fep blue focus formulary (907) effective january 1, …...fep® blue focus formulary (907) effective...

FEP® Blue Focus Formulary (907) Effective January 1, 2020 v2

The FEP formulary includes a preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION ........................................................................................................................................................................................................................ 4 PREFACE ................................................................................................................................................................................................................................... 4 PRIOR APPROVAL ................................................................................................................................................................................................................... 4 QUANTITY LIMITATIONS ......................................................................................................................................................................................................... 4 PHARMACY AND MEDICAL POLICY COMMITTEE ................................................................................................................................................................ 4 PRODUCT SELECTION CRITERIA .......................................................................................................................................................................................... 5 FORMULARY PRODUCT DESCRIPTIONS .............................................................................................................................................................................. 5 GENERIC SUBSTITUTION ........................................................................................................................................................................................................ 6 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ......................................................................................................................................................... 6 EDITOR ...................................................................................................................................................................................................................................... 6 NOTICE ...................................................................................................................................................................................................................................... 6 LEGEND ..................................................................................................................................................................................................................................... 6 ANALGESICS ............................................................................................................................................................................................................................ 8

NSAIDs ............................................................................................................................................................................................................................. 8 NSAIDs, COMBINATIONS ............................................................................................................................................................................................... 8 NSAIDs, TOPICAL ........................................................................................................................................................................................................... 8 COX-2 INHIBITORS ......................................................................................................................................................................................................... 8 GOUT ............................................................................................................................................................................................................................... 8 OPIOID ANALGESICS ..................................................................................................................................................................................................... 8 NON-OPIOID ANALGESICS ........................................................................................................................................................................................... 9 VISCOSUPPLEMENTS ................................................................................................................................................................................................... 9

ANTI-INFECTIVES ..................................................................................................................................................................................................................... 9 ANTIBACTERIALS ......................................................................................................................................................................................................... 10 ANTIFUNGALS .............................................................................................................................................................................................................. 11 ANTIMALARIALS ........................................................................................................................................................................................................... 11 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................ 11 ANTITUBERCULAR AGENTS ....................................................................................................................................................................................... 12 ANTIVIRALS .................................................................................................................................................................................................................. 12 MISCELLANEOUS ......................................................................................................................................................................................................... 13

ANTINEOPLASTIC AGENTS .................................................................................................................................................................................................. 13 ALKYLATING AGENTS ................................................................................................................................................................................................. 14 ANTIMETABOLITES ...................................................................................................................................................................................................... 14 HORMONAL ANTINEOPLASTIC AGENTS................................................................................................................................................................... 14 IMMUNOMODULATORS ............................................................................................................................................................................................... 15 KINASE INHIBITORS .................................................................................................................................................................................................... 15 TOPOISOMERASE INHIBITORS .................................................................................................................................................................................. 16 MISCELLANEOUS ......................................................................................................................................................................................................... 16

CARDIOVASCULAR ................................................................................................................................................................................................................ 17 ACE INHIBITORS .......................................................................................................................................................................................................... 17 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .......................................................................................................................... 17 ACE INHIBITOR/DIURETIC COMBINATIONS .............................................................................................................................................................. 17 ADRENOLYTICS, CENTRAL ........................................................................................................................................................................................ 18 ALDOSTERONE RECEPTOR ANTAGONISTS ............................................................................................................................................................ 18 ALPHA BLOCKERS ....................................................................................................................................................................................................... 18 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ............................................................................................................ 18 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................... 18 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ......................................................... 18

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ANTIARRHYTHMICS ..................................................................................................................................................................................................... 18 ANTILIPEMICS .............................................................................................................................................................................................................. 19 BETA-BLOCKERS ......................................................................................................................................................................................................... 19 BETA-BLOCKER/DIURETIC COMBINATIONS............................................................................................................................................................. 20 CALCIUM CHANNEL BLOCKERS ................................................................................................................................................................................ 20 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .............................................................................................................................. 20 DIGITALIS GLYCOSIDES ............................................................................................................................................................................................. 20 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ......................................................................................................................................... 20 DIURETICS .................................................................................................................................................................................................................... 20 HEART FAILURE ........................................................................................................................................................................................................... 21 NITRATES ...................................................................................................................................................................................................................... 21 PULMONARY ARTERIAL HYPERTENSION ................................................................................................................................................................ 21 MISCELLANEOUS ......................................................................................................................................................................................................... 21

CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................................. 21 ANTIANXIETY ................................................................................................................................................................................................................ 22 ANTICONVULSANTS .................................................................................................................................................................................................... 22 ANTIDEMENTIA............................................................................................................................................................................................................. 23 ANTIDEPRESSANTS .................................................................................................................................................................................................... 23 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................................... 24 ANTIPSYCHOTICS ........................................................................................................................................................................................................ 24 ATTENTION DEFICIT HYPERACTIVITY DISORDER .................................................................................................................................................. 24 FIBROMYALGIA ............................................................................................................................................................................................................ 25 HYPNOTICS .................................................................................................................................................................................................................. 25 MIGRAINE ...................................................................................................................................................................................................................... 25 MOOD STABILIZERS .................................................................................................................................................................................................... 26 MOVEMENT DISORDERS ............................................................................................................................................................................................ 26 MULTIPLE SCLEROSIS ................................................................................................................................................................................................ 26 MUSCULOSKELETAL THERAPY AGENTS ................................................................................................................................................................. 26 MYASTHENIA GRAVIS ................................................................................................................................................................................................. 26 NARCOLEPSY/CATAPLEXY ........................................................................................................................................................................................ 26 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................................... 26 MISCELLANEOUS ......................................................................................................................................................................................................... 27

ENDOCRINE AND METABOLIC ............................................................................................................................................................................................. 27 ANDROGENS ................................................................................................................................................................................................................ 27 ANTIDIABETICS ............................................................................................................................................................................................................ 28 CALCIUM RECEPTOR ANTAGONISTS ....................................................................................................................................................................... 29 CALCIUM REGULATORS ............................................................................................................................................................................................. 30 CARNITINE DEFICIENCY AGENTS ............................................................................................................................................................................. 30 CONTRACEPTIVES ...................................................................................................................................................................................................... 30 ENDOMETRIOSIS ......................................................................................................................................................................................................... 31 ESTROGENS ................................................................................................................................................................................................................. 31 ESTROGEN/PROGESTINS .......................................................................................................................................................................................... 32 FERTILITY REGULATORS ........................................................................................................................................................................................... 32 GAUCHER DISEASE ..................................................................................................................................................................................................... 32 GLUCOCORTICOIDS .................................................................................................................................................................................................... 32 GLUCOSE ELEVATING AGENTS ................................................................................................................................................................................. 32 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ......................................................................................................................................................... 32 HUMAN GROWTH HORMONES .................................................................................................................................................................................. 33 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................................... 33 INSULIN-LIKE GROWTH FACTOR-1 AGENTS ............................................................................................................................................................ 33 PHENYLKETONURIA TREATMENT AGENTS ............................................................................................................................................................. 33 PHOSPHATE BINDER AGENTS ................................................................................................................................................................................... 33 PROGESTINS ................................................................................................................................................................................................................ 33 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................................... 33 THYROID AGENTS ....................................................................................................................................................................................................... 33 UREA CYCLE DISORDERS .......................................................................................................................................................................................... 33 VASOPRESSINS ........................................................................................................................................................................................................... 33 MISCELLANEOUS ......................................................................................................................................................................................................... 34

GASTROINTESTINAL ............................................................................................................................................................................................................. 34 ANTIDIARRHEALS ........................................................................................................................................................................................................ 34 ANTIEMETICS ............................................................................................................................................................................................................... 34 ANTISPASMODICS ....................................................................................................................................................................................................... 35 CHOLELITHOLYTICS .................................................................................................................................................................................................... 35 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................................... 35 INFLAMMATORY BOWEL DISEASE ............................................................................................................................................................................ 35

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IRRITABLE BOWEL SYNDROME ................................................................................................................................................................................. 35 LAXATIVES .................................................................................................................................................................................................................... 35 OPIOID-INDUCED CONSTIPATION ............................................................................................................................................................................. 35 PANCREATIC ENZYMES .............................................................................................................................................................................................. 36 PROSTAGLANDINS ...................................................................................................................................................................................................... 36 PROTON PUMP INHIBITORS ....................................................................................................................................................................................... 36 SALIVA STIMULANTS ................................................................................................................................................................................................... 36 STEROIDS, RECTAL ..................................................................................................................................................................................................... 36 ULCER THERAPY COMBINATIONS ............................................................................................................................................................................ 36 MISCELLANEOUS ......................................................................................................................................................................................................... 36

GENITOURINARY .................................................................................................................................................................................................................... 36 BENIGN PROSTATIC HYPERPLASIA .......................................................................................................................................................................... 36 URINARY ANTISPASMODICS ...................................................................................................................................................................................... 36 VAGINAL ANTI-INFECTIVES ........................................................................................................................................................................................ 37 MISCELLANEOUS ......................................................................................................................................................................................................... 37

HEMATOLOGIC ....................................................................................................................................................................................................................... 37 ANTICOAGULANTS ...................................................................................................................................................................................................... 37 HEMATOPOIETIC GROWTH FACTORS ...................................................................................................................................................................... 37 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .......................................................................................... 37 HEREDITARY ANGIOEDEMA AGENTS ....................................................................................................................................................................... 38 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ........................................................................................................................................ 38 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................................... 38 PLATELET SYNTHESIS INHIBITORS .......................................................................................................................................................................... 38 STEM CELL MOBILIZERS ............................................................................................................................................................................................ 38 MISCELLANEOUS ......................................................................................................................................................................................................... 38

IMMUNOLOGIC AGENTS ....................................................................................................................................................................................................... 38 ALLERGENIC EXTRACTS ............................................................................................................................................................................................ 38 AUTOIMMUNE AGENTS ............................................................................................................................................................................................... 38 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................................... 39 IMMUNE GLOBULINS ................................................................................................................................................................................................... 39 IMMUNOMODULATORS ............................................................................................................................................................................................... 39 IMMUNOSUPPRESSANTS ........................................................................................................................................................................................... 39

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................................. 40 ELECTROLYTES ........................................................................................................................................................................................................... 40 VITAMINS AND MINERALS .......................................................................................................................................................................................... 40

RESPIRATORY ........................................................................................................................................................................................................................ 40 ANAPHYLAXIS TREATMENT AGENTS ....................................................................................................................................................................... 40 ANTICHOLINERGICS .................................................................................................................................................................................................... 40 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................................. 41 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ......................................................................................................... 41 ANTIHISTAMINES, SEDATING ..................................................................................................................................................................................... 41 ANTITUSSIVES ............................................................................................................................................................................................................. 41 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................................... 41 BETA AGONISTS .......................................................................................................................................................................................................... 41 CYSTIC FIBROSIS ........................................................................................................................................................................................................ 41 LEUKOTRIENE MODULATORS ................................................................................................................................................................................... 42 MAST CELL STABILIZERS ........................................................................................................................................................................................... 42 NASAL ANTIHISTAMINES ............................................................................................................................................................................................ 42 NASAL STEROIDS ........................................................................................................................................................................................................ 42 PULMONARY ENZYME DEFICIENCY AGENTS .......................................................................................................................................................... 42 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................................... 42 SEVERE ASTHMA AGENTS ......................................................................................................................................................................................... 42 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................................... 42 STEROID INHALANTS .................................................................................................................................................................................................. 42 XANTHINES ................................................................................................................................................................................................................... 42 MISCELLANEOUS ......................................................................................................................................................................................................... 42

TOPICAL .................................................................................................................................................................................................................................. 43 DERMATOLOGY ........................................................................................................................................................................................................... 43 MOUTH/THROAT/DENTAL AGENTS ........................................................................................................................................................................... 45 OPHTHALMIC ................................................................................................................................................................................................................ 45 OTIC ............................................................................................................................................................................................................................... 48

WEBSITES ............................................................................................................................................................................................................................... 49 INDEX ....................................................................................................................................................................................................................................... 51

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The Retail Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.

INTRODUCTION

FEP is pleased to provide the 2020 FEP Blue Focus Drug Formulary as a useful reference for drug product coverage. The drugs on the FEP Blue Focus Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP Blue Focus Formulary is provided as a reference for drug therapy coverage. Specific drug selection for an individual patient rests solely with the prescriber.

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

PREFACE The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.

The FEP Blue Focus Formulary is a closed formulary that does not cover all FDA-approved drugs. Coverage consists of mainly generics, some preferred brands, and preferred specialty drugs.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Preferred generics Preferred brand-name, preferred generic specialty,

and preferred brand-name specialty FEP Blue Focus Preferred Retail Pharmacy

$5 copay for a 0 to 30-day supply $15 copay for a 31 to 90-day supply

40% coinsurance (up to $350 for a 0 to 30-day supply)***

FEP Blue Focus Specialty Drug Pharmacy Program***

40% coinsurance (up to $350 for a 0 to 30-day supply)

*** Specialty medications are limited to a 30-day supply. If a 31 to 90-day supply of a specialty drug has to be dispensed due to manufacturer packaging, you pay 40% of the Plan allowance (up to a $1,050 maximum) for each purchase. Drug products shown in boldface type indicate generic availability.

PRIOR APPROVAL Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page.

QUANTITY LIMITATIONS Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page.

PHARMACY AND MEDICAL POLICY COMMITTEE The role of the FEP Pharmacy and Medical Policy Committee includes the evaluation of new medications, and making recommendations to FEP for their designation as preferred or non-covered on the FEP Blue Focus Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP.

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PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation on the FEP Blue Focus Formulary. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

• Safety • Efficacy • Comparison studies • Drug interactions • Approved indications • Formulation and administration • Adverse effects • Contraindications • Pharmacokinetics • Patient compliance considerations • Medical outcome and pharmacoeconomic studies

When a new drug is considered for preferred status on the FEP Blue Focus Formulary, an attempt will be made to examine the drug relative to similar drugs currently preferred on the FEP Blue Focus Formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a non-covered designation to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-covered designation in the FEP Blue Focus Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role.

All the information in the FEP Blue Focus Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber.

FORMULARY PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are preferred, 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.

Preferred products include all strengths and dosage forms of the cited brand-name product.

lacosamide Vimpat Vimpat injection, tablets and solution would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not.

entecavir soln Baraclude soln The solution dosage form of Baraclude is preferred. From this entry, the tablets cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry.

sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary.

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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 FDA 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 to the same extent as 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.

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products.

EDITOR Your comments and suggestions regarding this FEP Blue Focus Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115

NOTICE The information contained in this FEP Blue Focus Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP Blue Focus Formulary is not a complete list of all covered medications. This FEP Blue Focus 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. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

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

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date.

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LEGEND † Generic contraceptives are covered at no charge to qualifying members ‡ Medication is covered at no charge to the member d DESI drug OTC Over the counter PA Prior Approval QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits

apply for both brands and generics ST Step Therapy - indicates the requirement for previous use of one or more drugs before

coverage is provided for the targeted drug 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

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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org NSAIDs diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 etodolac ext-rel Tier 1 flurbiprofen Tier 1 ibuprofen Tier 1 indomethacin Tier 1 indomethacin ext-rel Tier 1 ketoprofen Tier 1 ketoprofen ext-rel Tier 1 ketorolac Tier 1 meloxicam Tier 1 nabumetone Tier 1 naproxen Tier 1 naproxen sodium Tier 1 oxaprozin Tier 1 piroxicam Tier 1 sulindac Tier 1 ibuprofen inj CALDOLOR Tier 2 NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1 NSAIDs, TOPICAL QL diclofenac sodium gel 1% Tier 1 diclofenac sodium soln Tier 1 COX-2 INHIBITORS PA celecoxib Tier 1 GOUT allopurinol Tier 1 colchicine Tier 1 PA febuxostat Tier 1 probenecid Tier 1 OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html QL buprenorphine transdermal Tier 1 QL butalbital/acetaminophen/caffeine/codeine Tier 1 QL butalbital/aspirin/caffeine/codeine Tier 1 QL butorphanol nasal spray Tier 1 QL codeine/acetaminophen Tier 1 PA fentanyl citrate buccal Tier 1 QL fentanyl transdermal Tier 1 PA fentanyl transmucosal lozenge Tier 1

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QL hydrocodone/acetaminophen - Vicodin Tier 1 QL hydrocodone/acetaminophen - Vicodin ES Tier 1 QL hydromorphone 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 Tier 1 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 QL oxymorphone Tier 1 QL tramadol Tier 1 QL tramadol ext-rel Tier 1 QL tramadol/acetaminophen Tier 1 NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 QL butalbital/aspirin/caffeine Tier 1 ziconotide PRIALT Tier 2 VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 2 PA sodium hyaluronate GELSYN-3 Tier 2 PA sodium hyaluronate HYALGAN Tier 2 PA sodium hyaluronate SUPARTZ FX Tier 2 ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

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ANTIBACTERIALS Cephalosporins First Generation cephalexin Tier 1 Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1 Third Generation cefdinir Tier 1 cefditoren Tier 1 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 cefotaxime Tier 1 cefpodoxime Tier 1 ceftazidime Tier 1 ceftriaxone Tier 1 cefixime (except caps, 100 mg/5 mL, 200 mg/5 mL susp) SUPRAX (except caps, 100 mg/5

mL, 200 mg/5 mL susp) Tier 2

Fourth Generation cefepime Tier 1 Erythromycins/Macrolides azithromycin Tier 1 clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin delayed-rel - Ery-tab Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 fidaxomicin DIFICID Tier 2 Fluoroquinolones ciprofloxacin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 ofloxacin Tier 1 Penicillins amoxicillin, except film-coated tabs Tier 1 amoxicillin/clavulanate Tier 1 amoxicillin/clavulanate ext-rel Tier 1 amoxicillin/clavulanate susp 600 mg Tier 1 ampicillin Tier 1 ampicillin sodium/sulbactam sodium Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1 piperacillin/tazobactam Tier 1 Tetracyclines doxycycline hyclate Tier 1 doxycycline monohydrate Tier 1 minocycline Tier 1 minocycline ext-rel Tier 1 tetracycline Tier 1

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ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 PA itraconazole Tier 1 PA ketoconazole tabs Tier 1 nystatin Tier 1 PA posaconazole delayed-rel tabs 100 mg Tier 1 terbinafine tabs Tier 1 QL voriconazole Tier 1 amphotericin B lipid complex inj ABELCET Tier 2 amphotericin B liposome inj AMBISOME Tier 2 anidulafungin ERAXIS Tier 2 PA posaconazole (except 100 mg delayed-rel tabs) NOXAFIL (except 100 mg delayed-

rel tabs) Tier 2

ANTIMALARIALS atovaquone/proguanil Tier 1 chloroquine Tier 1 mefloquine Tier 1 primaquine Tier 1 artemether/lumefantrine COARTEM Tier 2 PA pyrimethamine DARAPRIM Tier 2 ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants cobicistat TYBOST Tier 2 Antiretroviral Combinations abacavir/lamivudine Tier 1 abacavir/lamivudine/zidovudine Tier 1 lamivudine/zidovudine Tier 1 abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 atazanavir/cobicistat EVOTAZ Tier 2 bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY Tier 2 darunavir/cobicistat PREZCOBIX Tier 2 darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2 doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2 efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2 emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY Tier 2 emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2 emtricitabine/tenofovir alafenamide DESCOVY Tier 2 emtricitabine/tenofovir disoproxil fumarate TRUVADA Tier 2 Chemokine Receptor Antagonists maraviroc SELZENTRY Tier 2 Fusion Inhibitors enfuvirtide FUZEON Tier 2 Integrase Inhibitors dolutegravir TIVICAY Tier 2 raltegravir ISENTRESS Tier 2

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Monoclonal Antibody PA ibalizumab-uiyk TROGARZO Tier 2 Non-nucleoside Reverse Transcriptase Inhibitors efavirenz Tier 1 nevirapine Tier 1 nevirapine ext-rel Tier 1 delavirdine RESCRIPTOR Tier 2 etravirine INTELENCE Tier 2 rilpivirine EDURANT Tier 2 Nucleoside Reverse Transcriptase Inhibitors abacavir Tier 1 abacavir soln Tier 1 didanosine delayed-rel Tier 1 lamivudine Tier 1 stavudine Tier 1 zidovudine Tier 1 didanosine soln VIDEX soln Tier 2 emtricitabine EMTRIVA Tier 2 Nucleotide Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate tabs 300 mg Tier 1 tenofovir disoproxil fumarate (except 300 mg tabs) VIREAD (except 300 mg tabs) Tier 2 Protease Inhibitors atazanavir caps Tier 1 fosamprenavir Tier 1 lopinavir/ritonavir soln Tier 1 ritonavir tabs Tier 1 darunavir PREZISTA Tier 2 indinavir CRIXIVAN Tier 2 lopinavir/ritonavir tabs KALETRA tabs Tier 2 nelfinavir VIRACEPT Tier 2 tipranavir APTIVUS Tier 2 ANTITUBERCULAR AGENTS ethambutol Tier 1 isoniazid Tier 1 pyrazinamide Tier 1 rifampin Tier 1 rifampin/isoniazid/pyrazinamide RIFATER Tier 2 rifapentine PRIFTIN Tier 2 ANTIVIRALS Cytomegalovirus Agents cidofovir Tier 1 PA valganciclovir Tier 1 ganciclovir inj Tier 2 cytomegalovirus immune globulin CYTOGAM Tier 2 PA letermovir PREVYMIS Tier 2 Hepatitis Agents Hepatitis B lamivudine Tier 1 adefovir dipivoxil Tier 2 entecavir tabs Tier 2 entecavir soln BARACLUDE soln Tier 2

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telbivudine TYZEKA Tier 2 tenofovir alafenamide VEMLIDY Tier 2 Hepatitis C PA ledipasvir/sofosbuvir Tier 2 HARVONI Tier 2 PA ribavirin caps Tier 2 PA ribavirin caps - Ribasphere Tier 2 PA ribavirin tabs Tier 2 PA sofosbuvir/velpatasvir Tier 2 EPCLUSA Tier 2 PA glecaprevir/pibrentasvir MAVYRET Tier 2 PA sofosbuvir SOVALDI Tier 2 PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 2 Herpes Agents acyclovir caps, susp, tabs Tier 1 famciclovir Tier 1 valacyclovir Tier 1 Influenza Agents QL oseltamivir Tier 1 rimantadine Tier 1 QL baloxavir XOFLUZA Tier 2 QL zanamivir RELENZA Tier 2 Respiratory Syncytial Virus Agents PA palivizumab SYNAGIS Tier 2 MISCELLANEOUS atovaquone Tier 1 aztreonam Tier 1 clindamycin Tier 1 dapsone Tier 1 daptomycin 500 mg Tier 1 ertapenem Tier 1 imipenem/cilastatin Tier 1 QL linezolid Tier 1 meropenem Tier 1 methenamine hippurate, prophylaxis Tier 1 metronidazole tabs Tier 1 nitrofurantoin ext-rel Tier 1 nitrofurantoin macrocrystals Tier 1 rifabutin Tier 1 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tigecycline Tier 1 tinidazole Tier 1 trimethoprim Tier 1 vancomycin Tier 1 miltefosine IMPAVIDO Tier 2 nitazoxanide ALINIA Tier 2 QL rifaximin XIFAXAN Tier 2 QL tedizolid tabs SIVEXTRO tabs Tier 2 vancomycin oral soln FIRVANQ Tier 2

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ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS busulfan Tier 1 ifosfamide/mesna Tier 1 carmustine Tier 2 cyclophosphamide caps Tier 2 CYCLOPHOSPHAMIDE

CAPSULES Tier 2

cyclophosphamide inj Tier 2 dacarbazine Tier 2 melphalan inj Tier 2 melphalan tabs Tier 2 temozolomide Tier 2 thiotepa Tier 2 busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 lomustine GLEOSTINE Tier 2 PA mechlorethamine gel VALCHLOR Tier 2 streptozocin ZANOSAR Tier 2 thiotepa 100 mg TEPADINA 100 mg Tier 2 PA trabectedin YONDELIS Tier 2 ANTIMETABOLITES mercaptopurine Tier 1 capecitabine Tier 2 cladribine Tier 2 clofarabine Tier 2 cytarabine Tier 2 floxuridine Tier 2 fludarabine Tier 2 fluorouracil inj Tier 2 ADRUCIL Tier 2 gemcitabine Tier 2 mercaptopurine susp PURIXAN Tier 2 pemetrexed ALIMTA Tier 2 pentostatin NIPENT Tier 2 pralatrexate FOLOTYN Tier 2 rasburicase ELITEK Tier 2 thioguanine TABLOID Tier 2 HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 flutamide Tier 1 PA nilutamide Tier 1 PA abiraterone 250 mg Tier 2 PA abiraterone YONSA Tier 2 PA enzalutamide XTANDI Tier 2 Antiestrogens tamoxifen Tier 1 toremifene Tier 1 fulvestrant Tier 2

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Aromatase Inhibitors anastrozole Tier 1 exemestane Tier 1 letrozole Tier 1 Gonadotropin-Releasing Hormone (GnRH) Antagonists PA degarelix acetate FIRMAGON Tier 2 Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 2 PA goserelin acetate ZOLADEX Tier 2 PA histrelin acetate VANTAS Tier 2 PA leuprolide acetate ELIGARD Tier 2 PA leuprolide acetate LUPRON DEPOT Tier 2 PA triptorelin pamoate TRELSTAR Tier 2 PA triptorelin pamoate TRELSTAR DEPOT Tier 2 PA triptorelin pamoate TRELSTAR LA Tier 2 Progestins megestrol acetate Tier 1 hydroxyprogesterone caproate Tier 2 MAKENA 275 mg Tier 2 IMMUNOMODULATORS PA pomalidomide POMALYST Tier 2 PA lenalidomide REVLIMID Tier 2 PA pembrolizumab KEYTRUDA Tier 2 thalidomide THALOMID Tier 2 KINASE INHIBITORS PA erlotinib Tier 2 PA imatinib mesylate Tier 2 temsirolimus Tier 2 PA abemaciclib VERZENIO Tier 2 PA acalabrutinib CALQUENCE Tier 2 PA afatinib GILOTRIF Tier 2 PA alectinib ALECENSA Tier 2 PA axitinib INLYTA Tier 2 PA bosutinib BOSULIF Tier 2 PA brigatinib ALUNBRIG Tier 2 PA cabozantinib CABOMETYX Tier 2 PA cabozantinib COMETRIQ Tier 2 PA ceritinib ZYKADIA Tier 2 PA cobimetinib COTELLIC Tier 2 PA crizotinib XALKORI Tier 2 PA dabrafenib TAFINLAR Tier 2 PA dacomitinib VIZIMPRO Tier 2 PA dasatinib SPRYCEL Tier 2 PA everolimus AFINITOR Tier 2 PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 2 PA gefitinib IRESSA Tier 2 PA ibrutinib IMBRUVICA Tier 2 PA idelalisib ZYDELIG Tier 2 PA lapatinib TYKERB Tier 2 PA larotrectinib VITRAKVI Tier 2 PA lenvatinib LENVIMA Tier 2 PA midostaurin RYDAPT Tier 2 PA neratinib NERLYNX Tier 2 PA nilotinib TASIGNA Tier 2

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PA osimertinib TAGRISSO Tier 2 PA palbociclib IBRANCE Tier 2 PA pazopanib VOTRIENT Tier 2 PA ponatinib ICLUSIG Tier 2 PA regorafenib STIVARGA Tier 2 PA ribociclib KISQALI Tier 2 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 2 PA ruxolitinib JAKAFI Tier 2 PA sorafenib NEXAVAR Tier 2 PA sunitinib SUTENT Tier 2 PA trametinib MEKINIST Tier 2 PA vandetanib CAPRELSA Tier 2 PA vemurafenib ZELBORAF Tier 2 TOPOISOMERASE INHIBITORS topotecan inj Tier 2 topotecan caps HYCAMTIN caps Tier 2 MISCELLANEOUS hydroxyurea Tier 1 leucovorin calcium Tier 1 amifostine Tier 2 arsenic trioxide Tier 2 PA bexarotene caps Tier 2 bleomycin sulfate Tier 2 carboplatin Tier 2 cisplatin Tier 2 dactinomycin Tier 2 daunorubicin Tier 2 decitabine Tier 2 dexrazoxane Tier 2 docetaxel Tier 2 etoposide Tier 2 idarubicin Tier 2 ifosfamide Tier 2 irinotecan Tier 2 levoleucovorin calcium Tier 2 mesna inj Tier 2 mitomycin Tier 2 mitoxantrone Tier 2 oxaliplatin Tier 2 paclitaxel Tier 2 teniposide Tier 2 valrubicin Tier 2 vinblastine Tier 2 vincristine Tier 2 vinorelbine Tier 2 aldesleukin PROLEUKIN Tier 2 asparaginase ELSPAR Tier 2 BCG live vaccine TICE BCG Tier 2 PA bevacizumab-awwb MVASI Tier 2 PA bexarotene gel TARGRETIN gel Tier 2 PA blinatumomab BLINCYTO Tier 2 PA brentuximab vedotin ADCETRIS Tier 2 PA cabazitaxel JEVTANA Tier 2 PA carfilzomib KYPROLIS Tier 2 PA enasidenib IDHIFA Tier 2 PA eribulin HALAVEN Tier 2

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glucarpidase VORAXAZE Tier 2 PA ivosidenib TIBSOVO Tier 2 PA ixazomib NINLARO Tier 2 mesna tabs 400 mg MESNEX Tier 2 mitotane LYSODREN Tier 2 nelarabine ARRANON Tier 2 PA niraparib ZEJULA Tier 2 PA nivolumab OPDIVO Tier 2 PA olaparib LYNPARZA Tier 2 PA omacetaxine mepesuccinate SYNRIBO Tier 2 PA panobinostat FARYDAK Tier 2 PA pertuzumab PERJETA Tier 2 procarbazine MATULANE Tier 2 PA ramucirumab CYRAMZA Tier 2 PA rucaparib RUBRACA Tier 2 samarium sm 153 lexidronam QUADRAMET Tier 2 PA sonidegib ODOMZO Tier 2 PA talazoparib TALZENNA Tier 2 PA talimogene laherparepvec IMLYGIC Tier 2 PA trastuzumab-anns KANJINTI Tier 2 PA trifluridine/tipiracil LONSURF Tier 2 PA venetoclax VENCLEXTA Tier 2 PA vismodegib ERIVEDGE Tier 2 PA vorinostat ZOLINZA Tier 2 PA ziv-aflibercept ZALTRAP Tier 2 CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org benazepril Tier 1 enalapril Tier 1 fosinopril Tier 1 lisinopril Tier 1 perindopril Tier 1 quinapril Tier 1 ramipril Tier 1 trandolapril Tier 1 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine Tier 1 trandolapril/verapamil ext-rel Tier 1 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide Tier 1 captopril/hydrochlorothiazide Tier 1

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enalapril/hydrochlorothiazide Tier 1 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 quinapril/hydrochlorothiazide Tier 1 ADRENOLYTICS, CENTRAL clonidine Tier 1 clonidine transdermal Tier 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 spironolactone Tier 1 ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 doxazosin Tier 1 prazosin Tier 1 terazosin Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 eprosartan Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 olmesartan/amlodipine/hydrochlorothiazide Tier 1 ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org amiodarone Tier 1 disopyramide Tier 1 flecainide Tier 1 mexiletine Tier 1 propafenone ext-rel Tier 1

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quinidine gluconate ext-rel Tier 1 sotalol Tier 1 dofetilide Tier 2 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2 ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins cholestyramine pkt Tier 1 colesevelam Tier 1 colestipol Tier 1 Cholesterol Absorption Inhibitors ezetimibe Tier 1 Fibrates fenofibrate Tier 1 fenofibric acid delayed-rel Tier 1 gemfibrozil Tier 1 HMG-CoA Reductase Inhibitors/Combinations ‡, * atorvastatin Tier 1 ezetimibe/simvastatin Tier 1 ‡, * fluvastatin Tier 1 ‡, * fluvastatin ext-rel Tier 1 ‡, * lovastatin Tier 1 ‡, * pravastatin Tier 1 ‡, * rosuvastatin Tier 1 ‡, * simvastatin Tier 1 * Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy. Microsomal Triglyceride Transfer Protein Inhibitors PA lomitapide JUXTAPID Tier 2 Niacin niacin ext-rel Tier 1 Omega-3 Fatty Acids omega-3 acid ethyl esters Tier 1 PCSK9 Inhibitors PA evolocumab REPATHA Tier 2 BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org acebutolol Tier 1 atenolol Tier 1 carvedilol Tier 1 carvedilol phosphate ext-rel Tier 1

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esmolol Tier 1 metoprolol succinate ext-rel Tier 1 metoprolol tartrate Tier 1 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 nebivolol BYSTOLIC Tier 2 BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 1 metoprolol/hydrochlorothiazide Tier 1 CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1 felodipine ext-rel Tier 1 nicardipine Tier 1 nifedipine ext-rel Tier 1 nimodipine Tier 1 nisoldipine ext-rel Tier 1 Nondihydropyridines diltiazem Tier 1 diltiazem ext-rel Tier 1 verapamil Tier 1 verapamil ext-rel Tier 1 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 1 DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1 Loop Diuretics bumetanide Tier 1 ethacrynic acid Tier 1 furosemide Tier 1 torsemide Tier 1 Potassium-sparing Diuretics amiloride Tier 1

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Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1 Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 triamterene/hydrochlorothiazide Tier 1 HEART FAILURE isosorbide dinitrate/hydralazine BIDIL Tier 2 PA ivabradine CORLANOR Tier 2 PA sacubitril/valsartan ENTRESTO Tier 2 NITRATES Oral isosorbide dinitrate oral Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1 Sublingual/Translingual nitroglycerin lingual spray Tier 1 nitroglycerin sublingual Tier 1 Transdermal nitroglycerin transdermal Tier 1 PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA ambrisentan Tier 2 PA bosentan Tier 2 PA macitentan OPSUMIT Tier 2 Phosphodiesterase Inhibitors PA, * sildenafil tabs, oral susp Tier 2 PA tadalafil tabs 20 mg Tier 2 PA tadalafil tabs 20 mg - Alyq Tier 2 * generic for Revatio Prostaglandin Vasodilators PA epoprostenol sodium Tier 2 PA treprostinil Tier 2 PA iloprost VENTAVIS Tier 2 PA treprostinil ext-rel ORENITRAM Tier 2 Soluble Guanylate Cyclase Stimulators PA riociguat ADEMPAS Tier 2 MISCELLANEOUS hydralazine Tier 1 midodrine Tier 1 minoxidil tabs Tier 1 ranolazine ext-rel Tier 1

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CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines alprazolam Tier 1 alprazolam ext-rel Tier 1 chlordiazepoxide Tier 1 clonazepam Tier 1 clorazepate Tier 1 diazepam Tier 1 lorazepam Tier 1 oxazepam Tier 1 Miscellaneous buspirone Tier 1 clomipramine Tier 1 fluvoxamine Tier 1 fluvoxamine ext-rel Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine Tier 1 carbamazepine ext-rel Tier 1 clobazam Tier 1 diazepam rectal gel Tier 1 divalproex sodium delayed-rel Tier 1 divalproex sodium ext-rel Tier 1 divalproex sodium sprinkle caps Tier 1 ethosuximide Tier 1 felbamate Tier 1 QL gabapentin Tier 1 lamotrigine Tier 1 lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1 levetiracetam Tier 1 levetiracetam ext-rel Tier 1 oxcarbazepine Tier 1 phenobarbital Tier 1 phenytoin Tier 1 phenytoin sodium extended Tier 1 primidone Tier 1 tiagabine Tier 1 topiramate Tier 1 topiramate ext-rel Tier 1 valproic acid Tier 1 zonisamide Tier 1 PA vigabatrin Tier 2 PA vigabatrin powder - Vigadrone Tier 2 lacosamide VIMPAT Tier 2 rufinamide BANZEL Tier 2

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ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com donepezil Tier 1 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 galantamine ext-rel Tier 1 memantine Tier 1 rivastigmine Tier 1 rivastigmine transdermal Tier 1 ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 tranylcypromine Tier 1 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 escitalopram Tier 1 fluoxetine Tier 1 fluoxetine delayed-rel Tier 1 paroxetine HCl Tier 1 paroxetine HCl ext-rel Tier 1 sertraline Tier 1 Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 duloxetine delayed-rel Tier 1 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 venlafaxine ext-rel tabs Tier 1 Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 desipramine Tier 1 doxepin Tier 1 imipramine HCl Tier 1 imipramine pamoate Tier 1 nortriptyline Tier 1 protriptyline Tier 1 Miscellaneous Agents amitriptyline/perphenazine Tier 1 bupropion Tier 1 bupropion ext-rel Tier 1 mirtazapine Tier 1 nefazodone Tier 1 trazodone Tier 1

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ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com amantadine, except tabs Tier 1 benztropine Tier 1 bromocriptine Tier 1 carbidopa/levodopa Tier 1 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 carbidopa/levodopa/entacapone Tier 1 diphenhydramine Tier 1 entacapone Tier 1 pramipexole Tier 1 pramipexole ext-rel Tier 1 rasagiline Tier 1 ropinirole Tier 1 ropinirole ext-rel Tier 1 selegiline caps Tier 1 tolcapone Tier 1 trihexyphenidyl Tier 1 apomorphine APOKYN Tier 2 rotigotine transdermal NEUPRO Tier 2 selegiline orally disintegrating tabs ZELAPAR Tier 2 ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 aripiprazole orally disintegrating tabs Tier 1 clozapine Tier 1 clozapine orally disintegrating tabs Tier 1 olanzapine Tier 1 olanzapine/fluoxetine Tier 1 paliperidone ext-rel Tier 1 quetiapine Tier 1 quetiapine ext-rel Tier 1 risperidone Tier 1 risperidone orally disintegrating tabs Tier 1 ziprasidone Tier 1 paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2 risperidone long-acting inj RISPERDAL CONSTA Tier 2 Miscellaneous fluphenazine Tier 1 haloperidol Tier 1 haloperidol decanoate inj Tier 1 haloperidol lactate inj Tier 1 loxapine Tier 1 perphenazine Tier 1 thioridazine Tier 1 thiothixene Tier 1 trifluoperazine Tier 1

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ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org PA amphetamine/dextroamphetamine mixed salts Tier 1 PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 atomoxetine Tier 1 clonidine ext-rel Tier 1 PA dexmethylphenidate Tier 1 PA dexmethylphenidate ext-rel Tier 1 PA dextroamphetamine Tier 1 PA dextroamphetamine ext-rel Tier 1 PA dextroamphetamine soln Tier 1 guanfacine ext-rel Tier 1 PA methamphetamine Tier 1 PA methylphenidate Tier 1 PA methylphenidate ext-rel Tier 1 PA lisdexamfetamine VYVANSE Tier 2 FIBROMYALGIA QL pregabalin Tier 1 HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org Benzodiazepines QL estazolam Tier 1 QL flurazepam Tier 1 QL temazepam Tier 1 QL triazolam Tier 1 Nonbenzodiazepines QL eszopiclone Tier 1 QL ramelteon Tier 1 QL zaleplon Tier 1 QL zolpidem Tier 1 QL zolpidem ext-rel Tier 1 PA tasimelteon HETLIOZ Tier 2 MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Ergotamine Derivatives dihydroergotamine inj Tier 1 ergotamine/caffeine Tier 1 ergotamine/caffeine supp Tier 1 MIGERGOT Tier 1 Monoclonal Antibodies PA erenumab-aooe AIMOVIG Tier 2 PA galcanezumab-gnlm EMGALITY Tier 2 Selective Serotonin Agonists QL almotriptan Tier 1 QL eletriptan Tier 1

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QL frovatriptan Tier 1 QL naratriptan Tier 1 QL rizatriptan Tier 1 QL sumatriptan Tier 1 QL zolmitriptan Tier 1 MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 MOVEMENT DISORDERS PA tetrabenazine Tier 2 MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: https://www.aan.com PA dalfampridine ext-rel Tier 2 PA glatiramer Tier 2 PA glatiramer - Glatopa Tier 2 PA alemtuzumab LEMTRADA Tier 2 PA dimethyl fumarate delayed-rel TECFIDERA Tier 2 PA fingolimod GILENYA Tier 2 PA interferon beta-1a AVONEX Tier 2 PA interferon beta-1a REBIF Tier 2 PA interferon beta-1a REBIF REBIDOSE Tier 2 PA interferon beta-1b BETASERON Tier 2 PA natalizumab TYSABRI Tier 2 PA ocrelizumab OCREVUS Tier 2 PA peginterferon beta-1a PLEGRIDY Tier 2 PA peginterferon beta-1a PLEGRIDY PEN Tier 2 PA teriflunomide AUBAGIO Tier 2 MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 cyclobenzaprine Tier 1 dantrolene Tier 1 MYASTHENIA GRAVIS pyridostigmine ext-rel tabs 180 mg Tier 1 pyridostigmine syrup Tier 1 pyridostigmine tabs 60 mg Tier 1 NARCOLEPSY/CATAPLEXY PA armodafinil Tier 1 PA modafinil Tier 1 PA sodium oxybate XYREM Tier 2 PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1 naltrexone Tier 1 naltrexone microspheres VIVITROL Tier 2

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Opioid Antagonists naloxone inj Tier 1 naloxone nasal spray NARCAN Tier 1 Partial Opioid Agonists QL buprenorphine Tier 1 PA buprenorphine ext-rel inj SUBLOCADE Tier 2 Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual film Tier 1 QL buprenorphine/naloxone sublingual tabs Tier 1 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2 Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2 Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2 MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 PA edaravone RADICAVA Tier 2 Botulinum Toxins PA abobotulinumtoxinA DYSPORT Tier 2 PA incobotulinumtoxinA XEOMIN Tier 2 PA onabotulinumtoxinA BOTOX Tier 2 PA rimabotulinumtoxinB MYOBLOC Tier 2 Duchenne Muscular Dystrophy PA deflazacort EMFLAZA Tier 2 PA eteplirsen EXONDYS 51 Tier 2 Lambert-Eaton Myasthenic Syndrome PA amifampridine FIRDAPSE Tier 2 Tardive Dyskinesia PA valbenazine INGREZZA Tier 2 ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone undecanoate inj AVEED Tier 2

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ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 1 miglitol Tier 1 Amylin Analogs pramlintide SYMLINPEN Tier 2 Biguanides * metformin Tier 1 metformin ext-rel Tier 1 * Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require PA Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 glyburide/metformin Tier 1 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin Tier 1 sitagliptin phosphate JANUVIA Tier 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations alogliptin/metformin Tier 1 sitagliptin/metformin JANUMET Tier 2 sitagliptin/metformin ext-rel JANUMET XR Tier 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations alogliptin/pioglitazone Tier 1 Incretin Mimetic Agents dulaglutide TRULICITY Tier 2 liraglutide VICTOZA Tier 2 semaglutide OZEMPIC Tier 2 Insulins insulin aspart FIASP Tier 2 insulin aspart FIASP FLEXTOUCH Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2 insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin human HUMULIN R U-500 Tier 2 OTC insulin human NOVOLIN R Tier 2 OTC insulin isophane human NOVOLIN N Tier 2 OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2 Insulin Sensitizers pioglitazone Tier 1 Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 1

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Meglitinides nateglinide Tier 1 repaglinide Tier 1 Meglitinide/Biguanide Combinations repaglinide/metformin Tier 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors ST dapagliflozin FARXIGA Tier 2 ST empagliflozin JARDIANCE Tier 2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST empagliflozin/metformin SYNJARDY Tier 2 ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2 Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations ST dapagliflozin/saxagliptin QTERN Tier 2 ST empagliflozin/linagliptin GLYXAMBI Tier 2 Sulfonylureas glimepiride Tier 1 glipizide Tier 1 glipizide ext-rel Tier 1 glyburide Tier 1 glyburide, micronized Tier 1 Supplies PA blood glucose continuous monitoring receivers, sensors,

transmitters FREESTYLE LIBRE

CONTINUOUS GLUCOSE MONITORING SYSTEM

Tier 2

OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2 OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2 OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2 OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2 OTC insulin syringes, needles BD INSULIN SYRINGES AND

NEEDLES Tier 2

OTC lancet device ACCU-CHEK FASTCLIX LANCET DEVICE

Tier 2

OTC lancet device SOFTCLIX LANCET DEVICE Tier 2 OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2 OTC lancets ACCU-CHEK FASTCLIX

LANCETS Tier 2

OTC lancets ONETOUCH LANCETS Tier 2 OTC lancets SOFTCLIX LANCETS Tier 2 OTC lancets SOFTTOUCH LANCETS Tier 2 OTC urine test strips CHEMSTRIP K URINE KETONE

STRIPS Tier 2

OTC urine test strips CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS

Tier 2

OTC urine test strips CHEMSTRIP UG URINE GLUCOSE STRIPS

Tier 2

CALCIUM RECEPTOR ANTAGONISTS PA cinacalcet Tier 2

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CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate Tier 1 etidronate Tier 1 ibandronate Tier 1 risedronate Tier 1 risedronate delayed-rel Tier 1 pamidronate Tier 2 zoledronic acid Tier 2 Calcitonins calcitonin-salmon spray Tier 1 Parathyroid Hormones PA parathyroid hormone (recombinant) NATPARA Tier 2 PA teriparatide FORTEO Tier 2 Miscellaneous PA denosumab PROLIA Tier 2 PA denosumab XGEVA Tier 2 CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1 CONTRACEPTIVES EE = ethinyl estradiol Monophasic 20 mcg Estrogen † drospirenone/EE 3/20 - Gianvi Tier 1 † levonorgestrel/EE 0.1/20 Tier 1 † norethindrone acetate/EE 1/20 Tier 1 † norethindrone acetate/EE 1/20 and iron Tier 1 30 mcg Estrogen † desogestrel/EE 0.15/30 Tier 1 † drospirenone/EE 3/30 Tier 1 † levonorgestrel/EE 0.15/30 Tier 1 † levonorgestrel/EE 0.15/30 - Levora Tier 1 † norethindrone acetate/EE 1.5/30 Tier 1 † norethindrone acetate/EE 1.5/30 and iron Tier 1 † norgestrel/EE 0.3/30 - Cryselle Tier 1 † norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 35 mcg Estrogen † ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 † norethindrone/EE 0.4/35 Tier 1 † norethindrone/EE 0.5/35 Tier 1 † norethindrone/EE 1/35 Tier 1 † norgestimate/EE 0.25/35 Tier 1 50 mcg Estrogen † ethynodiol diacetate/EE 1/50 Tier 1 † norgestrel/EE 0.5/50 Tier 1

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Biphasic † desogestrel/EE Tier 1 Triphasic † desogestrel/EE Tier 1 † levonorgestrel/EE - Trivora Tier 1 † norethindrone acetate/EE and iron Tier 1 † norethindrone/EE Tier 1 † norgestimate/EE Tier 1 Extended Cycle † levonorgestrel/EE 0.1/20 and EE 10 Tier 1 † levonorgestrel/EE 0.15/30 - Jolessa Tier 1 † levonorgestrel/EE 0.15/30 and EE 10 Tier 1 Continuous † levonorgestrel/EE 0.09/20 - Amethyst Tier 1 Progestin Only † norethindrone Tier 1 Implant ‡ etonogestrel implant NEXPLANON Tier 2 Injectable † medroxyprogesterone acetate 150 mg/mL Tier 1 Intrauterine Devices ‡ intrauterine copper contraceptive PARAGARD T 380A Tier 2 ‡ levonorgestrel-releasing IUD KYLEENA Tier 2 ‡ levonorgestrel-releasing IUD MIRENA Tier 2 ‡ levonorgestrel-releasing IUD SKYLA Tier 2 Transdermal † norelgestromin/EE Tier 1 Vaginal ‡ etonogestrel/EE ring NUVARING Tier 2 ENDOMETRIOSIS danazol Tier 1 leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 2 PA nafarelin SYNAREL Tier 2 ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Injectable estradiol valerate Tier 1 Oral estradiol Tier 1 estrogens, esterified/methyltestosterone Tier 1 estrogens, conjugated PREMARIN Tier 2

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Transdermal estradiol Tier 1 estradiol transdermal spray EVAMIST Tier 2 Vaginal estradiol vaginal crm Tier 1 estradiol vaginal tabs Tier 1 estrogens, conjugated crm PREMARIN crm Tier 2 ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone acetate Tier 1 estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2 estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2 Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 FERTILITY REGULATORS PA clomiphene Tier 1 PA chorionic gonadotropin Tier 2 PA ganirelix acetate inj Tier 2 GANIRELIX ACETATE Tier 2 PA cetrorelix CETROTIDE Tier 2 PA choriogonadotropin alfa OVIDREL Tier 2 PA chorionic gonadotropin NOVAREL Tier 2 PA chorionic gonadotropin PREGNYL Tier 2 PA follitropin beta FOLLISTIM AQ Tier 2 PA gonadorelin LUTREPULSE Tier 2 PA menotropins MENOPUR Tier 2 GAUCHER DISEASE PA eliglustat CERDELGA Tier 2 PA imiglucerase CEREZYME Tier 2 GLUCOCORTICOIDS cortisone acetate Tier 1 dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 methylprednisolone Tier 1 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate orally disintegrating tabs Tier 1 prednisolone syrup Tier 1 prednisone Tier 1 GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGON EMERGENCY KIT Tier 2 HEREDITARY TYROSINEMIA TYPE 1 AGENTS nitisinone Tier 2 ORFADIN Tier 2 nitisinone NITYR Tier 2

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HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines PA somatropin NORDITROPIN Tier 2 PA, * somatropin SEROSTIM Tier 2 PA, ** somatropin ZORBTIVE Tier 2 * Indicated for AIDS wasting only ** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 doxercalciferol Tier 1 paricalcitol Tier 1 INSULIN-LIKE GROWTH FACTOR-1 AGENTS PA mecasermin INCRELEX Tier 2 PHENYLKETONURIA TREATMENT AGENTS PA sapropterin KUVAN Tier 2 PHOSPHATE BINDER AGENTS calcium acetate Tier 1 lanthanum carbonate chew tabs Tier 1 sevelamer carbonate Tier 1 sevelamer HCl Tier 1 lanthanum carbonate oral packets FOSRENOL ORAL PACKETS Tier 2 PROGESTINS Oral medroxyprogesterone acetate Tier 1 megestrol acetate susp Tier 1 norethindrone acetate Tier 1 PA progesterone, micronized Tier 1 Vaginal PA progesterone vaginal inserts ENDOMETRIN Tier 2 SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene Tier 1 THYROID AGENTS Antithyroid Agents methimazole Tier 1 propylthiouracil Tier 1 Thyroid Supplements levothyroxine Tier 1 SYNTHROID Tier 2 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 UREA CYCLE DISORDERS PA sodium phenylbutyrate Tier 2 VASOPRESSINS desmopressin spray, tabs Tier 1

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MISCELLANEOUS acetylcysteine Tier 1 methylergonovine Tier 1 trientine Tier 1 corticotropin powder Tier 2 PA miglustat Tier 2 octreotide acetate Tier 2 PA agalsidase beta FABRAZYME Tier 2 PA alglucosidase alfa LUMIZYME Tier 2 PA asfotase alfa STRENSIQ Tier 2 betaine anhydrous CYSTADANE Tier 2 PA burosumab-twza CRYSVITA Tier 2 PA carglumic acid CARBAGLU Tier 2 cysteamine CYSTAGON Tier 2 PA cysteamine delayed-rel PROCYSBI Tier 2 PA elapegademase-lvlr REVCOVI Tier 2 PA glycerol phenylbutyrate RAVICTI Tier 2 PA histrelin acetate SUPPRELIN LA Tier 2 hydroxocobalamin CYANOKIT Tier 2 PA lanreotide acetate SOMATULINE DEPOT Tier 2 PA leuprolide acetate LUPRON DEPOT-PED Tier 2 PA metreleptin MYALEPT Tier 2 PA mifepristone KORLYM Tier 2 PA octreotide acetate SANDOSTATIN LAR Tier 2 PA pasireotide SIGNIFOR Tier 2 pegademase, bovine ADAGEN Tier 2 pegvisomant SOMAVERT Tier 2 PA taliglucerase alfa ELELYSO Tier 2 PA tesamorelin EGRIFTA Tier 2 thyrotropin alfa THYROGEN Tier 2 PA tolvaptan JYNARQUE Tier 2 PA tolvaptan SAMSCA Tier 2 PA triptorelin pamoate TRIPTODUR Tier 2 PA velaglucerase alfa VPRIV Tier 2 PA vestronidase alfa-vjbk MEPSEVII Tier 2 GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS diphenoxylate/atropine Tier 1 loperamide Tier 1 ANTIEMETICS QL aprepitant caps Tier 1 PA doxylamine/pyridoxine delayed-rel Tier 1 QL dronabinol Tier 1 granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 QL ondansetron Tier 1 QL ondansetron orally disintegrating tabs Tier 1 PA palonosetron Tier 1 prochlorperazine Tier 1 promethazine Tier 1

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scopolamine transdermal Tier 1 trimethobenzamide Tier 1 QL granisetron transdermal SANCUSO Tier 2 QL rolapitant VARUBI Tier 2 ANTISPASMODICS chlordiazepoxide/clidinium Tier 1 dicyclomine Tier 1 d hyoscyamine sulfate Tier 1 d hyoscyamine sulfate ext-rel Tier 1 propantheline 15 mg Tier 1 CHOLELITHOLYTICS ursodiol Tier 1 H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 * famotidine Tier 1 famotidine susp Tier 1 nizatidine Tier 1 ranitidine Tier 1 * Except 20 mg INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 mesalamine delayed-rel caps Tier 1 mesalamine delayed-rel tabs Tier 1 sulfasalazine Tier 1 sulfasalazine delayed-rel Tier 1 mesalamine ext-rel caps APRISO Tier 2 mesalamine ext-rel caps PENTASA Tier 2 Rectal Agents hydrocortisone enema Tier 1 mesalamine rectal susp Tier 1 mesalamine supp Tier 1 hydrocortisone acetate foam CORTIFOAM Tier 2 IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA linaclotide LINZESS Tier 2 Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 LAXATIVES lactulose Tier 1 peg 3350/electrolytes Tier 1 peg 3350/electrolytes MOVIPREP Tier 2 sodium sulfate/potassium sulfate/magnesium sulfate SUPREP Tier 2 OPIOID-INDUCED CONSTIPATION PA methylnaltrexone RELISTOR Tier 2 PA naloxegol MOVANTIK Tier 2

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PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 PROSTAGLANDINS misoprostol Tier 1 PROTON PUMP INHIBITORS QL esomeprazole delayed-rel Tier 1 QL lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 QL pantoprazole delayed-rel Tier 1 QL rabeprazole delayed-rel Tier 1 SALIVA STIMULANTS cevimeline Tier 1 pilocarpine tabs Tier 1 STEROIDS, RECTAL d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2 d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2 ULCER THERAPY COMBINATIONS QL lansoprazole + amoxicillin + clarithromycin Tier 1 QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2 MISCELLANEOUS cromolyn sodium Tier 1 sucralfate Tier 1 PA cholic acid CHOLBAM Tier 2 dextranomer/sodium hyaluronate SOLESTA Tier 2 PA obeticholic acid OCALIVA Tier 2 PA palifermin KEPIVANCE Tier 2 sucralfate susp CARAFATE susp Tier 2 PA teduglutide GATTEX Tier 2 PA telotristat XERMELO Tier 2 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel Tier 1 dutasteride Tier 1 dutasteride/tamsulosin Tier 1 finasteride Tier 1 silodosin Tier 1 PA tadalafil tabs 2.5 mg, 5 mg Tier 1 tamsulosin Tier 1 URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 oxybutynin Tier 1 oxybutynin ext-rel Tier 1 solifenacin Tier 1 tolterodine Tier 1 tolterodine ext-rel Tier 1

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trospium Tier 1 trospium ext-rel Tier 1 VAGINAL ANTI-INFECTIVES metronidazole Tier 1 terconazole crm Tier 1 terconazole supp 80 mg Tier 1 clindamycin supp CLEOCIN vaginal supp Tier 2 MISCELLANEOUS bethanechol Tier 1 phenazopyridine Tier 1 potassium citrate ext-rel Tier 1 pentosan polysulfate sodium ELMIRON Tier 2 HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable enoxaparin Tier 1 dalteparin FRAGMIN Tier 2 Oral warfarin Tier 1 apixaban ELIQUIS Tier 2 rivaroxaban XARELTO Tier 2 Synthetic Heparinoid-like Agents fondaparinux Tier 1 HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines PA darbepoetin alfa ARANESP Tier 2 PA epoetin alfa-epbx RETACRIT Tier 2 PA filgrastim-sndz ZARXIO Tier 2 PA methoxy polyethylene glycol/epoetin beta MIRCERA Tier 2 PA pegfilgrastim-cbqv UDENYCA Tier 2 PA pegfilgrastim-jmdb FULPHILA Tier 2 PA tbo-filgrastim GRANIX Tier 2 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org AHF, human/VWF, human HUMATE-P Tier 2 antihemophilic factor ALPHANATE Tier 2 antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 2 antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 2 antihemophilic factor, recombinant KOGENATE FS Tier 2 antihemophilic factor, recombinant KOVALTRY Tier 2 antihemophilic factor, recombinant RECOMBINATE Tier 2

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coagulation factor VIIa NOVOSEVEN RT Tier 2 desmopressin spray STIMATE Tier 2 emicizumab-kxwh HEMLIBRA Tier 2 factor IX concentrate BENEFIX Tier 2 factor IX concentrate RIXUBIS Tier 2 factor IX recombinant, Fc fusion protein ALPROLIX Tier 2 HEREDITARY ANGIOEDEMA AGENTS PA icatibant Tier 2 PA C1 esterase inhibitor BERINERT Tier 2 PA C1 esterase inhibitor CINRYZE Tier 2 PA C1 esterase inhibitor HAEGARDA Tier 2 PA C1 esterase inhibitor, recombinant RUCONEST Tier 2 PA ecallantide KALBITOR Tier 2 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA eltrombopag PROMACTA Tier 2 PA romiplostim NPLATE Tier 2 PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 prasugrel Tier 1 PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 STEM CELL MOBILIZERS plerixafor MOZOBIL Tier 2 MISCELLANEOUS aminocaproic acid Tier 1 cilostazol Tier 1 pentoxifylline ext-rel Tier 1 tranexamic acid Tier 1 PA deferasirox Tier 2 deferoxamine Tier 2 PA deferiprone FERRIPROX Tier 2 PA L-glutamine oral powder ENDARI Tier 2 IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 2 Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org AUTOIMMUNE AGENTS PA adalimumab HUMIRA Tier 2 PA anakinra KINERET Tier 2 PA apremilast OTEZLA Tier 2 PA etanercept ENBREL Tier 2 PA etanercept ENBREL SURECLICK Tier 2 PA tocilizumab ACTEMRA Tier 2

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DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine Tier 1 leflunomide Tier 1 methotrexate inj Tier 1 methotrexate oral Tier 1 IMMUNE GLOBULINS hepatitis B immune globulin HEPAGAM B Tier 2 hepatitis B immune globulin HYPERHEP B S-D Tier 2 hepatitis B immune globulin NABI-HB Tier 2 PA immune globulin (human)-ifas PANZYGA Tier 2 PA immune globulin, gamma GAMUNEX-C Tier 2 PA immune globulin, gamma (IGG) GAMMAKED Tier 2 PA immune globulin, gamma (IGG) GAMMAPLEX Tier 2 PA immune globulin, intravenous FLEBOGAMMA Tier 2 PA immune globulin, intravenous GAMMAGARD LIQUID Tier 2 PA immune globulin, intravenous GAMMAGARD S-D Tier 2 PA immune globulin, subcutaneous CUVITRU Tier 2 PA immune globulin, subcutaneous HIZENTRA Tier 2 PA immune globulin/hyaluronidase HYQVIA Tier 2 Rho (D) immune globulin HYPERRHO S-D Tier 2 Rho (D) immune globulin MICRHOGAM Tier 2 Rho (D) immune globulin MICRHOGAM PLUS Tier 2 Rho (D) immune globulin RHOGAM Tier 2 Rho (D) immune globulin RHOGAM PLUS Tier 2 varicella zoster immune globulin VARIZIG Tier 2 IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons PA interferon alfa-2b INTRON A Tier 2 PA interferon gamma-1b, recombinant ACTIMMUNE Tier 2 PA peginterferon alfa-2a PEGASYS Tier 2 PA peginterferon alfa-2b PEGINTRON Tier 2 Miscellaneous PA canakinumab ILARIS Tier 2 PA rilonacept ARCALYST Tier 2 IMMUNOSUPPRESSANTS Antimetabolites azathioprine Tier 1 mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 Calcineurin Inhibitors cyclosporine Tier 1 cyclosporine, modified Tier 1 tacrolimus Tier 1 tacrolimus ext-rel ASTAGRAF XL Tier 2 Rapamycin Derivatives sirolimus Tier 1

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everolimus ZORTRESS Tier 2 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1 potassium chloride powder Tier 1 Potassium-Removing Agents sodium polystyrene sulfonate Tier 1 VITAMINS AND MINERALS Folic Acid Agents folic acid Tier 1 Prenatal Vitamins prenatal vitamins/folic acid DUET DHA Tier 2 prenatal vitamins/folic acid PRENATE ELITE Tier 2 Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 fluoride drops, tabs Tier 1 multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1 phytonadione Tier 1 sodium ferric gluconate inj Tier 1 vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1 cyanocobalamin spray NASCOBAL Tier 2 ferumoxytol inj FERAHEME Tier 2 iron sucrose inj VENOFER Tier 2 zinc acetate GALZIN Tier 2 RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 2 epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 2 epinephrine inj (0.15 mg and 0.30 mg) Tier 1 ANTICHOLINERGICS ipratropium soln Tier 1 tiotropium SPIRIVA Tier 2 tiotropium SPIRIVA RESPIMAT Tier 2

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ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol soln Tier 1 Long Acting tiotropium/olodaterol STIOLTO RESPIMAT Tier 2 umeclidinium/vilanterol ANORO ELLIPTA Tier 2 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2 ANTIHISTAMINES, SEDATING cyproheptadine Tier 1 diphenhydramine Tier 1 hydroxyzine HCl Tier 1 hydroxyzine pamoate Tier 1 promethazine Tier 1 ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate Tier 1 ANTITUSSIVE COMBINATIONS Opioid QL codeine/promethazine Tier 1 QL codeine/promethazine/phenylephrine Tier 1 QL hydrocodone/chlorpheniramine/pseudoephedrine Tier 1 hydrocodone/homatropine Tier 1 BETA AGONISTS Inhalants Short Acting albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 2 levalbuterol inhalation soln Tier 1 levalbuterol nebulizer soln concentrate Tier 1 levalbuterol tartrate, CFC-free aerosol Tier 1 albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2 Long Acting Hand-held Active Inhalation salmeterol xinafoate SEREVENT DISKUS Tier 2 Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 metaproterenol Tier 1 terbutaline Tier 1 CYSTIC FIBROSIS tobramycin inhalation soln Tier 2 aztreonam lysine inhalation soln CAYSTON Tier 2 PA dornase alfa PULMOZYME Tier 2 PA ivacaftor KALYDECO Tier 2 PA lumacaftor/ivacaftor ORKAMBI Tier 2 PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 2

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LEUKOTRIENE MODULATORS montelukast Tier 1 zafirlukast Tier 1 MAST CELL STABILIZERS cromolyn soln Tier 1 NASAL ANTIHISTAMINES azelastine spray Tier 1 olopatadine spray Tier 1 NASAL STEROIDS flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 PULMONARY ENZYME DEFICIENCY AGENTS PA alpha-1 proteinase inhibitor ARALAST NP Tier 2 PA alpha-1 proteinase inhibitor GLASSIA Tier 2 PA alpha-1 proteinase inhibitor ZEMAIRA Tier 2 PULMONARY FIBROSIS AGENTS PA nintedanib OFEV Tier 2 PA pirfenidone ESBRIET Tier 2 SEVERE ASTHMA AGENTS PA omalizumab XOLAIR Tier 2 STEROID/BETA AGONIST COMBINATIONS fluticasone/salmeterol Tier 1 fluticasone/salmeterol Tier 1 ADVAIR Tier 2 budesonide/formoterol SYMBICORT Tier 2 fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 fluticasone/vilanterol BREO ELLIPTA Tier 2 mometasone/formoterol DULERA Tier 2 STEROID INHALANTS budesonide inhalation suspension Tier 1 beclomethasone, CFC-free aerosol QVAR Tier 2 budesonide PULMICORT FLEXHALER Tier 2 fluticasone FLOVENT Tier 2 fluticasone, CFC-free aerosol FLOVENT HFA Tier 2 mometasone ASMANEX Tier 2 mometasone, CFC-free aerosol ASMANEX HFA Tier 2 XANTHINES caffeine citrate Tier 1 theophylline ext-rel tabs Tier 1 theophylline ext-rel caps THEO-24 Tier 2 theophylline liquid ELIXOPHYLLIN Tier 2 MISCELLANEOUS ipratropium nasal spray Tier 1

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TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral isotretinoin Tier 1 Topical PA adapalene crm, gel, lotion Tier 1 PA adapalene/benzoyl peroxide Tier 1 benzoyl peroxide Tier 1 clindamycin gel, lotion, soln Tier 1 clindamycin swabs Tier 1 clindamycin/benzoyl peroxide Tier 1 PA clindamycin/tretinoin Tier 1 erythromycin gel 2% Tier 1 erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 PA tazarotene crm 0.1% Tier 1 PA tretinoin Tier 1 PA tretinoin gel microsphere Tier 1 Actinic Keratosis PA diclofenac sodium gel 3% Tier 1 fluorouracil Tier 1 Antibiotics gentamicin Tier 1 mafenide acetate packets 5% Tier 1 mupirocin Tier 1 silver sulfadiazine Tier 1 retapamulin ALTABAX Tier 2 Antifungals ciclopirox Tier 1 clotrimazole Tier 1 clotrimazole/betamethasone Tier 1 econazole Tier 1 ketoconazole Tier 1 miconazole nitrate/zinc oxide Tier 1 naftifine Tier 1 nystatin Tier 1 oxiconazole Tier 1 Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Oral acitretin Tier 1 methoxsalen oral Tier 1 Topical betamethasone dipropionate/calcipotriene Tier 1 calcipotriene Tier 1 calcitriol oint Tier 1

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Antiseborrheics ketoconazole shampoo 2% Tier 1 selenium sulfide shampoo 2.5% Tier 1 Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Topical pimecrolimus Tier 1 tacrolimus Tier 1 Corticosteroids Low Potency alclometasone crm, oint 0.05% Tier 1 desonide crm, lotion, oint 0.05% Tier 1 fluocinolone acetonide soln 0.01% Tier 1 hydrocortisone crm 2.5% Tier 1 hydrocortisone lotion 1% Tier 1 desonide foam 0.05% VERDESO Tier 2 desonide gel 0.05% DESONATE Tier 2 Medium Potency betamethasone valerate crm, lotion, oint 0.1% Tier 1 clocortolone pivalate crm 0.1% Tier 1 desoximetasone crm, oint 0.05% Tier 1 fluocinolone acetonide crm, oint 0.025% Tier 1 fluocinolone acetonide oil 0.01% Tier 1 flurandrenolide crm, lotion, oint 0.05% Tier 1 fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1 hydrocortisone butyrate crm 0.1% Tier 1 hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1 hydrocortisone valerate crm, oint 0.2% Tier 1 mometasone crm, lotion, oint 0.1% Tier 1 triamcinolone acetonide crm, lotion 0.025% Tier 1 triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 flurandrenolide tape CORDRAN TAPE Tier 2 triamcinolone oint 0.05% TRIANEX Tier 2 High Potency amcinonide crm, lotion, oint 0.1% Tier 1 betamethasone dipropionate augmented crm 0.05% Tier 1 betamethasone dipropionate augmented lotion 0.05% Tier 1 betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 diflorasone diacetate crm 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1 triamcinolone acetonide crm 0.5% Tier 1 triamcinolone acetonide topical spray Tier 1 Very High Potency betamethasone dipropionate augmented gel, oint 0.05% Tier 1 clobetasol propionate crm, gel, oint, soln 0.05% Tier 1 clobetasol propionate lotion, shampoo, spray 0.05% Tier 1 diflorasone diacetate oint 0.05% Tier 1 fluocinonide crm 0.1% Tier 1 halobetasol propionate crm, oint 0.05% Tier 1

44

Emollients ammonium lactate 12% Tier 1 Local Analgesics QL lidocaine patch Tier 1 Local Anesthetics QL lidocaine Tier 1 QL lidocaine/prilocaine Tier 1 Rosacea azelaic acid gel Tier 1 doxycycline monohydrate delayed-rel caps Tier 1 metronidazole crm 0.75% Tier 1 metronidazole gel 0.75% Tier 1 metronidazole gel 1% Tier 1 metronidazole lotion 0.75% Tier 1 sulfacetamide/sulfur Tier 1 Scabicides and Pediculicides crotamiton lotion Tier 1 lindane Tier 1 permethrin 5% Tier 1 spinosad Tier 1 crotamiton crm EURAX crm Tier 2 ivermectin SKLICE Tier 2 Miscellaneous Skin and Mucous Membrane acyclovir crm Tier 1 acyclovir oint Tier 1 QL doxepin crm Tier 1 d, PA hydrocortisone/aloe polysaccharide/iodoquinol Tier 1 d, PA hydrocortisone/iodoquinol Tier 1 PA imiquimod crm pump 3.75% Tier 1 podofilox Tier 1 alitretinoin PANRETIN Tier 2 PA becaplermin REGRANEX Tier 2 PA collagenase clostridium histolyticum XIAFLEX Tier 2 PA imiquimod crm 3.75%, crm pump 2.5% ZYCLARA crm 3.75%, crm pump

2.5% Tier 2

PA interferon alfa-n3 ALFERON N Tier 2 MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1 Steroids - Mouth/Throat triamcinolone paste Tier 1 Miscellaneous sodium fluoride Tier 1

45

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics cromolyn sodium Tier 1 epinastine Tier 1 olopatadine Tier 1 phenylephrine Tier 1 Antifungals natamycin NATACYN Tier 2 Anti-infectives bacitracin Tier 1 ciprofloxacin Tier 1 erythromycin Tier 1 gentamicin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1 ofloxacin Tier 1 polymyxin B/bacitracin Tier 1 polymyxin B/trimethoprim Tier 1 sulfacetamide soln 10% Tier 1 tobramycin Tier 1 azithromycin AZASITE Tier 2 besifloxacin BESIVANCE Tier 2 Anti-infective/Anti-inflammatory Combinations neomycin/dexamethasone Tier 1 neomycin/polymyxin B/dexamethasone Tier 1 neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 tobramycin/dexamethasone oint 0.3%/0.1% TOBRADEX OINTMENT Tier 2 tobramycin/loteprednol ZYLET Tier 2 Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 flurbiprofen Tier 1 ketorolac 0.5% Tier 1 Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 loteprednol 0.5% susp Tier 1 prednisolone acetate 1% Tier 1 prednisolone phosphate 1% Tier 1 difluprednate DUREZOL Tier 2 loteprednol LOTEMAX (except 0.5% susp) Tier 2 loteprednol 0.2% ALREX Tier 2 prednisolone acetate 0.12% PRED MILD Tier 2 rimexolone VEXOL Tier 2

46

Antivirals trifluridine Tier 1 ganciclovir ZIRGAN Tier 2 Beta-blockers Nonselective carteolol Tier 1 levobunolol Tier 1 timolol maleate Tier 1 timolol maleate gel Tier 1 Carbonic Anhydrase Inhibitors Topical dorzolamide Tier 1 brinzolamide AZOPT Tier 2 Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Tier 2 Dry Eye Disease PA cyclosporine, emulsion RESTASIS Tier 2 PA lifitegrast XIIDRA Tier 2 Mydriatics atropine sulfate soln Tier 1 cyclopentolate Tier 1 homatropine Tier 1 scopolamine ISOPTO HYOSCINE Tier 2 Neurotrophic Keratitis PA cenegermin-bkbj OXERVATE Tier 2 Prostaglandins latanoprost Tier 1 travoprost TRAVATAN Z Tier 2 Retinal Disorders PA aflibercept EYLEA Tier 2 PA ranibizumab LUCENTIS Tier 2 Sympathomimetics brimonidine 0.15% Tier 1 brimonidine 0.2% Tier 1 brimonidine 0.1% ALPHAGAN P 0.1% Tier 2 Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Tier 2 Miscellaneous naphazoline Tier 1 cysteamine CYSTARAN Tier 2 PA ocriplasmin JETREA Tier 2 verteporfin VISUDYNE Tier 2

47

OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives acetic acid Tier 1 ciprofloxacin otic Tier 1 ofloxacin otic Tier 1 Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 neomycin/polymyxin B/hydrocortisone Tier 1 ciprofloxacin/dexamethasone CIPRODEX Tier 2 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2 Miscellaneous fluocinolone acetonide Tier 1

48

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

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

49

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

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

50

INDEX

A abacavir, 12 abacavir soln, 12 abacavir/dolutegravir/lamivudine, 11 abacavir/lamivudine, 11 abacavir/lamivudine/zidovudine, 11 ABELCET, 11 abemaciclib, 15 abiraterone, 14 abiraterone 250 mg, 14 abobotulinumtoxinA, 27 acalabrutinib, 15 acamprosate calcium, 26 acarbose, 28 ACCU-CHEK FASTCLIX LANCET DEVICE, 29 ACCU-CHEK FASTCLIX LANCETS, 29 ACCU-CHEK METERS AND KITS, 29 ACCU-CHEK TEST STRIPS, 29 acebutolol, 19 acetazolamide, 20 acetazolamide ext-rel, 20 acetic acid, 48 acetic acid/hydrocortisone, 48 acetylcysteine, 34 acitretin, 43 ACTEMRA, 38 ACTIMMUNE, 39 acyclovir caps, susp, tabs, 13 acyclovir crm, 45 acyclovir oint, 45 ADAGEN, 34 adalimumab, 38 adapalene crm, gel, lotion, 43 adapalene/benzoyl peroxide, 43 ADCETRIS, 16 adefovir dipivoxil, 12 ADEMPAS, 21 ADRUCIL, 14 ADVAIR, 42 ADVAIR HFA, 42 afatinib, 15 AFINITOR, 15 AFINITOR DISPERZ, 15 aflibercept, 47 agalsidase beta, 34 AHF, human/VWF, human, 37 AIMOVIG, 25 albuterol, 41 albuterol ext-rel, 41 albuterol soln, 41 albuterol sulfate aerosol powder breath-activated, 41 albuterol sulfate, CFC-free aerosol, 41 alclometasone crm, oint 0.05%, 44 aldesleukin, 16 ALECENSA, 15 alectinib, 15 alemtuzumab, 26 alendronate, 30 ALFERON N, 45 alfuzosin ext-rel, 36 alglucosidase alfa, 34 ALIMTA, 14

ALINIA, 13 aliskiren, 20 aliskiren/hydrochlorothiazide, 20 alitretinoin, 45 allopurinol, 8 almotriptan, 25 alogliptin, 28 alogliptin/metformin, 28 alogliptin/pioglitazone, 28 alosetron, 35 alpha-1 proteinase inhibitor, 42 ALPHAGAN P 0.1%, 47 ALPHANATE, 37 alprazolam, 22 alprazolam ext-rel, 22 ALPROLIX, 38 ALREX, 46 ALTABAX, 43 ALUNBRIG, 15 amantadine, except tabs, 24 AMBISOME, 11 ambrisentan, 21 amcinonide crm, lotion, oint 0.1%, 44 amifampridine, 27 amifostine, 16 amiloride, 20 amiloride/hydrochlorothiazide, 21 aminocaproic acid, 38 amiodarone, 18 amitriptyline, 23 amitriptyline/perphenazine, 23 amlodipine, 20 amlodipine/atorvastatin, 20 amlodipine/olmesartan, 18 amlodipine/telmisartan, 18 amlodipine/valsartan, 18 amlodipine/valsartan/hydrochlorothiazide, 18 ammonium lactate 12%, 45 amoxicillin, except film-coated tabs, 10 amoxicillin/clavulanate, 10 amoxicillin/clavulanate ext-rel, 10 amoxicillin/clavulanate susp 600 mg, 10 amphetamine/dextroamphetamine mixed salts, 25 amphetamine/dextroamphetamine mixed salts ext-rel, 25 amphotericin B lipid complex inj, 11 amphotericin B liposome inj, 11 ampicillin, 10 ampicillin sodium/sulbactam sodium, 10 anagrelide, 38 anakinra, 38 anastrozole, 15 ANDRODERM, 27 anidulafungin, 11 ANORO ELLIPTA, 41 antihemophilic factor, 37 antihemophilic factor (recombinant) pegylated-aucl, 37 antihemophilic factor recombinant, Fc fusion protein, 37 antihemophilic factor, recombinant, 37 apixaban, 37 APOKYN, 24 apomorphine, 24 apremilast, 38 aprepitant caps, 34

51

APRISO, 35 APTIVUS, 12 ARALAST NP, 42 ARANESP, 37 ARCALYST, 39 aripiprazole, 24 aripiprazole orally disintegrating tabs, 24 armodafinil, 26 ARRANON, 17 arsenic trioxide, 16 artemether/lumefantrine, 11 asfotase alfa, 34 ASMANEX, 42 ASMANEX HFA, 42 asparaginase, 16 ASTAGRAF XL, 39 atazanavir caps, 12 atazanavir/cobicistat, 11 atenolol, 19 atenolol/chlorthalidone, 20 atomoxetine, 25 atorvastatin, 19 atovaquone, 13 atovaquone/proguanil, 11 ATRIPLA, 11 atropine sulfate soln, 47 AUBAGIO, 26 AVEED, 27 AVONEX, 26 axitinib, 15 AZASITE, 46 azathioprine, 39 azelaic acid gel, 45 azelastine spray, 42 azithromycin, 10, 46 AZOPT, 47 aztreonam, 13 aztreonam lysine inhalation soln, 41 B bacitracin, 46 baclofen, 26 baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 26 baloxavir, 13 balsalazide, 35 BANZEL, 22 BARACLUDE soln, 12 BASAGLAR, 28 BCG live vaccine, 16 BD INSULIN SYRINGES AND NEEDLES, 29 becaplermin, 45 beclomethasone, CFC-free aerosol, 42 benazepril, 17 benazepril/amlodipine, 17 benazepril/hydrochlorothiazide, 17 BENEFIX, 38 benzonatate, 41 benzoyl peroxide, 43 benztropine, 24 BERINERT, 38 besifloxacin, 46 BESIVANCE, 46 betaine anhydrous, 34 betamethasone dipropionate augmented crm 0.05%, 44 betamethasone dipropionate augmented gel, oint 0.05%, 44 betamethasone dipropionate augmented lotion 0.05%, 44

betamethasone dipropionate crm, lotion, oint 0.05%, 44 betamethasone dipropionate/calcipotriene, 43 betamethasone valerate crm, lotion, oint 0.1%, 44 BETASERON, 26 bethanechol, 37 bevacizumab-awwb, 16 bexarotene caps, 16 bexarotene gel, 16 bicalutamide, 14 bictegravir/emtricitabine/tenofovir alafenamide, 11 BIDIL, 21 BIKTARVY, 11 bismuth subsalicylate + metronidazole + tetracycline, 36 bisoprolol/hydrochlorothiazide, 20 bleomycin sulfate, 16 blinatumomab, 16 BLINCYTO, 16 blood glucose continuous monitoring receivers, sensors, transmitters,

29 blood glucose meters and kits, 29 blood glucose test strips, 29 bosentan, 21 BOSULIF, 15 bosutinib, 15 BOTOX, 27 brentuximab vedotin, 16 BREO ELLIPTA, 42 brigatinib, 15 brimonidine 0.1%, 47 brimonidine 0.15%, 47 brimonidine 0.2%, 47 brimonidine/timolol, 47 brinzolamide, 47 brinzolamide/brimonidine, 47 bromfenac sodium, 46 bromocriptine, 24 budesonide, 42 budesonide delayed-rel caps, 35 budesonide inhalation suspension, 42 budesonide/formoterol, 42 bumetanide, 20 buprenorphine, 27 buprenorphine ext-rel inj, 27 buprenorphine transdermal, 8 buprenorphine/naloxone sublingual film, 27 buprenorphine/naloxone sublingual tabs, 27 bupropion, 23 bupropion ext-rel, 23, 27 burosumab-twza, 34 buspirone, 22 busulfan, 14 butalbital/acetaminophen, 9 butalbital/acetaminophen/caffeine, 9 butalbital/acetaminophen/caffeine/codeine, 8 butalbital/aspirin/caffeine, 9 butalbital/aspirin/caffeine/codeine, 8 butorphanol nasal spray, 8 BYSTOLIC, 20 C C1 esterase inhibitor, 38 C1 esterase inhibitor, recombinant, 38 cabazitaxel, 16 CABOMETYX, 15 cabozantinib, 15 caffeine citrate, 42

52

calcipotriene, 43 calcitonin-salmon spray, 30 calcitriol (1,25-D3), 33 calcitriol oint, 43 calcium acetate, 33 CALDOLOR, 8 CALQUENCE, 15 canakinumab, 39 candesartan, 18 candesartan/hydrochlorothiazide, 18 capecitabine, 14 CAPRELSA, 16 captopril/hydrochlorothiazide, 17 CARAFATE susp, 36 CARBAGLU, 34 carbamazepine, 22 carbamazepine ext-rel, 22 carbidopa/levodopa, 24 carbidopa/levodopa ext-rel, 24 carbidopa/levodopa orally disintegrating tabs, 24 carbidopa/levodopa/entacapone, 24 carboplatin, 16 carfilzomib, 16 carglumic acid, 34 carmustine, 14 carteolol, 47 carvedilol, 19 carvedilol phosphate ext-rel, 19 CAYSTON, 41 cefaclor, 10 cefdinir, 10 cefditoren, 10 cefepime, 10 cefixime (except caps, 100 mg/5 mL, 200 mg/5 mL susp), 10 cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 10 cefotaxime, 10 cefoxitin, 10 cefpodoxime, 10 cefprozil, 10 ceftazidime, 10 ceftriaxone, 10 cefuroxime axetil, 10 celecoxib, 8 cenegermin-bkbj, 47 cephalexin, 10 CERDELGA, 32 CEREZYME, 32 ceritinib, 15 cetrorelix, 32 CETROTIDE, 32 cevimeline, 36 CHANTIX, 27 CHEMSTRIP K URINE KETONE STRIPS, 29 CHEMSTRIP UG URINE GLUCOSE STRIPS, 29 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 29 chlorambucil, 14 chlordiazepoxide, 22 chlordiazepoxide/clidinium, 35 chloroquine, 11 chlorthalidone, 21 CHOLBAM, 36 cholestyramine pkt, 19 cholic acid, 36 choriogonadotropin alfa, 32 chorionic gonadotropin, 32 ciclopirox, 43

cidofovir, 12 cilostazol, 38 cimetidine, 35 cinacalcet, 29 CINRYZE, 38 CIPRO HC OTIC, 48 CIPRODEX, 48 ciprofloxacin, 10, 46 ciprofloxacin otic, 48 ciprofloxacin/dexamethasone, 48 ciprofloxacin/hydrocortisone, 48 cisplatin, 16 citalopram, 23 cladribine, 14 clarithromycin, 10 clarithromycin ext-rel, 10 CLEOCIN vaginal supp, 37 CLIMARA PRO, 32 clindamycin, 13 clindamycin gel, lotion, soln, 43 clindamycin supp, 37 clindamycin swabs, 43 clindamycin/benzoyl peroxide, 43 clindamycin/tretinoin, 43 clobazam, 22 clobetasol propionate crm, gel, oint, soln 0.05%, 44 clobetasol propionate lotion, shampoo, spray 0.05%, 44 clocortolone pivalate crm 0.1%, 44 clofarabine, 14 clomiphene, 32 clomipramine, 22 clonazepam, 22 clonidine, 18 clonidine ext-rel, 25 clonidine transdermal, 18 clopidogrel, 38 clorazepate, 22 clotrimazole, 43 clotrimazole troches, 11 clotrimazole/betamethasone, 43 clozapine, 24 clozapine orally disintegrating tabs, 24 coagulation factor VIIa, 38 COARTEM, 11 cobicistat, 11 cobimetinib, 15 codeine/acetaminophen, 8 codeine/promethazine, 41 codeine/promethazine/phenylephrine, 41 colchicine, 8 colesevelam, 19 colestipol, 19 collagenase clostridium histolyticum, 45 COMBIGAN, 47 COMETRIQ, 15 COMPLERA, 11 CORDRAN TAPE, 44 CORLANOR, 21 corticotropin powder, 34 CORTIFOAM, 35 cortisone acetate, 32 COTELLIC, 15 CREON, 36 CRIXIVAN, 12 crizotinib, 15 cromolyn sodium, 36, 46

53

cromolyn soln, 42 crotamiton crm, 45 crotamiton lotion, 45 CRYSVITA, 34 CUVITRU, 39 cyanocobalamin inj, 40 cyanocobalamin spray, 40 CYANOKIT, 34 cyclobenzaprine, 26 cyclopentolate, 47 cyclophosphamide caps, 14 CYCLOPHOSPHAMIDE CAPSULES, 14 cyclophosphamide inj, 14 cyclosporine, 39 cyclosporine, emulsion, 47 cyclosporine, modified, 39 cyproheptadine, 41 CYRAMZA, 17 CYSTADANE, 34 CYSTAGON, 34 CYSTARAN, 47 cysteamine, 34, 47 cysteamine delayed-rel, 34 cytarabine, 14 CYTOGAM, 12 cytomegalovirus immune globulin, 12 D dabrafenib, 15 dacarbazine, 14 dacomitinib, 15 dactinomycin, 16 dalfampridine ext-rel, 26 dalteparin, 37 danazol, 31 dantrolene, 26 dapagliflozin, 29 dapagliflozin/metformin ext-rel, 29 dapagliflozin/saxagliptin, 29 dapsone, 13 daptomycin 500 mg, 13 DARAPRIM, 11 darbepoetin alfa, 37 darifenacin ext-rel, 36 darunavir, 12 darunavir/cobicistat, 11 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 11 dasatinib, 15 daunorubicin, 16 decitabine, 16 deferasirox, 38 deferiprone, 38 deferoxamine, 38 deflazacort, 27 degarelix acetate, 15 delavirdine, 12 DELSTRIGO, 11 denosumab, 30 DESCOVY, 11 desipramine, 23 desmopressin spray, 38 desmopressin spray, tabs, 33 desogestrel/EE, 31 desogestrel/EE 0.15/30, 30 DESONATE, 44 desonide crm, lotion, oint 0.05%, 44

desonide foam 0.05%, 44 desonide gel 0.05%, 44 desoximetasone crm, oint 0.05%, 44 desoximetasone crm, oint, spray 0.25%, gel 0.05%, 44 desvenlafaxine ext-rel, 23 dexamethasone, 32 dexamethasone sodium phosphate, 46 dexmethylphenidate, 25 dexmethylphenidate ext-rel, 25 dexrazoxane, 16 dextranomer/sodium hyaluronate, 36 dextroamphetamine, 25 dextroamphetamine ext-rel, 25 dextroamphetamine soln, 25 dextromethorphan/quinidine, 27 diazepam, 22 diazepam rectal gel, 22 diclofenac sodium, 46 diclofenac sodium delayed-rel, 8 diclofenac sodium delayed-rel/misoprostol, 8 diclofenac sodium ext-rel, 8 diclofenac sodium gel 1%, 8 diclofenac sodium gel 3%, 43 diclofenac sodium soln, 8 dicloxacillin, 10 dicyclomine, 35 didanosine delayed-rel, 12 didanosine soln, 12 DIFICID, 10 diflorasone diacetate crm 0.05%, 44 diflorasone diacetate oint 0.05%, 44 diflunisal, 8 difluprednate, 46 digoxin, 20 dihydroergotamine inj, 25 diltiazem, 20 diltiazem ext-rel, 20 dimethyl fumarate delayed-rel, 26 diphenhydramine, 24, 41 diphenoxylate/atropine, 34 dipyridamole, 38 dipyridamole ext-rel/aspirin, 38 disopyramide, 18 disopyramide ext-rel, 19 disulfiram, 26 divalproex sodium delayed-rel, 22 divalproex sodium ext-rel, 22 divalproex sodium sprinkle caps, 22 docetaxel, 16 dofetilide, 19 dolutegravir, 11 donepezil, 23 donepezil orally disintegrating tabs, 23 doravirine/lamivudine/tenofovir disoproxil fumarate, 11 dornase alfa, 41 dorzolamide, 47 dorzolamide/timolol maleate, 47 doxazosin, 18 doxepin, 23 doxepin crm, 45 doxercalciferol, 33 doxycycline hyclate, 10 doxycycline monohydrate, 10 doxycycline monohydrate delayed-rel caps, 45 doxylamine/pyridoxine delayed-rel, 34 dronabinol, 34

54

dronedarone, 19 drospirenone/EE 3/20 - Gianvi, 30 drospirenone/EE 3/30, 30 DUET DHA, 40 dulaglutide, 28 DULERA, 42 duloxetine delayed-rel, 23 DUREZOL, 46 dutasteride, 36 dutasteride/tamsulosin, 36 DYSPORT, 27 E ecallantide, 38 econazole, 43 edaravone, 27 EDURANT, 12 EE/norethindrone acetate, 32 EE/norethindrone acetate - Jinteli, 32 efavirenz, 12 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 11 EGRIFTA, 34 elapegademase-lvlr, 34 ELELYSO, 34 eletriptan, 25 ELIGARD, 15 eliglustat, 32 ELIQUIS, 37 ELITEK, 14 ELIXOPHYLLIN, 42 ELMIRON, 37 ELOCTATE, 37 ELSPAR, 16 eltrombopag, 38 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 11 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 11 EMFLAZA, 27 EMGALITY, 25 emicizumab-kxwh, 38 empagliflozin, 29 empagliflozin/linagliptin, 29 empagliflozin/metformin, 29 empagliflozin/metformin ext-rel, 29 emtricitabine, 12 emtricitabine/rilpivirine/tenofovir alafenamide, 11 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 11 emtricitabine/tenofovir alafenamide, 11 emtricitabine/tenofovir disoproxil fumarate, 11 EMTRIVA, 12 enalapril, 17 enalapril/hydrochlorothiazide, 18 enasidenib, 16 ENBREL, 38 ENBREL SURECLICK, 38 ENDARI, 38 ENDOMETRIN, 33 enfuvirtide, 11 enoxaparin, 37 entacapone, 24 entecavir soln, 12 entecavir tabs, 12 ENTRESTO, 21 enzalutamide, 14 EPCLUSA, 13 EPIFOAM, 36 epinastine, 46

epinephrine auto-injector 0.15 mg, 40 epinephrine auto-injector 0.30 mg, 40 epinephrine inj (0.15 mg and 0.30 mg), 40 EPIPEN, 40 EPIPEN JR., 40 eplerenone, 18 epoetin alfa-epbx, 37 epoprostenol sodium, 21 eprosartan, 18 ERAXIS, 11 erenumab-aooe, 25 ergocalciferol (D2), 40 ergotamine/caffeine, 25 ergotamine/caffeine supp, 25 eribulin, 16 ERIVEDGE, 17 erlotinib, 15 ertapenem, 13 erythromycin, 46 erythromycin delayed-rel, 10 erythromycin delayed-rel - Ery-tab, 10 erythromycin ethylsuccinate, 10 erythromycin gel 2%, 43 erythromycin soln, 43 erythromycin stearate, 10 erythromycin/benzoyl peroxide, 43 ESBRIET, 42 escitalopram, 23 esmolol, 20 esomeprazole delayed-rel, 36 estazolam, 25 estradiol, 31, 32 estradiol transdermal spray, 32 estradiol vaginal crm, 32 estradiol vaginal tabs, 32 estradiol valerate, 31 estradiol/levonorgestrel, 32 estradiol/norethindrone acetate, 32 estrogens, conjugated, 31 estrogens, conjugated crm, 32 estrogens, conjugated/medroxyprogesterone, 32 estrogens, esterified/methyltestosterone, 31 eszopiclone, 25 etanercept, 38 eteplirsen, 27 ethacrynic acid, 20 ethambutol, 12 ethosuximide, 22 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 30 ethynodiol diacetate/EE 1/50, 30 etidronate, 30 etodolac, 8 etodolac ext-rel, 8 etonogestrel implant, 31 etonogestrel/EE ring, 31 etoposide, 16 etravirine, 12 EURAX crm, 45 EVAMIST, 32 everolimus, 15, 40 everolimus tabs for oral suspension, 15 evolocumab, 19 EVOTAZ, 11 exemestane, 15 EXONDYS 51, 27 EYLEA, 47

55

ezetimibe, 19 ezetimibe/simvastatin, 19 F FABRAZYME, 34 factor IX concentrate, 38 factor IX recombinant, Fc fusion protein, 38 famciclovir, 13 famotidine, 35 famotidine susp, 35 FARXIGA, 29 FARYDAK, 17 febuxostat, 8 felbamate, 22 felodipine ext-rel, 20 fenofibrate, 19 fenofibric acid delayed-rel, 19 fentanyl citrate buccal, 8 fentanyl transdermal, 8 fentanyl transmucosal lozenge, 8 FERAHEME, 40 FERRIPROX, 38 ferumoxytol inj, 40 FIASP, 28 FIASP FLEXTOUCH, 28 fidaxomicin, 10 filgrastim-sndz, 37 finasteride, 36 fingolimod, 26 FIRDAPSE, 27 FIRMAGON, 15 FIRVANQ, 13 FLEBOGAMMA, 39 flecainide, 18 FLOVENT, 42 FLOVENT HFA, 42 floxuridine, 14 fluconazole, 11 fludarabine, 14 fludrocortisone, 32 flunisolide spray, 42 fluocinolone acetonide, 48 fluocinolone acetonide crm, oint 0.025%, 44 fluocinolone acetonide oil 0.01%, 44 fluocinolone acetonide soln 0.01%, 44 fluocinonide crm 0.1%, 44 fluocinonide crm, gel, oint, soln 0.05%, 44 fluoride drops, tabs, 40 fluorometholone, 46 fluorouracil, 43 fluorouracil inj, 14 fluoxetine, 23 fluoxetine delayed-rel, 23 fluphenazine, 24 flurandrenolide crm, lotion, oint 0.05%, 44 flurandrenolide tape, 44 flurazepam, 25 flurbiprofen, 8, 46 flutamide, 14 fluticasone, 42 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 44 fluticasone spray, 42 fluticasone, CFC-free aerosol, 42 fluticasone/salmeterol, 42 fluticasone/salmeterol, CFC-free aerosol, 42 fluticasone/umeclidinium/vilanterol, 41

fluticasone/vilanterol, 42 fluvastatin, 19 fluvastatin ext-rel, 19 fluvoxamine, 22 fluvoxamine ext-rel, 22 folic acid, 40 FOLLISTIM AQ, 32 follitropin beta, 32 FOLOTYN, 14 fondaparinux, 37 FORTEO, 30 fosamprenavir, 12 fosinopril, 17 fosinopril/hydrochlorothiazide, 18 FOSRENOL ORAL PACKETS, 33 FRAGMIN, 37 FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING

SYSTEM, 29 frovatriptan, 26 FULPHILA, 37 fulvestrant, 14 furosemide, 20 FUZEON, 11 G gabapentin, 22 galantamine, 23 galantamine ext-rel, 23 galcanezumab-gnlm, 25 GALZIN, 40 GAMMAGARD LIQUID, 39 GAMMAGARD S-D, 39 GAMMAKED, 39 GAMMAPLEX, 39 GAMUNEX-C, 39 ganciclovir, 47 ganciclovir inj, 12 GANIRELIX ACETATE, 32 ganirelix acetate inj, 32 GATTEX, 36 gefitinib, 15 GEL-ONE, 9 GELSYN-3, 9 gemcitabine, 14 gemfibrozil, 19 gentamicin, 43, 46 GENVOYA, 11 GILENYA, 26 GILOTRIF, 15 GLASSIA, 42 glatiramer, 26 glatiramer - Glatopa, 26 glecaprevir/pibrentasvir, 13 GLEOSTINE, 14 glimepiride, 29 glipizide, 29 glipizide ext-rel, 29 glipizide/metformin, 28 GLUCAGON EMERGENCY KIT, 32 glucagon, human recombinant, 32 glucarpidase, 17 glyburide, 29 glyburide, micronized, 29 glyburide/metformin, 28 glycerol phenylbutyrate, 34 GLYXAMBI, 29

56

gonadorelin, 32 goserelin acetate, 15 granisetron, 34 granisetron transdermal, 35 GRANIX, 37 grass mixed pollen allergen extract, 38 griseofulvin microsize, 11 griseofulvin ultramicrosize, 11 guanfacine ext-rel, 25 H HAEGARDA, 38 HALAVEN, 16 halobetasol propionate crm, oint 0.05%, 44 haloperidol, 24 haloperidol decanoate inj, 24 haloperidol lactate inj, 24 HARVONI, 13 HEMLIBRA, 38 HEPAGAM B, 39 hepatitis B immune globulin, 39 HETLIOZ, 25 histrelin acetate, 15, 34 HIZENTRA, 39 homatropine, 47 HUMATE-P, 37 HUMIRA, 38 HUMULIN R U-500, 28 HYALGAN, 9 HYCAMTIN caps, 16 hydralazine, 21 hydrochlorothiazide, 21 hydrocodone/acetaminophen - Vicodin, 9 hydrocodone/acetaminophen - Vicodin ES, 9 hydrocodone/chlorpheniramine/pseudoephedrine, 41 hydrocodone/homatropine, 41 hydrocortisone, 32 hydrocortisone acetate foam, 35 hydrocortisone acetate/pramoxine foam, 36 hydrocortisone butyrate crm 0.1%, 44 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 44 hydrocortisone crm 2.5%, 44 hydrocortisone enema, 35 hydrocortisone lotion 1%, 44 hydrocortisone valerate crm, oint 0.2%, 44 hydrocortisone/aloe polysaccharide/iodoquinol, 45 hydrocortisone/iodoquinol, 45 hydromorphone, 9 hydromorphone ext-rel, 9 hydroxocobalamin, 34 hydroxychloroquine, 39 hydroxyprogesterone caproate, 15 hydroxyurea, 16 hydroxyzine HCl, 22, 41 hydroxyzine pamoate, 22, 41 hyoscyamine sulfate, 35 hyoscyamine sulfate ext-rel, 35 HYPERHEP B S-D, 39 HYPERRHO S-D, 39 HYQVIA, 39 I ibalizumab-uiyk, 12 ibandronate, 30 IBRANCE, 16 ibrutinib, 15 ibuprofen, 8

ibuprofen inj, 8 icatibant, 38 ICLUSIG, 16 idarubicin, 16 idelalisib, 15 IDHIFA, 16 ifosfamide, 16 ifosfamide/mesna, 14 ILARIS, 39 iloprost, 21 imatinib mesylate, 15 IMBRUVICA, 15 imiglucerase, 32 imipenem/cilastatin, 13 imipramine HCl, 23 imipramine pamoate, 23 imiquimod crm 3.75%, crm pump 2.5%, 45 imiquimod crm pump 3.75%, 45 IMLYGIC, 17 immune globulin (human)-ifas, 39 immune globulin, gamma, 39 immune globulin, gamma (IGG), 39 immune globulin, intravenous, 39 immune globulin, subcutaneous, 39 immune globulin/hyaluronidase, 39 IMPAVIDO, 13 incobotulinumtoxinA, 27 INCRELEX, 33 indapamide, 21 indinavir, 12 indomethacin, 8 indomethacin ext-rel, 8 INGREZZA, 27 INLYTA, 15 insulin aspart, 28 insulin aspart protamine 70%/insulin aspart 30%, 28 insulin detemir, 28 insulin glargine, 28 insulin human, 28 insulin isophane human, 28 insulin isophane human 70%/regular 30%, 28 insulin syringes, needles, 29 INTELENCE, 12 interferon alfa-2b, 39 interferon alfa-n3, 45 interferon beta-1a, 26 interferon beta-1b, 26 interferon gamma-1b, recombinant, 39 intrauterine copper contraceptive, 31 INTRON A, 39 INVEGA SUSTENNA, 24 ipratropium nasal spray, 42 ipratropium soln, 40 ipratropium/albuterol soln, 41 irbesartan, 18 irbesartan/hydrochlorothiazide, 18 IRESSA, 15 irinotecan, 16 iron sucrose inj, 40 ISENTRESS, 11 isoniazid, 12 ISOPTO HYOSCINE, 47 isosorbide dinitrate oral, 21 isosorbide dinitrate/hydralazine, 21 isosorbide mononitrate, 21 isosorbide mononitrate ext-rel, 21

57

isotretinoin, 43 itraconazole, 11 ivabradine, 21 ivacaftor, 41 ivermectin, 45 ivosidenib, 17 ixazomib, 17 J JAKAFI, 16 JANUMET, 28 JANUMET XR, 28 JANUVIA, 28 JARDIANCE, 29 JETREA, 47 JEVTANA, 16 JIVI, 37 JUXTAPID, 19 JYNARQUE, 34 K KALBITOR, 38 KALETRA tabs, 12 KALYDECO, 41 KANJINTI, 17 KEPIVANCE, 36 ketoconazole, 43 ketoconazole shampoo 2%, 44 ketoconazole tabs, 11 ketoprofen, 8 ketoprofen ext-rel, 8 ketorolac, 8 ketorolac 0.5%, 46 KEYTRUDA, 15 KINERET, 38 KISQALI, 16 KISQALI FEMARA CO-PACK, 16 KOGENATE FS, 37 KORLYM, 34 KOVALTRY, 37 KUVAN, 33 KYLEENA, 31 KYPROLIS, 16 L lacosamide, 22 lactulose, 35 lamivudine, 12 lamivudine/zidovudine, 11 lamotrigine, 22 lamotrigine ext-rel, 22 lamotrigine orally disintegrating tabs, 22 lancet device, 29 lancets, 29 LANOXIN, 20 lanreotide acetate, 34 lansoprazole + amoxicillin + clarithromycin, 36 lansoprazole delayed-rel, 36 lanthanum carbonate chew tabs, 33 lanthanum carbonate oral packets, 33 lapatinib, 15 larotrectinib, 15 latanoprost, 47 ledipasvir/sofosbuvir, 13 leflunomide, 39 LEMTRADA, 26 lenalidomide, 15

lenvatinib, 15 LENVIMA, 15 letermovir, 12 letrozole, 15 leucovorin calcium, 16 LEUKERAN, 14 leuprolide acetate, 15, 34 leuprolide acetate/norethindrone acetate, 31 levalbuterol inhalation soln, 41 levalbuterol nebulizer soln concentrate, 41 levalbuterol tartrate, CFC-free aerosol, 41 LEVEMIR, 28 levetiracetam, 22 levetiracetam ext-rel, 22 levobunolol, 47 levocarnitine, 30 levofloxacin, 10, 46 levoleucovorin calcium, 16 levonorgestrel/EE - Trivora, 31 levonorgestrel/EE 0.09/20 - Amethyst, 31 levonorgestrel/EE 0.1/20, 30 levonorgestrel/EE 0.1/20 and EE 10, 31 levonorgestrel/EE 0.15/30, 30 levonorgestrel/EE 0.15/30 - Jolessa, 31 levonorgestrel/EE 0.15/30 - Levora, 30 levonorgestrel/EE 0.15/30 and EE 10, 31 levonorgestrel-releasing IUD, 31 levothyroxine, 33 levothyroxine - Levoxyl, 33 L-glutamine oral powder, 38 lidocaine, 45 lidocaine patch, 45 lidocaine viscous, 45 lidocaine/prilocaine, 45 lifitegrast, 47 linaclotide, 35 lindane, 45 linezolid, 13 LINZESS, 35 liothyronine, 33 liraglutide, 28 lisdexamfetamine, 25 lisinopril, 17 lisinopril/hydrochlorothiazide, 18 lithium carbonate, 26 lithium carbonate ext-rel tabs 300 mg, 26 lithium carbonate ext-rel tabs 450 mg, 26 lomitapide, 19 lomustine, 14 LONSURF, 17 loperamide, 34 lopinavir/ritonavir soln, 12 lopinavir/ritonavir tabs, 12 lorazepam, 22 losartan, 18 losartan/hydrochlorothiazide, 18 LOTEMAX (except 0.5% susp), 46 loteprednol, 46 loteprednol 0.2%, 46 loteprednol 0.5% susp, 46 lovastatin, 19 loxapine, 24 LUCENTIS, 47 lumacaftor/ivacaftor, 41 LUMIZYME, 34 LUPANETA PACK, 31

58

LUPRON DEPOT, 15 LUPRON DEPOT-PED, 34 LUTREPULSE, 32 LYNPARZA, 17 LYSODREN, 17 M macitentan, 21 mafenide acetate packets 5%, 43 MAKENA 275 mg, 15 maraviroc, 11 MATULANE, 17 MAVYRET, 13 mecasermin, 33 mechlorethamine gel, 14 meclizine, 34 medroxyprogesterone acetate, 33 medroxyprogesterone acetate 150 mg/mL, 31 mefloquine, 11 megestrol acetate, 15 megestrol acetate susp, 33 MEKINIST, 16 meloxicam, 8 melphalan inj, 14 melphalan tabs, 14 memantine, 23 MENOPUR, 32 menotropins, 32 MEPSEVII, 34 mercaptopurine, 14 mercaptopurine susp, 14 meropenem, 13 mesalamine delayed-rel caps, 35 mesalamine delayed-rel tabs, 35 mesalamine ext-rel caps, 35 mesalamine rectal susp, 35 mesalamine supp, 35 mesna inj, 16 mesna tabs 400 mg, 17 MESNEX, 17 metaproterenol, 41 metformin, 28 metformin ext-rel, 28 methadone, 9 methamphetamine, 25 methazolamide, 20 methenamine hippurate, prophylaxis, 13 methimazole, 33 methotrexate inj, 39 methotrexate oral, 39 methoxsalen oral, 43 methoxy polyethylene glycol/epoetin beta, 37 methylergonovine, 34 methylnaltrexone, 35 methylphenidate, 25 methylphenidate ext-rel, 25 methylprednisolone, 32 metoclopramide, 34 metolazone, 21 metoprolol succinate ext-rel, 20 metoprolol tartrate, 20 metoprolol/hydrochlorothiazide, 20 metreleptin, 34 metronidazole, 37 metronidazole crm 0.75%, 45 metronidazole gel 0.75%, 45

metronidazole gel 1%, 45 metronidazole lotion 0.75%, 45 metronidazole tabs, 13 mexiletine, 18 miconazole nitrate/zinc oxide, 43 MICRHOGAM, 39 MICRHOGAM PLUS, 39 midodrine, 21 midostaurin, 15 mifepristone, 34 MIGERGOT, 25 miglitol, 28 miglustat, 34 miltefosine, 13 minocycline, 10 minocycline ext-rel, 10 minoxidil tabs, 21 MIRCERA, 37 MIRENA, 31 mirtazapine, 23 misoprostol, 36 mitomycin, 16 mitotane, 17 mitoxantrone, 16 modafinil, 26 mometasone, 42 mometasone crm, lotion, oint 0.1%, 44 mometasone spray, 42 mometasone, CFC-free aerosol, 42 mometasone/formoterol, 42 montelukast, 42 morphine, 9 morphine ext-rel, 9 morphine supp, 9 MOVANTIK, 35 MOVIPREP, 35 moxifloxacin, 10, 46 MOZOBIL, 38 MULTAQ, 19 multivitamins/fluoride drops, tabs, 40 multivitamins/fluoride/iron drops, tabs, 40 mupirocin, 43 MVASI, 16 MYALEPT, 34 mycophenolate mofetil, 39 mycophenolate sodium delayed-rel, 39 MYLERAN, 14 MYOBLOC, 27 N NABI-HB, 39 nabumetone, 8 nafarelin, 31 naftifine, 43 naloxegol, 35 naloxone inj, 27 naloxone nasal spray, 27 naltrexone, 26 naltrexone microspheres, 26 naphazoline, 47 naproxen, 8 naproxen sodium, 8 naratriptan, 26 NARCAN, 27 NASCOBAL, 40 NATACYN, 46

59

natalizumab, 26 natamycin, 46 nateglinide, 29 NATPARA, 30 nebivolol, 20 nefazodone, 23 nelarabine, 17 nelfinavir, 12 neomycin/dexamethasone, 46 neomycin/polymyxin B/dexamethasone, 46 neomycin/polymyxin B/gramicidin, 46 neomycin/polymyxin B/hydrocortisone, 48 neomycin/polymyxin B/hydrocortisone susp, 46 neratinib, 15 NERLYNX, 15 NEUPRO, 24 nevirapine, 12 nevirapine ext-rel, 12 NEXAVAR, 16 NEXPLANON, 31 niacin ext-rel, 19 nicardipine, 20 nifedipine ext-rel, 20 nilotinib, 15 nilutamide, 14 nimodipine, 20 NINLARO, 17 nintedanib, 42 NIPENT, 14 niraparib, 17 nisoldipine ext-rel, 20 nitazoxanide, 13 nitisinone, 32 nitrofurantoin ext-rel, 13 nitrofurantoin macrocrystals, 13 nitroglycerin lingual spray, 21 nitroglycerin sublingual, 21 nitroglycerin transdermal, 21 NITYR, 32 nivolumab, 17 nizatidine, 35 NORDITROPIN, 33 norelgestromin/EE, 31 norethindrone, 31 norethindrone acetate, 33 norethindrone acetate/EE 1.5/30, 30 norethindrone acetate/EE 1.5/30 and iron, 30 norethindrone acetate/EE 1/20, 30 norethindrone acetate/EE 1/20 and iron, 30 norethindrone acetate/EE and iron, 31 norethindrone/EE, 31 norethindrone/EE 0.4/35, 30 norethindrone/EE 0.5/35, 30 norethindrone/EE 1/35, 30 norgestimate/EE, 31 norgestimate/EE 0.25/35, 30 norgestrel/EE 0.3/30 - Cryselle, 30 norgestrel/EE 0.3/30 - Low-Ogestrel, 30 norgestrel/EE 0.5/50, 30 NORPACE CR, 19 nortriptyline, 23 NOVAREL, 32 NOVOLIN 70/30, 28 NOVOLIN N, 28 NOVOLIN R, 28 NOVOLOG, 28

NOVOLOG MIX 70/30, 28 NOVOSEVEN RT, 38 NOXAFIL (except 100 mg delayed-rel tabs), 11 NPLATE, 38 NUEDEXTA, 27 NUVARING, 31 nystatin, 11, 43 O obeticholic acid, 36 OCALIVA, 36 ocrelizumab, 26 OCREVUS, 26 ocriplasmin, 47 octreotide acetate, 34 ODEFSEY, 11 ODOMZO, 17 OFEV, 42 ofloxacin, 10, 46 ofloxacin otic, 48 olanzapine, 24 olanzapine/fluoxetine, 24 olaparib, 17 olmesartan, 18 olmesartan/amlodipine/hydrochlorothiazide, 18 olmesartan/hydrochlorothiazide, 18 olopatadine, 46 olopatadine spray, 42 omacetaxine mepesuccinate, 17 omalizumab, 42 omega-3 acid ethyl esters, 19 omeprazole delayed-rel, 36 onabotulinumtoxinA, 27 ondansetron, 34 ondansetron orally disintegrating tabs, 34 ONETOUCH LANCETS, 29 ONETOUCH METERS AND KITS, 29 ONETOUCH TEST STRIPS, 29 OPDIVO, 17 OPSUMIT, 21 ORALAIR, 38 ORENITRAM, 21 ORFADIN, 32 ORKAMBI, 41 oseltamivir, 13 osimertinib, 16 OTEZLA, 38 OVIDREL, 32 oxaliplatin, 16 oxaprozin, 8 oxazepam, 22 oxcarbazepine, 22 OXERVATE, 47 oxiconazole, 43 oxybutynin, 36 oxybutynin ext-rel, 36 oxycodone, 9 oxycodone concentrate 20 mg/mL, 9 oxycodone soln, 9 oxycodone/acetaminophen 5/325, 9 oxymorphone, 9 OZEMPIC, 28 P paclitaxel, 16 palbociclib, 16 palifermin, 36

60

paliperidone ext-rel, 24 paliperidone palmitate ext-rel inj, 24 palivizumab, 13 palonosetron, 34 pamidronate, 30 pancrelipase, 36 pancrelipase delayed-rel, 36 panobinostat, 17 PANRETIN, 45 pantoprazole delayed-rel, 36 PANZYGA, 39 PARAGARD T 380A, 31 parathyroid hormone (recombinant), 30 paricalcitol, 33 paroxetine HCl, 23 paroxetine HCl ext-rel, 23 pasireotide, 34 pazopanib, 16 peg 3350/electrolytes, 35 pegademase, bovine, 34 PEGASYS, 39 pegfilgrastim-cbqv, 37 pegfilgrastim-jmdb, 37 peginterferon alfa-2a, 39 peginterferon alfa-2b, 39 peginterferon beta-1a, 26 PEGINTRON, 39 pegvisomant, 34 pembrolizumab, 15 pemetrexed, 14 penicillin VK, 10 PENTASA, 35 pentosan polysulfate sodium, 37 pentostatin, 14 pentoxifylline ext-rel, 38 perindopril, 17 PERJETA, 17 permethrin 5%, 45 perphenazine, 24 pertuzumab, 17 phenazopyridine, 37 phenelzine, 23 phenobarbital, 22 phenylephrine, 46 phenytoin, 22 phenytoin sodium extended, 22 phytonadione, 40 pilocarpine tabs, 36 pimecrolimus, 44 pindolol, 20 pioglitazone, 28 pioglitazone/glimepiride, 28 pioglitazone/metformin, 28 piperacillin/tazobactam, 10 pirfenidone, 42 piroxicam, 8 PLEGRIDY, 26 PLEGRIDY PEN, 26 plerixafor, 38 podofilox, 45 polymyxin B/bacitracin, 46 polymyxin B/trimethoprim, 46 pomalidomide, 15 POMALYST, 15 ponatinib, 16 posaconazole (except 100 mg delayed-rel tabs), 11

posaconazole delayed-rel tabs 100 mg, 11 potassium chloride ext-rel, 40 potassium chloride liquid, 40 potassium chloride powder, 40 potassium citrate ext-rel, 37 pralatrexate, 14 pramipexole, 24 pramipexole ext-rel, 24 pramlintide, 28 prasugrel, 38 pravastatin, 19 prazosin, 18 PRED MILD, 46 prednisolone, 32 prednisolone acetate 0.12%, 46 prednisolone acetate 1%, 46 prednisolone phosphate 1%, 46 prednisolone sodium phosphate, 32 prednisolone sodium phosphate orally disintegrating tabs, 32 prednisolone syrup, 32 prednisone, 32 pregabalin, 25 PREGNYL, 32 PREMARIN, 31 PREMARIN crm, 32 PREMPHASE, 32 PREMPRO, 32 prenatal vitamins/folic acid, 40 PRENATE ELITE, 40 PREVYMIS, 12 PREZCOBIX, 11 PREZISTA, 12 PRIALT, 9 PRIFTIN, 12 primaquine, 11 primidone, 22 PROAIR HFA, 41 PROAIR RESPICLICK, 41 probenecid, 8 procarbazine, 17 prochlorperazine, 34 PROCTOFOAM-HC, 36 PROCYSBI, 34 progesterone vaginal inserts, 33 progesterone, micronized, 33 PROLEUKIN, 16 PROLIA, 30 PROMACTA, 38 promethazine, 34, 41 propafenone ext-rel, 18 propantheline 15 mg, 35 propranolol, 20 propranolol ext-rel, 20 propylthiouracil, 33 protriptyline, 23 PULMICORT FLEXHALER, 42 PULMOZYME, 41 PURIXAN, 14 PYLERA, 36 pyrazinamide, 12 pyridostigmine ext-rel tabs 180 mg, 26 pyridostigmine syrup, 26 pyridostigmine tabs 60 mg, 26 pyrimethamine, 11

61

Q QTERN, 29 QUADRAMET, 17 quetiapine, 24 quetiapine ext-rel, 24 quinapril, 17 quinapril/hydrochlorothiazide, 18 quinidine gluconate ext-rel, 19 QVAR, 42 R rabeprazole delayed-rel, 36 RADICAVA, 27 raloxifene, 33 raltegravir, 11 ramelteon, 25 ramipril, 17 ramucirumab, 17 ranibizumab, 47 ranitidine, 35 ranolazine ext-rel, 21 rasagiline, 24 rasburicase, 14 RAVICTI, 34 REBIF, 26 REBIF REBIDOSE, 26 RECOMBINATE, 37 regorafenib, 16 REGRANEX, 45 RELENZA, 13 RELISTOR, 35 repaglinide, 29 repaglinide/metformin, 29 REPATHA, 19 RESCRIPTOR, 12 RESTASIS, 47 RETACRIT, 37 retapamulin, 43 REVCOVI, 34 REVLIMID, 15 Rho (D) immune globulin, 39 RHOGAM, 39 RHOGAM PLUS, 39 ribavirin caps, 13 ribavirin caps - Ribasphere, 13 ribavirin tabs, 13 ribociclib, 16 ribociclib + letrozole, 16 rifabutin, 13 rifampin, 12 rifampin/isoniazid/pyrazinamide, 12 rifapentine, 12 RIFATER, 12 rifaximin, 13 rilonacept, 39 rilpivirine, 12 riluzole, 27 rimabotulinumtoxinB, 27 rimantadine, 13 rimexolone, 46 riociguat, 21 risedronate, 30 risedronate delayed-rel, 30 RISPERDAL CONSTA, 24 risperidone, 24 risperidone long-acting inj, 24

risperidone orally disintegrating tabs, 24 ritonavir tabs, 12 rivaroxaban, 37 rivastigmine, 23 rivastigmine transdermal, 23 RIXUBIS, 38 rizatriptan, 26 rolapitant, 35 romiplostim, 38 ropinirole, 24 ropinirole ext-rel, 24 rosuvastatin, 19 rotigotine transdermal, 24 RUBRACA, 17 rucaparib, 17 RUCONEST, 38 rufinamide, 22 ruxolitinib, 16 RYDAPT, 15 S sacubitril/valsartan, 21 salmeterol xinafoate, 41 samarium sm 153 lexidronam, 17 SAMSCA, 34 SANCUSO, 35 SANDOSTATIN LAR, 34 sapropterin, 33 scopolamine, 47 scopolamine transdermal, 35 selegiline caps, 24 selegiline orally disintegrating tabs, 24 selenium sulfide shampoo 2.5%, 44 SELZENTRY, 11 semaglutide, 28 SEREVENT DISKUS, 41 SEROSTIM, 33 sertraline, 23 sevelamer carbonate, 33 sevelamer HCl, 33 SIGNIFOR, 34 sildenafil tabs, oral susp, 21 silodosin, 36 silver sulfadiazine, 43 SIMBRINZA, 47 simvastatin, 19 sirolimus, 39 sitagliptin phosphate, 28 sitagliptin/metformin, 28 sitagliptin/metformin ext-rel, 28 SIVEXTRO tabs, 13 SKLICE, 45 SKYLA, 31 sodium ferric gluconate inj, 40 sodium fluoride, 45 sodium hyaluronate, 9 sodium oxybate, 26 sodium phenylbutyrate, 33 sodium polystyrene sulfonate, 40 sodium sulfate/potassium sulfate/magnesium sulfate, 35 sofosbuvir, 13 sofosbuvir/velpatasvir, 13 sofosbuvir/velpatasvir/voxilaprevir, 13 SOFTCLIX LANCET DEVICE, 29 SOFTCLIX LANCETS, 29 SOFTTOUCH LANCET DEVICE, 29

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SOFTTOUCH LANCETS, 29 SOLESTA, 36 solifenacin, 36 somatropin, 33 SOMATULINE DEPOT, 34 SOMAVERT, 34 sonidegib, 17 sorafenib, 16 sotalol, 19 SOVALDI, 13 spinosad, 45 SPIRIVA, 40 SPIRIVA RESPIMAT, 40 spironolactone, 18 spironolactone/hydrochlorothiazide, 21 SPRYCEL, 15 stavudine, 12 STIMATE, 38 STIOLTO RESPIMAT, 41 STIVARGA, 16 STRENSIQ, 34 streptozocin, 14 STRIBILD, 11 SUBLOCADE, 27 sucralfate, 36 sucralfate susp, 36 sulfacetamide soln 10%, 46 sulfacetamide/prednisolone phosphate 10%/0.25%, 46 sulfacetamide/sulfur, 45 sulfamethoxazole/trimethoprim, 13 sulfamethoxazole/trimethoprim DS, 13 sulfasalazine, 35 sulfasalazine delayed-rel, 35 sulindac, 8 sumatriptan, 26 sunitinib, 16 SUPARTZ FX, 9 SUPPRELIN LA, 34 SUPRAX (except caps, 100 mg/5 mL, 200 mg/5 mL susp), 10 SUPREP, 35 SUTENT, 16 SYMBICORT, 42 SYMDEKO, 41 SYMLINPEN, 28 SYMTUZA, 11 SYNAGIS, 13 SYNAREL, 31 SYNJARDY, 29 SYNJARDY XR, 29 SYNRIBO, 17 SYNTHROID, 33 T TABLOID, 14 tacrolimus, 39, 44 tacrolimus ext-rel, 39 tadalafil tabs 2.5 mg, 5 mg, 36 tadalafil tabs 20 mg, 21 tadalafil tabs 20 mg - Alyq, 21 TAFINLAR, 15 TAGRISSO, 16 talazoparib, 17 taliglucerase alfa, 34 talimogene laherparepvec, 17 TALZENNA, 17 tamoxifen, 14

tamsulosin, 36 TARGRETIN gel, 16 TASIGNA, 15 tasimelteon, 25 tazarotene crm 0.1%, 43 tbo-filgrastim, 37 TECFIDERA, 26 tedizolid tabs, 13 teduglutide, 36 TEKTURNA HCT, 20 telbivudine, 13 telmisartan, 18 telmisartan/hydrochlorothiazide, 18 telotristat, 36 temazepam, 25 temozolomide, 14 temsirolimus, 15 teniposide, 16 tenofovir alafenamide, 13 tenofovir disoproxil fumarate (except 300 mg tabs), 12 tenofovir disoproxil fumarate tabs 300 mg, 12 TEPADINA 100 mg, 14 terazosin, 18 terbinafine tabs, 11 terbutaline, 41 terconazole crm, 37 terconazole supp 80 mg, 37 teriflunomide, 26 teriparatide, 30 tesamorelin, 34 testosterone cypionate, 27 testosterone enanthate, 27 testosterone gel, 27 testosterone soln, 27 testosterone transdermal, 27 testosterone undecanoate inj, 27 tetrabenazine, 26 tetracycline, 10 tezacaftor/ivacaftor + ivacaftor, 41 thalidomide, 15 THALOMID, 15 THEO-24, 42 theophylline ext-rel caps, 42 theophylline ext-rel tabs, 42 theophylline liquid, 42 thioguanine, 14 thioridazine, 24 thiotepa, 14 thiotepa 100 mg, 14 thiothixene, 24 THYROGEN, 34 thyrotropin alfa, 34 tiagabine, 22 TIBSOVO, 17 TICE BCG, 16 tigecycline, 13 timolol maleate, 47 timolol maleate gel, 47 tinidazole, 13 tiotropium, 40 tiotropium/olodaterol, 41 tipranavir, 12 TIVICAY, 11 TOBRADEX OINTMENT, 46 tobramycin, 46 tobramycin inhalation soln, 41

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tobramycin/dexamethasone oint 0.3%/0.1%, 46 tobramycin/dexamethasone susp 0.3%/0.1%, 46 tobramycin/loteprednol, 46 tocilizumab, 38 tolcapone, 24 tolterodine, 36 tolterodine ext-rel, 36 tolvaptan, 34 topiramate, 22 topiramate ext-rel, 22 topotecan caps, 16 topotecan inj, 16 toremifene, 14 torsemide, 20 trabectedin, 14 tramadol, 9 tramadol ext-rel, 9 tramadol/acetaminophen, 9 trametinib, 16 trandolapril, 17 trandolapril/verapamil ext-rel, 17 tranexamic acid, 38 tranylcypromine, 23 trastuzumab-anns, 17 TRAVATAN Z, 47 travoprost, 47 trazodone, 23 TRELEGY ELLIPTA, 41 TRELSTAR, 15 TRELSTAR DEPOT, 15 TRELSTAR LA, 15 treprostinil, 21 treprostinil ext-rel, 21 tretinoin, 43 tretinoin gel microsphere, 43 triamcinolone acetonide crm 0.5%, 44 triamcinolone acetonide crm, lotion 0.025%, 44 triamcinolone acetonide crm, lotion, oint 0.1%, 44 triamcinolone acetonide topical spray, 44 triamcinolone oint 0.05%, 44 triamcinolone paste, 45 triamterene/hydrochlorothiazide, 21 TRIANEX, 44 triazolam, 25 trientine, 34 trifluoperazine, 24 trifluridine, 47 trifluridine/tipiracil, 17 trihexyphenidyl, 24 trimethobenzamide, 35 trimethoprim, 13 TRIPTODUR, 34 triptorelin pamoate, 15, 34 TRIUMEQ, 11 TROGARZO, 12 trospium, 37 trospium ext-rel, 37 TRULICITY, 28 TRUVADA, 11 TYBOST, 11 TYKERB, 15 TYSABRI, 26 TYZEKA, 13 U UDENYCA, 37

umeclidinium/vilanterol, 41 urine test strips, 29 ursodiol, 35 V valacyclovir, 13 valbenazine, 27 VALCHLOR, 14 valganciclovir, 12 valproic acid, 22 valrubicin, 16 valsartan, 18 valsartan/hydrochlorothiazide, 18 vancomycin, 13 vancomycin oral soln, 13 vandetanib, 16 VANTAS, 15 varenicline, 27 varicella zoster immune globulin, 39 VARIZIG, 39 VARUBI, 35 velaglucerase alfa, 34 VEMLIDY, 13 vemurafenib, 16 VENCLEXTA, 17 venetoclax, 17 venlafaxine, 23 venlafaxine ext-rel, 23 venlafaxine ext-rel tabs, 23 VENOFER, 40 VENTAVIS, 21 verapamil, 20 verapamil ext-rel, 20 VERDESO, 44 verteporfin, 47 VERZENIO, 15 vestronidase alfa-vjbk, 34 VEXOL, 46 VICTOZA, 28 VIDEX soln, 12 vigabatrin, 22 vigabatrin powder - Vigadrone, 22 VIMPAT, 22 vinblastine, 16 vincristine, 16 vinorelbine, 16 VIOKACE, 36 VIRACEPT, 12 VIREAD (except 300 mg tabs), 12 vismodegib, 17 VISUDYNE, 47 vitamin ADC/fluoride drops, 40 vitamin ADC/fluoride/iron drops, 40 VITRAKVI, 15 VIVITROL, 26 VIZIMPRO, 15 VORAXAZE, 17 voriconazole, 11 vorinostat, 17 VOSEVI, 13 VOTRIENT, 16 VPRIV, 34 VYVANSE, 25 W warfarin, 37

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X XALKORI, 15 XARELTO, 37 XEOMIN, 27 XERMELO, 36 XGEVA, 30 XIAFLEX, 45 XIFAXAN, 13 XIGDUO XR, 29 XIIDRA, 47 XOFLUZA, 13 XOLAIR, 42 XTANDI, 14 XYREM, 26 Y YONDELIS, 14 YONSA, 14 Z zafirlukast, 42 zaleplon, 25 ZALTRAP, 17 zanamivir, 13 ZANOSAR, 14 ZARXIO, 37

ZEJULA, 17 ZELAPAR, 24 ZELBORAF, 16 ZEMAIRA, 42 ziconotide, 9 zidovudine, 12 zinc acetate, 40 ziprasidone, 24 ZIRGAN, 47 ziv-aflibercept, 17 ZOLADEX, 15 zoledronic acid, 30 ZOLINZA, 17 zolmitriptan, 26 zolpidem, 25 zolpidem ext-rel, 25 zonisamide, 22 ZORBTIVE, 33 ZORTRESS, 40 ZUBSOLV, 27 ZYCLARA crm 3.75%, crm pump 2.5%, 45 ZYDELIG, 15 ZYKADIA, 15 ZYLET, 46

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fep blue focus formulary (907) effective january 1, …...fep® blue focus formulary (907) effective...

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