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Formulary 07/01/2020

INTRODUCTION ...................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 4 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 LEGEND ................................................................................................................................................................................................................... 6 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7

NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8 VISCOSUPPLEMENTS ................................................................................................................................................................................. 8

ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10 ANTIVIRALS................................................................................................................................................................................................. 10 MISCELLANEOUS ....................................................................................................................................................................................... 11

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 11 ALKYLATING AGENTS ............................................................................................................................................................................... 11 ANTIMETABOLITES .................................................................................................................................................................................... 11 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 12 MISCELLANEOUS ....................................................................................................................................................................................... 12

CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS ........................................................................................................................................................................................ 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 13 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 13 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 13 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 14 ANTILIPEMICS............................................................................................................................................................................................. 14 BETA-BLOCKERS ....................................................................................................................................................................................... 15 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES .................................................................................................................................................................................................... 17 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17 MISCELLANEOUS ....................................................................................................................................................................................... 17

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 17 ANTIANXIETY .............................................................................................................................................................................................. 17 ANTICONVULSANTS .................................................................................................................................................................................. 18

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ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 18 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 19 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA .......................................................................................................................................................................................... 20 HYPNOTICS ................................................................................................................................................................................................. 20 MIGRAINE .................................................................................................................................................................................................... 21 MOOD STABILIZERS .................................................................................................................................................................................. 21 MOVEMENT DISORDERS .......................................................................................................................................................................... 21 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 21 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22 MYASTHENIA GRAVIS ............................................................................................................................................................................... 22 NARCOLEPSY ............................................................................................................................................................................................. 22 POSTHERPETIC NEURALGIA (PHN)......................................................................................................................................................... 22 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 22

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 22 ACROMEGALY ............................................................................................................................................................................................ 22 ANDROGENS .............................................................................................................................................................................................. 23 ANTIDIABETICS .......................................................................................................................................................................................... 23 ANTIOBESITY .............................................................................................................................................................................................. 24 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 24 CALCIUM REGULATORS ........................................................................................................................................................................... 25 CARNITINE DEFICIENCY AGENTS ........................................................................................................................................................... 25 CONTRACEPTIVES .................................................................................................................................................................................... 25 ENDOMETRIOSIS ....................................................................................................................................................................................... 26 ESTROGENS ............................................................................................................................................................................................... 26 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 26 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 27 FERTILITY REGULATORS .......................................................................................................................................................................... 27 GAUCHER DISEASE ................................................................................................................................................................................... 27 GLUCOCORTICOIDS .................................................................................................................................................................................. 27 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 27 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ....................................................................................................................................... 27 HUMAN GROWTH HORMONES ................................................................................................................................................................. 27 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 27 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 27 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 27 POTASSIUM-REMOVING AGENTS ............................................................................................................................................................ 28 PROGESTINS .............................................................................................................................................................................................. 28 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 28 THYROID AGENTS ..................................................................................................................................................................................... 28 VASOPRESSINS ......................................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28

GASTROINTESTINAL ........................................................................................................................................................................................... 28 ANTIDIARRHEALS ...................................................................................................................................................................................... 28 ANTIEMETICS ............................................................................................................................................................................................. 28 ANTISPASMODICS ..................................................................................................................................................................................... 29 CHOLELITHOLYTICS .................................................................................................................................................................................. 29 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 29 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 29 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 29 LAXATIVES .................................................................................................................................................................................................. 29 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 29 PANCREATIC ENZYMES ............................................................................................................................................................................ 29 PROSTAGLANDINS .................................................................................................................................................................................... 30 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 30 SALIVA STIMULANTS ................................................................................................................................................................................. 30 STEROIDS, RECTAL ................................................................................................................................................................................... 30 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 30 MISCELLANEOUS ....................................................................................................................................................................................... 30

GENITOURINARY .................................................................................................................................................................................................. 30 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 30 ERECTILE DYSFUNCTION ......................................................................................................................................................................... 30 URINARY ANTISPASMODICS .................................................................................................................................................................... 30

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VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31

HEMATOLOGIC ..................................................................................................................................................................................................... 31 ANTICOAGULANTS .................................................................................................................................................................................... 31 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 31 HEMOPHILIA A AGENTS ............................................................................................................................................................................ 31 HEMOPHILIA B AGENTS ............................................................................................................................................................................ 31 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 32 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 32 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 32 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 32 STEM CELL MOBILIZERS ........................................................................................................................................................................... 32 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 32 MISCELLANEOUS ....................................................................................................................................................................................... 32

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 32 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 32 AUTOIMMUNE AGENTS ‡ .......................................................................................................................................................................... 32 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 32 HEREDITARY ANGIOEDEMA ..................................................................................................................................................................... 32 IMMUNOMODULATORS ............................................................................................................................................................................. 33 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 33

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 33 ELECTROLYTES ......................................................................................................................................................................................... 33 VITAMINS AND MINERALS ........................................................................................................................................................................ 33

RESPIRATORY ...................................................................................................................................................................................................... 34 ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 34 ANTICHOLINERGICS .................................................................................................................................................................................. 34 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 34 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ........................................................................................ 34 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 34 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 34 ANTITUSSIVES............................................................................................................................................................................................ 34 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 34 BETA AGONISTS ........................................................................................................................................................................................ 35 CYSTIC FIBROSIS ...................................................................................................................................................................................... 35 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 35 MAST CELL STABILIZERS ......................................................................................................................................................................... 35 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 35 NASAL STEROIDS/COMBINATIONS ......................................................................................................................................................... 35 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 35 PULMONARY ENZYME DEFICIENCY AGENTS ........................................................................................................................................ 35 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 36 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 36 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 36 STEROID INHALANTS ................................................................................................................................................................................ 36 XANTHINES ................................................................................................................................................................................................. 36 MISCELLANEOUS ....................................................................................................................................................................................... 36

TOPICAL ................................................................................................................................................................................................................ 36 DERMATOLOGY ......................................................................................................................................................................................... 36 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 39 OPHTHALMIC .............................................................................................................................................................................................. 39 OTIC ............................................................................................................................................................................................................. 41

WEBSITES ............................................................................................................................................................................................................. 42 INDEX ..................................................................................................................................................................................................................... 44

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INTRODUCTION

We are pleased to provide the 2020 Formulary as a useful reference and informational tool. The Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The Formulary is reflective of current medical practice as of the date of review.

The information contained in the 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. The 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 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. Note: This list is a plan sponsored formulary and not a CVS Caremark® formulary.

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 manufacturer's product literature or standard references for more detailed information.

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

PREFACE

This 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 this 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 this 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 this 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 drugs, including those on this Formulary. Tier 2: Intermediate plan member copayment: Preferred brand-name products on this Formulary selected

for Tier 2. Tier 3: Highest plan member copayment: Brand-name products on this Formulary not selected for Tier 2,

and all non-preferred brand-name products. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this highest tier.

DRUG LIST PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are on this 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.

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Products on this 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 this Formulary. Other strengths/dosage forms of the reference product are not. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on this 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. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Formulary. Dosage forms on this Formulary will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY 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 Prescribing Guide.

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 U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and 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

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LEGEND

OTC Over the counter

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

NOTICE

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2020. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark.

When viewing this Formulary via the Internet, please be advised that this Formulary is updated periodically and changes may appear prior to their effective date to allow for client notification. The prescription benefit plan design may not cover certain products or categories regardless of their appearance in this document.

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ANALGESICS

Practice guidelines of pain management are available at: https://www.asahq.org NSAIDs

diclofenac sodium delayed-rel Tier 1 diflunisal Tier 1 etodolac Tier 1

ibuprofen Tier 1 meloxicam Tier 1

nabumetone Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1

oxaprozin Tier 1 sulindac Tier 1

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1

NSAIDs, TOPICAL * 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 1 GOUT

allopurinol Tier 1 colchicine Tier 1 probenecid Tier 1

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html buprenorphine transdermal Tier 1

codeine/acetaminophen Tier 1 fentanyl transdermal Tier 1 fentanyl transmucosal lozenge Tier 1

hydrocodone/acetaminophen Tier 1 hydromorphone Tier 1

hydromorphone ext-rel Tier 1 methadone Tier 1 morphine Tier 1

morphine ext-rel Tier 1 morphine supp Tier 1

oxycodone caps 5 mg Tier 1 oxycodone concentrate 20 mg/mL Tier 1

oxycodone soln 5 mg/5 mL Tier 1 oxycodone tabs 5 mg, 15 mg, 30 mg Tier 1 oxycodone/acetaminophen 5/325 Tier 1

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* tramadol Tier 1

tramadol ext-rel Tier 1 buprenorphine Tier 2 BELBUCA fentanyl sublingual spray Tier 2 SUBSYS

oxycodone ext-rel Tier 2 XTAMPZA ER tapentadol Tier 2 NUCYNTA

tapentadol ext-rel Tier 2 NUCYNTA ER * Listing does not include NDC 52817019610. 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. NON-OPIOID ANALGESICS butalbital/acetaminophen/caffeine tabs Tier 1

butalbital/aspirin/caffeine Tier 1 VISCOSUPPLEMENTS

sodium hyaluronate Tier 2 DUROLANE sodium hyaluronate Tier 2 GEL-ONE

sodium hyaluronate Tier 2 GELSYN-3 sodium hyaluronate Tier 2 SUPARTZ FX

sodium hyaluronate Tier 2 VISCO-3

ANTI-INFECTIVES

Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Cephalosporins First Generation cefadroxil Tier 1

cephalexin Tier 3 KEFLEX

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Second Generation cefprozil Tier 1

cefuroxime axetil Tier 1 Third Generation

cefdinir Tier 1 cefixime Tier 2 SUPRAX

Erythromycins/Macrolides clarithromycin Tier 1

clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1

erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 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 amoxicillin/clavulanate ext-rel Tier 1

ampicillin Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1

amoxicillin/clavulanate Tier 3 AUGMENTIN Tetracyclines

doxycycline hyclate 20 mg Tier 1 minocycline Tier 1

tetracycline Tier 1 doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS clotrimazole troches Tier 1

griseofulvin ultramicrosize Tier 1 itraconazole Tier 1 nystatin Tier 1

terbinafine tabs Tier 1 fluconazole Tier 3 DIFLUCAN

voriconazole Tier 3 VFEND ANTIMALARIALS

chloroquine Tier 1 mefloquine Tier 1

atovaquone/proguanil Tier 3 MALARONE ANTIRETROVIRAL AGENTS Antiretroviral Combinations

abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ atazanavir/cobicistat Tier 2 EVOTAZ

bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY darunavir/cobicistat Tier 2 PREZCOBIX darunavir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 SYMTUZA

efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 2 ATRIPLA

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efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI

efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI LO elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil

fumarate Tier 2 STRIBILD

emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA

emtricitabine/tenofovir alafenamide Tier 2 DESCOVY emtricitabine/tenofovir disoproxil fumarate Tier 2 TRUVADA

lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS

abacavir/lamivudine Tier 3 EPZICOM lamivudine/zidovudine Tier 3 COMBIVIR Fusion Inhibitors enfuvirtide Tier 3 FUZEON Integrase Inhibitors dolutegravir Tier 2 TIVICAY raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors

efavirenz Tier 1 nevirapine Tier 1 nevirapine ext-rel Tier 1

etravirine Tier 3 INTELENCE rilpivirine Tier 3 EDURANT

Nucleoside Reverse Transcriptase Inhibitors stavudine Tier 1

abacavir tabs Tier 3 ZIAGEN didanosine delayed-rel Tier 3 VIDEX EC emtricitabine Tier 3 EMTRIVA

lamivudine Tier 3 EPIVIR zidovudine Tier 3 RETROVIR

Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate Tier 3 VIREAD

Protease Inhibitors atazanavir Tier 1

darunavir Tier 2 PREZISTA ritonavir Tier 2 NORVIR

lopinavir/ritonavir soln Tier 3 KALETRA lopinavir/ritonavir tabs Tier 3 KALETRA ANTITUBERCULAR AGENTS isoniazid Tier 1

pyrazinamide Tier 1 ethambutol Tier 3 MYAMBUTOL rifampin Tier 3 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

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Hepatitis Agents Hepatitis B

entecavir tabs Tier 1 lamivudine Tier 1 tenofovir alafenamide Tier 2 VEMLIDY

entecavir soln Tier 3 BARACLUDE Hepatitis C ribavirin Tier 1 † ledipasvir/sofosbuvir Tier 2 HARVONI † sofosbuvir/velpatasvir Tier 2 EPCLUSA † sofosbuvir/velpatasvir/voxilaprevir Tier 2 VOSEVI

† HARVONI only for genotypes 1, 4, 5 and 6 EPCLUSA only for genotypes 1, 2, 3, 4, 5 and 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 oseltamivir Tier 1

zanamivir Tier 2 RELENZA MISCELLANEOUS

dapsone Tier 1 linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 nitrofurantoin susp Tier 1 sulfamethoxazole/trimethoprim Tier 1

sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1

trimethoprim Tier 1 mebendazole chewable Tier 2 EMVERM

rifaximin 550 mg Tier 2 XIFAXAN clindamycin Tier 3 CLEOCIN ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL nitrofurantoin ext-rel Tier 3 MACROBID

vancomycin caps Tier 3 VANCOCIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS cyclophosphamide caps Tier 1 busulfan Tier 3 MYLERAN

chlorambucil Tier 3 LEUKERAN melphalan Tier 3 ALKERAN

temozolomide Tier 3 TEMODAR ANTIMETABOLITES

mercaptopurine Tier 1

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capecitabine Tier 3 XELODA

methotrexate Tier 3 TREXALL thioguanine Tier 3 TABLOID HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens abiraterone Tier 1

flutamide Tier 1 abiraterone Tier 2 YONSA

apalutamide Tier 2 ERLEADA darolutamide Tier 2 NUBEQA enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX Antiestrogens

tamoxifen Tier 1 Aromatase Inhibitors

anastrozole Tier 3 ARIMIDEX exemestane Tier 3 AROMASIN

letrozole Tier 3 FEMARA Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

leuprolide acetate Tier 1 leuprolide acetate Tier 2 ELIGARD

leuprolide acetate Tier 2 LUPRON DEPOT Progestins

megestrol acetate tabs Tier 1 IMMUNOMODULATORS

lenalidomide Tier 3 REVLIMID pomalidomide Tier 3 POMALYST

thalidomide Tier 3 THALOMID KINASE INHIBITORS

erlotinib Tier 1 imatinib mesylate Tier 1 bosutinib Tier 2 BOSULIF

cabozantinib Tier 2 CABOMETYX dasatinib Tier 2 SPRYCEL

everolimus Tier 2 AFINITOR gefitinib Tier 2 IRESSA midostaurin Tier 2 RYDAPT

palbociclib Tier 2 IBRANCE ribociclib Tier 2 KISQALI

ribociclib + letrozole Tier 2 KISQALI FEMARA CO-PACK lapatinib Tier 3 TYKERB

pazopanib Tier 3 VOTRIENT sunitinib Tier 3 SUTENT TOPOISOMERASE INHIBITORS topotecan caps Tier 3 HYCAMTIN MISCELLANEOUS etoposide Tier 1 tretinoin caps Tier 1

niraparib Tier 2 ZEJULA

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olaparib Tier 2 LYNPARZA

rucaparib Tier 2 RUBRACA sonidegib Tier 2 ODOMZO uridine triacetate Tier 2 VISTOGARD

bexarotene caps Tier 3 TARGRETIN hydroxyurea Tier 3 HYDREA

mitotane Tier 3 LYSODREN procarbazine Tier 3 MATULANE vorinostat Tier 3 ZOLINZA

CARDIOVASCULAR

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org 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 INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/benazepril Tier 3 LOTREL trandolapril/verapamil ext-rel Tier 3 TARKA ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide Tier 1

fosinopril/hydrochlorothiazide Tier 1 benazepril/hydrochlorothiazide Tier 3 LOTENSIN HCT enalapril/hydrochlorothiazide Tier 3 VASERETIC

lisinopril/hydrochlorothiazide Tier 3 ZESTORETIC quinapril/hydrochlorothiazide Tier 3 ACCURETIC

ADRENOLYTICS, CENTRAL guanfacine Tier 1

clonidine Tier 3 CATAPRES clonidine transdermal Tier 3 CATAPRES-TTS ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 3 INSPRA

spironolactone Tier 3 ALDACTONE

14

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 terazosin Tier 1

doxazosin Tier 3 CARDURA ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 eprosartan Tier 1

irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1

olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 valsartan Tier 1

valsartan/hydrochlorothiazide Tier 1 losartan Tier 3 COZAAR

losartan/hydrochlorothiazide Tier 3 HYZAAR telmisartan Tier 3 MICARDIS

telmisartan/hydrochlorothiazide Tier 3 MICARDIS HCT ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1 amlodipine/olmesartan Tier 3 AZOR

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1

olmesartan/amlodipine/hydrochlorothiazide Tier 3 TRIBENZOR ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org

amiodarone Tier 1 flecainide Tier 1 propafenone Tier 1

sotalol Tier 1 dronedarone Tier 2 MULTAQ

disopyramide Tier 3 NORPACE disopyramide ext-rel Tier 3 NORPACE CR

dofetilide Tier 3 TIKOSYN propafenone ext-rel Tier 3 RYTHMOL SR ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins colesevelam Tier 1

cholestyramine Tier 3 QUESTRAN/QUESTRAN LIGHT

15

colestipol Tier 3 COLESTID

Cholesterol Absorption Inhibitors ezetimibe Tier 1

Fibrates * fenofibrate Tier 1

fenofibrate Tier 3 ANTARA 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 Inhibitors/Combinations atorvastatin Tier 1

fluvastatin Tier 1 lovastatin Tier 1

rosuvastatin Tier 1 ezetimibe/simvastatin Tier 3 VYTORIN

pravastatin Tier 3 PRAVACHOL simvastatin Tier 3 ZOCOR Niacins niacin ext-rel Tier 3 NIASPAN Omega-3 Fatty Acids icosapent ethyl Tier 2 VASCEPA omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors

alirocumab Tier 2 PRALUENT BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

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-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol/chlorthalidone Tier 1

bisoprolol/hydrochlorothiazide Tier 3 ZIAC

16

metoprolol/hydrochlorothiazide Tier 3 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 * Listing does not include generic CARDIZEM LA. CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES digoxin 0.125 mg, 0.25 mg Tier 1

digoxin ped elixir Tier 1 digoxin 0.0625 mg, 0.1875 mg Tier 3 LANOXIN DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 aliskiren/hydrochlorothiazide 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 amiloride/hydrochlorothiazide Tier 1

spironolactone/hydrochlorothiazide Tier 3 ALDACTAZIDE triamterene/hydrochlorothiazide Tier 3 DYAZIDE

triamterene/hydrochlorothiazide Tier 3 MAXZIDE HEART FAILURE

isosorbide dinitrate/hydralazine Tier 2 BIDIL ivabradine Tier 2 CORLANOR

17

sacubitril/valsartan Tier 2 ENTRESTO

NITRATES Oral isosorbide dinitrate Tier 1

isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1

Sublingual/Translingual nitroglycerin lingual spray Tier 3 NITROLINGUAL

nitroglycerin sublingual Tier 3 NITROSTAT Transdermal

nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 3 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

ambrisentan Tier 1 bosentan Tier 1 macitentan Tier 2 OPSUMIT

Phosphodiesterase Inhibitors tadalafil Tier 1

sildenafil Tier 3 REVATIO Prostacyclin Receptor Agonists

selexipag Tier 2 UPTRAVI Prostaglandin Vasodilators treprostinil ext-rel Tier 2 ORENITRAM epoprostenol sodium Tier 3 FLOLAN

Soluble Guanylate Cyclase Stimulators riociguat Tier 2 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: https://www.psychiatry.org ANTIANXIETY Benzodiazepines alprazolam Tier 1

oxazepam Tier 1 clonazepam Tier 3 KLONOPIN diazepam Tier 3 VALIUM

lorazepam Tier 3 ATIVAN Miscellaneous

buspirone Tier 1 fluvoxamine Tier 1

clomipramine Tier 3 ANAFRANIL

18

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com 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 topiramate ext-rel Tier 1 valproic acid Tier 1

vigabatrin Tier 1 zonisamide Tier 1

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

topiramate ext-rel Tier 2 TROKENDI XR 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 ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com memantine ext-rel Tier 1

rivastigmine Tier 1 memantine/donepezil 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: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 3 NARDIL tranylcypromine Tier 3 PARNATE

19

Selective Serotonin Reuptake Inhibitors (SSRIs) escitalopram Tier 1

* fluoxetine Tier 1 vilazodone Tier 2 VIIBRYD

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

* Listing does not include fluoxetine tablet 60 mg. 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 imipramine HCl Tier 1 desipramine Tier 3 NORPRAMIN

nortriptyline Tier 3 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 Parkinson's disease are available at: https://www.aan.com amantadine Tier 1

benztropine Tier 1 carbidopa/levodopa 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 carbidopa/levodopa Tier 3 SINEMET

carbidopa/levodopa ext-rel Tier 3 SINEMET CR carbidopa/levodopa/entacapone Tier 3 STALEVO

entacapone Tier 3 COMTAN pramipexole Tier 3 MIRAPEX 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

20

aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA

aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA INITIO cariprazine Tier 2 VRAYLAR lurasidone Tier 2 LATUDA

clozapine Tier 3 CLOZARIL olanzapine Tier 3 ZYPREXA

quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL risperidone long-acting injection Tier 3 RISPERDAL CONSTA

ziprasidone Tier 3 GEODON Miscellaneous chlorpromazine Tier 1 fluphenazine Tier 1

haloperidol Tier 1 perphenazine Tier 1

thiothixene Tier 1 trifluoperazine Tier 1 ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org amphetamine/dextroamphetamine mixed salts Tier 1 amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR

dextroamphetamine Tier 1 guanfacine ext-rel Tier 1

methylphenidate ext-rel Tier 1 methylphenidate ext-rel Tier 1 CONCERTA amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS

lisdexamfetamine Tier 2 VYVANSE atomoxetine Tier 3 STRATTERA

dexmethylphenidate Tier 3 FOCALIN dexmethylphenidate ext-rel Tier 3 FOCALIN XR

dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE methylphenidate Tier 3 METHYLIN methylphenidate Tier 3 RITALIN

FIBROMYALGIA pregabalin Tier 1

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org Benzodiazepines

temazepam Tier 3 RESTORIL Nonbenzodiazepines

eszopiclone Tier 1 ramelteon Tier 1

zolpidem sublingual Tier 1 suvorexant Tier 2 BELSOMRA zolpidem Tier 3 AMBIEN

zolpidem ext-rel Tier 3 AMBIEN CR

21

Tricyclics doxepin Tier 2 SILENOR

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Acute Migraine Agents Ergotamine Derivatives

dihydroergotamine inj Tier 3 D.H.E. 45 Newer Agents

lasmiditan Tier 2 REYVOW rimegepant Tier 2 NURTEC ODT

ubrogepant Tier 2 UBRELVY Triptans

naratriptan Tier 1 sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH sumatriptan nasal powder Tier 2 ONZETRA XSAIL

zolmitriptan nasal spray Tier 2 ZOMIG eletriptan Tier 3 RELPAX

rizatriptan Tier 3 MAXALT sumatriptan Tier 3 IMITREX

sumatriptan inj Tier 3 IMITREX sumatriptan nasal spray Tier 3 IMITREX zolmitriptan Tier 3 ZOMIG

Preventive Migraine Agents Monoclonal Antibodies

erenumab-aooe Tier 2 AIMOVIG fremanezumab-vfrm Tier 2 AJOVY galcanezumab-gnlm Tier 2 EMGALITY

MOOD STABILIZERS

lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 3 LITHOBID

MOVEMENT DISORDERS tetrabenazine Tier 1

deutetrabenazine Tier 2 AUSTEDO valbenazine Tier 2 INGREZZA

MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com dimethyl fumarate delayed-rel Tier 2 TECFIDERA diroximel fumarate delayed-rel Tier 2 VUMERITY

fingolimod Tier 2 GILENYA glatiramer Tier 2 COPAXONE

interferon beta-1a Tier 2 REBIF interferon beta-1b Tier 2 BETASERON natalizumab Tier 2 TYSABRI

siponimod Tier 2 MAYZENT teriflunomide Tier 2 AUBAGIO

22

MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1

carisoprodol Tier 1 chlorzoxazone 500 mg Tier 1

* cyclobenzaprine Tier 1 dantrolene Tier 3 DANTRIUM metaxalone Tier 3 SKELAXIN

methocarbamol Tier 3 ROBAXIN tizanidine tabs Tier 3 ZANAFLEX

* Listing does not include cyclobenzaprine tablet 7.5 mg. MYASTHENIA GRAVIS

pyridostigmine Tier 1 pyridostigmine ext-rel Tier 1

NARCOLEPSY armodafinil Tier 1

solriamfetol Tier 2 SUNOSI POSTHERPETIC NEURALGIA (PHN)

gabapentin ext-rel Tier 2 GRALISE PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 3 ANTABUSE

Opioid Antagonists

naloxone inj Tier 1 naltrexone Tier 1 naloxone nasal spray Tier 2 NARCAN

Partial Opioid Agonist/Opioid Antagonist Combinations buprenorphine/naloxone sublingual Tier 1

buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV Pseudobulbar Affect Agents dextromethorphan/quinidine Tier 2 NUEDEXTA Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

bupropion ext-rel Tier 1 varenicline Tier 3 CHANTIX

Vasomotor Symptom Agents paroxetine mesylate Tier 1

ENDOCRINE AND METABOLIC

ACROMEGALY

lanreotide acetate Tier 2 SOMATULINE DEPOT pegvisomant Tier 2 SOMAVERT

23

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com testosterone cypionate Tier 1

testosterone enanthate Tier 1 * testosterone gel Tier 1 testosterone soln Tier 1

testosterone transdermal Tier 2 ANDRODERM * Listing does not include the authorized generics for TESTIM and VOGELXO. ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 3 PRECOSE

Amylin Analogs pramlintide Tier 2 SYMLINPEN

Biguanides metformin Tier 3 GLUCOPHAGE

metformin ext-rel Tier 3 GLUCOPHAGE XR Biguanide/Sulfonylurea Combinations

glipizide/metformin Tier 1 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors sitagliptin phosphate Tier 2 JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations sitagliptin/metformin Tier 2 JANUMET sitagliptin/metformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents

dulaglutide Tier 2 TRULICITY liraglutide Tier 2 VICTOZA semaglutide Tier 2 OZEMPIC

semaglutide Tier 2 RYBELSUS Incretin Mimetic Agent/Insulin Combinations

liraglutide/insulin degludec Tier 2 XULTOPHY lixisenatide/insulin glargine Tier 2 SOLIQUA

Insulins insulin aspart Tier 2 FIASP

insulin aspart Tier 2 NOVOLOG insulin aspart protamine 70%/insulin aspart 30% Tier 2 NOVOLOG MIX 70/30

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 70%/regular 30% Tier 2 NOVOLIN 70/30

24

Insulin Sensitizers pioglitazone Tier 1

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 3 ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations

pioglitazone/glimepiride Tier 3 DUETACT Meglitinides

nateglinide Tier 1 repaglinide Tier 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors dapagliflozin Tier 2 FARXIGA empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations

dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR empagliflozin/metformin Tier 2 SYNJARDY empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations empagliflozin/linagliptin Tier 2 GLYXAMBI

Sulfonylureas glimepiride Tier 3 AMARYL

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

Supplies blood glucose continuous monitoring receivers, sensors,

transmitters Tier 2 DEXCOM CONTINUOUS

GLUCOSE MONITORING SYSTEM blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK AVIVA PLUS kits and

test strips

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

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

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

insulin infusion disposable pump Tier 2 OMNIPOD INSULIN INFUSION PUMP

insulin infusion disposable pump Tier 2 V-GO INSULIN INFUSION PUMP

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

ANTIOBESITY Guidelines of treatment and management of obesity are available at: https://www.aace.com https://www.nhlbi.nih.gov/health-topics/managing-overweight-obesity-in-adults liraglutide Tier 2 SAXENDA CALCIUM RECEPTOR ANTAGONISTS cinacalcet Tier 1

25

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org 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 abaloparatide Tier 2 TYMLOS teriparatide Tier 2 FORTEO

Miscellaneous denosumab Tier 2 PROLIA

CARNITINE DEFICIENCY AGENTS

levocarnitine Tier 1 CONTRACEPTIVES EE = ethinyl estradiol Monophasic 20 mcg Estrogen

drospirenone/EE 3/20 Tier 1 drospirenone/EE/levomefolate 3/20 and levomefolate Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1

norethindrone acetate/EE 1/20 and iron chewable Tier 1 norethindrone acetate/EE 1/20 Tier 3 LOESTRIN 1/20

norethindrone acetate/EE 1/20 and iron Tier 3 LOESTRIN FE 1/20 30 mcg Estrogen

desogestrel/EE 0.15/30 Tier 1 drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1

norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 drospirenone/EE 3/30 Tier 3 YASMIN

norethindrone acetate/EE 1.5/30 Tier 3 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron Tier 3 LOESTRIN FE 1.5/30

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1

norethindrone/EE 0.5/35 Tier 1 norethindrone/EE 1/35 Tier 1 norgestimate/EE 0.25/35 Tier 1

norethindrone/EE 1/35 Tier 3 ORTHO-NOVUM 1/35 Biphasic

norethindrone acetate/EE 1/10 and EE 10 and iron Tier 2 LO LOESTRIN FE desogestrel/EE Tier 3 MIRCETTE

Triphasic desogestrel/EE Tier 1

26

levonorgestrel/EE - Trivora Tier 1

norgestimate/EE Tier 1 norethindrone/EE Tier 3 ORTHO-NOVUM 7/7/7 Extended Cycle levonorgestrel/EE 0.15/30 Tier 1 levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE

levonorgestrel/EE 0.15/30 and EE 10 Tier 3 SEASONIQUE Progestin Only norethindrone Tier 1 norethindrone Tier 3 ORTHO MICRONOR

Injectable medroxyprogesterone acetate 150 mg/mL Tier 3 DEPO-PROVERA

Progestin Intrauterine Devices levonorgestrel releasing IUD Tier 2 KYLEENA

levonorgestrel releasing IUD Tier 2 MIRENA levonorgestrel releasing IUD Tier 2 SKYLA

Transdermal norelgestromin/EE Tier 1

Vaginal etonogestrel/EE ring Tier 1

ENDOMETRIOSIS danazol Tier 1

elagolix Tier 2 ORILISSA ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf 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

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate - Jinteli Tier 1

estradiol/norethindrone Tier 1 estrogens, conjugated/medroxyprogesterone Tier 2 PREMPHASE

estrogens, conjugated/medroxyprogesterone Tier 2 PREMPRO

27

Transdermal

estradiol/levonorgestrel Tier 2 CLIMARA PRO estradiol/norethindrone acetate Tier 2 COMBIPATCH ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene Tier 2 DUAVEE

FERTILITY REGULATORS GNRH/LHRH Antagonists ganirelix acetate Tier 1

cetrorelix Tier 2 CETROTIDE Ovulation Stimulants, Gonadotropins

choriogonadotropin alfa Tier 2 OVIDREL follitropin alfa Tier 2 GONAL-F

Ovulation Stimulants, Synthetic clomiphene Tier 1

GAUCHER DISEASE eliglustat Tier 2 CERDELGA

imiglucerase Tier 2 CEREZYME GLUCOCORTICOIDS dexamethasone Tier 1 fludrocortisone Tier 1

prednisolone Tier 1 prednisone Tier 1

hydrocortisone Tier 3 CORTEF methylprednisolone Tier 3 MEDROL GLUCOSE ELEVATING AGENTS glucagon nasal powder Tier 2 BAQSIMI glucagon, human recombinant Tier 2 GLUCAGEN HYPOKIT

glucagon, human recombinant Tier 2 GLUCAGON EMERGENCY KIT HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 2 ORFADIN HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines

somatropin Tier 2 GENOTROPIN somatropin Tier 2 HUMATROPE

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 3 ROCALTROL

doxercalciferol Tier 3 HECTOROL paricalcitol Tier 3 ZEMPLAR PHENYLKETONURIA TREATMENT AGENTS sapropterin Tier 3 KUVAN PHOSPHATE BINDER AGENTS calcium acetate Tier 1

sevelamer carbonate Tier 1

28

calcium acetate Tier 2 PHOSLYRA

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

progesterone gel Tier 2 CRINONE progesterone vaginal inserts Tier 2 ENDOMETRIN SELECTIVE ESTROGEN RECEPTOR MODULATORS ospemifene Tier 2 OSPHENA

raloxifene Tier 3 EVISTA THYROID AGENTS Antithyroid Agents

propylthiouracil Tier 1 methimazole Tier 3 TAPAZOLE

Thyroid Supplements levothyroxine Tier 1

levothyroxine - Levoxyl Tier 1 levothyroxine Tier 2 SYNTHROID

liothyronine Tier 3 CYTOMEL VASOPRESSINS

desmopressin spray, tabs Tier 3 DDAVP MISCELLANEOUS

cabergoline Tier 1

GASTROINTESTINAL

Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS loperamide Tier 1 diphenoxylate/atropine Tier 3 LOMOTIL

ANTIEMETICS

doxylamine/pyridoxine delayed-rel Tier 1 granisetron Tier 1 meclizine Tier 1

prochlorperazine Tier 1 promethazine Tier 1

scopolamine transdermal Tier 1 granisetron transdermal Tier 2 SANCUSO rolapitant Tier 2 VARUBI

dronabinol Tier 3 MARINOL

29

metoclopramide Tier 3 REGLAN

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 3 BENTYL hyoscyamine sulfate Tier 3 LEVSIN

hyoscyamine sulfate ext-rel Tier 3 LEVBID CHOLELITHOLYTICS

ursodiol Tier 3 ACTIGALL ursodiol Tier 3 URSO

H2 RECEPTOR ANTAGONISTS cimetidine 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 1 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 sulfate/potassium sulfate/magnesium sulfate Tier 2 SUPREP

peg 3350/electrolytes Tier 3 GOLYTELY peg 3350/electrolytes Tier 3 NULYTELY OPIOID-INDUCED CONSTIPATION naldemedine Tier 2 SYMPROIC naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES

pancrelipase Tier 2 VIOKACE

30

pancrelipase delayed-rel Tier 2 CREON

pancrelipase delayed-rel Tier 2 ZENPEP PROSTAGLANDINS

misoprostol Tier 3 CYTOTEC PROTON PUMP INHIBITORS

esomeprazole delayed-rel Tier 1 lansoprazole delayed-rel Tier 1

pantoprazole delayed-rel Tier 1 dexlansoprazole delayed-rel Tier 2 DEXILANT omeprazole delayed-rel Tier 3 PRILOSEC

SALIVA STIMULANTS cevimeline Tier 3 EVOXAC

pilocarpine tabs Tier 3 SALAGEN STEROIDS, RECTAL

hydrocortisone acetate/pramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 3 ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

bismuth/metronidazole/tetracycline Tier 2 PYLERA MISCELLANEOUS

sucralfate Tier 1

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel Tier 1 dutasteride/tamsulosin Tier 1

silodosin Tier 1 dutasteride Tier 3 AVODART

finasteride Tier 3 PROSCAR tamsulosin Tier 3 FLOMAX ERECTILE DYSFUNCTION Guidelines for the management of erectile dysfunction are available at: https://www.auanet.org/guidelines Alprostadil Agents alprostadil supp Tier 2 MUSE Phosphodiesterase Inhibitors sildenafil Tier 1

tadalafil Tier 1 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

31

fesoterodine ext-rel Tier 2 TOVIAZ

mirabegron ext-rel Tier 2 MYRBETRIQ oxybutynin ext-rel Tier 3 DITROPAN XL tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES metronidazole Tier 1

terconazole Tier 1 clindamycin crm Tier 3 CLEOCIN

MISCELLANEOUS bethanechol Tier 3 URECHOLINE

potassium citrate ext-rel Tier 3 UROCIT-K

HEMATOLOGIC

Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable

enoxaparin Tier 1 dalteparin Tier 3 FRAGMIN

Oral warfarin Tier 1

apixaban Tier 2 ELIQUIS rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents fondaparinux Tier 3 ARIXTRA

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines

darbepoetin alfa Tier 2 ARANESP epoetin alfa-epbx Tier 2 RETACRIT

filgrastim-aafi Tier 2 NIVESTYM pegfilgrastim Tier 2 NEULASTA pegfilgrastim-cbqv Tier 2 UDENYCA

HEMOPHILIA A AGENTS antihemophilic factor (recombinant) Tier 2 KOGENATE FS

antihemophilic factor (recombinant) Tier 2 KOVALTRY antihemophilic factor (recombinant) Tier 2 NOVOEIGHT

antihemophilic factor (recombinant) pegylated Tier 2 ADYNOVATE antihemophilic factor (recombinant) pegylated-aucl Tier 2 JIVI

human coagulation factor VIII (rDNA) simoctocog alfa Tier 2 NUWIQ HEMOPHILIA B AGENTS

coagulation factor IX (recombinant) glycopegylated Tier 2 REBINYN

32

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS eltrombopag Tier 3 PROMACTA

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS eculizumab Tier 3 SOLIRIS

PLATELET AGGREGATION INHIBITORS

clopidogrel Tier 1 dipyridamole Tier 1 prasugrel Tier 1

ticagrelor Tier 2 BRILINTA dipyridamole ext-rel/aspirin Tier 3 AGGRENOX

PLATELET SYNTHESIS INHIBITORS anagrelide Tier 3 AGRYLIN

STEM CELL MOBILIZERS plerixafor Tier 3 MOZOBIL

THROMBOCYTOPENIA AGENTS lusutrombopag Tier 2 MULPLETA

MISCELLANEOUS cilostazol Tier 1

IMMUNOLOGIC AGENTS

Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org ALLERGENIC EXTRACTS

grass mixed pollen allergen extract Tier 2 ORALAIR ragweed pollen allergen extract Tier 2 RAGWITEK timothy grass pollen allergen extract Tier 2 GRASTEK

AUTOIMMUNE AGENTS ‡ adalimumab Tier 2 HUMIRA

apremilast Tier 2 OTEZLA etanercept Tier 2 ENBREL

guselkumab Tier 2 TREMFYA risankizumab-rzaa Tier 2 SKYRIZI

secukinumab Tier 2 COSENTYX tofacitinib Tier 2 XELJANZ tofacitinib ext-rel Tier 2 XELJANZ XR

upadacitinib Tier 2 RINVOQ ustekinumab Tier 2 STELARA SUBCUTANEOUS

‡ Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis) DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

methotrexate Tier 1 methotrexate auto-injector Tier 2 RASUVO

hydroxychloroquine Tier 3 PLAQUENIL leflunomide Tier 3 ARAVA HEREDITARY ANGIOEDEMA C1 esterase inhibitor, recombinant Tier 2 RUCONEST icatibant Tier 2 FIRAZYR

lanadelumab-flyo Tier 2 TAKHZYRO

33

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons interferon alfa-2b Tier 3 INTRON A

peginterferon alfa-2a Tier 3 PEGASYS peginterferon alfa-2b Tier 3 SYLATRON

Miscellaneous canakinumab Tier 3 ILARIS

IMMUNOSUPPRESSANTS Antimetabolites

mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 3 AZASAN

azathioprine Tier 3 IMURAN Calcineurin Inhibitors

cyclosporine Tier 1 cyclosporine, modified Tier 1

tacrolimus Tier 1 Rapamycin Derivatives

sirolimus Tier 1

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES Potassium potassium chloride ext-rel Tier 1

potassium chloride liquid Tier 1 VITAMINS AND MINERALS Folic Acid/Combinations folic acid Tier 1

folic acid/vitamin B6/vitamin B12 Tier 1 Prenatal Vitamins

prenatal vitamins Tier 1 prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL 90 DHA prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL DHA

prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL HARMONY prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX

prenatal vitamins/docusate/folic acid + DHA Tier 2 CITRANATAL ASSURE prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM Miscellaneous cyanocobalamin inj Tier 1

ergocalciferol (D2) Tier 1 fluoride drops Tier 1 fluoride tabs Tier 1

multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1

34

vitamin ADC/fluoride drops Tier 1

vitamin ADC/fluoride/iron drops Tier 1

RESPIRATORY

Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector Tier 1

epinephrine Tier 2 SYMJEPI epinephrine auto-injector Tier 2 EPIPEN epinephrine auto-injector Tier 2 EPIPEN JR.

ANTICHOLINERGICS ipratropium soln Tier 1

revefenacin inhalation solution Tier 2 YUPELRI tiotropium Tier 2 SPIRIVA

umeclidinium bromide Tier 2 INCRUSE ELLIPTA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 Long Acting glycopyrrolate/formoterol Tier 2 BEVESPI AEROSPHERE

tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT umeclidinium/vilanterol Tier 2 ANORO ELLIPTA ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA ANTIHISTAMINES, LOW SEDATING levocetirizine Tier 1 ANTIHISTAMINES, SEDATING clemastine 2.68 mg Tier 1

cyproheptadine Tier 1 hydroxyzine HCl Tier 1 ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf

* benzonatate Tier 3 TESSALON * Listing does not include NDCs 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. ANTITUSSIVE COMBINATIONS Opioid codeine/guaifenesin liquid Tier 1

35

codeine/guaifenesin/pseudoephedrine Tier 1

codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/homatropine Tier 1

Non-opioid dextromethorphan/brompheniramine/pseudoephedrine Tier 1

dextromethorphan/promethazine Tier 1 BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1

albuterol sulfate, CFC-free aerosol Tier 1 levalbuterol tartrate, CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation

olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT salmeterol xinafoate Tier 2 SEREVENT Nebulized Passive Inhalation formoterol inhalation soln Tier 2 PERFOROMIST Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1

terbutaline Tier 1 CYSTIC FIBROSIS tobramycin inhalation soln Tier 1 tobramycin inhalation soln Tier 2 BETHKIS

dornase alfa Tier 3 PULMOZYME LEUKOTRIENE MODULATORS

montelukast Tier 1 zafirlukast Tier 1

zileuton ext-rel Tier 1 MAST CELL STABILIZERS

cromolyn soln Tier 1 NASAL ANTIHISTAMINES

azelastine spray Tier 1 azelastine spray Tier 3 ASTEPRO

olopatadine spray Tier 3 PATANASE NASAL STEROIDS/COMBINATIONS

flunisolide spray Tier 1 fluticasone spray Tier 1

mometasone spray Tier 1 azelastine/fluticasone spray Tier 2 DYMISTA PHOSPHODIESTERASE-4 INHIBITORS roflumilast Tier 2 DALIRESP PULMONARY ENZYME DEFICIENCY AGENTS alpha-1 proteinase inhibitor Tier 2 PROLASTIN-C

36

PULMONARY FIBROSIS AGENTS

nintedanib Tier 2 OFEV pirfenidone Tier 2 ESBRIET SEVERE ASTHMA AGENTS benralizumab Tier 2 FASENRA

dupilumab Tier 2 DUPIXENT mepolizumab Tier 2 NUCALA omalizumab Tier 2 XOLAIR

STEROID/BETA AGONIST COMBINATIONS fluticasone/salmeterol Tier 1 ADVAIR DISKUS

budesonide/formoterol Tier 2 SYMBICORT fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA

fluticasone/vilanterol Tier 2 BREO ELLIPTA STEROID INHALANTS

beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER budesonide Tier 2 PULMICORT FLEXHALER

fluticasone Tier 2 ARNUITY ELLIPTA fluticasone Tier 2 FLOVENT DISKUS fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA

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: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral

isotretinoin Tier 1 Topical

adapalene Tier 1 * clindamycin gel Tier 1 clindamycin/benzoyl peroxide Tier 1

erythromycin gel 2% Tier 1 erythromycin soln Tier 1

tretinoin Tier 1 tretinoin - Avita Tier 1 tretinoin gel microsphere Tier 1

adapalene/benzoyl peroxide Tier 2 EPIDUO adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE

clindamycin/benzoyl peroxide Tier 2 ONEXTON tazarotene Tier 2 TAZORAC

benzoyl peroxide Tier 3 BENZAC AC clindamycin gel, lotion, soln Tier 3 CLEOCIN T erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN

37

sulfacetamide lotion 10% Tier 3 KLARON

tretinoin Tier 3 RETIN-A * Listing does not include NDC 68682046275. 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. 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

gentamicin Tier 1 mupirocin oint Tier 1 silver sulfadiazine Tier 3 SILVADENE

Antifungals

clotrimazole Tier 1 econazole Tier 1 ketoconazole crm 2% Tier 1

luliconazole Tier 1 nystatin Tier 1

naftifine Tier 2 NAFTIN ciclopirox Tier 3 LOPROX Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Oral acitretin Tier 3 SORIATANE methoxsalen oral Tier 3 OXSORALEN-ULTRA

Topical

calcipotriene oint, soln 0.005% Tier 1 Antiseborrheics

selenium sulfide lotion 2.5% Tier 1 ketoconazole shampoo 2% Tier 3 NIZORAL Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Injectable dupilumab Tier 2 DUPIXENT Topical pimecrolimus Tier 1

tacrolimus Tier 1 crisaborole Tier 2 EUCRISA Corticosteroids Low Potency alclometasone crm, oint 0.05% Tier 1

fluocinolone acetonide soln 0.01% Tier 1 hydrocortisone crm 2.5% Tier 1

38

hydrocortisone lotion 1% Tier 1

desonide crm, lotion, oint 0.05% Tier 3 DESOWEN Medium Potency

betamethasone valerate crm, lotion, oint 0.1% Tier 1 desoximetasone crm, oint 0.05% Tier 1 fluocinolone acetonide crm, oint 0.025% Tier 1

fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1 hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1

hydrocortisone valerate crm, oint 0.2% Tier 1 triamcinolone acetonide crm, lotion 0.025% Tier 1

triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 mometasone crm, lotion, oint 0.1% Tier 3 ELOCON High Potency betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 desoximetasone crm, oint 0.25%, gel 0.05% Tier 1

fluocinonide crm, gel, oint, soln 0.05% Tier 1 triamcinolone acetonide crm 0.5% Tier 1

halobetasol propionate lotion 0.01% Tier 2 BRYHALI betamethasone dipropionate augmented crm 0.05% Tier 3 DIPROLENE AF betamethasone dipropionate augmented lotion 0.05% Tier 3 DIPROLENE

Very High Potency

clobetasol propionate foam 0.05% Tier 1 betamethasone dipropionate augmented gel, oint 0.05% Tier 3 DIPROLENE clobetasol propionate crm, gel, oint, soln 0.05% Tier 3 TEMOVATE

clobetasol propionate lotion, shampoo 0.05% Tier 3 CLOBEX halobetasol propionate crm, oint 0.05% Tier 3 ULTRAVATE

Emollients ammonium lactate 12% Tier 3 LAC-HYDRIN

Local Analgesics lidocaine patch Tier 3 LIDODERM

Local Anesthetics lidocaine/prilocaine Tier 1

Rosacea azelaic acid gel Tier 1

doxycycline monohydrate delayed-rel caps Tier 1 metronidazole gel 0.75% Tier 1

azelaic acid foam Tier 2 FINACEA FOAM ivermectin Tier 2 SOOLANTRA metronidazole crm 0.75% Tier 3 METROCREAM

metronidazole gel 1% Tier 3 METROGEL metronidazole lotion 0.75% Tier 3 METROLOTION

Scabicides and Pediculicides permethrin 5% Tier 1

malathion Tier 3 OVIDE Miscellaneous Skin and Mucous Membrane

imiquimod Tier 1 podofilox Tier 3 CONDYLOX

39

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral

lidocaine viscous Tier 1 Protectants - Mouth/Throat

benzyl alcohol/carbomer 941/glycerin Tier 2 MUGARD soy phospholipid/glycerol dioleate Tier 2 EPISIL

Steroids - Mouth/Throat triamcinolone paste Tier 1

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics azelastine Tier 1

cromolyn sodium Tier 1 olopatadine Tier 1 alcaftadine Tier 2 LASTACAFT

olopatadine Tier 2 PAZEO Anti-infectives bacitracin Tier 1 erythromycin Tier 1

gentamicin Tier 1 levofloxacin Tier 1

neomycin/polymyxin B/gramicidin Tier 1 polymyxin B/bacitracin Tier 1 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 B/trimethoprim Tier 3 POLYTRIM

sulfacetamide soln 10% Tier 3 BLEPH-10 tobramycin Tier 3 TOBREX Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint Tier 1

neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone oint 0.3%/0.1% Tier 2 TOBRADEX

tobramycin/dexamethasone susp 0.3%/0.05% Tier 2 TOBRADEX ST neomycin/polymyxin B/dexamethasone Tier 3 MAXITROL

tobramycin/dexamethasone susp 0.3%/0.1% 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 ketorolac Tier 3 ACULAR

40

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 S.O.P.

prednisolone acetate Tier 2 PRED MILD prednisolone phosphate 1% Tier 3

Antivirals trifluridine Tier 1

Beta-blockers Nonselective levobunolol Tier 1

timolol maleate gel Tier 1 timolol hemihydrate Tier 2 BETIMOL

timolol maleate Tier 3 TIMOPTIC Selective

betaxolol Tier 2 BETOPTIC S Carbonic Anhydrase Inhibitors Topical brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations

dorzolamide/timolol maleate Tier 3 COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations

brinzolamide/brimonidine Tier 2 SIMBRINZA Dry Eye Disease

cyclosporine, emulsion Tier 2 RESTASIS lifitegrast Tier 2 XIIDRA Prostaglandins bimatoprost 0.01% Tier 2 LUMIGAN

travoprost Tier 2 TRAVATAN Z latanoprost Tier 3 XALATAN Retinal Disorders aflibercept Tier 2 EYLEA ranibizumab Tier 2 LUCENTIS

Rho Kinase Inhibitors

netarsudil Tier 2 RHOPRESSA Rho Kinase Inhibitor/Prostaglandin Combinations

netarsudil/latanoprost Tier 2 ROCKLATAN Sympathomimetics

brimonidine 0.2% Tier 1 brimonidine Tier 2 ALPHAGAN P

41

Sympathomimetic/Beta-blocker Combinations

brimonidine/timolol Tier 2 COMBIGAN OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives

acetic acid Tier 1 ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/hydrocortisone Tier 1

ciprofloxacin/dexamethasone Tier 2 CIPRODEX

42

WEBSITES

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

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

43

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

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

44

INDEX

A abacavir tabs, 10 abacavir/dolutegravir/lamivudine, 9 abacavir/lamivudine, 10 abaloparatide, 25 ABILIFY MAINTENA, 19 abiraterone, 12 acamprosate calcium, 22 acarbose, 23 ACCU-CHEK AVIVA PLUS kits and test strips, 24 ACCU-CHEK COMPACT PLUS kits and test strips, 24 ACCU-CHEK GUIDE kits and test strips, 24 ACCU-CHEK SMARTVIEW kits and test strips, 24 ACCUPRIL, 13 ACCURETIC, 13 acetazolamide, 16 acetazolamide ext-rel, 16 acetic acid, 41 acitretin, 37 ACTIGALL, 29 ACTONEL, 25 ACTOPLUS MET, 24 ACULAR, 39 ACUVAIL, 39 acyclovir caps, tabs, 11 ADALAT CC, 16 adalimumab, 32 adapalene, 36 adapalene/benzoyl peroxide, 36 ADDERALL XR, 20 ADEMPAS, 17 ADVAIR DISKUS, 36 ADVAIR HFA, 36 ADYNOVATE, 31 AFINITOR, 12 aflibercept, 40 AGGRENOX, 32 AGRYLIN, 32 AIMOVIG, 21 AJOVY, 21 albuterol, 35 albuterol ext-rel, 35 albuterol soln, 35 albuterol sulfate, CFC-free aerosol, 35 alcaftadine, 39 alclometasone crm, oint 0.05%, 37 ALDACTAZIDE, 16 ALDACTONE, 13 alendronate, 25 alfuzosin ext-rel, 30 alirocumab, 15 aliskiren, 16 aliskiren/hydrochlorothiazide, 16 ALKERAN, 11 allopurinol, 7 alosetron, 29 alpha-1 proteinase inhibitor, 35 ALPHAGAN P, 40 alprazolam, 17 alprostadil supp, 30 ALTACE, 13 amantadine, 19

AMARYL, 24 AMBIEN, 20 AMBIEN CR, 20 ambrisentan, 17 amiloride, 16 amiloride/hydrochlorothiazide, 16 amiodarone, 14 AMITIZA, 29 amitriptyline, 19 amlodipine, 16 amlodipine/atorvastatin, 16 amlodipine/benazepril, 13 amlodipine/olmesartan, 14 amlodipine/telmisartan, 14 amlodipine/valsartan, 14 amlodipine/valsartan/hydrochlorothiazide, 14 ammonium lactate 12%, 38 amoxicillin, 9 amoxicillin/clavulanate, 9 amoxicillin/clavulanate ext-rel, 9 amphetamine/dextroamphetamine mixed salts, 20 amphetamine/dextroamphetamine mixed salts ext-rel, 20 ampicillin, 9 ANAFRANIL, 17 anagrelide, 32 anastrozole, 12 ANDRODERM, 23 ANORO ELLIPTA, 34 ANTABUSE, 22 ANTARA, 15 antihemophilic factor (recombinant), 31 antihemophilic factor (recombinant) pegylated, 31 antihemophilic factor (recombinant) pegylated-aucl, 31 ANUSOL-HC, 30 apalutamide, 12 apixaban, 31 apremilast, 32 ARANESP, 31 ARAVA, 32 ARICEPT, 18 ARIMIDEX, 12 aripiprazole, 19 aripiprazole ext-rel inj, 19 aripiprazole lauroxil ext-rel inj, 20 ARISTADA, 20 ARISTADA INITIO, 20 ARIXTRA, 31 armodafinil, 22 ARNUITY ELLIPTA, 36 AROMASIN, 12 ASTEPRO, 35 atazanavir, 10 atazanavir/cobicistat, 9 ATELVIA, 25 atenolol, 15 atenolol/chlorthalidone, 15 ATIVAN, 17 atomoxetine, 20 atorvastatin, 15 atovaquone/proguanil, 9 ATRIPLA, 9 AUBAGIO, 21 AUGMENTIN, 9

45

AUSTEDO, 21 AVELOX, 9 AVODART, 30 AYGESTIN, 28 AZASAN, 33 azathioprine, 33 azelaic acid foam, 38 azelaic acid gel, 38 azelastine, 39 azelastine spray, 35 azelastine/fluticasone spray, 35 azithromycin, 9 AZOPT, 40 AZOR, 14 AZULFIDINE, 29 AZULFIDINE EN-TABS, 29

B bacitracin, 39 baclofen, 22 balsalazide, 29 BAQSIMI, 27 BARACLUDE, 11 BASAGLAR, 23 BD ULTRAFINE insulin syringes and needles, 24 beclomethasone breath-activated aerosol, 36 BELBUCA, 8 BELSOMRA, 20 benazepril, 13 benazepril/hydrochlorothiazide, 13 benralizumab, 36 BENTYL, 29 BENZAC AC, 36 BENZAMYCIN, 36 benzonatate, 34 benzoyl peroxide, 36 benztropine, 19 benzyl alcohol/carbomer 941/glycerin, 39 besifloxacin, 39 BESIVANCE, 39 betamethasone dipropionate augmented crm 0.05%, 38 betamethasone dipropionate augmented gel, oint 0.05%, 38 betamethasone dipropionate augmented lotion 0.05%, 38 betamethasone dipropionate crm, lotion, oint 0.05%, 38 betamethasone valerate crm, lotion, oint 0.1%, 38 BETASERON, 21 betaxolol, 40 bethanechol, 31 BETHKIS, 35 BETIMOL, 40 BETOPTIC S, 40 BEVESPI AEROSPHERE, 34 bexarotene caps, 13 bicalutamide, 12 bictegravir/emtricitabine/tenofovir alafenamide, 9 BIDIL, 16 BIKTARVY, 9 bimatoprost 0.01%, 40 bismuth/metronidazole/tetracycline, 30 bisoprolol, 15 bisoprolol/hydrochlorothiazide, 15 BLEPH-10, 39 blood glucose continuous monitoring receivers, sensors,

transmitters, 24 blood glucose monitoring kits, test strips, 24 BONIVA, 25

bosentan, 17 BOSULIF, 12 bosutinib, 12 BREO ELLIPTA, 36 BRILINTA, 32 brimonidine, 40 brimonidine 0.2%, 40 brimonidine/timolol, 41 brinzolamide, 40 brinzolamide/brimonidine, 40 bromfenac sodium, 39 bromocriptine, 19 BRYHALI, 38 budesonide, 36 budesonide delayed-rel caps, 29 budesonide ext-rel, 29 budesonide inhalation susp, 36 budesonide/formoterol, 36 bumetanide, 16 buprenorphine, 8 buprenorphine transdermal, 7 buprenorphine/naloxone sublingual, 22 buprenorphine/naloxone sublingual tabs, 22 bupropion, 19 bupropion ext-rel, 19, 22 buspirone, 17 busulfan, 11 butalbital/acetaminophen/caffeine tabs, 8 butalbital/aspirin/caffeine, 8 BYSTOLIC, 15

C C1 esterase inhibitor, recombinant, 32 cabergoline, 28 CABOMETYX, 12 cabozantinib, 12 CADUET, 16 CALAN SR, 16 calcipotriene oint, soln 0.005%, 37 calcitonin-salmon spray, 25 calcitriol (1,25-D3), 27 calcium acetate, 27, 28 canakinumab, 33 candesartan, 14 candesartan/hydrochlorothiazide, 14 capecitabine, 12 captopril, 13 captopril/hydrochlorothiazide, 13 carbamazepine, 18 carbamazepine ext-rel, 18 CARBATROL, 18 carbidopa/levodopa, 19 carbidopa/levodopa ext-rel, 19 carbidopa/levodopa orally disintegrating tabs, 19 carbidopa/levodopa/entacapone, 19 CARDURA, 14 cariprazine, 20 carisoprodol, 22 carvedilol, 15 carvedilol phosphate ext-rel, 15 CASODEX, 12 CATAPRES, 13 CATAPRES-TTS, 13 cefadroxil, 8 cefdinir, 9 cefixime, 9

46

cefprozil, 9 cefuroxime axetil, 9 celecoxib, 7 CELEXA, 19 cephalexin, 8 CERDELGA, 27 CEREZYME, 27 cetrorelix, 27 CETROTIDE, 27 cevimeline, 30 CHANTIX, 22 chlorambucil, 11 chloroquine, 9 chlorpromazine, 20 chlorthalidone, 16 chlorzoxazone 500 mg, 22 cholestyramine, 14 choriogonadotropin alfa, 27 ciclopirox, 37 cilostazol, 32 CILOXAN, 39 CIMDUO, 10 cimetidine, 29 cinacalcet, 24 CIPRO, 9 CIPRODEX, 41 ciprofloxacin, 9 ciprofloxacin oint, 39 ciprofloxacin soln, 39 ciprofloxacin/dexamethasone, 41 citalopram, 19 CITRANATAL 90 DHA, 33 CITRANATAL ASSURE, 33 CITRANATAL B-CALM, 33 CITRANATAL DHA, 33 CITRANATAL HARMONY, 33 CITRANATAL RX, 33 clarithromycin, 9 clarithromycin ext-rel, 9 clemastine 2.68 mg, 34 CLEOCIN, 11, 31 CLEOCIN T, 36 CLIMARA, 26 CLIMARA PRO, 27 clindamycin, 11 clindamycin crm, 31 clindamycin gel, 36 clindamycin gel, lotion, soln, 36 clindamycin/benzoyl peroxide, 36 clobazam, 18 clobetasol propionate crm, gel, oint, soln 0.05%, 38 clobetasol propionate foam 0.05%, 38 clobetasol propionate lotion, shampoo 0.05%, 38 CLOBEX, 38 clomiphene, 27 clomipramine, 17 clonazepam, 17 clonidine, 13 clonidine transdermal, 13 clopidogrel, 32 clotrimazole, 37 clotrimazole troches, 9 clozapine, 20 CLOZARIL, 20 coagulation factor IX (recombinant) glycopegylated, 31 codeine/acetaminophen, 7

codeine/guaifenesin liquid, 34 codeine/guaifenesin/pseudoephedrine, 35 codeine/promethazine, 35 codeine/promethazine/phenylephrine, 35 colchicine, 7 colesevelam, 14 COLESTID, 15 colestipol, 15 COMBIGAN, 41 COMBIPATCH, 27 COMBIVIR, 10 COMPLERA, 10 COMTAN, 19 CONCERTA, 20 CONDYLOX, 38 conjugated estrogens/bazedoxifene, 27 COPAXONE, 21 COREG, 15 CORGARD, 15 CORLANOR, 16 CORTEF, 27 CORTIFOAM, 29 COSENTYX, 32 COSOPT, 40 COZAAR, 14 CREON, 30 CRINONE, 28 crisaborole, 37 cromolyn sodium, 39 cromolyn soln, 35 cyanocobalamin inj, 33 cyclobenzaprine, 22 cyclophosphamide caps, 11 cyclosporine, 33 cyclosporine, emulsion, 40 cyclosporine, modified, 33 cyproheptadine, 34 CYTOMEL, 28 CYTOTEC, 30

D D.H.E. 45, 21 DALIRESP, 35 dalteparin, 31 danazol, 26 DANTRIUM, 22 dantrolene, 22 dapagliflozin, 24 dapagliflozin/metformin ext-rel, 24 dapsone, 11 darbepoetin alfa, 31 darifenacin ext-rel, 30 darolutamide, 12 darunavir, 10 darunavir/cobicistat, 9 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 9 dasatinib, 12 DDAVP, 28 denosumab, 25 DEPAKOTE, 18 DEPAKOTE ER, 18 DEPO-PROVERA, 26 DESCOVY, 10 desipramine, 19 desmopressin spray, tabs, 28 desogestrel/EE, 25

47

desogestrel/EE 0.15/30, 25 desonide crm, lotion, oint 0.05%, 38 DESOWEN, 38 desoximetasone crm, oint 0.05%, 38 desoximetasone crm, oint 0.25%, gel 0.05%, 38 desvenlafaxine ext-rel, 19 DETROL, 31 deutetrabenazine, 21 dexamethasone, 27, 40 dexamethasone sodium phosphate, 40 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM,

24 DEXEDRINE SPANSULE, 20 DEXILANT, 30 dexlansoprazole delayed-rel, 30 dexmethylphenidate, 20 dexmethylphenidate ext-rel, 20 dextroamphetamine, 20 dextroamphetamine ext-rel, 20 dextromethorphan/brompheniramine/pseudoephedrine, 35 dextromethorphan/promethazine, 35 dextromethorphan/quinidine, 22 DIASTAT, 18 diazepam, 17 diazepam rectal gel, 18 diclofenac sodium, 39 diclofenac sodium delayed-rel, 7 diclofenac sodium delayed-rel/misoprostol, 7 diclofenac sodium gel 1%, 7 diclofenac sodium soln, 7 dicloxacillin, 9 dicyclomine, 29 didanosine delayed-rel, 10 DIFICID, 9 DIFLUCAN, 9 diflunisal, 7 difluprednate, 40 digoxin 0.0625 mg, 0.1875 mg, 16 digoxin 0.125 mg, 0.25 mg, 16 digoxin ped elixir, 16 dihydroergotamine inj, 21 DILANTIN, 18 DILANTIN INFATABS, 18 diltiazem ext-rel, 16 dimethyl fumarate delayed-rel, 21 diphenoxylate/atropine, 28 DIPROLENE, 38 DIPROLENE AF, 38 dipyridamole, 32 dipyridamole ext-rel/aspirin, 32 diroximel fumarate delayed-rel, 21 disopyramide, 14 disopyramide ext-rel, 14 disulfiram, 22 DITROPAN XL, 31 divalproex sodium delayed-rel, 18 divalproex sodium ext-rel, 18 DIVIGEL, 26 dofetilide, 14 dolutegravir, 10 donepezil, 18 dornase alfa, 35 dorzolamide, 40 dorzolamide/timolol maleate, 40 doxazosin, 14 doxepin, 19, 21

doxercalciferol, 27 doxycycline hyclate, 9 doxycycline hyclate 20 mg, 9 doxycycline monohydrate delayed-rel caps, 38 doxylamine/pyridoxine delayed-rel, 28 dronabinol, 28 dronedarone, 14 drospirenone/EE 3/20, 25 drospirenone/EE 3/30, 25 drospirenone/EE/levomefolate 3/20 and levomefolate, 25 drospirenone/EE/levomefolate 3/30 and levomefolate, 25 DUAVEE, 27 DUETACT, 24 dulaglutide, 23 duloxetine delayed-rel, 19 dupilumab, 36, 37 DUPIXENT, 36, 37 DUREZOL, 40 DUROLANE, 8 dutasteride, 30 dutasteride/tamsulosin, 30 DYAZIDE, 16 DYMISTA, 35

E econazole, 37 eculizumab, 32 EDURANT, 10 EE/norethindrone acetate - Jinteli, 26 efavirenz, 10 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 9 efavirenz/lamivudine/tenofovir disoproxil fumarate, 10 elagolix, 26 eletriptan, 21 ELIGARD, 12 eliglustat, 27 ELIQUIS, 31 ELOCON, 38 eltrombopag, 32 eluxadoline, 29 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate,

10 EMGALITY, 21 empagliflozin, 24 empagliflozin/linagliptin, 24 empagliflozin/metformin, 24 empagliflozin/metformin ext-rel, 24 emtricitabine, 10 emtricitabine/rilpivirine/tenofovir alafenamide, 10 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 10 emtricitabine/tenofovir alafenamide, 10 emtricitabine/tenofovir disoproxil fumarate, 10 EMTRIVA, 10 EMVERM, 11 enalapril, 13 enalapril/hydrochlorothiazide, 13 ENBREL, 32 ENDOMETRIN, 28 enfuvirtide, 10 enoxaparin, 31 entacapone, 19 entecavir soln, 11 entecavir tabs, 11 ENTRESTO, 17 enzalutamide, 12

48

EPCLUSA, 11 EPIDUO, 36 EPIDUO FORTE, 36 epinephrine, 34 epinephrine auto-injector, 34 EPIPEN, 34 EPIPEN JR., 34 EPISIL, 39 EPIVIR, 10 eplerenone, 13 epoetin alfa-epbx, 31 epoprostenol sodium, 17 eprosartan, 14 EPZICOM, 10 erenumab-aooe, 21 ergocalciferol (D2), 33 ERLEADA, 12 erlotinib, 12 erythromycin, 39 erythromycin delayed-rel, 9 erythromycin ethylsuccinate, 9 erythromycin gel 2%, 36 erythromycin soln, 36 erythromycin stearate, 9 erythromycin/benzoyl peroxide, 36 ESBRIET, 36 escitalopram, 19 esomeprazole delayed-rel, 30 ESTRACE, 26 estradiol, 26 estradiol vaginal crm, 26 estradiol vaginal ring, 26 estradiol vaginal tabs, 26 estradiol/levonorgestrel, 27 estradiol/norethindrone, 26 estradiol/norethindrone acetate, 27 ESTRING, 26 estrogens, conjugated, 26 estrogens, conjugated crm, 26 estrogens, conjugated/medroxyprogesterone, 26 eszopiclone, 20 etanercept, 32 ethambutol, 10 ethosuximide, 18 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 25 etodolac, 7 etonogestrel/EE ring, 26 etoposide, 12 etravirine, 10 EUCRISA, 37 EVAMIST, 26 everolimus, 12 EVISTA, 28 EVOTAZ, 9 EVOXAC, 30 EXELON, 18 exemestane, 12 EYLEA, 40 ezetimibe, 15 ezetimibe/simvastatin, 15

F famciclovir, 11 famotidine, 29 FARXIGA, 24 FASENRA, 36

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, 31 FIASP, 23 fidaxomicin, 9 filgrastim-aafi, 31 FINACEA FOAM, 38 finasteride, 30 fingolimod, 21 FIRAZYR, 32 FLAGYL, 11 flecainide, 14 FLOLAN, 17 FLOMAX, 30 FLOVENT DISKUS, 36 FLOVENT HFA, 36 fluconazole, 9 fludrocortisone, 27 flunisolide spray, 35 fluocinolone acetonide crm, oint 0.025%, 38 fluocinolone acetonide soln 0.01%, 37 fluocinonide crm, gel, oint, soln 0.05%, 38 fluoride drops, 33 fluoride tabs, 33 fluorometholone, 40 fluorouracil crm 4%, 37 fluorouracil crm 5%, soln 5%, soln 2%, 37 fluoxetine, 19 fluphenazine, 20 flutamide, 12 fluticasone, 36 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 38 fluticasone spray, 35 fluticasone, CFC-free aerosol, 36 fluticasone/salmeterol, 36 fluticasone/salmeterol, CFC-free aerosol, 36 fluticasone/umeclidinium/vilanterol, 34 fluticasone/vilanterol, 36 fluvastatin, 15 fluvoxamine, 17 FML FORTE, 40 FML S.O.P., 40 FOCALIN, 20 FOCALIN XR, 20 folic acid, 33 folic acid/vitamin B6/vitamin B12, 33 follitropin alfa, 27 fondaparinux, 31 formoterol inhalation soln, 35 FORTEO, 25 FOSAMAX, 25 fosinopril, 13 fosinopril/hydrochlorothiazide, 13 FRAGMIN, 31 fremanezumab-vfrm, 21 furosemide, 16 FUZEON, 10 FYCOMPA, 18

G gabapentin, 18

49

gabapentin ext-rel, 22 galantamine, 18 galantamine ext-rel, 18 galcanezumab-gnlm, 21 ganirelix acetate, 27 gefitinib, 12 GEL-ONE, 8 GELSYN-3, 8 gemfibrozil, 15 GENOTROPIN, 27 gentamicin, 37, 39 GENVOYA, 10 GEODON, 20 GILENYA, 21 glatiramer, 21 glimepiride, 24 glipizide, 24 glipizide ext-rel, 24 glipizide/metformin, 23 GLUCAGEN HYPOKIT, 27 GLUCAGON EMERGENCY KIT, 27 glucagon nasal powder, 27 glucagon, human recombinant, 27 GLUCOPHAGE, 23 GLUCOPHAGE XR, 23 GLUCOTROL, 24 GLUCOTROL XL, 24 glycopyrrolate/formoterol, 34 GLYXAMBI, 24 GOLYTELY, 29 GONAL-F, 27 GRALISE, 22 granisetron, 28 granisetron transdermal, 28 grass mixed pollen allergen extract, 32 GRASTEK, 32 griseofulvin ultramicrosize, 9 guanfacine, 13 guanfacine ext-rel, 20 guselkumab, 32

H halobetasol propionate crm, oint 0.05%, 38 halobetasol propionate lotion 0.01%, 38 haloperidol, 20 HARVONI, 11 HECTOROL, 27 human coagulation factor VIII (rDNA) simoctocog alfa, 31 HUMATROPE, 27 HUMIRA, 32 HUMULIN R U-500, 23 HYCAMTIN, 12 hydralazine, 17 HYDREA, 13 hydrochlorothiazide, 16 hydrocodone/acetaminophen, 7 hydrocodone/homatropine, 35 hydrocortisone, 27 hydrocortisone acetate foam, 29 hydrocortisone acetate/pramoxine foam, 30 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 38 hydrocortisone crm, 30 hydrocortisone crm 2.5%, 37 hydrocortisone enema, 29 hydrocortisone lotion 1%, 38 hydrocortisone valerate crm, oint 0.2%, 38

hydromorphone, 7 hydromorphone ext-rel, 7 hydroxychloroquine, 32 hydroxyurea, 13 hydroxyzine HCl, 34 hyoscyamine sulfate, 29 hyoscyamine sulfate ext-rel, 29 hyoscyamine sulfate ext-rel caps, 29 hyoscyamine sulfate orally disintegrating tabs, 29 HYZAAR, 14

I ibandronate, 25 IBRANCE, 12 ibuprofen, 7 icatibant, 32 icosapent ethyl, 15 ILARIS, 33 ILEVRO, 39 imatinib mesylate, 12 imiglucerase, 27 imipramine HCl, 19 imiquimod, 37, 38 IMITREX, 21 IMURAN, 33 INCRUSE ELLIPTA, 34 indapamide, 16 INDERAL LA, 15 ingenol mebutate, 37 INGREZZA, 21 INSPRA, 13 insulin aspart, 23 insulin aspart protamine 70%/insulin aspart 30%, 23 insulin degludec, 23 insulin detemir, 23 insulin glargine, 23 insulin human, 23 insulin infusion disposable pump, 24 insulin isophane human, 23 insulin isophane human 70%/regular 30%, 23 insulin syringes, needles, 24 INTELENCE, 10 interferon alfa-2b, 33 interferon beta-1a, 21 interferon beta-1b, 21 INTRON A, 33 ipratropium soln, 34 ipratropium spray, 36 ipratropium/albuterol soln, 34 irbesartan, 14 irbesartan/hydrochlorothiazide, 14 IRESSA, 12 ISENTRESS, 10 isoniazid, 10 isosorbide dinitrate oral, 17 isosorbide dinitrate/hydralazine, 16 isosorbide mononitrate, 17 isosorbide mononitrate ext-rel, 17 isotretinoin, 36 itraconazole, 9 ivabradine, 16 ivermectin, 11, 38

J JANUMET, 23 JANUMET XR, 23 JANUVIA, 23

50

JARDIANCE, 24 JIVI, 31

K KALETRA, 10 KEFLEX, 8 KEPPRA, 18 KEPPRA XR, 18 ketoconazole crm 2%, 37 ketoconazole shampoo 2%, 37 ketorolac, 39 ketorolac tromethamine, 39 KISQALI, 12 KISQALI FEMARA CO-PACK, 12 KLARON, 37 KLONOPIN, 17 KOGENATE FS, 31 KOVALTRY, 31 KUVAN, 27 KYLEENA, 26

L labetalol, 15 LAC-HYDRIN, 38 lacosamide, 18 lactulose soln, 29 lamivudine, 10, 11 lamivudine/tenofovir disoproxil fumarate, 10 lamivudine/zidovudine, 10 lamotrigine, 18 lamotrigine ext-rel, 18 lamotrigine orally disintegrating tabs, 18 lanadelumab-flyo, 32 LANOXIN, 16 lanreotide acetate, 22 lansoprazole + amoxicillin + clarithromycin, 30 lansoprazole delayed-rel, 30 lapatinib, 12 LASIX, 16 lasmiditan, 21 LASTACAFT, 39 latanoprost, 40 LATUDA, 20 ledipasvir/sofosbuvir, 11 leflunomide, 32 lenalidomide, 12 letrozole, 12 LEUKERAN, 11 leuprolide acetate, 12 levalbuterol tartrate, CFC-free aerosol, 35 LEVAQUIN, 9 LEVBID, 29 LEVEMIR, 23 levetiracetam, 18 levetiracetam ext-rel, 18 levobunolol, 40 levocarnitine, 25 levocetirizine, 34 levofloxacin, 9, 39 levonorgestrel releasing IUD, 26 levonorgestrel/EE - Trivora, 26 levonorgestrel/EE 0.1/20 - Lessina, 25 levonorgestrel/EE 0.1/20 and EE 10, 26 levonorgestrel/EE 0.15/30, 26 levonorgestrel/EE 0.15/30 - Levora, 25 levonorgestrel/EE 0.15/30 and EE 10, 26 levothyroxine, 28

levothyroxine - Levoxyl, 28 LEVSIN, 29 lidocaine patch, 38 lidocaine viscous, 39 lidocaine/prilocaine, 38 LIDODERM, 38 lifitegrast, 40 linaclotide, 29 linezolid, 11 LINZESS, 29 liothyronine, 28 LIPOFEN, 15 liraglutide, 23, 24 liraglutide/insulin degludec, 23 lisdexamfetamine, 20 lisinopril, 13 lisinopril/hydrochlorothiazide, 13 lithium carbonate, 21 lithium carbonate ext-rel tabs 300 mg, 21 lithium carbonate ext-rel tabs 450 mg, 21 LITHOBID, 21 lixisenatide/insulin glargine, 23 LO LOESTRIN FE, 25 LOESTRIN 1.5/30, 25 LOESTRIN 1/20, 25 LOESTRIN FE 1.5/30, 25 LOESTRIN FE 1/20, 25 LOKELMA, 28 LOMOTIL, 28 loperamide, 28 LOPID, 15 lopinavir/ritonavir soln, 10 lopinavir/ritonavir tabs, 10 LOPRESSOR, 15 LOPRESSOR HCT, 16 LOPROX, 37 lorazepam, 17 losartan, 14 losartan/hydrochlorothiazide, 14 LOSEASONIQUE, 26 LOTENSIN, 13 LOTENSIN HCT, 13 loteprednol, 40 LOTREL, 13 lovastatin, 15 LOVAZA, 15 lubiprostone, 29 LUCENTIS, 40 luliconazole, 37 LUMIGAN, 40 LUPRON DEPOT, 12 lurasidone, 20 lusutrombopag, 32 LYNPARZA, 13 LYSODREN, 13

M macitentan, 17 MACROBID, 11 MALARONE, 9 malathion, 38 MARINOL, 28 MATULANE, 13 MAXALT, 21 MAXIDEX, 40 MAXITROL, 39

51

MAXZIDE, 16 MAYZENT, 21 mebendazole chewable, 11 meclizine, 28 MEDROL, 27 medroxyprogesterone acetate, 28 medroxyprogesterone acetate 150 mg/mL, 26 mefloquine, 9 MEGACE ES, 28 megestrol acetate susp, 28 megestrol acetate tabs, 12 meloxicam, 7 melphalan, 11 memantine, 18 memantine ext-rel, 18 memantine/donepezil, 18 mepolizumab, 36 mercaptopurine, 11 mesalamine delayed-rel caps, 29 mesalamine delayed-rel tabs, 29 mesalamine ext-rel caps, 29 mesalamine supp, 29 mesalamine susp, 29 metaxalone, 22 metformin, 23 metformin ext-rel, 23 methadone, 7 methazolamide, 16 methimazole, 28 methocarbamol, 22 methotrexate, 12, 32 methotrexate auto-injector, 32 methoxsalen oral, 37 methyldopa, 17 METHYLIN, 20 methylphenidate, 20 methylphenidate ext-rel, 20 methylprednisolone, 27 metoclopramide, 29 metolazone, 16 metoprolol succinate ext-rel, 15 metoprolol tartrate, 15 metoprolol/hydrochlorothiazide, 16 METROCREAM, 38 METROGEL, 38 METROLOTION, 38 metronidazole, 11, 31 metronidazole crm 0.75%, 38 metronidazole gel 0.75%, 38 metronidazole gel 1%, 38 metronidazole lotion 0.75%, 38 MICARDIS, 14 MICARDIS HCT, 14 midodrine, 17 midostaurin, 12 minocycline, 9 mirabegron ext-rel, 31 MIRAPEX, 19 MIRCETTE, 25 MIRENA, 26 mirtazapine, 19 misoprostol, 30 mitotane, 13 mometasone crm, lotion, oint 0.1%, 38 mometasone spray, 35 montelukast, 35

morphine, 7 morphine ext-rel, 7 morphine supp, 7 MOVANTIK, 29 MOXEZA, 39 moxifloxacin, 9, 39 MOZOBIL, 32 MUGARD, 39 MULPLETA, 32 MULTAQ, 14 multivitamins/fluoride drops, tabs, 33 multivitamins/fluoride/iron drops, tabs, 33 mupirocin oint, 37 MUSE, 30 MYAMBUTOL, 10 mycophenolate mofetil, 33 mycophenolate sodium delayed-rel, 33 MYDAYIS, 20 MYLERAN, 11 MYRBETRIQ, 31 MYSOLINE, 18

N nabumetone, 7 nadolol, 15 naftifine, 37 NAFTIN, 37 naldemedine, 29 naloxegol, 29 naloxone inj, 22 naloxone nasal spray, 22 naltrexone, 22 NAMENDA, 18 NAMZARIC, 18 naproxen sodium tabs, 7 naproxen tabs, 7 naratriptan, 21 NARCAN, 22 NARDIL, 18 natalizumab, 21 nateglinide, 24 nebivolol, 15 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 39 neomycin/polymyxin B/dexamethasone, 39 neomycin/polymyxin B/gramicidin, 39 neomycin/polymyxin B/hydrocortisone, 41 neomycin/polymyxin B/hydrocortisone susp, 39 nepafenac, 39 netarsudil, 40 netarsudil/latanoprost, 40 NEULASTA, 31 NEUPRO, 19 NEURONTIN, 18 NEVANAC, 39 nevirapine, 10 nevirapine ext-rel, 10 niacin ext-rel, 15 NIASPAN, 15 nifedipine ext-rel, 16 nintedanib, 36 niraparib, 12 nitisinone, 27 NITRO-DUR, 17 nitrofurantoin ext-rel, 11 nitrofurantoin macrocrystals, 11 nitrofurantoin susp, 11

52

nitroglycerin lingual spray, 17 nitroglycerin sublingual, 17 nitroglycerin transdermal, 17 NITROLINGUAL, 17 NITROSTAT, 17 NIVESTYM, 31 NIZORAL, 37 norelgestromin/EE, 26 norethindrone, 26 norethindrone acetate, 28 norethindrone acetate/EE 1.5/30, 25 norethindrone acetate/EE 1.5/30 and iron, 25 norethindrone acetate/EE 1/10 and EE 10 and iron, 25 norethindrone acetate/EE 1/20, 25 norethindrone acetate/EE 1/20 and iron, 25 norethindrone acetate/EE 1/20 and iron chewable, 25 norethindrone/EE, 26 norethindrone/EE 0.5/35, 25 norethindrone/EE 1/35, 25 norgestimate/EE, 26 norgestimate/EE 0.25/35, 25 norgestrel/EE 0.3/30 - Low-Ogestrel, 25 NORPACE, 14 NORPACE CR, 14 NORPRAMIN, 19 nortriptyline, 19 NORVIR, 10 NOVOEIGHT, 31 NOVOLIN 70/30, 23 NOVOLIN N, 23 NOVOLIN R, 23 NOVOLOG, 23 NOVOLOG MIX 70/30, 23 NUBEQA, 12 NUCALA, 36 NUCYNTA, 8 NUCYNTA ER, 8 NUEDEXTA, 22 NULYTELY, 29 NURTEC ODT, 21 NUWIQ, 31 nystatin, 9, 37

O OCUFLOX, 39 ODEFSEY, 10 ODOMZO, 13 OFEV, 36 ofloxacin, 39 ofloxacin otic, 41 olanzapine, 20 olaparib, 13 olmesartan, 14 olmesartan/amlodipine/hydrochlorothiazide, 14 olmesartan/hydrochlorothiazide, 14 olodaterol, CFC-free aerosol, 35 olopatadine, 39 olopatadine spray, 35 omalizumab, 36 omega-3 acid ethyl esters, 15 omeprazole delayed-rel, 30 OMNIPOD INSULIN INFUSION PUMP, 24 ondansetron, 29 ONEXTON, 36 ONZETRA XSAIL, 21 OPSUMIT, 17

ORALAIR, 32 ORENITRAM, 17 ORFADIN, 27 ORILISSA, 26 ORTHO MICRONOR, 26 ORTHO-NOVUM 1/35, 25 ORTHO-NOVUM 7/7/7, 26 oseltamivir, 11 ospemifene, 28 OSPHENA, 28 OTEZLA, 32 OVIDE, 38 OVIDREL, 27 oxaprozin, 7 oxazepam, 17 oxcarbazepine, 18 oxcarbazepine ext-rel, 18 OXSORALEN-ULTRA, 37 OXTELLAR XR, 18 oxybutynin, 30 oxybutynin ext-rel, 31 oxycodone caps 5 mg, 7 oxycodone concentrate 20 mg/mL, 7 oxycodone ext-rel, 8 oxycodone soln 5 mg/5 mL, 7 oxycodone tabs 5 mg, 15 mg, 30 mg, 7 oxycodone/acetaminophen 5/325, 7 OZEMPIC, 23

P palbociclib, 12 PAMELOR, 19 pancrelipase, 29 pancrelipase delayed-rel, 30 pantoprazole delayed-rel, 30 paricalcitol, 27 PARLODEL, 19 PARNATE, 18 paroxetine HCl, 19 paroxetine HCl ext-rel, 19 paroxetine mesylate, 22 PATANASE, 35 patiromer sorbitex, 28 PAXIL, 19 PAXIL CR, 19 PAZEO, 39 pazopanib, 12 peg 3350/electrolytes, 29 PEGASYS, 33 pegfilgrastim, 31 pegfilgrastim-cbqv, 31 peginterferon alfa-2a, 33 peginterferon alfa-2b, 33 pegvisomant, 22 penicillin VK, 9 PENTASA, 29 PEPCID, 29 perampanel, 18 PERFOROMIST, 35 perindopril, 13 permethrin 5%, 38 perphenazine, 20 phenelzine, 18 phenobarbital, 18 phenytoin, 18 phenytoin sodium extended, 18

53

PHOSLYRA, 28 PICATO, 37 pilocarpine tabs, 30 pimecrolimus, 37 pindolol, 15 pioglitazone, 24 pioglitazone/glimepiride, 24 pioglitazone/metformin, 24 pirfenidone, 36 PLAQUENIL, 32 plerixafor, 32 podofilox, 38 polymyxin B/bacitracin, 39 polymyxin B/trimethoprim, 39 POLYTRIM, 39 pomalidomide, 12 POMALYST, 12 potassium chloride ext-rel, 33 potassium chloride liquid, 33 potassium citrate ext-rel, 31 PRALUENT, 15 pramipexole, 19 pramipexole ext-rel, 19 pramlintide, 23 prasugrel, 32 PRAVACHOL, 15 pravastatin, 15 PRECOSE, 23 PRED MILD, 40 prednisolone, 27 prednisolone acetate, 40 prednisolone acetate 1%, 40 prednisolone phosphate 1%, 40 prednisone, 27 pregabalin, 20 PREMARIN, 26 PREMPHASE, 26 PREMPRO, 26 prenatal vitamins, 33 prenatal vitamins/DHA/docusate/folic acid, 33 prenatal vitamins/docusate/folic acid, 33 prenatal vitamins/docusate/folic acid + DHA, 33 prenatal vitamins/folic acid + pyridoxine, 33 PREZCOBIX, 9 PREZISTA, 10 PRILOSEC, 30 primidone, 18 probenecid, 7 procarbazine, 13 PROCARDIA XL, 16 prochlorperazine, 28 PROCTOFOAM-HC, 30 progesterone gel, 28 progesterone vaginal inserts, 28 progesterone, micronized, 28 PROLASTIN-C, 35 PROLIA, 25 PROMACTA, 32 promethazine, 28 PROMETRIUM, 28 propafenone, 14 propafenone ext-rel, 14 propranolol, 15 propranolol ext-rel, 15 propylthiouracil, 28 PROSCAR, 30

PROVERA, 28 PULMICORT FLEXHALER, 36 PULMICORT RESPULES, 36 PULMOZYME, 35 PYLERA, 30 pyrazinamide, 10 pyridostigmine, 22 pyridostigmine ext-rel, 22

Q QUESTRAN/QUESTRAN LIGHT, 14 quetiapine, 20 quetiapine ext-rel, 19 quinapril, 13 quinapril/hydrochlorothiazide, 13 QVAR REDIHALER, 36

R ragweed pollen allergen extract, 32 RAGWITEK, 32 raloxifene, 28 raltegravir, 10 ramelteon, 20 ramipril, 13 ranibizumab, 40 ranolazine ext-rel, 17 rasagiline, 19 RASUVO, 32 RAZADYNE, 18 RAZADYNE ER, 18 REBIF, 21 REBINYN, 31 REGLAN, 29 RELENZA, 11 RELPAX, 21 REMERON, 19 repaglinide, 24 REQUIP XL, 19 RESTASIS, 40 RESTORIL, 20 RETACRIT, 31 RETIN-A, 37 RETROVIR, 10 REVATIO, 17 revefenacin inhalation solution, 34 REVLIMID, 12 REYVOW, 21 RHOPRESSA, 40 ribavirin, 11 ribociclib, 12 ribociclib + letrozole, 12 RIFADIN, 10 rifampin, 10 rifaximin 550 mg, 11 rilpivirine, 10 rimegepant, 21 RINVOQ, 32 riociguat, 17 risankizumab-rzaa, 32 risedronate, 25 risedronate delayed-rel, 25 RISPERDAL, 20 RISPERDAL CONSTA, 20 risperidone, 20 risperidone long-acting injection, 20 RITALIN, 20 ritonavir, 10

54

rivaroxaban, 31 rivastigmine, 18 rivastigmine transdermal, 18 rizatriptan, 21 ROBAXIN, 22 ROCALTROL, 27 ROCKLATAN, 40 roflumilast, 35 rolapitant, 28 ropinirole, 19 ropinirole ext-rel, 19 rosuvastatin, 15 rotigotine transdermal, 19 ROWASA, 29 RUBRACA, 13 rucaparib, 13 RUCONEST, 32 RYBELSUS, 23 RYDAPT, 12 RYTHMOL SR, 14

S sacubitril/valsartan, 17 SALAGEN, 30 salmeterol xinafoate, 35 SANCUSO, 28 sapropterin, 27 SAXENDA, 24 scopolamine transdermal, 28 SEASONIQUE, 26 secukinumab, 32 selegiline, 19 selenium sulfide lotion 2.5%, 37 selexipag, 17 semaglutide, 23 SEREVENT, 35 SEROQUEL, 20 sertraline, 19 sevelamer carbonate, 27 sildenafil, 17, 30 SILENOR, 21 silodosin, 30 SILVADENE, 37 silver sulfadiazine, 37 SIMBRINZA, 40 simvastatin, 15 SINEMET, 19 SINEMET CR, 19 siponimod, 21 sirolimus, 33 sitagliptin phosphate, 23 sitagliptin/metformin, 23 sitagliptin/metformin ext-rel, 23 SKELAXIN, 22 SKYLA, 26 SKYRIZI, 32 sodium hyaluronate, 8 sodium sulfate/potassium sulfate/magnesium sulfate, 29 sodium zirconium cyclosilicate, 28 sofosbuvir/velpatasvir, 11 sofosbuvir/velpatasvir/voxilaprevir, 11 solifenacin, 30 SOLIQUA, 23 SOLIRIS, 32 solriamfetol, 22 somatropin, 27

SOMATULINE DEPOT, 22 SOMAVERT, 22 sonidegib, 13 SOOLANTRA, 38 SORIATANE, 37 sotalol, 14 soy phospholipid/glycerol dioleate, 39 SPIRIVA, 34 spironolactone, 13 spironolactone/hydrochlorothiazide, 16 SPRYCEL, 12 STALEVO, 19 stavudine, 10 STELARA SUBCUTANEOUS, 32 STIOLTO RESPIMAT, 34 STRATTERA, 20 STRIBILD, 10 STRIVERDI RESPIMAT, 35 STROMECTOL, 11 SUBSYS, 8 sucralfate, 30 sucroferric oxyhydroxide, 28 sulfacetamide lotion 10%, 37 sulfacetamide oint 10%, 39 sulfacetamide soln 10%, 39 sulfacetamide/prednisolone phosphate 10%/0.25%, 39 sulfamethoxazole/trimethoprim, 11 sulfamethoxazole/trimethoprim DS, 11 sulfasalazine, 29 sulfasalazine delayed-rel, 29 sulindac, 7 sumatriptan, 21 sumatriptan inj, 21 sumatriptan nasal powder, 21 sumatriptan nasal spray, 21 sunitinib, 12 SUNOSI, 22 SUPARTZ FX, 8 SUPRAX, 9 SUPREP, 29 SUTENT, 12 suvorexant, 20 SYLATRON, 33 SYMBICORT, 36 SYMFI, 10 SYMFI LO, 10 SYMJEPI, 34 SYMLINPEN, 23 SYMPROIC, 29 SYMTUZA, 9 SYNJARDY, 24 SYNJARDY XR, 24 SYNTHROID, 28

T TABLOID, 12 tacrolimus, 33, 37 tadalafil, 17, 30 TAKHZYRO, 32 tamoxifen, 12 tamsulosin, 30 TAPAZOLE, 28 tapentadol, 8 tapentadol ext-rel, 8 TARGRETIN, 13 TARKA, 13

55

tazarotene, 36 TAZORAC, 36 TECFIDERA, 21 TEGRETOL, 18 TEKTURNA HCT, 16 telmisartan, 14 telmisartan/hydrochlorothiazide, 14 temazepam, 20 TEMIXYS, 10 TEMODAR, 11 TEMOVATE, 38 temozolomide, 11 tenofovir alafenamide, 11 tenofovir disoproxil fumarate, 10 terazosin, 14 terbinafine tabs, 9 terbutaline, 35 terconazole, 31 teriflunomide, 21 teriparatide, 25 TESSALON, 34 testosterone cypionate, 23 testosterone enanthate, 23 testosterone gel, 23 testosterone soln, 23 testosterone transdermal, 23 tetrabenazine, 21 tetracycline, 9 thalidomide, 12 THALOMID, 12 theophylline ext-rel tabs, 36 thioguanine, 12 thiothixene, 20 tiagabine, 18 TIAZAC, 16 ticagrelor, 32 TIGAN, 29 TIKOSYN, 14 timolol hemihydrate, 40 timolol maleate, 40 timolol maleate gel, 40 TIMOPTIC, 40 timothy grass pollen allergen extract, 32 tinidazole, 11 tiotropium, 34 tiotropium/olodaterol, 34 TIVICAY, 10 tizanidine tabs, 22 TOBRADEX, 39 TOBRADEX ST, 39 tobramycin, 39 tobramycin inhalation soln, 35 tobramycin/dexamethasone oint 0.3%/0.1%, 39 tobramycin/dexamethasone susp 0.3%/0.05%, 39 tobramycin/dexamethasone susp 0.3%/0.1%, 39 TOBREX, 39 tofacitinib, 32 tofacitinib ext-rel, 32 TOLAK, 37 tolterodine, 31 tolterodine ext-rel, 30 TOPAMAX, 18 topiramate, 18 topiramate ext-rel, 18 topotecan caps, 12 torsemide, 16

TOVIAZ, 31 tramadol, 8 tramadol ext-rel, 8 trandolapril, 13 trandolapril/verapamil ext-rel, 13 tranylcypromine, 18 TRAVATAN Z, 40 travoprost, 40 trazodone, 19 TRELEGY ELLIPTA, 34 TREMFYA, 32 treprostinil ext-rel, 17 TRESIBA, 23 tretinoin, 36, 37 tretinoin - Avita, 36 tretinoin caps, 12 tretinoin gel microsphere, 36 TREXALL, 12 triamcinolone acetonide crm 0.5%, 38 triamcinolone acetonide crm, lotion 0.025%, 38 triamcinolone acetonide crm, lotion, oint 0.1%, 38 triamcinolone paste, 39 triamterene, 16 triamterene/hydrochlorothiazide, 16 TRIBENZOR, 14 trifluoperazine, 20 trifluridine, 40 trihexyphenidyl, 19 TRILEPTAL, 18 TRILIPIX, 15 trimethobenzamide, 29 trimethoprim, 11 TRINTELLIX, 19 TRIUMEQ, 9 TROKENDI XR, 18 trospium, 30 trospium ext-rel, 30 TRULICITY, 23 TRUSOPT, 40 TRUVADA, 10 TYKERB, 12 TYMLOS, 25 TYSABRI, 21

U UBRELVY, 21 ubrogepant, 21 UDENYCA, 31 ULTRAVATE, 38 umeclidinium bromide, 34 umeclidinium/vilanterol, 34 upadacitinib, 32 UPTRAVI, 17 URECHOLINE, 31 uridine triacetate, 13 UROCIT-K, 31 URSO, 29 ursodiol, 29 ustekinumab, 32

V VAGIFEM, 26 valacyclovir, 11 valbenazine, 21 valganciclovir, 10 VALIUM, 17 valproic acid, 18

56

valsartan, 14 valsartan/hydrochlorothiazide, 14 VANCOCIN, 11 vancomycin caps, 11 varenicline, 22 VARUBI, 28 VASCEPA, 15 VASERETIC, 13 VASOTEC, 13 VELPHORO, 28 VELTASSA, 28 VEMLIDY, 11 venlafaxine, 19 venlafaxine ext-rel, 19 verapamil ext-rel, 16 VFEND, 9 V-GO INSULIN INFUSION PUMP, 24 VIBERZI, 29 VIBRAMYCIN, 9 VICTOZA, 23 VIDEX EC, 10 vigabatrin, 18 VIGAMOX, 39 VIIBRYD, 19 vilazodone, 19 VIMPAT, 18 VIOKACE, 29 VIREAD, 10 VISCO-3, 8 VISTOGARD, 13 vitamin ADC/fluoride drops, 34 vitamin ADC/fluoride/iron drops, 34 voriconazole, 9 vorinostat, 13 vortioxetine, 19 VOSEVI, 11 VOTRIENT, 12 VRAYLAR, 20 VUMERITY, 21 VYTORIN, 15 VYVANSE, 20

W warfarin, 31 WELLBUTRIN SR, 19 WELLBUTRIN XL, 19

X XALATAN, 40

XARELTO, 31 XELJANZ, 32 XELJANZ XR, 32 XELODA, 12 XIFAXAN, 11 XIGDUO XR, 24 XIIDRA, 40 XOLAIR, 36 XTAMPZA ER, 8 XTANDI, 12 XULTOPHY, 23

Y YASMIN, 25 YONSA, 12 YUPELRI, 34

Z zafirlukast, 35 ZANAFLEX, 22 zanamivir, 11 ZARONTIN, 18 ZEJULA, 12 ZEMBRACE SYMTOUCH, 21 ZEMPLAR, 27 ZENPEP, 30 ZESTORETIC, 13 ZESTRIL, 13 ZIAC, 15 ZIAGEN, 10 zidovudine, 10 zileuton ext-rel, 35 ziprasidone, 20 ZITHROMAX, 9 ZOCOR, 15 ZOFRAN, 29 ZOLINZA, 13 zolmitriptan, 21 zolmitriptan nasal spray, 21 ZOLOFT, 19 zolpidem, 20 zolpidem ext-rel, 20 zolpidem sublingual, 20 ZOMIG, 21 zonisamide, 18 ZOVIRAX, 11 ZUBSOLV, 22 ZYCLARA, 37 ZYPREXA, 20