Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties

Transcription

1 208 Formulary/Formulario (List of Covered Drugs)/ (Lista de medicamentos cubiertos) Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA: ESTE DOCUMENTO TIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS EN ESTE PLAN StayWe (HMO) ll If you remember these special moments, you re ready for AgeWell New York HPMS Approved Formulary File Submission ID: 8327, Version Number: 0 This formulary was updated on 06/0/208. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or for TTY users, 7, 7 days a week 24 hours a day or visit H4922_SWFormulary085 Accepted

2 208 Part D Formulary (Comprehensive) 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 AgeWell New York. When it refers to plan or our plan, it means StayWell (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 06/0/208. 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, 208, and from time to time during the year. What is the StayWell (HMO) s Formulary? A formulary is a list of covered drugs selected by our plan 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. StayWell (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 06/0/208. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event that the plan makes a mid-year non-maintenance formulary change, we will mail you updated information at least 60 days prior to the date the change becomes effective. i

3 208 Part D Formulary (Comprehensive) 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 Page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 3. 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? Our Plan 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: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, the plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that the plan will cover. For example, our plan provides 9 tablets per prescription for Sumatriptan Succinate 00mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan 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, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. ii

4 208 Part D Formulary (Comprehensive) 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 StayWell (HMO) 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 StayWell (HMO) formulary? on page iii for information about how to request an exception. 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 StayWell (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan. You can ask the plan 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 StayWell (HMO) s Formulary? You can ask the plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan 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, StayWell (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii

5 208 Part D Formulary (Comprehensive) 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. 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 at least 9 or up to a 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. Existing Member with Level of Care Changes If you are outside your transition period and experience a level of care change in which you are changing from one treatment setting to another (example: Long Term Care to hospital, hospital to home, home to Long Term Care), upon admission or discharge from a treatment setting or Long Term Care, we will allow you access to a 30/3 day refill (30 days in the retail setting and 3 days in the Long Term Care setting) for formulary medications and an emergency 30/3 day refill (30 days in the retail setting and 3 days in the Long Term Care setting) for non-formulary medications (including Part D drugs that are on our formulary but require prior authorization or step therapy). This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from Long Term Care or hospital facilities. iv

6 208 Part D Formulary (Comprehensive) To the extent that you are outside your 90-day transition period and are in an outpatient setting, we will still provide an emergency 30 day supply of non-formulary medications (including Part D drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), on a case by case basis, while an exception request is being processed. To the extent that you are outside your 90-day transition period and are in a Long Term Care setting, we will still provide an emergency 3 day supply of Part D covered non-formulary medications (including Part D covered drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), while an exception request is being processed. For more information For more detailed information about your StayWell (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about StayWell (HMO), 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 -800-MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit StayWell (HMO) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by StayWell (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 3. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NAMENDA XR) and generic drugs are listed in lower-case italics (e.g., memantine). The information in the Requirements/Limits column tells you if the plan has any special requirements for coverage of your drug. v

7 208 Part D Formulary (Comprehensive) LEGEND Symbol Name QL Quantity Limit PA Prior Authorization ST Step Therapy Description There is a limit on the amount of this drug that is covered per prescription or within a specific time frame. You (or your physician) are required to obtain a prior authorization before you fill your prescription for this drug. Without a prior authorization, we may not cover this drug. 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. MO Mail Order This prescription may also be available via mail. LA Limited Access This prescription drug is limited to certain pharmacies. HRM BD High Risk Medications Part B vs. Part D The Centers for Medicare and Medicaid Services (CMS) has identified the drug listed as posing a higher risk to patients, especially to seniors (PA required for ages 65 or over) This prescription drug may be covered under Medicare Part B or Part D depending on the circumstances. Tier Name Covered Medications vi

8 Formulario de la Parte D 208 (Integral) Nota para los miembros existentes: Este formulario ha sufrido modificaciones desde el año pasado. Revise este documento para asegurarse de que contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) dice nosotros, nos o nuestro/a, hace referencia a AgeWell New York. Cuando dice plan o nuestro plan, hace referencia a StayWell (HMO). Este documento incluye una lista de los medicamentos (formulario) para nuestro plan, actualizada al 06/0/208. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. En general, debe utilizar las farmacias de la red para sus beneficios de medicamentos con receta. Los beneficios, el formulario, la red de farmacias y los copagos o coseguros pueden sufrir modificaciones el de enero del 208 y ocasionalmente durante el año. Qué es el Formulario de StayWell (HMO)? Un formulario es una lista de medicamentos cubiertos por nuestro plan en consulta con un equipo de proveedores de atención médica, que representa las terapias recetadas que se consideran una parte necesaria del programa de tratamiento de calidad. En general, StayWell (HMO) cubre los medicamentos enumerados en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta sea presentada en una farmacia de la red del plan y se respeten otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, revise su Evidencia de cobertura. Puedo modificar el Formulario (lista de medicamentos)? Generalmente, si está tomando un medicamento incluido en nuestro formulario 208 que estaba cubierto al comienzo del año, no suspenderemos ni reduciremos la cobertura del medicamento durante el 208, salvo que se desarrolle un nuevo medicamento genérico más económico o que se divulgue información adversa sobre la seguridad o la eficacia de un medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento de nuestro formulario, no afectará a los miembros que estén tomando ese medicamento. El medicamento seguirá disponible con la misma distribución de costos para los miembros que lo estén tomando durante el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, salvo en los casos en los cuales puede ahorrar dinero o podemos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, o agregamos una autorización previa, límites de cantidad o restricciones de tratamiento escalonado con respecto a un medicamento o cambiamos un medicamento a un nivel de distribución de costos más alto, debemos notificar del cambio a los miembros afectados con una antelación mínima de 60 días a la fecha de entrada en vigencia del cambio o cuando el miembro solicita un resurtido del medicamento, momento en el cual el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que un medicamento en nuestro formulario no es seguro o el fabricante del medicamento decide retirar el medicamento del mercado, eliminaremos inmediatamente el medicamento de nuestro formulario y vii

9 Formulario de la Parte D 208 (Integral) notificaremos a los miembros que estén tomando ese medicamento. El formulario adjunto está actualizado al 06/0/208. Para obtener información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto se encuentra en la portada frontal y trasera. En el caso de que el plan realice un cambio que no sea de mantenimiento en el formulario a mitad de año, le enviaremos la información actualizada por correo con una antelación mínima de 60 días a la entrada en vigencia del cambio. Cómo utilizo el Formulario? Hay dos formas de encontrar un medicamento dentro del formulario: Afección médica El formulario comienza en la página. Los medicamentos en este formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran bajo la categoría Agentes cardiovasculares. Si sabe para qué se utiliza el medicamento que está tomando, busque el nombre de la categoría en la lista que comienza en la página. Luego busque el nombre de su medicamento dentro de esa categoría. Listado en orden alfabético Si no sabe en qué categoría buscar, debe buscar su medicamento en el Índice que empieza en la página 3. El Índice proporciona una lista en orden alfabético de los medicamentos incluidos en este documento. El Índice incluye medicamentos de marca y medicamentos genéricos. Busque en el Índice y encuentre su medicamento. Al lado del medicamento, verá el número de página en donde puede encontrar la información de cobertura. Vaya a la página indicada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Nuestro plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico es un medicamento aprobado por la FDA que tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos tienen un costo menor que los medicamentos de marca. Hay alguna restricción o limitación en mi cobertura? Algunos medicamentos cubiertos podrían tener requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Nuestro plan requiere que usted o su médico obtengan autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus medicamentos con receta. Si no tiene la aprobación, es posible que el plan no cubra el medicamento. Límites de cantidad: Para determinados medicamentos, nuestro plan limita la cantidad de medicamento que cubrirá. Por ejemplo, nuestro plan provee 9 comprimidos por receta viii

10 Formulario de la Parte D 208 (Integral) de Sumatriptan succinato 00 mg. Esto puede sumarse a un suministro estándar de un mes o tres meses. Tratamiento escalonado: En algunos casos, nuestro plan le podría solicitar que primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, el plan entonces cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el formulario que empieza en la página. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones en tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. Puede solicitarle a StayWell (HMO) que realice una excepción a estas restricciones o límites o que incluya otros medicamentos similares que sirvan para tratar su afección médica. Consulte la sección Cómo hago para solicitar una excepción al formulario de StayWell (HMO)? en la página ix para obtener información sobre cómo solicitar una excepción. Qué sucede si mi medicamento no está incluido en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), debe comunicarse con Servicios para miembros y preguntar si su medicamento está cubierto. Si le informan que StayWell (HMO) no cubre su medicamento, tiene dos opciones: Puede solicitarle a Servicios para miembros una lista de medicamentos similares cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por el plan. O puede pedirle al plan que haga una excepción y cubra su medicamento. Debajo encontrará más información sobre cómo solicitar una excepción. Cómo hago para solicitar una excepción al Formulario de StayWell (HMO)? Puede solicitarle al plan que realice una excepción a sus normas de cobertura. Puede solicitar distintos tipos de excepciones. Puede solicitarnos la cobertura de un medicamento incluso si no está incluido en este formulario. Si aprobamos su solicitud, este medicamento será cubierto a un nivel de distribución de costos predeterminado y usted no podrá solicitarnos que le proporcionemos el medicamento a un nivel de distribución de costos más bajo. ix

11 Formulario de la Parte D 208 (Integral) Puede solicitarnos la cobertura de un medicamento incluido en el formulario a un nivel de distribución de costos más bajo si dicho medicamento no se encuentra en el nivel especial. Si aprobamos su solicitud, reduciremos el monto que debe pagar por su medicamento. Puede solicitarnos que cancelemos las restricciones o límites de cobertura con respecto a su medicamento. Por ejemplo, para determinados medicamentos, el plan limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede solicitarnos que renunciemos al límite y le brindemos cobertura por una cantidad mayor. En general, StayWell (HMO) aprobará su solicitud de realizar una excepción únicamente si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con una distribución de costos más baja o las restricciones de utilizaciones adicionales, no fueran eficaces para el tratamiento de su afección o le provocaran efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario o a una restricción de utilización. Cuando solicite una excepción al formulario o a una restricción de utilización, debe presentar una declaración de la persona autorizada a dar recetas o de su médico que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72 horas de haber recibido la declaración de respaldo de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud puede verse seriamente perjudicada si se demora 72 horas en tomar una decisión. Si su solicitud acelerada es aceptada, debemos tomar una decisión dentro de las 24 horas posteriores a la recepción de la declaración de respaldo de su médico u otra persona autorizada a dar recetas. Qué debo hacer antes de hablar con mi médico sobre el cambio de medicamento o antes de solicitar una excepción? Como miembro nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no estén incluidos en nuestro formulario. O es posible que esté tomando un medicamento incluido en nuestro formulario pero que su capacidad para obtenerlo esté limitada. Por ejemplo, es posible que necesite nuestra autorización previa para obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar a otro medicamento apropiado que esté cubierto por nuestro plan o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción adecuado en su caso, es posible que le brindemos cobertura en determinados casos durante los primeros 90 días de su participación en nuestro plan. Para cada uno de los medicamentos que no estén incluidos en nuestro formulario o si su capacidad para obtener sus medicamentos está limitada, le brindaremos cobertura para un suministro de 30 días (salvo que tenga una receta escrita por un plazo menor) en una farmacia de la red. Después de su primer suministro de 30 días, no cubriremos estos medicamentos, incluso si ha sido miembro del plan por menos de 90 días. x

12 Formulario de la Parte D 208 (Integral) Si usted vive en un centro de atención a largo plazo, le permitiremos resurtir su medicamento hasta proporcionarle un suministro de transición de al menos 9 días y hasta 98 días, compatible con el incremento de entrega (salvo que tenga una receta escrita por un plazo menor). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días de su membresía en nuestro plan. Si necesita un medicamento que no está incluido en nuestro formulario o si su capacidad para obtener sus medicamentos está limitada y han transcurrido los primeros 90 días de su membresía en nuestro plan, cubriremos un suministro de emergencia de 3 días de ese medicamento (salvo que tenga una receta escrita por un plazo menor) mientras solicita una excepción al formulario. Miembro existente con cambios en el nivel de atención Si se encuentra fuera del periodo de transición y sufre un cambio en el nivel de atención en el cual cambia de un ambiente de tratamiento a otro (por ejemplo: Atención a largo plazo al hospital, hospital al hogar, hogar a Atención a largo plazo), al momento de admisión o alta de un ambiente de tratamiento o centro de Atención a largo plazo, le permitiremos acceder a un resurtido de 30/3 días (30 días en un ambiente particular y 3 días en un ambiente de Atención a largo plazo) para medicamentos incluidos en el formulario y un resurtido de emergencia de 30/3 días (30 días en un ambiente particular y 3 días en un ambiente de Atención a largo plazo) para medicamentos no incluidos en el formulario (incluso medicamentos de la Parte D que no estén incluidos en nuestro formulario pero requieran autorización previa o tratamiento escalonado). Esta política no es aplicable a las licencias a corto plazo (p. ej., feriados o vacaciones) de centros de Atención a largo plazo u hospitales. En la medida que esté fuera del periodo de transición de 90 días y se encuentre en un ambiente ambulatorio, le proporcionaremos un suministro de emergencia de 30 días de medicamentos no incluidos en el formulario (incluso medicamentos de la Parte D que estén incluidos en nuestro formulario y que de otro modo requieren autorización previa o tratamiento escalonado en virtud de nuestras normas de administración de utilización), según el caso, mientras procesamos una solicitud de excepción. En la medida que esté fuera del periodo de transición de 90 días y se encuentre en un centro de Atención a largo plazo, le proporcionaremos un suministro de emergencia de 3 días de medicamentos no incluidos en el formulario cubiertos en la Parte D (incluso medicamentos cubiertos en la Parte D que estén incluidos en nuestro formulario y que de otro modo requieren autorización previa o tratamiento escalonado en virtud de nuestras normas de administración de utilización), mientras procesamos una solicitud de excepción. Para obtener más información Para obtener información más detallada sobre su cobertura de medicamentos con receta de StayWell (HMO), revise su Evidencia de cobertura y otro material del plan. Si tiene alguna consulta sobre StayWell (HMO), comuníquese con nosotros. Nuestra información de contacto, y la fecha de la última actualización del formulario, se encuentran en la portada frontal y trasera. xi

13 Formulario de la Parte D 208 (Integral) Si tiene consultas generales sobre la cobertura de medicamentos con receta de Medicare, comuníquese con Medicare al -800-MEDICARE ( ) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O visite Formulario de StayWell (HMO) El formulario debajo le brinda información de cobertura sobre los medicamentos cubiertos por StayWell (HMO). Si tiene alguna dificultad para encontrar en la lista el medicamento que toma, consulte el Índice que comienza en la página 3. En la primera columna de esta tabla se indica el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., NAMENDA XR) y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., memantine). La información en la columna Requisitos/Límites le indica si el plan tiene algún requisito especial para la cobertura de su medicamento. xii

14 Formulario de la Parte D 208 (Integral) LEYENDA Símbolo Nombre QL PA ST Límites de cantidad Autorización previa Tratamiento escalonado Descripción Existe un límite con respecto a la cantidad de este medicamento que se cubre mediante receta o en un plazo específico. Usted (o su médico) debe obtener una autorización previa antes de surtir la receta de este medicamento. Sin autorización previa, es posible que no cubramos este medicamento. En algunos casos, es posible que deba probar otros medicamentos para tratar su afección médica, antes de que podamos cubrir otro medicamento para dicha afección. MO Pedidos por correo Esta receta también podría estar disponible por correo. LA Acceso limitado Este medicamento con receta está limitado a ciertas farmacias. HRM BD Medicamentos de alto riesgo Parte B vs. Parte D Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) han identificado el medicamento detallado como un medicamento con riesgo elevado para los pacientes, especialmente para personas mayores (se requiere autorización previa para pacientes de 65 años o más) Este medicamento con receta puede estar cubierto por la Parte B o la Parte D de Medicare, según las circunstancias. Nivel Nombre Medicamentos cubiertos xiii

15 Agewell -Tier (List of Covered Drugs) Drug Tier Requirements/Limits ANALGESICS OPIOID ANALGESICS, LONG- ACTING ALLZITAL ORAL TABLET MG butalbital-acetaminophen oral tablet mg butalbital-apap-caffeine oral capsule mg, mg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid mg/ml methadone hcl injection solution 0 mg/ml methadone hcl oral solution 0 mg/5ml, 5 mg/5ml methadone hcl oral tablet 0 mg, 5 mg 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 abusedeterrent 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG PHRENILIN FORTE ORAL CAPSULE MG TENCON ORAL TABLET MG ZEBUTAL ORAL CAPSULE MG OPIOID ANALGESICS, SHORT- ACTING You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 2 ST; QL (0 EA per 30 days) acetaminophen-codeine #2 oral tablet mg QL (400 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (400 EA per 30 days) acetaminophen-codeine #4 oral tablet mg QL (400 EA per 30 days)

16 acetaminophen-codeine oral solution 20-2 mg/5ml acetaminophen-codeine oral tablet mg, mg ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg duramorph injection solution 0.5 mg/ml, mg/ml FENTORA BUCCAL TABLET 00 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 hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone hcl injection solution 2 mg/ml hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg hydromorphone hcl pf injection solution 0 mg/ml, 50 mg/5ml HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SOLUTION 00 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate (pf) intravenous solution 2 mg/ml morphine sulfate injection solution 5 mg/ml morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 5 mg, 30 mg QL (5000 ML per 30 days) QL (400 EA per 30 days) PA; HRM; QL (80 EA per 30 days) QL (80 EA per 30 days) PA PA; HRM; QL (370 EA per 30 days) PA; HRM; QL (80 EA per 30 days) QL (5500 ML per 30 days) QL (370 EA per 30 days) QL (50 EA per 30 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: 8327, Ver. 0 Last updated 06/0/208 3

17 nalbuphine hcl injection solution 0 mg/ml, 20 mg/ml oxycodone hcl oral capsule 5 mg oxycodone hcl oral tablet 0 mg, 5 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (370 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet mg QL (360 EA per 30 days) oxymorphone hcl oral tablet 0 mg, 5 mg pentazocine-naloxone hcl oral tablet mg PA; HRM tramadol hcl oral tablet 50 mg QL (240 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (370 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, % lidocaine hcl injection solution 0.5 %, 2 % lidocaine-prilocaine external cream % ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS 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 injection solution 0.3 mg/ml (cartridge) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HR, 5 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution cartridge 0.4 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 4

18 naloxone hcl injection solution prefilled syringe 2 mg/2ml ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG SMOKING CESSATION AGENTS bupropion hcl er (sr) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG QL (56 EA per 28 days) CHANTIX ORAL TABLET 0.5 MG QL (60 EA per 30 days) CHANTIX ORAL TABLET MG QL (80 EA per 90 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 NICOTROL INHALATION INHALER 0 MG ANTIBACTERIALS AMINOGLYCOSIDES BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML gentamicin in saline intravenous solution mg/ml-%, -0.9 mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 40 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm tobramycin inhalation nebulization solution 300 mg/5ml 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 QL (53 EA per 30 days) 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: 8327, Ver. 0 Last updated 06/0/208 5

19 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml colistimethate sodium (cba) injection solution reconstituted 50 mg colistimethate sodium injection solution reconstituted 50 mg daptomycin intravenous solution reconstituted 500 mg lincomycin hcl injection solution 300 mg/ml BD linezolid intravenous solution 600 mg/300ml linezolid oral suspension reconstituted 00 mg/5ml linezolid oral tablet 600 mg metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg, 500 mg nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG tigecycline intravenous solution reconstituted 50 mg trimethoprim oral tablet 00 mg vancomycin hcl intravenous solution reconstituted 0 gm, 000 mg, 500 mg vancomycin hcl oral capsule 25 mg, 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: 8327, Ver. 0 Last updated 06/0/208 6 BD XIFAXAN ORAL TABLET 200 MG PA XIFAXAN ORAL TABLET 550 MG PA; MO BETA-LACTAM, CEPHALOSPORINS cefaclor er oral tablet extended release 2 hour 500 mg

20 cefaclor oral capsule 250 mg, 500 mg cefazolin sodium injection solution reconstituted gm, 0 gm, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml 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 gm, 2 gm, 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, 750 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TAZICEF INJECTION SOLUTION RECONSTITUTED GM, 2 GM, 6 GM TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 7

21 BETA-LACTAM, OTHER AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION GM, 2 GM AZACTAM INJECTION SOLUTION RECONSTITUTED GM, 2 GM aztreonam injection solution reconstituted gm baciim intramuscular solution reconstituted unit CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 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 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, 5 (0-5) gm, 3 (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: 8327, Ver. 0 Last updated 06/0/208 8

22 ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML 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, 0 gm nafcillin sodium intravenous solution reconstituted 0 gm penicillin g pot in dextrose intravenous solution unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit, unit penicillin g sodium 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 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) 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 oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ST E.E.S. 400 ORAL TABLET 400 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 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: 8327, Ver. 0 Last updated 06/0/208 9

23 erythromycin base oral capsule delayed release particles 250 mg erythromycin ethylsuccinate oral tablet 400 mg 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%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 mg, 500 mg levofloxacin in d5w intravenous solution 500 mg/00ml, 750 mg/50ml 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, 400 mg SULFONAMIDES sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg TETRACYCLINES DOXY 00 INTRAVENOUS SOLUTION RECONSTITUTED 00 MG doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 50 mg, 20 mg, 75 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 0

24 doxycycline hyclate oral tablet delayed release 00 mg, 50 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 00 mg, 50 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml 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 ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam in nacl intravenous solution 000 mg/00ml, 500 mg/00ml, 500 mg/00ml 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 ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG BARBITURATES ; QL (90 EA per 30 days) ; QL (20 EA per 30 days) phenobarbital oral elixir 20 mg/5ml PA; MO; HRM phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg PA; MO; HRM primidone oral tablet 250 mg, 50 mg BENZODIAZEPINES clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 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: 8327, Ver. 0 Last updated 06/0/208

25 DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 0 mg, 2.5 mg ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 0 MG, 20 MG CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 2 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 tablet delayed release 250 mg, 500 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG SABRIL ORAL TABLET 500 MG tiagabine hcl oral tablet 2 mg, 6 mg, 2 mg, 4 mg valproate sodium intravenous solution 00 mg/ml valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg vigabatrin oral packet 500 mg LA; MO GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml

26 felbamate oral tablet 400 mg, 600 mg LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-00 (7) MG, 25 (84)-00(4) MG LAMICTAL XR ORAL KIT 25 & 50 & 00 MG, 25 (2)-50 (7) MG, 50 & 00 & 200 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 lamotrigine starter kit-blue oral kit 25 (35) mg lamotrigine starter kit-green oral kit 25 (84)- 00(4) mg lamotrigine starter kit-orange oral kit 25 (42)-00 (7) 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 200 mg, 25 mg, 50 mg 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, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 0 MG/ML PA; MO BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 2 hour 200 mg, 300 mg carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 3

27 carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg CEREBYX INJECTION SOLUTION 500 MG PE/0ML DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 200 MG EQUETRO ORAL CAPSULE EXTENDED RELEASE 2 HOUR 00 MG, 200 MG, 300 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 VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet mg PA; MO; HRM CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 0 mg, 23 mg, 5 mg donepezil hcl oral tablet dispersible 0 mg, 5 mg 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 4

28 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 memantine hcl er oral capsule extended release 24 hour 4 mg, 2 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 0 mg, 5 mg memantine hcl oral tablet 5 (28)-0 (2) mg NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 &28 MG NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 4 & 2 &28-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 74 MG, 348 MG, 522 MG bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 5 bupropion hcl oral tablet 00 mg, 75 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg

29 nefazodone hcl oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 00 mg trazodone hcl oral tablet 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 ST; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 6 MARPLAN ORAL TABLET 0 MG 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, 20 mg, 40 mg 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, 40 mg, 60 mg escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg fluoxetine hcl oral capsule delayed release 90 mg fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 0 mg, 20 mg, 60 mg

30 fluvoxamine maleate er oral capsule extended release 24 hour 00 mg, 50 mg fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg olanzapine-fluoxetine hcl oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg paroxetine mesylate oral capsule 7.5 mg PAXIL ORAL SUSPENSION 0 MG/5ML PEXEVA ORAL TABLET 0 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 00 mg, 25 mg, 50 mg 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 amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg chlordiazepoxide-amitriptyline oral tablet 0-25 mg, 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; MO; HRM PA; MO; HRM PA; MO; HRM PA; MO; HRM doxepin hcl oral concentrate 0 mg/ml PA; MO; HRM imipramine hcl oral tablet 0 mg, 25 mg, 50 mg PA; MO; HRM imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg PA; MO; HRM You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 7

31 nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml protriptyline hcl oral tablet 0 mg, 5 mg trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 2.5 mg, 25 mg PA; MO; HRM metoclopramide hcl oral tablet 5 mg scopolamine transdermal patch 72 hour mg/3days EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 8 BD dronabinol oral capsule 0 mg, 2.5 mg, 5 mg BD; QL (60 EA per 30 days) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EMEND ORAL SUSPENSION RECONSTITUTED 25 MG granisetron hcl intravenous solution 0. mg/ml, mg/ml granisetron hcl intravenous solution 4 mg/4ml BD BD BD granisetron hcl oral tablet mg BD; QL (60 EA per 30 days) ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml (2ml syringe) BD ondansetron hcl oral solution 4 mg/5ml BD ondansetron hcl oral tablet 24 mg BD; QL (30 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg BD; QL (90 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg BD; QL (90 EA per 30 days) SANCUSO TRANSDERMAL PATCH 3. MG/24HR QL (4 EA per 28 days) SYNDROS ORAL SOLUTION 5 MG/ML BD; QL (20 ML per 30 days) VARUBI ORAL TABLET 90 MG BD ANTIFUNGALS ANTIFUNGALS

32 ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg clotrimazole mouth/throat lozenge 0 mg ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 25 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg ketoconazole oral tablet 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG BD 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: 8327, Ver. 0 Last updated 06/0/208 9 BD NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nystatin oral tablet unit voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg ANTIGOUT AGENTS ANTIGOUT AGENTS

33 allopurinol oral tablet 00 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG ST; MO ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI- INFLAMMATORY DRUGS celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg 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 er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 00 mg, 50 mg IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 00 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg PA; MO; HRM indomethacin oral capsule 25 mg, 50 mg PA; MO; HRM ketoprofen er oral capsule extended release 24 hour 200 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml PA; HRM PA; HRM ketorolac tromethamine oral tablet 0 mg PA; HRM meclofenamate sodium 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: 8327, Ver. 0 Last updated 06/0/208 20

34 meloxicam oral tablet 5 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg 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 naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg tolmetin sodium oral capsule 400 mg tolmetin sodium oral tablet 600 mg ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS, PROPHYLACTIC divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg topiramate oral tablet 00 mg ERGOT ALKALOIDS dihydroergotamine mesylate injection solution mg/ml dihydroergotamine mesylate nasal solution 4 mg/ml ergotamine-caffeine oral tablet -00 mg QL (40 EA per 28 days) SEROTONIN (5-HT) B/D RECEPTOR AGONISTS eletriptan hydrobromide oral tablet 20 mg, 40 mg QL (9 EA per 30 days) sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 2 QL (9 EA per 30 days) QL (0 ML per 30 days) QL (4.5 ML per 30 days)

35 guanidine hcl oral tablet 25 mg MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 00 mg, 25 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg ANTITUBERCULARS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM ethambutol hcl oral tablet 00 mg, 400 mg isoniazid injection solution 00 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 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 cyclophosphamide oral capsule 25 mg, 50 mg BD GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG ANTIANGIOGENIC AGENTS AVASTIN INTRAVENOUS SOLUTION 00 MG/4ML, 400 MG/6ML DEPEN TITRATABS ORAL TABLET 250 MG REVLIMID ORAL CAPSULE 0 MG, 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: 8327, Ver. 0 Last updated 06/0/ LA

36 REVLIMID ORAL CAPSULE 2.5 MG, 20 MG SYPRINE ORAL CAPSULE 250 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG trientine hcl oral capsule 250 mg ANTIMETABOLITES ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 500 MG azacitidine injection suspension reconstituted 00 mg decitabine intravenous solution reconstituted 50 mg fludarabine phosphate intravenous solution reconstituted 50 mg 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, 250 mg/0ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/0ml methotrexate sodium injection solution reconstituted gm primaquine phosphate oral tablet 26.3 mg PURIXAN ORAL SUSPENSION 2000 MG/00ML TABLOID ORAL TABLET 40 MG BD BD BD XATMEP ORAL SOLUTION 2.5 MG/ML BD ANTINEOPLASTICS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 00 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ADRIAMYCIN INTRAVENOUS SOLUTION 2 MG/ML ADRUCIL INTRAVENOUS SOLUTION 500 MG/0ML BD LA; MO 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: 8327, Ver. 0 Last updated 06/0/208 23

37 AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLET THERAPY PACK 90 & 80 MG ARRANON INTRAVENOUS SOLUTION 5 MG/ML PA; LA PA PA BD AZASAN ORAL TABLET 00 MG, 75 MG BD; MO BAVENCIO INTRAVENOUS SOLUTION 200 MG/0ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG BD bexarotene oral capsule 75 mg PA bicalutamide oral tablet 50 mg BICNU INTRAVENOUS SOLUTION RECONSTITUTED 00 MG bleomycin sulfate injection solution reconstituted 30 unit bortezomib intravenous solution reconstituted 3.5 mg BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG BD BD PA busulfan intravenous solution 6 mg/ml BD CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG PA; LA CAPRELSA ORAL TABLET 00 MG, 300 MG carboplatin intravenous solution 50 mg/5ml BD cisplatin intravenous solution 00 mg/00ml, 50 mg/50ml BD cladribine intravenous solution 0 mg/0ml BD clofarabine intravenous solution 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: 8327, Ver. 0 Last updated 06/0/208 24

38 COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG COTELLIC ORAL TABLET 20 MG LA CYRAMZA INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD cytarabine (pf) injection solution 00 mg/ml BD cytarabine injection solution 20 mg/ml BD dacarbazine intravenous solution reconstituted 200 mg dactinomycin intravenous solution reconstituted 0.5 mg DARZALEX INTRAVENOUS SOLUTION 00 MG/5ML BD BD LA 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 60 mg/6ml, 80 mg/8ml DOXIL INTRAVENOUS INJECTABLE 2 MG/ML BD BD BD doxorubicin hcl intravenous solution 2 mg/ml BD doxorubicin hcl liposomal intravenous injectable 2 mg/ml ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED.5 MG, 7.5 MG EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 400 MG BD BD BD PA epirubicin hcl intravenous solution 200 mg/00ml BD

39 ERBITUX INTRAVENOUS SOLUTION 00 MG/50ML ERIVEDGE ORAL CAPSULE 50 MG BD ERLEADA ORAL TABLET 60 MG PA; LA ERWINAZE INJECTION SOLUTION RECONSTITUTED 0000 UNIT ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG etoposide intravenous solution 00 mg/5ml, 500 mg/25ml PA BD BD FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 20 MG, 80 MG fluorouracil external solution 2 %, 5 % fluorouracil intravenous solution 2.5 gm/50ml, 5 gm/00ml flutamide oral capsule 25 mg FOLOTYN INTRAVENOUS SOLUTION 40 MG/2ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG HALAVEN INTRAVENOUS SOLUTION MG/2ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 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 BD BD 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: 8327, Ver. 0 Last updated 06/0/ BD PA PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA idarubicin hcl intravenous solution 0 mg/0ml BD IDHIFA ORAL TABLET 00 MG, 50 MG PA ifosfamide intravenous solution reconstituted gm BD

40 imatinib mesylate oral tablet 00 mg, 400 mg IMBRUVICA ORAL CAPSULE 40 MG, 70 MG IMBRUVICA ORAL TABLET 40 MG, 280 MG, 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 20 MG/2.4ML, 500 MG/0ML INLYTA ORAL TABLET MG, 5 MG INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT IRESSA ORAL TABLET 250 MG PA PA PA irinotecan hcl intravenous solution 00 mg/5ml BD ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 0 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 60 MG/.5ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 60 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4ML You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD BD 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 90 MG/9ML, 500 MG/50ML PA PA PA BD PA

41 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, 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 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 LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD BD BD LYNPARZA ORAL CAPSULE 50 MG PA LYNPARZA ORAL TABLET 00 MG, 50 MG PA; LA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 mg/ml PA; HRM megestrol acetate oral suspension 625 mg/5ml PA; MO; HRM megestrol acetate oral tablet 20 mg, 40 mg PA; HRM

42 MEKINIST ORAL TABLET 0.5 MG, 2 MG LA melphalan hcl intravenous solution reconstituted 50 mg MESNEX ORAL TABLET 400 MG mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg mitoxantrone hcl intravenous concentrate 25 mg/2.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 0 MG MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG 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: 8327, Ver. 0 Last updated 06/0/ BD PA; LA NERLYNX ORAL TABLET 40 MG PA; LA NEXAVAR ORAL TABLET 200 MG LA nilutamide oral tablet 50 mg NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 0 MG BD ODOMZO ORAL CAPSULE 200 MG LA OPDIVO INTRAVENOUS SOLUTION 00 MG/0ML, 40 MG/4ML PA oxaliplatin intravenous solution 00 mg/20ml BD oxaliplatin intravenous solution reconstituted 00 mg paclitaxel intravenous concentrate 00 mg/6.7ml, 300 mg/50ml PERJETA INTRAVENOUS SOLUTION 420 MG/4ML POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG BD BD LA BD PA RYDAPT ORAL CAPSULE 25 MG PA SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG

43 STIVARGA ORAL TABLET 40 MG PA 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 TAFINLAR ORAL CAPSULE 50 MG, 75 MG LA TAGRISSO ORAL TABLET 40 MG, 80 MG LA tamoxifen citrate oral tablet 0 mg, 20 mg TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG TASIGNA ORAL CAPSULE 50 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 200 MG/20ML BD thiotepa injection solution reconstituted 5 mg BD TOPOSAR INTRAVENOUS SOLUTION GM/50ML topotecan hcl intravenous solution reconstituted 4 mg TORISEL INTRAVENOUS SOLUTION 25 MG/ML TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 25 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED.25 MG, 22.5 MG, 3.75 MG tretinoin oral capsule 0 mg TRISENOX INTRAVENOUS SOLUTION 2 MG/6ML TYKERB ORAL TABLET 250 MG VECTIBIX INTRAVENOUS SOLUTION 00 MG/5ML 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 BD BD BD BD BD BD BD PA; LA PA; LA You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 30

44 VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA; LA 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 VOTRIENT ORAL TABLET 200 MG VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED MG BD PA XALKORI ORAL CAPSULE 200 MG, 250 MG PA XTANDI ORAL CAPSULE 40 MG PA; ST YERVOY INTRAVENOUS SOLUTION 50 MG/0ML YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG ZALTRAP INTRAVENOUS SOLUTION 00 MG/4ML ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED GM You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 3 PA BD ZEJULA ORAL CAPSULE 00 MG PA ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 250 MG, 500 MG PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg TREATMENT ADJUNCTS allopurinol oral tablet 300 mg mesna intravenous solution 00 mg/ml BD ANTIPARASITICS ANTHELMINTICS

45 ALBENZA ORAL TABLET 200 MG EMVERM ORAL TABLET CHEWABLE 00 MG ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ALINIA ORAL TABLET 500 MG 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 DARAPRIM ORAL TABLET 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: 8327, Ver. 0 Last updated 06/0/ hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG quinine sulfate oral capsule 324 mg ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate injection solution mg/ml benztropine mesylate oral tablet 0.5 mg, mg, 2 mg BD PA; MO; HRM trihexyphenidyl hcl oral elixir 0.4 mg/ml PA; MO; HRM trihexyphenidyl hcl oral tablet 2 mg, 5 mg PA; MO; HRM 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 GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 37 MG, 68.5 MG DOPAMINE AGONISTS PA; MO

46 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML LA 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 mg, 0.75 mg,.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg 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 MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline mesylate oral tablet 0.5 mg, mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS ST GENERATION/TYPICAL chlorpromazine hcl injection solution 50 mg/2ml BD chlorpromazine hcl oral tablet 0 mg BD; MO chlorpromazine hcl oral tablet 00 mg, 200 mg, 25 mg, 50 mg COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 33

47 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, 00 mg/ml ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml, 5 mg/ml( ml prefilled syringe) 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg perphenazine-amitriptyline oral tablet 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg PA; MO; HRM 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 PA; MO; HRM thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet mg, 0 mg, 2 mg, 5 mg 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (.5ML SYRINGE), 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution mg/ml ; QL (750 ML per 30 days) aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet dispersible 0 mg, 5 mg

48 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, 234 MG/.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 40 MG/.35ML, 546 MG/.75ML, 89 MG/2.625ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ NUPLAZID ORAL TABLET 7 MG PA; MO olanzapine intramuscular solution reconstituted 0 mg olanzapine oral tablet 0 mg, 5 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 0 mg, 5 mg, 20 mg, 5 mg paliperidone er oral tablet extended release 24 hour.5 mg, 3 mg, 6 mg, 9 mg quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 300 mg, 400 mg, 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, 37.5 MG, 50 MG risperidone oral solution mg/ml risperidone oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg 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

49 VRAYLAR ORAL CAPSULE.5 MG ST; MO; QL (20 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG ST; MO; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG ST; MO; QL (30 EA per 30 days) 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 clozapine oral tablet 00 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 00 mg, 2.5 mg, 50 mg, 200 mg, 25 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS ganciclovir sodium intravenous solution reconstituted 500 mg valganciclovir hcl oral solution reconstituted 50 mg/ml ST You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD valganciclovir hcl oral tablet 450 mg VEMLIDY ORAL TABLET 25 MG PA; MO ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 0 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, mg RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET 200 & 400 MG, 400 & 600 MG, 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING

50 EPCLUSA ORAL TABLET MG PA MAVYRET ORAL TABLET MG PA ZEPATIER ORAL TABLET MG PA ANTI-HEPATITIS C (HCV) AGENTS, OTHER MODERIBA 200 DOSE PACK ORAL TABLET 600 MG MODERIBA 800 DOSE PACK ORAL TABLET 400 MG MODERIBA ORAL TABLET 200 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 35 MCG/0.5ML, 80 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/0.5ML, 80 MCG/ML ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg 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, 500 mg ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg, 50 mg efavirenz oral tablet 600 mg GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG nevirapine er oral tablet extended release 24 hour 00 mg, 400 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 37

51 nevirapine oral tablet 200 mg ODEFSEY ORAL TABLET MG RESCRIPTOR ORAL TABLET 00 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL TABLET 600 MG SYMFI LO ORAL TABLET MG ; QL (30 EA per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral solution 20 mg/ml abacavir sulfate oral tablet 300 mg abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg BIKTARVY ORAL TABLET MG ; QL (30 EA per 30 days) DESCOVY ORAL TABLET MG desloratadine oral tablet dispersible 5 mg didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/ML EVOTAZ ORAL TABLET MG JULUCA ORAL TABLET MG lamivudine oral solution 0 mg/ml lamivudine oral tablet 00 mg, 50 mg, 300 mg lamivudine-zidovudine oral tablet mg PREZCOBIX ORAL TABLET MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML stavudine oral capsule 5 mg, 20 mg, 30 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: 8327, Ver. 0 Last updated 06/0/ tenofovir disoproxil fumarate oral tablet 300 mg TRIUMEQ ORAL TABLET MG

52 TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX EC ORAL CAPSULE DELAYED RELEASE 25 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ZERIT ORAL SOLUTION RECONSTITUTED MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 00 MG, 25 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 25 MG, 300 MG, 75 MG STRIBILD ORAL TABLET MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TYBOST ORAL TABLET 50 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir sulfate oral capsule 50 mg, 200 mg, 300 mg CRIXIVAN ORAL CAPSULE 200 MG, 400 MG You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 39

53 fosamprenavir calcium oral tablet 700 mg INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL TABLET MG, MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution mg/5ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL PACKET 50 MG ritonavir oral tablet 00 mg VIRACEPT ORAL TABLET 250 MG, 625 MG ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg oseltamivir phosphate oral suspension reconstituted 6 mg/ml 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ PA; HRM hydroxyzine hcl oral syrup 0 mg/5ml PA; HRM hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg PA; HRM hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg PA; HRM meprobamate oral tablet 200 mg, 400 mg PA; HRM

54 BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5 mg, mg, 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML QL (20 EA per 30 days) QL (300 ML per 30 days) alprazolam oral tablet 0.25 mg, 0.5 mg QL (20 EA per 30 days) alprazolam oral tablet mg QL (80 EA per 30 days) alprazolam oral tablet 2 mg QL (50 EA per 30 days) alprazolam oral tablet dispersible 0.25 mg QL (720 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg QL (80 EA per 30 days) alprazolam oral tablet dispersible mg QL (360 EA per 30 days) alprazolam oral tablet dispersible 2 mg QL (50 EA per 30 days) chlordiazepoxide hcl oral capsule 0 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML QL (20 EA per 30 days) QL (80 EA per 30 days) QL (240 ML per 30 days) diazepam oral solution mg/ml QL (200 ML per 30 days) diazepam oral tablet 0 mg QL (20 EA per 30 days) diazepam oral tablet 2 mg QL (600 EA per 30 days) diazepam oral tablet 5 mg QL (240 EA per 30 days) LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML QL (240 ML per 30 days) lorazepam oral concentrate 2 mg/ml QL (240 ML per 30 days) lorazepam oral tablet 0.5 mg, mg, 2 mg QL (50 EA per 30 days) oxazepam oral capsule 0 mg, 5 mg, 30 mg QL (20 EA per 30 days) BIPOLAR AGENTS MOOD STABILIZERS carbamazepine er oral capsule extended release 2 hour 00 mg carbamazepine oral tablet chewable 00 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 4

55 lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 00 mg, 25 mg, 50 mg ASSURE ID INSULIN SAFETY SYR 29G X /2" ML AVANDIA ORAL TABLET 2 MG, 4 MG chlorpropamide oral tablet 00 mg, 250 mg PA; MO; HRM COMFORT ASSIST INSULIN SYRINGE 29G X /2" ML cvs gauze sterile pad 2"x2" CYCLOSET ORAL TABLET 0.8 MG EXEL COMFORT POINT PEN NEEDLE 29G X 2MM glimepiride oral tablet mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hour 0 mg, 2.5 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: 8327, Ver. 0 Last updated 06/0/ glipizide oral tablet 0 mg, 5 mg glipizide-metformin hcl oral tablet mg, mg, mg global alcohol prep ease pad 70 % glyburide micronized oral tablet.5 mg, 3 mg, 6 mg PA; MO; HRM glyburide oral tablet.25 mg, 2.5 mg, 5 mg PA; MO; HRM glyburide-metformin oral tablet mg, mg, mg INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG PA; MO; HRM INVOKANA ORAL TABLET 00 MG, 300 MG 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

56 JARDIANCE ORAL TABLET 0 MG, 25 MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG metformin hcl er (osm) oral tablet extended release 24 hour 000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 000 mg, 500 mg, 850 mg miglitol oral tablet 00 mg, 25 mg, 50 mg nateglinide oral tablet 20 mg, 60 mg pioglitazone hcl oral tablet 5 mg, 30 mg, 45 mg pioglitazone hcl-glimepiride oral tablet 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg preferred plus insulin syringe 28g x /2" 0.5 ml RELI-ON INSULIN SYRINGE 29G 0.3 ML repaglinide oral tablet 0.5 mg, mg, 2 mg repaglinide-metformin hcl oral tablet -500 mg, mg RIOMET ORAL SOLUTION 500 MG/5ML SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 MCG/.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML,.5 MG/0.5ML valsartan-hydrochlorothiazide 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: 8327, Ver. 0 Last updated 06/0/208 43

57 VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 8 MG/3ML XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML 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 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 ST; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 44

58 TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML, 200 UNIT/ML BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS argatroban intravenous solution 25 mg/25ml BD ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 00 mg/ml, 20 mg/0.8ml, 50 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 45

59 EPOGEN INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 00 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML 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 PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG tranexamic acid intravenous solution 000 mg/0ml tranexamic acid oral tablet 650 mg ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML PLATELET MODIFYING AGENTS PA BD PA anagrelide hcl oral capsule 0.5 mg, mg 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 300 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg PA; MO; HRM CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 46

60 clonidine hcl transdermal patch weekly 0. mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr methyldopa oral tablet 250 mg, 500 mg PA; MO; HRM 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; HRM 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, 32 mg, 4 mg, 8 mg eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 50 mg, 300 mg, 75 mg losartan potassium oral tablet 00 mg, 25 mg, 50 mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 47

61 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 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 PA; MO; HRM 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 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 ALDACTAZIDE ORAL TABLET MG 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 48

62 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 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 ENTRESTO ORAL TABLET MG, 49-5 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 PA; MO PA; MO; HRM pioglitazone hcl-glimepiride oral tablet 30-2 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 49

63 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 trandolapril-verapamil hcl er oral tablet extended release -240 mg, 2-80 mg, mg, mg triamterene-hctz oral capsule mg, mg triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet 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 carvedilol phosphate er oral capsule extended release 24 hour 0 mg, 20 mg, 40 mg, 80 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 BD 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 50

64 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 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, 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, 80 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 5 isradipine oral capsule 2.5 mg, 5 mg 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

65 nifedipine oral capsule 0 mg, 20 mg PA; MO; HRM nimodipine oral capsule 30 mg 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, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 00 mg, 20 mg, 80 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 20 mg, 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 CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; MO DIGITEK ORAL TABLET 25 MCG, 250 MCG DIGOX ORAL TABLET 25 MCG, 250 MCG digoxin injection solution 0.25 mg/ml digoxin oral solution 0.05 mg/ml digoxin oral tablet 25 mcg, 250 mcg 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 DIURETICS, CARBONIC ANHYDRASE INHIBITORS PA acetazolamide oral tablet 25 mg, 250 mg methazolamide oral tablet 25 mg, 50 mg DIURETICS, LOOP bumetanide injection solution 0.25 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 52

66 furosemide injection solution 0 mg/ml, 0 mg/ml (4ml syringe) furosemide oral solution 0 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg DIURETICS, POTASSIUM-SPARING amiloride hcl oral tablet 5 mg DEMSER ORAL CAPSULE 250 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 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 fenofibrate oral tablet 20 mg, 45 mg, 60 mg, 40 mg, 48 mg, 54 mg gemfibrozil oral tablet 600 mg DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 80 mg fluvastatin sodium er oral tablet extended release 24 hour 80 mg fluvastatin sodium oral capsule 20 mg, 40 mg LIVALO ORAL TABLET MG, 2 MG, 4 MG ST; MO lovastatin oral tablet 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: 8327, Ver. 0 Last updated 06/0/208 53

67 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 powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet gm ezetimibe oral tablet 0 mg ezetimibe-simvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg fenofibric acid oral tablet 05 mg, 35 mg 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 PA; MO PA; MO omega-3-acid ethyl esters oral capsule gm PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 50 MG/ML, 75 MG/ML PA; MO PREVALITE ORAL PACKET 4 GM PREVALITE ORAL POWDER 4 GM/DOSE 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 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS PA; MO PA; MO PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 54

68 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, 0.4 MG/HR, 0.6 MG/HR NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 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, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray 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, 30 mg, 5 mg, 7.5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg, 5 mg, 5 mg dextroamphetamine sulfate oral tablet 0 mg, 5 mg ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 55

69 atomoxetine hcl oral capsule 0 mg, 00 mg, 8 mg, 25 mg, 40 mg, 60 mg, 80 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg guanfacine hcl er oral tablet extended release 24 hour mg, 2 mg, 3 mg, 4 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 0 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg methylphenidate hcl er oral tablet extended release 0 mg, 8 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 8 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 0 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 0 mg, 20 mg, 5 mg methylphenidate hcl oral tablet chewable 0 mg, 2.5 mg, 5 mg CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO ORAL TABLET 2 MG, 6 MG, 9 MG PA; MO; HRM NUEDEXTA ORAL CAPSULE 20-0 MG RADICAVA INTRAVENOUS SOLUTION 30 MG/00ML PA; MO riluzole oral tablet 50 mg tetrabenazine oral tablet 2.5 mg, 25 mg FIBROMYALGIA AGENTS LYRICA ORAL CAPSULE 00 MG, 50 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 56

70 AMPYRA ORAL TABLET EXTENDED RELEASE 2 HOUR 0 MG PA; MO AUBAGIO ORAL TABLET 4 MG, 7 MG PA; LA; MO BETASERON SUBCUTANEOUS KIT 0.3 MG PA; MO GILENYA ORAL CAPSULE 0.5 MG PA; MO glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml PA; MO SOLTAMOX ORAL SOLUTION 0 MG/5ML TYSABRI INTRAVENOUS CONCENTRATE 300 MG/5ML DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS chlorhexidine gluconate mouth/throat solution 0.2 % lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG PERIOGARD MOUTH/THROAT SOLUTION 0.2 % PA pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0. % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS acitretin oral capsule 0 mg, 7.5 mg, 25 mg 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 lotion 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: 8327, Ver. 0 Last updated 06/0/208 57

71 betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % ciclopirox external gel 0.77 % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % CLARAVIS ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG clindamycin phos-benzoyl perox external gel -5 % clindamycin phosphate external gel % clindamycin phosphate external lotion % clindamycin phosphate external solution % clindamycin phosphate external swab % clobetasol propionate e external cream 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clotrimazole external cream % clotrimazole external solution % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CONDYLOX EXTERNAL GEL 0.5 % COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML desonide 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: 8327, Ver. 0 Last updated 06/0/ ST; MO ST; MO

72 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 % diclofenac sodium transdermal gel %, 3 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % econazole nitrate external cream % ELIDEL EXTERNAL CREAM % erythromycin external gel 2 % erythromycin external solution 2 % EURAX EXTERNAL CREAM 0 % fluocinolone acetonide body external oil 0.0 % fluocinolone acetonide external cream 0.0 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.0 % fluocinolone acetonide scalp external oil 0.0 % fluocinonide emulsified base external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluorouracil external cream 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone ace-pramoxine rectal cream - % hydrocortisone external cream %, 2.5 % hydrocortisone external lotion 2.5 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 59

73 hydrocortisone external ointment %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % imiquimod external cream 5 % isotretinoin oral capsule 0 mg, 20 mg, 30 mg, 40 mg ketoconazole external cream 2 % ketoconazole external shampoo 2 % lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine hcl external gel 2 % lidocaine hcl external solution 4 % lindane external shampoo % methoxsalen rapid oral capsule 0 mg metronidazole external cream 0.75 % metronidazole external gel 0.75 %, % metronidazole external lotion 0.75 % mometasone furoate external cream 0. % mometasone furoate external ointment 0. % mupirocin calcium external cream 2 % mupirocin external ointment 2 % NYAMYC EXTERNAL POWDER UNIT/GM nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM PANRETIN EXTERNAL GEL 0. % permethrin external cream 5 % PICATO EXTERNAL GEL 0.05 %, 0.05 % podofilox external solution 0.5 % prednicarbate external cream 0. % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 60

74 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 % SSD EXTERNAL CREAM % STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML sulfacetamide sodium (acne) external lotion 0 % tacrolimus external ointment 0.03 %, 0. % TARGRETIN EXTERNAL GEL % tazarotene external cream 0. % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0. % TOLAK EXTERNAL CREAM 4 % tretinoin external gel 0.0 %, %, 0.05 % triamcinolone acetonide external cream %, 0. %, 0.5 % triamcinolone acetonide external lotion %, 0. % triamcinolone acetonide external ointment %, 0. %, 0.5 % ST; MO ST; MO UCERIS RECTAL FOAM 2 MG/ACT ST VALCHLOR EXTERNAL GEL 0.06 % ELECTROLYTES/MINERALS/META LS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT CARBAGLU 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: 8327, Ver. 0 Last updated 06/0/208 6

75 dextrose in lactated ringers intravenous solution 5 % dextrose-nacl intravenous solution %, %, %, %, %, %, %, % ISOLYTE-P IN D5W INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution 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 KLOR-CON M5 ORAL TABLET EXTENDED RELEASE 5 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ KLOR-CON ORAL PACKET 20 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 0 MEQ, 8 MEQ K-TAB 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 IN D5W INTRAVENOUS SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 48 INTRAVENOUS SOLUTION

76 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-% potassium chloride intravenous solution 0 meq/00ml, 2 meq/ml, 20 meq/00ml, 40 meq/00ml potassium chloride oral solution 20 meq/5ml (0%), 40 meq/5ml (20%) potassium citrate er oral tablet extended release 0 meq (080 mg), 5 meq (620 mg), 5 meq (540 mg) ringers intravenous solution sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES INTRAVENOUS SOLUTION ELECTROLYTE/MINERAL/METAL MODIFIERS EXJADE ORAL TABLET SOLUBLE 25 MG, 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: 8327, Ver. 0 Last updated 06/0/ FERRIPROX ORAL SOLUTION 00 MG/ML FERRIPROX ORAL TABLET 500 MG JADENU SPRINKLE ORAL PACKET 80 MG, 360 MG, 90 MG KIONEX ORAL POWDER KIONEX ORAL SUSPENSION 5 GM/60ML SAMSCA ORAL TABLET 5 MG, 30 MG PA sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 5 gm/60ml

77 SPS ORAL SUSPENSION 5 GM/60ML NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 0 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 0 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % CLINIMIX E/DEXTROSE (2.75/0) INTRAVENOUS SOLUTION 2.75 % 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 (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) 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 % BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD 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: 8327, Ver. 0 Last updated 06/0/208 64

78 CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINISOL SF INTRAVENOUS SOLUTION 5 % BD BD BD BD dextrose intravenous solution 0 %, 5 % BD FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % HEPATAMINE INTRAVENOUS SOLUTION 8 % NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % BD BD BD nutrilipid intravenous emulsion 20 % BD PLENAMINE INTRAVENOUS SOLUTION 5 % PREMASOL INTRAVENOUS SOLUTION 0 %, 6 % PROCALAMINE INTRAVENOUS SOLUTION 3 % BD BD BD PROSOL INTRAVENOUS SOLUTION 20 % BD TRAVASOL INTRAVENOUS SOLUTION 0 % TROPHAMINE INTRAVENOUS SOLUTION 0 % VITAMINS prenatal oral tablet 27- mg sodium fluoride oral tablet 2.2 ( f) mg 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 dicyclomine hcl oral tablet 20 mg 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: 8327, Ver. 0 Last updated 06/0/208 65

79 glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg GASTROINTESTINAL AGENTS, OTHER diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg GATTEX SUBCUTANEOUS KIT 5 MG 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 MOVANTIK ORAL TABLET 2.5 MG, 25 MG MYTESI ORAL TABLET DELAYED RELEASE 25 MG RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6ML, 2 MG/0.6ML (0.6ML SYRINGE), 8 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: 8327, Ver. 0 Last updated 06/0/ ursodiol oral tablet 250 mg, 500 mg HISTAMINE2 (H2) RECEPTOR ANTAGONISTS famotidine intravenous solution 20 mg/2ml famotidine oral tablet 20 mg, 40 mg famotidine premixed intravenous solution mg/50ml-% ranitidine hcl injection solution 50 mg/2ml ranitidine hcl oral capsule 50 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml ranitidine hcl oral tablet 50 mg, 300 mg ZANTAC INJECTION SOLUTION 000 MG/40ML IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5 mg, mg AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

80 CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML ST; MO CIMZIA SUBCUTANEOUS KIT 2 X 200 MG ST LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG LAXATIVES constulose oral solution 0 gm/5ml enulose oral solution 0 gm/5ml GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM generlac oral solution 0 gm/5ml lactulose oral solution 0 gm/5ml MOVIPREP ORAL SOLUTION RECONSTITUTED 00 GM peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM- GM TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM PROTECTANTS CARAFATE ORAL SUSPENSION GM/0ML misoprostol oral tablet 00 mcg, 200 mcg sucralfate oral tablet gm PROTON PUMP INHIBITORS 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 intravenous solution reconstituted 40 mg pantoprazole sodium oral tablet delayed release 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: 8327, Ver. 0 Last updated 06/0/208 67

81 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ENZYME REPLACEMENT/ MODIFIERS ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT LA BD; LA BD; LA CYSTADANE ORAL POWDER ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 5 MG KANUMA INTRAVENOUS SOLUTION 20 MG/0ML BD BD; LA BD PA KUVAN ORAL PACKET 00 MG, 500 MG KUVAN ORAL TABLET SOLUBLE 00 MG LA; MO 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD ORFADIN ORAL SUSPENSION 4 MG/ML LA; MO RAVICTI ORAL LIQUID. GM/ML VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT XURIDEN ORAL PACKET 2 GM PA; MO

82 ZAVESCA ORAL CAPSULE 00 MG ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 0000 UNIT, 5000 UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT, UNIT GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin hydrobromide er oral tablet extended release 24 hour 5 mg, 7.5 mg 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 ST; MO oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate oral tablet mg, 2 mg VESICARE ORAL TABLET 0 MG, 5 MG BENIGN PROSTATIC HYPERTROPHY AGENTS dutasteride oral capsule 0.5 mg dutasteride-tamsulosin hcl oral capsule mg finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE 4 MG, 8 MG tamsulosin hcl oral capsule 0.4 mg GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 50 MG, 50 MG ELMIRON ORAL CAPSULE 00 MG neomycin-polymyxin b gu irrigation solution sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS calcium acetate (phos binder) oral capsule 667 mg You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ calcium acetate (phos binder) oral tablet 667 mg sevelamer carbonate oral packet 0.8 gm, 2.4 gm sevelamer carbonate oral tablet 800 mg

83 VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2 % estradiol vaginal cream 0. mg/gm estradiol vaginal tablet 0 mcg metronidazole vaginal gel 0.75 % miconazole 3 vaginal suppository 200 mg PREMARIN VAGINAL CREAM MG/GM terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg VANDAZOLE VAGINAL GEL 0.75 % YUVAFEM VAGINAL TABLET 0 MCG HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOC ORTICOIDS budesonide oral capsule delayed release particles 3 mg DEPO-MEDROL INJECTION SUSPENSION 20 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 oral solution 5 mg/5ml prednisolone sodium phosphate oral solution 5 mg/5ml, 25 mg/5ml, 6.7 (5 base) 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: 8327, Ver. 0 Last updated 06/0/208 70

84 prednisolone sodium phosphate oral tablet dispersible 0 mg, 5 mg, 30 mg 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) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM 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 oxandrolone oral tablet 0 mg, 2.5 mg ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (.62%) ANDROGEL TRANSDERMAL GEL MG/.25GM (.62%), 40.5 MG/2.5GM (.62%) danazol oral capsule 00 mg, 200 mg, 50 mg ST methyltestosterone oral capsule 0 mg testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml CONTRACEPTIVES ALTAVERA ORAL TABLET MG- MCG alyacen /35 oral tablet -35 mg-mcg AMETHIA ORAL TABLET &0.0 MG APRI ORAL TABLET 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: 8327, Ver. 0 Last updated 06/0/208 7

85 ASHLYNA ORAL TABLET &0.0 MG AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BEKYREE ORAL TABLET /0.0 MG (2/5) BLISOVI 24 FE ORAL TABLET -20 MG- MCG(24) BLISOVI FE.5/30 ORAL TABLET.5-30 MG-MCG BLISOVI FE /20 ORAL TABLET -20 MG- MCG briellyn oral tablet mg-mcg CAMILA ORAL TABLET 0.35 MG CAZIANT ORAL TABLET 0./0.25/ MG CYCLAFEM /35 ORAL TABLET -35 MG- MCG DEBLITANE ORAL TABLET 0.35 MG DELYLA ORAL TABLET MG-MCG DEPO-SUBQ PROVERA 04 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 04 MG/0.65ML desogestrel-ethinyl estradiol oral tablet /0.0 mg (2/5), mg-mcg drospirenone-ethinyl estradiol oral tablet mg, mg EMOQUETTE ORAL TABLET 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: 8327, Ver. 0 Last updated 06/0/ ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MG-MCG ERRIN ORAL TABLET 0.35 MG ethynodiol diac-eth estradiol oral tablet -35 mgmcg, -50 mg-mcg FALMINA ORAL TABLET MG-MCG FEMYNOR ORAL TABLET MG-MCG GIANVI ORAL TABLET MG GILDAGIA ORAL TABLET MG-MCG

86 INTROVALE ORAL TABLET MG ISIBLOOM ORAL TABLET MG-MCG JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG-MCG JUNEL FE.5/30 ORAL TABLET.5-30 MG- MCG JUNEL FE /20 ORAL TABLET -20 MG-MCG JUNEL FE 24 ORAL TABLET -20 MG- MCG(24) KAITLIB FE ORAL TABLET CHEWABLE MG-MCG KARIVA ORAL TABLET /0.0 MG (2/5) KELNOR /50 ORAL TABLET -50 MG-MCG KIMIDESS ORAL TABLET /0.0 MG (2/5) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ KURVELO ORAL TABLET 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 LAYOLIS FE ORAL TABLET CHEWABLE MG-MCG LESSINA ORAL TABLET MG-MCG LEVONEST ORAL TABLET levonorgest-eth est & eth est oral tablet days levonorgest-eth estrad 9-day oral tablet &0.0 mg, mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg-mcg levonorg-eth estrad triphasic oral tablet LEVORA 0.5/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG- MCG LUTERA ORAL TABLET MG-MCG LYZA ORAL TABLET 0.35 MG

87 marlissa oral tablet mg-mcg medroxyprogesterone acetate intramuscular suspension 50 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 50 mg/ml MICROGESTIN FE.5/30 ORAL TABLET.5-30 MG-MCG MICROGESTIN FE /20 ORAL TABLET -20 MG-MCG NECON 0.5/35 (28) ORAL TABLET 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 norethin-eth estradiol-fe oral tablet chewable mg-mcg norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.8/0.25/0.25 mg-25 mcg, 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 OCELLA ORAL TABLET MG ORSYTHIA ORAL TABLET MG-MCG PIMTREA ORAL TABLET /0.0 MG (2/5) PIRMELLA /35 ORAL TABLET -35 MG- MCG PORTIA-28 ORAL TABLET 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: 8327, Ver. 0 Last updated 06/0/208 74

88 QUARTETTE ORAL TABLET DAYS QUASENSE ORAL TABLET MG RECLIPSEN ORAL TABLET MG- MCG SETLAKIN ORAL TABLET MG SHAROBEL ORAL TABLET 0.35 MG SRONYX ORAL TABLET MG-MCG TARINA FE /20 ORAL TABLET -20 MG- MCG TRI-LO-ESTARYLLA ORAL TABLET 0.8/0.25/0.25 MG-25 MCG TRI-LO-SPRINTEC ORAL TABLET 0.8/0.25/0.25 MG-25 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 VIENVA ORAL TABLET MG-MCG VYFEMLA ORAL TABLET MG-MCG WYMZYA FE ORAL TABLET CHEWABLE MG-MCG ZENCHENT ORAL TABLET MG-MCG ESTROGENS ESTRACE ORAL TABLET 0.5 MG, MG, 2 MG PA; MO; HRM estradiol oral tablet 0.5 mg, mg, 2 mg PA; MO; HRM FYAVOLV ORAL TABLET MG-MCG, -5 MG-MCG PA; MO; HRM JINTELI ORAL TABLET -5 MG-MCG PA; MO; HRM MENEST ORAL TABLET 0.3 MG, MG,.25 MG PA; MO; HRM You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 75

89 norethindrone-eth estradiol oral tablet mg-mcg, -5 mg-mcg PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PA; MO; HRM PA; MO; HRM PREMPHASE ORAL TABLET MG PA; MO; HRM PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS MAKENA INTRAMUSCULAR OIL 250 MG/ML MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/.ML medroxyprogesterone acetate oral tablet 0 mg, 2.5 mg, 5 mg PA; MO; HRM norethindrone acetate oral tablet 5 mg SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS raloxifene hcl oral tablet 60 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 rhinal tube nasal solution 0.0 % desmopressin ace spray refrig nasal solution 0.0 % desmopressin acetate injection solution 4 mcg/ml PA desmopressin acetate oral tablet 0. mg, 0.2 mg INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML LA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 76

90 NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 0 MG/.5ML, 5 MG/.5ML, 30 MG/3ML, 5 MG/.5ML NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) LEVO-T 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 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 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 (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) PA; MO PA KORLYM ORAL TABLET 300 MG PA; LA; MO LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.25 MG LUPRON DEPOT-PED (-MONTH) INTRAMUSCULAR KIT.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: 8327, Ver. 0 Last updated 06/0/208 77

91 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, 25 MG, 30 MG SYNAREL NASAL SOLUTION 2 MG/ML HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ LA; MO 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 BD; MO azathioprine oral tablet 50 mg BD; MO azathioprine sodium injection solution reconstituted 00 mg BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 20 MG BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 400 MG BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML BD BD cyclosporine intravenous solution 50 mg/ml BD cyclosporine modified oral capsule 00 mg, 25 mg, 50 mg BD; MO cyclosporine modified oral solution 00 mg/ml BD; MO

92 cyclosporine oral capsule 00 mg, 25 mg BD; MO 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 ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, MG, 4 MG BD; MO GENGRAF ORAL CAPSULE 00 MG, 25 MG BD; MO GENGRAF ORAL SOLUTION 00 MG/ML BD; MO 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 KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/0.67ML mycophenolate mofetil hcl intravenous solution reconstituted 500 mg ST; MO BD mycophenolate mofetil oral capsule 250 mg BD; MO mycophenolate mofetil oral suspension reconstituted 200 mg/ml BD; MO mycophenolate mofetil oral tablet 500 mg BD; MO mycophenolate sodium oral tablet delayed release 80 mg, 360 mg NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG PROGRAF INTRAVENOUS SOLUTION 5 MG/ML BD; MO BD BD RAPAMUNE ORAL SOLUTION MG/ML BD; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 79

93 SANDIMMUNE ORAL CAPSULE 00 MG, 25 MG SANDIMMUNE ORAL SOLUTION 00 MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 00 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML, 50 MG/0.5ML SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 20 MG BD; MO BD; MO ST; MO ST; MO ST; MO BD sirolimus oral tablet 0.5 mg, mg, 2 mg BD; MO tacrolimus oral capsule 0.5 mg, mg, 5 mg BD; MO TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG IMMUNIZING AGENTS, PASSIVE ATGAM INTRAVENOUS INJECTABLE 50 MG/ML BIVIGAM INTRAVENOUS SOLUTION 0 GM/00ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMASTAN S/D INTRAMUSCULAR INJECTABLE (0ML), (2ML) GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 0 GM, 5 GM GAMMAKED INJECTION SOLUTION GM/0ML GAMMAPLEX INTRAVENOUS SOLUTION 0 GM/00ML, 0 GM/200ML, 20 GM/200ML, 5 GM/50ML BD BD; MO BD BD BD BD BD BD BD 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: 8327, Ver. 0 Last updated 06/0/208 80

94 GAMUNEX-C INJECTION SOLUTION GM/0ML HYPERRAB S/D INJECTION SOLUTION 500 UNIT/0ML, 300 UNIT/2ML HYPERRAB S/D INTRAMUSCULAR INJECTABLE 50 UNIT/ML, 50 UNIT/ML (0ML) OCTAGAM INTRAVENOUS SOLUTION GM/20ML, 2 GM/20ML PRIVIGEN INTRAVENOUS SOLUTION 20 GM/200ML SYNAGIS INTRAMUSCULAR SOLUTION 00 MG/ML, 50 MG/0.5ML THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG 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 BD You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 8 BD BD BD ST ST; MO BD; MO leflunomide oral tablet 0 mg, 20 mg 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 ST; MO ST; MO ST; MO XELJANZ ORAL TABLET 5 MG ST; MO VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION (PREFILLED SYRINGE), LF- MCG/0.5 bcg vaccine injection injectable

95 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) DAPTACEL INTRAMUSCULAR SUSPENSION 0-5-5, LF-MCG/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml 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, 440 EL U/ML ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML HIBERIX INJECTION SOLUTION RECONSTITUTED 0 MCG 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 You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD BD

96 RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 0 MCG/ML, 0 MCG/ML (ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG 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, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML ML VARIVAX SUBCUTANEOUS INJECTABLE 350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 9400 UNT/0.65ML INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 mg LIALDA ORAL TABLET DELAYED RELEASE.2 GM mesalamine oral tablet delayed release 800 mg mesalamine rectal enema 4 gm mesalamine-cleanser rectal kit 4 gm 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: 8327, Ver. 0 Last updated 06/0/ BD

97 METABOLIC BONE DISEASE AGENTS HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) MIACALCIN INJECTION SOLUTION 200 UNIT/ML SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 0 mg, 35 mg, 5 mg, 70 mg alendronate sodium oral tablet 40 mg BD; MO calcitonin (salmon) nasal solution 200 unit/act BD; MO calcitriol intravenous solution mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution mcg/ml FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML FOSAMAX PLUS D ORAL TABLET MG-UNIT FOSAMAX PLUS D ORAL TABLET MG-UNIT ; QL (4 EA per 28 days) ibandronate sodium oral tablet 50 mg NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG, 25 MCG, 50 MCG, 75 MCG pamidronate disodium intravenous solution 30 mg/0ml, 6 mg/ml, 90 mg/0ml paricalcitol intravenous solution 2 mcg/ml paricalcitol intravenous solution 5 mcg/ml BD paricalcitol oral capsule mcg, 2 mcg, 4 mcg BD; MO PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML risedronate sodium oral tablet 50 mg, 35 mg, 35 mg (2 pack), 35 mg (4 pack), 5 mg risedronate sodium oral tablet 30 mg risedronate sodium oral tablet delayed release 35 mg ST You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 84

98 TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 320 MCG/.56ML XGEVA SUBCUTANEOUS SOLUTION 20 MG/.7ML zoledronic acid intravenous concentrate 4 mg/5ml BD zoledronic acid intravenous solution 5 mg/00ml BD ZOMETA INTRAVENOUS SOLUTION 4 MG/00ML MISCELLANEOUS MISCELLANEOUS CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD ENDARI ORAL PACKET 5 GM PA; LA; QL (80 EA per 30 days) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML lactated ringers irrigation solution PHYSIOLYTE IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost ophthalmic solution 0.03 % latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.0 % TRAVATAN Z OPHTHALMIC SOLUTION % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution % RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC ANTI INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm

99 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate ophthalmic solution 0.3 % MOXEZA OPHTHALMIC SOLUTION 0.5 % moxifloxacin hcl ophthalmic solution 0.5 % NATACYN OPHTHALMIC SUSPENSION 5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic solution 0 % tobramycin ophthalmic solution 0.3 % trifluridine ophthalmic solution % ZIRGAN OPHTHALMIC GEL 0.5 % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION.5 % cromolyn sodium ophthalmic solution 4 % olopatadine hcl ophthalmic solution 0. % PATADAY OPHTHALMIC SOLUTION 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % PROLENSA OPHTHALMIC SOLUTION 0.07 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0. % apraclonidine hcl ophthalmic solution 0.5 % You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ AZOPT OPHTHALMIC SUSPENSION % betaxolol hcl ophthalmic solution 0.5 %

100 brimonidine tartrate ophthalmic solution 0.5 %, 0.2 % carteolol hcl ophthalmic solution % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution 2 % 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 % SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) OPHTHALMIC ANTI- INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CYSTARAN OPHTHALMIC SOLUTION 0.44 % dexamethasone sodium phosphate ophthalmic solution 0. % diclofenac sodium ophthalmic solution 0. % DUREZOL OPHTHALMIC EMULSION 0.05 % 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 % PA; MO; QL (60 ML per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 87

101 LOTEMAX OPHTHALMIC SUSPENSION 0.5 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension prednisolone acetate ophthalmic suspension % prednisolone sodium phosphate ophthalmic solution % sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % OTIC AGENTS OTIC AGENTS acetic acid otic solution 2 % CIPRODEX OTIC SUSPENSION % fluocinolone acetonide otic oil 0.0 % neomycin-polymyxin-hc otic solution % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS ANTIHISTAMINES cetirizine hcl oral solution mg/ml cetirizine hcl oral syrup mg/ml cyproheptadine hcl oral tablet 4 mg PA; HRM desloratadine oral tablet 5 mg desloratadine oral tablet dispersible 2.5 mg diphenhydramine hcl injection solution 50 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 88

102 levocetirizine dihydrochloride oral tablet 5 mg promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/ACT, 200 MCG/ACT ASMANEX 20 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 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, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 80 MCG/ACT, 90 MCG/ACT ANTILEUKOTRIENES You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ BD; MO montelukast sodium oral packet 4 mg montelukast sodium oral tablet 0 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 0 mg, 20 mg zileuton er oral tablet extended release 2 hour 600 mg ZYFLO ORAL TABLET 600 MG BRONCHODILATORS, ANTICHOLINERGIC

103 ATROVENT HFA INHALATION AEROSOL SOLUTION 7 MCG/ACT ipratropium bromide inhalation solution 0.02 % BD; MO SPIRIVA HANDIHALER INHALATION CAPSULE 8 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.25 MCG/ACT, 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 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 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 BD; MO 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 fluticasone-salmeterol inhalation aerosol powder breath activated 3-4 mcg/act, mcg/act, 55-4 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: 8327, Ver. 0 Last updated 06/0/208 90

104 ipratropium-albuterol inhalation solution (3) mg/3ml levalbuterol hcl inhalation nebulization solution 0.63 mg/3ml,.25 mg/0.5ml PROAIR HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 08 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT terbutaline sulfate injection solution mg/ml MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 20 mg/2ml NASAL AGENTS azelastine hcl nasal solution 0. %, 0.5 % flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act ipratropium bromide nasal solution 0.03 %, 0.06 % mometasone furoate nasal suspension 50 mcg/act PULMONARY ANTIHYPERTENSIVES BD; MO BD; MO BD; MO ADCIRCA ORAL TABLET 20 MG PA; MO ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG PA; MO LETAIRIS ORAL TABLET 0 MG, 5 MG OPSUMIT ORAL TABLET 0 MG PA; MO sildenafil citrate intravenous solution 0 mg/2.5ml PA sildenafil citrate oral tablet 20 mg PA; MO TRACLEER ORAL TABLET 25 MG, 62.5 MG LA; MO TRACLEER ORAL TABLET SOLUBLE 32 MG LA; MO You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 9

105 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 PULMONARY FIBROSIS AGENTS PA; LA; MO PA; LA BD; MO ESBRIET ORAL CAPSULE 267 MG PA; MO ESBRIET ORAL TABLET 267 MG, 80 MG PA; MO OFEV ORAL CAPSULE 00 MG, 50 MG RESPIRATORY TRACT AGENTS, OTHER acetylcysteine inhalation solution 0 %, 20 % BD DALIRESP ORAL TABLET 250 MCG, 500 MCG epinephrine injection solution auto-injector 0.5 mg/0.3ml, 0.3 mg/0.3ml KALYDECO ORAL PACKET 50 MG, 75 MG PA; MO KALYDECO ORAL TABLET 50 MG PA; MO NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 00 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 000 MG PULMOZYME INHALATION SOLUTION MG/ML SYMDEKO ORAL TABLET THERAPY PACK & 50 MG XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 50 MG ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 000 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/ PA; MO PA; MO BD BD; MO PA; LA; MO LA PA baclofen oral tablet 0 mg, 20 mg cyclobenzaprine hcl oral tablet 0 mg, 5 mg, 7.5 mg PA; HRM

106 methocarbamol injection solution 000 mg/0ml PA; HRM methocarbamol oral tablet 500 mg, 750 mg PA; HRM orphenadrine citrate er oral tablet extended release 2 hour 00 mg PA; HRM orphenadrine citrate injection solution 30 mg/ml PA; HRM tizanidine hcl oral tablet 2 mg, 4 mg SLEEP DISORDER AGENTS BENZODIAZEPINES estazolam oral tablet mg QL (60 EA per 30 days) estazolam oral tablet 2 mg QL (30 EA per 30 days) flurazepam hcl oral capsule 5 mg QL (60 EA per 30 days) flurazepam hcl oral capsule 30 mg QL (30 EA per 30 days) temazepam oral capsule 5 mg, 22.5 mg, 30 mg QL (30 EA per 30 days) temazepam oral capsule 7.5 mg QL (20 EA per 30 days) triazolam oral tablet 0.25 mg QL (30 EA per 30 days) triazolam oral tablet 0.25 mg QL (60 EA per 30 days) GABA RECEPTOR MODULATORS ROZEREM ORAL TABLET 8 MG zaleplon oral capsule 0 mg zaleplon oral capsule 5 mg zolpidem tartrate oral tablet 0 mg, 5 mg zolpidem tartrate sublingual tablet sublingual.75 mg, 3.5 mg SLEEP DISORDERS, OTHER BELSOMRA ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG HETLIOZ ORAL CAPSULE 20 MG PA; MO modafinil oral tablet 00 mg, 200 mg PA; MO SILENOR ORAL TABLET 3 MG, 6 MG XYREM ORAL SOLUTION 500 MG/ML LA PA; HRM; QL (60 EA per 30 days) PA; HRM; QL (30 EA per 30 days) PA; HRM; QL (30 EA per 30 days) PA; HRM; QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page of the introduction. Formulary ID: 8327, Ver. 0 Last updated 06/0/208 93

107 Alphabetical Listing A abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET... 9 ABILIFY MAINTENA ABRAXANE acamprosate calcium... 4 acarbose acebutolol hcl acetaminophen-codeine... 3 acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetazolamide acetic acid acetylcysteine acitretin ACTEMRA... 8 ACTHIB... 8 ACTIMMUNE acyclovir acyclovir sodium ADACEL... 8 ADAGEN ADCIRCA... 9 adefovir dipivoxil ADEMPAS... 9 ADRIAMYCIN ADRUCIL ADVAIR DISKUS ADVAIR HFA AFEDITAB CR... 5 AFINITOR AFINITOR DISPERZ ALBENZA albuterol sulfate albuterol sulfate er ALDACTAZIDE ALDURAZYME ALECENSA alendronate sodium ALIMTA ALINIA ALIQOPA allopurinol... 20, 3 ALLZITAL... 2 alosetron hcl ALPHAGAN P alprazolam... 4 alprazolam er... 4 ALPRAZOLAM INTENSOL 4 ALTAVERA... 7 ALUNBRIG alyacen / amantadine hcl AMBISOME... 9 amcinonide AMETHIA... 7 amiloride hcl amiloride-hydrochlorothiazide48 aminophylline AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYTE S AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl AMITIZA amitriptyline hcl... 7 amlodipine besy-benazepril hcl amlodipine besylate... 5 amlodipine besylate-valsartan 48 amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan-hctz ammonium lactate AMNESTEEM amoxapine... 7 amoxicillin... 8 amoxicillin-pot clavulanate... 8 amphetaminedextroamphetamine amphotericin b... 9 ampicillin... 8 ampicillin sodium... 8 ampicillin-sulbactam sodium 8, 9 AMPYRA ANADROL anagrelide hcl anastrozole... 3 ANDRODERM... 7 ANDROGEL... 7 ANDROGEL PUMP... 7 APLENZIN... 5 APOKYN apraclonidine hcl aprepitant... 8 APRI... 7 APRISO APTIOM... 3 APTIVUS ARCALYST... 8 argatroban aripiprazole ARNUITY ELLIPTA ARRANON ASCOMP-CODEINE... 3 ASHLYNA ASMANEX 20 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-dipyridamole er ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atazanavir sulfate atenolol atenolol-chlorthalidone ATGAM atomoxetine hcl atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate... 65, 85 ATROVENT HFA AUBAGIO AUBRA AUGMENTIN... 9 AUSTEDO AVANDIA AVASTIN AVIANE azacitidine AZACTAM... 8 AZACTAM IN DEXTROSE... 8 AZASAN

108 azathioprine azathioprine sodium azelastine hcl... 86, 9 azithromycin... 9 AZOPT aztreonam... 8 B baciim... 8 bacitracin... 5, 85 bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen balsalazide disodium BALZIVA BANZEL... 3 BARACLUDE BAVENCIO bcg vaccine... 8 BEKYREE BELEODAQ BELSOMRA benazepril hcl benazepril-hydrochlorothiazide BENLYSTA benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate.. 57, 58 betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 50, 86 BETHKIS... 5 bexarotene BEXSERO bicalutamide BICILLIN L-A... 9 BICNU BIKTARVY bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin sulfate BLEPHAMIDE BLEPHAMIDE S.O.P BLISOVI 24 FE BLISOVI FE.5/ BLISOVI FE / BOOSTRIX bortezomib BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRIVIACT... 3 bromocriptine mesylate budesonide... 70, 89 bumetanide buprenorphine hcl... 4 bupropion hcl... 5 bupropion hcl er (smoking det)... 5 bupropion hcl er (sr)... 5, 5 bupropion hcl er (xl)... 5 buspirone hcl busulfan butalbital-acetaminophen... 2 butalbital-apap-caff-cod... 3 butalbital-apap-caffeine... 2 butalbital-asa-caff-codeine... 3 BUTRANS... 4 C cabergoline CABOMETYX calcipotriene calcitonin (salmon) calcitriol calcium acetate (phos binder). 69 CALQUENCE CAMILA candesartan cilexetil candesartan cilexetil-hctz CAPASTAT SULFATE CAPRELSA captopril captopril-hydrochlorothiazide 49 CARAFATE CARBAGLU... 6 carbamazepine... 4, 4 carbamazepine er... 3, 4 carbidopa-levodopa carbidopa-levodopa er carboplatin CARIMUNE NF carteolol hcl CARTIA XT... 5 carvedilol carvedilol phosphate er caspofungin acetate... 9 CAYSTON... 8 CAZIANT cefaclor... 7 cefaclor er... 6 cefazolin sodium... 7 cefdinir... 7 cefepime hcl... 7 cefixime... 7 cefoxitin sodium... 7 cefpodoxime proxetil... 7 cefprozil... 7 ceftazidime... 7 ceftriaxone sodium... 7 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib CELONTIN... 2 cephalexin... 7 CEREBYX... 4 CEREZYME cetirizine hcl CHANTIX... 5 CHANTIX CONTINUING MONTH PAK... 5 CHANTIX STARTING MONTH PAK... 5 chloramphenicol sod succinate. 5 chlordiazepoxide hcl... 4 chlordiazepoxide-amitriptyline... 7 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpromazine hcl chlorpropamide chlorthalidone cholestyramine cholestyramine light chorionic gonadotropin ciclopirox ciclopirox olamine cilostazol

109 CIMZIA CIMZIA PREFILLED CINRYZE CIPRODEX ciprofloxacin... 0 ciprofloxacin hcl... 0, 86 ciprofloxacin in d5w... 0 ciprofloxacin-ciproflox hcl er. 0 cisplatin citalopram hydrobromide... 6 cladribine CLARAVIS clarithromycin... 9 clindamycin hcl... 5 clindamycin palmitate hcl... 6 clindamycin phos-benzoyl perox clindamycin phosphate. 6, 58, 70 clindamycin phosphate in d5w. 6 CLINIMIX E/DEXTROSE (2.75/0) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/0) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/5) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) 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) CLINISOL SF clobetasol propionate clobetasol propionate e clofarabine clomipramine hcl... 7 clonazepam... clonidine hcl... 46, 47 clopidogrel bisulfate clorazepate dipotassium... 4 clotrimazole... 9, 58 clotrimazole-betamethasone clozapine COARTEM colchicine colestipol hcl colistimethate sodium... 6 colistimethate sodium (cba)... 6 COMBIGAN COMBIVENT RESPIMAT COMETRIQ (00 MG DAILY DOSE) COMETRIQ (40 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE COMPLERA COMPRO CONDYLOX constulose CORLANOR COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COTELLIC CREON CRIXIVAN cromolyn sodium... 86, 9 cvs gauze sterile CYCLAFEM / cyclobenzaprine hcl cyclophosphamide CYCLOSET cyclosporine... 78, 79 cyclosporine modified cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) D dacarbazine dactinomycin DALIRESP danazol... 7 dapsone DAPTACEL daptomycin... 6 DARAPRIM darifenacin hydrobromide er.. 69 DARZALEX daunorubicin hcl DEBLITANE decitabine DELYLA DEMSER DEPEN TITRATABS DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DESCOVY desipramine hcl... 7 desloratadine... 38, 88 desmopressin ace rhinal tube.. 76 desmopressin ace spray refrig 76 desmopressin acetate desogestrel-ethinyl estradiol desonide... 58, 59 desoximetasone desvenlafaxine er... 6 desvenlafaxine succinate er... 6 dexamethasone dexamethasone sodium phosphate... 70, 87 dexmethylphenidate hcl er dexrazoxane dextroamphetamine sulfate dextroamphetamine sulfate er. 55 dextrose dextrose in lactated ringers dextrose-nacl DIASTAT ACUDIAL... 2 DIASTAT PEDIATRIC... 2 diazepam... 2, 4 96

110 DIAZEPAM INTENSOL... 4 diclofenac potassium diclofenac sodium... 20, 59, 87 diclofenac sodium er dicloxacillin sodium... 9 dicyclomine hcl didanosine DIFICID... 9 diflorasone diacetate diflunisal DIGITEK DIGOX digoxin dihydroergotamine mesylate.. 2 DILANTIN... 4 diltiazem hcl... 5 diltiazem hcl er... 5 diltiazem hcl er beads... 5 diltiazem hcl er coated beads. 5 dilt-xr... 5 diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoids dt.. 82 dipyridamole disopyramide phosphate disulfiram... 4 divalproex sodium... 2, 2 divalproex sodium er... 2 docetaxel dofetilide donepezil hcl... 4 doripenem... 8 dorzolamide hcl dorzolamide hcl-timolol mal.. 87 doxazosin mesylate doxepin hcl... 7 DOXIL doxorubicin hcl doxorubicin hcl liposomal DOXY doxycycline hyclate... 0, doxycycline monohydrate... dronabinol... 8 drospirenone-ethinyl estradiol 72 duloxetine hcl... 6 duramorph... 3 DUREZOL dutasteride dutasteride-tamsulosin hcl E E.E.S econazole nitrate EDURANT efavirenz ELAPRASE eletriptan hydrobromide... 2 ELIDEL ELIGARD ELIQUIS ELIQUIS STARTER PACK.. 45 ELITEK ELMIRON EMCYT EMEND... 8 EMOQUETTE EMPLICITI EMSAM... 6 EMTRIVA EMVERM enalapril maleate enalapril-hydrochlorothiazide 49 ENBREL ENBREL SURECLICK ENDARI ENGERIX-B enoxaparin sodium ENPRESSE ENSKYCE entacapone entecavir ENTRESTO enulose ENVARSUS XR EPCLUSA epinephrine epirubicin hcl EPITOL... 4 EPIVIR HBV eplerenone EPOGEN eprosartan mesylate EQUETRO... 4 ERAXIS... 9 ERBITUX ergoloid mesylates... 4 ergotamine-caffeine... 2 ERIVEDGE ERLEADA ERRIN ERWINAZE ERYTHROCIN LACTOBIONATE... 9 ERYTHROCIN STEARATE... 9 erythromycin... 59, 86 erythromycin base... 0 erythromycin ethylsuccinate... 0 ESBRIET escitalopram oxalate... 6 esomeprazole sodium estazolam ESTRACE estradiol... 70, 75 ethambutol hcl ethosuximide... 2 ethynodiol diac-eth estradiol.. 72 etodolac etodolac er ETOPOPHOS etoposide EURAX EVOTAZ EXEL COMFORT POINT PEN NEEDLE exemestane... 3 EXJADE ezetimibe ezetimibe-simvastatin F FABRAZYME FALMINA famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON FARYDAK FASLODEX felbamate... 2, 3 felodipine er... 5 FEMYNOR fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fentanyl... 2 FENTORA... 3 FERRIPROX

111 FETZIMA... 6 FETZIMA TITRATION finasteride FIRAZYR FIRMAGON FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole... 9 fluconazole in sodium chloride... 9 flucytosine... 9 fludarabine phosphate fludrocortisone acetate flunisolide... 9 fluocinolone acetonide... 59, 88 fluocinolone acetonide body.. 59 fluocinolone acetonide scalp.. 59 fluocinonide fluocinonide emulsified base.. 59 fluocinonide-e fluorouracil... 26, 59 fluoxetine hcl... 6 fluphenazine decanoate fluphenazine hcl... 33, 34 flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate... 59, 9 fluticasone-salmeterol fluvastatin sodium fluvastatin sodium er fluvoxamine maleate... 7 fluvoxamine maleate er... 7 FOLOTYN fondaparinux sodium FORFIVO XL... 5 FORTEO FOSAMAX PLUS D fosamprenavir calcium fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium... 4 FRAGMIN FREAMINE HBC furosemide FUZEON FYAVOLV FYCOMPA... 2 G gabapentin... 2 GABITRIL... 2 galantamine hydrobromide... 4 galantamine hydrobromide er. 4 GAMASTAN S/D GAMMAGARD GAMMAGARD S/D LESS IGA GAMMAKED GAMMAPLEX GAMUNEX-C... 8 ganciclovir sodium GARDASIL GATTEX GAVILYTE-N WITH FLAVOR PACK gemcitabine hcl gemfibrozil generlac GENGRAF GENTAK gentamicin in saline... 5 gentamicin sulfate... 5, 59, 86 GENVOYA GEODON GIANVI GILDAGIA GILENYA GILOTRIF glatiramer acetate GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY 44 glyburide glyburide micronized glyburide-metformin glycopyrrolate GOCOVRI granisetron hcl... 8 griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guanfacine hcl er guanidine hcl H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HAVRIX heparin (porcine) in d5w heparin sod (porcine) in d5w.. 45 heparin sodium (porcine) HEPATAMINE HERCEPTIN HETLIOZ 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... 59, 60, 70 hydrocortisone ace-pramoxine59 hydrocortisone valerate hydromorphone hcl... 2, 3 hydromorphone hcl pf... 3 hydroxychloroquine sulfate hydroxyprogesterone caproate 26 hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D... 8 HYSINGLA ER... 3 I ibandronate sodium IBRANCE IBU ibuprofen ICLUSIG idarubicin hcl IDHIFA ifosfamide ILEVRO imatinib mesylate

112 IMBRUVICA IMFINZI imipenem-cilastatin... 8 imipramine hcl... 7 imipramine pamoate... 7 imiquimod IMOVAX RABIES INCRELEX indapamide indomethacin indomethacin er INFANRIX INLYTA INTELENCE INTRON A INTROVALE INVANZ... 8 INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IPOL ipratropium bromide... 90, 9 ipratropium-albuterol... 9 irbesartan irbesartan-hydrochlorothiazide IRESSA irinotecan hcl ISENTRESS ISENTRESS HD ISIBLOOM ISOLYTE-P IN D5W ISOLYTE-S isoniazid isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isotretinoin isradipine... 5 ISTODAX (OVERFILL) itraconazole... 9 ivermectin IXIARO J JADENU SPRINKLE JAKAFI JANTOVEN JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JEVTANA JINTELI JOLIVETTE JULEBER JULUCA JUNEL FE.5/ JUNEL FE / JUNEL FE JUXTAPID K KADCYLA KAITLIB FE KALETRA KALYDECO KANUMA KARIVA kcl in dextrose-nacl kcl-lactated ringers-d5w KELNOR / KEPIVANCE ketoconazole... 9, 60 ketoprofen ketoprofen er ketorolac tromethamine... 20, 87 KEYTRUDA KIMIDESS 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 KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KORLYM K-TAB KURVELO KUVAN KYNAMRO KYPROLIS L labetalol hcl lactated ringers... 62, 85 lactulose LAMICTAL STARTER... 3 LAMICTAL XR... 3 lamivudine lamivudine-zidovudine lamotrigine... 3 lamotrigine er... 3 lamotrigine starter kit-blue... 3 lamotrigine starter kit-green... 3 lamotrigine starter kit-orange. 3 lansoprazole LANTUS LANTUS SOLOSTAR LARIN FE.5/ LARIN FE / LARISSIA LARTRUVO latanoprost LATUDA LAYOLIS FE LAZANDA... 3 leflunomide... 8 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 LETAIRIS... 9 letrozole... 3 leucovorin calcium LEUKERAN LEUKINE

113 leuprolide acetate levalbuterol hcl... 9 LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... levetiracetam er... levetiracetam in nacl... levobunolol hcl levocarnitine levocetirizine dihydrochloride 89 levofloxacin... 0 levofloxacin in d5w... 0 levoleucovorin calcium LEVONEST levonorgest-eth est & eth est.. 73 levonorgest-eth estrad 9-day 73 levonorgestrel-ethinyl estrad.. 73 levonorg-eth estrad triphasic.. 73 LEVORA 0.5/30 (28) LEVO-T levothyroxine sodium LEVOXYL LEXIVA LIALDA lidocaine lidocaine hcl... 4, 60 lidocaine hcl (pf)... 4 lidocaine viscous lidocaine-prilocaine... 4 lincomycin hcl... 6 lindane linezolid... 6 LINZESS liothyronine sodium lisinopril lisinopril-hydrochlorothiazide 49 lithium lithium carbonate... 4 lithium carbonate er... 4 LIVALO LONSURF loperamide hcl lopinavir-ritonavir lorazepam... 4 LORAZEPAM INTENSOL... 4 LORYNA losartan potassium losartan potassium-hctz LOTEMAX... 87, 88 lovastatin LOW-OGESTREL loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT (-MONTH) LUPRON DEPOT (3-MONTH)... 28, 77 LUPRON DEPOT (4-MONTH) LUPRON DEPOT (6-MONTH) LUPRON DEPOT-PED (- MONTH) LUPRON DEPOT-PED (3- MONTH) LUTERA LYNPARZA LYRICA... 2, 56 LYSODREN LYZA M magnesium sulfate MAKENA maprotiline hcl... 5 marlissa MARPLAN... 6 MATULANE MAVYRET meclizine hcl... 8 meclofenamate sodium medroxyprogesterone acetate 74, 76 mefloquine hcl megestrol acetate MEKINIST meloxicam... 2 melphalan hcl memantine hcl... 5 memantine hcl er... 5 MENACTRA MENEST MENVEO meprobamate mercaptopurine meropenem... 8 mesalamine mesalamine-cleanser mesna... 3 MESNEX MESTINON METADATE ER metformin hcl metformin hcl er metformin hcl er (osm) methadone hcl... 2 methazolamide methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate hcl methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methylprednisolone acetate methylprednisolone sodium succ methyltestosterone... 7 metipranolol metoclopramide hcl... 8, 66 metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 6, 60, 70 metronidazole in nacl... 6 mexiletine hcl MIACALCIN miconazole MICROGESTIN FE.5/ MICROGESTIN FE / midodrine hcl miglitol MINITRAN minocycline hcl... minoxidil MIRCERA mirtazapine... 5 misoprostol

114 mitomycin mitoxantrone hcl M-M-R II modafinil MODERIBA MODERIBA 200 DOSE PACK MODERIBA 800 DOSE PACK moexipril hcl moexipril-hydrochlorothiazide mometasone furoate... 60, 9 montelukast sodium morphine sulfate... 3 morphine sulfate (concentrate). 3 morphine sulfate (pf)... 3 morphine sulfate er... 2 morphine sulfate er beads... 2 MOVANTIK MOVIPREP MOXEZA moxifloxacin hcl... 0, 86 MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN MYCAMINE... 9 mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG MYRBETRIQ MYTESI N nabumetone... 2 nadolol nadolol-bendroflumethiazide. 49 nafcillin sodium... 9 NAGLAZYME nalbuphine hcl... 4 naloxone hcl... 4, 5 naltrexone hcl... 4 NAMENDA XR... 5 NAMENDA XR TITRATION PACK... 5 NAMZARIC... 5 naproxen... 2 naproxen dr... 2 naproxen sodium... 2 NATACYN nateglinide NATPARA NEBUPENT NECON 0.5/35 (28) nefazodone hcl... 6 neomycin sulfate... 5 neomycin-bacitracin znpolymyx neomycin-polymyxin b gu neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc NEPHRAMINE NERLYNX NEUPOGEN NEUPRO nevirapine nevirapine er NEXAVAR niacin er (antihyperlipidemic) 54 NIACOR nicardipine hcl... 5 NICOTROL... 5 nifedipine nifedipine er... 5 nifedipine er osmotic release.. 5 NIKKI nilutamide nimodipine NINLARO NIPENT nisoldipine er NITRO-DUR nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro. 6 nitroglycerin NORA-BE NORDITROPIN FLEXPRO.. 77 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est 74 norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic 74 NORLYROC NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORTHERA NORTREL 0.5/35 (28) NORTREL /35 (2) NORTREL /35 (28) nortriptyline hcl... 8 NORVIR NOVAREL NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL... 9 NUCALA NUEDEXTA NULOJIX NUPLAZID nutrilipid NYAMYC nystatin... 9, 57, 60 nystatin-triamcinolone NYSTOP O OCELLA OCTAGAM... 8 octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 0, 86, 88 olanzapine olanzapine-fluoxetine hcl... 7 olmesartan medoxomil olmesartan medoxomil-hctz olmesartan-amlodipine-hctz olopatadine hcl omega-3-acid ethyl esters omeprazole ondansetron... 8 ondansetron hcl... 8 ONFI... 2 OPDIVO

115 OPSUMIT... 9 ORAVIG ORENCIA... 8 ORENCIA CLICKJECT... 8 ORFADIN ORKAMBI orphenadrine citrate orphenadrine citrate er ORSYTHIA oseltamivir phosphate oxaliplatin oxandrolone... 7 oxaprozin... 2 oxazepam... 4 oxcarbazepine... 4 OXTELLAR XR... 4 oxybutynin chloride oxybutynin chloride er oxycodone hcl... 4 oxycodone hcl er... 2 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 oxycodone-ibuprofen... 4 OXYCONTIN... 2 oxymorphone hcl... 4 P PACERONE paclitaxel paliperidone er pamidronate disodium PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate... 5 paroxetine hcl... 7 paroxetine hcl er... 7 paroxetine mesylate... 7 PASER PATADAY PAXIL... 7 PAZEO PEDIARIX PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl PEGANONE... 4 PEGASYS PEGASYS PROCLICK penicillin g pot in dextrose... 9 penicillin g potassium... 9 penicillin g sodium... 9 penicillin v potassium... 9 PENTAM pentazocine-naloxone hcl... 4 pentoxifylline er perindopril erbumine PERIOGARD PERJETA permethrin perphenazine perphenazine-amitriptyline PEXEVA... 7 phenelzine sulfate... 6 phenobarbital... phenytoin... 4 phenytoin sodium... 4 phenytoin sodium extended... 4 PHOSPHOLINE IODIDE PHRENILIN FORTE... 2 PHYSIOLYTE PHYSIOSOL IRRIGATION.. 85 PICATO pilocarpine hcl pimozide PIMTREA pindolol pioglitazone hcl pioglitazone hcl-glimepiride.. 43, 49 pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so. 9 PIRMELLA / piroxicam... 2 PLASMA-LYTE PLENAMINE 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.. 33 pramipexole dihydrochloride er pravastatin sodium prazosin hcl prednicarbate... 60, 6 prednisolone prednisolone acetate prednisolone sodium phosphate... 70, 7, 88 prednisone... 7 preferred plus insulin syringe. 43 PREMARIN... 70, 76 PREMASOL PREMPHASE PREMPRO prenatal PREPOPIK PREVALITE PREZCOBIX PREZISTA PRIFTIN primaquine phosphate primidone... PRIVIGEN... 8 PROAIR HFA... 9 PROAIR RESPICLICK... 9 probenecid procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTO-MED HC... 6 PROCTO-PAK... 6 PROCTOSOL HC... 6 PROCTOZONE-HC... 6 PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl propafenone hcl propranolol hcl... 50, 5 propranolol hcl er propranolol-hctz

116 propylthiouracil PROQUAD PROSOL protriptyline hcl... 8 PULMICORT FLEXHALER 89 PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QUADRACEL QUARTETTE QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl quinapril-hydrochlorothiazide 50 quinidine gluconate er quinidine sulfate quinine sulfate R RABAVERT RADICAVA raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RAVICTI RECLIPSEN RECOMBIVAX HB REGRANEX... 6 RELENZA DISKHALER RELI-ON INSULIN SYRINGE RELISTOR repaglinide repaglinide-metformin hcl REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR RESTASIS RETROVIR REVLIMID... 22, 23 REXULTI REYATAZ RIBASPHERE RIBASPHERE RIBAPAK ribavirin rifabutin rifampin RIFATER riluzole rimantadine hcl ringers ringers irrigation RIOMET risedronate sodium RISPERDAL CONSTA risperidone ritonavir RITUXAN rivastigmine... 5 rivastigmine tartrate... 5 ropinirole hcl rosuvastatin calcium ROTARIX ROTATEQ ROWEEPRA... ROWEEPRA XR... ROZEREM RUBRACA RYDAPT S SABRIL... 2 SAMSCA SANCUSO... 8 SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL... 6 SAPHRIS SAVELLA SAVELLA TITRATION PACK scopolamine... 8 selegiline hcl selenium sulfide... 6 SELZENTRY SENSIPAR SEREVENT DISKUS... 9 sertraline hcl... 7 SETLAKIN sevelamer carbonate SHAROBEL SHINGRIX SIGNIFOR sildenafil citrate... 9 SILENOR silver sulfadiazine... 6 SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT simvastatin sirolimus SIRTURO sodium chloride... 63, 69 sodium fluoride sodium lactate sodium polystyrene sulfonate. 63 SOLTAMOX SOLU-MEDROL... 7 SOMATULINE DEPOT SOMAVERT SORINE... 5 sotalol hcl... 5 sotalol hcl (af)... 5 SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz SPRITAM... SPRYCEL SPS SRONYX SSD... 6 stavudine STELARA... 6 STIOLTO RESPIMAT... 9 STIVARGA streptomycin sulfate... 5 STRIBILD sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 6 sulfacetamide-prednisolone sulfadiazine... 0 sulfamethoxazole-trimethoprim... 0 sulfasalazine... 0 sulindac... 2 sumatriptan succinate... 2 SUPRAX... 7 SUSTIVA SUTENT

117 SYLATRON SYMDEKO SYMFI LO SYMLINPEN SYMLINPEN SYNAGIS... 8 SYNAREL SYNDROS... 8 SYNERCID... 6 SYNJARDY SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus... 6, 80 TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN... 6 TARINA FE / TASIGNA tazarotene... 6 TAZICEF... 7 TAZORAC... 6 TAZTIA XT TECENTRIQ TEFLARO... 7 telmisartan telmisartan-amlodipine telmisartan-hctz temazepam TENCON... 2 TENIVAC tenofovir disoproxil fumarate. 38 terazosin hcl terbutaline sulfate... 9 terconazole testosterone cypionate... 7 testosterone enanthate... 7 tetanus-diphtheria toxoids td.. 83 tetrabenazine THALOMID theophylline er thioridazine hcl thiotepa thiothixene THYMOGLOBULIN... 8 tiagabine hcl... 2 tigecycline... 6 timolol maleate... 5, 87 TIVICAY tizanidine hcl TOBRADEX TOBRADEX ST tobramycin... 5, 86 tobramycin sulfate... 5 tobramycin-dexamethasone TOLAK... 6 tolazamide tolbutamide tolmetin sodium... 2 tolterodine tartrate topiramate... 3, 2 topiramate er... 3 TOPOSAR topotecan hcl TORISEL torsemide TOUJEO SOLOSTAR TPN ELECTROLYTES TRACLEER... 9 TRADJENTA tramadol hcl... 4 tramadol-acetaminophen... 4 trandolapril trandolapril-verapamil hcl er.. 50 tranexamic acid tranylcypromine sulfate... 6 TRAVASOL TRAVATAN Z trazodone hcl... 6 TREANDA TRECATOR TRELSTAR MIXJECT TRESIBA FLEXTOUCH tretinoin... 30, 6 TREXALL triamcinolone acetonide... 57, 6 triamterene-hctz triazolam trientine hcl trifluoperazine hcl trifluridine trihexyphenidyl hcl TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE trimethoprim... 6 trimipramine maleate... 8 TRINESSA (28) TRINTELLIX... 6 TRI-PREVIFEM TRISENOX TRI-SPRINTEC TRIUMEQ TRIVORA (28) TROKENDI XR... 3 TROPHAMINE TRULICITY TRUMENBA TRUVADA TWINRIX TYBOST TYKERB TYMLOS TYPHIM VI TYSABRI U UCERIS... 6, 7 ULORIC UNITHROID UPTRAVI ursodiol V valacyclovir hcl VALCHLOR... 6 valganciclovir hcl valproate sodium... 2 valproic acid... 2 valsartan valsartan-hydrochlorothiazide... 43, 50 vancomycin hcl... 6 VANDAZOLE VAQTA VARIVAX VARIZIG... 8 VARUBI... 8 VECTIBIX VELCADE VELIVET VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl

118 AgeWell New York, LLC is a Health Maintenance Organization (HMO) plan with a Medicare contract and a contract with the New York State Medicaid Program. Enrollment in AgeWell New York depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary. Limitations, copayments, and restrictions may apply. This document may be available in an alternate format such as Braille, larger print, or audio. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Assistance services for other languages are also available free of charge. AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AgeWell New York does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AgeWell New York provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact AgeWell New York Member Services at If you believe that AgeWell New York has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: AgeWell New York Civil Rights Coordination Unit 99 Marcus Avenue Suite M20 Lake Success, New York TTY/TDD: Fax: civilrightsunit@agewellnewyork.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordination Unit is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, , TDD: Complaint forms are available at 25

119 AgeWell New York, LLC es un plan de Organización para el mantenimiento de la salud (Health Maintenance Organization, HMO) bajo un contrato con Medicare y un contrato con el programa del estado de Nueva York de Medicaid. La inscripción en AgeWell New York depende de la renovación del contrato. El Formulario puede sufrir modificaciones en cualquier momento. Usted recibirá un aviso cuando sea necesario. Se pueden aplicar limitaciones, copagos y restricciones. Este documento puede estar disponible en formato alternativo, como braille, letra más grande o audio. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). Los servicios de asistencia en otros idiomas también están disponibles de forma gratuita. AgeWell New York cumple con todas las leyes federales sobre derechos civiles que corresponden y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York no excluye a las personas ni las trata diferente por su raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York proporciona ayuda y servicios gratuitos a personas con discapacidades a fin de que puedan comunicarse con nosotros eficazmente, como los siguientes: Intérpretes calificados de lenguaje de señas Información escrita en otros formatos (tamaño de letra grande, audio, formatos de acceso electrónico, otros formatos) Servicios lingüísticos gratuitos para personas cuyo idioma nativo no sea inglés, como intérpretes calificados e información escrita en otros idiomas Si necesita estos servicios, comuníquese con Servicios para miembros de AgeWell New York al Si considera que AgeWell New York no proporcionó estos servicios o hizo algún tipo de discriminación por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo ante: AgeWell New York Civil Rights Coordination Unit 99 Marcus Avenue Suite M20 Lake Success, New York TTY/TDD: Fax: Correo electrónico: civilrightsunit@agewellnewyork.com Puede interponer un reclamo personalmente o por correo postal, fax o correo electrónico. Si necesita ayuda para presentar un reclamo, la Unidad de Coordinación de Derechos Civiles está disponible para usted. También puede presentar una queja relacionada con los derechos civiles ante el Departamento de Salud y Servicios Sociales, Oficina de Derechos Civiles, en forma electrónica a través del Portal de Quejas ante la Oficina de Derechos Civiles, disponible en o bien, por teléfono o por correo a: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, , TDD: Los formularios de denuncias se encuentran disponibles en 26

120 Multi-Language Insert / Encarte multilingüe English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Chínese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). Yiddish: Bengali: אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופ (TTY: ) লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم:.)

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122 We re here for your call. This formulary was updated on 06/0/208. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or for TTY users, 7, 7 days a week 24 hours a day or visit agewellnewyork.com TTY/TDD