If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com.

A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association.

CRP1811_0878 EME48802 MG48278M (Revise Date 01/01/2019)

BlueCross BlueShield of Western New York Formulary 1Please bring this guide with you the next time you visit your doctor.

Inside front cover

ii

IntroductIon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

understandIng the symbols used throughout thIs book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

usIng thIs formulary book to help contaIn costs . iv

Save Money on Your Prescription Drugs . . . . . . . . . . . . . . . . . iv

Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . v

sectIon 1 — therapeutIc drug categorIes . . . . . . . . . . 1

sectIon II — Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

TABLE OF CONTENTS

iii

The BlueCross BlueShield of Western New York Formulary 1 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price.

IntroductIon

BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

understandIng the symbols used throughout thIs book

Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows:

Key

P = A step edit applies to this drug. Step therapy means that in order to receive the medication with a step edit, a preferred medication must be tried first.

z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication.

= Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately.

u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay.

+ = Access restricted to CVS Specialty pharmacy for members with an exclusive CVS Specialty pharmacy network. Medications must be obtained through specialty pharmacy.

> = Access restricted to Accredo specialty pharmacy for members with an exclusive Accredo specialty pharmacy network. Medications must be obtained through specialty pharmacy.

o = Customer Home Delivery. The medication should be obtained through the mail service pharmacy. The medication is subject to a retail refill allowance.

iv

usIng thIs formulary book to help contaIn costs

Many employers, benefit sponsors, and individuals may use the formulary to help manage the overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient medications.

Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed formulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card.

Save Money on Your Prescription Drugs

Here’s what you can do to save money:

1. Bring this member guide to your doctor and review the cost-saving information below.

2. Ask your doctor whether a drug listed in this guide is right for you.*

Lowest cost to you Highest cost to you

The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage.

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan.

Contraceptive Coverage under New York Insurance Law

Contraceptives (for members whose benefits align with contraceptive coverage requirements under New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives with a generic equivalent are covered at the copayment based on your plan design unless deemed medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on the prescription in order for the brand-name contraceptive with a generic equivalent to be considered medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC) products are covered only when prescribed by a licensed health care provider and require a valid prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan.

Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide for specific product examples.

Customer Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance is exhausted for members with Customer Home Delivery Benefit.

Tier 3 Tier 2 Tier 1

* Some plan designs require that you use a Tier 1 generic drug if a generic is available.

Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 1. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.

v

Finding Medications in the Guide

This guide lists medications two different ways:

Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)

Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).

Section 2: Alphabetically by drug name. Use this list to find your drug.

Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the BlueCross BlueShield of Western New York Formulary 1. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com.

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

Allergy/Cough & ColdAntihistamines & Decongestants brompheniramine/phenylephrine 1 brompheniramine/pseudoephedrine 1o cetirizine 1 clemastine 1 cyproheptadine 1 dexchlorpheniramine 1 diphenhydramine 1 hydroxyzine HCl 1 hydroxyzine pamoate 1zo levocetirizine 1 loratadine 1 loratadine-D 1 pseudoephedrine 1 Semprex-D 2zo Clarinex-D 3zo desloratadine 3z Grastek 3z Odactra 3+z Oralair 3z Ragwitek 3Expectorant & Cough Products benzonatate 1 guaifenesin/codeine 1 hydrocodone/chlorpheniramine 1 hydrocodone/homatropine 1 promethazine/codeine 1 promethazine/DM 1 promethazine/phenylephrine/codeine 1 pseudoephedrine/codeine 1 Cardec/DM 3 Guaifenesin DM 3 Hycodan 3 Rondec DM/TR 3 Vituz 3Mucolytic Agents acetylcysteine inh soln. 1Nasal Medications azelastine nasal spray 1 budesonide nasal spray 1 Clarispray 1 Flonase Allergy Relief 1 Flonase Sensimist 1zo fluticasone nasal spray 1 ipratropium nasal spray 1zo mometasone nasal spray 1z Nasacort Allergy 24HR 1 Rhinocort Allergy 1 triamcinolone nasal spray 1 Atrovent Nasal Spray 3Pzo Beconase AQ 3 Dymista 3zo flunisolide nasal spray 3Pzo Nasacort AQ 3Pzo Omnaris 3Pzo Qnasl 3z Xhance 3Pzo Zetonna 3Alzheimer Agentszo donepezil 1 ergoloid mesylates 1zo galantamine 1zo galantamine ER 1zo memantine 1zo memantine ER 1zo rivastigmine 1zo rivastigmine patch 1z Namzaric 2Bladder/KidneyAcidifiers K-Phos 3Alkalinizers citric acid/sod citrate 1 potassium citrate 1 Oracit 3Analgesics phenazopyridine 1Anticholinergicsz oxybutynin 1z oxybutynin ER 1z Oxytrol for Women 1z tolterodine 1z tolterodine ER 1z trospium 1

z trospium ER 1z Myrbetriq 2z Toviaz 2z Vesicare 2Pz Detrol 3Pz Detrol LA 3Pz Ditropan XL 3Pz Enablex 3Pz Gelnique 3Pz Oxytrol 3Pz Sanctura 3Pz Sanctura XR 3Cholinergic Agents Urecholine 3Miscellaneousz> Jynarque 3BloodAnticoagulants/antithrombotics anagrelide 1o aspirin/dipyridamole 1o clopidogrel 1o dipyridamole 1 enoxaparin 1 fondaparinux sodium 1 heparin 1 jantoven 1o prasugrel 1o ticlopidine 1 warfarin 1o Brilinta 2 Coumadin 2 Eliquis 2 Fragmin 2z Pradaxa 2 Xarelto 2zo Zontivity 2 Bevyxxa 3zo Durlaza 3 Innohep 3z Savaysa 3Other Blood Modifierso cilostazol 1 pentoxifylline 1z trientine 1+>z Actimmune 2+> Aranesp 2+> Exjade 2+> Jadenu 2+> Leukine 2o Miacalcin inj. 2> Neulasta 2+> Neupogen 2+> Procrit 2+>z Promacta 2+>z Revlimid 2 Strensiq 2+> Alprolix 3+>z Doptelet 3+> Eloctate 3z Endari 3+> Epogen 3 Ferriprox 3 Fulphila 3+> Granix 3+> Hemlibra 3 Mircera 3+>z Mulpleta 3+ Nivestym 3 Omontys 3 Retacrit 3z Tavalisse 3+> Zarxio 3z Zontivity 3Cancer DrugsAlkylating Agents cyclophosphamide 1 Alkeran 2 CeeNu 2 Emcyt 2 Hexalen 2 Leukeran 2 Myleran 2Antimetabolites+> capecitabine 1 mercaptopurine 1 methotrexate 1

Purixan 2 Trexall 3z Xatmep 3Hormones anastrozole 1 bicalutamide 1 exemestane 1 flutamide 1 letrozole 1 leuprolide 1 megestrol 1zo raloxifene 1 tamoxifen 1 Fareston 2Miscellaneous etoposide 1 hydroxyurea 1+>z imatinib 1 nilutamide 1+> temozolomide 1+>z Afinitor 2+>z Alecensa 2+>z Arcalyst 2+>z Bosulif 2+>z Cabometyx 2z Caprelsa 2z Cometriq 2+>z Cotellic 2+>z Erivedge 2+>z Farydak 2>z Gilotrif 2+> Hycamtin 2+>z Ibrance 2z Iclusig 2z Imbruvica 2+>z Inlyta 2+> Intron A 2+>z Iressa 2+>z Jakafi 2>z Lenvima 2+>z Lonsurf 2>z Lynparza 2 Lysodren 2 Matulane 2+>z Mekinist 2 Mesnex 2+>z Nexavar 2+>z Ninlaro 2+>z Odomzo 2+>z Pomalyst 2+>z Sprycel 2+> Stivarga 2+>z Sutent 2+>z Sylatron 2z Synribo 2+>z Tafinlar 2+>z Tagrisso 2+>z Tarceva 2+>z Tasigna 2+> Thalomid 2+>z Tykerb 2>z Valchlor 2+>z Votrient 2+>z Xalkori 2+>z Xtandi 2+>z Zelboraf 2+>z Zolinza 2+z Zydelig 2+>z Zykadia 2+>z Zytiga 2+>z Alunbrig 3z Braftovi 3z Calquence 3 Copiktra 3+>z Erleada 3+>z Idhifa 3+>z Kisqali 3+>z Kisqali Femara Co-Pack 3z Mektovi 3+>z Nerlynx 3+z Rubraca 3z Rydapt 3 Talzenna 3+> Temodar 3z Tibsovo 3z Venclexta 3+>z Verzenio 3

+ Vizimpro 3z Yonsa 3z Zejula 3Rexinoids+> bexarotene 1+> Targretin gel 3DiabetesPlease refer to your plan documents to confirm your cost share for diabetic drugs. Cost share may vary by plan.

Antidiabetic Agents, Injectablez Bydureon 2z Byetta 2 Humalog insulin 2 Humulin (all types) 2 Lantus 2z Symlin 2 Toujeo 2z Victoza 2P Admelog 3z Adlyxin 3P Apidra 3 Basaglar 3P Fiasp 3P Levemir 3P Novolin 3P Novolog 3z Ozempic 3z Soliqua 3z Tanzeum 3P Tresiba 3z Trulicity 3z Xultophy 3Antidiabetic Agents, Glucose Elevating agents acarbose 1 chlorpropamide 1z glimepiride 1 glipizide 1z glipizide ER 1z glipizide/metformin 1 glyburide 1 glyburide micronized 1 metformin 1z metformin ER (generic Glucophage XR) 1z metformin/glyburide 1z nateglinide 1z pioglitazone/metformin 1z repaglinide 1 tolazamide 1 tolbutamide 1z Avandamet 2z Avandaryl 2z Avandia 2z Duetact 2z Farxiga 2 GlucaGen 2 Glucagon 2z Glyxambi 2z Invokamet 2z Invokamet XR 2z Invokana 2z Janumet 2z Janumet XR 2z Januvia 2z Jardiance 2 Jentadueto 2z Jentadueto XR 2 Juvisync 2 Riomet solution 2z Synjardy 2z Synjardy XR 2 Tradjenta 2z Xigduo XR 2 Afrezza 3P Fortamet 3Pz Glumetza 3P Kazano 3P Kombiglyze XR 3Pz metformin ER (not generic

Glucophage XR) 3 miglitol 3P Nesina 3P Onglyza 3P Oseni 3

TIER TIER TIER TIER

1

Section i — therapeutic drug categorieS

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

2

z Qtern 3 repaglinide/metformin 3z Segluromet 3z Steglatro 3z Steglujan 3Diabetic SuppliesPlease refer to your plan documents to confirm your cost share for diabetic supplies. Cost share may vary by plan. Test strips other than OneTouch require prior authorization. OneTouch Test Strips P Accu-Chek P Ascensia Breeze P Contour P Freestyle P Precision P TRUEtest P TRUEtrack EarAnti-infective Agents acetic acid otic 1 acetic acid/aluminum acetate 1 ciprofloxacin otic 1 ofloxacin otic 1 Domeboro 3 Xtoro 3Anti-infective/Anti-inflammatory combinations acetic acid HC otic 1 neomycin/polymyxin/HC otic 1 Ciprodex 2 Cipro HC 3EyeAntiallergy Agents (Eye) azelastine ophth 1 cromolyn ophth 1 olopatadine ophth 1 Alomide 2 Alrex 2 Bepreve 2 Pataday 2 ketotifen opthalmic solution 3 Pazeo 3 Zaditor 3 Zerviate 3Anti-infective Agents bacitracin ophth 1 bacitracin/polymyxin 1 ciprofloxacin ophth 1 erythromycin ophth 1 gatifloxacin 1 gentamicin ophth 1 neomycin/bacitracin/poly B 1 ofloxacin ophth 1 polymyxin B/TMP 1 sulfacetamide 10% 1 tobramycin soln 1 Besivance 2 Moxeza 2 Tobrex ointment 2 Vigamox 2 Azasite 3 Ciloxan 3 Tobrex solution 3Anti-inflammatory fluorometholone ophth 1 prednisolone acetate 1 prednisolone sod phosphate 1 FML Forte 2 FML S.O.P. 2 Lotemax 2 Pred Mild 2 Flarex 3 Maxidex 3Anti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B 1 neomycin/bacitracin/poly B/HC 1 sulfacetamide/prednisolone ophth 1 tobramycin/dexameth 1 Tobradex ointment 2 Tobradex ST 2 Zylet 2 Maxitrol ophth 3 Pred-G 3

Antiviralz famciclovir ophth 1 trifluridine 1Beta-Blockers (Eye)o betaxolol HCl 1o carteolol 1o levobunolol 1o metipranolol 1o timolol 1o Betoptic-S 2o Istalol 3Carbonic Anhydrase Inhibitorso dorzolamide 2% eye drops 1o dorzolamide/timolol eye drops 1o Azopt 2Mioticso pilocarpine 1 Phospholine Iodide 2Miscellaneouso Combigan 2 Cystaran 2z Restasis 2z Xiidra 2z Cequa 3Po Rhopressa 3Mydriatics atropine sulfate ophth 1 homatropine 1 tropicamide 1NSAIDs bromfenac 1 diclofenac 1 flurbiprofen ophth 1 Ilevro 2 Nevanac 2 Prolensa 2 Acular PF 3Prostaglandin Analogues/Prostamines bimatoprost 0.03% 1o latanoprost 1o travoprost 1o Lumigan 0.01% 2P Izba 3Po Rescula 3Po Travatan Z 3Po Vyzulta 3Po Xalatan 3Po Zioptan 3Sympathomimeticso brimonidine 1o Alphagan P 0.1% 2Vasoconstrictors naphazoline 1 phenylephrine ophth 1Gout allopurinol 1 colchicine/probenecid 1 probenecid 1 Colcrys 2z Mitigare 2z Uloric 2z Duzallo 3Pz Zurampic 3HeartAngiotensin Converting Enzyme Inhibitorso benazepril 1o captopril 1o enalapril 1o fosinopril 1o lisinopril 1o moexipril 1o perindopril 1o quinapril 1o ramipril 1o trandolapril 1zo Epaned 3zo Qbrelis 3Angiotensin II Antagonistszo eprosartan 600mg 1zo irbesartan 1zo losartan 1zo olmesartan 1

zo telmisartan 1zo valsartan 1zo Edarbi 3Pz Prexxartan 3Anti-Adrenergic Blockers Centrally Actingo clonidine, oral, patch 1o guanfacine 1o methyldopa 1 midodrine 1o phenoxybenzamine 1+>z Northera 2Anti-Adrenergic Blockers Peripheralo doxazosin 1o prazosin 1o terazosin 1o Cardura XL 3Antiarrhythmicso amiodarone 1 digoxin 1o disopyramide 1o flecainide 1o mexiletine 1 procainamide 1o propafenone 1o propafenone SR 1o quinidine gluconate 1o quinidine sulfate SR 1o sotalol 1 Lanoxin 2o Multaq 2o dofetilide 3o Norpace CR 3Antilipidemicszuo atorvastatin calcium 1o cholestyramine 1o colestipol 1o colesevelam 1zo ezetimibe 1o fenofibrate 1o fenofibric acid, tab 1o gemfibrozil 1zuo lovastatin 1o niacin ER 1zo niacin/simvastatin 1zuo pravastatin 1zo rosuvastatin 1zuo simvastatin 1o Advicor 2o Colestid 2+>z Kynamro 2o Lipofen 2o Livalo 2+>z Praluent 2+>z Repatha 2 Vascepa 2zo Altoprev 3z Epanova 3zo ezetimibe-simvastatin 3zo fenofibric acid, capsule DR 3zo fluvastatin 3>z Juxtapid 3z Nikita 3z omega-3 acid ethyl esters 3z Omtryg 3zo Zypitamag 3Beta Blockerso acebutolol 1o atenolol 1 betaxolol 1o bisoprolol 1o carvedilol 1o carvedilol ER 1o labetalol 1o metoprolol 1o metoprolol ER 1o metoprolol/HCTZ 1o nadolol 1o pindolol 1o propranolol 1o timolol 1o Bystolic 2o Innopran XL 2 Hemangeol 3Calcium Channel Blockerso amlodipine 1o cartia XT 1

o diltia XT 1o diltiazem 1o diltiazem CD/SR/ER/XR 1o felodipine ER 1o isradipine 1o nicardipine 1o nifediac CC 1o nifedical XL 1o nifedipine 1o nifedipine SR 1o nimodipine 1o nisoldipine 1o verapamil/SR 1 Dynacirc/CR 3zo Nymalize 3Combination Anti-Hypertensivezo amlodipine/atorvastatin 1o amlodipine/benazepril 1o amlodipine/valsartan/HCTZ 1o atenolol/chlorthalidone 1o benazepril/HCTZ 1o bisoprolol/HCTZ 1zo candesartan/HCTZ 1o captopril/HCTZ 1o enalapril/HCTZ 1o fosinopril/HCTZ 1zo irbesartan/HCTZ 1o lisinopril/HCTZ 1zo losartan/HCTZ 1o methyldopa/HCTZ 1o metoprolol/HCTZ 1zo olmesartan/amlodipine 1zo olmesartan/amlodipine/HCTZ 1zo olmesartan/HCTZ 1o propranolol/HCTZ 1o quinapril/HCTZ 1zo telmisartan/HCTZ 1zo valsartan/HCTZ 1zo Byvalson 2Pzo Tekturna 2Pzo Tekturna HCT 2zo amlodipine/valsartan 3Pz Amturnide 3zo Edarbyclor 3zo Prestalia 3zo telmisartan/amlodipine 3o trandolapril/verapamil 3Diureticso acetazolamide 1o acetazolamide ER 1o amiloride 1o amiloride/HCTZ 1o bumetanide 1o chlorothiazide 1o chlorthalidone 1o furosemide 1o hydrochlorothiazide 1o indapamide 1o methazolamide 1o methyclothiazide 1o metolazone 1o spironolactone 1o spironolactone/HCTZ 1o torsemide 1 triamterene/HCTZ 1zo Carospir 3Miscellaneous Cardiovascular Agentszo eplerenone 1 midodrine 1+>z Berinert 2+>z Cinryze 2+>z Firazyr 2o Ranexa 2+>z Ruconest 2+>z Samsca 2Pz Consensi 3zo Corlanor 3zo Entresto 3+>z Haegarda 3+>z Takhzyro 3 Vecamyl 3

TIER TIER TIER TIER

Section i — therapeutic drug categorieS (cont’d)

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

3

Pulmonary Arterial Hypertension+> epoprostenol 1+>z sildenafil citrate 20mg 1+>z tadalafil (generic Adcirca) 1+>z Adempas 2+>z Letairis 2+>z Opsumit 2+>z Tracleer 2+>z Uptravi 2+> Orenitram 3+>z Tyvaso 3+> veletri 3+>z Ventavis 3Vasodilatorso hydralazine 1o isosorbide dinitrate 1o isosorbide mononitrate 1o isosorbide mononitrate SA 1o isoxsuprine 1o minoxidil oral 1 nitroglycerin pumpspray 1 nitroglycerin SR 1 nitroglycerin transdermal patch 1o Dilatrate SR 2 Nitrostat SL tabs 2 Gonitro 3 Minitran 3 NitroDur patches 3HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor efavirenz 1 Atripla 2 Edurant 2 Intelence 2 Rescriptor 2 Viramune, XR 2Nucleoside Analog Reverse Transcriptase Inhibitor Combination abacavir/lamivudine/zidovudine 1 lamivudine/zidovudine 1 tenofovir 300mg 1 Biktarvy 2 Cimduo 2 Complera 2 Descovy 2 Dutrebis 2 Odefsey 2 Stribild 2 Symfi 2 Symfi Lo 2 Triumeq 2 Truvada 2 Viread 150mg, 200mg, 250mg,

40mg/scoop powder 2Nucleoside Reverse Transcriptase Inhibitors abacavir-lamivudine 1 didanosine 1 lamivudine tabs 1 stavudine 1 zidovudine 1 Emtriva 2 Epivir solution 2 Videx 2 Ziagen 2Other+ Fuzeon 2 Genvoya 2 Isentress 2 Juluca 2 Selzentry 2 Tivicay 2 Tybost 2 Vitekta 2Protease Inhibitors atazanavir 1 ritonavir tablet 1 Aptivus 2 Crixivan 2 Evotaz 2 Invirase 2 Lexiva 2 Norvir capsule, solution 2 Prezcobix 2 Prezista 2 Viracept 2

Protease Inhibitors Combinations Kaletra 2Huntington’s Disease+>z tetrabenazine 1+>z Austedo 3z Ingrezza 3Immunosuppressants azathioprine 1 cyclosporine 1 gengraf 1 mycophenolate mofetil 1 mycophenolic acid 1 sirolimus 1 tacrolimus 1 Astagraf XL 2 Cellcept 2z Envarsus XR 2 Neoral 2 Prograf 2 Sandimmune 2 Rapamune solution 2 Zortress 2InfectionAntibacterial Agents/Antibiotics amoxicillin 1 amoxicillin-clavulanate ER 1 ampicillin 1 azithromycin suspension 1 azithromycin tablets 1 cefaclor 1 cefadroxil 1 cefdinir 1 cefpodoxime 1 cefprozil 1 cefuroxime 1 cephalexin 1 ciprofloxacin 1 clarithromycin susp 1 clarithromycin tabs 1 clindamycin 1 dicloxacillin 1 doxycycline 1 erythromycin base 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 erythromycin/sulfisoxazole 1 levofloxacin 1 minocycline 1 nitrofurantoin 1 ofloxacin 1 penicillin VK 1 sulfamethoxazole/trimethoprim 1 tetracycline 1 Ery-Tab 2 Ketek 2 Zmax 2z Acticlate 3 Baxdela 3 Biaxin XL 3 Ceftin 3 Cleocin 3 erythromycin estolate 3 Factive 3z Lymepak 3 Minocin 3 moxifloxacin 3 Noroxin 3 PCE 3 Spectracef 3 Suprax 3 Vibramycin 3Antifungals clotrimazole lozenge 1 fluconazole 1 flucytosine 1 griseofulvin 1z itraconazole 1 ketoconazole 1 nystatin 1z terbinafine 1z voriconazole 1z Noxafil 2z Sporanox suspension 2

z Cresemba 3 Ecoza 3z Lamisil Oral 3 Luzu 3 Oravig 3Antimalarials atovaquone/proguanil HCl 1 chloroquine phosphate 1 mefloquine 1 Daraprim 2 Primaquine 2 quinine sulfate 3Antituberculosiso ethambutol 1o isoniazid 1o pyrazinamide 1o rifabutin 1o rifampin 1 Coartem 2o Rifater 2o Rifamate 3o Sirturo 3Antiviralsz acyclovir oral 1o amantadine 1z famciclovir 1 ganciclovir 1+> moderiba 1 oseltamivir 1+> ribapak 1+> ribasphere 1+> ribavirin 1 rimantadine 1z valacyclovir 1 valganciclovir tablets 1+>Pz Daklinza 2+>z Epclusa 2 Epivir-HBV solution 2+>z Harvoni 2z Hepsera 2+>z Mavyret 2+z Olysio 2+> Pegasys 2 Relenza 2+>z Sovaldi 2+ Victrelis 2+>Pz Viekira 2+>Pz Viekira XR 2 Baraclude solution 3 entecavir tablets 3+>P Peg-Intron 3z Prevymis tablets 3+> Rebetol 3+ Ribatab 3z Sitavig 3+>Pz Technivie 3z Tyzeka 3 valganciclovir solution 3z Valtrex 3z Vemlidy 3+>z Vosevi 3+>Pz Zepatier 3Other Anti-Infectives atovaquone 1 dapsone tablets 1z linezolid 1 methenamine combination 1 metronidazole 1 neomycin 1 nitrofurantoin 1 paromomycin 1 tinidazole 1+> tobramycin ampule/neb 1 trimethoprim 1 vancomycin caps 1 Firvanq 2 Nebupent 2z Sivextro 2+> Tobi Podhaler 2z Xifaxan 2+ Bethkis 3

> Cayston 3z Dificid 3 Flagyl/ER 3z Impavido 3+>z Kitabis Pak 3 Macrodantin 3+> Tobi 3 Vancocin 3Men’s HealthImpotence - possible contract exclusion; refer to individual contractzo sildenafil citrate 25mg, 50mg, 100mg 1zo tadalafil (generic Cialis) 1z Caverject 2z MUSE 2zo Cialis 3z Edex 3Pzo Levitra 3Pzo Staxyn 3Pzo Stendra 3Pzo Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthate 1 Androderm patch 2z Androgel 2 Android 3Pz Axiron 3 fluoxymesterone 3Pz Fortesta 3Pz Natesto 3P Striant 3Pz Testim 3Pz Testosterone gel (brand) 3Pz Vogelxo 3Prostate Healthzo alfuzosin 1zo dutasteride 1o dutasteride/tamsulosin 1zo finasteride 5mg 1o tamsulosin 1o Rapaflo 2Mental HealthAntidepressants amitriptyline 1 amitriptyline/chlordiazepoxide 1 amitriptyline/perphenazine 1 amoxapine 1 bupropion 1 bupropion 12HR 1 bupropion 24HR 1u citalopram 1 clomipramine 1 desipramine 1 desvenlafaxine succinate ER 1 doxepin 1 duloxetine 1u escitalopram 1u fluoxetine 10mg and 20mg tablet 1 fluoxetine capsule 1u fluvoxamine tablet 1 imipramine 1 maprotiline 1u mirtazapine 1 nefazodone 1 nortriptyline 1u paroxetine 1 phenelzine 1 protriptyline 1u sertraline 1 tranylcypromine 1 trazodone 1u venlafaxine 1 venlafaxine ER 1 Viibryd 2 Desvenlafaxine ER 3 Desvenlafaxine Fumarate ER 3 Fetzima 3 fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3 Forfivo 3 Khedezla 3zu Oleptro ER 3

TIER TIER TIER TIER

Section i — therapeutic drug categorieS (cont’d)

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

Pexeva 3 Sarafem 3 Trintellix 3Antimanic Agents lithium carbonate 1Antipsychotic Agents aripiprazole 1 chlorpromazine 1 clozapine 1 fluphenazine 1 haloperidol 1 loxapine 1z olanzapine 1 perphenazine 1z quetiapine 1z quetiapine fumarate ER 1z risperidone 1z risperidone m-tab 1 thioridazine 1 thiothixene 1 trifluoperazine 1z ziprasidone caps 1z Latuda 2z Saphris 2z Fanapt 3 Fazaclo 3 Invega 3+>z Nuplazid 3z olanzapine/fluoxetine 3z paliperidone 3z Rexulti 3P Versacloz 3z Vraylar 3z Zyprexa 3z Zyprexa Zydis 3Anxiolytics, Sedatives, and Hypnotics alprazolam/ER 1 buspirone 1 chloral hydrate 1 chlordiazepoxide 1 clorazepate 1 diazepam 1 estazolam 1 flurazepam 1 lorazepam 1 meprobamate 1 oxazepam 1 temazepam 1 triazolam 1z zaleplon 1z zolpidem 1z zolpidem ER 1>z Hetlioz 2z Xyrem 2Pz Ambien 3Pz Ambien CR 3 Ativan 3Pz Belsomra 3Pz Edluar 3z eszopiclone 3Pz Intermezzo 3 Librium 3P Rozerem 3Pz Silenor 3 Somnote 3Pz Sonata 3Pz zolpidem ER sublingual tablet 3Pz Zolpimist 3Cerebral Stimulantsz armodafinil 1 atomoxetine 1 dexmethylphenidate 1 dexmethylphenidate XR 1 dextroamphetamine tabs 1 generic Adderall 1 generic Adderall XR 1 generic Concerta 1 generic Dexedrine spansules 1 guanfacine ER 1 metadate ER 1 methylphenidate CD 1 methylphenidate/SR 1z modafinil 1 procentra 1

zenzedi 5mg, 10mg 1 Daytrana 2z Mydayis 2 Quillivant XR 2 Ritalin LA 10mg, 60mg 2 Vyvanse 2z Adzenys 3z Cotempla XR 3z Dyanavel XR 3 Focalin XR 3z Jornay PM 3z Quillichew ER 3MiscellaneousAntidiuretic Agents desmopressin solution 1 desmopressin tabs 1 Stimate 2 DDAVP nasal spray 3 DDAVP sol, tab 3z Nocdurna 3z Noctiva 3Other CNS acamprosate calcium tablet EC 1 buprenorphine 1 buprenorphine-naloxone 1 disulfiram 1 naltrexone 1 riluzole 1z Gralise 2z Narcan Nasal Spray 2z Nuedexta 2 Savella 2 Suboxone film 2 Zubsolv 2 Bunavail 3 Campral dosepack 3z Evzio 3Pz Horizant 3 Lucemyra 3Other Endocrine danazol 1 fludrocortisone 1+> miglustat 1+> octreotide 1+>z Cerdelga 2+>z Egrifta 2+>z HP Acthar Gel 2>z Myalept 2+> Norditropin 2+>o Sensipar 2+> Somatuline Depot 2z Synarel 2> Zavesca 2+>P Genotropin 3+>P Humatrope 3> Increlex 3+>z Natpara 3+>P Nutropin/AQ 3+>P Omnitrope 3+>P Saizen 3+> Sandostatin 3+> Sandostatin LAR 3+>P Serostim 3+>z Somavert 3+>P Tev-Tropin 3+>P Zorbtive 3Other Miscellaneous+>zo Keveyis 2>z Signifor 2> Carbaglu 3 Cystadane 3+ Cystagon 3>z Galafold 3z Korlym 3> Procysbi 3+> Ravicti 3+ sodium phenylbutyrate 3 Tegsedi 3z Veltassa 3z Xuriden 3

Miscellaneous Immunologicals+> Cuvitru 3+> Gammagard Liquid 3+> Gammaked 3+> Gamunex-C 3+> Hizentra 3+> HyQvia 3Multiple Sclerosis Agents+>z dalfampridine ER 1+> glatiramer acetate 1+>z glatopa 1+> Avonex 2+> Copaxone 20mg 2+> Copaxone 40mg 2+> Rebif 2+>z Gilenya 2+>z Plegridy 2+>z Tecfidera 2+>P Betaseron 3+>z Aubagio 3+>P Extavia 3Muscle Relaxants baclofen 1 carisoprodol 1 carisoprodol/ASA 1 chlorzoxazone 1 cyclobenzaprine 1 dantrolene sodium 1 metaxalone 1 methocarbamol 1 orphenadrine 1 tizanidine 1Osteoporosiszo alendronate 1zo calcitonin-salmon 1zo fortical NS 1zo ibandronate tabs 1zo raloxifene 1+>z Forteo 2+>z Tymlos 2Pzo Actonel 3Pzo Atelvia 3Pzo Binosto 3Pzo Boniva 3Pzo Fosamax 3Pzo Fosamax D 3zo risedronate 150mg 3Pzo risedronate DR 3Pain/ArthritisAnalgesics, Opioid - Medications listed under this category may require additional review for coverage based on recommendations from the Centers for Disease Control and Prevention (CDC).z acetaminophen w/codeine 1z belladonna & opium supp 1z butalbital/APAP/codeine 1z butalbital/aspirin/codeine 1z butorphanol NS 1z codeine sulfate 1z endocet 1z fentanyl lozenge 1 fentanyl patch 1z hydrocodone/APAP 1z hydrocodone/ibuprofen 1z hydromorphone 1z meperidine 1 methadone 1 morphine SR 1z morphine sulfate ER 1 morphine tab, soln, supp 1z oxycodone 1z oxycodone/acetaminophen 1z oxycodone/aspirin 1z oxycodone/ibuprofen 1 oxymorphone/ER 1z pentazocine/naloxone 1 Buprenorphine TD patch 2 Butrans 2 Kadian (40mg, 70mg, 130mg,

150mg, 200mg) 2z Nucynta 2 Nucynta ER 2

Oxycodone ER 2 Oxycontin 2z Abstral 3z Belbuca 3z Demerol 3 Embeda 3z Fentora 3 fentanyl patch 37.5mcg/hr, 62.5mcg/hr,

and 87.5mcg/hr 3z Fioricet/codeine 3z Fiorinal/codeine 3 hydromorphone ER 3 Hysingla ER 3z Lazanda 3z Roxicet Soln 3z Subsys 3z Trezix 3z Tylenol/codeine 3z Vicodin/ES 3 Xartemis XR 3z Xtampza ER 3 Zohydro ER 3Analgesics, Salicylateso choline mag. trisalicylate 1o diflunisal 1o salsalate 1oz Yosprala 3Anti-Rheumatico hydroxychloroquine 1 leflunomide 1 methotrexate 1+>Pz Actemra 2oz Cuprimine 2+>z Enbrel 2+>z Humira 2z Kineret 2+>z Otezla 2o Ridaura 2+>z Xeljanz 2+>z Xeljanz XR 2+>Pz Cimzia 3oz Depen 3+>z Kevzara 3+>Pz Olumiant 3+>Pz Orencia SC 3 Otrexup 3 Rasuvo 3+>Pz Simponi 3Cox-2szo celecoxib 1Migraine (Analgesics, Non-opioid) butalbital/APAP 50mg-325mg 1 butalbital/APAP/caffeine 1 butalbital/aspirin/caffeine 1z dihydroergotamine mesylate 1z eletriptan 1 ergotamine/caffeine 1 isometh/dichloralphen/APAP 1z naratriptan 1z rizatriptan 1z sumatriptan 1 tramadol/acetaminopen 1 tramadol/ER tablet 1z zolmitriptan 1z Sumavel 2z Treximet 2Pz Amerge 3Pz Axert 3 butalbital/APAP 50mg-300mg 3 Cafergot 3z Cambia 3z Ergomar 3Pz Frova 3Pz Imitrex 3Pz Maxalt 3Pz Maxalt MLT 3Pz Onzetra 3Pz Relpax 3 tramadol ER capsule 3+Pz Zecuity 3Pz Zembrace 3Pz Zomig 3Pz Zomig Nasal 3Pz Zomig ZMT 3Migraine (Miscellaneous)z Aimovig 3 Ajovy 3

TIER TIER TIER TIER

4

Section i — therapeutic drug categorieS (cont’d)

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

5

TIER TIER TIER TIER Emgality 3Nonsteroidal Anti-Inflammatory/Combination Productso diclofenac potassium 1o diclofenac sodium 1z diclofenac sodium gel 1% 1o etodolac 1o etodolac SA 1o fenoprofen 1o flurbiprofen 1o ibuprofen 1o indomethacin 1o ketoprofen 1 ketorolac inj. 1z ketorolac tab 1o meclofenamate 1o mefenamic acid 1o meloxicam 1o nabumetone 1o naproxen/EC 1o oxaprozin 1o piroxicam 1o sulindac 1o tolmetin 1o Zorvolex 2Pz diclofenac sodium 3% gel 3o diclofenac sodium/misoprostol 3Pz diclofenac sodium topical solution 3Pz Duexis 3Pz Flector 3Pz Pennsaid 3z Sprix 3o Tivorbex 3Pzo Vimovo 3Pzo Vivlodex 3Parkinson’s Diseaseo benztropine 1o bromocriptine 1o carbidopa/levodopa 1o carbidopa/levodopa SA 1o entacapone 1o pramipexole 1zo rasagiline 1o ropinirole 1zo selegiline 1o trihexyphenidyl 1+>z Apokyn 2>z Duopa 2o carbidopa 3z Gocovri 3Pzo Osmolex ER 3 pergolide 3o pramipexole ER 3o ropinirole ER 3o Rytary 3 tolcapone 3zo Xadago 3PotassiumPotassium agentso potassium bicarb/potassium chloride 1o potassium bicarbonate 1o potassium chloride 1Potassium Removing agent sod. polystyrene sulfonate 1Respiratory/AsthmaAdrenergic Epinephrine (Impax) 2 Epinephrine (Mylan) 2P Adrenaclick 3P AuviQ 3P Epipen/Jr. 3 Symjepi 3Corticosteroidso budesonide inh.

(0.25mg/2ml, 0.5mg/2ml) 1zo Arnuity Ellipta 2zo Asmanex 2zo Flovent HFA/Diskus 2zo Pulmicort flexhaler/powder 2o Pulmicort respules (1mg/2ml) 2

zo Qvar 2z Aerobid/M 3o Alvesco 3zo ArmonAir 3Leukotrieneso montelukast 1o zafirlukast 1zo zileuton ER 3zo Zyflo 3Other Agents cromolyn inh. soln. 1 ipratropium inh. soln. 1 ipratropium/albuterol 1z Advair diskus 2 Advair HFA 2 Anoro Ellipta 2z Atrovent HFA 2 Breo Ellipta 2z Combivent Respimat 2o Daliresp 2+>z Esbriet 2> Kalydeco 2+>z Ofev 2>z Orkambi 2+> Pulmozyme 2z Spiriva 2z Spiriva Respimat 2z Stiolto Respimat 2z Symbicort 2z Symdeko 2z Trelegy Ellipta 2 Tudorza 2z AirDuo 3z Bevespi Aerosphere 3z Dulera 3z Fluticasone-Salmeterol 3+> Glassia 3z Incruse Ellipta 3z Lonhala Magnair 3> Orkambi granules 3z Seebri 3z Utibron 3Sympathomimeticso albuterol sulfate ER 1o albuterol tab, syr 1o metaproterenol syr 1o terbutaline tab 1 Arcapta 2z Foradil 2z Maxair Autohaler 2 Perforomist 2z ProAir HFA/RespiClick 2z Serevent Diskus 2z Ventolin HFA 2 Levalbuterol Tartrate HFA 3z Proventil HFA 3z Striverdi Respimat 3 Xopenex HFA 3Xanthine Derivativeso aminophylline 1o theochron 1o theophylline/SR tabs, liquid 1o Theo-24 2o Elixophyllin 3SeizuresBarbiturates mephobarbital 1 phenobarbital 1Hydantoinso phenytoin 1o Dilantin 2o Peganone 3Miscellaneouso carbamazepine 1o carbamazepine XR 200mg, 400mg 1 clonazepam 1o divalproex sodium/ER 1 felbamate 1o gabapentin 1o lamotrigine 1o levetiracetam 1o oxcarbazepine 1

o primidone 1o tiagabine 1o topiramate 1o valproic acid 1o zonisamide 1o Banzel tablets 2z Fycompa 2 Lyrica 2o Oxtellar XR 2o Qudexy XR 2o Tegretol 2o Tegretol XR 100mg 2 Vimpat 2o Aptiom 3o Banzel suspension 3z Briviact 3z Diacomit 3+ Epidiolex 3o lamotrigine ER/ODT 3Pz Lyrica CR 3 Potiga 3+> Sabril 3o topiramate ER 3o Trokendi XR 3+> vigabatrin oral powder 3Succinimideso ethosuximide 1o Celontin 2SkinAcne/Rosacea adapalene gel/cream 1 amnesteem 1 avita cream 1 benzoyl peroxide 1 claravis 1 clindamycin/benzoyl peroxide 1 clindamycin phospate 1 dapsone 5% 1 erythromycin/benz peroxide 1 minocycline 1 prascion RA 1 sodium sulfacetamide 1 sod. sulfacetamide/sulfur emulsion

cleanser 1 sod. sulfacetamide/sulfur lot 1 sotret 1 tazarotene cream 1 tretinoin cr/gel 1 Absorica 2 Acanya 2 Atralin 2 Avita gel 2 EpiDuo 2 EpiDuo Forte 2 Mirvaso 2 Onexton 2 Soolantra 2 Tazorac gel 2 Veltin gel 2 Ziana gel 2 Aczone 3 Adapalene lotion 3 adapalene solution 3P Doryx 3P doxycycline hyclate DR 3P Doxycycline IR-DR 3 Fabior 3P minocycline HCl ER 3P Oracea 3P Solodyn 3 tretinoin microsphere 3P Ximino 3Antibiotics (Topical) clindamycin sol/swabs/gel/lotion 1 erythromycin sol/swabs/gel 1 gentamicin cr/oint 1 metronidazole cream/lotion/ 0.75% gel 1 mupirocin 1 Finacea 2 Metrogel topical 1% 2 Noritate 2 Bactroban cream 3 Centany 3P Xepi 3

Antipsoriatics acitretin 1 calcipotriene 1 tacrolimus 1+>z Cosentyx 2 Dritho-Scalp 2 Elidel 2+>z Stelara 2+>Pz Tremfya 2P calcipotriene-betamethasone ointment 3 calcitriol ointment 3P Enstilar 3+>Pz Siliq 3P Taclonex 3+>Pz Taltz 3Burn preparation silver sulfadiazine 1Fungicides betamethasone/clotrimazole 1 ciclopirox cream 1 ciclopirox soln 1 econazole 1 ketoconazole 1 nystatin 1 nystatin/triamcinolone 1 nystop 1 oxiconazole cream 1 Exelderm 2 Oxistat lotion 2z Jublia 3z Kerydin 3 Naftin 3Miscellaneous aluminum chloride 20% 1 fluorouracil 5% cr/sol 1 fluorouracil 2% sol 1 imiquimod 5% cream 1 podofilox 1 sodium chloride irrigating soln 1 Carac 2+>z Dupixent 2 Panretin 2 Phisohex 2 Picato 2 Regranex 2+>z Benlysta SC 3 Eucresa 3 Fluoroplex 3 Fluorouracil 0.5% cream 3z Qbrexza 3 Regenecare 3Psoralens methoxsalen capsule 1 8-MOP 2Scabicides & Pediculicides acticin 1 permethrin 1 spinosad 1 Lindane 2 Ulesfia 2 Eurax 3 Sklice 3Topical Anti-Inflammatory Agents alclometasone 1 amcinonide 1 aug. betamethasone diprop 1 betamethasone dipropionate 1 betamethasone valerate 1 clobetasol emol/emuls 1 clobetasol proprionate

foam/gel/oint/cr/sol 1 desonide 1 desoximetasone 1 diflorasone 1 fluocinolone acetonide 1 fluocinonide 1 fluticasone propionate 1 halobetasol 1 halobetasol propionate 1 hydrocortisone 2.5% 1 hydrocortisone valerate 1 hydrocortisone/iodoquinol 1 mometasone cr/oint 1 prednicarbate 1 triamcinolone acetonide 1 Cordran tape 2

Section i — therapeutic drug categorieS (cont’d)

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

6

TIER TIER TIER TIER betamethasone valerate foam 3 Capex Shampoo 3 clobetasol propionate

lotion/shampoo/spray 3 Cordran ointment 3 fluocinonide cream (generic Vanos) 3 flurandrenolide cream/lotion 3 Halog 3 hydrocortisone butyrate/emoll cream 3P Impoyz 3 Kenalog/aerosol 3Topical Antipruritics/Anesthetics lidocaine 1z lidocaine patch 1 selenium sulf 2.5% suspension 1 Rectiv 2Topical Antivirals acyclovir ointment 1 Zovirax Cream 2 Denavir 3Smoking CessationMembers coverage varies by plan. Patient should be in a smoking cessation program. bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3Steroids cortisone acetate 1 dexamethasone oral 1 hydrocortisone oral 1 methylprednisolone 4mg, 8mg,

16mg, 32mg 1 prednisolone oral 1 prednisone oral 1 Medrol 2mg 2z Emflaza 3 Rayos 3Stomach/UlcerAnorectal hydrocortisone rectal cr. & supp. 1 hydrocortisone rectal enema 1 pramoxine/HC acetate 2.5% 1 Analpram-HC 1-1% 2 Cortifoam 2 Proctofoam-HC 2 Analpram-HC 2.5% cr/lot 3Anticholinergics/Antispasmodic/GI Motility belladonna/phenobarbital 1 chlordiazepoxide/clindinium 1 dicyclomine 1 glycopyrrolate 1 hyoscyamine/CR 1 metoclopramide 1 Donnatal tablet 2Antidiarrheal diphenoxylate/atropine 1 paregoric 1z Alinia 2 Fulyzaq 2Antiemetic/Antivertigoz aprepitant 1z granisetron 1 meclizine 1z ondansetron 1 prochlorperazine 1 promethazine 1 scopolamine patch 1 trimethobenzamide 1Pz Akynzeo 2 Antivert 50mg 2z Anzemet 2z Emend 2z Sancuso 2z Varubi 2z Bonjesta 3

z Diclegis 3z Granisol 3z Syndros 3z Zuplenz 3Bowel Evacuants peg 3350/electrolyte 1 Trilyte 1 Halflytely 2 Moviprep 2 Suprep 2 Nulytely 3 Prepopik 3 Suclear 3Digestantso Creon 2o Zenpep 2o Pancreaze 3o Pertzye 3o Ultresa 3o Viokace 3Gallstone Solubilizing Agentso ursodiol 1+>z Ocaliva 3H2 Antagonistso cimetidine 1o famotidine 1o nizatidine 1o ranitidine (all) 1Other Antiulcero misoprostol 1 propantheline bromide 1o sucralfate 1 Pylera 2 Helidac 3 lansoprazole/amox/clarith 3Other GI Products balsalazide 1 budesonide EC 1o cromolyn sodium 1 enulose 1 lactulose 1 mesalamine DR tablet 800mg 1 mesalamine enema 1o sulfasalazine 1o sulfasalazine EC 1z Amitiza 2 Canasa supp. 2 Cholbam 2 Delzicol 2+> Kuvan 2 Linzess 2 Pentasa 2z Relistor injection 2z Relistor tablets 2 alosetron 3 Apriso 3o Azulfidine 3 budesonide ER tablet 3z Dipentum 3+> Gattex 3 Giazo 3 mesalamine DR tablet 1.2g 3z Movantik 3>z Palynziq 3z Symproic 3Pz Trulance 3 Uceris 3z Xermelo 3Proton Pump Inhibitorszo esomeprazole magnesium 1zo lansoprazole 1Pz lansoprazole DR ODT 1z Nexium 24HR 1zo omeprazole 1zo pantoprazole 1z Prevacid 24HR 1z Prilosec-OTC 1zo rabeprazole 1z Zegerid OTC 1zo Nexium/susp 2zo Prevacid Solutab 2Pzo Aciphex 3Pzo Dexilant 3Pzo Nexium 3

Pzo omeprazole/sodium bicarbonate 3Pzo Prevacid 3Pzo Prilosec 3Pzo Protonix 3Pzo Zegerid 3ThyroidAntithyroido methimazole 1o propylthiouracil 1Thyroid levothroid 1o levothyroxine 1o levoxyl 1o liothyronine 1o thyroid 1o unithroid 1o Synthroid 2o Thyroid (Armour) 2o Thyrolar 2Vitaminso calcitriol 1o calcitriol inj 1 calcium acetate 1 cholecalciferol 1o cyanocobalamin inj. 1 ergocalciferol capsule 1o etidronate 1o folic acid Rx 1mg tab 1 lanthanum carbonate tablet 1 leucovorin 1 levocarnitine 1o multivitamin + fluoride (Rx-only) 1o Pediatric sodium fluoride chewable tab &

drops 1 potassium aminobenzoate 1o pre-natal vitamins (Rx-only) 1 sevelamer 1o vit A,D,C + fluoride (Rx-only) 1o vit A,D,C + fluoride and iron (Rx-only) 1 Galzin 2o Mephyton 2o Nascobal 2 Orfadin 2o phytonadione 2o Prenate Elite 2 Renagel 2 Renvela 2z Auryxia 3 paricalcitol 3o Poly-Vi-Flor +> Iron 3z Rayaldee 3 Tri-Vi-Flor 3 Velphoro 3Weight Loss - possible contract exclusion; refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3z Belviq XR 3z Contrave 3z Qsymia 3z Saxenda 3 Suprenza ODT 3 Xenical 3Women’s HealthPlease refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan.Contraceptives - Othero xulane 1+ Mirena 2o NuvaRing 2+ Skyla 2 Caya Contoured Diaphragm 3 Conceptrol 3o Depo-SubQ Provera 3 FC2 Female Condom 3 Femcap 3 gynol II 3

+ Kyleena 3> Liletta 3+> Nexplanon 3 Paragard 3 Today Contraceptive Sponge 3 VCF 3Fertility Induction Agents - possible contract exclusion; refer to individual contract clomiphene 1 progesterone in oil 1 serophene 1 Bravelle 2 Cetrotide 2 Follistim AQ 2 Menopur 3 Novarel 2 Ovidrel 2 Repronex 2 Chorionic gonadotropin 3 Ganirelix 3P Gonal F 3 Pregnyl 3Hormoneszo estradiol/noreth ac 1o estradiol 0.01% cream 1zo estradiol oral 1zo estradiol patches 1zo estropipate 1zo estrogen/methyltesterone 1zo jinteli 1o medroxyprogesterone 1o norethindrone 1o progesterone, micronized 1o yuvafem 1zo Alora 2 Cenestin 2zo Combipatch 2o Crinone 2o Divigel 2 Duavee 2 Endometrin 2o Enjuvia 2zo Estraderm 2zo Estring 2o Evamist 2o Menest 2zo Minivelle 2o Premarin 2o Premarin vag cream 2o Premphase 2 Prempro 2zo Climara Pro 3zo Estrasorb packet 3zo Estrogel 3zo Femring 3z Imvexxy 3z Intrarosa 3zo Menostar 3z Orilissa 3 Ortho-Est 3 Osphena 3zo Prefest 3Miscellaneous paroxetine 7.5mg 1z Addyi 3Oral Contraceptiveso altavera 1o alyacen 1o amethia 1o amethia lo 1o amethyst 1o apri 1o aranelle 1o ashlyna 1o aubra 1o aubra eq 1o aviane 1o azurette 1o balziva 1o bekyree 1o blisovi 24 fe 1

Section i — therapeutic drug categorieS (cont’d)

P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required. u = Included in Tablet-Splitting Program

+ = Access restricted to CVS Specialty pharmacy if applicable. > = Access restricted to Accredo specialty pharmacy if applicable. o = Home Service Delivery.

KEY:

7

TIER TIER TIER TIERo blisovi fe 1o briellyn 1o camila 1o camrese 1o camrese lo 1o caziant 1o chateal 1o chateal eq 1o cryselle 1o cyclafem 1o cyred 1o dasetta 1o daysee 1o deblitane 1o delyla 1o desogestrel-ethinyl estradiol 1o desogestr-eth estrad eth estra 1o drospirenone-ethinyl estradiol 1 econtra ez 1 econtra one-step 1o elinest 1o emoquette 1o enpresse 1o enskyce 1o errin 1o estarylla 1o ethynodiol-ethinyl estradiol 1 fallback solo 1o falmina 1o femynor 1o gianvi 1o gildagia 1o gildess 1o gildess 24 fe 1o gildess fe 1o heather 1o incassia 1o introvale 1o isibloom 1o jencycla 1o jolessa 1o jolivette 1

o juleber 1o junel 1o junel fe 1o kaitlib fe 1o kariva 1o kelnor 1-35 1o kelnor 1-50 1o kimidess 1o kurvelo 1o larin 1o larin fe 1o larissia 1o layolis fe 1o leena 1o lessina 1o levonest 1 levonorgestrel 1o levonorgestrel-eth estradiol 1o levonorg-eth estrad eth estrad 1 levora 1o lillow 1o lomedia 24 fe 1o loryna 1o low-ogestrel 1o lutera 1o lyza 1o marlissa 1o melodetta 24 fe 1o mibelas 24 fe 1o microgestin 1o microgestin fe 1o mili 1o mono-linyah 1o mononessa 1 my choice 1 my way 1o myzilra 1o necon 1 new day 1 next choice one dose 1o nikki 1o nora-be 1

o norethindrone acetate 1o norethindrone-ethin estradiol 1o norethin-eth estra ferrous fum 1o norgestimate-ethinyl estradiol 1o norgestrel-ethiny estra 1o norlyda 1o norlyroc 1o nortrel 1o ocella 1o ogestrel 1 opcicon one-step 1 option 2 1o orsythia 1o philith 1o pimtrea 1o pirmella 1o portia 1o previfem 1o quasense 1 react 1o reclipsen 1o setlakin 1o sharobel 1o sprintec 1o sronyx 1o syeda 1o tarina fe 1o tilia fe 1o tri femynor 1o tri-estarylla 1o tri-legest fe 1o tri-linyah 1o tri-lo-estarylla 1o tri-lo-marzia 1o tri-lo-sprintec 1o tri-mili 1o trinessa 1o trinessa lo 1o tri-previfem 1o tri-sprintec 1 trivora 1o tri-vylibra 1

o tulana 1o tydemy 1o velivet 1o vestura 1o vienva 1o viorele 1o vyfemla 1o vylibra 1o wera 1o wymzya fe 1o zarah 1o zenchent 1o zenchent fe 1o zeosa 1 zovia 1o Lo Loestrin Fe 2o Natazia 2o Balcoltra 3o drospirenone-eth estra-levomef 3 Ella 3o fayosim 3o rajani 3o rivelsa 3o Taytulla 3Oxytocic Agents methylergonovine maleate 1 Methergine 3Vaginal Preparations miconazole vag supp 1 nystatin vag tab 1 terconazole 1 vandazole vag 1 Cleocin Vag/Ovules 3 Clindesse 3 Gynazole-1 3

Section i — therapeutic drug categorieS (cont’d)

8

Aabacavir-lamivudine 3abacavir/lamivudine/zidovudine 3Absorica 5Abstral 4acamprosate calcium tablet EC 4Acanya 5acarbose 1Accu-Chek 2acebutolol 2acetaminophen w/codeine 4acetazolamide 2acetazolamide ER 2acetic acid HC otic 2acetic acid otic 2acetic acid/aluminum acetate 2acetylcysteine inh soln. 1Aciphex 6acitretin 5Actemra 4acticin 5Acticlate 3Actimmune 1Actonel 4Acular PF 2acyclovir ointment 6acyclovir oral 3Aczone 5adapalene gel/cream 5Adapalene lotion 5adapalene solution 5Addyi 6Adempas 3Adlyxin 1Admelog 1Adrenaclick 5Advair diskus 5Advair HFA 5Advicor 2Adzenys 4Aerobid/M 5Afinitor 1Afrezza 1Aimovig 4AirDuo 5Ajovy 4Akynzeo 6albuterol sulfate ER 5albuterol tab, syr 5alclometasone 5Alecensa 1alendronate 4alfuzosin 3Alinia 6Alkeran 1allopurinol 2Alomide 2Alora 6alosetron 6Alphagan P 0.1% 2alprazolam/ER 4Alprolix 1Alrex 2altavera 6Altoprev 2aluminum chloride 20% 5Alunbrig 1Alvesco 5alyacen 6amantadine 3Ambien 4Ambien CR 4amcinonide 5Amerge 4amethia 6amethia lo 6amethyst 6amiloride 2amiloride/HCTZ 2aminophylline 5amiodarone 2Amitiza 6amitriptyline 3amitriptyline/chlordiazepoxide 3amitriptyline/perphenazine 3amlodipine 2amlodipine/atorvastatin 2amlodipine/benazepril 2amlodipine/valsartan 2amlodipine/valsartan/HCTZ 2amnesteem 5amoxapine 3amoxicillin 3amoxicillin-clavulanate ER 3ampicillin 3Amturnide 2anagrelide 1Analpram-HC 1-1% 6Analpram-HC 2.5% cr/lot 6

anastrozole 1Androderm patch 3Androgel 3Android 3Anoro Ellipta 5Antivert 50mg 6Anzemet 6Apidra 1Apokyn 5aprepitant 6apri 6Apriso 6Aptiom 5Aptivus 3aranelle 6Aranesp 1Arcalyst 1Arcapta 5aripiprazole 4armodafinil 4ArmonAir 5Arnuity Ellipta 5Ascensia Breeze 2ashlyna 6Asmanex 5aspirin/dipyridamole 1Astagraf XL 3atazanavir 3Atelvia 4atenolol 2atenolol/chlorthalidone 2Ativan 4atomoxetine 4atorvastatin calcium 2atovaquone 3atovaquone/proguanil HCl 3Atralin 5Atripla 3atropine sulfate ophth 2Atrovent HFA 5Atrovent Nasal Spray 1Aubagio 4aubra 6aubra eq 6aug. betamethasone diprop 5Auryxia 6Austedo 3AuviQ 5Avandamet 1Avandaryl 1Avandia 1aviane 6avita cream 5Avita gel 5Avonex 4Axert 4Axiron 3Azasite 2azathioprine 3azelastine nasal spray 1azelastine ophth 2azithromycin suspension 3azithromycin tablets 3Azopt 2Azulfidine 6azurette 6

Bbacitracin ophth 2bacitracin/polymyxin 2baclofen 4Bactroban cream 5Balcoltra 7balsalazide 6balziva 6Banzel suspension 5Banzel tablets 5Baraclude solution 3Basaglar 1Baxdela 3Beconase AQ 1bekyree 6Belbuca 4belladonna & opium supp 4belladonna/phenobarbital 6Belsomra 4Belviq 6Belviq XR 6benazepril 2benazepril/HCTZ 2Benlysta SC 5benzonatate 1benzoyl peroxide 5benzphetamine 6benztropine 5Bepreve 2Berinert 2Besivance 2betamethasone dipropionate 5

betamethasone valerate 5betamethasone valerate foam 6betamethasone/clotrimazole 5Betaseron 4betaxolol 2betaxolol HCl 2Bethkis 3Betoptic-S 2Bevespi Aerosphere 5Bevyxxa 1bexarotene 1Biaxin XL 3bicalutamide 1Biktarvy 3bimatoprost 0.03% 2Binosto 4bisoprolol 2bisoprolol/HCTZ 2blisovi 24 fe 6blisovi fe 7Boniva 4Bonjesta 6Bosulif 1Braftovi 1Bravelle 6Breo Ellipta 5briellyn 7Brilinta 1brimonidine 2Briviact 5bromfenac 2bromocriptine 5brompheniramine/phenylephrine 1brompheniramine/pseudoephedrine 1budesonide EC 6budesonide ER tablet 6budesonide inh. (0.25mg/2ml,

0.5mg/2ml) 5budesonide nasal spray 1bumetanide 2Bunavail 4buprenorphine 4Buprenorphine TD patch 4buprenorphine-naloxone 4bupropion 3bupropion 6bupropion 12HR 3bupropion 24HR 3buspirone 4butalbital/APAP 50mg-300mg 4butalbital/APAP 50mg-325mg 4butalbital/APAP/caffeine 4butalbital/APAP/codeine 4butalbital/aspirin/caffeine 4butalbital/aspirin/codeine 4butorphanol NS 4Butrans 4Bydureon 1Byetta 1Bystolic 2Byvalson 2

CCabometyx 1Cafergot 4calcipotriene 5calcipotriene-betamethasone ointment 5calcitonin-salmon 4calcitriol 6calcitriol inj 6calcitriol ointment 5calcium acetate 6Calquence 1Cambia 4camila 7Campral dosepack 4camrese 7camrese lo 7Canasa supp. 6candesartan/HCTZ 2capecitabine 1Capex Shampoo 6Caprelsa 1captopril 2captopril/HCTZ 2Carac 5Carbaglu 4carbamazepine 5carbamazepine XR 200mg, 400mg 5carbidopa 5carbidopa/levodopa 5carbidopa/levodopa SA 5Cardec/DM 1Cardura XL 2carisoprodol 4carisoprodol/ASA 4Carospir 2carteolol 2cartia XT 2

carvedilol 2carvedilol ER 2Caverject 3Caya Contoured Diaphragm 6Cayston 3caziant 7CeeNu 1cefaclor 3cefadroxil 3cefdinir 3cefpodoxime 3cefprozil 3Ceftin 3cefuroxime 3celecoxib 4Cellcept 3Celontin 5Cenestin 6Centany 5cephalexin 3Cequa 2Cerdelga 4cetirizine 1Cetrotide 6Chantix 6chateal 7chateal eq 7chloral hydrate 4chlordiazepoxide 4chlordiazepoxide/clindinium 6chloroquine phosphate 3chlorothiazide 2chlorpromazine 4chlorpropamide 1chlorthalidone 2chlorzoxazone 4Cholbam 6cholecalciferol 6cholestyramine 2choline mag. trisalicylate 4Chorionic gonadotropin 6Cialis 3ciclopirox cream 5ciclopirox soln 5cilostazol 1Ciloxan 2Cimduo 3cimetidine 6Cimzia 4Cinryze 2Cipro HC 2Ciprodex 2ciprofloxacin 3ciprofloxacin ophth 2ciprofloxacin otic 2citalopram 3citric acid/sod citrate 1claravis 5Clarinex-D 1Clarispray 1clarithromycin susp 3clarithromycin tabs 3clemastine 1Cleocin 3Cleocin Vag/Ovules 7Climara Pro 6clindamycin 3clindamycin phospate 5clindamycin sol/swabs/gel/lotion 5clindamycin/benzoyl peroxide 5Clindesse 7clobetasol emol/emuls 5clobetasol propionate lotion/

shampoo/spray 6clobetasol proprionate foam/gel/

oint/cr/sol 5clomiphene 6clomipramine 3clonazepam 5clonidine, oral, patch 2clopidogrel 1clorazepate 4clotrimazole lozenge 3clozapine 4Coartem 3codeine sulfate 4colchicine/probenecid 2Colcrys 2colesevelam 2Colestid 2colestipol 2Combigan 2Combipatch 6Combivent Respimat 5Cometriq 1Commit 6Complera 3Conceptrol 6Consensi 2

Contour 2Contrave 6Copaxone 20mg 4Copaxone 40mg 4Copiktra 1Cordran ointment 6Cordran tape 5Corlanor 2Cortifoam 6cortisone acetate 6Cosentyx 5Cotellic 1Cotempla XR 4Coumadin 1Creon 6Cresemba 3Crinone 6Crixivan 3cromolyn inh. soln. 5cromolyn ophth 2cromolyn sodium 6cryselle 7Cuprimine 4Cuvitru 4cyanocobalamin inj. 6cyclafem 7cyclobenzaprine 4cyclophosphamide 1cyclosporine 3cyproheptadine 1cyred 7Cystadane 4Cystagon 4Cystaran 2

DDaklinza 3dalfampridine ER 4Daliresp 5danazol 4dantrolene sodium 4dapsone 5% 5dapsone tablets 3Daraprim 3dasetta 7daysee 7Daytrana 4DDAVP nasal spray 4DDAVP sol, tab 4deblitane 7delyla 7Delzicol 6Demerol 4Denavir 6Depen 4Depo-SubQ Provera 6Descovy 3desipramine 3desloratadine 1desmopressin solution 4desmopressin tabs 4desogestr-eth estrad eth estra 7desogestrel-ethinyl estradiol 7desonide 5desoximetasone 5Desvenlafaxine ER 3Desvenlafaxine Fumarate ER 3desvenlafaxine succinate ER 3Detrol 1Detrol LA 1dexameth/neomycin/poly B 2dexamethasone oral 6dexchlorpheniramine 1Dexilant 6dexmethylphenidate 4dexmethylphenidate XR 4dextroamphetamine tabs 4Diacomit 5diazepam 4Diclegis 6diclofenac 2diclofenac potassium 5diclofenac sodium 5diclofenac sodium 3% gel 5diclofenac sodium gel 1% 5diclofenac sodium topical solution 5diclofenac sodium/misoprostol 5dicloxacillin 3dicyclomine 6didanosine 3diethylpropion 6Dificid 3diflorasone 5diflunisal 4digoxin 2dihydroergotamine mesylate 4Dilantin 5Dilatrate SR 3diltia XT 2

diltiazem 2diltiazem CD/SR/ER/XR 2Dipentum 6diphenhydramine 1diphenoxylate/atropine 6dipyridamole 1disopyramide 2disulfiram 4Ditropan XL 1divalproex sodium/ER 5Divigel 6dofetilide 2Domeboro 2donepezil 1Donnatal tablet 6Doptelet 1Doryx 5dorzolamide 2% eye drops 2dorzolamide/timolol eye drops 2doxazosin 2doxepin 3doxycycline 3doxycycline hyclate DR 5Doxycycline IR-DR 5Dritho-Scalp 5drospirenone-eth estra-levomef 7drospirenone-ethinyl estradiol 7Duavee 6Duetact 1Duexis 5Dulera 5duloxetine 3Duopa 5Dupixent 5Durlaza 1dutasteride 3dutasteride/tamsulosin 3Dutrebis 3Duzallo 2Dyanavel XR 4Dymista 1Dynacirc/CR 2

Eeconazole 5econtra ez 7econtra one-step 7Ecoza 3Edarbi 2Edarbyclor 2Edex 3Edluar 4Edurant 3efavirenz 3Egrifta 48-MOP 5eletriptan 4Elidel 5elinest 7Eliquis 1Elixophyllin 5Ella 7Eloctate 1Embeda 4Emcyt 1Emend 6Emflaza 6Emgality 5emoquette 7Emtriva 3Enablex 1enalapril 2enalapril/HCTZ 2Enbrel 4Endari 1endocet 4Endometrin 6Enjuvia 6enoxaparin 1enpresse 7enskyce 7Enstilar 5entacapone 5entecavir tablets 3Entresto 2enulose 6Envarsus XR 3Epaned 2Epanova 2Epclusa 3Epidiolex 5EpiDuo 5EpiDuo Forte 5Epinephrine (Impax) 5Epinephrine (Mylan) 5Epipen/Jr. 5Epivir solution 3Epivir-HBV solution 3eplerenone 2

Section ii — index DRUG NAME PAGE

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99

Epogen 1epoprostenol 3eprosartan 600mg 2ergocalciferol capsule 6ergoloid mesylates 1Ergomar 4ergotamine/caffeine 4Erivedge 1Erleada 1errin 7Ery-Tab 3erythromycin base 3erythromycin estolate 3erythromycin ethylsuccinate 3erythromycin ophth 2erythromycin sol/swabs/gel 5erythromycin stearate 3erythromycin/benz peroxide 5erythromycin/sulfisoxazole 3Esbriet 5escitalopram 3esomeprazole magnesium 6estarylla 7estazolam 4Estraderm 6estradiol 0.01% cream 6estradiol oral 6estradiol patches 6estradiol/noreth ac 6Estrasorb packet 6Estring 6Estrogel 6estrogen/methyltesterone 6estropipate 6eszopiclone 4ethambutol 3ethosuximide 5ethynodiol-ethinyl estradiol 7etidronate 6etodolac 5etodolac SA 5etoposide 1Eucresa 5Eurax 5Evamist 6Evotaz 3Evzio 4Exelderm 5exemestane 1Exjade 1Extavia 4ezetimibe 2ezetimibe-simvastatin 2

FFabior 5Factive 3fallback solo 7falmina 7famciclovir 3famciclovir ophth 2famotidine 6Fanapt 4Fareston 1Farxiga 1Farydak 1fayosim 7Fazaclo 4FC2 Female Condom 6felbamate 5felodipine ER 2Femcap 6Femring 6femynor 7fenofibrate 2fenofibric acid, capsule DR 2fenofibric acid, tab 2fenoprofen 5fentanyl lozenge 4fentanyl patch 4 fentanyl patch 37.5mcg/hr,

62.5mcg/hr, and 87.5mcg/hr 4Fentora 4Ferriprox 1Fetzima 3Fiasp 1Finacea 5finasteride 5mg 3Fioricet/codeine 4Fiorinal/codeine 4Firazyr 2Firvanq 3Flagyl/ER 3Flarex 2flecainide 2Flector 5Flonase Allergy Relief 1Flonase Sensimist 1Flovent HFA/Diskus 5

fluconazole 3flucytosine 3fludrocortisone 4flunisolide nasal spray 1fluocinolone acetonide 5fluocinonide 5fluocinonide cream (generic Vanos) 6fluorometholone ophth 2Fluoroplex 5Fluorouracil 0.5% cream 5fluorouracil 2% sol 5fluorouracil 5% cr/sol 5fluoxetine 10mg and 20mg tablet 3fluoxetine 60mg tablet 3fluoxetine capsule 3fluoxymesterone 3fluphenazine 4flurandrenolide cream/lotion 6flurazepam 4flurbiprofen 5flurbiprofen ophth 2flutamide 1fluticasone nasal spray 1fluticasone propionate 5Fluticasone-Salmeterol 5fluvastatin 2fluvoxamine ER capsule 3fluvoxamine tablet 3FML Forte 2FML S.O.P. 2Focalin XR 4folic acid Rx 1mg tab 6Follistim AQ 6fondaparinux sodium 1Foradil 5Forfivo 3Fortamet 1Forteo 4Fortesta 3fortical NS 4Fosamax 4Fosamax D 4fosinopril 2fosinopril/HCTZ 2Fragmin 1Freestyle 2Frova 4Fulphila 1Fulyzaq 6furosemide 2Fuzeon 3Fycompa 5

Ggabapentin 5Galafold 4galantamine 1galantamine ER 1Galzin 6Gammagard Liquid 4Gammaked 4Gamunex-C 4ganciclovir 3Ganirelix 6gatifloxacin 2Gattex 6Gelnique 1gemfibrozil 2generic Adderall 4generic Adderall XR 4generic Concerta 4generic Dexedrine spansules 4gengraf 3Genotropin 4gentamicin cr/oint 5gentamicin ophth 2Genvoya 3gianvi 7Giazo 6gildagia 7gildess 7gildess 24 fe 7gildess fe 7Gilenya 4Gilotrif 1Glassia 5glatiramer acetate 4glatopa 4glimepiride 1glipizide 1glipizide ER 1glipizide/metformin 1GlucaGen 1Glucagon 1Glumetza 1glyburide 1glyburide micronized 1glycopyrrolate 6Glyxambi 1

Gocovri 5Gonal F 6Gonitro 3Gralise 4granisetron 6Granisol 6Granix 1Grastek 1griseofulvin 3Guaifenesin DM 1guaifenesin/codeine 1guanfacine 2guanfacine ER 4Gynazole-1 7gynol II 6

HHaegarda 2Halflytely 6halobetasol 5halobetasol propionate 5Halog 6haloperidol 4Harvoni 3heather 7Helidac 6Hemangeol 2Hemlibra 1heparin 1Hepsera 3Hetlioz 4Hexalen 1Hizentra 4homatropine 2Horizant 4HP Acthar Gel 4Humalog insulin 1Humatrope 4Humira 4Humulin (all types) 1Hycamtin 1Hycodan 1hydralazine 3hydrochlorothiazide 2hydrocodone/APAP 4hydrocodone/chlorpheniramine 1hydrocodone/homatropine 1hydrocodone/ibuprofen 4hydrocortisone 2.5% 5hydrocortisone butyrate/emoll cream 6hydrocortisone oral 6hydrocortisone rectal cr. & supp. 6hydrocortisone rectal enema 6hydrocortisone valerate 5hydrocortisone/iodoquinol 5hydromorphone 4hydromorphone ER 4hydroxychloroquine 4hydroxyurea 1hydroxyzine HCl 1hydroxyzine pamoate 1hyoscyamine/CR 6HyQvia 4Hysingla ER 4

Iibandronate tabs 4Ibrance 1ibuprofen 5Iclusig 1Idhifa 1Ilevro 2imatinib 1Imbruvica 1imipramine 3imiquimod 5% cream 5Imitrex 4Impavido 3Impoyz 6Imvexxy 6incassia 7Increlex 4Incruse Ellipta 5indapamide 2indomethacin 5Ingrezza 3Inlyta 1Innohep 1Innopran XL 2Intelence 3Intermezzo 4Intrarosa 6Intron A 1introvale 7Invega 4Invirase 3Invokamet 1Invokamet XR 1Invokana 1ipratropium inh. soln. 5

ipratropium nasal spray 1ipratropium/albuterol 5irbesartan 2irbesartan/HCTZ 2Iressa 1Isentress 3isibloom 7isometh/dichloralphen/APAP 4isoniazid 3isosorbide dinitrate 3isosorbide mononitrate 3isosorbide mononitrate SA 3isoxsuprine 3isradipine 2Istalol 2itraconazole 3Izba 2

JJadenu 1Jakafi 1jantoven 1Janumet 1Janumet XR 1Januvia 1Jardiance 1jencycla 7Jentadueto 1Jentadueto XR 1jinteli 6jolessa 7jolivette 7Jornay PM 4Jublia 5juleber 7Juluca 3junel 7junel fe 7Juvisync 1Juxtapid 2Jynarque 1

KK-Phos 1Kadian (40mg, 70mg, 130mg,

150mg, 200mg) 4kaitlib fe 7Kaletra 3Kalydeco 5kariva 7Kazano 1kelnor 1-35 7kelnor 1-50 7Kenalog/aerosol 6Kerydin 5Ketek 3ketoconazole 3ketoconazole 5ketoprofen 5ketorolac inj. 5ketorolac tab 5ketotifen opthalmic solution 2Keveyis 4Kevzara 4Khedezla 3kimidess 7Kineret 4Kisqali 1Kisqali Femara Co-Pack 1Kitabis Pak 3Kombiglyze XR 1Korlym 4kurvelo 7Kuvan 6Kyleena 6Kynamro 2

Llabetalol 2lactulose 6Lamisil Oral 3lamivudine tabs 3lamivudine/zidovudine 3lamotrigine 5lamotrigine ER/ODT 5Lanoxin 2lansoprazole 6lansoprazole DR ODT 6lansoprazole/amox/clarith 6lanthanum carbonate tablet 6Lantus 1larin 7larin fe 7larissia 7latanoprost 2Latuda 4layolis fe 7Lazanda 4leena 7leflunomide 4

Lenvima 1lessina 7Letairis 3letrozole 1leucovorin 6Leukeran 1Leukine 1leuprolide 1Levalbuterol Tartrate HFA 5Levemir 1levetiracetam 5Levitra 3levobunolol 2levocarnitine 6levocetirizine 1levofloxacin 3levonest 7levonorg-eth estrad eth estrad 7levonorgestrel 7levonorgestrel-eth estradiol 7levora 7levothroid 6levothyroxine 6levoxyl 6Lexiva 3Librium 4lidocaine 6lidocaine patch 6Liletta 6lillow 7Lindane 5linezolid 3Linzess 6liothyronine 6Lipofen 2lisinopril 2lisinopril/HCTZ 2lithium carbonate 4Livalo 2Lo Loestrin Fe 7lomedia 24 fe 7Lonhala Magnair 5Lonsurf 1loratadine 1loratadine-D 1lorazepam 4loryna 7losartan 2losartan/HCTZ 2Lotemax 2lovastatin 2low-ogestrel 7loxapine 4Lucemyra 4Lumigan 0.01% 2lutera 7Luzu 3Lymepak 3Lynparza 1Lyrica 5Lyrica CR 5Lysodren 1lyza 7

MMacrodantin 3maprotiline 3marlissa 7Matulane 1Mavyret 3Maxair Autohaler 5Maxalt 4Maxalt MLT 4Maxidex 2Maxitrol ophth 2meclizine 6meclofenamate 5Medrol 2mg 6medroxyprogesterone 6mefenamic acid 5mefloquine 3megestrol 1Mekinist 1Mektovi 1melodetta 24 fe 7meloxicam 5memantine 1memantine ER 1Menest 6Menopur 6Menostar 6meperidine 4mephobarbital 5Mephyton 6meprobamate 4mercaptopurine 1mesalamine DR tablet 1.2g 6mesalamine DR tablet 800mg 6mesalamine enema 6

Mesnex 1metadate ER 4metaproterenol syr 5metaxalone 4metformin 1metformin ER (generic

Glucophage XR) 1 metformin ER (not generic

Glucophage XR) 1metformin/glyburide 1methadone 4methazolamide 2methenamine combination 3Methergine 7methimazole 6methocarbamol 4methotrexate 1methotrexate 4methoxsalen capsule 5methyclothiazide 2methyldopa 2methyldopa/HCTZ 2methylergonovine maleate 7methylphenidate CD 4methylphenidate/SR 4methylprednisolone 4mg, 8mg, 16mg,

32mg 6metipranolol 2metoclopramide 6metolazone 2metoprolol 2metoprolol ER 2metoprolol/HCTZ 2metoprolol/HCTZ 2Metrogel topical 1% 5metronidazole 3metronidazole cream/lotion/0.75% gel 5mexiletine 2Miacalcin inj. 1mibelas 24 fe 7miconazole vag supp 7microgestin 7microgestin fe 7midodrine 2midodrine 2miglitol 1miglustat 4mili 7Minitran 3Minivelle 6Minocin 3minocycline 3minocycline 5minocycline HCl ER 5minoxidil oral 3Mircera 1Mirena 6mirtazapine 3Mirvaso 5misoprostol 6Mitigare 2modafinil 4moderiba 3moexipril 2mometasone cr/oint 5mometasone nasal spray 1mono-linyah 7mononessa 7montelukast 5morphine SR 4morphine sulfate ER 4morphine tab, soln, supp 4Movantik 6Moviprep 6Moxeza 2moxifloxacin 3Mulpleta 1Multaq 2multivitamin + fluoride (Rx-only) 6mupirocin 5MUSE 3my choice 7my way 7Myalept 4mycophenolate mofetil 3mycophenolic acid 3Mydayis 4Myleran 1Myrbetriq 1myzilra 7

Nnabumetone 5nadolol 2Naftin 5naltrexone 4Namzaric 1naphazoline 2naproxen/EC 5naratriptan 4

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Section ii — index (cont’d)

1010

Narcan Nasal Spray 4Nasacort Allergy 24HR 1Nasacort AQ 1Nascobal 6Natazia 7nateglinide 1Natesto 3Natpara 4Nebupent 3necon 7nefazodone 3neomycin 3neomycin/bacitracin/poly B 2neomycin/bacitracin/poly B/HC 2neomycin/polymyxin/HC otic 2Neoral 3Nerlynx 1Nesina 1Neulasta 1Neupogen 1Nevanac 2new day 7Nexavar 1Nexium 6Nexium 24HR 6Nexium/susp 6Nexplanon 6next choice one dose 7niacin ER 2niacin/simvastatin 2nicardipine 2Nicorelief gum 6Nicorelief lozenge 6Nicotine Gum 6Nicotine lozenges 6Nicotine patches various 6Nicotrol Inhaler 6Nicotrol NS 6nifediac CC 2nifedical XL 2nifedipine 2nifedipine SR 2Nikita 2nikki 7nilutamide 1nimodipine 2Ninlaro 1nisoldipine 2NitroDur patches 3nitrofurantoin 3nitrofurantoin 3nitroglycerin pumpspray 3nitroglycerin SR 3nitroglycerin transdermal patch 3Nitrostat SL tabs 3Nivestym 1nizatidine 6Nocdurna 4Noctiva 4nora-be 7Norditropin 4norethin-eth estra ferrous fum 7norethindrone 6norethindrone acetate 7norethindrone-ethin estradiol 7norgestimate-ethinyl estradiol 7norgestrel-ethiny estra 7Noritate 5norlyda 7norlyroc 7Noroxin 3Norpace CR 2Northera 2nortrel 7nortriptyline 3Norvir capsule, solution 3Novarel 6Novolin 1Novolog 1Noxafil 3Nucynta 4Nucynta ER 4Nuedexta 4Nulytely 6Nuplazid 4Nutropin/AQ 4NuvaRing 6Nymalize 2nystatin 3nystatin 5nystatin vag tab 7nystatin/triamcinolone 5nystop 5

OOcaliva 6ocella 7octreotide 4Odactra 1

Odefsey 3Odomzo 1Ofev 5ofloxacin 3ofloxacin ophth 2ofloxacin otic 2ogestrel 7olanzapine 4olanzapine/fluoxetine 4Oleptro ER 3olmesartan 2olmesartan/amlodipine 2olmesartan/amlodipine/HCTZ 2olmesartan/HCTZ 2olopatadine ophth 2Olumiant 4Olysio 3omega-3 acid ethyl esters 2omeprazole 6omeprazole/sodium bicarbonate 6Omnaris 1Omnitrope 4Omontys 1Omtryg 2ondansetron 6OneTouch Test Strips 2Onexton 5Onglyza 1Onzetra 4opcicon one-step 7Opsumit 3option 2 7Oracea 5Oracit 1Oralair 1Oravig 3Orencia SC 4Orenitram 3Orfadin 6Orilissa 6Orkambi 5Orkambi granules 5orphenadrine 4orsythia 7Ortho-Est 6oseltamivir 3Oseni 1Osmolex ER 5Osphena 6Otezla 4Otrexup 4Ovidrel 6oxaprozin 5oxazepam 4oxcarbazepine 5oxiconazole cream 5Oxistat lotion 5Oxtellar XR 5oxybutynin 1oxybutynin ER 1oxycodone 4Oxycodone ER 4oxycodone/acetaminophen 4oxycodone/aspirin 4oxycodone/ibuprofen 4Oxycontin 4oxymorphone/ER 4Oxytrol 1Oxytrol for Women 1Ozempic 1

Ppaliperidone 4Palynziq 6Pancreaze 6Panretin 5pantoprazole 6Paragard 6paregoric 6paricalcitol 6paromomycin 3paroxetine 3paroxetine 7.5mg 6Pataday 2Pazeo 2PCE 3Pediatric sodium fluoride chewable tab

& drops 6peg 3350/electrolyte 6Peg-Intron 3Peganone 5Pegasys 3penicillin VK 3Pennsaid 5Pentasa 6pentazocine/naloxone 4pentoxifylline 1Perforomist 5pergolide 5

perindopril 2permethrin 5perphenazine 4Pertzye 6Pexeva 4phenazopyridine 1phendimetrazine 6phenelzine 3phenobarbital 5phenoxybenzamine 2phentermine 6phenylephrine ophth 2phenytoin 5philith 7Phisohex 5Phospholine Iodide 2phytonadione 6Picato 5pilocarpine 2pimtrea 7pindolol 2pioglitazone/metformin 1pirmella 7piroxicam 5Plegridy 4podofilox 5Poly-Vi-Flor +> Iron 6polymyxin B/TMP 2Pomalyst 1portia 7potassium aminobenzoate 6potassium bicarb/potassium

chloride 5potassium bicarbonate 5potassium chloride 5potassium citrate 1Potiga 5Pradaxa 1Praluent 2pramipexole 5pramipexole ER 5pramoxine/HC acetate 2.5% 6prascion RA 5prasugrel 1pravastatin 2prazosin 2pre-natal vitamins (Rx-only) 6Precision 2Pred Mild 2Pred-G 2prednicarbate 5prednisolone acetate 2prednisolone oral 6prednisolone sod phosphate 2prednisone oral 6Prefest 6Pregnyl 6Premarin 6Premarin vag cream 6Premphase 6Prempro 6Prenate Elite 6Prepopik 6Prestalia 2Prevacid 6Prevacid 24HR 6Prevacid Solutab 6previfem 7Prevymis tablets 3Prexxartan 2Prezcobix 3Prezista 3Prilosec 6Prilosec-OTC 6Primaquine 3primidone 5ProAir HFA/RespiClick 5probenecid 2procainamide 2procentra 4prochlorperazine 6Procrit 1Proctofoam-HC 6Procysbi 4progesterone in oil 6progesterone, micronized 6Prograf 3Prolensa 2Promacta 1promethazine 6promethazine/codeine 1promethazine/DM 1promethazine/phenylephrine/

codeine 1propafenone 2propafenone SR 2propantheline bromide 6propranolol 2propranolol/HCTZ 2

propylthiouracil 6Protonix 6protriptyline 3Proventil HFA 5pseudoephedrine 1pseudoephedrine/codeine 1Pulmicort flexhaler/powder 5Pulmicort respules (1mg/2ml) 5Pulmozyme 5Purixan 1Pylera 6pyrazinamide 3

QQbrelis 2Qbrexza 5Qnasl 1Qsymia 6Qtern 2quasense 7Qudexy XR 5quetiapine 4quetiapine fumarate ER 4Quillichew ER 4Quillivant XR 4quinapril 2quinapril/HCTZ 2quinidine gluconate 2quinidine sulfate SR 2quinine sulfate 3Qvar 5

Rrabeprazole 6Ragwitek 1rajani 7raloxifene 1raloxifene 4ramipril 2Ranexa 2ranitidine (all) 6Rapaflo 3Rapamune solution 3rasagiline 5Rasuvo 4Ravicti 4Rayaldee 6Rayos 6react 7Rebetol 3Rebif 4reclipsen 7Rectiv 6Regenecare 5Regranex 5Relenza 3Relistor injection 6Relistor tablets 6Relpax 4Renagel 6Renvela 6repaglinide 1repaglinide/metformin 2Repatha 2Repronex 6Rescriptor 3Rescula 2Restasis 2Retacrit 1Revlimid 1Rexulti 4Rhinocort Allergy 1Rhopressa 2ribapak 3ribasphere 3Ribatab 3ribavirin 3Ridaura 4rifabutin 3Rifamate 3rifampin 3Rifater 3riluzole 4rimantadine 3Riomet solution 1risedronate 150mg 4risedronate DR 4risperidone 4risperidone m-tab 4Ritalin LA 10mg, 60mg 4ritonavir tablet 3rivastigmine 1rivastigmine patch 1rivelsa 7rizatriptan 4Rondec DM/TR 1ropinirole 5ropinirole ER 5rosuvastatin 2Roxicet Soln 4

Rozerem 4Rubraca 1Ruconest 2Rydapt 1Rytary 5

SSabril 5Saizen 4salsalate 4Samsca 2Sanctura 1Sanctura XR 1Sancuso 6Sandimmune 3Sandostatin 4Sandostatin LAR 4Saphris 4Sarafem 4Savaysa 1Savella 4Saxenda 6scopolamine patch 6Seebri 5Segluromet 2selegiline 5selenium sulf 2.5% suspension 6Selzentry 3Semprex-D 1Sensipar 4Serevent Diskus 5serophene 6Serostim 4sertraline 3setlakin 7sevelamer 6sharobel 7Signifor 4sildenafil citrate 20mg 3sildenafil citrate 25mg, 50mg,

100mg 3Silenor 4Siliq 5silver sulfadiazine 5Simponi 4simvastatin 2sirolimus 3Sirturo 3Sitavig 3Sivextro 3Sklice 5Skyla 6sod. polystyrene sulfonate 5sod. sulfacetamide/sulfur emulsion

cleanser 5sod. sulfacetamide/sulfur lot 5sodium chloride irrigating soln 5sodium phenylbutyrate 4sodium sulfacetamide 5Soliqua 1Solodyn 5Somatuline Depot 4Somavert 4Somnote 4Sonata 4Soolantra 5sotalol 2sotret 5Sovaldi 3Spectracef 3spinosad 5Spiriva 5Spiriva Respimat 5spironolactone 2spironolactone/HCTZ 2Sporanox suspension 3sprintec 7Sprix 5Sprycel 1sronyx 7stavudine 3Staxyn 3Steglatro 2Steglujan 2Stelara 5Stendra 3Stimate 4Stiolto Respimat 5Stivarga 1Strensiq 1Striant 3Stribild 3Striverdi Respimat 5Suboxone film 4Subsys 4Suclear 6sucralfate 6sulfacetamide 10% 2sulfacetamide/prednisolone ophth 2

sulfamethoxazole/trimethoprim 3sulfasalazine 6sulfasalazine EC 6sulindac 5sumatriptan 4Sumavel 4Suprax 3Suprenza ODT 6Suprep 6Sutent 1syeda 7Sylatron 1Symbicort 5Symdeko 5Symfi 3Symfi Lo 3Symjepi 5Symlin 1Symproic 6Synarel 4Syndros 6Synjardy 1Synjardy XR 1Synribo 1Synthroid 6

TTaclonex 5tacrolimus 3tacrolimus 5tadalafil (generic Adcirca) 3tadalafil (generic Cialis) 3Tafinlar 1Tagrisso 1Takhzyro 2Taltz 5Talzenna 1tamoxifen 1tamsulosin 3Tanzeum 1Tarceva 1Targretin gel 1tarina fe 7Tasigna 1Tavalisse 1Taytulla 7tazarotene cream 5Tazorac gel 5Tecfidera 4Technivie 3Tegretol 5Tegretol XR 100mg 5Tegsedi 4Tekturna 2Tekturna HCT 2telmisartan 2telmisartan/amlodipine 2telmisartan/HCTZ 2temazepam 4Temodar 1temozolomide 1tenofovir 300mg 3terazosin 2terbinafine 3terbutaline tab 5terconazole 7Testim 3testosterone cypionate 3testosterone enanthate 3Testosterone gel (brand) 3tetrabenazine 3tetracycline 3Tev-Tropin 4Thalomid 1Theo-24 5theochron 5theophylline/SR tabs, liquid 5thioridazine 4thiothixene 4thyroid 6Thyroid (Armour) 6Thyrolar 6tiagabine 5Tibsovo 1ticlopidine 1tilia fe 7timolol 2timolol 2tinidazole 3Tivicay 3Tivorbex 5tizanidine 4Tobi 3Tobi Podhaler 3Tobradex ointment 2Tobradex ST 2tobramycin ampule/neb 3tobramycin soln 2tobramycin/dexameth 2

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Section ii — index (cont’d)

1111

Tobrex ointment 2Tobrex solution 2Today Contraceptive Sponge 6tolazamide 1tolbutamide 1tolcapone 5tolmetin 5tolterodine 1tolterodine ER 1topiramate 5topiramate ER 5torsemide 2Toujeo 1Toviaz 1Tracleer 3Tradjenta 1tramadol ER capsule 4tramadol/acetaminopen 4tramadol/ER tablet 4trandolapril 2trandolapril/verapamil 2tranylcypromine 3Travatan Z 2travoprost 2trazodone 3Trelegy Ellipta 5Tremfya 5Tresiba 1tretinoin cr/gel 5tretinoin microsphere 5Trexall 1Treximet 4Trezix 4tri femynor 7tri-estarylla 7tri-legest fe 7tri-linyah 7tri-lo-estarylla 7tri-lo-marzia 7tri-lo-sprintec 7tri-mili 7tri-previfem 7tri-sprintec 7

Tri-Vi-Flor 6tri-vylibra 7triamcinolone acetonide 5triamcinolone nasal spray 1triamterene/HCTZ 2triazolam 4trientine 1trifluoperazine 4trifluridine 2trihexyphenidyl 5Trilyte 6trimethobenzamide 6trimethoprim 3trinessa 7trinessa lo 7Trintellix 4Triumeq 3trivora 7Trokendi XR 5tropicamide 2trospium 1trospium ER 1TRUEtest 2TRUEtrack 2Trulance 6Trulicity 1Truvada 3Tudorza 5tulana 7Tybost 3tydemy 7Tykerb 1Tylenol/codeine 4Tymlos 4Tyvaso 3Tyzeka 3

UUceris 6Ulesfia 5Uloric 2Ultresa 6unithroid 6

Uptravi 3Urecholine 1ursodiol 6Utibron 5

Vvalacyclovir 3Valchlor 1valganciclovir solution 3valganciclovir tablets 3valproic acid 5valsartan 2valsartan/HCTZ 2Valtrex 3Vancocin 3vancomycin caps 3vandazole vag 7Varubi 6Vascepa 2VCF 6Vecamyl 2veletri 3velivet 7Velphoro 6Veltassa 4Veltin gel 5Vemlidy 3Venclexta 1venlafaxine 3venlafaxine ER 3Ventavis 3Ventolin HFA 5verapamil/SR 2Versacloz 4Verzenio 1Vesicare 1vestura 7Viagra 3Vibramycin 3Vicodin/ES 4Victoza 1Victrelis 3Videx 3

Viekira 3Viekira XR 3vienva 7vigabatrin oral powder 5Vigamox 2Viibryd 3Vimovo 5Vimpat 5Viokace 6viorele 7Viracept 3Viramune, XR 3Viread 150mg, 200mg, 250mg,

40mg/scoop powder 3vit A,D,C + fluoride (Rx-only) 6vit A,D,C + fluoride and iron (Rx-only) 6Vitekta 3Vituz 1Vivlodex 5Vizimpro 1Vogelxo 3voriconazole 3Vosevi 3Votrient 1Vraylar 4vyfemla 7vylibra 7Vyvanse 4Vyzulta 2

Wwarfarin 1wera 7wymzya fe 7

XXadago 5Xalatan 2Xalkori 1Xarelto 1Xartemis XR 4Xatmep 1Xeljanz 4

Xeljanz XR 4Xenical 6Xepi 5Xermelo 6Xhance 1Xifaxan 3Xigduo XR 1Xiidra 2Ximino 5Xopenex HFA 5Xtampza ER 4Xtandi 1Xtoro 2xulane 6Xultophy 1Xuriden 4Xyrem 4

YYonsa 1Yosprala 4yuvafem 6

ZZaditor 2zafirlukast 5zaleplon 4zarah 7Zarxio 1Zavesca 4Zecuity 4Zegerid 6Zegerid OTC 6Zejula 1Zelboraf 1Zembrace 4zenchent 7zenchent fe 7Zenpep 6zenzedi 5mg, 10mg 4zeosa 7Zepatier 3Zerviate 2

Zetonna 1Ziagen 3Ziana gel 5zidovudine 3zileuton ER 5Zioptan 2ziprasidone caps 4Zmax 3Zohydro ER 4Zolinza 1zolmitriptan 4zolpidem 4zolpidem ER 4zolpidem ER sublingual tablet 4Zolpimist 4Zomig 4Zomig Nasal 4Zomig ZMT 4zonisamide 5Zontivity 1Zontivity 1Zorbtive 4Zortress 3Zorvolex 5zovia 7Zovirax Cream 6Zubsolv 4Zuplenz 6Zurampic 2Zyban 6Zydelig 1Zyflo 5Zykadia 1Zylet 2Zypitamag 2Zyprexa 4Zyprexa Zydis 4Zytiga 1

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Section ii — index (cont’d)