1 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Formulary 01/01/2020

INTRODUCTION....................................................................................................................................................................................................... 4

PREFACE ................................................................................................................................................................................................................. 4

DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 5

GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5

LEGEND ................................................................................................................................................................................................................... 6

NOTICE ..................................................................................................................................................................................................................... 6

ANALGESICS........................................................................................................................................................................................................... 7 NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8 VISCOSUPPLEMENTS ................................................................................................................................................................................. 8

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

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

CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS......................................................................................................................................................................................... 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 14 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 15 ANTILIPEMICS............................................................................................................................................................................................. 15 BETA-BLOCKERS ....................................................................................................................................................................................... 16 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 17 NITRATES .................................................................................................................................................................................................... 17 PULMONARY ARTERIAL HYPERTENSION............................................................................................................................................... 17 MISCELLANEOUS ....................................................................................................................................................................................... 18

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18 ANTIANXIETY .............................................................................................................................................................................................. 18 ANTICONVULSANTS .................................................................................................................................................................................. 18

2 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTIDEMENTIA ........................................................................................................................................................................................... 19 ANTIDEPRESSANTS .................................................................................................................................................................................. 19 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 20 ANTIPSYCHOTICS ...................................................................................................................................................................................... 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 21 FIBROMYALGIA........................................................................................................................................................................................... 21 HYPNOTICS................................................................................................................................................................................................. 21 MIGRAINE .................................................................................................................................................................................................... 21 MOOD STABILIZERS .................................................................................................................................................................................. 22 MOVEMENT DISORDERS .......................................................................................................................................................................... 22 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 22 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22 MYASTHENIA GRAVIS................................................................................................................................................................................ 22 NARCOLEPSY ............................................................................................................................................................................................. 22 POSTHERPETIC NEURALGIA (PHN) ......................................................................................................................................................... 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 23

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 23 ACROMEGALY ............................................................................................................................................................................................ 23 ANDROGENS .............................................................................................................................................................................................. 23 ANTIDIABETICS .......................................................................................................................................................................................... 23 ANTIOBESITY .............................................................................................................................................................................................. 25 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 25 CALCIUM REGULATORS ........................................................................................................................................................................... 25 CARNITINE DEFICIENCY AGENTS ........................................................................................................................................................... 26 CONTRACEPTIVES .................................................................................................................................................................................... 26 ENDOMETRIOSIS ....................................................................................................................................................................................... 27 ESTROGENS ............................................................................................................................................................................................... 27 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 27 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 27 FERTILITY REGULATORS .......................................................................................................................................................................... 27 GAUCHER DISEASE ................................................................................................................................................................................... 28 GLUCOCORTICOIDS .................................................................................................................................................................................. 28 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 28 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ....................................................................................................................................... 28 HUMAN GROWTH HORMONES ................................................................................................................................................................. 28 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 28 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 28 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 28 POTASSIUM-REMOVING AGENTS ............................................................................................................................................................ 28 PROGESTINS .............................................................................................................................................................................................. 29 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 29 THYROID AGENTS...................................................................................................................................................................................... 29 VASOPRESSINS ......................................................................................................................................................................................... 29 MISCELLANEOUS ....................................................................................................................................................................................... 29

GASTROINTESTINAL ........................................................................................................................................................................................... 29 ANTIDIARRHEALS ...................................................................................................................................................................................... 29 ANTIEMETICS ............................................................................................................................................................................................. 29 ANTISPASMODICS ..................................................................................................................................................................................... 30 CHOLELITHOLYTICS .................................................................................................................................................................................. 30 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 30

INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 30 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 30 LAXATIVES .................................................................................................................................................................................................. 30 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 30 PANCREATIC ENZYMES ............................................................................................................................................................................ 30 PROSTAGLANDINS .................................................................................................................................................................................... 31 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 31 SALIVA STIMULANTS ................................................................................................................................................................................. 31 STEROIDS, RECTAL ................................................................................................................................................................................... 31 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31

GENITOURINARY .................................................................................................................................................................................................. 31 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 31 ERECTILE DYSFUNCTION ......................................................................................................................................................................... 31 URINARY ANTISPASMODICS .................................................................................................................................................................... 31

3 Nippon Life Insurance Company of America® NC20016-4 (1/20)

VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 32 MISCELLANEOUS ....................................................................................................................................................................................... 32

HEMATOLOGIC ..................................................................................................................................................................................................... 32 ANTICOAGULANTS .................................................................................................................................................................................... 32 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 32 HEMOPHILIA A AGENTS ............................................................................................................................................................................ 32 HEMOPHILIA B AGENTS ............................................................................................................................................................................ 33 HEREDITARY ANGIOEDEMA ..................................................................................................................................................................... 33 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 33 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 33 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 33 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 33 STEM CELL MOBILIZERS ........................................................................................................................................................................... 33 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 33 MISCELLANEOUS ....................................................................................................................................................................................... 33

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 33 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 33 AUTOIMMUNE AGENTS ‡ .......................................................................................................................................................................... 33 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 34 IMMUNOMODULATORS ............................................................................................................................................................................. 34 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 34

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 34 ELECTROLYTES ......................................................................................................................................................................................... 34 VITAMINS AND MINERALS ........................................................................................................................................................................ 34

RESPIRATORY ...................................................................................................................................................................................................... 35 ANAPHYLAXIS TREATMENT AGENTS ...................................................................................................................................................... 35 ANTICHOLINERGICS .................................................................................................................................................................................. 35 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 35 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ........................................................................................ 35 ANTIHISTAMINES, LOW SEDATING .......................................................................................................................................................... 35 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 35 ANTITUSSIVES............................................................................................................................................................................................ 36 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 36 BETA AGONISTS ........................................................................................................................................................................................ 36 CYSTIC FIBROSIS ....................................................................................................................................................................................... 36 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 36 MAST CELL STABILIZERS ......................................................................................................................................................................... 36 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 37 NASAL STEROIDS/COMBINATIONS ......................................................................................................................................................... 37 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 37 PULMONARY ENZYME DEFICIENCY AGENTS ........................................................................................................................................ 37 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 37 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 37 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 37 STEROID INHALANTS ................................................................................................................................................................................ 37 XANTHINES ................................................................................................................................................................................................. 37 MISCELLANEOUS ....................................................................................................................................................................................... 37

TOPICAL ................................................................................................................................................................................................................ 37 DERMATOLOGY.......................................................................................................................................................................................... 37 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 40 OPHTHALMIC .............................................................................................................................................................................................. 40 OTIC ............................................................................................................................................................................................................. 42

WEBSITES ............................................................................................................................................................................................................. 43

INDEX ..................................................................................................................................................................................................................... 45

4 Nippon Life Insurance Company of America® NC20016-4 (1/20)

INTRODUCTION

We are pleased to provide the 2020 Formulary as a useful reference and informational tool. The Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients.

The Formulary is reflective of current medical practice as of the date of review.

The information contained in the Formulary and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

Note: This list is a plan sponsored formulary and not a CVS Caremark® formulary.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.

PREFACE

This Formulary is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in this Formulary. Generics should be considered the first line of prescribing.

Individual pharmacy benefit plans may impose restrictions or not reimburse some products. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states. OTC products are listed for informational purposes. If covered in the pharmacy benefit, OTC products require a valid prescription.

Drugs represented in this Formulary may have varying cost to the plan member. Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated. Generic medications typically are available at the lowest cost, brand-name medications on this Formulary will generally cost more than generics, and brand-name medications not on the list will generally cost the most.

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner:

Tier 1: Lowest plan member copayment: All generic drugs, including those on this Formulary. Tier 2: Intermediate plan member copayment: Preferred brand-name products on this Formulary selected

for Tier 2. Tier 3: Highest plan member copayment: Brand-name products on this Formulary not selected for Tier 2,

and all non-preferred brand-name products. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this highest tier.

5 Nippon Life Insurance Company of America® NC20016-4 (1/20)

DRUG LIST PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are on this Formulary, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Products on this Formulary include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica

Oral capsules, oral solution and all strengths of Lyrica would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is on this Formulary. Other strengths/dosage forms of the reference product are not.

acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on this Formulary. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet

The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.

sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Formulary.

Dosage forms on this Formulary will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin

Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of this Formulary.

GENERIC SUBSTITUTION

Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may:

Incur higher copayment (tier 3)

Require payment of the difference in price between generic and brand, in addition to copayment

Require mandatory generic dispensing

6 Nippon Life Insurance Company of America® NC20016-4 (1/20)

LEGEND

OTC Over the counter

boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name

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

ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

NOTICE

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark.

When viewing this Formulary via the Internet, please be advised that this Formulary is updated periodically and changes may appear prior to their effective date to allow for client notification.

The prescription benefit plan design may not cover certain products or categories regardless of their appearance in this document.

7 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANALGESICS

Practice guidelines of pain management are available at: https://www.asahq.org

NSAIDs

NSAIDs, COMBINATIONS

diclofenac sodium delayed-rel/misoprostol Tier 1

NSAIDs, TOPICAL

* diclofenac sodium gel 1% Tier 1

diclofenac sodium soln Tier 1

* Listing does not include NDC 69499031866. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

COX-2 INHIBITORS

celecoxib Tier 3 CELEBREX

GOUT

colchicine Tier 1 probenecid Tier 1 febuxostat Tier 2 ULORIC

allopurinol Tier 3 ZYLOPRIM

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org

Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html

codeine/acetaminophen Tier 1 fentanyl transdermal Tier 1 fentanyl transmucosal lozenge Tier 1 hydromorphone ext-rel Tier 1 methadone Tier 1 morphine Tier 1 morphine ext-rel Tier 1 morphine supp Tier 1 oxycodone caps, tabs 5 mg Tier 1 oxycodone concentrate 20 mg/mL Tier 1 oxycodone/acetaminophen 5/325 Tier 1 tramadol ext-rel Tier 1 buprenorphine Tier 2 BELBUCA

diclofenac sodium delayed-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 ibuprofen Tier 1 nabumetone Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1 sulindac Tier 1 meloxicam Tier 3 MOBIC

oxaprozin Tier 3 DAYPRO

8 Nippon Life Insurance Company of America® NC20016-4 (1/20)

fentanyl sublingual spray Tier 2 SUBSYS morphine/naltrexone ext-rel Tier 2 EMBEDA

oxycodone ext-rel Tier 2 XTAMPZA ER

tapentadol Tier 2 NUCYNTA

tapentadol ext-rel Tier 2 NUCYNTA ER hydrocodone/acetaminophen Tier 3 NORCO

hydromorphone Tier 3 DILAUDID

morphine ext-rel Tier 3 KADIAN morphine ext-rel Tier 3 MS CONTIN

oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL Tier 3 ROXICODONE

oxycodone/acetaminophen soln Tier 3 ROXICET tramadol Tier 3 ULTRAM

NON-OPIOID ANALGESICS

butalbital/acetaminophen/caffeine tabs Tier 3 ESGIC butalbital/aspirin/caffeine Tier 3 FIORINAL

VISCOSUPPLEMENTS

sodium hyaluronate Tier 2 DUROLANE sodium hyaluronate Tier 2 GEL-ONE

sodium hyaluronate Tier 2 GELSYN-3 sodium hyaluronate Tier 2 SUPARTZ FX

sodium hyaluronate Tier 2 VISCO-3

ANTI-INFECTIVES

Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org

Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org

HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html

International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html

Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

9 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTIBACTERIALS Cephalosporins First Generation

cefadroxil Tier 1 cephalexin Tier 3 KEFLEX

Second Generation cefprozil Tier 1 cefuroxime axetil Tier 1

Third Generation

cefdinir Tier 1 cefixime Tier 2 SUPRAX

Erythromycins/Macrolides

clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 fidaxomicin Tier 2 DIFICID

azithromycin Tier 3 ZITHROMAX

Fluoroquinolones

ciprofloxacin Tier 3 CIPRO levofloxacin Tier 3 LEVAQUIN

moxifloxacin Tier 3 AVELOX

Penicillins

amoxicillin Tier 1 amoxicillin/clavulanate ext-rel Tier 1 ampicillin Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1 amoxicillin/clavulanate Tier 3 AUGMENTIN

Tetracyclines

doxycycline hyclate 20 mg Tier 1 minocycline Tier 1 tetracycline Tier 1 doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS

clotrimazole troches Tier 1 griseofulvin ultramicrosize Tier 1 itraconazole Tier 1 nystatin Tier 1 terbinafine tabs Tier 1 fluconazole Tier 3 DIFLUCAN voriconazole Tier 3 VFEND

ANTIMALARIALS

chloroquine Tier 1 mefloquine Tier 1 atovaquone/proguanil Tier 3 MALARONE

10 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTIRETROVIRAL AGENTS Antiretroviral Combinations

abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ atazanavir/cobicistat Tier 2 EVOTAZ bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY

darunavir/cobicistat Tier 2 PREZCOBIX

efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 2 ATRIPLA efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI

efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 2 SYMFI LO

elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA

elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate

Tier 2 STRIBILD

emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY

emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA emtricitabine/tenofovir alafenamide Tier 2 DESCOVY

emtricitabine/tenofovir disoproxil fumarate Tier 2 TRUVADA

lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS

abacavir/lamivudine Tier 3 EPZICOM

lamivudine/zidovudine Tier 3 COMBIVIR

Fusion Inhibitors

enfuvirtide Tier 3 FUZEON

Integrase Inhibitors

dolutegravir Tier 2 TIVICAY raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors

efavirenz Tier 1 nevirapine Tier 1 nevirapine ext-rel Tier 1 etravirine Tier 3 INTELENCE rilpivirine Tier 3 EDURANT

Nucleoside Reverse Transcriptase Inhibitors

stavudine Tier 1 abacavir tabs Tier 3 ZIAGEN didanosine delayed-rel Tier 3 VIDEX EC

emtricitabine Tier 3 EMTRIVA lamivudine Tier 3 EPIVIR

zidovudine Tier 3 RETROVIR

Nucleotide Reverse Transcriptase Inhibitors

tenofovir disoproxil fumarate Tier 3 VIREAD

Protease Inhibitors

atazanavir Tier 1 darunavir Tier 2 PREZISTA ritonavir Tier 2 NORVIR

lopinavir/ritonavir soln Tier 3 KALETRA

lopinavir/ritonavir tabs Tier 3 KALETRA

ANTITUBERCULAR AGENTS

isoniazid Tier 1 pyrazinamide Tier 1

11 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ethambutol Tier 3 MYAMBUTOL rifampin Tier 3 RIFADIN

ANTIVIRALS Cytomegalovirus Agents

valganciclovir Tier 1

Hepatitis Agents Hepatitis B

entecavir tabs Tier 1 lamivudine Tier 1 tenofovir alafenamide Tier 2 VEMLIDY

entecavir soln Tier 3 BARACLUDE

Hepatitis C

ribavirin tabs Tier 1 † ledipasvir/sofosbuvir Tier 2 HARVONI † sofosbuvir/velpatasvir Tier 2 EPCLUSA † sofosbuvir/velpatasvir/voxilaprevir Tier 2 VOSEVI

ribavirin caps Tier 3 REBETOL

ribavirin oral soln Tier 3 REBETOL

†HARVONI only for genotypes 1, 4, 5 and 6 EPCLUSA only for genotypes 1, 2, 3, 4, 5 and 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3)

Herpes Agents

famciclovir Tier 1 valacyclovir Tier 1 acyclovir caps, tabs Tier 3 ZOVIRAX

Influenza Agents

oseltamivir Tier 1 zanamivir Tier 2 RELENZA

MISCELLANEOUS

dapsone Tier 1 linezolid Tier 1 nitrofurantoin macrocrystals Tier 1 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1 trimethoprim Tier 1 mebendazole chewable Tier 2 EMVERM

rifaximin 550 mg Tier 2 XIFAXAN clindamycin Tier 3 CLEOCIN

ivermectin Tier 3 STROMECTOL

metronidazole Tier 3 FLAGYL nitrofurantoin ext-rel Tier 3 MACROBID

nitrofurantoin susp Tier 3 FURADANTIN

vancomycin Tier 3 VANCOCIN

12 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org

ALKYLATING AGENTS

cyclophosphamide caps Tier 1 busulfan Tier 3 MYLERAN chlorambucil Tier 3 LEUKERAN

melphalan Tier 3 ALKERAN

temozolomide Tier 3 TEMODAR

ANTIMETABOLITES

mercaptopurine Tier 1 capecitabine Tier 3 XELODA methotrexate Tier 3 TREXALL

thioguanine Tier 3 TABLOID

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

abiraterone Tier 1 flutamide Tier 1 abiraterone Tier 2 YONSA

apalutamide Tier 2 ERLEADA darolutamide Tier 2 NUBEQA

enzalutamide Tier 2 XTANDI

bicalutamide Tier 3 CASODEX

Antiestrogens

tamoxifen Tier 1

Aromatase Inhibitors

anastrozole Tier 3 ARIMIDEX exemestane Tier 3 AROMASIN letrozole Tier 3 FEMARA

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

leuprolide acetate Tier 1 leuprolide acetate Tier 2 ELIGARD

leuprolide acetate Tier 2 LUPRON DEPOT

Progestins

megestrol acetate tabs Tier 1

IMMUNOMODULATORS

lenalidomide Tier 3 REVLIMID

pomalidomide Tier 3 POMALYST thalidomide Tier 3 THALOMID

KINASE INHIBITORS

erlotinib Tier 1 imatinib mesylate Tier 1 bosutinib Tier 2 BOSULIF cabozantinib Tier 2 CABOMETYX

dasatinib Tier 2 SPRYCEL gefitinib Tier 2 IRESSA

13 Nippon Life Insurance Company of America® NC20016-4 (1/20)

midostaurin Tier 2 RYDAPT palbociclib Tier 2 IBRANCE

ribociclib Tier 2 KISQALI

ribociclib + letrozole Tier 2 KISQALI FEMARA CO-PACK

everolimus Tier 3 AFINITOR lapatinib Tier 3 TYKERB

pazopanib Tier 3 VOTRIENT

sunitinib Tier 3 SUTENT

TOPOISOMERASE INHIBITORS

topotecan caps Tier 3 HYCAMTIN

MISCELLANEOUS

etoposide Tier 1 tretinoin caps Tier 1 niraparib Tier 2 ZEJULA

olaparib Tier 2 LYNPARZA

rucaparib Tier 2 RUBRACA sonidegib Tier 2 ODOMZO

uridine triacetate Tier 2 VISTOGARD

bexarotene caps Tier 3 TARGRETIN hydroxyurea Tier 3 HYDREA

mitotane Tier 3 LYSODREN procarbazine Tier 3 MATULANE

vorinostat Tier 3 ZOLINZA

CARDIOVASCULAR

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org

captopril Tier 1 fosinopril Tier 1 perindopril Tier 1 trandolapril Tier 1 benazepril Tier 3 LOTENSIN

enalapril Tier 3 VASOTEC

lisinopril Tier 3 ZESTRIL quinapril Tier 3 ACCUPRIL

ramipril Tier 3 ALTACE

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/benazepril Tier 3 LOTREL

trandolapril/verapamil ext-rel Tier 3 TARKA

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ACE INHIBITOR/DIURETIC COMBINATIONS

captopril/hydrochlorothiazide Tier 1 fosinopril/hydrochlorothiazide Tier 1 benazepril/hydrochlorothiazide Tier 3 LOTENSIN HCT

enalapril/hydrochlorothiazide Tier 3 VASERETIC lisinopril/hydrochlorothiazide Tier 3 ZESTORETIC

quinapril/hydrochlorothiazide Tier 3 ACCURETIC

ADRENOLYTICS, CENTRAL

guanfacine Tier 1 clonidine Tier 3 CATAPRES clonidine transdermal Tier 3 CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 3 INSPRA spironolactone Tier 3 ALDACTONE

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

terazosin Tier 1 doxazosin Tier 3 CARDURA

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 eprosartan Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1 losartan Tier 3 COZAAR

losartan/hydrochlorothiazide Tier 3 HYZAAR

telmisartan Tier 3 MICARDIS

telmisartan/hydrochlorothiazide Tier 3 MICARDIS HCT

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1 amlodipine/olmesartan Tier 3 AZOR

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/hydrochlorothiazide Tier 1 olmesartan/amlodipine/hydrochlorothiazide Tier 3 TRIBENZOR

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ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org

amiodarone Tier 1 flecainide Tier 1 propafenone Tier 1 sotalol Tier 1 dronedarone Tier 2 MULTAQ

disopyramide Tier 3 NORPACE disopyramide ext-rel Tier 3 NORPACE CR

dofetilide Tier 3 TIKOSYN

propafenone ext-rel Tier 3 RYTHMOL SR

ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625

Bile Acid Resins

Cholesterol Absorption Inhibitors

ezetimibe Tier 1

Fibrates

* fenofibrate Tie r 1

fenofibrate Tie r 3 ANTARA fenofibrate Tie r 3 LIPOFEN

fenofibric ac id delayed-rel Tie r 3 TRILIPIX

gemfibrozil Tie r 3 LOPID

* Listing does not include fenofibrate tablet 120 mg.

HMG-CoA Reductase Inhibitors/Combinations atorvastatin Tier 1 fluvastatin Tier 1 lovastatin Tier 1 rosuvastatin Tier 1 ezetimibe/simvastatin Tier 3 VYTORIN

pravastatin Tier 3 PRAVACHOL simvastatin Tier 3 ZOCOR

Niacins

niacin ext-rel Tier 3 NIASPAN

Omega-3 Fatty Acids

icosapent ethyl Tier 2 VASCEPA omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors

evolocumab Tier 2 REPATHA

colesevelam Tier 1 cholestyramine Tier 3 QUESTRAN/QUESTRAN LIGHT

colestipol Tier 3 COLESTID

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BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol Tier 1 bisoprolol Tier 1 carvedilol phosphate ext-rel Tier 1 labetalol Tier 1 metoprolol succinate ext-rel Tier 1 pindolol Tier 1 propranolol Tier 1 nebivolol Tier 2 BYSTOLIC

carvedilol Tier 3 COREG metoprolol tartrate Tier 3 LOPRESSOR

nadolol Tier 3 CORGARD

propranolol ext-rel Tier 3 INDERAL LA

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 3 ZIAC

metoprolol/hydrochlorothiazide Tier 3 LOPRESSOR HCT

CALCIUM CHANNEL BLOCKERS Dihydropyridines

amlodipine Tier 1 felodipine ext-rel Tier 1 nifedipine ext-rel Tier 3 ADALAT CC nifedipine ext-rel Tier 3 PROCARDIA XL

Nondihydropyridines

* diltiaze m ext-rel Tie r 1 diltiaze m ext-rel Tie r 3 TIAZAC

verapam il ext-rel Tie r 3 CALAN SR

* Listing does not include generic CARDIZEM LA

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES

digoxin 0.125 mg, 0.25 mg Tier 1 digoxin ped elixir Tier 1 digoxin 0.0625 mg, 0.1875 mg Tier 3 LANOXIN

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

aliskiren Tier 1 aliskiren/hydrochlorothiazide Tier 2 TEKTURNA HCT

DIURETICS Carbonic Anhydrase Inhibitors

acetazolamide Tier 1

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acetazolamide ext-rel Tier 1 methazolamide Tier 1

Loop Diuretics bumetanide Tier 1 furosemide Tier 3 LASIX

torsemide Tier 3 DEMADEX

Potassium-sparing Diuretics

amiloride Tier 1

Thiazides and Thiazide-like Diuretics

chlorthalidone Tier 1

hydrochlorothiazide Tier 1 indapamide Tier 1

metolazone Tier 1

Diuretic Combinations

amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 3 ALDACTAZIDE

triamterene/hydrochlorothiazide Tier 3 DYAZIDE triamterene/hydrochlorothiazide Tier 3 MAXZIDE

HEART FAILURE

isosorbide dinitrate/hydralazine Tier 2 BIDIL ivabradine Tier 2 CORLANOR

sacubitril/valsartan Tier 2 ENTRESTO

NITRATES Oral

isosorbide dinitrate ext-rel tabs Tier 1 isosorbide mononitrate Tier 1 isosorbide dinitrate oral Tier 3 ISORDIL isosorbide mononitrate ext-rel Tier 3 IMDUR

Sublingual/Translingual

nitroglycerin lingual spray Tier 3 NITROLINGUAL nitroglycerin sublingual Tier 3 NITROSTAT

Transdermal

nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 3 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

ambrisentan Tier 1 bosentan Tier 1 macitentan Tier 2 OPSUMIT

Phosphodiesterase Inhibitors

tadalafil Tier 1 sildenafil Tier 3 REVATIO

Prostacyclin Receptor Agonists

selexipag Tier 2 UPTRAVI

18 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Prostaglandin Vasodilators

treprostinil ext-rel Tier 2 ORENITRAM epoprostenol sodium Tier 3 FLOLAN

Soluble Guanylate Cyclase Stimulators

riociguat Tier 2 ADEMPAS

MISCELLANEOUS

hydralazine Tier 1

methyldopa Tier 1 midodrine Tier 1

ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org

ANTIANXIETY Benzodiazepines

alprazolam Tier 1 oxazepam Tier 1 clonazepam Tier 3 KLONOPIN

diazepam Tier 3 VALIUM

lorazepam Tier 3 ATIVAN

Miscellaneous

buspirone Tier 1 fluvoxamine Tier 1 clomipramine Tier 3 ANAFRANIL

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com

carbamazepine ext-rel Tier 1 clobazam Tier 1 lamotrigine Tier 1 lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1 phenobarbital Tier 1 tiagabine Tier 1 topiramate ext-rel Tier 1 vigabatrin Tier 1 zonisamide Tier 1 lacosamide Tier 2 VIMPAT

oxcarbazepine ext-rel Tier 2 OXTELLAR XR

perampanel Tier 2 FYCOMPA topiramate ext-rel Tier 2 TROKENDI XR

carbamazepine Tier 3 TEGRETOL

carbamazepine ext-rel Tier 3 CARBATROL

diazepam rectal gel Tier 3 DIASTAT divalproex sodium delayed-rel Tier 3 DEPAKOTE

divalproex sodium ext-rel Tier 3 DEPAKOTE ER

ethosuximide Tier 3 ZARONTIN gabapentin Tier 3 NEURONTIN

levetiracetam Tier 3 KEPPRA

19 Nippon Life Insurance Company of America® NC20016-4 (1/20)

levetiracetam ext-rel Tier 3 KEPPRA XR oxcarbazepine Tier 3 TRILEPTAL

phenytoin Tier 3 DILANTIN INFATABS

phenytoin sodium extended Tier 3 DILANTIN

primidone Tier 3 MYSOLINE topiramate Tier 3 TOPAMAX

valproic acid Tier 3 DEPAKENE

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com

memantine ext-rel Tier 1 rivastigmine Tier 1 memantine/donepezil Tier 2 NAMZARIC

donepezil Tier 3 ARICEPT

galantamine Tier 3 RAZADYNE galantamine ext-rel Tier 3 RAZADYNE ER

memantine Tier 3 NAMENDA

rivastigmine transdermal Tier 3 EXELON

ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.

Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org

Monoamine Oxidase Inhibitors (MAOIs)

Selective Serotonin Reuptake Inhibitors (SSRIs)

escitalopram Tier 1 fluoxetine Tier 1 vilazodone Tier 2 VIIBRYD

vortioxetine Tier 2 TRINTELLIX

citalopram Tier 3 CELEXA paroxetine HCl Tier 3 PAXIL

paroxetine HCl ext-rel Tier 3 PAXIL CR

sertraline Tier 3 ZOLOFT

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine ext-rel Tier 1

duloxetine delayed-rel Tier 1 venlafaxine Tier 1

venlafaxine ext-rel Tier 1

Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1 doxepin Tier 1 desipramine Tier 3 NORPRAMIN

imipramine HCl Tier 3 TOFRANIL

nortriptyline Tier 3 PAMELOR

phenelzine Tier 3 NARDIL

tranylcypromine Tier 3 PARNATE

20 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Miscellaneous Agents

bupropion Tier 1 trazodone Tier 1 bupropion ext-rel Tier 3 WELLBUTRIN SR

bupropion ext-rel Tier 3 WELLBUTRIN XL mirtazapine Tier 3 REMERON

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com

amantadine Tier 1 benztropine Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 pramipexole ext-rel Tier 1 rasagiline Tier 1 ropinirole Tier 1 selegiline Tier 1 trihexyphenidyl Tier 1 rotigotine transdermal Tier 2 NEUPRO bromocriptine Tier 3 PARLODEL

carbidopa/levodopa Tier 3 SINEMET

carbidopa/levodopa ext-rel Tier 3 SINEMET CR

carbidopa/levodopa/entacapone Tier 3 STALEVO entacapone Tier 3 COMTAN

pramipexole Tier 3 MIRAPEX

ropinirole ext-rel Tier 3 REQUIP XL

ANTIPSYCHOTICS Atypicals

aripiprazole Tier 1 quetiapine ext-rel Tier 1 aripiprazole ext-rel inj Tier 2 ABILIFY MAINTENA aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA

aripiprazole lauroxil ext-rel inj Tier 2 ARISTADA INITIO cariprazine Tier 2 VRAYLAR

lurasidone Tier 2 LATUDA clozapine Tier 3 CLOZARIL

olanzapine Tier 3 ZYPREXA

quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL

risperidone long-acting injection Tier 3 RISPERDAL CONSTA

ziprasidone Tier 3 GEODON

Miscellaneous

chlorpromazine Tier 1 fluphenazine Tier 1

haloperidol Tier 1

perphenazine Tier 1 thiothixene Tier 1

trifluoperazine Tier 1

21 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org

amphetamine/dextroamphetamine mixed salts Tier 1 amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 dextroamphetamine Tier 1 guanfacine ext-rel Tier 1 methylphenidate ext-rel Tier 1 amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS

lisdexamfetamine Tier 2 VYVANSE

atomoxetine Tier 3 STRATTERA

dexmethylphenidate Tier 3 FOCALIN dexmethylphenidate ext-rel Tier 3 FOCALIN XR

dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE

methylphenidate Tier 3 METHYLIN methylphenidate Tier 3 RITALIN

methylphenidate ext-rel Tier 3 CONCERTA

FIBROMYALGIA

pregabalin Tier 2 LYRICA

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org

Benzodiazepines

Nonbenzodiazepines

eszopiclone Tier 1 zolpidem sublingual Tier 1 suvorexant Tier 2 BELSOMRA zolpidem Tier 3 AMBIEN

zolpidem ext-rel Tier 3 AMBIEN CR

Tricyclics

doxepin Tier 2 SILENOR

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com

Ergotamine Derivatives

Monoclonal Antibodies

erenumab-aooe Tier 2 AIMOVIG fremanezumab-vfrm Tier 2 AJOVY

galcanezumab-gnlm Tier 2 EMGALITY

Selective Serotonin Agonists

naratriptan Tier 1

temazepam Tier 3 RESTORIL

ergotamine/caffeine Tier 1 dihydroergotamine inj Tier 3 D.H.E. 45

22 Nippon Life Insurance Company of America® NC20016-4 (1/20)

sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH sumatriptan nasal powder Tier 2 ONZETRA XSAIL

zolmitriptan nasal spray Tier 2 ZOMIG

eletriptan Tier 3 RELPAX

rizatriptan Tier 3 MAXALT sumatriptan Tier 3 IMITREX

sumatriptan inj Tier 3 IMITREX

sumatriptan nasal spray Tier 3 IMITREX zolmitriptan Tier 3 ZOMIG

Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations

sumatriptan/naproxen sodium Tier 2 TREXIMET

MOOD STABILIZERS

lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 3 LITHOBID

MOVEMENT DISORDERS

tetrabenazine Tier 1 deutetrabenazine Tier 2 AUSTEDO valbenazine Tier 2 INGREZZA

MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com

dimethyl fumarate delayed-rel Tier 2 TECFIDERA fingolimod Tier 2 GILENYA

glatiramer Tier 2 COPAXONE interferon beta-1a Tier 2 REBIF

interferon beta-1b Tier 2 BETASERON

natalizumab Tier 2 TYSABRI siponimod Tier 2 MAYZENT

teriflunomide Tier 2 AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS

baclofen Tier 1 carisoprodol Tier 1 chlorzoxazone Tier 1 cyclobenzaprine Tier 1 orphenadrine/aspirin/caffeine Tier 1 dantrolene Tier 3 DANTRIUM metaxalone Tier 3 SKELAXIN

methocarbamol Tier 3 ROBAXIN

tizanidine tabs Tier 3 ZANAFLEX

MYASTHENIA GRAVIS

pyridostigmine Tier 1 pyridostigmine ext-rel Tier 1

NARCOLEPSY

armodafinil Tier 1 solriamfetol Tier 2 SUNOSI

23 Nippon Life Insurance Company of America® NC20016-4 (1/20)

POSTHERPETIC NEURALGIA (PHN)

gabapentin ext-rel Tier 2 GRALISE

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents

acamprosate calcium Tier 3 CAMPRAL disulfiram Tier 3 ANTABUSE

Opioid Antagonists

naloxone inj Tier 1 naltrexone Tier 1 naloxone nasal spray Tier 2 NARCAN

Partial Opioid Agonist/Opioid Antagonist Combinations

buprenorphine/naloxone sublingual Tier 1 buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV

Pseudobulbar Affect Agents

dextromethorphan/quinidine Tier 2 NUEDEXTA

Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

bupropion ext-rel Tier 3 ZYBAN varenicline Tier 3 CHANTIX

Vasomotor Symptom Agents

paroxetine mesylate Tier 1

ENDOCRINE AND METABOLIC

ACROMEGALY

lanreotide acetate Tier 2 SOMATULINE DEPOT pegvisomant Tier 2 SOMAVERT

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com

testosterone cypionate Tier 1 testosterone enanthate Tier 1 testosterone gel Tier 1 testosterone soln Tier 1 testosterone transdermal Tier 2 ANDRODERM

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org

Alpha-glucosidase Inhibitors

Amylin Analogs

pramlintide Tier 2 SYMLINPEN

acarbose Tier 3 PRECOSE

24 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Biguanides

metformin Tier 3 GLUCOPHAGE metformin ext-rel Tier 3 GLUCOPHAGE XR

Biguanide/Sulfonylurea Combinations

glipizide/metformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

sitagliptin/metformin Tier 2 JANUMET

sitagliptin/metformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents

dulaglutide Tier 2 TRULICITY liraglutide Tier 2 VICTOZA semaglutide Tier 2 OZEMPIC

Incretin Mimetic Agent/Insulin Combinations

liraglutide/insulin degludec Tier 2 XULTOPHY lixisenatide/insulin glargine Tier 2 SOLIQUA

Insulins

insulin aspart Tier 2 FIASP

insulin aspart Tier 2 NOVOLOG

insulin aspart protamine 70%/insulin aspart 30% Tier 2 NOVOLOG MIX 70/30

insulin degludec Tier 2 TRESIBA

insulin detemir Tier 2 LEVEMIR

insulin glargine Tier 2 BASAGLAR

insulin human Tier 2 HUMULIN R U-500

OTC insulin human Tier 2 NOVOLIN R

OTC insulin isophane human Tier 2 NOVOLIN N OTC insulin isophane human 70%/regular 30% Tier 2 NOVOLIN 70/30

Insulin Sensitizers

pioglitazone Tier 1

Insulin Sensitizer/Biguanide Combinations

pioglitazone/metformin Tier 3 ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations

pioglitazone/glimepiride Tier 3 DUETACT

Meglitinides

nateglinide Tier 1 repaglinide Tier 3 PRANDIN

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors dapagliflozin Tier 2 FARXIGA

empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations

dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR empagliflozin/metformin Tier 2 SYNJARDY empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR

25 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

empagliflozin/linagliptin Tier 2 GLYXAMBI

Sulfonylureas

glyburide Tier 1 glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL

glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies

blood glucose continuous monitoring receivers, sensors, transmitters

Tier 2 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK AVIVA PLUS kits and test strips

blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK COMPACT PLUS kits and test strips

blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK GUIDE kits and test strips

blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK SMARTVIEW kits and test strips

insulin infusion disposable pump Tier 2 OMNIPOD INSULIN INFUSION PUMP

insulin infusion disposable pump Tier 2 V-GO INSULIN INFUSION PUMP

OTC insulin syringes, needles Tier 2 BD ULTRAFINE insulin syringes and needles

ANTIOBESITY Guidelines of treatment and management of obesity are available at: https://www.aace.com https://www.nhlbi.nih.gov/health-topics/managing-overweight-obesity-in-adults

Injectable

Oral

lorcaserin Tier 2 BELVIQ lorcaserin ext-rel Tier 2 BELVIQ XR

CALCIUM RECEPTOR ANTAGONISTS

cinacalcet Tier 2 SENSIPAR

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org

Bisphosphonates

alendronate Tier 3 FOSAMAX ibandronate Tier 3 BONIVA

risedronate Tier 3 ACTONEL

risedronate delayed-rel Tier 3 ATELVIA

Calcitonins

calcitonin-salmon spray Tier 1

liraglutide Tier 2 SAXENDA

26 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Parathyroid Hormones

abaloparatide Tier 2 TYMLOS teriparatide Tier 2 FORTEO

Miscellaneous

denosumab Tier 2 PROLIA

CARNITINE DEFICIENCY AGENTS

levocarnitine Tier 1

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen

drospirenone/EE 3/20 Tier 1 drospirenone/EE/levomefolate 3/20 and levomefolate Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1 norethindrone acetate/EE 1/20 and iron chewable Tier 1 norethindrone acetate/EE 1/20 Tier 3 LOESTRIN 1/20

norethindrone acetate/EE 1/20 and iron Tier 3 LOESTRIN FE 1/20

30 mcg Estrogen desogestrel/EE 0.15/30 Tier 1 drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1 norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 drospirenone/EE 3/30 Tier 3 YASMIN

norethindrone acetate/EE 1.5/30 Tier 3 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron Tier 3 LOESTRIN FE 1.5/30

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 norethindrone/EE 0.5/35 Tier 1 norethindrone/EE 1/35 Tier 1 norgestimate/EE 0.25/35 Tier 1 norethindrone/EE 1/35 Tier 3 ORTHO-NOVUM 1/35

Biphasic

desogestrel/EE Tier 3 MIRCETTE

Triphasic

desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1 norgestimate/EE Tier 1 norethindrone/EE Tier 3 ORTHO-NOVUM 7/7/7

Extended Cycle

levonorgestrel/EE 0.15/30 Tier 1 levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE

levonorgestrel/EE 0.15/30 and EE 10 Tier 3 SEASONIQUE

Progestin Only

norethindrone Tier 1 norethindrone Tier 3 ORTHO MICRONOR

27 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Injectable

medroxyprogesterone acetate 150 mg/mL Tier 3 DEPO-PROVERA

Progestin Intrauterine Devices

levonorgestrel releasing IUD Tier 2 KYLEENA

levonorgestrel releasing IUD Tier 2 MIRENA

levonorgestrel releasing IUD Tier 2 SKYLA

Transdermal

norelgestromin/EE Tier 1

Vaginal

etonogestrel/EE ring Tier 2 NUVARING

ENDOMETRIOSIS

danazol Tier 1 elagolix Tier 2 ORILISSA

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf

Oral

estrogens, conjugated Tier 2 PREMARIN estradiol Tier 3 ESTRACE

Transdermal

estradiol Tier 1 estradiol Tier 2 DIVIGEL

estradiol Tier 2 EVAMIST

estradiol Tier 3 CLIMARA

Vaginal

estradiol vaginal crm Tier 1 estradiol vaginal ring Tier 2 ESTRING

estrogens, conjugated crm Tier 2 PREMARIN

estradiol vaginal tabs Tier 3 VAGIFEM

ESTROGEN/PROGESTINS Oral

EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone Tier 1 estrogens, conjugated/medroxyprogesterone Tier 2 PREMPHASE

estrogens, conjugated/medroxyprogesterone Tier 2 PREMPRO

Transdermal

estradiol/levonorgestrel Tier 2 CLIMARA PRO estradiol/norethindrone acetate Tier 2 COMBIPATCH

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

conjugated estrogens/bazedoxifene Tier 2 DUAVEE

FERTILITY REGULATORS GNRH/LHRH Antagonists

ganirelix acetate Tier 1

28 Nippon Life Insurance Company of America® NC20016-4 (1/20)

cetrorelix Tier 2 CETROTIDE

Ovulation Stimulants, Gonadotropins

choriogonadotropin alfa Tier 2 OVIDREL follitropin alfa Tier 2 GONAL-F

Ovulation Stimulants, Synthetic

clomiphene Tier 1

GAUCHER DISEASE

eliglustat Tier 2 CERDELGA

imiglucerase Tier 2 CEREZYME

GLUCOCORTICOIDS

dexamethasone Tier 1 fludrocortisone Tier 1 prednisolone Tier 1 prednisone Tier 1 hydrocortisone Tier 3 CORTEF

methylprednisolone Tier 3 MEDROL

GLUCOSE ELEVATING AGENTS

glucagon, human recombinant Tier 2 GLUCAGEN HYPOKIT glucagon, human recombinant Tier 2 GLUCAGON EMERGENCY KIT

HEREDITARY TYROSINEMIA TYPE 1 AGENTS

nitisinone Tier 2 ORFADIN

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines

somatropin Tier 2 GENOTROPIN somatropin Tier 2 HUMATROPE

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol (1,25-D3) Tier 3 ROCALTROL doxercalciferol Tier 3 HECTOROL

paricalcitol Tier 3 ZEMPLAR

PHENYLKETONURIA TREATMENT AGENTS

sapropterin Tier 3 KUVAN

PHOSPHATE BINDER AGENTS

calcium acetate Tier 1 lanthanum carbonate Tier 1 sevelamer carbonate Tier 1 calcium acetate Tier 2 PHOSLYRA sucroferric oxyhydroxide Tier 2 VELPHORO

POTASSIUM-REMOVING AGENTS

patiromer sorbitex Tier 2 VELTASSA sodium zirconium cyclosilicate Tier 2 LOKELMA

29 Nippon Life Insurance Company of America® NC20016-4 (1/20)

PROGESTINS Oral

medroxyprogesterone acetate Tier 3 PROVERA megestrol acetate susp Tier 3 MEGACE ES norethindrone acetate Tier 3 AYGESTIN

progesterone, micronized Tier 3 PROMETRIUM

Vaginal

progesterone gel Tier 2 CRINONE progesterone vaginal inserts Tier 2 ENDOMETRIN

SELECTIVE ESTROGEN RECEPTOR MODULATORS

ospemifene Tier 2 OSPHENA

raloxifene Tier 3 EVISTA

THYROID AGENTS Antithyroid Agents

propylthiouracil Tier 1 methimazole Tier 3 TAPAZOLE

Thyroid Supplements

levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1 levothyroxine Tier 2 SYNTHROID

liothyronine Tier 3 CYTOMEL

VASOPRESSINS

desmopressin spray, tabs Tier 3 DDAVP

MISCELLANEOUS

cabergoline Tier 1

GASTROINTESTINAL

Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org

ANTIDIARRHEALS

loperamide Tier 1 diphenoxylate/atropine Tier 3 LOMOTIL

ANTIEMETICS

doxylamine/pyridoxine delayed-rel Tier 1 granisetron Tier 1 meclizine Tier 1 prochlorperazine Tier 1 promethazine Tier 1 scopolamine transdermal Tier 1 granisetron transdermal Tier 2 SANCUSO rolapitant Tier 2 VARUBI

dronabinol Tier 3 MARINOL

metoclopramide Tier 3 REGLAN

ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

30 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTISPASMODICS

hyoscyamine sulfate ext-rel caps Tier 1 hyoscyamine sulfate orally disintegrating tabs Tier 1 dicyclomine Tier 3 BENTYL

hyoscyamine sulfate Tier 3 LEVSIN hyoscyamine sulfate ext-rel Tier 3 LEVBID

CHOLELITHOLYTICS

ursodiol Tier 3 ACTIGALL ursodiol Tier 3 URSO

H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 famotidine Tier 3 PEPCID ranitidine Tier 3 ZANTAC

INFLAMMATORY BOWEL DISEASE Oral Agents

balsalazide Tier 1 budesonide delayed-rel caps Tier 1 budesonide ext-rel Tier 1 mesalamine delayed-rel tabs Tier 1 mesalamine ext-rel caps Tier 2 APRISO

mesalamine ext-rel caps Tier 2 PENTASA sulfasalazine Tier 3 AZULFIDINE

sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS

Rectal Agents

hydrocortisone enema Tier 1 mesalamine supp Tier 1 hydrocortisone acetate foam Tier 2 CORTIFOAM

mesalamine susp Tier 3 ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation

linaclotide Tier 2 LINZESS lubiprostone Tier 2 AMITIZA

Irritable Bowel Syndrome with Diarrhea

alosetron Tier 1 eluxadoline Tier 2 VIBERZI

LAXATIVES

lactulose soln Tier 1 sodium sulfate/potassium sulfate/magnesium sulfate Tier 2 SUPREP

peg 3350/electrolytes Tier 3 GOLYTELY peg 3350/electrolytes Tier 3 NULYTELY

OPIOID-INDUCED CONSTIPATION

naldemedine Tier 2 SYMPROIC naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES

pancrelipase Tier 2 VIOKACE pancrelipase delayed-rel Tier 2 CREON

pancrelipase delayed-rel Tier 2 ZENPEP

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PROSTAGLANDINS

misoprostol Tier 3 CYTOTEC

PROTON PUMP INHIBITORS

esomeprazole delayed-rel Tier 1 lansoprazole delayed-rel Tier 1 pantoprazole delayed-rel Tier 1 dexlansoprazole delayed-rel Tier 2 DEXILANT

omeprazole delayed-rel Tier 3 PRILOSEC

SALIVA STIMULANTS

cevimeline Tier 3 EVOXAC

pilocarpine tabs Tier 3 SALAGEN

STEROIDS, RECTAL

hydrocortisone acetate/pramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 3 ANUSOL-HC

ULCER THERAPY COMBINATIONS

lansoprazole + amoxicillin + clarithromycin Tier 1 bismuth/metronidazole/tetracycline Tier 2 PYLERA

MISCELLANEOUS

sucralfate Tier 1

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines

alfuzosin ext-rel Tier 1 dutasteride/tamsulosin Tier 1 silodosin Tier 1 dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR

tamsulosin Tier 3 FLOMAX

ERECTILE DYSFUNCTION Guidelines for the management of erectile dysfunction are available at: https://www.auanet.org/guidelines

Alprostadil Agents

Phosphodiesterase Inhibitors

sildenafil Tier 1 tadalafil Tier 1

URINARY ANTISPASMODICS

darifenacin ext-rel Tier 1 oxybutynin Tier 1 solifenacin Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 fesoterodine ext-rel Tier 2 TOVIAZ

alprostadil supp Tier 2 MUSE

32 Nippon Life Insurance Company of America® NC20016-4 (1/20)

mirabegron ext-rel Tier 2 MYRBETRIQ oxybutynin ext-rel Tier 3 DITROPAN XL

tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES terconazole Tier 1 clindamycin crm Tier 3 CLEOCIN

metronidazole Tier 3 METROGEL-VAGINAL

MISCELLANEOUS

bethanechol Tier 3 URECHOLINE potassium citrate ext-rel Tier 3 UROCIT-K

HEMATOLOGIC

Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org

ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular

Injectable

Oral

warfarin Tier 1 apixaban Tier 2 ELIQUIS

rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents

fondaparinux Tier 3 ARIXTRA

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org

Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines

darbepoetin alfa Tier 2 ARANESP epoetin alfa-epbx Tier 2 RETACRIT filgrastim-aafi Tier 2 NIVESTYM

pegfilgrastim Tier 2 NEULASTA

pegfilgrastim-cbqv Tier 2 UDENYCA

HEMOPHILIA A AGENTS

antihemophilic factor (recombinant) Tier 2 KOGENATE FS antihemophilic factor (recombinant) Tier 2 KOVALTRY

antihemophilic factor (recombinant) Tier 2 NOVOEIGHT

antihemophilic factor (recombinant) pegylated Tier 2 ADYNOVATE antihemophilic factor (recombinant) pegylated-aucl Tier 2 JIVI

human coagulation factor VIII (rDNA) simoctocog alfa Tier 2 NUWIQ

dalteparin Tier 3 FRAGMIN

enoxaparin Tier 3 LOVENOX

33 Nippon Life Insurance Company of America® NC20016-4 (1/20)

HEMOPHILIA B AGENTS

coagulation factor IX (recombinant) glycopegylated Tier 2 REBINYN

HEREDITARY ANGIOEDEMA

C1 esterase inhibitor, recombinant Tier 2 RUCONEST

icatibant Tier 2 FIRAZYR

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS

eltrombopag Tier 3 PROMACTA

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS

eculizumab Tier 3 SOLIRIS

PLATELET AGGREGATION INHIBITORS

clopidogrel Tier 1 dipyridamole Tier 1 prasugrel Tier 1 ticagrelor Tier 2 BRILINTA

dipyridamole ext-rel/aspirin Tier 3 AGGRENOX

PLATELET SYNTHESIS INHIBITORS

anagrelide Tier 3 AGRYLIN

STEM CELL MOBILIZERS

plerixafor Tier 3 MOZOBIL

THROMBOCYTOPENIA AGENTS

lusutrombopag Tier 2 MULPLETA

MISCELLANEOUS

cilostazol Tier 1

IMMUNOLOGIC AGENTS

Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org

ALLERGENIC EXTRACTS

AUTOIMMUNE AGENTS ‡

adalimumab Tier 2 HUMIRA apremilast Tier 2 OTEZLA

etanercept Tier 2 ENBREL

guselkumab Tier 2 TREMFYA risankizumab-rzaa Tier 2 SKYRIZI

secukinumab Tier 2 COSENTYX

tofacitinib Tier 2 XELJANZ

tofacitinib ext-rel Tier 2 XELJANZ XR upadacitinib Tier 2 RINVOQ

ustekinumab Tier 2 STELARA SUBCUTANEOUS

‡ Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis)

grass mixed pollen allergen extract Tier 2 ORALAIR ragweed pollen allergen extract Tier 2 RAGWITEK

timothy grass pollen allergen extract Tier 2 GRASTEK

34 Nippon Life Insurance Company of America® NC20016-4 (1/20)

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

methotrexate Tier 1 methotrexate auto-injector Tier 2 RASUVO

hydroxychloroquine Tier 3 PLAQUENIL

leflunomide Tier 3 ARAVA

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of hepatitis are available at: https://www.aasld.org

Interferons

Miscellaneous

canakinumab Tier 3 ILARIS

IMMUNOSUPPRESSANTS Antimetabolites

mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 3 AZASAN

azathioprine Tier 3 IMURAN

Calcineurin Inhibitors

cyclosporine Tier 1 cyclosporine, modified Tier 1

tacrolimus Tier 1

Rapamycin Derivatives

sirolimus Tier 1

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES Potassium

potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1

VITAMINS AND MINERALS Folic Acid/Combinations

folic acid Tier 1 folic acid/vitamin B6/vitamin B12 Tier 1

Prenatal Vitamins

prenatal vitamins Tier 1 prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL 90 DHA

prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL DHA

prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL HARMONY prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX

prenatal vitamins/docusate/folic acid + DHA Tier 2 CITRANATAL ASSURE

prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM

interferon alfa-2b Tier 3 INTRON A

peginterferon alfa-2a Tier 3 PEGASYS peginterferon alfa-2b Tier 3 SYLATRON

35 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Miscellaneous

cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1

fluoride drops Tier 1

fluoride tabs Tier 1 multivitamins/fluoride drops, tabs Tier 1

multivitamins/fluoride/iron drops, tabs Tier 1

vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1

RESPIRATORY

Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov

The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org

ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector Tier 1 epinephrine auto-injector Tier 2 EPIPEN

epinephrine auto-injector Tier 2 EPIPEN JR.

ANTICHOLINERGICS

ipratropium soln Tier 1 tiotropium Tier 2 SPIRIVA

umeclidinium bromide Tier 2 INCRUSE ELLIPTA

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting

ipratropium/albuterol soln Tier 1

Long Acting

glycopyrrolate/formoterol Tier 2 BEVESPI AEROSPHERE tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT

umeclidinium/vilanterol Tier 2 ANORO ELLIPTA

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS

fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES, LOW SEDATING

levocetirizine Tier 1

ANTIHISTAMINES, SEDATING

clemastine 2.68 mg Tier 1 cyproheptadine Tier 1

hydroxyzine HCl Tier 1

36 Nippon Life Insurance Company of America® NC20016-4 (1/20)

ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf

* benzonatate Tier 3 TESSALON

* Listing does not include NDCs 69336012615 and 69499032915. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTITUSSIVE COMBINATIONS Opioid

codeine/guaifenesin liquid Tier 1

codeine/guaifenesin/pseudoephedrine Tier 1

codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1

hydrocodone/homatropine Tier 1

Non-opioid

dextromethorphan/brompheniramine/pseudoephedrine Tier 1 dextromethorphan/promethazine Tier 1

BETA AGONISTS Inhalants Short Acting

albuterol soln Tier 1 albuterol sulfate, CFC-free aerosol Tier 1

levalbuterol tartrate, CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation

olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT

salmeterol xinafoate Tier 2 SEREVENT

Nebulized Passive Inhalation

formoterol inhalation soln Tier 2 PERFOROMIST

Oral Agents

albuterol Tier 1

albuterol ext-rel Tier 1 terbutaline Tier 1

CYSTIC FIBROSIS

tobramycin inhalation soln Tier 1 tobramycin inhalation soln Tier 2 BETHKIS

dornase alfa Tier 3 PULMOZYME

LEUKOTRIENE MODULATORS

montelukast Tier 1 zafirlukast Tier 1 zileuton ext-rel Tier 1

MAST CELL STABILIZERS

cromolyn soln Tier 1

37 Nippon Life Insurance Company of America® NC20016-4 (1/20)

NASAL ANTIHISTAMINES

azelastine spray Tier 1 azelastine spray Tier 3 ASTEPRO

olopatadine spray Tier 3 PATANASE

NASAL STEROIDS/COMBINATIONS

flunisolide spray Tier 1 fluticasone spray Tier 1 mometasone spray Tier 1 triamcinolone acetonide spray Tier 1 azelastine/fluticasone spray Tier 2 DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast Tier 2 DALIRESP

PULMONARY ENZYME DEFICIENCY AGENTS

alpha-1 proteinase inhibitor Tier 2 PROLASTIN-C

PULMONARY FIBROSIS AGENTS

nintedanib Tier 2 OFEV pirfenidone Tier 2 ESBRIET

SEVERE ASTHMA AGENTS

benralizumab Tier 2 FASENRA

dupilumab Tier 2 DUPIXENT

mepolizumab Tier 2 NUCALA

omalizumab Tier 2 XOLAIR

STEROID/BETA AGONIST COMBINATIONS

fluticasone/salmeterol Tier 1 ADVAIR DISKUS budesonide/formoterol Tier 2 SYMBICORT fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA

fluticasone/vilanterol Tier 2 BREO ELLIPTA

STEROID INHALANTS

beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER budesonide Tier 2 PULMICORT FLEXHALER

fluticasone Tier 2 ARNUITY ELLIPTA

fluticasone Tier 2 FLOVENT DISKUS

fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA budesonide inhalation susp Tier 3 PULMICORT RESPULES

XANTHINES

theophylline ext-rel tabs Tier 1

MISCELLANEOUS

ipratropium spray Tier 1

TOPICAL

DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Oral

isotretinoin Tier 1

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Topical adapalene Tier 1 clindamycin gel Tier 1 clindamycin/benzoyl peroxide Tier 1 erythromycin gel 2% Tier 1 erythromycin soln Tier 1 tretinoin Tier 1 tretinoin - Avita Tier 1 tretinoin gel microsphere Tier 1 adapalene/benzoyl peroxide Tier 2 EPIDUO

adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE tazarotene Tier 2 TAZORAC

benzoyl peroxide Tier 3 BENZAC AC

clindamycin gel, lotion, soln Tier 3 CLEOCIN T clindamycin/benzoyl peroxide Tier 3 DUAC

erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN

sulfacetamide lotion 10% Tier 3 KLARON

tretinoin Tier 3 RETIN-A

Actinic Keratosis

fluorouracil crm 5%, soln 5%, soln 2% Tier 1 fluorouracil crm 4% Tier 2 TOLAK

imiquimod Tier 2 ZYCLARA

ingenol mebutate Tier 2 PICATO

Antibiotics

gentamicin Tier 1 mupirocin oint Tier 1 silver sulfadiazine Tier 3 SILVADENE

Antifungals

clotrimazole Tier 1 econazole Tier 1 ketoconazole Tier 1 luliconazole Tier 1 nystatin Tier 1 naftifine Tier 2 NAFTIN ciclopirox Tier 3 LOPROX

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org

Oral

acitretin Tier 3 SORIATANE

methoxsalen oral Tier 3 OXSORALEN-ULTRA

Topical

calcipotriene oint, soln 0.005% Tier 1

Antiseborrheics

selenium sulfide shampoo 2.5% Tier 1 ketoconazole shampoo 2% Tier 3 NIZORAL

39 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Injectable

dupilumab Tier 2 DUPIXENT

Topical

pimecrolimus Tier 1 tacrolimus Tier 1 crisaborole Tier 2 EUCRISA

Corticosteroids Low Potency

alclometasone crm, oint 0.05% Tier 1 fluocinolone acetonide soln 0.01% Tier 1 hydrocortisone crm 2.5% Tier 1 hydrocortisone lotion 1% Tier 1 desonide crm, lotion, oint 0.05% Tier 3 DESOWEN

Medium Potency

betamethasone valerate crm, lotion, oint 0.1% Tier 1 desoximetasone crm, oint 0.05% Tier 1 fluocinolone acetonide crm, oint 0.025% Tier 1 hydrocortisone butyrate crm, oint, soln 0.1% Tier 1 hydrocortisone valerate crm, oint 0.2% Tier 1 triamcinolone acetonide crm, lotion 0.025% Tier 1 triamcinolone acetonide crm, lotion, oint 0.1% Tier 1 fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 3 CUTIVATE mometasone crm, lotion, oint 0.1% Tier 3 ELOCON

High Potency betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 desoximetasone crm, oint 0.25%, gel 0.05% Tier 1 fluocinonide crm, gel, oint, soln 0.05% Tier 1 triamcinolone acetonide crm 0.5% Tier 1 betamethasone dipropionate augmented crm 0.05% Tier 3 DIPROLENE AF

betamethasone dipropionate augmented lotion 0.05% Tier 3 DIPROLENE

Very High Potency

clobetasol propionate foam 0.05% Tier 1 betamethasone dipropionate augmented gel, oint 0.05% Tier 3 DIPROLENE clobetasol propionate crm, gel, oint, soln 0.05% Tier 3 TEMOVATE

clobetasol propionate lotion, shampoo 0.05% Tier 3 CLOBEX

halobetasol propionate crm, oint 0.05% Tier 3 ULTRAVATE

Emollients

ammonium lactate 12% Tier 3 LAC-HYDRIN

Local Analgesics

lidocaine patch Tier 3 LIDODERM

Local Anesthetics

lidocaine/prilocaine Tier 1

40 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Rosacea

azelaic acid gel Tier 1 doxycycline monohydrate delayed-rel caps Tier 1 metronidazole gel 0.75% Tier 1 azelaic acid foam Tier 2 FINACEA FOAM ivermectin Tier 2 SOOLANTRA

metronidazole crm 0.75% Tier 3 METROCREAM

metronidazole gel 1% Tier 3 METROGEL metronidazole lotion 0.75% Tier 3 METROLOTION

Scabicides and Pediculicides permethrin 5% Tier 1 malathion Tier 3 OVIDE

Miscellaneous Skin and Mucous Membrane

imiquimod Tier 3 ALDARA podofilox Tier 3 CONDYLOX

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral

lidocaine viscous Tier 1

Protectants - Mouth/Throat

benzyl alcohol/carbomer 941/glycerin Tier 2 MUGARD

soy phospholipid/glycerol dioleate Tier 2 EPISIL

Steroids - Mouth/Throat

triamcinolone paste Tier 1

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org

Antiallergics

Anti-infectives

bacitracin Tier 1 erythromycin Tier 1 gentamicin Tier 1 levofloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1 polymyxin B/bacitracin Tier 1 sulfacetamide oint 10% Tier 1 besifloxacin Tier 2 BESIVANCE

ciprofloxacin oint Tier 2 CILOXAN

moxifloxacin Tier 2 MOXEZA ciprofloxacin soln Tier 3 CILOXAN

moxifloxacin Tier 3 VIGAMOX

ofloxacin Tier 3 OCUFLOX polymyxin B/trimethoprim Tier 3 POLYTRIM

azelastine Tier 1 cromolyn sodium Tier 1 alcaftadine Tier 2 LASTACAFT

olopatadine Tier 2 PAZEO olopatadine Tier 3 PATADAY

olopatadine Tier 3 PATANOL

41 Nippon Life Insurance Company of America® NC20016-4 (1/20)

sulfacetamide soln 10% Tier 3 BLEPH-10 tobramycin Tier 3 TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint Tier 1 neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone oint 0.3%/0.1% Tier 2 TOBRADEX tobramycin/dexamethasone susp 0.3%/0.05% Tier 2 TOBRADEX ST

neomycin/polymyxin B/dexamethasone Tier 3 MAXITROL

tobramycin/dexamethasone susp 0.3%/0.1% Tier 3 TOBRADEX

Anti-inflammatories Nonsteroidal

bromfenac sodium Tier 1 diclofenac sodium Tier 1 ketorolac tromethamine Tier 2 ACUVAIL nepafenac Tier 2 ILEVRO

nepafenac Tier 2 NEVANAC

ketorolac Tier 3 ACULAR

Steroidal

dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 loteprednol Tier 1 prednisolone acetate 1% Tier 1 dexamethasone Tier 2 MAXIDEX difluprednate Tier 2 DUREZOL

fluorometholone Tier 2 FML FORTE

fluorometholone Tier 2 FML S.O.P. prednisolone acetate Tier 2 PRED MILD

prednisolone phosphate 1% Tier 3

Antivirals

trifluridine Tier 1

Beta-blockers Nonselective

levobunolol Tier 1 timolol maleate gel Tier 1 timolol hemihydrate Tier 2 BETIMOL

timolol maleate Tier 3 TIMOPTIC

Selective

betaxolol Tier 2 BETOPTIC S

Carbonic Anhydrase Inhibitors Topical

brinzolamide Tier 2 AZOPT dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations

dorzolamide/timolol maleate Tier 3 COSOPT

Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations

brinzolamide/brimonidine Tier 2 SIMBRINZA

42 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Dry Eye Disease

cyclosporine, emulsion Tier 2 RESTASIS

lifitegrast Tier 2 XIIDRA

Prostaglandins

bimatoprost Tier 2 LUMIGAN travoprost Tier 2 TRAVATAN Z

latanoprost Tier 3 XALATAN

Retinal Disorders

aflibercept Tier 2 EYLEA

ranibizumab Tier 2 LUCENTIS

Rho Kinase Inhibitors

netarsudil Tier 2 RHOPRESSA

Rho Kinase Inhibitor/Prostaglandin Combinations

netarsudil/latanoprost Tier 2 ROCKLATAN

Sympathomimetics

brimonidine 0.2% Tier 1 brimonidine Tier 2 ALPHAGAN P

Sympathomimetic/Beta-blocker Combinations

brimonidine/timolol Tier 2 COMBIGAN

OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org

Anti-infectives

Anti-infective/Anti-inflammatory Combinations

ciprofloxacin/dexamethasone Tier 2 CIPRODEX neomycin/polymyxin B/hydrocortisone Tier 3 CORTISPORIN OTIC

acetic acid Tier 1 ofloxacin otic Tier 1

43 Nippon Life Insurance Company of America® NC20016-4 (1/20)

WEBSITES

Agency for Healthcare Research and Quality https://www.ahrq.gov

Alzheimer's Association https://www.alz.org

American Academy of Allergy, Asthma and Immunology https://www.aaaai.org

American Academy of Child & Adolescent Psychiatry https://www.aacap.org

American Academy of Dermatology https://www.aad.org

American Academy of Neurology https://www.aan.com

American Academy of Ophthalmology https://www.aao.org

American Academy of Pediatrics https://www.aap.org

American Association for the Study of Liver Disease https://www.aasld.org

American Association of Clinical Endocrinologists https://www.aace.com

American Association of Diabetes Educators https://www.diabeteseducator.org

American Cancer Society https://www.cancer.org

American College of Allergy, Asthma and Immunology https://www.acaai.org

American College of Cardiology https://www.acc.org

American College of Chest Physicians https://www.chestnet.org

American College of Gastroenterology https://gi.org

American College of Physicians https://www.acponline.org

American College of Rheumatology https://www.rheumatology.org

American Congress of Obstetricians and Gynecologists https://www.acog.org

American Diabetes Association http://www.diabetes.org

American Gastroenterological Association https://www.gastro.org

American Headache Society Committee for Headache Education https://americanheadachesociety.org

American Heart Association https://professional.heart.org

American Lung Association https://www.lung.org

American Medical Association https://www.ama-assn.org

American Psychiatric Association https://www.psychiatry.org

American Society of Anesthesiologists https://www.asahq.org

American Society of Clinical Oncology https://www.asco.org

American Society of Interventional Pain Physicians https://www.asipp.org

American Urological Association https://www.auanet.org

Centers for Disease Control and Prevention https://www.cdc.gov

Centers for Disease Control and Prevention Guideline topics: AIDS https://www.cdc.gov/hiv/default.html

Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm

CVS Caremark https://www.caremark.com

The Food and Drug Administration https://www.fda.gov

44 Nippon Life Insurance Company of America® NC20016-4 (1/20)

Global Initiative for Asthma https://ginasthma.org

Infectious Diseases Society of America https://www.idsociety.org

Institute for Safe Medication Practices https://www.ismp.org

Johns Hopkins AIDS Service https://www.thebody.com/content/art12096.html

Juvenile Diabetes Research Foundation International https://www.jdrf.org

MedWatch https://www.fda.gov/Safety/MedWatch/default.htm

National Agricultural Library https://www.nal.usda.gov

National Cancer Institute https://www.cancer.gov/about-cancer

National Comprehensive Cancer Network https://www.nccn.org

National Foundation for Infectious Diseases http://www.nfid.org

National Guideline Clearinghouse https://www.ahrq.gov

National Heart, Lung and Blood Institute https://www.nhlbi.nih.gov

National Institutes of Health https://www.nih.gov

National Kidney Foundation https://www.kidney.org

National Osteoporosis Foundation https://www.nof.org

North American Menopause Society https://www.menopause.org

United States Department of Health and Human Services https://www.hhs.gov

World Health Organization https://www.who.int

45 Nippon Life Insurance Company of America® NC20016-4 (1/20)

INDEX

A abacavir tabs, 10 abacavir/dolutegravir/lamivudine, 10 abacavir/lamivudine, 10 abaloparatide, 26 ABILIFY MAINTENA, 20 abiraterone, 12 acamprosate calcium, 23 acarbose, 23 ACCU-CHEK AVIVA PLUS kits and test strips, 25 ACCU-CHEK COMPACT PLUS kits and test strips, 25 ACCU-CHEK GUIDE kits and test strips, 25 ACCU-CHEK SMARTVIEW kits and test strips, 25 ACCUPRIL, 13 ACCURETIC, 14 acetazolamide, 16 acetazolamide ext-rel, 17 acetic acid, 42 acitretin, 38 ACTIGALL, 30 ACTONEL, 25 ACTOPLUS MET, 24 ACULAR, 41 ACUVAIL, 41 acyclovir caps, tabs, 11 ADALAT CC, 16 adalimumab, 33 adapalene, 38 adapalene/benzoyl peroxide, 38 ADEMPAS, 18 ADVAIR DISKUS, 37 ADVAIR HFA, 37 ADYNOVATE, 32 AFINITOR, 13 aflibercept, 42 AGGRENOX, 33 AGRYLIN, 33 AIMOVIG, 21 AJOVY, 21 albuterol, 36 albuterol ext-rel, 36 albuterol soln, 36 albuterol sulfate, CFC-free aerosol, 36 alcaftadine, 40 alclometasone crm, oint 0.05%, 39 ALDACTAZIDE, 17 ALDACTONE, 14 ALDARA, 40 alendronate, 25 alfuzosin ext-rel, 31 aliskiren, 16 aliskiren/hydrochlorothiazide, 16 ALKERAN, 12 allopurinol, 7 alosetron, 30 alpha-1 proteinase inhibitor, 37 ALPHAGAN P, 42 alprazolam, 18 alprostadil supp, 31 ALTACE, 13

amantadine, 20 AMARYL, 25 AMBIEN, 21 AMBIEN CR, 21 ambrisentan, 17 amiloride, 17 amiloride/hydrochlorothiazide, 17 amiodarone, 15 AMITIZA, 30 amitriptyline, 19 amlodipine, 16 amlodipine/atorvastatin, 16 amlodipine/benazepril, 13 amlodipine/olmesartan, 14 amlodipine/telmisartan, 14 amlodipine/valsartan, 14 amlodipine/valsartan/hydrochlorothiazide, 14 ammonium lactate 12%, 39 amoxicillin, 9 amoxicillin/clavulanate, 9 amoxicillin/clavulanate ext-rel, 9 amphetamine/dextroamphetamine mixed salts, 21 amphetamine/dextroamphetamine mixed salts ext-rel, 21 ampicillin, 9 ANAFRANIL, 18 anagrelide, 33 anastrozole, 12 ANDRODERM, 23 ANORO ELLIPTA, 35 ANTABUSE, 23 ANTARA, 15 antihemophilic factor (recombinant), 32 antihemophilic factor (recombinant) pegylated, 32 antihemophilic factor (recombinant) pegylated-aucl, 32 ANUSOL-HC, 31 apalutamide, 12 apixaban, 32 apremilast, 33 APRISO, 30 ARANESP, 32 ARAVA, 34 ARICEPT, 19 ARIMIDEX, 12 aripiprazole, 20 aripiprazole ext-rel inj, 20 aripiprazole lauroxil ext-rel inj, 20 ARISTADA, 20 ARISTADA INITIO, 20 ARIXTRA, 32 armodafinil, 22 ARNUITY ELLIPTA, 37 AROMASIN, 12 ASTEPRO, 37 atazanavir, 10 atazanavir/cobicistat, 10 ATELVIA, 25 atenolol, 16 atenolol/chlorthalidone, 16 ATIVAN, 18 atomoxetine, 21 atorvastatin, 15

46 Nippon Life Insurance Company of America® NC20016-4 (1/20)

atovaquone/proguanil, 9 ATRIPLA, 10 AUBAGIO, 22 AUGMENTIN, 9 AUSTEDO, 22 AVELOX, 9 AVODART, 31 AYGESTIN, 29 AZASAN, 34 azathioprine, 34 azelaic acid foam, 40 azelaic acid gel, 40 azelastine, 40 azelastine spray, 37 azelastine/fluticasone spray, 37 azithromycin, 9 AZOPT, 41 AZOR, 14 AZULFIDINE, 30 AZULFIDINE EN-TABS, 30

B bacitracin, 40 baclofen, 22 balsalazide, 30 BARACLUDE, 11 BASAGLAR, 24 BD ULTRAFINE insulin syringes and needles, 25 beclomethasone breath-activated aerosol, 37 BELBUCA, 7 BELSOMRA, 21 BELVIQ, 25 BELVIQ XR, 25 benazepril, 13 benazepril/hydrochlorothiazide, 14 benralizumab, 37 BENTYL, 30 BENZAC AC, 38 BENZAMYCIN, 38 benzonatate, 36 benzoyl peroxide, 38 benztropine, 20 benzyl alcohol/carbomer 941/glycerin, 40 besifloxacin, 40 BESIVANCE, 40 betamethasone dipropionate augmented crm 0.05%, 39 betamethasone dipropionate augmented gel, oint 0.05%, 39 betamethasone dipropionate augmented lotion 0.05%, 39 betamethasone dipropionate crm, lotion, oint 0.05%, 39 betamethasone valerate crm, lotion, oint 0.1%, 39 BETASERON, 22 betaxolol, 41 bethanechol, 32 BETHKIS, 36 BETIMOL, 41 BETOPTIC S, 41 BEVESPI AEROSPHERE, 35 bexarotene caps, 13 bicalutamide, 12 bictegravir/emtricitabine/tenofovir alafenamide, 10 BIDIL, 17 BIKTARVY, 10 bimatoprost, 42 bismuth/metronidazole/tetracycline, 31

bisoprolol, 16 bisoprolol/hydrochlorothiazide, 16 BLEPH-10, 41 blood glucose continuous monitoring receivers, sensors,

transmitters, 25 blood glucose monitoring kits, test strips, 25 BONIVA, 25 bosentan, 17 BOSULIF, 12 bosutinib, 12 BREO ELLIPTA, 37 BRILINTA, 33 brimonidine, 42 brimonidine 0.2%, 42 brimonidine/timolol, 42 brinzolamide, 41 brinzolamide/brimonidine, 41 bromfenac sodium, 41 bromocriptine, 20 budesonide, 37 budesonide delayed-rel caps, 30 budesonide ext-rel, 30 budesonide inhalation susp, 37 budesonide/formoterol, 37 bumetanide, 17 buprenorphine, 7 buprenorphine/naloxone sublingual, 23 buprenorphine/naloxone sublingual tabs, 23 bupropion, 20 bupropion ext-rel, 20, 23 buspirone, 18 busulfan, 12 butalbital/acetaminophen/caffeine tabs, 8 butalbital/aspirin/caffeine, 8 BYSTOLIC, 16

C C1 esterase inhibitor, recombinant, 33 cabergoline, 29 CABOMETYX, 12 cabozantinib, 12 CADUET, 16 CALAN SR, 16 calcipotriene oint, soln 0.005%, 38 calcitonin-salmon spray, 25 calcitriol (1,25-D3), 28 calcium acetate, 28 CAMPRAL, 23 canakinumab, 34 candesartan, 14 candesartan/hydrochlorothiazide, 14 capecitabine, 12 captopril, 13 captopril/hydrochlorothiazide, 14 carbamazepine, 18 carbamazepine ext-rel, 18 CARBATROL, 18 carbidopa/levodopa, 20 carbidopa/levodopa ext-rel, 20 carbidopa/levodopa orally disintegrating tabs, 20 carbidopa/levodopa/entacapone, 20 CARDURA, 14 cariprazine, 20 carisoprodol, 22

47 Nippon Life Insurance Company of America® NC20016-4 (1/20)

carvedilol, 16 carvedilol phosphate ext-rel, 16 CASODEX, 12 CATAPRES, 14 CATAPRES-TTS, 14 cefadroxil, 9 cefdinir, 9 cefixime, 9 cefprozil, 9 cefuroxime axetil, 9 CELEBREX, 7 celecoxib, 7 CELEXA, 19 cephalexin, 9 CERDELGA, 28 CEREZYME, 28 cetrorelix, 28 CETROTIDE, 28 cevimeline, 31 CHANTIX, 23 chlorambucil, 12 chloroquine, 9 chlorpromazine, 20 chlorthalidone, 17 chlorzoxazone, 22 cholestyramine, 15 choriogonadotropin alfa, 28 ciclopirox, 38 cilostazol, 33 CILOXAN, 40 CIMDUO, 10 cimetidine, 30 cinacalcet, 25 CIPRO, 9 CIPRODEX, 42 ciprofloxacin, 9 ciprofloxacin oint, 40 ciprofloxacin soln, 40 ciprofloxacin/dexamethasone, 42 citalopram, 19 CITRANATAL 90 DHA, 34 CITRANATAL ASSURE, 34 CITRANATAL B-CALM, 34 CITRANATAL DHA, 34 CITRANATAL HARMONY, 34 CITRANATAL RX, 34 clarithromycin, 9 clarithromycin ext-rel, 9 clemastine 2.68 mg, 35 CLEOCIN, 11, 32 CLEOCIN T, 38 CLIMARA, 27 CLIMARA PRO, 27 clindamycin, 11 clindamycin crm, 32 clindamycin gel, 38 clindamycin gel, lotion, soln, 38 clindamycin/benzoyl peroxide, 38 clobazam, 18 clobetasol propionate crm, gel, oint, soln 0.05%, 39 clobetasol propionate foam 0.05%, 39 clobetasol propionate lotion, shampoo 0.05%, 39 CLOBEX, 39

clomiphene, 28

48 Nippon Life Insurance Company of America® NC20016-4 (1/20)

clomipramine, 18 clonazepam, 18 clonidine, 14 clonidine transdermal, 14 clopidogrel, 33 clotrimazole, 38 clotrimazole troches, 9 clozapine, 20 CLOZARIL, 20 coagulation factor IX (recombinant) glycopegylated, 33 codeine/acetaminophen, 7 codeine/guaifenesin liquid, 36 codeine/guaifenesin/pseudoephedrine, 36 codeine/promethazine, 36 codeine/promethazine/phenylephrine, 36 colchicine, 7 colesevelam, 15 COLESTID, 15 colestipol, 15 COMBIGAN, 42 COMBIPATCH, 27 COMBIVIR, 10 COMPLERA, 10 COMTAN, 20 CONCERTA, 21 CONDYLOX, 40 conjugated estrogens/bazedoxifene, 27 COPAXONE, 22 COREG, 16 CORGARD, 16 CORLANOR, 17 CORTEF, 28 CORTIFOAM, 30 CORTISPORIN OTIC, 42 COSENTYX, 33 COSOPT, 41 COZAAR, 14 CREON, 30 CRINONE, 29 crisaborole, 39 cromolyn sodium, 40 cromolyn soln, 36 CUTIVATE, 39 cyanocobalamin inj, 35 cyclobenzaprine, 22 cyclophosphamide caps, 12 cyclosporine, 34 cyclosporine, emulsion, 42 cyclosporine, modified, 34 cyproheptadine, 35 CYTOMEL, 29 CYTOTEC, 31

D D.H.E. 45, 21 DALIRESP, 37

dalteparin, 32 danazol, 27 DANTRIUM, 22 dantrolene, 22 dapagliflozin, 24 dapagliflozin/metformin ext-rel, 24 dapsone, 11 darbepoetin alfa, 32

49 Nippon Life Insurance Company of America® NC20016-4 (1/20)

darifenacin ext-rel, 31 darolutamide, 12 darunavir, 10 darunavir/cobicistat, 10 dasatinib, 12 DAYPRO, 7 DDAVP, 29 DEMADEX, 17 denosumab, 26 DEPAKENE, 19 DEPAKOTE, 18 DEPAKOTE ER, 18 DEPO-PROVERA, 27 DESCOVY, 10 desipramine, 19 desmopressin spray, tabs, 29 desogestrel/EE, 26 desogestrel/EE 0.15/30, 26 desonide crm, lotion, oint 0.05%, 39 DESOWEN, 39 desoximetasone crm, oint 0.05%, 39 desoximetasone crm, oint 0.25%, gel 0.05%, 39 desvenlafaxine ext-rel, 19 DETROL, 32 deutetrabenazine, 22 dexamethasone, 28, 41 dexamethasone sodium phosphate, 41 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM,

25 DEXEDRINE SPANSULE, 21 DEXILANT, 31 dexlansoprazole delayed-rel, 31 dexmethylphenidate, 21 dexmethylphenidate ext-rel, 21 dextroamphetamine, 21 dextroamphetamine ext-rel, 21 dextromethorphan/brompheniramine/pseudoephedrine, 36 dextromethorphan/promethazine, 36 dextromethorphan/quinidine, 23 DIASTAT, 18 diazepam, 18 diazepam rectal gel, 18 diclofenac sodium, 41 diclofenac sodium delayed-rel, 7 diclofenac sodium delayed-rel/misoprostol, 7 diclofenac sodium gel 1%, 7 diclofenac sodium soln, 7 dicloxacillin, 9 dicyclomine, 30 didanosine delayed-rel, 10 DIFICID, 9 DIFLUCAN, 9 diflunisal, 7 difluprednate, 41 digoxin 0.0625 mg, 0.1875 mg, 16 digoxin 0.125 mg, 0.25 mg, 16 digoxin ped elixir, 16 dihydroergotamine inj, 21 DILANTIN, 19 DILANTIN INFATABS, 19 DILAUDID, 8 diltiazem ext-rel, 16 dimethyl fumarate delayed-rel, 22

diphenoxylate/atropine, 29

50 Nippon Life Insurance Company of America® NC20016-4 (1/20)

DIPROLENE, 39 DIPROLENE AF, 39 dipyridamole, 33 dipyridamole ext-rel/aspirin, 33 disopyramide, 15 disopyramide ext-rel, 15 disulfiram, 23 DITROPAN XL, 32 divalproex sodium delayed-rel, 18 divalproex sodium ext-rel, 18 DIVIGEL, 27 dofetilide, 15 dolutegravir, 10 donepezil, 19 dornase alfa, 36 dorzolamide, 41 dorzolamide/timolol maleate, 41 doxazosin, 14 doxepin, 19, 21 doxercalciferol, 28 doxycycline hyclate, 9 doxycycline hyclate 20 mg, 9 doxycycline monohydrate delayed-rel caps, 40 doxylamine/pyridoxine delayed-rel, 29 dronabinol, 29 dronedarone, 15 drospirenone/EE 3/20, 26 drospirenone/EE 3/30, 26 drospirenone/EE/levomefolate 3/20 and levomefolate, 26 drospirenone/EE/levomefolate 3/30 and levomefolate, 26 DUAC, 38 DUAVEE, 27 DUETACT, 24 dulaglutide, 24 duloxetine delayed-rel, 19 dupilumab, 37, 39 DUPIXENT, 37, 39 DUREZOL, 41 DUROLANE, 8 dutasteride, 31 dutasteride/tamsulosin, 31 DYAZIDE, 17 DYMISTA, 37

E econazole, 38 eculizumab, 33 EDURANT, 10 EE/norethindrone acetate - Jinteli, 27 efavirenz, 10 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 10 efavirenz/lamivudine/tenofovir disoproxil fumarate, 10 elagolix, 27 eletriptan, 22 ELIGARD, 12 eliglustat, 28 ELIQUIS, 32 ELOCON, 39 eltrombopag, 33 eluxadoline, 30 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate,

10 EMBEDA, 8

51 Nippon Life Insurance Company of America® NC20016-4 (1/20)

EMGALITY, 21 empagliflozin, 24 empagliflozin/linagliptin, 25 empagliflozin/metformin, 24 empagliflozin/metformin ext-rel, 24 emtricitabine, 10 emtricitabine/rilpivirine/tenofovir alafenamide, 10 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 10 emtricitabine/tenofovir alafenamide, 10 emtricitabine/tenofovir disoproxil fumarate, 10 EMTRIVA, 10 EMVERM, 11 enalapril, 13 enalapril/hydrochlorothiazide, 14 ENBREL, 33 ENDOMETRIN, 29 enfuvirtide, 10 enoxaparin, 32 entacapone, 20 entecavir soln, 11 entecavir tabs, 11 ENTRESTO, 17 enzalutamide, 12 EPCLUSA, 11 EPIDUO, 38 EPIDUO FORTE, 38 epinephrine auto-injector, 35 EPIPEN, 35 EPIPEN JR., 35 EPISIL, 40 EPIVIR, 10 eplerenone, 14 epoetin alfa-epbx, 32 epoprostenol sodium, 18 eprosartan, 14 EPZICOM, 10 erenumab-aooe, 21 ergocalciferol (D2), 35 ergotamine/caffeine, 21 ERLEADA, 12 erlotinib, 12 erythromycin, 40 erythromycin delayed-rel, 9 erythromycin ethylsuccinate, 9 erythromycin gel 2%, 38 erythromycin soln, 38 erythromycin stearate, 9 erythromycin/benzoyl peroxide, 38 ESBRIET, 37 escitalopram, 19 ESGIC, 8 esomeprazole delayed-rel, 31 ESTRACE, 27 estradiol, 27 estradiol vaginal crm, 27 estradiol vaginal ring, 27 estradiol vaginal tabs, 27 estradiol/levonorgestrel, 27 estradiol/norethindrone, 27 estradiol/norethindrone acetate, 27 ESTRING, 27 estrogens, conjugated, 27 estrogens, conjugated crm, 27

estrogens, conjugated/medroxyprogesterone, 27

52 Nippon Life Insurance Company of America® NC20016-4 (1/20)

eszopiclone, 21 etanercept, 33 ethambutol, 11 ethosuximide, 18 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 26 etodolac, 7 etonogestrel/EE ring, 27 etoposide, 13 etravirine, 10 EUCRISA, 39 EVAMIST, 27 everolimus, 13 EVISTA, 29 evolocumab, 15 EVOTAZ, 10 EVOXAC, 31 EXELON, 19 exemestane, 12 EYLEA, 42 ezetimibe, 15 ezetimibe/simvastatin, 15

F famciclovir, 11 famotidine, 30 FARXIGA, 24 FASENRA, 37 febuxostat, 7 felodipine ext-rel, 16 FEMARA, 12 fenofibrate, 15 fenofibric acid delayed-rel, 15 fentanyl sublingual spray, 8 fentanyl transdermal, 7 fentanyl transmucosal lozenge, 7 fesoterodine ext-rel, 31 FIASP, 24 fidaxomicin, 9 filgrastim-aafi, 32 FINACEA FOAM, 40 finasteride, 31 fingolimod, 22 FIORINAL, 8 FIRAZYR, 33 FLAGYL, 11 flecainide, 15 FLOLAN, 18 FLOMAX, 31 FLOVENT DISKUS, 37 FLOVENT HFA, 37 fluconazole, 9 fludrocortisone, 28 flunisolide spray, 37 fluocinolone acetonide crm, oint 0.025%, 39 fluocinolone acetonide soln 0.01%, 39 fluocinonide crm, gel, oint, soln 0.05%, 39 fluoride drops, 35 fluoride tabs, 35 fluorometholone, 41 fluorouracil crm 4%, 38 fluorouracil crm 5%, soln 5%, soln 2%, 38

fluoxetine, 19 fluphenazine, 20 flutamide, 12

53 Nippon Life Insurance Company of America® NC20016-4 (1/20)

fluticasone, 37 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 39 fluticasone spray, 37 fluticasone, CFC-free aerosol, 37 fluticasone/salmeterol, 37 fluticasone/salmeterol, CFC-free aerosol, 37 fluticasone/umeclidinium/vilanterol, 35 fluticasone/vilanterol, 37 fluvastatin, 15 fluvoxamine, 18 FML FORTE, 41 FML S.O.P., 41 FOCALIN, 21 FOCALIN XR, 21 folic acid, 34 folic acid/vitamin B6/vitamin B12, 34 follitropin alfa, 28 fondaparinux, 32 formoterol inhalation soln, 36 FORTEO, 26 FOSAMAX, 25 fosinopril, 13 fosinopril/hydrochlorothiazide, 14 FRAGMIN, 32 fremanezumab-vfrm, 21 FURADANTIN, 11 furosemide, 17 FUZEON, 10 FYCOMPA, 18

G gabapentin, 18 gabapentin ext-rel, 23 galantamine, 19 galantamine ext-rel, 19 galcanezumab-gnlm, 21 ganirelix acetate, 27 gefitinib, 12 GEL-ONE, 8 GELSYN-3, 8 gemfibrozil, 15 GENOTROPIN, 28 gentamicin, 38, 40 GENVOYA, 10 GEODON, 20 GILENYA, 22 glatiramer, 22 glimepiride, 25 glipizide, 25 glipizide ext-rel, 25 glipizide/metformin, 24 GLUCAGEN HYPOKIT, 28 GLUCAGON EMERGENCY KIT, 28 glucagon, human recombinant, 28 GLUCOPHAGE, 24 GLUCOPHAGE XR, 24 GLUCOTROL, 25 GLUCOTROL XL, 25 glyburide, 25 glycopyrrolate/formoterol, 35 GLYXAMBI, 25 GOLYTELY, 30 GONAL-F, 28 GRALISE, 23

granisetron, 29 granisetron transdermal, 29 grass mixed pollen allergen extract, 33 GRASTEK, 33 griseofulvin ultramicrosize, 9 guanfacine, 14 guanfacine ext-rel, 21 guselkumab, 33

H halobetasol propionate crm, oint 0.05%, 39 haloperidol, 20 HARVONI, 11 HECTOROL, 28 human coagulation factor VIII (rDNA) simoctocog alfa, 32 HUMATROPE, 28 HUMIRA, 33 HUMULIN R U-500, 24 HYCAMTIN, 13 hydralazine, 18 HYDREA, 13 hydrochlorothiazide, 17 hydrocodone/acetaminophen, 8 hydrocodone/homatropine, 36 hydrocortisone, 28 hydrocortisone acetate foam, 30 hydrocortisone acetate/pramoxine foam, 31 hydrocortisone butyrate crm, oint, soln 0.1%, 39 hydrocortisone crm, 31 hydrocortisone crm 2.5%, 39 hydrocortisone enema, 30 hydrocortisone lotion 1%, 39 hydrocortisone valerate crm, oint 0.2%, 39 hydromorphone, 8 hydromorphone ext-rel, 7 hydroxychloroquine, 34 hydroxyurea, 13 hydroxyzine HCl, 35 hyoscyamine sulfate, 30 hyoscyamine sulfate ext-rel, 30 hyoscyamine sulfate ext-rel caps, 30 hyoscyamine sulfate orally disintegrating tabs, 30 HYZAAR, 14

I ibandronate, 25 IBRANCE, 13 ibuprofen, 7 icatibant, 33 icosapent ethyl, 15 ILARIS, 34 ILEVRO, 41 imatinib mesylate, 12 IMDUR, 17 imiglucerase, 28 imipramine HCl, 19 imiquimod, 38, 40 IMITREX, 22 IMURAN, 34 INCRUSE ELLIPTA, 35 indapamide, 17 INDERAL LA, 16 ingenol mebutate, 38 INGREZZA, 22

54 Nippon Life Insurance Company of America® NC20016-4 (1/20)

INSPRA, 14 insulin aspart, 24 insulin aspart protamine 70%/insulin aspart 30%, 24 insulin degludec, 24 insulin detemir, 24 insulin glargine, 24 insulin human, 24 insulin infusion disposable pump, 25 insulin isophane human, 24 insulin isophane human 70%/regular 30%, 24 insulin syringes, needles, 25 INTELENCE, 10 interferon alfa-2b, 34 interferon beta-1a, 22 interferon beta-1b, 22 INTRON A, 34 ipratropium soln, 35 ipratropium spray, 37 ipratropium/albuterol soln, 35 irbesartan, 14 irbesartan/hydrochlorothiazide, 14 IRESSA, 12 ISENTRESS, 10 isoniazid, 10 ISORDIL, 17 isosorbide dinitrate ext-rel tabs, 17 isosorbide dinitrate oral, 17 isosorbide dinitrate/hydralazine, 17 isosorbide mononitrate, 17 isosorbide mononitrate ext-rel, 17 isotretinoin, 37 itraconazole, 9 ivabradine, 17 ivermectin, 11, 40

J JANUMET, 24 JANUMET XR, 24 JANUVIA, 24 JARDIANCE, 24 JIVI, 32

K KADIAN, 8 KALETRA, 10 KEFLEX, 9 KEPPRA, 18 KEPPRA XR, 19 ketoconazole, 38 ketoconazole shampoo 2%, 38 ketorolac, 41 ketorolac tromethamine, 41 KISQALI, 13 KISQALI FEMARA CO-PACK, 13 KLARON, 38 KLONOPIN, 18 KOGENATE FS, 32 KOVALTRY, 32 KUVAN, 28 KYLEENA, 27

L labetalol, 16 LAC-HYDRIN, 39 lacosamide, 18

lactulose soln, 30 lamivudine, 10, 11 lamivudine/tenofovir disoproxil fumarate, 10 lamivudine/zidovudine, 10 lamotrigine, 18 lamotrigine ext-rel, 18 lamotrigine orally disintegrating tabs, 18 LANOXIN, 16 lanreotide acetate, 23 lansoprazole + amoxicillin + clarithromycin, 31 lansoprazole delayed-rel, 31 lanthanum carbonate, 28 lapatinib, 13 LASIX, 17 LASTACAFT, 40 latanoprost, 42 LATUDA, 20 ledipasvir/sofosbuvir, 11 leflunomide, 34 lenalidomide, 12 letrozole, 12 LEUKERAN, 12 leuprolide acetate, 12 levalbuterol tartrate, CFC-free aerosol, 36 LEVAQUIN, 9 LEVBID, 30 LEVEMIR, 24 levetiracetam, 18 levetiracetam ext-rel, 19 levobunolol, 41 levocarnitine, 26 levocetirizine, 35 levofloxacin, 9, 40 levonorgestrel releasing IUD, 27 levonorgestrel/EE - Trivora, 26 levonorgestrel/EE 0.1/20 - Lessina, 26 levonorgestrel/EE 0.1/20 and EE 10, 26 levonorgestrel/EE 0.15/30, 26 levonorgestrel/EE 0.15/30 - Levora, 26 levonorgestrel/EE 0.15/30 and EE 10, 26 levothyroxine, 29 levothyroxine - Levoxyl, 29 LEVSIN, 30 lidocaine patch, 39 lidocaine viscous, 40 lidocaine/prilocaine, 39 LIDODERM, 39 lifitegrast, 42 linaclotide, 30 linezolid, 11 LINZESS, 30 liothyronine, 29 LIPOFEN, 15 liraglutide, 24, 25 liraglutide/insulin degludec, 24 lisdexamfetamine, 21 lisinopril, 13 lisinopril/hydrochlorothiazide, 14 lithium carbonate, 22 lithium carbonate ext-rel tabs 300 mg, 22 lithium carbonate ext-rel tabs 450 mg, 22 LITHOBID, 22 lixisenatide/insulin glargine, 24

55 Nippon Life Insurance Company of America® NC20016-4 (1/20)

LOESTRIN 1.5/30, 26

56 Nippon Life Insurance Company of America® NC20016-4 (1/20)

LOESTRIN 1/20, 26 LOESTRIN FE 1.5/30, 26 LOESTRIN FE 1/20, 26 LOKELMA, 28 LOMOTIL, 29 loperamide, 29 LOPID, 15 lopinavir/ritonavir soln, 10 lopinavir/ritonavir tabs, 10 LOPRESSOR, 16 LOPRESSOR HCT, 16 LOPROX, 38 lorazepam, 18 lorcaserin, 25 lorcaserin ext-rel, 25 losartan, 14 losartan/hydrochlorothiazide, 14 LOSEASONIQUE, 26 LOTENSIN, 13 LOTENSIN HCT, 14 loteprednol, 41 LOTREL, 13 lovastatin, 15 LOVAZA, 15 LOVENOX, 32 lubiprostone, 30 LUCENTIS, 42 luliconazole, 38 LUMIGAN, 42 LUPRON DEPOT, 12 lurasidone, 20 lusutrombopag, 33 LYNPARZA, 13 LYRICA, 21 LYSODREN, 13

M macitentan, 17 MACROBID, 11 MALARONE, 9 malathion, 40 MARINOL, 29 MATULANE, 13 MAXALT, 22 MAXIDEX, 41 MAXITROL, 41 MAXZIDE, 17 MAYZENT, 22 mebendazole chewable, 11 meclizine, 29 MEDROL, 28 medroxyprogesterone acetate, 29 medroxyprogesterone acetate 150 mg/mL, 27 mefloquine, 9 MEGACE ES, 29 megestrol acetate susp, 29 megestrol acetate tabs, 12 meloxicam, 7 melphalan, 12 memantine, 19 memantine ext-rel, 19 memantine/donepezil, 19 mepolizumab, 37 mercaptopurine, 12

mesalamine delayed-rel tabs, 30 mesalamine ext-rel caps, 30 mesalamine supp, 30 mesalamine susp, 30 metaxalone, 22 metformin, 24 metformin ext-rel, 24 methadone, 7 methazolamide, 17 methimazole, 29 methocarbamol, 22 methotrexate, 12, 34 methotrexate auto-injector, 34 methoxsalen oral, 38 methyldopa, 18 METHYLIN, 21 methylphenidate, 21 methylphenidate ext-rel, 21 methylprednisolone, 28 metoclopramide, 29 metolazone, 17 metoprolol succinate ext-rel, 16 metoprolol tartrate, 16 metoprolol/hydrochlorothiazide, 16 METROCREAM, 40 METROGEL, 40 METROGEL-VAGINAL, 32 METROLOTION, 40 metronidazole, 11, 32 metronidazole crm 0.75%, 40 metronidazole gel 0.75%, 40 metronidazole gel 1%, 40 metronidazole lotion 0.75%, 40 MICARDIS, 14 MICARDIS HCT, 14 midodrine, 18 midostaurin, 13 minocycline, 9 mirabegron ext-rel, 32 MIRAPEX, 20 MIRCETTE, 26 MIRENA, 27 mirtazapine, 20 misoprostol, 31 mitotane, 13 MOBIC, 7 mometasone crm, lotion, oint 0.1%, 39 mometasone spray, 37 montelukast, 36 morphine, 7 morphine ext-rel, 7, 8 morphine supp, 7 morphine/naltrexone ext-rel, 8 MOVANTIK, 30 MOXEZA, 40 moxifloxacin, 9, 40 MOZOBIL, 33 MS CONTIN, 8 MUGARD, 40 MULPLETA, 33 MULTAQ, 15 multivitamins/fluoride drops, tabs, 35 multivitamins/fluoride/iron drops, tabs, 35

57 Nippon Life Insurance Company of America® NC20016-4 (1/20)

mupirocin oint, 38

58 Nippon Life Insurance Company of America® NC20016-4 (1/20)

MUSE, 31 MYAMBUTOL, 11 mycophenolate mofetil, 34 mycophenolate sodium delayed-rel, 34 MYDAYIS, 21 MYLERAN, 12 MYRBETRIQ, 32 MYSOLINE, 19

N nabumetone, 7 nadolol, 16 naftifine, 38 NAFTIN, 38 naldemedine, 30 naloxegol, 30 naloxone inj, 23 naloxone nasal spray, 23 naltrexone, 23 NAMENDA, 19 NAMZARIC, 19 naproxen sodium tabs, 7 naproxen tabs, 7 naratriptan, 21 NARCAN, 23 NARDIL, 19 natalizumab, 22 nateglinide, 24 nebivolol, 16 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 41 neomycin/polymyxin B/dexamethasone, 41 neomycin/polymyxin B/gramicidin, 40

neomycin/polymyxin B/hydrocortisone, 42 neomycin/polymyxin B/hydrocortisone susp, 41 nepafenac, 41 netarsudil, 42 netarsudil/latanoprost, 42 NEULASTA, 32 NEUPRO, 20 NEURONTIN, 18 NEVANAC, 41 nevirapine, 10 nevirapine ext-rel, 10 niacin ext-rel, 15 NIASPAN, 15 nifedipine ext-rel, 16 nintedanib, 37 niraparib, 13 nitisinone, 28 NITRO-DUR, 17 nitrofurantoin ext-rel, 11 nitrofurantoin macrocrystals, 11 nitrofurantoin susp, 11 nitroglycerin lingual spray, 17 nitroglycerin sublingual, 17 nitroglycerin transdermal, 17 NITROLINGUAL, 17 NITROSTAT, 17 NIVESTYM, 32 NIZORAL, 38 NORCO, 8 norelgestromin/EE, 27 norethindrone, 26 norethindrone acetate, 29

norethindrone acetate/EE 1.5/30, 26 norethindrone acetate/EE 1.5/30 and iron, 26 norethindrone acetate/EE 1/20, 26 norethindrone acetate/EE 1/20 and iron, 26 norethindrone acetate/EE 1/20 and iron chewable, 26 norethindrone/EE, 26 norethindrone/EE 0.5/35, 26 norethindrone/EE 1/35, 26 norgestimate/EE, 26 norgestimate/EE 0.25/35, 26 norgestrel/EE 0.3/30 - Low-Ogestrel, 26 NORPACE, 15 NORPACE CR, 15 NORPRAMIN, 19 nortriptyline, 19 NORVIR, 10 NOVOEIGHT, 32 NOVOLIN 70/30, 24 NOVOLIN N, 24 NOVOLIN R, 24 NOVOLOG, 24 NOVOLOG MIX 70/30, 24 NUBEQA, 12 NUCALA, 37 NUCYNTA, 8 NUCYNTA ER, 8 NUEDEXTA, 23 NULYTELY, 30 NUVARING, 27 NUWIQ, 32 nystatin, 9, 38

O OCUFLOX, 40 ODEFSEY, 10 ODOMZO, 13 OFEV, 37 ofloxacin, 40 ofloxacin otic, 42 olanzapine, 20 olaparib, 13 olmesartan, 14 olmesartan/amlodipine/hydrochlorothiazide, 14 olmesartan/hydrochlorothiazide, 14 olodaterol, CFC-free aerosol, 36 olopatadine, 40 olopatadine spray, 37 omalizumab, 37 omega-3 acid ethyl esters, 15 omeprazole delayed-rel, 31 OMNIPOD INSULIN INFUSION PUMP, 25 ondansetron, 29 ONZETRA XSAIL, 22 OPSUMIT, 17 ORALAIR, 33 ORENITRAM, 18 ORFADIN, 28 ORILISSA, 27 orphenadrine/aspirin/caffeine, 22 ORTHO MICRONOR, 26 ORTHO-NOVUM 1/35, 26 ORTHO-NOVUM 7/7/7, 26 oseltamivir, 11 ospemifene, 29

59 Nippon Life Insurance Company of America® NC20016-4 (1/20)

OSPHENA, 29 OTEZLA, 33 OVIDE, 40 OVIDREL, 28 oxaprozin, 7 oxazepam, 18 oxcarbazepine, 19 oxcarbazepine ext-rel, 18 OXSORALEN-ULTRA, 38 OXTELLAR XR, 18 oxybutynin, 31 oxybutynin ext-rel, 32 oxycodone caps, tabs 5 mg, 7 oxycodone concentrate 20 mg/mL, 7 oxycodone ext-rel, 8 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 8 oxycodone/acetaminophen 5/325, 7 oxycodone/acetaminophen soln, 8 OZEMPIC, 24

P palbociclib, 13 PAMELOR, 19 pancrelipase, 30 pancrelipase delayed-rel, 30 pantoprazole delayed-rel, 31 paricalcitol, 28 PARLODEL, 20 PARNATE, 19 paroxetine HCl, 19 paroxetine HCl ext-rel, 19 paroxetine mesylate, 23 PATADAY, 40

PATANASE, 37 PATANOL, 40 patiromer sorbitex, 28 PAXIL, 19 PAXIL CR, 19 PAZEO, 40 pazopanib, 13 peg 3350/electrolytes, 30 PEGASYS, 34 pegfilgrastim, 32 pegfilgrastim-cbqv, 32 peginterferon alfa-2a, 34 peginterferon alfa-2b, 34 pegvisomant, 23 penicillin VK, 9 PENTASA, 30 PEPCID, 30 perampanel, 18 PERFOROMIST, 36 perindopril, 13 permethrin 5%, 40 perphenazine, 20 phenelzine, 19 phenobarbital, 18 phenytoin, 19 phenytoin sodium extended, 19 PHOSLYRA, 28 PICATO, 38 pilocarpine tabs, 31 pimecrolimus, 39 pindolol, 16

pioglitazone, 24 pioglitazone/glimepiride, 24 pioglitazone/metformin, 24 pirfenidone, 37 PLAQUENIL, 34 plerixafor, 33 podofilox, 40 polymyxin B/bacitracin, 40 polymyxin B/trimethoprim, 40 POLYTRIM, 40 pomalidomide, 12 POMALYST, 12 potassium chloride ext-rel, 34 potassium chloride liquid, 34 potassium citrate ext-rel, 32 pramipexole, 20 pramipexole ext-rel, 20 pramlintide, 23 PRANDIN, 24 prasugrel, 33 PRAVACHOL, 15 pravastatin, 15 PRECOSE, 23 PRED MILD, 41 prednisolone, 28 prednisolone acetate, 41 prednisolone acetate 1%, 41 prednisolone phosphate 1%, 41 prednisone, 28 pregabalin, 21 PREMARIN, 27 PREMPHASE, 27 PREMPRO, 27 prenatal vitamins, 34 prenatal vitamins/DHA/docusate/folic acid, 34 prenatal vitamins/docusate/folic acid, 34 prenatal vitamins/docusate/folic acid + DHA, 34 prenatal vitamins/folic acid + pyridoxine, 34 PREZCOBIX, 10 PREZISTA, 10 PRILOSEC, 31 primidone, 19 probenecid, 7 procarbazine, 13 PROCARDIA XL, 16 prochlorperazine, 29 PROCTOFOAM-HC, 31 progesterone gel, 29 progesterone vaginal inserts, 29 progesterone, micronized, 29 PROLASTIN-C, 37

PROLIA, 26 PROMACTA, 33 promethazine, 29 PROMETRIUM, 29 propafenone, 15 propafenone ext-rel, 15 propranolol, 16 propranolol ext-rel, 16 propylthiouracil, 29 PROSCAR, 31 PROVERA, 29 PULMICORT FLEXHALER, 37

60 Nippon Life Insurance Company of America® NC20016-4 (1/20)

PULMICORT RESPULES, 37

61 Nippon Life Insurance Company of America® NC20016-4 (1/20)

PULMOZYME, 36 PYLERA, 31 pyrazinamide, 10 pyridostigmine, 22 pyridostigmine ext-rel, 22

Q QUESTRAN/QUESTRAN LIGHT, 15 quetiapine, 20 quetiapine ext-rel, 20 quinapril, 13 quinapril/hydrochlorothiazide, 14 QVAR REDIHALER, 37

R ragweed pollen allergen extract, 33 RAGWITEK, 33 raloxifene, 29 raltegravir, 10 ramipril, 13 ranibizumab, 42 ranitidine, 30 ranolazine ext-rel, 18 rasagiline, 20 RASUVO, 34 RAZADYNE, 19 RAZADYNE ER, 19 REBETOL, 11 REBIF, 22 REBINYN, 33 REGLAN, 29 RELENZA, 11 RELPAX, 22 REMERON, 20 repaglinide, 24 REPATHA, 15 REQUIP XL, 20 RESTASIS, 42 RESTORIL, 21 RETACRIT, 32 RETIN-A, 38 RETROVIR, 10 REVATIO, 17 REVLIMID, 12 RHOPRESSA, 42 ribavirin caps, 11 ribavirin oral soln, 11 ribavirin tabs, 11 ribociclib, 13 ribociclib + letrozole, 13 RIFADIN, 11 rifampin, 11 rifaximin 550 mg, 11 rilpivirine, 10 RINVOQ, 33 riociguat, 18 risankizumab-rzaa, 33 risedronate, 25 risedronate delayed-rel, 25 RISPERDAL, 20 RISPERDAL CONSTA, 20 risperidone, 20 risperidone long-acting injection, 20 RITALIN, 21

ritonavir, 10 rivaroxaban, 32 rivastigmine, 19 rivastigmine transdermal, 19 rizatriptan, 22 ROBAXIN, 22 ROCALTROL, 28 ROCKLATAN, 42 roflumilast, 37 rolapitant, 29 ropinirole, 20 ropinirole ext-rel, 20 rosuvastatin, 15 rotigotine transdermal, 20 ROWASA, 30 ROXICET, 8 ROXICODONE, 8 RUBRACA, 13 rucaparib, 13 RUCONEST, 33 RYDAPT, 13 RYTHMOL SR, 15

S sacubitril/valsartan, 17 SALAGEN, 31 salmeterol xinafoate, 36 SANCUSO, 29 sapropterin, 28 SAXENDA, 25 scopolamine transdermal, 29 SEASONIQUE, 26 secukinumab, 33 selegiline, 20 selenium sulfide shampoo 2.5%, 38 selexipag, 17 semaglutide, 24 SENSIPAR, 25 SEREVENT, 36 SEROQUEL, 20 sertraline, 19 sevelamer carbonate, 28 sildenafil, 17, 31 SILENOR, 21 silodosin, 31 SILVADENE, 38 silver sulfadiazine, 38 SIMBRINZA, 41 simvastatin, 15 SINEMET, 20 SINEMET CR, 20 siponimod, 22 sirolimus, 34 sitagliptin phosphate, 24 sitagliptin/metformin, 24 sitagliptin/metformin ext-rel, 24 SKELAXIN, 22 SKYLA, 27 SKYRIZI, 33 sodium hyaluronate, 8 sodium sulfate/potassium sulfate/magnesium sulfate, 30 sodium zirconium cyclosilicate, 28 sofosbuvir/velpatasvir, 11 sofosbuvir/velpatasvir/voxilaprevir, 11

62 Nippon Life Insurance Company of America® NC20016-4 (1/20)

solifenacin, 31 SOLIQUA, 24 SOLIRIS, 33 solriamfetol, 22 somatropin, 28 SOMATULINE DEPOT, 23 SOMAVERT, 23 sonidegib, 13 SOOLANTRA, 40 SORIATANE, 38 sotalol, 15 soy phospholipid/glycerol dioleate, 40 SPIRIVA, 35 spironolactone, 14 spironolactone/hydrochlorothiazide, 17 SPRYCEL, 12 STALEVO, 20 stavudine, 10 STELARA SUBCUTANEOUS, 33 STIOLTO RESPIMAT, 35 STRATTERA, 21 STRIBILD, 10 STRIVERDI RESPIMAT, 36 STROMECTOL, 11 SUBSYS, 8 sucralfate, 31 sucroferric oxyhydroxide, 28 sulfacetamide lotion 10%, 38 sulfacetamide oint 10%, 40 sulfacetamide soln 10%, 41 sulfacetamide/prednisolone phosphate 10%/0.25%, 41 sulfamethoxazole/trimethoprim, 11 sulfamethoxazole/trimethoprim DS, 11

sulfasalazine, 30 sulfasalazine delayed-rel, 30 sulindac, 7 sumatriptan, 22 sumatriptan inj, 22 sumatriptan nasal powder, 22 sumatriptan nasal spray, 22 sumatriptan/naproxen sodium, 22 sunitinib, 13 SUNOSI, 22 SUPARTZ FX, 8 SUPRAX, 9 SUPREP, 30 SUTENT, 13 suvorexant, 21 SYLATRON, 34 SYMBICORT, 37 SYMFI, 10 SYMFI LO, 10 SYMLINPEN, 23 SYMPROIC, 30 SYNJARDY, 24 SYNJARDY XR, 24 SYNTHROID, 29

T TABLOID, 12 tacrolimus, 34, 39 tadalafil, 17, 31 tamoxifen, 12 tamsulosin, 31

TAPAZOLE, 29 tapentadol, 8 tapentadol ext-rel, 8 TARGRETIN, 13 TARKA, 13 tazarotene, 38 TAZORAC, 38 TECFIDERA, 22 TEGRETOL, 18 TEKTURNA HCT, 16 telmisartan, 14 telmisartan/hydrochlorothiazide, 14 temazepam, 21 TEMIXYS, 10 TEMODAR, 12 TEMOVATE, 39 temozolomide, 12 tenofovir alafenamide, 11 tenofovir disoproxil fumarate, 10 terazosin, 14 terbinafine tabs, 9 terbutaline, 36 terconazole, 32 teriflunomide, 22 teriparatide, 26 TESSALON, 36 testosterone cypionate, 23 testosterone enanthate, 23 testosterone gel, 23 testosterone soln, 23 testosterone transdermal, 23 tetrabenazine, 22 tetracycline, 9 thalidomide, 12 THALOMID, 12 theophylline ext-rel tabs, 37 thioguanine, 12 thiothixene, 20 tiagabine, 18 TIAZAC, 16 ticagrelor, 33 TIGAN, 29 TIKOSYN, 15 timolol hemihydrate, 41 timolol maleate, 41 timolol maleate gel, 41 TIMOPTIC, 41 timothy grass pollen allergen extract, 33 tinidazole, 11 tiotropium, 35 tiotropium/olodaterol, 35 TIVICAY, 10 tizanidine tabs, 22 TOBRADEX, 41 TOBRADEX ST, 41 tobramycin, 41 tobramycin inhalation soln, 36 tobramycin/dexamethasone oint 0.3%/0.1%, 41 tobramycin/dexamethasone susp 0.3%/0.05%, 41 tobramycin/dexamethasone susp 0.3%/0.1%, 41 TOBREX, 41 tofacitinib, 33 tofacitinib ext-rel, 33

63 Nippon Life Insurance Company of America® NC20016-4 (1/20)

TOFRANIL, 19

64 Nippon Life Insurance Company of America® NC20016-4 (1/20)

TOLAK, 38 tolterodine, 32 tolterodine ext-rel, 31 TOPAMAX, 19 topiramate, 19 topiramate ext-rel, 18 topotecan caps, 13 torsemide, 17 TOVIAZ, 31 tramadol, 8 tramadol ext-rel, 7 trandolapril, 13 trandolapril/verapamil ext-rel, 13 tranylcypromine, 19 TRAVATAN Z, 42 travoprost, 42 trazodone, 20 TRELEGY ELLIPTA, 35 TREMFYA, 33 treprostinil ext-rel, 18 TRESIBA, 24 tretinoin, 38 tretinoin - Avita, 38 tretinoin caps, 13 tretinoin gel microsphere, 38 TREXALL, 12 TREXIMET, 22 triamcinolone acetonide crm 0.5%, 39 triamcinolone acetonide crm, lotion 0.025%, 39 triamcinolone acetonide crm, lotion, oint 0.1%, 39 triamcinolone acetonide spray, 37 triamcinolone paste, 40 triamterene/hydrochlorothiazide, 17 TRIBENZOR, 14 trifluoperazine, 20 trifluridine, 41 trihexyphenidyl, 20 TRILEPTAL, 19 TRILIPIX, 15 trimethobenzamide, 29 trimethoprim, 11 TRINTELLIX, 19 TRIUMEQ, 10 TROKENDI XR, 18 trospium, 31 trospium ext-rel, 31 TRULICITY, 24 TRUSOPT, 41 TRUVADA, 10 TYKERB, 13 TYMLOS, 26 TYSABRI, 22

U UDENYCA, 32 ULORIC, 7 ULTRAM, 8 ULTRAVATE, 39 umeclidinium bromide, 35 umeclidinium/vilanterol, 35 upadacitinib, 33 UPTRAVI, 17 URECHOLINE, 32 uridine triacetate, 13

UROCIT-K, 32 URSO, 30 ursodiol, 30 ustekinumab, 33

V VAGIFEM, 27 valacyclovir, 11 valbenazine, 22 valganciclovir, 11 VALIUM, 18 valproic acid, 19 valsartan, 14 valsartan/hydrochlorothiazide, 14 VANCOCIN, 11 vancomycin, 11 varenicline, 23 VARUBI, 29 VASCEPA, 15 VASERETIC, 14 VASOTEC, 13 VELPHORO, 28 VELTASSA, 28 VEMLIDY, 11 venlafaxine, 19 venlafaxine ext-rel, 19 verapamil ext-rel, 16 VFEND, 9 V-GO INSULIN INFUSION PUMP, 25 VIBERZI, 30 VIBRAMYCIN, 9 VICTOZA, 24 VIDEX EC, 10 vigabatrin, 18 VIGAMOX, 40 VIIBRYD, 19 vilazodone, 19 VIMPAT, 18 VIOKACE, 30 VIREAD, 10 VISCO-3, 8 VISTOGARD, 13 vitamin ADC/fluoride drops, 35 vitamin ADC/fluoride/iron drops, 35 voriconazole, 9 vorinostat, 13 vortioxetine, 19 VOSEVI, 11 VOTRIENT, 13 VRAYLAR, 20 VYTORIN, 15 VYVANSE, 21

W warfarin, 32 WELLBUTRIN SR, 20 WELLBUTRIN XL, 20

X XALATAN, 42 XARELTO, 32 XELJANZ, 33 XELJANZ XR, 33 XELODA, 12 XIFAXAN, 11

65 Nippon Life Insurance Company of America® NC20016-4 (1/20)

XIGDUO XR, 24 XIIDRA, 42 XOLAIR, 37 XTAMPZA ER, 8 XTANDI, 12 XULTOPHY, 24

Y YASMIN, 26 YONSA, 12

Z zafirlukast, 36 ZANAFLEX, 22 zanamivir, 11 ZANTAC, 30 ZARONTIN, 18 ZEJULA, 13 ZEMBRACE SYMTOUCH, 22 ZEMPLAR, 28 ZENPEP, 30 ZESTORETIC, 14 ZESTRIL, 13 ZIAC, 16

ZIAGEN, 10 zidovudine, 10 zileuton ext-rel, 36 ziprasidone, 20 ZITHROMAX, 9 ZOCOR, 15 ZOFRAN, 29 ZOLINZA, 13 zolmitriptan, 22 zolmitriptan nasal spray, 22 ZOLOFT, 19 zolpidem, 21 zolpidem ext-rel, 21 zolpidem sublingual, 21 ZOMIG, 22 zonisamide, 18 ZOVIRAX, 11 ZUBSOLV, 23 ZYBAN, 23 ZYCLARA, 38 ZYLOPRIM, 7 ZYPREXA, 20