5 Tier Commercial Formulary 1st Quarter 2017

Transcription

1 5 Tier Commercial Formulary 1st Quarter 2017 Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 1

2 Notes ST= ST applies Drug Tier Notes 8-Mop PA abacavir abacavir-lamivudine-zidovudine Abelcet PA Abilify oral tablet Abraxane PA acamprosate PA acarbose Accolate Accu-Chek Aviva Control Soln Accu-Chek Aviva Plus Meter QL Accu-Chek Aviva Plus test strp Accu-Chek FastClix Accu-Chek Multiclix Lancet Accu-Chek Nano Accu-Chek SmartView Contrl Sol Accu-Chek SmartView Test Strip Accu-Chek Soft Dev Lancets Accu-Chek Softclix Lancet Dev Accu-Chek Softclix Lancets Accupril Aceon oral tablet 4 mg, 8 mg acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 2

3 Acetasol HC acetazolamide oral capsule, extended release PA acetazolamide oral tablet acetazolamide sodium acetic acid otic acetic acid-aluminum acetate acetylcysteine Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female Aciphex PA acitretin Actemra intravenous PA Acthar H.P. PA Actimmune PA Activase intravenous recon soln 50 mg PA Activella Actonel Actoplus MET Actoplus Met XR Actos acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir topical PA Aczone topical gel Adagen PA adapalene topical cream adapalene topical gel 0.1 % Adcetris PA Adcirca PA Adderall XR adefovir PA Adrenalin nasal Adrucil PA 3

4 Advair Diskus Advair HFA Advate PA Afinitor oral tablet 10 mg, 2.5 mg, 5 mg PA Afinitor oral tablet 7.5 mg Aggrenox Ala-Seb Alavert Alavert D-12 Allergy-Sinus Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 4 Alaway QL Albenza albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup albuterol sulfate oral tablet Aldactazide oral tablet mg Aldurazyme PA alendronate oral tablet Alferon N PA alfuzosin Alimta PA Alinia Alkeran intravenous PA Alkeran oral allopurinol Alocril Alomide Alora Aloxi PA Alphanate intravenous recon soln 1,000 (400 vwf) unit/10 ml, 1,500 (600 vwf) unit/10 ml, 250 (100 vwf) unit/5 ml, 500 (200 vwf) unit/5 ml PA

5 AlphaNine SD PA alprazolam oral tablet Alrex Altabax Altace amantadine HCl oral capsule amantadine HCl oral solution Ambien CR PA AmBisome PA amcinonide topical cream amifostine crystalline PA amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml amiloride amiloride-hydrochlorothiazide aminocaproic acid intravenous PA aminophylline intravenous solution 250 mg/10 ml PA amiodarone oral tablet 200 mg Amitiza amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-benazepril oral capsule mg, mg, mg amlodipine-valsartan ST amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg ammonium chloride ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin oral capsule PA ST Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 5

6 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate amphotericin B ampicillin Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 6 ampicillin sodium PA ampicillin-sulbactam PA Ampyra PA Anadrol-50 anagrelide anastrozole Ancobon Androel Male Androxy Angeliq Anoro Ellipta Anzemet intravenous solution 100 mg/5 ml, 20 mg/ml Anzemet oral PA; QL Apidra Apidra SoloStar APOKYN PA apraclonidine Apri P Female Aptivus Aralast NP PA Aranelle (28) P Female Aranesp (in polysorbate) injection solution PA Aranesp (in polysorbate) injection syringe 100 mcg/0.5 ml, 150 mcg/0.3 ml, 200 mcg/0.4 ml, 25 mcg/0.42 ml, 300 mcg/0.6 ml, 40 mcg/0.4 ml, 500 mcg/ml, 60 mcg/0.3 ml PA PA

7 Arcalyst PA Arcapta Neohaler Arimidex aripiprazole oral tablet Armour Thyroid Arnuity Ellipta Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female Aromasin PA Arranon PA Artificial Tears (polyvin alc) Arzerra intravenous solution 100 mg/5 ml PA Asmanex HFA Asmanex Twisthaler aspirin-dipyridamole Astepro nasal spray,non-aerosol Atacand ST Atacand HCT oral tablet mg atenolol Atgam PA atorvastatin atovaquone PA atovaquone-proguanil ATRIPLA atropine injection syringe 0.1 mg/ml Atrovent HFA Aubagio PA Aubra P Female Augmentin XR Avage Avalide ST Avandamet oral tablet 2-1,000 mg, mg Avandia oral tablet 2 mg, 4 mg Avapro ST 7

8 Avastin PA Avelox QL Avelox ABC Pack QL Aviane P Female Avodart Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 8 Avonex (with albumin) PA Avonex intramuscular pen injector kit PA Avonex intramuscular syringe kit PA Azactam PA Azactam in dextrose (iso-osm) PA Azasan Azasite azathioprine azelastine Azelex Azilect azithromycin oral packet QL azithromycin oral suspension for reconstitution QL azithromycin oral tablet 250 mg, 500 mg, 600 mg QL Azopt Azor PA aztreonam PA bacitracin intramuscular bacitracin ophthalmic bacitracin-polymyxin B ophthalmic baclofen Bactroban Nasal balsalazide Balziva (28) P Female Banophen oral liquid Banzel oral tablet PA Baraclude

9 BD AutoShield Duo Pen Needle BD Insulin Pen Needle UF Mini BD Insulin Pen Needle UF Orig BD Insulin Pen Needle UF Short BD Insulin Syringe Ultra-Fine syringe 0.3 ml 30 gauge x 1/2", 0.3 ml 31 gauge x 5/16, 1 ml 29 gauge x 1/2", 1/2 ml 30 gauge x 1/2" BD Ultra-Fine Nano Pen Needles Beconase AQ PA benazepril benazepril-hydrochlorothiazide BeneFIX PA Benicar ST Benicar HCT ST Benlysta PA Benzamycin PA benzonatate oral capsule 100 mg, 200 mg benzoyl peroxide topical gel 10 % benztropine oral Bepreve PA Berinert intravenous kit PA Besivance betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment Betaseron subcutaneous kit PA betaxolol ophthalmic bethanechol chloride Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 9

10 Betimol ophthalmic drops 0.5 % bicalutamide Bicillin C-R Bicillin L-A Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 10 BiCNU PA Biltricide bisoprolol fumarate bisoprolol-hydrochlorothiazide Bivigam PA bleomycin PA Boniva intravenous PA Boniva oral Bosulif Botox PA Botox Cosmetic intramuscular PA Bravelle PA Breo Ellipta Brilinta brimonidine ophthalmic drops 0.2 % Bromfed DM bromfenac bromocriptine Brovana budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml budesonide nasal PA budesonide oral PA bumetanide oral Buphenyl oral tablet buprenorphine HCl sublingual PA buprenorphine-naloxone PA bupropion HCl QL

11 buspirone oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg Busulfex PA Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen butalbital-acetaminophen-caff oral tablet mg butorphanol tartrate nasal PA Butrans transdermal patch weekly 10 mcg/hour, 20 mcg/hour, 5 mcg/hour Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female Bydureon ST Byetta ST Bystolic cabergoline Caduet caffeine citrated oral calcipotriene topical cream calcipotriene-betamethasone calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule calcitriol topical calcium acetate oral capsule calcium acetate oral tablet 667 mg Camila P Female Camptosar PA Camrese P Female Canasa Cancidas PA candesartan ST candesartan-hydrochlorothiazid ST Capastat PA 11

12 capecitabine PA Caprelsa PA capsaicin topical cream % captopril captopril-hydrochlorothiazide Carafate oral suspension Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 12 Carbaglu PA carbamazepine oral capsule, ER multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable carbidopa carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbinoxamine maleate oral tablet carboplatin PA Cardizem LA Carimune NF Nanofiltered intravenous recon soln 12 gram, 6 gram carisoprodol oral tablet 350 mg Carnitor (sugar-free) Carnitor oral carteolol carvedilol Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 Cathflo Activase PA Cayston PA Cedax oral capsule PA

13 cefaclor oral capsule cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir cefditoren pivoxil oral tablet 200 mg cefepime PA cefepime in dextrose 5 % PA cefepime in dextrose,iso-osm PA cefotaxime PA cefotetan PA cefotetan in dextrose, iso-osm PA cefoxitin intravenous recon soln 1 gram cefpodoxime cefprozil ceftazidime PA Ceftin oral suspension for reconstitution 250 mg/5 ml ceftriaxone in dextrose,iso-os PA ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg ceftriaxone intravenous PA cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram PA cefuroxime sodium intravenous PA Celebrex ST celecoxib ST Celestone Soluspan PA PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 13

14 CellCept Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 14 CellCept Intravenous PA Celontin oral capsule 300 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution Cerezyme intravenous recon soln 400 unit PA Cesamet cetirizine oral solution 1 mg/ml cetirizine oral tablet cetirizine-pseudoephedrine Cetraxal cevimeline Chantix P QL Chantix Starting Month Box P QL Chateal P Female Chemet chloramphenicol sod succinate chlordiazepoxide HCl chlorhexidine gluconate mucous membrane chloroquine phosphate oral chlorothiazide chlorpromazine oral chlorpropamide chlorthalidone oral tablet 25 mg, 50 mg chlorzoxazone cholestyramine (with sugar) Cholestyramine Light oral powder in packet choline,magnesium salicylate chromium chloride Cialis ciclopirox topical gel ciclopirox topical solution

15 ciclopirox topical suspension cidofovir PA cilostazol Ciloxan ophthalmic ointment cimetidine cimetidine HCl oral Cimzia PA Cimzia Powder for Reconst PA Cinryze PA Cipro HC Cipro in D5W intravenous piggyback 400 mg/200 ml Cipro oral suspension,microcapsule recon Cipro XR Ciprodex ciprofloxacin ciprofloxacin HCl ophthalmic ciprofloxacin HCl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 ml cisplatin PA citalopram cladribine PA Claforan injection recon soln 1 gram, 10 gram, 2 gram Claforan intravenous recon soln PA Claravis PA Clarinex oral syrup PA Clarinex oral tablet PA Clarinex-D 12 HOUR PA clarithromycin QL Claritin RediTabs oral tablet,disintegrating 5 mg PA QL PA PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 15

16 clemastine oral tablet 2.68 mg Cleocin in 5 % dextrose PA Cleocin injection PA Cleocin intravenous solution 900 mg/6 ml PA Cleviprex Climara Climara Pro clindamycin HCl oral capsule 150 mg, 300 mg clindamycin palmitate HCl Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 16 clindamycin phosphate injection PA clindamycin phosphate intravenous solution 900 mg/6 ml clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin phosphate vaginal clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % Clinisol SF 15 % PA Clinpro 5000 clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream Cloderm P Clolar PA clomipramine clonazepam oral tablet clonidine clonidine (PF) epidural solution 1,000 mcg/10 ml (100 mcg/ml) PA

17 clonidine HCl oral tablet clopidogrel clorazepate dipotassium Clorpres clotrimazole mucous membrane clotrimazole topical clotrimazole-betamethasone topical cream QL clotrimazole-betamethasone topical lotion clozapine oral tablet Coartem codeine sulfate oral tablet colchicine-probenecid Colcrys PA colestipol oral tablet colistin (colistimethate Na) PA Coly-Mycin M Parenteral PA Coly-Mycin S Combigan CombiPatch Combivent Respimat Cometriq Complera CompleteNate P Female Comtan PA Condylox topical gel Contrave PA ConZip oral capsule,er biphase 24 hr mg Copaxone subcutaneous syringe PA Copegus PA Cordran topical cream Cordran topical lotion Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 17

18 Coreg CR Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 18 Corifact PA cortisone Cortisporin topical Cortrosyn PA Cosmegen PA cosyntropin injection PA Cozaar Creon Crestor Crinone Crixivan oral capsule 200 mg, 400 mg cromolyn inhalation cromolyn ophthalmic cromolyn oral Cryselle (28) P Female Cubicin PA Cuprimine cyclobenzaprine oral tablet 10 mg, 5 mg cyclopentolate ophthalmic drops 2 % cyclophosphamide intravenous PA cyclophosphamide oral capsule cycloserine Cycloset cyclosporine intravenous PA cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine oral capsule Cymbalta cyproheptadine Cystadane Cystagon cytarabine PA

19 cytarabine (PF) injection solution PA Cytoam intravenous solution 50 mg/ml PA Cytomel Cytovene PA D5 %-0.45 % sodium chloride PA dacarbazine PA Dacogen PA Daklinza PA Daliresp ST danazol oral PA dantrolene dapsone Daraprim daunorubicin intravenous solution PA Daytrana deferoxamine PA Delzicol oral capsule (with del rel tablets) demeclocycline Demser Denavir QL DepoCyt (PF) PA Depo-Provera intramuscular solution Female Depo-Provera intramuscular suspension Depo-Provera intramuscular syringe Dermacea Non-Woven topical sponge 4 X 4 " Dermazene DermOtic Oil Desferal PA desipramine oral tablet 10 mg, 150 mg, 25 mg, 50 mg desloratadine PA desmopressin nasal solution PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 19

20 desmopressin nasal spray,non-aerosol PA desmopressin oral PA desonide topical ointment desoximetasone topical cream Detrol LA dexamethasone Dexamethasone Intensol dexamethasone sodium phos (PF) dexamethasone sodium phosphate ophthalmic Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 20 Dexilant ST dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 30 mg, 5 mg dexrazoxane HCl PA dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextrose 70 % in water (D70W) PA Diamox Sequels diazepam oral tablet diazepam rectal QL Dibenzyline diclofenac potassium diclofenac sodium ophthalmic diclofenac sodium oral tablet,delayed release (DR/EC) diclofenac sodium topical gel 3 % dicloxacillin dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet didanosine Differin topical lotion Dificid

21 diflorasone topical cream Diflucan oral suspension for reconstitution Diflucan oral tablet 100 mg, 200 mg, 50 mg Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female Diflucan oral tablet 150 mg QL diflunisal Digox digoxin oral tablet dihydroergotamine injection dihydroergotamine nasal QL Dilantin Dilantin Infatabs diltiazem HCl oral capsule, extended release diltiazem HCl oral capsule,ext release degradable diltiazem HCl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem HCl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral tablet DILT-XR Diovan ST Diovan HCT diphenhydramine HCl injection solution 50 mg/ml diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule diphenhydramine HCl oral tablet 25 mg diphenoxylate-atropine dipyridamole oral disopyramide phosphate oral capsule disulfiram Diuril divalproex Divigel 21

22 Docefrez PA docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) donepezil oral tablet 10 mg, 5 mg donepezil oral tablet,disintegrating Doribax PA Doryx oral tablet,delayed release (DR/EC) 200 mg, 50 mg dorzolamide dorzolamide-timolol doxazosin doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate doxercalciferol oral Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 22 doxorubicin intravenous solution PA doxorubicin, peg-liposomal doxycycline hyclate intravenous PA doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg Drithocreme HP dronabinol oral capsule 2.5 mg droperidol injection solution drospirenone-ethinyl estradiol oral tablet mg Droxia P Duac PA Duavee DUETACT Dulera QL PA Female

23 duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg Duraclon (PF) epidural solution 1,000 mcg/10 ml (100 mcg/ml) Durezol Dyrenium Dysport PA Easy Touch needle 31 gauge x 3/16" econazole topical Edarbi PA Edarbyclor PA Edecrin Edluar PA Edurant Effient Egrifta subcutaneous recon soln 1 mg PA Elaprase PA Elelyso Elidel PA Eligard PA Eliphos PA Eliquis Elitek PA Ella P Female Ellence PA Elmiron PA Emadine PA Embeda Emcyt Emend intravenous Emend oral capsule 125 mg, 80 mg Emend oral capsule 40 mg QL Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 23

24 Emend oral capsule,dose pack Emsam Emtriva Enablex enalapril maleate Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 24 enalaprilat intravenous solution PA enalapril-hydrochlorothiazide Enbrel PA Enbrel SureClick PA Endocet oral tablet mg Endodan Endometrin PA Enjuvia oral tablet mg, 0.9 mg, 1.25 mg enoxaparin Enpresse P Female entacapone PA entecavir Entereg Entocort EC PA Epiduo topical gel epinastine epinephrine injection solution epinephrine injection syringe 0.1 mg/ml EpiPen QL EpiPen 2-Pak QL EpiPen Jr QL EpiPen Jr 2-Pak QL epirubicin intravenous recon soln 50 mg PA epirubicin intravenous solution PA Epivir Epivir HBV PA eplerenone

25 Epogen injection solution 10,000 unit/ml, 2,000 unit/ml, 20,000 unit/2 ml, 20,000 unit/ml, 3,000 unit/ml, 4,000 unit/ml epoprostenol (glycine) PA eprosartan PA Epzicom Equetro oral capsule, ER multiphase 12 hr 100 mg Eraxis(Water Diluent) PA Erbitux PA ergocalciferol (vitamin D2) oral capsule ergoloid Ergomar Erivedge PA Errin P Female Ertaczo Erwinaze PA Ery Pads EryPed 200 EryPed 400 Ery-Tab Erythrocin Erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin ophthalmic erythromycin oral capsule,delayed release(dr/ec) erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin-benzoyl peroxide escitalopram oxalate estazolam estradiol estradiol valerate intramuscular oil 40 mg/ml PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 25

26 estradiol-norethindrone acet Estring Estroel estrogens-methyltestosterone estropipate Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 26 eszopiclone PA ethambutol ethosuximide etidronate disodium etodolac oral tablet 500 mg Etopophos PA etoposide PA Euflexxa PA Eurax topical lotion QL Evekeo Evista Female Evotaz Evoxac PA Exalgo ER oral tablet extended release 24 hr 32 mg Exelderm topical cream Exelon transdermal patch 24 hour 4.6 mg/24 hr, 9.5 mg/24 hr exemestane Exforge ST Exforge HCT ST Exjade PA Extavia subcutaneous kit PA Eylea PA Fabrazyme PA Factive famciclovir

27 famotidine oral tablet 20 mg, 40 mg Famvir Fanapt oral tablet 1 mg Fareston PA Farxiga ST Faslodex PA FE C Plus Feiba NF PA felbamate oral tablet felodipine Femara P Femhrt Low Dose Female Femring fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 160 mg, 54 mg fenoprofen oral tablet fentanyl citrate (PF) injection fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr Feraheme PA Ferriprox oral tablet PA Ferrlecit PA fexofenadine oral suspension ST fexofenadine oral tablet 180 mg ST Finacea topical gel finasteride Firazyr PA Flarex flavoxate Flebogamma DIF intravenous solution 5 % PA flecainide QL Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 27

28 Flector Flolan PA Flovent Diskus Flovent HFA floxuridine PA fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml fluconazole in NaCl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 mg Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 28 fluconazole oral tablet 150 mg QL flucytosine fludarabine PA fludrocortisone flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluocinolone acetonide oil fluocinolone and shower cap fluocinolone topical cream fluocinolone topical ointment fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution Fluocinonide-E Fluoritab oral drops fluorometholone fluorouracil intravenous PA fluorouracil topical cream 5 % fluorouracil topical solution 2 % fluoxetine oral capsule 10 mg, 20 mg fluoxetine oral capsule 40 mg PA P PA PA

29 fluoxetine oral solution fluphenazine decanoate fluphenazine HCl injection fluphenazine HCl oral tablet flurbiprofen oral tablet 100 mg flurbiprofen sodium flutamide Male fluticasone fluvoxamine oral tablet FML Forte FML S.O.P. Focalin XR folic acid oral tablet 1 mg Folotyn PA fondaparinux subcutaneous syringe 10 mg/0.8 ml Foradil Aerolizer Fortaz in dextrose 5 % PA Fortaz injection recon soln 1 gram, 2 gram, 6 gram PA Fortaz intravenous PA Forteo PA Fosamax oral tablet 70 mg Fosamax Plus D foscarnet PA fosinopril fosinopril-hydrochlorothiazide fosphenytoin Fosrenol Fragmin subcutaneous solution Frova PA; QL furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 29

30 Fusilev PA Fuzeon subcutaneous recon soln PA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg galantamine oral capsule,ext rel. pellets 24 hr 24 mg alzin PA amastan S/D PA ammagard Liquid PA ammaplex PA amunex-c injection solution 1 gram/10 ml (10 %), 10 gram/100 ml (10 %), 2.5 gram/25 ml (10 %), 20 gram/200 ml (10 %), 5 gram/50 ml (10 %) gatifloxacin Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 30 attex 30-Vial PA attex One-Vial PA gemcitabine PA gemfibrozil oral emzar PA engraf oral capsule 100 mg, 25 mg enotropin PA enotropin MiniQuick PA entak ophthalmic ointment gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml gentamicin injection PA gentamicin ophthalmic drops gentamicin sulfate (PF) intravenous solution 100 mg/10 ml, 60 mg/6 ml gentamicin topical ilenya PA PA PA PA

31 lassia PA leevec PA liadel Wafer PA glimepiride glipizide glipizide-metformin lucaen HypoKit QL lucagon Emergency Kit (human) QL glyburide micronized glyburide oral glyburide-metformin glycopyrrolate injection glycopyrrolate oral lyset oral tablet 100 mg ralise PA granisetron (PF) PA granisetron HCl intravenous PA granisetron HCl oral PA rastek griseofulvin microsize griseofulvin ultramicrosize oral tablet 125 mg griseofulvin ultramicrosize oral tablet 250 mg PA ris-pe (ultramicrosize) PA guanfacine guanidine ynazole-1 Halaven PA halobetasol propionate topical cream Halog haloperidol decanoate haloperidol lactate Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 31

32 haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 20 mg, 5 mg haloperidol oral tablet 10 mg PA Harvoni PA Hectorol oral Helixate FS PA Hemofil M High PA Hemofil M Low PA Hemofil M Mid PA Hemofil M Super High PA heparin (porcine) in 5 % dex PA heparin (porcine) in NaCl (PF) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection solution 10,000 unit/ml, 5,000 unit/ml Hepsera PA Herceptin PA Hexalen PA Hizentra subcutaneous solution 1 gram/5 ml (20 %), 2 gram/10 ml (20 %), 4 gram/20 ml (20 %) Horizant oral tablet extended release 600 mg Humalog QL Humalog KwikPen subcutaneous insulin pen 100 unit/ml Humalog Mix QL Humalog Mix KwikPen QL Humalog Mix QL Humalog Mix KwikPen QL Humate-P intravenous kit 1,000-2,400 unit PA Humatrope PA Humira Pen Crohn's-UC-HS Start PA Humira Pen Psoriasis Starter PA PA PA QL Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 32

33 Humira subcutaneous syringe kit 20 mg/0.4 ml, 40 mg/0.8 ml Humulin 70/30 QL Humulin N QL Humulin R QL Humulin R U-500 (Concentrated) QL Hyalgan PA Hycamtin PA hydralazine oral hydrochlorothiazide oral tablet hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-homatropine oral syrup mg/5 ml hydrocodone-homatropine oral tablet hydrocodone-ibuprofen oral tablet mg PA hydrocortisone oral hydrocortisone rectal enema hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone-acetic acid hydrocortisone-aloe vera topical cream 1 % hydrocortisone-min oil-wht pet hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 32 mg hydromorphone rectal hydroxychloroquine oral hydroxyurea PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 33

34 hydroxyzine HCl oral solution 10 mg/5 ml hydroxyzine HCl oral tablet hydroxyzine pamoate hyoscyamine sulfate oral ibandronate oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen-oxycodone Iclusig Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 34 Idamycin PFS PA idarubicin PA Ifex PA ifosfamide PA ifosfamide-mesna intravenous kit 1-1 gram PA Ilaris (PF) PA Ilevro imipramine HCl imipramine pamoate imiquimod QL Increlex PA Incruse Ellipta indapamide Inderal LA Inderal XL Indocin oral indomethacin oral Infed PA Infumorph P/F injection solution 10 mg/ml Inlyta PA InnoPran XL Inspra Insulin Syringe MicroFine syringe 0.3 ml 28 gauge x 1/2"

35 Intelence Intralipid intravenous emulsion 20 %, 30 % PA Intron A injection PA Intuniv ER Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female Invanz PA Invega Sustenna PA Invirase Invokamet ST Invokana ST ipratropium bromide ipratropium-albuterol irbesartan ST irbesartan-hydrochlorothiazide ST irinotecan PA Isentress Isolyte-S isoniazid oral Isordil isosorbide dinitrate oral isosorbide mononitrate isradipine Istodax PA itraconazole Ixempra PA Jakafi PA Jalyn Janumet ST Janumet XR ST Januvia ST Jentadueto ST Jetrea (PF) PA Jevtana PA 35

36 Jinteli Jolessa P Female Jolivette P Female Junel 1.5/30 (21) P Female Junel 1/20 (21) P Female Junel FE 1.5/30 (28) P Female Junel FE 1/20 (28) P Female Kadcyla PA Kadian oral capsule,extend.release pellets 10 mg, 200 mg Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 36 Kalbitor PA Kaletra Kalydeco oral tablet PA Kariva (28) P Female Kelnor 1/35 (28) P Female Kepivance PA Keppra intravenous PA Ketek ketoconazole oral ketoconazole topical cream ketoconazole topical shampoo ST ketoprofen oral capsule ketorolac ophthalmic ketorolac oral ketotifen fumarate QL Kineret PA Klor-Con Klor-Con 8 Klor-Con M10 Klor-Con M20 Koate-DVI intravenous recon soln PA Kogenate FS PA

37 Kombiglyze XR ST Krystexxa PA Kuvan oral tablet,soluble PA Kynamro PA Kyprolis intravenous recon soln 60 mg PA labetalol oral lactulose oral solution 10 gram/15 ml Lamictal Starter (Blue) Kit Lamictal Starter (reen) Kit Lamictal Starter (Orange) Kit Lamisil lamivudine oral solution Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female lamivudine oral tablet 100 mg PA lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible lansoprazole oral capsule,delayed release(dr/ec) PA Lantus QL Lantus Solostar QL Lastacaft PA latanoprost Latuda Leena 28 P Female leflunomide Lessina P Female Letairis PA letrozole QL leucovorin calcium injection recon soln PA leucovorin calcium oral Leukeran Leukine injection recon soln PA 37

38 leuprolide subcutaneous kit PA levalbuterol HCl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml Levaquin oral tablet 250 mg, 500 mg Levatol Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 38 Levemir QL Levemir FlexTouch QL levetiracetam intravenous PA levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr levobunolol ophthalmic drops 0.5 % levocarnitine oral tablet levocetirizine oral solution PA levocetirizine oral tablet ST levofloxacin oral solution QL levofloxacin oral tablet QL Levora-28 P Female levorphanol tartrate levothyroxine oral Lexiva Lialda lidocaine (PF) intravenous syringe 100 mg/5 ml (2 %) lidocaine HCl injection solution 5 mg/ml (0.5 %) lidocaine HCl mucous membrane jelly in applicator lidocaine HCl mucous membrane solution 4 % (40 mg/ml) lidocaine HCl topical cream 3 % lidocaine topical adhesive patch,medicated PA lidocaine topical ointment

39 Lidocaine Viscous lidocaine-prilocaine topical cream QL Lidoderm PA Lincocin PA linezolid oral tablet Lioresal PA liothyronine oral Liposyn II PA Liposyn III PA lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate oral solution 8 meq/5 ml Livalo Lodosyn loperamide oral capsule loratadine oral solution loratadine oral tablet Loratadine-D oral tablet extended release 24 hr lorazepam oral tablet losartan losartan-hydrochlorothiazide Lotemax ophthalmic drops,suspension Lotensin oral tablet 20 mg, 40 mg Lotrel oral capsule mg, mg, 5-10 mg, 5-20 mg, 5-40 mg Lotronex PA lovastatin Lovaza Lovenox Low-Ogestrel (28) P Female loxapine succinate Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 39

40 Lucentis PA Lumigan ophthalmic drops 0.01 % Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 40 Lumizyme PA Lunesta PA Lupron Depot PA Lupron Depot (3 Month) PA Lupron Depot (4 Month) PA Lupron Depot (6 Month) PA Lupron Depot-Ped PA Lupron Depot-Ped (3 Month) intramuscular syringe kit 30 mg Lutera (28) P Female Lyrica oral capsule Lysodren Lyza P Female Macrodantin oral capsule 25 mg Macugen PA magnesium sulfate in D5W intravenous piggyback 1 gram/100 ml magnesium sulfate in D5W intravenous solution 10 gram/500 ml magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection PA Makena intramuscular oil 250 mg/ml PA Malarone Malarone Pediatric malathion maprotiline Marplan Matulane Mavik oral tablet 1 mg, 2 mg Maxalt PA; QL PA

41 Maxalt-MLT PA; QL Maxidex meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable meclofenamate oral Medrol oral tablet 2 mg medroxyprogesterone intramuscular P Female medroxyprogesterone oral Female mefenamic acid mefloquine Megace ES QL megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml QL megestrol oral tablet meloxicam oral tablet melphalan HCl PA memantine oral tablet memantine oral tablets,dose pack Menest Menostar Mentax meperidine oral Mephyton meprobamate Mepron PA mercaptopurine meropenem PA Merrem PA mesalamine rectal mesna PA Mesnex intravenous PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 41

42 Mestinon oral Mestinon Timespan metaproterenol oral tablet metaxalone oral tablet 800 mg metformin oral tablet metformin oral tablet extended release 24 hr methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble methamphetamine methazolamide oral methenamine hippurate methenamine mandelate oral tablet 1 gram methimazole oral tablet 10 mg, 5 mg Methitest methocarbamol oral methotrexate sodium methotrexate sodium (PF) injection solution Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 42 methoxsalen rapid PA methscopolamine oral methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate methylergonovine oral methylphenidate oral solution 10 mg/5 ml methylphenidate oral tablet methylphenidate oral tablet extended release 20 mg methylphenidate oral tablet extended release 24hr methylphenidate oral tablet,chewable

43 methylprednisolone methylprednisolone sodium succ intravenous PA metipranolol metoclopramide HCl oral solution metoclopramide HCl oral tablet metolazone metoprolol succinate metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg Metro I.V. PA Metrogel topical gel 1 % PA metronidazole in NaCl (iso-os) PA metronidazole oral tablet metronidazole topical gel metronidazole topical lotion metronidazole vaginal mexiletine Miacalcin Micardis PA Micardis HCT PA Miconazole-3 vaginal suppository MICRhoAM Ultra-Filtered PLUS PA Microgestin 1.5/30 (21) P Female Microgestin 1/20 (21) P Female Microgestin Fe 1.5/30 (28) P Female Microgestin FE 1/20 (28) P Female midodrine Migranal QL Mineral Oil Heavy oral Minivelle transdermal patch semiweekly mg/24 hr Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 43

44 Minivelle transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr minocycline oral capsule 100 mg, 50 mg minoxidil oral Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 44 Mirena PA mirtazapine misoprostol mitomycin PA mitoxantrone PA modafinil moexipril moexipril-hydrochlorothiazide mometasone topical cream QL mometasone topical ointment QL mometasone topical solution Monoclate-P intravenous recon soln 1,000 (+/-) unit Monodox Female Mononessa (28) P Female Mononine PA montelukast Monurol morphine concentrate oral solution morphine intravenous cartridge 8 mg/ml morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution morphine oral tablet morphine oral tablet extended release morphine rectal Motofen Movantik PA

45 MoviPrep Moxatag PA Moxeza moxifloxacin QL Mozobil PA Multaq PA Multigen Multigen Folic Multigen Plus Multi-Vit with Fluoride-Iron Multi-Vitamin With Fluoride oral drops Multivitamins With Fluoride oral tablet,chewable 0.5 mg, 1 mg mupirocin mupirocin calcium Mustargen PA Myambutol oral tablet 400 mg P P P P P P Mycamine PA Mycobutin mycophenolate mofetil oral capsule mycophenolate mofetil oral tablet Myleran Mynatal oral tablet P Female Mynatal Plus P Female Mynatal-Z P Female Mynate 90 Plus P Female Myobloc PA Myozyme PA Myrbetriq nabumetone oral tablet 750 mg nadolol Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 45

46 nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml nafcillin injection PA Naftin topical gel 1 % Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 46 Naglazyme PA nalbuphine naloxone injection syringe 1 mg/ml naltrexone Namenda oral tablet Namenda Titration Pak Namenda XR Namzaric naproxen naproxen sodium oral tablet 275 mg, 550 mg Nasacort ST Nasonex nateglinide Natroba ST Nature-Throid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg Navelbine PA Nebupent PA Necon 1/35 (28) P Female Necon 1/50 (28) P Female Necon 10/11 (28) P Female Necon 7/7/7 (28) P Female nefazodone neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin B U neomycin-polymyxin B-dexameth PA

47 neomycin-polymyxin-gramicidin neomycin-polymyxin-hc Neoral Neulasta subcutaneous syringe PA Neupogen PA Nevanac nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 400 mg Nexavar PA Nexium PA Nexium 24HR oral capsule,delayed release(dr/ec) Nexium Packet oral granules DR for susp in packet 10 mg, 20 mg, 40 mg Next Choice One Dose P Female niacin oral tablet extended release 24 hr Niacor Niaspan Extended-Release nicardipine oral Nicomide Nicotrol Nicotrol NS P QL Nifedical XL nifedipine oral capsule nifedipine oral tablet extended release 24hr Nilandron PA nimodipine Nipent PA nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg P ST PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 47

48 Nitro-Dur transdermal patch 24 hour 0.3 mg/hr, 0.8 mg/hr nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin oral nitroglycerin oral capsule, extended release 2.5 mg, 6.5 mg nitroglycerin sublingual tablet 0.4 mg nitroglycerin transdermal patch 24 hour Nitrostat Nitro-Time oral capsule, extended release 9 mg nizatidine oral capsule Nizoral A-D Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 48 Nora-BE P Female Norditropin FlexPro subcutaneous pen injector 10 mg/1.5 ml (6.7 mg/ml), 15 mg/1.5 ml (10 mg/ml), 5 mg/1.5 ml (3.3 mg/ml) norethindrone acetate Female Normosol-R ph 7.4 Norpace CR Nortrel 0.5/35 (28) P Female Nortrel 1/35 (21) P Female Nortrel 1/35 (28) P Female Nortrel 7/7/7 (28) P Female nortriptyline oral capsule Norvasc Norvir Novolin 70/30 Novolin N Novolin R Novolog Novolog Flexpen Novolog Mix PA

49 Novolog Mix FlexPen Novolog PenFill Novoseven RT PA Noxafil Nplate PA Nucynta ER Nucynta oral tablet 100 mg Nuedexta Nulojix Nutropin AQ PA Nutropin AQ Nuspin subcutaneous pen injector 10 mg/2 ml (5 mg/ml), 5 mg/2 ml (2.5 mg/ml) NuvaRing P Female Nuvigil oral tablet 150 mg, 250 mg, 50 mg nystatin oral nystatin topical cream nystatin topical ointment nystatin-triamcinolone Ocella P Female octreotide acetate PA ofloxacin ophthalmic ofloxacin oral tablet 400 mg ofloxacin otic Ogestrel (28) P Female olanzapine oral tablet olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 mg omega-3 acid ethyl esters omeprazole magnesium ST omeprazole oral capsule,delayed release(dr/ec) omeprazole-sodium bicarbonate ST Omnaris PA PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 49

50 Omnitrope PA ondansetron QL ondansetron HCl (PF) injection solution PA ondansetron HCl intravenous PA ondansetron HCl oral solution QL ondansetron HCl oral tablet 4 mg, 8 mg QL Onglyza ST Opana ER oral tablet,oral only,ext.rel.12 hr Oracea Oralone Orap Oravig Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 50 Orencia PA Orencia (with maltose) PA Orfadin oral capsule PA orphenadrine citrate oral Ortho Tri-Cyclen Lo (28) P Female ORTHOVISC PA OsmoPrep Otovel oxacillin in dextrose(iso-osm) oxacillin injection PA oxaliplatin PA oxandrolone PA oxaprozin oxazepam oxcarbazepine oral tablet Oxistat topical lotion Oxsoralen Oxsoralen Ultra PA oxybutynin chloride oral oxycodone oral capsule

51 oxycodone oral concentrate oxycodone oral tablet oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 20 mg, 40 mg, 80 mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin OxyContin oral tablet,oral only,ext.rel.12 hr PA oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 12 hr 15 mg Ozurdex PA paclitaxel PA pamidronate PA Panhematin PA Panretin pantoprazole oral papaverine injection solution paricalcitol oral Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female paromomycin PA; QL paroxetine HCl oral tablet paroxetine HCl oral tablet extended release 24 hr Paser PA Pataday ST; QL Patanase Patanol ST; QL Paxil oral suspension Pazeo ST; QL PCE Pediaderm TA peg 3350-electrolytes oral recon soln gram Peganone Pegasys ProClick PA PA 51

52 Pegasys subcutaneous solution PA PegIntron PA PegIntron Redipen PA penicillin pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin potassium PA penicillin procaine penicillin sodium penicillin V potassium Pentasa pentazocine-naloxone pentoxifylline perindopril erbumine Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 52 Perjeta PA permethrin topical cream QL permethrin topical liquid QL perphenazine perphenazine-amitriptyline Pfizerpen- PA phenazopyridine oral tablet 100 mg, 200 mg phenelzine phenobarbital phenylephrine HCl injection phenylephrine HCl ophthalmic phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg Phospholine Iodide Photofrin PA Picato pilocarpine HCl ophthalmic drops 1 %, 2 %, 4 % pilocarpine HCl oral

53 pindolol Pin-X oral suspension Pin-X oral tablet,chewable pioglitazone pioglitazone-metformin piperacillin-tazobactam PA piroxicam Plan B One-Step P PA; Female Plasma-Lyte 148 Plegridy PA Pneumovax 23 injection solution podofilox polyethylene glycol 3350 oral powder polymyxin B sulfate polymyxin B sulf-trimethoprim P Portia P Female potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % NaCl potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) Potiga PR Natal 400 P Female PR Natal 400 EC P Female PR Natal 430 P Female Pradaxa pramipexole oral tablet Prandin Pravachol oral tablet 20 mg, 40 mg, 80 mg ST Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 53

54 pravastatin ST prazosin oral Precose Pred Mild Pred- Pred- S.O.P. prednicarbate prednisolone acetate prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate ophthalmic prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating 10 mg, 15 mg Prednisone Intensol prednisone oral Prefest Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 54 Premarin oral Female Premarin vaginal Female Premphase Female Prempro Female Prenatal 19 (with docusate) P Female Prenatal Low Iron P Female Prenatal Vitamin Plus Low Iron P Female Prevacid PA Prevacid SoluTab Prevalite Prevpac Prezcobix Prezista oral suspension Prezista oral tablet 150 mg, 600 mg, 75 mg, 800 mg

55 Prialt PA Priftin Prilosec oral susp,delayed release for recon PA Prilosec OTC primaquine Primaxin IV intravenous recon soln 250 mg PA primidone Prinivil oral tablet 10 mg, 20 mg, 5 mg Pristiq Privigen PA probenecid procainamide injection prochlorperazine prochlorperazine Edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral Procrit PA Proctofoam HC Proctosol HC Proctozone-HC Profilnine PA Proglycem Prograf intravenous PA Prograf oral Prolastin-C PA Proleukin PA Prolia PA Promacta PA promethazine injection solution promethazine oral promethazine rectal suppository 12.5 mg, 25 mg Promethazine VC Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 55

56 Promethazine VC-Codeine promethazine-codeine promethazine-dm Prometrium propafenone oral tablet propantheline proparacaine propranolol oral propranolol-hydrochlorothiazid propylthiouracil Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 56 Prosol 20 % PA Protonix oral granules DR for susp in packet PA Protopic PA protriptyline Provenge PA Pulmicort inhalation suspension for nebulization 1 mg/2 ml Pulmozyme PA Pylera pyrazinamide pyridostigmine bromide oral tablet Qualaquin Quasense P Female quetiapine QuilliChew ER Quillivant XR quinapril quinidine sulfate oral tablet quinine sulfate Qvar rabeprazole PA Ragwitek QL

57 raloxifene Female ramipril Ranexa ranitidine HCl injection solution 50 mg/2 ml (25 mg/ml) ranitidine HCl oral syrup ranitidine HCl oral tablet 150 mg, 300 mg Rapaflo Rapamune REBETOL oral solution PA Rebif (with albumin) PA Rebif Titration Pack PA Reclast PA Reclipsen (28) P Female Recombinate PA Rectiv Regonol Regranex Relenza Diskhaler QL Relpax Remicade PA Remodulin PA Renova topical cream 0.02 % PA Renvela oral tablet repaglinide oral tablet 2 mg Repatha SureClick PA Repatha Syringe PA Rescriptor reserpine Restasis Retin-A Micro topical gel 0.04 % PA Retisert PA PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 57

58 Retrovir intravenous Retrovir oral capsule Retrovir oral syrup Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 58 Revatio intravenous PA Revatio oral tablet PA Revlimid PA Reyataz oral capsule 150 mg, 200 mg, 300 mg Reyataz oral powder in packet Rheumatrex RhoAM Ultra-Filtered PLUS PA Rhophylac PA Ribasphere oral tablet 400 mg, 600 mg PA Ribasphere RibaPak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule PA ribavirin oral tablet 200 mg PA Ridaura rifabutin Rifadin intravenous PA Rifamate rifampin intravenous PA rifampin oral Rifater Rilutek PA riluzole PA rimantadine risedronate oral tablet Risperdal Consta PA risperidone oral solution risperidone oral tablet Rituxan PA PA

59 rivastigmine tartrate rizatriptan oral tablet PA; QL rizatriptan oral tablet,disintegrating 10 mg PA; QL rizatriptan oral tablet,disintegrating 5 mg QL ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Rozerem ST Rythmol SR Sabril PA Saizen PA Saizen click.easy PA salsalate Samsca PA Sandimmune intravenous PA Sandimmune oral Sandostatin PA Sandostatin LAR Depot intramuscular kit PA Santyl Saphris (black cherry) sublingual tablet 5 mg Savella scopolamine HBr PA selegiline HCl selenium sulfide topical shampoo 2.25 % Selzentry Se-Natal 19 P Female Se-Natal 19 (with docusate) P Female Sensipar PA Serevent Diskus Seroquel XR oral tablet extended release 24 hr Serostim subcutaneous recon soln 4 mg, 5 mg, 6 mg sertraline PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 59

60 SF SF 5000 Plus Silenor silver sulfadiazine Simbrinza Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 60 P P Simponi subcutaneous pen injector 50 mg/0.5 ml PA Simponi subcutaneous syringe 50 mg/0.5 ml PA Simulect PA simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Singulair Sklice Skyla PA sodium chlor 0.9% bacteriostat sodium chloride 0.9 % injection syringe sodium chloride 5 % PA sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride irrigation Sodium Edecrin sodium fluoride dental sodium fluoride oral drops sodium fluoride oral tablet,chewable sodium polystyrene (sorb free) Soft Touch Lancets Solaraze Solesta P P P Soliris PA Solu-Medrol intravenous recon soln 1,000 mg, 500 mg Somatuline Depot PA Somavert subcutaneous recon soln 10 mg, 15 mg, 20 mg Soriatane oral capsule 10 mg, 17.5 mg, 25 mg PA PA

61 Sotalol AF sotalol oral Sovaldi PA Spectracef oral tablet 400 mg spinosad ST Spiriva Respimat Spiriva with HandiHaler spironolactone spironolacton-hydrochlorothiaz Sporanox Sprintec (28) P Female Sprycel PA SPS rectal Sronyx P Female SSKI Starlix stavudine Stelara subcutaneous syringe PA Stivarga QL Strattera streptomycin intramuscular Stribild Stromectol Suboxone Sucraid PA sucralfate oral tablet sufentanil citrate Sular oral tablet extended release 24 hr 17 mg, 34 mg, 8.5 mg sulfacetamide sodium (acne) sulfacetamide sodium ophthalmic drops Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 61

62 sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) sulfacetamide-prednisolone sulfadiazine oral sulfamethoxazole-trimethoprim intravenous PA sulfamethoxazole-trimethoprim oral Sulfamylon topical packet PA sulfasalazine sulindac oral tablet 200 mg sumatriptan QL sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL sumatriptan succinate subcutaneous solution QL Supprelin LA PA Suprax oral capsule Suprax oral suspension for reconstitution Suprax oral tablet,chewable Suprep Bowel Prep Kit Sustiva Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 62 Sutent oral capsule 12.5 mg, 25 mg, 50 mg PA Syeda P Female Symbicort SymlinPen 120 SymlinPen 60 Synagis PA Synalar TS Synarel Synera Synercid PA Synribo Synthroid

63 Synvisc PA Synvisc-One PA Syprine PA Tabloid Taclonex tacrolimus oral tacrolimus topical ointment 0.03 % PA Talwin Tamiflu QL tamoxifen Female tamsulosin Male Tarceva PA Targretin PA Tarka Tasigna PA Tasmar oral tablet 100 mg PA Taxotere intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml) TAZICEF intravenous PA Tazorac topical cream Taztia XT Tears Naturale Free (PF) Tears Naturale II Tecfidera PA Teflaro intravenous recon soln 400 mg Tegretol XR oral tablet extended release 12 hr 100 mg Tekamlo ST Tekturna ST Tekturna HCT ST temazepam oral capsule 15 mg, 30 mg Temodar PA PA Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 63

64 temozolomide PA teniposide PA terazosin terbinafine HCl oral QL terbutaline oral terconazole Testim PA testosterone cypionate intramuscular oil 200 mg/ml testosterone enanthate QL testosterone transdermal gel PA tetracycline Thalomid PA Theo-24 theophylline oral tablet extended release theophylline oral tablet extended release 12 hr 200 mg, 300 mg Status = eneric, = Non-Preferred Brand, P = Preventative = Preferred Brand,Female = Female 64 Theracys P PA thioridazine PA thiotepa PA thiothixene Thymoglobulin PA Thyrogen PA Thyrolar-1 Thyrolar-1/2 Thyrolar-1/4 Thyrolar-2 Thyrolar-3 tiagabine Tiazac Tice BC P PA ticlopidine QL