Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs

Transcription

1 Signature Advantage (HMO SNP) 208 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, Version 09 This formulary was updated on 03/20/208. For more recent information or other questions, please contact Signature Advantage Health Plan (HMO ISNP) Member Services at or, for TTY users, 7, Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February 4, and Monday to Friday (except holidays) from February 5 through September 30, or visit signatureadvantageplan.com. Signature Advantage is an HMO plan with a Medicare contract. Enrollment in Signature Advantage depends on contract renewal. Signature Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Signature Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Signature Advantage 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而 歧視任何人 This information is available for free in other languages. Esta información está disponible en otros idiomas de manera gratuita. Comuníquese con Servicios al Cliente al (TTY: 7). Horario de Atención al Cliente: Del de Octubre hasta el 4 de Febrero, de 8 a.m. a 8 p.m. los siete días de la semana (excepto Día de Acción de Gracias y Navidad), y del 5 de Febrero al 30 de Septiembre, de Lunes a Viernes (excepto feriados). H2400_208_drug0 Accepted

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Signature Advantage. When it refers to plan or our plan, it means Signature Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 03/20/208. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 208, and from time to time during the year.

3 What is the Signature Advantage (HMO ISNP) Formulary? A formulary is a list of covered drugs selected by Signature Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Signature Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Signature Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 03/20/208. To get updated information about the drugs covered by Signature Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event that Signature Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, Signature Advantage will update our formulary and post in on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents-Misc. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 06. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your 2

4 drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Signature Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA): Signature Advantage requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Signature Advantage before you fill your prescriptions. If you don t get approval, Signature Advantage may not cover the drug. Prior Authorization Restriction for Part B vs Part D Determination (PA BvD): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Signature Advantage to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Signature Advantage may not cover this drug. Prior Authorization Restriction for New Starts Only (PA NSO): If you are a new member, you (or your physician) are required to get prior authorization from Signature Advantage before you fill your prescription for this drug. Without prior approval, Signature Advantage may not cover this drug. Quantity Limits (QL): For certain drugs, Signature Advantage limits the amount of the drug that Signature Advantage (HMO SNP) will cover. For example, Signature Advantage provides 9 tabs per prescription for sumatriptan tab. This may be in addition to a standard one month or three-month supply. Step Therapy (ST): In some cases, Signature Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Signature Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Signature Advantage will then cover Drug B. Non-Mail-Order Drug (NM): You may be able to receive greater than a -month supply of most of the drugs on your Formulary via mail order at a reduced cost share. Drugs not available via your mail-order benefit are noted with NM in the notes column of your Formulary. Limited Distribution (LD): The symbol (LD) next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. 3

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Signature Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Signature Advantage s formulary? on this page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Signature Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Signature Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Signature Advantage. You can ask Signature Advantage to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Signature Advantage Formulary? You can ask Signature Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Signature Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Signature Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 4

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 3-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 3-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. We will provide a one-time 3-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level of care change may include: Entering or leaving a LTC facility Discharged from a hospital to a home End a Medicare Part A skilled nursing facility stay Give up Hospice status and revert back to standard Medicarebenefits End an LTC facility stay and return to their home During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. For more information For more detailed information about your Signature Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Signature Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 5

7 Signature Advantage s Formulary The formulary below provides coverage information about the drugs covered by Signature Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 04. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., lidocaine). The second column of the chart lists the Drug Tier. The information in the Notes column tells you if Signature Advantage (HMO SNP) has any special requirements for coverage of your drug. The symbol LD in the Notes column next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. The symbol PA in the Notes column indicates that prior authorization may apply. The symbol PA BvD in the Notes column indicates that prior authorization may apply for medications that could be eligible for payment under either Medicare Part B or Part D. The symbol PA NSO in the Notes column indicates that prior authorization may apply on certain medications for new members of the plan. The symbol QL in the Notes column indicates that quantities dispensed may be limited. The symbol ST in the Notes column indicates that step therapy may apply. The symbol NM in the Notes column indicates that the drug is not available via your mail-order benefit.

8 LEGEND : Tier BvD: BvD: This drug may be covered by Part B or Part D. LA: Limited Access: This prescription drug is limited to certain pharmacies. PA: Prior Authorization: You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL: Quantity Limit: There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST: Step Therapy: In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

9 Signature Advantage (List of Covered Drugs) DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES amphetamine-dextroamphet er oral capsule extended release 24 hour 0 mg, 5 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg, 5 mg, 5 mg dextroamphetamine sulfate oral tablet 0 mg, 5 mg methamphetamine hcl oral tablet 5 mg PA VYVANSE ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET CHEWABLE 0 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl oral capsule 0 mg, 00 mg, 8 mg, 25 mg, 40 mg, 60 mg, 80 mg guanfacine hcl er oral tablet extended release 24 hour mg, 2 mg, 3 mg, 4 mg STIMULANTS - MISC. armodafinil oral tablet 50 mg, 200 mg, 250 mg, 50 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 0 mg, 2.5 mg, 5 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 0 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er oral tablet extended release 0 mg, 20 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 2 QL (60 EA per 30 days) PA; QL (30 EA per 30 days)

10 methylphenidate hcl er oral tablet extended release 24 hour 8 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 0 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 0 mg, 20 mg, 5 mg methylphenidate hcl oral tablet chewable 0 mg, 2.5 mg, 5 mg modafinil oral tablet 00 mg, 200 mg PA; QL (60 EA per 30 days) AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/2ml gentamicin in saline intravenous solution mg/ml-%, -0.9 mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 40 mg/ml gentamicin sulfate intravenous solution 0 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 mg/5ml tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK) HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 3 PA PA PA PA PA

11 HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG INTERLEUKIN- BLOCKERS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG INTERLEUKIN-BETA BLOCKERS ILARIS (50MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 4 PA PA PA PA PA NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral tablet delayed release mg, mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral capsule 400 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral suspension 00 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION 25 MG/5ML QL (60 EA per 30 days)

12 indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml ketorolac tromethamine oral tablet 0 mg QL (20 EA per 5 days) meclofenamate sodium oral capsule 00 mg, 50 mg mefenamic acid oral capsule 250 mg meloxicam oral tablet 5 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg PYRIMIDINE SYNTHESIS INHIBITORS leflunomide oral tablet 0 mg, 20 mg SELECTIVE COSTIMULATION MODULATORS ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 25 MG/ML ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 5 PA PA PA SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML PA

13 ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ANALGESICS - NONNARCOTIC SALICYLATES diflunisal oral tablet 500 mg ANALGESICS - OPIOID OPIOID AGONISTS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 6 PA PA codeine sulfate oral tablet 5 mg, 30 mg QL (240 EA per 30 days) codeine sulfate oral tablet 60 mg QL (80 EA per 30 days) duramorph injection solution 0.5 mg/ml, mg/ml BvD EMBEDA ORAL CAPSULE EXTENDED RELEASE 00-4 MG, MG, MG, 50-2 MG, MG, MG fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET 00 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 2 mg, 6 mg, 32 mg, 8 mg hydromorphone hcl injection solution 2 mg/ml QL (60 EA per 30 days) PA; QL (20 EA per 30 days) QL (0 EA per 30 days) PA; QL (20 EA per 30 days) QL (60 EA per 30 days) hydromorphone hcl oral liquid mg/ml QL (2400 ML per 30 days) hydromorphone hcl oral tablet 2 mg QL (450 EA per 30 days) hydromorphone hcl oral tablet 4 mg QL (240 EA per 30 days) hydromorphone hcl oral tablet 8 mg QL (20 EA per 30 days) hydromorphone hcl pf injection solution 0 mg/ml, 50 mg/5ml HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 EA per 30 days) levorphanol tartrate oral tablet 2 mg QL (240 EA per 30 days)

14 meperidine hcl oral tablet 00 mg QL (360 EA per 30 days) meperidine hcl oral tablet 50 mg QL (720 EA per 30 days) methadone hcl oral solution 0 mg/5ml QL (800 ML per 30 days) methadone hcl oral solution 5 mg/5ml QL (3600 ML per 30 days) methadone hcl oral tablet 0 mg, 5 mg QL (360 EA per 30 days) morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate (pf) intravenous solution 2 mg/ml morphine sulfate er beads oral capsule extended release 24 hour 20 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 0 mg, 00 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 00 mg, 5 mg, 200 mg, 30 mg, 60 mg morphine sulfate injection solution 5 mg/ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 7 QL (80 ML per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (20 EA per 30 days) morphine sulfate oral solution 0 mg/5ml QL (800 ML per 30 days) morphine sulfate oral solution 20 mg/5ml QL (900 ML per 30 days) morphine sulfate oral tablet 5 mg, 30 mg QL (80 EA per 30 days) oxycodone hcl oral capsule 5 mg QL (360 EA per 30 days) oxycodone hcl oral concentrate 00 mg/5ml QL (270 ML per 30 days) oxycodone hcl oral solution 5 mg/5ml QL (5400 ML per 30 days) oxycodone hcl oral tablet 0 mg, 5 mg, 20 mg, 30 mg QL (80 EA per 30 days) oxycodone hcl oral tablet 5 mg QL (360 EA per 30 days) OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 80 MG QL (60 EA per 30 days) QL (20 EA per 30 days) oxymorphone hcl oral tablet 0 mg, 5 mg QL (360 EA per 30 days) tramadol hcl er (biphasic) oral tablet extended release 24 hour 00 mg, 200 mg, 300 mg, 300 mg (matrix delivery) tramadol hcl er oral tablet extended release 24 hour 00 mg, 200 mg QL (60 EA per 30 days) QL (60 EA per 30 days)

15 tramadol hcl oral tablet 50 mg QL (240 EA per 30 days) OPIOID COMBINATIONS acetaminophen-codeine #2 oral tablet mg QL (390 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (390 EA per 30 days) acetaminophen-codeine #4 oral tablet mg QL (390 EA per 30 days) acetaminophen-codeine oral solution 20-2 mg/5ml acetaminophen-codeine oral tablet mg, mg ENDOCET ORAL TABLET MG, MG, MG hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (4980 ML per 30 days) QL (390 EA per 30 days) QL (360 EA per 30 days) QL (5400 ML per 30 days) QL (390 EA per 30 days) QL (360 EA per 30 days) QL (480 EA per 30 days) LORCET HD ORAL TABLET MG QL (360 EA per 30 days) LORCET ORAL TABLET MG QL (360 EA per 30 days) LORCET PLUS ORAL TABLET MG QL (360 EA per 30 days) oxycodone-acetaminophen oral solution mg/5ml oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (800 ML per 30 days) QL (360 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet mg QL (240 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (360 EA per 30 days) VICODIN ES ORAL TABLET MG QL (390 EA per 30 days) VICODIN HP ORAL TABLET MG QL (390 EA per 30 days) VICODIN ORAL TABLET MG QL (390 EA per 30 days) OPIOID PARTIAL AGONISTS BUNAVAIL BUCCAL FILM MG, MG QL (90 EA per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 8

16 BUNAVAIL BUCCAL FILM 6.3- MG QL (60 EA per 30 days) buprenorphine hcl injection solution 0.3 mg/ml, 0.3 mg/ml (cartridge) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg butorphanol tartrate injection solution mg/ml, 2 mg/ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 9 PA butorphanol tartrate nasal solution 0 mg/ml QL (0 ML per 30 days) pentazocine-naloxone hcl oral tablet mg QL (360 EA per 30 days) SUBOXONE SUBLINGUAL FILM 2-3 MG QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM MG, 4- MG, 8-2 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 0 mg, 2.5 mg ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR ANDRODERM TRANSDERMAL PATCH 24 HOUR 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (.62%) ANDROGEL TRANSDERMAL GEL MG/.25GM (.62%) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (%), 50 MG/5GM (%) ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (.62%) danazol oral capsule 00 mg, 200 mg, 50 mg testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml QL (90 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) PA; QL (60 EA per 30 days) PA; QL (30 EA per 30 days) PA; QL (50 GM per 30 days) PA; QL (37.5 GM per 30 days) PA; QL (300 GM per 30 days) PA; QL (50 GM per 30 days)

17 testosterone enanthate intramuscular solution 200 mg/ml testosterone transdermal gel 2.5 mg/act (%), 25 mg/2.5gm (%), 50 mg/5gm (%) testosterone transdermal solution 30 mg/act PA ANORECTAL AGENTS INTRARECTAL STEROIDS COLOCORT RECTAL ENEMA 00 MG/60ML hydrocortisone rectal enema 00 mg/60ml UCERIS RECTAL FOAM 2 MG/ACT PA RECTAL STEROIDS PROCTO-MED HC RECTAL CREAM 2.5 % PROCTO-PAK RECTAL CREAM % PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % ANTHELMINTICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG ivermectin oral tablet 3 mg ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR 000 MG, 500 MG NITRATES isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 20 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 0 mg, 20 mg MINITRAN TRANSDERMAL PATCH 24 HOUR 0. MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 0 PA; QL (300 GM per 30 days)

18 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone hcl oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral syrup 0 mg/5ml hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5 mg, mg, 2 mg, 3 mg alprazolam oral tablet 0.25 mg, 0.5 mg, mg, 2 mg alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, mg, 2 mg chlordiazepoxide hcl oral capsule 0 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 mg/ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208

19 lorazepam oral tablet 0.5 mg, mg, 2 mg oxazepam oral capsule 0 mg, 5 mg, 30 mg ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide phosphate oral capsule 00 mg, 50 mg NORPACE CR ORAL CAPSULE EXTENDED RELEASE 2 HOUR 00 MG, 50 MG procainamide hcl injection solution 00 mg/ml, 500 mg/ml quinidine gluconate er oral tablet extended release 324 mg quinidine gluconate injection solution 80 mg/ml quinidine sulfate oral tablet 200 mg, 300 mg ANTIARRHYTHMICS TYPE I-B mexiletine hcl oral capsule 50 mg, 200 mg, 250 mg ANTIARRHYTHMICS TYPE I-C flecainide acetate oral tablet 00 mg, 50 mg, 50 mg propafenone hcl er oral capsule extended release 2 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 50 mg, 225 mg, 300 mg ANTIARRHYTHMICS TYPE III amiodarone hcl intravenous solution 50 mg/3ml amiodarone hcl oral tablet 00 mg, 200 mg, 400 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg MULTAQ ORAL TABLET 400 MG NEXTERONE INTRAVENOUS SOLUTION MG/00ML-%, MG/200ML-% PACERONE ORAL TABLET 200 MG, 400 MG ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 2

20 NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 00 MG XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 50 MG ANTI-INFLAMMATORY AGENTS cromolyn sodium inhalation nebulization solution 20 mg/2ml BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL SOLUTION 7 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 3 PA PA BvD ipratropium bromide inhalation solution 0.02 % BvD LEUKOTRIENE MODULATORS montelukast sodium oral packet 4 mg montelukast sodium oral tablet 0 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 0 mg, 20 mg zileuton er oral tablet extended release 2 hour 600 mg SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP ORAL TABLET 500 MCG STEROID INHALANTS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/ACT, 200 MCG/ACT ASMANEX 20 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH QL (30 EA per 30 days) QL ( EA per 30 days) QL ( EA per 30 days) QL ( EA per 30 days)

21 ASMANEX HFA INHALATION AEROSOL 00 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 0 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT SYMPATHOMIMETICS ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL 5-2 MCG/ACT, MCG/ACT, 45-2 MCG/ACT albuterol sulfate er oral tablet extended release 2 hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml,.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH BROVANA INHALATION NEBULIZATION SOLUTION 5 MCG/2ML COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL 00-5 MCG/ACT, MCG/ACT QL (3 GM per 30 days) BvD; QL (20 ML per 30 days) QL (60 EA per 30 days) QL (24 GM per 30 days) QL (2.2 GM per 30 days) QL (60 EA per 30 days) QL (2 GM per 30 days) BvD QL (60 EA per 30 days) QL (60 EA per 30 days) BvD QL (3 GM per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 4

22 fluticasone-salmeterol inhalation aerosol powder breath activated 3-4 mcg/act, mcg/act, 55-4 mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml levalbuterol hcl inhalation nebulization solution 0.3 mg/3ml, 0.63 mg/3ml,.25 mg/0.5ml,.25 mg/3ml metaproterenol sulfate oral syrup 0 mg/5ml metaproterenol sulfate oral tablet 0 mg, 20 mg SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT terbutaline sulfate injection solution mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT XANTHINES aminophylline intravenous solution 25 mg/ml theophylline er oral tablet extended release 2 hour 00 mg, 200 mg, 300 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/5ml ANTICOAGULANTS COUMARIN ANTICOAGULANTS JANTOVEN ORAL TABLET MG, 0 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg DIRECT FACTOR XA INHIBITORS ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG BvD BvD QL (4 GM per 30 days) QL (36 GM per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 5

23 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 20 MG HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium injection solution 300 mg/3ml QL (5 ML per 7 days) enoxaparin sodium subcutaneous solution 00 mg/ml, 50 mg/ml enoxaparin sodium subcutaneous solution 20 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous solution 30 mg/0.3ml enoxaparin sodium subcutaneous solution 40 mg/0.4ml enoxaparin sodium subcutaneous solution 60 mg/0.6ml fondaparinux sodium subcutaneous solution 0 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin sod (porcine) in d5w intravenous solution 00 unit/ml heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, unit/ml, 5000 unit/ml THROMBIN INHIBITORS QL (34 ML per 7 days) QL (27.2 ML per 7 days) QL (0.2 ML per 7 days) QL (3.6 ML per 7 days) QL (20.4 ML per 7 days) PA BvD BvD BvD argatroban intravenous solution 25 mg/25ml BvD argatroban intravenous solution 250 mg/2.5ml PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 6

24 FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG ANTICONVULSANTS - BENZODIAZEPINES clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG PA ONFI ORAL SUSPENSION 2.5 MG/ML PA ONFI ORAL TABLET 0 MG, 20 MG PA ANTICONVULSANTS - MISC. APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA PA BRIVIACT ORAL SOLUTION 0 MG/ML PA BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 2 hour 00 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 00 mg EPITOL ORAL TABLET 200 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-00 (7) MG, 25 (84)-00(4) MG PA; QL (60 EA per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 7

25 LAMICTAL XR ORAL KIT 25 & 50 & 00 MG, 25 (2)-50 (7) MG, 50 & 00 & 200 MG lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 00 mg, 200 mg, 25 mg, 50 mg levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam in nacl intravenous solution 000 mg/00ml, 500 mg/00ml, 500 mg/00ml levetiracetam intravenous solution 500 mg/5ml levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 300 MG, 600 MG primidone oral tablet 250 mg, 50 mg QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG ROWEEPRA ORAL TABLET 000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG, 250 MG, 500 MG, 750 MG topiramate er oral capsule er 24 hour sprinkle 00 mg, 50 mg, 200 mg, 25 mg, 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 8 PA PA PA

26 topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 50 MG VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00 mg, 25 mg, 50 mg CARBAMATES felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg GABA MODULATORS GABITRIL ORAL TABLET 2 MG, 6 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 9 PA SABRIL ORAL PACKET 500 MG PA SABRIL ORAL TABLET 500 MG PA tiagabine hcl oral tablet 2 mg, 4 mg vigabatrin oral packet 500 mg PA HYDANTOINS DILANTIN ORAL CAPSULE 30 MG fosphenytoin sodium injection solution 00 mg pe/2ml PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 mg/ml SUCCINIMIDES CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg QL (60 EA per 30 days)

27 ethosuximide oral solution 250 mg/5ml VALPROIC ACID divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg valproate sodium intravenous solution 00 mg/ml valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg ANTIDEPRESSANTS - MISC. APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 74 MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 50 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg bupropion hcl oral tablet 00 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg ST SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral solution 0 mg/5ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 20

28 citalopram hydrobromide oral tablet 0 mg, 20 mg, 40 mg escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 0 mg, 20 mg fluvoxamine maleate er oral capsule extended release 24 hour 00 mg, 50 mg fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg PAXIL ORAL SUSPENSION 0 MG/5ML PEXEVA ORAL TABLET 0 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 00 mg, 25 mg, 50 mg SEROTONIN MODULATORS nefazodone hcl oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 00 mg, 50 mg, 300 mg, 50 mg TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 0 & 20 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 2 ST ST ST; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine er oral tablet extended release 24 hour 00 mg, 50 mg desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg ST

29 duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg duloxetine hcl oral capsule delayed release particles 40 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 00 MG, 50 MG venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 50 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg TRICYCLIC AGENTS amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 0 mg/ml imipramine hcl oral tablet 0 mg, 25 mg, 50 mg imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml protriptyline hcl oral tablet 0 mg, 5 mg trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ ST; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) ST

30 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet 00 mg, 25 mg, 50 mg miglitol oral tablet 00 mg, 25 mg, 50 mg ANTIDIABETIC COMBINATIONS glipizide-metformin hcl oral tablet mg, mg, mg glyburide-metformin oral tablet mg, mg, mg GLYXAMBI ORAL TABLET 0-5 MG, 25-5 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg SYNJARDY ORAL TABLET MG, MG, MG, MG XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML BIGUANIDES QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 23

31 metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 000 mg, 500 mg, 850 mg DIABETIC OTHER GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED MG GLUCAGON EMERGENCY INJECTION KIT MG KORLYM ORAL TABLET 300 MG PA PROGLYCEM ORAL SUSPENSION 50 MG/ML DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG QL (30 EA per 30 days) TRADJENTA ORAL TABLET 5 MG QL (30 EA per 30 days) INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS PEN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 8 MG/3ML INSULIN HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 24

32 LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 00 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML, 200 UNIT/ML INSULIN SENSITIZING AGENTS AVANDIA ORAL TABLET 2 MG, 4 MG pioglitazone hcl oral tablet 5 mg, 30 mg, 45 mg MEGLITINIDE ANALOGUES nateglinide oral tablet 20 mg, 60 mg repaglinide oral tablet 0.5 mg, mg, 2 mg SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA ORAL TABLET 0 MG, 5 MG QL (30 EA per 30 days) JARDIANCE ORAL TABLET 0 MG, 25 MG QL (30 EA per 30 days) SULFONYLUREAS chlorpropamide oral tablet 00 mg, 250 mg glimepiride oral tablet mg, 2 mg, 4 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 25

33 glipizide er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg glipizide oral tablet 0 mg, 5 mg glyburide micronized oral tablet.5 mg, 3 mg, 6 mg glyburide oral tablet.25 mg, 2.5 mg, 5 mg tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg ANTIDIARRHEALS ANTIPERISTALTIC AGENTS diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg loperamide hcl oral capsule 2 mg ANTIDOTES ANTIDOTES fomepizole intravenous solution gm/ml ANTIDOTES - CHELATING AGENTS CHEMET ORAL CAPSULE 00 MG FERRIPROX ORAL SOLUTION 00 MG/ML PA FERRIPROX ORAL TABLET 500 MG PA JADENU ORAL TABLET 80 MG, 90 MG ANTIDOTES AND SPECIFIC ANTAGONISTS EXJADE ORAL TABLET SOLUBLE 25 MG, 250 MG, 500 MG JADENU ORAL TABLET 360 MG JADENU SPRINKLE ORAL PACKET 80 MG, 360 MG, 90 MG OPIOID ANTAGONISTS naloxone hcl injection solution prefilled syringe 2 mg/2ml naltrexone hcl oral tablet 50 mg QL (2 ML per 2 days) NARCAN NASAL LIQUID 4 MG/0.ML QL (2 EA per 2 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 26

34 ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron hcl intravenous solution 0. mg/ml, mg/ml, 4 mg/4ml granisetron hcl oral tablet mg BvD; QL (60 EA per 30 days) ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml (2ml syringe) ondansetron hcl oral solution 4 mg/5ml BvD ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg BvD ondansetron oral tablet dispersible 4 mg, 8 mg BvD ANTIEMETICS - ANTICHOLINERGIC meclizine hcl oral tablet 2.5 mg, 25 mg scopolamine transdermal patch 72 hour mg/3days TRANSDERM-SCOP (.5 MG) TRANSDERMAL PATCH 72 HOUR MG/3DAYS trimethobenzamide hcl oral capsule 300 mg PA ANTIEMETICS - MISCELLANEOUS CESAMET ORAL CAPSULE MG PA dronabinol oral capsule 0 mg, 2.5 mg, 5 mg PA SYNDROS ORAL SOLUTION 5 MG/ML PA SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg BvD; QL (3 EA per 2 days) VARUBI ORAL TABLET 90 MG BvD; QL (2 EA per 4 days) ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 27

35 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 25 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg nystatin oral tablet unit terbinafine hcl oral tablet 250 mg IMIDAZOLE-RELATED ANTIFUNGALS fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD BvD BvD itraconazole oral capsule 00 mg PA ketoconazole oral tablet 200 mg NOXAFIL ORAL SUSPENSION 40 MG/ML PA NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml PA PA PA voriconazole oral tablet 200 mg, 50 mg PA ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES

36 carbinoxamine maleate oral solution 4 mg/5ml carbinoxamine maleate oral tablet 4 mg clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl injection solution 50 mg/ml ANTIHISTAMINES - NON-SEDATING cetirizine hcl oral syrup mg/ml desloratadine oral tablet 5 mg levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg ANTIHISTAMINES - PHENOTHIAZINES PHENADOZ RECTAL SUPPOSITORY 2.5 MG PHENERGAN RECTAL SUPPOSITORY 2.5 MG, 25 MG, 50 MG promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 2.5 mg, 25 mg, 50 mg PROMETHEGAN RECTAL SUPPOSITORY 25 MG, 50 MG ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML omega-3-acid ethyl esters oral capsule gm Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA VASCEPA ORAL CAPSULE 0.5 GM, GM PA BILE ACID SEQUESTRANTS cholestyramine light oral powder 4 gm/dose

37 cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet gm PREVALITE ORAL PACKET 4 GM PREVALITE ORAL POWDER 4 GM/DOSE WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 625 MG FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 mg fenofibrate oral capsule 50 mg, 50 mg fenofibrate oral tablet 45 mg, 60 mg, 48 mg, 54 mg fenofibric acid oral capsule delayed release 35 mg, 45 mg gemfibrozil oral tablet 600 mg HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 80 mg fluvastatin sodium er oral tablet extended release 24 hour 80 mg fluvastatin sodium oral capsule 20 mg, 40 mg lovastatin oral tablet 0 mg, 20 mg, 40 mg pravastatin sodium oral tablet 0 mg, 20 mg, 40 mg, 80 mg rosuvastatin calcium oral tablet 0 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg, 80 mg INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe oral tablet 0 mg QL (30 EA per 30 days) MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 30

38 JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG NICOTINIC ACID DERIVATIVES niacin er (antihyperlipidemic) oral tablet extended release 000 mg, 500 mg, 750 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 3 PA PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 50 MG/ML, 75 MG/ML REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40 MG/ML ANTIHYPERTENSIVES ACE INHIBITORS benazepril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 0 mg, 20 mg, 40 mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 5 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril hcl oral tablet 0 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg AGENTS FOR PHEOCHROMOCYTOMA DEMSER ORAL CAPSULE 250 MG phenoxybenzamine hcl oral capsule 0 mg PA; QL (2 ML per 28 days) PA; QL (3.5 ML per 28 days) PA; QL (2 ML per 28 days) PA; QL (2 ML per 28 days)

39 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 6 mg, 32 mg, 4 mg, 8 mg eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 50 mg, 300 mg, 75 mg losartan potassium oral tablet 00 mg, 25 mg, 50 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine hcl transdermal patch weekly 0. mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr doxazosin mesylate oral tablet mg, 2 mg, 4 mg, 8 mg guanfacine hcl oral tablet mg, 2 mg methyldopa oral tablet 250 mg, 500 mg prazosin hcl oral capsule mg, 2 mg, 5 mg terazosin hcl oral capsule mg, 0 mg, 2 mg, 5 mg ANTIHYPERTENSIVE COMBINATIONS amlodipine besy-benazepril hcl oral capsule 0-20 mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 0-60 mg, mg, 5-60 mg, mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan cilexetil-hctz oral tablet mg, mg, mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 32

40 captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril-hydrochlorothiazide oral tablet 0-25 mg, mg fosinopril sodium-hctz oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan potassium-hctz oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol-hydrochlorothiazide oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, 5-25 mg, mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg propranolol-hctz oral tablet mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg telmisartan-amlodipine oral tablet 40-0 mg, 40-5 mg, 80-0 mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, mg trandolapril-verapamil hcl er oral tablet extended release -240 mg, 2-80 mg, mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone oral tablet 25 mg, 50 mg VASODILATORS hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 33

41 minoxidil oral tablet 0 mg, 2.5 mg ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION GM, 2 GM AZACTAM INJECTION SOLUTION RECONSTITUTED GM, 2 GM aztreonam injection solution reconstituted gm baciim intramuscular solution reconstituted unit bacitracin intramuscular solution reconstituted unit CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG colistimethate sodium injection solution reconstituted 50 mg DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg, 500 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG tinidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 00 mg vancomycin hcl intravenous solution reconstituted 0 gm, 000 mg, 500 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA BvD BvD vancomycin hcl oral capsule 25 mg, 250 mg ST; QL (56 EA per 4 days) XIFAXAN ORAL TABLET 200 MG QL (9 EA per 3 days) XIFAXAN ORAL TABLET 550 MG QL (3 EA per day) ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim intravenous solution mg/5ml

42 sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg ANTIPROTOZOAL AGENTS ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml CARBAPENEMS doripenem intravenous solution reconstituted 500 mg imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted gm, 500 mg CHLORAMPHENICOLS chloramphenicol sod succinate intravenous solution reconstituted gm CYCLIC LIPOPEPTIDES CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG daptomycin intravenous solution reconstituted 500 mg GLYCYLCYCLINES tigecycline intravenous solution reconstituted 50 mg TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG LEPROSTATICS dapsone oral tablet 00 mg, 25 mg LINCOSAMIDES clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 35

43 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml lincomycin hcl injection solution 300 mg/ml OXAZOLIDINONES linezolid intravenous solution 600 mg/300ml PA linezolid oral suspension reconstituted 00 mg/5ml PA linezolid oral tablet 600 mg PA SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (6 EA per 6 days) SIVEXTRO ORAL TABLET 200 MG PA; QL (6 EA per 6 days) POLYMYXINS polymyxin b sulfate injection solution reconstituted unit STREPTOGRAMINS SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone-proguanil hcl oral tablet mg, mg COARTEM ORAL TABLET MG ANTIMALARIALS chloroquine phosphate oral tablet 250 mg, 500 mg DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg quinine sulfate oral capsule 324 mg ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS

44 guanidine hcl oral tablet 25 mg pyridostigmine bromide er oral tablet extended release 80 mg pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS RIFAMATE ORAL CAPSULE MG RIFATER ORAL TABLET MG ANTIMYCOBACTERIAL AGENTS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM ethambutol hcl oral tablet 00 mg, 400 mg isoniazid injection solution 00 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 50 mg, 300 mg SIRTURO ORAL TABLET 00 MG PA TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS BICNU INTRAVENOUS SOLUTION RECONSTITUTED 00 MG busulfan intravenous solution 6 mg/ml carboplatin intravenous solution 50 mg/5ml cisplatin intravenous solution 00 mg/00ml, 50 mg/50ml cyclophosphamide oral capsule 25 mg, 50 mg BvD Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 37

45 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG ifosfamide intravenous solution reconstituted gm LEUKERAN ORAL TABLET 2 MG melphalan hcl intravenous solution reconstituted 50 mg MUSTARGEN INJECTION SOLUTION RECONSTITUTED 0 MG oxaliplatin intravenous solution 00 mg/20ml oxaliplatin intravenous solution reconstituted 00 mg thiotepa injection solution reconstituted 5 mg TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 25 MG YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED GM ANTIMETABOLITES ADRUCIL INTRAVENOUS SOLUTION 500 MG/0ML ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ARRANON INTRAVENOUS SOLUTION 5 MG/ML azacitidine injection suspension reconstituted 00 mg PA PA BvD cladribine intravenous solution 0 mg/0ml BvD clofarabine intravenous solution mg/ml CLOLAR INTRAVENOUS SOLUTION MG/ML cytarabine (pf) injection solution 00 mg/ml BvD cytarabine injection solution 20 mg/ml BvD decitabine intravenous solution reconstituted 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 38

46 fludarabine phosphate intravenous solution reconstituted 50 mg fluorouracil intravenous solution 2.5 gm/50ml, 5 gm/00ml FOLOTYN INTRAVENOUS SOLUTION 40 MG/2ML gemcitabine hcl intravenous solution reconstituted gm mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium (pf) injection solution gm/40ml, 250 mg/0ml, 50 mg/2ml methotrexate sodium injection solution reconstituted gm PURIXAN ORAL SUSPENSION 2000 MG/00ML TABLOID ORAL TABLET 40 MG TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INTRAVENOUS SOLUTION 00 MG/4ML, 400 MG/6ML CYRAMZA INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML ZALTRAP INTRAVENOUS SOLUTION 00 MG/4ML ANTINEOPLASTIC - ANTIBODIES BAVENCIO INTRAVENOUS SOLUTION 200 MG/0ML DARZALEX INTRAVENOUS SOLUTION 00 MG/5ML EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 00 MG/50ML BvD PA PA PA PA PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 39

47 HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 440 MG IMFINZI INTRAVENOUS SOLUTION 20 MG/2.4ML, 500 MG/0ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 60 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4ML KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG LARTRUVO INTRAVENOUS SOLUTION 90 MG/9ML, 500 MG/50ML MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG OPDIVO INTRAVENOUS SOLUTION 00 MG/0ML, 40 MG/4ML PERJETA INTRAVENOUS SOLUTION 420 MG/4ML RITUXAN INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML TECENTRIQ INTRAVENOUS SOLUTION 200 MG/20ML VECTIBIX INTRAVENOUS SOLUTION 00 MG/5ML YERVOY INTRAVENOUS SOLUTION 50 MG/0ML ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA PA PA PA PA PA PA PA PA PA PA PA PA ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE ORAL CAPSULE 50 MG PA ODOMZO ORAL CAPSULE 200 MG PA ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole oral tablet mg bicalutamide oral tablet 50 mg

48 DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG EMCYT ORAL CAPSULE 40 MG exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 20 MG, 80 MG flutamide oral capsule 25 mg hydroxyprogesterone caproate intramuscular solution.25 gm/5ml letrozole oral tablet 2.5 mg leuprolide acetate injection kit mg/0.2ml LUPRON DEPOT (-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.25 MG, 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG LYSODREN ORAL TABLET 500 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 4 PA PA megestrol acetate oral suspension 40 mg/ml PA megestrol acetate oral tablet 20 mg, 40 mg PA NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg SOLTAMOX ORAL SOLUTION 0 MG/5ML PA tamoxifen citrate oral tablet 0 mg, 20 mg TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED.25 MG, 22.5 MG, 3.75 MG XTANDI ORAL CAPSULE 40 MG PA; QL (20 EA per 30 days) ZYTIGA ORAL TABLET 250 MG PA; QL (20 EA per 30 days)

49 ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG ANTINEOPLASTIC ANTIBIOTICS ADRIAMYCIN INTRAVENOUS SOLUTION 2 MG/ML bleomycin sulfate injection solution reconstituted 30 unit COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG dactinomycin intravenous solution reconstituted 0.5 mg daunorubicin hcl intravenous injectable 5 mg/ml PA BvD BvD BvD doxorubicin hcl intravenous solution 2 mg/ml BvD doxorubicin hcl liposomal intravenous injectable 2 mg/ml epirubicin hcl intravenous solution 200 mg/00ml idarubicin hcl intravenous solution 0 mg/0ml mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg mitoxantrone hcl intravenous concentrate 25 mg/2.5ml ANTINEOPLASTIC COMBINATIONS KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG LONSURF ORAL TABLET MG, MG VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED MG ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG PA PA PA PA PA PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 42

50 AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (30 EA per 30 days) ALECENSA ORAL CAPSULE 50 MG PA; QL (240 EA per 30 days) ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLET THERAPY PACK 90 & 80 MG BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG bortezomib intravenous solution reconstituted 3.5 mg BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA PA PA PA BvD PA PA CALQUENCE ORAL CAPSULE 00 MG PA CAPRELSA ORAL TABLET 00 MG, 300 MG PA COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA PA PA COTELLIC ORAL TABLET 20 MG PA FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA PA; QL (30 EA per 30 days) PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA IDHIFA ORAL TABLET 00 MG, 50 MG PA imatinib mesylate oral tablet 00 mg, 400 mg PA IMBRUVICA ORAL TABLET 40 MG PA; QL (20 EA per 30 days) INLYTA ORAL TABLET MG, 5 MG PA; QL (240 EA per 30 days)

51 IRESSA ORAL TABLET 250 MG PA ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 0 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA PA; QL (60 EA per 30 days) KISQALI 200 DOSE ORAL TABLET 200 MG PA; QL (63 EA per 28 days) KISQALI 400 DOSE ORAL TABLET 200 MG PA; QL (63 EA per 28 days) KISQALI 600 DOSE ORAL TABLET 200 MG PA; QL (63 EA per 28 days) KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 MG LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 (2) & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG PA PA PA PA PA PA PA LYNPARZA ORAL CAPSULE 50 MG PA LYNPARZA ORAL TABLET 00 MG, 50 MG PA MEKINIST ORAL TABLET 0.5 MG, 2 MG PA NERLYNX ORAL TABLET 40 MG PA NEXAVAR ORAL TABLET 200 MG PA NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA RUBRACA ORAL TABLET 200 MG, 300 MG PA; QL (20 EA per 30 days) RYDAPT ORAL CAPSULE 25 MG PA SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG PA STIVARGA ORAL TABLET 40 MG PA; QL (20 EA per 30 days) SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG PA

52 TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; QL (20 EA per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG PA TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG PA TASIGNA ORAL CAPSULE 50 MG, 200 MG PA TORISEL INTRAVENOUS SOLUTION 25 MG/ML TYKERB ORAL TABLET 250 MG PA VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA VOTRIENT ORAL TABLET 200 MG PA XALKORI ORAL CAPSULE 200 MG, 250 MG PA ZEJULA ORAL CAPSULE 00 MG PA ZELBORAF ORAL TABLET 240 MG PA ZOLINZA ORAL CAPSULE 00 MG PA ZYDELIG ORAL TABLET 00 MG, 50 MG PA ZYKADIA ORAL CAPSULE 50 MG PA ANTINEOPLASTIC ENZYMES ERWINAZE INJECTION SOLUTION RECONSTITUTED 0000 UNIT ANTINEOPLASTICS MISC. ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML PA bexarotene oral capsule 75 mg PA dacarbazine intravenous solution reconstituted 200 mg hydroxyurea oral capsule 500 mg INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT MATULANE ORAL CAPSULE 50 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 45

53 NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 0 MG PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG tretinoin oral capsule 0 mg TRISENOX INTRAVENOUS SOLUTION 0 MG/0ML, 2 MG/6ML CHEMOTHERAPY ADJUNCTS ELITEK INTRAVENOUS SOLUTION RECONSTITUTED.5 MG, 7.5 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS dexrazoxane intravenous solution reconstituted 250 mg FUSILEV INTRAVENOUS SOLUTION RECONSTITUTED 50 MG leucovorin calcium injection solution reconstituted 00 mg, 350 mg leucovorin calcium oral tablet 0 mg, 5 mg, 25 mg, 5 mg levoleucovorin calcium intravenous solution 75 mg/7.5ml mesna intravenous solution 00 mg/ml MESNEX ORAL TABLET 400 MG MITOTIC INHIBITORS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 00 MG docetaxel intravenous concentrate 80 mg/4ml docetaxel intravenous solution 60 mg/6ml, 80 mg/8ml ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA

54 etoposide intravenous solution 00 mg/5ml, 500 mg/25ml HALAVEN INTRAVENOUS SOLUTION MG/2ML JEVTANA INTRAVENOUS SOLUTION 60 MG/.5ML paclitaxel intravenous concentrate 00 mg/6.7ml, 300 mg/50ml TOPOSAR INTRAVENOUS SOLUTION GM/50ML vinblastine sulfate intravenous solution mg/ml BvD VINCASAR PFS INTRAVENOUS SOLUTION MG/ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD vincristine sulfate intravenous solution mg/ml BvD vinorelbine tartrate intravenous solution 50 mg/5ml TOPOISOMERASE I INHIBITORS irinotecan hcl intravenous solution 00 mg/5ml topotecan hcl intravenous solution reconstituted 4 mg ANTIPARKINSON AGENTS ANTIPARKINSON ADJUVANTS carbidopa oral tablet 25 mg ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate injection solution mg/ml benztropine mesylate oral tablet 0.5 mg, mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg ANTIPARKINSON COMT INHIBITORS entacapone oral tablet 200 mg tolcapone oral tablet 00 mg ANTIPARKINSON DOPAMINERGICS amantadine hcl oral capsule 00 mg amantadine hcl oral syrup 50 mg/5ml

55 amantadine hcl oral tablet 00 mg APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet 0-00 mg, mg, mg carbidopa-levodopa oral tablet dispersible 0-00 mg, mg, mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 37 MG, 68.5 MG NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hour mg, 0.75 mg,.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg ropinirole hcl er oral tablet extended release 24 hour 2 mg, 2 mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg STALEVO 00 ORAL TABLET MG STALEVO 25 ORAL TABLET MG STALEVO 50 ORAL TABLET MG STALEVO 200 ORAL TABLET MG STALEVO 50 ORAL TABLET MG STALEVO 75 ORAL TABLET MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

56 rasagiline mesylate oral tablet 0.5 mg, mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate er oral tablet extended release 300 mg, 450 mg lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml ANTIPSYCHOTICS - MISC. EQUETRO ORAL CAPSULE EXTENDED RELEASE 2 HOUR 00 MG, 200 MG, 300 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG NUPLAZID ORAL TABLET 7 MG PA VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK.5 & 3 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg BENZISOXAZOLES FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET & 2 & 4 & 6 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 7 MG/0.75ML, 56 MG/ML, 234 MG/.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 40 MG/.35ML, 546 MG/.75ML, 89 MG/2.625ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (30 EA per 30 days) PA; QL (30 EA per 30 days) PA; QL (30 EA per 30 days) PA; QL (60 EA per 30 days) PA; QL (60 EA per 30 days) PA PA

57 paliperidone er oral tablet extended release 24 hour.5 mg, 3 mg, 6 mg, 9 mg RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2.5 MG, 25 MG, 37.5 MG, 50 MG risperidone oral solution mg/ml risperidone oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg BUTYROPHENONES haloperidol decanoate intramuscular solution 00 mg/ml, 00 mg/ml ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg DIBENZAPINES clozapine oral tablet 00 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 00 mg, 2.5 mg, 50 mg, 200 mg, 25 mg FAZACLO ORAL TABLET DISPERSIBLE 2.5 MG, 50 MG, 200 MG loxapine succinate oral capsule 0 mg, 25 mg, 5 mg, 50 mg olanzapine intramuscular solution reconstituted 0 mg olanzapine oral tablet 0 mg, 5 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 0 mg, 5 mg, 20 mg, 5 mg quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 50 mg quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA PA QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days)

58 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 0 MG, 2.5 MG, 5 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 20 MG PHENOTHIAZINES chlorpromazine hcl injection solution 50 mg/2ml chlorpromazine hcl oral tablet 0 mg, 00 mg, 200 mg, 25 mg, 50 mg COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg thioridazine hcl oral tablet 0 mg, 00 mg, 25 mg, 50 mg trifluoperazine hcl oral tablet mg, 0 mg, 2 mg, 5 mg QUINOLINONE DERIVATIVES ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (.5ML SYRINGE), 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG PA; QL (60 EA per 30 days) PA PA PA aripiprazole oral solution mg/ml PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 5

59 aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg QL (30 EA per 30 days) aripiprazole oral tablet dispersible 0 mg, 5 mg PA; QL (60 EA per 30 days) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 064 MG/3.9ML, 44 MG/.6ML, 662 MG/2.4ML, 882 MG/3.2ML REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG THIOXANTHENES thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg ANTIVIRALS ANTIRETROVIRALS abacavir sulfate oral tablet 300 mg abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir sulfate oral capsule 50 mg, 200 mg, 300 mg ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule delayed release 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG efavirenz oral capsule 50 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG fosamprenavir calcium oral tablet 700 mg PA QL (30 EA per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 52

60 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 00 MG, 25 MG JULUCA ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 mg/ml lamivudine oral tablet 50 mg, 300 mg lamivudine-zidovudine oral tablet mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution mg/5ml nevirapine er oral tablet extended release 24 hour 00 mg, 400 mg nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 200 mg NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 53

61 RESCRIPTOR ORAL TABLET 00 MG, 200 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 5 mg, 20 mg, 30 mg, 40 mg STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG tenofovir disoproxil fumarate oral tablet 300 mg TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG TYBOST ORAL TABLET 50 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE ORAL SUSPENSION 50 MG/5ML VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG ZERIT ORAL SOLUTION RECONSTITUTED MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 54

62 CMV AGENTS cidofovir intravenous solution 75 mg/ml ganciclovir sodium intravenous solution reconstituted 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral solution reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg HEPATITIS AGENTS adefovir dipivoxil oral tablet 0 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD EPCLUSA ORAL TABLET MG PA; QL (30 EA per 30 days) EPIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 00 mg MAVYRET ORAL TABLET MG PA; QL (68 EA per 365 days) MODERIBA 200 DOSE PACK ORAL TABLET 600 MG MODERIBA 800 DOSE PACK ORAL TABLET 400 MG MODERIBA ORAL TABLET 200 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 35 MCG/0.5ML, 80 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/0.5ML, 80 MCG/ML RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg VEMLIDY ORAL TABLET 25 MG ZEPATIER ORAL TABLET MG PA; QL (30 EA per 30 days)

63 HERPES AGENTS acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous solution 50 mg/ml BvD famciclovir oral tablet 25 mg, 250 mg, 500 mg valacyclovir hcl oral tablet gm, 500 mg INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg QL (84 EA per 80 days) oseltamivir phosphate oral capsule 45 mg, 75 mg QL (28 EA per 80 days) oseltamivir phosphate oral suspension reconstituted 6 mg/ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 00 mg TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML ASSORTED CLASSES CHELATING AGENTS DEPEN TITRATABS ORAL TABLET 250 MG SYPRINE ORAL CAPSULE 250 MG PA IMMUNOMODULATORS REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, MG, 5 MG ATGAM INTRAVENOUS INJECTABLE 50 MG/ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ QL (550 ML per 80 days) QL (56 EA per 80 days) QL (550 ML per 80 days) PA; QL (30 EA per 30 days) PA BvD BvD AZASAN ORAL TABLET 00 MG, 75 MG BvD azathioprine oral tablet 50 mg BvD

64 cyclosporine intravenous solution 50 mg/ml BvD cyclosporine modified oral capsule 00 mg, 25 mg BvD cyclosporine modified oral solution 00 mg/ml BvD cyclosporine oral capsule 00 mg, 25 mg BvD ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, MG, 4 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD GENGRAF ORAL CAPSULE 00 MG, 25 MG BvD GENGRAF ORAL SOLUTION 00 MG/ML BvD mycophenolate mofetil oral capsule 250 mg BvD mycophenolate mofetil oral suspension reconstituted 200 mg/ml BvD mycophenolate mofetil oral tablet 500 mg BvD mycophenolate sodium oral tablet delayed release 80 mg, 360 mg NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG PROGRAF INTRAVENOUS SOLUTION 5 MG/ML BvD BvD BvD RAPAMUNE ORAL SOLUTION MG/ML BvD SANDIMMUNE ORAL SOLUTION 00 MG/ML BvD SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 20 MG sirolimus oral tablet 0.5 mg, mg, 2 mg BvD tacrolimus oral capsule 0.5 mg, mg, 5 mg BvD THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG IRRIGATION SOLUTIONS lactated ringers irrigation solution PHYSIOLYTE IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION ringers irrigation irrigation solution sterile water for irrigation irrigation solution BvD BvD

65 LYMPHATIC AGENTS SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 00 MG POTASSIUM REMOVING RESINS KIONEX ORAL POWDER KIONEX ORAL SUSPENSION 5 GM/60ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 5 gm/60ml SPS ORAL SUSPENSION 5 GM/60ML VELTASSA ORAL PACKET 6.8 GM, 25.2 GM, 8.4 GM SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 400 MG BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg carvedilol phosphate er oral capsule extended release 24 hour 80 mg labetalol hcl intravenous solution 5 mg/ml labetalol hcl oral tablet 00 mg, 200 mg, 300 mg BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 00 mg, 25 mg, 50 mg betaxolol hcl oral tablet 0 mg, 20 mg bisoprolol fumarate oral tablet 0 mg, 5 mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 58

66 metoprolol succinate er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml metoprolol tartrate intravenous solution cartridge 5 mg/5ml metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg BETA BLOCKERS NON-SELECTIVE INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 80 MG nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 0 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 20 mg, 60 mg, 60 mg, 80 mg propranolol hcl intravenous solution mg/ml propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 20 MG, 60 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 20 mg sotalol hcl oral tablet 60 mg, 240 mg, 80 mg timolol maleate oral tablet 0 mg, 20 mg, 5 mg BIOLOGICALS MISC BIOLOGICALS MISC ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG amlodipine besylate oral tablet 0 mg, 2.5 mg, 5 mg CARDENE IV INTRAVENOUS SOLUTION MG/200ML-%, MG/200ML-% Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA

67 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 80 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 80 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg, 300 mg diltiazem hcl er oral capsule extended release 2 hour 20 mg, 60 mg, 90 mg diltiazem hcl intravenous solution 50 mg/0ml diltiazem hcl intravenous solution reconstituted 00 mg diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release 24 hour 20 mg, 80 mg, 240 mg felodipine er oral tablet extended release 24 hour 0 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG, 240 MG, 300 MG, 360 MG, 420 MG nicardipine hcl intravenous solution 2.5 mg/ml nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 0 mg, 20 mg nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release 24 hour 7 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 80 MG, 240 MG, 300 MG, 360 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 60

68 verapamil hcl er oral capsule extended release 24 hour 00 mg, 20 mg, 80 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 20 mg, 80 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml verapamil hcl oral tablet 20 mg, 40 mg, 80 mg CARDIOTONICS CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 25 MCG, 250 MCG digoxin injection solution 0.25 mg/ml digoxin oral solution 0.05 mg/ml digoxin oral tablet 25 mcg, 250 mcg CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine-atorvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg, mg, mg, mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg BIDIL ORAL TABLET MG ENTRESTO ORAL TABLET MG, 49-5 MG, MG PROSTAGLANDIN VASODILATORS REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML VENTAVIS INHALATION SOLUTION 0 MCG/ML, 20 MCG/ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 6 PA; QL (60 EA per 30 days) BvD PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS ORAL TABLET 0 MG, 5 MG PA; QL (30 EA per 30 days) OPSUMIT ORAL TABLET 0 MG PA; QL (30 EA per 30 days) TRACLEER ORAL TABLET 25 MG, 62.5 MG PA; QL (60 EA per 30 days) TRACLEER ORAL TABLET SOLUBLE 32 MG PA; QL (60 EA per 30 days) PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS sildenafil citrate oral tablet 20 mg PA PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

69 UPTRAVI ORAL TABLET 000 MCG, 200 MCG, 400 MCG, 600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (60 EA per 30 days) PA; QL (200 EA per 30 days) PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG SINUS NODE INHIBITORS PA CORLANOR ORAL TABLET 5 MG, 7.5 MG PA CEPHALOSPORINS CEPHALOSPORIN COMBINATIONS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED.5 (-0.5) GM CEPHALOSPORINS - ST GENERATION cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 0 gm, 500 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml CEPHALOSPORINS - 2ND GENERATION cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 25 mg/5ml, 250 mg/5ml, 375 mg/5ml cefotetan disodium injection solution reconstituted gm, 2 gm cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm

70 cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted.5 gm, 7.5 gm, 750 mg CEPHALOSPORINS - 3RD GENERATION cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml cefotaxime sodium injection solution reconstituted gm, 2 gm, 500 mg cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg ceftazidime injection solution reconstituted gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted gm, 0 gm, 2 gm SUPRAX ORAL CAPSULE 400 MG TAZICEF INJECTION SOLUTION RECONSTITUTED GM, 2 GM, 6 GM CEPHALOSPORINS - 4TH GENERATION cefepime hcl injection solution reconstituted gm, 2 gm CEPHALOSPORINS - 5TH GENERATION TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL ALTAVERA ORAL TABLET MG-MCG alyacen /35 oral tablet -35 mg-mcg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 63

71 AMETHIA LO ORAL TABLET & 0.0 MG AMETHIA ORAL TABLET &0.0 MG APRI ORAL TABLET MG-MCG ARANELLE ORAL TABLET 0.5// MG- MCG ASHLYNA ORAL TABLET &0.0 MG AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BEKYREE ORAL TABLET /0.0 MG (2/5) BLISOVI 24 FE ORAL TABLET -20 MG- MCG(24) BLISOVI FE.5/30 ORAL TABLET.5-30 MG- MCG BLISOVI FE /20 ORAL TABLET -20 MG- MCG briellyn oral tablet mg-mcg CAMRESE LO ORAL TABLET & 0.0 MG CAZIANT ORAL TABLET 0./0.25/ MG CRYSELLE-28 ORAL TABLET MG- MCG CYCLAFEM /35 ORAL TABLET -35 MG- MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/-35 MG-MCG DELYLA ORAL TABLET MG-MCG desogestrel-ethinyl estradiol oral tablet /0.0 mg (2/5), mg-mcg drospiren-eth estrad-levomefol oral tablet mg drospirenone-ethinyl estradiol oral tablet mg, mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 64

72 EMOQUETTE ORAL TABLET MG- MCG ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MG-MCG ethynodiol diac-eth estradiol oral tablet -35 mgmcg, -50 mg-mcg FALMINA ORAL TABLET MG-MCG FAYOSIM ORAL TABLET DAYS FEMYNOR ORAL TABLET MG-MCG GIANVI ORAL TABLET MG GILDAGIA ORAL TABLET MG-MCG INTROVALE ORAL TABLET MG ISIBLOOM ORAL TABLET MG-MCG JULEBER ORAL TABLET MG-MCG JUNEL.5/30 ORAL TABLET.5-30 MG-MCG JUNEL /20 ORAL TABLET -20 MG-MCG JUNEL FE.5/30 ORAL TABLET.5-30 MG- MCG JUNEL FE /20 ORAL TABLET -20 MG-MCG JUNEL FE 24 ORAL TABLET -20 MG- MCG(24) KAITLIB FE ORAL TABLET CHEWABLE MG-MCG KARIVA ORAL TABLET /0.0 MG (2/5) KELNOR /35 ORAL TABLET -35 MG-MCG KIMIDESS ORAL TABLET /0.0 MG (2/5) KURVELO ORAL TABLET MG-MCG LARIN.5/30 ORAL TABLET.5-30 MG-MCG LARIN /20 ORAL TABLET -20 MG-MCG LARIN FE.5/30 ORAL TABLET.5-30 MG- MCG LARIN FE /20 ORAL TABLET -20 MG-MCG LARISSIA ORAL TABLET MG-MCG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 65

73 LAYOLIS FE ORAL TABLET CHEWABLE MG-MCG LEENA ORAL TABLET 0.5// MG-MCG LESSINA ORAL TABLET MG-MCG LEVONEST ORAL TABLET levonorgest-eth est & eth est oral tablet days levonorgest-eth estrad 9-day oral tablet &0.0 mg, mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg-mcg, mcg levonorg-eth estrad triphasic oral tablet LEVORA 0.5/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG- MCG LUTERA ORAL TABLET MG-MCG marlissa oral tablet mg-mcg MICROGESTIN.5/30 ORAL TABLET.5-30 MG-MCG MICROGESTIN /20 ORAL TABLET -20 MG- MCG MICROGESTIN FE.5/30 ORAL TABLET.5-30 MG-MCG MICROGESTIN FE /20 ORAL TABLET -20 MG-MCG MONONESSA ORAL TABLET MG- MCG NATAZIA ORAL TABLET 3/2-2/2-3/ MG NECON 0.5/35 (28) ORAL TABLET MG- MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/-35 MG-MCG NIKKI ORAL TABLET MG norethin ace-eth estrad-fe oral tablet -20 mgmcg(24) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 66

74 norethindrone acet-ethinyl est oral tablet -20 mgmcg norethin-eth estradiol-fe oral tablet chewable mg-mcg, mg-mcg norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.8/0.25/0.25 mg-25 mcg, 0.8/0.25/0.25 mg- 35 mcg NORTREL 0.5/35 (28) ORAL TABLET MG-MCG NORTREL /35 (2) ORAL TABLET -35 MG- MCG NORTREL /35 (28) ORAL TABLET -35 MG- MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/-35 MG-MCG OCELLA ORAL TABLET MG ORSYTHIA ORAL TABLET MG-MCG PIMTREA ORAL TABLET /0.0 MG (2/5) PIRMELLA /35 ORAL TABLET -35 MG- MCG PORTIA-28 ORAL TABLET MG-MCG PREVIFEM ORAL TABLET MG-MCG QUASENSE ORAL TABLET MG RECLIPSEN ORAL TABLET MG-MCG RIVELSA ORAL TABLET DAYS SETLAKIN ORAL TABLET MG SPRINTEC 28 ORAL TABLET MG- MCG SRONYX ORAL TABLET MG-MCG TARINA FE /20 ORAL TABLET -20 MG- MCG TRI-LEGEST FE ORAL TABLET -20/-30/-35 MG-MCG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 67

75 TRI-LO-ESTARYLLA ORAL TABLET 0.8/0.25/0.25 MG-25 MCG TRI-LO-SPRINTEC ORAL TABLET 0.8/0.25/0.25 MG-25 MCG TRINESSA (28) ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRI-SPRINTEC ORAL TABLET 0.8/0.25/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0./0.25/ MG VESTURA ORAL TABLET MG VIENVA ORAL TABLET MG-MCG VYFEMLA ORAL TABLET MG-MCG WYMZYA FE ORAL TABLET CHEWABLE MG-MCG ZARAH ORAL TABLET MG ZENCHENT ORAL TABLET MG-MCG ZOVIA /35E (28) ORAL TABLET -35 MG- MCG ZOVIA /50E (28) ORAL TABLET -50 MG- MCG COMBINATION CONTRACEPTIVES - TRANSDERMAL XULANE TRANSDERMAL PATCH WEEKLY MCG/24HR COMBINATION CONTRACEPTIVES - VAGINAL NUVARING VAGINAL RING MG/24HR PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate intramuscular suspension 50 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 50 mg/ml PROGESTIN CONTRACEPTIVES - ORAL Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 68

76 CAMILA ORAL TABLET 0.35 MG DEBLITANE ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG LYZA ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG norethindrone oral tablet 0.35 mg NORLYROC ORAL TABLET 0.35 MG SHAROBEL ORAL TABLET 0.35 MG CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide oral capsule delayed release particles 3 mg cortisone acetate oral tablet 25 mg DEXAMETHASONE INTENSOL ORAL CONCENTRATE MG/ML dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 0 mg/ml, 20 mg/30ml hydrocortisone oral tablet 0 mg, 20 mg, 5 mg KENALOG INJECTION SUSPENSION 0 MG/ML, 40 MG/ML MEDROL ORAL TABLET 2 MG methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy pack 4 mg methylprednisolone sodium succ injection solution reconstituted 000 mg, 25 mg, 40 mg prednisolone oral solution 5 mg/5ml prednisolone sodium phosphate oral solution 5 mg/5ml, 6.7 (5 base) mg/5ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD

77 prednisolone sodium phosphate oral tablet dispersible 0 mg, 5 mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5ml prednisone oral tablet mg, 0 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 0 mg (2), 0 mg (48), 5 mg (2), 5 mg (48) SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 00 MG, 250 MG UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG MINERALOCORTICOIDS fludrocortisone acetate oral tablet 0. mg COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COMBINATIONS CLARINEX-D 2 HOUR ORAL TABLET EXTENDED RELEASE 2 HOUR MG promethazine vc plain oral solution mg/5ml promethazine vc plain oral syrup mg/5ml MUCOLYTICS acetylcysteine inhalation solution 0 %, 20 % BvD DERMATOLOGICALS ACNE PRODUCTS adapalene external cream 0. % PA adapalene external gel 0. %, 0.3 % PA adapalene-benzoyl peroxide external gel % PA AVITA EXTERNAL CREAM % PA AVITA EXTERNAL GEL % PA benzoyl peroxide-erythromycin external gel 5-3 % CLARAVIS ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG CLINDACIN-P EXTERNAL SWAB % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (30 EA per 30 days)

78 clindamycin phos-benzoyl perox external gel -5 % clindamycin phosphate external foam % clindamycin phosphate external gel % clindamycin phosphate external lotion % clindamycin phosphate external solution % clindamycin phosphate external swab % DIFFERIN EXTERNAL LOTION 0. % PA EPIDUO EXTERNAL GEL % PA EPIDUO FORTE EXTERNAL GEL % PA ery external pad 2 % erythromycin external gel 2 % erythromycin external solution 2 % MYORISAN ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG sulfacetamide sodium (acne) external lotion 0 % tretinoin external cream %, 0.05 %, 0. % PA tretinoin external gel 0.0 %, %, 0.05 % PA tretinoin microsphere external gel 0.04 %, 0. % PA ZENATANE ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG ANTIBIOTICS - TOPICAL gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % mupirocin calcium external cream 2 % mupirocin external ointment 2 % ANTIFUNGALS - TOPICAL ciclopirox external gel 0.77 % ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 7

79 clotrimazole external solution % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % econazole nitrate external cream % ERTACZO EXTERNAL CREAM 2 % ketoconazole external cream 2 % ketoconazole external foam 2 % ketoconazole external shampoo 2 % naftifine hcl external cream 2 % NYAMYC EXTERNAL POWDER UNIT/GM nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium transdermal gel % QL (000 GM per 30 days) diclofenac sodium transdermal solution.5 % ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL diclofenac sodium transdermal gel 3 % PA fluorouracil external cream 0.5 %, 5 % fluorouracil external solution 2 %, 5 % PANRETIN EXTERNAL GEL 0. % PICATO EXTERNAL GEL 0.05 % QL (3 EA per 0 days) PICATO EXTERNAL GEL 0.05 % QL (2 EA per 0 days) TARGRETIN EXTERNAL GEL % TOLAK EXTERNAL CREAM 4 % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 72

80 VALCHLOR EXTERNAL GEL 0.06 % PA; QL (240 GM per 30 days) ANTIPSORIATICS acitretin oral capsule 0 mg, 7.5 mg, 25 mg calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML methoxsalen rapid oral capsule 0 mg tazarotene external cream 0. % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0. % ANTISEBORRHEIC PRODUCTS selenium sulfide external lotion 2.5 % ANTIVIRALS - TOPICAL acyclovir external ointment 5 % DENAVIR EXTERNAL CREAM % BURN PRODUCTS silver sulfadiazine external cream % SSD EXTERNAL CREAM % SULFAMYLON EXTERNAL CREAM 85 MG/GM CORTICOSTEROIDS - TOPICAL ala-cort external cream %, 2.5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % PA PA amcinonide external cream 0. % PA amcinonide external ointment 0. % PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 73

81 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 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external foam 0.2 % PA betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % calcipotriene-betameth diprop external ointment % clobetasol propionate e external cream 0.05 % PA clobetasol propionate external foam 0.05 % PA clobetasol propionate external gel 0.05 % PA clobetasol propionate external liquid 0.05 % PA clobetasol propionate external lotion 0.05 % PA clobetasol propionate external ointment 0.05 % PA clobetasol propionate external shampoo 0.05 % PA clobetasol propionate external solution 0.05 % PA CLODAN EXTERNAL SHAMPOO 0.05 % PA desonide external cream 0.05 % PA desonide external lotion 0.05 % PA desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.25 % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 74

82 diflorasone diacetate external cream 0.05 % PA diflorasone diacetate external ointment 0.05 % PA fluocinolone acetonide body external oil 0.0 % fluocinolone acetonide external cream 0.0 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.0 % fluocinolone acetonide scalp external oil 0.0 % fluocinonide emulsified base external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external lotion 0.05 % PA fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone external cream %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % mometasone furoate external cream 0. % mometasone furoate external ointment 0. % mometasone furoate external solution 0. % prednicarbate external cream 0. % prednicarbate external ointment 0. % psorcon external cream 0.05 % PA TOPICORT EXTERNAL CREAM 0.05 % triamcinolone acetonide external aerosol solution 0.47 mg/gm Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 75

83 triamcinolone acetonide external cream %, 0. %, 0.5 % triamcinolone acetonide external lotion %, 0. % triamcinolone acetonide external ointment %, 0. %, 0.5 % TRIDERM EXTERNAL CREAM 0. % EMOLLIENTS ammonium lactate external cream 2 % ammonium lactate external lotion 2 % ENZYMES - TOPICAL SANTYL EXTERNAL OINTMENT 250 UNIT/GM IMMUNOMODULATING AGENTS - TOPICAL imiquimod external cream 5 % ZYCLARA PUMP EXTERNAL CREAM 2.5 % IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL EXTERNAL CREAM % tacrolimus external ointment 0.03 %, 0. % KERATOLYTIC/ANTIMITOTIC AGENTS podofilox external solution 0.5 % LOCAL ANESTHETICS - TOPICAL lidocaine external ointment 5 % ST; QL (07 GM per 30 days) lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine hcl external gel 2 % lidocaine hcl external solution 4 % lidocaine-prilocaine external cream % ROSACEA AGENTS FINACEA EXTERNAL FOAM 5 % FINACEA EXTERNAL GEL 5 % metronidazole external cream 0.75 % metronidazole external gel 0.75 %, % metronidazole external lotion 0.75 % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 76

84 SCABICIDES PEDICULICIDES EURAX EXTERNAL CREAM 0 % lindane external shampoo % malathion external lotion 0.5 % permethrin external cream 5 % WOUND CARE PRODUCTS REGRANEX EXTERNAL GEL 0.0 % QL (30 GM per 5 days) DIGESTIVE AIDS DIGESTIVE ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 0500 UNIT, 6800 UNIT, 2000 UNIT, 2600 UNIT, 4200 UNIT Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ ST SUCRAID ORAL SOLUTION 8500 UNIT/ML PA DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide er oral capsule extended release 2 hour 500 mg acetazolamide oral tablet 25 mg, 250 mg acetazolamide sodium injection solution reconstituted 500 mg methazolamide oral tablet 25 mg, 50 mg DIURETIC COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 mg spironolactone-hctz oral tablet mg triamterene-hctz oral capsule mg, mg triamterene-hctz oral tablet mg, mg LOOP DIURETICS bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, mg, 2 mg

85 ethacrynic acid oral tablet 25 mg furosemide injection solution 0 mg/ml, 0 mg/ml (4ml syringe) furosemide oral solution 0 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg POTASSIUM SPARING DIURETICS amiloride hcl oral tablet 5 mg CAROSPIR ORAL SUSPENSION 25 MG/5ML DYRENIUM ORAL CAPSULE 00 MG, 50 MG spironolactone oral tablet 00 mg, 25 mg, 50 mg THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous solution reconstituted 500 mg chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL SUSPENSION 250 MG/5ML hydrochlorothiazide oral capsule 2.5 mg hydrochlorothiazide oral tablet 2.5 mg, 25 mg, 50 mg indapamide oral tablet.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 0 mg, 2.5 mg, 5 mg ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS alendronate sodium oral solution 70 mg/75ml alendronate sodium oral tablet 0 mg, 35 mg, 40 mg, 5 mg, 70 mg calcitonin (salmon) nasal solution 200 unit/act etidronate disodium oral tablet 200 mg, 400 mg FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA ibandronate sodium intravenous solution 3 mg/3ml BvD ibandronate sodium oral tablet 50 mg QL ( EA per 30 days)

86 MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG, 25 MCG, 50 MCG, 75 MCG pamidronate disodium intravenous solution 30 mg/0ml, 6 mg/ml, 90 mg/0ml PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML risedronate sodium oral tablet 50 mg, 30 mg, 35 mg, 35 mg (2 pack), 35 mg (4 pack), 5 mg XGEVA SUBCUTANEOUS SOLUTION 20 MG/.7ML zoledronic acid intravenous concentrate 4 mg/5ml zoledronic acid intravenous solution 5 mg/00ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00ML GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 0 MG, 5 MG, 20 MG, 25 MG, 30 MG GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 0 MG/.5ML, 5 MG/.5ML, 30 MG/3ML, 5 MG/.5ML HORMONE RECEPTOR MODULATORS NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT raloxifene hcl oral tablet 60 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD PA BvD PA PA PA INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT-PED (-MONTH) INTRAMUSCULAR KIT.25 MG, 5 MG LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED) SYNAREL NASAL SOLUTION 2 MG/ML

87 METABOLIC MODIFIERS ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML calcitriol intravenous solution mcg/ml BvD calcitriol oral capsule 0.25 mcg, 0.5 mcg BvD calcitriol oral solution mcg/ml BvD CARBAGLU ORAL TABLET 200 MG PA doxercalciferol intravenous solution 4 mcg/2ml BvD doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD KUVAN ORAL PACKET 00 MG, 500 MG PA KUVAN ORAL TABLET SOLUBLE 00 MG PA levocarnitine oral solution gm/0ml BvD levocarnitine oral tablet 330 mg BvD LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NAGLAZYME INTRAVENOUS SOLUTION MG/ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 5 MG PA ORFADIN ORAL SUSPENSION 4 MG/ML PA paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml BvD paricalcitol oral capsule mcg, 2 mcg, 4 mcg BvD RAVICTI ORAL LIQUID. GM/ML PA RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG sodium phenylbutyrate oral powder 3 gm/tsp STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML, 80 MG/0.8ML BvD PA

88 XURIDEN ORAL PACKET 2 GM POSTERIOR PITUITARY HORMONES desmopressin ace rhinal tube nasal solution 0.0 % desmopressin ace spray refrig nasal solution 0.0 % desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0. mg, 0.2 mg STIMATE NASAL SOLUTION.5 MG/ML PROLACTIN INHIBITORS cabergoline oral tablet 0.5 mg SOMATOSTATIC AGENTS octreotide acetate injection solution 00 mcg/ml, 000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 20 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML ESTROGENS ESTROGEN COMBINATIONS AMABELZ ORAL TABLET MG, -0.5 MG COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY MG/DAY, MG/DAY estradiol-norethindrone acet oral tablet mg, -0.5 mg FYAVOLV ORAL TABLET MG-MCG, -5 MG-MCG JINTELI ORAL TABLET -5 MG-MCG MIMVEY LO ORAL TABLET MG MIMVEY ORAL TABLET -0.5 MG norethindrone-eth estradiol oral tablet mgmcg, -5 mg-mcg PREMPHASE ORAL TABLET MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 8 PA; QL (60 ML per 30 days)

89 PREMPRO ORAL TABLET MG, MG, MG, MG ESTROGENS estradiol oral tablet 0.5 mg, mg, 2 mg estradiol transdermal patch twice weekly mg/24hr, mg/24hr, 0.05 mg/24hr, mg/24hr, 0. mg/24hr estradiol transdermal patch weekly mg/24hr, mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, mg/24hr, 0. mg/24hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estropipate oral tablet 0.75 mg,.5 mg, 3 mg PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG FLUOROQUINOLONES FLUOROQUINOLONES AVELOX INTRAVENOUS SOLUTION 400 MG/250ML ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 200 mg/00ml ciprofloxacin intravenous solution 400 mg/40ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) levofloxacin in d5w intravenous solution 500 mg/00ml, 750 mg/50ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg moxifloxacin hcl intravenous solution 400 mg/250ml moxifloxacin hcl oral tablet 400 mg ofloxacin oral tablet 400 mg GASTROINTESTINAL AGENTS - MISC. Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 82

90 BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM ORAL CAPSULE 250 MG, 50 MG PA FARNESOID X RECEPTOR (FXR) AGONISTS OCALIVA ORAL TABLET 0 MG, 5 MG PA; QL (30 EA per 30 days) GALLSTONE SOLUBILIZING AGENTS CHENODAL ORAL TABLET 250 MG ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium oral concentrate 00 mg/5ml GASTROINTESTINAL STIMULANTS metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg INFLAMMATORY BOWEL AGENTS APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 mg CANASA RECTAL SUPPOSITORY 000 MG DIPENTUM ORAL CAPSULE 250 MG LIALDA ORAL TABLET DELAYED RELEASE.2 GM mesalamine rectal enema 4 gm mesalamine-cleanser rectal kit 4 gm sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg INTESTINAL ACIDIFIERS enulose oral solution 0 gm/5ml generlac oral solution 0 gm/5ml IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl oral tablet 0.5 mg, mg LINZESS ORAL CAPSULE 45 MCG, 290 PA; QL (30 EA per 30 days) MCG, 72 MCG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 83

91 PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK ORAL TABLET 2.5 MG, 25 MG PA RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6ML, 2 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML PHOSPHATE BINDER AGENTS AURYXIA ORAL TABLET GM 20 MG(FE) calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg FOSRENOL ORAL PACKET 000 MG, 750 MG FOSRENOL ORAL TABLET CHEWABLE 000 MG, 500 MG, 750 MG lanthanum carbonate oral tablet chewable 000 mg, 500 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 MG/5ML RENVELA ORAL TABLET 800 MG sevelamer carbonate oral packet 0.8 gm, 2.4 gm sevelamer carbonate oral tablet 800 mg SHORT BOWEL SYNDROME (SBS) AGENTS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA GATTEX SUBCUTANEOUS KIT 5 MG PA GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS potassium citrate er oral tablet extended release 0 meq (080 mg), 5 meq (620 mg), 5 meq (540 mg) CYSTINOSIS AGENTS CYSTAGON ORAL CAPSULE 50 MG, 50 MG PA GENITOURINARY IRRIGANTS neomycin-polymyxin b gu irrigation solution sodium chloride irrigation solution 0.9 % INTERSTITIAL CYSTITIS AGENTS ELMIRON ORAL CAPSULE 00 MG PROSTATIC HYPERTROPHY AGENTS

92 alfuzosin hcl er oral tablet extended release 24 hour 0 mg dutasteride oral capsule 0.5 mg dutasteride-tamsulosin hcl oral capsule mg finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE 4 MG, 8 MG tamsulosin hcl oral capsule 0.4 mg URINARY STONE AGENTS LITHOSTAT ORAL TABLET 250 MG THIOLA ORAL TABLET 00 MG GOUT AGENTS GOUT AGENT COMBINATIONS colchicine-probenecid oral tablet mg GOUT AGENTS allopurinol oral tablet 00 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg PA MITIGARE ORAL CAPSULE 0.6 MG ULORIC ORAL TABLET 40 MG, 80 MG ST URICOSURICS probenecid oral tablet 500 mg HEMATOLOGICAL AGENTS - MISC. BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML COMPLEMENT INHIBITORS PA BERINERT INTRAVENOUS KIT 500 UNIT PA CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT HEMATORHEOLOGIC AGENTS PA PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 85

93 pentoxifylline er oral tablet extended release 400 mg PLATELET AGGREGATION INHIBITORS anagrelide hcl oral capsule 0.5 mg, mg aspirin-dipyridamole er oral capsule extended release 2 hour mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT ZAVESCA ORAL CAPSULE 00 MG PA AGENTS FOR SICKLE CELL ANEMIA DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 00 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 0 MCG/0.4ML, 00 MCG/0.5ML, 50 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML EPOGEN INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD; ST BvD; ST BvD

94 LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML STEM CELL MOBILIZERS MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2ML HEMOSTATICS HEMOSTATICS - SYSTEMIC tranexamic acid intravenous solution 000 mg/0ml tranexamic acid oral tablet 650 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA BvD PA HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS BARBITURATE HYPNOTICS BUTISOL SODIUM ORAL TABLET 30 MG phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg NON-BARBITURATE HYPNOTICS estazolam oral tablet mg, 2 mg eszopiclone oral tablet mg, 2 mg, 3 mg QL (30 EA per 30 days) flurazepam hcl oral capsule 5 mg, 30 mg temazepam oral capsule 5 mg, 22.5 mg, 30 mg, 7.5 mg triazolam oral tablet 0.25 mg, 0.25 mg zaleplon oral capsule 0 mg, 5 mg QL (30 EA per 30 days) zolpidem tartrate oral tablet 0 mg QL (30 EA per 30 days)

95 zolpidem tartrate oral tablet 5 mg QL (60 EA per 30 days) SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ ORAL CAPSULE 20 MG PA; QL (30 EA per 30 days) ROZEREM ORAL TABLET 8 MG PA; QL (30 EA per 30 days) LAXATIVES LAXATIVE COMBINATIONS GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM MOVIPREP ORAL SOLUTION RECONSTITUTED 00 GM peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM LAXATIVES - MISCELLANEOUS constulose oral solution 0 gm/5ml lactulose oral solution 0 gm/5ml polyethylene glycol 3350 oral powder LOCAL ANESTHETICS-PARENTERAL LOCAL ANESTHETICS - AMIDES lidocaine hcl (pf) injection solution 0.5 %, % lidocaine hcl injection solution 2 % MACROLIDES AZITHROMYCIN azithromycin intravenous solution reconstituted 500 mg azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 88

96 azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg CLARITHROMYCIN clarithromycin er oral tablet extended release 24 hour 500 mg clarithromycin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg ERYTHROMYCINS ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml MEDICAL DEVICES PARENTERAL THERAPY SUPPLIES preferred plus insulin syringe 28g x /2" 0.5 ml MEDICAL DEVICES AND SUPPLIES BANDAGES-DRESSINGS-TAPE cvs gauze sterile pad 2"x2" MISC. DEVICES global alcohol prep ease pad 70 % PARENTERAL THERAPY SUPPLIES ASSURE ID INSULIN SAFETY SYR 29G X /2" ML COMFORT ASSIST INSULIN SYRINGE 29G X /2" ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 89

97 EXEL COMFORT POINT PEN NEEDLE 29G X 2MM RELI-ON INSULIN SYRINGE 29G 0.3 ML METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 320 MCG/.56ML MIGRAINE PRODUCTS MIGRAINE PRODUCTS dihydroergotamine mesylate nasal solution 4 mg/ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (.56 ML per 30 days) QL (6 ML per 30 days) MIGRANAL NASAL SOLUTION 4 MG/ML QL (6 ML per 30 days) SEROTONIN AGONISTS eletriptan hydrobromide oral tablet 20 mg, 40 mg QL (9 EA per 30 days) naratriptan hcl oral tablet mg, 2.5 mg QL (8 EA per 30 days) rizatriptan benzoate oral tablet 0 mg, 5 mg QL (36 EA per 60 days) rizatriptan benzoate oral tablet dispersible 0 mg, 5 mg QL (36 EA per 60 days) sumatriptan nasal solution 20 mg/act, 5 mg/act QL (2 EA per 30 days) sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution autoinjector 4 mg/0.5ml, 6 mg/0.5ml QL (8 EA per 30 days) QL (5 ML per 30 days) QL (5 ML per 30 days) QL (5 ML per 30 days) zolmitriptan oral tablet 2.5 mg, 5 mg QL (8 EA per 30 days) zolmitriptan oral tablet dispersible 2.5 mg, 5 mg QL (8 EA per 30 days) ZOMIG NASAL SOLUTION 2.5 MG QL (6 EA per 30 days) ZOMIG NASAL SOLUTION 5 MG QL (2 EA per 30 days) MINERALS ELECTROLYTES BICARBONATES sodium lactate intravenous solution 5 meq/ml

98 ELECTROLYTE MIXTURES dextrose in lactated ringers intravenous solution 5 % dextrose-nacl intravenous solution %, %, %, %, %, %, %, % IONOSOL-MB IN D5W INTRAVENOUS SOLUTION ISOLYTE-P IN D5W INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l- %-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l lactated ringers intravenous solution NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 48 INTRAVENOUS SOLUTION PLASMA-LYTE A INTRAVENOUS SOLUTION potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-% ringers intravenous solution TPN ELECTROLYTES INTRAVENOUS SOLUTION MAGNESIUM Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 9

99 magnesium sulfate injection solution 50 %, 50 % (0ml syringe) POTASSIUM KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON M0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON M5 ORAL TABLET EXTENDED RELEASE 5 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 0 MEQ, 8 MEQ K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ potassium chloride crys er oral tablet extended release 0 meq, 20 meq potassium chloride er oral capsule extended release 0 meq, 8 meq potassium chloride er oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride intravenous solution 0 meq/00ml, 2 meq/ml potassium chloride oral solution 20 meq/5ml (0%), 40 meq/5ml (20%) SODIUM sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % MISCELLANEOUS THERAPEUTIC CLASSES IMMUNOSUPPRESSIVE AGENTS azathioprine sodium injection solution reconstituted 00 mg BvD GENGRAF ORAL CAPSULE 50 MG BvD Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 92

100 mycophenolate mofetil hcl intravenous solution reconstituted 500 mg MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine viscous mouth/throat solution 2 % ANTI-INFECTIVES - THROAT clotrimazole mouth/throat lozenge 0 mg nystatin mouth/throat suspension unit/ml ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate mouth/throat solution 0.2 % PERIOGARD MOUTH/THROAT SOLUTION 0.2 % STEROIDS - MOUTH/THROAT triamcinolone acetonide mouth/throat paste 0. % THROAT PRODUCTS - MISC. cevimeline hcl oral capsule 30 mg pilocarpine hcl oral tablet 5 mg, 7.5 mg MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen oral tablet 0 mg, 20 mg carisoprodol oral tablet 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine hcl oral tablet 0 mg, 5 mg, 7.5 mg METAXALL ORAL TABLET 800 MG metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg orphenadrine citrate er oral tablet extended release 2 hour 00 mg orphenadrine citrate injection solution 30 mg/ml tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg tizanidine hcl oral tablet 2 mg, 4 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD

101 DIRECT MUSCLE RELAXANTS dantrolene sodium oral capsule 00 mg, 25 mg, 50 mg MUSCLE RELAXANT COMBINATIONS carisoprodol-aspirin oral tablet mg carisoprodol-aspirin-codeine oral tablet mg NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTIALLERGY azelastine hcl nasal solution 0. %, 0.5 % olopatadine hcl nasal solution 0.6 % NASAL ANTICHOLINERGICS ipratropium bromide nasal solution 0.03 %, 0.06 % NASAL STEROIDS flunisolide nasal solution 25 mcg/act (0.025%) QL (50 ML per 5 days) fluticasone propionate nasal suspension 50 mcg/act Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ QL (32 GM per 5 days) triamcinolone acetonide nasal aerosol 55 mcg/act QL (33 GM per 5 days) NEUROMUSCULAR AGENTS ALS AGENTS riluzole oral tablet 50 mg MUSCULAR DYSTROPHY AGENTS EXONDYS 5 INTRAVENOUS SOLUTION 00 MG/2ML, 500 MG/0ML NUTRIENTS CARBOHYDRATES dextrose intravenous solution 0 %, 5 % LIPIDS INTRALIPID INTRAVENOUS EMULSION 20 % PA BvD nutrilipid intravenous emulsion 20 % BvD PROTEINS

102 AMINOSYN II INTRAVENOUS SOLUTION 0 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 0 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % CLINIMIX E/DEXTROSE (2.75/0) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (4.25/0) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (4.25/0) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD BvD Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 95

103 CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINISOL SF INTRAVENOUS SOLUTION 5 % FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % HEPATAMINE INTRAVENOUS SOLUTION 8 % NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % PLENAMINE INTRAVENOUS SOLUTION 5 % PREMASOL INTRAVENOUS SOLUTION 0 %, 6 % PROCALAMINE INTRAVENOUS SOLUTION 3 % Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD BvD BvD BvD BvD BvD BvD BvD BvD PROSOL INTRAVENOUS SOLUTION 20 % BvD TRAVASOL INTRAVENOUS SOLUTION 0 % BvD TROPHAMINE INTRAVENOUS SOLUTION 0 % OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS LACRISERT OPHTHALMIC INSERT 5 MG BETA-BLOCKERS - OPHTHALMIC betaxolol hcl ophthalmic solution 0.5 % BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % carteolol hcl ophthalmic solution % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl-timolol mal ophthalmic solution mg/ml ISTALOL OPHTHALMIC SOLUTION 0.5 % BvD

104 levobunolol hcl ophthalmic solution 0.5 % metipranolol ophthalmic solution 0.3 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) CYCLOPLEGIC MYDRIATICS atropine sulfate ophthalmic solution % MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.25 % pilocarpine hcl ophthalmic solution %, 2 %, 4 % OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0. % apraclonidine hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.5 %, 0.2 % IOPIDINE OPHTHALMIC SOLUTION % SIMBRINZA OPHTHALMIC SUSPENSION % OPHTHALMIC ANTI-INFECTIVES AZASITE OPHTHALMIC SOLUTION % bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ ST gatifloxacin ophthalmic solution 0.5 % ST GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate ophthalmic solution 0.3 % levofloxacin ophthalmic solution 0.5 % moxifloxacin hcl ophthalmic solution 0.5 %

105 NATACYN OPHTHALMIC SUSPENSION 5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic ointment 0 % sulfacetamide sodium ophthalmic solution 0 % tobramycin ophthalmic solution 0.3 % trifluridine ophthalmic solution % VIGAMOX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC GEL 0.5 % OPHTHALMIC IMMUNOMODULATORS RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC LOCAL ANESTHETICS proparacaine hcl ophthalmic solution 0.5 % OPHTHALMIC STEROIDS ALREX OPHTHALMIC SUSPENSION 0.2 % bacitra-neomycin-polymyxin-hc ophthalmic ointment % BLEPHAMIDE OPHTHALMIC SUSPENSION % dexamethasone sodium phosphate ophthalmic solution 0. % DUREZOL OPHTHALMIC EMULSION 0.05 % fluorometholone ophthalmic suspension 0. % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % MAXIDEX OPHTHALMIC SUSPENSION 0. % neomycin-polymyxin-dexameth ophthalmic ointment Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 98

106 neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension PRED MILD OPHTHALMIC SUSPENSION 0.2 % PRED-G OPHTHALMIC SUSPENSION 0.3- % prednisolone acetate ophthalmic suspension % prednisolone sodium phosphate ophthalmic solution % sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % OPHTHALMICS - MISC. ALOCRIL OPHTHALMIC SOLUTION 2 % ALOMIDE OPHTHALMIC SOLUTION 0. % azelastine hcl ophthalmic solution 0.05 % AZOPT OPHTHALMIC SUSPENSION % cromolyn sodium ophthalmic solution 4 % CYSTARAN OPHTHALMIC SOLUTION 0.44 % diclofenac sodium ophthalmic solution 0. % dorzolamide hcl ophthalmic solution 2 % epinastine hcl ophthalmic solution 0.05 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % NEVANAC OPHTHALMIC SUSPENSION 0. % olopatadine hcl ophthalmic solution 0. %, 0.2 % PA; QL (60 ML per 30 days) Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 99

107 PROSTAGLANDINS - OPHTHALMIC bimatoprost ophthalmic solution 0.03 % QL (5 ML per 30 days) latanoprost ophthalmic solution % QL (5 ML per 30 days) LUMIGAN OPHTHALMIC SOLUTION 0.0 % QL (5 ML per 30 days) TRAVATAN Z OPHTHALMIC SOLUTION % OTIC AGENTS OTIC AGENTS - MISCELLANEOUS acetic acid otic solution 2 % OTIC ANTI-INFECTIVES ofloxacin otic solution 0.3 % OTIC COMBINATIONS CIPRODEX OTIC SUSPENSION % COLY-MYCIN S OTIC SUSPENSION MG/ML neomycin-polymyxin-hc otic solution % neomycin-polymyxin-hc otic suspension OTIC STEROIDS fluocinolone acetonide otic oil 0.0 % hydrocortisone-acetic acid otic solution -2 % PASSIVE IMMUNIZING AGENTS IMMUNE SERUMS BIVIGAM INTRAVENOUS SOLUTION 0 GM/00ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMASTAN S/D INTRAMUSCULAR INJECTABLE (0ML), (2ML) GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML QL (5 ML per 30 days) PA PA PA PA PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 00

108 GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 0 GM, 5 GM GAMMAKED INJECTION SOLUTION GM/0ML GAMMAPLEX INTRAVENOUS SOLUTION 0 GM/200ML GAMUNEX-C INJECTION SOLUTION GM/0ML OCTAGAM INTRAVENOUS SOLUTION GM/20ML PRIVIGEN INTRAVENOUS SOLUTION 20 GM/200ML MONOCLONAL ANTIBODIES SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 0 PA PA PA PA PA PA PA PASSIVE IMMUNIZING AND TREATMENT AGENTS IMMUNE SERUMS GAMMAPLEX INTRAVENOUS SOLUTION 0 GM/00ML, 20 GM/200ML, 5 GM/50ML HYPERRAB S/D INTRAMUSCULAR INJECTABLE 50 UNIT/ML, 50 UNIT/ML (0ML) IMOGAM RABIES-HT INTRAMUSCULAR INJECTABLE 50 UNIT/ML OCTAGAM INTRAVENOUS SOLUTION 2 GM/20ML PENICILLINS AMINOPENICILLINS amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg ampicillin oral capsule 500 mg ampicillin sodium injection solution reconstituted gm, 25 mg PA BvD BvD PA

109 ampicillin sodium intravenous solution reconstituted 0 gm NATURAL PENICILLINS BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML penicillin g pot in dextrose intravenous solution unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit, unit penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg PENICILLIN COMBINATIONS amoxicillin-pot clavulanate er oral tablet extended release 2 hour mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm, 5 (0-5) gm, 3 (2-) gm ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 02

110 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 ZOSYN INTRAVENOUS SOLUTION GM/50ML, GM/50ML PENICILLINASE-RESISTANT PENICILLINS BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION GM/50ML, 2 GM/50ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted gm, 0 gm oxacillin sodium injection solution reconstituted 0 gm, 2 gm PROGESTINS PROGESTINS medroxyprogesterone acetate oral tablet 0 mg, 2.5 mg, 5 mg megestrol acetate oral suspension 625 mg/5ml PA norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 00 mg, 200 mg PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg ANTI-CATAPLECTIC AGENTS XYREM ORAL SOLUTION 500 MG/ML PA; QL (540 ML per 30 days) ANTIDEMENTIA AGENTS donepezil hcl oral tablet 0 mg, 5 mg QL (60 EA per 30 days) donepezil hcl oral tablet 23 mg ST; QL (30 EA per 30 days) donepezil hcl oral tablet dispersible 0 mg, 5 mg QL (30 EA per 30 days) galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 03

111 galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 0 mg, 5 (28)-0 (2) mg, 5 mg NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 &28 MG NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 4 & 2 &28-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide-amitriptyline oral tablet 0-25 mg, mg olanzapine-fluoxetine hcl oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 mg, 6-50 mg perphenazine-amitriptyline oral tablet 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg FIBROMYALGIA AGENTS SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 2.5 & 25 & 50 MG MOVEMENT DISORDER DRUG THERAPY AUSTEDO ORAL TABLET 2 MG, 6 MG, 9 MG ST ST QL (60 EA per 30 days) PA tetrabenazine oral tablet 2.5 mg, 25 mg PA MULTIPLE SCLEROSIS AGENTS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 04

112 AMPYRA ORAL TABLET EXTENDED RELEASE 2 HOUR 0 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (60 EA per 30 days) AUBAGIO ORAL TABLET 4 MG, 7 MG PA; QL (30 EA per 30 days) AVONEX INTRAMUSCULAR KIT 30 MCG AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG ST GILENYA ORAL CAPSULE 0.5 MG PA; QL (30 EA per 30 days) glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 25 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MCG/0.5ML TECFIDERA ORAL 20 & 240 MG TECFIDERA ORAL CAPSULE DELAYED RELEASE 20 MG, 240 MG TYSABRI INTRAVENOUS CONCENTRATE 300 MG/5ML PSEUDOBULBAR AFFECT (PBA) AGENTS PA NUEDEXTA ORAL CAPSULE 20-0 MG QL (60 EA per 30 days) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ergoloid mesylates oral tablet mg pimozide oral tablet mg, 2 mg SMOKING DETERRENTS bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG

113 CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 NICOTROL INHALATION INHALER 0 MG NICOTROL NS NASAL SOLUTION 0 MG/ML RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 000 MG, 500 MG GLASSIA INTRAVENOUS SOLUTION 000 MG/50ML PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 000 MG ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 000 MG CYSTIC FIBROSIS AGENTS KALYDECO ORAL PACKET 50 MG, 75 MG PA; QL (60 EA per 30 days) KALYDECO ORAL TABLET 50 MG PA; QL (60 EA per 30 days) ORKAMBI ORAL TABLET MG, MG PULMOZYME INHALATION SOLUTION MG/ML PULMONARY FIBROSIS AGENTS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ PA; QL (20 EA per 30 days) BvD ESBRIET ORAL CAPSULE 267 MG PA ESBRIET ORAL TABLET 267 MG, 80 MG PA OFEV ORAL CAPSULE 00 MG, 50 MG PA SULFONAMIDES SULFONAMIDES sulfadiazine oral tablet 500 mg TETRACYCLINES TETRACYCLINES demeclocycline hcl oral tablet 50 mg, 300 mg DOXY 00 INTRAVENOUS SOLUTION RECONSTITUTED 00 MG

114 doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 00 mg, 50 mg, 75 mg minocycline hcl oral capsule 00 mg, 50 mg, 75 mg minocycline hcl oral tablet 00 mg, 50 mg, 75 mg MORGIDOX ORAL CAPSULE 50 MG tetracycline hcl oral capsule 250 mg, 500 mg THYROID AGENTS ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg propylthiouracil oral tablet 50 mg THYROID HORMONES LEVO-T ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium intravenous solution 0 mcg/ml liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 07

115 THYROLAR- ORAL TABLET 60 (2.5-50) MG (MCG) THYROLAR-/2 ORAL TABLET 30 ( ) MG (MCG) THYROLAR-/4 ORAL TABLET 5 (3.-2.5) MG (MCG) THYROLAR-2 ORAL TABLET 20 (25-00) MG (MCG) THYROLAR-3 ORAL TABLET 80 ( ) MG (MCG) UNITHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG TOXOIDS TOXOID COMBINATIONS ADACEL INTRAMUSCULAR SUSPENSION (PREFILLED SYRINGE), LF- MCG/0.5 BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) DAPTACEL INTRAMUSCULAR SUSPENSION 0-5-5, LF-MCG/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml INFANRIX INTRAMUSCULAR SUSPENSION KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML PEDIARIX INTRAMUSCULAR SUSPENSION QUADRACEL INTRAMUSCULAR SUSPENSION TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml ULCER DRUGS ANTISPASMODICS Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/ BvD BvD BvD

116 atropine sulfate injection solution prefilled syringe 0.25 mg/5ml dicyclomine hcl oral capsule 0 mg dicyclomine hcl oral solution 0 mg/5ml dicyclomine hcl oral tablet 20 mg glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg propantheline bromide oral tablet 5 mg H-2 ANTAGONISTS cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg famotidine intravenous solution 20 mg/2ml famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg famotidine premixed intravenous solution mg/50ml-% nizatidine oral capsule 50 mg, 300 mg nizatidine oral solution 5 mg/ml ranitidine hcl injection solution 50 mg/2ml ranitidine hcl oral capsule 50 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml ranitidine hcl oral tablet 50 mg, 300 mg MISC. ANTI-ULCER sucralfate oral tablet gm PROTON PUMP INHIBITORS esomeprazole sodium intravenous solution reconstituted 20 mg, 40 mg lansoprazole oral capsule delayed release 5 mg, 30 mg omeprazole oral capsule delayed release 0 mg, 20 mg, 40 mg Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 09

117 pantoprazole sodium intravenous solution reconstituted 40 mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg rabeprazole sodium oral tablet delayed release 20 mg ULCER DRUGS - PROSTAGLANDINS misoprostol oral tablet 00 mcg, 200 mcg ULCER THERAPY COMBINATIONS amoxicill-clarithro-lansopraz oral PYLERA ORAL CAPSULE MG URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES methenamine hippurate oral tablet gm nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg nitrofurantoin oral suspension 25 mg/5ml URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) oxybutynin chloride er oral tablet extended release 24 hour 0 mg, 5 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet mg, 2 mg trospium chloride er oral capsule extended release 24 hour 60 mg trospium chloride oral tablet 20 mg VESICARE ORAL TABLET 0 MG, 5 MG URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 0

118 URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS flavoxate hcl oral tablet 00 mg VACCINES BACTERIAL VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED bcg vaccine injection injectable BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HIBERIX INJECTION SOLUTION RECONSTITUTED 0 MCG MENACTRA INTRAMUSCULAR INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) VIRAL VACCINES ENGERIX-B INJECTION SUSPENSION 0 MCG/0.5ML, 0 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 440 EL U/ML, 440 EL U/ML ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML BvD PA PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208

119 IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION M-M-R II SUBCUTANEOUS INJECTABLE PROQUAD SUBCUTANEOUS INJECTABLE RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 0 MCG/ML, 0 MCG/ML (ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG TWINRIX INTRAMUSCULAR SUSPENSION VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML ML VARIVAX SUBCUTANEOUS INJECTABLE 350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 9400 UNT/0.65ML VAGINAL PRODUCTS VAGINAL ANTI-INFECTIVES AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg VANDAZOLE VAGINAL GEL 0.75 % VAGINAL ESTROGENS estradiol vaginal cream 0. mg/gm Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 2 BvD BvD BvD PA

120 estradiol vaginal tablet 0 mcg ESTRING VAGINAL RING 2 MG ST PREMARIN VAGINAL CREAM MG/GM VAGINAL PROGESTINS CRINONE VAGINAL GEL 4 %, 8 % PA VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS epinephrine injection solution auto-injector 0.5 mg/0.3ml, 0.3 mg/0.3ml QL (2 EA per 5 days) NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG VASOPRESSORS midodrine hcl oral tablet 0 mg, 2.5 mg, 5 mg PA Youcan find information on what the symbols and abbreviations on this table meanby going to page of the introduction. Formulary ID: 8336 Ver. 0 Last Updated: 03/20/208 EffectiveDate: 04/0/208 3

121 Alphabetical Listing A abacavir sulfate abacavir sulfate-lamivudine. 52 abacavir-lamivudinezidovudine ABELCET ABILIFY MAINTENA... 5 ABRAXANE acamprosate calcium acarbose acebutolol hcl acetaminophen-codeine... 8 acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetazolamide acetazolamide er acetazolamide sodium acetic acid acetylcysteine acitretin ACTHIB... ACTIMMUNE acyclovir... 56, 73 acyclovir sodium ADACEL ADAGEN adapalene adapalene-benzoyl peroxide. 70 adefovir dipivoxil ADEMPAS ADRIAMYCIN ADRUCIL ADVAIR DISKUS... 4 ADVAIR HFA... 4 AFEDITAB CR AFINITOR AFINITOR DISPERZ ala-cort ALBENZA... 0 albuterol sulfate... 4 albuterol sulfate er... 4 alclometasone dipropionate.. 73 ALDURAZYME ALECENSA alendronate sodium alfuzosin hcl er ALIMTA ALINIA ALIQOPA allopurinol ALOCRIL ALOMIDE alosetron hcl ALPHAGAN P alprazolam... alprazolam er... ALREX ALTAVERA ALUNBRIG alyacen / AMABELZ... 8 amantadine hcl... 47, 48 AMBISOME amcinonide AMETHIA AMETHIA LO amikacin sulfate... 3 amiloride hcl amiloride-hydrochlorothiazide aminophylline... 5 AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYT ES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... 2 amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin... 6 amlodipine-valsartan-hctz ammonium lactate amoxapine amoxicill-clarithro-lansopraz... 0 amoxicillin... 0 amoxicillin-pot clavulanate 02 amoxicillin-pot clavulanate er amphetamine-dextroamphet er... 2 amphetaminedextroamphetamine... 2 amphotericin b ampicillin... 0 ampicillin sodium... 0, 02 ampicillin-sulbactam sodium AMPYRA ANADROL anagrelide hcl anastrozole ANDRODERM... 9 ANDROGEL... 9 ANDROGEL PUMP... 9 ANORO ELLIPTA... 4 APLENZIN APOKYN apraclonidine hcl aprepitant APRI APRISO APTIOM... 7 APTIVUS ARALAST NP ARANELLE ARANESP (ALBUMIN FREE) ARCALYST... 4 argatroban... 6 aripiprazole... 5, 52 ARISTADA armodafinil... 2 ARNUITY ELLIPTA... 3 ARRANON ASHLYNA ASMANEX 20 METERED DOSES... 3 ASMANEX 30 METERED DOSES... 3 ASMANEX 60 METERED DOSES... 3 ASMANEX HFA... 4 aspirin-dipyridamole er

122 ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atazanavir sulfate atenolol atenolol-chlorthalidone ATGAM atomoxetine hcl... 2 atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate... 97, 09 ATROVENT HFA... 3 AUBAGIO AUBRA AUGMENTIN AURYXIA AUSTEDO AVANDIA AVASTIN AVC VAGINAL... 2 AVELOX AVIANE AVITA AVONEX AVONEX PEN AVONEX PREFILLED AVYCAZ azacitidine AZACTAM AZACTAM IN DEXTROSE AZASAN AZASITE azathioprine azathioprine sodium azelastine hcl... 94, 99 azithromycin... 88, 89 AZOPT aztreonam B baciim bacitracin... 34, 97 bacitracin-polymyxin b bacitra-neomycin-polymyxinhc baclofen BACTOCILL IN DEXTROSE balsalazide disodium BALZIVA BANZEL... 7 BARACLUDE BAVENCIO bcg vaccine... BEKYREE BELEODAQ benazepril hcl... 3 benazepril-hydrochlorothiazide BENLYSTA benzoyl peroxide-erythromycin benztropine mesylate BERINERT BESIVANCE betamethasone dipropionate. 74 betamethasone dipropionate aug betamethasone valerate betaxolol hcl... 58, 96 bethanechol chloride... BETIMOL BETOPTIC-S bexarotene BEXSERO... bicalutamide BICILLIN C-R BICILLIN C-R 900/ BICILLIN L-A BICNU BIDIL... 6 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin sulfate BLEPHAMIDE BLISOVI 24 FE BLISOVI FE.5/ BLISOVI FE / BOOSTRIX bortezomib BOSULIF BREO ELLIPTA... 4 briellyn BRILINTA brimonidine tartrate BRIVIACT... 7 bromocriptine mesylate BROVANA... 4 budesonide... 4, 69 bumetanide BUNAVAIL... 8, 9 buprenorphine hcl... 9 bupropion hcl bupropion hcl er (smoking det) bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl... busulfan BUTISOL SODIUM butorphanol tartrate... 9 BYDUREON BYDUREON BCISE BYSTOLIC C cabergoline... 8 CABOMETYX calcipotriene calcipotriene-betameth diprop calcitonin (salmon) calcitriol calcium acetate (phos binder) CALQUENCE CAMILA CAMRESE LO CANASA CANCIDAS candesartan cilexetil candesartan cilexetil-hctz CAPASTAT SULFATE CAPRELSA captopril... 3 captopril-hydrochlorothiazide CARBAGLU carbamazepine... 7 carbamazepine er... 7 carbidopa carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopaentacapone carbinoxamine maleate carboplatin CARDENE IV CARIMUNE NF

123 carisoprodol carisoprodol-aspirin carisoprodol-aspirin-codeine 94 CAROSPIR carteolol hcl CARTIA XT carvedilol carvedilol phosphate er caspofungin acetate CAYSTON CAZIANT cefaclor cefadroxil cefazolin sodium cefdinir cefepime hcl cefixime cefotaxime sodium cefotetan disodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium celecoxib... 4 CELONTIN... 9 cephalexin CEREZYME CESAMET cetirizine hcl cevimeline hcl CHANTIX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH PAK CHEMET CHENODAL chloramphenicol sod succinate chlordiazepoxide hcl... chlordiazepoxide-amitriptyline chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine hcl... 5 chlorpropamide chlorthalidone chlorzoxazone CHOLBAM cholestyramine cholestyramine light ciclopirox... 7 ciclopirox olamine... 7 cidofovir cilostazol cimetidine cimetidine hcl CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 82, 97 ciprofloxacin in d5w cisplatin citalopram hydrobromide20, 2 cladribine CLARAVIS CLARINEX-D 2 HOUR clarithromycin clarithromycin er clemastine fumarate CLINDACIN-P clindamycin hcl clindamycin palmitate hcl clindamycin phos-benzoyl perox... 7 clindamycin phosphate.. 36, 7, 2 clindamycin phosphate in d5w CLINIMIX E/DEXTROSE (2.75/0) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/0) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/5) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (4.25/0) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/5) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) CLINISOL SF clobetasol propionate clobetasol propionate e CLODAN clofarabine CLOLAR clomipramine hcl clonazepam... 7 clonidine hcl clopidogrel bisulfate clorazepate dipotassium... clotrimazole... 7, 72, 93 clotrimazole-betamethasone. 72 clozapine COARTEM codeine sulfate... 6 colchicine colchicine-probenecid colestipol hcl colistimethate sodium COLOCORT... 0 COLY-MYCIN S COMBIGAN COMBIPATCH... 8 COMBIVENT RESPIMAT.. 4 COMETRIQ (00 MG DAILY DOSE) COMETRIQ (40 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE COMPLERA COMPRO... 5 constulose COPAXONE CORLANOR cortisone acetate

124 COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COSMEGEN COTELLIC CREON CRINONE... 3 CRIXIVAN cromolyn sodium... 3, 83, 99 CRYSELLE CUBICIN cvs gauze sterile CYCLAFEM / CYCLAFEM 7/7/ cyclobenzaprine hcl cyclophosphamide cyclosporine cyclosporine modified cyproheptadine hcl CYRAMZA CYSTAGON CYSTARAN cytarabine cytarabine (pf) D dacarbazine dactinomycin DALIRESP... 3 DALVANCE danazol... 9 dantrolene sodium dapsone DAPTACEL daptomycin DARAPRIM DARZALEX daunorubicin hcl DEBLITANE decitabine DELYLA demeclocycline hcl DEMSER... 3 DENAVIR DEPEN TITRATABS DEPO-PROVERA... 4 DESCOVY desipramine hcl desloratadine desmopressin ace rhinal tube 8 desmopressin ace spray refrig... 8 desmopressin acetate... 8 desogestrel-ethinyl estradiol. 64 desonide desoximetasone desvenlafaxine er... 2 desvenlafaxine succinate er.. 2 dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phosphate... 69, 98 dexmethylphenidate hcl... 2 dexmethylphenidate hcl er... 2 dexrazoxane dextroamphetamine sulfate... 2 dextroamphetamine sulfate er 2 dextrose dextrose in lactated ringers... 9 dextrose-nacl... 9 DIASTAT ACUDIAL... 7 DIASTAT PEDIATRIC... 7 diazepam... DIAZEPAM INTENSOL... diclofenac potassium... 4 diclofenac sodium... 4, 72, 99 diclofenac sodium er... 4 diclofenac-misoprostol... 4 dicloxacillin sodium dicyclomine hcl didanosine DIFFERIN... 7 diflorasone diacetate diflunisal... 6 DIGITEK... 6 digoxin... 6 dihydroergotamine mesylate 90 DILANTIN... 9 diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads 60 dilt-xr DIPENTUM diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoids dt dipyridamole disopyramide phosphate... 2 disulfiram DIURIL divalproex sodium divalproex sodium er docetaxel dofetilide... 2 donepezil hcl doripenem dorzolamide hcl dorzolamide hcl-timolol mal 96 doxazosin mesylate doxepin hcl doxercalciferol doxorubicin hcl doxorubicin hcl liposomal DOXY doxycycline hyclate doxycycline monohydrate.. 07 dronabinol drospiren-eth estrad-levomefol drospirenone-ethinyl estradiol DROXIA DULERA... 4 duloxetine hcl duramorph... 6 DUREZOL dutasteride dutasteride-tamsulosin hcl DYRENIUM E econazole nitrate EDURANT efavirenz ELAPRASE eletriptan hydrobromide ELIDEL ELIGARD... 4 ELIQUIS... 5 ELITEK ELMIRON EMBEDA... 6 EMCYT... 4 EMOQUETTE EMPLICITI EMSAM EMTRIVA enalapril maleate... 3 enalapril-hydrochlorothiazide ENBREL... 5, 6 ENBREL SURECLICK

125 ENDOCET... 8 ENGERIX-B... enoxaparin sodium... 6 ENPRESSE ENSKYCE entacapone entecavir ENTRESTO... 6 enulose ENVARSUS XR EPCLUSA EPIDUO... 7 EPIDUO FORTE... 7 epinastine hcl epinephrine... 3 epirubicin hcl EPITOL... 7 EPIVIR HBV eplerenone EPOGEN eprosartan mesylate EPZICOM EQUETRO ERAXIS ERBITUX ergoloid mesylates ERIVEDGE ERRIN ERTACZO ERWINAZE ery... 7 ERYPED ERY-TAB ERYTHROCIN LACTOBIONATE erythromycin... 7, 97 erythromycin base erythromycin ethylsuccinate 89 ESBRIET escitalopram oxalate... 2 esomeprazole sodium estazolam estradiol... 82, 2, 3 estradiol valerate estradiol-norethindrone acet. 8 ESTRING... 3 estropipate eszopiclone ethacrynic acid ethambutol hcl ethosuximide... 9, 20 ethynodiol diac-eth estradiol 65 etidronate disodium etodolac... 4 etodolac er... 4 ETOPOPHOS etoposide EURAX EVOTAZ EXEL COMFORT POINT PEN NEEDLE exemestane... 4 EXJADE EXONDYS EXTAVIA ezetimibe F FABRAZYME FALMINA famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON... 4 FARXIGA FARYDAK FASLODEX... 4 FAYOSIM FAZACLO felbamate... 9 felodipine er FEMYNOR fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium... 4 fentanyl... 6 fentanyl citrate... 6 FENTORA... 6 FERRIPROX FETZIMA FETZIMA TITRATION FINACEA finasteride FIRAZYR FIRMAGON... 4 flavoxate hcl... FLEBOGAMMA DIF flecainide acetate... 2 FLOVENT DISKUS... 4 FLOVENT HFA... 4 fluconazole fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide.. 75, 00 fluocinolone acetonide body. 75 fluocinolone acetonide scalp 75 fluocinonide fluocinonide emulsified base 75 fluocinonide-e fluorometholone fluorouracil... 39, 72 fluoxetine hcl... 2 fluphenazine decanoate... 5 fluphenazine hcl... 5 flurazepam hcl flurbiprofen... 4 flurbiprofen sodium flutamide... 4 fluticasone propionate... 75, 94 fluticasone-salmeterol... 5 fluvastatin sodium fluvastatin sodium er fluvoxamine maleate... 2 fluvoxamine maleate er... 2 FOLOTYN fomepizole fondaparinux sodium... 6 FORTEO fosamprenavir calcium fosinopril sodium... 3 fosinopril sodium-hctz fosphenytoin sodium... 9 FOSRENOL FRAGMIN... 6 FREAMINE HBC furosemide FUSILEV FUZEON FYAVOLV... 8 FYCOMPA... 6, 7 G gabapentin... 7 GABITRIL... 9 galantamine hydrobromide 03, 04 8

126 galantamine hydrobromide er GAMASTAN S/D GAMMAGARD GAMMAGARD S/D LESS IGA... 0 GAMMAKED... 0 GAMMAPLEX... 0 GAMUNEX-C... 0 ganciclovir sodium GARDASIL 9... gatifloxacin GATTEX GAVILYTE-C GAVILYTE-G GAVILYTE-N WITH FLAVOR PACK gemcitabine hcl gemfibrozil generlac GENGRAF... 57, 92 GENTAK gentamicin in saline... 3 gentamicin sulfate... 3, 7, 97 GENVOYA GEODON GIANVI GILDAGIA GILENYA GILOTRIF GLASSIA glatiramer acetate GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glyburide glyburide micronized glyburide-metformin glycopyrrolate GLYXAMBI GOCOVRI granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er... 2 guanidine hcl H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HAVRIX... heparin (porcine) in d5w... 6 heparin sod (porcine) in d5w 6 heparin sodium (porcine)... 6 HEPATAMINE HERCEPTIN HETLIOZ HEXALEN HIBERIX... HUMIRA... 4 HUMIRA PEDIATRIC CROHNS START... 3 HUMIRA PEN... 3 HUMIRA PEN-CROHNS STARTER... 3 HUMIRA PEN-PSORIASIS STARTER... 4 HUMULIN R U-500 (CONCENTRATED) HUMULIN R U-500 KWIKPEN hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen.. 8 hydrocodone-ibuprofen... 8 hydrocortisone... 0, 69, 75 hydrocortisone valerate hydrocortisone-acetic acid.. 00 hydromorphone hcl... 6 hydromorphone hcl er... 6 hydromorphone hcl pf... 6 hydroxychloroquine sulfate.. 36 hydroxyprogesterone caproate... 4 hydroxyurea hydroxyzine hcl... hydroxyzine pamoate... HYPERRAB S/D... 0 HYSINGLA ER... 6 I ibandronate sodium IBRANCE ibuprofen... 4 ICLUSIG idarubicin hcl IDHIFA ifosfamide ILARIS (50MG DELIVERED)... 4 ILEVRO imatinib mesylate IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT... 0 IMOVAX RABIES... 2 INCRELEX INCRUSE ELLIPTA... 3 indapamide INDOCIN... 4 indomethacin... 5 indomethacin er... 5 INFANRIX INLYTA INNOPRAN XL INTELENCE INTRALIPID INTRON A INTROVALE INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE IONOSOL-MB IN D5W... 9 IOPIDINE IPOL... 2 ipratropium bromide... 3, 94 ipratropium-albuterol... 5 irbesartan irbesartan-hydrochlorothiazide IRESSA irinotecan hcl ISENTRESS ISIBLOOM ISOLYTE-P IN D5W... 9 ISOLYTE-S... 9 isoniazid isosorbide dinitrate... 0 isosorbide dinitrate er

127 isosorbide mononitrate... 0 isosorbide mononitrate er... 0 isradipine ISTALOL ISTODAX (OVERFILL) itraconazole ivermectin... 0 IXIARO... 2 J JADENU JADENU SPRINKLE JAKAFI JANTOVEN... 5 JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JEVTANA JINTELI... 8 JOLIVETTE JULEBER JULUCA JUNEL.5/ JUNEL / JUNEL FE.5/ JUNEL FE / JUNEL FE JUXTAPID... 3 K KADCYLA KAITLIB FE KALETRA KALYDECO KARIVA kcl in dextrose-nacl... 9 kcl-lactated ringers-d5w... 9 KELNOR / KENALOG KEPIVANCE ketoconazole... 28, 72 ketoprofen... 5 ketorolac tromethamine... 5, 99 KEYTRUDA KHEDEZLA KIMIDESS KINRIX KIONEX KISQALI 200 DOSE KISQALI 400 DOSE KISQALI 600 DOSE KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KORLYM K-TAB KURVELO KUVAN KYNAMRO KYPROLIS L labetalol hcl LACRISERT lactated ringers... 57, 9 lactulose LAMICTAL STARTER... 7 LAMICTAL XR... 8 lamivudine... 53, 55 lamivudine-zidovudine lamotrigine... 8 lamotrigine er... 8 lansoprazole lanthanum carbonate LANTUS LANTUS SOLOSTAR LARIN.5/ LARIN / LARIN FE.5/ LARIN FE / LARISSIA LARTRUVO latanoprost LATUDA LAYOLIS FE LEENA leflunomide... 5 LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LESSINA LETAIRIS... 6 letrozole... 4 leucovorin calcium LEUKERAN LEUKINE leuprolide acetate... 4 levalbuterol hcl... 5 LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... 8 levetiracetam er... 8 levetiracetam in nacl... 8 levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin... 82, 97 levofloxacin in d5w levoleucovorin calcium LEVONEST levonorgest-eth est & eth est 66 levonorgest-eth estrad 9-day levonorgestrel-ethinyl estrad 66 levonorg-eth estrad triphasic 66 LEVORA 0.5/30 (28) levorphanol tartrate... 6 LEVO-T levothyroxine sodium LEVOXYL LEXIVA LIALDA lidocaine lidocaine hcl... 76, 88 lidocaine hcl (pf) lidocaine viscous lidocaine-prilocaine lincomycin hcl lindane linezolid LINZESS liothyronine sodium lisinopril

128 lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er LITHOSTAT LONSURF loperamide hcl lopinavir-ritonavir lorazepam..., 2 LORAZEPAM INTENSOL. LORCET... 8 LORCET HD... 8 LORCET PLUS... 8 LORYNA losartan potassium losartan potassium-hctz LOTEMAX lovastatin LOW-OGESTREL loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT (- MONTH)... 4 LUPRON DEPOT (3- MONTH)... 4 LUPRON DEPOT (4- MONTH)... 4 LUPRON DEPOT (6- MONTH)... 4 LUPRON DEPOT-PED (- MONTH) LUPRON DEPOT-PED (3- MONTH) LUTERA LYNPARZA LYRICA... 8 LYSODREN... 4 LYZA M magnesium sulfate malathion maprotiline hcl marlissa MARPLAN MATULANE MATZIM LA MAVYRET MAXIDEX meclizine hcl meclofenamate sodium... 5 MEDROL medroxyprogesterone acetate... 68, 03 mefenamic acid... 5 mefloquine hcl megestrol acetate... 4, 03 MEKINIST meloxicam... 5 melphalan hcl memantine hcl MENACTRA... MENVEO... meperidine hcl... 7 meprobamate... mercaptopurine meropenem mesalamine mesalamine-cleanser mesna MESNEX METADATE ER... 2 metaproterenol sulfate... 5 METAXALL metaxalone metformin hcl metformin hcl er methadone hcl... 7 methamphetamine hcl... 2 methazolamide methenamine hippurate... 0 methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide. 09 methyclothiazide methyldopa methyldopahydrochlorothiazide methylphenidate hcl... 3 methylphenidate hcl er... 2, 3 methylphenidate hcl er (cd)... 2 methylphenidate hcl er (la)... 2 methylprednisolone methylprednisolone acetate.. 69 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprololhydrochlorothiazide metronidazole... 34, 76, 2 metronidazole in nacl mexiletine hcl... 2 MIACALCIN MICROGESTIN.5/ MICROGESTIN / MICROGESTIN FE.5/ MICROGESTIN FE / midodrine hcl... 3 miglitol MIGRANAL MIMVEY... 8 MIMVEY LO... 8 MINITRAN... 0 minocycline hcl minoxidil mirtazapine misoprostol... 0 MITIGARE mitomycin mitoxantrone hcl M-M-R II... 2 modafinil... 3 MODERIBA MODERIBA 200 DOSE PACK MODERIBA 800 DOSE PACK moexipril hcl... 3 moexipril-hydrochlorothiazide mometasone furoate MONONESSA montelukast sodium... 3 MORGIDOX morphine sulfate... 7 morphine sulfate (concentrate)... 7 morphine sulfate (pf)... 7 morphine sulfate er... 7 morphine sulfate er beads... 7 MOVANTIK MOVIPREP moxifloxacin hcl... 82, 97 MOZOBIL

129 MULTAQ... 2 mupirocin... 7 mupirocin calcium... 7 MUSTARGEN MYCAMINE mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG MYORISAN... 7 MYRBETRIQ... 0 N nabumetone... 5 nadolol nadolol-bendroflumethiazide 33 nafcillin sodium naftifine hcl NAGLAZYME naloxone hcl naltrexone hcl NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC naproxen... 5 naproxen dr... 5 naproxen sodium... 5 naratriptan hcl NARCAN NATACYN NATAZIA nateglinide NATPARA NEBUPENT NECON 0.5/35 (28) NECON 7/7/ nefazodone hcl... 2 neomycin sulfate... 3 neomycin-bacitracin znpolymyx neomycin-polymyxin b gu neomycin-polymyxindexameth... 98, 99 neomycin-polymyxingramicidin neomycin-polymyxin-hc... 99, 00 NEPHRAMINE NERLYNX NEULASTA NEUPRO NEVANAC nevirapine nevirapine er NEXAVAR NEXTERONE... 2 niacin er (antihyperlipidemic)... 3 nicardipine hcl NICOTROL NICOTROL NS nifedipine nifedipine er nifedipine er osmotic release 60 NIKKI NILANDRON... 4 nilutamide... 4 nimodipine NINLARO NIPENT nisoldipine er NITRO-DUR... nitrofurantoin... 0 nitrofurantoin macrocrystal 0 nitrofurantoin monohyd macro... 0 nitroglycerin... nizatidine NORA-BE NORDITROPIN FLEXPRO 79 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est norethindrone-eth estradiol... 8 norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic NORLYROC NORMOSOL-M IN D5W... 9 NORMOSOL-R IN D5W... 9 NORMOSOL-R PH NORPACE CR... 2 NORTHERA... 3 NORTREL 0.5/35 (28) NORTREL /35 (2) NORTREL /35 (28) NORTREL 7/7/ nortriptyline hcl NORVIR NOVAREL NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA... 3 NUEDEXTA NULOJIX NUPLAZID nutrilipid NUVARING NYAMYC nystatin... 28, 72, 93 nystatin-triamcinolone NYSTOP O OCALIVA OCELLA OCTAGAM... 0 octreotide acetate... 8 ODEFSEY ODOMZO OFEV ofloxacin... 82, 98, 00 olanzapine olanzapine-fluoxetine hcl olopatadine hcl... 94, 99 omega-3-acid ethyl esters omeprazole ondansetron ondansetron hcl ONFI... 7 OPDIVO OPSUMIT... 6 ORENCIA... 5 ORENCIA CLICKJECT... 5 ORFADIN ORKAMBI orphenadrine citrate orphenadrine citrate er ORSYTHIA oseltamivir phosphate oxacillin sodium oxaliplatin oxandrolone

130 oxaprozin... 5 oxazepam... 2 oxcarbazepine... 8 OXTELLAR XR... 8 oxybutynin chloride... 0 oxybutynin chloride er... 0 oxycodone hcl... 7 oxycodone-acetaminophen... 8 oxycodone-aspirin... 8 oxycodone-ibuprofen... 8 OXYCONTIN... 7 oxymorphone hcl... 7 P PACERONE... 2 paclitaxel paliperidone er pamidronate disodium PANCREAZE PANRETIN pantoprazole sodium... 0 paricalcitol paromomycin sulfate... 3 paroxetine hcl... 2 paroxetine hcl er... 2 PASER PAXIL... 2 PEDIARIX PEDVAX HIB... peg 3350-kcl-na bicarb-nacl. 88 peg-3350/electrolytes PEGANONE... 9 PEGASYS PEGASYS PROCLICK penicillin g pot in dextrose. 02 penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM pentazocine-naloxone hcl... 9 pentoxifylline er perindopril erbumine... 3 PERIOGARD PERJETA permethrin perphenazine... 5 perphenazine-amitriptyline. 04 PEXEVA... 2 PHENADOZ phenelzine sulfate PHENERGAN phenobarbital phenoxybenzamine hcl... 3 phenytoin... 9 phenytoin sodium... 9 phenytoin sodium extended.. 9 PHOSLYRA PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION 57 PICATO pilocarpine hcl... 93, 97 pimozide PIMTREA pindolol pioglitazone hcl pioglitazone hcl-glimepiride. 23 pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so PIRMELLA / piroxicam... 5 PLASMA-LYTE PLASMA-LYTE A... 9 PLEGRIDY PLEGRIDY STARTER PACK PLENAMINE podofilox polyethylene glycol polymyxin b sulfate polymyxin b-trimethoprim POMALYST PORTIA potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose... 9 potassium chloride in nacl... 9 potassium citrate er PRADAXA... 6 PRALUENT... 3 pramipexole dihydrochloride 48 pramipexole dihydrochloride er pravastatin sodium prazosin hcl PRED MILD PRED-G prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 69, 70, 99 prednisone PREDNISONE INTENSOL. 70 preferred plus insulin syringe PREMARIN... 82, 3 PREMASOL PREMPHASE... 8 PREMPRO PREVALITE PREVIFEM PREZCOBIX PREZISTA PRIFTIN primaquine phosphate primidone... 8 PRIVIGEN... 0 probenecid procainamide hcl... 2 PROCALAMINE prochlorperazine... 5 prochlorperazine edisylate... 5 prochlorperazine maleate... 5 PROCRIT PROCTO-MED HC... 0 PROCTO-PAK... 0 PROCTOSOL HC... 0 PROCTOZONE-HC... 0 progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine hcl promethazine vc plain PROMETHEGAN propafenone hcl... 2 propafenone hcl er... 2 propantheline bromide proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD... 2 PROSOL

131 protriptyline hcl psorcon PULMOZYME PURIXAN PYLERA... 0 pyrazinamide pyridostigmine bromide pyridostigmine bromide er Q QUADRACEL QUASENSE QUDEXY XR... 8 quetiapine fumarate quetiapine fumarate er quinapril hcl... 3 quinapril-hydrochlorothiazide quinidine gluconate... 2 quinidine gluconate er... 2 quinidine sulfate... 2 quinine sulfate R RABAVERT... 2 rabeprazole sodium... 0 raloxifene hcl ramipril... 3 RANEXA... 0 ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RAVICTI RAYALDEE RECLIPSEN RECOMBIVAX HB... 2 REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE RELISTOR REMODULIN... 6 RENVELA repaglinide REPATHA... 3 REPATHA PUSHTRONEX SYSTEM... 3 REPATHA SURECLICK... 3 RESCRIPTOR RESTASIS RETROVIR REVLIMID REXULTI REYATAZ RIBASPHERE RIBASPHERE RIBAPAK ribavirin RIDAURA... 4 rifabutin RIFAMATE rifampin RIFATER riluzole rimantadine hcl ringers... 9 ringers irrigation risedronate sodium RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate RIVELSA rizatriptan benzoate ropinirole hcl ropinirole hcl er rosuvastatin calcium ROTARIX... 2 ROTATEQ... 2 ROWEEPRA... 8 ROWEEPRA XR... 8 ROZEREM RUBRACA RUCONEST RYDAPT S SABRIL... 9 SANDIMMUNE SANTYL SAPHRIS... 5 SAVELLA SAVELLA TITRATION PACK scopolamine selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS... 5 sertraline hcl... 2 SETLAKIN sevelamer carbonate SHAROBEL SHINGRIX... 2 SIGNIFOR... 8 sildenafil citrate... 6 silver sulfadiazine SIMBRINZA SIMPONI ARIA... 4 SIMULECT simvastatin sirolimus SIRTURO SIVEXTRO sodium chloride... 84, 92 sodium lactate sodium phenylbutyrate sodium polystyrene sulfonate SOLTAMOX... 4 SOLU-CORTEF SOMATULINE DEPOT... 8 SOMAVERT SORINE sotalol hcl sotalol hcl (af) spironolactone spironolactone-hctz SPRINTEC SPRITAM... 8 SPRYCEL SPS SRONYX SSD STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO stavudine sterile water for irrigation STIMATE... 8 STIOLTO RESPIMAT... 5 STIVARGA STRENSIQ streptomycin sulfate... 3 STRIBILD SUBOXONE... 9 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 7 sulfacetamide-prednisolone

132 sulfadiazine sulfamethoxazole-trimethoprim... 34, 35 SULFAMYLON sulfasalazine sulindac... 5 sumatriptan sumatriptan succinate sumatriptan succinate refill.. 90 SUPRAX SUSTIVA SUTENT SYLATRON SYLVANT SYNAGIS... 0 SYNAREL SYNDROS SYNERCID SYNJARDY SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus... 57, 76 TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate... 4 tamsulosin hcl TARCEVA TARGRETIN TARINA FE / TASIGNA tazarotene TAZICEF TAZORAC TAZTIA XT TECENTRIQ TECFIDERA TEFLARO telmisartan telmisartan-amlodipine telmisartan-hctz temazepam TENIVAC tenofovir disoproxil fumarate terazosin hcl terbinafine hcl terbutaline sulfate... 5 terconazole... 2 testosterone... 0 testosterone cypionate... 9 testosterone enanthate... 0 tetanus-diphtheria toxoids td tetrabenazine tetracycline hcl THALOMID theophylline... 5 theophylline er... 5 THIOLA thioridazine hcl... 5 thiotepa thiothixene THYMOGLOBULIN THYROLAR THYROLAR-/ THYROLAR-/ THYROLAR THYROLAR tiagabine hcl... 9 tigecycline timolol maleate... 59, 97 tinidazole TIVICAY tizanidine hcl TOBI PODHALER... 3 TOBRADEX tobramycin... 3, 98 tobramycin sulfate... 3 tobramycin-dexamethasone.. 99 TOLAK tolazamide tolbutamide tolcapone tolterodine tartrate... 0 tolterodine tartrate er... 0 TOPICORT topiramate... 9 topiramate er... 8 TOPOSAR topotecan hcl TORISEL torsemide TOUJEO SOLOSTAR TPN ELECTROLYTES... 9 TRACLEER... 6 TRADJENTA tramadol hcl... 8 tramadol hcl er... 7 tramadol hcl er (biphasic)... 7 tramadol-acetaminophen... 8 trandolapril... 3 trandolapril-verapamil hcl er 33 tranexamic acid TRANSDERM-SCOP (.5 MG) tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl... 2 TREANDA TRECATOR TRELSTAR MIXJECT... 4 TRESIBA FLEXTOUCH tretinoin... 46, 7 tretinoin microsphere... 7 TREXALL triamcinolone acetonide. 75, 76, 93, 94 triamterene-hctz triazolam TRIDERM trifluoperazine hcl... 5 trifluridine trihexyphenidyl hcl TRI-LEGEST FE TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE trimethobenzamide hcl trimethoprim trimipramine maleate TRINESSA (28) TRINTELLIX... 2 TRI-PREVIFEM TRISENOX TRI-SPRINTEC TRIUMEQ TRIVORA (28) TROKENDI XR... 9 TROPHAMINE trospium chloride... 0 trospium chloride er... 0 TRUMENBA... TRUVADA TWINRIX... 2 TYBOST TYGACIL TYKERB TYMLOS

133 TYPHIM VI... TYSABRI U UCERIS... 0, 70 ULORIC UNITHROID UPTRAVI ursodiol V valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide vancomycin hcl VANDAZOLE... 2 VAQTA... 2 VARIVAX... 2 VARUBI VASCEPA VECTIBIX VELCADE VELIVET VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl venlafaxine hcl er VENTAVIS... 6 VENTOLIN HFA... 5 verapamil hcl... 6 verapamil hcl er... 6 VERSACLOZ... 5 VERZENIO VESICARE... 0 VESTURA VICODIN... 8 VICODIN ES... 8 VICODIN HP... 8 VICTOZA VIDEX VIENVA vigabatrin... 9 VIGAMOX VIIBRYD... 2 VIIBRYD STARTER PACK... 2 VIMPAT... 9 vinblastine sulfate VINCASAR PFS vincristine sulfate vinorelbine tartrate VIRACEPT VIRAMUNE VIREAD voriconazole VOTRIENT VPRIV VRAYLAR VYFEMLA VYVANSE... 2 VYXEOS W warfarin sodium... 5 WELCHOL WYMZYA FE X XALKORI XARELTO... 5 XARELTO STARTER PACK... 6 XATMEP XGEVA XIFAXAN XIGDUO XR XOLAIR... 3 XTANDI... 4 XULANE XULTOPHY XURIDEN... 8 XYREM Y YERVOY YF-VAX... 2 YONDELIS Z zafirlukast... 3 zaleplon ZALTRAP ZANOSAR ZARAH ZARXIO ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZENATANE... 7 ZENCHENT ZEPATIER ZERBAXA ZERIT ZIAGEN zidovudine zileuton er... 3 ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolmitriptan zolpidem tartrate... 87, 88 ZOMETA ZOMIG zonisamide... 9 ZORTRESS ZOSTAVAX... 2 ZOSYN ZOVIA /35E (28) ZOVIA /50E (28) ZUBSOLV... 9 ZYCLARA PUMP ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV... 5 ZYTIGA

134 Discrimination is Against the Law Signature Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Signature Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Signature Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact our Corporate Compliance Officer If you believe that Signature Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Corporate Compliance Officer, 0900 Nuckols Road, Suite 20, Glen Allen, VA 23060, phone: , TTY 7, fax: , compliance@signatureadvantageplan.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance our Corporate Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

135 English: ATTENTION: If you speak [insert language], language assistance services, free of charge, are available to you. Call TTY: 7. Multi-Language Interpreter Services Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al TTY: 7. Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:7) German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: TTY: 7. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số TTY: 7. Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم 7 (. Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 7). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:7) まで お電話にてご連絡ください French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 7). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수 있습니다 TTY: 7 번으로전화해주십시오. Pennsylvanian Dutch: Wann du Deitsch (Pennsylvania German / Dutch) schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call TTY: 7. Nepali: य न दन ह स : तप ल न प ल ब ल न ह न छ भन तप क दनम त भ ष सह यत स व ह द श ल क पम उपलब छ फ न गन ह स (द द व : 7)

136 Cushite (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa TTY: 7. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa TTY: 7. Bantu: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona (TTY: 7).

137 This formulary was updated on 08/22/207. For more recent information or other questions, please contact Signature Advantage (HMO ISNP) Member Services at or, for TTY users, 7, Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February 4, and Monday to Friday (except holidays) from February 5 through September 30, or visit Signature Advantage is an HMO plan with a Medicare contract. Enrollment in Signature Advantage depends on contract renewal. Signature Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Signature Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Signature Advantage 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而 歧視任何人 This information is available for free in other languages. Esta información está disponible en otros idiomas de manera gratuita. Comuníquese con Servicios al Cliente al (TTY: 7). Horario de Atención al Cliente: Del de Octubre hasta el 4 de Febrero, de 8 a.m. a 8 p.m. los siete días de la semana (excepto Día de Acción de Gracias y Navidad), y del 5 de Febrero al 30 de Septiembre, de Lunes a Viernes (excepto feriados).