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MetroPlus Health Plan (10/01/2020) INTRODUCTION ..................................................................................................................................................................................................... 4PREFACE ............................................................................................................................................................................................................... 4DRUG LIST PRODUCT DESCRIPTIONS .............................................................................................................................................................. 4GENERIC SUBSTITUTION ..................................................................................................................................................................................... 5NON-COVERED MEDICATIONS ........................................................................................................................................................................... 5OVER-THE-COUNTER DRUG COVERAGE .......................................................................................................................................................... 5SPECIALTY PLAN DESIGN ................................................................................................................................................................................... 5PLAN DESIGN ........................................................................................................................................................................................................ 6LEGEND .................................................................................................................................................................................................................. 6NOTICE ................................................................................................................................................................................................................... 6ANALGESICS ......................................................................................................................................................................................................... 7

NSAIDs ......................................................................................................................................................................................................... 7COX-2 INHIBITORS ..................................................................................................................................................................................... 7GOUT ............................................................................................................................................................................................................ 7OPIOID ANALGESICS ................................................................................................................................................................................. 7NON-OPIOID ANALGESICS ........................................................................................................................................................................ 8

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

ANTINEOPLASTIC AGENTS ............................................................................................................................................................................... 11ALKYLATING AGENTS .............................................................................................................................................................................. 11ANTIMETABOLITES ................................................................................................................................................................................... 11HORMONAL ANTINEOPLASTIC AGENTS ............................................................................................................................................... 12IMMUNOMODULATORS ............................................................................................................................................................................ 12KINASE INHIBITORS ................................................................................................................................................................................. 12MISCELLANEOUS ..................................................................................................................................................................................... 13

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

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

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ANTIDEMENTIA ......................................................................................................................................................................................... 18ANTIDEPRESSANTS ................................................................................................................................................................................. 18ANTIPARKINSONIAN AGENTS ................................................................................................................................................................. 19ANTIPSYCHOTICS .................................................................................................................................................................................... 19ATTENTION DEFICIT HYPERACTIVITY DISORDER ............................................................................................................................... 19FIBROMYALGIA ......................................................................................................................................................................................... 20HYPNOTICS ............................................................................................................................................................................................... 20MIGRAINE .................................................................................................................................................................................................. 20MOOD STABILIZERS ................................................................................................................................................................................. 20MULTIPLE SCLEROSIS AGENTS ............................................................................................................................................................. 20MUSCULOSKELETAL THERAPY AGENTS .............................................................................................................................................. 20MYASTHENIA GRAVIS .............................................................................................................................................................................. 21NARCOLEPSY ........................................................................................................................................................................................... 21PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................ 21

ENDOCRINE AND METABOLIC .......................................................................................................................................................................... 21ANDROGENS ............................................................................................................................................................................................. 21ANTIDIABETICS ......................................................................................................................................................................................... 22CALCIUM REGULATORS .......................................................................................................................................................................... 23CONTRACEPTIVES ................................................................................................................................................................................... 23ENDOMETRIOSIS ...................................................................................................................................................................................... 24ESTROGENS ............................................................................................................................................................................................. 24ESTROGEN/PROGESTINS ....................................................................................................................................................................... 25FERTILITY REGULATORS ........................................................................................................................................................................ 25GLUCOCORTICOIDS ................................................................................................................................................................................. 25GLUCOSE ELEVATING AGENTS ............................................................................................................................................................. 25HUMAN GROWTH HORMONES ............................................................................................................................................................... 25HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................ 25PHENYLKETONURIA TREATMENT AGENTS .......................................................................................................................................... 25PHOSPHATE BINDER AGENTS ............................................................................................................................................................... 25POTASSIUM-REMOVING AGENTS .......................................................................................................................................................... 25PROGESTINS ............................................................................................................................................................................................ 26SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................ 26THYROID AGENTS .................................................................................................................................................................................... 26UREA CYCLE DISORDERS ....................................................................................................................................................................... 26VASOPRESSIN RECEPTOR ANTAGONISTS .......................................................................................................................................... 26VASOPRESSINS ........................................................................................................................................................................................ 26MISCELLANEOUS ..................................................................................................................................................................................... 26

GASTROINTESTINAL .......................................................................................................................................................................................... 26ANTIDIARRHEALS ..................................................................................................................................................................................... 26ANTIEMETICS ............................................................................................................................................................................................ 26ANTISPASMODICS .................................................................................................................................................................................... 27CHOLELITHOLYTICS ................................................................................................................................................................................ 27H2 RECEPTOR ANTAGONISTS ................................................................................................................................................................. 27INFLAMMATORY BOWEL DISEASE ......................................................................................................................................................... 27LAXATIVES/STOOL SOFTENERS ............................................................................................................................................................ 27OPIOID-INDUCED CONSTIPATION .......................................................................................................................................................... 27PANCREATIC ENZYMES .......................................................................................................................................................................... 27PROSTAGLANDINS ................................................................................................................................................................................... 27PROTON PUMP INHIBITORS .................................................................................................................................................................... 27SALIVA STIMULANTS ................................................................................................................................................................................ 27STEROIDS, RECTAL ................................................................................................................................................................................. 28MISCELLANEOUS ..................................................................................................................................................................................... 28

GENITOURINARY ................................................................................................................................................................................................ 28BENIGN PROSTATIC HYPERPLASIA ....................................................................................................................................................... 28URINARY ANTISPASMODICS ................................................................................................................................................................... 28VAGINAL ANTI-INFECTIVES ..................................................................................................................................................................... 28MISCELLANEOUS ..................................................................................................................................................................................... 28

HEMATOLOGIC .................................................................................................................................................................................................... 28ANTICOAGULANTS ................................................................................................................................................................................... 28HEMATOPOIETIC GROWTH FACTORS ................................................................................................................................................... 29PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ....................................................................................................... 29PLATELET AGGREGATION INHIBITORS ................................................................................................................................................. 29PLATELET SYNTHESIS INHIBITORS ....................................................................................................................................................... 29THROMBOCYTOPENIA AGENTS ............................................................................................................................................................. 29MISCELLANEOUS ..................................................................................................................................................................................... 29

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IMMUNOLOGIC AGENTS .................................................................................................................................................................................... 29AUTOIMMUNE AGENTS ............................................................................................................................................................................ 29DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................ 29HEREDITARY ANGIOEDEMA AGENTS .................................................................................................................................................... 30IMMUNOMODULATORS ............................................................................................................................................................................ 30IMMUNOSUPPRESSANTS ........................................................................................................................................................................ 30

NUTRITIONAL/SUPPLEMENTS .......................................................................................................................................................................... 30ELECTROLYTES ........................................................................................................................................................................................ 30VITAMINS AND MINERALS ....................................................................................................................................................................... 30

RESPIRATORY ..................................................................................................................................................................................................... 31ANAPHYLAXIS TREATMENT AGENTS .................................................................................................................................................... 31ANTICHOLINERGICS ................................................................................................................................................................................ 31ANTICHOLINERGIC/BETA AGONIST COMBINATIONS .......................................................................................................................... 31ANTIHISTAMINES, LOW SEDATING ........................................................................................................................................................ 31ANTIHISTAMINES, SEDATING ................................................................................................................................................................. 31ANTIHISTAMINE/DECONGESTANT COMBINATIONS ............................................................................................................................ 31ANTITUSSIVES .......................................................................................................................................................................................... 31ANTITUSSIVE COMBINATIONS ................................................................................................................................................................ 32BETA AGONISTS ....................................................................................................................................................................................... 32CYSTIC FIBROSIS ..................................................................................................................................................................................... 32LEUKOTRIENE MODULATORS ................................................................................................................................................................ 32MAST CELL STABILIZERS ........................................................................................................................................................................ 32MEDICAL SUPPLIES ................................................................................................................................................................................. 32NASAL ANTIHISTAMINES ......................................................................................................................................................................... 32NASAL STEROIDS ..................................................................................................................................................................................... 32RESPIRATORY SYNCYTIAL VIRUS ......................................................................................................................................................... 32SEVERE ASTHMA AGENTS ...................................................................................................................................................................... 33STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................ 33STEROID INHALANTS ............................................................................................................................................................................... 33XANTHINES ............................................................................................................................................................................................... 33MISCELLANEOUS ..................................................................................................................................................................................... 33

TOPICAL ............................................................................................................................................................................................................... 33DERMATOLOGY ........................................................................................................................................................................................ 33MOUTH/THROAT/DENTAL AGENTS ........................................................................................................................................................ 35OPHTHALMIC ............................................................................................................................................................................................ 35OTIC ........................................................................................................................................................................................................... 36

WEBSITES ............................................................................................................................................................................................................ 37INDEX .................................................................................................................................................................................................................... 39

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INTRODUCTION We are pleased to provide the 2020 MetroPlus Health Plan Formulary as a useful reference and informational tool. This document can assist medical providers in selecting clinically appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the Websites section of this publication.

PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable oral dosage forms and strengths of the drug cited are included in the document. Drugs represented in this document may have varying cost to the plan member based on the plan's benefit structure. Generic medications typically are available at the lower cost, brand-name medications on the document will generally cost more than generics. Generics should be considered the first line of prescribing subject to applicable rules.

DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the document. Any exceptions are noted. Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg, 10

mg Nexium suspension

The oral suspension dosage form of Nexium is on the document. From this entry, the oral capsule cannot be assumed to be on the list unless there is a separate entry. Extended-release and delayed-release products require their own entry. tofacitinib Xeljanz The immediate-release product listing of Xeljanz alone would not include the extended-release product Xeljanz XR. tofacitinib ext-rel Xeljanz XR A separate entry for Xeljanz XR confirms that the extended-release product is on the document.

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Dosage forms on the document will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the document.

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 most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product to the market. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration (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 extent compared to the brand-name drug (bioequivalence). 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 (therapeutic equivalence).

NON-COVERED MEDICATIONS • Pharmaceuticals determined by the FDA to be less than effective and identical, related, or similar drugs

(commonly referred to as DESI 5 and 6 drugs). • MetroPlus only covers drugs from manufacturers participating in the Federal Medicaid drug rebate program.

OVER-THE-COUNTER DRUG COVERAGE MetroPlus covers over-the-counter (OTC) drugs that obtain fiscal orders that meet Medicaid criteria. These include select medications in the following categories: analgesic and antipyretic, antacid, anti-diarrheal, antihistamine, anti-vertigo, artificial tears and ocular/oral lubricants, chronic renal disease, cough and cold, dermatological, family planning, fecal softener and laxative, hematinic, insulin, pediculicide, smoking cessation agents, and vitamins/minerals. All categories are represented on the formulary. However, not every item made by every manufacturer is covered. Furthermore, not all formulations and/or package sizes are covered. Quantities may also be limited based on acute/episodic vs. chronic/maintenance uses. For the most up-to-date list of covered OTC products, please reference: https://www.emedny.org/info/formfile.aspx

SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM) SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to help ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the document as “SGM” for your reference. Prescribers may call 1-866-814-5506 to enroll patients in Specialty plan design.

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PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.

LEGEND

AL Age Limit OTC Over the counter PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit SGM Specialty Guideline Management ST Step Therapy boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the

listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for

clarification

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2020. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. MetroPlus Health Plan does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by MetroPlus Health Plan. Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.

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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org NSAIDs diclofenac sodium delayed-rel diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN naproxen sodium oxaprozin DAYPRO sulindac COX-2 INHIBITORS PA celecoxib CELEBREX GOUT allopurinol ZYLOPRIM QL colchicine tabs COLCRYS probenecid 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 The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MMEs) per day based on a 30-day supply. Members may be subject to additional quantity limit restrictions, including a first-fill limit of 7 days (for members who are opioid-naïve) and 90 days of treatment per 365 days. QL codeine/acetaminophen PA, QL fentanyl transdermal DURAGESIC QL hydrocodone/acetaminophen NORCO PA, QL hydromorphone ext-rel QL hydromorphone tabs DILAUDID PA, QL methadone tabs 5 mg, 10 mg DOLOPHINE QL morphine PA, QL morphine ext-rel MS CONTIN QL oxycodone QL oxycodone ROXICODONE QL oxycodone/acetaminophen PERCOCET QL oxycodone/acetaminophen solution QL oxycodone/aspirin PERCODAN QL tramadol 50 mg ULTRAM

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PA, QL tramadol ext-rel tabs QL tramadol/acetaminophen ULTRACET NON-OPIOID ANALGESICS QL butalbital/acetaminophen/caffeine ESGIC QL butalbital/aspirin/caffeine FIORINAL ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Aminoglycosides neomycin Cephalosporins Cephalosporin Combinations PA ceftolozane/tazobactam ZERBAXA First Generation cefadroxil cephalexin KEFLEX Second Generation cefprozil cefuroxime axetil Third Generation cefdinir Erythromycins/Macrolides azithromycin ZITHROMAX clarithromycin

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clarithromycin ext-rel erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate E.E.S. erythromycin stearate Fluoroquinolones ciprofloxacin tabs CIPRO levofloxacin Penicillins amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin G BICILLIN L-A penicillin VK Sulfonamides sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS Tetracyclines doxycycline monohydrate caps 50 mg, 100 mg doxycycline monohydrate suspension VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 75 mg, 100 mg minocycline MINOCIN tetracycline ANTIFUNGALS clotrimazole troches fluconazole DIFLUCAN griseofulvin microsize suspension griseofulvin ultramicrosize PA, QL itraconazole caps SPORANOX nystatin QL terbinafine tabs PA voriconazole VFEND ANTIMALARIALS QL atovaquone/proguanil MALARONE QL chloroquine QL mefloquine ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants QL cobicistat TYBOST Antiretroviral Combinations QL abacavir/dolutegravir/lamivudine TRIUMEQ QL abacavir/lamivudine EPZICOM QL abacavir/lamivudine/zidovudine TRIZIVIR QL atazanavir/cobicistat EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY QL darunavir/cobicistat PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL dolutegravir/lamivudine DOVATO

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QL dolutegravir/rilpivirine JULUCA QL efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD QL emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA QL, * emtricitabine/tenofovir alafenamide DESCOVY QL, * emtricitabine/tenofovir disoproxil fumarate TRUVADA QL lamivudine/tenofovir disoproxil fumarate CIMDUO QL lamivudine/zidovudine COMBIVIR * Documentation may be required for select instances in which product labeling dictates monitoring Chemokine Receptor Antagonists QL maraviroc SELZENTRY Integrase Inhibitors QL dolutegravir TIVICAY QL raltegravir ISENTRESS Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz SUSTIVA QL etravirine INTELENCE QL nevirapine VIRAMUNE QL nevirapine ext-rel VIRAMUNE XR QL rilpivirine EDURANT Nucleoside Reverse Transcriptase Inhibitors QL abacavir ZIAGEN QL didanosine delayed-rel QL emtricitabine EMTRIVA QL lamivudine EPIVIR QL stavudine QL zidovudine RETROVIR Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate VIREAD Protease Inhibitors QL atazanavir REYATAZ QL darunavir PREZISTA QL fosamprenavir LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir KALETRA QL nelfinavir VIRACEPT QL ritonavir NORVIR QL saquinavir mesylate INVIRASE QL tipranavir APTIVUS ANTITUBERCULAR AGENTS ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN

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ANTIVIRALS Cytomegalovirus Agents QL valganciclovir VALCYTE Hepatitis Agents Hepatitis B adefovir dipivoxil HEPSERA entecavir solution BARACLUDE entecavir tabs BARACLUDE lamivudine tabs EPIVIR-HBV Hepatitis C #, SGM glecaprevir/pibrentasvir MAVYRET SGM ribavirin caps, tabs 200mg SGM sofosbuvir/velpatasvir # MAVYRET for genotypes 1, 2, 3, 4, 5, 6 Herpes Agents acyclovir caps, suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX Influenza Agents QL oseltamivir TAMIFLU MISCELLANEOUS ST atovaquone MEPRON clindamycin CLEOCIN dapsone ivermectin STROMECTOL PA linezolid ZYVOX PA linezolid injection ZYVOX QL mebendazole EMVERM metronidazole FLAGYL nitrofurantoin ext-rel MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin suspension PA pyrimethamine DARAPRIM rifabutin MYCOBUTIN trimethoprim QL vancomycin VANCOCIN ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide caps lomustine GLEOSTINE melphalan ALKERAN SGM temozolomide TEMODAR ANTIMETABOLITES SGM capecitabine XELODA

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mercaptopurine methotrexate TREXALL HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide CASODEX SGM enzalutamide XTANDI flutamide Antiestrogens SGM fulvestrant FASLODEX tamoxifen toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Luteinizing Hormone-Releasing Hormone (LHRH) Agonists SGM goserelin acetate ZOLADEX SGM leuprolide acetate SGM leuprolide acetate LUPRON DEPOT SGM triptorelin pamoate TRELSTAR Gonadotropin Releasing Hormone (GnRH) Antagonists SGM degarelix acetate FIRMAGON Progestins megestrol acetate MEGACE IMMUNOMODULATORS SGM lenalidomide REVLIMID KINASE INHIBITORS SGM afatinib GILOTRIF SGM axitinib INLYTA SGM bosutinib BOSULIF SGM, QL cabozantinib CABOMETYX SGM cabozantinib COMETRIQ SGM ceritinib ZYKADIA SGM dabrafenib TAFINLAR SGM dasatinib SPRYCEL SGM erlotinib TARCEVA SGM everolimus AFINITOR SGM ibrutinib IMBRUVICA SGM idelalisib ZYDELIG SGM imatinib mesylate GLEEVEC SGM lapatinib TYKERB SGM lenvatinib LENVIMA SGM midostaurin RYDAPT SGM nilotinib TASIGNA SGM palbociclib IBRANCE SGM pazopanib VOTRIENT SGM ponatinib ICLUSIG SGM regorafenib STIVARGA SGM ruxolitinib JAKAFI SGM sorafenib NEXAVAR

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SGM sunitinib SUTENT SGM trametinib MEKINIST SGM vandetanib CAPRELSA SGM vemurafenib ZELBORAF MISCELLANEOUS SGM bexarotene caps TARGRETIN etoposide hydroxyurea HYDREA leucovorin mitotane LYSODREN SGM niraparib ZEJULA SGM olaparib LYNPARZA SGM panobinostat FARYDAK procarbazine MATULANE SGM rucaparib RUBRACA tretinoin caps QL uridine triacetate VISTOGARD SGM venetoclax VENCLEXTA SGM vismodegib ERIVEDGE SGM vorinostat ZOLINZA CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org benazepril LOTENSIN captopril enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL ramipril ALTACE trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC quinapril/hydrochlorothiazide ACCURETIC

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ADRENOLYTICS, CENTRAL clonidine CATAPRES clonidine transdermal CATAPRES-TTS guanfacine ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone INSPRA spironolactone ALDACTONE ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 doxazosin CARDURA prazosin MINIPRESS terazosin 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 irbesartan AVAPRO irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR valsartan DIOVAN valsartan/hydrochlorothiazide DIOVAN HCT ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org amiodarone disopyramide NORPACE disopyramide ext-rel NORPACE CR SGM dofetilide TIKOSYN flecainide propafenone propafenone ext-rel RYTHMOL SR sotalol BETAPACE sotalol BETAPACE AF 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 QUESTRAN/QUESTRAN LIGHT colestipol COLESTID Cholesterol Absorption Inhibitors ezetimibe ZETIA Fibrates fenofibrate fenofibrate TRICOR

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gemfibrozil LOPID HMG-CoA Reductase Inhibitors atorvastatin LIPITOR lovastatin pravastatin PRAVACHOL ST rosuvastatin CRESTOR simvastatin ZOCOR Niacins niacin ext-rel NIASPAN Omega-3 Fatty Acids PA icosapent ethyl VASCEPA PCSK9 Inhibitors SGM evolocumab REPATHA BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol TENORMIN bisoprolol carvedilol COREG labetalol metoprolol succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol 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 TENORETIC bisoprolol/hydrochlorothiazide ZIAC metoprolol/hydrochlorothiazide LOPRESSOR HCT CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine NORVASC felodipine ext-rel nifedipine ext-rel nifedipine ext-rel PROCARDIA XL Nondihydropyridines diltiazem CARDIZEM diltiazem ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC diltiazem ext-rel, except 120 mg CARDIZEM LA verapamil ext-rel CALAN SR

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verapamil ext-rel VERELAN PM DIGITALIS GLYCOSIDES digoxin LANOXIN digoxin pediatric elixir DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide Loop Diuretics bumetanide furosemide LASIX torsemide Potassium-sparing Diuretics amiloride Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE HEART FAILURE ivabradine CORLANOR sacubitril/valsartan ENTRESTO NITRATES Oral isosorbide dinitrate oral ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel nitroglycerin ext-rel Sublingual nitroglycerin sublingual NITROSTAT Transdermal nitroglycerin ointment NITRO-BID nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists SGM ambrisentan LETAIRIS SGM bosentan TRACLEER Phosphodiesterase Inhibitors SGM sildenafil REVATIO

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Prostaglandin Vasodilators SGM epoprostenol sodium FLOLAN SGM iloprost VENTAVIS SGM treprostinil REMODULIN SGM treprostinil TYVASO MISCELLANEOUS hydralazine methyldopa midodrine CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines QL alprazolam XANAX QL chlordiazepoxide QL clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL oxazepam Miscellaneous buspirone QL* clomipramine ANAFRANIL fluvoxamine QL* Only applies to members of age 65 and older ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN QL gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA levetiracetam injection KEPPRA oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic acid SGM vigabatrin SABRIL zonisamide ZONEGRAN

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ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com donepezil ARICEPT galantamine RAZADYNE galantamine ext-rel RAZADYNE ER PA* memantine NAMENDA PA rivastigmine caps, solution PA rivastigmine transdermal EXELON PATCH PA* Only applies to members < 30 years of age 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) isocarboxazid MARPLAN phenelzine NARDIL tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram CELEXA escitalopram LEXAPRO fluoxetine PROZAC paroxetine HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL sertraline ZOLOFT Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) PA duloxetine delayed-rel CYMBALTA venlafaxine venlafaxine ext-rel EFFEXOR XR Tricyclic Antidepressants (TCAs) QL* amitriptyline QL* desipramine NORPRAMIN QL* doxepin QL* imipramine HCl QL* nortriptyline PAMELOR QL* Only applies to members of age 65 and older Miscellaneous Agents bupropion bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON trazodone

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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 benztropine PA bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel carbidopa/levodopa orally disintegrating tabs carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole MIRAPEX ropinirole selegiline trihexyphenidyl ANTIPSYCHOTICS Atypicals aripiprazole ABILIFY aripiprazole ext-rel injection ABILIFY MAINTENA aripiprazole lauroxil ext-rel injection ARISTADA aripiprazole lauroxil ext-rel injection ARISTADA INITIO aripiprazole orally disintegrating tabs PA asenapine SAPHRIS clozapine CLOZARIL clozapine orally disintegrating tabs PA iloperidone FANAPT PA lurasidone LATUDA olanzapine ZYPREXA PA paliperidone ext-rel INVEGA paliperidone palmitate ext-rel injection INVEGA SUSTENNA paliperidone palmitate ext-rel injection INVEGA TRINZA quetiapine SEROQUEL PA quetiapine ext-rel SEROQUEL XR risperidone RISPERDAL risperidone long-acting injection RISPERDAL CONSTA ziprasidone GEODON Miscellaneous chlorpromazine fluphenazine fluphenazine decanoate injection fluphenazine injection haloperidol haloperidol decanoate injection HALDOL DECANOATE haloperidol lactate injection HALDOL perphenazine SGM pimavanserin NUPLAZID thiothixene trifluoperazine 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 QL amphetamine/dextroamphetamine mixed salts ADDERALL

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QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR ST, QL atomoxetine STRATTERA QL dexmethylphenidate FOCALIN QL dextroamphetamine ext-rel DEXEDRINE SPANSULE QL dextroamphetamine tabs 5 mg, 10 mg QL methylphenidate RITALIN QL methylphenidate ext-rel QL methylphenidate ext-rel CONCERTA ST, QL methylphenidate ext-rel 20 mg, 30 mg, 40 mg RITALIN LA QL methylphenidate ext-rel tabs 20 mg - Metadate ER QL methylphenidate solution, tabs METHYLIN FIBROMYALGIA PA milnacipran SAVELLA PA, QL pregabalin LYRICA HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia are available at: https://aasm.org Benzodiazepines QL temazepam RESTORIL Nonbenzodiazepines QL zolpidem AMBIEN MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Selective Serotonin Agonists ST, QL naratriptan AMERGE ST, QL rizatriptan MAXALT QL sumatriptan IMITREX QL sumatriptan injection IMITREX QL sumatriptan nasal spray IMITREX ST, QL zolmitriptan ZOMIG MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg lithium citrate MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com SGM fingolimod GILENYA SGM glatiramer COPAXONE SGM interferon beta-1a REBIF SGM interferon beta-1b EXTAVIA SGM teriflunomide AUBAGIO MUSCULOSKELETAL THERAPY AGENTS baclofen 10 mg, 20 mg QL carisoprodol SOMA

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chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM methocarbamol ROBAXIN orphenadrine ext-rel tizanidine tabs ZANAFLEX MYASTHENIA GRAVIS pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN NARCOLEPSY PA armodafinil NUVIGIL PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium disulfiram ANTABUSE naltrexone microspheres VIVITROL Opioid Antagonists naloxone injection QL naloxone nasal spray NARCAN naltrexone Partial Opioid Agonists buprenorphine sublingual Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel nicotine inhaler NICOTROL nicotine nasal spray NICOTROL NS varenicline CHANTIX ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com PA testosterone cypionate DEPO-TESTOSTERONE PA testosterone enanthate DELATESTRYL PA testosterone gel FORTESTA PA testosterone gel 25 mg/2.5 g ANDROGEL

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ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose PRECOSE Biguanides metformin metformin ext-rel Biguanide/Sulfonylurea Combinations glipizide/metformin METAGLIP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST alogliptin Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST alogliptin/metformin Incretin Mimetic Agents ST dulaglutide TRULICITY ST liraglutide VICTOZA Insulins insulin human HUMULIN R insulin human NOVOLIN R insulin isophane human HUMULIN N insulin isophane human NOVOLIN N insulin isophane human 70%/regular 30% HUMULIN 70/30 insulin isophane human 70%/regular 30% NOVOLIN 70/30 insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 insulin glargine BASAGLAR insulin lispro ADMELOG insulin lispro protamine/insulin lispro HUMALOG MIX Insulin Sensitizers pioglitazone ACTOS Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin ACTOPLUS MET Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride DUETACT Meglitinides nateglinide STARLIX repaglinide Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors PA* empagliflozin JARDIANCE ST ertugliflozin STEGLATRO PA* Covered for cardiovascular indication Sulfonylureas glimepiride AMARYL glipizide GLUCOTROL

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glipizide ext-rel GLUCOTROL XL Supplies OTC, QL alcohol swabs OTC blood glucose monitoring kits, test strips FREESTYLE FREEDOM LITE kits and

test strips OTC blood glucose monitoring kits, test strips FREESTYLE INSULINX kits and test

strips OTC blood glucose monitoring kits, test strips FREESTYLE LITE kits and test strips OTC blood glucose monitoring kits, test strips PRECISION XTRA kits and test strips OTC insulin syringes, needles BD ULTRAFINE insulin syringes and

needles OTC lancets OTC, QL multiple urine test products KETO-DIASTIX OTC, QL multiple urine test products MULTISTIX CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate tabs FOSAMAX Calcitonins calcitonin-salmon MIACALCIN CONTRACEPTIVES EE = ethinyl estradiol In accordance with the Comprehensive Contraception Coverage Act (CCCA), contraceptives may be dispensed as a 12-month supply at one time. Monophasic † † Products in this category may be dispensed as a 12-month supply at one time. 20 mcg Estrogen drospirenone/EE 3/20 YAZ levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20 30 mcg Estrogen desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30 35 mcg Estrogen ethynodiol diacetate/EE 1/35 norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35

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50 mcg Estrogen ethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50 Biphasic † † Products in this category may be dispensed as a 12-month supply at one time. desogestrel/EE MIRCETTE Triphasic † † Products in this category may be dispensed as a 12-month supply at one time. desogestrel/EE levonorgestrel/EE norethindrone/EE norgestimate/EE Progestin Only † † Products in this category may be dispensed as a 12-month supply at one time. norethindrone ORTHO MICRONOR Emergency Contraception QL ulipristal ELLA Injectable † † Products in this category may be dispensed as a 12-month supply at one time. QL medroxyprogesterone acetate 104 mg/0.65 mL DEPO-SUBQ PROVERA 104 QL medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA Transdermal † † Products in this category may be dispensed as a 12-month supply at one time. norelgestromin/EE Vaginal † † Products in this category may be dispensed as a 12-month supply at one time. etonogestrel/EE ring NUVARING Miscellaneous QL diaphragm ENDOMETRIOSIS danazol nafarelin SYNAREL ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Oral estradiol ESTRACE Transdermal estradiol CLIMARA

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Vaginal estradiol vaginal tabs VAGIFEM estrogens, conjugated cream PREMARIN ESTROGEN/PROGESTINS Oral EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone acetate ACTIVELLA Transdermal estradiol/norethindrone acetate COMBIPATCH FERTILITY REGULATORS Ovulation Stimulants, Synthetic PA, QL clomiphene GLUCOCORTICOIDS dexamethasone fludrocortisone hydrocortisone CORTEF methylprednisolone MEDROL methylprednisolone 2 mg MEDROL methylprednisolone injection SOLU-MEDROL prednisolone sodium phosphate orally disintegrating tabs ORAPRED ODT prednisolone sodium phosphate solution 5 mg/5 mL,

15 mg/5 mL, 25 mg/5 mL

prednisolone syrup PRELONE prednisone GLUCOSE ELEVATING AGENTS QL glucagon, human recombinant GLUCAGEN HYPOKIT QL glucagon, human recombinant GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines SGM somatropin NORDITROPIN SGM somatropin SEROSTIM SGM somatropin ZORBTIVE HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL paricalcitol ZEMPLAR PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin KUVAN PHOSPHATE BINDER AGENTS calcium acetate sevelamer carbonate tabs ST sucroferric oxyhydroxide VELPHORO POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate

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PROGESTINS Injectable SGM hydroxyprogesterone caproate MAKENA Oral medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene EVISTA THYROID AGENTS Antithyroid Agents methimazole TAPAZOLE propylthiouracil Thyroid Supplements levothyroxine levothyroxine SYNTHROID levothyroxine - Levoxyl liothyronine CYTOMEL UREA CYCLE DISORDERS SGM sodium phenylbutyrate BUPHENYL VASOPRESSIN RECEPTOR ANTAGONISTS SGM tolvaptan SAMSCA VASOPRESSINS PA desmopressin spray PA desmopressin spray, tabs DDAVP MISCELLANEOUS cabergoline SGM cysteamine CYSTAGON 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 LOMOTIL loperamide ANTIEMETICS PA, QL aprepitant caps EMEND QL dronabinol QL granisetron tabs meclizine metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine promethazine promethazine suppository trimethobenzamide TIGAN

27

ANTISPASMODICS chlordiazepoxide/clidinium dicyclomine BENTYL glycopyrrolate tabs 1 mg, 2 mg hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs CHOLELITHOLYTICS ursodiol ACTIGALL ursodiol URSO H2 RECEPTOR ANTAGONISTS cimetidine famotidine PEPCID nizatidine INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide budesonide delayed-rel caps ENTOCORT EC mesalamine ext-rel caps APRISO sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS Rectal Agents hydrocortisone enema mesalamine rectal suspension ROWASA mesalamine suppository CANASA LAXATIVES/STOOL SOFTENERS lactulose solution peg 3350/electrolytes peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY OPIOID-INDUCED CONSTIPATION naloxegol MOVANTIK PANCREATIC ENZYMES PA pancrelipase VIOKACE PA pancrelipase delayed-rel CREON PA pancrelipase delayed-rel ZENPEP PROSTAGLANDINS misoprostol CYTOTEC PROTON PUMP INHIBITORS AL*, QL esomeprazole magnesium delayed-rel suspension 2.5 mg,

5 mg, 10 mg NEXIUM

QL omeprazole delayed-rel caps PRILOSEC QL pantoprazole delayed-rel tabs PROTONIX AL* Covered for < 1 year only SALIVA STIMULANTS pilocarpine tabs SALAGEN

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STEROIDS, RECTAL hydrocortisone cream ANUSOL-HC 2.5% hydrocortisone cream PROCTOCORT 1% MISCELLANEOUS PA* glycopyrrolate CUVPOSA sucralfate tabs PA* Covered for 3-16 years of age GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel DITROPAN XL trospium * Gender restriction - Coverage for females VAGINAL ANTI-INFECTIVES clindamycin cream CLEOCIN clotrimazole metronidazole miconazole terconazole MISCELLANEOUS bethanechol pentosan polysulfate sodium ELMIRON phenazopyridine PYRIDIUM potassium citrate ext-rel UROCIT-K HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable enoxaparin LOVENOX

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Oral apixaban ELIQUIS rivaroxaban XARELTO * warfarin COUMADIN * Both Coumadin and warfarin are covered. Synthetic Heparinoid-like Agents fondaparinux ARIXTRA HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines SGM darbepoetin alfa ARANESP SGM filgrastim-sndz ZARXIO SGM pegfilgrastim-cbqv UDENYCA PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SGM eculizumab SOLIRIS PLATELET AGGREGATION INHIBITORS clopidogrel PLAVIX dipyridamole prasugrel EFFIENT ticagrelor BRILINTA PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN THROMBOCYTOPENIA AGENTS SGM eltrombopag tabs PROMACTA MISCELLANEOUS cilostazol IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org AUTOIMMUNE AGENTS SGM adalimumab HUMIRA SGM brodalumab SILIQ SGM etanercept ENBREL SGM sarilumab KEVZARA SGM, QL secukinumab COSENTYX SGM tofacitinib XELJANZ SGM tofacitinib ext-rel XELJANZ XR DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate SGM methotrexate injection RASUVO

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HEREDITARY ANGIOEDEMA AGENTS SGM C1 esterase inhibitor CINRYZE SGM C1 esterase inhibitor, recombinant RUCONEST 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 SGM interferon alfa-2b INTRON A SGM peginterferon alfa-2a PEGASYS Miscellaneous SGM canakinumab ILARIS IMMUNOSUPPRESSANTS Antimetabolites azathioprine AZASAN azathioprine IMURAN mycophenolate mofetil CELLCEPT Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus PROGRAF Rapamycin Derivatives sirolimus RAPAMUNE NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium bicarbonate effervescent tabs 25 mEq potassium chloride ext-rel potassium chloride ext-rel K-TAB potassium chloride liquid Miscellaneous potassium phosphate K-PHOS VITAMINS AND MINERALS Folic Acid/Combinations folic acid folic acid/vitamin B6/vitamin B12 Prenatal Vitamins prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal

AD

prenatal vitamins/carbonyl iron/ferrous fumarate/folic acid + DHA CITRANATAL MEDLEY prenatal vitamins/carbonyl iron/folic acid - Prenatabs Rx prenatal vitamins/DHA/docusate/folic acid CITRANATAL 90 DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL HARMONY prenatal vitamins/docusate/folic acid CITRANATAL RX prenatal vitamins/docusate/folic acid + DHA CITRANATAL ASSURE

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prenatal vitamins/ferrous fumarate/docusate/folic acid - Prenatal 19

prenatal vitamins/folic acid + pyridoxine CITRANATAL B-CALM Miscellaneous cyanocobalamin injection ergocalciferol (D2) fluoride drops, tabs multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs phytonadione MEPHYTON vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid NEPHROCAPS RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS QL epinephrine EPIPEN QL epinephrine EPIPEN JR. QL epinephrine auto-injector ANTICHOLINERGICS QL ipratropium inhalation solution QL tiotropium SPIRIVA RESPIMAT QL umeclidinium INCRUSE ELLIPTA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol inhalation solution ANTIHISTAMINES, LOW SEDATING cetirizine ANTIHISTAMINES, SEDATING clemastine cyproheptadine diphenhydramine hydroxyzine HCl hydroxyzine pamoate VISTARIL ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine/phenylephrine ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate TESSALON

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ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine Non-opioid dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine BETA AGONISTS Inhalants Short Acting QL albuterol inhalation solution QL albuterol sulfate, CFC-free aerosol Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Oral Agents albuterol albuterol ext-rel terbutaline CYSTIC FIBROSIS SGM dornase alfa PULMOZYME SGM elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA SGM ivacaftor KALYDECO SGM lumacaftor/ivacaftor ORKAMBI SGM tobramycin inhalation solution KITABIS PAK SGM tobramycin inhalation solution TOBI LEUKOTRIENE MODULATORS montelukast SINGULAIR MAST CELL STABILIZERS QL cromolyn inhalation solution MEDICAL SUPPLIES OTC, QL mask OTC, QL nebulizer OTC sodium chloride inhalation solution OTC, QL spacer AEROCHAMBER OTC, QL vaporizer sodium chloride inhalation solution NASAL ANTIHISTAMINES QL azelastine spray NASAL STEROIDS QL flunisolide spray RESPIRATORY SYNCYTIAL VIRUS SGM palivizumab SYNAGIS

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SEVERE ASTHMA AGENTS SGM omalizumab XOLAIR STEROID/BETA AGONIST COMBINATIONS QL budesonide/formoterol SYMBICORT AL*, QL fluticasone/salmeterol 100/50 ADVAIR DISKUS ST, QL mometasone/formoterol DULERA AL* Covered for ages 4-11 years only STEROID INHALANTS QL budesonide inhalation suspension PULMICORT RESPULES QL fluticasone FLOVENT DISKUS QL fluticasone, CFC-free aerosol FLOVENT HFA QL mometasone ASMANEX QL mometasone, CFC-free aerosol ASMANEX HFA XANTHINES theophylline ext-rel caps THEO-24 theophylline ext-rel tabs theophylline liquid theophylline liquid ELIXOPHYLLIN MISCELLANEOUS ipratropium nasal spray TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral PA isotretinoin PA isotretinoin - Amnesteem PA isotretinoin - Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane Topical benzoyl peroxide, except foam QL clindamycin gel, lotion, solution CLEOCIN T QL erythromycin gel 2% QL erythromycin solution sulfacetamide lotion 10% KLARON PA tretinoin RETIN-A Actinic Keratosis fluorouracil cream 4% TOLAK fluorouracil cream 5% EFUDEX Antibiotics gentamicin mupirocin ointment silver sulfadiazine SILVADENE Antifungals QL ciclopirox LOPROX

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QL clotrimazole QL ketoconazole cream 2% QL nystatin Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Topical ST, QL calcipotriene ointment, solution 0.005% DOVONEX Antiseborrheics ketoconazole shampoo 2% selenium sulfide lotion 2.5% Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines ST* tacrolimus PROTOPIC ST* tacrolimus 0.1%: In addition to clinical criteria, the member must be at least 16 years of age. Corticosteroids Low Potency alclometasone cream, ointment 0.05% fluocinolone acetonide solution 0.01% QL hydrocortisone cream, lotion, ointment 2.5% Medium Potency QL betamethasone valerate cream, lotion, ointment 0.1% fluocinolone acetonide cream, ointment 0.025% QL fluticasone propionate cream 0.05%, ointment 0.005% CUTIVATE hydrocortisone butyrate solution 0.1% LOCOID QL mometasone cream, lotion, ointment 0.1% QL triamcinolone acetonide cream, lotion, ointment 0.025% QL triamcinolone acetonide cream, lotion, ointment 0.1% High Potency QL betamethasone dipropionate augmented cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream, lotion, ointment 0.05% desoximetasone cream 0.25% TOPICORT QL fluocinonide cream, gel, ointment 0.05% fluocinonide solution 0.05% QL triamcinolone acetonide cream, ointment 0.5% Very High Potency QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE clobetasol propionate solution 0.05% QL halobetasol propionate cream, ointment 0.05% ULTRAVATE Emollients ammonium lactate 12% Local Analgesics PA lidocaine patch LIDODERM

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Local Anesthetics QL lidocaine/prilocaine cream lidocaine/prilocaine kit Rosacea metronidazole cream 0.75% METROCREAM metronidazole gel 0.75% ST metronidazole gel 1% METROGEL metronidazole lotion 0.75% METROLOTION Scabicides and Pediculicides ST malathion OVIDE permethrin ST spinosad NATROBA Miscellaneous Skin and Mucous Membrane imiquimod ALDARA podofilox solution CONDYLOX MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Steroids - Mouth/Throat triamcinolone paste Miscellaneous chlorhexidine PERIDEX AL sodium fluoride PREVIDENT AL Covered to maximum patient age of 21 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics cromolyn sodium Antifungals natamycin NATACYN Anti-infectives bacitracin ciprofloxacin solution CILOXAN erythromycin gentamicin levofloxacin moxifloxacin VIGAMOX neomycin/polymyxin B/gramicidin ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide solution 10% BLEPH-10 tobramycin solution TOBREX Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone ointment

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neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone suspension sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX Anti-inflammatories Nonsteroidal diclofenac sodium ketorolac 0.4% ACULAR LS ketorolac 0.5% ACULAR Steroidal dexamethasone sodium phosphate fluorometholone 0.1% suspension FML LIQUIFILM prednisolone acetate 1% PRED FORTE prednisolone phosphate 1% Antivirals trifluridine Beta-blockers Nonselective levobunolol timolol hemihydrate BETIMOL timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE Selective betaxolol 0.5% Carbonic Anhydrase Inhibitors Topical dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine SIMBRINZA Prostaglandins latanoprost XALATAN Sympathomimetics brimonidine 0.15% ALPHAGAN P brimonidine 0.2% OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives acetic acid ofloxacin otic Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone CIPRODEX neomycin/polymyxin B/hydrocortisone

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

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

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

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

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INDEX

Aabacavir, 10 abacavir/dolutegravir/lamivudine, 9 abacavir/lamivudine, 9 abacavir/lamivudine/zidovudine, 9 ABILIFY, 19 ABILIFY MAINTENA, 19 acamprosate calcium, 21 acarbose, 22 ACCUPRIL, 13 ACCURETIC, 13 acetazolamide, 16 acetazolamide ext-rel, 16 acetic acid, 36 ACTIGALL, 27 ACTIVELLA, 25 ACTOPLUS MET, 22 ACTOS, 22 ACULAR, 36 ACULAR LS, 36 acyclovir caps, suspension, tabs, 11 adalimumab, 29 ADDERALL, 19 ADDERALL XR, 20 adefovir dipivoxil, 11 ADMELOG, 22 ADVAIR DISKUS, 33 AEROCHAMBER, 32 afatinib, 12 AFINITOR, 12 AGRYLIN, 29 albuterol, 32 albuterol ext-rel, 32 albuterol inhalation solution, 32 albuterol sulfate, CFC-free aerosol, 32 alclometasone cream, ointment 0.05%, 34 alcohol swabs, 23 ALDACTAZIDE, 16 ALDACTONE, 14 ALDARA, 35 alendronate tabs, 23 alfuzosin ext-rel, 28 ALKERAN, 11 allopurinol, 7 alogliptin, 22 alogliptin/metformin, 22 ALPHAGAN P, 36 alprazolam, 17 ALTACE, 13 amantadine, 19 AMARYL, 22 AMBIEN, 20 ambrisentan, 16 AMERGE, 20 amiloride, 16 amiloride/hydrochlorothiazide, 16 amiodarone, 14 amitriptyline, 18 amlodipine, 15 amlodipine/benazepril, 13 ammonium lactate 12%, 34 amoxicillin, 9

amoxicillin/clavulanate, 9 amphetamine/dextroamphetamine mixed salts, 19 amphetamine/dextroamphetamine mixed salts ext-rel, 20 ampicillin, 9 ANAFRANIL, 17 anagrelide, 29 anastrozole, 12 ANDROGEL, 21 ANTABUSE, 21 ANUSOL-HC 2.5%, 28 apixaban, 29 aprepitant caps, 26 APRISO, 27 APTIVUS, 10 ARANESP, 29 ARAVA, 29 ARICEPT, 18 ARIMIDEX, 12 aripiprazole, 19 aripiprazole ext-rel injection, 19 aripiprazole lauroxil ext-rel injection, 19 aripiprazole orally disintegrating tabs, 19 ARISTADA, 19 ARISTADA INITIO, 19 ARIXTRA, 29 armodafinil, 21 AROMASIN, 12 asenapine, 19 ASMANEX, 33 ASMANEX HFA, 33 atazanavir, 10 atazanavir/cobicistat, 9 atenolol, 15 atenolol/chlorthalidone, 15 ATIVAN, 17 atomoxetine, 20 atorvastatin, 15 atovaquone, 11 atovaquone/proguanil, 9 ATRIPLA, 10 AUBAGIO, 20 AUGMENTIN, 9 AVALIDE, 14 AVAPRO, 14 axitinib, 12 AYGESTIN, 26 AZASAN, 30 azathioprine, 30 azelastine spray, 32 azithromycin, 8 AZULFIDINE, 27 AZULFIDINE EN-TABS, 27 Bbacitracin, 35 baclofen 10 mg, 20 mg, 20 balsalazide, 27 BARACLUDE, 11 BASAGLAR, 22 BD ULTRAFINE insulin syringes and needles, 23 benazepril, 13 benazepril/hydrochlorothiazide, 13 BENTYL, 27

40

benzonatate, 31 benzoyl peroxide, except foam, 33 benztropine, 19 betamethasone dipropion