General Formulary Information

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1 List of covered drugs for Triple Choice and Traditional Plans 8 Member formulary

2 General Formulary Information This formulary is applicable to the Triple Choice and Traditional Prescription Medication Benefit plans offered by Geisinger Health Plan, Geisinger Choice PPO and Geisinger Health Options. We offer two main prescription medication benefits: the Triple Choice benefit and the Traditional benefit. Depending on the specific plan chosen by you or your employer, additional Tiers may also apply. You are enrolled in only one plan. We encourage you to contact our Pharmacy Customer Service Team if you have any questions about this information or the type of benefit in which you are enrolled. Also, please refer to your benefit documents, as formulary exclusions may differ based on the specific benefit. This formulary represents both the Triple Choice benefit and Traditional Prescription Medication benefit. This formulary was designed to be a useful tool if you have prescription medication coverage. It lists the medications covered by your plan. Medications are listed in this formulary by medication category; individual medications can be looked up by using the index at the back. Please note that you can also view the formulary online at Pharmacy Customer Service Team Contact Information Telephone: (8) or (57) ; TDD/TTY 7 Fax: Mailing address: Geisinger Health Plan Pharmacy Department Internal Mail Code 3-46 North Academy Avenue Danville, PA 78 Triple Choice Benefit The Triple Choice benefit assigns each prescription medication to one of three different tiers, each representing a set copay amount. The copay amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under the Triple Choice benefit. The definitions of the copay levels are listed below: Tier Includes most generic medications and has the lowest copayment. Prior authorization is usually not necessary for medications in this tier. Tier Includes certain formulary brand name medications with no generic equivalent and select generic medications. Prior authorization may be necessary for medications in this tier. Tier 3 Includes certain formulary brand name medications, brand name medications with a generic equivalent (unless higher cost-sharing applies), and non-formulary brand name medications. Prior authorization may be necessary for medications in this tier. I

3 The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to: Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace. Traditional Benefit The Traditional benefit has either a flat copayment/coinsurance, one copayment for generic and one copayment for brand, or assigns each prescription medication to one of two different tiers, each representing a set copayment amount. The copay amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under the Traditional benefit. The definitions of the copay levels are listed below: Tier Includes most generic medications and has the lowest copayment. Prior authorization is usually not necessary for medications in this tier. Tier Includes certain formulary brand name medications with no generic equivalent and select generic medications. Prior authorization may be necessary for medications in this tier. *** For the Traditional Benefit any drug (without a generic) listed at Tier 3 in this formulary will be covered at Tier *** The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to: Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace II

4 Specialty Vendor Medication Program Certain medications require the use of a contracted specialty pharmacy vendor for purchase. Please contact the Pharmacy Service Team for additional information on the program and a complete list of the medications included. Note that a maximum of a 34-day supply may be dispensed for specialty vendor medications unless a shorter duration is specified in the formulary or in your specific benefit documents. Medications included in the Specialty Vendor Medication Program are designated in the formulary with SP in the Requirements/Limits column. A few things you should remember when using this formulary and your prescription benefit: All prescriptions must be filled at a participating pharmacy. You will pay the applicable copay, coinsurance, or deductible when you receive the prescription. Under the Triple Choice benefit, a brand name medication with a generic equivalent may require prior authorization and you could be required to pay the difference in cost between the brand and generic, otherwise it will be covered at the highest applicable copay. Under the Traditional benefit a brand name medication with a generic equivalent requires prior authorization. Some medications on the formulary require prior authorization or step therapy which your provider may request through our Pharmacy Customer Service Team. If you require medications not listed on this formulary, your provider may request an exception through our Pharmacy Customer Service Team. Those items listed as specific exclusions are not available through the exceptions process. Non-formulary medications not requiring prior authorization will be available at the highest copay level. Some medications and diabetic supplies may be restricted to a specific manufacturer, vendor or supplier and may be subject to quantity limits. Quantity limits may apply to certain medications. Brand and generic Triptan medications for migraines have a quantity limit of 6 units per 8 days across all products (sumatriptan, rizatriptan, naratriptan, almotriptan, frovatriptan, eletriptan, zolmitriptan, and sumatriptan/naproxen). Insulin syringes and lancets are covered at Tier. Non-prescription (over-the-counter) medications are not covered unless required by health care reform legislation. Note that if certain conditions are met, some medications may be covered with no copay/coinsurance due to health care reform legislation. Please contact the Pharmacy Customer Service Team for more information. Many compounded prescriptions require prior authorization review, which your provider may request through our Pharmacy Customer Service Team. If an exception is approved, you will be charged at the Tier 4 copay level. If your request is denied, the medication will be excluded from coverage under your prescription medication benefits. Medications listed on Tier are covered at $ copay. All prescriptions for adults for a total morphine equivalent dose (MED) of or greater will require prior authorization. III

5 Using this formulary Please note: a percentage (%) copay applies for human growth hormone and is dependent upon your prescription medication rider. Medication names with QL in the Requirements/Limits column have quantity limits Medication names followed by PA in the Requirements/Limits column require prior authorization. Medication names followed by ST in the Requirements/Limits column have step therapy requirements. Medication names followed by SP in the Requirements/Limits column must be obtained from a network specialty vendor. This formulary is accurate as of April, 8, and is subject to change. Any additions or deletions to the formulary throughout the year may be found in the following publications: Member Update for members and Healthcare Provider Update for providers. The most up-to-date source for formulary information is the online formulary search available at Restrictions in medication availability may result from use of a formulary. Certain prescription medications listed in this formulary may not be covered for everyone. Your prescription medication benefits are dependent upon the coverage selected by you or your employer. Please be aware that if you choose to obtain a non-formulary medication, you may be required to pay the full price of that medication. For information about your specific prescription medication benefits, please contact the Pharmacy Customer Service Team. Quantity Limits Quantity limits are listed in the Requirements/Limits Column Note that non-formulary medications in the same class/category as formulary drugs with quantity limits will have the same quantity limits applied. If not listed above, the maximum day supply for specialty vendor medications is 34 days or as otherwise defined in the prescription medication benefit documents. Step Therapy For details regarding step therapy requirements please contact the Pharmacy Customer Service Team at (8) or (57) IV

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

7 Health Care Reform The Affordable Care Act (ACA) was signed into law on March 3,. Under the ACA, the government created provisions, or laws, that health insurers must adapt to, which change health benefits for consumers. These changes include the expansion of preventive services, including vaccinations, prescription drugs, and more. In accordance with the ACA requirements, and subject to any applicable limitations of your pharmacy plan, the following preventive medications will be covered with no cost-sharing under the prescription drug benefit: Aspirin Products Low dose (8 ) aspirin products o For the primary prevention of cardiovascular disease and colorectal cancer in adults ages 5-59 years who have a percent or greater -year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least years and are willing to take low-dose aspirin daily for at least years. o As preventive medication after weeks of gestation in women who are at high risk for preeclampsia. Contraceptives Brands with no generic and generic products (other contraceptives may be covered under the medical benefit) o For females. Bowel Preparations for Colonoscopy Brands with no generic and generic products o In preparation of a screening colonoscopy for members 5-75 years of age. Breast Cancer Prevention Generic raloxifene and generic tamoxifen o For women who are at increased risk of breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as raloxifene or tamoxifen. Folic Acid Supplements Generic folic acid.4 and.8 tablets o All women who are planning or capable of pregnancy. Fluoride Supplements Fluoride drops and chewable tablets o Oral fluoride supplementation starting at 6 months for children whose water supply is fluoride sufficient up to age 5 years for the prevention of dental caries. Iron Supplements Pediatric Iron supplements o For members 6 months of age. Smoking Cessation Products Brands with no generic and generic products o Two, 9-day treatment courses per benefit year. Statin Preventive Medication low- to moderate-dose generic products o For adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke) for the prevention of CVD events and mortality when all of the following criteria are met: ) they are ages 4 to 75 years; ) they have or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated - year risk of a cardiovascular event of % or greater. Identification of dyslipidemia and calculation of -year CVD event risk requires universal lipids screening in adults ages 4 to 75 years. Vaccinations Herpes Zoster and Influenza (Flu) Vaccine (Other preventive vaccinations may be covered under the medical benefit) Vitamin D Generic vitamin D 4 unit supplements o To prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls VI

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

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

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

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12 Table of Contents Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents... Antibacterials... Anticancer Agents... 6 Anticholinergic Agents... Anticonvulsants... Antidementia Agents... 3 Antidepressants... 3 Antidiabetic Agents... 5 Antifungals... 9 Antigout Agents... 3 Antihistamines... 3 Anti-Infectives (Skin And Mucous Membrane)... 3 Antimigraine Agents... 3 Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 4 Caloric Agents Cardiovascular Agents... 45

13 Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Detergents Devices Enzyme Replacement/Modifiers... 8 Eye, Ear, Nose, Throat Agents... 8 Gastrointestinal Agents Genitourinary Agents... 9 Heavy Metal Antagonists... 9 Hormonal Agents, Stimulant/Replacement/Modifying... 9 Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents... Miscellaneous Therapeutic Agents... Ophthalmic Agents... Replacement Preparations... 3 Respiratory Tract Agents... 4 Skeletal Muscle Relaxants... 8 Sleep Disorder Agents... 8 Urine And Feces Contents... 9 Vasodilating Agents... 9 Vitamins And Minerals...

14 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET MCG, MCG, 3 MCG, 4 MCG, 6 MCG, 8 MCG acetaminophen-caff-dihydrocod oral tablet acetaminophen-codeine oral solution - /5 ml acetaminophen-codeine oral tablet 3-5 acetaminophen-codeine oral tablet 3-3 acetaminophen-codeine oral tablet 3-6 ascomp with codeine oral capsule aspirin-caffeine-dihydrocodein oral capsule belladonna alkaloids-opium rectal suppository 6.-6 belladonna-opium rectal suppository buprenorphine transdermal patch weekly mcg/hour, 5 mcg/hour, mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet 5-3 butalbital-acetaminophen oral tablet 5-35 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule (Panlor(acetam-caffdihydrocod)) (Tylenol-Codeine #3) (Tylenol-Codeine #4) 3 PA; QL (36 per 34 (Butrans) QL (.4 per day) (Bupap) (Marten-Tab) (Fioricet) (Capacet) (Esgic) (Fiorinal) Geisinger 8 Commercial Formulary 3 Effective: April, 8

15 butorphanol tartrate nasal spray,nonaerosol /ml capacet oral capsule CODEINE SULFATE ORAL SOLUTION 3 MG/5 ML codeine sulfate oral tablet 5, 3, 6 DISKETS ORAL TABLET,SOLUBLE 4 MG endocet oral tablet -35,.5-35, 5-35, fentanyl citrate buccal lozenge on a handle, mcg,,6 mcg, mcg, 4 mcg, 6 mcg, 8 mcg fentanyl transdermal patch 7 hour mcg/hr, mcg/hr, 5 mcg/hr, 5 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 37.5 mcg/hour, 6.5 mcg/hour, 87.5 mcg/hour FENTORA BUCCAL TABLET, EFFERVESCENT MCG, MCG, 4 MCG, 6 MCG, 8 MCG hydrocodone-acetaminophen oral solution.5-67 /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet -3 hydrocodone-acetaminophen oral tablet -35 hydrocodone-acetaminophen oral tablet.5-35 hydrocodone-acetaminophen oral tablet 5-3 hydrocodone-acetaminophen oral tablet 5-35 hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet -, 5- hydrocodone-ibuprofen oral tablet.5-, 7.5- (Actiq) PA; QL (36 per 34 (Duragesic) (Hycet) (Vicodin HP) (Lorcet HD) (Verdrocet) (Vicodin) (Lorcet (hydrocodone)) (Vicodin ES) (Lorcet Plus) (Ibudone) 3 PA Geisinger 8 Commercial Formulary 4 Effective: April, 8

16 hydromorphone oral liquid /ml (Dilaudid) hydromorphone oral tablet, 4, 8 (Dilaudid) ibuprofen-oxycodone oral tablet 4-5 levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet 5-35 lorcet hd oral tablet -35 lorcet plus oral tablet margesic oral capsule marten-tab oral tablet 5-35 meperidine oral solution 5 /5 ml meperidine oral tablet (Demerol) meperidine oral tablet 5 methadone oral concentrate /ml (Methadone Intensol) methadone oral solution /5 ml, 5 /5 ml methadone oral tablet, 5 (Dolophine) methadone oral tablet,soluble 4 (Diskets) methadose oral tablet,soluble 4 morphine concentrate oral solution /5 ml ( /ml) morphine oral capsule, er multiphase 4 hr, 3, 45, 6, 75, 9 morphine oral capsule,extend.release (Kadian) pellets,,, 3, 5, 6, 8 morphine oral solution /5 ml, /5 ml (4 /ml) MORPHINE ORAL TABLET 5 MG, 3 MG morphine oral tablet extended release (MS Contin), 5,, 3, 6 morphine rectal suppository,, 3, 5 NUCYNTA ER ORAL TABLET 3 PA EXTENDED RELEASE HR MG, 5 MG, MG, 5 MG, 5 MG NUCYNTA ORAL TABLET MG, 5 3 PA MG, 75 MG oxycodone oral capsule 5 oxycodone oral concentrate /ml oxycodone oral solution 5 /5 ml Geisinger 8 Commercial Formulary 5 Effective: April, 8

17 oxycodone oral tablet, oxycodone oral tablet 5, 3, 5 (Roxicodone) oxycodone oral tablet,oral only,ext.rel. (OxyContin) PA hr, 5,, 3, 4, 6, 8 oxycodone-acetaminophen oral solution 5-35 /5 ml oxycodone-acetaminophen oral tablet - (Primlev) 3, 5-3, oxycodone-acetaminophen oral tablet - (Endocet) 35,.5-35, 5-35, oxycodone-aspirin oral tablet OXYCONTIN ORAL TABLET,ORAL 3 PA ONLY,EXT.REL. HR MG, 5 MG, MG, 3 MG, 4 MG, 6 MG, 8 MG oxymorphone oral tablet, 5 (Opana) panlor(acetam-caff-dihydrocod) oral tablet pentazocine-naloxone oral tablet 5-.5 reprexain oral tablet -,.5-, 5- ROXICODONE ORAL TABLET 5 MG SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL, MCG (6 3 PA; QL (36 per 34 MCG/SPRAY X ),,6 MCG (8 MCG/SPRAY X ), MCG/SPRAY, MCG/SPRAY, 4 MCG/SPRAY, 6 MCG/SPRAY, 8 MCG/SPRAY tencon oral tablet 5-35 tramadol oral capsule,er biphase 4 hr (ConZip) 5-75, tramadol oral capsule,er biphase 4 hr tramadol oral tablet 5 (Ultram) tramadol oral tablet extended release 4 hr,, 3 tramadol oral tablet, er multiphase 4 hr,, 3 tramadol-acetaminophen oral tablet (Ultracet) 35 xylon oral tablet - Geisinger 8 Commercial Formulary 6 Effective: April, 8

18 zebutal oral capsule Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule,, (Celebrex) 4, 5 choline,magnesium salicylate oral liquid 5 /5 ml diclofenac potassium oral tablet 5 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr diclofenac sodium oral tablet,delayed release (dr/ec) 5, 5, 75 diclofenac-misoprostol oral (Arthrotec 5) tablet,ir,delayed rel,biphasic 5- mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic 75- mcg diflunisal oral tablet 5 etodolac oral capsule, 3 etodolac oral tablet 4 (Lodine) etodolac oral tablet 5 etodolac oral tablet extended release 4 hr 4, 5, 6 fenoprofen oral capsule (Fenortho) fenoprofen oral capsule 4 (Nalfon) fenoprofen oral tablet 6 (ProFeno) flurbiprofen oral tablet, 5 ibuprofen oral suspension /5 ml (Child Ibuprofen) ibuprofen oral tablet 4, 6, 8 INDOCIN ORAL SUSPENSION 5 MG/5 ML indomethacin oral capsule 5, 5 indomethacin oral capsule, extended release 75 ketoprofen oral capsule 5, 75 ketoprofen oral capsule,ext rel. pellets 4 hr ketorolac oral tablet QL ( per day) meclofenamate oral capsule, 5 mefenamic acid oral capsule 5 meloxicam oral suspension 7.5 /5 ml Geisinger 8 Commercial Formulary 7 Effective: April, 8

19 meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 5, 75 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 5, 375 naproxen oral tablet 5 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 5 naproxen sodium oral tablet 75 naproxen sodium oral tablet 55 (Anaprox DS) oxaprozin oral tablet 6 (Daypro) piroxicam oral capsule, (Feldene) salsalate oral tablet 5, 75 (Disalcid) sulindac oral tablet 5, tolmetin oral capsule 4 tolmetin oral tablet, 6 VIMOVO ORAL 3 PA; QL ( per day) TABLET,IR,DELAYED REL,BIPHASIC 375- MG, 5- MG Anesthetics Local Anesthetics CIDALEAZE TOPICAL CREAM 3 % glydo mucous membrane jelly in applicator % LIDO BDK KIT GAUGE X "-.5 %-.5 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (4 /ml) lidocaine hcl topical cream 3 % (CidalEaze) lidocaine hcl topical cream 3.88 % (Lidotral) lidocaine hcl topical lotion 3 % (Lido-K) lidocaine hcl-hydrocortison ac rectal kit 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream 3-.5 % lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-hydrocortisone-aloe rectal kit - % (Ana-Lex Kit) Geisinger 8 Commercial Formulary 8 Effective: April, 8

20 lidocaine-hydrocortisone-aloe rectal kit 3-.5 % (7 gram) lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % (AgonEaze) RELADOR PAK TOPICAL KIT.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -.5, 8- bupropion hcl (smoking deter) oral tablet extended release hr 5 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK.5 MG ()- MG (4) PA; QL (34 days supply per fill) PA; QL (34 days supply per fill) (Zyban) QL ( per day) QL ( per day) QL (53 per 8 disulfiram oral tablet 5, 5 (Antabuse) naloxone injection syringe.4 /ml, /ml naltrexone oral tablet 5 NARCAN NASAL SPRAY,NON- QL (4 per 3 AEROSOL MG/ACTUATION, 4 MG/ACTUATION nicorelief buccal gum, 4 nicotine (polacrilex) buccal gum, 4 (Nicorelief) nicotine (polacrilex) buccal lozenge, (Nicorette) 4 nicotine transdermal patch 4 hour 4 (Nicoderm CQ) /4 hr, /4 hr, 7 /4 hr nicotine transdermal patch 4 hour /4 hr NICOTINE TRANSDERMAL PATCH, TD DAILY, SEQUENTIAL -4-7 MG/4 HR Geisinger 8 Commercial Formulary 9 Effective: April, 8

21 NICOTROL INHALATION CARTRIDGE MG NICOTROL NS NASAL SPRAY,NON- AEROSOL MG/ML stop smoking aid buccal lozenge, 4 SUBOXONE SUBLINGUAL FILM -3 MG, -.5 MG, 4- MG, 8- MG Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML alprazolam oral tablet.5,.5,, (Xanax) alprazolam oral tablet extended release 4 (Xanax XR) hr.5,,, 3 alprazolam oral tablet,disintegrating.5,.5,, buspirone oral tablet, 5, 3, 5, 7.5 chlordiazepoxide hcl oral capsule, 5, 5 clonazepam oral tablet.5,, (Klonopin) clonazepam oral tablet,disintegrating.5,.5,.5,, clorazepate dipotassium oral tablet 5, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) DIASTAT ACUDIAL RECTAL KIT MG, MG diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml ( /ml) diazepam oral tablet,, 5 (Valium) diazepam rectal kit , 5- (Diastat AcuDial) 7.5- diazepam rectal kit.5 (Diastat) estazolam oral tablet, flurazepam oral capsule 5, 3 lorazepam oral concentrate /ml (Lorazepam Intensol) lorazepam oral tablet.5,, (Ativan) meprobamate oral tablet, 4 3 PA; QL (34 days supply per fill) Geisinger 8 Commercial Formulary Effective: April, 8

22 midazolam oral syrup /ml ONFI ORAL SUSPENSION.5 MG/ML 3 PA ONFI ORAL TABLET MG, MG 3 PA oxazepam oral capsule, 5, 3 quazepam oral tablet 5 (Doral) temazepam oral capsule 5,.5, 3, 7.5 (Restoril) triazolam oral tablet.5 triazolam oral tablet.5 (Halcion) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 3 MG/4 ML neomycin oral tablet 5 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG 3 PA; SP; QL (4 per 56 3 PA; SP; QL (4 per 56 tobramycin in.5 % nacl inhalation solution for nebulization 3 /5 ml (Tobi) PA; SP; QL (8 per 56 Antibacterials, Miscellaneous clindamycin hcl oral capsule 5, 3 (Cleocin HCl), 75 clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml hyolev mb oral tablet linezolid oral suspension for reconstitution (Zyvox) PA /5 ml linezolid oral tablet 6 (Zyvox) QL ( per 8 methenamine hippurate oral tablet gram (Hiprex) methenamine mandelate oral tablet.5 g, gram metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 5, 5 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin), 5, 5 nitrofurantoin monohyd/m-cryst oral capsule (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) PHOSPHASAL ORAL TABLET MG SIVEXTRO ORAL TABLET MG 3 PA; QL (6 per 365 trimethoprim oral tablet Geisinger 8 Commercial Formulary Effective: April, 8

23 ur n-c oral tablet uretron d-s oral tablet URETRON D-S ORAL TABLET MG urimar-t oral tablet URIN DS ORAL TABLET MG uro-458 oral tablet uro-blue oral tablet urogesic-blue oral tablet urolet mb oral tablet vancomycin in.9 % sodium chl intravenous solution.5 gram/5 ml vancomycin intravenous recon soln,, gram, 5 gram, 5, 75 vancomycin oral capsule 5, 5 (Vancocin) XIFAXAN ORAL TABLET MG, 55 3 PA MG Cephalosporins cefaclor oral capsule 5, 5 cefaclor oral suspension for reconstitution 5 /5 ml, 5 /5 ml, 375 /5 ml cefaclor oral tablet extended release hr 5 cefadroxil oral capsule 5 cefadroxil oral suspension for reconstitution 5 /5 ml, 5 /5 ml cefadroxil oral tablet gram cefdinir oral capsule 3 cefdinir oral suspension for reconstitution 5 /5 ml, 5 /5 ml cefditoren pivoxil oral tablet cefditoren pivoxil oral tablet 4 (Spectracef) cefixime oral suspension for reconstitution (Suprax) /5 ml, /5 ml cefpodoxime oral suspension for reconstitution /5 ml, 5 /5 ml cefpodoxime oral tablet, cefprozil oral suspension for reconstitution 5 /5 ml, 5 /5 ml cefprozil oral tablet 5, 5 Geisinger 8 Commercial Formulary Effective: April, 8

24 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 5 MG/5 ML, 5 MG/5 ML cefuroxime axetil oral tablet 5, 5 cephalexin oral capsule 5, 5 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 5 /5 ml cephalexin oral tablet 5, 5 SUPRAX ORAL CAPSULE 4 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 5 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE MG, MG Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution /5 ml, /5 ml azithromycin oral tablet 5, 5, (Zithromax) 6 clarithromycin oral suspension for reconstitution 5 /5 ml, 5 /5 ml clarithromycin oral tablet 5, 5 clarithromycin oral tablet extended release 4 hr 5 DIFICID ORAL TABLET MG 3 PA; QL ( per day) e.e.s. 4 oral tablet 4 E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML ERYPED ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML ERYPED 4 ORAL SUSPENSION FOR RECONSTITUTION 4 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 5, 5 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 5 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution /5 ml erythromycin ethylsuccinate oral tablet 4 (E.E.S. 4) Geisinger 8 Commercial Formulary 3 Effective: April, 8

25 erythromycin oral capsule,delayed release(dr/ec) 5 erythromycin oral tablet 5, 5 Penicillins amoxicillin oral capsule 5, 5 amoxicillin oral suspension for reconstitution 5 /5 ml, /5 ml, 5 /5 ml, 4 /5 ml amoxicillin oral tablet 5, 875 amoxicillin oral tablet,chewable 5, 5 amoxicillin-pot clavulanate oral suspension for reconstitution -8.5 /5 ml, 4-57 /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-6) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 5-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 5-5, amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr,-6.5 amoxicillin-pot clavulanate oral tablet,chewable -8.5, 4-57 ampicillin oral capsule 5, 5 ampicillin oral suspension for reconstitution 5 /5 ml, 5 /5 ml AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML dicloxacillin oral capsule 5, 5 penicillin v potassium oral recon soln 5 /5 ml, 5 /5 ml penicillin v potassium oral tablet 5, 5 Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 4 hr,, 5 ciprofloxacin hcl oral tablet, 75 Geisinger 8 Commercial Formulary 4 Effective: April, 8

26 ciprofloxacin hcl oral tablet 5, 5 (Cipro) ciprofloxacin oral (Cipro) suspension,microcapsule recon 5 /5 ml, 5 /5 ml levofloxacin oral solution 5 / ml levofloxacin oral tablet 5, 5, (Levaquin) 75 moxifloxacin oral tablet 4 (Avelox) ofloxacin oral tablet 3, 4 Sulfonamides sulfadiazine oral tablet 5 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension -4 /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) 4-8 sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 8-6 sulfatrim oral suspension -4 /5 ml Tetracyclines demeclocycline oral tablet 5, 3 doxycycline hyclate oral capsule, (Morgidox) 5 doxycycline hyclate oral tablet, doxycycline hyclate oral tablet 5, 75 (Acticlate) doxycycline hyclate oral tablet,delayed release (dr/ec), 5, 75 doxycycline monohydrate oral capsule (Mondoxyne NL), 5, 75 doxycycline monohydrate oral capsule 5 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet (Avidoxy) doxycycline monohydrate oral tablet 5, 5, 75 minocycline oral capsule, 5, (Minocin) 75 minocycline oral tablet, 5, 75 Geisinger 8 Commercial Formulary 5 Effective: April, 8

27 minocycline oral tablet extended release 4 hr 5, 65 minocycline oral tablet extended release 4 hr 35, 45, 9 (Solodyn) PA (CoreMino) tetracycline oral capsule 5, 5 Anticancer Agents Anticancer Agents AFINITOR ORAL TABLET MG,.5 MG, 5 MG, 7.5 MG PA; QL (8 days supply per fill) ALECENSA ORAL CAPSULE 5 MG PA; SP; QL (4 per 3 ALUNBRIG ORAL TABLET 8 MG, 9 MG PA; SP; QL (3 per 3 ALUNBRIG ORAL TABLET 3 MG PA; SP; QL ( per 3 ALUNBRIG ORAL TABLETS,DOSE PACK 9 MG (7)- 8 MG (3) PA; SP; QL (3 per 3 anastrozole oral tablet (Arimidex) bexarotene oral capsule 75 (Targretin) PA bicalutamide oral tablet 5 (Casodex) BOSULIF ORAL TABLET MG PA; SP; QL ( per 3 BOSULIF ORAL TABLET 4 MG, 5 MG PA; SP; QL (3 per 3 CABOMETYX ORAL TABLET MG, 4 MG, 6 MG PA; SP; QL (3 per 3 CALQUENCE ORAL CAPSULE MG PA; SP; QL (6 per 3 capecitabine oral tablet 5, 5 (Xeloda) CAPRELSA ORAL TABLET MG, 3 MG PA; SP; QL (3 days supply per fill) CASODEX ORAL TABLET 5 MG COMETRIQ ORAL CAPSULE MG/DAY(8 MG X- MG X), 4 PA; SP; QL (8 days supply per fill) MG/DAY(8 MG X- MG X3), 6 MG/DAY ( MG X 3/DAY) COTELLIC ORAL TABLET MG PA; SP; QL (9 per 3 CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 5 MG EMCYT ORAL CAPSULE 4 MG ERIVEDGE ORAL CAPSULE 5 MG PA; SP; QL (8 per 8 Geisinger 8 Commercial Formulary 6 Effective: April, 8

28 etoposide oral capsule 5 exemestane oral tablet 5 (Aromasin) FARYDAK ORAL CAPSULE MG, 5 MG, MG PA; SP; QL (6 per flutamide oral capsule 5 GILOTRIF ORAL TABLET MG, 3 MG, 4 MG PA; SP; QL (3 per 3 GLEEVEC ORAL TABLET MG, 4 MG GLEOSTINE ORAL CAPSULE MG, MG, 4 MG GLEOSTINE ORAL CAPSULE 5 MG HEXALEN ORAL CAPSULE 5 MG HYCAMTIN ORAL CAPSULE.5 MG, MG SP; QL (34 days supply per fill) hydroxyurea oral capsule 5 (Hydrea) IBRANCE ORAL CAPSULE MG, 5 MG, 75 MG PA; SP; QL ( per 8 ICLUSIG ORAL TABLET 5 MG, 45 MG PA; SP; QL (3 days supply per fill) IDHIFA ORAL TABLET MG, 5 MG PA; SP; QL (3 per 3 imatinib oral tablet, 4 (Gleevec) IMBRUVICA ORAL CAPSULE 4 MG PA; SP; QL ( per 3 INLYTA ORAL TABLET MG, 5 MG PA; SP; QL (3 days supply per fill) IRESSA ORAL TABLET 5 MG PA; SP; QL (3 per 3 JAKAFI ORAL TABLET MG, 5 MG, MG, 5 MG, 5 MG PA; SP; QL (6 per 3 KISQALI FEMARA CO-PACK ORAL TABLET MG/DAY( MG X )-.5 MG PA; SP; QL (49 per 8 KISQALI FEMARA CO-PACK ORAL TABLET 4 MG/DAY( MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 6 MG/DAY( MG X 3)-.5 MG KISQALI ORAL TABLET MG/DAY ( MG X ) KISQALI ORAL TABLET 4 MG/DAY ( MG X ) PA; SP; QL (7 per 8 PA; SP; QL (9 per 8 PA; SP; QL ( per 8 PA; SP; QL (4 per 8 Geisinger 8 Commercial Formulary 7 Effective: April, 8

29 KISQALI ORAL TABLET 6 MG/DAY ( MG X 3) PA; SP; QL (63 per 8 LENVIMA ORAL CAPSULE MG/DAY ( MG X /DAY), 4 PA; SP; QL (9 per 3 MG/DAY( MG X -4 MG X ), 8 MG/DAY ( MG X -4 MG X), MG/DAY ( MG X ), 4 MG/DAY( MG X -4 MG X ) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X ) PA; SP; QL (9 per 3 letrozole oral tablet.5 (Femara) AGE (Min 45 Years) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /. ml lomustine oral capsule,, 4 (Gleostine) LONSURF ORAL TABLET MG, -8.9 MG PA; SP; QL (8 days supply per fill) LYNPARZA ORAL CAPSULE 5 MG PA; SP; QL (448 per 8 LYNPARZA ORAL TABLET MG, 5 MG PA; SP; QL ( per 3 LYSODREN ORAL TABLET 5 MG MATULANE ORAL CAPSULE 5 MG SP; QL (34 days supply per fill) megestrol oral tablet, 4 MEKINIST ORAL TABLET.5 MG PA; SP; QL (9 per 3 MEKINIST ORAL TABLET MG PA; SP; QL (3 per 3 melphalan oral tablet (Alkeran) mercaptopurine oral tablet 5 methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 MYLERAN ORAL TABLET MG NERLYNX ORAL TABLET 4 MG PA; SP; QL (8 per 3 NEXAVAR ORAL TABLET MG PA; SP; QL (3 days supply per fill) nilutamide oral tablet 5 (Nilandron) NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG PA; SP; QL (3 per 8 Geisinger 8 Commercial Formulary 8 Effective: April, 8

30 ODOMZO ORAL CAPSULE MG PA; SP; QL (3 per 3 POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG PA; SP; QL ( per 8 REVLIMID ORAL CAPSULE MG, 5 MG,.5 MG, MG, 5 MG, 5 MG PA; SP; QL (34 days supply per fill) RUBRACA ORAL TABLET MG, 5 MG, 3 MG PA; SP; QL ( per 3 RYDAPT ORAL CAPSULE 5 MG PA; SP; QL ( per 8 SPRYCEL ORAL TABLET MG, 4 MG, MG, 5 MG, 7 MG, 8 MG PA; SP; QL (3 days supply per fill) STIVARGA ORAL TABLET 4 MG PA; SP; QL (84 per 8 SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 5 MG PA; SP; QL (8 per 8 TAFINLAR ORAL CAPSULE 5 MG, 75 MG PA; SP; QL ( per 3 TAGRISSO ORAL TABLET 4 MG, 8 MG PA; SP; QL (3 per 3 tamoxifen oral tablet, $ copay for women TARCEVA ORAL TABLET MG, 5 MG PA NSO; SP; QL (3 per 3 TARCEVA ORAL TABLET 5 MG PA NSO; SP; QL (9 per 3 TARGRETIN ORAL CAPSULE 75 MG PA TARGRETIN TOPICAL GEL % PA TASIGNA ORAL CAPSULE 5 MG, MG PA; SP; QL (8 days supply per fill) temozolomide oral capsule, 4 (Temodar), 8,, 5, 5 tretinoin (chemotherapy) oral capsule TYKERB ORAL TABLET 5 MG PA; SP; QL (3 days supply per fill) VENCLEXTA ORAL TABLET MG PA; SP; QL (56 per 8 VENCLEXTA ORAL TABLET MG PA; SP; QL ( per 3 VENCLEXTA ORAL TABLET 5 MG PA; SP; QL (8 per 8 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK MG-5 MG- MG PA; SP; QL (4 per 8 Geisinger 8 Commercial Formulary 9 Effective: April, 8

31 VERZENIO ORAL TABLET MG, 5 MG, MG, 5 MG PA; SP; QL (56 per 8 VOTRIENT ORAL TABLET MG PA; SP; QL (3 days supply per fill) XALKORI ORAL CAPSULE MG, 5 MG PA; SP; QL (6 per 3 XTANDI ORAL CAPSULE 4 MG PA; SP; QL ( per 3 ZEJULA ORAL CAPSULE MG PA; SP; QL (9 per 3 ZELBORAF ORAL TABLET 4 MG PA; SP; QL (4 per 3 ZOLINZA ORAL CAPSULE MG PA; SP; QL (3 days supply per fill) ZYDELIG ORAL TABLET MG, 5 MG PA; SP; QL (6 per 3 ZYKADIA ORAL CAPSULE 5 MG PA; SP; QL (4 per 8 ZYTIGA ORAL TABLET 5 MG PA; SP; QL ( per 3 ZYTIGA ORAL TABLET 5 MG PA; SP; QL (6 per 3 Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium oral capsule 5-.5 ME-PB-HYOS ORAL ELIXIR MG/5 ML phenobarb-hyoscy-atropine-scop oral (Librax (with clidinium)) (Donnatal) tablet propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET MG, 4 MG APTIOM ORAL TABLET 6 MG, 8 MG BANZEL ORAL SUSPENSION 4 MG/ML BANZEL ORAL TABLET MG, 4 MG carbamazepine oral capsule, er multiphase hr,, 3 (Carbatrol) 3 PA; QL ( per day) 3 PA; QL ( per day) 3 PA 3 PA Geisinger 8 Commercial Formulary Effective: April, 8

32 carbamazepine oral suspension /5 (Tegretol) ml carbamazepine oral tablet (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr,, 4 carbamazepine oral tablet,chewable DILANTIN INFATABS ORAL TABLET,CHEWABLE 5 MG DILANTIN ORAL CAPSULE 3 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 5 divalproex oral tablet extended release 4 (Depakote ER) hr 5, 5 divalproex oral tablet,delayed release (Depakote) (dr/ec) 5, 5, 5 epitol oral tablet ethosuximide oral capsule 5 (Zarontin) ethosuximide oral solution 5 /5 ml (Zarontin) felbamate oral suspension 6 /5 ml (Felbatol) felbamate oral tablet 4, 6 (Felbatol) FYCOMPA ORAL SUSPENSION.5 3 PA; QL (4 per day) MG/ML FYCOMPA ORAL TABLET MG, MG, MG, 4 MG, 6 MG, 8 MG 3 PA; QL ( per day) gabapentin oral capsule, 3, (Neurontin) 4 gabapentin oral solution 5 /5 ml (Neurontin) gabapentin oral tablet 6, 8 (Neurontin) GABITRIL ORAL TABLET MG, 6 MG lamotrigine oral tablet, 5, (Lamictal), 5 lamotrigine oral tablet extended release (Lamictal XR) 4hr,, 5, 5, 3, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 lamotrigine oral tablets,dose pack 5 (Lamictal Starter (Blue) (35) Kit) levetiracetam oral solution /ml (Keppra) levetiracetam oral tablet,, 5, 5, 75 (Keppra) Geisinger 8 Commercial Formulary Effective: April, 8

33 levetiracetam oral tablet extended release (Keppra XR) 4 hr 5, 75 LYRICA ORAL CAPSULE MG, 5 MG, MG, 5 MG, 5 MG, 3 MG, 5 MG, 75 MG LYRICA ORAL SOLUTION MG/ML oxcarbazepine oral suspension 3 /5 ml (6 /ml) (Trileptal) oxcarbazepine oral tablet 5, 3, (Trileptal) 6 phenobarbital oral elixir /5 ml (4 /ml) phenobarbital oral tablet, 5, 6., 3, 3.4, 6, 64.8, 97. PHENYTEK ORAL CAPSULE MG, 3 MG phenytoin oral suspension 5 /5 ml (Dilantin-5) phenytoin oral tablet,chewable 5 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) phenytoin sodium extended oral capsule (Phenytek), 3 primidone oral tablet 5, 5 (Mysoline) SABRIL ORAL TABLET 5 MG 3 PA; SP; QL (34 days supply per fill) tiagabine oral tablet, 4 (Gabitril) topiramate oral capsule, sprinkle 5, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) PA, 5,, 5, 5 topiramate oral tablet,, 5 (Topamax), 5 TROKENDI XR ORAL 3 PA CAPSULE,EXTENDED RELEASE 4HR MG, MG, 5 MG, 5 MG valproic acid (as sodium salt) oral (Depakene) solution 5 /5 ml valproic acid oral capsule 5 (Depakene) vigabatrin oral powder in packet 5 (Sabril) PA VIMPAT ORAL SOLUTION MG/ML 3 PA VIMPAT ORAL TABLET MG, 5 3 PA MG, MG, 5 MG zonisamide oral capsule, 5 (Zonegran) Geisinger 8 Commercial Formulary Effective: April, 8

34 zonisamide oral capsule 5 Antidementia Agents Antidementia Agents donepezil oral tablet, 3, 5 (Aricept) donepezil oral tablet,disintegrating, 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) 4 hr 6, 4, 8 galantamine oral solution 4 /ml galantamine oral tablet, 4, 8 (Razadyne) memantine oral capsule,sprinkle,er 4hr (Namenda XR) PA 4,, 8, 7 memantine oral solution /ml memantine oral tablet, 5 (Namenda) rivastigmine tartrate oral capsule.5, 3, 4.5, 6 Antidepressants Antidepressants amitriptyline oral tablet,, 5, 5, 5, 75 amitriptyline-chlordiazepoxide oral tablet.5-5, 5- amoxapine oral tablet, 5, 5, 5 APLENZIN ORAL TABLET 3 PA EXTENDED RELEASE 4 HR 74 MG, 348 MG, 5 MG bupropion hcl oral tablet, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) hr, 5, bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 5, 3 citalopram oral solution /5 ml citalopram oral tablet,, 4 (Celexa) clomipramine oral capsule 5, 5, (Anafranil) 75 desipramine oral tablet, 5 (Norpramin) desipramine oral tablet, 5, 5, 75 desvenlafaxine succinate oral tablet extended release 4 hr, 5, 5 (Pristiq) QL ( per day) Geisinger 8 Commercial Formulary 3 Effective: April, 8

35 doxepin oral capsule,, 5, 5, 5, 75 doxepin oral concentrate /ml duloxetine oral capsule,delayed (Cymbalta) release(dr/ec), 3, 6 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet,, 5 (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 3 PA 4HR DOSE PACK MG ()- 4 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR MG, MG, 4 MG, 8 MG 3 PA fluoxetine oral capsule,, 4 (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 9 fluoxetine oral solution /5 ml (4 /ml) fluoxetine oral tablet, (Sarafem) FLUOXETINE ORAL TABLET 6 MG fluvoxamine oral tablet, 5, 5 FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 45 MG 3 PA; QL ( per day) imipramine hcl oral tablet, 5, (Tofranil) 5 imipramine pamoate oral capsule, 5, 5, 75 maprotiline oral tablet 5, 5, 75 mirtazapine oral tablet 5, 3, 45 (Remeron) mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 5 (Remeron SolTab), 3, 45 nefazodone oral tablet, 5,, 5, 5 nortriptyline oral capsule, 5, (Pamelor) 5, 75 nortriptyline oral solution /5 ml Geisinger 8 Commercial Formulary 4 Effective: April, 8

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