OCTOBER 2018 Q4 F O R M U L A R Y

Transcription

1 To Improve the Health of Our Members Through the Provision of High Quality Care and Services Mejorar la salud de nuestros miembros a través del suministro de atención y servicio de alta calidad OCTOER Q FORMULARY For Questions and old Coast Health Plan Information, Please Call

2 INTRODUCTION We are pleased to provide the old Coast Health Plan List of Covered Drugs as a useful reference and informational tool. The CHP List of Covered Drugs can assist practitioners in selecting clinically appropriate and cost effective products for their patients. The information contained in the CHP List of Covered Drugs is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This List of Covered Drugs is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in this List of Covered Drugs is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National uideline Clearinghouse site at PREFACE The CHP List of Covered Drugs is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the CHP List of Covered Drugs. enerics should be considered the first line of prescribing. Drugs represented in the CHP List of Covered Drugs may have varying cost to the plan member based on the plans benefit structure. eneric medications typically are available at the lowest cost, brand-name medications on the CHP List of Covered Drugs will generally cost more than generics, and brand-name medications not on the list will generally cost the most. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the CHP Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts. The P&T Committee's voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. ENERIC SUSTITUTION eneric substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. However, not all strengths or dosage forms of the generic name in may be generically available. The CHP List of Covered Drugs is a mandatory generic drug list. So whenever a generic to a covered agent becomes available, it is added. And if the branded agent was part of the cover drug list, the branded agent will be removed from the covered drug list. eneric drugs are usually priced lower than their brand-name equivalents. eneric drugs are: Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). enerics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs. When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). i

3 SPECIALTY PLAN DESIN Specialty uideline Management (SM) SM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. The utilization management program is available for all therapeutic areas dispensed by our specialty pharmacies. SM is designed to ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SM program are identified in the CHP List of Covered Drugs under the heading of Specialty for your reference. SM may also be combined with Inventory Management/ Dose Optimization and Optimal Drug Mix through High Performance Specialty Design to appropriately manage specialty medications. PLAN DESIN The CHP List of Covered Drugs is a closed drug list plan design. The medications listed on the drug list are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, LMN, C, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. Should it become necessary to write a prescription for a drug, which is not on the CHP List of Covered Drugs, one must obtain clinical prior authorization. LEEND Prior Authorization QL Quantity Limit ST Step Therapy SP Specialty - Limited to Specialty Pharmacies ii

4 EXCLUDED THERAPEUTIC CLASSES AND DRUS FROM CHP LIST OF COVERED DRUS These therapeutic classes of drugs are carved out from the CHP List of Covered Drugs. This means that when one of these medications is prescribed, it will be filled by the pharmacist, who in turn will bill the State of California for reimbursement. Acamprosate Calcium uprenorphine HCl uprenorphine HCl-Naloxone HCl DEPENDENCY TREATMENT uprenorphine Transdermal Patch Naltrexone Naltrexone HCl Naltrexone Microsphere Injectable Suspension Naloxone HCL HIV Abacavir Sulfate Elvitegravir-Cobicistat-Emtricitabine- Lopinavir-Ritonavir Abacavir Sulfate-Lamivudine Tenofovir DF Maraviroc Abacavir Sulfate-Lamivudine-Zidovudine Elvitegravir-Cobicistat-Emtricitabine- Nevirapine Abacavir Sulfate-Dolutegravir-Lamivudine Tenofovir Alafenamide Nelfinavir Mesylate Atazanavir Sulfate Emtricitabine Raltegravir Potassium Atazanavir-Cobisitat Emtricitabine-Rilpivirine-Tenofovir DF Rilpirvirine Hydrochloride Cobicistat Emtricitabine-Rilpivirine-Tenofovir Alafen. Ritonavir Darunavir Ethanolate Emtricitabine-Tenofovir DF Saquinavir Darunavir-Cobicistat Enfuvirtide Saquinavir Mesylate Delavirdine Mesylate Etravirine Stavudine Dolutegravir Fosamprenavir Calcium Tenofovir Disoproxil Fumarate Efavirenz Indinavir Sulfate Tipranavir Efavirenz-Emtricitabine-Tenofovir DF Elvitegravir Lamivudine Lamivudine-Zidovudine ERECTILE DYSFUNCTION COAULATION FACTORS Antihemophilic Factor(Factor VIII) Factor VIIa Factor IX Factor IX Complex Factor XIIIa Factor XIII Antihemophilic Factor/Von Willebrand Complex Anti-inhibitor Coagulant Complex Von Willebrand Factor Complex PSYCHIATRIC Amantadine HCl Iloperidone Phenelzine Sulfate Aripiprazole Isocarboxazid Pimozide Asenapine Maleate Lithium Carbonate Quetiapine enztropine Mesylate Lithium Citrate Risperidone rexpiprazole Loxapine Succinate Selegiline TD Patch Cariprazine (pending) Lurasidone Hydrochloride Thioridazine HCl Chlorpromazine HCl Molindone HCl Thiothixene Clozapine Olanzapine Thiothixene HCl Fluphenazine Decanoate Olanzapine-Fluoxetine HCl Tranylcypromine Sulfate Fluphenazine HCl Olanzapine Pamoate Trifluoperazine HCl Haloperidol Paliperidone Trihexyphenidyl Haloperidol Decanoate Paliperidone Palmitate Ziprasidone HCl Haloperidol Lactate Perphenazine Ziprasidone Mesylate NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with old Coast Health Plan. When viewing the CHP List of Covered Drugs via the Internet, please be advised that the CHP List of Covered Drugs is updated periodically and changes may appear prior to their effective date to allow for client notification. 1

5 Table of Contents Analgesics - Drugs for Pain... 4 Analgesics - Drugs for Pain and Inflammation Anesthetics Anti-Addiction / Substance Abuse Treatment Agents Antibacterials Anticoagulants Anticonvulsants - Drugs for Seizures Antidementia Agents - Drugs for Alzheimer's Disease and Dementia Antidepressants Antiemetics - Drugs for Nausea and Vomiting Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics - Drugs for Cancer Antiparasitics Antiparkinson Agents Antiplatelets Antivirals Anxiolytics - Drugs for Anxiety lood Products / Modifiers / Volume Expanders - Drugs for leeding Disorders Cardiovascular Agents - Drugs for Heart and Circulation Conditions Central Nervous System Agents - Drugs for Attention Deficit Disorder Central Nervous System Agents - Drugs for Multiple Sclerosis Central Nervous System Agents - Miscellaneous Dental and Oral Agents - Drugs for Mouth and Throat Conditions Dermatological Agents - Drugs for Skin Conditions Diabetes - Antidiabetic Agents Diabetes - lucose Monitoring

6 Diabetes - lycemic Agents Diabetes - Insulins Electrolytes / Minerals / Metals / Vitamins astrointestinal Agents - Drugs for Acid Reflux and Ulcer astrointestinal Agents - Drugs for owel, Intestine and Stomach Conditions enetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment enitourinary Agents - Drugs for ladder, enital and Kidney Conditions enitourinary Agents - Drugs for Prostate Conditions Hormonal Agents - Adrenal Hormonal Agents - Men's Health Hormonal Agents - Osteoporosis Hormonal Agents - Parathyroid Hormonal Agents - Pituitary Hormonal Agents - Sex Hormones and irth Control Hormonal Agents - Thyroid Immunological Agents - Drugs for Immune System Stimulation or Suppression Immunological Agents - Drugs for Vaccination Inflammatory owel Disease Agents Metabolic one Disease Agents - Drugs for Osteoporosis Miscellaneous Therapeutic Agents Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation Ophthalmic Agents - Drugs for laucoma Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions Otic Agents - Drugs for Ear Conditions Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm Sleep Disorder Agents

7 Drug Name Reference rand-eneric Notes Analgesics - Drugs for Pain acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml apap-caff-dihydrocodeine oral capsule apap-caff-dihydrocodeine oral tablet ascomp-codeine oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen oral tablet Tylenol with Codeine #3 Tylenol with Codeine #4 Tylenol with Codeine #4 Trezix Ascomp-Codeine upap Tencon butalbital-apap oral tablet Tencon butalbital-apap-caff-cod oral capsule butalbital-apap-caff-cod oral capsule butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral capsule Fioricet/Codeine Fioricet Esgic Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 4 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31

8 Drug Name Reference rand-eneric Notes butalbital-apap-caffeine oral tablet butalbital-asa-caff-codeine oral capsule butalbital-asa-caffeine oral capsule butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate injection solution 1 /ml, 2 /ml butorphanol tartrate nasal solution 10 /ml Esgic Ascomp-Codeine Fiorinal Fiorinal capacet oral capsule Esgic carisoprodol-aspirin-codeine oral tablet codeine sulfate oral tablet 15, 30, 60 DILAUDID ORAL TALET 2 M, 4 M, 8 M duramorph injection solution 0.5 /ml, 1 /ml duraxin oral capsule endocet oral tablet , , 5-325, Dilaudid Endocet esgic oral capsule Esgic fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate intravenous solution prefilled syringe 100 mcg/2ml fentanyl citrate-nacl epidural solution /250ml-% fentanyl citrate-nacl intravenous solution /100ml-%, /250ml-%, /250ml-%, mcg/50ml- %, /250ml-% Actiq Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 5 QL (124 EA per 31 QL (186 EA per 31 QL (124 EA per 31 QL (124 EA per 31

9 Drug Name Reference rand-eneric Notes fentanyl citrate-nacl intravenous solution prefilled syringe mcg/3ml-%, mcg/5ml-%, mcg/50ml-% fentanyl cit-ropivacaine-nacl epidural solution /100ml-%, /100ml-%, /100ml-%, /200ml-%, /100ml-%, /250ml-%, /250ml- % fentanyl cit-ropivacaine-nacl epidural solution prefilled syringe /50ml-%, /50ml-% fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr FENTORA UCCAL TALET 100 MC, 200 MC, 400 MC, 600 MC, 800 MC hydrocodone-acetaminophen oral solution /15ml, /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet Duragesic-100 Duragesic-12 Duragesic-25 Duragesic-50 Duragesic-75 Vicodin HP Lorcet HD Verdrocet Vicodin Lorcet Vicodin ES Lorcet Plus QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 ; QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 6

10 Drug Name Reference rand-eneric Notes hydrocodone-ibuprofen oral tablet , hydrocodone-ibuprofen oral tablet hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12, 16, 32, 8 hydromorphone hcl injection solution 1 /ml, 2 /ml hydromorphone hcl injection solution 4 /ml Ibudone Exalgo Dilaudid hydromorphone hcl oral liquid 1 /ml Dilaudid hydromorphone hcl oral tablet 2, 4, 8 hydromorphone hcl pf injection solution 1 /ml, 10 /ml, 2 /ml, 4 /ml, 50 /5ml, 500 /50ml hydromorphone hcl rectal suppository 3 hydromorphone hcl-nacl intravenous solution prefilled syringe /5ml-%, /25ml-%, /50ml-%, /60ml-%, /30ml-%, /50ml-%, /30ml-%, /25ml-% hydromorphone-bupivacaine-nacl epidural solution /250ml-% hydromorphone-ropivacaine-nacl epidural solution /200ml-% Dilaudid ibudone oral tablet Ibudone levorphanol tartrate oral tablet 2 lorcet hd oral tablet Lorcet HD lorcet oral tablet Lorcet lorcet plus oral tablet Lorcet Plus mapap oral liquid 160 /5ml Little Remedies for Fever marten-tab oral tablet Tencon meperidine hcl injection solution 10 /ml QL (186 EA per 31 QL (186 EA per 31 QL (500 ML per 31 QL (186 EA per 31 QL (186 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (248 EA per 31 ; AL (Max 10 Years) Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 7

11 Drug Name Reference rand-eneric Notes meperidine hcl injection solution 100 /ml, 25 /ml, 50 /ml meperidine hcl oral solution 50 /5ml meperidine hcl oral tablet 100, 50 meperidine hcl-sodium chloride intravenous solution /100ml- %, /50ml-% meperidine-promethazine oral capsule methadone hcl injection solution 10 /ml methadone hcl intensol oral concentrate 10 /ml Demerol Methadone HCl Intensol methadone hcl oral concentrate 10 /ml Methadone HCl Intensol methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 Dolophine methadone hcl oral tablet soluble 40 Methadose methadose oral concentrate 10 /ml Methadone HCl Intensol methadose oral tablet soluble 40 Methadose methadose sugar-free oral concentrate 10 /ml mitigo injection solution 200 /20ml (10 /ml), 500 /20ml (25 /ml) morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate (pf) injection solution 0.5 /ml, 1 /ml, 10 /ml, 2 /ml, 4 /ml, 5 /ml, 8 /ml morphine sulfate (pf) intravenous solution 10 /ml, 2 /ml, 4 /ml, 8 /ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10 morphine sulfate er oral capsule extended release 24 hour 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 Methadone HCl Intensol Kadian Kadian MS Contin Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 8 QL (250 ML per 31 QL (250 ML per 31 QL (500 ML per 31 QL (124 EA per 31 QL (250 ML per 31 QL (250 ML per 31 QL (240 ML per 31 QL (93 EA per 31 QL (93 EA per 31

12 Drug Name Reference rand-eneric Notes morphine sulfate injection solution 10 /ml, 15 /ml, 2 /ml, 4 /ml, 5 /ml, 8 /ml morphine sulfate intramuscular device 10 /0.7ml morphine sulfate intravenous solution 1 /ml, 150 /30ml, 25 /ml, 50 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 morphine sulfate-nacl intravenous solution /50ml-% morphine sulfate-nacl intravenous solution prefilled syringe /ml-%, /50ml-% MS CONTIN ORAL TALET EXTENDED RELEASE 100 M nalbuphine hcl injection solution 10 /ml, 20 /ml NUCYNTA ORAL TALET 50 M ONA ER ORAL TALET ER 12 HOUR AUSE-DETERRENT 10 M, 15 M, 20 M, 30 M, 40 M, 5 M, 7.5 M oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 oxycodone hcl oral tablet 15, 30, 5 oxycodone-acetaminophen oral solution /5ml oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet MS Contin Roxicodone Endocet QL (93 EA per 31 QL (30 EA per 30 ST; QL (62 EA per 31 QL (186 EA per 31 QL (186 EA per 31 QL (186 EA per 31 QL (124 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 9

13 Drug Name Reference rand-eneric Notes oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 oxymorphone hcl oral tablet 10, 5 Opana panlor oral tablet pentazocine-naloxone hcl oral tablet phrenilin forte oral capsule Fioricet remifentanil hcl intravenous solution reconstituted 1, 2, 5 sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml Ultiva tencon oral tablet Tencon tramadol hcl er (biphasic) oral tablet extended release 24 hour 100, 200, 300 tramadol hcl er oral capsule extended release 24 hour 150 tramadol hcl er oral tablet extended release 24 hour 100, 300 tramadol hcl er oral tablet extended release 24 hour 200 tramadol hcl oral tablet 50 Ultram tramadol-acetaminophen oral tablet vanatol lq oral solution /15ml vanatol s oral solution /15ml Ultracet verdrocet oral tablet Verdrocet vicodin es oral tablet Vicodin ES vicodin hp oral tablet Vicodin HP vicodin oral tablet Vicodin xylon oral tablet Ibudone zebutal oral capsule Esgic ZOHYDRO ER ORAL CAPSULE ER 12 HOUR AUSE-DETERRENT 10 M, 15 M, 20 M, 30 M, 40 M, 50 M ST; QL (124 EA per 31 QL (31 EA per 31 QL (31 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (186 EA per 31 QL (124 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 10

14 Drug Name Reference rand-eneric Notes Analgesics - Drugs for Pain and Inflammation aspirin ec low dose oral tablet delayed release 81 aspirin low dose oral tablet delayed release 81 aspirin oral tablet 325 Aspir-Low Aspir-Low ayer Advanced Aspirin Reg St aspirin oral tablet delayed release 325 ayer Aspirin Regimen bayer aspirin ec low dose oral tablet delayed release 81 bayer aspirin oral tablet 325 celecoxib oral capsule 100, 200, 400, 50 choline-mag trisalicylate oral liquid 500 /5ml diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 Aspir-Low ayer Advanced Aspirin Reg St CeleREX diclofenac sodium transdermal gel 1 % Voltaren diclofenac sodium transdermal solution 1.5 % diclofenac-misoprostol oral tablet delayed release , diclofex dc combination therapy pack 1.5 & % diclopak combination therapy pack 1.5 & % diclosaicin combination therapy pack 1.5 & % diclotral combination therapy pack 1.5 & % diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 Klofensaid II Arthrotec DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak etodolac oral tablet 400 Lodine etodolac oral tablet 500 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 11 QL (122 EA per 31 QL (122 EA per 31 QL (120 EA per 30 QL (122 EA per 31 QL (122 EA per 31 QL (120 EA per 30 QL (500 M per 30

15 Drug Name Reference rand-eneric Notes fenoprofen calcium oral capsule 200 Fenortho fenoprofen calcium oral capsule 400 Nalfon fenoprofen calcium oral tablet 600 ProFeno fenortho oral capsule 200 Fenortho fenortho oral capsule 400 Nalfon flurbiprofen oral tablet 100, 50 gnp all day pain relief oral tablet 220 Aleve ibuprofen childrens oral suspension 100 /5ml ibuprofen lysine intravenous solution 10 /ml Childrens Advil NeoProfen ibuprofen oral suspension 100 /5ml Childrens Advil ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 indomethacin sodium intravenous solution reconstituted 1 inflammacin combination therapy pack 75 & % isometheptene-caffeine-apap oral tablet isometheptene-dichloral-apap oral capsule ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 25, 50, 75 ketorolac tromethamine injection solution 15 /ml, 30 /ml ketorolac tromethamine intramuscular solution 60 /2ml ketorolac tromethamine oral tablet 10 IU Inflammacin klofensaid ii transdermal solution 1.5 % Klofensaid II meclofenamate sodium oral capsule 100, 50 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 12 QL (106 EA per 31 QL (248 ML per 30 ; AL (Max 11 Years) QL (248 ML per 30 ; AL (Max 11 Years) QL (160 EA per 30

16 Drug Name Reference rand-eneric Notes mefenamic acid oral capsule 250 Ponstel meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium er oral tablet extended release 24 hour 375, 500 Naprelan naproxen sodium oral capsule 220 Aleve naproxen sodium oral tablet 220 Aleve naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 Anaprox DS nodolor oral capsule nudiclo solupak combination therapy pack 1.5 & % nudiclo tabpak combination therapy pack 75 & % DermacinRx Lexitral PharmaPak Inflammacin oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene previdolrx plus analgesic combination therapy pack 75 & % Inflammacin profeno oral tablet 600 ProFeno salsalate oral tablet 500, 750 sulindac oral tablet 150, 200 sure result dss premium pack combination therapy pack 1.5 & % tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 xelitral combination therapy pack 1.5 & % xenaflamm combination therapy pack 75 & % Anesthetics DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak Inflammacin agoneaze external kit % DermacinRx Empricaine anodyne lpt external kit % DermacinRx Empricaine Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 13 QL (106 EA per 31 QL (106 EA per 31

17 Drug Name Reference rand-eneric Notes bd pudendal/local tray/1% lido injection kit 1 % bupivacaine hcl (pf) injection solution 0.25 %, 0.5 % bupivacaine hcl (pf) injection solution 0.75 % bupivacaine hcl injection solution 0.25 %, 0.5 % bupivacaine in dextrose intrathecal solution % bupivacaine spinal intrathecal solution % bupivacaine-epinephrine (pf) injection solution 0.25% -1:200000, 0.5% - 1: bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1: chloroprocaine hcl (pf) injection solution 2 %, 3 % cocaine hcl external solution 4 % dermacinrx empricaine external kit % Marcaine Preservative Free Marcaine Marcaine Marcaine Spinal Marcaine Spinal Marcaine/Epinephrine PF Marcaine/Epinephrine Nesacaine-MPF DermacinRx Empricaine dermacinrx prizopak external kit % DermacinRx Empricaine ethyl chloride external aerosol glydo external gel 2 % 7T Lido leva set/occlusive dressing external kit % DermacinRx Empricaine lidenza external patch 4-1 % Endoxcin lido bdk external kit % DermacinRx Empricaine lidocaine external ointment 5 % lidocaine external patch 5 % Lidoderm lidocaine hcl (cardiac) intravenous solution 10 /ml, 20 /ml lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 % lidocaine hcl (pf) injection solution 4 % lidocaine hcl external cream 3 % Xylocaine-MPF lidocaine hcl external cream 3.88 % Lidotral lidocaine hcl external gel 2 % 7T Lido lidocaine hcl external lotion 3 % Lidozion lidocaine hcl external solution 4 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 14 ST; QL (3 EA per 1 day)

18 Drug Name Reference rand-eneric Notes lidocaine hcl injection solution 0.5 %, 1 %, 2 % lidocaine in d5w intravenous solution 4-5 /ml-%, 8-5 /ml-% lidocaine pak external ointment 5 % lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1: lidocaine-epinephrine injection solution 1.5 %-1:200000, 2 %-1: lidocaine-epinephrine injection solution 2 %-1:100000, 2 %-1:50000 lidocaine-prilocaine external cream % Xylocaine Xylocaine/Epinephrine Xylocaine- MPF/Epinephrine Xylocaine Dental lidocaine-prilocaine external kit % DermacinRx Empricaine lido-k external lotion 3 % Lidozion lidopin external cream 3 % lidopril external kit % DermacinRx Empricaine lidopril xr external kit % DermacinRx Empricaine lido-prilo caine pack external kit % DermacinRx Empricaine liprozonepak external kit % DermacinRx Empricaine livixil pak external kit % DermacinRx Empricaine lorenza external patch 4-1 % Endoxcin lp lite pak external kit % DermacinRx Empricaine medolor pak external kit % DermacinRx Empricaine polocaine injection solution 1 %, 2 % polocaine-mpf injection solution 1 %, 1.5 %, 2 % port-prep external kit % DermacinRx Empricaine premium lidocaine external ointment 5 % prikaan external kit % DermacinRx Empricaine prikaan lite external kit % DermacinRx Empricaine prilolid external kit % DermacinRx Empricaine prilovix external kit % DermacinRx Empricaine priloxx lp external kit % DermacinRx Empricaine relador pak external kit % DermacinRx Empricaine relador pak plus external kit % DermacinRx Empricaine releevia ml external patch 4-1 % Endoxcin ropivacaine hcl injection solution 10 /ml, 2 /ml, 5 /ml, 7.5 /ml Naropin Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 15

19 Drug Name Reference rand-eneric Notes ropivacaine hcl-nacl epidural solution prefilled syringe % sensorcaine injection solution 0.25 %, 0.5 % sensorcaine/epinephrine injection solution 0.25% -1:200000, 0.5% -1: sensorcaine-mpf injection solution 0.25 %, 0.5 % Marcaine sensorcaine-mpf injection solution 0.75 % Marcaine sensorcaine-mpf spinal intrathecal solution % sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% - 1: Marcaine/Epinephrine Marcaine Preservative Free Marcaine Spinal Marcaine/Epinephrine PF soluline external kit % DermacinRx Empricaine solupicc external kit % DermacinRx Empricaine synvexia external patch 4-1 % Endoxcin tetracaine hcl injection solution 1 % xylocaine dental injection solution 2 %- 1:100000, 2 %-1:50000 Xylocaine Dental zeruvia external patch 4-1 % Endoxcin Anti-Addiction / Substance Abuse Treatment Agents bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 CHANTIX CONTINUIN MONTH K ORAL TALET 1 M Zyban CHANTIX ORAL TALET 0.5 M, 1 M CHANTIX STARTIN MONTH K ORAL TALET 0.5 M X 11 & 1 M X 42 disulfiram oral tablet 250, 500 Antabuse NICORETTE MOUTH/THROAT UM 2 M KLS Quit2 nicotine polacrilex mouth/throat gum 2 KLS Quit2 nicotine polacrilex mouth/throat gum 4 KLS Quit4 nicotine polacrilex mouth/throat lozenge 2, 4 nicotine step 1 transdermal patch 24 hour 21 /24hr nicotine step 2 transdermal patch 24 hour 14 /24hr Commit Nicoderm CQ Nicoderm CQ Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 16

20 Drug Name Reference rand-eneric Notes nicotine step 3 transdermal patch 24 hour 7 /24hr NICOTROL INHALATION INHALER 10 M NICOTROL NS NASAL SOLUTION 10 M/ML Antibacterials amikacin sulfate injection solution 1 gm/4ml, 500 /2ml amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-potassium clavulanate er oral tablet extended release 12 hour amoxicillin-potassium clavulanate oral suspension reconstituted /5ml, /5ml amoxicillin-potassium clavulanate oral suspension reconstituted /5ml amoxicillin-potassium clavulanate oral suspension reconstituted /5ml amoxicillin-potassium clavulanate oral tablet amoxicillin-potassium clavulanate oral tablet , amoxicillin-potassium clavulanate oral tablet chewable , ampicillin oral capsule 500 ampicillin sodium injection solution reconstituted 1 gm, 10 gm, 125, 2 gm, 250, 500 ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm Nicoderm CQ Augmentin XR Augmentin Augmentin ES-600 Augmentin ST ST Unasyn Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 17

21 Drug Name Reference rand-eneric Notes ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm avidoxy oral tablet 100 azithromycin intravenous solution reconstituted 500 Zithromax azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml Zithromax azithromycin oral tablet 250, 600 Zithromax azithromycin oral tablet 500 Zithromax QL (4 EA per 10 aztreonam injection solution reconstituted 1 gm, 2 gm baciim intramuscular solution reconstituted unit bacitracin intramuscular solution reconstituted unit ACTROAN NASAL NASAL OINTMENT 2 % benzalkonium chloride external solution, 50 % ICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML cefaclor er oral tablet extended release 12 hour 500 cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin in d5w intravenous solution 3 gm/100ml cefazolin in sodium chloride intravenous solution gm/50ml-% cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 cefazolin sodium intravenous solution reconstituted 1 gm Azactam Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 18

22 Drug Name Reference rand-eneric Notes cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-% cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, 2-3 gm- % cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 Spectracef cefepime hcl injection solution reconstituted 1 gm, 2 gm cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml cefepime-dextrose intravenous solution reconstituted 1 gm/50ml, 2 gm/50ml cefixime oral suspension reconstituted 100 /5ml cefixime oral suspension reconstituted 200 /5ml CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 M, 2 M cefotaxime sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 500 cefotetan disodium injection solution reconstituted 1 gm, 2 gm cefotetan disodium injection solution reconstituted 10 gm cefotetan disodium-dextrose intravenous solution reconstituted gm-%, gm-% cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefoxitin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, gm-% cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml Maxipime Suprax Suprax Cefotan Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 19 ; QL (150 ML per 31 Cefotan

23 Drug Name Reference rand-eneric Notes cefprozil oral tablet 250, 500 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftibuten oral capsule 400 ceftibuten oral suspension reconstituted 180 /5ml ceftriaxone sodium in dextrose intravenous solution 20 /ml, 40 /ml ceftriaxone sodium injection solution reconstituted 1 gm ceftriaxone sodium injection solution reconstituted 100 gm, 2 gm, 250, 500 ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm ceftriaxone sodium-dextrose intravenous solution reconstituted gm-%, gm-% cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 7.5 gm, 750 cefuroxime sodium intravenous solution reconstituted 1.5 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250, 500 chloramphenicol sod succinate intravenous solution reconstituted 1 gm CIPRO ORAL SUSPENSION RECONSTITUTED 250 M/5ML (5%) ciprofloxacin hcl oral tablet 100, 750 ciprofloxacin hcl oral tablet 250, 500 ciprofloxacin in d5w intravenous solution 200 /100ml ciprofloxacin in d5w intravenous solution 400 /200ml ciprofloxacin intravenous solution 200 /20ml, 400 /40ml Tazicef Rocephin Keflex Cipro Cipro Cipro in D5W QL (20 EA per 10 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 20

24 Drug Name Reference rand-eneric Notes ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000, 500 CLAFORAN INJECTION SOLUTION RECONSTITUTED 10 M, 2 M CLAFORAN INJECTION SOLUTION RECONSTITUTED 500 M CLAFORAN INTRAVENOUS SOLUTION RECONSTITUTED 1 M, 2 M clarithromycin er oral tablet extended release 24 hour 500 clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml clarithromycin oral tablet 250 Cipro Cipro XR clarithromycin oral tablet 500 iaxin clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml, 9000 /60ml clindamycin phosphate intravenous solution 150 /ml, 300 /2ml, 600 /4ml, 900 /6ml Cleocin Cleocin clindamycin phosphate vaginal cream 2 % Cleocin colistimethate sodium (cba) injection solution reconstituted 150 COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 M coremino oral tablet extended release 24 hour 135, 45, 90 CUICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 M CUICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 M Cleocin in D5W Cleocin Phosphate Cleocin Phosphate Coly-Mycin M Coly-Mycin M CoreMino Cubicin Cubicin QL (280 ML per 14 QL (28 EA per 14 QL (28 EA per 14 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 21

25 Drug Name Reference rand-eneric Notes DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 M daptomycin intravenous solution reconstituted 500 demeclocycline hcl oral tablet 150, 300 dicloxacillin sodium oral capsule 250, 500 doxy 100 intravenous solution reconstituted 100 doxycycline hyclate intravenous solution reconstituted 100 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline hyclate oral tablet 150, 75 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 22 Cubicin Doxy 100 Doxy 100 Morgidox Acticlate doxycycline hyclate oral tablet 50 TargaDOX doxycycline hyclate oral tablet delayed release 100, 75 doxycycline hyclate oral tablet delayed release 150 doxycycline hyclate oral tablet delayed release 200, 50 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 75 doxycycline monohydrate oral suspension reconstituted 25 /5ml doxycycline monohydrate oral tablet 100, 150, 50, 75 Soloxide Doryx Mondoxyne NL Okebo Vibramycin e.e.s. 400 oral tablet 400 E.E.S. 400 ertapenem sodium injection solution reconstituted 1 gm erythrocin lactobionate intravenous solution reconstituted 500 erythromycin base oral capsule delayed release particles 250 erythromycin base oral tablet 250, 500 INVanz

26 Drug Name Reference rand-eneric Notes erythromycin ethylsuccinate oral suspension reconstituted 200 /5ml erythromycin ethylsuccinate oral tablet 400 FIRVANQ ORAL SOLUTION RECONSTITUTED 25 M/ML, 50 M/ML gentamicin in saline intravenous solution /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml- % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate injection solution 10 /ml, 40 /ml hydrogen peroxide solution 30 % imipenem-cilastatin intravenous solution reconstituted 250 imipenem-cilastatin intravenous solution reconstituted 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 M INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 M iodine tincture external tincture 2 % iodoquinol-hc-aloe polysacch external gel % levofloxacin in d5w intravenous solution 250 /50ml, 500 /100ml, 750 /150ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 lincomycin hcl injection solution 300 /ml linezolid in sodium chloride intravenous solution /300ml-% linezolid intravenous solution 600 /300ml linezolid oral suspension reconstituted 100 /5ml E.E.S. ranules E.E.S. 400 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 23 ; AL (Max 11 Years) Primaxin IV INVanz Alcortin A Levaquin Lincocin Zyvox Zyvox

27 Drug Name Reference rand-eneric Notes linezolid oral tablet 600 Zyvox lugols external solution MACRODANTIN ORAL CAPSULE 25 M Macrodantin mafenide acetate external packet 5 % Sulfamylon meropenem intravenous solution reconstituted 1 gm, 500 meropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml, 500 /50ml Merrem methenamine hippurate oral tablet 1 gm Hiprex methenamine mandelate oral tablet 0.5 gm, 1 gm metronidazole in nacl intravenous solution /ml-%, /100ml-% metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl metronidazole vaginal gel 0.75 % Metroel-Vaginal minocycline hcl er oral tablet extended release 24 hour 115, 65 minocycline hcl er oral tablet extended release 24 hour 135, 45, 90 minocycline hcl oral capsule 100, 50 minocycline hcl oral capsule 75 minocycline hcl oral tablet 100, 50, 75 mondoxyne nl oral capsule 100, 50 Solodyn CoreMino Minocin Mondoxyne NL mondoxyne nl oral capsule 75 Okebo morgidox oral capsule 100, 50 Morgidox moxifloxacin hcl in nacl intravenous solution 400 /250ml moxifloxacin hcl intravenous solution 400 /250ml Avelox moxifloxacin hcl oral tablet 400 Avelox mupirocin calcium external cream 2 % actroban mupirocin external ointment 2 % Centany nafcillin sodium in dextrose intravenous solution 1 gm/50ml, 2 gm/100ml nafcillin sodium injection solution reconstituted 1 gm, 2 gm Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 24

28 Drug Name Reference rand-eneric Notes nafcillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm neomycin sulfate oral tablet 500 QL (2 EA per 31 neomycin-polymyxin b gu irrigation solution nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohydrate macrocrystals oral capsule 100 Macrodantin Macrobid nitrofurantoin oral suspension 25 /5ml Furadantin ofloxacin oral tablet 300, 400 okebo oral capsule 75 Okebo oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm paromomycin sulfate oral capsule 250 penicillin g potassium injection solution Pfizerpen reconstituted unit, unit penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 pfizerpen injection solution reconstituted unit piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm 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 polymyxin b sulfate injection solution reconstituted unit silver nitrate external ointment 10 % silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 25 Pfizerpen Zosyn silver sulfadiazine external cream 1 % Silvadene soloxide oral tablet delayed release 150 Soloxide ssd external cream 1 % Silvadene

29 Drug Name Reference rand-eneric Notes streptomycin sulfate intramuscular solution reconstituted 1 gm sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet sulfatrim pediatric oral suspension /5ml SUPRAX ORAL CAPSULE 400 M SUPRAX ORAL SUSPENSION RECONSTITUTED 100 M/5ML tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm tazicef intravenous solution reconstituted 1 gm, 2 gm tetracycline hcl oral capsule 250, 500 tigecycline intravenous solution reconstituted 50 tinidazole oral tablet 250 Sulfatrim Pediatric actrim actrim DS Sulfatrim Pediatric Suprax Tazicef ; QL (2 EA per 31 ; QL (150 ML per 31 Tygacil tinidazole oral tablet 500 Tindamax tobramycin sulfate injection solution 1.2 gm/30ml, 10 /ml, 2 gm/50ml, 80 /2ml tobramycin sulfate injection solution reconstituted 1.2 gm trimethoprim oral tablet 100 TYACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 M UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) M, 15 (10-5) M, 3 (2-1) M vancomycin hcl in dextrose intravenous solution 1-5 gm/100ml-%, 1-5 gm/200ml- %, 1-5 gm/250ml-%, gm/250ml-%, 2-5 gm/500ml-%, /100ml-%, /150ml-% Tygacil Unasyn Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 26

30 Drug Name Reference rand-eneric Notes vancomycin hcl in nacl intravenous solution gm/150ml-%, gm/200ml-%, gm/250ml-%, gm/150ml-%, gm/250ml-%, gm/500ml-%, gm/250ml-%, gm/300ml-%, gm/250ml-%, /100ml-%, /150ml- % vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 1000, 250, 500, 5000, 750 vancomycin hcl oral capsule 125 Vancocin HCl vancomycin hcl oral capsule 250 Vancocin HCl vandazole vaginal gel 0.75 % Metroel-Vaginal VIATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 M XIFAXAN ORAL TALET 200 M, 550 M ZEMDRI INTRAVENOUS SOLUTION 500 M/10ML Anticoagulants acd formula a in vitro solution gm/100ml acd formula b in vitro solution acd-a noclot-50 in vitro solution gm/100ml anticoagulant cit dext soln a in vitro solution gm/100ml anticoagulant sodium citrate in vitro solution 4 gm/100ml argatroban in sodium chloride intravenous solution 250 /250ml argatroban intravenous solution 125 /125ml, 250 /2.5ml, 50 /50ml bivalirudin trifluoroacetate intravenous solution reconstituted 250 CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 M ELIQUIS ORAL TALET 2.5 M, 5 M ELIQUIS STARTER CK ORAL TALET 5 M enoxaparin sodium injection solution 300 /3ml ACD-A noclot-50 ACD-A noclot-50 ACD-A noclot-50 Angiomax Lovenox Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 27 ST QL (2 EA per 31

31 Drug Name Reference rand-eneric Notes enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml FRAMIN SUCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML FRAMIN SUCUTANEOUS SOLUTION UNIT/3.8ML heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, unit/ml-%, unit/ml-% heparin (porcine) in nacl intravenous solution ut/500ml-% heparin (porcine) in nacl intravenous solution prefilled syringe unt/20ml- %, unt/50ml-% heparin sod (porcine) in d5w intravenous solution 100 unit/ml, 40-5 unit/ml-% heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) intravenous solution prefilled syringe unit/10ml, 3000 unit/3ml, 5000 unit/5ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml heparin sodium/d5w intravenous solution 50-5 unit/ml-% jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 M, 150 M, 75 M SAVAYSA ORAL TALET 15 M, 30 M, 60 M THROMATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT Lovenox QL (2 ML per 1 day) Lovenox QL (1 ML per 1 day) Arixtra QL (1 ML per 1 day) Coumadin Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 28 ; QL (1 ML per 1 day) ; QL (10 ML per 30 ST

32 Drug Name Reference rand-eneric Notes warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TALET 10 M, 15 M, 20 M XARELTO STARTER CK ORAL TALET THERAPY CK 15 & 20 M Anticonvulsants - Drugs for Seizures Coumadin ANZEL ORAL SUSPENSION 40 M/ML ANZEL ORAL TALET 200 M, 400 M RIVIACT INTRAVENOUS SOLUTION 50 M/5ML RIVIACT ORAL SOLUTION 10 M/ML ST RIVIACT ORAL TALET 10 M, 100 M, 25 M, 50 M, 75 M carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release 12 hour 100, 200, 400 TEretol-XR carbamazepine oral suspension 100 /5ml TEretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 CARATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 M, 200 M, 300 M Carbatrol diazepam rectal gel 10, 20 Diastat AcuDial diazepam rectal gel 2.5 Diastat Pediatric divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 Depakote ER Depakote Sprinkles Depakote epitol oral tablet 200 Epitol ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol ST ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 29

33 Drug Name Reference rand-eneric Notes fosphenytoin sodium injection solution 100 pe/2ml, 500 pe/10ml gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml, 300 /6ml Cerebyx Neurontin Neurontin gabapentin oral tablet 600, 800 Neurontin KEPPRA XR ORAL TALET EXTENDED RELEASE 24 HOUR 500 M, 750 M lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, 300, 50 lamotrigine oral kit 25 & 50 & 100, 25 (21)-50 (7), 50 (42)-100(14) lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 lamotrigine starter kit-blue oral kit 25 (35) lamotrigine starter kit-green oral kit 25 (84)-100(14) lamotrigine starter kit-orange oral kit 25 (42)-100 (7) levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam in nacl intravenous solution 1000 /100ml, 1500 /100ml, 500 /100ml levetiracetam intravenous solution 500 /5ml Keppra XR LaMICtal XR LaMICtal ODT LaMICtal LaMICtal LaMICtal ODT LaMICtal Starter LaMICtal Starter LaMICtal Starter Keppra XR Keppra levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 pentobarbital sodium injection solution 50 /ml phenobarbital oral elixir 20 /5ml phenobarbital oral solution 20 /5ml Keppra Trileptal Trileptal Nembutal Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 30

34 Drug Name Reference rand-eneric Notes phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 phenobarbital sodium injection solution 130 /ml, 65 /ml phenytoin infatabs oral tablet chewable 50 Dilantin Infatabs phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 phenytoin sodium extended oral capsule 200, 300 phenytoin sodium injection solution 50 /ml Dilantin Phenytek primidone oral tablet 250, 50 Mysoline roweepra oral tablet 1000, 500, 750 roweepra xr oral tablet extended release 24 hour 500, 750 subvenite oral tablet 100, 150, 200, 25 subvenite starter kit-blue oral kit 25 (35) subvenite starter kit-green oral kit 25 (84)- 100(14) subvenite starter kit-orange oral kit 25 (42)-100 (7) tiagabine hcl oral tablet 12, 16, 2, 4 topiramate er oral capsule er 24 hour sprinkle 100, 150, 200, 25, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 valproate sodium intravenous solution 100 /ml, 500 /5ml valproate sodium oral solution 250 /5ml Keppra Keppra XR LaMICtal LaMICtal Starter LaMICtal Starter LaMICtal Starter abitril Qudexy XR Topamax Sprinkle Topamax Depacon Depakene valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 31

35 Drug Name Reference rand-eneric Notes vigabatrin oral packet 500 Sabril vigadrone oral packet 500 Sabril VIMT INTRAVENOUS SOLUTION 200 M/20ML VIMT ORAL SOLUTION 10 M/ML VIMT ORAL TALET 100 M, 150 M, 200 M, 50 M zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia donepezil hcl oral tablet 10, 23, 5 donepezil hcl oral tablet dispersible 10, 5 galantamine hydrobromide er oral capsule extended release 24 hour 16, 24, 8 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12, 4, 8 memantine hcl er oral capsule extended release 24 hour 14, 21, 28, 7 memantine hcl oral solution 2 /ml Aricept Razadyne ER Razadyne Namenda XR memantine hcl oral tablet 10, 5 Namenda memantine hcl oral tablet 5 (28)-10 (21) NAMENDA XR TITRATION CK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 M rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 13.3 /24hr, 4.6 /24hr, 9.5 /24hr Antidepressants amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 ANAFRANIL ORAL CAPSULE 25 M, 50 M, 75 M Namenda Titration Pak Exelon Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 32 Anafranil

36 Drug Name Reference rand-eneric Notes APLENZIN ORAL TALET EXTENDED RELEASE 24 HOUR 174 M, 348 M, 522 M RISDELLE ORAL CAPSULE 7.5 M risdelle bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 chlordiazepoxide-amitriptyline oral tablet 10-25, citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 clomipramine hcl oral capsule 25, 50, 75 Wellbutrin SR Wellbutrin XL CeleXA desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml duloxetine hcl oral capsule delayed release particles 20, 30, 60 duloxetine hcl oral capsule delayed release particles 40 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl (pmdd) oral capsule 10, 20 fluoxetine hcl (pmdd) oral tablet 10, 20 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml Anafranil Pristiq Cymbalta Lexapro Sarafem PROzac ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 33

37 Drug Name Reference rand-eneric Notes fluoxetine hcl oral tablet 10, 20, 60 fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25, 50 imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15, 30 Remeron mirtazapine oral tablet 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30, 40 Remeron SolTab Pamelor Paxil CR Paxil paroxetine mesylate oral capsule 7.5 risdelle perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 protriptyline hcl oral tablet 10, 5 sertraline hcl oral concentrate 20 /ml Zoloft sertraline hcl oral tablet 100, 25, 50 trazodone hcl oral tablet 100, 150, 300, 50 trimipramine maleate oral capsule 100, 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hour 150, 225, 37.5, 75 Zoloft Surmontil Effexor XR Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 34

38 Drug Name Reference rand-eneric Notes venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 VIIRYD ORAL TALET 10 M, 20 M, 40 M ZOLOFT ORAL TALET 100 M, 25 M, 50 M Antiemetics - Drugs for Nausea and Vomiting ALOXI INTRAVENOUS SOLUTION 0.25 M/5ML Zoloft Aloxi QL (1 ML per 31 anti-nausea oral solution Emetrol anti-nausea/rekematol oral solution aprepitant oral capsule 125, 40, 80 Emetrol Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 35 ST Emend aprepitant oral capsule 80 & 125 Emend Tri-Pack compro rectal suppository 25 Compro dimenhydrinate injection solution 50 /ml dronabinol oral capsule 10, 2.5, 5 droperidol injection solution 2.5 /ml EMEND ORAL CAPSULE 125 M, 40 M, 80 M Marinol Emend formula em oral solution Emetrol granisetron hcl intravenous solution 0.1 /ml, 4 /4ml granisetron hcl intravenous solution 1 /ml granisetron hcl oral tablet 1 little tummys nausea relief oral solution meclizine hcl oral tablet 12.5 Emetrol meclizine hcl oral tablet 25 Dramamine Less Drowsy metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 10 /10ml, 5 /5ml metoclopramide hcl oral tablet 10, 5 Reglan QL (240 ML per 31 QL (240 ML per 31 QL (240 ML per 31 ; QL (2 ML per 30 ; QL (2 EA per 31 QL (240 ML per 31

39 Drug Name Reference rand-eneric Notes metoclopramide hcl oral tablet dispersible 10, 5 nausatrol oral solution Emetrol ondansetron hcl injection solution 4 /2ml, 40 /20ml ondansetron hcl oral solution 4 /5ml Zofran Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 36 QL (240 ML per 31 ondansetron hcl oral tablet 24 QL (3 EA per 31 ondansetron hcl oral tablet 4, 8 Zofran ondansetron hcl-nacl intravenous solution /50ml-%, /50ml-%, /50ml-% ondansetron odt oral tablet dispersible 4, 8 palonosetron hcl intravenous solution 0.25 /2ml palonosetron hcl intravenous solution 0.25 /5ml palonosetron hcl intravenous solution prefilled syringe 0.25 /5ml prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 Zofran ODT prochlorperazine rectal suppository 25 Compro scopolamine transdermal patch 72 hour 1 /3days trimethobenzamide hcl oral capsule 300 QL (31 EA per 31 Aloxi QL (1 ML per 31 Transderm-Scop (1.5 M) Tigan VARUI ORAL TALET 90 M Antifungals AELCET INTRAVENOUS SUSPENSION 5 M/ML AMISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 M amphotericin b injection solution reconstituted 50 bio-statin oral powder CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 M, 70 M caspofungin acetate intravenous solution reconstituted 50, 70 Cancidas Cancidas

40 Drug Name Reference rand-eneric Notes ciclodan external cream 0.77 % Loprox ciclodan external solution 8 % Ciclodan ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % Loprox ciclopirox external solution 8 % Ciclodan ciclopirox olamine external cream 0.77 % Loprox ciclopirox olamine external suspension 0.77 % Loprox ciclopirox treatment external kit 8 % Ciclodan Solution clotrimazole external cream 1 % Clotrimazole Rx clotrimazole external solution 1 % clotrimazole mouth/throat lozenge 10 clotrimazole mouth/throat troche 10 FungiCure Intensive/Nailuard clotrimazole vaginal cream 1 % yne-lotrimin CRESEMA INTRAVENOUS SOLUTION RECONSTITUTED 372 M CRESEMA ORAL CAPSULE 186 M econazole nitrate external cream 1 % exoderm external lotion 25-1 % fluconazole in dextrose intravenous solution 200 /100ml, 400 /200ml fluconazole in sodium chloride intravenous solution /50ml-%, /100ml-%, /200ml- % fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 200, 50 Diflucan Diflucan fluconazole oral tablet 150 Diflucan QL (2 EA per 31 flucytosine oral capsule 250, 500 Ancobon griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 RIS-PE ORAL TALET 125 M, 250 M itraconazole oral capsule 100 Sporanox itraconazole oral solution 10 /ml Sporanox Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 37

41 Drug Name Reference rand-eneric Notes JULIA EXTERNAL SOLUTION 10 % ketoconazole external cream 2 % ketoconazole external foam 2 % Extina ketoconazole external shampoo 2 % Nizoral ketoconazole oral tablet 200 miconazole 3 vaginal suppository 200 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 M, 50 M naftifine hcl external cream 1 % naftifine hcl external cream 2 % Naftin NOXAFIL ORAL SUSPENSION 40 M/ML NOXAFIL ORAL TALET DELAYED RELEASE 100 M nyamyc external powder unit/gm Nyamyc nyata external powder unit/gm Nyamyc nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm Nyamyc nystatin mouth/throat suspension unit/ml nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% nystop external powder unit/gm Nyamyc oxiconazole nitrate external cream 1 % Oxistat terbinafine hcl oral tablet 250 LamISIL terconazole vaginal cream 0.4 % Terazol 7 terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 tgt clotrimazole external cream 1 % Clotrimazole Rx VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 M VFEND ORAL SUSPENSION RECONSTITUTED 40 M/ML ST ST Vfend IV ST Vfend ST VFEND ORAL TALET 200 M, 50 M Vfend ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 38

42 Drug Name Reference rand-eneric Notes voriconazole intravenous solution reconstituted 200 voriconazole oral suspension reconstituted 40 /ml Vfend IV ST Vfend ST voriconazole oral tablet 200, 50 Vfend ST Antigout Agents allopurinol oral tablet 100, 300 Zyloprim allopurinol sodium intravenous solution reconstituted 500 Aloprim COLCHICINE ORAL TALET 0.6 M Colcrys colchicine-probenecid oral tablet COLCRYS ORAL TALET 0.6 M Colcrys probenecid oral tablet 500 ULORIC ORAL TALET 40 M, 80 M ST ZURAMPIC ORAL TALET 200 M Antimigraine Agents almotriptan malate oral tablet 12.5 almotriptan malate oral tablet 6.25 AXERT ORAL TALET 12.5 M AXERT ORAL TALET 6.25 M dihydroergotamine mesylate injection solution 1 /ml dihydroergotamine mesylate nasal solution 4 /ml eletriptan hydrobromide oral tablet 20, 40 D.H.E. 45 Migranal Relpax ergotamine-caffeine oral tablet Cafergot frovatriptan succinate oral tablet 2.5 Frova naratriptan hcl oral tablet 1, 2.5 Amerge RELX ORAL TALET 20 M, 40 M Relpax rizatriptan benzoate oral tablet 10 Maxalt rizatriptan benzoate oral tablet 5 rizatriptan benzoate oral tablet dispersible 10 Maxalt-MLT Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 39 ST; QL (12 EA per 31 ST; QL (6 EA per 31 ST; QL (12 EA per 31 ST; QL (6 EA per 31 ST; QL (9 EA per 31 ST; QL (9 EA per 31 ST; QL (9 EA per 31 ST; QL (9 EA per 31 QL (11 EA per 31

43 Drug Name Reference rand-eneric Notes rizatriptan benzoate oral tablet dispersible 5 sumatriptan nasal solution 20 /act, 5 /act sumatriptan succinate oral tablet 100, 25, 50 sumatriptan succinate refill subcutaneous solution cartridge 4 /0.5ml, 6 /0.5ml sumatriptan succinate subcutaneous solution 6 /0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 /0.5ml, 6 /0.5ml sumatriptan-naproxen sodium oral tablet Maxalt-MLT Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 40 QL (10 EA per 31 Imitrex QL (6 EA per 31 Imitrex Imitrex STATdose Refill ST Imitrex Imitrex STATdose System Treximet zolmitriptan oral tablet 2.5, 5 Zomig zolmitriptan oral tablet dispersible 2.5, 5 ZOMI NASAL SOLUTION 2.5 M, 5 M Antimyasthenic Agents guanidine hcl oral tablet 125 MESTINON ORAL SYRUP 60 M/5ML Zomig ZMT MESTINON ORAL TALET 60 M Mestinon MESTINON ORAL TALET EXTENDED RELEASE 180 M neostigmine methylsulfate injection solution 0.5 /ml, 1 /ml neostigmine methylsulfate intravenous solution 10 /10ml, 5 /10ml pyridostigmine bromide er oral tablet extended release 180 Mestinon loxiverz Mestinon pyridostigmine bromide oral tablet 60 Mestinon regonol intravenous solution 10 /2ml Antimycobacterials cycloserine oral capsule 250 Seromycin dapsone oral tablet 100, 25 ethambutol hcl oral tablet 100, 400 Myambutol isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 ST; QL (9 EA per 31 ST; QL (9 ML per 31 ST ST; QL (9 EA per 31 ST; QL (9 EA per 31 ST; QL (9 EA per 31

44 Drug Name Reference rand-eneric Notes pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin intravenous solution reconstituted 600 Rifadin rifampin oral capsule 150, 300 Rifadin Antineoplastics - Drugs for Cancer adriamycin intravenous solution 2 /ml Adriamycin adriamycin intravenous solution reconstituted 10 adriamycin intravenous solution reconstituted 50 adrucil intravenous solution 2.5 gm/50ml, 5 gm/100ml, 500 /10ml AFINITOR DISPERZ ORAL TALET SOLULE 2 M, 3 M, 5 M AFINITOR ORAL TALET 10 M, 2.5 M, 5 M, 7.5 M Adriamycin Adrucil ALECENSA ORAL CAPSULE 150 M ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 M, 500 M ALUNRI ORAL TALET 180 M, 30 M, 90 M amifostine intravenous solution reconstituted 500 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 41 Ethyol anastrozole oral tablet 1 Arimidex ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 10 M/10ML AVASTIN INTRAVENOUS SOLUTION 100 M/4ML, 400 M/16ML azacitidine injection suspension reconstituted 100 Vidaza bexarotene oral capsule 75 Targretin bicalutamide oral tablet 50 Casodex ICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 M bleomycin sulfate injection solution reconstituted 15 unit, 30 unit RAFTOVI ORAL CAPSULE 50 M, 75 M icnu busulfan intravenous solution 6 /ml usulfex CAOMETYX ORAL TALET 20 M, 40 M, 60 M

45 Drug Name Reference rand-eneric Notes CALQUENCE ORAL CAPSULE 100 M CAMTH INTRAVENOUS SOLUTION 30 M/ML capecitabine oral tablet 150, 500 Xeloda carboplatin intravenous solution 150 /15ml, 450 /45ml, 50 /5ml, 600 /60ml carmustine intravenous solution reconstituted 100 cisplatin intravenous solution 100 /100ml, 200 /200ml, 50 /50ml cladribine intravenous solution 10 /10ml icnu clofarabine intravenous solution 1 /ml Clolar COTELLIC ORAL TALET 20 M cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 cyclophosphamide oral capsule 25, 50 cytarabine (pf) injection solution 100 /ml, 20 /ml cytarabine injection solution 20 /ml dacarbazine intravenous solution reconstituted 100, 200 dactinomycin intravenous solution reconstituted 0.5 daunorubicin hcl intravenous injectable 5 /ml daunorubicin hcl intravenous solution 20 /4ml, 50 /10ml decitabine intravenous solution reconstituted 50 dexrazoxane intravenous solution reconstituted 250 dexrazoxane intravenous solution reconstituted 500 docetaxel (non-alcohol) intravenous solution 160 /8ml, 20 /ml, 80 /4ml docetaxel intravenous concentrate 160 /8ml, 20 /0.5ml, 200 /10ml, 80 /2ml docetaxel intravenous concentrate 20 /ml, 80 /4ml Cosmegen Dacogen Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 42 Zinecard Totect Taxotere

46 Drug Name Reference rand-eneric Notes docetaxel intravenous solution 160 /16ml, 20 /2ml, 80 /8ml doxorubicin hcl intravenous solution 2 /ml doxorubicin hcl intravenous solution reconstituted 10 doxorubicin hcl intravenous solution reconstituted 50 doxorubicin hcl liposomal intravenous injectable 2 /ml epirubicin hcl intravenous solution 200 /100ml, 50 /25ml ERITUX INTRAVENOUS SOLUTION 100 M/50ML, 200 M/100ML Adriamycin Adriamycin Doxil Ellence ERLEADA ORAL TALET 60 M etoposide intravenous solution 1 gm/50ml, 100 /5ml, 500 /25ml etoposide oral capsule 50 Toposar exemestane oral tablet 25 Aromasin FARYDAK ORAL CAPSULE 10 M, 15 M, 20 M FASLODEX INTRAMUSCULAR SOLUTION 250 M/5ML floxuridine injection solution reconstituted 0.5 gm fludarabine phosphate intravenous solution 50 /2ml fludarabine phosphate intravenous solution reconstituted 50 fluorouracil intravenous solution 1 gm/20ml fluorouracil intravenous solution 2.5 gm/50ml, 5 gm/100ml, 500 /10ml flutamide oral capsule 125 gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 /5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 200 gemcitabine hcl intravenous solution reconstituted 2 gm ILOTRIF ORAL TALET 20 M, 30 M, 40 M Adrucil emzar HALAVEN INTRAVENOUS SOLUTION 1 M/2ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 43

47 Drug Name Reference rand-eneric Notes HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 440 M HYCAMTIN ORAL CAPSULE 0.25 M, 1 M hydroxyurea oral capsule 500 Hydrea IRANCE ORAL CAPSULE 100 M, 125 M, 75 M idarubicin hcl intravenous solution 10 /10ml, 20 /20ml, 5 /5ml Idamycin PFS IDHIFA ORAL TALET 100 M, 50 M ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml ifosfamide intravenous solution reconstituted 1 gm, 3 gm imatinib mesylate oral tablet 100, 400 IMRUVICA ORAL CAPSULE 140 M, 70 M IMRUVICA ORAL TALET 140 M, 280 M, 420 M, 560 M irinotecan hcl intravenous solution 100 /5ml, 40 /2ml irinotecan hcl intravenous solution 500 /25ml IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 M, 45 M KISQALI 200 DOSE ORAL TALET 200 M KISQALI 400 DOSE ORAL TALET 200 M KISQALI 600 DOSE ORAL TALET 200 M LENVIMA 10 M DAILY DOSE ORAL CAPSULE THERAPY CK 10 M LENVIMA 14 M DAILY DOSE ORAL CAPSULE THERAPY CK 10 & 4 M LENVIMA 18 M DAILY DOSE ORAL CAPSULE THERAPY CK 10 & 4 (2) M LENVIMA 20 M DAILY DOSE ORAL CAPSULE THERAPY CK 10 (2) M Ifex leevec Camptosar Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 44

48 Drug Name Reference rand-eneric Notes LENVIMA 24 M DAILY DOSE ORAL CAPSULE THERAPY CK 10 (2) & 4 M LENVIMA 8 M DAILY DOSE ORAL CAPSULE THERAPY CK 4 (2) M letrozole oral tablet 2.5 Femara leucovorin calcium injection solution reconstituted 100, 200, 350, 50, 500 leucovorin calcium oral tablet 10, 15, 25, 5 levoleucovorin calcium intravenous solution 175 /17.5ml levoleucovorin calcium intravenous solution reconstituted 175 levoleucovorin calcium intravenous solution reconstituted 50 levoleucovorin calcium pf intravenous solution 250 /25ml Fusilev lipodox 50 intravenous injectable 2 /ml Doxil LONSURF ORAL TALET M, M LYNRZA ORAL CAPSULE 50 M LYNRZA ORAL TALET 100 M, 150 M MATULANE ORAL CAPSULE 50 M MEKINIST ORAL TALET 0.5 M, 2 M MEKTOVI ORAL TALET 15 M melphalan hcl intravenous solution reconstituted 50 Alkeran melphalan oral tablet 2 Alkeran mercaptopurine oral tablet 50 mesna intravenous solution 100 /ml Mesnex mitomycin intravenous solution reconstituted 20, 40, 5 mitoxantrone hcl intravenous concentrate 20 /10ml, 25 /12.5ml, 30 /15ml mutamycin intravenous solution reconstituted 20 mutamycin intravenous solution reconstituted 40, 5 Mutamycin Mutamycin Mutamycin NERLYNX ORAL TALET 40 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 45

49 Drug Name Reference rand-eneric Notes NEXAVAR ORAL TALET 200 M nilutamide oral tablet 150 Nilandron NINLARO ORAL CAPSULE 2.3 M, 3 M, 4 M ODOMZO ORAL CAPSULE 200 M oxaliplatin intravenous solution 100 /20ml, 50 /10ml oxaliplatin intravenous solution reconstituted 100, 50 paclitaxel intravenous concentrate 100 /16.7ml, 150 /25ml, 30 /5ml, 300 /50ml POMALYST ORAL CAPSULE 1 M, 2 M, 3 M, 4 M REVLIMID ORAL CAPSULE 10 M, 15 M, 2.5 M, 20 M, 25 M, 5 M RITUXAN INTRAVENOUS SOLUTION 100 M/10ML, 500 M/50ML RURACA ORAL TALET 200 M, 250 M, 300 M RYDAPT ORAL CAPSULE 25 M SPRYCEL ORAL TALET 100 M, 140 M, 20 M, 50 M, 70 M, 80 M STIVARA ORAL TALET 40 M SUTENT ORAL CAPSULE 12.5 M, 25 M, 37.5 M, 50 M TAFINLAR ORAL CAPSULE 50 M, 75 M TARISSO ORAL TALET 40 M, 80 M tamoxifen citrate oral tablet 10, 20 TARCEVA ORAL TALET 100 M, 150 M, 25 M TARRETIN EXTERNAL EL 1 % TASINA ORAL CAPSULE 150 M, 200 M, 50 M TECENTRIQ INTRAVENOUS SOLUTION 1200 M/20ML temozolomide oral capsule 100, 140, 180, 20, 250, 5 teniposide intravenous solution 10 /ml THALOMID ORAL CAPSULE 100 M, 150 M, 200 M, 50 M Temodar Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 46

50 Drug Name Reference rand-eneric Notes thiotepa injection solution reconstituted 15 Tepadina TISOVO ORAL TALET 250 M toposar intravenous solution 1 gm/50ml, 100 /5ml, 500 /25ml topotecan hcl intravenous solution 4 /4ml topotecan hcl intravenous solution reconstituted 4 TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 M, 25 M tretinoin oral capsule 10 TYKER ORAL TALET 250 M Toposar Hycamtin VALCHLOR EXTERNAL EL % VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 M VENCLEXTA ORAL TALET 10 M, 100 M, 50 M VERZENIO ORAL TALET 100 M, 150 M, 200 M, 50 M vinblastine sulfate intravenous solution 1 /ml vincasar pfs intravenous solution 1 /ml Vincasar PFS vincristine sulfate intravenous solution 1 /ml vinorelbine tartrate intravenous solution 10 /ml, 50 /5ml VOTRIENT ORAL TALET 200 M Vincasar PFS Navelbine ZEJULA ORAL CAPSULE 100 M ZYDELI ORAL TALET 100 M, 150 M ZYKADIA ORAL CAPSULE 150 M Antiparasitics ALENZA ORAL TALET 200 M ALINIA ORAL TALET 500 M atovaquone oral suspension 750 /5ml Mepron atovaquone-proguanil hcl oral tablet , ENZNIDAZOLE ORAL TALET 100 M, 12.5 M chloroquine phosphate oral tablet 250, 500 Malarone Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 47

51 Drug Name Reference rand-eneric Notes crotan external lotion 10 % ST EMVERM ORAL TALET CHEWALE 100 M EURAX EXTERNAL CREAM 10 % ST EURAX EXTERNAL LOTION 10 % ST hydroxychloroquine sulfate oral tablet 200 Plaquenil IMVIDO ORAL CAPSULE 50 M ivermectin oral tablet 3 Stromectol lice treatment external liquid 1 % Nix Creme Rinse lice treatment external lotion 1 % lindane external shampoo 1 % malathion external lotion 0.5 % Ovide mefloquine hcl oral tablet 250 OVIDE EXTERNAL LOTION 0.5 % Ovide permethrin external cream 5 % Elimite praziquantel oral tablet 600 iltricide primaquine phosphate oral tablet 26.3 quinine sulfate oral capsule 324 Qualaquin SOLOSEC ORAL CKET 2 M ST spinosad external suspension 0.9 % Natroba sulfurated lime external solution Antiparkinson Agents APOKYN SUCUTANEOUS SOLUTION CARTRIDE 30 M/3ML AZILECT ORAL TALET 0.5 M, 1 M Azilect ST bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel carbidopa oral tablet 25 Lodosyn ST carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , Sinemet CR Sinemet Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 48 QL (148 ML per 31 QL (240 ML per 31 QL (60 ML per 30 QL (60 ML per 30 QL (240 M per 31

52 Drug Name Reference rand-eneric Notes carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet Stalevo 50 Stalevo 75 Stalevo 100 Stalevo 125 Stalevo 150 Stalevo 200 ELDEPRYL ORAL CAPSULE 5 M Eldepryl entacapone oral tablet 200 Comtan ST LODOSYN ORAL TALET 25 M Lodosyn ST pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375, 0.75, 1.5, 2.25, 3, 3.75, 4.5 pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 rasagiline mesylate oral tablet 0.5, 1 REQUIP XL ORAL TALET EXTENDED RELEASE 24 HOUR 12 M, 2 M, 4 M, 6 M, 8 M ropinirole hcl er oral tablet extended release 24 hour 12, 2, 4, 6, 8 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Mirapex ER ST Mirapex ST Azilect ST Requip XL Requip XL Requip selegiline hcl oral capsule 5 Eldepryl selegiline hcl oral tablet 5 tolcapone oral tablet 100 Tasmar Antiplatelets aspirin-dipyridamole er oral capsule extended release 12 hour Aggrenox ST RILINTA ORAL TALET 60 M, 90 M ST cilostazol oral tablet 100, 50 clopidogrel bisulfate oral tablet 300, 75 Plavix Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 49

53 Drug Name Reference rand-eneric Notes dipyridamole oral tablet 25, 50, 75 eptifibatide intravenous solution 20 /10ml, 200 /100ml, 75 /100ml Integrilin prasugrel hcl oral tablet 10, 5 Effient ST Antivirals acyclovir external ointment 5 % Zovirax acyclovir oral capsule 200 Zovirax acyclovir oral suspension 200 /5ml Zovirax acyclovir oral tablet 400, 800 Zovirax acyclovir sodium intravenous solution 50 /ml acyclovir sodium intravenous solution reconstituted 500 adefovir dipivoxil oral tablet 10 Hepsera ARACLUDE ORAL SOLUTION 0.05 M/ML cidofovir intravenous solution 75 /ml DAKLINZA ORAL TALET 30 M, 60 M, 90 M entecavir oral tablet 0.5, 1 araclude EPCLUSA ORAL TALET M famciclovir oral tablet 125, 250, 500 ganciclovir sodium intravenous solution 500 /10ml ganciclovir sodium intravenous solution reconstituted 500 Cytovene HARVONI ORAL TALET M INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT lamivudine oral tablet 100 Epivir HV MAVYRET ORAL TALET M MODERIA 1200 DOSE CK ORAL TALET 600 M MODERIA 800 DOSE CK ORAL TALET 400 M moderiba oral tablet 200 Moderiba Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 50

54 Drug Name Reference rand-eneric Notes OLYSIO ORAL CAPSULE 150 M oseltamivir phosphate oral capsule 30 Tamiflu oseltamivir phosphate oral capsule 45, 75 oseltamivir phosphate oral suspension reconstituted 6 /ml PEASYS PROCLICK SUCUTANEOUS SOLUTION 135 MC/0.5ML, 180 MC/0.5ML PEASYS SUCUTANEOUS SOLUTION 180 MC/0.5ML, 180 MC/ML PREVYMIS ORAL TALET 240 M, 480 M RELENZA DISKHALER INHALATION AEROSOL POWDER REATH ACTIVATED 5 M/LISTER RETROVIR INTRAVENOUS SOLUTION 10 M/ML Tamiflu Tamiflu RETROVIR ORAL CAPSULE 100 M Retrovir ribasphere oral capsule 200 Rebetol ribasphere oral tablet 200 Moderiba ribasphere oral tablet 400, 600 ribasphere ribapak oral tablet 400, 600 ribavirin inhalation solution reconstituted 6 gm Virazole ribavirin oral capsule 200 Rebetol ribavirin oral tablet 200 Moderiba rimantadine hcl oral tablet 100 Flumadine SOVALDI ORAL TALET 400 M TAMIFLU ORAL CAPSULE 30 M Tamiflu TAMIFLU ORAL CAPSULE 45 M, 75 M TECHNIVIE ORAL TALET M Tamiflu valacyclovir hcl oral tablet 1 gm, 500 Valtrex valganciclovir hcl oral solution reconstituted 50 /ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 51 QL (20 EA per 31 QL (10 EA per 31 QL (180 ML per 31 QL (20 EA per 31 QL (20 EA per 31 QL (10 EA per 31 Valcyte valganciclovir hcl oral tablet 450 Valcyte

55 Drug Name Reference rand-eneric Notes VIEKIRA K ORAL TALET THERAPY CK &250 M ZETIER ORAL TALET M zidovudine oral capsule 100 Retrovir zidovudine oral syrup 50 /5ml Retrovir zidovudine oral tablet 300 Anxiolytics - Drugs for Anxiety alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 alprazolam oral tablet 0.25, 0.5, 1 Xanax XR Xanax alprazolam oral tablet 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 buspirone hcl oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 25, 5 Xanax XR clonazepam oral tablet 0.5, 1 KlonoPIN clonazepam oral tablet 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 diazepam injection solution 5 /ml diazepam intensol oral concentrate 5 /ml diazepam intramuscular solution autoinjector 10 /2ml Tranxene-T Diazepam Intensol diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 1 /ml diazepam oral tablet 10 Valium diazepam oral tablet 2, 5 Valium ST; QL (124 EA per 31 ST; QL (62 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (62 EA per 31 ST; QL (93 EA per 31 ST; QL (93 EA per 31 QL (31 EA per 31 QL (124 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 52

56 Drug Name Reference rand-eneric Notes estazolam oral tablet 1, 2 hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 lorazepam injection solution 2 /ml, 4 /ml lorazepam intensol oral concentrate 2 /ml Vistaril Ativan LORazepam Intensol lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1 Ativan lorazepam oral tablet 2 Ativan lorazepam-dextrose intravenous solution /100ml-% lorazepam-sodium chloride intravenous solution /100ml-% meprobamate oral tablet 200, 400 midazolam hcl injection solution 10 /10ml, 10 /2ml, 2 /2ml, 25 /5ml, 5 /5ml, 5 /ml, 50 /10ml midazolam hcl oral syrup 2 /ml midazolam hcl-nacl intravenous solution /100ml-% midazolam hcl-sodium chloride intravenous solution /100ml-% midazolam hcl-sodium chloride intravenous solution prefilled syringe /2ml-% oxazepam oral capsule 10, 15, 30 quazepam oral tablet 15 Doral triazolam oral tablet triazolam oral tablet 0.25 Halcion lood Products / Modifiers / Volume Expanders - Drugs for leeding Disorders Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 53 QL (124 EA per 31 QL (62 EA per 31

57 Drug Name Reference rand-eneric Notes aminocaproic acid intravenous solution 250 /ml anagrelide hcl oral capsule 0.5 Agrylin anagrelide hcl oral capsule 1 ARANESP (ALUMIN FREE) INJECTION SOLUTION 100 MC/ML, 200 MC/ML, 25 MC/ML, 300 MC/ML, 40 MC/ML, 60 MC/ML ARANESP (ALUMIN FREE) INJECTION SOLUTION PREFILLED SYRINE 10 MC/0.4ML ARANESP (ALUMIN FREE) INJECTION SOLUTION PREFILLED SYRINE 100 MC/0.5ML, 150 MC/0.3ML, 200 MC/0.4ML, 25 MC/0.42ML, 300 MC/0.6ML, 40 MC/0.4ML, 60 MC/0.3ML ARANESP (ALUMIN FREE) INJECTION SOLUTION PREFILLED SYRINE 500 MC/ML DOPTELET ORAL TALET 20 M EPOEN INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML FULPHILA SUCUTANEOUS SOLUTION PREFILLED SYRINE 6 M/0.6ML hetastarch-nacl intravenous solution % lmd in d5w intravenous solution 10-5 % lmd in nacl intravenous solution % NEULASTA ONPRO SUCUTANEOUS PREFILLED SYRINE KIT 6 M/0.6ML NEULASTA SUCUTANEOUS SOLUTION PREFILLED SYRINE 6 M/0.6ML NEUPOEN INJECTION SOLUTION 300 MC/ML NEUPOEN INJECTION SOLUTION 480 MC/1.6ML NEUPOEN INJECTION SOLUTION PREFILLED SYRINE 300 MC/0.5ML NEUPOEN INJECTION SOLUTION PREFILLED SYRINE 480 MC/0.8ML Hespan QL (2 ML per 28 QL (2 ML per 28 QL (1 ML per 28 QL (12 ML per 28 QL (14 ML per 31 QL (22.4 ML per 30 QL (7 ML per 30 QL (11.2 ML per 30 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 54

58 Drug Name Reference rand-eneric Notes NPLATE SUCUTANEOUS SOLUTION RECONSTITUTED 250 MC, 500 MC PROCRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML protamine sulfate intravenous solution 10 /ml RETACRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML RETACRIT INJECTION SOLUTION UNIT/ML TAVALISSE ORAL TALET 100 M, 150 M tranexamic acid intravenous solution 1000 /10ml Cyklokapron tranexamic acid oral tablet 650 Lysteda ZARXIO INJECTION SOLUTION PREFILLED SYRINE 300 MC/0.5ML, 480 MC/0.8ML Cardiovascular Agents - Drugs for Heart and Circulation Conditions acebutolol hcl oral capsule 200, 400 acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125, 250 acetazolamide sodium injection solution reconstituted 500 adenosine intravenous solution 12 /4ml, 6 /2ml adenosine intravenous solution prefilled syringe 90 /30ml afeditab cr oral tablet extended release 24 hour 30, 60 Adenocard Adalat CC amiloride hcl oral tablet 5 ST amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone hcl in dextrose intravenous solution /100ml-% amiodarone hcl intravenous solution 150 /3ml, 450 /9ml, 900 /18ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 55 QL (12 ML per 28 QL (1 ML per 7 QL (12 ML per 28 QL (1 ML per 7 QL (14 ML per 31

59 Drug Name Reference rand-eneric Notes amiodarone hcl oral tablet 100, 200, 400 amlodipine besylate oral tablet 10, 2.5, 5 amlodipine besylate-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besylate-benazepril hcl oral capsule , 5-40 amlodipine besylate-valsartan oral tablet , , 5-160, amlodipine-atorvastatin oral tablet 10-10, 10-20, 10-40, 10-80, 5-10, 5-20, 5-40, 5-80 amlodipine-atorvastatin oral tablet , , amlodipine-olmesartan oral tablet 10-20, 10-40, 5-20, 5-40 amlodipine-valsartan-hctz oral tablet , , , , Pacerone Norvasc Lotrel Exforge Caduet Azor ST Exforge HCT atenolol oral tablet 100, 25, 50 Tenormin atenolol-chlorthalidone oral tablet atenolol-chlorthalidone oral tablet atorvastatin calcium oral tablet 10, 20, 40, 80 benazepril hcl oral tablet 10, 20, 40 benazepril hcl oral tablet 5 benazepril-hydrochlorothiazide oral tablet , , benazepril-hydrochlorothiazide oral tablet betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10, 5 bisoprolol-hydrochlorothiazide oral tablet , , bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 Tenoretic 100 Tenoretic 50 Lipitor Lotensin Lotensin HCT Ziac umex Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 56

60 Drug Name Reference rand-eneric Notes candesartan cilexetil oral tablet 16, 32, 4, 8 candesartan cilexetil-hctz oral tablet , , captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, cartia xt oral capsule extended release 24 hour 120 cartia xt oral capsule extended release 24 hour 180, 240, 300 carvedilol oral tablet 12.5, 25, 3.125, 6.25 carvedilol phosphate er oral capsule extended release 24 hour 10, 20, 40, 80 chlorothiazide oral tablet 250, 500 chlorothiazide sodium intravenous solution reconstituted 500 chlorthalidone oral tablet 25, 50 Atacand Atacand HCT Cardizem CD Cardizem CD Coreg Coreg CR Sodium Diuril cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran choline fenofibrate oral capsule delayed release 135 clonidine hcl (analgesia) epidural solution 100 mcg/ml clonidine hcl (analgesia) epidural solution 500 mcg/ml clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr, 0.2 /24hr, 0.3 /24hr Trilipix ST Duraclon Catapres colesevelam hcl oral packet 3.75 gm Welchol colesevelam hcl oral tablet 625 Welchol COLESTID FLAVORED ORAL RANULES 5 M COLESTID FLAVORED ORAL CKET 5 M Colestid ST Colestid ST COLESTID ORAL RANULES 5 M Colestid ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 57

61 Drug Name Reference rand-eneric Notes COLESTID ORAL CKET 5 M Colestid ST COLESTID ORAL TALET 1 M Colestid ST colestipol hcl oral granules 5 gm Colestid ST colestipol hcl oral packet 5 gm Colestid ST colestipol hcl oral tablet 1 gm Colestid ST CORLANOR ORAL TALET 5 M, 7.5 M digitek oral tablet 125 mcg, 250 mcg Digitek digox oral tablet 125 mcg, 250 mcg Digitek digoxin injection solution 0.25 /ml Lanoxin digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg Digitek diltiazem cd oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er beads oral capsule extended release 24 hour 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er coated beads oral tablet extended release 24 hour 180, 240, 300, 360, 420 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl intravenous solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl intravenous solution reconstituted 100 diltiazem hcl oral tablet 120, 30, 60 diltiazem hcl oral tablet 90 diltiazem hcl-dextrose intravenous solution /100ml-%, /125ml-%, /250ml-% diltiazem hcl-sodium chloride intravenous solution /100ml-%, /125ml-% Cardizem CD Taztia XT Tiazac Cardizem CD Cardizem LA Cardizem Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 58

62 Drug Name Reference rand-eneric Notes dilt-xr oral capsule extended release 24 hour 120, 180, 240 disopyramide phosphate oral capsule 100, 150 dobutamine hcl intravenous solution 250 /20ml, 500 /40ml dobutamine in d5w intravenous solution 1-5 /ml-%, 2 /ml, 4-5 /ml-% dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg dopamine hcl intravenous solution 160 /ml, 40 /ml, 80 /ml dopamine in d5w intravenous solution /ml-%, /ml-%, /ml-% doxazosin mesylate oral tablet 1, 2, 4, 8 Norpace Tikosyn Cardura EDECRIN ORAL TALET 25 M Edecrin enalapril maleate oral tablet 10, 2.5, 20, 5 enalaprilat intravenous injectable 1.25 /ml enalapril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet ENTRESTO ORAL TALET M, M, M ephedrine sulfate injection solution 50 /ml ephedrine sulfate intravenous solution 50 /ml epinephrine injection solution 30 /30ml epinephrine pf injection solution 1 /ml epinephrine pf injection solution prefilled syringe 1 /10ml Vasotec Vaseretic Akovaz eplerenone oral tablet 25, 50 Inspra eprosartan mesylate oral tablet 600 esmolol hcl intravenous solution 100 /10ml esmolol hcl-sodium chloride intravenous solution 2000 /100ml, 2500 /250ml revibloc revibloc in NaCl ethacrynate sodium intravenous solution Sodium Edecrin reconstituted 50 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 59

63 Drug Name Reference rand-eneric Notes ethacrynic acid oral tablet 25 Edecrin ezetimibe oral tablet 10 Zetia ezetimibe-simvastatin oral tablet 10-10, 10-20, 10-40, felodipine er oral tablet extended release 24 hour 10, 2.5, 5 fenofibrate micronized oral capsule 130, 43 fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral capsule 134, 200, 67 Vytorin fenofibrate oral capsule 150, 50 Lipofen fenofibrate oral tablet 120, 40 Fenoglide fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 fenofibric acid oral capsule delayed release 135, 45 ST Trilipix ST fenofibric acid oral tablet 105, 35 Fibricor flecainide acetate oral tablet 100, 150, 50 fluvastatin sodium er oral tablet extended release 24 hour 80 Lescol XL fluvastatin sodium oral capsule 20 Lescol fluvastatin sodium oral capsule 40 fosinopril sodium oral tablet 10, 20, 40 fosinopril sodium-hctz oral tablet , furosemide injection solution 10 /ml furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 Lasix gemfibrozil oral tablet 600 Lopid guanfacine hcl oral tablet 1, 2 HEMANEOL ORAL SOLUTION 4.28 M/ML hydralazine hcl injection solution 20 /ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 60

64 Drug Name Reference rand-eneric Notes hydralazine hcl oral tablet 10, 100, 25, 50 hydrochlorothiazide oral capsule 12.5 Microzide hydrochlorothiazide oral tablet 12.5, 25, 50 ibutilide fumarate intravenous solution 1 /10ml indapamide oral tablet 1.25, 2.5 irbesartan oral tablet 150, 300, 75 irbesartan-hydrochlorothiazide oral tablet , isoproterenol hcl injection solution 0.2 /ml isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 Corvert Avapro ST Avalide ST Isuprel isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 isoxsuprine hcl oral tablet 10, 20 isradipine oral capsule 2.5, 5 KYNAMRO SUCUTANEOUS SOLUTION PREFILLED SYRINE 200 M/ML labetalol hcl intravenous solution 5 /ml labetalol hcl oral tablet 100, 200, 300 lisinopril oral tablet 10, 20, 5 Prinivil lisinopril oral tablet 2.5, 30, 40 Zestril lisinopril-hydrochlorothiazide oral tablet , , losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet , , lovastatin oral tablet 10, 20 Zestoretic Cozaar Hyzaar lovastatin oral tablet 40 Mevacor Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 61

65 Drug Name Reference rand-eneric Notes mannitol intravenous solution 20 % Osmitrol mannitol intravenous solution 25 % matzim la oral tablet extended release 24 hour 180, 240, 300, 360, 420 methyclothiazide oral tablet 5 methyldopa oral tablet 250, 500 methyldopa-hydrochlorothiazide oral tablet , methyldopate hcl intravenous solution 250 /5ml metolazone oral tablet 10, 2.5, 5 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 metoprolol tartrate intravenous solution 5 /5ml metoprolol tartrate intravenous solution cartridge 5 /5ml metoprolol tartrate oral tablet 100, 50 metoprolol tartrate oral tablet 25, 37.5, 75 metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet mexiletine hcl oral capsule 150, 200, 250 midodrine hcl oral tablet 10, 2.5, 5 milrinone lactate in dextrose intravenous solution 20-5 /100ml-%, 40-5 /200ml-% milrinone lactate intravenous solution 10 /10ml, 20 /20ml, 50 /50ml minitran transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr minoxidil oral tablet 10, 2.5 moexipril hcl oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet , 15-25, Cardizem LA Toprol XL Lopressor Lopressor HCT Minitran ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 62

66 Drug Name Reference rand-eneric Notes nadolol oral tablet 20, 40, 80 Corgard nadolol-bendroflumethiazide oral tablet 40-5, 80-5 niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 niacor oral tablet 500 NIASN ORAL TALET EXTENDED RELEASE 1000 M, 500 M, 750 M nicardipine hcl intravenous solution 2.5 /ml nicardipine hcl oral capsule 20, 30 nifedical xl oral tablet extended release 24 hour 60 nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 Corzide Niaspan Niaspan Nifedical XL Adalat CC Procardia XL Nifedical XL nifedipine oral capsule 10 Procardia nifedipine oral capsule 20 nimodipine oral capsule 30 nisoldipine er oral tablet extended release 24 hour 17, 34, 8.5 nisoldipine er oral tablet extended release 24 hour 20, 25.5, 30, 40 nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin in d5w intravenous solution mcg/ml-%, mcg/ml-%, mcg/ml-% nitroglycerin intravenous solution 5 /ml nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray nitroprusside sodium intravenous solution 25 /ml NITROSTAT SULINUAL TALET SULINUAL 0.3 M, 0.4 M, 0.6 M Sular Nitro-Time Nitrostat Minitran ST Nitrolingual Nitropress Nitrostat Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 63

67 Drug Name Reference rand-eneric Notes nitro-time oral capsule extended release 2.5, 6.5, 9 norepinephrine bitartrate intravenous solution 1 /ml norepinephrine-dextrose intravenous solution 4-5 /250ml-%, 4-5 /500ml- % norepinephrine-sodium chloride intravenous solution /250ml-%, /500ml-%, /250ml-%, /250ml-% norepinephrine-sodium chloride intravenous solution prefilled syringe /10ml-%, /10ml- %, /50ml-% NORTHERA ORAL CAPSULE 100 M, 200 M, 300 M olmesartan medoxomil oral tablet 20, 40, 5 olmesartan medoxomil-hctz oral tablet , , olmesartan-amlodipine-hctz oral tablet , , , , omega-3-acid ethyl esters oral capsule 1 gm osmitrol intravenous solution 10 %, 15 %, 5 % Nitro-Time Levophed enicar ST enicar HCT Tribenzor Lovaza osmitrol intravenous solution 20 % Osmitrol pacerone oral tablet 100, 200, 400 papaverine hcl injection solution 30 /ml pentoxifylline er oral tablet extended release 400 perindopril erbumine oral tablet 2, 4, 8 phenoxybenzamine hcl oral capsule 10 phentolamine mesylate injection solution reconstituted 5 phenylephrine hcl injection solution 10 /ml phenylephrine hcl intravenous solution 10 /ml Pacerone Dibenzyline Vazculep Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 64

68 Drug Name Reference rand-eneric Notes phenylephrine hcl-nacl intravenous solution prefilled syringe /50ml- %, /50ml-% pindolol oral tablet 10, 5 pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 prazosin hcl oral capsule 1, 2, 5 Pravachol Minipress prevalite oral packet 4 gm Prevalite prevalite oral powder 4 gm/dose Prevalite procainamide hcl injection solution 100 /ml, 500 /ml propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 propranolol-hctz oral tablet 40-25, quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet , , quinidine gluconate er oral tablet extended release 324 quinidine gluconate injection solution 80 /ml quinidine sulfate oral tablet 200, 300 ramipril oral capsule 1.25, 10, 2.5, 5 RANEXA ORAL TALET EXTENDED RELEASE 12 HOUR 1000 M, 500 M rosuvastatin calcium oral tablet 10, 20, 40, 5 Rythmol SR Inderal LA Accupril Accuretic Altace Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 65 Crestor ST

69 Drug Name Reference rand-eneric Notes simvastatin oral tablet 10, 20, 40, 5 Zocor simvastatin oral tablet 80 Zocor sorine oral tablet 120, 160, 80 etapace sorine oral tablet 240 Sorine sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl intravenous solution 150 /10ml sotalol hcl oral tablet 120, 160, 80 etapace AF etapace sotalol hcl oral tablet 240 Sorine spironolactone oral tablet 100, 25, 50 Aldactone spironolactone-hctz oral tablet Aldactazide taztia xt oral capsule extended release 24 hour 120, 180, 240, 300, 360 telmisartan oral tablet 20, 40, 80 telmisartan-amlodipine oral tablet 40-10, 40-5, 80-10, 80-5 telmisartan-hctz oral tablet , , timolol maleate oral tablet 10, 20, 5 Taztia XT Micardis ST Twynsta Micardis HCT torsemide oral tablet 10, 20 Demadex torsemide oral tablet 100, 5 trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik trandolapril-verapamil hcl er oral tablet extended release trandolapril-verapamil hcl er oral tablet extended release 2-180, 2-240, Tarka triamterene-hctz oral capsule Dyazide triamterene-hctz oral capsule triamterene-hctz oral tablet Maxzide-25 triamterene-hctz oral tablet Maxzide triklo oral capsule 1 gm Lovaza valsartan oral tablet 160, 320, 40, 80 Diovan Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 66

70 Drug Name Reference rand-eneric Notes valsartan-hydrochlorothiazide oral tablet , , , , verapamil hcl er oral capsule extended release 24 hour 100, 200, 300 verapamil hcl er oral capsule extended release 24 hour 120, 180, 240, 360 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl intravenous solution 2.5 /ml Diovan HCT Verelan PM Verelan Calan SR verapamil hcl oral tablet 120, 80 Calan verapamil hcl oral tablet 40 ZETIA ORAL TALET 10 M Zetia Central Nervous System Agents - Drugs for Attention Deficit Disorder amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 clonidine hcl er oral tablet extended release 12 hour 0.1 dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral solution 5 /5ml dextroamphetamine sulfate oral tablet 10, 5 FOCALIN ORAL TALET 10 M, 2.5 M, 5 M guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 Adderall XR Adderall Strattera Kapvay Focalin XR AL (Max 22 Years) Focalin AL (Max 23 Years) Dexedrine ProCentra Zenzedi Focalin AL (Max 23 Years) Intuniv Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 67

71 Drug Name Reference rand-eneric Notes INTUNIV ORAL TALET EXTENDED RELEASE 24 HOUR 1 M, 2 M, 3 M, 4 M metadate er oral tablet extended release 20 Intuniv Metadate ER AL (Max 23 Years) methamphetamine hcl oral tablet 5 Desoxyn methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 10, 20, 30, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 72 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10, 2.5, 5 relexxii oral tablet extended release 72 VYVANSE ORAL CAPSULE 10 M, 20 M, 30 M, 40 M, 50 M, 60 M, 70 M VYVANSE ORAL TALET CHEWALE 10 M, 20 M, 30 M, 40 M, 50 M, 60 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 68 AL (Max 23 Years) Ritalin LA AL (Max 23 Years) AL (Max 23 Years) AL (Max 23 Years) Concerta AL (Max 23 Years) Metadate ER AL (Max 23 Years) AL (Max 23 Years) Relexxii AL (Max 23 Years) Methylin AL (Max 23 Years) Ritalin AL (Max 23 Years) AL (Max 23 Years) Relexxii AL (Max 23 Years) zenzedi oral tablet 10, 5 Zenzedi Central Nervous System Agents - Drugs for Multiple Sclerosis AMPYRA ORAL TALET EXTENDED RELEASE 12 HOUR 10 M Ampyra

72 Drug Name Reference rand-eneric Notes AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MC/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINE KIT 30 MC/0.5ML AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MC ETASERON SUCUTANEOUS KIT 0.3 M dalfampridine er oral tablet extended release 12 hour 10 ST Ampyra EXTAVIA SUCUTANEOUS KIT 0.3 M ILENYA ORAL CAPSULE 0.5 M glatiramer acetate subcutaneous solution prefilled syringe 20 /ml, 40 /ml glatopa subcutaneous solution prefilled syringe 20 /ml, 40 /ml PLERIDY STARTER CK SUCUTANEOUS SOLUTION PEN- INJECTOR 63 & 94 MC/0.5ML PLERIDY STARTER CK SUCUTANEOUS SOLUTION PREFILLED SYRINE 63 & 94 MC/0.5ML PLERIDY SUCUTANEOUS SOLUTION PEN-INJECTOR 125 MC/0.5ML PLERIDY SUCUTANEOUS SOLUTION PREFILLED SYRINE 125 MC/0.5ML REIF REIDOSE SUCUTANEOUS SOLUTION AUTO-INJECTOR 22 MC/0.5ML, 44 MC/0.5ML REIF REIDOSE TITRATION CK SUCUTANEOUS SOLUTION AUTO- INJECTOR 6X8.8 & 6X22 MC REIF SUCUTANEOUS SOLUTION PREFILLED SYRINE 22 MC/0.5ML, 44 MC/0.5ML REIF TITRATION CK SUCUTANEOUS SOLUTION PREFILLED SYRINE 6X8.8 & 6X22 MC Copaxone Copaxone TECFIDERA ORAL 120 & 240 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 69

73 Drug Name Reference rand-eneric Notes TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 M, 240 M TYSARI INTRAVENOUS CONCENTRATE 300 M/15ML ZINRYTA SUCUTANEOUS SOLUTION PREFILLED SYRINE 150 M/ML Central Nervous System Agents - Miscellaneous atracurium besylate intravenous solution 100 /10ml, 50 /5ml ELVIQ ORAL TALET 10 M ELVIQ XR ORAL TALET EXTENDED RELEASE 24 HOUR 20 M benzphetamine hcl oral tablet 25 Regimex benzphetamine hcl oral tablet 50 Didrex caffeine citrate intravenous solution 60 /3ml caffeine citrate oral solution 20 /ml, 60 /3ml caffeine-sodium benzoate injection solution /ml cisatracurium besylate (pf) intravenous solution 10 /5ml, 200 /20ml cisatracurium besylate intravenous solution 20 /10ml CONTRAVE ORAL TALET EXTENDED RELEASE 12 HOUR 8-90 M diethylpropion hcl er oral tablet extended release 24 hour 75 Cafcit Nimbex Nimbex diethylpropion hcl oral tablet 25 LYRICA ORAL CAPSULE 100 M, 150 M, 200 M, 225 M, 25 M, 300 M, 50 M, 75 M pancuronium bromide intravenous solution 1 /ml, 2 /ml phendimetrazine tartrate er oral capsule extended release 24 hour 105 phendimetrazine tartrate oral tablet 35 phentermine hcl oral capsule 15, 30 phentermine hcl oral capsule 37.5 Adipex-P phentermine hcl oral tablet 37.5 Adipex-P Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 70 ST ST

74 Drug Name Reference rand-eneric Notes QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR M, M, M, M RADICAVA INTRAVENOUS SOLUTION 30 M/100ML riluzole oral tablet 50 Rilutek rocuronium bromide intravenous solution 100 /10ml, 50 /5ml SAVELLA ORAL TALET 100 M, 12.5 M, 25 M, 50 M SAVELLA TITRATION CK ORAL 12.5 & 25 & 50 M succinylcholine chloride injection solution 20 /ml Anectine tetrabenazine oral tablet 12.5, 25 Xenazine vecuronium bromide intravenous solution reconstituted 10, 20 XENICAL ORAL CAPSULE 120 M Dental and Oral Agents - Drugs for Mouth and Throat Conditions cavarest dental gel 1.1 % Cavarest cevimeline hcl oral capsule 30 Evoxac chlorhexidine gluconate mouth/throat solution 0.12 % clinpro 5000 dental paste 1.1 % Paroex denta 5000 plus dental cream 1.1 % Denta 5000 Plus dentagel dental gel 1.1 % Cavarest easygel dental gel 0.4 % fluoridex daily renewal mouth/throat concentrate 0.63 % fluoridex dental paste 1.1 % fluoridex enhanced whitening dental paste 1.1 % fluoridex sensitivity relief dental paste % lidocaine hcl mouth/throat solution 4 % lidocaine viscous mouth/throat solution 2 % neutragard advanced dental gel 1.1 % Cavarest neutral sodium fluoride mouth/throat solution 0.2 % numoisyn mouth/throat liquid PreviDent Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 71 ST ST

75 Drug Name Reference rand-eneric Notes oralone mouth/throat paste 0.1 % Oralone paroex mouth/throat solution 0.12 % Paroex periogard mouth/throat solution 0.12 % Paroex phos-flur dental gel 1.1 % Cavarest pilocarpine hcl oral tablet 5, 7.5 Salagen prevident mouth/throat solution 0.2 % PreviDent SALAEN ORAL TALET 5 M, 7.5 M Salagen sf 5000 plus dental cream 1.1 % Denta 5000 Plus sf dental gel 1.1 % Cavarest topex topical anesthetic mouth/throat aerosol 20 % triamcinolone acetonide mouth/throat paste 0.1 % Dermatological Agents - Drugs for Skin Conditions Oralone acitretin oral capsule 10, 25 Soriatane acitretin oral capsule 17.5 acne medication 5 external gel 5 % adapalene external cream 0.1 % Differin adapalene external gel 0.1 %, 0.3 % Differin adapalene-benzoyl peroxide external gel % alevicyn dermal spray external solution Epiduo ammonium lactate external cream 12 % eri-hydrolac 12 ammonium lactate external lotion 12 % AL12 amnesteem oral capsule 10, 20, 40 arzol silver nit applicators external % Absorica avar cleanser external emulsion 10-5 % Avar Cleanser avar-e emollient external cream 10-5 % Avar-e Emollient avar-e green external cream 10-5 % Avar-e Emollient avita external cream % Avita avita external gel % Avita beau rx external gel Celacyn benzepro creamy wash external liquid 7 % enzepro Creamy Wash benzepro external foam 5.3 % enzefoam Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 72 QL (90 M per 31

76 Drug Name Reference rand-eneric Notes benzepro foaming cloths external 6 % benzepro short contact external foam 9.8 % benziq wash external liquid 5.25 % benzoin compound external tincture benzoin external tincture enzepro Foaming Cloths enzefoamultra Steri-Strip Compound enzoin benzoyl peroxide external foam 9.8 % enzefoamultra benzoyl peroxide external gel 5 % benzoyl peroxide-erythromycin external gel 5-3 % bp 10-1 external emulsion 10-1 % bp cleansing wash external emulsion 10-4 % enzamycin bp foam external foam 5.3 % enzefoam bp foam external foam 9.8 % enzefoamultra bp foaming wash external liquid 10 % PanOxyl Wash bp gel external gel 5 % bp wash external liquid 2.5 % PanOxyl bp wash external liquid 7 % enzepro Creamy Wash bpo foaming cloths external 6 % enzepro Foaming Cloths calcipotriene external cream % Dovonex calcipotriene external ointment % Calcitrene calcipotriene external solution % calcipotriene-betameth diprop ointment % external % calcipotriene-betameth diprop ointment % external % Taclonex Taclonex calcitrene external ointment % Calcitrene calcitriol external ointment 3 mcg/gm Vectical CARAC EXTERNAL CREAM 0.5 % Carac celacyn external gel Celacyn cem-urea external solution 45 % ceramax external cream cerisa wash external emulsion 10-1 % cerovel external lotion 40 % Cerovel Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 73 QL (90 M per 31 QL (90 M per 31

77 Drug Name Reference rand-eneric Notes claravis oral capsule 10, 20, 30, 40 Absorica clindacin etz external swab 1 % Cleocin-T clindacin-p external swab 1 % Cleocin-T clindamycin phos-benzoyl perox external gel % clindamycin phosphate-benzoyl peroxide external gel 1-5 % Duac enzaclin clindamycin phosphate external foam 1 % Evoclin clindamycin phosphate external gel 1 % Cleocin-T clindamycin phosphate external lotion 1 % Cleocin-T clindamycin phosphate external solution 1 % Cleocin-T clindamycin phosphate external swab 1 % Cleocin-T clindamycin-tretinoin external gel % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % coal tar external solution 20 % Veltin Lotrisone dapsone external gel 5 % Aczone dermazene external cream 1-1 % Dermazene diab external gel diab f.d.g. freeze-dried external gel diclofenac sodium transdermal gel 3 % doxepin hcl external cream 5 % Prudoxin doxycycline oral capsule delayed release 40 dritho-creme hp external cream 1 % Oracea ELIDEL EXTERNAL CREAM 1 % EPIDUO FORTE EXTERNAL EL % ery external pad 2 % erythromycin external gel 2 % Erygel erythromycin external pad 2 % erythromycin external solution 2 % EUCRISA EXTERNAL OINTMENT 2 % FINACEA EXTERNAL FOAM 15 % ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 74

78 Drug Name Reference rand-eneric Notes FINACEA EXTERNAL EL 15 % ST FLUOROURACIL EXTERNAL CREAM 0.5 % Carac fluorouracil external cream 5 % Efudex fluorouracil external solution 2 %, 5 % glycolic acid solution 70 % halac external kit 0.05 & 12 % hydrocortisone ace-pramoxine external cream % hydrocortisone-iodoquinol external cream 1-1 % Pramosone Dermazene imiquimod external cream 5 % Aldara iodoquinol-hydrocortisone-aloe external cream % isotretinoin oral capsule 10, 20, 30, 40 lactic acid e external cream %- unt/30gm lactic acid external lotion 10 % latrix external suspension 50 % latrix xm external emulsion 45 % levicyn dermal spray external solution lidocaine-hydrocortisone ace external cream 1-1 % luxamend external cream methoxsalen oral capsule 10 Vytone Absorica methoxsalen rapid oral capsule 10 Oxsoralen Ultra methyl salicylate external liquid metopic external cream 41 % MeTopic metronidazole external cream 0.75 % MetroCream metronidazole external gel 0.75 % Rosadan metronidazole external gel 1 % Metrogel metronidazole external lotion 0.75 % MetroLotion MIRVASO EXTERNAL EL 0.33 % myorisan oral capsule 10, 20, 30, 40 Absorica neuac external gel % Duac podocon external solution 25 % podofilox external solution 0.5 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 75

79 Drug Name Reference rand-eneric Notes pr benzoyl peroxide wash external liquid 7 % pramox external gel 1 % prutect external emulsion pyrogallic acid external ointment 25-2 % radiagel external gel enzepro Creamy Wash rea lo 39 external cream 39 % Uredeb rea lo 40 external cream 40 % Rea Lo 40 rea lo 40 external lotion 40 % Cerovel recedo external gel Celacyn remeven external cream 50 % restizan external gel Celacyn RETIN-A EXTERNAL CREAM % Avita RETIN-A EXTERNAL CREAM 0.05 %, 0.1 % Retin-A rosadan external cream 0.75 % MetroCream rosadan external gel 0.75 % Rosadan rosanil cleanser external emulsion 10-5 % Avar Cleanser salacyn external cream 6 % salacyn external lotion 6 % salicylic acid er external solution 28.5 % UltraSal-ER salicylic acid external cream 6 % salicylic acid external foam 6 % Salvax salicylic acid external gel 6 % Keralyt salicylic acid external liquid 26 % salicylic acid external liquid 27.5 % Virasal salicylic acid external lotion 6 % salicylic acid external shampoo 6 % Salex salicylic acid external solution 26 % salicylic acid wart remover external liquid 27.5 % salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion) salimez external cream 6 % salisol forte external solution 26 % salitech forte external lotion 6 % Virasal Salex salvax external foam 6 % Salvax seb-prev wash external liquid 10 % Ovace Plus Wash Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 76

80 Drug Name Reference rand-eneric Notes selenium sulfide external lotion 2.5 % selenium sulfide external shampoo 2.25 % selenium sulfide external shampoo 2.3 % SelRx selenium sulf-pyrithione-urea external shampoo 2.25 % sodium hyaluronate external gel 0.2 % Hylira sodium sulfacetamide external shampoo 10 % sonafine external emulsion Ovace Plus SOOLANTRA EXTERNAL CREAM 1 % sss 10-5 external cream 10-5 % Avar-e Emollient sss 10-5 external foam 10-5 % sulfacetamide sodium (acne) external lotion 10 % sulfacetamide sodium external gel 10 % (cleans) Klaron ST Ovace Plus Wash sulfacetamide sodium external liquid 10 % Ovace Plus Wash sulfacetamide sodium-sulfur external cream 10-2 % sulfacetamide sodium-sulfur external cream 10-5 % sulfacetamide sodium-sulfur external cream % sulfacetamide sodium-sulfur external emulsion 10-5 % sulfacetamide sodium-sulfur external liquid 10-2 % sulfacetamide sodium-sulfur external liquid % sulfacetamide sodium-sulfur external liquid 9-4 % sulfacetamide sodium-sulfur external liquid % sulfacetamide sodium-sulfur external lotion 10-5 % sulfacetamide sodium-sulfur external lotion % sulfacetamide sodium-sulfur external pad 10-4 % sulfacetamide sodium-sulfur external suspension 10-5 % Avar-e LS Avar-e Emollient Plexion Avar Cleanser Avar LS Cleanser Plexion Cleanser Sumaxin Wash Sumadan Wash Plexion Sumaxin Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 77

81 Drug Name Reference rand-eneric Notes sulfacetamide sodium-sulfur external suspension 8-4 % sulfacetamide sod-sulfur wash external kit % sulfacetamide-sulfur in urea external emulsion 10-5 % sulfacetamide-sulfur-sunscreen external kit % sulfacleanse 8/4 external suspension 8-4 % sulfamez wash external emulsion 10-1 % tacrolimus external ointment 0.03 %, 0.1 % SulfaCleanse 8/4 Sumadan Sumadan XLT SulfaCleanse 8/4 Protopic tazarotene external cream 0.1 % Tazorac TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL CREAM 0.1 % Tazorac TAZORAC EXTERNAL EL 0.05 %, 0.1 % tetrix external cream tretinoin external cream % Avita tretinoin external cream 0.05 %, 0.1 % Retin-A tretinoin external gel 0.01 % Retin-A tretinoin external gel % Avita tretinoin external gel 0.05 % Atralin tretinoin microsphere external gel 0.04 %, 0.1 % tretinoin microsphere pump external gel 0.04 %, 0.1 % TRETIN-X EXTERNAL CREAM % turpentine external spirit umecta mousse external foam 40 % uramaxin external foam 20 % RETIN-A MICRO EL 0.04 %, 0.1 % RETIN-A MICRO EL 0.04 %, 0.1 % urea external cream 39 % Uredeb urea external cream 40 % Rea Lo 40 urea external cream 41 % MeTopic urea external cream 45 %, 50 % urea external cream 47 % Keralac urea external emulsion 50 % urea external lotion 40 % Cerovel urea external lotion 45 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 78

82 Drug Name Reference rand-eneric Notes urea external suspension 40 %, 50 % urea hydrating external foam 35 % Hydro 35 urea in zn undecyl-lactic acid external emulsion 50 % urea nail external gel 45 % Uramaxin urea nail external kit 40 & 0.2 % urea-c40 external lotion 40 % Cerovel uredeb external cream 39 % Uredeb ure-k external cream 50 % uremez-40 external cream 40 % Rea Lo 40 vashe cleansing external solution VECTICAL EXTERNAL OINTMENT 3 MC/M zaclir cleansing external lotion 8 % zenatane oral capsule 10, 20, 30, 40 Vectical Absorica zencia external liquid 9-4 % Sumaxin Wash Diabetes - Antidiabetic Agents acarbose oral tablet 100, 25, 50 ACTOPLUS MET ORAL TALET M, M ADLYXIN SUCUTANEOUS SOLUTION PEN-INJECTOR 20 MC/0.2ML YDUREON CISE AUTOINJECTOR SUCUTANEOUS AUTO-INJECTOR 2 M/0.85ML YDUREON SUCUTANEOUS PEN- INJECTOR 2 M YDUREON SUCUTANEOUS SUSPENSION RECONSTITUTED ER 2 M YETTA 10 MC PEN SUCUTANEOUS SOLUTION PEN- INJECTOR 10 MC/0.04ML YETTA 5 MC PEN SUCUTANEOUS SOLUTION PEN-INJECTOR 5 MC/0.02ML chlorpropamide oral tablet 100, 250 Precose Actoplus Met ST FARXIA ORAL TALET 10 M, 5 M ST ST ST ST ST ST ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 79

83 Drug Name Reference rand-eneric Notes FORTAMET ORAL TALET EXTENDED RELEASE 24 HOUR 1000 M, 500 M Fortamet glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 lucotrol XL glipizide oral tablet 10, 5 lucotrol glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glipizide-metformin hcl oral tablet , , LUCOPHAE ORAL TALET 1000 M, 500 M, 850 M LUMETZA ORAL TALET EXTENDED RELEASE 24 HOUR 1000 M, 500 M glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet , , LYXAMI ORAL TALET 10-5 M, 25-5 M INVOKAMET ORAL TALET M, M, M, M INVOKAMET XR ORAL TALET EXTENDED RELEASE 24 HOUR M, M, M, M INVOKANA ORAL TALET 100 M, 300 M JANUMET ORAL TALET M, M JANUMET XR ORAL TALET EXTENDED RELEASE 24 HOUR M, M, M JANUVIA ORAL TALET 100 M, 25 M, 50 M JARDIANCE ORAL TALET 10 M, 25 M metformin hcl er (mod) oral tablet extended release 24 hour 1000, 500 lucotrol XL lucophage lumetza lynase ST ST ST ST ST ST ST ST lumetza Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 80

84 Drug Name Reference rand-eneric Notes metformin hcl er (osm) oral tablet extended release 24 hour 1000, 500 metformin hcl er oral tablet extended release 24 hour 500, 750 METFORMIN HCL ORAL SOLUTION 500 M/5ML metformin hcl oral tablet 1000, 500, 850 Fortamet lucophage XR Riomet lucophage miglitol oral tablet 100, 25, 50 lyset nateglinide oral tablet 120, 60 Starlix ONLYZA ORAL TALET 2.5 M, 5 M ST pioglitazone hcl oral tablet 15, 30, 45 pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet , repaglinide oral tablet 0.5 Actos ST Duetact ST Actoplus Met ST repaglinide oral tablet 1, 2 Prandin repaglinide-metformin hcl oral tablet 1-500, RIOMET ORAL SOLUTION 500 M/5ML Riomet SOLIQUA SUCUTANEOUS SOLUTION PEN-INJECTOR UNT-MC/ML STELATRO ORAL TALET 15 M, 5 M STELUJAN ORAL TALET M, M SYMLINPEN 120 SUCUTANEOUS SOLUTION PEN-INJECTOR 2700 MC/2.7ML SYMLINPEN 60 SUCUTANEOUS SOLUTION PEN-INJECTOR 1500 MC/1.5ML SYNJARDY ORAL TALET M, M, M, M SYNJARDY XR ORAL TALET EXTENDED RELEASE 24 HOUR M, M, M, M TANZEUM SUCUTANEOUS PEN- INJECTOR 30 M, 50 M tolazamide oral tablet 250, 500 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 81 ST ST ; QL (8 ML per 30 ; QL (8 ML per 30 ST ST ST

85 Drug Name Reference rand-eneric Notes tolbutamide oral tablet 500 TRULICITY SUCUTANEOUS SOLUTION PEN-INJECTOR 0.75 M/0.5ML, 1.5 M/0.5ML VICTOZA SUCUTANEOUS SOLUTION PEN-INJECTOR 18 M/3ML XIDUO XR ORAL TALET EXTENDED RELEASE 24 HOUR M, M, M, M, M Diabetes - lucose Monitoring ACCU-CHEK FASTCLIX LANCETS ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SOFT TOUCH LANCETS ACCU-CHEK SOFTCLIX LANCETS FREESTYLE FREEDOM LITE KIT W/DEVICE FREESTYLE INSULINX SYSTEM KIT W/DEVICE FREESTYLE INSULINX TEST IN VITRO STRIP LANCETS PRECISION XTRA LOOD LUCOSE IN VITRO STRIP PRECISION XTRA DEVICE PRECISION XTRA KETONE IN VITRO STRIP Diabetes - lycemic Agents LUCAEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 M LUCAON EMERENCY INJECTION KIT 1 M Diabetes - Insulins ADMELO SOLOSTAR SUCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML ADMELO SUCUTANEOUS SOLUTION 100 UNIT/ML Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 82 ST ST ST QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (100 EA per 31 QL (100 EA per 31 QL (100 EA per 31 QL (200 EA per 31 QL (100 EA per 31 QL (100 EA per 31 QL (100 EA per 31 ; QL (1 EA per 365

86 Drug Name Reference rand-eneric Notes AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 (30) & 8 (60) UNIT, 4 (60) & 8 (30) UNIT, 4 (90) & 8 (90) UNIT, 4 UNIT, 8 (60)& 12 (30) UNIT, 8 UNIT APIDRA SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML ASSURE ID SAFETY PEN NEEDLES 30 X 5 MM ASSURE ID SAFETY PEN NEEDLES 30 X 8 MM ASSURE ID SAFETY PEN NEEDLES 31 X 5 MM ASALAR KWIKPEN SUCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML DROPLET INSULIN SYRINE 30 X 1/2" 0.3 ML, 30 X 1/2" 0.5 ML, 30 X 1/2" 1 ML DROPLET INSULIN SYRINE 30 X 15/64" 0.3 ML, 30 X 15/64" 0.5 ML, 30 X 15/64" 1 ML DROPLET INSULIN SYRINE 30 X 5/16" 0.3 ML DROPLET INSULIN SYRINE 30 X 5/16" 0.5 ML, 30 X 5/16" 1 ML, 31 X 5/16" 0.3 ML, 31 X 5/16" 1 ML DROPLET INSULIN SYRINE 31 X 15/64" 0.3 ML, 31 X 15/64" 0.5 ML, 31 X 15/64" 1 ML DROPLET INSULIN SYRINE 31 X 5/16" 0.5 ML FIASP FLEXTOUCH SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP SUCUTANEOUS SOLUTION 100 UNIT/ML Assure ID Safety Pen Needles HUMALO U-100 AND U-200 KWIKPEN HUMALO MIX 50/50 KWIKPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (225 ML per 90 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 83

87 Drug Name Reference rand-eneric Notes HUMALO MIX 50/50 VIAL SUCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALO MIX 75/25 KWIKPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALO MIX 75/25 VIAL SUCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALO U-100 JUNIOR KWIKPEN SUCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALO U-100 VIAL AND CARTRIDE SUCUTANEOUS SOLUTION 100 UNIT/ML HUMALO U-100 VIAL AND CARTRIDE SUCUTANEOUS SOLUTION CARTRIDE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 VIAL SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR 100 UNIT/ML HUMULIN N VIAL SUCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R U-500 KWIKPEN SUCUTANEOUS SOLUTION PEN- INJECTOR 500 UNIT/ML HUMULIN R U-500 VIAL (CONCENTRATED) SUCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML INSULIN PEN NEEDLES 29 X 12.7MM INSULIN PEN NEEDLES 30 X 8 MM INSULIN PEN NEEDLES 31 X 5 MM Assure ID Safety Pen Needles INSULIN PEN NEEDLES 31 X 6 MM CareFine Pen Needles INSULIN PEN NEEDLES 31 X 8 MM Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 84 QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31

88 Drug Name Reference rand-eneric Notes INSULIN PEN NEEDLES 32 X 4 MM INSULIN PEN NEEDLES 33 X 4 MM INSULIN SYRINES 28 X 1/2" 1 ML, 29 X 1/2" 1 ML INSULIN SYRINES 30 X 1/2" 0.5 ML INSULIN SYRINES 31 X 15/64" 0.3 ML, 31 X 15/64" 0.5 ML INSULIN SYRINES 31 X 5/16" 0.3 ML, 31 X 5/16" 1 ML INSULIN SYRINES 31 X 5/16" 0.5 ML LANTUS SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS U-100 VIAL SUCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR U-100 FLEXTOUCH SUCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LEVEMIR U-100 VIAL SUCUTANEOUS SOLUTION 100 UNIT/ML NOVOFINE AUTOCOVER PEN NEEDLE 30 X 8 MM NOVOFINE PEN NEEDLE 32 X 6 MM NOVOFINE PLUS PEN NEEDLE 32 X 4 MM NOVOLIN 70/30 RELION SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 VIAL SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N VIAL SUCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML Advocate Insulin Pen Needles Assure ID Safety Pen Needles QL (200 EA per 31 QL (200 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (200 EA per 31 QL (200 EA per 31 QL (200 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 85

89 Drug Name Reference rand-eneric Notes NOVOLO FLEXPEN SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLO MIX 70/30 FLEXPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLO MIX 70/30 VIAL SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLO PENFILL SUCUTANEOUS SOLUTION CARTRIDE 100 UNIT/ML NOVOLO U-100 VIAL SUCUTANEOUS SOLUTION 100 UNIT/ML NOVOTWIST PEN NEEDLE 32 X 5 MM PRO COMFORT INSULIN SYRINE 30 X 1/2" 0.5 ML, 30 X 1/2" 1 ML PRO COMFORT INSULIN SYRINE 30 X 5/16" 0.5 ML, 30 X 5/16" 1 ML, 31 X 5/16" 1 ML TOUJEO MAX SOLOSTAR SUCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIA FLEXTOUCH SUCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML Electrolytes / Minerals / Metals / Vitamins abaneu-sl sublingual tablet sublingual mcg airavite oral tablet Airavite alcohol intravenous solution 98 % AMINO ACID INTRAVENOUS SOLUTION 10 % aminoam rms oral capsule aminobenzoate potassium oral packet 2 gm aminorelief rms oral capsule AMINOSYN II INTRAVENOUS SOLUTION 10 % Aminosyn Aminosyn QL (200 EA per 31 QL (110 EA per 31 QL (110 EA per 31 QL (225 ML per 90 QL (225 ML per 90 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 86

90 Drug Name Reference rand-eneric Notes aminosyn ii/electrolytes intravenous solution 8.5 % AMINOSYN INTRAVENOUS SOLUTION 10 % aminosyn/electrolytes intravenous solution 8.5 % AMINOSYN-PF INTRAVENOUS SOLUTION 10 % argyle sterile saline irrigation solution 0.9 % ascorbic acid injection solution 500 /ml av-phos 250 neutral oral tablet Aminosyn Aminosyn Argyle Sterile Saline K-Phos-Neutral av-vite fb oral tablet Airavite b complex vitamins injection solution b-6 folic acid oral capsule mcg-mcg- bd posiflush intravenous solution 0.9 % D PosiFlush biocel oral tablet AC Plus Senior bp vit 3 oral capsule 1 Taliva b-plex oral tablet Milco--Forte b-plex plus oral tablet AC Plus Senior calcium chloride intravenous solution 10 % calcium gluconate intravenous solution 10 % calcium gluconate-dextrose intravenous solution 1-5 gm/100ml-%, 1-5 gm/50ml-%, 2-5 gm/100ml-% calcium gluconate-nacl intravenous solution gm/100ml-%, gm/100ml-%, gm/50ml-%, gm/100ml-% calcium gluconate-nacl intravenous solution prefilled syringe gm/50ml-% calcium-folic acid plus d oral wafer cardioplegic perfusion solution Plegisol CHEMET ORAL CAPSULE 100 M chloromag injection solution 200 /ml chromagen oral capsule Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 87

91 Drug Name Reference rand-eneric Notes chromic chloride intravenous solution 40 mcg/10ml CITRANATAL MEDLEY ORAL CAPSULE M clinimix e/dextrose (4.25/25) intravenous solution 4.25 % clinimix/dextrose (4.25/10) intravenous solution 4.25 % clinimix/dextrose (4.25/20) intravenous solution 4.25 % clinimix/dextrose (4.25/25) intravenous solution 4.25 % clinisol sf intravenous solution 15 % cod liver oil oral oil copper chloride intravenous solution 0.4 /ml corvita 150 oral tablet corvita oral tablet 1.25 corvite free oral tablet AC Plus Senior curity sterile saline irrigation solution 0.9 % cyanocobalamin injection solution 1000 mcg/ml Argyle Sterile Saline cytra k crystals oral packet Taron-Crystals dehydrated alcohol intravenous solution 98 % dexifol oral tablet 5 Dexifol dextrose in lactated ringers intravenous solution 5 % dextrose intravenous solution 10 %, 20 %, 250 /ml, 30 %, 40 %, 5 %, 50 %, 70 % dextrose-nacl intravenous solution %, %, %, %, %, %, %, %, %, % dialyvite oral tablet Dialyvite effer-k oral tablet effervescent 25 meq Effer-K effervescent pot chloride oral tablet effervescent 25 meq ergocalciferol oral capsule unit Drisdol EXJADE ORAL TALET SOLULE 125 M, 250 M, 500 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 88 ST

92 Drug Name Reference rand-eneric Notes fabb oral tablet Folgard RX fa-vitamin b-6-vitamin b-12 oral tablet ferocon oral capsule Tricon ferosul oral elixir 220 (44 fe) /5ml FeroSul ferotrinsic oral capsule Tricon ferraplus 90 oral tablet 90-1 ferrocite plus oral tablet Ferrocite Plus ferrous sulfate oral elixir 220 (44 fe) /5ml ferrous sulfate oral liquid 220 (44 fe) /5ml ferrous sulfate oral tablet delayed release 325 (65 fe) floriva oral tablet chewable 0.25 FeroSul floriva plus oral solution 0.25 /ml Floriva Plus fluor-a-day oral solution (0.125 f) /drop fluoritab oral solution (0.125 f) /drop fluoritab oral tablet chewable 0.55 (0.25 f), 1.1 (0.5 f), 2.2 (1 f) NaFrinse Drops NaFrinse Drops Ludent folbee oral tablet Airavite folbee plus cz oral tablet 5 folbee plus oral tablet Dexifol folic acid injection solution 5 /ml folic acid oral tablet 1 folplex 2.2 oral tablet foltrin oral capsule Tricon FREAMINE III INTRAVENOUS SOLUTION 10 % glucose intravenous solution 5 % hematinic plus vit/minerals oral tablet Aminosyn Ferrocite Plus hematinic/folic acid oral tablet Hemocyte-F hematogen fa oral capsule hematogen forte oral capsule hematogen oral capsule Hematogen Forte Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 89 QL (480 ML per 31 QL (480 ML per 31 QL (480 ML per 31 QL (100 EA per 31

93 Drug Name Reference rand-eneric Notes hemocyte-f oral tablet Hemocyte-F hemocyte-plus oral tablet Ferrocite Plus hepatamine intravenous solution 8 % hydroxocobalamin intramuscular solution 1000 mcg/ml hyperlyte-cr intravenous solution iferex 150 forte oral capsule mcg- infuvite adult intravenous injectable infuvite pediatric intravenous solution iferex 150 Forte intralipid intravenous emulsion 20 % Intralipid INTRALIPID INTRAVENOUS EMULSION 30 % iodine strong oral solution 5 % JYNARQUE ORAL TALET THERAPY CK 45 & 15 M, 60 & 30 M, 90 & 30 M kcl in d5w lactated ringers intravenous solution 40 meq/l kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%- %, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l kcl-lidocaine in d5w intravenous solution meq- /100ml k-effervescent oral tablet effervescent 25 meq klor-con 10 oral tablet extended release 10 meq klor-con m10 oral tablet extended release 10 meq klor-con m20 oral tablet extended release 20 meq Effer-K K-Tab Klor-Con M10 Klor-Con M20 klor-con oral packet 20 meq Klor-Con klor-con oral tablet extended release 8 meq klor-con sprinkle oral capsule extended release 10 meq, 8 meq K-Tab klor-con/ef oral tablet effervescent 25 meq Effer-K Klor-Con Sprinkle Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 90

94 Drug Name Reference rand-eneric Notes k-prime oral tablet effervescent 25 meq Effer-K k-tan plus oral capsule K-Tan Plus k-vescent oral tablet effervescent 25 meq Effer-K lactated ringers intravenous solution lecithin oral granules levocarnitine oral solution 1 gm/10ml Carnitor levocarnitine oral tablet 330 Carnitor l-methylfolate ca me-cbl nac oral tablet l-methylfolate formula 15 oral capsule l-methylfolate forte oral capsule l-methylfolate-algae oral capsule l-methylfolate-algae-b12-b6 oral capsule l-methylfolate-b6-b12 oral tablet l-methylfolate-b6-b12 oral tablet ludent oral tablet chewable 0.55 (0.25 f), 1.1 (0.5 f), 2.2 (1 f) Cerefolin NAC Deplin 15 Deplin 15 Deplin 15 Foltanx RF Folbic RF Foltanx Ludent lysiplex plus oral tablet AC Plus Senior magnesium chloride injection solution 200 /ml magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%, 2-5 gm/100ml- %, 3-5 gm/50ml-% magnesium sulfate injection solution 50 % magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml magnesium sulfate-lact ringers intravenous solution 20 gm/250ml magnesium sulfate-nacl intravenous solution gm/50ml-%, gm/100ml-%, gm/l-%, gm/150ml-% manganese chloride intravenous solution 0.1 /ml manganese sulfate intravenous solution 0.1 /ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 91

95 Drug Name Reference rand-eneric Notes mega-c/a plus injection solution 500 /ml metafolbic plus rf oral tablet methylfol-algae-b12-acetylcyst oral tablet monoject flush syringe intravenous solution 0.9 % monoject sodium chloride flush intravenous solution 0.9 % multi vitamin/fluoride oral tablet chewable 0.25, 1 multigen folic oral tablet multigen oral tablet 70 multigen plus oral tablet multitrace-4 concentrate intravenous solution /ml multitrace-4 intravenous solution mcg/ml multitrace-4 neonatal intravenous solution mcg/ml multitrace-5 concentrate intravenous solution mcg/ml multitrace-5 intravenous solution mcg/ml Cerefolin NAC Cerefolin NAC D PosiFlush D PosiFlush MVC-Fluoride multi-vit/fluoride oral solution 0.25 /ml Floriva Plus multi-vit/fluoride oral solution 0.5 /ml Quflora Pediatric multi-vit/fluoride/iron oral solution /ml multi-vit/iron/fluoride oral solution /ml multivitamin/fluoride oral solution 0.25 /ml multi-vitamin/fluoride oral solution 0.25 /ml multivitamin/fluoride oral solution 0.5 /ml multi-vitamin/fluoride oral solution 0.5 /ml multivitamin/fluoride oral tablet chewable 0.25, 0.5, 1 multivitamin/fluoride/iron oral solution /ml Floriva Plus Floriva Plus Quflora Pediatric Quflora Pediatric MVC-Fluoride Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 92

96 Drug Name Reference rand-eneric Notes multi-vitamin/fluoride/iron oral solution /ml multivitamins/fluoride oral tablet chewable 0.5 MVC-Fluoride mvc-fluoride oral tablet chewable 0.25 MVC-Fluoride mvc-fluoride oral tablet chewable 0.5 MVC-Fluoride mvc-fluoride oral tablet chewable 1 MVC-Fluoride myferon 150 forte oral capsule mcg- iferex 150 Forte mynephrocaps oral capsule 1 Mynephron mynephron oral capsule 1 Mynephron na ferric gluc cplx in sucrose intravenous solution 12.5 /ml Ferrlecit n-acetyl-l-cysteine oral capsule 600 NF Formulas NAC nafrinse drops oral solution (0.125 f) /drop nafrinse oral tablet chewable 2.2 (1 f) Ludent NEONATAL VITAMIN ORAL TALET M NaFrinse Drops nephronex oral tablet Dialyvite normal saline flush intravenous solution 0.9 % normosol-m in d5w intravenous solution normosol-r in d5w intravenous solution normosol-r intravenous solution D PosiFlush nufol oral tablet Airavite nutricap oral tablet AC Plus Senior nutrifac zx oral tablet AC Plus Senior nutrilipid intravenous emulsion 20 % Intralipid nutrilyte intravenous concentrate TPN Electrolytes ortho-cs 250 injection solution 250 /ml phospha 250 neutral oral tablet K-Phos-Neutral phosphorous oral tablet K-Phos-Neutral phospho-trin 250 neutral oral tablet phytonadione injection solution 1 /0.5ml K-Phos-Neutral phytonadione oral tablet 5 Mephyton plenamine intravenous solution 15 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 93 QL (100 EA per 31

97 Drug Name Reference rand-eneric Notes PNV PRENATAL PLUS MULTIVIT+DHA ORAL 27-1 & 312 M poly-iron 150 forte oral capsule mcg- polysaccharide iron forte oral capsule mcg- pot bicarb-pot chloride oral tablet effervescent 25 meq potassium acetate intravenous solution 2 meq/ml potassium bicarbonate oral tablet effervescent 25 meq potassium chloride crys er oral tablet extended release 10 meq potassium chloride crys er oral tablet extended release 20 meq potassium chloride er oral capsule extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 10 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 10 meq/100ml, meq/l-%, meq/l-%, 30 meq/100ml, meq/l-% potassium chloride intravenous solution 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml potassium chloride intravenous solution 2 meq/ml iferex 150 Forte iferex 150 Forte Effer-K Klor-Con M10 Klor-Con M20 Klor-Con Sprinkle K-Tab Potassium Chloride PROAMP potassium chloride oral packet 20 meq Klor-Con potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) potassium chloride proamp intravenous solution 2 meq/ml potassium citrate er oral tablet extended release 10 meq (1080 ) potassium citrate er oral tablet extended release 15 meq (1620 ) potassium citrate er oral tablet extended release 5 meq (540 ) Potassium Chloride PROAMP Urocit-K 10 Urocit-K 15 Urocit-K 5 ST; QL (100 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 94

98 Drug Name Reference rand-eneric Notes potassium citrate-citric acid oral packet potassium citrate-citric acid oral solution /5ml potassium phosphates intravenous solution 15 mmole/5ml, 150 mmole/50ml, 45 mmole/15ml PREMASOL INTRAVENOUS SOLUTION 10 % premasol intravenous solution 6 % PREMESISRX ORAL TALET 1 M PRENATAL MULTI +DHA ORAL CAPSULE M PRENATAL MULTI +DHA ORAL CAPSULE M, M PRENATAL PLUS IRON ORAL TALET 29-1 M purevit dualfe plus oral capsule pyridoxine hcl injection solution 100 /ml Taron-Crystals Aminosyn Prenatabs Rx K-Tan Plus quflora pediatric oral solution 0.25 /ml Floriva Plus quflora pediatric oral solution 0.5 /ml Quflora Pediatric quflora pediatric oral tablet chewable 0.25 quflora pediatric oral tablet chewable 0.5 quflora pediatric oral tablet chewable 1 MVC-Fluoride MVC-Fluoride MVC-Fluoride ra iron oral tablet 325 (65 fe) FeroSul RELNATE DHA ORAL CAPSULE M Viva DHA renal oral capsule 1 Mynephron ringers intravenous solution saline flush intravenous solution 0.9 % D PosiFlush saline flush zr intravenous solution 0.9 % D PosiFlush selenium intravenous solution 40 mcg/ml se-tan plus oral capsule K-Tan Plus siderol oral tablet AC Plus Senior Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 95 ST; QL (100 EA per 31 QL (100 EA per 31 ST; QL (100 EA per 31 QL (100 EA per 31 ST; QL (100 EA per 31

99 Drug Name Reference rand-eneric Notes sod citrate-citric acid oral solution /5ml sodium acetate intravenous solution 2 meq/ml, 4 meq/ml sodium ascorbate injection solution 250 /ml sodium bicarbonate intravenous solution 4.2 %, 7.5 %, 8.4 % sodium chloride flush intravenous solution 0.9 % sodium chloride injection solution 0.9 %, 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 4 meq/ml, 5 % Shohls Modified D PosiFlush sodium chloride irrigation solution 0.9 % Argyle Sterile Saline sodium fluoride oral solution 1.1 (0.5 f) /ml sodium fluoride oral tablet 1.1 (0.5 f), 2.2 (1 f) sodium fluoride oral tablet chewable 0.55 (0.25 f), 1.1 (0.5 f), 2.2 (1 f) sodium lactate intravenous solution 5 meq/ml sodium phosphate-nacl intravenous solution 15 mmol/250ml sodium phosphates intravenous solution 15 mmole/5ml, 45 mmole/15ml Ludent strovite forte oral tablet AC Plus Senior swabflush saline flush intravenous solution 0.9 % SYNTHAMIN 17 INTRAVENOUS SOLUTION 10 % tandem f oral capsule D PosiFlush Aminosyn taron-crystals oral packet Taron-Crystals thiamine hcl injection solution 100 /ml tl gard rx oral tablet Folgard RX tl icon oral capsule Tricon tl-hem 150 oral tablet Abatron AF tpn electrolytes intravenous solution TPN Electrolytes TRAVASOL INTRAVENOUS SOLUTION 10 % Aminosyn Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 96

100 Drug Name Reference rand-eneric Notes tricitrates oral solution /5ml tricon oral capsule Tricon trigels-f forte oral capsule Hematogen Forte triphrocaps oral capsule 1 Mynephron tri-vit/fluoride oral solution 0.25 /ml, 0.5 /ml tri-vit/fluoride/iron oral solution /ml tri-vitamin/fluoride oral solution 0.25 /ml, 0.5 /ml tronvite oral tablet 1 Dialyvite TROPHAMINE INTRAVENOUS SOLUTION 10 % tryptophan oral capsule 500 Aminosyn urosex oral tablet Allerwell Allergy Formula v-c forte oral capsule ActivNutrients vic-forte oral capsule ActivNutrients virt-caps oral capsule 1 Mynephron virt-gard oral tablet Folgard RX virt-phos 250 neutral oral tablet K-Phos-Neutral virtrate-2 oral solution /5ml Shohls Modified virtrate-3 oral solution /5ml virtrate-k oral solution /5ml virt-vite oral tablet Airavite virt-vite plus oral tablet 5 Dexifol vit b12-methionine-inos-chol intramuscular solution vita s forte oral tablet AC Plus Senior vitacel oral tablet AC Plus Senior vitamax pediatric oral solution vitamin b complex 100 injection injectable vitamin b-6 oral tablet 100 QL (2 EA per 1 day) vitamin b-complex 100 injection injectable vitamin d (ergocalciferol) oral capsule unit Drisdol Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 97

101 Drug Name Reference rand-eneric Notes vitamin k1 injection solution 1 /0.5ml, 10 /ml vita-min oral capsule ActivNutrients vitamins acd-fluoride oral solution 0.25 /ml vp-vite rx oral tablet 1 Dialyvite wheat germ oil oral oil zinc sulfate intravenous solution 1 /ml, 5 /ml zinc trace metal intravenous solution 1 /ml astrointestinal Agents - Drugs for Acid Reflux and Ulcer acid reducer oral tablet 150 CARAFATE ORAL SUSPENSION 1 M/10ML cimetidine hcl oral solution 300 /5ml Wal-Zan 150 Maximum Strength cimetidine oral tablet 200 Tagamet H cimetidine oral tablet 300, 400, 800 DEXILANT ORAL CAPSULE DELAYED RELEASE 30 M, 60 M esomeprazole magnesium oral capsule delayed release 20 esomeprazole magnesium oral capsule delayed release 40 esomeprazole sodium intravenous solution reconstituted 20 esomeprazole sodium intravenous solution reconstituted 40 famotidine intravenous solution 20 /2ml, 200 /20ml, 40 /4ml famotidine oral suspension reconstituted 40 /5ml oodsense Esomeprazole NexIUM NexIUM I.V. Pepcid QL (62 EA per 31 ST; QL (1 EA per 1 day) QL (150 ML per 31 famotidine oral tablet 10 Pepcid AC QL (3 EA per 1 day) famotidine oral tablet 20 Pepcid QL (3 EA per 1 day) famotidine oral tablet 40 Pepcid famotidine premixed intravenous solution /50ml-% goodsense acid reducer oral tablet 150 Wal-Zan 150 Maximum Strength QL (62 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 98

102 Drug Name Reference rand-eneric Notes heartburn relief 150 max st oral tablet 150 lansoprazole oral capsule delayed release 15, 30 lansoprazole oral tablet dispersible 15, 30 Wal-Zan 150 Maximum Strength Prevacid misoprostol oral tablet 100 mcg, 200 mcg Cytotec nizatidine oral capsule 150, 300 nizatidine oral solution 15 /ml Prevacid SoluTab omeppi oral capsule OmePPi omeppi oral capsule OmePPi omeprazole oral capsule delayed release 10, 20, 40 omeprazole-sodium bicarbonate oral capsule , omeprazole-sodium bicarbonate oral packet , pantoprazole sodium intravenous solution reconstituted 40 pantoprazole sodium oral tablet delayed release 20, 40 pepcid ac maximum strength oral tablet 20 PREVACID SOLUTA ORAL TALET DISPERSILE 15 M, 30 M PRILOSEC OTC ORAL TALET DELAYED RELEASE 20 M rabeprazole sodium oral tablet delayed release 20 OmePPi Zegerid Protonix Protonix QL (62 EA per 31 QL (372 EA per 365 Pepcid QL (3 EA per 1 day) Prevacid SoluTab Aciphex ranitidine acid reducer oral tablet 75 Wal-Zan 75 ranitidine hcl injection solution 150 /6ml, 50 /2ml ranitidine hcl oral capsule 150 ranitidine hcl oral capsule 300 ranitidine hcl oral syrup 15 /ml, 150 /10ml, 75 /5ml ranitidine hcl oral tablet 150 Zantac Wal-Zan 150 Maximum Strength ranitidine hcl oral tablet 300 Zantac QL (62 EA per 31 QL (67 EA per 31 QL (310 ML per 31 QL (62 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 99

103 Drug Name Reference rand-eneric Notes ranitidine hcl oral tablet 75 Wal-Zan 75 sucralfate oral tablet 1 gm Carafate astrointestinal Agents - Drugs for owel, Intestine and Stomach Conditions alosetron hcl oral tablet 0.5, 1 Lotronex AMITIZA ORAL CAPSULE 24 MC, 8 MC amoxicill-clarithro-lansopraz oral Prevpac anti-diarrheal oral tablet 2 Imodium A-D atropine sulfate (pf) injection solution 0.4 /0.5ml atropine sulfate injection solution 0.4 /ml, 1 /ml, 8 /20ml atropine sulfate injection solution prefilled syringe 0.25 /5ml, 0.5 /5ml, 1 /10ml atropine sulfate intravenous solution prefilled syringe 2 /5ml belladonna alkaloids-opium rectal suppository belladonna-opium rectal suppository cascara sagrada oral fluid extract 1 gm/ml chlordiazepoxide-clidinium oral capsule CHOLAM ORAL CAPSULE 250 M, 50 M Librax clearlax oral powder ClearLax constulose oral solution 10 gm/15ml cromolyn sodium oral concentrate 100 /5ml dicyclomine hcl intramuscular solution 10 /ml dicyclomine hcl oral capsule 10 dicyclomine hcl oral solution 10 /5ml dicyclomine hcl oral tablet 20 diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet astrocrom entyl Lomotil QL (62 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 100 ; QL (2 EA per 1 day)

104 Drug Name Reference rand-eneric Notes docusate sodium oral capsule 250 DOK ed-spaz oral tablet dispersible Anaspaz enulose oral solution 10 gm/15ml gavilax oral powder ClearLax gavilyte-c oral solution reconstituted 240 gm gavilyte-g oral solution reconstituted 236 gm gavilyte-h oral kit gm gavilyte-n with flavor pack oral solution reconstituted 420 gm generlac oral solution 10 gm/15ml Colyte with Flavor Packs avilyte- avilyte-n with Flavor Pack glycolax oral powder ClearLax glycopyrrolate injection solution 0.2 /ml, 0.4 /2ml, 1 /5ml, 4 /20ml glycopyrrolate oral tablet 1 Robinul glycopyrrolate oral tablet 2 Robinul-Forte hyoscyamine sulfate er oral tablet extended release 12 hour hyoscyamine sulfate oral elixir /5ml hyoscyamine sulfate oral solution /ml Levbid hyoscyamine sulfate oral tablet Levsin hyoscyamine sulfate oral tablet dispersible hyoscyamine sulfate sl sublingual tablet sublingual hyoscyamine sulfate sublingual tablet sublingual hyosyne oral elixir /5ml hyosyne oral solution /ml lactulose encephalopathy oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml, 20 gm/30ml LINZESS ORAL CAPSULE 145 MC, 290 MC, 72 MC Anaspaz Levsin/SL Levsin/SL loperamide hcl oral capsule 2 Imodium A-D loperamide hcl oral tablet 2 Imodium A-D QL (62 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 101 QL (31 EA per 31

105 Drug Name Reference rand-eneric Notes methscopolamine bromide oral tablet 2.5, 5 mineral oil heavy oral oil mm anti-diarrheal oral tablet 2 Imodium A-D nulev oral tablet dispersible Anaspaz opium oral tincture 10 /ml (1%) oscimin oral tablet Levsin oscimin oral tablet dispersible Anaspaz oscimin sr oral tablet extended release 12 hour oscimin sublingual tablet sublingual paregoric oral tincture 2 /5ml pb-hyoscy-atropine-scopolamine oral tablet 16.2 peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm peg-prep oral kit gm Levbid Levsin/SL Donnatal Colyte with Flavor Packs avilyte-n with Flavor Pack avilyte- pegylax oral powder ClearLax phenobarbital-belladonna alk oral elixir 16.2 /5ml Donnatal phenohytro oral elixir 16.2 /5ml Donnatal phenohytro oral tablet 16.2 Donnatal polyethylene glycol 3350 oral packet CVS Purelax polyethylene glycol 3350 oral powder ClearLax propantheline bromide oral tablet 15 SEROSTIM SUCUTANEOUS SOLUTION RECONSTITUTED 4 M, 5 M, 6 M sodium bicarbonate oral powder stool softener oral capsule 100 Colace stool softener oral capsule 250 DOK symax-sl sublingual tablet sublingual Levsin/SL QL (124 EA per 31 QL (62 EA per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 102

106 Drug Name Reference rand-eneric Notes symax-sr oral tablet extended release 12 hour trilyte oral solution reconstituted 420 gm Levbid avilyte-n with Flavor Pack ursodiol oral capsule 300 Actigall ursodiol oral tablet 250 Urso 250 ursodiol oral tablet 500 Urso Forte XERMELO ORAL TALET 250 M ZORTIVE SUCUTANEOUS SOLUTION RECONSTITUTED 8.8 M enetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment ALDURAZYME INTRAVENOUS SOLUTION 2.9 M/5ML CERDELA ORAL CAPSULE 84 M CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT CREON ORAL CAPSULE DELAYED RELEASE RTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT CRYSVITA SUCUTANEOUS SOLUTION 10 M/ML, 20 M/ML, 30 M/ML ELAPRASE INTRAVENOUS SOLUTION 6 M/3ML FARAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 M, 5 M KUVAN ORAL CKET 100 M, 500 M KUVAN ORAL TALET SOLULE 100 M LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 M MEPSEVII INTRAVENOUS SOLUTION 10 M/5ML miglustat oral capsule 100 Zavesca NALAZYME INTRAVENOUS SOLUTION 1 M/ML PROCYSI ORAL CAPSULE DELAYED RELEASE 25 M, 75 M RAVICTI ORAL LIQUID 1.1 M/ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 103

107 Drug Name Reference rand-eneric Notes sod benz-sod phenylacet intravenous solution % sodium phenylbutyrate oral powder 3 gm/tsp Ammonul uphenyl sodium phenylbutyrate oral tablet 500 uphenyl enitourinary Agents - Drugs for ladder, enital and Kidney Conditions acetic acid irrigation solution 0.25 % aminoacetic acid irrigation solution 1.5 % azuphen mb oral capsule 120 Ustell bethanechol chloride oral tablet 10, 25, 5, 50 calcium acetate (phos binder) oral capsule 667 calcium acetate (phos binder) oral tablet 667 Urecholine PhosLo Calphron calcium acetate oral capsule 667 PhosLo darifenacin hydrobromide er oral tablet extended release 24 hour 15, 7.5 flavoxate hcl oral tablet 100 ELNIQUE PUMP TRANSDERMAL EL 10 % ELNIQUE TRANSDERMAL EL 10 % glycine irrigation solution 1.5 % glycine urologic irrigation solution 1.5 % Enablex ST hyolev mb oral tablet 81 Urelle hyophen oral tablet 81.6 indiomin mb oral capsule 120 lanthanum carbonate oral tablet chewable 1000, 500, 750 Fosrenol me/naphos/mb/hyo1 oral tablet 81.6 Urogesic-lue MYRETRIQ ORAL TALET EXTENDED RELEASE 24 HOUR 25 M, 50 M oxybutynin chloride er oral tablet extended release 24 hour 10, 5 oxybutynin chloride er oral tablet extended release 24 hour 15 oxybutynin chloride oral syrup 5 /5ml oxybutynin chloride oral tablet 5 Ditropan XL AL (Min 65 Years) Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 104

108 Drug Name Reference rand-eneric Notes OXYTROL FOR WOMEN TRANSDERMAL TCH TWICE WEEKLY 3.9 M/24HR OXYTROL TRANSDERMAL TCH TWICE WEEKLY 3.9 M/24HR phenazo oral tablet 200 Phenazo phenazopyridine hcl oral tablet 100 Pyridium phenazopyridine hcl oral tablet 200 Phenazo phosphasal oral tablet 81.6 Phosphasal RENAEL ORAL TALET 400 M, 800 M sevelamer carbonate oral packet 0.8 gm, 2.4 gm Renvela sevelamer carbonate oral tablet 800 Renvela tolterodine tartrate er oral capsule extended release 24 hour 2, 4 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 105 ST ST Detrol LA ST tolterodine tartrate oral tablet 1, 2 Detrol ST TOVIAZ ORAL TALET EXTENDED RELEASE 24 HOUR 4 M, 8 M trospium chloride er oral capsule extended release 24 hour 60 trospium chloride oral tablet 20 ST ur n-c oral tablet 81.6 Phosphasal uramit mb oral capsule 118 Uribel urelle oral tablet 81 Urelle uretron d/s oral tablet uribel oral capsule 118 Uribel urimar-t oral tablet 120 urin ds oral tablet Phosphasal uro-458 oral tablet 81 Urelle uroav-81 oral tablet 81 Urelle uroav-b oral capsule 118 Uribel uro-mp oral capsule 118 Uribel urophen mb oral tablet 81.6 uryl oral tablet 81.6 Urogesic-lue ustell oral capsule 120 Ustell uta oral capsule 120 uticap oral capsule 120 Ustell utira-c oral tablet 81.6 Phosphasal ST

109 Drug Name Reference rand-eneric Notes utrona-c oral tablet 81.6 Phosphasal VESICARE ORAL TALET 10 M, 5 M ST vilamit mb oral capsule 118 Uribel vilevev mb oral tablet 81 Urelle enitourinary Agents - Drugs for Prostate Conditions alfuzosin hcl er oral tablet extended release 24 hour 10 Uroxatral AVODART ORAL CAPSULE 0.5 M Avodart ST dutasteride oral capsule 0.5 Avodart ST dutasteride-tamsulosin hcl oral capsule Jalyn finasteride oral tablet 5 Proscar RAFLO ORAL CAPSULE 4 M, 8 M ST tamsulosin hcl oral capsule 0.4 Flomax terazosin hcl oral capsule 1, 10, 2, 5 Hormonal Agents - Adrenal ala-cort external cream 1 % Aveeno Anti-Itch Max St ala-cort external cream 2.5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % apexicon e external cream 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % Diprolene AF Diprolene Diprolene Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 106

110 Drug Name Reference rand-eneric Notes betamethasone dipropionate external ointment 0.05 % betamethasone sod phos & acet injection suspension 6 (3-3) /ml betamethasone valerate external cream 0.1 % betamethasone valerate external foam 0.12 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol prop emollient base external cream 0.05 % clobetasol propionate e external cream 0.05 % clobetasol propionate emulsion external foam 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external foam 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external liquid 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external shampoo 0.05 % clobetasol propionate external solution 0.05 % clocortolone pivalate external cream 0.1 % clocortolone pivalate pump external cream 0.1 % Celestone Soluspan Luxiq Olux-E Temovate Olux Clobex Spray Clobex Temovate Clobex Cloderm Cloderm clodan external shampoo 0.05 % Clobex cormax scalp application external solution 0.05 % cortisone acetate oral tablet 25 deltasone oral tablet 20 Deltasone derma silkrx sds pak external kit 0.1 & 5 NuTriaRx CreamPak % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 107

111 Drug Name Reference rand-eneric Notes dermawerx sds external kit 0.1 & 5 % NuTriaRx CreamPak desonide external cream 0.05 % DesOwen desonide external lotion 0.05 % DesOwen desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % Topicort desoximetasone external gel 0.05 % Topicort desoximetasone external liquid 0.25 % Topicort Spray desoximetasone external ointment 0.05 %, 0.25 % Topicort dexamethasone oral elixir 0.5 /5ml Decadron dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 4, 6 dexamethasone oral tablet 1, 1.5, 2 dexamethasone oral tablet therapy pack 1.5 (21) dexamethasone oral tablet therapy pack 1.5 (35) dexamethasone oral tablet therapy pack 1.5 (51) dexamethasone sod phos-nacl intravenous solution /50ml-% dexamethasone sod phosphate pf injection solution 10 /ml dexamethasone sodium phosphate injection solution 10 /ml, 100 /10ml, 120 /30ml, 20 /5ml, 4 /ml diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % fludrocortisone acetate oral tablet 0.1 fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream % fluocinolone acetonide external ointment % Decadron DexPak 6 Day DexPak 10 Day DexPak 13 Day Derma-Smoothe/FS ody Synalar Synalar Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 108

112 Drug Name Reference rand-eneric Notes fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide emulsified base external cream 0.05 % fluocinonide external cream 0.05 % Synalar Derma-Smoothe/FS Scalp fluocinonide external cream 0.1 % Vanos fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % flurandrenolide external cream 0.05 % Cordran flurandrenolide external lotion 0.05 % Cordran flurandrenolide external ointment 0.05 % Cordran fluticasone propionate external cream 0.05 % fluticasone propionate external lotion 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyr lipo base external cream 0.1 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external lotion 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % Cutivate Ultravate Ultravate Locoid Lipocream Locoid Locoid Locoid hydrocortisone external cream 1 % Aveeno Anti-Itch Max St hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 % Cortizone-10 hydrocortisone external ointment 2.5 % hydrocortisone in absorbase external ointment 1 % Cortizone-10 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 109

113 Drug Name Reference rand-eneric Notes hydrocortisone oral tablet 10, 20, 5 hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % methylprednisolone ace-lido injection suspension /ml, /ml methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablet therapy pack 4 methylprednisolone sodium succ injection solution reconstituted 1000 methylprednisolone sodium succ injection solution reconstituted 125, 40 mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % Cortef Depo-Medrol Medrol Medrol Solu-MEDROL SOLU-medrol Elocon Elocon nolix external cream 0.05 % Cordran nolix external lotion 0.05 % Cordran nutriarx creampak external kit 0.1 & 5 % NuTriaRx CreamPak prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % prednisolone oral solution 15 /5ml prednisolone oral syrup 15 /5ml prednisolone sodium phosphate oral solution 10 /5ml prednisolone sodium phosphate oral solution 15 /5ml, 25 /5ml, 6.7 (5 base) /5ml prednisolone sodium phosphate oral solution 20 /5ml prednisolone sodium phosphate oral tablet dispersible 10, 15, 30 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 5, 50 Millipred Veripred 20 Orapred ODT Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 110

114 Drug Name Reference rand-eneric Notes prednisone oral tablet 20 Deltasone prednisone oral tablet therapy pack 10 (21), 10 (48), 5 (21), 5 (48) sanadermrx skin repair external kit 0.1 & 5 % SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 M, 1000 M, 250 M, 500 M NuTriaRx CreamPak synalar external cream % Synalar synalar external ointment % Synalar triamcinolone acetonide external aerosol solution /gm triamcinolone acetonide external cream % triamcinolone acetonide external cream 0.1 %, 0.5 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment %, 0.1 %, 0.5 % triamcinolone acetonide injection suspension 40 /ml Kenalog Triderm Kenalog triderm external cream 0.1 %, 0.5 % Triderm tri-sila external kit 0.1 & 5 % NuTriaRx CreamPak VERIPRED 20 ORAL SOLUTION 20 M/5ML Hormonal Agents - Men's Health ANDRODERM TRANSDERMAL TCH 24 HOUR 2 M/24HR, 4 M/24HR ANDROEL PUMP TRANSDERMAL EL M/ACT (1.62%) ANDROEL TRANSDERMAL EL M/1.25M (1.62%), 40.5 M/2.5M (1.62%) ANDROEL TRANSDERMAL EL 25 M/2.5M (1%), 50 M/5M (1%) danazol oral capsule 100, 200, 50 FORTESTA TRANSDERMAL EL 10 M/ACT (2%) methyltestosterone oral capsule 10 NATESTO NASAL EL 5.5 M/ACT Veripred 20 Androel Fortesta oxandrolone oral tablet 10 Oxandrin Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 111

115 Drug Name Reference rand-eneric Notes oxandrolone oral tablet 2.5 TESTIM TRANSDERMAL EL 50 M/5M (1%) testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml TESTOSTERONE TRANSDERMAL EL 10 M/ACT (2%) testosterone transdermal gel 12.5 /act (1%) testosterone transdermal gel 25 /2.5gm (1%), 50 /5gm (1%) testosterone transdermal solution 30 /act VOELXO PUMP TRANSDERMAL EL 12.5 M/ACT (1%) VOELXO TRANSDERMAL EL 50 M/5M (1%) Hormonal Agents - Osteoporosis Androel Depo-Testosterone Fortesta Vogelxo Pump Androel Vogelxo Pump Androel raloxifene hcl oral tablet 60 Evista ST Hormonal Agents - Parathyroid SENSIR ORAL TALET 30 M, 60 M, 90 M Hormonal Agents - Pituitary cabergoline oral tablet 0.5 DDAVP INJECTION SOLUTION 4 MC/ML DDAVP DDAVP ORAL TALET 0.1 M, 0.2 M DDAVP desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % ELIARD SUCUTANEOUS KIT 22.5 M, 30 M, 45 M, 7.5 M DDAVP DDAVP DDAVP Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 112

116 Drug Name Reference rand-eneric Notes ENOTROPIN MINIQUICK SUCUTANEOUS SOLUTION RECONSTITUTED 0.2 M, 0.4 M, 0.6 M, 0.8 M, 1 M, 1.2 M, 1.4 M, 1.6 M, 1.8 M, 2 M ENOTROPIN SUCUTANEOUS SOLUTION RECONSTITUTED 12 M, 5 M HP ACTHAR INJECTION EL 80 UNIT/ML HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 M, 24 M, 5 M, 6 M INCRELEX SUCUTANEOUS SOLUTION 40 M/4ML leuprolide acetate injection kit 1 /0.2ml LUNETA CK COMINATION KIT & 5 M, 3.75 & 5 M LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 M, 7.5 M LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT M, 22.5 M LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30M INTRAMUSCULAR KIT 30 M LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45M INTRAMUSCULAR KIT 45 M LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT M, 15 M, 7.5 M LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT M (PED), 30 M (PED) NOCTIVA NASAL EMULSION 0.83 MC/0.1ML, 1.66 MC/0.1ML NORDITROPIN FLEXPRO SUCUTANEOUS SOLUTION 10 M/1.5ML, 15 M/1.5ML, 30 M/3ML, 5 M/1.5ML NUTROPIN AQ NUSPIN 10 SUCUTANEOUS SOLUTION 10 M/2ML ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 113

117 Drug Name Reference rand-eneric Notes NUTROPIN AQ NUSPIN 20 SUCUTANEOUS SOLUTION 20 M/2ML NUTROPIN AQ NUSPIN 5 SUCUTANEOUS SOLUTION 5 M/2ML octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml OMNITROPE SUCUTANEOUS SOLUTION 10 M/1.5ML, 5 M/1.5ML OMNITROPE SUCUTANEOUS SOLUTION RECONSTITUTED 5.8 M SandoSTATIN oxytocin injection solution 10 unit/ml Pitocin oxytocin-dextrose intravenous solution 10-5 unt/l-%, 20-5 unt/l-% oxytocin-sodium chloride intravenous solution unit/l-% SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED 8.8 M SAIZEN INJECTION SOLUTION RECONSTITUTED 5 M, 8.8 M SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 M SOMAVERT SUCUTANEOUS SOLUTION RECONSTITUTED 10 M, 15 M, 20 M, 25 M, 30 M STIMATE NASAL SOLUTION 1.5 M/ML SUPPRELIN LA SUCUTANEOUS KIT 50 M SYNAREL NASAL SOLUTION 2 M/ML TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED M, 22.5 M, 3.75 M VANTAS SUCUTANEOUS KIT 50 M vasopressin-sodium chloride intravenous solution ut/100ml-%, ut/50ml-%, ut/100ml-% ZOLADEX SUCUTANEOUS IMPLANT 10.8 M, 3.6 M ZOMACTON SUCUTANEOUS SOLUTION RECONSTITUTED 10 M, 5 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 114

118 Drug Name Reference rand-eneric Notes Hormonal Agents - Sex Hormones and irth Control altavera oral tablet mcg Altavera alyacen 1/35 oral tablet mcg Cyclafem 1/35 alyacen 7/7/7 oral tablet 0.5/0.75/1-35 -mcg Cyclafem 7/7/7 amabelz oral tablet , Activella amethia lo oral tablet & 0.01 Amethia Lo amethia oral tablet &0.01 Amethia ANELIQ ORAL TALET M, M apri oral tablet mcg Apri aranelle oral tablet 0.5/1/ mcg ashlyna oral tablet &0.01 Amethia aubra eq oral tablet mcg Aubra aubra oral tablet mcg Aubra aviane oral tablet mcg Aubra azurette oral tablet /0.01 (21/5) Azurette balziva oral tablet mcg alziva bekyree oral tablet /0.01 (21/5) Azurette blisovi 24 fe oral tablet mcg(24) lisovi 24 Fe blisovi fe 1.5/30 oral tablet mcg blisovi fe 1/20 oral tablet mcg lisovi FE 1/20 briellyn oral tablet mcg alziva camila oral tablet 0.35 Camila camrese lo oral tablet & 0.01 Amethia Lo camrese oral tablet &0.01 Amethia caziant oral tablet 0.1/0.125/ chateal eq oral tablet mcg Altavera chateal oral tablet mcg Altavera CLIMARA PRO TRANSDERMAL TCH WEEKLY M/DAY CLIMARA TRANSDERMAL TCH WEEKLY M/24HR, M/24HR, 0.05 M/24HR, 0.06 M/24HR, M/24HR, 0.1 M/24HR Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 115 QL (4 EA per 28 Climara QL (4 EA per 28

119 Drug Name Reference rand-eneric Notes COMITCH TRANSDERMAL TCH TWICE WEEKLY M/DAY, M/DAY covaryx hs oral tablet Covaryx HS covaryx oral tablet Covaryx cryselle-28 oral tablet mcg cyclafem 1/35 oral tablet mcg Cyclafem 1/35 cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 -mcg Cyclafem 7/7/7 cyred oral tablet mcg Apri dasetta 1/35 oral tablet mcg Cyclafem 1/35 dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mcg Cyclafem 7/7/7 daysee oral tablet &0.01 Amethia deblitane oral tablet 0.35 Camila delyla oral tablet mcg Aubra DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 M/ML desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) desogestrel-ethinyl estradiol oral tablet mcg drospiren-eth estrad-levomefol oral tablet drospirenone-ethinyl estradiol oral tablet drospirenone-ethinyl estradiol oral tablet Azurette Apri eyaz ianvi Ocella DUAVEE ORAL TALET M ST eemt hs oral tablet Covaryx HS eemt oral tablet Covaryx elinest oral tablet mcg ELLA ORAL TALET 30 M emoquette oral tablet mcg Apri enpresse-28 oral tablet Enpresse-28 enskyce oral tablet mcg Apri errin oral tablet 0.35 Camila est estrogens-methyltest ds oral tablet Covaryx QL (8 EA per 28 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 116

120 Drug Name Reference rand-eneric Notes est estrogens-methyltest hs oral tablet est estrogens-methyltest oral tablet Covaryx HS Covaryx estarylla oral tablet mcg Estarylla estradiol oral tablet 0.5, 1, 2 Estrace estradiol transdermal patch twice weekly /24hr, 0.05 /24hr, /24hr, 0.1 /24hr estradiol transdermal patch twice weekly /24hr estradiol transdermal patch weekly /24hr, /24hr, 0.05 /24hr, 0.06 /24hr, /24hr, 0.1 /24hr Alora Minivelle Climara QL (4 EA per 28 estradiol vaginal cream 0.1 /gm Estrace estradiol vaginal tablet 10 mcg Vagifem estradiol valerate intramuscular oil 20 /ml, 40 /ml estradiol-norethindrone acet oral tablet , ESTROEL TRANSDERMAL EL 0.75 M/1.25 M (0.06%) estropipate oral tablet 0.75, 1.5, 3 ethynodiol diac-eth estradiol oral tablet mcg ethynodiol diac-eth estradiol oral tablet mcg Delestrogen Activella Kelnor 1/35 Kelnor 1/50 falmina oral tablet mcg Aubra fayosim oral tablet days Fayosim femynor oral tablet mcg Estarylla fyavolv oral tablet mcg Femhrt Low Dose fyavolv oral tablet 1-5 -mcg Fyavolv gianvi oral tablet ianvi gildagia oral tablet mcg alziva heather oral tablet 0.35 Camila hydroxyprogesterone caproate intramuscular oil 250 /ml hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml Makena incassia oral tablet 0.35 Camila Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 117 QL (2 M per 31

121 Drug Name Reference rand-eneric Notes introvale oral tablet Introvale isibloom oral tablet mcg Apri jencycla oral tablet 0.35 Camila jevantique lo oral tablet mcg Femhrt Low Dose jinteli oral tablet 1-5 -mcg Fyavolv jolessa oral tablet Introvale jolivette oral tablet 0.35 Camila juleber oral tablet mcg Apri junel 1.5/30 oral tablet mcg junel 1/20 oral tablet mcg Junel 1/20 junel fe 1.5/30 oral tablet mcg junel fe 1/20 oral tablet mcg lisovi FE 1/20 junel fe 24 oral tablet mcg(24) lisovi 24 Fe kaitlib fe oral tablet chewable mcg eneress FE kariva oral tablet /0.01 (21/5) Azurette kelnor 1/35 oral tablet mcg Kelnor 1/35 kelnor 1/50 oral tablet mcg Kelnor 1/50 kimidess oral tablet /0.01 (21/5) Azurette kurvelo oral tablet mcg Altavera larin 1.5/30 oral tablet mcg larin 1/20 oral tablet mcg Junel 1/20 larin 24 fe oral tablet mcg(24) lisovi 24 Fe larin fe 1.5/30 oral tablet mcg larin fe 1/20 oral tablet mcg lisovi FE 1/20 larissia oral tablet mcg Aubra layolis fe oral tablet chewable mcg leena oral tablet 0.5/1/ mcg eneress FE lessina oral tablet mcg Aubra levonest oral tablet Enpresse-28 levonorgest-eth est & eth est oral tablet days levonorgest-eth estrad 91-day oral tablet & 0.01 levonorgest-eth estrad 91-day oral tablet &0.01 Fayosim Amethia Lo Amethia Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 118

122 Drug Name Reference rand-eneric Notes levonorgest-eth estrad 91-day oral tablet Introvale levonorgestrel oral tablet 1.5 Aftera QL (1 EA per 31 levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablet mcg Aubra Altavera Amethyst levonorg-eth estrad triphasic oral tablet Enpresse-28 levora 0.15/30 (28) oral tablet mcg Altavera lillow oral tablet mcg Altavera lomedia 24 fe oral tablet mcg(24) lisovi 24 Fe lopreeza oral tablet , Activella loryna oral tablet ianvi low-ogestrel oral tablet mcg lutera oral tablet mcg Aubra lyza oral tablet 0.35 Camila MAKENA SUCUTANEOUS SOLUTION AUTO-INJECTOR 275 M/1.1ML marlissa oral tablet mcg Altavera medroxyprogesterone acetate intramuscular suspension 150 /ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 /ml medroxyprogesterone acetate oral tablet 10, 2.5, 5 megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral suspension 625 /5ml megestrol acetate oral tablet 20, 40 melodetta 24 fe oral tablet chewable mcg(24) MENOSTAR TRANSDERMAL TCH WEEKLY 14 MC/24HR mibelas 24 fe oral tablet chewable mcg(24) Depo-Provera Depo-Provera Provera Megace ES Melodetta 24 Fe Melodetta 24 Fe QL (4 EA per 28 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 119

123 Drug Name Reference rand-eneric Notes microgestin 1.5/30 oral tablet mcg microgestin 1/20 oral tablet mcg Junel 1/20 microgestin fe 1.5/30 oral tablet mcg microgestin fe 1/20 oral tablet 1-20 mcg lisovi FE 1/20 mili oral tablet mcg Estarylla mimvey lo oral tablet Activella mimvey oral tablet Activella mono-linyah oral tablet mcg Estarylla mononessa oral tablet mcg Estarylla myzilra oral tablet Enpresse-28 necon 0.5/35 (28) oral tablet mcg necon 1/35 (28) oral tablet mcg Cyclafem 1/35 necon 1/50 (28) oral tablet mcg necon 7/7/7 oral tablet 0.5/0.75/1-35 mcg Cyclafem 7/7/7 nikki oral tablet ianvi nora-be oral tablet 0.35 Camila norethin ace-eth estrad-fe oral tablet mcg norethin ace-eth estrad-fe oral tablet mcg(24) norethin ace-eth estrad-fe oral tablet chewable mcg(24) lisovi FE 1/20 lisovi 24 Fe Melodetta 24 Fe norethindrone acetate oral tablet 5 Aygestin norethindrone acet-ethinyl est oral tablet mcg norethindrone acet-ethinyl est oral tablet chewable mcg(24) Junel 1/20 Melodetta 24 Fe norethindrone oral tablet 0.35 Camila norethindrone-eth estradiol oral tablet mcg norethindrone-eth estradiol oral tablet 1-5 -mcg norethin-eth estradiol-fe oral tablet chewable mcg norethin-eth estradiol-fe oral tablet chewable mcg Femhrt Low Dose Fyavolv Wymzya Fe eneress FE Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 120

124 Drug Name Reference rand-eneric Notes norgestimate-eth estradiol oral tablet mcg norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ mcg norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/ mcg Estarylla Ortho Tri-Cyclen Lo Ortho Tri-Cyclen (28) norlyda oral tablet 0.35 Camila norlyroc oral tablet 0.35 Camila nortrel 0.5/35 (28) oral tablet mcg nortrel 1/35 (21) oral tablet mcg Cyclafem 1/35 nortrel 1/35 (28) oral tablet mcg Cyclafem 1/35 nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mcg NUVARIN VAINAL RIN M/24HR Cyclafem 7/7/7 ocella oral tablet Ocella ogestrel oral tablet mcg orsythia oral tablet mcg Aubra philith oral tablet mcg alziva pimtrea oral tablet /0.01 (21/5) Azurette pirmella 1/35 oral tablet mcg Cyclafem 1/35 pirmella 7/7/7 oral tablet 0.5/0.75/1-35 -mcg PLAN ONE-STEP ORAL TALET 1.5 M Cyclafem 7/7/7 Aftera QL (1 EA per 31 portia-28 oral tablet mcg Altavera PREFEST ORAL TALET 1/ M (15/15) PREMARIN ORAL TALET 0.3 M, 0.45 M, M, 0.9 M, 1.25 M PREMARIN VAINAL CREAM M/M PREMPHASE ORAL TALET M PREMPRO ORAL TALET M, M, M, M previfem oral tablet mcg Estarylla progesterone intramuscular oil 50 /ml progesterone micronized oral capsule 100, 200 Prometrium Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 121

125 Drug Name Reference rand-eneric Notes progesterone micronized transdermal cream 10 % quasense oral tablet Introvale rajani oral tablet eyaz reclipsen oral tablet mcg Apri rivelsa oral tablet days Fayosim setlakin oral tablet Introvale sharobel oral tablet 0.35 Camila sprintec 28 oral tablet mcg Estarylla sronyx oral tablet mcg Aubra syeda oral tablet Ocella tarina fe 1/20 oral tablet mcg lisovi FE 1/20 tilia fe oral tablet 1-20/1-30/1-35 -mcg tri femynor oral tablet 0.18/0.215/ mcg tri-estarylla oral tablet 0.18/0.215/ mcg tri-legest fe oral tablet 1-20/1-30/1-35 mcg tri-linyah oral tablet 0.18/0.215/ mcg tri-lo-estarylla oral tablet 0.18/0.215/ mcg tri-lo-marzia oral tablet 0.18/0.215/ mcg tri-lo-sprintec oral tablet 0.18/0.215/ mcg tri-mili oral tablet 0.18/0.215/ mcg trinessa (28) oral tablet 0.18/0.215/ mcg trinessa lo oral tablet 0.18/0.215/ mcg tri-previfem oral tablet 0.18/0.215/ mcg tri-sprintec oral tablet 0.18/0.215/ mcg Ortho Tri-Cyclen (28) Ortho Tri-Cyclen (28) Ortho Tri-Cyclen (28) Ortho Tri-Cyclen Lo Ortho Tri-Cyclen Lo Ortho Tri-Cyclen Lo Ortho Tri-Cyclen (28) Ortho Tri-Cyclen (28) Ortho Tri-Cyclen Lo Ortho Tri-Cyclen (28) Ortho Tri-Cyclen (28) trivora (28) oral tablet Enpresse-28 tri-vylibra oral tablet 0.18/0.215/ mcg Ortho Tri-Cyclen (28) tulana oral tablet 0.35 Camila Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 122

126 Drug Name Reference rand-eneric Notes tydemy oral tablet VAIFEM VAINAL TALET 10 MC Vagifem velivet oral tablet 0.1/0.125/ vestura oral tablet ianvi vienva oral tablet mcg Aubra viorele oral tablet /0.01 (21/5) VIVELLE-DOT TRANSDERMAL TCH TWICE WEEKLY M/24HR, 0.05 M/24HR, M/24HR, 0.1 M/24HR VIVELLE-DOT TRANSDERMAL TCH TWICE WEEKLY M/24HR Azurette Alora QL (8 EA per 28 Minivelle QL (8 EA per 28 vyfemla oral tablet mcg alziva vylibra oral tablet mcg Estarylla wera oral tablet mcg wymzya fe oral tablet chewable mcg xulane transdermal patch weekly mcg/24hr Wymzya Fe yuvafem vaginal tablet 10 mcg Vagifem zarah oral tablet Ocella zenchent oral tablet mcg alziva zovia 1/35e (28) oral tablet mcg Kelnor 1/35 zovia 1/50e (28) oral tablet mcg Kelnor 1/50 Hormonal Agents - Thyroid levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine-liothyronine oral tablet 120, 15, 30, 60, 90 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium intravenous solution 10 mcg/ml Levo-T Levo-T Armour Thyroid Levo-T Triostat Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 123 QL (3 EA per 28

127 Drug Name Reference rand-eneric Notes liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Cytomel methimazole oral tablet 10, 5 Tapazole nature-throid oral tablet 130, 16.25, 195, 32.5 nature-throid oral tablet 65 np thyroid oral tablet 120, 15, 30, 60, 90 propylthiouracil oral tablet 50 SYNTHROID ORAL TALET 100 MC, 112 MC, 125 MC, 137 MC, 150 MC, 175 MC, 200 MC, 25 MC, 300 MC, 50 MC, 75 MC, 88 MC unithroid direct oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg westhroid oral tablet 130, 32.5 westhroid oral tablet 65 Immunological Agents - Drugs for Immune System Stimulation or Suppression ACTIMMUNE SUCUTANEOUS SOLUTION UNIT/0.5ML ALFERON N INJECTION SOLUTION UNIT/ML ARCALYST SUCUTANEOUS SOLUTION RECONSTITUTED 220 M Armour Thyroid Levo-T Levo-T Levo-T azathioprine oral tablet 50 Imuran azathioprine sodium injection solution reconstituted 100 ENLYSTA SUCUTANEOUS SOLUTION AUTO-INJECTOR 200 M/ML ENLYSTA SUCUTANEOUS SOLUTION PREFILLED SYRINE 200 M/ML IVIAM INTRAVENOUS SOLUTION 10 M/100ML, 5 M/50ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 124

128 Drug Name Reference rand-eneric Notes carimune nf intravenous solution reconstituted 12 gm, 6 gm CIMZIA PREFILLED KIT SUCUTANEOUS KIT 2 X 200 M/ML CIMZIA STARTER KIT SUCUTANEOUS KIT 6 X 200 M/ML CIMZIA VIAL KIT CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT COSENTYX 150 M/ML SUCUTANEOUS SOLUTION PREFILLED SYRINE 150 M/ML COSENTYX 300 DOSE SUCUTANEOUS SOLUTION PREFILLED SYRINE 150 M/ML COSENTYX SENSOREADY 300 DOSE SUCUTANEOUS SOLUTION AUTO- INJECTOR 150 M/ML COSENTYX SENSOREADY PEN SUCUTANEOUS SOLUTION AUTO- INJECTOR 150 M/ML CUVITRU SUCUTANEOUS SOLUTION 1 M/5ML, 2 M/10ML, 4 M/20ML, 8 M/40ML cyclosporine intravenous solution 50 /ml cyclosporine modified oral capsule 100, 25 cyclosporine modified oral capsule 50 cyclosporine modified oral solution 100 /ml SandIMMUNE engraf engraf cyclosporine oral capsule 100, 25 SandIMMUNE CYTOAM INTRAVENOUS INJECTALE 50 M/ML ENREL SUCUTANEOUS SOLUTION PREFILLED SYRINE 25 M/0.5ML, 50 M/ML ENREL SUCUTANEOUS SOLUTION RECONSTITUTED 25 M ENREL SURECLICK SUCUTANEOUS SOLUTION AUTO-INJECTOR 50 M/ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 125

129 Drug Name Reference rand-eneric Notes FLEOAMMA DIF INTRAVENOUS SOLUTION 0.5 M/10ML, 10 M/100ML, 10 M/200ML, 2.5 M/50ML, 20 M/200ML, 20 M/400ML, 5 M/100ML, 5 M/50ML AMASTAN INTRAMUSCULAR INJECTALE gamastan s/d injectable intramuscular AMASTAN S/D INJECTALE INTRAMUSCULAR AMMAARD INJECTION SOLUTION 1 M/10ML, 10 M/100ML, 2.5 M/25ML, 20 M/200ML, 30 M/300ML, 5 M/50ML AMMAARD S/D LESS IA INTRAVENOUS SOLUTION RECONSTITUTED 10 M, 5 M AMMAKED INJECTION SOLUTION 1 M/10ML, 10 M/100ML, 2.5 M/25ML, 20 M/200ML, 5 M/50ML AMMAPLEX INTRAVENOUS SOLUTION 10 M/100ML, 10 M/200ML, 20 M/200ML, 20 M/400ML, 5 M/100ML, 5 M/50ML AMUNEX-C INJECTION SOLUTION 1 M/10ML, 10 M/100ML, 2.5 M/25ML, 20 M/200ML, 40 M/400ML, 5 M/50ML gengraf oral capsule 100, 25 engraf gengraf oral capsule 50 gengraf oral solution 100 /ml engraf HIZENTRA SUCUTANEOUS SOLUTION 1 M/5ML, 10 M/50ML, 2 M/10ML, 4 M/20ML HUMIRA PEDIATRIC CROHNS START SUCUTANEOUS PREFILLED SYRINE KIT 40 M/0.8ML HUMIRA PEN SUCUTANEOUS PEN- INJECTOR KIT 40 M/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUCUTANEOUS PEN-INJECTOR KIT 40 M/0.8ML HUMIRA PEN-PS/UV STARTER SUCUTANEOUS PEN-INJECTOR KIT 40 M/0.8ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 126

130 Drug Name Reference rand-eneric Notes HUMIRA SUCUTANEOUS PREFILLED SYRINE KIT 10 M/0.2ML, 20 M/0.4ML, 40 M/0.8ML HYPERHEP S/D INTRAMUSCULAR SOLUTION HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINE 1500 UNIT, 250 UNIT INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 M KINERET SUCUTANEOUS SOLUTION PREFILLED SYRINE 100 M/0.67ML leflunomide oral tablet 10, 20 Arava methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 200 /8ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution 250 /10ml, 50 /2ml methotrexate sodium injection solution reconstituted 1 gm methotrexate sodium oral tablet 2.5 MICRHOAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINE 250 UNIT mycophenolate mofetil hcl intravenous solution reconstituted 500 mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml CellCept Intravenous CellCept CellCept mycophenolate mofetil oral tablet 500 CellCept mycophenolate sodium oral tablet delayed release 180, 360 Myfortic nabi-hb intramuscular solution OCTAAM INTRAVENOUS SOLUTION 1 M/20ML, 10 M/100ML, 10 M/200ML, 2 M/20ML, 2.5 M/50ML, 20 M/200ML, 25 M/500ML, 5 M/100ML, 5 M/50ML OTEZLA ORAL TALET 30 M ST OTEZLA ORAL TALET THERAPY CK 10 & 20 & 30 M ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 127

131 Drug Name Reference rand-eneric Notes OTREXUP SUCUTANEOUS SOLUTION AUTO-INJECTOR 10 M/0.4ML, 12.5 M/0.4ML, 15 M/0.4ML, 17.5 M/0.4ML, 20 M/0.4ML, 22.5 M/0.4ML, 25 M/0.4ML, 7.5 M/0.4ML PRIVIEN INTRAVENOUS SOLUTION 10 M/100ML, 20 M/200ML, 40 M/400ML, 5 M/50ML RASUVO SUCUTANEOUS SOLUTION AUTO-INJECTOR 10 M/0.2ML, 12.5 M/0.25ML, 15 M/0.3ML, 17.5 M/0.35ML, 20 M/0.4ML, 22.5 M/0.45ML, 25 M/0.5ML, 27.5 M/0.55ML, 30 M/0.6ML, 7.5 M/0.15ML REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 M RHOAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINE 1500 UNIT RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINE 1500 UNIT/2ML RIDAURA ORAL CAPSULE 3 M SILIQ SUCUTANEOUS SOLUTION PREFILLED SYRINE 210 M/1.5ML sirolimus oral tablet 0.5, 1, 2 Rapamune tacrolimus oral capsule 0.5, 1, 5 temsirolimus intravenous solution 25 /ml THYMOLOULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 M TICE C INTRAVESICAL SUSPENSION RECONSTITUTED 50 M TORISEL INTRAVENOUS SOLUTION 25 M/ML WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML Immunological Agents - Drugs for Vaccination ADACEL INTRAMUSCULAR SUSPENSION LF-MC/0.5 AFLURIA INTRAMUSCULAR SUSPENSION Prograf Torisel Torisel Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 128

132 Drug Name Reference rand-eneric Notes AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML bcg vaccine injection injectable OOSTRIX INTRAMUSCULAR SUSPENSION DAPTACEL INTRAMUSCULAR SUSPENSION LF-MC/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml ENERIX- INTRAMUSCULAR INJECTALE 10 MC/0.5ML, 20 MC/ML EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINE KIT 0.5 ML FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLULOK INTRAMUSCULAR SOLUTION FLULOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINE 0.5 ML FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 129

133 Drug Name Reference rand-eneric Notes FLUVIRIN INTRAMUSCULAR SUSPENSION FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLUZONE HIH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.5 ML FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN- INJECTOR 9 MC/STRAIN FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION, 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 0.25 ML, 0.5 ML ARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINE ARDASIL INTRAMUSCULAR SUSPENSION HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML INFANRIX INTRAMUSCULAR SUSPENSION MEDICAL PROVIDER EZ AFLURIA PF INTRAMUSCULAR PREFILLED SYRINE KIT 0.5 ML MEDICAL PROVIDER EZ FLU PF INTRAMUSCULAR PREFILLED SYRINE KIT 0.5 ML MEDICAL PROVIDER EZ FLU SHOT INTRAMUSCULAR PREFILLED SYRINE KIT 0.25 ML MEDICAL PROVIDER EZ FLUVIRIN INTRAMUSCULAR PREFILLED SYRINE KIT 0.5 ML MENACTRA INTRAMUSCULAR INJECTALE MENOMUNE SUCUTANEOUS INJECTALE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED pneumovax 23 injectable 25 mcg/0.5ml injection 25 mcg/0.5ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 130

134 Drug Name Reference rand-eneric Notes PNEUMOVAX 23 INJECTALE 25 MC/0.5ML INJECTION 25 MC/0.5ML PREVNAR 13 INTRAMUSCULAR SUSPENSION RAAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED SHINRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MC TENIVAC INTRAMUSCULAR INJECTALE 5-2 LFU tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml TRUMENA INTRAMUSCULAR SUSPENSION PREFILLED SYRINE TWINRIX INTRAMUSCULAR SUSPENSION VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUCUTANEOUS INJECTALE 1350 PFU/0.5ML yf-vax subcutaneous injectable ZOSTAVAX SUCUTANEOUS SUSPENSION RECONSTITUTED UNT/0.65ML Inflammatory owel Disease Agents ana-lex rectal kit 2-2 % Ana-Lex anucort-hc rectal suppository 25 Anusol-HC anusol-hc rectal suppository 25 Anusol-HC ASACOL HD ORAL TALET DELAYED RELEASE 800 M balsalazide disodium oral capsule 750 Colazal budesonide er oral tablet extended release 24 hour 9 budesonide oral capsule delayed release particles 3 CANASA RECTAL SUPPOSITORY 1000 M Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 131 QL (2 EA per 1 day) Asacol HD Uceris Entocort EC colocort rectal enema 100 /60ml Colocort DELZICOL ORAL CAPSULE DELAYED RELEASE 400 M DIPENTUM ORAL CAPSULE 250 M

135 Drug Name Reference rand-eneric Notes hemmorex-hc rectal suppository 25 Anusol-HC hemmorex-hc rectal suppository 30 Proctocort hydrocortisone ace-pramoxine rectal cream 1-1 % hydrocortisone ace-pramoxine rectal cream % hydrocortisone acetate rectal suppository 25 hydrocortisone acetate rectal suppository 30 Analpram-HC Analpram HC Anusol-HC Proctocort hydrocortisone rectal cream 1 % Procto-Pak hydrocortisone rectal cream 2.5 % Anusol-HC hydrocortisone rectal enema 100 /60ml Colocort lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal gel % lidocaine-hydrocortisone ace rectal kit 2-2 % lidocaine-hydrocortisone ace rectal kit %, 3-1 %, % mesalamine oral tablet delayed release 1.2 gm mesalamine oral tablet delayed release 800 mesalamine rectal enema 4 gm Ana-Lex Lialda Asacol HD mesalamine-cleanser rectal kit 4 gm Rowasa PENTASA ORAL CAPSULE EXTENDED RELEASE 250 M, 500 M pramcort rectal cream 1-1 % Analpram-HC procto-med hc rectal cream 2.5 % Anusol-HC procto-pak rectal cream 1 % Procto-Pak proctosol hc rectal cream 2.5 % Anusol-HC proctozone-hc rectal cream 2.5 % Anusol-HC sulfasalazine oral tablet 500 Azulfidine sulfasalazine oral tablet delayed release 500 Azulfidine EN-tabs UCERIS RECTAL FOAM 2 M/ACT ST Metabolic one Disease Agents - Drugs for Osteoporosis Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 132

136 Drug Name Reference rand-eneric Notes ACTONEL ORAL TALET 150 M, 30 M, 35 M, 5 M alendronate sodium oral solution 70 /75ml alendronate sodium oral tablet 10, 40, 5 Actonel alendronate sodium oral tablet 35 QL (4 EA per 28 alendronate sodium oral tablet 70 Fosamax QL (4 EA per 28 ONIVA ORAL TALET 150 M oniva calcitonin (salmon) nasal solution 200 unit/act calcitriol intravenous solution 1 mcg/ml Miacalcin calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol calcitriol oral solution 1 mcg/ml Rocaltrol doxercalciferol capsule 1 mcg oral 1 mcg ST doxercalciferol capsule 1 mcg oral 1 mcg doxercalciferol intravenous solution 4 mcg/2ml doxercalciferol oral capsule 0.5 mcg, 2.5 mcg etidronate disodium oral tablet 200, 400 FORTEO SUCUTANEOUS SOLUTION 600 MC/2.4ML ibandronate sodium intravenous solution 3 /3ml Hectorol ST ST oniva ibandronate sodium oral tablet 150 oniva MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATRA SUCUTANEOUS CARTRIDE 100 MC, 25 MC, 50 MC, 75 MC pamidronate disodium intravenous solution 30 /10ml, 6 /ml, 90 /10ml pamidronate disodium intravenous solution reconstituted 30, 90 paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml Zemplar paricalcitol oral capsule 1 mcg, 2 mcg Zemplar paricalcitol oral capsule 4 mcg Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 133

137 Drug Name Reference rand-eneric Notes PROLIA SUCUTANEOUS SOLUTION 60 M/ML risedronate sodium oral tablet 150, 30, 35, 5 risedronate sodium oral tablet delayed release 35 TYMLOS SUCUTANEOUS SOLUTION PEN-INJECTOR 3120 MC/1.56ML zoledronic acid intravenous concentrate 4 /5ml zoledronic acid intravenous solution 4 /100ml zoledronic acid intravenous solution 5 /100ml zoledronic acid intravenous solution reconstituted 4 Miscellaneous Therapeutic Agents acetylcysteine intravenous solution 200 /ml ACTHREL INTRAVENOUS SOLUTION RECONSTITUTED 100 MC adenosine (diagnostic) intravenous solution 3 /ml Actonel Atelvia Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 134 Zometa Zometa Reclast Acetadote Adenoscan adenosine intravenous solution 3 /ml Adenoscan albuked 25 intravenous solution 25 % Albuked 25 albuked 5 intravenous solution 5 % Albuked 5 albumin human intravenous solution 25 % Albuked 25 albumin human intravenous solution 5 % Albuked 5 albuminar-25 intravenous solution 25 % Albuked 25 albuminar-5 intravenous solution 5 % Albuked 5 albumin-zlb intravenous solution 25 % Albuked 25 albumin-zlb intravenous solution 5 % Albuked 5 alburx intravenous solution 5 % Albuked 5 albutein intravenous solution 25 % Albuked 25 albutein intravenous solution 5 % Albuked 5 anesthesia needle 23gx1-3/8" D Filter Needle/5 Micron antivenin latrodectus mactans injection kit antivenin micrurus fulvius intravenous solution reconstituted arnica flower tincture asilnasal rms oral capsule

138 Drug Name Reference rand-eneric Notes av-vite fb forte oral tablet Folbic boric acid external granules OTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT REATHE EASE LARE DEVICE REATHE EASE MEDIUM DEVICE REATHE EASE SMALL DEVICE REATHERITE AeroChamber Mini Chamber AeroChamber Mini Chamber AeroChamber Mini Chamber AeroChamber Mini Chamber buminate intravenous solution 25 % Albuked 25 buminate intravenous solution 5 % Albuked 5 calcium disodium versenate injection solution 1 gm/5ml chlorhexidine gluconate solution 20 % cicatrace pad external kit condoms cosyntropin injection solution reconstituted 0.25 deferoxamine mesylate injection solution reconstituted 2 gm deferoxamine mesylate injection solution reconstituted 500 dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml dexmedetomidine hcl intravenous solution 1000 mcg/10ml, 400 mcg/4ml dexmedetomidine hcl intravenous solution 200 mcg/2ml dipyridamole intravenous solution 5 /ml dover vinyl urethral cath 16fr Rexasil Patch & Vitamin E Liq LifeStyles Assorted Colors Cortrosyn Desferal Precedex Precedex Advance EX External Catheter DUREX EXTRA SENSITIVE DEVICE Durex Extra Sensitive DUREX REALFEEL DEVICE EASIVENT ergoloid mesylates oral tablet 1 AeroChamber Mini Chamber Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 135 QL (1 EA per 365 QL (1 EA per 365 QL (1 EA per 365 QL (1 EA per 365 QL (14 EA per 30 QL (14 EA per 30 QL (14 EA per 30 QL (1 EA per 365

139 Drug Name Reference rand-eneric Notes etomidate intravenous solution 2 /ml Amidate face mask resp n-100 part CPR Microshield face mask respirator r-95 part CPR Microshield flexbumin intravenous solution 25 % Albuked 25 flexbumin intravenous solution 5 % Albuked 5 flumazenil intravenous solution 0.5 /5ml, 1 /10ml folbic oral tablet Folbic foley catheter 2-way fomepizole intravenous solution 1 gm/ml, 1.5 gm/1.5ml Advance EX External Catheter Antizol formadon external solution 10 % Formadon formaldehyde external solution 10 % Formadon formaldehyde external solution 37 % forma-ray external solution 20 % fresenius propoven intravenous emulsion 1000 /100ml, 200 /20ml, 500 /50ml glucagon hcl (diagnostic) injection solution reconstituted 1 glutaraldehyde external solution 25 % heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml heparin sodium flush intravenous kit unit/ml-%, unit/ml-% heparin sodium lock flush intravenous solution 100 unit/ml human albumin grifols intravenous solution 25 % indigo carmine injection solution 8 /ml indocyanine green intravenous solution reconstituted 25 infed injection solution 50 /ml Diprivan Albuked 25 IC reen infusion needle 15gx2" D Filter Needle/5 Micron insulin pump ir2020 kit Accu-Chek Combo inulin intravenous solution /ml- % isoflurane inhalation solution Forane isosulfan blue subcutaneous solution 1 % ; QL (1 EA per 365 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 136

140 Drug Name Reference rand-eneric Notes karaya gum powder kedbumin intravenous solution 25 % Albuked 25 ketamine hcl injection solution 10 /ml, 100 /ml, 50 /ml ketamine hcl intravenous solution prefilled syringe 100 /2ml ketamine hcl-sodium chloride intravenous solution prefilled syringe /10ml-%, /2ml-% Ketalar KIMONO MICRO THIN Trustex Non-Lubricated l-cysteine hcl intravenous solution 50 /ml l-methylfolate calcium oral tablet 15, 7.5 Elfolate l-methylfolate oral tablet 15, 7.5 Elfolate methergine oral tablet 0.2 methohexital sodium intravenous solution prefilled syringe 50 /5ml methylene blue injection solution 1 % methylergonovine maleate injection solution 0.2 /ml monoject flush syr/hep lock intravenous solution 10 unit/ml, 100 unit/ml monoject prefill adv heparin intravenous solution 10 unit/ml MYALEPT SUCUTANEOUS SOLUTION RECONSTITUTED 11.3 M niva-fol oral tablet Folbic piston irrigation syringe ard Irrigation Syringe/ulb plasbumin-25 intravenous solution 25 % Albuked 25 plasbumin-5 intravenous solution 5 % Albuked 5 pocket spacer device pralidoxime chloride intramuscular solution auto-injector 600 /2ml AeroChamber Mini Chamber premium condoms lubricated Durex Extra Sensitive propofol intravenous emulsion 1000 /100ml, 200 /20ml, 500 /50ml Diprivan reusable syringe barrel 1.5oz D Filter Needle/5 Micron QL (14 EA per 30 QL (1 EA per 365 QL (14 EA per 30 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 137

141 Drug Name Reference rand-eneric Notes reusable syringe barrel 1oz D Filter Needle/5 Micron reusable syringe barrel 2oz D Filter Needle/5 Micron reusable syringe barrel 3oz D Filter Needle/5 Micron reusable syringe barrel 4oz D Filter Needle/5 Micron robb-type angio syringe 80cc D Filter Needle/5 Micron sash kit intravenous kit unit/ml-%, unit/ml-% sevoflurane inhalation solution Ultane sharps container sodium nitrite intravenous solution 30 /ml sodium saccharin dihydrate powder sodium saccharin powder sodium thiosulfate intravenous solution 25 % sorbitol irrigation solution 3.3 % sorbitol-mannitol irrigation solution gm/100ml D Nestable Sharps Collector tb syringe 1 ml D Filter Needle/5 Micron terrell inhalation solution Forane THYROEN INTRAMUSCULAR SOLUTION RECONSTITUTED 1.1 M titus needle 18gx1-1/4" D Filter Needle/5 Micron TODAY SPONE VAINAL 1000 M tonsil ndl curved 23gx1/2" D Filter Needle/5 Micron tonsil ndl straight 23gx3/4 D Filter Needle/5 Micron TRUSTEX NON-LURICATED Trustex Non-Lubricated TRUSTEX RIA NON-LURICATED Trustex Non-Lubricated vcf vaginal contraceptive vaginal foam 12.5 % virt-vite forte oral tablet Folbic VISTOARD ORAL CKET 10 M vp-precip oral capsule XURIDEN ORAL CKET 2 M Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation QL (14 EA per 30 QL (14 EA per 30 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 138

142 Drug Name Reference rand-eneric Notes ALREX OPHTHALMIC SUSPENSION 0.2 % AZASITE OPHTHALMIC SOLUTION 1 % azelastine hcl ophthalmic solution 0.05 % bacitracin ophthalmic ointment 500 unit/gm bromfenac sodium (once-daily) ophthalmic solution 0.09 % ciprofloxacin hcl ophthalmic solution 0.3 % cromolyn sodium ophthalmic solution 4 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % Ciloxan epinastine hcl ophthalmic solution 0.05 % Elestat erythromycin ophthalmic ointment 5 /gm fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % FML FORTE OPHTHALMIC SUSPENSION 0.25 % FML Liquifilm gatifloxacin ophthalmic solution 0.5 % Zymaxid gentak ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % ketorolac tromethamine ophthalmic solution 0.4 % ketorolac tromethamine ophthalmic solution 0.5 % levofloxacin ophthalmic solution 0.5 % LOTEMAX OPHTHALMIC EL 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % moxifloxacin hcl ophthalmic solution 0.5 % Acular LS Acular Vigamox ofloxacin ophthalmic solution 0.3 % Ocuflox olopatadine hcl ophthalmic solution 0.1 % Patanol olopatadine hcl ophthalmic solution 0.2 % Pataday Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 139

143 Drug Name Reference rand-eneric Notes prednisolone acetate ophthalmic suspension 1 % prednisolone acetate p-f ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % prednisolon-moxiflox-bromfenac ophthalmic solution % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % Omnipred Omnipred leph-10 tobramycin ophthalmic solution 0.3 % Tobrex trifluridine ophthalmic solution 1 % Viroptic VIAMOX OPHTHALMIC SOLUTION 0.5 % VIROPTIC OPHTHALMIC SOLUTION 1 % Vigamox Viroptic ZIRAN OPHTHALMIC EL 0.15 % ST Ophthalmic Agents - Drugs for laucoma apraclonidine hcl ophthalmic solution 0.5 % betaxolol hcl ophthalmic solution 0.5 % bimatoprost ophthalmic solution 0.03 % brimonidine tartrate ophthalmic solution 0.15 % brimonidine tartrate ophthalmic solution 0.2 % carteolol hcl ophthalmic solution 1 % Iopidine Alphagan P dorzolamide hcl ophthalmic solution 2 % Trusopt dorzolamide hcl-timolol mal ophthalmic solution /ml dorzolamide hcl-timolol mal pf ophthalmic solution /ml Cosopt Cosopt PF latanoprost ophthalmic solution % Xalatan levobunolol hcl ophthalmic solution 0.5 % etagan LUMIAN OPHTHALMIC SOLUTION 0.01 % methazolamide oral tablet 25, 50 metipranolol ophthalmic solution 0.3 % Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 140

144 Drug Name Reference rand-eneric Notes pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.5 % (daily) Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions Isopto Carpine Timoptic-XE Timoptic Istalol ak-fluor intravenous solution 10 % Fluorescite ak-fluor intravenous solution 25 % altacaine ophthalmic solution 0.5 % Altacaine altafluor benox ophthalmic solution % Altafluor altafluor ophthalmic solution % Altafluor altafrin ophthalmic solution 10 %, 2.5 % Altafrin atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % Isopto Atropine bacitracin-polymyxin b ophthalmic ointment unit/gm bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % Polycin Neo-Polycin HC balanced salt intraocular solution SS bio glo ophthalmic strip 1 bss intraocular solution SS bss plus intraocular solution SS cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % Cyclogyl flucaine ophthalmic solution % Flucaine fluorescein-benoxinate ophthalmic solution % fluor-i-strips a.t. ophthalmic strip 1 Altafluor flurox ophthalmic solution % Altafluor ful-glo ophthalmic strip 1 glostrips ophthalmic strip 1 green glo lissamine green ophthalmic strip 1.5 reen lo Lissamine reen homatropaire ophthalmic solution 5 % Homatropaire homatropine hbr ophthalmic solution 5 % Homatropaire Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 141

145 Drug Name Reference rand-eneric Notes LASTACAFT OPHTHALMIC SOLUTION 0.25 % lissamine green ophthalmic strip 1.5 LUCENTIS INTRAVITREAL SOLUTION 0.3 M/0.05ML, 0.5 M/0.05ML LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINE 0.5 M/0.05ML MACUEN INTRAOCULAR SOLUTION 0.3 M neomycin-bacitracin zn-polymyx ophthalmic ointment , neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-gramicidin ophthalmic solution neomycin-polymyxin-hc ophthalmic suspension reen lo Lissamine reen Neo-Polycin Maxitrol Maxitrol Neosporin neo-polycin hc ophthalmic ointment 1 % Neo-Polycin HC neo-polycin ophthalmic ointment ocucoat viscoadherent intraocular solution 2 % phenylephrine hcl ophthalmic solution 10 %, 2.5 % polycin ophthalmic ointment unit/gm polymyxin b-trimethoprim ophthalmic solution unit/ml-% prednisolone-moxifloxacin ophthalmic solution % proparacaine hcl ophthalmic solution 0.5 % proparacaine-fluorescein ophthalmic solution % RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % RESTASIS OPHTHALMIC EMULSION 0.05 % sulfacetamide-prednisolone ophthalmic solution % Neo-Polycin Altafrin Polycin Polytrim Alcaine Flucaine Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 142 QL (60 ML per 31 QL (60 EA per 31

146 Drug Name Reference rand-eneric Notes tetcaine ophthalmic solution 0.5 % Altacaine tetracaine hcl ophthalmic solution 0.5 % Altacaine tetravisc forte ophthalmic solution 0.5 % Altacaine tetravisc ophthalmic solution 0.5 % Altacaine tobramycin-dexamethasone ophthalmic suspension % tropicamide ophthalmic solution 0.5 % TobraDex tropicamide ophthalmic solution 1 % Mydriacyl VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 M Otic Agents - Drugs for Ear Conditions acetasol hc otic solution 2-1 % Acetasol HC acetic acid otic solution 2 % CIPRODEX OTIC SUSPENSION % ciprofloxacin hcl otic solution 0.2 % Cetraxal COLY-MYCIN S OTIC SUSPENSION M/ML cortic-nd otic solution /ml Cortane- cyotic otic solution /ml Cortane- exotic-hc otic solution /ml Cortane- fluocinolone acetonide otic oil 0.01 % DermOtic hydrocortisone-acetic acid otic solution 1-2 % neomycin-polymyxin-hc otic solution 1 %, neomycin-polymyxin-hc otic suspension Acetasol HC ofloxacin otic solution 0.3 % Floxin Otic otomax-hc otic solution /ml Cortane- Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold 12 hour allergy-d oral tablet extended release 12 hour all day allergy d-12 oral tablet extended release 12 hour allergy 24hour indoor/outdoor oral tablet 10 KLS Aller-Tec D KLS Aller-Tec D Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 143 ST; QL (31 EA per 31 ST; QL (31 EA per 31 KLS Aller-Tec QL (1 EA per 1 day) allergy 24-hr oral tablet 180 Allegra Allergy QL (1 EA per 1 day) allergy childrens oral syrup 5 /5ml Claritin QL (10 ML per 1 day)

147 Drug Name Reference rand-eneric Notes allergy oral tablet 10 Claritin QL (1 EA per 1 day) allergy relief oral tablet dispersible 10 Alavert QL (1 EA per 1 day) ASTEPRO NASAL SOLUTION 0.15 % Astepro QL (2 ML per 31 azelastine hcl nasal solution 0.1 %, 137 mcg/spray Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 144 QL (30 ML per 30 azelastine hcl nasal solution 0.15 % Astepro QL (2 ML per 31 banophen oral capsule 25 anophen QL (4 EA per 1 day) banophen oral liquid 12.5 /5ml anophen ECONASE AQ NASAL SUSPENSION 42 MC/SPRAY benadryl-d allergy/sinus child oral solution /5ml benzonatate oral capsule 100 Tessalon Perles benzonatate oral capsule 150, 200 biotuss oral liquid /5ml iltuss Cough & Cold biotuss pediatric oral liquid /ml bromfed dm oral syrup /5ml romfed DM brompheniramine maleate intramuscular solution 10 /ml brompheniramine tannate oral tablet chewable 12 budesonide nasal suspension 32 mcg/act Rhinocort Allergy carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 carbinoxamine maleate oral tablet 6 RyVent cetirizine hcl childrens alrgy oral syrup 1 /ml cetirizine hcl childrens oral tablet chewable 5 cetirizine hcl oral solution 1 /ml, 5 /5ml QL (240 ML per 31 ; AL (Max 12 Years) ST QL (248 ML per 31 ; AL (Max 12 Years) KLS Aller-Tec Childrens QL (10 ML per 1 day) Wal-Zyr Childrens KLS Aller-Tec Childrens QL (10 ML per 1 day) cetirizine hcl oral tablet 10 KLS Aller-Tec QL (1 EA per 1 day) childrens allergy oral liquid 12.5 /5ml anophen CLARITIN REDITAS ORAL TALET DISPERSILE 5 M QL (240 ML per 31 ; AL (Max 12 Years) QL (1 EA per 1 day)

148 Drug Name Reference rand-eneric Notes clemastine fumarate oral tablet 2.68 cough dm oral suspension extended release 30 /5ml cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 Delsym desloratadine oral tablet 5 Clarinex desloratadine oral tablet dispersible 2.5, 5 diphenhydramine hcl injection solution 50 /ml QL (148 ML per 31 diphenhydramine hcl oral capsule 25 anophen QL (4 EA per 1 day) diphenhydramine hcl oral elixir 12.5 /5ml fexofenadine hcl oral tablet 180 Allegra Allergy QL (1 EA per 1 day) fexofenadine hcl oral tablet 60 Allegra Allergy QL (2 EA per 1 day) fexofenadine-pseudoephed er oral tablet extended release 12 hour fexofenadine-pseudoephed er oral tablet extended release 24 hour flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act giltuss pediatric oral liquid /ml hydrocodone polst-cpm polst er oral suspension extended release 10-8 /5ml hydrocodone-homatropine oral syrup /5ml hydrocodone-homatropine oral tablet hydromet oral syrup /5ml ipratropium bromide nasal solution 0.03 %, 0.06 % levocetirizine dihydrochloride oral solution 2.5 /5ml levocetirizine dihydrochloride oral tablet 5 Allegra-D Allergy & Congestion Allegra-D Allergy & Congestion QL (2 EA per 1 day) QL (1 EA per 1 day) QL (3 ML per 31 ClariSpray QL (1 M per 31 Tussionex Pennkinetic ER Xyzal Allergy 24HR Childrens Xyzal Allergy 24HR loratadine oral tablet 10 Claritin QL (1 EA per 1 day) mometasone furoate nasal suspension 50 mcg/act Nasonex Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 145

149 Drug Name Reference rand-eneric Notes NASONEX NASAL SUSPENSION 50 MC/ACT nebusal inhalation nebulization solution 3 % nortuss-ex oral liquid /5ml Nasonex Nebusal olopatadine hcl nasal solution 0.6 % Patanase ST OMNARIS NASAL SUSPENSION 50 MC/ACT phenadoz rectal suppository 12.5, 25 phenergan rectal suppository 12.5, 25 Phenadoz Phenadoz phenergan rectal suppository 50 Promethegan phenylephrine-guaifenesin oral liquid /ml promethazine hcl injection solution 25 /ml, 50 /ml promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 promethazine hcl rectal suppository 50 promethazine vc plain oral solution /5ml promethazine vc/codeine oral syrup /5ml promethazine-codeine oral syrup /5ml promethazine-dm oral syrup /5ml promethazine-phenyleph-codeine oral syrup /5ml promethazine-phenylephrine oral syrup /5ml promethegan rectal suppository 12.5, 25 Phenergan Phenadoz Promethegan Phenadoz promethegan rectal suppository 50 Promethegan pseudoeph-chlorphen-hydrocod oral solution /5ml Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 146 ST

150 Drug Name Reference rand-eneric Notes pseudoephedrine-bromphen-dm oral syrup /5ml pulmosal inhalation nebulization solution 7 % robitussin 12 hour cough child oral suspension extended release 30 /5ml romfed DM HyperSal Delsym ryvent oral tablet 6 RyVent sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % sodium chloride inhalation nebulization solution 7 % triamcinolone acetonide nasal aerosol 55 mcg/act tussigon oral tablet wal-fex d allergy & congestion oral tablet extended release 24 hour XOLAIR SUCUTANEOUS SOLUTION RECONSTITUTED 150 M Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions acetylcysteine inhalation solution 10 %, 20 % ADRENACLICK INJECTION SOLUTION AUTO-INJECTOR 0.15 M/0.15ML ADVAIR DISKUS INHALATION AEROSOL POWDER REATH ACTIVATED MC/DOSE, MC/DOSE, MC/DOSE ADVAIR HFA INHALATION AEROSOL MC/ACT, MC/ACT, MC/ACT AEROSN INHALATION AEROSOL SOLUTION 80 MC/ACT albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 Nebusal HyperSal Nasacort Allergy 24HR Allegra-D Allergy & Congestion QL (148 ML per 31 QL (1 EA per 1 day) Auvi-Q QL (4 EA per 31 QL (1 EA per 31 QL (1 M per 31 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 147

151 Drug Name Reference rand-eneric Notes aminophylline intravenous solution 25 /ml ANORO ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED MC/INH ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 M, 500 M ARNUITY ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED 100 MC/ACT, 200 MC/ACT, 50 MC/ACT ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 220 MC/INH ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 220 MC/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 110 MC/INH, 220 MC/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 220 MC/INH ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 110 MC/INH ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MC/ACT AUVI-Q INJECTION SOLUTION AUTO- INJECTOR 0.15 M/0.15ML, 0.3 M/0.3ML EVESPI AEROSPHERE INHALATION AEROSOL MC/ACT REO ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED MC/INH, MC/INH ROVANA INHALATION NEULIZATION SOLUTION 15 MC/2ML budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml cromolyn sodium inhalation nebulization solution 20 /2ml DALIRESP ORAL TALET 250 MC, 500 MC Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 148 ST ST ST ST ST QL (2 M per 31 Auvi-Q QL (4 EA per 31 ST Pulmicort ST

152 Drug Name Reference rand-eneric Notes difil-g forte oral liquid /5ml EPINEPHRINE INJECTION SOLUTION 0.3 M/0.3ML EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 M/0.15ML, 0.3 M/0.3ML EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 M/0.3ML EPIPEN 2-K INJECTION SOLUTION AUTO-INJECTOR 0.3 M/0.3ML EPIPEN JR 2-K INJECTION SOLUTION AUTO-INJECTOR 0.15 M/0.3ML QL (4 EA per 31 Auvi-Q QL (4 EA per 31 EpiPen Jr 2-Pak QL (4 EA per 31 Auvi-Q QL (4 EA per 31 EpiPen Jr 2-Pak QL (4 EA per 31 ESRIET ORAL CAPSULE 267 M ESRIET ORAL TALET 267 M, 801 M FLOVENT HFA INHALATION AEROSOL 110 MC/ACT, 220 MC/ACT, 44 MC/ACT FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER REATH ACTIVATED MC/ACT FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER REATH ACTIVATED MC/ACT FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER REATH ACTIVATED MC/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED 62.5 MC/INH ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution (3) /3ml levalbuterol hcl inhalation nebulization solution 0.31 /3ml, 0.63 /3ml, 1.25 /3ml levalbuterol hcl inhalation nebulization solution 1.25 /0.5ml LEVALUTEROL HFA INHALATION AEROSOL 45 MC/ACT LONHALA MANAIR REFILL KIT INHALATION SOLUTION 25 MC/ML AirDuo RespiClick 113/14 AirDuo RespiClick 232/14 AirDuo RespiClick 55/14 Xopenex ST Xopenex Concentrate ST Xopenex HFA ; QL (1 M per 31 QL (30 M per 30 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 149

153 Drug Name Reference rand-eneric Notes LONHALA MANAIR STARTER KIT INHALATION SOLUTION 25 MC/ML metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral packet 4 Singulair montelukast sodium oral tablet 10 Singulair montelukast sodium oral tablet chewable 4, 5 Singulair OFEV ORAL CAPSULE 100 M, 150 M PERFOROMIST INHALATION NEULIZATION SOLUTION 20 MC/2ML PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 ASE) MC/ACT PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 M PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 ASE) MC/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER REATH ACTIVATED 180 MC/ACT, 90 MC/ACT PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 M/2ML, 0.5 M/2ML, 1 M/2ML QVAR INHALATION AEROSOL SOLUTION 40 MC/ACT, 80 MC/ACT QVAR REDIHALER INHALATION AEROSOL REATH ACTIVATED 40 MC/ACT, 80 MC/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER REATH ACTIVATED 50 MC/DOSE SPIRIVA HANDIHALER INHALATION CAPSULE 18 MC SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MC/ACT, 2.5 MC/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MC/ACT STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MC/ACT Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 150 ; QL (120 ML per 30 QL (2 M per 31 Pulmicort QL (2 M per 31 QL (1 EA per 31 ST QL (1 EA per 31

154 Drug Name Reference rand-eneric Notes SYMICORT INHALATION AEROSOL MC/ACT, MC/ACT terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 theochron oral tablet extended release 12 hour 100, 200, 300 Theochron theophylline er oral tablet extended release 12 hour 100, 200, 300 Theochron theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline in d5w intravenous solution /ml-% theophylline oral solution 80 /15ml TRELEY ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED MC/INH TUDORZA PRESSAIR INHALATION AEROSOL POWDER REATH ACTIVATED 400 MC/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 ASE) MC/ACT XOPENEX HFA INHALATION AEROSOL 45 MC/ACT Xopenex HFA zafirlukast oral tablet 10, 20 Accolate ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 M zileuton er oral tablet extended release 12 hour 600 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis Zyflo CR KITAIS K INHALATION Kitabis Pak NEULIZATION SOLUTION 300 M/5ML ORKAMI ORAL TALET M, M PULMOZYME INHALATION SOLUTION 1 M/ML TOI NEULIZER INHALATION Kitabis Pak ST NEULIZATION SOLUTION 300 M/5ML TOI PODHALER INHALATION CAPSULE 28 M QL (1 M per 31 ST QL (1 EA per 31 QL (2 M per 31 QL (30 M per 30 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 151

155 Drug Name Reference rand-eneric Notes tobramycin nebulization solution 300 /5ml inhalation 300 /5ml TORAMYCIN NEULIZATION SOLUTION 300 M/5ML INHALATION 300 M/5ML Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension Kitabis Pak Kitabis Pak ADCIRCA ORAL TALET 20 M Adcirca ADEMS ORAL TALET 0.5 M, 1 M, 1.5 M, 2 M, 2.5 M epoprostenol sodium intravenous solution reconstituted 0.5, 1.5 Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 152 Flolan LETAIRIS ORAL TALET 10 M, 5 M OPSUMIT ORAL TALET 10 M ORENITRAM ORAL TALET EXTENDED RELEASE M, 0.25 M, 1 M, 2.5 M, 5 M REMODULIN INJECTION SOLUTION 1 M/ML, 10 M/ML, 2.5 M/ML, 5 M/ML REVATIO ORAL SUSPENSION RECONSTITUTED 10 M/ML sildenafil citrate intravenous solution 10 /12.5ml Revatio sildenafil citrate oral tablet 20 Revatio tadalafil (pah) oral tablet 20 Adcirca TRACLEER ORAL TALET 125 M, 62.5 M TRACLEER ORAL TALET SOLULE 32 M UPTRAVI ORAL TALET 1000 MC, 1200 MC, 1400 MC, 1600 MC, 200 MC, 400 MC, 600 MC, 800 MC UPTRAVI ORAL TALET THERAPY CK 200 & 800 MC VENTAVIS INHALATION SOLUTION 10 MC/ML, 20 MC/ML Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen external cream 2 % baclofen oral tablet 10, 20, 5 carisoprodol oral tablet 250 Soma ST carisoprodol oral tablet 350 Soma ST; QL (45 EA per 31

156 Drug Name Reference rand-eneric Notes carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 500 cyclobenzaprine hcl oral tablet 10, 5 cyclobenzaprine hcl oral tablet 7.5 Fexmid dantrolene sodium oral capsule 100 dantrolene sodium oral capsule 25, 50 enovarx-cyclobenzaprine hcl transdermal cream 20 /gm Dantrium metaxall oral tablet 800 Metaxall metaxalone oral tablet 400 metaxalone oral tablet 800 Metaxall methocarbamol injection solution 1000 /10ml Robaxin methocarbamol oral tablet 500 Robaxin methocarbamol oral tablet 750 Robaxin-750 orphenadrine citrate er oral tablet extended release 12 hour 100 orphenadrine citrate injection solution 30 /ml revonto intravenous solution reconstituted 20 tizanidine hcl oral capsule 2, 4 Zanaflex tizanidine hcl oral capsule 6 Zanaflex tizanidine hcl oral tablet 2 tizanidine hcl oral tablet 4 Zanaflex vecuronium bromide-nacl intravenous solution /100ml-% Sleep Disorder Agents armodafinil oral tablet 150, 200, 250, 50 ELSOMRA ORAL TALET 10 M, 15 M, 20 M, 5 M eszopiclone oral tablet 1, 2, 3 Lunesta flurazepam hcl oral capsule 15, 30 QL (93 EA per 31 QL (63 EA per 31 Nuvigil AL (Max 23 Years) HETLIOZ ORAL CAPSULE 20 M modafinil oral tablet 100, 200 Provigil AL (Max 23 Years) ST Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 153

157 Drug Name Reference rand-eneric Notes NUVIIL ORAL TALET 150 M, 200 M, 250 M, 50 M PROVIIL ORAL TALET 100 M, 200 M RESTORIL ORAL CAPSULE 15 M, 30 M, 7.5 M ROZEREM ORAL TALET 8 M temazepam oral capsule 15, 30, 7.5 Nuvigil AL (Max 23 Years) Provigil AL (Max 23 Years) Restoril QL (1 EA per 1 day) ST; QL (1 EA per 1 day) Restoril QL (1 EA per 1 day) temazepam oral capsule 22.5 Restoril zaleplon oral capsule 10, 5 Sonata zolpidem tartrate er oral tablet extended release 12.5, 6.25 Ambien CR QL (1 EA per 1 day) zolpidem tartrate oral tablet 10, 5 Ambien QL (1 EA per 1 day) zolpidem tartrate sublingual tablet sublingual 1.75, 3.5 Intermezzo Effective October 1, 2018 =Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 154

158 Index of Drugs 1 12 hour allergy-d A abaneu-sl AELCET acarbose ACCU-CHEK FASTCLIX LANCETS ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SOFT TOUCH LANCETS ACCU-CHEK SOFTCLIX LANCETS acd formula a acd formula b acd-a noclot acebutolol hcl acetaminophen-codeine...4 acetaminophen-codeine #2...4 acetaminophen-codeine #3...4 acetaminophen-codeine #4...4 acetasol hc acetazolamide acetazolamide er acetazolamide sodium acetic acid , 143 acetylcysteine , 147 acid reducer acitretin acne medication ACTHREL ACTIMMUNE ACTONEL ACTOPLUS MET acyclovir acyclovir sodium ADACEL adapalene adapalene-benzoyl peroxide.. 72 ADCIRCA adefovir dipivoxil ADEMS adenosine... 55, 134 adenosine (diagnostic) ADLYXIN ADMELO ADMELO SOLOSTAR ADRENACLICK adriamycin adrucil ADVAIR DISKUS ADVAIR HFA AEROSN afeditab cr AFINITOR AFINITOR DISPERZ AFLURIA AFLURIA PRESERVATIVE FREE AFLURIA QUADRIVALENT. 129 AFREZZA agoneaze airavite ak-fluor ala-cort ALENZA albuked albuked albumin human albuminar albuminar albumin-zlb alburx albutein albuterol sulfate albuterol sulfate er alclometasone dipropionate. 106 alcohol ALDURAZYME ALECENSA alendronate sodium alevicyn dermal spray alfentanil hcl... 4 ALFERON N alfuzosin hcl er ALIMTA ALINIA all day allergy d allergy allergy 24hour indoor/outdoor allergy 24-hr allergy childrens allergy relief allopurinol allopurinol sodium almotriptan malate alosetron hcl ALOXI alprazolam alprazolam er alprazolam xr ALREX altacaine altafluor altafluor benox altafrin altavera ALUNRI alyacen 1/ alyacen 7/7/ amabelz AMISOME amcinonide amethia amethia lo amifostine amikacin sulfate amiloride hcl amiloride-hydrochlorothiazide 55 AMINO ACID aminoacetic acid aminoam rms aminobenzoate potassium aminocaproic acid aminophylline aminorelief rms AMINOSYN AMINOSYN II aminosyn ii/electrolytes aminosyn/electrolytes AMINOSYN-PF amiodarone hcl... 55, 56 amiodarone hcl in dextrose AMITIZA amitriptyline hcl amlodipine besylate amlodipine besylate-benazepril hcl amlodipine besylate-valsartan 56 amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan-hctz ammonium lactate amnesteem amoxapine amoxicill-clarithro-lansopraz 100 amoxicillin amoxicillin-potassium clavulanate amoxicillin-potassium clavulanate er amphetaminedextroamphetamine

159 amphetaminedextroamphetamine er amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam sodium. 17, 18 AMPYRA ANAFRANIL anagrelide hcl ana-lex anastrozole ANDRODERM ANDROEL ANDROEL PUMP anesthesia needle 23gx1-3/ ANELIQ anodyne lpt ANORO ELLIPTA anticoagulant cit dext soln a anticoagulant sodium citrate.. 27 anti-diarrheal anti-nausea anti-nausea/rekematol antivenin latrodectus mactans antivenin micrurus fulvius anucort-hc anusol-hc apap-caff-dihydrocodeine...4 apexicon e APIDRA SOLOSTAR APIDRA VIAL APLENZIN APOKYN apraclonidine hcl aprepitant apri ARALAST NP aranelle ARANESP (ALUMIN FREE) 54 ARCALYST argatroban argatroban in sodium chloride 27 argyle sterile saline armodafinil arnica flower ARNUITY ELLIPTA ARSENIC TRIOXIDE arzol silver nit applicators ASACOL HD ascomp-codeine...4 ascorbic acid ashlyna asilnasal rms ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX 7 METERED DOSES aspirin aspirin ec low dose aspirin low dose aspirin-dipyridamole er ASSURE ID SAFETY PEN NEEDLES ASTEPRO atenolol atenolol-chlorthalidone atomoxetine hcl atorvastatin calcium atovaquone atovaquone-proguanil hcl atracurium besylate atropine sulfate , 141 atropine sulfate (pf) ATROVENT HFA aubra aubra eq AUVI-Q avar cleanser avar-e emollient avar-e green AVASTIN aviane avidoxy avita AVODART AVONEX PEN AVONEX PREFILLED AVONEX VIAL INTRAMUSCULAR KIT av-phos 250 neutral av-vite fb av-vite fb forte AXERT azacitidine AZASITE azathioprine azathioprine sodium azelastine hcl , 144 AZILECT azithromycin aztreonam azuphen mb azurette b complex vitamins b-6 folic acid baciim bacitracin... 18, 139 bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen ACTROAN NASAL balanced salt balsalazide disodium balziva banophen ANZEL ARACLUDE ASALAR KWIKPEN bayer aspirin bayer aspirin ec low dose bcg vaccine bd posiflush bd pudendal/local tray/1% lido beau rx ECONASE AQ bekyree belladonna alkaloids-opium. 100 belladonna-opium ELSOMRA ELVIQ ELVIQ XR benadryl-d allergy/sinus child benazepril hcl benazepril-hydrochlorothiazide ENLYSTA benzalkonium chloride benzepro benzepro creamy wash benzepro foaming cloths benzepro short contact benziq wash ENZNIDAZOLE benzoin benzoin compound benzonatate benzoyl peroxide benzoyl peroxide-erythromycin benzphetamine hcl betamethasone dipropionate...106,

160 betamethasone dipropionate aug betamethasone sod phos & acet betamethasone valerate ETASERON betaxolol hcl... 56, 140 bethanechol chloride EVESPI AEROSPHERE bexarotene bicalutamide ICILLIN L-A ICNU bimatoprost bio glo biocel bio-statin biotuss biotuss pediatric bisoprolol fumarate bisoprolol-hydrochlorothiazide56 bivalirudin trifluoroacetate IVIAM bleomycin sulfate blisovi 24 fe blisovi fe 1.5/ blisovi fe 1/ ONIVA OOSTRIX boric acid OTOX bp bp cleansing wash bp foam bp foaming wash bp gel bp vit bp wash b-plex b-plex plus bpo foaming cloths RAFTOVI REATHE EASE LARE REATHE EASE MEDIUM REATHE EASE SMALL REATHERITE REO ELLIPTA briellyn RILINTA brimonidine tartrate RISDELLE RIVIACT bromfed dm bromfenac sodium (once-daily) bromocriptine mesylate brompheniramine maleate brompheniramine tannate ROVANA bss bss plus budesonide , 144, 148 budesonide er bumetanide buminate bupivacaine hcl bupivacaine hcl (pf) bupivacaine in dextrose bupivacaine spinal bupivacaine-epinephrine bupivacaine-epinephrine (pf). 14 bupropion hcl bupropion hcl er (smoking det) bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl busulfan butalbital-acetaminophen... 4 butalbital-apap... 4 butalbital-apap-caff-cod... 4 butalbital-apap-caffeine... 4, 5 butalbital-asa-caff-codeine... 5 butalbital-asa-caffeine... 5 butalbital-aspirin-caffeine... 5 butorphanol tartrate... 5 YDUREON YDUREON CISE AUTOINJECTOR YETTA 10 MC PEN YETTA 5 MC PEN C cabergoline CAOMETYX caffeine citrate caffeine-sodium benzoate calcipotriene calcipotriene-betameth diprop 73 calcitonin (salmon) calcitrene calcitriol... 73, 133 calcium acetate calcium acetate (phos binder) calcium chloride calcium disodium versenate 135 calcium gluconate calcium gluconate-dextrose calcium gluconate-nacl calcium-folic acid plus d CALQUENCE camila CAMTH camrese camrese lo CANASA CANCIDAS candesartan cilexetil candesartan cilexetil-hctz capacet... 5 capecitabine captopril captopril-hydrochlorothiazide 57 CARAC CARAFATE carbamazepine carbamazepine er CARATROL carbidopa carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin cardioplegic carimune nf carisoprodol carisoprodol-aspirin carisoprodol-aspirin-codeine... 5 carmustine carteolol hcl cartia xt carvedilol carvedilol phosphate er cascara sagrada caspofungin acetate CATHFLO ACTIVASE cavarest caziant cefaclor cefaclor er cefadroxil cefazolin in d5w cefazolin in sodium chloride.. 18 cefazolin sodium cefazolin sodium-dextrose cefdinir cefditoren pivoxil cefepime hcl cefepime-dextrose cefixime CEFOTAN cefotaxime sodium cefotetan disodium

161 cefotetan disodium-dextrose.. 19 cefoxitin sodium cefoxitin sodium-dextrose cefpodoxime proxetil cefprozil... 19, 20 ceftazidime ceftibuten ceftriaxone sodium ceftriaxone sodium in dextrose ceftriaxone sodium-dextrose.. 20 cefuroxime axetil cefuroxime sodium celacyn celecoxib cem-urea cephalexin ceramax CERDELA CEREZYME cerisa wash cerovel cetirizine hcl cetirizine hcl childrens cetirizine hcl childrens alrgy. 144 cevimeline hcl CHANTIX CHANTIX CONTINUIN MONTH K CHANTIX STARTIN MONTH K chateal chateal eq CHEMET childrens allergy chloramphenicol sod succinate chlordiazepoxide hcl chlordiazepoxide-amitriptyline 33 chlordiazepoxide-clidinium chlorhexidine gluconate. 71, 135 chloromag chloroprocaine hcl (pf) chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpropamide chlorthalidone chlorzoxazone CHOLAM cholestyramine cholestyramine light choline fenofibrate choline-mag trisalicylate chromagen chromic chloride cicatrace pad ciclodan ciclopirox ciclopirox olamine ciclopirox treatment cidofovir cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA PREFILLED KIT CIMZIA STARTER KIT CINRYZE CIPRO CIPRODEX ciprofloxacin... 20, 21 ciprofloxacin hcl... 20, 139, 143 ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er.. 21 cisatracurium besylate cisatracurium besylate (pf) cisplatin citalopram hydrobromide CITRANATAL MEDLEY cladribine CLAFORAN claravis clarithromycin clarithromycin er CLARITIN REDITAS clearlax clemastine fumarate CLIMARA CLIMARA PRO clindacin etz clindacin-p clindamycin hcl clindamycin palmitate hcl clindamycin phosphate... 21, 74 clindamycin phosphate in d5w clindamycin phosphate-benzoyl peroxide clindamycin-tretinoin clinimix e/dextrose (4.25/25).. 88 clinimix/dextrose (4.25/10) clinimix/dextrose (4.25/20) clinimix/dextrose (4.25/25) clinisol sf clinpro clobetasol prop emollient base clobetasol propionate clobetasol propionate e clobetasol propionate emulsion clocortolone pivalate clocortolone pivalate pump clodan clofarabine clomipramine hcl clonazepam clonidine hcl clonidine hcl (analgesia) clonidine hcl er clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole-betamethasone. 74 coal tar cocaine hcl cod liver oil codeine sulfate... 5 COLCHICINE colchicine-probenecid COLCRYS colesevelam hcl COLESTID... 57, 58 COLESTID FLAVORED colestipol hcl colistimethate sodium (cba) colocort COLY-MYCIN M COLY-MYCIN S COMITCH compro condoms constulose CONTRAVE copper chloride coremino CORLANOR cormax scalp application cortic-nd cortisone acetate corvita corvita corvite free COSENTYX 150 M/ML COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COSENTYX SENSOREADY PEN cosyntropin COTELLIC cough dm covaryx covaryx hs

162 CREON CRESEMA cromolyn sodium.. 100, 139, 148 crotan cryselle CRYSVITA CUICIN CUICIN RF curity sterile saline CUVITRU cyanocobalamin cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl cyclopentolate hcl cyclophosphamide cycloserine cyclosporine cyclosporine modified cyotic cyproheptadine hcl cyred cytarabine cytarabine (pf) CYTOAM cytra k crystals D dacarbazine dactinomycin DAKLINZA dalfampridine er DALIRESP DALVANCE danazol dantrolene sodium dapsone... 40, 74 DAPTACEL daptomycin darifenacin hydrobromide er 104 dasetta 1/ dasetta 7/7/ daunorubicin hcl daysee DDAVP deblitane decitabine deferoxamine mesylate dehydrated alcohol deltasone delyla DELZICOL demeclocycline hcl denta 5000 plus dentagel DEPO-PROVERA derma silkrx sds pak dermacinrx empricaine dermacinrx prizopak dermawerx sds dermazene desipramine hcl desloratadine desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray 112 desogestrel-ethinyl estradiol 116 desonide desoximetasone desvenlafaxine succinate er.. 33 dexamethasone dexamethasone sod phos-nacl dexamethasone sod phosphate pf dexamethasone sodium phosphate , 139 dexifol DEXILANT dexmedetomidine hcl dexmedetomidine hcl in nacl 135 dexmethylphenidate hcl dexmethylphenidate hcl er dexrazoxane dextroamphetamine sulfate dextroamphetamine sulfate er 67 dextrose dextrose in lactated ringers dextrose-nacl diab diab f.d.g. freeze-dried dialyvite diazepam... 29, 52 diazepam intensol diclofenac potassium diclofenac sodium... 11, 74, 139 diclofenac sodium er diclofenac-misoprostol diclofex dc diclopak diclosaicin diclotral dicloxacillin sodium dicyclomine hcl diethylpropion hcl diethylpropion hcl er difil-g forte diflorasone diacetate diflunisal digitek digox digoxin dihydroergotamine mesylate. 39 DILAUDID... 5 diltiazem cd diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads 58 diltiazem hcl-dextrose diltiazem hcl-sodium chloride 58 dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoids dt 129 dipyridamole... 50, 135 disopyramide phosphate disulfiram divalproex sodium divalproex sodium er dobutamine hcl dobutamine in d5w docetaxel... 42, 43 docetaxel (non-alcohol) docusate sodium dofetilide donepezil hcl dopamine hcl dopamine in d5w DOPTELET dorzolamide hcl dorzolamide hcl-timolol mal. 140 dorzolamide hcl-timolol mal pf dover vinyl urethral cath 16fr 135 doxazosin mesylate doxepin hcl... 33, 74 doxercalciferol doxorubicin hcl doxorubicin hcl liposomal doxy doxycycline doxycycline hyclate doxycycline monohydrate dritho-creme hp dronabinol droperidol DROPLET INSULIN SYRINE drospiren-eth estrad-levomefol drospirenone-ethinyl estradiol

163 DUAVEE duloxetine hcl duramorph...5 duraxin...5 DUREX EXTRA SENSITIVE 135 DUREX REALFEEL dutasteride dutasteride-tamsulosin hcl E e.e.s EASIVENT easygel econazole nitrate EDECRIN ed-spaz eemt eemt hs effer-k effervescent pot chloride ELAPRASE ELDEPRYL eletriptan hydrobromide ELIDEL ELIARD elinest ELIQUIS ELIQUIS STARTER CK ELLA EMEND emoquette EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide. 59 ENREL ENREL SURECLICK endocet...5 ENERIX enovarx-cyclobenzaprine hcl 153 enoxaparin sodium... 27, 28 enpresse enskyce entacapone entecavir ENTRESTO enulose EPCLUSA ephedrine sulfate EPIDUO FORTE epinastine hcl epinephrine EPINEPHRINE epinephrine pf EPIPEN 2-K EPIPEN JR 2-K epirubicin hcl epitol eplerenone EPOEN epoprostenol sodium eprosartan mesylate eptifibatide ERITUX ergocalciferol ergoloid mesylates ergotamine-caffeine ERLEADA errin ertapenem sodium ery erythrocin lactobionate erythromycin... 74, 139 erythromycin base erythromycin ethylsuccinate.. 23 ESRIET escitalopram oxalate esgic... 5 esmolol hcl esmolol hcl-sodium chloride.. 59 esomeprazole magnesium esomeprazole sodium est estrogens-methyltest est estrogens-methyltest ds. 116 est estrogens-methyltest hs. 117 estarylla estazolam estradiol estradiol valerate estradiol-norethindrone acet 117 ESTROEL estropipate eszopiclone ethacrynate sodium ethacrynic acid ethambutol hcl ethosuximide ethyl chloride ethynodiol diac-eth estradiol 117 etidronate disodium etodolac etodolac er etomidate etoposide EUCRISA EURAX exemestane EXJADE exoderm exotic-hc EXTAVIA EZ FLU SHOT-FLUCELVAX QUAD ezetimibe ezetimibe-simvastatin F fabb FARAZYME face mask resp n-100 part face mask respirator r-95 part falmina famciclovir famotidine famotidine premixed FARXIA FARYDAK FASLODEX fa-vitamin b-6-vitamin b fayosim felbamate felodipine er femynor fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fenortho fentanyl... 6 fentanyl citrate... 5 fentanyl citrate (pf)... 5 fentanyl citrate-nacl... 5, 6 fentanyl cit-ropivacaine-nacl... 6 FENTORA... 6 ferocon ferosul ferotrinsic ferraplus ferrocite plus ferrous sulfate fexofenadine hcl fexofenadine-pseudoephed er FIASP FIASP FLEXTOUCH FINACEA... 74, 75 finasteride FIRVANQ flavoxate hcl FLEOAMMA DIF flecainide acetate flexbumin floriva floriva plus FLOVENT HFA floxuridine

164 FLUAD FLUARIX QUADRIVALENT. 129 FLULOK FLULOK QUADRIVALENT 129 flucaine FLUCELVAX FLUCELVAX QUADRIVALENT fluconazole fluconazole in dextrose fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate FLULAVAL QUADRIVALENT flumazenil flunisolide fluocinolone acetonide 108, 109, 143 fluocinolone acetonide body. 108 fluocinolone acetonide scalp 109 fluocinonide fluocinonide emulsified base 109 fluor-a-day fluorescein-benoxinate fluoridex fluoridex daily renewal fluoridex enhanced whitening. 71 fluoridex sensitivity relief fluor-i-strips a.t fluoritab fluorometholone fluorouracil... 43, 75 FLUOROURACIL fluoxetine hcl... 33, 34 fluoxetine hcl (pmdd) flurandrenolide flurazepam hcl flurbiprofen flurbiprofen sodium flurox flutamide fluticasone propionate.. 109, 145 FLUTICASONE-SALMETEROL fluvastatin sodium fluvastatin sodium er FLUVIRIN fluvoxamine maleate fluvoxamine maleate er FLUZONE HIH-DOSE FLUZONE QUADRIVALENT130 FML FORTE FOCALIN folbee folbee plus folbee plus cz folbic foley catheter 2-way folic acid folplex foltrin fomepizole fondaparinux sodium formadon formaldehyde forma-ray formula em FORTAMET FORTEO FORTESTA fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium FRAMIN FREAMINE III FREESTYLE FREEDOM LITE FREESTYLE INSULINX SYSTEM FREESTYLE INSULINX TEST fresenius propoven frovatriptan succinate ful-glo FULPHILA furosemide fyavolv gabapentin galantamine hydrobromide galantamine hydrobromide er 32 AMASTAN gamastan s/d AMASTAN S/D AMMAARD AMMAARD S/D LESS IA AMMAKED AMMAPLEX AMUNEX-C ganciclovir sodium ARDASIL ARDASIL gatifloxacin gavilax gavilyte-c gavilyte-g gavilyte-h gavilyte-n with flavor pack ELNIQUE ELNIQUE PUMP gemcitabine hcl gemfibrozil generlac gengraf ENOTROPIN ENOTROPIN MINIQUICK 113 gentak gentamicin in saline gentamicin sulfate... 23, 139 gianvi gildagia ILENYA ILOTRIF giltuss pediatric glatiramer acetate glatopa glimepiride glipizide er glipizide ir glipizide xl glipizide-metformin hcl glostrips LUCAEN HYPOKIT LUCAON EMERENCY.. 82 glucagon hcl (diagnostic) LUCOPHAE glucose LUMETZA glutaraldehyde glyburide glyburide micronized glyburide-metformin glycine glycine urologic glycolax glycolic acid glycopyrrolate glydo LYXAMI gnp all day pain relief goodsense acid reducer granisetron hcl green glo lissamine green griseofulvin microsize griseofulvin ultramicrosize RIS-PE guanfacine hcl guanfacine hcl er guanidine hcl H halac

165 HALAVEN halobetasol propionate HARVONI HAVRIX heartburn relief 150 max st heather HEMANEOL hematinic plus vit/minerals hematinic/folic acid hematogen hematogen fa hematogen forte hemmorex-hc hemocyte-f hemocyte-plus heparin (porcine) in d5w heparin (porcine) in nacl heparin lock flush heparin sod (porcine) in d5w.. 28 heparin sodium (porcine) heparin sodium (porcine) pf heparin sodium flush heparin sodium lock flush heparin sodium/d5w hepatamine HERCEPTIN hetastarch-nacl HETLIOZ HIZENTRA homatropaire homatropine hbr HP ACTHAR HUMALO KWIKPEN HUMALO MIX 50/50 KWIKPEN HUMALO MIX 50/50 VIAL HUMALO MIX 75/25 KWIKPEN HUMALO MIX 75/25 VIAL HUMALO U-100 JUNIOR KWIKPEN HUMALO U-100 VIAL AND CARTRIDE human albumin grifols HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CD/UC/HS STARTER HUMIRA PEN-PS/UV STARTER HUMULIN 70/30 KWIKPEN HUMULIN 70/30 VIAL HUMULIN N KWIKPEN HUMULIN N VIAL HUMULIN R U-500 KWIKPEN HUMULIN R U-500 VIAL (CONCENTRATED) HUMULIN R VIAL HYCAMTIN hydralazine hcl... 60, 61 hydrochlorothiazide hydrocodone polst-cpm polst er hydrocodone-acetaminophen.. 6 hydrocodone-homatropine hydrocodone-ibuprofen... 7 hydrocortisone , 110, 132 hydrocortisone ace-pramoxine... 75, 132 hydrocortisone acetate hydrocortisone butyr lipo base hydrocortisone butyrate hydrocortisone in absorbase 109 hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-iodoquinol hydrogen peroxide hydromet hydromorphone hcl... 7 hydromorphone hcl er... 7 hydromorphone hcl pf... 7 hydromorphone hcl-nacl... 7 hydromorphone-bupivacainenacl... 7 hydromorphone-ropivacainenacl... 7 hydroxocobalamin hydroxychloroquine sulfate hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate hyolev mb hyophen hyoscyamine sulfate hyoscyamine sulfate er hyoscyamine sulfate sl hyosyne HYPERHEP S/D hyperlyte-cr HYPERRHO S/D I ibandronate sodium IRANCE ibudone... 7 ibuprofen ibuprofen childrens ibuprofen lysine ibutilide fumarate idarubicin hcl IDHIFA iferex 150 forte ifosfamide imatinib mesylate IMRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMVIDO incassia INCRELEX INCRUSE ELLIPTA indapamide indigo carmine indiomin mb indocyanine green indomethacin indomethacin er indomethacin sodium INFANRIX infed inflammacin INFLECTRA infusion needle 15gx infuvite adult infuvite pediatric INSULIN PEN NEEDLES 84, 85 insulin pump ir INSULIN SYRINES intralipid INTRALIPID INTRON A introvale INTUNIV inulin INVANZ INVOKAMET INVOKAMET XR INVOKANA iodine strong iodine tincture iodoquinol-hc-aloe polysacch 23 iodoquinol-hydrocortisone-aloe ipratropium bromide...145, 149 ipratropium-albuterol irbesartan

166 irbesartan-hydrochlorothiazide irinotecan hcl isibloom isoflurane isometheptene-caffeine-apap. 12 isometheptene-dichloral-apap 12 isoniazid isoproterenol hcl isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isosulfan blue isotretinoin isoxsuprine hcl isradipine itraconazole ivermectin IXEMPRA KIT J jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla jevantique lo jinteli jolessa jolivette JULIA juleber junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ junel fe JYNARQUE K kaitlib fe karaya gum kariva kcl in d5w lactated ringers kcl in dextrose-nacl kcl-lactated ringers-d5w kcl-lidocaine in d5w kedbumin k-effervescent kelnor 1/ kelnor 1/ KEPPRA XR ketamine hcl ketamine hcl-sodium chloride ketoconazole ketoprofen ketoprofen er ketorolac tromethamine. 12, 139 kimidess KIMONO MICRO THIN KINERET KISQALI 200 DOSE KISQALI 400 DOSE KISQALI 600 DOSE KITAIS K klofensaid ii klor-con klor-con klor-con m klor-con m klor-con sprinkle klor-con/ef k-prime k-tan plus kurvelo KUVAN k-vescent KYNAMRO L labetalol hcl lactated ringers lactic acid lactic acid e lactulose lactulose encephalopathy lamivudine lamotrigine lamotrigine er lamotrigine starter kit-blue lamotrigine starter kit-green lamotrigine starter kit-orange. 30 LANCETS lansoprazole lanthanum carbonate LANTUS SOLOSTAR LANTUS U-100 VIAL larin 1.5/ larin 1/ larin 24 fe larin fe 1.5/ larin fe 1/ larissia LASTACAFT latanoprost latrix latrix xm layolis fe l-cysteine hcl lecithin leena leflunomide LENVIMA 10 M DAILY DOSE LENVIMA 14 M DAILY DOSE LENVIMA 18 M DAILY DOSE LENVIMA 20 M DAILY DOSE LENVIMA 24 M DAILY DOSE LENVIMA 8 M DAILY DOSE lessina LETAIRIS letrozole leucovorin calcium leuprolide acetate leva set/occlusive dressing levalbuterol hcl LEVALUTEROL HFA LEVEMIR U-100 FLEXTOUCH LEVEMIR U-100 VIAL levetiracetam levetiracetam er levetiracetam in nacl levicyn dermal spray levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin... 23, 139 levofloxacin in d5w levoleucovorin calcium levoleucovorin calcium pf levonest levonorgest-eth est & eth est118 levonorgest-eth estrad 91-day...118, 119 levonorgestrel levonorgestrel-ethinyl estrad 119 levonorg-eth estrad triphasic 119 levora 0.15/30 (28) levorphanol tartrate... 7 levo-t levothyroxine sodium levothyroxine-liothyronine levoxyl lice treatment lidenza lido bdk lidocaine lidocaine hcl... 14, 15,

167 lidocaine hcl (cardiac) lidocaine hcl (pf) lidocaine in d5w lidocaine pak lidocaine viscous lidocaine-epinephrine lidocaine-hydrocortisone ace 75, 132 lidocaine-prilocaine lido-k lidopin lidopril lidopril xr lido-prilo caine pack lillow lincomycin hcl lindane linezolid... 23, 24 linezolid in sodium chloride LINZESS liothyronine sodium , 124 lipodox liprozonepak lisinopril lisinopril-hydrochlorothiazide.. 61 lissamine green little tummys nausea relief livixil pak lmd in d5w lmd in nacl l-methylfolate l-methylfolate ca me-cbl nac.. 91 l-methylfolate calcium l-methylfolate formula l-methylfolate forte l-methylfolate-algae l-methylfolate-algae-b12-b l-methylfolate-b6-b LODOSYN lomedia 24 fe LONHALA MANAIR REFILL KIT LONHALA MANAIR STARTER KIT LONSURF loperamide hcl lopreeza loratadine lorazepam lorazepam intensol lorazepam-dextrose lorazepam-sodium chloride lorcet...7 lorcet hd...7 lorcet plus...7 lorenza loryna losartan potassium losartan potassium-hctz LOTEMAX lovastatin low-ogestrel lp lite pak LUCENTIS ludent lugols LUMIAN LUMIZYME LUNETA CK LUPRON DEPOT (1-MONTH) LUPRON DEPOT (3-MONTH) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30M LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45M LUPRON DEPOT-PED (1- MONTH) LUPRON DEPOT-PED (3- MONTH) lutera luxamend LYNRZA LYRICA lysiplex plus lyza M MACRODANTIN MACUEN mafenide acetate magnesium chloride magnesium sulfate magnesium sulfate in d5w magnesium sulfate-lact ringers magnesium sulfate-nacl MAKENA malathion manganese chloride manganese sulfate mannitol mapap... 7 maprotiline hcl marlissa marten-tab... 7 MATULANE matzim la MAVYRET me/naphos/mb/hyo meclizine hcl meclofenamate sodium MEDICAL PROVIDER EZ AFLURIA PF MEDICAL PROVIDER EZ FLU PF MEDICAL PROVIDER EZ FLU SHOT MEDICAL PROVIDER EZ FLUVIRIN medolor pak medroxyprogesterone acetate mefenamic acid mefloquine hcl mega-c/a plus megestrol acetate MEKINIST MEKTOVI melodetta 24 fe meloxicam melphalan melphalan hcl memantine hcl memantine hcl er MENACTRA MENOMUNE MENOSTAR MENVEO meperidine hcl... 7, 8 meperidine hcl-sodium chloride8 meperidine-promethazine... 8 meprobamate MEPSEVII mercaptopurine meropenem meropenem-sodium chloride. 24 mesalamine mesalamine-cleanser mesna MESTINON metadate er metafolbic plus rf metaproterenol sulfate metaxall metaxalone metformin hcl er metformin hcl er (mod) metformin hcl er (osm) metformin hcl ir METFORMIN HCL IR methadone hcl... 8 methadone hcl intensol

168 methadose...8 methadose sugar-free...8 methamphetamine hcl methazolamide methenamine hippurate methenamine mandelate methergine methimazole methocarbamol methohexital sodium methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen methoxsalen rapid methscopolamine bromide methyclothiazide methyl salicylate methyldopa methyldopa-hydrochlorothiazide methyldopate hcl methylene blue methylergonovine maleate methylfol-algae-b12-acetylcyst methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methylprednisolone ace-lido 110 methylprednisolone acetate. 110 methylprednisolone sodium succ methyltestosterone metipranolol metoclopramide hcl... 35, 36 metolazone metopic metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 24, 75 metronidazole in nacl mexiletine hcl MIACALCIN mibelas 24 fe miconazole MICRHOAM ULTRA- FILTERED PLUS microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ midazolam hcl midazolam hcl-nacl midazolam hcl-sodium chloride midodrine hcl miglitol miglustat mili milrinone lactate milrinone lactate in dextrose.. 62 mimvey mimvey lo mineral oil heavy minitran minocycline hcl minocycline hcl er minoxidil mirtazapine MIRVASO misoprostol mitigo... 8 mitomycin mitoxantrone hcl mm anti-diarrheal modafinil moderiba MODERIA 1200 DOSE CK MODERIA 800 DOSE CK moexipril hcl moexipril-hydrochlorothiazide 62 mometasone furoate , 145 mondoxyne nl monoject flush syr/hep lock. 137 monoject flush syringe monoject prefill adv heparin. 137 monoject sodium chloride flush mono-linyah mononessa montelukast sodium morgidox morphine sulfate... 9 morphine sulfate (concentrate) 8 morphine sulfate (pf)... 8 morphine sulfate er... 8 morphine sulfate er beads... 8 morphine sulfate-nacl... 9 moxifloxacin hcl... 24, 139 moxifloxacin hcl in nacl MS CONTIN... 9 multi vitamin/fluoride multigen multigen folic multigen plus multitrace multitrace-4 concentrate multitrace-4 neonatal multitrace multitrace-5 concentrate multi-vit/fluoride multi-vit/fluoride/iron multi-vit/iron/fluoride multivitamin/fluoride multi-vitamin/fluoride multi-vitamin/fluoride multivitamin/fluoride/iron multi-vitamin/fluoride/iron multivitamins/fluoride mupirocin mupirocin calcium mutamycin mvc-fluoride MYALEPT MYCAMINE mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium myferon 150 forte mynephrocaps mynephron myorisan MYRETRIQ myzilra N na ferric gluc cplx in sucrose. 93 nabi-hb nabumetone n-acetyl-l-cysteine nadolol nadolol-bendroflumethiazide. 63 nafcillin sodium... 24, 25 nafcillin sodium in dextrose nafrinse nafrinse drops naftifine hcl NALAZYME nalbuphine hcl... 9 NAMENDA XR TITRATION CK naproxen naproxen dr naproxen sodium naproxen sodium er naratriptan hcl NASONEX nateglinide NATESTO

169 NATRA nature-throid nausatrol nebusal necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 7/7/ nefazodone hcl neomycin sulfate neomycin-bacitracin zn-polymyx neomycin-polymyxin b gu neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc 142, 143 NEONATAL VITAMIN neo-polycin neo-polycin hc neostigmine methylsulfate nephronex NERLYNX neuac NEULASTA NEULASTA ONPRO NEUPOEN neutragard advanced neutral sodium fluoride NEXAVAR niacin er (antihyperlipidemic). 63 niacor NIASN nicardipine hcl NICORETTE nicotine polacrilex nicotine step nicotine step nicotine step NICOTROL NICOTROL NS nifedical xl nifedipine nifedipine er nifedipine er osmotic release. 63 nikki nilutamide nimodipine NINLARO nisoldipine er nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohydrate macrocrystals nitroglycerin nitroglycerin er nitroglycerin in d5w nitroprusside sodium NITROSTAT nitro-time niva-fol nizatidine NOCTIVA nodolor nolix nora-be NORDITROPIN FLEXPRO norepinephrine bitartrate norepinephrine-dextrose norepinephrine-sodium chloride norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestimate-ethinyl estradiol triphasic norlyda norlyroc normal saline flush normosol-m in d5w normosol-r normosol-r in d5w NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/ nortriptyline hcl nortuss-ex NOVOFINE AUTOCOVER PEN NEEDLE NOVOFINE PEN NEEDLE NOVOFINE PLUS PEN NEEDLE NOVOLIN 70/30 RELION NOVOLIN 70/30 VIAL NOVOLIN N RELION NOVOLIN N VIAL NOVOLIN R RELION NOVOLIN R VIAL NOVOLO FLEXPEN NOVOLO MIX 70/30 FLEXPEN NOVOLO MIX 70/30 VIAL.. 86 NOVOLO PENFILL NOVOLO U-100 VIAL NOVOTWIST PEN NEEDLE. 86 NOXAFIL np thyroid NPLATE NUCYNTA... 9 nudiclo solupak nudiclo tabpak nufol nulev numoisyn nutriarx creampak nutricap nutrifac zx nutrilipid nutrilyte NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUVARIN NUVIIL nyamyc nyata nystatin nystatin-triamcinolone nystop O ocella OCTAAM octreotide acetate ocucoat viscoadherent ODOMZO OFEV ofloxacin... 25, 139, 143 ogestrel okebo olmesartan medoxomil olmesartan medoxomil-hctz.. 64 olmesartan-amlodipine-hctz.. 64 olopatadine hcl...139, 146 OLYSIO omega-3-acid ethyl esters omeppi omeprazole omeprazole-sodium bicarbonate OMNARIS OMNITROPE ondansetron hcl ondansetron hcl-nacl ondansetron odt ONLYZA ONA ER... 9 opium

170 OPSUMIT oralone ORENITRAM ORKAMI orphenadrine citrate orphenadrine citrate er orsythia ortho-cs oscimin oscimin sr oseltamivir phosphate osmitrol OTEZLA otomax-hc OTREXUP OVIDE oxacillin sodium oxaliplatin oxandrolone , 112 oxaprozin oxazepam oxcarbazepine oxiconazole nitrate oxybutynin chloride oxybutynin chloride er oxycodone hcl...9 oxycodone-acetaminophen...9 oxycodone-aspirin...9 oxycodone-ibuprofen...9 oxymorphone hcl oxymorphone hcl er oxytocin oxytocin-dextrose oxytocin-sodium chloride OXYTROL OXYTROL FOR WOMEN P pacerone paclitaxel palonosetron hcl pamidronate disodium pancuronium bromide panlor pantoprazole sodium papaverine hcl paregoric paricalcitol paroex paromomycin sulfate paroxetine hcl paroxetine hcl er paroxetine mesylate pb-hyoscy-atropinescopolamine peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl 102 peg-3350/electrolytes PEASYS PEASYS PROCLICK peg-prep pegylax penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTASA pentazocine-naloxone hcl pentobarbital sodium pentoxifylline er pepcid ac maximum strength. 99 PERFOROMIST perindopril erbumine periogard permethrin perphenazine-amitriptyline pfizerpen phenadoz phenazo phenazopyridine hcl phendimetrazine tartrate phendimetrazine tartrate er phenergan phenobarbital... 30, 31 phenobarbital sodium phenobarbital-belladonna alk phenohytro phenoxybenzamine hcl phentermine hcl phentolamine mesylate phenylephrine hcl... 64, 142 phenylephrine hcl-nacl phenylephrine-guaifenesin phenytoin phenytoin infatabs phenytoin sodium phenytoin sodium extended philith phos-flur phospha 250 neutral phosphasal phosphorous phospho-trin 250 neutral phrenilin forte phytonadione pilocarpine hcl... 72, 141 pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl 81 piperacillin sod-tazobactam so pirmella 1/ pirmella 7/7/ piroxicam piston irrigation syringe PLAN ONE-STEP plasbumin plasbumin PLERIDY PLERIDY STARTER CK 69 plenamine pneumovax PNEUMOVAX PNV PRENATAL PLUS MULTIVIT+DHA pocket spacer podocon podofilox polocaine polocaine-mpf polycin polyethylene glycol poly-iron 150 forte polymyxin b sulfate polymyxin b-trimethoprim polysaccharide iron forte POMALYST portia port-prep pot bicarb-pot chloride potassium acetate potassium bicarbonate potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium chloride proamp potassium citrate er potassium citrate-citric acid potassium phosphates pr benzoyl peroxide wash PRADAXA pralidoxime chloride pramcort pramipexole dihydrochloride. 49 pramipexole dihydrochloride er pramox prasugrel hcl pravastatin sodium praziquantel

171 prazosin hcl PRECISION XTRA PRECISION XTRA LOOD LUCOSE PRECISION XTRA KETONE. 82 prednicarbate prednisolone prednisolone acetate prednisolone acetate p-f prednisolone sodium phosphate , 140 prednisolone-moxifloxacin prednisolon-moxiflox-bromfenac prednisone , 111 PREFEST PREMARIN premasol PREMASOL PREMESISRX premium condoms lubricated premium lidocaine PREMPHASE PREMPRO PRENATAL MULTI +DHA PRENATAL PLUS IRON PREVACID SOLUTA prevalite prevident previdolrx plus analgesic previfem PREVNAR PREVYMIS prikaan prikaan lite prilolid PRILOSEC OTC prilovix priloxx lp primaquine phosphate primidone PRIVIEN PRO COMFORT INSULIN SYRINE PROAIR HFA probenecid procainamide hcl prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSI profeno progesterone progesterone micronized , 122 PROLASTIN-C PROLIA promethazine hcl promethazine vc plain promethazine vc/codeine promethazine-codeine promethazine-dm promethazine-phenylephcodeine promethazine-phenylephrine 146 promethegan propafenone hcl propafenone hcl er propantheline bromide proparacaine hcl proparacaine-fluorescein propofol propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil protamine sulfate protriptyline hcl PROVENTIL HFA PROVIIL prutect pseudoeph-chlorphen-hydrocod pseudoephedrine-bromphen-dm PULMICORT FLEXHALER PULMICORT SUSPENSION150 pulmosal PULMOZYME purevit dualfe plus pyrazinamide pyridostigmine bromide pyridostigmine bromide er pyridoxine hcl pyrogallic acid Q QSYMIA quasense quazepam quflora pediatric quinapril hcl quinapril-hydrochlorothiazide. 65 quinidine gluconate quinidine gluconate er quinidine sulfate quinine sulfate QVAR QVAR REDIHALER R ra iron RAAVERT rabeprazole sodium radiagel RADICAVA rajani raloxifene hcl ramipril RANEXA ranitidine acid reducer ranitidine hcl... 99, 100 RAFLO rasagiline mesylate RASUVO RAVICTI rea lo rea lo REIF REIF REIDOSE REIF REIDOSE TITRATION CK REIF TITRATION CK recedo reclipsen regonol relador pak relador pak plus releevia ml RELENZA DISKHALER relexxii RELNATE DHA RELX remeven REMICADE remifentanil hcl REMODULIN RENAEL renal repaglinide repaglinide-metformin hcl REQUIP XL RESTASIS RESTASIS MULTIDOSE restizan RESTORIL RETACRIT RETIN-A RETROVIR reusable syringe barrel 1.5oz

172 reusable syringe barrel 1oz reusable syringe barrel 2oz reusable syringe barrel 3oz reusable syringe barrel 4oz REVATIO REVLIMID revonto RHOAM ULTRA-FILTERED PLUS RHOPHYLAC ribasphere ribasphere ribapak ribavirin RIDAURA rifabutin rifampin riluzole rimantadine hcl ringers RIOMET risedronate sodium RITUXAN rivastigmine rivastigmine tartrate rivelsa rizatriptan benzoate... 39, 40 robb-type angio syringe 80cc robitussin 12 hour cough child rocuronium bromide ropinirole hcl ropinirole hcl er ropivacaine hcl ropivacaine hcl-nacl rosadan rosanil cleanser rosuvastatin calcium roweepra roweepra xr ROZEREM RURACA RYDAPT ryvent S SAIZEN SAIZEN CLICK.EASY SAIZENPREP salacyn SALAEN salicylic acid salicylic acid er salicylic acid wart remover salicylic acid-cleanser salimez saline flush saline flush zr salisol forte salitech forte salsalate salvax sanadermrx skin repair sash kit SAVAYSA SAVELLA SAVELLA TITRATION CK 71 scopolamine seb-prev wash selegiline hcl selenium selenium sulfide selenium sulf-pyrithione-urea. 77 SENSIR sensorcaine sensorcaine/epinephrine sensorcaine-mpf sensorcaine-mpf spinal sensorcaine-mpf/epinephrine 16 SEREVENT DISKUS SEROSTIM sertraline hcl se-tan plus setlakin sevelamer carbonate sevoflurane sf 72 sf 5000 plus sharobel sharps container SHINRIX siderol sildenafil citrate SILIQ silver nitrate silver sulfadiazine simvastatin sirolimus sod benz-sod phenylacet sod citrate-citric acid sodium acetate sodium ascorbate sodium bicarbonate... 96, 102 sodium chloride... 96, 147 sodium chloride flush sodium fluoride sodium hyaluronate sodium lactate sodium nitrite sodium phenylbutyrate sodium phosphate-nacl sodium phosphates sodium saccharin sodium saccharin dihydrate. 138 sodium sulfacetamide sodium thiosulfate SOLIQUA SOLOSEC soloxide SOLU-CORTEF soluline solupicc SOMAVERT sonafine SOOLANTRA sorbitol sorbitol-mannitol sorine sotalol hcl sotalol hcl (af) SOVALDI spinosad SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz sprintec SPRYCEL sronyx ssd sss STELATRO STELUJAN STIMATE STIOLTO RESPIMAT STIVARA stool softener streptomycin sulfate STRIVERDI RESPIMAT strovite forte subvenite subvenite starter kit-blue subvenite starter kit-green subvenite starter kit-orange succinylcholine chloride sucralfate sufentanil citrate sulfacetamide sodium... 77, 140 sulfacetamide sodium (acne) 77 sulfacetamide sodium-sulfur. 77, 78 sulfacetamide sod-sulfur wash sulfacetamide-prednisolone 142 sulfacetamide-sulfur in urea

173 sulfacetamide-sulfur-sunscreen sulfacleanse 8/ sulfadiazine sulfamethoxazole-trimethoprim sulfamez wash sulfasalazine sulfatrim pediatric sulfurated lime sulindac sumatriptan sumatriptan succinate sumatriptan succinate refill sumatriptan-naproxen sodium 40 SUPPRELIN LA SUPRAX sure result dss premium pack 13 SUTENT swabflush saline flush syeda symax-sl symax-sr SYMICORT SYMLINPEN SYMLINPEN synalar SYNAREL SYNJARDY SYNJARDY XR SYNTHAMIN SYNTHROID synvexia T tacrolimus... 78, 128 tadalafil (pah) TAFINLAR TARISSO TAMIFLU tamoxifen citrate tamsulosin hcl tandem f TANZEUM TARCEVA TARRETIN tarina fe 1/ taron-crystals TASINA TAVALISSE tazarotene tazicef TAZORAC taztia xt tb syringe 1 ml TECENTRIQ TECFIDERA... 69, 70 TECHNIVIE telmisartan telmisartan-amlodipine telmisartan-hctz temazepam temozolomide temsirolimus tencon teniposide TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole terrell TESTIM testosterone TESTOSTERONE testosterone cypionate testosterone enanthate tetanus-diphtheria toxoids td 131 tetcaine tetrabenazine tetracaine hcl... 16, 143 tetracycline hcl tetravisc tetravisc forte tetrix tgt clotrimazole THALOMID theochron theophylline theophylline er theophylline in d5w thiamine hcl thiotepa THROMATE III THYMOLOULIN THYROEN tiagabine hcl TISOVO TICE C tigecycline tilia fe timolol maleate... 66, 141 tinidazole titus needle 18gx1-1/ tizanidine hcl tl gard rx tl icon tl-hem TOI NEULIZER TOI PODHALER tobramycin , 152 TORAMYCIN tobramycin sulfate tobramycin-dexamethasone 143 TODAY SPONE tolazamide tolbutamide tolcapone tolmetin sodium tolterodine tartrate tolterodine tartrate er tonsil ndl curved 23gx1/ tonsil ndl straight 23gx3/ topex topical anesthetic topiramate topiramate er toposar topotecan hcl TORISEL torsemide TOUJEO MAX SOLOSTAR.. 86 TOUJEO SOLOSTAR TOVIAZ tpn electrolytes TRACLEER tramadol hcl er tramadol hcl er (biphasic) tramadol hcl ir tramadol-acetaminophen trandolapril trandolapril-verapamil hcl er.. 66 tranexamic acid TRAVASOL trazodone hcl TREANDA TRELEY ELLIPTA TRELSTAR MIXJECT TRESIA FLEXTOUCH tretinoin... 47, 78 tretinoin microsphere tretinoin microsphere pump TRETIN-X tri femynor triamcinolone acetonide 72, 111, 147 triamterene-hctz triazolam tricitrates tricon triderm tri-estarylla trifluridine trigels-f forte triklo tri-legest fe tri-linyah

174 tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte trimethobenzamide hcl trimethoprim tri-mili trimipramine maleate trinessa (28) trinessa lo triphrocaps tri-previfem tri-sila tri-sprintec tri-vit/fluoride tri-vit/fluoride/iron tri-vitamin/fluoride trivora (28) tri-vylibra tronvite TROPHAMINE tropicamide trospium chloride trospium chloride er TRULICITY TRUMENA TRUSTEX NON-LURICATED TRUSTEX RIA NON- LURICATED tryptophan TUDORZA PRESSAIR tulana turpentine tussigon TWINRIX tydemy TYACIL TYKER TYMLOS TYSARI U UCERIS ULORIC umecta mousse UNASYN unithroid unithroid direct UPTRAVI ur n-c uramaxin uramit mb urea... 78, 79 urea hydrating urea in zn undecyl-lactic acid. 79 urea nail urea-c uredeb ure-k urelle uremez uretron d/s uribel urimar-t urin ds uro uroav uroav-b uro-mp urophen mb urosex ursodiol uryl ustell uta uticap utira-c utrona-c V VAIFEM valacyclovir hcl VALCHLOR valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide 67 vanatol lq vanatol s vancomycin hcl vancomycin hcl in dextrose vancomycin hcl in nacl vandazole VANTAS VAQTA VARIVAX VARUI vashe cleansing vasopressin-sodium chloride 114 v-c forte vcf vaginal contraceptive VECTICAL vecuronium bromide vecuronium bromide-nacl VELCADE velivet VENCLEXTA venlafaxine hcl venlafaxine hcl er VENTAVIS VENTOLIN HFA verapamil hcl verapamil hcl er verdrocet VERIPRED VERZENIO VESICARE vestura VFEND VFEND IV VIATIV vic-forte vicodin vicodin es vicodin hp VICTOZA VIEKIRA K vienva vigabatrin vigadrone VIAMOX VIIRYD vilamit mb vilevev mb VIMT vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate viorele VIROPTIC virt-caps virt-gard virt-phos 250 neutral virtrate virtrate virtrate-k virt-vite virt-vite forte virt-vite plus VISTOARD VISUDYNE vit b12-methionine-inos-chol. 97 vita s forte vitacel vitamax pediatric vita-min vitamin b complex vitamin b vitamin b-complex vitamin d (ergocalciferol) vitamin k vitamins acd-fluoride VIVELLE-DOT VOELXO

175 VOELXO PUMP voriconazole VOTRIENT vp-precip vp-vite rx vyfemla vylibra VYVANSE W wal-fex d allergy & congestion warfarin sodium wera westhroid wheat germ oil WINRHO SDF wymzya fe X XARELTO XARELTO STARTER CK.. 29 xelitral xenaflamm XENICAL XERMELO XIFAXAN XIDUO XR XOLAIR XOPENEX HFA xulane XURIDEN xylocaine dental xylon Y yf-vax yuvafem Z zaclir cleansing zafirlukast zaleplon zarah ZARXIO zebutal ZEJULA ZEMAIRA ZEMDRI zenatane zenchent zencia zenzedi ZETIER zeruvia ZETIA zidovudine zileuton er ZINRYTA zinc sulfate zinc trace metal ZIRAN ZOHYDRO ER ZOLADEX zoledronic acid zolmitriptan ZOLOFT zolpidem tartrate zolpidem tartrate er ZOMACTON ZOMI zonisamide ZORTIVE ZOSTAVAX zovia 1/35e (28) zovia 1/50e (28) ZURAMPIC ZYDELI ZYKADIA

176 Integrity Accountability Collaboration Respect Trust OCTOER 2018 Q4 For questions and old Coast Health Plan information, please call old Coast Health Plan. All rights reserved. CHP_Formulary_English_Effective 10/2018