 12 HOUR AIRDUO RESPICLICK E 10-8 MG 113/14 tussin cf multi-symptom AIRDUO RESPICLICK E E cold 232/14 tussin dm max adult E AIRDUO RESPICLICK E tussin dm max oral 55/14 E liquid 20-400 mg/20ml albuterol sulfate er 1 tussin dm oral syrup E albuterol sulfate hfa 100-10 mg/5ml aerosol solution 108 1 QL TUXARIN ER E (90 base) mcg/act TUZISTRA XR ORAL inhalation SUSPENSION E ALBUTEROL EXTENDED RELEASE SULFATE HFA AEROSOL SOLUTION virtussin ac w/alc 1 PA; QL E 108 (90 BASE) wal-tap cold/allergy oral E MCG/ACT elixir INHALATION wal-zyr oral tablet E albuterol sulfate XHANCE E inhalation nebulization solution (2.5 mg/3ml) XOLAIR 2 PA; SP 1 QL 0.083%, 0.63 mg/3ml, ZETONNA 3 QL 1.25 mg/3ml, 2.5 ZYRTEC ALLERGY mg/0.5ml E ORAL TABLET ALBUTEROL Respiratory Tract / SULFATE Pulmonary Agents - NEBULIZATION E Drugs for Asthma and SOLUTION (5 MG/ML) Other Lung 0.5% INHALATION Conditions albuterol sulfate ACCOLATE 3 nebulization solution (5 1 QL acetylcysteine mg/ml) 0.5% inhalation 1 inhalation albuterol sulfate oral 1 ALVESCO E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 131 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ANORO ELLIPTA 2 QL COMBIVENT 2 QL ARALAST NP RESPIMAT INTRAVENOUS cromolyn sodium 1 SOLUTION 3 PA; SP inhalation RECONSTITUTED DALIRESP 3 PA 1000 MG, 500 MG difil-g forte 1 ARCAPTA NEOHALER 3 ST DUAKLIR PRESSAIR E ARMONAIR E DIGIHALER DULERA E ARNUITY ELLIPTA 2 QL ELIXOPHYLLIN 2 ASMANEX (120 epinephrine injection E METERED DOSES) solution auto-injector 1 ST 0.15 mg/0.15ml ASMANEX (14 E METERED DOSES) epinephrine injection solution auto-injector 1 ASMANEX (30 E 0.15 mg/0.3ml METERED DOSES) EPINEPHRINE ASMANEX (60 E E PROFESSIONAL METERED DOSES) epinephrine solution ASMANEX (7 E auto-injector 0.3 1 ST METERED DOSES) mg/0.3ml injection ASMANEX HFA E epinephrine solution ATROVENT HFA 3 QL auto-injector 0.3 1 AUVI-Q INJECTION mg/0.3ml injection SOLUTION AUTO- EPINEPHRINESNAP- 3 QL E INJECTOR 0.1 EMS MG/0.1ML EPINEPHRINESNAP-V E AUVI-Q INJECTION EPIPEN 2-PAK SOLUTION AUTO- INJECTION 3 ST INJECTOR 0.15 E SOLUTION AUTO- MG/0.15ML, 0.3 INJECTOR MG/0.3ML EPIPEN JR 2-PAK BEVESPI INJECTION E E AEROSPHERE SOLUTION AUTO- BREO ELLIPTA 2 QL INJECTOR BREZTRI EPISNAP E E AEROSPHERE ESBRIET 3 PA; SP BROVANA 3 QL FLOVENT DISKUS 2 QL budesonide inhalation 1 QL FLOVENT HFA 2 QL BUDESONIDE- FORMOTEROL E FUMARATE

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 132 Drug Name Drug Tier Notes Drug Name Drug Tier Notes fluticasone-salmeterol PROLASTIN-C inhalation aerosol INTRAVENOUS powder breath SOLUTION 3 PA; SP activated 100-50 E RECONSTITUTED mcg/dose, 250-50 1000 MG mcg/dose, 500-50 PROVENTIL HFA E mcg/dose PULMICORT 2 QL FLUTICASONE- FLEXHALER SALMETEROL PULMICORT INHALATION E AEROSOL POWDER SUSPENSION 1 ST; QL BREATH ACTIVATED QVAR REDIHALER E 113-14 MCG/ACT, 232- SEEBRI NEOHALER E 14 MCG/ACT, 55-14 MCG/ACT SEREVENT DISKUS 2 QL GLASSIA 3 PA; SP SINGULAIR E SPIRIVA INCRUSE ELLIPTA E 2 QL HANDIHALER ipratropium bromide 1 QL inhalation SPIRIVA RESPIMAT INHALATION ipratropium-albuterol 1 QL AEROSOL SOLUTION 2 QL levalbuterol hcl 1.25 MCG/ACT, 2.5 inhalation nebulization MCG/ACT solution 0.31 mg/3ml, 1 QL STERITALC 3 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml STIOLTO RESPIMAT INHALATION 2 QL LEVALBUTEROL HFA AEROSOL SOLUTION INHALATION E 2.5-2.5 MCG/ACT AEROSOL 45 STRIVERDI MCG/ACT 2 ST; QL RESPIMAT LONHALA MAGNAIR 3 QL REFILL KIT SYMBICORT 2 QL LONHALA MAGNAIR SYMJEPI 3 3 QL STARTER KIT terbutaline sulfate E montelukast sodium injection 1 oral terbutaline sulfate oral 1 OFEV 3 PA; SP THEO-24 3 PERFOROMIST 3 QL theophylline 1 PROAIR DIGIHALER E theophylline er oral tablet extended release PROAIR HFA E 1 12 hour 300 mg, 450 PROAIR RESPICLICK E mg PROLASTIN-C theophylline er oral INTRAVENOUS 3 PA; SP tablet extended release 1 SOLUTION 24 hour

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 133 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TRELEGY ELLIPTA 2 QL TRIKAFTA 3 PA; SP; QL TUDORZA PRESSAIR Respiratory Tract / INHALATION Pulmonary Agents - AEROSOL POWDER E Drugs for Pulmonary BREATH ACTIVATED Hypertension 400 MCG/ACT ADCIRCA 3 PA; SP; QL UTIBRON NEOHALER E ADEMPAS 2 PA; SP; QL VENTOLIN HFA E alyq 1 PA; SP; QL wixela inhub E ambrisentan 1 PA; SP; QL XOPENEX NEB 3 QL bosentan 1 PA; SP; QL XOPENEX 3 QL epoprostenol sodium 1 PA; SP CONCENTRATE FLOLAN 3 PA; SP XOPENEX HFA E LETAIRIS 3 PA; SP; QL YUPELRI 3 QL OPSUMIT 2 PA; SP; QL zafirlukast 1 ORENITRAM 3 PA; SP ZEMAIRA 3 PA; SP REMODULIN zileuton er 1 ST INJECTION ZYFLO E SOLUTION 100 Respiratory Tract / MG/20ML, 20 E SP Pulmonary Agents - MG/20ML, 200 Drugs for Cystic MG/20ML, 50 Fibrosis MG/20ML REVATIO BETHKIS 2 SP 3 PA; SP INTRAVENOUS CAYSTON 3 PA; SP REVATIO ORAL 3 PA; SP; QL KALYDECO 3 PA; SP sildenafil citrate 1 PA; SP KITABIS PAK E SP intravenous ORKAMBI 3 PA; SP; QL sildenafil citrate oral PULMOZYME 2 PA; SP suspension 1 PA; SP; QL SYMDEKO 3 PA; SP; QL reconstituted sildenafil citrate oral TOBI NEBULIZER E SP 1 PA; SP; QL tablet 20 mg TOBI PODHALER 3 ST; SP; QL tadalafil (pah) 1 PA; SP; QL tobramycin inhalation TRACLEER 62.5 MG, nebulization solution 1 SP E SP 300 mg/4ml 125 MG tobramycin nebulization TRACLEER 32 MG 3 PA; SP; QL solution 300 mg/5ml E SP treprostinil 1 PA; SP inhalation TYVASO 3 PA; SP; QL TOBRAMYCIN TYVASO REFILL 3 PA; SP; QL NEBULIZATION E SP SOLUTION 300 TYVASO STARTER 3 PA; SP; QL MG/5ML INHALATION UPTRAVI 3 PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 134 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VELETRI 3 PA; SP GABLOFEN VENTAVIS 3 PA; SP; QL INTRATHECAL SOLUTION 10000 E Skeletal Muscle MCG/20ML, 20000 Relaxants - Drugs for MCG/20ML, 40000 Muscle Pain and MCG/20ML Spasm GABLOFEN active-cyclobenzaprine E INTRATHECAL AMRIX E SOLUTION BACLOFEN PREFILLED SYRINGE E E EXTERNAL 10000 MCG/20ML, 20000 MCG/20ML, baclofen intrathecal E 40000 MCG/20ML, 50 baclofen oral 1 MCG/ML carisoprodol oral 1 LIORESAL E chlorzoxazone oral LORZONE 3 1 QL tablet 250 mg METAXALL CP E chlorzoxazone oral metaxalone 1 tablet 375 mg, 500 mg, 1 750 mg methocarbamol oral 1 CYCLO/GABA 10/300 E NOPIOID-LMC KIT E cyclobenzaprine hcl er 1 NORGESIC FORTE E cyclobenzaprine hcl orphenadrine citrate er 1 1 oral tablet 5 mg, 7.5 mg orphenadrine-asa- 1 cyclobenzaprine hcl caffeine 1 tablet 10 mg oral ORPHENGESIC cyclobenzaprine hcl FORTE ORAL TABLET E E tablet 10 mg oral 50-770-60 MG CYCLOPAK 3 OZOBAX E CYCLOPHENE ROBAXIN-750 3 E RAPIDPAQ SKELAXIN E DANTRIUM ORAL SOMA 3 CAPSULE 25 MG, 50 3 TABRADOL FUSEPAQ E MG TABRADOL E dantrolene sodium oral 1 RAPIDPAQ enovarx-baclofen E tizanidine hcl oral 1 enovarx- E VANADOM 3 cyclobenzaprine hcl ZANAFLEX E FEXMID 3 Sleep Disorder FIRST-BACLOFEN E Agents AMBIEN E AMBIEN CR E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 135 Drug Name Drug Tier Notes armodafinil 1 PA; QL BELSOMRA 3 ST; QL DAYVIGO 3 ST; QL doxepin hcl oral tablet 1 QL EDLUAR E eszopiclone 1 QL flurazepam hcl 1 PA; QL HETLIOZ 3 PA; SP; QL INTERMEZZO SUBLINGUAL TABLET 3 QL SUBLINGUAL 1.75 MG LUNESTA E modafinil 1 PA; QL NUVIGIL E PROVIGIL E ramelteon 1 QL RESTORIL E ROZEREM 3 QL SILENOR 3 QL sleep aid E (diphenhydramine) sleep-aid oral capsule E SUNOSI 2 PA; QL temazepam 1 QL WAKIX 3 PA; SP; QL XYREM 3 PA; SP; QL XYWAV E SP zaleplon 1 QL zolpidem tartrate 1 QL zolpidem tartrate er 1 QL ZOLPIMIST 3 ST; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section on page 6 of this booklet. 136 Index of Drugs 12 hour allergy-d...... 127 ACCU-CHEK SMARTVIEW ACTIVE INJECTION LM-DEP- 12 hour nasal decongestant....127 CONTROL...... 74 2...... 95 12hr allergy & congestion...... 127 ACCU-CHEK SMARTVIEW active-cyclobenzaprine...... 135 1ST MEDX-PATCH/ TEST STRIPS...... 74 ACTIVE-KETOPROFEN...... 14 LIDOCAINE...... 17 ACCU-CHEK SOFTCLIX ACTIVELLA...... 100 24hr allergy relief...... 127 LANCET DEVICE KIT...... 74 ACTIVE-PREP KIT I...... 14 3232a infant formula...... 113 ACCU-CHEK TENDER 1 ACTIVE-PREP KIT II...... 14 7T LIDO...... 17 INFUSION...... 113 ACTIVE-PREP KIT III...... 14 8 hour pain reliever...... 9 ACCU-CHEK ULTRAFLEX ACTIVE-PREP KIT IV...... 60 8 hr arthritis pain relief...... 9 INF SET...... 113 ACTIVE-PREP KIT V...... 31 A.A.G.C. KIT IN TERODERM... 60 ACCUPRIL...... 50 active-tramadol...... 60 abacavir sulfate...... 44 ACCURETIC...... 50 ACTIVITE...... 77 abacavir sulfate-lamivudine...... 44 ACD-A NOCLOT-50...... 25 ACTONEL...... 112 abacavir-lamivudine- acebutolol hcl...... 50 ACTOPLUS MET...... 72 zidovudine...... 44 ACESO AG...... 60 ACTOS...... 72 ABANEU-SL...... 77 acetaminophen...... 9 ACULAR...... 121 ABILIFY...... 43 acetaminophen 8 hour...... 9 ACULAR LS...... 121 ABILIFY MAINTENA...... 43 acetaminophen childrens...... 9 ACUNOL...... 113 ABILIFY MYCITE...... 43 acetaminophen er...... 9 acyclovir...... 44 abiraterone acetate...... 35 acetaminophen extra strength.... 9 ACZONE...... 60 ABRAXANE...... 35 acetaminophen-codeine...... 9 ADACEL...... 109 ABREVA...... 60 acetaminophen-codeine #2...... 9 ADAKVEO...... 113 ABSORICA...... 60 acetaminophen-codeine #3...... 9 ADALAT CC...... 50 ABSORICA LD...... 60 acetaminophen-codeine #4...... 9 adapalene...... 60 ACACIA...... 113 acetazolamide...... 123 ADAPALENE...... 60 acamprosate calcium...... 20 acetazolamide er...... 123 ADAPALENE-BENZOYL PER- ACANYA...... 60 acetic acid...... 127 CLINDAMY...... 60 acarbose...... 72 acetylcysteine...... 131 ADAPALENE-BENZOYL PER- ACCOLATE...... 131 acid reducer...... 86 NIACINAM...... 60 ACCUCAINE...... 17 ACIPHEX...... 86 adapalene-benzoyl peroxide.....60 ACCU-CHEK AVIVA ACIPHEX SPRINKLE...... 86 ADASUVE...... 43 CONNECT KIT W/DEVICE...... 73 acitretin...... 60 adc/f (0.5mg/ml)...... 77 ACCU-CHEK AVIVA DEVICE...73 ACREMONIUM...... 113 ADCETRIS...... 35 ACCU-CHEK AVIVA PLUS ACTEMRA...... 105 ADCIRCA...... 134 KIT W/DEVICE...... 73 ACTEMRA ACTPEN...... 106 ADDERALL...... 56 ACCU-CHEK COMPACT ACTHAR...... 98 ADDERALL XR...... 56 PLUS CARE KIT...... 73 ACTHIB...... 109 ADDYI...... 58 ACCU-CHEK COMPACT ACTHREL...... 113 adefovir dipivoxil...... 44 PLUS CONTROL...... 73 ACTICLATE...... 20 ADEMPAS...... 134 ACCU-CHEK COMPACT ACTIFOAM COLLAGEN ADHANSIA XR...... 56 PLUS TEST STRIPS...... 73 SPONGE...... 113 ADIPEX-P...... 58 ACCU-CHEK FASTCLIX ACTIGALL...... 87 ADLYXIN...... 72 LANCET KIT...... 73 ACTIMMUNE...... 106 ADLYXIN STARTER PACK...... 72 ACCU-CHEK FLEXLINK PLUS ACTIPHLORA...... 87 ADMELOG...... 75 6MM...... 113 ACTIQ...... 9 ADMELOG SOLOSTAR...... 75 ACCU-CHEK GUIDE ACTITROM-D...... 77 ADRENAL C FORMULA...... 77 CONTROL...... 73 ACTIVASE...... 26 ADRENALIN...... 127, 131 ACCU-CHEK GUIDE KIT active fe...... 77 adriamycin...... 35 W/DEVICE...... 73 ACTIVE INJECTION D...... 95 ADULT AEROSOL MASK...... 113 ACCU-CHEK MULTICLIX ACTIVE INJECTION KIT L...... 95 adult aspirin regimen...... 14 LANCET DEVICE KIT...... 73 ACTIVE INJECTION KL-3...... 95 ADVAIR DISKUS...... 131 ACCU-CHEK NANO ACTIVE INJECTION LM-2...... 17 ADVAIR HFA...... 131 SMARTVIEW KIT W/DEVICE...73 137 ADVANCED ALLERGY ALCOHOL PREP PADS... 61, 113 alprazolam xr...... 47 COLLECTION...... 60 ALCORTIN A...... 31 ALPROLIX...... 48 ADVATE...... 48 ALDACTAZIDE...... 50 ALREX...... 122 ADVIL...... 14 ALDACTONE...... 50 ALTABAX...... 20 ADVIL JUNIOR STRENGTH.... 14 ALDARA...... 61 altacaine...... 124 ADVIL LIQUI-GELS MINIS...... 14 ALDER...... 113 ALTACE...... 50 ADVIL MIGRAINE...... 14 ALDURAZYME...... 92 altachlore...... 124 ADYNOVATE...... 48 ALECENSA...... 35 altafluor benox...... 124 ADYPHREN...... 131 alendronate sodium...... 112 altafrin...... 124 ADYPHREN AMP...... 131 ALEVAMAX...... 61 altavera...... 100 ADYPHREN AMP II...... 131 ALEVE...... 14 ALTERNARIA...... 113 ADYPHREN II...... 131 ALFERON N...... 106 ALTOPREV...... 50 ADZENYS ER...... 56 alfuzosin hcl er...... 95 ALTRENO...... 61 ADZENYS XR-ODT...... 56 ALIMTA...... 35 alum & mag hydroxide-simeth.. 87 AEMCOLO...... 20 ALINIA...... 41 alumina-magnesia-simethicone 87 AERIVA CONCENTRATOR ALIQOPA...... 35 ALUNBRIG...... 35 NEBULIZER...... 113 aliskiren fumarate...... 50 ALVESCO...... 131 AFINITOR...... 35 ALKERAN...... 35 alvimopan...... 87 AFINITOR DISPERZ...... 35 ALKINDI SPRINKLE...... 95 alyacen 1/35...... 100 afirmelle...... 100 all day allergy d...... 127 alyacen 7/7/7...... 100 AFLURIA QUADRIVALENT....109 all day allergy d-12...... 127 alyq...... 134 AFREZZA...... 76 allergy 24hour indoor/outdoor. 127 ALZAIR ALLERGY NASAL AFSTYLA...... 48 allergy 24-hr...... 127 SPRAY...... 127 AGONEAZE...... 17 allergy childrens...... 127 amabelz...... 100 AGRYLIN...... 48 allergy rel child (loratadine).....127 amantadine hcl...... 42 aif #2 drug preparation kit...... 14 allergy relief...... 127 AMARYL...... 72 AIF #3 DRUG PREPARATION allergy relief cetirizine...... 127 AMBIEN...... 135 KIT...... 14 allergy relief childrens...... 127 AMBIEN CR...... 135 AIMOVIG...... 34 allergy relief d-12...... 127 ambrisentan...... 134 airavite...... 77 allergy relief/indoor/outdoor.... 127 amcinonide...... 61 AIRDUO DIGIHALER...... 131 allergy relief/nasal decongest. 127 AMELUZ...... 61 AIRDUO RESPICLICK 113/14 131 allergy relief-d...... 127 AMERGE...... 34 AIRDUO RESPICLICK 232/14 131 allopurinol...... 34 AMERICAN BEECH...... 113 AIRDUO RESPICLICK 55/14..131 ALLZITAL...... 9 AMERICAN COCKROACH.....113 AJOVY...... 34 almotriptan malate...... 34 AMERICAN ELM...... 113 AKLIEF...... 60 ALOCRIL...... 121 AMERICAN SYCAMORE...... 113 AKOVAZ...... 50 ALOE VESTA CLEAR amethia...... 100 ak-poly-bac...... 124 ANTIFUNGAL...... 31 amethia lo...... 100 AKTEN...... 124 ALOGLIPTIN BENZOATE...... 72 amethyst...... 100 AKYNZEO...... 30 ALOGLIPTIN-METFORMIN AMICAR...... 48 ALA SCALP...... 60 HCL...... 72 amikacin sulfate...... 21 ala-cort...... 60 ALOGLIPTIN-PIOGLITAZONE. 72 amiloride hcl...... 50 ala-quin...... 31 ALOMIDE...... 122 amiloride-hydrochlorothiazide... 50 ALAWAY...... 121 ALORA...... 100 aminoacetic acid...... 93 albendazole...... 41 alosetron hcl...... 87 aminoamrms...... 77 ALBENZA...... 41 ALOXI...... 30 aminobenzoate potassium...... 77 albuterol sulfate...... 131 ALPHAGAN P...... 123 aminocaproic acid...... 48 ALBUTEROL SULFATE...... 131 ALPHANATE/VWF AMINOPMRMS...... 113 albuterol sulfate er...... 131 COMPLEX/HUMAN...... 48 aminoreliefrms...... 77 albuterol sulfate hfa...... 131 ALPHANINE SD...... 48 amiodarone hcl...... 50 ALBUTEROL SULFATE HFA. 131 alprazolam...... 47 AMITIZA...... 87 ALCAINE...... 124 alprazolam er...... 47 amitriptyline hcl...... 29 alclometasone dipropionate...... 60 alprazolam intensol...... 47

138 AMLODIPINE antacid anti-gas max strength...87 ARIDOL...... 113 BES+SYRSPEND SF...... 50 antacid calcium...... 87 ARIKAYCE...... 21 amlodipine besylate...... 50 antacid calcium rich...... 87 ARIMIDEX...... 36 amlodipine besylate-benazepril antacid extra strength...... 87 aripiprazole...... 43 hcl...... 50 antacid maximum...... 87 ARISTADA...... 43 amlodipine besylate-valsartan.. 50 antacid regular strength...... 87 ARISTADA INITIO...... 43 amlodipine-atorvastatin...... 50 antacid ultra strength...... 87 ARIXTRA...... 26 amlodipine-olmesartan...... 50 ANTARA...... 50 ARIZONA CYPRESS...... 113 amlodipine-valsartan-hctz...... 50 anticoagulant cit dext soln a...... 26 armodafinil...... 136 ammonium lactate...... 61 ANTICOAGULANT SODIUM ARMONAIR DIGIHALER...... 132 amnesteem...... 61 CITRATE...... 26 ARMOUR THYROID...... 105 amoxapine...... 29 anti-diarrheal...... 87 ARNUITY ELLIPTA...... 132 amoxicill-clarithro-lansopraz..... 87 antihistamine & nasal AROMASIN...... 36 amoxicillin...... 21 deconges...... 128 ARRANON...... 36 amoxicillin-potassium ANTIVENIN LATRODECTUS arsenic trioxide...... 36 clavulanate...... 21 MACTANS...... 113 ARTHROTEC...... 14 amoxicillin-potassium ANTIVENIN MICRURUS artificial tears...... 124 clavulanate er...... 21 FULVIUS...... 113 ARTISS...... 113 AMPHETAMINE ER...... 56 anucort-hc...... 111 ARYMO ER...... 9 amphetamine sulfate...... 56 ANUSOL-HC...... 111 ARZERRA...... 36 amphetamine- ANZEMET...... 30 arzol silver nit applicators...... 61 dextroamphetamine...... 56 APADAZ...... 9 ASACOL HD...... 111 amphetamine- apap-caff-dihydrocodeine...... 9 ASCENIV...... 106 dextroamphetamine er...... 56 APEXICON E...... 61 ascomp-codeine...... 9 amphotericin b...... 31 APIDRA SOLOSTAR...... 76 ASCOR...... 77 ampicillin...... 21 APIDRA VIAL...... 76 ASCORBIC ACID...... 77 ampicillin-sulbactam sodium..... 21 APLENZIN...... 29 ascorbic acid...... 77 AMPYRA...... 57 APOKYN...... 42 ashlyna...... 101 AMRIX...... 135 APP SLIM RMS...... 113 asilnasalrms...... 113 AMZEEQ...... 61 APPTRIM...... 113 ASMANEX (120 METERED ANACAINE...... 61 APPTRIM-D...... 113 DOSES)...... 132 ANADROL-50...... 97 apraclonidine hcl...... 123 ASMANEX (14 METERED ANAFRANIL...... 29 aprepitant...... 30 DOSES)...... 132 anagrelide hcl...... 48 apri...... 101 ASMANEX (30 METERED ana-lex...... 111 APRISO...... 111 DOSES)...... 132 ANALPRAM HC...... 111 APRIZIO PAK...... 17 ASMANEX (60 METERED ANALPRAM HC SINGLES..... 111 APRIZIO PAK II...... 17 DOSES)...... 132 ANALPRAM-HC...... 111 APTENSIO XR...... 56 ASMANEX (7 METERED ANASPAZ...... 87 APTIOM...... 26 DOSES)...... 132 anastrozole...... 35 APTIVUS...... 44 ASMANEX HFA...... 132 ANCOBON...... 31 AQUAPHILIC...... 61 ASPARLAS...... 36 ANDEXXA...... 113 AQUASOL A...... 77 ASPARTAME...... 113 ANDRODERM...... 97 ARAKODA...... 41 ASPARTAME ANDROGEL...... 97 ARALAST NP...... 132 (NUTRASWEET)...... 113 ANDROGEL PUMP...... 97 aranelle...... 101 aspirin...... 14 ANGELIQ...... 101 ARANESP (ALBUMIN FREE)...48 aspirin adult...... 14 animal shapes...... 77 ARAVA...... 106 aspirin adult low strength...... 14 ANIMI-3...... 77 ARAZLO...... 61 aspirin childrens...... 14 ANIMI-3/VITAMIN D...... 77 ARCALYST...... 106 aspirin ec...... 14 ANNOVERA...... 101 ARCAPTA NEOHALER...... 132 aspirin ec low dose...... 14 ANODYNE LPT...... 17 ARESTIN...... 59 aspirin ec low strength...... 14 ANORO ELLIPTA...... 132 ARICEPT...... 28 aspirin low dose...... 14 antacid...... 87 ARIDA...... 61 aspirin-dipyridamole er...... 43

139 ASPIRIN-OMEPRAZOLE...... 43 AVALIDE...... 50 bacitracin zinc...... 21 ASTAGRAF XL...... 106 AVANDIA...... 72 bacitracin-polymyxin b...... 124 ASTERO...... 17 AVAPRO...... 50 bacitra-neomycin-polymyxin-hc ASTRINGYN...... 48 avar cleanser...... 61 ...... 124 ATABEX OB...... 77 AVAR LS CLEANSER...... 61 BACLOFEN...... 135 ATACAND...... 50 AVAR-E EMOLLIENT...... 61 baclofen...... 135 ATACAND HCT...... 50 AVAR-E GREEN...... 61 BACMIN...... 77 atazanavir sulfate...... 44 AVAR-E LS...... 61 BACTRIM...... 21 ATELVIA...... 112 AVASTIN...... 36 BACTRIM DS...... 21 atenolol...... 50 AVEED...... 97 BAFIERTAM...... 57 ATENOLOL+SYRSPEND SF... 50 AVEIDAOXIA...... 61 BAHIA...... 113 atenolol-chlorthalidone...... 50 aviane...... 101 BALCOLTRA...... 101 ATGAM...... 106 avidoxy...... 21 BALD CYPRESS...... 113 athletes foot (terbinafine)...... 31 AVIDOXY DK...... 21 balsalazide disodium...... 111 ATIVAN...... 47 avita...... 61 balsam peru-castor oil...... 61 atomoxetine hcl...... 56 AVITENE...... 113 BALVERSA...... 36 ATOPADERM...... 61 AVITENE FLOUR...... 113 balziva...... 101 ATOPICLAIR...... 61 AVODART...... 95 banophen...... 128 atorvastatin calcium...... 50 AVONEX PEN...... 57 BANZEL...... 26 atovaquone...... 41 AVONEX PREFILLED...... 57 BAQSIMI ONE PACK...... 75 atovaquone-proguanil hcl...... 41 AVSOLA...... 106 BAQSIMI TWO PACK...... 75 ATRALIN...... 61 AXONA...... 113 BARACLUDE...... 44 ATRIPLA...... 44 AYGESTIN...... 101 BASAGLAR KWIKPEN...... 76 ATROPEN...... 87 ayuna...... 101 BAVENCIO...... 36 atropine sulfate...... 87, 88, 124 AYVAKIT...... 36 BAXDELA...... 21 ATROPINE SULFATE...... 88, 124 azacitidine...... 36 BAYBERRY (WAX MYRTLE). 113 ATROVENT HFA...... 132 AZADROX...... 61 BAYER ASPIRIN...... 14 AUBAGIO...... 57 AZALGIA...... 113 BAYER ASPIRIN EC LOW aubra...... 101 AZASAN...... 106 DOSE...... 14 aubra eq...... 101 AZASITE...... 122 BCG VACCINE...... 109 AUGMENTIN...... 21 azathioprine...... 106 b-complex/b-12...... 77 AUGMENTIN ES-600...... 21 azathioprine sodium...... 106 BEAU RX...... 61 AUREOBASIDIUM...... 113 azelaic acid...... 61 BECONASE AQ...... 128 aurodryl allergy childrens...... 128 AZELAIC ACID-NIACINAMIDE.61 bekyree...... 101 aurophen childrens...... 9 azelastine hcl...... 122, 128 BELBUCA...... 9 aurovela 1.5/30...... 101 azelastine-fluticasone...... 128 BELEODAQ...... 36 aurovela 1/20...... 101 AZELEX...... 61 belladonna alkaloids-opium...... 88 aurovela 24 fe...... 101 AZESCHEW BELRAPZO...... 36 aurovela fe 1.5/30...... 101 PRENATAL/POSTNATAL...... 77 BELSOMRA...... 136 aurovela fe 1/20...... 101 AZESCO...... 77 benazepril hcl...... 51 AURYXIA...... 93 AZILECT...... 42 benazepril-hydrochlorothiazide. 51 AUSTEDO...... 58 azithromycin...... 21 BENDEKA...... 36 AUSTRALIAN PINE...... 113 azo tabs...... 93 BENEFIX...... 48 AUTOLET II CLINISAFE...... 74 AZOPT...... 123 BENICAR...... 51 AUTOLET LANCING DEVICE.. 74 AZOR...... 50 BENICAR HCT...... 51 AUTOSOFT 30 INFUSION AZULFIDINE...... 111 BENLYSTA...... 106 SET...... 113 AZULFIDINE EN-TABS...... 111 BENSAL HP...... 61 AUTOSOFT 90 INFUSION azurette...... 101 BENZ PER-CLIND-NIACIN- SET...... 113 B-12 COMPLIANCE TRETIN...... 61 AUTOSOFT XC INFUSION INJECTION...... 77 BENZAC AC WASH...... 61 SET...... 113 b-6 folic acid...... 77 BENZACLIN...... 61 AUVI-Q...... 132 BACICAP...... 88 BENZACLIN WITH PUMP...... 61 AVAILNEX...... 113 bacitracin...... 21, 122 BENZALKONIUM CHLORIDE.. 21

140 benzalkonium chloride...... 21 bethanechol chloride...... 93 BLUESTAR...... 74 BENZAMYCIN...... 61 BETHKIS...... 134 BONIVA...... 112 BENZEPRO...... 61 BETIMOL...... 123 BONJESTA...... 30 benzepro...... 61 BETOPTIC-S...... 123 BOOSTRIX...... 109 benzepro creamy wash...... 61 BEVACIZUMAB...... 124 BORTEZOMIB...... 36 benzepro foaming cloths...... 61 BEVESPI AEROSPHERE...... 132 bosentan...... 134 BENZEPRO SHORT bexarotene...... 36 BOSULIF...... 36 CONTACT...... 61 BEXSERO...... 109 BOTOX...... 114 BENZHYDROCODONE- BEYAZ...... 101 BOTOX COSMETIC...... 62 ACETAMINOPHEN...... 9 BHI URI-CONTROL...... 113 BOTRYTIS...... 114 BENZNIDAZOLE...... 41 BIAFINE...... 62 BOX ELDER...... 114 BENZODOX...... 21 bicalutamide...... 36 bp 10-1...... 62 BENZOIN...... 61 BICILLIN L-A...... 21 bp cleansing wash...... 62 benzoin compound...... 61 BICNU...... 36 bp vit 3...... 77 BENZO-LIDOCAINE- BIDIL...... 51 bp wash...... 62 TETRACAINE...... 17 BI-EST 80:20 BPCO...... 62 benzonatate...... 128 PROGESTERONE...... 101 b-plex...... 77 BENZOYL PEROX- BIEST/PROGESTERONE...... 101 b-plex plus...... 77 HYDROCORTISONE...... 61 BIIFENAC 1000...... 14 BRAFTOVI...... 36 benzoyl peroxide...... 61 BIIFENAC 500...... 14 BREATHE EASE HUMIDIFIER BENZOYL PEROXIDE...... 61 BIJUVA...... 101 ...... 114 BENZOYL PEROXIDE BIKTARVY...... 44 BREATHE EASE NEB FORTE- HC...... 61 BILTRICIDE...... 41 MASK/CHILD...... 114 benzoyl peroxide-erythromycin. 61 bimatoprost...... 123, 124 BREATHE EASE NEB benzphetamine hcl...... 58 BI-MIX...... 93 MASK/INFANT...... 114 benztropine mesylate...... 42 BINOSTO...... 112 BREO ELLIPTA...... 132 BEOVU...... 124 bio glo...... 124 BREZTRI AEROSPHERE...... 132 BEPREVE...... 122 biocel...... 77 BRIDION...... 114 BERINERT...... 106 BIONECT...... 62 briellyn...... 101 BERMUDA GRASS...... 113 biopetit...... 77 BRILINTA...... 43 BESER...... 61 BIO-STATIN...... 31 brimonidine tartrate...... 123 beser...... 62 bio-statin...... 31 BRIMONIDINE- BESIVANCE...... 122 BIOTHRAX...... 109 DORZOLAMIDE...... 123 BESPONSA...... 36 biotin...... 77 BRINEURA...... 92 BETA 1 KIT...... 95 bisacodyl...... 88 BRISDELLE...... 29 BETADINE OPHTHALMIC bisacodyl ec...... 88 BRIVIACT...... 26 PREP...... 122 bismuth subsalicylate...... 88 BROME...... 114 BETALOAN SUIK...... 95 bisoprolol fumarate...... 51 bromfed dm...... 128 BETAMETHASONE COMBO... 95 bisoprolol-hydrochlorothiazide.. 51 bromfenac sodium (once-daily) betamethasone dipropionate.... 62 BIVIGAM...... 106 ...... 122 betamethasone dipropionate BLACK WALNUT POLLEN.....114 bromocriptine mesylate...... 42 aug...... 62 BLACK WILLOW...... 114 BROMSITE...... 122 BETAMETHASONE DIPROP- blanche...... 62 BROVANA...... 132 MINOXIDIL...... 62 BLENREP...... 36 BRUKINSA...... 36 BETAMETHASONE SOD bleomycin sulfate...... 36 BRYHALI...... 62 PHOS & ACET...... 95 BLEPH-10...... 122 BSP 0820...... 95 betamethasone sod phos & BLEPHAMIDE...... 124 budesonide...... 111, 132 acet...... 95 BLEPHAMIDE S.O.P...... 124 budesonide er...... 111 betamethasone valerate...... 62 BLINCYTO...... 36 BUDESONIDE- BETAPACE...... 51 blisovi 24 fe...... 101 FORMOTEROL FUMARATE..132 BETAPACE AF...... 51 blisovi fe 1.5/30...... 101 bumetanide...... 51 BETASERON...... 57 blisovi fe 1/20...... 101 BUMEX...... 51 betaxolol hcl...... 51, 123 blue tube/ aloe...... 17 BUNAVAIL...... 20

141 BUPAP...... 9 calcitriol...... 62, 112 CARDIOPLEGIA IND PLASMA BUPHENYL...... 92 calcium acetate...... 93 HIGH K...... 78 bupivacaine fisiopharma...... 17 calcium acetate (phos binder)...93 CARDIOPLEGIA IND BUPIVACAINE HCL...... 17, 18 calcium carb-cholecalciferol...... 78 PLASMA-TROMET...... 78 bupivacaine hcl...... 18 calcium carbonate...... 78 CARDIOPLEGIA INDUCTION bupivacaine hcl (pf)...... 17 calcium carbonate-vitamin d..... 78 HIGH K...... 78 BUPRENEX...... 9 calcium-folic acid plus d...... 78 CARDIOPLEGIA INDUCTION buprenorphine...... 9 CALDOLOR...... 14 LOW DEX...... 78 buprenorphine hcl...... 9, 20 CALIFORNIA PEPPER TREE 114 CARDIOPLEGIA INDUCTION buprenorphine hcl-naloxone CALQUENCE...... 36 NON-ENR...... 78 hcl...... 20 CAMBIA...... 14 CARDIOPLEGIA MAIN LOW bupropion hcl...... 29 camila...... 101 DEXTROSE...... 78 bupropion hcl er (smoking det). 20 CAMINO PRO CARDIOPLEGIA MAIN LOW bupropion hcl er (sr)...... 29 COMPLETE/GLYTACTIN...... 114 TROMETHA...... 78 bupropion hcl er (xl)...... 29 CAMPATH...... 36 CARDIOPLEGIA MAIN BUPROPION HCL ER (XL)...... 29 CAMPTOSAR...... 36 PLASMA-TROME...... 78 buspirone hcl...... 47 camrese...... 101 CARDIOPLEGIA busulfan...... 36 camrese lo...... 101 MAINTENANCE...... 78 BUSULFEX...... 36 CANASA...... 111 CARDIOPLEGIA butalbital-acetaminophen...... 9 CANCIDAS...... 31 REPERFUSATE 4:1...... 78 BUTALBITAL- candesartan cilexetil...... 51 CARDIOVID PLUS...... 114 ACETAMINOPHEN...... 9 candesartan cilexetil-hctz...... 51 CARDIZEM...... 51 butalbital-apap-caff-cod...... 9 CANDIDA ALBICANS CARDIZEM CD...... 51 butalbital-apap-caffeine...... 9 EXTRACT...... 114 CARDIZEM LA...... 51 butalbital-asa-caff-codeine...... 9 CANTHARIDIN...... 62 CARDURA...... 51 butalbital-aspirin-caffeine...... 9 CAPASTAT SULFATE...... 35 CARDURA XL...... 95 butorphanol tartrate...... 9, 10 capecitabine...... 36 CARETOUCH 2 CPAP HOSE BUTRANS...... 10 CAPEX...... 62 HANGER...... 114 BYDUREON...... 72 CAPLYTA...... 43 CARETOUCH CONTROL SOL BYDUREON BCISE CAPRELSA...... 36 LEVEL 2...... 74 AUTOINJECTOR...... 72 capsaicin...... 62 CARETOUCH CPAP & BIPAP BYETTA 10 MCG PEN...... 72 CAPSAICIN-MENTHOL...... 18 HOSE...... 114 BYETTA 5 MCG PEN...... 72 CAPSFENAC PAK...... 14 CARETOUCH CPAP MASK BYNFEZIA PEN...... 98 CAPSINAC...... 14 WIPES...... 114 BYSTOLIC...... 51 captopril...... 51 CARETOUCH CPAP PRE- cabergoline...... 98 captopril-hydrochlorothiazide.... 51 WASH SOLN...... 114 CABLIVI...... 43 capzix...... 62 CARETOUCH CPAP TUBE CABOMETYX...... 36 CARAC...... 62 BRUSH...... 114 CADIRAMD...... 18 CARAFATE...... 86 CARETOUCH CADUET...... 51 CARBAGLU...... 78 LANCING/EJECTOR...... 74 CAFERGOT...... 34 carbamazepine...... 26 CARETOUCH TEST...... 74 caffeine citrate...... 58 carbamazepine er...... 26 CARETOUCH UNIVERSL CALAN SR...... 51 CARBATROL...... 26 CPAP FILTER...... 114 calcidol...... 77 carbidopa...... 42 CARIMUNE NF...... 106 CALCIFOL...... 78 carbidopa-levodopa...... 42 carisoprodol...... 135 calcipotriene...... 62 carbidopa-levodopa er...... 42 carisoprodol-aspirin-codeine.....10 CALCIPOTRIENE...... 62 carbidopa-levodopa- carmustine...... 36 calcipotriene-betameth diprop...62 entacapone...... 42 CARNITOR...... 78 CALCIPOTRIENE- carbinoxamine maleate...... 128 CARNITOR SF...... 78 CLOBETASOL PROP...... 62 carboplatin...... 36 CAROSPIR...... 51 calcitonin (salmon)...... 112 CARDIOPLEGIA DEL NIDO carteolol hcl...... 123 calcitrate...... 78 FORMULA...... 78 cartia xt...... 51 CALCITRENE...... 62 CARTICEL...... 114

142 carvedilol...... 51 CEQUR SIMPLICITY 2U...... 74 ciclodan...... 32 carvedilol phosphate er...... 51 CERACADE...... 62 ciclopirox...... 32 cascara sagrada...... 88 CERDELGA...... 92 ciclopirox olamine...... 32 CASODEX...... 36 CEREBYX...... 26 ciclopirox treatment...... 32 caspofungin acetate...... 31 CEREFOLIN...... 78 CICLOPIROX-CLOBETASOL...62 CAT HAIR EXTRACT...... 114 cerefolin nac...... 78 CICLOPIROX-CLOBETASOL- CATAPRES...... 51 CEREZYME...... 92 SAL ACID...... 62 CATAPRES-TTS-1...... 51 cerovel...... 62 CICLOPIROX-SALICYLIC CATAPRES-TTS-2...... 51 CERVIDIL...... 93 ACID...... 62 CATAPRES-TTS-3...... 51 CETACAINE...... 18 cidofovir...... 44 CATHFLO ACTIVASE...... 26 cetirizine hcl...... 128 CIFEREX...... 78 CATTLE EPITHELIUM...... 114 cetirizine hcl childrens...... 128 CIFRAZOL...... 78 cavarest...... 59 CETRAXAL...... 127 cilostazol...... 43 CAVERJECT...... 93 CETROTIDE...... 98 CILOXAN...... 122 CAVERJECT IMPULSE...... 93 cevimeline hcl...... 59 CIMDUO...... 44 CAYA...... 114 CHANTIX...... 20 cimetidine...... 86 CAYSTON...... 134 CHANTIX CONTINUING cimetidine hcl...... 86 caziant...... 101 MONTH PAK...... 20 CIMETIDINE-LIDO- CBD4 FREEZE PUMP CHANTIX STARTING MONTH SALICYLIC ACID...... 62 MAXIMUM STR...... 18 PAK...... 20 CIMZIA...... 106 CEDAR ELM...... 114 charlotte 24 fe...... 101 CIMZIA PREFILLED KIT...... 106 cefaclor...... 21 chateal...... 101 CIMZIA STARTER KIT...... 106 cefaclor er...... 21 chateal eq...... 101 cinacalcet hcl...... 112 cefadroxil...... 21 CHEMET...... 78 CINQAIR...... 128 cefazolin sodium...... 21 CHEMSTRIP UGK...... 74 CINRYZE...... 106 cefazolin sodium-dextrose...... 21 CHENODAL...... 88 CIPRO...... 22 cefdinir...... 21 chest congestion relief...... 128 CIPRO HC...... 127 cefepime hcl...... 21 chest congestion relief dm...... 128 CIPRODEX...... 127 cefixime...... 21 childrens acetaminophen...... 10 ciprofloxacin hcl...... 22, 122, 127 CEFOTAN...... 21 childrens apap...... 10 ciprofloxacin-dexamethasone. 127 cefotaxime sodium...... 21 childrens chewable vitamins..... 78 CIPROFLOXACIN- cefotetan disodium...... 21 childrens non-aspirin...... 10 FLUOCINOLONE PF...... 127 cefoxitin sodium...... 21 CHLOOXIA...... 62 cisplatin...... 36 cefpodoxime proxetil...... 21 chloramphenicol sod succinate.22 CISPLATIN...... 36 cefprozil...... 21 chlordiazepoxide hcl...... 47 citalopram hydrobromide...... 29 ceftazidime...... 22 chlordiazepoxide-amitriptyline...29 CITRANATAL BLOOM...... 78 ceftriaxone sodium...... 22 chlordiazepoxide-clidinium...... 88 CITRANATAL ESSENCE...... 78 cefuroxime axetil...... 22 chlorhexidine gluconate...... 59 CITRANATAL MEDLEY...... 78 CELEBREX...... 14 chloroquine phosphate...... 41 citroma...... 88 celecoxib...... 14 chlorpheniramine maleate er.. 128 CLADOSPORIUM CELESTONE SOLUSPAN...... 95 chlorpromazine hcl...... 43 CLADOSPORIOIDES...... 114 CELEXA...... 29 chlorthalidone...... 51 CLADOSPORIUM CELLCEPT...... 106 CHLOR-TRIMETON...... 128 SPHAEROSPERMUM...... 114 CELLCEPT INTRAVENOUS.. 106 chlorzoxazone...... 135 cladribine...... 36 CELONTIN...... 26 chocolated laxative...... 88 claravis...... 62 CEM-UREA...... 62 CHOLBAM...... 92 CLARINEX...... 128 CENFOL...... 78 CHOLECAL DF...... 78 CLARINEX-D 12 HOUR...... 128 CENTANY...... 22 cholestyramine...... 51 clarithromycin...... 22 CENTANY AT...... 22 cholestyramine light...... 51 clarithromycin er...... 22 CENTRATEX...... 78 CHONDROITIN SULFATE..... 125 CLARITIN...... 128 cephalexin...... 22 chorionic gonadotropin...... 98 CLARITIN REDITABS...... 128 CEPROTIN...... 48 chromagen...... 78 CLARITIN-D 12 HOUR...... 128 CEQUA...... 124 CIALIS...... 93 clearlax...... 88

143 clemastine fumarate...... 128 clopidogrel bisulfate...... 43 CONSENSI...... 51 CLENPIQ...... 88 clorazepate dipotassium...... 47 constulose...... 88 CLEOCIN...... 22 clotrimazole...... 32 CONTOUR CONTROL...... 74 CLEOCIN-T...... 62 clotrimazole-betamethasone.....32 CONTOUR NEXT CONTROL...74 CLIMARA...... 101 clovique...... 78 CONTOUR NEXT LINK...... 74 CLIMARA PRO...... 101 clozapine...... 43 CONTOUR NEXT MONITOR... 74 CLINDACIN ETZ...... 62 CLOZARIL...... 43 CONTOUR NEXT TEST...... 74 clindacin etz...... 62 COAGADEX...... 48 CONTOUR TEST...... 74 CLINDACIN PAC...... 62 COAL TAR...... 63 CONTRAST ALLERGY clindacin-p...... 62 COARTEM...... 41 PREMED PACK...... 95 CLINDAGEL...... 62 COCAINE HCL...... 18 CONTRAVE...... 58 CLINDAMY-BENZOYL PER- COCKLEBUR...... 114 CONVENIENCE PAK...... 58 NIACINAM...... 62 COD LIVER OIL...... 78 CONZIP...... 10 clindamycin hcl...... 22 codeine sulfate...... 10 COPADERM...... 63 clindamycin palmitate hcl...... 22 coenzyme q10...... 114 COPASIL...... 63 CLINDAMYCIN PHOS- COLAZAL...... 111 COPAXONE...... 57 NIACINAMIDE...... 62 COLCHICINE...... 34 COPIKTRA...... 36 clindamycin phosphate. 22, 62, 63 colchicine...... 34 CORDRAN...... 63 CLINDAMYCIN PHOSPHATE.. 63 colchicine-probenecid...... 34 COREG...... 51 clindamycin phosphate- COLCIGEL...... 114 COREG CR...... 51 benzoyl peroxide...... 62 COLCRYS...... 34 coremino...... 22 CLINDAMYCIN-NIACIN- cold & flu relief daytime...... 128 CORGARD...... 51 TRETINOIN...... 63 cold/flu daytime relief...... 128 CORIFACT...... 48 clindamycin-tretinoin...... 63 COLD-EEZE NATURAL CORLANOR...... 51 CLINDESSE...... 22 MULTI-SYMP...... 114 corn & callus remover...... 63 CLIND-NIACIN- COLD-EEZE PLUS DEFENSE CORN POLLEN...... 114 SPIRONOLAC-TRETIN...... 63 ...... 114 CORTANE-B...... 63 CLINOIN...... 63 COLD-EEZE SUGAR FREE... 114 CORTEF...... 95 clinpro 5000...... 59 colesevelam hcl...... 51 CORTENEMA...... 111 clobazam...... 26 COLESTID...... 51 cortic-nd...... 127 clobetasol prop emollient base. 63 COLESTID FLAVORED...... 51 CORTIFOAM...... 111 clobetasol propionate...... 63 colestipol hcl...... 51 cortisone acetate...... 95 clobetasol propionate e...... 63 colistimethate sodium (cba)...... 22 CORTISPORIN...... 63 clobetasol propionate emulsion 63 COLLATYL...... 63 CORTROSYN...... 114 CLOBETASOL PROP- COLY-MYCIN M...... 22 corvita...... 78 LEVOCETIRIZINE...... 63 COMBIGAN...... 123 corvita 150...... 78 CLOBETASOL PROP- COMBIPATCH...... 101 CORVITE 150...... 78 NIACINAMIDE...... 63 COMBIVENT RESPIMAT...... 132 corvite fe...... 78 CLOBETAVIX...... 63 COMBIVIR...... 44 COSENTYX (300 MG DOSE).106 CLOBEX...... 63 COMETRIQ (100 MG DAILY COSENTYX 150 MG/ML...... 106 CLOBEX SPRAY...... 63 DOSE)...... 36 COSENTYX SENSOREADY clocortolone pivalate...... 63 COMETRIQ (140 MG DAILY (300 MG)...... 106 CLODAN...... 63 DOSE)...... 36 COSENTYX SENSOREADY clodan...... 63 COMETRIQ (60 MG DAILY PEN...... 106 CLODERM...... 63 DOSE)...... 36 COSMEGEN...... 36 clofarabine...... 36 COMPLERA...... 44 COSOPT...... 123 CLOLAR...... 36 complete lice treatment...... 41 COSOPT PF...... 123 clomiphene citrate...... 98 compro...... 30 cosyntropin...... 114 clomipramine hcl...... 29 COMTAN...... 42 COTELLIC...... 36 clonazepam...... 47 CONCERTA...... 56 COTEMPLA XR-ODT...... 56 clonidine...... 51 CONDOMS...... 114 cough dm...... 128 clonidine hcl...... 51 CONDYLOX...... 63 cough/chest congestion dm.... 128 clonidine hcl er...... 56 CONJUPRI...... 51 covaryx...... 101

144 covaryx hs...... 101 cyred...... 101 DECARA...... 79 COZAAR...... 51 cyred eq...... 101 decitabine...... 37 CREON...... 92 CYSTADANE...... 92 deferasirox...... 79 CRESEMBA...... 32 CYSTADROPS...... 125 deferasirox granules...... 79 CRESTOR...... 51 CYSTAGON...... 92 deferiprone...... 79 CRINONE...... 101 CYSTARAN...... 125 deferoxamine mesylate...... 114 CRIXIVAN...... 44 cytarabine...... 36 dehydrated alcohol...... 79 CROFAB...... 114 cytarabine (pf)...... 36 DELESTROGEN...... 101 cromolyn sodium...... 88, 122, 132 CYTOGAM...... 106 DELSTRIGO...... 44 crotan...... 41 CYTOMEL...... 105 DELTEC COZMO CLEO SET cryselle-28...... 101 CYTOTEC...... 86 24" 6MM...... 114 CRYSVITA...... 92 cytra k crystals...... 78 DELUO...... 63 CUBICIN...... 22 D.H.E. 45...... 34 delyla...... 101 CUBICIN RF...... 22 d3 high potency...... 78 DELZICOL...... 111 CUPRIMINE...... 93 d3 super strength...... 78 demeclocycline hcl...... 22 CUROSURF...... 128 dacarbazine...... 36 DEMEROL...... 10 CURVULARIA...... 114 DACOGEN...... 36 DEMSER...... 51 CUTAQUIG...... 106 dactinomycin...... 36 DENAVIR...... 45 CUTIVATE...... 63 daflonex-xl...... 78 denta 5000 plus...... 59 CUVITRU...... 106 dalfampridine er...... 57 dentagel...... 59 CUVPOSA...... 88 DALIRESP...... 132 DEOXIA...... 63 cvs acetaminophen ex st...... 10 danazol...... 97 DEPAKOTE...... 26 cvs antacid extra strength...... 88 DANDELION...... 114 DEPAKOTE ER...... 26 cvs clotrimazole 3...... 32 DANTRIUM...... 135 DEPAKOTE SPRINKLES...... 26 cvs gentle laxative...... 88 dantrolene sodium...... 135 DEPEN TITRATABS...... 93 cvs lubricant eye drops...... 125 dapsone...... 35, 63 DEPLIN 15...... 79 cvs motion sickness...... 30 DAPSONE...... 63 DEPLIN 7.5...... 79 cvs stool softener...... 88 DAPSONE-NIACINAMIDE...... 63 DEPO-ESTRADIOL...... 101 cvs vitamin e...... 78 DAPSONE-NIACINAMIDE- DEPO-MEDROL...... 95 cyanocobalamin...... 78 SPIRONOLAC...... 63 DEPO-PROVERA...... 101 CYANOCOBALAMIN...... 78 DAPTACEL...... 109 DEPO-SUBQ PROVERA 104.101 cyclafem 1/35...... 101 daptomycin...... 22 DEPO-TESTOSTERONE...... 97 cyclafem 7/7/7...... 101 DARAPRIM...... 41 DERMACINRX ANALGESIC CYCLO/GABA 10/300...... 135 darifenacin hydrobromide er..... 93 COMBOPAK...... 14 cyclobenzaprine hcl...... 135 DARZALEX...... 37 DERMACINRX AZENASE cyclobenzaprine hcl er...... 135 DARZALEX FASPRO...... 37 PAK...... 128 CYCLOGYL...... 125 dasetta 1/35...... 101 DERMACINRX CYCLOMYDRIL...... 125 dasetta 7/7/7...... 101 CLORHEXACIN...... 59 CYCLOPAK...... 135 daunorubicin hcl...... 37 DERMACINRX DUOPATCH cyclopentolate hcl...... 125 DAURISMO...... 37 PHARMAPAK...... 18 CYCLOPHENE RAPIDPAQ....135 dayhist allergy 12 hour relief... 128 DERMACINRX EMPRICAINE.. 18 cyclophosphamide...... 36 DAYPRO...... 14 DERMACINRX LEXITRAL CYCLOPHOSPHAMIDE...... 36 daysee...... 101 PHARMAPAK...... 14 cycloserine...... 35 daytime cold & flu relief...... 128 DERMACINRX NEUROTRAL CYCLOSET...... 72 daytime cold/flu relief...... 128 PHARMAPAK...... 18 cyclosporine...... 106 DAYTRANA...... 56 DERMACINRX PENETRAL...... 63 CYCLOSPORINE IN KLARITY DAYVIGO...... 136 DERMACINRX PHN...... 18 ...... 125 DDAVP...... 98 DERMACINRX PRIZOPAK...... 18 cyclosporine modified...... 106 DDAVP RHINAL TUBE...... 98 DERMACINRX PUREFOLIX.... 79 CYKLOKAPRON...... 48 DEBACTEROL...... 59 DERMACINRX SURGICAL CYMBALTA...... 29 deblitane...... 101 COMBOPAK...... 63 cyproheptadine hcl...... 128 DECADRON...... 95 DERMACINRX SURGICAL CYRAMZA...... 36 decara...... 78 PHARMAPAK...... 59

145 DERMACINRX THERAZOLE DEXYCU...... 122 DIGIFAB...... 115 PAK...... 32 DFS DR/MS/MENTH/CAP digitek...... 51 DERMACINRX TICANASE PAK...... 15 digox...... 51 PAK...... 128 DFS/MS/MENTH/CAP PAK...... 15 digoxin...... 51 DERMACINRX ZRM...... 18 DIACOMIT...... 26 dihydroergotamine mesylate.....34 DERMA-SMOOTHE/FS BODY.63 DIADIMAXIA...... 64 DILANTIN...... 27 DERMA-SMOOTHE/FS dialyvite...... 79 DILANTIN INFATABS...... 27 SCALP...... 63 DIALYVITE 3000...... 79 DILATRATE-SR...... 51 dermazene...... 32 DIALYVITE 5000...... 79 DILAUDID...... 10 DERMOTIC...... 127 DIALYVITE SUPREME D...... 79 diltiazem hcl...... 52 DERMULCERA...... 63 DIALYVITE/ZINC...... 79 diltiazem hcl er...... 52 DESCOVY...... 45 DIAOXIA...... 64 diltiazem hcl er beads...... 51 DESENEX...... 32 diaper rash...... 64 diltiazem hcl er coated beads... 51 DESFERAL...... 115 DIASDIMAXIA...... 64 DILTIAZEM HCL-DEXTROSE.. 52 desflurane...... 115 DIASOXIA...... 64 dilt-xr...... 52 desipramine hcl...... 29 DIASTAT ACUDIAL...... 26 dimaphen dm cold/cough...... 128 desloratadine...... 128 DIASTAT PEDIATRIC...... 26 DIMENTHO...... 15 desmopressin ace spray refrig..98 diazepam...... 26, 47 dimethyl fumarate...... 57 desmopressin acetate...... 98 diazepam intensol...... 47 dimethyl fumarate starter pack..57 desmopressin acetate spray..... 98 diazoxide...... 75 DIMOXIA...... 64 desogestrel-ethinyl estradiol... 101 DIBENZYLINE...... 51 diotame instydose...... 88 DESONATE...... 63 DICLEGIS...... 30 DIOVAN...... 52 desonide...... 64 DICLOFENAC...... 15 DIOVAN HCT...... 52 DESOWEN...... 64 DICLOFENAC EPOLAMINE.....15 DIPENTUM...... 111 desoximetasone...... 64 diclofenac potassium...... 15 diphen...... 128 DESOXYN...... 56 diclofenac sodium...... 15, 64, 122 DI-PHEN...... 128 DESVENLAFAXINE ER...... 29 diclofenac sodium er...... 15 diphenhydramine hcl...... 129 desvenlafaxine succinate er...... 29 diclofenac-misoprostol...... 15 diphenoxylate-atropine...... 88 DETROL...... 93 DICLOFENAC-NA DIPHTHERIA-TETANUS DETROL LA...... 93 HYALURON-NIACIN...... 64 TOXOIDS DT...... 109 DEXABLISS...... 95 diclofex dc...... 15 DIPROLENE...... 64 dexamethasone...... 95 DICLOFONO...... 15 DIPROLENE AF...... 64 dexamethasone intensol...... 95 DICLOPR...... 15 dipyridamole...... 43 dexamethasone sod diclosaicin...... 15 disopyramide phosphate...... 52 phosphate pf...... 95 DICLOSTREAM...... 15 disulfiram...... 20 dexamethasone sodium DICLOTREX...... 15 DITROPAN XL...... 93 phosphate...... 96, 122 DICLOVIX...... 15 DIURIL...... 52 DEXAMETHASONE SODIUM DICLOVIX M...... 15 divalproex sodium...... 27 PHOSPHATE...... 96 dicloxacillin sodium...... 22 divalproex sodium er...... 27 dexchlorpheniramine maleate.128 DICLOZOR...... 15 DIVIGEL...... 101 DEXEDRINE...... 56 DICOPANOL FUSEPAQ...... 128 DMT SUIK...... 96 DEXERYL...... 64 DICOPANOL RAPIDPAQ...... 128 docetaxel...... 37 dexifol...... 79 dicyclomine hcl...... 88 docosanol...... 64 DEXILANT...... 86 didanosine...... 45 docusate mini...... 88 dexmedetomidine hcl...... 115 diethylpropion hcl...... 58 docusate sodium...... 88 dexmedetomidine hcl in nacl...115 diethylpropion hcl er...... 58 docuzen...... 88 dexmethylphenidate hcl...... 57 DIFFERIN...... 64 dofetilide...... 52 dexmethylphenidate hcl er...... 57 DIFICID...... 22 DOG EPITHELIUM...... 115 DEXONTO 0.4%...... 96 difil-g forte...... 132 DOG FENNEL...... 115 dexrazoxane hcl...... 37 diflorasone diacetate...... 64 DOJOLVI...... 115 DEXTENZA...... 122 DIFLUCAN...... 32 dok...... 88 dextroamphetamine sulfate...... 57 diflunisal...... 15 DOLOPHINE...... 10 dextroamphetamine sulfate er.. 57 DIFMETIOXRIME...... 32 donepezil hcl...... 28

146 DONNATAL...... 88 DURAGESIC-100...... 10 ed-spaz...... 88 DOPTELET...... 48 DURAGESIC-12...... 10 EDURANT...... 45 DORAL...... 47 DURAGESIC-25...... 10 eemt...... 102 DORYX...... 22 DURAGESIC-50...... 10 eemt hs...... 102 DORYX MPC...... 22 DURAGESIC-75...... 10 efavirenz...... 45 DORZOLAMIDE HCL...... 123 duramorph...... 10 efavirenz-emtricitab-tenofovir....45 dorzolamide hcl...... 123 DUREZOL...... 122 efavirenz-lamivudine-tenofovir.. 45 dorzolamide hcl-timolol mal.... 123 DURLAZA...... 43 EFFER-K...... 79 dorzolamide hcl-timolol mal pf 123 DUROLANE...... 115 effer-k...... 79 dotti...... 101 DURYSTA...... 123 EFFEXOR XR...... 29 DOUBLE PM...... 125 DUST MITE MIXED EFFIENT...... 43 DOUBLEDEX...... 96 ALLERGEN EXT...... 115 EFUDEX...... 64 DOVATO...... 45 dutasteride...... 95 EGATEN...... 41 DOVONEX...... 64 dutasteride-tamsulosin hcl...... 95 EGRIFTA SV...... 98 doxazosin mesylate...... 52 DUTOPROL...... 52 EHA...... 18 doxepin hcl...... 29, 64, 136 d-vite pediatric...... 79 ELAPRASE...... 92 doxercalciferol...... 112 DXEVO 11-DAY...... 96 ELELYSO...... 92 DOXIL...... 37 DYANAVEL XR...... 57 ELESTRIN...... 102 doxorubicin hcl...... 37 DYAZIDE...... 52 ELETONE...... 64 doxorubicin hcl liposomal...... 37 DYMISTA...... 129 eletriptan hydrobromide...... 34 doxy 100...... 22 DYRENIUM...... 52 ELFOLATE...... 79 doxycycline...... 64 DYSPORT...... 115 ELFOLATE PLUS...... 79 doxycycline hyclate...... 22 DYURAL-40...... 96 ELIDEL...... 64 DOXYCYCLINE HYCLATE...... 22 DYURAL-80...... 96 ELIGARD...... 98 doxycycline monohydrate... 22, 23 DYURAL-L...... 96 ELIMITE...... 42 doxylamine-pyridoxine...... 30 DYURAL-LM...... 96 elinest...... 102 DR SMITHS ADULT BARRIER 64 E.E.S. GRANULES...... 23 ELIQUIS...... 26 DRAXACE...... 64 EASIVENT...... 115 ELIQUIS DVT/PE STARTER DRAXACE LOTION EASTERN COTTONWOOD... 115 PACK...... 26 CLEANSER...... 64 easygel...... 59 ELITEK...... 37 DRECHSLERA...... 115 EASYMAX 15 LEVEL 2-3 ELITE-OB...... 79 DRISDOL...... 79 CONTROL...... 74 ELIXOPHYLLIN...... 132 DRITHO-CREME HP...... 64 EASYMAX CONTROL...... 74 ELLA...... 102 DRIXECE...... 64 EASYMAX CONTROL ELLENCE...... 37 DRIZALMA SPRINKLE...... 29 NORMAL/HIGH...... 74 ELLZIA PAK...... 64 dronabinol...... 30 ECEOXIA...... 64 ELMIRON...... 93 drospiren-eth estrad-levomefol101 EC-NAPROSYN...... 15 ELOCTATE...... 48 drospirenone-ethinyl estradiol.102 ec-naproxen...... 15 eluryng...... 102 DROXIA...... 37 ECONASIL...... 32 ELZONRIS...... 37 DRYSOL...... 64 econazole nitrate...... 32 EMCYT...... 37 DSUVIA...... 10 ECONAZOLE NITRATE- EMEND...... 30 DUAKLIR PRESSAIR...... 132 NIACINAMIDE...... 32 EMEND TRI-PACK...... 30 DUAL COMPLEX FORMULA 1 ECOZA...... 32 EMFLAZA...... 34 KIT...... 15 EC-RX DHEA...... 115 EMGALITY...... 34 DUAVEE...... 102 EC-RX ESTRADIOL...... 102 EMGALITY (300 MG DOSE).... 34 DUETACT...... 72 EC-RX PROGESTERONE..... 102 emoquette...... 102 DUEXIS...... 15 EC-RX TESTOSTERONE...... 98 EMPLICITI...... 37 DULERA...... 132 ECZEMOL...... 115 EMPRICAINE-II...... 18 duloxetine hcl...... 29 EDARBI...... 52 EMSAM...... 29 DUOBRII...... 64 EDARBYCLOR...... 52 emtricitabine...... 45 DUOPA...... 42 EDECRIN...... 52 emtricitabine-tenofovir df...... 45 DUPIXENT...... 64 EDEX...... 93 EMTRIVA...... 45 DURACHOL...... 79 EDLUAR...... 136 EMULSION SB...... 64

147 EMVERM...... 42 EPANED...... 52 ERYPED 200...... 23 ENABLEX...... 93 EPCLUSA...... 45 ERYPED 400...... 23 enalapril maleate...... 52 ephedrine sulfate...... 52 ERY-TAB...... 23 enalapril-hydrochlorothiazide.... 52 EPHEDRINE SULFATE-NACL. 52 ERYTHROCIN STEARATE...... 23 ENBRACE HR...... 79 EPICERAM...... 64 erythromycin...... 23, 64, 65, 122 ENBREL...... 106 EPICOCCUM...... 115 erythromycin base...... 23 ENBREL MINI...... 106 EPIDIOLEX...... 27 erythromycin ethylsuccinate...... 23 ENBREL SURECLICK...... 106 EPIDUO...... 64 ESBRIET...... 132 ENDARI...... 115 EPIDUO FORTE...... 64 escitalopram oxalate...... 29 ENDO AVITENE...... 115 EPIFOAM...... 64 ESGIC...... 10 endocet...... 10 epinastine hcl...... 122 ESKATA...... 65 ENDOMETRIN...... 102 epinephrine...... 132 ESOMEP-EZS...... 86 ENFAGROW NEUROPRO epinephrine hcl (nasal)...... 129 esomeprazole magnesium...... 86 TODDLER...... 115 EPINEPHRINE ESOMEPRAZOLE ENFAMIL GENTLEASE...... 115 PROFESSIONAL...... 132 STRONTIUM...... 86 ENFAMIL INFANT...... 115 EPINEPHRINESNAP-EMS.....132 ESPEROCT...... 48 ENFAMIL NEUROPRO EPINEPHRINESNAP-V...... 132 ESSENTIAL CARE JR...... 115 SENSITIVE...... 115 EPIPEN 2-PAK...... 132 est estrogens-methyltest...... 102 ENFAMIL NUTRAMIGEN...... 115 EPIPEN JR 2-PAK...... 132 est estrogens-methyltest ds.... 102 ENFAMIL NUTRAMIGEN EPIQUIN MICRO...... 64 est estrogens-methyltest hs.... 102 LIPIL...... 115 epirubicin hcl...... 37 estarylla...... 102 ENGERIX-B...... 109 EPISIL...... 115 estazolam...... 47 ENGLISH PLANTAIN...... 115 EPISNAP...... 132 ESTRACE...... 102 ENHERTU...... 37 epitol...... 27 estradiol...... 102 ENLITE GLUCOSE SENSOR...74 EPIVIR...... 45 estradiol valerate...... 102 ENLYTE...... 115 EPIVIR HBV...... 45 estradiol-norethindrone acet... 102 enovarx-amitriptyline...... 115 eplerenone...... 52 ESTRING...... 102 enovarx-baclofen...... 135 EPOGEN...... 48 ESTROGEL...... 102 enovarx-cyclobenzaprine hcl.. 135 epoprostenol sodium...... 134 ESTROSTEP FE...... 102 ENOVARX-DICLOFENAC EPZICOM...... 45 eszopiclone...... 136 SODIUM...... 15 eq anti-diarrheal...... 88 ethacrynic acid...... 52 enovarx-ibuprofen...... 15 EQUACARE JR...... 115 ethambutol hcl...... 35 enovarx-lidocaine hcl...... 18 EQUAPAX/ATORVASTATIN/C ethosuximide...... 27 enovarx-naproxen...... 15 OQ10...... 52 ETHOXIA...... 65 enovarx-tramadol...... 64 EQUAPAX/IBUPROFEN/MINR ethyl chloride...... 18 enoxaparin sodium...... 26 EX...... 15 ethynodiol diac-eth estradiol... 102 enpresse-28...... 102 EQUETRO...... 48 ETHYOL...... 37 enskyce...... 102 ERAXIS...... 32 etodolac...... 15 ENSPRYNG...... 106 ERBITUX...... 37 etodolac er...... 15 ENSTILAR...... 64 ERGOCAL...... 79 etonogestrel-ethinyl estradiol.. 102 entacapone...... 42 ergocalciferol...... 79 ETOPOPHOS...... 37 entecavir...... 45 ergoloid mesylates...... 115 etoposide...... 37 ENTERAGAM...... 115 ERGOMAR...... 34 EUCRISA...... 65 ENTEREG...... 88 ergotamine-caffeine...... 34 EUFLEXXA...... 115 enteric fish oil...... 115 ERIVEDGE...... 37 euthyrox...... 105 ENTOCORT EC...... 111 ERLEADA...... 37 EVAMIST...... 102 ENTRESTO...... 52 erlotinib hcl...... 37 EVEKEO...... 57 ENTTY SPRAY...... 64 errin...... 102 EVEKEO ODT...... 57 ENTYVIO...... 106 ERTACZO...... 32 EVENITY...... 112 enulose...... 88 ertapenem sodium...... 23 everolimus...... 37, 106 ENVARSUS XR...... 106 ERWINAZE...... 37 EVISTA...... 98 ENZADYNE...... 92 ery...... 64 EVOCLIN...... 65 ENZOCLEAR...... 64 ERYGEL...... 64 EVOMELA...... 37

148 EVOTAZ...... 45 fenofibrate...... 52 FIRMAGON...... 98 EVOXAC...... 59 fenofibrate micronized...... 52 FIRMAGON (240 MG DOSE)... 98 EVRYSDI...... 115 fenofibric acid...... 52 FIRST - METOPROLOL...... 52 EXELDERM...... 32 FENOGLIDE...... 52 FIRST-ATENOLOL...... 52 EXELON...... 28 fenoprofen calcium...... 15 FIRST-BACLOFEN...... 135 exemestane...... 37 fenortho...... 15 FIRST-LANSOPRAZOLE...... 86 EXFORGE...... 52 FENSOLVI (6 MONTH)...... 98 FIRST-METRONIDAZOLE...... 23 EXFORGE HCT...... 52 fentanyl...... 10 FIRST-MOUTHWASH BLM...... 59 EXJADE...... 79 fentanyl citrate...... 10 FIRST-OMEPRAZOLE...... 86 EX-LAX ULTRA...... 88 FENTANYL CITRATE...... 10 FIRST-PROGESTERONE exoderm...... 32 fentanyl citrate (pf)...... 10 VGS...... 102 EXONDYS 51...... 92 FENTANYL CITRATE-NACL.... 10 FIRVANQ...... 23 exotic-hc...... 127 FENTANYL-BUPIVACAINE- flac...... 127 EXPAREL...... 18 NACL...... 10, 11 FLAGYL...... 23 EXTAVIA...... 58 FENTORA...... 11 FLAREX...... 122 EXTINA...... 32 FERAHEME...... 79 flavoxate hcl...... 93 eye itch relief...... 122 FERIVA 21/7...... 79 FLEBOGAMMA DIF...... 106 EYLEA...... 125 FERIVAFA...... 79 flecainide acetate...... 53 EYSUVIS...... 122 ferocon...... 79 FLEXICHAMBER ADULT EZALLOR SPRINKLE...... 52 ferotrinsic...... 79 MASK/SMALL...... 115 ezetimibe...... 52 FERRALET 90...... 79 FLEXICHAMBER CHILD ezetimibe-simvastatin...... 52 ferraplus 90...... 79 MASK/LARGE...... 115 fabb...... 79 FERRIPROX...... 79 FLEXICHAMBER CHILD FABIOR...... 65 FERRIPROX TWICE-A-DAY.... 79 MASK/SMALL...... 116 FABRAZYME...... 92 FERRLECIT...... 79 FLEXIN...... 18 FALESSA...... 102 ferrocite plus...... 79 FLEXIPAK...... 15 falmina...... 102 FERRO-PLEX HEMATINIC...... 79 FLOLAN...... 134 famciclovir...... 45 FERROTRIN...... 79 FLOLIPID...... 53 famotidine...... 86 ferrous sulfate...... 79 FLOMAX...... 95 FANAPT...... 43 FETROJA...... 23 FLORIVA...... 79 FANAPT TITRATION PACK..... 43 FETZIMA...... 29 FLORIVA PLUS...... 79 FANATREX FUSEPAQ...... 27 FETZIMA TITRATION...... 29 FLOVENT DISKUS...... 132 FARESTON...... 37 FEXMID...... 135 FLOVENT HFA...... 132 FARXIGA...... 72 fexofenadine hcl...... 129 floxuridine...... 37 FARYDAK...... 37 fexofenadine-pseudoephed er 129 FLUAD...... 109 FASENRA...... 129 FIASP...... 76 FLUAD QUADRIVALENT...... 110 FASENRA PEN...... 129 FIASP FLEXTOUCH...... 76 FLUARIX QUADRIVALENT....110 FASLODEX...... 37 FIASP PENFILL...... 76 flucaine...... 125 FAVIPIRAVIR...... 45 fiber...... 88 FLUCELVAX fa-vitamin b-6-vitamin b-12...... 79 fiber laxative...... 88 QUADRIVALENT...... 110 fayosim...... 102 FIBRICOR...... 52 fluconazole...... 32 FBL KIT...... 15 FIBRYGA...... 48 FLUCON-IBUPROF- febuxostat...... 34 FINACEA...... 65 ITRACON-TERBINA...... 32 FEIBA...... 48 finasteride...... 65, 95 flucytosine...... 32 felbamate...... 27 FINASTERIDE-MINOXIDIL...... 65 fludarabine phosphate...... 37 FELBATOL...... 27 FINTEPLA...... 27 fludrocortisone acetate...... 96 FELDENE...... 15 FIORICET...... 11 FLULAVAL QUADRIVALENT. 110 felodipine er...... 52 FIORICET/CODEINE...... 11 FLUMIST QUADRIVALENT....110 FEM PH...... 93 FIORINAL...... 11 flunisolide...... 129 FEMARA...... 37 FIORINAL/CODEINE #3...... 11 FLUOCINOLONE ACET- FEMHRT LOW DOSE...... 102 FIRAZYR...... 106 NIACINAMIDE...... 65 FEMRING...... 102 FIRDAPSE...... 115 fluocinolone acetonide...... 65, 127 femynor...... 102 FIRE ANT...... 115 fluocinolone acetonide body..... 65

149 fluocinolone acetonide scalp.....65 FOLIKA PROBIOTIC...... 88 FREESTYLE LIBRE SENSOR fluocinonide...... 65 FOLITE...... 80 SYSTEM...... 74 fluocinonide emulsified base.....65 FOLIVANE-F...... 80 FREESTYLE PRECISION FLUOPAR...... 65 FOLIVANE-PLUS...... 80 NEO TEST...... 74 FLUORABON...... 79 FOLIXAPURE...... 80 FROTEK...... 15 fluorescein-benoxinate...... 125 FOLLISTIM AQ...... 99 FROVA...... 34 fluoridex...... 59 FOLOTYN...... 37 frovatriptan succinate...... 34 fluoridex daily renewal...... 59 folplex 2.2...... 80 FUL-GLO...... 125 fluoridex enhanced whitening... 59 foltanx...... 80 ful-glo...... 125 fluoridex sensitivity relief...... 59 FOLTANX RF...... 80 FULPHILA...... 48 fluor-i-strips a.t...... 125 FOLTRATE...... 80 fulvestrant...... 37 fluoritab...... 79 FOLTREXYL...... 80 FUNGIMEZ...... 32 fluorometholone...... 122 foltrin...... 80 furosemide...... 53 FLUOROPLEX...... 65 FOLTX...... 80 FUSARIUM...... 116 fluorouracil...... 37, 65 FOLVITE-D...... 80 FUSION PLUS...... 80 FLUOROURACIL...... 65 fondaparinux sodium...... 26 FUZEON...... 45 FLUOVIX...... 65 FORANE...... 116 fyavolv...... 102 FLUOVIX PLUS...... 65 FORAXA...... 65 FYCOMPA...... 27 fluoxetine hcl...... 29 FORFIVO XL...... 29 GABACAINE...... 58 FLUOXETINE HCL (PMDD)..... 29 formaldehyde...... 116 GABADONE...... 116 fluphenazine decanoate...... 43 FORMALDEHYDE...... 116 gabapentin...... 27 fluphenazine hcl...... 43 FORTAMET...... 72 GABAPENTIN-NAPROXEN FLURA-DROPS...... 79 FORTAZ...... 23 CMPD KIT...... 15 flurandrenolide...... 65 FORTEO...... 112 GABITRIL...... 27 FLURA-SAFE...... 125 FORTESTA...... 98 GABLOFEN...... 135 flurazepam hcl...... 136 FORTISCARE CONTROL...... 74 GALAFOLD...... 92 flurbiprofen...... 15 FORTISCARE GLUCOSE galantamine hydrobromide...... 28 flurbiprofen sodium...... 122 SYSTEM...... 74 galantamine hydrobromide er... 28 flutamide...... 37 FORTISCARE T1 GLUCOSE GALZIN...... 80 fluticasone propionate...... 65, 129 SYSTEM...... 74 GAMASTAN...... 106 fluticasone-salmeterol...... 133 FOSAMAX...... 112 GAMIFANT...... 106 FLUTICASONE- FOSAMAX PLUS D...... 112 GAMMAGARD...... 106 SALMETEROL...... 133 fosamprenavir calcium...... 45 GAMMAGARD S/D LESS IGA 107 fluvastatin sodium...... 53 fosaprepitant dimeglumine...... 30 GAMMAKED...... 107 fluvastatin sodium er...... 53 FOSCAVIR...... 45 GAMMAPLEX...... 107 fluvoxamine maleate...... 29 fosfomycin tromethamine...... 23 GAMUNEX-C...... 107 fluvoxamine maleate er...... 29 fosinopril sodium...... 53 ganirelix acetate...... 99 FLUZONE QUADRIVALENT.. 110 fosinopril sodium-hctz...... 53 GARDASIL 9...... 110 FML...... 122 fosphenytoin sodium...... 27 gas relief...... 88 FML FORTE...... 122 FOSRENOL...... 94 gas relief extra strength...... 88 FML LIQUIFILM...... 122 FOSTEUM...... 80 GASTROCROM...... 88 FOCALIN...... 57 FOSTEUM PLUS...... 116 gatifloxacin...... 122 FOCALIN XR...... 57 FOVEX...... 116 GATTEX...... 88 folbee...... 79 FRAGMIN...... 26 gavilax...... 88 folbee plus...... 79 FREESTYLE LIBRE 14 DAY gavilyte-c...... 88 folbee plus cz...... 79 READER...... 74 gavilyte-g...... 88 FOLBIC RF...... 80 FREESTYLE LIBRE 14 DAY gavilyte-h...... 88 FOLGARD OS...... 80 SENSOR...... 74 gavilyte-n with flavor pack...... 88 FOLGARD RX...... 80 FREESTYLE LIBRE 2 GAVRETO...... 37 folic acid...... 80 READER SYSTM...... 74 GAZYVA...... 37 FOLIC D3...... 80 FREESTYLE LIBRE 2 GEBAUERS PAIN EASE...... 18 FOLIC-K...... 80 SENSOR SYSTM...... 74 GEBAUERS SPRAY AND FOLI-D...... 80 FREESTYLE LIBRE READER..74 STRETCH...... 18

150 GELCLAIR...... 116 GIVLAARI...... 116 GLYTACTIN SWIRL 15PE...... 116 GELFILM...... 116, 125 GLASSIA...... 133 GLYXAMBI...... 72 GEL-FLOW...... 116 glatiramer acetate...... 58 gnp aspirin low dose...... 15 GEL-FLOW NT...... 116 glatopa...... 58 gnp senna lax...... 89 GELFOAM...... 116 GLEEVEC...... 37 GOCOVRI...... 42 GELFOAM COMPRESSED GLEOLAN...... 116 GOLDENROD...... 116 SIZE 100...... 116 GLEOSTINE...... 37 GOLYTELY...... 89 GELFOAM DENTAL PACK glimepiride...... 72 GONAL-F...... 99 SIZE 4...... 116 glipizide er...... 72 GONAL-F RFF...... 99 GELFOAM SPONGE...... 116 glipizide ir...... 72 GONAL-F RFF REDIJECT...... 99 GELFOAM SPONGE SIZE glipizide xl...... 72 GONITRO...... 53 100...... 116 glipizide-metformin hcl...... 72 goodsense antacid...... 89 GELFOAM SPONGE SIZE GLOPERBA...... 34 goodsense anti-diarrheal...... 89 200...... 116 glostrips...... 125 goodsense aspirin low dose...... 15 GELFOAM SPONGE SIZE 50 116 GLUCAGEN HYPOKIT...... 75 goodsense ibuprofen...... 15 GELFOAM-JMI POWDER...... 116 GLUCAGON EMERGENCY goodsense motion sickness...... 31 GELFOAM-JMI SPONGE...... 116 KIT...... 75 goodsense pain relief...... 11 GELNIQUE...... 94 GLUCOTROL...... 72 goodsense tussin dm max...... 129 GELSYN-3...... 116 GLUCOTROL XL...... 72 GOPRELTO...... 18 GELUSIL...... 88 GLUCOVANCE...... 72 GORDOFILM...... 65 GELX...... 116 GLUMETZA...... 72 grafco silver nit applicator...... 65 gemcitabine hcl...... 37 GLUTARALDEHYDE...... 116 GRALISE...... 58 gemfibrozil...... 53 glyburide...... 72 granisetron hcl...... 31 gemmily...... 102 glyburide micronized...... 72 GRANIX...... 48 GEN7T...... 18 glyburide-metformin...... 72 GRASTEK...... 116 GEN7T PLUS...... 18 GLYCATE...... 89 green glo lissamine green...... 125 GENADUR...... 65 glycine...... 94 griseofulvin microsize...... 32 GENERESS FE...... 102 glycine urologic...... 94 griseofulvin ultramicrosize...... 32 generlac...... 88 glycolax...... 89 guaiatussin ac...... 129 gengraf...... 107 GLYCOPYRROLATE...... 89 guaifenesin...... 129 GENICIN VITA-D...... 80 glycopyrrolate...... 89 guaifenesin ac...... 129 GENICIN VITA-Q...... 80 glycopyrrolate pf...... 89 guaifenesin-dm...... 129 GENICIN VITA-S...... 80 GLYNASE...... 72 guanfacine hcl...... 53 GENOTROPIN...... 99 GLYSET...... 72 guanfacine hcl er...... 57 GENOTROPIN MINIQUICK...... 99 GLYTACTIN BETTERMILK 15116 GUANIDINE HCL...... 35 gentak...... 122 GLYTACTIN BETTERMILK GUARDIAN CONNECT gentamicin sulfate...... 23, 122 DE-LITE...... 116 TRANSMITTER...... 74 GENTEAL TEARS...... 125 GLYTACTIN BUILD 10PE...... 116 GUARDIAN LINK 3 GENTEAL TEARS NIGHT- GLYTACTIN BUILD 20/20...... 116 TRANSMITTER...... 74 TIME...... 125 GLYTACTIN BUILD 20/20 GUARDIAN SENSOR (3)...... 74 gentle laxative...... 89 PKU...... 116 GVOKE HYPOPEN 1-PACK.....75 GENVOYA...... 45 GLYTACTIN BURST...... 116 GVOKE HYPOPEN 2-PACK.....75 GEODON...... 43 GLYTACTIN COMPLETE GVOKE PFS...... 75 geri-dryl...... 129 10PE...... 116 GYNAZOLE-1...... 32 geri-kot...... 89 GLYTACTIN RESTORE 10.... 116 H2Q...... 116 GERMAN COCKROACH...... 116 GLYTACTIN RESTORE 5...... 116 HACKBERRY...... 116 GIALAX...... 89 GLYTACTIN RESTORE LITE HAEGARDA...... 107 gianvi...... 102 10...... 116 hailey 1.5/30...... 102 GILENYA...... 58 GLYTACTIN RESTORE LITE hailey 24 fe...... 102 GILOTRIF...... 37 10PE...... 116 hailey fe 1.5/30...... 102 GILPHEX TR...... 129 GLYTACTIN RTD 10...... 116 hailey fe 1/20...... 102 GILTUSS TR...... 129 GLYTACTIN RTD 15...... 116 HALAVEN...... 37 GIMOTI...... 30 GLYTACTIN RTD LITE 15...... 116 halcinonide...... 65

151 HALCION...... 47 hm stool softener...... 89 HYDREA...... 38 HALDOL DECANOATE...... 43 HOMACTIN AA PLUS...... 117 HYDRO 40...... 65 halobetasol propionate...... 65 homatropaire...... 125 hydrochlorothiazide...... 53 HALOBETASOL HOME PAP KIT...... 117 hydrocodone bitartrate er...... 11 PROPIONATE...... 65 HONEY BEE VENOM...... 117 hydrocodone polst-chlorphen HALOG...... 65 HORIZANT...... 58 polst er susp...... 129 haloperidol...... 44 HORSE EPITHELIUM...... 117 hydrocodone-acetaminophen... 11 haloperidol decanoate...... 44 HPR PLUS...... 65 hydrocodone-homatropine...... 129 haloperidol lactate...... 44 hpr plus...... 65 hydrocodone-ibuprofen...... 11 HALUCORT...... 65 HPR PLUS HYDROGEL...... 65 hydrocortisone...... 66, 96, 111 HARVONI...... 45 HUMALOG KWIKPEN...... 76 hydrocortisone (perianal)...... 111 HAVRIX...... 110 HUMALOG MIX 50/50 hydrocortisone ace-pramoxine headache relief...... 11 KWIKPEN...... 76 ...... 66, 111 heartburn relief...... 86 HUMALOG MIX 50/50 VIAL...... 76 hydrocortisone acetate...... 66, 111 heather...... 102 HUMALOG MIX 75/25 hydrocortisone butyr lipo base.. 66 HELIDAC THERAPY...... 89 KWIKPEN...... 76 hydrocortisone butyrate...... 66 HEMADY...... 96 HUMALOG MIX 75/25 VIAL...... 76 hydrocortisone valerate...... 66 HEMANGEOL...... 53 HUMALOG U-100 JUNIOR hydrocortisone-acetic acid...... 127 hematinic plus vit/minerals...... 80 KWIKPEN...... 76 hydrocortisone-iodoquinol...... 32 hematinic/folic acid...... 80 HUMALOG VIAL...... 76 hydrocort-pramoxine (perianal) HEMATOGEN...... 80 HUMATE-P...... 49 ...... 111 HEMATOGEN FA...... 80 HUMATROPE...... 99 hydromet...... 129 HEMATRON-AF...... 80 HUMATROPEN FOR 12MG... 117 hydromorphone hcl...... 11 HEMETAB...... 80 HUMATROPEN FOR 24MG... 117 hydromorphone hcl er...... 11 HEMLIBRA...... 48 HUMATROPEN FOR 6MG..... 117 HYDROMORPHONE HCL- hemmorex-hc...... 111 HUMIRA...... 107 NACL...... 11 HEMOCYTE PLUS...... 80 HUMIRA PEDIATRIC hydroquinone...... 66 hemocyte-f...... 80 CROHNS START...... 107 HYDROQUINONE...... 66 hemocyte-plus...... 80 HUMIRA PEN...... 107 HYDROQUINONE-HC- HEMOFIL M...... 48 HUMIRA PEN-CD/UC/HS TRETINOIN...... 66 hemorrhoidal-hc...... 111 STARTER...... 107 HYDROQUINONE- HEPAGAM B...... 107 HUMIRA PEN-PS/UV/ADOL HYDROCORTISONE...... 66 heparin (porcine) in nacl...... 26 HS START...... 107 hydroxychloroquine sulfate...... 42 heparin lock flush...... 116 HUMIRA PEN-PSOR/UVEIT hydroxyprogesterone caproate102 heparin sodium (porcine)...... 26 STARTER...... 107 hydroxyurea...... 38 heparin sodium (porcine) pf...... 26 HUMULIN 70/30 KWIKPEN...... 76 hydroxyzine hcl...... 47 heparin sodium lock flush...... 116 HUMULIN 70/30 VIAL...... 76 hydroxyzine pamoate...... 47 HEPLISAV-B...... 110 HUMULIN N KWIKPEN...... 76 HYLAFEM...... 117 HEPMED...... 117 HUMULIN N VIAL...... 76 HYLATOPIC PLUS...... 66 HEPSERA...... 45 HUMULIN R U-500 KWIKPEN..76 HYLAVITE...... 80 HERCEPTIN...... 37 HUMULIN R U-500 VIAL...... 76 HYLAZINC...... 80 HERCEPTIN HYLECTA...... 37 HUMULIN R VIAL...... 76 HYMOVIS...... 117 HERZUMA...... 37 HYALGAN...... 117 hyophen...... 94 HETLIOZ...... 136 HYALUCIL-4...... 65 hyoscyamine sulfate...... 89 HIBERIX...... 110 HYALURONATE-NIACINAM- hyoscyamine sulfate er...... 89 HIBICLENS...... 117 TRETINOIN...... 65 hyoscyamine sulfate sl...... 89 HIDEX 6-DAY...... 96 HYALURONATE-NIACIN- hyosyne...... 89 high potency probiotic...... 89 TACROLIMUS...... 65 HYPERHEP B S/D...... 107 HIPREX...... 23 HYALURONIC ACID- HYPERRAB...... 107 HIZENTRA...... 107 HYDROQUINONE...... 65 HYPERRAB S/D...... 107 hm adult tussin cough & chest 129 HYCAMTIN...... 38 HYPERRHO S/D...... 107 hm loratadine...... 129 HYCODAN...... 129 HYPERSAL...... 129 hm stomach relief...... 89 hydralazine hcl...... 53 HYPERTENSA...... 117

152 HYPERTET S/D...... 107 IMVEXXY MAINTENANCE INSULIN LISPRO PROT & HYPOCYN...... 125 PACK...... 102 LISPRO...... 76 HYQVIA...... 107 IMVEXXY STARTER PACK... 102 INSULIN PEN NEEDLES...... 76 HYSINGLA ER...... 11 inavix...... 15 INSULIN SYRINGES...... 76 HYZAAR...... 53 INBRIJA...... 42 INTEGRA F...... 80 ibandronate sodium...... 112 incassia...... 102 INTEGRA PLUS...... 80 IBRANCE...... 38 INCRELEX...... 99 INTELENCE...... 45 IBUPAK...... 15 INCRUSE ELLIPTA...... 133 INTERCEED...... 117 ibuprofen...... 15 indapamide...... 53 INTERMEZZO...... 136 ibuprofen infants...... 15 INDERAL LA...... 53 INTRAROSA...... 94 ICAR-C PLUS...... 80 INDERAL XL...... 53 INTRON A...... 45 icatibant acetate...... 107 INDOCIN...... 15, 16 introvale...... 102 ICLUSIG...... 38 INDOMETHACIN...... 16 INTUNIV...... 57 icosapent ethyl...... 53 indomethacin...... 16 INVANZ...... 23 IDAMYCIN PFS...... 38 indomethacin er...... 16 INVEGA...... 44 idarubicin hcl...... 38 INFANRIX...... 110 INVEGA SUSTENNA...... 44 IDELVION...... 49 infants gas relief...... 89 INVEGA TRINZA...... 44 IDHIFA...... 38 INFASURF...... 129 INVELTYS...... 122 iferex 150 forte...... 80 INFED...... 80 INVIRASE...... 45 IFEX...... 38 INFLAMMACIN...... 16 INVOKAMET...... 72 ifosfamide...... 38 INFLATHERM...... 16 INVOKAMET XR...... 72 ILARIS...... 107 INFLECTRA...... 107 INVOKANA...... 72 ILEVRO...... 122 INFUGEM...... 38 IODINE STRONG...... 80 ILUMYA...... 107 INFUMORPH 200...... 11 iodine tincture...... 23 ILUVIEN...... 122 INFUMORPH 500...... 11 IODOQUIMEZ-HC...... 32 imatinib mesylate...... 38 INFUVITE ADULT...... 80 iodoquinol-hc-aloe polysacch....32 IMBRUVICA...... 38 INFUVITE PEDIATRIC...... 80 IODOQUINOL-HC- IMFINZI...... 38 INGREZZA...... 58 KETOCONAZOLE...... 32 IMIOXIA...... 32 INLYTA...... 38 iodoquinol-hydrocortisone-aloe.32 imipenem-cilastatin...... 23 INNOPRAN XL...... 53 IOPIDINE...... 123 imipramine hcl...... 29 INOVA...... 66 IOSAT...... 117 imipramine pamoate...... 29 INOVA 4/1 ACNE CONTROL IPOL...... 110 imiquimod...... 66 THERAPY...... 66 ipratropium bromide...... 129, 133 IMIQUIMOD PUMP...... 66 INOVA 8/2 ACNE CONTROL ipratropium-albuterol...... 133 IMIQUIMOD-LEVOCETIRIZIN- THERAPY...... 66 irbesartan...... 53 NIACIN...... 66 INQOVI...... 38 irbesartan-hydrochlorothiazide..53 IMIQUIMOD-LEVOCET- INREBIC...... 38 IRESSA...... 38 TRETINOIN...... 66 INSPIREASE RESERVOIR irinotecan hcl...... 38 IMITREX...... 34 BAGS...... 117 IROSPAN 24/6...... 80 IMITREX STATDOSE REFILL..34 INSPRA...... 53 ISENTRESS...... 45 IMITREX STATDOSE INSULIN ASP PROT & ASP ISENTRESS HD...... 45 SYSTEM...... 34 FLEXPEN...... 76 isibloom...... 102 IMLYGIC...... 38 INSULIN ASPART...... 76 isoflurane...... 117 IMODIUM A-D...... 89 INSULIN ASPART FLEXPEN... 76 ISOLYTE-S...... 80 IMODIUM MULTI-SYMPTOM INSULIN ASPART PENFILL.....76 isoniazid...... 35 RELIEF...... 89 INSULIN ASPART PROT & ISOPTO ATROPINE...... 125 IMOGAM RABIES-HT...... 107 ASPART...... 76 ISOPTO CARPINE...... 123 IMOVAX RABIES...... 110 INSULIN LISPRO...... 76 ISORDIL TITRADOSE...... 53 IMPAVIDO...... 42 INSULIN LISPRO (1 UNIT isosorbide dinitrate...... 53 IMPEKLO...... 66 DIAL)...... 76 isosorbide mononitrate...... 53 IMPOYZ...... 66 INSULIN LISPRO JUNIOR isosorbide mononitrate er...... 53 IMURAN...... 107 KWIKPEN...... 76 isotretinoin...... 66 ISOVACTIN AA PLUS...... 117

153 isoxsuprine hcl...... 53 kalliga...... 103 KETOVIE PEPTIDE...... 117 isradipine...... 53 KALYDECO...... 134 KEVARYA...... 66 ISTALOL...... 124 KAMDOY...... 66 KEVEYIS...... 124 ISTODAX (OVERFILL)...... 38 KANJINTI...... 38 KEVZARA...... 107 ISTURISA...... 99 KANUMA...... 92 KEXM...... 66 ITHOXIA...... 66 KAPOK...... 117 KEYA...... 66 itraconazole...... 32 KAPSPARGO SPRINKLE...... 53 KEYTRUDA...... 38 ivermectin...... 42 KAPVAY...... 57 KHAPZORY...... 38 IVERMECTIN- KARBINAL ER...... 129 KINERET...... 107 METRONIDAZOL-NIACIN...... 66 kariva...... 103 kionex...... 80 IXEMPRA KIT...... 38 KATARYA...... 66 KISQALI (200 MG DOSE)...... 38 IXIARO...... 110 KATARYAXN...... 66 KISQALI (400 MG DOSE)...... 38 IXINITY...... 49 KATERZIA...... 53 KISQALI (600 MG DOSE)...... 38 JADENU...... 80 KAXM...... 66 KISQALI FEMARA (400 MG JADENU SPRINKLE...... 80 KAZANO...... 73 DOSE)...... 38 jaimiess...... 102 KCL-LIDOCAINE-NACL...... 80 KISQALI FEMARA (600 MG JAKAFI...... 38 KEDRAB...... 107 DOSE)...... 38 JALYN...... 95 KEFLEX...... 23 KISQALI FEMARA(200 MG jantoven...... 26 KEIDO...... 66 DOSE)...... 38 JANUMET...... 72 KELARX...... 66 KITABIS PAK...... 134 JANUMET XR...... 73 kelnor 1/35...... 103 KIVIK...... 67 JANUVIA...... 73 kelnor 1/50...... 103 KLARITY-A...... 122 JARDIANCE...... 73 KENALOG...... 66, 96 KLARITY-L...... 122 jasmiel...... 102 KENALOG-80...... 96 KLARON...... 67 JATENZO...... 98 KEPIVANCE...... 59 KLONOPIN...... 47 JELMYTO...... 38 KEPPRA...... 27 klor-con...... 80 jencycla...... 102 KEPPRA XR...... 27 klor-con 10...... 80 JENTADUETO...... 73 KERAGEL...... 66 klor-con m10...... 80 JENTADUETO XR...... 73 KERALAC...... 66 KLOR-CON M15...... 80 JEVTANA...... 38 KERALYT...... 66 klor-con m20...... 80 jinteli...... 102 KERALYT SCALP...... 66 klor-con sprinkle...... 80 JIVI...... 49 KERAMATRIX REPLICINE klor-con/ef...... 80 JOHNSON GRASS...... 117 5CMX5CM...... 66 KOATE...... 49 jolessa...... 102 KERYDIN...... 32 KOATE-DVI...... 49 JORNAY PM...... 57 KESIMPTA...... 58 KOCHIA...... 117 JUBLIA...... 32 KETAMINE HCL...... 117 KOGENATE FS...... 49 juleber...... 102 KETAMINE HCL-SODIUM KOMBIGLYZE XR...... 73 JULUCA...... 45 CHLORIDE...... 117 KORLYM...... 100 JUNE GRASS POLLEN KETARYA...... 66 KOSELUGO...... 38 STANDARDIZED...... 117 ketoconazole...... 32 KOVALTRY...... 49 junel 1.5/30...... 103 KETOCONAZOLE- K-PHOS...... 80 junel 1/20...... 103 HYDROCORTISONE...... 32 K-PHOS NO 2...... 80 junel fe 1.5/30...... 103 ketodan...... 32 K-PHOS-NEUTRAL...... 81 junel fe 1/20...... 103 KETODAN...... 32 k-prime...... 81 junel fe 24...... 103 KETONE TEST...... 74 KRINTAFEL...... 42 JUXTAPID...... 53 KETOPHENE RAPIDPAQ...... 16 KRISTALOSE...... 89 JYNARQUE...... 80 ketoprofen...... 16 KRYSTEXXA...... 34 K.B.G.L IN TERODERM...... 16 ketoprofen er...... 16 K-TAB...... 81 KADCYLA...... 38 KETOROLAC k-tan plus...... 81 KADIAN...... 11 TROMETHAMINE...... 16 kurvelo...... 103 kaitlib fe...... 103 ketorolac tromethamine.... 16, 122 KUTARYAXM...... 67 KALBITOR...... 107 KETOSTIX...... 74 KUTARYAXMPA...... 67 KALETRA...... 45 KETOVIE...... 117 KUTEA...... 67

154 KUVAN...... 92 laxative max str...... 89 levonorgest-eth est & eth est.. 103 KUVARYA...... 67 laxative regular strength...... 89 levonorgest-eth estrad 91-day 103 KUVARYE...... 67 layolis fe...... 103 levonorgestrel...... 103 KUXM...... 67 LAZANDA...... 11 levonorgestrel-ethinyl estrad...103 KYLEENA...... 103 L-CYSTINE...... 81 levonorg-eth estrad triphasic...103 KYMRIAH...... 107 LDO PLUS...... 18 levora 0.15/30 (28)...... 103 KYNMOBI...... 42 LEDIPASVIR-SOFOSBUVIR.... 45 levorphanol tartrate...... 11 KYNMOBI TITRATION KIT...... 42 leena...... 103 levo-t...... 105 KYPROLIS...... 38 leflunomide...... 107 LEVOTHYROXINE SODIUM.. 105 labetalol hcl...... 53 LEMTRADA...... 58 levothyroxine sodium...... 105 LACRISERT...... 125 LENSCALE...... 117 levoxyl...... 105 lactic acid...... 67 LENVIMA (10 MG DAILY LEVSIN...... 89 lactic acid e...... 67 DOSE)...... 38 LEVSIN/SL...... 89 LACTIC ACID-NIACINAMIDE...67 LENVIMA (12 MG DAILY LEVULAN KERASTICK...... 67 lactobacillus...... 89 DOSE)...... 38 LEXAPRO...... 29 LACTOJEN...... 89 LENVIMA (14 MG DAILY LEXETTE...... 67 lactulose...... 89 DOSE)...... 38 LEXIVA...... 45 lactulose encephalopathy...... 89 LENVIMA (18 MG DAILY LIALDA...... 111 LAMBS QUARTERS...... 117 DOSE)...... 38 LIBRAX...... 90 LAMICTAL...... 27 LENVIMA (20 MG DAILY LIBTAYO...... 39 LAMICTAL ODT...... 27 DOSE)...... 38 LICART...... 16 LAMICTAL STARTER...... 27 LENVIMA (24 MG DAILY lice killing...... 42 LAMICTAL XR...... 27 DOSE)...... 38 lice treatment...... 42 lamivudine...... 45 LENVIMA (4 MG DAILY LIDO BDK...... 18 lamivudine-zidovudine...... 45 DOSE)...... 38 lidocaine...... 18, 19 lamotrigine...... 27 LENVIMA (8 MG DAILY lidocaine hcl...... 18, 59 lamotrigine er...... 27 DOSE)...... 38 LIDOCAINE HCL...... 18 lamotrigine starter kit-blue...... 27 LESCOL XL...... 53 lidocaine hcl (pf)...... 18 lamotrigine starter kit-green...... 27 lessina...... 103 lidocaine hcl urethral/mucosal...18 lamotrigine starter kit-orange.... 27 LETAIRIS...... 134 lidocaine viscous hcl...... 59 LAMPIT...... 42 letrozole...... 38 lidocaine-hydrocort (perianal). 111 LANCETS...... 74 lets...... 18 LIDOCAINE- LANOXIN...... 53 leucovorin calcium...... 38 HYDROCORTISONE ACE67, 111 lansoprazole...... 86, 87 LEUKERAN...... 38 lidocaine-hydrocortisone ace.. 111 lanthanum carbonate...... 94 LEUKINE...... 49 lidocaine-prilocaine...... 19 LANTUS SOLOSTAR...... 76 leuprolide acetate...... 99 LIDOCAINE-TETRACAINE...... 19 LANTUS U-100 VIAL...... 76 levalbuterol hcl...... 133 LIDOCANNA...... 19 lapatinib ditosylate...... 38 LEVALBUTEROL HFA...... 133 LIDOCORT...... 111 larin 1.5/30...... 103 LEVATIO...... 18 LIDODERM...... 19 larin 1/20...... 103 LEVBID...... 89 LIDO-EPINEPHRINE- larin 24 fe...... 103 LEVEMIR U-100 FLEXTOUCH.76 TETRACAINE...... 19 larin fe 1.5/30...... 103 LEVEMIR U-100 VIAL...... 76 LIDOMARK 2/5...... 19 larin fe 1/20...... 103 levetiracetam...... 27 LIDOPAC...... 19 larissia...... 103 levetiracetam er...... 27 lidopin...... 19 LARTRUVO...... 38 LEVITRA...... 94 LIDOPIN...... 19 LASIX...... 53 levobunolol hcl...... 124 LIDOPRIL...... 19 LASTACAFT...... 125 levocarnitine...... 81 LIDOPRIL XR...... 19 latanoprost...... 124 levocarnitine sf...... 81 LIDO-PRILO CAINE PACK...... 19 LATANOPROST-TIMOLOL levocetirizine dihydrochloride..129 LIDOPURE PATCH...... 19 MALEATE...... 124 levofloxacin...... 23, 122 LIDORX...... 19 LATISSE...... 125 levoleucovorin calcium...... 38 LIDO-SORB...... 19 LATUDA...... 44 levoleucovorin calcium pf...... 39 LIDOSTREAM...... 19 lavare wound wash...... 67 levonest...... 103 LIDOTHOL...... 19

155 LIDOTRAL...... 19 LOKELMA...... 81 LUMOXITI...... 39 LIDOTREX...... 67 LOMAIRA...... 58 LUNESTA...... 136 LIDOVIX L...... 19 LOMOTIL...... 90 LUPANETA PACK...... 99 LIDTOPIC MAX...... 19 LONHALA MAGNAIR REFILL LUPRON DEPOT (1-MONTH)..99 LILETTA (52 MG)...... 103 KIT...... 133 LUPRON DEPOT (3-MONTH)..99 lillow...... 103 LONHALA MAGNAIR LUPRON DEPOT (4-MONTH) LIMBREL...... 117 STARTER KIT...... 133 INTRAMUSCULAR KIT 30MG..99 LIMBREL250...... 117 LONSURF...... 39 LUPRON DEPOT (6-MONTH) LIMBREL500...... 117 loperamide hcl...... 90 INTRAMUSCULAR KIT 45MG..99 LINCOCIN...... 23 LOPID...... 53 LUPRON DEPOT-PED (1- lincomycin hcl...... 23 lopinavir-ritonavir...... 45 MONTH)...... 99 lindane...... 42 LOPRESSOR...... 53 LUPRON DEPOT-PED (3- linezolid...... 23 LOPRESSOR HCT...... 53 MONTH)...... 99 linezolid in sodium chloride...... 23 LOPROX...... 33 LUTATHERA...... 39 LINZESS...... 90 loratadine...... 129 lutera...... 103 LIORESAL...... 135 loratadine-d 12hr...... 129 LUXIQ...... 67 liothyronine sodium...... 105 loratadine-d 24hr...... 129 LUXTURNA...... 125 LIPITOR...... 53 lorazepam...... 47 LUZU...... 33 LIPOFEN...... 53 lorazepam intensol...... 47 LYDEXA...... 19 LIPRITIN II...... 58 LORBRENA...... 39 lyllana...... 103 liquid acetaminophen...... 11 LORID...... 81 LYNPARZA...... 39 lisinopril...... 53 LORMATE...... 117 LYRICA...... 58 lisinopril-hydrochlorothiazide.....53 LORTAB...... 11 LYRICA CR...... 58 L-ISOLEUCINE...... 81 loryna...... 103 lysiplex plus...... 81 lissamine green...... 125 LORZONE...... 135 LYSODREN...... 39 LISTER-V...... 117 losartan potassium...... 53 LYSTEDA...... 49 lithium...... 48 losartan potassium-hctz...... 53 LYUMJEV...... 76 lithium carbonate...... 48 LOSEASONIQUE...... 103 LYUMJEV KWIKPEN...... 76 lithium carbonate er...... 48 LOTEMAX...... 122 lyza...... 103 LITHOBID...... 48 LOTEMAX SM...... 122 M.V.I. ADULT...... 81 LITHOSTAT...... 94 LOTENSIN...... 53 M.V.I. PEDIATRIC...... 81 LIVALO...... 53 LOTENSIN HCT...... 53 MAALOX MULTI SYMPTOM LIVIXIL PAK...... 19 loteprednol etabonate...... 122 MAX ST...... 90 l-methylfolate...... 81 LOTREL...... 53 MACRILEN...... 117 l-methylfolate ca me-cbl nac..... 81 LOTRIMIN AF...... 33 MACROBID...... 23 l-methylfolate calcium...... 81 LOTRONEX...... 90 MACRODANTIN...... 23 l-methylfolate forte...... 81 lovastatin...... 53 MACUTEK...... 117 l-methylfolate-algae...... 81 LOVAZA...... 53 mafenide acetate...... 23 l-methylfolate-algae-b12-b6...... 81 LOVENOX...... 26 MAGNEBIND 400...... 81 l-methylfolate-b6-b12...... 81 low-ogestrel...... 103 magnesium citrate...... 90 l-methyl-mc...... 81 loxapine succinate...... 44 magnesium oxide...... 81, 90 l-methyl-mc nac...... 81 lo-zumandimine...... 103 magnesium sulfate...... 81 LMR PLUS...... 19 lubricant eye drops...... 125 MAGNESIUM SULFATE...... 81 LO LOESTRIN FE...... 103 lubricant eye drops pf...... 125 magnesium-oxide...... 81 LOCOID...... 67 lubricant eye pm...... 125 mag-oxide...... 81 LOCOID LIPOCREAM...... 67 lubricant pm...... 125 MAKENA...... 103 LODINE...... 16 lubricating eye drops...... 125 MALARONE...... 42 LODOSYN...... 42 lubricating plus eye drops...... 125 malathion...... 42 LOESTRIN 1.5/30 (21)...... 103 LUCEMYRA...... 20 maprotiline hcl...... 29 LOESTRIN 1/20 (21)...... 103 LUCENTIS...... 125 MARCAINE...... 19 LOESTRIN FE 1.5/30...... 103 LULICONAZOLE...... 33 MARCAINE PRESERVATIVE LOESTRIN FE 1/20...... 103 LUMIGAN...... 124 FREE...... 19 lojaimiess...... 103 LUMIZYME...... 92 MARINOL...... 31

156 marlido...... 19 MEKTOVI...... 39 methenamine mandelate...... 23 MARLIDO-25...... 19 MELALEUCA...... 117 methergine...... 117 marlissa...... 103 melodetta 24 fe...... 103 methimazole...... 105 MARPLAN...... 29 meloxicam...... 16 METHITEST...... 98 MARQIBO...... 39 melphalan...... 39 methocarbamol...... 135 MARVONA SUIK...... 19 melphalan hcl...... 39 METHOHEXITAL SODIUM.....117 MAS CARE-PAK...... 96 memantine hcl...... 28, 29 methotrexate...... 107 MASK VORTEX...... 117 memantine hcl er...... 28 methotrexate sodium...... 108 MATULANE...... 39 MEMBRANEBLUE...... 125 methotrexate sodium (pf)...... 108 matzim la...... 53 MENACTRA...... 110 methoxsalen rapid...... 67 MAVENCLAD (10 TABS)...... 58 MENEST...... 103 methscopolamine bromide...... 90 MAVENCLAD (4 TABS)...... 58 MENOPUR...... 99 methyl salicylate...... 67 MAVENCLAD (5 TABS)...... 58 MENOSTAR...... 103 methyldopa...... 53 MAVENCLAD (6 TABS)...... 58 MENQUADFI...... 110 methyldopa- MAVENCLAD (7 TABS)...... 58 MENTAX...... 33 hydrochlorothiazide...... 53 MAVENCLAD (8 TABS)...... 58 MENVEO...... 110 methylergonovine maleate...... 117 MAVENCLAD (9 TABS)...... 58 meperidine hcl...... 11 methylfol-algae-b12-acetylcyst. 81 MAVYRET...... 45 MEPHYTON...... 81 METHYLIN...... 57 MAXALT...... 34 meprobamate...... 47 methylphenidate hcl...... 57 MAXALT-MLT...... 34 MEPRON...... 42 methylphenidate hcl er...... 57 MAXICOMFORT SYR 27G X MEPSEVII...... 92 methylphenidate hcl er (cd)...... 57 1/2"...... 76 mercaptopurine...... 39 methylphenidate hcl er (la)...... 57 MAXIDEX...... 122 meropenem...... 23 methylphenidate hcl er (xr)...... 57 MAXITROL...... 125 MEROPENEM-SODIUM methylprednisolone...... 96 maxi-tuss ac...... 129 CHLORIDE...... 23 METHYLPREDNISOLONE maxi-tuss gmx...... 129 MERREM...... 23 ACETATE...... 96 maxi-tuss pe max...... 129 mesalamine...... 111 methylprednisolone acetate...... 96 MAXZIDE...... 53 mesalamine er...... 111 methyltestosterone...... 98 MAXZIDE-25...... 53 mesalamine-cleanser...... 111 metoclopramide hcl...... 31 MAYZENT...... 58 mesna...... 39 metolazone...... 53 MAYZENT STARTER PACK.... 58 MESNEX...... 39 METOPIRONE...... 117 m-dryl...... 129 MESQUITE...... 117 metoprolol succinate er...... 53 me/naphos/mb/hyo1...... 94 MESTINON...... 35 metoprolol tartrate...... 54 MEADOW FESCUE GRASS metadate er...... 57 metoprolol-hydrochlorothiazide.54 POLLEN...... 117 metafolbic...... 81 METROCREAM...... 67 meclizine hcl...... 31 metafolbic plus...... 81 METROGEL...... 67 meclofenamate sodium...... 16 metafolbic plus rf...... 81 METROLOTION...... 67 MEDERMA...... 67 METANX...... 81 metronidazole...... 23, 67 MEDERMA FOR KIDS...... 67 METAXALL CP...... 135 METRONIDAZOLE MEDERMA SPF 30...... 67 metaxalone...... 135 BENZO+SYRSPEND...... 23 MEDI-DERM/L-RX...... 19 metformin hcl er...... 73 metyrosine...... 54 MEDI-DERM-RX...... 11 metformin hcl er (mod)...... 73 mexiletine hcl...... 54 MEDI-PATCH RX...... 19 metformin hcl er (osm)...... 73 MIACALCIN...... 112 MEDPURA ALCOHOL PADS... 67 metformin hcl ir...... 73 mi-acid...... 90 MEDROL...... 96 METHACHOLINE CHLORIDE 117 mi-acid maximum strength...... 90 MEDROLOAN II SUIK...... 96 methadone hcl...... 11, 12 mibelas 24 fe...... 103 MEDROLOAN SUIK...... 96 methadone hcl intensol...... 11 micaderm...... 33 MEDROX-RX...... 11 methadose...... 12 micafungin sodium...... 33 medroxyprogesterone acetate 103 methadose sugar-free...... 12 MICARDIS...... 54 mefenamic acid...... 16 methamphetamine hcl...... 57 MICARDIS HCT...... 54 mefloquine hcl...... 42 METHAVER...... 117 MICLARA LQ...... 129 megestrol acetate...... 103 methazolamide...... 124 miconazole 1...... 33 MEKINIST...... 39 methenamine hippurate...... 23 miconazole 3...... 33

157 miconazole 7...... 33 MIRCETTE...... 104 MOTRIN IB...... 16 miconazole nitrate...... 33 MIRENA (52 MG)...... 104 MOTRIN INFANTS DROPS...... 16 MICONAZOLE-ZINC OXIDE- mirtazapine...... 29 MOUNTAIN CEDAR...... 118 PETROLAT...... 33 MIRVASO...... 67 MOUSE EPITHELIUM...... 118 MICRHOGAM ULTRA- misoprostol...... 87 MOUTH KOTE REMINT...... 59 FILTERED PLUS...... 108 MITE (D. FARINAE)...... 117 MOVANTIK...... 90 MICRODOT TEST...... 74 MITE (D. PTERONYSSINUS).117 MOVIPREP...... 90 microgestin 1.5/30...... 103 MITIGARE...... 34 MOXEZA...... 122 microgestin 1/20...... 103 mitigo...... 12 moxifloxacin hcl...... 24, 122 microgestin fe 1.5/30...... 103 mitomycin...... 39 moxifloxacin hcl (2x day)...... 122 microgestin fe 1/20...... 103 MITOMYCIN...... 39 moxifloxacin hcl in nacl...... 24 MICROLET NEXT LANCING MITOSOL...... 122 MOZOBIL...... 49 DEVICE...... 74 mitoxantrone hcl...... 39 m-pap...... 12 MICROPLEGIA MSA-MSG...... 81 MIXED ASPERGILLUS...... 117 MS CONTIN...... 12 midazolam hcl...... 47 MIXED FEATHERS...... 117 MUCINEX CHILDRENS MIDAZOLAM HCL-SODIUM MIXED RAGWEED...... 117 FREEFROM...... 129 CHLORIDE...... 47 MIXED VESPID VENOM MUCINEX CHILDRENS MIDAZOLAM+SYRSPEND SF. 47 PROTEIN...... 118 STUFFY NOSE...... 129 midodrine hcl...... 54 MKO MELT DOSE PACK...... 118 MUCINEX DM...... 129 MIFEPREX...... 81 mlk f1...... 118 MUCINEX FAST-MAX DM mifepristone...... 81 mlk f2...... 118 MAX...... 129 MIGERGOT...... 34 mlk f3...... 118 MUCOR...... 118 miglitol...... 73 mlk f4...... 118 MUCOSITISRX...... 59 miglustat...... 92 mm stool softener laxative...... 90 MUCOTROL...... 118 MIGRAINE PACK...... 34 M-M-R II...... 110 mucus dm...... 129 migraine relief...... 12 M-NATAL PLUS...... 81 mucus relief d...... 130 MIGRANAL...... 34 MOBIC...... 16 mucus relief dm...... 130 MIGRANOW...... 34 modafinil...... 136 mucus relief max st...... 130 mili...... 103 moexipril hcl...... 54 mucus-d...... 130 milk of magnesia...... 90 moisturel...... 67 mucus-er max...... 130 MILLIPRED...... 96 molindone hcl...... 44 MUGARD...... 118 MILLIPRED DP 12-DAY...... 96 mometasone furoate...... 67, 129 MUGWORT...... 118 milrinone lactate...... 54 mondoxyne nl...... 24 MULPLETA...... 49 milrinone lactate in dextrose..... 54 MONJUVI...... 39 MULTAQ...... 54 mimvey...... 103 mono-linyah...... 104 MULTIGEN...... 81 MIMYX...... 67 MONONINE...... 49 MULTIGEN FOLIC...... 81 MINASTRIN 24 FE...... 103 MONOVISC...... 118 MULTIGEN PLUS...... 81 mineral oil heavy...... 90 monsels ferric subsulfate...... 49 multiple vitamin-folic acid...... 81 MINIMED PUMP RESERVOIR montelukast sodium...... 133 MULTIPRO...... 81 3ML...... 117 MONUROL...... 24 MULTI-SPECIALTY...... 96 MINIPRESS...... 54 MORCIN...... 118 multi-vit/iron/fluoride...... 81 minitran...... 54 MORGIDOX...... 24 multivitamin/fluoride...... 81 MINIVELLE...... 103 morgidox...... 24 MULTIVITAMIN/FLUORIDE..... 82 minocycline hcl...... 23 MORPHINE SULFATE...... 12 multi-vitamin/fluoride...... 81 MINOCYCLINE HCL ER...... 23 morphine sulfate...... 12 multi-vitamin/fluoride/iron...... 82 minocycline hcl er...... 23 morphine sulfate (concentrate). 12 multivitamins/fluoride...... 82 MINOLIRA...... 24 morphine sulfate (pf)...... 12 mupirocin...... 24 minoxidil...... 54 morphine sulfate er...... 12 mupirocin calcium...... 24 MINOXIDIL-PROGEST- morphine sulfate er beads...... 12 MURO 128...... 125 TRETINOIN...... 67 MORPHINE SULFATE-NACL...12 MUSE...... 94 MIRAPEX...... 42 MOTEGRITY...... 90 mutamycin...... 39 MIRAPEX ER...... 42 motion sickness relief...... 31 MVASI...... 39 MIRCERA...... 49 MOTOFEN...... 90 MYALEPT...... 92

158 MYAMBUTOL...... 35 naproxen-esomeprazole...... 16 NEO-SYNEPHRINE MYCAMINE...... 33 naratriptan hcl...... 34 COLD/ALLRGY EXT...... 130 MYCAPSSA...... 99 NARCAN...... 20 NEO-SYNEPHRINE MYCOBUTIN...... 35 NARDIL...... 29 COLD/ALLRGY REG...... 130 mycophenolate mofetil...... 108 NASACORT ALLERGY 24HR 130 NEOTUSS PLUS...... 130 mycophenolate mofetil hcl...... 108 nasal decongestant...... 130 NEOVITE...... 82 mycophenolate sodium...... 108 nasal decongestant pe...... 130 NEPHPLEX RX...... 82 MYDAYIS...... 57 nasal moisturizing spray...... 130 NEPHRON FA...... 82 MYDRIACYL...... 125 nasal spray 12 hour...... 130 nephronex...... 82 MYFORTIC...... 108 nasal spray no drip...... 130 NEPHRO-VITE RX...... 82 MYLERAN...... 39 NASCOBAL...... 82 NERLYNX...... 39 MYLOTARG...... 39 NASONEX...... 130 NESINA...... 73 mynephrocaps...... 82 NATACYN...... 122 NESTABS...... 82 mynephron...... 82 NATAZIA...... 104 NESTABS ONE...... 82 MYOBLOC...... 118 nateglinide...... 73 neuac...... 67 myorisan...... 67 NATESTO...... 98 NEUAC...... 67 MYRBETRIQ...... 94 NATPARA...... 112 NEULASTA...... 49 MYSOLINE...... 27 NATROBA...... 42 NEULASTA ONPRO...... 49 MYTESI...... 90 natural fiber laxative...... 90 NEUPOGEN...... 49 MYXREDLIN...... 76 natural senna laxative...... 90 NEUPRO...... 42 na ferric gluc cplx in sucrose.....82 NATURE-THROID...... 105 NEURAPTINE...... 59 NABI-HB...... 108 NAVELBINE...... 39 NEUREPA...... 118 nabumetone...... 16 NAYZILAM...... 27 NEURIN-SL...... 82 n-acetyl-l-cysteine...... 82 NEBUPENT...... 42 NEURONTIN...... 27 nadolol...... 54 necon 0.5/35 (28)...... 104 NEVANAC...... 122 nafcillin sodium...... 24 nefazodone hcl...... 29 nevirapine...... 45 nafrinse...... 82 NEOCERA...... 67 nevirapine er...... 45 NAFRINSE DAILY NEODOT THERMOMETER... 118 NEXAVAR...... 39 ACIDULATED...... 59 neomycin sulfate...... 24 NEXIUM...... 87 NAFRINSE DAILY/NEUTRAL...59 neomycin-bacitracin zn- NEXLETOL...... 54 nafrinse drops...... 82 polymyx...... 125 NEXLIZET...... 54 NAFRINSE WEEKLY...... 59 neomycin-polymyxin b gu...... 24 NEXPLANON...... 104 naftifine hcl...... 33 neomycin-polymyxin-dexameth niacin...... 82 NAFTIN...... 33 ...... 125 niacin (antihyperlipidemic)...... 54 NAGLAZYME...... 92 neomycin-polymyxin- niacin er (antihyperlipidemic).... 54 nalbuphine hcl...... 12 gramicidin...... 125 NIACINAMIDE- NALFON...... 16 neomycin-polymyxin-hc.. 126, 127 SPIRONOLACTONE...... 67 NALOCET...... 12 NEONATAL + DHA...... 82 NIACINAMIDE- naloxone hcl...... 20 NEONATAL 19...... 82 SULFACETAMIDE...... 67 NALTREXONE...... 20 NEONATAL COMPLETE...... 82 NIACINAMIDE-TACROLIMUS..67 naltrexone hcl...... 20 NEONATAL FE...... 82 NIACINAMIDE-TAZAROTENE. 67 NAMENDA...... 29 NEONATAL PLUS...... 82 NIACINAMIDE-TRETINOIN...... 67 NAMENDA TITRATION PAK....29 neo-polycin...... 126 NIACINAMIDE- NAMENDA XR...... 29 neo-polycin hc...... 126 TRIAMCINOLONE ACET...... 67 NAMENDA XR TITRATION NEORAL...... 108 NIACIN-SPIRONOLACTON- PACK...... 29 NEOSALUS...... 67 TRETINOIN...... 67 NAMZARIC...... 29 NEOSALUS CP...... 67 niacor...... 54 NAPRELAN...... 16 NEOSPORIN ORIGINAL...... 67 NIASPAN...... 54 NAPROSYN...... 16 NEOSTIGMINE NICADAN...... 82 naproxen...... 16 METHYLSULFATE...... 35 NICAPRIN...... 118 naproxen dr...... 16 NEO-SYNALAR...... 67 nicardipine hcl...... 54 naproxen sodium...... 16 NEO-SYNEPHRINE NICAZEL...... 82 naproxen sodium er...... 16 COLD/ALLRG MILD...... 130 NICAZEL FORTE...... 82

159 NICAZYME...... 118 norgestimate-ethinyl estradiol NP #2 DRUG PREPARATION NICOMIDE...... 82 triphasic...... 104 KIT...... 16 NICORETTE...... 20 NORITATE...... 67 np thyroid...... 105 nicotine polacrilex...... 20 norlyda...... 104 NPLATE...... 49 nicotine step 1...... 20 norlyroc...... 104 NUBEQA...... 39 nicotine step 2...... 20 NORPACE...... 54 NUCALA...... 130 nicotine step 3...... 20 NORPACE CR...... 54 NUCARACLINPAK...... 68 NICOTROL...... 20 NORPRAMIN...... 29 NUCARARXPAK...... 68 NICOTROL NS...... 20 NORTHERA...... 54 NUCORT...... 68 nifedipine...... 54 nortrel 0.5/35 (28)...... 104 NUCYNTA...... 12 nifedipine er...... 54 nortrel 1/35 (21)...... 104 NUCYNTA ER...... 12 nifedipine er osmotic release.... 54 nortrel 1/35 (28)...... 104 NUDERMRXPAK 120...... 68 NIFEREX...... 82 nortrel 7/7/7...... 104 NUDERMRXPAK 60...... 68 nikki...... 104 nortriptyline hcl...... 29 NUDICLO SOLUPAK...... 16 nilutamide...... 39 NORVASC...... 54 NUDICLO TABPAK...... 16 nimodipine...... 54 NORVIR...... 45 NUDROXIPAK...... 16 NINLARO...... 39 NOURIANZ...... 42 NUDROXIPAK DSDR-50...... 16 NIPENT...... 39 NOVACORT...... 68 NUDROXIPAK DSDR-75...... 17 nisoldipine er...... 54 novamv pediatric multi-vitamin..82 NUDROXIPAK E-400...... 17 nitazoxanide...... 42 novarel...... 99 NUDROXIPAK I-800...... 17 nitisinone...... 92 NOVAREL...... 99 NUDROXIPAK M-15...... 17 NITRO-BID...... 54 NOVOEIGHT...... 49 NUDROXIPAK N-500...... 17 NITRO-DUR...... 54 NOVOFINE AUTOCOVER NUEDEXTA...... 59 nitrofurantoin...... 24 PEN NEEDLE...... 76 NUFERA...... 82 nitrofurantoin macrocrystal...... 24 NOVOFINE PEN NEEDLE...... 76 nufol...... 82 nitrofurantoin monohydrate NOVOFINE PLUS PEN NULEV...... 90 macrocrystals...... 24 NEEDLE...... 76 NULOJIX...... 108 nitroglycerin...... 54 NOVOLIN 70/30 FLEXPEN...... 76 NULYTELY LEMON-LIME...... 90 NITROLINGUAL...... 54 NOVOLIN 70/30 FLEXPEN NULYTELY WITH FLAVOR NITROMIST...... 54 RELION...... 77 PACKS...... 90 NITROSTAT...... 54 NOVOLIN 70/30 RELION...... 77 NUMBRINO...... 19 nitro-time...... 54 NOVOLIN 70/30 VIAL...... 77 NUPLAZID...... 44 NITYR...... 92 NOVOLIN N FLEXPEN...... 77 NURTEC...... 34 NIVATOPIC PLUS...... 67 NOVOLIN N FLEXPEN NUSURGEPAK SURGICAL NIVESTYM...... 49 RELION...... 77 PREP/CARE...... 59 nizatidine...... 87 NOVOLIN N RELION...... 77 NUTRASEB...... 68 NOCDURNA...... 99 NOVOLIN N VIAL...... 77 NUTRIARX CREAMPAK...... 68 nolix...... 67 NOVOLIN R FLEXPEN...... 77 NUTRICAP...... 82 NOPIOID-LMC KIT...... 135 NOVOLIN R FLEXPEN NUTRIDOX...... 24 nora-be...... 104 RELION...... 77 nutrifac zx...... 82 NORCO...... 12 NOVOLIN R RELION...... 77 NUTRIVIT...... 82 NORDIPEN 5 INJECTION NOVOLIN R VIAL...... 77 NUTROPIN AQ NUSPIN 10..... 99 DEVICE...... 118 NOVOLOG FLEXPEN...... 77 NUTROPIN AQ NUSPIN 20... 100 NORDITROPIN FLEXPRO...... 99 NOVOLOG MIX 70/30 NUTROPIN AQ NUSPIN 5..... 100 norethin ace-eth estrad-fe...... 104 FLEXPEN...... 77 NUVAIL...... 68 norethindrone...... 104 NOVOLOG MIX 70/30 VIAL...... 77 NUVAKAAN...... 19 norethindrone acetate...... 104 NOVOLOG PENFILL...... 77 NUVAKAAN-II...... 19 norethindrone acet-ethinyl est.104 NOVOLOG U-100 VIAL...... 77 NUVARING...... 104 norethindrone-eth estradiol..... 104 NOVOPEN ECHO...... 74 NUVESSA...... 24 norethin-eth estradiol-fe...... 104 NOVOSEVEN RT...... 49 NUVIGIL...... 136 NORGESIC FORTE...... 135 NOVOTWIST PEN NEEDLE.... 77 NUWIQ...... 49 norgestimate-eth estradiol...... 104 NOXAFIL...... 33 NUZYRA...... 24 nyamyc...... 33

160 NYMALIZE...... 54 ONETOUCH ULTRA 2 KIT orphenadrine citrate er...... 135 nystatin...... 33 W/DEVICE...... 74 orphenadrine-asa-caffeine...... 135 nystatin-triamcinolone...... 33 ONETOUCH ULTRA MINI KIT ORPHENGESIC FORTE...... 135 nystop...... 33 W/DEVICE...... 75 orsythia...... 104 OBIZUR...... 49 ONETOUCH VERIO FLEX ORTHO DF...... 82 OCALIVA...... 92 SYSTEM KIT W/DEVICE...... 75 ORTHO MICRONOR...... 104 ocella...... 104 ONETOUCH VERIO IQ ORTHOVISC...... 118 OCREVUS...... 58 SYSTEM...... 75 ORTIKOS...... 111 OCTAGAM...... 108 ONETOUCH VERIO KIT oscimin...... 90 octreotide acetate...... 100 W/DEVICE...... 75 oscimin sr...... 90 OCUFLOX...... 122 ONETOUCH VERIO oseltamivir phosphate...... 45 OCUVEL...... 82 REFLECT...... 75 OSENI...... 73 ODEFSEY...... 45 ONETOUCH VERIO SYNC OSMOLEX ER...... 43 ODOMZO...... 39 SYSTEM KIT W/DEVICE...... 75 OSMOPREP...... 90 odorless coated fish oil...... 118 ONEVITE...... 82 OSPHENA...... 98 OFEV...... 133 ONEXTON...... 68 OTEZLA...... 108 ofloxacin...... 24, 122, 127 ONFI...... 27 OTICIN HC NR...... 127 OGIVRI...... 39 ONGENTYS...... 43 OTIPRIO...... 127 olanzapine...... 44 ONGLYZA...... 73 OTOVEL...... 127 olanzapine-fluoxetine hcl...... 30 ONIVYDE...... 39 OTREXUP...... 108 OLIVE TREE...... 118 ONPATTRO...... 59 OVACE PLUS...... 68 olmesartan medoxomil...... 54 ONTRUZANT...... 39 OVACE PLUS WASH...... 68 olmesartan medoxomil-hctz...... 54 ONUREG...... 39 OVACE WASH...... 68 olmesartan-amlodipine-hctz...... 54 ONYCHO-MED...... 33 OVEEZA...... 82 olopatadine hcl...... 122, 123, 130 ONZETRA XSAIL...... 34 OVIDE...... 42 OLUMIANT...... 108 OPDIVO...... 39 OVIDREL...... 100 OLUX...... 68 opium...... 90 oxacillin sodium...... 24 OLUX-E...... 68 OPSUMIT...... 134 oxaliplatin...... 39 OMECLAMOX-PAK...... 90 OPTIONS CONCEPTROL...... 118 oxandrolone...... 98 OMEGA-3 RX COMPLETE...... 54 ORACEA...... 68 oxaprozin...... 17 OMEGA-3/D-3 WELLNESS ORACIT...... 82 OXAYDO...... 12 PACK...... 54 ORALAIR...... 118 oxazepam...... 47 omega-3-acid ethyl esters...... 54 ORALAIR ADULT SAMPLE OXBRYTA...... 118 omeprazole...... 87 KIT...... 118 oxcarbazepine...... 27 omeprazole magnesium...... 87 ORALAIR ADULT STARTER OXERVATE...... 126 OMEPRAZOLE+SYRSPEND PACK...... 118 oxiconazole nitrate...... 33 SF ALKA...... 87 ORALAIR CHILDRENS OXISTAT...... 33 omeprazole-sodium SAMPLE KIT...... 118 OXSORALEN ULTRA...... 68 bicarbonate...... 87 ORALAIR CHILDRENS OXTELLAR XR...... 27 OMNARIS...... 130 STARTER PACK...... 118 oxybutynin chloride...... 94 OMNITROPE...... 100 oralone...... 59 oxybutynin chloride er...... 94 OMNIVEX...... 118 ORAMAGICRX...... 118 oxycodone hcl...... 12 ONCASPAR...... 39 ORAPRED ODT...... 96 OXYCODONE HCL ER...... 12 ondansetron hcl...... 31 ORAVIG...... 33 OXYCODONE- ondansetron odt...... 31 ORCHARD GRASS POLLEN. 118 ACETAMINOPHEN...... 12 one daily...... 82 ORENCIA...... 108 oxycodone-acetaminophen...... 13 ONE VITE WOMENS...... 82 ORENCIA CLICKJECT...... 108 oxycodone-aspirin...... 13 ONE VITE WOMENS PLUS..... 82 ORENITRAM...... 134 OXYCONTIN...... 13 ONETOUCH DELICA ORFADIN...... 92 oxymorphone hcl...... 13 LANCING DEV...... 74 ORIAHNN...... 104 oxymorphone hcl er...... 13 ONETOUCH DELICA PLUS ORILISSA...... 100 OXYTOCIN-LACTATED LANCING...... 74 ORKAMBI...... 134 RINGERS...... 100 ONETOUCH ULTRA...... 74 ORMECA...... 17

161 OXYTOCIN-SODIUM PANADOL EXTRA peg-3350/electrolytes/ascorbat.90 CHLORIDE...... 100 STRENGTH...... 13 PEGASYS...... 45 OXYTROL...... 94 PANADOL INFANTS...... 13 PEGINTRON...... 46 OXYTROL FOR WOMEN...... 94 PANCREAZE...... 92 peg-kcl-nacl-nasulf-na asc-c..... 90 oyster shell calcium/d...... 82 PANDEL...... 68 peg-prep...... 90 oyster shell calcium/vitamin d... 82 PANHEMATIN...... 49 PEMAZYRE...... 39 OZEMPIC...... 73 PANRETIN...... 39 penicillamine...... 94 OZOBAX...... 135 pantoprazole sodium...... 87 penicillin g potassium...... 24 OZURDEX...... 123 PANZYGA...... 108 penicillin g procaine...... 24 PACERONE...... 54 papaverine hcl...... 54 penicillin g sodium...... 24 pacerone...... 54 PARADIGM QUICK-SET 23" penicillin v potassium...... 24 paclitaxel...... 39 9MM...... 118 PENICILLIUM NOTATUM...... 119 PADCEV...... 39 PARAGARD INTRAUTERINE PENLEN...... 68 pain & fever childrens...... 13 COPPER...... 104 PENNSAID...... 17 pain & fever infants...... 13 paraplatin...... 39 PENTAM...... 42 pain relief...... 13 PAREMYD...... 126 pentamidine isethionate...... 42 pain relief childrens...... 13 PARI ALTERA NEBULIZER PENTASA...... 111 pain relief extra strength...... 13 HANDSET...... 119 pentazocine-naloxone hcl...... 13 pain relief regular strength...... 13 PARI TREK S COMBO PACK 119 PENTOSAN POLYSULFATE PAINGO KFT...... 19 PARI VORTEX ADULT MASK 119 SODIUM...... 94 PALFORZIA (12 MG DAILY paricalcitol...... 112 pentoxifylline er...... 54 DOSE)...... 118 PARLODEL...... 43 PEPCID...... 87 PALFORZIA (120 MG DAILY PARNATE...... 30 PEPTO-BISMOL...... 90 DOSE)...... 118 paroex...... 59 PERCOCET...... 13 PALFORZIA (160 MG DAILY paromomycin sulfate...... 24 PERCURA...... 119 DOSE)...... 118 paroxetine hcl...... 30 PERDIEM OVERNIGHT PALFORZIA (20 MG DAILY paroxetine hcl er...... 30 RELIEF...... 90 DOSE)...... 118 paroxetine mesylate...... 30 PERENNIAL RYE GRASS PALFORZIA (200 MG DAILY PARSABIV...... 112 POLLEN...... 119 DOSE)...... 118 PASER...... 35 PERFOROMIST...... 133 PALFORZIA (240 MG DAILY PATADAY...... 123 PERIDEX...... 59 DOSE)...... 118 PATANASE...... 130 perindopril erbumine...... 54 PALFORZIA (3 MG DAILY PAXIL...... 30 periogard...... 60 DOSE)...... 118 PAXIL CR...... 30 PERJETA...... 39 PALFORZIA (300 MG pb-hyoscy-atropine- permethrin...... 42 MAINTENANCE)...... 118 scopolamine...... 90 perphenazine...... 31 PALFORZIA (300 MG P-CARE K40...... 96 perphenazine-amitriptyline...... 30 TITRATION)...... 118 P-CARE K40G...... 96 PERSERIS...... 44 PALFORZIA (40 MG DAILY P-CARE K40MX...... 96 PERTZYE...... 92 DOSE)...... 118 P-CARE K80...... 96 PEXEVA...... 30 PALFORZIA (6 MG DAILY P-CARE K80G...... 96 PFIZERPEN...... 24 DOSE)...... 118 P-CARE K80MX...... 96 PH STRIPS...... 119 PALFORZIA (80 MG DAILY PCP 100...... 90 PHENACTIN AA PLUS...... 119 DOSE)...... 118 PECAN POLLEN...... 119 phenazo...... 94 PALFORZIA INITIAL pediaclear pd childrens...... 130 phenazopyridine hcl...... 94 ESCALATION...... 118 PEDIALYTE...... 82 phendimetrazine tartrate...... 59 paliperidone er...... 44 PEDIAPRED...... 96 phendimetrazine tartrate er...... 59 palonosetron hcl...... 31 pediatric electrolyte...... 82 phenelzine sulfate...... 30 PALYNZIQ...... 92 pediavit...... 82 PHENERGAN...... 130 PAMELOR...... 30 PEDIZOLPAK...... 33 phenobarbital...... 27, 28 pamidronate disodium...... 112 PEDVAX HIB...... 110 phenobarbital-belladonna alk....90 PANADOL CHILDRENS...... 13 peg 3350-kcl-na bicarb-nacl...... 90 phenohytro...... 90 PANADOL EXTRA...... 13 peg-3350/electrolytes...... 90 phenoxybenzamine hcl...... 55

162 phentermine hcl...... 59 PIQRAY (300 MG DAILY PR BENZOYL PEROXIDE...... 68 phentolamine mesylate...... 55 DOSE)...... 39 pr benzoyl peroxide wash...... 68 PHENYLEPHRINE HCL...... 94 pirmella 1/35...... 104 PR CREAM...... 68 phenylephrine hcl...... 126 pirmella 7/7/7...... 104 PRADAXA...... 26 PHENYLEPHRINE HCL-NACL.55 piroxicam...... 17 PRALUENT...... 55 PHENYTEK...... 28 PLAN B ONE-STEP...... 104 pramipexole dihydrochloride..... 43 phenytoin...... 28 PLAQUENIL...... 42 pramipexole dihydrochloride er.43 phenytoin infatabs...... 28 PLASMA-LYTE 148...... 83 pramosone...... 68 phenytoin sodium extended...... 28 PLASMA-LYTE A...... 83 PRAMOSONE...... 68 PHEODOYO...... 33 PLAVIX...... 43 PRAMOTIC...... 127 PHESGO...... 39 PLEGRIDY...... 58 pramox...... 68 PHEXXI...... 119 PLEGRIDY STARTER PACK... 58 PRASTERA...... 17 PHEYO...... 33 PLENVU...... 90 prasugrel hcl...... 43 philith...... 104 PLEXION...... 68 PRAVACHOL...... 55 PHLAG SPRAY...... 68 PLEXION CLEANSER...... 68 pravastatin sodium...... 55 PHOMA EXIGUA...... 119 PLEXION CLEANSING PRAXBIND...... 119 PHOSLYRA...... 94 CLOTH...... 68 praziquantel...... 42 phospha 250 neutral...... 82 PLIAGLIS...... 19 prazosin hcl...... 55 phosphasal...... 94 PNEUMOVAX 23...... 110 PRE & POST SX POUCH...... 68 PHOSPHOLINE IODIDE...... 124 podactin...... 33 PRECEDEX...... 119 phosphorous...... 82 POD-CARE 100K...... 97 PRECISION LINK...... 75 phosphorus supplement...... 82 PODIAPN...... 83 PRECISION PCX PLUS TEST. 75 phosphorus w/sod & podocon...... 68 PRECISION QID MONITOR.....75 potassium...... 82 podofilox...... 68 PRECISION QID TEST...... 75 phospho-trin 250 neutral...... 83 POINT OF CARE L.2...... 97 PRECISION SOF-TACT PHOTOFRIN...... 39 POINT OF CARE L.5...... 97 MONITOR...... 75 PHOTREXA-PHOTREXA POINT OF CARE LM DEP 2.....97 PRECISION SOF-TACT TEST. 75 VISCOUS KIT...... 119 POINT OF CARE LM-2.2...... 19 PRECISION XTRA...... 75 PHOXILLUM BK4/2.5...... 83 POINT OF CARE LM-2.5...... 19 PRECISION XTRA BLOOD PHYSICIANS EZ USE B-12...... 83 POLIVY...... 39 GLUCOSE...... 75 physicians ez use joint/tunnel... 96 polycin...... 126 PRECISION XTRA KETONE....75 PHYSICIANS EZ USE M- poly-iron 150 forte...... 83 PRECISION XTRA MONITOR..75 PRED...... 97 polymyxin b sulfate...... 24 PRECOSE...... 73 PHYSIOLYTE...... 83 polymyxin b-trimethoprim...... 126 PRED FORTE...... 123 PHYSIOSOL IRRIGATION...... 83 POLYSPORIN...... 24 PRED MILD...... 123 phytonadione...... 83 POLYTRIM...... 126 PRED-G...... 126 PICATO...... 68 POLY-VI-FLOR...... 83 PRED-G S.O.P...... 126 PIFELTRO...... 46 POLY-VI-FLOR FS...... 83 prednicarbate...... 68 pilocarpine hcl...... 60, 124 POLY-VI-FLOR/IRON...... 83 PREDNISOL ACE- pimecrolimus...... 68 poly-vite pediatric...... 83 MOXIFLOX-BROMFEN...... 123 pimozide...... 44 POMALYST...... 39 prednisolone...... 97 pimtrea...... 104 portia-28...... 104 prednisolone acetate...... 123 pindolol...... 55 PORTRAZZA...... 39 prednisolone acetate p-f...... 123 pink bismuth maximum posaconazole...... 33 PREDNISOLONE ACETATE- strength...... 90 POTABA...... 83 NEPAFENAC...... 126 pioglitazone hcl...... 73 potassium chloride...... 83 PREDNISOLONE ACET- pioglitazone hcl-glimepiride...... 73 potassium chloride crys er...... 83 MOXIFLOXACIN...... 126 pioglitazone hcl-metformin hcl.. 73 potassium chloride er...... 83 prednisolone sodium piperacillin sod-tazobactam so..24 potassium chloride in nacl...... 83 phosphate...... 97, 123 PIQRAY (200 MG DAILY potassium citrate er...... 83 PREDNISOLONE- DOSE)...... 39 potassium citrate-citric acid...... 83 BROMFENAC...... 126 PIQRAY (250 MG DAILY POTELIGEO...... 39 PREDNISOLONE- DOSE)...... 39 POVIDONE-IODINE...... 123 GATIFLOXACIN...... 126

163 PREDNISOLONE- PREVIDENT 5000 BOOSTER PRO-C-DURE 6...... 97 MOXIFLOXACIN...... 126 PLUS...... 60 PROCENTRA...... 57 PREDNISOLON-GATIFLOX- PREVIDENT 5000 DRY prochlorperazine...... 31 BROMFENAC...... 126 MOUTH...... 60 prochlorperazine maleate...... 31 PREDNISOLON-MOXIFLOX- PREVIDENT 5000 ENAMEL PROCORT...... 111 BROMFENAC...... 126 PROTECT...... 60 PROCRIT...... 49 PREDNISOLON-MOXIFLOX- PREVIDENT 5000 ORTHO PRO-CRITIC...... 119 NEPAFENAC...... 123 DEFENSE...... 60 PROCTOCORT...... 111 prednisone...... 97 PREVIDENT 5000 PLUS...... 60 PROCTOFOAM HC...... 111 prednisone intensol...... 97 PREVIDENT 5000 SENSITIVE.60 procto-med hc...... 111 PREFEST...... 104 PREVIDOLRX ANALGESIC..... 17 procto-pak...... 111 pregabalin...... 59 previdolrx plus analgesic...... 17 proctozone-hc...... 111 PREGENNA...... 83 previfem...... 104 PROCYSBI...... 92 pregnyl...... 100 PREVNAR 13...... 110 PRODIGEN...... 90 PREMARIN...... 104 PREVYMIS...... 46 PROFESSIONAL DNA PREMESISRX...... 83 PREZCOBIX...... 46 COLLECTION...... 119 PREMIUM CONDOMS PREZISTA...... 46 PROFILNINE...... 49 LUBRICATED...... 119 PRIALT...... 13 progesterone...... 104 premium lidocaine...... 19 PRID...... 119 PROGESTERONE PREMIUM SCAR...... 19 PRIFTIN...... 35 COMPOUNDING KIT...... 104 PREMPHASE...... 104 PRILO PATCH...... 19 progesterone micronized...... 104 PREMPRO...... 104 PRILO PATCH II...... 19 PROGESTERONE PRENAISSANCE...... 83 PRILOLID...... 19 MICRONIZED...... 104 PRENARA...... 83 PRILOSEC...... 87 PROGESTERONE- prenatal...... 83 PRILOVIX...... 19 MINOXIDIL...... 68 prenatal plus iron...... 83 PRILOVIX LITE...... 19 PROGLYCEM...... 75 prenatal vitamin plus low iron....83 PRILOVIX LITE PLUS...... 19 PROGRAF...... 108 PRENATE...... 83 PRILOVIX PLUS...... 19 PROLASTIN-C...... 133 PRENATE DHA...... 83 prilovix ultralite...... 19 PROLATE...... 13 PRENATE ELITE...... 83 prilovix ultralite plus...... 19 PROLENSA...... 123 PRENATE ENHANCE...... 83 PRILOVIXIL...... 19 PROLEUKIN...... 39 PRENATE ESSENTIAL...... 83 PRIMACARE...... 84 PROLEVA...... 119 PRENATE MINI...... 83 primaquine phosphate...... 42 PROLIA...... 112 PRENATE PIXIE...... 83 primidone...... 28 PROMACTA...... 49 PRENATE RESTORE...... 83 PRIMLEV...... 13 PROMACTIN AA PLUS 20PE 119 PRENATRIX...... 83 PRIMSOL...... 24 PROMELLA IN PREBIOTIC..... 90 PRENATRYL...... 83 PRINIVIL...... 55 promethazine hcl...... 130 PRENATVITE COMPLETE...... 83 PRISTIQ...... 30 promethazine-codeine...... 130 PRENATVITE PLUS...... 83 PRIVET...... 119 promethazine-dm...... 130 PRENATVITE RX...... 84 PRIVIGEN...... 108 promethazine-phenyleph- PREPIDIL...... 94 PRIZOPAK II...... 19 codeine...... 130 PREPIV SUPPLY...... 19 PRIZOTRAL...... 19 promethazine-phenylephrine.. 130 preplus...... 84 PRIZOTRAL-II...... 19 promethegan...... 130 PRESERA...... 68 PROAIR DIGIHALER...... 133 PROMETRIUM...... 104 PRESTALIA...... 55 PROAIR HFA...... 133 PROMISEB...... 68 pretab...... 84 PROAIR RESPICLICK...... 133 PRONEB ULTRA FILTER SET PRETOMANID...... 35 probenecid...... 34 ...... 119 PREVACID...... 87 PROBICHEW...... 90 propafenone hcl...... 55 PREVACID 24HR...... 87 PROBUPHINE IMPLANT KIT... 13 propafenone hcl er...... 55 PREVACID SOLUTAB...... 87 procainamide hcl...... 55 propantheline bromide...... 90 prevalite...... 55 PROCARDIA...... 55 proparacaine hcl...... 126 PREVIDENT...... 60 PROCARDIA XL...... 55 proparacaine-fluorescein...... 126 PRO-C-DURE 5...... 97 PROPECIA...... 68

164 PROPEL...... 130 QDOLO...... 13 rasagiline mesylate...... 43 PROPEL MINI...... 130 QINLOCK...... 39 RASUVO...... 108 propranolol hcl...... 55 QMIIZ ODT...... 17 RAVICTI...... 92 propranolol hcl er...... 55 QNASL...... 130 RAYALDEE...... 112 propranolol-hctz...... 55 QNASL CHILDRENS...... 130 RAYOS...... 97 propylthiouracil...... 105 QSYMIA...... 59 RAZADYNE ER...... 29 PROSCAR...... 95 QTERN...... 73 READYSHARP ANESTH + PROSILK...... 68 QUAD-MIX...... 94 METHYLPRED...... 97 PROSTIN E2...... 94 QUAD-PROBIOTIC...... 91 READYSHARP PROTEINEX P18...... 84 QUALAQUIN...... 42 BETAMETHASONE...... 97 PROTEXA...... 68 QUARTETTE...... 104 READYSHARP PROTONIX...... 87 quazepam...... 47 DEXAMETHASONE...... 97 PROTOPIC...... 68 QUDEXY XR...... 28 READYSHARP KETOROLAC.. 17 protriptyline hcl...... 30 QUEEN PALM...... 119 READYSHARP-A...... 19 PROTYL AG...... 68 QUESTRAN...... 55 REBIF...... 58 PROVENGE...... 108 QUESTRAN LIGHT...... 55 REBIF REBIDOSE...... 58 PROVENTIL HFA...... 133 quetiapine fumarate...... 44 REBIF REBIDOSE PROVERA...... 104 quetiapine fumarate er...... 44 TITRATION PACK...... 58 PROVIGIL...... 136 QUFLORA FE...... 84 REBIF TITRATION PACK...... 58 PROZAC...... 30 QUFLORA FE PEDIATRIC...... 84 REBINYN...... 49 PRUCLAIR...... 68 QUFLORA GUMMIES...... 84 REBLOZYL...... 49 PRUDOXIN...... 68 QUFLORA PEDIATRIC...... 84 RECARBRIO...... 24 PRUMYX...... 68 QUILLICHEW ER...... 57 RECEDO...... 68 pseudoephedrine hcl er...... 130 QUILLIVANT XR...... 57 RECLAST...... 112 pseudoephedrine-bromphen- quinapril hcl...... 55 reclipsen...... 104 dm...... 130 quinapril-hydrochlorothiazide.... 55 RECOMBINATE...... 49 pseudoephedrine-guaifenesin quinidine gluconate er...... 55 RECOMBIVAX HB...... 110 er...... 130 quinidine sulfate...... 55 RECOTHROM...... 49 PSORCON...... 68 quinine sulfate...... 42 RECOTHROM SPRAY KIT...... 49 PSORIZIDE FORTE...... 119 QUINIXIL...... 68 RECTIV...... 55 PSORIZIDE ULTRA...... 119 QUINJA...... 33 RECURA...... 33 PULMICORT FLEXHALER.....133 QUTENZA...... 68 RED BIRCH...... 119 PULMICORT SUSPENSION.. 133 QUTENZA (2 PATCH)...... 68 RED CEDAR...... 119 PULMONA...... 119 QVAR REDIHALER...... 133 RED MAPLE...... 119 PULMOZYME...... 134 ra acetaminophen rapid melts...13 RED MULBERRY...... 119 PURAMINO DHA/ARA...... 119 ra omeprazole-sodium bicarb... 87 RED TOP GRASS POLLEN... 119 purevit dualfe plus...... 84 RABAVERT...... 110 REDITREX...... 108 PURIXAN...... 39 RABBIT EPITHELIUM...... 119 REFISSA...... 68 PYLERA...... 90 RABEPRAZOLE SODIUM...... 87 REFRESH RELIEVA...... 126 pyrazinamide...... 35 rabeprazole sodium...... 87 REFRESH RELIEVA PF...... 126 PYRIDIUM...... 94 RADIAGEL...... 68 REGENECARE...... 68 pyridostigmine bromide...... 35 RADIAPLEXRX...... 68 REGIOCIT...... 26 pyridostigmine bromide er...... 35 RADICAVA...... 59 REGLAN...... 31 PYRIDOXINE HCL...... 84 RADIOGARDASE...... 119 REGRANEX...... 68 pyridoxine hcl...... 84 RAGWITEK...... 119 RELADOR PAK...... 19 pyrimethamine...... 42 raloxifene hcl...... 98 RELADOR PAK PLUS...... 19 PYRIMETHAMINE- ramelteon...... 136 RELAFEN...... 17 LEUCOVORIN...... 42 ramipril...... 55 RELAFEN DS...... 17 PYROGALLIC ACID...... 68 RANEXA...... 55 RELENZA DISKHALER...... 46 QBRELIS...... 55 ranolazine er...... 55 relexxii...... 57 QBREXZA...... 68 RAPAFLO...... 95 RELION BLOOD GLUCOSE qc aspirin low dose...... 17 RAPAMUNE...... 108 TEST...... 75 qc magnesium citrate...... 91 RAPID GEL RX...... 119 RELION ULTIMA TEST...... 75

165 RELISTOR...... 91 REXULTI...... 44 rosuvastatin calcium...... 55 RELNATE DHA...... 84 REYATAZ...... 46 ROTARIX...... 110 RELPAX...... 34 REYVOW...... 34 ROTATEQ...... 110 REMEDIENT...... 84 RHEUMATE...... 119 ROUGH MARSH ELDER...... 119 remergent hq...... 69 RHIZOPUS...... 119 ROUGH PIGWEED...... 119 REMERON...... 30 RHOFADE...... 69 ROWASA...... 112 REMERON SOLTAB...... 30 RHOGAM ULTRA-FILTERED roweepra...... 28 REMICADE...... 108 PLUS...... 108 ROXICODONE...... 13 REMIGEN...... 69 RHOPHYLAC...... 108 ROZEREM...... 136 REMODULIN...... 134 RHOPRESSA...... 124 ROZLYTREK...... 40 RENACIDIN...... 94 RIASTAP...... 49 RUBRACA...... 40 RENAGEL...... 94 RIAX...... 69 RUCONEST...... 109 renal...... 84 ribavirin...... 46 rufinamide...... 28 RENAL MULTIVITAMIN RIBOZEL...... 119 RUKOBIA...... 46 FORMULA...... 84 RIDAURA...... 109 RUSSIAN THISTLE...... 119 RENATABS...... 84 rifabutin...... 35 RUXIENCE...... 40 RENATABS WITH IRON...... 84 rifampin...... 35 RUZURGI...... 119 rena-vite...... 84 RIFAMPIN+SYRSPEND SF..... 35 RYBELSUS...... 73 RENFLEXIS...... 108 RILUTEK...... 59 RYCLORA...... 130 reno caps...... 84 riluzole...... 59 RYDAPT...... 40 RENOVA...... 69 rimantadine hcl...... 46 RYTARY...... 43 RENOVA PUMP...... 69 RIMSO-50...... 94 RYTHMOL SR...... 55 RENOVO...... 20 ringers irrigation...... 84 ryvent...... 130 RENVELA...... 94 RINVOQ...... 109 SABRIL...... 28 repaglinide...... 73 RIOMET...... 73 saccharomyces boulardii...... 91 REPATHA...... 55 RIOMET ER...... 73 SACCHAROMYCES REPATHA PUSHTRONEX risedronate sodium...... 112 CEREVISIAE...... 119 SYSTEM...... 55 RISPERDAL...... 44 SAFYRAL...... 104 REPATHA SURECLICK...... 55 RISPERDAL CONSTA...... 44 SAGEBRUSH...... 119 REQ 49+...... 84 risperidone...... 44 SAIZEN...... 100 RESECTISOL...... 119 RITALIN...... 57 SAIZENPREP...... 100 RESORCINOL-SULFUR...... 69 RITALIN LA...... 57 SALAGEN...... 60 RESOURCE THICKENUP ritonavir...... 46 SALEX...... 69 JUICE...... 119 RITUXAN...... 40 SALICEPT...... 119 RESTASIS...... 126 RITUXAN HYCELA...... 39 salicylic acid...... 69 RESTASIS MULTIDOSE...... 126 rivastigmine...... 29 salicylic acid er...... 69 RESTORA RX...... 91 rivastigmine tartrate...... 29 salicylic acid wart remover...... 69 RESTORIL...... 136 rivelsa...... 104 salicylic acid-cleanser...... 69 RETACRIT...... 49 RIXUBIS...... 49 SALICYLIC ACID- RETEVMO...... 39 rizatriptan benzoate...... 34 SULFACETAMIDE...... 69 RETIN-A...... 69 ROBAXIN-750...... 135 salimez...... 69 RETIN-A MICRO GEL 0.04 %, ROBITUSSIN 12 HOUR SALIMEZ FORTE...... 69 0.1 %...... 69 COUGH CHILD...... 130 SALIVAMAX...... 60 RETIN-A MICRO PUMP...... 69 ROBITUSSIN salsalate...... 17 RETISERT...... 123 COUGH+CHEST CONG DM..130 SALVAX...... 69 RETROVIR...... 46 ROCALTROL...... 112 SALVAX DUO PLUS...... 69 REVATIO...... 134 ROCKLATAN...... 124 SAMSCA...... 84 REVCOVI...... 92 ROMIDEPSIN...... 40 SANADERMRX SKIN REPAIR.69 REVESTA...... 84 ropinirole hcl...... 43 SANCUSO...... 31 REVLIMID...... 39 ropinirole hcl er...... 43 SANDIMMUNE...... 109 REXAPHENAC...... 17 rosadan...... 69 SANDOSTATIN...... 100 REXASIL PATCH & VITAMIN ROSADAN...... 69 SANDOSTATIN LAR DEPOT. 100 E LIQ...... 69 ROSE GLO...... 126 SANTYL...... 69

166 SAPHRIS...... 44 SEVENFACT...... 49 SLOWMAG MG sapropterin dihydrochloride...... 92 sevoflurane...... 119 MUSCLE/HEART...... 84 SARCLISA...... 40 SEYSARA...... 24 SLYND...... 104 SAVAYSA...... 26 sf...... 60 sod citrate-citric acid...... 84 SAVELLA...... 59 sf 5000 plus...... 60 sodium bicarbonate...... 84, 91 SAVELLA TITRATION PACK... 59 SFROWASA...... 112 SODIUM BICARBONATE...84, 91 SAXENDA...... 59 SHAGBARK HICKORY...... 120 sodium chloride...... 84, 130 SCALACORT DK...... 69 sharobel...... 104 sodium chloride (hypertonic)...126 SCARCARE GEL-PAD SHARPS CONTAINER...... 120 sodium chloride (pf)...... 84 KIT/LARGE...... 69 SHEEP SORREL...... 120 sodium fluoride...... 60, 84 SCARCIN...... 69 SHINGRIX...... 110 sodium fluoride 5000 plus...... 60 SCARSILK...... 69 SHORT RAGWEED POLLEN sodium fluoride 5000 ppm...... 60 SCARZEN SKIN REPAIR...... 69 EXT...... 120 sodium fluoride 5000 sensitive..60 SCENESSE...... 69 SIDEROL...... 84 sodium hyaluronate...... 69 scopolamine...... 31 SIGNIFOR...... 100 SODIUM HYALURONATE...... 120 SCRUB CARE POVIDONE- SIGNIFOR LAR...... 100 sodium phenylbutyrate...... 92 IODINE...... 24 SIKLOS...... 40 sodium polystyrene sulfonate... 84 SEASONIQUE...... 104 SILA III...... 69 sodium sulfacetamide...... 69 SECUADO...... 44 sildenafil citrate...... 94, 134 sodium sulfacetamide wash...... 69 SEEBRI NEOHALER...... 133 SILENOR...... 136 SODIUM SULFACETAMIDE- SEGLUROMET...... 73 SILIPAC...... 69 BAKUCHIOL...... 70 SELECT-OB...... 84 SILIQ...... 109 SOFOSBUVIR-VELPATASVIR.46 selegiline hcl...... 43 silodosin...... 95 SOLARAVIX...... 70 selenium sulfide...... 69 SILTREX...... 120 solifenacin succinate...... 94 SELRX...... 69 SILVADENE...... 24 SOLIQUA...... 73 SELZENTRY...... 46 silver nitrate...... 24 SOLIRIS...... 49 SEMGLEE...... 77 silver sulfadiazine...... 24 SOLODYN...... 24 SEMPREX-D...... 130 SILVERSEAL HYDROGEL SOLOSEC...... 24 senexon-s...... 91 DRESSING...... 69 SOLOX...... 70 senna...... 91 SIMBRINZA...... 124 SOLTAMOX...... 40 senna plus...... 91 simethicone...... 91 SOLU-CORTEF...... 97 senna s...... 91 simliya...... 104 soluvita e...... 84 senna smooth...... 91 simpesse...... 104 SOMA...... 135 senna-docusate sodium...... 91 SIMPONI...... 109 SOMATULINE DEPOT...... 100 senna-plus...... 91 SIMPONI ARIA...... 109 SOMAVERT...... 100 SENOKOT EXTRA SIMULECT...... 109 SOOLANTRA...... 70 STRENGTH...... 91 simvastatin...... 55 soothe...... 91 SENOKOT S...... 91 SINEMET...... 43 SOOTHEE...... 20 SENSIPAR...... 112 SINGULAIR...... 133 SORBITOL...... 120 sensorcaine...... 20 sinus 12 hour...... 130 sorbitol-mannitol...... 120 sensorcaine-mpf...... 20 SINUVA...... 130 SORIATANE...... 70 SENTRA AM...... 119 sirolimus...... 109 SORILUX...... 70 SENTRA PM...... 119 SIRTURO...... 35 SORREL/DOCK MIX...... 120 SEREVENT DISKUS...... 133 SITAVIG...... 46 sotalol hcl...... 55 SERNIVO...... 69 SIVEXTRO...... 24 sotalol hcl (af)...... 55 SEROQUEL...... 44 skarjel...... 69 SOTYLIZE...... 55 SEROQUEL XR...... 44 SKELAXIN...... 135 SOVALDI...... 46 SEROSTIM...... 91 SKLICE...... 42 SPEEDGEL RX...... 120 sertraline hcl...... 30 SKYLA...... 104 spinosad...... 42 se-tan plus...... 84 SKYRIZI (150 MG DOSE)...... 109 SPINRAZA...... 120 setlakin...... 104 sleep aid (diphenhydramine)...136 SPINY PIGWEED...... 120 sevelamer carbonate...... 94 sleep-aid...... 136 SPIRIVA HANDIHALER...... 133 sevelamer hcl...... 94 SPIRIVA RESPIMAT...... 133

167 spironolactone...... 55 STROVITE FORTE...... 84 SUPRANE...... 120 spironolactone-hctz...... 55 STROVITE ONE...... 84 SUPRAX...... 25 SPORANOX...... 33 SUBLOCADE...... 20 SUPREP BOWEL PREP KIT....91 SPORANOX PULSEPAK...... 33 SUBOXONE...... 20 sure result dss premium pack... 17 SPRAVATO (56 MG DOSE)..... 30 SUBSYS...... 13 SURE RESULT O3D3 SPRAVATO (84 MG DOSE)..... 30 subvenite...... 28 SYSTEM...... 55 sprintec 28...... 104 subvenite starter kit-blue...... 28 SURESTEP PRO HIGH SPRITAM...... 28 subvenite starter kit-green...... 28 GLUCOSE...... 75 SPRIX...... 17 subvenite starter kit-orange...... 28 SURESTEP PRO LOW SPRYCEL...... 40 SUCCINYLCHOLINE GLUCOSE...... 75 sps...... 84 CHLORIDE...... 59 SURESTEP PRO NORMAL sronyx...... 105 SUCRAID...... 92 GLUCOSE...... 75 ssd...... 24 sucralfate...... 87 SURVANTA...... 131 SSKI...... 130 SUDAFED CONGESTION...... 130 SUSTIVA...... 46 sss 10-5...... 70 sudogest...... 131 SUTAB...... 91 ST JOSEPH LOW DOSE...... 17 sudogest 12 hour...... 130 SUTENT...... 40 STALEVO 100...... 43 sudogest maximum strength...130 SUVICORT...... 70 STALEVO 125...... 43 SULAR...... 55 SWEET GUM...... 120 STALEVO 150...... 43 SULCONAZOLE NITRATE...... 33 SWEET VERNAL GRASS STALEVO 200...... 43 sulfacetamide sodium...... 70, 123 POLLEN...... 120 STALEVO 50...... 43 sulfacetamide sodium (acne).... 70 SX1 MEDICATED POST- STALEVO 75...... 43 sulfacetamide sodium-sulfur..... 70 OPERATIVE...... 20 STAMARIL...... 110 sulfacetamide sod-sulfur wash..70 syeda...... 105 STARLIX...... 73 sulfacetamide-prednisolone.... 126 SYLVANT...... 40 stavudine...... 46 sulfacetamide-sulfur in urea...... 70 SYMAX DUOTAB...... 91 STAXYN...... 94 sulfacleanse 8/4...... 70 symax-sl...... 91 STEGLATRO...... 73 sulfadiazine...... 25 symax-sr...... 91 STEGLUJAN...... 73 sulfamethoxazole-trimethoprim.25 SYMBICORT...... 133 STELARA...... 109 sulfamez wash...... 70 SYMBYAX...... 30 STEMPHYLIUM...... 120 SULFAMYLON...... 25 SYMDEKO...... 134 STENDRA...... 94 sulfasalazine...... 112 SYMFI...... 46 STERITALC...... 133 sulfatrim pediatric...... 25 SYMFI LO...... 46 STIMATE...... 100 SULFURATED LIME...... 42 SYMJEPI...... 133 stimulant laxative...... 91 sulindac...... 17 SYMLINPEN 120...... 73 STIOLTO RESPIMAT...... 133 SUMADAN...... 70 SYMLINPEN 60...... 73 STIVARGA...... 40 SUMADAN WASH...... 70 SYMPAZAN...... 28 stomach relief...... 91 SUMADAN XLT...... 70 SYMPROIC...... 91 stool softener...... 91 sumatriptan...... 34 SYMTUZA...... 46 stool softener laxative...... 91 sumatriptan succinate...... 34, 35 SYNAGEX...... 85 stool softener plus laxative...... 91 sumatriptan succinate refill...... 34 SYNAGIS...... 109 stool softener/laxative...... 91 sumatriptan-naproxen sodium.. 35 SYNALAR...... 70 stop lice complete treatment..... 42 SUMAXIN...... 70 SYNALAR (CREAM)...... 70 STRATA CTX...... 70 SUMAXIN CP...... 70 SYNALAR (OINTMENT)...... 70 STRATA GRT...... 70 SUMAXIN WASH...... 70 SYNALAR TS...... 70 STRATA MARK...... 70 SUNOSI...... 136 SYNAPRYN FUSEPAQ...... 13 STRATA TRIZ...... 70 SUPARTZ FX...... 120 SYNAREL...... 100 STRATA XRT...... 70 SUPER BI-MIX...... 94 SYNDROS...... 31 STRATTERA...... 57 SUPER QUAD-MIX...... 94 SYNERA...... 20 STRENSIQ...... 92 SUPER TRI-MIX...... 94 SYNERDERM...... 70 streptomycin sulfate...... 24 SUPERVITE...... 84 SYNJARDY...... 73 STRIBILD...... 46 support...... 84 SYNJARDY XR...... 73 STRIVERDI RESPIMAT...... 133 SUPPORT-500...... 84 SYNRIBO...... 40 STROMECTOL...... 42 SUPPRELIN LA...... 100 SYNTHROID...... 105

168 SYNVEXIA TC...... 20 tazarotene...... 70 TETANUS-DIPHTHERIA SYNVISC...... 120 tazicef...... 25 TOXOIDS TD...... 110 SYNVISC ONE...... 120 TAZORAC...... 70, 71 tetrabenazine...... 59 SYPRINE...... 85 taztia xt...... 55 tetracaine hcl...... 126 SYRINGE AVITENE...... 120 TAZVERIK...... 40 tetracycline hcl...... 25 SYSTANE COMPLETE...... 126 TDVAX...... 110 TETRIX...... 71 SYSTANE HYDRATION PF... 126 TECARTUS...... 40 TEXACORT...... 71 SYSTANE ICAPS AREDS2...... 85 TECENTRIQ...... 40 THALOMID...... 40 SYSTANE ULTRA PF...... 126 TECFIDERA...... 58 THEO-24...... 133 TABLOID...... 40 TEFLARO...... 25 theophylline...... 133 TABRADOL FUSEPAQ...... 135 TEGRETOL...... 28 theophylline er...... 133 TABRADOL RAPIDPAQ...... 135 TEGRETOL-XR...... 28 THERAMINE...... 120 TABRECTA...... 40 TEGSEDI...... 59 THERAMINE PLUS...... 120 TACHOSIL...... 120 TEKTURNA...... 55 thiamine hcl...... 85 TACLONEX...... 70 TEKTURNA HCT...... 55 THIOLA...... 94 TACROLIMUS...... 70 telmisartan...... 55 THIOLA EC...... 94 tacrolimus...... 70, 109 telmisartan-amlodipine...... 55 thioridazine hcl...... 44 tadalafil...... 94 telmisartan-hctz...... 55 thiotepa...... 40 tadalafil (pah)...... 134 temazepam...... 136 thiothixene...... 44 TAFINLAR...... 40 TEMIXYS...... 46 THROMBATE III...... 26 TAGRISSO...... 40 TEMODAR...... 40 THROMBI-GEL 10...... 120 TAKHZYRO...... 109 TEMOVATE...... 71 THROMBI-GEL 100...... 120 TALICIA...... 91 temozolomide...... 40 THROMBI-GEL 40...... 120 TALIVA...... 85 temsirolimus...... 109 THROMBIN-JMI...... 50 TALL RAGWEED...... 120 tencon...... 13 THROMBIN-JMI EPISTAXIS.... 49 TALTZ...... 109 teniposide...... 40 THROMBI-PAD...... 120 TALZENNA...... 40 TENIVAC...... 110 THROMBOGEN...... 50 TAMIFLU...... 46 tenofovir disoproxil fumarate.....46 THYMOGLOBULIN...... 109 tamoxifen citrate...... 40 TENORETIC 100...... 55 THYROGEN...... 120 tamsulosin hcl...... 95 TENORETIC 50...... 55 tiadylt er...... 56 TAPAZOLE...... 105 TENORMIN...... 56 tiagabine hcl...... 28 TAPERDEX 12-DAY...... 97 TEPADINA...... 40 TIAZAC...... 56 TAPERDEX 6-DAY...... 97 TEPEZZA...... 100 TIBSOVO...... 40 TAPERDEX 7-DAY...... 97 terazosin hcl...... 95 TICE BCG...... 109 TARCEVA...... 40 terbinafine hcl...... 33 TIGAN...... 31 TARDEOXIA...... 70 terbutaline sulfate...... 133 tigecycline...... 25 TARDIMAXIA...... 70 terconazole...... 33 TIGLUTIK...... 59 TARGADOX...... 25 TERIPARATIDE TIKOSYN...... 56 TARGRETIN...... 40 (RECOMBINANT)...... 112 tilia fe...... 105 tarina 24 fe...... 105 terrell...... 120 timolol maleate...... 56, 124 tarina fe 1/20...... 105 TESSALON PERLES...... 131 timolol maleate pf...... 124 tarina fe 1/20 eq...... 105 TESTIM...... 98 TIMOLOL-BRIMON-DORZOL- TARKA...... 55 TESTONE CIK...... 98 LATANOPR...... 124 TARON FORTE...... 85 TESTOPEL...... 98 TIMOLOL-BRIMONIDINE- taron-crystals...... 85 TESTOSTERONE...... 98 DORZOLAMID...... 124 TAROXIA...... 70 testosterone...... 98 TIMOLOL-DORZOLAMID- TASIGNA...... 40 TESTOSTERONE LATANOPROST...... 124 TASMAR...... 43 COMPOUNDING KIT...... 98 TIMOPTIC...... 124 TASOPROL...... 70 TESTOSTERONE TIMOPTIC OCUDOSE...... 124 tavaborole...... 33 CYPIONATE...... 98 TIMOPTIC-XE...... 124 TAVALISSE...... 49 testosterone cypionate...... 98 TIMOTHY GRASS POLLEN TAXOTERE...... 40 testosterone enanthate...... 98 ALLERGEN...... 120 TAYTULLA...... 105 tinidazole...... 25

169 TIROSINT...... 105 TOVET...... 71 TRIBENZOR...... 56 TIROSINT-SOL...... 105 TOVIAZ...... 94 tri-buffered aspirin...... 17 TISSEEL...... 120 TOXICOLOGY SALIVA TRICARE PRENATAL DHA tis-u-sol...... 85 COLLECTION...... 120 ONE...... 85 TIVICAY...... 46 TRACLEER...... 134 TRI-CHLOR...... 71 TIVICAY PD...... 46 TRADJENTA...... 73 TRICHOPHYTON...... 120 TIVORBEX...... 17 TRAMADOL HCL ER...... 13 TRICHOPHYTON tizanidine hcl...... 135 tramadol hcl er...... 13 MENTAGROPHYTES...... 120 tl hydroquinone...... 71 tramadol hcl er (biphasic)...... 13 TRICITRASOL...... 26 tl-hem 150...... 85 tramadol hcl ir...... 13 tricitrates...... 85 TL-ICARE...... 120 tramadol-acetaminophen...... 13 tricon...... 85 TOBAKIENT...... 120 trandolapril...... 56 TRICOR...... 56 TOBI NEBULIZER...... 134 trandolapril-verapamil hcl er...... 56 triderm...... 71 TOBI PODHALER...... 134 tranexamic acid...... 50 TRIDESILON...... 71 TOBRADEX...... 126 TRANEXAMIC ACID-NACL...... 50 trientine hcl...... 85 TOBRADEX ST...... 126 TRANSDERM SCOP (1.5 MG).31 tri-estarylla...... 105 tobramycin...... 123, 134 TRANSDERM-SCOP (1.5 MG).31 TRIFERIC...... 85 TOBRAMYCIN...... 134 TRANXENE-T...... 47 trifluoperazine hcl...... 44 tobramycin-dexamethasone....126 tranylcypromine sulfate...... 30 trifluridine...... 123 TOBREX...... 123 TRANZGEL...... 120 trihexyphenidyl hcl...... 43 TOLAK...... 71 TRAUMEEL...... 120 TRIJARDY XR...... 73 tolbutamide...... 73 TRAVATAN Z...... 124 TRIKAFTA...... 134 tolcapone...... 43 travel sickness...... 31 tri-legest fe...... 105 tolmetin sodium...... 17 travoprost (bak free)...... 124 TRILEPTAL...... 28 tolnaftate...... 33 TRAZIMERA...... 40 tri-linyah...... 105 tolnaftate antifungal...... 33 trazodone hcl...... 30 TRILIPIX...... 56 TOLSURA...... 33 TREANDA...... 40 TRILOAN II SUIK...... 97 tolterodine tartrate...... 94 TRECATOR...... 35 TRILOAN SUIK...... 97 tolterodine tartrate er...... 94 TRELEGY ELLIPTA...... 134 tri-lo-estarylla...... 105 TOLVAPTAN...... 85 TRELSTAR MIXJECT...... 100 tri-lo-marzia...... 105 tolvaptan...... 85 TREMFYA...... 109 tri-lo-mili...... 105 TOPAMAX...... 28 TREPADONE...... 120 tri-lo-sprintec...... 105 TOPAMAX SPRINKLE...... 28 treprostinil...... 134 TRI-LUMA...... 71 TOPEX TOPICAL TRESIBA...... 77 TRILURON...... 120 ANESTHETIC...... 60 TRESIBA FLEXTOUCH...... 77 trilyte...... 91 TOPICORT...... 71 tretinoin...... 40, 71 trimethobenzamide hcl...... 31 TOPICORT SPRAY...... 71 tretinoin (emollient)...... 71 trimethoprim...... 25 TOPIDEX...... 97 tretinoin microsphere...... 71 tri-mili...... 105 topiramate...... 28 tretinoin microsphere pump...... 71 trimipramine maleate...... 30 topiramate er...... 28 TRETTEN...... 50 TRI-MIX...... 94 toposar...... 40 TREXALL...... 109 trinate...... 85 topotecan hcl...... 40 TREXIMET...... 35 TRINAZ...... 85 TOPROL XL...... 56 TREZIX...... 13 TRINTELLIX...... 30 toremifene citrate...... 40 tri femynor...... 105 triphrocaps...... 85 TORISEL...... 109 triamcinolone acetonide 60, 71, 97 triple antibiotic...... 71 TORONOVA II SUIK...... 17 TRIAMCINOLONE triple antibiotic+pain relief...... 71 TORONOVA SUIK...... 17 ACETONIDE...... 97 TRIPLE COMPLEX FORMULA torsemide...... 56 TRIAMSIL COMBIPAK...... 71 3 KIT...... 17 TOSYMRA...... 35 TRIAMSIL MULTIPAK...... 71 TRIPLE PMB...... 123 TOTECT...... 40 triamterene...... 56 TRIPLE PMK...... 123 TOUJEO MAX SOLOSTAR...... 77 triamterene-hctz...... 56 tri-previfem...... 105 TOUJEO SOLOSTAR...... 77 trianex...... 71 triprolidine hcl...... 131 tovet...... 71 triazolam...... 47 TRIPTODUR...... 100

170 TRISENOX...... 40 TUSSICAPS...... 131 ULTRAFOAM SPONGE tri-sprintec...... 105 tussin cf multi-symptom cold...131 8X6.25X1CM...... 121 TRISTART ONE...... 85 tussin dm...... 131 ULTRAM...... 13 TRIUMEQ...... 46 tussin dm max...... 131 ULTRASAL-ER...... 71 TRI-VI-FLOR...... 85 tussin dm max adult...... 131 ULTRAVATE...... 71 TRI-VI-FLORO...... 85 TUXARIN ER...... 131 UMECTA MOUSSE...... 71 tri-vite pediatric...... 85 TUZISTRA XR...... 131 UNASYN...... 25 tri-vite/fluoride...... 85 TWINRIX...... 110 UNISTRIP CONTROL...... 75 TRIVIX...... 71 TWIRLA...... 105 unithroid...... 105 trivora (28)...... 105 TWYNSTA...... 56 UNITUXIN...... 40 tri-vylibra...... 105 tyblume...... 105 UPLIZNA...... 109 tri-vylibra lo...... 105 TYBOST...... 46 UPNEEQ...... 123 TRIZIVIR...... 46 tydemy...... 105 UPTRAVI...... 134 TRODELVY...... 40 TYGACIL...... 25 URAMAXIN...... 71 TROGARZO...... 46 TYKERB...... 40 urea...... 71 TROKENDI XR...... 28 TYLACTIN BUILD 20PE TYR. 120 UREA...... 71 TRONVITE...... 85 TYLACTIN COMPLETE 15 PE urea hydrating...... 71 tropicamide...... 126 ...... 120 urea nail...... 71 TROPICAMIDE- TYLACTIN RESTORE 10...... 120 urea-c40...... 71 CYCLOPENTOLATE-PE...... 126 TYLACTIN RESTORE 5PE.... 120 ureacin-10...... 71 TROPICAMIDE- TYLACTIN RTD 15...... 120 ureacin-20...... 71 PHENYLEPHRINE...... 126 TYLENOL...... 13 uredeb...... 71 TROPIC-CYCLOPENT-PE- TYLENOL 8 HOUR...... 13 URELLE...... 94 KETOROLAC...... 126 TYLENOL EXTRA uremez-40...... 71 TROPIC-CYCLOP-PE-KETO- STRENGTH...... 13 URESOL...... 71 PROPAR...... 126 TYLENOL INFANTS uretron d/s...... 94 TROPIC-PROPARACA-PE- PAIN+FEVER...... 13 URIBEL...... 94 KETOROLAC...... 127 TYMLOS...... 112 URIMAR-T...... 94 trospium chloride...... 94 TYPHIM VI...... 110 urin ds...... 94 trospium chloride er...... 94 TYROS 2...... 120 urinary pain relief...... 95 TRUE METRIX BLOOD TYSABRI...... 58 URO-458...... 95 GLUCOSE TEST...... 75 TYVASO...... 134 UROCIT-K 10...... 85 TRUE METRIX LEVEL 1...... 75 TYVASO REFILL...... 134 UROCIT-K 15...... 85 TRUE METRIX LEVEL 2...... 75 TYVASO STARTER...... 134 UROCIT-K 5...... 85 TRUE METRIX LEVEL 3...... 75 UBRELVY...... 35 UROGESIC-BLUE...... 95 TRUE METRIX PRO BLOOD UCERIS...... 112 uro-mp...... 95 GLUCOSE...... 75 UDAMIN SP...... 85 urosex...... 85 TRUETRACK TEST...... 75 UDENYCA...... 50 UROXATRAL...... 95 TRULANCE...... 91 ULORIC...... 34 URSO 250...... 91 TRULICITY...... 73 ULTANE...... 120 URSO FORTE...... 91 TRUMENBA...... 110 ULTOMIRIS...... 50 ursodiol...... 91 TRUSOPT...... 124 ultra fresh pm...... 127 URSODIOL+SYRSPEND SF....91 TRUSTEEL INFUSION SET... 120 ultra lubricating eye drops...... 127 ustell...... 95 TRUVADA...... 46 ULTRACET...... 13 UTIBRON NEOHALER...... 134 TRUXIMA...... 40 ULTRAFOAM SPONGE uticap...... 95 TRYPTOPHAN...... 85 2X6.25X7CM...... 120 utira-c...... 95 T-SUPPORT MAX...... 120 ULTRAFOAM SPONGE UTOPIC...... 71 TUDORZA PRESSAIR...... 134 8X12.5X1CM...... 120 utrona-c...... 95 TUKYSA...... 40 ULTRAFOAM SPONGE VAGIFEM...... 105 tulana...... 105 8X12.5X3CM...... 121 valacyclovir hcl...... 46 TUMS CHEWY BITES...... 91 ULTRAFOAM SPONGE VALCHLOR...... 40 TURALIO...... 40 8X25X1CM...... 121 VALCYTE...... 46 TURPENTINE...... 71 valganciclovir hcl...... 46

171 VALIUM...... 47 VELTIN...... 72 VIRAMUNE...... 46 valproic acid...... 28 VEMLIDY...... 46 VIRAMUNE XR...... 46 valrubicin...... 40 VENCLEXTA...... 41 VIRASAL...... 72 valsartan...... 56 VENCLEXTA STARTING VIRAZOLE...... 46 valsartan-hydrochlorothiazide... 56 PACK...... 41 VIREAD...... 46, 47 VALSTAR...... 40 VENELEX...... 72 VIRGINIA LIVE OAK...... 121 VALTOCO 10 MG DOSE...... 28 VENIPUNCTURE PX1 virt-caps...... 85 VALTOCO 15 MG DOSE...... 28 PHLEBOTOMY...... 20 VIRT-FEFA PLUS...... 85 VALTOCO 20 MG DOSE...... 28 venlafaxine hcl...... 30 virt-gard...... 85 VALTOCO 5 MG DOSE...... 28 venlafaxine hcl er...... 30 virt-phos 250 neutral...... 85 VALTREX...... 46 VENNGEL ONE...... 17 virtussin ac w/alc...... 131 VANADOM...... 135 VENOFER...... 85 VISBIOME...... 91 VANATOL LQ...... 14 VENTAVIS...... 135 VISIONBLUE...... 127 VANCOCIN...... 25 VENTOLIN HFA...... 134 VISTARIL...... 47 VANCOCIN HCL...... 25 verapamil hcl...... 56 VISTOGARD...... 121 vancomycin hcl...... 25 verapamil hcl er...... 56 VISUDYNE...... 127 vancomycin hcl in nacl...... 25 VERDESO...... 72 vita s forte...... 85 VANCOMYCIN+SYRSPEND VEREGEN...... 72 vitacel...... 85 SF...... 25 VERELAN...... 56 VITAFOL...... 85 vandazole...... 25 VERELAN PM...... 56 VITAFOL FE+...... 85 VANICREAM...... 72 VERSACLOZ...... 44 VITAFOL STRIPS...... 85 VANIQA...... 72 VERZENIO...... 41 VITAFOL-OB+DHA...... 85 VANOS...... 72 VESICARE...... 95 VITAL-D RX...... 85 VANOXIDE-HC...... 72 VEXASYN...... 72 VITAMAX PEDIATRIC...... 85 VANTAS...... 100 VEXATROL...... 20 VITAMEZ...... 85 VAQTA...... 110 VFEND...... 33 vita-min...... 85 vardenafil hcl...... 95 VIAGRA...... 95 vitamin b complex 100...... 85 VARDIMAXIA...... 72 VIBERZI...... 91 vitamin b-6...... 85 VARISOFT INFUSION SET....121 VIBRAMYCIN...... 25 vitamin b-complex 100...... 85 VARIVAX...... 110 vic-forte...... 85 vitamin c...... 85 VARIZIG...... 109 VICTOZA...... 73 vitamin d (cholecalciferol)...... 85 VAROPHEN...... 17 VIDAZA...... 41 vitamin d (ergocalciferol)...... 85 VAROXIA...... 72 VIEKIRA PAK...... 46 vitamin d3...... 85, 86 VARUBI (180 MG DOSE)...... 31 vienva...... 105 VITAMIN DEFICIENCY VASCEPA...... 56 vigabatrin...... 28 SYSTEM-B12...... 86 VASCULERA...... 121 vigadrone...... 28 vitamin e...... 86 VASERETIC...... 56 VIGAMOX...... 123 vitamin k1...... 86 VASOTEC...... 56 VIIBRYD...... 30 vitamins acd-fluoride...... 86 VAXCHORA...... 110 VIIBRYD STARTER PACK...... 30 VITAROCA PLUS...... 86 v-c forte...... 85 VILACTIN AA PLUS...... 121 VITA-RX DIABETIC VITAMIN...86 VCF VAGINAL vilamit mb...... 95 VITASURE...... 86 CONTRACEPTIVE...... 121 VILEVEV MB...... 95 VITATHELY WITH GINGER..... 86 vcf vaginal contraceptive...... 121 VILTEPSO...... 121 VITRAKVI...... 41 VECAMYL...... 56 VIMIZIM...... 92 VITRASE...... 121 VECTIBIX...... 41 VIMOVO...... 17 VITREXATE...... 86 VECTICAL...... 72 VIMPAT...... 28 VITREXATE FE...... 86 VECURONIUM BROMIDE...... 59 vinate one...... 85 VITREXYL...... 86 vegetable lax+stool softener..... 91 vinblastine sulfate...... 41 VITREXYL + IRON...... 86 VELCADE...... 41 vincristine sulfate...... 41 VIVELLE-DOT...... 105 VELETRI...... 135 vinorelbine tartrate...... 41 VIVITROL...... 20 velivet...... 105 VIOKACE...... 92 VIVLODEX...... 17 VELPHORO...... 95 viorele...... 105 VIVOTIF...... 111 VELTASSA...... 85 VIRACEPT...... 46 VIZIMPRO...... 41

172 VOGELXO...... 98 WHITE FACED HORNET XHANCE...... 131 VOGELXO PUMP...... 98 VENOM...... 121 XIAFLEX...... 121 volnea...... 105 WHITE MULBERRY...... 121 XIFAXAN...... 25 VOLTAREN...... 17 WHITE OAK...... 121 XIGDUO XR...... 73 VONVENDI...... 50 WHITE PINE...... 121 XIIDRA...... 127 VORAXAZE...... 41 WIDE-SEAL DIAPHRAGM 60 121 XIMINO...... 25 voriconazole...... 33 WIDE-SEAL DIAPHRAGM 65 121 XOFIGO...... 41 VORTEX HOLDING WIDE-SEAL DIAPHRAGM 70 121 XOFLUZA (40 MG DOSE)...... 47 CHAMBER/MASK...... 121 WIDE-SEAL DIAPHRAGM 75 121 XOFLUZA (80 MG DOSE)...... 47 VOSEVI...... 47 WIDE-SEAL DIAPHRAGM 80 121 XOLAIR...... 131 VOTRIENT...... 41 WIDE-SEAL DIAPHRAGM 85 121 XOLEGEL...... 33 VP FC KIT...... 17 WIDE-SEAL DIAPHRAGM 90 121 XOLEGEL COREPAK...... 33 VP GKL KIT...... 17 WIDE-SEAL DIAPHRAGM 95 121 XOLEGEL DUO/HEAD & vp-pnv-dha...... 86 WILATE...... 50 SHOULDERS...... 33 VPRIV...... 92 WINRHO SDF...... 109 XOLEGEL DUO/XOLEX...... 33 vp-vite rx...... 86 wixela inhub...... 134 XOPENEX CONCENTRATE.. 134 VRAYLAR...... 44 WP THYROID...... 105 XOPENEX HFA...... 134 VTOL LQ...... 14 WPR PLUS WOUND XOPENEX NEB...... 134 VUMERITY...... 58 HEALING SYSTEM...... 20 XOSPATA...... 41 VUSION...... 33 wymzya fe...... 105 XPOVIO (100 MG ONCE VYEPTI...... 35 XADAGO...... 43 WEEKLY)...... 41 vyfemla...... 105 XALATAN...... 124 XPOVIO (40 MG ONCE VYLEESI...... 59 XALIX...... 72 WEEKLY)...... 41 vylibra...... 105 XALKORI...... 41 XPOVIO (40 MG TWICE VYNDAMAX...... 56 XANAX...... 47 WEEKLY)...... 41 VYNDAQEL...... 56 XANAX XR...... 47 XPOVIO (60 MG ONCE VYONDYS 53...... 92 XAQUIL XR...... 86 WEEKLY)...... 41 VYTONE...... 33 XARACOLL...... 20 XPOVIO (60 MG TWICE VYTORIN...... 56 XARELTO...... 26 WEEKLY)...... 41 VYVANSE...... 57 XARELTO STARTER PACK.....26 XPOVIO (80 MG ONCE VYXEOS...... 41 XATMEP...... 109 WEEKLY)...... 41 VYZULTA...... 124 XCOPRI...... 28 XPOVIO (80 MG TWICE WAKIX...... 136 XCOPRI (250 MG DAILY WEEKLY)...... 41 wal-tap cold/allergy...... 131 DOSE)...... 28 XRYLIX...... 17 wal-zyr...... 131 XCOPRI (350 MG DAILY XTAMPZA ER...... 14 warfarin sodium...... 26 DOSE)...... 28 XTANDI...... 41 WASP VENOM PROTEIN...... 121 XELJANZ...... 109 xulane...... 105 weekly-d...... 86 XELJANZ XR...... 109 XULTOPHY...... 73 WELCHOL...... 56 XELODA...... 41 xurea...... 72 WELLBUTRIN SR...... 30 XELPROS...... 124 XURIDEN...... 92 WELLBUTRIN XL...... 30 XEMBIFY...... 109 XVITE...... 86 WELLMIND VERTIGO...... 121 XENAZINE...... 59 XYLOCAINE...... 20 wera...... 105 XENICAL...... 59 XYLOCAINE-MPF...... 20 westab max...... 121 XENLETA...... 25 XYNTHA...... 50 westab mini...... 86 XEOMIN...... 121 XYNTHA SOLOFUSE...... 50 westab one...... 86 XEPI...... 25 XYOSTED...... 98 WESTAB PLUS...... 86 XERAC AC...... 72 XYREM...... 136 WESTERN JUNIPER...... 121 XERALUX...... 72 XYWAV...... 136 WESTGEL DHA...... 86 XERESE...... 47 XYZBAC...... 121 WESTHROID...... 105 XERMELO...... 92 XYZMUNE...... 121 WHEAT GERM OIL...... 86 XEROSTOMIA RELIEF YASMIN 28...... 105 WHITE ASH...... 121 SPRAY...... 60 YAZ...... 105 WHITE BIRCH...... 121 XGEVA...... 112 YELLOW DOCK...... 121

173 YELLOW HORNET VENOM ZETONNA...... 131 ZOLINZA...... 41 PROTEIN...... 121 ZEVALIN Y-90...... 41 zolmitriptan...... 35 YELLOW JACKET VENOM ZIAC...... 56 ZOLOFT...... 30 PROTEIN...... 121 ZIAGEN...... 47 ZOLPAK...... 34 YERVOY...... 41 ZIANA...... 72 zolpidem tartrate...... 136 YESCARTA...... 41 zidovudine...... 47 zolpidem tartrate er...... 136 YF-VAX...... 111 ZIEXTENZO...... 50 ZOLPIMIST...... 136 YONDELIS...... 41 ZILACAINE PATCH...... 20 ZOMACTON...... 100 YONSA...... 41 zileuton er...... 134 ZOMACTON (FOR ZOMA-JET YOSPRALA...... 43 ZILRETTA...... 97 10)...... 100 YUPELRI...... 134 ZILXI...... 72 ZOMIG...... 35 YUTIQ...... 123 zinc sulfate...... 86 ZOMIG ZMT...... 35 yuvafem...... 105 ZINGO...... 20 ZONALON...... 72 ZACARE...... 72 ZINPLAVA...... 109 ZONEGRAN...... 28 zaclir cleansing...... 72 ZIONODIL...... 20 zonisamide...... 28 ZADITOR...... 123 ZIONODIL 100...... 20 ZONTIVITY...... 43 zafirlukast...... 134 ZIOPTAN...... 124 ZORBTIVE...... 92 zaleplon...... 136 ziprasidone hcl...... 44 ZORTRESS...... 109 ZALTRAP...... 41 ziprasidone mesylate...... 44 ZORVOLEX...... 17 ZALVIT...... 86 ZIPSOR...... 17 zovia 1/35 (28)...... 105 ZANAFLEX...... 135 ZIRABEV...... 41 zovia 1/35e (28)...... 105 ZANOSAR...... 41 ZIRGAN...... 123 ZOVIRAX...... 47 zarah...... 105 ZITHRANOL...... 72 ZTLIDO...... 20 ZARONTIN...... 28 ZITHROMAX...... 25 ZUBSOLV...... 20 ZARXIO...... 50 ZITHROMAX TRI-PAK...... 25 ZULRESSO...... 30 ZAVESCA...... 92 ZITHROMAX Z-PAK...... 25 zumandimine...... 105 ZCORT 7-DAY...... 97 ZOCOR...... 56 ZUPLENZ...... 31 ZEASORB-AF...... 34 ZOFRAN...... 31 ZYCLARA...... 72 ZEBUTAL...... 14 ZOHYDRO ER...... 14 ZYCLARA PUMP...... 72 ZEGERID...... 87 ZOLADEX...... 100 ZYDELIG...... 41 ZEJULA...... 41 zoledronic acid...... 112 ZYFLO...... 134 ZELAC...... 92 ZOLGENSMA 10.1-10.5 KG..... 92 ZYKADIA...... 41 ZELAPAR...... 43 ZOLGENSMA 10.6-11.0 KG..... 92 ZYLET...... 127 ZELBORAF...... 41 ZOLGENSMA 11.1-11.5 KG..... 92 ZYLOPRIM...... 34 ZELNORM...... 92 ZOLGENSMA 11.6-12.0 KG..... 93 ZYMAXID...... 123 ZEMAIRA...... 134 ZOLGENSMA 12.1-12.5 KG..... 93 ZYPITAMAG...... 56 ZEMBRACE SYMTOUCH...... 35 ZOLGENSMA 12.6-13.0 KG..... 93 ZYPREXA...... 44 ZEMDRI...... 25 ZOLGENSMA 13.1-13.5 KG..... 93 ZYPREXA RELPREVV...... 44 ZEMPLAR...... 112 ZOLGENSMA 2.6-3.0 KG...... 93 ZYPREXA ZYDIS...... 44 zenatane...... 72 ZOLGENSMA 3.1-3.5 KG...... 93 ZYRTEC ALLERGY...... 131 ZENPEP...... 92 ZOLGENSMA 3.6-4.0 KG...... 93 ZYTIGA...... 41 ZENZEDI...... 57 ZOLGENSMA 4.1-4.5 KG...... 93 ZYVEXOL...... 121 ZEPATIER...... 47 ZOLGENSMA 4.6-5.0 KG...... 93 ZYVIT...... 121 ZEPOSIA...... 58 ZOLGENSMA 5.1-5.5 KG...... 93 ZYVOX...... 25 ZEPOSIA 7-DAY STARTER ZOLGENSMA 5.6-6.0 KG...... 93 PACK...... 58 ZOLGENSMA 6.1-6.5 KG...... 93 ZEPOSIA STARTER KIT...... 58 ZOLGENSMA 6.6-7.0 KG...... 93 ZEPZELCA...... 41 ZOLGENSMA 7.1-7.5 KG...... 93 ZERUVIA...... 20 ZOLGENSMA 7.6-8.0 KG...... 93 ZERVIATE...... 123 ZOLGENSMA 8.1-8.5 KG...... 93 ZESTORETIC...... 56 ZOLGENSMA 8.6-9.0 KG...... 93 ZESTRIL...... 56 ZOLGENSMA 9.1-9.5 KG...... 93 ZETIA...... 56 ZOLGENSMA 9.6-10.0 KG...... 93

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

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

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

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If you need help filing a grievance, please call toll-free (855) 828-9834 (TTY 711), 24 hours a day, 7 days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone or mail: Online https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free (800) 868-1019, (800) 537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

English Text: You have the right to get help and information in your language at no cost. To request an interpreter, please call toll-free (855) 828-9834 (TTY 711), 24 hours a day, 7 days a week. This letter is also available in other formats like large print. To request the document in another format, please call toll-free (855) 828-9834 (TTY 711), 24 hours a day, 7 days a week.

-Continued on back- 1 Spanish Tiene derecho a recibir ayuda e información en su idioma sin costo. Para solicitar un intérprete, llame al número de teléfono gratuito para miembros que se encuentra en su tarjeta de identificación del plan de salud y presione 0. TTY 711 2 Vietnamese Quý vị có quyền được giúp đỡ và cấp thông tin bằng ngôn ngữ của quý vị miễn phí. Để yêu cầu được thông dịch viên giúp đỡ, vui lòng gọi số điện thoại miễn phí dành cho hội viên được nêu trên thẻ ID chương trình bảo hiểm y tế của quý vị, bấm số 0. TTY 711 3 Chinese 您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥打您健保計劃會員卡上的免付費會員電話號碼，再按 0。聽力語言殘障服務專線 711 4 Korean 귀하는 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 통역사를 요청하기 위해서는 귀하의 플랜 ID카드에 기재된 무료 회원 전화번호로 전화하여 0번을 누르십시오. TTY 711 ﻟ ك ا ﻟ قﺣ ﻲﻓ لوﺻﺣﻟا ﻰﻠﻋ ةدﻋﺎﺳﻣﻟا تﺎﻣوﻠﻌﻣﻟاو كﺗﻐﻠﺑ نود لﻣﺣﺗ يأ .ﺔﻔﻠﻛﺗ بﻠطﻟ مﺟرﺗﻣ ،يروﻓ لﺻﺗا مﻗرﺑ فﺗﺎﮭﻟا ﻲﻧﺎﺟﻣﻟا Arabic 5 ا ﻟ ﺧ صﺎ ﺑ ﺎ ﺎﺿﻋﻷ ء ا ﻟ ﻣ د جر ﺑ ﺑ ط ﺎ ﻗ ﺔ ُ ﻣ رﻌ ّ ف ا ﻟ ﯾوﺿﻌ ﺔ ا ﺔﺻﺎﺧﻟ كﺗطﺧﺑ ا ﺔﯾﺣﺻﻟ ، و ا ﻐﺿ ط ﻋ ﻠ ﻰ 0 . ا ﻟ ﮭ ﺎ ﺗ ف ا ﻟ ﻧ ﻲﺻ ( TTY ) 711 پآ وﮐ ا ﭘ ﯽﻧ ﺑز نﺎ ںﯾﻣ تﻔﻣ ددﻣ روا تﺎﻣوﻠﻌﻣ لﺻﺎﺣ ﮯﻧرﮐ ﺎﮐ قﺣ ۔ﮯﮨ ﯽﺳﮐ نﺎﻣﺟرﺗ ﮯﺳ ﺑ تﺎ ﮯﻧرﮐ ﮯﮐ ﻟ ،ﮯﺋ لوﭨ یرﻓ Urdu 6 رﺑﻣﻣ نوﻓ رﺑﻣﻧ رﭘ لﺎﮐ ںﯾرﮐ وﺟ پآ ﮯﮐ ﮭﺗﻠﯾﮨ نﻼﭘ ﯽﺋآ یڈ ڈرﺎﮐ رﭘ جرد ،ﮯﮨ 0 د ﺑ ﺎ ﺋ ۔ںﯾ TTY 711 7 Tagalog May karapatan kang makatanggap ng tulong at impormasyon sa iyong wika nang walang bayad. Upang humiling ng tagasalin, tawagan ang toll-free na numero ng telepono na nakalagay sa iyong ID card ng planong pangkalusugan, pindutin ang 0. TTY 711 8 French Vous avez le droit d'obtenir gratuitement de l'aide et des renseignements dans votre langue. Pour demander à parler à un interprète, appelez le numéro de téléphone sans frais figurant sur votre carte d’affilié du régime de soins de santé et appuyez sur la touche 0. ATS 711. 9 Hindi आप के पास अपनी भाषा म- सहायता एवं जानकार6 7न:श:कु ;ा<त करने का अ=धकार है। दभाBषएु के Cलए अनुरोध करने के Cलए, अपने है:थ <लान ID काडH पर सचीबLधू टोल-NO नंबर पर फ़ोन कर-, 0 दबाएं। TTY 711 ﺎﻣﺷ قﺣ د ﯾرا د ﮫﮐ ﮏﻣﮐ و تﺎﻋﻼطا ﺑ ﮫ ﺑز نﺎ دوﺧ ار ﺑ ﮫ روط ار نﺎﮕﯾ ﯾرد ﺎ تﻓ ﺎﻣﻧ ﯾ .دﯾ یارﺑ تﺳاوﺧرد مﺟرﺗﻣ ﻔﺷ ﯽھﺎ ﺑ ﺎ هرﺎﻣﺷ Persian 10 ﺗ ﻠ نﻔ ار نﺎﮕﯾ دﯾﻗ دﺷ ه رد ﮐ ﺎ تر ﻧﺷ ﺎﺳﺎ ﯽﯾ ﻧرﺑ ﺎ ﮫﻣ ﺑ دﮭ ﯽﺗﺷا دوﺧ ﺗ ﻣ سﺎ لﺻﺎﺣ ﻧ دوﻣ ه و 0 ار رﺎﺷﻓ ﯾھد د . Farsi) TTY 711) 11 German Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um einen Dolmetscher anzufordern, rufen Sie die gebührenfreie Nummer auf Ihrer Krankenversicherungskarte an und drücken Sie die 0. TTY 711 12 Gujarati તમને િવના ( ૂ*ય ે મદદ અને તમાર/ ભાષામાં મા3હતી મેળવવાનો અિધકાર છે. ;ુભાિષયા માટ> િવન ંતી કરવા, તમારા હ>*થ @લાન ID કાડC પરની E ૂચ ીમ ા ં આપેલ ટોલ-H/ મેIબર ફોન ન ંબર ઉપર કોલ કરો, ૦ દબાવો. TTY 711 13 Russian Вы имеете право на бесплатное получение помощи и информации на вашем языке. Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона, указанному на обратной стороне вашей идентификационной карты и нажмите 0. Линия TTY 711 14 Japanese ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳をご希望の場合は、医療プランのID カードに記載されているメンバー用のフリーダイヤルまでお電話の上、0を押してください。TTY専用番号は 711です。 15 Laotian ທ່ ານມີ ິສດທີ່ ຈະໄດ້ ຮັ ບການຊ່ ວ ຍ ເ ຫຼ ື ອແລະຂໍ້ ມູ ນຂ່ າວສານທີ່ ເປັ ນພາສາຂອງທ່ ານບໍ່ ມີ ຄ່ າໃຊ້ ຈ່ າຍ. ເພື່ ອຂໍ ຮ້ ອງນາຍພາສາ,ໂທຟຣີ ຫາຫມາຍເລກໂທລະສັ ບສໍ າລັ ບ ສະມາຊິ ກທີ່ ໄດ້ ລະບຸ ໄວ້ ໃນບັ ດສະມາຊິ ກຂອງທ່ ານ,ກົ ດເລກ 0. TTY 711

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