2016 Comprehensive Formulary. (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL.

Transcription

1 06 Comprehensive Formulary (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL

2 06 SUMMACARE COMPREHENSIVE FORMULARY SMALL GROUP AND INDIVIDUAL PRESCRIPTION DRUG BENEFITS The following is a listing by drug class of medications most commonly prescribed under the SummaCare Prescription Drug Benefit. Brand-name drugs are capitalized and generic drugs are listed in lowercase. Prescription drug benefits vary, but in most cases, brand name medications that have a generic equivalent require the patient to pay the difference in cost between the brand and generic medication. Some benefits may exclude certain drugs on this list. Refer to your plan documents for more coverage information. ABOUT TIERS Tier Prescription Drugs have the lowest copayment. This tier will contain low cost medications that may be preferred generic, single source, or multi-source Brand Drugs. Tier Prescription Drugs will have a higher copayment than those in Tier. This tier will contain preferred medications that may be non-preferred generic, single source, or multisource Preferred Brand Drugs. Tier Prescription Drugs will have a higher copayment than those in Tier. This tier will contain non-preferred and higher cost medications. Tier 4 Prescription Drugs will have a higher coinsurance level and cost more than the Tier drugs. These drugs are part of the Specialty Tier. Note: Some benefits may require a deductible be met before copays apply. Refer to your plan documents for further information. USING YOUR SUMMACARE ID CARD It is important to show your SummaCare ID card when filling prescriptions. When you show your SummaCare ID card, safety checks are performed such as drug-drug interactions, therapeutic duplications and dose checks, even if you use multiple pharmacies, including mail order. MEDIMPACT MedImpact is SummaCare s Pharmacy Benefit Manager and is responsible for processing pharmacy claims for SummaCare members. MedImpact also handles pharmacy benefit customer service and utilization management requests on SummaCare s behalf. To reach MedImpact, members should call the SummaCare customer service number on the back of their ID card. WOMEN S PREVENTIVE DRUGS Your cost share for selected women s preventive care services may be waived when provided by a network pharmacy provider. Please refer to your benefit documents for further information. PHARMACY UTILIZATION PROGRAMS SummaCare s Prescription Drug Benefit incorporates utilization management programs (prior authorization, step therapy and quantity limits). Drugs requiring utilization management are indicated on the formulary document with a PA, PA NSO, QL or ST. If you are prescribed one of these drugs, the prescriber may need to contact MedImpact to provide supporting medical information. Prior Authorization = PA Prior Authorization requirements are placed on medications when they have limited conditions for which they are prescribed, special monitoring or dispensing requirements or an extremely high cost. Guidelines for approving coverage for Prior Authorization drugs are developed and approved by a panel of practicing physicians and pharmacists.

3 Prior Authorization for New Starts Only = PA NSO If you are a new member, you may be required to get Prior Authorization on particular drugs before you fill your prescription. In this scenario, the same requirements as listed above under Prior Authorization would apply. Step Therapy = ST Step Therapy is the practice of initiating drug therapy for a medical condition with the most costeffective and safest drug, and then progressing to other more costly or risky drugs only if necessary (i.e., you must try drug A before you can get drug B ). The goal is to control costs and minimize risks. Step therapy is an automated process. If you present a prescription for a step therapy drug (i.e., B ) to a pharmacy, an automated check of your prescription history will occur. If the system finds that you have received the qualifying drug(s) (i.e., A ), your prescription will be processed. If the system does not find that you received a qualifying drug (i.e., A ) in recent history, a prior authorization will be necessary. Quantity Limits = QL When a drug has a Quantity Limit, the amount of medication per prescription is limited to a specified amount per 0 days. These limitations are usually in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient. Gender Edits = GF or GM Gender edits may be added to certain medications when they are only to be prescribed for a male or female based on FDA prescribing indications. Drugs that are only to be prescribed for females will be indicated with a GF and drugs that are only to be prescribed for males will be indicated with a GM. EXCEPTION PROCESS FOR NON-FORMULARY DRUGS What is an exception request? Exception requests are a kind of coverage determination. Exceptions can be requested by you and/or your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that: Is not on the formulary (list of drugs the plan covers) Requires prior authorization Has quantity limitations There are two types of exception requests. The first one is an expedited exception request, which is defined under exigent circumstances only and if the drug is not approved may seriously jeopardize life, health or ability to regain maximum function, or may jeopardize undergoing current treatment using a non-formulary drug. The second is a standard exception request. If SummaCare s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. The exception request must include your prescribing physician s statement that he/she has determined that the preferred formulary drug either would not be as effective or would have adverse effects for you. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal. Exception requests can be made verbally by contacting SummaCare s Pharmacy Benefit Manager, MedImpact Healthcare Systems, Inc., at or can be sent via fax to

4 When will I receive a decision on my exception request? SummaCare must notify you and your prescriber of our decision no more than 4 hours following receipt of an Expedited Request and 7 hours following the receipt of a Standard Exception Request. If your request is denied, then you or your prescribing physician may file an appeal. If the exception request is granted, we will treat the excepted drug as an Essential Health Benefit and the cost share will be counted towards your annual limitation on cost-sharing and we will cover the drug for the duration of the prescription including refills. FOR MORE INFORMATION ABOUT SUMMACARE S PRESCRIPTION DRUG BENEFIT CALL: Employers and Members: Please refer to the number on the back of your Member ID card or call Group Customer Service at Persons with Hearing or Speech Disabilities: Call Ohio Relay (TTY) at Providers: Call SummaCare Provider Services at To view the most recent formulary, please visit or mysummacare.com. 5

5 Table of Contents Analgesics... Anesthetics... Anti-Addiction/Substance Abuse Treatment Agents... Antianxiety Agents... Antibacterials... 4 Anticancer Agents... Anticholinergic Agents... 6 Anticonvulsants... 7 Antidementia Agents... Antidepressants... 4 Antidiabetic Agents... 8 Antifungals Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents... 5 Antiparkinsonian Agents... 5 Antipsychotic Agents... 5 Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 6 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products... 9 Dental And Oral Agents Dermatological Agents Devices... Enzyme Replacement/Modifiers... Eye, Ear, Nose, Throat Agents... Gastrointestinal Agents... 0 Genitourinary Agents... 6 Heavy Metal Antagonists... 7 Hormonal Agents, Stimulant/Replacement/Modifying... 8 Immunological Agents... 6 Inflammatory Bowel Disease Agents... 9 Metabolic Bone Disease Agents... 9 Miscellaneous Therapeutic Agents SummaCare HIEX Formulary 07 Effective: February 0, 07

6 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals SummaCare HIEX Formulary 07 Effective: February 0, 07

7 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG acetaminophen-codeine oral solution 0- mg/5 ml acetaminophen-codeine oral tablet 00-5 mg, 00-0 mg, mg alagesic lq oral solution mg/5 ml aspirin-caffeine-dihydrocodein oral capsule mg belladonna alkaloids-opium rectal suppository mg belladonna-opium rectal suppository 6.-0 mg (Acetaminophen With Codeine) (Tylenol-Codeine No.) (Butalb/Acetaminophe n/caffeine) (Synalgos-Dc) (Opium/Belladonna Alkaloids) (Opium/Belladonna Alkaloids) bupap oral tablet mg (Tencon) butalbital compound w/codeine oral (Fiorinal With Codeine capsule mg #) butalbital-acetaminop-caf-cod oral (Fioricet With capsule mg Codeine) butalbital-acetaminop-caf-cod oral (Fioricet With capsule mg Codeine) butalbital-acetaminophen oral tablet (Tencon) 50-5 mg butalbital-acetaminophen-caff oral (Fioricet) capsule mg, mg butalbital-acetaminophen-caff oral tablet (Fioricet) mg, mg butalbital-aspirin-caffeine oral capsule (Fiorinal) mg butalbital-aspirin-caffeine oral tablet (Butalbital/Aspirin/Caf mg feine) butorphanol tartrate nasal (Butorphanol Tartrate) spray,non-aerosol 0 mg/ml PA; QL (0 per 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

8 BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR QL (4 per 8 capacet oral capsule mg (Fioricet) CAPITAL WITH CODEINE ORAL SUSPENSION 0- /5 ML CODEINE SULFATE ORAL SOLUTION 0 /5 ML codeine sulfate oral tablet 5 mg, 0 mg, (Codeine Sulfate) 60 mg DEMEROL (PF) INJECTION SYRINGE 5 /ML, 50 /ML DILAUDID ORAL LIQUID /ML DISKETS ORAL TABLET,SOLUBLE 40 EMBEDA ORAL CAPSULE,ORAL QL (0 per 0 ONLY,EXT.REL PELL 00-4 EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 0-0.8, 0-., 50-, 60-.4, 80-. QL (60 per 0 endocet oral tablet 0-5 mg,.5-5 (Percocet) mg, 5-5 mg, mg endodan oral tablet mg (Percodan) ESGIC-PLUS ORAL CAPSULE fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG (Actiq) PA; QL (0 per 0 (Duragesic) PA; QL ( per 0 4 SummaCare HIEX Formulary 07 Effective: February 0, 07

9 hydrocodone-acetaminophen oral solution (Lortab) 0-5 mg/5 ml(5 ml),.5-67 mg/5 ml, mg/5 ml hydrocodone-acetaminophen oral tablet (Norco) QL ( per day) 0-00 mg, 5-00 mg, mg hydrocodone-acetaminophen oral tablet (Norco) QL (60 per mg,.5-5 mg, 5-5 mg, mg hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) mg,.5-00 mg, 5-00 mg hydrocodone-ibuprofen oral tablet (Ibudone) mg hydromorphone oral liquid mg/ml (Dilaudid) hydromorphone oral tablet mg, 4 mg, 8 (Dilaudid) mg hydromorphone oral tablet extended (Exalgo) QL (0 per 0 release 4 hr mg, 6 mg, 8 mg hydromorphone oral tablet extended (Exalgo) QL (60 per 0 release 4 hr mg hydromorphone rectal suppository mg (Hydromorphone Hcl) HYSINGLA ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL.4 HR 00, 0, 0, 0, 40, 60, 80 ibuprofen-oxycodone oral tablet (Ibuprofen/Oxycodone mg Hcl) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 0, 50, 00, 40, 70 QL (60 per 0 LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY PA; QL (5 per 0 levorphanol tartrate oral tablet mg (Levorphanol Tartrate) lorcet (hydrocodone) oral tablet 5-5 (Norco) QL (60 per 0 mg lorcet hd oral tablet 0-5 mg (Norco) QL (60 per 0 5 SummaCare HIEX Formulary 07 Effective: February 0, 07

10 lorcet plus oral tablet mg (Norco) QL (60 per 0 MAGNACET ORAL TABLET 0-400, margesic oral capsule mg (Fioricet) marten-tab oral tablet 50-5 mg (Tencon) meperidine (pf) injection solution 00 (Meperidine Hcl/Pf) mg/ml, 5 mg/ml, 50 mg/ml meperidine injection cartridge 0 mg/ml (Meperidine Hcl) meperidine oral solution 50 mg/5 ml (Meperidine Hcl) meperidine oral tablet 00 mg, 50 mg (Demerol) methadone intensol oral concentrate 0 (Methadose) mg/ml methadone oral solution 0 mg/5 ml, 5 (Methadone Hcl) mg/5 ml methadone oral tablet 0 mg, 5 mg (Dolophine Hcl) METHADOSE ORAL CONCENTRATE 0 /ML methadose oral tablet,soluble 40 mg (Diskets) morphine concentrate oral solution 00 (Morphine Sulfate) mg/5 ml (0 mg/ml) morphine in 0.9 % nacl intravenous (Morphine Sulfate In syringe mg/ml ( ml), 4 mg/ml ( ml) 0.9 % Nacl) morphine intramuscular pen injector 0 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 0 mg/ml, (Morphine Sulfate) 5 mg/ml, mg/ml, 4 mg/ml, 8 mg/ml morphine oral capsule, er multiphase 4 (Avinza) QL (0 per 0 hr 0 mg, 45 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 4 (Avinza) QL (60 per 0 hr 0 mg, 60 mg morphine oral capsule,extend.release (Kadian) pellets 0 mg morphine oral capsule,extend.release (Kadian) QL (60 per 0 pellets 00 mg, 0 mg, 0 mg, 50 mg, 60 mg, 80 mg morphine oral solution 0 mg/5 ml, 0 mg/5 ml (4 mg/ml) (Morphine Sulfate) 6 SummaCare HIEX Formulary 07 Effective: February 0, 07

11 MORPHINE ORAL TABLET 5, 0 morphine oral tablet extended release 00 (Ms Contin) mg, 5 mg, 00 mg, 0 mg, 60 mg morphine rectal suppository 0 mg, 0 mg, 0 mg, 5 mg (Morphine Sulfate) NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE HR 00, 50, 00, 50, 50 NUCYNTA ORAL TABLET 00, QL (80 per 0 50, 75 ONSOLIS BUCCAL FILM,00 MCG, 00 MCG, 400 MCG, 600 MCG, PA; QL (0 per MCG ORBIVAN CF ORAL TABLET ORBIVAN ORAL CAPSULE OXAYDO ORAL TABLET, ORAL ONLY 5, 7.5 OXECTA ORAL TABLET, ORAL ONLY 5, 7.5 oxycodone oral capsule 5 mg (Oxycodone Hcl) oxycodone oral concentrate 0 mg/ml (Oxycodone Hcl) oxycodone oral solution 5 mg/5 ml (Oxycodone Hcl) oxycodone oral tablet 0 mg, 5 mg, 0 (Roxicodone) mg, 0 mg, 5 mg oxycodone oral tablet,oral only,ext.rel. (Oxycontin) QL (60 per 0 hr 0 mg, 5 mg, 0 mg, 0 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel. (Oxycontin) QL (0 per 0 hr 80 mg oxycodone-acetaminophen oral solution (Oxycodone 5-5 mg/5 ml Hcl/Acetaminophen) oxycodone-acetaminophen oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg (Percocet) 7 SummaCare HIEX Formulary 07 Effective: February 0, 07

12 oxycodone-aspirin oral tablet mg (Percodan) OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL. HR 0, 5, 0, 0, 40, 60 OXYCONTIN ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL. HR 80 oxymorphone oral tablet 0 mg, 5 mg (Opana) QL (0 per 0 oxymorphone oral tablet extended release (Opana Er) QL (60 per 0 hr 0 mg, 0 mg, 0 mg, 40 mg, 5 mg oxymorphone oral tablet extended release (Opana Er) QL (0 per 0 hr 5 mg oxymorphone oral tablet extended release (Opana Er) hr 7.5 mg pentazocine-acetaminophen oral tablet (Pentazocine mg Hcl/Acetaminophen) pentazocine-naloxone oral tablet (Pentazocine mg Hcl/Naloxone Hcl) PHRENILIN FORTE ORAL CAPSULE PRIMLEV ORAL TABLET 0-00, 5-00, promacet oral tablet mg (Tencon) repan oral tablet mg (Fioricet) reprexain oral tablet 0-00 mg,.5-00 (Ibudone) mg, 5-00 mg roxicet oral solution 5-5 mg/5 ml (Oxycodone Hcl/Acetaminophen) roxicet oral tablet 5-5 mg (Percocet) SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL,00 MCG (600 MCG/SPRAY X ),,600 MCG (800 MCG/SPRAY X ), 00 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY PA; QL (0 per 0 8 SummaCare HIEX Formulary 07 Effective: February 0, 07

13 tencon oral tablet 50-5 mg (Tencon) tramadol oral tablet 50 mg (Ultram) tramadol oral tablet extended release 4 (Ultram Er) QL (0 per 0 hr 00 mg, 00 mg, 00 mg tramadol-acetaminophen oral tablet (Ultracet) mg trezix oral capsule mg (Trezix) vicodin es oral tablet mg (Norco) QL ( per day) vicodin hp oral tablet 0-00 mg (Norco) QL ( per day) vicodin oral tablet 5-00 mg (Norco) QL ( per day) XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 ONLY,IR - ER, BIPHASE xylon 0 oral tablet 0-00 mg (Ibudone) ZAMICET ORAL SOLUTION 0-5 /5 ML zebutal oral capsule mg (Fioricet) ZEBUTAL ORAL CAPSULE Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet,delayed release (dr/ec) 650 mg (Ecotrin) aspirin rectal suppository 00 mg, 600 mg (Aspirin) CAMBIA ORAL POWDER IN PACKET 50 ST; QL (9 per 0 celecoxib oral capsule 00 mg, 50 mg (Celebrex) PA; QL (60 per 0 celecoxib oral capsule 00 mg, 400 mg (Celebrex) PA; QL (0 per 0 choline,magnesium salicylate oral liquid (Choline Salicyl/Mag 500 mg/5 ml Salicylate) diclofenac potassium oral tablet 50 mg (Cataflam) diclofenac sodium oral tablet extended (Voltaren-Xr) release 4 hr 00 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical drops.5 % (Pennsaid) 9 SummaCare HIEX Formulary 07 Effective: February 0, 07

14 diclofenac sodium topical gel %, % (Voltaren) diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) DUEXIS ORAL TABLET ST; QL (90 per 0 etodolac oral capsule 00 mg, 00 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Lodine) etodolac oral tablet extended release 4 (Etodolac) hr 400 mg, 500 mg, 600 mg fenoprofen oral capsule 00 mg, 400 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH HOUR. % flurbiprofen oral tablet 00 mg, 50 mg (Flurbiprofen) ibuprofen oral suspension 00 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, (Ibuprofen) 800 mg INDOCIN ORAL SUSPENSION 5 /5 ML INDOCIN RECTAL SUPPOSITORY 50 indomethacin oral capsule 5 mg, 50 mg (Indomethacin) indomethacin oral capsule, extended (Indomethacin) release 75 mg ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 4 (Ketoprofen) hr 00 mg ketorolac oral tablet 0 mg (Ketorolac Tromethamine) LEVACET ORAL TABLET meclofenamate oral capsule 00 mg, 50 (Meclofenamate mg Sodium) mefenamic acid oral capsule 50 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

15 meloxicam oral tablet 5 mg, 7.5 mg (Mobic) METHYL SALICYLATE TOPICAL LIQUID nabumetone oral tablet 500 mg, 750 mg (Nabumetone) NAPRELAN CR ORAL TABLET, ER MULTIPHASE 4 HR 750 naproxen oral suspension 5 mg/5 ml (Naprosyn) naproxen oral tablet 50 mg, 75 mg, 500 (Naprosyn) mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 (Anaprox Ds) mg naproxen sodium oral tablet, er (Naprelan) multiphase 4 hr 75 mg, 500 mg oxaprozin oral tablet 600 mg (Daypro) piroxicam oral capsule 0 mg, 0 mg (Feldene) salsalate oral tablet 500 mg, 750 mg (Disalcid) SPRIX NASAL SPRAY,NON-AEROSOL 5.75 /SPRAY QL (5 per 0 sulindac oral tablet 50 mg, 00 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 00 mg, 600 mg (Tolmetin Sodium) VIMOVO ORAL ST; QL (60 per 0 TABLET,IR,DELAYED REL,BIPHASIC 75-0, VOLTAREN TOPICAL GEL % ZIPSOR ORAL CAPSULE 5 ST; QL (0 per 0 Anesthetics Local Anesthetics glydo mucous membrane jelly in (Lidocaine Hcl) applicator % lidocaine hcl mucous membrane jelly % (Lidocaine Hcl) SummaCare HIEX Formulary 07 Effective: February 0, 07

16 lidocaine hcl mucous membrane solution (Xylocaine) 4 % (40 mg/ml) lidocaine hcl topical cream % (Lidocaine Hcl) lidocaine hcl topical lotion % (Lidocaine Hcl) lidocaine hcl-hydrocortison ac topical (Lidocaine/Hydrocortis cream -0.5 % one Ac) lidocaine topical adhesive (Lidoderm) patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) lidocaine viscous mucous membrane (Xylocaine) solution % lidocaine-prilocaine topical cream.5-.5 (Emla) % lidocaine-prilocaine topical kit.5-.5 % (Relador Pak) lidocaine-tetracaine topical cream 7-7 % (Pliaglis) SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (Campral) (dr/ec) mg buprenorphine hcl sublingual tablet mg, 8 mg (Buprenorphine Hcl) PA; QL (90 per 0 buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg (Suboxone) PA; QL (90 per 0 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 50 mg CHANTIX CONTINUING MONTH QL (6 per 65 BOX ORAL TABLET CHANTIX ORAL TABLET 0.5 QL (67 per 65 CHANTIX ORAL TABLET QL (6 per 65 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 ()- (4) QL (06 per 65 SummaCare HIEX Formulary 07 Effective: February 0, 07

17 disulfiram oral tablet 50 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone Hcl) naloxone injection syringe mg/ml (Naloxone Hcl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL QL ( per 0 SPRAY,NON-AEROSOL 4 /ACTUATION SUBOXONE SUBLINGUAL FILM -, 8- PA; QL (60 per 0 SUBOXONE SUBLINGUAL FILM -0.5, 4- PA; QL (0 per 0 ZYBAN ORAL TABLET EXTENDED RELEASE 50 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE /ML alprazolam oral tablet 0.5 mg, 0.5 mg, (Xanax) mg, mg alprazolam oral tablet extended release 4 hr 0.5 mg, mg, mg, mg (Xanax Xr) alprazolam oral tablet,disintegrating 0.5 (Niravam) mg, 0.5 mg, mg, mg chlordiazepoxide hcl oral capsule 0 mg, (Chlordiazepoxide Hcl) 5 mg, 5 mg clonazepam oral tablet 0.5 mg, mg, (Klonopin) mg clonazepam oral tablet,disintegrating (Clonazepam) 0.5 mg, 0.5 mg, 0.5 mg, mg, mg clorazepate dipotassium oral tablet 5 (Tranxene T-Tab) mg,.75 mg, 7.5 mg diazepam intensol oral concentrate 5 (Diazepam) mg/ml diazepam oral solution 5 mg/5 ml ( (Diazepam) mg/ml) diazepam oral tablet 0 mg, mg, 5 mg (Valium) SummaCare HIEX Formulary 07 Effective: February 0, 07

18 diazepam rectal kit mg, (Diastat Acudial).5 mg, mg estazolam oral tablet mg, mg (Estazolam) flurazepam oral capsule 5 mg, 0 mg (Flurazepam Hcl) lorazepam oral concentrate mg/ml (Lorazepam) lorazepam oral tablet 0.5 mg, mg, mg (Ativan) midazolam oral syrup mg/ml (Midazolam Hcl) ONFI ORAL SUSPENSION.5 /ML PA; QL (480 per 0 ONFI ORAL TABLET 5 PA; QL (60 per 0 oxazepam oral capsule 0 mg, 5 mg, 0 (Oxazepam) mg quazepam oral tablet 5 mg (Doral) temazepam oral capsule 5 mg,.5 mg, (Restoril) 0 mg, 7.5 mg triazolam oral tablet 0.5 mg, 0.5 mg (Halcion) Antibacterials Aminoglycosides neomycin oral tablet 500 mg (Neomycin Sulfate) TOBI INHALATION SOLUTION 4 FOR NEBULIZATION 00 /5 ML TOBI PODHALER INHALATION 4 CAPSULE, W/INHALATION DEVICE 8 tobramycin in 0.5 % nacl inhalation (Tobi) 4 solution for nebulization 00 mg/5 ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 50 mg, 00 (Cleocin Hcl) mg, 75 mg clindamycin palmitate hcl oral recon soln (Cleocin Palmitate) 75 mg/5 ml FLAGYL ER ORAL TABLET EXTENDED RELEASE 750 hyolev mb oral tablet mg (Urelle) linezolid oral suspension for reconstitution 00 mg/5 ml (Zyvox) PA 4 SummaCare HIEX Formulary 07 Effective: February 0, 07

19 linezolid oral tablet 600 mg (Zyvox) PA MACRODANTIN ORAL CAPSULE 5 methenamine hippurate oral tablet (Hiprex) gram methenamine mandelate oral tablet 0.5 g, (Methenamine gram Mandelate) metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 50 mg, 500 mg (Flagyl) MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 00 mg, 5 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (Macrobid) nitrofurantoin oral suspension 5 mg/5 ml (Furadantin) PHOSPHASAL ORAL TABLET PRIMSOL ORAL SOLUTION 50 /5 ML SIVEXTRO ORAL TABLET 00 4 trimethoprim oral tablet 00 mg (Trimethoprim) ur n-c oral tablet mg (Urelle) uretron d-s oral tablet mg (Methen/M-Blue/Sal/N a Phos/Hyos) URETRON D-S ORAL TABLET URIN DS ORAL TABLET uro-458 oral tablet mg (Urelle) uro-blue oral tablet mg (Uryl) urogesic-blue oral tablet (Uryl) mg urolet mb oral tablet mg (Uryl) UROQID-ACID NO. ORAL TABLET vancomycin oral capsule 5 mg, 50 mg (Vancocin Hcl) 5 SummaCare HIEX Formulary 07 Effective: February 0, 07

20 XIFAXAN ORAL TABLET 00 QL (6 per XIFAXAN ORAL TABLET 550 PA; QL (60 per 0 Cephalosporins cefaclor oral capsule 50 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 5 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release (Cefaclor) hr 500 mg cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram (Cefadroxil) cefdinir oral capsule 00 mg (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 5 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg, 400 (Spectracef) mg cefixime oral suspension for (Suprax) reconstitution 00 mg/5 ml, 00 mg/5 ml cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 00 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg (Cefprozil) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 mg/5 ml CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 5 /5 ML, 50 /5 ML cefuroxime axetil oral tablet 50 mg, 500 (Ceftin) mg cephalexin oral capsule 50 mg, 500 mg, 750 mg (Keflex) 6 SummaCare HIEX Formulary 07 Effective: February 0, 07

21 cephalexin oral suspension for (Cephalexin) reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg (Cephalexin) SUPRAX ORAL CAPSULE 400 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML, 500 /5 ML SUPRAX ORAL TABLET 400 SUPRAX ORAL TABLET,CHEWABLE 00, 00 Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 500 mg, (Zithromax) 600 mg clarithromycin oral suspension for (Biaxin) reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 (Biaxin) mg clarithromycin oral tablet extended release 4 hr 500 mg (Biaxin Xl) DIFICID ORAL TABLET 00 ST; QL (0 per 0 e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for (Eryped 00) reconstitution 00 mg/5 ml ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 /5 ML ery-tab oral tablet,delayed release (Erythromycin Base) (dr/ec) 50 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) ery-tab oral tablet,delayed release (dr/ec) 500 mg (Erythromycin Base) 7 SummaCare HIEX Formulary 07 Effective: February 0, 07

22 erythrocin (as stearate) oral tablet 50 (Erythromycin mg Stearate) erythromycin ethylsuccinate oral (Eryped 00) suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet (Erythromycin 400 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 50 mg erythromycin oral tablet 50 mg, 500 mg (Erythromycin Base) erythromycin-sulfisoxazole oral (Ery suspension for reconstitution mg/5 ml E-Succ/Sulfisoxazole) KETEK ORAL TABLET 00, 400 PCE ORAL TABLET, PARTICLES/CRYSTALS, 500 ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 /ML Penicillins amoxicillin oral capsule 50 mg, 500 mg (Amoxicillin) amoxicillin oral suspension for (Amoxicillin) reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) amoxicillin oral tablet, er multiphase 4 (Moxatag) hr 775 mg amoxicillin oral tablet,chewable 5 mg, 50 mg, 400 mg (Amoxicillin) 4 PA; QL (84 per 56 8 SummaCare HIEX Formulary 07 Effective: February 0, 07

23 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) 50-5 mg, mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin Xr) extended release hr, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, mg Clav) ampicillin oral capsule 50 mg, 500 mg (Ampicillin Trihydrate) ampicillin oral suspension for (Ampicillin Trihydrate) reconstitution 5 mg/5 ml, 50 mg/5 ml AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 5-.5 /5 ML dicloxacillin oral capsule 50 mg, 500 mg (Dicloxacillin Sodium) penicillin v potassium oral recon soln 5 (Penicillin V mg/5 ml, 50 mg/5 ml Potassium) penicillin v potassium oral tablet 50 mg, (Penicillin V 500 mg Potassium) Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro Xr) multiphase 4 hr,000 mg, 500 mg ciprofloxacin hcl oral tablet 00 mg, 50 (Cipro) mg, 500 mg, 750 mg ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 0 levofloxacin oral solution 50 mg/0 ml (Levaquin) levofloxacin oral tablet 50 mg, 500 mg, (Levaquin) 750 mg moxifloxacin oral tablet 400 mg (Avelox) NOROXIN ORAL TABLET 400 ofloxacin oral tablet 00 mg, 00 mg, 400 (Ofloxacin) mg 9 SummaCare HIEX Formulary 07 Effective: February 0, 07

24 Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri suspension mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim Ds) tablet mg, mg sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 500 mg Tetracyclines demeclocycline oral tablet 50 mg, 00 mg (Demeclocycline Hcl) DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 00, 50 PA doxycycline hyclate oral capsule 00 mg, (Vibramycin) 50 mg doxycycline hyclate oral tablet 00 mg, (Doryx) 0 mg doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00 mg, 50 mg, 75 mg doxycycline hyclate oral tablet,delayed (Doryx) PA release (dr/ec) 00 mg, 50 mg doxycycline monohydrate oral capsule (Monodox) 00 mg, 50 mg, 50 mg doxycycline monohydrate oral capsule,ir (Oracea) - delay rel,biphase 40 mg doxycycline monohydrate oral tablet 00 (Avidoxy) mg, 50 mg, 50 mg, 75 mg MINOCIN KIT WITH WIPES COMBO PACK 00, 50 minocycline oral capsule 00 mg, 50 mg, (Minocin) 75 mg minocycline oral tablet 00 mg, 50 mg, (Dynacin) 75 mg minocycline oral tablet extended release 4 hr 5 mg, 45 mg, 90 mg (Solodyn) PA 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

25 MONDOXYNE NL ORAL CAPSULE PA 00, 50, 75 MORGIDOX X00 KIT 00 MORGIDOX ORAL CAPSULE 50 tetracycline oral capsule 50 mg, 500 mg (Tetracycline Hcl) VIBRAMYCIN ORAL SYRUP 50 /5 ML Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION,, 5 4 PA; QL ( per 8 AFINITOR ORAL TABLET 0, PA; QL (60 per 0 AFINITOR ORAL TABLET.5, 5 4 PA; QL (0 per 0 ALECENSA ORAL CAPSULE 50 4 PA; QL (40 per 0 ALKERAN ORAL TABLET anastrozole oral tablet mg (Arimidex) AROMASIN ORAL TABLET 5 ST bexarotene oral capsule 75 mg (Targretin) 4 PA NSO; QL (4 per day) bicalutamide oral tablet 50 mg (Casodex) BOSULIF ORAL TABLET 00 4 PA; QL (0 per 0 BOSULIF ORAL TABLET PA; QL (0 per 0 CABOMETYX ORAL TABLET 0, 60 4 PA; QL (0 per 0 CABOMETYX ORAL TABLET 40 4 PA; QL (60 per 0 capecitabine oral tablet 50 mg, 500 mg (Xeloda) 4 CAPRELSA ORAL TABLET 00 4 PA; QL (60 per 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

26 CAPRELSA ORAL TABLET 00 4 PA; QL (0 per 0 CEENU ORAL CAPSULE 0, 4 00, 40 COMETRIQ ORAL CAPSULE 00 /DAY(80 X-0 X), 40 4 PA; QL ( per 8 /DAY(80 X-0 X), 60 /DAY (0 X /DAY) COTELLIC ORAL TABLET 0 4 PA; QL (6 per 8 CYCLOPHOSPHAMIDE ORAL CAPSULE 5, 50 4 cyclophosphamide oral tablet 5 mg, 50 (Cyclophosphamide) 4 mg DROXIA ORAL CAPSULE 00, 00, 400 EMCYT ORAL CAPSULE 40 4 ERIVEDGE ORAL CAPSULE 50 4 PA; QL (0 per 0 etoposide oral capsule 50 mg (Etoposide) exemestane oral tablet 5 mg (Aromasin) ST FARESTON ORAL TABLET 60 4 FARYDAK ORAL CAPSULE 0 4 PA; QL (6 per, 5, 0 flutamide oral capsule 5 mg (Flutamide) GILOTRIF ORAL TABLET 0, 0, 40 4 PA; QL (0 per 0 GLEEVEC ORAL TABLET 00 4 PA; QL (60 per 0 GLEEVEC ORAL TABLET PA; QL (0 per 0 GLEOSTINE ORAL CAPSULE 0 4, 00, 40, 5 HEXALEN ORAL CAPSULE 50 4 HYCAMTIN ORAL CAPSULE 0.5 4, HYDREA ORAL CAPSULE 500 SummaCare HIEX Formulary 07 Effective: February 0, 07

27 hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 00, 5, 75 4 PA; QL ( per 8 ICLUSIG ORAL TABLET 5 4 PA; QL (60 per 0 ICLUSIG ORAL TABLET 45 4 PA; QL (0 per 0 imatinib oral tablet 00 mg (Gleevec) 4 PA; QL (60 per 0 imatinib oral tablet 400 mg (Gleevec) 4 PA; QL (0 per 0 IMBRUVICA ORAL CAPSULE 40 4 PA; QL (0 per 0 INLYTA ORAL TABLET 4 PA; QL (80 per 0 INLYTA ORAL TABLET 5 4 PA; QL (0 per 0 IRESSA ORAL TABLET 50 4 PA; QL (60 per 0 JAKAFI ORAL TABLET 0, 5, 0, 5, 5 4 PA; QL (60 per 0 LENVIMA ORAL CAPSULE 0 /DAY (0 X /DAY) 4 PA; QL (0 per 0 LENVIMA ORAL CAPSULE 4 /DAY(0 X -4 X ), 0 /DAY (0 X ), 8 /DAY (4 X ) 4 PA; QL (60 per 0 LENVIMA ORAL CAPSULE 8 /DAY (0 X -4 X), 4 /DAY(0 X -4 X ) letrozole oral tablet.5 mg (Femara) LEUKERAN ORAL TABLET 4 leuprolide subcutaneous kit mg/0. ml (Leuprolide Acetate) 4 PA lomustine oral capsule 0 mg, 00 mg, 40 mg (Ceenu) 4 LONSURF ORAL TABLET PA; QL (90 per 0 4 PA; QL (00 per 8 SummaCare HIEX Formulary 07 Effective: February 0, 07

28 LONSURF ORAL TABLET PA; QL (80 per 8 LYNPARZA ORAL CAPSULE 50 4 PA; QL (6 per day) LYSODREN ORAL TABLET MATULANE ORAL CAPSULE 50 4 megestrol oral tablet 0 mg, 40 mg (Megestrol Acetate) MEKINIST ORAL TABLET PA; QL (90 per 0 MEKINIST ORAL TABLET 4 PA; QL (0 per 0 mercaptopurine oral tablet 50 mg (Purinethol) methotrexate sodium (pf) injection recon soln gram (Methotrexate Sodium/Pf) methotrexate sodium injection solution 5 (Methotrexate Sodium) mg/ml methotrexate sodium oral tablet.5 mg (Methotrexate Sodium) MYLERAN ORAL TABLET 4 NEXAVAR ORAL TABLET 00 4 PA; QL (0 per 0 NILANDRON ORAL TABLET 50 4 nilutamide oral tablet 50 mg (Nilandron) 4 NINLARO ORAL CAPSULE., 4 PA; QL ( per 8, 4 ODOMZO ORAL CAPSULE 00 4 PA; QL (0 per 0 POMALYST ORAL CAPSULE,,, 4 4 PA; QL ( per 8 PURINETHOL ORAL TABLET 50 PURIXAN ORAL SUSPENSION 0 /ML REVLIMID ORAL CAPSULE 0, 5,.5, 0, 5, 5 4 PA; QL (8 per 8 4 SummaCare HIEX Formulary 07 Effective: February 0, 07

29 RHEUMATREX ORAL TABLETS,DOSE PACK.5 SOLTAMOX ORAL SOLUTION 0 /5 ML SPRYCEL ORAL TABLET 00, 40, 50, 70, 80 4 PA; QL (0 per 0 SPRYCEL ORAL TABLET 0 4 PA; QL (60 per 0 STIVARGA ORAL TABLET 40 4 PA; QL (84 per 8 SUTENT ORAL CAPSULE.5, 5, 7.5, 50 4 PA; QL (0 per 0 SYNRIBO SUBCUTANEOUS RECON SOLN.5 4 PA; QL (8 per 8 TABLOID ORAL TABLET 40 4 TAFINLAR ORAL CAPSULE 50, 75 4 PA; QL (0 per 0 TAGRISSO ORAL TABLET 40, 80 4 PA; QL (0 per 0 TARCEVA ORAL TABLET 00, 5 4 PA; QL (60 per 0 TARCEVA ORAL TABLET 50 4 PA; QL (90 per 0 TARGRETIN ORAL CAPSULE 75 4 PA NSO; QL (4 per day) TARGRETIN TOPICAL GEL % 4 PA NSO; QL (60 per 0 TASIGNA ORAL CAPSULE 50, 00 4 PA; QL (0 per 0 TEMODAR ORAL CAPSULE 00, 40, 80, 0, 50, 5 4 temozolomide oral capsule 00 mg, 40 (Temodar) 4 mg, 80 mg, 0 mg, 50 mg, 5 mg tretinoin (chemotherapy) oral capsule 0 (Tretinoin) 4 mg TREXALL ORAL TABLET 0, 5, 5, SummaCare HIEX Formulary 07 Effective: February 0, 07

30 TYKERB ORAL TABLET 50 4 PA; QL (80 per 0 VENCLEXTA ORAL TABLET 0 4 PA; QL (60 per 0 VENCLEXTA ORAL TABLET 00 4 PA; QL (0 per 0 VENCLEXTA ORAL TABLET 50 4 PA; QL (0 per 0 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 4 PA; QL (4 per VOTRIENT ORAL TABLET 00 4 PA; QL (0 per 0 XALKORI ORAL CAPSULE 00, 50 4 PA; QL (60 per 0 XELODA ORAL TABLET 50, 4 PA 500 XTANDI ORAL CAPSULE 40 4 PA; QL (0 per 0 ZELBORAF ORAL TABLET 40 4 PA; QL (40 per 0 ZOLINZA ORAL CAPSULE 00 4 ZYDELIG ORAL TABLET 00, 4 50 ZYKADIA ORAL CAPSULE 50 4 PA; QL (40 per 8 ZYTIGA ORAL TABLET 50 4 PA; QL (0 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER MCG chlordiazepoxide-clidinium oral capsule 5-.5 mg DONNATAL ORAL TABLET (Librax) ST; QL (0.7 per 0 6 SummaCare HIEX Formulary 07 Effective: February 0, 07

31 PAMINE FQ ORAL COMBO PACK 5-8 BILLION -CELL phenobarb-hyoscy-atropine-scop oral tablet mg propantheline oral tablet 5 mg quadrapax oral elixir mg/5 ml STIOLTO RESPIMAT INHALATION MIST.5-.5 MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00, 400, 800 (Phenobarb/Hyoscy/At ropine/scop) (Propantheline Bromide) (Phenobarb/Hyoscy/At ropine/scop) QL (4 per 8 ST; QL (0 per 0 APTIOM ORAL TABLET 600 ST; QL (60 per 0 BANZEL ORAL SUSPENSION 40 /ML BANZEL ORAL TABLET 00, 400 carbamazepine oral capsule, er (Carbatrol) multiphase hr 00 mg, 00 mg, 00 mg carbamazepine oral suspension 00 mg/5 (Tegretol) ml carbamazepine oral tablet 00 mg (Tegretol) carbamazepine oral tablet extended (Tegretol Xr) release hr 00 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 00 (Carbamazepine) mg CARBATROL ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 00 CELONTIN ORAL CAPSULE 00 DEPAKENE ORAL CAPSULE 50 7 SummaCare HIEX Formulary 07 Effective: February 0, 07

32 DEPAKENE ORAL SOLUTION 50 /5 ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 4 HR 50, 500 DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 5, 50, 500 DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE 5 DILANTIN EXTENDED ORAL CAPSULE 00 DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 DILANTIN ORAL CAPSULE 0 DILANTIN-5 ORAL SUSPENSION 5 /5 ML divalproex oral capsule, sprinkle 5 mg (Depakote Sprinkle) divalproex oral tablet extended release 4 (Depakote Er) hr 50 mg, 500 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 5 mg, 50 mg, 500 mg epitol oral tablet 00 mg (Tegretol) EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 00 ethosuximide oral capsule 50 mg (Zarontin) ethosuximide oral solution 50 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) FELBATOL ORAL SUSPENSION 600 /5 ML FELBATOL ORAL TABLET 400, 600 FYCOMPA ORAL SUSPENSION 0.5 /ML ST; QL (680 per 8 8 SummaCare HIEX Formulary 07 Effective: February 0, 07

33 FYCOMPA ORAL TABLET 0, ST; QL (0 per 0, 8 FYCOMPA ORAL TABLET ST; QL (0 per 0 FYCOMPA ORAL TABLET 4, 6 ST; QL (60 per 0 gabapentin oral capsule 00 mg, 00 mg, (Neurontin) 400 mg gabapentin oral solution 50 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET, 6 GRALISE 0-DAY STARTER PACK ST; QL (78 per 0 ORAL TABLET EXTENDED RELEASE 4 HR 00 (9)- 600 (69) GRALISE ORAL TABLET ST; QL (90 per 0 EXTENDED RELEASE 4 HR 00, 600 HORIZANT ORAL TABLET ST; QL (0 per 0 EXTENDED RELEASE 00 HORIZANT ORAL TABLET ST; QL (60 per 0 EXTENDED RELEASE 600 LAMICTAL ODT ORAL TABLET,DISINTEGRATING 00, 00, 5, 50 LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 5 () -50 (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 (4) -00 (4) LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 5 (4)-50 (4)-00 (7) 9 SummaCare HIEX Formulary 07 Effective: February 0, 07

34 LAMICTAL ORAL TABLET 00, 50, 00, 5 LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 5, 5 LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 5 (5) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 (84) -00 (4) LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 5 (4) -00 (7) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 4HR 00, 00, 5, 50, 00, 50 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 5 () -50 (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 (4)-00 (4)-00 (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 5 (4)-50 (4)-00 (7) lamotrigine oral tablet 00 mg, 50 mg, (Lamictal) 00 mg, 5 mg lamotrigine oral tablet disintegrating, dose pk 5 mg () -50 mg (7), 5 mg(4)-50 mg (4)-00 mg (7), 50 mg (4) -00 mg (4) (Lamictal Odt (Orange)) 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

35 lamotrigine oral tablet extended release (Lamictal Xr) 4hr 00 mg, 00 mg, 5 mg, 50 mg, 00 mg, 50 mg lamotrigine oral tablet, chewable (Lamictal) dispersible 5 mg, 5 mg lamotrigine oral tablet,disintegrating 00 (Lamictal Odt) mg, 00 mg, 5 mg, 50 mg lamotrigine oral tablets,dose pack 5 mg (Lamictal (Blue)) (5) levetiracetam oral solution 00 mg/ml (Keppra) levetiracetam oral tablet,000 mg, 50 (Keppra) mg, 500 mg, 750 mg levetiracetam oral tablet extended release (Keppra Xr) 4 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 00, 50, 00, 5, 5, 00, 50, 75 LYRICA ORAL SOLUTION 0 /ML oxcarbazepine oral suspension 00 mg/5 (Trileptal) ml oxcarbazepine oral tablet 50 mg, 00 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 50, 00 ST; QL (0 per 0 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 600 PEGANONE ORAL TABLET 50 phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 0 mg,.4 mg, 60 mg, 64.8 mg, 97. mg PHENYTEK ORAL CAPSULE 00, 00 (Phenobarbital) (Phenobarbital) ST; QL (0 per 0 SummaCare HIEX Formulary 07 Effective: February 0, 07

36 phenytoin oral suspension 5 mg/5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 00 mg, 00 mg, 00 mg (Dilantin) POTIGA ORAL TABLET 00, ST; QL (90 per 0 00, 400 POTIGA ORAL TABLET 50 ST; QL (70 per 0 primidone oral tablet 50 mg, 50 mg (Mysoline) QUDEXY XR ORAL ST; QL (0 per 0 CAPSULE,SPRINKLE,ER 4HR 00, 5, 50 QUDEXY XR ORAL ST; QL (60 per 0 CAPSULE,SPRINKLE,ER 4HR 50, 00 SABRIL ORAL POWDER IN PACKET 500 SABRIL ORAL TABLET 500 SPRITAM ORAL TABLET FOR ST; QL (60 per 0 SUSPENSION,000 SPRITAM ORAL TABLET FOR SUSPENSION 50, 500, 750 ST; QL (0 per 0 STAVZOR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 5, 50, 500 TEGRETOL ORAL SUSPENSION 00 /5 ML TEGRETOL ORAL TABLET 00 TEGRETOL XR ORAL TABLET EXTENDED RELEASE HR 00, 00, 400 tiagabine oral tablet mg, 4 mg (Gabitril) TOPAMAX ORAL CAPSULE, SPRINKLE 5, 5 TOPAMAX ORAL TABLET 00, 00, 5, 50 SummaCare HIEX Formulary 07 Effective: February 0, 07

37 topiragen oral tablet 00 mg, 00 mg, 5 (Topamax) mg, 50 mg topiramate oral capsule, sprinkle 5 mg, (Topamax) 5 mg topiramate oral tablet 00 mg, 00 mg, (Topamax) 5 mg, 50 mg TRILEPTAL ORAL SUSPENSION 00 /5 ML valproic acid (as sodium salt) oral (Depakene) solution 50 mg/5 ml valproic acid oral capsule 50 mg (Depakene) VIMPAT ORAL SOLUTION 0 /ML VIMPAT ORAL TABLET 00, 50, 00, 50 ZARONTIN ORAL CAPSULE 50 ZARONTIN ORAL SOLUTION 50 /5 ML ZONEGRAN ORAL CAPSULE 00, 5 zonisamide oral capsule 00 mg, 5 mg, (Zonegran) 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 0 mg, 5 mg (Aricept) donepezil oral tablet mg (Aricept) donepezil oral tablet,disintegrating 0 (Aricept Odt) mg, 5 mg EXELON ORAL SOLUTION /ML galantamine oral capsule,ext rel. pellets (Razadyne Er) 4 hr 6 mg, 4 mg, 8 mg galantamine oral solution 4 mg/ml (Razadyne) galantamine oral tablet mg, 4 mg, 8 (Razadyne) mg memantine oral solution mg/ml (Namenda) SummaCare HIEX Formulary 07 Effective: February 0, 07

38 memantine oral tablet 0 mg, 5 mg (Namenda) memantine oral tablets,dose pack 5-0 (Namenda) mg NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 4,, 8, 7 NAMZARIC ORAL ST; QL (8 per 8 CAP,SPRINKLE,ER 4HR DOSE PACK 7/4//8-0 NAMZARIC ORAL CAPSULE,SPRINKLE,ER 4HR 4-0, -0, 8-0, 7-0 ST; QL (0 per 0 rivastigmine tartrate oral capsule.5 mg, (Exelon) mg, 4.5 mg, 6 mg rivastigmine transdermal patch 4 hour (Exelon). mg/4 hour, 4.6 mg/4 hr, 9.5 mg/4 hr Antidepressants Antidepressants amitriptyline oral tablet 0 mg, 00 mg, (Amitriptyline Hcl) 50 mg, 5 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral tablet (Amitriptyline/Chlordi.5-5 mg, 5-0 mg azepoxide) amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg (Amoxapine) APLENZIN ORAL TABLET QL (0 per 0 EXTENDED RELEASE 4 HR 74, 48, 5 BRINTELLIX ORAL TABLET 0, 0, 5 ST; QL (0 per 0 budeprion sr oral tablet extended release 00 mg, 50 mg (Wellbutrin Sr) buproban oral tablet extended release 50 (Wellbutrin Sr) mg 4 SummaCare HIEX Formulary 07 Effective: February 0, 07

39 bupropion hcl oral tablet 00 mg, 75 mg (Wellbutrin Sr) bupropion hcl oral tablet extended release 00 mg, 50 mg, 00 mg (Wellbutrin Sr) bupropion hcl oral tablet extended release (Wellbutrin Xl) 4 hr 50 mg, 00 mg citalopram oral solution 0 mg/5 ml (Citalopram Hydrobromide) citalopram oral tablet 0 mg, 0 mg, 40 (Celexa) mg clomipramine oral capsule 5 mg, 50 mg, (Anafranil) 75 mg desipramine oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg (Norpramin) DESVENLAFAXINE FUMARATE ST; QL (0 per 0 ORAL TABLET EXTENDED RELEASE 4HR 00, 50 DESVENLAFAXINE ORAL ST; QL (0 per 0 TABLET EXTENDED RELEASE 4 HR 00, 50 desvenlafaxine oral tablet extended (Khedezla) ST; QL (0 per 0 release 4hr 00 mg, 50 mg doxepin oral capsule 0 mg, 00 mg, 50 (Doxepin Hcl) mg, 5 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml (Doxepin Hcl) duloxetine oral capsule,delayed (Cymbalta) release(dr/ec) 0 mg, 0 mg, 40 mg, 60 mg EMSAM TRANSDERMAL PATCH 4 HOUR /4 HR, 6 /4 HR, 9 /4 HR escitalopram oxalate oral solution 5 mg/5 (Lexapro) ml escitalopram oxalate oral tablet 0 mg, (Lexapro) 0 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 ()- 40 (6) ST; QL (0 per 0 5 SummaCare HIEX Formulary 07 Effective: February 0, 07

40 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0, 0, 40, 80 ST; QL (0 per 0 fluoxetine oral capsule 0 mg, 0 mg, 40 (Prozac) mg fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 mg fluoxetine oral solution 0 mg/5 ml (4 (Fluoxetine Hcl) mg/ml) fluoxetine oral tablet 0 mg, 0 mg (Fluoxetine Hcl) FLUOXETINE ORAL TABLET 60 fluvoxamine oral capsule,extended (Luvox Cr) release 4hr 00 mg, 50 mg fluvoxamine oral tablet 00 mg, 5 mg, 50 mg (Fluvoxamine Maleate) FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 ST; QL (0 per 0 imipramine hcl oral tablet 0 mg, 5 mg, 50 mg (Tofranil) imipramine pamoate oral capsule 00 mg, (Tofranil-Pm) 5 mg, 50 mg, 75 mg maprotiline oral tablet 5 mg, 50 mg, 75 (Maprotiline Hcl) mg MARPLAN ORAL TABLET 0 mirtazapine oral tablet 5 mg, 0 mg, 45 (Remeron) mg, 7.5 mg mirtazapine oral tablet,disintegrating 5 (Remeron) mg, 0 mg, 45 mg nefazodone oral tablet 00 mg, 50 mg, (Nefazodone Hcl) 00 mg, 50 mg, 50 mg nortriptyline oral capsule 0 mg, 5 mg, (Pamelor) 50 mg, 75 mg nortriptyline oral solution 0 mg/5 ml (Nortriptyline Hcl) olanzapine-fluoxetine oral capsule -5 mg, -50 mg, -5 mg, 6-5 mg, 6-50 mg (Symbyax) 6 SummaCare HIEX Formulary 07 Effective: February 0, 07

41 OLEPTRO ER ORAL TABLET EXTENDED RELEASE 4 HR 50, 00 paroxetine hcl oral tablet 0 mg, 0 mg, 0 mg, 40 mg paroxetine hcl oral tablet extended release 4 hr.5 mg, 5 mg, 7.5 mg PAXIL ORAL SUSPENSION 0 /5 ML perphenazine-amitriptyline oral tablet -0 mg, -5 mg, 4-0 mg, 4-5 mg, 4-50 mg PEXEVA ORAL TABLET 0, 0, 0, 40 (Paxil) (Paxil Cr) (Perphenazine/Amitript yline Hcl) phenelzine oral tablet 5 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 00, 5, 50 ST; QL (0 per 0 protriptyline oral tablet 0 mg, 5 mg (Vivactil) SARAFEM ORAL TABLET 0, 0 sertraline oral concentrate 0 mg/ml (Zoloft) sertraline oral tablet 00 mg, 5 mg, 50 (Zoloft) mg SILENOR ORAL TABLET, 6 SURMONTIL ORAL CAPSULE 00, 5, 50 tranylcypromine oral tablet 0 mg (Parnate) trazodone oral tablet 00 mg, 50 mg, 00 mg, 50 mg (Trazodone Hcl) trimipramine oral capsule 00 mg, 5 mg, (Trimipramine 50 mg Maleate) TRINTELLIX ORAL TABLET 0, 0, 5 ST; QL (0 per 0 venlafaxine oral capsule,extended release 4hr 50 mg, 7.5 mg, 75 mg (Effexor Xr) 7 SummaCare HIEX Formulary 07 Effective: February 0, 07

42 venlafaxine oral tablet 00 mg, 5 mg, 7.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 4hr 50 mg, 5 mg, 7.5 mg, 75 mg VIIBRYD ORAL TABLET 0, 0, 40 VIIBRYD ORAL TABLETS,DOSE PACK 0 (7)- 0 (), 0 (7)-0 (7)-40 (6) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00 mg, 5 mg, 50 mg ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 4 HR 5-,000, 0-,000 alogliptin oral tablet.5 mg, 5 mg, 6.5 mg alogliptin-metformin oral tablet.5-,000 mg, mg alogliptin-pioglitazone oral tablet.5-5 mg,.5-0 mg,.5-45 mg, 5-5 mg, 5-0 mg, 5-45 mg AVANDAMET ORAL TABLET -,000, -500, 4-,000, AVANDARYL ORAL TABLET 4-, 4-, 4-4, 8-, 8-4 AVANDIA ORAL TABLET, 4, 8 BYDUREON SUBCUTANEOUS PEN INJECTOR /0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON (Venlafaxine Hcl) (Venlafaxine Hcl) (Precose) (Nesina) ST; QL (0 per 0 (Kazano) ST; QL (0 per 0 (Oseni) ST; QL (0 per 0 ST ST ST ST; QL (4 per 8 ST; QL (4 per 8 8 SummaCare HIEX Formulary 07 Effective: February 0, 07

43 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(50 MCG/ML).4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML). ML ST; QL (.4 per 0 ST; QL (. per 0 CYCLOSET ORAL TABLET 0.8 FARXIGA ORAL TABLET 0, 5 ST; QL (0 per 0 GLYSET ORAL TABLET 00, 5, 50 GLYXAMBI ORAL TABLET 0-5 ST; QL (0 per 0, 5-5 INVOKAMET ORAL TABLET ST; QL (60 per 0 50-,000, , 50-,000, INVOKAMET XR ORAL TABLET, ST; QL (60 per 0 IR - ER, BIPHASIC 4HR 50-,000, , 50-,000, INVOKANA ORAL TABLET 00 ST; QL (0 per 0, 00 JANUMET ORAL TABLET 50-,000, JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 00-,000, 50-,000, JANUVIA ORAL TABLET 00, 5, 50 JARDIANCE ORAL TABLET 0 ST; QL (0 per 0, 5 JENTADUETO ORAL TABLET QL (60 per 0.5-,000,.5-500, JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-,000 QL (60 per 0 9 SummaCare HIEX Formulary 07 Effective: February 0, 07

44 JENTADUETO XR ORAL TABLET, QL (0 per 0 IR - ER, BIPHASIC 4HR 5-,000 KAZANO ORAL TABLET.5-,000 ST; QL (60 per 0, KOMBIGLYZE XR ORAL TABLET, ST; QL (60 per 0 ER MULTIPHASE 4 HR.5-,000 KOMBIGLYZE XR ORAL TABLET, ST; QL (0 per 0 ER MULTIPHASE 4 HR 5-,000, KORLYM ORAL TABLET 00 4 PA; QL (0 per 0 metformin oral tablet,000 mg, 500 mg, (Glucophage) 850 mg metformin oral tablet extended release 4 (Glucophage Xr) hr 500 mg, 750 mg metformin oral tablet extended release (Glucophage Xr) 4hr,000 mg, 500 mg miglitol oral tablet 00 mg, 5 mg, 50 mg (Glyset) nateglinide oral tablet 0 mg, 60 mg (Starlix) NESINA ORAL TABLET.5, 5 ST; QL (0 per 0, 6.5 ONGLYZA ORAL TABLET.5, ST; QL (0 per 0 5 OSENI ORAL TABLET.5-5,.5-0,.5-45, 5-5, 5-0, 5-45 ST; QL (0 per 0 pioglitazone oral tablet 5 mg, 0 mg, 45 (Actos) mg pioglitazone-glimepiride oral tablet 0- (Duetact) mg, 0-4 mg pioglitazone-metformin oral tablet mg, mg (Actoplus Met) repaglinide oral tablet 0.5 mg, mg, mg (Prandin) repaglinide-metformin oral tablet -500 (Prandimet) mg, -500 mg RIOMET ORAL SOLUTION 500 /5 ML 40 SummaCare HIEX Formulary 07 Effective: February 0, 07