Table of Contents. Access Medicare 2016 Part D Formulary Formulary ID: Version: 19

Transcription

1 Table of Contents Table of Contents Analgesics... Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 6 Antianxiety Agents... 6 Antibacterials... 7 Anticancer Agents... Anticholinergic Agents... 4 Anticonvulsants... 4 Antidementia Agents... 6 Antidepressants... 6 Antidiabetic Agents... 8 Antifungals... 9 Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials... 2 Antinausea Agents... 2 Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 5 Contraceptives... 6 Dental And Oral Agents... 9 Dermatological Agents... 9 Devices... 4 Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 5 Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Effective: December 0, 206

2 Table of Contents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents... 6 Vitamins And Minerals Effective: December 0, 206

3 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 20-2 /5 ml solution 20-2 /5 ml acetaminophen-codeine oral solution 00-0 /2.5 ml acetaminophen-codeine oral tablet 00-5, 00-0 acetaminophen-codeine oral tablet butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet endocet oral tablet 0-25, 5-25, hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-00, 5-00, hydrocodone-acetaminophen oral tablet 0-25, , 5-25, lorcet (hydrocodone) oral tablet 5-25 (Acetaminophen with Codeine) QL (2700 per 0 (Acetaminophen with QL (2700 per 0 Codeine) (Tylenol-Codeine QL (60 per 0 No.) (Tylenol-Codeine QL (80 per 0 No.) (Esgic) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) (Xolox) QL (60 per 0 (Hycet) QL (2700 per 0 (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 (Norco) QL (60 per 0 (Norco) QL (60 per 0 lorcet hd oral tablet 0-25 (Norco) QL (60 per 0 lorcet plus oral tablet (Norco) QL (60 per 0 morphine 0 /ml carpuject 0 /ml (Morphine Sulfate) morphine 2 /ml carpuject outer, (Morphine Sulfate) latex-f, p/f 2 /ml morphine 4 /ml carpuject outer,latex-free,p/f 4 /ml (Morphine Sulfate) Effective: December 0, 206

4 morphine 8 /ml syringe 8 /ml (Morphine Sulfate) morphine concentrate oral solution 00 /5 ml (20 /ml) (Morphine Sulfate) QL (200 per 0 morphine intravenous syringe 0 /ml, 2 (Morphine Sulfate) /ml, 4 /ml, 8 /ml morphine oral solution 0 /5 ml (Morphine Sulfate) QL (700 per 0 morphine oral solution 20 /5 ml (4 (Morphine Sulfate) QL (00 per 0 /ml) MORPHINE ORAL TABLET 5 MG, 0 MG 4 QL (80 per 0 morphine oral tablet extended release 00 (MS Contin) QL (20 per 0, 0, 60 morphine oral tablet extended release 5 (MS Contin) QL (80 per 0, 200 oxycodone oral capsule 5 (Oxycodone HCl) 2 QL (80 per 0 oxycodone oral concentrate 20 /ml (Oxycodone HCl) QL (80 per 0 oxycodone oral solution 5 /5 ml (Oxycodone HCl) QL (00 per 0 oxycodone oral tablet 0, 5, 20 (Roxicodone) QL (80 per 0, 0, 5 oxycodone oral tablet,oral only,ext.rel.2 (Oxycontin) 2 QL (60 per 0 hr 0, 5, 20, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.2 (Oxycontin) 5 QL (20 per 0 hr 80 oxycodone-acetaminophen oral solution (Oxycodone QL (800 per /5 ml HCl/Acetaminophen) oxycodone-acetaminophen oral tablet (Xolox) QL (60 per , , 5-25, OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (20 per 0 TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG tramadol oral tablet 50 (Ultram) QL (240 per 0 4 Effective: December 0, 206

5 vicodin es oral tablet (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 vicodin hp oral tablet 0-00 (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 vicodin oral tablet 5-00 (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 ONLY,IR - ER, BIPHASE MG zebutal oral capsule (Esgic) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 25, 50, 75 diclofenac sodium topical gel % (Voltaren) 5 ibuprofen oral suspension 00 /5 ml (Ibuprofen) ibuprofen oral tablet 400, 600, (Ibuprofen) 800 indomethacin oral capsule 25 (Indomethacin) QL (240 per 0 indomethacin oral capsule 50 (Indomethacin) QL (20 per 0 indomethacin oral capsule, extended (Indomethacin) 2 QL (60 per 0 release 75 meloxicam oral suspension 7.5 /5 ml (Mobic) 2 meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 (Nabumetone) naproxen oral suspension 25 /5 ml (Naprosyn) naproxen oral tablet 250, 75, 500 (Naprosyn) 5 Effective: December 0, 206

6 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 75, 500 VOLTAREN TOPICAL GEL % 2 Anesthetics Local Anesthetics lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 20 /ml (Xylocaine) (2 %) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) 2 %, 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) 2 PA patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) 2 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5,, 2 alprazolam oral tablet extended release 24 hr 0.5,, 2 alprazolam oral tablet extended release 24 hr (Buprenorphine HCl/Naloxone HCl) 2 PA; QL (90 per 0 QL (68 per 84 QL (5 per 28 PA; QL (90 per 0 (Xanax) QL (20 per 0 (Xanax XR) QL (20 per 0 (Xanax XR) QL (90 per 0 6 Effective: December 0, 206

7 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 0 clonazepam oral tablet 2 (Klonopin) QL (00 per 0 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per , 0.25, 0.5, clonazepam oral tablet,disintegrating 2 (Clonazepam) QL (00 per 0 lorazepam intensol oral concentrate 2 (Ativan) QL (50 per 0 /ml lorazepam oral tablet 0.5,, 2 (Ativan) QL (90 per 0 Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD SOLUTION FOR NEBULIZATION 00 MG/4 ML gentamicin injection solution 40 /ml (Gentamicin Sulfate) neomycin oral tablet 500 (Neomycin Sulfate) TOBI PODHALER INHALATION 5 QL (224 per 28 CAPSULE, W/INHALATION DEVICE 28 MG Antibacterials, Miscellaneous clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Palmitate) 2 clindamycin hcl oral capsule 50, 00 (Cleocin HCl), 75 clindamycin pediatric oral recon soln 75 (Cleocin Palmitate) 2 /5 ml metronidazole oral capsule 75 (Flagyl) 2 metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 25, 50 (Macrodantin/Macrobi d) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 0 ; AGE (Max 64 Years) 7 Effective: December 0, 206

8 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin monohyd/m-cryst oral capsule 00 (75/25) (Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 0 ; AGE (Max 64 Years) (Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 0 ; AGE (Max 64 Years) trimethoprim oral tablet 00 (Trimethoprim) XIFAXAN ORAL TABLET 200 MG 5 PA; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA Cephalosporins cefadroxil oral capsule 500 (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram (Cefadroxil) cefdinir oral capsule 00 (Cefdinir) 2 cefdinir oral suspension for reconstitution (Cefdinir) 2 25 /5 ml, 250 /5 ml cefpodoxime oral suspension for (Cefpodoxime Proxetil) 2 reconstitution 00 /5 ml cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 50 /5 ml cefpodoxime oral tablet 00, 200 (Cefpodoxime Proxetil) 2 cefprozil oral suspension for (Cefprozil) 2 reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 (Cefprozil) 2 8 Effective: December 0, 206

9 cefuroxime axetil oral tablet 250, 500 (Ceftin) cephalexin oral capsule 250, 500, (Keflex) 750 cephalexin oral suspension for (Cephalexin) reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 (Cephalexin) Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (Zithromax) (6 pack), 500, 600 clarithromycin oral suspension for (Biaxin) 2 reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 (Biaxin) 2 clarithromycin oral tablet extended (Clarithromycin) 2 release 24 hr 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION 5 LA SOLUTION FOR NEBULIZATION 75 MG/ML INVANZ INJECTION RECON SOLN 4 GRAM Penicillins amoxicillin oral capsule 250, 500 (Amoxicillin) amoxicillin oral suspension for (Amoxicillin) reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 (Amoxicillin) amoxicillin oral tablet,chewable 25, 250 (Amoxicillin) 9 Effective: December 0, 206

10 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr, amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable , Clav) dicloxacillin oral capsule 250, 500 (Dicloxacillin Sodium) penicillin v potassium oral recon soln 25 (Penicillin V /5 ml, 250 /5 ml Potassium) penicillin v potassium oral tablet 250, (Penicillin V 500 Potassium) Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) 2 multiphase 24 hr,000, 500 ciprofloxacin hcl oral tablet 00, 250 (Cipro), 500, 750 levofloxacin intravenous solution 25 (Levofloxacin) /ml levofloxacin oral solution 250 /0 ml (Levaquin) 2 levofloxacin oral tablet 250, 500, (Levaquin) 750 Sulfonamides sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri intravenous solution /5 ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri suspension /5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim) tablet , sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 500 Tetracyclines doxycycline hyclate oral capsule 00 (Adoxa) 0 Effective: December 0, 206

11 doxycycline hyclate oral tablet 00, (Avidoxy) 50 doxycycline mono 00 cap 00 (Adoxa) doxycycline mono 00 tablet f/c 00 (Avidoxy) doxycycline mono 50 tablet 50 (Avidoxy) doxycycline monohydrate oral capsule (Adoxa) 2 50, 75 doxycycline monohydrate oral capsule 50 (Adoxa) doxycycline monohydrate oral suspension (Vibramycin) 2 for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 50 (Avidoxy) 2, 75 minocycline oral capsule 00, 50, (Minocin) 75 minocycline oral tablet 00, 50, (Minocycline HCl) 2 75 minocycline oral tablet extended release 24 hr 5, 45, 90 (Minocycline HCl) 2 Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, MG, 5 MG 5 PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG 5 PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 5 PA NSO; QL (28 per 28 anastrozole oral tablet (Arimidex) bicalutamide oral tablet 50 (Casodex) 2 DROXIA ORAL CAPSULE 200 MG, 00 MG, 400 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 22.5 MG 4 QL ( per 84 Effective: December 0, 206

12 ELIGARD (4 MONTH) 4 QL ( per 2 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 QL ( per 68 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) 4 exemestane oral tablet 25 (Aromasin) 2 flutamide oral capsule 25 (Flutamide) 2 hydroxyurea oral capsule 500 (Hydrea) JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG 5 PA NSO; QL (60 per 0 letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG 4 leuprolide subcutaneous kit /0.2 ml (Leuprolide Acetate) 2 LUPRON DEPOT ( MONTH) 5 QL ( per 84 INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) 5 QL ( per 84 INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) 5 QL ( per 68 INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT 5 INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYSODREN ORAL TABLET 500 MG megestrol oral tablet 20, 40 (Megestrol Acetate) mercaptopurine oral tablet 50 (Mercaptopurine) 2 methotrexate 50 /2 ml vial latex-free, (Methotrexate Sodium) PA BvD 5's, mdv 25 /ml methotrexate sodium (pf) injection (Methotrexate Sodium) PA BvD solution 25 /ml methotrexate sodium oral tablet 2.5 (Methotrexate Sodium) PA BvD; ST NEXAVAR ORAL TABLET 200 MG 5 PA NSO; QL (20 per 0 2 Effective: December 0, 206

13 POMALYST ORAL CAPSULE MG, 2 MG, MG, 4 MG 5 PA NSO; QL (2 per 28 PURIXAN ORAL SUSPENSION 20 5 MG/ML REVLIMID ORAL CAPSULE 0 5 PA NSO; LA MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG SOLTAMOX ORAL SOLUTION 0 4 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (0 per 0 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; QL (60 per 0 SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 7.5 MG, 50 MG 5 PA NSO; QL (0 per 0 tamoxifen oral tablet 0, 20 (Tamoxifen Citrate) TARCEVA ORAL TABLET 00 MG, 25 MG 5 PA NSO; QL (60 per 0 TARCEVA ORAL TABLET 50 MG 5 PA NSO; QL (90 per 0 TASIGNA ORAL CAPSULE 50 MG, 200 MG 5 PA NSO; QL (2 per 28 tretinoin (chemotherapy) oral capsule 0 (Tretinoin) 5 (capsule: 0) TREXALL ORAL TABLET 0 MG, 4 PA BvD; ST 5 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG 5 VOTRIENT ORAL TABLET 200 MG 5 PA NSO; QL (20 per 0 XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; QL (60 per 0 XTANDI ORAL CAPSULE 40 MG 5 PA NSO; QL (20 per 0 ZELBORAF ORAL TABLET 240 MG 5 PA NSO; QL (240 per 0 ZYTIGA ORAL TABLET 250 MG 5 PA NSO; QL (20 per 0 Effective: December 0, 206

14 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml propantheline oral tablet 5 (Atropine Sulfate) (Propantheline Bromide) STIOLTO RESPIMAT QL (4 per 28 INHALATION MIST MCG/ACTUATION Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) 2 multiphase 2 hr 00, 200, 00 carbamazepine oral suspension 00 /5 (Tegretol) 2 ml carbamazepine oral tablet 200 (Tegretol) carbamazepine oral tablet extended (Tegretol XR) 2 release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 (Carbamazepine) DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, sprinkle 25 (Depakote Sprinkle) 2 divalproex oral tablet extended release 24 (Depakote ER) 2 hr 250, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 25, 250, 500 epitol oral tablet 200 (Tegretol) gabapentin oral capsule 00, 00, (Neurontin) 400 gabapentin oral solution 250 /5 ml (Neurontin) 2 gabapentin oral tablet 600, 800 (Neurontin) 2 GRALISE 0-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 00 MG (9)- 600 MG (69) 4 ST; QL (78 per 0 4 Effective: December 0, 206

15 GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 00 MG, 600 MG 4 ST; QL (90 per 0 lamotrigine oral tablet 00, 50, (Lamictal) 200, 25 lamotrigine oral tablet extended release (Lamictal XR) 2 24hr 00, 200, 25, 250, 00, 50 lamotrigine oral tablet, chewable (Lamictal) dispersible 25, 5 lamotrigine oral tablet,disintegrating 00 (Lamictal Odt) 2, 200, 25, 50 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 00 /ml (Keppra) 2 levetiracetam oral tablet,000, 250 (Roweepra) 2, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 (Keppra XR) 2 LYRICA ORAL CAPSULE 00 MG, QL (90 per 0 50 MG, 200 MG, 225 MG, 25 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML QL (900 per 0 phenytoin sodium extended oral capsule (Dilantin) 00, 200, 00 ROWEEPRA ORAL TABLET 500 MG 2 SPRITAM ORAL TABLET FOR SUSPENSION,000 MG 4 ST; QL (60 per 0 SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG 4 ST; QL (20 per 0 5 Effective: December 0, 206

16 topiramate oral capsule, sprinkle 5, (Topamax) 2 25 topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 2 00, 50, 200, 25, 50 topiramate oral tablet 00, 200, (Topamax) 25, 50 TROKENDI XR ORAL 4 CAPSULE,EXTENDED RELEASE 24HR 00 MG, 200 MG, 25 MG, 50 MG Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) QL (0 per 0 donepezil oral tablet 2 (Aricept) 2 QL (0 per 0 donepezil oral tablet,disintegrating 0 (Donepezil HCl) QL (0 per 0, 5 memantine oral solution 2 /ml (Namenda) 2 QL (60 per 0 memantine oral tablet 0, 5 (Namenda) 2 QL (60 per 0 memantine oral tablets,dose pack 5-0 (Namenda) 2 QL (49 per 28 NAMENDA XR ORAL QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG rivastigmine transdermal patch 24 hour (Exelon) 2 QL (0 per 0. /24 hour, 4.6 /24 hr, 9.5 /24 hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 25, 50, 75 (Amitriptyline HCl) PA NSO-HRM bupropion hcl (smoking deter) oral tablet (Wellbutrin SR) 2 extended release 50 bupropion hcl oral tablet 00, 75 (Wellbutrin) 6 Effective: December 0, 206

17 bupropion hcl oral tablet extended release 00, 50, 200 (Wellbutrin SR) 2 bupropion hcl oral tablet extended release (Wellbutrin XL) 2 24 hr 50, 00 citalopram oral solution 0 /5 ml (Citalopram 2 Hydrobromide) citalopram oral tablet 0, 20, 40 (Celexa) QL (0 per 0 escitalopram oxalate oral solution 5 /5 (Lexapro) 2 ml escitalopram oxalate oral tablet 0, (Lexapro) 2 20, 5 fluoxetine oral capsule 0, 20, 40 (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) 2 release(dr/ec) 90 fluoxetine oral solution 20 /5 ml (4 (Fluoxetine HCl) /ml) fluoxetine oral tablet 0, 20 (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 4 MG paroxetine hcl oral tablet 0, 20, (Paxil) 0, 40 paroxetine hcl oral tablet extended (Paxil CR) 2 release 24 hr 2.5, 25, 7.5 PAXIL ORAL SUSPENSION 0 4 MG/5 ML sertraline oral concentrate 20 /ml (Zoloft) 2 sertraline oral tablet 00, 25, 50 (Zoloft) trazodone oral tablet 00, 50, (Trazodone HCl) 00, 50 venlafaxine oral capsule,extended release (Effexor XR) 24hr 50, 7.5, 75 venlafaxine oral tablet 00, 25, 7.5, 50, 75 (Venlafaxine HCl) 7 Effective: December 0, 206

18 venlafaxine oral tablet extended release (Venlafaxine HCl) 2 24hr 50, 7.5, 75 venlafaxine oral tablet extended release (Venlafaxine HCl) 24hr 225 Antidiabetic Agents Antidiabetic Agents, Miscellaneous INVOKANA ORAL TABLET 00 ST MG, 00 MG JANUMET ORAL TABLET 50-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG metformin oral tablet,000 (Glucophage) QL (75 per 0 metformin oral tablet 500 (Glucophage) QL (50 per 0 metformin oral tablet 850 (Glucophage) QL (90 per 0 metformin oral tablet extended release 24 (Glucophage XR) QL (20 per 0 hr 500 metformin oral tablet extended release 24 (Glucophage XR) QL (90 per 0 hr 750 metformin oral tablet extended release (Fortamet) QL (60 per 0 24hr,000 pioglitazone oral tablet 5, 0, 45 (Actos) 2 QL (0 per 0 TRADJENTA ORAL TABLET 5 MG VICTOZA Insulins HUMALOG 00 UNITS/ML QL (0 per 28 CARTRIDGE 5'S, OUTER 00 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML QL (0 per 28 8 Effective: December 0, 206

19 HUMALOG KWIKPEN QL (2 per 28 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML ( ML) HUMALOG SUBCUTANEOUS QL (40 per 28 SOLUTION 00 UNIT/ML HUMALOG SUBCUTANEOUS QL (0 per 28 SOLUTION 00 UNIT/ML (PREFILLED SYRINGE) LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (.5 ML) Sulfonylureas glimepiride oral tablet, 2 (Amaryl) QL (0 per 0 glimepiride oral tablet 4 (Amaryl) QL (60 per 0 glipizide oral tablet 0 (Glucotrol) QL (20 per 0 glipizide oral tablet 5 (Glucotrol) QL (60 per 0 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 0 0 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (0 per 0 2.5, 5 Antifungals Antifungals clotrimazole mucous membrane troche 0 (Clotrimazole) clotrimazole topical cream % (Clotrimazole) clotrimazole topical solution % (Clotrimazole) clotrimazole-betamethasone topical cream % (Lotrisone) 2 clotrimazole-betamethasone topical lotion % (Clotrimazole/Betamet hasone Dip) 2 9 Effective: December 0, 206

20 fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, (Diflucan) 200, 50 ketoconazole oral tablet 200 (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) nyamyc topical powder 00,000 (Nystatin) unit/gram nystatin oral suspension 00,000 unit/ml (Nystatin) nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 00,000 unit/gram (Nystatin) nystatin topical ointment 00,000 (Nystatin) unit/gram nystatin topical powder 00,000 (Nystatin) unit/gram nystop topical powder 00,000 unit/gram (Nystatin) terbinafine hcl oral tablet 250 (Lamisil) Antihistamines Antihistamines cyproheptadine oral syrup 2 /5 ml (Cyproheptadine HCl) 2 cyproheptadine oral tablet 4 (Cyproheptadine HCl) 2 levocetirizine oral solution 2.5 /5 ml (Xyzal) 2 levocetirizine oral tablet 5 (Xyzal) Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 (Terconazole) Antimigraine Agents Antimigraine Agents rizatriptan oral tablet 0, 5 (Maxalt) 2 QL (8 per Effective: December 0, 206

21 rizatriptan oral tablet,disintegrating 0, 5 sumatriptan 6 /0.5 ml syrng p/f,dehp/f,pvc/f 6 /0.5 ml sumatriptan succinate oral tablet 00, 25, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml sumatriptan succinate subcutaneous cartridge 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml sumatriptan succinate subcutaneous pen injector 6 /0.5 ml, 6 /0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 /0.5 ml (Maxalt Mlt) 2 QL (8 per 28 (Sumatriptan 2 QL (4 per 28 Succinate) (Imitrex) QL (8 per 28 (Sumatriptan 2 QL (4 per 28 Succinate) (Imitrex) 2 QL (4 per 28 (Sumatriptan Succinate) (Sumatriptan Succinate) 2 QL (4 per 28 2 QL (4 per 28 (Imitrex) 2 QL (4 per 28 Antimycobacterials Antimycobacterials dapsone oral tablet 00, 25 (Dapsone) isoniazid oral solution 50 /5 ml (Isoniazid) isoniazid oral tablet 00, 00 (Isoniazid) rifampin intravenous recon soln 600 (Rifadin) 2 rifampin oral capsule 50, 00 (Rifadin) 2 Antinausea Agents Antinausea Agents meclizine oral tablet 2.5, 25 (Meclizine HCl) ondansetron oral tablet,disintegrating 4 (Zofran Odt) PA BvD, 8 phenadoz rectal suppository 2.5 (Phenergan) 2 PA-HRM; AGE (Max 64 Years) prochlorperazine maleate oral tablet 0 (Compazine), 5 promethazine oral tablet 2.5, 25, 50 (Promethazine HCl) PA-HRM; AGE (Max 64 Years) 2 Effective: December 0, 206

22 promethazine rectal suppository 2.5, 25, 50 promethegan rectal suppository 25, 50 Antiparasite Agents Antiparasite Agents (Phenergan) 2 PA-HRM; AGE (Max 64 Years) (Phenergan) 2 PA-HRM; AGE (Max 64 Years) ALBENZA ORAL TABLET 200 MG 4 atovaquone-proguanil oral tablet (Malarone) 2, hydroxychloroquine oral tablet 200 (Plaquenil) mefloquine oral tablet 250 (Mefloquine HCl) 2 Antiparkinsonian Agents Antiparkinsonian Agents benztropine injection solution 2 /2 ml (Cogentin) 2 PA-HRM; AGE (Max 64 Years) benztropine oral tablet 0.5,, 2 (Benztropine Mesylate) PA-HRM; AGE (Max 64 Years) carbidopa-levodopa oral tablet 0-00 (Sinemet CR), 25-00, carbidopa-levodopa oral tablet extended (Sinemet CR) 2 release 25-00, carbidopa-levodopa oral (Carbidopa/Levodopa) 2 tablet,disintegrating 0-00, 25-00, pramipexole oral tablet 0.25, 0.25 (Mirapex) 2, 0.5, 0.75,,.5 ropinirole oral tablet 0.25, 0.5, (Requip), 2,, 4, 5 ropinirole oral tablet extended release 24 (Requip XL) 2 hr 2, 2, 4, 6, 8 Antipsychotic Agents Antipsychotic Agents chlorpromazine injection solution 25 (Chlorpromazine HCl) /ml chlorpromazine oral tablet 0, 00, 200, 25, 50 (Chlorpromazine HCl) 2 22 Effective: December 0, 206

23 clozapine oral tablet 00 (Clozaril) 2 QL (270 per 0 clozapine oral tablet 200 (Clozaril) 2 QL (5 per 0 clozapine oral tablet 25, 50 (Clozaril) 2 QL (90 per 0 clozapine oral tablet,disintegrating 00 (Fazaclo) 2 ST, 2.5, 50, 200, 25 haloperidol oral tablet 0.5,, 0 (Haloperidol), 2, 20, 5 LATUDA ORAL TABLET 20 MG, 4 20 MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 0 (Zyprexa) 2 QL (0 per 0 olanzapine oral tablet 0, 5, 2.5 (Zyprexa) 2 QL (0 per 0, 20, 5, 7.5 olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) 2 QL (0 per 0, 5, 5 olanzapine oral tablet,disintegrating 20 (Zyprexa Zydis) 2 QL ( per 0 perphenazine oral tablet 6, 2, 4 (Perphenazine) 2, 8 quetiapine oral tablet 00, 200, 25 (Seroquel) QL (90 per 0, 00, 400, 50 risperidone oral solution /ml (Risperdal) QL (480 per 0 risperidone oral tablet 0.25, 0.5, (Risperdal) QL (60 per 0, 2,, 4 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) 2 QL (60 per 0, 0.5,, 2 risperidone oral tablet,disintegrating (Risperdal M-Tab) 2 QL (20 per 0, 4 SEROQUEL XR ORAL TABLET 4 ST; QL (60 per 0 EXTENDED RELEASE 24 HR 50 MG, 00 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG 4 ST; QL (0 per 0 VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 ST; QL (540 per 0 2 Effective: December 0, 206

24 ziprasidone hcl oral capsule 20, 40 (Geodon) 2 QL (60 per 0, 60, 80 Antivirals (Systemic) Antiretrovirals ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EPZICOM ORAL TABLET MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG 5 ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG PREZISTA ORAL SUSPENSION 00 4 MG/ML PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, MG REYATAZ ORAL CAPSULE 50 5 MG, 200 MG, 00 MG REYATAZ ORAL POWDER IN 5 PACKET 50 MG STRIBILD ORAL TABLET MG TRUVADA ORAL TABLET MG, -200 MG, MG, MG 5 24 Effective: December 0, 206

25 VIREAD ORAL POWDER 40 5 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, MG, 250 MG, 00 MG Antivirals, Miscellaneous SYNAGIS 00 MG/ ML VIAL 00 5 MG/ML SYNAGIS INTRAMUSCULAR 5 SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 0 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals OLYSIO ORAL CAPSULE 50 MG 5 PA; QL (28 per 28 SOVALDI ORAL TABLET 400 MG 5 PA; QL (28 per 28 Interferons INTRON A 25 MILLION UNIT/2.5 4 PA NSO ML 0 MILLION UNIT/ML INTRON A INJECTION RECON 4 PA NSO SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 4 PA NSO 6 MILLION UNIT/ML PEGASYS PROCLICK 5 PA SUBCUTANEOUS PEN INJECTOR 5 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS 5 PA SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS 5 PA SYRINGE 80 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 (Zovirax) acyclovir oral suspension 200 /5 ml (Zovirax) 2 25 Effective: December 0, 206

26 acyclovir oral tablet 400, 800 (Zovirax) famciclovir oral tablet 25, 250, (Famvir) valacyclovir oral tablet gram, 500 (Valtrex) 2 Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin subcutaneous solution 00 (Lovenox) 2 / ml enoxaparin subcutaneous syringe 00 (Lovenox) 5 /ml, 20 /0.8 ml, 50 /ml enoxaparin subcutaneous syringe 0 (Lovenox) 2 /0. ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml jantoven oral tablet, 0, 2, (Coumadin) 2.5,, 4, 5, 6, 7.5 warfarin oral tablet, 0, 2, (Coumadin) 2.5,, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers EPOGEN 0,000 UNITS/ML VIAL SDV, P/F, OUTER 0,000 UNIT/ML PA; QL (2 per 28 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, PA; QL (2 per 28 20,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML NEULASTA SUBCUTANEOUS 5 SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION 5 SOLUTION 00 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 00 MCG/0.5 ML, 480 MCG/0.8 ML 5 26 Effective: December 0, 206

27 PROCRIT 0,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PA; QL (2 per 28 PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, PA; QL (2 per 28,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML 5 PA; QL (2 per 28 PROCRIT INJECTION SOLUTION 5 PA; QL (6 per 28 40,000 UNIT/ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5, (Agrylin) 2 tranexamic acid intravenous solution (Tranexamic Acid) 2,000 /0 ml (00 /ml) tranexamic acid oral tablet 650 (Lysteda) 2 QL (0 per 0 Platelet-Aggregation Inhibitors clopidogrel oral tablet 00, 75 (Plavix) EFFIENT ORAL TABLET 0 MG, 5 QL (0 per 0 MG Caloric Agents Caloric Agents AMINO ACIDS 5 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 0 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 0 % CLINIMIX 4 PA BvD 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.25%/D25W SUL 4 PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % 4 PA BvD 27 Effective: December 0, 206

28 CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in water (d5w) intravenous parenteral solution INTRALIPID INTRAVENOUS EMULSION 20 %, 0 % NUTRILIPID INTRAVENOUS EMULSION 20 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0., 0.2, 0. doxazosin oral tablet, 2, 4, 8 Angiotensin Ii Receptor Antagonists BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG irbesartan oral tablet 50, 00, 75 losartan oral tablet 00, 25, 50 losartan-hydrochlorothiazide oral tablet , 00-25, (Dextrose 0 % in Water) (Dextrose 5 % in Water) (Catapres) (Cardura) (Avapro) 2 (Cozaar) (Hyzaar) 4 PA BvD 4 PA BvD PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 2 28 Effective: December 0, 206

29 valsartan-hydrochlorothiazide oral tablet (Diovan HCT) , 60-25, , 20-25, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0, 20, 40 (Lotensin), 5 enalapril maleate oral tablet 0, 2.5 (Vasotec), 20, 5 lisinopril oral tablet 0, 2.5, 20 (Zestril), 0, 40, 5 lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 0-2.5, , ramipril oral capsule.25, 0, 2.5 (Altace), 5 Antiarrhythmic Agents amiodarone intravenous solution 50 (Amiodarone HCl) /ml amiodarone oral tablet 200, 400 (Cordarone) flecainide oral tablet 00, 50, 50 (Tambocor) pacerone oral tablet 00, 200, 400 (Cordarone) propafenone oral capsule,extended (Rythmol SR) 2 release 2 hr 225, 25, 425 propafenone oral tablet 50, 225, (Rythmol) 2 00 Beta-Adrenergic Blocking Agents atenolol oral tablet 00, 25, 50 (Tenormin) carvedilol oral tablet 2.5, 25, (Coreg).25, 6.25 metoprolol succinate oral tablet extended release 24 hr 00, 200, 25, 50 (Toprol XL) metoprolol tartrate intravenous solution 5 (Metoprolol Tartrate) /5 ml 29 Effective: December 0, 206

30 metoprolol tartrate intravenous syringe 5 /5 ml (Metoprolol Tartrate) metoprolol tartrate oral tablet 00, 25 (Lopressor), 50 propranolol intravenous solution /ml (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr 20, 60, 60, 80 propranolol oral solution 20 /5 ml (4 (Propranolol HCl) /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 20, 40 (Propranolol HCl), 60, 80 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release (Cardizem CD) 2 24hr 20, 80, 240, 00 diltiazem 24hr er 80 cap 80 (Cardizem CD) 2 diltiazem 24hr er 60 cap 60 (Cardizem CD) 2 diltiazem hcl intravenous recon soln 00 (Cardizem CD) diltiazem hcl intravenous solution 5 (Cardizem CD) /ml diltiazem hcl oral capsule, extended (Cardizem CD) 2 release 80, 60, 420 diltiazem hcl oral capsule,extended (Cardizem CD) 2 release 2 hr 20, 60, 90 diltiazem hcl oral capsule,extended (Cardizem CD) 2 release 24hr 20, 240, 00 diltiazem hcl oral tablet 20, 0, (Cardizem CD) 60, 90 dilt-xr oral capsule,ext release (Cardizem CD) 2 degradable 20, 80, 240 matzim la oral tablet extended release 24 (Cardizem CD) 2 hr 80, 240, 00, 60, 420 taztia xt oral capsule, extended release (Cardizem CD) 2 20, 80, 240, 00, 60 verapamil oral capsule, 24 hr er pellet ct 00, 200, 00 (Verelan Pm) 0 Effective: December 0, 206

31 verapamil oral capsule,ext rel. pellets 24 (Verelan) hr 20, 80, 240, 60 verapamil oral tablet 20, 40, 80 (Calan) verapamil oral tablet extended release (Calan SR) 20, 80, 240 Cardiovascular Agents, Miscellaneous digitek oral tablet 25 mcg (Lanoxin) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 ; AGE (Max 64 Years) digox 25 mcg tablet 25 mcg (Lanoxin) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 digox 250 mcg tablet 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 ; AGE (Max 64 Years) digoxin 0.25 /ml syringe 250 mcg/ml (Digoxin) PA-HRM; AGE (Max 64 Years) digoxin injection solution 250 mcg/ml (Digoxin) PA-HRM; AGE (Max 64 Years) Effective: December 0, 206

32 DIGOXIN ORAL SOLUTION 50 MCG/ML PA-HRM; QL (00 per 0 ; AGE (Max 64 Years) digoxin oral tablet 25 mcg (Lanoxin) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 digoxin oral tablet 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 ; AGE (Max 64 Years) hydralazine injection solution 20 /ml (Hydralazine HCl) hydralazine oral tablet 0, 00, 25 (Hydralazine HCl), 50 LANOXIN ORAL TABLET 87.5 MCG LANOXIN ORAL TABLET 62.5 MCG Dihydropyridines afeditab cr oral tablet extended release 0, 60 amlodipine oral tablet 0, 2.5, 5 (Adalat CC) (Norvasc) 4 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 ; AGE (Max 64 Years) 4 (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (0 per 0 2 Effective: December 0, 206

33 amlodipine-benazepril oral capsule 0-20 (Lotrel) 2, 0-40, 2.5-0, 5-0, 5-20, 5-40 nifedical xl oral tablet extended release (Procardia XL) 24hr 0, 60 nifedipine er 0 tablet f/c 0 (Adalat CC) nifedipine oral tablet extended release (Adalat CC) 24hr 0 nifedipine oral tablet extended release (Procardia XL) 24hr 60, 90 Diuretics chlorthalidone oral tablet 25, 50 (Chlorthalidone) furosemide injection solution 0 /ml (Furosemide) furosemide injection syringe 0 /ml (Furosemide) furosemide oral solution 0 /ml, 40 (Furosemide) /5 ml (8 /ml) furosemide oral tablet 20, 40, 80 (Lasix) hydrochlorothiazide oral capsule 2.5 (Microzide) hydrochlorothiazide oral tablet 2.5, (Hydrochlorothiazide) 25, 50 triamterene-hydrochlorothiazid oral (Dyazide) capsule , triamterene-hydrochlorothiazid oral (Maxzide) tablet , Dyslipidemics ALTOPREV ORAL TABLET 4 EXTENDED RELEASE 24 HR 20 MG, 40 MG atorvastatin oral tablet 0, 20, 40 (Lipitor), 80 fenofibrate oral tablet 20, 60, (Lofibra) 2 40, 54 gemfibrozil oral tablet 600 (Lopid) lovastatin oral tablet 0, 20, 40 (Mevacor) Effective: December 0, 206

34 pravastatin oral tablet 0, 20, 40 (Pravachol), 80 rosuvastatin oral tablet 0, 20, 40 (Crestor) 2, 5 simvastatin oral tablet 0, 20, 40 (Zocor), 5 simvastatin oral tablet 80 (Zocor) QL (0 per 0 ZETIA ORAL TABLET 0 MG 4 Renin-Angiotensin-Aldosterone System Inhibitors spironolactone oral tablet 00, 25, (Aldactone) 50 spironolacton-hydrochlorothiaz oral (Aldactazide) tablet Vasodilators isosorbide mononitrate oral tablet 0, (Isosorbide 20 Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 24 hr 20, 0, 60 minitran transdermal patch 24 hour 0. (Nitro-Dur) QL (0 per 0 /hr, 0.2 /hr, 0.6 /hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) QL (60 per 0 /hr NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 (Nitroglycerin) /0 ml (5 /ml) nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (0 per 0 0. /hr, 0.2 /hr, 0.6 /hr nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (60 per /hr NITROSTAT SUBLINGUAL TABLET 0. MG, 0.4 MG, 0.6 MG 4 Effective: December 0, 206

35 Central Nervous System Agents Central Nervous System Agents dextroamphetamine-amphetamine oral (Adderall XR) 2 QL (0 per 0 capsule,extended release 24hr 0, 5, 5 dextroamphetamine-amphetamine oral (Adderall XR) 2 QL (60 per 0 capsule,extended release 24hr 20, 25, 0 dextroamphetamine-amphetamine oral (Adderall) QL (60 per 0 tablet 0, 2.5, 5, 20, 0, 5, 7.5 lithium carbonate oral capsule 50, (Lithium Carbonate) 00, 600 lithium carbonate oral tablet 00 (Lithobid) lithium carbonate oral tablet extended (Lithobid) release 00, 450 methylphenidate cd 20 cap 20 (Metadate Cd) 2 QL (0 per 0 methylphenidate cd 40 cap 40 (Metadate Cd) 2 QL (0 per 0 methylphenidate oral capsule, er biphasic (Metadate Cd) 2 QL (0 per , 50, 60 methylphenidate oral capsule, er biphasic (Metadate Cd) 2 QL (60 per methylphenidate oral capsule,er biphasic (Metadate Cd) 2 QL (0 per , 40 methylphenidate oral solution 0 /5 (Methylin) QL (900 per 0 ml, 5 /5 ml methylphenidate oral tablet 0, 20 (Ritalin) QL (90 per 0, 5 methylphenidate oral tablet extended (Methylphenidate HCl) QL (90 per 0 release 0, 20 methylphenidate oral tablet extended (Concerta) 2 QL (0 per 0 release 24hr 8, 27, 54 methylphenidate oral tablet extended release 24hr 6 (Concerta) 2 QL (60 per 0 5 Effective: December 0, 206

36 QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG Contraceptives Contraceptives apri oral tablet (Desogen) aubra oral tablet mcg (Amethyst) aviane oral tablet mcg (Amethyst) blisovi 24 fe oral tablet -20 mcg (Loestrin Fe) (24)/75 (4) blisovi fe.5/0 (28) oral tablet.5 (Loestrin Fe) -0 mcg (2)/75 (7) blisovi fe /20 (28) oral tablet -20 (Loestrin Fe) mcg (2)/75 (7) caziant (28) oral tablet 0./.25/.5-25 (Desogen) -mcg delyla (28) oral tablet mcg (Amethyst) drospirenone-ethinyl estradiol oral tablet (Yaz) , -0.0 emoquette oral tablet (Desogen) enpresse oral tablet 50-0 (6)/75-40 (Amethyst) (5)/25-0(0) falmina (28) oral tablet mcg (Amethyst) gianvi (28) oral tablet (Yaz) 2 gildess 24 fe oral tablet -20 mcg (Loestrin Fe) (24)/75 (4) introvale oral tablets,dose pack, month (Levonorgestrel-Ethin QL (9 per mcg Estradiol) juleber oral tablet (Desogen) junel fe.5/0 (28) oral tablet.5-0 mcg (2)/75 (7) (Loestrin Fe) 6 Effective: December 0, 206

37 junel fe /20 (28) oral tablet -20 (Loestrin Fe) mcg (2)/75 (7) junel fe 24 oral tablet -20 mcg (Loestrin Fe) (24)/75 (4) larin fe.5/0 (28) oral tablet.5-0 (Loestrin Fe) mcg (2)/75 (7) larin fe /20 (28) oral tablet -20 (Loestrin Fe) mcg (2)/75 (7) larissia oral tablet mcg (Amethyst) lessina oral tablet mcg (Amethyst) levonest (28) oral tablet 50-0 (6)/75-40 (Amethyst) (5)/25-0(0) levonor-eth estrad outer (Amethyst) QL (9 per levonorgestrel-ethinyl estrad oral tablet (Amethyst) mcg levonorgestrel-ethinyl estrad oral (Amethyst) QL (9 per 84 tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet (Amethyst) 2 QL (9 per (6)/75-40 (5)/25-0(0) levora-28 oral tablet (Amethyst) lomedia 24 fe oral tablet -20 mcg (Loestrin Fe) (24)/75 (4) loryna (28) oral tablet (Yaz) 2 lutera (28) oral tablet mcg (Amethyst) marlissa oral tablet (Amethyst) microgestin fe.5/0 (28) oral tablet.5 (Loestrin Fe) -0 mcg (2)/75 (7) microgestin fe /20 (28) oral tablet (Loestrin Fe) -20 mcg (2)/75 (7) mononessa (28) oral tablet (Ortho-Cyclen) -mcg nikki (28) oral tablet (Yaz) 2 norethindrone-e.estradiol-iron oral tablet -20 mcg (24)/75 (4) (Loestrin Fe) 7 Effective: December 0, 206

38 norg-ee /0.05 x28 day (Ortho-Cyclen) regimen 0.8/0.25/ mcg (28) norgestimate-ethinyl estradiol oral tablet (Ortho-Cyclen) 0.8/0.25/ mcg ocella oral tablet -0.0 (Yaz) 2 orsythia oral tablet mcg (Amethyst) portia oral tablet (Amethyst) previfem oral tablet mcg (Ortho-Cyclen) quasense oral tablets,dose pack, month (Levonorgestrel-Ethin QL (9 per mcg Estradiol) reclipsen (28) oral tablet (Desogen) setlakin oral tablets,dose pack, month (Levonorgestrel-Ethin QL (9 per mcg Estradiol) sprintec (28) oral tablet mcg (Ortho-Cyclen) sronyx oral tablet mcg (Amethyst) tarina fe /20 (28) oral tablet -20 (Loestrin Fe) mcg (2)/75 (7) tri-legest fe oral tablet -20(5)/-0(7) /-5mcg (9) (Loestrin Fe) 2 tri-lo-estarylla oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) -25 mcg tri-lo-sprintec oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) -25 mcg trinessa (28) oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) -5 mcg (28) tri-previfem (28) oral tablet (Ortho-Cyclen) 0.8/0.25/ mcg (28) tri-sprintec (28) oral tablet (Ortho-Cyclen) 0.8/0.25/ mcg (28) trivora (28) oral tablet 50-0 (6)/75-40 (Amethyst) (5)/25-0(0) velivet triphasic regimen (28) oral tablet (Desogen) 0./.25/ mcg vestura (28) oral tablet (Yaz) 2 vienva oral tablet mcg (Amethyst) 8 Effective: December 0, 206

39 Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous membrane mouthwash 0.2 % periogard mucous membrane mouthwash 0.2 % triamcinolone acetonide dental paste 0. % (Peridex) (Peridex) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other acyclovir topical ointment 5 % (Zovirax) 2 QL (0 per 0 ammonium lactate topical cream 2 % (Lac-Hydrin) ammonium lactate topical lotion 2 % (Lac-Hydrin) calcipotriene scalp solution % (Calcipotriene) 2 calcipotriene topical cream % (Dovonex) 2 calcipotriene topical ointment % (Calcipotriene) 2 fluorouracil topical cream 0.5 %, 5 % (Carac) 2 fluorouracil topical solution 2 %, 5 % (Fluorouracil) 2 imiquimod topical cream in packet 5 % (Aldara) 2 PA NSO; QL (24 per 0 SANTYL TOPICAL OINTMENT UNIT/GRAM TOLAK TOPICAL CREAM 4 % 4 ZOVIRAX TOPICAL CREAM 5 % QL (5 per 0 Dermatological Antibacterials clindamycin phosphate topical foam % (Evoclin) 2 clindamycin phosphate topical gel % (Cleocin T) clindamycin phosphate topical lotion % (Cleocin T) clindamycin phosphate topical solution (Cleocin T) % clindamycin phosphate topical swab % (Cleocin T) metronidazole topical cream 0.75 % (Metrocream) 2 metronidazole topical gel 0.75 %, % (Rosadan) 2 metronidazole topical lotion 0.75 % (Metrolotion) 2 silver sulfadiazine topical cream % (Silvadene) 9 Effective: December 0, 206

40 ssd topical cream % (Silvadene) Dermatological Anti-Inflammatory Agents ala-cort topical cream % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Clobetasol Propionate) clobetasol topical foam 0.05 % (Olux) 2 clobetasol topical gel 0.05 % (Clobetasol Propionate) clobetasol topical lotion 0.05 % (Clobex) 2 clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) 2 clobetasol-emollient topical cream 0.05 % (Temovate) colocort rectal enema 00 /60 ml (Cortenema) 2 cormax scalp solution 0.05 % (Clobetasol 2 Propionate) desonide topical cream 0.05 % (Desowen) desonide topical lotion 0.05 % (Desowen) 2 desonide topical ointment 0.05 % (Desonide) fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) hydrocortisone rectal enema 00 /60 (Cortenema) 2 ml hydrocortisone topical cream %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment %, 2.5 (Hydrocortisone) % procto-med hc topical cream with (Hydrocortisone) perineal applicator 2.5 % procto-pak topical cream with perineal (Hydrocortisone) applicator % proctosol hc rectal cream 2.5 % (Hydrocortisone) 40 Effective: December 0, 206

41 proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) proctozone-hc topical cream with perineal (Hydrocortisone) applicator 2.5 % triamcinolone acetonide topical cream (Triamcinolone %, 0. %, 0.5 % Acetonide) triamcinolone acetonide topical lotion (Triamcinolone %, 0. % Acetonide) triamcinolone acetonide topical ointment (Triamcinolone %, 0. %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream 0. % (Differin) 2 adapalene topical gel 0. % (Differin) 2 tretinoin topical cream %, 0.05 %, (Retin-A) PA 0. % tretinoin topical gel 0.0 %, %, (Retin-A) PA 0.05 % Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) 2 permethrin topical cream 5 % (Elimite) 2 Devices Devices BD INSULIN SYR 0.5 ML GX5/6" 0.5 ML GAUGE X 5/6 BD INSULIN SYR ML GX5/6" ML GAUGE X 5/6 INSULIN SYRINGE-NEEDLE U-00 SYRINGE ML 29 GAUGE X /2", /2 ML 28 GAUGE 4 Effective: December 0, 206

42 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-8,000-60,000 UNIT, 24,000-76,000-20,000 UNIT,,000-9,500-5,000 UNIT, 6,000-4,000-80,000 UNIT, 6,000-9,000-0,000 UNIT KUVAN ORAL TABLET,SOLUBLE 5 00 MG ORFADIN ORAL CAPSULE 0 MG, 5 2 MG, 5 MG PERTZYE ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 6,000-57,500-60,500 UNIT, 8,000-28,750-0,250 UNIT PULMOZYME INHALATION 5 PA BvD SOLUTION MG/ML ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-4,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-6,000 UNIT,,000-0,000-6,000 UNIT, 40,000-6,000-28,000 UNIT, 5,000-7,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous azelastine nasal aerosol,spray 7 mcg (0. %) (Astepro) 2 QL (0 per 25 azelastine nasal spray,non-aerosol 0.5 % (Astepro) 2 QL (0 per 25 (205.5 mcg) azelastine ophthalmic drops 0.05 % (Azelastine HCl) 2 42 Effective: December 0, 206

43 cromolyn ophthalmic drops 4 % (Cromolyn Sodium) ipratropium bromide nasal (Atrovent) QL (0 per 28 spray,non-aerosol 0.0 % ipratropium bromide nasal (Atrovent) QL (5 per 0 spray,non-aerosol 0.06 % olopatadine nasal spray,non-aerosol 0.6 (Patanase) 2 QL (0.5 per 0 % olopatadine ophthalmic drops 0. % (Patanol) 2 PATADAY OPHTHALMIC DROPS 4 ST 0.2 % Eye, Ear, Nose, Throat Anti-Infectives Agents CIPRODEX OTIC DROPS,SUSPENSION % erythromycin ophthalmic ointment 5 (Ilotycin) /gram (0.5 %) gentak ophthalmic ointment 0. % ( (Garamycin) /gram) gentamicin ophthalmic drops 0. % (Garamycin) gentamicin ophthalmic ointment 0. % ( (Garamycin) /gram) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic drops,suspension.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic ointment.5 /g-0,000 unit/g-0. % neomycin-polymyxin-hc ophthalmic drops,suspension.5-0, unit-/ml (Neomycin/Polymyxin B Sulf/HC) neomycin-polymyxin-hc otic drops,suspension.5-0,000- /ml-unit/ml-% neomycin-polymyxin-hc otic solution.5-0,000- /ml-unit/ml-% (Neomycin/Polymyxin B Sulf/HC) (Cortisporin) 4 Effective: December 0, 206

44 ofloxacin ophthalmic drops 0. % (Floxin) ofloxacin otic drops 0. % (Floxin) TOBRADEX OPHTHALMIC 4 OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin-dexamethasone ophthalmic (Tobradex) 2 drops,suspension % VIGAMOX OPHTHALMIC DROPS 0.5 % Eye, Ear, Nose, Throat Anti-Inflammatory Agents fluticasone nasal spray,suspension 50 (Fluticasone mcg/actuation Propionate) ketorolac ophthalmic drops 0.4 %, 0.5 % (Acular) prednisolone acetate ophthalmic drops,suspension % (Omnipred) 2 RESTASIS OPHTHALMIC QL (60 per 0 DROPPERETTE 0.05 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants famotidine (pf) intravenous solution 20 (Famotidine) /2 ml famotidine 40 /4 ml vial 25's,outer 0 (Famotidine) /ml famotidine oral suspension 40 /5 ml (8 (Pepcid) 2 (Rx Product Only) /ml) famotidine oral tablet 20, 40 (Pepcid) (Rx Product Only) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) 0, 20, 40 pantoprazole intravenous recon soln 40 (Protonix IV) 2 pantoprazole oral tablet,delayed release (dr/ec) 20, 40 (Protonix) 44 Effective: December 0, 206

45 ranitidine hcl oral capsule 50, 00 (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral syrup 5 /ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 50, 00 (Zantac) (Rx Product Only) Gastrointestinal Agents, Other constulose oral solution 0 gram/5 ml (Lactulose) dicyclomine oral capsule 0 (Bentyl) dicyclomine oral solution 0 /5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate /5 ml HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) enulose oral solution 0 gram/5 ml (Lactulose) generlac oral solution 0 gram/5 ml (Lactulose) lactulose oral solution 0 gram/5 ml (Lactulose) loperamide oral capsule 2 (Loperamide HCl) metoclopramide hcl injection solution 5 (Metoclopramide HCl) /ml metoclopramide hcl oral solution 5 /5 (Metoclopramide HCl) ml metoclopramide hcl oral tablet 0, 5 (Reglan) ursodiol oral capsule 00 (Actigall) 2 ursodiol oral tablet 250, 500 (Urso) 2 Laxatives gavilyte-c oral recon soln (Golytely) gram gavilyte-g oral recon soln (Golytely) gram gavilyte-n oral recon soln 420 gram (Nulytely with Flavor Packs) peg 50-electrolytes oral recon soln (Golytely) gram peg-electrolyte soln oral recon soln 420 gram (Nulytely with Flavor Packs) 45 Effective: December 0, 206