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Pharmacy | PDLYour 2023 Prescription Drug ListAdvantage 4-TierEffective May 1, 2023This Prescription Drug List (PDL) is accurate as of May 1, 2023 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, Neighborhood Health Plan, UnitedHealthcare Freedom Plans, River Valley, All Savers and Oxford medical plans with a pharmacy benefit subject to the Advantage 4-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

Table of contentsUnderstanding your Prescription Drug List (PDL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Reading your PDL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Analgesics Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Drugs for Pain and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Anti-Addiction / Substance Abuse Treatment Agents. . . . . . . . . . . . . . . . . . . . . . . . . 8Antibacterials Drugs for Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Anticoagulants Drugs to Treat or Prevent Blood Clots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Anticonvulsants Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antidepressants Drugs for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antiemetics Drugs for Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Antifungals Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Antigout Agents Drugs for Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Antimigraine Agents Drugs for Migraines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Antineoplastics Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Antiparasitics Drugs for Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Antiparkinson Agents Drugs for Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Antiplatelets Drugs for Heart Attack and Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Antipsychotics Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Antivirals Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Anxiolytics Drugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Bipolar Agents Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Cardiovascular Agents Drugs for Heart and Circulation Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Central Nervous System Agents Drugs for Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Dental and Oral Agents Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Dermatological Agents Drugs for Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Diabetes Glucose Monitoring and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Drugs for Blood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Drugs for Pregnancy Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Gastrointestinal Agents Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . 22Genetic or Enzyme Disorder Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 22Genitourinary Agents Drugs for Bladder, Genital and Kidney Conditions. . . . . . . . . . . . . . . . . . . . . . . . . 22Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Hormonal Agents Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Testosterone Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Immunological Agents Drugs for Immune System Stimulation or Suppression. . . . . . . . . . . . . . . . . . . . . 26Drugs for Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Infertility Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Inflammatory Bowel Disease Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Metabolic Bone Disease Agents Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Ophthalmic Agents Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . 27Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Otic Agents Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Respiratory Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Respiratory Tract / Pulmonary Agents Drugs for Allergies, Cough, Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Drugs for Asthma and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Drugs for Cystic Fibrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Drugs for Pulmonary Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Drugs for Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Skeletal Muscle Relaxants Drugs for Muscle Pain and Spasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Sleep Disorder Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Understanding your Prescription Drug List (PDL)What is a PDL?This document is a list of the most commonly prescribed medications. It includes About this PDLboth brand-name and generic prescription medications approved by the Food and Where differences exist between Drug Administration (FDA). Medications are listed by common categories or classes this PDL and your benefit plan and placed in tiers that represent the cost you pay out-of-pocket. They are then documents, the benefit plan listed in alphabetical order. documents rule. This PDL is not a complete list of medications, How do I use my PDL?and not all medications listed may be covered by your plan. You and your doctor can consult the PDL to help you select the most cost-effective Please look at the benefit plan prescription medications. This guide tells you if a medication is generic or a brand-documents provided by your name, and if there are coverage requirements or limits. Bring this list with you employer or health plan to see when you see your doctor. If your medication is not listed here, please visit your which medications are covered plan’s member website or call the toll-free member phone number on your member under your plan. ID card.What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or benefit plan. This is how much you will pay when you fill a prescription. See page 6 for more information.When does the PDL change?PDL changes typically occur 2-3 times per year. However, changes that have a positive impact for you — such as coverage for new medications or cost savings — may occur at any time. You can log in to the member website listed on your member ID card at any time to check your medication coverage and lower-cost options.Why are some medications excluded from coverage?We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage 1 or be subject to prior authorization (sometimes referred to as precertification) if similar alternatives are available at a lower cost. Examples include medications that work the same way, but one is much more expensive than the other, or options that 2 are available without a prescription (also referred to as over-the-counter medications ). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your member ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter medications available. Who decides which medications are covered?Thousands of medications are already available and more come to the market regularly. Often, several medications are available ® to treat the same condition. The UnitedHealthcare Pharmacy and Therapeutics Committee, which includes both internal and external doctors and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL ® Management Committee, which includes senior UnitedHealth Group doctors and business leaders, meets to evaluate overall health care value. They also set coverage and tier status for all medications.1. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 2. For New York and New Jersey plans, a prescription drug product that is therapeutically equal to an over-the-counter drug may be covered if it is determined to be medically necessary.4

Medication tipsWhat is the difference between brand-name and Over-the-counter generic medications? (OTC) medicationsGeneric medications contain the same active ingredients (what makes the An OTC medication may be the medication work) as brand-name medications, but they often cost less. Once right treatment option for some the patent for a brand-name medication ends, the FDA can approve a generic conditions. Talk to your doctor version with the same active ingredients. These types of medications are about available OTC options. known as generic medications. Sometimes, the same company that makes a Even though these medications brand-name medication also makes the generic version. may not be covered by your pharmacy benefit, they may What if my doctor writes a brand-name prescription?cost less than a prescription If your doctor gives you a prescription for a brand-name medication, ask if a medication. generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equal is available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and the generic equivalent.What if I am taking a specialty medication?Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your member ID card or call the toll-free phone number on your member ID card to learn more.Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll-free phone number on your member ID card to talk with a pharmacist about finding lower-cost options.5

Reading your PDLThe PDL gives you choices so you and your doctor can decide your best course of treatment. In this PDL, brand-name medications are shown in UPPERCASE and generic medications in lowercase.Tier informationUsing lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible.In the chart below, overall value indicates medications’ effectiveness and safety, cost, and the availability of alternative medications to treat the same or similar medical condition(s).Drug Tier Includes Helpful TipsTier 1 $ Lower-cost Medications that provide the highest overall value. Mostly generic drugs. Some brand-name drugs may also be included.Use Tier 1 drugs for the lowest out-of-pocket costs.Tiers $$ Mid-range cost Use Tier 2 or Tier 3 drugs, 2 and 3Medications that provide good overall value. A mix of brand instead of Tier 4, to help reduce name and generic drugs.your out-of-pocket costs.Tier 4 $$$ Highest-cost Many Tier 4 drugs have lower-cost Medications that provide the lowest overall value. Mostly options in Tiers 1, 2 or 3. Ask your brand-name drugs, as well as some generics.doctor if they could work for you.Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan sets how these medications may be covered for you.E May be excluded from coverage. May be subject to Prior Authorization for fully insured benefit plans governed by state law in Connecticut, New Jersey, and New York. (Referred to as First Start in New Jersey) — Lower-cost options are available and covered.H Health Care Reform Preventive— This medication is part of a health care reform preventive benefit and may be available at no additional cost to you.H-PA Health Care Reform Preventive with Prior Authorization — May be part of health care reform preventive and available at no additional cost to you if prior authorization criteria is met.3PA Prior Authorization (sometimes referred to as precertification) — Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.QL Quantity Limits — Specifies the largest quantity of medication covered per copayment or in a defined period of time.4RS Refill and Save Program — Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.SP Specialty Medication —Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.ST Step Therapy (referred to as First Start in New Jersey) — Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.3. Depending on your benefit, you may have notification or medical necessity requirements for select medications. 4. Not applicable to Neighborhood Health Plan, some UnitedHealthcare Freedom Plans, Golden Rule, Oxford and UnitedHealthOne.6

Reading your PDL (continued)Coverage detailsSome drug classes in this PDL have additional/important coverage details. Review this list to see if drug classes that apply to you are noted.• Central nervous system: sedatives/hypnotics Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.• Diabetes: blood glucose monitoring; insulin; non-insulin Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans. Please see your Summary of Benefits and Coverage (SBC) for specifics. • Diabetes: continuous glucose monitors, sensors Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Diabetic self-management items, including continuous glucose monitors, may be covered under the consumer pharmacy and/or medical plan depending on the benefit.• Endocrine: growth hormone Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.• Infertility Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans or where a state mandates infertility drug coverage. This is not a covered benefit for Neighborhood Health Plan.• Medications for sexual dysfunction Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. • Termination of pregnancy Coverage under the prescription drug benefit is set by the consumer’s medical benefit plan. Please consult plan documents regarding benefit coverage, exclusions and cost-sharing. More information will be available on myuhc.com in early 2023. Additionally, more information is available by calling the number on the back of your ID card.QuestionsFor the most current list of covered medications or if you have questions:Call the toll-free phone number on your member ID cardAnd, if home delivery services are included in your pharmacy Visit your plan’s member website listed on your member ID card to: benefit, you can also:• View your pharmacy benefit and coverage information, including • Refill prescriptions prescription history• Check the status of your order• View medication interactions and side effects• Set up reminders for refills• Locate a participating retail pharmacy by ZIP code• Manage your account• Look up possible lower-cost medication alternatives• Compare medication pricing and options7

Drug Name Drug RequirementsTier & LimitsBggg gg BBgg BgB Bg gB gg BB BB Bg BggBgggB gg ggBBBgBBBBBBgBBgBggBggBggBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsAnalgesics - Drugs for Painacetaminophen-codeine #2 1acetaminophen-codeine #3 1acetaminophen-codeine #4 1acetaminophen-codeine oral tablet 1apap-caff-dihydrocodeine 4 QLbac 1 QLBELBUCA 3 PA, QLbutalbital-apap-caffeine oral tablet 1 QLDILAUDID ORAL TABLET Eendocet 1ESGIC ORAL TABLET 4 QLGEN7T EXTERNAL PATCH Ehydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mgEhydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg1hydromorphone hcl oral tablet 1lidocaine external patch 5 % 3 PA, QLLIDODERM E PA, QLmorphine sulfate er oral tablet extended release1 PA, QLMS CONTIN E PA, QLNALOCET E QLNUCYNTA 4 QLNUCYNTA ER 3 PA, QLOXAYDO E QLoxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg1oxycodone hcl oral tablet 5 mg 1 QLOXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MGEoxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg1OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MGE QLPERCOCET EPROLATE ORAL TABLET EROXICODONE Etramadol hcl oral tablet 100 mg Etramadol hcl oral tablet 50 mg 1TREZIX 4 QLXTAMPZA ER 4 PA, QLZTLIDO 3 PA, QLAnalgesics - Drugs for Pain and InflammationCELEBREX E QLcelecoxib oral 2 QLdiclofenac sodium oral 1DUROLANE EEUFLEXXA EGELSYN-3 EHYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGEEibuprofen oral tablet 400 mg, 600 mg, 800 mg1INDOMETHACIN ORAL CAPSULE 20 MGEindomethacin oral capsule 25 mg, 50 mg1ketorolac tromethamine oral 1meloxicam oral tablet 1nabumetone oral 1NAPROSYN ORAL TABLET Enaproxen oral tablet 1RELAFEN ERELAFEN DS ESUPARTZ FX ESYNOJOYNT ETRILURON EAnti-Addiction / Substance Abuse Treatment Agentsbuprenorphine hcl sublingual 1 QLbuprenorphine hcl-naloxone hcl 2 QLKLOXXADO 2 QLnaloxone hcl injection solution prefilled syringe1naloxone hcl nasal 1 QLnaltrexone hcl oral 1NARCAN 2 QL8

Drug Name Drug RequirementsTier & LimitsB gBgBgBgggBBgBgggggB ggBg gg gg BBBB gg ggBBggBgBBBgBBBBBgB gB Bg Bg gggBBggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsSUBOXONE E PA, QLZIMHI 2 QLZUBSOLV 2 QLAntibacterials - Drugs for InfectionsACTICLATE Eamoxicillin oral capsule 1amoxicillin oral suspension reconstituted1amoxicillin oral tablet 1amoxicillin-potassium clavulanate oral suspension reconstituted1amoxicillin-potassium clavulanate oral tablet1AUGMENTIN EAUGMENTIN ES-600 Eavidoxy 1azithromycin oral suspension reconstituted1azithromycin oral tablet 1BACTRIM 4BACTRIM DS 4cefdinir 1cefuroxime axetil 1CENTANY 4 QLcephalexin oral capsule 1cephalexin oral suspension reconstituted1CIPRO ORAL TABLET 4ciprofloxacin hcl oral 1CLEOCIN ORAL CAPSULE 150 MG, 300 MG4CLEOCIN ORAL CAPSULE 75 MG 2clindamycin hcl oral 1CLINDESSE 2DIFICID ORAL TABLET 3 QLdoxycycline hyclate oral capsule 2doxycycline hyclate oral tablet 100 mg2doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mgEdoxycycline hyclate oral tablet 20 mg1doxycycline monohydrate oral capsule 100 mg, 50 mg1doxycycline monohydrate oral capsule 150 mg, 75 mgEdoxycycline monohydrate oral tablet1levofloxacin oral tablet 1LYMEPAK EMACROBID 4MACRODANTIN 4metronidazole oral tablet 1metronidazole vaginal 2minocycline hcl oral capsule 1mondoxyne nl 1mupirocin external 1 QLnitrofurantoin macrocrystal 1nitrofurantoin monohydrate macrocrystals1NUVESSA ENUZYRA ORAL 4 QLpenicillin v potassium oral tablet 1sulfamethoxazole-trimethoprim oral tablet1TARGADOX Evandazole 4VIBRAMYCIN ORAL CAPSULE 4XENLETA ORAL 3ZITHROMAX ORAL SUSPENSION RECONSTITUTED4ZITHROMAX ORAL TABLET 4ZITHROMAX TRI-PAK 4ZITHROMAX Z-PAK 4Anticoagulants - Drugs to Treat or Prevent Blood Clotsdabigatran etexilate mesylate 1 QLELIQUIS 2 QLELIQUIS DVT/PE STARTER PACK 2 QLenoxaparin sodium 2 QLjantoven 1LOVENOX E QLPRADAXA 2 QLwarfarin sodium oral 19

Drug Name Drug RequirementsTier & LimitsB BBgBBBgBBBgggggBggBBgggBgBgggggBBBBBggggBggBBgBBBBBgBgBBg gggBgBggBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsXARELTO 2 QLXARELTO STARTER PACK 2 QLAnticonvulsants - Drugs for SeizuresAPTIOM 3 PABRIVIACT ORAL TABLET 3 PADEPAKOTE 4 PADEPAKOTE ER 4 PAdivalproex sodium er 2divalproex sodium oral tablet delayed release1EPIDIOLEX 3 PA, SPgabapentin oral capsule 1GABAPENTIN ORAL TABLET 25 MG, 50 MGE PAgabapentin oral tablet 600 mg, 800 mg1KEPPRA ORAL TABLET 4 PALAMICTAL ORAL TABLET 4 PAlamotrigine oral tablet 1levetiracetam oral tablet 1NAYZILAM 3 PA, QLNEURONTIN ORAL CAPSULE 4 PANEURONTIN ORAL TABLET 4 PAoxcarbazepine oral tablet 1roweepra 1subvenite 1TOPAMAX 4 PAtopiramate oral tablet 1TRILEPTAL ORAL TABLET 4 PAVALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML3 PA, QLXCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG3 PAZONEGRAN 4 PAzonisamide oral 1Antidepressants - Drugs for Depressionamitriptyline hcl oral 1bupropion hcl er (sr) 1bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg1BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MGE QLbupropion hcl oral 1CELEXA Ecitalopram hydrobromide oral tablet 1CYMBALTA Edesvenlafaxine succinate er 3 QLdoxepin hcl oral capsule 1duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg2duloxetine hcl oral capsule delayed release particles 40 mgEEFFEXOR XR Eescitalopram oxalate oral tablet 1fluoxetine hcl oral capsule 1fluoxetine hcl oral tablet 10 mg 3 QLfluoxetine hcl oral tablet 20 mg 3fluoxetine hcl oral tablet 60 mg Efluvoxamine maleate 1FORFIVO XL E QLLEXAPRO Emirtazapine oral tablet 1nortriptyline hcl oral capsule 1PAMELOR Eparoxetine hcl oral tablet 1PAXIL ORAL TABLET EPRISTIQ E QLPROZAC EREMERON Esertraline hcl oral tablet 1trazodone hcl oral 1TRINTELLIX 4 ST, QLvenlafaxine hcl 1venlafaxine hcl er oral capsule extended release 24 hour1VIIBRYD E QLVIIBRYD STARTER PACK 4vilazodone hcl 3 QLWELLBUTRIN SR E10

Drug Name Drug RequirementsTier & LimitsB BB BBg Bggg gg Bg B BBgBBBgBggBBBggBBBgBgBgBgBgBBBgBBBBBBBgBgBBgBBgBBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsWELLBUTRIN XL EZOLOFT ORAL TABLET EAntiemetics - Drugs for Nausea and Vomitingmetoclopramide hcl oral tablet 1ondansetron hcl oral tablet 1ondansetron odt 1prochlorperazine maleate oral 1promethazine hcl oral tablet 1REGLAN 4scopolamine 3TRANSDERM-SCOP EAntifungals - Drugs for Fungal Infectionsciclodan 1ciclopirox external solution 1CRESEMBA ORAL 3DIFLUCAN ORAL TABLET Efluconazole oral tablet 1GYNAZOLE-1 3ketoconazole external cream 1 QLketoconazole external shampoo 1nystatin external cream 1 QLnystatin mouth/throat 1terbinafine hcl oral 1 QLVIVJOA E PAAntigout Agents - Drugs for Goutallopurinol oral tablet 100 mg, 300 mg1ALLOPURINOL ORAL TABLET 200 MGECOLCHICINE ORAL CAPSULE EMITIGARE 2ZYLOPRIM 4Antimigraine Agents - Drugs for MigrainesAIMOVIG 2 PA, STAIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML2 PA, ST, QLeletriptan hydrobromide 2 QLEMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML2 PA, ST, QLIMITREX ORAL E QLMAXALT E QLNURTEC 2 PA, ST, QLRELPAX E QLrizatriptan benzoate 1 QLsumatriptan succinate oral 1 QLUBRELVY 2 PA, ST, QLZOLMITRIPTAN NASAL SOLUTION 2.5 MGE QLZOMIG NASAL SOLUTION 2.5 MG 3 QLZOMIG NASAL SOLUTION 5 MG 2 QLAntineoplastics - Drugs for CancerALECENSA 2 PA, QL, SPALUNBRIG 2 PA, QL, SPanastrozole oral 1 H-PAARIMIDEX Ebexarotene external E QL, SPCALQUENCE 2 PA, QL, SPERIVEDGE 2 PA, QL, SPERLEADA 2 PA, QL, SPEXKIVITY 4 PA, QL, SPFEMARA EGAVRETO 4 PA, QL, SPIBRANCE ORAL CAPSULE 2 PA, QL, SPICLUSIG ORAL TABLET 10 MG, 30 MG3 PA, QL, SPICLUSIG ORAL TABLET 15 MG, 45 MG3 PA, QL, SPIDHIFA 2 PA, QL, SPIMBRUVICA 2 PA, QL, SPKOSELUGO 3 PA, QL, SPlenalidomide oral capsule 10 mg, 15 mg, 25 mg, 5 mg2 PA, QL, SPlenalidomide oral capsule 2.5 mg, 20 mg1 PA, QL, SPletrozole oral 1 H-PALUMAKRAS 4 PA, QL, SPLYNPARZA 2 PA, QL, SPNUBEQA 2 PA, QL, SPODOMZO 2 PA, QL, SPORGOVYX 3 PA, QL, SP11

Drug Name Drug RequirementsTier & LimitsB BB BB gB BB Bg Bg BBBgB BB BBBB Bg Bgg BBBBBBBBBBBggBgBBBBBgBBBBBBgBBBgBgBggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsPOMALYST 3 PA, QL, SPREVLIMID 2 PA, QL, SPSTIVARGA 2 PA, QL, SPTABRECTA 4 PA, QL, SPTAGRISSO 3 PA, QL, SPtamoxifen citrate oral tablet 10 mg 1tamoxifen citrate oral tablet 20 mg 1 H-PATARGRETIN EXTERNAL 3 QL, SPTARGRETIN ORAL 2 SPTASIGNA 2 PA, ST, QL, SPVERZENIO 2 PA, QL, SPVITRAKVI 2 PA, QL, SPZEJULA 2 PA, QL, SPAntiparasitics - Drugs for Parasitic InfectionsARAKODA 4 QLhydroxychloroquine sulfate oral 1KRINTAFEL 1 QLPLAQUENIL EAntiparkinson Agents - Drugs for Parkinson's DiseaseINBRIJA 3 PA, QL, SPKYNMOBI 3 PA, QL, SPNEUPRO 3NOURIANZ 3 PA, QLpramipexole dihydrochloride 1ropinirole hcl 1Antiplatelets - Drugs for Heart Attack and Stroke PreventionBRILINTA 4 QLclopidogrel bisulfate oral 1PLAVIX EAntipsychotics - Drugs for Mood DisordersABILIFY Earipiprazole oral tablet 2LATUDA 4 QLolanzapine oral tablet 1quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg1quetiapine fumarate oral tablet 150 mgEREXULTI 4 PA, ST, QLRISPERDAL ORAL TABLET Erisperidone oral tablet 1SAPHRIS 3 QLSEROQUEL EVRAYLAR ORAL CAPSULE 4 QLZYPREXA ORAL EAntivirals - Drugs for Viral Infectionsacyclovir oral tablet 1BIKTARVY 4 QLCIMDUO 2 QLDESCOVY E PA, ST, QLDOVATO 2 QLemtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg1 QLemtricitabine-tenofovir df oral tablet 200-300 mg1 QL, HEPCLUSA ORAL TABLET 2 PA, QL, SPHARVONI ORAL TABLET 2 PA, ST, QL, SPJULUCA 2 QLLEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SPMAVYRET ORAL PACKET 2 QL, SPoseltamivir phosphate oral capsule 2PAXLOVID (150/100) 3PAXLOVID (300/100) 3PREZCOBIX 2RUKOBIA 4 PASITAVIG E QLSOFOSBUVIR-VELPATASVIR 2 PA, QL, SPSYMFI 2 QLSYMFI LO 2 QLTAMIFLU ORAL CAPSULE ETIVICAY 3TRIUMEQ 2 QLTRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG4 QLTRUVADA ORAL TABLET 200-300 MGE QLvalacyclovir hcl oral 1 QL12

Drug Name Drug RequirementsTier & LimitsB BB BB gB BBg BB gg gBgg BB Bggg gB gg gBgB BB BBBggBgBBgBBBggBBggggggggBgggggggggBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsVALTREX E QLVOSEVI 2 PA, QL, SPXOFLUZA (40 MG DOSE) 3 QLXOFLUZA (80 MG DOSE) 3 QLAnxiolytics - Drugs for Anxietyalprazolam oral tablet 1ATIVAN ORAL Ebuspirone hcl oral 1clonazepam oral tablet 1diazepam oral tablet 1HALCION 4hydroxyzine hcl oral tablet 1hydroxyzine pamoate oral 1KLONOPIN Elorazepam oral tablet 1triazolam 1VALIUM EVISTARIL 4XANAX EBipolar Agents - Drugs for Mood Disorderslithium carbonate er 1lithium carbonate oral capsule 1LITHOBID 4 PACardiovascular Agents - Drugs for Heart and Circulation ConditionsALDACTONE Ealiskiren fumarate 3ALTACE Eamiodarone hcl oral 1amlodipine besylate oral 1amlodipine besylate-benazepril hcl 1amlodipine besylate-valsartan 2amlodipine besylate-valsartan-hydrochlorothiazideEatenolol oral 1atenolol-chlorthalidone 1atorvastatin calcium oral tablet 10 mg, 20 mg1 H-PAatorvastatin calcium oral tablet 40 mg, 80 mg1AVALIDE EAVAPRO Ebenazepril hcl oral 1BENICAR EBENICAR HCT EBIDIL 2bisoprolol fumarate oral 1bisoprolol-hydrochlorothiazide 1CALAN SR 4CARDIZEM CD ECARDURA 4cartia xt 2carvedilol 1chlorthalidone 1clonidine hcl oral 1COREG ECORLANOR 3 PA, QLCOZAAR ECRESTOR Ediltiazem hcl er coated beads oral capsule extended release 24 hour2DIOVAN EDIOVAN HCT Edoxazosin mesylate oral 1EDARBI 3EDARBYCLOR 3enalapril maleate oral tablet 1ENTRESTO 4 PA, QLezetimibe 2fenofibrate oral tablet 120 mg, 40 mgEfenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg2FENOGLIDE Eflecainide acetate 1furosemide oral tablet 1gemfibrozil oral 1hydralazine hcl oral 1hydrochlorothiazide oral 1HYZAAR E13

Drug Name Drug RequirementsTier & LimitsB gg gg BgBggggBBBgggggBBBBgBggBgBggBBBgBBgBgg BBgBBgBgBgBBBgBgBBggggBBBBBBBgSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsINDERAL LA Eirbesartan 1irbesartan-hydrochlorothiazide 1isosorb dinitrate-hydralazine 2isosorbide mononitrate er 1labetalol hcl oral 1LASIX 4LIPITOR Elisinopril oral 1lisinopril-hydrochlorothiazide 1LOPID 4LOPRESSOR 4losartan potassium oral 1losartan potassium-hctz 1LOTENSIN 4LOTREL Elovastatin oral 1 HLOVAZA EMAXZIDE 4MAXZIDE-25 4metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 50 mg2metoprolol succinate er oral tablet extended release 24 hour 25 mg1metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg1metoprolol tartrate oral tablet 37.5 mg, 75 mgEMICARDIS EMINIPRESS 4MULTAQ 4 PANEXLETOL 2 PA, ST, QLNEXLIZET 2 PA, ST, QLnifedipine er 1nifedipine er osmotic release 1nitroglycerin sublingual 1NITROSTAT 4NORLIQVA 4 PANORVASC Eolmesartan medoxomil oral 2olmesartan medoxomil-hctz 2omega-3-acid ethyl esters 2PACERONE ORAL TABLET 100 MG, 400 MG3PACERONE ORAL TABLET 200 MG 4pravastatin sodium 1prazosin hcl oral 1PROCARDIA XL Epropranolol hcl er 2propranolol hcl oral tablet 1ramipril 1REPATHA 2 PA, ST, QLREPATHA PUSHTRONEX SYSTEM 2 PA, ST, QLREPATHA SURECLICK 2 PA, ST, QLrosuvastatin calcium 2simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg1 H-PAsimvastatin oral tablet 80 mg 1SOAANZ E QLspironolactone oral 1TEKTURNA 3TEKTURNA HCT 3telmisartan 2TENORETIC 100 ETENORETIC 50 ETENORMIN ETHALITONE ETOPROL XL Etorsemide 1triamterene-hctz 1TRICOR Evalsartan oral tablet 2valsartan-hydrochlorothiazide 1VASOTEC Everapamil hcl er oral tablet extended release1VERQUVO 4 PA, QLZESTORETIC EZESTRIL EZETIA E14

Drug Name Drug RequirementsTier & LimitsBBBB BBBBBBBBBgggggBBgBBBggBBBBgBBBBgBgBggBBBgBggggBgBgBBBgBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG3ZIAC ORAL TABLET 5-6.25 MG 4ZOCOR ECentral Nervous System Agents - Drugs for Attention Deficit DisorderADDERALL EADDERALL XR 2 QLADHANSIA XR E QLamphetamine-dextroamphetamine 1amphetamine-dextroamphetamine erE QLAPTENSIO XR E QLatomoxetine hcl 3 QLCONCERTA 2 QLdexmethylphenidate hcl 1dexmethylphenidate hcl er 3 QLFOCALIN 4FOCALIN XR E QLguanfacine hcl er 2INTUNIV EJORNAY PM E QLmethylphenidate hcl er (cd) 2 QLmethylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg2 QLmethylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg2methylphenidate hcl er (osm) E QLmethylphenidate hcl er (xr) E QLmethylphenidate hcl er oral tablet extended release4 QLmethylphenidate hcl oral tablet 1MYDAYIS E QLRELEXXI E QLRITALIN ERITALIN LA E QLSTRATTERA E QLVYVANSE 3 QLCentral Nervous System Agents - Drugs for Multiple SclerosisAUBAGIO 3 PA, QL, SPAVONEX PEN 2 PA, QL, SPAVONEX PREFILLED 2 PA, QL, SPBAFIERTAM 2 PA, QL, SPBETASERON 2 PA, QL, SPCOPAXONE E PA, QL, SPEXTAVIA E PA, ST, QL, SPfingolimod hcl 2 PA, QL, SPglatiramer acetate 2 PA, QL, SPglatopa 2 PA, QL, SPKESIMPTA 2 PA, QL, SPMAVENCLAD 3 PA, ST, QL, SPMAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG4 PA, QL, SPMAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG3 PA, QL, SPPLEGRIDY INTRAMUSCULAR 3 PA, QL, SPPLEGRIDY STARTER PACK 3 PA, QL, SPPLEGRIDY SUBCUTANEOUS 3 PA, QL, SPCentral Nervous System Agents - MiscellaneousAUSTEDO 2 PA, QL, SPLYRICA ORAL CAPSULE 4 PApregabalin oral capsule 2 QLTIGLUTIK 4 PAZEPOSIA 3 PA, ST, QL, SPZEPOSIA 7-DAY STARTER PACK 3 PA, ST, QL, SPZEPOSIA STARTER KIT 3 PA, ST, QL, SPDental and Oral Agents - Drugs for Mouth and Throat Conditionschlorhexidine gluconate mouth/ throat1lidocaine hcl mouth/throat 1lidocaine viscous hcl 1PERIDEX 4periogard 115

Drug Name Drug RequirementsTier & LimitsBBBg Bg BBgggBgBgBBggBBggggBgggggggggggg BBggBggBgBBgBBBBBgBBBBBggBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsDermatological Agents - Drugs for Skin ConditionsABSORICA E PAaccutane 2ala-cort external cream 1 % Eala-cort external cream 2.5 % 1amnesteem 2AMZEEQ 4 PA, QLAVITA EXTERNAL CREAM E PA, QLCARAC ECIBINQO 2 PA, QL, SPclaravis 2CLEOCIN-T 4clindacin etz external swab 1clindacin-p 1CLINDAGEL E QLclindamycin phosphate external lotion3clindamycin phosphate external solution1clindamycin phosphate external swab1clindamycin phosphate gel 1 % externalE QLclindamycin phosphate gel 1 % external3 QLclobetasol propionate external cream2 QLclobetasol propionate external ointment2 QLclobetasol propionate external solution1 QLclotrimazole-betamethasone external cream1 QLDAZOMON E PADUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR2 PA, QL, SPDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML2 PA, QLDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML2 PA, QL, SPEFUDEX 4ENSTILAR 4 QLEUCRISA 3 ST, QLFINACEA 4FLUOROPLEX 4FLUOROURACIL EXTERNAL CREAM 0.5 %Efluorouracil external cream 5 % 1hydrocortisone external cream 1 % Ehydrocortisone external cream 2.5 %1hydrocortisone external ointment 1 %, 2.5 %1IMPOYZ E QLisotretinoin capsule 10 mg oral E PAisotretinoin capsule 10 mg oral 2isotretinoin capsule 20 mg oral E PAisotretinoin capsule 20 mg oral 2isotretinoin capsule 30 mg oral E PAisotretinoin capsule 30 mg oral 2isotretinoin capsule 40 mg oral E PAisotretinoin capsule 40 mg oral 2isotretinoin oral capsule 25 mg, 35 mgE PAKLISYRI 4 ST, QLMETROCREAM 4metronidazole external cream 1MIRVASO 4 PA, QLmyorisan 2NORITATE EOPZELURA 4 PA, QL, SPPICATO 3 QLPROTOPIC E ST, QLRETIN-A EXTERNAL CREAM E PA, QLRHOFADE 4 PA, QLrosadan external cream 1SANTYL 3 QLSOOLANTRA 4 QLTACLONEX EXTERNAL OINTMENT E QLtacrolimus external 2 ST, QLtretinoin external cream 3 QL16

Drug Name Drug RequirementsTier & Limitsg gBgBBgBgBgBBBggBgB BBBgBBBBBBBBB BB BBBBBBBBBBBBBBBBBBBBBBggBgBgSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitstriamcinolone acetonide external cream 0.025 %, 0.1 %1triamcinolone acetonide external cream 0.5 %1 QLtriamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %1triamcinolone acetonide external ointment 0.05 %Etriamcinolone in absorbase ETRIANEX Etriderm external cream 0.1 % 1triderm external cream 0.5 % 1 QLtritocin EVTAMA 4 PA, QLXEPI 3 QLzenatane 2ZILXI 4 PA, ST, QLDiabetes - Glucose Monitoring and SuppliesACCU-CHEK AVIVA PLUS TEST STRIPSE QLACCU-CHEK FASTCLIX LANCET KIT1ACCU-CHEK FASTCLIX LANCETS 1ACCU-CHEK GUIDE KIT W/DEVICE 3 (Accu-Chek Guide Me)ACCU-CHEK GUIDE KIT W/DEVICE 3ACCU-CHEK GUIDE TEST STRIPS 3 QLACCU-CHEK MULTICLIX LANCET KIT1ACCU-CHEK MULTICLIX LANCETS 1ACCU-CHEK SMARTVIEW TEST STRIPSE QLACCU-CHEK SOFT TOUCH LANCETS1ACCU-CHEK SOFTCLIX LANCET DEVICE KIT1ACCU-CHEK SOFTCLIX LANCETS 1ACCUTREND GLUCOSE E QLbd autoshield duo pen needles 2 QLbd U-500 insulin syringes 2 QLbd ultra-fine insulin syringes 2 QLbd ultra-fine pen needles 2 QLbd veo ultra-fine insulin syringes 2 QLBLOOD GLUCOSE TEST STRIPS E QLCARETOUCH MONITOR SYSTEM ECARETOUCH TEST E QLCONTOUR MONITOR KIT W/DEVICEECONTOUR NEXT EZ KIT W/DEVICEECONTOUR NEXT GEN MONITOR ECONTOUR NEXT LINK KIT W/DEVICE4CONTOUR NEXT LINK KIT W/DEVICEE (Contour Next Link 24 )CONTOUR NEXT MONITOR KIT W/DEVICE2CONTOUR NEXT ONE KIT 2CONTOUR NEXT TEST STRIPS 2 QLCONTOUR TEST STRIPS E QLCVS ADVANCED GLUCOSE TEST E QLCVS GLUCOSE METER TEST STRIPSE QLD-CARE BLOOD GLUCOSE E QLD-CARE GLUCOMETER EDEXCOM G6 RECEIVER 3 PA, QLDEXCOM G6 SENSOR 3 PA, QLDEXCOM G6 TRANSMITTER 3 PA, QLDIABETES MONITOR DIGIT ADD-ONEDIABETES MONITOR DIGIT SOLN EEASY TOUCH TEST E QLEASYGLUCO EEASYMAX 15 TEST E QLEASYMAX NG BLOOD GLUCOSE KITEENLITE GLUCOSE SENSOR 3 PAEQ BLOOD GLUCOSE TEST E QLEVERSENSE SENSOR/HOLDER 3 PAEVERSENSE SMART TRANSMITTER3 PAFORTISCARE G1 TEST STRIP E QLFORTISCARE TEST E QL17

Drug Name Drug RequirementsTier & LimitsB BB BB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsFREESTYLE LIBRE 14 DAY READER3 PA, QLFREESTYLE LIBRE 14 DAY SENSOR3 PA, QLFREESTYLE LIBRE 2 READER 3 PA, QLFREESTYLE LIBRE 2 SENSOR 3 PAFREESTYLE LIBRE 3 SENSOR 3 PAFREESTYLE LIBRE CONTINUOUS BLOOD GLUCOSE MONITOR SYSTEM3 PAFREESTYLE LIBRE READER 3 PA, QLFREESTYLE PRECISION NEO SYSTEMEFREESTYLE PRECISION NEO TESTE QLFREESTYLE TEST E QLGLUCOCARD EXPRESSION TEST E QLGLUCOCARD SHINE TEST E QLGLUCOCARD VITAL TEST E QLGUARDIAN CONNECT TRANSMITTER3 PA, QLGUARDIAN LINK 3 TRANSMITTER 3 PA, QLGUARDIAN REAL-TIME REPLACE PED3 PAGUARDIAN SENSOR (3) 3 PA, QLINSULIN PEN NEEDLES 2 QLMICRODOT TEST E QLMINILINK REAL-TIME TRANSMITTER3 PAMINIMED 630G GUARDIAN PRESS 3 PAMM EASY TOUCH GLUCOSE METERENEUTEK 2TEK TEST E QLNOVOFINE AUTOCOVER PEN NEEDLE2 QLNOVOFINE PEN NEEDLE 2 QLNOVOFINE PLUS PEN NEEDLE 2 QLNOVOTWIST 2OMNIPOD 5 G6 INTRO (GEN 5) 2 PA, QLOMNIPOD 5 G6 POD (GEN 5) 2 PA, QLONETOUCH CLUB LANCETS FINE PT1ONETOUCH DELICA LANCETS 30G1ONETOUCH DELICA LANCETS 33G1ONETOUCH DELICA PLUS LANCET30G1ONETOUCH DELICA PLUS LANCET33G1ONETOUCH FINEPOINT LANCETS 1ONETOUCH SOLUTIONS STARTER KIT4ONETOUCH ULTRA 2 KIT W/DEVICE1ONETOUCH ULTRA MINI KIT W/DEVICE1ONETOUCH ULTRA TEST STRIPS 1 QLONETOUCH ULTRASOFT LANCETS1ONETOUCH VERIO FLEX SYSTEM 1ONETOUCH VERIO IQ SYSTEM 1ONETOUCH VERIO KIT W/DEVICE 1ONETOUCH VERIO REFLECT KIT W/DEVICE1ONETOUCH VERIO TEST STRIPS 1 QLOPTIUMEZ TEST E QLPARADIGM REAL-TIME TRANSMITTER3 PAPRECISION XTRA EPRECISION XTRA BLOOD GLUCOSEE QLPREMIUM BLOOD GLUCOSE TEST E QLPTS PANELS EGLU TEST E QLQUINTET AC BLOOD GLUCOSE TESTE QLQUINTET BLOOD GLUCOSE TEST E QLRELION TRUE MET AIR GLUC METERERELION TRUE METRIX TEST STRIPSE QLRELION ULTIMA GLUCOSE SYSTEMERELION ULTIMA TEST E QL18

Drug Name Drug RequirementsTier & LimitsB BB BB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBgBgBgSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsTECHLITE (ARKAY) INSULIN SYRINGES2 QLTECHLITE (ARKAY) PEN NEEDLES 2 QLTRUE FOCUS BLOOD GLUCOSE STRIPE QLTRUE METRIX AIR GLUCOSE METER KITETRUE METRIX BLOOD GLUCOSE TESTE QLTRUE METRIX GO GLUCOSE METERETRUE METRIX METER KIT ETRUE METRIX PRO BLOOD GLUCOSEE QLTRUETRACK TEST E QLUNISTRIP1 GENERIC E QLDiabetes - InsulinADMELOG E QLADMELOG SOLOSTAR E QLBASAGLAR KWIKPEN E QLHUMALOG INJECTION 1 QLHUMALOG KWIKPEN 2 QLHUMALOG MIX 50/50 KWIKPEN 2 QLHUMALOG MIX 50/50 VIAL 1 QLHUMALOG MIX 75/25 KWIKPEN 2 QLHUMALOG MIX 75/25 VIAL 1 QLHUMALOG SUBCUTANEOUS 2 QLHUMALOG U-100 JUNIOR KWIKPEN2 QLHUMULIN 70/30 KWIKPEN 2 QLHUMULIN 70/30 VIAL 1 QLHUMULIN N KWIKPEN 2 QLHUMULIN N VIAL 1 QLHUMULIN R U-500 KWIKPEN 2 QLHUMULIN R U-500 VIAL 1 QLHUMULIN R VIAL 1 QLINSULIN GLARGINE E QLINSULIN GLARGINE SOLOSTAR E QLINSULIN LISPRO E QLINSULIN LISPRO (1 UNIT DIAL) E QLINSULIN LISPRO JUNIOR KWIKPENE QLINSULIN LISPRO KWIKPEN EINSULIN LISPRO PROT & LISPRO E QLLANTUS SOLOSTAR 1 QLLANTUS U-100 VIAL 1 QLLYUMJEV KWIKPEN 2 QLLYUMJEV VIAL 1 QLNOVOLIN 70/30 FLEXPEN E ST, QLNOVOLIN 70/30 FLEXPEN RELION E ST, QLNOVOLIN 70/30 RELION E ST, QLNOVOLIN 70/30 VIAL E ST, QLNOVOLIN N FLEXPEN E ST, QLNOVOLIN N FLEXPEN RELION E ST, QLNOVOLIN N RELION E ST, QLNOVOLIN N VIAL E ST, QLNOVOLIN R FLEXPEN E ST, QLNOVOLIN R FLEXPEN RELION E ST, QLNOVOLIN R RELION E ST, QLNOVOLIN R VIAL E ST, QLTOUJEO MAX SOLOSTAR 2 QLTOUJEO SOLOSTAR 2 QLDiabetes - Non-Insulin AgentsACTOS E QLADLYXIN 4 PA, ST, QLADLYXIN STARTER PACK 4 PA, ST, QLALOGLIPTIN BENZOATE E QLALOGLIPTIN-METFORMIN HCL E QLALOGLIPTIN-PIOGLITAZONE E QLAMARYL EBAQSIMI ONE PACK 2 QLBAQSIMI TWO PACK 2 QLBYDUREON BCISE 2 PA, ST, QLBYDUREON PEN 2 PA, ST, QLBYETTA 10 MCG PEN 2 PA, ST, QLBYETTA 5 MCG PEN 2 PA, ST, QLglimepiride 1glipizide er 1glipizide ir 119

Drug Name Drug RequirementsTier & Limitsg BBBBBBgBBB BBBB BBBBBBBBBgBgBgBgBBgBBBBBBBBBBBgBBBBBBBBBBBBBBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitsglipizide xl 1GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED2 QLGLUCOTROL XL 4GLUMETZA E PAglyburide oral 1GLYXAMBI 2 ST, QLGVOKE HYPOPEN 1-PACK 2 QLGVOKE HYPOPEN 2-PACK 2 QLGVOKE PREFILLED SYRINGE 2 QLJARDIANCE 2 QLJENTADUETO 2 QLJENTADUETO XR 2 QLKAZANO 2 QLKOMBIGLYZE XR 2 QLmetformin hcl er 1metformin hcl er (mod) E PAmetformin hcl er (osm) E PAmetformin hcl oral tablet 1000 mg, 500 mg, 850 mg1metformin hcl oral tablet 625 mg EMOUNJARO 2 PA, ST, QLNESINA 2 QLONGLYZA 2 QLOSENI 2 QLOZEMPIC 2 PA, ST, QLpioglitazone hcl 1 QLRYBELSUS 2 PA, ST, QLSOLIQUA 2 QLSYMLINPEN 120 3 QLSYMLINPEN 60 3 QLSYNJARDY 2 QLSYNJARDY XR 2 QLTRADJENTA 2 QLTRIJARDY XR 2 QLTRULICITY 2 PA, ST, QLVICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS2 PA, ST, (2 Pak), QLVICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS3 PA, ST, (3 Pak), QLZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR2 QLDrugs for Blood DisordersADVATE 2 SPADYNOVATE 4 PA, SPAFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT4 PAAFSTYLA INTRAVENOUS KIT 1500 UNIT, 2500 UNIT4 PA, SPALPHANATE 2 SPARANESP (ALBUMIN FREE) 2 QL, SPDOPTELET 4 PA, QL, SPELOCTATE 4 PA, SPHEMLIBRA 2 PA, SPHEMOFIL M 2 SPHUMATE-P 2 SPJIVI 4 PA, SPKOATE 2 SPKOATE-DVI 2 SPKOGENATE FS 2 SPKOVALTRY 2 SPMULPLETA 2 PA, QL, SPNEULASTA 3NOVOEIGHT 2 SPNUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT2 SPNUWIQ INTRAVENOUS KIT 1500 UNIT2RECOMBINATE 2 SPRETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML2 QL, SPRETACRIT INJECTION SOLUTION 20000 UNIT/ML2TAVALISSE 4 PA, QL, SP20

Drug Name Drug RequirementsTier & LimitsB B BgBB gBBBBBBBgBggBgggBBBBgBBBBBBgBgggBgBgBgBgBgBBggBgBggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsWILATE 2ZARXIO 2ZIEXTENZO 3 SPDrugs for Pregnancy Terminationmifepristone 1Drugs for Sexual DysfunctionADDYI 4 PA, QLCIALIS E QLIMVEXXY MAINTENANCE PACK 2 QLIMVEXXY STARTER PACK 2 QLOSPHENA 3 PA, QLsildenafil citrate oral tablet 100 mg, 25 mg, 50 mg2 QLSTENDRA 4 PA, QLtadalafil oral 2 QLVIAGRA E QLVYLEESI 4 PA, QLElectrolytes / Vitaminscyanocobalamin injection solution 1000 mcg/ml1CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML3DODEX 4DRISDOL 4ergocalciferol oral capsule 1folic acid oral tablet 1 mg 1klor-con 10 1klor-con m10 1klor-con m15 3klor-con m20 1klor-con oral tablet extended release1K-TAB 3LOKELMA 3 PA, QLmultivitamin/fluoride tablet chewable 0.25 mg oral (rx)1MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.25 MG ORAL (RX)3multivitamin/fluoride tablet chewable 0.5 mg oral (rx)1MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.5 MG ORAL (RX)3multivitamin/fluoride tablet chewable 1 mg oral (rx)1MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 1 MG ORAL (RX)3MULTI-VIT-FLOR 3NASCOBAL 3POLY-VI-FLOR ORAL TABLET CHEWABLE3potassium chloride crys er oral tablet extended release 10 meq, 20 meq1potassium chloride crys er oral tablet extended release 15 meq3potassium chloride er 1potassium citrate er 1QUFLORA GUMMIES EQUFLORA PEDIATRIC ORAL TABLET CHEWABLE3UROCIT-K 10 4UROCIT-K 15 4UROCIT-K 5 4VELTASSA 3 PA, QLvitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit1Gastrointestinal Agents - Drugs for Acid Reflux and UlcerACIPHEX E QLCARAFATE ORAL TABLET ECYTOTEC 4DEXILANT E QLDEXLANSOPRAZOLE E QLfamotidine oral suspension reconstituted1misoprostol oral 1OMECLAMOX-PAK 3 QLomeprazole oral capsule delayed release1pantoprazole sodium oral tablet delayed release121

Drug Name Drug RequirementsTier & LimitsB BBBgBggggBgggBBggBBBBBBBgBggBgBggBBBBggBBgBBBgBgggBgBgBgBgBgBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsPROTONIX ORAL TABLET DELAYED RELEASEEPYLERA 3 QLrabeprazole sodium oral tablet delayed release2 QLsucralfate oral tablet 1Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach ConditionsCLENPIQ 3dicyclomine hcl oral capsule 1dicyclomine hcl oral tablet 1GLYCATE Eglycopyrrolate oral tablet 1 mg, 2 mg1GLYCOPYRROLATE ORAL TABLET 1.5 MGELINZESS 2 PA, QLMOTEGRITY 3 PA, QLMOVIPREP 3 QLpeg 3350-kcl-na bicarb-nacl 1 QL, Hpeg-3350/electrolytes/ascorbat 3 QLpeg-kcl-nacl-nasulf-na asc-c 3 QLPLENVU 3 QLROBINUL EROBINUL-FORTE Esodium sulfate-potassium sulfate-magnesium sulfate3 QLSUTAB 3SYMPROIC 2 PA, QLVIBERZI 3 PA, QLZELNORM 3 PA, ST, QLGenetic or Enzyme Disorder - Drugs for Replacement, Modification, TreatmentCERDELGA 2 PA, SPCREON 2DEPEN TITRATABS 2 SPORFADIN 2 PA, SPPANCREAZE 3 STPERTZYE 4 STSTRENSIQ 2 PA, QL, SPTEGSEDI 2 PA, QL, SPZENPEP 2Genitourinary Agents - Drugs for Bladder, Genital and Kidney ConditionsDITROPAN XL Eoxybutynin chloride er 2oxybutynin chloride oral tablet 1phenazo oral tablet 200 mg 1phenazopyridine hcl oral tablet 100 mg, 200 mg1PYRIDIUM 3solifenacin succinate 3THIOLA 4 SPTHIOLA EC 3 SPVELPHORO 2VESICARE EGenitourinary Agents - Drugs for Prostate Conditionsalfuzosin hcl er 1finasteride oral tablet 5 mg 1FLOMAX EPROSCAR Etamsulosin hcl 1UROXATRAL EHormonal Agents - Hormone Replacement and Birth Controlafirmelle 1 HALORA 3 QLaltavera 1 HANNOVERA 3 QLapri 1 Haubra 1 Haubra eq 1 Haurovela 1.5/30 1 Haurovela 1/20 1 Haurovela 24 fe 1 Haurovela fe 1.5/30 1 Haurovela fe 1/20 1 Haviane 1 HAYGESTIN 422

Drug Name Drug RequirementsTier & Limitsg gBggggggggggBgBggBgBgggBggBgggBggggBgggggBgBgggggggggggBgggggg gggggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitsayuna 1 HBIJUVA 3blisovi 24 fe 1 Hblisovi fe 1.5/30 1 Hblisovi fe 1/20 1 Hcamila 1 Hchateal 1 Hchateal eq 1 HCLIMARA E QLCLIMARA PRO 3 QLcryselle-28 1 Hcyred 1 Hcyred eq 1 Hdeblitane 1 Hdelyla 1 HDEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE4 QLDEPO-SUBQ PROVERA 104 2 QLdesogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg1 HDIVIGEL 3dotti 2 QLdrospirenone-ethinyl estradiol 3DUAVEE 3 QLELESTRIN 3elinest 1 Heluryng 1 Henskyce 1 Herrin 1 Hestarylla 1 HESTRACE Eestradiol oral 1estradiol patch twice weekly 0.025 mg/24hr transdermal2 QLestradiol patch twice weekly 0.0375 mg/24hr transdermal2 QLestradiol patch twice weekly 0.05 mg/24hr transdermal2 QLestradiol patch twice weekly 0.075 mg/24hr transdermal2 QLestradiol patch twice weekly 0.075 mg/24hr transdermal2 QLestradiol patch twice weekly 0.1 mg/24hr transdermal2 QLestradiol transdermal gel 3estradiol transdermal patch weekly 1 (generic for Climara), QLestradiol vaginal cream 3estradiol vaginal tablet 2ESTRING 2 QLESTROGEL 3 QLetonogestrel-ethinyl estradiol 1 HEVAMIST 2falmina 1 Hfemynor 1 Hhailey 1.5/30 1 Hhailey 24 fe 1 Hhailey fe 1.5/30 1 Hhailey fe 1/20 1 Hheather 1 Hincassia 1 Hisibloom 1 Hjasmiel 3jencycla 1 Hjuleber 1 Hjunel 1.5/30 1 Hjunel 1/20 1 Hjunel fe 1.5/30 1 Hjunel fe 1/20 1 Hjunel fe 24 1 Hkalliga 1 Hkurvelo 1 Hlarin 1.5/30 1 Hlarin 1/20 1 Hlarin 24 fe 1 Hlarin fe 1.5/30 1 Hlarin fe 1/20 1 H23

Drug Name Drug RequirementsTier & Limitsg gg gggB gBBgBBBggggggBgBgBgBgggBgBgg gB gg gg gg gg gg gg gB gg gB gB gg gg gg ggggggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitslessina 1 Hlevonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg1 Hlevora 0.15/30 (28) 1 HLO LOESTRIN FE 1 HLOESTRIN 1.5/30 (21) ELOESTRIN 1/20 (21) ELOESTRIN FE 1.5/30 ELOESTRIN FE 1/20 Eloryna 3low-ogestrel 1 Hlo-zumandimine 3lutera 1 Hlyleq 1 Hlyllana 4 QLlyza 1 Hmarlissa 1 Hmedroxyprogesterone acetate intramuscular suspension prefilled syringe1 QL, Hmedroxyprogesterone acetate oral 1MENOSTAR 3 QLmicrogestin 1.5/30 1 Hmicrogestin 1/20 1 Hmicrogestin 24 fe 1 Hmicrogestin fe 1.5/30 1 Hmicrogestin fe 1/20 1 Hmili 1 HMINIVELLE E QLmono-linyah 1 HMYFEMBREE 2 PA, QLNATAZIA 2nikki 3nora-be 1 Hnorethin ace-eth estrad-fe oral tablet1 Hnorethindrone acetate oral 1norethindrone acet-ethinyl est 1 Hnorethindrone oral 1 Hnorgestimate-eth estradiol 1 Hnorgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ 0.25 mg-25 mcg2norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ 0.25 mg-35 mcg1 Hnorlyroc 1 HNUVARING Enymyo 1 Hocella 3portia-28 1 HPREMARIN ORAL 3PREMARIN VAGINAL 3PREMPHASE 3PREMPRO 3progesterone oral 2PROMETRIUM EPROVERA 4reclipsen 1 Hsharobel 1 Hsprintec 28 1 Hsronyx 1 Hsyeda 3tarina 24 fe 1 Htarina fe 1/20 1 Htarina fe 1/20 eq 1 Htri femynor 1 Htri-estarylla 1 Htri-linyah 1 Htri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 1 Htri-nymyo 1 Htri-sprintec 1 Htri-vylibra 1 H24

Drug Name Drug RequirementsTier & Limitsg BB Bgg BBBgggBBBBBgBgBgBBBBBBggBBBB BB BgBBgBBBgBBgggBgBgB BBBgBgSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitstri-vylibra lo 2VAGIFEM Evestura 3vienva 1 HVIVELLE-DOT E QLvylibra 1 Hxulane 3 HYASMIN 28 2YAZ 2yuvafem 2zafemy 3 Hzumandimine 3Hormonal Agents - Oral SteroidsCORTEF 4DEXABLISS Edexamethasone oral tablet 1dexamethasone oral tablet therapy pack3DXEVO 11-DAY EHEMADY EHIDEX 6-DAY Ehydrocortisone oral 1MEDROL ORAL TABLET THERAPY PACK4methylprednisolone oral tablet therapy pack1PEDIAPRED 2prednisolone sodium phosphate oral solution 10 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5mlEprednisolone sodium phosphate oral solution 15 mg/5ml1prednisolone sodium phosphate oral solution 20 mg/5mlE QLprednisone oral tablet 1prednisone oral tablet therapy pack 1TAPERDEX 12-DAY 3TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG4TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)3TAPERDEX 7-DAY 3ZCORT 7-DAY EHormonal Agents - OtherELIGARD SUBCUTANEOUS KIT 7.5 MG3 PALANREOTIDE ACETATE E SPleuprolide acetate injection 1 PALUPRON DEPOT (1-MONTH) ENOCDURNA 3 PA, QLNORDITROPIN FLEXPRO 2 PA, QL, SPNUTROPIN AQ NUSPIN 10 2 PA, QL, SPNUTROPIN AQ NUSPIN 20 2 PA, QL, SPNUTROPIN AQ NUSPIN 5 2 PA, QL, SPORIAHNN 2 PA, QLORILISSA 2 PA, QLSOMATULINE DEPOT 4 SPHormonal Agents - Testosterone ReplacementANDRODERM 2 PA, QLANDROGEL E PA, QLANDROGEL PUMP E PA, QLDEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML3DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML4FORTESTA E PA, QLNATESTO E PA, QLTESTIM 2 PA, QLTESTOSTERONE CYPIONATE INJECTIONEtestosterone cypionate intramuscular1VOGELXO E PA, QLVOGELXO PUMP E PA, QLHormonal Agents - ThyroidARMOUR THYROID 3CYTOMEL Eeuthyrox 1levo-t 125

Drug Name Drug RequirementsTier & Limitsg Bg Bg Bg Bg BBBBBBBgBBBBBBBgggggBBBBBBBBBBBBBBBBBBBBBBBBgBBBBBBBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitslevothyroxine sodium oral tablet 1levoxyl 2liothyronine sodium oral 2methimazole oral 1np thyroid 1SYNTHROID ETHYQUIDITY E PATIROSINT-SOL 2 PAunithroid 1Immunological Agents - Drugs for Immune System Stimulation or SuppressionACTEMRA ACTPEN 3 PA, ST, QL, SPACTEMRA SUBCUTANEOUS 3 PA, ST, QL, SPADBRY 2 PA, SPAZASAN 4azathioprine oral tablet 100 mg, 75 mg3azathioprine oral tablet 50 mg 1BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR2 PA, QL, SPCELLCEPT ORAL TABLET ECIMZIA E PACIMZIA PREFILLED KIT 2 PA, QL, SPCIMZIA STARTER KIT 2 PA, QL, SPCINRYZE E PA, QL, SPCOSENTYX (300 MG DOSE) 3 PA, ST, QL, SPCOSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML3 PA, ST, QL, SPCOSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 MG/0.5ML3 PA, ST, QL, SPCOSENTYX SENSOREADY (300 MG)3 PA, ST, QL, SPCOSENTYX SENSOREADY PEN 3 PA, ST, QL, SPEMPAVELI 2 PA, QL, SPENBREL MINI 2 PA, QL, SPENBREL SUBCUTANEOUS SOLUTION2 PA, QL, SPENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE2 PA, QL, SPENBREL SURECLICK 2 PA, QL, SPFIRAZYR E PA, QL, SPHAEGARDA 2 PA, QL, SPHUMIRA 2 PA, QL, SPHUMIRA PEDIATRIC CROHNS START2 PA, QL, SPHUMIRA PEN 2 PA, QL, SPHUMIRA PEN-CD/UC/HS STARTER 2 PA, QL, SPHUMIRA PEN-PEDIATRIC UC START2 PA, QL, SPHUMIRA PEN-PS/UV/ADOL HS START2 PA, QL, SPHUMIRA PEN-PSOR/UVEIT STARTER2 PA, QL, SPIMURAN Emethotrexate oral 1methotrexate sodium oral 1mycophenolate mofetil oral tablet 1OLUMIANT ORAL TABLET 1 MG, 4 MG2 PA, QL, SPOLUMIANT ORAL TABLET 2 MG 2 PA, QL, SPORENCIA CLICKJECT 3 PA, ST, QL, SPORENCIA SUBCUTANEOUS 3 PA, ST, QL, SPOTEZLA ORAL TABLET 2 PA, QL, SPOTREXUP E QLPROGRAF ORAL CAPSULE 4RASUVO 2 QLRINVOQ 2 PA, QL, SPRUCONEST 4 PA, QL, SPSIMPONI 2 PA, QL, SPSKYRIZI PEN 2 PA, QL, SPSKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE2 PA, QL, SPSTELARA SUBCUTANEOUS 2 PA, QL, SPtacrolimus oral 1TAKHZYRO SUBCUTANEOUS SOLUTION2 PA, QL, SPTALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTORE PA, ST, QL, SPTREMFYA 2 PA, QL, SPTREXALL 226

Drug Name Drug RequirementsTier & LimitsB BB BgBgBgBBBBBBBBBBBBBBgBBBBBBgBBBBBBBBBBgBBBBBBBBBgSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsXELJANZ 2 PA, QL, SPXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG2 PA, QL, SPXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 MG2 PA, QL, SPXOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE2 PA, QL, SPXOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTEDE SPImmunological Agents - Drugs for VaccinationAFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE3 HBOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE2 HCOMIRNATY 3 HFLUARIX QUADRIVALENT 3 HFLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE3 HFLULAVAL QUADRIVALENT 3 HFLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE3 HMODERNA COVID-19 VAC (BOOSTER)3 HMODERNA COVID-19 VACC 6M-5Y 3 HMODERNA COVID-19 VACCINE 3 HPFIZER COVID-19 VAC BIVAL 5-11 3 HPFIZER COVID-19 VAC BIVALENT 3 HPFIZER COVID-19 VAC-TRIS 5-11Y 3 HPFIZER COVID-19 VAC-TRIS 6M-4Y 3 HPFIZER-BIONT COVID-19 VAC-TRIS 3 HPFIZER-BIONTECH COVID-19 VACC3 HSHINGRIX 3 HSPIKEVAX COVID-19 VACCINE 3 HInfertility AgentsCHORIONIC GONADOTROPIN INTRAMUSCULAR4 SPENDOMETRIN 2FOLLISTIM AQ 2 SPfyremadel 3 (manufactured by Ferring), QL, SPganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous4 (manufactured by Ferring), QL, SPganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous2 (manufactured by Merck/ Organon), QL, SPNOVAREL 3 SPOVIDREL 4 SPPREGNYL 1 SPInflammatory Bowel Disease AgentsAPRISO 2ASACOL HD ECORTIFOAM 2DIPENTUM 3LIALDA 2mesalamine oral tablet delayed releaseEPROCTOFOAM HC 2UCERIS ORAL 3UCERIS RECTAL 2Metabolic Bone Disease Agents - Drugs for Osteoporosisalendronate sodium oral tablet 1FORTEO E PA, ST, SPFOSAMAX 4TERIPARATIDE (RECOMBINANT) 3 PA, SPTYMLOS 3 PA, SPMetabolic Bone Disease Agents - Othercalcitriol oral capsule 1ROCALTROL ORAL CAPSULE 4Ophthalmic Agents - Drugs for Eye Allergy, Infection and InflammationALREX 4 QLAZASITE 3BESIVANCE 3ciprofloxacin hcl ophthalmic 127

Drug Name Drug RequirementsTier & LimitsgBBBBBBBBgBgBBgBgBBBgBgggB BgBBgBgBgggggBBBBgBgBBBBBgggBBBBBBgBBBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & Limitserythromycin ophthalmic 1 H-PAEYSUVIS 4 QLFLAREX 2ILEVRO EINVELTYS 3KLARITY-A ELASTACAFT 3 QLLOTEMAX OPHTHALMIC GEL ELOTEMAX OPHTHALMIC OINTMENT3LOTEMAX OPHTHALMIC SUSPENSIONE QLLOTEMAX SM 3 QLloteprednol etabonate ophthalmic gelEloteprednol etabonate ophthalmic suspension3 QLMAXITROL OPHTHALMIC SUSPENSION4MOXEZA 4moxifloxacin hcl (2x day) 3moxifloxacin hcl ophthalmic solution3neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.11NEVANAC 4OCUFLOX 4ofloxacin ophthalmic 1polymyxin b-trimethoprim 1POLYTRIM 4PRED FORTE EPRED MILD 3prednisolone acetate ophthalmic 1prednisolone acetate p-f ETOBRADEX OPHTHALMIC SUSPENSION4TOBRADEX ST Etobramycin-dexamethasone 2VIGAMOX EZYLET 3Ophthalmic Agents - Drugs for GlaucomaALPHAGAN P OPHTHALMIC SOLUTION 0.1 %2 QLALPHAGAN P OPHTHALMIC SOLUTION 0.15 %4 QLBETIMOL 2 QLbimatoprost ophthalmic E QLbrimonidine tartrate ophthalmic solution 0.15 %2 QLbrimonidine tartrate ophthalmic solution 0.2 %1brimonidine tartrate-timolol E QLCOMBIGAN 2 QLCOSOPT 4COSOPT PF E QLdorzolamide hcl-timolol mal 2dorzolamide hcl-timolol mal pf E QLISTALOL 4latanoprost ophthalmic 1LUMIGAN 2RHOPRESSA 3 QLROCKLATAN 3 QLtimolol maleate (once-daily) 3timolol maleate ocudose 2timolol maleate ophthalmic solution 1timolol maleate pf 2TIMOPTIC 4TIMOPTIC OCUDOSE 4XALATAN EZIOPTAN 3 ST, QLOphthalmic Agents - Drugs for Miscellaneous Eye ConditionsCYCLOSPORINE IN KLARITY E PAcyclosporine ophthalmic E PA, QLRESTASIS 4 PA, QLRESTASIS MULTIDOSE E PA, QLTYRVAYA 4 PA, QLVERKAZIA 4 PA, QLXIIDRA 4 PA, QL28

Drug Name Drug RequirementsTier & LimitsggBg Bgg BBBBg BBgg gg gBgg g gBggBBBBBBBgBg BBgggBgg BBgBgBSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsOtic Agents - Drugs for Ear ConditionsCIPRODEX 3ciprofloxacin-dexamethasone Eneomycin-polymyxin-hc otic suspension1ofloxacin otic 2Respiratory - Drugs for AnaphylaxisAUVI-Q 2 QLepinephrine solution auto-injector 0.15 mg/0.15ml injection1 (generic for Adrenaclick), QLepinephrine solution auto-injector 0.15 mg/0.15ml injection1 QLepinephrine solution auto-injector 0.15 mg/0.3ml injection1 (generic for EpiPen-Single Pack), QLepinephrine solution auto-injector 0.15 mg/0.3ml injection1 (generic for EpiPen), QLepinephrine solution auto-injector 0.3 mg/0.3ml injection1 (generic for Adrenaclick), QLepinephrine solution auto-injector 0.3 mg/0.3ml injection1 (generic for EpiPen-Single Pack), QLepinephrine solution auto-injector 0.3 mg/0.3ml injection1 QLepinephrine solution auto-injector 0.3 mg/0.3ml injection1 (generic for EpiPen), QLEPIPEN 2-PAK E QLEPIPEN JR 2-PAK E QLSYMJEPI 2 QLRespiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Coldazelastine hcl nasal solution 0.1 %, 137 mcg/spray3azelastine hcl nasal solution 0.15 % Ebenzonatate oral capsule 100 mg, 200 mg1benzonatate oral capsule 150 mg Ecyproheptadine hcl oral tablet 1fluticasone propionate nasal 2 QLipratropium bromide nasal 1levocetirizine dihydrochloride oral tablet1promethazine-dm 1pseudoephedrine-bromphen-dm 1ZETONNA 3 QLRespiratory Tract / Pulmonary Agents - Drugs for Asthma and COPDADVAIR DISKUS 3 QL, RSADVAIR HFA 3 QL, RSAIRDUO RESPICLICK 113/14 E QLAIRDUO RESPICLICK 232/14 E QLAIRDUO RESPICLICK 55/14 E QLalbuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation2 QLalbuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation2 (generic for ProAir HFA or Proventil HFA), QLALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATIONE (generic for Ventolin HFA), QLalbuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml1ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ ML) 0.5% INHALATIONEalbuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation1ANORO ELLIPTA 3 QLARCAPTA NEOHALER 3ARNUITY ELLIPTA 1 QLATROVENT HFA 3 QLBEVESPI AEROSPHERE 2 QLBREO ELLIPTA 3 QL, RSBREZTRI AEROSPHERE 3 QL, RSbudesonide inhalation 2 QLBUDESONIDE-FORMOTEROL FUMARATEE QL, RSCOMBIVENT RESPIMAT 3 QLFASENRA PEN 4 PA, QLFLOVENT DISKUS 1 QLFLOVENT HFA 1 QL29

Drug Name Drug RequirementsTier & LimitsB BBBgBBBBBBgBBgBgBBBgBBgBBBBBBBBBBgBgBgBgBgBBBBgBgBBBggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsFLUTICASONE FUROATE-VILANTEROLE QL, RSFLUTICASONE PROPIONATE HFA E QLfluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/actE QL, RSFLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ ACT, 232-14 MCG/ACT, 55-14 MCG/ ACT2 QLipratropium-albuterol 2LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT3 QLmontelukast sodium oral tablet 1montelukast sodium oral tablet chewable1NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR4 PA, QL, SPNUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML4 PA, QL, SPNUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/0.4ML4 PAPERFOROMIST 4 QLPROVENTIL HFA E QLPULMICORT FLEXHALER 1 QLPULMICORT SUSPENSION E QLSEREVENT DISKUS 2 QLSINGULAIR ORAL TABLET ESINGULAIR ORAL TABLET CHEWABLEESPIRIVA HANDIHALER 2 QLSPIRIVA RESPIMAT 2 QLSTIOLTO RESPIMAT 2 QLSTRIVERDI RESPIMAT 2 QLSYMBICORT 3 QL, RSTRELEGY ELLIPTA 3 QL, RSVENTOLIN HFA E QLwixela inhub E QL, RSXOPENEX HFA 3 QLYUPELRI 4 PA, QLRespiratory Tract / Pulmonary Agents - Drugs for Cystic FibrosisBRONCHITOL 3 PA, ST, QL, SPBRONCHITOL TOLERANCE TEST 3 PA, ST, QL, SPPULMOZYME 2 PA, QL, SPTOBI PODHALER 3 PA, QL, SPRespiratory Tract / Pulmonary Agents - Drugs for Pulmonary FibrosisOFEV 4 PA, QL, SPRespiratory Tract / Pulmonary Agents - Drugs for Pulmonary HypertensionADEMPAS 2 PA, QL, SPOPSUMIT 2 PA, QL, SPREMODULIN E PAREVATIO ORAL TABLET E QLsildenafil citrate oral tablet 20 mg 1 QLTRACLEER 62.5 MG, 125 MG 2 PA, QL, SPtreprostinil E PATYVASO 2 PA, SPTYVASO DPI MAINTENANCE KIT 2 PA, QL, SPTYVASO DPI TITRATION KIT 2 PA, QL, SPTYVASO REFILL 2 PA, SPTYVASO STARTER 2 PA, SPSkeletal Muscle Relaxants - Drugs for Muscle Pain and Spasmbaclofen oral tablet 1carisoprodol oral tablet 250 mg Ecarisoprodol oral tablet 350 mg 1cyclobenzaprine hcl oral tablet 10 mg, 5 mg1cyclobenzaprine hcl oral tablet 7.5 mgEFEXMID Emethocarbamol oral tablet 1000 mg Emethocarbamol oral tablet 500 mg, 750 mg1SOMA Etizanidine hcl oral tablet 130

BBBBBBgBgBBBgBBBggSee page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as First Start in New Jersey).Drug Name Drug TierRequirements & LimitsVANADOM EZANAFLEX ORAL TABLET 4Sleep Disorder AgentsAMBIEN EAMBIEN CR EBELSOMRA 4 ST, QLDAYVIGO 4 ST, QLeszopiclone 2LUNESTA Emodafinil 2 PA, QLPROVIGIL E PA, QLRESTORIL 4SUNOSI 2 PA, QLtemazepam 1WAKIX 4 PA, QL, SPXYREM 4 PA, QL, SPXYWAV 4 PA, QL, SPzolpidem tartrate er 3zolpidem tartrate oral 131

IndexAABILIFY . . . . . . . . . . . . . . . . . . . . . . . . 12ABSORICA . . . . . . . . . . . . . . . . . . . . . . 16ACCU-CHEK AVIVA PLUS TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK FASTCLIX LANCET KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK FASTCLIX LANCETS . . 17ACCU-CHEK GUIDE KIT W/DEVICE . 17ACCU-CHEK GUIDE TEST STRIPS . . 17ACCU-CHEK MULTICLIX LANCET KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK MULTICLIX LANCETS . 17ACCU-CHEK SMARTVIEW TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFT TOUCH LANCETS . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFTCLIX LANCET DEVICE KIT . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFTCLIX LANCETS. . 17accutane . . . . . . . . . . . . . . . . . . . . . . . . 16ACCUTREND GLUCOSE . . . . . . . . . . 17acetaminophen-codeine #2 . . . . . . . . . 8acetaminophen-codeine #3 . . . . . . . . . 8acetaminophen-codeine #4 . . . . . . . . . 8acetaminophen-codeine oral tablet . . . 8ACIPHEX . . . . . . . . . . . . . . . . . . . . . . . 21ACTEMRA ACTPEN . . . . . . . . . . . . . . 26ACTEMRA SUBCUTANEOUS . . . . . . 26ACTICLATE . . . . . . . . . . . . . . . . . . . . . . 9ACTOS . . . . . . . . . . . . . . . . . . . . . . . . . 19acyclovir oral tablet . . . . . . . . . . . . . . . 12ADBRY . . . . . . . . . . . . . . . . . . . . . . . . . 26ADDERALL . . . . . . . . . . . . . . . . . . . . . 15ADDERALL XR . . . . . . . . . . . . . . . . . . 15ADDYI . . . . . . . . . . . . . . . . . . . . . . . . . . 21ADEMPAS . . . . . . . . . . . . . . . . . . . . . . 30ADHANSIA XR . . . . . . . . . . . . . . . . . . . 15ADLYXIN . . . . . . . . . . . . . . . . . . . . . . . . 19ADLYXIN STARTER PACK . . . . . . . . . 19ADMELOG . . . . . . . . . . . . . . . . . . . . . . 19ADMELOG SOLOSTAR . . . . . . . . . . . . 19ADVAIR DISKUS . . . . . . . . . . . . . . . . . 29 ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . 29ADVATE . . . . . . . . . . . . . . . . . . . . . . . . 20ADYNOVATE . . . . . . . . . . . . . . . . . . . . 20afirmelle . . . . . . . . . . . . . . . . . . . . . . . . 22AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . 27AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT . . . . . . . . . . . . . . . . . . 20AFSTYLA INTRAVENOUS KIT 1500 UNIT, 2500 UNIT . . . . . . . . . . . . . . . . . 20AIMOVIG. . . . . . . . . . . . . . . . . . . . . . . . 11AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML . . . . . . . . . . . . . . . . . . . . . 11AIRDUO RESPICLICK 113/14 . . . . . . 29AIRDUO RESPICLICK 232/14 . . . . . . 29AIRDUO RESPICLICK 55/14 . . . . . . . 29ala-cort external cream 1 % . . . . . . . . 16ala-cort external cream 2.5 % . . . . . . 16albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation . . . . . . . . . . . . . . . . . . . . . . . 29albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml . . . . . . . . . . . . . . . . . . . . 29ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION . . . . . . 29ALDACTONE . . . . . . . . . . . . . . . . . . . . 13ALECENSA . . . . . . . . . . . . . . . . . . . . . . 11alendronate sodium oral tablet . . . . . 27alfuzosin hcl er . . . . . . . . . . . . . . . . . . . 22aliskiren fumarate . . . . . . . . . . . . . . . . 13allopurinol oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . . . . . . . 11ALLOPURINOL ORAL TABLET 200 MG . . . . . . . . . . . . . . . . . . . . . . . . . 11ALOGLIPTIN BENZOATE . . . . . . . . . . 19ALOGLIPTIN-METFORMIN HCL . . . . 19ALOGLIPTIN-PIOGLITAZONE . . . . . . 19ALORA . . . . . . . . . . . . . . . . . . . . . . . . . 22ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % . . . . . . . . . . . . . . . . . 28 ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % . . . . . . . . . . . . . . . . 28ALPHANATE . . . . . . . . . . . . . . . . . . . . 20alprazolam oral tablet . . . . . . . . . . . . . 13ALREX . . . . . . . . . . . . . . . . . . . . . . . . . 27ALTACE . . . . . . . . . . . . . . . . . . . . . . . . . 13altavera . . . . . . . . . . . . . . . . . . . . . . . . . 22ALUNBRIG . . . . . . . . . . . . . . . . . . . . . . 11AMARYL . . . . . . . . . . . . . . . . . . . . . . . . 19AMBIEN . . . . . . . . . . . . . . . . . . . . . . . . 31AMBIEN CR . . . . . . . . . . . . . . . . . . . . . 31amiodarone hcl oral . . . . . . . . . . . . . . 13amitriptyline hcl oral . . . . . . . . . . . . . . 10amlodipine besylate oral . . . . . . . . . . . 13amlodipine besylate-benazepril hcl . . 13amlodipine besylate-valsartan . . . . . . 13amlodipine besylate-valsartan-hydrochlorothiazide . . . . . . . . . . . . . . . 13amnesteem . . . . . . . . . . . . . . . . . . . . . 16amoxicillin oral capsule . . . . . . . . . . . . . 9amoxicillin oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . . 9amoxicillin oral tablet . . . . . . . . . . . . . . 9amoxicillin-potassium clavulanate oral suspension reconstituted . . . . . . . 9amoxicillin-potassium clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . 9amphetamine-dextroamphetamine . . 15amphetamine-dextroamphetamine er . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15AMZEEQ . . . . . . . . . . . . . . . . . . . . . . . . 16anastrozole oral . . . . . . . . . . . . . . . . . . 11ANDRODERM . . . . . . . . . . . . . . . . . . . 25ANDROGEL . . . . . . . . . . . . . . . . . . . . . 25ANDROGEL PUMP . . . . . . . . . . . . . . . 25ANNOVERA . . . . . . . . . . . . . . . . . . . . . 22ANORO ELLIPTA . . . . . . . . . . . . . . . . . 29apap-caff-dihydrocodeine . . . . . . . . . . 8apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22APRISO . . . . . . . . . . . . . . . . . . . . . . . . 27APTENSIO XR . . . . . . . . . . . . . . . . . . . 15APTIOM . . . . . . . . . . . . . . . . . . . . . . . . 10ARAKODA . . . . . . . . . . . . . . . . . . . . . . 12ARANESP (ALBUMIN FREE) . . . . . . . 2032

ARCAPTA NEOHALER . . . . . . . . . . . . 29ARIMIDEX . . . . . . . . . . . . . . . . . . . . . . 11aripiprazole oral tablet . . . . . . . . . . . . 12ARMOUR THYROID . . . . . . . . . . . . . . 25ARNUITY ELLIPTA . . . . . . . . . . . . . . . 29ASACOL HD . . . . . . . . . . . . . . . . . . . . . 27atenolol oral . . . . . . . . . . . . . . . . . . . . . 13atenolol-chlorthalidone . . . . . . . . . . . . 13ATIVAN ORAL . . . . . . . . . . . . . . . . . . . 13atomoxetine hcl . . . . . . . . . . . . . . . . . . 15atorvastatin calcium oral tablet 10 mg, 20 mg . . . . . . . . . . . . . . . . . . . . 13atorvastatin calcium oral tablet 40 mg, 80 mg . . . . . . . . . . . . . . . . . . . . 13ATROVENT HFA . . . . . . . . . . . . . . . . . 29AUBAGIO . . . . . . . . . . . . . . . . . . . . . . . 15aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . 22aubra eq . . . . . . . . . . . . . . . . . . . . . . . . 22AUGMENTIN . . . . . . . . . . . . . . . . . . . . . 9AUGMENTIN ES-600 . . . . . . . . . . . . . . 9aurovela 1/20 . . . . . . . . . . . . . . . . . . . . 22aurovela 1.5/30 . . . . . . . . . . . . . . . . . . 22aurovela 24 fe . . . . . . . . . . . . . . . . . . . . 22aurovela fe 1/20 . . . . . . . . . . . . . . . . . . 22aurovela fe 1.5/30 . . . . . . . . . . . . . . . . 22AUSTEDO . . . . . . . . . . . . . . . . . . . . . . . 15AUVI-Q . . . . . . . . . . . . . . . . . . . . . . . . . 29AVALIDE . . . . . . . . . . . . . . . . . . . . . . . . 13AVAPRO . . . . . . . . . . . . . . . . . . . . . . . . 13aviane . . . . . . . . . . . . . . . . . . . . . . . . . . 22avidoxy . . . . . . . . . . . . . . . . . . . . . . . . . . 9AVITA EXTERNAL CREAM . . . . . . . . . 16AVONEX PEN . . . . . . . . . . . . . . . . . . . . 15AVONEX PREFILLED . . . . . . . . . . . . . 15AYGESTIN . . . . . . . . . . . . . . . . . . . . . . 22ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . 23AZASAN . . . . . . . . . . . . . . . . . . . . . . . . 26AZASITE . . . . . . . . . . . . . . . . . . . . . . . . 27azathioprine oral tablet 100 mg, 75 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 26azathioprine oral tablet 50 mg . . . . . . 26azelastine hcl nasal solution 0.1 %, 137 mcg/spray . . . . . . . . . . . . . . . . . . . 29azelastine hcl nasal solution 0.15 % . . 29azithromycin oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . . 9azithromycin oral tablet . . . . . . . . . . . . . 9Bbac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8baclofen oral tablet . . . . . . . . . . . . . . . 30BACTRIM . . . . . . . . . . . . . . . . . . . . . . . . 9BACTRIM DS . . . . . . . . . . . . . . . . . . . . . 9BAFIERTAM . . . . . . . . . . . . . . . . . . . . . 15BAQSIMI ONE PACK . . . . . . . . . . . . . . 19BAQSIMI TWO PACK . . . . . . . . . . . . . 19BASAGLAR KWIKPEN . . . . . . . . . . . . 19bd autoshield duo pen needles . . . . . 17bd U-500 insulin syringes . . . . . . . . . . 17bd ultra-fine insulin syringes . . . . . . . . 17bd ultra-fine pen needles . . . . . . . . . . 17bd veo ultra-fine insulin syringes . . . . 17BELBUCA . . . . . . . . . . . . . . . . . . . . . . . . 8BELSOMRA . . . . . . . . . . . . . . . . . . . . . 31benazepril hcl oral . . . . . . . . . . . . . . . . 13BENICAR . . . . . . . . . . . . . . . . . . . . . . . 13BENICAR HCT . . . . . . . . . . . . . . . . . . . 13BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . . 26benzonatate oral capsule 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . . . . . . . 29benzonatate oral capsule 150 mg . . . 29BESIVANCE . . . . . . . . . . . . . . . . . . . . . 27BETASERON . . . . . . . . . . . . . . . . . . . . 15BETIMOL . . . . . . . . . . . . . . . . . . . . . . . 28BEVESPI AEROSPHERE . . . . . . . . . . 29bexarotene external . . . . . . . . . . . . . . 11BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . 13BIJUVA . . . . . . . . . . . . . . . . . . . . . . . . . 23BIKTARVY . . . . . . . . . . . . . . . . . . . . . . 12bimatoprost ophthalmic . . . . . . . . . . . 28bisoprolol fumarate oral . . . . . . . . . . . 13bisoprolol-hydrochlorothiazide . . . . . 13blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . 23blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . 23blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . 23BLOOD GLUCOSE TEST STRIPS . . . 17BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . . . . . . . . . . . 27BREO ELLIPTA . . . . . . . . . . . . . . . . . . 29BREZTRI AEROSPHERE . . . . . . . . . . 29BRILINTA . . . . . . . . . . . . . . . . . . . . . . . 12brimonidine tartrate ophthalmic solution 0.15 % . . . . . . . . . . . . . . . . . . . 28brimonidine tartrate ophthalmic solution 0.2 % . . . . . . . . . . . . . . . . . . . . 28brimonidine tartrate-timolol . . . . . . . . 28BRIVIACT ORAL TABLET . . . . . . . . . . 10BRONCHITOL . . . . . . . . . . . . . . . . . . . 30BRONCHITOL TOLERANCE TEST . . 30budesonide inhalation. . . . . . . . . . . . . 29BUDESONIDE-FORMOTEROL FUMARATE . . . . . . . . . . . . . . . . . . . . . 29buprenorphine hcl sublingual . . . . . . . 8buprenorphine hcl-naloxone hcl . . . . . 8bupropion hcl er (sr) . . . . . . . . . . . . . . 10bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . . . . . . . 10BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG . . . . . . . . . . . . . . . . 10bupropion hcl oral . . . . . . . . . . . . . . . . 10buspirone hcl oral . . . . . . . . . . . . . . . . 13butalbital-apap-caffeine oral tablet . . . 8BYDUREON BCISE . . . . . . . . . . . . . . . 19BYDUREON PEN . . . . . . . . . . . . . . . . . 19BYETTA 10 MCG PEN . . . . . . . . . . . . . 19BYETTA 5 MCG PEN . . . . . . . . . . . . . . 19CCALAN SR . . . . . . . . . . . . . . . . . . . . . . 13calcitriol oral capsule . . . . . . . . . . . . . 27CALQUENCE . . . . . . . . . . . . . . . . . . . . 11camila . . . . . . . . . . . . . . . . . . . . . . . . . . 23CARAC . . . . . . . . . . . . . . . . . . . . . . . . . 16CARAFATE ORAL TABLET. . . . . . . . . 21CARDIZEM CD . . . . . . . . . . . . . . . . . . 13CARDURA . . . . . . . . . . . . . . . . . . . . . . 13CARETOUCH MONITOR SYSTEM . . 17CARETOUCH TEST . . . . . . . . . . . . . . 17carisoprodol oral tablet 250 mg . . . . . 30carisoprodol oral tablet 350 mg . . . . . 30cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . 13carvedilol . . . . . . . . . . . . . . . . . . . . . . . 13cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . 9cefuroxime axetil . . . . . . . . . . . . . . . . . . 933

CELEBREX . . . . . . . . . . . . . . . . . . . . . . . 8celecoxib oral. . . . . . . . . . . . . . . . . . . . . 8CELEXA . . . . . . . . . . . . . . . . . . . . . . . . 10CELLCEPT ORAL TABLET . . . . . . . . . 26CENTANY . . . . . . . . . . . . . . . . . . . . . . . . 9cephalexin oral capsule . . . . . . . . . . . . 9cephalexin oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . . 9CERDELGA . . . . . . . . . . . . . . . . . . . . . 22chateal . . . . . . . . . . . . . . . . . . . . . . . . . 23chateal eq . . . . . . . . . . . . . . . . . . . . . . . 23chlorhexidine gluconate mouth/ throat. . . . . . . . . . . . . . . . . . . . . . . . . . . 15chlorthalidone . . . . . . . . . . . . . . . . . . . 13CHORIONIC GONADOTROPIN INTRAMUSCULAR . . . . . . . . . . . . . . . 27CIALIS . . . . . . . . . . . . . . . . . . . . . . . . . . 21CIBINQO. . . . . . . . . . . . . . . . . . . . . . . . 16ciclodan . . . . . . . . . . . . . . . . . . . . . . . . 11ciclopirox external solution . . . . . . . . . 11CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . 12CIMZIA . . . . . . . . . . . . . . . . . . . . . . . . . 26CIMZIA PREFILLED KIT . . . . . . . . . . . 26CIMZIA STARTER KIT . . . . . . . . . . . . . 26CINRYZE . . . . . . . . . . . . . . . . . . . . . . . 26CIPRO ORAL TABLET . . . . . . . . . . . . . 9CIPRODEX . . . . . . . . . . . . . . . . . . . . . . 29ciprofloxacin hcl ophthalmic . . . . . . . 27ciprofloxacin hcl oral . . . . . . . . . . . . . . . 9ciprofloxacin-dexamethasone . . . . . . 29citalopram hydrobromide oral tablet . 10claravis . . . . . . . . . . . . . . . . . . . . . . . . . 16CLENPIQ . . . . . . . . . . . . . . . . . . . . . . . 22CLEOCIN ORAL CAPSULE 150 MG, 300 MG . . . . . . . . . . . . . . . . . . 9CLEOCIN ORAL CAPSULE 75 MG . . . 9CLEOCIN-T . . . . . . . . . . . . . . . . . . . . . . 16CLIMARA . . . . . . . . . . . . . . . . . . . . . . . 23CLIMARA PRO . . . . . . . . . . . . . . . . . . 23clindacin etz external swab . . . . . . . . 16clindacin-p . . . . . . . . . . . . . . . . . . . . . . 16CLINDAGEL . . . . . . . . . . . . . . . . . . . . . 16clindamycin hcl oral . . . . . . . . . . . . . . . 9clindamycin phosphate external lotion . . . . . . . . . . . . . . . . . . . . . . . . . . . 16clindamycin phosphate external solution . . . . . . . . . . . . . . . . . . . . . . . . . 16clindamycin phosphate external swab . . . . . . . . . . . . . . . . . . . . . . . . . . . 16clindamycin phosphate gel 1 % external . . . . . . . . . . . . . . . . . . . . . . . . . 16CLINDESSE . . . . . . . . . . . . . . . . . . . . . . 9clobetasol propionate external cream . . . . . . . . . . . . . . . . . . . . . . . . . . 16clobetasol propionate external ointment . . . . . . . . . . . . . . . . . . . . . . . . 16clobetasol propionate external solution . . . . . . . . . . . . . . . . . . . . . . . . . 16clonazepam oral tablet . . . . . . . . . . . . 13clonidine hcl oral . . . . . . . . . . . . . . . . . 13clopidogrel bisulfate oral . . . . . . . . . . 12clotrimazole-betamethasone external cream . . . . . . . . . . . . . . . . . . . 16COLCHICINE ORAL CAPSULE . . . . . 11COMBIGAN . . . . . . . . . . . . . . . . . . . . . 28COMBIVENT RESPIMAT . . . . . . . . . . 29COMIRNATY . . . . . . . . . . . . . . . . . . . . 27CONCERTA . . . . . . . . . . . . . . . . . . . . . 15CONTOUR MONITOR KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT EZ KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT GEN MONITOR . . . 17CONTOUR NEXT LINK KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT MONITOR KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT ONE KIT . . . . . . . . . 17CONTOUR NEXT TEST STRIPS . . . . 17CONTOUR TEST STRIPS . . . . . . . . . . 17COPAXONE . . . . . . . . . . . . . . . . . . . . . 15COREG . . . . . . . . . . . . . . . . . . . . . . . . . 13CORLANOR . . . . . . . . . . . . . . . . . . . . . 13CORTEF . . . . . . . . . . . . . . . . . . . . . . . . 25CORTIFOAM . . . . . . . . . . . . . . . . . . . . 27COSENTYX (300 MG DOSE) . . . . . . . 26COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML . . 26COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 MG/0.5ML . . . . . . . . . . . . . . . . . . . . 26COSENTYX SENSOREADY (300 MG) . . . . . . . . . . . . . . . . . . . . . . . . 26COSENTYX SENSOREADY PEN . . . . 26COSOPT . . . . . . . . . . . . . . . . . . . . . . . . 28COSOPT PF . . . . . . . . . . . . . . . . . . . . . 28COZAAR . . . . . . . . . . . . . . . . . . . . . . . 13CREON . . . . . . . . . . . . . . . . . . . . . . . . . 22CRESEMBA ORAL . . . . . . . . . . . . . . . 11CRESTOR. . . . . . . . . . . . . . . . . . . . . . . 13cryselle-28 . . . . . . . . . . . . . . . . . . . . . . 23CVS ADVANCED GLUCOSE TEST . . 17CVS GLUCOSE METER TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . 17cyanocobalamin injection solution 1000 mcg/ml . . . . . . . . . . . . . . . . . . . . 21CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML. . . . . . . . . 21cyclobenzaprine hcl oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . 30cyclobenzaprine hcl oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 30CYCLOSPORINE IN KLARITY . . . . . . 28cyclosporine ophthalmic. . . . . . . . . . . 28CYMBALTA . . . . . . . . . . . . . . . . . . . . . . 10cyproheptadine hcl oral tablet . . . . . . 29cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . 23cyred eq . . . . . . . . . . . . . . . . . . . . . . . . 23CYTOMEL . . . . . . . . . . . . . . . . . . . . . . 25CYTOTEC . . . . . . . . . . . . . . . . . . . . . . . 21DD-CARE BLOOD GLUCOSE . . . . . . . . 17D-CARE GLUCOMETER . . . . . . . . . . . 17dabigatran etexilate mesylate . . . . . . . 9DAYVIGO . . . . . . . . . . . . . . . . . . . . . . . 31DAZOMON . . . . . . . . . . . . . . . . . . . . . . 16deblitane . . . . . . . . . . . . . . . . . . . . . . . . 23delyla . . . . . . . . . . . . . . . . . . . . . . . . . . 23DEPAKOTE . . . . . . . . . . . . . . . . . . . . . . 10DEPAKOTE ER . . . . . . . . . . . . . . . . . . . 10DEPEN TITRATABS . . . . . . . . . . . . . . . 22DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . 23DEPO-SUBQ PROVERA 104 . . . . . . . 2334

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML . . . . . . . . . . . . . . . . . . . . . 25DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML . . . . . . . . . . . . . . . . . . . . . 25DESCOVY. . . . . . . . . . . . . . . . . . . . . . . 12desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg . . . . . . . . . . . . 23desvenlafaxine succinate er . . . . . . . . 10DEXABLISS . . . . . . . . . . . . . . . . . . . . . 25dexamethasone oral tablet . . . . . . . . . 25dexamethasone oral tablet therapy pack . . . . . . . . . . . . . . . . . . . . . . . . . . . 25DEXCOM G6 RECEIVER. . . . . . . . . . . 17DEXCOM G6 SENSOR . . . . . . . . . . . . 17DEXCOM G6 TRANSMITTER . . . . . . 17DEXILANT . . . . . . . . . . . . . . . . . . . . . . 21DEXLANSOPRAZOLE . . . . . . . . . . . . 21dexmethylphenidate hcl . . . . . . . . . . . 15dexmethylphenidate hcl er . . . . . . . . . 15DIABETES MONITOR DIGIT ADD-ON . . . . . . . . . . . . . . . . . . . . . . . . 17DIABETES MONITOR DIGIT SOLN . . 17diazepam oral tablet . . . . . . . . . . . . . . 13diclofenac sodium oral . . . . . . . . . . . . . 8dicyclomine hcl oral capsule . . . . . . . 22dicyclomine hcl oral tablet . . . . . . . . . 22DIFICID ORAL TABLET . . . . . . . . . . . . . 9DIFLUCAN ORAL TABLET . . . . . . . . . 11DILAUDID ORAL TABLET . . . . . . . . . . 8diltiazem hcl er coated beads oral capsule extended release 24 hour . . 13DIOVAN . . . . . . . . . . . . . . . . . . . . . . . . 13DIOVAN HCT . . . . . . . . . . . . . . . . . . . . 13DIPENTUM . . . . . . . . . . . . . . . . . . . . . . 27DITROPAN XL . . . . . . . . . . . . . . . . . . . 22divalproex sodium er . . . . . . . . . . . . . . 10divalproex sodium oral tablet delayed release . . . . . . . . . . . . . . . . . . 10DIVIGEL . . . . . . . . . . . . . . . . . . . . . . . . 23DODEX . . . . . . . . . . . . . . . . . . . . . . . . . 21DOPTELET . . . . . . . . . . . . . . . . . . . . . . 20dorzolamide hcl-timolol mal . . . . . . . . 28dorzolamide hcl-timolol mal pf . . . . . . 28dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23DOVATO . . . . . . . . . . . . . . . . . . . . . . . . 12doxazosin mesylate oral . . . . . . . . . . . 13doxepin hcl oral capsule . . . . . . . . . . . 10doxycycline hyclate oral capsule . . . . . 9doxycycline hyclate oral tablet 100 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 9doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg . . . . . . . . . . . . . 9doxycycline hyclate oral tablet 20 mg . 9doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . . . . . 9doxycycline monohydrate oral capsule 150 mg, 75 mg . . . . . . . . . . . . . 9doxycycline monohydrate oral tablet . 9DRISDOL . . . . . . . . . . . . . . . . . . . . . . . 21drospirenone-ethinyl estradiol . . . . . . 23DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . 23duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 10duloxetine hcl oral capsule delayed release particles 40 mg . . . . . . . . . . . 10DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR . . . . . . . . 16DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML . . . . . . . . . . . . . . . . . . 16DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML . . . . . 16DUROLANE . . . . . . . . . . . . . . . . . . . . . . 8DXEVO 11-DAY . . . . . . . . . . . . . . . . . . . 25EEASY TOUCH TEST . . . . . . . . . . . . . . 17EASYGLUCO . . . . . . . . . . . . . . . . . . . . 17EASYMAX 15 TEST . . . . . . . . . . . . . . . 17EASYMAX NG BLOOD GLUCOSE KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . 13EDARBYCLOR . . . . . . . . . . . . . . . . . . . 13EFFEXOR XR . . . . . . . . . . . . . . . . . . . . 10EFUDEX . . . . . . . . . . . . . . . . . . . . . . . . 16ELESTRIN . . . . . . . . . . . . . . . . . . . . . . . 23eletriptan hydrobromide . . . . . . . . . . . 11ELIGARD SUBCUTANEOUS KIT 7.5 MG . . . . . . . . . . . . . . . . . . . . . . . . . 25elinest . . . . . . . . . . . . . . . . . . . . . . . . . . 23ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . 9ELIQUIS DVT/PE STARTER PACK. . . . 9ELOCTATE . . . . . . . . . . . . . . . . . . . . . . 20eluryng . . . . . . . . . . . . . . . . . . . . . . . . . 23EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML . . . . . . . . . . . . . . . . . . . . . 11EMPAVELI . . . . . . . . . . . . . . . . . . . . . . 26emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg . . . . . . . . . . . . . . . . . . . . . . 12emtricitabine-tenofovir df oral tablet 200-300 mg . . . . . . . . . . . . . . . . . . . . . 12enalapril maleate oral tablet . . . . . . . . 13ENBREL MINI. . . . . . . . . . . . . . . . . . . . 26ENBREL SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . 26ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE . . . 26ENBREL SURECLICK . . . . . . . . . . . . . 26endocet . . . . . . . . . . . . . . . . . . . . . . . . . 8ENDOMETRIN . . . . . . . . . . . . . . . . . . . 27ENLITE GLUCOSE SENSOR . . . . . . . 17enoxaparin sodium . . . . . . . . . . . . . . . . 9enskyce . . . . . . . . . . . . . . . . . . . . . . . . 23ENSTILAR . . . . . . . . . . . . . . . . . . . . . . 16ENTRESTO . . . . . . . . . . . . . . . . . . . . . . 13EPCLUSA ORAL TABLET . . . . . . . . . . 12EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . 10epinephrine solution auto-injector 0.15 mg/0.15ml injection . . . . . . . . . . . 29epinephrine solution auto-injector 0.15 mg/0.3ml injection . . . . . . . . . . . . 29epinephrine solution auto-injector 0.3 mg/0.3ml injection . . . . . . . . . . . . 29EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . 29EPIPEN JR 2-PAK . . . . . . . . . . . . . . . . 29EQ BLOOD GLUCOSE TEST . . . . . . . 17ergocalciferol oral capsule . . . . . . . . . 21ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . 11ERLEADA . . . . . . . . . . . . . . . . . . . . . . . 11errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23erythromycin ophthalmic . . . . . . . . . . 28escitalopram oxalate oral tablet . . . . . 10ESGIC ORAL TABLET . . . . . . . . . . . . . . 8estarylla . . . . . . . . . . . . . . . . . . . . . . . . 23ESTRACE . . . . . . . . . . . . . . . . . . . . . . . 2335

estradiol oral . . . . . . . . . . . . . . . . . . . . 23estradiol patch twice weekly 0.025 mg/24hr transdermal . . . . . . . . 23estradiol patch twice weekly 0.0375 mg/24hr transdermal . . . . . . . 23estradiol patch twice weekly 0.05 mg/24hr transdermal . . . . . . . . . 23estradiol patch twice weekly 0.075 mg/24hr transdermal . . . . . . . . 23estradiol patch twice weekly 0.1 mg/24hr transdermal . . . . . . . . . . 23estradiol transdermal gel . . . . . . . . . . 23estradiol transdermal patch weekly . . 23estradiol vaginal cream . . . . . . . . . . . . 23estradiol vaginal tablet . . . . . . . . . . . . 23ESTRING . . . . . . . . . . . . . . . . . . . . . . . 23ESTROGEL . . . . . . . . . . . . . . . . . . . . . 23eszopiclone . . . . . . . . . . . . . . . . . . . . . 31etonogestrel-ethinyl estradiol . . . . . . . 23EUCRISA . . . . . . . . . . . . . . . . . . . . . . . 16EUFLEXXA . . . . . . . . . . . . . . . . . . . . . . . 8euthyrox . . . . . . . . . . . . . . . . . . . . . . . . 25EVAMIST . . . . . . . . . . . . . . . . . . . . . . . 23EVERSENSE SENSOR/HOLDER . . . 17EVERSENSE SMART TRANSMITTER . . . . . . . . . . . . . . . . . . 17EXKIVITY . . . . . . . . . . . . . . . . . . . . . . . 11EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . 15EYSUVIS . . . . . . . . . . . . . . . . . . . . . . . . 28ezetimibe . . . . . . . . . . . . . . . . . . . . . . . 13Ffalmina . . . . . . . . . . . . . . . . . . . . . . . . . 23famotidine oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . 21FASENRA PEN . . . . . . . . . . . . . . . . . . . 29FEMARA . . . . . . . . . . . . . . . . . . . . . . . . 11femynor . . . . . . . . . . . . . . . . . . . . . . 23, 24fenofibrate oral tablet 120 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 13fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg . . . . . . . . . . . . 13FENOGLIDE . . . . . . . . . . . . . . . . . . . . . 13FEXMID . . . . . . . . . . . . . . . . . . . . . . . . . 30FINACEA . . . . . . . . . . . . . . . . . . . . . . . 16finasteride oral tablet 5 mg . . . . . . . . . 22fingolimod hcl . . . . . . . . . . . . . . . . . . . 15FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . 26FLAREX . . . . . . . . . . . . . . . . . . . . . . . . 28flecainide acetate . . . . . . . . . . . . . . . . 13FLOMAX . . . . . . . . . . . . . . . . . . . . . . . . 22FLOVENT DISKUS . . . . . . . . . . . . . . . . 29FLOVENT HFA . . . . . . . . . . . . . . . . . . . 29FLUARIX QUADRIVALENT . . . . . . . . . 27FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . 27fluconazole oral tablet . . . . . . . . . . . . . 11FLULAVAL QUADRIVALENT . . . . . . . 27FLUOROPLEX . . . . . . . . . . . . . . . . . . . 16FLUOROURACIL EXTERNAL CREAM 0.5 % . . . . . . . . . . . . . . . . . . . 16fluorouracil external cream 5 % . . . . . 16fluoxetine hcl oral capsule . . . . . . . . . 10fluoxetine hcl oral tablet 10 mg . . . . . 10fluoxetine hcl oral tablet 20 mg . . . . . 10fluoxetine hcl oral tablet 60 mg . . . . . 10FLUTICASONE FUROATE-VILANTEROL . . . . . . . . . . . . . . . . . . . . 30FLUTICASONE PROPIONATE HFA . . 30fluticasone propionate nasal . . . . . . . 29fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act . . . . . . . . . . . . . . . . . . 30FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ ACT, 232-14 MCG/ACT, 55-14 MCG/ACT . . . . . . . . . . . . . . . . . 30fluvoxamine maleate . . . . . . . . . . . . . . 10FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . 27FOCALIN . . . . . . . . . . . . . . . . . . . . . . . 15FOCALIN XR . . . . . . . . . . . . . . . . . . . . 15folic acid oral tablet 1 mg . . . . . . . . . . 21FOLLISTIM AQ . . . . . . . . . . . . . . . . . . . 27FORFIVO XL . . . . . . . . . . . . . . . . . . . . . 10FORTEO . . . . . . . . . . . . . . . . . . . . . . . . 27FORTESTA . . . . . . . . . . . . . . . . . . . . . . 25FORTISCARE G1 TEST STRIP . . . . . . 17FORTISCARE TEST . . . . . . . . . . . . . . 17FOSAMAX . . . . . . . . . . . . . . . . . . . . . . 27FREESTYLE LIBRE 14 DAY READER . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE LIBRE 14 DAY SENSOR . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE LIBRE 2 READER . . . . . 18FREESTYLE LIBRE 2 SENSOR . . . . . 18FREESTYLE LIBRE 3 SENSOR . . . . . 18FREESTYLE LIBRE CONTINUOUS BLOOD GLUCOSE MONITOR SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE LIBRE READER . . . . . . . 18FREESTYLE PRECISION NEO SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE PRECISION NEO TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE TEST . . . . . . . . . . . . . . . . 18furosemide oral tablet . . . . . . . . . . . . . 13fyremadel . . . . . . . . . . . . . . . . . . . . . . . 27Ggabapentin oral capsule . . . . . . . . . . . 10GABAPENTIN ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . 10gabapentin oral tablet 600 mg, 800 mg . . . . . . . . . . . . . . . . . . . . . . . . . 10ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous . . . . . . . . . . . . . . . . . . . 27GAVRETO . . . . . . . . . . . . . . . . . . . . . . . 11GELSYN-3 . . . . . . . . . . . . . . . . . . . . . . . 8gemfibrozil oral . . . . . . . . . . . . . . . . . . 13GEN7T EXTERNAL PATCH . . . . . . . . . 8glatiramer acetate . . . . . . . . . . . . . . . . 15glatopa . . . . . . . . . . . . . . . . . . . . . . . . . 15glimepiride . . . . . . . . . . . . . . . . . . . . . . 19glipizide er . . . . . . . . . . . . . . . . . . . . . . 19glipizide ir . . . . . . . . . . . . . . . . . . . . . . . 19glipizide xl . . . . . . . . . . . . . . . . . . . . . . . 20GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED . . . . . . . . . . . . . . . . 20GLUCOCARD EXPRESSION TEST . . 18GLUCOCARD SHINE TEST . . . . . . . . 18GLUCOCARD VITAL TEST . . . . . . . . . 18GLUCOTROL XL . . . . . . . . . . . . . . . . . 20GLUMETZA . . . . . . . . . . . . . . . . . . . . . 20glyburide oral . . . . . . . . . . . . . . . . . . . . 2036

GLYCATE . . . . . . . . . . . . . . . . . . . . . . . 22glycopyrrolate oral tablet 1 mg, 2 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . 22GLYCOPYRROLATE ORAL TABLET 1.5 MG . . . . . . . . . . . . . . . . . . 22GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . 20guanfacine hcl er . . . . . . . . . . . . . . . . . 15GUARDIAN CONNECT TRANSMITTER . . . . . . . . . . . . . . . . . . 18GUARDIAN LINK 3 TRANSMITTER . 18GUARDIAN REAL-TIME REPLACE PED . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18GUARDIAN SENSOR (3) . . . . . . . . . . . 18GVOKE HYPOPEN 1-PACK . . . . . . . . 20GVOKE HYPOPEN 2-PACK . . . . . . . . 20GVOKE PREFILLED SYRINGE . . . . . . 20GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . 11HHAEGARDA . . . . . . . . . . . . . . . . . . . . . 26hailey 1.5/30 . . . . . . . . . . . . . . . . . . . . . 23hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . 23hailey fe 1/20 . . . . . . . . . . . . . . . . . . . . 23hailey fe 1.5/30 . . . . . . . . . . . . . . . . . . . 23HALCION . . . . . . . . . . . . . . . . . . . . . . . 13HARVONI ORAL TABLET . . . . . . . . . . 12heather . . . . . . . . . . . . . . . . . . . . . . . . . 23HEMADY . . . . . . . . . . . . . . . . . . . . . . . . 25HEMLIBRA . . . . . . . . . . . . . . . . . . . . . . 20HEMOFIL M . . . . . . . . . . . . . . . . . . . . . 20HIDEX 6-DAY . . . . . . . . . . . . . . . . . . . . 25HUMALOG INJECTION . . . . . . . . . . . 19HUMALOG KWIKPEN . . . . . . . . . . . . . 19HUMALOG MIX 50/50 KWIKPEN . . . 19HUMALOG MIX 50/50 VIAL . . . . . . . . 19HUMALOG MIX 75/25 KWIKPEN . . . 19HUMALOG MIX 75/25 VIAL . . . . . . . . 19HUMALOG SUBCUTANEOUS . . . . . . 19HUMALOG U-100 JUNIOR KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . 19HUMATE-P . . . . . . . . . . . . . . . . . . . . . . 20HUMIRA . . . . . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEDIATRIC CROHNS START . . . . . . . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEN . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEN-CD/UC/HS STARTER . . . . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEN-PEDIATRIC UC START . . . . . . . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEN-PS/UV/ADOL HS START . . . . . . . . . . . . . . . . . . . . . . . . . . 26HUMIRA PEN-PSOR/UVEIT STARTER . . . . . . . . . . . . . . . . . . . . . . . 26HUMULIN 70/30 KWIKPEN . . . . . . . . 19HUMULIN 70/30 VIAL . . . . . . . . . . . . . 19HUMULIN N KWIKPEN . . . . . . . . . . . . 19HUMULIN N VIAL . . . . . . . . . . . . . . . . 19HUMULIN R U-500 KWIKPEN . . . . . . 19HUMULIN R U-500 VIAL . . . . . . . . . . . 19HUMULIN R VIAL . . . . . . . . . . . . . . . . 19HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE . . . . 8hydralazine hcl oral . . . . . . . . . . . . . . . 13hydrochlorothiazide oral . . . . . . . . . . . 13hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg . . . . . . . . . . . . . . . . . . . . . . . 8hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . . . . . . . . . . . 8hydrocortisone external cream 1 % . . 16hydrocortisone external cream 2.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . 16hydrocortisone external ointment 1 %, 2.5 % . . . . . . . . . . . . . . . . . . . . . . . 16hydrocortisone oral . . . . . . . . . . . . . . . 25hydromorphone hcl oral tablet . . . . . . . 8hydroxychloroquine sulfate oral . . . . . 12hydroxyzine hcl oral tablet . . . . . . . . . 13hydroxyzine pamoate oral . . . . . . . . . 13HYZAAR . . . . . . . . . . . . . . . . . . . . . . . . 13IIBRANCE ORAL CAPSULE . . . . . . . . 11ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . . . . . . . . 8ICLUSIG ORAL TABLET 10 MG, 30 MG . . . . . . . . . . . . . . . . . . . . . . . . . . 11ICLUSIG ORAL TABLET 15 MG, 45 MG . . . . . . . . . . . . . . . . . . . . . . . . . . 11IDHIFA. . . . . . . . . . . . . . . . . . . . . . . . . . 11ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . 28IMBRUVICA . . . . . . . . . . . . . . . . . . . . . 11IMITREX ORAL . . . . . . . . . . . . . . . . . . 11IMPOYZ . . . . . . . . . . . . . . . . . . . . . . . . 16IMURAN . . . . . . . . . . . . . . . . . . . . . . . . 26IMVEXXY MAINTENANCE PACK . . . 21IMVEXXY STARTER PACK . . . . . . . . . 21INBRIJA . . . . . . . . . . . . . . . . . . . . . . . . 12incassia . . . . . . . . . . . . . . . . . . . . . . . . . 23INDERAL LA . . . . . . . . . . . . . . . . . . . . 14INDOMETHACIN ORAL CAPSULE 20 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 8indomethacin oral capsule 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . 8INSULIN GLARGINE . . . . . . . . . . . . . . 19INSULIN GLARGINE SOLOSTAR . . . 19INSULIN LISPRO . . . . . . . . . . . . . . . . . 19INSULIN LISPRO (1 UNIT DIAL) . . . . . 19INSULIN LISPRO JUNIOR KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . 19INSULIN LISPRO KWIKPEN . . . . . . . . 19INSULIN LISPRO PROT & LISPRO . . 19INSULIN PEN NEEDLES . . . . . . . . . . . 18INTUNIV . . . . . . . . . . . . . . . . . . . . . . . . 15INVELTYS . . . . . . . . . . . . . . . . . . . . . . . 28ipratropium bromide nasal . . . . . . . . . 29ipratropium-albuterol . . . . . . . . . . . . . 30irbesartan . . . . . . . . . . . . . . . . . . . . . . . 14irbesartan-hydrochlorothiazide . . . . . 14isibloom . . . . . . . . . . . . . . . . . . . . . . . . 23isosorb dinitrate-hydralazine . . . . . . . 14isosorbide mononitrate er . . . . . . . . . 14isotretinoin capsule 10 mg oral . . . . . 16isotretinoin capsule 20 mg oral . . . . . 16isotretinoin capsule 30 mg oral . . . . . 16isotretinoin capsule 40 mg oral . . . . . 16isotretinoin oral capsule 25 mg, 35 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 16ISTALOL . . . . . . . . . . . . . . . . . . . . . . . . 28Jjantoven . . . . . . . . . . . . . . . . . . . . . . . . . 9JARDIANCE . . . . . . . . . . . . . . . . . . . . . 20jasmiel. . . . . . . . . . . . . . . . . . . . . . . . . . 23jencycla. . . . . . . . . . . . . . . . . . . . . . . . . 23JENTADUETO . . . . . . . . . . . . . . . . . . . 20JENTADUETO XR . . . . . . . . . . . . . . . . 20JIVI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2037

JORNAY PM . . . . . . . . . . . . . . . . . . . . . 15juleber . . . . . . . . . . . . . . . . . . . . . . . . . . 23JULUCA . . . . . . . . . . . . . . . . . . . . . . . . 12junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . 23junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . 23junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . 23junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . 23junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . 23KK-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 21kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . 23KAZANO . . . . . . . . . . . . . . . . . . . . . . . 20KEPPRA ORAL TABLET . . . . . . . . . . . 10KESIMPTA . . . . . . . . . . . . . . . . . . . . . . 15ketoconazole external cream . . . . . . . 11ketoconazole external shampoo . . . . 11ketorolac tromethamine oral . . . . . . . . 8KLARITY-A . . . . . . . . . . . . . . . . . . . . . . 28KLISYRI . . . . . . . . . . . . . . . . . . . . . . . . 16KLONOPIN . . . . . . . . . . . . . . . . . . . . . . 13klor-con 10 . . . . . . . . . . . . . . . . . . . . . . 21klor-con m10 . . . . . . . . . . . . . . . . . . . . 21klor-con m15. . . . . . . . . . . . . . . . . . . . . 21klor-con m20 . . . . . . . . . . . . . . . . . . . . 21klor-con oral tablet extended release . . . . . . . . . . . . . . . . . . . . . . . . . 21KLOXXADO . . . . . . . . . . . . . . . . . . . . . . 8KOATE . . . . . . . . . . . . . . . . . . . . . . . . . 20KOATE-DVI . . . . . . . . . . . . . . . . . . . . . . 20KOGENATE FS . . . . . . . . . . . . . . . . . . . 20KOMBIGLYZE XR . . . . . . . . . . . . . . . . 20KOSELUGO . . . . . . . . . . . . . . . . . . . . . 11KOVALTRY . . . . . . . . . . . . . . . . . . . . . . 20KRINTAFEL . . . . . . . . . . . . . . . . . . . . . 12kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . 23KYNMOBI . . . . . . . . . . . . . . . . . . . . . . . 12Llabetalol hcl oral . . . . . . . . . . . . . . . . . 14LAMICTAL ORAL TABLET . . . . . . . . . 10lamotrigine oral tablet . . . . . . . . . . . . . 10LANREOTIDE ACETATE . . . . . . . . . . . 25LANTUS SOLOSTAR . . . . . . . . . . . . . 19LANTUS U-100 VIAL . . . . . . . . . . . . . . 19larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . 23larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . 23larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . 23larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . 23larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 23LASIX . . . . . . . . . . . . . . . . . . . . . . . . . . 14LASTACAFT . . . . . . . . . . . . . . . . . . . . . 28latanoprost ophthalmic . . . . . . . . . . . . 28LATUDA . . . . . . . . . . . . . . . . . . . . . . . . 12LEDIPASVIR-SOFOSBUVIR . . . . . . . . 12lenalidomide oral capsule 10 mg, 15 mg, 25 mg, 5 mg. . . . . . . . . . . . . . . 11lenalidomide oral capsule 2.5 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 11lessina . . . . . . . . . . . . . . . . . . . . . . . . . . 24letrozole oral . . . . . . . . . . . . . . . . . . . . 11leuprolide acetate injection . . . . . . . . 25LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT . . . . . . . . . . 30levetiracetam oral tablet . . . . . . . . . . . 10levo-t . . . . . . . . . . . . . . . . . . . . . . . . . . . 25levocetirizine dihydrochloride oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . 29levofloxacin oral tablet . . . . . . . . . . . . . 9levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg . . . . . . . . . . . . . . . . . . 24levora 0.15/30 (28) . . . . . . . . . . . . . . . . 24levothyroxine sodium oral tablet . . . . 26levoxyl . . . . . . . . . . . . . . . . . . . . . . . . . . 26LEXAPRO . . . . . . . . . . . . . . . . . . . . . . . 10LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . 27lidocaine external patch 5 % . . . . . . . . 8lidocaine hcl mouth/throat . . . . . . . . . 15lidocaine viscous hcl . . . . . . . . . . . . . . 15LIDODERM . . . . . . . . . . . . . . . . . . . . . . . 8LINZESS . . . . . . . . . . . . . . . . . . . . . . . . 22liothyronine sodium oral . . . . . . . . . . . 26LIPITOR . . . . . . . . . . . . . . . . . . . . . . . . 14lisinopril oral . . . . . . . . . . . . . . . . . . . . . 14lisinopril-hydrochlorothiazide . . . . . . . 14lithium carbonate er . . . . . . . . . . . . . . 13lithium carbonate oral capsule . . . . . . 13LITHOBID . . . . . . . . . . . . . . . . . . . . . . . 13LO LOESTRIN FE. . . . . . . . . . . . . . . . . 24lo-zumandimine . . . . . . . . . . . . . . . . . . 24LOESTRIN 1/20 (21) . . . . . . . . . . . . . . 24LOESTRIN 1.5/30 (21) . . . . . . . . . . . . . 24LOESTRIN FE 1/20 . . . . . . . . . . . . . . . 24LOESTRIN FE 1.5/30 . . . . . . . . . . . . . . 24LOKELMA . . . . . . . . . . . . . . . . . . . . . . . 21LOPID . . . . . . . . . . . . . . . . . . . . . . . . . . 14LOPRESSOR . . . . . . . . . . . . . . . . . . . . 14lorazepam oral tablet . . . . . . . . . . . . . 13loryna . . . . . . . . . . . . . . . . . . . . . . . . . . 24losartan potassium oral . . . . . . . . . . . 14losartan potassium-hctz . . . . . . . . . . . 14LOTEMAX OPHTHALMIC GEL . . . . . 28LOTEMAX OPHTHALMIC OINTMENT . . . . . . . . . . . . . . . . . . . . . . 28LOTEMAX OPHTHALMIC SUSPENSION . . . . . . . . . . . . . . . . . . . 28LOTEMAX SM . . . . . . . . . . . . . . . . . . . 28LOTENSIN . . . . . . . . . . . . . . . . . . . . . . 14loteprednol etabonate ophthalmic gel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28loteprednol etabonate ophthalmic suspension . . . . . . . . . . . . . . . . . . . . . . 28LOTREL . . . . . . . . . . . . . . . . . . . . . . . . 14lovastatin oral . . . . . . . . . . . . . . . . . . . . 14LOVAZA . . . . . . . . . . . . . . . . . . . . . . . . 14LOVENOX . . . . . . . . . . . . . . . . . . . . . . . . 9low-ogestrel . . . . . . . . . . . . . . . . . . . . . 24LUMAKRAS . . . . . . . . . . . . . . . . . . . . . 11LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . 28LUNESTA . . . . . . . . . . . . . . . . . . . . . . . 31LUPRON DEPOT (1-MONTH) . . . . . . . 25lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . 24lyleq . . . . . . . . . . . . . . . . . . . . . . . . . . . 24lyllana . . . . . . . . . . . . . . . . . . . . . . . . . . 24LYMEPAK . . . . . . . . . . . . . . . . . . . . . . . . 9LYNPARZA . . . . . . . . . . . . . . . . . . . . . . 11LYRICA ORAL CAPSULE . . . . . . . . . . 15LYUMJEV KWIKPEN . . . . . . . . . . . . . . 19LYUMJEV VIAL . . . . . . . . . . . . . . . . . . 19lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MMACROBID . . . . . . . . . . . . . . . . . . . . . . 9MACRODANTIN . . . . . . . . . . . . . . . . . . 9marlissa . . . . . . . . . . . . . . . . . . . . . . . . 24MAVENCLAD . . . . . . . . . . . . . . . . . . . . 1538

MAVYRET ORAL PACKET . . . . . . . . . 12MAXALT . . . . . . . . . . . . . . . . . . . . . . . . 11MAXITROL OPHTHALMIC SUSPENSION . . . . . . . . . . . . . . . . . . . 28MAXZIDE . . . . . . . . . . . . . . . . . . . . . . . 14MAXZIDE-25 . . . . . . . . . . . . . . . . . . . . 14MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG . . 15MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG . . . . . . . . . . . . . . . . . . . . 15MEDROL ORAL TABLET THERAPY PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . 25medroxyprogesterone acetate intramuscular suspension prefilled syringe . . . . . . . . . . . . . . . . . . . . . . . . . 24medroxyprogesterone acetate oral . . 24meloxicam oral tablet . . . . . . . . . . . . . . 8MENOSTAR . . . . . . . . . . . . . . . . . . . . . 24mesalamine oral tablet delayed release . . . . . . . . . . . . . . . . . . . . . . . . . 27metformin hcl er . . . . . . . . . . . . . . . . . 20metformin hcl er (mod) . . . . . . . . . . . . 20metformin hcl er (osm) . . . . . . . . . . . . 20metformin hcl oral tablet 1000 mg, 500 mg, 850 mg. . . . . . . . . . . . . . . . . . 20metformin hcl oral tablet 625 mg . . . . 20methimazole oral . . . . . . . . . . . . . . . . . 26methocarbamol oral tablet 1000 mg . 30methocarbamol oral tablet 500 mg, 750 mg . . . . . . . . . . . . . . . . . . . . . . . . . 30methotrexate oral . . . . . . . . . . . . . . . . 26methotrexate sodium oral . . . . . . . . . . 26methylphenidate hcl er (cd) . . . . . . . . 15methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg . . . . . . . 15methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 15methylphenidate hcl er (osm) . . . . . . . 15methylphenidate hcl er (xr) . . . . . . . . . 15methylphenidate hcl er oral tablet extended release . . . . . . . . . . . . . . . . . 15methylphenidate hcl oral tablet . . . . . 15methylprednisolone oral tablet therapy pack . . . . . . . . . . . . . . . . . . . . 25metoclopramide hcl oral tablet . . . . . 11metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 50 mg . . . . . . . . . . . . . . . . . . . 14metoprolol succinate er oral tablet extended release 24 hour 25 mg . . . . 14metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg . . . . . . . . . . . . 14metoprolol tartrate oral tablet 37.5 mg, 75 mg . . . . . . . . . . . . . . . . . . 14METROCREAM . . . . . . . . . . . . . . . . . . 16metronidazole external cream . . . . . . 16metronidazole oral tablet . . . . . . . . . . . 9metronidazole vaginal . . . . . . . . . . . . . . 9MICARDIS . . . . . . . . . . . . . . . . . . . . . . 14MICRODOT TEST . . . . . . . . . . . . . . . . 18microgestin 1/20 . . . . . . . . . . . . . . . . . 24microgestin 1.5/30 . . . . . . . . . . . . . . . 24microgestin 24 fe . . . . . . . . . . . . . . . . . 24microgestin fe 1/20 . . . . . . . . . . . . . . . 24microgestin fe 1.5/30 . . . . . . . . . . . . . 24mifepristone . . . . . . . . . . . . . . . . . . . . . 21mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MINILINK REAL-TIME TRANSMITTER . . . . . . . . . . . . . . . . . . 18MINIMED 630G GUARDIAN PRESS . 18MINIPRESS . . . . . . . . . . . . . . . . . . . . . 14MINIVELLE . . . . . . . . . . . . . . . . . . . . . . 24minocycline hcl oral capsule . . . . . . . . 9mirtazapine oral tablet . . . . . . . . . . . . 10MIRVASO . . . . . . . . . . . . . . . . . . . . . . . 16misoprostol oral . . . . . . . . . . . . . . . . . . 21MITIGARE . . . . . . . . . . . . . . . . . . . . . . 11MM EASY TOUCH GLUCOSE METER . . . . . . . . . . . . . . . . . . . . . . . . . 18modafinil . . . . . . . . . . . . . . . . . . . . . . . . 31MODERNA COVID-19 VAC (BOOSTER) . . . . . . . . . . . . . . . . . . . . . 27MODERNA COVID-19 VACC 6M-5Y . 27MODERNA COVID-19 VACCINE . . . . 27mondoxyne nl . . . . . . . . . . . . . . . . . . . . 9mono-linyah . . . . . . . . . . . . . . . . . . . . . 24montelukast sodium oral tablet . . . . . 30montelukast sodium oral tablet chewable . . . . . . . . . . . . . . . . . . . . . . . 30morphine sulfate er oral tablet extended release . . . . . . . . . . . . . . . . . . 8MOTEGRITY . . . . . . . . . . . . . . . . . . . . 22MOUNJARO . . . . . . . . . . . . . . . . . . . . . 20MOVIPREP . . . . . . . . . . . . . . . . . . . . . . 22MOXEZA . . . . . . . . . . . . . . . . . . . . . . . . 28moxifloxacin hcl (2x day) . . . . . . . . . . . 28moxifloxacin hcl ophthalmic solution . . . . . . . . . . . . . . . . . . . . . . . . . 28MS CONTIN . . . . . . . . . . . . . . . . . . . . . . 8MULPLETA . . . . . . . . . . . . . . . . . . . . . . 20MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . 14MULTI-VIT-FLOR . . . . . . . . . . . . . . . . . 21multivitamin/fluoride tablet chewable 0.25 mg oral (rx) . . . . . . . . . 21multivitamin/fluoride tablet chewable 0.5 mg oral (rx) . . . . . . . . . . 21multivitamin/fluoride tablet chewable 1 mg oral (rx). . . . . . . . . . . . 21mupirocin external . . . . . . . . . . . . . . . . . 9mycophenolate mofetil oral tablet . . . 26MYDAYIS . . . . . . . . . . . . . . . . . . . . . . . 15MYFEMBREE . . . . . . . . . . . . . . . . . . . . 24myorisan . . . . . . . . . . . . . . . . . . . . . . . . 16Nnabumetone oral . . . . . . . . . . . . . . . . . . 8NALOCET . . . . . . . . . . . . . . . . . . . . . . . . 8naloxone hcl injection solution prefilled syringe . . . . . . . . . . . . . . . . . . . 8naloxone hcl nasal . . . . . . . . . . . . . . . . . 8naltrexone hcl oral . . . . . . . . . . . . . . . . . 8NAPROSYN ORAL TABLET . . . . . . . . . 8naproxen oral tablet . . . . . . . . . . . . . . . 8NARCAN . . . . . . . . . . . . . . . . . . . . . . . . 8NASCOBAL . . . . . . . . . . . . . . . . . . . . . 21NATAZIA . . . . . . . . . . . . . . . . . . . . . . . . 24NATESTO . . . . . . . . . . . . . . . . . . . . . . . 25NAYZILAM . . . . . . . . . . . . . . . . . . . . . . 10neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 . . . . . . . . . . . . . . . . . . . . 28neomycin-polymyxin-hc otic suspension . . . . . . . . . . . . . . . . . . . . . . 29NESINA . . . . . . . . . . . . . . . . . . . . . . . . . 20NEULASTA . . . . . . . . . . . . . . . . . . . . . . 20NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . 12NEURONTIN ORAL CAPSULE . . . . . 10NEURONTIN ORAL TABLET . . . . . . . 1039

NEUTEK 2TEK TEST . . . . . . . . . . . . . . 18NEVANAC . . . . . . . . . . . . . . . . . . . . . . . 28NEXLETOL . . . . . . . . . . . . . . . . . . . . . . 14NEXLIZET . . . . . . . . . . . . . . . . . . . . . . . 14nifedipine er . . . . . . . . . . . . . . . . . . . . . 14nifedipine er osmotic release . . . . . . . 14nikki . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nitrofurantoin macrocrystal . . . . . . . . . 9nitrofurantoin monohydrate macrocrystals . . . . . . . . . . . . . . . . . . . . 9nitroglycerin sublingual . . . . . . . . . . . . 14NITROSTAT . . . . . . . . . . . . . . . . . . . . . 14NOCDURNA . . . . . . . . . . . . . . . . . . . . . 25nora-be . . . . . . . . . . . . . . . . . . . . . . . . . 24NORDITROPIN FLEXPRO . . . . . . . . . 25norethin ace-eth estrad-fe oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . 24norethindrone acet-ethinyl est . . . . . . 24norethindrone acetate oral . . . . . . . . . 24norethindrone oral . . . . . . . . . . . . . . . . 24norgestimate-eth estradiol . . . . . . . . . 24norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ 0.25 mg-25 mcg . . . . . . . . . . . . . . . . . . 24norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ 0.25 mg-35 mcg. . . . . . . . . . . . . . . . . . 24NORITATE . . . . . . . . . . . . . . . . . . . . . . 16NORLIQVA . . . . . . . . . . . . . . . . . . . . . . 14norlyroc . . . . . . . . . . . . . . . . . . . . . . . . 24nortriptyline hcl oral capsule . . . . . . . 10NORVASC . . . . . . . . . . . . . . . . . . . . . . 14NOURIANZ . . . . . . . . . . . . . . . . . . . . . . 12NOVAREL . . . . . . . . . . . . . . . . . . . . . . . 27NOVOEIGHT . . . . . . . . . . . . . . . . . . . . 20NOVOFINE AUTOCOVER PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . 18NOVOFINE PEN NEEDLE . . . . . . . . . . 18NOVOFINE PLUS PEN NEEDLE . . . . 18NOVOLIN 70/30 FLEXPEN . . . . . . . . . 19NOVOLIN 70/30 FLEXPEN RELION . 19NOVOLIN 70/30 RELION . . . . . . . . . . 19NOVOLIN 70/30 VIAL . . . . . . . . . . . . . 19NOVOLIN N FLEXPEN . . . . . . . . . . . . 19NOVOLIN N FLEXPEN RELION . . . . . 19NOVOLIN N RELION . . . . . . . . . . . . . . 19NOVOLIN N VIAL . . . . . . . . . . . . . . . . . 19NOVOLIN R FLEXPEN . . . . . . . . . . . . 19NOVOLIN R FLEXPEN RELION . . . . . 19NOVOLIN R RELION . . . . . . . . . . . . . . 19NOVOLIN R VIAL . . . . . . . . . . . . . . . . . 19NOVOTWIST . . . . . . . . . . . . . . . . . . . . 18np thyroid . . . . . . . . . . . . . . . . . . . . . . . 26NUBEQA. . . . . . . . . . . . . . . . . . . . . . . . 11NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . . 30NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML . . . . . . . . . . . . . . . . . . . . . 30NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/0.4ML . . . . . . . . . . . . . . . . . . . . 30NUCYNTA . . . . . . . . . . . . . . . . . . . . . . . . 8NUCYNTA ER . . . . . . . . . . . . . . . . . . . . . 8NURTEC . . . . . . . . . . . . . . . . . . . . . . . . 11NUTROPIN AQ NUSPIN 10 . . . . . . . . 25NUTROPIN AQ NUSPIN 20 . . . . . . . . 25NUTROPIN AQ NUSPIN 5 . . . . . . . . . 25NUVARING . . . . . . . . . . . . . . . . . . . . . . 24NUVESSA . . . . . . . . . . . . . . . . . . . . . . . . 9NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT . . . . . . . . . . . . . . . . . . . . . . . . . . . 20NUWIQ INTRAVENOUS KIT 1500 UNIT . . . . . . . . . . . . . . . . . . . . . . . . . . . 20NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 9nymyo . . . . . . . . . . . . . . . . . . . . . . . . . . 24nystatin external cream . . . . . . . . . . . . 11nystatin mouth/throat . . . . . . . . . . . . . 11Oocella . . . . . . . . . . . . . . . . . . . . . . . . . . 24OCUFLOX . . . . . . . . . . . . . . . . . . . . . . . 28ODOMZO . . . . . . . . . . . . . . . . . . . . . . . 11OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ofloxacin ophthalmic . . . . . . . . . . . . . . 28ofloxacin otic . . . . . . . . . . . . . . . . . . . . 29olanzapine oral tablet . . . . . . . . . . . . . 12olmesartan medoxomil oral . . . . . . . . 14olmesartan medoxomil-hctz . . . . . . . . 14OLUMIANT ORAL TABLET 1 MG, 4 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 26OLUMIANT ORAL TABLET 2 MG . . . 26OMECLAMOX-PAK . . . . . . . . . . . . . . . 21omega-3-acid ethyl esters . . . . . . . . . 14omeprazole oral capsule delayed release . . . . . . . . . . . . . . . . . . . . . . . . . 21OMNIPOD 5 G6 INTRO (GEN 5) . . . . 18OMNIPOD 5 G6 POD (GEN 5) . . . . . . 18ondansetron hcl oral tablet . . . . . . . . 11ondansetron odt . . . . . . . . . . . . . . . . . 11ONETOUCH CLUB LANCETS FINE PT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA LANCETS 30G . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA LANCETS 33G . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA PLUS LANCET30G . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA PLUS LANCET33G . . . . . . . . . . . . . . . . . . . . 18ONETOUCH FINEPOINT LANCETS . 18ONETOUCH SOLUTIONS STARTER KIT . . . . . . . . . . . . . . . . . . . . 18ONETOUCH ULTRA 2 KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH ULTRA MINI KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH ULTRA TEST STRIPS . . 18ONETOUCH ULTRASOFT LANCETS . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH VERIO FLEX SYSTEM. . 18ONETOUCH VERIO IQ SYSTEM . . . . 18ONETOUCH VERIO KIT W/DEVICE . 18ONETOUCH VERIO REFLECT KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH VERIO TEST STRIPS . . 18ONGLYZA . . . . . . . . . . . . . . . . . . . . . . . 20OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . 30OPTIUMEZ TEST . . . . . . . . . . . . . . . . . 18OPZELURA . . . . . . . . . . . . . . . . . . . . . 16ORENCIA CLICKJECT . . . . . . . . . . . . 26ORENCIA SUBCUTANEOUS . . . . . . . 26ORFADIN . . . . . . . . . . . . . . . . . . . . . . . 22ORGOVYX . . . . . . . . . . . . . . . . . . . . . . 11ORIAHNN . . . . . . . . . . . . . . . . . . . . . . . 25ORILISSA . . . . . . . . . . . . . . . . . . . . . . . 25oseltamivir phosphate oral capsule . . 12OSENI . . . . . . . . . . . . . . . . . . . . . . . . . . 2040

OSPHENA . . . . . . . . . . . . . . . . . . . . . . 21OTEZLA ORAL TABLET . . . . . . . . . . . 26OTREXUP . . . . . . . . . . . . . . . . . . . . . . . 26OVIDREL . . . . . . . . . . . . . . . . . . . . . . . 27OXAYDO . . . . . . . . . . . . . . . . . . . . . . . . . 8oxcarbazepine oral tablet . . . . . . . . . . 10oxybutynin chloride er . . . . . . . . . . . . 22oxybutynin chloride oral tablet . . . . . . 22oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg . . . . . . . . . . . . . . 8oxycodone hcl oral tablet 5 mg . . . . . . 8OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG . . . . . . . . . . . . . 8oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . . 8OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MG . . . . . . . . . 8OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . 20PPACERONE ORAL TABLET 100 MG, 400 MG . . . . . . . . . . . . . . . . . 14PACERONE ORAL TABLET 200 MG . 14PAMELOR . . . . . . . . . . . . . . . . . . . . . . 10PANCREAZE . . . . . . . . . . . . . . . . . . . . 22pantoprazole sodium oral tablet delayed release . . . . . . . . . . . . . . . . . . 21PARADIGM REAL-TIME TRANSMITTER . . . . . . . . . . . . . . . . . . 18paroxetine hcl oral tablet . . . . . . . . . . 10PAXIL ORAL TABLET . . . . . . . . . . . . . 10PAXLOVID (150/100) . . . . . . . . . . . . . . 12PAXLOVID (300/100) . . . . . . . . . . . . . . 12PEDIAPRED . . . . . . . . . . . . . . . . . . . . . 25peg 3350-kcl-na bicarb-nacl . . . . . . . 22peg-3350/electrolytes/ascorbat . . . . 22peg-kcl-nacl-nasulf-na asc-c . . . . . . . 22penicillin v potassium oral tablet . . . . . 9PERCOCET . . . . . . . . . . . . . . . . . . . . . . 8PERFOROMIST . . . . . . . . . . . . . . . . . . 30PERIDEX . . . . . . . . . . . . . . . . . . . . . . . . 15periogard . . . . . . . . . . . . . . . . . . . . . . . 15PERTZYE . . . . . . . . . . . . . . . . . . . . . . . 22PFIZER COVID-19 VAC BIVAL 5-11 . . 27PFIZER COVID-19 VAC BIVALENT. . . 27PFIZER COVID-19 VAC-TRIS 5-11Y . . 27PFIZER COVID-19 VAC-TRIS 6M-4Y . 27PFIZER-BIONT COVID-19 VAC-TRIS . . . . . . . . . . . . . . . . . . . . . . . 27PFIZER-BIONTECH COVID-19 VACC . . . . . . . . . . . . . . . . . . . . . . . . . . 27phenazo oral tablet 200 mg . . . . . . . . 22phenazopyridine hcl oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . 22PICATO . . . . . . . . . . . . . . . . . . . . . . . . . 16pioglitazone hcl . . . . . . . . . . . . . . . . . . 20PLAQUENIL . . . . . . . . . . . . . . . . . . . . . 12PLAVIX . . . . . . . . . . . . . . . . . . . . . . . . . 12PLEGRIDY INTRAMUSCULAR . . . . . 15PLEGRIDY STARTER PACK . . . . . . . . 15PLEGRIDY SUBCUTANEOUS . . . . . . 15PLENVU . . . . . . . . . . . . . . . . . . . . . . . . 22POLY-VI-FLOR ORAL TABLET CHEWABLE . . . . . . . . . . . . . . . . . . . . . 21polymyxin b-trimethoprim . . . . . . . . . . 28POLYTRIM . . . . . . . . . . . . . . . . . . . . . . 28POMALYST . . . . . . . . . . . . . . . . . . . . . 12portia-28 . . . . . . . . . . . . . . . . . . . . . . . . 24potassium chloride crys er oral tablet extended release 10 meq, 20 meq . . . . . . . . . . . . . . . . . . . . . . . . . 21potassium chloride crys er oral tablet extended release 15 meq . . . . 21potassium chloride er . . . . . . . . . . . . . 21potassium citrate er. . . . . . . . . . . . . . . 21PRADAXA . . . . . . . . . . . . . . . . . . . . . . . 9pramipexole dihydrochloride . . . . . . . 12pravastatin sodium . . . . . . . . . . . . . . . 14prazosin hcl oral . . . . . . . . . . . . . . . . . 14PRECISION XTRA . . . . . . . . . . . . . . . . 18PRECISION XTRA BLOOD GLUCOSE . . . . . . . . . . . . . . . . . . . . . . 18PRED FORTE . . . . . . . . . . . . . . . . . . . . 28PRED MILD . . . . . . . . . . . . . . . . . . . . . 28prednisolone acetate ophthalmic . . . 28prednisolone acetate p-f . . . . . . . . . . . 28prednisolone sodium phosphate oral solution 10 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml . . . . 25prednisolone sodium phosphate oral solution 15 mg/5ml . . . . . . . . . . . 25prednisolone sodium phosphate oral solution 20 mg/5ml . . . . . . . . . . . 25prednisone oral tablet . . . . . . . . . . . . . 25prednisone oral tablet therapy pack . 25pregabalin oral capsule . . . . . . . . . . . 15PREGNYL . . . . . . . . . . . . . . . . . . . . . . . 27PREMARIN ORAL . . . . . . . . . . . . . . . . 24PREMARIN VAGINAL . . . . . . . . . . . . . 24PREMIUM BLOOD GLUCOSE TEST . 18PREMPHASE . . . . . . . . . . . . . . . . . . . . 24PREMPRO . . . . . . . . . . . . . . . . . . . . . . 24PREZCOBIX . . . . . . . . . . . . . . . . . . . . . 12PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . . . . . . . . 14prochlorperazine maleate oral . . . . . . 11PROCTOFOAM HC . . . . . . . . . . . . . . . 27progesterone oral . . . . . . . . . . . . . . . . 24PROGRAF ORAL CAPSULE . . . . . . . 26PROLATE ORAL TABLET . . . . . . . . . . . 8promethazine hcl oral tablet . . . . . . . . 11promethazine-dm . . . . . . . . . . . . . . . . 29PROMETRIUM . . . . . . . . . . . . . . . . . . . 24propranolol hcl er . . . . . . . . . . . . . . . . 14propranolol hcl oral tablet . . . . . . . . . 14PROSCAR . . . . . . . . . . . . . . . . . . . . . . 22PROTONIX ORAL TABLET DELAYED RELEASE . . . . . . . . . . . . . . 22PROTOPIC . . . . . . . . . . . . . . . . . . . . . . 16PROVENTIL HFA . . . . . . . . . . . . . . 29, 30PROVERA . . . . . . . . . . . . . . . . . . . . 23, 24PROVIGIL . . . . . . . . . . . . . . . . . . . . . . . 31PROZAC . . . . . . . . . . . . . . . . . . . . . . . . 10pseudoephedrine-bromphen-dm . . . 29PTS PANELS EGLU TEST . . . . . . . . . 18PULMICORT FLEXHALER . . . . . . . . . 30PULMICORT SUSPENSION . . . . . . . . 30PULMOZYME . . . . . . . . . . . . . . . . . . . 30PYLERA . . . . . . . . . . . . . . . . . . . . . . . . 22PYRIDIUM . . . . . . . . . . . . . . . . . . . . . . 22Qquetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg . . . . . . . . . . . . . . . . . . . 12quetiapine fumarate oral tablet 150 mg . . . . . . . . . . . . . . . . . . . . . . . . . 1241

QUFLORA GUMMIES . . . . . . . . . . . . . 21QUFLORA PEDIATRIC ORAL TABLET CHEWABLE . . . . . . . . . . . . . 21QUINTET AC BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . 18QUINTET BLOOD GLUCOSE TEST . 18Rrabeprazole sodium oral tablet delayed release . . . . . . . . . . . . . . . . . . 22ramipril . . . . . . . . . . . . . . . . . . . . . . . . . 14RASUVO . . . . . . . . . . . . . . . . . . . . . . . . 26reclipsen . . . . . . . . . . . . . . . . . . . . . . . . 24RECOMBINATE . . . . . . . . . . . . . . . . . . 20REGLAN . . . . . . . . . . . . . . . . . . . . . . . . 11RELAFEN . . . . . . . . . . . . . . . . . . . . . . . . 8RELAFEN DS . . . . . . . . . . . . . . . . . . . . . 8RELEXXI . . . . . . . . . . . . . . . . . . . . . . . . 15RELION TRUE MET AIR GLUC METER . . . . . . . . . . . . . . . . . . . . . . . . . 18RELION TRUE METRIX TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . 18RELION ULTIMA GLUCOSE SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . 18RELION ULTIMA TEST . . . . . . . . . . . . 18RELPAX . . . . . . . . . . . . . . . . . . . . . . . . 11REMERON . . . . . . . . . . . . . . . . . . . . . . 10REMODULIN . . . . . . . . . . . . . . . . . . . . 30REPATHA . . . . . . . . . . . . . . . . . . . . . . . 14REPATHA PUSHTRONEX SYSTEM. . 14REPATHA SURECLICK . . . . . . . . . . . . 14RESTASIS . . . . . . . . . . . . . . . . . . . . . . . 28RESTASIS MULTIDOSE . . . . . . . . . . . 28RESTORIL . . . . . . . . . . . . . . . . . . . . . . 31RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML . . . . . . . . . . . . . . . . . . 20RETACRIT INJECTION SOLUTION 20000 UNIT/ML . . . . . . . . . . . . . . . . . . 20RETIN-A EXTERNAL CREAM . . . . . . 16REVATIO ORAL TABLET . . . . . . . . . . 30REVLIMID . . . . . . . . . . . . . . . . . . . . . . . 12REXULTI . . . . . . . . . . . . . . . . . . . . . . . . 12RHOFADE. . . . . . . . . . . . . . . . . . . . . . . 16RHOPRESSA . . . . . . . . . . . . . . . . . . . . 28RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . 26RISPERDAL ORAL TABLET . . . . . . . . 12risperidone oral tablet . . . . . . . . . . . . . 12RITALIN . . . . . . . . . . . . . . . . . . . . . . . . 15RITALIN LA. . . . . . . . . . . . . . . . . . . . . . 15rizatriptan benzoate . . . . . . . . . . . . . . . 11ROBINUL . . . . . . . . . . . . . . . . . . . . . . . 22ROBINUL-FORTE . . . . . . . . . . . . . . . . 22ROCALTROL ORAL CAPSULE . . . . . 27ROCKLATAN . . . . . . . . . . . . . . . . . . . . 28ropinirole hcl . . . . . . . . . . . . . . . . . . . . 12rosadan external cream . . . . . . . . . . . 16rosuvastatin calcium . . . . . . . . . . . . . . 14roweepra . . . . . . . . . . . . . . . . . . . . . . . 10ROXICODONE . . . . . . . . . . . . . . . . . . . . 8RUCONEST . . . . . . . . . . . . . . . . . . . . . 26RUKOBIA . . . . . . . . . . . . . . . . . . . . . . . 12RYBELSUS . . . . . . . . . . . . . . . . . . . . . . 20SSANTYL . . . . . . . . . . . . . . . . . . . . . . . . 16SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . 12scopolamine . . . . . . . . . . . . . . . . . . . . 11SEREVENT DISKUS . . . . . . . . . . . . . . 30SEROQUEL . . . . . . . . . . . . . . . . . . . . . 12sertraline hcl oral tablet . . . . . . . . . . . 10sharobel . . . . . . . . . . . . . . . . . . . . . . . . 24SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . 27sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . 21sildenafil citrate oral tablet 20 mg . . . 30SIMPONI . . . . . . . . . . . . . . . . . . . . . . . . 26simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg . . . . . . . . . . . . . . 14simvastatin oral tablet 80 mg . . . . . . . 14SINGULAIR ORAL TABLET . . . . . . . . 30SINGULAIR ORAL TABLET CHEWABLE . . . . . . . . . . . . . . . . . . . . . 30SITAVIG . . . . . . . . . . . . . . . . . . . . . . . . 12SKYRIZI PEN . . . . . . . . . . . . . . . . . . . . 26SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE . . . 26SOAANZ . . . . . . . . . . . . . . . . . . . . . . . . 14sodium sulfate-potassium sulfate-magnesium sulfate . . . . . . . . . . . . . . . 22SOFOSBUVIR-VELPATASVIR . . . . . . . 12solifenacin succinate . . . . . . . . . . . . . . 22SOLIQUA . . . . . . . . . . . . . . . . . . . . . . . 20SOMA . . . . . . . . . . . . . . . . . . . . . . . . . . 30SOMATULINE DEPOT . . . . . . . . . . . . . 25SOOLANTRA . . . . . . . . . . . . . . . . . . . . 16SPIKEVAX COVID-19 VACCINE . . . . . 27SPIRIVA HANDIHALER . . . . . . . . . . . . 30SPIRIVA RESPIMAT . . . . . . . . . . . . . . 30spironolactone oral . . . . . . . . . . . . . . . 14sprintec 28 . . . . . . . . . . . . . . . . . . . . . . 24sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . 24STELARA SUBCUTANEOUS . . . . . . . 26STENDRA . . . . . . . . . . . . . . . . . . . . . . . 21STIOLTO RESPIMAT . . . . . . . . . . . . . . 30STIVARGA . . . . . . . . . . . . . . . . . . . . . . 12STRATTERA . . . . . . . . . . . . . . . . . . . . 15STRENSIQ . . . . . . . . . . . . . . . . . . . . . . 22STRIVERDI RESPIMAT . . . . . . . . . . . . 30SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 9subvenite . . . . . . . . . . . . . . . . . . . . . . . 10sucralfate oral tablet . . . . . . . . . . . . . . 22sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9sumatriptan succinate oral . . . . . . . . . 11SUNOSI . . . . . . . . . . . . . . . . . . . . . . . . 31SUPARTZ FX . . . . . . . . . . . . . . . . . . . . . 8SUTAB . . . . . . . . . . . . . . . . . . . . . . . . . 22syeda . . . . . . . . . . . . . . . . . . . . . . . . . . 24SYMBICORT . . . . . . . . . . . . . . . . . . . . 30SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . 12SYMJEPI . . . . . . . . . . . . . . . . . . . . . . . . 29SYMLINPEN 120 . . . . . . . . . . . . . . . . . 20SYMLINPEN 60 . . . . . . . . . . . . . . . . . . 20SYMPROIC . . . . . . . . . . . . . . . . . . . . . . 22SYNJARDY . . . . . . . . . . . . . . . . . . . . . . 20SYNJARDY XR . . . . . . . . . . . . . . . . . . . 20SYNOJOYNT . . . . . . . . . . . . . . . . . . . . . 8SYNTHROID . . . . . . . . . . . . . . . . . . . . . 26TTABRECTA . . . . . . . . . . . . . . . . . . . . . . 12TACLONEX EXTERNAL OINTMENT . 16tacrolimus external . . . . . . . . . . . . . . . 16tacrolimus oral . . . . . . . . . . . . . . . . . . . 26tadalafil oral . . . . . . . . . . . . . . . . . . . . . 2142

TAGRISSO . . . . . . . . . . . . . . . . . . . . . . 12TAKHZYRO SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . 26TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . . 26TAMIFLU ORAL CAPSULE . . . . . . . . . 12tamoxifen citrate oral tablet 10 mg . . 12tamoxifen citrate oral tablet 20 mg . . 12tamsulosin hcl . . . . . . . . . . . . . . . . . . . 22TAPERDEX 12-DAY . . . . . . . . . . . . . . . 25TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG . . . . . . . . . . . 25TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21) . . . . . . . 25TAPERDEX 7-DAY . . . . . . . . . . . . . . . . 25TARGADOX . . . . . . . . . . . . . . . . . . . . . . 9TARGRETIN EXTERNAL . . . . . . . . . . 12TARGRETIN ORAL . . . . . . . . . . . . . . . 12tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . 24tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . 24tarina fe 1/20 eq . . . . . . . . . . . . . . . . . . 24TASIGNA . . . . . . . . . . . . . . . . . . . . . . . 12TAVALISSE . . . . . . . . . . . . . . . . . . . . . . 20TECHLITE (ARKAY) INSULIN SYRINGES . . . . . . . . . . . . . . . . . . . . . . 19TECHLITE (ARKAY) PEN NEEDLES . 19TEGSEDI. . . . . . . . . . . . . . . . . . . . . . . . 22TEKTURNA . . . . . . . . . . . . . . . . . . . . . 14TEKTURNA HCT . . . . . . . . . . . . . . . . . 14telmisartan . . . . . . . . . . . . . . . . . . . . . . 14temazepam . . . . . . . . . . . . . . . . . . . . . 31TENORETIC 100 . . . . . . . . . . . . . . . . . 14TENORETIC 50 . . . . . . . . . . . . . . . . . . 14TENORMIN . . . . . . . . . . . . . . . . . . . . . 14terbinafine hcl oral . . . . . . . . . . . . . . . . 11TERIPARATIDE (RECOMBINANT). . . 27TESTIM . . . . . . . . . . . . . . . . . . . . . . . . . 25TESTOSTERONE CYPIONATE INJECTION . . . . . . . . . . . . . . . . . . . . . . 25testosterone cypionate intramuscular . . . . . . . . . . . . . . . . . . . . 25THALITONE . . . . . . . . . . . . . . . . . . . . . 14THIOLA . . . . . . . . . . . . . . . . . . . . . . . . . 22THIOLA EC . . . . . . . . . . . . . . . . . . . . . . 22THYQUIDITY . . . . . . . . . . . . . . . . . . . . 26TIGLUTIK . . . . . . . . . . . . . . . . . . . . . . . 15timolol maleate (once-daily) . . . . . . . . 28timolol maleate ocudose . . . . . . . . . . 28timolol maleate ophthalmic solution . 28timolol maleate pf . . . . . . . . . . . . . . . . 28TIMOPTIC . . . . . . . . . . . . . . . . . . . . . . 28TIMOPTIC OCUDOSE . . . . . . . . . . . . . 28TIROSINT-SOL . . . . . . . . . . . . . . . . . . . 26TIVICAY. . . . . . . . . . . . . . . . . . . . . . . . . 12tizanidine hcl oral tablet . . . . . . . . . . . 30TOBI PODHALER . . . . . . . . . . . . . . . . 30TOBRADEX OPHTHALMIC SUSPENSION . . . . . . . . . . . . . . . . . . . 28TOBRADEX ST . . . . . . . . . . . . . . . . . . 28tobramycin-dexamethasone . . . . . . . . 28TOPAMAX . . . . . . . . . . . . . . . . . . . . . . 10topiramate oral tablet . . . . . . . . . . . . . 10TOPROL XL . . . . . . . . . . . . . . . . . . . . . 14torsemide . . . . . . . . . . . . . . . . . . . . . . . 14TOUJEO MAX SOLOSTAR . . . . . . . . . 19TOUJEO SOLOSTAR . . . . . . . . . . . . . 19TRACLEER 62.5 MG, 125 MG . . . . . . 30TRADJENTA . . . . . . . . . . . . . . . . . . . . . 20tramadol hcl oral tablet 100 mg . . . . . . 8tramadol hcl oral tablet 50 mg . . . . . . . 8TRANSDERM-SCOP . . . . . . . . . . . . . . 11trazodone hcl oral . . . . . . . . . . . . . . . . 10TRELEGY ELLIPTA . . . . . . . . . . . . . . . 30TREMFYA . . . . . . . . . . . . . . . . . . . . . . . 26treprostinil . . . . . . . . . . . . . . . . . . . . . . 30tretinoin external cream . . . . . . . . . . . 16TREXALL . . . . . . . . . . . . . . . . . . . . . . . 26TREZIX . . . . . . . . . . . . . . . . . . . . . . . . . . 8tri femynor . . . . . . . . . . . . . . . . . . . . . . 24tri-estarylla . . . . . . . . . . . . . . . . . . . . . . 24tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . 24tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . 24tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . 24tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . 24tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . 24tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 24tri-nymyo . . . . . . . . . . . . . . . . . . . . . . . . 24tri-sprintec . . . . . . . . . . . . . . . . . . . . . . 24tri-vylibra . . . . . . . . . . . . . . . . . . . . . 24, 25tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . 25triamcinolone acetonide external cream 0.025 %, 0.1 % . . . . . . . . . . . . . 17triamcinolone acetonide external cream 0.5 % . . . . . . . . . . . . . . . . . . . . . 17triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % . . . . . 17triamcinolone acetonide external ointment 0.05 % . . . . . . . . . . . . . . . . . . 17triamcinolone in absorbase . . . . . . . . 17triamterene-hctz . . . . . . . . . . . . . . . . . 14TRIANEX . . . . . . . . . . . . . . . . . . . . . . . 17triazolam . . . . . . . . . . . . . . . . . . . . . . . . 13TRICOR . . . . . . . . . . . . . . . . . . . . . . . . 14triderm external cream 0.1 % . . . . . . . 17triderm external cream 0.5 % . . . . . . . 17TRIJARDY XR . . . . . . . . . . . . . . . . . . . 20TRILEPTAL ORAL TABLET . . . . . . . . 10TRILURON . . . . . . . . . . . . . . . . . . . . . . . 8TRINTELLIX . . . . . . . . . . . . . . . . . . . . . 10tritocin . . . . . . . . . . . . . . . . . . . . . . . . . . 17TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . 12TRUE FOCUS BLOOD GLUCOSE STRIP . . . . . . . . . . . . . . . . . . . . . . . . . . 19TRUE METRIX AIR GLUCOSE METER KIT . . . . . . . . . . . . . . . . . . . . . . 19TRUE METRIX BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . 19TRUE METRIX GO GLUCOSE METER . . . . . . . . . . . . . . . . . . . . . . . . . 19TRUE METRIX METER KIT. . . . . . . . . 19TRUE METRIX PRO BLOOD GLUCOSE . . . . . . . . . . . . . . . . . . . . . . 19TRUETRACK TEST . . . . . . . . . . . . . . . 19TRULICITY . . . . . . . . . . . . . . . . . . . . . . 20TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG . . . . . . . . . . . . . . . . . . . . . 12TRUVADA ORAL TABLET 200-300 MG . . . . . . . . . . . . . . . . . . . . . 12TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . 27TYRVAYA . . . . . . . . . . . . . . . . . . . . . . . 28TYVASO . . . . . . . . . . . . . . . . . . . . . . . . 30TYVASO DPI MAINTENANCE KIT . . . 30TYVASO DPI TITRATION KIT . . . . . . . 30TYVASO REFILL . . . . . . . . . . . . . . . . . 30TYVASO STARTER . . . . . . . . . . . . . . . 3043

UUBRELVY . . . . . . . . . . . . . . . . . . . . . . . 11UCERIS ORAL . . . . . . . . . . . . . . . . . . . 27UCERIS RECTAL . . . . . . . . . . . . . . . . . 27UNISTRIP1 GENERIC . . . . . . . . . . . . . 19unithroid . . . . . . . . . . . . . . . . . . . . . . . . 26UROCIT-K 10 . . . . . . . . . . . . . . . . . . . . 21UROCIT-K 15 . . . . . . . . . . . . . . . . . . . . 21UROCIT-K 5 . . . . . . . . . . . . . . . . . . . . . 21UROXATRAL . . . . . . . . . . . . . . . . . . . . 22VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . . 25valacyclovir hcl oral . . . . . . . . . . . . . . . 12VALIUM . . . . . . . . . . . . . . . . . . . . . . . . . 13valsartan oral tablet . . . . . . . . . . . . . . . 14valsartan-hydrochlorothiazide . . . . . . 14VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML . . . . . . . . 10VALTREX . . . . . . . . . . . . . . . . . . . . . . . 13VANADOM . . . . . . . . . . . . . . . . . . . . . . 31vandazole . . . . . . . . . . . . . . . . . . . . . . . . 9VASOTEC . . . . . . . . . . . . . . . . . . . . . . . 14VELPHORO . . . . . . . . . . . . . . . . . . . . . 22VELTASSA . . . . . . . . . . . . . . . . . . . . . . 21venlafaxine hcl . . . . . . . . . . . . . . . . . . . 10venlafaxine hcl er oral capsule extended release 24 hour . . . . . . . . . . 10VENTOLIN HFA . . . . . . . . . . . . . . . 29, 30verapamil hcl er oral tablet extended release . . . . . . . . . . . . . . . . . 14VERKAZIA . . . . . . . . . . . . . . . . . . . . . . 28VERQUVO . . . . . . . . . . . . . . . . . . . . . . 14VERZENIO . . . . . . . . . . . . . . . . . . . . . . 12VESICARE . . . . . . . . . . . . . . . . . . . . . . 22vestura . . . . . . . . . . . . . . . . . . . . . . . . . 25VIAGRA . . . . . . . . . . . . . . . . . . . . . . . . 21VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . 22VIBRAMYCIN ORAL CAPSULE . . . . . . 9VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS . . . . . . . . . . . . . . . . 20vienva . . . . . . . . . . . . . . . . . . . . . . . . . . 25VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . 28VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . 10VIIBRYD STARTER PACK . . . . . . . . . . 10vilazodone hcl . . . . . . . . . . . . . . . . . . . 10VISTARIL . . . . . . . . . . . . . . . . . . . . . . . 13vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21VITRAKVI . . . . . . . . . . . . . . . . . . . . . . . 12VIVELLE-DOT . . . . . . . . . . . . . . . . . . . . 25VIVJOA . . . . . . . . . . . . . . . . . . . . . . . . . 11VOGELXO . . . . . . . . . . . . . . . . . . . . . . . 25VOGELXO PUMP . . . . . . . . . . . . . . . . . 25VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . 13VRAYLAR ORAL CAPSULE . . . . . . . . 12VTAMA . . . . . . . . . . . . . . . . . . . . . . . . . 17VYLEESI . . . . . . . . . . . . . . . . . . . . . . . . 21vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 25VYVANSE . . . . . . . . . . . . . . . . . . . . . . . 15WWAKIX . . . . . . . . . . . . . . . . . . . . . . . . . . 31warfarin sodium oral . . . . . . . . . . . . . . . 9WELLBUTRIN SR . . . . . . . . . . . . . . . . 10WELLBUTRIN XL . . . . . . . . . . . . . . . . . 11WILATE . . . . . . . . . . . . . . . . . . . . . . . . . 21wixela inhub . . . . . . . . . . . . . . . . . . . . . 30XXALATAN . . . . . . . . . . . . . . . . . . . . . . . 28XANAX . . . . . . . . . . . . . . . . . . . . . . . . . 13XARELTO . . . . . . . . . . . . . . . . . . . . . . . 10XARELTO STARTER PACK. . . . . . . . . 10XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG . . . . . . . . . . 10XELJANZ . . . . . . . . . . . . . . . . . . . . . . . 27XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG . . . . . . . . . . . . . . . . . . . . . . . . . . 27XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 MG . . . . . . . . . . . . . . . . . . . . . . . . . . 27XENLETA ORAL . . . . . . . . . . . . . . . . . . 9XEPI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17XIIDRA . . . . . . . . . . . . . . . . . . . . . . . . . 28XOFLUZA (40 MG DOSE) . . . . . . . . . . 13XOFLUZA (80 MG DOSE) . . . . . . . . . . 13XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE . . . 27XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED . . . . . . 27XOPENEX HFA . . . . . . . . . . . . . . . . . . . 30XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 8xulane . . . . . . . . . . . . . . . . . . . . . . . . . . 25XYREM . . . . . . . . . . . . . . . . . . . . . . . . . 31XYWAV . . . . . . . . . . . . . . . . . . . . . . . . . 31YYASMIN 28 . . . . . . . . . . . . . . . . . . . . . . 25YAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25YUPELRI . . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem . . . . . . . . . . . . . . . . . . . . . . . . 25Zzafemy . . . . . . . . . . . . . . . . . . . . . . . . . 25ZANAFLEX ORAL TABLET . . . . . . . . 31ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . 21ZCORT 7-DAY . . . . . . . . . . . . . . . . . . . 25ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . . 20ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . 12ZELNORM . . . . . . . . . . . . . . . . . . . . . . 22zenatane . . . . . . . . . . . . . . . . . . . . . . . . 17ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . 22ZEPOSIA . . . . . . . . . . . . . . . . . . . . . . . 15ZEPOSIA 7-DAY STARTER PACK . . . 15ZEPOSIA STARTER KIT . . . . . . . . . . . 15ZESTORETIC . . . . . . . . . . . . . . . . . . . . 14ZESTRIL . . . . . . . . . . . . . . . . . . . . . . . . 14ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . 14ZETONNA. . . . . . . . . . . . . . . . . . . . . . . 29ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG . . . . . . . . . . . . . . . . . . . . . 15ZIAC ORAL TABLET 5-6.25 MG . . . . 15ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . 21ZILXI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ZIMHI . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . 28ZITHROMAX ORAL SUSPENSION RECONSTITUTED . . . . . . . . . . . . . . . . . 9ZITHROMAX ORAL TABLET . . . . . . . . 9ZITHROMAX TRI-PAK . . . . . . . . . . . . . . 9ZITHROMAX Z-PAK . . . . . . . . . . . . . . . . 9ZOCOR . . . . . . . . . . . . . . . . . . . . . . . . . 1544

ZOLMITRIPTAN NASAL SOLUTION 2.5 MG . . . . . . . . . . . . . . . . . . . . . . . . . 11ZOLOFT ORAL TABLET . . . . . . . . . . . 11zolpidem tartrate er . . . . . . . . . . . . . . . 31zolpidem tartrate oral . . . . . . . . . . . . . 31ZOMIG NASAL SOLUTION 2.5 MG . . 11ZOMIG NASAL SOLUTION 5 MG . . . 11ZONEGRAN . . . . . . . . . . . . . . . . . . . . . 10zonisamide oral . . . . . . . . . . . . . . . . . . 10ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . 8ZUBSOLV . . . . . . . . . . . . . . . . . . . . . . . . 9zumandimine . . . . . . . . . . . . . . . . . . . . 25ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYLOPRIM . . . . . . . . . . . . . . . . . . . . . . 11ZYPREXA ORAL . . . . . . . . . . . . . . . . . 1245

Nondiscrimination notice and access to communication services ® UnitedHealthcare and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in their health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: UHC_Civil_Rights@uhc.comMail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.You can also file a complaint with the U.S. Dept. of Health and Human Services.Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmlPhone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.46

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。Ýý, quýôýATANSYON: Si w pale Kreyl ayisyen (Haitian Creole), ou kapab  sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat  w.     (Farsi)   ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें।CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo)OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.Multi-language interpreter servicesMulti-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong   (Russian)(Arabic) ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés polsku (Polish)português (Portuguese)ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証に記載されているフリーダイヤルにお電話ください。47

This document applies to members of UnitedHealthcare, Oxford New York and New Jersey and UnitedHealthOne plans.Insurance coverage provided by or through UnitedHealthcare Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company (except CA, MA, MN, NJ and NY), UnitedHealthcare Insurance Company in MA and MN, UnitedHealthcare Life Insurance Company in NJ, UnitedHealthcare Insurance Company of New York in NY, and All Savers Life Insurance Company of California in CA. UnitedHealthcare Freedom Plans are underwritten by Tufts Health Freedom Insurance Company. Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc., Oxford Health Plans LLC or their affiliates, and UnitedHealthcare Service LLC in NY. Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company. UnitedHealthOne plans provided by or through Oxford Health Plans (NJ), Inc. UnitedHealthcare® is a registered trademark owned by UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. 12/22 ©2023 United HealthCare Services, Inc. WF8952858-B 2023 Prescription Drug List — Advantage 4-Tier