HealthPartners PreferredRx

Transcription

1 HealthPartners PreferredRx Drug List (formulary) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, HealthPartners

2 What s the PreferredRx drug list? This is the list of medicines (a drug list sometimes also called a formulary) covered by your health plan. The drug list is reviewed by a team of clinical experts every three months for new medicines, safety alerts and other developments. Who decides what s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee (P&T) manages the list. This team of clinical experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information on how we decide what medicines are included on the drug lists. How do you use the drug list? The medicines on the drug list are listed in alphabetical order by medicine category starting on page 4. Some medicines are listed in ALL CAPS and others are lower italics to help you determine which medicines are brand and which are generic. Brand medicines are the most costly. Generic medicines are just as safe and effective as brand medicines but cost you less, and some generic medicines are very low-cost. Use this key to help: What do the abbreviations in the More details column mean? This column gives special information about the medicine you re searching for. The abbreviations let you know there might be a special program or rules for the medicine. Use this key to help you navigate the drug list: Prior Authorization Required Step Therapy Required Age Edit Gender Edit Female Gender Edit Male Quantity Limit Smoking Cessation Specialty Drugs Trial Drug Program Weight Loss Oncology Brand medicines are in ALL CAPS (e.g., KEFLEX) What s Step Therapy? Generic medicines are in lower italics (e.g., cephalexin) o o High-Cost Generics Low-Cost Generics Why do you need prior authorization for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits. Your doctor will get the approval for you. The approval decision is usually made within 2 to 3 working days of the request. Some medicines are on the drug list, but require you to try one or more other drug list medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't tried the other medicine(s) first, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance. The approval decision is usually made within 2 to 3 working days of the request. What s Age Edit? An age edit means some medicines are only covered if you re within a specific age range. If you're not in the approved age range, you or your doctor will need to

3 request approval from HealthPartners if you want your medicine to be covered by your pharmacy benefits. The approval decision is usually made within 2 to 3 working days of the request. What s Gender Edit? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners if you want your medicine to be covered by your pharmacy benefits. The approval decision is usually made within 2 to 3 working days of the request. What s Trial Drug Program? The trial drug program applies to new prescriptions for certain medicines that may not be well tolerated due to: Side effects High cost High potential for waste Your first fill of a trial drug may be limited to less than a month supply. If the drug is well tolerated and effective, you ll get the remainder of your first month supply. If a flat dollar copay applies to the medicine, you ll pay no more than one copay for each one month supply. What s a Quantity Limit? This means HealthPartners limits the amount of the medicine that you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description. What s Smoking Cessation? These are medicines that can be used to help you stop smoking. Some medicines used for smoking cessation may have limits on the amount you get. What s Specialty Medicine? Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require a higher degree of management, have a high price and aren t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than nonspecialty medicines. Log on to your secure myhealthpartners account and click on "My plan benefits" on the Medical Plan tab to check your benefits for specialty medicines. What s Weight Loss? This type of medicine may have limits on the amount you get or may not be covered under all contracts. Log on to your secure myhealthpartners account and click on "My plan benefits" on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category. What s Oncology? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but are not subject to the specialty benefit. Instead, your regular generic or brand pharmacy copay or coinsurance will apply. The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (4/15) 2013 HealthPartners

4 Table of Contents Alcohol Dependency... 3 Allergy... 3 Alpha-1 Antitrypsin Deficiency... 4 Anti-Addiction/Substance Abuse Treatment Agents... 4 Anti-Infective... 4 Arthritis Asthma & COPD Behavioral Health Birth Control Bleeding Disorders Blood Modifier Blood Thinner Bone Health Cancer Corticosteroids Cough & Cold Cystic Fibrosis Dementia Diabetes Ear Conditions Enzyme Replacement Eye Conditions Gout Heart Health Hereditary Angioedema Immune Deficiency Immune Suppressant Kidney Failure Men's Health Migraine Mouth & Throat Multiple Sclerosis Muscle Relaxant Other Conditions Pain Parkinson's Pulmonary Hypertension Seizures / Epilepsy Skin Conditions Sleep Disorders Smoking Cessation Stomach / Gastrointestinal Thyroid Urinary & Bladder Health

5 Vaccines Vitamins And Minerals Weight Loss Women's Health Index

6 Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone oral tablet 50 mg Allergy Allergy, Eye azelastine ophthalmic drops 0.05 % cromolyn ophthalmic drops 4 % epinastine ophthalmic drops 0.05 % PATADAY OPHTHALMIC DROPS 0.2 % Allergy, Injection AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML (1:1,000) EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000) EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML (1:2,000) Allergy, Other Nasal azelastine nasal aerosol,spray 137 mcg ipratropium bromide nasal spray,non-aerosol 0.03 %, 0.06 % Allergy, Other Oral GRASTEK SUBLINGUAL TABLET 2,800 BAU RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT Antihistamines, Oral clemastine oral syrup 0.67 mg/5 ml cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg PreferredRx April 1,

7 hydroxyzine hcl oral syrup 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg Corticosteroids, Nasal flunisolide nasal spray,non-aerosol 25 mcg (0.025 %), 29 mcg (0.025 %) fluticasone nasal spray,suspension 50 mcg/actuation NASONEX NASAL SPRAY,NON-AEROSOL 50 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION, 80 MCG/ACTUATION VERAMYST NASAL SPRAY,SUSPENSION 27.5 MCG/ACTUATION Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) PROLASTIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents naloxone injection syringe 1 mg/ml Anti-Infective Antibiotics, Cephalosporins cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml PreferredRx April 1,

8 cefadroxil oral tablet 1 gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250 mg, 500 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET 400 MG Antibiotics, Macrolides azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg PreferredRx April 1,

9 erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg erythromycin-sulfisoxazole oral suspension for reconstitution mg/5 ml Antibiotics, Other clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml neomycin oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg trimethoprim oral tablet 100 mg vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg vancomycin oral capsule 125 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ZYVOX ORAL TABLET 600 MG Antibiotics, Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg PreferredRx April 1,

10 amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml dicloxacillin oral capsule 250 mg, 500 mg penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg Antibiotics, Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg moxifloxacin oral tablet 400 mg Antibiotics, Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg minocycline oral capsule 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg Antifungals clotrimazole mucous membrane troche 10 mg fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml PreferredRx April 1,

11 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg ketoconazole oral tablet 200 mg NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 250 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg Anti-Infective, Other ALBENZA ORAL TABLET 200 MG atovaquone oral suspension 750 mg/5 ml BILTRICIDE ORAL TABLET 600 MG dapsone oral tablet 100 mg, 25 mg ivermectin oral tablet 3 mg rifabutin oral capsule 150 mg SIVEXTRO ORAL TABLET 200 MG PreferredRx April 1,

12 Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone-proguanil oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine oral tablet 200 mg mefloquine oral tablet 250 mg metronidazole oral tablet 250 mg, 500 mg YODOXIN ORAL TABLET 210 MG, 650 MG Antiviral, Hepatitis B adefovir oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, 1 mg EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) lamivudine oral tablet 100 mg TYZEKA ORAL TABLET 600 MG Antiviral, Hepatitis C HARVONI ORAL TABLET MG INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML OLYSIO ORAL CAPSULE 150 MG PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML PreferredRx April 1,

13 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML REBETOL ORAL SOLUTION 40 MG/ML ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg SOVALDI ORAL TABLET 400 MG Antiviral, HIV abacavir oral tablet 300 mg abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML PreferredRx April 1,

14 EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine oral tablet mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml nevirapine oral tablet 200 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PreferredRx April 1,

15 NORVIR SOFT GELATIN ORAL CAPSULE 100 MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG REYATAZ ORAL CAPSULE 100 MG, 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg stavudine oral recon soln 1 mg/ml STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG TYBOST ORAL TABLET 150 MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG PreferredRx April 1,

16 VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg zidovudine oral syrup 10 mg/ml zidovudine oral tablet 300 mg Antiviral, Other acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet 400 mg, 800 mg amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML valacyclovir oral tablet 1 gram, 500 mg VALCYTE ORAL RECON SOLN 50 MG/ML valganciclovir oral tablet 450 mg Tuberculosis cycloserine oral capsule 250 mg PreferredRx April 1,

17 ethambutol oral tablet 100 mg, 400 mg isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifampin oral capsule 150 mg, 300 mg SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Urinary Anti-Infectives MACRODANTIN ORAL CAPSULE 25 MG MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml Arthritis Arthritis, Other CUPRIMINE ORAL CAPSULE 250 MG DEPEN TITRATABS ORAL TABLET 250 MG Disease Modifying Agents ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PreferredRx April 1,

18 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg RIDAURA ORAL CAPSULE 3 MG Asthma & COPD Asthma & COPD, Other ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION cromolyn inhalation solution for nebulization 20 mg/2 ml DALIRESP ORAL TABLET 500 MCG ipratropium bromide inhalation solution 0.02 % montelukast oral granules in packet 4 mg montelukast oral tablet 10 mg montelukast oral tablet,chewable 4 mg, 5 mg SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG Bronchodilators, Inhaled albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 12 MCG MAXAIR AUTOHALER INHALATION AEROSOL BREATH ACTIVATED 200 MCG/INHALATION PreferredRx April 1,

19 SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Bronchodilators, Oral albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg terbutaline oral tablet 2.5 mg, 5 mg theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 400 mg, 600 mg Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE COMBIVENT INHALATION AEROSOL MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml Corticosteroids, Inhaled ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml PreferredRx April 1,

20 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Behavioral Health Antipsychotic ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG ABILIFY ORAL SOLUTION 1 MG/ML ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg PreferredRx April 1,

21 olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg risperidone oral solution 1 mg/ml risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Anxiety alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clonazepam oral tablet 0.5 mg, 1 mg, 2 mg diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml diazepam oral tablet 10 mg, 2 mg, 5 mg diazepam rectal kit mg, 2.5 mg, mg lorazepam oral concentrate 2 mg/ml PreferredRx April 1,

22 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Attention Deficit/Hyperactivity Disorder (ADHD) adderall xr oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg methylphenidate oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic mg, 30 mg, 40 mg methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg, 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Bipolar Disorder divalproex oral capsule, sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg PreferredRx April 1,

23 lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml Depression amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg budeprion sr oral tablet extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg fluoxetine oral capsule 10 mg, 20 mg, 40 mg fluoxetine oral solution 20 mg/5 ml fluoxetine oral tablet 10 mg, 20 mg PreferredRx April 1,

24 fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg PAXIL ORAL SUSPENSION 10 MG/5 ML phenelzine oral tablet 15 mg sertraline oral concentrate 20 mg/ml sertraline oral tablet 100 mg, 25 mg, 50 mg tranylcypromine oral tablet 10 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg Birth Control Contraceptives, Other NUVARING VAGINAL RING MG/24 HR xulane transdermal patch weekly mcg/24 hr Emergency Contraception ELLA ORAL TABLET 30 MG levonorgestrel oral tablet 0.75 mg, 1.5 mg my way oral tablet 1.5 mg PreferredRx April 1,

25 next choice one dose oral tablet 1.5 mg Oral Contraceptives altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mg-mcg aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mg-mcg brevicon (28) oral tablet mg-mcg briellyn oral tablet mg-mcg camila oral tablet 0.35 mg caziant (28) oral tablet 0.1/.125/ mg-mcg cesia (28) oral tablet 0.1/.125/ mg-mcg chateal oral tablet mg cryselle (28) oral tablet mg-mcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg PreferredRx April 1,

26 desogestrel-ethinyl estradiol oral tablet mg drospirenone-ethinyl estradiol oral tablet mg elinest oral tablet mg-mcg emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg falmina (28) oral tablet mg-mcg gianvi (28) oral tablet mg gildagia oral tablet mg-mcg gildess fe oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg- 30 mcg (21)/75 mg (7) gildess oral tablet 1-20 mg-mcg, mg-mcg heather oral tablet 0.35 mg introvale oral tablets,dose pack,3 month mg-mcg jencycla oral tablet 0.35 mg jolessa oral tablets,dose pack,3 month mg-mcg jolivette oral tablet 0.35 mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mg-mcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) PreferredRx April 1,

27 junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kurvelo oral tablet mg larin 1/20 (21) oral tablet 1-20 mg-mcg larin fe oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levlen (28) oral tablet mg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month mg-mcg levora-28 oral tablet mg loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet mg microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) PreferredRx April 1,

28 microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mg-mcg myzilra oral tablet (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet mg-mcg necon 1/35 (28) oral tablet 1-35 mg-mcg necon 1/50 (28) oral tablet 1-50 mg-mcg necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg nora-be oral tablet 0.35 mg norethindrone (contraceptive) oral tablet 0.35 mg norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg norgestrel-ethinyl estradiol oral tablet mg-mcg norinyl 1+35 (28) oral tablet 1-35 mg-mcg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg ocella oral tablet mg ogestrel (28) oral tablet mg-mcg orsythia oral tablet mg-mcg PreferredRx April 1,

29 philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 month mg-mcg reclipsen (28) oral tablet mg sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg viorele (28) oral tablet mgx21 /0.01 mg x 5 PreferredRx April 1,

30 vyfemla (28) oral tablet mg-mcg wera (28) oral tablet mg-mcg zarah oral tablet mg zenchent (28) oral tablet mg-mcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg Bleeding Disorders Bleeding Disorders, Hemophilia STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Bleeding Disorders, Other aminocaproic acid oral solution 25 % aminocaproic acid oral tablet 500 mg Blood Modifier Blood Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML 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 CORIFACT INTRAVENOUS KIT 1,000-1,600 UNIT LEUKINE INJECTION RECON SOLN 250 MCG LEUKINE INJECTION SOLUTION 500 MCG/ML NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML PreferredRx April 1,

31 NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 % PROCRIT 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 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT Clotting Disorders ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 3,000 UNIT, 500 UNIT BEBULIN VH INTRAVENOUS RECON SOLN 700 (+/-) UNIT BENEFIX INTRAVENOUS KIT 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT, 750 UNIT FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, UNIT, 651-1,200 UNIT HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,500 UNIT HEMOFIL M LOW INTRAVENOUS RECON SOLN UNIT PreferredRx April 1,

32 HEMOFIL M MID INTRAVENOUS RECON SOLN UNIT HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT HUMATE-P INTRAVENOUS KIT 1,000-2,400 UNIT, UNIT, 500-1,200 UNIT KOATE-DVI INTRAVENOUS KIT 500 (+/-) UNIT KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT MONOCLATE-P INTRAVENOUS KIT 1,000 (+/-) UNIT, 1,500 (+/-) UNIT MONONINE INTRAVENOUS KIT 1,000 (+/-) UNIT NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,200 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT WILATE INTRAVENOUS KIT 1,000-1,000 UNIT, UNIT, UNIT, UNIT XYNTHA INTRAVENOUS KIT 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE KIT 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT Blood Thinner Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml PreferredRx April 1,

33 enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Platelet Inhibitors AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR MG anagrelide oral capsule 0.5 mg, 1 mg BRILINTA ORAL TABLET 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 mg ZONTIVITY ORAL TABLET 2.08 MG Bone Health Bone Health, Other PreferredRx April 1,

34 etidronate disodium oral tablet 200 mg, 400 mg Osteoporosis ACTONEL ORAL TABLET 30 MG, 35 MG, 5 MG alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML FORTICAL NASAL SPRAY,NON-AEROSOL 200 UNIT/ACTUATION FOSAMAX PLUS D ORAL TABLET 70-2,800 MG-UNIT, 70-5,600 MG-UNIT raloxifene oral tablet 60 mg risedronate oral tablet 150 mg Cancer Cancer AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALKERAN ORAL TABLET 2 MG anastrozole oral tablet 1 mg bicalutamide oral tablet 50 mg BOSULIF ORAL TABLET 100 MG, 500 MG capecitabine oral tablet 150 mg, 500 mg CAPRELSA ORAL TABLET 100 MG, 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY) PreferredRx April 1,

35 cyclophosphamide oral capsule 25 mg, 50 mg cyclophosphamide oral tablet 25 mg, 50 mg EMCYT ORAL CAPSULE 140 MG ERIVEDGE ORAL CAPSULE 150 MG etoposide oral capsule 50 mg exemestane oral tablet 25 mg flutamide oral capsule 125 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG HEXALEN ORAL CAPSULE 50 MG HYCAMTIN INTRAVENOUS RECON SOLN 4 MG HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG hydroxyurea oral capsule 500 mg ICLUSIG ORAL TABLET 15 MG, 45 MG IMBRUVICA ORAL CAPSULE 140 MG INLYTA ORAL TABLET 1 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG letrozole oral tablet 2.5 mg LEUKERAN ORAL TABLET 2 MG lomustine oral capsule 10 mg, 100 mg, 40 mg MATULANE ORAL CAPSULE 50 MG PreferredRx April 1,

36 megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG, 2 MG mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg MYLERAN ORAL TABLET 2 MG NEXAVAR ORAL TABLET 200 MG POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg PreferredRx April 1,

37 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG tretinoin (chemotherapy) oral capsule 10 mg TYKERB ORAL TABLET 250 MG VALCHLOR TOPICAL GEL % VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYTIGA ORAL TABLET 250 MG Corticosteroids Corticosteroids, Oral DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral solution 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg MEDROL ORAL TABLET 2 MG methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg MILLIPRED ORAL TABLET 5 MG PreferredRx April 1,

38 prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablets,dose pack 10 mg, 5 mg Cough & Cold Cough & Cold benzonatate oral capsule 100 mg, 200 mg codeine-guaifenesin oral liquid mg/5 ml guaiatussin ac oral liquid mg/5 ml promethazine vc oral syrup mg/5 ml promethazine-dm oral syrup mg/5 ml promethazine-phenyleph-codeine oral syrup mg/5 ml Cystic Fibrosis Cystic Fibrosis acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML KALYDECO ORAL TABLET 150 MG PULMOZYME INHALATION SOLUTION 1 MG/ML tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml Dementia Dementia donepezil oral tablet 10 mg, 5 mg PreferredRx April 1,

39 donepezil oral tablet,disintegrating 10 mg, 5 mg EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5 MG/24 HR galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml galantamine oral tablet 12 mg, 4 mg, 8 mg NAMENDA ORAL SOLUTION 10 MG/5 ML NAMENDA ORAL TABLET 10 MG, 5 MG NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 5-10 MG NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg Diabetes Diabetes, Injection BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGEN INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) PreferredRx April 1,

40 Diabetes, Oral acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide oral tablet 10 mg, 5 mg glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg glipizide-metformin oral tablet mg, mg, mg GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG metformin oral tablet 1,000 mg, 500 mg, 850 mg metformin oral tablet extended release 24 hr 500 mg, 750 mg nateglinide oral tablet 120 mg, 60 mg pioglitazone oral tablet 15 mg, 30 mg, 45 mg pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg repaglinide oral tablet 0.5 mg, 1 mg, 2 mg TRADJENTA ORAL TABLET 5 MG Insulin HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML PreferredRx April 1,

41 HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN 70/30 PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 "CONCENTRATED" SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML Ear Conditions Anti-Infectives, Ear acetic acid otic solution 2 % CIPRO OTIC DROPS,SUSPENSION % PreferredRx April 1,

42 CIPRODEX OTIC DROPS,SUSPENSION % neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% ofloxacin otic drops 0.3 % Ear Conditions, Other antipyrine-benzocaine otic drops % fluocinolone acetonide oil otic drops 0.01 % Enzyme Replacement Enzyme Replacement CERDELGA ORAL CAPSULE 84 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT SUCRAID ORAL SOLUTION 8,500 UNIT/ML ZAVESCA ORAL CAPSULE 100 MG Eye Conditions Anti-Infectives, Eye AZASITE OPHTHALMIC DROPS 1 % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram BESIVANCE OPHTHALMIC DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CILOXAN OPHTHALMIC OINTMENT 0.3 % ciprofloxacin hcl ophthalmic drops 0.3 % erythromycin ophthalmic ointment 5 mg/gram (0.5 %) PreferredRx April 1,

43 gatifloxacin ophthalmic drops 0.5 % gentamicin ophthalmic ointment 0.3 % (3 mg/gram) neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml ofloxacin ophthalmic drops 0.3 % polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % tobramycin ophthalmic drops 0.3 % tobramycin-dexamethasone ophthalmic drops,suspension % TOBREX OPHTHALMIC OINTMENT 0.3 % trifluridine ophthalmic drops 1 % VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Anti-Inflammatories, Eye ACUVAIL (PF) OPHTHALMIC DROPPERETTE 0.45 % ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % PreferredRx April 1,

44 dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % FML S.O.P. OPHTHALMIC OINTMENT 0.1 % ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % PRED FORTE OPHTHALMIC DROPS,SUSPENSION 1 % PRED MILD OPHTHALMIC DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % Eye Conditions, Other altafrin ophthalmic drops 10 % atropine ophthalmic drops 1 % atropine ophthalmic ointment 1 % CYCLOGYL OPHTHALMIC DROPS 0.5 % PreferredRx April 1,

45 cyclopentolate ophthalmic drops 1 %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % homatropaire ophthalmic drops 5 % ISOPTO HYOSCINE OPHTHALMIC DROPS 0.25 % LACRISERT OPHTHALMIC INSERT 5 MG phenylephrine hcl ophthalmic drops 10 %, 2.5 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Glaucoma acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 0.25 % brimonidine ophthalmic drops 0.15 %, 0.2 % carteolol ophthalmic drops 1 % COMBIGAN OPHTHALMIC DROPS % COSOPT (PF) OPHTHALMIC DROPPERETTE % dorzolamide ophthalmic drops 2 % dorzolamide-timolol ophthalmic drops mg/ml latanoprost ophthalmic drops % levobunolol ophthalmic drops 0.25 %, 0.5 % PreferredRx April 1,

46 LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 mg PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % PILOPINE HS OPHTHALMIC GEL 4 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Gout Gout allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG Heart Health Angina ISORDIL ORAL TABLET 40 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg PreferredRx April 1,

47 isosorbide dinitrate oral tablet extended release 40 mg isosorbide dinitrate sublingual tablet 2.5 mg, 5 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg flecainide oral tablet 100 mg, 150 mg, 50 mg mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg sotalol af oral tablet 120 mg sotalol af oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg PreferredRx April 1,