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Pharmacy | PDLYour 2024 Prescription Drug ListTexas Advantage 3-TierEffective January 1, 2024This Prescription Drug List (PDL) is accurate as of January 1, 2024 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare and Student Resources medical plans with a pharmacy benefit subject to the Advantage 3-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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Anticoagulants Drugs to Treat or Prevent Blood Clots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Anticonvulsants Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antidepressants Drugs for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antiemetics Drugs for Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Dermatological Agents Drugs for Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Diabetes Glucose Monitoring and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Drugs for Blood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Gastrointestinal Agents Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . 21Genetic 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Respiratory Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Respiratory 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Understanding your Prescription Drug List (PDL)What is a PDL?This document is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then listed in alphabetical order.How do I use my PDL?You and your doctor can consult the PDL to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or a brand-name, and if there are coverage requirements or limits. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the toll-free member phone number on your member 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?• Medications may move to a lower tier at any time.• Medications may move to a higher tier when a generic becomes available.• Medications may move to a higher tier or be excluded from coverage most often upon your group’s renewal.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 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 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.About this PDLWhere differences exist between this PDL and your benefit plan documents, the benefit plan documents rule. This PDL is not a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or health plan to see which medications are covered under your plan.4

Medication tipsWhat is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a 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.Over-the-counter (OTC) medicationsAn OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.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.Tier 2$$ Mid-range cost Medications that provide good overall value. A mix of brand name and generic drugs.Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.Tier 3 $$$ Highest-cost Medications that provide the lowest overall value. Mostly brand-name drugs, as well as some generics.Ask your doctor if a Tier 1 or Tier 2 option 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 — 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.PA Prior Authorization (sometimes referred to as precertification)1—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.RS Refill and Save Program2— 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 3—Requires prior authorization and may require you to try one or more other medications before the medication you are requesting may be covered.1. For certain Student Resources plans, applies to specialty medications and topical retinoids only.2. Not applicable to Student Resources plans.3. Not applicable to certain Student Resources plans.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.• 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. • 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. Additional information is also 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 cardVisit your plan’s member website listed on your member ID card to:• View your pharmacy benefit and coverage information, including prescription history• View medication interactions and side effects• Locate a participating retail pharmacy by ZIP code• Look up possible lower-cost medication alternatives• Compare medication pricing and optionsAnd, if home delivery services are included in your pharmacy benefit, you can also:• Refill prescriptions• Check the status of your order• Set up reminders for refills• Manage your account7

Drug Name Drug RequirementsTier & Limitsgggg Bg BBBgB Bg gB gB gggggggBgggBBgggBBBgBBgBggBgBBBBgggBgBgBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsAnalgesics - Drugs for Painacetaminophen-codeine oral tablet 1apap-caff-dihydrocodeine 3 QLbac 1 QLBELBUCA 3 PA, QLbutalbital-apap-caffeine oral tablet 1 QLDILAUDID ORAL TABLET Eendocet 1ESGIC ORAL TABLET 3 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 3 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 3 QLXTAMPZA ER 3 PA, QLZTLIDO 3 PA, QLAnalgesics - Drugs for Pain and InflammationCELEBREX E QLcelecoxib oral 2 QLdiclofenac sodium oral 1ibuprofen oral tablet 400 mg, 600 mg, 800 mg1indomethacin oral 1ketorolac tromethamine oral 1meloxicam oral tablet 1nabumetone oral 1NAPROSYN ORAL TABLET Enaproxen oral tablet 1RELAFEN DS 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 (includes OTC) QLSUBOXONE E PA, QLZIMHI 2 QLZUBSOLV 2 QLAntibacterials - Drugs for Infectionsamoxicillin oral capsule 1amoxicillin oral suspension reconstituted1amoxicillin oral tablet 1amoxicillin-potassium clavulanate oral suspension reconstituted18

Drug Name Drug RequirementsTier & Limitsg ggBgBggggBgBBgBggg Bg Bg BBBBgB B BBBgBgBBgBggggBgBggBgBgBgBBBBBgggSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsamoxicillin-potassium clavulanate oral tablet1AUGMENTIN EAUGMENTIN ES-600 Eavidoxy 1azithromycin oral suspension reconstituted1azithromycin oral tablet 1BACTRIM 3BACTRIM DS 3cefdinir 1cefuroxime axetil 1cephalexin oral capsule 1cephalexin oral suspension reconstituted1CIPRO ORAL TABLET 3ciprofloxacin hcl oral 1CLEOCIN ORAL CAPSULE 150 MG, 300 MG3CLEOCIN 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 tablet 1levofloxacin oral tablet 1MACROBID 3MACRODANTIN 3metronidazole oral tablet 1metronidazole vaginal 2minocycline hcl oral capsule 1mondoxyne nl 1mupirocin external 1 QLnitrofurantoin macrocrystal 1nitrofurantoin monohydrate macrocrystals1NUVESSA ENUZYRA ORAL 3 QLpenicillin v potassium oral tablet 1sulfamethoxazole-trimethoprim oral tablet1TARGADOX EVANDAZOLE 3VIBRAMYCIN ORAL CAPSULE 3XENLETA ORAL 3ZITHROMAX ORAL SUSPENSION RECONSTITUTED3ZITHROMAX ORAL TABLET 3ZITHROMAX TRI-PAK 3ZITHROMAX Z-PAK 3Anticoagulants - Drugs to Treat or Prevent Blood Clotsdabigatran etexilate mesylate 2 QLELIQUIS 2 QLELIQUIS DVT/PE STARTER PACK 2 QLenoxaparin sodium injection solution prefilled syringe2 QLjantoven 1LOVENOX INJECTION SOLUTION PREFILLED SYRINGEE QLPRADAXA ORAL CAPSULE 2 QLwarfarin sodium oral 1XARELTO 2 QLXARELTO STARTER PACK 2 QLAnticonvulsants - Drugs for SeizuresAPTIOM 3 PABRIVIACT ORAL TABLET 3 PADEPAKOTE 3 PADEPAKOTE ER 3 PAdivalproex sodium er 29

Drug Name Drug RequirementsTier & Limitsg gBgggBgBgBgggggBgBBBBgggggBBggBBBBBB BgBggBggggg BBgBBBBgBgggBggggSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsdivalproex sodium oral tablet delayed release1EPIDIOLEX 3 PA, SPgabapentin oral capsule 1gabapentin oral tablet 600 mg, 800 mg1KEPPRA ORAL TABLET 3 PALAMICTAL ORAL TABLET 3 PAlamotrigine oral tablet 1levetiracetam oral tablet 1NAYZILAM 3 PA, QLNEURONTIN ORAL CAPSULE 3 PANEURONTIN ORAL TABLET 3 PAoxcarbazepine oral tablet 1roweepra 1subvenite 1TOPAMAX 3 PAtopiramate oral tablet 1TRILEPTAL ORAL TABLET 3 PAVALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML3 PA, QLXCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG3 PAZONEGRAN 3 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 3 ST, QLvenlafaxine hcl 1venlafaxine hcl er oral capsule extended release 24 hour1VIIBRYD E QLVIIBRYD STARTER PACK 3vilazodone hcl 3 QLWELLBUTRIN SR EWELLBUTRIN XL EZOLOFT ORAL TABLET EAntiemetics - Drugs for Nausea and Vomitingmetoclopramide hcl oral tablet 1ondansetron hcl oral tablet 1ondansetron odt 1prochlorperazine maleate oral 110

Drug Name Drug RequirementsTier & Limitsg BB gg gB BBg BgB BB Bg gB Bg Bg Bg Bg Bg BB BBg BBBBBBgB BB BBBgBgBgg BB BBBBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitspromethazine hcl oral tablet 1REGLAN 3scopolamine 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 3 PA, QLAntigout Agents - Drugs for Goutallopurinol oral tablet 100 mg, 300 mg1ALLOPURINOL ORAL TABLET 200 MGECOLCHICINE ORAL CAPSULE Ecolchicine oral tablet 2COLCRYS EMITIGARE 2ZYLOPRIM 3Antimigraine 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, QLZOMIG NASAL SOLUTION 2.5 MG 3 QLZOMIG NASAL SOLUTION 5 MG 2 QLAntineoplastics - Drugs for CancerALECENSA 2 PA, QLALUNBRIG 2 PA, QL, SPanastrozole oral 1 H-PAARIMIDEX ECALQUENCE 2 PA, QL, SPCOTELLIC 2 PA, QL, SPERIVEDGE 2 PA, QL, SPERLEADA ORAL TABLET 240 MG 2 PA, QLERLEADA ORAL TABLET 60 MG 2 PA, QL, SPEXKIVITY 3 PA, QL, SPFEMARA EGAVRETO 3 PA, QL, SPIBRANCE ORAL CAPSULE 2 PA, QL, SPICLUSIG ORAL TABLET 10 MG, 30 MG3 PA, QLICLUSIG ORAL TABLET 15 MG, 45 MG3 PA, QL, SPIDHIFA 2 PA, QL, SPIMBRUVICA ORAL TABLET 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 3 PA, QL, SPLYNPARZA 2 PA, QL, SPNUBEQA 2 PA, QL, SPODOMZO 2 PA, QL, SPORGOVYX 3 PA, QL, SPPOMALYST 3 PA, QL, SP11

Drug Name Drug Requirements Drug Name Drug RequirementsTier & Limits Tier & LimitsB BRETEVMO ORAL CAPSULE 40 MG 3 PA, QL, SP REXULTI 3 PA, ST, QLB BRETEVMO ORAL CAPSULE 80 MG 3 PA, SP RISPERDAL ORAL TABLET EB gREVLIMID 2 PA, QL, SP risperidone oral tablet 1B BSTIVARGA 2 PA, QL, SP SEROQUEL EB BTABRECTA 3 PA, QL, SP VRAYLAR ORAL CAPSULE 3 QLB BTAGRISSO 3 PA, QL, SP ZYPREXA ORAL Egtamoxifen citrate oral tablet 10 mg 1 Antivirals - Drugs for Viral Infectionsg gtamoxifen citrate oral tablet 20 mg 1 H-PAacyclovir oral tablet 1BBTASIGNA 2 PA, ST, QL, SP BIKTARVY 3 QLB BVERZENIO 2 PA, QL, SP CIMDUO 2 QLB BVITRAKVI 2 PA, QL, SPDESCOVY E PA, ST, QLBBXTANDI 2 PA, QL, SP DOVATO 2 QLB gZEJULA ORAL CAPSULE 2 PA, QL, SP emtricitabine-tenofovir df oral tablet 1 QL100-150 mg, 133-200 mg, BZELBORAF 2 PA, QL, SP167-250 mgAntiparasitics - Drugs for Parasitic Infectionsgemtricitabine-tenofovir df oral tablet 1 QL, HBARAKODA 3 QL200-300 mgghydroxychloroquine sulfate oral 1BEPCLUSA ORAL TABLET 2 PA, QL, SPBKRINTAFEL 1 QLBHARVONI ORAL TABLET 2 PA, ST, QL, SPBPLAQUENIL EBJULUCA 2 QLAntiparkinson Agents - Drugs for Parkinson's DiseaseBLEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SPBINBRIJA 3 PA, QL, SPBMAVYRET ORAL PACKET 2 PA, QL, SPBKYNMOBI 3 PA, QL, SPgoseltamivir phosphate oral capsule 2BNEUPRO 3BPAXLOVID (150/100) 3 QLBNOURIANZ 3 PA, QLBPAXLOVID (300/100) 3 QLgpramipexole dihydrochloride 1BPREZCOBIX 2gropinirole hcl 1BRUKOBIA 3 PAAntiplatelets - Drugs for Heart Attack and Stroke BSITAVIG E QLPreventionBSOFOSBUVIR-VELPATASVIR 2 PA, QL, SPBBRILINTA 3 QLBSYMFI 2 QLgclopidogrel bisulfate oral 1BSYMFI LO 2 QLBPLAVIX EBTAMIFLU ORAL CAPSULE EAntipsychotics - Drugs for Mood DisordersBTIVICAY 3BABILIFY EBTRIUMEQ 2 QLgaripiprazole oral tablet 2BTRUVADA ORAL TABLET 3 QLBLATUDA E QL100-150 MG, 133-200 MG, glurasidone hcl 3 QL167-250 MGgBolanzapine oral tablet 1TRUVADA ORAL TABLET E QL200-300 MGgquetiapine fumarate 1See page 6, 7 for coverage details. 12

Drug Name Drug RequirementsTier & Limitsg BB gB BB BB ggg BB Bggg gg ggBg Bg BB BBgg gB BBBB ggBgBgB gggBgBBggBggggggggggBgBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsvalacyclovir hcl oral 1 QLVALTREX 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 3hydroxyzine hcl oral tablet 1hydroxyzine pamoate oral 1KLONOPIN Elorazepam oral tablet 1triazolam 1VALIUM EVISTARIL 3XANAX EBipolar Agents - Drugs for Mood Disorderslithium carbonate er 1lithium carbonate oral capsule 1LITHOBID 3 PACardiovascular Agents - Drugs for Heart and Circulation ConditionsALDACTONE Ealiskiren fumarate 3ALTACE Eamiodarone hcl oral 1amlodipine besylate oral 1amlodipine besylate-benazepril hcl 1amlodipine besylate-valsartan 2atenolol oral 1atorvastatin calcium oral tablet 10 mg, 20 mg1 H-PAatorvastatin calcium oral tablet 40 mg, 80 mg1AVALIDE EAVAPRO Ebenazepril hcl oral 1BENICAR EBENICAR HCT Ebisoprolol fumarate oral 1bisoprolol-hydrochlorothiazide 1CARDIZEM CD ECARDURA 3cartia xt 2carvedilol 1chlorthalidone 1clonidine hcl oral 1COREG ECORLANOR 3 PA, QLCOZAAR ECRESTOR Ediltiazem hcl er coated beads 2DIOVAN EDIOVAN HCT Edoxazosin mesylate oral 1enalapril maleate oral tablet 1ENTRESTO 3 PA, QLEXFORGE Eezetimibe 2fenofibrate oral tablet 120 mg, 40 mgEfenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg2FENOGLIDE Eflecainide acetate 1FUROSCIX 3 PA, QLfurosemide oral tablet 1gemfibrozil oral 1guanfacine hcl 1hydralazine hcl oral 1hydrochlorothiazide oral 1HYZAAR EINDERAL LA E13

Drug Name Drug RequirementsTier & Limitsg gg gg gg BBBBggggBBgBggggBBBBBggBgBBggBgg BBggBgBBBgBggBBgBgBBggd ggBBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsirbesartan 1irbesartan-hydrochlorothiazide 1isosorbide mononitrate er 1labetalol hcl oral 1LASIX 3LIPITOR Elisinopril oral 1lisinopril-hydrochlorothiazide 1LOPID 3LOPRESSOR 3losartan potassium oral 1losartan potassium-hctz 1LOTENSIN 3LOTREL Elovastatin oral 1 HLOVAZA EMAXZIDE 3MAXZIDE-25 3metoprolol 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 3minoxidil oral 1MULTAQ 3 PANEXLETOL 2 PA, ST, QLNEXLIZET 2 PA, ST, QLnifedipine er 1nifedipine er osmotic release 1nitroglycerin sublingual 1NITROSTAT 3NORLIQVA 3 PANORVASC Eolmesartan medoxomil oral 2olmesartan medoxomil-hctz 2omega-3-acid ethyl esters 2PACERONE ORAL TABLET 100 MG, 400 MG3PACERONE ORAL TABLET 200 MG 3pravastatin 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 2TENORMIN ETHALITONE ETOPROL XL Etorsemide 1triamterene-hctz 1TRICOR Evalsartan oral tablet 2valsartan-hydrochlorothiazide 1VASOTEC Everapamil hcl er oral tablet extende release1VERQUVO 3 PA, QLZESTORETIC EZESTRIL E14

Drug Name Drug RequirementsTier & LimitsB gB BBBBBBBBBBgBgBBgBBBgBgBBBBgggBgBBgBgBg Bg BBBBBBBBBgggBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsZETIA EZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG3ZIAC ORAL TABLET 5-6.25 MG 3ZOCOR ECentral Nervous System Agents - Drugs for Attention Deficit DisorderADDERALL EADDERALL XR E QLamphetamine-dextroamphetamine 1amphetamine-dextroamphetamine er2 QLAPTENSIO XR E QLatomoxetine hcl 3 QLCONCERTA E QLdexmethylphenidate hcl 1dexmethylphenidate hcl er 3 QLFOCALIN 3FOCALIN 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) oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg2 QLMETHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 45 MGE QLMETHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 63 MGEmethylphenidate hcl er (xr) E QLmethylphenidate hcl er oral tablet extended release3 QLmethylphenidate hcl oral tablet 1MYDAYIS E QLRELEXXII ORAL TABLET EXTENDED RELEASE 45 MG, 72 MGE QLRELEXXII ORAL TABLET EXTENDED RELEASE 63 MGERITALIN ERITALIN LA E QLSTRATTERA E QLVYVANSE E QLCentral Nervous System Agents - Drugs for Multiple SclerosisAVONEX 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 1 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 MG3 PA, QL, SPMAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG3 PA, QL, SPPLEGRIDY INTRAMUSCULAR 3 PA, QLPLEGRIDY STARTER PACK 3 PA, QL, SPPLEGRIDY SUBCUTANEOUS 3 PA, QL, SPREBIF E PA, QL, SPREBIF TITRATION PACK E PA, QL, SPCentral Nervous System Agents - MiscellaneousAUSTEDO 2 PA, QL, SPLYRICA ORAL CAPSULE 3 PApregabalin oral capsule 2RADICAVA ORS 3 PA, QL, SP15

Drug Name Drug RequirementsTier & LimitsB gBgBBBBBBggBgBBgBBBBgBBBBggBgBgBgggBBgBBggBgBBgBgBBBgBgBgSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsRADICAVA ORS STARTER KIT 3 PA, QL, SPTIGLUTIK 3 PAZEPOSIA 3 PA, ST, QL, SPZEPOSIA 7-DAY STARTER PACK 3 PA, ST, QL, SPZEPOSIA STARTER KIT 3 PA, ST, SPDental and Oral Agents - Drugs for Mouth and Throat Conditionschlorhexidine gluconate mouth/ throat1lidocaine hcl mouth/throat 1lidocaine viscous hcl 1PERIDEX 3periogard 1Dermatological Agents - Drugs for Skin ConditionsAKLIEF 3 PA, QLala-cort EAMZEEQ 3 QLAVITA E PA, QLbrimonidine tartrate external 3 PA, QLCARAC ECIBINQO 2 PA, QL, SPCLEOCIN-T 3clindacin etz external swab 1clindacin-p 1CLINDAGEL E QLclindamycin phosphate external lotion3clindamycin phosphate external solution1clindamycin phosphate external swab1clindamycin phosphate gel 1 % externalE (generic for Clindagel), QLclindamycin phosphate gel 1 % external2 (generic for Cleocin T gel) QLclindamycin phosphate gel 1 % external2 (generic for Cleocin T gel) QLclobetasol propionate external ointment2 QLclobetasol propionate external solution1 QLclotrimazole-betamethasone external cream1DAZOMON 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 3ENSTILAR 3 QLEUCRISA 3 ST, QLFINACEA EXTERNAL FOAM 3FLUOROPLEX 3FLUOROURACIL 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 QLKLISYRI 3 ST, QLMETROCREAM 3metronidazole external cream 1MIRVASO 3 PA, QLNORITATE EOPZELURA 3 PA, QL, SPRETIN-A EXTERNAL CREAM E PA, QLRHOFADE 3 PA, QLSANTYL 3 QLSOOLANTRA 3 QLTACLONEX EXTERNAL OINTMENT E QLtacrolimus external 2 QLTOLAK E16

Drug Name Drug RequirementsTier & Limitsg Bg BBgBBgBgBBgBBgBEgBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBTBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitstretinoin external cream 3triamcinolone 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 1 QLtritocin EVTAMA 3 PA, QLXEPI 3 QLZILXI 3 PA, ST, QLZORYVE 3 PA, QLDiabetes - Glucose Monitoring and SuppliesACCU-CHEK AVIVA PLUS TEST STRIPSE QLACCU-CHEK FASTCLIX LANCET 1ACCU-CHEK FASTCLIX LANCET KIT1ACCU-CHEK GUIDE KIT W/DEVICE 3 (Accu-Chek Guide Me)ACCU-CHEK GUIDE TEST STRIPS 3 QLACCU-CHEK MULTICLIX LANCET 1ACCU-CHEK MULTICLIX LANCET KIT1ACCU-CHEK SMARTVIEW TEST STRIPSE QLACCU-CHEK SOFT TOUCH LANCET 1ACCU-CHEK SOFTCLIX LANCET DEVICE KIT1ACCU-CHEK SOFTCLIX LANCETS 1ACCUTREND GLUCOSE E QLAQINJECT PEN NEEDLE 2 QLbd autoshield duo pen needles 2bd ultra-fine insulin syringes 2bd ultra-fine insulin syringes u-500 2BD ULTRA-FINE PEN NEEDLES 2 QLbd veo ultra-fine insulin syringes 2BIGFOOT UNITY PROGRAM EBLOOD GLUCOSE TEST STRIPS E QLBLOOD GLUCOSE TEST STRIPS 333E QLCARETOUCH MONITOR SYSTEM ECARETOUCH TEST E QLCONTOUR MONITOR KIT W/DEVICEECONTOUR NEXT EZ KIT W/DEVIC ECONTOUR NEXT GEN MONITOR ECONTOUR NEXT GEN TEST STRIPS2 QLCONTOUR NEXT MONITOR KIT W/DEVICE2CONTOUR NEXT ONE KIT 2CONTOUR TEST STRIPS E QLCVS ADVANCED GLUCOSE TEST E QLCVS GLUCOSE METER TEST STRIPSE QLD-CARE BLOOD GLUCOSE E QLD-CARE GLUCOMETER EDEXCOM G7 RECEIVER 3 PA, QLDEXCOM G7 SENSOR 3 PA, QLDIABETES MONITOR DIGIT ADD-ONEDIABETES MONITOR DIGIT SOLN EEASY TOUCH HEALTHPRO GLUCOSEEEASY TOUCH TEST E QLEASYGLUCO EEASYMAX 15 TEST E QLEASYMAX NG BLOOD GLUCOSE KITEEMBRACE BLOOD GLUCOSE TES E QLENLITE GLUCOSE SENSOR 3 PAEQ BLOOD GLUCOSE TEST E QL17

Drug Name Drug RequirementsTier & LimitsB BB BB BBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsFORTISCARE G1 TEST STRIP E QLFORTISCARE TEST E QLFREESTYLE LIBRE 14 DAY SENSOR3 PA, QLFREESTYLE LIBRE 2 SENSOR 3 PA, QLFREESTYLE LIBRE 3 SENSOR 3 PA, QLFREESTYLE PRECISION NEO SYSTEMEFREESTYLE PRECISION NEO TEST E QLFREESTYLE TEST E QLGLUCOCARD EXPRESSION TEST E QLGLUCOCARD SHINE TEST E QLGLUCOCARD VITAL TEST E QLGUARDIAN 4 GLUCOSE SENSOR E PAGUARDIAN 4 TRANSMITTER E PAGUARDIAN CONNECT TRANSMITTER3 PA, QLGUARDIAN LINK 3 TRANSMITTER 3 PA, QLGUARDIAN SENSOR (3) 3 PA, QLGUARDIAN SENSOR 3 3 PA, QLGVOKE HYPOPEN 1-PACK 2 QLGVOKE HYPOPEN 2-PACK 2 QLGVOKE KIT 2GVOKE PFS 2 QLHEALTHPRO BLOOD GLUCOSE MONITOEINSULIN PEN NEEDLES 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM2 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 PEN NEEDLE 2 QLOMNIPOD 5 G6 INTRO (GEN 5) 2 PA, QLOMNIPOD 5 G6 POD (GEN 5) 2 PA, QLON CALL EXPRESS BLOOD GLUCOSEE QLON CALL EXPRESS MONITORING SYSEONETOUCH CLUB LANCETS FINE PT1ONETOUCH DELICA LANCETS 30G1ONETOUCH DELICA LANCETS 33G1ONETOUCH DELICA PLUS LANCET30G1ONETOUCH DELICA PLUS LANCET33G1ONETOUCH FINEPOINT LANCETS 1ONETOUCH ULTRA 2 KIT W/DEVICE1ONETOUCH ULTRA TEST STRIPS 1 QLONETOUCH ULTRASOFT LANCETS1ONETOUCH VERIO FLEX SYSTEM KITEONETOUCH VERIO IQ BLOOD GLUCOSE METER1ONETOUCH VERIO REFLECT KIT W/DEVICE1ONETOUCH VERIO TEST STRIPS 1 QLOPTIUMEZ TEST E QLPARADIGM REAL-TIME TRANSMITTER3 PAPIP BLOOD GLUCOSE TEST STRIP E QLPRECISION XTRA EPRECISION XTRA BLOOD GLUCOSEE QLPREMIUM BLOOD GLUCOSE TEST E QLPTS PANELS EGLU TEST E QLQUINTET AC BLOOD GLUCOSE TESTE QL18

Drug Name Drug RequirementsTier & LimitsB BB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsQUINTET BLOOD GLUCOSE TEST E QLRELION TRUE MET AIR GLUC METERERELION TRUE METRIX TEST STRIPSE QLRELION ULTIMA GLUCOSE SYSTEMERELION ULTIMA TEST E QLRIGHTEST GT333 GLUCOSE TEST E QLTECHLITE INSULIN SYRINGES 2 (manufactured by Arkay) QLTECHLITE PEN NEEDLES 2 (manufactured by Arkay) QLTEMPO REFILL ETEMPO WELCOME ETRUE 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 QLBASAGLAR TEMPO PEN EHUMALOG 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 TEMPO PEN EHUMALOG U-100 JUNIOR KWIKPEN2 QLHUMALOG VIAL E 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 JUNIOR KWIKPEN2 QLINSULIN LISPRO KWIKPEN 2 QLINSULIN LISPRO PROTAMINE / INSULIN LISPRO KWIKPEN2 QLINSULIN LISPRO VIAL 1 QLLANTUS SOLOSTAR 1 QLLANTUS U-100 VIAL 1 QLLYUMJEV KWIKPEN 2 QLLYUMJEV TEMPO PEN ELYUMJEV 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 3 ST, QL19

Drug Name Drug RequirementsTier & LimitsB BB BB BB BB BB BBBBgggBgBBBBB BgB BBBBBBBBBgBgBgBgBBgBBBBBBBBBBBgBBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsALOGLIPTIN BENZOATE E QLALOGLIPTIN-METFORMIN HCL E QLALOGLIPTIN-PIOGLITAZONE E QLBAQSIMI ONE PACK 2 QLBAQSIMI TWO PACK 2 QLBYDUREON BCISE 2 PA, ST, QLBYETTA 10 MCG PEN 2 PA, ST, QLBYETTA 5 MCG PEN 2 PA, ST, QLglimepiride 1glipizide er 1glipizide ir 1glipizide xl 1GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED2 QLGLUCOTROL XL 3GLUMETZA E PAglyburide oral 1GLYXAMBI 2 ST, QLJARDIANCE 2 QLJENTADUETO 2 QLJENTADUETO XR 2 QLKAZANO 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 E 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 3 PA, SPAFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT3 PAAFSTYLA INTRAVENOUS KIT 1500 UNIT, 2500 UNIT3 PA, SPALPHANATE 2 SPALPROLIX 3 SPALTUVIIIO E PA, SPARANESP (ALBUMIN FREE) 2 QL, SPDOPTELET 3 PA, QL, SPELOCTATE 3 PA, SPHEMLIBRA 2 PA, SPHEMOFIL M 2 SPHUMATE-P 2 SPKOATE 2 SPKOATE-DVI 2 SPKOGENATE FS 2 SPKOVALTRY 2 SPMULPLETA 2 PA, QL, SPNEULASTA 2NOVOEIGHT 2 SPNUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT2 SP20

Drug Name Drug RequirementsTier & LimitsB BBBgBggBBBBBBBgBBBBBgBgBBBBggBggBBgBggBBBBgBg gggBggggggggBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsNUWIQ 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 3 PA, QL, SPUDENYCA 2WILATE 2ZARXIO 2Drugs for Sexual DysfunctionADDYI 3 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 3 PA, QLtadalafil oral 2 QLVIAGRA E QLVYLEESI 3 PA, QLElectrolytes / Vitaminscyanocobalamin injection solution 1000 mcg/ml1CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML3DODEX 3DRISDOL 3ergocalciferol oral capsule 1folic acid oral tablet 1 mg 1klor-con 10 1klor-con m10 1klor-con m15 1klor-con m20 1klor-con oral tablet extended release 1K-TAB 3LOKELMA 3 PA, QLNASCOBAL 3potassium chloride crys er 1potassium chloride er 1potassium citrate er 1UROCIT-K 10 3UROCIT-K 15 3UROCIT-K 5 3VELTASSA 3 PA, QLvitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit1Gastrointestinal Agents - Drugs for Acid Reflux and UlcerACIPHEX E QLbis subcit-metronid-tetracyc 3 QLbismuth/metronidaz/tetracyclin 3 QLCARAFATE ORAL TABLET ECYTOTEC 3famotidine oral suspension reconstituted1misoprostol oral 1OMECLAMOX-PAK 3 QLomeprazole oral capsule delayed release1pantoprazole sodium oral tablet delayed release1PROTONIX 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 1gavilyte-c 1 Hgavilyte-g 1 QL, H21

Drug Name Drug RequirementsTier & LimitsB gg ggBBgBBBBBBBBggggggBgBBgBBBBBgBBBgBBggBgBgBgBgBgBgBBBgBBggBgggggSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsGLYCATE Eglycopyrrolate oral tablet 1 mg, 2 mg1GLYCOPYRROLATE ORAL TABLET 1.5 MGEGOLYTELY 3 QLLINZESS 2 PA, QLMOTEGRITY 3 PA, QLMOVIPREP 3 QLna sulfate-k sulfate-mg sulf 3 QLpeg 3350-kcl-na bicarb-nacl 1 QL, Hpeg-3350/electrolytes 1 QL, Hpeg-3350/electrolytes/ascorbat 3 QLpeg-kcl-nacl-nasulf-na asc-c 3 QLPLENVU 3 QLROBINUL EROBINUL-FORTE ESUPREP BOWEL PREP KIT 3 QLSUTAB 3SYMPROIC 2 PA, QLVIBERZI 3 PA, QLZELNORM 3 PA, STGenetic or Enzyme Disorder - Drugs for Replacement, Modification, TreatmentCERDELGA 2 PA, SPCREON 2DEPEN TITRATABS 2 SPORFADIN 2 PA, SPPANCREAZE 3 STPERTZYE 3 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 2.5 mg3oxybutynin chloride oral tablet 5 mg 1phenazo oral tablet 200 mg 1phenazopyridine hcl oral 1PYRIDIUM 3solifenacin succinate 2THIOLA 3 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 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 3ayuna 1 HBIJUVA 3blisovi 24 fe 1 Hblisovi fe 1.5/30 1 Hblisovi fe 1/20 1 Hcamila 1 Hchateal eq 1 H22

Drug Name Drug RequirementsTier & LimitsB gBggggBgBBgBBgBgggggBgBgggggggggBggggggggggggggggggggggggggggBgBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsCLIMARA E QLCLIMARA PRO 3 QLcyred eq 1 Hdeblitane 1 Hdelyla 1 HDEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE3 QLDEPO-SUBQ PROVERA 104 2 QLDIVIGEL 3dotti 2 QLdrospirenone-ethinyl estradiol 3DUAVEE 3 QLELESTRIN 3eluryng 1 Henskyce 1 Herrin 1 Hestarylla 1 HESTRACE Eestradiol oral 1estradiol patch twice weekly 0.025 mg/24hr transdermal2 (generic for Minivelle), QLestradiol patch twice weekly 0.025 mg/24hr transdermal2 (generic for Vivelle-Dot), QLestradiol patch twice weekly 0.0375 mg/24hr transdermal2 (generic for Minivelle), QLestradiol patch twice weekly 0.0375 mg/24hr transdermal2 (generic for Vivelle-Dot), QLestradiol patch twice weekly 0.05 mg/24hr transdermal2 (generic for Minivelle), QLestradiol patch twice weekly 0.05 mg/24hr transdermal2 (generic for Vivelle-Dot), QLestradiol patch twice weekly 0.075 mg/24hr transdermal2 (generic for Minivelle), QLestradiol patch twice weekly 0.075 mg/24hr transdermal2 (generic for Vivelle-Dot), QLestradiol patch twice weekly 0.1 mg/24hr transdermal2 (generic for Minivelle), QLestradiol patch twice weekly 0.1 mg/24hr transdermal2 (generic for Vivelle-Dot), 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 Hhailey 1.5/30 1 Hhailey 24 fe 1 Hhailey fe 1.5/30 1 Hhailey fe 1/20 1 Hhaloette 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 Hlessina 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) E23

Drug Name Drug RequirementsTier & LimitsB BB gB gg gg Bg Bg Bg Bg gg Bg BggggBgggggggggggggBgggBgBggggggggggBgggggBgggBBgSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsLOESTRIN 1/20 (21) ELOESTRIN FE 1.5/30 ELOESTRIN FE 1/20 Eloryna 3lo-zumandimine 3lutera 1 Hlyleq 1 Hlyllana 2 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 1nikki 3nora-be 1 Hnorethin ace-eth estrad-fe oral tablet 1 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 3reclipsen 1 Hsharobel 1 Hsprintec 28 1 Hsronyx 1 Hsyeda 3tarina 24 fe 1 Htarina fe 1/20 eq 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 Htri-vylibra lo 2VAGIFEM Evestura 3vienva 1 HVIVELLE-DOT E QLvylibra 1 Hxulane 3 HYASMIN 28 2YAZ 224

Drug Name Drug RequirementsTier & Limitsg Bg Bg BBBBB Bgg BBBBBBBgBBgBBBgggB BgBgBBgBggBgBggBggBgBgBBgBBBgBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsyuvafem 2zafemy 3 Hzumandimine 3Hormonal Agents - Oral SteroidsCORTEF 3DEXABLISS Edexamethasone oral tablet 1dexamethasone oral tablet therapy pack3DXEVO 11-DAY EHEMADY EHIDEX 6-DAY Ehydrocortisone oral 1MEDROL ORAL TABLET THERAPY PACK3methylprednisolone oral tablet therapy pack1PEDIAPRED 2prednisolone oral solution 1prednisolone 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 MG3TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)3TAPERDEX 7-DAY 3Hormonal Agents - Othercabergoline 2LANREOTIDE ACETATE E SPNOCDURNA 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, QLSKYTROFA E PA, QL, SPSOMATULINE DEPOT 3 SPHormonal Agents - Testosterone ReplacementANDRODERM 2 PA, QLANDROGEL PUMP E PA, QLDEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML3DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML3FORTESTA E PA, QLNATESTO E PA, QLTESTIM 2 PA, QLtestosterone cypionate intramuscular1VOGELXO E PA, QLVOGELXO PUMP E PA, QLHormonal Agents - ThyroidADTHYZA EARMOUR THYROID 3CYTOMEL EERMEZA 2 PAeuthyrox 1levo-t 1levothyroxine sodium oral tablet 1levoxyl 2liothyronine sodium oral 2methimazole oral 1np thyroid 1SYNTHROID ETHYQUIDITY E PAthyroid oral 1TIROSINT-SOL 2 PAunithroid 125

Drug Name Drug RequirementsTier & LimitsBBBB BBBRBBBBBBgBBgB BBBBBB ggBgBBBBBBBBBBBBBBBBBBBBBBBBBgBBBBBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsImmunological Agents - Drugs for Immune System Stimulation or SuppressionACTEMRA ACTPEN 3 PA, ST, QL, SPACTEMRA SUBCUTANEOUS 3 PA, ST, QL, SPADALIMUMAB-ADAZ 2 (manufactured by Sandoz) PA, QL, SPADBRY 2 PA, QL, SPAMJEVITA 2 PA, QL, SPAZASAN 3azathioprine oral tablet 100 mg, 75 mg3azathioprine oral tablet 50 mg 1BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR2 PA, QL, SPCELLCEPT ORAL TABLET ECIMZIA STARTER KIT 2 PA, QLCIMZIA SUBCUTANEOUS KIT E PACIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT2 PA, QLCINRYZE 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, QLCOSENTYX SENSOREADY (300 MG)3 PA, ST, QL, SPCOSENTYX SENSOREADY PEN 3 PA, ST, QL, SPCYLTEZO 2 PA, 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, SPHADLIMA 2 PA, SPHAEGARDA 2 PA, QL, SPHUMIRA 2 PA, QL, SPHUMIRA PEDIATRIC CROHNS START2 PA, QL, SPHUMIRA PEN 2 PA, QL, SPHUMIRA PEN-CD/UC/HS STARTE 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, SPHYFTOR 3 PA, QLIMURAN EKEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR3 PA, ST, QL, SPKINERET 3 PA, ST, QL, SPLUPKYNIS 3 PA, QL, SPmethotrexate oral 1methotrexate sodium oral 1mycophenolate mofetil oral tablet 1OLUMIANT ORAL TABLET 1 MG, 4 MG2 PA, QLOLUMIANT 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 3RASUVO 2 QLRINVOQ 2 PA, QL, SPRUCONEST 3 PA, QL, SPSIMPONI 2 PA, QL, SPSKYRIZI PEN 2 PA, QLSKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE2 PA, QLSTELARA SUBCUTANEOUS 2 PA, QLtacrolimus oral 1TAKHZYRO 2 PA, QL, SPTALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTORE PA, ST, QL, SP26

Drug Name Drug RequirementsTier & LimitsB gB BB BBBgBBBBBBgBBBBBBBggBBBBBBBBBBBgBgBgBBgBggBBBgBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsTALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGEE PA, ST, QLTREMFYA 2 PA, QL, SPTREXALL 2XELJANZ 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, QLXOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE2 PA, QLXOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTEDEImmunological Agents - Drugs for VaccinationBOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE2 HFLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE3 HPFIZER COVID-19 VAC BIVAL 5-11 3 HPFIZER COVID-19 VAC BIVALENT 3 HSHINGRIX 3 HInfertility AgentsENDOMETRIN 2FOLLISTIM AQ 2 SPfyremadel 3 QL, SPganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous3 (manufactured by Ferring), QL, SPganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous2 (manufactured by Merck/ Organon), QL, SPInflammatory Bowel Disease AgentsAPRISO 1budesonide rectal 2CORTIFOAM 2DIPENTUM 3LIALDA Emesalamine oral tablet delayed release2PROCTOFOAM HC 2UCERIS ORAL 3Metabolic Bone Disease Agents - Drugs for Osteoporosisalendronate sodium oral tablet 1FORTEO E PA, ST, SPFOSAMAX 3TERIPARATIDE (RECOMBINANT) 3 PA, SPTYMLOS 3 PA, SPMetabolic Bone Disease Agents - Othercalcitriol oral capsule 1ROCALTROL ORAL CAPSULE 3Ophthalmic Agents - Drugs for Eye Allergy, Infection and InflammationALREX 3 QLAZASITE 3BESIVANCE 3ciprofloxacin hcl ophthalmic 1erythromycin ophthalmic 1 H-PAEYSUVIS 3 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 SUSPENSION 0.1 %3moxifloxacin hcl (2x day) 327

Drug Name Drug RequirementsTier & Limitsg Bg BBgBgBggggBBBBBBgBBBgBBBgBgBBBBBBggBgBgBgggggBBgBgggBgSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsmoxifloxacin hcl ophthalmic 3neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.11NEVANAC 3OCUFLOX 3ofloxacin ophthalmic 1polymyxin b-trimethoprim 1POLYTRIM 3PRED FORTE EPRED MILD 3prednisolone acetate ophthalmic 1PREDNISOLONE ACETATE P-F ETOBRADEX OPHTHALMIC SUSPENSION3TOBRADEX ST Etobramycin ophthalmic 1 QLtobramycin-dexamethasone 2VIGAMOX EZYLET 3Ophthalmic Agents - Drugs for GlaucomaALPHAGAN P OPHTHALMIC SOLUTION 0.1 %2 QLALPHAGAN P OPHTHALMIC SOLUTION 0.15 %3 QLBETIMOL 2 QLbimatoprost ophthalmic 2 QLbrimonidine tartrate ophthalmic solution 0.15 %2 QLbrimonidine tartrate ophthalmic solution 0.2 %1brimonidine tartrate-timolol E QLCOMBIGAN 2 QLCOSOPT 3COSOPT PF E QLdorzolamide hcl-timolol mal 2dorzolamide hcl-timolol mal pf E QLISTALOL 3latanoprost ophthalmic 1LUMIGAN 2RHOPRESSA 3 QLROCKLATAN 3 QLtafluprost (pf) 3 ST, QLtimolol maleate (once-daily) 3timolol maleate ophthalmic solution 1timolol maleate pf 2TIMOPTIC OCUDOSE 3XALATAN EZIOPTAN 3 ST, QLOphthalmic Agents - Drugs for Miscellaneous Eye ConditionsCYCLOSPORINE IN KLARITY E PAcyclosporine ophthalmic E PA, QLRESTASIS 3 PA, QLRESTASIS MULTIDOSE E PA, QLTYRVAYA 3 PA, QLVERKAZIA 3 PA, QLXIIDRA 3 PA, QLOtic Agents - Drugs for Ear ConditionsCIPRODEX Eciprofloxacin-dexamethasone 3neomycin-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/0.3ml 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), QL28

Drug Name Drug RequirementsTier & Limitsg g gBBBBBBBBgBBgBgggBgBgg BBgBgBgBBgBBBBBBBg gB gBgSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & Limitsepinephrine solution auto-injector 0.3 mg/0.3ml injection1 (generic for EpiPen-Single Pack), 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 E QLADVAIR HFA 3 QL, RSAIRDUO DIGIHALER E QLAIRDUO 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 (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 INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5%3ANORO ELLIPTA 3 QLARMONAIR DIGIHALER E QLARNUITY 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 3 PA, QLFLOVENT HFA E QLFLUTICASONE FUROATE-VILANTEROLE QL, RSFLUTICASONE PROPIONATE HFA E QLFLUTICASONE-SALMETEROL INHALATION AEROSOLE QL, RSfluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act3 QL, RSFLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ ACT, 232-14 MCG/ACT, 55-14 MCG/ ACT3 QLipratropium-albuterol 2LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT3 QLmontelukast sodium oral tablet 1montelukast sodium oral tablet chewable129

Drug Name Drug RequirementsTier & LimitsB gB BBBBBBBBBBBBBBgBBBBgBBBBBBBBBBBgBggBgBBgBgBBgBBBBBBBgBSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsNUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR3 PA, QL, SPNUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML3 PA, QL, SPNUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/0.4ML3 PA, QLPERFOROMIST 3 QLPROVENTIL HFA E QLPULMICORT SUSPENSION E QLQVAR REDIHALER 1 QLSEREVENT DISKUS 2 QLSINGULAIR ORAL TABLET ESINGULAIR ORAL TABLET CHEWABLEESPIRIVA HANDIHALER 2 QLSPIRIVA RESPIMAT 2 QLSTIOLTO RESPIMAT 2 QLSTRIVERDI RESPIMAT 2 QLSYMBICORT 3 QL, RSTEZSPIRE SUBCUTANEOUS SOLUTION AUTO-INJECTOR3TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGEE QLTRELEGY ELLIPTA 3 QL, RSVENTOLIN HFA E QLwixela inhub E QL, RSXOPENEX HFA 3 QLYUPELRI 3 PA, QLRespiratory Tract / Pulmonary Agents - Drugs for Cystic FibrosisBETHKIS E PA, QL, SPBRONCHITOL 3 PA, ST, QL, SPBRONCHITOL TOLERANCE TEST 3 PA, ST, QL, SPKITABIS PAK E PA, QL, SPPULMOZYME 2 PA, QL, SPTOBI NEBULIZER E PA, QL, SPTOBI PODHALER 3 PA, QL, SPtobramycin inhalation nebulization solution 300 mg/4ml2 PA, QL, SPtobramycin nebulization solution 300 mg/5ml inhalationE PA, QL, SPTOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATIONE PA, QL, SPRespiratory Tract / Pulmonary Agents - Drugs for Pulmonary FibrosisOFEV 3 PA, QL, SPRespiratory Tract / Pulmonary Agents - Drugs for Pulmonary HypertensionADEMPAS 2 PA, QL, SPOPSUMIT 2 PA, QL, SPREMODULIN E PAREVATIO ORAL TABLET E QL, SPsildenafil citrate oral tablet 20 mg 1 QLTADLIQ 3 PA, QL, SPTRACLEER 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 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 mg1tizanidine hcl oral tablet 1ZANAFLEX ORAL TABLET 3Sleep Disorder AgentsAMBIEN EAMBIEN CR EBELSOMRA 3 ST, QL30

BgBgBBBBgBBggSee page 6, 7 for coverage details. Drug Name Drug TierRequirements & LimitsDAYVIGO 3 ST, QLeszopiclone 2LUNESTA Emodafinil 2 QLPROVIGIL E QLRESTORIL 3SODIUM OXYBATE 3 (manufactured by Hikma), PA, QL, SPSUNOSI 2 PA, QLtemazepam 1WAKIX 3 PA, QL, SPXYWAV 3 PA, QL, SPzolpidem tartrate er 2zolpidem tartrate oral tablet 131

IndexAABILIFY . . . . . . . . . . . . . . . . . . . . . . . 12ACCU-CHEK AVIVA PLUS TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK FASTCLIX LANCET . . 17ACCU-CHEK FASTCLIX LANCET KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK GUIDE KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK GUIDE TEST STRIPS . 17ACCU-CHEK MULTICLIX LANCET . 17ACCU-CHEK MULTICLIX LANCET KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SMARTVIEW TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFT TOUCH LANCET . . . . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFTCLIX LANCET DEVICE KIT . . . . . . . . . . . . . . . . . . . . 17ACCU-CHEK SOFTCLIX LANCETS 17ACCUTREND GLUCOSE . . . . . . . . . 17acetaminophen-codeine oral tablet . . 8ACIPHEX . . . . . . . . . . . . . . . . . . . . . . 21ACTEMRA ACTPEN . . . . . . . . . . . . . 26ACTEMRA SUBCUTANEOUS . . . . . 26ACTOS . . . . . . . . . . . . . . . . . . . . . . . . 19acyclovir oral tablet . . . . . . . . . . . . . . 12ADALIMUMAB-ADAZ . . . . . . . . . . . . 26ADBRY . . . . . . . . . . . . . . . . . . . . . . . . 26ADDERALL . . . . . . . . . . . . . . . . . . . . 15ADDERALL XR . . . . . . . . . . . . . . . . . 15ADDYI . . . . . . . . . . . . . . . . . . . . . . . . . 21ADEMPAS . . . . . . . . . . . . . . . . . . . . . 30ADLYXIN . . . . . . . . . . . . . . . . . . . . . . . 19ADMELOG . . . . . . . . . . . . . . . . . . . . . 19ADMELOG SOLOSTAR . . . . . . . . . . . 19ADTHYZA . . . . . . . . . . . . . . . . . . . . . . 25ADVAIR DISKUS . . . . . . . . . . . . . . . . 29ADVAIR HFA . . . . . . . . . . . . . . . . . . . . 29ADVATE . . . . . . . . . . . . . . . . . . . . . . . 20 ADYNOVATE . . . . . . . . . . . . . . . . . . . 20afirmelle . . . . . . . . . . . . . . . . . . . . . . . 22AFSTYLA 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 DIGIHALER . . . . . . . . . . . . . 29AIRDUO RESPICLICK 113/14 . . . . . 29AIRDUO RESPICLICK 232/14 . . . . . 29AIRDUO RESPICLICK 55/14 . . . . . . 29AKLIEF . . . . . . . . . . . . . . . . . . . . . . . . 16ala-cort . . . . . . . . . . . . . . . . . . . . . . . . 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 INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5% . . . . . . 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 . . . . . . . . . 20ALOGLIPTIN-METFORMIN HCL . . . 20ALOGLIPTIN-PIOGLITAZONE . . . . . 20ALORA . . . . . . . . . . . . . . . . . . . . . . . . 22ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % . . . . . . . . . . . . . . . . 28 ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % . . . . . . . . . . . . . . . 28ALPHANATE . . . . . . . . . . . . . . . . . . . 20alprazolam oral tablet . . . . . . . . . . . . 13ALPROLIX . . . . . . . . . . . . . . . . . . . . . 20ALREX . . . . . . . . . . . . . . . . . . . . . . . . 27ALTACE . . . . . . . . . . . . . . . . . . . . . . . . 13altavera . . . . . . . . . . . . . . . . . . . . . . . . 22ALTUVIIIO . . . . . . . . . . . . . . . . . . . . . . 20ALUNBRIG . . . . . . . . . . . . . . . . . . . . . 11AMBIEN . . . . . . . . . . . . . . . . . . . . . . . 30AMBIEN CR . . . . . . . . . . . . . . . . . . . . 30amiodarone hcl oral . . . . . . . . . . . . . 13amitriptyline hcl oral . . . . . . . . . . . . . 10AMJEVITA . . . . . . . . . . . . . . . . . . . . . 26amlodipine besylate oral . . . . . . . . . . 13amlodipine besylate-benazepril hcl . 13amlodipine besylate-valsartan . . . . . 13amoxicillin oral capsule . . . . . . . . . . . . 8amoxicillin oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . 8amoxicillin oral tablet . . . . . . . . . . . . . 8amoxicillin-potassium clavulanate oral suspension reconstituted . . . . . . 8amoxicillin-potassium clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . 9amphetamine-dextroamphetamine . 15amphetamine-dextroamphetamine er . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15AMZEEQ . . . . . . . . . . . . . . . . . . . . . . . 16anastrozole oral . . . . . . . . . . . . . . . . . 11ANDRODERM . . . . . . . . . . . . . . . . . . 25ANDROGEL PUMP . . . . . . . . . . . . . . 25ANNOVERA . . . . . . . . . . . . . . . . . . . . 22ANORO ELLIPTA . . . . . . . . . . . . . . . . 29apap-caff-dihydrocodeine . . . . . . . . . 8apri . . . . . . . . . . . . . . . . . . . . . . . . . . . 22APRISO . . . . . . . . . . . . . . . . . . . . . . . 27APTENSIO XR . . . . . . . . . . . . . . . . . . 15APTIOM . . . . . . . . . . . . . . . . . . . . . . . . 932

AQINJECT PEN NEEDLE . . . . . . . . . 17ARAKODA . . . . . . . . . . . . . . . . . . . . . 12ARANESP (ALBUMIN FREE) . . . . . . 20ARIMIDEX . . . . . . . . . . . . . . . . . . . . . 11aripiprazole oral tablet . . . . . . . . . . . 12ARMONAIR DIGIHALER . . . . . . . . . . 29ARMOUR THYROID . . . . . . . . . . . . . 25ARNUITY ELLIPTA . . . . . . . . . . . . . . 29atenolol oral . . . . . . . . . . . . . . . . . . . . 13ATIVAN ORAL . . . . . . . . . . . . . . . . . . 13atomoxetine hcl . . . . . . . . . . . . . . . . . 15atorvastatin calcium oral tablet 10 mg, 20 mg . . . . . . . . . . . . . . . . . . . 13atorvastatin calcium oral tablet 40 mg, 80 mg . . . . . . . . . . . . . . . . . . . 13ATROVENT HFA . . . . . . . . . . . . . . . . 29aubra 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 . . . . . . . . . . . . . . . . . . . . . . . . 28AVALIDE . . . . . . . . . . . . . . . . . . . . . . . 13AVAPRO . . . . . . . . . . . . . . . . . . . . . . . 13aviane . . . . . . . . . . . . . . . . . . . . . . . . . 22avidoxy . . . . . . . . . . . . . . . . . . . . . . . . . 9AVITA . . . . . . . . . . . . . . . . . . . . . . . . . 16AVONEX PEN . . . . . . . . . . . . . . . . . . . 15AVONEX PREFILLED . . . . . . . . . . . . 15AYGESTIN . . . . . . . . . . . . . . . . . . . . . 22ayuna . . . . . . . . . . . . . . . . . . . . . . . . . 22AZASAN . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . 20BAQSIMI TWO PACK . . . . . . . . . . . . 20BASAGLAR KWIKPEN . . . . . . . . . . . 19BASAGLAR TEMPO PEN . . . . . . . . . 19bd autoshield duo pen needles . . . . 17bd ultra-fine insulin syringes . . . . . . . 17bd ultra-fine insulin syringes u-500 . 17BD ULTRA-FINE PEN NEEDLES . . . 17bd veo ultra-fine insulin syringes . . . 17BELBUCA . . . . . . . . . . . . . . . . . . . . . . . 8BELSOMRA . . . . . . . . . . . . . . . . . . . . 30benazepril hcl oral . . . . . . . . . . . . . . . 13BENICAR . . . . . . . . . . . . . . . . . . . . . . 13BENICAR HCT . . . . . . . . . . . . . . . . . . 13BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . 26benzonatate oral capsule 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . . . . . . 29benzonatate oral capsule 150 mg . . 29BESIVANCE . . . . . . . . . . . . . . . . . . . . 27BETASERON . . . . . . . . . . . . . . . . . . . 15BETHKIS . . . . . . . . . . . . . . . . . . . . . . 30BETIMOL . . . . . . . . . . . . . . . . . . . . . . 28BEVESPI AEROSPHERE . . . . . . . . . 29BIGFOOT UNITY PROGRAM . . . . . . 17BIJUVA . . . . . . . . . . . . . . . . . . . . . . . . 22BIKTARVY . . . . . . . . . . . . . . . . . . . . . 12bimatoprost ophthalmic . . . . . . . . . . 28bis subcit-metronid-tetracyc . . . . . . . 21bismuth/metronidaz/tetracyclin . . . . 21bisoprolol fumarate oral . . . . . . . . . . 13bisoprolol-hydrochlorothiazide . . . . 13blisovi 24 fe . . . . . . . . . . . . . . . . . . . . 22blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . 22blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . 22BLOOD GLUCOSE TEST STRIPS . . 17BLOOD GLUCOSE TEST STRIPS 333 . . . . . . . . . . . . . . . . . . . . . . . . . . . 17BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . . . . . . . . . . . 27BREO ELLIPTA . . . . . . . . . . . . . . . . . 29BREZTRI AEROSPHERE . . . . . . . . . 29BRILINTA . . . . . . . . . . . . . . . . . . . . . . 12brimonidine tartrate external . . . . . . 16brimonidine tartrate ophthalmic solution 0.15 % . . . . . . . . . . . . . . . . . . 28brimonidine tartrate ophthalmic solution 0.2 % . . . . . . . . . . . . . . . . . . . 28brimonidine tartrate-timolol . . . . . . . 28BRIVIACT ORAL TABLET . . . . . . . . . . 9BRONCHITOL . . . . . . . . . . . . . . . . . . 30BRONCHITOL TOLERANCE TEST . 30budesonide inhalation. . . . . . . . . . . . 29budesonide rectal . . . . . . . . . . . . . . . 27BUDESONIDE-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 . . . . . . . . . . . . . . 20BYETTA 10 MCG PEN . . . . . . . . . . . . 20BYETTA 5 MCG PEN . . . . . . . . . . . . . 2033

Ccabergoline . . . . . . . . . . . . . . . . . . . . 25calcitriol oral capsule . . . . . . . . . . . . 27CALQUENCE . . . . . . . . . . . . . . . . . . . 11camila . . . . . . . . . . . . . . . . . . . . . . . . . 22CARAC . . . . . . . . . . . . . . . . . . . . . . . . 16CARAFATE ORAL TABLET. . . . . . . . 21CARDIZEM CD . . . . . . . . . . . . . . . . . 13CARDURA . . . . . . . . . . . . . . . . . . . . . 13CARETOUCH MONITOR SYSTEM . 17CARETOUCH TEST . . . . . . . . . . . . . 17cartia xt . . . . . . . . . . . . . . . . . . . . . . . . 13carvedilol . . . . . . . . . . . . . . . . . . . . . . 13cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . 9cefuroxime axetil . . . . . . . . . . . . . . . . . 9CELEBREX . . . . . . . . . . . . . . . . . . . . . . 8celecoxib oral. . . . . . . . . . . . . . . . . . . . 8CELEXA . . . . . . . . . . . . . . . . . . . . . . . 10CELLCEPT ORAL TABLET . . . . . . . . 26cephalexin oral capsule . . . . . . . . . . . 9cephalexin oral suspension reconstituted . . . . . . . . . . . . . . . . . . . . 9CERDELGA . . . . . . . . . . . . . . . . . . . . 22chateal eq . . . . . . . . . . . . . . . . . . . . . . 22chlorhexidine gluconate mouth/throat. . . . . . . . . . . . . . . . . . . . . . . . . . 16chlorthalidone . . . . . . . . . . . . . . . . . . 13CIALIS . . . . . . . . . . . . . . . . . . . . . . . . . 21CIBINQO. . . . . . . . . . . . . . . . . . . . . . . 16ciclodan . . . . . . . . . . . . . . . . . . . . . . . 11ciclopirox external solution . . . . . . . . 11CIMDUO . . . . . . . . . . . . . . . . . . . . . . . 12CIMZIA STARTER KIT . . . . . . . . . . . . 26CIMZIA SUBCUTANEOUS KIT . . . . . 26CIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT . . . . . . . . 26CINRYZE . . . . . . . . . . . . . . . . . . . . . . 26CIPRO ORAL TABLET . . . . . . . . . . . . 9CIPRODEX . . . . . . . . . . . . . . . . . . . . . 28ciprofloxacin hcl ophthalmic . . . . . . 27ciprofloxacin hcl oral . . . . . . . . . . . . . . 9ciprofloxacin-dexamethasone . . . . . 28citalopram hydrobromide oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . . 10CLENPIQ . . . . . . . . . . . . . . . . . . . . . . 21CLEOCIN 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 ointment . . . . . . . . . . . . . . . . . . . . . . . 16clobetasol propionate external solution . . . . . . . . . . . . . . . . . . . . . . . . 16clonazepam oral tablet . . . . . . . . . . . 13clonidine hcl oral . . . . . . . . . . . . . . . . 13clopidogrel bisulfate oral . . . . . . . . . 12clotrimazole-betamethasone external cream . . . . . . . . . . . . . . . . . . 16COLCHICINE ORAL CAPSULE . . . . 11colchicine oral tablet . . . . . . . . . . . . . 11COLCRYS . . . . . . . . . . . . . . . . . . . . . . 11COMBIGAN . . . . . . . . . . . . . . . . . . . . 28COMBIVENT RESPIMAT . . . . . . . . . 29CONCERTA . . . . . . . . . . . . . . . . . . . . 15CONTOUR MONITOR KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT EZ KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT GEN MONITOR . . 17CONTOUR NEXT GEN TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT MONITOR KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . 17CONTOUR NEXT ONE KIT . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . 28COTELLIC . . . . . . . . . . . . . . . . . . . . . 11COZAAR . . . . . . . . . . . . . . . . . . . . . . 13CREON . . . . . . . . . . . . . . . . . . . . . . . . 22CRESEMBA ORAL . . . . . . . . . . . . . . 11CRESTOR. . . . . . . . . . . . . . . . . . . . . . 13CVS 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. . . . . . . . . . 28CYLTEZO . . . . . . . . . . . . . . . . . . . . . . 26CYMBALTA . . . . . . . . . . . . . . . . . . . . . 1034

cyproheptadine hcl oral tablet . . . . . 29cyred eq . . . . . . . . . . . . . . . . . . . . . . . 23CYTOMEL . . . . . . . . . . . . . . . . . . . . . 25CYTOTEC . . . . . . . . . . . . . . . . . . . . . . 21DD-CARE BLOOD GLUCOSE . . . . . . . 17D-CARE GLUCOMETER . . . . . . . . . . 17dabigatran etexilate mesylate . . . . . . 9DAYVIGO . . . . . . . . . . . . . . . . . . . . . . 31DAZOMON . . . . . . . . . . . . . . . . . . . . . 16deblitane . . . . . . . . . . . . . . . . . . . . . . . 23delyla . . . . . . . . . . . . . . . . . . . . . . . . . 23DEPAKOTE . . . . . . . . . . . . . . . . . . . . . . 9DEPAKOTE ER . . . . . . . . . . . . . . . . . . . 9DEPEN TITRATABS . . . . . . . . . . . . . . 22DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . 23DEPO-SUBQ PROVERA 104 . . . . . . 23DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML . . . . . . . . . . . . . . . . . . . . 25DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML . . . . . . . . . . . . . . . . . . . . 25DESCOVY. . . . . . . . . . . . . . . . . . . . . . 12desvenlafaxine succinate er . . . . . . . 10DEXABLISS . . . . . . . . . . . . . . . . . . . . 25dexamethasone oral tablet . . . . . . . . 25dexamethasone oral tablet therapy pack . . . . . . . . . . . . . . . . . . . . . . . . . . 25DEXCOM G7 RECEIVER . . . . . . . . . . 17DEXCOM G7 SENSOR . . . . . . . . . . . 17dexmethylphenidate hcl . . . . . . . . . . 15dexmethylphenidate hcl er . . . . . . . . 15DIABETES MONITOR DIGIT ADD-ON . . . . . . . . . . . . . . . . . . . . . . . 17DIABETES MONITOR DIGIT SOLN . 17diazepam oral tablet . . . . . . . . . . . . . 13diclofenac sodium oral . . . . . . . . . . . . 8dicyclomine hcl oral capsule . . . . . . 21dicyclomine hcl oral tablet . . . . . . . . 21DIFICID ORAL TABLET . . . . . . . . . . . . 9DIFLUCAN ORAL TABLET . . . . . . . . 11DILAUDID ORAL TABLET . . . . . . . . . 8diltiazem hcl er coated beads . . . . . 13DIOVAN . . . . . . . . . . . . . . . . . . . . . . . 13DIOVAN HCT . . . . . . . . . . . . . . . . . . . 13DIPENTUM . . . . . . . . . . . . . . . . . . . . . 27DITROPAN XL . . . . . . . . . . . . . . . . . . 22divalproex sodium er . . . . . . . . . . . . . . 9divalproex 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 . . . . 16DXEVO 11-DAY . . . . . . . . . . . . . . . . . . 25EEASY TOUCH HEALTHPRO GLUCOSE . . . . . . . . . . . . . . . . . . . . . 17EASY TOUCH TEST . . . . . . . . . . . . . 17EASYGLUCO . . . . . . . . . . . . . . . . . . . 17EASYMAX 15 TEST . . . . . . . . . . . . . . 17EASYMAX NG BLOOD GLUCOSE KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17EFFEXOR XR . . . . . . . . . . . . . . . . . . . 10EFUDEX . . . . . . . . . . . . . . . . . . . . . . . 16ELESTRIN . . . . . . . . . . . . . . . . . . . . . . 23eletriptan hydrobromide . . . . . . . . . . 11ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . 9ELIQUIS DVT/PE STARTER PACK. . . 9ELOCTATE . . . . . . . . . . . . . . . . . . . . . 20eluryng . . . . . . . . . . . . . . . . . . . . . . . . 23EMBRACE BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 17EMGALITY 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 . . . . . . . . . . . . . . . . . . 2735

ENLITE GLUCOSE SENSOR . . . . . . 17enoxaparin sodium injection solution prefilled syringe . . . . . . . . . . . 9enskyce . . . . . . . . . . . . . . . . . . . . . . . 23ENSTILAR . . . . . . . . . . . . . . . . . . . . . 16ENTRESTO . . . . . . . . . . . . . . . . . . . . . 13EPCLUSA ORAL TABLET . . . . . . . . . 12EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . 10epinephrine solution auto-injector 0.15 mg/0.15ml injection . . . . . . . . . . 28epinephrine solution auto-injector 0.15 mg/0.3ml injection . . . . . . . . . . . 28epinephrine solution auto-injector 0.3 mg/0.3ml injection . . . . . . . . 28, 29EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . 29EPIPEN JR 2-PAK . . . . . . . . . . . . . . . 29EQ BLOOD GLUCOSE TEST . . . . . . 17ergocalciferol oral capsule . . . . . . . . 21ERIVEDGE . . . . . . . . . . . . . . . . . . . . . 11ERLEADA ORAL TABLET 240 MG . 11ERLEADA ORAL TABLET 60 MG . . 11ERMEZA . . . . . . . . . . . . . . . . . . . . . . . 25errin . . . . . . . . . . . . . . . . . . . . . . . . . . . 23erythromycin ophthalmic . . . . . . . . . 27escitalopram oxalate oral tablet . . . . 10ESGIC ORAL TABLET . . . . . . . . . . . . . 8estarylla . . . . . . . . . . . . . . . . . . . . . . . 23ESTRACE . . . . . . . . . . . . . . . . . . . . . . 23estradiol 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 . . . . . . . . . . . . . . . . . . . . . . 16euthyrox . . . . . . . . . . . . . . . . . . . . . . . 25EVAMIST . . . . . . . . . . . . . . . . . . . . . . 23EXFORGE . . . . . . . . . . . . . . . . . . . . . . 13EXKIVITY . . . . . . . . . . . . . . . . . . . . . . 11EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . 15EYSUVIS . . . . . . . . . . . . . . . . . . . . . . . 27ezetimibe . . . . . . . . . . . . . . . . . . . . . . 13Ffalmina . . . . . . . . . . . . . . . . . . . . . . . . 23famotidine oral suspension reconstituted . . . . . . . . . . . . . . . . . . . 21FASENRA PEN . . . . . . . . . . . . . . . . . . 29FEMARA . . . . . . . . . . . . . . . . . . . . . . . 11fenofibrate oral tablet 120 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . . . . . 13fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg . . . . . . . . . . . 13FENOGLIDE . . . . . . . . . . . . . . . . . . . . 13FEXMID . . . . . . . . . . . . . . . . . . . . . . . . 30FINACEA EXTERNAL FOAM . . . . . . 16finasteride oral tablet 5 mg . . . . . . . . 22fingolimod hcl . . . . . . . . . . . . . . . . . . 15FLAREX . . . . . . . . . . . . . . . . . . . . . . . 27flecainide acetate . . . . . . . . . . . . . . . 13FLOMAX . . . . . . . . . . . . . . . . . . . . . . . 22FLOVENT HFA . . . . . . . . . . . . . . . . . . 29FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE . . . . . . . . . . . . 27fluconazole oral tablet . . . . . . . . . . . . 11FLUOROPLEX . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . 29FLUTICASONE PROPIONATE HFA . 29fluticasone propionate nasal . . . . . . 29FLUTICASONE-SALMETEROL INHALATION AEROSOL . . . . . . . . . . 29fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act . . . . . . . . . . . . . . . . . 29FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT . . . . . . . . . . . . . . . . 29fluvoxamine maleate . . . . . . . . . . . . . 10FOCALIN . . . . . . . . . . . . . . . . . . . . . . 15FOCALIN XR . . . . . . . . . . . . . . . . . . . 15folic acid oral tablet 1 mg . . . . . . . . . 21FOLLISTIM AQ . . . . . . . . . . . . . . . . . . 27FORFIVO XL . . . . . . . . . . . . . . . . . . . . 10FORTEO . . . . . . . . . . . . . . . . . . . . . . . 27FORTESTA . . . . . . . . . . . . . . . . . . . . . 25FORTISCARE G1 TEST STRIP . . . . . 18FORTISCARE TEST . . . . . . . . . . . . . 18FOSAMAX . . . . . . . . . . . . . . . . . . . . . 27FREESTYLE LIBRE 14 DAY SENSOR . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE LIBRE 2 SENSOR . . . . 18FREESTYLE LIBRE 3 SENSOR . . . . 18FREESTYLE PRECISION NEO SYSTEM . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE PRECISION NEO TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 18FREESTYLE TEST . . . . . . . . . . . . . . . 18FUROSCIX . . . . . . . . . . . . . . . . . . . . . 13furosemide oral tablet . . . . . . . . . . . . 13fyremadel . . . . . . . . . . . . . . . . . . . . . . 27Ggabapentin oral capsule . . . . . . . . . . 10gabapentin oral tablet 600 mg, 800 mg . . . . . . . . . . . . . . . . . . . . . . . . 1036

ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous . . . . . . . . . . . . . . . . . . 27gavilyte-c . . . . . . . . . . . . . . . . . . . . . . 21gavilyte-g . . . . . . . . . . . . . . . . . . . . . . 21GAVRETO . . . . . . . . . . . . . . . . . . . . . . 11gemfibrozil oral . . . . . . . . . . . . . . . . . 13GEN7T EXTERNAL PATCH . . . . . . . . 8glatiramer acetate . . . . . . . . . . . . . . . 15glatopa . . . . . . . . . . . . . . . . . . . . . . . . 15glimepiride . . . . . . . . . . . . . . . . . . . . . 20glipizide er . . . . . . . . . . . . . . . . . . . . . 20glipizide ir . . . . . . . . . . . . . . . . . . . . . . 20glipizide xl . . . . . . . . . . . . . . . . . . . . . . 20GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED . . . . . . . . . . . . . . . 20GLUCOCARD EXPRESSION TEST . 18GLUCOCARD SHINE TEST . . . . . . . 18GLUCOCARD VITAL TEST . . . . . . . . 18GLUCOTROL XL . . . . . . . . . . . . . . . . 20GLUMETZA . . . . . . . . . . . . . . . . . . . . 20glyburide oral . . . . . . . . . . . . . . . . . . . 20GLYCATE . . . . . . . . . . . . . . . . . . . . . . 22glycopyrrolate oral tablet 1 mg, 2 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 22GLYCOPYRROLATE ORAL TABLET 1.5 MG . . . . . . . . . . . . . . . . . 22GLYXAMBI . . . . . . . . . . . . . . . . . . . . . 20GOLYTELY . . . . . . . . . . . . . . . . . . . . . 22guanfacine hcl . . . . . . . . . . . . . . . 13, 15guanfacine hcl er . . . . . . . . . . . . . . . . 15GUARDIAN 4 GLUCOSE SENSOR . 18GUARDIAN 4 TRANSMITTER . . . . . 18GUARDIAN CONNECT TRANSMITTER . . . . . . . . . . . . . . . . . 18GUARDIAN LINK 3 TRANSMITTER . . . . . . . . . . . . . . . . . 18GUARDIAN SENSOR (3) . . . . . . . . . . 18GUARDIAN SENSOR 3 . . . . . . . . . . . 18GVOKE HYPOPEN 1-PACK . . . . . . . 18GVOKE HYPOPEN 2-PACK . . . . . . . 18GVOKE KIT . . . . . . . . . . . . . . . . . . . . . 18GVOKE PFS . . . . . . . . . . . . . . . . . . . . 18GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . 11HHADLIMA . . . . . . . . . . . . . . . . . . . . . . 26HAEGARDA . . . . . . . . . . . . . . . . . . . . 26hailey 1.5/30 . . . . . . . . . . . . . . . . . . . . 23hailey 24 fe . . . . . . . . . . . . . . . . . . . . . 23hailey fe 1/20 . . . . . . . . . . . . . . . . . . . 23hailey fe 1.5/30 . . . . . . . . . . . . . . . . . . 23HALCION . . . . . . . . . . . . . . . . . . . . . . 13haloette . . . . . . . . . . . . . . . . . . . . . . . . 23HARVONI ORAL TABLET . . . . . . . . . 12HEALTHPRO BLOOD GLUCOSE MONITO . . . . . . . . . . . . . . . . . . . . . . . 18heather . . . . . . . . . . . . . . . . . . . . . . . . 23HEMADY . . . . . . . . . . . . . . . . . . . . . . . 25HEMLIBRA . . . . . . . . . . . . . . . . . . . . . 20HEMOFIL M . . . . . . . . . . . . . . . . . . . . 20HIDEX 6-DAY . . . . . . . . . . . . . . . . . . . 25HUMALOG KWIKPEN . . . . . . . . . . . . 19HUMALOG MIX 50/50 KWIKPEN . . 19HUMALOG MIX 50/50 VIAL . . . . . . . 19HUMALOG MIX 75/25 KWIKPEN . . 19HUMALOG MIX 75/25 VIAL . . . . . . . 19HUMALOG TEMPO PEN . . . . . . . . . 19HUMALOG U-100 JUNIOR KWIKPEN . . . . . . . . . . . . . . . . . . . . . . 19HUMALOG VIAL . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . 19hydralazine 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 . . . . . . . . 13HYFTOR . . . . . . . . . . . . . . . . . . . . . . . 26HYZAAR . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . 27IMBRUVICA ORAL TABLET . . . . . . . 11IMITREX ORAL . . . . . . . . . . . . . . . . . 11IMPOYZ . . . . . . . . . . . . . . . . . . . . . . . 16IMURAN . . . . . . . . . . . . . . . . . . . . . . . 26IMVEXXY MAINTENANCE PACK . . 21IMVEXXY STARTER PACK . . . . . . . . 2137

INBRIJA . . . . . . . . . . . . . . . . . . . . . . . 12incassia . . . . . . . . . . . . . . . . . . . . . . . . 23INDERAL LA . . . . . . . . . . . . . . . . . . . 13indomethacin oral . . . . . . . . . . . . . . . . 8INSULIN GLARGINE . . . . . . . . . . . . . 19INSULIN GLARGINE SOLOSTAR . . 19INSULIN LISPRO JUNIOR KWIKPEN . . . . . . . . . . . . . . . . . . . . . . 19INSULIN LISPRO KWIKPEN . . . . . . . 19INSULIN LISPRO PROTAMINE / INSULIN LISPRO KWIKPEN . . . . . . . 19INSULIN LISPRO VIAL . . . . . . . . . . . 19INSULIN PEN NEEDLES 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM . . . . . . . . 18INTUNIV . . . . . . . . . . . . . . . . . . . . . . . 15INVELTYS . . . . . . . . . . . . . . . . . . . . . . 27ipratropium bromide nasal . . . . . . . . 29ipratropium-albuterol . . . . . . . . . . . . 29irbesartan . . . . . . . . . . . . . . . . . . . . . . 14irbesartan-hydrochlorothiazide . . . . 14isibloom . . . . . . . . . . . . . . . . . . . . . . . 23isosorbide mononitrate er . . . . . . . . 14ISTALOL . . . . . . . . . . . . . . . . . . . . . . . 28Jjantoven . . . . . . . . . . . . . . . . . . . . . . . . 9JARDIANCE . . . . . . . . . . . . . . . . . . . . 20jasmiel. . . . . . . . . . . . . . . . . . . . . . . . . 23jencycla. . . . . . . . . . . . . . . . . . . . . . . . 23JENTADUETO . . . . . . . . . . . . . . . . . . 20JENTADUETO XR . . . . . . . . . . . . . . . 20JORNAY 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 . . . . . . . 8KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . 26KINERET . . . . . . . . . . . . . . . . . . . . . . 26KITABIS PAK . . . . . . . . . . . . . . . . . . . 30KLARITY-A . . . . . . . . . . . . . . . . . . . . . 27KLISYRI . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . 27latanoprost ophthalmic . . . . . . . . . . . 28LATUDA . . . . . . . . . . . . . . . . . . . . . . . 12LEDIPASVIR-SOFOSBUVIR . . . . . . . 12lenalidomide oral capsule 10 mg, 15 mg, 25 mg, 5 mg. . . . . . . . . . . . . . 11lenalidomide oral capsule 2.5 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . . . . . 11lessina . . . . . . . . . . . . . . . . . . . . . . . . . 23letrozole oral . . . . . . . . . . . . . . . . . . . 11LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT . . . . . . . . . 29levetiracetam 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 . . . . . . . . . . . . . . . . . 23levora 0.15/30 (28) . . . . . . . . . . . . . . . 23levothyroxine sodium oral tablet . . . 25levoxyl . . . . . . . . . . . . . . . . . . . . . . . . . 25LEXAPRO . . . . . . . . . . . . . . . . . . . . . . 10LIALDA . . . . . . . . . . . . . . . . . . . . . . . . 27lidocaine external patch 5 % . . . . . . . 8lidocaine hcl mouth/throat . . . . . . . . 16lidocaine viscous hcl . . . . . . . . . . . . . 16LIDODERM . . . . . . . . . . . . . . . . . . . . . . 8LINZESS . . . . . . . . . . . . . . . . . . . . . . . 22liothyronine sodium oral . . . . . . . . . . 25LIPITOR . . . . . . . . . . . . . . . . . . . . . . . 14lisinopril oral . . . . . . . . . . . . . . . . . . . . 14lisinopril-hydrochlorothiazide . . . . . . 14lithium carbonate er . . . . . . . . . . . . . 13lithium carbonate oral capsule . . . . . 13LITHOBID . . . . . . . . . . . . . . . . . . . . . . 13LO LOESTRIN FE. . . . . . . . . . . . . . . . 23lo-zumandimine . . . . . . . . . . . . . . . . . 24LOESTRIN 1/20 (21) . . . . . . . . . . . . . 2438

LOESTRIN 1.5/30 (21) . . . . . . . . . . . . 23LOESTRIN FE 1/20 . . . . . . . . . . . . . . 24LOESTRIN FE 1.5/30 . . . . . . . . . . . . . 24LOKELMA . . . . . . . . . . . . . . . . . . . . . . 21LOPID . . . . . . . . . . . . . . . . . . . . . . . . . 14LOPRESSOR . . . . . . . . . . . . . . . . . . . 14lorazepam oral tablet . . . . . . . . . . . . 13loryna . . . . . . . . . . . . . . . . . . . . . . . . . 24losartan potassium oral . . . . . . . . . . 14losartan potassium-hctz . . . . . . . . . . 14LOTEMAX OPHTHALMIC GEL . . . . 27LOTEMAX OPHTHALMIC OINTMENT . . . . . . . . . . . . . . . . . . . . . 27LOTEMAX OPHTHALMIC SUSPENSION . . . . . . . . . . . . . . . . . . 27LOTEMAX SM . . . . . . . . . . . . . . . . . . 27LOTENSIN . . . . . . . . . . . . . . . . . . . . . 14loteprednol etabonate ophthalmic gel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27loteprednol etabonate ophthalmic suspension . . . . . . . . . . . . . . . . . . . . . 27LOTREL . . . . . . . . . . . . . . . . . . . . . . . 14lovastatin oral . . . . . . . . . . . . . . . . . . . 14LOVAZA . . . . . . . . . . . . . . . . . . . . . . . 14LOVENOX INJECTION SOLUTION PREFILLED SYRINGE . . . . . . . . . . . . . 9LUMAKRAS . . . . . . . . . . . . . . . . . . . . 11LUMIGAN . . . . . . . . . . . . . . . . . . . . . . 28LUNESTA . . . . . . . . . . . . . . . . . . . . . . 31LUPKYNIS . . . . . . . . . . . . . . . . . . . . . 26lurasidone hcl . . . . . . . . . . . . . . . . . . 12lutera . . . . . . . . . . . . . . . . . . . . . . . . . . 24lyleq . . . . . . . . . . . . . . . . . . . . . . . . . . 24lyllana . . . . . . . . . . . . . . . . . . . . . . . . . 24LYNPARZA . . . . . . . . . . . . . . . . . . . . . 11LYRICA ORAL CAPSULE . . . . . . . . . 15LYUMJEV KWIKPEN . . . . . . . . . . . . . 19LYUMJEV TEMPO PEN . . . . . . . . . . . 19LYUMJEV VIAL . . . . . . . . . . . . . . . . . 19lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MMACROBID . . . . . . . . . . . . . . . . . . . . . 9MACRODANTIN . . . . . . . . . . . . . . . . . 9marlissa . . . . . . . . . . . . . . . . . . . . . . . 24MAVENCLAD . . . . . . . . . . . . . . . . . . . 15MAVYRET ORAL PACKET . . . . . . . . 12MAXALT . . . . . . . . . . . . . . . . . . . . . . . 11MAXITROL OPHTHALMIC SUSPENSION 0.1 % . . . . . . . . . . . . . 27MAXZIDE . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . 25methocarbamol 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) oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg, 72 mg . . . . . . 15METHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 45 MG . . . . . . . . . . . . . . . . 15METHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 63 MG . . . . . . . . . . . . . . . . 15methylphenidate hcl er (xr) . . . . . . . . 15methylphenidate hcl er oral tablet extended release . . . . . . . . . . . . . . . . 15methylphenidate hcl oral tablet . . . . 15methylprednisolone oral tablet therapy pack . . . . . . . . . . . . . . . . . . . 25metoclopramide hcl oral tablet . . . . 10metoprolol 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 . . . . . . . . . . . . 24mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MINILINK REAL-TIME TRANSMITTER . . . . . . . . . . . . . . . . . 18MINIMED 630G GUARDIAN PRESS . . . . . . . . . . . . . . . . . . . . . . . . 18MINIPRESS . . . . . . . . . . . . . . . . . . . . 14MINIVELLE . . . . . . . . . . . . . . . . . . 23, 2439

minocycline hcl oral capsule . . . . . . . 9minoxidil oral . . . . . . . . . . . . . . . . . . . 14mirtazapine oral tablet . . . . . . . . . . . 10MIRVASO . . . . . . . . . . . . . . . . . . . . . . 16misoprostol oral . . . . . . . . . . . . . . . . . 21MITIGARE . . . . . . . . . . . . . . . . . . . . . 11MM EASY TOUCH GLUCOSE METER . . . . . . . . . . . . . . . . . . . . . . . . 18modafinil . . . . . . . . . . . . . . . . . . . . . . . 31mondoxyne nl . . . . . . . . . . . . . . . . . . . 9mono-linyah . . . . . . . . . . . . . . . . . . . . 24montelukast sodium oral tablet . . . . 29montelukast sodium oral tablet chewable . . . . . . . . . . . . . . . . . . . . . . 29morphine sulfate er oral tablet extended release . . . . . . . . . . . . . . . . . 8MOTEGRITY . . . . . . . . . . . . . . . . . . . 22MOUNJARO . . . . . . . . . . . . . . . . . . . . 20MOVIPREP . . . . . . . . . . . . . . . . . . . . . 22moxifloxacin hcl (2x day) . . . . . . . . . . 27moxifloxacin hcl ophthalmic . . . . . . . 28MS CONTIN . . . . . . . . . . . . . . . . . . . . . 8MULPLETA . . . . . . . . . . . . . . . . . . . . . 20MULTAQ . . . . . . . . . . . . . . . . . . . . . . . 14mupirocin external . . . . . . . . . . . . . . . . 9mycophenolate mofetil oral tablet . . 26MYDAYIS . . . . . . . . . . . . . . . . . . . . . . 15MYFEMBREE . . . . . . . . . . . . . . . . . . . 24Nna sulfate-k sulfate-mg sulf . . . . . . . . 22nabumetone 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 . . . . . . . . . . . . . . . . . . . . . 28NESINA . . . . . . . . . . . . . . . . . . . . . . . . 20NEULASTA . . . . . . . . . . . . . . . . . . . . . 20NEUPRO . . . . . . . . . . . . . . . . . . . . . . . 12NEURONTIN ORAL CAPSULE . . . . 10NEURONTIN ORAL TABLET . . . . . . 10NEUTEK 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 . . . . . . . . . . . . . . . . . . . . . 12NOVOEIGHT . . . . . . . . . . . . . . . . . . . 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 PEN NEEDLE . . . . . . . 18np thyroid . . . . . . . . . . . . . . . . . . . . . . 25NUBEQA. . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . 2140

NUZYRA ORAL . . . . . . . . . . . . . . . . . . 9nymyo . . . . . . . . . . . . . . . . . . . . . . . . . 24nystatin external cream . . . . . . . . . . . 11nystatin mouth/throat . . . . . . . . . . . . 11Oocella . . . . . . . . . . . . . . . . . . . . . . . . . 24OCUFLOX . . . . . . . . . . . . . . . . . . . . . . 28ODOMZO . . . . . . . . . . . . . . . . . . . . . . 11OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . 30ofloxacin ophthalmic . . . . . . . . . . . . . 28ofloxacin otic . . . . . . . . . . . . . . . . . . . 28olanzapine 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) . . . . . 18ON CALL EXPRESS BLOOD GLUCOSE . . . . . . . . . . . . . . . . . . . . . 18ON CALL EXPRESS MONITORING SYS . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ondansetron hcl oral tablet . . . . . . . 10ondansetron odt . . . . . . . . . . . . . . . . 10ONETOUCH CLUB LANCETS FINE PT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA LANCETS 30G . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA LANCETS 33G . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA PLUS LANCET30G . . . . . . . . . . . . . . . . . . . 18ONETOUCH DELICA PLUS LANCET33G . . . . . . . . . . . . . . . . . . . 18ONETOUCH FINEPOINT LANCETS . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH ULTRA 2 KIT W/DEVICE . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH ULTRA TEST STRIPS . 18ONETOUCH ULTRASOFT LANCETS . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH VERIO FLEX SYSTEM KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ONETOUCH VERIO IQ BLOOD GLUCOSE METER . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . 20OSPHENA . . . . . . . . . . . . . . . . . . . . . 21OTEZLA ORAL TABLET . . . . . . . . . . 26OTREXUP . . . . . . . . . . . . . . . . . . . . . . 26OXAYDO . . . . . . . . . . . . . . . . . . . . . . . . 8oxcarbazepine oral tablet . . . . . . . . . 10oxybutynin chloride er . . . . . . . . . . . 22oxybutynin chloride oral tablet 2.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . 22oxybutynin chloride oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . 22peg-3350/electrolytes/ascorbat . . . 22peg-kcl-nacl-nasulf-na asc-c . . . . . . 22penicillin v potassium oral tablet . . . . 9PERCOCET . . . . . . . . . . . . . . . . . . . . . 8PERFOROMIST . . . . . . . . . . . . . . . . . 30PERIDEX . . . . . . . . . . . . . . . . . . . . . . . 16periogard . . . . . . . . . . . . . . . . . . . . . . 16PERTZYE . . . . . . . . . . . . . . . . . . . . . . 22PFIZER COVID-19 VAC BIVAL 5-11 . 27PFIZER COVID-19 VAC BIVALENT. . 27phenazo oral tablet 200 mg . . . . . . . 22phenazopyridine hcl oral . . . . . . . . . 22pioglitazone hcl . . . . . . . . . . . . . . . . . 20PIP BLOOD GLUCOSE TEST STRIP . . . . . . . . . . . . . . . . . . . . . . . . . 18PLAQUENIL . . . . . . . . . . . . . . . . . . . . 12PLAVIX . . . . . . . . . . . . . . . . . . . . . . . . 12PLEGRIDY INTRAMUSCULAR . . . . 15PLEGRIDY STARTER PACK . . . . . . . 15PLEGRIDY SUBCUTANEOUS . . . . . 15PLENVU . . . . . . . . . . . . . . . . . . . . . . . 22polymyxin b-trimethoprim . . . . . . . . . 28POLYTRIM . . . . . . . . . . . . . . . . . . . . . 2841

POMALYST . . . . . . . . . . . . . . . . . . . . 11portia-28 . . . . . . . . . . . . . . . . . . . . . . . 24potassium chloride crys er . . . . . . . . 21potassium chloride er . . . . . . . . . . . . 21potassium citrate er. . . . . . . . . . . . . . 21PRADAXA ORAL CAPSULE . . . . . . . 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 oral solution . . . . . . . . 25prednisolone 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 . . . . . . . . . . 15PREMARIN ORAL . . . . . . . . . . . . . . . 24PREMARIN VAGINAL . . . . . . . . . . . . 24PREMIUM BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 18PREMPHASE . . . . . . . . . . . . . . . . . . . 24PREMPRO . . . . . . . . . . . . . . . . . . . . . 24PREZCOBIX . . . . . . . . . . . . . . . . . . . . 12PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . . . . . . . 14prochlorperazine maleate oral . . . . . 10PROCTOFOAM 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 . . . . . . . . . . . . . 21PROVENTIL HFA . . . . . . . . . . . . . 29, 30PROVERA . . . . . . . . . . . . . . . . . . . 23, 24PROVIGIL . . . . . . . . . . . . . . . . . . . . . . 31PROZAC . . . . . . . . . . . . . . . . . . . . . . . 10pseudoephedrine-bromphen-dm . . 29PTS PANELS EGLU TEST . . . . . . . . 18PULMICORT SUSPENSION . . . . . . . 30PULMOZYME . . . . . . . . . . . . . . . . . . 30PYLERA . . . . . . . . . . . . . . . . . . . . . . . 21PYRIDIUM . . . . . . . . . . . . . . . . . . . . . 22Qquetiapine fumarate . . . . . . . . . . . . . 12QUINTET AC BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 18QUINTET BLOOD GLUCOSE TEST 19QVAR REDIHALER . . . . . . . . . . . . . . 30Rrabeprazole sodium oral tablet delayed release . . . . . . . . . . . . . . . . . 21RADICAVA ORS . . . . . . . . . . . . . . 15, 16RADICAVA ORS STARTER KIT . . . . 16ramipril . . . . . . . . . . . . . . . . . . . . . . . . 14RASUVO . . . . . . . . . . . . . . . . . . . . . . . 26REBIF . . . . . . . . . . . . . . . . . . . . . . . . . 15REBIF TITRATION PACK . . . . . . . . . 15reclipsen . . . . . . . . . . . . . . . . . . . . . . . 24RECOMBINATE . . . . . . . . . . . . . . . . . 21REGLAN . . . . . . . . . . . . . . . . . . . . . . . 11RELAFEN DS . . . . . . . . . . . . . . . . . . . . 8RELEXXII ORAL TABLET EXTENDED RELEASE 45 MG, 72 MG . . . . . . . . . . . . . . . . . . . . . . . . . 15RELEXXII ORAL TABLET EXTENDED RELEASE 63 MG . . . . . 15RELION TRUE MET AIR GLUC METER . . . . . . . . . . . . . . . . . . . . . . . . 19RELION TRUE METRIX TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . 19RELION ULTIMA GLUCOSE SYSTEM . . . . . . . . . . . . . . . . . . . . . . . 19RELION ULTIMA TEST . . . . . . . . . . . 19RELPAX . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . 21RETACRIT INJECTION SOLUTION 20000 UNIT/ML . . . . . . . . . . . . . . . . . 21RETEVMO ORAL CAPSULE 40 MG . . . . . . . . . . . . . . . . . . . . . . . . . 12RETEVMO ORAL CAPSULE 80 MG . . . . . . . . . . . . . . . . . . . . . . . . . 12RETIN-A EXTERNAL CREAM . . . . . 16REVATIO ORAL TABLET . . . . . . . . . 30REVLIMID . . . . . . . . . . . . . . . . . . . . . . 12REXULTI . . . . . . . . . . . . . . . . . . . . . . . 12RHOFADE. . . . . . . . . . . . . . . . . . . . . . 16RHOPRESSA . . . . . . . . . . . . . . . . . . . 28RIGHTEST GT333 GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 19RINVOQ . . . . . . . . . . . . . . . . . . . . . . . 26RISPERDAL ORAL TABLET . . . . . . . 12risperidone oral tablet . . . . . . . . . . . . 12RITALIN . . . . . . . . . . . . . . . . . . . . . . . 15RITALIN LA. . . . . . . . . . . . . . . . . . . . . 15rizatriptan benzoate . . . . . . . . . . . . . . 11ROBINUL . . . . . . . . . . . . . . . . . . . . . . 2242

ROBINUL-FORTE . . . . . . . . . . . . . . . 22ROCALTROL ORAL CAPSULE . . . . 27ROCKLATAN . . . . . . . . . . . . . . . . . . . 28ropinirole hcl . . . . . . . . . . . . . . . . . . . 12rosuvastatin calcium . . . . . . . . . . . . . 14roweepra . . . . . . . . . . . . . . . . . . . . . . 10ROXICODONE . . . . . . . . . . . . . . . . . . . 8RUCONEST . . . . . . . . . . . . . . . . . . . . 26RUKOBIA . . . . . . . . . . . . . . . . . . . . . . 12RYBELSUS . . . . . . . . . . . . . . . . . . . . . 20SSANTYL . . . . . . . . . . . . . . . . . . . . . . . 16scopolamine . . . . . . . . . . . . . . . . . . . 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 . . 26SKYTROFA . . . . . . . . . . . . . . . . . . . . 25SOAANZ . . . . . . . . . . . . . . . . . . . . . . . 14SODIUM OXYBATE . . . . . . . . . . . . . . 31SOFOSBUVIR-VELPATASVIR . . . . . . 12solifenacin succinate . . . . . . . . . . . . . 22SOLIQUA . . . . . . . . . . . . . . . . . . . . . . 20SOMATULINE DEPOT . . . . . . . . . . . . 25SOOLANTRA . . . . . . . . . . . . . . . . . . . 16SPIRIVA HANDIHALER . . . . . . . . . . . 30SPIRIVA RESPIMAT . . . . . . . . . . . . . 30spironolactone oral . . . . . . . . . . . . . . 14sprintec 28 . . . . . . . . . . . . . . . . . . . . . 24sronyx . . . . . . . . . . . . . . . . . . . . . . . . . 24STELARA SUBCUTANEOUS . . . . . . 26STENDRA . . . . . . . . . . . . . . . . . . . . . . 21STIOLTO RESPIMAT . . . . . . . . . . . . . 30STIVARGA . . . . . . . . . . . . . . . . . . . . . 12STRATTERA . . . . . . . . . . . . . . . . . . . 15STRENSIQ . . . . . . . . . . . . . . . . . . . . . 22STRIVERDI RESPIMAT . . . . . . . . . . . 30SUBOXONE . . . . . . . . . . . . . . . . . . . . . 8subvenite . . . . . . . . . . . . . . . . . . . . . . 10sucralfate oral tablet . . . . . . . . . . . . . 21sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . 9sumatriptan succinate oral . . . . . . . . 11SUNOSI . . . . . . . . . . . . . . . . . . . . . . . 31SUPREP BOWEL PREP KIT . . . . . . . 22SUTAB . . . . . . . . . . . . . . . . . . . . . . . . 22syeda . . . . . . . . . . . . . . . . . . . . . . . . . 24SYMBICORT . . . . . . . . . . . . . . . . . . . 30SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . 12SYMFI LO . . . . . . . . . . . . . . . . . . . . . . 12SYMJEPI . . . . . . . . . . . . . . . . . . . . . . . 29SYMLINPEN 120 . . . . . . . . . . . . . . . . 20SYMLINPEN 60 . . . . . . . . . . . . . . . . . 20SYMPROIC . . . . . . . . . . . . . . . . . . . . . 22SYNJARDY . . . . . . . . . . . . . . . . . . . . . 20SYNJARDY XR . . . . . . . . . . . . . . . . . . 20SYNTHROID . . . . . . . . . . . . . . . . . . . . 25TTABRECTA . . . . . . . . . . . . . . . . . . . . . 12TACLONEX EXTERNAL OINTMENT . . . . . . . . . . . . . . . . . . . . . 16tacrolimus external . . . . . . . . . . . . . . 16tacrolimus oral . . . . . . . . . . . . . . . . . . 26tadalafil oral . . . . . . . . . . . . . . . . . . . . 21TADLIQ . . . . . . . . . . . . . . . . . . . . . . . . 30tafluprost (pf) . . . . . . . . . . . . . . . . . . . 28TAGRISSO . . . . . . . . . . . . . . . . . . . . . 12TAKHZYRO . . . . . . . . . . . . . . . . . . . . 26TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . 26TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE . . 27TAMIFLU 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 . . . . . . . . . . . . . . . . . . . . . 9tarina 24 fe . . . . . . . . . . . . . . . . . . . . . 24tarina fe 1/20 eq . . . . . . . . . . . . . . . . . 24TASIGNA . . . . . . . . . . . . . . . . . . . . . . 12TAVALISSE . . . . . . . . . . . . . . . . . . . . . 21TECHLITE INSULIN SYRINGES . . . . 19TECHLITE PEN NEEDLES . . . . . . . . 19TEGSEDI. . . . . . . . . . . . . . . . . . . . . . . 22TEKTURNA . . . . . . . . . . . . . . . . . . . . 14TEKTURNA HCT . . . . . . . . . . . . . . . . 14telmisartan . . . . . . . . . . . . . . . . . . . . . 14temazepam . . . . . . . . . . . . . . . . . . . . 31TEMPO REFILL . . . . . . . . . . . . . . . . . 19TEMPO WELCOME . . . . . . . . . . . . . . 19TENORMIN . . . . . . . . . . . . . . . . . . . . 14terbinafine hcl oral . . . . . . . . . . . . . . . 11TERIPARATIDE (RECOMBINANT). . 27TESTIM . . . . . . . . . . . . . . . . . . . . . . . . 25testosterone cypionate intramuscular . . . . . . . . . . . . . . . . . . . 25TEZSPIRE SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . 30TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE . . 30THALITONE . . . . . . . . . . . . . . . . . . . . 14THIOLA . . . . . . . . . . . . . . . . . . . . . . . . 22THIOLA EC . . . . . . . . . . . . . . . . . . . . . 22THYQUIDITY . . . . . . . . . . . . . . . . . . . 2543

thyroid oral . . . . . . . . . . . . . . . . . . . . . 25TIGLUTIK . . . . . . . . . . . . . . . . . . . . . . 16timolol maleate (once-daily) . . . . . . . 28timolol maleate ophthalmic solution . . . . . . . . . . . . . . . . . . . . . . . . 28timolol maleate pf . . . . . . . . . . . . . . . 28TIMOPTIC OCUDOSE . . . . . . . . . . . . 28TIROSINT-SOL . . . . . . . . . . . . . . . . . . 25TIVICAY. . . . . . . . . . . . . . . . . . . . . . . . 12tizanidine hcl oral tablet . . . . . . . . . . 30TOBI NEBULIZER . . . . . . . . . . . . . . . 30TOBI PODHALER . . . . . . . . . . . . . . . 30TOBRADEX OPHTHALMIC SUSPENSION . . . . . . . . . . . . . . . . . . 28TOBRADEX ST . . . . . . . . . . . . . . . . . 28tobramycin inhalation nebulization solution 300 mg/4ml . . . . . . . . . . . . . 30tobramycin nebulization solution 300 mg/5ml inhalation . . . . . . . . . . . 30tobramycin ophthalmic . . . . . . . . . . . 28tobramycin-dexamethasone . . . . . . . 28TOLAK . . . . . . . . . . . . . . . . . . . . . . . . 16TOPAMAX . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . 27treprostinil . . . . . . . . . . . . . . . . . . . . . 30tretinoin external cream . . . . . . . . . . 17TREXALL . . . . . . . . . . . . . . . . . . . . . . 27TREZIX . . . . . . . . . . . . . . . . . . . . . . . . . 8tri-estarylla . . . . . . . . . . . . . . . . . . . . . 24tri-linyah . . . . . . . . . . . . . . . . . . . . . . . 24tri-lo-estarylla . . . . . . . . . . . . . . . . . . . 24tri-lo-marzia . . . . . . . . . . . . . . . . . . . . 24tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . 24tri-lo-sprintec . . . . . . . . . . . . . . . . . . . 24tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . 24tri-nymyo . . . . . . . . . . . . . . . . . . . . . . . 24tri-sprintec . . . . . . . . . . . . . . . . . . . . . 24tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . 24tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . 24triamcinolone 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 . . . . . . . . . . . . . . . . . . . . . . . . 17TRIJARDY XR . . . . . . . . . . . . . . . . . . 20TRILEPTAL ORAL TABLET . . . . . . . 10TRINTELLIX . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . 30UUBRELVY . . . . . . . . . . . . . . . . . . . . . . 11UCERIS ORAL . . . . . . . . . . . . . . . . . . 27UDENYCA . . . . . . . . . . . . . . . . . . . . . 21UNISTRIP1 GENERIC . . . . . . . . . . . . 19unithroid . . . . . . . . . . . . . . . . . . . . . . . 25UROCIT-K 10 . . . . . . . . . . . . . . . . . . . 21UROCIT-K 15 . . . . . . . . . . . . . . . . . . . 21UROCIT-K 5 . . . . . . . . . . . . . . . . . . . . 21UROXATRAL . . . . . . . . . . . . . . . . . . . 22VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . 24valacyclovir hcl oral . . . . . . . . . . . . . . 13VALIUM . . . . . . . . . . . . . . . . . . . . . . . . 13valsartan oral tablet . . . . . . . . . . . . . . 14valsartan-hydrochlorothiazide . . . . . 14VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML . . . . . . . 10VALTREX . . . . . . . . . . . . . . . . . . . . . . 13VANDAZOLE . . . . . . . . . . . . . . . . . . . . 9VASOTEC . . . . . . . . . . . . . . . . . . . . . . 14VELPHORO . . . . . . . . . . . . . . . . . . . . 22VELTASSA . . . . . . . . . . . . . . . . . . . . . 21venlafaxine hcl . . . . . . . . . . . . . . . . . . 10venlafaxine hcl er oral capsule extended release 24 hour . . . . . . . . . 10VENTOLIN HFA . . . . . . . . . . . . . . 29, 30verapamil hcl er oral tablet extended release . . . . . . . . . . . . . . . . 1444

VERKAZIA . . . . . . . . . . . . . . . . . . . . . 28VERQUVO . . . . . . . . . . . . . . . . . . . . . 14VERZENIO . . . . . . . . . . . . . . . . . . . . . 12VESICARE . . . . . . . . . . . . . . . . . . . . . 22vestura . . . . . . . . . . . . . . . . . . . . . . . . 24VIAGRA . . . . . . . . . . . . . . . . . . . . . . . 21VIBERZI . . . . . . . . . . . . . . . . . . . . . . . 22VIBRAMYCIN ORAL CAPSULE . . . . . 9VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS . . . . . . . . . . . . . . . 20vienva . . . . . . . . . . . . . . . . . . . . . . . . . 24VIGAMOX . . . . . . . . . . . . . . . . . . . . . . 28VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . 10VIIBRYD STARTER PACK . . . . . . . . . 10vilazodone hcl . . . . . . . . . . . . . . . . . . 10VISTARIL . . . . . . . . . . . . . . . . . . . . . . 13vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 21VITRAKVI . . . . . . . . . . . . . . . . . . . . . . 12VIVELLE-DOT . . . . . . . . . . . . . . . . 23, 24VIVJOA . . . . . . . . . . . . . . . . . . . . . . . . 11VOGELXO . . . . . . . . . . . . . . . . . . . . . . 25VOGELXO PUMP . . . . . . . . . . . . . . . . 25VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . 13VRAYLAR ORAL CAPSULE . . . . . . . 12VTAMA . . . . . . . . . . . . . . . . . . . . . . . . 17VYLEESI . . . . . . . . . . . . . . . . . . . . . . . 21vylibra . . . . . . . . . . . . . . . . . . . . . . . . . 24VYVANSE . . . . . . . . . . . . . . . . . . . . . . 15WWAKIX . . . . . . . . . . . . . . . . . . . . . . . . . 31warfarin sodium oral . . . . . . . . . . . . . . 9WELLBUTRIN SR . . . . . . . . . . . . . . . 10WELLBUTRIN XL . . . . . . . . . . . . . . . . 10WILATE . . . . . . . . . . . . . . . . . . . . . . . . 21wixela inhub . . . . . . . . . . . . . . . . . . . . 30XXALATAN . . . . . . . . . . . . . . . . . . . . . . 28XANAX . . . . . . . . . . . . . . . . . . . . . . . . 13XARELTO . . . . . . . . . . . . . . . . . . . . . . . 9XARELTO STARTER PACK. . . . . . . . . 9XCOPRI 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 . . . . . . . . . . . . . . . . . . . . 8XTANDI . . . . . . . . . . . . . . . . . . . . . . . . 12xulane . . . . . . . . . . . . . . . . . . . . . . . . . 24XYWAV . . . . . . . . . . . . . . . . . . . . . . . . 31YYASMIN 28 . . . . . . . . . . . . . . . . . . . . . 24YAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 24YUPELRI . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem . . . . . . . . . . . . . . . . . . . . . . . 25Zzafemy . . . . . . . . . . . . . . . . . . . . . . . . 25ZANAFLEX ORAL TABLET . . . . . . . 30ZARXIO . . . . . . . . . . . . . . . . . . . . . . . 21ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR . . . . . 20ZEJULA ORAL CAPSULE . . . . . . . . 12ZELBORAF . . . . . . . . . . . . . . . . . . . . . 12ZELNORM . . . . . . . . . . . . . . . . . . . . . 22ZENPEP . . . . . . . . . . . . . . . . . . . . . . . 22ZEPOSIA . . . . . . . . . . . . . . . . . . . . . . 16ZEPOSIA 7-DAY STARTER PACK . . 16ZEPOSIA STARTER KIT . . . . . . . . . . 16ZESTORETIC . . . . . . . . . . . . . . . . . . . 14ZESTRIL . . . . . . . . . . . . . . . . . . . . . . . 14ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . 15ZETONNA. . . . . . . . . . . . . . . . . . . . . . 29ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG . . . . . . . . . . . . . . . . . . . . 15ZIAC ORAL TABLET 5-6.25 MG . . . 15ZILXI . . . . . . . . . . . . . . . . . . . . . . . . . . 17ZIMHI . . . . . . . . . . . . . . . . . . . . . . . . . . 8ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . 28ZITHROMAX ORAL SUSPENSION RECONSTITUTED . . . . . . . . . . . . . . . . 9ZITHROMAX ORAL TABLET . . . . . . . 9ZITHROMAX TRI-PAK . . . . . . . . . . . . . 9ZITHROMAX Z-PAK . . . . . . . . . . . . . . . 9ZOCOR . . . . . . . . . . . . . . . . . . . . . . . . 15ZOLOFT ORAL TABLET . . . . . . . . . . 10zolpidem tartrate er . . . . . . . . . . . . . . 31zolpidem tartrate oral tablet . . . . . . . 31ZOMIG NASAL SOLUTION 2.5 MG . 11ZOMIG NASAL SOLUTION 5 MG . . 11ZONEGRAN . . . . . . . . . . . . . . . . . . . . 10zonisamide oral . . . . . . . . . . . . . . . . . 10ZORYVE . . . . . . . . . . . . . . . . . . . . . . . 17ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . 8ZUBSOLV . . . . . . . . . . . . . . . . . . . . . . . 8zumandimine . . . . . . . . . . . . . . . . . . . 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 services Multi-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 commercial group members of UnitedHealthcare and Oxford New York and New Jersey 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.9/23 ©2024 United HealthCare Services, Inc. WF11051746-P 2024 Prescription Drug List - Texas Advantage 3-Tier