2018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

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1 Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order by therapeutic class. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). Some medications may be excluded as determined by benefit. MPC Effective /1/018

2 PHP Individual and Family Metal Group Plans/ Employer Group Metal Plans Formulary lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs 018 Drug Name Tier Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** guanfacine hcl er oral tablet extended release 4 hour 1,,, 4 *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule 10, 100, 18, 5, 40, 60, 80 *ANALEPTICS*** caffeine citrate intravenous solution 60 /ml caffeine citrate oral solution 0 /ml *ANOREXIANTS NON-AMPHETAMINE*** phendimetrazine tartrate er oral capsule extended release 4 hour 105 QL (0 EA per 0 days) 4 ST; QL (0 EA per 0 days) 4 ; QL (0 EA per 0 days) phendimetrazine tartrate oral tablet 5 4 ; QL (90 EA per 0 days) phentermine hcl oral capsule 15, 0, *AMINOGLYCOSIDES* *AMINOGLYCOSIDES*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 50 tobramycin inhalation nebulization solution 00 /5ml *ANALGESICS - ANTI-INFLAMMATORY* *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 5 SP 5 ; SP 5 ; SP 5 ; SP 5 ; SP MPC0184 Effective /1/018

3 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.ML, 0 MG/0.4ML, 40 MG/0.8ML *ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.ML, 0 MG/0.4ML, 40 MG/0.8ML *CYCLOOXYGENASE (COX-) INHIBITORS*** celecoxib oral capsule 100, 00, 400, 50 *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE MG *INTERLEUKIN-6 RECEPTOR INHIBITORS*** ACTEMRA INTRAVENOUS SOLUTION 00 MG/10ML, 400 MG/0ML, 80 MG/4ML ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 16 MG/0.9ML *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** diclofenac-misoprostol oral tablet delayed release 50-0., *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** diclofenac sodium er oral tablet extended release 4 hour 100 diclofenac sodium oral tablet delayed release 5, 50, 75 etodolac er oral tablet extended release 4 hour 400, 500, 600 etodolac oral capsule 00, 00 etodolac oral tablet 400, 500 FENOPROFEN CALCIUM ORAL TABLET 600 MG flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 400, 600, ; SP 5 ; SP 5 ; SP 5 ; SP 5 ; SP 5 ; SP 4 QL (60 EA per 0 days) ; SP 5 ; SP; QL (.6 ML per 0 days) 4 MPC0184 Effective /1/018

4 indomethacin er oral capsule extended release 75 indomethacin oral capsule 5, 50 ketoprofen oral capsule 75 ketorolac tromethamine oral tablet 10 QL (0 EA per 0 days) meclofenamate sodium oral capsule 100 MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 75, 500 naproxen oral tablet 50, 75, 500 naproxen sodium oral tablet 75, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 0 sulindac oral tablet 150, 00 TOLMETIN SODIUM ORAL CAPSULE 400 MG TOLMETIN SODIUM ORAL TABLET 600 MG *PYRIMIDINE SYNTHESIS INHIBITORS*** leflunomide oral tablet 10, 0 *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 15 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 15 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *ANALGESICS-SEDATIVES*** 5 ; SP; QL (4 ML per 8 days) 5 ; SP; QL (4 ML per 8 days) 5 ; SP 5 ; SP butalbital-acetaminophen oral tablet 50-5 QL (1 EA per 1 day) butalbital-apap-caffeine oral tablet QL (6 EA per 1 day) *SALICYLATES*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** MPC Effective /1/018

5 acetaminophen-codeine # oral tablet acetaminophen-codeine # oral tablet 00-0 acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution 10-1 /5ml acetaminophen-codeine oral tablet butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *OPIOID AGONISTS*** NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG tramadol hcl er (biphasic) oral tablet extended release 4 hour 100 tramadol hcl er (biphasic) oral tablet extended release 4 hour 00 tramadol hcl er oral tablet extended release 4 hour 100 tramadol hcl er oral tablet extended release 4 hour 00 tramadol hcl oral tablet 50 *OPIOID COMBINATIONS*** QL (1 EA per 1 day); AG (Min 1 Years) QL (1 EA per 1 day); AG (Min 1 Years) QL (1 EA per 1 day); AG (Min 1 Years) QL (166 ML per 1 day); AG (Min 1 Years) QL (1 EA per 1 day); AG (Min 1 Years) QL (6 EA per 1 day); AG (Min 1 Years) QL (6 EA per 1 day); AG (Min 1 Years) 4 ; QL (60 EA per 0 days) QL (90 EA per 0 days); AG (Min 1 Years) QL (0 EA per 0 days); AG (Min 1 Years) QL (90 EA per 0 days); AG (Min 1 Years) QL (0 EA per 0 days); AG (Min 1 Years) QL (40 EA per 0 days); AG (Min 1 Years) endocet oral tablet.5-5 QL (1 EA per 1 day) oxycodone-acetaminophen oral solution 5-5 /5ml *OPIOID RTIAL AGONISTS*** buprenorphine hcl sublingual tablet sublingual 4 ; QL (90 EA per 0 days) buprenorphine hcl sublingual tablet sublingual 8 4 ; QL (60 EA per 0 days) buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5, 8- QL (90 EA per 0 days) butorphanol tartrate nasal solution 10 /ml 4 QL (10 ML per 0 days) nalbuphine hcl injection solution 10 /ml SUBOXONE SUBLINGUAL FILM 1- MG 4 SUBOXONE SUBLINGUAL FILM -0.5 MG, 4-1 MG, 8- MG *TRAMADOL COMBINATIONS*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *ANDROGENS*** 4 QL (60 EA per 0 days); AG (Min 16 Years) QL (90 EA per 0 days); AG (Min 16 Years) QL (00 EA per 0 days); AG (Min 1 Years) MPC Effective /1/018

6 ANDRODERM TRANSDERMAL TCH 4 HOUR MG/4HR, 4 MG/4HR ANDROGEL PUMP TRANSDERMAL GEL 0.5 MG/ACT (1.6%) ANDROGEL TRANSDERMAL GEL 40.5 MG/.5GM (1.6%) danazol oral capsule 100, 00, 50 testosterone cypionate intramuscular solution 100 /ml, 00 /ml testosterone enanthate intramuscular solution 00 /ml 4 ; QL (60 EA per 0 days) ; QL (00 GM per 0 days) ; QL (150 GM per 0 days) testosterone transdermal gel 10 /act (%) 4 ; QL (10 GM per 0 days) *ANORECTAL AGENTS* *INTRARECTAL STEROIDS*** CORTIFOAM RECTAL FOAM 10 % 4 hydrocortisone rectal enema 100 /60ml *RECTAL ANESTHETIC/STEROIDS*** hydrocortisone ace-pramoxine rectal cream 1-1 % lidocaine-hydrocortisone ace rectal cream -0.5 % *RECTAL STEROIDS*** hydrocortisone rectal cream.5 % proctocare-hc rectal cream.5 % procto-med hc rectal cream.5 % PROCTOSOL HC RECTAL CREAM.5 % proctozone-hc rectal cream.5 % *ANTHELMINTICS* *ANTHELMINTICS*** ALBENZA ORAL TABLET 00 MG 4 BILTRICIDE ORAL TABLET 600 MG 4 ivermectin oral tablet 4 QL (1 EA per 10 days) *ANTIANGINAL AGENTS* *ANTIANGINALS-OTHER*** RANEXA ORAL TABLET EXTENDED RELEASE 1 HOUR 1000 MG, 500 MG *NITRATES*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG ISOSORBIDE DINITRATE ER ORAL TABLET EXTENDED RELEASE 40 MG isosorbide dinitrate oral tablet 10, 0, 0, 5 isosorbide mononitrate er oral tablet extended release 4 hour 10, 0, 60 4 ST MPC Effective /1/018

7 isosorbide mononitrate oral tablet 10, 0 MINITRAN TRANSDERMAL TCH 4 HOUR 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin er oral capsule extended release.5, 6.5, 9 nitroglycerin transdermal patch 4 hour 0.1 /hr, 0. /hr, 0.4 /hr, 0.6 /hr *ANTIANXIETY AGENTS* *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral tablet 10, 15, 0, 5, 7.5 hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 5, 50 hydroxyzine pamoate oral capsule 100, 5, 50 meprobamate oral tablet 00, 400 *BENZODIAZEPINES*** alprazolam oral tablet 0.5, 0.5, 1 QL (90 EA per 0 days) alprazolam oral tablet QL (15 EA per 0 days) chlordiazepoxide hcl oral capsule 10, 5, 5 QL (10 EA per 0 days) clorazepate dipotassium oral tablet 15 QL (180 EA per 0 days) clorazepate dipotassium oral tablet.75, 7.5 QL (90 EA per 0 days) diazepam oral tablet 10,, 5 QL (10 EA per 0 days) lorazepam injection solution /ml, 4 /ml QL (.5 ML per 1 day) lorazepam oral concentrate /ml QL (150 ML per 0 days) lorazepam oral tablet 0.5, 1, QL (90 EA per 0 days) oxazepam oral capsule 10, 15, 0 QL (10 EA per 0 days) *ANTIARRHYTHMICS* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral capsule 100, 150 quinidine gluconate er oral tablet extended release 4 QUINIDINE SULFATE ORAL TABLET 00 MG, 00 MG *ANTIARRHYTHMICS TYPE I-B*** mexiletine hcl oral capsule 150, 00, 50 *ANTIARRHYTHMICS TYPE I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 5, 00 *ANTIARRHYTHMICS TYPE III*** amiodarone hcl intravenous solution 150 /ml MPC Effective /1/018

8 amiodarone hcl oral tablet 00, 400 MULTAQ ORAL TABLET 400 MG 4 ; QL (60 EA per 0 days) TIKOSYN ORAL CAPSULE 15 MCG, 50 MCG, 500 MCG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-LIPOXYGENASE INHIBITORS*** zileuton er oral tablet extended release 1 hour 600 *ADRENERGIC COMBINATIONS*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, 0-1 MCG/ACT, 45-1 MCG/ACT ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, 00-5 MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, -14 mcg/act, mcg/act ipratropium-albuterol inhalation solution () /ml SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT *ANTI-INFLAMMATORY AGENTS*** cromolyn sodium inhalation nebulization solution 0 /ml *BETA ADRENERGICS*** albuterol sulfate er oral tablet extended release 1 hour 4, 8 albuterol sulfate inhalation nebulization solution (.5 /ml) 0.08%, (5 /ml) 0.5%, 0.6 /ml, 1.5 /ml albuterol sulfate oral syrup /5ml albuterol sulfate oral tablet, 4 isoproterenol hcl injection solution 0. /ml 4 5 ; SP; QL (10 EA per 0 days) 4 ST; QL (60 EA per 0 days) 4 ST; QL (1 GM per 0 days) 4 ST 4 QL (4 GM per 0 days) 4 ST; QL (1 GM per 0 days) ST; QL (1 EA per 0 days) ST; QL (7 GM per 0 days) ST; QL (6.9 GM per 0 days) levalbuterol tartrate inhalation aerosol 45 mcg/act 4 ST; QL (0 GM per 0 days) METAPROTERENOL SULFATE ORAL SYRUP 10 MG/5ML MPC Effective /1/018

9 METAPROTERENOL SULFATE ORAL TABLET 10 MG, 0 MG SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.0 % SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.5 MCG/ACT *LEUKOTRIENE RECEPTOR ANTAGONISTS*** montelukast sodium oral tablet 10 QL (0 EA per 0 days) montelukast sodium oral tablet chewable 4, 5 QL (0 EA per 0 days) zafirlukast oral tablet 10, 0 *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** DALIRESP ORAL TABLET 500 MCG ; QL (0 EA per 0 days) *STEROID INHALANTS*** ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT ALVESCO INHALATION AEROSOL SOLUTION 80 MCG/ACT ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 0 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 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 00 MCG/ACT 4 ST; QL (1. GM per 0 days) 4 ST; QL (6.1 GM per 0 days) QL (1 GM per 0 days) MPC Effective /1/018

10 budesonide inhalation suspension 0.5 /ml, 0.5 /ml QL (10 ML per 0 days); AG (Max 1 Years) budesonide inhalation suspension 1 /ml 5 ; QL (60 ML per 0 days) 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, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *XANTHINES*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 4 THEOCHRON ORAL TABLET EXTENDED RELEASE 1 HOUR 00 MG theophylline er oral tablet extended release 1 hour 100, 00, 00, 450 theophylline er oral tablet extended release 4 hour 400, 600 *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** warfarin sodium oral tablet 1, 10,,.5,, 4, 5, 6, 7.5 *DIRECT FACTOR XA INHIBITORS*** 4 4 XARELTO ORAL TABLET 10 MG, 0 MG QL (0 EA per 0 days) XARELTO ORAL TABLET 15 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 0 MG *HERINS AND HERINOID-LIKE AGENTS*** heparin sodium (porcine) injection solution unit/ml, 5000 unit/ml heparin sodium lock flush intravenous solution 100 unit/ml *LOW MOLECULAR WEIGHT HERINS*** FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/0.ML, 7500 UNIT/0.ML *SYNTHETIC HERINOID-LIKE AGENTS*** fondaparinux sodium subcutaneous solution 10 /0.8ml,.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml QL (51 EA per 90 days) 5 ; QL (0 ML per 0 days) 5 MPC Effective /1/018

11 *THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE*** PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG *ANTICONVULSANTS* *ANTICONVULSANTS - BENZODIAZEPINES*** 4 ; QL (60 EA per 0 days) clonazepam oral tablet 0.5, 1, QL (90 EA per 0 days) clonazepam oral tablet dispersible 0.15, 0.5, 0.5, 1, QL (90 EA per 0 days) diazepam rectal gel 10,.5, 0 ST; QL (5 EA per 0 days) *ANTICONVULSANTS - MISC.*** carbamazepine er oral capsule extended release 1 hour 100, 00, 00 carbamazepine er oral tablet extended release 1 hour 100, 00, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 00 carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 00, 400 gabapentin oral solution 50 /5ml gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet chewable 5, 5 levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 50, 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG oxcarbazepine oral suspension 00 /5ml oxcarbazepine oral tablet 150, 00, 600 primidone oral tablet 50, 50 topiramate oral capsule sprinkle 15, 5 topiramate oral tablet 100, 00, 5, 50 4 ; QL (90 EA per 0 days) VIMT ORAL SOLUTION 10 MG/ML 5 ST; QL (100 ML per 0 days) VIMT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG zonisamide oral capsule 100, 5, 50 *CARBAMATES*** felbamate oral suspension 600 /5ml 4 felbamate oral tablet 400, ST; QL (60 EA per 0 days) MPC Effective /1/018

12 *GABA MODULATORS*** GABITRIL ORAL TABLET 1 MG, 16 MG 4 tiagabine hcl oral tablet, 4 4 *HYDANTOINS*** DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG DILANTIN ORAL CAPSULE 0 MG 4 fosphenytoin sodium injection solution 100 pe/ml, 500 pe/10ml phenytoin oral suspension 15 /5ml phenytoin sodium extended oral capsule 100, 00, 00 *SUCCINIMIDES*** ethosuximide oral capsule 50 ethosuximide oral solution 50 /5ml *VALPROIC ACID*** divalproex sodium er oral tablet extended release 4 hour 50, 500 divalproex sodium oral tablet delayed release 15, 50, 500 valproic acid oral capsule 50 *ANTIDEPRESSANTS* *ALPHA- RECEPTOR ANTAGONISTS (TETRACYCLICS)*** mirtazapine oral tablet 15, 0, 45 1 QL (0 EA per 0 days) mirtazapine oral tablet dispersible 15, 0, 45 *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) oral tablet extended release 1 hour 100, 150, 00 bupropion hcl er (xl) oral tablet extended release 4 hour 150 bupropion hcl er (xl) oral tablet extended release 4 hour 00 bupropion hcl oral tablet 100, 75 MAPROTILINE HCL ORAL TABLET 5 MG, 50 MG, 75 MG *MODIFIED CYCLICS*** nefazodone hcl oral tablet 100, 150, 00, 50 trazodone hcl oral tablet 100, 150, 00, 50 4 QL (60 EA per 0 days) QL (90 EA per 0 days) QL (0 EA per 0 days) VIIBRYD ORAL TABLET 10 MG, 0 MG, 40 MG 4 ; QL (0 EA per 0 days) 4 MPC Effective /1/018

13 *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** EMSAM TRANSDERMAL TCH 4 HOUR 1 MG/4HR, 6 MG/4HR, 9 MG/4HR phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** 5 ; QL (0 EA per 0 days) citalopram hydrobromide oral solution 10 /5ml QL (600 ML per 0 days) citalopram hydrobromide oral tablet 10, 0 1 QL (60 EA per 0 days) citalopram hydrobromide oral tablet 40 1 QL (0 EA per 0 days) escitalopram oxalate oral solution 5 /5ml QL (600 ML per 0 days) escitalopram oxalate oral tablet 10 QL (45 EA per 0 days) escitalopram oxalate oral tablet 0, 5 QL (0 EA per 0 days) fluoxetine hcl oral capsule 10, 0, 40 1 fluoxetine hcl oral solution 0 /5ml fluvoxamine maleate oral tablet 100, 5, 50 paroxetine hcl er oral tablet extended release 4 hour 1.5 paroxetine hcl er oral tablet extended release 4 hour 5, 7.5 ST; QL (0 EA per 0 days) ST paroxetine hcl oral tablet 10, 0, 0 1 QL (0 EA per 0 days) paroxetine hcl oral tablet 40 1 QL (45 EA per 0 days) XIL ORAL SUSPENSION 10 MG/5ML QL (450 ML per 0 days) sertraline hcl oral concentrate 0 /ml sertraline hcl oral tablet 100, 5 1 QL (60 EA per 0 days) sertraline hcl oral tablet 50 1 QL (45 EA per 0 days) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** desvenlafaxine succinate er oral tablet extended release 4 hour 100, 5, 50 duloxetine hcl oral capsule delayed release particles 0, 0 duloxetine hcl oral capsule delayed release particles 60 venlafaxine hcl er oral capsule extended release 4 hour 150, 7.5 venlafaxine hcl er oral capsule extended release 4 hour 75 venlafaxine hcl oral tablet 100, 5, 7.5, 50, 75 *TRICYCLIC AGENTS*** amitriptyline hcl oral tablet 10, 100, 150, 5, 50, 75 4 ; QL (0 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) QL (60 EA per 0 days) QL (90 EA per 0 days) MPC Effective /1/018

14 amoxapine oral tablet 100, 150, 5, 50 clomipramine hcl oral capsule 5, 50, 75 desipramine hcl oral tablet 10, 100, 150, 5, 50, 75 doxepin hcl oral capsule 10, 100, 150, 5, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 5, 50 nortriptyline hcl oral capsule 10, 5, 50, 75 *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose oral tablet 100, 5, 50 1 *ANTIDIABETIC - AMYLIN ANALOGS*** SYMLINPEN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR 700 MCG/.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR 1500 MCG/1.5ML *BIGUANIDES*** metformin hcl er oral tablet extended release 4 hour 500 metformin hcl er oral tablet extended release 4 hour 750 metformin hcl oral tablet 1000, 500, *DIABETIC OTHER*** GLUCAGON EMERGENCY INJECTION KIT 1 MG *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** alogliptin benzoate oral tablet 1.5, 5, ST; QL (0 EA per 0 days) JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG ST; QL (0 EA per 0 days) ONGLYZA ORAL TABLET.5 MG, 5 MG 4 ; QL (0 EA per 0 days) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR- BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl oral tablet , ST; QL (60 EA per 0 days) JANUMET ORAL TABLET MG, MG ST; QL (60 EA per 0 days) JANUMET XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG ST; QL (0 EA per 0 days) ST; QL (60 EA per 0 days) 4 ; QL (60 EA per 0 days) 4 ; QL (0 EA per 0 days) MPC Effective /1/018

15 *HUMAN INSULIN*** APIDRA INJECTION SOLUTION 100 UNIT/ML 4 QL (50 ML per 0 days) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/5 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-5) 100 UNIT/ML HUMALOG MIX 75/5 SUBCUTANEOUS SUSPENSION (75-5) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML 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 NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/0 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-0) 100 UNIT/ML NOVOLOG MIX 70/0 SUBCUTANEOUS SUSPENSION (70-0) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/ML *MEGLITINIDE ANALOGUES*** nateglinide oral tablet 10, 60 1 repaglinide oral tablet 0.5, 1, 4 *SODIUM-GLUCOSE CO-TRANSPORTER (SGLT) INHIBITORS*** 4 ST; QL (45 ML per 0 days) 4 ST; QL (45 ML per 0 days) 4 ST; QL (50 ML per 0 days) 4 ST; QL (45 ML per 0 days) 4 ST; QL (50 ML per 0 days) 4 ST; QL (50 ML per 0 days) 4 ST; QL (50 ML per 0 days) 5 ST; QL (0 ML per 0 days) QL (45 ML per 0 days) QL (50 ML per 0 days) QL (45 ML per 0 days) QL (50 ML per 0 days) QL (45 ML per 0 days) QL (45 ML per 0 days) QL (50 ML per 0 days) QL (45 ML per 0 days) QL (50 ML per 0 days) 4 ST; QL ( ML per 8 days) ST; QL (9 ML per 0 days) MPC Effective /1/018

16 FARXIGA ORAL TABLET 10 MG, 5 MG ST; QL (0 EA per 0 days) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** glipizide-metformin hcl oral tablet.5-50 glipizide-metformin hcl oral tablet.5-500, glyburide-metformin oral tablet , glyburide-metformin oral tablet *SULFONYLUREAS*** CHLORPROMIDE ORAL TABLET 100 MG chlorpropamide oral tablet 50 glimepiride oral tablet 1,, 4 1 glipizide er oral tablet extended release 4 hour 10,.5, 5 glipizide oral tablet 10, 5 1 glyburide micronized oral tablet 1.5,, 6 1 glyburide oral tablet 1.5,.5, 5 1 TOLAZAMIDE ORAL TABLET 50 MG, 500 MG TOLBUTAMIDE ORAL TABLET 500 MG *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride oral tablet 0-, 0-4 *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** pioglitazone hcl-metformin hcl oral tablet , *THIAZOLIDINEDIONES*** 1 1 ST ST AVANDIA ORAL TABLET MG, 4 MG 4 ST pioglitazone hcl oral tablet 15, 0, 45 ST; QL (0 EA per 0 days) *ANTIDIARRHEALS* *ANTIPERISTALTIC AGENTS*** DIPHENOXYLATE-ATROPINE ORAL LIQUID MG/5ML diphenoxylate-atropine oral tablet *ANTIDOTES* *OPIOID ANTAGONISTS*** naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML *ANTIEMETICS* *5-HT RECEPTOR ANTAGONISTS*** MPC Effective /1/018

17 ANZEMET ORAL TABLET 100 MG, 50 MG 4 ; QL (4 EA per 0 days) granisetron hcl oral tablet 1 ST; QL (0 EA per 0 days) ondansetron hcl injection solution 4 /ml ondansetron hcl oral solution 4 /5ml AG (Max 4 Years) ondansetron hcl oral tablet 4, 8 QL (90 EA per 0 days) ondansetron oral tablet dispersible 4, 8 QL (90 EA per 0 days) *ANTIEMETICS - ANTICHOLINERGIC*** meclizine hcl oral tablet 5 scopolamine transdermal patch 7 hour 1 /days 4 trimethobenzamide hcl oral capsule 00 *ANTIFUNGALS* *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** caspofungin acetate intravenous solution reconstituted 50, 70 *ANTIFUNGALS*** BIO-STATIN ORAL CAPSULE UNIT griseofulvin microsize oral suspension 15 /5ml griseofulvin ultramicrosize oral tablet 15 4 GRIS-PEG ORAL TABLET 50 MG 4 nystatin oral tablet unit terbinafine hcl oral tablet 50 QL (90 EA per 65 days) *IMIDAZOLES*** ketoconazole oral tablet 00 *TRIAZOLES*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 00, 50 itraconazole oral capsule ST; QL (168 EA per 65 days) voriconazole oral suspension reconstituted 40 /ml 5 voriconazole oral tablet 00, 50 5 ; QL (60 EA per 0 days) *ANTIHISTAMINES* *ANTIHISTAMINES - ETHANOLAMINES*** carbinoxamine maleate oral tablet 4 4 diphenhydramine hcl oral elixir 1.5 /5ml *ANTIHISTAMINES - NON-SEDATING*** desloratadine oral tablet 5 4 levocetirizine dihydrochloride oral solution.5 /5ml 4 levocetirizine dihydrochloride oral tablet 5 4 MPC Effective /1/018

18 *ANTIHISTAMINES - PHENOTHIAZINES*** promethazine hcl injection solution 5 /ml, 50 /ml promethazine hcl oral syrup 6.5 /5ml promethazine hcl oral tablet 1.5, 5, 50 promethazine hcl rectal suppository 1.5, 5, 50 promethegan rectal suppository 5 PROMETHEGAN RECTAL SUPPOSITORY 50 MG *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral syrup /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *ANTIHYPERLIPIDEMICS - MISC.*** omega--acid ethyl esters oral capsule 1 gm 4 QL (10 EA per 0 days) *BILE ACID SEQUESTRANTS*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose colestipol hcl oral tablet 1 gm 4 prevalite oral packet 4 gm PREVALITE ORAL POWDER 4 GM/DOSE WELCHOL ORAL CKET.75 GM WELCHOL ORAL TABLET 65 MG *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 14, 00, 67 fenofibrate oral tablet 145, 160, 48, 54 gemfibrozil oral tablet 600 *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral tablet 10, 0, 40, 80 fluvastatin sodium oral capsule 0, 40 4 LIVALO ORAL TABLET 1 MG, MG, 4 MG 4 ST pravastatin sodium oral tablet 10, 0, 40, 80 rosuvastatin calcium oral tablet 10, 0, 40, 5 *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** 1 QL (0 EA per 0 days) 1 MPC Effective /1/018

19 ezetimibe-simvastatin oral tablet 10-10, 10-0, 10-40, *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** ezetimibe oral tablet 10 *NICOTINIC ACID DERIVATIVES*** niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 *ANTIHYPERTENSIVES* *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl oral capsule 10-0, 10-40,.5-10, 5-10, 5-0, 5-40 *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril-hydrochlorothiazide oral tablet , 0-1.5, 0-5, CAPTOPRIL-HYDROCHLOROTHIAZIDE ORAL TABLET 5-15 MG, 5-5 MG, MG, 50-5 MG enalapril-hydrochlorothiazide oral tablet 10-5, fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , 0-1.5, 0-5 moexipril-hydrochlorothiazide oral tablet , 15-5, quinapril-hydrochlorothiazide oral tablet , 0-1.5, 0-5 *ACE INHIBITORS*** benazepril hcl oral tablet 10, 0, 40, 5 1 captopril oral tablet 100, 1.5, 5, 50 1 enalapril maleate oral tablet 10,.5, 0, 5 fosinopril sodium oral tablet 10, 0, 40 lisinopril oral tablet 10,.5, 0, 0, 40, 5 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet, 4, 8 4 quinapril hcl oral tablet 10, 0, 40, 5 ramipril oral capsule 1.5, 10,.5, 5 trandolapril oral tablet 1,, 4 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE*** MPC Effective /1/018

20 candesartan cilexetil-hctz oral tablet , - 1.5, -5 losartan potassium-hctz oral tablet , 100-5, olmesartan medoxomil-hctz oral tablet 0-1.5, , 40-5 valsartan-hydrochlorothiazide oral tablet , 160-5, 0-1.5, 0-5, *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil oral tablet 16,, 4, 8 losartan potassium oral tablet 100, 5, 50 olmesartan medoxomil oral tablet 0, 40, 5 4 telmisartan oral tablet 0, 40, 80 4 ST; QL (0 EA per 0 days) valsartan oral tablet 160, 0, 40, 80 4 *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral tablet 0.1, 0., 0. 1 clonidine hcl transdermal patch weekly 0.1 /4hr, 0. /4hr, 0. /4hr guanfacine hcl oral tablet 1, 1 methyldopa oral tablet 50, *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate oral tablet 1,, 4, 8 prazosin hcl oral capsule 1,, 5 terazosin hcl oral capsule 1, 10,, 5 *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone oral tablet 100-5, 50-5 bisoprolol-hydrochlorothiazide oral tablet ,.5-6.5, metoprolol-hydrochlorothiazide oral tablet 100-5, , 50-5 PROPRANOLOL-HCTZ ORAL TABLET 40-5 MG, 80-5 MG tenoretic 100 oral tablet tenoretic 50 oral tablet 50-5 *DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB*** TEKTURNA HCT ORAL TABLET MG, MG, MG, 00-5 MG ; QL (0 EA per 0 days) MPC Effective /1/018

21 *DIRECT RENIN INHIBITORS*** TEKTURNA ORAL TABLET 150 MG, 00 MG 4 ; QL (0 EA per 0 days) *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** eplerenone oral tablet 5, 50 4 *VASODILATORS*** hydralazine hcl injection solution 0 /ml hydralazine hcl oral tablet 10, 100, 5, 50 minoxidil oral tablet 10,.5 *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** baciim intramuscular solution reconstituted unit 4 metronidazole oral tablet 50, 500 nebupent inhalation solution reconstituted 00 SP PENTAM INJECTION SOLUTION RECONSTITUTED 00 MG trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 1000, 500, SP vancomycin hcl oral capsule 15, 50 5 XIFAXAN ORAL TABLET 00 MG 5 ; QL (9 EA per 0 days) XIFAXAN ORAL TABLET 550 MG 5 ; QL (60 EA per 0 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , *ANTIPROTOZOAL AGENTS*** atovaquone oral suspension 750 /5ml *LEPROSTATICS*** dapsone oral tablet 100, 5 *LINCOSAMIDES*** clindamycin hcl oral capsule 150, 00 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *OXAZOLIDINONES*** linezolid oral suspension reconstituted 100 /5ml 5 linezolid oral tablet *ANTIMALARIALS* *ANTIMALARIALS*** MPC Effective /1/018

22 chloroquine phosphate oral tablet 50, 500 hydroxychloroquine sulfate oral tablet 00 primaquine phosphate oral tablet 6. *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC AGENTS*** MESTINON ORAL SYRUP 60 MG/5ML 4 pyridostigmine bromide oral tablet 60 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*** MESTINON ORAL SYRUP 60 MG/5ML 4 pyridostigmine bromide oral tablet 60 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* MESTINON ORAL SYRUP 60 MG/5ML 4 pyridostigmine bromide oral tablet 60 *ANTIMYCOBACTERIAL AGENTS* *ANTIMYCOBACTERIAL AGENTS*** ethambutol hcl oral tablet 100, 400 ISONIAZID ORAL SYRUP 50 MG/5ML isoniazid oral tablet 100, 00 SER ORAL CKET 4 GM PRIFTIN ORAL TABLET 150 MG 4 pyrazinamide oral tablet 500 rifabutin oral capsule rifampin oral capsule 150, 00 TRECATOR ORAL TABLET 50 MG 4 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** busulfan intravenous solution 6 /ml HEXALEN ORAL CAPSULE 50 MG 5 ; SP *ANDROGEN BIOSYNTHESIS INHIBITORS*** ZYTIGA ORAL TABLET 50 MG 5 ; QL (10 EA per 0 days) ZYTIGA ORAL TABLET 500 MG 5 ; QL (60 EA per 0 days) *ANTIADRENALS*** LYSODREN ORAL TABLET 500 MG 5 *ANTIANDROGENS*** bicalutamide oral tablet 50 MPC0184 Effective /1/018

23 flutamide oral capsule 15 XTANDI ORAL CAPSULE 40 MG 5 ; SP; QL (10 EA per 0 days) *ANTIESTROGENS*** FARESTON ORAL TABLET 60 MG 5 ; SP; QL (0 EA per 0 days) tamoxifen citrate oral tablet 10, 0 *ANTIMETABOLITES*** capecitabine oral tablet 150, ; SP mercaptopurine oral tablet 50 methotrexate oral tablet.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 100 /4ml, 50 /10ml, 50 /ml methotrexate sodium injection solution reconstituted 1 gm TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 ; SP; QL (10 EA per 0 days) ZELBORAF ORAL TABLET 40 MG 5 ; SP; QL (40 EA per 0 days) *ANTINEOPLASTIC - HEDGEHOG THWAY INHIBITORS*** ERIVEDGE ORAL CAPSULE 150 MG 5 ; SP; QL (0 EA per 0 days) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG 5 ; QL (6 EA per 1 days) ZOLINZA ORAL CAPSULE 100 MG 5 ; SP; QL (10 EA per 0 days) *ANTINEOPLASTIC - IMMUNOMODULATORS*** POMALYST ORAL CAPSULE 1 MG, MG, MG, 4 MG *ANTINEOPLASTIC - MEK INHIBITORS*** 5 ; SP; QL (1 EA per 8 days) MEKINIST ORAL TABLET 0.5 MG 5 ; SP; QL (90 EA per 0 days) MEKINIST ORAL TABLET MG 5 ; SP; QL (0 EA per 0 days) *ANTINEOPLASTIC - MONOCLONAL ANTIBODIES*** BAVENCIO INTRAVENOUS SOLUTION 00 MG/10ML *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG 5 ; SP 5 ; SP MPC0184 Effective /1/018

24 *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** NEXAVAR ORAL TABLET 00 MG 5 ; SP; QL (10 EA per 0 days) STIVARGA ORAL TABLET 40 MG 5 ; SP; QL (10 EA per 0 days) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG *ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS*** 5 ; SP ALUNBRIG ORAL TABLET 0 MG 5 ; QL (180 EA per 0 days) BOSULIF ORAL TABLET 100 MG, 500 MG 5 ; SP; QL (10 EA per 0 days) CALQUENCE ORAL CAPSULE 100 MG 5 ; QL (60 EA per 0 days) CAPRELSA ORAL TABLET 100 MG 5 ; SP; QL (60 EA per 0 days) CAPRELSA ORAL TABLET 00 MG 5 ; SP; QL (0 EA per 0 days) COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 0 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & X 0 MG 5 5 COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG 5 GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG 5 ; QL (0 EA per 0 days) imatinib mesylate oral tablet 100, ; SP INLYTA ORAL TABLET 1 MG, 5 MG 5 ; SP; QL (10 EA per 0 days) LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 MG LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 & 4 MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 () MG LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 () & 4 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 0 MG, 50 MG, 70 MG, 80 MG 5 ; QL (0 EA per 0 days) 5 ; QL (60 EA per 0 days) 5 ; QL (60 EA per 0 days) 5 ; QL (90 EA per 0 days) 5 ; SP; QL (0 EA per 0 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG 5 ; SP; QL (60 EA per 0 days) TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 ; SP; QL (10 EA per 0 days) TYKERB ORAL TABLET 50 MG 5 ; SP; QL (180 EA per 0 days) VOTRIENT ORAL TABLET 00 MG 5 ; SP; QL (10 EA per 0 days) XALKORI ORAL CAPSULE 00 MG, 50 MG 5 ; SP; QL (60 EA per 0 days) ZYKADIA ORAL CAPSULE 150 MG 5 ; SP; QL (150 EA per 0 days) *ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES*** BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG *ANTINEOPLASTIC COMBINATIONS*** KISQALI FEMARA 00 DOSE TABLET THERAPY CK 00 &.5 MG ORAL 00 &.5 MG 5 ; QL (49 EA per 8 days) MPC Effective /1/018

25 KISQALI FEMARA 400 DOSE TABLET THERAPY CK 00 &.5 MG ORAL 00 &.5 MG KISQALI FEMARA 600 DOSE TABLET THERAPY CK 00 &.5 MG ORAL 00 &.5 MG *ANTINEOPLASTICS MISC.*** hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML 5 ; QL (70 EA per 8 days) 5 ; QL (91 EA per 8 days) 5 SP MATULANE ORAL CAPSULE 50 MG 5 ; SP SYLATRON SUBCUTANEOUS KIT 600 MCG 5 ; SP *AROMATASE INHIBITORS*** anastrozole oral tablet 1 exemestane oral tablet 5 4 letrozole oral tablet.5 *ESTROGENS-ANTINEOPLASTIC*** EMCYT ORAL CAPSULE 140 MG 5 ; SP *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** LEUCOVORIN CALCIUM ORAL TABLET 10 MG, 15 MG leucovorin calcium oral tablet 5, 5 *IMIDAZOTETRAZINES*** temozolomide oral capsule 100, 140, 180, 0, 50, 5 *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG *MITOTIC INHIBITORS*** 5 ; SP etoposide oral capsule 50 4 SP *NITROGEN MUSTARDS*** melphalan oral tablet *PROGESTINS-ANTINEOPLASTIC*** megestrol acetate oral tablet 0, 40 *TOPOISOMERASE I INHIBITORS*** HYCAMTIN ORAL CAPSULE 0.5 MG, 1 MG 5 ; SP *URINARY TRACT PROTECTIVE AGENTS*** MESNEX ORAL TABLET 400 MG *ANTI-OBESITY AGENT COMBINATIONS** *ANTI-OBESITY AGENT COMBINATIONS** 5 ; SP; QL (60 EA per 0 days) MPC Effective /1/018

26 CONTRAVE ORAL TABLET EXTENDED RELEASE 1 HOUR 8-90 MG *ANTIRKINSON AGENTS* *ANTIRKINSON ANTICHOLINERGICS*** benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet, 5 *ANTIRKINSON DOMINERGICS*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet.5 *ANTIRKINSON MONOAMINE OXIDASE INHIBITORS*** rasagiline mesylate oral tablet 0.5, 1 4 ST selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *CENTRAL/PERIPHERAL COMT INHIBITORS*** tolcapone oral tablet *LEVODO COMBINATIONS*** carbidopa-levodopa er oral tablet extended release 5-100, carbidopa-levodopa oral tablet , 5-100, 5-50 carbidopa-levodopa oral tablet dispersible , 5-100, 5-50 carbidopa-levodopa-entacapone oral tablet , , , , , *NONERGOLINE DOMINE RECEPTOR AGONISTS*** pramipexole dihydrochloride oral tablet 0.15, 0.5, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.5, 0.5, 1,,, 4, 5 *PERIPHERAL COMT INHIBITORS*** entacapone oral tablet 00 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* 4 ; QL (10 EA per 0 days) 4 MPC Effective /1/018

27 *ANTIMANIC AGENTS*** lithium carbonate er oral tablet extended release 00, 450 lithium carbonate oral capsule 150, 00, 600 lithium carbonate oral tablet 00 LITHIUM ORAL SOLUTION 8 MEQ/5ML *ANTIPSYCHOTICS - MISC.*** ziprasidone hcl oral capsule 0, 40, 60, 80 *BENZISOXAZOLES*** FANAPT ORAL TABLET 1 MG, 10 MG, 1 MG, MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION CK ORAL TABLET 1 & & 4 & 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 4 HOUR 1.5 MG, MG, 6 MG, 9 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 9 MG/0.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 4 MG/1.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 7 MG/0.875ML, 410 MG/1.15ML, 546 MG/1.75ML, 819 MG/.65ML RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 1.5 MG, 5 MG, 7.5 MG, 50 MG risperidone oral solution 1 /ml risperidone oral tablet 0.5, 0.5, 1,,, 4 risperidone oral tablet dispersible 0.5, 1,,, 4 *BUTYROPHENONES*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5, 1, 10,, 0, 5 *DIBENZODIAZEPINES*** clozapine oral tablet 100, 00, 5, 50 *DIBENZO-OXEPINO PYRROLES*** SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,.5 MG, 5 MG *DIBENZOTHIAZEPINES*** QL (60 EA per 0 days) 5 ST; QL (60 EA per 0 days) 5 ST; QL (1 EA Max Qty Per Fill Retail) 5 ; QL (0 EA per 0 days) 5 SP 5 ; SP 5 ; SP 5 SP 4 5 ; QL (60 EA per 0 days) MPC Effective /1/018

28 quetiapine fumarate oral tablet 100, 00, 00, 400 quetiapine fumarate oral tablet 5, 50 *DIBENZOXAZEPINES*** loxapine succinate oral capsule 10, 5, 5, 50 *PHENOTHIAZINES*** chlorpromazine hcl oral tablet 10, 100, 00, 5, 50 COMPRO RECTAL SUPPOSITORY 5 MG fluphenazine decanoate injection solution 5 /ml FLUPHENAZINE HCL ORAL CONCENTRATE 5 MG/ML FLUPHENAZINE HCL ORAL ELIXIR.5 MG/5ML fluphenazine hcl oral tablet 1, 10,.5, 5 perphenazine oral tablet 16,, 4, 8 prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 5 thioridazine hcl oral tablet 10, 100, 5, 50 trifluoperazine hcl oral tablet 1, 10,, 5 *QUINOLINONE DERIVATIVES*** aripiprazole oral tablet 10, 15,, 0, 0, 5 ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/.9ML, 441 MG/1.6ML, 66 MG/.4ML, 88 MG/.ML *THIOXANTHENES*** thiothixene oral capsule 1, 10,, 5 *ANTIRETROVIRALS ADJUVANTS*** *ANTIRETROVIRALS ADJUVANTS*** QL (90 EA per 0 days) QL (90 EA per 0 days); AG (Max 1 Years) 5 ; QL (0 EA per 0 days) 5 SP TYBOST ORAL TABLET 150 MG QL (0 EA per 0 days) *ANTISEPTICS & DISINFECTANTS* *CHLORINE ANTISEPTICS*** chlorhexidine gluconate solution 0 % *ANTIVIRALS* *ANTIRETROVIRAL COMBINATIONS*** abacavir sulfate-lamivudine oral tablet QL (0 EA per 0 days) abacavir-lamivudine-zidovudine oral tablet QL (60 EA per 0 days) ATRIPLA ORAL TABLET MG QL (0 EA per 0 days) MPC Effective /1/018

29 COMPLERA ORAL TABLET MG 5 DESCOVY ORAL TABLET 00-5 MG 5 QL (0 EA per 0 days) EVOTAZ ORAL TABLET MG 5 QL (0 EA per 0 days) GENVOYA ORAL TABLET MG 5 QL (0 EA per 0 days) KALETRA ORAL TABLET MG, MG QL (10 EA per 0 days) lamivudine-zidovudine oral tablet QL (60 EA per 0 days) lopinavir-ritonavir oral solution /5ml QL (00 ML per 0 days) PREZCOBIX ORAL TABLET MG 5 QL (0 EA per 0 days) STRIBILD ORAL TABLET MG 5 QL (0 EA per 0 days) TRIUMEQ ORAL TABLET MG 5 QL (0 EA per 0 days) TRUVADA ORAL TABLET MG, 1-00 MG QL (0 EA per 0 Days) TRUVADA ORAL TABLET MG QL (0 EA per 0 days) *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** SELZENTRY ORAL TABLET 150 MG, 00 MG QL (10 EA per 0 days) *ANTIRETROVIRALS - FUSION INHIBITORS*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** isentress hd oral tablet 600 QL (60 EA per 0 days) ISENTRESS ORAL CKET 100 MG QL (60 EA per 0 days) ISENTRESS ORAL TABLET 400 MG QL (60 EA per 0 days) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 5 MG 5 QL (10 EA per 0 days) TIVICAY ORAL TABLET 10 MG 4 QL (0 EA per 0 days) TIVICAY ORAL TABLET 5 MG, 50 MG 5 QL (0 EA per 0 days) *ANTIRETROVIRALS - PROTEASE INHIBITORS*** APTIVUS ORAL CAPSULE 50 MG QL (10 EA per 0 days) APTIVUS ORAL SOLUTION 100 MG/ML atazanavir sulfate oral capsule 150, 00, 00 QL (60 EA per 0 days) CRIXIVAN ORAL CAPSULE 00 MG, 400 MG QL (180 EA per 0 days) INVIRASE ORAL CAPSULE 00 MG QL (10 EA per 0 days) INVIRASE ORAL TABLET 500 MG QL (10 EA per 0 days) LEXIVA ORAL SUSPENSION 50 MG/ML NORVIR ORAL CAPSULE 100 MG QL (60 EA per 0 days) NORVIR ORAL SOLUTION 80 MG/ML QL (450 ML per 0 days) NORVIR ORAL TABLET 100 MG QL (60 EA per 0 days) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG QL (60 EA per 0 days) PREZISTA ORAL TABLET 800 MG QL (0 EA per 0 days) MPC Effective /1/018

30 REYATAZ ORAL CKET 50 MG QL (150 EA per 0 days); AG (Max 8 Years) VIRACEPT ORAL TABLET 50 MG, 65 MG QL (10 EA per 0 days) *ANTIRETROVIRALS - RTI-NON- NUCLEOSIDE ANALOGUES*** EDURANT ORAL TABLET 5 MG 5 INTELENCE ORAL TABLET 100 MG, 00 MG, 5 MG nevirapine er oral tablet extended release 4 hour 400 QL (60 EA per 0 days) QL (0 EA per 0 days) nevirapine oral tablet 00 QL (0 EA per 0 days) RESCRIPTOR ORAL TABLET 100 MG, 00 MG QL (180 EA per 0 days) SUSTIVA ORAL TABLET 600 MG QL (0 EA per 0 days) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES*** abacavir sulfate oral tablet 00 QL (60 EA per 0 days) didanosine oral capsule delayed release 00, 50, 400 VIDEX ORAL SOLUTION RECONSTITUTED GM, 4 GM *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES*** QL (0 EA per 0 days) QL (100 ML per 0 days) EMTRIVA ORAL CAPSULE 00 MG QL (0 EA per 0 days) EMTRIVA ORAL SOLUTION 10 MG/ML lamivudine oral solution 10 /ml QL (900 ML per 0 days) lamivudine oral tablet 150 lamivudine oral tablet 00 QL (0 EA per 0 days) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES*** stavudine oral capsule 15, 0, 0, 40 QL (60 EA per 0 days) zidovudine oral capsule 100 QL (60 EA per 0 days) zidovudine oral syrup 50 /5ml QL (1800 ML per 0 days) zidovudine oral tablet 00 QL (60 EA per 0 days) *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** tenofovir disoproxil fumarate oral tablet 00 5 QL (0 EA per 0 days) VIREAD ORAL POWDER 40 MG/GM 5 VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG 5 *HETITIS B AGENTS*** entecavir oral tablet 0.5, 1 5 EPIVIR HBV ORAL SOLUTION 5 MG/ML QL (900 ML per 0 days) lamivudine oral tablet 100 QL (0 EA per 0 days) VEMLIDY ORAL TABLET 5 MG 5 QL (0 EA per 0 days) MPC Effective /1/018

31 *HETITIS C AGENTS*** PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML 5 ; SP ribavirin oral capsule 00 5 ; SP ribavirin oral tablet 00 5 ; SP *HERPES AGENTS - PURINE ANALOGUES*** acyclovir oral capsule 00 acyclovir oral suspension 00 /5ml acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 *HERPES AGENTS - THYMIDINE ANALOGUES*** famciclovir oral tablet 15, 50, 500 *INFLUENZA AGENTS*** rimantadine hcl oral tablet 100 *NEURAMINIDASE INHIBITORS*** oseltamivir phosphate oral capsule 0 4 QL (0 EA per 180 days) oseltamivir phosphate oral capsule 45, 75 4 QL (10 EA per 180 days) oseltamivir phosphate oral suspension reconstituted 6 /ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER *ASSORTED CLASSES* *ANTILEPROTICS*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG *B-LYMPHOCYTE STIMULATOR (BLYS)- SPECIFIC INHIBITORS*** BENLYSTA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 00 MG/ML *CHELATING AGENTS*** CUPRIMINE ORAL CAPSULE 50 MG DEPEN TITRATABS ORAL TABLET 50 MG *CYCLOSPORINE ANALOGS*** cyclosporine modified oral capsule 100, 5, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 5 GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML 4 QL (180 ML per 180 days) 4 QL (0 EA per 16 days) 5 5 ; SP; QL (4 ML per 8 days) MPC Effective /1/018

32 *IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 MG, 5 MG 5 ; SP REVLIMID ORAL CAPSULE.5 MG, 0 MG 5 *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** mycophenolate mofetil oral capsule 50 mycophenolate mofetil oral suspension reconstituted 00 /ml mycophenolate mofetil oral tablet 500 *MACROLIDE IMMUNOSUPPRESSANTS*** RAMUNE ORAL SOLUTION 1 MG/ML 4 sirolimus oral tablet 0.5, 1, 4 tacrolimus oral capsule 0.5, 1, 5 ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG *POTASSIUM REMOVING RESINS*** KIONEX ORAL POWDER KIONEX ORAL SUSPENSION 15 GM/60ML sodium polystyrene sulfonate oral powder *PURINE ANALOGS*** azathioprine oral tablet 50 *BETA BLOCKERS* *ALPHA-BETA BLOCKERS*** carvedilol oral tablet 1.5, 5,.15, 6.5 labetalol hcl intravenous solution 5 /ml labetalol hcl oral tablet 100, 00, 00 1 *BETA BLOCKERS CARDIO- SELECTIVE*** acebutolol hcl oral capsule 00, 400 atenolol oral tablet 100, 5, 50 betaxolol hcl oral tablet 10, 0 bisoprolol fumarate oral tablet 10, 5 BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG metoprolol succinate er oral tablet extended release 4 hour 100, 00, 5, 50 metoprolol tartrate oral tablet 100, 5, MPC0184 Effective /1/018

33 *BETA BLOCKERS NON-SELECTIVE*** nadolol oral tablet 0, 40, 80 1 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 4 hour 10, 160, 60, 80 PROPRANOLOL HCL ORAL SOLUTION 0 MG/5ML, 40 MG/5ML propranolol hcl oral tablet 10, 0, 40, 60, 80 sotalol hcl (af) oral tablet 10, 160, 80 1 sotalol hcl oral tablet 10, 160, 40, 80 1 TIMOLOL MALEATE ORAL TABLET 10 MG, 0 MG, 5 MG *CALCIUM CHANNEL BLOCKERS* *CALCIUM CHANNEL BLOCKERS*** amlodipine besylate oral tablet 10,.5, 5 1 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 4 HOUR 10 MG, 180 MG, 40 MG, 00 MG diltiazem hcl er beads oral capsule extended release 4 hour 10, 180, 40, 60 diltiazem hcl er beads oral capsule extended release 4 hour 00, 40 diltiazem hcl er coated beads oral capsule extended release 4 hour 10, 180, 40, 00 diltiazem hcl er oral capsule extended release 1 hour 10, 60, 90 diltiazem hcl er oral capsule extended release 4 hour 10, 180, 40 diltiazem hcl intravenous solution 50 /10ml diltiazem hcl oral tablet 10, 0, 60, 90 felodipine er oral tablet extended release 4 hour 10,.5, 5 isradipine oral capsule.5, 5 nicardipine hcl oral capsule 0, 0 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 4 HOUR 60 MG nifedipine er oral tablet extended release 4 hour 0, 60, 90 nifedipine er osmotic release oral tablet extended release 4 hour 0, 60, 90 nifedipine oral capsule 10, nimodipine oral capsule 0 4 nisoldipine er oral tablet extended release 4 hour 17, 0, 5.5, 0, 4, 40, ST; QL (0 EA per 0 days) MPC0184 Effective /1/018

34 TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 4 HOUR 10 MG, 180 MG, 40 MG, 00 MG, 60 MG verapamil hcl er oral capsule extended release 4 hour 100, 10, 180, 00, 40, 00, 60 verapamil hcl er oral tablet extended release 180, 40 verapamil hcl oral tablet 10, 40, 80 1 *CARDIOTONICS* *CARDIAC GLYCOSIDES*** digoxin oral tablet 15 mcg, 50 mcg *CARDIOVASCULAR AGENTS - MISC.* *CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB*** amlodipine-atorvastatin oral tablet 10-10, 10-0, 10-40, 10-80,.5-10,.5-0,.5-40, 5-10, 5-0, 5-40, 5-80 *PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS*** 4 QL (0 EA per 0 days) LETAIRIS ORAL TABLET 10 MG, 5 MG 5 ; SP; QL (0 EA per 0 days) *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** sildenafil citrate oral tablet 0 4 ; QL (90 EA per 0 days) *CEPHALOSPORINS* *CEPHALOSPORINS - 1ST GENERATION*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 50 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 50, 500 cephalexin oral suspension reconstituted 15 /5ml, 50 /5ml *CEPHALOSPORINS - ND GENERATION*** cefaclor oral capsule 50, 500 cefprozil oral suspension reconstituted 15 /5ml, 50 /5ml cefprozil oral tablet 50, 500 cefuroxime axetil oral tablet 50, 500 *CEPHALOSPORINS - RD GENERATION*** MPC Effective /1/018

35 cefdinir oral capsule 00 cefdinir oral suspension reconstituted 15 /5ml, 50 /5ml cefixime oral suspension reconstituted 100 /5ml, 00 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 00 ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, gm, 50, 500 *CONTRACEPTIVES* *BIPHASIC CONTRACEPTIVES - ORAL*** AZURETTE ORAL TABLET /0.01 MG (1/5) bekyree oral tablet /0.01 (1/5) desogestrel-ethinyl estradiol oral tablet /0.01 (1/5) KARIVA ORAL TABLET /0.01 MG (1/5) kimidess oral tablet /0.01 (1/5) PIMTREA ORAL TABLET /0.01 MG (1/5) viorele oral tablet /0.01 (1/5) *COMBINATION CONTRACEPTIVES - ORAL*** altavera oral tablet mcg AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG Zero Copayment Zero Copayment BALZIVA ORAL TABLET MG-MCG blisovi 4 fe oral tablet 1-0 -mcg(4) briellyn oral tablet mcg CHATEAL ORAL TABLET MG-MCG DELYLA ORAL TABLET MG-MCG drospiren-eth estrad-levomefol oral tablet drospirenone-ethinyl estradiol oral tablet -0.0, Zero Copayment ethynodiol diac-eth estradiol oral tablet mcg FALMINA ORAL TABLET MG-MCG 4 Zero Copayment gianvi oral tablet -0.0 JUNEL 1.5/0 ORAL TABLET MG-MCG JUNEL 1/0 ORAL TABLET 1-0 MG-MCG JUNEL FE 4 ORAL TABLET 1-0 MG-MCG(4) kaitlib fe oral tablet chewable mcg MPC Effective /1/018

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