2017 FORMULARY OF COVERED PRESCRIPTION DRUGS

Transcription

1 A Medicare Advantage Plan 207 FORMULARY OF COVERED PRESCRIPTION DRUGS Approved Formulary Submission ID Number: , Version 7 H5549_20 Formulary_085_DSB Accepted Preferred (HMO SNP) VNSNY CHOICE Total (HMO SNP) Maximum (HMO SNP) Classic (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/24/206. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday Friday from 8 am 8 pm or visit

2 Multi-Language Insert Multi-language Interpreter Services ATTENTION: Language assistance services, free of charge, are available to you. Call (TTY: 7). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (7) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 7). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 7). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 7) লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন (TTY: 7) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 7). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 7. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 7). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں (TTY: 7). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 7).

3 KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 7). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 7) पर क ल कर ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 7). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 7) まで お電話にてご連絡ください

4 and VNSNY CHOICE Total 207 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Includes members enrolled in Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Approved Formulary Submission ID Number: , Version: 7 This formulary was updated on August 24, 206. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8 am 8 pmor visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means VNSNY CHOICE Medicare. When it refers to plan or our plan, it means our VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). This document includes a list of the drugs (formulary) for our plan, which is current as of August 24, 206. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January, 208, and from time to time during the year. is an HMO plan with a Medicare contract. Enrollment in depends on contract renewal. Last updated: 08/24/206 I

5 What is the Formulary? A formulary is a list of covered drugs selected by in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. VNSNY CHOICE Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 207 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 207 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 24, 206. To get updated information about the drugs covered by, please contact us. Our contact information appears on the front cover and back cover pages. If we update our printed formulary with non-maintenance formulary changes, we will send you a notice that includes this information. II

6 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 3. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 3. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on I-. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from before you fill your prescriptions. If you don t get approval, may not cover the drug. Quantity Limits: For certain drugs, limits the amount of the drug that will cover. For example, provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one-month or three-month supply. III

7 Step Therapy: In some cases, requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, may not cover Drug B unless you try Drug A first. If Drug A does not work for you, VNSNY CHOICE Medicare will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You can ask to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the s formulary? on page V for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. pays for certain OTC drugs. COVERED OVER-THE-COUNTER (OTC) DRUGS DRUG Generic Name cetirizine hydrochloride cetirizine hydrochloride/ pseudoephedrine hydrochloride (Reference Brand Name) (Zyrtec) (Zyrtec-D) Dosage Form Chewable Tablets, Solution, Tablets 2 Hour Tablets loratadine (Claritin) Solution, Tablets loratadine/ 2 Hour Tablets (Claritin-D) pseudoephedrine sulfate 24 Hour Tablets ketotifen fumarate (Zaditor) Drops will provide these OTC drugs at no cost to you. The cost to of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) IV

8 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by. You can ask to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Formulary? You can ask to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower costsharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. V

9 When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. A transition fill is provided to current members that are in need of a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change. VI

10 For more information For more detailed information about your prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit This information is available for free in other languages. Please call Member Services at for additional information. (TTY users should call 7 Toll-free) Monday through Friday from 8:00 AM to 8:00 PM. Member Services also has free language interpreter services available for non-english speakers. is an HMO with a Medicare contract. Enrollment in depends on contract renewal. VII

11 s Formulary The formulary that begins on page 3 provides coverage information about the drugs covered by. If you have trouble finding your drug in the list, turn to the Index that begins on page I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., naproxen). The information in the Requirements/Limits column tells you if VNSNY CHOICE Medicare has any special requirements for coverage of your drug. The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VNSNY VIII

12 ABBREVIATION DESCRIPTION EXPLANATION CHOICE Medicare may not cover this drug. PA-HRM PA NSO QL ST Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug If you are a new member, you (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. limits the amount of this drug that is covered per prescription, or within a specific time frame. Before will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. IX

13 The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , Monday through Friday from 8:00 am to 8:00 pm. TTY/TDD users should call 7. You may be able to receive greater than a -month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. X

14 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 2hr cpmp 24hr DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 2 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 2 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam combination: ointment, lotion combination: tablet, pad combination package capsule, 2 hour multiphasic capsule, 24 hour multiphasic XI

15 ABBREVIATION DESCRIPTION cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution jel jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator XII

16 ABBREVIATION kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl DESCRIPTION kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator XIII

17 ABBREVIATION sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff DESCRIPTION solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 2 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 2 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent XIV

18 ABBREVIATION tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPTION tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 2 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring XV

19 Notice of Non-Discrimination Discrimination is Against the Law The Visiting Nurse Service of New York and all of its subsidiaries and affiliates* ( VNSNY ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. VNSNY does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. VNSNY provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters; written information in other formats (large print, audio, accessible electronic formats, other formats); and provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the VNSNY Civil Rights Coordinator: For VNSNY CHOICE Health Plans: Susan Underwood If you believe that VNSNY has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the above-named Civil Rights Coordinator: By mail or in person: 250 Broadway th Floor, New York, New York 000 By telephone: For VNSNY CHOICE Health Plans: BY TYY: 7 By fax: By CivilRightsCoordinator@vnsny.org On the web: If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at *Subsidiaries and Affiliates are: Visiting Nurse Service of New York Home Care, VNSNY Hospice and Palliative Care, and Partners in Care (collectively, the VNSNY Providers ), and VNSNY CHOICE and VNS Continuing Care Development Corporation (collectively, VNSNY CHOICE ). The VNSNY Providers and VNSNY CHOICE are collectively VNSNY. XVI

20 y VNSNY CHOICE Total Formulario de Medicamentos 207 (Listado de Medicamentos Cubiertos) Incluye miembros inscritos en Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Aprobado Formulario Número de la petición: , Versión 7 Este formulario de medicamentos fue actualizado 08/24/206. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al o, para aquellos que utilizan TTY, al 7, de lunes a viernes, de 8:00 AM a 8:00 PM o visite Aviso para miembros existentes: Este formulario de medicamentos ha cambiado desde el año pasado. Por favor, revise este documento para asegurar que aún contiene los medicamentos que usted toma. Cuando esta relación de medicamentos (formulario de medicamentos) hace referencia a nos, nosotros, o nuestro, se refiere a. Cuando hace referencia al plan o nuestro plan, se refiere a nuestro VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). Este documento incluye una relación de los medicamentos (formulario de medicamentos) para nuestro plan, que se encuentra actualizado a partir del 08/24/206. Para recibir un formulario de medicamentos actualizado, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Por lo general, debe utilizar las farmacias dentro de la red para poder utilizar su beneficio de medicamentos con receta. Los beneficios, el formulario de medicamentos, la red de farmacias, las primas y/o copagos/coaseguro pueden cambiar el de enero de 208. es un plan de HMO con contrato de Medicare. La inscripción en depende de la renovación del contrato. XVII Última actualización: 24/08/206

21 Qué es el formulario de medicamentos de? Un formulario de medicamentos es una relación de medicamentos cubiertos seleccionados por en consulta con un equipo de proveedores de servicios médicos, que representan los tratamientos con receta que se piensan ser una parte necesaria de un programa de tratamiento de calidad. VNSNY CHOICE Medicare, por lo general, cubrirá los medicamentos que aparecen en nuestro formulario de medicamentos siempre que dicho medicamento es médicamente necesario, la receta se llena en una farmacia de la red de, y se siguen otros reglamentos del plan. Para más información sobre cómo llenar sus recetas, sírvase revisar su Evidencia de Cobertura. Puede cambiar el formulario de medicamentos (relación de medicamentos)? Generalmente, si está tomando un medicamento que se encuentra en nuestro formulario de medicamentos de 207 que fue cubierto al comienzo del año, no descontinuaremos ni reduciremos la cobertura de ese medicamento durante el año de cobertura de 207 con la excepción de que se haga disponible un medicamento genérico nuevo y más económico o si se difunde nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario de medicamentos, tal como eliminar un medicamento del mismo, no afectará a los miembros que están tomando el medicamento actualmente. Permanecerá disponible al mismo costo compartido para aquellos miembros que lo toman durante lo que resta del año de cobertura. Pensamos que es importante que usted tenga acceso continuado a los medicamentos del formulario de medicamentos que tenía disponible cuando escogió nuestro plan, para lo que resta del año de cobertura, con excepción de los casos en los cuales puede ahorrar dinero adicional o podemos asegurar su seguridad. Si eliminamos medicamentos de nuestro formulario de medicamentos, o añadimos restricciones de autorización previa, límites de cantidad y/o terapias escalonadas para un medicamento o si cambiamos un medicamento a un nivel de costo compartido más alto, debemos notificar a los miembros afectados de dicho cambio un mínimo de 60 días antes de que tome vigencia, o cuando el miembro pide una reposición del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días de dicho medicamento. Si el Organismo para el Control de Alimentos y Fármacos (FDA, por sus siglas en inglés) considera que un medicamento que se encuentra en nuestro formulario de medicamentos no es seguro o el fabricante del medicamento lo retira del mercado, nosotros eliminaremos el mismo de nuestro formulario de medicamentos de inmediato y le daremos aviso a aquellos miembros que toman ese medicamento. El formulario de medicamentos adjunto se encuentra actualizado a partir 08/24/206. Para recibir información actualizada sobre los medicamentos cubiertos por VNSNY CHOICE Medicare, sírvase comunicarse con nosotros. Nuestra información de contacto aparece en la portada y contraportada. Si actualizamos nuestro formulario de medicamentos XVIII

22 impreso con cambios que no son de mantenimiento, le enviaremos una notificación que contiene esta información. Cómo utilizo el formulario de medicamentos? Existen dos formas de encontrar su medicamento dentro del formulario de medicamentos: Condición médica El formulario de medicamentos comienza en la página 3. Los medicamentos en este formulario de medicamentos están agrupados en categorías de acuerdo a los tipos de condiciones médicas para los cuales son utilizados. Por ejemplo, los medicamentos utilizados para tratar una condición cardíaca se encuentran bajo la categoría, Cardiovascular Agents. Si sabe para qué se utiliza el medicamento, busque el nombre de la categoría en la relación que comienza en la página 3. Luego, mire bajo el nombre de categoría para buscar ese medicamento. Relación alfabética Si no está seguro en qué categoría buscar, debe buscar el medicamento en el Índice que comienza en la página I-. El Índice ofrece una relación alfabética de todos los medicamentos incluidos en este documento. Los medicamentos de marca, al igual que los medicamentos genéricos, se encuentran en el Índice. Busque en el Índice y encuentre el medicamento. Al lado del medicamento, verá el número de la página en la cual puede encontrar la información de cobertura. Vaya a la página mencionada en el Índice y encuentre el nombre del medicamento en la primera columna de la relación. Qué son los medicamentos genéricos? cubre los medicamentos de marca al igual que los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA como teniendo el mismo ingrediente activo que el de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca. XIX

23 Existe alguna restricción sobre mi cobertura? Algunos medicamentos cubiertos pueden tener requerimientos o limitaciones adicionales sobre su cobertura. Estos requerimientos y limitaciones pueden incluir: Autorización previa: exige que usted o su médico reciba autorización previa para ciertos medicamentos. Esto implica que deberá recibir aprobación de antes de llenar sus recetas. Si no consigue aprobación, es posible que no cubra el medicamento. Limitaciones de cantidad: Para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad del medicamento que cubrirá. Por ejemplo, suministra 60 cápsulas por cada receta para el medicamento Celebrex. Esto puede ser además de un suministro estándar de un mes o tres meses. Tratamiento escalonado: En algunos casos, exige que pruebe ciertos medicamentos primero, para tratar su condición médica, antes que cubriremos otro medicamento para tratar esa condición. Por ejemplo, si Medicamento A y Medicamento B pueden tratar su condición médica, es posible que no cubra el Medicamento B al menos que primero pruebe con el Medicamento A. Si no le funciona el Medicamento A, entonces cubrirá el medicamento B. Usted puede determinar si su medicamento tiene algún requerimiento adicional o limitación con buscar en el formulario de medicamentos que comienza en la página 3. También puede recibir más información sobre las restricciones que aplican a ciertos medicamentos cubiertos con visitar nuestro sitio Web. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Puede pedirle a para hacer una excepción a estas restricciones o limitaciones o para una relación de otros medicamentos similares que pueden tratar su condición de salud. Véase la sección, Cómo pido una excepción al formulario de medicamentos de? que se encuentra en la página XXII para obtener más información sobre cómo solicitar una excepción. XX

24 MEDICAMENTOS DE VENTA LIBRE (OTC) CON COBERTURA MEDICAMENTOS Nombre genérico (Nombre de marca de referencia) Presentación hidrocloruro de Tabletas masticables, (Zyrtec) cetirizina solución, tabletas hidrocloruro de cetirizina/ hidrocloruro de (Zyrtec-D) Tabletas de 2 horas pseudoefedrina loratadina (Claritin) Solución, tabletas loratadina/ Tabletas de 2 horas sulfato de (Claritin-D) Tabletas de 24 horas pseudoefedrina fumarato de cetotifeno (Zaditor) Gotas Y Si mi medicamento no se encuentra en el formulario de medicamentos? Si su medicamento no se incluye en este formulario de medicamentos (relación de medicamentos cubiertos), debe primero comunicarse con Servicios para Miembros para consultar si su medicamento se encuentra cubierto. Si descubre que no cubre su medicamento, usted tiene dos opciones: Puede pedirle a Servicios para Miembros para una relación de medicamentos similares que están cubiertos por. Cuando recibe la relación, muéstrela a su médico y pídale que recete un medicamento similar que sea cubierto por. Puede pedirle a para que haga una excepción y cubra su medicamento. Véase a continuación para obtener información sobre cómo solicitar una excepción. XXI

25 Cómo pido una excepción al Vademécum de VNSNY CHOICE Medicare? Puede pedirle a de hacer una excepción a los reglamentos de cobertura. Existen varios tipos de excepciones que nos puede pedir. Nos puede pedir cubrir un medicamento, aunque no se encuentra en nuestro formulario de medicamentos. Si es aprobado, este medicamento será cubierto en un nivel de costo compartido predeterminado, y no podrá pedirnos ofrecer el medicamento a un nivel de costo compartido inferior. Nos puede pedir cubrir un medicamento que se encuentra en el formulario de medicamentos a un nivel de costo compartido inferior si el medicamento no se encuentra en el nivel especializado. Si es aprobado, esto reduciría el monto que debe pagar para su medicamento. Nos puede pedir eliminar las restricciones o limitaciones de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, nos puede pedir eliminar ese límite y cubrir una cantidad mayor. Por lo general, solamente aprobará su solicitud para una excepción si los medicamentos alternativos incluidos en el formulario de medicamentos del plan, el medicamento de costo compartido inferior o las restricciones de utilización adicionales no serían tan eficaces en tratar su condición y/o le causaría tener efectos médicos adversos. Debe comunicarse con nosotros para pedirnos una decisión de cobertura inicial para una excepción de restricción al formulario de medicamentos, escalonamiento o utilización. Cuando solicita una excepción de restricción al formulario de medicamentos, escalonamiento o utilización, debe presentar una declaración del prescriptor o médico apoyando su petición. Por lo general, debemos tomar nuestra decisión dentro de 72 horas de recibir la declaración de apoyo de su prescriptor. Puede pedir una excepción acelerada (rápida) si usted o su médico piensa que su salud puede ser seriamente perjudicada si espera hasta 72 horas para recibir una decisión. Si se le otorga su petición para acelerar, le debemos dar una decisión no menos de 24 horas después de recibir la declaración de apoyo de su médico u otro prescriptor. XXII

26 Qué debo hacer antes de hablar con mi médico sobre cambiar mis medicamentos o pedir una excepción? Como un miembro nuevo o continuado de nuestro plan, es posible que usted está tomando medicamentos que no se encuentran en nuestro formulario de medicamentos. También es posible que esté tomando un medicamento que se encuentra en nuestro formulario de medicamentos pero su habilidad de conseguirlo es limitada. Por ejemplo, usted puede necesitar una autorización previa de nosotros antes de poder llenar su receta. Debe consultar con su médico para determinar si debe cambiar a un medicamento apropiado que cubrimos o pedir una excepción al formulario de medicamentos para poder cubrirle el medicamento que toma. Mientras consulta con su médico para determinar el curso apropiado para usted, es posible que cubriremos su medicamentos en ciertos casos durante los primeros 90 días que usted es un miembro de nuestro plan. Por cada uno de los medicamentos que no se encuentran en nuestro formulario de medicamentos o si tiene habilidad limitada de conseguir sus medicamentos, cubriremos un suministro provisional de 30 días (al menos que tiene una receta escrita para menos días) cuando vaya a una farmacia dentro de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aunque ha sido un miembro del plan menos de 90 días. Si es residente de una centro de atención a largo plazo, le permitiremos reposicionar su receta hasta que le hayamos proveído con un suministro de 9 días, consistente con el incremento de dispensación (al menos que tiene una receta escrita por menos días). Cubriremos más de una reposición de estos medicamentos para los primeros 90 días si es un miembro de nuestro plan. Si necesita de un medicamento que no se encuentra en nuestro formulario de medicamentos o si tiene habilidad limitada en conseguir sus medicamentos, pero se encuentran pasados los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 3 días para ese medicamento (al menos que tiene una receta para menos días) mientras solicita una excepción al formulario de medicamentos. Un resurtido de transición sera proporcionado, por una vez, a los miembros actuales que están en necesidad de un resurtido de emergencia o que han sido recetado un medicamento fuera del formulario debido a un cambio de nivel de atención. XXIII

27 Para más información Para obtener más información sobre su cobertura de medicamentos con receta de, sírvase revisar la Evidencia de Cobertura y demás materiales del plan. Si tiene alguna duda sobre, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Si tiene alguna duda en general sobre la cobertura de medicamentos con receta de Medicare sírvase llamar al -800-MEDICARE ( ) las 24 horas del día/7 días a la semana. Los usuarios de TTY deben llamar al O, visite Esta información está disponible gratis en otros idiomas. Comuníquese con nuestros Servicios al miembro al número para obtener información adicional. (Los usuarios de TTY deben llamar al 7.) Horario de atención de lunes a viernes de 8:00 a.m. a 8:00 p.m. Los Servicios al miembro también tienen disponibles servicios gratis de intérpretes de idiomas para personas que no hablan ingles es un plan de HMO con contrato de Medicare. La inscripción en depende de la renovación del contrato. XXIV

28 Formulario de Medicamentos de El formulario de medicamentos que comienza en la página 3 ofrece información de cobertura sobre los medicamentos cubiertos por. Si tiene dificultad en encontrar su medicamento en esta relación, sírvase consultar el Índice que comienza en la página I-. En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca aparecen con letras mayúsculas (por ejemplo, CELEBREX) y los medicamentos genéricos aparecen con letras minúsculas y en bastardilla (por ejemplo, naproxen). La información que se encuentra en la columna de Requerimientos/Limitaciones le informa si tiene algún requerimiento especial para la cobertura de su medicamento. XXV

29 Las siguientes abreviaturas de Gestión de Uso se pueden encontrar en el cuerpo de este documento ABREVIATURAS DE LOS AVISOS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones en la Gestión de Uso PA PA BvD PA-HRM Restricciones de la Autorización previa Restricciones de Autorización previa para determinación de la Parte B frente a la Parte D Restricciones de autorización previa para Medicamentos de alto riesgo Se requiere que usted (o su médico) obtenga autorización previa de para poder surtir este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. Es posible que este medicamento sea elegible para pago según la Parte B o la Parte D de Medicare. Usted (o su médico) deben obtener autorización previa de para determinar si este medicamento está cubierto por la Parte D de Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que no cubra este medicamento. CMS considera que este medicamento es potencialmente dañino y, por consiguiente, se clasifica como medicamento de alto riesgo para los beneficiarios de Medicare de 65 años de edad o mayores. Se requiere que los afiliados de 65 años de edad o mayores obtengan autorización previa de antes de que se surta este medicamento con receta médica. Sin autorización previa, XXVI

30 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA NSO Restricciones de autorización previa para nuevos afiliados únicamente es posible que VNSNY CHOICE Medicare no cubra este medicamento. Si es un afiliado nuevo, se requiere que usted (o su médico) obtenga autorización previa de VNSNY CHOICE Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. QL ST Restricciones para los límites de cantidad Restricción en la terapia de pasos limita la cantidad de este medicamentos que es cubierto por receta médica, o dentro de un marco de tiempo específico. Antes de que VNSNY CHOICE Medicare le proporcione cobertura para este medicamento, primero debe intentar usar otro medicamento o medicamentos para tratar su condición médica. Este medicamente se cubrirá únicamente si los otros medicamentos no funcionan para usted. XXVII

31 Las siguientes abreviaturas de aviso de cobertura adicional se pueden encontrar en el cuerpo de este documento OTROS REQUERIMIENTOS ESPECIALES PARA LA COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN LA NM Medicamentos de acceso limitado Medicamentos que no se pueden enviar por correo Estos medicamentos con receta médica podrían estar disponibles únicamente en ciertas farmacias. Para obtener más información, consulte con el Directorio de proveedores y farmacias o llame a Servicios al afiliado al , de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al 7. Es posible que pueda recibir por correo más de un mes de suministros para la mayoría de los medicamentos en su formulario, con un costo compartido reducido. Los medicamentos que no están disponibles mediante el beneficio de pedido por correo, se identifican con las iniciales «NM» en la columna de Requerimientos/Límites de su formulario. XXVIII

32 ABREVIATURAS DE POTENCIA Y PRESENTACIÓN ABREVIATURA adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 2hr DESCRIPCIÓN parche adhesivo aerosol, activado por la respiración aerosol, polvo aerosol en polvo, activado por la respiración recarga de aerosol aerosol con adaptador ampolleta inyecciones de bolsa a granel cápsula, liberación retardada multifásica cápsula, paquete de dosis cápsula, 2 horas de acción prolongada cápsula, 24 horas de acción prolongada cápsula, liberación prolongada degradable cápsula, gránulos de liberación prolongada cápsula, multifásica cápsula, 24 horas de acción sostenida cápsula, 2 horas de liberación sostenida cápsula, 24 horas de liberación sostenida cápsula, gránulos de 24 horas de acción local controlada cápsula, gránulos de 24 horas de liberación sostenida cápsula, dispersable cápsula de gránulos de liberación sostenida cápsula con dispositivo cápsula de liberación prolongada cápsula de liberación extendida cápsula de acción sostenida combinación: cápsula, almohadilla combinación: ungüento, espuma combinación: ungüento, loción combinación: tableta, almohadilla paquete combinado cápsula, 2 horas multifásica XXIX

33 ABREVIATURA DESCRIPCIÓN cpmp 24hr cápsula, 24 horas multifásica cpmp cápsula, multifásicas, 30%-70% cpmp cápsula, multifásicas, 50%-50% cream(g), cream(gm) crema (gramos) cream(ml) crema (mililitros) cream/appl crema con aplicador cream, er (g) crema, liberación prolongada (gramos) cream pack crema, paquete dehp fr bg di(2-etilhexil)ftalato bolsa libre dis needle aguja desechable disk w/dev disco con dispositivo de inhalación disp syrin jeringa desechable drops susp gotas, suspensión drps hpvis gotas, hiperviscosas emul adhes emulsión adhesiva emul packt emulsión en paquete emulsn(g) emulsión (gramos) foam/appl. espuma con aplicador froz.piggy solución premezclada congelada g gramo gel/pf app gel con aplicador llenado previamente gel (gm) gel (gramos) gel (ml) gel (mililitros) gel md pmp gel en bomba de dosis medida gel w/appl gel con aplicador gel w/pump gel con bomba gran pack paquete de gránulos hfa aer ad adaptador de aerosoles hfa infus. btl frasco de infusión insuln pen pluma de insulina ip soln solución intraperitoneal irrig soln solución de irrigación iv soln. solución intravenosa jel gel jelly/app gel con aplicador XXX

34 ABREVIATURA jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack DESCRIPCIÓN gel con aplicador llenado previamente kit: limpiador y crema kit: crema, loción emoliente kit: loción, crema emoliente kit: ungüento, loción emoliente loción, liberación prolongada controlador de comprimidos parche de calor medicado tableta bucal mucoadhesiva microgramo almohadilla medicada hisopo medicado cinta adhesiva medicada miligramo mililitro sistema mucoadhesivo, 2 horas de liberación prolongada aguja para inyección suspensión en película para uñas ungüento (gramos) concentrado oral suspensión oral pasta (gramos) parche, 24 horas transdérmico parche, 72 horas transdérmico parche, transdérmico quincenal parche, transdérmico semanal jeringa de analgésico controlado por el paciente vial de analgésico controlado por el paciente gránulos (cada uno) kit de pluma de inyección pluma de inyección frasco de solución premezclada bolsa de plástico paquete de polvo XXXI

35 ABREVIATURA sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr DESCRIPCIÓN solución con bomba multidosificadora solución con aplicador solución con aplicador llenado previamente solución formadora de gel solución, reconstituida solución (gramos) atomizador, suspensión atomizador con bomba barra (cada una) supositorio, rectal supositorio, vaginal supositorio suspensión, 24 horas de liberación prolongada suspensión, liberación prolongada reconstituida suspensión, microcápsula reconstituida suspensión, paquete de liberación prolongada suspensión, reconstituida kit de jeringas tableta, masticable tableta, 2 horas liberación prolongada tableta, 24 horas liberación prolongada tableta, partículas de liberación prolongada tableta, hora liberación prolongada tableta, dispersable tableta, paquete de dosis tableta, 24 horas liberación prolongada tableta, multifásica tableta, partículas tableta, liberación prolongada de desintegración rápida tableta, desintegración rápida tableta, sublingual tableta, 2 horas liberación sostenida tableta, 24 horas liberación sostenida tableta, 24 horas liberación prolongada gradual tableta, liberación prolongada XXXII

36 ABREVIATURA tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPCIÓN tableta, liberación prolongada tableta, efervescente tableta, acción sostenida tableta, soluble tableta, paquete de dosis de liberación prolongada tableta, paquete de dosis multifásica tableta, paquete de dosis de desintegración rápida tableta, paquete de dosis para 3 meses tableta, 2 horas multifásica tableta, 24 horas multifásica unidad anillo vaginal XXXIII

37 Aviso de no discriminación La discriminación es contra la ley Servicio de Enfermeras Visitantes de Nueva York y todas sus subsidiarias y afiliadas* ( VNSNY ) cumplen con las leyes federales de derechos civiles y no discriminan con base en la raza, color, país de origen, edad, discapacidad o sexo. VNSNY no excluye a las personas ni las trata de manera diferente debido a su raza, color, país de origen, edad, discapacidad o sexo. VNSNY proporciona ayuda y servicios gratuitos a las personas con discapacidades para comunicarse eficazmente con nosotros, tales como intérpretes de lenguaje de señas, información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos); y proporciona servicios de idioma gratuitos a las personas cuyo idioma materno no es el inglés, tal como intérpretes calificados e información escrita en otros idiomas. Si usted necesita estos servicios, comuníquese con el Coordinador de derechos civiles de VNSNY: Para VNSNY CHOICE Health Plans: Susan Underwood Si usted considera que VNSNY no ha cumplido con prestar estos servicios o le ha discriminado de otra manera con base en la raza, color, país de origen, edad, discapacidad o sexo, puede presentar una queja con el Coordinador de derechos civiles mencionado antes: Por correo o en persona: 250 Broadway th Floor, New York, New York 000 Por teléfono: Para VNSNY CHOICE Health Plans: POR TYY: 7 Por fax: Por correo electrónico: CivilRightsCoordinator@vnsny.org En la web: Si necesita ayuda para presentar una queja, el Coordinador de derechos civiles está disponible para ayudarle. También puede presentar una queja de derechos civiles con el Departamento de Salud y Servicios Humanos de EE. UU., Oficina de Derechos Civiles, electrónicamente por medio del portal para quejas de la Oficina de Derechos Civiles en o por correo o teléfono al: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Los formularios de quejas están disponibles en *Las subsidiarias y afiliados son: Atención en el hogar de Visiting Nurse Service of New York, Atención paliativa y de hospicio de VNSNY y Partners in Care (en conjunto, los Proveedores de VNSNY ) y la Corporación de desarrollo de continuidad de la atención de VNSNY CHOICE y VNS (en conjunto, VNSNY CHOICE ). Los Proveedores de VNSNY y VNSNY CHOICE se llaman en conjunto VNSNY. XXXIV

38 與 VNSNY CHOICE Total 207 處方集 ( 給付藥品清單 ) 包含 Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) 核准的處方集提交 ID 號碼 : , 第 7 版 此處方集更新於 206 年 08 月 24 日 如需更多最新的資訊或有其他問題, 請聯絡 會員服務部, 電話 : ,TTY 使用者請撥 7, 週一到週五, 早上 8:00 到晚上 8:00, 或造訪 現有會員注意事項 : 此處方集已於去年變更 請檢閱此文件以確定其中仍然包含您服用的藥品 此藥品清單 ( 處方集 ) 所述的 我們 我方 或 我們的 均代表 VNSNY CHOICE Medicare 在提到 計畫 或 我們的計畫 時, 意指我們的 VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) 此文件包含我們計畫的藥品清單 ( 處方集 ), 是截至 206 年 8 月 24 日的最新版 想要獲得更新版的處方集, 請與我們聯絡 我們的聯絡資訊, 以及最後更新處方集的日期, 見封面與封底頁 您必須使用連網的藥房, 才能使用您的處方藥福利 福利 處方集 連網藥房 保費和 / 或共同負擔費用 / 共保費可能於 208 年 月 日變更 是搭配 Medicare 合約的 HMO 計畫 註冊 VNSNY CHOICE Medicare 取決於合約續訂 XXXV 最後更新 : 08/24/206

39 處方集是甚麼? 處方集是 諮詢醫療保健提供者團隊后所挑選的給付藥品清單, 代表據信高品質治療方案所需的處方療法 只要該藥品是醫療上必須的, 並且在 連網的藥房領取處方藥品, 且遵守其他的計畫規則, 那麼 將全面給付我們處方集所列的藥品 對於如何調劑處方的更多資訊, 請檢視您的 保險理賠項目說明書 處方集 ( 藥品清單 ) 可以更改嗎? 一般而言, 如果您在年初服用我們 207 年處方集所給付的藥品, 除非有較便宜的新學名藥可用, 或是新發佈關於該藥品安全性或功效的負面資訊以外, 在 207 年給付年度期間, 我們不會中止或減少藥品的給付 其他類型的處方集變更 ( 例如將一種藥品從處方集移除 ), 並不會影響目前服用該藥品的會員 服用該藥品的會員在給付年度的剩餘期間, 仍然可以相同的費用分攤取得 我們相信, 您在給付年度的剩餘期間, 仍然繼續取得您在選擇我們計畫時可用的處方集藥品是非常重要的, 除非您可以節省額外的費用或是我們可以確保您的安全 如果我們從處方集移除藥品或是新增藥品的事先核淮 數量限制和 / 或分階段療法限制, 或是將一種藥品轉到較高的費用分攤層級, 我們必須在變更生效的至少 60 天前, 或是會員要求補充藥品時, 通知受影響的會員, 屆時會員將收到 60 天的藥品 如果美國食品和藥品管理局認為我們處方集的藥品不安全, 或是藥品的製造商從市場撤除該藥品, 我們將立即從處方集中移除該藥品, 並通知服用該藥品的會員 所附的處方集是截至 206 年 24 月 08 日的最新版 如要取得關於 給付藥品的最新資訊, 請與我們聯絡 我們的聯絡資訊出現於封面與封底頁 如果我們以未維護的處方集變更更新我們的印刷處方集, 我們將寄給您包含此資訊的通知 XXXVI

40 我要如何使用處方集? 有兩种方法可找出處方集內您需要的藥品 : 醫療情況 處方集從第 3 頁開始 此處方集內的藥品是按照它們用於治療的醫療情況類型來分類的 例如, 用於治療心臟情況的藥品條列於 心血管 類別 如果您知道您的藥品用途, 在第 3 頁開始的清單上搜尋類別名稱 然後在類別名稱下方搜尋您的藥品 按字母排列的藥品清單 如果您不確定要搜尋的類別, 應該在 I- 開始的 索引 (Index) 搜尋您的藥品 索引 提供此文件全部的按字母排列的藥品清單 索引 同時條列專利藥與學名藥 從 索引 中查找您的藥品 在您的藥品旁邊, 會看到可以找到給付資訊的頁碼 翻到 索引 所列的頁碼, 並於清單的第一欄查找藥品的名稱 甚麼是學名藥? 同時給付專利藥和學名藥 學名藥是 FDA 核准和專利藥具有相同活性成分的藥品 一般而言, 學名藥比專利藥便宜 我的給付是否有任何限制? 有些給付藥品對給付範圍可能有其他要求或限制 這些要求與限制可能包括 : 事先授權 : 要求您或您的醫師針對特定藥品取得事先授權 這表示在依照您的處方領藥之前, 必須取得 的核准 若未經核淮, 可能無法給付藥品 數量限制 : 會針對特定藥品限制 VNSNY CHOICE Medicare 將給付的供應量 例如, 針對每張處方提供 60 顆 Celebrex 膠囊 這可能是附加於標準的一個月或三個月藥量 分階段療法 : 在某些情況下, 會在給付用於該病情的另一種藥品之前, 要求您先嘗試特定的藥品以治療您的醫療情況 例如, 如果 A 藥品與 B 藥品都能治療您的醫療情況, 可能在您先嘗試 A 藥品之後, 才給付 B 藥品 如果 A 藥品對您無效, 則 將給付 B 藥品 XXXVII

41 查找從第 3 頁開始的處方集, 可以了解您的藥品是否有其他要求或限制 造訪我們的網站也可以取得關於特定給付藥品限制的更多資訊 我們的聯絡資訊, 以及最後更新處方集的日期, 出現於封面與封底頁 您可以要求 對這些限制進行例外處理, 或是要求可以治療您的健康情況的其他類似藥品清單 請參閱第 XXXIX 頁 我如何要求對 VNSNY CHOICE Medicare 處方集進行例外處理 章節, 獲得關於如何要求例外處理的資訊 [ 成藥 (OTC) 是甚麼? OTC 藥品是 Medicare 處方藥品計畫一般不給付的非處方藥 給付特定的 OTC 藥品 給付的非處方藥 (OTC) 藥品學名 ( 參考專利藥 ) 劑量表 鹽酸西替利嗪 (cetirizine hydrochloride) (Zyrtec) 嚼錠 藥水 藥錠 鹽酸西替利嗪 (cetirizine hydrochloride)/ 偽麻黃堿鹽酸鹽 (Zyrtec-D) 2 小時藥錠 (pseudoephedrine hydrochloride) 氯雷他定 (loratadine) (Claritin) 藥水 藥錠 氯雷他定 (loratadine)/ 偽麻黃堿硫酸鹽 (pseudoephedrine sulfate) 富馬酸酮替芬 (ketotifen fumarate) (Claritin-D) (Zaditor) 2 小時藥錠 24 小時藥錠 滴劑 將免費向您提供這些 OTC 藥品 所支付的這些 OTC 藥品成本並不會計入您的 Part D 藥品總成本 ( 亦即您支付的金額並未計入給付範圍缺口 XXXVIII

42 如果我的藥品不在處方集內, 怎麼辦? 如果您的藥品並不在處方集 ( 給付藥品清單 ) 內, 您應該先聯絡會員服務部, 詢問您的藥品是否給付 如果您得知 並未給付您的藥品, 您有二種選擇 : 您可以要求會員服務部提供 給付的類似藥品清單 在收到清單時, 出示給您的醫生, 並要求開 給付的類似藥品處方 您可以要求 進行例外處理以給付您的藥品 請參閱以下如何要求例外處理的資訊 我要如何要求 處方集的例外處理? 您可以要求 針對我們的給付規則進行例外處理 您可以要求我們進行例外處理的類型有許多種 即使不在我們的處方集內, 您還是可以要求我們給付藥品 如果經核准, 此藥品將依照預先確定的費用分攤等級給付, 您不能要求我們以較低的費用分攤等級提供藥品 如果該藥品不屬於專門層級, 您可以要求我們以較低的費用分攤等級給付此處方集藥品 如果經核准, 這將會降低您必須支付的藥品金額 您可以要求我們取消對您藥品的給付範圍限制 例如, 會針對我們將給付的藥品, 限制我們將給付的藥品金額 如果您的藥品有數量限制, 您可以要求我們取消該限制, 並給付較高的金額 一般而言, 只有當計畫的處方集包含的替代藥品 費用分攤較低的藥品或其他的使用限制對您的治療情況無效, 或是會對您造成不良的醫療影響時, 才會核准您對例外處理的要求 您應該與我們聯絡, 要求我們針對處方集 分級或使用限制例外做出初步的給付決定 XXXIX

43 在您要求處方集 分級或使用率例外時, 您應該提交開立處方者或醫師支持您要求的聲明 一般情況下, 我們必須在取得您的開立處方者或醫師支持聲明的 72 小時內做出決定 如果您或您的醫師認為您的健康情況會因為等待決定長達 72 小時而受到嚴重的傷害, 您可以要求加速 ( 快速 ) 的例外處理 如果我們核准您要求加速的要求, 我們必須在取得您的開立處方者或醫師支持聲明的 24 小時內做出決定 在我和醫師討論變更我的藥品或要求例外處理之前, 我要做甚麼? 身為我們計畫的新會員或續約會員, 您可能正服用我們處方集以外的藥品 或者, 您服用的是處方集內的藥品, 但是您取得藥品的能力受到限制 例如, 您在依處方領藥之前, 可能需要事先核准 您應該和醫師討論以決定是否應該切換到我們給付的適當藥品, 或是要求處方集例外, 以便我們給付您所服用的藥品 與醫師討論決定適合您的行動方針時, 在特定的情況下, 我們可能於您成為我們會員的前 90 天給付您的藥物 對於您所服用不在我們處方集內的每種藥品, 或是如果您取得藥品的能力受限, 在您前往連網藥局時, 我們將給付臨時的 30 天供應量 ( 除非您的處方開立的是較少的天數 ) 在前 30 天供應量之後, 即使您成為計畫會員的時間不到 90 天, 我們將不會再給付這些藥品 如果您是長期照護機構的住民, 我們將允許您再次按處方領藥, 配合配藥增量, 直到我們提供您 9 天的轉換供應量 ( 除非您的處方開立的是較少的天數 ) 在您成為我們會員的第一個 90 天裏, 我們將給付這些藥品一次以上的補充量 如果您需要我們處方集以外的藥品, 或是您取得藥品的能力受限, 但是您成為我們計畫的會員已經超過 90 天, 在您要求處方集例外處理時, 我們將支付該藥品的 3 天緊急供應量 ( 除非您的處方開立的是較少的天數 ) 有需要一次性緊急配藥服務或需要配非處方藥因為護理級別更改的會員可以得到一次轉 換供應量 XL

44 如需更多資訊 如需關於 處方藥給付的更多詳細資訊, 請檢視您的 保險理賠項目說明書 與其他計畫資料 如果您有關於 的問題, 請與我們聯絡 我們的聯絡資訊, 以及最後更新處方集的日期, 出現於封面與封底頁 如果您有關於 Medicare 處方藥給付的一般問題, 請撥打 :-800-MEDICARE ( ) 與 Medicare 聯絡, 此專線 24 小時全天候提供服務 TTY 使用者請撥 : 或造訪 這份資訊同時提供其他語言版本, 完全免費 請撥打 與會員服務部聯絡以取得其他資訊 (TTY 使用者應撥打 7 免費電話 ) 服務時間為週一到週五早上 8 時至晚間 8 時 會員服務部也為非英語系國家人士提供免費的語言口譯服務 是搭配 Medicare 合約的 HMO 計畫 投保 VNSNY CHOICE Medicare 取決於續約 XLI

45 的處方集 從第 3 頁開始的處方集提供關於 給付藥物的相關給付資訊 如果您在清單中找不到您的藥品, 請翻到從第 I- 頁開始的 索引 圖表的第一欄會列出藥品的名稱 專利藥名稱是大寫 ( 例如 CELEBREX) 而學名藥則是小寫的斜體字 ( 例如 naproxen) 要求 / 限制 (Requirements/Limits) 欄的資訊說明 針對您的藥品給付是否有任何特殊的要求 以下的使用管理縮寫可能出現於 本文件的正文 保險給付注意事項縮寫 縮寫說明解釋 使用管理限制 PA PA BvD 事先授權限制 Part B 與 Part D 判定的事先授權限制 在按此處方領取藥品之前, 您或 ( 您的醫生 ) 必須先從 取得事先授權 如未事先核准, 可能無法給付此藥品 此藥品可能符合 Medicare Part B 或 Part D 的給付資格 在按此處方領取藥品之前, 您 ( 或您的醫生 ) 必須先從 取得事先授權, 以判定是否根據 Medicare Part D 給付此藥品 如未事先核准, 可能無法給付此藥品 XLII

46 縮寫說明解釋 PA-HRM PA NSO QL ST 高風險藥物的事先授權限制僅限新會員的事先授權限制數量限制分階段療法限制 CMS 認為此藥品具有潛在的傷害性, 因此是年滿 65 歲之 Medicare 受益人的高風險藥物 年滿 65 歲的會員在按此處方領取藥品之前, 必須先從 VNSNY CHOICE Medicare 取得事先授權 如未事先核准,VNSNY CHOICE Medicare 可能無法給付此藥品如果您是新會員, 在按此處方領取藥品之前, 您或 ( 您的醫生 ) 必須先從 取得事先授權 如未事先核准, 可能無法給付此藥品 限制每張處方簽或是在特定時間內給付此藥品的數量 在 提供此藥品的給付之前, 您必須先嘗試其他藥品以治療您的病症 如果其他藥品對您沒有功效, 才會給付此藥品 XLIII

47 以下的其他給付注意事項縮寫可能出現於本文件的正文保險給付的其他特殊要求 縮寫 說明 解釋 LA NM 取得受限的藥品 非郵購藥品 此處方可能只提供於特定的藥局 如需更多資訊, 請查閱您的 提供者及藥房目錄 或致電會員服務部, 電話 , 週一至週五, 早上 8:00 至晚上 8:00 TTY/TDD 使用者請撥打 7 透過郵購, 您可能以更低的分攤費用領取處方集大部分藥品 個月以上的藥量 無法透過郵購福利提供的藥品, 在處方集的 要求 / 限制 (Requirements/Limits) 欄標示為 "NM" XLIV

48 強度與劑量表縮寫 縮寫 adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt 說明貼布噴霧劑, 靠吸氣引動噴霧劑, 粉狀噴霧劑粉末, 靠吸氣引動噴霧補充劑附轉接頭的噴霧劑安瓿散裝袋注射膠囊, 多段式緩釋藥效膠囊, 劑量包膠囊,2 小時緩釋藥效膠囊,24 小時緩釋藥效膠囊, 緩釋藥效, 可降解膠囊, 緩釋藥效藥丸膠囊, 多段式膠囊,24 小時持續藥效膠囊,2 小時持續性藥效膠囊,24 小時持續性藥效膠囊,24 小時控制發作藥丸膠囊,24 小時持續性藥效藥丸膠囊, 分散型膠囊, 緩釋藥效藥丸附裝置的膠囊膠囊, 緩釋藥效膠囊, 緩釋藥效膠囊, 長效整合 : 膠囊, 墊整合 : 藥膏, 泡沫型整合 : 藥膏, 乳液型 XLV

49 縮寫 說明 cmb tabpad 整合 : 藥錠, 墊 combo. pkg 整合包裝 cpmp 2hr 膠囊,2 小時多段式 cpmp 24hr 膠囊,24 小時多段式 cpmp 膠囊, 多段式,30%-70% cpmp 膠囊, 多段式,50%-50% cream(g), cream(gm) 乳霜 ( 公克 ) cream(ml) 乳霜 ( 毫米 ) cream/appl 附塗抹器的乳霜 cream, er (g) 乳霜, 長效型 ( 公克 ) cream pack 乳霜, 包裝 dehp fr bg 不含鄰苯二甲酸二 (2- 乙基己基 ) 酯 (di(2- ethylhexyl)phthalate) 的袋子 dis needle 拋棄式針頭 disk w/dev 附吸入式裝置的圓盤 disp syrin 拋棄式針筒 drops susp 滴劑, 懸浮 drps hpvis 滴劑, 超黏性 emul adhes 乳化劑黏膠 emul packt 乳化劑包 emulsn(g) 乳化劑 ( 公克 ) foam/appl. 附塗抹器的泡沫 froz.piggy 冰敷背帶 g 公克 gel/pf app 附預充填塗抹器的凝膠 gel (gm) 凝膠 ( 公克 ) gel (ml) 凝膠 ( 毫米 ) gel md pmp 有刻度劑量幫浦的凝膠 gel w/appl 附塗抹器的凝膠 gel w/pump 附幫浦的凝膠 XLVI

50 縮寫 說明 gran pack 顆粒包 hfa aer ad hfa 噴霧劑轉接頭 infus. btl 輸液瓶 insuln pen 胰島素筆 ip soln 腹膜內溶液 irrig soln 灌注溶液 iv soln. 靜脈溶液 jel 膠狀物 jelly/app 附塗抹器的膠狀物 jel/pf app 附預充填塗抹器的膠狀物 kit cl&crm 組件 : 清潔劑與乳霜 kt crm le 組件 : 乳霜 乳液潤膚劑 kt lotn ce 組件 : 乳液 乳霜潤膚劑 kt oint le 組件 : 藥膏, 乳液潤膚劑 lotion, er 乳液, 緩釋藥效 lozenge hd 菱形握把 m.ht patch 含藥物的熱敷貼片 ma buc tab 黏膜吸附性口頰錠 mcg 微克 med. pad 含藥墊 med. swab 含藥棉花棒 med. tape 含藥膠帶 mg 毫克 ml 毫米 muc er 2h 黏膜吸附性系統,2 小時緩釋藥效 ndl fr inj 注射針 nl fm susp 指甲膜懸浮液 oint. (g), oint.(gm) 藥膏 ( 公克 ) oral conc 口服濃縮劑 oral susp 口服懸浮劑 XLVII

51 縮寫 說明 paste (g) 膏 ( 公克 ) patch td24 貼布,24 小時經皮膚 patch td72 貼布,72 小時經皮膚 patch tdsw 貼布, 雙週經皮膚 patch tdwk 貼布, 每週經皮膚 pca syring 由病患控制的止痛針筒 pca vial 由病患控制的止痛小瓶 pellet(ea) 藥丸 ( 每顆 ) pen ij kit 筆型注射器組件 pen injctr 筆型注射器 pggybk btl 肩背瓶 plast. bag 塑膠袋 powd pack 粉末包 sol md pmp 附多劑幫浦的溶液 sol w/appl 附塗抹器的溶液 sol/pf app 附預充填塗抹器的溶液 sol-gel 溶液, 凝膠狀 soln recon 溶液, 重組的 soln(gram) 溶液 ( 公克 ) spray susp 噴霧, 懸浮液 spray/pump 附幫浦的噴霧 stick(ea) 條狀 ( 每根 ) supp.rect 栓劑, 肛門 supp.vag 栓劑, 陰道 suppos. 栓劑 sus er 24h 懸浮液,24 小時緩釋藥效 sus er rec 懸浮液, 緩釋藥效重組 sus mc rec 懸浮液, 重組的微膠囊 suspdr pkt 懸浮液, 緩釋藥效包 susp recon 懸浮液, 重組的 XLVIII

52 縮寫 syringekit tab chew tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring 說明針筒組件藥錠, 可嚼藥錠,2 小時緩釋藥效藥錠,24 小時緩釋藥效藥錠, 緩釋藥效粒子藥錠, 緩釋藥效藥錠, 可分散藥錠, 劑量包藥錠,24 小時緩釋藥效藥錠, 多段式藥錠, 粒子藥錠, 快速崩解緩釋藥效藥錠, 快速崩解藥錠, 舌下藥錠,2 小時持續性藥效藥錠,24 小時持續性藥效藥錠,24 小時漸進緩釋藥效藥錠, 緩釋藥效藥錠, 緩釋藥效藥錠, 發泡劑藥錠, 長效藥錠, 可溶解藥錠, 緩釋劑量包藥錠, 多段式劑量包藥錠, 快速崩解劑量包藥錠,3 個月劑量包藥錠,2 小時多段式藥錠,24 小時多段式單位陰道環 XLIX

53 禁止歧視聲明 歧視係違法行為 紐約探訪護士服務及其所有子公司與關係企業 * ( VNSNY ) 一律遵守聯邦民權法, 不因種族 膚色 國籍 年齡 殘障或性別而歧視任何人 VNSNY 不因種族 膚色 國籍 年齡 殘障或性別而排擠任何人或給予差別待遇 為讓殘障人士能夠與 VNSNY 充分溝通, 我們提供免費的援助和服務, 例如合格的手語翻譯人員 其他格式 ( 大字印刷版 錄音版 方便易用的電子格式 其他格式 ) 的書面資訊 ; 同時也為母語非英語的人士提供免費的語言服務, 例如合格的口譯人員或其他語言版本的書面資訊 如需以上服務, 請聯絡 VNSNY 的民權協調員 (Civil Rights Coordinator): VNSNY CHOICE 健康計劃 :Susan Underwood 若您認為 VNSNY 並未提供以上服務, 或在其他方面因種族 膚色 國籍 年齡 殘障或性別而歧視您, 您可以向前述民權協調員提出申訴 : 郵寄或親自送到 :250 Broadway th Floor, New York, New York 000 致電 : VNSNY CHOICE 健康計劃 : TYY 服務專線 :7 傳真 : 電子郵件 :CivilRightsCoordinator@vnsny.org 網站 : 如在提出申訴方面需要任何協助, 民權協調員可以為您服務 您也可以向美國聯邦衛生和人類服務部 (U.S. Department of Health and Human Services) 的民權辦事處 (Office for Civil Rights) 提出投訴, 如欲透過電子方式提出投訴, 請利用民權辦事處投訴入口網站 (Office for Civil Rights Complaint Portal), 網址是 : 或者如需郵寄或致電, 請利用下列資訊 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C (TDD 服務專線 ) 如需投訴表, 請至 下載 * 子公司與關係企業係指 :Visiting Nurse Service of New York Home Care VNSNY Hospice and Palliative Care 和 Partners in Care ( 統稱 VNSNY 提供者 ), 以及 VNSNY CHOICE 和 VNS Continuing Care Development Corporation ( 統稱 VNSNY CHOICE ) VNSNY 提供者和 VNSNY CHOICE 統稱 VNSNY

54 Table of Contents Analgesics... 3 Anesthetics... 0 Anti-Addiction/Substance Abuse Treatment Agents... Antianxiety Agents... 2 Antibacterials... 5 Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants... 4 Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents... 7 Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 2 Genitourinary Agents... 6 Heavy Metal Antagonists... 7 Hormonal Agents, Stimulant/Replacement/Modifying... 8 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Formulary ID: Version: 7 Effective: January 0, 207

55 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents... 5 Vitamins And Minerals Formulary ID: Version: 7 2 Effective: January 0, 207

56 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 20 mg-2 mg/5 ml solution 20-2 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /2.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) (Buprenorphine HCl) (Buprenorphine HCl) (Fiorinal with Codeine #3) QL (2700 per 30 QL (2700 per 30 QL (360 per 30 QL (80 per 30 PA-HRM; QL (360 per 30 ; AGE (Max 64 Years) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) ST; QL (60 per 30 PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Fioricet with Codeine) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Tencon) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) Formulary ID: Version: 7 3 Effective: January 0, 207

57 butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Butorphanol Tartrate) QL (5 per 28 butorphanol tartrate nasal spray,non-aerosol 0 mg/ml BUTRANS TRANSDERMAL QL (4 per 28 PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 5 mg, 30 mg, (Codeine Sulfate) QL (80 per mg EMBEDA ORAL CAPSULE,ORAL QL (60 per 30 ONLY,EXT.REL PELL 00-4 MG, MG, MG, 50-2 MG, MG, MG endocet oral tablet mg (Xolox) QL (240 per 30 endocet oral tablet mg, mg (Xolox) QL (360 per 30 endocet oral tablet mg (Xolox) QL (300 per 30 endodan oral tablet mg (Oxycodone QL (360 per 30 HCl/Aspirin) fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, (Actiq) PA; QL (20 per mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 (Duragesic) QL (0 per 30 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution mg/5 ml(5 ml), mg/5 ml, mg/5 ml (Hycet) QL (2700 per 30 Formulary ID: Version: 7 4 Effective: January 0, 207

58 hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 0 (mg/ml) (5 ml), 0 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 (Norco) QL (360 per 30 (Ibudone) QL (50 per 30 (Hydromorphone HCl/PF) (Dilaudid) (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid mg/ml (Dilaudid) QL (200 per 30 hydromorphone oral tablet 2 mg, 4 mg, 8 (Dilaudid) QL (80 per 30 mg HYSINGLA ER ORAL QL (30 per 30 TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON-AEROSOL 00 PA; QL (30 per 30 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet (Norco) QL (360 per 30 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 lorcet plus oral tablet mg (Norco) QL (360 per 30 margesic oral capsule mg (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) methadone injection solution 0 mg/ml (Methadone HCl) methadone oral solution 0 mg/5 ml, 5 mg/5 ml (Methadone HCl) QL (800 per 30 Formulary ID: Version: 7 5 Effective: January 0, 207

59 methadone oral tablet 0 mg (Diskets) QL (360 per 30 methadone oral tablet 5 mg (Diskets) QL (80 per 30 methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 morphine 0 mg/ml carpuject 0 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml syringe p/f, latex-free (Morphine Sulfate) 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution 00 (Morphine Sulfate) QL (80 per 30 mg/5 ml (20 mg/ml) morphine intramuscular pen injector 0 (Morphine Sulfate) mg/0.7 ml morphine intravenous cartridge 5 mg/ml (Morphine Sulfate) morphine intravenous syringe 0 mg/ml, 2 (Morphine Sulfate) mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 0 mg/5 ml (Morphine Sulfate) QL (700 per 30 morphine oral solution 20 mg/5 ml (4 (Morphine Sulfate) QL (300 per 30 mg/ml) MORPHINE ORAL TABLET 5 MG QL (80 per 30 MORPHINE ORAL TABLET 30 MG QL (20 per 30 morphine oral tablet extended release 00 (MS Contin) QL (60 per 30 mg, 200 mg, 60 mg morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 mg morphine oral tablet extended release 30 (MS Contin) QL (20 per 30 mg NUCYNTA ER ORAL TABLET QL (60 per 30 EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, QL (8 per MG, 75 MG oxycodone oral capsule 5 mg (Oxycodone HCl) QL (80 per 30 oxycodone oral concentrate 20 mg/ml (Oxycodone HCl) QL (20 per 30 oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (300 per 30 oxycodone oral tablet 0 mg, 5 mg (Roxicodone) QL (80 per 30 Formulary ID: Version: 7 6 Effective: January 0, 207

60 oxycodone oral tablet 5 mg, 20 mg, 30 (Roxicodone) QL (20 per 30 mg oxycodone-acetaminophen oral solution (Oxycodone QL (800 per mg/5 ml HCl/Acetaminophen) oxycodone-acetaminophen oral tablet (Xolox) QL (240 per mg oxycodone-acetaminophen oral tablet (Xolox) QL (360 per mg, mg oxycodone-acetaminophen oral tablet (Xolox) QL (300 per mg oxycodone-aspirin oral tablet (Oxycodone QL (360 per 30 mg HCl/Aspirin) OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (20 per 30 TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg (Opana) QL (20 per 30 oxymorphone oral tablet 5 mg (Opana) QL (80 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 2 hr 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg reprexain oral tablet mg, (Ibudone) QL (50 per 30 mg, mg tencon oral tablet mg (Tencon) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (240 per mg vicodin es oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 Formulary ID: Version: 7 7 Effective: January 0, 207

61 vicodin hp oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 vicodin oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 XARTEMIS XR ORAL TAB,ORAL QL (300 per 30 ONLY,IR - ER, BIPHASE MG xylon 0 oral tablet mg (Ibudone) QL (50 per 30 zebutal oral capsule mg (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) ZOHYDRO ER ORAL CAPSULE, QL (60 per 30 ORAL ONLY, ER 2HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML) celecoxib oral capsule 00 mg, 200 mg, (Celebrex) QL (60 per mg, 50 mg diclofenac potassium oral tablet 50 mg (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Etodolac) Formulary ID: Version: 7 8 Effective: January 0, 207

62 etodolac oral tablet extended release 24 (Etodolac) hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 2 HOUR.3 % PA 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 indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 mg (Indomethacin) PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln mg (Indomethacin Sodium) PA-HRM; AGE (Max 64 Years) ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac injection cartridge 5 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection cartridge 30 mg/ml (Ketorolac QL (20 per 30 Tromethamine) ketorolac injection solution 5 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection solution 30 mg/ml ( (Ketorolac QL (20 per 30 ml) Tromethamine) ketorolac injection syringe 30 mg/ml (Ketorolac QL (20 per 30 Tromethamine) ketorolac intramuscular solution 60 mg/2 (Ketorolac QL (20 per 30 ml Tromethamine) ketorolac oral tablet 0 mg (Ketorolac Tromethamine) QL (20 per 30 Formulary ID: Version: 7 9 Effective: January 0, 207

63 mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 5 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 25 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 (Naprosyn) mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 (Anaprox Ds) mg piroxicam oral capsule 0 mg, 20 mg (Feldene) sulindac oral tablet 50 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 5 mg/ml (Xylocaine-MPF) (.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Pre-Attached Lta Kit) lidocaine hcl injection solution 0 mg/ml (Xylocaine) ( %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Pre-Attached Lta Kit) 2 %, 4 % (40 mg/ml) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Formulary ID: Version: 7 0 Effective: January 0, 207

64 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, 6.3- MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg buproban oral tablet extended release 50 mg bupropion hcl (smoking deter) oral tablet extended release 50 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) (Acamprosate Calcium) PA; QL (30 per 30 PA; QL (60 per 30 (Buprenorphine HCl) PA; QL (90 per 30 (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) (Zyban) (Zyban) QL (68 per 84 QL (68 per 84 QL (53 per 28 disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, (Naloxone HCl) mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL QL (4 per 30 SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 0 MG QL (008 per 90 Formulary ID: Version: 7 Effective: January 0, 207

65 SUBOXONE SUBLINGUAL FILM 2-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4- MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, mg PA; QL (60 per 30 PA; QL (30 per 30 PA; QL (30 per 30 PA; QL (60 per 30 (Xanax) QL (20 per 30 alprazolam oral tablet 2 mg (Xanax) QL (50 per 30 alprazolam oral tablet extended release (Xanax XR) QL (20 per hr 0.5 mg, mg, 2 mg alprazolam oral tablet extended release (Xanax XR) QL (90 per hr 3 mg chlordiazepoxide hcl oral capsule 0 mg, (Chlordiazepoxide QL (20 per mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating 2 (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 5 (Tranxene T-Tab) QL (80 per 30 mg, 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml (Diazepam) QL (0 per 28 diazepam intensol oral concentrate 5 (Diazepam) QL (200 per 30 mg/ml diazepam oral solution 5 mg/5 ml ( (Diazepam) QL (200 per 30 mg/ml) diazepam oral tablet 0 mg, 2 mg, 5 mg (Valium) QL (20 per 30 diazepam rectal kit mg, 2.5 mg, mg (Diastat) Formulary ID: Version: 7 2 Effective: January 0, 207

66 estazolam oral tablet mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) flurazepam oral capsule 5 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) Formulary ID: Version: 7 3 Effective: January 0, 207

67 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) lorazepam 2 mg/ml oral concent 2 mg/ml (Lorazepam) QL (50 per 30 lorazepam injection solution 2 mg/ml (Ativan) QL (2 per 30 lorazepam intensol oral concentrate 2 (Lorazepam) QL (50 per 30 mg/ml lorazepam oral tablet 0.5 mg, mg (Ativan) QL (90 per 30 lorazepam oral tablet 2 mg (Ativan) QL (50 per 30 midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (0 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML PA NSO; QL (480 per 30 ONFI ORAL TABLET 0 MG, 20 MG PA NSO; QL (60 per 30 temazepam oral capsule 5 mg, 22.5 mg, 30 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Formulary ID: Version: 7 4 Effective: January 0, 207

68 temazepam oral capsule 7.5 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (20 per 30 ; AGE (Max 64 Years) triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (20 per 30 ; AGE (Max 64 Years) triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML PA BvD Formulary ID: Version: 7 5 Effective: January 0, 207

69 gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon soln gram (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) PA BvD solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium piggyback 60 mg/50 ml Chloride) tobramycin sulfate injection solution 0 (Tobramycin Sulfate) mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 (Bacitracin) unit bacitracin intramuscular recon soln (Bacitracin) 50,000 unit chloramphenicol sod succinate (Chloramphenicol Sod intravenous recon soln gram Succ) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg (Cleocin HCl) clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Phosphate In D5w) (Cleocin Palmitate) Formulary ID: Version: 7 6 Effective: January 0, 207

70 clindamycin phosphate injection solution (Cleocin Phosphate) 50 (mg/ml) (6 ml), 50 mg/ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 mg/4 ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG CUBICIN RF INTRAVENOUS RECON SOLN 500 MG linezolid intravenous parenteral solution (Zyvox) 600 mg/300 ml linezolid oral suspension for (Zyvox) reconstitution 00 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metronidazole/Sodiu intravenous piggyback 500 mg/00 ml m Chloride) metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg (Macrodantin/Macrobi d) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 ; AGE (Max 64 Years) Formulary ID: Version: 7 7 Effective: January 0, 207

71 nitrofurantoin monohyd/m-cryst oral capsule 00 mg (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) nitrofurantoin oral suspension 25 mg/5 ml (Furadantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (2400 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg (Trimethoprim) vancomycin hcl g/200 ml bag (Vancomycin Hcl In gram/200 ml Dextrose 5 %) vancomycin intravenous recon soln,000 (Vancomycin HCl) mg, 0 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin Hcl In mg Dextrose 5 %) vancomycin oral capsule 25 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG PA Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml (Cefaclor) Formulary ID: Version: 7 8 Effective: January 0, 207

72 cefaclor oral tablet extended release 2 (Cefaclor) hr 500 mg cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback gram/50 ml, 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln gram, 0 (Cefazolin Sodium) gram, 500 mg cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 25 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 (Spectracef) mg CEFEPIME GM INJECTION GRAM/50 ML cefepime hcl gm vial 0's, sdv gram (Cefepime HCl) cefepime hcl 2 gram vial latex/f, sdv, (Cefepime HCl) outer 2 gram CEFEPIME INJECTION RECON SOLN GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 00 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln gram, (Claforan) 0 gram, 2 gram, 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 (Cefoxitin ml Sodium/Dextrose, Iso) cefoxitin 2 gm vial latex/f, outer 2 gram (Cefoxitin Sodium) cefoxitin intravenous recon soln gram, (Cefoxitin Sodium) 0 gram cefoxitin intravenous recon soln 2 gram (Cefoxitin Sodium/Dextrose, Iso) Formulary ID: Version: 7 9 Effective: January 0, 207

73 cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 200 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 25 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 mg/5 ml ceftriaxone gm piggyback 50ml (Ceftriaxone galaxycontainer gram/50 ml Na/Dextrose, Iso) ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln gram, (Ceftriaxone Sodium) 0 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 (Ceftin) mg cefuroxime sodium injection recon soln (Zinacef).5 gram, 750 mg cefuroxime sodium intravenous recon soln (Zinacef) 7.5 gram cephalexin oral capsule 250 mg, 500 mg, (Keflex) 750 mg cephalexin oral suspension for (Cephalexin) reconstitution 25 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG Formulary ID: Version: 7 20 Effective: January 0, 207

74 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG tazicef injection recon soln 2 gram, 6 (Fortaz) gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (Zithromax) (6 pack), 600 mg azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution 25 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 (Biaxin) mg clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 0 e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for (Eryped 200) reconstitution 200 mg/5 ml ery-tab oral tablet,delayed release (Erythromycin Base) (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg (Erythromycin Stearate) Formulary ID: Version: 7 2 Effective: January 0, 207

75 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet (Erythromycin 400 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg (Erythromycin Base) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, 2 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML LA imipenem-cilastatin intravenous recon (Primaxin) soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg (Amoxicillin) amoxicillin oral suspension for (Amoxicillin) reconstitution 25 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) amoxicillin oral tablet,chewable 25 mg, (Amoxicillin) 250 mg 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) mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 2 hr, mg (Augmentin XR) Formulary ID: Version: 7 22 Effective: January 0, 207

76 amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, mg Clav) ampicillin oral capsule 250 mg, 500 mg (Ampicillin Trihydrate) ampicillin oral suspension for (Ampicillin Trihydrate) reconstitution 25 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln (Ampicillin Sodium) gram, 0 gram, 25 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln (Ampicillin Sodium) 2 gram ampicillin-sulbactam.5 gm vl (Unasyn) 0's,sdv,latex-free.5 gram ampicillin-sulbactam injection recon soln (Unasyn) 5 gram, 3 gram ampicillin-sulbactam intravenous recon (Unasyn) soln.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg (Dicloxacillin Sodium) nafcillin 2 gm vial 0's, latex-free 2 gram (Nafcillin Sodium) nafcillin injection recon soln gram, 0 (Nafcillin Sodium) gram nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) oxacillin 2 gm vial 0's,outer 2 gram (Oxacillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin intravenous piggyback gram/50 ml, 2 gram/50 ml Sodium/Dextrose, Iso) oxacillin injection recon soln 0 gram (Oxacillin Sodium) oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) Formulary ID: Version: 7 23 Effective: January 0, 207

77 penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 25 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr,000 mg, 500 mg ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml, 400 mg/200 ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 25 mg/ml (Pen G Pot/Dextrose-Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) (Cipro XR) (Cipro) (Cipro I.V.) (Ciprofloxacin Lactate) (Cipro) (Levofloxacin/D5W) (Levofloxacin) levofloxacin oral solution 250 mg/0 ml (Levofloxacin) Formulary ID: Version: 7 24 Effective: January 0, 207

78 levofloxacin oral tablet 250 mg, 500 mg, (Levaquin) 750 mg moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri intravenous solution mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri suspension mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim) tablet mg, mg sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml (Sulfamethoxazole/Tri methoprim) Tetracyclines demeclocycline oral tablet 50 mg, 300 (Demeclocycline HCl) mg doxy-00 intravenous recon soln 00 mg (Doxycycline Hyclate) doxycycline hyclate intravenous recon (Doxycycline Hyclate) soln 00 mg doxycycline hyclate oral capsule 00 mg, (Morgidox) 50 mg doxycycline hyclate oral tablet 00 mg, (Doryx) 20 mg doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00 mg, 50 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule (Adoxa) 00 mg, 50 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 00 mg, 50 mg, 50 mg, 75 mg (Avidoxy) Formulary ID: Version: 7 25 Effective: January 0, 207

79 MINOCIN INTRAVENOUS RECON SOLN 00 MG minocycline oral capsule 00 mg, 50 mg, (Minocin) 75 mg minocycline oral tablet 00 mg, 50 mg, (Minocycline HCl) 75 mg minocycline oral tablet extended release (Minocycline HCl) 24 hr 35 mg, 45 mg, 90 mg tetracycline oral capsule 250 mg, 500 mg (Tetracycline HCl) TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG PA NSO; QL (4 per 2 adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml (Fluorouracil) PA BvD adrucil intravenous solution 500 mg/0 ml (Fluorouracil) PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; QL (28 per 28 ALECENSA ORAL CAPSULE 50 MG PA NSO; QL (240 per 30 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG anastrozole oral tablet mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) PA NSO Formulary ID: Version: 7 26 Effective: January 0, 207

80 azacitidine injection recon soln 00 mg (Vidaza) BELEODAQ INTRAVENOUS PA NSO RECON SOLN 500 MG BENDEKA INTRAVENOUS PA NSO SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) PA NSO; QL (420 per 30 bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 5 unit, 30 (Bleomycin Sulfate) PA BvD unit BLINCYTO INTRAVENOUS KIT 35 MCG PA NSO; QL (40 per 365 BOSULIF ORAL TABLET 00 MG PA NSO; QL (20 per 30 BOSULIF ORAL TABLET 500 MG PA NSO; QL (30 per 30 CABOMETYX ORAL TABLET 20 MG, 60 MG PA NSO; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG PA NSO; QL (30 per 30 carboplatin intravenous solution 0 (Carboplatin) mg/ml cladribine intravenous solution 0 mg/0 (Cladribine) PA BvD ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 PA NSO; QL (2 per 28 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG PA NSO; LA; QL (63 per 28 cyclophosphamide intravenous recon soln gram, 2 gram, 500 mg (Cyclophosphamide) PA BvD Formulary ID: Version: 7 27 Effective: January 0, 207

81 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS PA NSO SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML PA NSO; LA decitabine intravenous recon soln 50 mg (Dacogen) docetaxel 60 mg/6 ml vial mdv, (Taxotere) sterile,l/f 60 mg/6 ml (0 mg/ml) docetaxel intravenous solution 80 mg/4 (Taxotere) ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) doxorubicin, peg-liposomal intravenous (Doxil) PA BvD suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) QL ( per 84 SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) QL ( per 2 SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) QL ( per 68 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS PA NSO RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG PA NSO; QL (30 per 30 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG Formulary ID: Version: 7 28 Effective: January 0, 207

82 FARYDAK ORAL CAPSULE 0 PA NSO MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) PA BvD fluorouracil 5,000 mg/00 ml latex-free 5 (Fluorouracil) PA BvD gram/00 ml fluorouracil intravenous solution (Fluorouracil) PA BvD gram/20 ml, 2.5 gram/50 ml, 500 mg/0 ml flutamide oral capsule 25 mg (Flutamide) GAZYVA INTRAVENOUS PA NSO SOLUTION,000 MG/40 ML gemcitabine intravenous recon soln (Gemzar) gram, 2 gram, 200 mg gemcitabine intravenous solution (Gemzar) gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA NSO; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS PA NSO RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA NSO; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 ifosfamide gm/20 ml vial (Ifex) PA BvD sdv,p/f,latex-free gram/20 ml ifosfamide intravenous recon soln gram (Ifex) PA BvD Formulary ID: Version: 7 29 Effective: January 0, 207

83 ifosfamide-mesna intravenous kit - (Ifosfamide/Mesna) PA BvD gram, 3,000-,000 mg imatinib oral tablet 00 mg (Gleevec) PA NSO; QL (90 per 30 imatinib oral tablet 400 mg (Gleevec) PA NSO; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 PA NSO MG IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML PA NSO; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO; QL (8 per 28 INLYTA ORAL TABLET MG PA NSO; QL (80 per 30 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IRESSA ORAL TABLET 250 MG PA NSO; QL (60 per 30 irinotecan intravenous solution 00 mg/5 (Camptosar) ml, 40 mg/2 ml, 500 mg/25 ml IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; QL (60 per 30 KEYTRUDA INTRAVENOUS PA NSO RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) PA NSO KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG PA NSO; QL (6 per 28 Formulary ID: Version: 7 30 Effective: January 0, 207

84 LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) PA NSO letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit mg/0.2 ml (Leuprolide Acetate) LONSURF ORAL TABLET MG PA NSO; QL (00 per 28 LONSURF ORAL TABLET MG PA NSO; QL (80 per 28 LUPRON DEPOT (3 MONTH) QL ( per 84 INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) QL ( per 84 INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) QL ( per 68 INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG PA NSO; QL (480 per 30 LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/3 ML(0.6 MG/ML) FINAL PA NSO; QL (4 per 28 MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 Formulary ID: Version: 7 3 Effective: January 0, 207

85 MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 melphalan hcl intravenous recon soln 50 (Alkeran) mg mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate sodium (pf) injection recon (Methotrexate PA BvD soln gram Sodium/PF) methotrexate sodium (pf) injection solution 25 mg/ml (Methotrexate Sodium/PF) PA BvD methotrexate sodium injection solution 25 (Methotrexate Sodium) PA BvD mg/ml methotrexate sodium oral tablet 2.5 mg (Methotrexate Sodium) PA BvD; ST mitoxantrone intravenous concentrate 2 (Mitoxantrone HCl) mg/ml NEXAVAR ORAL TABLET 200 MG PA NSO; QL (20 per 30 NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA NSO; QL (3 per 28 ODOMZO ORAL CAPSULE 200 MG PA NSO; LA ONCASPAR INJECTION PA NSO SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS PA NSO SOLUTION 00 MG/0 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 00 (Oxaliplatin) mg, 50 mg oxaliplatin intravenous solution 00 (Oxaliplatin) mg/20 ml, 50 mg/0 ml (5 mg/ml) paclitaxel intravenous concentrate 6 (Paclitaxel) mg/ml PERJETA INTRAVENOUS SOLUTION 420 MG/4 ML (30 MG/ML) PA NSO Formulary ID: Version: 7 32 Effective: January 0, 207

86 POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PA NSO; QL (2 per 28 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 PA NSO; QL (00 per 2 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 PA NSO; LA MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS PA NSO CONCENTRATE 0 MG/ML SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 STIVARGA ORAL TABLET 40 MG PA NSO; QL (84 per 28 SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG PA NSO; QL (30 per 30 SYLVANT INTRAVENOUS RECON PA NSO SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG PA NSO; QL (28 per 28 TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA NSO; QL (20 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG PA NSO; LA; QL (30 per 30 tamoxifen oral tablet 0 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 00 MG, 25 MG PA NSO; QL (60 per 30 Formulary ID: Version: 7 33 Effective: January 0, 207

87 TARCEVA ORAL TABLET 50 MG PA NSO; QL (90 per 30 TARGRETIN ORAL CAPSULE 75 MG PA NSO; QL (420 per 30 TARGRETIN TOPICAL GEL % PA NSO; QL (60 per 28 TASIGNA ORAL CAPSULE 50 MG, 200 MG PA NSO; QL (2 per 28 TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 PA NSO; QL (20 per 2 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 00 MG PA NSO; (vial only) teniposide intravenous solution 50 mg/5 (Teniposide) ml thiotepa injection recon soln 5 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) topotecan hcl 4 mg/4 ml vial p/f, suv, (Hycamtin) latex-free 4 mg/4 ml ( mg/ml) topotecan intravenous recon soln 4 mg (Hycamtin) TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (0 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 00 MG TRELSTAR 22.5 MG SYRINGE WITH MIXJECT 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 mg PA BvD; QL (4 per 28 QL ( per 68 QL ( per 68 QL ( per 84 (Tretinoin) (capsule: 0mg) Formulary ID: Version: 7 34 Effective: January 0, 207

88 TREXALL ORAL TABLET 0 MG, PA BvD; ST 5 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS PA NSO SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VECTIBIX INTRAVENOUS PA NSO SOLUTION 00 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON PA NSO SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 00 MG PA NSO; LA; QL (20 per 30 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 PA NSO; LA; QL (42 per 28 MG-50 MG- 00 MG vinblastine intravenous solution mg/ml (Vinblastine Sulfate) PA BvD vincasar pfs 2 mg/2 ml vial 2 mg/2 ml (Vincristine Sulfate) PA BvD vincasar pfs intravenous solution mg/ml (Vincristine Sulfate) PA BvD vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2 (Vincristine Sulfate) PA BvD ml vincristine intravenous solution mg/ml (Vincristine Sulfate) PA BvD vinorelbine intravenous solution 0 (Navelbine) mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG PA NSO; QL (20 per 30 XALKORI ORAL CAPSULE 200 MG, 250 MG PA NSO; QL (60 per 30 XTANDI ORAL CAPSULE 40 MG PA NSO; QL (20 per 30 Formulary ID: Version: 7 35 Effective: January 0, 207

89 YERVOY INTRAVENOUS PA NSO SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS PA NSO RECON SOLN MG ZALTRAP INTRAVENOUS PA NSO SOLUTION 00 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZELBORAF ORAL TABLET 240 MG PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS QL ( per 28 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG PA NSO; QL (60 per 30 ZYKADIA ORAL CAPSULE 50 MG PA NSO; QL (40 per 28 ZYTIGA ORAL TABLET 250 MG PA NSO; QL (20 per 30 Anticholinergic Agents Antimuscarinics/Antispasmod ics atropine injection syringe 0.05 mg/ml, 0. mg/ml (Atropine Sulfate) propantheline oral tablet 5 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG (Propantheline Bromide) Formulary ID: Version: 7 36 Effective: January 0, 207

90 BRIVIACT INTRAVENOUS QL (80 per 30 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 QL (600 per 30 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr 00 mg, 200 mg, 300 mg carbamazepine oral suspension 00 mg/5 (Tegretol) ml carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 00 (Carbamazepine) mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle 25 mg (Depakote Sprinkle) divalproex oral tablet extended release 24 (Depakote ER) hr 250 mg, 500 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 25 mg, 250 mg, 500 mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 00 mg (Cerebyx) pe/2 ml, 500 mg pe/0 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg (Neurontin) Formulary ID: Version: 7 37 Effective: January 0, 207

91 gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 2 MG, 6 MG GRALISE 30-DAY STARTER PACK ST; QL (78 per 30 ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG ST; QL (90 per 30 lamotrigine oral tablet 00 mg, 50 mg, (Lamictal) 200 mg, 25 mg lamotrigine oral tablet disintegrating, (Lamictal Odt (Blue)) dose pk 25 mg (2) -50 mg (7), 25 mg(4)-50 mg (4)-00 mg (7), 50 mg (42) -00 mg (4) lamotrigine oral tablet extended release (Lamictal XR) 24hr 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable (Lamictal) dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 00 (Lamictal Odt) mg, 200 mg, 25 mg, 50 mg lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam in nacl (iso-os) intravenous (Levetiracetam In Nacl piggyback,000 mg/00 ml,,500 (Iso-Os)) mg/00 ml, 500 mg/00 ml levetiracetam intravenous solution 500 (Keppra) mg/5 ml levetiracetam oral solution 00 mg/ml (Keppra) levetiracetam oral tablet,000 mg, 250 (Keppra) mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) Formulary ID: Version: 7 38 Effective: January 0, 207

92 LYRICA ORAL CAPSULE 00 MG, QL (90 per MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML QL (900 per 30 oxcarbazepine oral suspension 300 mg/5 (Trileptal) ml oxcarbazepine oral tablet 50 mg, 300 (Trileptal) mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml (4 (Phenobarbital) QL (500 per 30 mg/ml) phenobarbital oral tablet 00 mg, 5 mg, (Phenobarbital) QL (90 per mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenytoin oral suspension 25 mg/5 ml (Dilantin-25) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule (Dilantin) 00 mg, 200 mg, 300 mg phenytoin sodium intravenous solution 50 (Phenytoin Sodium) mg/ml phenytoin sodium intravenous syringe 50 (Phenytoin Sodium) mg/ml POTIGA ORAL TABLET 200 MG, QL (90 per MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 primidone oral tablet 250 mg, 50 mg (Mysoline) SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG Formulary ID: Version: 7 39 Effective: January 0, 207

93 SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG ST; QL (20 per 30 tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiramate oral capsule, sprinkle 5 mg, (Topamax) 25 mg topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 00 mg, 50 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 00 mg, 200 mg, (Topamax) 25 mg, 50 mg TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 00 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution (Depacon) 500 mg/5 ml (00 mg/ml) valproic acid (as sodium salt) oral (Depakene) solution 250 mg/5 ml valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS QL (200 per 5 SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 0 QL (200 per 30 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG QL (60 per 30 zonisamide oral capsule 00 mg, 25 mg, (Zonegran) 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 0 mg, 23 mg, 5 mg (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating 0 (Donepezil HCl) QL (30 per 30 mg, 5 mg galantamine oral capsule,ext rel. pellets 24 hr 6 mg, 24 mg, 8 mg (Razadyne ER) QL (30 per 30 Formulary ID: Version: 7 40 Effective: January 0, 207

94 galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 galantamine oral tablet 2 mg, 4 mg, 8 (Razadyne) QL (60 per 30 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 memantine oral tablet 0 mg, 5 mg (Namenda) QL (60 per 30 memantine oral tablets,dose pack 5-0 (Namenda) QL (49 per 28 mg NAMENDA XR ORAL QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG NAMZARIC ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR 4-0 MG, 28-0 MG rivastigmine tartrate oral capsule.5 mg, (Exelon) QL (60 per 30 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour (Exelon) QL (30 per mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 0 mg, 00 mg, (Amitriptyline HCl) PA NSO-HRM 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, (Amoxapine) 25 mg, 50 mg BRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG bupropion hcl oral tablet 00 mg, 75 mg (Wellbutrin) bupropion hcl oral tablet extended release 00 mg, 50 mg, 200 mg (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr 50 mg, 300 mg citalopram oral solution 0 mg/5 ml (Citalopram Hydrobromide) QL (600 per 30 Formulary ID: Version: 7 4 Effective: January 0, 207

95 citalopram oral tablet 0 mg, 20 mg, 40 (Celexa) QL (30 per 30 mg clomipramine oral capsule 25 mg, 50 mg, (Anafranil) PA NSO-HRM 75 mg desipramine oral tablet 0 mg, 00 mg, (Norpramin) 50 mg, 25 mg, 50 mg, 75 mg doxepin oral capsule 0 mg, 00 mg, 50 (Doxepin HCl) PA NSO-HRM mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Irenka) (Cymbalta); QL (60 per 30 duloxetine oral capsule,delayed release(dr/ec) 30 mg (Irenka) (Cymbalta); QL (30 per 30 duloxetine oral capsule,delayed release(dr/ec) 40 mg (Irenka) (Irenka); QL (30 per 30 EMSAM TRANSDERMAL PATCH QL (30 per HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 (Lexapro) ml escitalopram oxalate oral tablet 0 mg, (Lexapro) 20 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0 mg, 20 mg, 40 (Prozac) mg fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml (4 (Fluoxetine HCl) mg/ml) fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG Formulary ID: Version: 7 42 Effective: January 0, 207

96 fluvoxamine oral capsule,extended (Fluvoxamine Maleate) release 24hr 00 mg, 50 mg fluvoxamine oral tablet 00 mg, 25 mg, (Fluvoxamine Maleate) 50 mg imipramine hcl oral tablet 0 mg, 25 mg, 50 mg (Tofranil) PA NSO-HRM imipramine pamoate oral capsule 00 mg, (Tofranil-Pm) PA NSO-HRM 25 mg, 50 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 (Maprotiline HCl) mg MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 mg, 30 mg, 45 (Remeron) mg, 7.5 mg mirtazapine oral tablet,disintegrating 5 (Remeron) mg, 30 mg, 45 mg nefazodone oral tablet 00 mg, 50 mg, (Nefazodone HCl) 200 mg, 250 mg, 50 mg nortriptyline oral capsule 0 mg, 25 mg, (Pamelor) 50 mg, 75 mg nortriptyline oral solution 0 mg/5 ml (Nortriptyline HCl) olanzapine-fluoxetine oral capsule 2-25 (Symbyax) mg, 2-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 0 mg, 20 mg, (Paxil) 30 mg, 40 mg paroxetine hcl oral tablet extended (Paxil CR) release 24 hr 2.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine-amitriptyline oral tablet (Perphenazine/Amitript PA NSO-HRM 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg yline HCl) phenelzine oral tablet 5 mg (Nardil) PRISTIQ ORAL TABLET QL (30 per 30 EXTENDED RELEASE 24 HR 00 MG, 25 MG, 50 MG protriptyline oral tablet 0 mg, 5 mg (Protriptyline HCl) Formulary ID: Version: 7 43 Effective: January 0, 207

97 sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 00 mg, 25 mg, 50 mg (Zoloft) SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG PA NSO-HRM tranylcypromine oral tablet 0 mg (Parnate) trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg (Trazodone HCl) trimipramine oral capsule 00 mg, 25 mg, (Trimipramine PA NSO-HRM 50 mg Maleate) TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) 24hr 50 mg, 37.5 mg, 75 mg venlafaxine oral tablet 00 mg, 25 mg, (Venlafaxine HCl) 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 24hr 50 mg, 225 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00 mg, 25 mg, 50 (Precose) QL (90 per 30 mg alogliptin oral tablet 2.5 mg, 25 mg, (Nesina) QL (30 per mg alogliptin-metformin oral tablet 2.5-,000 mg, mg (Kazano) QL (60 per 30 alogliptin-pioglitazone oral tablet (Oseni) QL (30 per 30 mg, mg, mg, 25-5 mg, mg, mg CYCLOSET ORAL TABLET 0.8 MG QL (80 per 30 Formulary ID: Version: 7 44 Effective: January 0, 207

98 GLYXAMBI ORAL TABLET 0-5 ST; QL (30 per 30 MG, 25-5 MG INVOKAMET ORAL TABLET ST; QL (60 per ,000 MG, MG, 50-,000 MG INVOKAMET ORAL TABLET MG ST; QL (20 per 30 INVOKANA ORAL TABLET 00 ST; QL (60 per 30 MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG JANUMET ORAL TABLET 50-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 0 ST; QL (30 per 30 MG, 25 MG JENTADUETO ORAL TABLET 2.5-,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG, 5-,000 MG KAZANO ORAL TABLET 2.5-,000 QL (60 per 30 MG, MG KOMBIGLYZE XR ORAL TABLET, QL (30 per 30 ER MULTIPHASE 24 HR 2.5-,000 MG, 5-,000 MG, MG KORLYM ORAL TABLET 300 MG PA; QL (2 per 28 metformin oral tablet,000 mg (Glucophage) QL (75 per 30 metformin oral tablet 500 mg (Glucophage) QL (50 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 Formulary ID: Version: 7 45 Effective: January 0, 207

99 metformin oral tablet extended release 24 (Glucophage XR) QL (20 per 30 hr 500 mg metformin oral tablet extended release 24 (Glucophage XR) QL (90 per 30 hr 750 mg metformin oral tablet extended release (Fortamet) ST; QL (60 per 30 24hr,000 mg metformin oral tablet extended release 24hr 500 mg (Fortamet) ST; QL (20 per 30 miglitol oral tablet 00 mg, 25 mg, 50 mg (Glyset) QL (90 per 30 nateglinide oral tablet 20 mg, 60 mg (Starlix) QL (90 per 30 NESINA ORAL TABLET 2.5 MG, 25 QL (30 per 30 MG, 6.25 MG ONGLYZA ORAL TABLET 2.5 MG, QL (30 per 30 5 MG OSENI ORAL TABLET MG, QL (30 per MG, MG, 25-5 MG, MG, MG pioglitazone oral tablet 5 mg, 30 mg, 45 (Actos) QL (30 per 30 mg pioglitazone-glimepiride oral tablet 30-2 (Duetact) QL (30 per 30 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg (Actoplus Met) QL (90 per 30 repaglinide oral tablet 0.5 mg, mg, 2 mg (Prandin) QL (240 per 30 repaglinide-metformin oral tablet -500 (Repaglinide/Metformi QL (50 per 30 mg, mg n HCl) SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML PA; QL (0.8 per 28 SYMLINPEN 60 SUBCUTANEOUS PA; QL (6 per 28 PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET ST; QL (60 per ,000 MG, MG, 5-,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML Formulary ID: Version: 7 46 Effective: January 0, 207

100 VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 00 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 00 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R INJECTION SOLUTION 00 UNIT/ML QL (30 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (40 per 28 Formulary ID: Version: 7 47 Effective: January 0, 207

101 HUMULIN R U-500 (CONC) QL (24 per 28 KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 QL (40 per 28 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR QL (30 per 28 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS QL (40 per 28 SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS QL (40 per 28 SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) QL (30 per 30 Formulary ID: Version: 7 48 Effective: January 0, 207

102 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 0 mg (Glucotrol) QL (20 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 30 0 mg glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per mg, 5 mg glipizide-metformin oral tablet (Glipizide/Metformin QL (240 per 30 mg HCl) glipizide-metformin oral tablet (Glipizide/Metformin QL (20 per 30 mg, mg HCl) glyburide micronized oral tablet.5 mg (Glynase) PA-HRM; QL (400 per 30 ; AGE (Max 64 Years) glyburide micronized oral tablet 3 mg (Glynase) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) glyburide micronized oral tablet 6 mg (Glynase) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) glyburide oral tablet.25 mg (Glyburide) PA-HRM; QL (280 per 30 ; AGE (Max 64 Years) glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 ; AGE (Max 64 Years) glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) glyburide-metformin oral tablet mg glyburide-metformin oral tablet mg, mg (Glucovance) PA-HRM; QL (240 per 30 ; AGE (Max 64 Years) (Glucovance) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) tolazamide oral tablet 250 mg (Tolazamide) QL (20 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 Formulary ID: Version: 7 49 Effective: January 0, 207

103 tolbutamide oral tablet 500 mg (Tolbutamide) QL (80 per 30 Antifungals Antifungals ABELCET INTRAVENOUS PA BvD SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS PA BvD SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg (Amphotericin B) PA BvD CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) ciclopirox topical gel 0.77 % (Ciclopirox) ciclopirox topical shampoo % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 % (Ciclopirox Olamine) clotrimazole mucous membrane troche 0 (Clotrimazole) mg clotrimazole topical cream % (Clotrimazole) clotrimazole topical solution % (Clotrimazole) clotrimazole-betamethasone topical (Lotrisone) cream % clotrimazole-betamethasone topical (Clotrimazole/Betamet lotion % hasone Dip) econazole topical cream % (Econazole Nitrate) EXELDERM TOPICAL CREAM % EXELDERM TOPICAL SOLUTION % fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 200 mg/00 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg (Fluconazole In Nacl,Iso-Osm) (Diflucan) (Diflucan) flucytosine oral capsule 250 mg, 500 mg (Ancobon) Formulary ID: Version: 7 50 Effective: January 0, 207

104 griseofulvin microsize oral suspension 25 mg/5 ml griseofulvin microsize oral tablet 500 mg (Griseofulvin, Microsize) (Griseofulvin, Microsize) (Gris-Peg) griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg (Sporanox) ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) miconazole-3 vaginal suppository 200 mg (Miconazole Nitrate) NOXAFIL INTRAVENOUS SOLUTION 300 MG/6.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 (Nystatin) unit/gram nystatin oral suspension 00,000 unit/ml (Nystatin) nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 00,000 unit/gram (Nystatin) nystatin topical ointment 00,000 (Nystatin) unit/gram nystatin topical powder 00,000 (Nystatin) unit/gram nystatin-triamcinolone topical cream (Nystatin/Triamcin) 00, unit/g-% nystatin-triamcinolone topical ointment (Nystatin/Triamcin) 00, unit/gram-% nystop topical powder 00,000 unit/gram (Nystatin) SPORANOX ORAL SOLUTION 0 MG/ML terbinafine hcl oral tablet 250 mg (Lamisil) voriconazole intravenous solution 200 mg (Vfend IV) Formulary ID: Version: 7 5 Effective: January 0, 207

105 voriconazole oral suspension for (Vfend) reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 00 mg, 300 mg (Zyloprim) colchicine-probenecid oral tablet (Colchicine/Probenecid mg ) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg (Probenecid) ULORIC ORAL TABLET 40 MG, 80 QL (30 per 30 MG Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 mg/5 (Carbinoxamine ml Maleate) carbinoxamine maleate oral tablet 4 mg (Carbinoxamine Maleate) clemastine oral tablet 2.68 mg (Clemastine Fumarate) cyproheptadine oral syrup 2 mg/5 ml (Cyproheptadine HCl) cyproheptadine oral tablet 4 mg (Cyproheptadine HCl) diphenhydramine hcl injection solution 50 (Diphenhydramine mg/ml HCl) diphenhydramine hcl injection syringe 50 (Diphenhydramine mg/ml HCl) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral solution 0 mg/5 ml (Hydroxyzine HCl) PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral tablet 0 mg, 25 mg, (Hydroxyzine HCl) PA-HRM; AGE (Max 50 mg 64 Years) levocetirizine oral solution 2.5 mg/5 ml (Xyzal) levocetirizine oral tablet 5 mg (Xyzal) promethazine oral syrup 6.25 mg/5 ml (Promethazine HCl) PA-HRM; AGE (Max 64 Years) Formulary ID: Version: 7 52 Effective: January 0, 207

106 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) Antimigraine Agents Antimigraine Agents almotriptan malate oral tablet 2.5 mg, (Axert) QL (2 per mg dihydroergotamine injection solution (D.H.E.45) QL (30 per 28 mg/ml dihydroergotamine nasal (Migranal) QL (8 per 28 spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ERGOMAR SUBLINGUAL TABLET QL (40 per 28 2 MG naratriptan oral tablet mg, 2.5 mg (Amerge) QL (8 per 28 rizatriptan oral tablet 0 mg, 5 mg (Maxalt) QL (8 per 28 rizatriptan oral tablet,disintegrating 0 (Maxalt Mlt) QL (8 per 28 mg, 5 mg sumatriptan 4 mg/0.5 ml inject latex-free (Imitrex) QL (4 per 28 4 mg/0.5 ml sumatriptan nasal spray,non-aerosol 20 (Imitrex) QL (2 per 28 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 00 mg, (Imitrex) QL (8 per mg, 50 mg sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 cartridge 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (Imitrex) QL (4 per 28 Formulary ID: Version: 7 53 Effective: January 0, 207

107 sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 solution 6 mg/0.5 ml sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 syringe 6 mg/0.5 ml Succinate) zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) QL (2 per 28 zolmitriptan oral tablet,disintegrating 2.5 (Zomig Zmt) QL (2 per 28 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN GRAM dapsone oral tablet 00 mg, 25 mg (Dapsone) ethambutol oral tablet 00 mg, 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 00 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 50 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 50 mg, 300 mg (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG PA; QL (88 per 68 TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE PA BvD MG compro rectal suppository 25 mg (Compazine) dimenhydrinate injection solution 50 mg/ml (Dimenhydrinate) Formulary ID: Version: 7 54 Effective: January 0, 207

108 dronabinol oral capsule 0 mg, 2.5 mg, 5 (Marinol) PA mg EMEND INTRAVENOUS RECON QL (2 per 28 SOLN 50 MG EMEND ORAL CAPSULE 25 MG, PA BvD 40 MG, 80 MG EMEND ORAL CAPSULE,DOSE PA BvD PACK 25 MG ()- 80 MG (2) EMEND ORAL SUSPENSION FOR PA BvD RECONSTITUTION 25 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 00 (Granisetron HCl/PF) mcg/ml granisetron hcl intravenous solution (Granisetron HCl) mg/ml, mg/ml ( ml) granisetron hcl oral tablet mg (Granisetron HCl) PA BvD meclizine oral tablet 2.5 mg, 25 mg (Meclizine HCl) ondansetron hcl (pf) injection solution 4 (Ondansetron HCl/PF) mg/2 ml ondansetron hcl (pf) injection syringe 4 (Ondansetron HCl/PF) mg/2 ml ondansetron hcl oral solution 4 mg/5 ml (Zofran) PA BvD ondansetron hcl oral tablet 24 mg, 4 mg, (Zofran) PA BvD 8 mg ondansetron oral tablet,disintegrating 4 (Zofran Odt) PA BvD mg, 8 mg phenadoz rectal suppository 2.5 mg, 25 mg (Phenergan) PA-HRM; AGE (Max 64 Years) prochlorperazine edisylate injection (Prochlorperazine solution 0 mg/2 ml (5 mg/ml) Edisylate) prochlorperazine maleate oral tablet 0 (Compazine) mg, 5 mg prochlorperazine rectal suppository 25 (Compazine) mg promethazine oral tablet 2.5 mg, 25 mg, 50 mg (Promethazine HCl) PA-HRM; AGE (Max 64 Years) Formulary ID: Version: 7 55 Effective: January 0, 207

109 promethazine rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 2.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY.5 MG ( MG OVER 3 DAYS) Antiparasite Agents Antiparasite Agents (Phenergan) PA-HRM; AGE (Max 64 Years) (Phenergan) PA-HRM; AGE (Max 64 Years) QL (0 per 30 ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet (Malarone) mg, mg chloroquine phosphate oral tablet 250 (Chloroquine mg, 500 mg Phosphate) COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG PA hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) NEBUPENT INHALATION RECON SOLN 300 MG PA BvD paromomycin oral capsule 250 mg (Paromomycin Sulfate) PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 QL (90 per 30 MG quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 tinidazole oral tablet 250 mg, 500 mg (Tindamax) Formulary ID: Version: 7 56 Effective: January 0, 207

110 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 00 mg (Amantadine HCl) APOKYN SUBCUTANEOUS QL (60 per 30 CARTRIDGE 0 MG/ML AZILECT ORAL TABLET 0.5 MG, MG benztropine injection solution 2 mg/2 ml (Cogentin) PA-HRM; AGE (Max 64 Years) benztropine oral tablet 0.5 mg, mg, 2 mg (Benztropine Mesylate) PA-HRM; AGE (Max 64 Years) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet 0-00 (Sinemet CR) mg, mg, mg carbidopa-levodopa oral tablet extended (Sinemet CR) release mg, mg carbidopa-levodopa oral (Carbidopa/Levodopa) tablet,disintegrating 0-00 mg, mg, mg carbidopa-levodopa-entacapone oral (Stalevo 50) tablet mg, mg, mg, mg, mg, mg COGENTIN INJECTION SOLUTION 2 MG/2 ML PA-HRM; AGE (Max 64 Years) entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR QL (30 per 30 Formulary ID: Version: 7 57 Effective: January 0, 207

111 pramipexole oral tablet 0.25 mg, 0.25 (Mirapex) mg, 0.5 mg, 0.75 mg, mg,.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, (Requip) mg, 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 (Requip XL) hr 2 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) PA-HRM; AGE (Max 64 Years) trihexyphenidyl oral tablet 2 mg, 5 mg (Trihexyphenidyl HCl) PA-HRM; AGE (Max 64 Years) Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA QL ( per 28 INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA QL ( per 28 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution mg/ml (Aripiprazole) QL (900 per 30 aripiprazole oral tablet 0 mg, 5 mg, 20 (Abilify) QL (30 per 30 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 aripiprazole oral tablet,disintegrating 0 (Aripiprazole) QL (90 per 30 mg aripiprazole oral tablet,disintegrating 5 (Aripiprazole) QL (60 per 30 mg ARISTADA INTRAMUSCULAR QL (.6 per 28 SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML QL (2.4 per 28 Formulary ID: Version: 7 58 Effective: January 0, 207

112 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML QL (3.2 per 28 chlorpromazine injection solution 25 (Chlorpromazine HCl) mg/ml chlorpromazine oral tablet 0 mg, 00 (Chlorpromazine HCl) mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 00 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) QL (35 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating 00 (Fazaclo) ST mg, 2.5 mg, 50 mg, 200 mg, 25 mg FANAPT ORAL TABLET MG, 0 ST; QL (60 per 30 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 PACK MG(2)-2MG(2)- 4MG(2)-6MG(2) fluphenazine decanoate injection solution (Fluphenazine 25 mg/ml Decanoate) fluphenazine hcl injection solution 2.5 mg/ml (Fluphenazine HCl) fluphenazine hcl oral concentrate 5 mg/ml (Fluphenazine HCl) fluphenazine hcl oral elixir 2.5 mg/5 ml (Fluphenazine HCl) fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg (Fluphenazine HCl) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) QL (6 per 28 haloperidol dec 50 mg/ml vial 50 mg/ml (Haloperidol Decanoate) haloperidol decanoate intramuscular (Haloperidol solution 00 mg/ml Decanoate) haloperidol decanoate intramuscular (Haldol Decanoate 50) solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml (Haloperidol Lactate) Formulary ID: Version: 7 59 Effective: January 0, 207

113 haloperidol lactate oral concentrate 2 (Haloperidol Lactate) mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg (Haloperidol) INVEGA SUSTENNA QL (0.75 per 28 INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA QL ( per 28 INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA QL (.5 per 28 INTRAMUSCULAR SYRINGE 234 MG/.5 ML INVEGA SUSTENNA QL (0.25 per 28 INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA QL (0.875 per 84 INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA QL (.35 per 84 INTRAMUSCULAR SYRINGE 40 MG/.35 ML INVEGA TRINZA QL (.75 per 84 INTRAMUSCULAR SYRINGE 546 MG/.75 ML INVEGA TRINZA QL (2.625 per 84 INTRAMUSCULAR SYRINGE 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 loxapine succinate oral capsule 0 mg, 25 (Loxapine Succinate) mg, 5 mg, 50 mg molindone oral tablet 0 mg (Molindone HCl) QL (240 per 30 molindone oral tablet 25 mg (Molindone HCl) QL (270 per 30 Formulary ID: Version: 7 60 Effective: January 0, 207

114 molindone oral tablet 5 mg (Molindone HCl) QL (20 per 30 NUPLAZID ORAL TABLET 7 MG PA NSO; QL (60 per 30 olanzapine intramuscular recon soln 0 (Zyprexa) QL (30 per 30 mg olanzapine oral tablet 0 mg, 5 mg, 2.5 (Zyprexa) QL (30 per 30 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) QL (30 per 30 mg, 5 mg, 20 mg, 5 mg paliperidone oral tablet extended release (Invega) QL (30 per 30 24hr.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release (Invega) QL (60 per 30 24hr 6 mg perphenazine oral tablet 6 mg, 2 mg, 4 (Perphenazine) mg, 8 mg pimozide oral tablet mg, 2 mg (Orap) quetiapine oral tablet 00 mg, 200 mg, 25 (Seroquel) QL (90 per 30 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG ST; QL (20 per 30 REXULTI ORAL TABLET 0.5 MG ST; QL (60 per 30 REXULTI ORAL TABLET MG, 2 ST; QL (30 per 30 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution mg/ml (Risperdal) QL (480 per 30 risperidone oral tablet 0.25 mg, 0.5 mg, (Risperdal) QL (60 per 30 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) QL (60 per 30 mg, 0.5 mg, mg, 2 mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (20 per 30 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG ST; QL (60 per 30 Formulary ID: Version: 7 6 Effective: January 0, 207

115 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG thioridazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine oral tablet mg, 0 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG Antivirals (Systemic) Antiretrovirals ST; QL (60 per 30 ST; QL (30 per 30 (Thioridazine HCl) PA NSO-HRM (Thiothixene) (Trifluoperazine HCl) ST; QL (540 per 30 ST; QL (30 per 30 ST; QL (7 per 30 (Geodon) QL (60 per 30 abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine-zidovudine oral (Trizivir) tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML QL (2 per 28 QL ( per 28 Formulary ID: Version: 7 62 Effective: January 0, 207

116 ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed (Videx EC) release(dr/ec) 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG Formulary ID: Version: 7 63 Effective: January 0, 207

117 KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 mg/ml (Epivir) lamivudine oral tablet 00 mg, 50 mg, (Epivir) 300 mg lamivudine-zidovudine oral tablet (Combivir) mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr 00 mg, 400 mg NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG Formulary ID: Version: 7 64 Effective: January 0, 207

118 REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 50 MG, 300 MG stavudine oral capsule 5 mg, 20 mg, 30 (Zerit) mg, 40 mg stavudine oral recon soln mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 50 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg (Retrovir) zidovudine oral syrup 0 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) PA BvD Formulary ID: Version: 7 65 Effective: January 0, 207

119 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 mg (Flumadine) SYNAGIS INTRAMUSCULAR PA SOLUTION 00 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG QL (84 per 80 TAMIFLU ORAL CAPSULE 45 MG QL (48 per 80 TAMIFLU ORAL CAPSULE 75 MG QL (42 per 80 TAMIFLU ORAL SUSPENSION QL (540 per 80 FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA; QL (28 per 28 EPCLUSA ORAL TABLET MG PA; QL (28 per 28 HARVONI ORAL TABLET MG PA; QL (30 per 30 OLYSIO ORAL CAPSULE 50 MG PA; QL (28 per 28 SOVALDI ORAL TABLET 400 MG PA; QL (28 per 28 TECHNIVIE ORAL TABLET MG PA; QL (56 per 28 VIEKIRA PAK ORAL TABLETS,DOSE PACK 2.5 MG-75 MG -50 MG/250 MG ZEPATIER ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) PA; QL (2 per 28 PA; QL (30 per 30 PA NSO Formulary ID: Version: 7 66 Effective: January 0, 207

120 INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 20 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) PA NSO PA PA PA PA PA NSO; QL (4 per 28 acyclovir sodium intravenous recon soln (Acyclovir Sodium) PA BvD 500 mg acyclovir sodium intravenous solution 50 (Acyclovir Sodium) PA BvD mg/ml adefovir oral tablet 0 mg (Hepsera) cidofovir intravenous solution 75 mg/ml (Vistide) entecavir oral tablet 0.5 mg, mg (Baraclude) famciclovir oral tablet 25 mg, 250 mg, (Famvir) 500 mg ganciclovir sodium intravenous recon soln (Cytovene) PA BvD 500 mg ribasphere oral capsule 200 mg (Rebetol) ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) Formulary ID: Version: 7 67 Effective: January 0, 207

121 ribasphere ribapak oral tablets,dose pack (Ribatab) 200 mg (7)- 400 mg (7), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet gram, 500 mg (Valtrex) VALCYTE ORAL RECON SOLN 50 MG/ML valganciclovir oral tablet 450 mg (Valcyte) VIRAZOLE INHALATION RECON PA BvD SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 (Lovenox) mg/3 ml enoxaparin subcutaneous syringe 00 (Lovenox) mg/ml, 20 mg/0.8 ml, 50 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 0 (Arixtra) QL (24 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) QL (5 per 30 mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) QL (2 per 30 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Arixtra) QL (8 per 30 Formulary ID: Version: 7 68 Effective: January 0, 207

122 heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (00 units/ml) bag latex-free, inner 25,000 unit/250 ml IPRIVASK SUBCUTANEOUS RECON SOLN 5 MG jantoven oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG SAVAYSA ORAL TABLET 5 MG, 30 MG, 60 MG warfarin oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 0,000 UNITS/ML VIAL SDV, P/F, OUTER 0,000 UNIT/ML (Heparin Sodium,Porcine/D5W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) PA; QL (24 per 28 (Coumadin) (Coumadin) ST; QL (60 per 30 PA PA; QL (2 per 28 Formulary ID: Version: 7 69 Effective: January 0, 207

123 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 00 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg, mg (Agrylin) protamine intravenous solution 0 mg/ml (Protamine Sulfate) PA; QL (2 per 28 PA; QL (0.6 per 28 PA; QL (2 per 28 PA; QL (6 per 28 PA; QL (30 per 30 ST Formulary ID: Version: 7 70 Effective: January 0, 207

124 tranexamic acid intravenous solution (Tranexamic Acid),000 mg/0 ml (00 mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 2 hr mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg (Cilostazol) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, (Persantine) 75 mg EFFIENT ORAL TABLET 0 MG, 5 QL (30 per 30 MG pentoxifylline oral tablet extended (Pentoxifylline) release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 5 % PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % AMINOSYN 3.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH PA BvD ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % PA BvD Formulary ID: Version: 7 7 Effective: January 0, 207

125 AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD Formulary ID: Version: 7 72 Effective: January 0, 207

126 CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD Formulary ID: Version: 7 73 Effective: January 0, 207

127 CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringers intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % (Dextrose 0 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5 % In Ringers) (Dextrose 5 % in Water) (Dextrose 50 % in Water) (Dextrose 50 % in Water) (Dextrose 70 % in Water) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD Formulary ID: Version: 7 74 Effective: January 0, 207

128 KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0. mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.-5 mg, mg, mg (Catapres) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD (Catapres-Tts ) QL (4 per 28 (Catapres-Tts ) QL (8 per 28 (Clonidine HCl/Chlorthalidone) Formulary ID: Version: 7 75 Effective: January 0, 207

129 doxazosin oral tablet mg, 2 mg, 4 mg, 8 (Cardura) mg guanfacine oral tablet mg, 2 mg (Tenex) PA-HRM; AGE (Max 64 Years) midodrine oral tablet 0 mg, 2.5 mg, 5 (Midodrine HCl) mg NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG PA; QL (80 per 30 phenylephrine hcl injection solution 0 (Vazculep) mg/ml prazosin oral capsule mg, 2 mg, 5 mg (Minipress) Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 6 mg, 32 mg, 4 (Atacand) mg, 8 mg candesartan-hydrochlorothiazid oral (Atacand HCT) tablet mg, mg, mg EDARBI ORAL TABLET 40 MG, 80 ST MG EDARBYCLOR ORAL TABLET ST MG, MG ENTRESTO ORAL TABLET QL (60 per 30 MG, 49-5 MG, MG eprosartan oral tablet 600 mg (Eprosartan Mesylate) irbesartan oral tablet 50 mg, 300 mg, 75 (Avapro) mg irbesartan-hydrochlorothiazide oral (Avalide) tablet mg, mg losartan oral tablet 00 mg, 25 mg, 50 (Cozaar) mg losartan-hydrochlorothiazide oral tablet mg, mg, mg (Hyzaar) Formulary ID: Version: 7 76 Effective: January 0, 207

130 telmisartan oral tablet 20 mg, 40 mg, 80 (Micardis) mg telmisartan-hydrochlorothiazid oral tablet mg, mg, mg (Micardis HCT) TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG ST valsartan oral tablet 60 mg, 320 mg, 40 (Diovan) mg, 80 mg valsartan-hydrochlorothiazide oral tablet (Diovan HCT) mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0 mg, 20 mg, 40 (Lotensin) mg, 5 mg benazepril-hydrochlorothiazide oral (Lotensin HCT) tablet mg, mg, mg, mg captopril oral tablet 00 mg, 2.5 mg, 25 (Captopril) mg, 50 mg captopril-hydrochlorothiazide oral tablet (Captopril/Hydrochlor 25-5 mg, mg, 50-5 mg, mg othiazide) enalapril maleate oral tablet 0 mg, 2.5 (Vasotec) mg, 20 mg, 5 mg enalaprilat intravenous solution.25 (Enalaprilat Dihydrate) mg/ml enalapril-hydrochlorothiazide oral tablet (Vaseretic) 0-25 mg, mg fosinopril oral tablet 0 mg, 20 mg, 40 (Fosinopril Sodium) mg fosinopril-hydrochlorothiazide oral tablet (Fosinopril/Hydrochlor mg, mg othiazide) lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Zestril) Formulary ID: Version: 7 77 Effective: January 0, 207

131 lisinopril-hydrochlorothiazide oral tablet (Zestoretic) mg, mg, mg moexipril oral tablet 5 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral tablet (Moexipril/Hydrochlor mg, 5-25 mg, mg othiazide) perindopril erbumine oral tablet 2 mg, 4 (Aceon) mg, 8 mg quinapril oral tablet 0 mg, 20 mg, 40 (Accupril) mg, 5 mg quinapril-hydrochlorothiazide oral tablet (Accuretic) mg, mg, mg ramipril oral capsule.25 mg, 0 mg, 2.5 (Altace) mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg (Mavik) Antiarrhythmic Agents amiodarone intravenous solution 50 mg/ml (Amiodarone HCl) amiodarone intravenous syringe 50 mg/3 (Amiodarone HCl) ml amiodarone oral tablet 00 mg, 200 mg, (Cordarone) 400 mg disopyramide phosphate oral capsule 00 (Norpace) mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, (Tikosyn) 500 mcg flecainide oral tablet 00 mg, 50 mg, 50 (Tambocor) mg lidocaine (pf) intravenous syringe 50 (Lidocaine HCl/PF) mg/5 ml ( %) lidocaine in 5 % dextrose (pf) (Lidocaine intravenous parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine oral capsule 50 mg, 200 mg, (Mexiletine HCl) 250 mg MULTAQ ORAL TABLET 400 MG Formulary ID: Version: 7 78 Effective: January 0, 207

132 pacerone oral tablet 00 mg, 200 mg, 400 (Cordarone) mg procainamide injection solution 00 (Procainamide HCl) mg/ml, 500 mg/ml propafenone oral capsule,extended (Rythmol SR) release 2 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 50 mg, 225 mg, (Rythmol) 300 mg quinidine gluconate oral tablet extended (Quinidine Gluconate) release 324 mg quinidine sulfate oral tablet 200 mg, 300 (Quinidine Sulfate) mg quinidine sulfate oral tablet extended (Quinidine Sulfate) release 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) atenolol oral tablet 00 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet (Tenoretic 50) mg, mg betaxolol oral tablet 0 mg, 20 mg (Betaxolol HCl) bisoprolol fumarate oral tablet 0 mg, 5 (Zebeta) mg bisoprolol-hydrochlorothiazide oral tablet (Ziac) mg, mg, mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 2.5 mg, 25 mg, (Coreg) 3.25 mg, 6.25 mg esmolol intravenous solution 00 mg/0 (Brevibloc) PA BvD ml (0 mg/ml) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 00 mg, 200 mg, 300 mg (Trandate) Formulary ID: Version: 7 79 Effective: January 0, 207

133 metoprolol succinate oral tablet extended (Toprol XL) release 24 hr 00 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, mg (Lopressor HCT) metoprolol tartrate intravenous solution 5 (Metoprolol Tartrate) mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml (Metoprolol Tartrate) metoprolol tartrate oral tablet 00 mg, 25 (Lopressor) mg, 37.5 mg, 50 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) pindolol oral tablet 0 mg, 5 mg (Pindolol) propranolol intravenous solution mg/ml (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr 20 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 (Propranolol HCl) mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 20 mg, 40 (Propranolol HCl) mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral (Propranolol/Hydrochl tablet mg, mg orothiazid) sorine oral tablet 20 mg, 60 mg, 240 (Betapace) mg, 80 mg sotalol 20 mg tablet 20 mg (Betapace) sotalol af oral tablet 20 mg (Betapace) sotalol oral tablet 60 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 0 mg, 20 mg, (Timolol Maleate) 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule,extended release (Cardizem CD) 24hr 20 mg, 80 mg, 240 mg, 300 mg diltiazem 24hr er 80 mg cap 80 mg (Cardizem CD) diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) Formulary ID: Version: 7 80 Effective: January 0, 207

134 diltiazem hcl intravenous recon soln 00 (Cardizem CD) mg diltiazem hcl intravenous solution 5 (Cardizem CD) mg/ml diltiazem hcl oral capsule, extended (Cardizem CD) release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) release 2 hr 20 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended (Cardizem CD) release 24hr 20 mg, 240 mg, 300 mg diltiazem hcl oral tablet 20 mg, 30 mg, (Cardizem CD) 60 mg, 90 mg diltiazem hcl oral tablet extended release (Cardizem LA) 24 hr 80 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release (Cardizem CD) degradable 20 mg, 80 mg, 240 mg matzim la oral tablet extended release 24 (Cardizem CD) hr 80 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release (Cardizem CD) 20 mg, 80 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 00 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 (Verelan) hr 20 mg, 80 mg, 240 mg, 360 mg verapamil oral tablet 20 mg, 40 mg, 80 (Calan) mg verapamil oral tablet extended release (Calan SR) 20 mg, 80 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, ST 7.5 MG DEMSER ORAL CAPSULE 250 MG Formulary ID: Version: 7 8 Effective: January 0, 207

135 digitek oral tablet 25 mcg, 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 ; AGE (Max 64 Years) digoxin 0.25 mg/ml syringe 250 mcg/ml (Digoxin) PA-HRM; AGE (Max 64 Years) digoxin injection solution 250 mcg/ml (Digoxin) PA-HRM; AGE (Max 64 Years) DIGOXIN ORAL SOLUTION 50 MCG/ML PA-HRM; AGE (Max 64 Years) digoxin oral tablet 25 mcg, 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 ; AGE (Max 64 Years) dobutamine in d5w intravenous parenteral solution,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (2.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) epinephrine hcl (pf) intravenous solution mg/ml ( ml) epinephrine injection auto-injector 0.5 mg/0.5 ml, 0.3 mg/0.3 ml (Dobutamine HCl/D5W) PA BvD (Dobutamine HCl) PA BvD (Dopamine HCl/D5W) PA BvD (Dopamine HCl) PA BvD (Epinephrine HCl/PF) (Adrenaclick) epinephrine injection syringe 0. mg/ml (Epinephrine) EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL (4 per 30 Formulary ID: Version: 7 82 Effective: January 0, 207

136 EPIPEN JR 2-PAK INJECTION QL (4 per 30 AUTO-INJECTOR 0.5 MG/0.3 ML FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml (Hydralazine HCl) hydralazine oral tablet 0 mg, 00 mg, 25 (Hydralazine HCl) mg, 50 mg LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 ; AGE (Max 64 Years) milrinone in 5 % dextrose intravenous piggyback 20 mg/00 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) (Milrinone Lactate/D5W) PA BvD milrinone intravenous solution mg/ml (Milrinone Lactate) PA BvD norepinephrine bitartrate intravenous (Levophed Bitartrate) PA BvD solution mg/ml RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release (Adalat CC) 30 mg, 60 mg amlodipine oral tablet 0 mg, 2.5 mg, 5 (Norvasc) mg amlodipine-benazepril oral capsule 0-20 (Lotrel) mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 0-60 (Exforge) mg, mg, 5-60 mg, mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, mg (Exforge HCT) Formulary ID: Version: 7 83 Effective: January 0, 207

137 AZOR ORAL TABLET 0-20 MG, ST 0-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/00 ML felodipine oral tablet extended release 24 (Felodipine) hr 0 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release (Procardia XL) 24hr 30 mg, 60 mg nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine er 60 mg tablet f/c 60 mg (Adalat CC) nifedipine oral tablet extended release (Adalat CC) 24hr 30 mg, 60 mg nifedipine oral tablet extended release (Procardia XL) 24hr 90 mg Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral tablet (Amiloride/Hydrochlor 5-50 mg othiazide) bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) chlorothiazide sodium intravenous recon (Sodium Diuril) soln 500 mg chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 00 MG, 50 MG furosemide injection solution 0 mg/ml (Furosemide) furosemide injection syringe 0 mg/ml (Furosemide) furosemide oral solution 0 mg/ml, 40 (Furosemide) mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 (Lasix) mg hydrochlorothiazide oral capsule 2.5 mg (Microzide) Formulary ID: Version: 7 84 Effective: January 0, 207

138 hydrochlorothiazide oral tablet 2.5 mg, (Hydrochlorothiazide) 25 mg, 50 mg indapamide oral tablet.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 0 mg, 2.5 mg, 5 (Zaroxolyn) mg spironolactone oral tablet 00 mg, 25 mg, (Aldactone) 50 mg spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg torsemide oral tablet 0 mg, 00 mg, 20 (Demadex) mg, 5 mg triamterene-hydrochlorothiazid oral (Dyazide) capsule mg, mg triamterene-hydrochlorothiazid oral (Maxzide) tablet mg, mg Dyslipidemics ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG amlodipine-atorvastatin oral tablet 0-0 (Caduet) mg, 0-20 mg, 0-40 mg, 0-80 mg, mg, mg, mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 0 mg, 20 mg, 40 (Lipitor) mg, 80 mg cholestyramine light oral powder in (Questran) packet 4 gram cholestyramine packet outer 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet gram (Colestid) fenofibrate micronized oral capsule 30 (Lofibra) mg, 34 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 45 mg, 48 mg (Tricor) Formulary ID: Version: 7 85 Effective: January 0, 207

139 fenofibrate oral tablet 20 mg, 60 mg, (Lofibra) 40 mg, 54 mg fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 35 mg, 45 mg fenofibric acid oral tablet 05 mg, 35 mg (Fibricor) fluvastatin oral capsule 20 mg, 40 mg (Lescol) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 0 MG, 30 MG, 40 MG, 60 MG PA; QL (30 per 30 JUXTAPID ORAL CAPSULE 20 MG PA; QL (90 per 30 JUXTAPID ORAL CAPSULE 5 MG PA; QL (45 per 30 KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML PA; QL (4 per 28 lovastatin oral tablet 0 mg, 20 mg, 40 (Lovastatin) mg niacin oral tablet extended release 24 hr (Niaspan),000 mg, 500 mg, 750 mg niacor oral tablet 500 mg (Niacin) omega-3 acid ethyl esters oral capsule (Lovaza) QL (20 per 30 gram PRALUENT PEN SUBCUTANEOUS PA; QL (2 per 28 PEN INJECTOR 50 MG/ML, 75 MG/ML PRALUENT SYRINGE PA; QL (2 per 28 SUBCUTANEOUS SYRINGE 50 MG/ML, 75 MG/ML pravastatin oral tablet 0 mg, 20 mg, 40 (Pravachol) mg, 80 mg prevalite oral powder 4 gram (Cholestyramine/Aspar tame) prevalite packet outer 4 gram (Cholestyramine/Aspar tame) Formulary ID: Version: 7 86 Effective: January 0, 207

140 REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML rosuvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Crestor) (Zocor) PA; QL (3.5 per 28 PA; QL (3 per 28 PA; QL (3 per 28 simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 VASCEPA ORAL CAPSULE QL (20 per 30 GRAM VYTORIN 0-0 ORAL TABLET 0-0 MG VYTORIN 0-20 ORAL TABLET 0-20 MG VYTORIN 0-40 ORAL TABLET 0-40 MG VYTORIN 0-80 ORAL TABLET 0-80 MG WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 0 MG Renin-Angiotensin-Aldostero ne System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) TEKAMLO ORAL TABLET 50-0 ST MG, 50-5 MG, MG, MG TEKTURNA HCT ORAL TABLET MG, MG, MG, MG ST Formulary ID: Version: 7 87 Effective: January 0, 207

141 TEKTURNA ORAL TABLET 50 ST MG, 300 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 0 mg, 20 (Isochron) mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended (Isochron) release 40 mg isosorbide mononitrate oral tablet 0 mg, (Isosorbide 20 mg Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 24 hr 20 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0. (Nitro-Dur) QL (30 per 30 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) QL (60 per 30 mg/hr minoxidil oral tablet 0 mg, 2.5 mg (Minoxidil) NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution 00 mg/250 ml (400 mcg/ml), 25 mg/250 ml (00 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 (Nitroglycerin) mg/0 ml (5 mg/ml) nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (30 per mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (60 per mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Formulary ID: Version: 7 88 Effective: January 0, 207

142 Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG AUBAGIO ORAL TABLET 4 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended release 2 hr 0. mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dexmethylphenidate oral tablet 0 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg dextroamphetamine oral tablet 0 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 0 mg, 5 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Cafcit) (Cafcit) (Kapvay) PA; QL (60 per 30 PA; QL (28 per 28 PA PA PA PA PA (Focalin) QL (60 per 30 (Dexedrine) QL (20 per 30 (Dexedrine) QL (80 per 30 (Adderall XR) QL (30 per 30 (Adderall XR) QL (60 per 30 Formulary ID: Version: 7 89 Effective: January 0, 207

143 dextroamphetamine-amphetamine oral (Adderall) QL (60 per 30 tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA flumazenil intravenous solution 0. mg/ml (Romazicon) GILENYA ORAL CAPSULE 0.5 MG PA; QL (28 per 28 guanfacine oral tablet extended release 24 hr mg, 2 mg, 3 mg, 4 mg (Intuniv) LEMTRADA INTRAVENOUS SOLUTION 2 MG/.2 ML PA lithium carbonate oral capsule 50 mg, (Lithium Carbonate) 300 mg, 600 mg lithium carbonate oral tablet 300 mg (Lithobid) lithium carbonate oral tablet extended (Lithobid) release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml (Lithium Citrate) methylphenidate cd 20 mg cap 20 mg (Metadate Cd) QL (30 per 30 methylphenidate cd 40 mg cap 40 mg (Metadate Cd) QL (30 per 30 methylphenidate oral capsule, er biphasic (Metadate Cd) QL (30 per mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (30 per mg, 40 mg methylphenidate oral solution 0 mg/5 (Methylin) QL (900 per 30 ml, 5 mg/5 ml methylphenidate oral tablet 0 mg, 20 (Ritalin) QL (90 per 30 mg, 5 mg methylphenidate oral tablet extended (Methylphenidate HCl) QL (90 per 30 release 0 mg, 20 mg methylphenidate oral tablet extended (Concerta) QL (30 per 30 release 24hr 8 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) QL (60 per 30 Formulary ID: Version: 7 90 Effective: January 0, 207

144 NUEDEXTA ORAL CAPSULE 20-0 QL (60 per 30 MG PLEGRIDY SUBCUTANEOUS PEN PA INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PA SYRINGE 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) PA SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE PA SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) PA riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 00 MG, QL (60 per MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE QL (60 per 30 PACK 2.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG PA; QL (4 per 30 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG PA; QL (60 per 30 tetrabenazine oral tablet 2.5 mg, 25 mg (Xenazine) PA; QL (2 per 28 Formulary ID: Version: 7 9 Effective: January 0, 207

145 Contraceptives Contraceptives altavera (28) oral tablet mg (Amethyst) alyacen /35 (28) oral tablet -35 (Modicon) mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/ (Modicon) mg- 35 mcg amethia lo oral tablets,dose pack,3 month (Seasonique) QL (9 per mg-20 mcg (84)/0 mcg (7) amethia oral tablets,dose pack,3 month (Seasonique) QL (9 per mg-30 mcg (84)/0 mcg (7) apri oral tablet mg (Desogen) aranelle (28) oral tablet 0.5// (Modicon) mg-mcg ashlyna oral tablets,dose pack,3 month (Seasonique) 0.5 mg-30 mcg (84)/0 mcg (7) aubra oral tablet mg-mcg (Amethyst) aviane oral tablet mg-mcg (Amethyst) azurette (28) oral tablet (Mircette) mgx2 /0.0 mg x 5 balziva (28) oral tablet mg-mcg (Modicon) bekyree (28) oral tablet mgx2 (Mircette) /0.0 mg x 5 blisovi 24 fe oral tablet mg-20 mcg (Loestrin Fe) (24)/75 mg (4) blisovi fe.5/30 (28) oral tablet.5 (Loestrin Fe) mg-30 mcg (2)/75 mg (7) blisovi fe /20 (28) oral tablet mg-20 (Loestrin Fe) mcg (2)/75 mg (7) briellyn oral tablet mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month (Seasonique) QL (9 per mg-20 mcg (84)/0 mcg (7) camrese oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) QL (9 per 84 Formulary ID: Version: 7 92 Effective: January 0, 207

146 caziant (28) oral tablet 0./.25/.5-25 (Desogen) mg-mcg cryselle (28) oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) cyclafem /35 (28) oral tablet -35 (Modicon) mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ (Modicon) mg- 35 mcg cyred oral tablet mg (Desogen) dasetta /35 (28) oral tablet -35 (Modicon) mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/ (Modicon) mg- 35 mcg daysee oral tablets,dose pack,3 month (Seasonique) QL (9 per mg-30 mcg (84)/0 mcg (7) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet mg-mcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet (Mircette) mgx2 /0.0 mg x 5 desogestrel-ethinyl estradiol oral tablet (Desogen) mg drospirenone-ethinyl estradiol oral tablet (Yaz) mg, mg elinest oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 emoquette oral tablet mg (Desogen) enpresse oral tablet (6)/75-40 (Amethyst) (5)/25-30(0) enskyce oral tablet mg (Desogen) errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet mg-mcg (Ortho-Cyclen) falmina (28) oral tablet mg-mcg (Amethyst) gianvi (28) oral tablet mg (Yaz) gildagia oral tablet mg-mcg (Modicon) Formulary ID: Version: 7 93 Effective: January 0, 207

147 gildess.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) gildess /20 (2) oral tablet -20 mg-mcg (Loestrin) gildess 24 fe oral tablet mg-20 mcg (Loestrin Fe) (24)/75 mg (4) gildess fe.5/30 (28) oral tablet.5 (Loestrin Fe) mg-30 mcg (2)/75 mg (7) gildess fe /20 (28) oral tablet mg-20 (Loestrin Fe) mcg (2)/75 mg (7) heather oral tablet 0.35 mg (Nor-Q-D) introvale oral tablets,dose pack,3 month (Levonorgestrel-Ethin QL (9 per mg-mcg Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 month (Levonorgestrel-Ethin QL (9 per mg-mcg Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet mg (Desogen) junel.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg junel /20 (2) oral tablet -20 mg-mcg (Loestrin) junel fe.5/30 (28) oral tablet.5 mg-30 (Loestrin Fe) mcg (2)/75 mg (7) junel fe /20 (28) oral tablet mg-20 (Loestrin Fe) mcg (2)/75 mg (7) junel fe 24 oral tablet mg-20 mcg (Loestrin Fe) (24)/75 mg (4) kariva (28) oral tablet mgx2 (Mircette) /0.0 mg x 5 kelnor /35 (28) oral tablet -35 mg-mcg (Demulen -50-2) kimidess (28) oral tablet (Mircette) mgx2 /0.0 mg x 5 kurvelo oral tablet mg (Amethyst) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (7), 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) QL (9 per 84 Formulary ID: Version: 7 94 Effective: January 0, 207

148 larin.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg larin /20 (2) oral tablet -20 mg-mcg (Loestrin) larin 24 fe oral tablet mg-20 mcg (Loestrin Fe) (24)/75 mg (4) larin fe.5/30 (28) oral tablet.5 mg-30 (Loestrin Fe) mcg (2)/75 mg (7) larin fe /20 (28) oral tablet mg-20 (Loestrin Fe) mcg (2)/75 mg (7) leena 28 oral tablet 0.5// mg-mcg (Modicon) lessina oral tablet mg-mcg (Amethyst) levonest (28) oral tablet (6)/75-40 (Amethyst) (5)/25-30(0) levonor-eth estrad outer (Amethyst) QL (9 per mg levonorgestrel-ethinyl estrad oral tablet (Amethyst) mg-mcg levonorgestrel-ethinyl estrad oral (Amethyst) QL (9 per 84 tablets,dose pack,3 month mg-mcg levonorg-eth estrad triphasic oral tablet (Amethyst) QL (9 per (6)/75-40 (5)/25-30(0) levora-28 oral tablet mg (Amethyst) lomedia 24 fe oral tablet mg-20 mcg (Loestrin Fe) (24)/75 mg (4) loryna (28) oral tablet mg (Yaz) low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet mg-mcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet mg (Amethyst) microgestin.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg microgestin /20 (2) oral tablet -20 mg-mcg (Loestrin) Formulary ID: Version: 7 95 Effective: January 0, 207

149 microgestin fe.5/30 (28) oral tablet.5 (Loestrin Fe) mg-30 mcg (2)/75 mg (7) microgestin fe /20 (28) oral tablet (Loestrin Fe) mg-20 mcg (2)/75 mg (7) mono-linyah oral tablet mg-mcg (Ortho-Cyclen) mononessa (28) oral tablet (Ortho-Cyclen) mg-mcg myzilra oral tablet (6)/75-40 (Amethyst) (5)/25-30(0) necon 0.5/35 (28) oral tablet (Modicon) mg-mcg necon /35 (28) oral tablet -35 mg-mcg (Modicon) necon /50 (28) oral tablet -50 mg-mcg (Norinyl +50) necon 0/ (28) oral tablet /-35 (Modicon) mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/ (Modicon) mg- 35 mcg nikki (28) oral tablet mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet (Nor-Q-D) 0.35 mg norethindrone ac-eth estradiol oral tablet (Loestrin) -20 mg-mcg norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) mg-20 mcg (24)/75 mg (4) norg-ee / x28 day (Ortho-Cyclen) regimen 0.8/0.25/0.25 mg-35 mcg (28) norgestimate-ethinyl estradiol oral tablet (Ortho-Cyclen) 0.8/0.25/0.25 mg-25 mcg, mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg nortrel /35 (2) oral tablet -35 mg-mcg (Modicon) Formulary ID: Version: 7 96 Effective: January 0, 207

150 nortrel /35 (28) oral tablet -35 (Modicon) mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) NUVARING VAGINAL RING MG/24 HR QL ( per 28 ocella oral tablet mg (Yaz) ogestrel (28) oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) orsythia oral tablet mg-mcg (Amethyst) philith oral tablet mg-mcg (Modicon) pimtrea (28) oral tablet mgx2 (Mircette) /0.0 mg x 5 pirmella oral tablet 0.5/0.75/ mg- 35 (Modicon) mcg, -35 mg-mcg portia oral tablet mg (Amethyst) previfem oral tablet mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 month (Levonorgestrel-Ethin QL (9 per mg-mcg Estradiol) reclipsen (28) oral tablet mg (Desogen) setlakin oral tablets,dose pack,3 month (Levonorgestrel-Ethin QL (9 per mg-mcg Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) sprintec (28) oral tablet mg-mcg (Ortho-Cyclen) sronyx oral tablet mg-mcg (Amethyst) syeda oral tablet mg (Yaz) tarina fe /20 (28) oral tablet mg-20 (Loestrin Fe) mcg (2)/75 mg (7) tilia fe oral tablet -20(5)/-30(7) (Loestrin Fe) /mg-35mcg (9) tri-estarylla oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) mg-35 mcg (28) tri-legest fe oral tablet -20(5)/-30(7) (Loestrin Fe) /mg-35mcg (9) tri-linyah oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) Formulary ID: Version: 7 97 Effective: January 0, 207

151 tri-lo-estarylla oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) mg-25 mcg tri-lo-marzia oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) mg-25 mcg tri-lo-sprintec oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) mg-25 mcg trinessa (28) oral tablet 0.8/0.25/0.25 (Ortho-Cyclen) mg-35 mcg (28) tri-previfem (28) oral tablet (Ortho-Cyclen) 0.8/0.25/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet (Ortho-Cyclen) 0.8/0.25/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (Amethyst) (5)/25-30(0) velivet triphasic regimen (28) oral tablet (Desogen) 0./.25/.5-25 mg-mcg vestura (28) oral tablet mg (Yaz) vienva oral tablet mg-mcg (Amethyst) viorele (28) oral tablet mgx2 (Mircette) /0.0 mg x 5 vyfemla (28) oral tablet mg-mcg (Modicon) wera (28) oral tablet mg-mcg (Modicon) wymzya fe oral tablet,chewable (Femcon Fe) 0.4mg-35mcg(2) and 75 mg (7) xulane transdermal patch weekly (Norelgestromin/Ethin. QL (3 per 28 mcg/24 hr Estradiol) zarah oral tablet mg (Yaz) zenchent (28) oral tablet mg-mcg (Modicon) zenchent fe oral tablet,chewable (Femcon Fe) 0.4mg-35mcg(2) and 75 mg (7) zovia /35e (28) oral tablet -35 mg-mcg (Demulen -50-2) zovia /50e (28) oral tablet -50 mg-mcg (Demulen -50-2) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) Formulary ID: Version: 7 98 Effective: January 0, 207

152 chlorhexidine gluconate mucous (Peridex) membrane mouthwash 0.2 % oralone dental paste 0. % (Triamcinolone Acetonide) periogard mucous membrane mouthwash (Peridex) 0.2 % pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen) triamcinolone acetonide dental paste 0. (Triamcinolone % Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 0 MG acitretin oral capsule 0 mg, 7.5 mg, 25 (Soriatane) mg acyclovir topical ointment 5 % (Zovirax) QL (5 per 4 ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS ammonium lactate topical cream 2 % (Ammonium Lactate) ammonium lactate topical lotion 2 % (Ammonium Lactate) ANACAINE TOPICAL OINTMENT 0 % calcipotriene scalp solution % (Calcipotriene) calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcipotriene) calcitrene topical ointment % (Calcipotriene) calcitriol topical ointment 3 mcg/gram (Vectical) CONDYLOX TOPICAL GEL 0.5 % COSENTYX (50 MG/ML) 300 MG PA DOSE-2 PENS 50 MG/ML COSENTYX (50 MG/ML) 300 MG PA DOSE-2 SYRINGES 50 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML PA Formulary ID: Version: 7 99 Effective: January 0, 207

153 COSENTYX SUBCUTANEOUS PA SYRINGE 50 MG/ML DENAVIR TOPICAL CREAM % diclofenac sodium topical gel 3 % (Solaraze) fluorouracil topical cream 0.5 %, 5 % (Carac) fluorouracil topical solution 2 %, 5 % (Fluorouracil) imiquimod topical cream in packet 5 % (Aldara) PA NSO; QL (24 per 30 methoxsalen rapid oral capsule 0 mg (Oxsoralen-Ultra) PANRETIN TOPICAL GEL 0. % PICATO TOPICAL GEL 0.05 % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox topical solution 0.5 % (Condylox) potassium hydroxide topical solution 5 % (Potassium Hydroxide) REGRANEX TOPICAL GEL 0.0 % PA; QL (30 per 30 SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ 80 MG/ML AUTOINJECTOR PA P/F,LATEX-FREE,OUTER 80 MG/ML TALTZ AUTOINJECTOR (3 PACK) PA SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.06 % VEREGEN TOPICAL OINTMENT 5 % zenatane oral capsule 0 mg, 20 mg, 30 (Isotretinoin) mg, 40 mg ZOVIRAX TOPICAL CREAM 5 % QL (5 per 4 Formulary ID: Version: 7 00 Effective: January 0, 207

154 Dermatological Antibacterials clindamycin phosphate topical foam % (Evoclin) clindamycin phosphate topical gel % (Cleocin T) clindamycin phosphate topical lotion % (Cleocin T) clindamycin phosphate topical solution (Cleocin T) % clindamycin phosphate topical swab % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) -5 %,.2 %( % base) -5 % ery pads topical swab 2 % (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical (Erythromycin solution 2 % Base/Ethanol) erythromycin with ethanol topical swab 2 (Erythromycin % Base/Ethanol) erythromycin-benzoyl peroxide topical (Benzamycin) gel 3-5 % gentamicin topical cream 0. % (Gentamicin Sulfate) gentamicin topical ointment 0. % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) neuac topical gel.2 %( % base) -5 % (Duac) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) silver nitrate topical ointment 0 % (Silver Nitrate) silver nitrate topical solution 0 %, 25 %, (Silver Nitrate) 50 % silver sulfadiazine topical cream % (Silvadene) Formulary ID: Version: 7 0 Effective: January 0, 207

155 ssd topical cream % (Silvadene) sulfacetamide sodium (acne) topical (Klaron) suspension 0 % Dermatological Anti-Inflammatory Agents ala-cort topical cream % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) alclometasone topical cream 0.05 % (Alclometasone Dipropionate) alclometasone topical ointment 0.05 % (Alclometasone Dipropionate) betamethasone dipropionate topical (Betamethasone cream 0.05 % Dipropionate) betamethasone dipropionate topical (Betamethasone lotion 0.05 % Dipropionate) betamethasone dipropionate topical (Betamethasone ointment 0.05 % Dipropionate) betamethasone valerate topical cream 0. (Betamethasone % Valerate) betamethasone valerate topical foam 0.2 (Luxiq) % betamethasone valerate topical lotion 0. (Betamethasone % Valerate) betamethasone valerate topical ointment (Betamethasone 0. % Valerate) betamethasone, augmented topical cream (Diprolene AF) 0.05 % betamethasone, augmented topical gel (Betamethasone 0.05 % Dipropionate) betamethasone, augmented topical lotion (Diprolene) 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Clobetasol Propionate) Formulary ID: Version: 7 02 Effective: January 0, 207

156 clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % (Clobetasol Propionate) clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0. % (Cloderm) cormax scalp solution 0.05 % (Clobetasol Propionate) desonide topical cream 0.05 % (Desowen) desonide topical lotion 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, (Topicort) 0.25 % desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, (Topicort) 0.25 % diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % (Diflorasone Diacetate) fluocinonide 0.05% cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluocinonide-e topical cream 0.05 % (Vanos) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 (Ultravate) % halobetasol propionate topical ointment (Ultravate) 0.05 % hydrocortisone buty 0.% cream 0. % (Locoid) hydrocortisone butyrate topical ointment 0. % (Locoid) Formulary ID: Version: 7 03 Effective: January 0, 207

157 hydrocortisone butyrate topical solution (Locoid) 0. % hydrocortisone butyr-emollient topical (Locoid) cream 0. % hydrocortisone topical cream %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream 0.2 (Hydrocortisone % Valerate) hydrocortisone valerate topical ointment (Hydrocortisone 0.2 % Valerate) mometasone topical cream 0. % (Elocon) mometasone topical ointment 0. % (Elocon) mometasone topical solution 0. % (Elocon) prednicarbate topical cream 0. % (Dermatop) prednicarbate topical ointment 0. % (Dermatop) procto-med hc rectal cream 2.5 % (Hydrocortisone) procto-pak rectal cream % (Anusol-HC) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctozone-hc rectal cream 2.5 % (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0. (Protopic) % triamcinolone acetonide topical cream (Triamcinolone %, 0. %, 0.5 % Acetonide) triamcinolone acetonide topical lotion (Triamcinolone %, 0. % Acetonide) triamcinolone acetonide topical ointment (Triamcinolone %, 0. %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone Acetonide) u-cort topical cream -0 % (Hydrocortisone Acetate/Urea) Dermatological Retinoids adapalene topical cream 0. % (Differin) adapalene topical gel 0. % (Differin) Formulary ID: Version: 7 04 Effective: January 0, 207

158 TAZORAC TOPICAL CREAM 0.05 %, 0. % tretinoin gel micro 0.04% tube 0.04 % (Retin-A Micro) PA tretinoin gel micro 0.% tube 0. % (Retin-A Micro) PA tretinoin microspheres topical gel with (Retin-A Micro) PA pump 0.04 %, 0. % tretinoin topical cream %, 0.05 %, (Retin-A) PA 0. % tretinoin topical gel 0.0 %, %, 0.05 % (Retin-A) PA Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) spinosad topical suspension 0.9 % (Natroba) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" BD INSULIN SYR 0.3 ML 3GX5/6 0.3 ML 3 GAUGE X 5/6 BD INSULIN SYR 0.5 ML 3GX5/6" 0.5 ML 3 GAUGE X 5/6 BD INSULIN SYR ML 3GX5/6" ML 3 GAUGE X 5/6 BD ULTRA-FINE PEN NDL 8MMX3G SHORT 3 GAUGE X 5/6" GAUZE PAD TOPICAL BANDAGE 2 X 2 " GAUZE PADS, STERILE 2"X2" 2 X 2 " INSULIN SYRINGE-NEEDLE U-00 SYRINGE 0.3 ML 29, ML 29 GAUGE X /2", /2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X /2" Formulary ID: Version: 7 05 Effective: January 0, 207

159 VGO 40 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS PA SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 00 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 5 MG Formulary ID: Version: 7 06 Effective: January 0, 207

160 ORFADIN ORAL SUSPENSION 4 MG/ML PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 6,000-57,500-60,500 UNIT, 8,000-28,750-30,250 UNIT PULMOZYME INHALATION PA BvD SOLUTION MG/ML STRENSIQ SUBCUTANEOUS PA; LA SOLUTION 00 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS PA SOLUTION 5 MG/5 ML ( MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 00 MG QL (90 per 30 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT, 5,000-7,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetracaine HCl) apraclonidine ophthalmic drops 0.5 % (Iopidine) atropine ophthalmic drops % (Isopto Atropine) azelastine nasal aerosol,spray 37 mcg (0. %) (Astepro) QL (30 per 25 Formulary ID: Version: 7 07 Effective: January 0, 207

161 azelastine nasal spray,non-aerosol 0.5 % (Astepro) QL (30 per 25 (205.5 mcg) azelastine ophthalmic drops 0.05 % (Azelastine HCl) BEPREVE OPHTHALMIC DROPS.5 % ST carteolol ophthalmic drops % (Carteolol HCl) cromolyn ophthalmic drops 4 % (Cromolyn Sodium) cyclopentolate ophthalmic drops 0.5 %, (Cyclogyl) %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % epinastine ophthalmic drops 0.05 % (Elestat) flucaine ophthalmic drops % (Proparacaine/Fluoresc ein Sod) homatropaire ophthalmic drops 5 % (Isopto Homatropine) homatropine hbr ophthalmic drops 5 % (Isopto Homatropine) ipratropium bromide nasal (Atrovent) QL (30 per 28 spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) QL (5 per 0 spray,non-aerosol 0.06 % LACRISERT OPHTHALMIC INSERT 5 MG naphazoline ophthalmic drops 0. % (Naphazoline HCl) olopatadine nasal spray,non-aerosol 0.6 (Patanase) QL (30.5 per 30 % olopatadine ophthalmic drops 0. % (Patanol) PATADAY OPHTHALMIC DROPS 0.2 % ST phenylephrine hcl ophthalmic drops 0 %, (Mydfrin) 2.5 % proparacaine ophthalmic drops 0.5 % (Proparacaine HCl) TYZINE NASAL DROPS 0. % TYZINE NASAL SPRAY,NON-AEROSOL 0. % Formulary ID: Version: 7 08 Effective: January 0, 207

162 Eye, Ear, Nose, Throat Anti-Infectives Agents acetasol hc otic drops -2 % (Vosol HC) acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 (Bacitracin) unit/gram bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin ointment 500-0,000 unit/gram B Sulfate) bleph-0 ophthalmic drops 0 % (Sulfacetamide Sodium) CILOXAN OPHTHALMIC OINTMENT 0.3 % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 (Ilotycin) mg/gram (0.5 %) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 (Garamycin) mg/gram) gentamicin ophthalmic drops 0.3 % (Garamycin) gentamicin ophthalmic ointment 0.3 % (3 (Garamycin) mg/gram) hydrocortisone-acetic acid otic drops -2 (Vosol HC) % levofloxacin ophthalmic drops 0.5 % (Levofloxacin) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mg-unit/g-% (Neomycin Su/Baci Zn/Poly/HC) Formulary ID: Version: 7 09 Effective: January 0, 207

163 neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-0,000-0 mg-unit-mg/ml neomycin-polymyxin-hc otic drops,suspension 3.5-0,000- mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-0,000- mg/ml-unit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-% neo-polycin ophthalmic ointment ,000 mg-unit-unit/g (Neomycin Su/Bacitra/Polymyxin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymyxin B Sulf/HC) (Neomycin/Polymyxin B Sulf/HC) (Neomycin/Polymyxin B Sulf/HC) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Bacitra/Polymyxin) ofloxacin ophthalmic drops 0.3 % (Ocuflox) ofloxacin otic drops 0.3 % (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) ophthalmic drops 0,000 unit- mg/ml sulfacetamide sodium ophthalmic drops (Sulfacetamide 0 % Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide ointment 0 % Sodium) sulfacetamide-prednisolone ophthalmic (Sulfacetamide/Prednis drops 0 %-0.23 % (0.25 %) olone Sp) TOBRADEX OPHTHALMIC OINTMENT % Formulary ID: Version: 7 0 Effective: January 0, 207

164 TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic (Tobradex) drops,suspension % trifluridine ophthalmic drops % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.5 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % ST bromfenac ophthalmic drops 0.09 % (Bromfenac Sodium) dexamethasone sodium phosphate (Dexamethasone Sod ophthalmic drops 0. % Phosphate) diclofenac sodium ophthalmic drops 0. (Diclofenac Sodium) % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 (Flunisolide) QL (50 per 25 mcg (0.025 %) fluocinolone acetonide oil otic drops 0.0 (Dermotic) % fluorometholone ophthalmic (FML) drops,suspension 0. % flurbiprofen sodium ophthalmic drops (Ocufen) 0.03 % fluticasone nasal spray,suspension 50 (Fluticasone mcg/actuation Propionate) ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % (Acular) Formulary ID: Version: 7 Effective: January 0, 207

165 LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0. % prednisolone acetate ophthalmic drops,suspension % prednisolone sodium phosphate ophthalmic drops % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % triamcinolone acetonide nasal aerosol,spray 55 mcg Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack mg CARAFATE ORAL SUSPENSION 00 MG/ML (Omnipred) (Prednisolone Sod Phosphate) (Triamcinolone Acetonide) (Prevpac) PA; QL (60 per 30 QL (6.5 per 30 cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, (Cimetidine) (Rx Product Only) 400 mg, 800 mg DEXILANT ORAL ST CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG esomeprazole sodium intravenous recon (Nexium I.V.) soln 20 mg, 40 mg famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) Formulary ID: Version: 7 2 Effective: January 0, 207

166 famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 40 mg/4 ml vial 25's,outer 0 (Famotidine) mg/ml famotidine oral suspension 40 mg/5 ml (8 (Pepcid) (Rx Product Only) mg/ml) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole oral capsule,delayed (Prevacid) (Rx Product Only) release(dr/ec) 5 mg, 30 mg misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) nizatidine oral capsule 50 mg, 300 mg (Nizatidine) nizatidine oral solution 50 mg/0 ml (Nizatidine) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) 0 mg, 20 mg, 40 mg pantoprazole oral tablet,delayed release (Protonix) (dr/ec) 20 mg, 40 mg ranitidine hcl 50 mg/2 ml vial sdv 50 mg/2 (Zantac) (Rx Product Only) ml (25 mg/ml) ranitidine hcl injection solution 25 mg/ml (Zantac) (Rx Product Only) ranitidine hcl oral capsule 50 mg, 300 (Ranitidine HCl) (Rx Product Only) mg ranitidine hcl oral syrup 5 mg/ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 50 mg, 300 mg (Zantac) (Rx Product Only) sucralfate oral tablet gram (Carafate) Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 24 MCG, QL (60 per 30 8 MCG BUPHENYL ORAL TABLET 500 MG CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG constulose oral solution 0 gram/5 ml (Lactulose) cromolyn oral concentrate 00 mg/5 ml (Gastrocrom) dicyclomine oral capsule 0 mg (Bentyl) dicyclomine oral solution 0 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) Formulary ID: Version: 7 3 Effective: January 0, 207

167 diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) mg enulose oral solution 0 gram/5 ml (Lactulose) GATTEX 5 MG 30-VIAL KIT 5 MG PA GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG PA generlac oral solution 0 gram/5 ml (Lactulose) glycopyrrolate injection solution 0.2 (Robinul) mg/ml glycopyrrolate oral tablet mg, 2 mg (Robinul) kionex 5 gm/60 ml suspension 5 (Sodium Polystyrene gram/60 ml Sulfonate) kionex oral powder (Sodium Polystyrene Sulfonate) lactulose oral solution 0 gram/5 ml (Lactulose) LINZESS ORAL CAPSULE 45 MCG, 290 MCG QL (30 per 30 loperamide oral capsule 2 mg (Loperamide HCl) methscopolamine oral tablet 2.5 mg, 5 mg (Methscopolamine Bromide) metoclopramide hcl injection solution 5 (Metoclopramide HCl) mg/ml metoclopramide hcl oral solution 5 mg/5 (Metoclopramide HCl) ml metoclopramide hcl oral tablet 0 mg, 5 mg (Reglan) MOVANTIK ORAL TABLET 2.5 QL (30 per 30 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 0 MG, 5 MG PA; QL (30 per 30 RAVICTI ORAL LIQUID. GRAM/ML PA Formulary ID: Version: 7 4 Effective: January 0, 207

168 RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6 ML PA; QL (28 per 28 RELISTOR SUBCUTANEOUS SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML PA; QL (28 per 28 sodium polystyrene (sorb free) oral (Sodium Polystyrene suspension 5 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal (Sodium Polystyrene enema 30 gram/20 ml Sulfonate) sps 5 gm/60 ml suspension 5 gram/60 (Sodium Polystyrene ml Sulfonate) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VIBERZI ORAL TABLET 00 MG, 75 ST; QL (60 per 30 MG Laxatives gavilyte-c oral recon soln (Golytely) gram gavilyte-g oral recon soln (Golytely) gram gavilyte-n oral recon soln 420 gram (Nulytely with Flavor Packs) MOVIPREP ORAL POWDER IN PACKET GRAM peg 3350-electrolytes oral recon soln (Golytely) gram, gram peg-electrolyte soln oral recon soln 420 (Nulytely with Flavor gram Packs) polyethylene glycol 3350 oral powder 7 (Gavilyte-N) gram/dose polyethylene glycol 3350 oral powder in (Polyethylene Glycol packet 7 gram 3350) PREPOPIK ORAL POWDER IN PACKET 0 MG-3.5 GRAM-2 GRAM Formulary ID: Version: 7 5 Effective: January 0, 207

169 trilyte with flavor packets oral recon soln 420 gram Phosphate Binders AURYXIA ORAL TABLET 20 MG IRON (Nulytely with Flavor Packs) calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) FOSRENOL ORAL POWDER IN PACKET,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG magnebind 400 oral tablet mg (Calcium Carbonate/Mag Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (69 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG VELPHORO ORAL TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 0 mg, (Urecholine) 25 mg, 5 mg, 50 mg flavoxate oral tablet 00 mg (Flavoxate HCl) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin Chloride) oxybutynin chloride oral tablet 5 mg (Oxybutynin Chloride) Formulary ID: Version: 7 6 Effective: January 0, 207

170 oxybutynin chloride oral tablet extended (Ditropan XL) release 24hr 0 mg, 5 mg, 5 mg tolterodine oral capsule,extended release (Detrol LA) 24hr 2 mg, 4 mg tolterodine oral tablet mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release (Trospium Chloride) 24hr 60 mg trospium oral tablet 20 mg (Trospium Chloride) VESICARE ORAL TABLET 0 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 (Uroxatral) hr 0 mg dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er (Jalyn) QL (30 per 30 multiphase 24 hr mg finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule,extended release (Flomax) 24hr 0.4 mg terazosin oral capsule mg, 0 mg, 2 mg, (Terazosin HCl) 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG PA deferoxamine injection recon soln 2 gram, (Desferal) PA BvD 500 mg DEPEN TITRATABS ORAL PA TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 25 MG, 250 MG, 500 MG Formulary ID: Version: 7 7 Effective: January 0, 207

171 FERRIPROX ORAL SOLUTION 00 MG/ML FERRIPROX ORAL TABLET 500 MG SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG PA ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM),.62 % (40.5 MG/2.5 GRAM) PA; QL (30 per 30 PA; QL (50 per 30 PA; QL (50 per 30 androxy oral tablet 0 mg (Fluoxymesterone) AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 30 MG/ACTUATION (.5 ML) PA; QL (80 per 28 danazol oral capsule 00 mg, 200 mg, 50 (Danazol) mg oxandrolone oral tablet 0 mg, 2.5 mg (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) PA 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil (Testosterone PA; QL (5 per mg/ml Enanthate) testosterone transdermal gel 50 mg/5 gram ( %) (Testim) PA; QL (300 per 30 testosterone transdermal gel in metered-dose pump.25 gram/ actuation ( %) (Vogelxo) PA; QL (300 per 30 Formulary ID: Version: 7 8 Effective: January 0, 207

172 testosterone transdermal gel in packet % (25 mg/2.5gram), % (50 mg/5 gram) Estrogens And Antiestrogens COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) (Androgel) PA; QL (300 per 30 PA-HRM; QL (8 per 28 ; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) estradiol oral tablet 0.5 mg, mg, 2 mg (Estrace) PA-HRM; AGE (Max 64 Years) estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0. mg/24 hr (Vivelle-Dot) PA-HRM; QL (8 per 28 ; AGE (Max 64 Years) estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0. mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg (Climara) PA-HRM; QL (4 per 28 ; AGE (Max 64 Years) (Delestrogen) (Activella) PA-HRM; AGE (Max 64 Years) ESTRING VAGINAL RING 2 MG QL ( per 84 estropipate oral tablet 0.75 mg,.5 mg, 3 mg (Estropipate) PA-HRM; AGE (Max 64 Years) FEMRING VAGINAL RING 0.05 QL ( per 84 MG/24 HR, 0. MG/24 HR fyavolv oral tablet -5 mg-mcg (Femhrt) PA-HRM; AGE (Max 64 Years) jinteli oral tablet -5 mg-mcg (Femhrt) PA-HRM; AGE (Max 64 Years) MENEST ORAL TABLET 0.3 MG, MG,.25 MG, 2.5 MG PA-HRM; AGE (Max 64 Years) mimvey lo oral tablet mg (Activella) PA-HRM; AGE (Max 64 Years) Formulary ID: Version: 7 9 Effective: January 0, 207

173 mimvey oral tablet -0.5 mg (Activella) PA-HRM; AGE (Max 64 Years) norethindrone ac-eth estradiol oral tablet -5 mg-mcg (Femhrt) PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PA-HRM; AGE (Max 64 Years) PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PA-HRM; AGE (Max 64 Years) PREMPRO ORAL TABLET MG, MG, MG, PA-HRM; AGE (Max 64 Years) MG raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 0 QL (8 per 28 MCG Glucocorticoids/Mineralocort icoids a-hydrocort injection recon soln 00 mg (Hydrocortisone Sod Succinate) betamethasone acet,sod phos injection (Celestone) suspension 6 mg/ml cortisone oral tablet 25 mg (Cortisone Acetate) PA BvD dexamethasone oral elixir 0.5 mg/5 ml (Dexamethasone) PA BvD dexamethasone oral tablet 0.5 mg, 0.75 (Dexamethasone) PA BvD mg, mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate (Dexamethasone Sod injection solution 0 mg/ml, 4 mg/ml Phosphate) fludrocortisone oral tablet 0. mg (Fludrocortisone Acetate) hydrocortisone oral tablet 0 mg, 20 mg, (Cortef) PA BvD 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) Formulary ID: Version: 7 20 Effective: January 0, 207

174 methylprednisolone oral tablet 6 mg, 32 (Medrol) PA BvD mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack (Medrol) 4 mg methylprednisolone sodium succ injection (Solu-Medrol) recon soln 25 mg, 40 mg methylprednisolone ss gm vl (Solu-Medrol) mdv,latex-free,000 mg prednisolone sodium phosphate oral (Pediapred) PA BvD solution 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml (Prednisone) PA BvD prednisone oral tablet mg, 2.5 mg, 20 (Prednisone) PA BvD mg, 5 mg, 50 mg prednisone oral tablet 0 mg (Prednisone) PA BvD prednisone oral tablets,dose pack 0 mg, (Prednisone) 5 mg SOLU-CORTEF (PF) INJECTION RECON SOLN,000 MG/8 ML, 00 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML triamcinolone acetonide injection (Triamcinolone suspension 0 mg/ml, 40 mg/ml Acetonide) Pituitary desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0. mg/ml (Desmopressin QL (5 per 30 (refrigerate) Acetate) desmopressin nasal spray,non-aerosol 0 (Desmopressin QL (5 per 30 mcg/spray (0. ml) Acetate) desmopressin oral tablet 0. mg, 0.2 mg (DDAVP) Formulary ID: Version: 7 2 Effective: January 0, 207

175 GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 2 MG/ML (36 UNIT/ML), 5 MG/ML (5 UNIT/ML) HUMATROPE INJECTION CARTRIDGE 2 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (8 UNIT) HUMATROPE INJECTION RECON SOLN 5 (5 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 0 MG/2 ML (5 MG/ML), 20 MG/2 ML (0 MG/ML), 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 0 MG/2 ML (5 MG/ML), 20 MG/2 ML (0 MG/ML) PA PA PA PA QL ( per 84 PA PA PA Formulary ID: Version: 7 22 Effective: January 0, 207

176 octreotide acet 50 mcg/ml syr outer,single-dose,0 50 mcg/ml ( ml) octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml OMNITROPE SUBCUTANEOUS CARTRIDGE 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 0 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL SPRAY,NON-AEROSOL 50 MCG/SPRAY (0. ML) SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) ZOMACTON SUBCUTANEOUS RECON SOLN 0 MG, 5 MG (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) PA PA PA PA PA QL ( per 28 QL ( per 360 PA Formulary ID: Version: 7 23 Effective: January 0, 207

177 ZORBTIVE SUBCUTANEOUS PA RECON SOLN 8.8 MG Progestins DEPO-PROVERA QL (0 per 28 INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate (Hydroxyprogesterone PA NSO intramuscular oil 250 mg/ml Caproate) medroxyprogesterone intramuscular (Medroxyprogesterone QL ( per 84 suspension 50 mg/ml Acetate) medroxyprogesterone intramuscular (Depo-Provera) QL ( per 84 syringe 50 mg/ml medroxyprogesterone oral tablet 0 mg, (Provera) 2.5 mg, 5 mg megestrol oral suspension 400 mg/0 ml (Megace) (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg (Aygestin) progesterone in oil intramuscular oil 50 (Progesterone) mg/ml progesterone micronized oral capsule 00 (Prometrium) mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 00 (Levothyroxine mcg, 200 mcg, 500 mcg Sodium) levothyroxine oral tablet 00 mcg, 2 (Levoxyl) mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 0 mcg/ml (Triostat) liothyronine oral tablet 25 mcg, 5 mcg, 50 (Cytomel) mcg methimazole oral tablet 0 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Formulary ID: Version: 7 24 Effective: January 0, 207

178 Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS PA SOLUTION 200 MG/0 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS PA SYRINGE 62 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL PA BvD CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG azathioprine oral tablet 50 mg (Imuran) PA BvD azathioprine sodium injection recon soln (Azathioprine Sodium) PA BvD 00 mg CARIMUNE NF NANOFILTERED PA BvD INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS PA BvD INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR RECONST PA SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 (Sandimmune) PA BvD mg/5 ml cyclosporine modified oral capsule 00 (Neoral) PA BvD mg, 25 mg, 50 mg cyclosporine modified oral solution 00 (Neoral) PA BvD mg/ml cyclosporine oral capsule 00 mg, 25 mg (Sandimmune) PA BvD ENBREL SUBCUTANEOUS RECON SOLN 25 MG ( ML) PA Formulary ID: Version: 7 25 Effective: January 0, 207

179 ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET PA BvD EXTENDED RELEASE 24 HR 0.75 MG, MG, 4 MG FLEBOGAMMA DIF PA BvD INTRAVENOUS SOLUTION 0 %, 5 % GAMASTAN S/D PA BvD INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID PA BvD INJECTION SOLUTION 0 % GAMMAPLEX INTRAVENOUS PA BvD SOLUTION 5 % GAMUNEX-C 20 GRAM/200 ML PA BvD VIAL P/F,LTX-FR,SUV,OUTER 20 GRAM/200 ML (0 %) GAMUNEX-C INJECTION PA BvD SOLUTION GRAM/0 ML (0 %) gengraf oral capsule 00 mg, 25 mg, 50 (Neoral) PA BvD mg gengraf oral solution 00 mg/ml (Neoral) PA BvD HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PA Formulary ID: Version: 7 26 Effective: January 0, 207

180 HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML, 50 UNIT/ML (0 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (0 %) HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 80 MG/.2 ML (50 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML PA PA BvD PA BvD PA PA; QL (8.76 per 28 leflunomide oral tablet 0 mg, 20 mg (Arava) mycophenolate mofetil oral capsule 250 (Cellcept) PA BvD mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml (Cellcept) PA BvD mycophenolate mofetil oral tablet 500 mg (Cellcept) PA BvD mycophenolate sodium oral (Myfortic) PA BvD tablet,delayed release (dr/ec) 80 mg, 360 mg NULOJIX INTRAVENOUS RECON PA BvD SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 0 %, 5 % PA BvD Formulary ID: Version: 7 27 Effective: January 0, 207

181 ORENCIA (WITH MALTOSE) PA INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS PA SYRINGE 25 MG/ML OTEZLA ORAL TABLET 30 MG PA; QL (60 per 30 OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47), 0 MG (4)-20 MG (4)-30 MG(9) OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 0 MG/0.4 ML, 2.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 0 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION MG/ML RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 0 MG/0.2 ML, 2.5 MG/0.25 ML, 5 MG/0.3 ML, 7.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.5 ML PA; QL (60 per 30 PA BvD PA BvD PA BvD RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS PA SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 00 MG/ML, 50 MG/0.5 ML PA Formulary ID: Version: 7 28 Effective: January 0, 207

182 SIMPONI SUBCUTANEOUS PA SYRINGE 00 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, mg, 2 mg (Rapamune) PA BvD STELARA SUBCUTANEOUS PA SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, mg, 5 (Hecoria) PA BvD mg TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML PA; LA; QL (5 per 28 XELJANZ ORAL TABLET 5 MG PA; QL (60 per 30 XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML PA; QL (30 per 30 PA BvD; QL (20 per 30 PA BvD Formulary ID: Version: 7 29 Effective: January 0, 207

183 BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PA BvD; QL (3 per 365 PA BvD; QL (4 per 365 PA BvD; QL (3 per 365 PA BvD; QL (3 per 365 QL (.5 per 365 QL (.5 per 365 QL (.5 per 365 QL (.5 per 365 Formulary ID: Version: 7 30 Effective: January 0, 207

184 HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG PA BvD Formulary ID: Version: 7 3 Effective: January 0, 207

185 MENOMUNE - A/C/Y/W-35 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML QL (2 per 365 QL (2 per 365 PA BvD PA BvD; QL (3 per 365 PA BvD; QL (3 per 365 PA BvD; QL (3 per 365 Formulary ID: Version: 7 32 Effective: January 0, 207

186 ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT -20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML (Tetanus, Diphtheria Tox,Adult) PA BvD Formulary ID: Version: 7 33 Effective: January 0, 207

187 VARIVAX (PF) SUBCUTANEOUS QL (2 per 365 SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS QL ( per 365 SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, mg (Lotronex) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral (Entocort EC) capsule,delayed,extend.release 3 mg colocort rectal enema 00 mg/60 ml (Cortenema) DELZICOL DR 400 MG CAPSULE 400 MG DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG DIPENTUM ORAL CAPSULE 250 MG ST hydrocortisone rectal enema 00 mg/60 ml (Cortenema) Formulary ID: Version: 7 34 Effective: January 0, 207

188 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % (Acetic Acid) LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) sodium chloride irrigation solution 0.9 % (Sodium Chloride Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution g/00 ml (Mannitol/Sorbitol Solution) water for irrigation, sterile irrigation solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents (Water For Irrigation,Sterile) alendronate oral solution 70 mg/75 ml (Alendronate Sodium) QL (300 per 28 alendronate oral tablet 0 mg, 40 mg, 5 (Fosamax) mg alendronate oral tablet 35 mg, 70 mg (Fosamax) QL (4 per 28 calcitonin (salmon) nasal (Miacalcin) QL (3.7 per 28 spray,non-aerosol 200 unit/actuation calcitriol intravenous solution mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 (Doxercalciferol) mcg/2 ml doxercalciferol oral capsule 0.5 mcg, (Hectorol) mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, (Etidronate Disodium) 400 mg FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML QL (2.4 per 28 Formulary ID: Version: 7 35 Effective: January 0, 207

189 FORTICAL NASAL QL (3.7 per 28 SPRAY,NON-AEROSOL 200 UNIT/ACTUATION ibandronate intravenous solution 3 mg/3 (Boniva) QL (3 per 84 ml ibandronate intravenous syringe 3 mg/3 (Boniva) QL (3 per 84 ml ibandronate oral tablet 50 mg (Boniva) QL ( per 28 MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 mg, 90 mg (Pamidronate Disodium) pamidronate intravenous solution 30 mg/0 ml (3 mg/ml), 60 mg/0 ml (6 mg/ml), 90 mg/0 ml (9 mg/ml) paricalcitol oral capsule mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML (Pamidronate Disodium) (Zemplar) QL ( per 80 risedronate oral tablet 50 mg (Actonel) QL ( per 28 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 30 risedronate oral tablet 35 mg, 35 mg (2 (Actonel) QL (4 per 28 pack), 35 mg (4 pack) XGEVA SUBCUTANEOUS PA SOLUTION 20 MG/.7 ML (70 MG/ML) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 (Zometa) mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/00 ml (Zoledronic Acid/Mannitol and Water) Formulary ID: Version: 7 36 Effective: January 0, 207

190 zoledronic acid-mannitol-water (Reclast) QL (00 per 300 intravenous solution 5 mg/00 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML amifostine crystalline intravenous recon (Amifostine soln 500 mg Crystalline) ammonium chloride intravenous solution (Ammonium Chloride) 5 meq/ml BENLYSTA INTRAVENOUS PA RECON SOLN 20 MG, 400 MG BOTOX INJECTION RECON SOLN PA; QL (4 per UNIT BOTOX INJECTION RECON SOLN PA; QL ( per UNIT buspirone oral tablet 0 mg, 5 mg, 30 (Buspirone HCl) mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 PA MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER GRAM/.7 ML dexrazoxane hcl intravenous recon soln (Zinecard) 250 mg, 500 mg droperidol injection solution 2.5 mg/ml (Droperidol) ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet mg (Ergoloid Mesylates) fomepizole intravenous solution gram/ml (Fomepizole) Formulary ID: Version: 7 37 Effective: January 0, 207

191 FUSILEV INTRAVENOUS RECON SOLN 50 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG guanidine oral tablet 25 mg (Guanidine HCl) hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg (Vistaril) PA-HRM; AGE (Max 64 Years) KEVEYIS ORAL TABLET 50 MG PA; QL (20 per 30 leucovorin calcium 200 mg vial sdv, p/f, (Leucovorin Calcium) latex-free 200 mg leucovorin calcium injection recon soln (Leucovorin Calcium) 00 mg, 350 mg leucovorin calcium oral tablet 0 mg, 5 (Leucovorin Calcium) mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution (Levocarnitine (With 00 mg/ml Sugar)) levocarnitine intravenous solution 200 (Carnitor) mg/ml levocarnitine oral tablet 330 mg (Carnitor) mesna intravenous solution 00 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML methylergonovine injection solution 0.2 (Methylergonovine mg/ml ( ml) Maleate) methylergonovine oral tablet 0.2 mg (Methergine) MYOBLOC INTRAMUSCULAR PA; QL (2 per 90 SOLUTION 0,000 UNIT/2 ML MYOBLOC INTRAMUSCULAR SOLUTION 2,500 UNIT/0.5 ML PA; QL (0.5 per 90 MYOBLOC INTRAMUSCULAR SOLUTION 5,000 UNIT/ML PA; QL ( per 90 Formulary ID: Version: 7 38 Effective: January 0, 207

192 NPLATE SUBCUTANEOUS RECON PA; QL (8 per 28 SOLN 250 MCG, 500 MCG ORENCIA CLICKJECT PA SUBCUTANEOUS AUTO-INJECTOR 25 MG/ML PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 80 mg (Mestinon) REMICADE INTRAVENOUS PA RECON SOLN 00 MG SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS QL (60 per 30 SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG PA NSO; QL (60 per 30 THIOLA ORAL TABLET 00 MG TYBOST ORAL TABLET 50 MG QL (30 per 30 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 25 mg, 250 mg (Acetazolamide) acetazolamide sodium injection recon (Acetazolamide soln 500 mg Sodium) ALPHAGAN P OPHTHALMIC DROPS 0. % AZOPT OPHTHALMIC DROPS,SUSPENSION % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) Formulary ID: Version: 7 39 Effective: January 0, 207

193 BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.5 %, 0.2 (Alphagan P) (drops: 0.5%, 0.20%) % COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops (Cosopt) mg/ml latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.0 % QL (2.5 per 25 methazolamide oral tablet 25 mg, 50 mg (Neptazane) metipranolol ophthalmic drops 0.3 % (Metipranolol) PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.25 % pilocarpine hcl ophthalmic drops %, 2 (Isopto Carpine) %, 4 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic drops 0.25 %, (Timolol Maleate) 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) TRAVATAN Z OPHTHALMIC QL (2.5 per 25 DROPS % travoprost (benzalkonium) ophthalmic (Travoprost QL (2.5 per 25 drops % (Benzalkonium)) ZIOPTAN (PF) OPHTHALMIC QL (30 per 30 DROPPERETTE % Replacement Preparations Replacement Preparations calcium chloride intravenous syringe 00 mg/ml (0 %) (Calcium Chloride) Formulary ID: Version: 7 40 Effective: January 0, 207

194 d0 %-0.45 % sodium chloride (Dextrose 0 % and intravenous parenteral solution 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and intravenous parenteral solution 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 intravenous parenteral solution % NaCl) d5 %-0.45 % sodium chloride intravenous parenteral solution (Dextrose 5 %-0.45 % NaCl) dextrose 0 % and 0.2 % nacl intravenous (Dextrose 0 % and 0.2 parenteral solution % NaCl) dextrose 5 %-lactated ringers intravenous (Dextrose 5%-Lactated parenteral solution Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % intravenous parenteral solution NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 intravenous parenteral solution % NaCl) dextrose with sodium chloride (Dextrose 5 %-0.2 % intravenous parenteral solution % NaCl) effer-k oral tablet, effervescent 25 meq (Klor-Con-Ef) electrolyte-48 in d5w intravenous (Electrolyte-48 parenteral solution Solution/D5W) IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION klor-con 0 oral tablet extended release (Potassium Chloride) 0 meq klor-con m0 tablet 0 meq (Potassium Chloride) klor-con m5 oral tablet,er particles/crystals 5 meq (Potassium Chloride) Formulary ID: Version: 7 4 Effective: January 0, 207

195 klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq magnesium sulfate in d5w intravenous piggyback gram/00 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION 2'S,LATEX-FREE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride) (Potassium Chloride) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Potassium Acetate) (Potassium Chloride/D5-0.45nacl) Formulary ID: Version: 7 42 Effective: January 0, 207

196 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) potassium chloride oral packet 20 meq (Klor-Con) potassium chloride oral tablet extended (K-Tab ER) release 8 meq potassium chloride oral tablet,er (K-Tab ER) particles/crystals 0 meq potassium chloride oral tablet,er (Potassium Chloride) particles/crystals 20 meq potassium chloride-0.45 % nacl (Potassium intravenous parenteral solution 20 meq/l Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride/D5-0.2%NaC l) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l (Potassium Chloride/D5-0.3%NaC l) (Potassium Chloride/D5-0.9%NaC l) Formulary ID: Version: 7 43 Effective: January 0, 207

197 potassium citrate oral tablet extended (Urocit-K) release 0 meq (,080 mg), 5 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet (Potassium 3,300-,002 mg Citrate/Citric Acid) potassium cl 0 meq/50 ml sol 0 meq/50 (Potassium Chloride) ml potassium cl 20 meq/50 ml sol 20 meq/50 (Potassium Chloride) ml potassium cl er 0 meq tablet f/c 0 meq (K-Tab ER) ringers intravenous parenteral solution (Ringers Solution) sodium acetate intravenous solution 2 (Sodium Acetate) meq/ml sodium bicarbonate intravenous syringe (Sodium Bicarbonate) 8.4 % ( meq/ml) sodium chloride 0.45 % intravenous (Sodium Chloride 0.45 parenteral solution 0.45 % %) sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) sodium chloride 3 % intravenous (Sodium Chloride 3 %) parenteral solution 3 % sodium chloride 5 % intravenous (Sodium Chloride 5 %) parenteral solution 5 % sodium chloride intravenous parenteral (Sodium Chloride) solution 2.5 meq/ml sodium lactate intravenous solution 5 (Sodium Lactate) meq/ml sodium phosphate intravenous solution 3 (Sodium mmol/ml Phos,M-Basic-D-Basic) TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Formulary ID: Version: 7 44 Effective: January 0, 207

198 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, mg/2 ml DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION QL (60 per 30 QL (2 per 28 QL (60 per 30 (Pulmicort) PA BvD QL (3 per 28 QL (60 per 30 QL (20 per 30 QL (2 per 28 QL (24 per 28 Formulary ID: Version: 7 45 Effective: January 0, 207

199 FLOVENT HFA INHALATION HFA QL (2.2 per 28 AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 QL (7.4 per 25 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 0 mg (Singulair) montelukast oral tablet,chewable 4 mg, 5 (Singulair) mg zafirlukast oral tablet 0 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for (Albuterol Sulfate) PA BvD nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml (Albuterol Sulfate) albuterol sulfate oral tablet 2 mg, 4 mg (Albuterol Sulfate) albuterol sulfate oral tablet extended (Vospire ER) release 2 hr 4 mg, 8 mg ATROVENT HFA INHALATION QL (25.8 per 28 HFA AEROSOL INHALER 7 MCG/ACTUATION COMBIVENT RESPIMAT QL (8 per 30 INHALATION MIST MCG/ACTUATION elixophyllin oral elixir 80 mg/5 ml (Theophylline Anhydrous) FORADIL AEROLIZER QL (60 per 30 INHALATION CAPSULE, W/INHALATION DEVICE 2 MCG ipratropium bromide inhalation solution (Ipratropium Bromide) PA BvD 0.02 % metaproterenol oral syrup 0 mg/5 ml (Metaproterenol Sulfate) Formulary ID: Version: 7 46 Effective: January 0, 207

200 metaproterenol oral tablet 0 mg, 20 mg (Metaproterenol Sulfate) PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION QL (60 per 30 BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STIOLTO RESPIMAT QL (4 per 28 INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION QL (4 per 28 terbutaline oral tablet 2.5 mg, 5 mg (Terbutaline Sulfate) terbutaline subcutaneous solution (Terbutaline Sulfate) mg/ml theophylline er 400 mg tablet 400 mg (Theophylline Anhydrous) theophylline er 600 mg tablet 600 mg (Theophylline Anhydrous) theophylline in dextrose 5 % intravenous (Theophylline/D5W) parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/5 ml (Theophylline Anhydrous) Formulary ID: Version: 7 47 Effective: January 0, 207

201 theophylline oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 400 mg, 600 mg VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) acetylcysteine solution 00 mg/ml (0 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 0 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml DALIRESP ORAL TABLET 500 MCG (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) PA BvD (Acetadote) PA BvD PA (Cromolyn Sodium) PA BvD QL (30 per 30 ESBRIET ORAL CAPSULE 267 MG PA; QL (270 per 30 KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG PA; QL (60 per 30 KALYDECO ORAL TABLET 50 MG PA; QL (60 per 30 NUCALA SUBCUTANEOUS RECON SOLN 00 MG PA; LA; QL ( per 28 OFEV ORAL CAPSULE 00 MG, 50 MG PA; QL (60 per 30 ORKAMBI ORAL TABLET MG PA; QL (20 per 30 PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG XOLAIR SUBCUTANEOUS RECON SOLN 50 MG PA Formulary ID: Version: 7 48 Effective: January 0, 207

202 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg (Soma) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) chlorzoxazone oral tablet 500 mg (Parafon Forte DSC) PA-HRM; AGE (Max 64 Years) cyclobenzaprine oral tablet 0 mg, 5 mg, 7.5 mg (Fexmid) PA-HRM; AGE (Max 64 Years) dantrolene oral capsule 00 mg, 25 mg, (Dantrium) 50 mg metaxall oral tablet 800 mg (Skelaxin) PA-HRM; AGE (Max 64 Years) metaxalone oral tablet 400 mg, 800 mg (Skelaxin) PA-HRM; AGE (Max 64 Years) methocarbamol oral tablet 500 mg, 750 mg (Robaxin) PA-HRM; AGE (Max 64 Years) revonto intravenous recon soln 20 mg (Dantrium) tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 50 mg, 200 mg, (Nuvigil) PA 250 mg, 50 mg BELSOMRA ORAL TABLET 0 MG, QL (30 per 30 5 MG, 20 MG, 5 MG eszopiclone oral tablet mg, 2 mg, 3 mg (Lunesta) PA-HRM; QL (30 per 30 ; AGE (Max 64 Years) HETLIOZ ORAL CAPSULE 20 MG PA; QL (30 per 30 ROZEREM ORAL TABLET 8 MG SILENOR ORAL TABLET 3 MG, 6 MG QL (30 per 30 Formulary ID: Version: 7 49 Effective: January 0, 207

203 XYREM ORAL SOLUTION 500 LA MG/ML zaleplon oral capsule 0 mg (Sonata) PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) zaleplon oral capsule 5 mg (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) zolpidem oral tablet 0 mg, 5 mg (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) zolpidem oral tablet,ext release multiphase 2.5 mg, 6.25 mg (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Formulary ID: Version: 7 50 Effective: January 0, 207

204 Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG PA; QL (60 per 30 ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG PA; QL (90 per 30 CIALIS ORAL TABLET 2.5 MG, 5 MG PA; QL (30 per 30 epoprostenol (glycine) intravenous recon (Flolan) PA soln 0.5 mg,.5 mg LETAIRIS ORAL TABLET 0 MG, 5 MG PA; QL (30 per 30 OPSUMIT ORAL TABLET 0 MG PA; QL (30 per 30 ORENITRAM ORAL TABLET PA EXTENDED RELEASE 0.25 MG, 0.25 MG, MG, 2.5 MG REMODULIN INJECTION PA SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 0 mg/2.5 (Revatio) PA; QL (37.5 per day) ml sildenafil oral tablet 20 mg (Revatio) PA; QL (90 per 30 TRACLEER ORAL TABLET 25 MG, 62.5 MG PA; LA; QL (60 per 30 TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) PA UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 400 MCG, 600 MCG, 800 MCG PA; QL (60 per 30 UPTRAVI ORAL TABLET 200 MCG PA; QL (240 per 30 UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) PA; QL (400 per 365 Formulary ID: Version: 7 5 Effective: January 0, 207

205 Vitamins And Minerals Vitamins And Minerals multivit-fluor 0.25 mg/ml drop 0.25 mg/ml pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- mg prenatal vitamin plus low iron oral tablet 27 mg iron- mg sodium fluoride oral tablet mg fluoride (2.2 mg) sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg) (Pedi Mvi No.82 with Fluoride) (Pnv with (All Rx Prenatal Ca,No.72/Iron/Fa) Vitamins Covered) (Pnv with (All Rx Prenatal Ca,No.72/Iron/Fa) Vitamins Covered) (Pedi Mvi No.82 with Fluoride) (Sodium Fluoride) Formulary ID: Version: 7 52 Effective: January 0, 207

206 8-MOP abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE acamprosate... acarbose acebutolol acetaminophen-codeine... 3 acetasol hc acetazolamide acetazolamide sodium acetic acid... 09, 35 acetylcysteine acitretin ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 67, 99 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCETRIS ADCIRCA... 5 adefovir ADEMPAS... 5 adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort AKTEN (PF) AKYNZEO ala-cort ala-scalp ALBENZA INDEX albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate alfuzosin... 7 ALIMTA ALINIA allopurinol ALLZITAL... 3 almotriptan malate alogliptin alogliptin-metformin alogliptin-pioglitazone alosetron ALPHAGAN P alprazolam... 2 ALREX... altacaine altavera (28) ALTOPREV alyacen /35 (28) alyacen 7/7/7 (28) amantadine hcl AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 5 %... 7 AMINOSYN 0 %... 7 AMINOSYN 3.5 %... 7 AMINOSYN 7 %... 7 AMINOSYN 7 % WITH ELECTROLYTES... 7 AMINOSYN 8.5 %... 7 AMINOSYN 8.5 %-ELECTROLYTES... 7 AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA... 3 amitriptyline... 4 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium chloride ammonium lactate amoxapine... 4 amoxicil-clarithromy-lansopraz... 2 amoxicillin amoxicillin-pot clavulanate... 22, 23 amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE ANADROL anagrelide anastrozole ANDRODERM... 8 ANDROGEL... 8 Formulary ID: Version: 7 I- Effective: January 0, 207

207 androxy... 8 APOKYN apraclonidine apri APRISO APTIOM APTIVUS aranelle (28) ARCALYST aripiprazole ARISTADA... 58, 59 armodafinil ASACOL HD ascomp with codeine... 3 ashlyna aspirin-dipyridamole... 7 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 36, 07 ATROVENT HFA AUBAGIO aubra AURYXIA... 6 AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) AXIRON... 8 azacitidine azathioprine azathioprine sodium azelastine... 07, 08 AZILECT azithromycin... 2 AZOPT AZOR aztreonam azurette (28) baciim... 6 bacitracin... 6, 09 bacitracin-polymyxin b baclofen balsalazide balziva (28) BANZEL BCG VACCINE, LIVE (PF) BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bekyree (28) BELBUCA... 3 BELEODAQ BELSOMRA benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT BENLYSTA benztropine BEPREVE betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 79, 39 bethanechol chloride... 6 BETHKIS... 5 BETOPTIC S bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP... 29, 30 BOSULIF BOTOX BREO ELLIPTA briellyn BRILINTA... 7 brimonidine BRINTELLIX... 4 BRIVIACT bromfenac... bromocriptine budesonide... 34, 45 bumetanide BUNAVAIL... BUPHENYL... 3 buprenorphine hcl... 3, buprenorphine-naloxone... buproban... bupropion hcl... 4 bupropion hcl (smoking deter)... buspirone butalbital compound w/codeine... 3 butalbital-acetaminop-caf-cod... 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff... 3, 4 butalbital-aspirin-caffeine... 4 butorphanol tartrate... 4 BUTRANS... 4 BYSTOLIC cabergoline CABOMETYX caffeine citrated calcipotriene calcitonin (salmon) Formulary ID: Version: 7 I-2 Effective: January 0, 207

208 calcitrene calcitriol... 99, 35 calcium acetate... 6 calcium chloride CALDOLOR... 8 camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE... 2 CARBAGLU... 3 carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor... 8, 9 cefadroxil... 9 cefazolin... 9 cefazolin in dextrose (iso-os)... 9 cefdinir... 9 cefditoren pivoxil... 9 cefepime... 9 CEFEPIME... 9 CEFEPIME IN DEXTROSE 5 %... 9 CEFEPIME IN DEXTROSE,ISO-OSM... 9 cefixime... 9 cefotaxime... 9 cefoxitin... 9 cefoxitin in dextrose, iso-osm... 9 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium celecoxib... 8 CELLCEPT INTRAVENOUS CELONTIN cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) CETYLEV cevimeline CHANTIX... CHANTIX CONTINUING MONTH BOX... CHANTIX STARTING MONTH BOX... chloramphenicol sod succinate... 6 chlordiazepoxide hcl... 2 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar) cholestyramine light CIALIS... 5 ciclopirox cidofovir cilostazol... 7 CILOXAN cimetidine... 2 cimetidine hcl... 2 CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 24, 09 ciprofloxacin in 5 % dextrose ciprofloxacin lactate citalopram... 4, 42 cladribine clarithromycin... 2 clemastine CLEVIPREX clindamycin hcl... 6 clindamycin in 5 % dextrose... 6 clindamycin palmitate hcl... 6 clindamycin pediatric... 6 clindamycin phosphate... 7, 53, 0 clindamycin-benzoyl peroxide... 0 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE Formulary ID: Version: 7 I-3 Effective: January 0, 207

209 CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol... 02, 03 clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 2 clonidine clonidine hcl... 75, 89 clopidogrel... 7 clorazepate dipotassium... 2 clorpres clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 4 COGENTIN colchicine-probenecid COLCRYS colestipol colistin (colistimethate na)... 7 colocort COLY-MYCIN S COMBIGAN COMBIPATCH... 9 COMBIVENT RESPIMAT COMETRIQ COMPLERA compro COMVAX (PF) CONDYLOX constulose... 3 COPAXONE CORLANOR... 8 cormax cortisone COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) COTELLIC CREON CRIXIVAN cromolyn... 08, 3, 48 cryselle (28) CUBICIN... 7 CUBICIN RF... 7 CUPRIMINE... 7 cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN d0 %-0.45 % sodium chloride... 4 d2.5 %-0.45 % sodium chloride... 4 d5 % and 0.9 % sodium chloride... 4 d5 %-0.45 % sodium chloride... 4 DAKLINZA DALIRESP danazol... 8 dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX dasetta /35 (28) dasetta 7/7/7 (28) daysee deblitane decitabine deferoxamine... 7 delyla (28) DELZICOL demeclocycline DEMSER... 8 DENAVIR DEPEN TITRATABS... 7 DEPO-PROVERA DESCOVY desipramine desmopressin... 2 desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone sodium phosphate..., 20 DEXILANT... 2 dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamine-amphetamine... 89, 90 dextrose 0 % and 0.2 % nacl... 4 Formulary ID: Version: 7 I-4 Effective: January 0, 207

210 dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers... 4 dextrose 5%-0.2 % sod chloride... 4 dextrose 5%-0.3 % sod.chloride... 4 dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride... 4 diazepam... 2 diazepam intensol... 2 diclofenac potassium... 8 diclofenac sodium... 8, 00, diclofenac-misoprostol... 8 dicloxacillin dicyclomine... 3 didanosine DIFICID... 2 diflorasone diflunisal... 8 digitek digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl... 80, 8 dilt-xr... 8 dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine... 4 dipyridamole... 7 disopyramide phosphate disulfiram... divalproex dobutamine dobutamine in d5w docetaxel dofetilide donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE... 9 DULERA duloxetine DUREZOL... dutasteride... 7 dutasteride-tamsulosin... 7 DYRENIUM e.e.s e.e.s. granules... 2 econazole EDARBI EDARBYCLOR EDURANT effer-k... 4 EFFIENT... 7 ELAPRASE electrolyte-48 in d5w... 4 ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos... 6 ELIQUIS ELITEK elixophyllin ELLA ELMIRON EMBEDA... 4 EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL... 25, 26 ENBREL SURECLICK endocet... 4 endodan... 4 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir ENTRESTO enulose... 4 ENVARSUS XR EPCLUSA epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epitol EPIVIR HBV eplerenone EPOGEN... 69, 70 epoprostenol (glycine)... 5 eprosartan EPZICOM ergoloid Formulary ID: Version: 7 I-5 Effective: January 0, 207

211 ERGOMAR ERIVEDGE errin ery pads... 0 ery-tab... 2 ERY-TAB... 2 ERYTHROCIN erythrocin (as stearate)... 2 erythromycin... 22, 09 erythromycin ethylsuccinate erythromycin with ethanol... 0 erythromycin-benzoyl peroxide... 0 ESBRIET escitalopram oxalate esmolol esomeprazole sodium... 2 estarylla estazolam... 3 ESTRACE... 9 estradiol... 9 estradiol valerate... 9 estradiol-norethindrone acet... 9 ESTRING... 9 estropipate... 9 eszopiclone ethambutol ethosuximide etidronate disodium etodolac... 8, 9 ETOPOPHOS etoposide EVOTAZ EXELDERM exemestane EXJADE... 7 EXTAVIA FABRAZYME falmina (28) famciclovir famotidine... 3 famotidine (pf)... 2 famotidine (pf)-nacl (iso-os)... 3 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine FEMRING... 9 fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen... 9 fentanyl... 4 fentanyl citrate... 4 FERRIPROX... 8 FETZIMA finasteride... 7 FIRAZYR flavoxate... 6 FLEBOGAMMA DIF flecainide FLECTOR... 9 FLOVENT DISKUS FLOVENT HFA... 45, 46 floxuridine flucaine fluconazole fluconazole in nacl (iso-osm) flucytosine fludrocortisone flumazenil flunisolide... fluocinolone acetonide oil... fluocinonide fluocinonide-e fluorometholone... fluorouracil... 29, 00 fluoxetine FLUOXETINE fluphenazine decanoate fluphenazine hcl flurazepam... 3, 4 flurbiprofen... 9 flurbiprofen sodium... flutamide fluticasone... 03, fluvastatin fluvoxamine fomepizole fondaparinux FORADIL AEROLIZER FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL... 6 FREAMINE HBC 6.9 % FREAMINE III 0 % furosemide FUSILEV FUZEON fyavolv... 9 FYCOMPA gabapentin... 37, 38 GABITRIL galantamine... 40, 4 GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL... 4 GATTEX ONE-VIAL... 4 GAUZE PAD gavilyte-c... 5 gavilyte-g... 5 gavilyte-n... 5 GAZYVA gemcitabine gemfibrozil generlac... 4 gengraf GENOTROPIN Formulary ID: Version: 7 I-6 Effective: January 0, 207

212 GENOTROPIN MINIQUICK gentak gentamicin... 6, 0, 09 gentamicin in nacl (iso-osm)... 6 gentamicin sulfate (ped) (pf)... 6 gentamicin sulfate (pf)... 6 GENVOYA GEODON gianvi (28) gildagia gildess.5/30 (2) gildess /20 (2) gildess 24 fe gildess fe.5/30 (28) gildess fe /20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride... 48, 49 glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin glycopyrrolate... 4 glydo... 0 GLYXAMBI GRALISE GRALISE 30-DAY STARTER PACK granisetron (pf) granisetron hcl GRANIX griseofulvin microsize... 5 griseofulvin ultramicrosize... 5 guanfacine... 76, 90 guanidine halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate... 59, 60 HARVONI HAVRIX (PF)... 3 heather heparin (porcine) heparin (porcine) in 5 % dex heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HIBERIX (PF)... 3 homatropaire homatropine hbr HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide... 84, 85 hydrocodone-acetaminophen... 4, 5 hydrocodone-ibuprofen... 5 hydrocortisone... 04, 20, 34 hydrocortisone butyrate... 03, 04 hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydromorphone... 5 hydromorphone (pf)... 5 hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 5 ibandronate IBRANCE ibuprofen... 9 ICLUSIG ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO... imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF)... 3 INCRELEX indapamide indomethacin... 9 indomethacin sodium... 9 INFANRIX (DTAP) (PF)... 3 INLYTA Formulary ID: Version: 7 I-7 Effective: January 0, 207

213 INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A... 66, 67 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W... 4 IONOSOL-MB IN D5W... 4 IPOL... 3 ipratropium bromide... 08, 46 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA irinotecan ISENTRESS ISOLYTE-P IN 5 % DEXTROSE... 4 ISOLYTE-S... 4 isoniazid isosorbide dinitrate isosorbide mononitrate isradipine itraconazole... 5 ivermectin IXEMPRA IXIARO (PF)... 3 JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jinteli... 9 jolessa jolivette juleber junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID KABIVEN KALETRA KALYDECO KANUMA kariva (28) KAZANO kelnor /35 (28) ketoconazole... 5 ketoprofen... 9 ketorolac... 9, KEVEYIS KEYTRUDA kimidess (28) KINERET KINRIX (PF)... 3 kionex... 4 klor-con klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS l norgest/e.estradiol-e.estrad labetalol LACRISERT LACTATED RINGERS lactulose... 4 lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole... 3 LANTUS LANTUS SOLOSTAR larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) latanoprost LATUDA LAZANDA... 5 leena leflunomide LEMTRADA LENVIMA... 3 lessina LETAIRIS... 5 letrozole... 3 leucovorin calcium LEUKERAN... 3 LEUKINE leuprolide... 3 levetiracetam levetiracetam in nacl (iso-os) levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 24, 25, 09 levofloxacin in d5w levonest (28) levonorgestrel-ethinyl estrad levonorg-eth estrad triphasic levora levothyroxine LEXIVA lidocaine... 0 lidocaine (pf)... 0, 78 lidocaine hcl... 0 lidocaine in 5 % dextrose (pf) lidocaine viscous... 0 lidocaine-prilocaine... 0 linezolid... 7 LINZESS... 4 Formulary ID: Version: 7 I-8 Effective: January 0, 207

214 liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate lomedia 24 fe LONSURF... 3 loperamide... 4 lorazepam... 4 lorazepam intensol... 4 lorcet (hydrocodone)... 5 lorcet hd... 5 lorcet plus... 5 loryna (28) losartan losartan-hydrochlorothiazide LOTEMAX... 2 lovastatin low-ogestrel (28) loxapine succinate LUMIGAN LUPRON DEPOT... 3 LUPRON DEPOT (3 MONTH)... 3 LUPRON DEPOT (4 MONTH)... 3 LUPRON DEPOT (6 MONTH)... 3 LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA... 3 LYRICA LYSODREN... 3 lyza magnebind magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline margesic... 5 marlissa MARPLAN MARQIBO... 3 MATULANE... 3 matzim la... 8 meclizine medroxyprogesterone mefenamic acid... 0 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) megestrol... 3, 24 MEKINIST... 3, 32 meloxicam... 0 melphalan hcl memantine... 4 MENACTRA (PF)... 3 MENEST... 9 MENHIBRIX (PF)... 3 MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-35 (PF)... 3 MENVEO A-C-Y-W-35-DIP (PF) mercaptopurine meropenem mesna MESNEX MESTINON metaproterenol... 46, 47 metaxall metaxalone metformin... 45, 46 methadone... 5, 6 methadose... 6 methazolamide methenamine hippurate... 7 methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine... 4 methyclothiazide methylergonovine methylphenidate methylprednisolone... 2 methylprednisolone acetate methylprednisolone sodium succ... 2 metipranolol metoclopramide hcl... 4 metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 7, 53, 0 metronidazole in nacl (iso-os)... 7 mexiletine MIACALCIN miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) midazolam... 4 midodrine miglitol milrinone milrinone in 5 % dextrose mimvey mimvey lo... 9 minitran MINOCIN minocycline minoxidil MIRCERA mirtazapine misoprostol... 3 mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone... 60, 6 mometasone mono-linyah mononessa (28) montelukast Formulary ID: Version: 7 I-9 Effective: January 0, 207

215 morphine... 6 MORPHINE... 6 morphine concentrate... 6 MOVANTIK... 4 MOVIPREP... 5 MOXEZA moxifloxacin MOZOBIL MULTAQ multi-vitamin with fluoride mupirocin... 0 mupirocin calcium... 0 mycophenolate mofetil mycophenolate sodium MYOBLOC MYOZYME MYRBETRIQ... 6 myzilra nabumetone... 0 nadolol nafcillin NAGLAZYME naloxone... naltrexone... NAMENDA XR... 4 NAMZARIC... 4 naphazoline naproxen... 0 naproxen sodium... 0 naratriptan NARCAN... NATACYN nateglinide NATPARA NEBUPENT necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nefazodone neomycin... 6 neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin... 0 neomycin-polymyxin b gu... 0 neomycin-polymyxin b-dexameth... 0 neomycin-polymyxin-gramicidin... 0 neomycin-polymyxin-hc... 0 neo-polycin... 0 neo-polycin hc... 0 NEPHRAMINE 5.4 % NESINA neuac... 0 NEULASTA NEUPOGEN NEUPRO NEVANAC... 2 nevirapine NEXAVAR niacin niacor nicardipine NICOTROL... nifedical xl nifedipine nikki (28) NILANDRON nilutamide NINLARO NITRO-BID nitrofurantoin... 8 nitrofurantoin macrocrystal... 7 nitrofurantoin monohyd/m-cryst... 8 nitroglycerin nitroglycerin in 5 % dextrose NITROSTAT nizatidine... 3 nora-be NORDITROPIN FLEXPRO norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 96, 20 norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... 5 NPLATE NUCALA NUCYNTA... 6 NUCYNTA ER... 6 NUEDEXTA... 9 NULOJIX NUPLAZID... 6 NUTRESTORE... 4 NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING nyamyc... 5 nystatin... 5 nystatin-triamcinolone... 5 nystop... 5 OCALIVA... 4 ocella OCTAGAM octreotide acetate ODEFSEY Formulary ID: Version: 7 I-0 Effective: January 0, 207

216 ODOMZO OFEV ofloxacin... 25, 0 ogestrel (28) olanzapine... 6 olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole... 3 OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 4 ONGLYZA OPDIVO OPSUMIT... 5 oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM... 5 ORFADIN... 06, 07 ORKAMBI orsythia OSENI OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone... 8 oxcarbazepine OXTELLAR XR oxybutynin chloride... 6, 7 oxycodone... 6, 7 oxycodone-acetaminophen... 7 oxycodone-aspirin... 7 OXYCONTIN... 7 oxymorphone... 7 pacerone paclitaxel paliperidone... 6 pamidronate PANRETIN pantoprazole... 3 paricalcitol paromomycin paroxetine hcl PASER PATADAY PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes... 5 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln... 5 PEGINTRON PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline... 7 PERIKABIVEN perindopril erbumine periogard PERJETA permethrin perphenazine... 6 perphenazine-amitriptyline PERTZYE pfizerpen-g phenadoz phenelzine phenobarbital phenylephrine hcl... 76, 08 phenytoin phenytoin sodium phenytoin sodium extended philith PHOSLYRA... 6 PHOSPHOLINE IODIDE PICATO pilocarpine hcl... 99, 40 pimozide... 6 pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam... 0 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY... 9 podofilox polyethylene glycol polymyxin b sulfate... 8 polymyxin b sulf-trimethoprim... 0 POMALYST portia PORTRAZZA potassium acetate potassium chlorid-d5-0.45%nacl potassium chloride... 43, 44 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate Formulary ID: Version: 7 I- Effective: January 0, 207

217 potassium citrate-citric acid potassium hydroxide POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate... 2 prednisolone sodium phosphate... 2, 2 prednisone... 2 PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron PREPOPIK... 5 prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA... 2 PROLEUKIN PROLIA PROMACTA promethazine... 52, 55, 56 promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protamine protriptyline PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide QUADRACEL (PF) quasense quetiapine... 6 quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl... 3 RAPAMUNE RASUVO (PF) RAVICTI... 4 REBIF (WITH ALBUMIN)... 9 REBIF REBIDOSE... 9 REBIF TITRATION PACK... 9 reclipsen (28) RECOMBIVAX HB (PF) REGRANEX RELENZA DISKHALER RELISTOR... 5 REMICADE REMODULIN... 5 RENAGEL... 6 RENVELA... 6 repaglinide repaglinide-metformin REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE reprexain... 7 RESCRIPTOR RESTASIS... 2 RETROVIR REVLIMID revonto REXULTI... 6 REYATAZ... 64, 65 ribasphere ribasphere ribapak ribavirin RIDAURA rifabutin rifampin RIFATER riluzole... 9 rimantadine ringers... 35, 44 risedronate RISPERDAL CONSTA... 6 risperidone... 6 RITUXAN rivastigmine... 4 rivastigmine tartrate... 4 rizatriptan ropinirole rosadan... 0 Formulary ID: Version: 7 I-2 Effective: January 0, 207

218 rosuvastatin ROTARIX ROTATEQ VACCINE ROZEREM SABRIL SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY)... 6 SAVAYSA SAVELLA... 9 selegiline hcl selenium sulfide... 0 SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin sharobel SIGNIFOR sildenafil... 5 SILENOR silver nitrate... 0 silver sulfadiazine... 0 SIMBRINZA SIMPONI... 28, 29 SIMPONI ARIA simvastatin sirolimus SIRTURO sodium acetate sodium bicarbonate sodium chloride... 35, 44 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free)... 5 sodium polystyrene sulfonate... 5 SOLTAMOX SOLU-CORTEF (PF)... 2 SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spinosad SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 5 sprintec (28) SPRITAM SPRYCEL sps... 5 sronyx ssd stavudine STELARA STERILE GAUZE PAD STIMATE STIOLTO RESPIMAT STIVARGA STRATTERA... 9 STRENSIQ streptomycin... 6 STRIBILD STRIVERDI RESPIMAT SUBOXONE... 2 sucralfate... 3 sulfacetamide sodium... 0 sulfacetamide sodium (acne) sulfacetamide-prednisolone... 0 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac... 0 sumatriptan sumatriptan succinate... 53, 54 SUPPRELIN LA SUPRAX... 20, 2 SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 8 SYNJARDY SYNRIBO SYPRINE... 8 TABLOID tacrolimus... 04, 29 TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin... 7 TARCEVA... 33, 34 TARGRETIN tarina fe /20 (28) TASIGNA tazicef... 2 TAZORAC taztia xt... 8 TECENTRIQ TECFIDERA... 9 Formulary ID: Version: 7 I-3 Effective: January 0, 207

219 TECHNIVIE TEFLARO... 2 TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazid temazepam... 4, 5 TEMODAR tencon... 7 teniposide TENIVAC (PF) terazosin... 7 terbinafine hcl... 5 terbutaline terconazole testosterone... 8, 9 testosterone cypionate... 8 testosterone enanthate... 8 TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td tetrabenazine... 9 tetracycline THALOMID theophylline... 47, 48 theophylline in dextrose 5 % THIOLA thioridazine thiotepa thiothixene tiagabine TICE BCG tilia fe timolol maleate... 80, 40 tinidazole TIVICAY tizanidine TOBI PODHALER... 6 TOBRADEX... 0 TOBRADEX ST... tobramycin... tobramycin in % nacl... 6 tobramycin in 0.9 % nacl... 6 tobramycin sulfate... 6 tobramycin-dexamethasone... TOLAK tolazamide tolbutamide tolmetin... 0 tolterodine... 7 topiramate toposar topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ... 7 TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER... 5 TRADJENTA tramadol... 7 tramadol-acetaminophen... 7 trandolapril tranexamic acid... 7 TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide... 99, 04, 2, 2 triamterene-hydrochlorothiazid trianex triazolam... 5 TRIBENZOR tri-estarylla trifluoperazine trifluridine... trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets... 6 trimethoprim... 8 trimipramine trinessa (28) TRINTELLIX tri-previfem (28) tri-sprintec (28) TRIUMEQ trivora (28) TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium... 7 TRULICITY TRUMENBA TRUVADA TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO... 5 TYZEKA TYZINE u-cort ULORIC UNITUXIN UPTRAVI... 5 ursodiol... 5 VAGIFEM valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) Formulary ID: Version: 7 I-4 Effective: January 0, 207

220 valsartan valsartan-hydrochlorothiazide VALSTAR vancomycin... 8 vancomycin in dextrose 5 %... 8 VAQTA (PF) VARIVAX (PF) VASCEPA VECTIBIX VELCADE velivet triphasic regimen (28) VELPHORO... 6 VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil... 8 VEREGEN VERSACLOZ VESICARE... 7 vestura (28) VGO VIBERZI... 5 vicodin... 8 vicodin es... 7 vicodin hp... 8 VICTOZA VIDEX 2 GRAM PEDIATRIC VIEKIRA PAK vienva VIGAMOX... VIIBRYD VIMIZIM VIMPAT vinblastine vincasar pfs vincristine vinorelbine viorele (28) VIRACEPT VIRAZOLE VIREAD VITEKTA VOLTAREN... 0 voriconazole... 5, 52 VOTRIENT VPRIV VRAYLAR vyfemla (28) VYTORIN VYTORIN VYTORIN VYTORIN warfarin water for irrigation, sterile WELCHOL wera (28) wymzya fe XALKORI XARELTO XARTEMIS XR... 8 XELJANZ XELJANZ XR XGEVA XIFAXAN... 8 XOLAIR XTANDI xulane xylon XYREM YERVOY YF-VAX (PF) YONDELIS zafirlukast zaleplon ZALTRAP zarah ZARXIO ZAVESCA zebutal... 8 ZELBORAF ZEMPLAR zenatane zenchent (28) zenchent fe ZENPEP ZEPATIER ZETIA ZIAGEN zidovudine ZIOPTAN (PF) ziprasidone hcl ZIRGAN... ZOHYDRO ER... 8 ZOLADEX zoledronic acid zoledronic acid-mannitol-water... 36, 37 ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide ZORBTIVE ZORTRESS ZOSTAVAX (PF) zovia /35e (28) zovia /50e (28) ZOVIRAX ZUBSOLV... 2 ZYDELIG ZYKADIA ZYLET... ZYPREXA RELPREVV ZYTIGA Formulary ID: Version: 7 I-5 Effective: January 0, 207

221 This formulary was updated on 08/24/206. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8 am 8 pmor visit Este formulario de medicamentos fue actualizado 08/24/206. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al o, para aquellos que utilizan TTY, al 7, de lunes a viernes, de 8:00 AM a 8:00 PM o visite 此處方集更新於 206 年 08 月 24 日 如需更多最新的資訊或有其他問題, 請聯絡 會員服務部, 電話 : ,TTY 使用者請撥 7, 週一到週五, 早上 8:00 到晚上 8:00, 或造訪

222 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/24/206. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday Friday from 8:00 AM to 8:00 PM or visit Any questions? Call toll free (TTY for the hearing impaired 7) 8 am 8 pm, Monday Friday 250 Broadway, th floor, New York, NY 000