2019 Formulary/Formulario (List of Covered Drugs)/(Lista de medicamentos cubiertos)

Transcription

1 209 Formulary/Formulario (List of Covered Drugs)/(Lista de medicamentos cubiertos) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA: ESTE DOCUMENTO TIENE INFORMACIÓN SOBRELOS MEDICAMENTOS CUBIERTOS EN ESTE PLAN FeelWel (HMO S l NP) CareWe l (HMO S l NP) Imagine your life with AgeWell New York The Way to Age Well in New York HPMS Approved Formulary File Submission ID: 958, Version Number: 5 This formulary was updated on 0/208. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or, for TTY users, , 7 days a week 24 hours a day, or visit H4922_SNPFormulary085_C NM

2 209 Part D Formulary (Comprehensive) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means AgeWell New York. When it refers to plan or our plan, it means FeelWell (HMO SNP), or CareWell (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 0/208. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 209, and from time to time during the year. What is the FeelWell (HMO SNP), or CareWell (HMO SNP) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at our plan s network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. i

3 209 Part D Formulary (Comprehensive) o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the plan s Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.). Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of 0/208. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event that the plan makes a mid-year non-maintenance formulary change, we will mail you updated information at least 60 days prior to the date the change becomes effective. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 2. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. ii

4 209 Part D Formulary (Comprehensive) What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, the plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that the plan will cover. For example, our plan provides 9 tablets per prescription for Sumatriptan Succinate 00 mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the plan s formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. iii

5 209 Part D Formulary (Comprehensive) If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan. You can ask the plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the FeelWell (HMO SNP), or CareWell (HMO SNP), Formulary? You can ask the plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. iv

6 209 Part D Formulary (Comprehensive) What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug while you pursue a formulary exception. Existing Member with Level of Care Changes If you are outside your transition period and experience a level of care change in which you are changing from one treatment setting to another (example: Long Term Care to hospital, hospital to home, home to Long Term Care), upon admission or discharge from a treatment setting or Long Term Care, we will allow you access to a 30/3 day refill (30 days in the retail setting and 3 days in the Long Term Care setting) for formulary medications and an emergency 30/3 day refill (30 days in the retail setting and 3 days in the Long Term Care setting) for non-formulary medications (including Part D drugs that are on our formulary but require prior authorization or step therapy). This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from Long Term Care or hospital facilities. To the extent that you are outside your 90-day transition period and are in an outpatient setting, we will still provide an emergency 30 day supply of non-formulary medications (including Part D drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), on a case by case basis, while an exception request is being processed. To the extent that you are outside your 90-day transition period and are in a Long Term Care setting, we will still provide an emergency 3 day supply of Part D covered non-formulary medications (including Part D covered drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), while an exception request is being processed. v

7 209 Part D Formulary (Comprehensive) For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit FeelWell (HMO SNP), or CareWell (HMO SNP) Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 2. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NAMENDA XR) and generic drugs are listed in lower-case italics (e.g., memantine). The information in the Requirements/Limits column tells you if the plan has any special requirements for coverage of your drug. vi

8 209 Part D Formulary (Comprehensive) LEGEND Symbol Name QL Quantity Limit PA Prior Authorization ST Step Therapy Description There is a limit on the amount of this drug that is covered per prescription or within a specific time frame. You (or your physician) are required to obtain a prior authorization before you fill your prescription for this drug. Without a prior authorization, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. MO Mail Order This prescription may also be available via mail. LA Limited Access This prescription drug is limited to certain pharmacies. HRM BD High Risk Medications Part B vs. Part D The Centers for Medicare and Medicaid Services (CMS) has identified the drug listed as posing a higher risk to patients, especially to seniors (PA required for ages 65 or over) This prescription drug may be covered under Medicare Part B or Part D depending on the circumstances. Tier Name Covered Medications vii

9 Formulario (integral) de la Parte D para 209 Nota para los miembros actuales: Este formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) dice nosotros, nos o nuestro/a, hace referencia a AgeWell New York. Cuando dice plan o nuestro plan, hace referencia a FeelWell (HMO SNP), ocarewell (HMO SNP). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual estará en vigencia a partir del 0/208. Para obtener un formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el Formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el de enero de 209 y periódicamente durante el año. Qué es el formulario FeelWell (HMO SNP), o CareWell (HMO SNP)? Un Formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, nuestro plan cubrirá los medicamentos incluidos en el Formulario siempre que el medicamento sea médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red del plan y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura. Puede cambiar el Formulario (lista de medicamentos)? En general, si usted toma un medicamento de nuestro Formulario para 209 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 209, excepto cuando esté disponible un nuevo medicamento genérico de menor costo, cuando se dé a conocer nueva información acerca de la seguridad o eficacia del medicamento o se retire el medicamento del mercado. (Para obtener más información sobre los cambios que afectan a los miembros que actualmente toman el medicamento, consulte las viñetas a continuación). Otros tipos de cambios en el Formulario, por ejemplo, la eliminación de un medicamento, no afectarán a los miembros que estén actualmente tomando el medicamento. Por el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo. A continuación, verá los cambios a la lista de medicamentos que también afectarán a los miembros que actualmente toman un medicamento: Medicamentos genéricos nuevos. Eliminaremos el medicamento de marca de la Lista de medicamentos de inmediato si lo reemplazaremos con un medicamento genérico nuevo que aparecerá en el mismo nivel de costo compartido o en uno inferior y con las mismas restricciones o menos restricciones. Además, cuando agreguemos un medicamento genérico nuevo, podemos decidir conservar el medicamento de marca en la Lista de medicamentos, pero lo pasaremos de inmediato a un nivel de costo compartido diferente o agregaremos restricciones nuevas. Si actualmente toma un medicamento de marca, podríamos no informarle antes de realizar el cambio, pero posteriormente le proporcionaremos información sobre los cambios específicos que realizamos. viii

10 Formulario (integral) de la Parte D para 209 o Si introducimos un cambio, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca. El aviso que le enviemos también incluirá información sobre los pasos que puede dar para solicitar una excepción y usted puede encontrar información en la siguiente sección titulada Cómo puedo solicitar una excepción al formulario del plan?. Medicamentos retirados del mercado. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que un medicamento de nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro Formulario y notificaremos a los miembros que toman el medicamento en cuestión. Otros cambios. Podríamos introducir otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca que actualmente esté en el Formulario o agregar restricciones nuevas al medicamento de marca o pasarlo a un nivel de costo compartido diferente. O bien, podríamos introducir cambios a partir de pautas clínicas nuevas. Si retiramos medicamentos de nuestro Formulario, [o] agregamos autorizaciones previas, límites de cantidad o restricciones en tratamientos escalonados en relación con un medicamento, debemos notificar sobre el cambio a los miembros afectados al menos 30 días antes de que entre en vigencia dicho cambio, o en el momento que el miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 30 días. El Formulario adjunto está vigente a partir del 0/208. Para recibir información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. En el caso de que el plan realice a mitad de año un cambio en el formulario no relacionado con su mantenimiento, le enviaremos por correo su información actualizada al menos 60 días antes de que entre en vigencia dicho cambio. Cómo utilizo el Formulario? Hay dos formas para encontrar su medicamento dentro del Formulario: Afección médica El Formulario empieza en la página. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca se enumeran dentro de la categoría agentes cardiovasculares. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página. Luego busque su medicamento debajo del nombre de la categoría. ix

11 Formulario (integral) de la Parte D para 209 Listado alfabético Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 2. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Nuestro plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Nuestro plan exige que usted [o su médico] obtengan una autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible que el plan no cubra el medicamento. Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Por ejemplo: nuestro plan provee 9 comprimidos de Sumatriptan Succinate 00 mg por receta. Esto puede ser complementario a un suministro estándar para uno o tres meses. Tratamiento escalonado: en algunos casos, nuestro plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces el plan cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el Formulario que empieza en la página. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones de tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. x

12 Formulario (integral) de la Parte D para 209 Puede pedirle a nuestro plan que haga una excepción a estas restricciones o límites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección Cómo solicito una excepción al formulario del plan? en la página IV para obtener información acerca de cómo solicitar una excepción. Qué pasa si mi medicamento no está en el Formulario? Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los miembros y preguntar si su medicamento está cubierto. Si resulta que nuestro plan no cubre el medicamento que toma, tiene dos alternativas: Puede pedir al Departamento de Servicios para los miembros una lista de medicamentos similares que estén cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por el plan. Puede solicitarle al plan que haga una excepción y cubra el medicamento. Consulte más abajo para obtener información sobre cómo solicitar una excepción. Cómo solicito una excepción para el formulario FeelWell (HMO SNP), o CareWell (HMO SNP)? Puede solicitarle al plan que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor. Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por ejemplo, para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor. xi

13 Formulario (integral) de la Parte D para 209 Por lo general, nuestro plan solo aprobará su pedido de excepción si los demás medicamentos incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario o a las restricciones de utilización. Cuando solicita una excepción al formulario o a la restricción de uso, usted debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite acelerado de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas. Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción? Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario, pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan. Para cada uno de los medicamentos que no está incluido en el Formulario, o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta está indicada para menos días, permitiremos obtener resurtidos de los medicamentos hasta llegar a un suministro máximo del medicamento para 30 días. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. Si reside en un centro de atención a largo plazo y necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 3 días mientras solicita la excepción al formulario. Miembro actual de un plan con cambios en el nivel de atención Si se encuentra fuera de su período de transición y experimenta cambios en el nivel de atención en el que pasaron de un entorno de tratamiento a otro (por ejemplo: de un centro de atención a largo plazo (Long Term Care, LTC) a un hospital, de un hospital a su casa, de su casa a un centro de LTC, al momento en que se lo admita o se le dé el alta en el entorno de tratamiento o centro de LTC, les permitiremos acceder a un resurtido para 30/3 días (30 días en el entorno minorista, y 3 días en el entorno de LTC) de medicamentos del formulario y a un resurtido de emergencia para 30/3 días (30 días en el entorno minorista, y 3 días en el entorno de LTC) de medicamentos que no se encuentran en el formulario (como medicamentos de la Parte xii

14 Formulario (integral) de la Parte D para 209 D que se encuentren en el formulario del patrocinador del plan pero que requieren autorización previa o tratamiento escalonado). Esta política no se aplica a licencias a corto plazo (como feriados y vacaciones) del centro de atención a largo plazo (LTC) o centro hospitalario. En la medida en que usted se encuentre fuera del período de transición de 90 días, y que se encuentre en un entorno para pacientes externos, le ofreceremos un suministro de emergencia para 30 días de medicamentos que no están en el formulario (como medicamentos de la Parte D que se encuentren en nuestro formulario y que de otro modo requerirían autorización previa o tratamiento escalonado en virtud de nuestras normas de manejo de la utilización de medicamentos), revisando caso por caso mientras se aguarda que se procese la solicitud de excepción. En la medida en que usted se encuentre fuera del período de transición de 90 días, y que se encuentre en un entorno de LTC, le ofreceremos un suministro de emergencia para 3 días de medicamentos cubiertos por la Parte D que no están en el formulario (como medicamentos cubiertos por la Parte D que se encuentren en nuestro formulario y que de otro modo requerirían autorización previa o tratamiento escalonado en virtud de nuestras normas de manejo de la utilización de medicamentos) mientras se aguarda que se procese la solicitud de excepción. Para obtener más información Para obtener información más detallada sobre la cobertura para medicamentos con receta del plan, consulte la Evidencia de cobertura y otra documentación del plan. Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al -800-MEDICARE ( ), durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite Formulario para FeelWell (HMO SNP), o CareWell (HMO SNP) El formulario que se incluye más abajo brinda información sobre la cobertura de los medicamentos que cubre nuestro plan. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice que comienza en la página 2. La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., NAMENDA XR), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., memantine). La información incluida en la columna de Requisitos/límites indica si el plan tiene algún requisito especial para la cobertura del medicamento. xiii

15 Formulario (integral) de la Parte D para 209 LEYENDA Símbolo Nombre QL PA ST Límite de cantidad Autorización previa Tratamiento escalonado Descripción Hay un límite en la cantidad de este medicamento que está cubierta por receta o dentro de un plazo de tiempo específico. Usted (o su médico) deben obtener una autorización previa antes de obtener su medicamento con receta. Es posible que no cubramos este medicamento sin una autorización previa. En algunos casos, es posible que usted primero deba probar ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. MO Pedido por correo Es posible que esta receta también esté disponible por correo. LA Acceso limitado Este medicamento con receta está limitado a ciertas farmacias. HRM BD Medicamento de alto riesgo Parte B en comparación con Parte D Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) identificaron los medicamentos que a continuación como de mayor riesgo para los pacientes, especialmente para los mayores (se necesita autorización previa para mayores de 65 años) Es posible que este medicamento con receta esté cubierto por la Parte B o la Parte D de Medicare, según las circunstancias. Nivel Nombre Medicamentos cubiertos xiv

16 LEGEND : Tier - Covered Medications BD: Part B vs Part D - This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HR: High Risk Medication - (PA required for ages 65 or over). LA: Limited Access - This prescription drug is limited to certain pharmacies. MO: Mail Order - This prescription may also be available via mail. PA: Prior Authorization - You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL: Quantity Limit - There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST: Step Therapy - In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208

17 Agewell (List of Covered Drugs) Drug Tier Requirements/Limits ANALGESICS OPIOID ANALGESICS, LONG- ACTING fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid mg/ml methadone hcl oral solution 0 mg/5ml, 5 mg/5ml methadone hcl oral tablet 0 mg, 5 mg morphine sulfate er beads oral capsule extended release 24 hour 20 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 0 mg, 00 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 00 mg, 5 mg, 200 mg, 30 mg, 60 mg oxycodone hcl er oral tablet er 2 hour abusedeterrent 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg OPIOID ANALGESICS, SHORT- ACTING PA; QL (20 EA per 30 days) QL (0 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (400 EA per 30 days) acetaminophen-codeine oral solution 20-2 mg/5ml acetaminophen-codeine oral tablet mg, mg ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg duramorph injection solution 0.5 mg/ml, mg/ml BD QL (5000 ML per 30 days) QL (400 EA per 30 days) PA; HR; QL (80 EA per 30 days) PA; HR; QL (370 EA per 30 days) PA; HR; QL (80 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 2

18 hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 5 mg, 30 mg oxycodone hcl oral capsule 5 mg oxycodone hcl oral concentrate 00 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 0 mg, 5 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (5500 ML per 30 days) QL (370 EA per 30 days) QL (50 EA per 30 days) QL (370 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet mg QL (360 EA per 30 days) oxymorphone hcl oral tablet 0 mg, 5 mg pentazocine-naloxone hcl oral tablet mg PA; HR tramadol hcl oral tablet 50 mg QL (240 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (370 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine-prilocaine external cream % ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI- CRAVING acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 3

19 VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG OPIOID ANTAGONISTS buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg, 8-2 mg naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution cartridge 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml NARCAN NASAL LIQUID 4 MG/0.ML SUBOXONE SUBLINGUAL FILM 2-3 MG, MG, 4- MG, 8-2 MG SMOKING CESSATION AGENTS bupropion hcl er (sr) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG QL (56 EA per 28 days) CHANTIX ORAL TABLET 0.5 MG QL (60 EA per 30 days) CHANTIX ORAL TABLET MG QL (80 EA per 90 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 NICOTROL INHALATION INHALER 0 MG ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/2ml gentamicin in saline intravenous solution mg/ml-%, -0.9 mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 40 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm tobramycin inhalation nebulization solution 300 mg/5ml QL (53 EA per 30 days) BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 4

20 tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml ANTIBACTERIALS, OTHER clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml colistimethate sodium (cba) injection solution reconstituted 50 mg daptomycin intravenous solution reconstituted 500 mg linezolid intravenous solution 600 mg/300ml linezolid oral suspension reconstituted 00 mg/5ml linezolid oral tablet 600 mg metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg, 500 mg nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg nitrofurantoin oral suspension 25 mg/5ml tigecycline intravenous solution reconstituted 50 mg trimethoprim oral tablet 00 mg vancomycin hcl intravenous solution reconstituted 0 gm, 000 mg, 500 mg vancomycin hcl oral capsule 25 mg vancomycin hcl oral capsule 250 mg XIFAXAN ORAL TABLET 200 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 5 BD BD XIFAXAN ORAL TABLET 550 MG BETA-LACTAM, CEPHALOSPORINS

21 cefaclor er oral tablet extended release 2 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 25 mg/5ml, 250 mg/5ml, 375 mg/5ml cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 0 gm, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 0 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg cefuroxime sodium intravenous solution reconstituted.5 gm cephalexin oral capsule 250 mg, 500 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 6 BD

22 cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TAZICEF INJECTION SOLUTION RECONSTITUTED GM, 2 GM, 6 GM TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG BETA-LACTAM, OTHER AZACTAM INJECTION SOLUTION RECONSTITUTED 2 GM aztreonam injection solution reconstituted gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 mg imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted gm, 500 mg BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 500 mg PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 7

23 ampicillin sodium injection solution reconstituted gm, 25 mg ampicillin sodium intravenous solution reconstituted 0 gm ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm, 5 (0-5) gm, 3 (2-) gm BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted gm nafcillin sodium intravenous solution reconstituted 0 gm oxacillin sodium injection solution reconstituted gm, 0 gm, 2 gm penicillin g pot in dextrose intravenous solution unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet gm azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack) azithromycin oral tablet 600 mg clarithromycin er oral tablet extended release 24 hour 500 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 8 BD BD

24 clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral tablet 400 mg QUINOLONES ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 200 mg/00ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 mg, 500 mg levofloxacin in d5w intravenous solution 500 mg/00ml, 750 mg/50ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg SULFONAMIDES sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg TETRACYCLINES DOXY 00 INTRAVENOUS SOLUTION RECONSTITUTED 00 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 9

25 doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet delayed release 00 mg, 50 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 00 mg, 50 mg, 50 mg, 75 mg minocycline hcl oral capsule 00 mg, 50 mg, 75 mg minocycline hcl oral tablet 00 mg, 50 mg, 75 mg SOLOXIDE ORAL TABLET DELAYED RELEASE 50 MG tetracycline hcl oral capsule 250 mg, 500 mg ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 0 levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg oxcarbazepine oral tablet 50 mg ROWEEPRA ORAL TABLET 000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG BARBITURATES ; QL (90 EA per 30 days) ; QL (20 EA per 30 days) phenobarbital oral elixir 20 mg/5ml PA; MO; HR phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg PA; MO; HR primidone oral tablet 250 mg, 50 mg BENZODIAZEPINES

26 clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 0 mg, 2.5 mg ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 0 MG ONFI ORAL TABLET 20 MG CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 00 mg, 25 mg, 50 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral tablet delayed release 250 mg, 500 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg SABRIL ORAL TABLET 500 MG tiagabine hcl oral tablet 2 mg, 6 mg, 2 mg, 4 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg vigabatrin oral packet 500 mg LA; MO

27 GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg LAMICTAL XR ORAL KIT 25 & 50 & 00 MG, 25 (2)-50 (7) MG, 50 & 00 & 200 MG lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 2 lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 00 mg, 200 mg, 25 mg, 50 mg lamotrigine starter kit-blue oral kit 25 (35) mg lamotrigine starter kit-green oral kit 25 (84)- 00(4) mg lamotrigine starter kit-orange oral kit 25 (42)-00 (7) mg topiramate er oral capsule er 24 hour sprinkle 00 mg, 50 mg, 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 200 mg, 25 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 25 MG, 50 MG TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG APTIOM ORAL TABLET 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 2 hour 200 mg, 300 mg carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg

28 carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 200 MG EQUETRO ORAL CAPSULE EXTENDED RELEASE 2 HOUR 00 MG, 200 MG, 300 MG oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg phenytoin sodium extended oral capsule 200 mg, 300 mg VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet mg PA; MO; HR CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 0 mg, 23 mg, 5 mg donepezil hcl oral tablet dispersible 0 mg, 5 mg galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 3

29 memantine hcl er oral capsule extended release 24 hour 4 mg, 2 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 0 mg, 5 mg memantine hcl oral tablet 5 (28)-0 (2) mg NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 4 & 2 &28-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 4 bupropion hcl oral tablet 00 mg, 75 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg nefazodone hcl oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 00 mg trazodone hcl oral tablet 50 mg, 50 mg trazodone hcl oral tablet 300 mg TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 0 & 20 MG MONOAMINE OXIDASE INHIBITORS ST; MO

30 EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral solution 0 mg/5ml citalopram hydrobromide oral tablet 0 mg, 20 mg, 40 mg desvenlafaxine er oral tablet extended release 24 hour 00 mg, 50 mg desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg fluoxetine hcl oral capsule delayed release 90 mg fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 0 mg, 20 mg fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er oral capsule extended release 24 hour 00 mg, 50 mg fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg olanzapine-fluoxetine hcl oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg paroxetine mesylate oral capsule 7.5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 5

31 PAXIL ORAL SUSPENSION 0 MG/5ML sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 00 mg, 25 mg, 50 mg venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 50 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg TRICYCLICS amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg PA; MO; HR PA; MO; HR PA; MO; HR doxepin hcl oral concentrate 0 mg/ml PA; MO; HR imipramine hcl oral tablet 0 mg, 25 mg, 50 mg PA; MO; HR imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg PA; MO; HR nortriptyline hcl oral solution 0 mg/5ml protriptyline hcl oral tablet 0 mg, 5 mg trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 2.5 mg, 25 mg PA; MO; HR metoclopramide hcl oral tablet 5 mg scopolamine transdermal patch 72 hour mg/3days EMETOGENIC THERAPY ADJUNCTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 6

32 aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg BD dronabinol oral capsule 0 mg BD; QL (60 EA per 30 days) dronabinol oral capsule 2.5 mg, 5 mg BD; QL (60 EA per 30 days) granisetron hcl oral tablet mg BD; QL (60 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml BD ondansetron hcl oral tablet 24 mg BD; QL (30 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg BD; QL (90 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg BD; QL (90 EA per 30 days) SYNDROS ORAL SOLUTION 5 MG/ML BD; QL (20 ML per 30 days) VARUBI ORAL TABLET 90 MG BD ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg clotrimazole mouth/throat lozenge 0 mg ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 25 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg BD BD BD BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 7

33 ketoconazole oral tablet 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nystatin oral tablet unit You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 8 terbinafine hcl oral tablet 250 mg QL (90 EA per 365 days) voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 00 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG ST; MO ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI- INFLAMMATORY DRUGS butalbital-apap-caffeine oral tablet mg QL (80 EA per 30 days) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg

34 flurbiprofen oral tablet 00 mg, 50 mg IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 00 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg PA; MO; HR indomethacin oral capsule 25 mg, 50 mg PA; MO; HR ketoprofen er oral capsule extended release 24 hour 200 mg ketorolac tromethamine oral tablet 0 mg PA; HR meloxicam oral tablet 5 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS, PROPHYLACTIC divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg topiramate oral tablet 00 mg ERGOT ALKALOIDS dihydroergotamine mesylate nasal solution 4 mg/ml ergotamine-caffeine oral tablet -00 mg QL (40 EA per 28 days) SEROTONIN (5-HT) B/D RECEPTOR AGONISTS eletriptan hydrobromide oral tablet 20 mg, 40 mg sumatriptan nasal solution 20 mg/act, 5 mg/act You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 9

35 sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 25 mg MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00 mg, 25 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg ANTITUBERCULARS ethambutol hcl oral tablet 00 mg, 400 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 50 MG rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 50 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25 mg, 50 mg BD GLEOSTINE ORAL CAPSULE 0 MG, 40 MG GLEOSTINE ORAL CAPSULE 00 MG HEXALEN ORAL CAPSULE 50 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 20

36 LEUKERAN ORAL TABLET 2 MG ANTIANGIOGENIC AGENTS DEPEN TITRATABS ORAL TABLET 250 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 25 MG, 5 MG PA; LA REVLIMID ORAL CAPSULE 2.5 MG, 20 MG PA THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG trientine hcl oral capsule 250 mg ANTIMETABOLITES DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG mercaptopurine oral tablet 50 mg PA; MO methotrexate oral tablet 2.5 mg BD methotrexate sodium (pf) injection solution 50 mg/2ml methotrexate sodium injection solution 250 mg/0ml primaquine phosphate oral tablet 26.3 mg PURIXAN ORAL SUSPENSION 2000 MG/00ML TABLOID ORAL TABLET 40 MG BD BD XATMEP ORAL SOLUTION 2.5 MG/ML BD ANTINEOPLASTICS ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 2 PA; LA; MO PA PA ALECENSA ORAL CAPSULE 50 MG PA ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLET THERAPY PACK 90 & 80 MG PA PA AZASAN ORAL TABLET 00 MG, 75 MG BD; MO bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg

37 BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA PA CALQUENCE ORAL CAPSULE 00 MG PA; LA CAPRELSA ORAL TABLET 00 MG, 300 MG PA COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA PA PA COTELLIC ORAL TABLET 20 MG PA; LA DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG EMCYT ORAL CAPSULE 40 MG BD BD ERIVEDGE ORAL CAPSULE 50 MG PA ERLEADA ORAL TABLET 60 MG PA; LA FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 20 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG fluorouracil external solution 2 %, 5 % flutamide oral capsule 25 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA BD BD PA PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA IDHIFA ORAL TABLET 00 MG, 50 MG PA imatinib mesylate oral tablet 00 mg, 400 mg PA IMBRUVICA ORAL CAPSULE 40 MG, 70 MG PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 22

38 IMBRUVICA ORAL TABLET 40 MG, 280 MG, 420 MG, 560 MG PA INLYTA ORAL TABLET MG, 5 MG PA INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT BD; MO BD; MO IRESSA ORAL TABLET 250 MG PA JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA KISQALI 200 DOSE ORAL TABLET 200 MG PA KISQALI 400 DOSE ORAL TABLET 200 MG PA KISQALI 600 DOSE ORAL TABLET 200 MG PA KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 MG LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG leucovorin calcium oral tablet 0 mg, 5 mg, 25 mg, 5 mg PA PA PA PA PA PA PA PA PA leuprolide acetate injection kit mg/0.2ml PA LONSURF ORAL TABLET MG, MG PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 23

39 LUPRON DEPOT (-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG PA PA PA PA LYNPARZA ORAL CAPSULE 50 MG PA LYNPARZA ORAL TABLET 00 MG, 50 MG PA; LA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 mg/ml PA; HR megestrol acetate oral suspension 625 mg/5ml PA; MO; HR megestrol acetate oral tablet 20 mg, 40 mg PA; HR MEKINIST ORAL TABLET 0.5 MG, 2 MG PA; LA NERLYNX ORAL TABLET 40 MG PA; LA NEXAVAR ORAL TABLET 200 MG PA; LA nilutamide oral tablet 50 mg NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA ODOMZO ORAL CAPSULE 200 MG PA; LA POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; LA PA RYDAPT ORAL CAPSULE 25 MG PA SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG PA STIVARGA ORAL TABLET 40 MG PA SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG PA PA; MO TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; LA TAGRISSO ORAL TABLET 40 MG, 80 MG PA; LA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 24

40 tamoxifen citrate oral tablet 0 mg, 20 mg TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG TASIGNA ORAL CAPSULE 50 MG, 200 MG, 50 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED.25 MG, 22.5 MG, 3.75 MG tretinoin oral capsule 0 mg TYKERB ORAL TABLET 250 MG PA PA BD VENCLEXTA ORAL TABLET 0 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 00 MG PA; LA VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA; LA PA; LA VOTRIENT ORAL TABLET 200 MG PA XALKORI ORAL CAPSULE 200 MG, 250 MG PA XTANDI ORAL CAPSULE 40 MG PA YONSA ORAL TABLET 25 MG PA ZEJULA ORAL CAPSULE 00 MG PA ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 00 MG PA ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG PA ZYTIGA ORAL TABLET 250 MG, 500 MG PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg TREATMENT ADJUNCTS allopurinol oral tablet 300 mg MESNEX ORAL TABLET 400 MG ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 25

41 benznidazole oral tablet 00 mg, 2.5 mg EMVERM ORAL TABLET CHEWABLE 00 MG ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG quinine sulfate oral capsule 324 mg ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate oral tablet 0.5 mg, mg, 2 mg BD PA; MO; HR trihexyphenidyl hcl oral elixir 0.4 mg/ml PA; MO; HR trihexyphenidyl hcl oral tablet 2 mg, 5 mg PA; MO; HR ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 00 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 00 mg entacapone oral tablet 200 mg GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 37 MG, 68.5 MG DOPAMINE AGONISTS PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 26

42 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML LA bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hour mg, 0.75 mg,.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, MG DOPAMINE PRECURSORS/ L- AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet 0-00 mg, mg, mg carbidopa-levodopa oral tablet dispersible 0-00 mg, mg, mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg MONOAMINE OXIDASE B (MAO-B) INHIBITORS ST; MO rasagiline mesylate oral tablet 0.5 mg, mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS ST GENERATION/TYPICAL chlorpromazine hcl oral tablet 0 mg, 25 mg BD; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 27

43 chlorpromazine hcl oral tablet 00 mg, 200 mg, 50 mg COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg haloperidol decanoate intramuscular solution 00 mg/ml, 00 mg/ml ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml, 5 mg/ml( ml prefilled syringe) haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 0 mg, 25 mg, 5 mg, 50 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg perphenazine-amitriptyline oral tablet 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg PA; MO; HR pimozide oral tablet mg, 2 mg prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg thioridazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg PA; MO; HR thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet mg, 0 mg, 2 mg, 5 mg 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 400 MG aripiprazole oral solution mg/ml ; QL (750 ML per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 28

44 aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet dispersible 0 mg, 5 mg FANAPT ORAL TABLET MG, 2 MG, 4 MG ST FANAPT ORAL TABLET 0 MG, 2 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET & 2 & 4 & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 7 MG/0.75ML, 56 MG/ML, 234 MG/.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 40 MG/.35ML, 546 MG/.75ML, 89 MG/2.625ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG ST ST ST NUPLAZID ORAL CAPSULE 34 MG PA; MO NUPLAZID ORAL TABLET 0 MG, 7 MG PA; MO olanzapine intramuscular solution reconstituted 0 mg olanzapine oral tablet 0 mg, 5 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 0 mg, 5 mg, 20 mg, 5 mg paliperidone er oral tablet extended release 24 hour.5 mg, 3 mg, 6 mg paliperidone er oral tablet extended release 24 hour 9 mg quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 29

45 RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG risperidone oral solution mg/ml risperidone oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 0 MG, 2.5 MG, 5 MG VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK.5 & 3 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 20 MG TREATMENT-RESISTANT clozapine oral tablet 00 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 00 mg, 2.5 mg, 50 mg, 25 mg clozapine oral tablet dispersible 200 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ ST; MO ST; MO ST ST VERSACLOZ ORAL SUSPENSION 50 MG/ML ST ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS valganciclovir hcl oral solution reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg VEMLIDY ORAL TABLET 25 MG ZIRGAN OPHTHALMIC GEL 0.5 % ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 0 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML

46 entecavir oral tablet 0.5 mg, mg RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG, 400 MG RIBASPHERE ORAL TABLET 600 MG ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING MAVYRET ORAL TABLET MG PA VOSEVI ORAL TABLET MG PA ANTI-HEPATITIS C (HCV) AGENTS, OTHER MODERIBA 200 DOSE PACK ORAL TABLET 600 MG MODERIBA 800 DOSE PACK ORAL TABLET 400 MG MODERIBA ORAL TABLET 200 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 80 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/0.5ML, 80 MCG/ML ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg ANTIHERPETIC AGENTS acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 3 PA PA acyclovir sodium intravenous solution 50 mg/ml BD famciclovir oral tablet 25 mg, 250 mg, 500 mg valacyclovir hcl oral tablet gm, 500 mg ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg, 50 mg efavirenz oral tablet 600 mg

47 GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG nevirapine er oral tablet extended release 24 hour 00 mg, 400 mg nevirapine oral tablet 200 mg ODEFSEY ORAL TABLET MG RESCRIPTOR ORAL TABLET 00 MG, 200 MG SYMFI LO ORAL TABLET MG ; QL (30 EA per 30 days) SYMFI ORAL TABLET MG ; QL (30 EA per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral solution 20 mg/ml abacavir sulfate oral tablet 300 mg abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg BIKTARVY ORAL TABLET MG ; QL (30 EA per 30 days) CIMDUO ORAL TABLET MG DESCOVY ORAL TABLET MG desloratadine oral tablet dispersible 5 mg didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/ML EVOTAZ ORAL TABLET MG JULUCA ORAL TABLET MG lamivudine oral solution 0 mg/ml lamivudine oral tablet 00 mg, 50 mg, 300 mg lamivudine-zidovudine oral tablet mg PREZCOBIX ORAL TABLET MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 32

48 stavudine oral capsule 5 mg, 20 mg, 30 mg, 40 mg tenofovir disoproxil fumarate oral tablet 300 mg TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX EC ORAL CAPSULE DELAYED RELEASE 25 MG VIDEX ORAL SOLUTION RECONSTITUTED 4 GM VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ZERIT ORAL SOLUTION RECONSTITUTED MG/ML zidovudine oral capsule 00 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 00 MG ISENTRESS ORAL TABLET CHEWABLE 25 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 300 MG, 75 MG SELZENTRY ORAL TABLET 25 MG STRIBILD ORAL TABLET MG TIVICAY ORAL TABLET 0 MG TIVICAY ORAL TABLET 25 MG, 50 MG TYBOST ORAL TABLET 50 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 33

49 ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir sulfate oral capsule 50 mg, 200 mg atazanavir sulfate oral capsule 300 mg CRIXIVAN ORAL CAPSULE 200 MG, 400 MG fosamprenavir calcium oral tablet 700 mg INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution mg/5ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL PACKET 00 MG NORVIR ORAL SOLUTION 80 MG/ML PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REYATAZ ORAL PACKET 50 MG ritonavir oral tablet 00 mg VIRACEPT ORAL TABLET 250 MG, 625 MG ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg oseltamivir phosphate oral suspension reconstituted 6 mg/ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 00 mg ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 34

50 hydroxyzine hcl oral syrup 0 mg/5ml PA; HR hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg PA; HR hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5 mg, mg, 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML PA; HR QL (20 EA per 30 days) QL (300 ML per 30 days) alprazolam oral tablet 0.25 mg, 0.5 mg QL (20 EA per 30 days) alprazolam oral tablet mg QL (80 EA per 30 days) alprazolam oral tablet 2 mg QL (50 EA per 30 days) alprazolam oral tablet dispersible 0.25 mg QL (720 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg QL (80 EA per 30 days) alprazolam oral tablet dispersible mg QL (360 EA per 30 days) alprazolam oral tablet dispersible 2 mg QL (50 EA per 30 days) chlordiazepoxide hcl oral capsule 0 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML QL (20 EA per 30 days) QL (80 EA per 30 days) QL (240 ML per 30 days) diazepam oral solution 5 mg/5ml QL (200 ML per 30 days) diazepam oral tablet 0 mg QL (20 EA per 30 days) diazepam oral tablet 2 mg QL (600 EA per 30 days) diazepam oral tablet 5 mg QL (240 EA per 30 days) lorazepam oral concentrate 2 mg/ml QL (240 ML per 30 days) lorazepam oral tablet 0.5 mg, mg, 2 mg QL (50 EA per 30 days) oxazepam oral capsule 0 mg, 5 mg, 30 mg QL (20 EA per 30 days) BIPOLAR AGENTS MOOD STABILIZERS carbamazepine er oral capsule extended release 2 hour 00 mg carbamazepine oral tablet chewable 00 mg lithium carbonate er oral tablet extended release 300 mg, 450 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 35

51 lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 00 mg, 25 mg, 50 mg ASSURE ID INSULIN SAFETY SYR 29G X /2" ML COMFORT ASSIST INSULIN SYRINGE 29G X /2" ML cvs gauze sterile pad 2"x2" CYCLOSET ORAL TABLET 0.8 MG EXEL COMFORT POINT PEN NEEDLE 29G X 2MM glimepiride oral tablet mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg glipizide oral tablet 0 mg, 5 mg glipizide-metformin hcl oral tablet mg, mg, mg global alcohol prep ease pad 70 % INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG INVOKANA ORAL TABLET 00 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 0 MG, 25 MG metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 36

52 metformin hcl oral tablet 000 mg, 500 mg, 850 mg miglitol oral tablet 00 mg, 25 mg, 50 mg nateglinide oral tablet 20 mg, 60 mg OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE, MG/DOSE pioglitazone hcl oral tablet 5 mg, 30 mg, 45 mg pioglitazone hcl-glimepiride oral tablet 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg preferred plus insulin syringe 28g x /2" 0.5 ml RELI-ON INSULIN SYRINGE 29G 0.3 ML repaglinide oral tablet 0.5 mg, mg, 2 mg repaglinide-metformin hcl oral tablet -500 mg, mg RIOMET ORAL SOLUTION 500 MG/5ML SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR UNT-MCG/ML SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 MCG/.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG ST; MO tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML,.5 MG/0.5ML valsartan-hydrochlorothiazide oral tablet mg VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 8 MG/3ML XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML ST; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 37

53 GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED MG GLUCAGON EMERGENCY INJECTION KIT MG PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 00 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 00 UNIT/ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 38

54 NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML, 200 UNIT/ML BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium subcutaneous solution 00 mg/ml, 20 mg/0.8ml, 50 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous solution 0 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, 7500 UNIT/0.3ML, UNIT/3.8ML FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET MG, 0 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin sodium oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 39

55 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 20 MG BLOOD FORMATION MODIFIERS EPOGEN INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 00 MCG/0.3ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG tranexamic acid oral tablet 650 mg ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML PLATELET MODIFYING AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ PA PA BD PA PA PA PA PA; MO PA anagrelide hcl oral capsule 0.5 mg, mg aspirin-dipyridamole er oral capsule extended release 2 hour mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg PA; MO; HR CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine hcl transdermal patch weekly 0. mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr methyldopa oral tablet 250 mg, 500 mg PA; MO; HR

56 midodrine hcl oral tablet 0 mg, 2.5 mg, 5 mg ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet mg, 2 mg, 4 mg, 8 mg prazosin hcl oral capsule mg, 2 mg, 5 mg terazosin hcl oral capsule mg, 0 mg, 2 mg, 5 mg terazosin hcl oral capsule 0 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 6 mg, 32 mg, 4 mg, 8 mg eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 50 mg, 300 mg, 75 mg losartan potassium oral tablet 00 mg, 25 mg, 50 mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 0 mg, 20 mg, 40 mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 5 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 4

57 ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg ANTIARRHYTHMICS amiodarone hcl oral tablet 00 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 00 mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 00 mg, 50 mg, 50 mg mexiletine hcl oral capsule 50 mg, 200 mg, 250 mg PA; MO; HR MULTAQ ORAL TABLET 400 MG PACERONE ORAL TABLET 00 MG, 200 MG, 400 MG propafenone hcl er oral capsule extended release 2 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 50 mg, 225 mg, 300 mg quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg ANTIHYPERTENSIVE COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine besy-benazepril hcl oral capsule 0-20 mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 0-60 mg, mg, 5-60 mg, mg amlodipine-olmesartan oral tablet 0-20 mg, 0-40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 42

58 benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan cilexetil-hctz oral tablet mg, mg, mg captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril-hydrochlorothiazide oral tablet 0-25 mg, mg ENTRESTO ORAL TABLET MG, 49-5 MG, MG fosinopril sodium-hctz oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan potassium-hctz oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol-hydrochlorothiazide oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, 5-25 mg, mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg olmesartan medoxomil-hctz oral tablet mg, mg, mg olmesartan-amlodipine-hctz oral tablet mg, mg, mg, mg, mg PA; MO PA; MO; HR pioglitazone hcl-glimepiride oral tablet 30-2 mg propranolol-hctz oral tablet mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg spironolactone-hctz oral tablet mg telmisartan-amlodipine oral tablet 40-0 mg, 40-5 mg, 80-0 mg, 80-5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 43

59 telmisartan-hctz oral tablet mg, mg, mg trandolapril-verapamil hcl er oral tablet extended release -240 mg, 2-80 mg, mg, mg triamterene-hctz oral capsule mg triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 00 mg, 25 mg, 50 mg bisoprolol fumarate oral tablet 0 mg, 5 mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg carvedilol phosphate er oral capsule extended release 24 hour 0 mg, 20 mg, 40 mg, 80 mg labetalol hcl oral tablet 00 mg, 200 mg, 300 mg metoprolol succinate er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 0 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 20 mg, 60 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 20 MG, 60 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 20 mg, 60 mg, 80 mg sotalol hcl oral tablet 20 mg, 60 mg, 240 mg, 80 mg timolol maleate oral tablet 0 mg, 20 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 44

60 CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG amlodipine besylate oral tablet 0 mg, 2.5 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 80 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg, 300 mg diltiazem hcl er oral capsule extended release 2 hour 20 mg, 60 mg, 90 mg diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg felodipine er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release 24 hour 7 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 80 MG, 240 MG, 300 MG TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG verapamil hcl er oral capsule extended release 24 hour 00 mg, 20 mg, 80 mg, 200 mg, 240 mg, 300 mg, 360 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 45

61 verapamil hcl er oral tablet extended release 20 mg, 80 mg, 240 mg verapamil hcl oral tablet 20 mg, 40 mg, 80 mg CARDIOVASCULAR AGENTS, OTHER amlodipine-atorvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg, mg, mg, mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg BIDIL ORAL TABLET MG CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; MO DIGITEK ORAL TABLET 25 MCG, 250 MCG DIGITEK ORAL TABLET 25 MCG, 250 MCG DIGOX ORAL TABLET 25 MCG, 250 MCG digoxin oral solution 0.05 mg/ml digoxin oral tablet 25 mcg, 250 mcg NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG pentoxifylline er oral tablet extended release 400 mg RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR 000 MG, 500 MG TEKTURNA HCT ORAL TABLET MG, MG, MG, MG PA TEKTURNA ORAL TABLET 50 MG, 300 MG DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide oral tablet 25 mg, 250 mg bumetanide oral tablet 0.5 mg, mg, 2 mg methazolamide oral tablet 25 mg, 50 mg DIURETICS, LOOP bumetanide injection solution 0.25 mg/ml furosemide injection solution 0 mg/ml, 0 mg/ml (4ml syringe) furosemide oral solution 0 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg DIURETICS, POTASSIUM-SPARING You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 46

62 amiloride hcl oral tablet 5 mg DEMSER ORAL CAPSULE 250 MG eplerenone oral tablet 25 mg, 50 mg spironolactone oral tablet 00 mg, 25 mg, 50 mg DIURETICS, THIAZIDE chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 2.5 mg hydrochlorothiazide oral tablet 2.5 mg, 25 mg, 50 mg indapamide oral tablet.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 0 mg, 2.5 mg, 5 mg DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 mg fenofibrate oral capsule 50 mg, 50 mg fenofibrate oral tablet 45 mg, 60 mg, 48 mg, 54 mg gemfibrozil oral tablet 600 mg DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 80 mg fluvastatin sodium er oral tablet extended release 24 hour 80 mg fluvastatin sodium oral capsule 20 mg, 40 mg LIVALO ORAL TABLET MG, 2 MG, 4 MG lovastatin oral tablet 0 mg, 20 mg, 40 mg pravastatin sodium oral tablet 0 mg, 20 mg, 40 mg, 80 mg rosuvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg, 80 mg DYSLIPIDEMICS, OTHER You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 47

63 cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet gm ezetimibe oral tablet 0 mg JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML niacin er (antihyperlipidemic) oral tablet extended release 000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG PA; MO PA; MO omega-3-acid ethyl esters oral capsule gm PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 50 MG/ML, 75 MG/ML REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40 MG/ML PA; MO PA; MO PA; MO PA; MO VASCEPA ORAL CAPSULE 0.5 GM, GM WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 625 MG VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 20 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 0 mg, 20 mg NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 48

64 nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg minoxidil oral tablet 0 mg, 2.5 mg CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg, 5 mg, 5 mg dextroamphetamine sulfate oral tablet 0 mg, 5 mg ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES atomoxetine hcl oral capsule 0 mg, 00 mg, 8 mg, 25 mg, 40 mg, 60 mg, 80 mg guanfacine hcl er oral tablet extended release 24 hour mg, 2 mg, 3 mg, 4 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 0 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 0 mg, 20 mg, 72 mg methylphenidate hcl er oral tablet extended release 24 hour 8 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 0 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 0 mg, 20 mg, 5 mg PA; MO; HR You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 49

65 CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO ORAL TABLET 2 MG, 6 MG, 9 MG PA; MO NUEDEXTA ORAL CAPSULE 20-0 MG PA; MO riluzole oral tablet 50 mg tetrabenazine oral tablet 2.5 mg, 25 mg PA; MO FIBROMYALGIA AGENTS LYRICA ORAL CAPSULE 00 MG, 50 MG SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 2.5 & 25 & 50 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 2 HOUR 0 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ PA; MO AUBAGIO ORAL TABLET 4 MG, 7 MG PA; LA; MO AVONEX INTRAMUSCULAR KIT 30 MCG PA; MO AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML PA; MO PA; MO BETASERON SUBCUTANEOUS KIT 0.3 MG PA; MO dalfampridine er oral tablet extended release 2 hour 0 mg PA; MO GILENYA ORAL CAPSULE 0.5 MG PA; MO glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN- INJECTOR 63 & 94 MCG/0.5ML PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 25 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MCG/0.5ML PA; MO PA PA PA; MO PA; MO SOLTAMOX ORAL SOLUTION 0 MG/5ML

66 TECFIDERA ORAL 20 & 240 MG PA TECFIDERA ORAL CAPSULE DELAYED RELEASE 20 MG, 240 MG DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS chlorhexidine gluconate mouth/throat solution 0.2 % lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG PA; MO pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0. % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS acitretin oral capsule 0 mg, 7.5 mg, 25 mg acyclovir external ointment 5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0. % amcinonide external lotion 0. % amcinonide external ointment 0. % ammonium lactate external cream 2 % ammonium lactate external lotion 2 % AMNESTEEM ORAL CAPSULE 0 MG, 20 MG, 40 MG benzoyl peroxide-erythromycin external gel 5-3 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 5

67 betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcitriol external ointment 3 mcg/gm ciclopirox external gel 0.77 % ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % CLARAVIS ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG clindamycin phosphate external gel % clindamycin phosphate external lotion % clindamycin phosphate external solution % clindamycin phosphate external swab % clobetasol prop emollient base external cream 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clotrimazole external cream % clotrimazole external solution % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CONDYLOX EXTERNAL GEL 0.5 % COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 52

68 COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.05 %, 0.25 % diclofenac sodium transdermal gel % PA; MO diclofenac sodium transdermal gel 3 % PA diclofenac sodium transdermal solution.5 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % econazole nitrate external cream % ELIDEL EXTERNAL CREAM % ery external pad 2 % erythromycin external gel 2 % erythromycin external solution 2 % EUCRISA EXTERNAL OINTMENT 2 % fluocinolone acetonide external cream 0.0 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.0 % fluocinolone acetonide scalp external oil 0.0 % fluocinonide emulsified base external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluorouracil external cream 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 53

69 HALOG EXTERNAL CREAM 0. % HALOG EXTERNAL OINTMENT 0. % hydrocortisone ace-pramoxine rectal cream - % hydrocortisone butyrate external cream 0. % hydrocortisone butyrate external ointment 0. % hydrocortisone butyrate external solution 0. % hydrocortisone external cream %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % imiquimod external cream 5 % isotretinoin oral capsule 0 mg, 20 mg, 30 mg, 40 mg JUBLIA EXTERNAL SOLUTION 0 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % lidocaine hcl external gel 2 % lidocaine hcl external solution 4 % lindane external shampoo % malathion external lotion 0.5 % methoxsalen rapid oral capsule 0 mg metronidazole external cream 0.75 % metronidazole external gel 0.75 %, % metronidazole external lotion 0.75 % mometasone furoate external cream 0. % mometasone furoate external ointment 0. % mometasone furoate external solution 0. % mupirocin calcium external cream 2 % mupirocin external ointment 2 % NYAMYC EXTERNAL POWDER UNIT/GM nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 54

70 nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM PANRETIN EXTERNAL GEL 0. % permethrin external cream 5 % PICATO EXTERNAL GEL 0.05 %, 0.05 % podofilox external solution 0.5 % prednicarbate external cream 0. % prednicarbate external ointment 0. % PROCTO-MED HC RECTAL CREAM 2.5 % PROCTO-PAK RECTAL CREAM % PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % REGRANEX EXTERNAL GEL 0.0 % PA SANTYL EXTERNAL OINTMENT 250 UNIT/GM selenium sulfide external lotion 2.5 % silver sulfadiazine external cream % SSD EXTERNAL CREAM % STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML sulfacetamide sodium (acne) external lotion 0 % tacrolimus external ointment 0.03 %, 0. % TARGRETIN EXTERNAL GEL % tazarotene external cream 0. % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0. % TOLAK EXTERNAL CREAM 4 % tretinoin external gel 0.0 %, %, 0.05 % triamcinolone acetonide external cream %, 0. %, 0.5 % PA; MO PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 55

71 triamcinolone acetonide external lotion %, 0. % triamcinolone acetonide external ointment %, 0. %, 0.5 % UCERIS RECTAL FOAM 2 MG/ACT VALCHLOR EXTERNAL GEL 0.06 % ELECTROLYTES/MINERALS/META LS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT CARBAGLU ORAL TABLET 200 MG dextrose-nacl intravenous solution %, %, %, %, %, %, %, % IONOSOL-MB IN D5W INTRAVENOUS SOLUTION ISOLYTE-P IN D5W INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON M0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON M5 ORAL TABLET EXTENDED RELEASE 5 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 0 MEQ, 8 MEQ magnesium sulfate injection solution 50 %, 50 % (0ml syringe) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 56

72 NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 48 INTRAVENOUS SOLUTION PLASMA-LYTE A INTRAVENOUS SOLUTION potassium chloride crys er oral tablet extended release 0 meq, 20 meq potassium chloride er oral capsule extended release 0 meq, 8 meq potassium chloride er oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-%, meq/l-% potassium chloride intravenous solution 0 meq/00ml, 2 meq/ml, 2 meq/ml (20 ml), 20 meq/00ml, 40 meq/00ml potassium chloride oral solution 20 meq/5ml (0%), 40 meq/5ml (20%) potassium citrate er oral tablet extended release 0 meq (080 mg), 5 meq (620 mg), 5 meq (540 mg) sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES INTRAVENOUS SOLUTION ELECTROLYTE/MINERAL/METAL MODIFIERS CHEMET ORAL CAPSULE 00 MG EXJADE ORAL TABLET SOLUBLE 25 MG, 250 MG, 500 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ FERRIPROX ORAL SOLUTION 00 MG/ML

73 FERRIPROX ORAL TABLET 500 MG KIONEX ORAL SUSPENSION 5 GM/60ML SAMSCA ORAL TABLET 5 MG, 30 MG PA sodium polystyrene sulfonate oral powder SPS ORAL SUSPENSION 5 GM/60ML VELTASSA ORAL PACKET 6.8 GM, 25.2 GM, 8.4 GM NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 0 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 0 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % CLINIMIX E/DEXTROSE (2.75/0) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (4.25/0) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX/DEXTROSE (4.25/0) INTRAVENOUS SOLUTION 4.25 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD

74 CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINISOL SF INTRAVENOUS SOLUTION 5 % BD BD BD BD BD BD BD dextrose intravenous solution 0 %, 5 % BD FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % HEPATAMINE INTRAVENOUS SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % BD BD BD BD nutrilipid intravenous emulsion 20 % BD PLENAMINE INTRAVENOUS SOLUTION 5 % PREMASOL INTRAVENOUS SOLUTION 0 %, 6 % PROCALAMINE INTRAVENOUS SOLUTION 3 % BD BD BD PROSOL INTRAVENOUS SOLUTION 20 % BD TRAVASOL INTRAVENOUS SOLUTION 0 % TROPHAMINE INTRAVENOUS SOLUTION 0 % VITAMINS prenatal oral tablet 27- mg sodium fluoride oral tablet 2.2 ( f) mg GASTROINTESTINAL AGENTS BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 59

75 ANTISPASMODICS, GASTROINTESTINAL dicyclomine hcl oral capsule 0 mg dicyclomine hcl oral solution 0 mg/5ml dicyclomine hcl oral tablet 20 mg glycopyrrolate oral tablet mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg GASTROINTESTINAL AGENTS, OTHER cromolyn sodium oral concentrate 00 mg/5ml diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg GATTEX SUBCUTANEOUS KIT 5 MG loperamide hcl oral capsule 2 mg metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg MOVANTIK ORAL TABLET 2.5 MG, 25 MG ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg HISTAMINE2 (H2) RECEPTOR ANTAGONISTS famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg ranitidine hcl oral capsule 50 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml ranitidine hcl oral tablet 50 mg, 300 mg IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5 mg, mg AMITIZA ORAL CAPSULE 24 MCG, 8 MCG LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG LAXATIVES You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 60

76 CLENPIQ ORAL SOLUTION MG- GM -GM/60ML enulose oral solution 0 gm/5ml GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM generlac oral solution 0 gm/5ml lactulose oral solution 0 gm/5ml peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM- GM SUPREP BOWEL PREP KIT ORAL SOLUTION GM/77ML TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM PROTECTANTS CARAFATE ORAL SUSPENSION GM/0ML misoprostol oral tablet 00 mcg, 200 mcg sucralfate oral tablet gm PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg lansoprazole oral capsule delayed release 5 mg, 30 mg omeprazole oral capsule delayed release 0 mg, 20 mg, 40 mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 6 ST; MO ST; MO

77 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ENZYME REPLACEMENT/ MODIFIERS CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT CYSTADANE ORAL POWDER KUVAN ORAL PACKET 00 MG, 500 MG PA; MO KUVAN ORAL TABLET SOLUBLE 00 MG PA; LA; MO levocarnitine oral solution gm/0ml BD; MO levocarnitine oral tablet 330 mg BD; MO miglustat oral capsule 00 mg PA; MO ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML LA; MO RAVICTI ORAL LIQUID. GM/ML XURIDEN ORAL PACKET 2 GM PA; MO ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT GENITOURINARY AGENTS ANTISPASMODICS, URINARY bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg darifenacin hydrobromide er oral tablet extended release 24 hour 5 mg, 7.5 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG oxybutynin chloride er oral tablet extended release 24 hour 0 mg, 5 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg ; QL (30 EA per 30 days)

78 tolterodine tartrate oral tablet mg, 2 mg BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er oral tablet extended release 24 hour 0 mg dutasteride oral capsule 0.5 mg dutasteride-tamsulosin hcl oral capsule mg ; QL (30 EA per 30 days) finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE 4 MG, 8 MG tamsulosin hcl oral capsule 0.4 mg GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 50 MG, 50 MG ELMIRON ORAL CAPSULE 00 MG sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS AURYXIA ORAL TABLET GM 20 MG(FE) PA; MO calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg sevelamer carbonate oral packet 0.8 gm, 2.4 gm sevelamer carbonate oral tablet 800 mg VELPHORO ORAL TABLET CHEWABLE 500 MG VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2 % estradiol vaginal cream 0. mg/gm estradiol vaginal tablet 0 mcg INTRAROSA VAGINAL INSERT 6.5 MG PA; MO metronidazole vaginal gel 0.75 % miconazole 3 vaginal suppository 200 mg PREMARIN VAGINAL CREAM MG/GM terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg YUVAFEM VAGINAL TABLET 0 MCG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 63

79 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOC ORTICOIDS budesonide er oral tablet extended release 24 hour 9 mg budesonide oral capsule delayed release particles 3 mg DEXAMETHASONE INTENSOL ORAL CONCENTRATE MG/ML dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg fludrocortisone acetate oral tablet 0. mg hydrocortisone oral tablet 0 mg, 20 mg, 5 mg methylprednisolone oral tablet 6 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy pack 4 mg prednisolone oral solution 5 mg/5ml prednisolone sodium phosphate oral solution 0 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 0 mg, 5 mg, 30 mg prednisone oral solution 5 mg/5ml prednisone oral tablet mg, 0 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 0 mg (2), 0 mg (48), 5 mg (2), 5 mg (48) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 0 mg oxandrolone oral tablet 2.5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 64

80 ANDROGENS ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (.62%) ANDROGEL TRANSDERMAL GEL MG/.25GM (.62%), 40.5 MG/2.5GM (.62%) danazol oral capsule 00 mg, 200 mg, 50 mg methyltestosterone oral capsule 0 mg testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml testosterone transdermal gel 0 mg/act (2%), 2.5 mg/act (%), 25 mg/2.5gm (%), 50 mg/5gm (%) testosterone transdermal solution 30 mg/act CONTRACEPTIVES ALTAVERA ORAL TABLET MG- MCG alyacen /35 oral tablet -35 mg-mcg AMETHIA ORAL TABLET &0.0 MG APRI ORAL TABLET MG-MCG ARANELLE ORAL TABLET 0.5// MG- MCG ASHLYNA ORAL TABLET &0.0 MG AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BLISOVI 24 FE ORAL TABLET -20 MG- MCG(24) BLISOVI FE.5/30 ORAL TABLET.5-30 MG-MCG BLISOVI FE /20 ORAL TABLET -20 MG- MCG briellyn oral tablet mg-mcg CAMILA ORAL TABLET 0.35 MG CAZIANT ORAL TABLET 0./0.25/ MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 65

81 CRYSELLE-28 ORAL TABLET MG- MCG CYCLAFEM /35 ORAL TABLET -35 MG- MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/- 35 MG-MCG DEBLITANE ORAL TABLET 0.35 MG DELYLA ORAL TABLET MG-MCG DEPO-SUBQ PROVERA 04 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 04 MG/0.65ML desogestrel-ethinyl estradiol oral tablet /0.0 mg (2/5), mg-mcg drospirenone-ethinyl estradiol oral tablet mg, mg EMOQUETTE ORAL TABLET MG- MCG ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MG-MCG ERRIN ORAL TABLET 0.35 MG ESTARYLLA ORAL TABLET MG- MCG ethynodiol diac-eth estradiol oral tablet -35 mgmcg, -50 mg-mcg FALMINA ORAL TABLET MG-MCG FEMYNOR ORAL TABLET MG-MCG GIANVI ORAL TABLET MG INCASSIA ORAL TABLET 0.35 MG INTROVALE ORAL TABLET MG ISIBLOOM ORAL TABLET MG-MCG JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG-MCG JUNEL.5/30 ORAL TABLET.5-30 MG- MCG JUNEL /20 ORAL TABLET -20 MG-MCG JUNEL FE.5/30 ORAL TABLET.5-30 MG- MCG JUNEL FE /20 ORAL TABLET -20 MG-MCG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 66

82 JUNEL FE 24 ORAL TABLET -20 MG- MCG(24) KARIVA ORAL TABLET /0.0 MG (2/5) KELNOR /35 ORAL TABLET -35 MG-MCG KELNOR /50 ORAL TABLET -50 MG-MCG KIMIDESS ORAL TABLET /0.0 MG (2/5) KURVELO ORAL TABLET MG-MCG LARIN.5/30 ORAL TABLET.5-30 MG- MCG LARIN /20 ORAL TABLET -20 MG-MCG LARIN FE.5/30 ORAL TABLET.5-30 MG- MCG LARIN FE /20 ORAL TABLET -20 MG-MCG LARISSIA ORAL TABLET MG-MCG LEENA ORAL TABLET 0.5// MG-MCG LESSINA ORAL TABLET MG-MCG LEVONEST ORAL TABLET levonorgest-eth estrad 9-day oral tablet &0.0 mg, mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg-mcg levonorg-eth estrad triphasic oral tablet LEVORA 0.5/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG- MCG LUTERA ORAL TABLET MG-MCG LYZA ORAL TABLET 0.35 MG marlissa oral tablet mg-mcg medroxyprogesterone acetate intramuscular suspension 50 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 50 mg/ml MICROGESTIN.5/30 ORAL TABLET.5-30 MG-MCG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 67

83 MICROGESTIN /20 ORAL TABLET -20 MG-MCG MICROGESTIN FE.5/30 ORAL TABLET.5-30 MG-MCG MICROGESTIN FE /20 ORAL TABLET -20 MG-MCG MILI ORAL TABLET MG-MCG MONONESSA ORAL TABLET MG- MCG NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/-35 MG-MCG NIKKI ORAL TABLET MG NORA-BE ORAL TABLET 0.35 MG norethin ace-eth estrad-fe oral tablet -20 mgmcg(24) norethindrone acet-ethinyl est oral tablet -20 mg-mcg norethindrone oral tablet 0.35 mg norethin-eth estradiol-fe oral tablet chewable mg-mcg norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.8/0.25/0.25 mg-25 mcg, 0.8/0.25/0.25 mg- 35 mcg NORLYROC ORAL TABLET 0.35 MG NORTREL 0.5/35 (28) ORAL TABLET MG-MCG NORTREL /35 (2) ORAL TABLET -35 MG- MCG NORTREL /35 (28) ORAL TABLET -35 MG- MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/-35 MG-MCG NUVARING VAGINAL RING MG/24HR OCELLA ORAL TABLET MG OGESTREL ORAL TABLET MG-MCG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 68

84 ORSYTHIA ORAL TABLET MG-MCG PIMTREA ORAL TABLET /0.0 MG (2/5) PIRMELLA /35 ORAL TABLET -35 MG- MCG PORTIA-28 ORAL TABLET MG-MCG PREVIFEM ORAL TABLET MG-MCG QUASENSE ORAL TABLET MG RECLIPSEN ORAL TABLET MG- MCG SETLAKIN ORAL TABLET MG SHAROBEL ORAL TABLET 0.35 MG SPRINTEC 28 ORAL TABLET MG- MCG SRONYX ORAL TABLET MG-MCG SYEDA ORAL TABLET MG TARINA FE /20 ORAL TABLET -20 MG- MCG TRI-LEGEST FE ORAL TABLET -20/-30/- 35 MG-MCG TRI-LO-ESTARYLLA ORAL TABLET 0.8/0.25/0.25 MG-25 MCG TRI-LO-SPRINTEC ORAL TABLET 0.8/0.25/0.25 MG-25 MCG TRI-MILI ORAL TABLET 0.8/0.25/0.25 MG- 35 MCG TRINESSA (28) ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRI-SPRINTEC ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET TRI-VYLIBRA ORAL TABLET 0.8/0.25/0.25 MG-35 MCG VELIVET ORAL TABLET 0./0.25/ MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ VIENVA ORAL TABLET MG-MCG VYFEMLA ORAL TABLET MG-MCG

85 VYLIBRA ORAL TABLET MG-MCG WYMZYA FE ORAL TABLET CHEWABLE MG-MCG ZARAH ORAL TABLET MG ZENCHENT ORAL TABLET MG-MCG ZOVIA /35E (28) ORAL TABLET -35 MG- MCG ESTROGENS estradiol oral tablet 0.5 mg, mg, 2 mg PA; MO; HR estradiol-norethindrone acet oral tablet mg, -0.5 mg PA; MO; HR FYAVOLV ORAL TABLET -5 MG-MCG PA; MO; HR JINTELI ORAL TABLET -5 MG-MCG PA; MO; HR MENEST ORAL TABLET 0.3 MG, MG,.25 MG norethindrone-eth estradiol oral tablet mg-mcg norethindrone-eth estradiol oral tablet -5 mgmcg PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PA; MO; HR PA; MO; HR PA; MO; HR PA; MO; HR PREMPHASE ORAL TABLET MG PA; MO; HR PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS medroxyprogesterone acetate oral tablet 0 mg, 2.5 mg, 5 mg PA; MO; HR norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 00 mg, 200 mg SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS OSPHENA ORAL TABLET 60 MG PA; MO raloxifene hcl oral tablet 60 mg HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 70

86 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) cabergoline oral tablet 0.5 mg desmopressin ace spray refrig nasal solution 0.0 % desmopressin acetate oral tablet 0. mg, 0.2 mg INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 0 MG/.5ML, 5 MG/.5ML, 30 MG/3ML, 5 MG/.5ML HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) LEVO-T ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG HORMONAL AGENTS, SUPPRESSANT (PITUITARY) PA; LA; MO PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 7

87 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) KORLYM ORAL TABLET 300 MG PA; LA; MO LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.25 MG octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection solution 000 mcg/ml, 500 mcg/ml SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 20 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SYNAREL NASAL SOLUTION 2 MG/ML HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS PA PA PA; LA; MO methimazole oral tablet 0 mg, 5 mg propylthiouracil oral tablet 50 mg IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG BD; MO BD; MO azathioprine oral tablet 50 mg BD; MO BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML cyclosporine modified oral capsule 00 mg, 25 mg, 50 mg BD; MO cyclosporine modified oral solution 00 mg/ml BD; MO cyclosporine oral capsule 00 mg, 25 mg BD; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 72

88 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, MG, 4 MG PA; MO PA PA; MO PA; MO BD; MO GENGRAF ORAL CAPSULE 00 MG, 25 MG BD; MO GENGRAF ORAL SOLUTION 00 MG/ML BD; MO HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.ML, 0 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML PA; MO PA; MO PA; MO PA; MO PA; MO mycophenolate mofetil oral capsule 250 mg BD; MO mycophenolate mofetil oral suspension reconstituted 200 mg/ml BD; MO mycophenolate mofetil oral tablet 500 mg BD; MO mycophenolate sodium oral tablet delayed release 80 mg, 360 mg BD; MO RAPAMUNE ORAL SOLUTION MG/ML BD; MO SANDIMMUNE ORAL SOLUTION 00 MG/ML SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 00 MG/ML, 50 MG/0.5ML BD; MO PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 73

89 SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML, 50 MG/0.5ML PA; MO sirolimus oral tablet 0.5 mg, mg BD; MO sirolimus oral tablet 2 mg BD; MO tacrolimus oral capsule 0.5 mg, mg BD; MO tacrolimus oral capsule 5 mg BD; MO TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG IMMUNIZING AGENTS, PASSIVE BIVIGAM INTRAVENOUS SOLUTION 0 GM/00ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 0 GM, 5 GM GAMMAKED INJECTION SOLUTION GM/0ML GAMMAPLEX INTRAVENOUS SOLUTION 0 GM/00ML, 0 GM/200ML, 20 GM/200ML, 5 GM/50ML GAMUNEX-C INJECTION SOLUTION GM/0ML OCTAGAM INTRAVENOUS SOLUTION GM/20ML, 2 GM/20ML PRIVIGEN INTRAVENOUS SOLUTION 20 GM/200ML VARIZIG INTRAMUSCULAR SOLUTION 25 UNIT/.2ML IMMUNOMODULATORS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG BD BD; MO BD BD BD BD BD BD BD BD BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ BD; MO leflunomide oral tablet 0 mg, 20 mg

90 XELJANZ ORAL TABLET 0 MG, 5 MG PA; MO XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION (PREFILLED SYRINGE), LF- MCG/0.5 bcg vaccine injection injectable BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) DAPTACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml ENGERIX-B INJECTION SUSPENSION 0 MCG/0.5ML, 20 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 440 EL U/ML, 440 EL U/ML ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML HIBERIX INJECTION SOLUTION RECONSTITUTED 0 MCG IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ BD BD

91 MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE PEDIARIX INTRAMUSCULAR SUSPENSION PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 0 MCG/ML, 0 MCG/ML (ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TWINRIX INTRAMUSCULAR SUSPENSION TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML ML VARIVAX SUBCUTANEOUS INJECTABLE 350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 9400 UNT/0.65ML INFLAMMATORY BOWEL DISEASE AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ BD BD

92 AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 mg LIALDA ORAL TABLET DELAYED RELEASE.2 GM mesalamine oral tablet delayed release 800 mg mesalamine rectal enema 4 gm METABOLIC BONE DISEASE AGENTS HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) paricalcitol oral capsule 4 mcg BD; MO SENSIPAR ORAL TABLET 30 MG BD; MO SENSIPAR ORAL TABLET 60 MG, 90 MG BD; MO METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 0 mg, 35 mg, 5 mg, 70 mg alendronate sodium oral tablet 40 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ calcitonin (salmon) nasal solution 200 unit/act BD; MO calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution mcg/ml ibandronate sodium oral tablet 50 mg NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG, 25 MCG, 50 MCG, 75 MCG PA; MO paricalcitol oral capsule mcg, 2 mcg BD; MO PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML risedronate sodium oral tablet 50 mg, 35 mg, 35 mg (2 pack), 35 mg (4 pack), 5 mg risedronate sodium oral tablet 30 mg risedronate sodium oral tablet delayed release 35 mg TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 320 MCG/.56ML XGEVA SUBCUTANEOUS SOLUTION 20 MG/.7ML PA; MO PA

93 MISCELLANEOUS MISCELLANEOUS CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT ENDARI ORAL PACKET 5 GM PA; LA; QL (80 EA per 30 days) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost ophthalmic solution 0.03 % latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.0 % TRAVATAN Z OPHTHALMIC SOLUTION % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution % pilocarpine hcl ophthalmic solution %, 2 %, 4 % proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC ANTI INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate ophthalmic solution 0.3 % MOXEZA OPHTHALMIC SOLUTION 0.5 % moxifloxacin hcl ophthalmic solution 0.5 % NATACYN OPHTHALMIC SUSPENSION 5 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 78

94 neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic solution 0 % tobramycin ophthalmic solution 0.3 % trifluridine ophthalmic solution % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION.5 % BROMSITE OPHTHALMIC SOLUTION % cromolyn sodium ophthalmic solution 4 % epinastine hcl ophthalmic solution 0.05 % olopatadine hcl ophthalmic solution 0. %, 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % PROLENSA OPHTHALMIC SOLUTION 0.07 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0. % apraclonidine hcl ophthalmic solution 0.5 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ AZOPT OPHTHALMIC SUSPENSION % betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.5 %, 0.2 % carteolol hcl ophthalmic solution % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution mg/ml levobunolol hcl ophthalmic solution 0.5 %

95 metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.25 % SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) OPHTHALMIC ANTI- INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CYSTARAN OPHTHALMIC SOLUTION 0.44 % dexamethasone sodium phosphate ophthalmic solution 0. % diclofenac sodium ophthalmic solution 0. % DUREZOL OPHTHALMIC EMULSION 0.05 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension prednisolone acetate ophthalmic suspension % PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 80

96 prednisolone sodium phosphate ophthalmic solution % sulfacetamide-prednisolone ophthalmic solution % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % OTIC AGENTS OTIC AGENTS acetic acid otic solution 2 % CIPRODEX OTIC SUSPENSION % ciprofloxacin hcl otic solution 0.2 % fluocinolone acetonide otic oil 0.0 % hydrocortisone-acetic acid otic solution -2 % neomycin-polymyxin-hc otic solution % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS ANTIHISTAMINES cetirizine hcl oral solution mg/ml desloratadine oral tablet 5 mg desloratadine oral tablet dispersible 2.5 mg levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT ASMANEX 20 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 8

97 ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 00 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 0 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT ANTILEUKOTRIENES BD; MO montelukast sodium oral packet 4 mg montelukast sodium oral tablet 0 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 0 mg, 20 mg zileuton er oral tablet extended release 2 hour 600 mg ZYFLO ORAL TABLET 600 MG BRONCHODILATORS, ANTICHOLINERGIC ipratropium bromide inhalation solution 0.02 % BD; MO SPIRIVA HANDIHALER INHALATION CAPSULE 8 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.25 MCG/ACT, 2.5 MCG/ACT BRONCHODILATORS, SYMPATHOMIMETIC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 82

98 ADVAIR HFA INHALATION AEROSOL 5-2 MCG/ACT, MCG/ACT, 45-2 MCG/ACT albuterol sulfate er oral tablet extended release 2 hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml,.25 mg/3ml BD; MO albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated 3-4 mcg/act, mcg/act, 55-4 mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml levalbuterol hcl inhalation nebulization solution 0.3 mg/3ml, 0.63 mg/3ml,.25 mg/0.5ml,.25 mg/3ml PROAIR HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 08 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT BD; MO BD; MO terbutaline sulfate oral tablet 2.5 mg, 5 mg TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH MAST CELL STABILIZERS ST; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 83

99 cromolyn sodium inhalation nebulization solution 20 mg/2ml NASAL AGENTS azelastine hcl nasal solution 0. %, 0.5 % flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act ipratropium bromide nasal solution 0.03 %, 0.06 % mometasone furoate nasal suspension 50 mcg/act PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE DALIRESP ORAL TABLET 250 MCG, 500 MCG theophylline er oral tablet extended release 2 hour 00 mg, 200 mg, 300 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg PULMONARY ANTIHYPERTENSIVES ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG BD; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/ ; QL (30 EA per 30 days) PA; MO LETAIRIS ORAL TABLET 0 MG, 5 MG PA; MO OPSUMIT ORAL TABLET 0 MG PA; MO sildenafil citrate oral tablet 20 mg PA; MO TRACLEER ORAL TABLET 25 MG, 62.5 MG PA; LA; MO TRACLEER ORAL TABLET SOLUBLE 32 MG PA; LA; MO UPTRAVI ORAL TABLET 000 MCG, 200 MCG, 400 MCG, 600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PULMONARY FIBROSIS AGENTS PA; LA; MO PA; LA ESBRIET ORAL CAPSULE 267 MG PA; MO ESBRIET ORAL TABLET 267 MG, 80 MG PA; MO OFEV ORAL CAPSULE 00 MG, 50 MG RESPIRATORY TRACT AGENTS, OTHER

100 acetylcysteine inhalation solution 0 %, 20 % BD epinephrine injection solution auto-injector 0.5 mg/0.3ml, 0.3 mg/0.3ml KALYDECO ORAL PACKET 50 MG, 75 MG PA; MO KALYDECO ORAL TABLET 50 MG PA; MO NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 00 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 000 MG PULMOZYME INHALATION SOLUTION MG/ML SYMDEKO ORAL TABLET THERAPY PACK & 50 MG XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 50 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS PA; MO PA; MO BD BD; MO PA; LA; MO PA; LA baclofen oral tablet 0 mg, 20 mg, 5 mg cyclobenzaprine hcl oral tablet 0 mg, 5 mg, 7.5 mg PA; HR methocarbamol oral tablet 500 mg, 750 mg PA; HR orphenadrine citrate er oral tablet extended release 2 hour 00 mg PA; HR tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg tizanidine hcl oral tablet 2 mg, 4 mg SLEEP DISORDER AGENTS BENZODIAZEPINES estazolam oral tablet mg QL (60 EA per 30 days) estazolam oral tablet 2 mg QL (30 EA per 30 days) flurazepam hcl oral capsule 5 mg QL (60 EA per 30 days) flurazepam hcl oral capsule 30 mg QL (30 EA per 30 days) temazepam oral capsule 5 mg, 22.5 mg, 30 mg QL (30 EA per 30 days) temazepam oral capsule 7.5 mg QL (20 EA per 30 days) triazolam oral tablet 0.25 mg QL (30 EA per 30 days) triazolam oral tablet 0.25 mg QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 85

101 GABA RECEPTOR MODULATORS zaleplon oral capsule 0 mg PA; HR; QL (60 EA per 30 days) zaleplon oral capsule 5 mg PA; HR; QL (30 EA per 30 days) zolpidem tartrate oral tablet 0 mg, 5 mg PA; HR; QL (30 EA per 30 days) SLEEP DISORDERS, OTHER BELSOMRA ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG HETLIOZ ORAL CAPSULE 20 MG PA; MO modafinil oral tablet 00 mg, 200 mg PA; MO; QL (30 EA per 30 days) SILENOR ORAL TABLET 3 MG, 6 MG XYREM ORAL SOLUTION 500 MG/ML LA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 958, Ver. 5 Updated 0/208 86

102 Alphabetical Listing A abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET... 7 ABILIFY MAINTENA acamprosate calcium... 3 acarbose acebutolol hcl acetaminophen-codeine... 2 acetaminophen-codeine # acetazolamide acetic acid... 8 acetylcysteine acitretin... 5 ACTHIB ACTIMMUNE... 2 acyclovir... 3, 5 acyclovir sodium... 3 ADACEL adefovir dipivoxil ADEMPAS ADVAIR DISKUS ADVAIR HFA AFEDITAB CR AFINITOR... 2 AFINITOR DISPERZ... 2 ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate... 5 ALECENSA... 2 alendronate sodium alfuzosin hcl er ALINIA allopurinol... 8, 25 alosetron hcl ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL 35 ALTAVERA ALUNBRIG... 2 alyacen / amantadine hcl AMBISOME... 7 amcinonide... 5 AMETHIA amikacin sulfate... 4 amiloride hcl amiloride-hydrochlorothiazide42 AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYTE S AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl AMITIZA amitriptyline hcl... 6 amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan 42 amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan-hctz ammonium lactate... 5 AMNESTEEM... 5 amoxapine... 6 amoxicillin... 7 amoxicillin-pot clavulanate... 7 amphetaminedextroamphetamine amphotericin b... 7 ampicillin... 7 ampicillin sodium... 8 ampicillin-sulbactam sodium... 8 AMPYRA ANADROL anagrelide hcl anastrozole ANDROGEL ANDROGEL PUMP ANORO ELLIPTA APOKYN apraclonidine hcl aprepitant... 7 APRI APRISO APTIOM... 2 APTIVUS ARANELLE ARCALYST aripiprazole... 28, 29 ARNUITY ELLIPTA... 8 ASCOMP-CODEINE... 2 ASHLYNA ASMANEX 20 METERED DOSES... 8 ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-dipyridamole er ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atazanavir sulfate atenolol atenolol-chlorthalidone atomoxetine hcl atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA... 3 atropine sulfate AUBAGIO AUBRA AURYXIA AUSTEDO AVIANE AVONEX AVONEX PEN AVONEX PREFILLED AZACTAM... 7 AZASAN... 2 azathioprine azelastine hcl... 79, 84 azithromycin... 8 AZOPT aztreonam... 7 B bacitracin bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen balsalazide disodium BALZIVA

103 BANZEL... 2 BARACLUDE bcg vaccine BELSOMRA benazepril hcl... 4 benazepril-hydrochlorothiazide BENLYSTA benznidazole benzoyl peroxide-erythromycin... 5 benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate.. 5, 52 betamethasone dipropionate aug... 5 betamethasone valerate BETASERON betaxolol hcl bethanechol chloride bexarotene... 2 BEXSERO bicalutamide... 2 BICILLIN L-A... 8 BIDIL BIKTARVY bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM BLEPHAMIDE BLEPHAMIDE S.O.P BLISOVI 24 FE BLISOVI FE.5/ BLISOVI FE / BOOSTRIX BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRIVIACT... 2 bromocriptine mesylate BROMSITE budesonide... 64, 82 budesonide er bumetanide buprenorphine hcl... 4 buprenorphine hcl-naloxone hcl... 4 bupropion hcl... 4 bupropion hcl er (smoking det)... 4 bupropion hcl er (sr)... 4, 4 bupropion hcl er (xl)... 4 buspirone hcl butalbital-apap-caff-cod... 2 butalbital-apap-caffeine... 8 butalbital-asa-caff-codeine... 2 BYSTOLIC C cabergoline... 7 CABOMETYX calcipotriene calcitonin (salmon) calcitriol... 52, 77 calcium acetate (phos binder). 63 CALQUENCE CAMILA candesartan cilexetil... 4 candesartan cilexetil-hctz CAPRELSA captopril... 4 captopril-hydrochlorothiazide 43 CARAFATE... 6 CARBAGLU carbamazepine... 3, 35 carbamazepine er... 2, 35 carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone CARIMUNE NF carteolol hcl CARTIA XT carvedilol carvedilol phosphate er caspofungin acetate... 7 CAYSTON... 7 CAZIANT cefaclor... 6 cefaclor er... 6 cefadroxil... 6 cefazolin sodium... 6 cefdinir... 6 cefepime hcl... 6 cefixime... 6 cefoxitin sodium... 6 cefpodoxime proxetil... 6 cefprozil... 6 ceftazidime... 6 ceftriaxone sodium... 6 cefuroxime axetil... 6 cefuroxime sodium... 6 celecoxib... 8 CELONTIN... cephalexin... 6, 7 cetirizine hcl... 8 CHANTIX... 4 CHANTIX CONTINUING MONTH PAK... 4 CHANTIX STARTING MONTH PAK... 4 CHEMET chlordiazepoxide hcl chlorhexidine gluconate... 5 chloroquine phosphate chlorothiazide chlorpromazine hcl... 27, 28 chlorthalidone cholestyramine cholestyramine light ciclopirox ciclopirox olamine cilostazol CIMDUO CINRYZE CIPRODEX... 8 ciprofloxacin... 9 ciprofloxacin hcl... 9, 78, 8 ciprofloxacin in d5w... 9 ciprofloxacin-ciproflox hcl er... 9 citalopram hydrobromide... 5 CLARAVIS clarithromycin... 9 clarithromycin er... 8 CLENPIQ... 6 clindamycin hcl... 5 clindamycin palmitate hcl... 5 clindamycin phosphate. 5, 52, 63 clindamycin phosphate in d5w. 5 CLINIMIX E/DEXTROSE (2.75/0) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/0)

104 CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/5) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/0) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/5) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) CLINISOL SF clobetasol prop emollient base52 clobetasol propionate clomipramine hcl... 6 clonazepam... clonidine hcl clopidogrel bisulfate clorazepate dipotassium clotrimazole... 7, 52 clotrimazole-betamethasone clozapine COARTEM colchicine... 8 colchicine-probenecid... 8 colestipol hcl colistimethate sodium (cba)... 5 COMBIGAN COMBIVENT RESPIMAT COMETRIQ (00 MG DAILY DOSE) COMETRIQ (40 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE COMPLERA... 3 COMPRO CONDYLOX CORLANOR COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COTELLIC CREON CRIXIVAN cromolyn sodium... 60, 79, 84 CRYSELLE cvs gauze sterile CYCLAFEM / CYCLAFEM 7/7/ cyclobenzaprine hcl cyclophosphamide CYCLOSET cyclosporine cyclosporine modified CYSTADANE CYSTAGON CYSTARAN D dalfampridine er DALIRESP danazol dapsone DAPTACEL daptomycin... 5 DARAPRIM darifenacin hydrobromide er.. 62 DEBLITANE DELYLA DEMSER DEPEN TITRATABS... 2 DEPO-PROVERA DEPO-SUBQ PROVERA DESCOVY desipramine hcl... 6 desloratadine... 32, 8 desmopressin ace spray refrig 7 desmopressin acetate... 7 desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine er... 5 desvenlafaxine succinate er... 5 dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phosphate DEXILANT... 6 dextroamphetamine sulfate dextroamphetamine sulfate er. 49 dextrose dextrose-nacl DIASTAT ACUDIAL... DIASTAT PEDIATRIC... diazepam..., 35 DIAZEPAM INTENSOL diclofenac potassium... 8 diclofenac sodium... 8, 53, 80 diclofenac sodium er... 8 dicloxacillin sodium... 8 dicyclomine hcl didanosine DIFICID... 9 diflorasone diacetate diflunisal... 8 DIGITEK DIGOX digoxin dihydroergotamine mesylate.. 9 DILANTIN... 3 diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads.. 45 dilt-xr diphenoxylate-atropine diphtheria-tetanus toxoids dt.. 75 dipyridamole disopyramide phosphate disulfiram... 3 divalproex sodium..., 9 divalproex sodium er... dofetilide donepezil hcl... 3 doripenem... 7 dorzolamide hcl dorzolamide hcl-timolol mal.. 79 doxazosin mesylate... 4 doxepin hcl... 6 DOXY doxycycline hyclate

105 doxycycline monohydrate... 0 dronabinol... 7 drospirenone-ethinyl estradiol 66 DROXIA... 2 duloxetine hcl... 5 duramorph... 2 DUREZOL dutasteride dutasteride-tamsulosin hcl E econazole nitrate EDURANT... 3 efavirenz... 3 eletriptan hydrobromide... 9 ELIDEL ELIGARD ELIQUIS ELIQUIS STARTER PACK.. 39 ELMIRON EMCYT EMOQUETTE EMSAM... 5 EMTRIVA EMVERM enalapril maleate... 4 enalapril-hydrochlorothiazide 43 ENBREL ENBREL SURECLICK ENDARI ENGERIX-B enoxaparin sodium ENPRESSE ENSKYCE entacapone entecavir... 3 ENTRESTO enulose... 6 ENVARSUS XR epinastine hcl epinephrine EPITOL... 3 EPIVIR HBV eplerenone EPOGEN eprosartan mesylate... 4 EQUETRO... 3 ERAXIS... 7 ergoloid mesylates... 3 ergotamine-caffeine... 9 ERIVEDGE ERLEADA ERRIN ery ERY-TAB... 9 ERYTHROCIN LACTOBIONATE... 9 ERYTHROCIN STEARATE... 9 erythromycin... 53, 78 erythromycin base... 9 erythromycin ethylsuccinate... 9 ESBRIET escitalopram oxalate... 5 esomeprazole magnesium... 6 ESTARYLLA estazolam estradiol... 63, 70 estradiol-norethindrone acet ethambutol hcl ethosuximide... ethynodiol diac-eth estradiol.. 66 etodolac... 8 etodolac er... 8 EUCRISA EVOTAZ EXEL COMFORT POINT PEN NEEDLE exemestane EXJADE ezetimibe F FALMINA famciclovir... 3 famotidine FANAPT FANAPT TITRATION PACK FARESTON FARYDAK felbamate... 2 felodipine er FEMYNOR fenofibrate fenofibrate micronized fentanyl... 2 fentanyl citrate... 2 FERRIPROX... 57, 58 FETZIMA... 5 FETZIMA TITRATION FIASP FIASP FLEXTOUCH finasteride FIRAZYR FIRMAGON FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole... 7 fluconazole in sodium chloride... 7 flucytosine... 7 fludrocortisone acetate flunisolide fluocinolone acetonide... 53, 8 fluocinolone acetonide scalp.. 53 fluocinonide fluocinonide emulsified base.. 53 fluorouracil... 22, 53 fluoxetine hcl... 5 fluphenazine decanoate fluphenazine hcl flurazepam hcl flurbiprofen... 9 flurbiprofen sodium flutamide fluticasone propionate... 53, 84 fluticasone-salmeterol fluvastatin sodium fluvastatin sodium er fluvoxamine maleate... 5 fluvoxamine maleate er... 5 fondaparinux sodium FORFIVO XL... 4 fosamprenavir calcium fosinopril sodium... 4 fosinopril sodium-hctz FRAGMIN FREAMINE HBC furosemide FUZEON FYAVOLV FYCOMPA... G gabapentin... galantamine hydrobromide... 3 galantamine hydrobromide er. 3 GAMMAGARD GAMMAGARD S/D LESS IGA GAMMAKED

106 GAMMAPLEX GAMUNEX-C GARDASIL GATTEX GAVILYTE-C... 6 GAVILYTE-G... 6 GAVILYTE-N WITH FLAVOR PACK... 6 gemfibrozil generlac... 6 GENGRAF GENTAK gentamicin in saline... 4 gentamicin sulfate... 4, 53, 78 GENVOYA GEODON GIANVI GILENYA GILOTRIF glatiramer acetate GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY 38 glycopyrrolate GOCOVRI granisetron hcl... 7 griseofulvin microsize... 7 griseofulvin ultramicrosize... 7 guanfacine hcl er guanidine hcl H halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HAVRIX heparin sodium (porcine) HEPATAMINE HETLIOZ HEXALEN HIBERIX HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CD/UC/HS STARTER HUMIRA PEN-PS/UV STARTER HUMULIN R U-500 (CONCENTRATED) HUMULIN R U-500 KWIKPEN hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 54, 64 hydrocortisone ace-pramoxine54 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid... 8 hydromorphone hcl... 2, 3 hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate I ibandronate sodium IBRANCE IBU... 9 ibuprofen... 9 ICLUSIG IDHIFA ILEVRO imatinib mesylate IMBRUVICA... 22, 23 imipenem-cilastatin... 7 imipramine hcl... 6 imipramine pamoate... 6 imiquimod IMOVAX RABIES INCASSIA INCRELEX... 7 indapamide indomethacin... 9 indomethacin er... 9 INFANRIX INLYTA INTELENCE INTRALIPID INTRAROSA INTRON A INTROVALE INVANZ... 7 INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W IPOL ipratropium bromide... 82, 84 ipratropium-albuterol irbesartan... 4 irbesartan-hydrochlorothiazide IRESSA ISENTRESS ISENTRESS HD ISIBLOOM ISOLYTE-P IN D5W ISOLYTE-S isoniazid isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isotretinoin isradipine itraconazole... 7 ivermectin IXIARO J JAKAFI JANTOVEN JANUMET JANUMET XR JANUVIA JARDIANCE JINTELI JOLIVETTE JUBLIA JULEBER JULUCA JUNEL.5/ JUNEL / JUNEL FE.5/ JUNEL FE / JUNEL FE JUXTAPID K KALETRA

107 KALYDECO KARIVA kcl in dextrose-nacl kcl-lactated ringers-d5w KELNOR / KELNOR / ketoconazole... 8, 54 ketoprofen er... 9 ketorolac tromethamine... 9, 80 KIMIDESS KINRIX KIONEX KISQALI 200 DOSE KISQALI 400 DOSE KISQALI 600 DOSE KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KORLYM KURVELO KUVAN KYNAMRO L labetalol hcl lactulose... 6 LAMICTAL XR... 2 lamivudine lamivudine-zidovudine lamotrigine... 2 lamotrigine er... 2 lamotrigine starter kit-blue... 2 lamotrigine starter kit-green... 2 lamotrigine starter kit-orange. 2 lansoprazole... 6 LANTUS LANTUS SOLOSTAR LARIN.5/ LARIN / LARIN FE.5/ LARIN FE / LARISSIA latanoprost LATUDA LEENA leflunomide LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN... 2 LEUKINE leuprolide acetate levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... 0 levetiracetam er... 0 levobunolol hcl levocarnitine levocetirizine dihydrochloride 8 levofloxacin... 9 levofloxacin in d5w... 9 LEVONEST levonorgest-eth estrad 9-day 67 levonorgestrel-ethinyl estrad.. 67 levonorg-eth estrad triphasic.. 67 LEVORA 0.5/30 (28) LEVO-T... 7 levothyroxine sodium... 7 LEVOXYL... 7 LEXIVA LIALDA lidocaine... 3 lidocaine hcl lidocaine viscous... 5 lidocaine-prilocaine... 3 lindane linezolid... 5 LINZESS liothyronine sodium... 7 lisinopril... 4 lisinopril-hydrochlorothiazide 43 lithium lithium carbonate lithium carbonate er LIVALO LONSURF loperamide hcl lopinavir-ritonavir lorazepam LORYNA losartan potassium... 4 losartan potassium-hctz LOTEMAX lovastatin LOW-OGESTREL loxapine succinate LUMIGAN LUPRON DEPOT (-MONTH) LUPRON DEPOT (3-MONTH)... 24, 72 LUPRON DEPOT (4-MONTH) LUPRON DEPOT (6-MONTH) LUTERA LYNPARZA LYRICA..., 50 LYSODREN LYZA M magnesium sulfate malathion maprotiline hcl... 4 marlissa MARPLAN... 5 MATULANE MAVYRET... 3 meclizine hcl... 6 medroxyprogesterone acetate 67, 70 mefloquine hcl megestrol acetate MEKINIST meloxicam... 9 memantine hcl... 4 memantine hcl er... 4 MENACTRA

108 MENEST MENVEO mercaptopurine... 2 meropenem... 7 mesalamine MESNEX MESTINON METADATE ER metformin hcl metformin hcl er methadone hcl... 2 methazolamide methimazole methocarbamol methotrexate... 2 methotrexate sodium... 2 methotrexate sodium (pf)... 2 methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylprednisolone methyltestosterone metipranolol metoclopramide hcl... 6, 60 metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 5, 54, 63 metronidazole in nacl... 5 mexiletine hcl miconazole MICROGESTIN.5/ MICROGESTIN / MICROGESTIN FE.5/ MICROGESTIN FE / midodrine hcl... 4 miglitol miglustat MILI minocycline hcl... 0 minoxidil MIRCERA mirtazapine... 4 misoprostol... 6 M-M-R II modafinil MODERIBA... 3 MODERIBA 200 DOSE PACK... 3 MODERIBA 800 DOSE PACK... 3 moexipril hcl... 4 moexipril-hydrochlorothiazide mometasone furoate... 54, 84 MONONESSA montelukast sodium morphine sulfate... 3 morphine sulfate (concentrate). 3 morphine sulfate er... 2 morphine sulfate er beads... 2 MOVANTIK MOXEZA moxifloxacin hcl MULTAQ mupirocin mupirocin calcium MYCAMINE... 8 mycophenolate mofetil mycophenolate sodium MYRBETRIQ N nabumetone... 9 nadolol nadolol-bendroflumethiazide.. 43 nafcillin sodium... 8 naloxone hcl... 4 naltrexone hcl... 3 NAMZARIC... 4 naproxen... 9 naproxen dr... 9 naproxen sodium... 9 NARCAN... 4 NATACYN nateglinide NATPARA NEBUPENT NECON 0.5/35 (28) NECON 7/7/ nefazodone hcl... 4 neomycin sulfate... 4 neomycin-bacitracin znpolymyx neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc... 80, 8 NEPHRAMINE NERLYNX NEUPOGEN NEUPRO nevirapine nevirapine er NEXAVAR niacin er (antihyperlipidemic) 48 NIACOR nicardipine hcl NICOTROL... 4 nifedipine er nifedipine er osmotic release.. 45 NIKKI nilutamide nimodipine NINLARO nisoldipine er NITRO-BID NITRO-DUR nitrofurantoin... 5 nitrofurantoin macrocrystal... 5 nitrofurantoin monohyd macro. 5 nitroglycerin... 48, 49 NORA-BE NORDITROPIN FLEXPRO.. 7 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est 68 norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic. 68 NORLYROC NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORTHERA NORTREL 0.5/35 (28) NORTREL /35 (2) NORTREL /35 (28) NORTREL 7/7/

109 nortriptyline hcl... 6 NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL... 8 NUCALA NUEDEXTA NUPLAZID nutrilipid NUVARING NYAMYC nystatin... 8, 5, 54 nystatin-triamcinolone NYSTOP O OCELLA OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 79, 8 OGESTREL olanzapine olanzapine-fluoxetine hcl... 5 olmesartan medoxomil... 4 olmesartan medoxomil-hctz olmesartan-amlodipine-hctz olopatadine hcl omega-3-acid ethyl esters omeprazole... 6 ondansetron... 7 ondansetron hcl... 7 ONFI... OPSUMIT ORAVIG... 5 ORFADIN ORKAMBI orphenadrine citrate er ORSYTHIA oseltamivir phosphate OSPHENA oxacillin sodium... 8 oxandrolone oxaprozin... 9 oxazepam oxcarbazepine... 0, 3 OXTELLAR XR... 3 oxybutynin chloride oxybutynin chloride er oxycodone hcl... 3 oxycodone hcl er... 2 oxycodone-acetaminophen... 3 oxycodone-aspirin... 3 oxycodone-ibuprofen... 3 oxymorphone hcl... 3 OZEMPIC P PACERONE paliperidone er PANRETIN pantoprazole sodium... 6 paricalcitol paromomycin sulfate... 4 paroxetine hcl... 5 paroxetine hcl er... 5 paroxetine mesylate... 5 PASER PAXIL... 6 PAZEO PEDIARIX PEDVAX HIB peg 3350/electrolytes... 6 peg 3350-kcl-na bicarb-nacl... 6 peg-3350/electrolytes... 6 PEGANONE... 3 PEGASYS... 3 PEGASYS PROCLICK... 3 penicillin g pot in dextrose... 8 penicillin g potassium... 8 penicillin g sodium... 8 penicillin v potassium... 8 PENTAM pentazocine-naloxone hcl... 3 pentoxifylline er perindopril erbumine... 4 permethrin perphenazine perphenazine-amitriptyline phenelzine sulfate... 5 phenobarbital... 0 phenytoin... 3 phenytoin sodium extended... 3 PHOSPHOLINE IODIDE PICATO pilocarpine hcl... 5, 78 pimozide PIMTREA pindolol pioglitazone hcl pioglitazone hcl-glimepiride.. 37, 43 pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so. 8 PIRMELLA / piroxicam... 9 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY PLEGRIDY STARTER PACK PLENAMINE podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST PORTIA potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er PRADAXA PRALUENT pramipexole dihydrochloride.. 27 pramipexole dihydrochloride er pravastatin sodium prazosin hcl... 4 prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 64, 8 prednisone preferred plus insulin syringe. 37 PREMARIN... 63, 70 PREMASOL PREMPHASE PREMPRO

110 prenatal PREPOPIK... 6 PREVIFEM PREZCOBIX PREZISTA PRIFTIN primaquine phosphate... 2 primidone... 0 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid... 8 PROCALAMINE prochlorperazine prochlorperazine maleate PROCRIT PROCTO-MED HC PROCTO-PAK PROCTOSOL HC PROCTOZONE-HC progesterone micronized PROGLYCEM PROLASTIN-C PROLENSA PROLIA PROMACTA promethazine hcl... 8 propafenone hcl propafenone hcl er proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl... 6 PULMOZYME PURIXAN... 2 pyrazinamide pyridostigmine bromide Q QUADRACEL QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl... 4 quinapril-hydrochlorothiazide 43 quinidine gluconate er quinidine sulfate quinine sulfate R RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RAVICTI RECLIPSEN RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE repaglinide repaglinide-metformin hcl REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR RESTASIS REVLIMID... 2 REXULTI REYATAZ RIBASPHERE... 3 ribavirin... 3 rifabutin rifampin RIFATER riluzole rimantadine hcl RIOMET risedronate sodium RISPERDAL CONSTA risperidone ritonavir rivastigmine... 3 rivastigmine tartrate... 3 ropinirole hcl rosuvastatin calcium ROTARIX ROTATEQ ROWEEPRA... 0 ROWEEPRA XR... 0 RUBRACA RYDAPT RYTARY S SABRIL... SAMSCA SANDIMMUNE SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK scopolamine... 6 selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline hcl... 6 SETLAKIN sevelamer carbonate SHAROBEL SHINGRIX SIGNIFOR sildenafil citrate SILENOR silver sulfadiazine SIMBRINZA SIMPONI... 73, 74 simvastatin sirolimus SIRTURO sodium chloride... 57, 63 sodium fluoride sodium lactate sodium polystyrene sulfonate. 58 SOLIQUA SOLOXIDE... 0 SOLTAMOX SOMATULINE DEPOT SOMAVERT SORINE sotalol hcl sotalol hcl (af) SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz SPRINTEC SPRITAM... 0 SPRYCEL SPS

111 SRONYX SSD stavudine STELARA STIOLTO RESPIMAT STIVARGA streptomycin sulfate... 4 STRIBILD SUBOXONE... 4 sucralfate... 6 sulfacetamide sodium sulfacetamide sodium (acne).. 55 sulfacetamide-prednisolone... 8 sulfadiazine... 9 sulfamethoxazole-trimethoprim 9 sulfasalazine... 9 sulindac... 9 sumatriptan... 9 sumatriptan succinate sumatriptan succinate refill SUPRAX... 7 SUPREP BOWEL PREP KIT 6 SUTENT SYEDA SYLATRON SYMDEKO SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYNAREL SYNDROS... 7 SYNJARDY SYNJARDY XR SYNRIBO SYNTHROID... 7 T TABLOID... 2 tacrolimus... 55, 74 TAFINLAR TAGRISSO tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN TARINA FE / TASIGNA tazarotene TAZICEF... 7 TAZORAC TAZTIA XT TECFIDERA... 5 TEFLARO... 7 TEKTURNA TEKTURNA HCT telmisartan... 4 telmisartan-amlodipine telmisartan-hctz temazepam TENIVAC tenofovir disoproxil fumarate. 33 terazosin hcl... 4 terbinafine hcl... 8 terbutaline sulfate terconazole testosterone testosterone cypionate testosterone enanthate tetanus-diphtheria toxoids td.. 76 tetrabenazine tetracycline hcl... 0 THALOMID... 2 theophylline er thioridazine hcl thiothixene tiagabine hcl... tigecycline... 5 timolol maleate... 44, 80 TIVICAY tizanidine hcl tobramycin... 4, 79 tobramycin sulfate... 5 tobramycin-dexamethasone... 8 TOLAK tolazamide tolbutamide tolterodine tartrate tolterodine tartrate er topiramate... 2, 9 topiramate er... 2 torsemide TOUJEO MAX SOLOSTAR. 39 TOUJEO SOLOSTAR TPN ELECTROLYTES TRACLEER tramadol hcl... 3 tramadol-acetaminophen... 3 trandolapril trandolapril-verapamil hcl er.. 44 tranexamic acid tranylcypromine sulfate... 5 TRAVASOL TRAVATAN Z trazodone hcl... 4 TRECATOR TRELEGY ELLIPTA TRELSTAR MIXJECT TRESIBA FLEXTOUCH tretinoin... 25, 55 TREXALL triamcinolone acetonide... 5, 55, 56 triamterene-hctz triazolam trientine hcl... 2 trifluoperazine hcl trifluridine trihexyphenidyl hcl TRI-LEGEST FE TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE... 6 trimethoprim... 5 TRI-MILI trimipramine maleate... 6 TRINESSA (28) TRINTELLIX... 4 TRI-PREVIFEM TRI-SPRINTEC TRIUMEQ TRIVORA (28) TRI-VYLIBRA TROKENDI XR... 2 TROPHAMINE TRULICITY TRUMENBA TRUVADA TWINRIX TYBOST TYKERB TYMLOS TYPHIM VI U UCERIS ULORIC... 8 UNITHROID... 7 UPTRAVI ursodiol V valacyclovir hcl

112 VALCHLOR valganciclovir hcl valproate sodium... valproic acid... valsartan... 4 valsartan-hydrochlorothiazide... 37, 44 vancomycin hcl... 5 VAQTA VARIVAX VARIZIG VARUBI... 7 VASCEPA VELIVET VELPHORO VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl... 6 venlafaxine hcl er... 6 verapamil hcl verapamil hcl er... 45, 46 VERSACLOZ VERZENIO VICTOZA VIDEX VIDEX EC VIENVA vigabatrin... VIIBRYD... 4 VIIBRYD STARTER PACK. 4 VIMPAT... 3 VIRACEPT VIRAMUNE VIREAD VIVITROL... 4 voriconazole... 8 VOSEVI... 3 VOTRIENT VRAYLAR VYFEMLA VYLIBRA W warfarin sodium WELCHOL WYMZYA FE X XALKORI XARELTO XARELTO STARTER PACK XATMEP... 2 XELJANZ XELJANZ XR XGEVA XIFAXAN... 5 XOLAIR XTANDI XULTOPHY XURIDEN XYREM Y YF-VAX YONSA YUVAFEM Z zafirlukast zaleplon ZARAH ZARXIO ZEJULA ZELBORAF ZENCHENT ZENPEP ZERIT zidovudine zileuton er ziprasidone hcl ZIRGAN ZOLINZA zolpidem tartrate zonisamide... ZORTRESS ZOSTAVAX ZOVIA /35E (28) ZYDELIG ZYFLO ZYKADIA ZYLET... 8 ZYPREXA RELPREVV ZYTIGA

113 AgeWell New York, LLC is a Health Maintenance Organization (HMO) plan with a Medicare contract and a Coordination of Benefits Agreement with New York State Department of Health. Enrollment in AgeWell New York, LLC depends on contract renewal. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Assistance services for other languages are also available free of charge at the number above. Notice of Non-Discrimination AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AgeWell New York does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AgeWell New York provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact AgeWell New York Member Services at If you believe that AgeWell New York has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: AgeWell New York Civil Rights Coordination Unit 99 Marcus Avenue Suite M20 Lake Success, New York TTY/TDD: Fax: civilrightsunit@agewellnewyork.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordination Unit is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, , TDD: Complaint forms are available at 24

114 AgeWell New York, LLC es un plan deorganización para el mantenimiento de la salud (Health Maintenance Organization, HMO) que tiene un contrato con Medicare y un convenio de coordinación de beneficios con el Departamento de Salud del estado de Nueva York. La inscripción en AgeWell New York, LLC depende de la renovación del contrato. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). También hay disponibles servicios de asistencia gratuitos para otros idiomas llamando al número que se menciona arriba. Aviso sobre no discriminación AgeWell New York cumple con todas las leyes federales sobre derechos civiles que corresponden y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York no excluye a las personas ni las trata diferente por su raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York proporciona ayuda y servicios gratuitos a personas con discapacidades a fin de que puedan comunicarse con nosotros eficazmente, como los siguientes: Intérpretes calificados de lenguaje de señas Información escrita en otros formatos (tamaño de letra grande, audio, formatos de acceso electrónico, otros formatos) Servicios lingüísticos gratuitos para personas cuyo idioma nativo no sea inglés, como intérpretes calificados e información escrita en otros idiomas Si necesita estos servicios, comuníquese con Servicios para miembros de AgeWell New York al Si considera que AgeWell New York no proporcionó estos servicios o hizo algún tipo de discriminación por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo ante: AgeWell New York Civil Rights Coordination Unit 99 Marcus Avenue Suite M20 Lake Success, New York TTY/TDD: Fax: Correo electrónico: civilrightsunit@agewellnewyork.com Puede interponer un reclamo personalmente o por correo postal, fax o correo electrónico. Si necesita ayuda para presentar un reclamo, la Unidad de Coordinación de Derechos Civiles está disponible para usted. También puede presentar una queja relacionada con los derechos civiles ante el Departamento de Salud y Servicios Sociales, Oficina de Derechos Civiles, en forma electrónica a través del Portal de Quejas ante la Oficina de Derechos Civiles, disponible en o bien por teléfono o correo a: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, , TDD: Los formularios de quejas se encuentran disponibles en 25

115 Multi-Language Insert / Encarte multilingüe English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Chínese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). Yiddish: אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופ ) (TTY: Bengali: লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). 26

116 Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Urdu : خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں.(TTY: ) Tagolog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). 27

117 We re here for your c all. This formulary was updated on 0/208. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or, for TTY users, , 7 days a week 24 hours a day, or visit agewellnewyork.com TTY/TDD