Blue Rx Basic Formulary Effective 12/01/2016

INTRODUCTION The Blue Rx Basic formulary is a list of drugs covered under your pharmacy benefit and developed to serve as a guide for physicians, pharmacists, healthcare professionals and members in the selection of cost-effective drug therapy. Wellmark recognizes that drug therapy is an integral part of effective health management. The vast availability of drug options, however, warrants a reasonable program for drug selection and use. Wellmark continually reviews new and existing drugs to ensure the formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the-counter (OTC) agents while minimizing potential duplications. The formulary is a continually reviewed and modified document that represents covered drugs under your pharmacy benefit. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at www.Wellmark.com. Wellmark welcomes your input and feedback on the information provided in this document.

FORMULARY OVERVIEW The Blue Rx Basic formulary is continually changing to reflect new advances in drug treatment therapies and current practices of Wellmark providers. Due to the rapidly changing environment, this process ensures appropriate formulary review and tier placement. To continue to provide sustainable pharmacy benefits and access to needed cost-effective treatments, concentrated evaluation and analysis of drug products in formularies is accomplished through this process. Wellmark has developed the Pharmacy and Therapeutics Committee (P&T) to ensure all drugs in the Blue Rx Basic formulary and new drugs approved by the United States Food and Drug Administration (FDA) are reviewed by licensed physicians actively practicing medicine in Iowa and South Dakota. In addition, the process allows P&T members the opportunity to receive evidence-based clinical data and make clinical recommendations for formulary placement and utilization management. The entire Wellmark formulary is reviewed annually by P&T including all new drugs approved by the FDA.

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The P&T includes licensed physicians and pharmacists. These clinicians serve in an evaluation, education and advisory capacity to the Wellmark Pharmacy program specific to the coverage and limitations of drugs on the Wellmark formularies. Through review and discussion, P&T votes whether the drug or drug class is therapeutically unique, similar or inferior to existing treatment options. In addition, the P&T makes utilization management recommendations to Wellmark for consideration when there are therapeutically interchangeable alternatives. The P&T meets quarterly to evaluate drugs requested for addition to the Wellmark formularies, reviews existing drugs in the Wellmark formularies and establishes recommendations for utilization management.

HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within one tier on the formulary. Each tier is assigned a cost, which is determined by the member's pharmacy benefit plan. You may refer to the formulary as a guide to select the most appropriate drugs and associated cost share.

Specialty Drugs (SP-P): Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient's drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit.

• Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share.

Specialty pharmacies specialize in the delivery and clinical management of specialty drugs. Wellmark has two preferred specialty pharmacy providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy Solutions. You can find more information about their services at www.Wellmark.com. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described below:

• Prior Authorization (PA): This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at

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1-800-600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6 p.m. CST Prior authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Wellmark. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. A list of edits recommended by Wellmark is available upon request. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage.

• Quantity Limits (QL): Wellmark typically covers a 30-day supply for

prescriptions per co-pay. Some drugs, however, have a quantity limit. Amounts over the specified quantity limits are not a covered benefit. Quantity limits are in place to ensure the drug is being used correctly and other treatments are not appropriate. Most people would not need to take these drugs more often than what Wellmark allows. No special steps are necessary by the physician or member to have these drugs covered as long as the drugs prescribed do not exceed quantity limits. A few drugs may also require prior authorization (for example, Viagra). If you require one of these drugs in a larger quantity than is allowed, your physician may make a special request for coverage. Your physician may be asked to provide details about your medical condition and treatment plan. After reviewing the information, coverage will be evaluated based on medical necessity. Your benefits certificate, coverage manual, or policy has specific information about your plan's prior authorization requirements.

• Preventive Drugs (PV): Preventive drugs are defined by the Internal Revenue Service, and your deductible obligation may be waived for these drugs. Preventive drugs are prescribed to prevent the occurrence of a disease or condition with risk factors such as high blood pressure, high cholesterol, diabetes, asthma, heart attack and stroke, or to prevent the recurrence of the disease or condition for individuals who have recovered. Preventive drugs do not include drugs used to treat an existing illness, injury or condition. For some pharmacy plans that require you to pay a certain amount before the plan coverage begins, preventive drugs may be covered before you reach that amount. To be sure, you should read your enrollment information to see how preventive drugs are covered specific to your plan.

• Generic Available (GA): Indicates a generic equivalent is available

for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved "A"-rated generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for

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the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug.

HEALTH CARE REFORM PREVENTIVE DRUGS

Preventive drugs with an "A" or "B" rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

HOW TO READ YOUR FORMULARY

BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Basic formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits.

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FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health professional through an exception request for a non-formulary prescription drug (outlined below). Generally, the following guidelines must be documented in order for an exception to be granted:

• All covered formulary drugs on any tier will be ineffective; OR • All covered formulary drugs on any tier have been ineffective; OR • All covered formulary drugs on any tier would not be as effective as

the non-formulary drug; OR • All covered formulary drugs would have adverse effects

COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to:

• OTC drugs or their equivalents unless otherwise specified in the formulary listing.

• Drug products used for cosmetic purposes • Experimental drug products, or any drug product used in an

experimental manner • Replacement of a lost or stolen drug • Foreign drugs or drugs not approved by the United States Food & Drug

Administration (FDA)

GENERIC DRUG SUBSTITUTION In most cases, Wellmark promotes the use of equally effective generic drugs whenever possible. If a member or physician requests a brand-name product when the prescription is filled and a generic equivalent is available, the member will typically be required to pay the difference in cost between the brand and the generic drug. When a brand-name drug becomes available as a generic, the brand-name product may move to a higher tier. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. Members will not be responsible for the cost difference between brands and generics when choosing one of the products listed below:

• Coumadin • Equetro • Tegretol/Tegretol XR • Cytomel • Lanoxin • Theophylline products • Depakene • Stavzor • Thyrolar • Depakote/Depakote ER • Synthroid • Tirosint • Dilantin

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DRUG REQUESTS PROCEDURE Drug requests, questions or information regarding the drug requests, formulary status or other coverage may be requested.

1. The appropriate forms for drug review are available at Wellmark.com or by calling the Wellmark Pharmacy program at 1-800-600-8065.

2. Completed Wellmark Prior Authorization forms should be faxed to 1-888-836-0730

3. Completed Formulary Exception request forms should be faxed to 1-888-836-0730

The requesting provider will be provided written notification of Wellmark review decisions. Non-approved requests may be appealed. The physician must provide information to support the appeal on the basis of medical necessity.

WELLMARK'S CLAIMS APPEAL AND EXTERNAL REVIEW PROCESS Finding out that a claim has been denied or paid differently than you expected can be frustrating. It's important you understand the reasons behind any decision to deny payment for a claim (also known as an adverse benefit determination). You can always contact Customer Service with a question about how a claim was decided, but for a full and fair review of a denied claim, use Wellmark's Claims Appeal and External Review Process. Here's how it works: Step 1: Filing an appeal for Review by Wellmark

• Whether you have coverage through your employer or you are an individual policyholder, you have a right to file an appeal when you receive an adverse benefit determination for payment of services under your benefit plan. (If your employer has a "self-funded" group health plan, the group is responsible for final claim determinations. However, your employer may have Wellmark review appeal requests on behalf of the self-funded plan.)

• Individuals applying for individual insurance policies may also file an appeal if their application for membership is initially denied through the medical underwriting process.

• The appeal must be filed in writing using a Wellmark Appeal/Review Form for Iowa or South Dakota and must be filed within 180 days of the date of the decision. However, if the situation is medically urgent, the appeal may be submitted verbally by calling Wellmark.

• More information is available in our How to Appeal notifications for Iowa and South Dakota.

Step 2: Filing a Request for External Review If you have exhausted our internal Appeal Process (Step 1) and you are not satisfied with the outcome (final adverse benefit determination) relating to a covered benefit that is denied, and the claim denial involves medical judgment or appropriateness, you may request an external review with the state's insurance division:

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• The request must be filed in writing using an External Review Request Form for Iowa or South Dakota. External review may not be available for all members or for all types of claims, and is not available for Medicare Supplemental or most dental plans. Self-funded group health plans may use a different external review process.

• An expedited external review process is available if you have a medical condition where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function. Information regarding an expedited external review may be available from the state insurance division.

Please refer to your health plan benefits document, coverage manual or summary plan description for additional details on the Internal Appeal and External Review processes that is applicable to your specific plan.

LEGEND

GA Generic Available PA Prior Authorization PV Preventive Medication QL Quantity Limit SP-P Specialty Preferred lowercase Indicates generic availability UPPERCASE Indicates brand availability

CONTACT INFORMATION The Blue Rx formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx formulary, other quick-reference guides are available on our web site at Wellmark.com.

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Wellmark Basic Drug Name Drug Tier Requirements/Limits ANALGESICS COX-II INHIBITORS celecoxib 1 QL GOUT allopurinol 1 colchicine 1 colchicine/probenecid 1 probenecid 1 NON-OPIOID ANALGESICS acetaminophen/salicylamide/phenyltoloxa

mine 1

butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/aspirin/caffeine 1 NSAIDS choline/magnesium trisalicylates 1 diclofenac potassium 1 diclofenac sodium delayed-rel 1 diclofenac sodium ext-rel 1 diflunisal 1 etodolac 1 etodolac ext-rel 1 fenoprofen 1 flurbiprofen 1 ibuprofen 1 indomethacin 1 indomethacin ext-rel 1 ketoprofen 1 ketoprofen ext-rel 1 ketorolac 1 meclofenamate sodium 1 mefenamic acid 1 meloxicam 1 nabumetone 1 naproxen 1 naproxen delayed-rel 1 naproxen sodium 1 naproxen sodium ext-rel 1 oxaprozin 1 piroxicam 1 salsalate 1 sulindac 1

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Drug Name Drug Tier Requirements/Limits tolmetin sodium 1 NSAIDS, COMBINATIONS diclofenac/misoprostol 1 OPIOID ANALGESICS alfentanil injection 1 butalbital/acetaminophen/caffeine/codeine 1 butalbital/aspirin/caffeine/codeine 1 butorphanol nasal spray 1 QL CAPITAL W/CODEINE 1 codeine 1 codeine/acetaminophen 1 dihydrocodeine/acetaminophen/caffeine 1 dihydrocodeine/aspirin/caffeine 1 fentanyl transdermal 12mcg, 25mcg,

50mcg, 75mcg, 100mcg 1 QL

FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG, 87.5MCG

1 QL

fentanyl transmucosal lozenge 1 PA hydrocodone/acetaminophen 1 hydrocodone/ibuprofen 1 hydromorphone 1 hydromorphone ext-rel 1 QL HYDROMORPHONE SUPP 1 levorphanol 1 meperidine 1 methadone 1 morphine 1 morphine ext-rel 1 QL morphine supp 5mg, 10mg, 20mg 1 MORPHINE SUPP 30MG 1 oxycodone 1 oxycodone/acetaminophen 1 oxycodone/aspirin 1 oxycodone/ibuprofen 1 oxymorphone 1 oxymorphone ext-rel 1 QL pentazocine/naloxone 1 tramadol 1 tramadol ext-rel tabs 1 tramadol/acetaminophen 1 ANTI-INFECTIVES AMINOGLYCOSIDES neomycin 1 paromomycin 1 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil 1

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Drug Name Drug Tier Requirements/Limits cephalexin 1 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor 1 cefprozil 1 cefuroxime axetil 1 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir 1 cefixime 1 cefpodoxime 1 ceftibuten 1 ceftriaxone 1 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin 1 clarithromycin 1 clarithromycin ext-rel 1 erythromycin base 1 erythromycin delayed-rel 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin 1 ciprofloxacin ext-rel 1 ciprofloxacin oral susp 1 levofloxacin 1 levofloxacin oral soln 1 moxifloxacin 1 ofloxacin 1 ANTIBACTERIALS, PENICILLINS amoxicillin 1 amoxicillin/clavulanate 1 amoxicillin/clavulanate ext-rel 1 ampicillin 1 dicloxacillin 1 penicillin vk 1 ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE 1 sulfamethoxazole/trimethoprim 1 ANTIBACTERIALS, TETRACYCLINES demeclocycline 1 doxycycline hyclate 1 doxycycline hyclate delayed-rel 1 PA doxycycline monohydrate caps 50mg,

75mg, 100mg 1

doxycycline monohydrate caps 150mg 1 PA doxycycline monohydrate susp 1 doxycycline monohydrate tabs 1 PA 10

Drug Name Drug Tier Requirements/Limits minocycline 1 minocycline ext-rel 1 PA tetracycline 1 ANTIFUNGALS clotrimazole troche 1 fluconazole 1 flucytosine 1 griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole 1 PA ketoconazole tabs 1 nystatin oral 1 terbinafine 1 voriconazole 1 ANTIMALARIALS atovaquone/proguanil 1 PV chloroquine 1 PV mefloquine 1 PV PRIMAQUINE 1 PV quinine sulfate 1 ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir/lamivudine 1 abacavir/lamivudine/zidovudine 1 lamivudine/zidovudine 1 ANTIRETROVIRALS, FUSION INHIBITORS FUZEON SP-P ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

NUCLEOSIDE nevirapine 1 nevirapine ext-rel 1 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir 1 didanosine 1 lamivudine soln, tabs 1 stavudine 1 zidovudine 1 ANTITUBERCULAR AGENTS cycloserine 1 ethambutol 1 isoniazid 1 PASER GRANULES 1 pyrazinamide 1 rifampin 1 ANTIVIRALS, CMV AGENTS

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Drug Name Drug Tier Requirements/Limits valganciclovir 1 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil 1 entecavir 1 lamivudine tabs 1 TYZEKA SP-P ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA SP-P PA; QL HARVONI SP-P PA; QL ribavirin 1 SOVALDI SP-P PA; QL ANTIVIRALS, HERPES AGENTS acyclovir 1 famciclovir 1 valacyclovir 1 ANTIVIRALS, INFLUENZA AGENTS rimantadine 1 MISCELLANEOUS atovaquone 1 clindamycin caps, oral soln 1 dapsone 1 ivermectin 1 linezolid 1 metronidazole 1 nitrofurantoin 1 rifabutin 1 tinidazole 1 trimethoprim 1 vancomycin caps 1 vancomycin inj 500mg, 1000mg 1 VANCOMYCIN INJECTION 750MG 1 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS CYCLOPHOSPHAMIDE CAPS 1 EMCYT SP-P temozolomide SP-P ANTIMETABOLITES capecitabine SP-P mercaptopurine 1 methotrexate 1 HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide 1 flutamide 1 XTANDI SP-P ZYTIGA SP-P

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Drug Name Drug Tier Requirements/Limits HORMONAL ANTINEOPLASTICS, ANTIESTROGENS tamoxifen 1 PA; PV HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole 1 exemestane 1 letrozole 1 HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate 1 IMMUNOMODULATORS POMALYST SP-P REVLIMID SP-P THALOMID SP-P KINASE INHIBITORS AFINITOR SP-P QL AFINITOR DISPERZ SP-P ALECENSA SP-P BOSULIF SP-P CABOMETYX SP-P COTELLIC SP-P IBRANCE SP-P ICLUSIG SP-P imatinib mesylate SP-P IMBRUVICA SP-P INLYTA SP-P JAKAFI SP-P MEKINIST SP-P NEXAVAR SP-P SPRYCEL SP-P STIVARGA SP-P SUTENT SP-P TAFINLAR SP-P TAGRISSO SP-P TARCEVA SP-P TASIGNA SP-P TYKERB SP-P QL VOTRIENT SP-P XALKORI SP-P ZELBORAF SP-P ZYKADIA SP-P MISCELLANEOUS bexarotene SP-P etoposide SP-P FARYDAK SP-P hydroxyurea 1 leucovorin 1 LONSURF SP-P 13

Drug Name Drug Tier Requirements/Limits NINLARO SP-P ODOMZO SP-P TARGRETIN GEL SP-P tretinoin caps 1 VENCLEXTA SP-P VISTOGARD SP-P ZOLINZA SP-P TOPOISOMERASE INHIBITORS HYCAMTIN SP-P CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril 1 PV trandolapril/verapamil 1 PV ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide 1 PV captopril/hydrochlorothiazide 1 PV enalapril/hydrochlorothiazide 1 PV fosinopril/hydrochlorothiazide 1 PV lisinopril/hydrochlorothiazide 1 PV moexipril/hydrochlorothiazide 1 PV quinapril/hydrochlorothiazide 1 PV ACE INHIBITORS benazepril 1 PV captopril 1 PV enalapril 1 PV fosinopril 1 PV lisinopril 1 PV moexipril 1 PV perindopril 1 PV quinapril 1 PV ramipril 1 PV trandolapril 1 PV ADRENOLYTICS, CENTRAL clonidine 1 PV clonidine transdermal 1 PV guanfacine 1 PV ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1 spironolactone 1 ALPHA BLOCKERS doxazosin 1 prazosin 1 terazosin 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS

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Drug Name Drug Tier Requirements/Limits amlodipine/valsartan 1 PV telmisartan/amlodipine 1 PV ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide 1 PV ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS candesartan/hydrochlorothiazide 1 PV irbesartan/hydrochlorothiazide 1 PV losartan/hydrochlorothiazide 1 PV telmisartan/hydrochlorothiazide 1 PV valsartan/hydrochlorothiazide 1 PV ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan 1 PV eprosartan 1 PV irbesartan 1 PV losartan 1 PV telmisartan 1 PV valsartan 1 PV ANTIARRHYTHMICS amiodarone 1 PV disopyramide 1 PV dofetilide 1 flecainide 1 PV mexiletine 1 propafenone 1 PV propafenone ext-rel 1 PV quinidine gluconate 1 quinidine sulfate 1 quinidine sulfate ext-rel 1 sotalol 1 PV sotalol af 1 PV ANTILIPEMICS, BILE ACID RESINS cholestyramine powder 1 PV cholestyramine powder light 1 PV colestipol 1 PV ANTILIPEMICS, FIBRATES fenofibrate caps, tabs 1 PV fenofibric acid 1 PV fenofibric acid delayed-rel 1 PV gemfibrozil 1 PV ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS atorvastatin 1 PV fluvastatin 1 PV

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Drug Name Drug Tier Requirements/Limits fluvastatin ext-rel 1 lovastatin 1 PV pravastatin 1 PV simvastatin 1 PV ANTILIPEMICS, MISCELLANEOUS JUXTAPID SP-P PA; QL KYNAMRO SP-P PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin ext-rel 1 PV ANTILIPEMICS, PCSK9 INHIBITORS REPATHA SP-P PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone 1 PV bisoprolol/hydrochlorothiazide 1 PV metoprolol/hydrochlorothiazide 1 PV nadolol/bendroflumethiazide 1 PV propranolol/hydrochlorothiazide 1 PV BETA-BLOCKERS acebutolol 1 PV atenolol 1 PV betaxolol 1 PV bisoprolol 1 PV carvedilol 1 PV labetalol 1 PV metoprolol succinate ext-rel 1 PV metoprolol tartrate 1 PV nadolol 1 PV pindolol 1 PV propranolol 1 PV propranolol ext-rel 1 PV timolol 1 PV CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin 1 PV CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine 1 PV felodipine ext-rel 1 PV isradipine 1 PV nicardipine 1 PV nifedipine 1 PV nifedipine ext-rel 1 PV nimodipine 1 nisoldipine ext-rel 1 PV CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES diltiazem 1 PV diltiazem ext-rel 1 PV

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Drug Name Drug Tier Requirements/Limits verapamil 1 PV verapamil ext-rel 1 PV DIGITALIS GLYCOSIDES digoxin 1 DIURETICS amiloride 1 amiloride/hydrochlorothiazide 1 PV bumetanide 1 chlorothiazide 1 PV chlorthalidone 1 PV furosemide 1 furosemide soln 10mg/ml 1 hydrochlorothiazide 1 PV indapamide 1 PV methyclothiazide 1 PV metolazone 1 spironolactone/hydrochlorothiazide 1 PV torsemide 1 triamterene/hydrochlorothiazide 1 PV MISCELLANEOUS hydralazine 1 PV isoxsuprine 10mg 1 methyldopa 1 PV methyldopa/hydrochlorothiazide 1 PV midodrine 1 minoxidil 1 PV phenoxybenzamine 1 reserpine 1 PV NITRATES, ORAL isosorbide dinitrate 1 PV isosorbide dinitrate ext-rel 1 PV isosorbide mononitrate 1 PV isosorbide mononitrate ext-rel 1 PV nitroglycerin caps 1 PV NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 1 nitroglycerin lingual spray 1 PV nitroglycerin sublingual 1 NITRATES, TRANSDERMAL nitroglycerin transdermal 1 PV PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST LETAIRIS SP-P PA; QL OPSUMIT SP-P PA; QL TRACLEER SP-P PA; QL

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Drug Name Drug Tier Requirements/Limits PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITOR ADCIRCA SP-P PA; QL sildenafil SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR

AGONIST UPTRAVI SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM SP-P PA TYVASO SP-P PA; QL VENTAVIS SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS SP-P PA; QL CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES alprazolam 1 alprazolam ext-rel 1 ALPRAZOLAM INTENSOL 1 chlordiazepoxide 1 clonazepam 1 PV clorazepate 1 diazepam 1 lorazepam 1 oxazepam 1 ANTIANXIETY, MISCELLANEOUS buspirone 1 clomipramine 1 PV fluvoxamine 1 PV fluvoxamine ext-rel 1 PA; PV meprobamate 1 ANTICONVULSANTS carbamazepine 1 PV carbamazepine ext-rel 1 PV diazepam gel 1 divalproex sodium 1 PV divalproex sodium delayed-rel 1 PV divalproex sodium ext-rel 1 PV ethosuximide 1 PV felbamate 1 PV gabapentin 1 lamotrigine 1 PV lamotrigine ext-rel 1 PV levetiracetam 1 PV

18

Drug Name Drug Tier Requirements/Limits oxcarbazepine 1 PV phenobarbital 1 PV phenytoin 1 PV phenytoin sodium extended 1 PV primidone 1 PV SABRIL POWDER SP-P PA; QL SABRIL TABS SP-P QL tiagabine 1 PV topiramate 1 PV valproic acid 1 PV zonisamide 1 PV ANTIDEMENTIA donepezil 1 galantamine 1 galantamine ext-rel 1 memantine 1 rivastigmine 1 rivastigmine transdermal 1 ANTIDEPRESSANTS, MAOIS phenelzine 1 PV tranylcypromine 1 PV ANTIDEPRESSANTS, MISCELLANEOUS bupropion 1 PV bupropion delayed-rel 1 PV bupropion ext-rel (12hr) 1 PV bupropion ext-rel (24hr) 1 PV chlordiazepoxide/amitriptyline 1 maprotiline 1 PV mirtazapine 1 PV nefazodone 1 PV trazodone 1 PV ANTIDEPRESSANTS, SNRIS desvenlafaxine ext-rel 50mg, 100mg 1 PA; PV; QL duloxetine 1 PV venlafaxine 1 PV venlafaxine ext-rel 1 PV ANTIDEPRESSANTS, SSRIS citalopram 1 PV escitalopram 1 PV fluoxetine 1 PV FLUOXETINE 60MG 1 PV fluoxetine delayed-rel 1 PV paroxetine 1 PV paroxetine ext-rel 1 PV sertraline 1 PV ANTIDEPRESSANTS, TCAS 19

Drug Name Drug Tier Requirements/Limits amitriptyline 1 PV amoxapine 1 PV desipramine 1 PV doxepin 1 PV imipramine hcl 1 PV imipramine pamoate 1 PV nortriptyline 1 PV protriptyline 1 PV trimipramine 1 PV ANTIPARKINSONIAN AGENTS amantadine 1 benztropine 1 bromocriptine 1 carbidopa 1 carbidopa/levodopa 1 carbidopa/levodopa ext-rel 1 carbidopa/levodopa/entacapone 1 entacapone 1 pramipexole 1 pramipexole ext-rel 1 PA ropinirole 1 ropinirole ext-rel 1 PA selegiline 1 tolcapone 1 trihexyphenidyl 1 ANTIPSYCHOTICS, ATYPICALS aripiprazole soln 1 aripiprazole tabs 1 PV clozapine 1 PV loxapine 1 PV olanzapine 1 PV olanzapine/fluoxetine 1 paliperidone ext-rel 1 quetiapine 1 PV risperidone 1 PV ziprasidone 1 PV ANTIPSYCHOTICS, MISCELLANEOUS chlorpromazine 1 PV fluphenazine 1 PV haloperidol 1 PV perphenazine 1 PV perphenazine/amitriptyline 1 pimozide 1 thioridazine 1 PV thiothixene 1 PV trifluoperazine 1 PV

20

Drug Name Drug Tier Requirements/Limits ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine/dextroamphetamine 1 amphetamine/dextroamphetamine ext-rel 1 PA clonidine ext-rel 1 PA dexmethylphenidate 1 dexmethylphenidate ext-rel 1 PA dextroamphetamine 5mg, 10mg 1 dextroamphetamine ext-rel 5mg, 10mg,

15mg 1 PA

dextroamphetamine soln 1 guanfacine ext-rel 1 methamphetamine tabs 5mg 1 methylphenidate chew 2.5mg, 5mg, 10mg 1 methylphenidate ext-rel 18mg, 27mg,

36mg, 54mg 1 PA

methylphenidate ext-rel caps 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

1 PA

methylphenidate ext-rel caps 20mg, 30mg, 40mg

1 PA

methylphenidate ext-rel tabs 10mg, 20mg 1 PA methylphenidate soln 1 methylphenidate tabs 5mg, 10mg, 20mg 1 HUNTINGTON'S DISEASE AGENTS tetrabenazine SP-P QL HYPNOTICS: BENZODIAZEPINES estazolam 1 flurazepam 1 temazepam 1 triazolam 1 HYPNOTICS: NON-BENZODIAZEPINES eszopiclone 1 PA HETLIOZ SP-P PA; QL zaleplon 1 zolpidem 1 zolpidem ext-rel 1 PA zolpidem sublingual 1 PA MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine inj 1 dihydroergotamine nasal spray 1 QL migergot supp 1 MIGRAINE, MISCELLANEOUS isometheptene/caffeine/acetaminophen 1 isometheptene/dichloralphenazone/acetam

inophen 1

MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan 1 QL

21

Drug Name Drug Tier Requirements/Limits frovatriptan 1 PA; QL naratriptan 1 QL rizatriptan 1 QL sumatriptan 1 QL zolmitriptan 1 QL MISCELLANEOUS ergoloid mesylates 1 riluzole 1 MOOD STABILIZERS lithium carbonate 1 lithium carbonate ext-rel 1 MULTIPLE SCLEROSIS AMPYRA SP-P QL AUBAGIO SP-P PA; QL AVONEX SP-P PA; QL AVONEX PEN SP-P PA; QL AVONEX PREFILLED SYG SP-P PA; QL BETASERON SP-P PA; QL EXTAVIA SP-P PA; QL GILENYA SP-P PA; QL glatopa 20 mg SP-P PA; QL PLEGRIDY SP-P PA; QL REBIF SP-P PA; QL TECFIDERA SP-P PA; QL ZINBRYTA SP-P PA MUSCULOSKELETAL THERAPY AGENTS baclofen 1 carisoprodol 1 carisoprodol/aspirin 1 carisoprodol/aspirin/codeine 1 chlorzoxazone 1 cyclobenzaprine 1 dantrolene 1 metaxalone 1 methocarbamol 1 orphenadrine ext-rel 1 orphenadrine/aspirin/caffeine 1 tizanidine 1 MYASTHENIA GRAVIS pyridostigmine 1 pyridostigmine ext-rel 1 NARCOLEPSY/CATAPLEXY armodafinil 1 PA; QL modafinil 1 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS

22

Drug Name Drug Tier Requirements/Limits acamprosate calcium 1 PV disulfiram 1 PV PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST naltrexone 1 PV PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

ANTAGONIST COMBINATIONS buprenorphine/naloxone sublingual 1 PV PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine sublingual 1 PV PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion ext-rel 1 ENDOCRINE AND METABOLIC ANDROGENS oxandrolone 1 testosterone cypionate 1 testosterone enanthate 1 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose 1 PV ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide/metformin 1 PV glyburide/metformin 1 PV ANTIDIABETICS, BIGUANIDES metformin 1 PV metformin ext-rel 1 PV ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone/metformin 1 PV ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone/glimepiride 1 PV ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone 1 PV ANTIDIABETICS, MEGLITINIDE nateglinide 1 PV repaglinide 1 PV ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide/metformin 1 ANTIDIABETICS, SULFONYLUREAS chlorpropamide 1 PV glimepiride 1 PV glipizide 1 PV glipizide ext-rel 1 PV glyburide 1 PV glyburide micronized 1 PV tolazamide 1 PV tolbutamide 1 PV

23

Drug Name Drug Tier Requirements/Limits CALCIUM RECEPTOR ANTAGONISTS SENSIPAR SP-P CALCIUM REGULATORS, BISPHOSPHONATES alendronate 5mg, 10mg, 35mg, 70mg 1 PV alendronate 40mg 1 etidronate 1 ibandronate 1 PV risedronate 1 PV risedronate delayed-rel 1 PV CALCIUM REGULATORS, CALCITONINS calcitonin nasal spray 1 PV CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SP-P CONTRACEPTIVES, BIPHASIC azurette 1 PV desogestrel/ethinyl estradiol 1 PV kariva 1 PV kimidess 1 PV pimtrea 1 PV viorele 1 PV CONTRACEPTIVES, CONTINUOUS amethyst 1 levonorgestrel/ethinyl estradiol 1 CONTRACEPTIVES, EXTENDED CYCLE amethia 1 amethia lo 1 ashlyna 1 camrese 1 camrese lo 1 daysee 1 introvale 1 jolessa 1 levonorgestrel/ethinyl estradiol 1 quasense 1 setlakin 1 CONTRACEPTIVES, INJECTABLE medroxyprogesterone acetate 150mg/ml 1 CONTRACEPTIVES, MONOPHASIC altavera 1 alyacen 1 apri 1 PV aubra 1 aviane 1 balziva 1 briellyn 1

24

Drug Name Drug Tier Requirements/Limits chateal 1 cryselle 1 cyclafem 1 cyred 1 PV dasetta 1 delyla 1 desogestrel/ethinyl estradiol 1 PV drospirenone/ethinyl estradiol 1 elinest 1 emoquette 1 PV enskyce 1 PV estarylla 1 falmina 1 gianvi 1 gildagia 1 gildess 1 PV gildess fe 1 PV gildess fe 24 1 juleber 1 PV junel 1 PV junel fe 1 PV junel fe 24 1 kelnor 1 kurvelo 1 larin 1 PV larin fe 1 PV larin fe 24 1 layolis fe chew 1 lessina 1 levonorgestrel/ethinyl estradiol 1 levora 1 lomedia fe 24 1 loryna 1 low-ogestrel 1 lutera 1 marlissa 1 microgestin 1 PV microgestin fe 1 PV microgestin fe 24 1 mono-linyah 1 mononessa 1 necon 1 nikki 1 norethindrone/ethinyl estradiol 1 PV norethindrone/ethinyl estradiol fe 1 norethindrone/ethinyl estradiol fe 1 PV norethindrone/ethinyl estradiol fe chew 1 25

Drug Name Drug Tier Requirements/Limits norgestimate/ethinyl estradiol 1 nortrel 1 ocella 1 ogestrel 1 orsythia 1 philith 1 pirmella 1 portia 1 previfem 1 reclipsen 1 PV sprintec 1 sronyx 1 syeda 1 tarina fe 1 PV vestura 1 vyfemla 1 wera 1 wymzya fe chew 1 PV zarah 1 zenchent 1 zenchent fe chew 1 PV zovia 1 CONTRACEPTIVES, PROGESTIN ONLY camila 1 deblitane 1 errin 1 heather 1 jencycla 1 jolivette 1 lyza 1 nora-be 1 norethindrone 1 norlyroc 1 sharobel 1 CONTRACEPTIVES, TRANSDERMAL xulane 1 CONTRACEPTIVES, TRIPHASIC alyacen 1 aranelle 1 caziant 1 PV cyclafem 1 dasetta 1 enpresse 1 leena 1 levonorgestrel/ethinyl estradiol 1 myzilra 1

26

Drug Name Drug Tier Requirements/Limits necon 1 norgestimate/ethinyl estradiol 1 nortrel 1 pirmella 1 tilia fe 1 PV tri-estaryll 1 tri-legest fe 1 PV tri-linyah 1 tri-lo-sprintec 1 tri-previfem 1 tri-sprintec 1 trinessa 1 trivora 1 velivet 1 PV ENDOMETRIOSIS danazol 1 ESTROGEN/PROGESTIN, ORAL estradiol/norethindrone 1 ethinyl estradiol/norethindrone 1 jinteli 1 lopreeza 1 mimvey 1 mimvey lo 1 ESTROGENS, ORAL covaryx 1 covaryx hs 1 eemt 1 eemt hs 1 esterified estrogens/methyltestosterone 1 estradiol 1 estropipate 1 ESTROGENS, TRANSDERMAL estradiol transdermal twice weekly 1 QL estradiol transdermal weekly 1 ESTROGENS, VAGINAL yuvafem 1 GLUCOCORTICOIDS dexamethasone 1 DEXAMETHASONE INTENSOL 1 dexamethasone oral soln 0.5mg/5ml 1 fludrocortisone 1 hydrocortisone 1 methylprednisolone 1 prednisolone sodium phosphate odt, soln 1 prednisolone syrup 1 prednisone 1 27

Drug Name Drug Tier Requirements/Limits PREDNISONE INTENSOL 1 HUMAN GROWTH HORMONES NORDITROPIN SP-P PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol caps 1 doxercalciferol 1 paricalcitol 1 INSULIN-LIKE GROWTH FACTOR INCRELEX SP-P LYSOSOMAL STORAGE DISORDERS CERDELGA SP-P ZAVESCA SP-P MISCELLANEOUS cabergoline 1 levocarnitine 1 methylergonovine 1 octreotide SP-P RAVICTI SP-P PA; QL SOMAVERT SP-P STRENSIQ SP-P PHENYLKETONURIA TREATMENT AGENTS KUVAN SP-P PA PHOSPHATE BINDER AGENTS calcium acetate 1 PROGESTINS, INJECTABLE progesterone 50mg/ml 1 PROGESTINS, ORAL medroxyprogesterone acetate 1 megestrol susp 1 norethindrone acetate 1 progesterone micronized 1 SELECTIVE ESTROGEN RECEPTOR MODULATOR raloxifene 1 PA; PV THYROID AGENTS, ANTITHYROID AGENTS methimazole 1 propylthiouracil 1 THYROID SUPPLEMENTS levothyroxine 1 levoxyl 1 liothyronine 1 thyroid tab 1 unithroid 1 VASOPRESSINS desmopressin 1

28

Drug Name Drug Tier Requirements/Limits GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate/atropine 1 opium tincture 1 ANTIEMETICS dronabinol 1 granisetron 1 metoclopramide 1 ondansetron 1 ondansetron soln 1 QL prochlorperazine 1 prochlorperazine supp 1 promethazine 1 promethazine supp 1 trimethobenzamide 1 ANTISPASMODICS BELLADONNA/OPIUM SUPP 1 chlordiazepoxide/clidinium 1 dicyclomine 1 glycopyrrolate 1 hyoscyamine sulfate 1 hyoscyamine sulfate ext-rel 1 methscopolamine 1 propantheline 1 CHOLELITHOLYTICS ursodiol 1 H2-RECEPTOR ANTAGONISTS cimetidine 1 famotidine 1 nizatidine 1 ranitidine 1 INFLAMMATORY BOWEL DISEASE, ORAL AGENTS balsalazide 1 budesonide caps 1 sulfasalazine 1 sulfasalazine delayed-rel 1 INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS hydrocortisone enema 1 mesalamine enema 1 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron 1 LAXATIVES/STOOL SOFTENERS KRISTALOSE 1 lactulose 1 peg 3350/electrolytes 1 PV

29

Drug Name Drug Tier Requirements/Limits MISCELLANEOUS cromolyn sodium 100mg/5ml 1 lactulose (encephalopathy) 1 OCALIVA SP-P PA sucralfate 1 PROSTAGLANDINS misoprostol 1 PROTON PUMP INHIBITORS (PPI) esomeprazole 1 QL lansoprazole 1 QL omeprazole 1 QL pantoprazole 1 QL rabeprazole 1 QL SALIVA STIMULANTS cevimeline 1 pilocarpine 1 STEROIDS, RECTAL hydrocortisone acetate supp 1 hydrocortisone cream 1 hydrocortisone/pramoxine 1 lidazone 1 lidocaine/hydrocortisone 1 LIDOCAINE/HYDROCORTISONE GEL 1 ULCER THERAPY COMBINATION lansoprazole/amoxicillin/clarithromycin 1 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin 1 dutasteride 1 dutasteride/tamsulosin 1 finasteride 1 tamsulosin 1 MISCELLANEOUS bethanechol 1 methenamine hippurate 1 methenamine mandelate 1 methenamine/hyoscyamine/methylene

blue/phenyl salicylate/benzoic acid 1

methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium bisphosphonate

1

methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium phosphate

1

methenamine/hyoscyamine/methylene blue/sodium phosphate

1

phenazopyridine 1 30

Drug Name Drug Tier Requirements/Limits potassium citrate 1 potassium citrate/citric acid 1 potassium citrate/sodium citrate/citric acid 1 sodium citrate/citric acid 1 URINARY ANTISPASMODICS darifenacin ext-rel 1 flavoxate 1 oxybutynin 1 oxybutynin ext-rel 1 tolterodine 1 tolterodine ext-rel 1 trospium 1 trospium ext-rel 1 VAGINAL ANTI-INFECTIVES clindamycin cream 1 metronidazole gel 0.75% 1 terconazole cream 0.4% 1 terconazole cream 0.8% 1 PV terconazole supp 1 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE enoxaparin 1 fondaparinux 1 ANTICOAGULANTS, ORAL warfarin 1 PV HEMATOPOIETIC GROWTH FACTORS ARANESP SP-P EPOGEN SP-P GRANIX SP-P LEUKINE SP-P NEULASTA SP-P NEUPOGEN SP-P PROCRIT SP-P ZARXIO SP-P HEMOSTATICS, SYSTEMIC tranexamic acid 1 HEREDITARY ANGIOEDEMA AGENTS FIRAZYR SP-P PA IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA SP-P QL MISCELLANEOUS cilostazol 1 pentoxifylline 1 PLATELET AGGREGATION INHIBITORS aspirin/dipyridamole ext-rel 1

31

Drug Name Drug Tier Requirements/Limits clopidogrel 1 PV dipyridamole 1 PV PLATELET SYNTHESIS INHIBITORS anagrelide 1 IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA SP-P PA; QL ENBREL SP-P PA; QL HUMIRA SP-P PA; QL KINERET SP-P PA; QL ORENCIA SP-P PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) hydroxychloroquine 1 leflunomide 1 XELJANX XR SP-P PA; QL XELJANZ SP-P PA; QL IMMUNOMODULATORS, INTERFERONS ACTIMMUNE SP-P PEGASYS SP-P PA; QL PEGINTRON SP-P PA; QL SYLATRON SP-P IMMUNOMODULATORS, MISCELLANEOUS OTEZLA SP-P PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN 1 azathioprine 1 mycophenolate mofetil 1 PV mycophenolate sodium delayed-rel 1 PV IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine 1 PV cyclosporine modified 1 PV tacrolimus 1 PV IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE sirolimus 1 PV ZORTRESS SP-P NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS potassium/sodium phosphates 1 ELECTROLYTES, POTASSIUM KLOR-CON M15 1 potassium bicarbonate effervescent 1 potassium bicarbonate/chloride

effervescent 1

potassium chloride ext-rel 1 potassium chloride powder 1

32

Drug Name Drug Tier Requirements/Limits potassium chloride soln 1 ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate susp 1 VELTASSA SP-P VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS folic acid 1 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ipratropium/albuterol nebulizer soln 1 ANTICHOLINERGICS ipratropium nebulizer soln 1 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine/phenylephrine 1 ANTIHISTAMINES, LOW-SEDATING levocetirizine 1 ANTIHISTAMINES, NONSEDATING desloratadine 1 ANTIHISTAMINES, SEDATING brompheniramine 1 carbinoxamine 1 clemastine 1 cyproheptadine 1 hydroxyzine hcl 1 hydroxyzine pamoate 1 ANTITUSSIVE COMBINATIONS, NON-OPIOID dextromethorphan/brompheniramine/pseu

doephedrine 1

dextromethorphan/guaifenesin/phenylephrine

1

giltuss pediatric 1 promethazine/dextromethorphan 1 ANTITUSSIVE COMBINATIONS, OPIOID hydrocodone polistirex/chlorpheniramine 1 hydrocodone/chlorpheniramine/pseudoeph

edrine 1

hydrocodone/homatropine 1 promethazine/codeine 1 promethazine/phenylephrine/codeine 1 ANTITUSSIVES benzonatate 1 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol nebulizer soln 1 levalbuterol nebulizer soln 1 metaproterenol 1 PROAIR HFA 1

33

Drug Name Drug Tier Requirements/Limits BETA AGONISTS, ORAL AGENTS albuterol 1 albuterol ext-rel 1 terbutaline 1 CYSTIC FIBROSIS KALYDECO SP-P PA; QL ORKAMBI SP-P PA; QL PULMOZYME SP-P tobramycin nebulizer soln SP-P DECONGESTANT/EXPECTORANT COMBINATIONS phenylephrine/guaifenesin 1 LEUKOTRIENE MODIFIERS montelukast 1 PV zafirlukast 1 PV MAST CELL STABILIZERS cromolyn sodium nebulizer soln 1 PV MISCELLANEOUS acetylcysteine 1 caffeine citrate 1 dyphylline-guaifenesin 1 ipratropium nasal spray 1 sodium chloride nebulizer soln 1 XOLAIR SP-P PA; QL NASAL ANTIHISTAMINES azelastine spray 1 olopatadine spray 1 NASAL STEROIDS flunisolide spray 1 mometasone spray 1 PA PULMONARY FIBROSIS AGENTS ESBRIET SP-P PA; QL OFEV SP-P PA; QL STEROID INHALANTS ASMANEX 1 PV budesonide nebulizer susp 1 PV QVAR 1 PV XANTHINES THEO-24 1 theophylline ext-rel 1 theophylline soln 1 TOPICAL DERMATOLOGY, ACNE: ORAL claravis 1 myorisan 1 zenatane 1 34

Drug Name Drug Tier Requirements/Limits DERMATOLOGY, ACNE: TOPICAL adapalene 1 benzoyl peroxide 1 BPO 1 clindamycin foam 1 PA clindamycin gel, lotn, soln, swab 1 clindamycin/benzoyl peroxide 1 PA erythromycin gel, pads, soln 1 erythromycin/benzoyl peroxide 1 sulfacetamide lotion 1 sulfacetamide/sulfur 1 tretinoin 1 PA DERMATOLOGY, ACTINIC KERATOSIS diclofenac gel 3% 1 PA fluorouracil cream 0.5% 1 PA fluorouracil cream, drop, soln 5% 1 fluorouracil drop, soln 2% 1 DERMATOLOGY, ANTIBIOTICS gentamicin 1 mupirocin 1 silver sulfadiazine 1 DERMATOLOGY, ANTIFUNGALS ciclopirox 1 clotrimazole/betamethasone 1 econazole 1 HALOTIN 1 ketoconazole 1 naftifine cream 1 nystatin topical 1 nystatin/triamcinolone 1 oxiconazole cream 1 DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX SP-P PA; QL COSENTYX PEN SP-P PA; QL DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin 1 methoxsalen 1 DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene 1 calcitriol oint 1 DERMATOLOGY, ANTISEBORRHEICS selenium sulfide 1 sulfacetamide gel, shampoo, wash 1 DERMATOLOGY, CORTICOSTEROID COMBINATIONS PRAMOSONE CREAM 1-1% 1

35

Drug Name Drug Tier Requirements/Limits PRAMOSONE LOTION 1 pramoxine/hydrocortisone 1-2.5% 1 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream, lotion 0.1% 1 AMCINONIDE OINT 0.1% 1 betamethasone dipropionate augmented

cream, lotion 0.05% 1

betamethasone dipropionate cream, lotion, oint 0.05%

1

desoximetasone cream, oint 0.25% 1 desoximetasone gel 0.05% 1 diflorasone 1 fluocinonide cream 0.1% 1 fluocinonide cream, gel, oint, soln 0.05% 1 fluocinonide-e cream 0.05% 1 triamcinolone cream, oint 0.5% 1 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone 1 desonide cream, lotion, oint 0.05% 1 fluocinolone acetonide cream, soln 0.01% 1 fluocinolone acetonide oil body, scalp 1 hydrocortisone cream, lotion, oint 2.5% 1 hydrocortisone lotion 2% 1 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream, lotion, oint

0.1% 1

betamethasone valerate foam 1 desoximetasone cream, oint 0.05% 1 fluocinolone acetonide cream, oint 0.025% 1 fluticasone cream, lotion 0.05% 1 fluticasone oint 0.005% 1 hydrocortisone butyrate cream, oint, soln

0.1% 1

hydrocortisone valerate cream, oint 0.2% 1 mometasone cream, oint, soln 0.1% 1 prednicarbate cream, oint 0.1% 1 triamcinolone cream 0.1% 1 triamcinolone cream, lotion, oint 0.1% 1 triamcinolone cream, lotion, oint 0.025% 1 triamcinolone spray 1 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented

gel, oint 0.05% 1

clobetasol cream, gel, lotion, oint, shampoo, soln, spray 0.05%

1

clobetasol emollient cream 0.05% 1 clobetasol foam 1 36

Drug Name Drug Tier Requirements/Limits diflorasone oint 0.05% 1 halobetasol cream, oint 0.05% 1 DERMATOLOGY, EMOLLIENTS urea cream 1 urea emulsion 1 urea foam 1 urea gel 1 urea lotion 1 urea nail gel 45% 1 urea nail susp 1 urea susp 1 DERMATOLOGY, IMMUNOMODULATORS tacrolimus oint 1 DERMATOLOGY, LOCAL ANALGESIC lidocaine pad 5% 1 DERMATOLOGY, LOCAL ANESTHETICS lidocaine oint 5% 1 lidocaine soln 4% 1 lidocaine/prilocaine 1 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 1 arzol silver nitrate applicators 1 doxepin cream 5% 1 imiquimod 1 PA PODOCON 25 1 podofilox soln 0.5% 1 SALICYLIC ACID 26% 1 salicylic acid soln 27.5% 1 silver nitrate applicators 1 SILVER NITRATE OINT, SOLN 10% 1 SILVER NITRATE SOLN 0.5%, 25%, 50% 1 TRI-CHLOR 1 DERMATOLOGY, ROSACEA metronidazole cream, gel, lotion 0.75% 1 metronidazole gel 1% 1 DERMATOLOGY, SCABICIDES AND PEDICULICIDES lindane 1 malathion 1 permethrin 1 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate 1 triamcinolone dental paste 1 viscous lidocaine 1 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS

37

Drug Name Drug Tier Requirements/Limits neomycin/polymyxin

b/bacitracin/hydrocortisone 1

neomycin/polymyxin b/dexamethasone 1 neomycin/polymyxin b/hydrocortisone 1 sulfacetamide/prednisolone 1 tobramycin/dexamethasone 1 OPHTHALMIC, ANTI-INFECTIVES bacitracin 1 bacitracin/polymyxin b 1 ciprofloxacin ophth 1 erythromycin oint 1 gatifloxacin 1 gentamicin ophth 1 levofloxacin soln 1 neomycin/bacitracin/polymyxin b 1 neomycin/polymyxin b/gramicidin 1 ofloxacin ophth 1 polymyxin b/trimethoprim 1 sulfacetamide ophth 1 tobramycin soln 1 OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL bromfenac 1 diclofenac 1 flurbiprofen soln 1 ketorolac soln 1 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL dexamethasone soln 1 fluorometholone 1 prednisolone acetate 1% 1 PREDNISOLONE PHOSPHATE 1% 1 OPHTHALMIC, ANTIALLERGICS azelastine 1 cromolyn sodium 1 epinastine 1 olopatadine 1 OPHTHALMIC, ANTIVIRAL trifluridine 1 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE carteolol 1 levobunolol 1 metipranolol 1 timolol gel soln 1 timolol soln 1 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol soln 1

38

Drug Name Drug Tier Requirements/Limits OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS dorzolamide/timolol 1 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide 1 acetazolamide ext-rel 1 methazolamide 1 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL dorzolamide 1 OPHTHALMIC, MISCELLANEOUS naphazoline 1 phenylephrine 1 proparacaine 1 tetracaine 1 OPHTHALMIC, MYDRIATICS ATROPINE OINT 1 atropine soln 1 cyclopentolate 1 homatropine 1 tropicamide 1 OPHTHALMIC, PARASYMPATHOMIMETICS pilocarpine soln 1 OPHTHALMIC, PROSTAGLANDINS bimatoprost 1 latanoprost 1 OPHTHALMIC, SYMPATHOMIMETICS apraclonidine 1 brimonidine 0.15%, 0.2% 1 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS hydrocortisone/acetic acid 1 neomycin/polymyxin b/hydrocortisone soln 1 neomycin/polymyxin b/hydrocortisone susp 1 OTIC, ANTI-INFECTIVES acetic acid 1 acetic acid/aluminum acetate 1 ciprofloxacin otic 1 ofloxacin otic 1 OTIC, MISCELLANEOUS antipyrine/benzocaine 1 antipyrine/benzocaine/polycosanol 1 fluocinolone acetonide oil 0.01% 1 MYOXIN 1 pramoxine/chloroxylenol 1 pramoxine/hydrocortisone/chloroxylenol 1

39

Index A abacavir .......................................... 11 abacavir/lamivudine .......................... 11 abacavir/lamivudine/zidovudine .......... 11 acamprosate calcium ......................... 23 acarbose .......................................... 23 acebutolol ........................................ 16 acetaminophen/salicylamide/phenyltoloxamine ............................................... 8 acetazolamide .................................. 39 acetazolamide ext-rel ........................ 39 acetic acid........................................ 39 acetic acid/aluminum acetate ............. 39 acetylcysteine .................................. 34 acitretin ........................................... 35 ACTEMRA ......................................... 32 ACTIMMUNE ..................................... 32 acyclovir .......................................... 12 acyclovir oint .................................... 37 adapalene ........................................ 35 ADCIRCA ......................................... 18 adefovir dipivoxil .............................. 12 ADEMPAS ......................................... 18 AFINITOR ........................................ 13 AFINITOR DISPERZ ........................... 13 albuterol .......................................... 34 albuterol ext-rel ................................ 34 albuterol nebulizer soln ...................... 33 alclometasone .................................. 36 ALECENSA ....................................... 13 alendronate 40mg ............................. 24 alendronate 5mg, 10mg, 35mg, 70mg . 24 alfentanil injection ............................. 9 alfuzosin .......................................... 30 allopurinol ......................................... 8 almotriptan ...................................... 21 alosetron ......................................... 29 alprazolam ....................................... 18 alprazolam ext-rel ............................. 18 ALPRAZOLAM INTENSOL .................... 18 altavera ........................................... 24 alyacen ...................................... 24, 26 amantadine ...................................... 20 amcinonide cream, lotion 0.1% .......... 36 AMCINONIDE OINT 0.1% ................... 36 amethia ........................................... 24 amethia lo ....................................... 24

amethyst ........................................ 24 amiloride ......................................... 17 amiloride/hydrochlorothiazide ............ 17 amiodarone ..................................... 15 amitriptyline .................................... 20 amlodipine ...................................... 16 amlodipine/atorvastatin .................... 16 amlodipine/benazepril ....................... 14 amlodipine/valsartan ........................ 15 amlodipine/valsartan/hydrochlorothiazide...................................................... 15 amoxapine ...................................... 20 amoxicillin ....................................... 10 amoxicillin/clavulanate ...................... 10 amoxicillin/clavulanate ext-rel ........... 10 amphetamine/dextroamphetamine ..... 21 amphetamine/dextroamphetamine ext-rel .................................................. 21 ampicillin ........................................ 10 AMPYRA .......................................... 22 anagrelide ....................................... 32 anastrozole ..................................... 13 antipyrine/benzocaine ....................... 39 antipyrine/benzocaine/polycosanol ..... 39 apraclonidine ................................... 39 apri ................................................ 24 aranelle .......................................... 26 ARANESP ........................................ 31 aripiprazole soln ............................... 20 aripiprazole tabs .............................. 20 armodafinil ...................................... 22 arzol silver nitrate applicators ............ 37 ashlyna ........................................... 24 ASMANEX ........................................ 34 aspirin/dipyridamole ext-rel ............... 31 atenolol .......................................... 16 atenolol/chlorthalidone ..................... 16 atorvastatin ..................................... 15 atovaquone ..................................... 12 atovaquone/proguanil ....................... 11 ATROPINE OINT ............................... 39 atropine soln ................................... 39 AUBAGIO ........................................ 22 aubra.............................................. 24 aviane ............................................ 24 AVONEX .......................................... 22 AVONEX PEN ................................... 22

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AVONEX PREFILLED SYG .................... 22 AZASAN ........................................... 32 azathioprine ..................................... 32 azelastine ........................................ 38 azelastine spray ................................ 34 azithromycin .................................... 10 azurette ........................................... 24 B bacitracin ......................................... 38 bacitracin/polymyxin b ...................... 38 baclofen .......................................... 22 balsalazide ....................................... 29 balziva ............................................ 24 BELLADONNA/OPIUM SUPP ................ 29 benazepril ........................................ 14 benazepril/hydrochlorothiazide ........... 14 benzonatate ..................................... 33 benzoyl peroxide .............................. 35 benztropine ...................................... 20 betamethasone dipropionate augmented cream, lotion 0.05% ......................... 36 betamethasone dipropionate augmented gel, oint 0.05% ................................ 36 betamethasone dipropionate cream, lotion, oint 0.05% ............................. 36 betamethasone valerate cream, lotion, oint 0.1% ........................................ 36 betamethasone valerate foam ............ 36 BETASERON ..................................... 22 betaxolol ......................................... 16 betaxolol soln ................................... 38 bethanechol ..................................... 30 bexarotene ...................................... 13 bicalutamide .................................... 12 bimatoprost ..................................... 39 bisoprolol ......................................... 16 bisoprolol/hydrochlorothiazide ............ 16 BOSULIF .......................................... 13 BPO ................................................ 35 briellyn ............................................ 24 brimonidine 0.15%, 0.2% .................. 39 bromfenac ....................................... 38 bromocriptine ................................... 20 brompheniramine ............................. 33 budesonide caps ............................... 29 budesonide nebulizer susp ................. 34 bumetanide ...................................... 17 buprenorphine sublingual ................... 23

buprenorphine/naloxone sublingual .... 23 bupropion ....................................... 19 bupropion delayed-rel ....................... 19 bupropion ext-rel ............................. 23 bupropion ext-rel (12hr) ................... 19 bupropion ext-rel (24hr) ................... 19 buspirone ........................................ 18 butalbital/acetaminophen .................... 8 butalbital/acetaminophen/caffeine ........ 8 butalbital/acetaminophen/caffeine/codeine ...................................................... 9 butalbital/aspirin/caffeine .................... 8 butalbital/aspirin/caffeine/codeine ........ 9 butorphanol nasal spray ...................... 9 C cabergoline ..................................... 28 CABOMETYX .................................... 13 caffeine citrate ................................. 34 calcipotriene .................................... 35 calcitonin nasal spray ....................... 24 calcitriol caps ................................... 28 calcitriol oint .................................... 35 calcium acetate ................................ 28 camila............................................. 26 camrese .......................................... 24 camrese lo ...................................... 24 candesartan .................................... 15 candesartan/hydrochlorothiazide ........ 15 capecitabine .................................... 12 CAPITAL W/CODEINE .......................... 9 captopril ......................................... 14 captopril/hydrochlorothiazide ............. 14 carbamazepine ................................ 18 carbamazepine ext-rel ...................... 18 carbidopa ........................................ 20 carbidopa/levodopa .......................... 20 carbidopa/levodopa ext-rel ................ 20 carbidopa/levodopa/entacapone ......... 20 carbinoxamine ................................. 33 carisoprodol ..................................... 22 carisoprodol/aspirin .......................... 22 carisoprodol/aspirin/codeine .............. 22 carteolol .......................................... 38 carvedilol ........................................ 16 caziant ............................................ 26 cefaclor ........................................... 10 cefadroxil .......................................... 9 cefdinir ........................................... 10

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cefixime ........................................... 10 cefpodoxime..................................... 10 cefprozil........................................... 10 ceftibuten ........................................ 10 ceftriaxone ....................................... 10 cefuroxime axetil .............................. 10 celecoxib .......................................... 8 cephalexin ....................................... 10 CERDELGA ....................................... 28 cevimeline ....................................... 30 chateal ............................................ 25 chlordiazepoxide ............................... 18 chlordiazepoxide/amitriptyline ............ 19 chlordiazepoxide/clidinium ................. 29 chlorhexidine gluconate ..................... 37 chloroquine ...................................... 11 chlorothiazide ................................... 17 chlorpromazine ................................. 20 chlorpropamide ................................ 23 chlorthalidone .................................. 17 chlorzoxazone .................................. 22 cholestyramine powder ...................... 15 cholestyramine powder light ............... 15 choline/magnesium trisalicylates .......... 8 ciclopirox ......................................... 35 cilostazol ......................................... 31 cimetidine ........................................ 29 ciprofloxacin ..................................... 10 ciprofloxacin ext-rel .......................... 10 ciprofloxacin ophth ............................ 38 ciprofloxacin oral susp ....................... 10 ciprofloxacin otic ............................... 39 citalopram ....................................... 19 claravis ............................................ 34 clarithromycin .................................. 10 clarithromycin ext-rel ........................ 10 clemastine ....................................... 33 clindamycin caps, oral soln ................. 12 clindamycin cream ............................ 31 clindamycin foam .............................. 35 clindamycin gel, lotn, soln, swab ......... 35 clindamycin/benzoyl peroxide ............. 35 clobetasol cream, gel, lotion, oint, shampoo, soln, spray 0.05% .............. 36 clobetasol emollient cream 0.05%....... 36 clobetasol foam ................................ 36 clomipramine ................................... 18 clonazepam ...................................... 18

clonidine ......................................... 14 clonidine ext-rel ............................... 21 clonidine transdermal ....................... 14 clopidogrel ...................................... 32 clorazepate...................................... 18 clotrimazole troche ........................... 11 clotrimazole/betamethasone .............. 35 clozapine ......................................... 20 codeine ............................................. 9 codeine/acetaminophen ...................... 9 colchicine .......................................... 8 colchicine/probenecid ......................... 8 colestipol ........................................ 15 COSENTYX ...................................... 35 COSENTYX PEN ................................ 35 COTELLIC ........................................ 13 covaryx ........................................... 27 covaryx hs ...................................... 27 cromolyn sodium .............................. 38 cromolyn sodium 100mg/5ml ............ 30 cromolyn sodium nebulizer soln ......... 34 cryselle ........................................... 25 cyclafem .................................... 25, 26 cyclobenzaprine ............................... 22 cyclopentolate ................................. 39 CYCLOPHOSPHAMIDE CAPS ............... 12 cycloserine ...................................... 11 cyclosporine .................................... 32 cyclosporine modified ....................... 32 cyproheptadine ................................ 33 cyred .............................................. 25 D danazol ........................................... 27 dantrolene ....................................... 22 dapsone .......................................... 12 darifenacin ext-rel ............................ 31 dasetta ...................................... 25, 26 daysee ............................................ 24 deblitane ......................................... 26 delyla ............................................. 25 demeclocycline ................................ 10 desipramine .................................... 20 desloratadine ................................... 33 desmopressin .................................. 28 desogestrel/ethinyl estradiol ......... 24, 25 desonide cream, lotion, oint 0.05% .... 36 desoximetasone cream, oint 0.05% .... 36 desoximetasone cream, oint 0.25% .... 36

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desoximetasone gel 0.05% ................ 36 desvenlafaxine ext-rel 50mg, 100mg... 19 dexamethasone ................................ 27 DEXAMETHASONE INTENSOL ............. 27 dexamethasone oral soln 0.5mg/5ml ... 27 dexamethasone soln ......................... 38 dexmethylphenidate .......................... 21 dexmethylphenidate ext-rel ............... 21 dextroamphetamine 5mg, 10mg ......... 21 dextroamphetamine ext-rel 5mg, 10mg, 15mg .............................................. 21 dextroamphetamine soln ................... 21 dextromethorphan/brompheniramine/pseudoephedrine ................................... 33 dextromethorphan/guaifenesin/phenylephrine ............................................... 33 diazepam ......................................... 18 diazepam gel .................................... 18 diclofenac ........................................ 38 diclofenac gel 3% ............................. 35 diclofenac potassium .......................... 8 diclofenac sodium delayed-rel .............. 8 diclofenac sodium ext-rel .................... 8 diclofenac/misoprostol ........................ 9 dicloxacillin ...................................... 10 dicyclomine ...................................... 29 didanosine ....................................... 11 diflorasone ....................................... 36 diflorasone oint 0.05% ...................... 37 diflunisal ........................................... 8 digoxin ............................................ 17 dihydrocodeine/acetaminophen/caffeine 9 dihydrocodeine/aspirin/caffeine ........... 9 dihydroergotamine inj ....................... 21 dihydroergotamine nasal spray ........... 21 diltiazem .......................................... 16 diltiazem ext-rel ............................... 16 diphenoxylate/atropine ...................... 29 dipyridamole .................................... 32 disopyramide ................................... 15 disulfiram ........................................ 23 divalproex sodium ............................. 18 divalproex sodium delayed-rel ............ 18 divalproex sodium ext-rel .................. 18 dofetilide ......................................... 15 donepezil ......................................... 19 dorzolamide ..................................... 39 dorzolamide/timolol .......................... 39

doxazosin ........................................ 14 doxepin ........................................... 20 doxepin cream 5% ........................... 37 doxercalciferol ................................. 28 doxycycline hyclate .......................... 10 doxycycline hyclate delayed-rel .......... 10 doxycycline monohydrate caps 150mg 10 doxycycline monohydrate caps 50mg, 75mg, 100mg .................................. 10 doxycycline monohydrate susp .......... 10 doxycycline monohydrate tabs ........... 10 dronabinol ....................................... 29 drospirenone/ethinyl estradiol ............ 25 duloxetine ....................................... 19 dutasteride ...................................... 30 dutasteride/tamsulosin ..................... 30 dyphylline-guaifenesin ...................... 34 E econazole ........................................ 35 eemt .............................................. 27 eemt hs .......................................... 27 elinest ............................................ 25 EMCYT ............................................ 12 emoquette ...................................... 25 enalapril .......................................... 14 enalapril/hydrochlorothiazide ............. 14 ENBREL ........................................... 32 enoxaparin ...................................... 31 enpresse ......................................... 26 enskyce .......................................... 25 entacapone ..................................... 20 entecavir ......................................... 12 EPCLUSA ......................................... 12 epinastine ....................................... 38 eplerenone ...................................... 14 EPOGEN .......................................... 31 eprosartan ...................................... 15 ergoloid mesylates ........................... 22 errin ............................................... 26 erythromycin base............................ 10 erythromycin delayed-rel .................. 10 erythromycin ethylsuccinate .............. 10 erythromycin gel, pads, soln .............. 35 erythromycin oint ............................. 38 erythromycin stearate ....................... 10 erythromycin/benzoyl peroxide .......... 35 ESBRIET ......................................... 34 escitalopram .................................... 19

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esomeprazole ................................... 30 estarylla .......................................... 25 estazolam ........................................ 21 esterified estrogens/methyltestosterone ...................................................... 27 estradiol .......................................... 27 estradiol transdermal twice weekly ...... 27 estradiol transdermal weekly .............. 27 estradiol/norethindrone ..................... 27 estropipate ...................................... 27 eszopiclone ...................................... 21 ethambutol ...................................... 11 ethinyl estradiol/norethindrone ........... 27 ethosuximide.................................... 18 etidronate ........................................ 24 etodolac ........................................... 8 etodolac ext-rel ................................. 8 etoposide ......................................... 13 exemestane ..................................... 13 EXTAVIA .......................................... 22 F falmina ............................................ 25 famciclovir ....................................... 12 famotidine ....................................... 29 FARYDAK ......................................... 13 felbamate ........................................ 18 felodipine ext-rel .............................. 16 fenofibrate caps, tabs ........................ 15 fenofibric acid ................................... 15 fenofibric acid delayed-rel .................. 15 fenoprofen ........................................ 8 fentanyl transdermal 12mcg, 25mcg, 50mcg, 75mcg, 100mcg ..................... 9 FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG, 87.5MCG ............................ 9 fentanyl transmucosal lozenge ............. 9 finasteride ....................................... 30 FIRAZYR .......................................... 31 flavoxate ......................................... 31 flecainide ......................................... 15 fluconazole ....................................... 11 flucytosine ....................................... 11 fludrocortisone ................................. 27 flunisolide spray ............................... 34 fluocinolone acetonide cream, oint 0.025% ........................................... 36 fluocinolone acetonide cream, soln 0.01% ............................................. 36

fluocinolone acetonide oil 0.01% ........ 39 fluocinolone acetonide oil body, scalp . 36 fluocinonide cream 0.1% ................... 36 fluocinonide cream, gel, oint, soln 0.05%...................................................... 36 fluocinonide-e cream 0.05% .............. 36 fluorometholone ............................... 38 fluorouracil cream 0.5% .................... 35 fluorouracil cream, drop, soln 5% ....... 35 fluorouracil drop, soln 2% ................. 35 fluoxetine ........................................ 19 FLUOXETINE 60MG ........................... 19 fluoxetine delayed-rel ....................... 19 fluphenazine .................................... 20 flurazepam ...................................... 21 flurbiprofen ....................................... 8 flurbiprofen soln ............................... 38 flutamide ........................................ 12 fluticasone cream, lotion 0.05% ......... 36 fluticasone oint 0.005% .................... 36 fluvastatin ....................................... 15 fluvastatin ext-rel ............................. 16 fluvoxamine .................................... 18 fluvoxamine ext-rel .......................... 18 folic acid ......................................... 33 fondaparinux ................................... 31 FORTEO .......................................... 24 fosinopril ......................................... 14 fosinopril/hydrochlorothiazide ............ 14 frovatriptan ..................................... 22 furosemide ...................................... 17 furosemide soln 10mg/ml .................. 17 FUZEON .......................................... 11 G gabapentin ...................................... 18 galantamine .................................... 19 galantamine ext-rel .......................... 19 gatifloxacin ...................................... 38 gemfibrozil ...................................... 15 gentamicin ...................................... 35 gentamicin ophth ............................. 38 gianvi ............................................. 25 gildagia ........................................... 25 gildess ............................................ 25 gildess fe ........................................ 25 gildess fe 24 .................................... 25 GILENYA ......................................... 22 giltuss pediatric................................ 33

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glatopa 20 mg .................................. 22 glimepiride ....................................... 23 glipizide ........................................... 23 glipizide ext-rel ................................. 23 glipizide/metformin ........................... 23 glyburide ......................................... 23 glyburide micronized ......................... 23 glyburide/metformin ......................... 23 glycopyrrolate .................................. 29 granisetron ...................................... 29 GRANIX ........................................... 31 griseofulvin microsize ........................ 11 griseofulvin ultramicrosize.................. 11 guanfacine ....................................... 14 guanfacine ext-rel ............................. 21 H halobetasol cream, oint 0.05% ........... 37 haloperidol ....................................... 20 HALOTIN.......................................... 35 HARVONI ......................................... 12 heather ........................................... 26 HETLIOZ .......................................... 21 homatropine .................................... 39 HUMIRA ........................................... 32 HYCAMTIN ....................................... 14 hydralazine ...................................... 17 hydrochlorothiazide ........................... 17 hydrocodone polistirex/chlorpheniramine ...................................................... 33 hydrocodone/acetaminophen ............... 9 hydrocodone/chlorpheniramine/pseudoephedrine ............................................ 33 hydrocodone/homatropine ................. 33 hydrocodone/ibuprofen ....................... 9 hydrocortisone ................................. 27 hydrocortisone acetate supp ............... 30 hydrocortisone butyrate cream, oint, soln 0.1% ............................................... 36 hydrocortisone cream ........................ 30 hydrocortisone cream, lotion, oint 2.5% ...................................................... 36 hydrocortisone enema ....................... 29 hydrocortisone lotion 2% ................... 36 hydrocortisone valerate cream, oint 0.2% ............................................... 36 hydrocortisone/acetic acid.................. 39 hydrocortisone/pramoxine ................. 30 hydromorphone ................................. 9

hydromorphone ext-rel ....................... 9 HYDROMORPHONE SUPP ..................... 9 hydroxychloroquine .......................... 32 hydroxyurea .................................... 13 hydroxyzine hcl ................................ 33 hydroxyzine pamoate ....................... 33 hyoscyamine sulfate ......................... 29 hyoscyamine sulfate ext-rel ............... 29 I ibandronate ..................................... 24 IBRANCE ......................................... 13 ibuprofen .......................................... 8 ICLUSIG .......................................... 13 imatinib mesylate ............................. 13 IMBRUVICA ..................................... 13 imipramine hcl ................................. 20 imipramine pamoate ......................... 20 imiquimod ....................................... 37 INCRELEX ....................................... 28 indapamide ..................................... 17 indomethacin ..................................... 8 indomethacin ext-rel........................... 8 INLYTA ........................................... 13 introvale ......................................... 24 ipratropium nasal spray .................... 34 ipratropium nebulizer soln ................. 33 ipratropium/albuterol nebulizer soln ... 33 irbesartan ....................................... 15 irbesartan/hydrochlorothiazide ........... 15 isometheptene/caffeine/acetaminophen...................................................... 21 isometheptene/dichloralphenazone/acetaminophen ........................................ 21 isoniazid ......................................... 11 isosorbide dinitrate ........................... 17 isosorbide dinitrate ext-rel................. 17 isosorbide mononitrate ..................... 17 isosorbide mononitrate ext-rel ........... 17 isoxsuprine 10mg ............................. 17 isradipine ........................................ 16 itraconazole ..................................... 11 ivermectin ....................................... 12 J JAKAFI ............................................ 13 jencycla .......................................... 26 jinteli .............................................. 27 jolessa ............................................ 24 jolivette .......................................... 26

45

juleber ............................................ 25 junel ............................................... 25 junel fe ............................................ 25 junel fe 24 ....................................... 25 JUXTAPID ........................................ 16 K KALYDECO ....................................... 34 kariva .............................................. 24 kelnor.............................................. 25 ketoconazole .................................... 35 ketoconazole tabs ............................. 11 ketoprofen ........................................ 8 ketoprofen ext-rel .............................. 8 ketorolac .......................................... 8 ketorolac soln ................................... 38 kimidess .......................................... 24 KINERET .......................................... 32 KLOR-CON M15 ................................ 32 KRISTALOSE .................................... 29 kurvelo ............................................ 25 KUVAN ............................................ 28 KYNAMRO ........................................ 16 L labetalol .......................................... 16 lactulose .......................................... 29 lactulose (encephalopathy) ................ 30 lamivudine soln, tabs ........................ 11 lamivudine tabs ................................ 12 lamivudine/zidovudine ....................... 11 lamotrigine ...................................... 18 lamotrigine ext-rel ............................ 18 lansoprazole ..................................... 30 lansoprazole/amoxicillin/clarithromycin 30 larin ................................................ 25 larin fe ............................................ 25 larin fe 24 ........................................ 25 latanoprost ...................................... 39 layolis fe chew .................................. 25 leena ............................................... 26 leflunomide ...................................... 32 lessina ............................................. 25 LETAIRIS ......................................... 17 letrozole .......................................... 13 leucovorin ........................................ 13 LEUKINE .......................................... 31 levalbuterol nebulizer soln ................. 33 levetiracetam ................................... 18 levobunolol ...................................... 38

levocarnitine .................................... 28 levocetirizine ................................... 33 levofloxacin ..................................... 10 levofloxacin oral soln ........................ 10 levofloxacin soln .............................. 38 levonorgestrel/ethinyl estradiol 24, 25, 26 levora ............................................. 25 levorphanol ....................................... 9 levothyroxine ................................... 28 levoxyl ............................................ 28 lidazone .......................................... 30 lidocaine oint 5% ............................. 37 lidocaine pad 5% ............................. 37 lidocaine soln 4% ............................. 37 lidocaine/hydrocortisone ................... 30 LIDOCAINE/HYDROCORTISONE GEL ... 30 lidocaine/prilocaine ........................... 37 lindane ........................................... 37 linezolid .......................................... 12 liothyronine ..................................... 28 lisinopril .......................................... 14 lisinopril/hydrochlorothiazide ............. 14 lithium carbonate ............................. 22 lithium carbonate ext-rel ................... 22 lomedia fe 24 .................................. 25 LONSURF ........................................ 13 lopreeza .......................................... 27 lorazepam ....................................... 18 loryna ............................................. 25 losartan .......................................... 15 losartan/hydrochlorothiazide .............. 15 lovastatin ........................................ 16 low-ogestrel .................................... 25 loxapine .......................................... 20 lutera ............................................. 25 lyza ................................................ 26 M malathion ........................................ 37 maprotiline ...................................... 19 marlissa .......................................... 25 meclofenamate sodium ....................... 8 medroxyprogesterone acetate ............ 28 medroxyprogesterone acetate 150mg/ml...................................................... 24 mefenamic acid .................................. 8 mefloquine ...................................... 11 megestrol acetate ............................ 13 megestrol susp ................................ 28

46

MEKINIST ........................................ 13 meloxicam ........................................ 8 memantine ...................................... 19 meperidine ........................................ 9 meprobamate ................................... 18 mercaptopurine ................................ 12 mesalamine enema ........................... 29 metaproterenol ................................. 33 metaxalone ...................................... 22 metformin ........................................ 23 metformin ext-rel ............................. 23 methadone ....................................... 9 methamphetamine tabs 5mg .............. 21 methazolamide ................................. 39 methenamine hippurate ..................... 30 methenamine mandelate ................... 30 methenamine/hyoscyamine/methylene blue/phenyl salicylate/benzoic acid ..... 30 methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium bisphosphonate ................................ 30 methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium phosphate ...................................................... 30 methenamine/hyoscyamine/methylene blue/sodium phosphate ..................... 30 methimazole .................................... 28 methocarbamol ................................ 22 methotrexate ................................... 12 methoxsalen .................................... 35 methscopolamine .............................. 29 methyclothiazide ............................... 17 methyldopa ...................................... 17 methyldopa/hydrochlorothiazide ......... 17 methylergonovine ............................. 28 methylphenidate chew 2.5mg, 5mg, 10mg .............................................. 21 methylphenidate ext-rel 18mg, 27mg, 36mg, 54mg .................................... 21 methylphenidate ext-rel caps 10mg, 20mg, 30mg, 40mg, 50mg, 60mg ...... 21 methylphenidate ext-rel caps 20mg, 30mg, 40mg .................................... 21 methylphenidate ext-rel tabs 10mg, 20mg .............................................. 21 methylphenidate soln ........................ 21 methylphenidate tabs 5mg, 10mg, 20mg ...................................................... 21

methylprednisolone .......................... 27 metipranolol .................................... 38 metoclopramide ............................... 29 metolazone ..................................... 17 metoprolol succinate ext-rel .............. 16 metoprolol tartrate ........................... 16 metoprolol/hydrochlorothiazide .......... 16 metronidazole .................................. 12 metronidazole cream, gel, lotion 0.75%...................................................... 37 metronidazole gel 0.75% .................. 31 metronidazole gel 1% ....................... 37 mexiletine ....................................... 15 microgestin ..................................... 25 microgestin fe .................................. 25 microgestin fe 24 ............................. 25 midodrine ........................................ 17 migergot supp ................................. 21 mimvey .......................................... 27 mimvey lo ....................................... 27 minocycline ..................................... 11 minocycline ext-rel ........................... 11 minoxidil ......................................... 17 mirtazapine ..................................... 19 misoprostol ..................................... 30 modafinil ......................................... 22 moexipril ......................................... 14 moexipril/hydrochlorothiazide ............ 14 mometasone cream, oint, soln 0.1% .. 36 mometasone spray ........................... 34 mono-linyah .................................... 25 mononessa ...................................... 25 montelukast .................................... 34 morphine .......................................... 9 morphine ext-rel ................................ 9 MORPHINE SUPP 30MG ....................... 9 morphine supp 5mg, 10mg, 20mg ........ 9 moxifloxacin .................................... 10 mupirocin ........................................ 35 mycophenolate mofetil ...................... 32 mycophenolate sodium delayed-rel..... 32 myorisan ......................................... 34 MYOXIN .......................................... 39 myzilra ........................................... 26 N nabumetone ...................................... 8 nadolol ........................................... 16 nadolol/bendroflumethiazide .............. 16

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naftifine cream ................................. 35 naltrexone ....................................... 23 naphazoline...................................... 39 naproxen .......................................... 8 naproxen delayed-rel ......................... 8 naproxen sodium ............................... 8 naproxen sodium ext-rel ..................... 8 naratriptan ....................................... 22 nateglinide ....................................... 23 necon ........................................ 25, 27 nefazodone ...................................... 19 neomycin .......................................... 9 neomycin/bacitracin/polymyxin b ........ 38 neomycin/polymyxin b/bacitracin/hydrocortisone ................ 38 neomycin/polymyxin b/dexamethasone ...................................................... 38 neomycin/polymyxin b/gramicidin ....... 38 neomycin/polymyxin b/hydrocortisone 38 neomycin/polymyxin b/hydrocortisone soln................................................. 39 neomycin/polymyxin b/hydrocortisone susp ................................................ 39 NEULASTA ....................................... 31 NEUPOGEN ...................................... 31 nevirapine ........................................ 11 nevirapine ext-rel ............................. 11 NEXAVAR ......................................... 13 niacin ext-rel .................................... 16 nicardipine ....................................... 16 nifedipine ......................................... 16 nifedipine ext-rel .............................. 16 nikki ................................................ 25 nimodipine ....................................... 16 NINLARO ......................................... 14 nisoldipine ext-rel ............................. 16 nitrofurantoin ................................... 12 nitroglycerin caps ............................. 17 nitroglycerin lingual aerosol................ 17 nitroglycerin lingual spray .................. 17 nitroglycerin sublingual ...................... 17 nitroglycerin transdermal ................... 17 nizatidine ......................................... 29 nora-be ........................................... 26 NORDITROPIN .................................. 28 norethindrone................................... 26 norethindrone acetate ....................... 28 norethindrone/ethinyl estradiol ........... 25

norethindrone/ethinyl estradiol fe ....... 25 norethindrone/ethinyl estradiol fe chew...................................................... 25 norgestimate/ethinyl estradiol ...... 26, 27 norlyroc .......................................... 26 nortrel ....................................... 26, 27 nortriptyline .................................... 20 nystatin oral .................................... 11 nystatin topical ................................ 35 nystatin/triamcinolone ...................... 35 O OCALIVA ......................................... 30 ocella .............................................. 26 octreotide........................................ 28 ODOMZO ......................................... 14 OFEV .............................................. 34 ofloxacin ......................................... 10 ofloxacin ophth ................................ 38 ofloxacin otic ................................... 39 ogestrel .......................................... 26 olanzapine ....................................... 20 olanzapine/fluoxetine ........................ 20 olopatadine ..................................... 38 olopatadine spray ............................. 34 omeprazole ..................................... 30 ondansetron .................................... 29 ondansetron soln ............................. 29 opium tincture ................................. 29 OPSUMIT ........................................ 17 ORENCIA ......................................... 32 ORENITRAM..................................... 18 ORKAMBI ........................................ 34 orphenadrine ext-rel ......................... 22 orphenadrine/aspirin/caffeine ............ 22 orsythia .......................................... 26 OTEZLA........................................... 32 oxandrolone .................................... 23 oxaprozin .......................................... 8 oxazepam ....................................... 18 oxcarbazepine ................................. 19 oxiconazole cream ............................ 35 oxybutynin ...................................... 31 oxybutynin ext-rel ............................ 31 oxycodone ......................................... 9 oxycodone/acetaminophen .................. 9 oxycodone/aspirin .............................. 9 oxycodone/ibuprofen .......................... 9 oxymorphone .................................... 9

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oxymorphone ext-rel .......................... 9 P paliperidone ext-rel ........................... 20 pantoprazole .................................... 30 paricalcitol ....................................... 28 paromomycin .................................... 9 paroxetine ....................................... 19 paroxetine ext-rel ............................. 19 PASER GRANULES ............................. 11 peg 3350/electrolytes ........................ 29 PEGASYS ......................................... 32 PEGINTRON ..................................... 32 penicillin vk ...................................... 10 pentazocine/naloxone ......................... 9 pentoxifylline .................................... 31 perindopril ....................................... 14 permethrin ....................................... 37 perphenazine ................................... 20 perphenazine/amitriptyline ................. 20 phenazopyridine ............................... 30 phenelzine ....................................... 19 phenobarbital ................................... 19 phenoxybenzamine ........................... 17 phenylephrine .................................. 39 phenylephrine/guaifenesin ................. 34 phenytoin ........................................ 19 phenytoin sodium extended ............... 19 philith .............................................. 26 pilocarpine ....................................... 30 pilocarpine soln ................................ 39 pimozide .......................................... 20 pimtrea ........................................... 24 pindolol ........................................... 16 pioglitazone ..................................... 23 pioglitazone/glimepiride ..................... 23 pioglitazone/metformin ...................... 23 pirmella ..................................... 26, 27 piroxicam .......................................... 8 PLEGRIDY ........................................ 22 PODOCON 25 ................................... 37 podofilox soln 0.5% .......................... 37 polymyxin b/trimethoprim .................. 38 POMALYST ....................................... 13 portia .............................................. 26 potassium bicarbonate effervescent .... 32 potassium bicarbonate/chloride effervescent ..................................... 32 potassium chloride ext-rel .................. 32

potassium chloride powder ................ 32 potassium chloride soln ..................... 33 potassium citrate ............................. 31 potassium citrate/citric acid ............... 31 potassium citrate/sodium citrate/citric acid ................................................ 31 potassium/sodium phosphates ........... 32 pramipexole .................................... 20 pramipexole ext-rel .......................... 20 PRAMOSONE CREAM 1-1% ................ 35 PRAMOSONE LOTION ........................ 36 pramoxine/chloroxylenol ................... 39 pramoxine/hydrocortisone 1-2.5% ..... 36 pramoxine/hydrocortisone/chloroxylenol...................................................... 39 pravastatin ...................................... 16 prazosin .......................................... 14 prednicarbate cream, oint 0.1% ......... 36 prednisolone acetate 1% ................... 38 PREDNISOLONE PHOSPHATE 1% ....... 38 prednisolone sodium phosphate odt, soln...................................................... 27 prednisolone syrup ........................... 27 prednisone ...................................... 27 PREDNISONE INTENSOL ................... 28 previfem ......................................... 26 PRIMAQUINE ................................... 11 primidone ........................................ 19 PROAIR HFA .................................... 33 probenecid ........................................ 8 prochlorperazine .............................. 29 prochlorperazine supp ....................... 29 PROCRIT ......................................... 31 progesterone 50mg/ml ..................... 28 progesterone micronized ................... 28 PROMACTA ...................................... 31 promethazine .................................. 29 promethazine supp ........................... 29 promethazine/codeine ...................... 33 promethazine/dextromethorphan ....... 33 promethazine/phenylephrine ............. 33 promethazine/phenylephrine/codeine . 33 propafenone .................................... 15 propafenone ext-rel .......................... 15 propantheline .................................. 29 proparacaine ................................... 39 propranolol ...................................... 16 propranolol ext-rel ........................... 16

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propranolol/hydrochlorothiazide .......... 16 propylthiouracil ................................. 28 protriptyline ..................................... 20 PULMOZYME ..................................... 34 pyrazinamide ................................... 11 pyridostigmine .................................. 22 pyridostigmine ext-rel ....................... 22 Q quasense ......................................... 24 quetiapine ........................................ 20 quinapril .......................................... 14 quinapril/hydrochlorothiazide ............. 14 quinidine gluconate ........................... 15 quinidine sulfate ............................... 15 quinidine sulfate ext-rel ..................... 15 quinine sulfate .................................. 11 QVAR .............................................. 34 R rabeprazole ...................................... 30 raloxifene ........................................ 28 ramipril ........................................... 14 ranitidine ......................................... 29 RAVICTI .......................................... 28 REBIF .............................................. 22 reclipsen .......................................... 26 repaglinide ....................................... 23 repaglinide/metformin ....................... 23 REPATHA ......................................... 16 reserpine ......................................... 17 REVLIMID ........................................ 13 ribavirin ........................................... 12 rifabutin .......................................... 12 rifampin ........................................... 11 riluzole ............................................ 22 rimantadine ..................................... 12 risedronate ...................................... 24 risedronate delayed-rel ...................... 24 risperidone ....................................... 20 rivastigmine ..................................... 19 rivastigmine transdermal ................... 19 rizatriptan ........................................ 22 ropinirole ......................................... 20 ropinirole ext-rel ............................... 20 S SABRIL POWDER .............................. 19 SABRIL TABS ................................... 19 SALICYLIC ACID 26% ........................ 37 salicylic acid soln 27.5% .................... 37

salsalate ........................................... 8 selegiline ......................................... 20 selenium sulfide ............................... 35 SENSIPAR ....................................... 24 sertraline ........................................ 19 setlakin ........................................... 24 sharobel .......................................... 26 sildenafil ......................................... 18 silver nitrate applicators .................... 37 SILVER NITRATE OINT, SOLN 10% ..... 37 SILVER NITRATE SOLN 0.5%, 25%, 50%...................................................... 37 silver sulfadiazine ............................. 35 simvastatin ..................................... 16 sirolimus ......................................... 32 sodium chloride nebulizer soln ........... 34 sodium citrate/citric acid ................... 31 sodium polystyrene sulfonate susp ..... 33 SOMAVERT ...................................... 28 sotalol ............................................ 15 sotalol af ......................................... 15 SOVALDI ......................................... 12 spironolactone ................................. 14 spironolactone/hydrochlorothiazide .... 17 sprintec .......................................... 26 SPRYCEL ......................................... 13 sronyx ............................................ 26 stavudine ........................................ 11 STIVARGA ....................................... 13 STRENSIQ ....................................... 28 sucralfate ........................................ 30 sulfacetamide gel, shampoo, wash ..... 35 sulfacetamide lotion ......................... 35 sulfacetamide ophth ......................... 38 sulfacetamide/prednisolone ............... 38 sulfacetamide/sulfur ......................... 35 SULFADIAZINE ................................ 10 sulfamethoxazole/trimethoprim .......... 10 sulfasalazine .................................... 29 sulfasalazine delayed-rel ................... 29 sulindac ............................................ 8 sumatriptan ..................................... 22 SUTENT .......................................... 13 syeda ............................................. 26 SYLATRON ....................................... 32 T tacrolimus ....................................... 32 tacrolimus oint ................................. 37

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TAFINLAR ........................................ 13 TAGRISSO ....................................... 13 tamoxifen ........................................ 13 tamsulosin ....................................... 30 TARCEVA ......................................... 13 TARGRETIN GEL ............................... 14 tarina fe .......................................... 26 TASIGNA ......................................... 13 TECFIDERA ...................................... 22 telmisartan ...................................... 15 telmisartan/amlodipine ...................... 15 telmisartan/hydrochlorothiazide .......... 15 temazepam ...................................... 21 temozolomide ................................... 12 terazosin ......................................... 14 terbinafine ....................................... 11 terbutaline ....................................... 34 terconazole cream 0.4% .................... 31 terconazole cream 0.8% .................... 31 terconazole supp .............................. 31 testosterone cypionate ...................... 23 testosterone enanthate ...................... 23 tetrabenazine ................................... 21 tetracaine ........................................ 39 tetracycline ...................................... 11 THALOMID ....................................... 13 THEO-24 .......................................... 34 theophylline ext-rel ........................... 34 theophylline soln............................... 34 thioridazine ...................................... 20 thiothixene ....................................... 20 thyroid tab ....................................... 28 tiagabine ......................................... 19 tilia fe.............................................. 27 timolol ............................................. 16 timolol gel soln ................................. 38 timolol soln ...................................... 38 tinidazole ......................................... 12 tizanidine ......................................... 22 tobramycin nebulizer soln .................. 34 tobramycin soln ................................ 38 tobramycin/dexamethasone ............... 38 tolazamide ....................................... 23 tolbutamide ...................................... 23 tolcapone ......................................... 20 tolmetin sodium ................................. 9 tolterodine ....................................... 31 tolterodine ext-rel ............................. 31

topiramate ...................................... 19 torsemide ........................................ 17 TRACLEER ....................................... 17 tramadol ........................................... 9 tramadol ext-rel tabs .......................... 9 tramadol/acetaminophen .................... 9 trandolapril...................................... 14 trandolapril/verapamil ...................... 14 tranexamic acid ............................... 31 tranylcypromine ............................... 19 trazodone ........................................ 19 tretinoin .......................................... 35 tretinoin caps .................................. 14 triamcinolone cream 0.1% ................ 36 triamcinolone cream, lotion, oint 0.025%...................................................... 36 triamcinolone cream, lotion, oint 0.1% 36 triamcinolone cream, oint 0.5% ......... 36 triamcinolone dental paste ................ 37 triamcinolone spray .......................... 36 triamterene/hydrochlorothiazide ........ 17 triazolam......................................... 21 TRI-CHLOR ...................................... 37 tri-estaryll ....................................... 27 trifluoperazine ................................. 20 trifluridine ....................................... 38 trihexyphenidyl ................................ 20 tri-legest fe ..................................... 27 tri-linyah ......................................... 27 tri-lo-sprintec .................................. 27 trimethobenzamide .......................... 29 trimethoprim ................................... 12 trimipramine .................................... 20 trinessa .......................................... 27 tri-previfem ..................................... 27 tri-sprintec ...................................... 27 trivora ............................................ 27 tropicamide ..................................... 39 trospium ......................................... 31 trospium ext-rel ............................... 31 TYKERB ........................................... 13 TYVASO .......................................... 18 TYZEKA ........................................... 12 U unithroid ......................................... 28 UPTRAVI ......................................... 18 urea cream ...................................... 37 urea emulsion .................................. 37

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urea foam ........................................ 37 urea gel ........................................... 37 urea lotion ....................................... 37 urea nail gel 45% ............................. 37 urea nail susp ................................... 37 urea susp ......................................... 37 ursodiol ........................................... 29 V valacyclovir ...................................... 12 valganciclovir ................................... 12 valproic acid ..................................... 19 valsartan ......................................... 15 valsartan/hydrochlorothiazide ............. 15 vancomycin caps .............................. 12 vancomycin inj 500mg, 1000mg ......... 12 VANCOMYCIN INJECTION 750MG ........ 12 velivet ............................................. 27 VELTASSA ........................................ 33 VENCLEXTA ...................................... 14 venlafaxine ...................................... 19 venlafaxine ext-rel ............................ 19 VENTAVIS ........................................ 18 verapamil ........................................ 17 verapamil ext-rel .............................. 17 vestura ............................................ 26 viorele ............................................. 24 viscous lidocaine ............................... 37 VISTOGARD ..................................... 14 voriconazole ..................................... 11 VOTRIENT ........................................ 13 vyfemla ........................................... 26 W warfarin ........................................... 31 wera ............................................... 26

wymzya fe chew .............................. 26 X XALKORI ......................................... 13 XELJANX XR .................................... 32 XELJANZ ......................................... 32 XOLAIR ........................................... 34 XTANDI ........................................... 12 xulane ............................................ 26 Y yuvafem ......................................... 27 Z zafirlukast ....................................... 34 zaleplon .......................................... 21 zarah .............................................. 26 ZARXIO........................................... 31 ZAVESCA ........................................ 28 ZELBORAF ....................................... 13 zenatane ......................................... 34 zenchent ......................................... 26 zenchent fe chew ............................. 26 zidovudine ....................................... 11 ZINBRYTA ....................................... 22 ziprasidone ...................................... 20 ZOLINZA ......................................... 14 zolmitriptan ..................................... 22 zolpidem ......................................... 21 zolpidem ext-rel ............................... 21 zolpidem sublingual .......................... 21 zonisamide ...................................... 19 ZORTRESS ...................................... 32 zovia .............................................. 26 ZYKADIA ......................................... 13 ZYTIGA ........................................... 12

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