3 Tier Drug Formulary - 2020...DAKOTACARE-ONE 2020 3-Tier Drug Formulary EFFECTIVE 04/01/2020 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Please

3 Tier Drug Formulary - 2020

DAKOTACARE-ONE 2020 3-Tier Drug Formulary EFFECTIVE 04/01/2020 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs.

WHAT IS THE DAKOTACARE DRUG FORMULARY? .......................................................................................................................................... 4 CAN THE DRUG FORMULARY CHANGE?............................................................................................................................................................ 4 HOW DO I USE THE DRUG FORMULARY? .......................................................................................................................................................... 4 DAKOTACARE DRUG FORMULARY ..................................................................................................................................................................... 4 WHAT IF MY DRUG IS NOT ON THE DRUG FORMULARY? ............................................................................................................................... 5 HOW LIKELY IS IT THAT I WILL GET THE FORMULARY EXCEPTION? ........................................................................................................... 5 WHAT DO THE TIERS MEAN ON THE DRUG FORMULARY? ............................................................................................................................. 5 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

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

CARDIOVASCULAR .............................................................................................................................................................................................. 12 ACE INHIBITORS......................................................................................................................................................................................... 12 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 12 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 12 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 12 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 13 ALPHA BLOCKERS ..................................................................................................................................................................................... 13 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 13 ANTIARRHYTHMICS ................................................................................................................................................................................... 13 ANTILIPEMICS............................................................................................................................................................................................. 14 BETA-BLOCKERS ....................................................................................................................................................................................... 14 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 15 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 15 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 15 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 15 DIURETICS .................................................................................................................................................................................................. 15 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES .................................................................................................................................................................................................... 16 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 16

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MISCELLANEOUS ....................................................................................................................................................................................... 17 CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 17

ANTIANXIETY .............................................................................................................................................................................................. 17 ANTICONVULSANTS .................................................................................................................................................................................. 17 ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 18 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 19 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA........................................................................................................................................................................................... 20 HYPNOTICS................................................................................................................................................................................................. 20 MIGRAINE .................................................................................................................................................................................................... 20 MOOD STABILIZERS .................................................................................................................................................................................. 21 MOVEMENT DISORDERS .......................................................................................................................................................................... 21 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 21 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 21 MYASTHENIA GRAVIS ............................................................................................................................................................................... 22 NARCOLEPSY ............................................................................................................................................................................................. 22 POSTHERPETIC NEURALGIA (PHN) ......................................................................................................................................................... 22 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 22

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 22 ACROMEGALY ............................................................................................................................................................................................ 22 ANDROGENS .............................................................................................................................................................................................. 22 ANTIDIABETICS .......................................................................................................................................................................................... 23 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 24 CALCIUM REGULATORS ........................................................................................................................................................................... 24 CARNITINE DEFICIENCY AGENTS ........................................................................................................................................................... 25 CONTRACEPTIVES .................................................................................................................................................................................... 25 ENDOMETRIOSIS ....................................................................................................................................................................................... 26 ESTROGENS ............................................................................................................................................................................................... 26 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 26 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 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............................................................................................................................................................ 27 PROGESTINS .............................................................................................................................................................................................. 28 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 28 THYROID AGENTS ..................................................................................................................................................................................... 28 VASOPRESSINS ......................................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28

GASTROINTESTINAL ........................................................................................................................................................................................... 28 ANTIDIARRHEALS ...................................................................................................................................................................................... 28 ANTIEMETICS ............................................................................................................................................................................................. 28 ANTISPASMODICS ..................................................................................................................................................................................... 29 CHOLELITHOLYTICS .................................................................................................................................................................................. 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 URINARY ANTISPASMODICS .................................................................................................................................................................... 30

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VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 30 MISCELLANEOUS ....................................................................................................................................................................................... 31

HEMATOLOGIC ..................................................................................................................................................................................................... 31 ANTICOAGULANTS .................................................................................................................................................................................... 31 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 31 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 31 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 31 MISCELLANEOUS ....................................................................................................................................................................................... 31

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 31 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 31 AUTOIMMUNE AGENTS ............................................................................................................................................................................. 32 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 32 HEREDITARY ANGIOEDEMA ..................................................................................................................................................................... 32 IMMUNOMODULATORS ............................................................................................................................................................................. 32 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 32

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

RESPIRATORY ...................................................................................................................................................................................................... 33 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 33 ANTICHOLINERGICS .................................................................................................................................................................................. 33 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 33 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ........................................................................................ 33 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 33 ANTITUSSIVES............................................................................................................................................................................................ 34 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 34 BETA AGONISTS ........................................................................................................................................................................................ 34 CYSTIC FIBROSIS ...................................................................................................................................................................................... 34 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 34 MAST CELL STABILIZERS ......................................................................................................................................................................... 35 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 35 NASAL STEROIDS/COMBINATIONS ......................................................................................................................................................... 35 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 35 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 35 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 35 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 35 STEROID INHALANTS ................................................................................................................................................................................ 35 XANTHINES ................................................................................................................................................................................................. 35 MISCELLANEOUS ....................................................................................................................................................................................... 35

TOPICAL ................................................................................................................................................................................................................ 35 DERMATOLOGY.......................................................................................................................................................................................... 35 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 38 OPHTHALMIC .............................................................................................................................................................................................. 38 OTIC ............................................................................................................................................................................................................. 40

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

Drug name, page number ............................................................................................................................................................................ 44

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What is the DAKOTACARE Drug Formulary? The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. DAKOTACARE works with a team of health care providers to choose drugs that provide quality treatment. DAKOTACARE covers drugs on the Drug Formulary that are:

• Medically necessary • Approved by the United States Food and Drug Administration (FDA) • Filled at a participating pharmacy

For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials.

Can the Drug Formulary change? The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by DAKOTACARE. To get updated information about the drugs covered by DAKOTACARE, please visit us online at DAKOTACARE.com or call CVS Caremark Customer Care toll-free at 1-866-406-8773.

How do I use the Drug Formulary? There are two ways to find your drug on the drug list: 1. Medical Condition The drugs on this Drug Formulary are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under CARDIOVASCULAR.

• If you know what your drug is used for, look for the category name in the table of contents • Then look under the category name for your drug

2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.

• Look in the Index and find your drug • Next to your drug, see the page number where you can find coverage information • Turn to the page listed in the Index and find the name of your drug in the first column of the list

For more information about your DAKOTACARE prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call CVS Caremark Customer Care toll-free at 1-866-406-8773 or visit us online at DAKOTACARE.com.

DAKOTACARE Drug Formulary The Drug Formulary gives you information about the drugs covered by DAKOTACARE. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary. The second column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case bold (e.g., atorvastatin). The third column will list what tier the brand drug is placed on in the Drug Formulary. If no brand name is listed, the tier represents the tire of the generic product. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier.

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The first column tells you if DAKOTACARE has any special requirements for coverage of your drug. These requirements and limits may include:

• Preauthorization (PA): DAKOTACARE needs your healthcare provider to get preauthorization for certain drugs by submitting a request online at www.dkc-pa.com. This means that approval from DAKOTACARE must be obtained before you fill your prescription. If you don't get approval, DAKOTACARE will not cover the cost of the drug. Additional information can be found online at DAKOTACARE.com.

• Quantity Limits (QL): For certain drugs, DAKOTACARE limits the amount of the drug that it will cover. For example, DAKOTACARE only covers 18 tablets of sumatriptan 50 mg per 30 days. DAKOTACARE also limits the amount of drugs you may receive within a class of drugs. For these classes, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.

• Step Therapy (ST): DAKOTACARE utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, DAKOTACARE will cover the step-two drugs. Visit us online at DAKOTACARE.com to review a list of Step Therapy Programs.

• Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age.

• Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on gender.

What if my drug is not on the Drug Formulary? If your drug is not on this Drug Formulary, you have two choices:

• Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you.

• You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following:

• Why no other prescription on the Drug Formulary will work as well as the requested drug • A list of other drugs that have been tried and how you responded to these drugs • Medical documentation to support the medical necessity

How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescriptions co-pays.

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What do the tiers mean on the Drug Formulary? Tier

Type of Drugs Included

Tier 1

Generic drugs

Tier 2

Preferred brand drugs

Tier 3

Non-preferred brand drugs

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.

DAKOTACARE and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by DAKOTACARE or CVS Caremark.

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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 nabumetone Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1 sulindac Tier 1 meloxicam Tier 3 MOBIC oxaprozin Tier 3 DAYPRO NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1 NSAIDs, TOPICAL QL, * diclofenac sodium gel 1% 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 QL celecoxib Tier 3 CELEBREX GOUT QL colchicine Tier 1 probenecid Tier 1 QL febuxostat Tier 2 ULORIC allopurinol Tier 3 ZYLOPRIM OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html QL buprenorphine transdermal Tier 1 QL codeine/acetaminophen Tier 1 QL fentanyl transdermal Tier 1 QL fentanyl transmucosal lozenge Tier 1 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine supp Tier 1

PA: Prior Authorization is required; QL: Quantity Limits; ST: Step Therapy criteria applies; lowercase, 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;

Tier status: Tier status listed represents the tier of the brand product. If no brand name is listed, tier represents the tier of the generic product

This document contains content that is copyrighted by CVS Health and/or one of its affiliates and reprinted with permission. 7

QL oxycodone caps, tabs 5 mg Tier 1 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 QL tramadol ext-rel Tier 1 buprenorphine Tier 2 BELBUCA QL, ST morphine/naltrexone ext-rel Tier 2 EMBEDA QL, ST oxycodone ext-rel Tier 2 XTAMPZA ER QL tapentadol Tier 2 NUCYNTA QL, ST tapentadol ext-rel Tier 2 NUCYNTA ER QL hydrocodone/acetaminophen Tier 3 NORCO QL hydromorphone Tier 3 DILAUDID QL, ST, * morphine ext-rel Tier 3 KADIAN QL, ST, * morphine ext-rel Tier 3 MS CONTIN QL oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL Tier 3 ROXICODONE QL tramadol Tier 3 ULTRAM * ST applies to brand products only NON-OPIOID ANALGESICS butalbital/acetaminophen/caffeine tabs Tier 3 ESGIC butalbital/aspirin/caffeine Tier 3 FIORINAL 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 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 QL fidaxomicin Tier 2 DIFICID azithromycin Tier 3 ZITHROMAX Fluoroquinolones ciprofloxacin Tier 3 CIPRO levofloxacin Tier 3 LEVAQUIN moxifloxacin Tier 3 AVELOX Penicillins amoxicillin Tier 1 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 QL itraconazole Tier 1 nystatin Tier 1 terbinafine tabs Tier 1 fluconazole Tier 3 DIFLUCAN QL voriconazole Tier 3 VFEND





ANTIMALARIALS chloroquine Tier 1 mefloquine Tier 1 atovaquone/proguanil Tier 3 MALARONE ANTIRETROVIRAL AGENTS Antiretroviral Combinations QL abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ QL atazanavir/cobicistat Tier 2 EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY QL darunavir/cobicistat Tier 2 PREZCOBIX efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 2 ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI LO elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil

fumarate Tier 2 STRIBILD

QL emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA QL emtricitabine/tenofovir alafenamide Tier 2 DESCOVY emtricitabine/tenofovir disoproxil fumarate Tier 2 TRUVADA QL lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO QL lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS abacavir/lamivudine Tier 3 EPZICOM lamivudine/zidovudine Tier 3 COMBIVIR Fusion Inhibitors QL enfuvirtide Tier 2 FUZEON Integrase Inhibitors QL dolutegravir Tier 2 TIVICAY QL raltegravir Tier 2 ISENTRESS Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 nevirapine Tier 1 QL nevirapine ext-rel Tier 1 QL etravirine Tier 2 INTELENCE QL rilpivirine Tier 2 EDURANT Nucleoside Reverse Transcriptase Inhibitors stavudine Tier 1 QL emtricitabine Tier 2 EMTRIVA abacavir tabs Tier 3 ZIAGEN didanosine delayed-rel Tier 3 VIDEX EC lamivudine Tier 3 EPIVIR zidovudine Tier 3 RETROVIR Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate Tier 2 VIREAD





Protease Inhibitors atazanavir Tier 1 QL darunavir Tier 2 PREZISTA lopinavir/ritonavir tabs Tier 2 KALETRA ritonavir Tier 2 NORVIR lopinavir/ritonavir soln 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 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 PA, QL, † ledipasvir/sofosbuvir Tier 2 HARVONI PA, QL, † sofosbuvir/velpatasvir Tier 2 EPCLUSA PA, QL, † sofosbuvir/velpatasvir/voxilaprevir Tier 2 VOSEVI † HARVONI only for genotypes 1, 4, 5, and 6 EPCLUSA for genotypes 1, 2, 3, 4, 5, 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). Herpes Agents famciclovir Tier 1 valacyclovir Tier 1 acyclovir caps, tabs Tier 3 ZOVIRAX Influenza Agents QL oseltamivir Tier 1 QL zanamivir Tier 2 RELENZA MISCELLANEOUS dapsone Tier 1 QL linezolid Tier 1 nitrofurantoin macrocrystals 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 nitrofurantoin susp Tier 3 FURADANTIN 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 QL clonidine transdermal Tier 3 CATAPRES-TTS





ALDOSTERONE RECEPTOR ANTAGONISTS QL eplerenone Tier 3 INSPRA spironolactone Tier 3 ALDACTONE 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 QL 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 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 QL atorvastatin Tier 1 fluvastatin Tier 1 lovastatin Tier 1 QL rosuvastatin Tier 1 ezetimibe/simvastatin Tier 3 VYTORIN pravastatin Tier 3 PRAVACHOL simvastatin Tier 3 ZOCOR Niacins QL niacin ext-rel Tier 3 NIASPAN Omega-3 Fatty Acids QL icosapent ethyl Tier 2 VASCEPA QL omega-3 acid ethyl esters Tier 3 LOVAZA PCSK9 Inhibitors PA, QL evolocumab Tier 2 REPATHA 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 QL carvedilol phosphate ext-rel Tier 1 labetalol Tier 1 metoprolol succinate ext-rel Tier 1 pindolol Tier 1





propranolol Tier 1 QL 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 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 QL aliskiren Tier 1 QL 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 QL ivabradine Tier 2 CORLANOR sacubitril/valsartan Tier 2 ENTRESTO NITRATES Oral isosorbide dinitrate ext-rel tabs Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1 isosorbide dinitrate oral Tier 3 ISORDIL 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 PA, QL ambrisentan Tier 1 PA, QL bosentan Tier 1 PA, QL macitentan Tier 2 OPSUMIT Phosphodiesterase Inhibitors PA, QL tadalafil Tier 1 QL sildenafil Tier 3 REVATIO Prostacyclin Receptor Agonists PA, QL selexipag Tier 2 UPTRAVI Prostaglandin Vasodilators PA, QL treprostinil ext-rel Tier 2 ORENITRAM





Soluble Guanylate Cyclase Stimulators PA, QL riociguat Tier 2 ADEMPAS MISCELLANEOUS hydralazine Tier 1 methyldopa Tier 1 midodrine Tier 1 QL 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 ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine ext-rel Tier 1 PA clobazam Tier 1 lamotrigine Tier 1 QL lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1 phenobarbital Tier 1 tiagabine Tier 1 topiramate ext-rel Tier 1 QL vigabatrin Tier 1 zonisamide Tier 1 QL lacosamide Tier 2 VIMPAT oxcarbazepine ext-rel Tier 2 OXTELLAR XR QL perampanel Tier 2 FYCOMPA QL 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 ST, * gabapentin Tier 3 NEURONTIN





levetiracetam Tier 3 KEPPRA QL levetiracetam ext-rel Tier 3 KEPPRA XR oxcarbazepine Tier 3 TRILEPTAL phenytoin Tier 3 DILANTIN INFATABS phenytoin sodium extended Tier 3 DILANTIN primidone Tier 3 MYSOLINE topiramate Tier 3 TOPAMAX valproic acid Tier 3 DEPAKENE * ST applies to brand products only ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com QL memantine ext-rel Tier 1 QL rivastigmine Tier 1 QL memantine/donepezil Tier 2 NAMZARIC QL donepezil Tier 3 ARICEPT QL galantamine Tier 3 RAZADYNE QL galantamine ext-rel Tier 3 RAZADYNE ER QL memantine Tier 3 NAMENDA QL 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 Selective Serotonin Reuptake Inhibitors (SSRIs) escitalopram Tier 1 fluoxetine Tier 1 QL vilazodone Tier 2 VIIBRYD QL vortioxetine Tier 2 TRINTELLIX citalopram Tier 3 CELEXA paroxetine HCl Tier 3 PAXIL paroxetine HCl ext-rel Tier 3 PAXIL CR sertraline Tier 3 ZOLOFT Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) QL desvenlafaxine ext-rel Tier 1 duloxetine delayed-rel Tier 1 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 Tricyclic Antidepressants (TCAs) amitriptyline Tier 1





doxepin Tier 1 desipramine Tier 3 NORPRAMIN imipramine HCl Tier 3 TOFRANIL nortriptyline Tier 3 PAMELOR Miscellaneous Agents bupropion Tier 1 trazodone Tier 1 QL, ST, * bupropion ext-rel Tier 3 WELLBUTRIN SR QL, ST, * bupropion ext-rel Tier 3 WELLBUTRIN XL QL mirtazapine tabs 7.5 mg, orally disintegrating Tier 3 REMERON mirtazapine tabs 15 mg, 30 mg, 45 mg Tier 3 REMERON * ST applies to brand products only 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 QL pramipexole ext-rel Tier 1 QL 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 QL pramipexole Tier 3 MIRAPEX QL ropinirole ext-rel Tier 3 REQUIP XL ANTIPSYCHOTICS Atypicals QL aripiprazole Tier 1 QL quetiapine ext-rel Tier 1 QL cariprazine Tier 2 VRAYLAR QL lurasidone Tier 2 LATUDA QL clozapine Tier 3 CLOZARIL olanzapine Tier 3 ZYPREXA quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL QL 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 dextroamphetamine Tier 1 QL guanfacine ext-rel Tier 1 QL methylphenidate ext-rel Tier 1 QL amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS QL lisdexamfetamine Tier 2 VYVANSE QL 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 ^ methylphenidate ext-rel Tier 3 CONCERTA ^ Listing does not include certain NDCs. 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. FIBROMYALGIA QL 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 QL temazepam Tier 3 RESTORIL Nonbenzodiazepines QL eszopiclone Tier 1 ramelteon Tier 1 QL zolpidem sublingual Tier 1 QL zolpidem Tier 3 AMBIEN QL zolpidem ext-rel Tier 3 AMBIEN CR Tricyclics QL doxepin Tier 2 SILENOR





MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Ergotamine Derivatives ergotamine/caffeine tabs Tier 1 dihydroergotamine inj Tier 3 D.H.E. 45 Monoclonal Antibodies PA erenumab-aooe Tier 2 AIMOVIG PA fremanezumab-vfrm Tier 2 AJOVY PA galcanezumab-gnlm Tier 2 EMGALITY Selective Serotonin Agonists QL naratriptan Tier 1 QL sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH QL sumatriptan nasal powder Tier 2 ONZETRA XSAIL QL zolmitriptan nasal spray Tier 2 ZOMIG QL eletriptan Tier 3 RELPAX QL rizatriptan Tier 3 MAXALT QL sumatriptan Tier 3 IMITREX QL sumatriptan inj Tier 3 IMITREX QL sumatriptan nasal spray Tier 3 IMITREX QL zolmitriptan Tier 3 ZOMIG MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 3 LITHOBID MOVEMENT DISORDERS PA tetrabenazine Tier 1 PA deutetrabenazine Tier 2 AUSTEDO PA, QL valbenazine Tier 2 INGREZZA MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com PA, QL dimethyl fumarate delayed-rel Tier 2 TECFIDERA PA, QL fingolimod Tier 2 GILENYA PA, QL glatiramer Tier 2 COPAXONE PA, QL interferon beta-1a Tier 2 REBIF PA, QL interferon beta-1b Tier 2 BETASERON PA siponimod Tier 2 MAYZENT PA, QL teriflunomide Tier 2 AUBAGIO MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 QL carisoprodol Tier 1 chlorzoxazone Tier 1 * cyclobenzaprine Tier 1





orphenadrine/aspirin/caffeine 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 ext-rel Tier 1 pyridostigmine soln, tabs 60 mg Tier 1 QL pyridostigmine tabs 30 mg Tier 3 NARCOLEPSY PA, QL armodafinil Tier 1 QL, ST 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 naltrexone Tier 1 QL naloxone nasal spray Tier 2 NARCAN Partial Opioid Agonist/Opioid Antagonist Combinations buprenorphine/naloxone sublingual Tier 1 PA buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV Pseudobulbar Affect Agents dextromethorphan/quinidine Tier 2 NUEDEXTA Vasomotor Symptom Agents QL paroxetine mesylate Tier 1 ENDOCRINE AND METABOLIC ACROMEGALY lanreotide acetate Tier 2 SOMATULINE DEPOT PA, QL pegvisomant Tier 2 SOMAVERT ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com testosterone cypionate Tier 1 testosterone enanthate Tier 1 QL testosterone gel Tier 1 QL testosterone soln Tier 1





QL testosterone transdermal Tier 2 ANDRODERM ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 3 PRECOSE Amylin Analogs PA, QL 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 QL sitagliptin phosphate Tier 2 JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations QL sitagliptin/metformin Tier 2 JANUMET QL sitagliptin/metformin ext-rel Tier 2 JANUMET XR Incretin Mimetic Agents QL dulaglutide Tier 2 TRULICITY QL liraglutide Tier 2 VICTOZA QL semaglutide Tier 2 OZEMPIC Incretin Mimetic Agent/Insulin Combinations QL, ST liraglutide/insulin degludec Tier 2 XULTOPHY QL, ST 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 insulin human Tier 2 NOVOLIN R insulin isophane human Tier 2 NOVOLIN N insulin isophane human 70%/regular 30% Tier 2 NOVOLIN 70/30 Insulin Sensitizers pioglitazone Tier 1 Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 3 ACTOPLUS MET





Insulin Sensitizer/Sulfonylurea Combinations QL pioglitazone/glimepiride Tier 3 DUETACT Meglitinides nateglinide Tier 1 repaglinide Tier 3 PRANDIN Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors QL, ST dapagliflozin Tier 2 FARXIGA QL, ST empagliflozin Tier 2 JARDIANCE Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations QL, ST dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR QL, ST empagliflozin/metformin Tier 2 SYNJARDY QL, ST empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations QL, ST empagliflozin/linagliptin Tier 2 GLYXAMBI Sulfonylureas glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL glipizide ext-rel Tier 3 GLUCOTROL XL Supplies QL blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK AVIVA PLUS kits

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

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

strips QL 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 QL insulin syringes, needles Tier 2 BD ULTRAFINE insulin syringes

and needles QL lancets Tier 2 CALCIUM RECEPTOR ANTAGONISTS cinacalcet Tier 2 SENSIPAR CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates QL alendronate Tier 3 FOSAMAX QL ibandronate Tier 3 BONIVA QL risedronate Tier 3 ACTONEL QL risedronate delayed-rel Tier 3 ATELVIA





Calcitonins calcitonin-salmon spray Tier 1 Parathyroid Hormones PA, QL abaloparatide Tier 2 TYMLOS PA, QL teriparatide Tier 2 FORTEO CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CONTRACEPTIVES EE = ethinyl estradiol Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1 norethindrone acetate/EE 1/20 and iron chewable Tier 1 ST, * norethindrone acetate/EE 1/20 Tier 3 LOESTRIN 1/20 ST, * norethindrone acetate/EE 1/20 and iron Tier 3 LOESTRIN FE 1/20 * ST applies to brand products only 30 mcg Estrogen desogestrel/EE 0.15/30 Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1 norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 ST, * drospirenone/EE 3/30 Tier 3 YASMIN ST, * norethindrone acetate/EE 1.5/30 Tier 3 LOESTRIN 1.5/30 ST, * norethindrone acetate/EE 1.5/30 and iron Tier 3 LOESTRIN FE 1.5/30 * ST applies to brand products only 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 ST, * norethindrone/EE 1/35 Tier 3 ORTHO-NOVUM 1/35 * ST applies to brand products only Biphasic ST, * desogestrel/EE Tier 3 MIRCETTE * ST applies to brand products only Triphasic desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1 norgestimate/EE Tier 1





ST, * norethindrone/EE Tier 3 ORTHO-NOVUM 7/7/7 * ST applies to brand products only Extended Cycle QL levonorgestrel/EE 0.15/30 Tier 1 QL, ST, * levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE QL, ST, * levonorgestrel/EE 0.15/30 and EE 10 Tier 3 SEASONIQUE * ST applies to brand products only Progestin Only norethindrone Tier 1 ST, * norethindrone Tier 3 ORTHO MICRONOR * ST applies to brand products only Transdermal norelgestromin/EE Tier 1 Vaginal etonogestrel/EE ring Tier 2 NUVARING ENDOMETRIOSIS danazol Tier 1 QL 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 estradiol Tier 1 estrogens, conjugated Tier 2 PREMARIN Transdermal QL estradiol Tier 1 QL estradiol Tier 2 DIVIGEL QL estradiol Tier 2 EVAMIST QL estradiol Tier 3 CLIMARA Vaginal estradiol vaginal crm Tier 2 ESTRACE QL 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 Transdermal QL estradiol/levonorgestrel Tier 2 CLIMARA PRO QL estradiol/norethindrone acetate Tier 2 COMBIPATCH ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS QL conjugated estrogens/bazedoxifene Tier 2 DUAVEE GAUCHER DISEASE PA, QL eliglustat Tier 2 CERDELGA 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, 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 PA somatropin Tier 2 GENOTROPIN PA 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 PA sapropterin Tier 2 KUVAN PHOSPHATE BINDER AGENTS calcium acetate Tier 1 sevelamer carbonate Tier 1 calcium acetate Tier 2 PHOSLYRA 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 SELECTIVE ESTROGEN RECEPTOR MODULATORS QL ospemifene Tier 2 OSPHENA QL 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 QL doxylamine/pyridoxine delayed-rel Tier 1 QL granisetron Tier 1 meclizine Tier 1 prochlorperazine Tier 1 promethazine Tier 1 QL scopolamine transdermal Tier 1 QL granisetron transdermal Tier 2 SANCUSO QL rolapitant Tier 2 VARUBI dronabinol Tier 3 MARINOL metoclopramide Tier 3 REGLAN





QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN ANTISPASMODICS hyoscyamine sulfate ext-rel caps Tier 1 hyoscyamine sulfate orally disintegrating tabs Tier 1 dicyclomine Tier 3 BENTYL hyoscyamine sulfate Tier 3 LEVSIN hyoscyamine sulfate ext-rel Tier 3 LEVBID CHOLELITHOLYTICS ursodiol Tier 3 ACTIGALL ursodiol Tier 3 URSO INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 QL mesalamine delayed-rel caps Tier 1 QL mesalamine delayed-rel tabs Tier 1 QL mesalamine ext-rel caps Tier 2 APRISO QL 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 QL linaclotide Tier 2 LINZESS QL lubiprostone Tier 2 AMITIZA Irritable Bowel Syndrome with Diarrhea QL alosetron Tier 1 QL 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 QL naloxegol Tier 2 MOVANTIK PANCREATIC ENZYMES pancrelipase Tier 2 VIOKACE





pancrelipase delayed-rel Tier 2 CREON pancrelipase delayed-rel Tier 2 ZENPEP PROSTAGLANDINS misoprostol Tier 3 CYTOTEC PROTON PUMP INHIBITORS QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel Tier 1 QL dexlansoprazole delayed-rel Tier 2 DEXILANT 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 QL alfuzosin ext-rel Tier 1 QL silodosin Tier 1 QL dutasteride Tier 3 AVODART QL finasteride Tier 3 PROSCAR tamsulosin Tier 3 FLOMAX URINARY ANTISPASMODICS QL darifenacin ext-rel Tier 1 oxybutynin Tier 1 QL solifenacin Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 QL fesoterodine ext-rel Tier 2 TOVIAZ QL mirabegron ext-rel Tier 2 MYRBETRIQ oxybutynin ext-rel Tier 3 DITROPAN XL tolterodine Tier 3 DETROL VAGINAL ANTI-INFECTIVES QL terconazole Tier 1





clindamycin crm Tier 3 CLEOCIN metronidazole Tier 3 METROGEL-VAGINAL 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 QL enoxaparin Tier 1 dalteparin Tier 3 FRAGMIN Oral warfarin Tier 1 QL apixaban Tier 2 ELIQUIS QL rivaroxaban Tier 2 XARELTO Synthetic Heparinoid-like Agents fondaparinux Tier 3 ARIXTRA PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 dipyridamole Tier 1 QL prasugrel Tier 1 QL ticagrelor Tier 2 BRILINTA dipyridamole ext-rel/aspirin Tier 3 AGGRENOX PLATELET SYNTHESIS INHIBITORS anagrelide Tier 3 AGRYLIN THROMBOCYTOPENIA AGENTS PA, QL eltrombopag Tier 2 PROMACTA PA 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 QL grass mixed pollen allergen extract Tier 2 ORALAIR QL ragweed pollen allergen extract Tier 2 RAGWITEK





QL timothy grass pollen allergen extract Tier 2 GRASTEK AUTOIMMUNE AGENTS PA, QL adalimumab Tier 2 HUMIRA PA, QL apremilast Tier 2 OTEZLA PA, QL etanercept Tier 2 ENBREL QL guselkumab Tier 2 TREMFYA PA, QL risankizumab-rzaa Tier 2 SKYRIZI PA, QL secukinumab Tier 2 COSENTYX PA, QL tofacitinib Tier 2 XELJANZ PA, QL tofacitinib ext-rel Tier 2 XELJANZ XR QL upadacitinib Tier 2 RINVOQ PA, QL ustekinumab Tier 2 STELARA SUBCUTANEOUS 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 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 2 INTRON A QL peginterferon alfa-2a Tier 2 PEGASYS QL peginterferon alfa-2b Tier 2 SYLATRON IMMUNOSUPPRESSANTS Antimetabolites mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 2 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 Prenatal Vitamins prenatal vitamins Tier 1 prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM 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 QL epinephrine auto-injector Tier 1 QL epinephrine auto-injector Tier 2 EPIPEN QL epinephrine auto-injector Tier 2 EPIPEN JR. ANTICHOLINERGICS ipratropium soln Tier 1 QL tiotropium Tier 2 SPIRIVA QL umeclidinium bromide Tier 2 INCRUSE ELLIPTA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 Long Acting QL glycopyrrolate/formoterol Tier 2 BEVESPI AEROSPHERE QL tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT QL umeclidinium/vilanterol Tier 2 ANORO ELLIPTA ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA 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 codeine/guaifenesin/pseudoephedrine Tier 1 codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/homatropine Tier 1 Non-opioid dextromethorphan/brompheniramine/pseudoephedri

ne Tier 1

dextromethorphan/promethazine Tier 1 BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate CFC-free aerosol Tier 1 QL levalbuterol tartrate, CFC-free aerosol Tier 1 Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT QL salmeterol xinafoate Tier 2 SEREVENT Nebulized Passive Inhalation QL formoterol inhalation soln Tier 2 PERFOROMIST Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 terbutaline Tier 1 CYSTIC FIBROSIS QL tobramycin inhalation soln Tier 1 QL tobramycin inhalation soln Tier 2 BETHKIS dornase alfa Tier 3 PULMOZYME LEUKOTRIENE MODULATORS montelukast Tier 1 QL zafirlukast Tier 1 QL zileuton ext-rel Tier 1





MAST CELL STABILIZERS cromolyn soln Tier 1 NASAL ANTIHISTAMINES QL azelastine spray Tier 1 QL azelastine spray Tier 3 ASTEPRO olopatadine spray Tier 3 PATANASE NASAL STEROIDS/COMBINATIONS flunisolide spray Tier 1 QL mometasone spray Tier 1 QL azelastine/fluticasone spray Tier 2 DYMISTA PHOSPHODIESTERASE-4 INHIBITORS QL roflumilast Tier 2 DALIRESP PULMONARY FIBROSIS AGENTS PA, QL nintedanib Tier 2 OFEV PA, QL pirfenidone Tier 2 ESBRIET SEVERE ASTHMA AGENTS PA dupilumab Tier 2 DUPIXENT PA mepolizumab Tier 2 NUCALA STEROID/BETA AGONIST COMBINATIONS QL fluticasone/salmeterol Tier 1 ADVAIR DISKUS QL budesonide/formoterol Tier 2 SYMBICORT QL fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA QL fluticasone/vilanterol Tier 2 BREO ELLIPTA STEROID INHALANTS QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER QL budesonide Tier 2 PULMICORT FLEXHALER QL fluticasone Tier 2 ARNUITY ELLIPTA QL fluticasone Tier 2 FLOVENT DISKUS QL fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA QL budesonide inhalation susp Tier 3 PULMICORT RESPULES XANTHINES theophylline ext-rel tabs Tier 1 MISCELLANEOUS QL 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 QL tretinoin gel microsphere Tier 1 QL adapalene/benzoyl peroxide Tier 2 EPIDUO QL adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE tazarotene Tier 2 TAZORAC clindamycin gel, lotion, soln Tier 3 CLEOCIN T clindamycin/benzoyl peroxide Tier 3 DUAC erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN sulfacetamide lotion 10% Tier 3 KLARON tretinoin Tier 3 RETIN-A Actinic Keratosis fluorouracil crm 5%, soln 5%, soln 2% Tier 1 fluorouracil crm 4% Tier 2 TOLAK imiquimod Tier 2 ZYCLARA QL 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 nystatin Tier 1 ST, * naftifine Tier 2 NAFTIN ST, * ciclopirox Tier 3 LOPROX * ST applies to brand products only Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Oral QL acitretin Tier 3 SORIATANE PA methoxsalen oral Tier 3 OXSORALEN-ULTRA Antiseborrheics selenium sulfide lotion 2.5% Tier 1





ST, * ketoconazole shampoo 2% Tier 3 NIZORAL * ST applies to brand products only Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Injectable PA dupilumab Tier 2 DUPIXENT Topical QL 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 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, 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 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, soln 0.05% Tier 3 TEMOVATE clobetasol propionate lotion, shampoo 0.05% Tier 3 CLOBEX halobetasol propionate crm, oint 0.05% Tier 3 ULTRAVATE





Local Analgesics QL lidocaine patch Tier 3 LIDODERM 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 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 alcaftadine Tier 2 LASTACAFT olopatadine Tier 2 PAZEO olopatadine Tier 3 PATADAY olopatadine Tier 3 PATANOL 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 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 QL cyclosporine, emulsion Tier 2 RESTASIS QL lifitegrast Tier 2 XIIDRA Prostaglandins ST bimatoprost Tier 2 LUMIGAN ST, * travoprost Tier 2 TRAVATAN Z ST, * latanoprost Tier 3 XALATAN * ST applies to brand products only 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 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





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

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

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

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

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INDEX Drug name, page number

A abacavir tabs, 10 abacavir/dolutegravir/lamivudine, 10 abacavir/lamivudine, 10 abaloparatide, 25 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, 12 ACCURETIC, 12 acetazolamide, 15 acetazolamide ext-rel, 15 acetic acid, 40 acitretin, 36 ACTIGALL, 29 ACTONEL, 24 ACTOPLUS MET, 23 ACULAR, 39 ACUVAIL, 39 acyclovir caps, tabs, 11 ADALAT CC, 15 adalimumab, 32 adapalene, 36 adapalene/benzoyl peroxide, 36 ADEMPAS, 17 ADVAIR DISKUS, 35 ADVAIR HFA, 35 aflibercept, 40 AGGRENOX, 31 AGRYLIN, 31 AIMOVIG, 21 AJOVY, 21 albuterol, 34 albuterol ext-rel, 34 albuterol soln, 34 albuterol sulfate CFC-free aerosol, 34 alcaftadine, 38 alclometasone crm, oint 0.05%, 37 ALDACTAZIDE, 16 ALDACTONE, 13 alendronate, 24 alfuzosin ext-rel, 30 aliskiren, 15 aliskiren/hydrochlorothiazide, 15 allopurinol, 7 alosetron, 29 ALPHAGAN P, 40 alprazolam, 17 ALTACE, 12 amantadine, 19 AMARYL, 24 AMBIEN, 20 AMBIEN CR, 20 ambrisentan, 16 amiloride, 16 amiloride/hydrochlorothiazide, 16

amiodarone, 13 AMITIZA, 29 amitriptyline, 18 amlodipine, 15 amlodipine/atorvastatin, 15 amlodipine/benazepril, 12 amlodipine/olmesartan, 13 amlodipine/telmisartan, 13 amlodipine/valsartan, 13 amlodipine/valsartan/hydrochlorothiazide, 13 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, 31 ANDRODERM, 23 ANORO ELLIPTA, 33 ANTABUSE, 22 ANTARA, 14 ANUSOL-HC, 30 apixaban, 31 apremilast, 32 APRISO, 29 ARAVA, 32 ARICEPT, 18 aripiprazole, 19 ARIXTRA, 31 armodafinil, 22 ARNUITY ELLIPTA, 35 ASTEPRO, 35 atazanavir, 11 atazanavir/cobicistat, 10 ATELVIA, 24 atenolol, 14 atenolol/chlorthalidone, 15 ATIVAN, 17 atomoxetine, 20 atorvastatin, 14 atovaquone/proguanil, 10 ATRIPLA, 10 AUBAGIO, 21 AUGMENTIN, 9 AUSTEDO, 21 AVELOX, 9 AVODART, 30 AYGESTIN, 28 AZASAN, 32 azathioprine, 32 azelaic acid foam, 38 azelaic acid gel, 38 azelastine, 38 azelastine spray, 35 azelastine/fluticasone spray, 35 azithromycin, 9 AZOPT, 40 AZOR, 13 AZULFIDINE, 29

44

AZULFIDINE EN-TABS, 29 B bacitracin, 38 baclofen, 21 balsalazide, 29 BARACLUDE, 11 BASAGLAR, 23 BD ULTRAFINE insulin syringes and needles, 24 beclomethasone breath-activated aerosol, 35 BELBUCA, 8 benazepril, 12 benazepril/hydrochlorothiazide, 12 BENTYL, 29 BENZAMYCIN, 36 benzonatate, 34 benztropine, 19 benzyl alcohol/carbomer 941/glycerin, 38 besifloxacin, 39 BESIVANCE, 39 betamethasone dipropionate augmented crm 0.05%, 37 betamethasone dipropionate augmented gel, oint 0.05%, 37 betamethasone dipropionate augmented lotion 0.05%, 37 betamethasone dipropionate crm, lotion, oint 0.05%, 37 betamethasone valerate crm, lotion, oint 0.1%, 37 BETASERON, 21 betaxolol, 40 bethanechol, 31 BETHKIS, 34 BETIMOL, 39 BETOPTIC S, 40 BEVESPI AEROSPHERE, 33 bictegravir/emtricitabine/tenofovir alafenamide, 10 BIDIL, 16 BIKTARVY, 10 bimatoprost, 40 bismuth/metronidazole/tetracycline, 30 bisoprolol, 14 bisoprolol/hydrochlorothiazide, 15 BLEPH-10, 39 blood glucose monitoring kits, test strips, 24 BONIVA, 24 bosentan, 16 BREO ELLIPTA, 35 BRILINTA, 31 brimonidine, 40 brimonidine 0.2%, 40 brimonidine/timolol, 40 brinzolamide, 40 brinzolamide/brimonidine, 40 bromfenac sodium, 39 bromocriptine, 19 budesonide, 35 budesonide delayed-rel caps, 29 budesonide inhalation susp, 35 budesonide/formoterol, 35 bumetanide, 15 buprenorphine, 8 buprenorphine transdermal, 7 buprenorphine/naloxone sublingual, 22 buprenorphine/naloxone sublingual tabs, 22 bupropion, 19 bupropion ext-rel, 19 buspirone, 17

butalbital/acetaminophen/caffeine tabs, 8 butalbital/aspirin/caffeine, 8 BYSTOLIC, 15 C C1 esterase inhibitor, recombinant, 32 cabergoline, 28 CADUET, 15 CALAN SR, 15 calcitonin-salmon spray, 25 calcitriol (1,25-D3), 27 calcium acetate, 27 candesartan, 13 candesartan/hydrochlorothiazide, 13 captopril, 12 captopril/hydrochlorothiazide, 12 carbamazepine, 17 carbamazepine ext-rel, 17 CARBATROL, 17 carbidopa/levodopa, 19 carbidopa/levodopa ext-rel, 19 carbidopa/levodopa orally disintegrating tabs, 19 carbidopa/levodopa/entacapone, 19 CARDURA, 13 cariprazine, 19 carisoprodol, 21 carvedilol, 15 carvedilol phosphate ext-rel, 14 CATAPRES, 12 CATAPRES-TTS, 12 cefadroxil, 9 cefdinir, 9 cefixime, 9 cefprozil, 9 cefuroxime axetil, 9 CELEBREX, 7 celecoxib, 7 CELEXA, 18 cephalexin, 9 CERDELGA, 27 cevimeline, 30 chloroquine, 10 chlorpromazine, 19 chlorthalidone, 16 chlorzoxazone, 21 cholestyramine, 14 ciclopirox, 36 cilostazol, 31 CILOXAN, 39 CIMDUO, 10 cinacalcet, 24 CIPRO, 9 CIPRODEX, 41 ciprofloxacin, 9 ciprofloxacin oint, 39 ciprofloxacin soln, 39 ciprofloxacin/dexamethasone, 41 citalopram, 18 CITRANATAL B-CALM, 33 CITRANATAL RX, 33 clarithromycin, 9 clarithromycin ext-rel, 9 clemastine 2.68 mg, 33 CLEOCIN, 12, 31

45

CLEOCIN T, 36 CLIMARA, 26 CLIMARA PRO, 27 clindamycin, 12 clindamycin crm, 31 clindamycin gel, 36 clindamycin gel, lotion, soln, 36 clindamycin/benzoyl peroxide, 36 clobazam, 17 clobetasol propionate crm, gel, soln 0.05%, 37 clobetasol propionate foam 0.05%, 37 clobetasol propionate lotion, shampoo 0.05%, 37 CLOBEX, 37 clomipramine, 17 clonazepam, 17 clonidine, 12 clonidine transdermal, 12 clopidogrel, 31 clotrimazole, 36 clotrimazole troches, 9 clozapine, 19 CLOZARIL, 19 codeine/acetaminophen, 7 codeine/guaifenesin liquid, 34 codeine/guaifenesin/pseudoephedrine, 34 codeine/promethazine, 34 codeine/promethazine/phenylephrine, 34 colchicine, 7 colesevelam, 14 COLESTID, 14 colestipol, 14 COMBIGAN, 40 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, 13 CREON, 30 CRINONE, 28 crisaborole, 37 cromolyn sodium, 38 cromolyn soln, 35 cyclobenzaprine, 21 cyclosporine, 32 cyclosporine, emulsion, 40 cyclosporine, modified, 32 cyproheptadine, 33 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 darifenacin ext-rel, 30 darunavir, 11 darunavir/cobicistat, 10 DAYPRO, 7 DDAVP, 28 DEPAKENE, 18 DEPAKOTE, 17 DEPAKOTE ER, 17 DESCOVY, 10 desipramine, 19 desmopressin spray, tabs, 28 desogestrel/EE, 25 desogestrel/EE 0.15/30, 25 desonide crm, lotion, oint 0.05%, 37 DESOWEN, 37 desoximetasone crm, oint 0.05%, 37 desoximetasone crm, oint 0.25%, gel 0.05%, 37 desvenlafaxine ext-rel, 18 DETROL, 30 deutetrabenazine, 21 dexamethasone, 27, 39 dexamethasone sodium phosphate, 39 DEXEDRINE SPANSULE, 20 DEXILANT, 30 dexlansoprazole delayed-rel, 30 dexmethylphenidate, 20 dexmethylphenidate ext-rel, 20 dextroamphetamine, 20 dextroamphetamine ext-rel, 20 dextromethorphan/brompheniramine/pseudoephedrine, 34 dextromethorphan/promethazine, 34 dextromethorphan/quinidine, 22 DIASTAT, 17 diazepam, 17 diazepam rectal gel, 17 diclofenac sodium, 39 diclofenac sodium delayed-rel, 7 diclofenac sodium delayed-rel/misoprostol, 7 diclofenac sodium gel 1%, 7 dicloxacillin, 9 dicyclomine, 29 didanosine delayed-rel, 10 DIFICID, 9 DIFLUCAN, 9 diflunisal, 7 difluprednate, 39 digoxin 0.0625 mg, 0.1875 mg, 15 digoxin 0.125 mg, 0.25 mg, 15 digoxin ped elixir, 15 dihydroergotamine inj, 21 DILANTIN, 18 DILANTIN INFATABS, 18 DILAUDID, 8 diltiazem ext-rel, 15 dimethyl fumarate delayed-rel, 21 diphenoxylate/atropine, 28 DIPROLENE, 37

46

DIPROLENE AF, 37 dipyridamole, 31 dipyridamole ext-rel/aspirin, 31 disopyramide, 13 disopyramide ext-rel, 13 disulfiram, 22 DITROPAN XL, 30 divalproex sodium delayed-rel, 17 divalproex sodium ext-rel, 17 DIVIGEL, 26 dofetilide, 13 dolutegravir, 10 donepezil, 18 dornase alfa, 34 dorzolamide, 40 dorzolamide/timolol maleate, 40 doxazosin, 13 doxepin, 19, 20 doxercalciferol, 27 doxycycline hyclate, 9 doxycycline hyclate 20 mg, 9 doxycycline monohydrate delayed-rel caps, 38 doxylamine/pyridoxine delayed-rel, 28 dronabinol, 28 dronedarone, 13 drospirenone/EE 3/20, 25 drospirenone/EE 3/30, 25 DUAC, 36 DUAVEE, 27 DUETACT, 24 dulaglutide, 23 duloxetine delayed-rel, 18 dupilumab, 35, 37 DUPIXENT, 35, 37 DUREZOL, 39 dutasteride, 30 DYAZIDE, 16 DYMISTA, 35 E econazole, 36 EDURANT, 10 EE/norethindrone acetate - Jinteli, 26 efavirenz, 10 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 10 efavirenz/lamivudine/tenofovir disoproxil fumarate, 10 elagolix, 26 eletriptan, 21 eliglustat, 27 ELIQUIS, 31 ELOCON, 37 eltrombopag, 31 eluxadoline, 29 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate,

10 EMBEDA, 8 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, 12 enalapril, 12 enalapril/hydrochlorothiazide, 12 ENBREL, 32 enfuvirtide, 10 enoxaparin, 31 entacapone, 19 entecavir soln, 11 entecavir tabs, 11 ENTRESTO, 16 EPCLUSA, 11 EPIDUO, 36 EPIDUO FORTE, 36 epinephrine auto-injector, 33 EPIPEN, 33 EPIPEN JR., 33 EPISIL, 38 EPIVIR, 10 eplerenone, 13 eprosartan, 13 EPZICOM, 10 erenumab-aooe, 21 ergotamine/caffeine tabs, 21 erythromycin, 38 erythromycin delayed-rel, 9 erythromycin ethylsuccinate, 9 erythromycin gel 2%, 36 erythromycin soln, 36 erythromycin stearate, 9 erythromycin/benzoyl peroxide, 36 ESBRIET, 35 escitalopram, 18 ESGIC, 8 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, 27 eszopiclone, 20 etanercept, 32 ethambutol, 11 ethosuximide, 17 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 25 etodolac, 7 etonogestrel/EE ring, 26 etravirine, 10 EUCRISA, 37 EVAMIST, 26 EVISTA, 28 evolocumab, 14 EVOTAZ, 10 EVOXAC, 30 EXELON, 18

47

EYLEA, 40 ezetimibe, 14 ezetimibe/simvastatin, 14 F famciclovir, 11 FARXIGA, 24 febuxostat, 7 felodipine ext-rel, 15 fenofibrate, 14 fenofibric acid delayed-rel, 14 fentanyl transdermal, 7 fentanyl transmucosal lozenge, 7 fesoterodine ext-rel, 30 FIASP, 23 fidaxomicin, 9 FINACEA FOAM, 38 finasteride, 30 fingolimod, 21 FIORINAL, 8 FIRAZYR, 32 FLAGYL, 12 flecainide, 13 FLOMAX, 30 FLOVENT DISKUS, 35 FLOVENT HFA, 35 fluconazole, 9 fludrocortisone, 27 flunisolide spray, 35 fluocinolone acetonide crm, oint 0.025%, 37 fluocinolone acetonide soln 0.01%, 37 fluocinonide crm, gel, oint, soln 0.05%, 37 fluorometholone, 39 fluorouracil crm 4%, 36 fluorouracil crm 5%, soln 5%, soln 2%, 36 fluoxetine, 18 fluphenazine, 19 fluticasone, 35 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 37 fluticasone, CFC-free aerosol, 35 fluticasone/salmeterol, 35 fluticasone/salmeterol, CFC-free aerosol, 35 fluticasone/umeclidinium/vilanterol, 33 fluticasone/vilanterol, 35 fluvastatin, 14 fluvoxamine, 17 FML FORTE, 39 FML S.O.P., 39 FOCALIN, 20 FOCALIN XR, 20 fondaparinux, 31 formoterol inhalation soln, 34 FORTEO, 25 FOSAMAX, 24 fosinopril, 12 fosinopril/hydrochlorothiazide, 12 FRAGMIN, 31 fremanezumab-vfrm, 21 FURADANTIN, 12 furosemide, 15 FUZEON, 10 FYCOMPA, 17 G gabapentin, 17

gabapentin ext-rel, 22 galantamine, 18 galantamine ext-rel, 18 galcanezumab-gnlm, 21 gemfibrozil, 14 GENOTROPIN, 27 gentamicin, 36, 38 GENVOYA, 10 GEODON, 19 GILENYA, 21 glatiramer, 21 glimepiride, 24 glipizide, 24 glipizide ext-rel, 24 glipizide/metformin, 23 GLUCAGEN HYPOKIT, 27 GLUCAGON EMERGENCY KIT, 27 glucagon, human recombinant, 27 GLUCOPHAGE, 23 GLUCOPHAGE XR, 23 GLUCOTROL, 24 GLUCOTROL XL, 24 glycopyrrolate/formoterol, 33 GLYXAMBI, 24 GOLYTELY, 29 GRALISE, 22 granisetron, 28 granisetron transdermal, 28 grass mixed pollen allergen extract, 31 GRASTEK, 32 griseofulvin ultramicrosize, 9 guanfacine, 12 guanfacine ext-rel, 20 guselkumab, 32 H halobetasol propionate crm, oint 0.05%, 37 haloperidol, 19 HARVONI, 11 HECTOROL, 27 HUMATROPE, 27 HUMIRA, 32 HUMULIN R U-500, 23 hydralazine, 17 hydrochlorothiazide, 16 hydrocodone/acetaminophen, 8 hydrocodone/homatropine, 34 hydrocortisone, 27 hydrocortisone acetate foam, 29 hydrocortisone acetate/pramoxine foam, 30 hydrocortisone butyrate crm, oint, soln 0.1%, 37 hydrocortisone crm, 30 hydrocortisone crm 2.5%, 37 hydrocortisone enema, 29 hydrocortisone valerate crm, oint 0.2%, 37 hydromorphone, 8 hydromorphone ext-rel, 7 hydroxychloroquine, 32 hydroxyzine HCl, 33 hyoscyamine sulfate, 29 hyoscyamine sulfate ext-rel, 29 hyoscyamine sulfate ext-rel caps, 29 hyoscyamine sulfate orally disintegrating tabs, 29 HYZAAR, 13

48

I ibandronate, 24 ibuprofen, 7 icatibant, 32 icosapent ethyl, 14 ILEVRO, 39 imipramine HCl, 19 imiquimod, 36, 38 IMITREX, 21 IMURAN, 32 INCRUSE ELLIPTA, 33 indapamide, 16 INDERAL LA, 15 ingenol mebutate, 36 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, 32 interferon beta-1a, 21 interferon beta-1b, 21 INTRON A, 32 ipratropium soln, 33 ipratropium spray, 35 ipratropium/albuterol soln, 33 irbesartan, 13 irbesartan/hydrochlorothiazide, 13 ISENTRESS, 10 isoniazid, 11 ISORDIL, 16 isosorbide dinitrate ext-rel tabs, 16 isosorbide dinitrate oral, 16 isosorbide dinitrate/hydralazine, 16 isosorbide mononitrate, 16 isosorbide mononitrate ext-rel, 16 isotretinoin, 36 itraconazole, 9 ivabradine, 16 ivermectin, 12, 38 J JANUMET, 23 JANUMET XR, 23 JANUVIA, 23 JARDIANCE, 24 K KADIAN, 8 KALETRA, 11 KEFLEX, 9 KEPPRA, 18 KEPPRA XR, 18 ketoconazole crm 2%, 36 ketoconazole shampoo 2%, 37 ketorolac, 39 ketorolac tromethamine, 39

KLARON, 36 KLONOPIN, 17 KUVAN, 27 L labetalol, 14 lacosamide, 17 lactulose soln, 29 lamivudine, 10, 11 lamivudine/tenofovir disoproxil fumarate, 10 lamivudine/zidovudine, 10 lamotrigine, 17 lamotrigine ext-rel, 17 lamotrigine orally disintegrating tabs, 17 lancets, 24 LANOXIN, 15 lanreotide acetate, 22 lansoprazole + amoxicillin + clarithromycin, 30 LASIX, 15 LASTACAFT, 38 latanoprost, 40 LATUDA, 19 ledipasvir/sofosbuvir, 11 leflunomide, 32 levalbuterol tartrate, CFC-free aerosol, 34 LEVAQUIN, 9 LEVBID, 29 LEVEMIR, 23 levetiracetam, 18 levetiracetam ext-rel, 18 levobunolol, 39 levocarnitine, 25 levofloxacin, 9, 38 levonorgestrel/EE - Trivora, 25 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, 38 LIDODERM, 38 lifitegrast, 40 linaclotide, 29 linezolid, 11 LINZESS, 29 liothyronine, 28 LIPOFEN, 14 liraglutide, 23 liraglutide/insulin degludec, 23 lisdexamfetamine, 20 lisinopril, 12 lisinopril/hydrochlorothiazide, 12 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 LOESTRIN 1.5/30, 25 LOESTRIN 1/20, 25 LOESTRIN FE 1.5/30, 25

49

LOESTRIN FE 1/20, 25 LOKELMA, 27 LOMOTIL, 28 loperamide, 28 LOPID, 14 lopinavir/ritonavir soln, 11 lopinavir/ritonavir tabs, 11 LOPRESSOR, 15 LOPRESSOR HCT, 15 LOPROX, 36 lorazepam, 17 losartan, 13 losartan/hydrochlorothiazide, 13 LOSEASONIQUE, 26 LOTENSIN, 12 LOTENSIN HCT, 12 loteprednol, 39 LOTREL, 12 lovastatin, 14 LOVAZA, 14 lubiprostone, 29 LUCENTIS, 40 LUMIGAN, 40 lurasidone, 19 lusutrombopag, 31 M macitentan, 16 MACROBID, 12 MALARONE, 10 malathion, 38 MARINOL, 28 MAXALT, 21 MAXIDEX, 39 MAXITROL, 39 MAXZIDE, 16 MAYZENT, 21 mebendazole chewable, 12 meclizine, 28 MEDROL, 27 medroxyprogesterone acetate, 28 mefloquine, 10 MEGACE ES, 28 megestrol acetate susp, 28 meloxicam, 7 memantine, 18 memantine ext-rel, 18 memantine/donepezil, 18 mepolizumab, 35 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, 15 methimazole, 28 methocarbamol, 22 methotrexate, 32 methotrexate auto-injector, 32 methoxsalen oral, 36

methyldopa, 17 METHYLIN, 20 methylphenidate, 20 methylphenidate ext-rel, 20 methylprednisolone, 27 metoclopramide, 28 metolazone, 16 metoprolol succinate ext-rel, 14 metoprolol tartrate, 15 metoprolol/hydrochlorothiazide, 15 METROCREAM, 38 METROGEL, 38 METROGEL-VAGINAL, 31 METROLOTION, 38 metronidazole, 12, 31 metronidazole crm 0.75%, 38 metronidazole gel 0.75%, 38 metronidazole gel 1%, 38 metronidazole lotion 0.75%, 38 MICARDIS, 13 MICARDIS HCT, 13 midodrine, 17 minocycline, 9 mirabegron ext-rel, 30 MIRAPEX, 19 MIRCETTE, 25 mirtazapine tabs 15 mg, 30 mg, 45 mg, 19 mirtazapine tabs 7.5 mg, orally disintegrating, 19 misoprostol, 30 MOBIC, 7 mometasone crm, lotion, oint 0.1%, 37 mometasone spray, 35 montelukast, 34 morphine, 7 morphine ext-rel, 7, 8 morphine supp, 7 morphine/naltrexone ext-rel, 8 MOVANTIK, 29 MOXEZA, 39 moxifloxacin, 9, 39 MS CONTIN, 8 MUGARD, 38 MULPLETA, 31 MULTAQ, 13 mupirocin oint, 36 MYAMBUTOL, 11 mycophenolate mofetil, 32 mycophenolate sodium delayed-rel, 32 MYDAYIS, 20 MYRBETRIQ, 30 MYSOLINE, 18 N nabumetone, 7 nadolol, 15 naftifine, 36 NAFTIN, 36 naldemedine, 29 naloxegol, 29 naloxone nasal spray, 22 naltrexone, 22 NAMENDA, 18 NAMZARIC, 18 naproxen sodium tabs, 7

50

naproxen tabs, 7 naratriptan, 21 NARCAN, 22 NARDIL, 18 nateglinide, 24 nebivolol, 15 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 39 neomycin/polymyxin B/dexamethasone, 39 neomycin/polymyxin B/gramicidin, 38 neomycin/polymyxin B/hydrocortisone, 40 neomycin/polymyxin B/hydrocortisone susp, 39 nepafenac, 39 netarsudil, 40 netarsudil/latanoprost, 40 NEUPRO, 19 NEURONTIN, 17 NEVANAC, 39 nevirapine, 10 nevirapine ext-rel, 10 niacin ext-rel, 14 NIASPAN, 14 nifedipine ext-rel, 15 nintedanib, 35 nitisinone, 27 NITRO-DUR, 16 nitrofurantoin ext-rel, 12 nitrofurantoin macrocrystals, 11 nitrofurantoin susp, 12 nitroglycerin lingual spray, 16 nitroglycerin sublingual, 16 nitroglycerin transdermal, 16 NITROLINGUAL, 16 NITROSTAT, 16 NIZORAL, 37 NORCO, 8 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 1/20, 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, 25 norgestimate/EE 0.25/35, 25 norgestrel/EE 0.3/30 - Low-Ogestrel, 25 NORPACE, 13 NORPACE CR, 13 NORPRAMIN, 19 nortriptyline, 19 NORVIR, 11 NOVOLIN 70/30, 23 NOVOLIN N, 23 NOVOLIN R, 23 NOVOLOG, 23 NOVOLOG MIX 70/30, 23 NUCALA, 35 NUCYNTA, 8 NUCYNTA ER, 8 NUEDEXTA, 22 NULYTELY, 29

NUVARING, 26 nystatin, 9, 36 O OCUFLOX, 39 ODEFSEY, 10 OFEV, 35 ofloxacin, 39 ofloxacin otic, 40 olanzapine, 19 olmesartan, 13 olmesartan/amlodipine/hydrochlorothiazide, 13 olmesartan/hydrochlorothiazide, 13 olodaterol, CFC-free aerosol, 34 olopatadine, 38 olopatadine spray, 35 omega-3 acid ethyl esters, 14 OMNIPOD INSULIN INFUSION PUMP, 24 ondansetron, 29 ONZETRA XSAIL, 21 OPSUMIT, 16 ORALAIR, 31 ORENITRAM, 16 ORFADIN, 27 ORILISSA, 26 orphenadrine/aspirin/caffeine, 22 ORTHO MICRONOR, 26 ORTHO-NOVUM 1/35, 25 ORTHO-NOVUM 7/7/7, 26 oseltamivir, 11 ospemifene, 28 OSPHENA, 28 OTEZLA, 32 OVIDE, 38 oxaprozin, 7 oxazepam, 17 oxcarbazepine, 18 oxcarbazepine ext-rel, 17 OXSORALEN-ULTRA, 36 OXTELLAR XR, 17 oxybutynin, 30 oxybutynin ext-rel, 30 oxycodone caps, tabs 5 mg, 8 oxycodone concentrate 20 mg/mL, 8 oxycodone ext-rel, 8 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 8 oxycodone/acetaminophen 5/325, 8 OZEMPIC, 23 P PAMELOR, 19 pancrelipase, 29 pancrelipase delayed-rel, 30 pantoprazole delayed-rel, 30 paricalcitol, 27 PARLODEL, 19 PARNATE, 18 paroxetine HCl, 18 paroxetine HCl ext-rel, 18 paroxetine mesylate, 22 PATADAY, 38 PATANASE, 35 PATANOL, 38 patiromer sorbitex, 27 PAXIL, 18

51

PAXIL CR, 18 PAZEO, 38 peg 3350/electrolytes, 29 PEGASYS, 32 peginterferon alfa-2a, 32 peginterferon alfa-2b, 32 pegvisomant, 22 penicillin VK, 9 PENTASA, 29 perampanel, 17 PERFOROMIST, 34 perindopril, 12 permethrin 5%, 38 perphenazine, 20 phenelzine, 18 phenobarbital, 17 phenytoin, 18 phenytoin sodium extended, 18 PHOSLYRA, 27 PICATO, 36 pilocarpine tabs, 30 pimecrolimus, 37 pindolol, 14 pioglitazone, 23 pioglitazone/glimepiride, 24 pioglitazone/metformin, 23 pirfenidone, 35 PLAQUENIL, 32 podofilox, 38 polymyxin B/bacitracin, 38 polymyxin B/trimethoprim, 39 POLYTRIM, 39 potassium chloride ext-rel, 33 potassium chloride liquid, 33 potassium citrate ext-rel, 31 pramipexole, 19 pramipexole ext-rel, 19 pramlintide, 23 PRANDIN, 24 prasugrel, 31 PRAVACHOL, 14 pravastatin, 14 PRECOSE, 23 PRED MILD, 39 prednisolone, 27 prednisolone acetate, 39 prednisolone acetate 1%, 39 prednisolone phosphate 1%, 39 prednisone, 27 pregabalin, 20 PREMARIN, 26 PREMPHASE, 27 PREMPRO, 27 prenatal vitamins, 33 prenatal vitamins/docusate/folic acid, 33 prenatal vitamins/folic acid + pyridoxine, 33 PREZCOBIX, 10 PREZISTA, 11 primidone, 18 probenecid, 7 PROCARDIA XL, 15 prochlorperazine, 28 PROCTOFOAM-HC, 30 progesterone gel, 28

progesterone, micronized, 28 PROMACTA, 31 promethazine, 28 PROMETRIUM, 28 propafenone, 13 propafenone ext-rel, 13 propranolol, 15 propranolol ext-rel, 15 propylthiouracil, 28 PROSCAR, 30 PROVERA, 28 PULMICORT FLEXHALER, 35 PULMICORT RESPULES, 35 PULMOZYME, 34 PYLERA, 30 pyrazinamide, 11 pyridostigmine ext-rel, 22 pyridostigmine soln, tabs 60 mg, 22 pyridostigmine tabs 30 mg, 22 Q QUESTRAN/QUESTRAN LIGHT, 14 quetiapine, 19 quetiapine ext-rel, 19 quinapril, 12 quinapril/hydrochlorothiazide, 12 QVAR REDIHALER, 35 R rabeprazole delayed-rel, 30 ragweed pollen allergen extract, 31 RAGWITEK, 31 raloxifene, 28 raltegravir, 10 ramelteon, 20 ramipril, 12 ranibizumab, 40 ranolazine ext-rel, 17 rasagiline, 19 RASUVO, 32 RAZADYNE, 18 RAZADYNE ER, 18 REBIF, 21 REGLAN, 28 RELENZA, 11 RELPAX, 21 REMERON, 19 repaglinide, 24 REPATHA, 14 REQUIP XL, 19 RESTASIS, 40 RESTORIL, 20 RETIN-A, 36 RETROVIR, 10 REVATIO, 16 RHOPRESSA, 40 ribavirin, 11 RIFADIN, 11 rifampin, 11 rifaximin 550 mg, 12 rilpivirine, 10 RINVOQ, 32 riociguat, 17 risankizumab-rzaa, 32 risedronate, 24

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risedronate delayed-rel, 24 RISPERDAL, 19 risperidone, 19 RITALIN, 20 ritonavir, 11 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, 14 rotigotine transdermal, 19 ROWASA, 29 ROXICODONE, 8 RUCONEST, 32 RYTHMOL SR, 13 S sacubitril/valsartan, 16 SALAGEN, 30 salmeterol xinafoate, 34 SANCUSO, 28 sapropterin, 27 scopolamine transdermal, 28 SEASONIQUE, 26 secukinumab, 32 selegiline, 19 selenium sulfide lotion 2.5%, 36 selexipag, 16 semaglutide, 23 SENSIPAR, 24 SEREVENT, 34 SEROQUEL, 19 sertraline, 18 sevelamer carbonate, 27 sildenafil, 16 SILENOR, 20 silodosin, 30 SILVADENE, 36 silver sulfadiazine, 36 SIMBRINZA, 40 simvastatin, 14 SINEMET, 19 SINEMET CR, 19 siponimod, 21 sirolimus, 32 sitagliptin phosphate, 23 sitagliptin/metformin, 23 sitagliptin/metformin ext-rel, 23 SKELAXIN, 22 SKYRIZI, 32 sodium sulfate/potassium sulfate/magnesium sulfate, 29 sodium zirconium cyclosilicate, 27 sofosbuvir/velpatasvir, 11 sofosbuvir/velpatasvir/voxilaprevir, 11 solifenacin, 30 SOLIQUA, 23 solriamfetol, 22

somatropin, 27 SOMATULINE DEPOT, 22 SOMAVERT, 22 SOOLANTRA, 38 SORIATANE, 36 sotalol, 13 soy phospholipid/glycerol dioleate, 38 SPIRIVA, 33 spironolactone, 13 spironolactone/hydrochlorothiazide, 16 STALEVO, 19 stavudine, 10 STELARA SUBCUTANEOUS, 32 STIOLTO RESPIMAT, 33 STRATTERA, 20 STRIBILD, 10 STRIVERDI RESPIMAT, 34 STROMECTOL, 12 sucralfate, 30 sulfacetamide lotion 10%, 36 sulfacetamide oint 10%, 38 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 SUNOSI, 22 SUPRAX, 9 SUPREP, 29 SYLATRON, 32 SYMBICORT, 35 SYMFI, 10 SYMFI LO, 10 SYMLINPEN, 23 SYMPROIC, 29 SYNJARDY, 24 SYNJARDY XR, 24 SYNTHROID, 28 T tacrolimus, 32, 37 tadalafil, 16 tamsulosin, 30 TAPAZOLE, 28 tapentadol, 8 tapentadol ext-rel, 8 TARKA, 12 tazarotene, 36 TAZORAC, 36 TECFIDERA, 21 TEGRETOL, 17 TEKTURNA HCT, 15 telmisartan, 13 telmisartan/hydrochlorothiazide, 13 temazepam, 20 TEMIXYS, 10 TEMOVATE, 37 tenofovir alafenamide, 11

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tenofovir disoproxil fumarate, 10 terazosin, 13 terbinafine tabs, 9 terbutaline, 34 terconazole, 30 teriflunomide, 21 teriparatide, 25 TESSALON, 34 testosterone cypionate, 22 testosterone enanthate, 22 testosterone gel, 22 testosterone soln, 22 testosterone transdermal, 23 tetrabenazine, 21 tetracycline, 9 theophylline ext-rel tabs, 35 thiothixene, 20 tiagabine, 17 TIAZAC, 15 ticagrelor, 31 TIGAN, 29 TIKOSYN, 13 timolol hemihydrate, 39 timolol maleate, 39 timolol maleate gel, 39 TIMOPTIC, 39 timothy grass pollen allergen extract, 32 tinidazole, 11 tiotropium, 33 tiotropium/olodaterol, 33 TIVICAY, 10 tizanidine tabs, 22 TOBRADEX, 39 TOBRADEX ST, 39 tobramycin, 39 tobramycin inhalation soln, 34 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 TOFRANIL, 19 TOLAK, 36 tolterodine, 30 tolterodine ext-rel, 30 TOPAMAX, 18 topiramate, 18 topiramate ext-rel, 17 torsemide, 15 TOVIAZ, 30 tramadol, 8 tramadol ext-rel, 8 trandolapril, 12 trandolapril/verapamil ext-rel, 12 tranylcypromine, 18 TRAVATAN Z, 40 travoprost, 40 trazodone, 19 TRELEGY ELLIPTA, 33 TREMFYA, 32 treprostinil ext-rel, 16 TRESIBA, 23 tretinoin, 36

tretinoin - Avita, 36 tretinoin gel microsphere, 36 triamcinolone acetonide crm 0.5%, 37 triamcinolone acetonide crm, lotion 0.025%, 37 triamcinolone acetonide crm, lotion, oint 0.1%, 37 triamcinolone paste, 38 triamterene, 16 triamterene/hydrochlorothiazide, 16 TRIBENZOR, 13 trifluoperazine, 20 trifluridine, 39 trihexyphenidyl, 19 TRILEPTAL, 18 TRILIPIX, 14 trimethobenzamide, 29 trimethoprim, 12 TRINTELLIX, 18 TRIUMEQ, 10 TROKENDI XR, 17 trospium, 30 trospium ext-rel, 30 TRULICITY, 23 TRUSOPT, 40 TRUVADA, 10 TYMLOS, 25 U ULORIC, 7 ULTRAM, 8 ULTRAVATE, 37 umeclidinium bromide, 33 umeclidinium/vilanterol, 33 upadacitinib, 32 UPTRAVI, 16 URECHOLINE, 31 UROCIT-K, 31 URSO, 29 ursodiol, 29 ustekinumab, 32 V VAGIFEM, 26 valacyclovir, 11 valbenazine, 21 valganciclovir, 11 VALIUM, 17 valproic acid, 18 valsartan, 13 valsartan/hydrochlorothiazide, 13 VARUBI, 28 VASCEPA, 14 VASERETIC, 12 VASOTEC, 12 VELTASSA, 27 VEMLIDY, 11 venlafaxine, 18 venlafaxine ext-rel, 18 verapamil ext-rel, 15 VFEND, 9 V-GO INSULIN INFUSION PUMP, 24 VIBERZI, 29 VIBRAMYCIN, 9 VICTOZA, 23 VIDEX EC, 10 vigabatrin, 17

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VIGAMOX, 39 VIIBRYD, 18 vilazodone, 18 VIMPAT, 17 VIOKACE, 29 VIREAD, 10 voriconazole, 9 vortioxetine, 18 VOSEVI, 11 VRAYLAR, 19 VYTORIN, 14 VYVANSE, 20 W warfarin, 31 WELLBUTRIN SR, 19 WELLBUTRIN XL, 19 X XALATAN, 40 XARELTO, 31 XELJANZ, 32 XELJANZ XR, 32 XIFAXAN, 12 XIGDUO XR, 24 XIIDRA, 40 XTAMPZA ER, 8 XULTOPHY, 23 Y YASMIN, 25

Z zafirlukast, 34 ZANAFLEX, 22 zanamivir, 11 ZARONTIN, 17 ZEMBRACE SYMTOUCH, 21 ZEMPLAR, 27 ZENPEP, 30 ZESTORETIC, 12 ZESTRIL, 12 ZIAC, 15 ZIAGEN, 10 zidovudine, 10 zileuton ext-rel, 34 ziprasidone, 19 ZITHROMAX, 9 ZOCOR, 14 ZOFRAN, 29 zolmitriptan, 21 zolmitriptan nasal spray, 21 ZOLOFT, 18 zolpidem, 20 zolpidem ext-rel, 20 zolpidem sublingual, 20 ZOMIG, 21 zonisamide, 17 ZOVIRAX, 11 ZUBSOLV, 22 ZYCLARA, 36 ZYLOPRIM, 7 ZYPREXA, 19

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3 Tier Drug Formulary - 2020...DAKOTACARE-ONE 2020 3-Tier Drug Formulary EFFECTIVE 04/01/2020 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Please