SourceRx 1.0 Four Tier Prescription Drug List

Transcription

1 < January SourceRx.0 Four Tier Prescription Drug List The Prescription Drug List is regularly updated. Contents Introduction... I How Drugs are Selected... I Coverage Considerations... I Member Prescription Benefit... II Brand Drugs and Generic Drugs... II Generic Substitution... II Compound Drugs... III Contraceptives... III... III Utilization Management... III... III... IV... IV Limited Distribution Drugs... IV Notice... IV Key... V Therapeutic Class Drug List Anti-Infective Drugs... Biologicals...0 Antineoplastic Agents... Endocrine and Metabolic Drugs... 7 Cardiovascular Agents... Respiratory Agents Gastrointestinal Agents... 5 Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics Neuromuscular Drugs Nutritional Products...9 Hematological Agents... 9 Topical Products...0 Miscellaneous Products... Index... 4 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 457-T AL Prime Therapeutics LLC 0/9

2 Introduction The attached SourceRx.0 Four Tier Prescription Drug List shows covered drugs for a broad range of diseases. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The SourceRx.0 Four Tier Prescription Drug List is organized into broad categories (e.g. anti-infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. penicillins) or by use for a specific medical condition (e.g. diabetes). Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician. If you have any questions, please contact the phone number on the back of your ID card. How Drugs are Selected for Coverage and Tier Placement Covered drugs on this list are selected and placed into tiers (refer to Member Prescription Benefit section) based on the recommendations of a Pharmacy and Therapeutics (P&T) Committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from the health insurer or claims administrator of your health plan, reviews prescription drugs regulated by the U.S. Food and Drug Administration (FDA) based on safety, efficacy, and uniqueness. Once drugs are deemed appropriate for coverage, and safety and efficacy have been evaluated, cost may be considered to determine final tier placement and coverage requirements. Drugs are reviewed by the P&T Committee when newly approved by the FDA and at least annually after initial review. Drug coverage is subject to change at any time but the drug list will be updated quarterly. There are many reasons why drug coverage or tier placement may change. Some examples are listed below. The tier level of a drug may increase or the drug may no longer be covered when an equivalent generic drug becomes available. The tier level of a drug may decrease if the cost of the drug decreases. Additional Coverage Considerations Coverage is limited to prescription drugs approved by the Food and Drug Administration (FDA) as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act). Newly marketed prescription drugs will not be covered until the P&T Committee has had an opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based on safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a new drug is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coverage may be submitted. Most prescription drug benefit plans provide coverage for up to a 0-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance drugs. Maintenance drugs are those drugs you may take on an ongoing basis for chronic conditions such as high blood pressure, diabetes or high cholesterol. You should refer to your benefit plan booklet for details about your particular benefits. SourceRx.0 Four Tier Prescription Drug List, January I

3 Member Prescription Benefit The prescription benefit is multi-tiered, placing prescription drugs into one of four tier levels. Tier primarily contains preferred (lowest cost) generic drugs. Based on cost considerations, there may be brands placed into this tier on occasion as well. Tier primarily contains preferred (based on efficacy, uniqueness, safety advantages, and/or cost considerations) brands. Tier primarily contains nonpreferred (less preferred compared to alternatives available based on efficacy, uniqueness, safety, and cost) brands. Tier 4 primarily contains specialty drugs. All tiers may contain drugs otherwise categorized as generic, brand, or specialty. Preferred drugs may offer a clinical or cost advantage over non-preferred drugs within the same therapeutic category. Coverage and copayment/co-insurance levels vary depending on the plan. Drugs that require,, or that have Dispensing Limits or are considered Limited Distribution are noted in the Prescription Drug List. Tier - primarily generics and select brands Tier - primarily preferred brands Tier - primarily non-preferred brands Tier 4 - primarily specialty Note: Drugs that are not covered on the formulary will be noted in the Prescription Drug List with the (not covered) indicator. Drugs that are indicated with a + next to the tier in the Prescription Drug List denote group specific coverage. Please refer to your benefit booklet for more information. Brand Drugs and Generic Drugs Classification Prescription drugs are classified as either a Brand drug or a Generic drug. The Brand or Generic status is provided by a nationally recognized company providing drug product information. The Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and change from Brand to Generic or from Generic to Brand. Such changes might change your copayment/co-insurance share. Brand drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have trade names. Generic Substitution Generic drug utilization is encouraged as a way to provide high quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict requirements of FDA s current Good Manufacturing Practice regulations required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality. An FDA-approved Generic drug may be substituted for the Brand counterpart when it: Contains the same active ingredient(s) as the brand drug; Is identical in strength, dosage form and route of administration; and Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile. SourceRx.0 Four Tier Prescription Drug List, January II

4 Compound Drugs Compound drugs are defined as a drug product made or modified to have characteristics that are specifically prescribed for an individual patient when commercial drug products are not available or appropriate. To be eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounds containing any ingredient not approved by the FDA will not be covered. All compounded drugs are subject to review and may require prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria and utilization management edits. Compounds are covered only when medically necessary. Compound drugs are always classified as the highest cost-sharing non-specialty drug Tier. Contraceptives Some or all of the contraceptive methods or prescription drugs listed in this Prescription Drug Guide may not be covered under your plan because of your employer s religious beliefs. To find out if contraceptive methods and prescription drugs are excluded, you may find this information in the exclusions section of your benefit booklet or you may contact your group administrator. Drugs drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. drugs covered under this prescription benefit are oral or injectable medications that may be self-administered. Some members must obtain their specialty drugs from the Pharmacy Select Network as the preferred provider. If the preferred provider is not utilized you may be responsible for up to 00 percent of the drug cost. If you have questions about your coverage for specialty drugs or your prescription drug benefit, call the number on the back of your ID card. Utilization Management Your plan is committed to supporting proper selection and use of drugs for its members. To help assure these goals are met, several programs have been developed to promote drug selection that encourages both cost-effectiveness and safety.drugs requiring or, or drugs with Dispensing Limits will be noted in the Therapeutic Class Drug List portion of the Prescription Drug List. Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective drug before coverage may be available for the drug included in the step therapy program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If step therapy is required for a drug listed in this document, it will be noted next to the drug with a dot under the step therapy column. SourceRx.0 Four Tier Prescription Drug List, January III

5 Your benefit plan may require prior authorization for certain drugs that have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the drug will be covered under your plan. If prior authorization is required for a drug listed in this document, it will be noted next to the drug with a dot under the prior authorization column. Drug dispensing limits help encourage drug use as intended by the FDA. Dispensing limits are placed on drugs in certain categories for safety reasons. For the drugs listed in this document, if a dispensing limit applies, it will be noted next to the drug with a dot under the dispensing limits column. Limits may include: quantity of covered drug per prescription and/or quantity of covered drug in a given time period. If your doctor prescribes a greater quantity of drug than what the dispensing limit allows, you can still get the drug. However, you will be responsible for the full cost of the prescription beyond what your coverage allows or your doctor will need to submit a request for an exception to the dispensing limit. If a dispensing limit applies for a drug listed in this document, it will be noted next to the drug with a dot under the dispensing limit column. Limited Distribution Drugs Limited distribution drugs have a restriction on which pharmacies have access to and can dispense those drugs, thereby limiting where the member may obtain the prescription. Members may be required to use the Pharmacy Select Network or other pharmacy for limited distribution prescription drugs. Notice The purpose of the SourceRx.0 Four Tier Prescription Drug List is to provide a guide to coverage. This SourceRx.0 Four Tier Prescription Drug List is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients. Drug List, nor the successful adjudication of a pharmacy claim, is guarantee of payment SourceRx.0 Four Tier Prescription Drug List, January IV

6 Key cap... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt.... orally disintegrating tabs oint... ointment ophth... opthalmic osm... osmotic release powd... powder sa...sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal SourceRx.0 Four Tier Prescription Drug List, January V

7 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN- amoxicillin (trihydrate) chew tab 5 mg AMOXICILLIN- amoxicillin (trihydrate) chew tab 50 mg amoxicillin (trihydrate) cap 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 5 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (Augmentin) amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr mg (Augmentin xr) amoxicillin & k clavulanate tab 50-5 mg amoxicillin & k clavulanate tab mg (Augmentin) amoxicillin & k clavulanate tab mg (Augmentin) AMOXICILLIN/CLAVULANATE P- amoxicillin & k clavulanate chew tab mg AMOXICILLIN/CLAVULANATE P- amoxicillin & k clavulanate chew tab mg AMPICILLIN- ampicillin cap 500 mg AUGMENTIN- amoxicillin & k clavulanate for susp 5-.5 mg/5ml dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg MOXATAG- amoxicillin (trihydrate) tab er 4hr 775 mg PENICILLIN V POTASSIUM- penicillin v potassium for soln 5 mg/5ml PENICILLIN V POTASSIUM- penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg CEPHALOSPORINS CEFACLOR- cefaclor for susp 5 mg/5ml CEFACLOR- cefaclor for susp 50 mg/5ml CEFACLOR- cefaclor for susp 75 mg/5ml cefaclor cap 50 mg cefaclor cap 500 mg CEFACLOR ER- cefaclor monohydrate tab er hr 500 mg cefadroxil cap 500 mg cefadroxil for susp 50 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab gm cefdinir cap 00 mg cefdinir for susp 5 mg/5ml cefdinir for susp 50 mg/5ml CEFDITOREN PIVOXIL- cefditoren pivoxil tab 00 mg (base equivalent) CEFDITOREN PIVOXIL- cefditoren pivoxil tab 400 mg (base equivalent) cefixime for susp 00 mg/5ml (Suprax) SourceRx.0 Four Tier Prescription Drug Guide January

8 cefixime for susp 00 mg/5ml (Suprax) cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 00 mg/5ml cefpodoxime proxetil tab 00 mg cefpodoxime proxetil tab 00 mg cefprozil for susp 5 mg/5ml cefprozil for susp 50 mg/5ml cefprozil tab 50 mg cefprozil tab 500 mg cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg CEPHALEXIN- cephalexin tab 50 mg CEPHALEXIN- cephalexin tab 500 mg cephalexin cap 50 mg (Keflex) cephalexin cap 500 mg (Keflex) cephalexin cap 750 mg (Keflex) cephalexin for susp 5 mg/5ml cephalexin for susp 50 mg/5ml SPECTRACEF- cefditoren pivoxil tab 400 mg (base equivalent) SUPRAX- cefixime cap 400 mg SUPRAX- cefixime chew tab 00 mg SUPRAX- cefixime chew tab 00 mg SUPRAX- cefixime for susp 500 mg/5ml MACROLIDES AZITHROMYCIN- azithromycin powd pack for susp gm azithromycin for susp 00 mg/5ml (Zithromax) azithromycin for susp 00 mg/5ml (Zithromax) azithromycin tab 50 mg (Zithromax) azithromycin tab 500 mg (Zithromax) azithromycin tab 600 mg (Zithromax) CLARITHROMYCIN- clarithromycin for susp 5 mg/5ml CLARITHROMYCIN- clarithromycin for susp 50 mg/5ml clarithromycin tab er 4hr 500 mg clarithromycin tab 50 mg clarithromycin tab 500 mg (Biaxin) DIFICID- fidaxomicin tab 00 mg E.E.S erythromycin ethylsuccinate tab 400 mg ERY-TAB- erythromycin tab delayed release 50 mg ERY-TAB- erythromycin tab delayed release mg ERY-TAB- erythromycin tab delayed release 500 mg ERYPED 400- erythromycin ethylsuccinate for susp 400 mg/5ml ERYTHROCIN STEARATEerythromycin stearate tab 50 mg ERYTHROMYCIN ETHYLSUCCINAerythromycin ethylsuccinate tab 400 mg erythromycin ethylsuccinate for susp 00 mg/5ml (E.e.s. granules) erythromycin tab 50 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 50 mg ZITHROMAX- azithromycin powd pack for susp gm TETRACYCLINES demeclocycline hcl tab 50 mg demeclocycline hcl tab 00 mg DORYX MPC- doxycycline hyclate tab delayed release 0 mg SourceRx.0 Four Tier Prescription Drug Guide January

9 DOXYCYCLINE HYCLATEdoxycycline hyclate tab 50 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 00 mg (Vibramycin) doxycycline hyclate tab delayed release 50 mg (Doryx) doxycycline hyclate tab delayed release 75 mg doxycycline hyclate tab delayed release 00 mg doxycycline hyclate tab delayed release 50 mg doxycycline hyclate tab delayed release 00 mg (Doryx) doxycycline hyclate tab 0 mg doxycycline hyclate tab 75 mg (Acticlate) doxycycline hyclate tab 00 mg doxycycline hyclate tab 50 mg (Acticlate) doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg (Monodox) doxycycline monohydrate cap 00 mg (Monodox) doxycycline monohydrate cap 50 mg (Adoxa) doxycycline monohydrate for susp 5 mg/5ml (Vibramycin) doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 00 mg doxycycline monohydrate tab 50 mg minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin) minocycline hcl cap 00 mg (Minocin) minocycline hcl tab er 4hr 45 mg minocycline hcl tab er 4hr 65 mg (Solodyn) minocycline hcl tab er 4hr 90 mg minocycline hcl tab er 4hr 5 mg (Solodyn) minocycline hcl tab er 4hr 5 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab 00 mg SOLODYN- minocycline hcl tab er 4hr 55 mg SOLODYN- minocycline hcl tab er 4hr 80 mg SOLODYN- minocycline hcl tab er 4hr 05 mg TARGADOX- doxycycline hyclate tab 50 mg tetracycline hcl cap 50 mg (Tetracycline hcl) tetracycline hcl cap 500 mg (Tetracycline hcl) VIBRAMYCIN- doxycycline calcium syrup 50 mg/5ml XIMINO- minocycline hcl cap er 4hr 45 mg (base equivalent) XIMINO- minocycline hcl cap er 4hr 90 mg (base equivalent) XIMINO- minocycline hcl cap er 4hr 5 mg (base equivalent) FLUOROQUINOLONES BAXDELA- delafloxacin meglumine tab 450 mg (base equiv) CIPRO- ciprofloxacin for oral susp 50 mg/5ml (5%) (5 gm/00ml) SourceRx.0 Four Tier Prescription Drug Guide January

10 ciprofloxacin for oral susp 500 mg/5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL- ciprofloxacin hcl tab 00 mg (base equiv) ciprofloxacin hcl tab 50 mg (base equiv) (Cipro) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 mg (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 mg(base eq) (Cipro xr) levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg (Levaquin) levofloxacin tab 500 mg (Levaquin) levofloxacin tab 750 mg (Levaquin) moxifloxacin hcl tab 400 mg (base equiv) (Avelox) OFLOXACIN- ofloxacin tab 00 mg ofloxacin tab 400 mg AMINOGLYCOSIDES BETHKIS- tobramycin nebu soln 00 mg/4ml KITABIS PAK- tobramycin nebu soln 00 mg/5ml neomycin sulfate tab 500 mg paromomycin sulfate cap 50 mg TOBI PODHALER- tobramycin inhal cap 8 mg TOBRAMYCIN- tobramycin nebu soln 00 mg/5ml tobramycin nebu soln 00 mg/5ml (Tobi) SULFONAMIDES SULFADIAZINE- sulfadiazine tab 500 mg ANTIMYCOBACTERIAL AGENTS CYCLOSERINE- cycloserine cap 50 mg ethambutol hcl tab 00 mg (Myambutol) ethambutol hcl tab 400 mg (Myambutol) ISONIAZID- isoniazid syrup 50 mg/5ml isoniazid tab 00 mg isoniazid tab 00 mg PASER- aminosalicylic acid er granules packet 4 gm PRIFTIN- rifapentine tab 50 mg pyrazinamide tab 500 mg rifabutin cap 50 mg (Mycobutin) RIFAMATE- isoniazid & rifampin cap mg rifampin cap 50 mg (Rifadin) rifampin cap 00 mg RIFATER- isoniazid-rifampin w/ pyrazinamide tab mg SIRTURO- bedaquiline fumarate tab 00 mg (base equiv) TRECATOR- ethionamide tab 50 mg ANTIFUNGALS CRESEMBA- isavuconazonium sulfate cap 86 mg fluconazole for susp 0 mg/ml (Diflucan) fluconazole for susp 40 mg/ml (Diflucan) fluconazole tab 50 mg (Diflucan) fluconazole tab 00 mg (Diflucan) fluconazole tab 50 mg (Diflucan) fluconazole tab 00 mg (Diflucan) flucytosine cap 50 mg (Ancobon) SourceRx.0 Four Tier Prescription Drug Guide January 4

11 flucytosine cap 500 mg (Ancobon) griseofulvin microsize susp 5 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 5 mg (Gris-peg) griseofulvin ultramicrosize tab 50 mg (Gris-peg) itraconazole cap 00 mg (Sporanox) itraconazole oral soln 0 mg/ml (Sporanox) ketoconazole tab 00 mg NOXAFIL- posaconazole susp 40 mg/ ml NOXAFIL- posaconazole tab delayed release 00 mg nystatin tab unit SPORANOX- itraconazole oral soln 0 mg/ml terbinafine hcl tab 50 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 50 mg (Vfend) voriconazole tab 00 mg (Vfend) ANTIVIRALS abacavir sulfate soln 0 mg/ml (base equiv) (Ziagen) abacavir sulfate tab 00 mg (base equiv) (Ziagen) abacavir sulfate-lamivudine tab mg (Epzicom) abacavir sulfate-lamivudinezidovudine tab mg (Trizivir) acyclovir cap 00 mg (Zovirax) acyclovir susp 00 mg/5ml (Zovirax) acyclovir tab 400 mg (Zovirax) acyclovir tab 800 mg (Zovirax) adefovir dipivoxil tab 0 mg (Hepsera) APTIVUS- tipranavir cap 50 mg APTIVUS- tipranavir oral soln 00 mg/ ml atazanavir sulfate cap 50 mg (base equiv) (Reyataz) atazanavir sulfate cap 00 mg (base equiv) (Reyataz) atazanavir sulfate cap 00 mg (base equiv) (Reyataz) ATRIPLA- efavirenz-emtricitabinetenofovir df tab mg BARACLUDE- entecavir oral soln 0.05 mg/ml BIKTARVY- bictegravir-emtricitabinetenofovir af tab mg CIMDUO- lamivudine-tenofovir disoproxil fumarate tab mg COMPLERA- emtricitabine-rilpivirinetenofovir df tab mg CRIXIVAN- indinavir sulfate cap 00 mg CRIXIVAN- indinavir sulfate cap 400 mg DAKLINZA- daclatasvir dihydrochloride tab 0 mg (base equivalent) DAKLINZA- daclatasvir dihydrochloride tab 60 mg (base equivalent) DAKLINZA- daclatasvir dihydrochloride tab 90 mg (base equivalent) DESCOVY- emtricitabine-tenofovir alafenamide fumarate tab 00-5 mg didanosine delayed release capsule 00 mg (Videx ec) didanosine delayed release capsule 50 mg (Videx ec) SourceRx.0 Four Tier Prescription Drug Guide January 5

12 didanosine delayed release capsule 400 mg (Videx ec) EDURANT- rilpivirine hcl tab 5 mg (base equivalent) efavirenz cap 50 mg (Sustiva) efavirenz cap 00 mg (Sustiva) efavirenz tab 600 mg (Sustiva) EMTRIVA- emtricitabine caps 00 mg EMTRIVA- emtricitabine soln 0 mg/ ml entecavir tab 0.5 mg (Baraclude) entecavir tab mg (Baraclude) EPCLUSA- sofosbuvir-velpatasvir tab mg EPIVIR HBV- lamivudine oral soln 5 mg/ml (hbv) EVOTAZ- atazanavir sulfate-cobicistat tab mg (base equiv) famciclovir tab 5 mg famciclovir tab 50 mg famciclovir tab 500 mg FLUMADINE- rimantadine hydrochloride tab 00 mg fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 4 FUZEON- enfuvirtide for inj 90 mg 4 GENVOYA- elvitegrav-cobicemtricitab-tenofov af tab mg HARVONI- ledipasvir-sofosbuvir tab mg 4 INTELEE- etravirine tab 5 mg INTELEE- etravirine tab 00 mg INTELEE- etravirine tab 00 mg INVIRASE- saquinavir mesylate cap 00 mg INVIRASE- saquinavir mesylate tab 500 mg ISENTRESS- raltegravir potassium chew tab 5 mg (base equiv) ISENTRESS- raltegravir potassium chew tab 00 mg (base equiv) ISENTRESS- raltegravir potassium packet for susp 00 mg (base equiv) ISENTRESS- raltegravir potassium tab 400 mg (base equiv) ISENTRESS HD- raltegravir potassium tab 600 mg (base equiv) JULUCA- dolutegravir sodiumrilpivirine hcl tab 50-5 mg (base eq) KALETRA- lopinavir-ritonavir tab 00-5 mg KALETRA- lopinavir-ritonavir tab mg lamivudine oral soln 0 mg/ml (Epivir) lamivudine tab 00 mg (hbv) (Epivir hbv) lamivudine tab 50 mg (Epivir) lamivudine tab 00 mg (Epivir) lamivudine-zidovudine tab mg (Combivir) LEXIVA- fosamprenavir calcium susp 50 mg/ml (base equiv) lopinavir-ritonavir soln mg/5ml (80-0 mg/ml) (Kaletra) MAVYRET- glecaprevir-pibrentasvir tab mg MODERIBA- ribavirin tab 00 mg & ribavirin 400 mg tab therapy pack MODERIBA- ribavirin tab 400 mg & ribavirin 600 mg tab therapy pack MODERIBA 00 DOSE PACKribavirin tab 600 mg MODERIBA 800 DOSE PACKribavirin tab 400 mg nevirapine susp 50 mg/5ml (Viramune) SourceRx.0 Four Tier Prescription Drug Guide January 6

13 nevirapine tab er 4hr 00 mg (Viramune xr) nevirapine tab er 4hr 400 mg (Viramune xr) nevirapine tab 00 mg (Viramune) NORVIR- ritonavir oral soln 80 mg/ml NORVIR- ritonavir powder packet 00 mg ODEFSEY- emtricitabine-rilpivirinetenofovir af tab mg oseltamivir phosphate cap 0 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) PEGASYS- peginterferon alfa-a inj 80 mcg/ml PEGASYS- peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK- peginterferon alfa-a inj 5 mcg/0.5ml PEGASYS PROCLICK- peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON- peginterferon alfa-b for inj kit 50 mcg/0.5ml PREVYMIS- letermovir tab 40 mg PREVYMIS- letermovir tab 480 mg PREZCOBIX- darunavir-cobicistat tab mg PREZISTA- darunavir ethanolate susp 00 mg/ml (base equiv) PREZISTA- darunavir ethanolate tab 75 mg (base equiv) PREZISTA- darunavir ethanolate tab 50 mg (base equiv) PREZISTA- darunavir ethanolate tab 600 mg (base equiv) PREZISTA- darunavir ethanolate tab 800 mg (base equiv) REBETOL- ribavirin soln 40 mg/ml 4 RELENZA DISKHALER- zanamivir aero powder breath activated 5 mg/ blister RESCRIPTOR- delavirdine mesylate tab 00 mg RESCRIPTOR- delavirdine mesylate tab 00 mg REYATAZ- atazanavir sulfate oral powder packet 50 mg (base equiv) RIBASPHERE- ribavirin tab 400 mg 4 RIBASPHERE- ribavirin tab 600 mg 4 RIBASPHERE RIBAPAK- ribavirin 4 tab 00 mg & ribavirin 400 mg tab therapy pack RIBASPHERE RIBAPAK- ribavirin 4 tab 400 mg & ribavirin 600 mg tab therapy pack RIBASPHERE RIBAPAK- ribavirin tab mg RIBASPHERE RIBAPAK- ribavirin tab mg ribavirin cap 00 mg (Rebetol) 4 ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 mg (Copegus) 4 rimantadine hydrochloride tab 00 mg (Flumadine) ritonavir tab 00 mg (Norvir) SELZENTRY- maraviroc oral soln 0 mg/ml SELZENTRY- maraviroc tab 5 mg SELZENTRY- maraviroc tab 75 mg SELZENTRY- maraviroc tab 50 mg SELZENTRY- maraviroc tab 00 mg SITAVIG- acyclovir buccal tab 50 mg SOVALDI- sofosbuvir tab 400 mg 4 stavudine cap 5 mg (Zerit) SourceRx.0 Four Tier Prescription Drug Guide January 7

14 stavudine cap 0 mg (Zerit) stavudine cap 0 mg (Zerit) stavudine cap 40 mg (Zerit) STRIBILD- elvitegrav-cobic-emtricitabtenofovdf tab mg SYMFI- efavirenz-lamivudine-tenofovir df tab mg SYMFI LO- efavirenz-lamivudinetenofovir df tab mg SYMTUZA- darunavir-cobicemtricitab-tenofov af tab mg TECHNIVIE- ombitasvir-paritaprevirritonavir tab mg tenofovir disoproxil fumarate tab 00 mg (Viread) TIVICAY- dolutegravir sodium tab 0 mg (base equiv) TIVICAY- dolutegravir sodium tab 5 mg (base equiv) TIVICAY- dolutegravir sodium tab 50 mg (base equiv) TRIUMEQ- abacavir-dolutegravirlamivudine tab mg TRUVADA- emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA- emtricitabine-tenofovir disoproxil fumarate tab -00 mg TRUVADA- emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA- emtricitabine-tenofovir disoproxil fumarate tab mg TYBOST- cobicistat tab 50 mg valacyclovir hcl tab 500 mg (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) SourceRx.0 Four Tier Prescription Drug Guide January 8 VEMLIDY- tenofovir alafenamide fumarate tab 5 mg VIDEX- didanosine for soln gm VIDEX- didanosine for soln 4 gm VIDEX EC- didanosine delayed release capsule 5 mg VIEKIRA PAK- ombitas-paritapreriton & dasab tab pak & 50 mg VIEKIRA XR- dasab-ombitparitap-riton tab er 4hr mg VIRACEPT- nelfinavir mesylate tab 50 mg VIRACEPT- nelfinavir mesylate tab 65 mg VIRAMUNE- nevirapine susp 50 mg/5ml VIREAD- tenofovir disoproxil fumarate oral powder 40 mg/gm VIREAD- tenofovir disoproxil fumarate tab 50 mg VIREAD- tenofovir disoproxil fumarate tab 00 mg VIREAD- tenofovir disoproxil fumarate tab 50 mg VOSEVI- sofosbuvir-velpatasvirvoxilaprevir tab mg 4 ZEPATIER- elbasvir-grazoprevir tab mg zidovudine cap 00 mg (Retrovir) zidovudine syrup 0 mg/ml (Retrovir) zidovudine tab 00 mg ANTIMALARIALS atovaquone-proguanil hcl tab mg (Malarone) atovaquone-proguanil hcl tab mg (Malarone) CHLOROQUINE PHOSPHATEchloroquine phosphate tab 50 mg

15 chloroquine phosphate tab 500 mg COARTEM- artemether-lumefantrine tab 0-0 mg DARAPRIM- pyrimethamine tab 5 mg hydroxychloroquine sulfate tab 00 mg (Plaquenil) MEFLOQUINE HCL- mefloquine hcl tab 50 mg PRIMAQUINE PHOSPHATEprimaquine phosphate tab 6. mg (5 mg base) quinine sulfate cap 4 mg (Qualaquin) AMEBICIDES SOLOSEC- secnidazole granules packet gm ANTHELMINTICS albendazole tab 00 mg (Albenza) ALBENZA- albendazole tab 00 mg BENZNIDAZOLE- benznidazole tab.5 mg BENZNIDAZOLE- benznidazole tab 00 mg EMVERM- mebendazole chew tab 00 mg ivermectin tab mg (Stromectol) praziquantel tab 600 mg (Biltricide) ANTI-INFECTIVE AGENTS - MISC. ALINIA- nitazoxanide for susp 00 mg/5ml ALINIA- nitazoxanide tab 500 mg atovaquone susp 750 mg/5ml (Mepron) CAYSTON- aztreonam lysine for inhal soln 75 mg (base equivalent) clindamycin hcl cap 75 mg (Cleocin) clindamycin hcl cap 50 mg (Cleocin) 4 clindamycin hcl cap 00 mg (Cleocin) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 mg dapsone tab 00 mg FIRVANQ- vancomycin hcl for oral soln 5 mg/ml (base equivalent) FIRVANQ- vancomycin hcl for oral soln 50 mg/ml (base equivalent) IMPAVIDO- miltefosine cap 50 mg linezolid for susp 00 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox) metronidazole cap 75 mg (Flagyl) metronidazole tab 50 mg (Flagyl) metronidazole tab 500 mg (Flagyl) NEBUPENT- pentamidine isethionate for nebulization soln 00 mg PRIMSOL- trimethoprim hcl oral soln 50 mg/5ml (base equiv) SIVEXTRO- tedizolid phosphate tab 00 mg sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg (Bactrim) sulfamethoxazole-trimethoprim tab mg (Bactrim ds) tinidazole tab 50 mg tinidazole tab 500 mg (Tindamax) trimethoprim tab 00 mg TRIMPEX- trimethoprim hcl oral soln 50 mg/5ml (base equiv) vancomycin hcl cap 5 mg (base equivalent) (Vancocin hcl) vancomycin hcl cap 50 mg (base equivalent) (Vancocin hcl) XIFAXAN- rifaximin tab 00 mg SourceRx.0 Four Tier Prescription Drug Guide January 9

16 XIFAXAN- rifaximin tab 550 mg BIOLOGICALS VACCINES ACTHIB- haemophilus b polysaccharide conjugate vaccine for inj AFLURIA PF 08-- influenza virus vaccine split pf susp pref syringe 0.5 ml AFLURIA QUADRIVALENT 08- influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 08- influenza virus vaccine split quadrivalent im inj AFLURIA 08-- influenza virus vaccine split im susp BEXSERO- meningococcal vac b (recomb omv adjuv) inj prefilled syringe ENGERIX-B- hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml ENGERIX-B- hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B- hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B- hepatitis b vaccine (recombinant) 0 mcg/ml FLUAD 08-- influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLUARIX QUADRIVALENT 08- influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT 08- influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0- influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0- influenza vac tissue-cultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 0- influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 0- influenza virus vaccine split quadrivalent im inj FLUMIST QUADRIVALENT- influenza virus vaccine live quadrivalent intranasal susp FLUZONE HIGH-DOSE PF 08- influenza virus vac split high-dose pf susp pref syr 0.5ml FLUZONE QUADRIVALENT 08- influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUADRIVALENT 08- influenza virus vac split quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT 08- influenza virus vaccine split quadrivalent im inj FLUZONE QUADRIVALENT 08- influenza virus vaccine split quadrivalent inj 0.5 ml GARDASIL 9- human papillomavirus (hpv) 9-valent recomb vac im susp GARDASIL 9- human papillomavirus (hpv) 9-valent recomb vac susp pref syr HAVRIX- hepatitis a vaccine inj susp 70 el unit/0.5ml HAVRIX- hepatitis a vaccine inj susp 440 el unit/ml HEPLISAV-B- hepatitis b vaccine recomb adjuvanted pref syr 0 mcg/0.5ml HEPLISAV-B- hepatitis b vaccine recombinant adjuvanted 0 mcg/0.5ml SourceRx.0 Four Tier Prescription Drug Guide January 0

17 HIBERIX- haemophilus b polysaccharide conjugate vac for inj 0 mcg IMOVAX RABIES (H.D.C.V.)- rabies virus vaccine, hdc inj IPOL INACTIVATED IPV- poliovirus vaccine, ipv injection M-M-R II- measles, mumps & rubella virus vaccines for inj MENACTRA- meningococcal (a, c, y, and w-5) conjugate vaccine inj MENVEO- meningococcal (a, c, y, and w-5) oligo conj vac for inj PEDVAX HIB- haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PNEUMOVAX - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVAX / DOSEpneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNAR - pneumococcal - valent conjugate vaccine inj PROQUAD- measles-mumps-rubellavaricella virus vaccines for susp RABAVERT- rabies vaccine, pcec for inj RECOMBIVAX HB- hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB- hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVAX HB- hepatitis b vaccine (recombinant) susp 40 mcg/ml ROTARIX- rotavirus vaccine, live for oral susp ROTATEQ- rotavirus vaccine, live oral pentavalent soln SHINGRIX- zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml TRUMENBA- meningococcal group b vac (recomb) im susp prefilled syr TWINRIX- hepatitis a (inact)-hep b (recomb) vac inj 70-0 elu-mcg/ml VAQTA- hepatitis a vaccine inj susp 5 unit/0.5ml VAQTA- hepatitis a vaccine inj susp 50 unit/ml VARIVAX- varicella virus vac live for subcutaneous inj 50 pfu/0.5ml VIVOTIF- typhoid vaccine cap delayed release ZOSTAVAX- zoster vaccine live for subcutaneous susp 9400 unit/0.65ml TOXOIDS ADACEL- tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml BOOSTRIX- tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml DAPTACEL- diph, acellular pert & tet tox inj 5 lf- mcg-5 lf/0.5ml DIPHTHERIA/TETANUS TOXOIDdiphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFANRIX- diph, acellular pert & tet tox inj 5 lf-58 mcg-0 lf/0.5ml KINRIX- diph-tetanus tox ad-acell pert & polio virus, ipv vac inj PEDIARIX- diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj PENTACEL- diph-ac per-tet tox adpoliov-haemoph b poly vac for im susp QUADRACEL- diph-tetanus tox adacell pert & polio virus, ipv vac inj TENIVAC- tetanus-diphtheria toxoids (td) inj 5- lfu TETANUS/DIPHTHERIA TOXOIDtetanus-diphtheria toxoids (td) inj - lf/0.5ml PASSIVE IMMUNIZING AGENTS SourceRx.0 Four Tier Prescription Drug Guide January

18 GAMUNEX-C- immune globulin (human) iv or subcutaneous soln gm/0ml GAMUNEX-C- immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMUNEX-C- immune globulin (human) iv or subcutaneous soln 5 gm/50ml GAMUNEX-C- immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C- immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C- immune globulin (human) iv or subcutaneous soln 40 gm/400ml HIZENTRA- immune globulin (human) subcutaneous inj gm/5ml HIZENTRA- immune globulin (human) subcutaneous inj gm/0ml HIZENTRA- immune globulin (human) subcutaneous inj 4 gm/0ml HIZENTRA- immune globulin (human) subcutaneous inj 0 gm/50ml HYQVIA- immun glob inj.5 gm/5mlhyaluron inj 00 unt/.5 ml kit HYQVIA- immun glob inj 5 gm/50mlhyaluron inj 400 unt/.5 ml kit HYQVIA- immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA- immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVIA- immun glob inj 0 gm/00ml-hyaluron inj 400 unt/5 ml kit BIOLOGICALS MISC GRASTEK- timothy grass pollen allergen ext sl tab 800 bau ODACTRA- dust mite mixed ext sl tab sq-hdm ORALAIR- grass mixed pollen ext sl tab 00 ir (index of reactivity) RAGWITEK- short ragweed pollen allergen extract sl tab amb a -u ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE- interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) 4 AFINITOR- everolimus tab.5 mg 4 AFINITOR- everolimus tab 5 mg 4 AFINITOR- everolimus tab 7.5 mg 4 AFINITOR- everolimus tab 0 mg 4 AFINITOR DISPERZ- everolimus tab for oral susp mg AFINITOR DISPERZ- everolimus tab for oral susp mg AFINITOR DISPERZ- everolimus tab for oral susp 5 mg ALECENSA- alectinib hcl cap 50 mg (base equivalent) ALUNBRIG- brigatinib tab initiation therapy pack 90 mg & 80 mg ALUNBRIG- brigatinib tab 0 mg 4 ALUNBRIG- brigatinib tab 90 mg 4 ALUNBRIG- brigatinib tab 80 mg 4 anastrozole tab mg (Arimidex) bexarotene cap 75 mg (Targretin) 4 bicalutamide tab 50 mg (Casodex) BOSULIF- bosutinib tab 00 mg 4 BOSULIF- bosutinib tab 400 mg 4 BOSULIF- bosutinib tab 500 mg 4 BRAFTOVI- encorafenib cap 50 mg 4 BRAFTOVI- encorafenib cap 75 mg 4 CABOMETYX- cabozantinib s-malate tab 0 mg (base equivalent) 4 SourceRx.0 Four Tier Prescription Drug Guide January

19 CABOMETYX- cabozantinib s-malate tab 40 mg (base equivalent) CABOMETYX- cabozantinib s-malate tab 60 mg (base equivalent) CALQUEE- acalabrutinib cap 00 mg capecitabine tab 50 mg (Xeloda) 4 capecitabine tab 500 mg (Xeloda) 4 CAPRELSA- vandetanib tab 00 mg 4 CAPRELSA- vandetanib tab 00 mg 4 COMETRIQ- cabozantinib s-mal cap x 80 mg & x 0 mg (00 dose) kit COMETRIQ- cabozantinib s-mal cap x 80 mg & x 0 mg (40 dose) kit COMETRIQ- cabozantinib s-malate cap x 0 mg (60 mg dose) kit COTELLIC- cobimetinib fumarate tab 0 mg (base equivalent) cyclophosphamide cap 5 mg (Cyclophosphamide) cyclophosphamide cap 50 mg (Cyclophosphamide) ELIGARD- leuprolide acetate ( month) for subcutaneous inj kit.5mg ELIGARD- leuprolide acetate (4 month) for subcutaneous inj kit 0 mg ELIGARD- leuprolide acetate (6 month) for subcutaneous inj kit 45 mg ELIGARD- leuprolide acetate for subcutaneous inj kit 7.5 mg EMCYT- estramustine phosphate sodium cap 40 mg ERIVEDGE- vismodegib cap 50 mg 4 ERLEADA- apalutamide tab 60 mg 4 ETOPOSIDE- etoposide cap 50 mg exemestane tab 5 mg (Aromasin) FARESTON- toremifene citrate tab 60 mg (base equivalent) FARYDAK- panobinostat lactate cap 0 mg (base equivalent) FARYDAK- panobinostat lactate cap 5 mg (base equivalent) FARYDAK- panobinostat lactate cap 0 mg (base equivalent) flutamide cap 5 mg GILOTRIF- afatinib dimaleate tab 0 mg (base equivalent) GILOTRIF- afatinib dimaleate tab 0 mg (base equivalent) GILOTRIF- afatinib dimaleate tab 40 mg (base equivalent) GLEOSTINE- lomustine cap 0 mg GLEOSTINE- lomustine cap 40 mg GLEOSTINE- lomustine cap 00 mg HYCAMTIN- topotecan hcl cap 0.5 mg (base equiv) HYCAMTIN- topotecan hcl cap mg (base equiv) hydroxyurea cap 500 mg (Hydrea) IBRAE- palbociclib cap 75 mg 4 IBRAE- palbociclib cap 00 mg 4 IBRAE- palbociclib cap 5 mg 4 ICLUSIG- ponatinib hcl tab 5 mg (base equiv) ICLUSIG- ponatinib hcl tab 45 mg (base equiv) IDHIFA- enasidenib mesylate tab 50 mg (base equivalent) IDHIFA- enasidenib mesylate tab 00 mg (base equivalent) imatinib mesylate tab 00 mg (base equivalent) (Gleevec) imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA- ibrutinib cap 70 mg 4 IMBRUVICA- ibrutinib cap 40 mg 4 SourceRx.0 Four Tier Prescription Drug Guide January

20 IMBRUVICA- ibrutinib tab 40 mg 4 IMBRUVICA- ibrutinib tab 80 mg 4 IMBRUVICA- ibrutinib tab 40 mg 4 IMBRUVICA- ibrutinib tab 560 mg 4 INLYTA- axitinib tab mg 4 INLYTA- axitinib tab 5 mg 4 INTRON A- interferon alfa-b inj unit/ml INTRON A- interferon alfa-b inj unit/ml INTRON A- interferon alfa-b for inj unit INTRON A- interferon alfa-b for inj unit INTRON A- interferon alfa-b for inj unit IRESSA- gefitinib tab 50 mg 4 4 JAKAFI- ruxolitinib phosphate tab 5 mg (base equivalent) JAKAFI- ruxolitinib phosphate tab 0 mg (base equivalent) JAKAFI- ruxolitinib phosphate tab 5 mg (base equivalent) JAKAFI- ruxolitinib phosphate tab 0 mg (base equivalent) JAKAFI- ruxolitinib phosphate tab 5 mg (base equivalent) KISQALI- ribociclib succinate tab 00 mg (base equiv) KISQALI FEMARA 00 DOSEribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQALI FEMARA 400 DOSEribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQALI FEMARA 600 DOSEribociclib tab 00 mg & letrozole tab.5 mg therapy pack LENVIMA 0 MG DAILY DOSElenvatinib cap therapy pack 0 mg (0 mg daily dose) LENVIMA MG DAILY DOSElenvatinib cap therapy pack 4 () mg ( mg daily dose) LENVIMA 4 MG DAILY DOSElenvatinib cap therapy pack 0 & 4 mg (4 mg daily dose) LENVIMA 8 MG DAILY DOSElenvatinib cap therapy pack 0 & 4 () mg (8 mg daily dose) LENVIMA 0 MG DAILY DOSElenvatinib cap therapy pack 0 () mg (0 mg daily dose) LENVIMA 4 MG DAILY DOSElenvatinib cap therapy pack 0 () & 4 mg (4 mg daily dose) LENVIMA 4 MG DAILY DOSElenvatinib cap therapy pack 4 mg (4 mg daily dose) LENVIMA 8 MG DAILY DOSElenvatinib cap therapy pack 4 () mg (8 mg daily dose) letrozole tab.5 mg (Femara) LEUCOVORIN CALCIUM- leucovorin calcium tab 0 mg LEUCOVORIN CALCIUM- leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg LEUKERAN- chlorambucil tab mg leuprolide acetate inj kit 5 mg/ml 4 LONSURF- trifluridine-tipiracil tab mg LONSURF- trifluridine-tipiracil tab mg LUPRON DEPOT (-MONTH)- leuprolide acetate for inj kit.75 mg LUPRON DEPOT (-MONTH)- leuprolide acetate for inj kit 7.5 mg LUPRON DEPOT (-MONTH)- leuprolide acetate ( month) for inj kit.5 mg SourceRx.0 Four Tier Prescription Drug Guide January 4

21 LUPRON DEPOT (-MONTH)- leuprolide acetate ( month) for inj kit.5 mg LUPRON DEPOT (4-MONTH)- leuprolide acetate (4 month) for inj kit 0 mg LUPRON DEPOT (6-MONTH)- leuprolide acetate (6 month) for inj kit 45 mg LYNPARZA- olaparib tab 00 mg 4 LYNPARZA- olaparib tab 50 mg 4 LYSODREN- mitotane tab 500 mg 4 MATULANE- procarbazine hcl cap 50 mg megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 0 mg megestrol acetate tab 40 mg MEKINIST- trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) MEKINIST- trametinib dimethyl sulfoxide tab mg (base equivalent) MEKTOVI- binimetinib tab 5 mg 4 melphalan tab mg (Alkeran) mercaptopurine tab 50 mg MESNEX- mesna tab 400 mg METHOTREXATE SODIUMmethotrexate sodium inj 50 mg/0ml (5 mg/ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 mg/ml (5 mg/ml) methotrexate sodium inj pf 50 mg/0ml (5 mg/ml) methotrexate sodium inj pf 000 mg/40ml (5 mg/ml) methotrexate sodium inj 50 mg/ml (5 mg/ml) methotrexate sodium tab.5 mg (base equiv) MYLERAN- busulfan tab mg NERLYNX- neratinib maleate tab 40 mg (base equivalent) NEXAVAR- sorafenib tosylate tab 00 mg (base equivalent) nilutamide tab 50 mg (Nilandron) NINLARO- ixazomib citrate cap. mg (base equivalent) NINLARO- ixazomib citrate cap mg (base equivalent) NINLARO- ixazomib citrate cap 4 mg (base equivalent) ODOMZO- sonidegib phosphate cap 00 mg (base equivalent) POMALYST- pomalidomide cap mg 4 POMALYST- pomalidomide cap mg 4 POMALYST- pomalidomide cap mg 4 POMALYST- pomalidomide cap 4 mg 4 PURIXAN- mercaptopurine susp 000 mg/00ml (0 mg/ml) RUBRACA- rucaparib camsylate tab 00 mg (base equivalent) RUBRACA- rucaparib camsylate tab 50 mg (base equivalent) RUBRACA- rucaparib camsylate tab 00 mg (base equivalent) RYDAPT- midostaurin cap 5 mg 4 SOLTAMOX- tamoxifen citrate oral soln 0 mg/5ml (base equivalent) SPRYCEL- dasatinib tab 0 mg 4 SPRYCEL- dasatinib tab 50 mg 4 SPRYCEL- dasatinib tab 70 mg 4 SPRYCEL- dasatinib tab 80 mg 4 SPRYCEL- dasatinib tab 00 mg 4 SPRYCEL- dasatinib tab 40 mg 4 STIVARGA- regorafenib tab 40 mg 4 SourceRx.0 Four Tier Prescription Drug Guide January 5

22 SUTENT- sunitinib malate cap.5 mg (base equivalent) SUTENT- sunitinib malate cap 5 mg (base equivalent) SUTENT- sunitinib malate cap 7.5 mg (base equivalent) SUTENT- sunitinib malate cap 50 mg (base equivalent) SYLATRON- peginterferon alfa-b for inj kit 00 mcg SYLATRON- peginterferon alfa-b for inj kit 00 mcg SYLATRON- peginterferon alfa-b for inj kit 600 mcg SYNRIBO- omacetaxine mepesuccinate for inj.5 mg TABLOID- thioguanine tab 40 mg TAFINLAR- dabrafenib mesylate cap 50 mg (base equivalent) TAFINLAR- dabrafenib mesylate cap 75 mg (base equivalent) TAGRISSO- osimertinib mesylate tab 40 mg (base equivalent) TAGRISSO- osimertinib mesylate tab 80 mg (base equivalent) tamoxifen citrate tab 0 mg (base equivalent) tamoxifen citrate tab 0 mg (base equivalent) TARCEVA- erlotinib hcl tab 5 mg (base equivalent) TARCEVA- erlotinib hcl tab 00 mg (base equivalent) TARCEVA- erlotinib hcl tab 50 mg (base equivalent) TASIGNA- nilotinib hcl cap 50 mg (base equivalent) TASIGNA- nilotinib hcl cap 50 mg (base equivalent) TASIGNA- nilotinib hcl cap 00 mg (base equivalent) temozolomide cap 5 mg (Temodar) 4 temozolomide cap 0 mg (Temodar) 4 4 temozolomide cap 00 mg (Temodar) temozolomide cap 40 mg (Temodar) temozolomide cap 80 mg (Temodar) temozolomide cap 50 mg (Temodar) TIBSOVO- ivosidenib tab 50 mg 4 tretinoin cap 0 mg 4 TREXALL- methotrexate sodium tab 5 mg (base equiv) TREXALL- methotrexate sodium tab 7.5 mg (base equiv) TREXALL- methotrexate sodium tab 0 mg (base equiv) TREXALL- methotrexate sodium tab 5 mg (base equiv) TYKERB- lapatinib ditosylate tab 50 mg (base equiv) 4 VELEXTA- venetoclax tab 0 mg 4 VELEXTA- venetoclax tab 50 mg 4 VELEXTA- venetoclax tab 00 mg 4 VELEXTA STARTING PACKvenetoclax tab therapy starter pack 0 & 50 & 00 mg 4 VERZENIO- abemaciclib tab 50 mg 4 VERZENIO- abemaciclib tab 00 mg 4 VERZENIO- abemaciclib tab 50 mg 4 VERZENIO- abemaciclib tab 00 mg 4 VOTRIENT- pazopanib hcl tab 00 mg (base equiv) 4 XALKORI- crizotinib cap 00 mg 4 XALKORI- crizotinib cap 50 mg 4 XATMEP- methotrexate oral soln.5 mg/ml XTANDI- enzalutamide cap 40 mg 4 SourceRx.0 Four Tier Prescription Drug Guide January 6

23 YONSA- abiraterone acetate tab 5 mg ZEJULA- niraparib tosylate cap 00 mg (base equivalent) 4 4 ZELBORAF- vemurafenib tab 40 mg 4 ZOLINZA- vorinostat cap 00 mg 4 ZYDELIG- idelalisib tab 00 mg 4 ZYDELIG- idelalisib tab 50 mg 4 ZYKADIA- ceritinib cap 50 mg 4 ZYTIGA- abiraterone acetate tab 50 mg ZYTIGA- abiraterone acetate tab 500 mg ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap mg (Entocort ec) budesonide tab er 4hr 9 mg (Uceris) CORTISONE ACETATE- cortisone acetate tab 5 mg DEXAMETHASONE- dexamethasone soln 0.5 mg/5ml DEXAMETHASONE- dexamethasone tab mg DEXAMETHASONE- dexamethasone tab mg dexamethasone elixir 0.5 mg/5ml DEXAMETHASONE INTENSOLdexamethasone conc mg/ml dexamethasone tab therapy pack.5 mg () (Dexpak 6 day) dexamethasone tab therapy pack.5 mg (5) (Dexpak 0 day) dexamethasone tab therapy pack.5 mg (5) (Dexpak day) dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab.5 mg 4 4 dexamethasone tab 4 mg dexamethasone tab 6 mg DEXPAK 0 DAY- dexamethasone tab therapy pack.5 mg (5) DEXPAK DAY- dexamethasone tab therapy pack.5 mg (5) DEXPAK 6 DAY- dexamethasone tab therapy pack.5 mg () fludrocortisone acetate tab 0. mg hydrocortisone tab 5 mg (Cortef) hydrocortisone tab 0 mg (Cortef) hydrocortisone tab 0 mg (Cortef) MEDROL- methylprednisolone tab mg methylprednisolone tab therapy pack 4 mg () (Medrol dosepak) methylprednisolone tab 4 mg (Medrol) methylprednisolone tab 8 mg (Medrol) methylprednisolone tab 6 mg (Medrol) methylprednisolone tab mg (Medrol) MILLIPRED- prednisolone tab 5 mg MILLIPRED DP- prednisolone tab therapy pack 5 mg () MILLIPRED DP- prednisolone tab therapy pack 5 mg (48) PREDNISOLONE- prednisolone syrup 5 mg/5ml (usp solution equivalent) prednisolone sod phos orally disintegr tab 0 mg (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 5 mg (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 0 mg (base eq) (Orapred odt) SourceRx.0 Four Tier Prescription Drug Guide January 7

24 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) prednisolone sod phosphate oral soln 5 mg/5ml (base equiv) prednisolone sod phosphate oral soln 0 mg/5ml (base equiv) (Millipred) prednisolone sod phosphate oral soln 0 mg/5ml (base equiv) (Veripred 0) PREDNISOLONE SODIUM PHOSPprednisolone sodium phosphate oral soln 5 mg/5ml (base eq) PREDNISONE- prednisone oral soln 5 mg/5ml PREDNISONE- prednisone tab therapy pack 5 mg () PREDNISONE- prednisone tab therapy pack 5 mg (48) PREDNISONE- prednisone tab therapy pack 0 mg () PREDNISONE- prednisone tab therapy pack 0 mg (48) PREDNISONE- prednisone tab 50 mg PREDNISONE INTENSOLprednisone conc 5 mg/ml prednisone tab mg prednisone tab.5 mg prednisone tab 5 mg prednisone tab 0 mg prednisone tab 0 mg RAYOS- prednisone tab delayed release mg RAYOS- prednisone tab delayed release mg RAYOS- prednisone tab delayed release 5 mg TAPERDEX -DAY- dexamethasone tab therapy pack.5 mg (49) TAPERDEX 6-DAY- dexamethasone tab therapy pack.5 mg () ANDROGEN-ANABOLIC ANADROL-50- oxymetholone tab 50 mg ANDRODERM- testosterone td patch 4hr mg/4hr ANDRODERM- testosterone td patch 4hr 4 mg/4hr ANDROGEL- testosterone td gel 0.5 mg/.5gm (.6%) ANDROGEL- testosterone td gel 40.5 mg/.5gm (.6%) ANDROGEL PUMP- testosterone td gel 0.5 mg/act (.6%) AVEED- testosterone undecanoate im inj in oil 750 mg/ml (50mg/ml) danazol cap 50 mg danazol cap 00 mg danazol cap 00 mg FORTESTA- testosterone td gel 0mg/act (%) METHITEST- methyltestosterone oral tab 0 mg METHYLTESTOSTERONEmethyltestosterone cap 0 mg NATESTO- testosterone nasal gel 5.5 mg/act oxandrolone tab.5 mg (Oxandrin) oxandrolone tab 0 mg (Oxandrin) STRIANT- testosterone buccal mucoadhesive system 0 mg TESTOSTERONE- testosterone td gel 5 mg/.5gm (%) TESTOSTERONE- testosterone td gel 50 mg/5gm (%) TESTOSTERONE- testosterone td gel 0mg/act (%) testosterone cypionate im inj in oil 00 mg/ml (Depo-testosterone) SourceRx.0 Four Tier Prescription Drug Guide January 8