USABLEreg AD MINISTRATORS

USAble Administrators Standard with Step Therapy and Tier 4 Specialty Formulary

(04012020)

INTRODUCTION 4

PREFACE4

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE5

DRUG LIST PRODUCT DESCRIPTIONS5

GENERIC SUBSTITUTION5

LEGEND 6

ANALGESICS 7 NSAIDs7 NSAIDs COMBINATIONS7 NSAIDs TOPICAL 7 COX-2 INHIBITORS7 GOUT 7 OPIOID ANALGESICS7 NON-OPIOID ANALGESICS 8

ANTI-INFECTIVES 8 ANTIBACTERIALS9 ANTIFUNGALS 9 ANTIMALARIALS 10 ANTIRETROVIRAL AGENTS 10 ANTITUBERCULAR AGENTS11 ANTIVIRALS 11 MISCELLANEOUS11

ANTINEOPLASTIC AGENTS 12 ALKYLATING AGENTS 12 ANTIMETABOLITES12 HORMONAL ANTINEOPLASTIC AGENTS12 IMMUNOMODULATORS13 KINASE INHIBITORS 13 TOPOISOMERASE INHIBITORS 13 MISCELLANEOUS13

CARDIOVASCULAR13 ACE INHIBITORS 13 ACE INHIBITORCALCIUM CHANNEL BLOCKER COMBINATIONS 14 ACE INHIBITORDIURETIC COMBINATIONS14 ADRENOLYTICS CENTRAL 14 ALDOSTERONE RECEPTOR ANTAGONISTS 14 ALPHA BLOCKERS14 ANGIOTENSIN II RECEPTOR ANTAGONISTSDIURETIC COMBINATIONS 14 ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKER COMBINATIONS 15 ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKERDIURETIC COMBINATIONS 15 ANTIARRHYTHMICS15 ANTILIPEMICS 15 BETA-BLOCKERS 16 BETA-BLOCKERDIURETIC COMBINATIONS16 CALCIUM CHANNEL BLOCKERS 16 CALCIUM CHANNEL BLOCKERANTILIPEMIC COMBINATIONS 17 DIGITALIS GLYCOSIDES 17 DIRECT RENIN INHIBITORSDIURETIC COMBINATIONS 17 DIURETICS 17 HEART FAILURE 17 NITRATES17 PULMONARY ARTERIAL HYPERTENSION 18

MISCELLANEOUS18

CENTRAL NERVOUS SYSTEM 18 ANTIANXIETY18 ANTICONVULSANTS 19 ANTIDEMENTIA19 ANTIDEPRESSANTS 19 ANTIPARKINSONIAN AGENTS 20 ANTIPSYCHOTICS21 ATTENTION DEFICIT HYPERACTIVITY DISORDER 21 FIBROMYALGIA 21 HYPNOTICS 22 MIGRAINE22 MOOD STABILIZERS 22 MOVEMENT DISORDERS 22 MULTIPLE SCLEROSIS AGENTS 23 MUSCULOSKELETAL THERAPY AGENTS 23 MYASTHENIA GRAVIS 23 NARCOLEPSY23 POSTHERPETIC NEURALGIA (PHN) 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS23

ENDOCRINE AND METABOLIC 25 ACROMEGALY 25 ANDROGENS 25 ANTIDIABETICS 25 CALCIUM RECEPTOR ANTAGONISTS 27 CALCIUM REGULATORS 27 CARNITINE DEFICIENCY AGENTS 27 CONTRACEPTIVES 27 ENDOMETRIOSIS 28 ESTROGENS29 ESTROGENPROGESTINS 29 ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS29 FERTILITY REGULATORS 29 GAUCHER DISEASE29 GLUCOCORTICOIDS29 GLUCOSE ELEVATING AGENTS30 HEREDITARY TYROSINEMIA TYPE 1 AGENTS30 HUMAN GROWTH HORMONES 30 HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS 30 PHENYLKETONURIA TREATMENT AGENTS30 PHOSPHATE BINDER AGENTS30 POTASSIUM-REMOVING AGENTS 30 PROGESTINS30 SELECTIVE ESTROGEN RECEPTOR MODULATORS30 THYROID AGENTS 31 VASOPRESSINS 31 MISCELLANEOUS31

GASTROINTESTINAL 31 ANTIDIARRHEALS 31 ANTIEMETICS 31 ANTISPASMODICS 31 CHOLELITHOLYTICS31 H2 RECEPTOR ANTAGONISTS31 INFLAMMATORY BOWEL DISEASE 32 IRRITABLE BOWEL SYNDROME32 LAXATIVES32 OPIOID-INDUCED CONSTIPATION 32 PANCREATIC ENZYMES32 PROSTAGLANDINS 32 PROTON PUMP INHIBITORS32 SALIVA STIMULANTS33 STEROIDS RECTAL33 ULCER THERAPY COMBINATIONS 33 MISCELLANEOUS33

GENITOURINARY33

2

BENIGN PROSTATIC HYPERPLASIA33 URINARY ANTISPASMODICS33 VAGINAL ANTI-INFECTIVES 33 MISCELLANEOUS33

HEMATOLOGIC34 ANTICOAGULANTS 34 HEMATOPOIETIC GROWTH FACTORS34 HEMOPHILIA A AGENTS34 HEMOPHILIA B AGENTS34 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS34 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 34 PLATELET AGGREGATION INHIBITORS34 PLATELET SYNTHESIS INHIBITORS 35 STEM CELL MOBILIZERS 35 THROMBOCYTOPENIA AGENTS 35 MISCELLANEOUS35

IMMUNOLOGIC AGENTS 35 ALLERGENIC EXTRACTS 35 AUTOIMMUNE AGENTS 35 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)35 IMMUNOMODULATORS35 IMMUNOSUPPRESSANTS 36

NUTRITIONALSUPPLEMENTS 36 ELECTROLYTES36 VITAMINS AND MINERALS 36

RESPIRATORY 37 ANAPHYLAXIS TREATMENT AGENTS 37 ANTICHOLINERGICS37 ANTICHOLINERGICBETA AGONIST COMBINATIONS 37 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 37 ANTIHISTAMINES LOW SEDATING 37 ANTIHISTAMINES SEDATING37 ANTITUSSIVES 37 ANTITUSSIVE COMBINATIONS38 BETA AGONISTS 38 CYSTIC FIBROSIS 38 LEUKOTRIENE MODULATORS 38 MAST CELL STABILIZERS 38 NASAL ANTIHISTAMINES 38 NASAL STEROIDSCOMBINATIONS 38 PHOSPHODIESTERASE-4 INHIBITORS39 PULMONARY ENZYME DEFICIENCY AGENTS39 PULMONARY FIBROSIS AGENTS39 SEVERE ASTHMA AGENTS39 STEROIDBETA AGONIST COMBINATIONS39 STEROID INHALANTS 39 XANTHINES39 MISCELLANEOUS39

TOPICAL 39 DERMATOLOGY 39 MOUTHTHROATDENTAL AGENTS 42 OPHTHALMIC42 OTIC44

WEBSITES 45

INDEX 47

3

INTRODUCTION

We are pleased to provide the 2020 USAble Administrators Standard with Step Therapy and Tier 4 Specialty Formulary as a useful reference and informational tool The Standard with Step Therapy and Tier 4 Specialty Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (PampT) Committee and are approved for inclusion The Standard with Step Therapy and Tier 4 Specialty Formulary is reflective of current medical practice as of the date of review

The information contained in this Standard with Step Therapy and Tier 4 Specialty Formulary and its appendices is provided solely for the convenience of medical providers We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature This Standard with Step Therapy and Tier 4 Specialty Formulary is not intended to be a substitute for the knowledge expertise skill and judgment of the medical provider in his or her choice of prescription drugs All the information in the Standard with Step Therapy and Tier 4 Specialty Formulary is provided as a reference for drug therapy selection Specific drug selection for an individual patient rests solely with the prescriber The document is subject to state-specific regulations and rules including but not limited to those regarding generic substitution controlled substance schedules preference for brands and mandatory generics whenever applicable

We assume no responsibility for the actions or omissions of any medical provider based upon reliance in whole or in part on the information contained herein The medical provider should consult the drug manufacturers product literature or standard references for more detailed information

National guidelines can be found on the National Guideline Clearinghouse site at httpsahrqgovgam on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication

PREFACE

The Standard with Step Therapy and Tier 4 Specialty Formulary is organized by sections Each section is divided by therapeutic drug class primarily defined by mechanism of action Products are listed by generic name with brand name for reference only Unless exceptions are noted generally all applicable dosage forms and strengths of the drug cited are included in the Standard with Step Therapy and Tier 4 Specialty Formulary Generics should be considered the first line of prescribing

Individual pharmacy benefit plans may impose restrictions or not reimburse some products In addition over-the-counter (OTC) products with the exception of insulin and diabetes monitoring products are usually not included in the pharmacy benefit Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states OTC products are listed for informational purposes If covered in the pharmacy benefit OTC products require a valid prescription

Drugs represented in the Standard with Step Therapy and Tier 4 Specialty Formulary may have varying cost to the plan member Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated Generic medications typically are available at the lowest cost brand-name medications on the Standard with Step Therapy and Tier 4 Specialty Formulary will generally cost more than generics and brand-name medications not on the list will generally cost the most

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner

Tier 1 Lowest plan member copayment All generic non-specialty drugs including those on the Standard with Step Therapy and Tier 4 Specialty Formulary

Tier 2 Intermediate plan member copayment Preferred brand-name products on the Standard with Step Therapy and Tier 4 Specialty Formulary selected for Tier 2

Tier 3 Higher plan member copayment Products on the Standard with Step Therapy and Tier 4 Specialty Formulary not selected for Tier 2 and all non-specialty non-preferred brand-name products In most cases there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this higher tier

Tier 4 Highest plan member copayment Specialty products are at Tier 4

4

MISCELLANEOUS18

CENTRAL NERVOUS SYSTEM 18 ANTIANXIETY18 ANTICONVULSANTS 19 ANTIDEMENTIA19 ANTIDEPRESSANTS 19 ANTIPARKINSONIAN AGENTS 20 ANTIPSYCHOTICS21 ATTENTION DEFICIT HYPERACTIVITY DISORDER 21 FIBROMYALGIA 21 HYPNOTICS 22 MIGRAINE22 MOOD STABILIZERS 22 MOVEMENT DISORDERS 22 MULTIPLE SCLEROSIS AGENTS 23 MUSCULOSKELETAL THERAPY AGENTS 23 MYASTHENIA GRAVIS 23 NARCOLEPSY23 POSTHERPETIC NEURALGIA (PHN) 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS23

ENDOCRINE AND METABOLIC 25 ACROMEGALY 25 ANDROGENS 25 ANTIDIABETICS 25 CALCIUM RECEPTOR ANTAGONISTS 27 CALCIUM REGULATORS 27 CARNITINE DEFICIENCY AGENTS 27 CONTRACEPTIVES 27 ENDOMETRIOSIS 28 ESTROGENS29 ESTROGENPROGESTINS 29 ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS29 FERTILITY REGULATORS 29 GAUCHER DISEASE29 GLUCOCORTICOIDS29 GLUCOSE ELEVATING AGENTS30 HEREDITARY TYROSINEMIA TYPE 1 AGENTS30 HUMAN GROWTH HORMONES 30 HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS 30 PHENYLKETONURIA TREATMENT AGENTS30 PHOSPHATE BINDER AGENTS30 POTASSIUM-REMOVING AGENTS 30 PROGESTINS30 SELECTIVE ESTROGEN RECEPTOR MODULATORS30 THYROID AGENTS 31 VASOPRESSINS 31 MISCELLANEOUS31

GASTROINTESTINAL 31 ANTIDIARRHEALS 31 ANTIEMETICS 31 ANTISPASMODICS 31 CHOLELITHOLYTICS31 H2 RECEPTOR ANTAGONISTS31 INFLAMMATORY BOWEL DISEASE 32 IRRITABLE BOWEL SYNDROME32 LAXATIVES32 OPIOID-INDUCED CONSTIPATION 32 PANCREATIC ENZYMES32 PROSTAGLANDINS 32 PROTON PUMP INHIBITORS32 SALIVA STIMULANTS33 STEROIDS RECTAL33 ULCER THERAPY COMBINATIONS 33 MISCELLANEOUS33

GENITOURINARY33

2

BENIGN PROSTATIC HYPERPLASIA33 URINARY ANTISPASMODICS33 VAGINAL ANTI-INFECTIVES 33 MISCELLANEOUS33

HEMATOLOGIC34 ANTICOAGULANTS 34 HEMATOPOIETIC GROWTH FACTORS34 HEMOPHILIA A AGENTS34 HEMOPHILIA B AGENTS34 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS34 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 34 PLATELET AGGREGATION INHIBITORS34 PLATELET SYNTHESIS INHIBITORS 35 STEM CELL MOBILIZERS 35 THROMBOCYTOPENIA AGENTS 35 MISCELLANEOUS35

IMMUNOLOGIC AGENTS 35 ALLERGENIC EXTRACTS 35 AUTOIMMUNE AGENTS 35 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)35 IMMUNOMODULATORS35 IMMUNOSUPPRESSANTS 36

NUTRITIONALSUPPLEMENTS 36 ELECTROLYTES36 VITAMINS AND MINERALS 36

RESPIRATORY 37 ANAPHYLAXIS TREATMENT AGENTS 37 ANTICHOLINERGICS37 ANTICHOLINERGICBETA AGONIST COMBINATIONS 37 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 37 ANTIHISTAMINES LOW SEDATING 37 ANTIHISTAMINES SEDATING37 ANTITUSSIVES 37 ANTITUSSIVE COMBINATIONS38 BETA AGONISTS 38 CYSTIC FIBROSIS 38 LEUKOTRIENE MODULATORS 38 MAST CELL STABILIZERS 38 NASAL ANTIHISTAMINES 38 NASAL STEROIDSCOMBINATIONS 38 PHOSPHODIESTERASE-4 INHIBITORS39 PULMONARY ENZYME DEFICIENCY AGENTS39 PULMONARY FIBROSIS AGENTS39 SEVERE ASTHMA AGENTS39 STEROIDBETA AGONIST COMBINATIONS39 STEROID INHALANTS 39 XANTHINES39 MISCELLANEOUS39

TOPICAL 39 DERMATOLOGY 39 MOUTHTHROATDENTAL AGENTS 42 OPHTHALMIC42 OTIC44

WEBSITES 45

INDEX 47

3

INTRODUCTION

We are pleased to provide the 2020 USAble Administrators Standard with Step Therapy and Tier 4 Specialty Formulary as a useful reference and informational tool The Standard with Step Therapy and Tier 4 Specialty Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (PampT) Committee and are approved for inclusion The Standard with Step Therapy and Tier 4 Specialty Formulary is reflective of current medical practice as of the date of review

The information contained in this Standard with Step Therapy and Tier 4 Specialty Formulary and its appendices is provided solely for the convenience of medical providers We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature This Standard with Step Therapy and Tier 4 Specialty Formulary is not intended to be a substitute for the knowledge expertise skill and judgment of the medical provider in his or her choice of prescription drugs All the information in the Standard with Step Therapy and Tier 4 Specialty Formulary is provided as a reference for drug therapy selection Specific drug selection for an individual patient rests solely with the prescriber The document is subject to state-specific regulations and rules including but not limited to those regarding generic substitution controlled substance schedules preference for brands and mandatory generics whenever applicable

We assume no responsibility for the actions or omissions of any medical provider based upon reliance in whole or in part on the information contained herein The medical provider should consult the drug manufacturers product literature or standard references for more detailed information

National guidelines can be found on the National Guideline Clearinghouse site at httpsahrqgovgam on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication

PREFACE

The Standard with Step Therapy and Tier 4 Specialty Formulary is organized by sections Each section is divided by therapeutic drug class primarily defined by mechanism of action Products are listed by generic name with brand name for reference only Unless exceptions are noted generally all applicable dosage forms and strengths of the drug cited are included in the Standard with Step Therapy and Tier 4 Specialty Formulary Generics should be considered the first line of prescribing

Individual pharmacy benefit plans may impose restrictions or not reimburse some products In addition over-the-counter (OTC) products with the exception of insulin and diabetes monitoring products are usually not included in the pharmacy benefit Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states OTC products are listed for informational purposes If covered in the pharmacy benefit OTC products require a valid prescription

Drugs represented in the Standard with Step Therapy and Tier 4 Specialty Formulary may have varying cost to the plan member Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated Generic medications typically are available at the lowest cost brand-name medications on the Standard with Step Therapy and Tier 4 Specialty Formulary will generally cost more than generics and brand-name medications not on the list will generally cost the most

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner

Tier 1 Lowest plan member copayment All generic non-specialty drugs including those on the Standard with Step Therapy and Tier 4 Specialty Formulary

Tier 2 Intermediate plan member copayment Preferred brand-name products on the Standard with Step Therapy and Tier 4 Specialty Formulary selected for Tier 2

Tier 3 Higher plan member copayment Products on the Standard with Step Therapy and Tier 4 Specialty Formulary not selected for Tier 2 and all non-specialty non-preferred brand-name products In most cases there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this higher tier

Tier 4 Highest plan member copayment Specialty products are at Tier 4

4

BENIGN PROSTATIC HYPERPLASIA33 URINARY ANTISPASMODICS33 VAGINAL ANTI-INFECTIVES 33 MISCELLANEOUS33

HEMATOLOGIC34 ANTICOAGULANTS 34 HEMATOPOIETIC GROWTH FACTORS34 HEMOPHILIA A AGENTS34 HEMOPHILIA B AGENTS34 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS34 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 34 PLATELET AGGREGATION INHIBITORS34 PLATELET SYNTHESIS INHIBITORS 35 STEM CELL MOBILIZERS 35 THROMBOCYTOPENIA AGENTS 35 MISCELLANEOUS35

IMMUNOLOGIC AGENTS 35 ALLERGENIC EXTRACTS 35 AUTOIMMUNE AGENTS 35 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)35 IMMUNOMODULATORS35 IMMUNOSUPPRESSANTS 36

NUTRITIONALSUPPLEMENTS 36 ELECTROLYTES36 VITAMINS AND MINERALS 36

RESPIRATORY 37 ANAPHYLAXIS TREATMENT AGENTS 37 ANTICHOLINERGICS37 ANTICHOLINERGICBETA AGONIST COMBINATIONS 37 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 37 ANTIHISTAMINES LOW SEDATING 37 ANTIHISTAMINES SEDATING37 ANTITUSSIVES 37 ANTITUSSIVE COMBINATIONS38 BETA AGONISTS 38 CYSTIC FIBROSIS 38 LEUKOTRIENE MODULATORS 38 MAST CELL STABILIZERS 38 NASAL ANTIHISTAMINES 38 NASAL STEROIDSCOMBINATIONS 38 PHOSPHODIESTERASE-4 INHIBITORS39 PULMONARY ENZYME DEFICIENCY AGENTS39 PULMONARY FIBROSIS AGENTS39 SEVERE ASTHMA AGENTS39 STEROIDBETA AGONIST COMBINATIONS39 STEROID INHALANTS 39 XANTHINES39 MISCELLANEOUS39

TOPICAL 39 DERMATOLOGY 39 MOUTHTHROATDENTAL AGENTS 42 OPHTHALMIC42 OTIC44

WEBSITES 45

INDEX 47

3

INTRODUCTION

We are pleased to provide the 2020 USAble Administrators Standard with Step Therapy and Tier 4 Specialty Formulary as a useful reference and informational tool The Standard with Step Therapy and Tier 4 Specialty Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (PampT) Committee and are approved for inclusion The Standard with Step Therapy and Tier 4 Specialty Formulary is reflective of current medical practice as of the date of review

The information contained in this Standard with Step Therapy and Tier 4 Specialty Formulary and its appendices is provided solely for the convenience of medical providers We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature This Standard with Step Therapy and Tier 4 Specialty Formulary is not intended to be a substitute for the knowledge expertise skill and judgment of the medical provider in his or her choice of prescription drugs All the information in the Standard with Step Therapy and Tier 4 Specialty Formulary is provided as a reference for drug therapy selection Specific drug selection for an individual patient rests solely with the prescriber The document is subject to state-specific regulations and rules including but not limited to those regarding generic substitution controlled substance schedules preference for brands and mandatory generics whenever applicable

We assume no responsibility for the actions or omissions of any medical provider based upon reliance in whole or in part on the information contained herein The medical provider should consult the drug manufacturers product literature or standard references for more detailed information

National guidelines can be found on the National Guideline Clearinghouse site at httpsahrqgovgam on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication

PREFACE

The Standard with Step Therapy and Tier 4 Specialty Formulary is organized by sections Each section is divided by therapeutic drug class primarily defined by mechanism of action Products are listed by generic name with brand name for reference only Unless exceptions are noted generally all applicable dosage forms and strengths of the drug cited are included in the Standard with Step Therapy and Tier 4 Specialty Formulary Generics should be considered the first line of prescribing

Individual pharmacy benefit plans may impose restrictions or not reimburse some products In addition over-the-counter (OTC) products with the exception of insulin and diabetes monitoring products are usually not included in the pharmacy benefit Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states OTC products are listed for informational purposes If covered in the pharmacy benefit OTC products require a valid prescription

Drugs represented in the Standard with Step Therapy and Tier 4 Specialty Formulary may have varying cost to the plan member Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated Generic medications typically are available at the lowest cost brand-name medications on the Standard with Step Therapy and Tier 4 Specialty Formulary will generally cost more than generics and brand-name medications not on the list will generally cost the most

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner

Tier 1 Lowest plan member copayment All generic non-specialty drugs including those on the Standard with Step Therapy and Tier 4 Specialty Formulary

Tier 2 Intermediate plan member copayment Preferred brand-name products on the Standard with Step Therapy and Tier 4 Specialty Formulary selected for Tier 2

Tier 3 Higher plan member copayment Products on the Standard with Step Therapy and Tier 4 Specialty Formulary not selected for Tier 2 and all non-specialty non-preferred brand-name products In most cases there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this higher tier

Tier 4 Highest plan member copayment Specialty products are at Tier 4

4

INTRODUCTION

We are pleased to provide the 2020 USAble Administrators Standard with Step Therapy and Tier 4 Specialty Formulary as a useful reference and informational tool The Standard with Step Therapy and Tier 4 Specialty Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (PampT) Committee and are approved for inclusion The Standard with Step Therapy and Tier 4 Specialty Formulary is reflective of current medical practice as of the date of review

The information contained in this Standard with Step Therapy and Tier 4 Specialty Formulary and its appendices is provided solely for the convenience of medical providers We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature This Standard with Step Therapy and Tier 4 Specialty Formulary is not intended to be a substitute for the knowledge expertise skill and judgment of the medical provider in his or her choice of prescription drugs All the information in the Standard with Step Therapy and Tier 4 Specialty Formulary is provided as a reference for drug therapy selection Specific drug selection for an individual patient rests solely with the prescriber The document is subject to state-specific regulations and rules including but not limited to those regarding generic substitution controlled substance schedules preference for brands and mandatory generics whenever applicable

We assume no responsibility for the actions or omissions of any medical provider based upon reliance in whole or in part on the information contained herein The medical provider should consult the drug manufacturers product literature or standard references for more detailed information

National guidelines can be found on the National Guideline Clearinghouse site at httpsahrqgovgam on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication

PREFACE

The Standard with Step Therapy and Tier 4 Specialty Formulary is organized by sections Each section is divided by therapeutic drug class primarily defined by mechanism of action Products are listed by generic name with brand name for reference only Unless exceptions are noted generally all applicable dosage forms and strengths of the drug cited are included in the Standard with Step Therapy and Tier 4 Specialty Formulary Generics should be considered the first line of prescribing

Individual pharmacy benefit plans may impose restrictions or not reimburse some products In addition over-the-counter (OTC) products with the exception of insulin and diabetes monitoring products are usually not included in the pharmacy benefit Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states OTC products are listed for informational purposes If covered in the pharmacy benefit OTC products require a valid prescription

Drugs represented in the Standard with Step Therapy and Tier 4 Specialty Formulary may have varying cost to the plan member Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated Generic medications typically are available at the lowest cost brand-name medications on the Standard with Step Therapy and Tier 4 Specialty Formulary will generally cost more than generics and brand-name medications not on the list will generally cost the most

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner

Tier 1 Lowest plan member copayment All generic non-specialty drugs including those on the Standard with Step Therapy and Tier 4 Specialty Formulary

Tier 2 Intermediate plan member copayment Preferred brand-name products on the Standard with Step Therapy and Tier 4 Specialty Formulary selected for Tier 2

Tier 3 Higher plan member copayment Products on the Standard with Step Therapy and Tier 4 Specialty Formulary not selected for Tier 2 and all non-specialty non-preferred brand-name products In most cases there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this higher tier

Tier 4 Highest plan member copayment Specialty products are at Tier 4

4

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE

The services of an independent National Pharmacy and Therapeutics Committee (PampT Committee) are utilized to approve safe and clinically effective drug therapies The PampT Committee is an external advisory body of clinical professionals from across the United States The PampT Committees voting members include physicians pharmacists a pharmacoeconomist and a medical ethicist all of whom have a broad background of clinical and academic expertise regarding prescription drugs Employees with significant clinical expertise are invited to meet with the PampT Committee but no employee may vote on issues before the PampT Committee Voting members of the PampT Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers

USAble Administrators will utilize the services of the independent National PampT Committee as well as internal pharmacy and medical advisory committees to direct formulary decisions as it relates to our benefit certificates and policies

DRUG LIST PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are on the Standard with Step Therapy and Tier 4 Specialty Formulary examples are noted below The general principles shown in the examples can usually be extended to other entries in the book Any exceptions are noted

Products on the Standard with Step Therapy and Tier 4 Specialty Formulary include all strengths and dosage forms of the cited brand-name product

cefixime Suprax Oral capsules oral chewable tablets oral suspension and all strengths of Suprax would be included in this listing

When a strength or dosage form is specified only the specified strength and dosage form is on the Standard with Step Therapy and Tier 4 Specialty Formulary Other strengthsdosage forms of the reference product are not

acyclovir caps tabs Zovirax The capsules and tablets of Zovirax are on the Standard with Step Therapy and Tier 4 Specialty Formulary From this entry the cream and ointment cannot be assumed to be on the list unless there is a specific entry

Extended-release and delayed-release products require their own entry sitagliptinmetformin Janumet

The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR

sitagliptinmetformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Standard with Step Therapy and Tier 4 Specialty Formulary

Dosage forms on the Standard with Step Therapy and Tier 4 Specialty Formulary will be consistent with the category and use where listed

nystatin The above nystatin entry listed in the TOPICALDERMATOLOGY section is limited to the topical dosage forms From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the Standard with Step Therapy and Tier 4 Specialty Formulary

GENERIC SUBSTITUTION

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

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

Approved by the US Food and Drug Administration for safety and effectiveness and are manufactured under the same strict standards that apply to brand-name drugs

5

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

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

When a generic drug is substituted for a brand-name drug you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug Brand-name drugs having a generic available may

Incur higher copayment (tier 3)

Require payment of the difference in price between generic and brand in addition to copayment

Require mandatory generic dispensing

LEGEND

dagger Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy

boldface Indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

delayed-rel Delayed-release (also known as enteric-coated) refer to the reference brand listed for clarification

ext-rel Extended-release (also known as sustained-release) refer to the reference brand listed for clarification

6

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1

nabumetone Tier 1 naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

Listing does not include NDC 69499031866 Drug products are identified by unique numerical product identifiers called National Drug Codes (NDC) which identify the manufacturer strength dosage form formulation and package size

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at httpswwwasahqorg httpswwwnccnorg

Opioid guidelines in the management of chronic non-malignant pain are available at httpswwwasipporgASIPP-Guidelineshtml

QL buprenorphine transdermal Tier 1

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1 PA fentanyl transmucosal lozenge Tier 1

QL hydromorphone ext-rel Tier 1

QL methadone Tier 1 QL morphine Tier 1

QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

7

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

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

When a generic drug is substituted for a brand-name drug you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug Brand-name drugs having a generic available may

Incur higher copayment (tier 3)

Require payment of the difference in price between generic and brand in addition to copayment

Require mandatory generic dispensing

LEGEND

dagger Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy

boldface Indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

delayed-rel Delayed-release (also known as enteric-coated) refer to the reference brand listed for clarification

ext-rel Extended-release (also known as sustained-release) refer to the reference brand listed for clarification

6

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1

nabumetone Tier 1 naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

Listing does not include NDC 69499031866 Drug products are identified by unique numerical product identifiers called National Drug Codes (NDC) which identify the manufacturer strength dosage form formulation and package size

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at httpswwwasahqorg httpswwwnccnorg

Opioid guidelines in the management of chronic non-malignant pain are available at httpswwwasipporgASIPP-Guidelineshtml

QL buprenorphine transdermal Tier 1

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1 PA fentanyl transmucosal lozenge Tier 1

QL hydromorphone ext-rel Tier 1

QL methadone Tier 1 QL morphine Tier 1

QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

7

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1

nabumetone Tier 1 naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

Listing does not include NDC 69499031866 Drug products are identified by unique numerical product identifiers called National Drug Codes (NDC) which identify the manufacturer strength dosage form formulation and package size

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at httpswwwasahqorg httpswwwnccnorg

Opioid guidelines in the management of chronic non-malignant pain are available at httpswwwasipporgASIPP-Guidelineshtml

QL buprenorphine transdermal Tier 1

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1 PA fentanyl transmucosal lozenge Tier 1

QL hydromorphone ext-rel Tier 1

QL methadone Tier 1 QL morphine Tier 1

QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

7

QL oxycodone tabs 5 mg Tier 1 QL oxycodoneacetaminophen 5325 Tier 1

QL tramadol ext-rel Tier 1

QL buprenorphine Tier 2 BELBUCA

PA fentanyl sublingual spray Tier 2 SUBSYS QL morphinenaltrexone ext-rel Tier 2 EMBEDA

QL oxycodone ext-rel Tier 2 XTAMPZA ER

QL tapentadol Tier 2 NUCYNTA QL tapentadol ext-rel Tier 2 NUCYNTA ER

QL hydrocodoneacetaminophen Tier 3 NORCO

QL hydromorphone Tier 3 DILAUDID QL morphine ext-rel Tier 3 KADIAN

QL morphine ext-rel Tier 3 MS CONTIN

QL oxycodone tabs 15 mg 30 mg soln 5 mg5 mL Tier 3 ROXICODONE

QL tramadol Tier 3 ULTRAM

NON-OPIOID ANALGESICS

butalbitalacetaminophencaffeine tabs Tier 2 ESGIC butalbitalaspirincaffeine Tier 3 FIORINAL

ANTI-INFECTIVES

Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at httpswwwidsocietyorg

Hepatitis CDC recommendations on the treatment of hepatitis are available at httpswwwcdcgovhepatitisResources

Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at httpswwwaasldorg

HIVAIDS Guidelines for the treatment of HIV patients by the US Department of Health and Human Services are available at httpswwwaidsinfonihgov

Infective Endocarditis American Heart Association recommendations for the prevention of bacterial endocarditis are available at httpsprofessionalheartorg

Influenza Recommendations of the Advisory Committee on Immunization Practices are available at httpswwwcdcgovvaccineshcpacip-recsvacc-specificfluhtml

International Travel CDC recommendations for international travel are available at httpswwwnccdcgovtravel

Respiratory Tract InfectionAntibiotic UseCommunity Acquired PneumoniaOther Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at httpswwwcdcgovpneumoniamanagement-prevention-guidelineshtml

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

8

Sexually Transmitted Diseases CDC Sexually Transmitted Diseases Guidelines are available at httpswwwcdcgovstdtreatmentdefaulthtm

ANTIBACTERIALS Cephalosporins First Generation

cefadroxil Tier 1

cephalexin Tier 3 KEFLEX

Second Generation

cefprozil Tier 1

cefuroxime axetil Tier 1

Third Generation

cefdinir Tier 1 cefixime Tier 2 SUPRAX

ErythromycinsMacrolides clarithromycin Tier 1

clarithromycin ext-rel Tier 1

erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1

erythromycin stearate Tier 1

ST QL fidaxomicin Tier 2 DIFICID

azithromycin Tier 3 ZITHROMAX

Fluoroquinolones

ciprofloxacin Tier 3 CIPRO levofloxacin Tier 3 LEVAQUIN

moxifloxacin Tier 3 AVELOX

Penicillins

amoxicillin Tier 1

amoxicillinclavulanate ext-rel Tier 1 ampicillin Tier 1

dicloxacillin Tier 1

penicillin VK Tier 1

amoxicillinclavulanate Tier 3 AUGMENTIN

Tetracyclines

doxycycline hyclate 20 mg Tier 1 minocycline Tier 1

tetracycline Tier 1

PA doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS

clotrimazole troches Tier 1 griseofulvin ultramicrosize Tier 1

PA itraconazole Tier 1

nystatin Tier 1

terbinafine tabs Tier 1 PA voriconazole Tier 2 VFEND

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

9

fluconazole Tier 3 DIFLUCAN

ANTIMALARIALS

chloroquine Tier 1 mefloquine Tier 1

atovaquoneproguanil Tier 2 MALARONE

ANTIRETROVIRAL AGENTS Antiretroviral Combinations

QL abacavirdolutegravirlamivudine Tier 2 TRIUMEQ

QL atazanavircobicistat Tier 2 EVOTAZ QL bictegraviremtricitabinetenofovir alafenamide Tier 2 BIKTARVY

QL darunavircobicistat Tier 2 PREZCOBIX

QL efavirenzemtricitabinetenofovir disoproxil fumarate Tier 2 ATRIPLA QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI

QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI LO

QL elvitegravircobicistatemtricitabinetenofovir alafenamide Tier 2 GENVOYA QL elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate Tier 2 STRIBILD

QL emtricitabinerilpivirinetenofovir alafenamide Tier 2 ODEFSEY

QL emtricitabinerilpivirinetenofovir disoproxil fumarate Tier 2 COMPLERA

QL emtricitabinetenofovir alafenamide Tier 2 DESCOVY QL emtricitabinetenofovir disoproxil fumarate Tier 2 TRUVADA

QL lamivudinetenofovir disoproxil fumarate Tier 2 CIMDUO

QL lamivudinetenofovir disoproxil fumarate Tier 2 TEMIXYS QL abacavirlamivudine Tier 3 EPZICOM

QL lamivudinezidovudine Tier 3 COMBIVIR

Fusion Inhibitors

QL enfuvirtide Tier 2 FUZEON

Integrase Inhibitors

QL dolutegravir Tier 2 TIVICAY

QL raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors

QL efavirenz Tier 1

QL nevirapine Tier 1 QL nevirapine ext-rel Tier 1

QL etravirine Tier 2 INTELENCE

QL rilpivirine Tier 2 EDURANT

Nucleoside Reverse Transcriptase Inhibitors

QL stavudine Tier 1 QL didanosine delayed-rel Tier 2 VIDEX EC

QL emtricitabine Tier 2 EMTRIVA

QL zidovudine Tier 2 RETROVIR

QL abacavir tabs Tier 3 ZIAGEN QL lamivudine Tier 3 EPIVIR

Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate Tier 2 VIREAD

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

10

Protease Inhibitors QL atazanavir Tier 2

QL darunavir Tier 2 PREZISTA

QL lopinavirritonavir soln Tier 2 KALETRA QL lopinavirritonavir tabs Tier 2 KALETRA

QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS

isoniazid Tier 1

pyrazinamide Tier 1

ethambutol Tier 2 MYAMBUTOL rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1 lamivudine Tier 1

entecavir soln Tier 2 BARACLUDE

tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C

SGM ledipasvirsofosbuvir Tier 4 HARVONI SGM ribavirin Tier 4

SGM sofosbuvirvelpatasvir Tier 4 EPCLUSA

SGM sofosbuvirvelpatasvirvoxilaprevir Tier 4 VOSEVI

HARVONI only for genotypes 1 4 5 and 6 EPCLUSA for genotypes 1 2 3 4 5 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3)

Herpes Agents

famciclovir Tier 1

valacyclovir Tier 1 acyclovir caps tabs Tier 3 ZOVIRAX

Influenza Agents QL oseltamivir Tier 1

QL zanamivir Tier 2 RELENZA

MISCELLANEOUS

dapsone Tier 1

PA linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 sulfamethoxazoletrimethoprim Tier 1

sulfamethoxazoletrimethoprim DS Tier 1

tinidazole Tier 1 trimethoprim Tier 1

clindamycin Tier 2 CLEOCIN

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

11

mebendazole chewable Tier 2 EMVERM nitrofurantoin ext-rel Tier 2 MACROBID

PA rifaximin 550 mg Tier 2 XIFAXAN

QL vancomycin caps Tier 2 VANCOCIN

ivermectin Tier 3 STROMECTOL metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS

cyclophosphamide caps Tier 1 busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN

melphalan Tier 2 ALKERAN SGM temozolomide Tier 4 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1 methotrexate Tier 2 TREXALL

thioguanine Tier 2 TABLOID

SGM capecitabine Tier 4 XELODA

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

flutamide Tier 1

bicalutamide Tier 3 CASODEX

SGM abiraterone Tier 4 SGM abiraterone Tier 4 YONSA

SGM apalutamide Tier 4 ERLEADA

SGM darolutamide Tier 4 NUBEQA

SGM enzalutamide Tier 4 XTANDI

Antiestrogens

tamoxifen Tier 1

Aromatase Inhibitors

anastrozole Tier 2 ARIMIDEX exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate

dagger leuprolide acetate ELIGARD dagger leuprolide acetate LUPRON DEPOT

Progestins megestrol acetate tabs Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

12

Protease Inhibitors QL atazanavir Tier 2

QL darunavir Tier 2 PREZISTA

QL lopinavirritonavir soln Tier 2 KALETRA QL lopinavirritonavir tabs Tier 2 KALETRA

QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS

isoniazid Tier 1

pyrazinamide Tier 1

ethambutol Tier 2 MYAMBUTOL rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1 lamivudine Tier 1

entecavir soln Tier 2 BARACLUDE

tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C

SGM ledipasvirsofosbuvir Tier 4 HARVONI SGM ribavirin Tier 4

SGM sofosbuvirvelpatasvir Tier 4 EPCLUSA

SGM sofosbuvirvelpatasvirvoxilaprevir Tier 4 VOSEVI

HARVONI only for genotypes 1 4 5 and 6 EPCLUSA for genotypes 1 2 3 4 5 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3)

Herpes Agents

famciclovir Tier 1

valacyclovir Tier 1 acyclovir caps tabs Tier 3 ZOVIRAX

Influenza Agents QL oseltamivir Tier 1

QL zanamivir Tier 2 RELENZA

MISCELLANEOUS

dapsone Tier 1

PA linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 sulfamethoxazoletrimethoprim Tier 1

sulfamethoxazoletrimethoprim DS Tier 1

tinidazole Tier 1 trimethoprim Tier 1

clindamycin Tier 2 CLEOCIN

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

11

mebendazole chewable Tier 2 EMVERM nitrofurantoin ext-rel Tier 2 MACROBID

PA rifaximin 550 mg Tier 2 XIFAXAN

QL vancomycin caps Tier 2 VANCOCIN

ivermectin Tier 3 STROMECTOL metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS

cyclophosphamide caps Tier 1 busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN

melphalan Tier 2 ALKERAN SGM temozolomide Tier 4 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1 methotrexate Tier 2 TREXALL

thioguanine Tier 2 TABLOID

SGM capecitabine Tier 4 XELODA

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

flutamide Tier 1

bicalutamide Tier 3 CASODEX

SGM abiraterone Tier 4 SGM abiraterone Tier 4 YONSA

SGM apalutamide Tier 4 ERLEADA

SGM darolutamide Tier 4 NUBEQA

SGM enzalutamide Tier 4 XTANDI

Antiestrogens

tamoxifen Tier 1

Aromatase Inhibitors

anastrozole Tier 2 ARIMIDEX exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate

dagger leuprolide acetate ELIGARD dagger leuprolide acetate LUPRON DEPOT

Progestins megestrol acetate tabs Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

12

mebendazole chewable Tier 2 EMVERM nitrofurantoin ext-rel Tier 2 MACROBID

PA rifaximin 550 mg Tier 2 XIFAXAN

QL vancomycin caps Tier 2 VANCOCIN

ivermectin Tier 3 STROMECTOL metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS

cyclophosphamide caps Tier 1 busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN

melphalan Tier 2 ALKERAN SGM temozolomide Tier 4 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1 methotrexate Tier 2 TREXALL

thioguanine Tier 2 TABLOID

SGM capecitabine Tier 4 XELODA

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

flutamide Tier 1

bicalutamide Tier 3 CASODEX

SGM abiraterone Tier 4 SGM abiraterone Tier 4 YONSA

SGM apalutamide Tier 4 ERLEADA

SGM darolutamide Tier 4 NUBEQA

SGM enzalutamide Tier 4 XTANDI

Antiestrogens

tamoxifen Tier 1

Aromatase Inhibitors

anastrozole Tier 2 ARIMIDEX exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate

dagger leuprolide acetate ELIGARD dagger leuprolide acetate LUPRON DEPOT

Progestins megestrol acetate tabs Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

12

IMMUNOMODULATORS SGM lenalidomide Tier 4 REVLIMID

SGM pomalidomide Tier 4 POMALYST

SGM thalidomide Tier 4 THALOMID

KINASE INHIBITORS

SGM bosutinib Tier 4 BOSULIF SGM cabozantinib Tier 4 CABOMETYX

SGM dasatinib Tier 4 SPRYCEL

SGM erlotinib Tier 4

SGM everolimus Tier 4 AFINITOR SGM gefitinib Tier 4 IRESSA

SGM imatinib mesylate Tier 4

SGM lapatinib Tier 4 TYKERB SGM midostaurin Tier 4 RYDAPT

SGM palbociclib Tier 4 IBRANCE

SGM pazopanib Tier 4 VOTRIENT

SGM ribociclib Tier 4 KISQALI SGM ribociclib + letrozole Tier 4 KISQALI FEMARA CO-PACK

SGM sunitinib Tier 4 SUTENT

TOPOISOMERASE INHIBITORS

SGM topotecan caps Tier 4 HYCAMTIN

MISCELLANEOUS

etoposide Tier 1

tretinoin caps Tier 1 hydroxyurea Tier 2 HYDREA

mitotane Tier 2 LYSODREN

procarbazine Tier 2 MATULANE

SGM bexarotene caps Tier 4 TARGRETIN SGM niraparib Tier 4 ZEJULA

SGM olaparib Tier 4 LYNPARZA

SGM rucaparib Tier 4 RUBRACA SGM sonidegib Tier 4 ODOMZO

SGM vorinostat Tier 4 ZOLINZA

CARDIOVASCULAR

The Eighth Report of the Joint National Committee on Prevention Detection Evaluation and Treatment of High Blood Pressure is available at httpsjamanetworkcomjournalsjamafullarticle1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at httpswwwaccorg httpsprofessionalheartorg

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at httpsjamanetworkcomjournalsjamafullarticle1791497 httpsprofessionaldiabetesorg httpswwwaccorg httpsprofessionalheartorg

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

13

captopril Tier 1

fosinopril Tier 1

perindopril Tier 1 trandolapril Tier 1

benazepril Tier 3 LOTENSIN

enalapril Tier 3 VASOTEC

lisinopril Tier 3 ZESTRIL quinapril Tier 3 ACCUPRIL

ramipril Tier 3 ALTACE

ACE INHIBITORCALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipinebenazepril Tier 2 LOTREL

trandolaprilverapamil ext-rel Tier 2 TARKA

ACE INHIBITORDIURETIC COMBINATIONS

captoprilhydrochlorothiazide Tier 1 fosinoprilhydrochlorothiazide Tier 1

benazeprilhydrochlorothiazide Tier 3 LOTENSIN HCT

enalaprilhydrochlorothiazide Tier 3 VASERETIC

lisinoprilhydrochlorothiazide Tier 3 ZESTORETIC quinaprilhydrochlorothiazide Tier 3 ACCURETIC

ADRENOLYTICS CENTRAL guanfacine Tier 1

clonidine Tier 2 CATAPRES

clonidine transdermal Tier 2 CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 2 INSPRA spironolactone Tier 2 ALDACTONE

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at httpsjamanetworkcomjournalsjamafullarticle1791497

terazosin Tier 1 doxazosin Tier 3 CARDURA

ANGIOTENSIN II RECEPTOR ANTAGONISTSDIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at httpsjamanetworkcomjournalsjamafullarticle1791497 httpsprofessionaldiabetesorg

candesartan Tier 1

candesartanhydrochlorothiazide Tier 1 eprosartan Tier 1

irbesartan Tier 1

irbesartanhydrochlorothiazide Tier 1 olmesartan Tier 1

olmesartanhydrochlorothiazide Tier 1

valsartan Tier 1

valsartanhydrochlorothiazide Tier 1 losartan Tier 3 COZAAR

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

14

losartanhydrochlorothiazide Tier 3 HYZAAR telmisartan Tier 3 MICARDIS

telmisartanhydrochlorothiazide Tier 3 MICARDIS HCT

ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipinetelmisartan Tier 1

amlodipinevalsartan Tier 1

amlodipineolmesartan Tier 3 AZOR

ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKERDIURETIC COMBINATIONS

amlodipinevalsartanhydrochlorothiazide Tier 1 olmesartanamlodipinehydrochlorothiazide Tier 3 TRIBENZOR

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at httpswwwaccorg

amiodarone Tier 1

flecainide Tier 1

propafenone Tier 1 sotalol Tier 1

disopyramide Tier 2 NORPACE

disopyramide ext-rel Tier 2 NORPACE CR dronedarone Tier 2 MULTAQ

propafenone ext-rel Tier 2 RYTHMOL SR

dofetilide Tier 4 TIKOSYN

ANTILIPEMICS The 2018 AHAACCAACVPRAAPAABCACPMADAAGSAPhAASPCNLAPCNA Guideline on the Management of Blood Cholesterol is available at httpswwwahajournalsorgdoi101161CIR0000000000000625

Bile Acid Resins

colesevelam Tier 1

cholestyramine Tier 3 QUESTRANQUESTRAN LIGHT colestipol Tier 3 COLESTID

Cholesterol Absorption Inhibitors ezetimibe Tier 1

Fibrates fenofibrate Tier 1

fenofibrate Tier 3 LIPOFEN

fenofibric acid delayed-rel Tier 3 TRILIPIX

gemfibrozil Tier 3 LOPID

Listing does not include fenofibrate tablet 120 mg

HMG-CoA Reductase InhibitorsCombinations

atorvastatin Tier 1

fluvastatin Tier 1 lovastatin Tier 1

rosuvastatin Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

15

ezetimibesimvastatin Tier 3 VYTORIN pravastatin Tier 3 PRAVACHOL

simvastatin Tier 3 ZOCOR

niacin ext-rel Tier 3 NIASPAN

Niacins

Omega-3 Fatty Acids

PA icosapent ethyl Tier 2 VASCEPA

PA omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors

PA evolocumab Tier 2 REPATHA

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at httpsjamanetworkcomjournalsjamafullarticle1791497 httpswwwaccorg

atenolol Tier 1

bisoprolol Tier 1

carvedilol phosphate ext-rel Tier 1

labetalol Tier 1 metoprolol succinate ext-rel Tier 1

pindolol Tier 1

propranolol Tier 1 nebivolol Tier 2 BYSTOLIC

carvedilol Tier 3 COREG

metoprolol tartrate Tier 3 LOPRESSOR

nadolol Tier 3 CORGARD propranolol ext-rel Tier 3 INDERAL LA

BETA-BLOCKERDIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at httpsjamanetworkcomjournalsjamafullarticle1791497 httpswwwaccorg

atenololchlorthalidone Tier 1 bisoprololhydrochlorothiazide Tier 2 ZIAC

metoprololhydrochlorothiazide Tier 2 LOPRESSOR HCT

CALCIUM CHANNEL BLOCKERS Dihydropyridines

amlodipine Tier 1 felodipine ext-rel Tier 1

nifedipine ext-rel Tier 3 ADALAT CC

nifedipine ext-rel Tier 3 PROCARDIA XL

Nondihydropyridines

diltiazem ext-rel Tier 1

diltiazem ext-rel Tier 3 TIAZAC verapamil ext-rel Tier 3 CALAN SR

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

16

Listing does not include generic CARDIZEM LA

CALCIUM CHANNEL BLOCKERANTILIPEMIC COMBINATIONS

amlodipineatorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES

digoxin 0125 mg 025 mg Tier 1 digoxin ped elixir Tier 1

digoxin 00625 mg 01875 mg Tier 2 LANOXIN

DIRECT RENIN INHIBITORSDIURETIC COMBINATIONS

aliskiren Tier 1

ST aliskirenhydrochlorothiazide Tier 2 TEKTURNA HCT

DIURETICS Carbonic Anhydrase Inhibitors

acetazolamide Tier 1

acetazolamide ext-rel Tier 1

methazolamide Tier 1

Loop Diuretics

bumetanide Tier 1

torsemide Tier 1 furosemide Tier 3 LASIX

Potassium-sparing Diuretics amiloride Tier 1

triamterene Tier 1

Thiazides and Thiazide-like Diuretics

chlorthalidone Tier 1

hydrochlorothiazide Tier 1 indapamide Tier 1

metolazone Tier 1

Diuretic Combinations

amiloridehydrochlorothiazide Tier 1

spironolactonehydrochlorothiazide Tier 3 ALDACTAZIDE

triamterenehydrochlorothiazide Tier 3 DYAZIDE triamterenehydrochlorothiazide Tier 3 MAXZIDE

HEART FAILURE isosorbide dinitratehydralazine Tier 2 BIDIL

ivabradine Tier 2 CORLANOR

sacubitrilvalsartan Tier 2 ENTRESTO

NITRATES Oral

isosorbide dinitrate ext-rel tabs Tier 1

isosorbide mononitrate Tier 1

isosorbide mononitrate ext-rel Tier 1

isosorbide dinitrate oral Tier 2 ISORDIL

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

17

SublingualTranslingual nitroglycerin lingual spray Tier 3 NITROLINGUAL

nitroglycerin sublingual Tier 3 NITROSTAT

Transdermal

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 2 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

SGM ambrisentan Tier 4

SGM bosentan Tier 4

SGM macitentan Tier 4 OPSUMIT

Phosphodiesterase Inhibitors

SGM sildenafil Tier 4

SGM tadalafil Tier 4

Prostacyclin Receptor Agonists

SGM selexipag Tier 4 UPTRAVI

Prostaglandin Vasodilators

dagger epoprostenol sodium FLOLAN SGM treprostinil ext-rel Tier 4 ORENITRAM

Soluble Guanylate Cyclase Stimulators SGM riociguat Tier 4 ADEMPAS

MISCELLANEOUS hydralazine Tier 1

methyldopa Tier 1

midodrine Tier 1

ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at httpswwwpsychiatryorg

ANTIANXIETY Benzodiazepines

alprazolam Tier 1

oxazepam Tier 1

diazepam Tier 2 VALIUM lorazepam Tier 2 ATIVAN

clonazepam Tier 3 KLONOPIN

Miscellaneous

buspirone Tier 1

fluvoxamine Tier 1 clomipramine Tier 2 ANAFRANIL

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

18

SublingualTranslingual nitroglycerin lingual spray Tier 3 NITROLINGUAL

nitroglycerin sublingual Tier 3 NITROSTAT

Transdermal

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 2 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

SGM ambrisentan Tier 4

SGM bosentan Tier 4

SGM macitentan Tier 4 OPSUMIT

Phosphodiesterase Inhibitors

SGM sildenafil Tier 4

SGM tadalafil Tier 4

Prostacyclin Receptor Agonists

SGM selexipag Tier 4 UPTRAVI

Prostaglandin Vasodilators

dagger epoprostenol sodium FLOLAN SGM treprostinil ext-rel Tier 4 ORENITRAM

Soluble Guanylate Cyclase Stimulators SGM riociguat Tier 4 ADEMPAS

MISCELLANEOUS hydralazine Tier 1

methyldopa Tier 1

midodrine Tier 1

ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at httpswwwpsychiatryorg

ANTIANXIETY Benzodiazepines

alprazolam Tier 1

oxazepam Tier 1

diazepam Tier 2 VALIUM lorazepam Tier 2 ATIVAN

clonazepam Tier 3 KLONOPIN

Miscellaneous

buspirone Tier 1

fluvoxamine Tier 1 clomipramine Tier 2 ANAFRANIL

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

18

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at httpswwwaancom

carbamazepine ext-rel Tier 1

clobazam Tier 1

lamotrigine Tier 1 lamotrigine ext-rel Tier 1

lamotrigine orally disintegrating tabs Tier 1

phenobarbital Tier 1 tiagabine Tier 1

zonisamide Tier 1

lacosamide Tier 2 VIMPAT

oxcarbazepine ext-rel Tier 2 OXTELLAR XR perampanel Tier 2 FYCOMPA

carbamazepine Tier 3 TEGRETOL

carbamazepine ext-rel Tier 3 CARBATROL diazepam rectal gel Tier 3 DIASTAT

divalproex sodium delayed-rel Tier 3 DEPAKOTE

divalproex sodium ext-rel Tier 3 DEPAKOTE ER ethosuximide Tier 3 ZARONTIN

gabapentin Tier 3 NEURONTIN

levetiracetam Tier 3 KEPPRA

levetiracetam ext-rel Tier 3 KEPPRA XR oxcarbazepine Tier 3 TRILEPTAL

phenytoin Tier 3 DILANTIN INFATABS

phenytoin sodium extended Tier 3 DILANTIN primidone Tier 3 MYSOLINE

topiramate Tier 3 TOPAMAX

valproic acid Tier 3 DEPAKENE

SGM vigabatrin Tier 4

ANTIDEMENTIA Practice guidelines for the management of dementia are available at httpswwwaancom

memantine ext-rel Tier 1

rivastigmine Tier 1

memantinedonepezil Tier 2 NAMZARIC

donepezil Tier 3 ARICEPT galantamine Tier 3 RAZADYNE

galantamine ext-rel Tier 3 RAZADYNE ER

memantine Tier 3 NAMENDA rivastigmine transdermal Tier 3 EXELON

ANTIDEPRESSANTS Although these agents are primarily indicated for depression some of these are also approved for other indications including bipolar disorder obsessive-compulsive disorder panic disorder and premenstrual dysphoric disorder

Guidelines for the evaluation and management of bipolar and depressive disorders are available at httpswwwpsychiatryorg

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

19

Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 2 NARDIL

tranylcypromine Tier 2 PARNATE

Selective Serotonin Reuptake Inhibitors (SSRIs)

escitalopram Tier 1

fluoxetine Tier 1 ST vilazodone Tier 2 VIIBRYD

ST vortioxetine Tier 2 TRINTELLIX

citalopram Tier 3 CELEXA

paroxetine HCl Tier 3 PAXIL paroxetine HCl ext-rel Tier 3 PAXIL CR

sertraline Tier 3 ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine ext-rel Tier 1

duloxetine delayed-rel Tier 1 venlafaxine Tier 1

venlafaxine ext-rel Tier 1

Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1

doxepin Tier 1

desipramine Tier 2 NORPRAMIN imipramine HCl Tier 2 TOFRANIL

nortriptyline Tier 2 PAMELOR

Miscellaneous Agents

bupropion Tier 1

trazodone Tier 1 bupropion ext-rel Tier 3 WELLBUTRIN SR

bupropion ext-rel Tier 3 WELLBUTRIN XL

mirtazapine Tier 3 REMERON

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinsons disease are available at httpswwwaancom

amantadine Tier 1 benztropine Tier 1

carbidopalevodopa orally disintegrating tabs Tier 1

pramipexole ext-rel Tier 1

rasagiline Tier 1 ropinirole Tier 1

selegiline Tier 1

trihexyphenidyl Tier 1 rotigotine transdermal Tier 2 NEUPRO

bromocriptine Tier 3 PARLODEL

carbidopalevodopa Tier 3 SINEMET

carbidopalevodopa ext-rel Tier 3 SINEMET CR carbidopalevodopaentacapone Tier 3 STALEVO

entacapone Tier 3 COMTAN

pramipexole Tier 3 MIRAPEX Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

20

ropinirole ext-rel Tier 3 REQUIP XL

ANTIPSYCHOTICS Atypicals

aripiprazole Tier 1

quetiapine ext-rel Tier 1

aripiprazole ext-rel inj Tier 2 ABILIFY MAINTENA dagger aripiprazole lauroxil ext-rel inj ARISTADA

dagger aripiprazole lauroxil ext-rel inj ARISTADA INITIO

ST cariprazine Tier 2 VRAYLAR

lurasidone Tier 2 LATUDA risperidone long-acting injection Tier 2 RISPERDAL CONSTA

clozapine Tier 3 CLOZARIL

olanzapine Tier 3 ZYPREXA paliperidone palmitate ext-rel inj Tier 3 INVEGA SUSTENNA

quetiapine Tier 3 SEROQUEL

risperidone Tier 3 RISPERDAL

ziprasidone Tier 3 GEODON

Miscellaneous

chlorpromazine Tier 1 fluphenazine Tier 1

haloperidol Tier 1

perphenazine Tier 1 prochlorperazine inj Tier 1

thiothixene Tier 1

trifluoperazine Tier 1

chlorpromazine inj Tier 3 haloperidol decanoate inj Tier 3 HALDOL DECANOATE

haloperidol inj Tier 3 HALDOL

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at httpswwwaacaporg httpswwwaaporg

QL amphetaminedextroamphetamine mixed salts Tier 1

QL amphetaminedextroamphetamine mixed salts ext-rel Tier 1

QL dextroamphetamine Tier 1

QL guanfacine ext-rel Tier 1 QL methylphenidate ext-rel Tier 1

QL amphetaminedextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS

QL lisdexamfetamine Tier 2 VYVANSE QL atomoxetine Tier 3 STRATTERA

QL dexmethylphenidate Tier 3 FOCALIN

QL dexmethylphenidate ext-rel Tier 3 FOCALIN XR QL dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE

QL methylphenidate Tier 3 METHYLIN

QL methylphenidate Tier 3 RITALIN

QL methylphenidate ext-rel Tier 3 CONCERTA

FIBROMYALGIA

ST QL pregabalin Tier 1 Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

21

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at httpsaasmorg

Benzodiazepines

temazepam Tier 3 RESTORIL

Nonbenzodiazepines

eszopiclone Tier 1

ramelteon Tier 1

zolpidem sublingual Tier 1 ST suvorexant Tier 2 BELSOMRA

zolpidem Tier 3 AMBIEN

zolpidem ext-rel Tier 3 AMBIEN CR

Tricyclics

ST doxepin Tier 2 SILENOR

MIGRAINE Guidelines for prevention and management of migraine headaches are available at httpswwwaancom

Ergotamine Derivatives

ergotaminecaffeine tabs Tier 1

dihydroergotamine inj Tier 2 DHE 45

Monoclonal Antibodies

ST erenumab-aooe Tier 2 AIMOVIG

ST fremanezumab-vfrm Tier 2 AJOVY ST galcanezumab-gnlm Tier 2 EMGALITY

Selective Serotonin Agonists QL naratriptan Tier 1

ST sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH

ST sumatriptan nasal powder Tier 2 ONZETRA XSAIL QL zolmitriptan nasal spray Tier 2 ZOMIG

QL eletriptan Tier 3 RELPAX

QL rizatriptan Tier 3 MAXALT

QL sumatriptan Tier 3 IMITREX QL sumatriptan inj Tier 3 IMITREX

QL sumatriptan nasal spray Tier 3 IMITREX

QL zolmitriptan Tier 3 ZOMIG

MOOD STABILIZERS

lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1

lithium carbonate ext-rel tabs 300 mg Tier 2 LITHOBID

MOVEMENT DISORDERS

SGM deutetrabenazine Tier 4 AUSTEDO

SGM tetrabenazine Tier 4

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

22

SGM valbenazine Tier 4 INGREZZA

MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at httpswwwaancom

dagger natalizumab TYSABRI SGM dimethyl fumarate delayed-rel Tier 4 TECFIDERA

SGM fingolimod Tier 4 GILENYA

SGM glatiramer Tier 4 COPAXONE SGM interferon beta-1a Tier 4 REBIF

SGM interferon beta-1b Tier 4 BETASERON

SGM siponimod Tier 4 MAYZENT

SGM teriflunomide Tier 4 AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS

baclofen Tier 1 carisoprodol Tier 1

chlorzoxazone Tier 1

cyclobenzaprine Tier 1 orphenadrineaspirincaffeine Tier 1

dantrolene Tier 2 DANTRIUM

metaxalone Tier 2 SKELAXIN

methocarbamol Tier 2 ROBAXIN tizanidine tabs Tier 2 ZANAFLEX

Listing does not include cyclobenzaprine tablet 75 mg

MYASTHENIA GRAVIS

pyridostigmine Tier 1 pyridostigmine ext-rel Tier 1

NARCOLEPSY PA armodafinil Tier 1

PA solriamfetol Tier 2 SUNOSI

POSTHERPETIC NEURALGIA (PHN)

ST gabapentin ext-rel Tier 2 GRALISE

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents

acamprosate calcium Tier 1 disulfiram Tier 2 ANTABUSE

Opioid Antagonists naloxone inj Tier 1

naltrexone Tier 1

naloxone nasal spray Tier 2 NARCAN

Partial Opioid AgonistOpioid Antagonist Combinations

QL buprenorphinenaloxone sublingual Tier 1

QL buprenorphinenaloxone sublingual tabs Tier 2 ZUBSOLV

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

23

Pseudobulbar Affect Agents PA dextromethorphanquinidine Tier 2 NUEDEXTA

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

24

Smoking Deterrents Treating Tobacco Use and Dependence 2008 Update-Clinical Practice Guideline is available at httpswwwahrqgovprofessionalsclinicians-providersguidelines-recommendationstobaccoindexhtml

bupropion ext-rel Tier 1

varenicline Tier 2 CHANTIX

Vasomotor Symptom Agents

paroxetine mesylate Tier 1

ENDOCRINE AND METABOLIC

ACROMEGALY

SGM lanreotide acetate Tier 4 SOMATULINE DEPOT

SGM pegvisomant Tier 4 SOMAVERT

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at httpswwwaacecom

PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1

PA testosterone gel Tier 1

PA testosterone soln Tier 1

PA testosterone transdermal Tier 2 ANDRODERM

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at httpsprofessionaldiabetesorg

Alpha-glucosidase Inhibitors

acarbose Tier 2 PRECOSE

Amylin Analogs

pramlintide Tier 2 SYMLINPEN

metformin Tier 3 GLUCOPHAGE

metformin ext-rel Tier 3 GLUCOPHAGE XR

Biguanides

BiguanideSulfonylurea Combinations

glipizidemetformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) InhibitorBiguanide Combinations

sitagliptinmetformin Tier 2 JANUMET

sitagliptinmetformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents

dulaglutide Tier 2 TRULICITY liraglutide Tier 2 VICTOZA

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

25

Smoking Deterrents Treating Tobacco Use and Dependence 2008 Update-Clinical Practice Guideline is available at httpswwwahrqgovprofessionalsclinicians-providersguidelines-recommendationstobaccoindexhtml

bupropion ext-rel Tier 1

varenicline Tier 2 CHANTIX

Vasomotor Symptom Agents

paroxetine mesylate Tier 1

ENDOCRINE AND METABOLIC

ACROMEGALY

SGM lanreotide acetate Tier 4 SOMATULINE DEPOT

SGM pegvisomant Tier 4 SOMAVERT

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at httpswwwaacecom

PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1

PA testosterone gel Tier 1

PA testosterone soln Tier 1

PA testosterone transdermal Tier 2 ANDRODERM

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at httpsprofessionaldiabetesorg

Alpha-glucosidase Inhibitors

acarbose Tier 2 PRECOSE

Amylin Analogs

pramlintide Tier 2 SYMLINPEN

metformin Tier 3 GLUCOPHAGE

metformin ext-rel Tier 3 GLUCOPHAGE XR

Biguanides

BiguanideSulfonylurea Combinations

glipizidemetformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) InhibitorBiguanide Combinations

sitagliptinmetformin Tier 2 JANUMET

sitagliptinmetformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents

dulaglutide Tier 2 TRULICITY liraglutide Tier 2 VICTOZA

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

25

semaglutide Tier 2 OZEMPIC

Incretin Mimetic AgentInsulin Combinations

liraglutideinsulin degludec Tier 2 XULTOPHY lixisenatideinsulin glargine Tier 2 SOLIQUA

Insulins insulin aspart Tier 2 FIASP

insulin aspart Tier 2 NOVOLOG

insulin aspart protamine 70insulin aspart 30 Tier 2 NOVOLOG MIX 7030

insulin degludec Tier 2 TRESIBA insulin detemir Tier 2 LEVEMIR

insulin glargine Tier 2 BASAGLAR

insulin human Tier 2 HUMULIN R U-500 OTC insulin human Tier 2 NOVOLIN R

OTC insulin isophane human Tier 2 NOVOLIN N

OTC insulin isophane human 70regular 30 Tier 2 NOVOLIN 7030

Insulin Sensitizers

pioglitazone Tier 1

Insulin SensitizerBiguanide Combinations

pioglitazonemetformin Tier 3 ACTOPLUS MET

Insulin SensitizerSulfonylurea Combinations

pioglitazoneglimepiride Tier 3 DUETACT

Meglitinides

nateglinide Tier 1

repaglinide Tier 3 PRANDIN

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

dapagliflozin Tier 2 FARXIGA empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) InhibitorBiguanide Combinations dapagliflozinmetformin ext-rel Tier 2 XIGDUO XR

empagliflozinmetformin Tier 2 SYNJARDY

empagliflozinmetformin ext-rel Tier 2 SYNJARDY XR

Sodium-Glucose Co-Transporter 2 (SGLT2) InhibitorDipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

empagliflozinlinagliptin Tier 2 GLYXAMBI

Sulfonylureas

glimepiride Tier 3 AMARYL

glipizide Tier 3 GLUCOTROL glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies

PA blood glucose continuous monitoring receivers sensors Tier 2 DEXCOM CONTINUOUS GLUCOSE transmitters MONITORING SYSTEM

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK AVIVA PLUS kits and test strips

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

26

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK COMPACT PLUS kits and test strips

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK GUIDE kits and test strips

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK SMARTVIEW kits and test strips

QL insulin management system Tier 2 OMNIPOD DASH

OTC insulin syringes needles Tier 2 BD ULTRAFINE insulin syringes and needles

OTC lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS

SGM cinacalcet Tier 4 SENSIPAR

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at httpswwwaacecom httpswwwnoforg

Bisphosphonates alendronate Tier 3 FOSAMAX

ibandronate Tier 3 BONIVA

risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones SGM abaloparatide Tier 4 TYMLOS

SGM teriparatide Tier 4 FORTEO

Miscellaneous

dagger denosumab PROLIA

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen

drospirenoneEE 320 Tier 1 drospirenoneEElevomefolate 320 and levomefolate Tier 1

levonorgestrelEE 0120 - Lessina Tier 1

norethindrone acetateEE 120 and iron chewable Tier 1

norethindrone acetateEE 120 Tier 3 LOESTRIN 120 norethindrone acetateEE 120 and iron Tier 3 LOESTRIN FE 120

30 mcg Estrogen desogestrelEE 01530 Tier 1

drospirenoneEElevomefolate 330 and levomefolate Tier 1

levonorgestrelEE 01530 - Levora Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

27

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK COMPACT PLUS kits and test strips

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK GUIDE kits and test strips

OTC blood glucose monitoring kits test strips Tier 2 ACCU-CHEK SMARTVIEW kits and test strips

QL insulin management system Tier 2 OMNIPOD DASH

OTC insulin syringes needles Tier 2 BD ULTRAFINE insulin syringes and needles

OTC lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS

SGM cinacalcet Tier 4 SENSIPAR

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at httpswwwaacecom httpswwwnoforg

Bisphosphonates alendronate Tier 3 FOSAMAX

ibandronate Tier 3 BONIVA

risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones SGM abaloparatide Tier 4 TYMLOS

SGM teriparatide Tier 4 FORTEO

Miscellaneous

dagger denosumab PROLIA

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen

drospirenoneEE 320 Tier 1 drospirenoneEElevomefolate 320 and levomefolate Tier 1

levonorgestrelEE 0120 - Lessina Tier 1

norethindrone acetateEE 120 and iron chewable Tier 1

norethindrone acetateEE 120 Tier 3 LOESTRIN 120 norethindrone acetateEE 120 and iron Tier 3 LOESTRIN FE 120

30 mcg Estrogen desogestrelEE 01530 Tier 1

drospirenoneEElevomefolate 330 and levomefolate Tier 1

levonorgestrelEE 01530 - Levora Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

27

norgestrelEE 0330 - Low-Ogestrel Tier 1 drospirenoneEE 330 Tier 3 YASMIN

norethindrone acetateEE 1530 Tier 3 LOESTRIN 1530

norethindrone acetateEE 1530 and iron Tier 3 LOESTRIN FE 1530

35 mcg Estrogen

ethynodiol diacetateEE 135 - Zovia 135 Tier 1

norethindroneEE 0535 Tier 1 norethindroneEE 135 Tier 1

norgestimateEE 02535 Tier 1

norethindroneEE 135 Tier 3 ORTHO-NOVUM 135

50 mcg Estrogen

ethynodiol diacetateEE 150 Tier 1

desogestrelEE Tier 2 MIRCETTE

Biphasic

Triphasic

desogestrelEE Tier 1 levonorgestrelEE - Trivora Tier 1

norgestimateEE Tier 1

norethindroneEE Tier 3 ORTHO-NOVUM 777

Extended Cycle

levonorgestrelEE 01530 Tier 1

levonorgestrelEE 0120 and EE 10 Tier 3 LOSEASONIQUE levonorgestrelEE 01530 and EE 10 Tier 3 SEASONIQUE

Progestin Only norethindrone Tier 1

norethindrone Tier 2 ORTHO MICRONOR

medroxyprogesterone acetate 150 mgmL Tier 2 DEPO-PROVERA

Injectable

Progestin Intrauterine Devices

dagger levonorgestrel releasing IUD KYLEENA

dagger levonorgestrel releasing IUD MIRENA

dagger levonorgestrel releasing IUD SKYLA

Transdermal

norelgestrominEE Tier 1

Vaginal

etonogestrelEE ring Tier 2 NUVARING

ENDOMETRIOSIS

danazol Tier 1 PA elagolix Tier 2 ORILISSA

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

28

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at httpswwwmenopauseorg httpswwwaacecomfilesmenopausepdf

Oral estrogens conjugated Tier 2 PREMARIN

estradiol Tier 3 ESTRACE

Transdermal

estradiol Tier 1

estradiol Tier 2 DIVIGEL

estradiol Tier 2 EVAMIST estradiol Tier 3 CLIMARA

Vaginal estradiol vaginal crm Tier 1

estradiol vaginal ring Tier 2 ESTRING

estrogens conjugated crm Tier 2 PREMARIN estradiol vaginal tabs Tier 3 VAGIFEM

ESTROGENPROGESTINS Oral

EEnorethindrone acetate - Jinteli

estradiolnorethindrone

estrogens conjugatedmedroxyprogesterone estrogens conjugatedmedroxyprogesterone

Tier 1

Tier 1

Tier 2 Tier 2

PREMPHASE PREMPRO

estradiollevonorgestrel

estradiolnorethindrone acetate

Tier 2

Tier 2

CLIMARA PRO

COMBIPATCH

Transdermal

ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

conjugated estrogensbazedoxifene Tier 2 DUAVEE

FERTILITY REGULATORS GNRHLHRH Antagonists

cetrorelix Tier 4 CETROTIDE ganirelix acetate Tier 4

Ovulation Stimulants Gonadotropins choriogonadotropin alfa Tier 4 OVIDREL

PA follitropin alfa Tier 4 GONAL-F

Ovulation Stimulants Synthetic

clomiphene Tier 1

GAUCHER DISEASE

dagger imiglucerase CEREZYME

SGM eliglustat Tier 4 CERDELGA

GLUCOCORTICOIDS

dexamethasone Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

29

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at httpswwwmenopauseorg httpswwwaacecomfilesmenopausepdf

Oral estrogens conjugated Tier 2 PREMARIN

estradiol Tier 3 ESTRACE

Transdermal

estradiol Tier 1

estradiol Tier 2 DIVIGEL

estradiol Tier 2 EVAMIST estradiol Tier 3 CLIMARA

Vaginal estradiol vaginal crm Tier 1

estradiol vaginal ring Tier 2 ESTRING

estrogens conjugated crm Tier 2 PREMARIN estradiol vaginal tabs Tier 3 VAGIFEM

ESTROGENPROGESTINS Oral

EEnorethindrone acetate - Jinteli

estradiolnorethindrone

estrogens conjugatedmedroxyprogesterone estrogens conjugatedmedroxyprogesterone

Tier 1

Tier 1

Tier 2 Tier 2

PREMPHASE PREMPRO

estradiollevonorgestrel

estradiolnorethindrone acetate

Tier 2

Tier 2

CLIMARA PRO

COMBIPATCH

Transdermal

ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

conjugated estrogensbazedoxifene Tier 2 DUAVEE

FERTILITY REGULATORS GNRHLHRH Antagonists

cetrorelix Tier 4 CETROTIDE ganirelix acetate Tier 4

Ovulation Stimulants Gonadotropins choriogonadotropin alfa Tier 4 OVIDREL

PA follitropin alfa Tier 4 GONAL-F

Ovulation Stimulants Synthetic

clomiphene Tier 1

GAUCHER DISEASE

dagger imiglucerase CEREZYME

SGM eliglustat Tier 4 CERDELGA

GLUCOCORTICOIDS

dexamethasone Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

29

fludrocortisone Tier 1 prednisolone Tier 1

prednisone Tier 1

hydrocortisone Tier 3 CORTEF

methylprednisolone Tier 3 MEDROL

GLUCOSE ELEVATING AGENTS

glucagon human recombinant Tier 2 GLUCAGEN HYPOKIT glucagon human recombinant Tier 2 GLUCAGON EMERGENCY KIT

HEREDITARY TYROSINEMIA TYPE 1 AGENTS SGM nitisinone Tier 4 ORFADIN

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at httpswwwaacecompublicationsguidelines

SGM somatropin Tier 4 GENOTROPIN

SGM somatropin Tier 4 HUMATROPE

HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS

calcitriol (125-D3) Tier 2 ROCALTROL

doxercalciferol Tier 2 HECTOROL paricalcitol Tier 2 ZEMPLAR

PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin Tier 4 KUVAN

PHOSPHATE BINDER AGENTS calcium acetate Tier 1

sevelamer carbonate Tier 1

calcium acetate Tier 2 PHOSLYRA

ST sucroferric oxyhydroxide Tier 2 VELPHORO

POTASSIUM-REMOVING AGENTS

patiromer sorbitex Tier 2 VELTASSA sodium zirconium cyclosilicate Tier 2 LOKELMA

PROGESTINS Oral

medroxyprogesterone acetate Tier 3 PROVERA

megestrol acetate susp Tier 3 MEGACE ES

norethindrone acetate Tier 3 AYGESTIN progesterone micronized Tier 3 PROMETRIUM

Vaginal PA progesterone gel Tier 2 CRINONE

PA progesterone vaginal inserts Tier 2 ENDOMETRIN

SELECTIVE ESTROGEN RECEPTOR MODULATORS

ospemifene Tier 2 OSPHENA

raloxifene Tier 3 EVISTA

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

30

THYROID AGENTS Antithyroid Agents

propylthiouracil Tier 1

methimazole Tier 2 TAPAZOLE

Thyroid Supplements

levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1

levothyroxine Tier 2 SYNTHROID

liothyronine Tier 2 CYTOMEL

VASOPRESSINS

desmopressin spray tabs Tier 2 DDAVP

MISCELLANEOUS

cabergoline Tier 1

GASTROINTESTINAL

Guidelines for the treatment and management of various gastrointestinal diseasesconditions are available at httpsgiorg httpswwwgastroorg

ANTIDIARRHEALS

loperamide Tier 1 diphenoxylateatropine Tier 2 LOMOTIL

ANTIEMETICS QL granisetron Tier 1

meclizine Tier 1

prochlorperazine Tier 1 promethazine Tier 1

scopolamine transdermal Tier 1

PA QL granisetron transdermal Tier 2 SANCUSO

QL rolapitant Tier 2 VARUBI PA QL dronabinol Tier 3 MARINOL

metoclopramide Tier 3 REGLAN

QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

ANTISPASMODICS hyoscyamine sulfate ext-rel caps Tier 1

hyoscyamine sulfate orally disintegrating tabs Tier 1

dicyclomine Tier 2 BENTYL

hyoscyamine sulfate Tier 2 LEVSIN hyoscyamine sulfate ext-rel Tier 2 LEVBID

CHOLELITHOLYTICS ursodiol Tier 2 ACTIGALL

ursodiol Tier 2 URSO

H2 RECEPTOR ANTAGONISTS

cimetidine Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

31

ranitidine Tier 1 famotidine Tier 3 PEPCID

INFLAMMATORY BOWEL DISEASE Oral Agents

balsalazide Tier 1

budesonide delayed-rel caps Tier 1 budesonide ext-rel Tier 1

mesalamine delayed-rel caps Tier 1

mesalamine delayed-rel tabs Tier 1

mesalamine ext-rel caps Tier 2 APRISO mesalamine ext-rel caps Tier 2 PENTASA

sulfasalazine Tier 3 AZULFIDINE

sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS

Rectal Agents

hydrocortisone enema Tier 1 mesalamine supp Tier 1

hydrocortisone acetate foam Tier 2 CORTIFOAM

mesalamine susp Tier 3 ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation

linaclotide Tier 2 LINZESS lubiprostone Tier 2 AMITIZA

Irritable Bowel Syndrome with Diarrhea alosetron Tier 1

eluxadoline Tier 2 VIBERZI

LAXATIVES

lactulose soln Tier 1

sodium sulfatepotassium sulfatemagnesium sulfate Tier 2 SUPREP peg 3350electrolytes Tier 3 GOLYTELY

peg 3350electrolytes Tier 3 NULYTELY

OPIOID-INDUCED CONSTIPATION

naldemedine Tier 2 SYMPROIC

naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES

pancrelipase Tier 2 VIOKACE

pancrelipase delayed-rel Tier 2 CREON pancrelipase delayed-rel Tier 2 ZENPEP

PROSTAGLANDINS misoprostol Tier 2 CYTOTEC

PROTON PUMP INHIBITORS esomeprazole delayed-rel Tier 1

lansoprazole delayed-rel Tier 1

pantoprazole delayed-rel Tier 1 ST dexlansoprazole delayed-rel Tier 2 DEXILANT

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

32

ST omeprazole delayed-rel Tier 3 PRILOSEC

Step Therapy applies to brand only

SALIVA STIMULANTS

cevimeline Tier 2 EVOXAC

pilocarpine tabs Tier 2 SALAGEN

STEROIDS RECTAL

hydrocortisone acetatepramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 2 ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

MISCELLANEOUS

sucralfate Tier 1

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at httpswwwauanetorgguidelines

alfuzosin ext-rel Tier 1 dutasteridetamsulosin Tier 1

silodosin Tier 1

dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR

tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS

darifenacin ext-rel Tier 1

oxybutynin Tier 1

solifenacin Tier 1 tolterodine ext-rel Tier 1

trospium Tier 1

trospium ext-rel Tier 1 ST fesoterodine ext-rel Tier 2 TOVIAZ

ST mirabegron ext-rel Tier 2 MYRBETRIQ

oxybutynin ext-rel Tier 3 DITROPAN XL tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES

terconazole Tier 1 clindamycin crm Tier 2 CLEOCIN

metronidazole Tier 2 METROGEL-VAGINAL

MISCELLANEOUS

bethanechol Tier 2 URECHOLINE

potassium citrate ext-rel Tier 2 UROCIT-K

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

33

ST omeprazole delayed-rel Tier 3 PRILOSEC

Step Therapy applies to brand only

SALIVA STIMULANTS

cevimeline Tier 2 EVOXAC

pilocarpine tabs Tier 2 SALAGEN

STEROIDS RECTAL

hydrocortisone acetatepramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 2 ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

MISCELLANEOUS

sucralfate Tier 1

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at httpswwwauanetorgguidelines

alfuzosin ext-rel Tier 1 dutasteridetamsulosin Tier 1

silodosin Tier 1

dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR

tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS

darifenacin ext-rel Tier 1

oxybutynin Tier 1

solifenacin Tier 1 tolterodine ext-rel Tier 1

trospium Tier 1

trospium ext-rel Tier 1 ST fesoterodine ext-rel Tier 2 TOVIAZ

ST mirabegron ext-rel Tier 2 MYRBETRIQ

oxybutynin ext-rel Tier 3 DITROPAN XL tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES

terconazole Tier 1 clindamycin crm Tier 2 CLEOCIN

metronidazole Tier 2 METROGEL-VAGINAL

MISCELLANEOUS

bethanechol Tier 2 URECHOLINE

potassium citrate ext-rel Tier 2 UROCIT-K

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

33

HEMATOLOGIC

Guidelines of treatment and management of hemophilia are available at httpswwwhemophiliaorg

ANTICOAGULANTS CHEST guidelines are available at httpswwwchestnetorgGuidelines-and-ResourcesCHEST-Guideline-Topic-AreasPulmonary-Vascular

Injectable

enoxaparin Tier 1

dalteparin Tier 2 FRAGMIN

Oral

warfarin Tier 1 apixaban Tier 2 ELIQUIS

rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents

fondaparinux Tier 2 ARIXTRA

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at httpswwwascoorg

Guidelines for the management of anemia associated with chronic kidney disease are available at httpswwwkidneyorgprofessionalsguidelinesguidelines

SGM darbepoetin alfa Tier 4 ARANESP

SGM epoetin alfa-epbx Tier 4 RETACRIT SGM filgrastim-aafi Tier 4 NIVESTYM

SGM pegfilgrastim Tier 4 NEULASTA

SGM pegfilgrastim-cbqv Tier 4 UDENYCA

HEMOPHILIA A AGENTS

dagger antihemophilic factor (recombinant) KOGENATE FS dagger antihemophilic factor (recombinant) KOVALTRY

dagger antihemophilic factor (recombinant) NOVOEIGHT

dagger antihemophilic factor (recombinant) pegylated ADYNOVATE dagger antihemophilic factor (recombinant) pegylated-aucl JIVI

dagger human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ

HEMOPHILIA B AGENTS dagger coagulation factor IX (recombinant) glycopegylated REBINYN

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS SGM eltrombopag Tier 4 PROMACTA

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS dagger eculizumab SOLIRIS

PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

34

dipyridamole Tier 1 prasugrel Tier 1

ticagrelor Tier 2 BRILINTA

dipyridamole ext-relaspirin Tier 3 AGGRENOX

PLATELET SYNTHESIS INHIBITORS

anagrelide Tier 2 AGRYLIN

STEM CELL MOBILIZERS

SGM plerixafor Tier 4 MOZOBIL

THROMBOCYTOPENIA AGENTS

SGM lusutrombopag Tier 4 MULPLETA

MISCELLANEOUS

cilostazol Tier 1

IMMUNOLOGIC AGENTS

Guidelines for the management of rheumatic diseases are available at httpswwwrheumatologyorg

ALLERGENIC EXTRACTS

PA ragweed pollen allergen extract Tier 2 RAGWITEK

PA timothy grass pollen allergen extract Tier 2 GRASTEK PA grass mixed pollen allergen extract Tier 4 ORALAIR

AUTOIMMUNE AGENTS Coverage may be altered or copay amounts may vary based on the condition being treated (eg psoriasis)

SGM adalimumab Tier 4 HUMIRA SGM apremilast Tier 4 OTEZLA

SGM etanercept Tier 4 ENBREL

SGM guselkumab Tier 4 TREMFYA

SGM risankizumab-rzaa Tier 4 SKYRIZI SGM secukinumab Tier 4 COSENTYX

SGM tofacitinib Tier 4 XELJANZ

SGM tofacitinib ext-rel Tier 4 XELJANZ XR SGM upadacitinib Tier 4 RINVOQ

SGM ustekinumab Tier 4 STELARA SUBCUTANEOUS

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

methotrexate Tier 1

hydroxychloroquine Tier 2 PLAQUENIL

leflunomide Tier 2 ARAVA SGM methotrexate auto-injector Tier 4 RASUVO

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at httpswwwcdcgovhepatitisResources

Guidelines for the management of hepatitis are available at httpswwwaasldorg

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

35

Interferons

SGM interferon alfa-2b Tier 4 INTRON A

SGM peginterferon alfa-2a Tier 4 PEGASYS SGM peginterferon alfa-2b Tier 4 SYLATRON

Miscellaneous SGM canakinumab Tier 4 ILARIS

IMMUNOSUPPRESSANTS Antimetabolites

mycophenolate mofetil Tier 1

mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 2 AZASAN

azathioprine Tier 2 IMURAN

Calcineurin Inhibitors cyclosporine Tier 1

cyclosporine modified Tier 1

tacrolimus Tier 1

Rapamycin Derivatives

sirolimus Tier 1

NUTRITIONALSUPPLEMENTS

ELECTROLYTES Potassium

potassium chloride ext-rel Tier 1

potassium chloride liquid Tier 1

VITAMINS AND MINERALS Folic AcidCombinations

folic acid Tier 1

folic acidvitamin B6vitamin B12 Tier 1

Prenatal Vitamins

prenatal vitamins Tier 1 prenatal vitaminsDHAdocusatefolic acid Tier 2 CITRANATAL 90 DHA

prenatal vitaminsDHAdocusatefolic acid Tier 2 CITRANATAL DHA

prenatal vitaminsDHAdocusatefolic acid Tier 2 CITRANATAL HARMONY prenatal vitaminsdocusatefolic acid Tier 2 CITRANATAL RX

prenatal vitaminsdocusatefolic acid + DHA Tier 2 CITRANATAL ASSURE

prenatal vitaminsfolic acid + pyridoxine Tier 2 CITRANATAL B-CALM

Miscellaneous

cyanocobalamin inj Tier 1

ergocalciferol (D2) Tier 1 fluoride drops Tier 1

fluoride tabs Tier 1

multivitaminsfluoride drops tabs Tier 1 multivitaminsfluorideiron drops tabs Tier 1

vitamin ADCfluoride drops Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

36

vitamin ADCfluorideiron drops Tier 1

RESPIRATORY

Guidelines to the management prevention or treatment of COPD and asthma are available at httpswwwaaaaiorg httpsginasthmaorg httpsgoldcopdorg httpswwwnhlbinihgov

The Allergy Report and guidelines for allergy-related conditions are available at httpswwwaaaaiorg

ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector Tier 1 epinephrine auto-injector Tier 2 EPIPEN

epinephrine auto-injector Tier 2 EPIPEN JR

ANTICHOLINERGICS

QL ipratropium soln Tier 1

QL tiotropium Tier 2 SPIRIVA QL umeclidinium bromide Tier 2 INCRUSE ELLIPTA

ANTICHOLINERGICBETA AGONIST COMBINATIONS Short Acting

QL ipratropiumalbuterol soln Tier 1

Long Acting QL glycopyrrolateformoterol Tier 2 BEVESPI AEROSPHERE

QL tiotropiumolodaterol Tier 2 STIOLTO RESPIMAT

QL umeclidiniumvilanterol Tier 2 ANORO ELLIPTA

ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS

QL fluticasoneumeclidiniumvilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES LOW SEDATING

levocetirizine Tier 1

ANTIHISTAMINES SEDATING

clemastine 268 mg Tier 1

cyproheptadine Tier 1 hydroxyzine HCl Tier 1

ANTITUSSIVES Clinical practice guidelines are available at httpsjournalchestnetorgarticleS0012-3692(15)52856-0pdf

benzonatate Tier 2 TESSALON

Listing does not include NDC 69336012615 and 69499032915 Drug products are identified by unique numerical product identifiers called National Drug Codes (NDC) which identify the manufacturer strength dosage form formulation and package size

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

37

vitamin ADCfluorideiron drops Tier 1

RESPIRATORY

Guidelines to the management prevention or treatment of COPD and asthma are available at httpswwwaaaaiorg httpsginasthmaorg httpsgoldcopdorg httpswwwnhlbinihgov

The Allergy Report and guidelines for allergy-related conditions are available at httpswwwaaaaiorg

ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector Tier 1 epinephrine auto-injector Tier 2 EPIPEN

epinephrine auto-injector Tier 2 EPIPEN JR

ANTICHOLINERGICS

QL ipratropium soln Tier 1

QL tiotropium Tier 2 SPIRIVA QL umeclidinium bromide Tier 2 INCRUSE ELLIPTA

ANTICHOLINERGICBETA AGONIST COMBINATIONS Short Acting

QL ipratropiumalbuterol soln Tier 1

Long Acting QL glycopyrrolateformoterol Tier 2 BEVESPI AEROSPHERE

QL tiotropiumolodaterol Tier 2 STIOLTO RESPIMAT

QL umeclidiniumvilanterol Tier 2 ANORO ELLIPTA

ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS

QL fluticasoneumeclidiniumvilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES LOW SEDATING

levocetirizine Tier 1

ANTIHISTAMINES SEDATING

clemastine 268 mg Tier 1

cyproheptadine Tier 1 hydroxyzine HCl Tier 1

ANTITUSSIVES Clinical practice guidelines are available at httpsjournalchestnetorgarticleS0012-3692(15)52856-0pdf

benzonatate Tier 2 TESSALON

Listing does not include NDC 69336012615 and 69499032915 Drug products are identified by unique numerical product identifiers called National Drug Codes (NDC) which identify the manufacturer strength dosage form formulation and package size

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

37

ANTITUSSIVE COMBINATIONS Opioid

codeinepromethazine Tier 1

codeinepromethazinephenylephrine Tier 1 hydrocodonehomatropine Tier 1

dextromethorphanbrompheniraminepseudoephedrine Tier 1

dextromethorphanpromethazine Tier 1

Non-opioid

BETA AGONISTS Inhalants Short Acting

QL albuterol soln Tier 1

QL albuterol sulfate CFC-free aerosol Tier 1

QL levalbuterol tartrate CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation

QL olodaterol CFC-free aerosol Tier 2 STRIVERDI RESPIMAT

QL salmeterol xinafoate Tier 2 SEREVENT

Nebulized Passive Inhalation

QL formoterol inhalation soln Tier 2 PERFOROMIST

Oral Agents

albuterol Tier 1 albuterol ext-rel Tier 1

terbutaline Tier 1

CYSTIC FIBROSIS

SGM dornase alfa Tier 4 PULMOZYME

SGM tobramycin inhalation soln Tier 4 SGM tobramycin inhalation soln Tier 4 BETHKIS

LEUKOTRIENE MODULATORS montelukast Tier 1

zafirlukast Tier 1

zileuton ext-rel Tier 1

MAST CELL STABILIZERS

QL cromolyn soln Tier 1

NASAL ANTIHISTAMINES

QL azelastine spray Tier 1

QL azelastine spray Tier 3 ASTEPRO ST QL olopatadine spray Tier 3 PATANASE

Step Therapy applies to brand only

NASAL STEROIDSCOMBINATIONS

QL flunisolide spray Tier 1 QL fluticasone spray Tier 1

QL mometasone spray Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

38

ST QL azelastinefluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast Tier 2 DALIRESP

PULMONARY ENZYME DEFICIENCY AGENTS

dagger alpha-1 proteinase inhibitor PROLASTIN-C

PULMONARY FIBROSIS AGENTS

SGM nintedanib Tier 4 OFEV

SGM pirfenidone Tier 4 ESBRIET

SEVERE ASTHMA AGENTS

dagger benralizumab FASENRA dagger omalizumab XOLAIR

SGM dupilumab Tier 4 DUPIXENT

SGM mepolizumab Tier 4 NUCALA autoinjector

STEROIDBETA AGONIST COMBINATIONS

QL budesonideformoterol Tier 2 SYMBICORT QL fluticasonesalmeterol Tier 2 ADVAIR DISKUS

QL fluticasonesalmeterol CFC-free aerosol Tier 2 ADVAIR HFA

QL fluticasonevilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS

QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER

QL budesonide Tier 2 PULMICORT FLEXHALER QL fluticasone Tier 2 ARNUITY ELLIPTA

QL fluticasone Tier 2 FLOVENT DISKUS

QL fluticasone CFC-free aerosol Tier 2 FLOVENT HFA QL budesonide inhalation susp Tier 3 PULMICORT RESPULES

XANTHINES theophylline ext-rel tabs Tier 1

MISCELLANEOUS ipratropium spray Tier 1

TOPICAL

DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at httpswwwaadorgpracticecenterqualityclinical-guidelines

Oral

PA isotretinoin Tier 1

Topical

PA adapalene Tier 1 QL clindamycin gel Tier 1

clindamycinbenzoyl peroxide Tier 1

QL erythromycin gel 2 Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

39

ST QL azelastinefluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast Tier 2 DALIRESP

PULMONARY ENZYME DEFICIENCY AGENTS

dagger alpha-1 proteinase inhibitor PROLASTIN-C

PULMONARY FIBROSIS AGENTS

SGM nintedanib Tier 4 OFEV

SGM pirfenidone Tier 4 ESBRIET

SEVERE ASTHMA AGENTS

dagger benralizumab FASENRA dagger omalizumab XOLAIR

SGM dupilumab Tier 4 DUPIXENT

SGM mepolizumab Tier 4 NUCALA autoinjector

STEROIDBETA AGONIST COMBINATIONS

QL budesonideformoterol Tier 2 SYMBICORT QL fluticasonesalmeterol Tier 2 ADVAIR DISKUS

QL fluticasonesalmeterol CFC-free aerosol Tier 2 ADVAIR HFA

QL fluticasonevilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS

QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER

QL budesonide Tier 2 PULMICORT FLEXHALER QL fluticasone Tier 2 ARNUITY ELLIPTA

QL fluticasone Tier 2 FLOVENT DISKUS

QL fluticasone CFC-free aerosol Tier 2 FLOVENT HFA QL budesonide inhalation susp Tier 3 PULMICORT RESPULES

XANTHINES theophylline ext-rel tabs Tier 1

MISCELLANEOUS ipratropium spray Tier 1

TOPICAL

DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at httpswwwaadorgpracticecenterqualityclinical-guidelines

Oral

PA isotretinoin Tier 1

Topical

PA adapalene Tier 1 QL clindamycin gel Tier 1

clindamycinbenzoyl peroxide Tier 1

QL erythromycin gel 2 Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

39

erythromycin soln Tier 1 PA tretinoin Tier 1

PA tretinoin - Avita Tier 1

PA tretinoin gel microsphere Tier 1

adapalenebenzoyl peroxide Tier 2 EPIDUO adapalenebenzoyl peroxide Tier 2 EPIDUO FORTE

PA tazarotene Tier 2 TAZORAC

benzoyl peroxide Tier 3 BENZAC AC clindamycin gel lotion Tier 3 CLEOCIN T

QL clindamycin soln Tier 3 CLEOCIN T

clindamycinbenzoyl peroxide Tier 3 DUAC erythromycinbenzoyl peroxide Tier 3 BENZAMYCIN

sulfacetamide lotion 10 Tier 3 KLARON

PA tretinoin Tier 3 RETIN-A

Prior Authorization applies for members age 35 and older Actinic Keratosis

fluorouracil crm 5 soln 5 soln 2 Tier 1 fluorouracil crm 4 Tier 2 TOLAK

imiquimod Tier 2 ZYCLARA

ingenol mebutate Tier 2 PICATO

Antibiotics

QL gentamicin Tier 1 QL mupirocin oint Tier 1

silver sulfadiazine Tier 2 SILVADENE

Antifungals

clotrimazole Tier 1

QL econazole Tier 1

QL ketoconazole crm 2 Tier 1 luliconazole Tier 1

QL nystatin Tier 1

naftifine Tier 2 NAFTIN PA ciclopirox Tier 3 LOPROX

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at httpswwwaadorg

Oral

PA acitretin Tier 3 SORIATANE

methoxsalen oral Tier 3 OXSORALEN-ULTRA

Topical

QL calcipotriene oint soln 0005 Tier 1

Antiseborrheics

selenium sulfide lotion 25 Tier 1 ketoconazole shampoo 2 Tier 3 NIZORAL

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

40

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at httpswwwaadorgpracticecenterqualityclinical-guidelines

Injectable

SGM dupilumab Tier 4 DUPIXENT

Topical

PA pimecrolimus Tier 1

PA tacrolimus Tier 1 ST crisaborole Tier 2 EUCRISA

Corticosteroids Low Potency

QL alclometasone crm oint 005 Tier 1

QL fluocinolone acetonide soln 001 Tier 1 QL hydrocortisone crm 25 Tier 1

QL hydrocortisone lotion 1 Tier 1

PA QL desonide crm lotion oint 005 Tier 2 DESOWEN

Prior Authorization applies to brand only

Medium Potency

QL betamethasone valerate crm lotion oint 01 Tier 1

QL desoximetasone crm oint 005 Tier 1 QL fluocinolone acetonide crm oint 0025 Tier 1

QL fluticasone propionate crm lotion 005 oint 0005 Tier 1

QL hydrocortisone butyrate crm oint soln 01 Tier 1

QL hydrocortisone valerate crm oint 02 Tier 1 QL triamcinolone acetonide crm lotion 0025 Tier 1

QL triamcinolone acetonide crm lotion oint 01 Tier 1

PA QL mometasone oint 01 Tier 2 ELOCON PA QL mometasone crm lotion 01 Tier 3 ELOCON

Prior Authorization applies to brand only

High Potency

QL betamethasone dipropionate crm lotion oint 005 Tier 1 QL desoximetasone crm oint 025 gel 005 Tier 1

QL fluocinonide crm gel oint soln 005 Tier 1

QL triamcinolone acetonide crm 05 Tier 1 PA QL betamethasone dipropionate augmented crm 005 Tier 3 DIPROLENE AF

PA QL betamethasone dipropionate augmented lotion 005 Tier 3 DIPROLENE

Prior Authorization applies to brand only

Very High Potency QL clobetasol propionate foam 005 Tier 1

PA QL betamethasone dipropionate augmented gel oint 005 Tier 2 DIPROLENE

PA QL clobetasol propionate crm gel oint 005 Tier 2 TEMOVATE

PA QL clobetasol propionate lotion shampoo 005 Tier 2 CLOBEX PA QL halobetasol propionate crm oint 005 Tier 2 ULTRAVATE

PA QL clobetasol propionate soln 005 Tier 3 TEMOVATE

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

41

Prior Authorization applies to brand only

Emollients ammonium lactate 12 Tier 2 LAC-HYDRIN

Local Analgesics PA lidocaine patch Tier 2 LIDODERM

Rosacea PA azelaic acid gel Tier 1

PA doxycycline monohydrate delayed-rel caps Tier 1

metronidazole gel 075 Tier 1 PA azelaic acid foam Tier 2 FINACEA FOAM

PA ivermectin Tier 2 SOOLANTRA

metronidazole crm 075 Tier 3 METROCREAM

metronidazole gel 1 Tier 3 METROGEL metronidazole lotion 075 Tier 3 METROLOTION

Scabicides and Pediculicides permethrin 5 Tier 1

malathion Tier 2 OVIDE

Miscellaneous Skin and Mucous Membrane

imiquimod Tier 1

podofilox Tier 2 CONDYLOX

MOUTHTHROATDENTAL AGENTS Anesthetics - Topical Oral

lidocaine viscous Tier 1

Steroids - MouthThroat triamcinolone paste Tier 1

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at httpsoneaaoorg

Antiallergics

azelastine Tier 1

cromolyn sodium Tier 1 alcaftadine Tier 2 LASTACAFT

olopatadine Tier 2 PAZEO

olopatadine Tier 3 PATADAY olopatadine Tier 3 PATANOL

Anti-infectives bacitracin Tier 1

erythromycin Tier 1

QL gentamicin Tier 1

levofloxacin Tier 1 neomycinpolymyxin Bgramicidin Tier 1

polymyxin Bbacitracin Tier 1

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

42

sulfacetamide oint 10 Tier 1 besifloxacin Tier 2 BESIVANCE

ciprofloxacin oint Tier 2 CILOXAN

moxifloxacin Tier 2 MOXEZA

ciprofloxacin soln Tier 3 CILOXAN moxifloxacin Tier 3 VIGAMOX

ofloxacin Tier 3 OCUFLOX

polymyxin Btrimethoprim Tier 3 POLYTRIM sulfacetamide soln 10 Tier 3 BLEPH-10

tobramycin Tier 3 TOBREX

Anti-infectiveAnti-inflammatory Combinations

neomycinpolymyxin Bbacitracinhydrocortisone oint Tier 1

neomycinpolymyxin Bhydrocortisone susp Tier 1

sulfacetamideprednisolone phosphate 10025 Tier 1 tobramycindexamethasone oint 0301 Tier 2 TOBRADEX

tobramycindexamethasone susp 03005 Tier 2 TOBRADEX ST

neomycinpolymyxin Bdexamethasone Tier 3 MAXITROL tobramycindexamethasone susp 0301 Tier 3 TOBRADEX

Anti-inflammatories Nonsteroidal

bromfenac sodium Tier 1

diclofenac sodium Tier 1 ketorolac tromethamine Tier 2 ACUVAIL

nepafenac Tier 2 ILEVRO

nepafenac Tier 2 NEVANAC

QL ketorolac Tier 3 ACULAR

Steroidal

dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1

loteprednol Tier 1

prednisolone acetate 1 Tier 1 dexamethasone Tier 2 MAXIDEX

difluprednate Tier 2 DUREZOL

fluorometholone Tier 2 FML FORTE fluorometholone Tier 2 FML SOP

prednisolone acetate Tier 2 PRED MILD

prednisolone phosphate 1 Tier 3

Antivirals

trifluridine Tier 1

levobunolol timolol maleate gel

timolol hemihydrate

timolol maleate

Tier 1 Tier 1

Tier 2

Tier 3

BETIMOL

TIMOPTIC

betaxolol Tier 2 BETOPTIC S

Beta-blockers Nonselective

Selective

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

43

Carbonic Anhydrase Inhibitors Topical

brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase InhibitorBeta-blocker Combinations dorzolamidetimolol maleate Tier 3 COSOPT

Carbonic Anhydrase InhibitorSympathomimetic Combinations brinzolamidebrimonidine Tier 2 SIMBRINZA

Dry Eye Disease cyclosporine emulsion Tier 2 RESTASIS

lifitegrast Tier 2 XIIDRA

Prostaglandins

ST bimatoprost Tier 2 LUMIGAN

travoprost Tier 2 TRAVATAN Z

latanoprost Tier 3 XALATAN

Retinal Disorders

dagger aflibercept EYLEA dagger ranibizumab LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase InhibitorProstaglandin Combinations ST netarsudillatanoprost Tier 2 ROCKLATAN

Sympathomimetics brimonidine 02 Tier 1

brimonidine Tier 2 ALPHAGAN P

SympathomimeticBeta-blocker Combinations

brimonidinetimolol Tier 2 COMBIGAN

OTIC Clinical practice guidelines for the treatment of otitis media are available at httpswwwaaporg

Anti-infectives

acetic acid Tier 1 ofloxacin otic Tier 1

Anti-infectiveAnti-inflammatory Combinations neomycinpolymyxin Bhydrocortisone Tier 1

ciprofloxacindexamethasone Tier 2 CIPRODEX

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

44

Carbonic Anhydrase Inhibitors Topical

brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase InhibitorBeta-blocker Combinations dorzolamidetimolol maleate Tier 3 COSOPT

Carbonic Anhydrase InhibitorSympathomimetic Combinations brinzolamidebrimonidine Tier 2 SIMBRINZA

Dry Eye Disease cyclosporine emulsion Tier 2 RESTASIS

lifitegrast Tier 2 XIIDRA

Prostaglandins

ST bimatoprost Tier 2 LUMIGAN

travoprost Tier 2 TRAVATAN Z

latanoprost Tier 3 XALATAN

Retinal Disorders

dagger aflibercept EYLEA dagger ranibizumab LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase InhibitorProstaglandin Combinations ST netarsudillatanoprost Tier 2 ROCKLATAN

Sympathomimetics brimonidine 02 Tier 1

brimonidine Tier 2 ALPHAGAN P

SympathomimeticBeta-blocker Combinations

brimonidinetimolol Tier 2 COMBIGAN

OTIC Clinical practice guidelines for the treatment of otitis media are available at httpswwwaaporg

Anti-infectives

acetic acid Tier 1 ofloxacin otic Tier 1

Anti-infectiveAnti-inflammatory Combinations neomycinpolymyxin Bhydrocortisone Tier 1

ciprofloxacindexamethasone Tier 2 CIPRODEX

Tier 1 - Generics Tier 2 ndash Preferred Brands Tier 3 ndash Non-Preferred Brands

boldface - indicates generic availability boldface may not apply to every strength or dosage form under the listed generic name

dagger - Coverage determined under the Medical Benefit OTC ndash Over the Counter PA ndash Prior Authorization QL ndash Quantity Limit

SGM ndash Specialty Guideline Management (may require additional copay andor PA) ST ndash Step Therapy

44

WEBSITES

Agency for Healthcare Research and Quality httpswwwahrqgov

Alzheimers Association httpswwwalzorg

American Academy of Allergy Asthma and Immunology httpswwwaaaaiorg

American Academy of Child amp Adolescent Psychiatry httpswwwaacaporg

American Academy of Dermatology httpswwwaadorg

American Academy of Neurology httpswwwaancom

American Academy of Ophthalmology httpswwwaaoorg

American Academy of Pediatrics httpswwwaaporg

American Association for the Study of Liver Disease httpswwwaasldorg

American Association of Clinical Endocrinologists httpswwwaacecom

American Association of Diabetes Educators httpswwwdiabeteseducatororg

American Cancer Society httpswwwcancerorg

American College of Allergy Asthma and Immunology httpswwwacaaiorg

American College of Cardiology httpswwwaccorg

American College of Chest Physicians httpswwwchestnetorg

American College of Gastroenterology httpsgiorg

American College of Physicians httpswwwacponlineorg

American College of Rheumatology httpswwwrheumatologyorg

American Congress of Obstetricians and Gynecologists httpswwwacogorg

American Diabetes Association httpwwwdiabetesorg

American Gastroenterological Association httpswwwgastroorg

American Headache Society Committee for Headache Education httpsamericanheadachesocietyorg

American Heart Association httpsprofessionalheartorg

American Lung Association httpswwwlungorg

American Medical Association httpswwwama-assnorg

American Psychiatric Association httpswwwpsychiatryorg

American Society of Anesthesiologists httpswwwasahqorg

American Society of Clinical Oncology httpswwwascoorg

American Society of Interventional Pain Physicians httpswwwasipporg

American Urological Association httpswwwauanetorg

Centers for Disease Control and Prevention httpswwwcdcgov

Centers for Disease Control and Prevention Guideline topics AIDS httpswwwcdcgovhivdefaulthtml

Centers for Disease Control and Prevention Guideline topics Sexually Transmitted Diseases httpswwwcdcgovstdtreatmentdefaulthtm

CVS Caremark httpswwwcaremarkcom

The Food and Drug Administration httpswwwfdagov

45

Global Initiative for Asthma National Foundation for Infectious Diseases httpsginasthmaorg httpwwwnfidorg

Infectious Diseases Society of America National Guideline Clearinghouse httpswwwidsocietyorg httpswwwahrqgov

Institute for Safe Medication Practices National Heart Lung and Blood Institute httpswwwismporg httpswwwnhlbinihgov

Johns Hopkins AIDS Service National Institutes of Health httpswwwthebodycomcontentart12096html httpswwwnihgov

Juvenile Diabetes Research Foundation International National Kidney Foundation httpswwwjdrforg httpswwwkidneyorg

MedWatch National Osteoporosis Foundation httpswwwfdagovSafetyMedWatchdefaulthtm httpswwwnoforg

National Agricultural Library North American Menopause Society httpswwwnalusdagov httpswwwmenopauseorg

National Cancer Institute United States Department of Health and Human httpswwwcancergovabout-cancer Services

httpswwwhhsgov National Comprehensive Cancer Network httpswwwnccnorg World Health Organization

httpswwwwhoint

46

INDEX

A abacavir tabs 10 abacavirdolutegravirlamivudine 10 abacavirlamivudine 10 abaloparatide 27 ABILIFY MAINTENA 21 abiraterone 12 acamprosate calcium 23 acarbose 25 ACCU-CHEK AVIVA PLUS kits and test strips 26 ACCU-CHEK COMPACT PLUS kits and test strips 27 ACCU-CHEK GUIDE kits and test strips 27 ACCU-CHEK SMARTVIEW kits and test strips 27 ACCUPRIL 14 ACCURETIC 14 acetazolamide 17 acetazolamide ext-rel 17 acetic acid 44 acitretin 40 ACTIGALL 31 ACTONEL 27 ACTOPLUS MET 26 ACULAR 43 ACUVAIL 43 acyclovir caps tabs 11 ADALAT CC 16 adalimumab 35 adapalene 39 adapalenebenzoyl peroxide 40 ADEMPAS 18 ADVAIR DISKUS 39 ADVAIR HFA 39 ADYNOVATE 34 AFINITOR 13 aflibercept 44 AGGRENOX 35 AGRYLIN 35 AIMOVIG 22 AJOVY 22 albuterol 38 albuterol ext-rel 38 albuterol soln 38 albuterol sulfate CFC-free aerosol 38 alcaftadine 42 alclometasone crm oint 005 41 ALDACTAZIDE 17 ALDACTONE 14 alendronate 27 alfuzosin ext-rel 33 aliskiren 17 aliskirenhydrochlorothiazide 17 ALKERAN 12 allopurinol 7 alosetron 32 alpha-1 proteinase inhibitor 39 ALPHAGAN P 44 alprazolam 18 ALTACE 14 amantadine 20 AMARYL 26 AMBIEN 22 AMBIEN CR 22

ambrisentan 18 amiloride 17 amiloridehydrochlorothiazide 17 amiodarone 15 AMITIZA 32 amitriptyline 20 amlodipine 16 amlodipineatorvastatin 17 amlodipinebenazepril 14 amlodipineolmesartan 15 amlodipinetelmisartan 15 amlodipinevalsartan 15 amlodipinevalsartanhydrochlorothiazide 15 ammonium lactate 12 42 amoxicillin 9 amoxicillinclavulanate 9 amoxicillinclavulanate ext-rel 9 amphetaminedextroamphetamine mixed salts 21 amphetaminedextroamphetamine mixed salts ext-rel 21 ampicillin 9 ANAFRANIL 18 anagrelide 35 anastrozole 12 ANDRODERM 25 ANORO ELLIPTA 37 ANTABUSE 23 antihemophilic factor (recombinant) 34 antihemophilic factor (recombinant) pegylated 34 antihemophilic factor (recombinant) pegylated-aucl 34 ANUSOL-HC 33 apalutamide 12 apixaban 34 apremilast 35 APRISO 32 ARANESP 34 ARAVA 35 ARICEPT 19 ARIMIDEX 12 aripiprazole 21 aripiprazole ext-rel inj 21 aripiprazole lauroxil ext-rel inj 21 ARISTADA 21 ARISTADA INITIO 21 ARIXTRA 34 armodafinil 23 ARNUITY ELLIPTA 39 AROMASIN 12 ASTEPRO 38 atazanavir 11 atazanavircobicistat 10 ATELVIA 27 atenolol 16 atenololchlorthalidone 16 ATIVAN 18 atomoxetine 21 atorvastatin 15 atovaquoneproguanil 10 ATRIPLA 10 AUBAGIO 23 AUGMENTIN 9 AUSTEDO 22 AVELOX 9

47

AVODART 33 AYGESTIN 30 AZASAN 36 azathioprine 36 azelaic acid foam 42 azelaic acid gel 42 azelastine 42 azelastine spray 38 azelastinefluticasone spray 39 azithromycin 9 AZOPT 44 AZOR 15 AZULFIDINE 32 AZULFIDINE EN-TABS 32

B bacitracin 42 baclofen 23 balsalazide 32 BARACLUDE 11 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 39 BELBUCA 8 BELSOMRA 22 benazepril 14 benazeprilhydrochlorothiazide 14 benralizumab 39 BENTYL 31 BENZAC AC 40 BENZAMYCIN 40 benzonatate 37 benzoyl peroxide 40 benztropine 20 besifloxacin 43 BESIVANCE 43 betamethasone dipropionate augmented crm 005 41 betamethasone dipropionate augmented gel oint 005 41 betamethasone dipropionate augmented lotion 005 41 betamethasone dipropionate crm lotion oint 005 41 betamethasone valerate crm lotion oint 01 41 BETASERON 23 betaxolol 43 bethanechol 33 BETHKIS 38 BETIMOL 43 BETOPTIC S 43 BEVESPI AEROSPHERE 37 bexarotene caps 13 bicalutamide 12 bictegraviremtricitabinetenofovir alafenamide 10 BIDIL 17 BIKTARVY 10 bimatoprost 44 bisoprolol 16 bisoprololhydrochlorothiazide 16 BLEPH-10 43 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 26 27 BONIVA 27 bosentan 18 BOSULIF 13 bosutinib 13 BREO ELLIPTA 39

BRILINTA 35 brimonidine 44 brimonidine 02 44 brimonidinetimolol 44 brinzolamide 44 brinzolamidebrimonidine 44 bromfenac sodium 43 bromocriptine 20 budesonide 39 budesonide delayed-rel caps 32 budesonide ext-rel 32 budesonide inhalation susp 39 budesonideformoterol 39 bumetanide 17 buprenorphine 8 buprenorphine transdermal 7 buprenorphinenaloxone sublingual 23 buprenorphinenaloxone sublingual tabs 23 bupropion 20 bupropion ext-rel 20 25 buspirone 18 busulfan 12 butalbitalacetaminophencaffeine tabs 8 butalbitalaspirincaffeine 8 BYSTOLIC 16

C cabergoline 31 CABOMETYX 13 cabozantinib 13 CADUET 17 CALAN SR 16 calcipotriene oint soln 0005 40 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 canakinumab 36 candesartan 14 candesartanhydrochlorothiazide 14 capecitabine 12 captopril 14 captoprilhydrochlorothiazide 14 carbamazepine 19 carbamazepine ext-rel 19 CARBATROL 19 carbidopalevodopa 20 carbidopalevodopa ext-rel 20 carbidopalevodopa orally disintegrating tabs 20 carbidopalevodopaentacapone 20 CARDURA 14 cariprazine 21 carisoprodol 23 carvedilol 16 carvedilol phosphate ext-rel 16 CASODEX 12 CATAPRES 14 CATAPRES-TTS 14 cefadroxil 9 cefdinir 9 cefixime 9 cefprozil 9 cefuroxime axetil 9 CELEBREX 7 celecoxib 7 CELEXA 20

26

48

cephalexin 9 CERDELGA 29 CEREZYME 29 cetrorelix 29 CETROTIDE 29 cevimeline 33 CHANTIX 25 chlorambucil 12 chloroquine 10 chlorpromazine 21 chlorpromazine inj 21 chlorthalidone 17 chlorzoxazone 23 cholestyramine 15 choriogonadotropin alfa 29 ciclopirox 40 cilostazol 35 CILOXAN 43 CIMDUO 10 cimetidine 31 cinacalcet 27 CIPRO 9 CIPRODEX 44 ciprofloxacin 9 ciprofloxacin oint 43 ciprofloxacin soln 43 ciprofloxacindexamethasone 44 citalopram 20 CITRANATAL 90 DHA 36 CITRANATAL ASSURE 36 CITRANATAL B-CALM 36 CITRANATAL DHA 36 CITRANATAL HARMONY 36 CITRANATAL RX 36 clarithromycin 9 clarithromycin ext-rel 9 clemastine 268 mg 37 CLEOCIN 11 33 CLEOCIN T 40 CLIMARA 29 CLIMARA PRO 29 clindamycin 11 clindamycin crm 33 clindamycin gel 39 clindamycin gel lotion 40 clindamycin soln 40 clindamycinbenzoyl peroxide 39 40 clobazam 19 clobetasol propionate crm gel oint 005 41 clobetasol propionate foam 005 41 clobetasol propionate lotion shampoo 005 41 clobetasol propionate soln 005 41 CLOBEX 41 clomiphene 29 clomipramine 18 clonazepam 18 clonidine 14 clonidine transdermal 14 clopidogrel 34 clotrimazole 40 clotrimazole troches 9 clozapine 21 CLOZARIL 21 coagulation factor IX (recombinant) glycopegylated 34 codeineacetaminophen 7

codeinepromethazine 38 codeinepromethazinephenylephrine 38 colchicine 7 colesevelam 15 COLESTID 15 colestipol 15 COMBIGAN 44 COMBIPATCH 29 COMBIVIR 10 COMPLERA 10 COMTAN 20 CONCERTA 21 CONDYLOX 42 conjugated estrogensbazedoxifene 29 COPAXONE 23 COREG 16 CORGARD 16 CORLANOR 17 CORTEF 30 CORTIFOAM 32 COSENTYX 35 COSOPT 44 COZAAR 14 CREON 32 CRINONE 30 crisaborole 41 cromolyn sodium 42 cromolyn soln 38 cyanocobalamin inj 36 cyclobenzaprine 23 cyclophosphamide caps 12 cyclosporine 36 cyclosporine emulsion 44 cyclosporine modified 36 cyproheptadine 37 CYTOMEL 31 CYTOTEC 32

D DHE 45 22 DALIRESP 39 dalteparin 34 danazol 28 DANTRIUM 23 dantrolene 23 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 11 darbepoetin alfa 34 darifenacin ext-rel 33 darolutamide 12 darunavir 11 darunavircobicistat 10 dasatinib 13 DAYPRO 7 DDAVP 31 denosumab 27 DEPAKENE 19 DEPAKOTE 19 DEPAKOTE ER 19 DEPO-PROVERA 28 DESCOVY 10 desipramine 20 desmopressin spray tabs 31 desogestrelEE 28

49

desogestrelEE 01530 27 desonide crm lotion oint 005 41 DESOWEN 41 desoximetasone crm oint 005 41 desoximetasone crm oint 025 gel 005 41 desvenlafaxine ext-rel 20 DETROL 33 deutetrabenazine 22 dexamethasone 29 43 dexamethasone sodium phosphate 43 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 26 DEXEDRINE SPANSULE 21 DEXILANT 32 dexlansoprazole delayed-rel 32 dexmethylphenidate 21 dexmethylphenidate ext-rel 21 dextroamphetamine 21 dextroamphetamine ext-rel 21 dextromethorphanbrompheniraminepseudoephedrine 38 dextromethorphanpromethazine 38 dextromethorphanquinidine 24 DIASTAT 19 diazepam 18 diazepam rectal gel 19 diclofenac sodium 43 diclofenac sodium delayed-rel 7 diclofenac sodium delayed-relmisoprostol 7 diclofenac sodium gel 1 7 diclofenac sodium soln 7 dicloxacillin 9 dicyclomine 31 didanosine delayed-rel 10 DIFICID 9 DIFLUCAN 10 diflunisal 7 difluprednate 43 digoxin 00625 mg 01875 mg 17 digoxin 0125 mg 025 mg 17 digoxin ped elixir 17 dihydroergotamine inj 22 DILANTIN 19 DILANTIN INFATABS 19 DILAUDID 8 diltiazem ext-rel 16 dimethyl fumarate delayed-rel 23 diphenoxylateatropine 31 DIPROLENE 41 DIPROLENE AF 41 dipyridamole 35 dipyridamole ext-relaspirin 35 disopyramide 15 disopyramide ext-rel 15 disulfiram 23 DITROPAN XL 33 divalproex sodium delayed-rel 19 divalproex sodium ext-rel 19 DIVIGEL 29 dofetilide 15 dolutegravir 10 donepezil 19 dornase alfa 38 dorzolamide 44 dorzolamidetimolol maleate 44 doxazosin 14 doxepin 20 22

doxercalciferol 30 doxycycline hyclate 9 doxycycline hyclate 20 mg 9 doxycycline monohydrate delayed-rel caps 42 dronabinol 31 dronedarone 15 drospirenoneEE 320 27 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 27 drospirenoneEElevomefolate 330 and levomefolate 27 DUAC 40 DUAVEE 29 DUETACT 26 dulaglutide 25 duloxetine delayed-rel 20 dupilumab 39 41 DUPIXENT 39 41 DUREZOL 43 dutasteride 33 dutasteridetamsulosin 33 DYAZIDE 17 DYMISTA 39

E econazole 40 eculizumab 34 EDURANT 10 EEnorethindrone acetate - Jinteli 29 efavirenz 10 efavirenzemtricitabinetenofovir disoproxil fumarate 10 efavirenzlamivudinetenofovir disoproxil fumarate 10 elagolix 28 eletriptan 22 ELIGARD 12 eliglustat 29 ELIQUIS 34 ELOCON 41 eltrombopag 34 eluxadoline 32 elvitegravircobicistatemtricitabinetenofovir alafenamide 10 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 10 EMBEDA 8 EMGALITY 22 empagliflozin 26 empagliflozinlinagliptin 26 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 10 emtricitabinerilpivirinetenofovir alafenamide 10 emtricitabinerilpivirinetenofovir disoproxil fumarate 10 emtricitabinetenofovir alafenamide 10 emtricitabinetenofovir disoproxil fumarate 10 EMTRIVA 10 EMVERM 12 enalapril 14 enalaprilhydrochlorothiazide 14 ENBREL 35 ENDOMETRIN 30 enfuvirtide 10 enoxaparin 34 entacapone 20 entecavir soln 11 entecavir tabs 11 ENTRESTO 17 enzalutamide 12

50

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

INDEX

A abacavir tabs 10 abacavirdolutegravirlamivudine 10 abacavirlamivudine 10 abaloparatide 27 ABILIFY MAINTENA 21 abiraterone 12 acamprosate calcium 23 acarbose 25 ACCU-CHEK AVIVA PLUS kits and test strips 26 ACCU-CHEK COMPACT PLUS kits and test strips 27 ACCU-CHEK GUIDE kits and test strips 27 ACCU-CHEK SMARTVIEW kits and test strips 27 ACCUPRIL 14 ACCURETIC 14 acetazolamide 17 acetazolamide ext-rel 17 acetic acid 44 acitretin 40 ACTIGALL 31 ACTONEL 27 ACTOPLUS MET 26 ACULAR 43 ACUVAIL 43 acyclovir caps tabs 11 ADALAT CC 16 adalimumab 35 adapalene 39 adapalenebenzoyl peroxide 40 ADEMPAS 18 ADVAIR DISKUS 39 ADVAIR HFA 39 ADYNOVATE 34 AFINITOR 13 aflibercept 44 AGGRENOX 35 AGRYLIN 35 AIMOVIG 22 AJOVY 22 albuterol 38 albuterol ext-rel 38 albuterol soln 38 albuterol sulfate CFC-free aerosol 38 alcaftadine 42 alclometasone crm oint 005 41 ALDACTAZIDE 17 ALDACTONE 14 alendronate 27 alfuzosin ext-rel 33 aliskiren 17 aliskirenhydrochlorothiazide 17 ALKERAN 12 allopurinol 7 alosetron 32 alpha-1 proteinase inhibitor 39 ALPHAGAN P 44 alprazolam 18 ALTACE 14 amantadine 20 AMARYL 26 AMBIEN 22 AMBIEN CR 22

ambrisentan 18 amiloride 17 amiloridehydrochlorothiazide 17 amiodarone 15 AMITIZA 32 amitriptyline 20 amlodipine 16 amlodipineatorvastatin 17 amlodipinebenazepril 14 amlodipineolmesartan 15 amlodipinetelmisartan 15 amlodipinevalsartan 15 amlodipinevalsartanhydrochlorothiazide 15 ammonium lactate 12 42 amoxicillin 9 amoxicillinclavulanate 9 amoxicillinclavulanate ext-rel 9 amphetaminedextroamphetamine mixed salts 21 amphetaminedextroamphetamine mixed salts ext-rel 21 ampicillin 9 ANAFRANIL 18 anagrelide 35 anastrozole 12 ANDRODERM 25 ANORO ELLIPTA 37 ANTABUSE 23 antihemophilic factor (recombinant) 34 antihemophilic factor (recombinant) pegylated 34 antihemophilic factor (recombinant) pegylated-aucl 34 ANUSOL-HC 33 apalutamide 12 apixaban 34 apremilast 35 APRISO 32 ARANESP 34 ARAVA 35 ARICEPT 19 ARIMIDEX 12 aripiprazole 21 aripiprazole ext-rel inj 21 aripiprazole lauroxil ext-rel inj 21 ARISTADA 21 ARISTADA INITIO 21 ARIXTRA 34 armodafinil 23 ARNUITY ELLIPTA 39 AROMASIN 12 ASTEPRO 38 atazanavir 11 atazanavircobicistat 10 ATELVIA 27 atenolol 16 atenololchlorthalidone 16 ATIVAN 18 atomoxetine 21 atorvastatin 15 atovaquoneproguanil 10 ATRIPLA 10 AUBAGIO 23 AUGMENTIN 9 AUSTEDO 22 AVELOX 9

47

AVODART 33 AYGESTIN 30 AZASAN 36 azathioprine 36 azelaic acid foam 42 azelaic acid gel 42 azelastine 42 azelastine spray 38 azelastinefluticasone spray 39 azithromycin 9 AZOPT 44 AZOR 15 AZULFIDINE 32 AZULFIDINE EN-TABS 32

B bacitracin 42 baclofen 23 balsalazide 32 BARACLUDE 11 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 39 BELBUCA 8 BELSOMRA 22 benazepril 14 benazeprilhydrochlorothiazide 14 benralizumab 39 BENTYL 31 BENZAC AC 40 BENZAMYCIN 40 benzonatate 37 benzoyl peroxide 40 benztropine 20 besifloxacin 43 BESIVANCE 43 betamethasone dipropionate augmented crm 005 41 betamethasone dipropionate augmented gel oint 005 41 betamethasone dipropionate augmented lotion 005 41 betamethasone dipropionate crm lotion oint 005 41 betamethasone valerate crm lotion oint 01 41 BETASERON 23 betaxolol 43 bethanechol 33 BETHKIS 38 BETIMOL 43 BETOPTIC S 43 BEVESPI AEROSPHERE 37 bexarotene caps 13 bicalutamide 12 bictegraviremtricitabinetenofovir alafenamide 10 BIDIL 17 BIKTARVY 10 bimatoprost 44 bisoprolol 16 bisoprololhydrochlorothiazide 16 BLEPH-10 43 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 26 27 BONIVA 27 bosentan 18 BOSULIF 13 bosutinib 13 BREO ELLIPTA 39

BRILINTA 35 brimonidine 44 brimonidine 02 44 brimonidinetimolol 44 brinzolamide 44 brinzolamidebrimonidine 44 bromfenac sodium 43 bromocriptine 20 budesonide 39 budesonide delayed-rel caps 32 budesonide ext-rel 32 budesonide inhalation susp 39 budesonideformoterol 39 bumetanide 17 buprenorphine 8 buprenorphine transdermal 7 buprenorphinenaloxone sublingual 23 buprenorphinenaloxone sublingual tabs 23 bupropion 20 bupropion ext-rel 20 25 buspirone 18 busulfan 12 butalbitalacetaminophencaffeine tabs 8 butalbitalaspirincaffeine 8 BYSTOLIC 16

C cabergoline 31 CABOMETYX 13 cabozantinib 13 CADUET 17 CALAN SR 16 calcipotriene oint soln 0005 40 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 canakinumab 36 candesartan 14 candesartanhydrochlorothiazide 14 capecitabine 12 captopril 14 captoprilhydrochlorothiazide 14 carbamazepine 19 carbamazepine ext-rel 19 CARBATROL 19 carbidopalevodopa 20 carbidopalevodopa ext-rel 20 carbidopalevodopa orally disintegrating tabs 20 carbidopalevodopaentacapone 20 CARDURA 14 cariprazine 21 carisoprodol 23 carvedilol 16 carvedilol phosphate ext-rel 16 CASODEX 12 CATAPRES 14 CATAPRES-TTS 14 cefadroxil 9 cefdinir 9 cefixime 9 cefprozil 9 cefuroxime axetil 9 CELEBREX 7 celecoxib 7 CELEXA 20

26

48

cephalexin 9 CERDELGA 29 CEREZYME 29 cetrorelix 29 CETROTIDE 29 cevimeline 33 CHANTIX 25 chlorambucil 12 chloroquine 10 chlorpromazine 21 chlorpromazine inj 21 chlorthalidone 17 chlorzoxazone 23 cholestyramine 15 choriogonadotropin alfa 29 ciclopirox 40 cilostazol 35 CILOXAN 43 CIMDUO 10 cimetidine 31 cinacalcet 27 CIPRO 9 CIPRODEX 44 ciprofloxacin 9 ciprofloxacin oint 43 ciprofloxacin soln 43 ciprofloxacindexamethasone 44 citalopram 20 CITRANATAL 90 DHA 36 CITRANATAL ASSURE 36 CITRANATAL B-CALM 36 CITRANATAL DHA 36 CITRANATAL HARMONY 36 CITRANATAL RX 36 clarithromycin 9 clarithromycin ext-rel 9 clemastine 268 mg 37 CLEOCIN 11 33 CLEOCIN T 40 CLIMARA 29 CLIMARA PRO 29 clindamycin 11 clindamycin crm 33 clindamycin gel 39 clindamycin gel lotion 40 clindamycin soln 40 clindamycinbenzoyl peroxide 39 40 clobazam 19 clobetasol propionate crm gel oint 005 41 clobetasol propionate foam 005 41 clobetasol propionate lotion shampoo 005 41 clobetasol propionate soln 005 41 CLOBEX 41 clomiphene 29 clomipramine 18 clonazepam 18 clonidine 14 clonidine transdermal 14 clopidogrel 34 clotrimazole 40 clotrimazole troches 9 clozapine 21 CLOZARIL 21 coagulation factor IX (recombinant) glycopegylated 34 codeineacetaminophen 7

codeinepromethazine 38 codeinepromethazinephenylephrine 38 colchicine 7 colesevelam 15 COLESTID 15 colestipol 15 COMBIGAN 44 COMBIPATCH 29 COMBIVIR 10 COMPLERA 10 COMTAN 20 CONCERTA 21 CONDYLOX 42 conjugated estrogensbazedoxifene 29 COPAXONE 23 COREG 16 CORGARD 16 CORLANOR 17 CORTEF 30 CORTIFOAM 32 COSENTYX 35 COSOPT 44 COZAAR 14 CREON 32 CRINONE 30 crisaborole 41 cromolyn sodium 42 cromolyn soln 38 cyanocobalamin inj 36 cyclobenzaprine 23 cyclophosphamide caps 12 cyclosporine 36 cyclosporine emulsion 44 cyclosporine modified 36 cyproheptadine 37 CYTOMEL 31 CYTOTEC 32

D DHE 45 22 DALIRESP 39 dalteparin 34 danazol 28 DANTRIUM 23 dantrolene 23 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 11 darbepoetin alfa 34 darifenacin ext-rel 33 darolutamide 12 darunavir 11 darunavircobicistat 10 dasatinib 13 DAYPRO 7 DDAVP 31 denosumab 27 DEPAKENE 19 DEPAKOTE 19 DEPAKOTE ER 19 DEPO-PROVERA 28 DESCOVY 10 desipramine 20 desmopressin spray tabs 31 desogestrelEE 28

49

desogestrelEE 01530 27 desonide crm lotion oint 005 41 DESOWEN 41 desoximetasone crm oint 005 41 desoximetasone crm oint 025 gel 005 41 desvenlafaxine ext-rel 20 DETROL 33 deutetrabenazine 22 dexamethasone 29 43 dexamethasone sodium phosphate 43 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 26 DEXEDRINE SPANSULE 21 DEXILANT 32 dexlansoprazole delayed-rel 32 dexmethylphenidate 21 dexmethylphenidate ext-rel 21 dextroamphetamine 21 dextroamphetamine ext-rel 21 dextromethorphanbrompheniraminepseudoephedrine 38 dextromethorphanpromethazine 38 dextromethorphanquinidine 24 DIASTAT 19 diazepam 18 diazepam rectal gel 19 diclofenac sodium 43 diclofenac sodium delayed-rel 7 diclofenac sodium delayed-relmisoprostol 7 diclofenac sodium gel 1 7 diclofenac sodium soln 7 dicloxacillin 9 dicyclomine 31 didanosine delayed-rel 10 DIFICID 9 DIFLUCAN 10 diflunisal 7 difluprednate 43 digoxin 00625 mg 01875 mg 17 digoxin 0125 mg 025 mg 17 digoxin ped elixir 17 dihydroergotamine inj 22 DILANTIN 19 DILANTIN INFATABS 19 DILAUDID 8 diltiazem ext-rel 16 dimethyl fumarate delayed-rel 23 diphenoxylateatropine 31 DIPROLENE 41 DIPROLENE AF 41 dipyridamole 35 dipyridamole ext-relaspirin 35 disopyramide 15 disopyramide ext-rel 15 disulfiram 23 DITROPAN XL 33 divalproex sodium delayed-rel 19 divalproex sodium ext-rel 19 DIVIGEL 29 dofetilide 15 dolutegravir 10 donepezil 19 dornase alfa 38 dorzolamide 44 dorzolamidetimolol maleate 44 doxazosin 14 doxepin 20 22

doxercalciferol 30 doxycycline hyclate 9 doxycycline hyclate 20 mg 9 doxycycline monohydrate delayed-rel caps 42 dronabinol 31 dronedarone 15 drospirenoneEE 320 27 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 27 drospirenoneEElevomefolate 330 and levomefolate 27 DUAC 40 DUAVEE 29 DUETACT 26 dulaglutide 25 duloxetine delayed-rel 20 dupilumab 39 41 DUPIXENT 39 41 DUREZOL 43 dutasteride 33 dutasteridetamsulosin 33 DYAZIDE 17 DYMISTA 39

E econazole 40 eculizumab 34 EDURANT 10 EEnorethindrone acetate - Jinteli 29 efavirenz 10 efavirenzemtricitabinetenofovir disoproxil fumarate 10 efavirenzlamivudinetenofovir disoproxil fumarate 10 elagolix 28 eletriptan 22 ELIGARD 12 eliglustat 29 ELIQUIS 34 ELOCON 41 eltrombopag 34 eluxadoline 32 elvitegravircobicistatemtricitabinetenofovir alafenamide 10 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 10 EMBEDA 8 EMGALITY 22 empagliflozin 26 empagliflozinlinagliptin 26 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 10 emtricitabinerilpivirinetenofovir alafenamide 10 emtricitabinerilpivirinetenofovir disoproxil fumarate 10 emtricitabinetenofovir alafenamide 10 emtricitabinetenofovir disoproxil fumarate 10 EMTRIVA 10 EMVERM 12 enalapril 14 enalaprilhydrochlorothiazide 14 ENBREL 35 ENDOMETRIN 30 enfuvirtide 10 enoxaparin 34 entacapone 20 entecavir soln 11 entecavir tabs 11 ENTRESTO 17 enzalutamide 12

50

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

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NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

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peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

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RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

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AVODART 33 AYGESTIN 30 AZASAN 36 azathioprine 36 azelaic acid foam 42 azelaic acid gel 42 azelastine 42 azelastine spray 38 azelastinefluticasone spray 39 azithromycin 9 AZOPT 44 AZOR 15 AZULFIDINE 32 AZULFIDINE EN-TABS 32

B bacitracin 42 baclofen 23 balsalazide 32 BARACLUDE 11 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 39 BELBUCA 8 BELSOMRA 22 benazepril 14 benazeprilhydrochlorothiazide 14 benralizumab 39 BENTYL 31 BENZAC AC 40 BENZAMYCIN 40 benzonatate 37 benzoyl peroxide 40 benztropine 20 besifloxacin 43 BESIVANCE 43 betamethasone dipropionate augmented crm 005 41 betamethasone dipropionate augmented gel oint 005 41 betamethasone dipropionate augmented lotion 005 41 betamethasone dipropionate crm lotion oint 005 41 betamethasone valerate crm lotion oint 01 41 BETASERON 23 betaxolol 43 bethanechol 33 BETHKIS 38 BETIMOL 43 BETOPTIC S 43 BEVESPI AEROSPHERE 37 bexarotene caps 13 bicalutamide 12 bictegraviremtricitabinetenofovir alafenamide 10 BIDIL 17 BIKTARVY 10 bimatoprost 44 bisoprolol 16 bisoprololhydrochlorothiazide 16 BLEPH-10 43 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 26 27 BONIVA 27 bosentan 18 BOSULIF 13 bosutinib 13 BREO ELLIPTA 39

BRILINTA 35 brimonidine 44 brimonidine 02 44 brimonidinetimolol 44 brinzolamide 44 brinzolamidebrimonidine 44 bromfenac sodium 43 bromocriptine 20 budesonide 39 budesonide delayed-rel caps 32 budesonide ext-rel 32 budesonide inhalation susp 39 budesonideformoterol 39 bumetanide 17 buprenorphine 8 buprenorphine transdermal 7 buprenorphinenaloxone sublingual 23 buprenorphinenaloxone sublingual tabs 23 bupropion 20 bupropion ext-rel 20 25 buspirone 18 busulfan 12 butalbitalacetaminophencaffeine tabs 8 butalbitalaspirincaffeine 8 BYSTOLIC 16

C cabergoline 31 CABOMETYX 13 cabozantinib 13 CADUET 17 CALAN SR 16 calcipotriene oint soln 0005 40 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 canakinumab 36 candesartan 14 candesartanhydrochlorothiazide 14 capecitabine 12 captopril 14 captoprilhydrochlorothiazide 14 carbamazepine 19 carbamazepine ext-rel 19 CARBATROL 19 carbidopalevodopa 20 carbidopalevodopa ext-rel 20 carbidopalevodopa orally disintegrating tabs 20 carbidopalevodopaentacapone 20 CARDURA 14 cariprazine 21 carisoprodol 23 carvedilol 16 carvedilol phosphate ext-rel 16 CASODEX 12 CATAPRES 14 CATAPRES-TTS 14 cefadroxil 9 cefdinir 9 cefixime 9 cefprozil 9 cefuroxime axetil 9 CELEBREX 7 celecoxib 7 CELEXA 20

26

48

cephalexin 9 CERDELGA 29 CEREZYME 29 cetrorelix 29 CETROTIDE 29 cevimeline 33 CHANTIX 25 chlorambucil 12 chloroquine 10 chlorpromazine 21 chlorpromazine inj 21 chlorthalidone 17 chlorzoxazone 23 cholestyramine 15 choriogonadotropin alfa 29 ciclopirox 40 cilostazol 35 CILOXAN 43 CIMDUO 10 cimetidine 31 cinacalcet 27 CIPRO 9 CIPRODEX 44 ciprofloxacin 9 ciprofloxacin oint 43 ciprofloxacin soln 43 ciprofloxacindexamethasone 44 citalopram 20 CITRANATAL 90 DHA 36 CITRANATAL ASSURE 36 CITRANATAL B-CALM 36 CITRANATAL DHA 36 CITRANATAL HARMONY 36 CITRANATAL RX 36 clarithromycin 9 clarithromycin ext-rel 9 clemastine 268 mg 37 CLEOCIN 11 33 CLEOCIN T 40 CLIMARA 29 CLIMARA PRO 29 clindamycin 11 clindamycin crm 33 clindamycin gel 39 clindamycin gel lotion 40 clindamycin soln 40 clindamycinbenzoyl peroxide 39 40 clobazam 19 clobetasol propionate crm gel oint 005 41 clobetasol propionate foam 005 41 clobetasol propionate lotion shampoo 005 41 clobetasol propionate soln 005 41 CLOBEX 41 clomiphene 29 clomipramine 18 clonazepam 18 clonidine 14 clonidine transdermal 14 clopidogrel 34 clotrimazole 40 clotrimazole troches 9 clozapine 21 CLOZARIL 21 coagulation factor IX (recombinant) glycopegylated 34 codeineacetaminophen 7

codeinepromethazine 38 codeinepromethazinephenylephrine 38 colchicine 7 colesevelam 15 COLESTID 15 colestipol 15 COMBIGAN 44 COMBIPATCH 29 COMBIVIR 10 COMPLERA 10 COMTAN 20 CONCERTA 21 CONDYLOX 42 conjugated estrogensbazedoxifene 29 COPAXONE 23 COREG 16 CORGARD 16 CORLANOR 17 CORTEF 30 CORTIFOAM 32 COSENTYX 35 COSOPT 44 COZAAR 14 CREON 32 CRINONE 30 crisaborole 41 cromolyn sodium 42 cromolyn soln 38 cyanocobalamin inj 36 cyclobenzaprine 23 cyclophosphamide caps 12 cyclosporine 36 cyclosporine emulsion 44 cyclosporine modified 36 cyproheptadine 37 CYTOMEL 31 CYTOTEC 32

D DHE 45 22 DALIRESP 39 dalteparin 34 danazol 28 DANTRIUM 23 dantrolene 23 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 11 darbepoetin alfa 34 darifenacin ext-rel 33 darolutamide 12 darunavir 11 darunavircobicistat 10 dasatinib 13 DAYPRO 7 DDAVP 31 denosumab 27 DEPAKENE 19 DEPAKOTE 19 DEPAKOTE ER 19 DEPO-PROVERA 28 DESCOVY 10 desipramine 20 desmopressin spray tabs 31 desogestrelEE 28

49

desogestrelEE 01530 27 desonide crm lotion oint 005 41 DESOWEN 41 desoximetasone crm oint 005 41 desoximetasone crm oint 025 gel 005 41 desvenlafaxine ext-rel 20 DETROL 33 deutetrabenazine 22 dexamethasone 29 43 dexamethasone sodium phosphate 43 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 26 DEXEDRINE SPANSULE 21 DEXILANT 32 dexlansoprazole delayed-rel 32 dexmethylphenidate 21 dexmethylphenidate ext-rel 21 dextroamphetamine 21 dextroamphetamine ext-rel 21 dextromethorphanbrompheniraminepseudoephedrine 38 dextromethorphanpromethazine 38 dextromethorphanquinidine 24 DIASTAT 19 diazepam 18 diazepam rectal gel 19 diclofenac sodium 43 diclofenac sodium delayed-rel 7 diclofenac sodium delayed-relmisoprostol 7 diclofenac sodium gel 1 7 diclofenac sodium soln 7 dicloxacillin 9 dicyclomine 31 didanosine delayed-rel 10 DIFICID 9 DIFLUCAN 10 diflunisal 7 difluprednate 43 digoxin 00625 mg 01875 mg 17 digoxin 0125 mg 025 mg 17 digoxin ped elixir 17 dihydroergotamine inj 22 DILANTIN 19 DILANTIN INFATABS 19 DILAUDID 8 diltiazem ext-rel 16 dimethyl fumarate delayed-rel 23 diphenoxylateatropine 31 DIPROLENE 41 DIPROLENE AF 41 dipyridamole 35 dipyridamole ext-relaspirin 35 disopyramide 15 disopyramide ext-rel 15 disulfiram 23 DITROPAN XL 33 divalproex sodium delayed-rel 19 divalproex sodium ext-rel 19 DIVIGEL 29 dofetilide 15 dolutegravir 10 donepezil 19 dornase alfa 38 dorzolamide 44 dorzolamidetimolol maleate 44 doxazosin 14 doxepin 20 22

doxercalciferol 30 doxycycline hyclate 9 doxycycline hyclate 20 mg 9 doxycycline monohydrate delayed-rel caps 42 dronabinol 31 dronedarone 15 drospirenoneEE 320 27 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 27 drospirenoneEElevomefolate 330 and levomefolate 27 DUAC 40 DUAVEE 29 DUETACT 26 dulaglutide 25 duloxetine delayed-rel 20 dupilumab 39 41 DUPIXENT 39 41 DUREZOL 43 dutasteride 33 dutasteridetamsulosin 33 DYAZIDE 17 DYMISTA 39

E econazole 40 eculizumab 34 EDURANT 10 EEnorethindrone acetate - Jinteli 29 efavirenz 10 efavirenzemtricitabinetenofovir disoproxil fumarate 10 efavirenzlamivudinetenofovir disoproxil fumarate 10 elagolix 28 eletriptan 22 ELIGARD 12 eliglustat 29 ELIQUIS 34 ELOCON 41 eltrombopag 34 eluxadoline 32 elvitegravircobicistatemtricitabinetenofovir alafenamide 10 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 10 EMBEDA 8 EMGALITY 22 empagliflozin 26 empagliflozinlinagliptin 26 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 10 emtricitabinerilpivirinetenofovir alafenamide 10 emtricitabinerilpivirinetenofovir disoproxil fumarate 10 emtricitabinetenofovir alafenamide 10 emtricitabinetenofovir disoproxil fumarate 10 EMTRIVA 10 EMVERM 12 enalapril 14 enalaprilhydrochlorothiazide 14 ENBREL 35 ENDOMETRIN 30 enfuvirtide 10 enoxaparin 34 entacapone 20 entecavir soln 11 entecavir tabs 11 ENTRESTO 17 enzalutamide 12

50

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

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isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

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M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

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NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

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peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

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RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

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cephalexin 9 CERDELGA 29 CEREZYME 29 cetrorelix 29 CETROTIDE 29 cevimeline 33 CHANTIX 25 chlorambucil 12 chloroquine 10 chlorpromazine 21 chlorpromazine inj 21 chlorthalidone 17 chlorzoxazone 23 cholestyramine 15 choriogonadotropin alfa 29 ciclopirox 40 cilostazol 35 CILOXAN 43 CIMDUO 10 cimetidine 31 cinacalcet 27 CIPRO 9 CIPRODEX 44 ciprofloxacin 9 ciprofloxacin oint 43 ciprofloxacin soln 43 ciprofloxacindexamethasone 44 citalopram 20 CITRANATAL 90 DHA 36 CITRANATAL ASSURE 36 CITRANATAL B-CALM 36 CITRANATAL DHA 36 CITRANATAL HARMONY 36 CITRANATAL RX 36 clarithromycin 9 clarithromycin ext-rel 9 clemastine 268 mg 37 CLEOCIN 11 33 CLEOCIN T 40 CLIMARA 29 CLIMARA PRO 29 clindamycin 11 clindamycin crm 33 clindamycin gel 39 clindamycin gel lotion 40 clindamycin soln 40 clindamycinbenzoyl peroxide 39 40 clobazam 19 clobetasol propionate crm gel oint 005 41 clobetasol propionate foam 005 41 clobetasol propionate lotion shampoo 005 41 clobetasol propionate soln 005 41 CLOBEX 41 clomiphene 29 clomipramine 18 clonazepam 18 clonidine 14 clonidine transdermal 14 clopidogrel 34 clotrimazole 40 clotrimazole troches 9 clozapine 21 CLOZARIL 21 coagulation factor IX (recombinant) glycopegylated 34 codeineacetaminophen 7

codeinepromethazine 38 codeinepromethazinephenylephrine 38 colchicine 7 colesevelam 15 COLESTID 15 colestipol 15 COMBIGAN 44 COMBIPATCH 29 COMBIVIR 10 COMPLERA 10 COMTAN 20 CONCERTA 21 CONDYLOX 42 conjugated estrogensbazedoxifene 29 COPAXONE 23 COREG 16 CORGARD 16 CORLANOR 17 CORTEF 30 CORTIFOAM 32 COSENTYX 35 COSOPT 44 COZAAR 14 CREON 32 CRINONE 30 crisaborole 41 cromolyn sodium 42 cromolyn soln 38 cyanocobalamin inj 36 cyclobenzaprine 23 cyclophosphamide caps 12 cyclosporine 36 cyclosporine emulsion 44 cyclosporine modified 36 cyproheptadine 37 CYTOMEL 31 CYTOTEC 32

D DHE 45 22 DALIRESP 39 dalteparin 34 danazol 28 DANTRIUM 23 dantrolene 23 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 11 darbepoetin alfa 34 darifenacin ext-rel 33 darolutamide 12 darunavir 11 darunavircobicistat 10 dasatinib 13 DAYPRO 7 DDAVP 31 denosumab 27 DEPAKENE 19 DEPAKOTE 19 DEPAKOTE ER 19 DEPO-PROVERA 28 DESCOVY 10 desipramine 20 desmopressin spray tabs 31 desogestrelEE 28

49

desogestrelEE 01530 27 desonide crm lotion oint 005 41 DESOWEN 41 desoximetasone crm oint 005 41 desoximetasone crm oint 025 gel 005 41 desvenlafaxine ext-rel 20 DETROL 33 deutetrabenazine 22 dexamethasone 29 43 dexamethasone sodium phosphate 43 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 26 DEXEDRINE SPANSULE 21 DEXILANT 32 dexlansoprazole delayed-rel 32 dexmethylphenidate 21 dexmethylphenidate ext-rel 21 dextroamphetamine 21 dextroamphetamine ext-rel 21 dextromethorphanbrompheniraminepseudoephedrine 38 dextromethorphanpromethazine 38 dextromethorphanquinidine 24 DIASTAT 19 diazepam 18 diazepam rectal gel 19 diclofenac sodium 43 diclofenac sodium delayed-rel 7 diclofenac sodium delayed-relmisoprostol 7 diclofenac sodium gel 1 7 diclofenac sodium soln 7 dicloxacillin 9 dicyclomine 31 didanosine delayed-rel 10 DIFICID 9 DIFLUCAN 10 diflunisal 7 difluprednate 43 digoxin 00625 mg 01875 mg 17 digoxin 0125 mg 025 mg 17 digoxin ped elixir 17 dihydroergotamine inj 22 DILANTIN 19 DILANTIN INFATABS 19 DILAUDID 8 diltiazem ext-rel 16 dimethyl fumarate delayed-rel 23 diphenoxylateatropine 31 DIPROLENE 41 DIPROLENE AF 41 dipyridamole 35 dipyridamole ext-relaspirin 35 disopyramide 15 disopyramide ext-rel 15 disulfiram 23 DITROPAN XL 33 divalproex sodium delayed-rel 19 divalproex sodium ext-rel 19 DIVIGEL 29 dofetilide 15 dolutegravir 10 donepezil 19 dornase alfa 38 dorzolamide 44 dorzolamidetimolol maleate 44 doxazosin 14 doxepin 20 22

doxercalciferol 30 doxycycline hyclate 9 doxycycline hyclate 20 mg 9 doxycycline monohydrate delayed-rel caps 42 dronabinol 31 dronedarone 15 drospirenoneEE 320 27 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 27 drospirenoneEElevomefolate 330 and levomefolate 27 DUAC 40 DUAVEE 29 DUETACT 26 dulaglutide 25 duloxetine delayed-rel 20 dupilumab 39 41 DUPIXENT 39 41 DUREZOL 43 dutasteride 33 dutasteridetamsulosin 33 DYAZIDE 17 DYMISTA 39

E econazole 40 eculizumab 34 EDURANT 10 EEnorethindrone acetate - Jinteli 29 efavirenz 10 efavirenzemtricitabinetenofovir disoproxil fumarate 10 efavirenzlamivudinetenofovir disoproxil fumarate 10 elagolix 28 eletriptan 22 ELIGARD 12 eliglustat 29 ELIQUIS 34 ELOCON 41 eltrombopag 34 eluxadoline 32 elvitegravircobicistatemtricitabinetenofovir alafenamide 10 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 10 EMBEDA 8 EMGALITY 22 empagliflozin 26 empagliflozinlinagliptin 26 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 10 emtricitabinerilpivirinetenofovir alafenamide 10 emtricitabinerilpivirinetenofovir disoproxil fumarate 10 emtricitabinetenofovir alafenamide 10 emtricitabinetenofovir disoproxil fumarate 10 EMTRIVA 10 EMVERM 12 enalapril 14 enalaprilhydrochlorothiazide 14 ENBREL 35 ENDOMETRIN 30 enfuvirtide 10 enoxaparin 34 entacapone 20 entecavir soln 11 entecavir tabs 11 ENTRESTO 17 enzalutamide 12

50

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

desogestrelEE 01530 27 desonide crm lotion oint 005 41 DESOWEN 41 desoximetasone crm oint 005 41 desoximetasone crm oint 025 gel 005 41 desvenlafaxine ext-rel 20 DETROL 33 deutetrabenazine 22 dexamethasone 29 43 dexamethasone sodium phosphate 43 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 26 DEXEDRINE SPANSULE 21 DEXILANT 32 dexlansoprazole delayed-rel 32 dexmethylphenidate 21 dexmethylphenidate ext-rel 21 dextroamphetamine 21 dextroamphetamine ext-rel 21 dextromethorphanbrompheniraminepseudoephedrine 38 dextromethorphanpromethazine 38 dextromethorphanquinidine 24 DIASTAT 19 diazepam 18 diazepam rectal gel 19 diclofenac sodium 43 diclofenac sodium delayed-rel 7 diclofenac sodium delayed-relmisoprostol 7 diclofenac sodium gel 1 7 diclofenac sodium soln 7 dicloxacillin 9 dicyclomine 31 didanosine delayed-rel 10 DIFICID 9 DIFLUCAN 10 diflunisal 7 difluprednate 43 digoxin 00625 mg 01875 mg 17 digoxin 0125 mg 025 mg 17 digoxin ped elixir 17 dihydroergotamine inj 22 DILANTIN 19 DILANTIN INFATABS 19 DILAUDID 8 diltiazem ext-rel 16 dimethyl fumarate delayed-rel 23 diphenoxylateatropine 31 DIPROLENE 41 DIPROLENE AF 41 dipyridamole 35 dipyridamole ext-relaspirin 35 disopyramide 15 disopyramide ext-rel 15 disulfiram 23 DITROPAN XL 33 divalproex sodium delayed-rel 19 divalproex sodium ext-rel 19 DIVIGEL 29 dofetilide 15 dolutegravir 10 donepezil 19 dornase alfa 38 dorzolamide 44 dorzolamidetimolol maleate 44 doxazosin 14 doxepin 20 22

doxercalciferol 30 doxycycline hyclate 9 doxycycline hyclate 20 mg 9 doxycycline monohydrate delayed-rel caps 42 dronabinol 31 dronedarone 15 drospirenoneEE 320 27 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 27 drospirenoneEElevomefolate 330 and levomefolate 27 DUAC 40 DUAVEE 29 DUETACT 26 dulaglutide 25 duloxetine delayed-rel 20 dupilumab 39 41 DUPIXENT 39 41 DUREZOL 43 dutasteride 33 dutasteridetamsulosin 33 DYAZIDE 17 DYMISTA 39

E econazole 40 eculizumab 34 EDURANT 10 EEnorethindrone acetate - Jinteli 29 efavirenz 10 efavirenzemtricitabinetenofovir disoproxil fumarate 10 efavirenzlamivudinetenofovir disoproxil fumarate 10 elagolix 28 eletriptan 22 ELIGARD 12 eliglustat 29 ELIQUIS 34 ELOCON 41 eltrombopag 34 eluxadoline 32 elvitegravircobicistatemtricitabinetenofovir alafenamide 10 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 10 EMBEDA 8 EMGALITY 22 empagliflozin 26 empagliflozinlinagliptin 26 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 10 emtricitabinerilpivirinetenofovir alafenamide 10 emtricitabinerilpivirinetenofovir disoproxil fumarate 10 emtricitabinetenofovir alafenamide 10 emtricitabinetenofovir disoproxil fumarate 10 EMTRIVA 10 EMVERM 12 enalapril 14 enalaprilhydrochlorothiazide 14 ENBREL 35 ENDOMETRIN 30 enfuvirtide 10 enoxaparin 34 entacapone 20 entecavir soln 11 entecavir tabs 11 ENTRESTO 17 enzalutamide 12

50

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

EPCLUSA 11 EPIDUO 40 EPIDUO FORTE 40 epinephrine auto-injector 37 EPIPEN 37 EPIPEN JR 37 EPIVIR 10 eplerenone 14 epoetin alfa-epbx 34 epoprostenol sodium 18 eprosartan 14 EPZICOM 10 erenumab-aooe 22 ergocalciferol (D2) 36 ergotaminecaffeine tabs 22 ERLEADA 12 erlotinib 13 erythromycin 42 erythromycin delayed-rel 9 erythromycin ethylsuccinate 9 erythromycin gel 2 39 erythromycin soln 40 erythromycin stearate 9 erythromycinbenzoyl peroxide 40 ESBRIET 39 escitalopram 20 ESGIC 8 esomeprazole delayed-rel 32 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 22 etanercept 35 ethambutol 11 ethosuximide 19 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 28 etoposide 13 etravirine 10 EUCRISA 41 EVAMIST 29 everolimus 13 EVISTA 30 evolocumab 16 EVOTAZ 10 EVOXAC 33 EXELON 19 exemestane 12 EYLEA 44 ezetimibe 15 ezetimibesimvastatin 16

F famciclovir 11 famotidine 32

FARXIGA 26 FASENRA 39 febuxostat 7 felodipine ext-rel 16 FEMARA 12 fenofibrate 15 fenofibric acid delayed-rel 15 fentanyl sublingual spray 8 fentanyl transdermal 7 fentanyl transmucosal lozenge 7 fesoterodine ext-rel 33 FIASP 26 fidaxomicin 9 filgrastim-aafi 34 FINACEA FOAM 42 finasteride 33 fingolimod 23 FIORINAL 8 FLAGYL 12 flecainide 15 FLOLAN 18 FLOMAX 33 FLOVENT DISKUS 39 FLOVENT HFA 39 fluconazole 10 fludrocortisone 30 flunisolide spray 38 fluocinolone acetonide crm oint 0025 41 fluocinolone acetonide soln 001 41 fluocinonide crm gel oint soln 005 41 fluoride drops 36 fluoride tabs 36 fluorometholone 43 fluorouracil crm 4 40 fluorouracil crm 5 soln 5 soln 2 40 fluoxetine 20 fluphenazine 21 flutamide 12 fluticasone 39 fluticasone propionate crm lotion 005 oint 0005 41 fluticasone spray 38 fluticasone CFC-free aerosol 39 fluticasonesalmeterol 39 fluticasonesalmeterol CFC-free aerosol 39 fluticasoneumeclidiniumvilanterol 37 fluticasonevilanterol 39 fluvastatin 15 fluvoxamine 18 FML FORTE 43 FML SOP 43 FOCALIN 21 FOCALIN XR 21 folic acid 36 folic acidvitamin B6vitamin B12 36 follitropin alfa 29 fondaparinux 34 formoterol inhalation soln 38 FORTEO 27 FOSAMAX 27 fosinopril 14 fosinoprilhydrochlorothiazide 14 FRAGMIN 34 fremanezumab-vfrm 22 FURADANTIN 12 furosemide 17

51

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

FUZEON 10 FYCOMPA 19

G gabapentin 19 gabapentin ext-rel 23 galantamine 19 galantamine ext-rel 19 galcanezumab-gnlm 22 ganirelix acetate 29 gefitinib 13 gemfibrozil 15 GENOTROPIN 30 gentamicin 40 42 GENVOYA 10 GEODON 21 GILENYA 23 glatiramer 23 glimepiride 26 glipizide 26 glipizide ext-rel 26 glipizidemetformin 25 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 26 GLUCOTROL XL 26 glycopyrrolateformoterol 37 GLYXAMBI 26 GOLYTELY 32 GONAL-F 29 GRALISE 23 granisetron 31 granisetron transdermal 31 grass mixed pollen allergen extract 35 GRASTEK 35 griseofulvin ultramicrosize 9 guanfacine 14 guanfacine ext-rel 21 guselkumab 35

H HALDOL 21 HALDOL DECANOATE 21 halobetasol propionate crm oint 005 41 haloperidol 21 haloperidol decanoate inj 21 haloperidol inj 21 HARVONI 11 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 34 HUMATROPE 30 HUMIRA 35 HUMULIN R U-500 26 HYCAMTIN 13 hydralazine 18 HYDREA 13 hydrochlorothiazide 17 hydrocodoneacetaminophen 8 hydrocodonehomatropine 38 hydrocortisone 30 hydrocortisone acetate foam 32 hydrocortisone acetatepramoxine foam 33 hydrocortisone butyrate crm oint soln 01 41

hydrocortisone crm 33 hydrocortisone crm 25 41 hydrocortisone enema 32 hydrocortisone lotion 1 41 hydrocortisone valerate crm oint 02 41 hydromorphone 8 hydromorphone ext-rel 7 hydroxychloroquine 35 hydroxyurea 13 hydroxyzine HCl 37 hyoscyamine sulfate 31 hyoscyamine sulfate ext-rel 31 hyoscyamine sulfate ext-rel caps 31 hyoscyamine sulfate orally disintegrating tabs 31 HYZAAR 15

I ibandronate 27 IBRANCE 13 ibuprofen 7 icosapent ethyl 16 ILARIS 36 ILEVRO 43 imatinib mesylate 13 imiglucerase 29 imipramine HCl 20 imiquimod 40 42 IMITREX 22 IMURAN 36 INCRUSE ELLIPTA 37 indapamide 17 INDERAL LA 16 ingenol mebutate 40 INGREZZA 23 INSPRA 14 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 10 interferon alfa-2b 36 interferon beta-1a 23 interferon beta-1b 23 INTRON A 36 INVEGA SUSTENNA 21 ipratropium soln 37 ipratropium spray 39 ipratropiumalbuterol soln 37 irbesartan 14 irbesartanhydrochlorothiazide 14 IRESSA 13 ISENTRESS 10 isoniazid 11 ISORDIL 17 isosorbide dinitrate ext-rel tabs 17 isosorbide dinitrate oral 17 isosorbide dinitratehydralazine 17 isosorbide mononitrate 17 isosorbide mononitrate ext-rel 17

52

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

isotretinoin 39 itraconazole 9 ivabradine 17 ivermectin 12 42

J JANUMET 25 JANUMET XR 25 JANUVIA 25 JARDIANCE 26 JIVI 34

K KADIAN 8 KALETRA 11 KEFLEX 9 KEPPRA 19 KEPPRA XR 19 ketoconazole crm 2 40 ketoconazole shampoo 2 40 ketorolac 43 ketorolac tromethamine 43 KISQALI 13 KISQALI FEMARA CO-PACK 13 KLARON 40 KLONOPIN 18 KOGENATE FS 34 KOVALTRY 34 KUVAN 30 KYLEENA 28

L labetalol 16 LAC-HYDRIN 42 lacosamide 19 lactulose soln 32 lamivudine 10 11 lamivudinetenofovir disoproxil fumarate 10 lamivudinezidovudine 10 lamotrigine 19 lamotrigine ext-rel 19 lamotrigine orally disintegrating tabs 19 lancets 27 LANOXIN 17 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 33 lansoprazole delayed-rel 32 lapatinib 13 LASIX 17 LASTACAFT 42 latanoprost 44 LATUDA 21 ledipasvirsofosbuvir 11 leflunomide 35 lenalidomide 13 letrozole 12 LEUKERAN 12 leuprolide acetate 12 levalbuterol tartrate CFC-free aerosol 38 LEVAQUIN 9 LEVBID 31 LEVEMIR 26 levetiracetam 19 levetiracetam ext-rel 19 levobunolol 43 levocarnitine 27

levocetirizine 37 levofloxacin 9 42 levonorgestrel releasing IUD 28 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 27 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 27 levonorgestrelEE 01530 and EE 10 28 levothyroxine 31 levothyroxine - Levoxyl 31 LEVSIN 31 lidocaine patch 42 lidocaine viscous 42 LIDODERM 42 lifitegrast 44 linaclotide 32 linezolid 11 LINZESS 32 liothyronine 31 LIPOFEN 15 liraglutide 25 liraglutideinsulin degludec 26 lisdexamfetamine 21 lisinopril 14 lisinoprilhydrochlorothiazide 14 lithium carbonate 22 lithium carbonate ext-rel tabs 300 mg 22 lithium carbonate ext-rel tabs 450 mg 22 LITHOBID 22 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 27 LOESTRIN FE 1530 28 LOESTRIN FE 120 27 LOKELMA 30 LOMOTIL 31 loperamide 31 LOPID 15 lopinavirritonavir soln 11 lopinavirritonavir tabs 11 LOPRESSOR 16 LOPRESSOR HCT 16 LOPROX 40 lorazepam 18 losartan 14 losartanhydrochlorothiazide 15 LOSEASONIQUE 28 LOTENSIN 14 LOTENSIN HCT 14 loteprednol 43 LOTREL 14 lovastatin 15 LOVAZA 16 lubiprostone 32 LUCENTIS 44 luliconazole 40 LUMIGAN 44 LUPRON DEPOT 12 lurasidone 21 lusutrombopag 35 LYNPARZA 13 LYSODREN 13

53

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

M macitentan 18 MACROBID 12 MALARONE 10 malathion 42 MARINOL 31 MATULANE 13 MAXALT 22 MAXIDEX 43 MAXITROL 43 MAXZIDE 17 MAYZENT 23 mebendazole chewable 12 meclizine 31 MEDROL 30 medroxyprogesterone acetate 30 medroxyprogesterone acetate 150 mgmL 28 mefloquine 10 MEGACE ES 30 megestrol acetate susp 30 megestrol acetate tabs 12 meloxicam 7 melphalan 12 memantine 19 memantine ext-rel 19 memantinedonepezil 19 mepolizumab 39 mercaptopurine 12 mesalamine delayed-rel caps 32 mesalamine delayed-rel tabs 32 mesalamine ext-rel caps 32 mesalamine supp 32 mesalamine susp 32 metaxalone 23 metformin 25 metformin ext-rel 25 methadone 7 methazolamide 17 methimazole 31 methocarbamol 23 methotrexate 12 35 methotrexate auto-injector 35 methoxsalen oral 40 methyldopa 18 METHYLIN 21 methylphenidate 21 methylphenidate ext-rel 21 methylprednisolone 30 metoclopramide 31 metolazone 17 metoprolol succinate ext-rel 16 metoprolol tartrate 16 metoprololhydrochlorothiazide 16 METROCREAM 42 METROGEL 42 METROGEL-VAGINAL 33 METROLOTION 42 metronidazole 12 33 metronidazole crm 075 42 metronidazole gel 075 42 metronidazole gel 1 42 metronidazole lotion 075 42 MICARDIS 15 MICARDIS HCT 15 midodrine 18

midostaurin 13 minocycline 9 mirabegron ext-rel 33 MIRAPEX 20 MIRCETTE 28 MIRENA 28 mirtazapine 20 misoprostol 32 mitotane 13 MOBIC 7 mometasone crm lotion 01 41 mometasone oint 01 41 mometasone spray 38 montelukast 38 morphine 7 morphine ext-rel 7 8 morphine supp 7 morphinenaltrexone ext-rel 8 MOVANTIK 32 MOXEZA 43 moxifloxacin 9 43 MOZOBIL 35 MS CONTIN 8 MULPLETA 35 MULTAQ 15 multivitaminsfluoride drops tabs 36 multivitaminsfluorideiron drops tabs 36 mupirocin oint 40 MYAMBUTOL 11 mycophenolate mofetil 36 mycophenolate sodium delayed-rel 36 MYDAYIS 21 MYLERAN 12 MYRBETRIQ 33 MYSOLINE 19

N nabumetone 7 nadolol 16 naftifine 40 NAFTIN 40 naldemedine 32 naloxegol 32 naloxone inj 23 naloxone nasal spray 23 naltrexone 23 NAMENDA 19 NAMZARIC 19 naproxen sodium tabs 7 naproxen tabs 7 naratriptan 22 NARCAN 23 NARDIL 20 natalizumab 23 nateglinide 26 nebivolol 16 neomycinpolymyxin Bbacitracinhydrocortisone oint 43 neomycinpolymyxin Bdexamethasone 43 neomycinpolymyxin Bgramicidin 42 neomycinpolymyxin Bhydrocortisone 44 neomycinpolymyxin Bhydrocortisone susp 43 nepafenac 43 netarsudil 44 netarsudillatanoprost 44 NEULASTA 34

54

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

NEUPRO 20 NEURONTIN 19 NEVANAC 43 nevirapine 10 nevirapine ext-rel 10 niacin ext-rel 16 NIASPAN 16 nifedipine ext-rel 16 nintedanib 39 niraparib 13 nitisinone 30 NITRO-DUR 18 nitrofurantoin ext-rel 12 nitrofurantoin macrocrystals 11 nitrofurantoin susp 12 nitroglycerin lingual spray 18 nitroglycerin sublingual 18 nitroglycerin transdermal 18 NITROLINGUAL 18 NITROSTAT 18 NIVESTYM 34 NIZORAL 40 NORCO 8 norelgestrominEE 28 norethindrone 28 norethindrone acetate 30 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 27 norethindrone acetateEE 120 and iron 27 norethindrone acetateEE 120 and iron chewable 27 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 15 NORPACE CR 15 NORPRAMIN 20 nortriptyline 20 NORVIR 11 NOVOEIGHT 34 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 12 NUCALA autoinjector 39 NUCYNTA 8 NUCYNTA ER 8 NUEDEXTA 24 NULYTELY 32 NUVARING 28 NUWIQ 34 nystatin 9 40

O OCUFLOX 43 ODEFSEY 10 ODOMZO 13 OFEV 39 ofloxacin 43 ofloxacin otic 44

olanzapine 21 olaparib 13 olmesartan 14 olmesartanamlodipinehydrochlorothiazide 15 olmesartanhydrochlorothiazide 14 olodaterol CFC-free aerosol 38 olopatadine 42 olopatadine spray 38 omalizumab 39 omega-3 acid ethyl esters 16 omeprazole delayed-rel 33 OMNIPOD DASH 27 ondansetron 31 ONZETRA XSAIL 22 OPSUMIT 18 ORALAIR 35 ORENITRAM 18 ORFADIN 30 ORILISSA 28 orphenadrineaspirincaffeine 23 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 11 ospemifene 30 OSPHENA 30 OTEZLA 35 OVIDE 42 OVIDREL 29 oxaprozin 7 oxazepam 18 oxcarbazepine 19 oxcarbazepine ext-rel 19 OXSORALEN-ULTRA 40 OXTELLAR XR 19 oxybutynin 33 oxybutynin ext-rel 33 oxycodone concentrate 20 mgmL 7 oxycodone ext-rel 8 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 8 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 8 OZEMPIC 26

P palbociclib 13 paliperidone palmitate ext-rel inj 21 PAMELOR 20 pancrelipase 32 pancrelipase delayed-rel 32 pantoprazole delayed-rel 32 paricalcitol 30 PARLODEL 20 PARNATE 20 paroxetine HCl 20 paroxetine HCl ext-rel 20 paroxetine mesylate 25 PATADAY 42 PATANASE 38 PATANOL 42 patiromer sorbitex 30 PAXIL 20 PAXIL CR 20 PAZEO 42 pazopanib 13

55

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

peg 3350electrolytes 32 PEGASYS 36 pegfilgrastim 34 pegfilgrastim-cbqv 34 peginterferon alfa-2a 36 peginterferon alfa-2b 36 pegvisomant 25 penicillin VK 9 PENTASA 32 PEPCID 32 perampanel 19 PERFOROMIST 38 perindopril 14 permethrin 5 42 perphenazine 21 phenelzine 20 phenobarbital 19 phenytoin 19 phenytoin sodium extended 19 PHOSLYRA 30 PICATO 40 pilocarpine tabs 33 pimecrolimus 41 pindolol 16 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 39 PLAQUENIL 35 plerixafor 35 podofilox 42 polymyxin Bbacitracin 42 polymyxin Btrimethoprim 43 POLYTRIM 43 pomalidomide 13 POMALYST 13 potassium chloride ext-rel 36 potassium chloride liquid 36 potassium citrate ext-rel 33 pramipexole 20 pramipexole ext-rel 20 pramlintide 25 PRANDIN 26 prasugrel 35 PRAVACHOL 16 pravastatin 16 PRECOSE 25 PRED MILD 43 prednisolone 30 prednisolone acetate 43 prednisolone acetate 1 43 prednisolone phosphate 1 43 prednisone 30 pregabalin 21 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 36 prenatal vitaminsDHAdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid 36 prenatal vitaminsdocusatefolic acid + DHA 36 prenatal vitaminsfolic acid + pyridoxine 36 PREZCOBIX 10 PREZISTA 11 PRILOSEC 33

primidone 19 probenecid 7 procarbazine 13 PROCARDIA XL 16 prochlorperazine 31 prochlorperazine inj 21 PROCTOFOAM-HC 33 progesterone gel 30 progesterone vaginal inserts 30 progesterone micronized 30 PROLASTIN-C 39 PROLIA 27 PROMACTA 34 promethazine 31 PROMETRIUM 30 propafenone 15 propafenone ext-rel 15 propranolol 16 propranolol ext-rel 16 propylthiouracil 31 PROSCAR 33 PROVERA 30 PULMICORT FLEXHALER 39 PULMICORT RESPULES 39 PULMOZYME 38 pyrazinamide 11 pyridostigmine 23 pyridostigmine ext-rel 23

Q QUESTRANQUESTRAN LIGHT 15 quetiapine 21 quetiapine ext-rel 21 quinapril 14 quinaprilhydrochlorothiazide 14 QVAR REDIHALER 39

R ragweed pollen allergen extract 35 RAGWITEK 35 raloxifene 30 raltegravir 10 ramelteon 22 ramipril 14 ranibizumab 44 ranitidine 32 ranolazine ext-rel 18 rasagiline 20 RASUVO 35 RAZADYNE 19 RAZADYNE ER 19 REBIF 23 REBINYN 34 REGLAN 31 RELENZA 11 RELPAX 22 REMERON 20 repaglinide 26 REPATHA 16 REQUIP XL 21 RESTASIS 44 RESTORIL 22 RETACRIT 34 RETIN-A 40 RETROVIR 10 REVLIMID 13

56

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

RHOPRESSA 44 ribavirin 11 ribociclib 13 ribociclib + letrozole 13 RIFADIN 11 rifampin 11 rifaximin 550 mg 12 rilpivirine 10 RINVOQ 35 riociguat 18 risankizumab-rzaa 35 risedronate 27 risedronate delayed-rel 27 RISPERDAL 21 RISPERDAL CONSTA 21 risperidone 21 risperidone long-acting injection 21 RITALIN 21 ritonavir 11 rivaroxaban 34 rivastigmine 19 rivastigmine transdermal 19 rizatriptan 22 ROBAXIN 23 ROCALTROL 30 ROCKLATAN 44 roflumilast 39 rolapitant 31 ropinirole 20 ropinirole ext-rel 21 rosuvastatin 15 rotigotine transdermal 20 ROWASA 32 ROXICODONE 8 RUBRACA 13 rucaparib 13 RYDAPT 13 RYTHMOL SR 15

S sacubitrilvalsartan 17 SALAGEN 33 salmeterol xinafoate 38 SANCUSO 31 sapropterin 30 scopolamine transdermal 31 SEASONIQUE 28 secukinumab 35 selegiline 20 selenium sulfide lotion 25 40 selexipag 18 semaglutide 26 SENSIPAR 27 SEREVENT 38 SEROQUEL 21 sertraline 20 sevelamer carbonate 30 sildenafil 18 SILENOR 22 silodosin 33 SILVADENE 40 silver sulfadiazine 40 SIMBRINZA 44 simvastatin 16 SINEMET 20

SINEMET CR 20 siponimod 23 sirolimus 36 sitagliptin phosphate 25 sitagliptinmetformin 25 sitagliptinmetformin ext-rel 25 SKELAXIN 23 SKYLA 28 SKYRIZI 35 sodium sulfatepotassium sulfatemagnesium sulfate 32 sodium zirconium cyclosilicate 30 sofosbuvirvelpatasvir 11 sofosbuvirvelpatasvirvoxilaprevir 11 solifenacin 33 SOLIQUA 26 SOLIRIS 34 solriamfetol 23 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 13 SOOLANTRA 42 SORIATANE 40 sotalol 15 SPIRIVA 37 spironolactone 14 spironolactonehydrochlorothiazide 17 SPRYCEL 13 STALEVO 20 stavudine 10 STELARA SUBCUTANEOUS 35 STIOLTO RESPIMAT 37 STRATTERA 21 STRIBILD 10 STRIVERDI RESPIMAT 38 STROMECTOL 12 SUBSYS 8 sucralfate 33 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 40 sulfacetamide oint 10 43 sulfacetamide soln 10 43 sulfacetamideprednisolone phosphate 10025 43 sulfamethoxazoletrimethoprim 11 sulfamethoxazoletrimethoprim DS 11 sulfasalazine 32 sulfasalazine delayed-rel 32 sulindac 7 sumatriptan 22 sumatriptan inj 22 sumatriptan nasal powder 22 sumatriptan nasal spray 22 sunitinib 13 SUNOSI 23 SUPRAX 9 SUPREP 32 SUTENT 13 suvorexant 22 SYLATRON 36 SYMBICORT 39 SYMFI 10 SYMFI LO 10 SYMLINPEN 25 SYMPROIC 32 SYNJARDY 26

57

SYNJARDY XR 26 SYNTHROID 31

T TABLOID 12 tacrolimus 36 41 tadalafil 18 tamoxifen 12 tamsulosin 33 TAPAZOLE 31 tapentadol 8 tapentadol ext-rel 8 TARGRETIN 13 TARKA 14 tazarotene 40 TAZORAC 40 TECFIDERA 23 TEGRETOL 19 TEKTURNA HCT 17 telmisartan 15 telmisartanhydrochlorothiazide 15 temazepam 22 TEMIXYS 10 TEMODAR 12 TEMOVATE 41 temozolomide 12 tenofovir alafenamide 11 tenofovir disoproxil fumarate 10 terazosin 14 terbinafine tabs 9 terbutaline 38 terconazole 33 teriflunomide 23 teriparatide 27 TESSALON 37 testosterone cypionate 25 testosterone enanthate 25 testosterone gel 25 testosterone soln 25 testosterone transdermal 25 tetrabenazine 22 tetracycline 9 thalidomide 13 THALOMID 13 theophylline ext-rel tabs 39 thioguanine 12 thiothixene 21 tiagabine 19 TIAZAC 16 ticagrelor 35 TIGAN 31 TIKOSYN 15 timolol hemihydrate 43 timolol maleate 43 timolol maleate gel 43 TIMOPTIC 43 timothy grass pollen allergen extract 35 tinidazole 11 tiotropium 37 tiotropiumolodaterol 37 TIVICAY 10 tizanidine tabs 23 TOBRADEX 43 TOBRADEX ST 43 tobramycin 43

tobramycin inhalation soln 38 tobramycindexamethasone oint 0301 43 tobramycindexamethasone susp 03005 43 tobramycindexamethasone susp 0301 43 TOBREX 43 tofacitinib 35 tofacitinib ext-rel 35 TOFRANIL 20 TOLAK 40 tolterodine 33 tolterodine ext-rel 33 TOPAMAX 19 topiramate 19 topotecan caps 13 torsemide 17 TOVIAZ 33 tramadol 8 tramadol ext-rel 8 trandolapril 14 trandolaprilverapamil ext-rel 14 tranylcypromine 20 TRAVATAN Z 44 travoprost 44 trazodone 20 TRELEGY ELLIPTA 37 TREMFYA 35 treprostinil ext-rel 18 TRESIBA 26 tretinoin 40 tretinoin - Avita 40 tretinoin caps 13 tretinoin gel microsphere 40 TREXALL 12 triamcinolone acetonide crm 05 41 triamcinolone acetonide crm lotion 0025 41 triamcinolone acetonide crm lotion oint 01 41 triamcinolone paste 42 triamterene 17 triamterenehydrochlorothiazide 17 TRIBENZOR 15 trifluoperazine 21 trifluridine 43 trihexyphenidyl 20 TRILEPTAL 19 TRILIPIX 15 trimethobenzamide 31 trimethoprim 11 TRINTELLIX 20 TRIUMEQ 10 trospium 33 trospium ext-rel 33 TRULICITY 25 TRUSOPT 44 TRUVADA 10 TYKERB 13 TYMLOS 27 TYSABRI 23

U UDENYCA 34 ULORIC 7 ULTRAM 8 ULTRAVATE 41 umeclidinium bromide 37 umeclidiniumvilanterol 37

58

V

upadacitinib 35 UPTRAVI 18 URECHOLINE 33 UROCIT-K 33 URSO 31 ursodiol 31 ustekinumab 35

VAGIFEM 29 valacyclovir 11 valbenazine 23 valganciclovir 11 VALIUM 18 valproic acid 19 valsartan 14 valsartanhydrochlorothiazide 14 VANCOCIN 12 vancomycin caps 12 varenicline 25 VARUBI 31 VASCEPA 16 VASERETIC 14 VASOTEC 14 VELPHORO 30 VELTASSA 30 VEMLIDY 11 venlafaxine 20 venlafaxine ext-rel 20 verapamil ext-rel 16 VFEND 9 VIBERZI 32 VIBRAMYCIN 9 VICTOZA 25 VIDEX EC 10 vigabatrin 19 VIGAMOX 43 VIIBRYD 20 vilazodone 20 VIMPAT 19 VIOKACE 32 VIREAD 10 vitamin ADCfluoride drops 36 vitamin ADCfluorideiron drops 37 voriconazole 9 vorinostat 13 vortioxetine 20 VOSEVI 11 VOTRIENT 13 VRAYLAR 21 VYTORIN 16 VYVANSE 21

W warfarin 34

WELLBUTRIN SR 20 WELLBUTRIN XL 20

X XALATAN 44 XARELTO 34 XELJANZ 35 XELJANZ XR 35 XELODA 12 XIFAXAN 12 XIGDUO XR 26 XIIDRA 44 XOLAIR 39 XTAMPZA ER 8 XTANDI 12 XULTOPHY 26

Y YASMIN 28 YONSA 12

Z zafirlukast 38 ZANAFLEX 23 zanamivir 11 ZARONTIN 19 ZEJULA 13 ZEMBRACE SYMTOUCH 22 ZEMPLAR 30 ZENPEP 32 ZESTORETIC 14 ZESTRIL 14 ZIAC 16 ZIAGEN 10 zidovudine 10 zileuton ext-rel 38 ziprasidone 21 ZITHROMAX 9 ZOCOR 16 ZOFRAN 31 ZOLINZA 13 zolmitriptan 22 zolmitriptan nasal spray 22 ZOLOFT 20 zolpidem 22 zolpidem ext-rel 22 zolpidem sublingual 22 ZOMIG 22 zonisamide 19 ZOVIRAX 11 ZUBSOLV 23 ZYCLARA 40 ZYLOPRIM 7 ZYPREXA 21

59

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

NOTICE Our Company complies with applicable federal and state civil rights laws and does not discriminate exclude or treat people differently on the basis of race color national origin age disability or sex

We provide free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters written information in various formats (large print audio accessible electronic formats other formats) and language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact our Civil Rights Coordinator

If you believe that we have failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with

Civil Rights Coordinator601 Gaines Street Little Rock AR 72201Phone 1-844-662-2276 TDD 1-844-662-2275

You can file a grievance in person by mail or by email If you need help filing a grievance our Civil Rights Coordinator is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

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NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

NOTICE Our Company complies with applicable federal and state civil rights laws and does not discriminate exclude or treat people differently on the basis of race color national origin age disability or sex

We provide free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters written information in various formats (large print audio accessible electronic formats other formats) and language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact our Civil Rights Coordinator

If you believe that we have failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with

Civil Rights Coordinator601 Gaines Street Little Rock AR 72201Phone 1-844-662-2276 TDD 1-844-662-2275

You can file a grievance in person by mail or by email If you need help filing a grievance our Civil Rights Coordinator is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Avenue SW Room 509F HHH Building Washington DC 20201Phone 1-800-368-1019 TDD 1-800-537-7697

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

ATTENTION Language assistance services free of charge are available to you Call 1-844-662-2276

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-844-662-2276

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-844-662-2276

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धयान द यदि आप हिी बोलत ह तो आपक ललए मफत म भाषा सहायता सवाए उपलबध ह 1-844-662-2276 पर कॉल कर

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau 1-844-662-2276

انتباہ اگر آپ اردو بولتے ہیں تو آپ کے لئے زبان کی مدد کی خدمات بال معاوضہ دستیاب ہیں 2276-662-844-1 پر کال کریں

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-844-662-2276

LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-844-662-2276

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