Partnership 2017 Formulary. List of Covered Drugs

Transcription

1 Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207. For more recent information or other questions, please contact Partnership Customer Service at or, for TTY users, Wisconsin Relay 7, 8 a.m. 8 p.m., 7 days a week, or visit H _CWHPFC0-24-7_FINAL Populated Template DHS Approved 9/8/206

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3 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 Care Wisconsin Health Plan, Inc. When it refers to plan or our plan, it means Partnership. This document includes a list of the drugs (formulary) for our plan which is current as of 0/24/207. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 207, and from time to time during the year. You will receive notice when necessary. Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is available for free in other languages or in an alternate format. Please call our customer service number from 8 a.m. to 8 pm.m CT / 7days a week at TTY users should call Wisconsin Relay System 7. i

4 What is the Partnership Formulary? A formulary is a list of covered drugs selected by Partnership 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. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership 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, 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 0/24/207. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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 Agents. If you know what your drug is used for, look for the category name in the list that begins on page 2. Then look under the category name for your drug. ii

5 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 96. 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? Partnership 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: Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 62 tablets per prescription for Xifaxan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Partnership 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, Partnership may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Partnership 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. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Partnership 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 Partnership s formulary? on page iv for information about how to request an exception. iii

6 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 Partnership does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership. You can ask Partnership 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 Partnership Formulary? You can ask Partnership 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. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Partnership 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, Partnership will only approve your request for an exception if the alternative drugs included on the plan s formulary 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 or utilization restriction exception. When you request a formulary 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. iv

7 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 days) 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 9 to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). 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 days) while you pursue a formulary exception. Current members with a change in where they receive care Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include: You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital. You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary. Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of medications that are highly individualized. Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy For more information For more detailed information about your Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Partnership, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit v

8 Partnership Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 96. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EMBEDA) and generic drugs are listed in lower-case italics (e.g., fentanyl). The information in the Requirements/Limits column tells you if Partnership has any special requirements for coverage of your drug. vi

9 LEGEND : Covered Medications BD: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HR: High Risk Medication (PA required for ages 65 or over) LA: This prescription drug is limited to certain pharmacies. PA: You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL: There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST: In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207

10 Care Wisconsin (List of Covered Drugs) Drug Tier Requirements/Limits ANALGESICS OPIOID ANALGESICS, LONG- ACTING EMBEDA ORAL CAPSULE EXTENDED RELEASE 00-4 MG, MG, MG, 50-2 MG, MG, MG fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 2 mg, 6 mg, 32 mg, 8 mg HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG METHADONE HCL INJECTION SOLUTION 0 MG/ML QL (62 EA per 3 days) PA; ST; QL ( EA per 33 days) QL (3 EA per 3 days) PA; QL (24 EA per 3 days) methadone hcl oral solution 0 mg/5ml QL (500 ML per 3 days) methadone hcl oral solution 5 mg/5ml QL (992 ML per 3 days) methadone hcl oral tablet 0 mg, 5 mg QL (248 EA per 3 days) morphine sulfate er beads oral capsule extended release 24 hour 20 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 0 mg, 00 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 00 mg, 5 mg, 200 mg, 30 mg, 60 mg OXYCODONE HCL ER ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 0 MG, 20 MG, 40 MG, 80 MG OXYCODONE HCL ER ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 5 MG, 30 MG, 60 MG OPIOID ANALGESICS, SHORT- ACTING acetaminophen-codeine #4 oral tablet mg QL (43 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (62 EA per 3 days) QL (62 EA per 3 days) QL (93 EA per 3 days) ST; QL (24 EA per 3 days) ST; QL (93 EA per 3 days) acetaminophen-codeine #2 oral tablet mg QL (43 EA per 3 days) acetaminophen-codeine #3 oral tablet mg QL (43 EA per 3 days) 2

11 acetaminophen-codeine oral solution 20-2 mg/5ml QL (567 ML per 3 days) ascomp-codeine oral capsule mg PA; HR; QL (382 EA per 3 days) butalbital-apap-caff-cod oral capsule mg, mg duramorph injection solution 0.5 mg/ml, mg/ml endocet oral tablet mg, mg, mg fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg PA; HR; QL (38 EA per 3 days) QL (382 EA per 3 days) PA; QL (86 EA per 3 days) QL (5683 ML per 3 days) QL (38 EA per 3 days) hydrocodone-ibuprofen oral tablet mg QL (86 EA per 3 days) hydromorphone hcl injection solution 2 mg/ml hydromorphone hcl oral liquid mg/ml QL (984 ML per 3 days) hydromorphone hcl oral tablet 2 mg, 4 mg QL (372 EA per 3 days) hydromorphone hcl oral tablet 8 mg QL (248 EA per 3 days) hydromorphone hcl pf injection solution 0 mg/ml, 50 mg/5ml LAZANDA NASAL SOLUTION 00 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT LEVORPHANOL TARTRATE ORAL TABLET 2 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; QL (3 EA per 3 days) QL (86 EA per 3 days) lorcet hd oral tablet mg QL (38 EA per 3 days) lorcet oral tablet mg QL (382 EA per 3 days) lorcet plus oral tablet mg QL (382 EA per 3 days) meperidine hcl injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml meperidine hcl oral solution 50 mg/5ml PA; HR meperidine hcl oral tablet 00 mg, 50 mg PA; HR; QL (372 EA per 3 days) morphine sulfate (concentrate) oral solution 00 mg/5ml MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 2 MG/ML QL (45 ML per 3 days) 3

12 morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml MORPHINE SULFATE ORAL TABLET 5 MG, 30 MG QL (550 ML per 3 days) QL (86 EA per 3 days) oxycodone hcl oral capsule 5 mg QL (86 EA per 3 days) oxycodone hcl oral concentrate 00 mg/5ml oxycodone hcl oral solution 5 mg/5ml QL (5580 ML per 3 days) oxycodone hcl oral tablet 0 mg, 5 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral solution mg/5ml oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (86 EA per 3 days) QL (860 ML per 3 days) QL (38 EA per 3 days) oxycodone-aspirin oral tablet mg QL (372 EA per 3 days) oxycodone-ibuprofen oral tablet mg QL (372 EA per 3 days) pentazocine-naloxone hcl oral tablet mg PA; HR; QL (372 EA per 3 days) SUBSYS SUBLINGUAL LIQUID 00 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG tramadol hcl er oral capsule extended release 24 hour 00 mg, 200 mg, 300 mg PA; QL (86 EA per 3 days) QL (3 EA per 3 days) tramadol hcl oral tablet 50 mg QL (248 EA per 3 days) tramadol-acetaminophen oral tablet mg QL (38 EA per 3 days) vicodin es oral tablet mg QL (382 EA per 3 days) vicodin hp oral tablet mg QL (382 EA per 3 days) vicodin oral tablet mg QL (382 EA per 3 days) ANESTHETICS LOCAL ANESTHETICS lidocaine external patch 5 % PA; QL (93 EA per 3 days) lidocaine hcl (pf) injection solution 0.5 %, % lidocaine hcl external gel 2 %, 2 % (0ml applicator), 2 % (5ml applicator) lidocaine hcl external solution 4 % lidocaine hcl injection solution 0.5 %, 2 % lidocaine-prilocaine external cream % ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 4

13 ALCOHOL DETERRENTS/ANTI- CRAVING acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg OPIOID ANTAGONISTS buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA NARCAN NASAL LIQUID 4 MG/0.ML QL (2 EA per 30 days) SUBOXONE SUBLINGUAL FILM 2-3 MG, MG, 4- MG, 8-2 MG SMOKING CESSATION AGENTS bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG QL (93 EA per 3 days) PA CHANTIX ORAL TABLET 0.5 MG PA; QL ( EA per 3 days) CHANTIX ORAL TABLET MG PA; QL (74 EA per 84 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 NICOTROL INHALATION INHALER 0 MG ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/2ml gentamicin in saline intravenous solution mg/ml-%, -0.9 mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % gentamicin sulfate injection solution 40 mg/ml gentamicin sulfate intravenous solution 0 mg/ml neomycin sulfate oral tablet 500 mg PA; QL (53 EA per 28 days) 5

14 paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml ANTIBACTERIALS, OTHER BACITRACIN INTRAMUSCULAR SOLUTION RECONSTITUTED UNIT chloramphenicol sod succinate intravenous solution reconstituted gm clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate external gel % clindamycin phosphate external lotion % clindamycin phosphate external solution % clindamycin phosphate external swab % clindamycin phosphate in d5w intravenous solution 600 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml colistimethate sodium injection solution reconstituted 50 mg daptomycin intravenous solution reconstituted 500 mg PA PA BD linezolid intravenous solution 600 mg/300ml PA linezolid oral suspension reconstituted 00 mg/5ml PA linezolid oral tablet 600 mg PA methenamine hippurate oral tablet gm metronidazole external cream 0.75 % metronidazole external gel 0.75 %, % metronidazole external lotion 0.75 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 6

15 METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION MG/00ML-% metronidazole oral tablet 250 mg, 500 mg mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg nitrofurantoin oral suspension 25 mg/5ml SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG BD PA; HR PA; HR PA; HR; QL (7850 ML per 20 days) PA; QL (6 EA per 28 days) SIVEXTRO ORAL TABLET 200 MG PA; QL (6 EA per 28 days) SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG trimethoprim oral tablet 00 mg TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous solution reconstituted 0 gm, 000 mg VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG vancomycin hcl oral capsule 25 mg, 250 mg BD BD BD BD BD XIFAXAN ORAL TABLET 550 MG PA; QL (62 EA per 3 days) BETA-LACTAM, CEPHALOSPORINS cefaclor er oral tablet extended release 2 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 0 gm, 500 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 7

16 cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefotaxime sodium injection solution reconstituted gm, 2 gm, 500 mg cefotetan disodium injection solution reconstituted gm, 2 gm cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted gm, 0 gm, 2 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted.5 gm, 7.5 gm, 750 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection solution reconstituted gm BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 8

17 CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted gm, 500 mg BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin sodium injection solution reconstituted gm, 25 mg ampicillin sodium intravenous solution reconstituted 0 gm ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm ampicillin-sulbactam sodium injection solution reconstituted 3 (2-) gm ampicillin-sulbactam sodium intravenous solution reconstituted.5 (-0.5) gm ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML PA; QL (84 ML per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 BD BD 9

18 BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg NAFCILLIN SODIUM INJECTION SOLUTION RECONSTITUTED GM nafcillin sodium injection solution reconstituted 0 gm oxacillin sodium injection solution reconstituted 0 gm penicillin g potassium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted ( ) gm, 4.5 (4-0.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet gm azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin er oral tablet extended release 24 hour 500 mg clarithromycin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG ery-tab oral tablet delayed release 500 mg erythrocin lactobionate intravenous solution reconstituted 500 mg erythrocin stearate oral tablet 250 mg erythromycin base oral tablet 250 mg, 500 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 0

19 erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin external gel 2 % erythromycin external solution 2 % QUINOLONES ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 200 mg/00ml ciprofloxacin intravenous solution 400 mg/40ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) levofloxacin in d5w intravenous solution 500 mg/00ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 MG/250ML OFLOXACIN ORAL TABLET 300 MG ofloxacin oral tablet 400 mg SULFONAMIDES PASER ORAL PACKET 4 GM sulfacetamide sodium external suspension 0 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg TETRACYCLINES doxy 00 intravenous solution reconstituted 00 mg doxycycline hyclate oral capsule 00 mg, 50 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207

20 doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet delayed release 50 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral tablet 00 mg, 50 mg, 50 mg, 75 mg minocycline hcl oral capsule 00 mg, 50 mg, 75 mg minocycline hcl oral tablet 00 mg, 50 mg, 75 mg tetracycline hcl oral capsule 250 mg TETRACYCLINE HCL ORAL CAPSULE 500 MG ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam intravenous solution 500 mg/5ml levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg roweepra oral tablet 000 mg, 500 mg, 750 mg SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG BARBITURATES QL (93 EA per 3 days) QL (24 EA per 3 days) ONFI ORAL SUSPENSION 2.5 MG/ML QL (496 ML per 3 days) phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 00 mg, 6.2 mg, 32.4 mg, 64.8 mg, 97.2 mg PA; HR; QL (550 ML per 3 days) PA; HR; QL (93 EA per 3 days) phenobarbital oral tablet 5 mg, 60 mg PA; HR; QL (24 EA per 3 days) phenobarbital oral tablet 30 mg PA; HR; QL (30 EA per 3 days) BENZODIAZEPINES clonazepam oral tablet 0.5 mg, mg, 2 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 2

21 clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 0 mg, 2.5 mg flurazepam hcl oral capsule 5 mg, 30 mg ONFI ORAL TABLET 0 MG, 20 MG QL (62 EA per 3 days) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 00 mg, 25 mg, 50 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML QL (744 ML per 3 days) FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) gabapentin oral capsule 00 mg, 300 mg, 400 mg QL (279 EA per 3 days) gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg QL (86 EA per 3 days) GABITRIL ORAL TABLET 2 MG, 6 MG primidone oral tablet 250 mg, 50 mg SABRIL ORAL PACKET 500 MG QL (86 EA per 3 days) SABRIL ORAL TABLET 500 MG QL (86 EA per 3 days) tiagabine hcl oral tablet 2 mg, 4 mg 3

22 valproate sodium intravenous solution 500 mg/5ml valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg vigabatrin oral packet 500 mg LA; QL (86 EA per 3 days) GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 00 mg, 200 mg, 25 mg, 50 mg TOPIRAMATE ER ORAL CAPSULE ER 24 HOUR SPRINKLE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 50 mg QL (24 EA per 3 days) topiramate oral tablet 25 mg QL (93 EA per 3 days) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 50 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) APTIOM ORAL TABLET 600 MG QL (62 EA per 3 days) BANZEL ORAL SUSPENSION 40 MG/ML QL (2852 ML per 3 days) BANZEL ORAL TABLET 200 MG QL (496 EA per 3 days) BANZEL ORAL TABLET 400 MG QL (248 EA per 3 days) BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 0 MG/ML PA BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG PA 4

23 carbamazepine er oral capsule extended release 2 hour 00 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 2 hour 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 00 mg DILANTIN ORAL CAPSULE 30 MG epitol oral tablet 200 mg fosphenytoin sodium injection solution 00 mg pe/2ml oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 mg/ml TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 2 HOUR 00 MG VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 0 MG/ML QL (442 ML per 3 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, COMBINATIONS NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4-0 MG, 28-0 MG ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 5

24 CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 0 mg QL (62 EA per 3 days) donepezil hcl oral tablet 5 mg QL (3 EA per 3 days) donepezil hcl oral tablet dispersible 0 mg QL (62 EA per 3 days) donepezil hcl oral tablet dispersible 5 mg QL (3 EA per 3 days) galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg GALANTAMINE HYDROBROMIDE ORAL SOLUTION 4 MG/ML galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg RIVASTIGMINE TRANSDERMAL PATCH 24 HOUR 3.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) memantine hcl oral solution 2 mg/ml QL (372 ML per 3 days) memantine hcl oral tablet 0 mg, 5 mg QL (62 EA per 3 days) memantine hcl oral tablet 5 (28)-0 (2) mg ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg bupropion hcl er (sr) oral tablet extended release 2 hour 50 mg bupropion hcl er (sr) oral tablet extended release 2 hour 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg QL (24 EA per 3 days) QL (93 EA per 3 days) QL (62 EA per 3 days) QL (93 EA per 3 days) bupropion hcl oral tablet 00 mg QL (86 EA per 3 days) bupropion hcl oral tablet 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral tablet 5 mg, 30 mg, 45 mg QL (3 EA per 3 days) mirtazapine oral tablet 7.5 mg 6

25 mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg nefazodone hcl oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 00 mg, 50 mg, 300 mg, 50 mg TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 0 & 20 MG MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG ST phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral solution 0 mg/5ml citalopram hydrobromide oral tablet 0 mg, 40 mg QL (3 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 ST; QL (3 EA per 3 days) QL ( EA per 26 days) ST; QL (3 EA per 3 days) QL (620 ML per 3 days) QL (3 EA per 3 days) citalopram hydrobromide oral tablet 20 mg QL (86 EA per 3 days) desvenlafaxine er oral tablet extended release 24 hour 00 mg, 50 mg desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg DULOXETINE HCL ORAL CAPSULE DELAYED RELEASE PARTICLES 40 MG QL (62 EA per 3 days) QL (62 EA per 3 days) escitalopram oxalate oral solution 5 mg/5ml QL (620 ML per 3 days) escitalopram oxalate oral tablet 0 mg QL (47 EA per 3 days) escitalopram oxalate oral tablet 20 mg, 5 mg QL (3 EA per 3 days) 7

26 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG ST ST fluoxetine hcl oral capsule 0 mg QL (86 EA per 3 days) fluoxetine hcl oral capsule 20 mg QL (24 EA per 3 days) fluoxetine hcl oral capsule 40 mg QL (62 EA per 3 days) fluoxetine hcl oral capsule delayed release 90 mg QL (4 EA per 28 days) fluoxetine hcl oral solution 20 mg/5ml QL (620 ML per 3 days) fluoxetine hcl oral tablet 0 mg, 20 mg QL (3 EA per 3 days) FLUOXETINE HCL ORAL TABLET 60 MG QL (3 EA per 3 days) fluvoxamine maleate er oral capsule extended release 24 hour 00 mg, 50 mg fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 37.5 mg paroxetine hcl er oral tablet extended release 24 hour 25 mg QL (62 EA per 3 days) QL (93 EA per 3 days) QL (62 EA per 3 days) QL (93 EA per 3 days) paroxetine hcl oral tablet 0 mg, 20 mg QL (3 EA per 3 days) paroxetine hcl oral tablet 30 mg, 40 mg QL (62 EA per 3 days) PAXIL ORAL SUSPENSION 0 MG/5ML ST; QL (930 ML per 3 days) PEXEVA ORAL TABLET 0 MG, 20 MG, 30 MG, 40 MG ST sertraline hcl oral concentrate 20 mg/ml QL (30 ML per 3 days) sertraline hcl oral tablet 00 mg QL (62 EA per 3 days) sertraline hcl oral tablet 25 mg, 50 mg QL (93 EA per 3 days) venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 50 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg TRICYCLICS amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg QL (62 EA per 3 days) QL (3 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR 8

27 amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg PA; HR PA; HR PA; HR PA; HR doxepin hcl oral concentrate 0 mg/ml PA; HR imipramine hcl oral tablet 0 mg, 25 mg, 50 mg PA; HR imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg NORTRIPTYLINE HCL ORAL SOLUTION 0 MG/5ML PA; HR PA; HR PA; HR protriptyline hcl oral tablet 0 mg, 5 mg PA; HR trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER PA; HR hydroxyzine hcl oral tablet 0 mg PA; HR promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 50 mg EMETOGENIC THERAPY ADJUNCTS PA; HR aprepitant oral capsule 25 mg, 40 mg, 80 mg BD; QL (3 EA per 3 days) aprepitant oral capsule 80 & 25 mg BD; QL (2 EA per 3 days) dronabinol oral capsule 0 mg, 2.5 mg, 5 mg PA; QL (62 EA per 3 days) EMEND ORAL SUSPENSION RECONSTITUTED 25 MG granisetron hcl intravenous solution 0. mg/ml, mg/ml BD BD; QL (62 ML per 3 days) granisetron hcl oral tablet mg BD; QL (62 EA per 3 days) meclizine hcl oral tablet 2.5 mg, 25 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 9

28 ondansetron hcl injection solution 4 mg/2ml BD ondansetron hcl oral solution 4 mg/5ml BD; QL (465 ML per 3 days) ondansetron hcl oral tablet 24 mg BD; QL (3 EA per 3 days) ondansetron hcl oral tablet 4 mg, 8 mg BD; QL (62 EA per 3 days) ondansetron oral tablet dispersible 4 mg, 8 mg BD; QL (62 EA per 3 days) TRANSDERM-SCOP (.5 MG) TRANSDERMAL PATCH 72 HOUR MG/3DAYS ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream % clotrimazole external solution % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % econazole nitrate external cream % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % QL (4 EA per 2 days) BD BD BD BD BD PA BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 20

29 fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 25 mg/5ml griseofulvin microsize oral tablet 500 mg itraconazole oral capsule 00 mg PA ketoconazole external cream 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 mg LUZU EXTERNAL CREAM % NOXAFIL ORAL SUSPENSION 40 MG/ML PA; QL (870 ML per 28 days) NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% nystop external powder unit/gm You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; QL (93 EA per 3 days) terbinafine hcl oral tablet 250 mg QL (93 EA per 365 days) voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml PA PA voriconazole oral tablet 200 mg, 50 mg PA; QL (24 EA per 3 days) ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 00 mg, 300 mg COLCHICINE ORAL TABLET 0.6 MG colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg 2

30 ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI- INFLAMMATORY DRUGS celecoxib oral capsule 00 mg, 200 mg, 50 mg QL (62 EA per 3 days) celecoxib oral capsule 400 mg QL (3 EA per 3 days) diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac oral capsule 200 mg QL (62 EA per 3 days) etodolac oral capsule 300 mg QL (93 EA per 3 days) etodolac oral tablet 400 mg, 500 mg QL (62 EA per 3 days) flurbiprofen oral tablet 00 mg, 50 mg QL (93 EA per 3 days) ibuprofen oral suspension 00 mg/5ml QL (5000 ML per 3 days) ibuprofen oral tablet 400 mg, 600 mg, 800 mg QL (24 EA per 3 days) indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg PA; HR PA; HR; QL (62 EA per 3 days) ketoprofen oral capsule 50 mg QL (86 EA per 3 days) ketoprofen oral capsule 75 mg QL (24 EA per 3 days) ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml PA; HR PA; HR ketorolac tromethamine oral tablet 0 mg PA; HR; QL (20 EA per 5 days) meloxicam oral tablet 5 mg QL (3 EA per 3 days) meloxicam oral tablet 7.5 mg QL (62 EA per 3 days) nabumetone oral tablet 500 mg QL (24 EA per 3 days) nabumetone oral tablet 750 mg QL (62 EA per 3 days) naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 22

31 naproxen sodium oral tablet 275 mg, 550 mg sulindac oral tablet 50 mg, 200 mg QL (62 EA per 3 days) ANTIMIGRAINE AGENTS ERGOT ALKALOIDS CAFERGOT ORAL TABLET -00 MG dihydroergotamine mesylate injection solution mg/ml SEROTONIN (5-HT) B/D RECEPTOR AGONISTS naratriptan hcl oral tablet mg, 2.5 mg QL (9 EA per 3 days) sumatriptan nasal solution 20 mg/act QL (8 EA per 3 days) sumatriptan nasal solution 5 mg/act QL (32 EA per 3 days) sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS GUANIDINE HCL ORAL TABLET 25 MG pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00 mg, 25 mg ethambutol hcl oral tablet 00 mg, 400 mg ANTITUBERCULARS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM isoniazid injection solution 00 mg/ml isoniazid oral syrup 50 mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (9 EA per 3 days) QL (5 ML per 3 days) QL (8 ML per 3 days) QL (5 ML per 3 days) QL (5 ML per 3 days) BD 23

32 isoniazid oral tablet 00 mg, 300 mg PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 50 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS BICNU INTRAVENOUS SOLUTION RECONSTITUTED 00 MG BD busulfan intravenous solution 6 mg/ml BD carboplatin intravenous solution 50 mg/5ml BD cisplatin intravenous solution 00 mg/00ml BD CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG BD HEXALEN ORAL CAPSULE 50 MG PA ifosfamide intravenous solution reconstituted gm LEUKERAN ORAL TABLET 2 MG melphalan hcl intravenous solution reconstituted 50 mg MUSTARGEN INJECTION SOLUTION RECONSTITUTED 0 MG BD BD BD oxaliplatin intravenous solution 00 mg/20ml BD THIOTEPA INJECTION SOLUTION RECONSTITUTED 5 MG TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG BD PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 24

33 ANTIANGIOGENIC AGENTS AVASTIN INTRAVENOUS SOLUTION 400 MG/6ML CYRAMZA INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 25 MG, 5 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; LA; QL (28 EA per 28 days) REVLIMID ORAL CAPSULE 20 MG PA; QL (28 EA per 28 days) THALOMID ORAL CAPSULE 00 MG, 200 MG, 50 MG PA; QL (3 EA per 3 days) THALOMID ORAL CAPSULE 50 MG PA; QL (62 EA per 3 days) ANTIMETABOLITES adrucil intravenous solution 500 mg/0ml BD ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG azacitidine injection suspension reconstituted 00 mg PA cladribine intravenous solution 0 mg/0ml BD clofarabine intravenous solution mg/ml BD cytarabine (pf) injection solution 00 mg/ml BD cytarabine injection solution 20 mg/ml BD decitabine intravenous solution reconstituted 50 mg fludarabine phosphate intravenous solution reconstituted 50 mg fluorouracil intravenous solution 2.5 gm/50ml BD GEMCITABINE HCL INTRAVENOUS SOLUTION RECONSTITUTED GM mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg BD methotrexate sodium (pf) injection solution gm/40ml BD methotrexate sodium injection solution 50 mg/2ml BD methotrexate sodium injection solution reconstituted gm PURIXAN ORAL SUSPENSION 2000 MG/00ML BD 25

34 TABLOID ORAL TABLET 40 MG PA TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG BD XATMEP ORAL SOLUTION 2.5 MG/ML BD ANTINEOPLASTICS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 00 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML BD PA; LA adriamycin intravenous solution 2 mg/ml BD AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG PA PA; QL (3 EA per 3 days) PA; QL (62 EA per 3 days) PA; QL (3 EA per 3 days) ALUNBRIG ORAL TABLET 30 MG PA; QL (86 EA per 3 days) AVASTIN INTRAVENOUS SOLUTION 00 MG/4ML BAVENCIO INTRAVENOUS SOLUTION 200 MG/0ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG PA PA PA bexarotene oral capsule 75 mg PA bicalutamide oral tablet 50 mg QL (3 EA per 3 days) bleomycin sulfate injection solution reconstituted 30 unit BD BOSULIF ORAL TABLET 00 MG PA; QL (24 EA per 3 days) BOSULIF ORAL TABLET 500 MG PA; QL (3 EA per 3 days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CAPRELSA ORAL TABLET 00 MG PA; QL (62 EA per 3 days) CAPRELSA ORAL TABLET 300 MG PA; QL (3 EA per 3 days) COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG PA; QL (56 EA per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 26

35 COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA; QL (2 EA per 28 days) PA; QL (84 EA per 28 days) COTELLIC ORAL TABLET 20 MG PA; LA dacarbazine intravenous solution reconstituted 200 mg BD daunorubicin hcl intravenous injectable 5 mg/ml BD DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML dexrazoxane intravenous solution reconstituted 250 mg DOCETAXEL INTRAVENOUS CONCENTRATE 80 MG/4ML DOCETAXEL INTRAVENOUS SOLUTION 80 MG/8ML BD doxorubicin hcl intravenous solution 2 mg/ml BD doxorubicin hcl liposomal intravenous injectable 2 mg/ml ELITEK INTRAVENOUS SOLUTION RECONSTITUTED.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 7.5 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 BD PA BD EMCYT ORAL CAPSULE 40 MG PA epirubicin hcl intravenous solution 200 mg/00ml BD ERIVEDGE ORAL CAPSULE 50 MG PA; QL (28 EA per 28 days) ERWINAZE INJECTION SOLUTION RECONSTITUTED 0000 UNIT etoposide intravenous solution 500 mg/25ml BD PA; QL (62 EA per 28 days) FARESTON ORAL TABLET 60 MG PA; QL (3 EA per 3 days) FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML flutamide oral capsule 25 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA BD; QL (3 ML per 3 days) PA; QL (3 EA per 3 days) GLEEVEC ORAL TABLET 00 MG PA; QL (86 EA per 3 days) 27

36 GLEEVEC ORAL TABLET 400 MG PA; QL (62 EA per 3 days) HALAVEN INTRAVENOUS SOLUTION MG/2ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 440 MG hydroxyprogesterone caproate intramuscular solution.25 gm/5ml hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA BD PA PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA idarubicin hcl intravenous solution 0 mg/0ml BD IDHIFA ORAL TABLET 00 MG PA; QL (3 EA per 3 days) IDHIFA ORAL TABLET 50 MG PA; QL (62 EA per 3 days) IMBRUVICA ORAL CAPSULE 40 MG PA; QL (24 EA per 3 days) IMFINZI INTRAVENOUS SOLUTION 20 MG/2.4ML, 500 MG/0ML PA INLYTA ORAL TABLET MG PA; QL (86 EA per 3 days) INLYTA ORAL TABLET 5 MG PA; QL (62 EA per 3 days) INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA PA IRESSA ORAL TABLET 250 MG PA irinotecan hcl intravenous solution 00 mg/5ml BD ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 0 MG ISTODAX INTRAVENOUS SOLUTION RECONSTITUTED 0 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4ML PA PA PA; QL (62 EA per 3 days) PA BD PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 28

37 KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG PA KISQALI 200 DOSE ORAL TABLET 200 MG PA KISQALI 400 DOSE ORAL TABLET 200 MG PA KISQALI 600 DOSE ORAL TABLET 200 MG PA KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 500 MG/50ML LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 MG LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG LEUCOVORIN CALCIUM INJECTION SOLUTION RECONSTITUTED 00 MG leucovorin calcium injection solution reconstituted 350 mg leucovorin calcium oral tablet 0 mg, 5 mg, 25 mg, 5 mg leuprolide acetate injection kit mg/0.2ml LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION 75 MG/7.5ML levoleucovorin calcium intravenous solution reconstituted 50 mg PA PA PA BD PA PA PA PA PA PA PA BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 29

38 LONSURF ORAL TABLET MG, MG LUPRON DEPOT (-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG PA LYNPARZA ORAL CAPSULE 50 MG PA PA; QL ( EA per 3 days) PA; QL ( EA per 90 days) PA; QL ( EA per 2 days) PA; QL ( EA per 2 days) LYNPARZA ORAL TABLET 00 MG, 50 MG PA; LA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG PA megestrol acetate oral suspension 40 mg/ml PA; HR megestrol acetate oral tablet 20 mg, 40 mg PA; HR MEKINIST ORAL TABLET 0.5 MG PA; LA; QL (24 EA per 3 days) MEKINIST ORAL TABLET 2 MG PA; LA; QL (3 EA per 3 days) mesna intravenous solution 00 mg/ml BD MESNEX ORAL TABLET 400 MG mitomycin intravenous solution reconstituted 20 mg, 40 mg MITOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 5 MG mitoxantrone hcl intravenous concentrate 25 mg/2.5ml BD NERLYNX ORAL TABLET 40 MG PA; LA; QL (86 EA per 3 days) NEXAVAR ORAL TABLET 200 MG PA; LA; QL (24 EA per 3 days) nilutamide oral tablet 50 mg QL (62 EA per 3 days) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA ODOMZO ORAL CAPSULE 200 MG PA; LA paclitaxel intravenous concentrate 300 mg/50ml BD PANRETIN EXTERNAL GEL 0. % PA POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PA; QL (2 EA per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 30

39 PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML PA PA RUBRACA ORAL TABLET 200 MG, 300 MG PA RYDAPT ORAL CAPSULE 25 MG PA; QL (248 EA per 3 days) SOLTAMOX ORAL SOLUTION 0 MG/5ML PA SPRYCEL ORAL TABLET 00 MG, 50 MG, 70 MG, 80 MG PA; QL (62 EA per 3 days) SPRYCEL ORAL TABLET 40 MG PA; QL (3 EA per 3 days) SPRYCEL ORAL TABLET 20 MG PA; QL (93 EA per 3 days) STIVARGA ORAL TABLET 40 MG PA; QL (84 EA per 28 days) SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG PA; QL (28 EA per 28 days) PA; QL (4 EA per 28 days) TAFINLAR ORAL CAPSULE 50 MG PA; LA; QL (86 EA per 3 days) TAFINLAR ORAL CAPSULE 75 MG PA; LA; QL (24 EA per 3 days) TAGRISSO ORAL TABLET 40 MG, 80 MG PA; LA tamoxifen citrate oral tablet 0 mg, 20 mg TARCEVA ORAL TABLET 00 MG, 50 MG PA; QL (3 EA per 3 days) TARCEVA ORAL TABLET 25 MG PA; QL (93 EA per 3 days) TARGRETIN EXTERNAL GEL % PA TASIGNA ORAL CAPSULE 50 MG, 200 MG PA; QL (24 EA per 3 days) TECENTRIQ INTRAVENOUS SOLUTION 200 MG/20ML topotecan hcl intravenous solution reconstituted 4 mg TORISEL INTRAVENOUS SOLUTION 25 MG/ML TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED.25 MG, 22.5 MG, 3.75 MG tretinoin oral capsule 0 mg BD BD BD; QL (00 ML per 28 days) PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 3

40 TRISENOX INTRAVENOUS SOLUTION 0 MG/0ML BD TYKERB ORAL TABLET 250 MG PA; QL (86 EA per 3 days) VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG PA; QL (4 EA per 2 days) PA PA vinblastine sulfate intravenous solution mg/ml BD vincasar pfs intravenous solution mg/ml BD vincristine sulfate intravenous solution mg/ml BD vinorelbine tartrate intravenous solution 50 mg/5ml BD VOTRIENT ORAL TABLET 200 MG PA; QL (24 EA per 3 days) VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED MG PA XALKORI ORAL CAPSULE 200 MG, 250 MG PA; QL (62 EA per 3 days) XTANDI ORAL CAPSULE 40 MG ST; QL (24 EA per 3 days) YERVOY INTRAVENOUS SOLUTION 50 MG/0ML PA ZEJULA ORAL CAPSULE 00 MG PA; QL (93 EA per 3 days) ZELBORAF ORAL TABLET 240 MG PA; QL (248 EA per 3 days) ZOLINZA ORAL CAPSULE 00 MG PA; QL (24 EA per 3 days) ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG QL (55 EA per 3 days) ZYTIGA ORAL TABLET 250 MG, 500 MG QL (24 EA per 3 days) AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet mg QL (3 EA per 3 days) exemestane oral tablet 25 mg QL (62 EA per 3 days) letrozole oral tablet 2.5 mg QL (3 EA per 3 days) ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 32

41 EMVERM ORAL TABLET CHEWABLE 00 MG ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (55 ML per 3 days) ALINIA ORAL TABLET 500 MG QL (4 EA per 3 days) atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG QL (24 EA per 3 days) DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG BD quinine sulfate oral capsule 324 mg PA; QL (44 EA per 7 days) PEDICULICIDES/SCABICIDES EURAX EXTERNAL CREAM 0 % EURAX EXTERNAL LOTION 0 % lindane external shampoo % malathion external lotion 0.5 % permethrin external cream 5 % ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate injection solution mg/ml benztropine mesylate oral tablet 0.5 mg, mg, 2 mg PA; HR trihexyphenidyl hcl oral elixir 0.4 mg/ml PA; HR trihexyphenidyl hcl oral tablet 2 mg, 5 mg PA; HR 33

42 ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 00 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 00 mg entacapone oral tablet 200 mg QL (30 EA per 3 days) DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hour 3.75 mg pramipexole dihydrochloride oral tablet 0.25 mg, 0.25 mg, 0.5 mg, mg,.5 mg PA; QL (62 ML per 28 days) QL (3 EA per 3 days) QL (93 EA per 3 days) QL (93 EA per 3 days) pramipexole dihydrochloride oral tablet 0.75 mg QL (86 EA per 3 days) ropinirole hcl oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg DOPAMINE PRECURSORS/ L- AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet 0-00 mg, mg, mg carbidopa-levodopa oral tablet dispersible 0-00 mg, mg, mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline mesylate oral tablet 0.5 mg, mg QL (3 EA per 3 days) selegiline hcl oral capsule 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 34

43 selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS ST GENERATION/TYPICAL chlorpromazine hcl injection solution 50 mg/2ml BD chlorpromazine hcl oral tablet 0 mg, 25 mg BD chlorpromazine hcl oral tablet 00 mg, 200 mg, 50 mg compro rectal suppository 25 mg fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg haloperidol decanoate intramuscular solution 00 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 0 mg, 25 mg, 5 mg, 50 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet mg, 2 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg thioridazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet mg, 0 mg, 2 mg, 5 mg 2ND GENERATION/ATYPICAL PA; HR You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 35

44 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (.5ML SYRINGE), 400 MG aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 0 MG, 5 MG ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 064 MG/3.9ML, 44 MG/.6ML, 662 MG/2.4ML, 882 MG/3.2ML FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET & 2 & 4 & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 7 MG/0.75ML, 56 MG/ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 234 MG/.5ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG ST; QL ( EA per 26 days) ST ST; QL (62 EA per 3 days) ST; QL (62 EA per 3 days) ST NUPLAZID ORAL TABLET 7 MG PA olanzapine intramuscular solution reconstituted 0 mg olanzapine oral tablet 0 mg, 5 mg, 2.5 mg, 5 mg, 7.5 mg ST; QL ( ML per 28 days) ST; QL (2 ML per 28 days) QL (62 EA per 3 days) QL (3 EA per 3 days) olanzapine oral tablet 20 mg QL (62 EA per 3 days) olanzapine oral tablet dispersible 0 mg, 5 mg, 20 mg, 5 mg paliperidone er oral tablet extended release 24 hour.5 mg, 3 mg, 9 mg paliperidone er oral tablet extended release 24 hour 6 mg QUETIAPINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG ST; QL (3 EA per 3 days) ST; QL (62 EA per 3 days) QL (93 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 36

45 QUETIAPINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 200 MG QUETIAPINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 300 MG quetiapine fumarate er oral tablet extended release 24 hour 400 mg QUETIAPINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG risperidone oral solution mg/ml risperidone oral tablet 0.25 mg, mg, 2 mg, 3 mg, 4 mg QL (3 EA per 3 days) QL (62 EA per 3 days) QL (62 EA per 3 days) QL (24 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA ST; QL (2 EA per 28 days) ST; QL (4 EA per 28 days) QL (62 EA per 3 days) risperidone oral tablet 0.5 mg QL (24 EA per 3 days) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 0 MG, 2.5 MG, 5 MG ST; QL (62 EA per 3 days) VRAYLAR ORAL CAPSULE.5 MG PA; QL (20 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK.5 & 3 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 20 MG TREATMENT-RESISTANT PA; QL (60 EA per 30 days) ST QL (62 EA per 3 days) 37

46 clozapine oral tablet 00 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 00 mg, 50 mg, 200 mg, 25 mg CLOZAPINE ORAL TABLET DISPERSIBLE 2.5 MG ST VERSACLOZ ORAL SUSPENSION 50 MG/ML ST; QL (558 ML per 3 days) ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS ganciclovir sodium intravenous solution reconstituted 500 mg valganciclovir hcl oral solution reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 0 mg BD BARACLUDE ORAL SOLUTION 0.05 MG/ML PA DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA entecavir oral tablet 0.5 mg, mg PA EPCLUSA ORAL TABLET MG PA HARVONI ORAL TABLET MG PA MAVYRET ORAL TABLET MG PA PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 35 MCG/0.5ML, 80 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/0.5ML, 80 MCG/ML PEG-INTRON REDIPEN SUBCUTANEOUS KIT 20 MCG/0.5ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML PA; QL (4 ML per 28 days) PA; QL (4 ML per 28 days) ribasphere oral capsule 200 mg QL (86 EA per 3 days) ribasphere oral tablet 200 mg QL (86 EA per 3 days) RIBASPHERE ORAL TABLET 400 MG ribavirin oral capsule 200 mg QL (86 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 38

47 ribavirin oral tablet 200 mg QL (86 EA per 3 days) SOVALDI ORAL TABLET 400 MG PA; QL (28 EA per 28 days) ZEPATIER ORAL TABLET MG PA ANTIHERPETIC AGENTS acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous solution 50 mg/ml BD famciclovir oral tablet 25 mg, 250 mg, 500 mg valacyclovir hcl oral tablet gm QL (93 EA per 3 days) valacyclovir hcl oral tablet 500 mg QL (62 EA per 3 days) ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS EDURANT ORAL TABLET 25 MG QL (3 EA per 3 days) INTELENCE ORAL TABLET 00 MG, 25 MG QL (24 EA per 3 days) INTELENCE ORAL TABLET 200 MG QL (62 EA per 3 days) nevirapine er oral tablet extended release 24 hour 00 mg nevirapine er oral tablet extended release 24 hour 400 mg NEVIRAPINE ORAL SUSPENSION 50 MG/5ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) QL (240 ML per 3 days) nevirapine oral tablet 200 mg QL (62 EA per 3 days) RESCRIPTOR ORAL TABLET 00 MG QL (372 EA per 3 days) RESCRIPTOR ORAL TABLET 200 MG QL (86 EA per 3 days) SUSTIVA ORAL CAPSULE 200 MG QL (24 EA per 3 days) SUSTIVA ORAL CAPSULE 50 MG QL (496 EA per 3 days) SUSTIVA ORAL TABLET 600 MG QL (3 EA per 3 days) ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral tablet 300 mg QL (62 EA per 3 days) abacavir sulfate-lamivudine oral tablet mg QL (3 EA per 3 days) 39

48 abacavir-lamivudine-zidovudine oral tablet mg DESCOVY ORAL TABLET MG QL (62 EA per 3 days) didanosine oral capsule delayed release 25 mg QL (93 EA per 3 days) didanosine oral capsule delayed release 200 mg QL (62 EA per 3 days) didanosine oral capsule delayed release 250 mg, 400 mg QL (3 EA per 3 days) EMTRIVA ORAL CAPSULE 200 MG QL (3 EA per 3 days) EMTRIVA ORAL SOLUTION 0 MG/ML QL (705 ML per 28 days) EPIVIR HBV ORAL SOLUTION 5 MG/ML EVOTAZ ORAL TABLET MG lamivudine oral solution 0 mg/ml QL (992 ML per 3 days) lamivudine oral tablet 00 mg lamivudine oral tablet 50 mg QL (62 EA per 3 days) lamivudine oral tablet 300 mg QL (3 EA per 3 days) lamivudine-zidovudine oral tablet mg QL (62 EA per 3 days) PREZCOBIX ORAL TABLET MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML stavudine oral capsule 5 mg, 20 mg QL (24 EA per 3 days) stavudine oral capsule 30 mg, 40 mg QL (62 EA per 3 days) TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) QL (240 ML per 3 days) VIREAD ORAL POWDER 40 MG/GM QL (248 GM per 3 days) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG ZERIT ORAL SOLUTION RECONSTITUTED MG/ML QL (3 EA per 3 days) QL (2480 ML per 3 days) ZIAGEN ORAL SOLUTION 20 MG/ML QL (995 ML per 3 days) zidovudine oral capsule 00 mg QL (86 EA per 3 days) zidovudine oral syrup 50 mg/5ml QL (736 ML per 28 days) zidovudine oral tablet 300 mg QL (62 EA per 3 days) ANTI-HIV AGENTS, OTHER ATRIPLA ORAL TABLET MG QL (3 EA per 3 days) 40

49 COMPLERA ORAL TABLET MG QL (3 EA per 3 days) FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG QL (62 EA per 3 days) ISENTRESS HD ORAL TABLET 600 MG QL (62 EA per 3 days) ISENTRESS ORAL PACKET 00 MG ISENTRESS ORAL TABLET 400 MG QL (24 EA per 3 days) ISENTRESS ORAL TABLET CHEWABLE 00 MG, 25 MG ODEFSEY ORAL TABLET MG QL (86 EA per 3 days) SELZENTRY ORAL TABLET 50 MG QL (248 EA per 3 days) SELZENTRY ORAL TABLET 25 MG, 300 MG QL (24 EA per 3 days) SELZENTRY ORAL TABLET 75 MG QL (62 EA per 3 days) STRIBILD ORAL TABLET MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TYBOST ORAL TABLET 50 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS QL (3 EA per 3 days) QL (62 EA per 3 days) APTIVUS ORAL CAPSULE 250 MG QL (24 EA per 3 days) APTIVUS ORAL SOLUTION 00 MG/ML QL (295 ML per 28 days) CRIXIVAN ORAL CAPSULE 200 MG QL (465 EA per 3 days) CRIXIVAN ORAL CAPSULE 400 MG QL (279 EA per 3 days) INVIRASE ORAL CAPSULE 200 MG QL (30 EA per 3 days) INVIRASE ORAL TABLET 500 MG QL (24 EA per 3 days) KALETRA ORAL TABLET MG QL (30 EA per 3 days) KALETRA ORAL TABLET MG QL (55 EA per 3 days) LEXIVA ORAL SUSPENSION 50 MG/ML QL (628 ML per 28 days) LEXIVA ORAL TABLET 700 MG QL (24 EA per 3 days) lopinavir-ritonavir oral solution mg/5ml NORVIR ORAL CAPSULE 00 MG QL (372 EA per 3 days) NORVIR ORAL SOLUTION 80 MG/ML QL (496 ML per 3 days) NORVIR ORAL TABLET 00 MG QL (372 EA per 3 days) PREZISTA ORAL SUSPENSION 00 MG/ML QL (372 ML per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 4

50 PREZISTA ORAL TABLET 50 MG QL (248 EA per 3 days) PREZISTA ORAL TABLET 600 MG QL (62 EA per 3 days) PREZISTA ORAL TABLET 75 MG QL (496 EA per 3 days) PREZISTA ORAL TABLET 800 MG QL (3 EA per 3 days) REYATAZ ORAL CAPSULE 50 MG, 200 MG QL (62 EA per 3 days) REYATAZ ORAL CAPSULE 300 MG QL (3 EA per 3 days) REYATAZ ORAL PACKET 50 MG VIRACEPT ORAL TABLET 250 MG QL (30 EA per 3 days) VIRACEPT ORAL TABLET 625 MG QL (24 EA per 3 days) ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg QL (2 EA per 365 days) oseltamivir phosphate oral capsule 45 mg, 75 mg QL (56 EA per 365 days) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 00 mg TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml QL (2 EA per 365 days) QL (540 ML per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR hydroxyzine hcl oral syrup 0 mg/5ml PA; HR hydroxyzine hcl oral tablet 25 mg, 50 mg PA; HR hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5 mg, mg, 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML PA; HR QL (24 EA per 3 days) alprazolam oral tablet 0.25 mg, 0.5 mg QL (24 EA per 3 days) alprazolam oral tablet mg QL (248 EA per 3 days) alprazolam oral tablet 2 mg QL (55 EA per 3 days) 42

51 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, mg, 2 mg alprazolam xr oral tablet extended release 24 hour 0.5 mg chlordiazepoxide hcl oral capsule 0 mg, 25 mg, 5 mg QL (86 EA per 3 days) QL (24 EA per 3 days) QL (24 EA per 3 days) clorazepate dipotassium oral tablet 5 mg QL (86 EA per 3 days) clorazepate dipotassium oral tablet 3.75 mg QL (744 EA per 3 days) clorazepate dipotassium oral tablet 7.5 mg QL (372 EA per 3 days) diazepam intensol oral concentrate 5 mg/ml QL (248 ML per 3 days) DIAZEPAM ORAL SOLUTION MG/ML QL (240 ML per 3 days) diazepam oral tablet 0 mg QL (24 EA per 3 days) diazepam oral tablet 2 mg QL (620 EA per 3 days) diazepam oral tablet 5 mg QL (248 EA per 3 days) lorazepam intensol oral concentrate 2 mg/ml QL (248 ML per 3 days) lorazepam oral tablet 0.5 mg, mg, 2 mg oxazepam oral capsule 0 mg, 5 mg, 30 mg QL (24 EA per 3 days) BIPOLAR AGENTS MOOD STABILIZERS carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg lithium carbonate er oral tablet extended release 300 mg, 450 mg lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 00 mg, 25 mg, 50 mg QL (93 EA per 3 days) BYDUREON SUBCUTANEOUS PEN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 0 MCG/0.04ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 43

52 BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML chlorpropamide oral tablet 00 mg, 250 mg FARXIGA ORAL TABLET 0 MG, 5 MG QL (3 EA per 3 days) glimepiride oral tablet mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg glipizide oral tablet 0 mg, 5 mg glipizide-metformin hcl oral tablet mg, mg, mg GLOBAL ALCOHOL PREP EASE PAD 70 % INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (62 EA per 3 days) QL (62 EA per 3 days) INVOKANA ORAL TABLET 00 MG, 300 MG QL (3 EA per 3 days) JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG KAZANO ORAL TABLET MG, MG KORLYM ORAL TABLET 300 MG PA metformin hcl er oral tablet extended release 24 hour 500 mg metformin hcl er oral tablet extended release 24 hour 750 mg QL (62 EA per 3 days) QL (62 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) QL (62 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) QL (24 EA per 3 days) QL (62 EA per 3 days) metformin hcl oral tablet 000 mg, 850 mg QL (62 EA per 3 days) 44

53 metformin hcl oral tablet 500 mg QL (24 EA per 3 days) nateglinide oral tablet 20 mg, 60 mg NESINA ORAL TABLET 2.5 MG, 25 MG, 6.25 MG OSENI ORAL TABLET MG, MG, MG, 25-5 MG, MG, MG QL (3 EA per 3 days) QL (3 EA per 3 days) pioglitazone hcl oral tablet 5 mg, 30 mg, 45 mg QL (3 EA per 3 days) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg repaglinide oral tablet 0.5 mg, mg, 2 mg SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 MCG/.5ML tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg TRADJENTA ORAL TABLET 5 MG QL (3 EA per 3 days) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 8 MG/3ML XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED MG GLUCAGON EMERGENCY INJECTION KIT MG PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML QL (3 EA per 3 days) QL (62 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 45

54 LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 00 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin sodium injection solution 300 mg/3ml QL (35 ML per 3 days) enoxaparin sodium subcutaneous solution 00 mg/ml, 50 mg/ml enoxaparin sodium subcutaneous solution 20 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous solution 30 mg/0.3ml enoxaparin sodium subcutaneous solution 40 mg/0.4ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 ML per 3 days) QL (24 ML per 3 days) QL (9 ML per 3 days) QL (2 ML per 3 days) 46

55 enoxaparin sodium subcutaneous solution 60 mg/0.6ml fondaparinux sodium subcutaneous solution 0 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin sod (porcine) in d5w intravenous solution 00 unit/ml heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, unit/ml, 5000 unit/ml 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 warfarin sodium 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 STARTER PACK ORAL TABLET THERAPY PACK 5 & 20 MG BLOOD FORMATION MODIFIERS EPOGEN INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML QL (8 ML per 3 days) QL (4 ML per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA PA; QL (8 ML per 3 days) PA; QL (4 ML per 3 days) PA; QL (4 ML per 3 days) 47

56 PROCRIT INJECTION SOLUTION 0000 UNIT/ML, UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 2000 UNIT/ML PROCRIT INJECTION SOLUTION 3000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML PA; QL (2 ML per 28 days) PA; QL (23 ML per 3 days) PA; QL (6 ML per 3 days) PA; QL (2 ML per 3 days) PROMACTA ORAL TABLET 2.5 MG PA; QL (62 EA per 3 days) PROMACTA ORAL TABLET 25 MG, 50 MG, 75 MG tranexamic acid intravenous solution 000 mg/0ml PA; QL (3 EA per 3 days) tranexamic acid oral tablet 650 mg QL (30 EA per 5 days) PLATELET MODIFYING AGENTS ASPIRIN-DIPYRIDAMOLE ER ORAL CAPSULE EXTENDED RELEASE 2 HOUR MG BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg clopidogrel bisulfate oral tablet 75 mg QL (3 EA per 3 days) dipyridamole oral tablet 25 mg, 50 mg, 75 mg CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine hcl transdermal patch weekly 0. mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet mg, 2 mg QL (4 EA per 28 days) methyldopa oral tablet 250 mg, 500 mg PA; HR methyldopate hcl intravenous solution 250 mg/5ml midodrine hcl oral tablet 0 mg, 2.5 mg, 5 mg ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet mg, 2 mg, 4 mg, 8 mg PA; HR You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 48

57 prazosin hcl oral capsule mg, 2 mg, 5 mg terazosin hcl oral capsule mg, 0 mg, 2 mg, 5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 6 mg, 4 mg, 8 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (62 EA per 3 days) candesartan cilexetil oral tablet 32 mg QL (3 EA per 3 days) eprosartan mesylate oral tablet 600 mg QL (3 EA per 3 days) irbesartan oral tablet 50 mg, 300 mg, 75 mg QL (3 EA per 3 days) losartan potassium oral tablet 00 mg, 25 mg, 50 mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg QL (3 EA per 3 days) QL (3 EA per 3 days) telmisartan oral tablet 20 mg, 40 mg, 80 mg QL (3 EA per 3 days) valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 0 mg, 20 mg, 40 mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 5 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg ANTIARRHYTHMICS 49

58 amiodarone hcl intravenous solution 50 mg/3ml amiodarone hcl oral tablet 00 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 00 mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 00 mg, 50 mg, 50 mg mexiletine hcl oral capsule 50 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide hcl injection solution 00 mg/ml, 500 mg/ml propafenone hcl er oral capsule extended release 2 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 50 mg, 225 mg, 300 mg quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg ANTIHYPERTENSIVE COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine besy-benazepril hcl oral capsule 0-20 mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 0-60 mg, mg, 5-60 mg, mg amlodipine-olmesartan oral tablet 0-20 mg, 0-40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) 50

59 benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan cilexetil-hctz oral tablet mg, mg, mg captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril-hydrochlorothiazide oral tablet 0-25 mg, mg fosinopril sodium-hctz oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan potassium-hctz oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol-hydrochlorothiazide oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, 5-25 mg, mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg olmesartan medoxomil-hctz oral tablet mg, mg, mg olmesartan-amlodipine-hctz oral tablet mg, mg, mg, mg, mg propranolol-hctz oral tablet mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg spironolactone-hctz oral tablet mg telmisartan-amlodipine oral tablet 40-0 mg, 40-5 mg, 80-0 mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) PA; HR QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) 5

60 triamterene-hctz oral capsule mg, mg triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 00 mg, 25 mg, 50 mg betaxolol hcl oral tablet 0 mg, 20 mg bisoprolol fumarate oral tablet 0 mg, 5 mg carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg labetalol hcl intravenous solution 5 mg/ml labetalol hcl oral tablet 00 mg, 200 mg, 300 mg metoprolol succinate er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml metoprolol tartrate intravenous solution cartridge 5 mg/5ml metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 0 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 20 mg, 60 mg, 60 mg, 80 mg propranolol hcl intravenous solution mg/ml propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg sorine oral tablet 20 mg, 60 mg, 240 mg, 80 mg sotalol hcl (af) oral tablet 20 mg sotalol hcl oral tablet 60 mg, 240 mg, 80 mg timolol maleate oral tablet 0 mg, 20 mg, 5 mg QL (3 EA per 3 days) QL (62 EA per 3 days) BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 52

61 CALCIUM CHANNEL BLOCKING AGENTS afeditab cr oral tablet extended release 24 hour 30 mg, 60 mg amlodipine besylate oral tablet 0 mg, 2.5 mg, 5 mg cartia xt oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg cartia xt oral capsule extended release 24 hour 300 mg diltiazem hcl er beads oral capsule extended release 24 hour 80 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 20 mg, 240 mg, 300 mg diltiazem hcl er oral capsule extended release 2 hour 20 mg, 60 mg, 90 mg diltiazem hcl intravenous solution 50 mg/0ml diltiazem hcl intravenous solution reconstituted 00 mg diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg felodipine er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg matzim la oral tablet extended release 24 hour 80 mg, 240 mg, 300 mg, 360 mg, 420 mg nicardipine hcl intravenous solution 2.5 mg/ml nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 0 mg, 20 mg nimodipine oral capsule 30 mg QL (62 EA per 3 days) QL (3 EA per 3 days) QL (86 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) QL (62 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 53

62 nisoldipine er oral tablet extended release 24 hour 7 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg taztia xt oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg taztia xt oral capsule extended release 24 hour 300 mg, 360 mg verapamil hcl er oral capsule extended release 24 hour 00 mg, 300 mg verapamil hcl er oral capsule extended release 24 hour 20 mg, 80 mg, 200 mg, 240 mg, 360 mg verapamil hcl er oral tablet extended release 80 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml verapamil hcl oral tablet 20 mg, 40 mg, 80 mg CARDIOVASCULAR AGENTS, OTHER amlodipine-atorvastatin oral tablet 0-0 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 CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT DEMSER ORAL CAPSULE 250 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (62 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) QL (62 EA per 3 days) PA; QL (00 EA per 3 days) digitek oral tablet 25 mcg QL (3 EA per 3 days) digitek oral tablet 250 mcg PA; HR; QL (3 EA per 3 days) digoxin injection solution 0.25 mg/ml PA; HR digoxin oral solution 0.05 mg/ml PA; HR digoxin oral tablet 25 mcg QL (3 EA per 3 days) digoxin oral tablet 250 mcg PA; HR; QL (3 EA per 3 days) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG pentoxifylline er oral tablet extended release 400 mg RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR 000 MG, 500 MG PA PA 54

63 DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide oral tablet 25 mg, 250 mg DIURETICS, LOOP bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, mg, 2 mg furosemide injection solution 0 mg/ml, 0 mg/ml (4ml syringe) furosemide oral tablet 20 mg, 40 mg, 80 mg torsemide oral tablet 00 mg, 20 mg DIURETICS, POTASSIUM-SPARING amiloride hcl oral tablet 5 mg eplerenone oral tablet 25 mg, 50 mg spironolactone oral tablet 00 mg, 25 mg, 50 mg DIURETICS, THIAZIDE chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous solution reconstituted 500 mg chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 2.5 mg hydrochlorothiazide oral tablet 2.5 mg, 25 mg, 50 mg indapamide oral tablet.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 0 mg, 2.5 mg, 5 mg DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 mg fenofibrate oral capsule 50 mg, 50 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) fenofibrate oral tablet 45 mg, 60 mg QL (3 EA per 3 days) fenofibrate oral tablet 48 mg, 54 mg QL (62 EA per 3 days) fenofibric acid oral capsule delayed release 35 mg, 45 mg gemfibrozil oral tablet 600 mg QL (62 EA per 3 days) 55

64 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 80 mg lovastatin oral tablet 0 mg, 20 mg, 40 mg pravastatin sodium oral tablet 0 mg, 20 mg, 40 mg, 80 mg rosuvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg, 80 mg DYSLIPIDEMICS, OTHER cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet gm QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) QL (3 EA per 3 days) ezetimibe oral tablet 0 mg QL (3 EA per 3 days) JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML niacin er (antihyperlipidemic) oral tablet extended release 000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG omega-3-acid ethyl esters oral capsule gm PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 50 MG/ML, 75 MG/ML REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40 MG/ML VASCEPA ORAL CAPSULE GM VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS PA PA; QL (4 ML per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA PA PA PA 56

65 isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 20 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 0 mg, 20 mg minitran transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr QL (3 EA per 3 days) minitran transdermal patch 24 hour 0.4 mg/hr QL (62 EA per 3 days) nitroglycerin intravenous solution 5 mg/ml nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg minoxidil oral tablet 0 mg, 2.5 mg CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 30 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg QL (3 EA per 3 days) QL (62 EA per 3 days) QL (93 EA per 3 days) QL (62 EA per 3 days) QL (86 EA per 3 days) QL (24 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 57

66 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg QL (372 EA per 3 days) dextroamphetamine sulfate oral tablet 0 mg QL (86 EA per 3 days) dextroamphetamine sulfate oral tablet 5 mg QL (55 EA per 3 days) zenzedi oral tablet 0 mg QL (86 EA per 3 days) zenzedi oral tablet 5 mg QL (55 EA per 3 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES ATOMOXETINE HCL ORAL CAPSULE 0 MG, 8 MG, 25 MG ATOMOXETINE HCL ORAL CAPSULE 00 MG, 40 MG, 60 MG, 80 MG QL (93 EA per 3 days) QL (3 EA per 3 days) dexmethylphenidate hcl oral tablet 2.5 mg QL (248 EA per 3 days) dexmethylphenidate hcl oral tablet 5 mg QL (24 EA per 3 days) guanfacine hcl er oral tablet extended release 24 hour mg, 2 mg, 3 mg, 4 mg PA metadate er oral tablet extended release 20 mg QL (93 EA per 3 days) methylphenidate hcl er (cd) oral capsule extended release 0 mg methylphenidate hcl er oral tablet extended release 0 mg, 20 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (93 EA per 3 days) methylphenidate hcl oral solution 0 mg/5ml QL (930 ML per 3 days) methylphenidate hcl oral solution 5 mg/5ml QL (860 ML per 3 days) methylphenidate hcl oral tablet 0 mg, 20 mg, 5 mg STRATTERA ORAL CAPSULE 0 MG, 8 MG, 25 MG STRATTERA ORAL CAPSULE 00 MG, 40 MG, 60 MG, 80 MG CENTRAL NERVOUS SYSTEM, OTHER NUEDEXTA ORAL CAPSULE 20-0 MG RADICAVA INTRAVENOUS SOLUTION 30 MG/00ML riluzole oral tablet 50 mg tetrabenazine oral tablet 2.5 mg, 25 mg QL (93 EA per 3 days) QL (93 EA per 3 days) QL (3 EA per 3 days) PA 58

67 XYREM ORAL SOLUTION 500 MG/ML LA; QL (558 ML per 3 days) FIBROMYALGIA AGENTS duloxetine hcl oral capsule delayed release particles 60 mg LYRICA ORAL CAPSULE 00 MG SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 2.5 & 25 & 50 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 2 HOUR 0 MG AUBAGIO ORAL TABLET 4 MG, 7 MG AVONEX INTRAMUSCULAR KIT 30 MCG PA AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML QL (62 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; ST; QL (62 EA per 3 days) PA PA PA; ST; LA; QL (30 EA per 30 days) BETASERON SUBCUTANEOUS KIT 0.3 MG PA; QL (5 EA per 3 days) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML GILENYA ORAL CAPSULE 0.5 MG PA PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MCG/0.5ML PA; QL (3 ML per 3 days) PA; QL (2 ML per 28 days) PA TECFIDERA ORAL 20 & 240 MG PA TECFIDERA ORAL CAPSULE DELAYED RELEASE 20 MG, 240 MG TYSABRI INTRAVENOUS CONCENTRATE 300 MG/5ML DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS cevimeline hcl oral capsule 30 mg chlorhexidine gluconate mouth/throat solution 0.2 % PA PA 59

68 clotrimazole mouth/throat troche 0 mg lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0. % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS ABSORICA ORAL CAPSULE 0 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG acitretin oral capsule 0 mg, 7.5 mg, 25 mg acyclovir external ointment 5 % adapalene external cream 0. % adapalene external gel 0. %, 0.3 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0. % amcinonide external lotion 0. % amcinonide external ointment 0. % ammonium lactate external cream 2 % ammonium lactate external lotion 2 % amnesteem oral capsule 0 mg, 20 mg, 40 mg benzoyl peroxide-erythromycin external gel 5-3 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 60

69 betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external foam 0.2 % betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcipotriene-betameth diprop external ointment % claravis oral capsule 0 mg, 20 mg, 30 mg, 40 mg clindamycin phos-benzoyl perox external gel -5 % clobetasol propionate e external cream 0.05 % clobetasol propionate external foam 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external shampoo 0.05 % clobetasol propionate external solution 0.05 % COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.25 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 ST ST diclofenac sodium transdermal gel % PA diclofenac sodium transdermal gel 3 % PA; QL (00 GM per 3 days) 6

70 diclofenac sodium transdermal solution.5 % diflorasone diacetate external cream 0.05 % DIFLORASONE DIACETATE EXTERNAL OINTMENT 0.05 % ELIDEL EXTERNAL CREAM % ST fluocinolone acetonide body external oil 0.0 % fluocinolone acetonide external cream 0.0 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.0 % fluocinonide external cream 0.05 %, 0. % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external lotion 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyr lipo base external cream 0. % hydrocortisone butyrate external ointment 0. % hydrocortisone butyrate external solution 0. % hydrocortisone external cream %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment %, 2.5 % hydrocortisone rectal enema 00 mg/60ml hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % imiquimod external cream 5 % methoxsalen rapid oral capsule 0 mg mometasone furoate external cream 0. % mometasone furoate external ointment 0. % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 62

71 myorisan oral capsule 0 mg, 20 mg, 40 mg neuac external gel.2-5 % PICATO EXTERNAL GEL 0.05 % QL (3 EA per 3 days) PICATO EXTERNAL GEL 0.05 % QL (2 EA per 3 days) podofilox external solution 0.5 % prednicarbate external cream 0. % prednicarbate external ointment 0. % procto-med hc rectal cream 2.5 % procto-pak rectal cream % proctosol hc rectal cream 2.5 % proctozone-hc rectal cream 2.5 % REGRANEX EXTERNAL GEL 0.0 % PA SANTYL EXTERNAL OINTMENT 250 UNIT/GM selenium sulfide external lotion 2.5 % silver sulfadiazine external cream % STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 90 MG/ML QL (3 GM per 3 days) ST PA; ST tacrolimus external ointment 0.03 %, 0. % ST tazarotene external cream 0. % PA TAZORAC EXTERNAL CREAM 0.05 % PA TAZORAC EXTERNAL GEL 0.05 %, 0. % PA tretinoin external cream %, 0.05 %, 0. % tretinoin external gel 0.0 %, % tretinoin microsphere external gel 0.04 %, 0. % triamcinolone acetonide external cream %, 0. %, 0.5 % triamcinolone acetonide external lotion %, 0. % triamcinolone acetonide external ointment %, 0. %, 0.5 % UCERIS RECTAL FOAM 2 MG/ACT ST VALCHLOR EXTERNAL GEL 0.06 % zenatane oral capsule 0 mg, 20 mg, 40 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 63

72 ENZYME REPLACEMENT/ MODIFIERS ENZYME REPLACEMENT/ MODIFIERS ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML CARBAGLU ORAL TABLET 200 MG CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT CYSTADANE ORAL POWDER FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG PA; LA PA PA KUVAN ORAL PACKET 00 MG, 500 MG PA KUVAN ORAL TABLET SOLUBLE 00 MG PA levocarnitine oral solution gm/0ml levocarnitine oral tablet 330 mg LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NAGLAZYME INTRAVENOUS SOLUTION MG/ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG PA PA PA ORFADIN ORAL SUSPENSION 4 MG/ML PA; LA RAVICTI ORAL LIQUID. GM/ML sodium phenylbutyrate oral powder 3 gm/tsp VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT ZAVESCA ORAL CAPSULE 00 MG PA; QL (93 EA per 3 days) GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL atropine sulfate injection solution prefilled syringe 0.25 mg/5ml dicyclomine hcl intramuscular solution 0 mg/ml dicyclomine hcl oral capsule 0 mg dicyclomine hcl oral solution 0 mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 64

73 dicyclomine hcl oral tablet 20 mg glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg propantheline bromide oral tablet 5 mg ROBINUL INJECTION SOLUTION 0.4 MG/2ML ROBINUL-FORTE ORAL TABLET 2 MG DIGESTIVE ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 0000 UNIT, 5000 UNIT, UNIT, UNIT, UNIT, UNIT zenpep oral capsule delayed release particles 5000 unit GASTROINTESTINAL AGENTS, OTHER amoxicill-clarithro-lansopraz oral cromolyn sodium oral concentrate 00 mg/5ml diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg enulose oral solution 0 gm/5ml GATTEX SUBCUTANEOUS KIT 5 MG generlac oral solution 0 gm/5ml loperamide hcl oral capsule 2 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 65

74 MYTESI ORAL TABLET DELAYED RELEASE 25 MG omeprazole-sodium bicarbonate oral capsule mg, mg RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6ML, 2 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg HISTAMINE2 (H2) RECEPTOR ANTAGONISTS famotidine intravenous solution 20 mg/2ml famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg FAMOTIDINE PREMIXED INTRAVENOUS SOLUTION MG/50ML-% nizatidine oral capsule 50 mg, 300 mg nizatidine oral solution 5 mg/ml ranitidine hcl injection solution 50 mg/2ml ranitidine hcl oral capsule 50 mg, 300 mg ranitidine hcl oral syrup 5 mg/ml ranitidine hcl oral tablet 50 mg, 300 mg IRRITABLE BOWEL SYNDROME AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 ST; QL (36 ML per 28 days) alosetron hcl oral tablet 0.5 mg, mg QL (62 EA per 3 days) AMITIZA ORAL CAPSULE 24 MCG, 8 MCG APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 mg DIPENTUM ORAL CAPSULE 250 MG LIALDA ORAL TABLET DELAYED RELEASE.2 GM LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG MESALAMINE ORAL TABLET DELAYED RELEASE 800 MG QL (24 EA per 3 days) 66

75 mesalamine-cleanser rectal kit 4 gm RELISTOR ORAL TABLET 50 MG ST sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg LAXATIVES gavilyte-c oral solution reconstituted 240 gm gavilyte-g oral solution reconstituted 236 gm gavilyte-n with flavor pack oral solution reconstituted 420 gm lactulose oral solution 0 gm/5ml MOVIPREP ORAL SOLUTION RECONSTITUTED 00 GM peg 3350/electrolytes oral solution reconstituted 240 gm peg-3350/electrolytes oral solution reconstituted 236 gm polyethylene glycol 3350 oral powder trilyte oral solution reconstituted 420 gm PROTECTANTS misoprostol oral tablet 00 mcg, 200 mcg sucralfate oral tablet gm PROTON PUMP INHIBITORS esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg esomeprazole sodium intravenous solution reconstituted 20 mg, 40 mg lansoprazole oral capsule delayed release 5 mg, 30 mg omeprazole oral capsule delayed release 0 mg, 20 mg, 40 mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg GENITOURINARY AGENTS ANTISPASMODICS, URINARY bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 67

76 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG oxybutynin chloride er oral tablet extended release 24 hour 0 mg, 5 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml PA; HR oxybutynin chloride oral tablet 5 mg PA; HR VESICARE ORAL TABLET 0 MG, 5 MG PA; HR BENIGN PROSTATIC HYPERTROPHY AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR; QL (62 EA per 3 days) CIALIS ORAL TABLET 2.5 MG, 5 MG PA; QL (3 EA per 3 days) dutasteride oral capsule 0.5 mg QL (3 EA per 3 days) dutasteride-tamsulosin hcl oral capsule mg QL (3 EA per 3 days) finasteride oral tablet 5 mg QL (3 EA per 3 days) RAPAFLO ORAL CAPSULE 4 MG, 8 MG QL (3 EA per 3 days) tamsulosin hcl oral capsule 0.4 mg QL (62 EA per 3 days) GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 50 MG, 50 MG neomycin-polymyxin b gu irrigation solution potassium citrate er oral tablet extended release 0 meq (080 mg), 5 meq (620 mg), 5 meq (540 mg) sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg RENVELA ORAL PACKET 0.8 GM QL (540 EA per 3 days) RENVELA ORAL PACKET 2.4 GM QL (86 EA per 3 days) RENVELA ORAL TABLET 800 MG QL (540 EA per 3 days) SEVELAMER CARBONATE ORAL PACKET 0.8 GM, 2.4 GM VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2 % ESTRACE VAGINAL CREAM 0. MG/GM 68

77 estradiol vaginal tablet 0 mcg metronidazole vaginal gel 0.75 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg yuvafem vaginal tablet 0 mcg HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOC ORTICOIDS cortisone acetate oral tablet 25 mg dexamethasone intensol oral concentrate mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 0 mg/ml, 20 mg/30ml fludrocortisone acetate oral tablet 0. mg hydrocortisone oral tablet 0 mg, 20 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy pack 4 mg methylprednisolone sodium succ injection solution reconstituted 000 mg, 25 mg, 40 mg prednisolone sodium phosphate oral solution 5 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 0 mg, 5 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml prednisone oral solution 5 mg/5ml prednisone oral tablet mg, 0 mg, 2.5 mg, 20 mg, 5 mg, 50 mg PREDNISONE ORAL TABLET THERAPY PACK 0 MG (2), 0 MG (48), 5 MG (2), 5 MG (48) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 69

78 UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG ST oxandrolone oral tablet 0 mg QL (62 EA per 3 days) oxandrolone oral tablet 2.5 mg ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR ANDROGEL TRANSDERMAL GEL MG/.25GM (.62%), 40.5 MG/2.5GM (.62%) danazol oral capsule 00 mg, 200 mg, 50 mg testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml testosterone transdermal gel 2.5 mg/act (%) CONTRACEPTIVES alyacen /35 oral tablet -35 mg-mcg amethia oral tablet &0.0 mg apri oral tablet mg-mcg aranelle oral tablet 0.5// mg-mcg aubra oral tablet mg-mcg aviane oral tablet mg-mcg balziva oral tablet mg-mcg briellyn oral tablet mg-mcg camila oral tablet 0.35 mg caziant oral tablet 0./0.25/ mg cryselle-28 oral tablet mg-mcg cyclafem /35 oral tablet -35 mg-mcg cyclafem 7/7/7 oral tablet 0.5/0.75/-35 mg-mcg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 70

79 deblitane oral tablet 0.35 mg delyla oral tablet mg-mcg desogestrel-ethinyl estradiol oral tablet /0.0 mg (2/5), mg-mcg drospirenone-ethinyl estradiol oral tablet mg emoquette oral tablet mg-mcg enpresse-28 oral tablet errin oral tablet 0.35 mg ethynodiol diac-eth estradiol oral tablet -50 mgmcg falmina oral tablet mg-mcg femynor oral tablet mg-mcg gianvi oral tablet mg gildagia oral tablet mg-mcg introvale oral tablet mg isibloom oral tablet mg-mcg jolivette oral tablet 0.35 mg junel.5/30 oral tablet.5-30 mg-mcg junel /20 oral tablet -20 mg-mcg junel fe.5/30 oral tablet.5-30 mg-mcg junel fe /20 oral tablet -20 mg-mcg kariva oral tablet /0.0 mg (2/5) kelnor /35 oral tablet -35 mg-mcg kimidess oral tablet /0.0 mg (2/5) larin.5/30 oral tablet.5-30 mg-mcg larin /20 oral tablet -20 mg-mcg larin fe.5/30 oral tablet.5-30 mg-mcg larin fe /20 oral tablet -20 mg-mcg larissia oral tablet mg-mcg leena oral tablet 0.5// mg-mcg lessina oral tablet mg-mcg levonest oral tablet levonorgest-eth estrad 9-day oral tablet mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 7

80 levora 0.5/30 (28) oral tablet mg-mcg lomedia 24 fe oral tablet -20 mg-mcg(24) loryna oral tablet mg low-ogestrel oral tablet mg-mcg lutera oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet mg-mcg medroxyprogesterone acetate intramuscular suspension 50 mg/ml microgestin.5/30 oral tablet.5-30 mg-mcg microgestin /20 oral tablet -20 mg-mcg microgestin fe.5/30 oral tablet.5-30 mg-mcg microgestin fe /20 oral tablet -20 mg-mcg mononessa oral tablet mg-mcg necon 0.5/35 (28) oral tablet mg-mcg necon 7/7/7 oral tablet 0.5/0.75/-35 mg-mcg nikki oral tablet mg nora-be oral tablet 0.35 mg norethin ace-eth estrad-fe oral tablet -20 mgmcg(24) norethindrone acet-ethinyl est oral tablet -20 mg-mcg norethindrone oral tablet 0.35 mg norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.8/0.25/0.25 mg-35 mcg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel /35 (2) oral tablet -35 mg-mcg nortrel /35 (28) oral tablet -35 mg-mcg nortrel 7/7/7 oral tablet 0.5/0.75/-35 mg-mcg ocella oral tablet mg ogestrel oral tablet mg-mcg orsythia oral tablet mg-mcg QL ( ML per 90 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 72

81 pimtrea oral tablet /0.0 mg (2/5) pirmella /35 oral tablet -35 mg-mcg portia-28 oral tablet mg-mcg previfem oral tablet mg-mcg quasense oral tablet mg reclipsen oral tablet mg-mcg sharobel oral tablet 0.35 mg sprintec 28 oral tablet mg-mcg sronyx oral tablet mg-mcg tarina fe /20 oral tablet -20 mg-mcg tri-legest fe oral tablet -20/-30/-35 mg-mcg trinessa (28) oral tablet 0.8/0.25/0.25 mg-35 mcg tri-previfem oral tablet 0.8/0.25/0.25 mg-35 mcg tri-sprintec oral tablet 0.8/0.25/0.25 mg-35 mcg trivora (28) oral tablet velivet oral tablet 0./0.25/ mg vestura oral tablet mg vyfemla oral tablet mg-mcg wymzya fe oral tablet chewable mg-mcg zenchent fe oral tablet chewable mg-mcg zenchent oral tablet mg-mcg zovia /35e (28) oral tablet -35 mg-mcg ESTROGENS estradiol oral tablet 0.5 mg, mg, 2 mg PA; HR estradiol transdermal patch weekly mg/24hr, mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, mg/24hr, 0. mg/24hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg estropipate oral tablet 0.75 mg,.5 mg, 3 mg jinteli oral tablet -5 mg-mcg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 73

82 MENEST ORAL TABLET 0.3 MG, MG,.25 MG mimvey lo oral tablet mg mimvey oral tablet -0.5 mg PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PA; HR PA; HR PA; HR PREMPHASE ORAL TABLET MG PA; HR PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS MAKENA INTRAMUSCULAR OIL 250 MG/ML medroxyprogesterone acetate oral tablet 0 mg, 2.5 mg, 5 mg PA; HR PA megestrol acetate oral suspension 625 mg/5ml PA; HR norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 00 mg, 200 mg HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) cabergoline oral tablet 0.5 mg chorionic gonadotropin intramuscular solution reconstituted 0000 unit desmopressin ace spray refrig nasal solution 0.0 % desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0. mg, 0.2 mg INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA PA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 74

83 NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 0 MG/.5ML, 5 MG/.5ML, 30 MG/3ML, 5 MG/.5ML HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) levothyroxine sodium oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium intravenous solution 0 mcg/ml liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 00 mcg, 2 mcg, 25 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) SENSIPAR ORAL TABLET 30 MG PA SENSIPAR ORAL TABLET 60 MG QL (62 EA per 3 days) SENSIPAR ORAL TABLET 90 MG QL (24 EA per 3 days) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 75

84 LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.25 MG LUPRON DEPOT-PED (-MONTH) INTRAMUSCULAR KIT.25 MG LUPRON DEPOT-PED (-MONTH) INTRAMUSCULAR KIT 5 MG octreotide acetate injection solution 00 mcg/ml, 000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 0 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 20 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 0 MG, 5 MG, 20 MG SYNAREL NASAL SOLUTION 2 MG/ML PA HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg propylthiouracil oral tablet 50 mg IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, MG, 5 MG PA; QL ( EA per 28 days) PA; QL ( EA per 90 days) PA; QL ( EA per 28 days) PA; LA; QL (62 ML per 3 days) PA; QL ( ML per 28 days) PA; QL (62 EA per 3 days) BD; ST AZASAN ORAL TABLET 00 MG, 75 MG BD; ST azathioprine oral tablet 50 mg BD AZATHIOPRINE SODIUM INJECTION SOLUTION RECONSTITUTED 00 MG BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 400 MG BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 76

85 BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML ST CIMZIA SUBCUTANEOUS KIT 2 X 200 MG ST cyclosporine intravenous solution 50 mg/ml BD cyclosporine modified oral capsule 00 mg, 25 mg, 50 mg BD cyclosporine modified oral solution 00 mg/ml BD cyclosporine oral capsule 00 mg, 25 mg BD gengraf oral capsule 00 mg, 25 mg, 50 mg BD gengraf oral solution 00 mg/ml BD mycophenolate mofetil hcl intravenous solution reconstituted 500 mg BD mycophenolate mofetil oral capsule 250 mg BD mycophenolate mofetil oral suspension reconstituted 200 mg/ml BD mycophenolate mofetil oral tablet 500 mg BD mycophenolate sodium oral tablet delayed release 80 mg, 360 mg NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG PROGRAF INTRAVENOUS SOLUTION 5 MG/ML BD BD; ST; QL (200 EA per 3 days) BD RAPAMUNE ORAL SOLUTION MG/ML BD SANDIMMUNE ORAL CAPSULE 00 MG, 25 MG SANDIMMUNE ORAL SOLUTION 00 MG/ML BD BD sirolimus oral tablet 0.5 mg, mg, 2 mg BD tacrolimus oral capsule 0.5 mg, mg, 5 mg BD THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG BD ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG BD; ST; QL (62 EA per 3 days) ZORTRESS ORAL TABLET 0.5 MG BD; ST; QL (24 EA per 3 days) IMMUNIZING AGENTS, PASSIVE You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 77

86 ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML GAMASTAN S/D INTRAMUSCULAR INJECTABLE GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML VARIZIG INTRAMUSCULAR SOLUTION 25 UNIT/.2ML IMMUNOMODULATORS ACTEMRA INTRAVENOUS SOLUTION 200 MG/0ML, 400 MG/20ML, 80 MG/4ML ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 62 MG/0.9ML ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK) HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML PA; LA BD BD PA PA ST ST You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 78

87 ILARIS (50MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/0.67ML PA ST leflunomide oral tablet 0 mg, 20 mg QL (3 EA per 3 days) ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 25 MG/ML ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML OTEZLA ORAL TABLET 30 MG SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 00 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML ST ST ST ST XELJANZ ORAL TABLET 5 MG ST VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 BCG VACCINE INJECTION INJECTABLE BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) DAPTACEL INTRAMUSCULAR SUSPENSION DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR SUSPENSION 25-5 LFU/0.5ML ST; QL (3 ML per 3 days) ST; QL (3 ML per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 79

88 ENGERIX-B INJECTION SUSPENSION 0 MCG/0.5ML, 0 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 440 EL U/ML, 720 EL U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 0 MCG HYPERRAB S/D INTRAMUSCULAR INJECTABLE 50 UNIT/ML, 50 UNIT/ML (0ML) IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE PEDIARIX INTRAMUSCULAR SUSPENSION PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 0 MCG/ML, 0 MCG/ML (ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 80

89 ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TWINRIX INTRAMUSCULAR SUSPENSION TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 9400 UNT/0.65ML METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 0 mg, 40 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 BD BD QL ( EA per 365 days) QL (3 EA per 3 days) alendronate sodium oral tablet 35 mg, 70 mg QL (4 EA per 28 days) calcitonin (salmon) nasal solution 200 unit/act BD; QL (4 ML per 28 days) calcitriol intravenous solution mcg/ml BD calcitriol oral capsule 0.25 mcg, 0.5 mcg BD calcitriol oral solution mcg/ml BD doxercalciferol intravenous solution 4 mcg/2ml doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML PA; QL (2.4 ML per 28 days) 8

90 ibandronate sodium intravenous solution 3 mg/3ml ibandronate sodium oral tablet 50 mg QL ( EA per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG, 25 MCG, 50 MCG, 75 MCG pamidronate disodium intravenous solution 30 mg/0ml, 6 mg/ml, 90 mg/0ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR paricalcitol intravenous solution 5 mcg/ml BD paricalcitol oral capsule mcg, 2 mcg, 4 mcg BD PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML raloxifene hcl oral tablet 60 mg TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 320 MCG/.56ML XGEVA SUBCUTANEOUS SOLUTION 20 MG/.7ML zoledronic acid intravenous concentrate 4 mg/5ml zoledronic acid intravenous solution 5 mg/00ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00ML MISCELLANEOUS MISCELLANEOUS ASSURE ID INSULIN SAFETY SYR 29G X /2" ML COMFORT ASSIST INSULIN SYRINGE 29G X /2" ML CVS GAUZE STERILE PAD 2"X2" DEPEN TITRATABS ORAL TABLET 250 MG DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG EXEL COMFORT POINT PEN NEEDLE 29G X 2MM lactated ringers irrigation solution PREFERRED PLUS INSULIN SYRINGE 28G X /2" 0.5 ML ST; QL ( ML per 80 days) PA PA; QL (2 ML per 28 days) BD 82

91 RELI-ON INSULIN SYRINGE 29G 0.3 ML ringers irrigation irrigation solution sterile water for irrigation irrigation solution SYPRINE ORAL CAPSULE 250 MG PA OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.0 % TRAVATAN Z OPHTHALMIC SOLUTION % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution % pilocarpine hcl ophthalmic solution %, 2 %, 4 % proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % QL (62 EA per 3 days) OPHTHALMIC ANTI INFECTIVES AZASITE OPHTHALMIC SOLUTION % bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm gatifloxacin ophthalmic solution 0.5 % gentamicin sulfate ophthalmic solution 0.3 % levofloxacin ophthalmic solution 0.5 % MOXEZA OPHTHALMIC SOLUTION 0.5 % moxifloxacin hcl ophthalmic solution 0.5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 83

92 polymyxin b-trimethoprim ophthalmic solution unit/ml-% SULFACETAMIDE SODIUM OPHTHALMIC OINTMENT 0 % sulfacetamide sodium ophthalmic solution 0 % tobramycin ophthalmic solution 0.3 % trifluridine ophthalmic solution % VIGAMOX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC GEL 0.5 % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % cromolyn sodium ophthalmic solution 4 % epinastine hcl ophthalmic solution 0.05 % olopatadine hcl ophthalmic solution 0. % PATADAY OPHTHALMIC SOLUTION 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0. %, 0.5 % apraclonidine hcl ophthalmic solution 0.5 % AZOPT OPHTHALMIC SUSPENSION % betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.5 %, 0.2 % carteolol hcl ophthalmic solution % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution 2 % QL (0 ML per 3 days) dorzolamide hcl-timolol mal ophthalmic solution mg/ml levobunolol hcl ophthalmic solution 0.5 % metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.25 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (0 ML per 28 days) 84

93 SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % OPHTHALMIC ANTI- INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % bromfenac sodium ophthalmic solution 0.09 % CYSTARAN OPHTHALMIC SOLUTION 0.44 % dexamethasone sodium phosphate ophthalmic solution 0. % diclofenac sodium ophthalmic solution 0. % DUREZOL OPHTHALMIC EMULSION 0.05 % fluorometholone ophthalmic suspension 0. % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension prednisolone sodium phosphate ophthalmic solution % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; QL (60 ML per 30 days) 85

94 sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX OPHTHALMIC SUSPENSION % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % OTIC AGENTS OTIC AGENTS acetic acid otic solution 2 % fluocinolone acetonide otic oil 0.0 % hydrocortisone-acetic acid otic solution -2 % neomycin-polymyxin-hc otic solution % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS ANTIHISTAMINES carbinoxamine maleate oral solution 4 mg/5ml carbinoxamine maleate oral tablet 4 mg cetirizine hcl oral syrup mg/ml QL (30 ML per 3 days) clemastine fumarate oral tablet 2.68 mg cyproheptadine hcl oral syrup 2 mg/5ml PA; HR cyproheptadine hcl oral tablet 4 mg PA; HR desloratadine oral tablet 5 mg desloratadine oral tablet dispersible 2.5 mg, 5 mg diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir 2.5 mg/5ml levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg promethazine vc plain oral solution mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 86

95 promethazine vc plain oral syrup mg/5ml ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 0 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 80 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT PULMICORT INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT ANTILEUKOTRIENES QL (3 EA per 3 days) BD QL (62 EA per 3 days) QL (24 GM per 24 days) QL ( GM per 3 days) QL ( EA per 30 days) QL (2 EA per 30 days) BD montelukast sodium oral packet 4 mg QL (3 EA per 3 days) montelukast sodium oral tablet 0 mg QL (3 EA per 3 days) montelukast sodium oral tablet chewable 4 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL (3 EA per 3 days) zafirlukast oral tablet 0 mg, 20 mg QL (62 EA per 3 days) BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA INHALATION AEROSOL SOLUTION 7 MCG/ACT ipratropium bromide inhalation solution 0.02 % BD SPIRIVA HANDIHALER INHALATION CAPSULE 8 MCG QL (3 GM per 3 days) QL (3 EA per 3 days) 87

96 SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.25 MCG/ACT SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) aminophylline intravenous solution 25 mg/ml theophylline er oral tablet extended release 2 hour 00 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/5ml BRONCHODILATORS, SYMPATHOMIMETIC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL 5-2 MCG/ACT, MCG/ACT, 45-2 MCG/ACT albuterol sulfate er oral tablet extended release 2 hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml,.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.5 MG/0.3ML EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML QL (4 GM per 30 days) QL (62 EA per 3 days) QL (2 GM per 30 days) BD QL (2 EA per 60 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 88

97 EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.5 MG/0.3ML FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 3-4 MCG/ACT, MCG/ACT, 55-4 MCG/ACT ipratropium-albuterol inhalation solution (3) mg/3ml metaproterenol sulfate oral syrup 0 mg/5ml metaproterenol sulfate oral tablet 0 mg, 20 mg PROAIR HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 08 (90 BASE) MCG/ACT PROVENTIL HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT terbutaline sulfate injection solution mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT NASAL AGENTS azelastine hcl nasal solution 0. %, 0.5 % budesonide nasal suspension 32 mcg/act You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 QL ( EA per 30 days) BD QL (27 GM per 3 days) QL (3 EA per 3 days) QL (34 GM per 3 days) QL (62 EA per 3 days) QL (4 GM per 30 days) QL ( GM per 30 days) QL (54 GM per 3 days) flunisolide nasal solution 25 mcg/act (0.025%) QL (50 ML per 3 days) fluticasone propionate nasal suspension 50 mcg/act QL (32 GM per 30 days) ipratropium bromide nasal solution 0.03 % QL (62 ML per 3 days) ipratropium bromide nasal solution 0.06 % QL (3 ML per 3 days) 89

98 olopatadine hcl nasal solution 0.6 % PULMONARY ANTIHYPERTENSIVES ADCIRCA ORAL TABLET 20 MG PA ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG QL (93 EA per 3 days) LETAIRIS ORAL TABLET 0 MG, 5 MG QL (3 EA per 3 days) OPSUMIT ORAL TABLET 0 MG ST; QL (93 EA per 3 days) REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML BD sildenafil citrate oral tablet 20 mg PA; QL (93 EA per 3 days) TRACLEER ORAL TABLET 25 MG, 62.5 MG QL (62 EA per 3 days) UPTRAVI ORAL TABLET 000 MCG, 200 MCG, 400 MCG, 600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG VENTAVIS INHALATION SOLUTION 0 MCG/ML, 20 MCG/ML RESPIRATORY TRACT AGENTS, OTHER PA; LA PA; LA acetylcysteine inhalation solution 0 %, 20 % BD CROMOLYN SODIUM INHALATION NEBULIZATION SOLUTION 20 MG/2ML BD; QL (270 ML per 30 days) BD DALIRESP ORAL TABLET 500 MCG QL (3 EA per 3 days) ESBRIET ORAL CAPSULE 267 MG PA ESBRIET ORAL TABLET 267 MG, 80 MG PA KALYDECO ORAL PACKET 50 MG, 75 MG PA KALYDECO ORAL TABLET 50 MG PA OFEV ORAL CAPSULE 00 MG, 50 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 000 MG PULMOZYME INHALATION SOLUTION MG/ML PA BD; QL (55 ML per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 90

99 tobramycin inhalation nebulization solution 300 mg/5ml XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 50 MG ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 000 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS baclofen oral tablet 0 mg, 20 mg BD PA; QL (2 EA per 3 days) carisoprodol-aspirin oral tablet mg PA; HR; QL (248 EA per 3 days) carisoprodol-aspirin-codeine oral tablet mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 PA; HR; QL (248 EA per 3 days) chlorzoxazone oral tablet 500 mg PA; HR; QL (86 EA per 3 days) cyclobenzaprine hcl oral tablet 0 mg, 5 mg PA; HR; QL (93 EA per 3 days) cyclobenzaprine hcl oral tablet 7.5 mg PA; HR; QL (86 EA per 3 days) metaxalone oral tablet 800 mg PA; HR; QL (24 EA per 3 days) methocarbamol injection solution 000 mg/0ml PA; HR methocarbamol oral tablet 500 mg, 750 mg PA; HR orphenadrine citrate er oral tablet extended release 2 hour 00 mg orphenadrine citrate injection solution 30 mg/ml PA; HR tizanidine hcl oral tablet 2 mg, 4 mg SLEEP DISORDER AGENTS BENZODIAZEPINES RESTORIL ORAL CAPSULE 5 MG, 22.5 MG, 7.5 MG PA; HR; QL (62 EA per 3 days) temazepam oral capsule 5 mg, 22.5 mg, 30 mg QL (3 EA per 3 days) temazepam oral capsule 7.5 mg QL (24 EA per 3 days) triazolam oral tablet 0.25 mg QL (3 EA per 3 days) triazolam oral tablet 0.25 mg QL (62 EA per 3 days) GABA RECEPTOR MODULATORS zaleplon oral capsule 0 mg, 5 mg PA; HR; QL (93 EA per 365 days) zolpidem tartrate oral tablet 0 mg, 5 mg PA; HR; QL (93 EA per 365 days) SLEEP DISORDERS, OTHER HETLIOZ ORAL CAPSULE 20 MG QL (3 EA per 3 days) 9

100 modafinil oral tablet 00 mg, 200 mg PA; QL (62 EA per 3 days) ROZEREM ORAL TABLET 8 MG QL (3 EA per 3 days) SILENOR ORAL TABLET 3 MG, 6 MG QL (3 EA per 3 days) THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS EXJADE ORAL TABLET SOLUBLE 25 MG, 250 MG, 500 MG FERRIPROX ORAL TABLET 500 MG fomepizole intravenous solution gm/ml kionex oral powder physiolyte irrigation solution physiosol irrigation irrigation solution PA SAMSCA ORAL TABLET 5 MG, 30 MG PA; QL (62 EA per 3 days) sodium polystyrene sulfonate oral suspension 5 gm/60ml sps oral suspension 5 gm/60ml ELECTROLYTE/MINERAL REPLACEMENT dextrose in lactated ringers intravenous solution 5 % DEXTROSE-NACL INTRAVENOUS SOLUTION % dextrose-nacl intravenous solution %, %, %, %, %, %, % kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l klor-con 0 oral tablet extended release 0 meq klor-con m0 oral tablet extended release 0 meq You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 92

101 klor-con m5 oral tablet extended release 5 meq klor-con m20 oral tablet extended release 20 meq lactated ringers intravenous solution magnesium sulfate injection solution 50 %, 50 % (0ml syringe) normosol-m in d5w intravenous solution NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION potassium chloride crys er oral tablet extended release 0 meq, 20 meq potassium chloride er oral capsule extended release 0 meq, 8 meq potassium chloride er oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-%, meq/l-% potassium chloride intravenous solution 2 meq/ml, 20 meq/00ml potassium chloride oral solution 20 meq/5ml (0%), 40 meq/5ml (20%) ringers intravenous solution sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % tpn electrolytes intravenous solution NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 0 %, 8.5 % aminosyn ii/electrolytes intravenous solution 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 % BD BD BD aminosyn/electrolytes intravenous solution 8.5 % BD AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 93

102 AMINOSYN-PF INTRAVENOUS SOLUTION 0 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (4.25/0) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % clinimix/dextrose (4.25/0) intravenous solution 4.25 % CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % dextrose intravenous solution 0 %, 5 % FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD hepatamine intravenous solution 8 % BD NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % BD nutrilipid intravenous emulsion 20 % BD PREMASOL INTRAVENOUS SOLUTION 0 % BD premasol intravenous solution 6 % BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 94

103 PROCALAMINE INTRAVENOUS SOLUTION 3 % BD PROSOL INTRAVENOUS SOLUTION 20 % BD TRAVASOL INTRAVENOUS SOLUTION 0 % TROPHAMINE INTRAVENOUS SOLUTION 0 % BD BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 7379, Ver. 26 Last updated 0/24/207 Effective Date: /0/207 95

104 Alphabetical Listing A abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE ABSORICA acamprosate calcium... 5 acarbose acebutolol hcl acetaminophen-codeine... 3 acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetazolamide acetic acid acetylcysteine acitretin ACTEMRA ACTHIB ACTIMMUNE acyclovir... 39, 60 acyclovir sodium ADACEL ADAGEN adapalene ADCIRCA adefovir dipivoxil ADEMPAS adriamycin adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate ALDURAZYME ALECENSA alendronate sodium... 8 ALIMTA ALINIA allopurinol... 2 alosetron hcl ALPHAGAN P alprazolam... 42, 43 alprazolam er ALPRAZOLAM INTENSOL 42 alprazolam xr ALUNBRIG alyacen / amantadine hcl AMBISOME amcinonide amethia amikacin sulfate... 5 amiloride hcl amiloride-hydrochlorothiazide50 aminophylline AMINOSYN II aminosyn ii/electrolytes aminosyn/electrolytes AMINOSYN/ELECTROLYTE S AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl AMITIZA amitriptyline hcl... 8 amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan 50 amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan-hctz ammonium lactate amnesteem amoxapine... 9 amoxicill-clarithro-lansopraz. 65 amoxicillin... 9 amoxicillin-pot clavulanate... 9 amphetaminedextroamphetamine amphotericin b ampicillin... 9 ampicillin sodium... 9 ampicillin-sulbactam sodium... 9 AMPYRA ANADROL anastrozole ANDRODERM ANDROGEL APOKYN apraclonidine hcl aprepitant... 9 apri APRISO APTIOM... 4 APTIVUS... 4 aranelle ARCALYST aripiprazole ARIPIPRAZOLE ARISTADA ARNUITY ELLIPTA ascomp-codeine... 3 ASPIRIN-DIPYRIDAMOLE ER ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atenolol atenolol-chlorthalidone ATOMOXETINE HCL atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate... 64, 83 ATROVENT HFA AUBAGIO aubra AVASTIN... 25, 26 aviane AVONEX AVONEX PEN AVONEX PREFILLED azacitidine AZASAN AZASITE azathioprine AZATHIOPRINE SODIUM.. 76 azelastine hcl... 84, 89 azithromycin... 0 AZOPT aztreonam... 8 B bacitracin BACITRACIN... 6 bacitracin-polymyxin b... 83

105 bacitra-neomycin-polymyxin-hc baclofen... 9 balsalazide disodium balziva BANZEL... 4 BARACLUDE BAVENCIO BCG VACCINE BELEODAQ benazepril hcl benazepril-hydrochlorothiazide... 5 BENLYSTA... 76, 77 benzoyl peroxide-erythromycin benztropine mesylate betamethasone dipropionate.. 60, 6 betamethasone dipropionate aug betamethasone valerate... 6 BETASERON betaxolol hcl... 52, 84 bethanechol chloride bexarotene BEXSERO bicalutamide BICILLIN C-R... 9 BICILLIN C-R 900/ BICILLIN L-A... 0 BICNU bisoprolol fumarate bisoprolol-hydrochlorothiazide... 5 bleomycin sulfate BLEPHAMIDE BLEPHAMIDE S.O.P BOOSTRIX BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRIVIACT... 4 bromfenac sodium bromocriptine mesylate budesonide... 87, 89 bumetanide buprenorphine hcl... 5 bupropion hcl... 6 bupropion hcl er (smoking det) 5 bupropion hcl er (sr)... 6 bupropion hcl er (xl)... 6 buspirone hcl busulfan butalbital-apap-caff-cod... 3 BYDUREON BYETTA 0 MCG PEN BYETTA 5 MCG PEN C cabergoline CABOMETYX CAFERGOT calcipotriene... 6 calcipotriene-betameth diprop 6 calcitonin (salmon)... 8 calcitriol... 8 calcium acetate (phos binder). 68 camila CANCIDAS candesartan cilexetil candesartan cilexetil-hctz... 5 CAPASTAT SULFATE CAPRELSA captopril captopril-hydrochlorothiazide 5 CARBAGLU carbamazepine... 5 carbamazepine er... 5, 43 carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin carisoprodol-aspirin... 9 carisoprodol-aspirin-codeine.. 9 carteolol hcl cartia xt carvedilol CASPOFUNGIN ACETATE. 20 CAYSTON... 9 caziant cefaclor... 7 cefaclor er... 7 cefadroxil... 7 cefazolin sodium... 7 cefdinir... 8 cefepime hcl... 8 cefotaxime sodium... 8 cefotetan disodium... 8 cefoxitin sodium... 8 cefpodoxime proxetil... 8 cefprozil... 8 ceftazidime... 8 ceftriaxone sodium... 8 cefuroxime axetil... 8 cefuroxime sodium... 8 celecoxib CELONTIN... 3 cephalexin... 8 CEREZYME cetirizine hcl cevimeline hcl CHANTIX... 5 CHANTIX CONTINUING MONTH PAK... 5 CHANTIX STARTING MONTH PAK... 5 chloramphenicol sod succinate. 6 chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine hcl chlorpropamide chlorthalidone chlorzoxazone... 9 cholestyramine light chorionic gonadotropin CIALIS ciclopirox ciclopirox olamine cilostazol CIMZIA CIMZIA PREFILLED CINRYZE ciprofloxacin... ciprofloxacin hcl..., 83 ciprofloxacin in d5w... cisplatin citalopram hydrobromide... 7 cladribine claravis... 6 clarithromycin... 0 clarithromycin er... 0 clemastine fumarate clindamycin hcl

106 clindamycin palmitate hcl... 6 clindamycin phos-benzoyl perox... 6 clindamycin phosphate... 6, 68 clindamycin phosphate in d5w. 6 CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/0) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (5/5) CLINIMIX/DEXTROSE (2.75/5) clinimix/dextrose (4.25/0) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/5) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) clobetasol propionate... 6 clobetasol propionate e... 6 clofarabine clomipramine hcl... 9 clonazepam... 2, 3 clonidine hcl clopidogrel bisulfate clorazepate dipotassium clotrimazole... 20, 60 clotrimazole-betamethasone clozapine CLOZAPINE COARTEM COLCHICINE... 2 colchicine-probenecid... 2 colestipol hcl colistimethate sodium... 6 COMBIGAN COMBIVENT RESPIMAT COMETRIQ (00 MG DAILY DOSE) COMETRIQ (40 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE COMPLERA... 4 compro COPAXONE cortisone acetate COSENTYX... 6 COSENTYX SENSOREADY PEN... 6 COTELLIC CREON CRIXIVAN... 4 cromolyn sodium... 65, 84 CROMOLYN SODIUM cryselle CVS GAUZE STERILE cyclafem / cyclafem 7/7/ cyclobenzaprine hcl... 9 CYCLOPHOSPHAMIDE cyclosporine cyclosporine modified cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) D dacarbazine DAKLINZA DALIRESP danazol dapsone DAPTACEL daptomycin... 6 DARAPRIM daunorubicin hcl deblitane... 7 decitabine delyla... 7 DEMSER DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine hcl... 9 desloratadine desmopressin ace spray refrig 74 desmopressin acetate desogestrel-ethinyl estradiol... 7 desonide... 6 desoximetasone... 6 desvenlafaxine er... 7 desvenlafaxine succinate er... 7 dexamethasone dexamethasone intensol dexamethasone sodium phosphate... 69, 85 dexmethylphenidate hcl dexrazoxane dextroamphetamine sulfate dextroamphetamine sulfate er 57, 58 dextrose dextrose in lactated ringers dextrose-nacl DEXTROSE-NACL DIASTAT ACUDIAL... 3 DIASTAT PEDIATRIC... 3 diazepam... 3, 43 DIAZEPAM diazepam intensol diclofenac potassium diclofenac sodium. 22, 6, 62, 85 diclofenac sodium er dicloxacillin sodium... 0 dicyclomine hcl... 64, 65 didanosine diflorasone diacetate DIFLORASONE DIACETATE diflunisal digitek digoxin dihydroergotamine mesylate.. 23 DILANTIN... 5 diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads.. 53 dilt-xr DIPENTUM diphenhydramine hcl diphenoxylate-atropine

107 DIPHTHERIA-TETANUS TOXOIDS DT dipyridamole disopyramide phosphate disulfiram... 5 divalproex sodium... 3 divalproex sodium er... 3 DOCETAXEL dofetilide donepezil hcl... 6 dorzolamide hcl dorzolamide hcl-timolol mal.. 84 doxazosin mesylate doxepin hcl... 9 doxercalciferol... 8 doxorubicin hcl doxorubicin hcl liposomal doxy doxycycline hyclate..., 2 doxycycline monohydrate... 2 dronabinol... 9 drospirenone-ethinyl estradiol 7 DROXIA duloxetine hcl... 7, 59 DULOXETINE HCL... 7 duramorph... 3 DUREZOL dutasteride dutasteride-tamsulosin hcl E econazole nitrate EDURANT ELIDEL ELIQUIS ELITEK EMBEDA... 2 EMCYT EMEND... 9 emoquette... 7 EMSAM... 7 EMTRIVA EMVERM enalapril maleate enalapril-hydrochlorothiazide 5 ENBREL ENBREL SURECLICK endocet... 3 ENGERIX-B enoxaparin sodium... 46, 47 enpresse entacapone entecavir enulose EPCLUSA epinastine hcl EPINEPHRINE EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin hcl epitol... 5 EPIVIR HBV eplerenone EPOGEN eprosartan mesylate ERAXIS ergoloid mesylates... 5 ERIVEDGE errin... 7 ERWINAZE ery-tab... 0 ERY-TAB... 0 erythrocin lactobionate... 0 erythrocin stearate... 0 erythromycin..., 83 erythromycin base... 0 erythromycin ethylsuccinate... ESBRIET escitalopram oxalate... 7 esomeprazole magnesium esomeprazole sodium ESTRACE estradiol... 69, 73 estradiol valerate estradiol-norethindrone acet estropipate ethambutol hcl ethosuximide... 3 ethynodiol diac-eth estradiol.. 7 etodolac etoposide EURAX EVOTAZ EXEL COMFORT POINT PEN NEEDLE exemestane EXJADE ezetimibe F FABRAZYME falmina... 7 famciclovir famotidine FAMOTIDINE PREMIXED.. 66 FANAPT FANAPT TITRATION PACK FARESTON FARXIGA FARYDAK FASLODEX felbamate... 4 felodipine er femynor... 7 fenofibrate fenofibrate micronized fenofibric acid fentanyl... 2 fentanyl citrate... 3 FERRIPROX FETZIMA... 8 FETZIMA TITRATION... 8 finasteride FIRAZYR flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole... 2 fluconazole in sodium chloride flucytosine... 2 fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide... 62, 86 fluocinolone acetonide body fluocinonide fluorometholone fluorouracil... 25, 62 fluoxetine hcl... 8 FLUOXETINE HCL... 8 fluphenazine decanoate fluphenazine hcl flurazepam hcl... 3 flurbiprofen flurbiprofen sodium flutamide fluticasone propionate... 62, 89 FLUTICASONE- SALMETEROL fluvoxamine maleate

108 fluvoxamine maleate er... 8 fomepizole fondaparinux sodium FORTEO... 8 fosinopril sodium fosinopril sodium-hctz... 5 fosphenytoin sodium... 5 FRAGMIN FREAMINE HBC furosemide FUZEON... 4 FYCOMPA... 3 G gabapentin... 3 GABITRIL... 3 galantamine hydrobromide... 6 GALANTAMINE HYDROBROMIDE... 6 galantamine hydrobromide er. 6 GAMASTAN S/D GAMMAGARD ganciclovir sodium GARDASIL gatifloxacin GATTEX gavilyte-c gavilyte-g gavilyte-n with flavor pack GEMCITABINE HCL gemfibrozil generlac gengraf gentamicin in saline... 5 gentamicin sulfate... 5, 83 GEODON gianvi... 7 gildagia... 7 GILENYA GILOTRIF GLEEVEC... 27, 28 GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl GLOBAL ALCOHOL PREP EASE GLUCAGEN HYPOKIT GLUCAGON EMERGENCY 45 glycopyrrolate granisetron hcl... 9 griseofulvin microsize... 2 guanfacine hcl guanfacine hcl er GUANIDINE HCL H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX heparin (porcine) in d5w heparin sod (porcine) in d5w.. 47 heparin sodium (porcine) hepatamine HERCEPTIN HETLIOZ... 9 HEXALEN HIBERIX HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 62, 69 hydrocortisone butyr lipo base62 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hcl... 3 hydromorphone hcl er... 2 hydromorphone hcl pf... 3 hydroxychloroquine sulfate hydroxyprogesterone caproate 28 hydroxyurea hydroxyzine hcl... 9, 42 hydroxyzine pamoate HYPERRAB S/D HYSINGLA ER... 2 I ibandronate sodium IBRANCE ibuprofen ICLUSIG idarubicin hcl IDHIFA ifosfamide ILARIS (50MG DELIVERED) ILEVRO IMBRUVICA IMFINZI imipenem-cilastatin... 9 imipramine hcl... 9 imipramine pamoate... 9 imiquimod IMOVAX RABIES INCRELEX indapamide indomethacin indomethacin er INFANRIX INLYTA INTELENCE INTRON A introvale... 7 INVANZ... 9 INVEGA SUSTENNA INVIRASE... 4 INVOKAMET INVOKAMET XR INVOKANA IPOL ipratropium bromide... 87, 89 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide... 5 IRESSA irinotecan hcl ISENTRESS... 4 ISENTRESS HD... 4 isibloom... 7 isoniazid... 23, 24 isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine ISTODAX ISTODAX (OVERFILL)

109 itraconazole... 2 ivermectin IXIARO J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR jinteli jolivette... 7 junel.5/ junel / junel fe.5/ junel fe / JUXTAPID K KADCYLA KALETRA... 4 KALYDECO kariva... 7 KAZANO kcl in dextrose-nacl kcl-lactated ringers-d5w kelnor / KEPIVANCE ketoconazole... 2 ketoprofen ketorolac tromethamine... 22, 85 KEYTRUDA... 28, 29 kimidess... 7 KINERET KINRIX kionex KISQALI 200 DOSE KISQALI 400 DOSE KISQALI 600 DOSE KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE klor-con klor-con m klor-con m klor-con m KORLYM KUVAN KYNAMRO KYPROLIS L labetalol hcl lactated ringers... 82, 93 lactulose lamivudine lamivudine-zidovudine lamotrigine... 4 lamotrigine er... 4 lansoprazole LANTUS LANTUS SOLOSTAR larin.5/ larin / larin fe.5/ larin fe / larissia... 7 LARTRUVO latanoprost LATUDA LAZANDA... 3 leena... 7 leflunomide LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE lessina... 7 LETAIRIS letrozole leucovorin calcium LEUCOVORIN CALCIUM LEUKERAN LEUKINE leuprolide acetate LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... 2 levetiracetam er... 2 levobunolol hcl levocarnitine levocetirizine dihydrochloride 86 levofloxacin..., 83 levofloxacin in d5w... levoleucovorin calcium LEVOLEUCOVORIN CALCIUM levonest... 7 levonorgest-eth estrad 9-day. 7 levora 0.5/30 (28) LEVORPHANOL TARTRATE... 3 levothyroxine sodium levoxyl LEXIVA... 4 LIALDA lidocaine... 4 lidocaine hcl... 4 lidocaine hcl (pf)... 4 lidocaine viscous lidocaine-prilocaine... 4 lindane linezolid... 6 LINZESS liothyronine sodium lisinopril lisinopril-hydrochlorothiazide 5 lithium lithium carbonate lithium carbonate er lomedia 24 fe LONSURF loperamide hcl lopinavir-ritonavir... 4 lorazepam lorazepam intensol lorcet... 3 lorcet hd... 3 lorcet plus... 3 loryna losartan potassium losartan potassium-hctz... 5 LOTEMAX lovastatin low-ogestrel loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT (-MONTH)

110 LUPRON DEPOT (3-MONTH)... 30, 76 LUPRON DEPOT (4-MONTH) LUPRON DEPOT (6-MONTH) LUPRON DEPOT-PED (- MONTH) lutera LUZU... 2 LYNPARZA LYRICA... 3, 59 LYSODREN lyza M magnesium sulfate MAKENA malathion maprotiline hcl... 6 marlissa MARPLAN... 7 MATULANE matzim la MAVYRET meclizine hcl... 9 medroxyprogesterone acetate 72, 74 mefloquine hcl megestrol acetate... 30, 74 MEKINIST meloxicam melphalan hcl memantine hcl... 6 MENACTRA MENEST MENVEO meperidine hcl... 3 mercaptopurine meropenem... 9 MESALAMINE mesalamine-cleanser mesna MESNEX metadate er metaproterenol sulfate metaxalone... 9 metformin hcl... 44, 45 metformin hcl er methadone hcl... 2 METHADONE HCL... 2 methenamine hippurate... 6 methimazole methocarbamol... 9 methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide... 5 methyldopate hcl methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide... 5 metronidazole... 6, 7, 69 METRONIDAZOLE IN NACL... 7 mexiletine hcl MIACALCIN microgestin.5/ microgestin / microgestin fe.5/ microgestin fe / midodrine hcl mimvey mimvey lo minitran minocycline hcl... 2 minoxidil mirtazapine... 6, 7 misoprostol mitomycin MITOMYCIN mitoxantrone hcl M-M-R II modafinil moexipril hcl moexipril-hydrochlorothiazide... 5 mometasone furoate mononessa montelukast sodium morphine sulfate... 4 MORPHINE SULFATE... 4 morphine sulfate (concentrate). 3 MORPHINE SULFATE (PF)... 3 morphine sulfate er... 2 morphine sulfate er beads... 2 MOVIPREP MOXEZA moxifloxacin hcl MOXIFLOXACIN HCL... MOZOBIL MULTAQ mupirocin... 7 MUSTARGEN mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium myorisan MYRBETRIQ MYTESI N nabumetone nadolol nadolol-bendroflumethiazide.. 5 nafcillin sodium... 0 NAFCILLIN SODIUM... 0 NAGLAZYME naloxone hcl... 5 naltrexone hcl... 5 NAMZARIC... 5 naproxen naproxen dr naproxen sodium naratriptan hcl NARCAN... 5 nateglinide NATPARA NEBUPENT necon 0.5/35 (28) necon 7/7/ nefazodone hcl... 7 neomycin sulfate... 5 neomycin-bacitracin znpolymyx neomycin-polymyxin b gu

111 neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc.. 85, 86 NEPHRAMINE NERLYNX NESINA neuac NEUPOGEN NEUPRO nevirapine NEVIRAPINE nevirapine er NEXAVAR niacin er (antihyperlipidemic) 56 NIACOR nicardipine hcl NICOTROL... 5 nifedipine nifedipine er nifedipine er osmotic release.. 53 nikki nilutamide nimodipine NINLARO nisoldipine er nitrofurantoin... 7 nitrofurantoin macrocrystal... 7 nitrofurantoin monohyd macro. 7 nitroglycerin nizatidine nora-be NORDITROPIN FLEXPRO.. 75 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est 72 norgestimate-eth estradiol norgestim-eth estrad triphasic 72 norlyroc normosol-m in d5w NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/ nortriptyline hcl... 9 NORTRIPTYLINE HCL... 9 NORVIR... 4 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL... 2 NUEDEXTA NULOJIX NUPLAZID nutrilipid nystatin... 2, 60 nystatin-triamcinolone... 2 nystop... 2 O ocella octreotide acetate ODEFSEY... 4 ODOMZO OFEV ofloxacin..., 83, 86 OFLOXACIN... ogestrel olanzapine olmesartan medoxomil olmesartan medoxomil-hctz... 5 olmesartan-amlodipine-hctz... 5 olopatadine hcl... 84, 90 omega-3-acid ethyl esters omeprazole omeprazole-sodium bicarbonate ondansetron ondansetron hcl ONFI... 2, 3 OPSUMIT ORAVIG ORENCIA ORENCIA CLICKJECT ORFADIN ORKAMBI orphenadrine citrate... 9 orphenadrine citrate er... 9 orsythia oseltamivir phosphate OSENI OTEZLA oxacillin sodium... 0 oxaliplatin oxandrolone oxazepam oxcarbazepine... 5 OXTELLAR XR... 5 oxybutynin chloride oxybutynin chloride er oxycodone hcl... 4 OXYCODONE HCL ER... 2 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 oxycodone-ibuprofen... 4 P pacerone paclitaxel paliperidone er pamidronate disodium PANCREAZE PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate... 6 paroxetine hcl... 8 paroxetine hcl er... 8 PASER... PATADAY PAXIL... 8 PAZEO PEDIARIX PEDVAX HIB peg 3350/electrolytes peg-3350/electrolytes PEGANONE... 5 PEGASYS PEGASYS PROCLICK PEGINTRON PEG-INTRON REDIPEN penicillin g potassium... 0 penicillin v potassium... 0 PENTAM pentazocine-naloxone hcl... 4 pentoxifylline er perindopril erbumine permethrin perphenazine PEXEVA... 8 phenelzine sulfate... 7 phenobarbital

112 phenytoin... 5 phenytoin sodium... 5 phenytoin sodium extended... 5 PHOSPHOLINE IODIDE physiolyte physiosol irrigation PICATO pilocarpine hcl... 60, 83 pimozide pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride.. 45 pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so0 pirmella / PLEGRIDY podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST portia potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er PRADAXA PRALUENT pramipexole dihydrochloride. 34 pramipexole dihydrochloride er pravastatin sodium prazosin hcl prednicarbate prednisolone sodium phosphate... 69, 85 prednisone PREDNISONE prednisone intensol PREFERRED PLUS INSULIN SYRINGE PREMARIN premasol PREMASOL PREMPHASE PREMPRO previfem PREZCOBIX PREZISTA... 4, 42 PRIFTIN PRIMAQUINE PHOSPHATE primidone... 3 PROAIR HFA PROAIR RESPICLICK probenecid... 2 procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN... 3 PROLIA PROMACTA promethazine hcl... 9 promethazine vc plain... 86, 87 propafenone hcl propafenone hcl er propantheline bromide proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz... 5 propylthiouracil PROQUAD PROSOL protriptyline hcl... 9 PROVENTIL HFA PULMICORT PULMICORT FLEXHALER. 87 PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QUADRACEL quasense quetiapine fumarate quetiapine fumarate er QUETIAPINE FUMARATE ER... 36, 37 quinapril hcl quinapril-hydrochlorothiazide 5 quinidine gluconate er quinidine sulfate quinine sulfate QVAR R RABAVERT RADICAVA raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RAVICTI reclipsen RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE RELISTOR... 66, 67 REMODULIN RENVELA repaglinide REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR RESTASIS RESTORIL... 9 RETROVIR REVLIMID REXULTI REYATAZ ribasphere RIBASPHERE ribavirin... 38, 39 rifabutin rifampin RIFATER riluzole rimantadine hcl

113 ringers ringers irrigation RISPERDAL CONSTA risperidone RITUXAN... 3 RIVASTIGMINE... 6 rivastigmine tartrate... 6 ROBINUL ROBINUL-FORTE ropinirole hcl rosuvastatin calcium ROTARIX... 8 ROTATEQ... 8 roweepra... 2 ROZEREM RUBRACA... 3 RYDAPT... 3 S SABRIL... 3 SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK selegiline hcl... 34, 35 selenium sulfide SELZENTRY... 4 SENSIPAR SEREVENT DISKUS sertraline hcl... 8 SEVELAMER CARBONATE sharobel SIGNIFOR sildenafil citrate SILENOR silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA simvastatin sirolimus SIRTURO SIVEXTRO... 7 sodium chloride... 68, 93 sodium phenylbutyrate sodium polystyrene sulfonate. 92 SOLTAMOX... 3 SOMATULINE DEPOT SOMAVERT sorine sotalol hcl sotalol hcl (af) SOVALDI SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz... 5 sprintec SPRITAM... 2 SPRYCEL... 3 sps sronyx stavudine STELARA sterile water for irrigation STIOLTO RESPIMAT STIVARGA... 3 STRATTERA streptomycin sulfate... 6 STRIBILD... 4 SUBOXONE... 5 SUBSYS... 4 sucralfate sulfacetamide sodium..., 84 SULFACETAMIDE SODIUM sulfacetamide-prednisolone sulfadiazine... sulfamethoxazole-trimethoprim... sulfasalazine sulindac sumatriptan sumatriptan succinate sumatriptan succinate refill SUPRAX... 8 SUSTIVA SUTENT... 3 SYLATRON... 3 SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 7 SYNRIBO... 3 SYNTHROID SYPRINE T TABLOID tacrolimus... 63, 77 TAFINLAR... 3 TAGRISSO... 3 TAMIFLU tamoxifen citrate... 3 tamsulosin hcl TARCEVA... 3 TARGRETIN... 3 tarina fe / TASIGNA... 3 tazarotene TAZORAC taztia xt TECENTRIQ... 3 TECFIDERA TEFLARO... 8 TEGRETOL-XR... 5 telmisartan telmisartan-amlodipine... 5 telmisartan-hctz... 5 temazepam... 9 TENIVAC... 8 terazosin hcl terbinafine hcl... 2 terbutaline sulfate terconazole testosterone testosterone cypionate testosterone enanthate TETANUS-DIPHTHERIA TOXOIDS TD... 8 tetrabenazine tetracycline hcl... 2 TETRACYCLINE HCL... 2 THALOMID theophylline theophylline er thioridazine hcl THIOTEPA thiothixene THYMOGLOBULIN tiagabine hcl... 3 TIGECYCLINE... 7 timolol maleate... 52, 85 TIVICAY

114 tizanidine hcl... 9 TOBI PODHALER... 6 TOBRADEX TOBRADEX ST tobramycin... 84, 9 tobramycin sulfate... 6 tobramycin-dexamethasone tolazamide tolbutamide topiramate... 4 TOPIRAMATE ER... 4 topotecan hcl... 3 TORISEL... 3 torsemide TOUJEO SOLOSTAR tpn electrolytes TRACLEER TRADJENTA tramadol hcl... 4 tramadol hcl er... 4 tramadol-acetaminophen... 4 trandolapril tranexamic acid TRANSDERM-SCOP (.5 MG) tranylcypromine sulfate... 7 TRAVASOL TRAVATAN Z trazodone hcl... 7 TREANDA TRECATOR TRELSTAR MIXJECT... 3 tretinoin... 3, 63 tretinoin microsphere TREXALL triamcinolone acetonide... 60, 63 triamterene-hctz triazolam... 9 trifluoperazine hcl trifluridine trihexyphenidyl hcl tri-legest fe trilyte trimethoprim... 7 trimipramine maleate... 9 trinessa (28) TRINTELLIX... 7 tri-previfem TRISENOX tri-sprintec TRIUMEQ... 4 trivora (28) TROKENDI XR... 4 TROPHAMINE TRUMENBA... 8 TRUVADA TWINRIX... 8 TYBOST... 4 TYGACIL... 7 TYKERB TYMLOS TYPHIM VI... 8 TYSABRI U UCERIS... 63, 70 unithroid UPTRAVI ursodiol V valacyclovir hcl VALCHLOR valganciclovir hcl valproate sodium... 4 valproic acid... 4 valsartan valsartan-hydrochlorothiazide 52 vancomycin hcl... 7 VANCOMYCIN HCL... 7 VAQTA... 8 VARIVAX... 8 VARIZIG VASCEPA VELCADE velivet VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl... 8 venlafaxine hcl er... 8 VENTAVIS VENTOLIN HFA verapamil hcl verapamil hcl er VERSACLOZ VESICARE vestura vicodin... 4 vicodin es... 4 vicodin hp... 4 VICTOZA VIDEX vigabatrin... 4 VIGAMOX VIIBRYD... 7 VIIBRYD STARTER PACK. 7 VIMPAT... 5 vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VIRACEPT VIREAD voriconazole... 2 VOTRIENT VPRIV VRAYLAR vyfemla VYXEOS W warfarin sodium wymzya fe X XALKORI XARELTO XARELTO STARTER PACK XATMEP XELJANZ XGEVA XIFAXAN... 7 XIGDUO XR XOLAIR... 9 XTANDI XYREM Y YERVOY YF-VAX... 8 YONDELIS yuvafem Z zafirlukast zaleplon... 9 ZAVESCA ZEJULA ZELBORAF ZEMAIRA... 9 zenatane zenchent zenchent fe zenpep

115 ZENPEP zenzedi ZEPATIER ZERIT ZIAGEN zidovudine ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolpidem tartrate... 9 ZOMETA zonisamide... 3 ZORTRESS ZOSTAVAX... 8 zovia /35e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA

116 This formulary was updated on 0/24/207. For more recent information or other questions, please contact Partnership Customer Service at or, for TTY users, Wisconsin Relay 7, 8 a.m. 8 p.m., 7 days a week, or visit Care Wisconsin Health Plan P.O. Box 407 Madison, Wisconsin TTY/TDD Wisconsin Relay System 7