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

Transcription

1 018 Formulary/Formulario (List of Covered Drugs)/ (Lista de medicamentos cubiertos) Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA: ESTE DOCUMENTO TIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS EN ESTE PLAN LiveWe (HMO) ll If you remember these special moments, you re ready for AgeWell New York HPMS Approved Formulary File Submission ID: 18330, Version Number: 7 This formulary was updated on 01/01/018. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or for TTY users, 711, 7 days a week hours a day or visit H9_LWFormulary1085 Accepted

2 018 Part D Formulary (Comprehensive) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means AgeWell New York. When it refers to plan or our plan, it means LiveWell (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 01/01/018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 018, and from time to time during the year. What is the LiveWell (HMO) s Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. LiveWell (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 01/01/018. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event that the plan makes a mid-year non-maintenance formulary change, we will mail you updated information at least 60 days prior to the date the change becomes effective. i

3 018 Part D Formulary (Comprehensive) How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 117. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, the plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that the plan will cover. For example, our plan provides 9 tablets per prescription for Sumatriptan Succinate 100mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. ii

4 018 Part D Formulary (Comprehensive) You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask LiveWell (HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the LiveWell (HMO) formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that LiveWell (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan. You can ask the plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the LiveWell (HMO) s Formulary? You can ask the plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, LiveWell (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii

5 018 Part D Formulary (Comprehensive) You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least 91 or up to a 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Existing Member with Level of Care Changes If you are outside your transition period and experience a level of care change in which you are changing from one treatment setting to another (example: Long Term Care to hospital, hospital to home, home to Long Term Care), upon admission or discharge from a treatment setting or Long Term Care, we will allow you access to a 30/31 day refill (30 days in the retail setting and 31 days in the Long Term Care setting) for formulary medications and an emergency 30/31 day refill (30 days in the retail setting and 31 days in the Long Term Care setting) for non-formulary medications (including Part D drugs that are on our formulary but require prior authorization or step therapy). This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from Long Term Care or hospital facilities. iv

6 018 Part D Formulary (Comprehensive) To the extent that you are outside your 90-day transition period and are in an outpatient setting, we will still provide an emergency 30 day supply of non-formulary medications (including Part D drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), on a case by case basis, while an exception request is being processed. To the extent that you are outside your 90-day transition period and are in a Long Term Care setting, we will still provide an emergency 31 day supply of Part D covered non-formulary medications (including Part D covered drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), while an exception request is being processed. For more information For more detailed information about your LiveWell (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about LiveWell (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit LiveWell (HMO) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by LiveWell (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 117. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NAMENDA XR) and generic drugs are listed in lower-case italics (e.g., memantine). The information in the Requirements/Limits column tells you if the plan has any special requirements for coverage of your drug. v

7 018 Part D Formulary (Comprehensive) LEGEND Symbol Name QL PA ST Quantity Limit Prior Authorization Step Therapy Description There is a limit on the amount of this drug that is covered per prescription or within a specific time frame. You (or your physician) are required to obtain a prior authorization before you fill your prescription for this drug. Without a prior authorization, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. GC Gap Coverage We provide additional coverage of this prescription drug in the coverage gap MO Mail Order This prescription may also be available via mail. LA Limited Access This prescription drug is limited to certain pharmacies. HRM BD High Risk Medications Part B vs. Part D The Centers for Medicare and Medicaid Services (CMS) has identified the drug listed as posing a higher risk to patients, especially to seniors (PA required for ages 65 or over) This prescription drug may be covered under Medicare Part B or Part D depending on the circumstances. Tier Name 1 Preferred Generic drugs This is the lowest cost-sharing tier. Generic drugs 3 Preferred Brand name drugs Non-preferred Brand name drugs 5 Specialty Drugs This is the highest cost-sharing tier. vi

8 Formulario de la Parte D 018 (Integral) Nota para los miembros existentes: Este formulario ha sufrido modificaciones desde el año pasado. Revise este documento para asegurarse de que contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) dice nosotros, nos o nuestro/a, hace referencia a AgeWell New York. Cuando dice plan o nuestro plan, hace referencia a LiveWell (HMO). Este documento incluye una lista de los medicamentos (formulario) para nuestro plan, actualizada al 01/01/018. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. En general, debe utilizar las farmacias de la red para sus beneficios de medicamentos con receta. Los beneficios, el formulario, la red de farmacias y los copagos o coseguros pueden sufrir modificaciones el 1 de enero del 018 y ocasionalmente durante el año. Qué es el Formulario de LiveWell (HMO)? Un formulario es una lista de medicamentos cubiertos por nuestro plan en consulta con un equipo de proveedores de atención médica, que representa las terapias recetadas que se consideran una parte necesaria del programa de tratamiento de calidad. En general, LiveWell (HMO) cubre los medicamentos enumerados en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta sea presentada en una farmacia de la red del plan y se respeten otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, revise su Evidencia de cobertura. Puedo modificar el Formulario (lista de medicamentos)? Generalmente, si está tomando un medicamento incluido en nuestro formulario 018 que estaba cubierto al comienzo del año, no suspenderemos ni reduciremos la cobertura del medicamento durante el 018, salvo que se desarrolle un nuevo medicamento genérico más económico o que se divulgue información adversa sobre la seguridad o la eficacia de un medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento de nuestro formulario, no afectará a los miembros que estén tomando ese medicamento. El medicamento seguirá disponible con la misma distribución de costos para los miembros que lo estén tomando durante el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, salvo en los casos en los cuales puede ahorrar dinero o podemos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, o agregamos una autorización previa, límites de cantidad o restricciones de tratamiento escalonado con respecto a un medicamento o cambiamos un medicamento a un nivel de distribución de costos más alto, debemos notificar del cambio a los miembros afectados con una antelación mínima de 60 días a la fecha de entrada en vigencia del cambio o cuando el miembro solicita un resurtido del medicamento, momento en el cual el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que un medicamento en nuestro formulario no es seguro o el fabricante del medicamento decide retirar el medicamento del mercado, eliminaremos inmediatamente el medicamento de nuestro formulario y vii

9 Formulario de la Parte D 018 (Integral) notificaremos a los miembros que estén tomando ese medicamento. El formulario adjunto está actualizado al 01/01/018. Para obtener información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto se encuentra en la portada frontal y trasera. En el caso de que el plan realice un cambio que no sea de mantenimiento en el formulario a mitad de año, le enviaremos la información actualizada por correo con una antelación mínima de 60 días a la entrada en vigencia del cambio. Cómo utilizo el Formulario? Hay dos formas de encontrar un medicamento dentro del formulario: Afección médica El formulario comienza en la página 1. Los medicamentos en este formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran bajo la categoría Agentes cardiovasculares. Si sabe para qué se utiliza el medicamento que está tomando, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque el nombre de su medicamento dentro de esa categoría. Listado en orden alfabético Si no sabe en qué categoría buscar, debe buscar su medicamento en el Índice que empieza en la página 117. El Índice proporciona una lista en orden alfabético de los medicamentos incluidos en este documento. El Índice incluye medicamentos de marca y medicamentos genéricos. Busque en el Índice y encuentre su medicamento. Al lado del medicamento, verá el número de página en donde puede encontrar la información de cobertura. Vaya a la página indicada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Nuestro plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico es un medicamento aprobado por la FDA que tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos tienen un costo menor que los medicamentos de marca. Hay alguna restricción o limitación en mi cobertura? Algunos medicamentos cubiertos podrían tener requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Nuestro plan requiere que usted o su médico obtengan autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus medicamentos con receta. Si no tiene la aprobación, es posible que el plan no cubra el medicamento. Límites de cantidad: Para determinados medicamentos, nuestro plan limita la cantidad de medicamento que cubrirá. Por ejemplo, nuestro plan provee 9 comprimidos por receta viii

10 Formulario de la Parte D 018 (Integral) de Sumatriptan succinato 100 mg. Esto puede sumarse a un suministro estándar de un mes o tres meses. Tratamiento escalonado: En algunos casos, nuestro plan le podría solicitar que primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, el plan entonces cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el formulario que empieza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones en tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. Puede solicitarle a LiveWell (HMO) que realice una excepción a estas restricciones o límites o que incluya otros medicamentos similares que sirvan para tratar su afección médica. Consulte la sección Cómo hago para solicitar una excepción al Formulario de LiveWell (HMO)? en la página ix para obtener información sobre cómo solicitar una excepción. Qué sucede si mi medicamento no está incluido en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), debe comunicarse con Servicios para miembros y preguntar si su medicamento está cubierto. Si le informan que LiveWell (HMO) no cubre su medicamento, tiene dos opciones: Puede solicitarle a Servicios para miembros una lista de medicamentos similares cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por el plan. O puede pedirle al plan que haga una excepción y cubra su medicamento. Debajo encontrará más información sobre cómo solicitar una excepción. Cómo hago para solicitar una excepción al Formulario de LiveWell (HMO)? Puede solicitarle al plan que realice una excepción a sus normas de cobertura. Puede solicitar distintos tipos de excepciones. Puede solicitarnos la cobertura de un medicamento incluso si no está incluido en este formulario. Si aprobamos su solicitud, este medicamento será cubierto a un nivel de distribución de costos predeterminado y usted no podrá solicitarnos que le proporcionemos el medicamento a un nivel de distribución de costos más bajo. ix

11 Formulario de la Parte D 018 (Integral) Puede solicitarnos la cobertura de un medicamento incluido en el formulario a un nivel de distribución de costos más bajo si dicho medicamento no se encuentra en el nivel especial. Si aprobamos su solicitud, reduciremos el monto que debe pagar por su medicamento. Puede solicitarnos que cancelemos las restricciones o límites de cobertura con respecto a su medicamento. Por ejemplo, para determinados medicamentos, el plan limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede solicitarnos que renunciemos al límite y le brindemos cobertura por una cantidad mayor. En general, LiveWell (HMO) aprobará su solicitud de realizar una excepción únicamente si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con una distribución de costos más baja o las restricciones de utilizaciones adicionales, no fueran eficaces para el tratamiento de su afección o le provocaran efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario o a una restricción de utilización. Cuando solicite una excepción al formulario o a una restricción de utilización, debe presentar una declaración de la persona autorizada a dar recetas o de su médico que respalde su solicitud. En general, debemos tomar una decisión dentro de las 7 horas de haber recibido la declaración de respaldo de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud puede verse seriamente perjudicada si se demora 7 horas en tomar una decisión. Si su solicitud acelerada es aceptada, debemos tomar una decisión dentro de las horas posteriores a la recepción de la declaración de respaldo de su médico u otra persona autorizada a dar recetas. Qué debo hacer antes de hablar con mi médico sobre el cambio de medicamento o antes de solicitar una excepción? Como miembro nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no estén incluidos en nuestro formulario. O es posible que esté tomando un medicamento incluido en nuestro formulario pero que su capacidad para obtenerlo esté limitada. Por ejemplo, es posible que necesite nuestra autorización previa para obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar a otro medicamento apropiado que esté cubierto por nuestro plan o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción adecuado en su caso, es posible que le brindemos cobertura en determinados casos durante los primeros 90 días de su participación en nuestro plan. Para cada uno de los medicamentos que no estén incluidos en nuestro formulario o si su capacidad para obtener sus medicamentos está limitada, le brindaremos cobertura para un suministro de 30 días (salvo que tenga una receta escrita por un plazo menor) en una farmacia de la red. Después de su primer suministro de 30 días, no cubriremos estos medicamentos, incluso si ha sido miembro del plan por menos de 90 días. x

12 Formulario de la Parte D 018 (Integral) Si usted vive en un centro de atención a largo plazo, le permitiremos resurtir su medicamento hasta proporcionarle un suministro de transición de al menos 91 días y hasta 98 días, compatible con el incremento de entrega (salvo que tenga una receta escrita por un plazo menor). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días de su membresía en nuestro plan. Si necesita un medicamento que no está incluido en nuestro formulario o si su capacidad para obtener sus medicamentos está limitada y han transcurrido los primeros 90 días de su membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (salvo que tenga una receta escrita por un plazo menor) mientras solicita una excepción al formulario. Miembro existente con cambios en el nivel de atención Si se encuentra fuera del periodo de transición y sufre un cambio en el nivel de atención en el cual cambia de un ambiente de tratamiento a otro (por ejemplo: Atención a largo plazo al hospital, hospital al hogar, hogar a Atención a largo plazo), al momento de admisión o alta de un ambiente de tratamiento o centro de Atención a largo plazo, le permitiremos acceder a un resurtido de 30/31 días (30 días en un ambiente particular y 31 días en un ambiente de Atención a largo plazo) para medicamentos incluidos en el formulario y un resurtido de emergencia de 30/31 días (30 días en un ambiente particular y 31 días en un ambiente de Atención a largo plazo) para medicamentos no incluidos en el formulario (incluso medicamentos de la Parte D que no estén incluidos en nuestro formulario pero requieran autorización previa o tratamiento escalonado). Esta política no es aplicable a las licencias a corto plazo (p. ej., feriados o vacaciones) de centros de Atención a largo plazo u hospitales. En la medida que esté fuera del periodo de transición de 90 días y se encuentre en un ambiente ambulatorio, le proporcionaremos un suministro de emergencia de 30 días de medicamentos no incluidos en el formulario (incluso medicamentos de la Parte D que estén incluidos en nuestro formulario y que de otro modo requieren autorización previa o tratamiento escalonado en virtud de nuestras normas de administración de utilización), según el caso, mientras procesamos una solicitud de excepción. En la medida que esté fuera del periodo de transición de 90 días y se encuentre en un centro de Atención a largo plazo, le proporcionaremos un suministro de emergencia de 31 días de medicamentos no incluidos en el formulario cubiertos en la Parte D (incluso medicamentos cubiertos en la Parte D que estén incluidos en nuestro formulario y que de otro modo requieren autorización previa o tratamiento escalonado en virtud de nuestras normas de administración de utilización), mientras procesamos una solicitud de excepción. Para obtener más información Para obtener información más detallada sobre su cobertura de medicamentos con receta de LiveWell (HMO), revise su Evidencia de cobertura y otro material del plan. Si tiene alguna consulta sobre LiveWell (HMO), comuníquese con nosotros. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. xi

13 Formulario de la Parte D 018 (Integral) Si tiene consultas generales sobre la cobertura de medicamentos con receta de Medicare, comuníquese con Medicare al MEDICARE ( ) las horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O visite Formulario de LiveWell (HMO) El formulario debajo le brinda información de cobertura sobre los medicamentos cubiertos por LiveWell (HMO). Si tiene alguna dificultad para encontrar en la lista el medicamento que toma, consulte el Índice que comienza en la página 117. En la primera columna de esta tabla se indica el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., NAMENDA XR) y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., memantine). La información en la columna Requisitos/Límites le indica si el plan tiene algún requisito especial para la cobertura de su medicamento. xii

14 Formulario de la Parte D 018 (Integral) LEYENDA Símbolo Nombre QL PA ST Límites de cantidad Autorización previa Tratamiento escalonado Descripción Existe un límite con respecto a la cantidad de este medicamento que se cubre mediante receta o en un plazo específico. Usted (o su médico) debe obtener una autorización previa antes de surtir la receta de este medicamento. Sin autorización previa, es posible que no cubramos este medicamento. En algunos casos, es posible que deba probar otros medicamentos para tratar su afección médica, antes de que podamos cubrir otro medicamento para dicha afección. GC Período sin cobertura Proporcionamos cobertura adicional para este medicamento con receta durante el período sin cobertura. MO Pedidos por correo Esta receta también podría estar disponible por correo. LA Acceso limitado Este medicamento con receta está limitado a ciertas farmacias. HRM BD Medicamentos de alto riesgo Parte B vs. Parte D Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) han identificado el medicamento detallado como un medicamento con riesgo elevado para los pacientes, especialmente para personas mayores (se requiere autorización previa para pacientes de 65 años o más) Este medicamento con receta puede estar cubierto por la Parte B o la Parte D de Medicare, según las circunstancias. Nivel Nombre 1 Medicamentos genéricos preferidos Este es el nivel de distribución de costos más bajo. Medicamentos genéricos 3 Medicamentos de marca preferidos Medicamentos de marca no preferidos 5 Medicamentos especiales Este es el nivel de distribución de costos más alto. xiii

15 Agewell 5-Tier (List of Covered Drugs) Drug Tier Requirements/Limits ANALGESICS OPIOID ANALGESICS, LONG- ACTING ALLZITAL ORAL TABLET 5-35 MG butalbital-acetaminophen oral tablet mg butalbital-apap-caffeine oral capsule mg, mg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 6.5 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid 1 mg/ml methadone hcl injection solution 10 mg/ml 3 methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg morphine sulfate er beads oral capsule extended release hour 10 mg, 30 mg, 5 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release hour 10 mg, 0 mg, 30 mg morphine sulfate er oral capsule extended release hour 100 mg morphine sulfate er oral capsule extended release hour 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 00 mg, 30 mg, 60 mg oxycodone hcl er oral tablet er 1 hour abusedeterrent 10 mg, 15 mg, 0 mg, 30 mg, 0 mg, 60 mg, 80 mg OXYCONTIN ORAL TABLET ER 1 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 0 MG, 30 MG, 0 MG, 60 MG, 80 MG TENCON ORAL TABLET MG 1 ZEBUTAL ORAL CAPSULE MG OPIOID ANALGESICS, SHORT- ACTING acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 ST; QL (10 EA per 30 days) 3 ST; QL (10 EA per 30 days)

16 acetaminophen-codeine #3 oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine oral solution 10-1 mg/5ml ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg duramorph injection solution 0.5 mg/ml, 1 mg/ml FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg, 5-35 mg, mg, mg hydrocodone-acetaminophen oral tablet.5-35 mg hydrocodone-ibuprofen oral tablet mg, 5-00 mg, mg hydromorphone hcl injection solution mg/ml hydromorphone hcl oral tablet mg, mg, 8 mg hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml HYSINGLA ER ORAL TABLET ER HOUR ABUSE-DETERRENT 100 MG, 10 MG, 0 MG, 30 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 00 MCG/ACT morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate (pf) intravenous solution mg/ml morphine sulfate oral solution 10 mg/5ml morphine sulfate oral solution 0 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg QL (5000 ML per 30 days) introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 3 PA; HRM; QL (180 EA per 30 days) QL (180 EA per 30 days) 5 PA PA; HRM; QL (370 EA per 30 days) PA; HRM; QL (180 EA per 30 days) 1 QL (5500 ML per 30 days) QL (370 EA per 30 days) 1 QL (370 EA per 30 days) QL (150 EA per 30 days) 3 5 PA 3

17 nalbuphine hcl injection solution 10 mg/ml, 0 mg/ml oxycodone hcl oral capsule 5 mg oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg oxycodone-acetaminophen oral solution 5-35 mg/5ml oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg QL (1800 ML per 30 days) QL (370 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet 5-00 mg QL (360 EA per 30 days) oxymorphone hcl oral tablet 10 mg, 5 mg pentazocine-naloxone hcl oral tablet mg PA; HRM tramadol hcl oral tablet 50 mg 1 QL (0 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (370 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 % 1 lidocaine hcl injection solution 0.5 %, % 1 lidocaine-prilocaine external cream.5-.5 % ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI- CRAVING acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 50 mg, 500 mg naltrexone hcl oral tablet 50 mg OPIOID ANTAGONISTS buprenorphine hcl injection solution 0.3 mg/ml (cartridge) buprenorphine hcl sublingual tablet sublingual mg, 8 mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 0 MCG/HR, 5 MCG/HR, 7.5 MCG/HR naloxone hcl injection solution 0. mg/ml 1 3 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018

18 naloxone hcl injection solution prefilled syringe mg/ml ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG SMOKING CESSATION AGENTS bupropion hcl er (sr) oral tablet extended release 1 hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ QL (56 EA per 8 days) CHANTIX ORAL TABLET 0.5 MG 3 QL (60 EA per 30 days) CHANTIX ORAL TABLET 1 MG 3 QL (180 EA per 90 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X NICOTROL INHALATION INHALER 10 MG ANTIBACTERIALS AMINOGLYCOSIDES BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/ML gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 0 mg/ml 1 gentamicin sulfate intravenous solution 10 mg/ml 1 neomycin sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 50 mg streptomycin sulfate intramuscular solution reconstituted 1 gm tobramycin inhalation nebulization solution 300 mg/5ml tobramycin sulfate injection solution 10 mg/ml, 80 mg/ml ANTIBACTERIALS, OTHER bacitracin intramuscular solution reconstituted unit chloramphenicol sod succinate intravenous solution reconstituted 1 gm clindamycin hcl oral capsule 150 mg 1 clindamycin hcl oral capsule 300 mg, 75 mg 3 QL (53 EA per 30 days) BD 1 BD 1

19 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/ml, 600 mg/ml, 900 mg/6ml colistimethate sodium injection solution reconstituted 150 mg daptomycin intravenous solution reconstituted 500 mg lincomycin hcl injection solution 300 mg/ml 1 BD linezolid intravenous solution 600 mg/300ml 5 linezolid oral suspension reconstituted 100 mg/5ml linezolid oral tablet 600 mg 5 metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral capsule 375 mg 1 metronidazole oral tablet 50 mg, 500 mg 1 nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg PRIMSOL ORAL SOLUTION 50 MG/5ML SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG tigecycline intravenous solution reconstituted 50 mg trimethoprim oral tablet 100 mg 1 vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg vancomycin hcl oral capsule 15 mg, 50 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD PA; HRM PA; HRM XIFAXAN ORAL TABLET 00 MG 5 PA XIFAXAN ORAL TABLET 550 MG 5 PA; MO BETA-LACTAM, CEPHALOSPORINS cefaclor er oral tablet extended release 1 hour 500 mg cefaclor oral capsule 50 mg, 500 mg 1 1

20 cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefepime hcl injection solution reconstituted 1 gm, gm cefixime oral suspension reconstituted 100 mg/5ml, 00 mg/5ml cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml cefpodoxime proxetil oral suspension reconstituted 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 00 mg cefprozil oral suspension reconstituted 15 mg/5ml cefprozil oral suspension reconstituted 50 mg/5ml cefprozil oral tablet 50 mg cefprozil oral tablet 500 mg 1 ceftazidime injection solution reconstituted 1 gm, gm, 6 gm ceftriaxone sodium injection solution reconstituted 50 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, gm cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cephalexin oral capsule 50 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg 1 SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

21 TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GM, GM, 6 GM TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 600 MG BETA-LACTAM, OTHER AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION GM aztreonam injection solution reconstituted 1 gm baciim intramuscular solution reconstituted unit CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 50 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted 1 gm, 500 mg BETA-LACTAM, PENICILLINS amoxicillin oral capsule 50 mg, 500 mg 1 amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 15 mg, 50 mg 1 amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 50 mg, 500 mg 1 ampicillin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 15 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

22 ampicillin sodium intravenous solution reconstituted 10 gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (-1) gm ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML, UNIT/ML, UNIT/ML dicloxacillin sodium oral capsule 50 mg, 500 mg nafcillin sodium injection solution reconstituted 1 gm, 10 gm penicillin g pot in dextrose intravenous solution 0000 unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml penicillin v potassium oral tablet 50 mg, 500 mg 1 piperacillin sod-tazobactam so intravenous solution reconstituted ( ) gm,.5 (- 0.5) gm, 0.5 (36-.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 00 mg/5ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral tablet 50 mg, 500 mg 1 DIFICID ORAL TABLET 00 MG 5 ST E.E.S. 00 ORAL TABLET 00 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

23 ERYTHROCIN STEARATE ORAL TABLET 50 MG erythromycin base oral capsule delayed release particles 50 mg erythromycin ethylsuccinate oral tablet 00 mg ZMAX ORAL SUSPENSION RECONSTITUTED GM QUINOLONES ciprofloxacin hcl oral tablet 100 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 00 mg/100ml ciprofloxacin intravenous solution 00 mg/0ml ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release hour 1000 mg, 500 mg levofloxacin in d5w intravenous solution 500 mg/100ml, 750 mg/150ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 5 mg/ml levofloxacin oral tablet 50 mg levofloxacin oral tablet 500 mg, 750 mg 1 moxifloxacin hcl intravenous solution 00 mg/50ml ofloxacin oral tablet 300 mg, 00 mg SULFONAMIDES sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg TETRACYCLINES introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 10

24 DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 0 mg 1 doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 00 mg, 75 mg doxycycline hyclate oral tablet delayed release 50 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 5 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 75 mg doxycycline monohydrate oral tablet 50 mg 1 minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam er oral tablet extended release hour 500 mg, 750 mg levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml levetiracetam intravenous solution 500 mg/5ml introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 50 mg, 500 mg, 750 mg ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 50 MG, 500 MG, 750 MG BARBITURATES MO; QL (90 EA per 30 days) MO; QL (10 EA per 30 days) phenobarbital oral elixir 0 mg/5ml 1 PA; MO; HRM phenobarbital oral tablet 100 mg, 15 mg, 16. mg, 30 mg, 3. mg, 60 mg, 6.8 mg, 97. mg 1 PA; MO; HRM primidone oral tablet 50 mg, 50 mg

25 BENZODIAZEPINES clonazepam oral tablet 0.5 mg, 1 mg, mg clonazepam oral tablet dispersible 0.15 mg, 0.5 mg, 0.5 mg, 1 mg, mg DIASTAT ACUDIAL RECTAL GEL 10 MG, 0 MG DIASTAT PEDIATRIC RECTAL GEL.5 MG diazepam rectal gel 10 mg,.5 mg ONFI ORAL SUSPENSION.5 MG/ML MO ONFI ORAL TABLET 10 MG MO ONFI ORAL TABLET 0 MG 5 MO CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG MO ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml LYRICA ORAL CAPSULE 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 1 LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 100 mg, 5 mg, 50 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release hour 50 mg, 500 mg divalproex sodium oral tablet delayed release 50 mg, 500 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML MO FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG MO gabapentin oral capsule 100 mg, 300 mg, 00 mg gabapentin oral solution 50 mg/5ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG MO SABRIL ORAL PACKET 500 MG 5 MO SABRIL ORAL TABLET 500 MG 5 MO tiagabine hcl oral tablet mg, mg valproate sodium intravenous solution 100 mg/ml 1

26 valproate sodium oral solution 50 mg/5ml valproic acid oral capsule 50 mg vigabatrin oral packet 500 mg 5 LA; MO GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml 5 MO felbamate oral tablet 00 mg, 600 mg MO LAMICTAL STARTER ORAL KIT 5 (35) MG, 5 ()-100 (7) MG, 5 (8)-100(1) MG LAMICTAL XR ORAL KIT 5 & 50 & 100 MG, 5 (1)-50 (7) MG, 50 & 100 & 00 MG lamotrigine er oral tablet extended release hour 100 mg, 00 mg, 5 mg, 50 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg lamotrigine oral tablet chewable 5 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 00 mg lamotrigine oral tablet dispersible 5 mg, 50 mg topiramate er oral capsule er hour sprinkle 100 mg, 150 mg, 00 mg, 5 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 5 mg topiramate oral tablet 00 mg, 5 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE HOUR 100 MG, 00 MG, 5 MG, 50 MG SODIUM CHANNEL AGENTS MO APTIOM ORAL TABLET 00 MG MO APTIOM ORAL TABLET 00 MG, 600 MG, 800 MG 5 MO BANZEL ORAL SUSPENSION 0 MG/ML 5 MO BANZEL ORAL TABLET 00 MG MO BANZEL ORAL TABLET 00 MG 5 MO BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 10 MG/ML 5 PA; MO BRIVIACT ORAL TABLET 10 MG PA; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 13

27 BRIVIACT ORAL TABLET 100 MG, 5 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 1 hour 00 mg, 300 mg carbamazepine er oral tablet extended release 1 hour 100 mg carbamazepine er oral tablet extended release 1 hour 00 mg carbamazepine er oral tablet extended release 1 hour 00 mg 5 PA; MO MO carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 00 mg CEREBYX INJECTION SOLUTION 500 MG PE/10ML DILANTIN ORAL CAPSULE 30 MG MO EPITOL ORAL TABLET 00 MG EQUETRO ORAL CAPSULE EXTENDED RELEASE 1 HOUR 100 MG, 00 MG, 300 MG fosphenytoin sodium injection solution 100 mg pe/ml MO oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg oxcarbazepine oral tablet 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR 150 MG, 300 MG, 600 MG MO PEGANONE ORAL TABLET 50 MG MO phenytoin oral suspension 15 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg phenytoin sodium extended oral capsule 00 mg, 300 mg phenytoin sodium injection solution 50 mg/ml 1 VIMPAT INTRAVENOUS SOLUTION 00 MG/0ML VIMPAT ORAL SOLUTION 10 MG/ML MO VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG ANTIDEMENTIA AGENTS MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 1

28 ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet 1 mg PA; MO; HRM CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10 mg, 3 mg, 5 mg donepezil hcl oral tablet dispersible 10 mg, 5 mg galantamine hydrobromide er oral capsule extended release hour 16 mg, mg, 8 mg galantamine hydrobromide oral solution mg/ml galantamine hydrobromide oral tablet 1 mg, mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg,.5 mg, 6 mg rivastigmine transdermal patch hour 13.3 mg/hr,.6 mg/hr, 9.5 mg/hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl oral solution mg/ml memantine hcl oral tablet 10 mg, 5 mg memantine hcl oral tablet 5 (8)-10 (1) mg NAMENDA XR ORAL CAPSULE EXTENDED RELEASE HOUR 1 MG, 1 MG, 8 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE HOUR 7 & 1 & 1 &8 MG NAMZARIC ORAL CAPSULE ER HOUR THERAPY PACK 7 & 1 & 1 &8-10 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR 1-10 MG, 1-10 MG, 8-10 MG, 7-10 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN ORAL TABLET EXTENDED RELEASE HOUR 17 MG, 38 MG, 5 MG bupropion hcl er (smoking det) oral tablet extended release 1 hour 150 mg bupropion hcl er (sr) oral tablet extended release 1 hour 100 mg, 00 mg 3 3 MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 15

29 bupropion hcl er (xl) oral tablet extended release hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE HOUR 50 MG maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg mirtazapine oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 5 mg nefazodone hcl oral tablet 100 mg, 150 mg, 00 mg, 50 mg nefazodone hcl oral tablet 50 mg trazodone hcl oral tablet 100 mg 1 trazodone hcl oral tablet 150 mg, 50 mg trazodone hcl oral tablet 300 mg TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD STARTER PACK ORAL KIT 10 & 0 MG MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH HOUR 1 MG/HR, 6 MG/HR, 9 MG/HR ST; MO 3 5 MO MARPLAN ORAL TABLET 10 MG MO phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS BRISDELLE ORAL CAPSULE 7.5 MG MO citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 0 mg, 0 mg desvenlafaxine er oral tablet extended release hour 100 mg, 50 mg MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 16

30 desvenlafaxine succinate er oral tablet extended release hour 100 mg, 5 mg, 50 mg duloxetine hcl oral capsule delayed release particles 0 mg, 30 mg, 0 mg, 60 mg MO escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine hcl oral capsule 10 mg, 0 mg, 0 mg fluoxetine hcl oral capsule delayed release 90 mg fluoxetine hcl oral solution 0 mg/5ml fluoxetine hcl oral tablet 10 mg, 0 mg fluoxetine hcl oral tablet 60 mg MO fluvoxamine maleate er oral capsule extended release hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 5 mg, 50 mg olanzapine-fluoxetine hcl oral capsule 1-5 mg, 1-50 mg, 3-5 mg, 6-5 mg, 6-50 mg paroxetine hcl er oral tablet extended release hour 1.5 mg, 5 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 0 mg, 30 mg, 0 mg PAXIL ORAL SUSPENSION 10 MG/5ML MO PEXEVA ORAL TABLET 10 MG, 0 MG, 30 MG, 0 MG MO sertraline hcl oral concentrate 0 mg/ml sertraline hcl oral tablet 100 mg, 5 mg, 50 mg venlafaxine hcl er oral capsule extended release hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release hour 150 mg, 5 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 5 mg, 37.5 mg, 50 mg, 75 mg TRICYCLICS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg 1 PA; MO; HRM introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 17

31 amoxapine oral tablet 100 mg amoxapine oral tablet 150 mg, 5 mg, 50 mg chlordiazepoxide-amitriptyline oral tablet 10-5 mg, mg clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg 1 PA; MO; HRM PA; MO; HRM desipramine hcl oral tablet 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 5 mg, 50 mg, 75 mg 1 PA; MO; HRM doxepin hcl oral capsule 150 mg PA; MO; HRM doxepin hcl oral concentrate 10 mg/ml 1 PA; MO; HRM imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA; MO; HRM imipramine pamoate oral capsule 100 mg, 15 mg, 150 mg, 75 mg PA; MO; HRM nortriptyline hcl oral capsule 10 mg, 5 mg nortriptyline hcl oral capsule 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg trimipramine maleate oral capsule 100 mg, 5 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 1.5 mg, 5 mg 1 PA; MO; HRM metoclopramide hcl oral tablet 5 mg TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 7 HOUR 1 MG/3DAYS EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 15 mg, 0 mg, 80 & 15 mg, 80 mg BD dronabinol oral capsule 10 mg 5 BD; QL (60 EA per 30 days) dronabinol oral capsule.5 mg, 5 mg BD; QL (60 EA per 30 days) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 18

32 EMEND ORAL SUSPENSION RECONSTITUTED 15 MG granisetron hcl intravenous solution 0.1 mg/ml, 1 mg/ml granisetron hcl intravenous solution mg/ml BD BD granisetron hcl oral tablet 1 mg BD; QL (60 EA per 30 days) ondansetron hcl injection solution mg/ml, mg/ml (ml syringe) BD ondansetron hcl oral solution mg/5ml BD ondansetron hcl oral tablet mg BD; QL (30 EA per 30 days) ondansetron hcl oral tablet mg, 8 mg BD; QL (90 EA per 30 days) ondansetron oral tablet dispersible mg, 8 mg BD; QL (90 EA per 30 days) SANCUSO TRANSDERMAL PATCH 3.1 MG/HR 5 QL ( EA per 8 days) SYNDROS ORAL SOLUTION 5 MG/ML 5 BD; QL (10 ML per 30 days) ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg clotrimazole mouth/throat lozenge 10 mg 1 ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/100ml-%, mg/00ml- % fluconazole oral suspension reconstituted 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg 5 BD BD BD BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 19

33 griseofulvin microsize oral suspension 15 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg ketoconazole oral tablet 00 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NOXAFIL ORAL SUSPENSION 0 MG/ML MO NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit 1 voriconazole intravenous solution reconstituted 00 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg 5 voriconazole oral tablet 50 mg ANTIGOUT AGENTS ANTIGOUT AGENTS introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO allopurinol oral tablet 100 mg colchicine oral capsule 0.6 mg 3 colchicine oral tablet 0.6 mg 3 probenecid oral tablet 500 mg ULORIC ORAL TABLET 0 MG, 80 MG ST; MO ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI- INFLAMMATORY DRUGS celecoxib oral capsule 100 mg, 00 mg, 00 mg, 50 mg 5 diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release hour 100 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg

34 diflunisal oral tablet 500 mg etodolac er oral tablet extended release hour 00 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 00 mg, 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml 1 ibuprofen oral tablet 00 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg PA; MO; HRM indomethacin oral capsule 5 mg, 50 mg 1 PA; MO; HRM ketoprofen er oral capsule extended release hour 00 mg ketoprofen oral capsule 50 mg ketoprofen oral capsule 75 mg ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/ml PA; HRM PA; HRM ketorolac tromethamine oral tablet 10 mg 1 PA; HRM meclofenamate sodium oral capsule 100 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 15 mg/5ml naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg tolmetin sodium oral capsule 00 mg tolmetin sodium oral tablet 600 mg ANTIMIGRAINE AGENTS introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 1

35 ANTIMIGRAINE AGENTS, PROPHYLACTIC divalproex sodium oral capsule delayed release sprinkle 15 mg divalproex sodium oral tablet delayed release 15 mg topiramate oral tablet 100 mg ERGOT ALKALOIDS dihydroergotamine mesylate injection solution 1 mg/ml dihydroergotamine mesylate nasal solution mg/ml ergotamine-caffeine oral tablet mg QL (0 EA per 8 days) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS eletriptan hydrobromide oral tablet 0 mg, 0 mg 3 QL (9 EA per 30 days) RELPAX ORAL TABLET 0 MG, 0 MG 3 QL (9 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 5 mg, 50 mg sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 15 mg MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100 mg, 5 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg ANTITUBERCULARS 3 QL (9 EA per 30 days) QL (10 ML per 30 days) QL (.5 ML per 30 days) QL (.5 ML per 30 days) introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018

36 CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM ethambutol hcl oral tablet 100 mg, 00 mg isoniazid injection solution 100 mg/ml 1 isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL PACKET GM PRIFTIN ORAL TABLET 150 MG rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 150 mg 1 rifampin oral capsule 300 mg RIFATER ORAL TABLET MG 3 SIRTURO ORAL TABLET 100 MG 5 TRECATOR ORAL TABLET 50 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 5 mg, 50 mg 3 BD GLEOSTINE ORAL CAPSULE 10 MG, 0 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG 5 HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET MG 3 ANTIANGIOGENIC AGENTS AVASTIN INTRAVENOUS SOLUTION 100 MG/ML, 00 MG/16ML DEPEN TITRATABS ORAL TABLET 50 MG 5 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 MG, 5 MG REVLIMID ORAL CAPSULE.5 MG, 0 MG 5 SYPRINE ORAL CAPSULE 50 MG 5 THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG ANTIMETABOLITES ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG LA 5 MO 5 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 3

37 azacitidine injection suspension reconstituted 100 mg decitabine intravenous solution reconstituted 50 mg fludarabine phosphate intravenous solution reconstituted 50 mg gemcitabine hcl intravenous solution reconstituted 1 gm mercaptopurine oral tablet 50 mg methotrexate oral tablet.5 mg BD methotrexate sodium (pf) injection solution 1 gm/0ml, 50 mg/ml methotrexate sodium injection solution reconstituted 1 gm primaquine phosphate oral tablet 6.3 mg PURIXAN ORAL SUSPENSION 000 MG/100ML TABLOID ORAL TABLET 0 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD 1 BD XATMEP ORAL SOLUTION.5 MG/ML 5 BD ANTINEOPLASTICS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ADRIAMYCIN INTRAVENOUS SOLUTION MG/ML ADRUCIL INTRAVENOUS SOLUTION 500 MG/10ML AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 BD 5 LA; MO BD BD ALUNBRIG ORAL TABLET 30 MG 5 PA ARRANON INTRAVENOUS SOLUTION 5 MG/ML 5 5 BD AZASAN ORAL TABLET 100 MG, 75 MG BD; MO BAVENCIO INTRAVENOUS SOLUTION 00 MG/10ML BD

38 BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG bexarotene oral capsule 75 mg 5 PA bicalutamide oral tablet 50 mg BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG bleomycin sulfate injection solution reconstituted 30 unit introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD BD BOSULIF ORAL TABLET 100 MG, 500 MG 5 PA busulfan intravenous solution 6 mg/ml BD CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 300 MG 5 carboplatin intravenous solution 150 mg/15ml BD cisplatin intravenous solution 100 mg/100ml BD cladribine intravenous solution 10 mg/10ml 3 BD clofarabine intravenous solution 1 mg/ml BD COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 0 MG COMETRIQ (10 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 0 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG BD COTELLIC ORAL TABLET 0 MG 5 LA CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML 5 BD cytarabine (pf) injection solution 100 mg/ml BD cytarabine injection solution 0 mg/ml BD dacarbazine intravenous solution reconstituted 00 mg DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML BD LA daunorubicin hcl intravenous injectable 5 mg/ml BD DEPO-PROVERA INTRAMUSCULAR SUSPENSION 00 MG/ML dexrazoxane intravenous solution reconstituted 50 mg BD 5 BD

39 docetaxel intravenous concentrate 80 mg/ml 5 docetaxel intravenous solution 80 mg/8ml 5 DOXIL INTRAVENOUS INJECTABLE MG/ML 5 BD doxorubicin hcl intravenous solution mg/ml BD doxorubicin hcl liposomal intravenous injectable mg/ml ELIGARD SUBCUTANEOUS KIT.5 MG, 30 MG, 5 MG, 7.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 7.5 MG EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 00 MG 5 BD BD 5 BD BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA epirubicin hcl intravenous solution 00 mg/100ml BD ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML ERIVEDGE ORAL CAPSULE 150 MG 5 ERWINAZE INJECTION SOLUTION RECONSTITUTED UNIT ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG 5 BD PA BD etoposide intravenous solution 500 mg/5ml BD FARESTON ORAL TABLET 60 MG 5 MO FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SOLUTION 50 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG fluorouracil external solution %, 5 % 5 PA 5 BD 5 BD BD fluorouracil intravenous solution.5 gm/50ml BD flutamide oral capsule 15 mg 1

40 FOLOTYN INTRAVENOUS SOLUTION 0 MG/ML GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 0 MG hydroxyprogesterone caproate intramuscular solution 1.5 gm/5ml hydroxyurea oral capsule 500 mg 1 IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG BD 5 PA introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD 5 PA 5 PA ICLUSIG ORAL TABLET 15 MG, 5 MG 5 PA idarubicin hcl intravenous solution 10 mg/10ml BD IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA ifosfamide intravenous solution reconstituted 1 gm imatinib mesylate oral tablet 100 mg, 00 mg 3 BD IMBRUVICA ORAL CAPSULE 10 MG 5 PA IMFINZI INTRAVENOUS SOLUTION 10 MG/.ML, 500 MG/10ML INLYTA ORAL TABLET 1 MG, 5 MG 5 INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT IRESSA ORAL TABLET 50 MG 5 5 PA 5 MO 5 MO irinotecan hcl intravenous solution 100 mg/5ml BD ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.5 MG BD 5 BD

41 KEYTRUDA INTRAVENOUS SOLUTION 100 MG/ML KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG 5 PA 5 PA KISQALI 00 DOSE ORAL TABLET 00 MG 5 PA KISQALI 00 DOSE ORAL TABLET 00 MG 5 PA KISQALI 600 DOSE ORAL TABLET 00 MG 5 PA KISQALI FEMARA 00 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG KISQALI FEMARA 00 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 500 MG/50ML LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG LENVIMA 1 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & () MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () & MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG leucovorin calcium injection solution reconstituted 100 mg, 350 mg leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg leucovorin calcium oral tablet 5 mg 1 leuprolide acetate injection kit 1 mg/0.ml 3 levoleucovorin calcium intravenous solution 175 mg/17.5ml LONSURF ORAL TABLET MG, MG 5 PA 5 PA 5 PA 5 BD PA BD 3 BD 5 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 8

42 LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.5 MG LUPRON DEPOT (-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA; LA LYSODREN ORAL TABLET 500 MG 3 MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 0 mg/ml 1 PA; HRM megestrol acetate oral suspension 65 mg/5ml PA; MO; HRM megestrol acetate oral tablet 0 mg, 0 mg 1 PA; HRM MEKINIST ORAL TABLET 0.5 MG, MG 5 LA melphalan hcl intravenous solution reconstituted 50 mg MESNEX ORAL TABLET 00 MG mitomycin intravenous solution reconstituted 0 mg, 0 mg, 5 mg mitoxantrone hcl intravenous concentrate 5 mg/1.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD 3 BD 1 BD NERLYNX ORAL TABLET 0 MG 5 PA; LA NEXAVAR ORAL TABLET 00 MG 5 LA nilutamide oral tablet 150 mg 5 NINLARO ORAL CAPSULE.3 MG, 3 MG, MG NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG 5 BD ODOMZO ORAL CAPSULE 00 MG 5 LA OPDIVO INTRAVENOUS SOLUTION 0 MG/ML 5 PA oxaliplatin intravenous solution 100 mg/0ml BD paclitaxel intravenous concentrate 300 mg/50ml BD PERJETA INTRAVENOUS SOLUTION 0 MG/1ML 5

43 POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, MG PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML 5 LA 5 BD RUBRACA ORAL TABLET 00 MG, 300 MG 5 PA RYDAPT ORAL CAPSULE 5 MG 5 PA SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG 5 PA SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 LA TAGRISSO ORAL TABLET 0 MG, 80 MG 5 LA tamoxifen citrate oral tablet 10 mg, 0 mg TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 TECENTRIQ INTRAVENOUS SOLUTION 100 MG/0ML 5 5 BD thiotepa injection solution reconstituted 15 mg 5 BD TOPOSAR INTRAVENOUS SOLUTION 1 GM/50ML topotecan hcl intravenous solution reconstituted mg TORISEL INTRAVENOUS SOLUTION 5 MG/ML TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.5 MG,.5 MG, 3.75 MG tretinoin oral capsule 10 mg 3 TRISENOX INTRAVENOUS SOLUTION 10 MG/10ML BD 3 BD 3 BD 5 BD 5 BD BD

44 TYKERB ORAL TABLET 50 MG 5 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG BD VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG 5 PA; LA VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA; LA vinblastine sulfate intravenous solution 1 mg/ml BD VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML BD vincristine sulfate intravenous solution 1 mg/ml BD vinorelbine tartrate intravenous solution 50 mg/5ml VOTRIENT ORAL TABLET 00 MG 5 VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 100- MG BD 5 PA XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA XTANDI ORAL CAPSULE 0 MG 5 PA; ST YERVOY INTRAVENOUS SOLUTION 50 MG/10ML YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/ML ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM 5 5 PA 5 BD ZEJULA ORAL CAPSULE 100 MG 5 PA ZELBORAF ORAL TABLET 0 MG 5 ZOLINZA ORAL CAPSULE 100 MG 5 ZYDELIG ORAL TABLET 100 MG, 150 MG 5 ZYKADIA ORAL CAPSULE 150 MG 5 ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 mg exemestane oral tablet 5 mg

45 letrozole oral tablet.5 mg TREATMENT ADJUNCTS allopurinol oral tablet 300 mg mesna intravenous solution 100 mg/ml BD ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 00 MG EMVERM ORAL TABLET CHEWABLE 100 MG ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg atovaquone-proguanil hcl oral tablet mg 1 chloroquine phosphate oral tablet 50 mg chloroquine phosphate oral tablet 500 mg COARTEM ORAL TABLET 0-10 MG DARAPRIM ORAL TABLET 5 MG 5 hydroxychloroquine sulfate oral tablet 00 mg mefloquine hcl oral tablet 50 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG quinine sulfate oral capsule 3 mg ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate injection solution 1 mg/ml benztropine mesylate oral tablet 0.5 mg, 1 mg, mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD 1 PA; MO; HRM trihexyphenidyl hcl oral elixir 0. mg/ml 1 PA; MO; HRM trihexyphenidyl hcl oral tablet mg, 5 mg 1 PA; MO; HRM ANTIPARKINSON AGENTS, OTHER

46 amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg entacapone oral tablet 00 mg DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML 5 LA bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet.5 mg NEUPRO TRANSDERMAL PATCH HOUR 1 MG/HR, MG/HR, 3 MG/HR, MG/HR, 6 MG/HR, 8 MG/HR pramipexole dihydrochloride er oral tablet extended release hour mg, 3 mg,.5 mg pramipexole dihydrochloride er oral tablet extended release hour 0.75 mg, 1.5 mg,.5 mg, 3.75 mg pramipexole dihydrochloride oral tablet 0.15 mg, 0.5 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg, 5 mg DOPAMINE PRECURSORS/ L- AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet mg, mg, 5-50 mg carbidopa-levodopa oral tablet dispersible mg, mg, 5-50 mg MONOAMINE OXIDASE B (MAO-B) INHIBITORS MO MO rasagiline mesylate oral tablet 0.5 mg, 1 mg MO selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl injection solution 50 mg/ml BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 33

47 chlorpromazine hcl oral tablet 10 mg 1 BD; MO chlorpromazine hcl oral tablet 100 mg, 00 mg, 50 mg chlorpromazine hcl oral tablet 5 mg COMPRO RECTAL SUPPOSITORY 5 MG fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg,.5 mg, 5 mg haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, mg, 5 mg 3 haloperidol oral tablet 0 mg loxapine succinate oral capsule 10 mg, 5 mg, 5 mg loxapine succinate oral capsule 50 mg perphenazine oral tablet 16 mg, mg, mg, 8 mg perphenazine-amitriptyline oral tablet -10 mg, -5 mg perphenazine-amitriptyline oral tablet -10 mg, -5 mg, -50 mg 1 PA; MO; HRM PA; MO; HRM pimozide oral tablet 1 mg, mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg prochlorperazine maleate oral tablet 5 mg prochlorperazine rectal suppository 5 mg thioridazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg 1 PA; MO; HRM thiothixene oral capsule 1 mg, mg

48 thiothixene oral capsule 10 mg, 5 mg trifluoperazine hcl oral tablet 1 mg, mg trifluoperazine hcl oral tablet 10 mg, 5 mg ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE), 00 MG MO aripiprazole oral tablet 10 mg, 15 mg, mg, 5 mg aripiprazole oral tablet 0 mg, 30 mg 5 MO aripiprazole oral tablet dispersible 10 mg, 15 mg 5 MO FANAPT ORAL TABLET 1 MG, MG, MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & & & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 0 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 3 MG/1.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 73 MG/0.875ML, 10 MG/1.315ML, 56 MG/1.75ML, 819 MG/.65ML LATUDA ORAL TABLET 10 MG, 0 MG, 0 MG, 60 MG, 80 MG MO MO NUPLAZID ORAL TABLET 17 MG 5 PA; MO olanzapine intramuscular solution reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg,.5 mg, 5 mg, 7.5 mg olanzapine oral tablet 0 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 0 mg, 5 mg paliperidone er oral tablet extended release hour 1.5 mg, 3 mg, 6 mg, 9 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 35

49 quetiapine fumarate er oral tablet extended release hour 150 mg, 00 mg, 300 mg, 00 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 00 mg, 5 mg, 300 mg, 00 mg, 50 mg REXULTI ORAL TABLET 0.5 MG, 0.5 MG, 1 MG, MG, 3 MG, MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 1.5 MG, 5 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG 5 PA; MO risperidone oral solution 1 mg/ml risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg risperidone oral tablet dispersible 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,.5 MG, 5 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO VRAYLAR ORAL CAPSULE 1.5 MG 5 ST; MO; QL (10 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG 5 ST; MO; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE.5 MG, 6 MG 5 ST; MO; QL (30 EA per 30 days) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG ziprasidone hcl oral capsule 0 mg, 0 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 10 MG TREATMENT-RESISTANT clozapine oral tablet 100 mg, 00 mg, 5 mg, 50 mg clozapine oral tablet dispersible 100 mg, 1.5 mg, 150 mg, 00 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS ganciclovir sodium intravenous solution reconstituted 500 mg ST BD

50 valganciclovir hcl oral solution reconstituted 50 mg/ml MO valganciclovir hcl oral tablet 50 mg 5 MO VEMLIDY ORAL TABLET 5 MG 5 PA; MO ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 mg 5 MO BARACLUDE ORAL SOLUTION 0.05 MG/ML MO entecavir oral tablet 0.5 mg, 1 mg 5 MO RIBASPHERE ORAL CAPSULE 00 MG RIBASPHERE ORAL TABLET 00 MG, 00 MG RIBASPHERE ORAL TABLET 600 MG RIBASPHERE RIBAPAK ORAL TABLET 00 & 00 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET 00 & 600 MG, 00 MG ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING EPCLUSA ORAL TABLET MG 5 PA MAVYRET ORAL TABLET MG 5 PA ZEPATIER ORAL TABLET MG 5 PA ANTI-HEPATITIS C (HCV) AGENTS, OTHER MODERIBA 100 DOSE PACK ORAL TABLET 600 MG MODERIBA 800 DOSE PACK ORAL TABLET 00 MG MODERIBA ORAL TABLET 00 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML ribavirin oral capsule 00 mg ribavirin oral tablet 00 mg ANTIHERPETIC AGENTS acyclovir oral capsule 00 mg 1 acyclovir oral suspension 00 mg/5ml introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

51 acyclovir oral tablet 00 mg, 800 mg acyclovir sodium intravenous solution 50 mg/ml 1 BD famciclovir oral tablet 15 mg, 50 mg, 500 mg valacyclovir hcl oral tablet 1 gm, 500 mg ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG 5 MO COMPLERA ORAL TABLET MG 5 MO EDURANT ORAL TABLET 5 MG 5 MO GENVOYA ORAL TABLET MG 5 MO INTELENCE ORAL TABLET 100 MG, 00 MG 5 MO INTELENCE ORAL TABLET 5 MG MO nevirapine er oral tablet extended release hour 100 mg, 00 mg nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 00 mg ODEFSEY ORAL TABLET MG 5 MO RESCRIPTOR ORAL TABLET 100 MG, 00 MG SUSTIVA ORAL CAPSULE 00 MG, 50 MG SUSTIVA ORAL TABLET 600 MG 5 MO ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral tablet 300 mg abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg MO 5 MO DESCOVY ORAL TABLET 00-5 MG 5 MO desloratadine oral tablet dispersible 5 mg didanosine oral capsule delayed release 15 mg, 00 mg, 50 mg, 00 mg EMTRIVA ORAL CAPSULE 00 MG MO EMTRIVA ORAL SOLUTION 10 MG/ML MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 38

52 EPIVIR HBV ORAL SOLUTION 5 MG/ML EVOTAZ ORAL TABLET MG 5 MO lamivudine oral solution 10 mg/ml lamivudine oral tablet 100 mg, 150 mg, 300 mg lamivudine-zidovudine oral tablet mg MO PREZCOBIX ORAL TABLET MG 5 MO RETROVIR INTRAVENOUS SOLUTION 10 MG/ML stavudine oral capsule 15 mg, 0 mg, 30 mg, 0 mg TRIUMEQ ORAL TABLET MG MO TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX ORAL SOLUTION RECONSTITUTED GM 5 MO VIREAD ORAL POWDER 0 MG/GM 5 MO VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG, 300 MG ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML 5 MO ZIAGEN ORAL SOLUTION 0 MG/ML MO zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG 5 MO ISENTRESS HD ORAL TABLET 600 MG 5 MO ISENTRESS ORAL PACKET 100 MG MO ISENTRESS ORAL TABLET 00 MG 5 MO ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 5 MG SELZENTRY ORAL TABLET 150 MG, 300 MG 5 MO 5 MO SELZENTRY ORAL TABLET 5 MG, 75 MG MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 39

53 STRIBILD ORAL TABLET MG 5 MO TIVICAY ORAL TABLET 10 MG, 5 MG MO TIVICAY ORAL TABLET 50 MG 5 MO TYBOST ORAL TABLET 150 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 50 MG 5 MO APTIVUS ORAL SOLUTION 100 MG/ML 5 MO CRIXIVAN ORAL CAPSULE 00 MG, 00 MG INVIRASE ORAL CAPSULE 00 MG 5 MO INVIRASE ORAL TABLET 500 MG 5 MO KALETRA ORAL TABLET MG MO KALETRA ORAL TABLET MG 5 MO LEXIVA ORAL SUSPENSION 50 MG/ML MO LEXIVA ORAL TABLET 700 MG 5 MO lopinavir-ritonavir oral solution mg/5ml MO NORVIR ORAL CAPSULE 100 MG MO NORVIR ORAL SOLUTION 80 MG/ML MO NORVIR ORAL TABLET 100 MG MO PREZISTA ORAL SUSPENSION 100 MG/ML MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG MO PREZISTA ORAL TABLET 800 MG 5 MO REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG 5 MO REYATAZ ORAL PACKET 50 MG 5 MO VIRACEPT ORAL TABLET 50 MG, 65 MG 5 MO ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg, 5 mg, 75 mg RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 mg 1 TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

54 ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg buspirone hcl oral tablet 7.5 mg hydroxyzine hcl intramuscular solution 5 mg/ml PA; HRM hydroxyzine hcl intramuscular solution 50 mg/ml 1 PA; HRM hydroxyzine hcl oral syrup 10 mg/5ml 1 PA; HRM hydroxyzine hcl oral tablet 10 mg, 5 mg, 50 mg 1 PA; HRM hydroxyzine pamoate oral capsule 100 mg, 5 mg, 50 mg 1 1 PA; HRM meprobamate oral tablet 00 mg, 00 mg PA; HRM BENZODIAZEPINES alprazolam er oral tablet extended release hour 0.5 mg, 1 mg, 3 mg alprazolam er oral tablet extended release hour mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML 1 QL (10 EA per 30 days) QL (10 EA per 30 days) QL (300 ML per 30 days) alprazolam oral tablet 0.5 mg, 0.5 mg 1 QL (10 EA per 30 days) alprazolam oral tablet 1 mg 1 QL (180 EA per 30 days) alprazolam oral tablet mg 1 QL (150 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg 1 QL (70 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg 1 QL (180 EA per 30 days) alprazolam oral tablet dispersible 1 mg 1 QL (360 EA per 30 days) alprazolam oral tablet dispersible mg QL (150 EA per 30 days) chlordiazepoxide hcl oral capsule 10 mg, 5 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 1 QL (10 EA per 30 days) 1 QL (180 EA per 30 days) QL (0 ML per 30 days) diazepam oral solution 1 mg/ml QL (100 ML per 30 days) diazepam oral tablet 10 mg 1 QL (10 EA per 30 days) diazepam oral tablet mg 1 QL (600 EA per 30 days) diazepam oral tablet 5 mg 1 QL (0 EA per 30 days) introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 1

55 LORAZEPAM INTENSOL ORAL CONCENTRATE MG/ML 1 QL (0 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, mg 1 QL (150 EA per 30 days) oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 QL (10 EA per 30 days) BIPOLAR AGENTS MOOD STABILIZERS carbamazepine er oral capsule extended release 1 hour 100 mg carbamazepine oral tablet chewable 100 mg lithium carbonate er oral tablet extended release 300 mg, 50 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 100 mg, 5 mg, 50 mg ASSURE ID INSULIN SAFETY SYR 9G X 1/" 1 ML AVANDIA ORAL TABLET MG, MG MO chlorpropamide oral tablet 100 mg 1 PA; MO; HRM chlorpropamide oral tablet 50 mg PA; MO; HRM COMFORT ASSIST INSULIN SYRINGE 9G X 1/" 1 ML cvs gauze sterile pad "x" 1 CYCLOSET ORAL TABLET 0.8 MG MO EXEL COMFORT POINT PEN NEEDLE 9G X 1MM glimepiride oral tablet 1 mg, mg, mg glipizide er oral tablet extended release hour 10 mg,.5 mg, 5 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 glipizide oral tablet 10 mg, 5 mg glipizide-metformin hcl oral tablet.5-50 mg, mg, mg global alcohol prep ease pad 70 % 1 glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 PA; MO; HRM

56 glyburide oral tablet 1.5 mg,.5 mg, 5 mg 1 PA; MO; HRM glyburide-metformin oral tablet mg, mg, mg INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG, MG, MG 1 PA; MO; HRM INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG metformin hcl er (osm) oral tablet extended release hour 1000 mg, 500 mg metformin hcl er oral tablet extended release hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg MO MO miglitol oral tablet 100 mg, 5 mg, 50 mg nateglinide oral tablet 10 mg, 60 mg pioglitazone hcl oral tablet 15 mg, 30 mg, 5 mg pioglitazone hcl-glimepiride oral tablet 30- mg pioglitazone hcl-metformin hcl oral tablet mg, mg preferred plus insulin syringe 8g x 1/" 0.5 ml RELI-ON INSULIN SYRINGE 9G 0.3 ML repaglinide oral tablet 0.5 mg, 1 mg, mg repaglinide-metformin hcl oral tablet mg, -500 mg RIOMET ORAL SOLUTION 500 MG/5ML MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 3

57 SYMLINPEN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR 700 MCG/.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG 5 MO MO tolazamide oral tablet 50 mg tolazamide oral tablet 500 mg tolbutamide oral tablet 500 mg TRADJENTA ORAL TABLET 5 MG MO TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML valsartan-hydrochlorothiazide oral tablet mg VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3 3 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018

58 NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 00 UNIT/ML BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS argatroban intravenous solution 15 mg/15ml BD ELIQUIS ORAL TABLET.5 MG, 5 MG enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 100 mg/ml, 10 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 0 mg/0.ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml,.5 mg/0.5ml, 7.5 mg/0.6ml fondaparinux sodium subcutaneous solution 5 mg/0.ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 7500 UNIT/0.3ML, UNIT/3.8ML FRAGMIN SUBCUTANEOUS SOLUTION 500 UNIT/0.ML, 5000 UNIT/0.ML heparin (porcine) in d5w intravenous solution 0-5 unit/ml-%, 50-5 unit/ml-% heparin sod (porcine) in d5w intravenous solution 100 unit/ml introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 5

59 heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 0000 unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET 1 MG, 10 MG, MG,.5 MG, 3 MG, MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1 mg, 10 mg, mg,.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 0 MG BLOOD FORMATION MODIFIERS EPOGEN INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 0000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MCG MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML MOZOBIL SUBCUTANEOUS SOLUTION MG/1.ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 80 MCG/1.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 80 MCG/0.8ML PROCRIT INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 0000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML, 0000 UNIT/ML PROMACTA ORAL TABLET 1.5 MG, 5 MG, 50 MG, 75 MG tranexamic acid intravenous solution 1000 mg/10ml tranexamic acid oral tablet 650 mg ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 80 MCG/0.8ML introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO 3 PA 5 BD PA 5 MO 3

60 PLATELET MODIFYING AGENTS anagrelide hcl oral capsule 0.5 mg, 1 mg aspirin-dipyridamole er oral capsule extended release 1 hour 5-00 mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel bisulfate oral tablet 300 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 5 mg, 50 mg, 75 mg 1 PA; MO; HRM CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0.1 mg, 0. mg, 0.3 mg clonidine hcl transdermal patch weekly 0.1 mg/hr, 0. mg/hr, 0.3 mg/hr methyldopa oral tablet 50 mg, 500 mg 1 PA; MO; HRM methyldopate hcl intravenous solution 50 mg/5ml midodrine hcl oral tablet 10 mg, 5 mg midodrine hcl oral tablet.5 mg 1 ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet 1 mg, mg, mg, 8 mg 1 PA; HRM prazosin hcl oral capsule 1 mg, mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, mg, 5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 16 mg, 3 mg, mg, 8 mg eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 150 mg, 300 mg irbesartan oral tablet 75 mg losartan potassium oral tablet 100 mg, 5 mg, 50 mg olmesartan medoxomil oral tablet 0 mg, 0 mg, 5 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 7

61 telmisartan oral tablet 0 mg, 0 mg, 80 mg valsartan oral tablet 160 mg, 30 mg, 80 mg valsartan oral tablet 0 mg ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg captopril oral tablet 100 mg, 5 mg, 50 mg captopril oral tablet 1.5 mg enalapril maleate oral tablet 10 mg,.5 mg, 0 mg, 5 mg fosinopril sodium oral tablet 10 mg, 0 mg, 0 mg lisinopril oral tablet 10 mg,.5 mg, 0 mg, 30 mg, 0 mg, 5 mg moexipril hcl oral tablet 15 mg moexipril hcl oral tablet 7.5 mg perindopril erbumine oral tablet mg, mg, 8 mg quinapril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg ramipril oral capsule 1.5 mg, 10 mg,.5 mg, 5 mg trandolapril oral tablet 1 mg, mg, mg ANTIARRHYTHMICS amiodarone hcl intravenous solution 150 mg/3ml 1 amiodarone hcl oral tablet 100 mg, 00 mg, 00 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 15 mcg, 50 mcg, 500 mcg PA; MO; HRM flecainide acetate oral tablet 100 mg, 150 mg flecainide acetate oral tablet 50 mg mexiletine hcl oral capsule 150 mg, 00 mg, 50 mg MULTAQ ORAL TABLET 00 MG PACERONE ORAL TABLET 100 MG, 00 MG, 00 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 8

62 procainamide hcl injection solution 100 mg/ml, 500 mg/ml propafenone hcl oral tablet 150 mg, 5 mg, 300 mg quinidine gluconate er oral tablet extended release 3 mg 1 quinidine sulfate oral tablet 00 mg, 300 mg ANTIHYPERTENSIVE COMBINATIONS ALDACTAZIDE ORAL TABLET MG amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine besy-benazepril hcl oral capsule 10-0 mg, 5-10 mg amlodipine besy-benazepril hcl oral capsule 10-0 mg,.5-10 mg, 5-0 mg, 5-0 mg amlodipine besylate-valsartan oral tablet mg, mg, mg amlodipine besylate-valsartan oral tablet 5-30 mg amlodipine-olmesartan oral tablet 10-0 mg, 10-0 mg, 5-0 mg, 5-0 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, 50-5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg benazepril-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan cilexetil-hctz oral tablet mg, mg, 3-5 mg captopril-hydrochlorothiazide oral tablet 5-15 mg, 5-5 mg, mg, 50-5 mg enalapril-hydrochlorothiazide oral tablet 10-5 mg, mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 9

63 ENTRESTO ORAL TABLET -6 MG, 9-51 MG, MG fosinopril sodium-hctz oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg irbesartan-hydrochlorothiazide oral tablet mg lisinopril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg losartan potassium-hctz oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, 50-5 mg metoprolol-hydrochlorothiazide oral tablet mg metoprolol-hydrochlorothiazide oral tablet mg, 50-5 mg moexipril-hydrochlorothiazide oral tablet mg, 15-5 mg, mg nadolol-bendroflumethiazide oral tablet 0-5 mg, 80-5 mg olmesartan medoxomil-hctz oral tablet mg, mg, 0-5 mg olmesartan-amlodipine-hctz oral tablet mg, mg, mg, mg, mg 3 PA; MO 1 PA; MO; HRM MO MO pioglitazone hcl-glimepiride oral tablet 30- mg propranolol-hctz oral tablet 0-5 mg, 80-5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg spironolactone-hctz oral tablet 5-5 mg telmisartan-amlodipine oral tablet 0-10 mg, 0-5 mg, mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, 80-5 mg trandolapril-verapamil hcl er oral tablet extended release 1-0 mg, -180 mg, -0 mg, -0 mg triamterene-hctz oral capsule mg, 50-5 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 50

64 triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, 30-5 mg BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl oral capsule 00 mg, 00 mg atenolol oral tablet 100 mg, 5 mg, 50 mg betaxolol hcl oral tablet 10 mg, 0 mg bisoprolol fumarate oral tablet 10 mg, 5 mg carvedilol oral tablet 1.5 mg, 5 mg, 3.15 mg, 6.5 mg labetalol hcl intravenous solution 5 mg/ml 1 labetalol hcl oral tablet 100 mg, 00 mg, 300 mg metoprolol succinate er oral tablet extended release hour 100 mg, 5 mg, 50 mg metoprolol succinate er oral tablet extended release hour 00 mg metoprolol tartrate intravenous solution 5 mg/5ml 1 metoprolol tartrate intravenous solution cartridge 5 mg/5ml metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg 1 BD nadolol oral tablet 0 mg, 0 mg nadolol oral tablet 80 mg pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release hour 10 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml 1 propranolol hcl oral solution 0 mg/5ml, 0 mg/5ml propranolol hcl oral tablet 10 mg, 0 mg, 0 mg, 60 mg, 80 mg SORINE ORAL TABLET 10 MG, 160 MG, 0 MG, 80 MG sotalol hcl (af) oral tablet 10 mg sotalol hcl oral tablet 160 mg, 0 mg, 80 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 51

65 timolol maleate oral tablet 10 mg, 0 mg, 5 mg CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR ORAL TABLET EXTENDED RELEASE HOUR 30 MG AFEDITAB CR ORAL TABLET EXTENDED RELEASE HOUR 60 MG amlodipine besylate oral tablet 10 mg,.5 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 180 MG, 0 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 300 MG diltiazem hcl er beads oral capsule extended release hour 180 mg diltiazem hcl er beads oral capsule extended release hour 360 mg, 0 mg diltiazem hcl er coated beads oral capsule extended release hour 10 mg, 0 mg diltiazem hcl er coated beads oral capsule extended release hour 300 mg diltiazem hcl er oral capsule extended release 1 hour 10 mg, 60 mg, 90 mg diltiazem hcl intravenous solution 50 mg/10ml 1 diltiazem hcl intravenous solution reconstituted 100 mg diltiazem hcl oral tablet 10 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release hour 10 mg, 180 mg, 0 mg felodipine er oral tablet extended release hour 10 mg felodipine er oral tablet extended release hour.5 mg, 5 mg 1 isradipine oral capsule.5 mg, 5 mg nicardipine hcl oral capsule 0 mg nicardipine hcl oral capsule 30 mg nifedipine er oral tablet extended release hour 30 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 5

66 nifedipine er oral tablet extended release hour 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release hour 30 mg, 60 mg nifedipine er osmotic release oral tablet extended release hour 90 mg nifedipine oral capsule 10 mg 1 PA; MO; HRM nifedipine oral capsule 0 mg PA; MO; HRM nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release hour 17 mg, 0 mg, 5.5 mg, 30 mg, 3 mg, 0 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 180 MG, 0 MG TAZTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 300 MG, 360 MG verapamil hcl er oral capsule extended release hour 100 mg, 180 mg, 00 mg, 0 mg, 300 mg, 360 mg verapamil hcl er oral capsule extended release hour 10 mg verapamil hcl er oral tablet extended release 10 mg, 180 mg, 0 mg verapamil hcl intravenous solution.5 mg/ml 1 verapamil hcl oral tablet 10 mg, 0 mg, 80 mg CARDIOVASCULAR AGENTS, OTHER amlodipine-atorvastatin oral tablet mg, 10-0 mg, 10-0 mg, mg,.5-10 mg,.5-0 mg,.5-0 mg, 5-10 mg, 5-0 mg, 5-0 mg, 5-80 mg CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; MO DIGITEK ORAL TABLET 15 MCG, 50 MCG digoxin injection solution 0.5 mg/ml digoxin oral solution 0.05 mg/ml digoxin oral tablet 15 mcg, 50 mcg NORTHERA ORAL CAPSULE 100 MG, 00 MG, 300 MG pentoxifylline er oral tablet extended release 00 mg 5 PA introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 53

67 RANEXA ORAL TABLET EXTENDED RELEASE 1 HOUR 1000 MG, 500 MG DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide oral tablet 15 mg, 50 mg methazolamide oral tablet 5 mg, 50 mg MO DIURETICS, LOOP bumetanide injection solution 0.5 mg/ml 1 furosemide injection solution 10 mg/ml, 10 mg/ml (ml syringe) furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 0 mg, 0 mg, 80 mg torsemide oral tablet 10 mg, 100 mg, 0 mg, 5 mg DIURETICS, POTASSIUM-SPARING amiloride hcl oral tablet 5 mg DEMSER ORAL CAPSULE 50 MG 5 eplerenone oral tablet 5 mg, 50 mg spironolactone oral tablet 100 mg, 5 mg, 50 mg DIURETICS, THIAZIDE chlorothiazide oral tablet 50 mg, 500 mg chlorthalidone oral tablet 5 mg, 50 mg hydrochlorothiazide oral capsule 1.5 mg hydrochlorothiazide oral tablet 1.5 mg, 5 mg, 50 mg indapamide oral tablet 1.5 mg,.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg,.5 mg, 5 mg DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 130 mg, 13 mg, 00 mg, 3 mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg fenofibrate oral tablet 10 mg, 15 mg, 160 mg, 0 mg, 8 mg, 5 mg gemfibrozil oral tablet 600 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 5

68 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 80 mg fluvastatin sodium er oral tablet extended release hour 80 mg fluvastatin sodium oral capsule 0 mg, 0 mg LIVALO ORAL TABLET 1 MG, MG, MG 3 ST; MO lovastatin oral tablet 10 mg, 0 mg, 0 mg pravastatin sodium oral tablet 10 mg, 0 mg, 0 mg, 80 mg rosuvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 5 mg simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg, 80 mg DYSLIPIDEMICS, OTHER cholestyramine light oral powder gm/dose cholestyramine oral powder gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm ezetimibe oral tablet 10 mg ezetimibe-simvastatin oral tablet mg, 10-0 mg, 10-0 mg, mg fenofibric acid oral tablet 105 mg, 35 mg JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 30 MG, 0 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG 1 5 PA; MO 5 PA; MO omega-3-acid ethyl esters oral capsule 1 gm PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML 5 PA; MO PREVALITE ORAL POWDER GM/DOSE REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 0 MG/3.5ML 5 PA; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 55

69 REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/ML VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS isosorbide dinitrate er oral tablet extended release 0 mg isosorbide dinitrate oral tablet 10 mg, 0 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release hour 10 mg, 30 mg, 60 mg 5 PA; MO 5 PA; MO isosorbide mononitrate oral tablet 10 mg, 0 mg MINITRAN TRANSDERMAL PATCH HOUR 0.1 MG/HR, 0. MG/HR, 0. MG/HR, 0.6 MG/HR NITRO-DUR TRANSDERMAL PATCH HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin intravenous solution 5 mg/ml 1 nitroglycerin sublingual tablet sublingual 0.3 mg, 0. mg, 0.6 mg nitroglycerin transdermal patch hour 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0. mg/spray VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl injection solution 0 mg/ml 1 hydralazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg minoxidil oral tablet 10 mg minoxidil oral tablet.5 mg CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg, 7.5 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 56

70 amphetamine-dextroamphetamine oral tablet 1.5 mg dextroamphetamine sulfate er oral capsule extended release hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 5 mg, 0 mg, 60 mg, 80 mg dexmethylphenidate hcl er oral capsule extended release hour 5 mg, 35 mg guanfacine hcl er oral tablet extended release hour 1 mg, mg, 3 mg, mg METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG methylphenidate hcl er (cd) oral capsule extended release 10 mg, 0 mg, 30 mg, 50 mg, 60 mg methylphenidate hcl er (cd) oral capsule extended release 0 mg methylphenidate hcl er (la) oral capsule extended release hour 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 0 mg methylphenidate hcl er oral tablet extended release hour 18 mg methylphenidate hcl er oral tablet extended release hour 7 mg, 36 mg, 5 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml PA; MO; HRM methylphenidate hcl oral tablet 10 mg, 5 mg methylphenidate hcl oral tablet 0 mg methylphenidate hcl oral tablet chewable 10 mg,.5 mg, 5 mg CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO ORAL TABLET 1 MG, 6 MG, 9 MG 5 MO NUEDEXTA ORAL CAPSULE 0-10 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 57

71 RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML 5 PA; MO riluzole oral tablet 50 mg MO tetrabenazine oral tablet 1.5 mg, 5 mg 5 MO FIBROMYALGIA AGENTS LYRICA ORAL CAPSULE 100 MG, 150 MG SAVELLA ORAL TABLET 100 MG, 1.5 MG, 5 MG, 50 MG SAVELLA TITRATION PACK ORAL 1.5 & 5 & 50 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 1 HOUR 10 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA; MO AUBAGIO ORAL TABLET 1 MG, 7 MG 5 PA; LA; MO BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; MO COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0 MG/ML, 0 MG/ML 5 PA; MO GILENYA ORAL CAPSULE 0.5 MG 5 PA; MO SOLTAMOX ORAL SOLUTION 10 MG/5ML MO TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS chlorhexidine gluconate mouth/throat solution 0.1 % nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG PERIOGARD MOUTH/THROAT SOLUTION 0.1 % 5 PA pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS acitretin oral capsule 10 mg, 17.5 mg, 5 mg amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % 1 1 1

72 ammonium lactate external cream 1 % 1 ammonium lactate external lotion 1 % 1 AMNESTEEM ORAL CAPSULE 10 MG, 0 MG, 0 MG benzoyl peroxide-erythromycin external gel 5-3 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 calcipotriene external solution % ciclopirox external gel 0.77 % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % CLARAVIS ORAL CAPSULE 10 MG, 0 MG, 0 MG CLARAVIS ORAL CAPSULE 30 MG 5 clindamycin phos-benzoyl perox external gel 1-5 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % clobetasol propionate e external cream 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clotrimazole external cream 1 % 1 clotrimazole external solution 1 % 1 clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

73 CONDYLOX EXTERNAL GEL 0.5 % COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.5 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.5 % diclofenac sodium transdermal gel 1 % diclofenac sodium transdermal gel 3 % 5 diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % econazole nitrate external cream 1 % ELIDEL EXTERNAL CREAM 1 % erythromycin external gel % erythromycin external solution % EURAX EXTERNAL CREAM 10 % fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 % 1 fluocinolone acetonide external cream 0.05 % fluocinolone acetonide external ointment 0.05 % fluocinolone acetonide external solution 0.01 % 1 fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluorouracil external cream 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % gentamicin sulfate external cream 0.1 % 1 gentamicin sulfate external ointment 0.1 % 1 halobetasol propionate external cream 0.05 % 5 ST; MO 5 ST; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 60

74 halobetasol propionate external ointment 0.05 % hydrocortisone external cream 1 %,.5 % 1 hydrocortisone external lotion.5 % 1 hydrocortisone external ointment 1 % 1 hydrocortisone external ointment.5 % hydrocortisone valerate external cream 0. % hydrocortisone valerate external ointment 0. % imiquimod external cream 5 % ketoconazole external cream % ketoconazole external shampoo % lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine hcl external gel % lidocaine hcl external solution % lindane external shampoo 1 % methoxsalen rapid oral capsule 10 mg metronidazole external cream 0.75 % metronidazole external gel 0.75 %, 1 % metronidazole external lotion 0.75 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mupirocin calcium external cream % mupirocin external ointment % NYAMYC EXTERNAL POWDER UNIT/GM nystatin external cream unit/gm 1 nystatin external ointment unit/gm 1 nystatin external powder unit/gm nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM PANRETIN EXTERNAL GEL 0.1 % permethrin external cream 5 % PICATO EXTERNAL GEL %, 0.05 % 5 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

75 podofilox external solution 0.5 % 1 prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % 1 PROCTO-MED HC RECTAL CREAM.5 % 1 PROCTO-PAK RECTAL CREAM 1 % PROCTOSOL HC RECTAL CREAM.5 % PROCTOZONE-HC RECTAL CREAM.5 % REGRANEX EXTERNAL GEL 0.01 % 5 PA SANTYL EXTERNAL OINTMENT 50 UNIT/GM selenium sulfide external lotion.5 % 1 silver sulfadiazine external cream 1 % 1 SSD EXTERNAL CREAM 1 % 1 STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML, 90 MG/ML sulfacetamide sodium (acne) external lotion 10 % TARGRETIN EXTERNAL GEL 1 % tazarotene external cream 0.1 % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0.1 % TOLAK EXTERNAL CREAM % tretinoin external gel 0.01 %, 0.05 %, 0.05 % triamcinolone acetonide external cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.05 %, 0.1 % triamcinolone acetonide external ointment 0.05 %, 0.5 % triamcinolone acetonide external ointment 0.1 % 1 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ ST; MO UCERIS RECTAL FOAM MG/ACT ST VALCHLOR EXTERNAL GEL % ELECTROLYTES/MINERALS/META LS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT CARBAGLU ORAL TABLET 00 MG 5 MO 1

76 dextrose in lactated ringers intravenous solution 5 % dextrose-nacl intravenous solution %, %, %, 5-0. %, %, %, %, % ISOLYTE-P IN D5W INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 0 meq/l KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ KLOR-CON M0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ K-TAB ORAL TABLET EXTENDED RELEASE 0 MEQ lactated ringers intravenous solution 1 magnesium sulfate injection solution 50 %, 50 % (10ml syringe) NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION NORMOSOL-R PH 7. INTRAVENOUS SOLUTION PLASMA-LYTE 18 INTRAVENOUS SOLUTION introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 63

77 potassium chloride crys er oral tablet extended release 10 meq potassium chloride crys er oral tablet extended release 0 meq potassium chloride er oral capsule extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 0 meq potassium chloride in dextrose intravenous solution 0-5 meq/l-%, 0-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-% potassium chloride intravenous solution 10 meq/100ml, meq/ml, 0 meq/100ml, 0 meq/100ml potassium chloride oral solution 0 meq/15ml (10%), 0 meq/15ml (0%) potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (160 mg), 5 meq (50 mg) ringers intravenous solution 1 sodium chloride injection solution.5 meq/ml 1 sodium chloride intravenous solution 0.5 %, 0.9 %, 3 %, 5 % sodium lactate intravenous solution 5 meq/ml 1 TPN ELECTROLYTES INTRAVENOUS SOLUTION ELECTROLYTE/MINERAL/METAL MODIFIERS EXJADE ORAL TABLET SOLUBLE 15 MG, 50 MG, 500 MG MO FERRIPROX ORAL SOLUTION 100 MG/ML 5 MO FERRIPROX ORAL TABLET 500 MG MO JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG KIONEX ORAL POWDER 5 MO SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 6

78 sodium polystyrene sulfonate oral suspension 15 gm/60ml SPS ORAL SUSPENSION 15 GM/60ML NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 10 %, 7 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5. % CLINIMIX E/DEXTROSE (.75/10) INTRAVENOUS SOLUTION.75 % CLINIMIX E/DEXTROSE (.75/5) INTRAVENOUS SOLUTION.75 % CLINIMIX E/DEXTROSE (.5/10) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/0) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (.75/5) INTRAVENOUS SOLUTION.75 % CLINIMIX/DEXTROSE (.5/10) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (.5/0) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD

79 CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/0) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINISOL SF INTRAVENOUS SOLUTION 15 % BD BD BD BD BD dextrose intravenous solution 10 % 1 BD dextrose intravenous solution 5 % BD FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % HEPATAMINE INTRAVENOUS SOLUTION 8 % NEPHRAMINE INTRAVENOUS SOLUTION 5. % BD BD BD nutrilipid intravenous emulsion 0 % BD PLENAMINE INTRAVENOUS SOLUTION 15 % PREMASOL INTRAVENOUS SOLUTION 10 % BD BD PREMASOL INTRAVENOUS SOLUTION 6 % BD PROCALAMINE INTRAVENOUS SOLUTION 3 % BD PROSOL INTRAVENOUS SOLUTION 0 % BD TRAVASOL INTRAVENOUS SOLUTION 10 % TROPHAMINE INTRAVENOUS SOLUTION 10 % VITAMINS prenatal oral tablet 7-1 mg 3 sodium fluoride oral tablet. (1 f) mg 1 GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL atropine sulfate injection solution prefilled syringe 0.5 mg/5ml BD BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

80 dicyclomine hcl intramuscular solution 10 mg/ml dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 0 mg 1 glycopyrrolate injection solution mg/0ml glycopyrrolate oral tablet 1 mg, mg 1 methscopolamine bromide oral tablet.5 mg, 5 mg GASTROINTESTINAL AGENTS, OTHER diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg GATTEX SUBCUTANEOUS KIT 5 MG 5 MO loperamide hcl oral capsule mg 1 metoclopramide hcl injection solution 5 mg/ml 1 metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 10 mg MOVANTIK ORAL TABLET 1.5 MG, 5 MG MYTESI ORAL TABLET DELAYED RELEASE 15 MG RELISTOR SUBCUTANEOUS SOLUTION 1 MG/0.6ML, 1 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.ML introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO ursodiol oral tablet 50 mg, 500 mg HISTAMINE (H) RECEPTOR ANTAGONISTS famotidine intravenous solution 0 mg/ml famotidine oral tablet 0 mg, 0 mg famotidine premixed intravenous solution mg/50ml-% ranitidine hcl injection solution 50 mg/ml ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml ranitidine hcl oral tablet 150 mg, 300 mg ZANTAC INJECTION SOLUTION 1000 MG/0ML 3

81 IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5 mg, 1 mg 5 MO AMITIZA ORAL CAPSULE MCG, 8 MCG CIMZIA PREFILLED SUBCUTANEOUS KIT X 00 MG/ML 5 ST; MO CIMZIA SUBCUTANEOUS KIT X 00 MG 5 ST LINZESS ORAL CAPSULE 15 MCG, 90 MCG, 7 MCG LAXATIVES constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 0 GM generlac oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM peg 3350-kcl-na bicarb-nacl oral solution reconstituted 0 gm polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM- GM TRILYTE ORAL SOLUTION RECONSTITUTED 0 GM PROTECTANTS CARAFATE ORAL SUSPENSION 1 GM/10ML MO misoprostol oral tablet 100 mcg, 00 mcg sucralfate oral tablet 1 gm PROTON PUMP INHIBITORS esomeprazole sodium intravenous solution reconstituted 0 mg esomeprazole sodium intravenous solution reconstituted 0 mg lansoprazole oral capsule delayed release 15 mg, 30 mg omeprazole oral capsule delayed release 10 mg, 0 mg, 0 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

82 pantoprazole sodium intravenous solution reconstituted 0 mg pantoprazole sodium oral tablet delayed release 0 mg, 0 mg GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ENZYME REPLACEMENT/ MODIFIERS ADAGEN INTRAMUSCULAR SOLUTION 50 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION.9 MG/5ML CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 00 UNIT CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 1000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT 5 LA 5 BD; LA 5 BD; LA CYSTADANE ORAL POWDER 5 MO ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG KANUMA INTRAVENOUS SOLUTION 0 MG/10ML 5 BD 5 BD; LA 5 PA KUVAN ORAL PACKET 100 MG, 500 MG 5 MO KUVAN ORAL TABLET SOLUBLE 100 MG 5 LA; MO levocarnitine oral solution 1 gm/10ml levocarnitine oral tablet 330 mg LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML ORFADIN ORAL CAPSULE 10 MG, MG, 0 MG, 5 MG 5 5 BD 5 MO ORFADIN ORAL SUSPENSION MG/ML 5 LA; MO RAVICTI ORAL LIQUID 1.1 GM/ML MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 69

83 VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 00 UNIT ZAVESCA ORAL CAPSULE 100 MG 5 MO ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, 0000 UNIT, 5000 UNIT, UNIT, 0000 UNIT, 5000 UNIT GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin hydrobromide er oral tablet extended release hour 15 mg, 7.5 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE HOUR 5 MG, 50 MG oxybutynin chloride er oral tablet extended release hour 10 mg, 15 mg, 5 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ ST; MO oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate oral tablet 1 mg, mg VESICARE ORAL TABLET 10 MG, 5 MG MO BENIGN PROSTATIC HYPERTROPHY AGENTS dutasteride oral capsule 0.5 mg dutasteride-tamsulosin hcl oral capsule mg finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE MG, 8 MG MO tamsulosin hcl oral capsule 0. mg GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 150 MG, 50 MG MO ELMIRON ORAL CAPSULE 100 MG 3 neomycin-polymyxin b gu irrigation solution sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg RENVELA ORAL TABLET 800 MG

84 sevelamer carbonate oral packet 0.8 gm,. gm VAGINAL PRODUCTS clindamycin phosphate vaginal cream % ESTRACE VAGINAL CREAM 0.1 MG/GM estradiol vaginal tablet 10 mcg metronidazole vaginal gel 0.75 % 1 miconazole 3 vaginal suppository 00 mg 1 PREMARIN VAGINAL CREAM 0.65 MG/GM terconazole vaginal cream 0. %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 VANDAZOLE VAGINAL GEL 0.75 % YUVAFEM VAGINAL TABLET 10 MCG ZAZOLE VAGINAL CREAM 0.8 % HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOC ORTICOIDS budesonide oral capsule delayed release particles 3 mg DEPO-MEDROL INJECTION SUSPENSION 0 MG/ML dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, mg, mg, 6 mg dexamethasone sodium phosphate injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/30ml fludrocortisone acetate oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 0 mg, 5 mg 1 methylprednisolone acetate injection suspension 0 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 3 mg, mg, 8 mg methylprednisolone oral tablet therapy pack mg 1 methylprednisolone sodium succ injection solution reconstituted 1000 mg, 15 mg, 0 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

85 prednisolone sodium phosphate oral solution 15 mg/5ml, 5 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg,.5 mg, 0 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 mg (1), 10 mg (8), 5 mg (1), 5 mg (8) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED GM UCERIS ORAL TABLET EXTENDED RELEASE HOUR 9 MG HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 10 mg 5 oxandrolone oral tablet.5 mg ANDROGENS ANDRODERM TRANSDERMAL PATCH HOUR MG/HR, MG/HR ANDROGEL PUMP TRANSDERMAL GEL 0.5 MG/ACT (1.6%) ANDROGEL TRANSDERMAL GEL 0.5 MG/1.5GM (1.6%), 0.5 MG/.5GM (1.6%) danazol oral capsule 100 mg, 00 mg, 50 mg ST methyltestosterone oral capsule 10 mg 5 MO testosterone cypionate intramuscular solution 100 mg/ml, 00 mg/ml testosterone enanthate intramuscular solution 00 mg/ml CONTRACEPTIVES alyacen 1/35 oral tablet 1-35 mg-mcg AMETHIA ORAL TABLET &0.01 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 7

86 APRI ORAL TABLET MG-MCG ASHLYNA ORAL TABLET &0.01 MG AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BEKYREE ORAL TABLET /0.01 MG (1/5) BLISOVI FE ORAL TABLET 1-0 MG- MCG() BLISOVI FE 1.5/30 ORAL TABLET MG-MCG BLISOVI FE 1/0 ORAL TABLET 1-0 MG- MCG briellyn oral tablet mg-mcg CAMILA ORAL TABLET 0.35 MG CAZIANT ORAL TABLET 0.1/0.15/ MG CYCLAFEM 1/35 ORAL TABLET 1-35 MG- MCG DEBLITANE ORAL TABLET 0.35 MG DELYLA ORAL TABLET MG-MCG DEPO-SUBQ PROVERA 10 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 10 MG/0.65ML desogestrel-ethinyl estradiol oral tablet /0.01 mg (1/5), mg-mcg drospirenone-ethinyl estradiol oral tablet mg, mg EMOQUETTE ORAL TABLET MG- MCG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ ENPRESSE-8 ORAL TABLET ERRIN ORAL TABLET 0.35 MG ethynodiol diac-eth estradiol oral tablet 1-50 mgmcg FALMINA ORAL TABLET MG-MCG FEMYNOR ORAL TABLET MG-MCG GIANVI ORAL TABLET MG GILDAGIA ORAL TABLET MG-MCG

87 INTROVALE ORAL TABLET MG ISIBLOOM ORAL TABLET MG-MCG JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG- MCG JUNEL FE 1/0 ORAL TABLET 1-0 MG-MCG JUNEL FE ORAL TABLET 1-0 MG- MCG() KAITLIB FE ORAL TABLET CHEWABLE MG-MCG KARIVA ORAL TABLET /0.01 MG (1/5) KIMIDESS ORAL TABLET /0.01 MG (1/5) LARIN FE 1.5/30 ORAL TABLET MG- MCG LARIN FE 1/0 ORAL TABLET 1-0 MG-MCG LARISSIA ORAL TABLET MG-MCG LAYOLIS FE ORAL TABLET CHEWABLE MG-MCG LESSINA ORAL TABLET MG-MCG LEVONEST ORAL TABLET levonorgest-eth estrad 91-day oral tablet &0.01 mg, mg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorg-eth estrad triphasic oral tablet LEVORA 0.15/30 (8) ORAL TABLET MG-MCG LOMEDIA FE ORAL TABLET 1-0 MG- MCG() LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG- MCG LUTERA ORAL TABLET MG-MCG LYZA ORAL TABLET 0.35 MG marlissa oral tablet mg-mcg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 7

88 medroxyprogesterone acetate intramuscular suspension 150 mg/ml MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1/0 ORAL TABLET 1-0 MG-MCG NECON 0.5/35 (8) ORAL TABLET MG-MCG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ NIKKI ORAL TABLET MG NORA-BE ORAL TABLET 0.35 MG norethin ace-eth estrad-fe oral tablet 1-0 mgmcg() norethindrone acet-ethinyl est oral tablet 1-0 mg-mcg norethindrone oral tablet 0.35 mg norethin-eth estradiol-fe oral tablet chewable mg-mcg norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.18/0.15/0.5 mg-5 mcg norgestim-eth estrad triphasic oral tablet 0.18/0.15/0.5 mg-35 mcg NORLYROC ORAL TABLET 0.35 MG NORTREL 0.5/35 (8) ORAL TABLET MG-MCG NORTREL 1/35 (1) ORAL TABLET 1-35 MG- MCG NORTREL 1/35 (8) ORAL TABLET 1-35 MG- MCG OCELLA ORAL TABLET MG ORSYTHIA ORAL TABLET MG-MCG PIMTREA ORAL TABLET /0.01 MG (1/5) PIRMELLA 1/35 ORAL TABLET 1-35 MG- MCG PORTIA-8 ORAL TABLET MG-MCG QUARTETTE ORAL TABLET DAYS MO QUASENSE ORAL TABLET MG

89 RECLIPSEN ORAL TABLET MG- MCG SETLAKIN ORAL TABLET MG SHAROBEL ORAL TABLET 0.35 MG SRONYX ORAL TABLET MG-MCG TARINA FE 1/0 ORAL TABLET 1-0 MG- MCG TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.15/0.5 MG-5 MCG TRI-LO-SPRINTEC ORAL TABLET 0.18/0.15/0.5 MG-5 MCG TRINESSA (8) ORAL TABLET 0.18/0.15/0.5 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.18/0.15/0.5 MG-35 MCG TRI-SPRINTEC ORAL TABLET 0.18/0.15/0.5 MG-35 MCG TRIVORA (8) ORAL TABLET VELIVET ORAL TABLET 0.1/0.15/ MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ VESTURA ORAL TABLET MG VIENVA ORAL TABLET MG-MCG VYFEMLA ORAL TABLET MG-MCG WYMZYA FE ORAL TABLET CHEWABLE MG-MCG ZENCHENT FE ORAL TABLET CHEWABLE MG-MCG ZENCHENT ORAL TABLET MG-MCG ESTROGENS ESTRACE ORAL TABLET 0.5 MG, 1 MG, MG 3 PA; MO; HRM estradiol oral tablet 0.5 mg, 1 mg, mg 1 PA; MO; HRM FYAVOLV ORAL TABLET MG-MCG, 1-5 MG-MCG 1 PA; MO; HRM JINTELI ORAL TABLET 1-5 MG-MCG 1 PA; MO; HRM MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG norethindrone-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg 3 PA; MO; HRM 1 PA; MO; HRM

90 PREMARIN INJECTION SOLUTION RECONSTITUTED 5 MG PREMARIN ORAL TABLET 0.3 MG, 0.5 MG, 0.65 MG, 0.9 MG, 1.5 MG introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA; MO; HRM PREMPHASE ORAL TABLET MG 3 PA; MO; HRM PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS MAKENA INTRAMUSCULAR OIL 50 MG/ML medroxyprogesterone acetate oral tablet 10 mg,.5 mg, 5 mg 3 PA; MO; HRM 5 norethindrone acetate oral tablet 5 mg SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS raloxifene hcl oral tablet 60 mg HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) cabergoline oral tablet 0.5 mg chorionic gonadotropin intramuscular solution reconstituted unit desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution mcg/ml PA desmopressin acetate oral tablet 0.1 mg, 0. mg INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) 5 LA; MO 5 PA; MO

91 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) levothyroxine sodium oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 5 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) KORLYM ORAL TABLET 300 MG 5 PA; LA; MO LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.5 MG LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.5 MG, 15 MG octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 0 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 10 MG/0.5ML, 60 MG/0.ML, 90 MG/0.3ML introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ MO 5 MO 5

92 SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 0 MG, 5 MG, 30 MG SYNAREL NASAL SOLUTION MG/ML 5 HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS 5 LA; MO methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 0.5 MG, 1 MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 5 MG BD; MO 5 BD; MO azathioprine oral tablet 50 mg BD; MO azathioprine sodium injection solution reconstituted 100 mg BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 10 MG BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 00 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML BD 5 BD 5 5 MO 5 MO cyclosporine intravenous solution 50 mg/ml BD cyclosporine modified oral capsule 100 mg, 5 mg, 50 mg BD; MO cyclosporine modified oral solution 100 mg/ml BD; MO cyclosporine oral capsule 100 mg, 5 mg BD; MO ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML 5 MO 5 MO 5 MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 79

93 ENVARSUS XR ORAL TABLET EXTENDED RELEASE HOUR 0.75 MG, 1 MG, MG GENGRAF ORAL CAPSULE 100 MG, 5 MG, 50 MG BD; MO BD; MO GENGRAF ORAL SOLUTION 100 MG/ML BD; MO HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML, 0 MG/0.8ML (6 PACK) HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 0 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 0 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 0 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.ML, 0 MG/0.ML, 0 MG/0.8ML KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML mycophenolate mofetil hcl intravenous solution reconstituted 500 mg 5 MO 5 MO 5 MO 5 MO 5 MO 5 ST; MO BD mycophenolate mofetil oral capsule 50 mg BD; MO mycophenolate mofetil oral suspension reconstituted 00 mg/ml BD; MO mycophenolate mofetil oral tablet 500 mg BD; MO mycophenolate sodium oral tablet delayed release 180 mg, 360 mg NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 50 MG PROGRAF INTRAVENOUS SOLUTION 5 MG/ML BD; MO 5 BD BD RAPAMUNE ORAL SOLUTION 1 MG/ML 3 BD; MO SANDIMMUNE ORAL CAPSULE 100 MG, 5 MG SANDIMMUNE ORAL SOLUTION 100 MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/ML BD; MO BD; MO 5 ST; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 80

94 SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 0 MG 5 ST; MO 5 ST; MO BD sirolimus oral tablet 0.5 mg, 1 mg, mg BD; MO tacrolimus oral capsule 0.5 mg, 1 mg BD; MO tacrolimus oral capsule 5 mg BD; MO TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG IMMUNIZING AGENTS, PASSIVE ATGAM INTRAVENOUS INJECTABLE 50 MG/ML BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMASTAN S/D INTRAMUSCULAR INJECTABLE (10ML), (ML) GAMMAGARD INJECTION SOLUTION.5 GM/5ML GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/00ML, 0 GM/00ML, 5 GM/50ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML HYPERRAB S/D INTRAMUSCULAR INJECTABLE 150 UNIT/ML, 150 UNIT/ML (10ML) BD 5 BD; MO 5 BD 5 BD 5 BD 5 BD BD 5 BD 5 BD 5 BD 5 BD 5 BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 81

95 OCTAGAM INTRAVENOUS SOLUTION 1 GM/0ML, GM/0ML PRIVIGEN INTRAVENOUS SOLUTION 0 GM/00ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 5 MG VARIZIG INTRAMUSCULAR SOLUTION 15 UNIT/1.ML IMMUNOMODULATORS ACTEMRA INTRAVENOUS SOLUTION 00 MG/10ML, 00 MG/0ML, 80 MG/ML ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 16 MG/0.9ML ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 0 MG ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG BD 5 BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ BD 5 ST 5 ST; MO 5 BD; MO leflunomide oral tablet 10 mg, 0 mg ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 15 MG/ML ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 15 MG/ML, 50 MG/0.ML, 87.5 MG/0.7ML 5 5 ST; MO 5 ST; MO 5 ST; MO XELJANZ ORAL TABLET 5 MG 5 ST; MO VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 bcg vaccine injection injectable BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE)

96 DAPTACEL INTRAMUSCULAR SUSPENSION diphtheria-tetanus toxoids dt intramuscular suspension 5-5 lfu/0.5ml ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML (0.5ML SYRINGE), 0 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 10 EL U/ML, 70 EL U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG IMOVAX RABIES INTRAMUSCULAR INJECTABLE.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION 3 KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE MENOMUNE SUBCUTANEOUS INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE PEDIARIX INTRAMUSCULAR SUSPENSION PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED BD BD BD introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 83

97 RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 0 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION 3 TENIVAC INTRAMUSCULAR INJECTABLE 5- LFU tetanus-diphtheria toxoids td intramuscular suspension - lf/0.5ml TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TWINRIX INTRAMUSCULAR SUSPENSION 70-0 TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5ML, 5 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 5 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 1900 UNT/0.65ML INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE HOUR GM balsalazide disodium oral capsule 750 mg 1 LIALDA ORAL TABLET DELAYED RELEASE 1. GM mesalamine oral tablet delayed release 800 mg 3 mesalamine-cleanser rectal kit gm 3 METABOLIC BONE DISEASE AGENTS HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) BD BD 3 introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 8

98 MIACALCIN INJECTION SOLUTION 00 UNIT/ML SENSIPAR ORAL TABLET 30 MG 3 BD; MO SENSIPAR ORAL TABLET 60 MG, 90 MG 5 BD; MO METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg alendronate sodium oral tablet 0 mg introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ calcitonin (salmon) nasal solution 00 unit/act BD; MO calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.5 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml FORTEO SUBCUTANEOUS SOLUTION 600 MCG/.ML FOSAMAX PLUS D ORAL TABLET MG-UNIT FOSAMAX PLUS D ORAL TABLET MG-UNIT 5 MO ; QL ( EA per 8 days) ibandronate sodium oral tablet 150 mg NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 5 MCG, 50 MCG, 75 MCG pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml paricalcitol intravenous solution mcg/ml 5 MO paricalcitol intravenous solution 5 mcg/ml BD paricalcitol oral capsule 1 mcg, mcg, mcg BD; MO PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML risedronate sodium oral tablet 150 mg, 35 mg, 35 mg (1 pack), 35 mg ( pack), 5 mg risedronate sodium oral tablet 30 mg risedronate sodium oral tablet delayed release 35 mg TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 310 MCG/1.56ML XGEVA SUBCUTANEOUS SOLUTION 10 MG/1.7ML ST 5 MO zoledronic acid intravenous concentrate mg/5ml BD 5

99 zoledronic acid intravenous solution 5 mg/100ml BD ZOMETA INTRAVENOUS SOLUTION MG/100ML MISCELLANEOUS MISCELLANEOUS CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT FETZIMA TITRATION ORAL CAPSULE ER HOUR THERAPY PACK 0 & 0 MG FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML lactated ringers irrigation solution 1 PHYSIOLYTE IRRIGATION SOLUTION 1 PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution 1 OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS BD bimatoprost ophthalmic solution 0.03 % latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.01 % TRAVATAN Z OPHTHALMIC SOLUTION 0.00 % OPHTHALMIC AGENTS, OTHER introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ atropine sulfate ophthalmic solution 1 % RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC ANTI INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic solution 0.3 % 1 erythromycin ophthalmic ointment 5 mg/gm 1 GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate ophthalmic solution 0.3 % 1

100 MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 moxifloxacin hcl ophthalmic solution 0.5 % 3 NATACYN OPHTHALMIC SUSPENSION 5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic solution 10 % 1 tobramycin ophthalmic solution 0.3 % 1 trifluridine ophthalmic solution 1 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 ZIRGAN OPHTHALMIC GEL 0.15 % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % cromolyn sodium ophthalmic solution % 1 olopatadine hcl ophthalmic solution 0.1 % PATADAY OPHTHALMIC SOLUTION 0. % 3 PAZEO OPHTHALMIC SOLUTION 0.7 % 3 PROLENSA OPHTHALMIC SOLUTION 0.07 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl ophthalmic solution 0.5 % introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.15 %, 0. % carteolol hcl ophthalmic solution 1 % COMBIGAN OPHTHALMIC SOLUTION % MO

101 dorzolamide hcl ophthalmic solution % dorzolamide hcl-timolol mal ophthalmic solution mg/ml levobunolol hcl ophthalmic solution 0.5 % metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.15 % SIMBRINZA OPHTHALMIC SUSPENSION 1-0. % timolol maleate ophthalmic gel forming solution 0.5 %, 0.5 % timolol maleate ophthalmic solution 0.5 %, 0.5 % OPHTHALMIC ANTI- INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CYSTARAN OPHTHALMIC SOLUTION 0. % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % 1 DUREZOL OPHTHALMIC EMULSION 0.05 % 3 flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0. %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA; MO; QL (60 ML per 30 days) 1

102 neomycin-polymyxin-hc ophthalmic suspension prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % OTIC AGENTS OTIC AGENTS acetic acid otic solution % CIPRODEX OTIC SUSPENSION % fluocinolone acetonide otic oil 0.01 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS ANTIHISTAMINES cetirizine hcl oral syrup 1 mg/ml 1 cyproheptadine hcl oral tablet mg 1 PA; HRM desloratadine oral tablet 5 mg 1 desloratadine oral tablet dispersible.5 mg diphenhydramine hcl injection solution 50 mg/ml 1 promethazine hcl oral tablet 1.5 mg, 5 mg, 50 mg ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 00 MCG/ACT introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/

103 ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 00 MCG/ACT budesonide inhalation suspension 0.5 mg/ml, 0.5 mg/ml, 1 mg/ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 0 MCG/ACT, MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT ANTILEUKOTRIENES BD; MO MO montelukast sodium oral packet mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable mg, 5 mg zafirlukast oral tablet 10 mg, 0 mg zileuton er oral tablet extended release 1 hour 600 mg 5 MO ZYFLO ORAL TABLET 600 MG 5 MO BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.0 % 1 BD; MO SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.5 MCG/ACT,.5 MCG/ACT introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 90

104 BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) aminophylline intravenous solution 5 mg/ml 1 theophylline er oral tablet extended release 1 hour 100 mg, 00 mg, 300 mg theophylline er oral tablet extended release hour 00 mg, 600 mg BRONCHODILATORS, SYMPATHOMIMETIC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, 30-1 MCG/ACT, 5-1 MCG/ACT albuterol sulfate er oral tablet extended release 1 hour mg albuterol sulfate er oral tablet extended release 1 hour 8 mg albuterol sulfate inhalation nebulization solution (.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.5 mg/3ml BD; MO albuterol sulfate oral syrup mg/5ml albuterol sulfate oral tablet mg, mg BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, 00-5 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, 3-1 mcg/act, 55-1 mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml levalbuterol hcl inhalation nebulization solution 1.5 mg/0.5ml PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT MO BD; MO BD; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 91

105 PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION.5-.5 MCG/ACT terbutaline sulfate injection solution 1 mg/ml MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 0 mg/ml NASAL AGENTS azelastine hcl nasal solution 0.1 %, 0.15 % flunisolide nasal solution 5 mcg/act (0.05%) fluticasone propionate nasal suspension 50 mcg/act ipratropium bromide nasal solution 0.03 %, 0.06 % mometasone furoate nasal suspension 50 mcg/act PULMONARY ANTIHYPERTENSIVES 1 BD; MO ADCIRCA ORAL TABLET 0 MG PA; MO ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG 5 PA; MO LETAIRIS ORAL TABLET 10 MG, 5 MG 5 MO OPSUMIT ORAL TABLET 10 MG 5 PA; MO sildenafil citrate intravenous solution 10 mg/1.5ml 3 PA sildenafil citrate oral tablet 0 mg PA; MO TRACLEER ORAL TABLET 15 MG, 6.5 MG 5 LA; MO UPTRAVI ORAL TABLET 1000 MCG, 100 MCG, 100 MCG, 1600 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 00 & 800 MCG VENTAVIS INHALATION SOLUTION 10 MCG/ML 5 PA; LA; MO 5 PA; LA 5 BD; MO introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 9

106 VENTAVIS INHALATION SOLUTION 0 MCG/ML PULMONARY FIBROSIS AGENTS BD; MO ESBRIET ORAL CAPSULE 67 MG 5 PA; MO ESBRIET ORAL TABLET 67 MG, 801 MG 5 PA; MO OFEV ORAL CAPSULE 100 MG, 150 MG 5 MO RESPIRATORY TRACT AGENTS, OTHER acetylcysteine inhalation solution 10 %, 0 % BD DALIRESP ORAL TABLET 500 MCG epinephrine injection solution auto-injector 0.15 mg/0.3ml epinephrine injection solution auto-injector 0.3 mg/0.3ml KALYDECO ORAL PACKET 50 MG, 75 MG 5 PA; MO KALYDECO ORAL TABLET 150 MG 5 PA; MO NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG PULMOZYME INHALATION SOLUTION 1 MG/ML XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/ PA; MO 5 PA; MO 5 BD 5 BD; MO 3 LA 5 PA baclofen oral tablet 10 mg baclofen oral tablet 0 mg cyclobenzaprine hcl oral tablet 10 mg 1 PA; HRM cyclobenzaprine hcl oral tablet 5 mg, 7.5 mg PA; HRM methocarbamol injection solution 1000 mg/10ml PA; HRM methocarbamol oral tablet 500 mg, 750 mg PA; HRM orphenadrine citrate er oral tablet extended release 1 hour 100 mg PA; HRM

107 orphenadrine citrate injection solution 30 mg/ml PA; HRM tizanidine hcl oral tablet mg, mg SLEEP DISORDER AGENTS BENZODIAZEPINES estazolam oral tablet 1 mg 1 QL (60 EA per 30 days) estazolam oral tablet mg 1 QL (30 EA per 30 days) flurazepam hcl oral capsule 15 mg QL (60 EA per 30 days) flurazepam hcl oral capsule 30 mg QL (30 EA per 30 days) temazepam oral capsule 15 mg QL (30 EA per 30 days) temazepam oral capsule.5 mg, 30 mg 3 QL (30 EA per 30 days) temazepam oral capsule 7.5 mg 3 QL (10 EA per 30 days) triazolam oral tablet 0.15 mg 3 QL (30 EA per 30 days) triazolam oral tablet 0.5 mg 1 QL (60 EA per 30 days) GABA RECEPTOR MODULATORS ROZEREM ORAL TABLET 8 MG MO zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zolpidem tartrate oral tablet 10 mg, 5 mg zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg SLEEP DISORDERS, OTHER BELSOMRA ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG HETLIOZ ORAL CAPSULE 0 MG 5 PA; MO modafinil oral tablet 100 mg, 00 mg PA; MO SILENOR ORAL TABLET 3 MG, 6 MG MO XYREM ORAL SOLUTION 500 MG/ML 5 LA PA; HRM; QL (60 EA per 30 days) PA; HRM; QL (30 EA per 30 days) PA; HRM; QL (30 EA per 30 days) PA; HRM; QL (30 EA per 30 days) introduction. Formulary ID: 18330, Ver. 7 Last updated 01/01/018 9

108 Alphabetical Listing A abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE... acamprosate calcium... acarbose... acebutolol hcl acetaminophen-codeine...3 acetaminophen-codeine #... acetaminophen-codeine #3...3 acetaminophen-codeine #...3 acetazolamide... 5 acetic acid acetylcysteine acitretin ACTEMRA... 8 ACTHIB... 8 ACTIMMUNE... acyclovir... 37, 38 acyclovir sodium ADACEL... 8 ADAGEN ADCIRCA... 9 adefovir dipivoxil ADEMPAS... 9 ADRIAMYCIN... ADRUCIL... ADVAIR DISKUS ADVAIR HFA AFEDITAB CR... 5 AFINITOR... AFINITOR DISPERZ... ALBENZA... 3 albuterol sulfate albuterol sulfate er ALDACTAZIDE... 9 ALDURAZYME ALECENSA... alendronate sodium ALIMTA... 3 ALINIA... 3 allopurinol... 0, 3 ALLZITAL... alosetron hcl ALPHAGAN P alprazolam... 1 alprazolam er... 1 ALPRAZOLAM INTENSOL 1 ALUNBRIG... alyacen 1/ amantadine hcl AMBISOME amcinonide AMETHIA... 7 amiloride hcl... 5 amiloride-hydrochlorothiazide9 aminophylline AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYTE S AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... 8 AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl... 9 amlodipine besylate... 5 amlodipine besylate-valsartan 9 amlodipine-atorvastatin amlodipine-olmesartan... 9 amlodipine-valsartan-hctz... 9 ammonium lactate AMNESTEEM amoxapine amoxicillin... 8 amoxicillin-pot clavulanate... 8 amphetaminedextroamphetamine... 56, 57 amphotericin b ampicillin... 8 ampicillin sodium... 8, 9 ampicillin-sulbactam sodium... 9 AMPYRA ANADROL anagrelide hcl... 7 anastrozole ANDRODERM... 7 ANDROGEL... 7 ANDROGEL PUMP... 7 APLENZIN APOKYN apraclonidine hcl aprepitant APRI APRISO... 8 APTIOM APTIVUS... 0 ARCALYST... 8 argatroban... 5 aripiprazole ARNUITY ELLIPTA ARRANON... ASCOMP-CODEINE... 3 ASHLYNA ASMANEX 10 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-dipyridamole er... 7 ASSURE ID INSULIN SAFETY SYR... ASTAGRAF XL atenolol atenolol-chlorthalidone... 9 ATGAM atomoxetine hcl atorvastatin calcium atovaquone... 3 atovaquone-proguanil hcl... 3 ATRIPLA atropine sulfate... 66, 86 ATROVENT HFA AUBAGIO AUBRA AUGMENTIN... 9 AUSTEDO AVANDIA... AVASTIN... 3 AVIANE azacitidine... AZACTAM IN DEXTROSE.. 8 AZASAN... azathioprine

109 azathioprine sodium azelastine hcl... 87, 9 azithromycin...9 AZOPT aztreonam...8 B baciim...8 bacitracin... 5, 86 bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen balsalazide disodium... 8 BALZIVA BANZEL BARACLUDE BAVENCIO... bcg vaccine... 8 BEKYREE BELEODAQ... 5 BELSOMRA... 9 benazepril hcl... 8 benazepril-hydrochlorothiazide... 9 BENLYSTA benzoyl peroxide-erythromycin benztropine mesylate... 3 BEPREVE BESIVANCE betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 51, 87 BETHKIS...5 bexarotene... 5 BEXSERO... 8 bicalutamide... 5 BICILLIN L-A...9 BICNU... 5 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide... 9 BIVIGAM bleomycin sulfate... 5 BLEPHAMIDE BLEPHAMIDE S.O.P BLISOVI FE BLISOVI FE 1.5/ BLISOVI FE 1/ BOOSTRIX... 8 BOSULIF... 5 BREO ELLIPTA briellyn BRILINTA... 7 brimonidine tartrate BRISDELLE BRIVIACT... 13, 1 bromocriptine mesylate budesonide... 71, 90 bumetanide... 5 buprenorphine hcl... bupropion hcl bupropion hcl er (smoking det) bupropion hcl er (sr)... 5, 15 bupropion hcl er (xl) buspirone hcl... 1 busulfan... 5 butalbital-acetaminophen... butalbital-apap-caff-cod... 3 butalbital-apap-caffeine... butalbital-asa-caff-codeine... 3 BUTRANS... C cabergoline CABOMETYX... 5 calcipotriene calcitonin (salmon) calcitriol calcium acetate (phos binder). 70 CAMILA CANCIDAS candesartan cilexetil... 7 candesartan cilexetil-hctz... 9 CAPASTAT SULFATE... 3 CAPRELSA... 5 captopril... 8 captopril-hydrochlorothiazide 9 CARAFATE CARBAGLU... 6 carbamazepine... 1, carbamazepine er... 1, carbidopa-levodopa carbidopa-levodopa er carboplatin... 5 CARIMUNE NF carteolol hcl CARTIA XT... 5 carvedilol caspofungin acetate CAYSTON... 8 CAZIANT cefaclor... 6 cefaclor er... 6 cefazolin sodium... 7 cefdinir... 7 cefepime hcl... 7 cefixime... 7 cefoxitin sodium... 7 cefpodoxime proxetil... 7 cefprozil... 7 ceftazidime... 7 ceftriaxone sodium... 7 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib... 0 CELONTIN... 1 cephalexin... 7 CEREBYX... 1 CEREZYME cetirizine hcl CHANTIX... 5 CHANTIX CONTINUING MONTH PAK... 5 CHANTIX STARTING MONTH PAK... 5 chloramphenicol sod succinate 5 chlordiazepoxide hcl... 1 chlordiazepoxide-amitriptyline chlorhexidine gluconate chloroquine phosphate... 3 chlorothiazide... 5 chlorpromazine hcl... 33, 3 chlorpropamide... chlorthalidone... 5 cholestyramine cholestyramine light chorionic gonadotropin ciclopirox ciclopirox olamine cilostazol... 7 CIMZIA CIMZIA PREFILLED CINRYZE CIPRODEX

110 ciprofloxacin ciprofloxacin hcl... 10, 86 ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er. 10 cisplatin... 5 citalopram hydrobromide cladribine... 5 CLARAVIS clarithromycin...9 clindamycin hcl...5 clindamycin palmitate hcl...6 clindamycin phos-benzoyl perox clindamycin phosphate. 6, 59, 71 clindamycin phosphate in d5w.6 CLINIMIX E/DEXTROSE (.75/10) CLINIMIX E/DEXTROSE (.75/5) CLINIMIX E/DEXTROSE (.5/10) CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/0) CLINIMIX E/DEXTROSE (5/5) CLINIMIX/DEXTROSE (.75/5) CLINIMIX/DEXTROSE (.5/10) CLINIMIX/DEXTROSE (.5/0) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/0) CLINIMIX/DEXTROSE (5/5) CLINISOL SF clobetasol propionate clobetasol propionate e clofarabine... 5 clomipramine hcl clonazepam... 1 clonidine hcl... 7 clopidogrel bisulfate... 7 clorazepate dipotassium... 1 clotrimazole... 19, 59 clotrimazole-betamethasone clozapine COARTEM... 3 colchicine... 0 colestipol hcl colistimethate sodium... 6 COMBIGAN COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE)... 5 COMETRIQ (10 MG DAILY DOSE)... 5 COMETRIQ (60 MG DAILY DOSE)... 5 COMFORT ASSIST INSULIN SYRINGE... COMPLERA COMPRO... 3 CONDYLOX constulose COPAXONE CORLANOR COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COSMEGEN... 5 COTELLIC... 5 CREON CRIXIVAN... 0 cromolyn sodium... 87, 9 cvs gauze sterile... CYCLAFEM 1/ cyclobenzaprine hcl cyclophosphamide... 3 CYCLOSET... cyclosporine cyclosporine modified cyproheptadine hcl CYRAMZA... 5 CYSTADANE CYSTAGON CYSTARAN cytarabine... 5 cytarabine (pf)... 5 D dacarbazine... 5 DALIRESP danazol... 7 dapsone... DAPTACEL daptomycin... 6 DARAPRIM... 3 darifenacin hydrobromide er.. 70 DARZALEX... 5 daunorubicin hcl... 5 DEBLITANE decitabine... DELYLA DEMSER... 5 DEPEN TITRATABS... 3 DEPO-MEDROL DEPO-PROVERA... 5 DEPO-SUBQ PROVERA DESCOVY desipramine hcl desloratadine... 38, 89 desmopressin ace rhinal tube. 77 desmopressin ace spray refrig 77 desmopressin acetate desogestrel-ethinyl estradiol.. 73 desonide desoximetasone desvenlafaxine er desvenlafaxine succinate er dexamethasone dexamethasone sodium phosphate... 71, 88 dexmethylphenidate hcl er dexrazoxane... 5 dextroamphetamine sulfate dextroamphetamine sulfate er 57 dextrose dextrose in lactated ringers dextrose-nacl DIASTAT ACUDIAL... 1 DIASTAT PEDIATRIC... 1 diazepam... 1, 1 DIAZEPAM INTENSOL... 1 diclofenac potassium... 0 diclofenac sodium... 0, 60, 88 diclofenac sodium er... 0 dicloxacillin sodium

111 dicyclomine hcl didanosine DIFICID...9 diflorasone diacetate diflunisal... 1 DIGITEK digoxin dihydroergotamine mesylate.. DILANTIN... 1 diltiazem hcl... 5 diltiazem hcl er... 5 diltiazem hcl er beads... 5 diltiazem hcl er coated beads.. 5 dilt-xr... 5 diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoids dt.. 83 dipyridamole... 7 disopyramide phosphate... 8 disulfiram... divalproex sodium... 1, divalproex sodium er... 1 docetaxel... 6 dofetilide... 8 donepezil hcl dorzolamide hcl dorzolamide hcl-timolol mal.. 88 doxazosin mesylate... 7 doxepin hcl DOXIL... 6 doxorubicin hcl... 6 doxorubicin hcl liposomal... 6 DOXY doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol 73 duloxetine hcl duramorph...3 DUREZOL dutasteride dutasteride-tamsulosin hcl E E.E.S econazole nitrate EDURANT ELAPRASE eletriptan hydrobromide... ELIDEL ELIGARD... 6 ELIQUIS... 5 ELITEK... 6 ELMIRON EMCYT... 6 EMEND... 18, 19 EMOQUETTE EMPLICITI... 6 EMSAM EMTRIVA EMVERM... 3 enalapril maleate... 8 enalapril-hydrochlorothiazide 9 ENBREL ENBREL SURECLICK ENGERIX-B enoxaparin sodium... 5 ENPRESSE entacapone entecavir ENTRESTO enulose ENVARSUS XR EPCLUSA epinephrine epirubicin hcl... 6 EPITOL... 1 EPIVIR HBV eplerenone... 5 EPOGEN... 6 eprosartan mesylate... 7 EQUETRO... 1 ERAXIS ERBITUX... 6 ergoloid mesylates ergotamine-caffeine... ERIVEDGE... 6 ERRIN ERWINAZE... 6 ERYTHROCIN LACTOBIONATE... 9 ERYTHROCIN STEARATE. 10 erythromycin... 60, 86 erythromycin base erythromycin ethylsuccinate.. 10 ESBRIET escitalopram oxalate esomeprazole sodium estazolam... 9 ESTRACE... 71, 76 estradiol... 71, 76 ethambutol hcl... 3 ethosuximide... 1 ethynodiol diac-eth estradiol.. 73 etodolac... 1 etodolac er... 1 ETOPOPHOS... 6 etoposide... 6 EURAX EVOTAZ EXEL COMFORT POINT PEN NEEDLE... exemestane EXJADE... 6 ezetimibe ezetimibe-simvastatin F FABRAZYME FALMINA famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON... 6 FARYDAK... 6 FASLODEX... 6 felbamate felodipine er... 5 FEMYNOR fenofibrate... 5 fenofibrate micronized... 5 fenofibric acid fenoprofen calcium... 1 fentanyl... FENTORA... 3 FERRIPROX... 6 FETZIMA FETZIMA TITRATION finasteride FIRAZYR FIRMAGON... 6 FLEBOGAMMA DIF flecainide acetate... 8 FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in sodium chloride flucytosine

112 fludarabine phosphate... fludrocortisone acetate flunisolide... 9 fluocinolone acetonide... 60, 89 fluocinolone acetonide body fluocinonide fluocinonide-e fluorouracil... 6, 60 fluoxetine hcl fluphenazine decanoate... 3 fluphenazine hcl... 3 flurazepam hcl... 9 flurbiprofen... 1 flurbiprofen sodium flutamide... 6 fluticasone propionate... 60, 9 fluticasone-salmeterol fluvastatin sodium fluvastatin sodium er fluvoxamine maleate fluvoxamine maleate er FOLOTYN... 7 fondaparinux sodium... 5 FORFIVO XL FORTEO FOSAMAX PLUS D fosinopril sodium... 8 fosinopril sodium-hctz fosphenytoin sodium... 1 FRAGMIN... 5 FREAMINE HBC furosemide... 5 FUZEON FYAVOLV FYCOMPA... 1 G gabapentin... 1 GABITRIL... 1 galantamine hydrobromide galantamine hydrobromide er. 15 GAMASTAN S/D GAMMAGARD GAMMAGARD S/D LESS IGA GAMMAKED GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL GATTEX GAVILYTE-N WITH FLAVOR PACK gemcitabine hcl... gemfibrozil... 5 generlac GENGRAF GENTAK gentamicin in saline... 5 gentamicin sulfate... 5, 60, 86 GENVOYA GEODON GIANVI GILDAGIA GILENYA GILOTRIF... 7 GLEOSTINE... 3 glimepiride... glipizide... glipizide er... glipizide-metformin hcl... global alcohol prep ease... GLUCAGEN HYPOKIT... GLUCAGON EMERGENCY glyburide... 3 glyburide micronized... glyburide-metformin... 3 glycopyrrolate granisetron hcl griseofulvin microsize... 0 griseofulvin ultramicrosize... 0 guanfacine hcl er guanidine hcl... H HALAVEN... 7 halobetasol propionate... 60, 61 haloperidol... 3 haloperidol decanoate... 3 haloperidol lactate... 3 HAVRIX heparin (porcine) in d5w... 5 heparin sod (porcine) in d5w. 5 heparin sodium (porcine)... 6 HEPATAMINE HERCEPTIN... 7 HETLIOZ... 9 HEXALEN... 3 HIBERIX HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER hydralazine hcl hydrochlorothiazide... 5 hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 61, 71 hydrocortisone valerate hydromorphone hcl..., 3 hydromorphone hcl pf... 3 hydroxychloroquine sulfate... 3 hydroxyprogesterone caproate 7 hydroxyurea... 7 hydroxyzine hcl... 1 hydroxyzine pamoate... 1 HYPERRAB S/D HYSINGLA ER... 3 I ibandronate sodium IBRANCE... 7 ibuprofen... 1 ICLUSIG... 7 idarubicin hcl... 7 IDHIFA... 7 ifosfamide... 7 ILARIS (150MG DELIVERED)... 8 ILEVRO imatinib mesylate... 7 IMBRUVICA... 7 IMFINZI... 7 imipenem-cilastatin... 8 imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES INCRELEX indapamide... 5 indomethacin... 1 indomethacin er... 1 INFANRIX INLYTA... 7 INTELENCE INTRON A... 7 INTROVALE... 7 INVANZ... 8 INVEGA SUSTENNA

113 INVEGA TRINZA INVIRASE... 0 INVOKAMET... 3 INVOKAMET XR... 3 INVOKANA... 3 IPOL ipratropium bromide... 90, 9 ipratropium-albuterol irbesartan... 7 irbesartan-hydrochlorothiazide IRESSA... 7 irinotecan hcl... 7 ISENTRESS ISENTRESS HD ISIBLOOM... 7 ISOLYTE-P IN D5W ISOLYTE-S isoniazid... 3 isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine... 5 ISTODAX (OVERFILL)... 7 itraconazole... 0 ivermectin... 3 IXIARO J JADENU SPRINKLE... 6 JAKAFI... 7 JANTOVEN... 6 JANUMET... 3 JANUMET XR... 3 JANUVIA... 3 JARDIANCE... 3 JENTADUETO... 3 JENTADUETO XR... 3 JEVTANA... 7 JINTELI JOLIVETTE... 7 JULEBER... 7 JUNEL FE 1.5/ JUNEL FE 1/ JUNEL FE... 7 JUXTAPID K KADCYLA... 7 KAITLIB FE... 7 KALETRA... 0 KALYDECO KANUMA KARIVA... 7 kcl in dextrose-nacl kcl-lactated ringers-d5w KEPIVANCE... 7 ketoconazole... 0, 61 ketoprofen... 1 ketoprofen er... 1 ketorolac tromethamine... 1, 88 KEYTRUDA... 8 KIMIDESS... 7 KINERET KINRIX KIONEX... 6 KISQALI 00 DOSE... 8 KISQALI 00 DOSE... 8 KISQALI 600 DOSE... 8 KISQALI FEMARA 00 DOSE... 8 KISQALI FEMARA 00 DOSE... 8 KISQALI FEMARA 600 DOSE... 8 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KORLYM K-TAB KUVAN KYNAMRO KYPROLIS... 8 L labetalol hcl lactated ringers... 63, 86 lactulose LAMICTAL STARTER LAMICTAL XR lamivudine lamivudine-zidovudine lamotrigine lamotrigine er lansoprazole LANTUS... LANTUS SOLOSTAR... LARIN FE 1.5/ LARIN FE 1/ LARISSIA... 7 LARTRUVO... 8 latanoprost LATUDA LAYOLIS FE... 7 LAZANDA... 3 leflunomide... 8 LENVIMA 10 MG DAILY DOSE... 8 LENVIMA 1 MG DAILY DOSE... 8 LENVIMA 18 MG DAILY DOSE... 8 LENVIMA 0 MG DAILY DOSE... 8 LENVIMA MG DAILY DOSE... 8 LENVIMA 8 MG DAILY DOSE... 8 LESSINA... 7 LETAIRIS... 9 letrozole... 3 leucovorin calcium... 8 LEUKERAN... 3 LEUKINE... 6 leuprolide acetate... 8 levalbuterol hcl LEVEMIR... LEVEMIR FLEXTOUCH... levetiracetam levetiracetam er levetiracetam in nacl levobunolol hcl levocarnitine levofloxacin levofloxacin in d5w levoleucovorin calcium... 8 LEVONEST... 7 levonorgest-eth estrad 91-day 7 levonorgestrel-ethinyl estrad. 7 levonorg-eth estrad triphasic.. 7 LEVORA 0.15/30 (8)... 7 levothyroxine sodium LEVOXYL LEXIVA... 0 LIALDA... 8 lidocaine lidocaine hcl..., 61 lidocaine hcl (pf)... lidocaine-prilocaine

114 lincomycin hcl...6 lindane linezolid...6 LINZESS liothyronine sodium lisinopril... 8 lisinopril-hydrochlorothiazide 50 lithium... lithium carbonate... lithium carbonate er... LIVALO LOMEDIA FE... 7 LONSURF... 8 loperamide hcl lopinavir-ritonavir... 0 lorazepam... LORAZEPAM INTENSOL... LORYNA... 7 losartan potassium... 7 losartan potassium-hctz LOTEMAX lovastatin LOW-OGESTREL... 7 loxapine succinate... 3 LUMIGAN LUMIZYME LUPRON DEPOT (1-MONTH)... 9 LUPRON DEPOT (3-MONTH)... 9, 78 LUPRON DEPOT (-MONTH)... 9 LUPRON DEPOT (6-MONTH)... 9 LUPRON DEPOT-PED (1- MONTH) LUTERA... 7 LYNPARZA... 9 LYRICA... 1, 58 LYSODREN... 9 LYZA... 7 M magnesium sulfate MAKENA maprotiline hcl marlissa... 7 MARPLAN MATULANE... 9 MAVYRET meclizine hcl meclofenamate sodium... 1 medroxyprogesterone acetate 75, 77 mefloquine hcl... 3 megestrol acetate... 9 MEKINIST... 9 meloxicam... 1 melphalan hcl... 9 memantine hcl MENACTRA MENEST MENOMUNE MENVEO meprobamate... 1 mercaptopurine... meropenem... 8 mesalamine... 8 mesalamine-cleanser... 8 mesna... 3 MESNEX... 9 MESTINON... METADATE ER metformin hcl... 3 metformin hcl er... 3 metformin hcl er (osm)... 3 methadone hcl... methazolamide... 5 methimazole methocarbamol methotrexate... methotrexate sodium... methotrexate sodium (pf)... methoxsalen rapid methscopolamine bromide methyclothiazide... 5 methyldopa... 7 methyldopa-hydrochlorothiazide methyldopate hcl... 7 methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methylprednisolone acetate methylprednisolone sodium succ methyltestosterone... 7 metipranolol metoclopramide hcl... 18, 67 metolazone... 5 metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 6, 61, 71 metronidazole in nacl... 6 mexiletine hcl... 8 MIACALCIN miconazole MICROGESTIN FE 1.5/ MICROGESTIN FE 1/ midodrine hcl... 7 miglitol... 3 MINITRAN minocycline hcl minoxidil MIRCERA... 6 mirtazapine misoprostol mitomycin... 9 mitoxantrone hcl... 9 M-M-R II modafinil... 9 MODERIBA MODERIBA 100 DOSE PACK MODERIBA 800 DOSE PACK moexipril hcl... 8 moexipril-hydrochlorothiazide mometasone furoate... 61, 9 montelukast sodium morphine sulfate... 3 morphine sulfate (concentrate) 3 morphine sulfate (pf)... 3 morphine sulfate er... morphine sulfate er beads... MOVANTIK MOVIPREP MOXEZA moxifloxacin hcl... 10, 87 MOZOBIL... 6 MULTAQ... 8 mupirocin mupirocin calcium MUSTARGEN... 9 MYCAMINE... 0 mycophenolate mofetil

115 mycophenolate mofetil hcl mycophenolate sodium MYRBETRIQ MYTESI N nabumetone... 1 nadolol nadolol-bendroflumethiazide.. 50 nafcillin sodium...9 NAGLAZYME nalbuphine hcl... naloxone hcl..., 5 naltrexone hcl... NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC naproxen... 1 naproxen dr... 1 naproxen sodium... 1 NATACYN nateglinide... 3 NATPARA NEBUPENT... 3 NECON 0.5/35 (8) nefazodone hcl neomycin sulfate...5 neomycin-bacitracin znpolymyx neomycin-polymyxin b gu neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc NEPHRAMINE NERLYNX... 9 NEUPOGEN... 6 NEUPRO nevirapine nevirapine er NEXAVAR... 9 niacin er (antihyperlipidemic) 55 NIACOR nicardipine hcl... 5 NICOTROL...5 nifedipine nifedipine er... 5, 53 nifedipine er osmotic release.. 53 NIKKI nilutamide... 9 nimodipine NINLARO... 9 NIPENT... 9 nisoldipine er NITRO-DUR nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro. 6 nitroglycerin NORA-BE NORDITROPIN FLEXPRO.. 77 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est 75 norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic 75 NORLYROC NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORTHERA NORTREL 0.5/35 (8) NORTREL 1/35 (1) NORTREL 1/35 (8) nortriptyline hcl NORVIR... 0 NOVOLIN 70/30... NOVOLIN N... NOVOLIN R... NOVOLOG... 5 NOVOLOG FLEXPEN... 5 NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN... 5 NOVOLOG PENFILL... 5 NOXAFIL... 0 NUCALA NUEDEXTA NULOJIX NUPLAZID nutrilipid NYAMYC nystatin... 0, 58, 61 nystatin-triamcinolone NYSTOP O OCELLA OCTAGAM... 8 octreotide acetate ODEFSEY ODOMZO... 9 OFEV ofloxacin... 10, 87, 89 olanzapine olanzapine-fluoxetine hcl olmesartan medoxomil... 7 olmesartan medoxomil-hctz olmesartan-amlodipine-hctz.. 50 olopatadine hcl omega-3-acid ethyl esters omeprazole ondansetron ondansetron hcl ONFI... 1 OPDIVO... 9 OPSUMIT... 9 ORAVIG ORENCIA... 8 ORENCIA CLICKJECT... 8 ORFADIN ORKAMBI orphenadrine citrate... 9 orphenadrine citrate er ORSYTHIA oseltamivir phosphate... 0 oxaliplatin... 9 oxandrolone... 7 oxaprozin... 1 oxazepam... oxcarbazepine... 1 OXTELLAR XR... 1 oxybutynin chloride oxybutynin chloride er oxycodone hcl... oxycodone hcl er... oxycodone-acetaminophen... oxycodone-aspirin... oxycodone-ibuprofen... OXYCONTIN... oxymorphone hcl... P PACERONE... 8 paclitaxel... 9 paliperidone er pamidronate disodium PANRETIN pantoprazole sodium

116 paricalcitol paromomycin sulfate...5 paroxetine hcl paroxetine hcl er PASER... 3 PATADAY PAXIL PAZEO PEDIARIX PEDVAX HIB peg 3350-kcl-na bicarb-nacl PEGANONE... 1 PEGASYS PEGASYS PROCLICK penicillin g pot in dextrose...9 penicillin g potassium...9 penicillin g sodium...9 penicillin v potassium...9 PENTAM... 3 pentazocine-naloxone hcl... pentoxifylline er perindopril erbumine... 8 PERIOGARD PERJETA... 9 permethrin perphenazine... 3 perphenazine-amitriptyline... 3 PEXEVA phenelzine sulfate phenobarbital phenytoin... 1 phenytoin sodium... 1 phenytoin sodium extended... 1 PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION.. 86 PICATO pilocarpine hcl pimozide... 3 PIMTREA pindolol pioglitazone hcl... 3 pioglitazone hcl-glimepiride.. 3, 50 pioglitazone hcl-metformin hcl... 3 piperacillin sod-tazobactam so.9 PIRMELLA 1/ piroxicam... 1 PLASMA-LYTE PLENAMINE podofilox... 6 polyethylene glycol polymyxin b-trimethoprim POMALYST PORTIA potassium chloride... 6 potassium chloride crys er... 6 potassium chloride er... 6 potassium chloride in dextrose... 6 potassium chloride in nacl... 6 potassium citrate er... 6 PRADAXA... 6 PRALUENT pramipexole dihydrochloride. 33 pramipexole dihydrochloride er pravastatin sodium prazosin hcl... 7 prednicarbate... 6 prednisolone acetate prednisolone sodium phosphate... 7, 89 prednisone... 7 preferred plus insulin syringe. 3 PREMARIN... 71, 77 PREMASOL PREMPHASE PREMPRO prenatal PREPOPIK PREVALITE PREZCOBIX PREZISTA... 0 PRIFTIN... 3 primaquine phosphate... primidone PRIMSOL... 6 PRIVIGEN... 8 PROAIR HFA PROAIR RESPICLICK... 9 probenecid... 0 procainamide hcl... 9 PROCALAMINE prochlorperazine... 3 prochlorperazine edisylate... 3 prochlorperazine maleate... 3 PROCRIT... 6 PROCTO-MED HC... 6 PROCTO-PAK... 6 PROCTOSOL HC... 6 PROCTOZONE-HC... 6 PROGLYCEM... PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA... 6 promethazine hcl propafenone hcl... 9 propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl PULMICORT FLEXHALER 90 PULMOZYME PURIXAN... pyrazinamide... pyridostigmine bromide... Q QUADRACEL QUARTETTE QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl... 8 quinapril-hydrochlorothiazide 50 quinidine gluconate er... 9 quinidine sulfate... 9 quinine sulfate... 3 R RABAVERT RADICAVA raloxifene hcl ramipril... 8 RANEXA... 5 ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RAVICTI RECLIPSEN RECOMBIVAX HB... 8 REGRANEX... 6 RELENZA DISKHALER

117 RELI-ON INSULIN SYRINGE... 3 RELISTOR RELPAX... RENVELA repaglinide... 3 repaglinide-metformin hcl... 3 REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR RESTASIS RETROVIR REVLIMID... 3 REXULTI REYATAZ... 0 RIBASPHERE RIBASPHERE RIBAPAK ribavirin rifabutin... rifampin... 3 RIFATER... 3 riluzole rimantadine hcl... 0 ringers... 6 ringers irrigation RIOMET... 3 risedronate sodium RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate ropinirole hcl rosuvastatin calcium ROTARIX... 8 ROTATEQ... 8 ROWEEPRA ROZEREM... 9 RUBRACA RYDAPT S SABRIL... 1 SAMSCA... 6 SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL... 6 SAPHRIS SAVELLA SAVELLA TITRATION PACK selegiline hcl selenium sulfide... 6 SELZENTRY SENSIPAR SEREVENT DISKUS... 9 sertraline hcl SETLAKIN sevelamer carbonate SHAROBEL SIGNIFOR sildenafil citrate... 9 SILENOR... 9 silver sulfadiazine... 6 SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT simvastatin sirolimus SIRTURO... 3 sodium chloride... 6, 70 sodium fluoride sodium lactate... 6 sodium polystyrene sulfonate. 65 SOLTAMOX SOLU-MEDROL... 7 SOMATULINE DEPOT SOMAVERT SORINE sotalol hcl sotalol hcl (af) SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone... 5 spironolactone-hctz SPRITAM SPRYCEL SPS SRONYX SSD... 6 stavudine STELARA... 6 STIOLTO RESPIMAT... 9 STIVARGA streptomycin sulfate... 5 STRIBILD... 0 sucralfate sulfacetamide sodium sulfacetamide sodium (acne). 6 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulindac... 1 sumatriptan succinate... SUPRAX... 7 SUSTIVA SUTENT SYLATRON SYMLINPEN SYMLINPEN SYNAGIS... 8 SYNAREL SYNDROS SYNERCID... 6 SYNJARDY... SYNRIBO SYNTHROID SYPRINE... 3 T TABLOID... tacrolimus TAFINLAR TAGRISSO TAMIFLU... 0 tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN... 6 TARINA FE 1/ TASIGNA tazarotene... 6 TAZICEF... 8 TAZORAC... 6 TAZTIA XT TECENTRIQ TEFLARO... 8 telmisartan... 8 telmisartan-amlodipine telmisartan-hctz temazepam... 9 TENCON... TENIVAC... 8 terazosin hcl... 7 terbutaline sulfate

118 terconazole testosterone cypionate... 7 testosterone enanthate... 7 tetanus-diphtheria toxoids td.. 8 tetrabenazine THALOMID... 3 theophylline er thioridazine hcl... 3 thiotepa thiothixene... 3, 35 THYMOGLOBULIN... 8 tiagabine hcl... 1 tigecycline...6 timolol maleate... 5, 88 TIVICAY... 0 tizanidine hcl... 9 TOBRADEX TOBRADEX ST tobramycin... 5, 87 tobramycin sulfate...5 tobramycin-dexamethasone TOLAK... 6 tolazamide... tolbutamide... tolmetin sodium... 1 tolterodine tartrate topiramate... 13, topiramate er TOPOSAR topotecan hcl TORISEL torsemide... 5 TOUJEO SOLOSTAR... 5 TPN ELECTROLYTES... 6 TRACLEER... 9 TRADJENTA... tramadol hcl... tramadol-acetaminophen... trandolapril... 8 trandolapril-verapamil hcl er.. 50 tranexamic acid... 6 TRANSDERM-SCOP (1.5 MG) tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl TREANDA TRECATOR... 3 TRELSTAR MIXJECT TRESIBA FLEXTOUCH... 5 tretinoin... 30, 6 TREXALL triamcinolone acetonide... 58, 6 triamterene-hctz... 50, 51 triazolam... 9 trifluoperazine hcl trifluridine trihexyphenidyl hcl... 3 TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE trimethoprim... 6 trimipramine maleate TRINESSA (8) TRINTELLIX TRI-PREVIFEM TRISENOX TRI-SPRINTEC TRIUMEQ TRIVORA (8) TROKENDI XR TROPHAMINE TRULICITY... TRUMENBA... 8 TRUVADA TWINRIX... 8 TYBOST... 0 TYKERB TYMLOS TYPHIM VI... 8 TYSABRI U UCERIS... 6, 7 ULORIC... 0 UNITHROID UPTRAVI... 9 ursodiol V valacyclovir hcl VALCHLOR... 6 valganciclovir hcl valproate sodium... 1, 13 valproic acid valsartan... 8 valsartan-hydrochlorothiazide..., 51 vancomycin hcl... 6 VANDAZOLE VAQTA... 8 VARIVAX... 8 VARIZIG... 8 VECTIBIX VELCADE VELIVET VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl venlafaxine hcl er VENTAVIS... 9, 93 verapamil hcl verapamil hcl er VERSACLOZ VESICARE VESTURA VICTOZA... VIDEX VIENVA vigabatrin VIGAMOX VIIBRYD VIIBRYD STARTER PACK 16 VIMPAT... 1 vinblastine sulfate VINCASAR PFS vincristine sulfate vinorelbine tartrate VIRACEPT... 0 VIREAD voriconazole... 0 VOTRIENT VPRIV VRAYLAR VYFEMLA VYXEOS W warfarin sodium... 6 WYMZYA FE X XALKORI XARELTO... 6 XARELTO STARTER PACK... 6 XATMEP... XELJANZ... 8 XGEVA XIFAXAN... 6 XOLAIR

119 XTANDI XYREM... 9 Y YERVOY YF-VAX... 8 YONDELIS YUVAFEM Z zafirlukast zaleplon... 9 ZALTRAP ZANOSAR ZANTAC ZARXIO... 6 ZAVESCA ZAZOLE ZEBUTAL... ZEJULA ZELBORAF ZEMAIRA ZENCHENT ZENCHENT FE ZENPEP ZEPATIER ZERIT ZIAGEN zidovudine zileuton er ziprasidone hcl ZIRGAN ZMAX zoledronic acid... 85, 86 ZOLINZA zolpidem tartrate... 9 ZOMETA zonisamide... 1 ZORTRESS ZOSTAVAX... 8 ZUBSOLV... 5 ZYDELIG ZYFLO ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA

120 AgeWell New York, LLC is a Health Maintenance Organization (HMO) plan with a Medicare contract and a contract with the New York State Medicaid Program. Enrollment in AgeWell New York depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary. Limitations, copayments, and restrictions may apply. This document may be available in an alternate format such as Braille, larger print, or audio. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AgeWell New York does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AgeWell New York provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact AgeWell New York Member Services at If you believe that AgeWell New York has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: AgeWell New York Civil Rights Coordination Unit 1991 Marcus Avenue Suite M01 Lake Success, New York TTY/TDD: Fax: civilrightsunit@agewellnewyork.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordination Unit is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 001, , TDD: Complaint forms are available at 19

121 AgeWell New York, LLC es un plan de Organización para el mantenimiento de la salud (Health Maintenance Organization, HMO) bajo un contrato con Medicare y un contrato con el programa del estado de Nueva York de Medicaid. La inscripción en AgeWell New York depende de la renovación del contrato. El Formulario puede sufrir modificaciones en cualquier momento. Usted recibirá un aviso cuando sea necesario. Se pueden aplicar limitaciones, copagos y restricciones. Este documento puede estar disponible en formato alternativo, como braille, letra más grande o audio. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). Los servicios de asistencia en otros idiomas también están disponibles de forma gratuita. AgeWell New York cumple con todas las leyes federales sobre derechos civiles que corresponden y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York no excluye a las personas ni las trata diferente por su raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York proporciona ayuda y servicios gratuitos a personas con discapacidades a fin de que puedan comunicarse con nosotros eficazmente, como los siguientes: Intérpretes calificados de lenguaje de señas Información escrita en otros formatos (tamaño de letra grande, audio, formatos de acceso electrónico, otros formatos) Servicios lingüísticos gratuitos para personas cuyo idioma nativo no sea inglés, como intérpretes calificados e información escrita en otros idiomas Si necesita estos servicios, comuníquese con Servicios para miembros de AgeWell New York al Si considera que AgeWell New York no proporcionó estos servicios o hizo algún tipo de discriminación por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo ante: AgeWell New York Civil Rights Coordination Unit 1991 Marcus Avenue Suite M01 Lake Success, New York TTY/TDD: Fax: Correo electrónico: civilrightsunit@agewellnewyork.com Puede interponer un reclamo personalmente o por correo postal, fax o correo electrónico. Si necesita ayuda para presentar un reclamo, la Unidad de Coordinación de Derechos Civiles está disponible para usted. También puede presentar una queja relacionada con los derechos civiles ante el Departamento de Salud y Servicios Sociales, Oficina de Derechos Civiles, en forma electrónica a través del Portal de Quejas ante la Oficina de Derechos Civiles, disponible en o bien, por teléfono o por correo a: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 001, , TDD: Los formularios de denuncias se encuentran disponibles en 130

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

123 French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Urdu : Tagolog: خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں.(TTY: ) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). 13

124 We re here for your call. This formulary was updated on 01/01/018. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or for TTY users, 711, 7 days a week hours a day or visit agewellnewyork.com TTY/TDD