ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

Arkansas Blue Cross and Blue Shield Standard with Step Therapy Formulary

(01012020)

INTRODUCTION 4

PREFACE4

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE4

DRUG LIST PRODUCT DESCRIPTIONS5

GENERIC SUBSTITUTION5

LEGEND 6

ANALGESICS 8 NSAIDs8 NSAIDs COMBINATIONS8 NSAIDs TOPICAL 8 COX-2 INHIBITORS8 GOUT 8 OPIOID ANALGESICS8 NON-OPIOID ANALGESICS 9

ANTI-INFECTIVES 9 ANTIBACTERIALS10 ANTIFUNGALS 10 ANTIMALARIALS 11 ANTIRETROVIRAL AGENTS 11 ANTITUBERCULAR AGENTS12 ANTIVIRALS 12 MISCELLANEOUS12

ANTINEOPLASTIC AGENTS 13 ALKYLATING AGENTS 13 ANTIMETABOLITES13 HORMONAL ANTINEOPLASTIC AGENTS13 IMMUNOMODULATORS14 KINASE INHIBITORS 14 TOPOISOMERASE INHIBITORS 14 MISCELLANEOUS14

CARDIOVASCULAR14 ACE INHIBITORS 14 ACE INHIBITORCALCIUM CHANNEL BLOCKER COMBINATIONS 15 ACE INHIBITORDIURETIC COMBINATIONS15 ADRENOLYTICS CENTRAL 15 ALDOSTERONE RECEPTOR ANTAGONISTS 15 ALPHA BLOCKERS15 ANGIOTENSIN II RECEPTOR ANTAGONISTSDIURETIC COMBINATIONS 15 ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKER COMBINATIONS 16 ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKERDIURETIC COMBINATIONS 16 ANTIARRHYTHMICS16 ANTILIPEMICS 16 BETA-BLOCKERS 17 BETA-BLOCKERDIURETIC COMBINATIONS17 CALCIUM CHANNEL BLOCKERS 17 CALCIUM CHANNEL BLOCKERANTILIPEMIC COMBINATIONS 18 DIGITALIS GLYCOSIDES 18 DIRECT RENIN INHIBITORSDIURETIC COMBINATIONS 18 DIURETICS 18 HEART FAILURE 18 NITRATES19 PULMONARY ARTERIAL HYPERTENSION 19 MISCELLANEOUS19

CENTRAL NERVOUS SYSTEM 19 ANTIANXIETY19

1

ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

ANTICONVULSANTS 20 ANTIDEMENTIA20 ANTIDEPRESSANTS 21 ANTIPARKINSONIAN AGENTS 21 ANTIPSYCHOTICS22 ATTENTION DEFICIT HYPERACTIVITY DISORDER 22 FIBROMYALGIA 23 HYPNOTICS 23 MIGRAINE23 MOOD STABILIZERS 24 MOVEMENT DISORDERS 24 MULTIPLE SCLEROSIS AGENTS 24 MUSCULOSKELETAL THERAPY AGENTS 24 MYASTHENIA GRAVIS 24 NARCOLEPSY24 POSTHERPETIC NEURALGIA (PHN) 24 PSYCHOTHERAPEUTIC-MISCELLANEOUS24

ENDOCRINE AND METABOLIC 25 ACROMEGALY 25 ANDROGENS 25 ANTIDIABETICS 25 CALCIUM RECEPTOR ANTAGONISTS 27 CALCIUM REGULATORS 27 CARNITINE DEFICIENCY AGENTS 27 CONTRACEPTIVES 28 ENDOMETRIOSIS 29 ESTROGENS29 ESTROGENPROGESTINS 29 ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS29 FERTILITY REGULATORS 30 GAUCHER DISEASE30 GLUCOCORTICOIDS30 GLUCOSE ELEVATING AGENTS30 HEREDITARY TYROSINEMIA TYPE 1 AGENTS30 HUMAN GROWTH HORMONES 30 HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS 30 PHENYLKETONURIA TREATMENT AGENTS30 PHOSPHATE BINDER AGENTS30 POTASSIUM-REMOVING AGENTS 31 PROGESTINS31 SELECTIVE ESTROGEN RECEPTOR MODULATORS31 THYROID AGENTS 31 VASOPRESSINS 32 MISCELLANEOUS32

GASTROINTESTINAL 32 ANTIDIARRHEALS 32 ANTIEMETICS 32 ANTISPASMODICS 32 CHOLELITHOLYTICS32 H2 RECEPTOR ANTAGONISTS32 INFLAMMATORY BOWEL DISEASE 33 IRRITABLE BOWEL SYNDROME33 LAXATIVES33 OPIOID-INDUCED CONSTIPATION 33 PANCREATIC ENZYMES33 PROSTAGLANDINS 33 PROTON PUMP INHIBITORS33 SALIVA STIMULANTS34 STEROIDS RECTAL34 ULCER THERAPY COMBINATIONS 34 MISCELLANEOUS34

GENITOURINARY34 BENIGN PROSTATIC HYPERPLASIA34 URINARY ANTISPASMODICS34

2

ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

VAGINAL ANTI-INFECTIVES 34 MISCELLANEOUS34

HEMATOLOGIC35 ANTICOAGULANTS 35 HEMATOPOIETIC GROWTH FACTORS35 HEMOPHILIA A AGENTS35 HEMOPHILIA B AGENTS35 HEREDITARY ANGIOEDEMA35 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS35 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 35 PLATELET AGGREGATION INHIBITORS36 PLATELET SYNTHESIS INHIBITORS 36 STEM CELL MOBILIZERS 36 THROMBOCYTOPENIA AGENTS 36 MISCELLANEOUS36

IMMUNOLOGIC AGENTS 36 ALLERGENIC EXTRACTS 36 AUTOIMMUNE AGENTS 36 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)36 IMMUNOMODULATORS36 IMMUNOSUPPRESSANTS 37

NUTRITIONALSUPPLEMENTS 37 ELECTROLYTES37 VITAMINS AND MINERALS 37

RESPIRATORY 38 ANAPHYLAXIS TREATMENT AGENTS 38 ANTICHOLINERGICS38 ANTICHOLINERGICBETA AGONIST COMBINATIONS 38 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 38 ANTIHISTAMINES LOW SEDATING 38 ANTIHISTAMINES SEDATING38 ANTITUSSIVES 38 ANTITUSSIVE COMBINATIONS39 BETA AGONISTS 39 CYSTIC FIBROSIS 39 LEUKOTRIENE MODULATORS 39 MAST CELL STABILIZERS 39 NASAL ANTIHISTAMINES 39 NASAL STEROIDSCOMBINATIONS 40 PHOSPHODIESTERASE-4 INHIBITORS40 PULMONARY ENZYME DEFICIENCY AGENTS40 PULMONARY FIBROSIS AGENTS40 SEVERE ASTHMA AGENTS40 STEROIDBETA AGONIST COMBINATIONS40 STEROID INHALANTS 40 XANTHINES40 MISCELLANEOUS40

TOPICAL 40 DERMATOLOGY 40 MOUTHTHROATDENTAL AGENTS 43 OPHTHALMIC43 OTIC46

WEBSITES 47

INDEX 49

3

INTRODUCTION

We are pleased to provide the 2020 Arkansas Blue Cross and Blue Shield Standard with Step Therapy Formulary as a useful reference and informational tool The Standard with Step Therapy Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

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

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

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

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

PREFACE

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

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

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

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

Tier 1 Lowest plan member copayment All generic drugs including those on the Standard with Step Therapy Formulary

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

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

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE

The services of an independent National Pharmacy and Therapeutics Committee (PampT Committee) are utilized to approve safe and clinically effective drug therapies The PampT Committee is an external advisory body of clinical professionals from across the United States The PampT Committees voting members include physicians pharmacists a pharmacoeconomist and a medical ethicist all of whom have a broad background of clinical and academic expertise

4

ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

ANTICONVULSANTS 20 ANTIDEMENTIA20 ANTIDEPRESSANTS 21 ANTIPARKINSONIAN AGENTS 21 ANTIPSYCHOTICS22 ATTENTION DEFICIT HYPERACTIVITY DISORDER 22 FIBROMYALGIA 23 HYPNOTICS 23 MIGRAINE23 MOOD STABILIZERS 24 MOVEMENT DISORDERS 24 MULTIPLE SCLEROSIS AGENTS 24 MUSCULOSKELETAL THERAPY AGENTS 24 MYASTHENIA GRAVIS 24 NARCOLEPSY24 POSTHERPETIC NEURALGIA (PHN) 24 PSYCHOTHERAPEUTIC-MISCELLANEOUS24

ENDOCRINE AND METABOLIC 25 ACROMEGALY 25 ANDROGENS 25 ANTIDIABETICS 25 CALCIUM RECEPTOR ANTAGONISTS 27 CALCIUM REGULATORS 27 CARNITINE DEFICIENCY AGENTS 27 CONTRACEPTIVES 28 ENDOMETRIOSIS 29 ESTROGENS29 ESTROGENPROGESTINS 29 ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS29 FERTILITY REGULATORS 30 GAUCHER DISEASE30 GLUCOCORTICOIDS30 GLUCOSE ELEVATING AGENTS30 HEREDITARY TYROSINEMIA TYPE 1 AGENTS30 HUMAN GROWTH HORMONES 30 HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS 30 PHENYLKETONURIA TREATMENT AGENTS30 PHOSPHATE BINDER AGENTS30 POTASSIUM-REMOVING AGENTS 31 PROGESTINS31 SELECTIVE ESTROGEN RECEPTOR MODULATORS31 THYROID AGENTS 31 VASOPRESSINS 32 MISCELLANEOUS32

GASTROINTESTINAL 32 ANTIDIARRHEALS 32 ANTIEMETICS 32 ANTISPASMODICS 32 CHOLELITHOLYTICS32 H2 RECEPTOR ANTAGONISTS32 INFLAMMATORY BOWEL DISEASE 33 IRRITABLE BOWEL SYNDROME33 LAXATIVES33 OPIOID-INDUCED CONSTIPATION 33 PANCREATIC ENZYMES33 PROSTAGLANDINS 33 PROTON PUMP INHIBITORS33 SALIVA STIMULANTS34 STEROIDS RECTAL34 ULCER THERAPY COMBINATIONS 34 MISCELLANEOUS34

GENITOURINARY34 BENIGN PROSTATIC HYPERPLASIA34 URINARY ANTISPASMODICS34

2

ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

VAGINAL ANTI-INFECTIVES 34 MISCELLANEOUS34

HEMATOLOGIC35 ANTICOAGULANTS 35 HEMATOPOIETIC GROWTH FACTORS35 HEMOPHILIA A AGENTS35 HEMOPHILIA B AGENTS35 HEREDITARY ANGIOEDEMA35 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS35 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 35 PLATELET AGGREGATION INHIBITORS36 PLATELET SYNTHESIS INHIBITORS 36 STEM CELL MOBILIZERS 36 THROMBOCYTOPENIA AGENTS 36 MISCELLANEOUS36

IMMUNOLOGIC AGENTS 36 ALLERGENIC EXTRACTS 36 AUTOIMMUNE AGENTS 36 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)36 IMMUNOMODULATORS36 IMMUNOSUPPRESSANTS 37

NUTRITIONALSUPPLEMENTS 37 ELECTROLYTES37 VITAMINS AND MINERALS 37

RESPIRATORY 38 ANAPHYLAXIS TREATMENT AGENTS 38 ANTICHOLINERGICS38 ANTICHOLINERGICBETA AGONIST COMBINATIONS 38 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 38 ANTIHISTAMINES LOW SEDATING 38 ANTIHISTAMINES SEDATING38 ANTITUSSIVES 38 ANTITUSSIVE COMBINATIONS39 BETA AGONISTS 39 CYSTIC FIBROSIS 39 LEUKOTRIENE MODULATORS 39 MAST CELL STABILIZERS 39 NASAL ANTIHISTAMINES 39 NASAL STEROIDSCOMBINATIONS 40 PHOSPHODIESTERASE-4 INHIBITORS40 PULMONARY ENZYME DEFICIENCY AGENTS40 PULMONARY FIBROSIS AGENTS40 SEVERE ASTHMA AGENTS40 STEROIDBETA AGONIST COMBINATIONS40 STEROID INHALANTS 40 XANTHINES40 MISCELLANEOUS40

TOPICAL 40 DERMATOLOGY 40 MOUTHTHROATDENTAL AGENTS 43 OPHTHALMIC43 OTIC46

WEBSITES 47

INDEX 49

3

INTRODUCTION

We are pleased to provide the 2020 Arkansas Blue Cross and Blue Shield Standard with Step Therapy Formulary as a useful reference and informational tool The Standard with Step Therapy Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

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

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

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

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

PREFACE

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

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

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

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

Tier 1 Lowest plan member copayment All generic drugs including those on the Standard with Step Therapy Formulary

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

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

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE

The services of an independent National Pharmacy and Therapeutics Committee (PampT Committee) are utilized to approve safe and clinically effective drug therapies The PampT Committee is an external advisory body of clinical professionals from across the United States The PampT Committees voting members include physicians pharmacists a pharmacoeconomist and a medical ethicist all of whom have a broad background of clinical and academic expertise

4

ampif Arkansas T ~ BlueCross BlueShield

amp if BlueAdvantage T VI Administrators of Arkansas

VAGINAL ANTI-INFECTIVES 34 MISCELLANEOUS34

HEMATOLOGIC35 ANTICOAGULANTS 35 HEMATOPOIETIC GROWTH FACTORS35 HEMOPHILIA A AGENTS35 HEMOPHILIA B AGENTS35 HEREDITARY ANGIOEDEMA35 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS35 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS 35 PLATELET AGGREGATION INHIBITORS36 PLATELET SYNTHESIS INHIBITORS 36 STEM CELL MOBILIZERS 36 THROMBOCYTOPENIA AGENTS 36 MISCELLANEOUS36

IMMUNOLOGIC AGENTS 36 ALLERGENIC EXTRACTS 36 AUTOIMMUNE AGENTS 36 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)36 IMMUNOMODULATORS36 IMMUNOSUPPRESSANTS 37

NUTRITIONALSUPPLEMENTS 37 ELECTROLYTES37 VITAMINS AND MINERALS 37

RESPIRATORY 38 ANAPHYLAXIS TREATMENT AGENTS 38 ANTICHOLINERGICS38 ANTICHOLINERGICBETA AGONIST COMBINATIONS 38 ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS 38 ANTIHISTAMINES LOW SEDATING 38 ANTIHISTAMINES SEDATING38 ANTITUSSIVES 38 ANTITUSSIVE COMBINATIONS39 BETA AGONISTS 39 CYSTIC FIBROSIS 39 LEUKOTRIENE MODULATORS 39 MAST CELL STABILIZERS 39 NASAL ANTIHISTAMINES 39 NASAL STEROIDSCOMBINATIONS 40 PHOSPHODIESTERASE-4 INHIBITORS40 PULMONARY ENZYME DEFICIENCY AGENTS40 PULMONARY FIBROSIS AGENTS40 SEVERE ASTHMA AGENTS40 STEROIDBETA AGONIST COMBINATIONS40 STEROID INHALANTS 40 XANTHINES40 MISCELLANEOUS40

TOPICAL 40 DERMATOLOGY 40 MOUTHTHROATDENTAL AGENTS 43 OPHTHALMIC43 OTIC46

WEBSITES 47

INDEX 49

3

INTRODUCTION

We are pleased to provide the 2020 Arkansas Blue Cross and Blue Shield Standard with Step Therapy Formulary as a useful reference and informational tool The Standard with Step Therapy Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

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

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

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

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

PREFACE

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

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

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

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

Tier 1 Lowest plan member copayment All generic drugs including those on the Standard with Step Therapy Formulary

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

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

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE

The services of an independent National Pharmacy and Therapeutics Committee (PampT Committee) are utilized to approve safe and clinically effective drug therapies The PampT Committee is an external advisory body of clinical professionals from across the United States The PampT Committees voting members include physicians pharmacists a pharmacoeconomist and a medical ethicist all of whom have a broad background of clinical and academic expertise

4

INTRODUCTION

We are pleased to provide the 2020 Arkansas Blue Cross and Blue Shield Standard with Step Therapy Formulary as a useful reference and informational tool The Standard with Step Therapy Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients

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

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

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

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

PREFACE

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

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

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

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

Tier 1 Lowest plan member copayment All generic drugs including those on the Standard with Step Therapy Formulary

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

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

PHARMACY AND THERAPEUTICS (PampT) COMMITTEE

The services of an independent National Pharmacy and Therapeutics Committee (PampT Committee) are utilized to approve safe and clinically effective drug therapies The PampT Committee is an external advisory body of clinical professionals from across the United States The PampT Committees voting members include physicians pharmacists a pharmacoeconomist and a medical ethicist all of whom have a broad background of clinical and academic expertise

4

regarding prescription drugs Employees with significant clinical expertise are invited to meet with the PampT Committee but no employee may vote on issues before the PampT Committee Voting members of the PampT Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers

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

DRUG LIST PRODUCT DESCRIPTIONS

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

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

pregabalin Lyrica Oral capsules oral solution and all strengths of Lyrica would be included in this listing

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

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

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

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

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

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

neomycinpolymyxin Bhydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section it is limited to the otic solution and suspension From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the Standard with Step Therapy Formulary

GENERIC SUBSTITUTION

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

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

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

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

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

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

Incur higher copayment (tier 3)

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

5

Require mandatory generic dispensing

6

LEGEND

dagger Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy (Note Step Therapy may not apply to all plans)

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

7

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1 nabumetone Tier 1

naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

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

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

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

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

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1

PA fentanyl transmucosal lozenge Tier 1 QL hydromorphone ext-rel Tier 1

QL methadone Tier 1

QL morphine Tier 1 QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

QL oxycodone tabs 5 mg Tier 1

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

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

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

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

8

Require mandatory generic dispensing

6

LEGEND

dagger Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy (Note Step Therapy may not apply to all plans)

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

7

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1 nabumetone Tier 1

naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

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

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

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

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

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1

PA fentanyl transmucosal lozenge Tier 1 QL hydromorphone ext-rel Tier 1

QL methadone Tier 1

QL morphine Tier 1 QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

QL oxycodone tabs 5 mg Tier 1

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

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

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

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

8

LEGEND

dagger Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy (Note Step Therapy may not apply to all plans)

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

7

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1 nabumetone Tier 1

naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

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

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

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

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

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1

PA fentanyl transmucosal lozenge Tier 1 QL hydromorphone ext-rel Tier 1

QL methadone Tier 1

QL morphine Tier 1 QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

QL oxycodone tabs 5 mg Tier 1

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

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

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

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

8

ANALGESICS

Practice guidelines of pain management are available at httpswwwasahqorg

NSAIDs diclofenac sodium delayed-rel Tier 1

diflunisal Tier 1

ibuprofen Tier 1 nabumetone Tier 1

naproxen sodium tabs Tier 1

naproxen tabs Tier 1

sulindac Tier 1 meloxicam Tier 2 MOBIC

oxaprozin Tier 2 DAYPRO

NSAIDs COMBINATIONS

diclofenac sodium delayed-relmisoprostol Tier 1

NSAIDs TOPICAL

PA diclofenac sodium gel 1 Tier 1

diclofenac sodium soln Tier 1

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

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1

febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

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

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

QL codeineacetaminophen Tier 1

QL fentanyl transdermal Tier 1

PA fentanyl transmucosal lozenge Tier 1 QL hydromorphone ext-rel Tier 1

QL methadone Tier 1

QL morphine Tier 1 QL morphine ext-rel Tier 1

QL morphine supp Tier 1

QL oxycodone concentrate 20 mgmL Tier 1

QL oxycodone tabs 5 mg Tier 1

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

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

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

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

8

QL oxycodoneacetaminophen 5325 Tier 1 QL tramadol ext-rel Tier 1

QL buprenorphine Tier 2 BELBUCA

PA fentanyl sublingual spray Tier 2 SUBSYS

QL morphinenaltrexone ext-rel Tier 2 EMBEDA QL oxycodone ext-rel Tier 2 XTAMPZA ER

QL oxycodoneacetaminophen soln Tier 2 ROXICET

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

QL hydrocodoneacetaminophen Tier 3 NORCO

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

QL morphine ext-rel Tier 3 MS CONTIN

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

QL tramadol Tier 3 ULTRAM

NON-OPIOID ANALGESICS

butalbitalacetaminophencaffeine tabs Tier 2 ESGIC butalbitalaspirincaffeine Tier 2 FIORINAL

ANTI-INFECTIVES

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

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

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

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

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

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

International Travel CDC recommendations for international travel are available at httpswwwnccdcgovtravel

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

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

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

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

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

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

9

ANTIBACTERIALS Cephalosporins First Generation

cefadroxil Tier 1 cephalexin Tier 3 KEFLEX

Second Generation cefprozil Tier 1

cefuroxime axetil Tier 1

Third Generation

cefdinir Tier 1

cefixime Tier 2 SUPRAX

ErythromycinsMacrolides

clarithromycin Tier 1 clarithromycin ext-rel Tier 1

erythromycin delayed-rel Tier 1

erythromycin ethylsuccinate Tier 1

erythromycin stearate Tier 1 ST QL fidaxomicin Tier 2 DIFICID

azithromycin Tier 3 ZITHROMAX

Fluoroquinolones

ciprofloxacin Tier 3 CIPRO

levofloxacin Tier 3 LEVAQUIN moxifloxacin Tier 3 AVELOX

Penicillins amoxicillin Tier 1

amoxicillinclavulanate ext-rel Tier 1

ampicillin Tier 1

dicloxacillin Tier 1 penicillin VK Tier 1

amoxicillinclavulanate Tier 3 AUGMENTIN

Tetracyclines

doxycycline hyclate 20 mg Tier 1

minocycline Tier 1 tetracycline Tier 1

PA doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS

clotrimazole troches Tier 1

griseofulvin ultramicrosize Tier 1

PA itraconazole Tier 1 nystatin Tier 1

terbinafine tabs Tier 1

PA voriconazole Tier 2 VFEND fluconazole Tier 3 DIFLUCAN

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

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

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

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

10

ANTIMALARIALS chloroquine Tier 1

mefloquine Tier 1

atovaquoneproguanil Tier 2 MALARONE

ANTIRETROVIRAL AGENTS Antiretroviral Combinations

QL abacavirdolutegravirlamivudine Tier 2 TRIUMEQ

QL atazanavircobicistat Tier 2 EVOTAZ

QL bictegraviremtricitabinetenofovir alafenamide Tier 2 BIKTARVY

QL darunavircobicistat Tier 2 PREZCOBIX QL efavirenzemtricitabinetenofovir disoproxil fumarate Tier 2 ATRIPLA

QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI

QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI LO QL elvitegravircobicistatemtricitabinetenofovir alafenamide Tier 2 GENVOYA

QL elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate Tier 2 STRIBILD

QL emtricitabinerilpivirinetenofovir alafenamide Tier 2 ODEFSEY QL emtricitabinerilpivirinetenofovir disoproxil fumarate Tier 2 COMPLERA

QL emtricitabinetenofovir alafenamide Tier 2 DESCOVY

QL emtricitabinetenofovir disoproxil fumarate Tier 2 TRUVADA

QL lamivudinetenofovir disoproxil fumarate Tier 2 CIMDUO QL lamivudinetenofovir disoproxil fumarate Tier 2 TEMIXYS

QL abacavirlamivudine Tier 3 EPZICOM

QL lamivudinezidovudine Tier 3 COMBIVIR

Fusion Inhibitors

QL enfuvirtide Tier 2 FUZEON

Integrase Inhibitors

QL dolutegravir Tier 2 TIVICAY QL raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz Tier 1

QL nevirapine Tier 1

QL nevirapine ext-rel Tier 1

QL etravirine Tier 2 INTELENCE QL rilpivirine Tier 2 EDURANT

Nucleoside Reverse Transcriptase Inhibitors QL stavudine Tier 1

QL didanosine delayed-rel Tier 2 VIDEX EC

QL emtricitabine Tier 2 EMTRIVA QL zidovudine Tier 2 RETROVIR

QL abacavir tabs Tier 3 ZIAGEN

QL lamivudine Tier 3 EPIVIR

Nucleotide Reverse Transcriptase Inhibitors

QL tenofovir disoproxil fumarate Tier 2 VIREAD

Protease Inhibitors

QL atazanavir Tier 1

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

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

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

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

11

QL darunavir Tier 2 PREZISTA QL lopinavirritonavir soln Tier 2 KALETRA

QL lopinavirritonavir tabs Tier 2 KALETRA

QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS

isoniazid Tier 1

pyrazinamide Tier 1 ethambutol Tier 2 MYAMBUTOL

rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1

lamivudine Tier 1

entecavir soln Tier 2 BARACLUDE tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C SGM ribavirin tabs Tier 1

SGM ledipasvirsofosbuvir Tier 2 HARVONI

SGM ribavirin oral soln Tier 2 REBETOL

SGM sofosbuvirvelpatasvir Tier 2 EPCLUSA SGM sofosbuvirvelpatasvirvoxilaprevir Tier 2 VOSEVI

SGM ribavirin caps Tier 3 REBETOL

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

linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 sulfamethoxazoletrimethoprim Tier 1

sulfamethoxazoletrimethoprim DS Tier 1

tinidazole Tier 1 trimethoprim Tier 1

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

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

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

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

12

clindamycin Tier 2 CLEOCIN mebendazole chewable Tier 2 EMVERM

nitrofurantoin ext-rel Tier 2 MACROBID

rifaximin 550 mg Tier 2 XIFAXAN

vancomycin Tier 2 VANCOCIN ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS cyclophosphamide caps Tier 1

busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN melphalan Tier 2 ALKERAN

SGM temozolomide Tier 2 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1

SGM capecitabine Tier 2 XELODA

methotrexate Tier 2 TREXALL thioguanine Tier 2 TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

SGM abiraterone Tier 1

flutamide Tier 1 SGM abiraterone Tier 2 YONSA

SGM apalutamide Tier 2 ERLEADA

SGM darolutamide Tier 2 NUBEQA SGM enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX

Antiestrogens tamoxifen Tier 1

Aromatase Inhibitors anastrozole Tier 2 ARIMIDEX

exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate dagger leuprolide acetate ELIGARD

dagger leuprolide acetate LUPRON DEPOT

Progestins

megestrol acetate tabs Tier 1

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

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

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

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

13

ANTIMALARIALS chloroquine Tier 1

mefloquine Tier 1

atovaquoneproguanil Tier 2 MALARONE

ANTIRETROVIRAL AGENTS Antiretroviral Combinations

QL abacavirdolutegravirlamivudine Tier 2 TRIUMEQ

QL atazanavircobicistat Tier 2 EVOTAZ

QL bictegraviremtricitabinetenofovir alafenamide Tier 2 BIKTARVY

QL darunavircobicistat Tier 2 PREZCOBIX QL efavirenzemtricitabinetenofovir disoproxil fumarate Tier 2 ATRIPLA

QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI

QL efavirenzlamivudinetenofovir disoproxil fumarate Tier 2 SYMFI LO QL elvitegravircobicistatemtricitabinetenofovir alafenamide Tier 2 GENVOYA

QL elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate Tier 2 STRIBILD

QL emtricitabinerilpivirinetenofovir alafenamide Tier 2 ODEFSEY QL emtricitabinerilpivirinetenofovir disoproxil fumarate Tier 2 COMPLERA

QL emtricitabinetenofovir alafenamide Tier 2 DESCOVY

QL emtricitabinetenofovir disoproxil fumarate Tier 2 TRUVADA

QL lamivudinetenofovir disoproxil fumarate Tier 2 CIMDUO QL lamivudinetenofovir disoproxil fumarate Tier 2 TEMIXYS

QL abacavirlamivudine Tier 3 EPZICOM

QL lamivudinezidovudine Tier 3 COMBIVIR

Fusion Inhibitors

QL enfuvirtide Tier 2 FUZEON

Integrase Inhibitors

QL dolutegravir Tier 2 TIVICAY QL raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz Tier 1

QL nevirapine Tier 1

QL nevirapine ext-rel Tier 1

QL etravirine Tier 2 INTELENCE QL rilpivirine Tier 2 EDURANT

Nucleoside Reverse Transcriptase Inhibitors QL stavudine Tier 1

QL didanosine delayed-rel Tier 2 VIDEX EC

QL emtricitabine Tier 2 EMTRIVA QL zidovudine Tier 2 RETROVIR

QL abacavir tabs Tier 3 ZIAGEN

QL lamivudine Tier 3 EPIVIR

Nucleotide Reverse Transcriptase Inhibitors

QL tenofovir disoproxil fumarate Tier 2 VIREAD

Protease Inhibitors

QL atazanavir Tier 1

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

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

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

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

11

QL darunavir Tier 2 PREZISTA QL lopinavirritonavir soln Tier 2 KALETRA

QL lopinavirritonavir tabs Tier 2 KALETRA

QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS

isoniazid Tier 1

pyrazinamide Tier 1 ethambutol Tier 2 MYAMBUTOL

rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1

lamivudine Tier 1

entecavir soln Tier 2 BARACLUDE tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C SGM ribavirin tabs Tier 1

SGM ledipasvirsofosbuvir Tier 2 HARVONI

SGM ribavirin oral soln Tier 2 REBETOL

SGM sofosbuvirvelpatasvir Tier 2 EPCLUSA SGM sofosbuvirvelpatasvirvoxilaprevir Tier 2 VOSEVI

SGM ribavirin caps Tier 3 REBETOL

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

linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 sulfamethoxazoletrimethoprim Tier 1

sulfamethoxazoletrimethoprim DS Tier 1

tinidazole Tier 1 trimethoprim Tier 1

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

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

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

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

12

clindamycin Tier 2 CLEOCIN mebendazole chewable Tier 2 EMVERM

nitrofurantoin ext-rel Tier 2 MACROBID

rifaximin 550 mg Tier 2 XIFAXAN

vancomycin Tier 2 VANCOCIN ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS cyclophosphamide caps Tier 1

busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN melphalan Tier 2 ALKERAN

SGM temozolomide Tier 2 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1

SGM capecitabine Tier 2 XELODA

methotrexate Tier 2 TREXALL thioguanine Tier 2 TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

SGM abiraterone Tier 1

flutamide Tier 1 SGM abiraterone Tier 2 YONSA

SGM apalutamide Tier 2 ERLEADA

SGM darolutamide Tier 2 NUBEQA SGM enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX

Antiestrogens tamoxifen Tier 1

Aromatase Inhibitors anastrozole Tier 2 ARIMIDEX

exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate dagger leuprolide acetate ELIGARD

dagger leuprolide acetate LUPRON DEPOT

Progestins

megestrol acetate tabs Tier 1

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

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

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

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

13

QL darunavir Tier 2 PREZISTA QL lopinavirritonavir soln Tier 2 KALETRA

QL lopinavirritonavir tabs Tier 2 KALETRA

QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS

isoniazid Tier 1

pyrazinamide Tier 1 ethambutol Tier 2 MYAMBUTOL

rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1

lamivudine Tier 1

entecavir soln Tier 2 BARACLUDE tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C SGM ribavirin tabs Tier 1

SGM ledipasvirsofosbuvir Tier 2 HARVONI

SGM ribavirin oral soln Tier 2 REBETOL

SGM sofosbuvirvelpatasvir Tier 2 EPCLUSA SGM sofosbuvirvelpatasvirvoxilaprevir Tier 2 VOSEVI

SGM ribavirin caps Tier 3 REBETOL

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

linezolid Tier 1

nitrofurantoin macrocrystals Tier 1 sulfamethoxazoletrimethoprim Tier 1

sulfamethoxazoletrimethoprim DS Tier 1

tinidazole Tier 1 trimethoprim Tier 1

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

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

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

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

12

clindamycin Tier 2 CLEOCIN mebendazole chewable Tier 2 EMVERM

nitrofurantoin ext-rel Tier 2 MACROBID

rifaximin 550 mg Tier 2 XIFAXAN

vancomycin Tier 2 VANCOCIN ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS cyclophosphamide caps Tier 1

busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN melphalan Tier 2 ALKERAN

SGM temozolomide Tier 2 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1

SGM capecitabine Tier 2 XELODA

methotrexate Tier 2 TREXALL thioguanine Tier 2 TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

SGM abiraterone Tier 1

flutamide Tier 1 SGM abiraterone Tier 2 YONSA

SGM apalutamide Tier 2 ERLEADA

SGM darolutamide Tier 2 NUBEQA SGM enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX

Antiestrogens tamoxifen Tier 1

Aromatase Inhibitors anastrozole Tier 2 ARIMIDEX

exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate dagger leuprolide acetate ELIGARD

dagger leuprolide acetate LUPRON DEPOT

Progestins

megestrol acetate tabs Tier 1

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

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

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

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

13

clindamycin Tier 2 CLEOCIN mebendazole chewable Tier 2 EMVERM

nitrofurantoin ext-rel Tier 2 MACROBID

rifaximin 550 mg Tier 2 XIFAXAN

vancomycin Tier 2 VANCOCIN ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL

nitrofurantoin susp Tier 3 FURADANTIN

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at httpswwwascoorg httpswwwnccnorg

ALKYLATING AGENTS cyclophosphamide caps Tier 1

busulfan Tier 2 MYLERAN

chlorambucil Tier 2 LEUKERAN melphalan Tier 2 ALKERAN

SGM temozolomide Tier 2 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1

SGM capecitabine Tier 2 XELODA

methotrexate Tier 2 TREXALL thioguanine Tier 2 TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

SGM abiraterone Tier 1

flutamide Tier 1 SGM abiraterone Tier 2 YONSA

SGM apalutamide Tier 2 ERLEADA

SGM darolutamide Tier 2 NUBEQA SGM enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX

Antiestrogens tamoxifen Tier 1

Aromatase Inhibitors anastrozole Tier 2 ARIMIDEX

exemestane Tier 2 AROMASIN

letrozole Tier 2 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

dagger leuprolide acetate dagger leuprolide acetate ELIGARD

dagger leuprolide acetate LUPRON DEPOT

Progestins

megestrol acetate tabs Tier 1

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

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

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

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

13

IMMUNOMODULATORS

SGM lenalidomide Tier 2 REVLIMID

SGM pomalidomide Tier 2 POMALYST SGM thalidomide Tier 2 THALOMID

KINASE INHIBITORS SGM erlotinib Tier 1

SGM imatinib mesylate Tier 1

SGM bosutinib Tier 2 BOSULIF

SGM cabozantinib Tier 2 CABOMETYX SGM dasatinib Tier 2 SPRYCEL

SGM everolimus Tier 2 AFINITOR

SGM gefitinib Tier 2 IRESSA SGM lapatinib Tier 2 TYKERB

SGM midostaurin Tier 2 RYDAPT

SGM palbociclib Tier 2 IBRANCE SGM pazopanib Tier 2 VOTRIENT

SGM ribociclib Tier 2 KISQALI

SGM ribociclib + letrozole Tier 2 KISQALI FEMARA CO-PACK

SGM sunitinib Tier 2 SUTENT

TOPOISOMERASE INHIBITORS

SGM topotecan caps Tier 2 HYCAMTIN

MISCELLANEOUS

etoposide Tier 1 tretinoin caps Tier 1

SGM bexarotene caps Tier 2 TARGRETIN

hydroxyurea Tier 2 HYDREA mitotane Tier 2 LYSODREN

SGM niraparib Tier 2 ZEJULA

SGM olaparib Tier 2 LYNPARZA

procarbazine Tier 2 MATULANE SGM rucaparib Tier 2 RUBRACA

SGM sonidegib Tier 2 ODOMZO

SGM vorinostat Tier 2 ZOLINZA

CARDIOVASCULAR

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

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

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

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

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

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

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

14

httpswwwaccorg httpsprofessionalheartorg

captopril Tier 1 fosinopril Tier 1

perindopril Tier 1

trandolapril Tier 1 benazepril Tier 3 LOTENSIN

enalapril Tier 3 VASOTEC

lisinopril Tier 3 ZESTRIL

quinapril Tier 3 ACCUPRIL ramipril Tier 3 ALTACE

ACE INHIBITORCALCIUM CHANNEL BLOCKER COMBINATIONS amlodipinebenazepril Tier 2 LOTREL

trandolaprilverapamil ext-rel Tier 2 TARKA

ACE INHIBITORDIURETIC COMBINATIONS

captoprilhydrochlorothiazide Tier 1

fosinoprilhydrochlorothiazide Tier 1 benazeprilhydrochlorothiazide Tier 3 LOTENSIN HCT

enalaprilhydrochlorothiazide Tier 3 VASERETIC

lisinoprilhydrochlorothiazide Tier 3 ZESTORETIC

quinaprilhydrochlorothiazide Tier 3 ACCURETIC

ADRENOLYTICS CENTRAL

guanfacine Tier 1 clonidine Tier 2 CATAPRES

clonidine transdermal Tier 2 CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 2 INSPRA

spironolactone Tier 2 ALDACTONE

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

terazosin Tier 1 doxazosin Tier 3 CARDURA

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

candesartan Tier 1

candesartanhydrochlorothiazide Tier 1 eprosartan Tier 1

irbesartan Tier 1

irbesartanhydrochlorothiazide Tier 1 olmesartan Tier 1

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

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

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

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

15

olmesartanhydrochlorothiazide Tier 1 valsartan Tier 1

valsartanhydrochlorothiazide Tier 1

losartan Tier 3 COZAAR

losartanhydrochlorothiazide Tier 3 HYZAAR telmisartan Tier 3 MICARDIS

telmisartanhydrochlorothiazide Tier 3 MICARDIS HCT

ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipinetelmisartan Tier 1

amlodipinevalsartan Tier 1 amlodipineolmesartan Tier 3 AZOR

ANGIOTENSIN II RECEPTOR ANTAGONISTCALCIUM CHANNEL BLOCKERDIURETIC COMBINATIONS amlodipinevalsartanhydrochlorothiazide Tier 1

olmesartanamlodipinehydrochlorothiazide Tier 3 TRIBENZOR

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

amiodarone Tier 1

flecainide Tier 1 propafenone Tier 1

sotalol Tier 1

disopyramide Tier 2 NORPACE

disopyramide ext-rel Tier 2 NORPACE CR dofetilide Tier 2 TIKOSYN

dronedarone Tier 2 MULTAQ

propafenone ext-rel Tier 2 RYTHMOL SR

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

Bile Acid Resins colesevelam Tier 1

cholestyramine Tier 3 QUESTRANQUESTRAN LIGHT

colestipol Tier 3 COLESTID

Cholesterol Absorption Inhibitors

ezetimibe Tier 1

Fibrates

fenofibrate Tier 1

fenofibrate Tier 3 LIPOFEN fenofibric acid delayed-rel Tier 3 TRILIPIX

gemfibrozil Tier 3 LOPID

Listing does not include fenofibrate tablet 120 mg

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

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

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

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

16

atorvastatin Tier 1

fluvastatin Tier 1 lovastatin Tier 1

rosuvastatin Tier 1

ezetimibesimvastatin Tier 3 VYTORIN pravastatin Tier 3 PRAVACHOL

simvastatin Tier 3 ZOCOR

Niacins

niacin ext-rel Tier 3 NIASPAN

HMG-CoA Reductase InhibitorsCombinations

Omega-3 Fatty Acids PA icosapent ethyl Tier 2 VASCEPA

PA omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors

PA evolocumab Tier 2 REPATHA

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

atenolol Tier 1

bisoprolol Tier 1

carvedilol phosphate ext-rel Tier 1

labetalol Tier 1 metoprolol succinate ext-rel Tier 1

pindolol Tier 1

propranolol Tier 1 nebivolol Tier 2 BYSTOLIC

carvedilol Tier 3 COREG

metoprolol tartrate Tier 3 LOPRESSOR

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

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

atenololchlorthalidone Tier 1 bisoprololhydrochlorothiazide Tier 2 ZIAC

metoprololhydrochlorothiazide Tier 2 LOPRESSOR HCT

CALCIUM CHANNEL BLOCKERS Dihydropyridines

amlodipine Tier 1

felodipine ext-rel Tier 1 nifedipine ext-rel Tier 3 ADALAT CC

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

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

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

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

17

isosorbide dinitratehydralazine Tier 2 BIDIL

ivabradine Tier 2 CORLANOR

sacubitrilvalsartan Tier 2 ENTRESTO

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 BLOCKERANTILIPEMIC COMBINATIONS amlodipineatorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES digoxin 0125 mg 025 mg Tier 1

digoxin ped elixir Tier 1

digoxin 00625 mg 01875 mg Tier 2 LANOXIN

DIRECT RENIN INHIBITORSDIURETIC COMBINATIONS

aliskiren Tier 1

ST aliskirenhydrochlorothiazide Tier 2 TEKTURNA HCT

DIURETICS Carbonic Anhydrase Inhibitors

acetazolamide Tier 1

acetazolamide ext-rel Tier 1

methazolamide Tier 1

Loop Diuretics

bumetanide Tier 1 furosemide Tier 3 LASIX

torsemide Tier 3 DEMADEX

Potassium-sparing Diuretics

amiloride Tier 1

Thiazides and Thiazide-like Diuretics

chlorthalidone Tier 1

hydrochlorothiazide Tier 1

indapamide Tier 1 metolazone Tier 1

Diuretic Combinations amiloridehydrochlorothiazide Tier 1

spironolactonehydrochlorothiazide Tier 3 ALDACTAZIDE

triamterenehydrochlorothiazide Tier 3 DYAZIDE triamterenehydrochlorothiazide Tier 3 MAXZIDE

HEART FAILURE

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

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

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

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

18

NITRATES Oral

isosorbide dinitrate ext-rel tabs Tier 1

isosorbide mononitrate Tier 1 isosorbide dinitrate oral Tier 2 ISORDIL

isosorbide mononitrate ext-rel Tier 2 IMDUR

SublingualTranslingual

Transdermal

nitroglycerin lingual spray Tier 3 NITROLINGUAL

nitroglycerin sublingual Tier 3 NITROSTAT

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 2 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

SGM ambrisentan Tier 1

SGM bosentan Tier 1

SGM macitentan Tier 2 OPSUMIT

Phosphodiesterase Inhibitors

SGM tadalafil Tier 1 SGM sildenafil Tier 3 REVATIO

Prostacyclin Receptor Agonists SGM selexipag Tier 2 UPTRAVI

Prostaglandin Vasodilators dagger epoprostenol sodium FLOLAN

SGM treprostinil ext-rel Tier 2 ORENITRAM

Soluble Guanylate Cyclase Stimulators

SGM riociguat Tier 2 ADEMPAS

MISCELLANEOUS

hydralazine Tier 1

methyldopa Tier 1

midodrine Tier 1 ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at httpswwwpsychiatryorg

ANTIANXIETY Benzodiazepines

alprazolam Tier 1

oxazepam Tier 1 diazepam Tier 2 VALIUM

lorazepam Tier 2 ATIVAN

clonazepam Tier 3 KLONOPIN

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

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

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

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

19

NITRATES Oral

isosorbide dinitrate ext-rel tabs Tier 1

isosorbide mononitrate Tier 1 isosorbide dinitrate oral Tier 2 ISORDIL

isosorbide mononitrate ext-rel Tier 2 IMDUR

SublingualTranslingual

Transdermal

nitroglycerin lingual spray Tier 3 NITROLINGUAL

nitroglycerin sublingual Tier 3 NITROSTAT

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 2 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

SGM ambrisentan Tier 1

SGM bosentan Tier 1

SGM macitentan Tier 2 OPSUMIT

Phosphodiesterase Inhibitors

SGM tadalafil Tier 1 SGM sildenafil Tier 3 REVATIO

Prostacyclin Receptor Agonists SGM selexipag Tier 2 UPTRAVI

Prostaglandin Vasodilators dagger epoprostenol sodium FLOLAN

SGM treprostinil ext-rel Tier 2 ORENITRAM

Soluble Guanylate Cyclase Stimulators

SGM riociguat Tier 2 ADEMPAS

MISCELLANEOUS

hydralazine Tier 1

methyldopa Tier 1

midodrine Tier 1 ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at httpswwwpsychiatryorg

ANTIANXIETY Benzodiazepines

alprazolam Tier 1

oxazepam Tier 1 diazepam Tier 2 VALIUM

lorazepam Tier 2 ATIVAN

clonazepam Tier 3 KLONOPIN

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

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

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

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

19

Miscellaneous

buspirone Tier 1

fluvoxamine Tier 1 clomipramine Tier 2 ANAFRANIL

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

carbamazepine ext-rel Tier 1

clobazam Tier 1

lamotrigine Tier 1 lamotrigine ext-rel Tier 1

lamotrigine orally disintegrating tabs Tier 1

phenobarbital Tier 1 tiagabine Tier 1

SGM vigabatrin Tier 1

zonisamide Tier 1

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

perampanel Tier 2 FYCOMPA

carbamazepine Tier 3 TEGRETOL carbamazepine ext-rel Tier 3 CARBATROL

diazepam rectal gel Tier 3 DIASTAT

divalproex sodium delayed-rel Tier 3 DEPAKOTE

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

gabapentin Tier 3 NEURONTIN

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

oxcarbazepine Tier 3 TRILEPTAL

phenytoin Tier 3 DILANTIN INFATABS phenytoin sodium extended Tier 3 DILANTIN

primidone Tier 3 MYSOLINE

topiramate Tier 3 TOPAMAX

valproic acid Tier 3 DEPAKENE

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

memantine ext-rel Tier 1

rivastigmine Tier 1

memantinedonepezil Tier 2 NAMZARIC

donepezil Tier 3 ARICEPT galantamine Tier 3 RAZADYNE

galantamine ext-rel Tier 3 RAZADYNE ER

memantine Tier 3 NAMENDA rivastigmine transdermal Tier 3 EXELON

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

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

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

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

20

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

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

Monoamine Oxidase Inhibitors (MAOIs)

phenelzine Tier 2 NARDIL tranylcypromine Tier 2 PARNATE

Selective Serotonin Reuptake Inhibitors (SSRIs) escitalopram Tier 1

fluoxetine Tier 1

ST vilazodone Tier 2 VIIBRYD

ST vortioxetine Tier 2 TRINTELLIX citalopram Tier 3 CELEXA

paroxetine HCl Tier 3 PAXIL

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

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1

duloxetine delayed-rel Tier 1

venlafaxine Tier 1 venlafaxine ext-rel Tier 1

Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1 doxepin Tier 1

desipramine Tier 2 NORPRAMIN

imipramine HCl Tier 2 TOFRANIL nortriptyline Tier 2 PAMELOR

Miscellaneous Agents bupropion Tier 1

trazodone Tier 1

bupropion ext-rel Tier 3 WELLBUTRIN SR bupropion ext-rel Tier 3 WELLBUTRIN XL

mirtazapine Tier 3 REMERON

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

amantadine Tier 1

benztropine Tier 1

carbidopalevodopa orally disintegrating tabs Tier 1 pramipexole ext-rel Tier 1

rasagiline Tier 1

ropinirole Tier 1 selegiline Tier 1

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

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

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

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

21

trihexyphenidyl Tier 1 rotigotine transdermal Tier 2 NEUPRO

bromocriptine Tier 3 PARLODEL

carbidopalevodopa Tier 3 SINEMET

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

entacapone Tier 3 COMTAN

pramipexole Tier 3 MIRAPEX ropinirole ext-rel Tier 3 REQUIP XL

ANTIPSYCHOTICS Atypicals

aripiprazole Tier 1

quetiapine ext-rel Tier 1 aripiprazole ext-rel inj Tier 2 ABILIFY MAINTENA

dagger aripiprazole lauroxil ext-rel inj ARISTADA

dagger aripiprazole lauroxil ext-rel inj ARISTADA INITIO

ST cariprazine Tier 2 VRAYLAR lurasidone Tier 2 LATUDA

risperidone long-acting injection Tier 2 RISPERDAL CONSTA

clozapine Tier 3 CLOZARIL olanzapine Tier 3 ZYPREXA

paliperidone palmitate ext-rel inj Tier 3 INVEGA SUSTENNA

quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL

ziprasidone Tier 3 GEODON

Miscellaneous

chlorpromazine Tier 1

fluphenazine Tier 1

haloperidol Tier 1 perphenazine Tier 1

prochlorperazine inj Tier 1

thiothixene Tier 1 trifluoperazine Tier 1

chlorpromazine inj Tier 3

haloperidol decanoate inj Tier 3 HALDOL DECANOATE

haloperidol inj Tier 3 HALDOL

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

QL amphetaminedextroamphetamine mixed salts Tier 1

QL amphetaminedextroamphetamine mixed salts ext-rel Tier 1 QL dextroamphetamine Tier 1

QL guanfacine ext-rel Tier 1

QL methylphenidate ext-rel Tier 1

QL amphetaminedextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS QL lisdexamfetamine Tier 2 VYVANSE

QL atomoxetine Tier 3 STRATTERA

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

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

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

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

22

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

QL dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE

QL methylphenidate Tier 3 METHYLIN

QL methylphenidate Tier 3 RITALIN QL methylphenidate ext-rel Tier 3 CONCERTA

FIBROMYALGIA ST QL pregabalin Tier 2 LYRICA

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

Benzodiazepines temazepam Tier 3 RESTORIL

Nonbenzodiazepines eszopiclone Tier 1

zolpidem sublingual Tier 1

ST suvorexant Tier 2 BELSOMRA

zolpidem Tier 3 AMBIEN zolpidem ext-rel Tier 3 AMBIEN CR

Tricyclics ST doxepin Tier 2 SILENOR

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

Ergotamine Derivatives

ergotaminecaffeine Tier 1

dihydroergotamine inj Tier 2 DHE 45

Monoclonal Antibodies

ST erenumab-aooe Tier 2 AIMOVIG ST fremanezumab-vfrm Tier 2 AJOVY

ST galcanezumab-gnlm Tier 2 EMGALITY

Selective Serotonin Agonists

QL naratriptan Tier 1

ST sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH ST sumatriptan nasal powder Tier 2 ONZETRA XSAIL

QL zolmitriptan nasal spray Tier 2 ZOMIG

QL eletriptan Tier 3 RELPAX

QL rizatriptan Tier 3 MAXALT QL sumatriptan Tier 3 IMITREX

QL sumatriptan inj Tier 3 IMITREX

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

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

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

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

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

23

MOOD STABILIZERS

lithium carbonate Tier 1

lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 2 LITHOBID

MOVEMENT DISORDERS SGM tetrabenazine Tier 1

SGM deutetrabenazine Tier 2 AUSTEDO

SGM valbenazine Tier 2 INGREZZA

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

SGM dimethyl fumarate delayed-rel Tier 2 TECFIDERA SGM fingolimod Tier 2 GILENYA

SGM glatiramer Tier 2 COPAXONE

SGM interferon beta-1a Tier 2 REBIF

SGM interferon beta-1b Tier 2 BETASERON dagger natalizumab TYSABRI

SGM siponimod Tier 2 MAYZENT

SGM teriflunomide Tier 2 AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS

baclofen Tier 1 carisoprodol Tier 1

chlorzoxazone Tier 1

cyclobenzaprine Tier 1 orphenadrineaspirincaffeine Tier 1

dantrolene Tier 2 DANTRIUM

metaxalone Tier 2 SKELAXIN

methocarbamol Tier 2 ROBAXIN tizanidine tabs Tier 2 ZANAFLEX

MYASTHENIA GRAVIS pyridostigmine Tier 1

pyridostigmine ext-rel Tier 1

NARCOLEPSY

PA armodafinil Tier 1

PA solriamfetol Tier 2 SUNOSI

POSTHERPETIC NEURALGIA (PHN)

ST gabapentin ext-rel Tier 2 GRALISE

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents

acamprosate calcium Tier 2 CAMPRAL

disulfiram Tier 2 ANTABUSE

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

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

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

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

24

pramlintide Tier 2 SYMLINPEN

Biguanides

metformin Tier 3 GLUCOPHAGE

metformin ext-rel Tier 3 GLUCOPHAGE XR

Opioid Antagonists naloxone inj Tier 1

naltrexone Tier 1

naloxone nasal spray Tier 2 NARCAN

Partial Opioid AgonistOpioid Antagonist Combinations

QL buprenorphinenaloxone sublingual Tier 1 QL buprenorphinenaloxone sublingual tabs Tier 2 ZUBSOLV

Pseudobulbar Affect Agents

PA dextromethorphanquinidine Tier 2 NUEDEXTA

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

bupropion ext-rel Tier 2 ZYBAN

varenicline Tier 2 CHANTIX

Vasomotor Symptom Agents

paroxetine mesylate Tier 1

ENDOCRINE AND METABOLIC

ACROMEGALY SGM lanreotide acetate Tier 2 SOMATULINE DEPOT

SGM pegvisomant Tier 2 SOMAVERT

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

PA testosterone cypionate Tier 1

PA testosterone enanthate Tier 1 PA testosterone gel Tier 1

PA testosterone soln Tier 1

PA testosterone transdermal Tier 2 ANDRODERM

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

Alpha-glucosidase Inhibitors acarbose Tier 2 PRECOSE

Amylin Analogs

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

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

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

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

25

dulaglutide Tier 2 TRULICITY

liraglutide Tier 2 VICTOZA

semaglutide Tier 2 OZEMPIC

dapagliflozinmetformin ext-rel Tier 2 XIGDUO XR

empagliflozinmetformin Tier 2 SYNJARDY

empagliflozinmetformin ext-rel Tier 2 SYNJARDY XR

BiguanideSulfonylurea Combinations glipizidemetformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) InhibitorBiguanide Combinations sitagliptinmetformin Tier 2 JANUMET

sitagliptinmetformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents

Incretin Mimetic AgentInsulin Combinations

liraglutideinsulin degludec Tier 2 XULTOPHY lixisenatideinsulin glargine Tier 2 SOLIQUA

Insulins insulin aspart Tier 2 FIASP

insulin aspart Tier 2 NOVOLOG

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

insulin detemir Tier 2 LEVEMIR

insulin glargine Tier 2 BASAGLAR

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

OTC insulin isophane human Tier 2 NOVOLIN N

OTC insulin isophane human 70regular 30 Tier 2 NOVOLIN 7030

Insulin Sensitizers

pioglitazone Tier 1

Insulin SensitizerBiguanide Combinations

pioglitazonemetformin Tier 3 ACTOPLUS MET

Insulin SensitizerSulfonylurea Combinations

pioglitazoneglimepiride Tier 3 DUETACT

Meglitinides

nateglinide Tier 1 repaglinide Tier 3 PRANDIN

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

dapagliflozin Tier 2 FARXIGA empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) InhibitorBiguanide Combinations

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

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

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

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

26

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

empagliflozinlinagliptin Tier 2 GLYXAMBI

Sulfonylureas

glyburide Tier 1

glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL

glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies

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

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

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

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

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

QL insulin management system Tier 2 OMNIPOD DASH

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

OTC lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS

SGM cinacalcet Tier 2 SENSIPAR

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

Bisphosphonates alendronate Tier 3 FOSAMAX

ibandronate Tier 3 BONIVA

risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones

SGM abaloparatide Tier 2 TYMLOS SGM teriparatide Tier 2 FORTEO

Miscellaneous dagger denosumab PROLIA

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

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

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

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

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

27

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

empagliflozinlinagliptin Tier 2 GLYXAMBI

Sulfonylureas

glyburide Tier 1

glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL

glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies

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

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

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

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

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

QL insulin management system Tier 2 OMNIPOD DASH

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

OTC lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS

SGM cinacalcet Tier 2 SENSIPAR

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

Bisphosphonates alendronate Tier 3 FOSAMAX

ibandronate Tier 3 BONIVA

risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones

SGM abaloparatide Tier 2 TYMLOS SGM teriparatide Tier 2 FORTEO

Miscellaneous dagger denosumab PROLIA

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

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

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

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

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

27

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen

drospirenoneEE 320 Tier 1

drospirenoneEElevomefolate 320 and levomefolate Tier 1 levonorgestrelEE 0120 - Lessina Tier 1

norethindrone acetateEE 120 and iron chewable Tier 1

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

30 mcg Estrogen desogestrelEE 01530 Tier 1

drospirenoneEElevomefolate 330 and levomefolate Tier 1

levonorgestrelEE 01530 - Levora Tier 1 norgestrelEE 0330 - Low-Ogestrel Tier 1

drospirenoneEE 330 Tier 3 YASMIN

norethindrone acetateEE 1530 Tier 3 LOESTRIN 1530

norethindrone acetateEE 1530 and iron Tier 3 LOESTRIN FE 1530

35 mcg Estrogen

ethynodiol diacetateEE 135 - Zovia 135 Tier 1 norethindroneEE 0535 Tier 1

norethindroneEE 135 Tier 1

norgestimateEE 02535 Tier 1 norethindroneEE 135 Tier 3 ORTHO-NOVUM 135

50 mcg Estrogen ethynodiol diacetateEE 150 Tier 1

desogestrelEE Tier 2 MIRCETTE

Biphasic

Triphasic

desogestrelEE Tier 1 levonorgestrelEE - Trivora Tier 1

norgestimateEE Tier 1

norethindroneEE Tier 3 ORTHO-NOVUM 777

Extended Cycle

levonorgestrelEE 01530 Tier 1 levonorgestrelEE 0120 and EE 10 Tier 3 LOSEASONIQUE

levonorgestrelEE 01530 and EE 10 Tier 3 SEASONIQUE

Progestin Only

norethindrone Tier 1

norethindrone Tier 2 ORTHO MICRONOR

medroxyprogesterone acetate 150 mgmL Tier 2 DEPO-PROVERA

Injectable

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

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

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

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

28

EEnorethindrone acetate - Jinteli Tier 1

estradiolnorethindrone Tier 1

estrogens conjugatedmedroxyprogesterone Tier 2 PREMPHASE estrogens conjugatedmedroxyprogesterone Tier 2 PREMPRO

Transdermal

estradiollevonorgestrel Tier 2 CLIMARA PRO

estradiolnorethindrone acetate Tier 2 COMBIPATCH

Progestin Intrauterine Devices dagger levonorgestrel releasing IUD KYLEENA

dagger levonorgestrel releasing IUD MIRENA

dagger levonorgestrel releasing IUD SKYLA

Transdermal

Vaginal

norelgestrominEE Tier 1

etonogestrelEE ring Tier 2 NUVARING

ENDOMETRIOSIS

danazol Tier 1

PA elagolix Tier 2 ORILISSA

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

Oral

estrogens conjugated Tier 2 PREMARIN estradiol Tier 3 ESTRACE

Transdermal estradiol Tier 1

estradiol Tier 2 DIVIGEL

estradiol Tier 2 EVAMIST

estradiol Tier 3 CLIMARA

Vaginal

estradiol vaginal crm Tier 1 estradiol vaginal ring Tier 2 ESTRING

estrogens conjugated crm Tier 2 PREMARIN

estradiol vaginal tabs Tier 3 VAGIFEM

ESTROGENPROGESTINS Oral

ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogensbazedoxifene Tier 2 DUAVEE

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

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

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

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

29

EEnorethindrone acetate - Jinteli Tier 1

estradiolnorethindrone Tier 1

estrogens conjugatedmedroxyprogesterone Tier 2 PREMPHASE estrogens conjugatedmedroxyprogesterone Tier 2 PREMPRO

Transdermal

estradiollevonorgestrel Tier 2 CLIMARA PRO

estradiolnorethindrone acetate Tier 2 COMBIPATCH

Progestin Intrauterine Devices dagger levonorgestrel releasing IUD KYLEENA

dagger levonorgestrel releasing IUD MIRENA

dagger levonorgestrel releasing IUD SKYLA

Transdermal

Vaginal

norelgestrominEE Tier 1

etonogestrelEE ring Tier 2 NUVARING

ENDOMETRIOSIS

danazol Tier 1

PA elagolix Tier 2 ORILISSA

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

Oral

estrogens conjugated Tier 2 PREMARIN estradiol Tier 3 ESTRACE

Transdermal estradiol Tier 1

estradiol Tier 2 DIVIGEL

estradiol Tier 2 EVAMIST

estradiol Tier 3 CLIMARA

Vaginal

estradiol vaginal crm Tier 1 estradiol vaginal ring Tier 2 ESTRING

estrogens conjugated crm Tier 2 PREMARIN

estradiol vaginal tabs Tier 3 VAGIFEM

ESTROGENPROGESTINS Oral

ESTROGENSELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogensbazedoxifene Tier 2 DUAVEE

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

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

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

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

29

FERTILITY REGULATORS GNRHLHRH Antagonists

ganirelix acetate Tier 1

cetrorelix Tier 2 CETROTIDE

Ovulation Stimulants Gonadotropins

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

Ovulation Stimulants Synthetic clomiphene Tier 1

GAUCHER DISEASE SGM eliglustat Tier 2 CERDELGA

dagger imiglucerase CEREZYME

GLUCOCORTICOIDS

dexamethasone Tier 1

fludrocortisone Tier 1

prednisolone Tier 1 prednisone Tier 1

hydrocortisone Tier 2 CORTEF

methylprednisolone Tier 2 MEDROL

GLUCOSE ELEVATING AGENTS

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

HEREDITARY TYROSINEMIA TYPE 1 AGENTS SGM nitisinone Tier 2 ORFADIN

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

SGM somatropin Tier 2 GENOTROPIN

SGM somatropin Tier 2 HUMATROPE

HYPERPARATHYROID TREATMENT VITAMIN D ANALOGS

calcitriol (125-D3) Tier 2 ROCALTROL

doxercalciferol Tier 2 HECTOROL

paricalcitol Tier 2 ZEMPLAR

PHENYLKETONURIA TREATMENT AGENTS

SGM sapropterin Tier 2 KUVAN

PHOSPHATE BINDER AGENTS

calcium acetate Tier 1 lanthanum carbonate Tier 1

sevelamer carbonate Tier 1

calcium acetate Tier 2 PHOSLYRA ST sucroferric oxyhydroxide Tier 2 VELPHORO

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

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

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

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

30

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

POTASSIUM-REMOVING AGENTS

Vaginal PA progesterone gel Tier 2 CRINONE

PA progesterone vaginal inserts Tier 2 ENDOMETRIN

SELECTIVE ESTROGEN RECEPTOR MODULATORS

ospemifene Tier 2 OSPHENA

raloxifene Tier 3 EVISTA

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

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

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

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

31

THYROID AGENTS Antithyroid Agents

propylthiouracil Tier 1

methimazole Tier 2 TAPAZOLE

Thyroid Supplements

levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1

levothyroxine Tier 2 SYNTHROID

liothyronine Tier 2 CYTOMEL

VASOPRESSINS

desmopressin spray tabs Tier 2 DDAVP

MISCELLANEOUS

cabergoline Tier 1

GASTROINTESTINAL

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

ANTIDIARRHEALS

loperamide Tier 1 diphenoxylateatropine Tier 2 LOMOTIL

ANTIEMETICS QL granisetron Tier 1

meclizine Tier 1

prochlorperazine Tier 1 promethazine Tier 1

scopolamine transdermal Tier 1

PA QL granisetron transdermal Tier 2 SANCUSO

QL rolapitant Tier 2 VARUBI PA QL dronabinol Tier 3 MARINOL

metoclopramide Tier 3 REGLAN

QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

ANTISPASMODICS hyoscyamine sulfate ext-rel caps Tier 1

hyoscyamine sulfate orally disintegrating tabs Tier 1

dicyclomine Tier 2 BENTYL

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

CHOLELITHOLYTICS ursodiol Tier 2 ACTIGALL

ursodiol Tier 2 URSO

H2 RECEPTOR ANTAGONISTS

cimetidine Tier 1

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

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

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

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

32

THYROID AGENTS Antithyroid Agents

propylthiouracil Tier 1

methimazole Tier 2 TAPAZOLE

Thyroid Supplements

levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1

levothyroxine Tier 2 SYNTHROID

liothyronine Tier 2 CYTOMEL

VASOPRESSINS

desmopressin spray tabs Tier 2 DDAVP

MISCELLANEOUS

cabergoline Tier 1

GASTROINTESTINAL

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

ANTIDIARRHEALS

loperamide Tier 1 diphenoxylateatropine Tier 2 LOMOTIL

ANTIEMETICS QL granisetron Tier 1

meclizine Tier 1

prochlorperazine Tier 1 promethazine Tier 1

scopolamine transdermal Tier 1

PA QL granisetron transdermal Tier 2 SANCUSO

QL rolapitant Tier 2 VARUBI PA QL dronabinol Tier 3 MARINOL

metoclopramide Tier 3 REGLAN

QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

ANTISPASMODICS hyoscyamine sulfate ext-rel caps Tier 1

hyoscyamine sulfate orally disintegrating tabs Tier 1

dicyclomine Tier 2 BENTYL

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

CHOLELITHOLYTICS ursodiol Tier 2 ACTIGALL

ursodiol Tier 2 URSO

H2 RECEPTOR ANTAGONISTS

cimetidine Tier 1

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

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

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

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

32

pancrelipase Tier 2 VIOKACE

pancrelipase delayed-rel Tier 2 CREON

pancrelipase delayed-rel Tier 2 ZENPEP

famotidine Tier 3 PEPCID ranitidine Tier 3 ZANTAC

INFLAMMATORY BOWEL DISEASE Oral Agents

Rectal Agents

balsalazide Tier 1

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

mesalamine delayed-rel tabs Tier 1

mesalamine ext-rel caps Tier 2 APRISO

mesalamine ext-rel caps Tier 2 PENTASA sulfasalazine Tier 3 AZULFIDINE

sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS

hydrocortisone enema Tier 1

mesalamine supp Tier 1 hydrocortisone acetate foam Tier 2 CORTIFOAM

mesalamine susp Tier 3 ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation

linaclotide Tier 2 LINZESS

lubiprostone Tier 2 AMITIZA

Irritable Bowel Syndrome with Diarrhea

alosetron Tier 1 eluxadoline Tier 2 VIBERZI

LAXATIVES lactulose soln Tier 1

sodium sulfatepotassium sulfatemagnesium sulfate Tier 2 SUPREP

peg 3350electrolytes Tier 3 GOLYTELY peg 3350electrolytes Tier 3 NULYTELY

OPIOID-INDUCED CONSTIPATION naldemedine Tier 2 SYMPROIC

naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES

PROSTAGLANDINS

misoprostol Tier 2 CYTOTEC

PROTON PUMP INHIBITORS

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

pantoprazole delayed-rel Tier 1

ST dexlansoprazole delayed-rel Tier 2 DEXILANT

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

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

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

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

33

ST omeprazole delayed-rel Tier 3 PRILOSEC

Step Therapy applies to brand only

SALIVA STIMULANTS

cevimeline Tier 2 EVOXAC

pilocarpine tabs Tier 2 SALAGEN

STEROIDS RECTAL

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

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

MISCELLANEOUS sucralfate Tier 1

GENITOURINARY

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

alfuzosin ext-rel Tier 1 dutasteridetamsulosin Tier 1

silodosin Tier 1

dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR

tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS

darifenacin ext-rel Tier 1

oxybutynin Tier 1

solifenacin Tier 1 tolterodine ext-rel Tier 1

trospium Tier 1

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

ST mirabegron ext-rel Tier 2 MYRBETRIQ

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

VAGINAL ANTI-INFECTIVES

terconazole Tier 1 clindamycin crm Tier 2 CLEOCIN

metronidazole Tier 2 METROGEL-VAGINAL

MISCELLANEOUS

bethanechol Tier 2 URECHOLINE

potassium citrate ext-rel Tier 2 UROCIT-K

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

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

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

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

34

ST omeprazole delayed-rel Tier 3 PRILOSEC

Step Therapy applies to brand only

SALIVA STIMULANTS

cevimeline Tier 2 EVOXAC

pilocarpine tabs Tier 2 SALAGEN

STEROIDS RECTAL

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

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

MISCELLANEOUS sucralfate Tier 1

GENITOURINARY

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

alfuzosin ext-rel Tier 1 dutasteridetamsulosin Tier 1

silodosin Tier 1

dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR

tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS

darifenacin ext-rel Tier 1

oxybutynin Tier 1

solifenacin Tier 1 tolterodine ext-rel Tier 1

trospium Tier 1

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

ST mirabegron ext-rel Tier 2 MYRBETRIQ

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

VAGINAL ANTI-INFECTIVES

terconazole Tier 1 clindamycin crm Tier 2 CLEOCIN

metronidazole Tier 2 METROGEL-VAGINAL

MISCELLANEOUS

bethanechol Tier 2 URECHOLINE

potassium citrate ext-rel Tier 2 UROCIT-K

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

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

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

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

34

HEMATOLOGIC

Guidelines of treatment and management of hemophilia are available at httpswwwhemophiliaorg

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

Injectable

dalteparin Tier 2 FRAGMIN

enoxaparin Tier 2 LOVENOX

Oral

warfarin Tier 1 apixaban Tier 2 ELIQUIS

rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents

fondaparinux Tier 2 ARIXTRA

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

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

SGM darbepoetin alfa Tier 2 ARANESP

SGM epoetin alfa-epbx Tier 2 RETACRIT SGM filgrastim-aafi Tier 2 NIVESTYM

SGM pegfilgrastim Tier 2 NEULASTA

SGM pegfilgrastim-cbqv Tier 2 UDENYCA

HEMOPHILIA A AGENTS

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

dagger antihemophilic factor (recombinant) NOVOEIGHT

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

dagger human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ

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

HEREDITARY ANGIOEDEMA SGM icatibant Tier 2 FIRAZYR

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS SGM eltrombopag Tier 2 PROMACTA

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS dagger eculizumab SOLIRIS

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

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

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

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

35

PLATELET AGGREGATION INHIBITORS

clopidogrel Tier 1

dipyridamole Tier 1 prasugrel Tier 1

ticagrelor Tier 2 BRILINTA

dipyridamole ext-relaspirin Tier 3 AGGRENOX

PLATELET SYNTHESIS INHIBITORS

anagrelide Tier 2 AGRYLIN

STEM CELL MOBILIZERS

SGM plerixafor Tier 2 MOZOBIL

THROMBOCYTOPENIA AGENTS

SGM lusutrombopag Tier 2 MULPLETA

MISCELLANEOUS

cilostazol Tier 1

IMMUNOLOGIC AGENTS

Guidelines for the management of rheumatic diseases are available at httpswwwrheumatologyorg

ALLERGENIC EXTRACTS

PA grass mixed pollen allergen extract Tier 2 ORALAIR

PA ragweed pollen allergen extract Tier 2 RAGWITEK PA timothy grass pollen allergen extract Tier 2 GRASTEK

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

SGM adalimumab Tier 2 HUMIRA SGM apremilast Tier 2 OTEZLA

SGM etanercept Tier 2 ENBREL

SGM guselkumab Tier 2 TREMFYA SGM risankizumab-rzaa Tier 2 SKYRIZI

SGM secukinumab Tier 2 COSENTYX

SGM tofacitinib Tier 2 XELJANZ

SGM tofacitinib ext-rel Tier 2 XELJANZ XR SGM upadacitinib Tier 2 RINVOQ

SGM ustekinumab Tier 2 STELARA SUBCUTANEOUS

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

methotrexate Tier 1

hydroxychloroquine Tier 2 PLAQUENIL leflunomide Tier 2 ARAVA

SGM methotrexate auto-injector Tier 2 RASUVO

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

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

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

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

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

36

Guidelines for the management of hepatitis are available at httpswwwaasldorg

Interferons

SGM interferon alfa-2b Tier 2 INTRON A

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

Miscellaneous SGM canakinumab Tier 2 ILARIS

IMMUNOSUPPRESSANTS Antimetabolites

mycophenolate mofetil Tier 1

mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 2 AZASAN

azathioprine Tier 2 IMURAN

Calcineurin Inhibitors

cyclosporine Tier 1

cyclosporine modified Tier 1 tacrolimus Tier 1

Rapamycin Derivatives sirolimus Tier 1

NUTRITIONALSUPPLEMENTS

ELECTROLYTES Potassium

potassium chloride ext-rel Tier 1

potassium chloride liquid Tier 1

VITAMINS AND MINERALS Folic AcidCombinations

folic acid Tier 1 folic acidvitamin B6vitamin B12 Tier 1

Prenatal Vitamins prenatal vitamins Tier 1

prenatal vitaminsDHAdocusatefolic acid Tier 2 CITRANATAL 90 DHA

prenatal vitaminsDHAdocusatefolic acid Tier 2 CITRANATAL DHA

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

prenatal vitaminsdocusatefolic acid + DHA Tier 2 CITRANATAL ASSURE

prenatal vitaminsfolic acid + pyridoxine Tier 2 CITRANATAL B-CALM

Miscellaneous

cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1

fluoride drops Tier 1

fluoride tabs Tier 1

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

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

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

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

37

multivitaminsfluoride drops tabs Tier 1 multivitaminsfluorideiron drops tabs Tier 1

vitamin ADCfluoride drops Tier 1

vitamin ADCfluorideiron drops Tier 1

RESPIRATORY

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

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

ANAPHYLAXIS TREATMENT AGENTS

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

epinephrine auto-injector Tier 2 EPIPEN JR

ANTICHOLINERGICS

QL ipratropium soln Tier 1

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

ANTICHOLINERGICBETA AGONIST COMBINATIONS Short Acting

QL ipratropiumalbuterol soln Tier 1

Long Acting

QL glycopyrrolateformoterol Tier 2 BEVESPI AEROSPHERE

QL tiotropiumolodaterol Tier 2 STIOLTO RESPIMAT

QL umeclidiniumvilanterol Tier 2 ANORO ELLIPTA

ANTICHOLINERGICBETA AGONISTSTEROID INHALANT COMBINATIONS

QL fluticasoneumeclidiniumvilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES LOW SEDATING

levocetirizine Tier 1

ANTIHISTAMINES SEDATING

clemastine 268 mg Tier 1 cyproheptadine Tier 1

hydroxyzine HCl Tier 1

ANTITUSSIVES Clinical practice guidelines are available at

httpsjournalchestnetorgarticleS0012-3692(15)52856-0pdf

benzonatate Tier 2 TESSALON

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

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

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

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

38

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

ANTITUSSIVE COMBINATIONS Opioid

Non-opioid

codeinepromethazine Tier 1

codeinepromethazinephenylephrine Tier 1 hydrocodonehomatropine Tier 1

dextromethorphanbrompheniraminepseudoephedrine Tier 1

dextromethorphanpromethazine Tier 1

BETA AGONISTS Inhalants Short Acting

QL albuterol soln Tier 1

QL albuterol sulfate CFC-free aerosol Tier 1

QL levalbuterol tartrate CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation

QL olodaterol CFC-free aerosol Tier 2 STRIVERDI RESPIMAT

QL salmeterol xinafoate Tier 2 SEREVENT

Nebulized Passive Inhalation

QL formoterol inhalation soln Tier 2 PERFOROMIST

Oral Agents

albuterol Tier 1

albuterol ext-rel Tier 1 terbutaline Tier 1

CYSTIC FIBROSIS

SGM tobramycin inhalation soln Tier 1 SGM dornase alfa Tier 2 PULMOZYME

SGM tobramycin inhalation soln Tier 2 BETHKIS

LEUKOTRIENE MODULATORS

montelukast Tier 1

zafirlukast Tier 1 zileuton ext-rel Tier 1

MAST CELL STABILIZERS QL cromolyn soln Tier 1

NASAL ANTIHISTAMINES QL azelastine spray Tier 1

QL azelastine spray Tier 3 ASTEPRO

ST QL olopatadine spray Tier 3 PATANASE

Step Therapy applies to brand only

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

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

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

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

39

NASAL STEROIDSCOMBINATIONS

QL flunisolide spray Tier 1

QL fluticasone spray Tier 1 QL mometasone spray Tier 1

QL triamcinolone acetonide spray Tier 1

ST QL azelastinefluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast Tier 2 DALIRESP

PULMONARY ENZYME DEFICIENCY AGENTS

dagger alpha-1 proteinase inhibitor PROLASTIN-C

PULMONARY FIBROSIS AGENTS

SGM nintedanib Tier 2 OFEV

SGM pirfenidone Tier 2 ESBRIET

SEVERE ASTHMA AGENTS

dagger benralizumab FASENRA SGM dupilumab Tier 2 DUPIXENT

SGM mepolizumab Tier 2 NUCALA autoinjector

dagger omalizumab XOLAIR

STEROIDBETA AGONIST COMBINATIONS

QL budesonideformoterol Tier 2 SYMBICORT QL fluticasonesalmeterol Tier 2 ADVAIR DISKUS

QL fluticasonesalmeterol CFC-free aerosol Tier 2 ADVAIR HFA

QL fluticasonevilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS

QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER

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

QL fluticasone Tier 2 FLOVENT DISKUS

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

XANTHINES theophylline ext-rel tabs Tier 1

MISCELLANEOUS ipratropium spray Tier 1

TOPICAL

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

Oral

PA isotretinoin Tier 1

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

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

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

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

40

NASAL STEROIDSCOMBINATIONS

QL flunisolide spray Tier 1

QL fluticasone spray Tier 1 QL mometasone spray Tier 1

QL triamcinolone acetonide spray Tier 1

ST QL azelastinefluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast Tier 2 DALIRESP

PULMONARY ENZYME DEFICIENCY AGENTS

dagger alpha-1 proteinase inhibitor PROLASTIN-C

PULMONARY FIBROSIS AGENTS

SGM nintedanib Tier 2 OFEV

SGM pirfenidone Tier 2 ESBRIET

SEVERE ASTHMA AGENTS

dagger benralizumab FASENRA SGM dupilumab Tier 2 DUPIXENT

SGM mepolizumab Tier 2 NUCALA autoinjector

dagger omalizumab XOLAIR

STEROIDBETA AGONIST COMBINATIONS

QL budesonideformoterol Tier 2 SYMBICORT QL fluticasonesalmeterol Tier 2 ADVAIR DISKUS

QL fluticasonesalmeterol CFC-free aerosol Tier 2 ADVAIR HFA

QL fluticasonevilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS

QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER

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

QL fluticasone Tier 2 FLOVENT DISKUS

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

XANTHINES theophylline ext-rel tabs Tier 1

MISCELLANEOUS ipratropium spray Tier 1

TOPICAL

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

Oral

PA isotretinoin Tier 1

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

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

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

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

40

Topical

PA adapalene Tier 1

clindamycin gel Tier 1 clindamycinbenzoyl peroxide Tier 1

QL erythromycin gel 2 Tier 1

erythromycin soln Tier 1 PA tretinoin Tier 1

PA tretinoin - Avita Tier 1

PA tretinoin gel microsphere Tier 1

adapalenebenzoyl peroxide Tier 2 EPIDUO adapalenebenzoyl peroxide Tier 2 EPIDUO FORTE

PA tazarotene Tier 2 TAZORAC

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

QL clindamycin soln Tier 3 CLEOCIN T

clindamycinbenzoyl peroxide Tier 3 DUAC

erythromycinbenzoyl peroxide Tier 3 BENZAMYCIN sulfacetamide lotion 10 Tier 3 KLARON

PA tretinoin Tier 3 RETIN-A

Prior Authorization applies for members age 35 and older

Actinic Keratosis fluorouracil crm 5 soln 5 soln 2 Tier 1

fluorouracil crm 4 Tier 2 TOLAK

imiquimod Tier 2 ZYCLARA ingenol mebutate Tier 2 PICATO

Antibiotics gentamicin Tier 1

QL mupirocin oint Tier 1

silver sulfadiazine Tier 2 SILVADENE

Antifungals

clotrimazole Tier 1

QL econazole Tier 1 QL ketoconazole Tier 1

luliconazole Tier 1

nystatin Tier 1 naftifine Tier 2 NAFTIN

PA ciclopirox Tier 3 LOPROX

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

Oral

PA acitretin Tier 3 SORIATANE methoxsalen oral Tier 3 OXSORALEN-ULTRA

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

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

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

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

41

Topical QL calcipotriene oint soln 0005 Tier 1

Antiseborrheics selenium sulfide shampoo 25 Tier 1

ketoconazole shampoo 2 Tier 2 NIZORAL

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

httpswwwaadorgpracticecenterqualityclinical-guidelines

Injectable

SGM dupilumab Tier 2 DUPIXENT

Topical

PA pimecrolimus Tier 1

PA tacrolimus Tier 1 ST crisaborole Tier 2 EUCRISA

Corticosteroids Low Potency

QL alclometasone crm oint 005 Tier 1

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

QL hydrocortisone lotion 1 Tier 1

PA QL desonide crm lotion oint 005 Tier 2 DESOWEN

Prior Authorization applies to brand only

Medium Potency

QL betamethasone valerate crm lotion oint 01 Tier 1

QL desoximetasone crm oint 005 Tier 1

QL fluocinolone acetonide crm oint 0025 Tier 1 QL hydrocortisone butyrate crm oint soln 01 Tier 1

QL hydrocortisone valerate crm oint 02 Tier 1

QL triamcinolone acetonide crm lotion 0025 Tier 1 QL triamcinolone acetonide crm lotion oint 01 Tier 1

PA QL fluticasone propionate oint 0005 Tier 2 CUTIVATE

PA QL mometasone oint 01 Tier 2 ELOCON

PA QL fluticasone propionate crm lotion 005 Tier 3 CUTIVATE PA QL mometasone crm lotion 01 Tier 3 ELOCON

Prior Authorization applies to brand only

High Potency

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

QL fluocinonide crm gel oint soln 005 Tier 1

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

PA QL betamethasone dipropionate augmented lotion 005 Tier 3 DIPROLENE

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

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

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

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

42

Prior Authorization applies to brand only

Very High Potency

QL clobetasol propionate foam 005 Tier 1 PA QL betamethasone dipropionate augmented gel oint 005 Tier 2 DIPROLENE

PA QL clobetasol propionate crm gel oint 005 Tier 2 TEMOVATE

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

PA QL clobetasol propionate soln 005 Tier 3 TEMOVATE

Prior Authorization applies to brand only

Emollients ammonium lactate 12 Tier 2 LAC-HYDRIN

Local Analgesics PA lidocaine patch Tier 2 LIDODERM

Rosacea PA azelaic acid gel Tier 1

PA doxycycline monohydrate delayed-rel caps Tier 1

metronidazole gel 075 Tier 1

PA azelaic acid foam Tier 2 FINACEA FOAM PA ivermectin Tier 2 SOOLANTRA

metronidazole crm 075 Tier 3 METROCREAM

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

Scabicides and Pediculicides permethrin 5 Tier 1

malathion Tier 2 OVIDE

Miscellaneous Skin and Mucous Membrane

imiquimod Tier 2 ALDARA

podofilox Tier 2 CONDYLOX

MOUTHTHROATDENTAL AGENTS Anesthetics - Topical Oral

lidocaine viscous Tier 1

Steroids - MouthThroat

triamcinolone paste Tier 1

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

Antiallergics

azelastine Tier 1

cromolyn sodium Tier 1 alcaftadine Tier 2 LASTACAFT

olopatadine Tier 2 PAZEO

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

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

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

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

43

olopatadine Tier 3 PATADAY olopatadine Tier 3 PATANOL

Anti-infectives bacitracin Tier 1

erythromycin Tier 1

gentamicin Tier 1

levofloxacin Tier 1 neomycinpolymyxin Bgramicidin Tier 1

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

tobramycin Tier 3 TOBREX

Anti-infectiveAnti-inflammatory Combinations

neomycinpolymyxin Bbacitracinhydrocortisone oint Tier 1

neomycinpolymyxin Bhydrocortisone susp Tier 1 sulfacetamideprednisolone phosphate 10025 Tier 1

tobramycindexamethasone oint 0301 Tier 2 TOBRADEX

tobramycindexamethasone susp 03005 Tier 2 TOBRADEX ST

neomycinpolymyxin Bdexamethasone Tier 3 MAXITROL tobramycindexamethasone susp 0301 Tier 3 TOBRADEX

Anti-inflammatories Nonsteroidal

bromfenac sodium Tier 1

diclofenac sodium Tier 1 ketorolac tromethamine Tier 2 ACUVAIL

nepafenac Tier 2 ILEVRO

nepafenac Tier 2 NEVANAC QL ketorolac Tier 3 ACULAR

Steroidal dexamethasone sodium phosphate Tier 1

fluorometholone Tier 1

loteprednol Tier 1

prednisolone acetate 1 Tier 1 dexamethasone Tier 2 MAXIDEX

difluprednate Tier 2 DUREZOL

fluorometholone Tier 2 FML FORTE fluorometholone Tier 2 FML SOP

prednisolone acetate Tier 2 PRED MILD

prednisolone phosphate 1 Tier 3

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

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

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

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

44

Antivirals

Beta-blockers Nonselective

trifluridine Tier 1

levobunolol

timolol maleate gel timolol hemihydrate

timolol maleate

Tier 1

Tier 1 Tier 2

Tier 3

BETIMOL

TIMOPTIC

betaxolol Tier 2 BETOPTIC S

Selective

Carbonic Anhydrase Inhibitors Topical

brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase InhibitorBeta-blocker Combinations

dorzolamidetimolol maleate Tier 3 COSOPT

Carbonic Anhydrase InhibitorSympathomimetic Combinations

brinzolamidebrimonidine Tier 2 SIMBRINZA

Dry Eye Disease

cyclosporine emulsion Tier 2 RESTASIS lifitegrast Tier 2 XIIDRA

Prostaglandins ST bimatoprost Tier 2 LUMIGAN

travoprost Tier 2 TRAVATAN Z

latanoprost Tier 3 XALATAN

Retinal Disorders

dagger aflibercept EYLEA dagger ranibizumab LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase InhibitorProstaglandin Combinations

ST netarsudillatanoprost Tier 2 ROCKLATAN

Sympathomimetics

brimonidine 02 Tier 1 brimonidine Tier 2 ALPHAGAN P

SympathomimeticBeta-blocker Combinations brimonidinetimolol Tier 2 COMBIGAN

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

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

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

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

45

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

Anti-infectives

acetic acid Tier 1

ofloxacin otic Tier 1

Anti-infectiveAnti-inflammatory Combinations

ciprofloxacindexamethasone Tier 2 CIPRODEX neomycinpolymyxin Bhydrocortisone Tier 2 CORTISPORIN OTIC

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

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

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

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

46

Antivirals

Beta-blockers Nonselective

trifluridine Tier 1

levobunolol

timolol maleate gel timolol hemihydrate

timolol maleate

Tier 1

Tier 1 Tier 2

Tier 3

BETIMOL

TIMOPTIC

betaxolol Tier 2 BETOPTIC S

Selective

Carbonic Anhydrase Inhibitors Topical

brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase InhibitorBeta-blocker Combinations

dorzolamidetimolol maleate Tier 3 COSOPT

Carbonic Anhydrase InhibitorSympathomimetic Combinations

brinzolamidebrimonidine Tier 2 SIMBRINZA

Dry Eye Disease

cyclosporine emulsion Tier 2 RESTASIS lifitegrast Tier 2 XIIDRA

Prostaglandins ST bimatoprost Tier 2 LUMIGAN

travoprost Tier 2 TRAVATAN Z

latanoprost Tier 3 XALATAN

Retinal Disorders

dagger aflibercept EYLEA dagger ranibizumab LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase InhibitorProstaglandin Combinations

ST netarsudillatanoprost Tier 2 ROCKLATAN

Sympathomimetics

brimonidine 02 Tier 1 brimonidine Tier 2 ALPHAGAN P

SympathomimeticBeta-blocker Combinations brimonidinetimolol Tier 2 COMBIGAN

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

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

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

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

45

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

Anti-infectives

acetic acid Tier 1

ofloxacin otic Tier 1

Anti-infectiveAnti-inflammatory Combinations

ciprofloxacindexamethasone Tier 2 CIPRODEX neomycinpolymyxin Bhydrocortisone Tier 2 CORTISPORIN OTIC

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

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

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

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

46

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

Anti-infectives

acetic acid Tier 1

ofloxacin otic Tier 1

Anti-infectiveAnti-inflammatory Combinations

ciprofloxacindexamethasone Tier 2 CIPRODEX neomycinpolymyxin Bhydrocortisone Tier 2 CORTISPORIN OTIC

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

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

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

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

46

WEBSITES

Agency for Healthcare Research and Quality httpswwwahrqgov

Alzheimers Association httpswwwalzorg

American Academy of Allergy Asthma and Immunology httpswwwaaaaiorg

American Academy of Child amp Adolescent Psychiatry httpswwwaacaporg

American Academy of Dermatology httpswwwaadorg

American Academy of Neurology httpswwwaancom

American Academy of Ophthalmology httpswwwaaoorg

American Academy of Pediatrics httpswwwaaporg

American Association for the Study of Liver Disease httpswwwaasldorg

American Association of Clinical Endocrinologists httpswwwaacecom

American Association of Diabetes Educators httpswwwdiabeteseducatororg

American Cancer Society httpswwwcancerorg

American College of Allergy Asthma and Immunology httpswwwacaaiorg

American College of Cardiology httpswwwaccorg

American College of Chest Physicians httpswwwchestnetorg

American College of Gastroenterology httpsgiorg

American College of Physicians httpswwwacponlineorg

American College of Rheumatology httpswwwrheumatologyorg

American Congress of Obstetricians and Gynecologists httpswwwacogorg

American Diabetes Association httpwwwdiabetesorg

American Gastroenterological Association httpswwwgastroorg

American Headache Society Committee for Headache Education httpsamericanheadachesocietyorg

American Heart Association httpsprofessionalheartorg

American Lung Association httpswwwlungorg

American Medical Association httpswwwama-assnorg

American Psychiatric Association httpswwwpsychiatryorg

American Society of Anesthesiologists httpswwwasahqorg

American Society of Clinical Oncology httpswwwascoorg

American Society of Interventional Pain Physicians httpswwwasipporg

American Urological Association httpswwwauanetorg

Centers for Disease Control and Prevention httpswwwcdcgov

Centers for Disease Control and Prevention Guideline topics AIDS httpswwwcdcgovhivdefaulthtml

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

CVS Caremark httpswwwcaremarkcom

The Food and Drug Administration httpswwwfdagov

47

Global Initiative for Asthma National Foundation for Infectious Diseases httpsginasthmaorg httpwwwnfidorg Infectious Diseases Society of America National Guideline Clearinghouse httpswwwidsocietyorg httpswwwahrqgov Institute for Safe Medication Practices National Heart Lung and Blood Institute httpswwwismporg httpswwwnhlbinihgov Johns Hopkins AIDS Service National Institutes of Health httpswwwthebodycomcontentart12096html httpswwwnihgov Juvenile Diabetes Research Foundation International National Kidney Foundation httpswwwjdrforg httpswwwkidneyorg MedWatch National Osteoporosis Foundation httpswwwfdagovSafetyMedWatchdefaulthtm httpswwwnoforg National Agricultural Library North American Menopause Society httpswwwnalusdagov httpswwwmenopauseorg National Cancer Institute United States Department of Health and Human httpswwwcancergovabout-cancer Services httpswwwhhsgov National Comprehensive Cancer Network httpswwwnccnorg World Health Organization httpswwwwhoint

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INDEX

A abacavir tabs 11 abacavirdolutegravirlamivudine 11 abacavirlamivudine 11 abaloparatide 27 ABILIFY MAINTENA 22 abiraterone 13 acamprosate calcium 24 acarbose 25 ACCU-CHEK AVIVA PLUS kits and test strips 27 ACCU-CHEK COMPACT PLUS kits and test strips 27 ACCU-CHEK GUIDE kits and test strips 27 ACCU-CHEK SMARTVIEW kits and test strips 27 ACCUPRIL 15 ACCURETIC 15 acetazolamide 18 acetazolamide ext-rel 18 acetic acid 46 acitretin 41 ACTIGALL 32 ACTONEL 27 ACTOPLUS MET 26 ACULAR 44 ACUVAIL 44 acyclovir caps tabs 12 ADALAT CC 17 adalimumab 36 adapalene 41 adapalenebenzoyl peroxide 41 ADEMPAS 19 ADVAIR DISKUS 40 ADVAIR HFA 40 ADYNOVATE 35 AFINITOR 14 aflibercept 45 AGGRENOX 36 AGRYLIN 36 AIMOVIG 23 AJOVY 23 albuterol 39 albuterol ext-rel 39 albuterol soln 39 albuterol sulfate CFC-free aerosol 39 alcaftadine 43 alclometasone crm oint 005 42 ALDACTAZIDE 18 ALDACTONE 15 ALDARA 43 alendronate 27 alfuzosin ext-rel 34 aliskiren 18 aliskirenhydrochlorothiazide 18 ALKERAN 13 allopurinol 8 alosetron 33 alpha-1 proteinase inhibitor 40 ALPHAGAN P 45 alprazolam 19 ALTACE 15 amantadine 21 AMARYL 27 AMBIEN 23

AMBIEN CR 23 ambrisentan 19 amiloride 18 amiloridehydrochlorothiazide 18 amiodarone 16 AMITIZA 33 amitriptyline 21 amlodipine 17 amlodipineatorvastatin 18 amlodipinebenazepril 15 amlodipineolmesartan 16 amlodipinetelmisartan 16 amlodipinevalsartan 16 amlodipinevalsartanhydrochlorothiazide 16 ammonium lactate 12 43 amoxicillin 10 amoxicillinclavulanate 10 amoxicillinclavulanate ext-rel 10 amphetaminedextroamphetamine mixed salts 22 amphetaminedextroamphetamine mixed salts ext-rel 22 ampicillin 10 ANAFRANIL 20 anagrelide 36 anastrozole 13 ANDRODERM 25 ANORO ELLIPTA 38 ANTABUSE 24 antihemophilic factor (recombinant) 35 antihemophilic factor (recombinant) pegylated 35 antihemophilic factor (recombinant) pegylated-aucl 35 ANUSOL-HC 34 apalutamide 13 apixaban 35 apremilast 36 APRISO 33 ARANESP 35 ARAVA 36 ARICEPT 20 ARIMIDEX 13 aripiprazole 22 aripiprazole ext-rel inj 22 aripiprazole lauroxil ext-rel inj 22 ARISTADA 22 ARISTADA INITIO 22 ARIXTRA 35 armodafinil 24 ARNUITY ELLIPTA 40 AROMASIN 13 ASTEPRO 39 atazanavir 11 atazanavircobicistat 11 ATELVIA 27 atenolol 17 atenololchlorthalidone 17 ATIVAN 19 atomoxetine 22 atorvastatin 17 atovaquoneproguanil 11 ATRIPLA 11 AUBAGIO 24 AUGMENTIN 10 AUSTEDO 24 AVELOX 10

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AVODART 34 AYGESTIN 31 AZASAN 37 azathioprine 37 azelaic acid foam 43 azelaic acid gel 43 azelastine 43 azelastine spray 39 azelastinefluticasone spray 40 azithromycin 10 AZOPT 45 AZOR 16 AZULFIDINE 33 AZULFIDINE EN-TABS 33

B bacitracin 44 baclofen 24 balsalazide 33 BARACLUDE 12 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 40 BELBUCA 9 BELSOMRA 23 benazepril 15 benazeprilhydrochlorothiazide 15 benralizumab 40 BENTYL 32 BENZAC AC 41 BENZAMYCIN 41 benzonatate 38 benzoyl peroxide 41 benztropine 21 besifloxacin 44 BESIVANCE 44 betamethasone dipropionate augmented crm 005 42 betamethasone dipropionate augmented gel oint 005 43 betamethasone dipropionate augmented lotion 005 42 betamethasone dipropionate crm lotion oint 005 42 betamethasone valerate crm lotion oint 01 42 BETASERON 24 betaxolol 45 bethanechol 34 BETHKIS 39 BETIMOL 45 BETOPTIC S 45 BEVESPI AEROSPHERE 38 bexarotene caps 14 bicalutamide 13 bictegraviremtricitabinetenofovir alafenamide 11 BIDIL 18 BIKTARVY 11 bimatoprost 45 bisoprolol 17 bisoprololhydrochlorothiazide 17 BLEPH-10 44 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 27 BONIVA 27 bosentan 19 BOSULIF 14 bosutinib 14 BREO ELLIPTA 40 BRILINTA 36

brimonidine 45 brimonidine 02 45 brimonidinetimolol 45 brinzolamide 45 brinzolamidebrimonidine 45 bromfenac sodium 44 bromocriptine 22 budesonide 40 budesonide delayed-rel caps 33 budesonide ext-rel 33 budesonide inhalation susp 40 budesonideformoterol 40 bumetanide 18 buprenorphine 9 buprenorphinenaloxone sublingual 25 buprenorphinenaloxone sublingual tabs 25 bupropion 21 bupropion ext-rel 21 25 buspirone 20 busulfan 13 butalbitalacetaminophencaffeine tabs 9 butalbitalaspirincaffeine 9 BYSTOLIC 17

C cabergoline 32 CABOMETYX 14 cabozantinib 14 CADUET 18 CALAN SR 18 calcipotriene oint soln 0005 41 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 CAMPRAL 24 canakinumab 37 candesartan 15 candesartanhydrochlorothiazide 15 capecitabine 13 captopril 15 captoprilhydrochlorothiazide 15 carbamazepine 20 carbamazepine ext-rel 20 CARBATROL 20 carbidopalevodopa 22 carbidopalevodopa ext-rel 22 carbidopalevodopa orally disintegrating tabs 21 carbidopalevodopaentacapone 22 CARDURA 15 cariprazine 22 carisoprodol 24 carvedilol 17 carvedilol phosphate ext-rel 17 CASODEX 13 CATAPRES 15 CATAPRES-TTS 15 cefadroxil 10 cefdinir 10 cefixime 10 cefprozil 10 cefuroxime axetil 10 CELEBREX 8 celecoxib 8 CELEXA 21 cephalexin 10 CERDELGA 30

27

50

CEREZYME 30 cetrorelix 30 CETROTIDE 30 cevimeline 34 CHANTIX 25 chlorambucil 13 chloroquine 11 chlorpromazine 22 chlorpromazine inj 22 chlorthalidone 18 chlorzoxazone 24 cholestyramine 16 choriogonadotropin alfa 30 ciclopirox 41 cilostazol 36 CILOXAN 44 CIMDUO 11 cimetidine 32 cinacalcet 27 CIPRO 10 CIPRODEX 46 ciprofloxacin 10 ciprofloxacin oint 44 ciprofloxacin soln 44 ciprofloxacindexamethasone 46 citalopram 21 CITRANATAL 90 DHA 37 CITRANATAL ASSURE 37 CITRANATAL B-CALM 37 CITRANATAL DHA 37 CITRANATAL HARMONY 37 CITRANATAL RX 37 clarithromycin 10 clarithromycin ext-rel 10 clemastine 268 mg 38 CLEOCIN 13 34 CLEOCIN T 41 CLIMARA 29 CLIMARA PRO 29 clindamycin 13 clindamycin crm 34 clindamycin gel 41 clindamycin gel lotion 41 clindamycin soln 41 clindamycinbenzoyl peroxide 41 clobazam 20 clobetasol propionate crm gel oint 005 43 clobetasol propionate foam 005 43 clobetasol propionate lotion shampoo 005 43 clobetasol propionate soln 005 43 CLOBEX 43 clomiphene 30 clomipramine 20 clonazepam 19 clonidine 15 clonidine transdermal 15 clopidogrel 36 clotrimazole 41 clotrimazole troches 10 clozapine 22 CLOZARIL 22 coagulation factor IX (recombinant) glycopegylated 35 codeineacetaminophen 8 codeinepromethazine 39 codeinepromethazinephenylephrine 39 colchicine 8

colesevelam 16 COLESTID 16 colestipol 16 COMBIGAN 45 COMBIPATCH 29 COMBIVIR 11 COMPLERA 11 COMTAN 22 CONCERTA 23 CONDYLOX 43 conjugated estrogensbazedoxifene 29 COPAXONE 24 COREG 17 CORGARD 17 CORLANOR 18 CORTEF 30 CORTIFOAM 33 CORTISPORIN OTIC 46 COSENTYX 36 COSOPT 45 COZAAR 16 CREON 33 CRINONE 31 crisaborole 42 cromolyn sodium 43 cromolyn soln 39 CUTIVATE 42 cyanocobalamin inj 37 cyclobenzaprine 24 cyclophosphamide caps 13 cyclosporine 37 cyclosporine emulsion 45 cyclosporine modified 37 cyproheptadine 38 CYTOMEL 32 CYTOTEC 33

D DHE 45 23 DALIRESP 40 dalteparin 35 danazol 29 DANTRIUM 24 dantrolene 24 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 12 darbepoetin alfa 35 darifenacin ext-rel 34 darolutamide 13 darunavir 12 darunavircobicistat 11 dasatinib 14 DAYPRO 8 DDAVP 32 DEMADEX 18 denosumab 27 DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPO-PROVERA 28 DESCOVY 11 desipramine 21 desmopressin spray tabs 32 desogestrelEE 28 desogestrelEE 01530 28

51

desonide crm lotion oint 005 42 DESOWEN 42 desoximetasone crm oint 005 42 desoximetasone crm oint 025 gel 005 42 desvenlafaxine ext-rel 21 DETROL 34 deutetrabenazine 24 dexamethasone 30 44 dexamethasone sodium phosphate 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 27 DEXEDRINE SPANSULE 23 DEXILANT 33 dexlansoprazole delayed-rel 33 dexmethylphenidate 23 dexmethylphenidate ext-rel 23 dextroamphetamine 22 dextroamphetamine ext-rel 23 dextromethorphanbrompheniraminepseudoephedrine 39 dextromethorphanpromethazine 39 dextromethorphanquinidine 25 DIASTAT 20 diazepam 19 diazepam rectal gel 20 diclofenac sodium 44 diclofenac sodium delayed-rel 8 diclofenac sodium delayed-relmisoprostol 8 diclofenac sodium gel 1 8 diclofenac sodium soln 8 dicloxacillin 10 dicyclomine 32 didanosine delayed-rel 11 DIFICID 10 DIFLUCAN 10 diflunisal 8 difluprednate 44 digoxin 00625 mg 01875 mg 18 digoxin 0125 mg 025 mg 18 digoxin ped elixir 18 dihydroergotamine inj 23 DILANTIN 20 DILANTIN INFATABS 20 DILAUDID 9 diltiazem ext-rel 18 dimethyl fumarate delayed-rel 24 diphenoxylateatropine 32 DIPROLENE 42 43 DIPROLENE AF 42 dipyridamole 36 dipyridamole ext-relaspirin 36 disopyramide 16 disopyramide ext-rel 16 disulfiram 24 DITROPAN XL 34 divalproex sodium delayed-rel 20 divalproex sodium ext-rel 20 DIVIGEL 29 dofetilide 16 dolutegravir 11 donepezil 20 dornase alfa 39 dorzolamide 45 dorzolamidetimolol maleate 45 doxazosin 15 doxepin 21 23 doxercalciferol 30 doxycycline hyclate 10

doxycycline hyclate 20 mg 10 doxycycline monohydrate delayed-rel caps 43 dronabinol 32 dronedarone 16 drospirenoneEE 320 28 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 28 drospirenoneEElevomefolate 330 and levomefolate 28 DUAC 41 DUAVEE 29 DUETACT 26 dulaglutide 26 duloxetine delayed-rel 21 dupilumab 40 42 DUPIXENT 40 42 DUREZOL 44 dutasteride 34 dutasteridetamsulosin 34 DYAZIDE 18 DYMISTA 40

E econazole 41 eculizumab 35 EDURANT 11 EEnorethindrone acetate - Jinteli 29 efavirenz 11 efavirenzemtricitabinetenofovir disoproxil fumarate 11 efavirenzlamivudinetenofovir disoproxil fumarate 11 elagolix 29 eletriptan 23 ELIGARD 13 eliglustat 30 ELIQUIS 35 ELOCON 42 eltrombopag 35 eluxadoline 33 elvitegravircobicistatemtricitabinetenofovir alafenamide 11 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 11 EMBEDA 9 EMGALITY 23 empagliflozin 26 empagliflozinlinagliptin 27 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 11 emtricitabinerilpivirinetenofovir alafenamide 11 emtricitabinerilpivirinetenofovir disoproxil fumarate 11 emtricitabinetenofovir alafenamide 11 emtricitabinetenofovir disoproxil fumarate 11 EMTRIVA 11 EMVERM 13 enalapril 15 enalaprilhydrochlorothiazide 15 ENBREL 36 ENDOMETRIN 31 enfuvirtide 11 enoxaparin 35 entacapone 22 entecavir soln 12 entecavir tabs 12 ENTRESTO 18 enzalutamide 13 EPCLUSA 12 EPIDUO 41 EPIDUO FORTE 41

52

epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

53

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

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itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

INDEX

A abacavir tabs 11 abacavirdolutegravirlamivudine 11 abacavirlamivudine 11 abaloparatide 27 ABILIFY MAINTENA 22 abiraterone 13 acamprosate calcium 24 acarbose 25 ACCU-CHEK AVIVA PLUS kits and test strips 27 ACCU-CHEK COMPACT PLUS kits and test strips 27 ACCU-CHEK GUIDE kits and test strips 27 ACCU-CHEK SMARTVIEW kits and test strips 27 ACCUPRIL 15 ACCURETIC 15 acetazolamide 18 acetazolamide ext-rel 18 acetic acid 46 acitretin 41 ACTIGALL 32 ACTONEL 27 ACTOPLUS MET 26 ACULAR 44 ACUVAIL 44 acyclovir caps tabs 12 ADALAT CC 17 adalimumab 36 adapalene 41 adapalenebenzoyl peroxide 41 ADEMPAS 19 ADVAIR DISKUS 40 ADVAIR HFA 40 ADYNOVATE 35 AFINITOR 14 aflibercept 45 AGGRENOX 36 AGRYLIN 36 AIMOVIG 23 AJOVY 23 albuterol 39 albuterol ext-rel 39 albuterol soln 39 albuterol sulfate CFC-free aerosol 39 alcaftadine 43 alclometasone crm oint 005 42 ALDACTAZIDE 18 ALDACTONE 15 ALDARA 43 alendronate 27 alfuzosin ext-rel 34 aliskiren 18 aliskirenhydrochlorothiazide 18 ALKERAN 13 allopurinol 8 alosetron 33 alpha-1 proteinase inhibitor 40 ALPHAGAN P 45 alprazolam 19 ALTACE 15 amantadine 21 AMARYL 27 AMBIEN 23

AMBIEN CR 23 ambrisentan 19 amiloride 18 amiloridehydrochlorothiazide 18 amiodarone 16 AMITIZA 33 amitriptyline 21 amlodipine 17 amlodipineatorvastatin 18 amlodipinebenazepril 15 amlodipineolmesartan 16 amlodipinetelmisartan 16 amlodipinevalsartan 16 amlodipinevalsartanhydrochlorothiazide 16 ammonium lactate 12 43 amoxicillin 10 amoxicillinclavulanate 10 amoxicillinclavulanate ext-rel 10 amphetaminedextroamphetamine mixed salts 22 amphetaminedextroamphetamine mixed salts ext-rel 22 ampicillin 10 ANAFRANIL 20 anagrelide 36 anastrozole 13 ANDRODERM 25 ANORO ELLIPTA 38 ANTABUSE 24 antihemophilic factor (recombinant) 35 antihemophilic factor (recombinant) pegylated 35 antihemophilic factor (recombinant) pegylated-aucl 35 ANUSOL-HC 34 apalutamide 13 apixaban 35 apremilast 36 APRISO 33 ARANESP 35 ARAVA 36 ARICEPT 20 ARIMIDEX 13 aripiprazole 22 aripiprazole ext-rel inj 22 aripiprazole lauroxil ext-rel inj 22 ARISTADA 22 ARISTADA INITIO 22 ARIXTRA 35 armodafinil 24 ARNUITY ELLIPTA 40 AROMASIN 13 ASTEPRO 39 atazanavir 11 atazanavircobicistat 11 ATELVIA 27 atenolol 17 atenololchlorthalidone 17 ATIVAN 19 atomoxetine 22 atorvastatin 17 atovaquoneproguanil 11 ATRIPLA 11 AUBAGIO 24 AUGMENTIN 10 AUSTEDO 24 AVELOX 10

49

AVODART 34 AYGESTIN 31 AZASAN 37 azathioprine 37 azelaic acid foam 43 azelaic acid gel 43 azelastine 43 azelastine spray 39 azelastinefluticasone spray 40 azithromycin 10 AZOPT 45 AZOR 16 AZULFIDINE 33 AZULFIDINE EN-TABS 33

B bacitracin 44 baclofen 24 balsalazide 33 BARACLUDE 12 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 40 BELBUCA 9 BELSOMRA 23 benazepril 15 benazeprilhydrochlorothiazide 15 benralizumab 40 BENTYL 32 BENZAC AC 41 BENZAMYCIN 41 benzonatate 38 benzoyl peroxide 41 benztropine 21 besifloxacin 44 BESIVANCE 44 betamethasone dipropionate augmented crm 005 42 betamethasone dipropionate augmented gel oint 005 43 betamethasone dipropionate augmented lotion 005 42 betamethasone dipropionate crm lotion oint 005 42 betamethasone valerate crm lotion oint 01 42 BETASERON 24 betaxolol 45 bethanechol 34 BETHKIS 39 BETIMOL 45 BETOPTIC S 45 BEVESPI AEROSPHERE 38 bexarotene caps 14 bicalutamide 13 bictegraviremtricitabinetenofovir alafenamide 11 BIDIL 18 BIKTARVY 11 bimatoprost 45 bisoprolol 17 bisoprololhydrochlorothiazide 17 BLEPH-10 44 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 27 BONIVA 27 bosentan 19 BOSULIF 14 bosutinib 14 BREO ELLIPTA 40 BRILINTA 36

brimonidine 45 brimonidine 02 45 brimonidinetimolol 45 brinzolamide 45 brinzolamidebrimonidine 45 bromfenac sodium 44 bromocriptine 22 budesonide 40 budesonide delayed-rel caps 33 budesonide ext-rel 33 budesonide inhalation susp 40 budesonideformoterol 40 bumetanide 18 buprenorphine 9 buprenorphinenaloxone sublingual 25 buprenorphinenaloxone sublingual tabs 25 bupropion 21 bupropion ext-rel 21 25 buspirone 20 busulfan 13 butalbitalacetaminophencaffeine tabs 9 butalbitalaspirincaffeine 9 BYSTOLIC 17

C cabergoline 32 CABOMETYX 14 cabozantinib 14 CADUET 18 CALAN SR 18 calcipotriene oint soln 0005 41 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 CAMPRAL 24 canakinumab 37 candesartan 15 candesartanhydrochlorothiazide 15 capecitabine 13 captopril 15 captoprilhydrochlorothiazide 15 carbamazepine 20 carbamazepine ext-rel 20 CARBATROL 20 carbidopalevodopa 22 carbidopalevodopa ext-rel 22 carbidopalevodopa orally disintegrating tabs 21 carbidopalevodopaentacapone 22 CARDURA 15 cariprazine 22 carisoprodol 24 carvedilol 17 carvedilol phosphate ext-rel 17 CASODEX 13 CATAPRES 15 CATAPRES-TTS 15 cefadroxil 10 cefdinir 10 cefixime 10 cefprozil 10 cefuroxime axetil 10 CELEBREX 8 celecoxib 8 CELEXA 21 cephalexin 10 CERDELGA 30

27

50

CEREZYME 30 cetrorelix 30 CETROTIDE 30 cevimeline 34 CHANTIX 25 chlorambucil 13 chloroquine 11 chlorpromazine 22 chlorpromazine inj 22 chlorthalidone 18 chlorzoxazone 24 cholestyramine 16 choriogonadotropin alfa 30 ciclopirox 41 cilostazol 36 CILOXAN 44 CIMDUO 11 cimetidine 32 cinacalcet 27 CIPRO 10 CIPRODEX 46 ciprofloxacin 10 ciprofloxacin oint 44 ciprofloxacin soln 44 ciprofloxacindexamethasone 46 citalopram 21 CITRANATAL 90 DHA 37 CITRANATAL ASSURE 37 CITRANATAL B-CALM 37 CITRANATAL DHA 37 CITRANATAL HARMONY 37 CITRANATAL RX 37 clarithromycin 10 clarithromycin ext-rel 10 clemastine 268 mg 38 CLEOCIN 13 34 CLEOCIN T 41 CLIMARA 29 CLIMARA PRO 29 clindamycin 13 clindamycin crm 34 clindamycin gel 41 clindamycin gel lotion 41 clindamycin soln 41 clindamycinbenzoyl peroxide 41 clobazam 20 clobetasol propionate crm gel oint 005 43 clobetasol propionate foam 005 43 clobetasol propionate lotion shampoo 005 43 clobetasol propionate soln 005 43 CLOBEX 43 clomiphene 30 clomipramine 20 clonazepam 19 clonidine 15 clonidine transdermal 15 clopidogrel 36 clotrimazole 41 clotrimazole troches 10 clozapine 22 CLOZARIL 22 coagulation factor IX (recombinant) glycopegylated 35 codeineacetaminophen 8 codeinepromethazine 39 codeinepromethazinephenylephrine 39 colchicine 8

colesevelam 16 COLESTID 16 colestipol 16 COMBIGAN 45 COMBIPATCH 29 COMBIVIR 11 COMPLERA 11 COMTAN 22 CONCERTA 23 CONDYLOX 43 conjugated estrogensbazedoxifene 29 COPAXONE 24 COREG 17 CORGARD 17 CORLANOR 18 CORTEF 30 CORTIFOAM 33 CORTISPORIN OTIC 46 COSENTYX 36 COSOPT 45 COZAAR 16 CREON 33 CRINONE 31 crisaborole 42 cromolyn sodium 43 cromolyn soln 39 CUTIVATE 42 cyanocobalamin inj 37 cyclobenzaprine 24 cyclophosphamide caps 13 cyclosporine 37 cyclosporine emulsion 45 cyclosporine modified 37 cyproheptadine 38 CYTOMEL 32 CYTOTEC 33

D DHE 45 23 DALIRESP 40 dalteparin 35 danazol 29 DANTRIUM 24 dantrolene 24 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 12 darbepoetin alfa 35 darifenacin ext-rel 34 darolutamide 13 darunavir 12 darunavircobicistat 11 dasatinib 14 DAYPRO 8 DDAVP 32 DEMADEX 18 denosumab 27 DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPO-PROVERA 28 DESCOVY 11 desipramine 21 desmopressin spray tabs 32 desogestrelEE 28 desogestrelEE 01530 28

51

desonide crm lotion oint 005 42 DESOWEN 42 desoximetasone crm oint 005 42 desoximetasone crm oint 025 gel 005 42 desvenlafaxine ext-rel 21 DETROL 34 deutetrabenazine 24 dexamethasone 30 44 dexamethasone sodium phosphate 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 27 DEXEDRINE SPANSULE 23 DEXILANT 33 dexlansoprazole delayed-rel 33 dexmethylphenidate 23 dexmethylphenidate ext-rel 23 dextroamphetamine 22 dextroamphetamine ext-rel 23 dextromethorphanbrompheniraminepseudoephedrine 39 dextromethorphanpromethazine 39 dextromethorphanquinidine 25 DIASTAT 20 diazepam 19 diazepam rectal gel 20 diclofenac sodium 44 diclofenac sodium delayed-rel 8 diclofenac sodium delayed-relmisoprostol 8 diclofenac sodium gel 1 8 diclofenac sodium soln 8 dicloxacillin 10 dicyclomine 32 didanosine delayed-rel 11 DIFICID 10 DIFLUCAN 10 diflunisal 8 difluprednate 44 digoxin 00625 mg 01875 mg 18 digoxin 0125 mg 025 mg 18 digoxin ped elixir 18 dihydroergotamine inj 23 DILANTIN 20 DILANTIN INFATABS 20 DILAUDID 9 diltiazem ext-rel 18 dimethyl fumarate delayed-rel 24 diphenoxylateatropine 32 DIPROLENE 42 43 DIPROLENE AF 42 dipyridamole 36 dipyridamole ext-relaspirin 36 disopyramide 16 disopyramide ext-rel 16 disulfiram 24 DITROPAN XL 34 divalproex sodium delayed-rel 20 divalproex sodium ext-rel 20 DIVIGEL 29 dofetilide 16 dolutegravir 11 donepezil 20 dornase alfa 39 dorzolamide 45 dorzolamidetimolol maleate 45 doxazosin 15 doxepin 21 23 doxercalciferol 30 doxycycline hyclate 10

doxycycline hyclate 20 mg 10 doxycycline monohydrate delayed-rel caps 43 dronabinol 32 dronedarone 16 drospirenoneEE 320 28 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 28 drospirenoneEElevomefolate 330 and levomefolate 28 DUAC 41 DUAVEE 29 DUETACT 26 dulaglutide 26 duloxetine delayed-rel 21 dupilumab 40 42 DUPIXENT 40 42 DUREZOL 44 dutasteride 34 dutasteridetamsulosin 34 DYAZIDE 18 DYMISTA 40

E econazole 41 eculizumab 35 EDURANT 11 EEnorethindrone acetate - Jinteli 29 efavirenz 11 efavirenzemtricitabinetenofovir disoproxil fumarate 11 efavirenzlamivudinetenofovir disoproxil fumarate 11 elagolix 29 eletriptan 23 ELIGARD 13 eliglustat 30 ELIQUIS 35 ELOCON 42 eltrombopag 35 eluxadoline 33 elvitegravircobicistatemtricitabinetenofovir alafenamide 11 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 11 EMBEDA 9 EMGALITY 23 empagliflozin 26 empagliflozinlinagliptin 27 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 11 emtricitabinerilpivirinetenofovir alafenamide 11 emtricitabinerilpivirinetenofovir disoproxil fumarate 11 emtricitabinetenofovir alafenamide 11 emtricitabinetenofovir disoproxil fumarate 11 EMTRIVA 11 EMVERM 13 enalapril 15 enalaprilhydrochlorothiazide 15 ENBREL 36 ENDOMETRIN 31 enfuvirtide 11 enoxaparin 35 entacapone 22 entecavir soln 12 entecavir tabs 12 ENTRESTO 18 enzalutamide 13 EPCLUSA 12 EPIDUO 41 EPIDUO FORTE 41

52

epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

53

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

54

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

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ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

AVODART 34 AYGESTIN 31 AZASAN 37 azathioprine 37 azelaic acid foam 43 azelaic acid gel 43 azelastine 43 azelastine spray 39 azelastinefluticasone spray 40 azithromycin 10 AZOPT 45 AZOR 16 AZULFIDINE 33 AZULFIDINE EN-TABS 33

B bacitracin 44 baclofen 24 balsalazide 33 BARACLUDE 12 BASAGLAR 26 BD ULTRAFINE insulin syringes and needles 27 beclomethasone breath-activated aerosol 40 BELBUCA 9 BELSOMRA 23 benazepril 15 benazeprilhydrochlorothiazide 15 benralizumab 40 BENTYL 32 BENZAC AC 41 BENZAMYCIN 41 benzonatate 38 benzoyl peroxide 41 benztropine 21 besifloxacin 44 BESIVANCE 44 betamethasone dipropionate augmented crm 005 42 betamethasone dipropionate augmented gel oint 005 43 betamethasone dipropionate augmented lotion 005 42 betamethasone dipropionate crm lotion oint 005 42 betamethasone valerate crm lotion oint 01 42 BETASERON 24 betaxolol 45 bethanechol 34 BETHKIS 39 BETIMOL 45 BETOPTIC S 45 BEVESPI AEROSPHERE 38 bexarotene caps 14 bicalutamide 13 bictegraviremtricitabinetenofovir alafenamide 11 BIDIL 18 BIKTARVY 11 bimatoprost 45 bisoprolol 17 bisoprololhydrochlorothiazide 17 BLEPH-10 44 blood glucose continuous monitoring receivers sensors transmitters

blood glucose monitoring kits test strips 27 BONIVA 27 bosentan 19 BOSULIF 14 bosutinib 14 BREO ELLIPTA 40 BRILINTA 36

brimonidine 45 brimonidine 02 45 brimonidinetimolol 45 brinzolamide 45 brinzolamidebrimonidine 45 bromfenac sodium 44 bromocriptine 22 budesonide 40 budesonide delayed-rel caps 33 budesonide ext-rel 33 budesonide inhalation susp 40 budesonideformoterol 40 bumetanide 18 buprenorphine 9 buprenorphinenaloxone sublingual 25 buprenorphinenaloxone sublingual tabs 25 bupropion 21 bupropion ext-rel 21 25 buspirone 20 busulfan 13 butalbitalacetaminophencaffeine tabs 9 butalbitalaspirincaffeine 9 BYSTOLIC 17

C cabergoline 32 CABOMETYX 14 cabozantinib 14 CADUET 18 CALAN SR 18 calcipotriene oint soln 0005 41 calcitonin-salmon spray 27 calcitriol (125-D3) 30 calcium acetate 30 CAMPRAL 24 canakinumab 37 candesartan 15 candesartanhydrochlorothiazide 15 capecitabine 13 captopril 15 captoprilhydrochlorothiazide 15 carbamazepine 20 carbamazepine ext-rel 20 CARBATROL 20 carbidopalevodopa 22 carbidopalevodopa ext-rel 22 carbidopalevodopa orally disintegrating tabs 21 carbidopalevodopaentacapone 22 CARDURA 15 cariprazine 22 carisoprodol 24 carvedilol 17 carvedilol phosphate ext-rel 17 CASODEX 13 CATAPRES 15 CATAPRES-TTS 15 cefadroxil 10 cefdinir 10 cefixime 10 cefprozil 10 cefuroxime axetil 10 CELEBREX 8 celecoxib 8 CELEXA 21 cephalexin 10 CERDELGA 30

27

50

CEREZYME 30 cetrorelix 30 CETROTIDE 30 cevimeline 34 CHANTIX 25 chlorambucil 13 chloroquine 11 chlorpromazine 22 chlorpromazine inj 22 chlorthalidone 18 chlorzoxazone 24 cholestyramine 16 choriogonadotropin alfa 30 ciclopirox 41 cilostazol 36 CILOXAN 44 CIMDUO 11 cimetidine 32 cinacalcet 27 CIPRO 10 CIPRODEX 46 ciprofloxacin 10 ciprofloxacin oint 44 ciprofloxacin soln 44 ciprofloxacindexamethasone 46 citalopram 21 CITRANATAL 90 DHA 37 CITRANATAL ASSURE 37 CITRANATAL B-CALM 37 CITRANATAL DHA 37 CITRANATAL HARMONY 37 CITRANATAL RX 37 clarithromycin 10 clarithromycin ext-rel 10 clemastine 268 mg 38 CLEOCIN 13 34 CLEOCIN T 41 CLIMARA 29 CLIMARA PRO 29 clindamycin 13 clindamycin crm 34 clindamycin gel 41 clindamycin gel lotion 41 clindamycin soln 41 clindamycinbenzoyl peroxide 41 clobazam 20 clobetasol propionate crm gel oint 005 43 clobetasol propionate foam 005 43 clobetasol propionate lotion shampoo 005 43 clobetasol propionate soln 005 43 CLOBEX 43 clomiphene 30 clomipramine 20 clonazepam 19 clonidine 15 clonidine transdermal 15 clopidogrel 36 clotrimazole 41 clotrimazole troches 10 clozapine 22 CLOZARIL 22 coagulation factor IX (recombinant) glycopegylated 35 codeineacetaminophen 8 codeinepromethazine 39 codeinepromethazinephenylephrine 39 colchicine 8

colesevelam 16 COLESTID 16 colestipol 16 COMBIGAN 45 COMBIPATCH 29 COMBIVIR 11 COMPLERA 11 COMTAN 22 CONCERTA 23 CONDYLOX 43 conjugated estrogensbazedoxifene 29 COPAXONE 24 COREG 17 CORGARD 17 CORLANOR 18 CORTEF 30 CORTIFOAM 33 CORTISPORIN OTIC 46 COSENTYX 36 COSOPT 45 COZAAR 16 CREON 33 CRINONE 31 crisaborole 42 cromolyn sodium 43 cromolyn soln 39 CUTIVATE 42 cyanocobalamin inj 37 cyclobenzaprine 24 cyclophosphamide caps 13 cyclosporine 37 cyclosporine emulsion 45 cyclosporine modified 37 cyproheptadine 38 CYTOMEL 32 CYTOTEC 33

D DHE 45 23 DALIRESP 40 dalteparin 35 danazol 29 DANTRIUM 24 dantrolene 24 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 12 darbepoetin alfa 35 darifenacin ext-rel 34 darolutamide 13 darunavir 12 darunavircobicistat 11 dasatinib 14 DAYPRO 8 DDAVP 32 DEMADEX 18 denosumab 27 DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPO-PROVERA 28 DESCOVY 11 desipramine 21 desmopressin spray tabs 32 desogestrelEE 28 desogestrelEE 01530 28

51

desonide crm lotion oint 005 42 DESOWEN 42 desoximetasone crm oint 005 42 desoximetasone crm oint 025 gel 005 42 desvenlafaxine ext-rel 21 DETROL 34 deutetrabenazine 24 dexamethasone 30 44 dexamethasone sodium phosphate 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 27 DEXEDRINE SPANSULE 23 DEXILANT 33 dexlansoprazole delayed-rel 33 dexmethylphenidate 23 dexmethylphenidate ext-rel 23 dextroamphetamine 22 dextroamphetamine ext-rel 23 dextromethorphanbrompheniraminepseudoephedrine 39 dextromethorphanpromethazine 39 dextromethorphanquinidine 25 DIASTAT 20 diazepam 19 diazepam rectal gel 20 diclofenac sodium 44 diclofenac sodium delayed-rel 8 diclofenac sodium delayed-relmisoprostol 8 diclofenac sodium gel 1 8 diclofenac sodium soln 8 dicloxacillin 10 dicyclomine 32 didanosine delayed-rel 11 DIFICID 10 DIFLUCAN 10 diflunisal 8 difluprednate 44 digoxin 00625 mg 01875 mg 18 digoxin 0125 mg 025 mg 18 digoxin ped elixir 18 dihydroergotamine inj 23 DILANTIN 20 DILANTIN INFATABS 20 DILAUDID 9 diltiazem ext-rel 18 dimethyl fumarate delayed-rel 24 diphenoxylateatropine 32 DIPROLENE 42 43 DIPROLENE AF 42 dipyridamole 36 dipyridamole ext-relaspirin 36 disopyramide 16 disopyramide ext-rel 16 disulfiram 24 DITROPAN XL 34 divalproex sodium delayed-rel 20 divalproex sodium ext-rel 20 DIVIGEL 29 dofetilide 16 dolutegravir 11 donepezil 20 dornase alfa 39 dorzolamide 45 dorzolamidetimolol maleate 45 doxazosin 15 doxepin 21 23 doxercalciferol 30 doxycycline hyclate 10

doxycycline hyclate 20 mg 10 doxycycline monohydrate delayed-rel caps 43 dronabinol 32 dronedarone 16 drospirenoneEE 320 28 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 28 drospirenoneEElevomefolate 330 and levomefolate 28 DUAC 41 DUAVEE 29 DUETACT 26 dulaglutide 26 duloxetine delayed-rel 21 dupilumab 40 42 DUPIXENT 40 42 DUREZOL 44 dutasteride 34 dutasteridetamsulosin 34 DYAZIDE 18 DYMISTA 40

E econazole 41 eculizumab 35 EDURANT 11 EEnorethindrone acetate - Jinteli 29 efavirenz 11 efavirenzemtricitabinetenofovir disoproxil fumarate 11 efavirenzlamivudinetenofovir disoproxil fumarate 11 elagolix 29 eletriptan 23 ELIGARD 13 eliglustat 30 ELIQUIS 35 ELOCON 42 eltrombopag 35 eluxadoline 33 elvitegravircobicistatemtricitabinetenofovir alafenamide 11 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 11 EMBEDA 9 EMGALITY 23 empagliflozin 26 empagliflozinlinagliptin 27 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 11 emtricitabinerilpivirinetenofovir alafenamide 11 emtricitabinerilpivirinetenofovir disoproxil fumarate 11 emtricitabinetenofovir alafenamide 11 emtricitabinetenofovir disoproxil fumarate 11 EMTRIVA 11 EMVERM 13 enalapril 15 enalaprilhydrochlorothiazide 15 ENBREL 36 ENDOMETRIN 31 enfuvirtide 11 enoxaparin 35 entacapone 22 entecavir soln 12 entecavir tabs 12 ENTRESTO 18 enzalutamide 13 EPCLUSA 12 EPIDUO 41 EPIDUO FORTE 41

52

epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

53

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

54

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

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nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

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peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

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ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

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CEREZYME 30 cetrorelix 30 CETROTIDE 30 cevimeline 34 CHANTIX 25 chlorambucil 13 chloroquine 11 chlorpromazine 22 chlorpromazine inj 22 chlorthalidone 18 chlorzoxazone 24 cholestyramine 16 choriogonadotropin alfa 30 ciclopirox 41 cilostazol 36 CILOXAN 44 CIMDUO 11 cimetidine 32 cinacalcet 27 CIPRO 10 CIPRODEX 46 ciprofloxacin 10 ciprofloxacin oint 44 ciprofloxacin soln 44 ciprofloxacindexamethasone 46 citalopram 21 CITRANATAL 90 DHA 37 CITRANATAL ASSURE 37 CITRANATAL B-CALM 37 CITRANATAL DHA 37 CITRANATAL HARMONY 37 CITRANATAL RX 37 clarithromycin 10 clarithromycin ext-rel 10 clemastine 268 mg 38 CLEOCIN 13 34 CLEOCIN T 41 CLIMARA 29 CLIMARA PRO 29 clindamycin 13 clindamycin crm 34 clindamycin gel 41 clindamycin gel lotion 41 clindamycin soln 41 clindamycinbenzoyl peroxide 41 clobazam 20 clobetasol propionate crm gel oint 005 43 clobetasol propionate foam 005 43 clobetasol propionate lotion shampoo 005 43 clobetasol propionate soln 005 43 CLOBEX 43 clomiphene 30 clomipramine 20 clonazepam 19 clonidine 15 clonidine transdermal 15 clopidogrel 36 clotrimazole 41 clotrimazole troches 10 clozapine 22 CLOZARIL 22 coagulation factor IX (recombinant) glycopegylated 35 codeineacetaminophen 8 codeinepromethazine 39 codeinepromethazinephenylephrine 39 colchicine 8

colesevelam 16 COLESTID 16 colestipol 16 COMBIGAN 45 COMBIPATCH 29 COMBIVIR 11 COMPLERA 11 COMTAN 22 CONCERTA 23 CONDYLOX 43 conjugated estrogensbazedoxifene 29 COPAXONE 24 COREG 17 CORGARD 17 CORLANOR 18 CORTEF 30 CORTIFOAM 33 CORTISPORIN OTIC 46 COSENTYX 36 COSOPT 45 COZAAR 16 CREON 33 CRINONE 31 crisaborole 42 cromolyn sodium 43 cromolyn soln 39 CUTIVATE 42 cyanocobalamin inj 37 cyclobenzaprine 24 cyclophosphamide caps 13 cyclosporine 37 cyclosporine emulsion 45 cyclosporine modified 37 cyproheptadine 38 CYTOMEL 32 CYTOTEC 33

D DHE 45 23 DALIRESP 40 dalteparin 35 danazol 29 DANTRIUM 24 dantrolene 24 dapagliflozin 26 dapagliflozinmetformin ext-rel 26 dapsone 12 darbepoetin alfa 35 darifenacin ext-rel 34 darolutamide 13 darunavir 12 darunavircobicistat 11 dasatinib 14 DAYPRO 8 DDAVP 32 DEMADEX 18 denosumab 27 DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPO-PROVERA 28 DESCOVY 11 desipramine 21 desmopressin spray tabs 32 desogestrelEE 28 desogestrelEE 01530 28

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desonide crm lotion oint 005 42 DESOWEN 42 desoximetasone crm oint 005 42 desoximetasone crm oint 025 gel 005 42 desvenlafaxine ext-rel 21 DETROL 34 deutetrabenazine 24 dexamethasone 30 44 dexamethasone sodium phosphate 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 27 DEXEDRINE SPANSULE 23 DEXILANT 33 dexlansoprazole delayed-rel 33 dexmethylphenidate 23 dexmethylphenidate ext-rel 23 dextroamphetamine 22 dextroamphetamine ext-rel 23 dextromethorphanbrompheniraminepseudoephedrine 39 dextromethorphanpromethazine 39 dextromethorphanquinidine 25 DIASTAT 20 diazepam 19 diazepam rectal gel 20 diclofenac sodium 44 diclofenac sodium delayed-rel 8 diclofenac sodium delayed-relmisoprostol 8 diclofenac sodium gel 1 8 diclofenac sodium soln 8 dicloxacillin 10 dicyclomine 32 didanosine delayed-rel 11 DIFICID 10 DIFLUCAN 10 diflunisal 8 difluprednate 44 digoxin 00625 mg 01875 mg 18 digoxin 0125 mg 025 mg 18 digoxin ped elixir 18 dihydroergotamine inj 23 DILANTIN 20 DILANTIN INFATABS 20 DILAUDID 9 diltiazem ext-rel 18 dimethyl fumarate delayed-rel 24 diphenoxylateatropine 32 DIPROLENE 42 43 DIPROLENE AF 42 dipyridamole 36 dipyridamole ext-relaspirin 36 disopyramide 16 disopyramide ext-rel 16 disulfiram 24 DITROPAN XL 34 divalproex sodium delayed-rel 20 divalproex sodium ext-rel 20 DIVIGEL 29 dofetilide 16 dolutegravir 11 donepezil 20 dornase alfa 39 dorzolamide 45 dorzolamidetimolol maleate 45 doxazosin 15 doxepin 21 23 doxercalciferol 30 doxycycline hyclate 10

doxycycline hyclate 20 mg 10 doxycycline monohydrate delayed-rel caps 43 dronabinol 32 dronedarone 16 drospirenoneEE 320 28 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 28 drospirenoneEElevomefolate 330 and levomefolate 28 DUAC 41 DUAVEE 29 DUETACT 26 dulaglutide 26 duloxetine delayed-rel 21 dupilumab 40 42 DUPIXENT 40 42 DUREZOL 44 dutasteride 34 dutasteridetamsulosin 34 DYAZIDE 18 DYMISTA 40

E econazole 41 eculizumab 35 EDURANT 11 EEnorethindrone acetate - Jinteli 29 efavirenz 11 efavirenzemtricitabinetenofovir disoproxil fumarate 11 efavirenzlamivudinetenofovir disoproxil fumarate 11 elagolix 29 eletriptan 23 ELIGARD 13 eliglustat 30 ELIQUIS 35 ELOCON 42 eltrombopag 35 eluxadoline 33 elvitegravircobicistatemtricitabinetenofovir alafenamide 11 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 11 EMBEDA 9 EMGALITY 23 empagliflozin 26 empagliflozinlinagliptin 27 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 11 emtricitabinerilpivirinetenofovir alafenamide 11 emtricitabinerilpivirinetenofovir disoproxil fumarate 11 emtricitabinetenofovir alafenamide 11 emtricitabinetenofovir disoproxil fumarate 11 EMTRIVA 11 EMVERM 13 enalapril 15 enalaprilhydrochlorothiazide 15 ENBREL 36 ENDOMETRIN 31 enfuvirtide 11 enoxaparin 35 entacapone 22 entecavir soln 12 entecavir tabs 12 ENTRESTO 18 enzalutamide 13 EPCLUSA 12 EPIDUO 41 EPIDUO FORTE 41

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epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

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G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

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itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

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M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

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nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

desonide crm lotion oint 005 42 DESOWEN 42 desoximetasone crm oint 005 42 desoximetasone crm oint 025 gel 005 42 desvenlafaxine ext-rel 21 DETROL 34 deutetrabenazine 24 dexamethasone 30 44 dexamethasone sodium phosphate 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM 27 DEXEDRINE SPANSULE 23 DEXILANT 33 dexlansoprazole delayed-rel 33 dexmethylphenidate 23 dexmethylphenidate ext-rel 23 dextroamphetamine 22 dextroamphetamine ext-rel 23 dextromethorphanbrompheniraminepseudoephedrine 39 dextromethorphanpromethazine 39 dextromethorphanquinidine 25 DIASTAT 20 diazepam 19 diazepam rectal gel 20 diclofenac sodium 44 diclofenac sodium delayed-rel 8 diclofenac sodium delayed-relmisoprostol 8 diclofenac sodium gel 1 8 diclofenac sodium soln 8 dicloxacillin 10 dicyclomine 32 didanosine delayed-rel 11 DIFICID 10 DIFLUCAN 10 diflunisal 8 difluprednate 44 digoxin 00625 mg 01875 mg 18 digoxin 0125 mg 025 mg 18 digoxin ped elixir 18 dihydroergotamine inj 23 DILANTIN 20 DILANTIN INFATABS 20 DILAUDID 9 diltiazem ext-rel 18 dimethyl fumarate delayed-rel 24 diphenoxylateatropine 32 DIPROLENE 42 43 DIPROLENE AF 42 dipyridamole 36 dipyridamole ext-relaspirin 36 disopyramide 16 disopyramide ext-rel 16 disulfiram 24 DITROPAN XL 34 divalproex sodium delayed-rel 20 divalproex sodium ext-rel 20 DIVIGEL 29 dofetilide 16 dolutegravir 11 donepezil 20 dornase alfa 39 dorzolamide 45 dorzolamidetimolol maleate 45 doxazosin 15 doxepin 21 23 doxercalciferol 30 doxycycline hyclate 10

doxycycline hyclate 20 mg 10 doxycycline monohydrate delayed-rel caps 43 dronabinol 32 dronedarone 16 drospirenoneEE 320 28 drospirenoneEE 330 28 drospirenoneEElevomefolate 320 and levomefolate 28 drospirenoneEElevomefolate 330 and levomefolate 28 DUAC 41 DUAVEE 29 DUETACT 26 dulaglutide 26 duloxetine delayed-rel 21 dupilumab 40 42 DUPIXENT 40 42 DUREZOL 44 dutasteride 34 dutasteridetamsulosin 34 DYAZIDE 18 DYMISTA 40

E econazole 41 eculizumab 35 EDURANT 11 EEnorethindrone acetate - Jinteli 29 efavirenz 11 efavirenzemtricitabinetenofovir disoproxil fumarate 11 efavirenzlamivudinetenofovir disoproxil fumarate 11 elagolix 29 eletriptan 23 ELIGARD 13 eliglustat 30 ELIQUIS 35 ELOCON 42 eltrombopag 35 eluxadoline 33 elvitegravircobicistatemtricitabinetenofovir alafenamide 11 elvitegravircobicistatemtricitabinetenofovir disoproxil fumarate 11 EMBEDA 9 EMGALITY 23 empagliflozin 26 empagliflozinlinagliptin 27 empagliflozinmetformin 26 empagliflozinmetformin ext-rel 26 emtricitabine 11 emtricitabinerilpivirinetenofovir alafenamide 11 emtricitabinerilpivirinetenofovir disoproxil fumarate 11 emtricitabinetenofovir alafenamide 11 emtricitabinetenofovir disoproxil fumarate 11 EMTRIVA 11 EMVERM 13 enalapril 15 enalaprilhydrochlorothiazide 15 ENBREL 36 ENDOMETRIN 31 enfuvirtide 11 enoxaparin 35 entacapone 22 entecavir soln 12 entecavir tabs 12 ENTRESTO 18 enzalutamide 13 EPCLUSA 12 EPIDUO 41 EPIDUO FORTE 41

52

epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

53

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

54

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

epinephrine auto-injector 38 EPIPEN 38 EPIPEN JR 38 EPIVIR 11 eplerenone 15 epoetin alfa-epbx 35 epoprostenol sodium 19 eprosartan 15 EPZICOM 11 erenumab-aooe 23 ergocalciferol (D2) 37 ergotaminecaffeine 23 ERLEADA 13 erlotinib 14 erythromycin 44 erythromycin delayed-rel 10 erythromycin ethylsuccinate 10 erythromycin gel 2 41 erythromycin soln 41 erythromycin stearate 10 erythromycinbenzoyl peroxide 41 ESBRIET 40 escitalopram 21 ESGIC 9 esomeprazole delayed-rel 33 ESTRACE 29 estradiol 29 estradiol vaginal crm 29 estradiol vaginal ring 29 estradiol vaginal tabs 29 estradiollevonorgestrel 29 estradiolnorethindrone 29 estradiolnorethindrone acetate 29 ESTRING 29 estrogens conjugated 29 estrogens conjugated crm 29 estrogens conjugatedmedroxyprogesterone 29 eszopiclone 23 etanercept 36 ethambutol 12 ethosuximide 20 ethynodiol diacetateEE 135 - Zovia 135 28 ethynodiol diacetateEE 150 28 etonogestrelEE ring 29 etoposide 14 etravirine 11 EUCRISA 42 EVAMIST 29 everolimus 14 EVISTA 31 evolocumab 17 EVOTAZ 11 EVOXAC 34 EXELON 20 exemestane 13 EYLEA 45 ezetimibe 16 ezetimibesimvastatin 17

F famciclovir 12 famotidine 33 FARXIGA 26 FASENRA 40 febuxostat 8 felodipine ext-rel 17

FEMARA 13 fenofibrate 16 fenofibric acid delayed-rel 16 fentanyl sublingual spray 9 fentanyl transdermal 8 fentanyl transmucosal lozenge 8 fesoterodine ext-rel 34 FIASP 26 fidaxomicin 10 filgrastim-aafi 35 FINACEA FOAM 43 finasteride 34 fingolimod 24 FIORINAL 9 FIRAZYR 35 FLAGYL 13 flecainide 16 FLOLAN 19 FLOMAX 34 FLOVENT DISKUS 40 FLOVENT HFA 40 fluconazole 10 fludrocortisone 30 flunisolide spray 40 fluocinolone acetonide crm oint 0025 42 fluocinolone acetonide soln 001 42 fluocinonide crm gel oint soln 005 42 fluoride drops 37 fluoride tabs 37 fluorometholone 44 fluorouracil crm 4 41 fluorouracil crm 5 soln 5 soln 2 41 fluoxetine 21 fluphenazine 22 flutamide 13 fluticasone 40 fluticasone propionate crm lotion 005 42 fluticasone propionate oint 0005 42 fluticasone spray 40 fluticasone CFC-free aerosol 40 fluticasonesalmeterol 40 fluticasonesalmeterol CFC-free aerosol 40 fluticasoneumeclidiniumvilanterol 38 fluticasonevilanterol 40 fluvastatin 17 fluvoxamine 20 FML FORTE 44 FML SOP 44 FOCALIN 23 FOCALIN XR 23 folic acid 37 folic acidvitamin B6vitamin B12 37 follitropin alfa 30 fondaparinux 35 formoterol inhalation soln 39 FORTEO 27 FOSAMAX 27 fosinopril 15 fosinoprilhydrochlorothiazide 15 FRAGMIN 35 fremanezumab-vfrm 23 FURADANTIN 13 furosemide 18 FUZEON 11 FYCOMPA 20

53

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

54

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

G gabapentin 20 gabapentin ext-rel 24 galantamine 20 galantamine ext-rel 20 galcanezumab-gnlm 23 ganirelix acetate 30 gefitinib 14 gemfibrozil 16 GENOTROPIN 30 gentamicin 41 44 GENVOYA 11 GEODON 22 GILENYA 24 glatiramer 24 glimepiride 27 glipizide 27 glipizide ext-rel 27 glipizidemetformin 26 GLUCAGEN HYPOKIT 30 GLUCAGON EMERGENCY KIT 30 glucagon human recombinant 30 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOTROL 27 GLUCOTROL XL 27 glyburide 27 glycopyrrolateformoterol 38 GLYXAMBI 27 GOLYTELY 33 GONAL-F 30 GRALISE 24 granisetron 32 granisetron transdermal 32 grass mixed pollen allergen extract 36 GRASTEK 36 griseofulvin ultramicrosize 10 guanfacine 15 guanfacine ext-rel 22 guselkumab 36

H HALDOL 22 HALDOL DECANOATE 22 halobetasol propionate crm oint 005 43 haloperidol 22 haloperidol decanoate inj 22 haloperidol inj 22 HARVONI 12 HECTOROL 30 human coagulation factor VIII (rDNA) simoctocog alfa 35 HUMATROPE 30 HUMIRA 36 HUMULIN R U-500 26 HYCAMTIN 14 hydralazine 19 HYDREA 14 hydrochlorothiazide 18 hydrocodoneacetaminophen 9 hydrocodonehomatropine 39 hydrocortisone 30 hydrocortisone acetate foam 33 hydrocortisone acetatepramoxine foam 34 hydrocortisone butyrate crm oint soln 01 42 hydrocortisone crm 34 hydrocortisone crm 25 42

hydrocortisone enema 33 hydrocortisone lotion 1 42 hydrocortisone valerate crm oint 02 42 hydromorphone 9 hydromorphone ext-rel 8 hydroxychloroquine 36 hydroxyurea 14 hydroxyzine HCl 38 hyoscyamine sulfate 32 hyoscyamine sulfate ext-rel 32 hyoscyamine sulfate ext-rel caps 32 hyoscyamine sulfate orally disintegrating tabs 32 HYZAAR 16

I ibandronate 27 IBRANCE 14 ibuprofen 8 icatibant 35 icosapent ethyl 17 ILARIS 37 ILEVRO 44 imatinib mesylate 14 IMDUR 19 imiglucerase 30 imipramine HCl 21 imiquimod 41 43 IMITREX 23 IMURAN 37 INCRUSE ELLIPTA 38 indapamide 18 INDERAL LA 17 ingenol mebutate 41 INGREZZA 24 INSPRA 15 insulin aspart 26 insulin aspart protamine 70insulin aspart 30 26 insulin degludec 26 insulin detemir 26 insulin glargine 26 insulin human 26 insulin isophane human 26 insulin isophane human 70regular 30 26 insulin management system 27 insulin syringes needles 27 INTELENCE 11 interferon alfa-2b 37 interferon beta-1a 24 interferon beta-1b 24 INTRON A 37 INVEGA SUSTENNA 22 ipratropium soln 38 ipratropium spray 40 ipratropiumalbuterol soln 38 irbesartan 15 irbesartanhydrochlorothiazide 15 IRESSA 14 ISENTRESS 11 isoniazid 12 ISORDIL 19 isosorbide dinitrate ext-rel tabs 19 isosorbide dinitrate oral 19 isosorbide dinitratehydralazine 18 isosorbide mononitrate 19 isosorbide mononitrate ext-rel 19 isotretinoin 40

54

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

itraconazole 10 ivabradine 18 ivermectin 13 43

J JANUMET 26 JANUMET XR 26 JANUVIA 26 JARDIANCE 26 JIVI 35

K KADIAN 9 KALETRA 12 KEFLEX 10 KEPPRA 20 KEPPRA XR 20 ketoconazole 41 ketoconazole shampoo 2 42 ketorolac 44 ketorolac tromethamine 44 KISQALI 14 KISQALI FEMARA CO-PACK 14 KLARON 41 KLONOPIN 19 KOGENATE FS 35 KOVALTRY 35 KUVAN 30 KYLEENA 29

L labetalol 17 LAC-HYDRIN 43 lacosamide 20 lactulose soln 33 lamivudine 11 12 lamivudinetenofovir disoproxil fumarate 11 lamivudinezidovudine 11 lamotrigine 20 lamotrigine ext-rel 20 lamotrigine orally disintegrating tabs 20 lancets 27 LANOXIN 18 lanreotide acetate 25 lansoprazole + amoxicillin + clarithromycin 34 lansoprazole delayed-rel 33 lanthanum carbonate 30 lapatinib 14 LASIX 18 LASTACAFT 43 latanoprost 45 LATUDA 22 ledipasvirsofosbuvir 12 leflunomide 36 lenalidomide 14 letrozole 13 LEUKERAN 13 leuprolide acetate 13 levalbuterol tartrate CFC-free aerosol 39 LEVAQUIN 10 LEVBID 32 LEVEMIR 26 levetiracetam 20 levetiracetam ext-rel 20 levobunolol 45 levocarnitine 27 levocetirizine 38

levofloxacin 10 44 levonorgestrel releasing IUD 29 levonorgestrelEE - Trivora 28 levonorgestrelEE 0120 - Lessina 28 levonorgestrelEE 0120 and EE 10 28 levonorgestrelEE 01530 28 levonorgestrelEE 01530 - Levora 28 levonorgestrelEE 01530 and EE 10 28 levothyroxine 32 levothyroxine - Levoxyl 32 LEVSIN 32 lidocaine patch 43 lidocaine viscous 43 LIDODERM 43 lifitegrast 45 linaclotide 33 linezolid 12 LINZESS 33 liothyronine 32 LIPOFEN 16 liraglutide 26 liraglutideinsulin degludec 26 lisdexamfetamine 22 lisinopril 15 lisinoprilhydrochlorothiazide 15 lithium carbonate 24 lithium carbonate ext-rel tabs 300 mg 24 lithium carbonate ext-rel tabs 450 mg 24 LITHOBID 24 lixisenatideinsulin glargine 26 LOESTRIN 1530 28 LOESTRIN 120 28 LOESTRIN FE 1530 28 LOESTRIN FE 120 28 LOKELMA 31 LOMOTIL 32 loperamide 32 LOPID 16 lopinavirritonavir soln 12 lopinavirritonavir tabs 12 LOPRESSOR 17 LOPRESSOR HCT 17 LOPROX 41 lorazepam 19 losartan 16 losartanhydrochlorothiazide 16 LOSEASONIQUE 28 LOTENSIN 15 LOTENSIN HCT 15 loteprednol 44 LOTREL 15 lovastatin 17 LOVAZA 17 LOVENOX 35 lubiprostone 33 LUCENTIS 45 luliconazole 41 LUMIGAN 45 LUPRON DEPOT 13 lurasidone 22 lusutrombopag 36 LYNPARZA 14 LYRICA 23 LYSODREN 14

55

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

M macitentan 19 MACROBID 13 MALARONE 11 malathion 43 MARINOL 32 MATULANE 14 MAXALT 23 MAXIDEX 44 MAXITROL 44 MAXZIDE 18 MAYZENT 24 mebendazole chewable 13 meclizine 32 MEDROL 30 medroxyprogesterone acetate 31 medroxyprogesterone acetate 150 mgmL 28 mefloquine 11 MEGACE ES 31 megestrol acetate susp 31 megestrol acetate tabs 13 meloxicam 8 melphalan 13 memantine 20 memantine ext-rel 20 memantinedonepezil 20 mepolizumab 40 mercaptopurine 13 mesalamine delayed-rel tabs 33 mesalamine ext-rel caps 33 mesalamine supp 33 mesalamine susp 33 metaxalone 24 metformin 25 metformin ext-rel 25 methadone 8 methazolamide 18 methimazole 32 methocarbamol 24 methotrexate 13 36 methotrexate auto-injector 36 methoxsalen oral 41 methyldopa 19 METHYLIN 23 methylphenidate 23 methylphenidate ext-rel 22 23 methylprednisolone 30 metoclopramide 32 metolazone 18 metoprolol succinate ext-rel 17 metoprolol tartrate 17 metoprololhydrochlorothiazide 17 METROCREAM 43 METROGEL 43 METROGEL-VAGINAL 34 METROLOTION 43 metronidazole 13 34 metronidazole crm 075 43 metronidazole gel 075 43 metronidazole gel 1 43 metronidazole lotion 075 43 MICARDIS 16 MICARDIS HCT 16 midodrine 19 midostaurin 14 minocycline 10

mirabegron ext-rel 34 MIRAPEX 22 MIRCETTE 28 MIRENA 29 mirtazapine 21 misoprostol 33 mitotane 14 MOBIC 8 mometasone crm lotion 01 42 mometasone oint 01 42 mometasone spray 40 montelukast 39 morphine 8 morphine ext-rel 8 9 morphine supp 8 morphinenaltrexone ext-rel 9 MOVANTIK 33 MOXEZA 44 moxifloxacin 10 44 MOZOBIL 36 MS CONTIN 9 MULPLETA 36 MULTAQ 16 multivitaminsfluoride drops tabs 38 multivitaminsfluorideiron drops tabs 38 mupirocin oint 41 MYAMBUTOL 12 mycophenolate mofetil 37 mycophenolate sodium delayed-rel 37 MYDAYIS 22 MYLERAN 13 MYRBETRIQ 34 MYSOLINE 20

N nabumetone 8 nadolol 17 naftifine 41 NAFTIN 41 naldemedine 33 naloxegol 33 naloxone inj 25 naloxone nasal spray 25 naltrexone 25 NAMENDA 20 NAMZARIC 20 naproxen sodium tabs 8 naproxen tabs 8 naratriptan 23 NARCAN 25 NARDIL 21 natalizumab 24 nateglinide 26 nebivolol 17 neomycinpolymyxin Bbacitracinhydrocortisone oint 44 neomycinpolymyxin Bdexamethasone 44 neomycinpolymyxin Bgramicidin 44 neomycinpolymyxin Bhydrocortisone 46 neomycinpolymyxin Bhydrocortisone susp 44 nepafenac 44 netarsudil 45 netarsudillatanoprost 45 NEULASTA 35 NEUPRO 22 NEURONTIN 20 NEVANAC 44

56

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

nevirapine 11 nevirapine ext-rel 11 niacin ext-rel 17 NIASPAN 17 nifedipine ext-rel 17 18 nintedanib 40 niraparib 14 nitisinone 30 NITRO-DUR 19 nitrofurantoin ext-rel 13 nitrofurantoin macrocrystals 12 nitrofurantoin susp 13 nitroglycerin lingual spray 19 nitroglycerin sublingual 19 nitroglycerin transdermal 19 NITROLINGUAL 19 NITROSTAT 19 NIVESTYM 35 NIZORAL 42 NORCO 9 norelgestrominEE 29 norethindrone 28 norethindrone acetate 31 norethindrone acetateEE 1530 28 norethindrone acetateEE 1530 and iron 28 norethindrone acetateEE 120 28 norethindrone acetateEE 120 and iron 28 norethindrone acetateEE 120 and iron chewable 28 norethindroneEE 28 norethindroneEE 0535 28 norethindroneEE 135 28 norgestimateEE 28 norgestimateEE 02535 28 norgestrelEE 0330 - Low-Ogestrel 28 NORPACE 16 NORPACE CR 16 NORPRAMIN 21 nortriptyline 21 NORVIR 12 NOVOEIGHT 35 NOVOLIN 7030 26 NOVOLIN N 26 NOVOLIN R 26 NOVOLOG 26 NOVOLOG MIX 7030 26 NUBEQA 13 NUCALA 40 NUCYNTA 9 NUCYNTA ER 9 NUEDEXTA 25 NULYTELY 33 NUVARING 29 NUWIQ 35 nystatin 10 41

O OCUFLOX 44 ODEFSEY 11 ODOMZO 14 OFEV 40 ofloxacin 44 ofloxacin otic 46 olanzapine 22 olaparib 14 olmesartan 15 olmesartanamlodipinehydrochlorothiazide 16

olmesartanhydrochlorothiazide 16 olodaterol CFC-free aerosol 39 olopatadine 43 olopatadine spray 39 omalizumab 40 omega-3 acid ethyl esters 17 omeprazole delayed-rel 34 OMNIPOD DASH 27 ondansetron 32 ONZETRA XSAIL 23 OPSUMIT 19 ORALAIR 36 ORENITRAM 19 ORFADIN 30 ORILISSA 29 orphenadrineaspirincaffeine 24 ORTHO MICRONOR 28 ORTHO-NOVUM 135 28 ORTHO-NOVUM 777 28 oseltamivir 12 ospemifene 31 OSPHENA 31 OTEZLA 36 OVIDE 43 OVIDREL 30 oxaprozin 8 oxazepam 19 oxcarbazepine 20 oxcarbazepine ext-rel 20 OXSORALEN-ULTRA 41 OXTELLAR XR 20 oxybutynin 34 oxybutynin ext-rel 34 oxycodone concentrate 20 mgmL 8 oxycodone ext-rel 9 oxycodone tabs 15 mg 30 mg soln 5 mg5 mL 9 oxycodone tabs 5 mg 8 oxycodoneacetaminophen 5325 9 oxycodoneacetaminophen soln 9 OZEMPIC 26

P palbociclib 14 paliperidone palmitate ext-rel inj 22 PAMELOR 21 pancrelipase 33 pancrelipase delayed-rel 33 pantoprazole delayed-rel 33 paricalcitol 30 PARLODEL 22 PARNATE 21 paroxetine HCl 21 paroxetine HCl ext-rel 21 paroxetine mesylate 25 PATADAY 43 PATANASE 39 PATANOL 43 patiromer sorbitex 31 PAXIL 21 PAXIL CR 21 PAZEO 43 pazopanib 14 peg 3350electrolytes 33 PEGASYS 37 pegfilgrastim 35 pegfilgrastim-cbqv 35

57

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

peginterferon alfa-2a 37 peginterferon alfa-2b 37 pegvisomant 25 penicillin VK 10 PENTASA 33 PEPCID 33 perampanel 20 PERFOROMIST 39 perindopril 15 permethrin 5 43 perphenazine 22 phenelzine 21 phenobarbital 20 phenytoin 20 phenytoin sodium extended 20 PHOSLYRA 30 PICATO 41 pilocarpine tabs 34 pimecrolimus 42 pindolol 17 pioglitazone 26 pioglitazoneglimepiride 26 pioglitazonemetformin 26 pirfenidone 40 PLAQUENIL 36 plerixafor 36 podofilox 43 polymyxin Bbacitracin 44 polymyxin Btrimethoprim 44 POLYTRIM 44 pomalidomide 14 POMALYST 14 potassium chloride ext-rel 37 potassium chloride liquid 37 potassium citrate ext-rel 34 pramipexole 22 pramipexole ext-rel 21 pramlintide 25 PRANDIN 26 prasugrel 36 PRAVACHOL 17 pravastatin 17 PRECOSE 25 PRED MILD 44 prednisolone 30 prednisolone acetate 44 prednisolone acetate 1 44 prednisolone phosphate 1 44 prednisone 30 pregabalin 23 PREMARIN 29 PREMPHASE 29 PREMPRO 29 prenatal vitamins 37 prenatal vitaminsDHAdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid 37 prenatal vitaminsdocusatefolic acid + DHA 37 prenatal vitaminsfolic acid + pyridoxine 37 PREZCOBIX 11 PREZISTA 12 PRILOSEC 34 primidone 20 probenecid 8 procarbazine 14 PROCARDIA XL 18 prochlorperazine 32

prochlorperazine inj 22 PROCTOFOAM-HC 34 progesterone gel 31 progesterone vaginal inserts 31 progesterone micronized 31 PROLASTIN-C 40 PROLIA 27 PROMACTA 35 promethazine 32 PROMETRIUM 31 propafenone 16 propafenone ext-rel 16 propranolol 17 propranolol ext-rel 17 propylthiouracil 32 PROSCAR 34 PROVERA 31 PULMICORT FLEXHALER 40 PULMICORT RESPULES 40 PULMOZYME 39 pyrazinamide 12 pyridostigmine 24 pyridostigmine ext-rel 24

Q QUESTRANQUESTRAN LIGHT 16 quetiapine 22 quetiapine ext-rel 22 quinapril 15 quinaprilhydrochlorothiazide 15 QVAR REDIHALER 40

R ragweed pollen allergen extract 36 RAGWITEK 36 raloxifene 31 raltegravir 11 ramipril 15 ranibizumab 45 ranitidine 33 ranolazine ext-rel 19 rasagiline 21 RASUVO 36 RAZADYNE 20 RAZADYNE ER 20 REBETOL 12 REBIF 24 REBINYN 35 REGLAN 32 RELENZA 12 RELPAX 23 REMERON 21 repaglinide 26 REPATHA 17 REQUIP XL 22 RESTASIS 45 RESTORIL 23 RETACRIT 35 RETIN-A 41 RETROVIR 11 REVATIO 19 REVLIMID 14 RHOPRESSA 45 ribavirin caps 12 ribavirin oral soln 12 ribavirin tabs 12 ribociclib 14

58

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

ribociclib + letrozole 14 RIFADIN 12 rifampin 12 rifaximin 550 mg 13 rilpivirine 11 RINVOQ 36 riociguat 19 risankizumab-rzaa 36 risedronate 27 risedronate delayed-rel 27 RISPERDAL 22 RISPERDAL CONSTA 22 risperidone 22 risperidone long-acting injection 22 RITALIN 23 ritonavir 12 rivaroxaban 35 rivastigmine 20 rivastigmine transdermal 20 rizatriptan 23 ROBAXIN 24 ROCALTROL 30 ROCKLATAN 45 roflumilast 40 rolapitant 32 ropinirole 21 ropinirole ext-rel 22 rosuvastatin 17 rotigotine transdermal 22 ROWASA 33 ROXICET 9 ROXICODONE 9 RUBRACA 14 rucaparib 14 RYDAPT 14 RYTHMOL SR 16

S sacubitrilvalsartan 18 SALAGEN 34 salmeterol xinafoate 39 SANCUSO 32 sapropterin 30 scopolamine transdermal 32 SEASONIQUE 28 secukinumab 36 selegiline 21 selenium sulfide shampoo 25 42 selexipag 19 semaglutide 26 SENSIPAR 27 SEREVENT 39 SEROQUEL 22 sertraline 21 sevelamer carbonate 30 sildenafil 19 SILENOR 23 silodosin 34 SILVADENE 41 silver sulfadiazine 41 SIMBRINZA 45 simvastatin 17 SINEMET 22 SINEMET CR 22 siponimod 24 sirolimus 37

sitagliptin phosphate 26 sitagliptinmetformin 26 sitagliptinmetformin ext-rel 26 SKELAXIN 24 SKYLA 29 SKYRIZI 36 sodium sulfatepotassium sulfatemagnesium sulfate 33 sodium zirconium cyclosilicate 31 sofosbuvirvelpatasvir 12 sofosbuvirvelpatasvirvoxilaprevir 12 solifenacin 34 SOLIQUA 26 SOLIRIS 35 solriamfetol 24 somatropin 30 SOMATULINE DEPOT 25 SOMAVERT 25 sonidegib 14 SOOLANTRA 43 SORIATANE 41 sotalol 16 SPIRIVA 38 spironolactone 15 spironolactonehydrochlorothiazide 18 SPRYCEL 14 STALEVO 22 stavudine 11 STELARA SUBCUTANEOUS 36 STIOLTO RESPIMAT 38 STRATTERA 22 STRIBILD 11 STRIVERDI RESPIMAT 39 STROMECTOL 13 SUBSYS 9 sucralfate 34 sucroferric oxyhydroxide 30 sulfacetamide lotion 10 41 sulfacetamide oint 10 44 sulfacetamide soln 10 44 sulfacetamideprednisolone phosphate 10025 44 sulfamethoxazoletrimethoprim 12 sulfamethoxazoletrimethoprim DS 12 sulfasalazine 33 sulfasalazine delayed-rel 33 sulindac 8 sumatriptan 23 sumatriptan inj 23 sumatriptan nasal powder 23 sumatriptan nasal spray 23 sunitinib 14 SUNOSI 24 SUPRAX 10 SUPREP 33 SUTENT 14 suvorexant 23 SYLATRON 37 SYMBICORT 40 SYMFI 11 SYMFI LO 11 SYMLINPEN 25 SYMPROIC 33 SYNJARDY 26 SYNJARDY XR 26 SYNTHROID 32

59

T TABLOID 13 tacrolimus 37 42 tadalafil 19 tamoxifen 13 tamsulosin 34 TAPAZOLE 32 tapentadol 9 tapentadol ext-rel 9 TARGRETIN 14 TARKA 15 tazarotene 41 TAZORAC 41 TECFIDERA 24 TEGRETOL 20 TEKTURNA HCT 18 telmisartan 16 telmisartanhydrochlorothiazide 16 temazepam 23 TEMIXYS 11 TEMODAR 13 TEMOVATE 43 temozolomide 13 tenofovir alafenamide 12 tenofovir disoproxil fumarate 11 terazosin 15 terbinafine tabs 10 terbutaline 39 terconazole 34 teriflunomide 24 teriparatide 27 TESSALON 38 testosterone cypionate 25 testosterone enanthate 25 testosterone gel 25 testosterone soln 25 testosterone transdermal 25 tetrabenazine 24 tetracycline 10 thalidomide 14 THALOMID 14 theophylline ext-rel tabs 40 thioguanine 13 thiothixene 22 tiagabine 20 TIAZAC 18 ticagrelor 36 TIGAN 32 TIKOSYN 16 timolol hemihydrate 45 timolol maleate 45 timolol maleate gel 45 TIMOPTIC 45 timothy grass pollen allergen extract 36 tinidazole 12 tiotropium 38 tiotropiumolodaterol 38 TIVICAY 11 tizanidine tabs 24 TOBRADEX 44 TOBRADEX ST 44 tobramycin 44 tobramycin inhalation soln 39 tobramycindexamethasone oint 0301 44 tobramycindexamethasone susp 03005 44 tobramycindexamethasone susp 0301 44

TOBREX 44 tofacitinib 36 tofacitinib ext-rel 36 TOFRANIL 21 TOLAK 41 tolterodine 34 tolterodine ext-rel 34 TOPAMAX 20 topiramate 20 topotecan caps 14 torsemide 18 TOVIAZ 34 tramadol 9 tramadol ext-rel 9 trandolapril 15 trandolaprilverapamil ext-rel 15 tranylcypromine 21 TRAVATAN Z 45 travoprost 45 trazodone 21 TRELEGY ELLIPTA 38 TREMFYA 36 treprostinil ext-rel 19 TRESIBA 26 tretinoin 41 tretinoin - Avita 41 tretinoin caps 14 tretinoin gel microsphere 41 TREXALL 13 triamcinolone acetonide crm 05 42 triamcinolone acetonide crm lotion 0025 42 triamcinolone acetonide crm lotion oint 01 42 triamcinolone acetonide spray 40 triamcinolone paste 43 triamterenehydrochlorothiazide 18 TRIBENZOR 16 trifluoperazine 22 trifluridine 44 trihexyphenidyl 22 TRILEPTAL 20 TRILIPIX 16 trimethobenzamide 32 trimethoprim 12 TRINTELLIX 21 TRIUMEQ 11 trospium 34 trospium ext-rel 34 TRULICITY 26 TRUSOPT 45 TRUVADA 11 TYKERB 14 TYMLOS 27 TYSABRI 24

U UDENYCA 35 ULORIC 8 ULTRAM 9 ULTRAVATE 43 umeclidinium bromide 38 umeclidiniumvilanterol 38 upadacitinib 36 UPTRAVI 19 URECHOLINE 34 UROCIT-K 34 URSO 32

60

V

ursodiol 32 ustekinumab 36

VAGIFEM 29 valacyclovir 12 valbenazine 24 valganciclovir 12 VALIUM 19 valproic acid 20 valsartan 16 valsartanhydrochlorothiazide 16 VANCOCIN 13 vancomycin 13 varenicline 25 VARUBI 32 VASCEPA 17 VASERETIC 15 VASOTEC 15 VELPHORO 30 VELTASSA 31 VEMLIDY 12 venlafaxine 21 venlafaxine ext-rel 21 verapamil ext-rel 18 VFEND 10 VIBERZI 33 VIBRAMYCIN 10 VICTOZA 26 VIDEX EC 11 vigabatrin 20 VIGAMOX 44 VIIBRYD 21 vilazodone 21 VIMPAT 20 VIOKACE 33 VIREAD 11 vitamin ADCfluoride drops 38 vitamin ADCfluorideiron drops 38 voriconazole 10 vorinostat 14 vortioxetine 21 VOSEVI 12 VOTRIENT 14 VRAYLAR 22 VYTORIN 17 VYVANSE 22

W warfarin 35 WELLBUTRIN SR 21 WELLBUTRIN XL 21

X XALATAN 45 XARELTO 35 XELJANZ 36 XELJANZ XR 36 XELODA 13 XIFAXAN 13 XIGDUO XR 26 XIIDRA 45 XOLAIR 40 XTAMPZA ER 9 XTANDI 13 XULTOPHY 26

Y YASMIN 28 YONSA 13

Z zafirlukast 39 ZANAFLEX 24 zanamivir 12 ZANTAC 33 ZARONTIN 20 ZEJULA 14 ZEMBRACE SYMTOUCH 23 ZEMPLAR 30 ZENPEP 33 ZESTORETIC 15 ZESTRIL 15 ZIAC 17 ZIAGEN 11 zidovudine 11 zileuton ext-rel 39 ziprasidone 22 ZITHROMAX 10 ZOCOR 17 ZOFRAN 32 ZOLINZA 14 zolmitriptan 23 zolmitriptan nasal spray 23 ZOLOFT 21 zolpidem 23 zolpidem ext-rel 23 zolpidem sublingual 23 ZOMIG 23 zonisamide 20 ZOVIRAX 12 ZUBSOLV 25 ZYBAN 25 ZYCLARA 41 ZYLOPRIM 8 ZYPREXA 22

61

62

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

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

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

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

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

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

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

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

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

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

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

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

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-844-662-2276

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-844-662-2276 번으로 전화해 주십시오

AR 1557 18v1NOTICE 1557 117

62

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

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

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

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

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

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

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

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

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

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

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

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

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-844-662-2276

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-844-662-2276 번으로 전화해 주십시오

AR 1557 18v1NOTICE 1557 117

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

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

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

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

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

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

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

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

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

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

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

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

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-844-662-2276

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-844-662-2276 번으로 전화해 주십시오

AR 1557 18v1NOTICE 1557 117

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-844-662-2276

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-844-662-2276

مالحظة إذا كنت تتحدث العربية فإن خدمات المساعدة اللغویة تتوافر لك بالمجان إتصل بالرقم 1-844-662-2276

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-844-662-2276

ATTENTION Si vous parlez franccedilais des services drsquoaide linguistique vous sont proposeacutes gratuitement Appelez le 1-844-662-2276

UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 1-844-662-2276

ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-844-662-2276

ATTENZIONE In caso la lingua parlata sia lrsquoitaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 1-844-662-2276

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-844-662-2276 までお電話にてご連絡ください

ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-844-662-2276

توجه اگر به زبان فارسی صحبت می کنيد خدمات و کمک های زبانی رایگان برای شما موجود است برای کسب اطالعات بيشتر با شماره 2276-662-844-1 تماس بگيرید

સચના જો તમ ગજરાતી બોલતા હો તો નિશલક ભાષા સહાય સવાઓ તમારા માટ ઉપલબધ છ ફોિ કરો 1-844-662-2276

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

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

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

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

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

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