List of covered drugs for all Geisinger

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1 List of covered drugs for all Geisinger Marketplace plans 018 Member formulary 1

2 General Formulary Information This formulary is applicable to the prescription coverage provided with all Marketplace plans offered by Geisinger Health Plan and Geisinger Choice. We encourage you to contact our Pharmacy Customer Service Team if you have any questions about this information or the type of benefit in which you are enrolled. Also, please refer to your benefit documents, as formulary exclusions may differ based on the specific benefit. This formulary was designed to be a useful tool for prescription medication coverage. It lists the medications covered by your plan. Medications are listed in this formulary by medication category; individual medications can be found by using the index at the back. Please note that you can also view the formulary online at Pharmacy Customer Service Team Contact Information Telephone: (800) or (570) ; TDD/TTY 711 Fax: Mailing address: Geisinger Health Plan Pharmacy Department Internal Mail Code North Academy Avenue Danville, PA 178 Tiers The Marketplace formulary assigns each prescription medication to one of 6 different tiers, each representing a set copay or coinsurance amount. The copay or coinsurance amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under your plan. The definitions of the copay or coinsurance levels are listed below: $0 Tier These medications have no copayment/coinsurance. Tier 1 (Generic Preferred) - Includes select generic medications and has the lowest copayment. Prior authorization is usually not necessary for medications in this tier. Tier (Generic Non-Preferred) - Includes most generic medications. Prior authorization is usually not necessary for medications in this tier. Tier 3 (Brand Preferred) Includes certain formulary brand name medications with no generic equivalent. Prior authorization may be necessary for medications in this tier. Tier 4 (Brand Non-Preferred) Includes certain formulary brand name medications, certain brand name medications with a generic equivalent, and non-formulary brand name medications (if approved). Prior authorization may be necessary for medications in this tier. I

3 Tier 5 (Specialty) Includes high-cost medications, often used to treat rare conditions, and may require special handling or training for use. A maximum of a 34-day supply may be dispensed for medications in this tier unless a shorter duration is specified in the formulary or in your specific benefit documents. The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to: Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace. Specialty Vendor Medication Program Certain medications require the use of a contracted specialty pharmacy vendor for purchase. Please contact the Pharmacy Customer Service Team for additional information on the program and a complete list of the medications included. Note that a maximum of a 34-day supply may be dispensed for specialty vendor medications unless a shorter duration is specified in the formulary or in your specific benefit documents. A few things you should remember when using this formulary and your prescription benefit: All prescriptions must be filled at a participating pharmacy. You will pay the applicable copay, coinsurance, or deductible when you receive the prescription. Most brand name medications with a generic equivalent require prior authorization. Some medications on the formulary require prior authorization or step therapy which your provider may request through our Pharmacy Customer Service Team. If you require medications not listed on this formulary, your provider may request an exception through our Pharmacy Customer Service Team. Those items listed as specific exclusions are not available through the exception process. Non-formulary medications requiring prior authorization will be available at the Tier 4 copayment/coinsurance level. Some medications and diabetic supplies may be restricted to a specific manufacturer, vendor or supplier and may be subject to quantity limits. Quantity limits may apply to certain medications. Brand and generic Triptan medications for migraines have a quantity limit of 16 units per 8 days across all products (sumatriptan, rizatriptan, naratriptan, almotriptan, frovatriptan, eletriptan, zolmitriptan, and sumatriptan/naproxen). II

4 Insulin syringes and lancets are covered at Tier 3. Most non-prescription (over-the-counter) medications are not covered unless required by health care reform legislation. Note that if certain conditions are met, some medications may be covered with no copay/coinsurance due to health care reform legislation. Please contact the Pharmacy Customer Service Team for more information. Many compounded prescriptions require prior authorization review, which your provider may request through our Pharmacy Customer Service Team. If an exception is approved, you will be charged at the Tier 4 copay level. If your request is denied, the medication will be excluded from coverage under your prescription medication benefits. Using this formulary Medication names with QL in the Requirements/Limits column have quantity limits. Other day supply limits may apply. Medication names followed by PA in the Requirements/Limits column require prior authorization. Medication names followed by ST in the Requirements/Limits column have step therapy requirements (Please see Step Therapy List below). Medication names followed by SP in the Requirements/Limits column require the use of a specialty pharmacy vendor. This formulary is accurate as of February 1, 018, and is subject to change. Any additions or deletions to the formulary throughout the year may be found in the following quarterly publications: Member Update for members and Briefly for providers or in the following monthly publication for providers: Formulary and Policy Update. The most up-to-date source for formulary information is the online formulary search available at Restrictions in medication availability may result from use of a formulary Certain prescription medications listed in this formulary may not be covered for everyone. Your prescription medication benefits are dependent upon the coverage selected by you or your employer. Please be aware that if you choose to obtain a non-formulary medication, you may be required to pay the full price of that medication. For information about your specific prescription medication benefits, please contact the Pharmacy Customer Service Team. Quantity Limits Quantity limits are listed in the Requirements/Limits Column Note that non-formulary medications in the same class/category as formulary drugs with quantity limits will have the same quantity limits applied if approved for coverage. A maximum of a 34-day supply may be dispensed for medications in Tier 5 and medications provided by a specialty vendor unless a shorter duration is specified in the formulary or in your specific benefit documents. III

5 Step Therapy List For details regarding step therapy requirements please contact the Pharmacy Customer Service Team at (800) or (570) What is a medication formulary? A medication formulary is a continually updated list of prescription medications. It represents the medications currently covered based upon the clinical judgment of the Pharmacy and Therapeutics Committee, which is made up of pharmacists and physicians. (The formulary is continually updated due to the high number of medications currently on the market, as well as the continuous introduction of new medications.) This committee thoroughly reviews medical literature to first determine which medications are likely to produce the best results for patients. Then, if two or more medications produce the same clinical results, elements like cost and ease of use are considered. A well-developed formulary enhances quality of patient care by encouraging physicians to prescribe medications that are safe, effective, and likely to achieve the best possible outcome for the patient. When you use a formulary medication, it is considered a covered medication and you pay your particular copay or coinsurance for that medication. The Plan recognizes that, in some situations, you may not respond well to a given formulary medication, or you may have an allergy or other condition that warrants the use of a non-formulary medication. An exception process exists for these special instances. Your physician may initiate a request for a formulary exception by contacting our Pharmacy Service Team. Your request will be reviewed, including review of pertinent medical records, treatment and laboratory data. We respond to such requests within 48 hours of receiving all necessary information. If an exception is approved, you will be charged at the Tier 4 copay level. If your request is denied, the medication will be excluded from coverage under your prescription medication benefits. Formulary exclusions There are certain medications that your plan will not cover under any circumstance. These are called exclusions. Some examples of excluded medications include those that are: Available over-the-counter Used for experimental, investigational, or unproven therapies Used for weight loss and weight management Life-style medications Used for cosmetic purposes Used for erectile dysfunction Other exclusions may apply and are subject to change so you should contact the Pharmacy Customer Service Team when you are unsure whether a medication is covered. IV

6 Health Care Reform The Affordable Care Act (ACA) was signed into law on March 3, 010. Under the ACA, the government created provisions, or laws, that health insurers must adapt to, which change health benefits for consumers. These changes include the expansion of preventive services, including vaccinations, prescription drugs, and more. In accordance with the ACA requirements, and subject to any applicable limitations of your pharmacy plan, the following preventive medications will be covered with no cost-sharing under the prescription drug benefit: Aspirin Products Low dose (81 mg) aspirin products o For the primary prevention of cardiovascular disease and colorectal cancer in adults ages years who have a 10 percent or greater 10-year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years and are willing to take low-dose aspirin daily for at least 10 years. o As preventive medication after 1 weeks of gestation in women who are at high risk for preeclampsia. Contraceptives Brands with no generic and generic products (other contraceptives may be covered under the medical benefit) o For females. Bowel Preparations for Colonoscopy Brands with no generic and generic products o In preparation of a screening colonoscopy for members years of age. Breast Cancer Prevention Generic raloxifene and generic tamoxifen o For women who are at increased risk of breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as raloxifene or tamoxifen. Folic Acid Supplements Generic folic acid 0.4 mg and 0.8 mg tablets o All women who are planning or capable of pregnancy. Fluoride Supplements Fluoride drops and chewable tablets o Oral fluoride supplementation starting at 6 months for children whose water supply is fluoride sufficient up to age 5 years for the prevention of dental caries. Iron Supplements Pediatric Iron supplements o For members 6 1 months of age. Smoking Cessation Products Brands with no generic and generic products o Two, 90-day treatment courses per benefit year. Statin Preventive Medication low- to moderate-dose generic products o For adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke) for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are ages 40 to 75 years; ) they have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10- year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults ages 40 to 75 years. Vaccinations Herpes Zoster and Influenza (Flu) Vaccine (Other preventive vaccinations may be covered under the medical benefit) Vitamin D Generic vitamin D 400 unit supplements o To prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls V

7 Please note: For details about how these medications may be covered under your specific plan please contact the Pharmacy Customer Service Team. A prescription is required to process any claim for preventive care medications or products under the pharmacy plan, including over-the-counter medications. Formulary development When deciding whether or not a medication should be included in the formulary, the Health Plan s Pharmacy and Therapeutics Committee carefully considers each medication for coverage or non-coverage in order to ensure safety and effectiveness in the medications being prescribed. This information is then shared with participating providers for review and feedback. Based upon the gathered information and provider feedback, the Pharmacy and Therapeutics Committee will determine a medication s inclusion or exclusion in the formulary. For the specific criteria used to determine a medication s inclusion or exclusion in this formulary, please contact the Pharmacy Customer Service Team. What are generics? When a company develops a new medication, it receives a patent that protects the medication company s right to be the only manufacturer of that medication for a certain period of time. This means that no generic can be manufactured during that time. After that patent expires, other companies can then make the same medication and sell it in its generic form. The generic form of a medication has the same active ingredients, the same strength, and the same dosage as the brand name medication. The inactive ingredients (which provide texture, shape and color) may be different, which is why a generic typically looks different than its brand name counterpart. Generic medications are usually less expensive than brand name medications, but are just as safe and effective. This is because generic manufacturers have lower advertising costs and greater competition from other generic manufacturers. Additionally, the U.S. Food and Drug Administration regulates all pharmaceuticals, including generics, to assure quality, strength, purity and potency. Your prescription plan is based on coverage of generic medications. Whenever possible, you should use a cost-effective generic medication. VI

8 Notes for providers Formulary review process: Medications selected for inclusion in the formulary are chosen in consideration of effectiveness, safety and overall value. Evaluation for formulary inclusion is based on formalized selection criteria to determine the most optimal benefit to members. These criteria include but are not limited to: Medication name/dosage form Medication class/pharmacology FDA-approved indications Adverse reactions Clinical evidence of safety and efficacy Recommendations of national agencies and organizations Therapeutic equivalence Cost analysis The criteria are reviewed by the Health Plan Pharmacy and Therapeutics Committee, which is comprised of pharmacists and participating physicians in active clinical practice from various specialties. The medication is then reviewed and evaluated by clinicians in particular specialties for additional feedback. The feedback is discussed by the Pharmacy and Therapeutics Committee prior to finalizing a decision on formulary status. To be included, the medication must offer a distinct advantage over existing formulary medications in the same therapeutic class. Specifically, the medication must demonstrate such attributes as: A distinct or unique therapeutic feature Greater efficacy, proven in clinical trials, over other medications in the same therapeutic category An improved dosing schedule, safety profile or cost-effectiveness over existing formulary medications If there are comparable therapeutic agents, additional analysis may be considered. These factors include: o Member satisfaction o Cost analysis o Contract terms and conditions o Market share analysis o Patent life assessment o Utilization management o Consumer advertising o Per member per month costs VII

9 Generic substitution policy: The Health Plan prescription benefits are generically based. Generic substitution will occur for those medications included in the Approved Medication Products with Therapeutic Equivalence Evaluations, also known as The Orange Book, published by the U.S. Department of Health and Human Services. Generic medications, which have an equivalent rating by these standards, are generally provided under the member s prescription medication benefit. The Health Plan may also elect to include only one brand-name medication in the formulary even if the medication is marketed by more than one company, or if the brand name medication does not significantly differ from the generic medication. Prior authorization: To promote the most appropriate utilization, select medications may require prior authorization by the Health Plan to be eligible for coverage under the member s prescription benefit. The Pharmacy and Therapeutics Committee determines prior authorization criteria. In order for a member to receive coverage for a medication requiring prior authorization, the prescribing physician must obtain prior authorization by contacting the Health Plan Pharmacy Department at the address, telephone, or fax number above. Submission of medical documentation is required. Step Therapy: Some medications may require that other medications be tried prior to or concomitantly with the requested medication. The pharmacy claims system looks for a record of the required medications and if they are not found, medical documentation must be submitted showing use of these medications or rationale for skipping the step therapy medications. Non-formulary medications: The formulary is designed to meet most therapeutic needs of the population served by the Health Plan. Occasionally, because of allergy, therapeutic failure, or a specific diagnostic-related need, formulary medications may not meet the special needs of an individual member. In these special instances, the prescribing physician may make requests to the Health Plan Pharmacy Department for non-formulary or restricted medications. The prescribing physician will receive written documentation and/or a verbal response from the Health Plan Pharmacy Department regarding the request. Formulary addition requests: Requests for changes or additions, comments, and suggestions for the formulary are welcome and can be made by written request to the Health Plan Pharmacy Department. Sources: Academy of Managed Care Pharmacy (AMCP), Formulary Management, Formularies, November 001. Health Insurance Association of America (HIAA), Guide to Managed Care: Choosing and Using a Health Plan. November 001. VIII

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11 Table of Contents Analgesics... 3 Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 8 Antibacterials... 8 Anticancer Agents... 1 Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents... 0 Antifungals... Antigout Agents... 3 Antihistamines... 4 Anti-Infectives (Skin And Mucous Membrane)... 4 Antimigraine Agents... 4 Antimycobacterials... 5 Antinausea Agents... 5 Antiparasite Agents... 6 Antiparkinsonian Agents... 7 Antipsychotic Agents... 7 Antivirals (Systemic)... 8 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives... 4 Geisinger 018 Marketplace Formulary 1

12 Cough And Cold Products Dental And Oral Agents Dermatological Agents Detergents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents... 7 Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Urine And Feces Contents Vasodilating Agents Vitamins And Minerals Geisinger 018 Marketplace Formulary

13 Analgesics Analgesics, Miscellaneous ABSTRAL 5 PA; QL (10 per 30 acetaminophen-caff-dihydrocod oral tablet mg acetaminophen-codeine oral solution 10-1 mg/5 ml, 360 mg-36 mg /15 ml (15 ml) acetaminophen-codeine oral tablet ascomp with codeine aspirin-caffeine-dihydrocodein (Synalgos-DC) belladonna alkaloids-opium belladonna-opium buprenorphine (Butrans) QL (0.14 per 1 day) butalbital compound w/codeine butalbital-acetaminop-caf-cod butalbital-acetaminophen (Marten-Tab) butalbital-acetaminophen-caff oral (Fioricet) capsule butalbital-acetaminophen-caff oral tablet (Esgic) mg butalbital-aspirin-caffeine oral capsule (Fiorinal) butorphanol tartrate nasal capacet codeine sulfate oral tablet EMBEDA ORAL CAPSULE,ORAL 4 PA ONLY,EXT.REL PELL endocet oral tablet mg,.5-35 mg, 5-35 mg, mg fentanyl (Duragesic) fentanyl citrate (Actiq) 5 PA; QL (10 per 30 FENTORA 5 PA; QL (10 per 30 hydrocodone-acetaminophen oral solution mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) mg/15 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) mg hydrocodone-acetaminophen oral tablet (Lorcet HD) mg hydrocodone-acetaminophen oral tablet.5-35 mg (Verdrocet) Geisinger 018 Marketplace Formulary 3

14 hydrocodone-acetaminophen oral tablet 5- (Vicodin) 300 mg hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) 35 mg hydrocodone-acetaminophen oral tablet (Vicodin ES) mg hydrocodone-acetaminophen oral tablet (Lorcet Plus) mg hydrocodone-ibuprofen (Reprexain) hydromorphone oral liquid (Dilaudid) hydromorphone oral tablet (Dilaudid) ibuprofen-oxycodone KADIAN ORAL 4 PA CAPSULE,EXTEND.RELEASE PELLETS 00 MG, 40 MG LAZANDA NASAL SPRAY,NON- 4 PA AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg margesic marten-tab meperidine oral solution meperidine oral tablet methadone oral concentrate (Methadone Intensol) methadone oral solution methadone oral tablet (Dolophine) methadose oral tablet,soluble morphine concentrate oral solution morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.release (Kadian) pellets morphine oral solution MORPHINE ORAL TABLET morphine oral tablet extended release (MS Contin) morphine rectal NUCYNTA 4 PA NUCYNTA ER 4 PA oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution Geisinger 018 Marketplace Formulary 4

15 oxycodone oral tablet (Roxicodone) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) PA hr oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 10- (Primlev) 300 mg, mg, mg oxycodone-acetaminophen oral tablet 10- (Endocet) 35 mg,.5-35 mg, 5-35 mg, mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL 4 PA ONLY,EXT.REL.1 HR oxymorphone oral tablet (Opana) oxymorphone oral tablet extended release PA 1 hr pentazocine-naloxone reprexain SUBSYS 5 PA; QL (10 per 30 tencon oral tablet mg tramadol oral capsule,er biphase 4 hr (ConZip) 5-75 tramadol oral tablet (Ultram) tramadol oral tablet extended release 4 hr tramadol oral tablet, er multiphase 4 hr tramadol-acetaminophen (Ultracet) vicodin vicodin es vicodin hp xylon 10 zebutal oral capsule mg Nonsteroidal Anti-Inflammatory Agents celecoxib (Celebrex) choline,magnesium salicylate diclofenac potassium diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical drops PA diclofenac sodium topical gel 1 % (Voltaren) QL (10 per 1 day) diclofenac-misoprostol (Arthrotec 50) diflunisal Geisinger 018 Marketplace Formulary 5

16 etodolac oral capsule etodolac oral tablet (Lodine) etodolac oral tablet extended release 4 hr fenoprofen oral capsule 00 mg (Fenortho) fenoprofen oral tablet (ProFeno) FLECTOR 4 PA flurbiprofen ibuprofen oral suspension (Child Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, mg INDOCIN ORAL 3 INDOCIN RECTAL 4 indomethacin oral ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg ketorolac oral QL (0 per 1 day) meclofenamate mefenamic acid (Ponstel) meloxicam oral suspension meloxicam oral tablet (Mobic) 1 nabumetone NAPRELAN CR ORAL TABLET, ER MULTIPHASE 4 HR 750 MG 4 PA naproxen oral suspension (Naprosyn) naproxen oral tablet naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) naproxen sodium oral tablet 75 mg naproxen sodium oral tablet 550 mg (Anaprox DS) naproxen sodium oral tablet, er (Naprelan CR) PA multiphase 4 hr oxaprozin (Daypro) piroxicam (Feldene) salsalate (Disalcid) SPRIX 4 PA sulindac tolmetin VIMOVO 4 PA ZIPSOR 4 PA Anesthetics Local Anesthetics altafluor Geisinger 018 Marketplace Formulary 6

17 CIDALEAZE FLUORESCEIN-BENOXINATE (Altafluor) glydo LIDO BDK lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl topical cream 3 % (CidalEaze) lidocaine hcl topical cream 3.88 % (Lidotral) lidocaine hcl topical lotion (Lido-K) lidocaine hcl-hydrocortison ac rectal kit 3-1 % (7 gram) lidocaine hcl-hydrocortison ac topical lidocaine topical adhesive (Lidoderm) PA patch,medicated lidocaine topical ointment lidocaine viscous lidocaine-hydrocortisone-aloe rectal kit 3-.5 % (7 gram) lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit (AgonEaze) LIDODERM 5 PA SYNERA 4 PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate buprenorphine hcl sublingual PA; QL (34 days supply per fill) buprenorphine-naloxone PA; QL (34 days supply per fill) buproban $0 bupropion hcl (smoking deter) (Zyban) CHANTIX $0 CHANTIX CONTINUING MONTH $0 BOX CHANTIX STARTING MONTH BOX $0 QL (106 per 365 disulfiram (Antabuse) naloxone injection syringe naltrexone NARCAN 3 QL (4 per 30 nicorelief $0 Geisinger 018 Marketplace Formulary 7

18 nicotine (polacrilex) buccal gum (Nicorelief) $0 nicotine (polacrilex) buccal lozenge (Nicorette) $0 nicotine transdermal patch 4 hour $0 NICOTINE TRANSDERMAL PATCH, TD DAILY, SEQUENTIAL $0 NICOTROL $0 NICOTROL NS $0 SUBOXONE 4 PA; QL (34 days supply per fill) Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL 3 alprazolam oral tablet (Xanax) alprazolam oral tablet extended release 4 (Xanax XR) hr alprazolam oral tablet,disintegrating chlordiazepoxide hcl clonazepam oral tablet (Klonopin) clonazepam oral tablet,disintegrating clorazepate dipotassium diazepam intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet (Valium) diazepam rectal (Diastat) estazolam flurazepam lorazepam oral concentrate (Lorazepam Intensol) lorazepam oral tablet (Ativan) midazolam oral syrup mg/ml ONFI ORAL SUSPENSION 4 PA ONFI ORAL TABLET 10 MG, 0 MG 4 PA oxazepam quazepam (Doral) temazepam (Restoril) triazolam Antibacterials Aminoglycosides BETHKIS 5 PA; SP; QL (4 per 56 neomycin TOBI 5 PA; SP; QL (80 per 56 Geisinger 018 Marketplace Formulary 8

19 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 5 PA; SP; QL (4 per 56 tobramycin in 0.5 % nacl (Tobi) PA; SP; QL (80 per 56 Antibacterials, Miscellaneous clindamycin hcl (Cleocin HCl) clindamycin palmitate hcl (Cleocin Pediatric) FLAGYL ER 4 PA hyolev mb linezolid oral suspension for reconstitution (Zyvox) PA linezolid oral tablet (Zyvox) QL (11 per 180 methenamine hippurate (Hiprex) methenamine mandelate metronidazole oral (Flagyl) MONUROL 4 PA nitrofurantoin (Furadantin) nitrofurantoin macrocrystal (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) PRIMSOL 4 PA SIVEXTRO ORAL 5 PA; QL (6 per 365 trimethoprim ur n-c uretron d-s oral tablet mg 3 URETRON D-S ORAL TABLET MG urimar-t uro-458 uro-blue urogesic-blue urolet mb vancomycin in 0.9% sodium cl intravenous PA solution 1.5 gram/500 ml vancomycin intravenous recon soln 10 PA gram, 5 gram, 750 mg vancomycin oral capsule (Vancocin) XIFAXAN 4 PA Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule Geisinger 018 Marketplace Formulary 9

20 cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefdinir cefditoren pivoxil cefixime (Suprax) cefpodoxime cefprozil CEFTIN ORAL SUSPENSION FOR 3 RECONSTITUTION CEFUROXIME AXETIL ORAL (Ceftin) SUSPENSION FOR RECONSTITUTION 15 MG/5 ML cefuroxime axetil oral tablet cephalexin oral capsule 50 mg, 500 mg (Keflex) 1 cephalexin oral capsule 750 mg (Keflex) cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE 3 SUPRAX ORAL SUSPENSION FOR 3 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 3 Macrolides azithromycin oral (Zithromax) clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 4 hr DIFICID 4 PA; QL (0 per 1 day) e.e.s. 400 oral tablet e.e.s. granules 3 ERYPED ery-tab oral tablet,delayed release (dr/ec) 50 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 mg erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution erythromycin ethylsuccinate oral tablet (E.E.S. 400) erythromycin oral capsule,delayed release(dr/ec) Geisinger 018 Marketplace Formulary 10

21 erythromycin oral tablet KETEK 4 PA PCE 4 PA ZMAX 4 PA Miscellaneous B-Lactam Antibiotics CAYSTON 5 PA; SP; QL (56 days supply per fill) Penicillins amoxicillin oral capsule 1 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg, 400 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin AUGMENTIN ORAL SUSPENSION 4 FOR RECONSTITUTION MG/5 ML dicloxacillin penicillin v potassium 1 Quinolones ciprofloxacin (Cipro) ciprofloxacin (mixture) (Cipro XR) ciprofloxacin hcl oral (Cipro) FACTIVE 4 PA levofloxacin oral (Levaquin) moxifloxacin oral (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine sulfamethoxazole-trimethoprim oral suspension (Sulfatrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 sulfasalazine (Azulfidine EN-tabs) sulfatrim Tetracyclines ALODOX 4 PA Geisinger 018 Marketplace Formulary 11

22 demeclocycline doxycycline hyclate oral capsule (Morgidox) doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension (Vibramycin) for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule (Minocin) minocycline oral tablet minocycline oral tablet extended release 4 hr SOLODYN ORAL TABLET EXTENDED RELEASE 4 HR 105 MG, 4 PA 115 MG, 55 MG, 65 MG, 80 MG tetracycline VIBRAMYCIN ORAL SYRUP 4 PA Anticancer Agents Anticancer Agents AFINITOR $0 PA; QL (8 days supply per fill) ALECENSA $0 PA; SP; QL (40 per 30 ALUNBRIG $0 PA; SP; QL (180 per 30 anastrozole (Arimidex) $0 bexarotene (Targretin) $0 PA bicalutamide (Casodex) $0 BOSULIF $0 PA; SP; QL (30 per 30 CABOMETYX $0 PA; SP; QL (30 per 30 capecitabine (Xeloda) $0 CAPRELSA ORAL TABLET 100 MG $0 PA; SP; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG $0 PA; SP; QL (30 per 30 COMETRIQ $0 PA; SP; QL (8 days supply per fill) COTELLIC $0 PA; SP; QL (90 per 30 CYCLOPHOSPHAMIDE ORAL CAPSULE Geisinger 018 Marketplace Formulary 1 $0

23 cyclophosphamide oral tablet $0 DROXIA $0 PA EMCYT $0 ERIVEDGE $0 PA; SP; QL (30 per 30 etoposide oral $0 exemestane (Aromasin) $0 FARESTON $0 PA FARYDAK $0 PA; SP; QL (6 per 1 flutamide $0 GILOTRIF $0 PA; SP; QL (30 per 30 GLEEVEC ORAL TABLET 100 MG $0 QL (10 per 30 GLEEVEC ORAL TABLET 400 MG $0 QL (30 per 30 GLEOSTINE ORAL CAPSULE 5 MG $0 HEXALEN $0 HYCAMTIN ORAL $0 SP; QL (34 days supply per fill) hydroxyurea (Hydrea) $0 IBRANCE $0 PA; SP; QL (1 per 8 ICLUSIG $0 PA; SP; QL (30 days supply per fill) IDHIFA $0 PA; SP; QL (30 per 30 imatinib oral tablet 100 mg (Gleevec) $0 QL (10 per 30 imatinib oral tablet 400 mg (Gleevec) $0 QL (30 per 30 IMBRUVICA $0 PA; SP; QL (10 per 30 INLYTA $0 PA; SP; QL (30 days supply per fill) IRESSA $0 PA; SP; QL (30 per 30 JAKAFI $0 PA; SP; QL (60 per 30 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG $0 PA; SP; QL (49 per 8 $0 PA; SP; QL (70 per 8 Geisinger 018 Marketplace Formulary 13

24 KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 400 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X 3) $0 PA; SP; QL (91 per 8 $0 PA; SP; QL (1 per 8 $0 PA; SP; QL (4 per 8 $0 PA; SP; QL (63 per 8 LENVIMA $0 PA; SP; QL (90 per 30 letrozole (Femara) $0 AGE (Min 45 Years) LEUKERAN $0 leuprolide subcutaneous kit 1 LONSURF $0 PA; SP; QL (8 days supply per fill) LYNPARZA ORAL CAPSULE $0 PA; SP; QL (448 per 8 LYNPARZA ORAL TABLET $0 PA; SP; QL (10 per 30 LYSODREN $0 MATULANE $0 SP; QL (34 days supply per fill) megestrol oral tablet $0 MEKINIST ORAL TABLET 0.5 MG $0 PA; SP; QL (90 per 30 MEKINIST ORAL TABLET MG $0 PA; SP; QL (30 per 30 melphalan (Alkeran) $0 mercaptopurine $0 methotrexate sodium methotrexate sodium (pf) injection solution MYLERAN $0 NERLYNX $0 PA; SP; QL (180 per 30 NEXAVAR $0 PA; SP; QL (10 per 30 nilutamide (Nilandron) $0 NINLARO $0 PA; SP; QL (3 per 8 ODOMZO $0 PA; SP; QL (30 per 30 Geisinger 018 Marketplace Formulary 14

25 POMALYST $0 PA; SP; QL (1 per 8 REVLIMID $0 PA; SP; QL (34 days supply per fill) RUBRACA $0 PA; SP; QL (10 per 30 RYDAPT $0 PA; SP; QL (11 per 8 SPRYCEL $0 PA; SP; QL (30 days supply per fill) STIVARGA $0 PA; SP; QL (84 per 8 SUTENT $0 PA; SP; QL (30 per 30 TABLOID $0 PA TAFINLAR $0 PA; SP; QL (10 per 30 TAGRISSO $0 PA; SP; QL (30 per 30 tamoxifen $0 TARCEVA ORAL TABLET 100 MG, 150 MG $0 PA; SP; QL (30 per 30 TARCEVA ORAL TABLET 5 MG $0 PA; SP; QL (90 per 30 TARGRETIN TOPICAL $0 PA TASIGNA $0 PA TEMODAR ORAL $0 temozolomide (Temodar) $0 tretinoin (chemotherapy) $0 AGE (Max 30 Years) TREXALL 4 PA TYKERB $0 PA; SP; QL (150 per 30 VENCLEXTA ORAL TABLET 10 MG $0 PA; SP; QL (60 per 30 VENCLEXTA ORAL TABLET 100 MG $0 PA; SP; QL (10 per 30 VENCLEXTA ORAL TABLET 50 MG $0 PA; SP; QL (30 per 30 VENCLEXTA STARTING PACK $0 PA; SP; QL (4 per 8 VERZENIO $0 PA; SP; QL (56 per 8 VOTRIENT $0 PA; SP; QL (10 per 30 Geisinger 018 Marketplace Formulary 15

26 XALKORI $0 PA; SP; QL (60 per 30 XELODA $0 XTANDI $0 PA; SP; QL (10 per 30 ZEJULA $0 PA; SP; QL (90 per 30 ZELBORAF $0 PA; SP; QL (30 days supply per fill) ZOLINZA $0 PA; SP; QL (10 per 30 ZYDELIG $0 PA; SP; QL (60 per 30 ZYKADIA $0 PA; SP; QL (140 per 8 ZYTIGA ORAL TABLET 50 MG $0 PA; SP; QL (10 per 30 ZYTIGA ORAL TABLET 500 MG $0 PA; SP; QL (60 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium (Librax (with clidinium)) ME-PB-HYOS ORAL ELIXIR phenobarb-hyoscy-atropine-scop oral tablet (Donnatal) propantheline Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, PA; QL (1 per 1 day) MG APTIOM ORAL TABLET 600 MG, PA; QL ( per 1 day) MG BANZEL 4 carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr carbamazepine oral suspension 100 mg/5 (Tegretol) ml carbamazepine oral tablet (Epitol) 1 carbamazepine oral tablet extended (Tegretol XR) release 1 hr carbamazepine oral tablet,chewable CARBATROL 4 CELONTIN ORAL CAPSULE 300 MG 4 PA Geisinger 018 Marketplace Formulary 16

27 DEPAKENE 4 DEPAKOTE 4 DEPAKOTE ER 4 DEPAKOTE SPRINKLES 4 DILANTIN 3 DILANTIN EXTENDED 4 DILANTIN INFATABS 4 DILANTIN-15 4 divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle divalproex oral tablet extended release 4 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) epitol EQUETRO 4 PA ethosuximide (Zarontin) felbamate (Felbatol) FELBATOL 4 FYCOMPA ORAL SUSPENSION 4 PA; QL (4 per 1 day) FYCOMPA ORAL TABLET 4 PA; QL (1 per 1 day) FYCOMPA ORAL TABLETS,DOSE PACK 4 PA; QL (1 per 1 day) gabapentin oral capsule (Neurontin) gabapentin oral solution 50 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 MG 3 GRALISE 4 PA GRALISE 30-DAY STARTER PACK 4 PA HORIZANT 4 PA KEPPRA ORAL 4 KEPPRA XR 4 LAMICTAL 4 LAMICTAL STARTER (BLUE) KIT 4 LAMICTAL XR 4 LAMICTAL XR STARTER (BLUE) 4 PA LAMICTAL XR STARTER (GREEN) 4 PA LAMICTAL XR STARTER (ORANGE) 4 PA lamotrigine oral tablet (Lamictal) lamotrigine oral tablet disintegrating, dose pk (Lamictal ODT Starter (Blue)) PA Geisinger 018 Marketplace Formulary 17

28 lamotrigine oral tablet extended release (Lamictal XR) 4hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablet,disintegrating (Lamictal ODT) PA lamotrigine oral tablets,dose pack (Lamictal Starter (Orange) Kit) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 4 hr LYRICA 3 oxcarbazepine (Trileptal) PEGANONE 4 phenobarbital PHENYTEK 3 phenytoin oral suspension 15 mg/5 ml (Dilantin-15) phenytoin oral tablet,chewable (Dilantin Infatabs) phenytoin sodium extended (Dilantin Extended) primidone (Mysoline) SABRIL ORAL TABLET 4 PA; SP; QL (34 days supply per fill) STAVZOR 4 PA TEGRETOL ORAL SUSPENSION 4 TEGRETOL ORAL TABLET 4 TEGRETOL XR ORAL TABLET 4 EXTENDED RELEASE 1 HR 00 MG, 400 MG tiagabine (Gabitril) TOPAMAX 4 topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) PA topiramate oral tablet (Topamax) TRILEPTAL 4 valproic acid (Depakene) valproic acid (as sodium salt) oral (Depakene) solution 50 mg/5 ml vigabatrin (Sabril) PA VIMPAT ORAL SOLUTION 4 PA VIMPAT ORAL TABLET 4 PA ZARONTIN 4 ZONEGRAN ORAL CAPSULE 100 MG, 5 MG 4 Geisinger 018 Marketplace Formulary 18

29 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets (Razadyne ER) 4 hr galantamine oral solution galantamine oral tablet (Razadyne) memantine oral solution memantine oral tablet (Namenda) memantine oral tablets,dose pack (Namenda Titration Pak) PA rivastigmine (Exelon) PA rivastigmine tartrate Antidepressants Antidepressants amitriptyline 1 amitriptyline-chlordiazepoxide amoxapine APLENZIN 4 PA bupropion hcl oral tablet bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr citalopram oral solution 1 citalopram oral tablet (Celexa) 1 clomipramine (Anafranil) desipramine (Norpramin) desvenlafaxine succinate (Pristiq) QL (1 per 1 day) doxepin oral duloxetine oral capsule,delayed (Cymbalta) release(dr/ec) 0 mg, 30 mg, 60 mg EMSAM 4 PA escitalopram oxalate (Lexapro) FETZIMA 4 PA fluoxetine oral capsule (Prozac) 1 fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 0 mg (Sarafem) 1 FLUOXETINE ORAL TABLET 60 MG Geisinger 018 Marketplace Formulary 19

30 fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet FORFIVO XL 4 PA imipramine hcl (Tofranil) imipramine pamoate maprotiline MARPLAN 4 PA mirtazapine nefazodone nortriptyline oral capsule (Pamelor) nortriptyline oral solution olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) 1 paroxetine hcl oral tablet extended release (Paxil CR) 4 hr PAXIL ORAL SUSPENSION 3 perphenazine-amitriptyline PEXEVA 4 PA phenelzine (Nardil) protriptyline SARAFEM ORAL TABLET 10 MG, 0 MG 4 PA sertraline oral concentrate (Zoloft) sertraline oral tablet (Zoloft) 1 tranylcypromine (Parnate) trazodone oral tablet 100 mg, 150 mg, 50 1 mg trazodone oral tablet 300 mg trimipramine (Surmontil) venlafaxine oral capsule,extended release (Effexor XR) 4hr venlafaxine oral tablet venlafaxine oral tablet extended release 4hr 4 VIIBRYD ORAL TABLET 4 PA VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) 4 PA Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) AVANDIA 4 PA BYDUREON 4 ST; QL (0.14 per 1 day) Geisinger 018 Marketplace Formulary 0

31 BYDUREON BCISE 4 ST; QL (0.1 per 1 day) CYCLOSET 4 PA GLYXAMBI 3 ST; QL (1 per 1 day) INVOKAMET 3 ST; QL ( per 1 day) INVOKAMET XR 3 ST; QL ( per 1 day) INVOKANA 3 ST; QL (1 per 1 day) JARDIANCE 3 ST; QL (1 per 1 day) JENTADUETO 3 ST; QL ( per 1 day) JENTADUETO XR ORAL TABLET, IR - 3 ST; QL ( per 1 day) ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - 3 ST; QL (1 per 1 day) ER, BIPHASIC 4HR 5-1,000 MG KOMBIGLYZE XR 4 PA KORLYM 5 PA; SP; QL (11 per 8 metformin oral tablet (Glucophage) 1 metformin oral tablet extended release 4 (Glucophage XR) hr miglitol (Glyset) nateglinide (Starlix) ONGLYZA 4 PA pioglitazone (Actos) pioglitazone-glimepiride (DUETACT) pioglitazone-metformin (Actoplus MET) repaglinide (Prandin) RIOMET 4 PA SYMLINPEN 10 4 PA SYMLINPEN 60 4 PA SYNJARDY 3 ST; QL ( per 1 day) SYNJARDY XR ORAL TABLET, IR - 3 ST; QL (1 per 1 day) ER, BIPHASIC 4HR 10-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - 3 ST; QL ( per 1 day) ER, BIPHASIC 4HR 1.5-1,000 MG, 5-1,000 MG TANZEUM 3 ST; QL (0.14 per 1 day) TRADJENTA 3 ST; QL (1 per 1 day) TRULICITY 4 ST; QL (0.07 per 1 day) VICTOZA 3 ST; QL (0.3 per 1 day) Insulins APIDRA 4 PA APIDRA SOLOSTAR 4 PA HUMALOG SUBCUTANEOUS 4 PA SOLUTION Geisinger 018 Marketplace Formulary 1

32 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 NOVOLIN 70/30 3 NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX NOVOLOG MIX FLEXPEN 3 NOVOLOG PENFILL 3 TOUJEO SOLOSTAR 3 AGE (Min 18 Years) TRESIBA FLEXTOUCH U TRESIBA FLEXTOUCH U-00 3 XULTOPHY 100/3.6 3 ST; QL (0.5 per 1 day) Sulfonylureas chlorpropamide DIABETA 4 PA glimepiride (Amaryl) 1 glipizide oral tablet (Glucotrol) 1 glipizide oral tablet extended release 4hr (Glucotrol XL) glipizide-metformin glyburide 1 glyburide micronized (Glynase) 1 glyburide-metformin tolazamide tolbutamide Antifungals Antifungals ciclopirox topical cream (Ciclodan) ciclopirox topical gel ciclopirox topical shampoo (Loprox) ciclopirox topical suspension (Loprox (as olamine)) clotrimazole mucous membrane clotrimazole topical clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion econazole ERTACZO 4 PA EXELDERM 4 PA fluconazole (Diflucan) Geisinger 018 Marketplace Formulary

33 flucytosine (Ancobon) 5 QL (34 days supply per fill) griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize (Gris-PEG (ultramicrosize)) itraconazole (Sporanox) PA ketoconazole oral ketoconazole topical cream ketoconazole topical foam (Extina) ketoconazole topical shampoo (Nizoral) LAMISIL ORAL GRANULES IN 4 PACKET LUZU 4 PA miconazole-3 vaginal suppository naftifine NAFTIN TOPICAL GEL 3 NOXAFIL ORAL 5 PA nyamyc NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral powder 150 million unit nystatin oral suspension nystatin oral tablet nystatin topical (Nyamyc) nystatin-triamcinolone nystop ORAVIG 4 PA oxiconazole (Oxistat) PA OXISTAT TOPICAL LOTION 4 PA SPORANOX ORAL SOLUTION 4 PA terbinafine hcl oral (Lamisil) VFEND 5 PA; QL (34 days supply per fill) voriconazole oral (Vfend) 5 PA; QL (34 days supply per fill) XOLEGEL 4 PA Antigout Agents Antigout Agents, Other allopurinol (Zyloprim) 1 colchicine oral tablet (Colcrys) probenecid probenecid-colchicine Geisinger 018 Marketplace Formulary 3

34 ULORIC 4 PA Antihistamines Antihistamines arbinoxa oral liquid arbinoxa oral tablet carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet centergy CLARINEX ORAL SYRUP 4 CLARINEX-D 1 HOUR 4 clemastine oral tablet.68 mg cyproheptadine desloratadine oral tablet (Clarinex) desloratadine oral tablet,disintegrating diphenhydramine hcl oral elixir (Children's Allergy (diphenhyd)) hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet levocetirizine (Xyzal) promethazine oral syrup promethazine vc Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL 3 CLEOCIN VAGINAL SUPPOSITORY 3 clindamycin phosphate vaginal (Cleocin) CLINDESSE 3 GYNAZOLE-1 4 PA metronidazole vaginal (Metrogel Vaginal) terconazole vaginal cream terconazole vaginal suppository VANDAZOLE 4 PA Antimigraine Agents Antimigraine Agents almotriptan malate (Axert) PA; QL (16 per 8 ALSUMA 4 PA; QL (8 per 8 dihydroergotamine injection (D.H.E.45) dihydroergotamine nasal (Migranal) eletriptan hbr (Relpax) PA; QL (16 per 8 ERGOMAR 4 PA Geisinger 018 Marketplace Formulary 4

35 ergotamine-caffeine (Cafergot) frovatriptan (Frova) PA; QL (16 per 8 isometh-dichloral-acetaminophn (Nodolor) isomethepten-caf-acetaminophen (Prodrin) MIGERGOT naratriptan (Amerge) QL (16 per 8 prodrin oral tablet mg rizatriptan oral tablet (Maxalt) QL (16 per 8 rizatriptan oral tablet,disintegrating (Maxalt-MLT) QL (16 per 8 sumatriptan (Imitrex) QL (16 per 8 sumatriptan succinate oral (Imitrex) QL (16 per 8 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (8 per 8 cartridge Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose Pen) QL (8 per 8 injector sumatriptan succinate subcutaneous (Imitrex) QL (8 per 8 solution sumatriptan succinate subcutaneous QL (8 per 8 syringe 6 mg/0.5 ml SUMAVEL DOSEPRO 4 PA; QL (8 per 8 TREXIMET 4 PA; QL (16 per 8 zolmitriptan oral tablet (Zomig) QL (16 per 8 zolmitriptan oral tablet,disintegrating (Zomig ZMT) QL (16 per 8 ZOMIG NASAL 4 PA; QL (16 per 8 Antimycobacterials Antimycobacterials cycloserine dapsone oral ethambutol isoniazid oral PASER 4 PA PRIFTIN 4 PA pyrazinamide rifabutin (Mycobutin) RIFAMATE 4 PA rifampin oral (Rifadin) RIFATER 3 TRECATOR 4 PA Antinausea Agents Antinausea Agents AKYNZEO 4 QL ( per 8 ANZEMET ORAL 4 PA aprepitant (Emend) Geisinger 018 Marketplace Formulary 5

36 CESAMET 4 PA compro DICLEGIS 4 QL (4 per 1 day) dronabinol (Marinol) EMEND ORAL SUSPENSION FOR RECONSTITUTION 4 granisetron hcl oral QL ( per 1 day) meclizine oral tablet 1.5 mg meclizine oral tablet 5 mg (Dramamine Less Drowsy) ondansetron (Zofran ODT) ondansetron hcl oral (Zofran (as hydrochloride)) phenadoz prochlorperazine (Compazine) prochlorperazine maleate (Compazine) promethazine oral tablet promethazine rectal (Phenergan) promethegan SANCUSO 4 PA scopolamine base (Transderm-Scop) trimethobenzamide oral (Tigan) VARUBI ORAL 4 QL ( per 14 ZUPLENZ 4 PA Antiparasite Agents Antiparasite Agents ALBENZA 4 QL (4 per 1 day) ALINIA 3 atovaquone (Mepron) atovaquone-proguanil (Malarone Pediatric) BILTRICIDE 4 PA chloroquine phosphate COARTEM 4 PA DARAPRIM 3 SP EMVERM 3 PA hydroxychloroquine (Plaquenil) ivermectin (Stromectol) mefloquine NEBUPENT 3 paromomycin PRIMAQUINE 4 PA quinine sulfate (Qualaquin) PA tinidazole Geisinger 018 Marketplace Formulary 6

37 YODOXIN 3 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl APOKYN 5 SP; QL (18 per 30 benztropine oral 1 bromocriptine (Parlodel) cabergoline carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet) carbidopa-levodopa oral tablet extended (Sinemet CR) release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone (Stalevo 100) entacapone (Comtan) pramipexole oral tablet (Mirapex) pramipexole oral tablet extended release (Mirapex ER) PA 4 hr rasagiline (Azilect) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 4 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet tolcapone (Tasmar) trihexyphenidyl ZELAPAR 4 PA Antipsychotic Agents Antipsychotic Agents aripiprazole oral solution aripiprazole oral tablet (Abilify) aripiprazole oral tablet,disintegrating chlorpromazine oral clozapine oral tablet (Clozaril) clozapine oral tablet,disintegrating (FazaClo) FANAPT 4 PA fluphenazine decanoate fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet 1 mg 1 fluphenazine hcl oral tablet 10 mg,.5 mg, 5 mg Geisinger 018 Marketplace Formulary 7

38 haloperidol haloperidol decanoate (Haldol Decanoate) haloperidol lactate LATUDA ORAL TABLET 10 MG, 0 4 PA MG, 40 MG, 80 MG loxapine succinate NUPLAZID 5 PA; QL ( per 1 day) olanzapine intramuscular (Zyprexa) olanzapine oral tablet (Zyprexa) olanzapine oral tablet,disintegrating (Zyprexa Zydis) paliperidone (Invega) PA perphenazine pimozide (Orap) quetiapine oral tablet (Seroquel) quetiapine oral tablet extended release 4 hr (Seroquel XR) risperidone oral solution (Risperdal) risperidone oral tablet (Risperdal) risperidone oral tablet,disintegrating (Risperdal M-TAB) SAPHRIS (BLACK CHERRY) 4 PA thioridazine thiothixene trifluoperazine VRAYLAR 4 PA; QL (1 per 1 day) ziprasidone hcl (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral solution (Ziagen) QL (30 per 1 day) abacavir oral tablet (Ziagen) QL ( per 1 day) abacavir-lamivudine (Epzicom) QL (1 per 1 day) abacavir-lamivudine-zidovudine (Trizivir) QL ( per 1 day) APTIVUS ORAL CAPSULE 3 QL (4 per 1 day) APTIVUS ORAL SOLUTION 3 QL (10 per 1 day) ATRIPLA 3 QL (1 per 1 day) COMPLERA 3 QL (1 per 1 day) CRIXIVAN ORAL CAPSULE 00 MG 3 QL (3 per 1 day) CRIXIVAN ORAL CAPSULE 400 MG 3 QL (6 per 1 day) DESCOVY 3 QL (1 per 1 day) didanosine (Videx EC) QL (1 per 1 day) EDURANT 3 QL ( per 1 day) efavirenz oral capsule 00 mg QL ( per 1 day) efavirenz oral capsule 50 mg QL (3 per 1 day) EMTRIVA ORAL CAPSULE 3 QL (1 per 1 day) Geisinger 018 Marketplace Formulary 8

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