ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

Transcription

1 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 0 - /5 ml (5 ml), /.5 ml acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet 300-5, , ASCOMP WITH CODEINE ORAL CAPSULE MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG butalbital-acetaminop-caf-cod oral capsule PA PA PA butalbital-acetaminophen oral tablet PA butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule carisoprodol-asa-codeine oral tablet PA PA PA PA carisoprodol-aspirin oral tablet PA codeine-butalbital-asa-caff oral capsule ENDOCET ORAL TABLET 0-35 MG,.5-35 MG, 5-35 MG, MG hydrocodone-acetaminophen oral tablet 0-35,.5-35, 5-35, hydrocodone-ibuprofen oral tablet 0-00, IBU ORAL TABLET 600 MG, 800 MG PA

2 ibuprofen-oxycodone oral tablet oxycodone-acetaminophen oral tablet 0-35,.5-35, 5-35, oxycodone-aspirin oral tablet pentazocine-naloxone oral tablet PA tramadol-acetaminophen oral tablet NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 00, 00, 400, 50 COMFORT PAC-IBUPROFEN KIT 800 MG COMFORT PAC-MELOXICAM KIT 5 MG COMFORT PAC-NAPROXEN KIT 500 MG diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 DICLOZOR TOPICAL KIT % diflunisal oral tablet 500 etodolac oral capsule 00, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 4 hr 400, 500, 600 flurbiprofen oral tablet 00, 50 hydrocodone-ibuprofen oral tablet 5-00 ibuprofen oral suspension 00 /5 ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5, 50 PA indomethacin oral capsule, extended release 75 PA ketorolac oral tablet 0 PAQL (0 EA per 30 days) meclofenamate oral capsule 00, 50 meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750

3 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 75, 550 piroxicam oral capsule 0, 0 sulindac oral tablet 50, 00 OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour fentanyl transdermal patch 7 hour 00 mcg/hr PA fentanyl transdermal patch 7 hour mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (4 EA per 8 days) QL (0 EA per 30 days) methadone oral solution 0 /5 ml QL (00 ML per 30 days) methadone oral solution 5 /5 ml QL (400 ML per 30 days) methadone oral tablet 0 PA methadone oral tablet 5 QL (80 EA per 30 days) morphine oral tablet extended release 00, 00 morphine oral tablet extended release 5, 30, 60 oxycodone oral tablet,oral only,ext.rel. hr 0, 5, 0, 30, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate nasal spray,non-aerosol 0 /ml DURARPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg PA QL (60 EA per 30 days) PA QL (5 ML per 30 days) B/D PAQL (0 EA per 30 days) 3

4 hydromorphone (pf) injection solution /ml, 0 (/ml) (5 ml), 0 /ml, 4 /ml hydromorphone injection syringe /ml hydromorphone oral tablet, 4, 8 QL (0 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY 4 PAQL (600 EA per 30 days) PAQL (50 EA per 30 days) meperidine oral solution 50 /5 ml PAQL (900 ML per 30 days) meperidine oral tablet 00, 50 PAQL (80 EA per 30 days) morphine oral tablet 5, 30 QL (0 EA per 30 days) nalbuphine injection solution 0 /ml B/D oxycodone oral solution 5 /5 ml QL (5400 ML per 30 days) oxycodone oral tablet 0, 5, 0, 30, 5 QL (0 EA per 30 days) tramadol oral tablet 50 QL (40 EA per 30 days) ANESTHETICS - LOCAL TREATMENT OF PAIN LOCAL ANESTHETICS ANODYNE LPT TOPICAL KIT.5-.5 % DERMACINRX EMPRICAINE TOPICAL KIT.5-.5 % diclofenac sodium topical gel % LEVA SET TOPICAL KIT.5-.5 % lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PAQL (90 EA per 30 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LIDOPAC TOPICAL KIT 5 %

5 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 LIDOPRIL TOPICAL KIT.5-.5 % LIDOPRIL XR TOPICAL KIT.5-.5 % LIDO-PRILO CAINE PACK TOPICAL KIT.5-.5 % LIPROZONEPAK TOPICAL KIT.5-.5 % LIVIXIL PAK TOPICAL KIT.5-.5 % MEDOLOR PAK TOPICAL KIT.5-.5 % PRILOLID TOPICAL KIT.5-.5 % ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED.8 % PA ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF SUBSTANCE ABUSE DISORDERS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 50, 500 OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- LUCEMYRA ORAL TABLET 0.8 MG PAQL (4 EA per 4 days) naltrexone oral tablet 50 OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION SKING CESSATION AGENTS bupropion hcl (smoking deter) oral tablet extended release hr 50 5

6 CHANTIX CONTINUING NTH BOX ORAL TABLET MG QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (336 EA per 365 days) CHANTIX STARTING NTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML QL (06 EA per 365 days) ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS AMINOGLYCOSIDES amikacin injection solution 500 / ml GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 80 /00 ml, 80 /50 ml gentamicin injection solution 40 /ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 paromomycin oral capsule 50 streptomycin intramuscular recon soln gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection recon soln. gram tobramycin sulfate injection solution 0 /ml, 40 /ml tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ANTIBACTERIALS, OTHER 6

7 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 acetic acid otic (ear) solution % AK-POLY-BAC OPHTHALMIC (EYE) OINTMENT 500-0,000 UNIT/GRAM bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % clindamycin hcl oral capsule 50, 300, 75 clindamycin in 0.9 % sod chlor intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML clindamycin phosphate injection solution 50 (/ml) (6 ml), 50 /ml clindamycin phosphate intravenous solution 300 / ml, 600 /4 ml, 900 /6 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 350, 500 PA 7

8 linezolid in dextrose 5% intravenous piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml methenamine hippurate oral tablet gram METRO I.V. INTRAVENOUS PIGGYBACK 500 MG/00 ML metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 50, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical gel with pump % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0, unit-/ml nitrofurantoin macrocrystal oral capsule 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 B/D 8 B/D QL (360 EA per 365 days) QL (80 EA per 365 days)

9 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 nitrofurantoin monohyd/m-cryst oral capsule 00 (75/5) polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- /ml tinidazole oral tablet 50, 500 trimethoprim oral tablet 00 vancomycin injection recon soln 00 gram vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin intravenous recon soln.5 gram,.5 gram, 50 vancomycin oral capsule 5, 50 BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefepime in dextrose 5 % intravenous piggyback gram/50 ml, gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, gram/00 ml QL (360 EA per 365 days) 9

10 cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, gram, 500 cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime in d5w intravenous piggyback gram/50 ml, gram/50 ml ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 ceftriaxone injection recon soln 00 gram ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 400 MG TAZICEF INJECTION RECON SOLN GRAM, GRAM, 6 GRAM 0

11 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 TAZICEF INTRAVENOUS RECON SOLN GRAM, GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection recon soln gram PA doripenem intravenous recon soln 500 PA ertapenem injection recon soln gram PA imipenem-cilastatin intravenous recon soln 50, 500 meropenem intravenous recon soln gram, 500 meropenem-0.9% sodium chloride intravenous piggyback gram/50 ml, 500 /50 ml VABOMERE INTRAVENOUS RECON SOLN GRAM BETA-LACTAM, PENICILLINS amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 500 B/D PA

12 ampicillin sodium injection recon soln gram, 0 gram, 5 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin injection recon soln gram nafcillin intravenous recon soln gram, gram penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous recon soln 3.5 gram piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram MACROLIDES azithromycin intravenous recon soln 500 azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 50 (6 pack), 500, 500 (3 pack), 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500

13 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG PA ERY PADS TOPICAL SWAB % ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) erythromycin oral tablet 50, 500 erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 00, 50, 500, 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 moxifloxacin in nacl (iso-osm) intravenous piggyback 400 /50 ml 3

14 moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 moxifloxacin-sod.ace,sul-water intravenous piggyback 400 /50 ml ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 300, 400 SULFONAMIDES silver sulfadiazine topical cream % SSD TOPICAL CREAM % sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , TETRACYCLINES DOXY-00 INTRAVENOUS RECON SOLN 00 MG doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral tablet 00, 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 RGIDOX X 50 KIT 50 MG RGIDOX ORAL CAPSULE 50 MG tetracycline oral capsule 50, 500 4

15 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ANTICONVULSANTS - TREATMENT OF SEIZURES ANTICONVULSANTS, OTHER BRIVIACT ORAL SOLUTION 0 MG/ML ST; BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG ST; EPIDIOLEX ORAL SOLUTION 00 MG/ML PA levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 4 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 00, 5, 50 ST; QL (60 EA per 30 days) ST; QL (0 EA per 30 days) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS clobazam oral suspension.5 /ml PAQL (480 ML per 30 days) clobazam oral tablet 0, 0 PAQL (60 EA per 30 days) 5

16 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam rectal kit ,.5, divalproex oral capsule, delayed rel sprinkle 5 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 gabapentin oral capsule 00, 300, 400 gabapentin oral solution 50 /5 ml, 50 /5 ml (5 ml), 300 /6 ml (6 ml) gabapentin oral tablet 600, 800 phenobarbital oral elixir 0 /5 ml (4 /ml) PA phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. primidone oral tablet 50, 50 PA SABRIL ORAL TABLET 500 MG PAQL (80 EA per 30 days) SYMPAZAN ORAL FILM 0 MG, 0 MG, 5 MG PAQL (60 EA per 30 days) tiagabine oral tablet, 6,, 4 valproic acid (as sodium salt) oral solution 50 /5 ml, 50 /5 ml (5 ml), 500 /0 ml (0 ml) valproic acid oral capsule 50 vigabatrin oral powder in packet 500 PA vigabatrin oral tablet 500 PAQL (80 EA per 30 days) VIGADRONE ORAL POWDER IN PACKET 500 MG GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 PA FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST; 6

17 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet extended release 4hr 00, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable dispersible 5, 5 SUBVENITE ORAL TABLET 00 MG, 50 MG, 00 MG, 5 MG SUBVENITE STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 5 MG (35) SUBVENITE STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 MG (84) -00 MG (4) SUBVENITE STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 5 MG (4) -00 MG (7) topiramate oral capsule, sprinkle 5, 5 topiramate oral tablet 00, 00, 5, 50 SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG ST; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG ST; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML PAQL (400 ML per 30 days) BANZEL ORAL TABLET 00 MG, 400 MG PAQL (40 EA per 30 days) carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet extended release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 00 MG 7

18 oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 PEGANONE ORAL TABLET 50 MG PHENYTEK ORAL CAPSULE 00 MG, 300 MG phenytoin oral suspension 00 /4 ml, 5 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 00, 300 VIMPAT ORAL SOLUTION 0 MG/ML ST; QL (00 ML per 30 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet PA CHOLINESTERASE INHIBITORS donepezil oral tablet 0, 3, 5 donepezil oral tablet,disintegrating 0, 5 galantamine oral capsule,ext rel. pellets 4 hr 6, 4, 8 galantamine oral tablet, 4, 8 rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 4 hour 3.3 /4 hour, 4.6 /4 hr, 9.5 /4 hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 4hr 4,, 8, 7 memantine oral tablet 0, 5 memantine oral tablets,dose pack 5-0 NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG ANTIDEPRESSANTS - TREATMENT OF DEPRESSION 8 ST; QL (60 EA per 30 days) QL (30 EA per 30 days)

19 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ANTIDEPRESSANTS, OTHER bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release 4 hr 50, 300, 450 bupropion hcl oral tablet sustained-release hr 00, 50, 00 FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 MG mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 30, 45 nefazodone oral tablet 00, 50, 00, 50, 50 perphenazine-amitriptyline oral tablet -0, - 5, 4-0, 4-5, 4-50 trazodone oral tablet 00, 50, 300, 50 NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 4 HOUR MG/4 HR, 6 MG/4 HR, 9 MG/4 HR MARPLAN ORAL TABLET 0 MG phenelzine oral tablet 5 tranylcypromine oral tablet 0 SSRIS/ SNRIS citalopram oral solution 0 /5 ml citalopram oral tablet 0, 0, 40 desvenlafaxine succinate oral tablet extended release 4 hr 00, 5, 50 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 PA 9

20 FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 0, 0 fluvoxamine oral tablet 00, 5, 50 maprotiline oral tablet 5, 50, 75 paroxetine hcl oral tablet 0, 0, 30, 40 paroxetine hcl oral tablet extended release 4 hr.5, 5, 37.5 PAXIL ORAL SUSPENSION 0 MG/5 ML sertraline oral concentrate 0 /ml sertraline oral tablet 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 50, 37.5, 75 venlafaxine oral tablet 00, 5, 37.5, 50, 75 venlafaxine oral tablet extended release 4hr 50, 5, 37.5, 75 VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 0 MG (3) TRICYCLICS amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amoxapine oral tablet 00, 50, 5, 50 ST; ST; 0 ST; ST; ST; PA

21 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 clomipramine oral capsule 5, 50, 75 PA desipramine oral tablet 0, 00, 50, 5, 50, 75 doxepin oral capsule 0, 00, 50, 5, 50, 75 PA doxepin oral concentrate 0 /ml PA imipramine hcl oral tablet 0, 5, 50 PA imipramine pamoate oral capsule 00, 5, 50, 75 nortriptyline oral capsule 0, 5, 50, 75 nortriptyline oral solution 0 /5 ml protriptyline oral tablet 0, 5 PA trimipramine oral capsule 00, 5, 50 PA ANTIEMETICS - TREATMENT OF VOMITING OR NAUSEA ANTIEMETICS, OTHER chlorpromazine oral tablet 0, 00, 00, 5, 50 meclizine oral tablet.5, 5 metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 perphenazine oral tablet 6,, 4, 8 prochlorperazine maleate oral tablet 0, 5 prochlorperazine rectal suppository 5 promethazine oral tablet.5, 5, 50 PA promethazine rectal suppository.5, 5 PA promethazine rectal suppository 50 PROMETHEGAN RECTAL SUPPOSITORY 50 MG scopolamine base transdermal patch 3 day over 3 days PA

22 trimethobenzamide oral capsule 300 PA EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 5, 40, 80 B/D; aprepitant oral capsule,dose pack 5 ()- 80 () B/D; dronabinol oral capsule 0,.5, 5 B/D; EMEND ORAL SUSPENSION FOR RECONSTITUTION 5 MG (5 MG/ ML FINAL CONC.) B/D; granisetron hcl oral tablet B/D; ondansetron hcl oral solution 4 /5 ml B/D; ondansetron hcl oral tablet 4, 4, 8 B/D; ondansetron oral tablet,disintegrating 4, 8 B/D; SYNDROS ORAL SOLUTION 5 MG/ML PA ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG B/D B/D amphotericin b injection recon soln 50 B/D caspofungin intravenous recon soln 50, 70 PA ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrimazole mucous membrane troche 0 clotrimazole topical cream % clotrimazole topical solution % econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG PA

23 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml, 400 /00 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 00, 50 flucytosine oral capsule 50 flucytosine oral capsule 500 griseofulvin microsize oral suspension 5 /5 ml itraconazole oral capsule 00 itraconazole oral solution 0 /ml ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % MENTAX TOPICAL CREAM % MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG NYAMYC TOPICAL POWDER 00,000 UNIT/GRAM nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram PA PA PA 3

24 NYSTOP TOPICAL POWDER 00,000 UNIT/GRAM terbinafine hcl oral tablet 50 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) voriconazole oral tablet 00, 50 ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS ANTIGOUT AGENTS allopurinol oral tablet 00, 300 colchicine oral capsule 0.6 colchicine oral tablet 0.6 probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG ST; ANTI-INFLAMMATORY AGENTS - TREATMENT OF INFLAMMATION GLUCOCORTICOIDS ALA-CORT TOPICAL CREAM %,.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % 4

25 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % clobetasol-emollient topical cream 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.5 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.5 % DEXAMETHASONE INTENSOL ORAL DROPS MG/ML dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75,,.5,, 4, 6 fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % FLUOCINONIDE-E TOPICAL CREAM 0.05 % fluocinonide-emollient topical cream 0.05 % fluticasone topical cream 0.05 % fluticasone topical lotion 0.05 % fluticasone topical ointment % 5

26 halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0. % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone butyr-emollient topical cream 0. % hydrocortisone topical cream %,.5 % hydrocortisone topical cream with perineal applicator % hydrocortisone topical lotion.5 % hydrocortisone topical ointment %,.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % methylprednisolone oral tablets,dose pack 4 mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % prednisolone oral solution 5 /5 ml prednisolone sodium phosphate oral solution 5 /5 ml (3 /ml), 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml prednisone oral tablet, 0,.5, 0, 5, 50 prednisone oral tablets,dose pack 0, 0 (48 pack), 5, 5 (48 pack) triamcinolone acetonide topical cream 0.05 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0. % triamcinolone acetonide topical ointment 0.05 %, 0. %, 0.5 % TRIDERM TOPICAL CREAM 0. % ANTIMIGRAINE AGENTS - TREATMENT OF MIGRAINE HEADACHES 6

27 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ERGOT ALKALOIDS dihydroergotamine injection solution /ml PA dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. (4 /ml) ergotamine-caffeine oral tablet -00 PROPHYLACTIC AIVIG AUTOINJECTOR ( PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML AIVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML SEROTONIN (5-HT) B/D RECEPTOR AGONISTS QL (8 ML per 30 days) PA PA rizatriptan oral tablet 0, 5 QL ( EA per 30 days) rizatriptan oral tablet,disintegrating 0, 5 QL ( EA per 30 days) sumatriptan nasal spray,non-aerosol 0 /actuation, 5 /actuation sumatriptan succinate oral tablet 00, 5, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml, 6 /0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution 6 /0.5 ml sumatriptan succinate subcutaneous syringe 6 /0.5 ml QL ( EA per 30 days) QL (9 EA per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) QL (4 ML per 30 days) ANTIMYASTHENIC AGENTS - TREATMENT OF MYASTHENIA PARASYMPATHOMIMETICS guanidine oral tablet 5 pyridostigmine bromide oral tablet 60 7

28 pyridostigmine bromide oral tablet extended release 80 ANTIMYCOBACTERIALS - TREATMENT FOR INFECTIONS BY TUBERCULOSIS- TYPE ORGANISMS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00, 5 rifabutin oral capsule 50 ANTITUBERCULARS ethambutol oral tablet 00, 400 isoniazid oral tablet 00, 300 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG PA TRECATOR ORAL TABLET 50 MG ANTINEOPLASTICS - TREATMENT OF CANCER ALKYLATING AGENTS cyclophosphamide oral capsule 5, 50 B/D; GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG PA HEXALEN ORAL CAPSULE 50 MG PA LEUKERAN ORAL TABLET MG MATULANE ORAL CAPSULE 50 MG VALCHLOR TOPICAL GEL 0.06 % ANTIANDROGENS abiraterone oral tablet 50 PA bicalutamide oral tablet 50 ERLEADA ORAL TABLET 60 MG PA 8

29 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 flutamide oral capsule 5 nilutamide oral tablet 50 XTANDI ORAL CAPSULE 40 MG PA YONSA ORAL TABLET 5 MG PA ZYTIGA ORAL TABLET 500 MG PA ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG ANTIESTROGENS/DIFIERS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML EMCYT ORAL CAPSULE 40 MG PA PALA PA FARESTON ORAL TABLET 60 MG PA SOLTAX ORAL SOLUTION 0 MG/5 ML tamoxifen oral tablet 0, 0 toremifene oral tablet 60 PA ANTIMETABOLITES DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution %, 5 % hydroxyurea oral capsule 500 mercaptopurine oral tablet 50 PURIXAN ORAL SUSPENSION 0 MG/ML TABLOID ORAL TABLET 40 MG PA ANTINEOPLASTICS, OTHER 9

30 diclofenac sodium topical gel 3 % leucovorin calcium oral tablet 0, 5, 5, 5 LONSURF ORAL TABLET MG, MG 30 PA LYNPARZA ORAL CAPSULE 50 MG PA LYNPARZA ORAL TABLET 00 MG, 50 MG PA MESNEX ORAL TABLET 400 MG NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG PA ODOMZO ORAL CAPSULE 00 MG PA SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA PA PA PA ZOLINZA ORAL CAPSULE 00 MG PA ZYDELIG ORAL TABLET 00 MG, 50 MG PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet exemestane oral tablet 5 letrozole oral tablet.5 ENZYME INHIBITORS COPIKTRA ORAL CAPSULE 5 MG, 5 MG PA TALZENNA ORAL CAPSULE 0.5 MG, MG PA VIZIMPRO ORAL TABLET 5 MG, 30 MG, 45 MG LECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG PA PA PA

31 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ALECENSA ORAL CAPSULE 50 MG PA ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG PA PA PA BRAFTOVI ORAL CAPSULE 50 MG, 75 MG PA CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG PA CALQUENCE ORAL CAPSULE 00 MG PA CAPRELSA ORAL TABLET 00 MG, 300 MG PA COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) PA COTELLIC ORAL TABLET 0 MG PA DAURIS ORAL TABLET 00 MG, 5 MG PA ERIVEDGE ORAL CAPSULE 50 MG PA FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA PA PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA IDHIFA ORAL TABLET 00 MG, 50 MG PA imatinib oral tablet 00, 400 PA IMBRUVICA ORAL CAPSULE 40 MG, 70 MG PA IMBRUVICA ORAL TABLET 40 MG, 80 MG, 40 MG, 560 MG PA INLYTA ORAL TABLET MG, 5 MG PA IRESSA ORAL TABLET 50 MG PA 3

32 JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG, 400 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) LENVIMA ORAL CAPSULE MG/DAY (4 MG X 3), 4 MG PA PA PA PA PA LORBRENA ORAL TABLET 00 MG, 5 MG PA MEKINIST ORAL TABLET 0.5 MG, MG PA MEKTOVI ORAL TABLET 5 MG PA NERLYNX ORAL TABLET 40 MG PA NEXAVAR ORAL TABLET 00 MG PA RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG PA RYDAPT ORAL CAPSULE 5 MG PA SPRYCEL ORAL TABLET 00 MG, 40 MG, 0 MG, 50 MG, 70 MG, 80 MG PA STIVARGA ORAL TABLET 40 MG PA SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG PA TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA TAGRISSO ORAL TABLET 40 MG, 80 MG PA TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG PA PA TIBSOVO ORAL TABLET 50 MG PA TYKERB ORAL TABLET 50 MG PA 3

33 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG PA VITRAKVI ORAL CAPSULE 00 MG, 5 MG PA VITRAKVI ORAL SOLUTION 0 MG/ML PA VOTRIENT ORAL TABLET 00 MG PA XALKORI ORAL CAPSULE 00 MG, 50 MG PA XOSPATA ORAL TABLET 40 MG PA ZEJULA ORAL CAPSULE 00 MG PA ZELBORAF ORAL TABLET 40 MG PA ZYKADIA ORAL CAPSULE 50 MG PA RETINOIDS bexarotene oral capsule 75 PANRETIN TOPICAL GEL 0. % PA TARGRETIN TOPICAL GEL % PA tretinoin (chemotherapy) oral capsule 0 TREATMENT ADJUNCTS LYSODREN ORAL TABLET 500 MG ANTIPARASITICS - TREATMENT OF INFECTIONS FROM PARASITES ANTHELMINTICS albendazole oral tablet 00 ALBENZA ORAL TABLET 00 MG BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 praziquantel oral tablet 600 ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml 33

34 atovaquone-proguanil oral tablet 50-00, benznidazole oral tablet 00,.5 PA chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-0 MG DARAPRIM ORAL TABLET 5 MG hydroxychloroquine oral tablet 00 mefloquine oral tablet 50 NEBUPENT INHALATION RECON SOLN 300 MG 34 B/D PENTAM INJECTION RECON SOLN 300 MG PA primaquine oral tablet 6.3 quinine sulfate oral capsule 34 PEDICULICIDES/ SCABICIDES lindane topical shampoo % malathion topical lotion 0.5 % permethrin topical cream 5 % ANTIPARKINSON AGENTS - TREATMENT OF PARKINSON'S DISEASE ANTICHOLINERGICS benztropine oral tablet 0.5,, PA trihexyphenidyl oral elixir 0.4 /ml PA trihexyphenidyl oral tablet, 5 PA ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 entacapone oral tablet 00 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 4HR 37 MG, 68.5 MG tolcapone oral tablet 00 DOPAMINE AGONISTS APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML PA PA

35 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 bromocriptine oral capsule 5 bromocriptine oral tablet.5 NEUPRO TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, MG/4 HOUR, 3 MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 pramipexole oral tablet extended release 4 hr 0.375, 0.75,.5,.5, 3, 3.75, 4.5 ropinirole oral tablet 0.5, 0.5,,, 3, 4, 5 ropinirole oral tablet extended release 4 hr,, 4, 6, 8 DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, carbidopa-levodopa oral tablet,disintegrating 0-00, 5-00, 5-50 carbidopa-levodopa-entacapone oral tablet , , , , , NOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline oral tablet 0.5, selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS - TREATMENT OF BEHAVIORAL AND ETIONAL DISORDERS ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 5 /ml 35

36 fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet, 0,.5, 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate intramuscular syringe 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 0,, 0, 5 loxapine succinate oral capsule 0, 5, 5, 50 molindone oral tablet 0, 5, 5 pimozide oral tablet, thioridazine oral tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 trifluoperazine oral tablet, 0,, 5 ND GENERATION/ ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG 36 PA PAQL ( EA per 8 days) PAQL ( EA per 8 days) aripiprazole oral solution /ml QL (900 ML per 30 days) aripiprazole oral tablet 0, 5,, 0, 30, 5 aripiprazole oral tablet,disintegrating 0, 5 ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/.4 ML QL (30 EA per 30 days) QL (60 EA per 30 days) PA

37 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/3. ML FANAPT ORAL TABLET MG, 0 MG, MG, MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK MG()-MG()- 4MG()-6MG() GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 34 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 73 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 40 MG/.35 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 MG/.65 ML PAQL (3.9 ML per 56 days) PAQL (.6 ML per 8 days) PAQL (.4 ML per 8 days) PAQL (3. ML per 8 days) PAQL (60 EA per 30 days) PA B/DQL (6 EA per 3 days) PAQL (0.75 ML per 8 days) PAQL ( ML per 8 days) PAQL (.5 ML per 8 days) PAQL (0.5 ML per 8 days) PAQL (0.5 ML per 8 days) PAQL (0.875 ML per 84 days) PAQL (.35 ML per 84 days) PAQL (.75 ML per 84 days) PAQL (.65 ML per 84 days) 37

38 LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG PAQL (30 EA per 30 days) LATUDA ORAL TABLET 80 MG PAQL (60 EA per 30 days) NUPLAZID ORAL CAPSULE 34 MG PAQL (30 EA per 30 days) NUPLAZID ORAL TABLET 0 MG PAQL (30 EA per 30 days) NUPLAZID ORAL TABLET 7 MG PAQL (60 EA per 30 days) olanzapine intramuscular recon soln 0 QL (90 EA per 30 days) olanzapine oral tablet 0, 5,.5, 0, 5, 7.5 olanzapine oral tablet,disintegrating 0, 5, 0, 5 paliperidone oral tablet extended release 4hr.5, 3, 9 paliperidone oral tablet extended release 4hr 6 PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 0 MG, 90 MG quetiapine oral tablet 00, 00, 300, 400 QL (30 EA per 30 days) QL (30 EA per 30 days) PAQL (30 EA per 30 days) PAQL (60 EA per 30 days) PA QL (60 EA per 30 days) quetiapine oral tablet 5, 50 QL (90 EA per 30 days) quetiapine oral tablet extended release 4 hr 50, 00 quetiapine oral tablet extended release 4 hr 300, 400, 50 REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML, 37.5 MG/ ML, 50 MG/ ML QL (30 EA per 30 days) QL (60 EA per 30 days) PAQL (30 EA per 30 days) PAQL ( EA per 8 days) risperidone oral solution /ml QL (40 ML per 30 days) risperidone oral tablet 0.5, 0.5,,, 3 QL (60 EA per 30 days) risperidone oral tablet 4 QL (0 EA per 30 days) risperidone oral tablet,disintegrating 0.5, 0.5,,, 3 QL (60 EA per 30 days) risperidone oral tablet,disintegrating 4 QL (0 EA per 30 days) 38

39 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 5 MG SAPHRIS SUBLINGUAL TABLET 0 MG,.5 MG, 5 MG VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 0, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 0 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG TREATMENT-RESISTANT QL (60 EA per 30 days) QL (60 EA per 30 days) PAQL (30 EA per 30 days) PAQL (8 EA per 8 days) QL (60 EA per 30 days) PAQL ( EA per 8 days) PAQL ( EA per 8 days) clozapine oral tablet 00 QL (70 EA per 30 days) clozapine oral tablet 00 QL (0 EA per 30 days) clozapine oral tablet 5, 50 QL (90 EA per 30 days) clozapine oral tablet,disintegrating 00 QL (70 EA per 30 days) clozapine oral tablet,disintegrating.5, 5 clozapine oral tablet,disintegrating 50 QL (80 EA per 30 days) clozapine oral tablet,disintegrating 00 QL (0 EA per 30 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML QL (540 ML per 30 days) ANTISPASTICITY AGENTS - TREATMENT OF MUSCLE SPASMS ANTISPASTICITY AGENTS baclofen oral tablet 0, 0, 5 COMFORT PAC-TIZANIDINE KIT 4 MG dantrolene oral capsule 00, 5, 50 tizanidine oral tablet, 4 39

40 ANTIVIRALS - TREATMENT OF INFECTIONS BY VIRUSES ANTI-CYTOMEGALOVIRUS (CMV) AGENTS ganciclovir sodium intravenous solution 50 /ml B/D; PREVYMIS ORAL TABLET 40 MG, 480 MG PA valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % ST; ANTI-HEPATITIS B (HBV) AGENTS adefovir oral tablet 0 PA BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) lamivudine oral solution 0 /ml lamivudine oral tablet 00 QL (30 EA per 30 days) lamivudine oral tablet 50 QL (60 EA per 30 days) lamivudine oral tablet 300 QL (30 EA per 30 days) PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML tenofovir disoproxil fumarate oral tablet 300 VEMLIDY ORAL TABLET 5 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG 40 PA PA PA ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS MAVYRET ORAL TABLET MG PA VOSEVI ORAL TABLET MG PA ANTI-HEPATITIS C (HCV) AGENTS, OTHER

41 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML ribavirin oral capsule 00 ribavirin oral tablet 00 ANTIHERPETIC AGENTS acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 PA PA acyclovir sodium intravenous solution 50 /ml B/D acyclovir topical ointment 5 % DENAVIR TOPICAL CREAM % famciclovir oral tablet 5, 50, 500 trifluridine ophthalmic (eye) drops % valacyclovir oral tablet gram, 500 ZOVIRAX TOPICAL CREAM 5 % ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) GENVOYA ORAL TABLET MG QL (30 EA per 30 days) ISENTRESS HD ORAL TABLET 600 MG QL (60 EA per 30 days) ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG QL (0 EA per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG QL (80 EA per 30 days) JULUCA ORAL TABLET 50-5 MG QL (30 EA per 30 days) STRIBILD ORAL TABLET MG QL (30 EA per 30 days) TIVICAY ORAL TABLET 0 MG QL (300 EA per 30 days) 4

42 TIVICAY ORAL TABLET 5 MG QL (0 EA per 30 days) TIVICAY ORAL TABLET 50 MG QL (60 EA per 30 days) TRIUMEQ ORAL TABLET MG QL (30 EA per 30 days) ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA ORAL TABLET MG QL (30 EA per 30 days) COMPLERA ORAL TABLET MG QL (30 EA per 30 days) DELSTRIGO ORAL TABLET MG QL (30 EA per 30 days) EDURANT ORAL TABLET 5 MG QL (30 EA per 30 days) efavirenz oral capsule 00 QL (0 EA per 30 days) efavirenz oral capsule 50 QL (360 EA per 30 days) efavirenz oral tablet 600 QL (30 EA per 30 days) INTELENCE ORAL TABLET 00 MG, 5 MG QL (0 EA per 30 days) INTELENCE ORAL TABLET 00 MG QL (60 EA per 30 days) nevirapine oral tablet 00 QL (60 EA per 30 days) nevirapine oral tablet extended release 4 hr 00 nevirapine oral tablet extended release 4 hr 400 QL (0 EA per 30 days) QL (30 EA per 30 days) ODEFSEY ORAL TABLET MG QL (30 EA per 30 days) PIFELTRO ORAL TABLET 00 MG QL (30 EA per 30 days) RESCRIPTOR ORAL TABLET 00 MG QL (80 EA per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG QL (360 EA per 30 days) SYMFI LO ORAL TABLET MG QL (30 EA per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5 ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir oral solution 0 /ml abacavir oral tablet 300 QL (60 EA per 30 days) abacavir-lamivudine oral tablet QL (30 EA per 30 days) abacavir-lamivudine-zidovudine oral tablet QL (60 EA per 30 days) 4

43 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 CIMDUO ORAL TABLET MG QL (30 EA per 30 days) DESCOVY ORAL TABLET 00-5 MG QL (30 EA per 30 days) didanosine oral capsule,delayed release(dr/ec) 5 didanosine oral capsule,delayed release(dr/ec) 00 didanosine oral capsule,delayed release(dr/ec) 50, 400 QL (90 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 00 MG QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 0 MG/ML lamivudine-zidovudine oral tablet QL (60 EA per 30 days) stavudine oral capsule 5, 0 QL (0 EA per 30 days) stavudine oral capsule 30, 40 QL (60 EA per 30 days) TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 5 MG ZERIT ORAL RECON SOLN MG/ML QL (30 EA per 30 days) QL (90 EA per 30 days) zidovudine oral capsule 00 QL (80 EA per 30 days) zidovudine oral syrup 0 /ml zidovudine oral tablet 300 QL (60 EA per 30 days) ANTI-HIV AGENTS, OTHER BIKTARVY ORAL TABLET MG QL (30 EA per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 90 MG SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 50 MG, 75 MG QL (60 EA per 30 days) SELZENTRY ORAL TABLET 5 MG, 300 MG QL (0 EA per 30 days) 43

44 SYMFI ORAL TABLET MG QL (30 EA per 30 days) SYMTUZA ORAL TABLET MG QL (30 EA per 30 days) TYBOST ORAL TABLET 50 MG QL (30 EA per 30 days) ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 50 MG QL (0 EA per 30 days) APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 300 QL (30 EA per 30 days) atazanavir oral capsule 00 QL (60 EA per 30 days) CRIXIVAN ORAL CAPSULE 00 MG QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG QL (80 EA per 30 days) EVOTAZ ORAL TABLET MG QL (30 EA per 30 days) fosamprenavir oral tablet 700 QL (0 EA per 30 days) INVIRASE ORAL TABLET 500 MG QL (0 EA per 30 days) KALETRA ORAL TABLET 00-5 MG QL (40 EA per 30 days) KALETRA ORAL TABLET MG QL (0 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5 ml NORVIR ORAL POWDER IN PACKET 00 MG QL (360 EA per 30 days) NORVIR ORAL SOLUTION 80 MG/ML PREZCOBIX ORAL TABLET MG-MG QL (30 EA per 30 days) PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG QL (80 EA per 30 days) PREZISTA ORAL TABLET 600 MG QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG QL (300 EA per 30 days) PREZISTA ORAL TABLET 800 MG QL (30 EA per 30 days) REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 00 QL (360 EA per 30 days) VIRACEPT ORAL TABLET 50 MG QL (300 EA per 30 days) VIRACEPT ORAL TABLET 65 MG QL (0 EA per 30 days) ANTI-INFLUENZA AGENTS oseltamivir oral capsule 30 QL (84 EA per 80 days) 44

45 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 oseltamivir oral capsule 45, 75 QL (4 EA per 80 days) oseltamivir oral suspension for reconstitution 6 /ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 QL (540 ML per 80 days) QL (60 EA per 80 days) ANXIOLYTICS - TREATMENT OF ANXIETY OR NERVOUSNESS ANXIOLYTICS, OTHER buspirone oral tablet 0, 5, 30, 5, 7.5 hydroxyzine pamoate oral capsule 00, 5, 50 BENZODIAZEPINES PA alprazolam oral tablet 0.5, 0.5, QL (0 EA per 30 days) alprazolam oral tablet QL (50 EA per 30 days) clonazepam oral tablet 0.5, PAQL (90 EA per 30 days) clonazepam oral tablet PAQL (300 EA per 30 days) clonazepam oral tablet,disintegrating 0.5, 0.5, 0.5, PAQL (90 EA per 30 days) clonazepam oral tablet,disintegrating PAQL (300 EA per 30 days) clorazepate dipotassium oral tablet 5 PAQL (80 EA per 30 days) clorazepate dipotassium oral tablet 3.75, 7.5 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML PAQL (90 EA per 30 days) PAQL (40 ML per 30 days) diazepam oral concentrate 5 /ml PAQL (40 ML per 30 days) diazepam oral solution 5 /5 ml ( /ml), 5 /5 ml ( /ml, 5 ml) PAQL (00 ML per 30 days) diazepam oral tablet 0,, 5 PAQL (0 EA per 30 days) LORAZEPAM INTENSOL ORAL CONCENTRATE MG/ML QL (50 ML per 30 days) lorazepam oral concentrate /ml QL (50 ML per 30 days) 45