ANALGESICS - TREATMENT OF PAIN ANALGESICS

Transcription

1 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ANALGESICS - TREATMENT OF PAIN ANALGESICS acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 0- /5 ml, 00-0 /.5 ml acetaminophen-codeine oral tablet 00-5, 00-0, ascomp with codeine oral capsule butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule PA PA PA butalbital-acetaminophen oral tablet 50-5 PA butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule carisoprodol-asa-codeine oral tablet PA PA PA PA carisoprodol-aspirin oral tablet 00-5 PA codeine-butalbital-asa-caff oral capsule hydrocodone-acetaminophen oral tablet 0-5,.5-5, 5-5, hydrocodone-ibuprofen oral tablet 0-00, 5-00, ibuprofen-oxycodone oral tablet oxycodone-acetaminophen oral tablet 0-5,.5-5, 5-5, oxycodone-aspirin oral tablet PA

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

3 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: naproxen oral tablet,delayed release (dr/ec) 75, 500 naproxen sodium oral tablet 75, 550 piroxicam oral capsule 0, 0 sulindac oral tablet 50, 00 ZORVOLEX ORAL CAPSULE 8 MG, 5 MG ST OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour QL (4 EA per 8 days) fentanyl transdermal patch 7 hour 00 mcg/hr PAQL (0 EA per 0 days) fentanyl transdermal patch 7 hour mcg/hr, 5 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (0 EA per 0 days) methadone oral solution 0 /5 ml QL (00 ML per 0 days) methadone oral solution 5 /5 ml QL (400 ML per 0 days) methadone oral tablet 0 PAQL (40 EA per 0 days) methadone oral tablet 5 QL (80 EA per 0 days) morphine oral tablet extended release 00, 00 morphine oral tablet extended release 5, 0, 60 oxycodone oral tablet,oral only,ext.rel. hr 0, 5, 0, 0, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate injection solution /ml, /ml butorphanol tartrate nasal spray,non-aerosol 0 /ml duramorph (pf) injection solution 0.5 /ml, /ml PAQL (60 EA per 0 days) QL (60 EA per 0 days) PAQL (60 EA per 0 days) QL (5 ML per 0 days) B/D

4 fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, /ml, 4 /ml hydromorphone injection syringe /ml PAQL (0 EA per 0 days) hydromorphone oral tablet, 4, 8 QL (0 EA per 0 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 400 MCG/SPRAY PAQL (600 EA per 0 days) PAQL (50 EA per 0 days) meperidine oral solution 50 /5 ml PAQL (900 ML per 0 days) meperidine oral tablet 00, 50 PAQL (80 EA per 0 days) morphine oral tablet 5, 0 QL (0 EA per 0 days) nalbuphine injection solution 0 /ml, 0 /ml B/D oxycodone oral solution 5 /5 ml QL (5400 ML per 0 days) oxycodone oral tablet 0, 5, 0, 0, 5 QL (0 EA per 0 days) tramadol oral tablet 50 QL (40 EA per 0 days) ANESTHETICS - LOCAL TREATMENT OF PAIN LOCAL ANESTHETICS ACCUCAINE KIT KIT 0 MG/ML ( %) ANODYNE LPT TOPICAL KIT.5-.5 % dermacinrx empricaine topical kit.5-.5 % LEVA SET TOPICAL KIT.5-.5 % lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection solution 5 /ml (0.5 %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % 4

5 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PAQL (90 EA per 0 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LIDOPAC TOPICAL KIT 5 % lidopril topical kit.5-.5 % lidopril xr topical kit.5-.5 % LIDO-PRILO CAINE PACK TOPICAL KIT.5-.5 % liprozonepak topical kit.5-.5 % livixil pak topical kit.5-.5 % MEDOLOR PAK TOPICAL KIT.5-.5 % prilolid topical kit.5-.5 % ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF SUBSTANCE ABUSE DISORDERS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet 50, 500 naltrexone oral tablet 50 OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml naloxone injection syringe /ml SKING CESSATION AGENTS 5

6 buproban oral tablet extended release hr 50 CHANTIX CONTINUING NTH BOX ORAL TABLET MG 6 QL (6 EA per 65 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (6 EA per 65 days) CHANTIX STARTING NTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML QL (06 EA per 65 days) ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS AMINOGLYCOSIDES amikacin injection solution,000 /4 ml, 500 / ml gentak ophthalmic (eye) ointment 0. % ( /gram) gentamicin injection solution 0 / ml gentamicin ophthalmic (eye) drops 0. % gentamicin ophthalmic (eye) ointment 0. % ( /gram) gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml gentamicin sulfate (pf) intravenous solution 80 /8 ml gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 paromomycin oral capsule 50 streptomycin intramuscular recon soln gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml B/D

7 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: tobramycin ophthalmic (eye) drops 0. % tobramycin sulfate injection recon soln. gram tobramycin sulfate injection solution 0 /ml, 40 /ml tobramycin with nebulizer inhalation solution for nebulization 00 /5 ml tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ANTIBACTERIALS, OTHER acetic acid otic (ear) solution % ak-poly-bac ophthalmic (eye) ointment 500-0,000 unit/gram bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 00, 75 clindamycin in 0.9 % sod chlor intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml), 50 /ml 5 B/D 4 7

8 clindamycin phosphate intravenous solution 00 / ml, 600 /4 ml, 900 /6 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % clindamycin-benzoyl peroxide topical gel. %( % base) -5 % colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 500 lincomycin injection solution 00 /ml linezolid intravenous parenteral solution 600 /00 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /00 ml methenamine hippurate oral tablet gram metro i.v. intravenous piggyback 500 /00 ml metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 75 metronidazole oral tablet 50, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical gel with pump % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-% 8

9 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b gu irrigation solution 40-00,000 unit/ml neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment.5 /g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-0, unit-/ml nitrofurantoin macrocrystal oral capsule 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin monohyd/m-cryst oral capsule 00 (75/5) polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- /ml SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin in 0.9 % sodium chl intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin in 0.9 % sodium chl intravenous solution.5 gram/50 ml, 750 /50 ml vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml QL (60 EA per 65 days) QL (80 EA per 65 days) QL (60 EA per 65 days) B/D B/D B/D vancomycin injection recon soln 00 gram B/D 9

10 vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 VANCOMYCIN ORAL CAPSULE 5 MG, 50 MG B/D 4 PA XIFAXAN ORAL TABLET 00 MG 4 PAQL (9 EA per days) XIFAXAN ORAL TABLET 550 MG QL (60 EA per 0 days) BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram cefazolin intravenous recon soln gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefepime in dextrose 5 % intravenous piggyback gram/50 ml, gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, gram/00 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, gram, 500 cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml 0

11 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: cefprozil oral tablet 50, 500 ceftazidime in d5w intravenous piggyback gram/50 ml, gram/50 ml ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 ceftriaxone injection recon soln 00 gram ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium intravenous recon soln.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 400 MG 4 TAZICEF INJECTION RECON SOLN GRAM, GRAM, 6 GRAM TAZICEF INTRAVENOUS RECON SOLN GRAM, GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection recon soln gram, gram 4 PA doripenem intravenous recon soln 50, 500 PA imipenem-cilastatin intravenous recon soln 50, 500 PA INVANZ INJECTION RECON SOLN GRAM 4 PA INVANZ INTRAVENOUS RECON SOLN GRAM 4 PA

12 meropenem intravenous recon soln gram, 500 meropenem-0.9% sodium chloride intravenous piggyback gram/50 ml, 500 /50 ml VABOMERE INTRAVENOUS RECON SOLN GRAM BETA-LACTAM, PENICILLINS amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, gram ampicillin-sulbactam intravenous recon soln.5 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml, gram/00 ml 4

13 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: nafcillin injection recon soln gram, gram nafcillin intravenous recon soln gram, gram penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous recon soln.5 gram piperacillin-tazobactam intravenous recon soln.5 gram,.75 gram, 4.5 gram, 40.5 gram MACROLIDES azithromycin intravenous recon soln 500, 500 ( /ml) azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 50 (6 pack), 500, 500 ( pack), 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 ery pads topical swab % erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 400 4

14 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) erythromycin oral tablet 50, 500 erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % QUINOLONES AVELOX IN NACL (ISO-OSTIC) INTRAVENOUS PIGGYBACK 400 MG/50 ML ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl ophthalmic (eye) drops 0. % ciprofloxacin hcl oral tablet 00 ciprofloxacin hcl oral tablet 50, 500, 750 ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml levofloxacin in d5w intravenous piggyback 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500 levofloxacin oral tablet 750 XEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin in nacl (iso-osm) intravenous piggyback 400 /50 ml moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 moxifloxacin-sod.ace,sul-water intravenous piggyback 400 /50 ml ofloxacin ophthalmic (eye) drops 0. % ofloxacin oral tablet 00, 400 VIGAX OPHTHALMIC (EYE) DROPS 0.5 % SULFONAMIDES silver sulfadiazine topical cream % 4 4

15 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ssd topical cream % sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , TETRACYCLINES demeclocycline oral tablet 50, 00 doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral tablet 00, 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 RGIDOX X 50 KIT 50 MG morgidox oral capsule 50 ANTICONVULSANTS - TREATMENT OF SEIZURES ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML 5

16 BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback,000 /00 ml,,500 /00 ml, 500 /00 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 ROWEEPRA ORAL TABLET,000 MG, 750 MG roweepra oral tablet 500 SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 00 MG 4 ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 00, 5, STQL (60 EA per 0 days) 5 STQL (0 EA per 0 days) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG 4 QL (40 EA per 0 days) 4 QL (0 EA per 0 days) DIASTAT RECTAL KIT.5 MG 4 QL (5 EA per 0 days) diazepam rectal kit QL (40 EA per 0 days)

17 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: diazepam rectal kit.5 QL (5 EA per 0 days) diazepam rectal kit QL (0 EA per 0 days) divalproex oral capsule, delayed rel sprinkle 5 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 gabapentin oral capsule 00, 00, 400 gabapentin oral solution 50 /5 ml, 50 /5 ml (5 ml), 00 /6 ml (6 ml) gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET MG, 6 MG 4 ONFI ORAL SUSPENSION.5 MG/ML 4 PAQL (480 ML per 0 days) ONFI ORAL TABLET 0 MG 4 PAQL (60 EA per 0 days) ONFI ORAL TABLET 0 MG QL (60 EA per 0 days) phenobarbital oral elixir 0 /5 ml (4 /ml) PA phenobarbital oral tablet 00, 5, 6., 0,.4, 60, 64.8, 97. primidone oral tablet 50, 50 PA SABRIL ORAL POWDER IN PACKET 500 MG 4 PA SABRIL ORAL TABLET 500 MG 4 PAQL (80 EA per 0 days) tiagabine oral tablet, 4 valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml, 50 /5 ml (5 ml), 500 /0 ml (0 ml) valproic acid oral capsule 50 vigabatrin oral powder in packet PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5 ml 7

18 felbamate oral tablet 400, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 ST FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 00, 50, 00, 5 lamotrigine oral tablet extended release 4hr 00, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 topiramate oral capsule, sprinkle 5, 5 topiramate oral tablet 00, 00, 5, 50 SODIUM CHANNEL AGENTS 4 STQL (0 EA per 0 days) APTIOM ORAL TABLET 00 MG 4 STQL (0 EA per 0 days) APTIOM ORAL TABLET 400 MG, 800 MG 5 STQL (0 EA per 0 days) APTIOM ORAL TABLET 600 MG 4 STQL (60 EA per 0 days) BANZEL ORAL SUSPENSION 40 MG/ML QL (400 ML per 0 days) BANZEL ORAL TABLET 00 MG 4 PAQL (40 EA per 0 days) BANZEL ORAL TABLET 400 MG QL (40 EA per 0 days) carbamazepine oral capsule, er multiphase hr 00, 00, 00 carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet extended release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 DILANTIN ORAL CAPSULE 0 MG 4 epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG, 00 MG, 00 MG fosphenytoin injection solution 00 pe/ ml, 500 pe/0 ml oxcarbazepine oral suspension 00 /5 ml (60 /ml) 8 4

19 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: oxcarbazepine oral tablet 50, 00, 600 PEGANONE ORAL TABLET 50 MG 4 PHENYTEK ORAL CAPSULE 00 MG, 00 MG phenytoin oral suspension 00 /4 ml, 5 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 00, 00 phenytoin sodium intravenous solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML 5 STQL (00 ML per 0 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA ANTIDEMENTIA AGENTS, OTHER ergoloid oral tablet PA CHOLINESTERASE INHIBITORS donepezil oral tablet 0,, 5 donepezil oral tablet,disintegrating 0, 5 rivastigmine tartrate oral capsule.5,, 4.5, 6 rivastigmine transdermal patch 4 hour. /4 hour, 4.6 /4 hr, 9.5 /4 hr 4 4 STQL (60 EA per 0 days) N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral tablet 0, 5 memantine oral tablets,dose pack 5-0 NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 4 MG, MG, 8 MG, 7 MG 4 ST 4 STQL (0 EA per 0 days) 9

20 ANTIDEPRESSANTS - TREATMENT OF DEPRESSION ANTIDEPRESSANTS, OTHER bupropion hcl (smoking deter) oral tablet extended release hr 50 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release hr 00, 50, 00 bupropion hcl oral tablet extended release 4 hr 50, 00 FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 MG mirtazapine oral tablet 5, 0, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 0, 45 nefazodone oral tablet 00, 50, 00, 50, 50 perphenazine-amitriptyline oral tablet -0, - 5, 4-0, 4-5, 4-50 trazodone oral tablet 00, 50, 00, 50 NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 4 HOUR MG/4 HR, 6 MG/4 HR, 9 MG/4 HR MARPLAN ORAL TABLET 0 MG 4 phenelzine oral tablet 5 tranylcypromine oral tablet 0 SSRIS/ SNRIS citalopram oral solution 0 /5 ml citalopram oral tablet 0, 0, 40 desvenlafaxine succinate oral tablet extended release 4 hr 00, 5, 50 duloxetine oral capsule,delayed release(dr/ec) 0, 0, 60 escitalopram oxalate oral solution 5 /5 ml 4 PA 4 0

21 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: escitalopram oxalate oral tablet 0, 0, 5 FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 0, 0 fluvoxamine oral tablet 00, 5, 50 maprotiline oral tablet 5, 50, 75 paroxetine hcl oral tablet 0, 0, 0, 40 paroxetine hcl oral tablet extended release 4 hr.5, 5, 7.5 PAXIL ORAL SUSPENSION 0 MG/5 ML 4 sertraline oral concentrate 0 /ml sertraline oral tablet 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 50, 7.5, 75 venlafaxine oral tablet 00, 5, 7.5, 50, 75 venlafaxine oral tablet extended release 4hr 50, 5, 7.5, 75 VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 0 MG () 4 ST 4 ST 4 ST 4 ST 4 ST

22 TRICYCLICS amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amoxapine oral tablet 00, 50, 5, 50 PA clomipramine oral capsule 5, 50, 75 PA desipramine oral tablet 0, 00, 50, 5, 50, 75 doxepin oral capsule 0, 00, 50, 5, 50, 75 PA doxepin oral concentrate 0 /ml PA imipramine hcl oral tablet 0, 5, 50 PA imipramine pamoate oral capsule 00, 5, 50, 75 nortriptyline oral capsule 0, 5, 50, 75 nortriptyline oral solution 0 /5 ml protriptyline oral tablet 0, 5 PA trimipramine oral capsule 00, 5, 50 PA ANTIEMETICS - TREATMENT OF VOMITING OR NAUSEA ANTIEMETICS, OTHER chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 0, 00, 00, 5, 50 compro rectal suppository 5 diphenhydramine hcl injection solution 50 /ml PA meclizine oral tablet.5, 5 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 perphenazine oral tablet 6,, 4, 8 phenadoz rectal suppository.5 PA prochlorperazine edisylate injection solution 0 / ml (5 /ml), 5 /ml prochlorperazine maleate oral tablet 0, 5

23 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: prochlorperazine rectal suppository 5 promethazine oral syrup 6.5 /5 ml PA promethazine oral tablet.5, 5, 50 PA promethazine rectal suppository.5, 5 PA promethegan rectal suppository 5, 50 PA scopolamine base transdermal patch day over days TRANSDERM-SCOP TRANSDERMAL PATCH DAY MG OVER DAYS trimethobenzamide oral capsule 00 PA EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 5, 40, 80 B/D aprepitant oral capsule,dose pack 5 ()- 80 () 4 B/D dronabinol oral capsule 0,.5, 5 B/D EMEND ORAL SUSPENSION FOR RECONSTITUTION 5 MG (5 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution /ml ( ml), 00 mcg/ml granisetron hcl intravenous solution /ml, /ml ( ml) 4 B/D B/D B/D granisetron hcl oral tablet B/D ondansetron hcl (pf) injection solution 4 / ml ondansetron hcl (pf) injection syringe 4 / ml ondansetron hcl intravenous solution /ml ondansetron hcl oral solution 4 /5 ml B/D ondansetron hcl oral tablet 4 B/DQL (5 EA per 0 days) ondansetron hcl oral tablet 4, 8 B/D ondansetron oral tablet,disintegrating 4, 8 B/D SYNDROS ORAL SOLUTION 5 MG/ML

24 ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS abelcet intravenous suspension 5 /ml B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 4 B/D amphotericin b injection recon soln 50 B/D CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50, 70 ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrimazole mucous membrane troche 0 clotrimazole topical cream % clotrimazole topical solution % econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /50 ml, 00 /00 ml, 400 /00 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 00, 50 flucytosine oral capsule 50 flucytosine oral capsule 500 griseofulvin microsize oral suspension 5 /5 ml itraconazole oral capsule 00 ketoconazole oral tablet 00 4 PA 4

25 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ketoconazole topical cream % ketoconazole topical shampoo % MENTAX TOPICAL CREAM % 4 MYCAMINE INTRAVENOUS RECON SOLN 00 MG MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 unit/gram nyata topical powder 00,000 unit/gram nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram nystop topical powder 00,000 unit/gram terbinafine hcl oral tablet 50 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) voriconazole oral tablet 00 5 voriconazole oral tablet 50 4 PA 4 PA ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS ANTIGOUT AGENTS allopurinol oral tablet 00, 00 colchicine oral capsule

26 colchicine oral tablet 0.6 probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG ST ANTI-INFLAMMATORY AGENTS - TREATMENT OF INFLAMMATION GLUCOCORTICOIDS ala-cort topical cream %,.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % cormax scalp solution 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.5 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.5 % dexamethasone intensol oral drops /ml 6

27 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75,,.5,, 4, 6 dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, 4 /ml dexamethasone sodium phosphate injection syringe 4 /ml fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluocinonide-e topical cream 0.05 % fluocinonide-emollient topical cream 0.05 % fluticasone topical cream 0.05 % fluticasone topical lotion 0.05 % fluticasone topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0. % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone butyr-emollient topical cream 0. % hydrocortisone topical cream %,.5 % 7

28 hydrocortisone topical cream with perineal applicator % hydrocortisone topical lotion.5 % hydrocortisone topical ointment %,.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6,, 4, 8 methylprednisolone oral tablets,dose pack 4 methylprednisolone sodium succ injection recon soln 5, 40 methylprednisolone sodium succ intravenous recon soln,000 mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % prednisolone sodium phosphate oral solution 5 /5 ml ( /ml), 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml prednisone oral tablet, 0,.5, 0, 5, 50 prednisone oral tablets,dose pack 0, 0 (48 pack) prednisone oral tablets,dose pack 5, 5 (48 pack) RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) MG, MG, 5 MG triamcinolone acetonide topical cream 0.05 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0. % triamcinolone acetonide topical ointment 0.05 %, 0. %, 0.5 % triderm topical cream 0. % 8 4

29 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ANTIMIGRAINE AGENTS - TREATMENT OF MIGRAINE HEADACHES ERGOT ALKALOIDS dihydroergotamine injection solution /ml PA dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. (4 /ml) ergotamine-caffeine oral tablet -00 SEROTONIN (5-HT) B/D RECEPTOR AGONISTS QL (8 ML per 0 days) rizatriptan oral tablet 0, 5 QL ( EA per 0 days) rizatriptan oral tablet,disintegrating 0, 5 QL ( EA per 0 days) sumatriptan nasal spray,non-aerosol 0 /actuation, 5 /actuation sumatriptan succinate oral tablet 00, 5, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml, 6 /0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution 6 /0.5 ml sumatriptan succinate subcutaneous syringe 6 /0.5 ml QL ( EA per 0 days) QL ( EA per 0 days) QL (4 ML per 0 days) QL (4 ML per 0 days) QL (4 ML per 0 days) QL (4 ML per 0 days) ANTIMYASTHENIC AGENTS - TREATMENT OF MYASTHENIA PARASYMPATHOMIMETICS guanidine oral tablet 5 pyridostigmine bromide oral tablet 60 ANTIMYCOBACTERIALS - TREATMENT FOR INFECTIONS BY TUBERCULOSIS- TYPE ORGANISMS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00, 5 rifabutin oral capsule 50 9

30 ANTITUBERCULARS CAPASTAT INJECTION RECON SOLN GRAM ethambutol oral tablet 00, 400 isoniazid injection solution 00 /ml isoniazid oral tablet 00, 00 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG 4 pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 50, 00 RIFATER ORAL TABLET MG 4 SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 50 MG 4 ANTINEOPLASTICS - TREATMENT OF CANCER ALKYLATING AGENTS BICNU INTRAVENOUS RECON SOLN 00 MG PA busulfan intravenous solution 60 /0 ml carboplatin intravenous recon soln 50 B/D carboplatin intravenous solution 0 /ml B/D cisplatin intravenous solution /ml B/D cyclophosphamide oral capsule 5, 50 B/D dacarbazine intravenous recon soln 00 B/D EMCYT ORAL CAPSULE 40 MG 4 PA GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG 4 PA HEXALEN ORAL CAPSULE 50 MG 4 PA ifosfamide intravenous recon soln gram 4 B/D LEUKERAN ORAL TABLET MG MATULANE ORAL CAPSULE 50 MG 4 melphalan hcl intravenous recon soln 50 5 B/D

31 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: MUSTARGEN INJECTION RECON SOLN 0 MG 4 PA oxaliplatin intravenous recon soln 00 B/D oxaliplatin intravenous solution 00 /0 ml B/D TEPADINA INJECTION RECON SOLN 00 MG, 5 MG 5 B/D thiotepa injection recon soln 5 5 B/D TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG VALCHLOR TOPICAL GEL 0.06 % 5 ZANOSAR INTRAVENOUS RECON SOLN GRAM ANTIANDROGENS bicalutamide oral tablet 50 flutamide oral capsule 5 nilutamide oral tablet 50 4 PA XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 50 MG, 500 MG ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE MG, MG, MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG ANTIESTROGENS/DIFIERS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML ; LA 5 4 PA FARESTON ORAL TABLET 60 MG 4 PA FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SOLTAX ORAL SOLUTION 0 MG/5 ML 4

32 tamoxifen oral tablet 0, 0 ANTIMETABOLITES ALIMTA INTRAVENOUS RECON SOLN 500 MG ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML cladribine intravenous solution 0 /0 ml 5 B/D cytarabine (pf) injection solution 00 /5 ml (0 /ml), gram/0 ml (00 /ml), 0 /ml B/D cytarabine injection solution 0 /ml B/D DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG fludarabine intravenous recon soln 50 4 PA fluorouracil intravenous solution gram/0 ml,.5 gram/50 ml, 5 gram/00 ml, 500 /0 ml fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution %, 5 % gemcitabine intravenous recon soln gram, gram, 00 gemcitabine intravenous solution gram/6. ml (8 /ml), gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) 4 B/D 5 B/D 5 B/D gemcitabine intravenous solution 00 /ml B/D hydroxyurea oral capsule 500 mercaptopurine oral tablet 50 NIPENT INTRAVENOUS RECON SOLN 0 MG PURIXAN ORAL SUSPENSION 0 MG/ML 5 TABLOID ORAL TABLET 40 MG 4 PA ANTINEOPLASTICS adriamycin intravenous solution 0 /0 ml B/D docetaxel intravenous solution 0 /ml 4 B/D KADCYLA INTRAVENOUS RECON SOLN 60 MG PICATO TOPICAL GEL 0.05 %, 0.05 %

33 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ANTINEOPLASTICS, OTHER azacitidine injection recon soln 00 BELEODAQ INTRAVENOUS RECON SOLN 500 MG bleomycin injection recon soln 0 unit B/D BORTEZOMIB INTRAVENOUS RECON SOLN.5 MG clofarabine intravenous solution 0 /0 ml dactinomycin intravenous recon soln 0.5 daunorubicin intravenous solution 5 /ml B/D decitabine intravenous recon soln 50 5 B/D dexrazoxane hcl intravenous recon soln 50 4 B/D doxorubicin intravenous solution 50 /5 ml B/D doxorubicin, peg-liposomal intravenous suspension /ml PA epirubicin intravenous solution 00 /00 ml 4 B/D ERWINAZE INJECTION RECON SOLN 0,000 UNIT FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG fludarabine intravenous solution 50 / ml 4 PA FUSILEV INTRAVENOUS RECON SOLN 50 MG HALAVEN INTRAVENOUS SOLUTION MG/ ML (0.5 MG/ML) 5 B/D idarubicin intravenous solution /ml B/D ISTODAX INTRAVENOUS RECON SOLN 0 MG/ ML KADCYLA INTRAVENOUS RECON SOLN 00 MG

34 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG, 400 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG leucovorin calcium injection recon soln 00, 00, 50, 50, 500 leucovorin calcium oral tablet 0, 5, 5, 5 B/D levoleucovorin intravenous recon soln 50 B/D levoleucovorin intravenous solution 0 /ml B/D LONSURF ORAL TABLET MG, MG 4 LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 00 MG, 50 MG mesna intravenous solution 00 /ml B/D MESNEX ORAL TABLET 400 MG 4 mitomycin intravenous recon soln 0, 40, 5 NINLARO ORAL CAPSULE. MG, MG, 4 MG B/D ODOMZO ORAL CAPSULE 00 MG PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT ROMIDEPSIN INTRAVENOUS RECON SOLN 0 MG/ ML RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TOTECT INTRAVENOUS RECON SOLN 500 MG

35 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: TRISENOX INTRAVENOUS SOLUTION 0 MG/0 ML, MG/ML 4 PA VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 0 MG, 50 MG 4 PA VENCLEXTA ORAL TABLET 00 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG vinblastine intravenous solution /ml B/D vincristine intravenous solution /ml B/D vinorelbine intravenous solution 50 /5 ml 4 B/D VYXEOS INTRAVENOUS RECON SOLN MG YONDELIS INTRAVENOUS RECON SOLN MG ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG AROMATASE INHIBITORS, RD GENERATION anastrozole oral tablet exemestane oral tablet 5 letrozole oral tablet.5 ENZYME INHIBITORS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG docetaxel intravenous solution 0 /ml 4 B/D 5

36 docetaxel intravenous solution 60 /6 ml (0 /ml), 60 /8 ml (0 /ml), 0 / ml (0 /ml), 0 /ml ( ml), 80 /4 ml (0 /ml), 80 /8 ml (0 /ml) ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG 4 B/D 4 PA etoposide intravenous solution 0 /ml B/D IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG irinotecan intravenous solution 00 /5 ml 4 B/D JEVTANA INTRAVENOUS SOLUTION 0 MG/ML (FIRST DILUTION) mitoxantrone intravenous concentrate /ml paclitaxel intravenous concentrate 6 /ml B/D topotecan intravenous recon soln 4 topotecan intravenous solution 4 /4 ml ( /ml) LECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 80 MG, 0 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG () BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG CAPRELSA ORAL TABLET 00 MG, 00 MG 6

37 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X), 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG ERIVEDGE ORAL CAPSULE 50 MG GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG ICLUSIG ORAL TABLET 5 MG, 45 MG IDHIFA ORAL TABLET 00 MG, 50 MG imatinib oral tablet 00, 400 PA IMBRUVICA ORAL CAPSULE 40 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) MEKINIST ORAL TABLET 0.5 MG, MG NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG RYDAPT ORAL CAPSULE 5 MG SPRYCEL ORAL TABLET 00 MG, 40 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG 7

38 TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TASIGNA ORAL CAPSULE 50 MG, 00 MG TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (0 MG/ML) (FIRST) TYKERB ORAL TABLET 50 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ZEJULA ORAL CAPSULE 00 MG ZELBORAF ORAL TABLET 40 MG ZYKADIA ORAL CAPSULE 50 MG NOCLONAL ANTIBODIES AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (6 ML) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 0 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML HERCEPTIN INTRAVENOUS RECON SOLN 50 MG, 440 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (0 ML) KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML 8

39 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG ( MG/ML INITIAL CONC) OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML, 40 MG/4 ML PERJETA INTRAVENOUS SOLUTION 40 MG/4 ML (0 MG/ML) RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), 600 MG/.4 ML (0 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML, 0 MG/ML (0 ML) TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) RETINOIDS bexarotene oral capsule 75 5 PANRETIN TOPICAL GEL 0. % PA TARGRETIN TOPICAL GEL % PA tretinoin (chemotherapy) oral capsule 0 5 ANTIPARASITICS - TREATMENT OF INFECTIONS FROM PARASITES ANTHELMINTICS ALBENZA ORAL TABLET 00 MG 4 benznidazole oral tablet 00,.5 4 PA BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG 4 4 9

40 atovaquone oral suspension 750 /5 ml 5 atovaquone-proguanil oral tablet 50-00, chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-0 MG 4 DARAPRIM ORAL TABLET 5 MG 4 hydroxychloroquine oral tablet 00 mefloquine oral tablet 50 NEBUPENT INHALATION RECON SOLN 00 MG 40 4 B/D PENTAM INJECTION RECON SOLN 00 MG 4 PA PRIMAQUINE ORAL TABLET 6. MG 4 quinine sulfate oral capsule 4 PEDICULICIDES/ SCABICIDES lindane topical shampoo % malathion topical lotion 0.5 % permethrin topical cream 5 % ANTIPARKINSON AGENTS - TREATMENT OF PARKINSON'S DISEASE ANTICHOLINERGICS benztropine oral tablet 0.5,, PA trihexyphenidyl oral elixir 0.4 /ml PA trihexyphenidyl oral tablet, 5 PA ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML entacapone oral tablet 00 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 4HR 7 MG, 68.5 MG tolcapone oral tablet 00 DOPAMINE AGONISTS

41 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: bromocriptine oral capsule 5 bromocriptine oral tablet.5 NEUPRO TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, MG/4 HOUR, MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 pramipexole oral tablet extended release 4 hr 0.75, 0.75,.5,.5,,.75, 4.5 ropinirole oral tablet 0.5, 0.5,,,, 4, 5 4 PA DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, NOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline oral tablet 0.5, selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS - TREATMENT OF BEHAVIORAL AND ETIONAL DISORDERS ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet, 0,.5, 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml 4

42 haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 0,, 0, 5 loxapine succinate oral capsule 0 QL (0 EA per 0 days) loxapine succinate oral capsule 5, 50 loxapine succinate oral capsule 5 QL (90 EA per 0 days) pimozide oral tablet, thioridazine oral tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 trifluoperazine oral tablet, 0,, 5 ND GENERATION/ ATYPICAL abilify maintena intramuscular suspension,extended rel recon 00 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG abilify maintena intramuscular suspension,extended rel syring 00, PA QL ( EA per 8 days) QL ( EA per 8 days) QL ( EA per 8 days) aripiprazole oral solution /ml 5 QL (900 ML per 0 days) aripiprazole oral tablet 0, 5,, 0, 0, 5 aripiprazole oral tablet,disintegrating 0, 5 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING,064 MG/.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/. ML QL (0 EA per 0 days) 5 QL (60 EA per 0 days) QL (.9 ML per 56 days) QL (.6 ML per 8 days) QL (.4 ML per 8 days) QL (. ML per 8 days)

43 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: FANAPT ORAL TABLET MG, MG, 4 MG 4 STQL (60 EA per 0 days) FANAPT ORAL TABLET 0 MG, MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK MG()-MG()- 4MG()-6MG() GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 4 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 40 MG/.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 MG/.65 ML LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG, 80 MG 5 STQL (60 EA per 0 days) 4 ST 4 PAQL ( EA per 0 days) QL (0.75 ML per 8 days) QL ( ML per 8 days) QL (.5 ML per 8 days) PAQL (0.5 ML per 8 days) QL (0.5 ML per 8 days) QL (0.875 ML per 84 days) QL (.5 ML per 84 days) QL (.75 ML per 84 days) QL (.65 ML per 84 days) 5 STQL (0 EA per 0 days) NUPLAZID ORAL TABLET 7 MG QL (60 EA per 0 days) olanzapine intramuscular recon soln 0 QL (90 EA per 0 days) olanzapine oral tablet 0, 5,.5, 0, 5, 7.5 olanzapine oral tablet,disintegrating 0, 5, 0, 5 QL (0 EA per 0 days) QL (0 EA per 0 days) 4

44 paliperidone oral tablet extended release 4hr.5,, 9 paliperidone oral tablet extended release 4hr 6 quetiapine oral tablet 00, 00, 00, 400 PAQL (0 EA per 0 days) PAQL (60 EA per 0 days) QL (60 EA per 0 days) quetiapine oral tablet 5, 50 QL (90 EA per 0 days) quetiapine oral tablet extended release 4 hr 50, 00 quetiapine oral tablet extended release 4 hr 00, 400, 50 REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 5 MG/ ML, 7.5 MG/ ML, 50 MG/ ML RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, MG RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING MG, MG, 4 MG QL (0 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) PAQL ( EA per 8 days) QL ( EA per 8 days) 4 QL (60 EA per 0 days) 5 QL (60 EA per 0 days) risperidone oral solution /ml QL (40 ML per 0 days) risperidone oral tablet 0.5, 0.5,,,, 4 risperidone oral tablet,disintegrating 0.5, 0.5,,,, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG,.5 MG, 5 MG VRAYLAR ORAL CAPSULE.5 MG, MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- MG (6) ziprasidone hcl oral capsule 0, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 0 MG, 00 MG QL (60 EA per 0 days) QL (60 EA per 0 days) QL (60 EA per 0 days) 5 STQL (0 EA per 0 days) 4 STQL (8 EA per 8 days) QL (60 EA per 0 days) QL ( EA per 8 days) 44

45 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG TREATMENT-RESISTANT QL ( EA per 8 days) clozapine oral tablet 00 QL (70 EA per 0 days) clozapine oral tablet 00 QL (0 EA per 0 days) clozapine oral tablet 5, 50 QL (90 EA per 0 days) clozapine oral tablet,disintegrating 00 QL (70 EA per 0 days) clozapine oral tablet,disintegrating.5, 5 clozapine oral tablet,disintegrating 50 QL (80 EA per 0 days) clozapine oral tablet,disintegrating 00 QL (0 EA per 0 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 QL (540 ML per 0 days) ANTISPASTICITY AGENTS - TREATMENT OF MUSCLE SPASMS ANTISPASTICITY AGENTS baclofen oral tablet 0, 0 COMFORT PAC-TIZANIDINE KIT 4 MG dantrolene oral capsule 00, 5, 50 tizanidine oral tablet, 4 ANTIVIRALS - TREATMENT OF INFECTIONS BY VIRUSES ANTI-CYTOMEGALOVIRUS (CMV) AGENTS cidofovir intravenous solution 75 /ml ganciclovir sodium intravenous recon soln 500 B/D PREVYMIS INTRAVENOUS SOLUTION 40 MG/ ML, 480 MG/4 ML PREVYMIS ORAL TABLET 40 MG, 480 MG valganciclovir oral recon soln 50 /ml 4 valganciclovir oral tablet ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % 4 ST ANTI-HEPATITIS B (HBV) AGENTS 45

46 ADEFOVIR ORAL TABLET 0 MG 4 PA BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 4 EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML lamivudine oral solution 0 /ml PA 4 PA lamivudine oral tablet 00 QL (0 EA per 0 days) lamivudine oral tablet 50 QL (60 EA per 0 days) lamivudine oral tablet 00 QL (0 EA per 0 days) tenofovir disoproxil fumarate oral tablet 00 VEMLIDY ORAL TABLET 5 MG 5 VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG, 00 MG ANTI-HEPATITIS C (HCV) AGENTS EPCLUSA ORAL TABLET MG MAVYRET ORAL TABLET MG PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 5 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML 5 5 ribavirin oral capsule 00 PA ribavirin oral tablet 00 PA VOSEVI ORAL TABLET MG ZEPATIER ORAL TABLET MG ANTIHERPETIC AGENTS acyclovir oral capsule 00