2016 Abridged Formulary (Partial List of Covered Drugs)

Transcription

1 2016 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN , 2 This abridged formulary was updated on 11/01/2016. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact us, Stanford Health Care Advantage Member Services, at or, for TTY users, 711, seven days a week from 8 am to 8 pm or visit H2986_PD_200_Accepted 2015

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

11 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals Formulary ID: Version: 2

12 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml (Acetaminophen with Codeine) 2 GC; QL (2700 per 30 acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml (Acetaminophen with Codeine) 2 GC; QL (2700 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (360 per 30 mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (180 per 30 mg No.3) butalbital-acetaminophen-caff oral capsule mg (Esgic) 2 GC; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) 2 GC; QL (180 per 30 CAPITAL WITH CODEINE ORAL QL (2700 per 30 SUSPENSION /5 ML CONZIP ORAL CAPSULE,ER QL (30 per 30 BIPHASE 2 HR CONZIP ORAL CAPSULE,ER QL (30 per 30 BIPHASE 2 HR , 200 DILAUDID ORAL LIQUID 1 QL (1200 per 30 /ML DILAUDID ORAL TABLET 2, QL (180 per 30 DILAUDID ORAL TABLET 8 QL (20 per 30 DOLOPHINE ORAL TABLET 10 QL (360 per 30, 5 DURAGESIC TRANSDERMAL 5 QL (10 per 30 PATCH 72 HOUR 100 MCG/HR, 75 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR QL (10 per 30 endocet oral tablet mg, mg, mg (Percocet) 2 GC; QL (360 per 30 3 Formulary ID: Version: 2

13 ESGIC ORAL TABLET QL (180 per 30 EXALGO ER ORAL TABLET EXTENDED RELEASE 2 HR 12, 16, 8 PA; QL (30 per 30 EXALGO ER ORAL TABLET EXTENDED RELEASE 2 HR 32 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour HYCET ORAL SOLUTION /15 ML hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg PA; QL (60 per 30 (Duragesic) 2 GC; QL (10 per 30 QL (2700 per 30 (Hycet) 2 GC; QL (2700 per 30 (Norco) 2 GC; (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 (Norco) 2 GC; QL (360 per 30 hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) 2 GC hydromorphone oral liquid 1 mg/ml (Dilaudid) 2 GC; QL (1200 per 30 hydromorphone oral tablet 2 mg, mg (Dilaudid) 2 GC; QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) 2 GC; QL (20 per 30 hydromorphone oral tablet extended release 2 hr 12 mg, 16 mg, 8 mg (Exalgo) 2 PA; GC; QL (30 per 30 hydromorphone oral tablet extended release 2 hr 32 mg (Exalgo) 2 PA; GC; QL (60 per 30 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10, 20, 30, 0, 50, 60, 80 ST; QL (60 per 30 Formulary ID: Version: 2

14 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 100 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 lorcet (hydrocodone) oral tablet mg 5 ST; QL (60 per 30 5 ST; QL (120 per 30 (Norco) 2 GC; QL (360 per 30 lorcet hd oral tablet mg (Norco) 2 GC; QL (360 per 30 lorcet plus oral tablet mg (Norco) 2 GC; QL (360 per 30 LORTAB ORAL TABLET QL (360 per LORTAB ORAL TABLET QL (360 per 30 LORTAB ORAL TABLET QL (360 per methadone injection solution 10 mg/ml (Methadone HCl) 2 GC methadone oral solution 10 mg/5 ml, 5 mg/5 ml (Methadone HCl) 2 GC; QL (1800 per 30 methadone oral tablet 10 mg, 5 mg (Dolophine HCl) 2 GC; QL (360 per 30 morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) 2 GC morphine 2 mg/ml carpuject outer, (Morphine Sulfate) 2 GC latex-f, p/f 2 mg/ml morphine mg/ml carpuject (Morphine Sulfate) 2 GC outer,latex-free,p/f mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) 2 GC morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) (Morphine Sulfate) 2 GC; QL (200 per 30 morphine intravenous syringe 10 mg/ml, 2 (Morphine Sulfate) 2 GC mg/ml, mg/ml, 8 mg/ml morphine oral capsule, er multiphase 2 hr 120 mg, 30 mg, 5 mg, 60 mg, 75 mg (Avinza) 2 ST; GC; QL (30 per 30 morphine oral capsule, er multiphase 2 hr 90 mg (Avinza) 2 ST; GC; QL (60 per 30 5 Formulary ID: Version: 2

15 morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral capsule,extend.release pellets 100 mg (Kadian) 2 ST; GC; QL (60 per 30 (Kadian) 5 ST; QL (60 per 30 morphine oral solution 10 mg/5 ml (Morphine Sulfate) 2 GC; QL (700 per 30 morphine oral solution 20 mg/5 ml ( mg/ml) (Morphine Sulfate) 2 GC; QL (300 per 30 MORPHINE ORAL TABLET 15, 30 QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) 2 GC; QL (120 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg (MS Contin) 2 GC; QL (180 per 30 MS CONTIN ORAL TABLET QL (120 per 30 EXTENDED RELEASE 100, 30, 60 MS CONTIN ORAL TABLET QL (180 per 30 EXTENDED RELEASE 15, 200 NORCO ORAL TABLET , QL (360 per , oxycodone oral capsule 5 mg (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral concentrate 20 mg/ml (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) 2 GC; QL (1300 per 30 oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg (Roxicodone) 2 GC; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 0 mg, (Oxycontin) 2 GC; QL (60 per mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg (Oxycontin) 5 QL (120 per 30 6 Formulary ID: Version: 2

16 oxycodone-acetaminophen oral solution mg/5 ml (Oxycodone HCl/Acetaminophen) 2 GC; QL (1800 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, (Percocet) 2 GC; QL (360 per mg OXYCONTIN ORAL 3 QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 10, 15, 20, 30, 0, 60 OXYCONTIN ORAL 3 QL (120 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 80 PERCOCET ORAL TABLET QL (360 per 30, , 5-325, PRIMLEV ORAL TABLET QL (390 per 30, 5-300, ROXICODONE ORAL TABLET 15 QL (180 per 30, 30, 5 SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL PA; QL (120 per 30 MCG/SPRAY, 200 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY tramadol hcl er 300 mg tablet 300 mg (Ultram ER) 2 GC; QL (30 per 30 tramadol oral capsule,er biphase 2 hr mg (Conzip) 2 GC; QL (30 per 30 tramadol oral capsule,er biphase 2 hr mg, 200 mg (Conzip) 2 GC; QL (30 per 30 tramadol oral tablet 50 mg (Ultram) 2 GC; QL (20 per 30 tramadol oral tablet extended release 2 hr 100 mg (Ultram ER) 2 GC; QL (90 per 30 tramadol oral tablet extended release 2 hr 200 mg (Ultram ER) 2 GC; QL (30 per 30 7 Formulary ID: Version: 2

17 tramadol oral tablet, er multiphase 2 hr 300 mg (Ultram ER) 2 GC; QL (30 per 30 TYLENOL-CODEINE #3 ORAL QL (360 per 30 TABLET TYLENOL-CODEINE # ORAL QL (180 per 30 TABLET ULTRAM ER ORAL TABLET QL (30 per 30 EXTENDED RELEASE 2 HR 300 ULTRAM ORAL TABLET 50 QL (20 per 30 vicodin es oral tablet mg (Norco) 2 GC; (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 vicodin hp oral tablet mg (Norco) 2 GC; (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 vicodin oral tablet mg (Norco) 2 GC; (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 XARTEMIS XR ORAL TAB,ORAL 3 QL (360 per 30 ONLY,IR - ER, BIPHASE XODOL 10/300 ORAL TABLET QL (390 per XODOL 5/300 ORAL TABLET QL (390 per 30 XODOL 7.5/300 ORAL TABLET QL (390 per ZAMICET ORAL SOLUTION QL (2700 per 30 /15 ML zebutal oral capsule mg (Esgic) 2 GC; QL (180 per 30 8 Formulary ID: Version: 2

18 Nonsteroidal Anti-Inflammatory Agents CELEBREX ORAL CAPSULE 100 QL (60 per 30, 200, 00, 50 celecoxib oral capsule 100 mg, 200 mg, 00 mg, 50 mg (Celebrex) 2 GC; QL (60 per 30 diclofenac sodium oral tablet extended (Voltaren-XR) 2 GC release 2 hr 100 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) 2 GC release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical drops 1.5 % (Pennsaid) 2 GC diclofenac sodium topical gel 1 % (Voltaren) 2 GC diclofenac sodium topical gel 3 % (Voltaren) 5 EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) 375, 500 etodolac oral capsule 200 mg, 300 mg (Etodolac) 2 GC etodolac oral tablet 00 mg, 500 mg (Etodolac) 2 GC etodolac oral tablet extended release 2 (Etodolac) 2 GC hr 00 mg, 500 mg, 600 mg ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) 2 GC ibuprofen oral tablet 00 mg, 600 mg, (Ibuprofen) 1 GC 800 mg INDOCIN ORAL SUSPENSION 25 /5 ML indomethacin oral capsule 25 mg (Indomethacin) 2 GC; QL (20 per 30 indomethacin oral capsule 50 mg (Indomethacin) 2 GC; QL (120 per 30 indomethacin oral capsule, extended release 75 mg (Indomethacin) 2 GC; QL (60 per 30 meloxicam oral suspension 7.5 mg/5 ml (Mobic) 2 GC meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 1 GC MOBIC ORAL TABLET 15, 7.5 nabumetone oral tablet 500 mg, 750 mg (Nabumetone) 2 GC 9 Formulary ID: Version: 2

19 NAPROSYN ORAL TABLET 500 naproxen oral suspension 125 mg/5 ml (Naprosyn) 2 GC naproxen oral tablet 250 mg, 375 mg, 500 (Naprosyn) 1 GC mg naproxen oral tablet,delayed release (Ec-Naprosyn) 2 GC (dr/ec) 375 mg, 500 mg PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 /GRAM /ACTUATION(2 %) SOLARAZE TOPICAL GEL 3 % 5 VOLTAREN TOPICAL GEL 1 % 3 Anesthetics Local Anesthetics lidocaine 2% viscous soln 2 % (Xylocaine) 2 GC lidocaine hcl injection solution 20 mg/ml (Xylocaine) 2 GC (2 %) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) 2 GC lidocaine hcl mucous membrane solution (Xylocaine) 2 GC 2 %, % (0 mg/ml) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) 2 GC LIDODERM TOPICAL ADHESIVE PA PATCH,MEDICATED 5 % XYLOCAINE INJECTION SOLUTION 20 /ML (2 %) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents BUNAVAIL BUCCAL FILM PA; QL (30 per 30 BUNAVAIL BUCCAL FILM.2-0.7, PA; QL (60 per Formulary ID: Version: 2

20 buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg CHANTIX ORAL TABLET 0.5, 1 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 (11)- 1 (2) SUBOXONE SUBLINGUAL FILM 12-3 SUBOXONE SUBLINGUAL FILM 2-0.5, -1, 8-2 ZUBSOLV SUBLINGUAL TABLET , , , , Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 /ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 2 hr 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 2 hr 3 mg alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg ATIVAN ORAL TABLET 0.5, 1, 2 (Buprenorphine HCl) 2 PA; GC; QL (90 per 30 (Buprenorphine 2 PA; GC; QL (90 per 30 HCl/Naloxone HCl) 3 QL (168 per 8 3 QL (53 per 28 PA; QL (60 per 30 PA; QL (90 per 30 3 PA; QL (90 per 30 QL (300 per 30 (Xanax) 2 GC; QL (120 per 30 (Xanax XR) 2 GC; QL (120 per 30 (Xanax XR) 2 GC; QL (90 per 30 (Alprazolam) 2 GC; QL (120 per 30 QL (90 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 2 GC; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) 2 GC; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) 2 GC; QL (90 per Formulary ID: Version: 2

21 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) 2 GC; QL (300 per 30 KLONOPIN ORAL TABLET 0.5, QL (90 per 30 1 KLONOPIN ORAL TABLET 2 QL (300 per 30 lorazepam intensol oral concentrate 2 mg/ml (Ativan) 2 GC; QL (150 per 30 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan) 2 GC; QL (90 per 30 XANAX ORAL TABLET 0.25, QL (120 per , 1, 2 XANAX XR ORAL TABLET QL (120 per 30 EXTENDED RELEASE 2 HR 0.5, 1, 2 XANAX XR ORAL TABLET QL (90 per 30 EXTENDED RELEASE 2 HR 3 Antibacterials Aminoglycosides gentamicin injection solution 0 mg/ml (Gentamicin Sulfate) 2 GC neomycin oral tablet 500 mg (Neomycin Sulfate) 2 GC TOBI INHALATION SOLUTION 5 PA BvD FOR NEBULIZATION 300 /5 ML tobramycin in % nacl inhalation (Tobi) 5 PA BvD solution for nebulization 300 mg/5 ml Antibacterials, Miscellaneous CLEOCIN ORAL CAPSULE 150, 300, 75 CLEOCIN ORAL RECON SOLN 75 /5 ML clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) 2 GC clindamycin hcl oral capsule 150 mg, 300 (Cleocin HCl) 2 GC mg, 75 mg clindamycin pediatric oral recon soln 75 (Cleocin Palmitate) 2 GC mg/5 ml FLAGYL ORAL CAPSULE Formulary ID: Version: 2

22 FLAGYL ORAL TABLET 250, 500 MACROBID ORAL CAPSULE 100 QL (120 per 30 MACRODANTIN ORAL CAPSULE QL (120 per , 25, 50 metronidazole oral capsule 375 mg (Flagyl) 2 GC metronidazole oral tablet 250 mg, 500 mg (Flagyl) 2 GC nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg (Macrodantin/Macrobi d) 2 GC; QL (120 per 30 nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) 2 GC; QL (120 per 30 nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrobid) 2 GC; QL (120 per 30 trimethoprim oral tablet 100 mg (Trimethoprim) 2 GC VANCOCIN ORAL CAPSULE 125 5, 250 vancomycin intravenous recon soln 1,000 (Vancomycin HCl) 2 GC mg, 10 gram vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) 5 XIFAXAN ORAL TABLET PA; QL (9 per 30 XIFAXAN ORAL TABLET PA Cephalosporins cefadroxil oral capsule 500 mg (Cefadroxil) 2 GC cefadroxil oral suspension for (Cefadroxil) 2 GC reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) 2 GC cefdinir oral capsule 300 mg (Cefdinir) 2 GC cefdinir oral suspension for reconstitution (Cefdinir) 2 GC 125 mg/5 ml, 250 mg/5 ml cefpodoxime oral suspension for (Cefpodoxime Proxetil) 2 GC reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg (Cefpodoxime Proxetil) 2 GC cefprozil oral suspension for (Cefprozil) 2 GC reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg (Cefprozil) 2 GC 13 Formulary ID: Version: 2

23 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 /5 ML, 250 /5 ML CEFTIN ORAL TABLET 500 ceftriaxone 1 gm vial 10's, fliptop,l/f 1 (Rocephin) 2 GC gram ceftriaxone injection recon soln 10 gram, (Rocephin) 2 GC 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 (Ceftin) 2 GC mg cephalexin oral capsule 250 mg, 500 mg, (Keflex) 1 GC 750 mg cephalexin oral suspension for (Cephalexin) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 1 GC Macrolides azithromycin intravenous recon soln 500 (Zithromax) 2 GC mg azithromycin oral packet 1 gram (Zithromax) 2 GC azithromycin oral suspension for (Zithromax) 2 GC reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (Zithromax) 2 GC (6 pack), 500 mg, 600 mg BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 /5 ML BIAXIN ORAL TABLET 250, 500 clarithromycin oral suspension for (Biaxin) 2 GC reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 (Biaxin) 2 GC mg clarithromycin oral tablet extended (Clarithromycin) 2 GC release 2 hr 500 mg ZITHROMAX INTRAVENOUS RECON SOLN Formulary ID: Version: 2

24 ZITHROMAX ORAL PACKET 1 GRAM ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 100 /5 ML, 200 /5 ML ZITHROMAX ORAL TABLET 250, 500, 600 ZITHROMAX TRI-PAK ORAL TABLET 500 ZITHROMAX Z-PAK ORAL TABLET 250 ZMAX ORAL SUSPENSION,EXTENDED REL RECON 2 GRAM/60 ML Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION 5 LA SOLUTION FOR NEBULIZATION 75 /ML INVANZ INJECTION RECON SOLN 1 GRAM Penicillins amoxicillin oral capsule 250 mg, 500 mg (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 00 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) 1 GC 250 mg amoxicillin-pot clavulanate oral (Augmentin) 2 GC suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg (Augmentin) 2 GC 15 Formulary ID: Version: 2

25 amoxicillin-pot clavulanate oral tablet (Augmentin XR) 2 GC extended release 12 hr 1, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium 2 GC tablet,chewable mg, mg Clav) ampicillin oral capsule 250 mg, 500 mg (Ampicillin Trihydrate) 1 GC ampicillin oral suspension for (Ampicillin Trihydrate) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION /5 ML dicloxacillin oral capsule 250 mg, 500 mg (Dicloxacillin Sodium) 2 GC MOXATAG ORAL TABLET, ER MULTIPHASE 2 HR 775 penicillin v potassium oral recon soln 125 (Penicillin V 2 GC mg/5 ml, 250 mg/5 ml Potassium) penicillin v potassium oral tablet 250 mg, (Penicillin V 2 GC 500 mg Potassium) Quinolones AVELOX ABC PACK ORAL TABLET 00 AVELOX ORAL TABLET 00 CIPRO ORAL TABLET 250, 500 ciprofloxacin hcl oral tablet 100 mg, 250 (Cipro) 1 GC mg, 500 mg, 750 mg LEVAQUIN ORAL TABLET 250, 500, 750 levofloxacin intravenous solution 25 (Levofloxacin) 2 GC mg/ml levofloxacin oral solution 250 mg/10 ml (Levaquin) 2 GC levofloxacin oral tablet 250 mg, 500 mg, (Levaquin) 1 GC 750 mg moxifloxacin oral tablet 00 mg (Avelox) 2 GC 16 Formulary ID: Version: 2

26 Sulfonamides AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 AZULFIDINE ORAL TABLET 500 BACTRIM DS ORAL TABLET BACTRIM ORAL TABLET sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri 2 GC intravenous solution mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri 2 GC suspension mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet mg, mg sulfasalazine oral tablet 500 mg (Azulfidine) 2 GC sulfasalazine oral tablet,delayed release (Azulfidine) 2 GC (dr/ec) 500 mg Tetracyclines doxycycline hyclate oral capsule 100 mg (Adoxa) 2 GC doxycycline hyclate oral tablet 100 mg, (Avidoxy) 2 GC 50 mg doxycycline mono 100 mg cap 100 mg (Adoxa) 2 GC doxycycline mono 100 mg tablet f/c 100 (Avidoxy) 2 GC mg doxycycline mono 50 mg tablet 50 mg (Avidoxy) 2 GC doxycycline monohydrate oral capsule (Adoxa) 2 GC 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension (Vibramycin) 2 GC for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 (Avidoxy) 2 GC mg, 75 mg MINOCIN ORAL CAPSULE 100, Formulary ID: Version: 2

27 minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg minocycline oral tablet extended release 2 hr 135 mg, 5 mg, 90 mg ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE 0 SOLODYN ORAL TABLET EXTENDED RELEASE 2 HR 105, 115, 55, 65, 80 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 25 /5 ML Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2, 3, 5 (Minocin) 2 GC (Minocycline HCl) 2 GC (Minocycline HCl) 2 GC 5 5 PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 5 PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5, 5, PA NSO; QL (28 per 28 anastrozole oral tablet 1 mg (Arimidex) 2 GC ARIMIDEX ORAL TABLET 1 AROMASIN ORAL TABLET 25 bexarotene oral capsule 75 mg (Targretin) 5 PA NSO; QL (20 per 30 bicalutamide oral tablet 50 mg (Casodex) 2 GC CASODEX ORAL TABLET 50 DROXIA ORAL CAPSULE 200, 3 300, 00 ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 QL (1 per 8 18 Formulary ID: Version: 2

28 ELIGARD ( MONTH) QL (1 per 112 SUBCUTANEOUS SYRINGE 30 ELIGARD (6 MONTH) QL (1 per 168 SUBCUTANEOUS SYRINGE 5 ELIGARD SUBCUTANEOUS SYRINGE 7.5 (1 MONTH) ERIVEDGE ORAL CAPSULE PA NSO; QL (30 per 30 exemestane oral tablet 25 mg (Aromasin) 2 GC FARESTON ORAL TABLET 60 5 FEMARA ORAL TABLET 2.5 flutamide oral capsule 125 mg (Flutamide) 2 GC GLEEVEC ORAL TABLET PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 00 5 PA NSO; QL (60 per 30 HYDREA ORAL CAPSULE 500 hydroxyurea oral capsule 500 mg (Hydrea) 2 GC imatinib oral tablet 100 mg (Gleevec) 5 PA NSO; QL (90 per 30 imatinib oral tablet 00 mg (Gleevec) 5 PA NSO; QL (60 per 30 INLYTA ORAL TABLET 1 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 5 PA NSO; QL (60 per 30 JAKAFI ORAL TABLET 10, 15, 20, 25, 5 5 PA NSO; QL (60 per 30 letrozole oral tablet 2.5 mg (Femara) 2 GC LEUKERAN ORAL TABLET 2 leuprolide subcutaneous kit 1 mg/0.2 ml (Leuprolide Acetate) 2 GC LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25, QL (1 per 8 19 Formulary ID: Version: 2

29 LUPRON DEPOT ( MONTH) 5 QL (1 per 8 INTRAMUSCULAR SYRINGE KIT 30 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 INTRAMUSCULAR SYRINGE KIT 5 LUPRON DEPOT 5 INTRAMUSCULAR SYRINGE KIT 3.75, 7.5 LYSODREN ORAL TABLET megestrol oral tablet 20 mg, 0 mg (Megestrol Acetate) 2 GC mercaptopurine oral tablet 50 mg (Mercaptopurine) 2 GC methotrexate 50 mg/2 ml vial latex-free, (Methotrexate Sodium) 2 PA BvD; GC 5's, mdv 25 mg/ml methotrexate sodium (pf) injection (Methotrexate Sodium) 2 PA BvD; GC solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg (Methotrexate Sodium) 2 PA BvD; ST; GC NEXAVAR ORAL TABLET PA NSO; QL (120 per 30 paclitaxel intravenous concentrate 6 (Paclitaxel) 2 GC mg/ml POMALYST ORAL CAPSULE 1, 2, 3, 5 PA NSO; QL (21 per 28 PURIXAN ORAL SUSPENSION 20 5 /ML REVLIMID ORAL CAPSULE 10 5 PA NSO; LA, 15, 2.5, 20, 25, 5 RHEUMATREX ORAL PA BvD; ST TABLETS,DOSE PACK 2.5, 2.5 (DOSE PACK 12), 2.5 (DOSE PACK 16), 2.5 (DOSE PACK 20), 2.5 (DOSE PACK 8) SOLTAMOX ORAL SOLUTION 10 /5 ML SPRYCEL ORAL TABLET 100, 10, 50, 70, 80 5 PA NSO; QL (30 per Formulary ID: Version: 2

30 SPRYCEL ORAL TABLET 20 5 PA NSO; QL (60 per 30 STIVARGA ORAL TABLET 0 5 PA NSO; QL (8 per 28 SUTENT ORAL CAPSULE 12.5, 25, 37.5, 50 5 PA NSO; QL (30 per 30 tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) 2 GC TARCEVA ORAL TABLET 100, 25 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET PA NSO; QL (90 per 30 TARGRETIN ORAL CAPSULE 75 5 PA NSO; QL (20 per 30 TARGRETIN TOPICAL GEL 1 % 5 PA NSO; QL (60 per 28 TASIGNA ORAL CAPSULE 150, PA NSO; QL (112 per 28 tretinoin (chemotherapy) oral capsule 10 (Tretinoin) 5 (capsule: 10mg) mg TREXALL ORAL TABLET 10, PA BvD; ST 15, 5, 7.5 TYKERB ORAL TABLET VOTRIENT ORAL TABLET PA NSO; QL (120 per 30 XALKORI ORAL CAPSULE 200, PA NSO; QL (60 per 30 XTANDI ORAL CAPSULE 0 5 PA NSO; QL (120 per 30 ZELBORAF ORAL TABLET 20 5 PA NSO; QL (20 per 30 ZYTIGA ORAL TABLET PA NSO; QL (120 per Formulary ID: Version: 2

31 Anticholinergic Agents Antimuscarinics/Antispasmod ics atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) 2 GC mg/ml propantheline oral tablet 15 mg (Propantheline 2 GC Bromide) STIOLTO RESPIMAT 3 QL ( per 28 INHALATION MIST MCG/ACTUATION Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) 2 GC multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 (Tegretol) 2 GC ml carbamazepine oral tablet 200 mg (Tegretol) 2 GC carbamazepine oral tablet extended (Tegretol XR) 2 GC release 12 hr 100 mg, 200 mg, 00 mg carbamazepine oral tablet,chewable 100 (Carbamazepine) 2 GC mg CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100, 200, 300 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 2 HR 250, 500 DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125, 250, 500 DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE 125 DILANTIN EXTENDED ORAL CAPSULE 100 DILANTIN ORAL CAPSULE 30 2 GC divalproex oral capsule, sprinkle 125 mg (Depakote Sprinkle) 2 GC 22 Formulary ID: Version: 2

32 divalproex oral tablet extended release 2 (Depakote ER) 2 GC hr 250 mg, 500 mg divalproex oral tablet,delayed release (Depakote) 2 GC (dr/ec) 125 mg, 250 mg, 500 mg epitol oral tablet 200 mg (Tegretol) 2 GC EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100, 200, 300 gabapentin oral capsule 100 mg, 300 mg, (Neurontin) 2 GC 00 mg gabapentin oral solution 250 mg/5 ml (Neurontin) 2 GC gabapentin oral tablet 600 mg, 800 mg (Neurontin) 2 GC GRALISE 30-DAY STARTER PACK ST; QL (78 per 30 ORAL TABLET EXTENDED RELEASE 2 HR 300 (9)- 600 (69) GRALISE ORAL TABLET ST; QL (90 per 30 EXTENDED RELEASE 2 HR 300, 600 KEPPRA ORAL SOLUTION 100 /ML KEPPRA ORAL TABLET 1,000, 250, 500, 750 KEPPRA XR ORAL TABLET EXTENDED RELEASE 2 HR 500, 750 LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100, 200, 25, 50 LAMICTAL ORAL TABLET 100, 150, 200, 25 LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25, 5 LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 (35) 23 Formulary ID: Version: 2

33 LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 (8) -100 (1) LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 (2) -100 (7) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 2HR 100, 200, 25, 250, 300, 50 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 (21) -50 (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 (1)-100 (1)-200 (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25 (1)-50 (1)-100 (7) lamotrigine oral tablet 100 mg, 150 mg, (Lamictal) 2 GC 200 mg, 25 mg lamotrigine oral tablet extended release (Lamictal XR) 2 GC 2hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable (Lamictal) 2 GC dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 (Lamictal Odt) 2 GC mg, 200 mg, 25 mg, 50 mg levetiracetam intravenous solution 500 (Keppra) 2 GC mg/5 ml levetiracetam oral solution 100 mg/ml (Keppra) 2 GC levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Keppra) 2 GC 2 Formulary ID: Version: 2

34 levetiracetam oral tablet extended release (Keppra XR) 2 GC 2 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100, 3 QL (90 per , 200, 225, 25, 300, 50, 75 LYRICA ORAL SOLUTION 20 3 QL (900 per 30 /ML NEURONTIN ORAL CAPSULE 100, 300, 00 NEURONTIN ORAL SOLUTION 250 /5 ML NEURONTIN ORAL TABLET 600, 800 PHENYTEK ORAL CAPSULE GC, 300 phenytoin sodium extended oral capsule (Dilantin) 2 GC 100 mg, 200 mg, 300 mg QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 2HR 100, 150, 200, 25, 50 ROWEEPRA ORAL TABLET GC SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION 1,000 SPRITAM ORAL TABLET FOR SUSPENSION 250, 500, 750 ST; QL (120 per 30 TEGRETOL ORAL SUSPENSION 100 /5 ML TEGRETOL ORAL TABLET 200 TEGRETOL XR ORAL TABLET 3 EXTENDED RELEASE 12 HR 100 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 200, Formulary ID: Version: 2

35 TOPAMAX ORAL CAPSULE, SPRINKLE 15, 25 TOPAMAX ORAL TABLET 100, 200, 25, 50 topiramate oral capsule, sprinkle 15 mg, (Topamax) 2 GC 25 mg topiramate oral capsule,sprinkle,er 2hr (Qudexy XR) 2 GC 100 mg, 150 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 100 mg, 200 mg, (Topamax) 2 GC 25 mg, 50 mg TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 2HR 100, 200, 25, 50 Antidementia Agents Antidementia Agents ARICEPT ORAL TABLET 10, 23 QL (30 per 30, 5 donepezil oral tablet 10 mg, 23 mg, 5 mg (Aricept) 2 GC; QL (30 per 30 donepezil oral tablet,disintegrating 10 mg, 5 mg (Donepezil HCl) 2 GC; QL (30 per 30 memantine oral solution 2 mg/ml (Namenda) 2 GC; QL (360 per 30 memantine oral tablet 10 mg, 5 mg (Namenda) 2 GC; QL (60 per 30 memantine oral tablets,dose pack 5-10 mg (Namenda) 2 GC; QL (9 per 28 NAMENDA ORAL SOLUTION 2 QL (360 per 30 /ML NAMENDA ORAL TABLET 10, QL (60 per 30 5 NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 5-10 QL (9 per Formulary ID: Version: 2

36 NAMENDA XR ORAL 3 QL (28 per 28 CAP,SPRINKLE,ER 2HR DOSE PACK NAMENDA XR ORAL 3 QL (30 per 30 CAPSULE,SPRINKLE,ER 2HR 1, 21, 28, 7 Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Amitriptyline HCl) 2 GC bupropion hcl (smoking deter) oral tablet (Wellbutrin SR) 2 GC extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release (Wellbutrin XL) 2 GC 2 hr 150 mg, 300 mg CELEXA ORAL TABLET 10, 20, 0 QL (30 per 30 citalopram oral solution 10 mg/5 ml (Citalopram 2 GC Hydrobromide) citalopram oral tablet 10 mg, 20 mg, 0 mg (Celexa) 1 GC; QL (30 per 30 CYMBALTA ORAL QL (60 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 20, 60 CYMBALTA ORAL QL (30 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 30 duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Duloxetine) 2 GC; (Cymbalta); QL (60 per 30 duloxetine oral capsule,delayed release(dr/ec) 30 mg (Duloxetine) 2 GC; (Cymbalta); QL (30 per 30 duloxetine oral capsule,delayed release(dr/ec) 0 mg (Duloxetine) 2 GC; (Irenka); QL (30 per Formulary ID: Version: 2

37 EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 2HR 150, 37.5, 75 escitalopram oxalate oral solution 5 mg/5 (Lexapro) 2 GC ml escitalopram oxalate oral tablet 10 mg, (Lexapro) 2 GC 20 mg, 5 mg fluoxetine oral capsule 10 mg, 20 mg, 0 (Prozac) 1 GC mg fluoxetine oral capsule,delayed (Prozac Weekly) 2 GC release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml ( (Fluoxetine HCl) 2 GC mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 2 GC FLUOXETINE ORAL TABLET 60 FORFIVO XL ORAL TABLET EXTENDED RELEASE 2 HR 50 IRENKA ORAL QL (30 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 0 LEXAPRO ORAL SOLUTION 5 /5 ML LEXAPRO ORAL TABLET 10, 20, 5 paroxetine hcl oral tablet 10 mg, 20 mg, (Paxil) 2 GC 30 mg, 0 mg paroxetine hcl oral tablet extended (Paxil CR) 2 GC release 2 hr 12.5 mg, 25 mg, 37.5 mg PAXIL CR ORAL TABLET EXTENDED RELEASE 2 HR 25, 37.5 PAXIL ORAL SUSPENSION 10 /5 ML PAXIL ORAL TABLET 10, 20, 30, 0 28 Formulary ID: Version: 2

38 PROZAC ORAL CAPSULE 10, 20, 0 PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 90 SARAFEM ORAL TABLET 10, 20 sertraline oral concentrate 20 mg/ml (Zoloft) 2 GC sertraline oral tablet 100 mg, 25 mg, 50 (Zoloft) 1 GC mg trazodone oral tablet 100 mg, 150 mg, (Trazodone HCl) 1 GC 300 mg, 50 mg venlafaxine oral capsule,extended release (Effexor XR) 2 GC 2hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, (Venlafaxine HCl) 2 GC 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 2 GC 2hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 3 2hr 225 mg WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 100, 150, 200 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 2 HR 150, 300 ZOLOFT ORAL CONCENTRATE 20 /ML ZOLOFT ORAL TABLET 100, 25, 50 Antidiabetic Agents Antidiabetic Agents, Miscellaneous ACTOS ORAL TABLET 15, 30, 5 QL (30 per Formulary ID: Version: 2

39 BYDUREON SUBCUTANEOUS PEN INJECTOR 2 /0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2. ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML FORTAMET ORAL TABLET EXTENDED RELEASE 2HR 1,000 FORTAMET ORAL TABLET EXTENDED RELEASE 2HR 500 GLUCOPHAGE ORAL TABLET 1,000 GLUCOPHAGE ORAL TABLET 500 GLUCOPHAGE ORAL TABLET 850 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 2 HR 500 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 2 HR 750 GLUMETZA ORAL TABLET,ER GAST.RETENTION 2 HR 1,000 GLUMETZA ORAL TABLET,ER GAST.RETENTION 2 HR 500 JANUMET ORAL TABLET 50-1,000, ST; QL ( per 28 ST; QL ( per 28 ST; QL (2. per 28 ST; QL (1.2 per 28 QL (60 per 30 QL (150 per 30 QL (75 per 30 QL (150 per 30 QL (90 per 30 QL (120 per 30 QL (60 per 30 QL (60 per 30 QL (120 per Formulary ID: Version: 2

40 JANUMET XR ORAL TABLET, ER 3 MULTIPHASE 2 HR 100-1,000, 50-1,000, JANUVIA ORAL TABLET 100, 3 25, 50 metformin oral tablet 1,000 mg (Glucophage) 1 GC; QL (75 per 30 metformin oral tablet 500 mg (Glucophage) 1 GC; QL (150 per 30 metformin oral tablet 850 mg (Glucophage) 1 GC; QL (90 per 30 metformin oral tablet extended release 2 hr 500 mg (Glucophage XR) 2 GC; QL (120 per 30 metformin oral tablet extended release 2 hr 750 mg (Glucophage XR) 2 GC; QL (90 per 30 metformin oral tablet extended release 2hr 1,000 mg (Glucophage XR) 2 GC; QL (60 per 30 ONGLYZA ORAL TABLET 2.5, QL (30 per 30 5 pioglitazone oral tablet 15 mg, 30 mg, 5 mg (Actos) 2 GC; QL (30 per 30 RIOMET ORAL SOLUTION 500 /5 ML QL (765 per 30 TRADJENTA ORAL TABLET 5 3 VICTOZA 3 Insulins HUMALOG 100 UNITS/ML CARTRIDGE 5'S, OUTER 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 6 GC; QL (30 per 28 6 GC; QL (30 per 28 6 GC; QL (12 per 28 6 GC; QL (0 per Formulary ID: Version: 2

41 HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas AMARYL ORAL TABLET 1, 2 6 GC; QL (30 per 28 6 GC 6 GC 6 GC; QL (30 per 28 6 GC; QL (30 per 28 6 GC; QL (0 per 28 6 GC QL (30 per 30 AMARYL ORAL TABLET QL (60 per 30 glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 GC; QL (30 per 30 glimepiride oral tablet mg (Amaryl) 1 GC; QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) 1 GC; QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) 1 GC; QL (60 per 30 glipizide oral tablet extended release 2hr 10 mg (Glucotrol XL) 2 GC; QL (60 per 30 glipizide oral tablet extended release 2hr 2.5 mg, 5 mg (Glucotrol XL) 2 GC; QL (30 per 30 GLUCOTROL ORAL TABLET 10 QL (120 per Formulary ID: Version: 2

42 GLUCOTROL ORAL TABLET 5 QL (30 per 30 GLUCOTROL XL ORAL TABLET QL (60 per 30 EXTENDED RELEASE 2HR 10 GLUCOTROL XL ORAL TABLET QL (30 per 30 EXTENDED RELEASE 2HR 2.5, 5 glyburide oral tablet 1.25 mg, 2.5 mg, 5 (Glyburide) 2 GC mg Antifungals Antifungals ciclopirox topical gel 0.77 % (Loprox) 2 GC ciclopirox topical shampoo 1 % (Loprox) 2 GC ciclopirox topical solution 8 % (Penlac) 2 GC clotrimazole mucous membrane troche 10 (Clotrimazole) 2 GC mg clotrimazole topical cream 1 % (Clotrimazole) 2 GC clotrimazole topical solution 1 % (Clotrimazole) 2 GC clotrimazole-betamethasone topical (Lotrisone) 2 GC cream % clotrimazole-betamethasone topical (Clotrimazole/Betamet 2 GC lotion % hasone Dip) DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 10 /ML, 0 /ML DIFLUCAN ORAL TABLET 100, 150, 200, 50 econazole topical cream 1 % (Econazole Nitrate) 2 GC EXTINA TOPICAL FOAM 2 % fluconazole oral suspension for (Diflucan) 2 GC reconstitution 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, (Diflucan) 2 GC 200 mg, 50 mg ketoconazole oral tablet 200 mg (Ketoconazole) 2 GC ketoconazole topical cream 2 % (Ketoconazole) 2 GC ketoconazole topical foam 2 % (Ketoconazole) 2 GC ketoconazole topical shampoo 2 % (Nizoral) 2 GC 33 Formulary ID: Version: 2

43 LAMISIL ORAL TABLET 250 LOPROX TOPICAL SHAMPOO 1 % LOTRISONE TOPICAL CREAM % NIZORAL TOPICAL SHAMPOO 2 % nyamyc topical powder 100,000 (Nystatin) 2 GC unit/gram nystatin oral suspension 100,000 unit/ml (Nystatin) 2 GC nystatin oral tablet 500,000 unit (Nystatin) 2 GC nystatin topical cream 100,000 unit/gram (Nystatin) 2 GC nystatin topical ointment 100,000 (Nystatin) 2 GC unit/gram nystatin topical powder 100,000 (Nystatin) 2 GC unit/gram nystatin-triamcinolone topical cream (Nystatin/Triamcin) 2 GC 100, unit/g-% nystatin-triamcinolone topical ointment (Nystatin/Triamcin) 2 GC 100, unit/gram-% nystop topical powder 100,000 unit/gram (Nystatin) 2 GC terbinafine hcl oral tablet 250 mg (Lamisil) 2 GC Antihistamines Antihistamines CLARINEX ORAL SYRUP 2.5 /5 ML (0.5 /ML) CLARINEX ORAL TABLET 5 cyproheptadine oral syrup 2 mg/5 ml (Cyproheptadine HCl) 2 GC cyproheptadine oral tablet mg (Cyproheptadine HCl) 2 GC desloratadine oral tablet 5 mg (Clarinex) 2 GC desloratadine oral tablet,disintegrating (Desloratadine) 2 GC 2.5 mg, 5 mg levocetirizine oral solution 2.5 mg/5 ml (Xyzal) 2 GC levocetirizine oral tablet 5 mg (Xyzal) 2 GC XYZAL ORAL SOLUTION 2.5 /5 ML XYZAL ORAL TABLET 5 3 Formulary ID: Version: 2

44 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) METROGEL VAGINAL VAGINAL GEL 0.75 % metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) 2 GC NUVESSA VAGINAL GEL 1.3 % TERAZOL 3 VAGINAL CREAM 0.8 % TERAZOL 7 VAGINAL CREAM 0. % terconazole vaginal cream 0. %, 0.8 % (Terazol 7) 2 GC terconazole vaginal suppository 80 mg (Terconazole) 2 GC VANDAZOLE VAGINAL GEL 0.75 % Antimigraine Agents Antimigraine Agents IMITREX ORAL TABLET 100, QL (18 per 28 25, 50 IMITREX STATDOSE KIT REFILL QL ( per 28 SUBCUTANEOUS CARTRIDGE /0.5 ML, 6 /0.5 ML IMITREX SUBCUTANEOUS QL ( per 28 SOLUTION 6 /0.5 ML MAXALT ORAL TABLET 10, 5 QL (18 per 28 MAXALT-MLT ORAL QL (18 per 28 TABLET,DISINTEGRATING 10, 5 ONZETRA XSAIL NASAL QL (16 per 28 AEROSOL POWDR BREATH ACTIVATED 11 RELPAX ORAL TABLET 20, 0 QL (12 per Formulary ID: Version: 2

45 rizatriptan oral tablet 10 mg, 5 mg (Maxalt) 2 GC; QL (18 per 28 rizatriptan oral tablet,disintegrating 10 mg, 5 mg (Maxalt Mlt) 2 GC; QL (18 per 28 sumatriptan 6 mg/0.5 ml syrng (Sumatriptan 2 GC; QL ( per 28 p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg (Imitrex) 2 GC; QL (18 per 28 sumatriptan succinate subcutaneous (Sumatriptan 2 GC; QL ( per 28 cartridge mg/0.5 ml Succinate) sumatriptan succinate subcutaneous (Imitrex) 2 GC; QL ( per 28 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Sumatriptan 2 GC; QL ( per 28 injector mg/0.5 ml Succinate) sumatriptan succinate subcutaneous pen (Sumatriptan 2 GC; QL ( per 28 injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) Succinate) sumatriptan succinate subcutaneous (Imitrex) 2 GC; QL ( per 28 solution 6 mg/0.5 ml SUMAVEL DOSEPRO QL ( per 28 SUBCUTANEOUS NEEDLE-FREE INJECTOR /0.5 ML, 6 /0.5 ML ZEMBRACE SYMTOUCH QL (8 per 28 SUBCUTANEOUS PEN INJECTOR 3 /0.5 ML Antimycobacterials Antimycobacterials dapsone oral tablet 100 mg, 25 mg (Dapsone) 2 GC ethambutol oral tablet 100 mg, 00 mg (Myambutol) 2 GC isoniazid injection solution 100 mg/ml (Isoniazid) 2 GC isoniazid oral solution 50 mg/5 ml (Isoniazid) 2 GC isoniazid oral tablet 100 mg, 300 mg (Isoniazid) 1 GC MYAMBUTOL ORAL TABLET Formulary ID: Version: 2

46 RIFADIN INTRAVENOUS RECON SOLN 600 RIFADIN ORAL CAPSULE 150, 300 rifampin intravenous recon soln 600 mg (Rifadin) 2 GC rifampin oral capsule 150 mg, 300 mg (Rifadin) 2 GC Antinausea Agents Antinausea Agents meclizine oral tablet 12.5 mg, 25 mg (Meclizine HCl) 2 GC ondansetron hcl oral solution mg/5 ml (Zofran) 2 PA BvD; GC ondansetron hcl oral tablet 2 mg, mg, (Zofran) 2 PA BvD; GC 8 mg ondansetron oral tablet,disintegrating (Zofran Odt) 2 PA BvD; GC mg, 8 mg phenadoz rectal suppository 12.5 mg (Phenergan) 2 GC PHENERGAN INJECTION SOLUTION 25 /ML, 50 /ML PHENERGAN RECTAL SUPPOSITORY 12.5, 25, 50 prochlorperazine maleate oral tablet 10 (Compazine) 1 GC mg, 5 mg promethazine injection solution 25 mg/ml (Promethazine HCl) 2 GC promethazine injection solution 50 mg/ml (Phenergan) 2 GC promethazine oral tablet 12.5 mg, 25 mg, (Promethazine HCl) 2 GC 50 mg promethazine rectal suppository 12.5 mg, (Phenergan) 2 GC 25 mg, 50 mg promethegan rectal suppository 25 mg, (Phenergan) 2 GC 50 mg TRANSDERM-SCOP QL (10 per 30 TRANSDERMAL PATCH 3 DAY 1.5 (1 OVER 3 DAYS) ZOFRAN (AS HYDROCHLORIDE) INTRAVENOUS SOLUTION 2 /ML 37 Formulary ID: Version: 2

47 ZOFRAN (AS HYDROCHLORIDE) PA BvD ORAL SOLUTION /5 ML ZOFRAN (AS HYDROCHLORIDE) 5 PA BvD ORAL TABLET, 8 ZOFRAN ODT ORAL 5 PA BvD TABLET,DISINTEGRATING, 8 ZUPLENZ ORAL FILM, 8 PA BvD Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 atovaquone-proguanil oral tablet (Malarone) 2 GC mg, mg hydroxychloroquine oral tablet 200 mg (Plaquenil) 2 GC MALARONE ORAL TABLET MALARONE PEDIATRIC ORAL TABLET mefloquine oral tablet 250 mg (Mefloquine HCl) 2 GC PLAQUENIL ORAL TABLET 200 TINDAMAX ORAL TABLET 500 tinidazole oral tablet 250 mg, 500 mg (Tindamax) 2 GC Antiparkinsonian Agents Antiparkinsonian Agents benztropine injection solution 2 mg/2 ml (Cogentin) 2 GC benztropine oral tablet 0.5 mg, 1 mg, 2 (Benztropine Mesylate) 2 GC mg carbidopa-levodopa oral tablet (Sinemet ) 2 GC mg, mg, mg carbidopa-levodopa oral tablet extended (Sinemet CR) 2 GC release mg, mg carbidopa-levodopa oral tablet,disintegrating mg, mg, mg (Carbidopa/Levodopa) 2 GC 38 Formulary ID: Version: 2

48 COGENTIN INJECTION SOLUTION 2 /2 ML MIRAPEX ER ORAL TABLET EXTENDED RELEASE 2 HR 0.375, 0.75, 1.5, 2.25, 3, 3.75,.5 MIRAPEX ORAL TABLET 0.125, 0.25, 0.5, 0.75, 1, 1.5 pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 2 hr mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg,.5 mg REQUIP ORAL TABLET 0.25, 0.5, 1, 2, 3,, 5 REQUIP XL ORAL TABLET EXTENDED RELEASE 2 HR 12, 2,, 6, 8 ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, mg, 5 mg ropinirole oral tablet extended release 2 hr 12 mg, 2 mg, mg, 6 mg, 8 mg RYTARY ORAL CAPSULE, EXTENDED RELEASE , , , SINEMET CR ORAL TABLET EXTENDED RELEASE , SINEMET ORAL TABLET , , (Mirapex) 2 GC (Mirapex ER) 2 GC (Requip) 2 GC (Requip XL) 2 GC 39 Formulary ID: Version: 2

49 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA 5 INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 ABILIFY MAINTENA 5 QL (1 per 28 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300, 00 ABILIFY ORAL TABLET 10, 15 QL (30 per 30, 20, 30, 5 ABILIFY ORAL TABLET 2 QL (60 per 30 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg (Abilify) 2 GC; QL (30 per 30 aripiprazole oral tablet 2 mg (Abilify) 2 GC; QL (60 per 30 aripiprazole oral tablet,disintegrating 10 mg (Abilify Discmelt) 2 GC; QL (90 per 30 aripiprazole oral tablet,disintegrating 15 mg (Abilify Discmelt) 2 GC; QL (60 per 30 clozapine oral tablet 100 mg (Clozaril) 2 GC; QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) 2 GC; QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) 2 GC; QL (90 per 30 clozapine oral tablet,disintegrating 100 (Fazaclo) 2 ST; GC mg, 12.5 mg, 150 mg, 200 mg, 25 mg CLOZARIL ORAL TABLET 100 QL (270 per 30 CLOZARIL ORAL TABLET 25 QL (90 per 30 FAZACLO ORAL TABLET,DISINTEGRATING 100, 12.5, 25 ST; QL (90 per 30 0 Formulary ID: Version: 2

50 FAZACLO ORAL TABLET,DISINTEGRATING 150 FAZACLO ORAL TABLET,DISINTEGRATING 200 GEODON ORAL CAPSULE 20, 0, 60, 80 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg LATUDA ORAL TABLET 120, 20, 0, 60, 80 olanzapine intramuscular recon soln 10 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 00 mg, 50 mg RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5, 1, 2 RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 3, RISPERDAL ORAL SOLUTION 1 /ML RISPERDAL ORAL TABLET 0.25, 0.5, 1, 2, 3, (Haloperidol) 2 GC ST; QL (180 per 30 ST; QL (120 per 30 QL (60 per 30 (Zyprexa) 2 GC; QL (30 per 30 (Zyprexa) 2 GC; QL (30 per 30 (Zyprexa Zydis) 2 GC; QL (30 per 30 (Zyprexa Zydis) 2 GC; QL (31 per 30 (Seroquel) 2 GC; QL (90 per 30 QL (60 per 30 QL (120 per 30 QL (80 per 30 QL (60 per 30 risperidone oral solution 1 mg/ml (Risperdal) 2 GC; QL (80 per 30 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, mg (Risperdal) 2 GC; QL (60 per 30 1 Formulary ID: Version: 2

51 risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, mg SEROQUEL ORAL TABLET 100, 200, 25, 300, 00, 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 2 HR 150, 300, 00, 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 2 HR 200 VERSACLOZ ORAL SUSPENSION 50 /ML ziprasidone hcl oral capsule 20 mg, 0 mg, 60 mg, 80 mg ZYPREXA INTRAMUSCULAR RECON SOLN 10 ZYPREXA ORAL TABLET 10, 15, 2.5, 20, 5, 7.5 ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10, 15, 20, 5 Antivirals (Systemic) Antiretrovirals ATRIPLA ORAL TABLET COMPLERA ORAL TABLET EPZICOM ORAL TABLET ISENTRESS ORAL POWDER IN PACKET 100 (Risperdal M-Tab) 2 GC; QL (60 per 30 (Risperdal M-Tab) 2 GC; QL (120 per 30 QL (90 per 30 ST; QL (60 per 30 ST; QL (30 per 30 5 ST; QL (50 per 30 (Geodon) 2 GC; QL (60 per 30 QL (30 per 30 ISENTRESS ORAL TABLET 00 5 QL (30 per 30 QL (30 per Formulary ID: Version: 2

52 ISENTRESS ORAL 3 TABLET,CHEWABLE 100, 25 NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION 80 3 /ML NORVIR ORAL TABLET PREZISTA ORAL SUSPENSION 100 /ML PREZISTA ORAL TABLET 150, 3 75 PREZISTA ORAL TABLET 600, REYATAZ ORAL CAPSULE 150 5, 200, 300 REYATAZ ORAL POWDER IN 5 PACKET 50 STRIBILD ORAL TABLET TRUVADA ORAL TABLET , , , VIREAD ORAL POWDER 0 5 /SCOOP (0 /GRAM) VIREAD ORAL TABLET 150, 5 200, 250, 300 Antivirals, Miscellaneous SYNAGIS 100 /1 ML VIAL /ML SYNAGIS INTRAMUSCULAR 5 SOLUTION 50 /0.5 ML TAMIFLU ORAL CAPSULE 30, 3 5, 75 TAMIFLU ORAL SUSPENSION 3 FOR RECONSTITUTION 6 /ML 3 Formulary ID: Version: 2

53 Hcv Antivirals OLYSIO ORAL CAPSULE PA; QL (28 per 28 SOVALDI ORAL TABLET 00 5 PA; QL (28 per 28 Interferons PEGASYS PROCLICK 5 PA SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS 5 PA SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS 5 PA SYRINGE 180 MCG/0.5 ML PEGINTRON REDIPEN 5 PA SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML 5 PA SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) 2 GC acyclovir oral suspension 200 mg/5 ml (Zovirax) 2 GC acyclovir oral tablet 00 mg, 800 mg (Zovirax) 2 GC famciclovir oral tablet 125 mg, 250 mg, (Famvir) 2 GC 500 mg FAMVIR ORAL TABLET 125, 250, 500 valacyclovir oral tablet 1 gram, 500 mg (Valtrex) 2 GC VALTREX ORAL TABLET 1 GRAM, 500 ZOVIRAX ORAL CAPSULE 200 ZOVIRAX ORAL SUSPENSION 200 /5 ML 5 PA NSO; QL ( per 28 Formulary ID: Version: 2

54 ZOVIRAX ORAL TABLET 800 Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1, 10, 2, 2.5, 3,, 5, 6, 7.5 enoxaparin subcutaneous solution 300 (Lovenox) 2 GC mg/3 ml enoxaparin subcutaneous syringe 100 (Lovenox) 5 mg/ml, 120 mg/0.8 ml, 150 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) 2 GC mg/0.3 ml, 0 mg/0. ml, 60 mg/0.6 ml, 80 mg/0.8 ml jantoven oral tablet 1 mg, 10 mg, 2 mg, (Coumadin) 1 GC 2.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg LOVENOX SUBCUTANEOUS SOLUTION 300 /3 ML LOVENOX SUBCUTANEOUS SYRINGE 100 /ML, 120 /0.8 ML, 150 /ML, 30 /0.3 ML, 0 /0. ML, 60 /0.6 ML, 80 /0.8 ML warfarin oral tablet 1 mg, 10 mg, 2 mg, (Coumadin) 1 GC 2.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10, 3 15, 20 XARELTO ORAL TABLETS,DOSE 3 PACK 15 (2)- 20 (9) Blood Formation Modifiers EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML 3 PA; QL (12 per 28 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML,,000 UNIT/ML 3 PA; QL (12 per 28 5 Formulary ID: Version: 2

55 NEULASTA SUBCUTANEOUS SYRINGE 6 /0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 80 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 80 MCG/0.8 ML PROCRIT 10,000 UNITS/ML VIAL 'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML Hematologic Agents, Miscellaneous AGRYLIN ORAL CAPSULE 0.5 anagrelide oral capsule 0.5 mg, 1 mg (Agrylin) 2 GC PA; QL (12 per 28 3 PA; QL (12 per 28 5 PA; QL (12 per 28 5 PA; QL (6 per 28 CYKLOKAPRON INTRAVENOUS SOLUTION 1,000 /10 ML (100 /ML) LYSTEDA ORAL TABLET 650 QL (30 per 30 tranexamic acid intravenous solution (Tranexamic Acid) 2 GC 1,000 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) 2 GC; QL (30 per 30 Platelet-Aggregation Inhibitors cilostazol oral tablet 100 mg, 50 mg (Pletal) 2 GC clopidogrel oral tablet 300 mg, 75 mg (Plavix) 2 GC EFFIENT ORAL TABLET 10, 5 3 QL (30 per 30 PLAVIX ORAL TABLET 300, 75 6 Formulary ID: Version: 2

56 Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 5 % in water (d5w) intravenous parenteral solution INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % NUTRILIPID INTRAVENOUS EMULSION 20 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % (Dextrose 10 % in Water) (Dextrose 5 % in Water) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 2 PA BvD; GC 2 GC PA BvD PA BvD PA BvD PA BvD 7 Formulary ID: Version: 2