FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option · 1 FEP 5 Tier Managed Rx Drug Formulary...

FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option Effective November 26, 2019

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION ........................................................................................................................................................................................................................ 5 PREFACE ................................................................................................................................................................................................................................... 5 MANAGED NOT COVERED DRUGS ........................................................................................................................................................................................ 6 PRIOR APPROVAL ................................................................................................................................................................................................................... 6 QUANTITY LIMITATIONS ......................................................................................................................................................................................................... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ................................................................................................................................................................ 6 PRODUCT SELECTION CRITERIA .......................................................................................................................................................................................... 6 FORMULARY PRODUCT DESCRIPTIONS .............................................................................................................................................................................. 7 GENERIC SUBSTITUTION ........................................................................................................................................................................................................ 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ......................................................................................................................................................... 8 EDITOR ...................................................................................................................................................................................................................................... 8 NOTICE ...................................................................................................................................................................................................................................... 8 LEGEND ..................................................................................................................................................................................................................................... 8 ANALGESICS ............................................................................................................................................................................................................................ 9

ANALGESICS, OTHER .................................................................................................................................................................................................... 9 NSAIDs ............................................................................................................................................................................................................................. 9 NSAIDs, COMBINATIONS ............................................................................................................................................................................................... 9 NSAIDs, TOPICAL ........................................................................................................................................................................................................... 9 COX-2 INHIBITORS ......................................................................................................................................................................................................... 9 GOUT ............................................................................................................................................................................................................................... 9 OPIOID ANALGESICS ..................................................................................................................................................................................................... 9 NON-OPIOID ANALGESICS ......................................................................................................................................................................................... 10 VISCOSUPPLEMENTS ................................................................................................................................................................................................. 10

ANTI-INFECTIVES ................................................................................................................................................................................................................... 11 ANTIBACTERIALS ......................................................................................................................................................................................................... 11 ANTIFUNGALS .............................................................................................................................................................................................................. 12 ANTIMALARIALS ........................................................................................................................................................................................................... 13 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................ 13 ANTITUBERCULAR AGENTS ....................................................................................................................................................................................... 14 ANTIVIRALS .................................................................................................................................................................................................................. 14 MISCELLANEOUS ......................................................................................................................................................................................................... 15

ANTINEOPLASTIC AGENTS .................................................................................................................................................................................................. 15 ALKYLATING AGENTS ................................................................................................................................................................................................. 15 ANTIMETABOLITES ...................................................................................................................................................................................................... 16 HORMONAL ANTINEOPLASTIC AGENTS................................................................................................................................................................... 16 IMMUNOMODULATORS ............................................................................................................................................................................................... 17 KINASE INHIBITORS .................................................................................................................................................................................................... 17 TOPOISOMERASE INHIBITORS .................................................................................................................................................................................. 18 MISCELLANEOUS ......................................................................................................................................................................................................... 18

CARDIOVASCULAR ................................................................................................................................................................................................................ 20 ACE INHIBITORS .......................................................................................................................................................................................................... 20 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .......................................................................................................................... 20 ACE INHIBITOR/DIURETIC COMBINATIONS .............................................................................................................................................................. 20 ADRENOLYTICS, CENTRAL ........................................................................................................................................................................................ 20 ALDOSTERONE RECEPTOR ANTAGONISTS ............................................................................................................................................................ 20 ALPHA BLOCKERS ....................................................................................................................................................................................................... 20

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ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ............................................................................................................ 21 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................... 21 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ......................................................... 21 ANTIARRHYTHMICS ..................................................................................................................................................................................................... 21 ANTILIPEMICS .............................................................................................................................................................................................................. 21 BETA-BLOCKERS ......................................................................................................................................................................................................... 22 BETA-BLOCKER/DIURETIC COMBINATIONS............................................................................................................................................................. 22 CALCIUM CHANNEL BLOCKERS ................................................................................................................................................................................ 23 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .............................................................................................................................. 23 DIGITALIS GLYCOSIDES ............................................................................................................................................................................................. 23 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ......................................................................................................................................... 23 DIURETICS .................................................................................................................................................................................................................... 23 HEART FAILURE ........................................................................................................................................................................................................... 24 NITRATES ...................................................................................................................................................................................................................... 24 PULMONARY ARTERIAL HYPERTENSION ................................................................................................................................................................ 24 MISCELLANEOUS ......................................................................................................................................................................................................... 24

CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................................. 25 ANTIANXIETY ................................................................................................................................................................................................................ 25 ANTICONVULSANTS .................................................................................................................................................................................................... 25 ANTIDEMENTIA............................................................................................................................................................................................................. 26 ANTIDEPRESSANTS .................................................................................................................................................................................................... 26 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................................... 27 ANTIPSYCHOTICS ........................................................................................................................................................................................................ 27 ATTENTION DEFICIT HYPERACTIVITY DISORDER .................................................................................................................................................. 28 FIBROMYALGIA ............................................................................................................................................................................................................ 29 HYPNOTICS .................................................................................................................................................................................................................. 29 MIGRAINE ...................................................................................................................................................................................................................... 29 MOOD STABILIZERS .................................................................................................................................................................................................... 30 MOVEMENT DISORDERS ............................................................................................................................................................................................ 30 MULTIPLE SCLEROSIS ................................................................................................................................................................................................ 30 MUSCULOSKELETAL THERAPY AGENTS ................................................................................................................................................................. 30 MYASTHENIA GRAVIS ................................................................................................................................................................................................. 30 NARCOLEPSY/CATAPLEXY ........................................................................................................................................................................................ 30 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................................... 30 MISCELLANEOUS ......................................................................................................................................................................................................... 31

ENDOCRINE AND METABOLIC ............................................................................................................................................................................................. 31 ANDROGENS ................................................................................................................................................................................................................ 31 ANTIDIABETICS ............................................................................................................................................................................................................ 32 CALCIUM RECEPTOR ANTAGONISTS ....................................................................................................................................................................... 34 CALCIUM REGULATORS ............................................................................................................................................................................................. 34 CARNITINE DEFICIENCY AGENTS ............................................................................................................................................................................. 34 CONTRACEPTIVES ...................................................................................................................................................................................................... 34 ENDOMETRIOSIS ......................................................................................................................................................................................................... 36 ESTROGENS ................................................................................................................................................................................................................. 36 ESTROGEN/PROGESTINS .......................................................................................................................................................................................... 36 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................................... 37 FERTILITY REGULATORS ........................................................................................................................................................................................... 37 GAUCHER DISEASE ..................................................................................................................................................................................................... 37 GLUCOCORTICOIDS .................................................................................................................................................................................................... 37 GLUCOSE ELEVATING AGENTS ................................................................................................................................................................................. 37 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ......................................................................................................................................................... 37 HUMAN GROWTH HORMONES .................................................................................................................................................................................. 37 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................................... 38 INSULIN-LIKE GROWTH FACTOR-1 AGENTS ............................................................................................................................................................ 38 PHENYLKETONURIA TREATMENT AGENTS ............................................................................................................................................................. 38 PHOSPHATE BINDER AGENTS ................................................................................................................................................................................... 38 POTASSIUM-REMOVING AGENTS ............................................................................................................................................................................. 38 PROGESTINS ................................................................................................................................................................................................................ 38 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................................... 38 THYROID AGENTS ....................................................................................................................................................................................................... 38 UREA CYCLE DISORDERS .......................................................................................................................................................................................... 38 VASOPRESSINS ........................................................................................................................................................................................................... 39 MISCELLANEOUS ......................................................................................................................................................................................................... 39

GASTROINTESTINAL ............................................................................................................................................................................................................. 39 ANTIDIARRHEALS ........................................................................................................................................................................................................ 39

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ANTIEMETICS ............................................................................................................................................................................................................... 40 ANTISPASMODICS ....................................................................................................................................................................................................... 40 CHOLELITHOLYTICS .................................................................................................................................................................................................... 40 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................................... 40 INFLAMMATORY BOWEL DISEASE ............................................................................................................................................................................ 40 IRRITABLE BOWEL SYNDROME ................................................................................................................................................................................. 41 LAXATIVES .................................................................................................................................................................................................................... 41 OPIOID-INDUCED CONSTIPATION ............................................................................................................................................................................. 41 PANCREATIC ENZYMES .............................................................................................................................................................................................. 41 PROSTAGLANDINS ...................................................................................................................................................................................................... 41 PROTON PUMP INHIBITORS ....................................................................................................................................................................................... 41 SALIVA STIMULANTS ................................................................................................................................................................................................... 41 STEROIDS, RECTAL ..................................................................................................................................................................................................... 41 ULCER THERAPY COMBINATIONS ............................................................................................................................................................................ 42 MISCELLANEOUS ......................................................................................................................................................................................................... 42

GENITOURINARY .................................................................................................................................................................................................................... 42 BENIGN PROSTATIC HYPERPLASIA .......................................................................................................................................................................... 42 URINARY ANTISPASMODICS ...................................................................................................................................................................................... 42 VAGINAL ANTI-INFECTIVES ........................................................................................................................................................................................ 42 MISCELLANEOUS ......................................................................................................................................................................................................... 42

HEMATOLOGIC ....................................................................................................................................................................................................................... 43 ANTICOAGULANTS ...................................................................................................................................................................................................... 43 HEMATOPOIETIC GROWTH FACTORS ...................................................................................................................................................................... 43 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .......................................................................................... 43 HEREDITARY ANGIOEDEMA AGENTS ....................................................................................................................................................................... 44 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ........................................................................................................................................ 44 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS .......................................................................................................................... 44 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................................... 44 PLATELET SYNTHESIS INHIBITORS .......................................................................................................................................................................... 44 STEM CELL MOBILIZERS ............................................................................................................................................................................................ 44 THROMBOCYTOPENIA AGENTS ................................................................................................................................................................................ 44 MISCELLANEOUS ......................................................................................................................................................................................................... 45

IMMUNOLOGIC AGENTS ....................................................................................................................................................................................................... 45 ALLERGENIC EXTRACTS ............................................................................................................................................................................................ 45 AUTOIMMUNE AGENTS ............................................................................................................................................................................................... 45 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................................... 45 IMMUNE GLOBULINS ................................................................................................................................................................................................... 45 IMMUNOMODULATORS ............................................................................................................................................................................................... 46 IMMUNOSUPPRESSANTS ........................................................................................................................................................................................... 46

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................................. 47 ELECTROLYTES ........................................................................................................................................................................................................... 47 VITAMINS AND MINERALS .......................................................................................................................................................................................... 47

RESPIRATORY ........................................................................................................................................................................................................................ 47 ANAPHYLAXIS TREATMENT AGENTS ....................................................................................................................................................................... 47 ANTICHOLINERGICS .................................................................................................................................................................................................... 48 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................................. 48 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ......................................................................................................... 48 ANTIHISTAMINES, SEDATING ..................................................................................................................................................................................... 48 ANTITUSSIVES ............................................................................................................................................................................................................. 48 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................................... 48 BETA AGONISTS .......................................................................................................................................................................................................... 48 CYSTIC FIBROSIS ........................................................................................................................................................................................................ 49 LEUKOTRIENE MODULATORS ................................................................................................................................................................................... 49 MAST CELL STABILIZERS ........................................................................................................................................................................................... 49 NASAL ANTIHISTAMINES ............................................................................................................................................................................................ 49 NASAL STEROIDS ........................................................................................................................................................................................................ 49 PHOSPHODIESTERASE-4 INHIBITORS...................................................................................................................................................................... 49 PULMONARY ENZYME DEFICIENCY AGENTS .......................................................................................................................................................... 49 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................................... 49 SEVERE ASTHMA AGENTS ......................................................................................................................................................................................... 49 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................................... 50 STEROID INHALANTS .................................................................................................................................................................................................. 50 XANTHINES ................................................................................................................................................................................................................... 50 MISCELLANEOUS ......................................................................................................................................................................................................... 50

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TOPICAL .................................................................................................................................................................................................................................. 50 DERMATOLOGY ........................................................................................................................................................................................................... 50 MOUTH/THROAT/DENTAL AGENTS ........................................................................................................................................................................... 54 OPHTHALMIC ................................................................................................................................................................................................................ 54 OTIC ............................................................................................................................................................................................................................... 56

WEBSITES ............................................................................................................................................................................................................................... 57 2019 FEP MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART ..................................................................................................................... 59 INDEX ....................................................................................................................................................................................................................................... 64

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The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.

INTRODUCTION

FEP is pleased to provide the 2019 FEP 5 Tier Managed Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Managed Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/ on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.

PREFACE The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Managed Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 generic drugs preferred brand-

name drugs non-preferred brand-name drugs and all compounded medications

preferred specialty drugs

non-preferred specialty drugs

Basic Option Preferred Retail Pharmacy

$10 copay for a 0 to 30-day supply $30 copay for 31 to 90-day supply


60% coinsurance* $65 copay Limit***: one 30-day supply fill at retail

$90 copay Limit***: one 30-day supply fill at retail

Basic Option Specialty Drug Pharmacy Program

$70 for a 0 to 30-day supply $210 for 31 to 90-day supply


Basic Option Retail Pharmacy (Med B Primary)



50% coinsurance** $60 copay Limit***: one 30-day supply fill at retail

$80 copay Limit***: one 30-day supply fill at retail

Basic Option Mail Pharmacy (Med B Primary)

$20 copay $100 copay $125 copay

Basic Option Specialty Drug Pharmacy Program (Med B Primary)



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* With a minimum payment of $75 for a 0 to 30-day supply ($210 for a 31 to 90-day supply) ** With a minimum payment of $60 for a 0 to 30-day supply ($175 for a 31 to 90-day supply)

*** First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication. Drug products shown in boldface type indicate generic availability.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non-preferred, typically if the cost-effectiveness is less than other similar drugs.

MANAGED NOT COVERED DRUGS Effective January 1, 2019, selected medications will no longer be covered on the Basic Option drug benefit plan. These medications known as Managed Not Covered drugs have available covered options in the same therapeutic class. For a full listing of these Managed Not Covered medications please see the MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART located on page 59 before the INDEX in this document.

Patients taking a Managed Not Covered medication on or after January 1, 2019 should expect to pay the full cost of the prescription.

PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page.

QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page.

PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes the evaluation of new medications, and making recommendations to FEP for their designation as preferred or non-preferred on the FEP 5 Tier Managed Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP.

PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

• Safety • Efficacy • Comparison studies • Drug interactions • Approved indications • Formulation and administration • Adverse effects • Contraindications • Pharmacokinetics • Patient compliance considerations • Medical outcome and pharmacoeconomic studies

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When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Managed Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber.

FORMULARY PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted. Preferred products include all strengths and dosage forms of the cited brand-name product. sevelamer carbonate Renvela Oral powder packets, tabs and all strengths of Renvela would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not. acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary. Dosage forms will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry, the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the formulary.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

• Manufactured in the same strength and dosage form as the brand-name drugs.

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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug.

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products.

EDITOR Your comments and suggestions regarding this FEP 5 Tier Managed Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115

NOTICE The information contained in this FEP 5 Tier Managed Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Managed Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Managed Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of FEP. ©2019. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

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

LEGEND † Generic contraceptives are covered at no charge to qualifying members ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for

both brands and generics ST Step Therapy - indicates the requirement for previous use of one or more drugs before coverage is

provided for the targeted drug boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the

listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for

clarification

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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org acetaminophen inj OFIRMEV Tier 3 NSAIDs diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac ext-rel Tier 1 fenoprofen Tier 1 NALFON Tier 3 flurbiprofen Tier 1 ibuprofen Tier 1 indomethacin Tier 1 indomethacin ext-rel Tier 1 ketoprofen Tier 1 ketoprofen ext-rel Tier 1 ketorolac Tier 1 meloxicam Tier 1 MOBIC Tier 3 nabumetone Tier 1 naproxen Tier 1 naproxen sodium Tier 1 naproxen sodium ext-rel Tier 1 oxaprozin Tier 1 DAYPRO Tier 3 piroxicam Tier 1 sulindac Tier 1 ibuprofen inj CALDOLOR Tier 2 indomethacin susp INDOCIN susp Tier 3 PA ketorolac tromethamine nasal spray SPRIX Tier 3 NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1 NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1 VOLTAREN GEL Tier 3 diclofenac sodium soln Tier 1 COX-2 INHIBITORS PA celecoxib Tier 1 CELEBREX Tier 3 GOUT allopurinol Tier 1 ZYLOPRIM Tier 3 colchicine Tier 1 COLCRYS Tier 3 PA febuxostat Tier 1 ULORIC Tier 3 probenecid Tier 1 colchicine MITIGARE Tier 3 PA pegloticase KRYSTEXXA Tier 5

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OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html QL buprenorphine transdermal Tier 1 BUTRANS Tier 3 QL butalbital/acetaminophen/caffeine/codeine Tier 1 FIORICET w/CODEINE Tier 3 QL butalbital/aspirin/caffeine/codeine Tier 1 FIORINAL w/CODEINE Tier 3 QL butorphanol nasal spray Tier 1 QL codeine/acetaminophen Tier 1 TYLENOL w/CODEINE Tier 3 PA fentanyl citrate buccal Tier 1 FENTORA Tier 3 QL fentanyl transdermal Tier 1 DURAGESIC Tier 3 PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3 QL hydrocodone/acetaminophen - Vicodin Tier 1 QL hydrocodone/acetaminophen - Vicodin ES Tier 1 QL hydromorphone Tier 1 DILAUDID Tier 3 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 KADIAN Tier 3 QL morphine ext-rel Tier 1 MS CONTIN Tier 3 QL morphine supp Tier 1 QL oxycodone Tier 1 ROXICODONE Tier 3 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3 QL oxymorphone Tier 1 OPANA Tier 3 QL tramadol Tier 1 ULTRAM Tier 3 QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3 QL tramadol/acetaminophen Tier 1 QL tapentadol NUCYNTA Tier 2 QL tapentadol ext-rel NUCYNTA ER Tier 2 PA fentanyl citrate nasal spray LAZANDA Tier 3 PA fentanyl sublingual spray SUBSYS Tier 3 PA fentanyl sublingual tablets ABSTRAL Tier 3 PA hydrocodone ext-rel caps ZOHYDRO ER Tier 3 PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3 QL morphine ext-rel MORPHABOND Tier 3 QL morphine/naltrexone ext-rel EMBEDA Tier 3 QL oxycodone ext-rel OXYCONTIN Tier 3 QL oxycodone ext-rel XTAMPZA ER Tier 3 QL oxycodone tabs ROXYBOND Tier 3 QL oxycodone/acetaminophen PRIMLEV Tier 3 NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3 QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3 ziconotide PRIALT Tier 4 VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 4 PA sodium hyaluronate GELSYN-3 Tier 4 PA sodium hyaluronate HYALGAN Tier 4

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PA sodium hyaluronate SUPARTZ FX Tier 4 PA high molecular weight hyaluronan HYMOVIS Tier 5 PA high molecular weight hyaluronan ORTHOVISC Tier 5 PA hylan G-F 20 SYNVISC Tier 5 PA hylan G-F 20 SYNVISC-ONE Tier 5 PA sodium hyaluronate DUROLANE Tier 5 PA sodium hyaluronate EUFLEXXA Tier 5 PA sodium hyaluronate MONOVISC Tier 5 ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Cephalosporins First Generation cephalexin Tier 1 KEFLEX Tier 3 Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1 Third Generation cefdinir Tier 1 cefditoren Tier 1 SPECTRACEF Tier 3 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 SUPRAX Tier 2 cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 ceftriaxone Tier 1 ROCEPHIN Tier 3

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Fourth Generation cefepime Tier 1 Fifth Generation ceftaroline fosamil TEFLARO Tier 2 Erythromycins/Macrolides azithromycin Tier 1 ZITHROMAX Tier 3 clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3 erythromycin ethylsuccinate Tier 1 ERYPED Tier 3 erythromycin stearate Tier 1 fidaxomicin DIFICID Tier 2 Fluoroquinolones ciprofloxacin Tier 1 CIPRO Tier 3 levofloxacin Tier 1 LEVAQUIN Tier 3 moxifloxacin Tier 1 AVELOX Tier 3 ofloxacin Tier 1 Penicillins amoxicillin, except film-coated tabs Tier 1 amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3 amoxicillin/clavulanate ext-rel Tier 1 amoxicillin/clavulanate susp 600 mg Tier 1 ampicillin Tier 1 ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3 dicloxacillin Tier 1 penicillin VK Tier 1 piperacillin/tazobactam Tier 1 ZOSYN Tier 3 Tetracyclines doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3 doxycycline monohydrate Tier 1 minocycline Tier 1 MINOCIN Tier 3 minocycline ext-rel Tier 1 SOLODYN Tier 3 tetracycline Tier 1 ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1 DIFLUCAN Tier 3 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 PA itraconazole Tier 1 SPORANOX Tier 3 PA ketoconazole tabs Tier 1 nystatin Tier 1 PA posaconazole delayed-rel tabs Tier 1 NOXAFIL Tier 2 terbinafine tabs Tier 1 QL voriconazole Tier 1 VFEND Tier 3 amphotericin B lipid complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 anidulafungin ERAXIS Tier 2 PA isavuconazonium CRESEMBA Tier 3

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micafungin MYCAMINE Tier 3 ANTIMALARIALS atovaquone/proguanil Tier 1 MALARONE Tier 3 chloroquine Tier 1 mefloquine Tier 1 primaquine Tier 1 artemether/lumefantrine COARTEM Tier 2 PA pyrimethamine DARAPRIM Tier 2 ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants cobicistat TYBOST Tier 2 Antiretroviral Combinations abacavir/lamivudine Tier 1 EPZICOM Tier 3 abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3 lamivudine/zidovudine Tier 1 COMBIVIR Tier 3 abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 atazanavir/cobicistat EVOTAZ Tier 2 bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY Tier 2 darunavir/cobicistat PREZCOBIX Tier 2 darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2 doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2 efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2 emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY Tier 2 emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 2 emtricitabine/tenofovir disoproxil fumarate TRUVADA Tier 2 Chemokine Receptor Antagonists maraviroc SELZENTRY Tier 2 Fusion Inhibitors enfuvirtide FUZEON Tier 4 Integrase Inhibitors dolutegravir TIVICAY Tier 2 raltegravir ISENTRESS Tier 2 Monoclonal Antibody PA ibalizumab-uiyk TROGARZO Tier 5 Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 SUSTIVA Tier 3 nevirapine Tier 1 VIRAMUNE Tier 3 nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3 delavirdine RESCRIPTOR Tier 2 etravirine INTELENCE Tier 2 rilpivirine EDURANT Tier 2 Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 ZIAGEN Tier 3 abacavir soln Tier 1 ZIAGEN soln Tier 3 didanosine delayed-rel Tier 1 VIDEX EC Tier 3

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lamivudine Tier 1 EPIVIR Tier 3 stavudine Tier 1 zidovudine Tier 1 RETROVIR Tier 3 didanosine soln VIDEX soln Tier 2 emtricitabine EMTRIVA Tier 2 Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate VIREAD Tier 2 Protease Inhibitors atazanavir caps Tier 1 REYATAZ Tier 3 fosamprenavir Tier 1 LEXIVA Tier 3 darunavir PREZISTA Tier 2 indinavir CRIXIVAN Tier 2 lopinavir/ritonavir KALETRA Tier 2 nelfinavir VIRACEPT Tier 2 ritonavir NORVIR Tier 2 saquinavir mesylate INVIRASE Tier 2 tipranavir APTIVUS Tier 2 ANTITUBERCULAR AGENTS ethambutol Tier 1 MYAMBUTOL Tier 3 isoniazid Tier 1 pyrazinamide Tier 1 rifampin Tier 1 RIFADIN Tier 3 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 rifapentine PRIFTIN Tier 2 bedaquiline SIRTURO Tier 3 ANTIVIRALS Cytomegalovirus Agents cidofovir Tier 1 VISTIDE Tier 3 PA valganciclovir Tier 1 VALCYTE Tier 3 ganciclovir inj Tier 4 CYTOVENE inj Tier 5 cytomegalovirus immune globulin CYTOGAM Tier 4 PA letermovir PREVYMIS Tier 4 Hepatitis Agents Hepatitis B lamivudine Tier 1 EPIVIR-HBV Tier 3 adefovir dipivoxil Tier 4 HEPSERA Tier 5 entecavir tabs Tier 4 BARACLUDE Tier 5 entecavir soln BARACLUDE soln Tier 4 telbivudine TYZEKA Tier 4 tenofovir alafenamide VEMLIDY Tier 4 Hepatitis C PA ledipasvir/sofosbuvir Tier 4 HARVONI Tier 4 PA ribavirin caps Tier 4 PA ribavirin caps - Ribasphere Tier 4 PA ribavirin tabs Tier 4 PA sofosbuvir/velpatasvir Tier 4 EPCLUSA Tier 4 PA glecaprevir/pibrentasvir MAVYRET Tier 4 PA sofosbuvir SOVALDI Tier 4 PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4

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Herpes Agents acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3 famciclovir Tier 1 valacyclovir Tier 1 VALTREX Tier 3 Influenza Agents QL oseltamivir Tier 1 TAMIFLU Tier 3 rimantadine Tier 1 QL zanamivir RELENZA Tier 2 QL baloxavir XOFLUZA Tier 3 Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 4 MISCELLANEOUS atovaquone Tier 1 MEPRON Tier 3 aztreonam Tier 1 AZACTAM Tier 3 clindamycin Tier 1 CLEOCIN Tier 3 dapsone Tier 1 daptomycin 500 mg Tier 1 CUBICIN Tier 2 ertapenem Tier 1 INVANZ Tier 3 imipenem/cilastatin Tier 1 PRIMAXIN Tier 3 QL linezolid Tier 1 ZYVOX Tier 3 meropenem Tier 1 MERREM Tier 3 methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3 metronidazole tabs Tier 1 FLAGYL Tier 3 nitrofurantoin ext-rel Tier 1 MACROBID Tier 3 nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3 rifabutin Tier 1 MYCOBUTIN Tier 3 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tigecycline Tier 1 TYGACIL Tier 3 tinidazole Tier 1 trimethoprim Tier 1 vancomycin Tier 1 VANCOCIN Tier 3 miltefosine IMPAVIDO Tier 2 nitazoxanide ALINIA Tier 2 QL rifaximin XIFAXAN Tier 2 QL tedizolid SIVEXTRO Tier 2 vancomycin oral soln FIRVANQ Tier 2 secnidazole SOLOSEC Tier 3 telavancin VIBATIV Tier 3 ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS busulfan Tier 1 BUSULFEX Tier 2 ifosfamide/mesna Tier 1 carmustine Tier 4 BICNU Tier 5 cyclophosphamide caps Tier 4 CYCLOPHOSPHAMIDE

CAPSULES Tier 4

cyclophosphamide inj Tier 4 dacarbazine Tier 4 melphalan inj Tier 4 ALKERAN inj Tier 5

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melphalan tabs Tier 4 ALKERAN tabs Tier 5 temozolomide Tier 4 TEMODAR Tier 5 thiotepa Tier 4 busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 lomustine GLEOSTINE Tier 2 PA mechlorethamine gel VALCHLOR Tier 4 streptozocin ZANOSAR Tier 4 PA trabectedin YONDELIS Tier 4 PA bendamustine TREANDA Tier 5 ANTIMETABOLITES mercaptopurine Tier 1 capecitabine Tier 4 XELODA Tier 5 cladribine Tier 4 clofarabine Tier 4 CLOLAR Tier 5 cytarabine Tier 4 floxuridine Tier 4 fludarabine Tier 4 FLUDARA Tier 4 fluorouracil inj Tier 4 gemcitabine inj Tier 4 GEMCITABINE Tier 4 thioguanine TABLOID Tier 2 fluorouracil inj ADRUCIL Tier 4 pemetrexed ALIMTA Tier 4 pentostatin NIPENT Tier 4 pralatrexate FOLOTYN Tier 4 rasburicase ELITEK Tier 4 mercaptopurine susp PURIXAN Tier 5 HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 CASODEX Tier 3 flutamide Tier 1 PA nilutamide Tier 1 NILANDRON Tier 3 PA abiraterone 250 mg Tier 4 ZYTIGA 250 mg Tier 5 PA abiraterone 500 mg ZYTIGA 500 mg Tier 4 PA enzalutamide XTANDI Tier 4 PA abiraterone YONSA Tier 5 PA apalutamide ERLEADA Tier 5 Antiestrogens tamoxifen Tier 1 toremifene Tier 1 FARESTON Tier 3 fulvestrant Tier 4 FASLODEX Tier 5 Aromatase Inhibitors anastrozole Tier 1 ARIMIDEX Tier 3 exemestane Tier 1 AROMASIN Tier 3 letrozole Tier 1 FEMARA Tier 3 Gonadotropin-Releasing Hormone (GnRH) Antagonists PA degarelix acetate FIRMAGON Tier 4 Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 4 PA goserelin acetate ZOLADEX Tier 4 PA histrelin acetate VANTAS Tier 4

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PA leuprolide acetate ELIGARD Tier 4 PA leuprolide acetate LUPRON DEPOT Tier 4 PA triptorelin pamoate TRELSTAR Tier 4 PA triptorelin pamoate TRELSTAR DEPOT Tier 4 PA triptorelin pamoate TRELSTAR LA Tier 4 Progestins megestrol acetate Tier 1 IMMUNOMODULATORS PA lenalidomide REVLIMID Tier 4 PA pembrolizumab KEYTRUDA Tier 4 thalidomide THALOMID Tier 4 PA pomalidomide POMALYST Tier 5 KINASE INHIBITORS PA erlotinib Tier 4 TARCEVA Tier 5 PA imatinib mesylate Tier 4 GLEEVEC Tier 5 temsirolimus Tier 4 TORISEL Tier 5 PA abemaciclib VERZENIO Tier 4 PA acalabrutinib CALQUENCE Tier 4 PA afatinib GILOTRIF Tier 4 PA axitinib INLYTA Tier 4 PA bosutinib BOSULIF Tier 4 PA cabozantinib CABOMETYX Tier 4 PA cabozantinib COMETRIQ Tier 4 PA ceritinib ZYKADIA Tier 4 PA cobimetinib COTELLIC Tier 4 PA crizotinib XALKORI Tier 4 PA dabrafenib TAFINLAR Tier 4 PA dasatinib SPRYCEL Tier 4 PA everolimus AFINITOR Tier 4 PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 4 PA ibrutinib IMBRUVICA Tier 4 PA idelalisib ZYDELIG Tier 4 PA lapatinib TYKERB Tier 4 PA larotrectinib VITRAKVI Tier 4 PA lenvatinib LENVIMA Tier 4 PA midostaurin RYDAPT Tier 4 PA palbociclib IBRANCE Tier 4 PA pazopanib VOTRIENT Tier 4 PA ponatinib ICLUSIG Tier 4 PA regorafenib STIVARGA Tier 4 PA ribociclib KISQALI Tier 4 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4 PA ruxolitinib JAKAFI Tier 4 PA sorafenib NEXAVAR Tier 4 PA sunitinib SUTENT Tier 4 PA trametinib MEKINIST Tier 4 PA vandetanib CAPRELSA Tier 4 PA vemurafenib ZELBORAF Tier 4 PA alectinib ALECENSA Tier 5 PA binimetinib MEKTOVI Tier 5 PA brigatinib ALUNBRIG Tier 5 PA dacomitinib VIZIMPRO Tier 5 PA duvelisib COPIKTRA Tier 5 PA encorafenib BRAFTOVI Tier 5

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PA gefitinib IRESSA Tier 5 PA lorlatinib LORBRENA Tier 5 PA neratinib NERLYNX Tier 5 PA nilotinib TASIGNA Tier 5 PA osimertinib TAGRISSO Tier 5 TOPOISOMERASE INHIBITORS topotecan inj Tier 4 HYCAMTIN inj Tier 5 topotecan HYCAMTIN Tier 4 PA irinotecan liposome inj ONIVYDE Tier 5 MISCELLANEOUS hydroxyurea Tier 1 HYDREA Tier 3 leucovorin calcium Tier 1 amifostine Tier 4 ETHYOL Tier 5 arsenic trioxide Tier 4 TRISENOX Tier 4 azacitidine Tier 4 VIDAZA Tier 5 PA bexarotene caps Tier 4 TARGRETIN caps Tier 5 bleomycin sulfate Tier 4 carboplatin Tier 4 cisplatin Tier 4 dactinomycin Tier 4 COSMEGEN Tier 5 daunorubicin Tier 4 decitabine Tier 4 DACOGEN Tier 5 dexrazoxane Tier 4 TOTECT Tier 5 dexrazoxane Tier 4 ZINECARD Tier 5 docetaxel Tier 4 TAXOTERE Tier 5 doxorubicin Tier 4 doxorubicin liposomal Tier 4 DOXIL Tier 5 epirubicin Tier 4 epirubicin Tier 4 ELLENCE Tier 5 etoposide Tier 4 idarubicin Tier 4 IDAMYCIN PFS Tier 5 ifosfamide Tier 4 IFEX Tier 5 irinotecan Tier 4 CAMPTOSAR Tier 5 levoleucovorin calcium Tier 4 FUSILEV Tier 4 mesna inj Tier 4 MESNEX inj Tier 5 mitomycin Tier 4 mitoxantrone Tier 4 oxaliplatin Tier 4 paclitaxel Tier 4 PA romidepsin Tier 4 ISTODAX Tier 5 teniposide Tier 4 valrubicin Tier 4 VALSTAR Tier 5 vinblastine Tier 4 vincristine Tier 4 vinorelbine Tier 4 NAVELBINE Tier 5 mitotane LYSODREN Tier 2 PA ado-trastuzumab emtansine KADCYLA Tier 4 aldesleukin PROLEUKIN Tier 4 PA alemtuzumab CAMPATH Tier 4 asparaginase ELSPAR Tier 4 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4 PA atezolizumab TECENTRIQ Tier 4 BCG live vaccine TICE BCG Tier 4 PA belinostat BELEODAQ Tier 4 PA bendamustine BENDEKA Tier 4

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PA bevacizumab AVASTIN Tier 4 PA bexarotene gel TARGRETIN gel Tier 4 PA blinatumomab BLINCYTO Tier 4 PA brentuximab vedotin ADCETRIS Tier 4 PA cabazitaxel JEVTANA Tier 4 PA cetuximab ERBITUX Tier 4 PA daratumumab DARZALEX Tier 4 doxorubicin ADRIAMYCIN Tier 4 PA elotuzumab EMPLICITI Tier 4 PA eribulin HALAVEN Tier 4 etoposide phosphate ETOPOPHOS Tier 4 glucarpidase VORAXAZE Tier 4 PA ipilimumab YERVOY Tier 4 ixabepilone IXEMPRA Tier 4 PA ixazomib NINLARO Tier 4 mesna tabs 400 mg MESNEX Tier 4 PA necitumumab PORTRAZZA Tier 4 nelarabine ARRANON Tier 4 PA niraparib ZEJULA Tier 4 PA nivolumab OPDIVO Tier 4 PA obinutuzumab GAZYVA Tier 4 PA ofatumumab ARZERRA Tier 4 PA olaparib LYNPARZA Tier 4 PA omacetaxine mepesuccinate SYNRIBO Tier 4 paclitaxel protein-bound particles ABRAXANE Tier 4 PA panitumumab VECTIBIX Tier 4 pegaspargase ONCASPAR Tier 4 PA pertuzumab PERJETA Tier 4 procarbazine MATULANE Tier 4 PA rucaparib RUBRACA Tier 4 samarium sm 153 lexidronam QUADRAMET Tier 4 PA talazoparib TALZENNA Tier 4 PA talimogene laherparepvec IMLYGIC Tier 4 PA trastuzumab HERCEPTIN Tier 4 PA venetoclax VENCLEXTA Tier 4 PA vincristine sulfate liposomal MARQIBO Tier 4 PA vismodegib ERIVEDGE Tier 4 PA vorinostat ZOLINZA Tier 4 PA ziv-aflibercept ZALTRAP Tier 4 PA avelumab BAVENCIO Tier 5 PA bortezomib VELCADE Tier 5 PA carfilzomib KYPROLIS Tier 5 PA durvalumab IMFINZI Tier 5 PA enasidenib IDHIFA Tier 5 PA gemtuzumab ozogamicin MYLOTARG Tier 5 PA glasdegib DAURISMO Tier 5 PA hydroxyurea SIKLOS Tier 5 PA inotuzumab ozogamicin BESPONSA Tier 5 PA ivosidenib TIBSOVO Tier 5 PA melphalan EVOMELA Tier 5 PA moxetumomab pasudotox-tdfk LUMOXITI Tier 5 PA panobinostat FARYDAK Tier 5 PA ramucirumab CYRAMZA Tier 5 PA rituximab RITUXAN Tier 5 PA sonidegib ODOMZO Tier 5 PA trifluridine/tipiracil LONSURF Tier 5

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CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org benazepril Tier 1 LOTENSIN Tier 3 enalapril Tier 1 VASOTEC Tier 3 fosinopril Tier 1 lisinopril Tier 1 PRINIVIL Tier 3 lisinopril Tier 1 ZESTRIL Tier 3 perindopril Tier 1 quinapril Tier 1 ACCUPRIL Tier 3 ramipril Tier 1 ALTACE Tier 3 trandolapril Tier 1 enalapril oral soln EPANED Tier 3 lisinopril oral soln QBRELIS Tier 3 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine Tier 1 LOTREL Tier 3 trandolapril/verapamil ext-rel Tier 1 TARKA Tier 3 perindopril arginine/amlodipine PRESTALIA Tier 3 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3 captopril/hydrochlorothiazide Tier 1 enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3 quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3 ADRENOLYTICS, CENTRAL clonidine Tier 1 CATAPRES Tier 3 clonidine transdermal Tier 1 CATAPRES-TTS Tier 3 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 INSPRA Tier 3 spironolactone Tier 1 ALDACTONE Tier 3 ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 doxazosin Tier 1 CARDURA Tier 3 prazosin Tier 1 MINIPRESS Tier 3 terazosin Tier 1

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ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 eprosartan Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 BENICAR Tier 3 olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 AZOR Tier 3 amlodipine/telmisartan Tier 1 TWYNSTA Tier 3 amlodipine/valsartan Tier 1 EXFORGE Tier 3 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 EXFORGE HCT Tier 3 olmesartan/amlodipine/hydrochlorothiazide Tier 1 TRIBENZOR Tier 3 ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org amiodarone Tier 1 disopyramide Tier 1 NORPACE Tier 3 flecainide Tier 1 mexiletine Tier 1 propafenone ext-rel Tier 1 RYTHMOL SR Tier 3 quinidine gluconate ext-rel Tier 1 sotalol Tier 1 BETAPACE Tier 3 dofetilide Tier 4 TIKOSYN Tier 5 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2 ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3 colesevelam Tier 1 WELCHOL Tier 3 colestipol Tier 1 COLESTID Tier 3 Cholesterol Absorption Inhibitors ezetimibe Tier 1 ZETIA Tier 3 Fibrates fenofibrate Tier 1 LIPOFEN Tier 3

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fenofibrate Tier 1 TRICOR Tier 3 fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3 gemfibrozil Tier 1 LOPID Tier 3 fenofibrate ANTARA Tier 3 fenofibrate TRIGLIDE Tier 3 HMG-CoA Reductase Inhibitors/Combinations ‡, * atorvastatin Tier 1 ezetimibe/simvastatin Tier 1 ‡, * fluvastatin Tier 1 ‡, * fluvastatin ext-rel Tier 1 ‡, * lovastatin Tier 1 ‡, * pravastatin Tier 1 ‡, * rosuvastatin Tier 1 ‡, * simvastatin Tier 1 * Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID Tier 4 Niacins niacin ext-rel Tier 1 NIASPAN Tier 3 Omega-3 Fatty Acids omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3 icosapent ethyl VASCEPA Tier 3 PCSK9 Inhibitors PA evolocumab REPATHA Tier 4 BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org acebutolol Tier 1 atenolol Tier 1 TENORMIN Tier 3 carvedilol Tier 1 COREG Tier 3 carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3 esmolol Tier 1 BREVIBLOC Tier 3 metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3 metoprolol tartrate Tier 1 LOPRESSOR Tier 3 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 INDERAL LA Tier 3 nebivolol BYSTOLIC Tier 2 penbutolol LEVATOL Tier 3 propranolol ext-rel INNOPRAN XL Tier 3 BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3

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metoprolol/hydrochlorothiazide Tier 1 LOPRESSOR HCT Tier 3 metoprolol succinate ext-rel/hydrochlorothiazide DUTOPROL Tier 3 CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1 NORVASC Tier 3 felodipine ext-rel Tier 1 nicardipine Tier 1 nifedipine ext-rel Tier 1 ADALAT CC Tier 3 nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3 nimodipine Tier 1 NIMOTOP Tier 3 nisoldipine ext-rel Tier 1 SULAR Tier 3 Nondihydropyridines diltiazem Tier 1 CARDIZEM Tier 3 diltiazem ext-rel Tier 1 CARDIZEM CD Tier 3 diltiazem ext-rel Tier 1 TIAZAC Tier 3 verapamil Tier 1 CALAN Tier 3 verapamil ext-rel Tier 1 CALAN SR Tier 3 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1 DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 TEKTURNA Tier 2 aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1 PA dichlorphenamide KEVEYIS Tier 3 Loop Diuretics bumetanide Tier 1 ethacrynic acid Tier 1 EDECRIN Tier 3 furosemide Tier 1 LASIX Tier 3 torsemide Tier 1 Potassium-sparing Diuretics amiloride Tier 1 Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1 Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3 triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3

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triamterene/hydrochlorothiazide 37.5/25 Tier 1 MAXZIDE-25 Tier 3 triamterene/hydrochlorothiazide 50/25 Tier 1 HEART FAILURE isosorbide dinitrate/hydralazine BIDIL Tier 2 PA ivabradine CORLANOR Tier 3 PA sacubitril/valsartan ENTRESTO Tier 3 NITRATES Oral isosorbide dinitrate oral Tier 1 ISORDIL Tier 3 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1 Sublingual/Translingual nitroglycerin lingual spray Tier 1 NITROLINGUAL Tier 3 nitroglycerin sublingual Tier 1 NITROSTAT Tier 3 nitroglycerin sublingual aerosol NITROMIST Tier 3 nitroglycerin sublingual powder GONITRO Tier 3 Transdermal nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3 nitroglycerin ointment NITRO-BID Tier 3 PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan Tier 4 LETAIRIS Tier 5 PA bosentan Tier 4 TRACLEER Tier 5 PA macitentan OPSUMIT Tier 4 Phosphodiesterase Inhibitors PA sildenafil Tier 4 REVATIO Tier 5 PA tadalafil tabs 20 mg Tier 4 ADCIRCA Tier 5 PA tadalafil tabs 20 mg - Alyq Tier 4 Prostacyclin Receptor Agonists PA selexipag UPTRAVI Tier 5 Prostaglandin Vasodilators PA epoprostenol sodium Tier 4 FLOLAN Tier 5 PA treprostinil Tier 4 REMODULIN Tier 5 PA iloprost VENTAVIS Tier 4 PA treprostinil ext-rel ORENITRAM Tier 4 PA epoprostenol VELETRI Tier 5 PA treprostinil TYVASO Tier 5 Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Tier 5 MISCELLANEOUS hydralazine Tier 1 midodrine Tier 1 minoxidil tabs Tier 1 ranolazine ext-rel Tier 1 RANEXA Tier 3 mecamylamine VECAMYL Tier 3 PA droxidopa NORTHERA Tier 5

24

CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines alprazolam Tier 1 XANAX Tier 3 alprazolam ext-rel Tier 1 XANAX XR Tier 3 chlordiazepoxide Tier 1 clonazepam Tier 1 KLONOPIN Tier 3 clorazepate Tier 1 TRANXENE T-TAB Tier 3 diazepam Tier 1 VALIUM Tier 3 lorazepam Tier 1 ATIVAN Tier 3 oxazepam Tier 1 Miscellaneous buspirone Tier 1 clomipramine Tier 1 ANAFRANIL Tier 3 fluvoxamine Tier 1 fluvoxamine ext-rel Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3 ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine Tier 1 TEGRETOL Tier 3 carbamazepine ext-rel Tier 1 CARBATROL Tier 3 carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3 clobazam Tier 1 ONFI Tier 3 diazepam rectal gel Tier 1 DIASTAT Tier 3 divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3 divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3 divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3 ethosuximide Tier 1 ZARONTIN Tier 3 felbamate Tier 1 FELBATOL Tier 3 QL gabapentin Tier 1 NEURONTIN Tier 3 lamotrigine Tier 1 LAMICTAL Tier 3 lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3 lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3 levetiracetam Tier 1 KEPPRA Tier 3 levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3 oxcarbazepine Tier 1 TRILEPTAL Tier 3 phenobarbital Tier 1 phenytoin Tier 1 DILANTIN INFATABS Tier 3 phenytoin sodium extended Tier 1 DILANTIN Tier 3 primidone Tier 1 MYSOLINE Tier 3 tiagabine Tier 1 GABITRIL Tier 3 topiramate Tier 1 TOPAMAX Tier 3 topiramate ext-rel Tier 1 QUDEXY XR Tier 3 valproic acid Tier 1 DEPAKENE Tier 3 zonisamide Tier 1 ZONEGRAN Tier 3 PA vigabatrin Tier 4 SABRIL Tier 5 lacosamide VIMPAT Tier 2 rufinamide BANZEL Tier 2

25

brivaracetam BRIVIACT Tier 3 eslicarbazepine APTIOM Tier 3 oxcarbazepine ext-rel OXTELLAR XR Tier 3 perampanel FYCOMPA Tier 3 topiramate ext-rel TROKENDI XR Tier 3 PA cannabidiol EPIDIOLEX Tier 5 PA stiripentol DIACOMIT Tier 5 ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com donepezil Tier 1 ARICEPT Tier 3 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 RAZADYNE Tier 3 galantamine ext-rel Tier 1 RAZADYNE ER Tier 3 memantine soln Tier 1 memantine tabs Tier 1 NAMENDA tabs Tier 3 rivastigmine Tier 1 rivastigmine transdermal Tier 1 EXELON PATCH Tier 3 ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 NARDIL Tier 3 tranylcypromine Tier 1 PARNATE Tier 3 isocarboxazid MARPLAN Tier 3 selegiline transdermal EMSAM Tier 3 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 CELEXA Tier 3 escitalopram Tier 1 LEXAPRO Tier 3 fluoxetine Tier 1 PROZAC Tier 3 fluoxetine Tier 1 SARAFEM Tier 3 fluoxetine delayed-rel Tier 1 paroxetine HCl Tier 1 PAXIL Tier 3 paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3 sertraline Tier 1 ZOLOFT Tier 3 paroxetine mesylate PEXEVA Tier 3 vilazodone VIIBRYD Tier 3 vortioxetine TRINTELLIX Tier 3 Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 KHEDEZLA Tier 3 desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3 duloxetine delayed-rel Tier 1 CYMBALTA Tier 3 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3 venlafaxine ext-rel tabs Tier 1 levomilnacipran ext-rel FETZIMA Tier 3 Tricyclic Antidepressants (TCAs) amitriptyline Tier 1

26

desipramine Tier 1 NORPRAMIN Tier 3 doxepin Tier 1 imipramine HCl Tier 1 TOFRANIL Tier 3 imipramine pamoate Tier 1 nortriptyline Tier 1 PAMELOR Tier 3 protriptyline Tier 1 Miscellaneous Agents amitriptyline/perphenazine Tier 1 bupropion Tier 1 bupropion ext-rel Tier 1 FORFIVO XL Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3 bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3 mirtazapine Tier 1 REMERON Tier 3 nefazodone Tier 1 trazodone Tier 1 bupropion ext-rel APLENZIN Tier 3 ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com amantadine, except tabs Tier 1 benztropine Tier 1 bromocriptine Tier 1 PARLODEL Tier 3 carbidopa/levodopa Tier 1 SINEMET Tier 3 carbidopa/levodopa ext-rel Tier 1 SINEMET CR Tier 3 carbidopa/levodopa orally disintegrating tabs Tier 1 carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3 diphenhydramine Tier 1 entacapone Tier 1 COMTAN Tier 3 pramipexole Tier 1 MIRAPEX Tier 3 pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3 rasagiline Tier 1 AZILECT Tier 3 ropinirole Tier 1 REQUIP Tier 3 ropinirole ext-rel Tier 1 REQUIP XL Tier 3 selegiline caps Tier 1 tolcapone Tier 1 trihexyphenidyl Tier 1 rotigotine transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 PA amantadine ext-rel GOCOVRI Tier 3 carbidopa/levodopa enteral susp DUOPA Tier 3 carbidopa/levodopa ext-rel RYTARY Tier 3 safinamide XADAGO Tier 3 apomorphine APOKYN Tier 4 ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 ABILIFY Tier 3 aripiprazole orally disintegrating tabs Tier 1 clozapine Tier 1 CLOZARIL Tier 3 clozapine orally disintegrating tabs Tier 1 FAZACLO Tier 3 olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3 olanzapine/fluoxetine Tier 1 SYMBYAX Tier 3 paliperidone ext-rel Tier 1 INVEGA Tier 3 quetiapine Tier 1 SEROQUEL Tier 3

27

quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3 risperidone Tier 1 RISPERDAL Tier 3 risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3 ziprasidone Tier 1 GEODON Tier 3 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3 aripiprazole lauroxil ext-rel inj ARISTADA Tier 3 asenapine SAPHRIS Tier 3 brexpiprazole REXULTI Tier 3 iloperidone FANAPT Tier 3 lurasidone LATUDA Tier 3 PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3 paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3 Miscellaneous fluphenazine Tier 1 haloperidol Tier 1 haloperidol decanoate inj Tier 1 HALDOL DECANOATE 100 Tier 3 haloperidol lactate inj Tier 1 HALDOL Tier 3 loxapine Tier 1 perphenazine Tier 1 thioridazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1 PA pimavanserin NUPLAZID Tier 5 ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org PA amphetamine sulfate Tier 1 EVEKEO Tier 3 PA amphetamine/dextroamphetamine mixed salts Tier 1 ADDERALL Tier 3 PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR Tier 3 atomoxetine Tier 1 STRATTERA Tier 3 clonidine ext-rel Tier 1 KAPVAY Tier 3 PA dexmethylphenidate Tier 1 FOCALIN Tier 3 PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3 PA dextroamphetamine Tier 1 PA dextroamphetamine Tier 1 ZENZEDI Tier 3 PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3 PA dextroamphetamine soln Tier 1 PROCENTRA Tier 3 guanfacine ext-rel Tier 1 INTUNIV Tier 3 PA methamphetamine Tier 1 DESOXYN Tier 3 PA methylphenidate Tier 1 METHYLIN Tier 3 PA methylphenidate Tier 1 RITALIN Tier 3 PA methylphenidate ext-rel Tier 1 PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3 PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3 PA lisdexamfetamine VYVANSE Tier 2 PA amphetamine ext-rel orally disintegrating tabs ADZENYS XR-ODT Tier 3 PA methylphenidate ext-rel caps APTENSIO XR Tier 3 PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3 PA methylphenidate transdermal DAYTRANA Tier 3

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FIBROMYALGIA QL pregabalin Tier 1 LYRICA Tier 2 QL milnacipran SAVELLA Tier 3 HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org Benzodiazepines QL estazolam Tier 1 QL flurazepam Tier 1 QL temazepam Tier 1 RESTORIL Tier 3 QL triazolam Tier 1 quazepam DORAL Tier 3 Nonbenzodiazepines QL eszopiclone Tier 1 QL ramelteon Tier 1 QL zaleplon Tier 1 QL zolpidem Tier 1 QL zolpidem ext-rel Tier 1 butabarbital BUTISOL SODIUM Tier 3 QL suvorexant BELSOMRA Tier 3 QL zolpidem spray ZOLPIMIST Tier 3 PA tasimelteon HETLIOZ Tier 4 Tricyclics doxepin SILENOR Tier 3 MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Ergotamine Derivatives dihydroergotamine inj Tier 1 D.H.E. 45 Tier 3 ergotamine/caffeine Tier 1 CAFERGOT Tier 3 ergotamine/caffeine supp Tier 1 MIGERGOT Tier 1 Monoclonal Antibodies PA erenumab-aooe AIMOVIG Tier 2 PA galcanezumab-gnlm EMGALITY Tier 2 Selective Serotonin Agonists QL almotriptan Tier 1 QL eletriptan Tier 1 RELPAX Tier 3 QL frovatriptan Tier 1 FROVA Tier 3 QL naratriptan Tier 1 AMERGE Tier 3 QL rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3 QL sumatriptan Tier 1 IMITREX Tier 3 QL zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3 QL sumatriptan inj ALSUMA Tier 3 QL zolmitriptan nasal spray ZOMIG Tier 3 Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations QL sumatriptan/naproxen sodium TREXIMET Tier 3

29

Miscellaneous diclofenac potassium packets CAMBIA Tier 3 MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 1 LITHOBID Tier 3 lithium carbonate ext-rel tabs 450 mg Tier 1 carbamazepine EQUETRO Tier 3 MOVEMENT DISORDERS PA tetrabenazine Tier 4 XENAZINE Tier 5 PA deutetrabenazine AUSTEDO Tier 5 MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: https://www.aan.com PA dalfampridine ext-rel Tier 4 AMPYRA Tier 5 PA glatiramer Tier 4 PA glatiramer - Glatopa Tier 4 PA dimethyl fumarate delayed-rel TECFIDERA Tier 4 PA fingolimod GILENYA Tier 4 PA interferon beta-1a AVONEX Tier 4 PA interferon beta-1a REBIF Tier 4 PA interferon beta-1a REBIF REBIDOSE Tier 4 PA interferon beta-1b BETASERON Tier 4 PA natalizumab TYSABRI Tier 4 PA ocrelizumab OCREVUS Tier 4 PA peginterferon beta-1a PLEGRIDY Tier 4 PA peginterferon beta-1a PLEGRIDY PEN Tier 4 PA teriflunomide AUBAGIO Tier 4 PA alemtuzumab LEMTRADA Tier 5 PA interferon beta-1b EXTAVIA Tier 5 MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 LIORESAL INTRATHECAL Tier 2 cyclobenzaprine Tier 1 cyclobenzaprine ext-rel caps Tier 1 dantrolene Tier 1 DANTRIUM Tier 3 MYASTHENIA GRAVIS pyridostigmine Tier 1 MESTINON Tier 3 pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 2 NARCOLEPSY/CATAPLEXY PA armodafinil Tier 1 NUVIGIL Tier 3 PA modafinil Tier 1 PROVIGIL Tier 3 PA sodium oxybate XYREM Tier 2 PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1 ANTABUSE Tier 3 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 4

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Opioid Antagonists naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 1 Partial Opioid Agonists QL buprenorphine Tier 1 PA buprenorphine ext-rel inj SUBLOCADE Tier 5 Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film Tier 1 SUBOXONE FILM Tier 3 QL buprenorphine/naloxone sublingual tabs Tier 1 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2 Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2 Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2 MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 RILUTEK Tier 3 PA edaravone RADICAVA Tier 5 Botulinum Toxins PA abobotulinumtoxinA DYSPORT Tier 4 PA incobotulinumtoxinA XEOMIN Tier 4 PA onabotulinumtoxinA BOTOX Tier 4 PA rimabotulinumtoxinB MYOBLOC Tier 4 Duchenne Muscular Dystrophy PA deflazacort EMFLAZA Tier 5 PA eteplirsen EXONDYS 51 Tier 5 Restless Legs Syndrome QL gabapentin enacarbil ext-rel HORIZANT Tier 3 Tardive Dyskinesia PA valbenazine INGREZZA Tier 5 ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 PA testosterone gel Tier 1 FORTESTA Tier 3 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone buccal STRIANT Tier 3 PA testosterone undecanoate inj AVEED Tier 4

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PA testosterone pellets TESTOPEL Tier 5 ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 1 PRECOSE Tier 3 miglitol Tier 1 GLYSET Tier 3 Amylin Analogs pramlintide SYMLINPEN Tier 2 Biguanides * metformin Tier 1 GLUCOPHAGE Tier 3 metformin ext-rel Tier 1 GLUCOPHAGE XR Tier 3 * Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require PA Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 glyburide/metformin Tier 1 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin Tier 1 linagliptin TRADJENTA Tier 2 sitagliptin phosphate JANUVIA Tier 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations alogliptin/metformin Tier 1 linagliptin/metformin JENTADUETO Tier 2 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2 linagliptin/metformin ext-rel JENTADUETO XR Tier 3 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/pioglitazone Tier 1 Incretin Mimetic Agents dulaglutide TRULICITY Tier 2 liraglutide VICTOZA Tier 2 semaglutide OZEMPIC Tier 2 exenatide BYETTA Tier 3 exenatide ext-rel BYDUREON Tier 3 lixisenatide ADLYXIN Tier 3 Incretin Mimetic Agent/Insulin Combinations PA liraglutide/insulin degludec XULTOPHY Tier 3 PA lixisenatide/insulin glargine SOLIQUA Tier 3 Insulins insulin aspart FIASP Tier 2 insulin aspart FIASP FLEXTOUCH Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2 insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin human HUMULIN R U-500 Tier 2

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OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 insulin degludec TRESIBA Tier 3 insulin glargine LANTUS Tier 3 insulin glargine TOUJEO Tier 3 PA insulin human inhalation powder AFREZZA Tier 3 Insulin Sensitizers pioglitazone Tier 1 ACTOS Tier 3 rosiglitazone AVANDIA Tier 3 Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3 pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 3 Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 1 DUETACT Tier 3 Meglitinides nateglinide Tier 1 STARLIX Tier 3 repaglinide Tier 1 PRANDIN Tier 3 Meglitinide/Biguanide Combinations repaglinide/metformin Tier 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST dapagliflozin FARXIGA Tier 2 ST empagliflozin JARDIANCE Tier 2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST empagliflozin/metformin SYNJARDY Tier 2 ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2 Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations ST dapagliflozin/saxagliptin QTERN Tier 3 ST empagliflozin/linagliptin GLYXAMBI Tier 3 Sulfonylureas glimepiride Tier 1 AMARYL Tier 3 glipizide Tier 1 GLUCOTROL Tier 3 glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3 glyburide Tier 1 glyburide, micronized Tier 1 GLYNASE Tier 3 Supplies PA blood glucose continuous monitoring receivers, sensors,

transmitters FREESTYLE LIBRE

CONTINUOUS GLUCOSE MONITORING SYSTEM

Tier 2

OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin syringes, needles BD INSULIN SYRINGES AND

NEEDLES Tier 2

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OTC lancet device ACCU-CHEK FASTCLIX LANCET DEVICE

Tier 2

OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX

LANCETS Tier 2

OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC urine test strips CHEMSTRIP K URINE KETONE

STRIPS Tier 2

OTC urine test strips CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS

Tier 2

OTC urine test strips CHEMSTRIP UG URINE GLUCOSE STRIPS

Tier 2

PA blood glucose continuous monitoring receivers, sensors, transmitters

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

Tier 3

CALCIUM RECEPTOR ANTAGONISTS PA cinacalcet Tier 4 SENSIPAR Tier 5 CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate Tier 1 FOSAMAX Tier 3 etidronate Tier 1 ibandronate Tier 1 BONIVA Tier 3 risedronate Tier 1 ACTONEL Tier 3 risedronate delayed-rel Tier 1 ATELVIA Tier 3 pamidronate Tier 4 zoledronic acid Tier 4 zoledronic acid Tier 4 RECLAST Tier 5 alendronate/vitamin D3 FOSAMAX PLUS D Tier 3 Calcitonins calcitonin-salmon spray Tier 1 MIACALCIN Tier 3 calcitonin-salmon inj MIACALCIN inj Tier 3 Parathyroid Hormones PA teriparatide FORTEO Tier 4 PA abaloparatide TYMLOS Tier 5 PA parathyroid hormone (recombinant) NATPARA Tier 5 Miscellaneous PA denosumab PROLIA Tier 4 PA denosumab XGEVA Tier 4 CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CARNITOR Tier 3

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CONTRACEPTIVES EE = ethinyl estradiol Monophasic 20 mcg Estrogen † drospirenone/EE 3/20 - Gianvi Tier 1 YAZ Tier 3 † levonorgestrel/EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 LOESTRIN 1/20 Tier 3 † norethindrone acetate/EE 1/20 and iron Tier 1 LOESTRIN FE 1/20 Tier 3 30 mcg Estrogen † desogestrel/EE 0.15/30 Tier 1 † drospirenone/EE 3/30 Tier 1 YASMIN Tier 3 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 LOESTRIN 1.5/30 Tier 3 † norethindrone acetate/EE 1.5/30 and iron Tier 1 LOESTRIN FE 1.5/30 Tier 3 † norgestrel/EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 † norethindrone/EE 0.4/35 Tier 1 † norethindrone/EE 0.5/35 Tier 1 † norethindrone/EE 1/35 Tier 1 ORTHO-NOVUM 1/35 Tier 3 † norgestimate/EE 0.25/35 Tier 1 ORTHO-CYCLEN Tier 3 50 mcg Estrogen † ethynodiol diacetate/EE 1/50 Tier 1 † norgestrel/EE 0.5/50 Tier 1 Biphasic † desogestrel/EE Tier 1 MIRCETTE Tier 3 Triphasic † desogestrel/EE Tier 1 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3 † norethindrone/EE Tier 1 ORTHO-NOVUM 7/7/7 Tier 3 † norethindrone/EE Tier 1 TRI-NORINYL Tier 3 † norgestimate/EE Tier 1 ORTHO TRI-CYCLEN Tier 3 † norgestimate/EE Tier 1 ORTHO TRI-CYCLEN LO Tier 3 Four Phase estradiol valerate and dienogest/estradiol valerate NATAZIA Tier 3 Extended Cycle † levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3 † levonorgestrel/EE 0.15/30 - Jolessa Tier 1 † levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3 Continuous † levonorgestrel/EE 0.09/20 - Amethyst Tier 1 Progestin Only † norethindrone Tier 1 ORTHO MICRONOR Tier 3

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Implant ‡ etonogestrel implant NEXPLANON Tier 4 Injectable † medroxyprogesterone acetate 150 mg/mL Tier 1 DEPO-PROVERA Tier 3 Intrauterine Devices ‡ intrauterine copper contraceptive PARAGARD T 380A Tier 2 ‡ levonorgestrel-releasing IUD KYLEENA Tier 4 ‡ levonorgestrel-releasing IUD MIRENA Tier 4 ‡ levonorgestrel-releasing IUD SKYLA Tier 4 levonorgestrel-releasing IUD LILETTA Tier 5 Transdermal † norelgestromin/EE Tier 1 Vaginal ‡ etonogestrel/EE ring NUVARING Tier 2 ENDOMETRIOSIS danazol Tier 1 PA nafarelin SYNAREL Tier 2 PA elagolix ORILISSA Tier 3 leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4 ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Injectable estradiol valerate Tier 1 DELESTROGEN Tier 2 Oral estradiol Tier 1 ESTRACE Tier 3 estrogens, esterified/methyltestosterone Tier 1 estrogens, conjugated PREMARIN Tier 2 Transdermal estradiol Tier 1 CLIMARA Tier 3 estradiol Tier 1 MINIVELLE Tier 3 estradiol Tier 1 VIVELLE-DOT Tier 3 estradiol transdermal spray EVAMIST Tier 2 estradiol ALORA Tier 3 estradiol transdermal gel ESTROGEL Tier 3 Vaginal estradiol vaginal crm Tier 1 ESTRACE Tier 3 estradiol vaginal tabs Tier 1 VAGIFEM Tier 3 estrogens, conjugated crm PREMARIN crm Tier 2 estradiol vaginal ring FEMRING Tier 3 ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 FEMHRT Tier 3 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3 estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2

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estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2 estradiol/norgestimate PREFEST Tier 3 Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 estradiol/norethindrone acetate COMBIPATCH Tier 3 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene DUAVEE Tier 3 FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic gonadotropin Tier 4 PA ganirelix acetate inj Tier 4 GANIRELIX ACETATE Tier 4 PA gonadorelin LUTREPULSE Tier 2 PA cetrorelix CETROTIDE Tier 4 PA choriogonadotropin alfa OVIDREL Tier 4 PA chorionic gonadotropin NOVAREL Tier 4 PA chorionic gonadotropin PREGNYL Tier 4 PA follitropin beta FOLLISTIM AQ Tier 4 PA menotropins MENOPUR Tier 4 PA follitropin alfa GONAL-F Tier 5 PA follitropin alfa GONAL-F RFF Tier 5 GAUCHER DISEASE PA eliglustat CERDELGA Tier 4 PA imiglucerase CEREZYME Tier 4 GLUCOCORTICOIDS cortisone acetate Tier 1 dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 methylprednisolone Tier 1 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally disintegrating tabs Tier 1 prednisolone syrup Tier 1 prednisone Tier 1 GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGON EMERGENCY KIT Tier 2 diazoxide PROGLYCEM Tier 3 HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 4 ORFADIN Tier 4 HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines PA somatropin NORDITROPIN Tier 4 PA, * somatropin SEROSTIM Tier 4 PA, ** somatropin ZORBTIVE Tier 4 * Indicated for AIDS wasting only ** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support

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HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3 doxercalciferol Tier 1 HECTOROL Tier 3 paricalcitol Tier 1 ZEMPLAR Tier 3 calcifediol ext-rel RAYALDEE Tier 3 INSULIN-LIKE GROWTH FACTOR-1 AGENTS PA mecasermin INCRELEX Tier 4 PHENYLKETONURIA TREATMENT AGENTS PA sapropterin KUVAN Tier 4 PA pegvaliase-pqpz PALYNZIQ Tier 5 PHOSPHATE BINDER AGENTS calcium acetate Tier 1 lanthanum carbonate chew tabs Tier 1 FOSRENOL CHEWABLE

TABLETS Tier 3

sevelamer carbonate Tier 1 RENVELA Tier 3 sevelamer HCl Tier 1 RENAGEL Tier 3 lanthanum oral powder FOSRENOL ORAL POWDER Tier 2 sucroferric oxyhydroxide VELPHORO Tier 3 POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate Tier 1 PA patiromer VELTASSA Tier 3 PA sodium zirconium cyclosilicate LOKELMA Tier 3 PROGESTINS Injectable hydroxyprogesterone caproate Tier 4 MAKENA Tier 5 Oral medroxyprogesterone acetate Tier 1 PROVERA Tier 3 megestrol acetate susp Tier 1 MEGACE ES Tier 3 norethindrone acetate Tier 1 AYGESTIN Tier 3 PA progesterone, micronized Tier 1 PROMETRIUM Tier 3 Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2 SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene Tier 1 EVISTA Tier 3 ospemifene OSPHENA Tier 3 THYROID AGENTS Antithyroid Agents methimazole Tier 1 TAPAZOLE Tier 3 propylthiouracil Tier 1 Thyroid Supplements levothyroxine Tier 1 SYNTHROID Tier 2 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 CYTOMEL Tier 3 thyroid ARMOUR THYROID Tier 3 UREA CYCLE DISORDERS PA sodium phenylbutyrate Tier 4 BUPHENYL Tier 5

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VASOPRESSINS desmopressin spray, tabs Tier 1 DDAVP Tier 3 MISCELLANEOUS acetylcysteine Tier 1 ACETADOTE Tier 3 methylergonovine Tier 1 trientine Tier 1 SYPRINE Tier 3 corticotropin powder Tier 4 PA miglustat Tier 4 ZAVESCA Tier 5 octreotide acetate Tier 4 SANDOSTATIN Tier 5 hydroxocobalamin CYANOKIT Tier 2 prasterone vaginal inserts INTRAROSA Tier 3 PA uridine triacetate XURIDEN Tier 3 PA agalsidase beta FABRAZYME Tier 4 PA alglucosidase alfa LUMIZYME Tier 4 PA asfotase alfa STRENSIQ Tier 4 betaine anhydrous CYSTADANE Tier 4 PA burosumab-twza CRYSVITA Tier 4 PA carglumic acid CARBAGLU Tier 4 cysteamine CYSTAGON Tier 4 PA cysteamine delayed-rel PROCYSBI Tier 4 PA elosulfase alfa VIMIZIM Tier 4 PA galsulfase NAGLAZYME Tier 4 PA glycerol phenylbutyrate RAVICTI Tier 4 PA histrelin acetate SUPPRELIN LA Tier 4 PA idursulfase ELAPRASE Tier 4 PA lanreotide acetate SOMATULINE DEPOT Tier 4 PA laronidase ALDURAZYME Tier 4 PA leuprolide acetate LUPRON DEPOT-PED Tier 4 PA mifepristone KORLYM Tier 4 PA octreotide acetate SANDOSTATIN LAR Tier 4 PA pasireotide SIGNIFOR Tier 4 pegademase, bovine ADAGEN Tier 4 pegvisomant SOMAVERT Tier 4 PA sebelipase alfa KANUMA Tier 4 PA taliglucerase alfa ELELYSO Tier 4 PA tesamorelin EGRIFTA Tier 4 thyrotropin alfa THYROGEN Tier 4 PA tolvaptan JYNARQUE Tier 4 PA tolvaptan SAMSCA Tier 4 PA velaglucerase alfa VPRIV Tier 4 PA vestronidase alfa-vjbk MEPSEVII Tier 4 PA corticotropin ACTHAR Tier 5 PA elapegademase-lvlr REVCOVI Tier 5 PA inotersen TEGSEDI Tier 5 PA metreleptin MYALEPT Tier 5 PA migalastat GALAFOLD Tier 5 PA triptorelin pamoate TRIPTODUR Tier 5 GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS diphenoxylate/atropine Tier 1 LOMOTIL Tier 3 loperamide Tier 1

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crofelemer delayed-rel MYTESI Tier 3 ANTIEMETICS QL aprepitant caps Tier 1 EMEND Tier 3 PA doxylamine/pyridoxine delayed-rel Tier 1 DICLEGIS Tier 3 QL dronabinol Tier 1 MARINOL Tier 3 granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 REGLAN Tier 3 QL ondansetron Tier 1 ZOFRAN Tier 3 QL ondansetron orally disintegrating tabs Tier 1 PA palonosetron Tier 1 ALOXI Tier 3 prochlorperazine Tier 1 promethazine Tier 1 scopolamine transdermal Tier 1 TRANSDERM SCOP Tier 3 trimethobenzamide Tier 1 TIGAN Tier 3 QL granisetron transdermal SANCUSO Tier 2 QL aprepitant CINVANTI Tier 3 QL aprepitant susp EMEND Tier 3 PA granisetron ext-rel inj SUSTOL Tier 3 QL nabilone CESAMET Tier 3 QL netupitant/palonosetron AKYNZEO Tier 3 QL ondansetron oral soluble film ZUPLENZ Tier 3 QL rolapitant VARUBI Tier 3 ANTISPASMODICS d atropine/hyoscyamine/scopolamine/phenobarbital Tier 1 DONNATAL Tier 3 chlordiazepoxide/clidinium Tier 1 dicyclomine Tier 1 BENTYL Tier 3 d hyoscyamine sulfate Tier 1 LEVSIN Tier 3 d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3 propantheline 15 mg Tier 1 CHOLELITHOLYTICS ursodiol Tier 1 ACTIGALL Tier 3 ursodiol Tier 1 URSO Tier 3 ursodiol Tier 1 URSO FORTE Tier 3 H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 * famotidine Tier 1 PEPCID Tier 3 famotidine susp Tier 1 PEPCID susp Tier 3 nizatidine Tier 1 ranitidine Tier 1 ZANTAC Tier 3 * Except 20 mg INFLAMMATORY BOWEL DISEASE Injectable Agents PA vedolizumab ENTYVIO Tier 5 Oral Agents balsalazide Tier 1 COLAZAL Tier 3 budesonide delayed-rel caps Tier 1 ENTOCORT EC Tier 3 mesalamine delayed-rel caps Tier 1 mesalamine delayed-rel tabs Tier 1 LIALDA Tier 3 sulfasalazine Tier 1 AZULFIDINE Tier 3

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sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3 mesalamine ext-rel caps APRISO Tier 2 mesalamine ext-rel caps PENTASA Tier 2 olsalazine DIPENTUM Tier 3 Rectal Agents hydrocortisone enema Tier 1 mesalamine rectal susp Tier 1 ROWASA Tier 3 mesalamine supp Tier 1 CANASA Tier 3 hydrocortisone acetate foam CORTIFOAM Tier 2 IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA linaclotide LINZESS Tier 2 PA lubiprostone AMITIZA Tier 3 Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 LOTRONEX Tier 3 PA eluxadoline VIBERZI Tier 3 LAXATIVES lactulose Tier 1 peg 3350/electrolytes Tier 1 COLYTE Tier 3 peg 3350/electrolytes Tier 1 GOLYTELY Tier 3 peg 3350/electrolytes Tier 1 NULYTELY Tier 3 peg 3350/electrolytes MOVIPREP Tier 2 sodium sulfate/potassium sulfate/magnesium sulfate SUPREP Tier 2 sodium phosphates OSMOPREP Tier 3 sodium picosulfate/magnesium oxide/citric acid PREPOPIK Tier 3 OPIOID-INDUCED CONSTIPATION PA naloxegol MOVANTIK Tier 2 PA methylnaltrexone RELISTOR Tier 3 PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 pancrelipase delayed-rel PANCREAZE Tier 3 PROSTAGLANDINS misoprostol Tier 1 CYTOTEC Tier 3 PROTON PUMP INHIBITORS QL esomeprazole delayed-rel Tier 1 QL lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 QL omeprazole/sodium bicarbonate Tier 1 QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel Tier 1 SALIVA STIMULANTS cevimeline Tier 1 EVOXAC Tier 3 pilocarpine tabs Tier 1 SALAGEN Tier 3 STEROIDS, RECTAL d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2 d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2

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ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + clarithromycin Tier 1 QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2 MISCELLANEOUS cromolyn sodium Tier 1 GASTROCROM Tier 3 sucralfate Tier 1 CARAFATE Tier 3 sucralfate susp CARAFATE susp Tier 2 alvimopan ENTEREG Tier 3 glycopyrrolate CUVPOSA Tier 3 nitroglycerin rectal oint 0.4% RECTIV Tier 3 PA plecanatide TRULANCE Tier 3 dextranomer/sodium hyaluronate SOLESTA Tier 4 PA palifermin KEPIVANCE Tier 4 PA teduglutide GATTEX Tier 4 PA cholic acid CHOLBAM Tier 5 PA obeticholic acid OCALIVA Tier 5 PA telotristat XERMELO Tier 5 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel Tier 1 UROXATRAL Tier 3 dutasteride Tier 1 AVODART Tier 3 dutasteride/tamsulosin Tier 1 finasteride Tier 1 PROSCAR Tier 3 silodosin Tier 1 RAPAFLO Tier 3 PA tadalafil 2.5 mg, 5 mg Tier 1 CIALIS Tier 3 tamsulosin Tier 1 FLOMAX Tier 3 URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 oxybutynin Tier 1 oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3 solifenacin Tier 1 VESICARE Tier 3 tolterodine Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 mirabegron ext-rel MYRBETRIQ Tier 3 VAGINAL ANTI-INFECTIVES metronidazole Tier 1 METROGEL-VAGINAL Tier 3 terconazole crm Tier 1 terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2 MISCELLANEOUS bethanechol Tier 1 URECHOLINE Tier 3 phenazopyridine Tier 1 PYRIDIUM Tier 3 potassium citrate ext-rel Tier 1 UROCIT-K Tier 3 potassium citrate ext-rel 15 mEq Tier 1 UROCIT-K 15 mEq Tier 2 pentosan polysulfate sodium ELMIRON Tier 2

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HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable enoxaparin Tier 1 LOVENOX Tier 3 dalteparin FRAGMIN Tier 2 Oral warfarin Tier 1 COUMADIN Tier 3 apixaban ELIQUIS Tier 2 rivaroxaban XARELTO Tier 2 Synthetic Heparinoid-like Agents fondaparinux Tier 1 ARIXTRA Tier 3 HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines PA darbepoetin alfa ARANESP Tier 4 PA epoetin alfa-epbx RETACRIT Tier 4 PA filgrastim-sndz ZARXIO Tier 4 PA pegfilgrastim-cbqv UDENYCA Tier 4 PA pegfilgrastim-jmdb FULPHILA Tier 4 PA tbo-filgrastim GRANIX Tier 4 PA epoetin alfa EPOGEN Tier 5 PA epoetin alfa PROCRIT Tier 5 PA filgrastim-aafi NIVESTYM Tier 5 PA pegfilgrastim NEULASTA Tier 5 PA sargramostim LEUKINE Tier 5 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org AHF, human/VWF, human HUMATE-P Tier 4 antihemophilic factor ALPHANATE Tier 4 antihemophilic factor HEMOFIL M Tier 4 antihemophilic factor KOATE-DVI Tier 4 antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 4 antihemophilic factor, recombinant ADVATE Tier 4 antihemophilic factor, recombinant AFSTYLA Tier 4 antihemophilic factor, recombinant KOGENATE FS Tier 4 antihemophilic factor, recombinant KOVALTRY Tier 4 antihemophilic factor, recombinant NOVOEIGHT Tier 4 antihemophilic factor, recombinant RECOMBINATE Tier 4 antihemophilic factor, recombinant XYNTHA Tier 4 antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4 anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4 coagulation factor IX (recombinant), glycopegylated REBINYN Tier 4 coagulation factor IX, recombinant IDELVION Tier 4 coagulation factor IX, recombinant IXINITY Tier 4

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coagulation factor VIIa NOVOSEVEN RT Tier 4 coagulation factor X, human COAGADEX Tier 4 desmopressin spray STIMATE Tier 4 emicizumab-kxwh HEMLIBRA Tier 4 factor IX concentrate ALPHANINE SD Tier 4 factor IX concentrate BENEFIX Tier 4 factor IX concentrate MONONINE Tier 4 factor IX concentrate PROFILNINE SD Tier 4 factor IX concentrate RIXUBIS Tier 4 factor IX recombinant, Fc fusion protein ALPROLIX Tier 4 factor XIII A-subunit recombinant TRETTEN Tier 4 factor XIII concentrate CORIFACT Tier 4 fibrinogen RIASTAP Tier 4 human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ Tier 4 von Willebrand factor, recombinant VONVENDI Tier 4 VWF, human/factor VIII complex WILATE Tier 4 antihemophilic factor (recombinant) pegylated ADYNOVATE Tier 5 antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 5 HEREDITARY ANGIOEDEMA AGENTS PA icatibant Tier 4 FIRAZYR Tier 5 PA C1 esterase inhibitor BERINERT Tier 4 PA C1 esterase inhibitor CINRYZE Tier 4 PA ecallantide KALBITOR Tier 4 PA C1 esterase inhibitor HAEGARDA Tier 5 PA C1 esterase inhibitor, recombinant RUCONEST Tier 5 PA lanadelumab-flyo TAKHZYRO Tier 5 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 4 PA romiplostim NPLATE Tier 4 PA fostamatinib TAVALISSE Tier 5 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PA eculizumab SOLIRIS Tier 4 PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 PLAVIX Tier 3 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 AGGRENOX Tier 3 prasugrel Tier 1 EFFIENT Tier 3 abciximab REOPRO Tier 3 PA aspirin ext-rel DURLAZA Tier 3 cangrelor KENGREAL Tier 3 eptifibatide INTEGRILIN Tier 3 ticagrelor BRILINTA Tier 3 tirofiban inj AGGRASTAT Tier 3 vorapaxar ZONTIVITY Tier 3 PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 AGRYLIN Tier 3 STEM CELL MOBILIZERS plerixafor MOZOBIL Tier 4 THROMBOCYTOPENIA AGENTS QL lusutrombopag MULPLETA Tier 5

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MISCELLANEOUS aminocaproic acid Tier 1 AMICAR Tier 3 cilostazol Tier 1 pentoxifylline ext-rel Tier 1 tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3 tranexamic acid Tier 1 LYSTEDA Tier 3 PA deferasirox Tier 4 EXJADE Tier 5 deferoxamine Tier 4 DESFERAL Tier 5 alteplase CATHFLO ACTIVASE Tier 2 PA deferiprone FERRIPROX Tier 4 PA protein C concentrate, human CEPROTIN Tier 4 PA avatrombopag DOPTELET Tier 5 PA deferasirox JADENU Tier 5 IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 5 AUTOIMMUNE AGENTS PA adalimumab HUMIRA Tier 4 PA apremilast OTEZLA Tier 4 PA etanercept ENBREL Tier 4 PA etanercept ENBREL SURECLICK Tier 4 PA abatacept ORENCIA Tier 5 PA anakinra KINERET Tier 5 PA baricitinib OLUMIANT Tier 5 PA brodalumab SILIQ Tier 5 PA certolizumab pegol CIMZIA Tier 5 PA golimumab SIMPONI Tier 5 PA, * infliximab REMICADE PA, * infliximab-abda RENFLEXIS PA, * infliximab-dyyb INFLECTRA PA ixekizumab TALTZ Tier 5 PA sarilumab KEVZARA Tier 5 PA tildrakizumab-asmn ILUMYA Tier 5 PA tocilizumab ACTEMRA Tier 5 PA tofacitinib XELJANZ Tier 5 PA tofacitinib ext-rel XELJANZ XR Tier 5 PA ustekinumab STELARA SUBCUTANEOUS Tier 5 * Medical Benefit only drug DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 PLAQUENIL Tier 3 leflunomide Tier 1 ARAVA Tier 3 methotrexate inj Tier 1 methotrexate oral Tier 1 auranofin RIDAURA Tier 3 PA methotrexate auto-injector RASUVO Tier 3 PA methotrexate inj OTREXUP Tier 3 IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 4

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hepatitis B immune globulin HYPERHEP B S-D Tier 4 hepatitis B immune globulin NABI-HB Tier 4 PA immune globulin (human)-ifas PANZYGA Tier 4 PA immune globulin, gamma GAMASTAN S-D Tier 4 PA immune globulin, gamma GAMUNEX-C Tier 4 PA immune globulin, gamma (IGG) GAMMAKED Tier 4 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4 PA immune globulin, intravenous BIVIGAM Tier 4 PA immune globulin, intravenous FLEBOGAMMA Tier 4 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4 PA immune globulin, intravenous GAMMAGARD S-D Tier 4 PA immune globulin, intravenous OCTAGAM Tier 4 PA immune globulin, intravenous PRIVIGEN Tier 4 PA immune globulin, subcutaneous HIZENTRA Tier 4 PA immune globulin/hyaluronidase HYQVIA Tier 4 Rho (D) immune globulin HYPERRHO S-D Tier 4 Rho (D) immune globulin MICRHOGAM Tier 4 Rho (D) immune globulin MICRHOGAM PLUS Tier 4 Rho (D) immune globulin RHOGAM Tier 4 Rho (D) immune globulin RHOGAM PLUS Tier 4 Rho (D) immune globulin RHOPHYLAC Tier 4 Rho (D) immune globulin WINRHO SDF Tier 4 varicella zoster immune globulin VARIZIG Tier 4 PA immune globulin, subcutaneous CUVITRU Tier 5 IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons PA interferon alfa-2b INTRON A Tier 4 PA interferon gamma-1b, recombinant ACTIMMUNE Tier 4 PA peginterferon alfa-2a PEGASYS Tier 4 PA peginterferon alfa-2b PEGINTRON Tier 4 Miscellaneous bezlotoxumab ZINPLAVA Tier 3 PA canakinumab ILARIS Tier 4 PA rilonacept ARCALYST Tier 4 IMMUNOSUPPRESSANTS Antimetabolites azathioprine Tier 1 IMURAN Tier 3 mycophenolate mofetil Tier 1 CELLCEPT Tier 3 mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 3 Calcineurin Inhibitors cyclosporine Tier 1 SANDIMMUNE Tier 3 cyclosporine, modified Tier 1 NEORAL Tier 3 tacrolimus Tier 1 PROGRAF Tier 3 tacrolimus ext-rel ASTAGRAF XL Tier 2 tacrolimus ext-rel ENVARSUS XR Tier 3

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Rapamycin Derivatives sirolimus Tier 1 RAPAMUNE Tier 3 everolimus ZORTRESS Tier 4 Miscellaneous belatacept NULOJIX Tier 4 PA belimumab BENLYSTA Tier 4 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1 potassium chloride powder Tier 1 VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1 Prenatal Vitamins prenatal vitamins/folic acid DUET DHA Tier 2 prenatal vitamins/folic acid PRENATE ELITE Tier 2 prenatal vitamins/docusate/folic acid CITRANATAL RX Tier 3 prenatal vitamins/folic acid VITAFOL-OB Tier 3 Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 fluoride drops, tabs Tier 1 multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1 phytonadione Tier 1 MEPHYTON Tier 3 sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3 vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1 cyanocobalamin spray NASCOBAL Tier 2 ferumoxytol inj FERAHEME Tier 2 iron sucrose inj VENOFER Tier 2 zinc acetate GALZIN Tier 2 ferric carboxymaltose inj INJECTAFER Tier 3 RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 2 epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 2 epinephrine inj (0.15 mg and 0.30 mg) Tier 1

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ANTICHOLINERGICS ipratropium soln Tier 1 ipratropium, CFC-free aerosol ATROVENT HFA Tier 2 tiotropium SPIRIVA Tier 2 tiotropium SPIRIVA RESPIMAT Tier 2 glycopyrrolate inhalation powder SEEBRI NEOHALER Tier 3 glycopyrrolate inhalation solution LONHALA MAGNAIR Tier 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 2 Long Acting tiotropium/olodaterol STIOLTO RESPIMAT Tier 2 umeclidinium/vilanterol ANORO ELLIPTA Tier 2 glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3 indacaterol/glycopyrrolate inhalation powder UTIBRON NEOHALER Tier 3 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2 ANTIHISTAMINES, SEDATING cyproheptadine Tier 1 diphenhydramine Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 VISTARIL Tier 3 promethazine Tier 1 ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate Tier 1 TESSALON Tier 3 ANTITUSSIVE COMBINATIONS Opioid QL codeine/promethazine Tier 1 QL codeine/promethazine/phenylephrine Tier 1 QL hydrocodone/chlorpheniramine/pseudoephedrine Tier 1 hydrocodone/homatropine Tier 1 BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 2 levalbuterol inhalation soln Tier 1 XOPENEX SOLUTION Tier 3 levalbuterol nebulizer soln concentrate Tier 1 XOPENEX CONCENTRATE Tier 3 levalbuterol tartrate, CFC-free aerosol Tier 1 albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2 Long Acting Hand-held Active Inhalation salmeterol xinafoate SEREVENT DISKUS Tier 2 formoterol inhalation caps FORADIL Tier 3 indacaterol ARCAPTA NEOHALER Tier 3 olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Tier 3

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Nebulized Passive Inhalation arformoterol soln BROVANA Tier 3 formoterol inhalation soln PERFOROMIST Tier 3 Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 metaproterenol Tier 1 terbutaline Tier 1 CYSTIC FIBROSIS tobramycin inhalation soln Tier 4 KITABIS PAK Tier 5 tobramycin inhalation soln Tier 4 TOBI Tier 5 aztreonam lysine inhalation soln CAYSTON Tier 4 PA dornase alfa PULMOZYME Tier 4 PA ivacaftor KALYDECO Tier 4 PA lumacaftor/ivacaftor ORKAMBI Tier 4 PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4 tobramycin inhalation powder TOBI PODHALER Tier 4 tobramycin inhalation soln BETHKIS Tier 4 PA amikacin liposome inhalation susp ARIKAYCE Tier 5 LEUKOTRIENE MODULATORS montelukast Tier 1 SINGULAIR Tier 3 zafirlukast Tier 1 ACCOLATE Tier 3 zileuton ext-rel Tier 1 ZYFLO CR Tier 3 MAST CELL STABILIZERS cromolyn soln Tier 1 NASAL ANTIHISTAMINES azelastine spray Tier 1 azelastine spray Tier 1 ASTEPRO Tier 3 olopatadine spray Tier 1 PATANASE Tier 3 NASAL STEROIDS flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 PHOSPHODIESTERASE-4 INHIBITORS roflumilast DALIRESP Tier 3 PULMONARY ENZYME DEFICIENCY AGENTS PA alpha-1 proteinase inhibitor ARALAST NP Tier 4 PA alpha-1 proteinase inhibitor GLASSIA Tier 4 PA alpha-1 proteinase inhibitor PROLASTIN-C Tier 4 PA alpha-1 proteinase inhibitor ZEMAIRA Tier 4 PULMONARY FIBROSIS AGENTS PA nintedanib OFEV Tier 4 PA pirfenidone ESBRIET Tier 4 SEVERE ASTHMA AGENTS PA omalizumab XOLAIR Tier 4 PA mepolizumab NUCALA Tier 5

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STEROID/BETA AGONIST COMBINATIONS fluticasone/salmeterol Tier 1 ADVAIR Tier 2 fluticasone/salmeterol Tier 1 AIRDUO RESPICLICK Tier 3 budesonide/formoterol SYMBICORT Tier 2 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 2 mometasone/formoterol DULERA Tier 2 STEROID INHALANTS budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3 beclomethasone, CFC-free aerosol QVAR Tier 2 budesonide PULMICORT FLEXHALER Tier 2 fluticasone FLOVENT Tier 2 fluticasone, CFC-free aerosol FLOVENT HFA Tier 2 mometasone ASMANEX Tier 2 mometasone, CFC-free aerosol ASMANEX HFA Tier 2 fluticasone ARNUITY ELLIPTA Tier 3 XANTHINES caffeine citrate Tier 1 CAFCIT Tier 3 theophylline ext-rel tabs Tier 1 theophylline ext-rel caps THEO-24 Tier 2 theophylline liquid ELIXOPHYLLIN Tier 2 MISCELLANEOUS ipratropium nasal spray Tier 1 PA benralizumab FASENRA Tier 5 PA reslizumab inj CINQAIR Tier 5 TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral isotretinoin Tier 1 isotretinoin ABSORICA Tier 3 Topical PA adapalene crm, gel, lotion Tier 1 DIFFERIN Tier 3 PA adapalene/benzoyl peroxide Tier 1 EPIDUO Tier 3 benzoyl peroxide Tier 1 BENZAC AC Tier 3 clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 ACANYA Tier 3 clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 3 clindamycin/benzoyl peroxide Tier 1 DUAC Tier 3 PA clindamycin/tretinoin Tier 1 ZIANA Tier 3 erythromycin gel 2% Tier 1 ERYGEL Tier 3 erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3 PA tazarotene crm 0.1% Tier 1 TAZORAC Tier 3 PA tretinoin Tier 1 ATRALIN Tier 2 PA tretinoin Tier 1 RETIN-A Tier 3 PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3 PA adapalene/benzoyl peroxide EPIDUO FORTE Tier 3

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azelaic acid AZELEX Tier 3 PA clindamycin/tretinoin VELTIN Tier 3 PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3 Actinic Keratosis PA diclofenac sodium gel 3% Tier 1 fluorouracil Tier 1 EFUDEX Tier 3 PA aminolevulinic acid gel 10% AMELUZ Tier 3 PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3 fluorouracil FLUOROPLEX Tier 3 fluorouracil crm 4% TOLAK Tier 3 ingenol mebutate PICATO Tier 3 Antibiotics gentamicin Tier 1 mafenide acetate packets 5% Tier 1 SULFAMYLON Tier 3 mupirocin Tier 1 silver sulfadiazine Tier 1 SILVADENE Tier 3 retapamulin ALTABAX Tier 2 Antifungals ciclopirox Tier 1 clotrimazole Tier 1 clotrimazole/betamethasone Tier 1 econazole Tier 1 ketoconazole Tier 1 miconazole nitrate/zinc oxide Tier 1 naftifine Tier 1 nystatin Tier 1 oxiconazole Tier 1 PA econazole foam ECOZA Tier 3 PA sulconazole EXELDERM Tier 3 Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Injectable PA guselkumab TREMFYA Tier 5 PA secukinumab COSENTYX Tier 5 PA ustekinumab STELARA Tier 5 Oral acitretin Tier 1 methoxsalen oral Tier 1 OXSORALEN-ULTRA Tier 3 Topical betamethasone dipropionate/calcipotriene Tier 1 calcipotriene Tier 1 DOVONEX Tier 3 calcitriol oint Tier 1 VECTICAL Tier 3 calcipotriene/betamethasone foam ENSTILAR Tier 3 Antiseborrheics ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3 selenium sulfide shampoo 2.5% Tier 1

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Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Injectable PA dupilumab DUPIXENT Tier 5 Topical pimecrolimus Tier 1 ELIDEL Tier 3 tacrolimus Tier 1 PROTOPIC Tier 3 PA crisaborole oint EUCRISA Tier 3 Corticosteroids Low Potency alclometasone crm, oint 0.05% Tier 1 desonide crm, lotion, oint 0.05% Tier 1 DESOWEN Tier 3 fluocinolone acetonide soln 0.01% Tier 1 hydrocortisone crm 2.5% Tier 1 hydrocortisone lotion 1% Tier 1 desonide foam 0.05% VERDESO Tier 2 desonide gel 0.05% DESONATE Tier 2 fluocinolone shampoo 0.01% CAPEX Tier 3 pramoxine/hydrocortisone PRAMOSONE Tier 3 Medium Potency betamethasone valerate crm, lotion, oint 0.1% Tier 1 clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3 desoximetasone crm, oint 0.05% Tier 1 TOPICORT LP Tier 3 fluocinolone acetonide crm, oint 0.025% Tier 1 SYNALAR Tier 3 fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3 flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3 fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1 CUTIVATE Tier 3 hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3 hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1 LOCOID Tier 3 hydrocortisone valerate crm, oint 0.2% Tier 1 mometasone crm, lotion, oint 0.1% Tier 1 ELOCON Tier 3 triamcinolone acetonide crm, lotion 0.025% Tier 1 triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 flurandrenolide tape CORDRAN TAPE Tier 2 triamcinolone oint 0.05% TRIANEX Tier 2 hydrocortisone probutate crm 0.1% PANDEL Tier 3 High Potency amcinonide crm, lotion, oint 0.1% Tier 1 betamethasone dipropionate augmented crm 0.05% Tier 1 DIPROLENE AF Tier 3 betamethasone dipropionate augmented lotion 0.05% Tier 1 DIPROLENE Tier 3 betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 TOPICORT Tier 3 diflorasone diacetate crm 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1 triamcinolone acetonide crm 0.5% Tier 1 triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3 betamethasone dipropionate spray 0.05% SERNIVO Tier 3 diflorasone diacetate cream 0.05% PSORCON Tier 3 diflorasone diacetate emollient crm 0.05% APEXICON E Tier 3 halcinonide crm, oint 0.1% HALOG Tier 3

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Very High Potency betamethasone dipropionate augmented gel, oint 0.05% Tier 1 DIPROLENE Tier 3 clobetasol propionate crm, gel, oint, soln 0.05% Tier 1 TEMOVATE Tier 3 clobetasol propionate lotion, shampoo, spray 0.05% Tier 1 CLOBEX Tier 3 diflorasone diacetate oint 0.05% Tier 1 fluocinonide crm 0.1% Tier 1 VANOS Tier 3 halobetasol propionate crm, oint 0.05% Tier 1 ULTRAVATE Tier 3 Emollients ammonium lactate 12% Tier 1 LAC-HYDRIN Tier 3 Local Analgesics QL lidocaine patch Tier 1 LIDODERM Tier 3 capsaicin 8% patch QUTENZA Tier 3 Local Anesthetics QL lidocaine Tier 1 XYLOCAINE Tier 3 QL lidocaine/prilocaine Tier 1 Rosacea azelaic acid gel Tier 1 FINACEA Tier 3 doxycycline monohydrate delayed-rel caps Tier 1 ORACEA Tier 3 metronidazole crm 0.75% Tier 1 METROCREAM Tier 3 metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 METROGEL Tier 3 metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3 sulfacetamide/sulfur Tier 1 PA brimonidine topical gel MIRVASO Tier 3 ivermectin SOOLANTRA Tier 3 PA oxymetazoline crm 1% RHOFADE Tier 3 Scabicides and Pediculicides crotamiton lotion Tier 1 EURAX lotion Tier 2 lindane Tier 1 permethrin 5% Tier 1 spinosad Tier 1 NATROBA Tier 3 crotamiton crm EURAX crm Tier 2 ivermectin SKLICE Tier 2 benzyl alcohol ULESFIA Tier 3 Miscellaneous Skin and Mucous Membrane acyclovir Tier 1 ZOVIRAX Tier 3 QL doxepin crm Tier 1 ZONALON Tier 3 d, PA hydrocortisone/aloe polysaccharide/iodoquinol Tier 1 d, PA hydrocortisone/iodoquinol Tier 1 PA imiquimod Tier 1 ALDARA Tier 3 podofilox Tier 1 CONDYLOX Tier 3 alitretinoin PANRETIN Tier 2 PA becaplermin REGRANEX Tier 2 PA imiquimod ZYCLARA Tier 2 absorbable fibrin sealant TACHOSIL Tier 3 acyclovir/hydrocortisone XERESE Tier 3 sinecatechins VEREGEN Tier 3 PA collagenase clostridium histolyticum XIAFLEX Tier 4 PA interferon alfa-n3 ALFERON N Tier 4

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MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1 Steroids - Mouth/Throat triamcinolone paste Tier 1 Miscellaneous sodium fluoride Tier 1 PREVIDENT Tier 3 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics cromolyn sodium Tier 1 epinastine Tier 1 olopatadine Tier 1 PATADAY Tier 3 olopatadine Tier 1 PATANOL Tier 3 phenylephrine Tier 1 alcaftadine LASTACAFT Tier 3 bepotastine BEPREVE Tier 3 lodoxamide ALOMIDE Tier 3 Antifungals natamycin NATACYN Tier 2 Anti-infectives bacitracin Tier 1 ciprofloxacin Tier 1 CILOXAN Tier 3 erythromycin Tier 1 gentamicin Tier 1 GARAMYCIN Tier 3 levofloxacin Tier 1 moxifloxacin Tier 1 VIGAMOX Tier 3 neomycin/polymyxin B/gramicidin Tier 1 ofloxacin Tier 1 OCUFLOX Tier 3 polymyxin B/bacitracin Tier 1 polymyxin B/trimethoprim Tier 1 POLYTRIM Tier 3 sulfacetamide soln 10% Tier 1 BLEPH-10 Tier 3 tobramycin Tier 1 TOBREX Tier 3 azithromycin AZASITE Tier 2 besifloxacin BESIVANCE Tier 2 moxifloxacin MOXEZA Tier 3 Anti-infective/Anti-inflammatory Combinations neomycin/dexamethasone Tier 1 neomycin/polymyxin B/dexamethasone Tier 1 MAXITROL Tier 3 neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 TOBRADEX SUSPENSION Tier 3 tobramycin/dexamethasone oint 0.3%/0.1% TOBRADEX OINTMENT Tier 2 tobramycin/loteprednol ZYLET Tier 2 gentamicin/prednisolone acetate PRED-G Tier 3 sulfacetamide/prednisolone acetate oint 10%/0.2% BLEPHAMIDE SOP Tier 3

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Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 flurbiprofen Tier 1 ketorolac 0.5% Tier 1 ACULAR Tier 3 bromfenac 0.075% BROMSITE Tier 3 bromfenac sodium 0.07% PROLENSA Tier 3 ketorolac 0.45% ACUVAIL Tier 3 nepafenac NEVANAC Tier 3 nepafenac 0.3% ILEVRO Tier 3 Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 FML Tier 3 loteprednol 0.5% Tier 1 LOTEMAX Tier 2 prednisolone acetate 1% Tier 1 PRED FORTE Tier 3 prednisolone phosphate 1% Tier 1 difluprednate DUREZOL Tier 2 loteprednol 0.2% ALREX Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 rimexolone VEXOL Tier 2 dexamethasone MAXIDEX Tier 3 dexamethasone OZURDEX Tier 3 fluorometholone acetate FLAREX Tier 3 Antivirals trifluridine Tier 1 ganciclovir ZIRGAN Tier 2 Beta-blockers Nonselective carteolol Tier 1 levobunolol Tier 1 timolol maleate Tier 1 ISTALOL Tier 3 timolol maleate Tier 1 TIMOPTIC Tier 3 timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3 timolol hemihydrate BETIMOL Tier 3 Selective betaxolol BETOPTIC S Tier 3 Carbonic Anhydrase Inhibitors Topical dorzolamide Tier 1 TRUSOPT Tier 3 brinzolamide AZOPT Tier 2 Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 COSOPT Tier 3 Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Tier 2 Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA lifitegrast XIIDRA Tier 2

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Mydriatics atropine sulfate soln Tier 1 cyclopentolate Tier 1 CYCLOGYL Tier 3 scopolamine ISOPTO HYOSCINE Tier 2 Neurotrophic Keratitis PA cenegermin-bkbj OXERVATE Tier 4 Parasympathomimetics pilocarpine PILOPINE HS GEL Tier 3 Prostaglandins latanoprost Tier 1 XALATAN Tier 3 travoprost TRAVATAN Z Tier 2 latanoprostene bunod VYZULTA Tier 3 tafluprost ZIOPTAN Tier 3 Retinal Disorders PA aflibercept EYLEA Tier 4 PA ranibizumab LUCENTIS Tier 4 Rho Kinase Inhibitors netarsudil RHOPRESSA Tier 3 Sympathomimetics brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3 brimonidine 0.2% Tier 1 brimonidine 0.1% ALPHAGAN P 0.1% Tier 2 Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Tier 2 Miscellaneous naphazoline Tier 1 cysteamine CYSTARAN Tier 4 PA ocriplasmin JETREA Tier 4 verteporfin VISUDYNE Tier 4 PA pegaptanib sodium MACUGEN Tier 5 OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives acetic acid Tier 1 ciprofloxacin otic Tier 1 CETRAXAL Tier 3 ofloxacin otic Tier 1 Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 neomycin/polymyxin B/hydrocortisone Tier 1 CORTISPORIN OTIC Tier 3 ciprofloxacin/dexamethasone CIPRODEX Tier 2 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2 Miscellaneous fluocinolone acetonide Tier 1 DERMOTIC Tier 3 triethanolamine polypeptide oleate CERUMENEX Tier 3

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WEBSITES Agency for Healthcare Research and Quality https://www.ahrq.gov Alzheimer's Association https://www.alz.org American Academy of Allergy, Asthma and Immunology https://www.aaaai.org American Academy of Child & Adolescent Psychiatry https://www.aacap.org American Academy of Dermatology https://www.aad.org American Academy of Neurology https://www.aan.com American Academy of Ophthalmology https://www.aao.org American Academy of Pediatrics https://www.aap.org American Association for the Study of Liver Disease https://www.aasld.org American Association of Clinical Endocrinologists https://www.aace.com American Association of Diabetes Educators https://www.diabeteseducator.org American Cancer Society https://www.cancer.org American College of Allergy, Asthma and Immunology https://www.acaai.org American College of Cardiology https://www.acc.org American College of Chest Physicians https://www.chestnet.org American College of Gastroenterology https://gi.org American College of Physicians https://www.acponline.org American College of Rheumatology https://www.rheumatology.org

American Congress of Obstetricians and Gynecologists https://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association https://www.gastro.org American Headache Society Committee for Headache Education https://americanheadachesociety.org American Heart Association https://professional.heart.org American Lung Association https://www.lung.org American Medical Association https://www.ama-assn.org American Psychiatric Association https://www.psychiatry.org American Society of Anesthesiologists https://www.asahq.org American Society of Clinical Oncology https://www.asco.org American Society of Interventional Pain Physicians https://www.asipp.org American Urological Association https://www.auanet.org Centers for Disease Control and Prevention https://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS https://www.cdc.gov/hiv/default.html Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm CVS Caremark® https://www.caremark.com The Food and Drug Administration https://www.fda.gov

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Global Initiative for Asthma https://ginasthma.org Infectious Diseases Society of America https://www.idsociety.org Institute for Safe Medication Practices https://www.ismp.org Johns Hopkins AIDS Service https://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International https://www.jdrf.org MedWatch https://www.fda.gov/Safety/MedWatch/default.htm National Agricultural Library https://www.nal.usda.gov National Cancer Institute https://www.cancer.gov/about-cancer National Comprehensive Cancer Network https://www.nccn.org

National Foundation for Infectious Diseases http://www.nfid.org National Guideline Clearinghouse https://www.ahrq.gov National Heart, Lung and Blood Institute https://www.nhlbi.nih.gov National Institutes of Health https://www.nih.gov National Kidney Foundation https://www.kidney.org National Osteoporosis Foundation https://www.nof.org North American Menopause Society https://www.menopause.org United States Department of Health and Human Services https://www.hhs.gov World Health Organization https://www.who.int

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2019 FEP MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART These listed drugs are not covered under Basic Option. If you use any of these Managed Not Covered Drugs, you will need to pay the full cost of the drug(s). If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options. CATEGORY* DRUG CLASS*

DRUGS NOT COVERED IN 2019 FOR BASIC OPTION

COVERED OPTIONS**

ACNE ORAL ANTIBIOTICS

SEYSARA azithromycin, doxycycline (except 20 mg), minocycline, minocycline ext-rel, sulfamethoxazole/trimethoprim, MINOCIN, SOLODYN, VIBRAMYCIN, ZITHROMAX

ALLERGIES ANTIHISTAMINES

cetirizine solution, desloratadine, levocetirizine, CLARINEX, CLARINEX-D, XYZAL

montelukast, zafirlukast, ACCOLATE, SINGULAIR

ALLERGIES NASAL STEROIDS

BECONASE AQ, DYMISTA, NASONEX, OMNARIS, QNASL, RHINOCORT AQUA, VERAMYST, ZETONNA

flunisolide spray, fluticasone spray

ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection/auto-injector (0.15 mg, 0.30 mg), EPIPEN, EPIPEN JR.

ANTICOAGULANTS PRADAXA warfarin, ELIQUIS, XARELTO

ANTIDIARRHEALS opium tincture diphenoxylate/atropine, loperamide

ANTI-INFLAMMATORIES NONSTEROIDAL ANTI-INFLAMMATORIES (NSAIDs)

ANAPROX DS, FELDENE, NAPRELAN, NAPROSYN, PENNSAID 2%, TIVORBEX, VIVLODEX, ZORVOLEX

diclofenac DR/ER, diclofenac gel/soln, etodolac/ER, flurbiprofen, ibuprofen, indomethacin/ER, ketoprofen/ER, meloxicam, nabumetone, naproxen/ER, oxaprozin, piroxicam, sulindac, VOLTAREN GEL

ANTI-INFLAMMATORIES NONSTEROIDAL ANTI-INFLAMMATORIES (NSAIDs) COMBINATIONS

ARTHROTEC, DUEXIS, VIMOVO diclofenac/misoprostol, esomeprazole, famotidine, ibuprofen, naproxen, ranitidine

ANTINEOPLASTIC AGENTS KINASE INHIBITORS

GLEEVEC imatinib mesylate

ANTIRHEUMATICS penicillamine, CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate

ANTISPASMOTICS LIBRAX chlordiazepoxide/clidinium, dicyclomine, hyoscyamine

ASTHMA BETA AGONIST (RESCUE INHALER)

PROVENTIL HFA, VENTOLIN HFA, XOPENEX HFA

albuterol solution, albuterol sulfate CFC-free aerosol, levalbuterol inhalation solution, levalbuterol nebulizer solution concentrate, levalbuterol tartrate CFC-free aerosol, PROAIR HFA, XOPENEX CONCENTRATE, XOPENEX SOLUTION

ASTHMA INHALED CORTICOSTEROID

AEROSPAN, ALVESCO budesonide inhalation suspension, ASMANEX, FLOVENT HFA, PULMICORT, QVAR

BENIGN PROSTATIC HYPERPLASIA (BPH)

JALYN alfuzosin, dutasteride, dutasteride/tamsulosin, finasteride, tamsulosin, AVODART, FLOMAX, PROSCAR, UROXATRAL

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CATEGORY* DRUG CLASS*


COVERED OPTIONS**

BLADDER AGENTS DETROL, DETROL LA, ENABLEX, GELNIQUE, OXYTROL, TOVIAZ

darifenacin ext-rel, oxybutynin, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, VESICARE

CARDIOVASCULAR HEART

aspirin/omeprazole delayed-rel tabs, YOSPRALA

aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

CENTRAL NERVOUS SYSTEM MISCELLANEOUS

JORNAY PM amphetamine sulfate, amphetamine/dextroamphetamine mixed salts/ER, dexmethylphenidate/ER, dextroamphetamine/ER, methylphenidate/ER, ADDERALL, ADDERALL XR, ADZENYS XR-ODT, APTENSIO XR, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, EVEKEO, FOCALIN, FOCALIN XR, METHYLIN, PROCENTRA, QUILLIVANT XR, RITALIN, RITALIN LA, VYVANSE, ZENZEDI

COPD INHALED LONG-ACTING MUSCARINIC RECEPTOR ANTAGONIST (LAMA)

INCRUSE ELLIPTA, TUDORZA PRESSAIR ipratropium, ATROVENT HFA, SPIRIVA

COPD INHALED LONG-ACTING MUSCARINIC RECEPTOR ANTAGONIST (LAMA)/LONG-ACTING BETA AGONIST (LABA) COMBINATIONS

DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT, UTIBRON NEOHALER

CORTICOSTEROIDS CORTEF, DELTASONE, MEDROL, MILLIPRED, ORAPRED ODT, RAYOS, TAPERDEX

cortisone acetate, dexamethasone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone

DERMATOLOGY ANTIFUNGAL

ALCORTIN-A, ERTACZO, JUBLIA, KERYDIN*, LOPROX, LOTRISONE*, LUZU, MENTAX, NAFTIN*, OXISTAT, VUSION*, XOLEGEL*

ciclopirox, clotrimazole, clotrimazole/betamethasone, econazole, hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/aloe, ketoconazole, miconazole nitrate/zinc oxide, naftifine, nystatin, terbinafine tablets, ECOZA, EXELDERM

DERMATOLOGY CORTICOSTEROIDS

halobetasol propionate topical foam, BRYHALI, IMPOYZ, LEXETTE, NOVACORT, OLUX, OLUX-E

betamethasone dipropionate (crm, lotion, oint), betamethasone dipropionate augmented (crm, lotion, gel, oint), clobetasol propionate, diflorasone diacetate, fluocinonide (crm, gel, oint, soln), halobetasol propionate crm, hydrocortisone/pramoxine, triamcinolone acetonide, APEXICON E, CLOBEX, DIPROLENE, DIPROLENE AF, HALOG, KENALOG SPRAY, PRAMOSONE, PSORCON, SERNIVO, TEMOVATE, TOPICORT, ULTRAVATE, VANOS

DERMATOLOGY FLUOROURACIL

CARAC, FLUOROURACIL CREAM 0.5% diclofenac sodium gel 3%, PICATO, TOLAK

DERMATOLOGY IMPETIGO

XEPI CREAM 1% mupirocin cream 2%, mupirocin ointment 2%, ALTABAX OINTMENT 1%

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COVERED OPTIONS**

DERMATOLOGY PSORIASIS

SORIATANE, TACLONEX acitretin, calcipotriene/betamethasone, calcitriol, methoxsalen, DOVONEX, OXSORALEN ULTRA

DERMATOLOGY ROSACEA

NORITATE azelaic acid gel, doxycycline (except 20 mg), flurandrenolide, metronidazole cream/gel/lotion, sulfacetamide/sulfur, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVASO, ORACEA, SOOLANTRA

DIABETES DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS/COMBINATIONS

KAZANO, KOMBIGLYZE XR, NESINA, ONGLYZA, OSENI

alogliptin, alogliptin/metformin, alogliptin/pioglitazone, JANUMET, JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA

DIABETES INSULINS

insulin lispro 100 units/mL, ADMELOG/SOLOSTAR, APIDRA/SOLOSTAR, HUMALOG

NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30

HUMULIN N NOVOLIN N

HUMULIN R NOVOLIN R

NOTE: HUMULIN R U-500 concentrate will continue to be covered

DIABETES METFORMIN

FORTAMET, GLUMETZA, RIOMET GLUCOPHAGE XR (metformin ER)

DIABETES OTHER

CYCLOSET alogliptin, alogliptin/metformin, alogliptin/pioglitazone, bromocriptine mesylate, glimepiride, glipizide, glyburide, glyburide/metformin, pioglitazone, repaglinide, repaglinide/metformin

DIABETES SGLT2 INHIBITORS

INVOKAMET, INVOKAMET XR, INVOKANA, SEGLUROMET, STEGLATRO, STEGLUJAN

FARXIGA, JARDIANCE, SYNJARDY, SYNJARDY XR, XIGDUO XR

GLAUCOMA LUMIGAN latanoprost, TRAVATAN Z, XALATAN, ZIOPTAN

GRANULOCYTE COLONY STIMULATING FACTOR

NEUPOGEN GRANIX, ZARXIO

GROWTH HORMONE GENOTROPIN, HUMATROPE, NUTROPIN, NUTROPIN AQ, OMNITROPE, SAIZEN, ZOMACTON

NORDITROPIN

HEPATITIS C ZEPATIER ledipasvir/sofosbuvir, sofosbuvir/velpatasvir, EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI

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COVERED OPTIONS**

HIGH BLOOD PRESSURE ANGIOTENSIN II RECEPTOR BLOCKERS/COMBINATIONS (ARBs)

ATACAND, ATACAND HCT, AVALIDE, AVAPRO, COZAAR, DIOVAN, DIOVAN HCT, EDARBI, EDARBYCLOR, HYZAAR, MICARDIS, MICARDIS HCT

candesartan, candesartan/HCTZ, irbesartan, irbesartan/HCTZ, losartan, losartan/HCTZ, olmesartan, olmesartan/HCTZ, telmisartan, telmisartan/HCTZ, valsartan, valsartan/HCTZ, BENICAR, BENICAR HCT

HIGH CHOLESTEROL PCSK9 INHIBITORS

PRALUENT REPATHA

HIGH CHOLESTEROL STATINS

ALTOPREV, CADUET, CRESTOR, FLOLIPID, LESCOL/XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, PRAVACHOL, VYTORIN, ZOCOR, ZYPITAMAG

amlodipine/atorvastatin, atorvastatin, ezetimibe/simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

INFLUENZA AGENTS FLUMADINE oseltamivir, rimantadine, RELENZA, TAMIFLU, XOFLUZA

MIGRAINE AGENTS CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS

AJOVY AIMOVIG, EMGALITY

MOVEMENT DISORDERS OSMOLEX ER, TASMAR amantadine IR, benztropine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, rasagiline, ropinirole/ER, selegiline, tolcapone, APOKYN, AZILECT, COMTAN, DUOPA, GOCOVRI, MIRAPEX, MIRAPEX XR, NEUPRO, PARLODEL, REQUIP, REQUIP XL, RYTARY, SINEMET, SINEMET CR, STALEVO, XADAGO, ZELAPAR

MULTIPLE SCLEROSIS COPAXONE glatiramer, GLATOPA

MUSCLE RELAXANTS AMRIX baclofen, cyclobenzaprine, dantrolene

NAUSEA AND VOMITING THERAPY (5HT-3 BLOCKER)

ANZEMET granisetron, ondansetron, palonosetron, promethazine

NAUSEA AND VOMITING PREGNANCY

BONJESTA doxylamine§, doxylamine/pyridoxine delayed-rel, pyridoxine (vitamin B6)§, DICLEGIS, UNISOM§

OPHTHALMOLOGY MISCELLANEOUS

atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate ophthalmic solution, homatropine ophthalmic solution

PAIN MEDICATIONS NEUROPATHIC PAIN

LYRICA CR gabapentin, HORIZANT, LYRICA, NEURONTIN

PAIN MEDICATIONS OPIOIDS

benzhydrocodone/acetaminophen, APADAZ, NALOCET

codeine/acetaminophen, hydrocodone/acetaminophen, oxycodone/acetaminophen, tramadol/acetaminophen, ENDOCET, LORCET, LORCET HD, LORTAB, NORCO, PERCOCET, PRIMLEV, VICODIN, VICODIN ES, VICODIN HP

62



COVERED OPTIONS**

PAIN MEDICATIONS TOPICAL

ZTLIDO lidocaine cream, lidocaine gel, lidocaine lotion, lidocaine ointment, lidocaine patch 5%, LIDODERM PATCH, QUTENZA PATCH, XYLOCAINE

PANCREATIC ENZYMES PERTZYE, ZENPEP CREON, PANCREAZE, VIOKACE

PROTON PUMP INHIBITORS ACIPHEX, DEXILANT, FIRST-LANSOPRAZOLE, NEXIUM, PREVACID, PRILOSEC, PROTONIX, ZEGERID

esomeprazole, lansoprazole, omeprazole, omeprazole/sodium bicarbonate, pantoprazole, rabeprazole

SLEEP AGENTS AMBIEN, AMBIEN CR, EDLUAR, INTERMEZZO, LUNESTA, ROZEREM, SECONAL, SONATA

estazolam, eszopiclone, flurazepam, ramelteon, temazepam, triazolam, zaleplon, zolpidem/ER, BELSOMRA, ZOLPIMIST

TESTOSTERONE AGENTS ANDROGEL, NATESTO, TESTIM, VOGELXO

testosterone gel, ANDRODERM, FORTESTA

ULCERATIVE COLITIS ASACOL HD, DELZICOL balsalazide, budesonide caps, mesalamine, mesalamine delayed-rel caps, sulfasalazine, APRISO, LIALDA, PENTASA

*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. **For more covered options, consult 2019 Basic Option formulary. ***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 12 through 79 and for pregnant women at risk of preeclampsia. § denotes over-the-counter (OTC) availability only, and not covered through the prescription benefit.

63

INDEX

A abacavir, 13 abacavir soln, 13 abacavir/dolutegravir/lamivudine, 13 abacavir/lamivudine, 13 abacavir/lamivudine/zidovudine, 13 abaloparatide, 34 abatacept, 45 abciximab, 44 ABELCET, 12 abemaciclib, 17 ABILIFY, 27 ABILIFY MAINTENA, 28 abiraterone, 16 abiraterone 250 mg, 16 abiraterone 500 mg, 16 abobotulinumtoxinA, 31 ABRAXANE, 19 absorbable fibrin sealant, 53 ABSORICA, 50 ABSTRAL, 10 acalabrutinib, 17 acamprosate calcium, 30 ACANYA, 50 acarbose, 32 ACCOLATE, 49 ACCU-CHEK FASTCLIX LANCET DEVICE, 34 ACCU-CHEK FASTCLIX LANCETS, 34 ACCU-CHEK METERS AND KITS, 33 ACCU-CHEK TEST STRIPS, 33 ACCUPRIL, 20 ACCURETIC, 20 acebutolol, 22 ACETADOTE, 39 acetaminophen inj, 9 acetazolamide, 23 acetazolamide ext-rel, 23 acetic acid, 56 acetic acid/hydrocortisone, 56 acetylcysteine, 39 acitretin, 51 ACTEMRA, 45 ACTHAR, 39 ACTIGALL, 40 ACTIMMUNE, 46 ACTIQ, 10 ACTIVELLA, 36 ACTONEL, 34 ACTOPLUS MET, 33 ACTOPLUS MET XR, 33 ACTOS, 33 ACULAR, 55 ACUVAIL, 55 acyclovir, 53 acyclovir caps, susp, tabs, 15 acyclovir/hydrocortisone, 53 ADAGEN, 39 ADALAT CC, 23 adalimumab, 45 adapalene crm, gel, lotion, 50 adapalene/benzoyl peroxide, 50 ADCETRIS, 19

ADCIRCA, 24 ADDERALL, 28 ADDERALL XR, 28 adefovir dipivoxil, 14 ADEMPAS, 24 ADLYXIN, 32 ado-trastuzumab emtansine, 18 ADRIAMYCIN, 19 ADRUCIL, 16 ADVAIR, 50 ADVAIR HFA, 50 ADVATE, 43 ADYNOVATE, 44 ADZENYS XR-ODT, 28 afatinib, 17 AFINITOR, 17 AFINITOR DISPERZ, 17 aflibercept, 56 AFREZZA, 33 AFSTYLA, 43 agalsidase beta, 39 AGGRASTAT, 44 AGGRENOX, 44 AGRYLIN, 44 AHF, human/VWF, human, 43 AIMOVIG, 29 AIRDUO RESPICLICK, 50 AKYNZEO, 40 albuterol, 49 albuterol ext-rel, 49 albuterol soln, 48 albuterol sulfate aerosol powder breath-activated, 48 albuterol sulfate, CFC-free aerosol, 48 alcaftadine, 54 alclometasone crm, oint 0.05%, 52 ALDACTAZIDE, 23 ALDACTONE, 20 ALDARA, 53 aldesleukin, 18 ALDURAZYME, 39 ALECENSA, 17 alectinib, 17 alemtuzumab, 18, 30 alendronate, 34 alendronate/vitamin D3, 34 ALFERON N, 53 alfuzosin ext-rel, 42 alglucosidase alfa, 39 ALIMTA, 16 ALINIA, 15 aliskiren, 23 aliskiren/hydrochlorothiazide, 23 alitretinoin, 53 ALKERAN inj, 15 ALKERAN tabs, 16 allopurinol, 9 almotriptan, 29 alogliptin, 32 alogliptin/metformin, 32 alogliptin/pioglitazone, 32 ALOMIDE, 54 ALORA, 36 alosetron, 41

64

ALOXI, 40 alpha-1 proteinase inhibitor, 49 ALPHAGAN P 0.1%, 56 ALPHAGAN P 0.15%, 56 ALPHANATE, 43 ALPHANINE SD, 44 alprazolam, 25 alprazolam ext-rel, 25 ALPROLIX, 44 ALREX, 55 ALSUMA, 29 ALTABAX, 51 ALTACE, 20 alteplase, 45 ALUNBRIG, 17 alvimopan, 42 amantadine ext-rel, 27 amantadine, except tabs, 27 AMARYL, 33 AMBISOME, 12 ambrisentan, 24 amcinonide crm, lotion, oint 0.1%, 52 AMELUZ, 51 AMERGE, 29 AMICAR, 45 amifostine, 18 amikacin liposome inhalation susp, 49 amiloride, 23 amiloride/hydrochlorothiazide, 23 aminocaproic acid, 45 aminolevulinic acid gel 10%, 51 aminolevulinic acid soln, 51 amiodarone, 21 AMITIZA, 41 amitriptyline, 26 amitriptyline/perphenazine, 27 amlodipine, 23 amlodipine/atorvastatin, 23 amlodipine/olmesartan, 21 amlodipine/telmisartan, 21 amlodipine/valsartan, 21 amlodipine/valsartan/hydrochlorothiazide, 21 ammonium lactate 12%, 53 amoxicillin, except film-coated tabs, 12 amoxicillin/clavulanate, 12 amoxicillin/clavulanate ext-rel, 12 amoxicillin/clavulanate susp 600 mg, 12 amphetamine ext-rel orally disintegrating tabs, 28 amphetamine sulfate, 28 amphetamine/dextroamphetamine mixed salts, 28 amphetamine/dextroamphetamine mixed salts ext-rel, 28 amphotericin B lipid complex inj, 12 amphotericin B liposome inj, 12 ampicillin, 12 ampicillin sodium/sulbactam sodium, 12 AMPYRA, 30 ANAFRANIL, 25 anagrelide, 44 anakinra, 45 anastrozole, 16 ANDRODERM, 31 anidulafungin, 12 ANORO ELLIPTA, 48 ANTABUSE, 30 ANTARA, 22 antihemophilic factor, 43

antihemophilic factor (recombinant) pegylated, 44 antihemophilic factor (recombinant) pegylated-aucl, 44 antihemophilic factor recombinant, Fc fusion protein, 43 antihemophilic factor, recombinant, 43 anti-inhibitor coagulant complex, 43 apalutamide, 16 APEXICON E, 52 apixaban, 43 APLENZIN, 27 APOKYN, 27 apomorphine, 27 apremilast, 45 aprepitant, 40 aprepitant caps, 40 aprepitant susp, 40 APRISO, 41 APTENSIO XR, 28 APTIOM, 26 APTIVUS, 14 ARALAST NP, 49 ARANESP, 43 ARAVA, 45 ARCALYST, 46 ARCAPTA NEOHALER, 48 arformoterol soln, 49 ARICEPT, 26 ARIKAYCE, 49 ARIMIDEX, 16 aripiprazole, 27 aripiprazole ext-rel inj, 28 aripiprazole lauroxil ext-rel inj, 28 aripiprazole orally disintegrating tabs, 27 ARISTADA, 28 ARIXTRA, 43 armodafinil, 30 ARMOUR THYROID, 38 ARNUITY ELLIPTA, 50 AROMASIN, 16 ARRANON, 19 arsenic trioxide, 18 artemether/lumefantrine, 13 ARZERRA, 19 asenapine, 28 asfotase alfa, 39 ASMANEX, 50 ASMANEX HFA, 50 asparaginase, 18 asparaginase Erwinia chrysanthemi, 18 aspirin ext-rel, 44 ASTAGRAF XL, 46 ASTEPRO, 49 atazanavir caps, 14 atazanavir/cobicistat, 13 ATELVIA, 34 atenolol, 22 atenolol/chlorthalidone, 22 atezolizumab, 18 ATIVAN, 25 atomoxetine, 28 atorvastatin, 22 atovaquone, 15 atovaquone/proguanil, 13 ATRALIN, 50 ATRIPLA, 13 atropine sulfate soln, 56 atropine/hyoscyamine/scopolamine/phenobarbital, 40

65

ATROVENT HFA, 48 AUBAGIO, 30 AUGMENTIN, 12 auranofin, 45 AUSTEDO, 30 AVANDIA, 33 AVASTIN, 19 avatrombopag, 45 AVEED, 31 AVELOX, 12 avelumab, 19 AVODART, 42 AVONEX, 30 axitinib, 17 AYGESTIN, 38 azacitidine, 18 AZACTAM, 15 AZASITE, 54 azathioprine, 46 azelaic acid, 51 azelaic acid gel, 53 azelastine spray, 49 AZELEX, 51 AZILECT, 27 azithromycin, 12, 54 AZOPT, 55 AZOR, 21 aztreonam, 15 aztreonam lysine inhalation soln, 49 AZULFIDINE, 40 AZULFIDINE EN-TABS, 41 B bacitracin, 54 baclofen, 30 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 30 baloxavir, 15 balsalazide, 40 BANZEL, 25 BARACLUDE, 14 BARACLUDE soln, 14 baricitinib, 45 BASAGLAR, 32 BAVENCIO, 19 BCG live vaccine, 18 BD INSULIN SYRINGES AND NEEDLES, 33 becaplermin, 53 beclomethasone, CFC-free aerosol, 50 bedaquiline, 14 belatacept, 47 BELEODAQ, 18 belimumab, 47 belinostat, 18 BELSOMRA, 29 benazepril, 20 benazepril/amlodipine, 20 benazepril/hydrochlorothiazide, 20 bendamustine, 16, 18 BENDEKA, 18 BENEFIX, 44 BENICAR, 21 BENICAR HCT, 21 BENLYSTA, 47 benralizumab, 50 BENTYL, 40 BENZAC AC, 50

BENZACLIN, 50 BENZAMYCIN, 50 benzonatate, 48 benzoyl peroxide, 50 benztropine, 27 benzyl alcohol, 53 bepotastine, 54 BEPREVE, 54 BERINERT, 44 besifloxacin, 54 BESIVANCE, 54 BESPONSA, 19 betaine anhydrous, 39 betamethasone dipropionate augmented crm 0.05%, 52 betamethasone dipropionate augmented gel, oint 0.05%, 53 betamethasone dipropionate augmented lotion 0.05%, 52 betamethasone dipropionate crm, lotion, oint 0.05%, 52 betamethasone dipropionate spray 0.05%, 52 betamethasone dipropionate/calcipotriene, 51 betamethasone valerate crm, lotion, oint 0.1%, 52 BETAPACE, 21 BETASERON, 30 betaxolol, 55 bethanechol, 42 BETHKIS, 49 BETIMOL, 55 BETOPTIC S, 55 bevacizumab, 19 BEVESPI AEROSPHERE, 48 bexarotene caps, 18 bexarotene gel, 19 bezlotoxumab, 46 bicalutamide, 16 BICNU, 15 bictegravir/emtricitabine/tenofovir alafenamide, 13 BIDIL, 24 BIKTARVY, 13 binimetinib, 17 bismuth subsalicylate + metronidazole + tetracycline, 42 bisoprolol/hydrochlorothiazide, 22 BIVIGAM, 46 bleomycin sulfate, 18 BLEPH-10, 54 BLEPHAMIDE SOP, 54 blinatumomab, 19 BLINCYTO, 19 blood glucose continuous monitoring receivers, sensors, transmitters,

33, 34 blood glucose meters and kits, 33 blood glucose test strips, 33 BONIVA, 34 bortezomib, 19 bosentan, 24 BOSULIF, 17 bosutinib, 17 BOTOX, 31 BRAFTOVI, 17 brentuximab vedotin, 19 BREO ELLIPTA, 50 BREVIBLOC, 22 brexpiprazole, 28 brigatinib, 17 BRILINTA, 44 brimonidine 0.1%, 56 brimonidine 0.15%, 56 brimonidine 0.2%, 56

66

brimonidine topical gel, 53 brimonidine/timolol, 56 brinzolamide, 55 brinzolamide/brimonidine, 55 brivaracetam, 26 BRIVIACT, 26 brodalumab, 45 bromfenac 0.075%, 55 bromfenac sodium, 55 bromfenac sodium 0.07%, 55 bromocriptine, 27 BROMSITE, 55 BROVANA, 49 budesonide, 50 budesonide delayed-rel caps, 40 budesonide inhalation suspension, 50 budesonide/formoterol, 50 bumetanide, 23 BUPHENYL, 38 buprenorphine, 31 buprenorphine ext-rel inj, 31 buprenorphine transdermal, 10 buprenorphine/naloxone sublingual film, 31 buprenorphine/naloxone sublingual tabs, 31 bupropion, 27 bupropion ext-rel, 27, 31 burosumab-twza, 39 buspirone, 25 busulfan, 15, 16 BUSULFEX, 15 butabarbital, 29 butalbital/acetaminophen, 10 butalbital/acetaminophen/caffeine, 10 butalbital/acetaminophen/caffeine/codeine, 10 butalbital/aspirin/caffeine, 10 butalbital/aspirin/caffeine/codeine, 10 BUTISOL SODIUM, 29 butorphanol nasal spray, 10 BUTRANS, 10 BYDUREON, 32 BYETTA, 32 BYSTOLIC, 22 C C1 esterase inhibitor, 44 C1 esterase inhibitor, recombinant, 44 cabazitaxel, 19 CABOMETYX, 17 cabozantinib, 17 CAFCIT, 50 CAFERGOT, 29 caffeine citrate, 50 CALAN, 23 CALAN SR, 23 calcifediol ext-rel, 38 calcipotriene, 51 calcipotriene/betamethasone foam, 51 calcitonin-salmon inj, 34 calcitonin-salmon spray, 34 calcitriol (1,25-D3), 38 calcitriol oint, 51 calcium acetate, 38 CALDOLOR, 9 CALQUENCE, 17 CAMBIA, 30 CAMPATH, 18

CAMPTOSAR, 18 canakinumab, 46 CANASA, 41 candesartan, 21 candesartan/hydrochlorothiazide, 21 cangrelor, 44 cannabidiol, 26 capecitabine, 16 CAPEX, 52 CAPRELSA, 17 capsaicin 8% patch, 53 captopril/hydrochlorothiazide, 20 CARAFATE, 42 CARAFATE susp, 42 CARBAGLU, 39 carbamazepine, 25, 30 carbamazepine ext-rel, 25 CARBATROL, 25 carbidopa/levodopa, 27 carbidopa/levodopa enteral susp, 27 carbidopa/levodopa ext-rel, 27 carbidopa/levodopa orally disintegrating tabs, 27 carbidopa/levodopa/entacapone, 27 carboplatin, 18 CARDIZEM, 23 CARDIZEM CD, 23 CARDURA, 20 carfilzomib, 19 carglumic acid, 39 carmustine, 15 CARNITOR, 34 carteolol, 55 carvedilol, 22 carvedilol phosphate ext-rel, 22 CASODEX, 16 CATAPRES, 20 CATAPRES-TTS, 20 CATHFLO ACTIVASE, 45 CAYSTON, 49 cefaclor, 11 cefdinir, 11 cefditoren, 11 cefepime, 12 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 11 cefotaxime, 11 cefoxitin, 11 cefpodoxime, 11 cefprozil, 11 ceftaroline fosamil, 12 ceftazidime, 11 ceftriaxone, 11 cefuroxime axetil, 11 CELEBREX, 9 celecoxib, 9 CELEXA, 26 CELLCEPT, 46 cenegermin-bkbj, 56 cephalexin, 11 CEPROTIN, 45 CERDELGA, 37 CEREZYME, 37 ceritinib, 17 certolizumab pegol, 45 CERUMENEX, 56 CESAMET, 40 CETRAXAL, 56

67

cetrorelix, 37 CETROTIDE, 37 cetuximab, 19 cevimeline, 41 CHANTIX, 31 CHEMSTRIP K URINE KETONE STRIPS, 34 CHEMSTRIP UG URINE GLUCOSE STRIPS, 34 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 34 chlorambucil, 16 chlordiazepoxide, 25 chlordiazepoxide/clidinium, 40 chloroquine, 13 chlorthalidone, 23 CHOLBAM, 42 cholestyramine pkt, 21 cholic acid, 42 choriogonadotropin alfa, 37 chorionic gonadotropin, 37 CIALIS, 42 ciclopirox, 51 cidofovir, 14 cilostazol, 45 CILOXAN, 54 cimetidine, 40 CIMZIA, 45 cinacalcet, 34 CINQAIR, 50 CINRYZE, 44 CINVANTI, 40 CIPRO, 12 CIPRO HC OTIC, 56 CIPRODEX, 56 ciprofloxacin, 12, 54 ciprofloxacin otic, 56 ciprofloxacin/dexamethasone, 56 ciprofloxacin/hydrocortisone, 56 cisplatin, 18 citalopram, 26 CITRANATAL RX, 47 cladribine, 16 clarithromycin, 12 clarithromycin ext-rel, 12 CLEOCIN, 15 CLEOCIN T, 50 CLEOCIN vaginal supp, 42 CLIMARA, 36 CLIMARA PRO, 37 clindamycin, 15 clindamycin gel, lotion, soln, 50 clindamycin supp, 42 clindamycin swabs, 50 clindamycin/benzoyl peroxide, 50 clindamycin/tretinoin, 50, 51 clobazam, 25 clobetasol propionate crm, gel, oint, soln 0.05%, 53 clobetasol propionate lotion, shampoo, spray 0.05%, 53 CLOBEX, 53 clocortolone pivalate crm 0.1%, 52 CLODERM, 52 clofarabine, 16 CLOLAR, 16 clomiphene, 37 clomipramine, 25 clonazepam, 25 clonidine, 20 clonidine ext-rel, 28

clonidine transdermal, 20 clopidogrel, 44 clorazepate, 25 clotrimazole, 51 clotrimazole troches, 12 clotrimazole/betamethasone, 51 clozapine, 27 clozapine orally disintegrating tabs, 27 CLOZARIL, 27 COAGADEX, 44 coagulation factor IX (recombinant), glycopegylated, 43 coagulation factor IX, recombinant, 43 coagulation factor VIIa, 44 coagulation factor X, human, 44 COARTEM, 13 cobicistat, 13 cobimetinib, 17 codeine/acetaminophen, 10 codeine/promethazine, 48 codeine/promethazine/phenylephrine, 48 COLAZAL, 40 colchicine, 9 COLCRYS, 9 colesevelam, 21 COLESTID, 21 colestipol, 21 collagenase clostridium histolyticum, 53 COLYTE, 41 COMBIGAN, 56 COMBIPATCH, 37 COMBIVENT RESPIMAT, 48 COMBIVIR, 13 COMETRIQ, 17 COMPLERA, 13 COMTAN, 27 CONCERTA, 28 CONDYLOX, 53 conjugated estrogens/bazedoxifene, 37 COPIKTRA, 17 CORDRAN crm, lotion, oint, 52 CORDRAN TAPE, 52 COREG, 22 COREG CR, 22 CORIFACT, 44 CORLANOR, 24 corticotropin, 39 corticotropin powder, 39 CORTIFOAM, 41 cortisone acetate, 37 CORTISPORIN OTIC, 56 COSENTYX, 51 COSMEGEN, 18 COSOPT, 55 COTELLIC, 17 COUMADIN, 43 CREON, 41 CRESEMBA, 12 crisaborole oint, 52 CRIXIVAN, 14 crizotinib, 17 crofelemer delayed-rel, 40 cromolyn sodium, 42, 54 cromolyn soln, 49 crotamiton crm, 53 crotamiton lotion, 53 CRYSVITA, 39

68

CUBICIN, 15 CUTIVATE, 52 CUVITRU, 46 CUVPOSA, 42 cyanocobalamin inj, 47 cyanocobalamin spray, 47 CYANOKIT, 39 cyclobenzaprine, 30 cyclobenzaprine ext-rel caps, 30 CYCLOGYL, 56 cyclopentolate, 56 cyclophosphamide caps, 15 CYCLOPHOSPHAMIDE CAPSULES, 15 cyclophosphamide inj, 15 cyclosporine, 46 cyclosporine, emulsion, 55 cyclosporine, modified, 46 CYKLOKAPRON inj, 45 CYMBALTA, 26 cyproheptadine, 48 CYRAMZA, 19 CYSTADANE, 39 CYSTAGON, 39 CYSTARAN, 56 cysteamine, 39, 56 cysteamine delayed-rel, 39 cytarabine, 16 CYTOGAM, 14 cytomegalovirus immune globulin, 14 CYTOMEL, 38 CYTOTEC, 41 CYTOVENE inj, 14 D D.H.E. 45, 29 dabrafenib, 17 dacarbazine, 15 DACOGEN, 18 dacomitinib, 17 dactinomycin, 18 dalfampridine ext-rel, 30 DALIRESP, 49 dalteparin, 43 danazol, 36 DANTRIUM, 30 dantrolene, 30 dapagliflozin, 33 dapagliflozin/metformin ext-rel, 33 dapagliflozin/saxagliptin, 33 dapsone, 15 daptomycin 500 mg, 15 DARAPRIM, 13 daratumumab, 19 darbepoetin alfa, 43 darifenacin ext-rel, 42 darunavir, 14 darunavir/cobicistat, 13 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 13 DARZALEX, 19 dasatinib, 17 daunorubicin, 18 DAURISMO, 19 DAYPRO, 9 DAYTRANA, 28 DDAVP, 39 decitabine, 18

deferasirox, 45 deferiprone, 45 deferoxamine, 45 deflazacort, 31 degarelix acetate, 16 delavirdine, 13 DELESTROGEN, 36 DELSTRIGO, 13 denosumab, 34 DEPAKENE, 25 DEPAKOTE, 25 DEPAKOTE ER, 25 DEPAKOTE SPRINKLE, 25 DEPO-PROVERA, 36 DERMA-SMOOTHE/FS, 52 DERMOTIC, 56 DESCOVY, 13 DESFERAL, 45 desipramine, 27 desmopressin spray, 44 desmopressin spray, tabs, 39 desogestrel/EE, 35 desogestrel/EE 0.15/30, 35 DESONATE, 52 desonide crm, lotion, oint 0.05%, 52 desonide foam 0.05%, 52 desonide gel 0.05%, 52 DESOWEN, 52 desoximetasone crm, oint 0.05%, 52 desoximetasone crm, oint, spray 0.25%, gel 0.05%, 52 DESOXYN, 28 desvenlafaxine ext-rel, 26 deutetrabenazine, 30 dexamethasone, 37, 55 dexamethasone sodium phosphate, 55 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 34 DEXEDRINE SPANSULE, 28 dexmethylphenidate, 28 dexmethylphenidate ext-rel, 28 dexrazoxane, 18 dextranomer/sodium hyaluronate, 42 dextroamphetamine, 28 dextroamphetamine ext-rel, 28 dextroamphetamine soln, 28 dextromethorphan/quinidine, 31 DIACOMIT, 26 DIASTAT, 25 diazepam, 25 diazepam rectal gel, 25 diazoxide, 37 dichlorphenamide, 23 DICLEGIS, 40 diclofenac potassium packets, 30 diclofenac sodium, 55 diclofenac sodium delayed-rel, 9 diclofenac sodium delayed-rel/misoprostol, 9 diclofenac sodium ext-rel, 9 diclofenac sodium gel 1%, 9 diclofenac sodium gel 3%, 51 diclofenac sodium soln, 9 dicloxacillin, 12 dicyclomine, 40 didanosine delayed-rel, 13 didanosine soln, 14 DIFFERIN, 50 DIFICID, 12

69

diflorasone diacetate cream 0.05%, 52 diflorasone diacetate crm 0.05%, 52 diflorasone diacetate emollient crm 0.05%, 52 diflorasone diacetate oint 0.05%, 53 DIFLUCAN, 12 diflunisal, 9 difluprednate, 55 digoxin, 23 dihydroergotamine inj, 29 DILANTIN, 25 DILANTIN INFATABS, 25 DILAUDID, 10 diltiazem, 23 diltiazem ext-rel, 23 dimethyl fumarate delayed-rel, 30 DIPENTUM, 41 diphenhydramine, 27, 48 diphenoxylate/atropine, 39 DIPROLENE, 52, 53 DIPROLENE AF, 52 dipyridamole, 44 dipyridamole ext-rel/aspirin, 44 disopyramide, 21 disopyramide ext-rel, 21 disulfiram, 30 DITROPAN XL, 42 divalproex sodium delayed-rel, 25 divalproex sodium ext-rel, 25 divalproex sodium sprinkle caps, 25 docetaxel, 18 dofetilide, 21 dolutegravir, 13 donepezil, 26 donepezil orally disintegrating tabs, 26 DONNATAL, 40 DOPTELET, 45 DORAL, 29 doravirine/lamivudine/tenofovir disoproxil fumarate, 13 dornase alfa, 49 dorzolamide, 55 dorzolamide/timolol maleate, 55 DOVONEX, 51 doxazosin, 20 doxepin, 27, 29 doxepin crm, 53 doxercalciferol, 38 DOXIL, 18 doxorubicin, 18, 19 doxorubicin liposomal, 18 doxycycline hyclate, 12 doxycycline monohydrate, 12 doxycycline monohydrate delayed-rel caps, 53 doxylamine/pyridoxine delayed-rel, 40 dronabinol, 40 dronedarone, 21 drospirenone/EE 3/20 - Gianvi, 35 drospirenone/EE 3/30, 35 droxidopa, 24 DUAC, 50 DUAVEE, 37 DUET DHA, 47 DUETACT, 33 dulaglutide, 32 DULERA, 50 duloxetine delayed-rel, 26 DUOPA, 27

dupilumab, 52 DUPIXENT, 52 DURAGESIC, 10 DUREZOL, 55 DURLAZA, 44 DUROLANE, 11 durvalumab, 19 dutasteride, 42 dutasteride/tamsulosin, 42 DUTOPROL, 23 duvelisib, 17 DYAZIDE, 23 DYSPORT, 31 E E.E.S., 12 ecallantide, 44 econazole, 51 econazole foam, 51 ECOZA, 51 eculizumab, 44 edaravone, 31 EDECRIN, 23 EDURANT, 13 EE/norethindrone acetate, 36 EE/norethindrone acetate - Jinteli, 36 efavirenz, 13 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 13 EFFEXOR XR, 26 EFFIENT, 44 EFUDEX, 51 EGRIFTA, 39 elagolix, 36 elapegademase-lvlr, 39 ELAPRASE, 39 ELELYSO, 39 eletriptan, 29 ELIDEL, 52 ELIGARD, 17 eliglustat, 37 ELIQUIS, 43 ELITEK, 16 ELIXOPHYLLIN, 50 ELLENCE, 18 ELMIRON, 42 ELOCON, 52 ELOCTATE, 43 elosulfase alfa, 39 elotuzumab, 19 ELSPAR, 18 eltrombopag, 44 eluxadoline, 41 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 13 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 13 EMBEDA, 10 EMEND, 40 EMFLAZA, 31 EMGALITY, 29 emicizumab-kxwh, 44 empagliflozin, 33 empagliflozin/linagliptin, 33 empagliflozin/metformin, 33 empagliflozin/metformin ext-rel, 33 EMPLICITI, 19 EMSAM, 26 emtricitabine, 14

70

emtricitabine/rilpivirine/tenofovir alafenamide, 13 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 13 emtricitabine/tenofovir alafenamide, 13 emtricitabine/tenofovir disoproxil fumarate, 13 EMTRIVA, 14 enalapril, 20 enalapril oral soln, 20 enalapril/hydrochlorothiazide, 20 enasidenib, 19 ENBREL, 45 ENBREL SURECLICK, 45 encorafenib, 17 ENDOMETRIN, 38 enfuvirtide, 13 enoxaparin, 43 ENSTILAR, 51 entacapone, 27 entecavir soln, 14 entecavir tabs, 14 ENTEREG, 42 ENTOCORT EC, 40 ENTRESTO, 24 ENTYVIO, 40 ENVARSUS XR, 46 enzalutamide, 16 EPANED, 20 EPCLUSA, 14 EPIDIOLEX, 26 EPIDUO, 50 EPIDUO FORTE, 50 EPIFOAM, 41 epinastine, 54 epinephrine auto-injector 0.15 mg, 47 epinephrine auto-injector 0.30 mg, 47 epinephrine inj (0.15 mg and 0.30 mg), 47 EPIPEN, 47 EPIPEN JR., 47 epirubicin, 18 EPIVIR, 14 EPIVIR-HBV, 14 eplerenone, 20 epoetin alfa, 43 epoetin alfa-epbx, 43 EPOGEN, 43 epoprostenol, 24 epoprostenol sodium, 24 eprosartan, 21 eptifibatide, 44 EPZICOM, 13 EQUETRO, 30 ERAXIS, 12 ERBITUX, 19 erenumab-aooe, 29 ergocalciferol (D2), 47 ergotamine/caffeine, 29 ergotamine/caffeine supp, 29 eribulin, 19 ERIVEDGE, 19 ERLEADA, 16 erlotinib, 17 ertapenem, 15 ERWINAZE, 18 ERYGEL, 50 ERYPED, 12 erythromycin, 54 erythromycin delayed-rel, 12

erythromycin delayed-rel - Ery-tab, 12 erythromycin ethylsuccinate, 12 erythromycin gel 2%, 50 erythromycin soln, 50 erythromycin stearate, 12 erythromycin/benzoyl peroxide, 50 ESBRIET, 49 escitalopram, 26 eslicarbazepine, 26 esmolol, 22 esomeprazole delayed-rel, 41 estazolam, 29 ESTRACE, 36 estradiol, 36 estradiol transdermal gel, 36 estradiol transdermal spray, 36 estradiol vaginal crm, 36 estradiol vaginal ring, 36 estradiol vaginal tabs, 36 estradiol valerate, 36 estradiol valerate and dienogest/estradiol valerate, 35 estradiol/levonorgestrel, 37 estradiol/norethindrone acetate, 36, 37 estradiol/norgestimate, 37 ESTROGEL, 36 estrogens, conjugated, 36 estrogens, conjugated crm, 36 estrogens, conjugated/medroxyprogesterone, 36, 37 estrogens, esterified/methyltestosterone, 36 ESTROSTEP FE, 35 eszopiclone, 29 etanercept, 45 eteplirsen, 31 ethacrynic acid, 23 ethambutol, 14 ethosuximide, 25 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 35 ethynodiol diacetate/EE 1/50, 35 ETHYOL, 18 etidronate, 34 etodolac, 9 etodolac ext-rel, 9 etonogestrel implant, 36 etonogestrel/EE ring, 36 ETOPOPHOS, 19 etoposide, 18 etoposide phosphate, 19 etravirine, 13 EUCRISA, 52 EUFLEXXA, 11 EURAX crm, 53 EURAX lotion, 53 EVAMIST, 36 EVEKEO, 28 everolimus, 17, 47 everolimus tabs for oral suspension, 17 EVISTA, 38 evolocumab, 22 EVOMELA, 19 EVOTAZ, 13 EVOXAC, 41 EXELDERM, 51 EXELON PATCH, 26 exemestane, 16 exenatide, 32 exenatide ext-rel, 32

71

EXFORGE, 21 EXFORGE HCT, 21 EXJADE, 45 EXONDYS 51, 31 EXTAVIA, 30 EYLEA, 56 ezetimibe, 21 ezetimibe/simvastatin, 22 F FABRAZYME, 39 factor IX concentrate, 44 factor IX recombinant, Fc fusion protein, 44 factor XIII A-subunit recombinant, 44 factor XIII concentrate, 44 famciclovir, 15 famotidine, 40 famotidine susp, 40 FANAPT, 28 FARESTON, 16 FARXIGA, 33 FARYDAK, 19 FASENRA, 50 FASLODEX, 16 FAZACLO, 27 febuxostat, 9 FEIBA VH IMMUNO, 43 felbamate, 25 FELBATOL, 25 felodipine ext-rel, 23 FEMARA, 16 FEMHRT, 36 FEMRING, 36 fenofibrate, 21, 22 fenofibric acid delayed-rel, 22 fenoprofen, 9 fentanyl citrate buccal, 10 fentanyl citrate nasal spray, 10 fentanyl sublingual spray, 10 fentanyl sublingual tablets, 10 fentanyl transdermal, 10 fentanyl transmucosal lozenge, 10 FENTORA, 10 FERAHEME, 47 ferric carboxymaltose inj, 47 FERRIPROX, 45 FERRLECIT, 47 ferumoxytol inj, 47 FETZIMA, 26 FIASP, 32 FIASP FLEXTOUCH, 32 fibrinogen, 44 fidaxomicin, 12 filgrastim-aafi, 43 filgrastim-sndz, 43 FINACEA, 53 finasteride, 42 fingolimod, 30 FIORICET, 10 FIORICET w/CODEINE, 10 FIORINAL, 10 FIORINAL w/CODEINE, 10 FIRAZYR, 44 FIRMAGON, 16 FIRVANQ, 15 FLAGYL, 15

FLAREX, 55 FLEBOGAMMA, 46 flecainide, 21 FLOLAN, 24 FLOMAX, 42 FLOVENT, 50 FLOVENT HFA, 50 floxuridine, 16 fluconazole, 12 FLUDARA, 16 fludarabine, 16 fludrocortisone, 37 flunisolide spray, 49 fluocinolone acetonide, 56 fluocinolone acetonide crm, oint 0.025%, 52 fluocinolone acetonide oil 0.01%, 52 fluocinolone acetonide soln 0.01%, 52 fluocinolone shampoo 0.01%, 52 fluocinonide crm 0.1%, 53 fluocinonide crm, gel, oint, soln 0.05%, 52 fluoride drops, tabs, 47 fluorometholone, 55 fluorometholone acetate, 55 FLUOROPLEX, 51 fluorouracil, 51 fluorouracil crm 4%, 51 fluorouracil inj, 16 fluoxetine, 26 fluoxetine delayed-rel, 26 fluphenazine, 28 flurandrenolide crm, lotion, oint 0.05%, 52 flurandrenolide tape, 52 flurazepam, 29 flurbiprofen, 9, 55 flutamide, 16 fluticasone, 50 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 52 fluticasone spray, 49 fluticasone, CFC-free aerosol, 50 fluticasone/salmeterol, 50 fluticasone/salmeterol, CFC-free aerosol, 50 fluticasone/umeclidinium/vilanterol, 48 fluticasone/vilanterol, 50 fluvastatin, 22 fluvastatin ext-rel, 22 fluvoxamine, 25 fluvoxamine ext-rel, 25 FML, 55 FOCALIN, 28 FOCALIN XR, 28 folic acid, 47 FOLLISTIM AQ, 37 follitropin alfa, 37 follitropin beta, 37 FOLOTYN, 16 fondaparinux, 43 FORADIL, 48 FORFIVO XL, 27 formoterol inhalation caps, 48 formoterol inhalation soln, 49 FORTEO, 34 FORTESTA, 31 FOSAMAX, 34 FOSAMAX PLUS D, 34 fosamprenavir, 14 fosinopril, 20

72

fosinopril/hydrochlorothiazide, 20 FOSRENOL CHEWABLE TABLETS, 38 FOSRENOL ORAL POWDER, 38 fostamatinib, 44 FRAGMIN, 43 FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING

SYSTEM, 33 FROVA, 29 frovatriptan, 29 FULPHILA, 43 fulvestrant, 16 furosemide, 23 FUSILEV, 18 FUZEON, 13 FYCOMPA, 26 G gabapentin, 25 gabapentin enacarbil ext-rel, 31 GABITRIL, 25 GALAFOLD, 39 galantamine, 26 galantamine ext-rel, 26 galcanezumab-gnlm, 29 galsulfase, 39 GALZIN, 47 GAMASTAN S-D, 46 GAMMAGARD LIQUID, 46 GAMMAGARD S-D, 46 GAMMAKED, 46 GAMMAPLEX, 46 GAMUNEX-C, 46 ganciclovir, 55 ganciclovir inj, 14 GANIRELIX ACETATE, 37 ganirelix acetate inj, 37 GARAMYCIN, 54 GASTROCROM, 42 GATTEX, 42 GAZYVA, 19 gefitinib, 18 GEL-ONE, 10 GELSYN-3, 10 GEMCITABINE, 16 gemcitabine inj, 16 gemfibrozil, 22 gemtuzumab ozogamicin, 19 gentamicin, 51, 54 gentamicin/prednisolone acetate, 54 GENVOYA, 13 GEODON, 28 GILENYA, 30 GILOTRIF, 17 glasdegib, 19 GLASSIA, 49 glatiramer, 30 glatiramer - Glatopa, 30 glecaprevir/pibrentasvir, 14 GLEEVEC, 17 GLEOSTINE, 16 glimepiride, 33 glipizide, 33 glipizide ext-rel, 33 glipizide/metformin, 32 GLUCAGON EMERGENCY KIT, 37 glucagon, human recombinant, 37

glucarpidase, 19 GLUCOPHAGE, 32 GLUCOPHAGE XR, 32 GLUCOTROL, 33 GLUCOTROL XL, 33 glyburide, 33 glyburide, micronized, 33 glyburide/metformin, 32 glycerol phenylbutyrate, 39 glycopyrrolate, 42 glycopyrrolate inhalation powder, 48 glycopyrrolate inhalation solution, 48 glycopyrrolate/formoterol, 48 GLYNASE, 33 GLYSET, 32 GLYXAMBI, 33 GOCOVRI, 27 golimumab, 45 GOLYTELY, 41 gonadorelin, 37 GONAL-F, 37 GONAL-F RFF, 37 GONITRO, 24 goserelin acetate, 16 granisetron, 40 granisetron ext-rel inj, 40 granisetron transdermal, 40 GRANIX, 43 grass mixed pollen allergen extract, 45 griseofulvin microsize, 12 griseofulvin ultramicrosize, 12 guanfacine ext-rel, 28 guselkumab, 51 H HAEGARDA, 44 HALAVEN, 19 halcinonide crm, oint 0.1%, 52 HALDOL, 28 HALDOL DECANOATE 100, 28 halobetasol propionate crm, oint 0.05%, 53 HALOG, 52 haloperidol, 28 haloperidol decanoate inj, 28 haloperidol lactate inj, 28 HARVONI, 14 HECTOROL, 38 HEMLIBRA, 44 HEMOFIL M, 43 HEPAGAM B, 45 hepatitis B immune globulin, 45, 46 HEPSERA, 14 HERCEPTIN, 19 HETLIOZ, 29 high molecular weight hyaluronan, 11 HIPREX, 15 histrelin acetate, 16, 39 HIZENTRA, 46 HORIZANT, 31 human coagulation factor VIII (rDNA) simoctocog alfa, 44 HUMATE-P, 43 HUMIRA, 45 HUMULIN R U-500, 32 HYALGAN, 10 HYCAMTIN, 18 HYCAMTIN inj, 18

73

hydralazine, 24 HYDREA, 18 hydrochlorothiazide, 23 hydrocodone ext-rel caps, 10 hydrocodone ext-rel tabs, 10 hydrocodone/acetaminophen - Vicodin, 10 hydrocodone/acetaminophen - Vicodin ES, 10 hydrocodone/chlorpheniramine/pseudoephedrine, 48 hydrocodone/homatropine, 48 hydrocortisone, 37 hydrocortisone acetate foam, 41 hydrocortisone acetate/pramoxine foam, 41 hydrocortisone butyrate crm 0.1%, 52 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 52 hydrocortisone crm 2.5%, 52 hydrocortisone enema, 41 hydrocortisone lotion 1%, 52 hydrocortisone probutate crm 0.1%, 52 hydrocortisone valerate crm, oint 0.2%, 52 hydrocortisone/aloe polysaccharide/iodoquinol, 53 hydrocortisone/iodoquinol, 53 hydromorphone, 10 hydromorphone ext-rel, 10 hydroxocobalamin, 39 hydroxychloroquine, 45 hydroxyprogesterone caproate, 38 hydroxyurea, 18, 19 hydroxyzine HCl, 25, 48 hydroxyzine pamoate, 25, 48 hylan G-F 20, 11 HYMOVIS, 11 hyoscyamine sulfate, 40 hyoscyamine sulfate ext-rel, 40 HYPERHEP B S-D, 46 HYPERRHO S-D, 46 HYQVIA, 46 HYSINGLA ER, 10 I ibalizumab-uiyk, 13 ibandronate, 34 IBRANCE, 17 ibrutinib, 17 ibuprofen, 9 ibuprofen inj, 9 icatibant, 44 ICLUSIG, 17 icosapent ethyl, 22 IDAMYCIN PFS, 18 idarubicin, 18 idelalisib, 17 IDELVION, 43 IDHIFA, 19 idursulfase, 39 IFEX, 18 ifosfamide, 18 ifosfamide/mesna, 15 ILARIS, 46 ILEVRO, 55 iloperidone, 28 iloprost, 24 ILUMYA, 45 imatinib mesylate, 17 IMBRUVICA, 17 IMFINZI, 19 imiglucerase, 37

imipenem/cilastatin, 15 imipramine HCl, 27 imipramine pamoate, 27 imiquimod, 53 IMITREX, 29 IMLYGIC, 19 immune globulin (human)-ifas, 46 immune globulin, gamma, 46 immune globulin, gamma (IGG), 46 immune globulin, intravenous, 46 immune globulin, subcutaneous, 46 immune globulin/hyaluronidase, 46 IMPAVIDO, 15 IMURAN, 46 incobotulinumtoxinA, 31 INCRELEX, 38 indacaterol, 48 indacaterol/glycopyrrolate inhalation powder, 48 indapamide, 23 INDERAL LA, 22 indinavir, 14 INDOCIN susp, 9 indomethacin, 9 indomethacin ext-rel, 9 indomethacin susp, 9 INFLECTRA, 45 infliximab, 45 infliximab-abda, 45 infliximab-dyyb, 45 ingenol mebutate, 51 INGREZZA, 31 INJECTAFER, 47 INLYTA, 17 INNOPRAN XL, 22 inotersen, 39 inotuzumab ozogamicin, 19 INSPRA, 20 insulin aspart, 32 insulin aspart protamine 70%/insulin aspart 30%, 32 insulin degludec, 33 insulin detemir, 32 insulin glargine, 32, 33 insulin human, 32, 33 insulin human inhalation powder, 33 insulin isophane human, 33 insulin isophane human 70%/regular 30%, 33 insulin syringes, needles, 33 INTEGRILIN, 44 INTELENCE, 13 interferon alfa-2b, 46 interferon alfa-n3, 53 interferon beta-1a, 30 interferon beta-1b, 30 interferon gamma-1b, recombinant, 46 INTRAROSA, 39 intrauterine copper contraceptive, 36 INTRON A, 46 INTUNIV, 28 INVANZ, 15 INVEGA, 27 INVEGA SUSTENNA, 28 INVEGA TRINZA, 28 INVIRASE, 14 ipilimumab, 19 ipratropium nasal spray, 50 ipratropium soln, 48

74

ipratropium, CFC-free aerosol, 48 ipratropium/albuterol soln, 48 ipratropium/albuterol, CFC-free aerosol, 48 irbesartan, 21 irbesartan/hydrochlorothiazide, 21 IRESSA, 18 irinotecan, 18 irinotecan liposome inj, 18 iron sucrose inj, 47 isavuconazonium, 12 ISENTRESS, 13 isocarboxazid, 26 isoniazid, 14 ISOPTO HYOSCINE, 56 ISORDIL, 24 isosorbide dinitrate oral, 24 isosorbide dinitrate/hydralazine, 24 isosorbide mononitrate, 24 isosorbide mononitrate ext-rel, 24 isotretinoin, 50 ISTALOL, 55 ISTODAX, 18 itraconazole, 12 ivabradine, 24 ivacaftor, 49 ivermectin, 53 ivosidenib, 19 ixabepilone, 19 ixazomib, 19 ixekizumab, 45 IXEMPRA, 19 IXINITY, 43 J JADENU, 45 JAKAFI, 17 JANUMET, 32 JANUMET XR, 32 JANUVIA, 32 JARDIANCE, 33 JENTADUETO, 32 JENTADUETO XR, 32 JETREA, 56 JEVTANA, 19 JIVI, 44 JUXTAPID, 22 JYNARQUE, 39 K KADCYLA, 18 KADIAN, 10 KALBITOR, 44 KALETRA, 14 KALYDECO, 49 KANUMA, 39 KAPVAY, 28 KEFLEX, 11 KENALOG SPRAY, 52 KENGREAL, 44 KEPIVANCE, 42 KEPPRA, 25 KEPPRA XR, 25 ketoconazole, 51 ketoconazole shampoo 2%, 51 ketoconazole tabs, 12 ketoprofen, 9 ketoprofen ext-rel, 9

ketorolac, 9 ketorolac 0.45%, 55 ketorolac 0.5%, 55 ketorolac tromethamine nasal spray, 9 KEVEYIS, 23 KEVZARA, 45 KEYTRUDA, 17 KHEDEZLA, 26 KINERET, 45 KISQALI, 17 KISQALI FEMARA CO-PACK, 17 KITABIS PAK, 49 KLONOPIN, 25 KOATE-DVI, 43 KOGENATE FS, 43 KORLYM, 39 KOVALTRY, 43 KRYSTEXXA, 9 KUVAN, 38 KYLEENA, 36 KYPROLIS, 19 L LAC-HYDRIN, 53 lacosamide, 25 lactulose, 41 LAMICTAL, 25 LAMICTAL ODT, 25 LAMICTAL XR, 25 lamivudine, 14 lamivudine/zidovudine, 13 lamotrigine, 25 lamotrigine ext-rel, 25 lamotrigine orally disintegrating tabs, 25 lanadelumab-flyo, 44 lancet device, 34 lancets, 34 LANOXIN, 23 lanreotide acetate, 39 lansoprazole + amoxicillin + clarithromycin, 42 lansoprazole delayed-rel, 41 lanthanum carbonate chew tabs, 38 lanthanum oral powder, 38 LANTUS, 33 lapatinib, 17 laronidase, 39 larotrectinib, 17 LASIX, 23 LASTACAFT, 54 latanoprost, 56 latanoprostene bunod, 56 LATUDA, 28 LAZANDA, 10 ledipasvir/sofosbuvir, 14 leflunomide, 45 LEMTRADA, 30 lenalidomide, 17 lenvatinib, 17 LENVIMA, 17 LETAIRIS, 24 letermovir, 14 letrozole, 16 leucovorin calcium, 18 LEUKERAN, 16 LEUKINE, 43 leuprolide acetate, 16, 17, 39

75

leuprolide acetate/norethindrone acetate, 36 levalbuterol inhalation soln, 48 levalbuterol nebulizer soln concentrate, 48 levalbuterol tartrate, CFC-free aerosol, 48 LEVAQUIN, 12 LEVATOL, 22 LEVBID, 40 LEVEMIR, 32 levetiracetam, 25 levetiracetam ext-rel, 25 levobunolol, 55 levocarnitine, 34 levofloxacin, 12, 54 levoleucovorin calcium, 18 levomilnacipran ext-rel, 26 levonorgestrel/EE - Trivora, 35 levonorgestrel/EE 0.09/20 - Amethyst, 35 levonorgestrel/EE 0.1/20, 35 levonorgestrel/EE 0.1/20 and EE 10, 35 levonorgestrel/EE 0.15/30, 35 levonorgestrel/EE 0.15/30 - Jolessa, 35 levonorgestrel/EE 0.15/30 - Levora, 35 levonorgestrel/EE 0.15/30 and EE 10, 35 levonorgestrel-releasing IUD, 36 levothyroxine, 38 levothyroxine - Levoxyl, 38 LEVSIN, 40 LEVULAN KERASTICK, 51 LEXAPRO, 26 LEXIVA, 14 LIALDA, 40 lidocaine, 53 lidocaine patch, 53 lidocaine viscous, 54 lidocaine/prilocaine, 53 LIDODERM, 53 lifitegrast, 55 LILETTA, 36 linaclotide, 41 linagliptin, 32 linagliptin/metformin, 32 linagliptin/metformin ext-rel, 32 lindane, 53 linezolid, 15 LINZESS, 41 LIORESAL INTRATHECAL, 30 liothyronine, 38 LIPOFEN, 21 liraglutide, 32 liraglutide/insulin degludec, 32 lisdexamfetamine, 28 lisinopril, 20 lisinopril oral soln, 20 lisinopril/hydrochlorothiazide, 20 lithium carbonate, 30 lithium carbonate ext-rel tabs 300 mg, 30 lithium carbonate ext-rel tabs 450 mg, 30 LITHOBID, 30 lixisenatide, 32 lixisenatide/insulin glargine, 32 LOCOID, 52 LOCOID LIPOCREAM, 52 lodoxamide, 54 LOESTRIN 1.5/30, 35 LOESTRIN 1/20, 35 LOESTRIN FE 1.5/30, 35

LOESTRIN FE 1/20, 35 LOKELMA, 38 lomitapide, 22 LOMOTIL, 39 lomustine, 16 LONHALA MAGNAIR, 48 LONSURF, 19 loperamide, 39 LOPID, 22 lopinavir/ritonavir, 14 LOPRESSOR, 22 LOPRESSOR HCT, 23 lorazepam, 25 LORBRENA, 18 lorlatinib, 18 losartan, 21 losartan/hydrochlorothiazide, 21 LOSEASONIQUE, 35 LOTEMAX, 55 LOTENSIN, 20 LOTENSIN HCT, 20 loteprednol 0.2%, 55 loteprednol 0.5%, 55 LOTREL, 20 LOTRONEX, 41 lovastatin, 22 LOVAZA, 22 LOVENOX, 43 loxapine, 28 lubiprostone, 41 LUCENTIS, 56 lumacaftor/ivacaftor, 49 LUMIZYME, 39 LUMOXITI, 19 LUPANETA PACK, 36 LUPRON DEPOT, 17 LUPRON DEPOT-PED, 39 lurasidone, 28 lusutrombopag, 44 LUTREPULSE, 37 LYNPARZA, 19 LYRICA, 29 LYSODREN, 18 LYSTEDA, 45 M macitentan, 24 MACROBID, 15 MACRODANTIN, 15 MACUGEN, 56 mafenide acetate packets 5%, 51 MAKENA, 38 MALARONE, 13 maraviroc, 13 MARINOL, 40 MARPLAN, 26 MARQIBO, 19 MATULANE, 19 MAVYRET, 14 MAXALT/MAXALT-MLT, 29 MAXIDEX, 55 MAXITROL, 54 MAXZIDE, 23 MAXZIDE-25, 24 mecamylamine, 24 mecasermin, 38

76

mechlorethamine gel, 16 meclizine, 40 medroxyprogesterone acetate, 38 medroxyprogesterone acetate 150 mg/mL, 36 mefloquine, 13 MEGACE ES, 38 megestrol acetate, 17 megestrol acetate susp, 38 MEKINIST, 17 MEKTOVI, 17 meloxicam, 9 melphalan, 19 melphalan inj, 15 melphalan tabs, 16 memantine soln, 26 memantine tabs, 26 MENOPUR, 37 menotropins, 37 MEPHYTON, 47 mepolizumab, 49 MEPRON, 15 MEPSEVII, 39 mercaptopurine, 16 mercaptopurine susp, 16 meropenem, 15 MERREM, 15 mesalamine delayed-rel caps, 40 mesalamine delayed-rel tabs, 40 mesalamine ext-rel caps, 41 mesalamine rectal susp, 41 mesalamine supp, 41 mesna inj, 18 mesna tabs 400 mg, 19 MESNEX, 19 MESNEX inj, 18 MESTINON, 30 MESTINON TIMESPAN, 30 metaproterenol, 49 metformin, 32 metformin ext-rel, 32 methadone, 10 methamphetamine, 28 methazolamide, 23 methenamine hippurate, prophylaxis, 15 methimazole, 38 methotrexate auto-injector, 45 methotrexate inj, 45 methotrexate oral, 45 methoxsalen oral, 51 methylergonovine, 39 METHYLIN, 28 methylnaltrexone, 41 methylphenidate, 28 methylphenidate ext-rel, 28 methylphenidate ext-rel caps, 28 methylphenidate ext-rel susp, 28 methylphenidate transdermal, 28 methylprednisolone, 37 metoclopramide, 40 metolazone, 23 metoprolol succinate ext-rel, 22 metoprolol succinate ext-rel/hydrochlorothiazide, 23 metoprolol tartrate, 22 metoprolol/hydrochlorothiazide, 23 metreleptin, 39 METROCREAM, 53

METROGEL, 53 METROGEL-VAGINAL, 42 METROLOTION, 53 metronidazole, 42 metronidazole crm 0.75%, 53 metronidazole gel 0.75%, 53 metronidazole gel 1%, 53 metronidazole lotion 0.75%, 53 metronidazole tabs, 15 mexiletine, 21 MIACALCIN, 34 MIACALCIN inj, 34 micafungin, 13 miconazole nitrate/zinc oxide, 51 MICRHOGAM, 46 MICRHOGAM PLUS, 46 midodrine, 24 midostaurin, 17 mifepristone, 39 migalastat, 39 MIGERGOT, 29 miglitol, 32 miglustat, 39 milnacipran, 29 miltefosine, 15 MINIPRESS, 20 MINIVELLE, 36 MINOCIN, 12 minocycline, 12 minocycline ext-rel, 12 minoxidil tabs, 24 mirabegron ext-rel, 42 MIRAPEX, 27 MIRAPEX ER, 27 MIRCETTE, 35 MIRENA, 36 mirtazapine, 27 MIRVASO, 53 misoprostol, 41 MITIGARE, 9 mitomycin, 18 mitotane, 18 mitoxantrone, 18 MOBIC, 9 modafinil, 30 mometasone, 50 mometasone crm, lotion, oint 0.1%, 52 mometasone spray, 49 mometasone, CFC-free aerosol, 50 mometasone/formoterol, 50 MONONINE, 44 MONOVISC, 11 montelukast, 49 MORPHABOND, 10 morphine, 10 morphine ext-rel, 10 morphine supp, 10 morphine/naltrexone ext-rel, 10 MOVANTIK, 41 MOVIPREP, 41 moxetumomab pasudotox-tdfk, 19 MOXEZA, 54 moxifloxacin, 12, 54 MOZOBIL, 44 MS CONTIN, 10 MULPLETA, 44

77

MULTAQ, 21 multivitamins/fluoride drops, tabs, 47 multivitamins/fluoride/iron drops, tabs, 47 mupirocin, 51 MYALEPT, 39 MYAMBUTOL, 14 MYCAMINE, 13 MYCOBUTIN, 15 mycophenolate mofetil, 46 mycophenolate sodium delayed-rel, 46 MYFORTIC, 46 MYLERAN, 16 MYLOTARG, 19 MYOBLOC, 31 MYRBETRIQ, 42 MYSOLINE, 25 MYTESI, 40 N NABI-HB, 46 nabilone, 40 nabumetone, 9 nafarelin, 36 naftifine, 51 NAGLAZYME, 39 NALFON, 9 naloxegol, 41 naloxone inj, 31 naloxone nasal spray, 31 naltrexone, 30 naltrexone microspheres, 30 NAMENDA tabs, 26 naphazoline, 56 naproxen, 9 naproxen sodium, 9 naproxen sodium ext-rel, 9 naratriptan, 29 NARCAN, 31 NARDIL, 26 NASCOBAL, 47 NATACYN, 54 natalizumab, 30 natamycin, 54 NATAZIA, 35 nateglinide, 33 NATPARA, 34 NATROBA, 53 NAVELBINE, 18 nebivolol, 22 necitumumab, 19 nefazodone, 27 nelarabine, 19 nelfinavir, 14 neomycin/dexamethasone, 54 neomycin/polymyxin B/dexamethasone, 54 neomycin/polymyxin B/gramicidin, 54 neomycin/polymyxin B/hydrocortisone, 56 neomycin/polymyxin B/hydrocortisone susp, 54 NEORAL, 46 nepafenac, 55 nepafenac 0.3%, 55 neratinib, 18 NERLYNX, 18 netarsudil, 56 netupitant/palonosetron, 40 NEULASTA, 43

NEUPRO, 27 NEURONTIN, 25 NEVANAC, 55 nevirapine, 13 nevirapine ext-rel, 13 NEXAVAR, 17 NEXPLANON, 36 niacin ext-rel, 22 NIASPAN, 22 nicardipine, 23 nifedipine ext-rel, 23 NILANDRON, 16 nilotinib, 18 nilutamide, 16 nimodipine, 23 NIMOTOP, 23 NINLARO, 19 nintedanib, 49 NIPENT, 16 niraparib, 19 nisoldipine ext-rel, 23 nitazoxanide, 15 nitisinone, 37 NITRO-BID, 24 NITRO-DUR, 24 nitrofurantoin ext-rel, 15 nitrofurantoin macrocrystals, 15 nitroglycerin lingual spray, 24 nitroglycerin ointment, 24 nitroglycerin rectal oint 0.4%, 42 nitroglycerin sublingual, 24 nitroglycerin sublingual aerosol, 24 nitroglycerin sublingual powder, 24 nitroglycerin transdermal, 24 NITROLINGUAL, 24 NITROMIST, 24 NITROSTAT, 24 NIVESTYM, 43 nivolumab, 19 nizatidine, 40 NIZORAL SHAMPOO, 51 NORDITROPIN, 37 norelgestromin/EE, 36 norethindrone, 35 norethindrone acetate, 38 norethindrone acetate/EE 1.5/30, 35 norethindrone acetate/EE 1.5/30 and iron, 35 norethindrone acetate/EE 1/20, 35 norethindrone acetate/EE 1/20 and iron, 35 norethindrone acetate/EE and iron, 35 norethindrone/EE, 35 norethindrone/EE 0.4/35, 35 norethindrone/EE 0.5/35, 35 norethindrone/EE 1/35, 35 norgestimate/EE, 35 norgestimate/EE 0.25/35, 35 norgestrel/EE 0.3/30 - Cryselle, 35 norgestrel/EE 0.3/30 - Low-Ogestrel, 35 norgestrel/EE 0.5/50, 35 NORPACE, 21 NORPACE CR, 21 NORPRAMIN, 27 NORTHERA, 24 nortriptyline, 27 NORVASC, 23 NORVIR, 14

78

NOVAREL, 37 NOVOEIGHT, 43 NOVOLIN 70/30, 33 NOVOLIN N, 33 NOVOLIN R, 33 NOVOLOG, 32 NOVOLOG MIX 70/30, 32 NOVOSEVEN RT, 44 NOXAFIL, 12 NPLATE, 44 NUCALA, 49 NUCYNTA, 10 NUCYNTA ER, 10 NUEDEXTA, 31 NULOJIX, 47 NULYTELY, 41 NUPLAZID, 28 NUVARING, 36 NUVIGIL, 30 NUWIQ, 44 nystatin, 12, 51 O obeticholic acid, 42 obinutuzumab, 19 OCALIVA, 42 ocrelizumab, 30 OCREVUS, 30 ocriplasmin, 56 OCTAGAM, 46 octreotide acetate, 39 OCUFLOX, 54 ODEFSEY, 13 ODOMZO, 19 ofatumumab, 19 OFEV, 49 OFIRMEV, 9 ofloxacin, 12, 54 ofloxacin otic, 56 olanzapine, 27 olanzapine pamoate ext-rel inj, 28 olanzapine/fluoxetine, 27 olaparib, 19 olmesartan, 21 olmesartan/amlodipine/hydrochlorothiazide, 21 olmesartan/hydrochlorothiazide, 21 olodaterol, CFC-free aerosol, 48 olopatadine, 54 olopatadine spray, 49 olsalazine, 41 OLUMIANT, 45 omacetaxine mepesuccinate, 19 omalizumab, 49 omega-3 acid ethyl esters, 22 omeprazole delayed-rel, 41 omeprazole/sodium bicarbonate, 41 onabotulinumtoxinA, 31 ONCASPAR, 19 ondansetron, 40 ondansetron oral soluble film, 40 ondansetron orally disintegrating tabs, 40 ONETOUCH LANCETS, 34 ONETOUCH METERS AND KITS, 33 ONETOUCH TEST STRIPS, 33 ONFI, 25 ONIVYDE, 18

OPANA, 10 OPDIVO, 19 OPSUMIT, 24 ORACEA, 53 ORALAIR, 45 ORENCIA, 45 ORENITRAM, 24 ORFADIN, 37 ORILISSA, 36 ORKAMBI, 49 ORTHO MICRONOR, 35 ORTHO TRI-CYCLEN, 35 ORTHO TRI-CYCLEN LO, 35 ORTHO-CYCLEN, 35 ORTHO-NOVUM 1/35, 35 ORTHO-NOVUM 7/7/7, 35 ORTHOVISC, 11 oseltamivir, 15 osimertinib, 18 OSMOPREP, 41 ospemifene, 38 OSPHENA, 38 OTEZLA, 45 OTREXUP, 45 OVIDREL, 37 oxaliplatin, 18 oxaprozin, 9 oxazepam, 25 oxcarbazepine, 25 oxcarbazepine ext-rel, 26 OXERVATE, 56 oxiconazole, 51 OXSORALEN-ULTRA, 51 OXTELLAR XR, 26 oxybutynin, 42 oxybutynin ext-rel, 42 oxycodone, 10 oxycodone concentrate 20 mg/mL, 10 oxycodone ext-rel, 10 oxycodone soln, 10 oxycodone tabs, 10 oxycodone/acetaminophen, 10 oxycodone/acetaminophen 5/325, 10 OXYCONTIN, 10 oxymetazoline crm 1%, 53 oxymorphone, 10 OZEMPIC, 32 OZURDEX, 55 P paclitaxel, 18 paclitaxel protein-bound particles, 19 palbociclib, 17 palifermin, 42 paliperidone ext-rel, 27 paliperidone palmitate ext-rel inj, 28 palivizumab, 15 palonosetron, 40 PALYNZIQ, 38 PAMELOR, 27 pamidronate, 34 PANCREAZE, 41 pancrelipase, 41 pancrelipase delayed-rel, 41 PANDEL, 52 panitumumab, 19

79

panobinostat, 19 PANRETIN, 53 pantoprazole delayed-rel, 41 PANZYGA, 46 PARAGARD T 380A, 36 parathyroid hormone (recombinant), 34 paricalcitol, 38 PARLODEL, 27 PARNATE, 26 paroxetine HCl, 26 paroxetine HCl ext-rel, 26 paroxetine mesylate, 26 pasireotide, 39 PATADAY, 54 PATANASE, 49 PATANOL, 54 patiromer, 38 PAXIL, 26 PAXIL CR, 26 pazopanib, 17 peg 3350/electrolytes, 41 pegademase, bovine, 39 pegaptanib sodium, 56 pegaspargase, 19 PEGASYS, 46 pegfilgrastim, 43 pegfilgrastim-cbqv, 43 pegfilgrastim-jmdb, 43 peginterferon alfa-2a, 46 peginterferon alfa-2b, 46 peginterferon beta-1a, 30 PEGINTRON, 46 pegloticase, 9 pegvaliase-pqpz, 38 pegvisomant, 39 pembrolizumab, 17 pemetrexed, 16 penbutolol, 22 penicillin VK, 12 PENTASA, 41 pentosan polysulfate sodium, 42 pentostatin, 16 pentoxifylline ext-rel, 45 PEPCID, 40 PEPCID susp, 40 perampanel, 26 PERCOCET, 10 PERFOROMIST, 49 perindopril, 20 perindopril arginine/amlodipine, 20 PERJETA, 19 permethrin 5%, 53 perphenazine, 28 pertuzumab, 19 PEXEVA, 26 phenazopyridine, 42 phenelzine, 26 phenobarbital, 25 phenylephrine, 54 phenytoin, 25 phenytoin sodium extended, 25 phytonadione, 47 PICATO, 51 pilocarpine, 56 pilocarpine tabs, 41 PILOPINE HS GEL, 56

pimavanserin, 28 pimecrolimus, 52 pindolol, 22 pioglitazone, 33 pioglitazone/glimepiride, 33 pioglitazone/metformin, 33 pioglitazone/metformin ext-rel, 33 piperacillin/tazobactam, 12 pirfenidone, 49 piroxicam, 9 PLAQUENIL, 45 PLAVIX, 44 plecanatide, 42 PLEGRIDY, 30 PLEGRIDY PEN, 30 plerixafor, 44 podofilox, 53 polymyxin B/bacitracin, 54 polymyxin B/trimethoprim, 54 POLYTRIM, 54 pomalidomide, 17 POMALYST, 17 ponatinib, 17 PORTRAZZA, 19 posaconazole delayed-rel tabs, 12 potassium chloride ext-rel, 47 potassium chloride liquid, 47 potassium chloride powder, 47 potassium citrate ext-rel, 42 potassium citrate ext-rel 15 mEq, 42 pralatrexate, 16 pramipexole, 27 pramipexole ext-rel, 27 pramlintide, 32 PRAMOSONE, 52 pramoxine/hydrocortisone, 52 PRANDIN, 33 prasterone vaginal inserts, 39 prasugrel, 44 pravastatin, 22 prazosin, 20 PRECOSE, 32 PRED FORTE, 55 PRED MILD, 55 PRED-G, 54 prednisolone, 37 prednisolone acetate 0.12%, 55 prednisolone acetate 1%, 55 prednisolone phosphate 1%, 55 prednisolone sodium phosphate, 37 prednisolone sodium phosphate orally disintegrating tabs, 37 prednisolone syrup, 37 prednisone, 37 PREFEST, 37 pregabalin, 29 PREGNYL, 37 PREMARIN, 36 PREMARIN crm, 36 PREMPHASE, 36 PREMPRO, 37 prenatal vitamins/docusate/folic acid, 47 prenatal vitamins/folic acid, 47 PRENATE ELITE, 47 PREPOPIK, 41 PRESTALIA, 20 PREVIDENT, 54

80

PREVYMIS, 14 PREZCOBIX, 13 PREZISTA, 14 PRIALT, 10 PRIFTIN, 14 primaquine, 13 PRIMAXIN, 15 primidone, 25 PRIMLEV, 10 PRINIVIL, 20 PRISTIQ, 26 PRIVIGEN, 46 PROAIR HFA, 48 PROAIR RESPICLICK, 48 probenecid, 9 procarbazine, 19 PROCARDIA XL, 23 PROCENTRA, 28 prochlorperazine, 40 PROCRIT, 43 PROCTOFOAM-HC, 41 PROCYSBI, 39 PROFILNINE SD, 44 progesterone vaginal inserts, 38 progesterone, micronized, 38 PROGLYCEM, 37 PROGRAF, 46 PROLASTIN-C, 49 PROLENSA, 55 PROLEUKIN, 18 PROLIA, 34 PROMACTA, 44 promethazine, 40, 48 PROMETRIUM, 38 propafenone ext-rel, 21 propantheline 15 mg, 40 propranolol, 22 propranolol ext-rel, 22 propylthiouracil, 38 PROSCAR, 42 protein C concentrate, human, 45 PROTOPIC, 52 protriptyline, 27 PROVERA, 38 PROVIGIL, 30 PROZAC, 26 PSORCON, 52 PULMICORT FLEXHALER, 50 PULMICORT RESPULES, 50 PULMOZYME, 49 PURIXAN, 16 PYLERA, 42 pyrazinamide, 14 PYRIDIUM, 42 pyridostigmine, 30 pyridostigmine ext-rel tabs 180 mg, 30 pyrimethamine, 13 Q QBRELIS, 20 QTERN, 33 QUADRAMET, 19 quazepam, 29 QUDEXY XR, 25 QUESTRAN/QUESTRAN LIGHT, 21 quetiapine, 27

quetiapine ext-rel, 28 QUILLIVANT XR, 28 quinapril, 20 quinapril/hydrochlorothiazide, 20 quinidine gluconate ext-rel, 21 QUTENZA, 53 QVAR, 50 R rabeprazole delayed-rel, 41 RADICAVA, 31 raloxifene, 38 raltegravir, 13 ramelteon, 29 ramipril, 20 ramucirumab, 19 RANEXA, 24 ranibizumab, 56 ranitidine, 40 ranolazine ext-rel, 24 RAPAFLO, 42 RAPAMUNE, 47 rasagiline, 27 rasburicase, 16 RASUVO, 45 RAVICTI, 39 RAYALDEE, 38 RAZADYNE, 26 RAZADYNE ER, 26 REBIF, 30 REBIF REBIDOSE, 30 REBINYN, 43 RECLAST, 34 RECOMBINATE, 43 RECTIV, 42 REGLAN, 40 regorafenib, 17 REGRANEX, 53 RELENZA, 15 RELISTOR, 41 RELPAX, 29 REMERON, 27 REMICADE, 45 REMODULIN, 24 RENAGEL, 38 RENFLEXIS, 45 RENVELA, 38 REOPRO, 44 repaglinide, 33 repaglinide/metformin, 33 REPATHA, 22 REQUIP, 27 REQUIP XL, 27 RESCRIPTOR, 13 reslizumab inj, 50 RESTASIS, 55 RESTORIL, 29 RETACRIT, 43 retapamulin, 51 RETIN-A, 50 RETIN-A MICRO, 50 RETROVIR, 14 REVATIO, 24 REVCOVI, 39 REVLIMID, 17 REXULTI, 28

81

REYATAZ, 14 Rho (D) immune globulin, 46 RHOFADE, 53 RHOGAM, 46 RHOGAM PLUS, 46 RHOPHYLAC, 46 RHOPRESSA, 56 RIASTAP, 44 ribavirin caps, 14 ribavirin caps - Ribasphere, 14 ribavirin tabs, 14 ribociclib, 17 ribociclib + letrozole, 17 RIDAURA, 45 rifabutin, 15 RIFADIN, 14 rifampin, 14 rifampin/isoniazid/pyrazinamide, 14 rifapentine, 14 RIFATER, 14 rifaximin, 15 rilonacept, 46 rilpivirine, 13 RILUTEK, 31 riluzole, 31 rimabotulinumtoxinB, 31 rimantadine, 15 rimexolone, 55 riociguat, 24 risedronate, 34 risedronate delayed-rel, 34 RISPERDAL, 28 RISPERDAL CONSTA, 28 RISPERDAL M-TABS, 28 risperidone, 28 risperidone long-acting inj, 28 risperidone orally disintegrating tabs, 28 RITALIN, 28 RITALIN LA, 28 ritonavir, 14 RITUXAN, 19 rituximab, 19 rivaroxaban, 43 rivastigmine, 26 rivastigmine transdermal, 26 RIXUBIS, 44 rizatriptan, 29 ROCALTROL, 38 ROCEPHIN, 11 roflumilast, 49 rolapitant, 40 romidepsin, 18 romiplostim, 44 ropinirole, 27 ropinirole ext-rel, 27 rosiglitazone, 33 rosuvastatin, 22 rotigotine transdermal, 27 ROWASA, 41 ROXICODONE, 10 ROXYBOND, 10 RUBRACA, 19 rucaparib, 19 RUCONEST, 44 rufinamide, 25 ruxolitinib, 17

RYDAPT, 17 RYTARY, 27 RYTHMOL SR, 21 S SABRIL, 25 sacubitril/valsartan, 24 safinamide, 27 SALAGEN, 41 salmeterol xinafoate, 48 samarium sm 153 lexidronam, 19 SAMSCA, 39 SANCUSO, 40 SANDIMMUNE, 46 SANDOSTATIN, 39 SANDOSTATIN LAR, 39 SAPHRIS, 28 sapropterin, 38 saquinavir mesylate, 14 SARAFEM, 26 sargramostim, 43 sarilumab, 45 SAVELLA, 29 scopolamine, 56 scopolamine transdermal, 40 SEASONIQUE, 35 sebelipase alfa, 39 secnidazole, 15 secukinumab, 51 SEEBRI NEOHALER, 48 selegiline caps, 27 selegiline orally disintegrating tabs, 27 selegiline transdermal, 26 selenium sulfide shampoo 2.5%, 51 selexipag, 24 SELZENTRY, 13 semaglutide, 32 SENSIPAR, 34 SEREVENT DISKUS, 48 SERNIVO, 52 SEROQUEL, 27 SEROQUEL XR, 28 SEROSTIM, 37 sertraline, 26 sevelamer carbonate, 38 sevelamer HCl, 38 SIGNIFOR, 39 SIKLOS, 19 sildenafil, 24 SILENOR, 29 SILIQ, 45 silodosin, 42 SILVADENE, 51 silver sulfadiazine, 51 SIMBRINZA, 55 SIMPONI, 45 simvastatin, 22 sinecatechins, 53 SINEMET, 27 SINEMET CR, 27 SINGULAIR, 49 sirolimus, 47 SIRTURO, 14 sitagliptin phosphate, 32 sitagliptin/metformin, 32 sitagliptin/metformin ext-rel, 32

82

SIVEXTRO, 15 SKLICE, 53 SKYLA, 36 sodium ferric gluconate inj, 47 sodium fluoride, 54 sodium hyaluronate, 10, 11 sodium oxybate, 30 sodium phenylbutyrate, 38 sodium phosphates, 41 sodium picosulfate/magnesium oxide/citric acid, 41 sodium polystyrene sulfonate, 38 sodium sulfate/potassium sulfate/magnesium sulfate, 41 sodium zirconium cyclosilicate, 38 sofosbuvir, 14 sofosbuvir/velpatasvir, 14 sofosbuvir/velpatasvir/voxilaprevir, 14 SOFTCLIX LANCET DEVICE, 34 SOFTCLIX LANCETS, 34 SOFTTOUCH LANCET DEVICE, 34 SOFTTOUCH LANCETS, 34 SOLESTA, 42 solifenacin, 42 SOLIQUA, 32 SOLIRIS, 44 SOLODYN, 12 SOLOSEC, 15 somatropin, 37 SOMATULINE DEPOT, 39 SOMAVERT, 39 sonidegib, 19 SOOLANTRA, 53 sorafenib, 17 sotalol, 21 SOVALDI, 14 SPECTRACEF, 11 spinosad, 53 SPIRIVA, 48 SPIRIVA RESPIMAT, 48 spironolactone, 20 spironolactone/hydrochlorothiazide, 23 SPORANOX, 12 SPRIX, 9 SPRYCEL, 17 STALEVO, 27 STARLIX, 33 stavudine, 14 STELARA, 51 STELARA SUBCUTANEOUS, 45 STIMATE, 44 STIOLTO RESPIMAT, 48 stiripentol, 26 STIVARGA, 17 STRATTERA, 28 STRENSIQ, 39 streptozocin, 16 STRIANT, 31 STRIBILD, 13 STRIVERDI RESPIMAT, 48 SUBLOCADE, 31 SUBOXONE FILM, 31 SUBSYS, 10 sucralfate, 42 sucralfate susp, 42 sucroferric oxyhydroxide, 38 SULAR, 23 sulconazole, 51

sulfacetamide soln 10%, 54 sulfacetamide/prednisolone acetate oint 10%/0.2%, 54 sulfacetamide/prednisolone phosphate 10%/0.25%, 54 sulfacetamide/sulfur, 53 sulfamethoxazole/trimethoprim, 15 sulfamethoxazole/trimethoprim DS, 15 SULFAMYLON, 51 sulfasalazine, 40 sulfasalazine delayed-rel, 41 sulindac, 9 sumatriptan, 29 sumatriptan inj, 29 sumatriptan/naproxen sodium, 29 sunitinib, 17 SUPARTZ FX, 11 SUPPRELIN LA, 39 SUPRAX, 11 SUPREP, 41 SUSTIVA, 13 SUSTOL, 40 SUTENT, 17 suvorexant, 29 SYMBICORT, 50 SYMBYAX, 27 SYMDEKO, 49 SYMLINPEN, 32 SYMTUZA, 13 SYNAGIS, 15 SYNALAR, 52 SYNAREL, 36 SYNJARDY, 33 SYNJARDY XR, 33 SYNRIBO, 19 SYNTHROID, 38 SYNVISC, 11 SYNVISC-ONE, 11 SYPRINE, 39 T TABLOID, 16 TACHOSIL, 53 tacrolimus, 46, 52 tacrolimus ext-rel, 46 tadalafil 2.5 mg, 5 mg, 42 tadalafil tabs 20 mg, 24 tadalafil tabs 20 mg - Alyq, 24 TAFINLAR, 17 tafluprost, 56 TAGRISSO, 18 TAKHZYRO, 44 talazoparib, 19 taliglucerase alfa, 39 talimogene laherparepvec, 19 TALTZ, 45 TALZENNA, 19 TAMIFLU, 15 tamoxifen, 16 tamsulosin, 42 TAPAZOLE, 38 tapentadol, 10 tapentadol ext-rel, 10 TARCEVA, 17 TARGRETIN caps, 18 TARGRETIN gel, 19 TARKA, 20 TASIGNA, 18

83

tasimelteon, 29 TAVALISSE, 44 TAXOTERE, 18 tazarotene crm 0.05%, gel 0.05%, 0.1%, 51 tazarotene crm 0.1%, 50 TAZORAC, 50, 51 tbo-filgrastim, 43 TECENTRIQ, 18 TECFIDERA, 30 tedizolid, 15 teduglutide, 42 TEFLARO, 12 TEGRETOL, 25 TEGRETOL-XR, 25 TEGSEDI, 39 TEKTURNA, 23 TEKTURNA HCT, 23 telavancin, 15 telbivudine, 14 telmisartan, 21 telmisartan/hydrochlorothiazide, 21 telotristat, 42 temazepam, 29 TEMODAR, 16 TEMOVATE, 53 temozolomide, 16 temsirolimus, 17 teniposide, 18 tenofovir alafenamide, 14 tenofovir disoproxil fumarate, 14 TENORMIN, 22 terazosin, 20 terbinafine tabs, 12 terbutaline, 49 terconazole crm, 42 terconazole supp 80 mg, 42 teriflunomide, 30 teriparatide, 34 tesamorelin, 39 TESSALON, 48 TESTOPEL, 32 testosterone buccal, 31 testosterone cypionate, 31 testosterone enanthate, 31 testosterone gel, 31 testosterone pellets, 32 testosterone soln, 31 testosterone transdermal, 31 testosterone undecanoate inj, 31 tetrabenazine, 30 tetracycline, 12 tezacaftor/ivacaftor + ivacaftor, 49 thalidomide, 17 THALOMID, 17 THEO-24, 50 theophylline ext-rel caps, 50 theophylline ext-rel tabs, 50 theophylline liquid, 50 thioguanine, 16 thioridazine, 28 thiotepa, 16 thiothixene, 28 THYROGEN, 39 thyroid, 38 thyrotropin alfa, 39 tiagabine, 25

TIAZAC, 23 TIBSOVO, 19 ticagrelor, 44 TICE BCG, 18 TIGAN, 40 tigecycline, 15 TIKOSYN, 21 tildrakizumab-asmn, 45 timolol hemihydrate, 55 timolol maleate, 55 timolol maleate gel, 55 TIMOPTIC, 55 TIMOPTIC-XE, 55 tinidazole, 15 tiotropium, 48 tiotropium/olodaterol, 48 tipranavir, 14 tirofiban inj, 44 TIVICAY, 13 TOBI, 49 TOBI PODHALER, 49 TOBRADEX OINTMENT, 54 TOBRADEX SUSPENSION, 54 tobramycin, 54 tobramycin inhalation powder, 49 tobramycin inhalation soln, 49 tobramycin/dexamethasone oint 0.3%/0.1%, 54 tobramycin/dexamethasone susp 0.3%/0.1%, 54 tobramycin/loteprednol, 54 TOBREX, 54 tocilizumab, 45 tofacitinib, 45 tofacitinib ext-rel, 45 TOFRANIL, 27 TOLAK, 51 tolcapone, 27 tolterodine, 42 tolterodine ext-rel, 42 tolvaptan, 39 TOPAMAX, 25 TOPICORT, 52 TOPICORT LP, 52 topiramate, 25 topiramate ext-rel, 25, 26 topotecan, 18 topotecan inj, 18 TOPROL-XL, 22 toremifene, 16 TORISEL, 17 torsemide, 23 TOTECT, 18 TOUJEO, 33 trabectedin, 16 TRACLEER, 24 TRADJENTA, 32 tramadol, 10 tramadol ext-rel, 10 tramadol/acetaminophen, 10 trametinib, 17 trandolapril, 20 trandolapril/verapamil ext-rel, 20 tranexamic acid, 45 TRANSDERM SCOP, 40 TRANXENE T-TAB, 25 tranylcypromine, 26 trastuzumab, 19

84

TRAVATAN Z, 56 travoprost, 56 trazodone, 27 TREANDA, 16 TRELEGY ELLIPTA, 48 TRELSTAR, 17 TRELSTAR DEPOT, 17 TRELSTAR LA, 17 TREMFYA, 51 treprostinil, 24 treprostinil ext-rel, 24 TRESIBA, 33 tretinoin, 50 tretinoin gel microsphere, 50 TRETTEN, 44 TREXIMET, 29 triamcinolone acetonide crm 0.5%, 52 triamcinolone acetonide crm, lotion 0.025%, 52 triamcinolone acetonide crm, lotion, oint 0.1%, 52 triamcinolone acetonide topical spray, 52 triamcinolone oint 0.05%, 52 triamcinolone paste, 54 triamterene/hydrochlorothiazide, 23 triamterene/hydrochlorothiazide 37.5/25, 24 triamterene/hydrochlorothiazide 50/25, 24 TRIANEX, 52 triazolam, 29 TRIBENZOR, 21 TRICOR, 22 trientine, 39 triethanolamine polypeptide oleate, 56 trifluoperazine, 28 trifluridine, 55 trifluridine/tipiracil, 19 TRIGLIDE, 22 trihexyphenidyl, 27 TRILEPTAL, 25 TRILIPIX, 22 trimethobenzamide, 40 trimethoprim, 15 TRI-NORINYL, 35 TRINTELLIX, 26 TRIPTODUR, 39 triptorelin pamoate, 17, 39 TRISENOX, 18 TRIUMEQ, 13 TRIZIVIR, 13 TROGARZO, 13 TROKENDI XR, 26 trospium, 42 trospium ext-rel, 42 TRULANCE, 42 TRULICITY, 32 TRUSOPT, 55 TRUVADA, 13 TWYNSTA, 21 TYBOST, 13 TYGACIL, 15 TYKERB, 17 TYLENOL w/CODEINE, 10 TYMLOS, 34 TYSABRI, 30 TYVASO, 24 TYZEKA, 14

U UDENYCA, 43 ULESFIA, 53 ULORIC, 9 ULTRAM, 10 ULTRAM ER, 10 ULTRAVATE, 53 umeclidinium/vilanterol, 48 UNASYN, 12 UPTRAVI, 24 URECHOLINE, 42 uridine triacetate, 39 urine test strips, 34 UROCIT-K, 42 UROCIT-K 15 mEq, 42 UROXATRAL, 42 URSO, 40 URSO FORTE, 40 ursodiol, 40 ustekinumab, 45, 51 UTIBRON NEOHALER, 48 V VAGIFEM, 36 valacyclovir, 15 valbenazine, 31 VALCHLOR, 16 VALCYTE, 14 valganciclovir, 14 VALIUM, 25 valproic acid, 25 valrubicin, 18 valsartan, 21 valsartan/hydrochlorothiazide, 21 VALSTAR, 18 VALTREX, 15 VANCOCIN, 15 vancomycin, 15 vancomycin oral soln, 15 vandetanib, 17 VANOS, 53 VANTAS, 16 varenicline, 31 varicella zoster immune globulin, 46 VARIZIG, 46 VARUBI, 40 VASCEPA, 22 VASERETIC, 20 VASOTEC, 20 VECAMYL, 24 VECTIBIX, 19 VECTICAL, 51 vedolizumab, 40 velaglucerase alfa, 39 VELCADE, 19 VELETRI, 24 VELPHORO, 38 VELTASSA, 38 VELTIN, 51 VEMLIDY, 14 vemurafenib, 17 VENCLEXTA, 19 venetoclax, 19 venlafaxine, 26 venlafaxine ext-rel, 26 venlafaxine ext-rel tabs, 26

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VENOFER, 47 VENTAVIS, 24 verapamil, 23 verapamil ext-rel, 23 VERDESO, 52 VEREGEN, 53 verteporfin, 56 VERZENIO, 17 VESICARE, 42 vestronidase alfa-vjbk, 39 VEXOL, 55 VFEND, 12 VIBATIV, 15 VIBERZI, 41 VIBRAMYCIN, 12 VICTOZA, 32 VIDAZA, 18 VIDEX EC, 13 VIDEX soln, 14 vigabatrin, 25 VIGAMOX, 54 VIIBRYD, 26 vilazodone, 26 VIMIZIM, 39 VIMPAT, 25 vinblastine, 18 vincristine, 18 vincristine sulfate liposomal, 19 vinorelbine, 18 VIOKACE, 41 VIRACEPT, 14 VIRAMUNE, 13 VIRAMUNE XR, 13 VIREAD, 14 vismodegib, 19 VISTARIL, 25, 48 VISTIDE, 14 VISUDYNE, 56 VITAFOL-OB, 47 vitamin ADC/fluoride drops, 47 vitamin ADC/fluoride/iron drops, 47 VITRAKVI, 17 VIVELLE-DOT, 36 VIVITROL, 30 VIZIMPRO, 17 VOLTAREN GEL, 9 von Willebrand factor, recombinant, 44 VONVENDI, 44 vorapaxar, 44 VORAXAZE, 19 voriconazole, 12 vorinostat, 19 vortioxetine, 26 VOSEVI, 14 VOTRIENT, 17 VPRIV, 39 VWF, human/factor VIII complex, 44 VYVANSE, 28 VYZULTA, 56 W warfarin, 43 WELCHOL, 21 WELLBUTRIN SR, 27 WELLBUTRIN XL, 27 WILATE, 44

WINRHO SDF, 46 X XADAGO, 27 XALATAN, 56 XALKORI, 17 XANAX, 25 XANAX XR, 25 XARELTO, 43 XELJANZ, 45 XELJANZ XR, 45 XELODA, 16 XENAZINE, 30 XEOMIN, 31 XERESE, 53 XERMELO, 42 XGEVA, 34 XIAFLEX, 53 XIFAXAN, 15 XIGDUO XR, 33 XIIDRA, 55 XOFLUZA, 15 XOLAIR, 49 XOPENEX CONCENTRATE, 48 XOPENEX SOLUTION, 48 XTAMPZA ER, 10 XTANDI, 16 XULTOPHY, 32 XURIDEN, 39 XYLOCAINE, 53 XYNTHA, 43 XYNTHA SOLOFUSE, 43 XYREM, 30 Y YASMIN, 35 YAZ, 35 YERVOY, 19 YONDELIS, 16 YONSA, 16 Z zafirlukast, 49 zaleplon, 29 ZALTRAP, 19 zanamivir, 15 ZANOSAR, 16 ZANTAC, 40 ZARONTIN, 25 ZARXIO, 43 ZAVESCA, 39 ZEJULA, 19 ZELAPAR, 27 ZELBORAF, 17 ZEMAIRA, 49 ZEMPLAR, 38 ZENZEDI, 28 ZESTORETIC, 20 ZESTRIL, 20 ZETIA, 21 ZIAC, 22 ZIAGEN, 13 ZIAGEN soln, 13 ZIANA, 50 ziconotide, 10 zidovudine, 14 zileuton ext-rel, 49

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zinc acetate, 47 ZINECARD, 18 ZINPLAVA, 46 ZIOPTAN, 56 ziprasidone, 28 ZIRGAN, 55 ZITHROMAX, 12 ziv-aflibercept, 19 ZOFRAN, 40 ZOHYDRO ER, 10 ZOLADEX, 16 zoledronic acid, 34 ZOLINZA, 19 zolmitriptan, 29 zolmitriptan nasal spray, 29 ZOLOFT, 26 zolpidem, 29 zolpidem ext-rel, 29 zolpidem spray, 29 ZOLPIMIST, 29 ZOMIG, 29 ZOMIG/ZOMIG-ZMT, 29

ZONALON, 53 ZONEGRAN, 25 zonisamide, 25 ZONTIVITY, 44 ZORBTIVE, 37 ZORTRESS, 47 ZOSYN, 12 ZOVIRAX, 15, 53 ZUBSOLV, 31 ZUPLENZ, 40 ZYCLARA, 53 ZYDELIG, 17 ZYFLO CR, 49 ZYKADIA, 17 ZYLET, 54 ZYLOPRIM, 9 ZYPREXA RELPREVV, 28 ZYPREXA/ZYPREXA ZYDIS, 27 ZYTIGA 250 mg, 16 ZYTIGA 500 mg, 16 ZYVOX, 15

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