Advantage Care (HMO)

Transcription

1 CENTERS PLAN FOR HEALTHY LIVING CENTERS PLAN ADVANTAGE CARE (HMO) CENTERS PLAN CARE COMPLETE (MMP) Advantage Care (HMO) Formulario de medicamentos completo 205 Para más información o para inscribirse Llamar (gratis) Usuarios TTY Lunes a domingos de 8 a.m. a 8 p.m. [email protected] We CARE... about your CARE H6988_ENR085_205_SP File and Use

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3 Centers Plan for Healthy Living Advantage Care (HMO) Formulario de medicamentos completo 205 (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN ID de entrega de archivo con formulario: 5450, Versión 2 Este formulario de medicamentos fue actualizado el 06/9/205. Para más información u otras preguntas, comuníquese con nosotros, Advantage Care HMO al o, para usuarios de TTY, , los siete días de la semana, de 8 a.m. a 8 p.m., o visite Centers Plan for Healthy Living Advantage Care HMO es una HMO con contrato con Medicare. La inscripción en Advantage Care HMO depende de la renovación del contrato. Esta Información está disponible gratis en otros idiomas. Comuníquese con nuestro Servicios para Miembros al para obtener información adicional. Los usuarios de TTY deben llamar al de 8:00 am a 8:00 pm los siete días de la semana. Esta información también está disponible en Braille, letras grandes u otros formatos alternativos si usted lo necesita. Nota para los miembros actuales: Este formulario de medicamentos cambió desde el año pasado. Revise este documento para asegurarse que los medicamentos que toma aún estén incluidos. Cuando esta lista de medicamentos (formulario) dice nosotros, a nosotros o nuestro significa Centers Plan for Healthy Living. Cuando dice plan o nuestro plan significa Advantage Care HMO. Este documento incluye una lista de medicamentos (formulario) para nuestro plan que está actualizado desde el º de enero de 205. Para recibir un formulario de medicamentos actualizado, completo e integral, comuníquese con nosotros. Nuestra información de contacto, junto a la fecha de la última actualización del formulario de medicamentos, aparece en la tapa y contratapa. En general, debe utilizar las farmacias de la red para tener acceso al beneficio de los medicamentos recetados. Los beneficios, el formulario de medicamentos, la red de farmacias, las primas y/o los copagos/coseguros pueden cambiar el º de enero de 206, y periódicamente durante el año. H6988_ENR085_205_SP File and Use

4 Qué es el formulario de medicamentos completo de Advantage Care HMO? Un formulario de medicamentos es una lista de medicamentos cubiertos seleccionados por Centers Plan for Healthy Living Advantage HMO según lo determinado junto con un equipo de proveedores de atención médica, el cual representa las terapias recetadas que se consideran parte necesaria de un programa de tratamientos de calidad. Centers Plan for Healthy Living Advantage HMO generalmente cubrirá los medicamentos que se detallan en nuestro formulario de medicamentos siempre y cuando el medicamento sea médicamente necesario, la receta se encargue en una farmacia de la red de Centers Plan for Healthy Living Advantage HMO y se cumplan con otras normas del plan. Para obtener más información sobre cómo presentar sus recetas, revise la Evidencia de Cobertura. Puede cambiar el formulario de medicamentos (lista de medicamentos)? Generalmente, si usted está tomando un medicamento de nuestro formulario de medicamentos 205 que estaba cubierto a principios del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 205 excepto cuando esté disponible un nuevo medicamento genérico menos costoso o cuando se publique información adversa nueva sobre la seguridad o eficacia del medicamento. Otros tipos de cambios en el formulario de medicamentos, tales como el retiro de un medicamento de nuestro formulario de medicamentos, no afectarán a los miembros que actualmente estén tomando el medicamento. Dicho medicamento se mantendrá disponible con el mismo costo compartido para aquellos miembros que lo tomen durante el resto del año de cobertura. Consideramos que es importante que usted tenga acceso permanente durante el resto del año de cobertura a los medicamentos del formulario que se encontraban disponibles cuando escogió nuestro plan, excepto en los casos en los que pueda ahorrar dinero adicional o cuando podamos garantizar su seguridad. Si quitamos medicamentos de nuestro formulario o agregamos autorizaciones previas, límites de cantidad y/o restricciones en una terapia escalonada con un medicamento o movemos un medicamento a un nivel más alto de costo compartido, debemos notificar a los miembros afectados por el cambio al menos 60 días antes de la fecha en que se efectiviza el cambio, o en el momento en que el miembro solicite una reposición del medicamento, en cuyo momento el miembro recibirá una provisión del medicamento para 60 días. Si la Administración de Alimentos y Drogas considera que un medicamento de nuestro formulario es inseguro o el fabricante del medicamento lo retira del mercado, inmediatamente eliminaremos el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está actualizado desde el º de enero de 205. Para recibir información actualizada sobre los medicamentos cubiertos por Centers Plan for Healthy Living Advantage HMO, comuníquese con nosotros. Nuestra información de contacto aparece en la tapa y contratapa de este manual. En el caso de cambios no relacionados con el mantenimiento en el formulario que se realicen a mitad de año, Centers Plan for Healthy Living Advantage Care HMO le enviará una hoja de fe de errata para actualizar su formulario impreso. Cómo debo utilizar el formulario? Hay dos formas de encontrar su medicamento en el formulario: Afección El formulario comienza en la página 2. Los medicamentos en este formulario se agrupan en categorías según el tipo de afecciones para los cuales se utilizan. Por ejemplo, los H6988_ENR085_205_SP File and Use

5 medicamentos que se utilizan para tratar una afección cardiaca se detallan en la categoría Agentes cardiovasculares. Si conoce para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 2. Luego, busque el nombre de la categoría de su medicamento. Listado por orden alfabético Si no está seguro de en qué categoría buscar, deberá buscar su medicamento en el índice que comienza en la página I-. El índice proporciona una lista en orden alfabético de todos los medicamentos que se incluyen en este documento. En el índice se incluyen tanto medicamentos de marca como genéricos. Busque su medicamento en el índice. Junto a su medicamento verá el número de página donde puede encontrar la información sobre la cobertura. Consulte en la página que se indica en el índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Centers Plan for Healthy Living Advantage HMO cubre medicamentos de marca y genéricos. Un medicamento genérico está aprobado por la FDA por tener el mismo ingrediente activo que el medicamento de marca. Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Centers Plan for Healthy Living Advantage Care HMO requiere que usted o su médico obtengan autorización previa para determinados medicamentos. Esto significa que deberá obtener la aprobación de Centers Plan for Healthy Living Advantage Care HMO antes de encargar sus recetas. Si no obtiene la aprobación, es posible que Centers Plan for Healthy Living Advantage Care HMO no cubra el medicamento. Límites de cantidad: Para ciertos medicamentos, Centers Plan for Healthy Living Advantage Care HMO limita la cantidad del medicamento que Centers Plan for Healthy Living Advantage Care HMO cubrirá. Por ejemplo, Centers Plan for Healthy Living Advantage Care HMO ofrece 2 comprimidos por receta para sumatriptan. Esto puede ser adicional a la provisión estándar de uno o tres meses. Terapia escalonada: En algunos casos, Centers Plan for Healthy Living Advantage Care HMO requiere que primero pruebe determinados medicamentos para tratar su afección antes de cubrir otro medicamento para el tratamiento de esa afección. Por ejemplo, si un Medicamento A y un Medicamento B tratan su afección, es posible que Centers Plan for Healthy Living Advantage Care HMO no cubra el Medicamento B a menos que primero pruebe el Medicamento A. Si el medicamento A no funciona, entonces Centers Plan for Healthy Living Advantage Care HMO cubrirá el Medicamento B. H6988_ENR085_205_SP File and Use

6 Puede averiguar si su medicamento tiene algún requisito o límite adicional en el formulario que comienza en la página 2. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en línea que explican nuestra restricción de autorización previa y las restricciones de terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto a la fecha de la última actualización del formulario, aparece en la tapa y contratapa. Puede solicitar a Centers Plan for Healthy Living Advantage Care HMO hacer una excepción a estas restricciones o límites o para acceder a una lista de otros medicamentos similares que pueden tratar su afección. Vea la sección Cómo solicitar una excepción al formulario de Centers Plan for Healthy Living Advantage Care HMO? a continuación para obtener información sobre cómo solicitar una excepción. Qué ocurre si mi medicamento no está en el formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos), primero debe comunicarse con el Departamento de Servicios al Miembro y confirmar si su medicamento no está cubierto. Para más información comuníquese con nosotros. Nuestra información de contacto, junto a la fecha de la última actualización del formulario, aparece en la tapa y contratapa. Si le informan que Centers Plan for Healthy Living Advantage Care HMO no cubre su medicamento, tiene dos opciones: Puede solicitar al Departamento de Servicios al Miembro una lista de medicamentos similares cubiertos por Centers Plan for Healthy Living Advantage Care HMO. Cuando recibe la lista, muéstresela a su médico y solicítele que le recete un medicamento similar que esté cubierto por Centers Plan for Healthy Living Advantage Care HMO. Puede solicitar a Centers Plan for Healthy Living Advantage Care HMO hacer una excepción y cubrir su medicamento. Vea a continuación para obtener información sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario de Centers Plan for Healthy Living Advantage Care HMO? Puede solicitar a Centers Plan for Healthy Living Advantage Care HMO hacer una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos. Puede solicitarnos que cubramos su medicamento incluso si éste no se encuentra en nuestro formulario. Si se aprueba, este medicamento tendrá cobertura en un nivel predeterminado de costo compartido, y no podrá solicitarnos que le proveamos el medicamento a un nivel de costo compartido más bajo. H6988_ENR085_205_SP File and Use

7 Puede solicitarnos la anulación de las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para determinados medicamentos, Centers Plan for Healthy Living Advantage Care HMO limita la cantidad de medicamentos que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos la anulación del límite y una mayor cobertura. Generalmente, Centers Plan for Healthy Living Advantage Care HMO sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, o las restricciones de utilización adicional no fueran muy eficaces en el tratamiento de su afección y/o tuvieran efectos secundarios en su salud. Deberá contactarnos para solicitar una decisión inicial de cobertura para una excepción al formulario, en la restricción de utilización. Al solicitar una excepción al formulario o en la restricción de utilización debe enviar un certificado de su médico u otro profesional que justifique su pedido. Generalmente, debemos tomar una decisión dentro de las 72 horas posteriores a la recepción de la justificación del médico que prescribe. Puede solicitar una excepción acelerada (urgente) si usted o su médico consideran que su salud podría verse afectada seriamente por esperar hasta 72 horas para obtener una decisión. Si se otorga su solicitud de acelerar la excepción, debemos comunicarle la decisión en un plazo de 24 horas después de recibir la justificación del médico o del profesional que prescribe. Qué puedo hacer antes de que pueda hablar con mi médico sobre la posibilidad de cambiar mis medicamentos o solicitar una excepción? Como nuevo miembro o miembro permanente de nuestro plan, puede estar tomando medicamentos que no están en nuestro formulario. O puede estar tomando un medicamento que está en nuestro formulario, pero su posibilidad para obtenerlo es limitada. Por ejemplo, puede necesitar que le otorguemos una autorización previa antes de poder presentar su receta. Debe hablar con su médico para decidir si debe cambiar por un medicamento adecuado que esté cubierto o solicitar una excepción al formulario para que cubramos el medicamento que toma. Hasta que se ponga en contacto con su médico para determinar las medidas de acción adecuadas para usted, podemos cubrir su medicamento en determinados casos durante al menos los primeros 90 días de su inscripción en nuestro plan. Para cada uno de los medicamentos no incluidos en nuestro formulario o si su posibilidad de obtener los medicamentos es limitada, cubriremos una provisión temporal de 30 días (a menos que tenga una receta escrita por menos días) si acude a una farmacia de la red. Después de su primera provisión de 30 días, no pagaremos estos medicamentos, incluso si usted ha sido miembro del plan por un periodo menor a 90 días. Si usted reside en un centro de atención a largo plazo, le permitiremos reponer su receta hasta que le hayamos brindado un suministro de transición de 9 días que podría llegar hasta los 98 días, dependiendo de los incrementos por entrega, (a menos que tenga una receta por menos días). Cubriremos más de una reposición de estos medicamentos para los primeros 90 días de su inscripción en nuestro plan. Si necesita un medicamento que no se encuentra en nuestro formulario y su posibilidad para obtener sus medicamentos es limitada, pero ha superado los primeros 90 días de inscripción en nuestro plan, cubriremos una provisión de emergencia de 3 días de ese medicamento (a H6988_ENR085_205_SP File and Use

8 menos que tenga una receta escrita por una menor cantidad de días) mientras obtiene una excepción al medicamento. Los medicamentos de transición se proveen a miembros que cambian el lugar del tratamiento por cambios en el nivel de atención (por ejemplo, personas que ingresan en centros de atención a largo plazo desde hospitales o ingresan en un entorno ambulatorio desde un hospital). Para obtener más información Para obtener información más detallada sobre la cobertura de medicamentos recetados de Centers Plan for Healthy Living Advantage Care HMO, revise la Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas sobre Centers Plan for Healthy Living Advantage Care HMO, comuníquese con nosotros. Nuestra información de contacto, junto a la fecha de la última actualización del formulario, aparece en la tapa y contratapa. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al MEDICARE ( ) las 24 horas del día, los 7 días de la semana. Los usuarios de teléfonos TTY deben llamar al O pueden visitar Formulario de Centers Plan for Healthy Living Advantage Care HMO El formulario que comienza en la página 2 ofrece información de cobertura sobre los medicamentos cubiertos por Centers Plan for Healthy Living Advantage Care HMO. Si tiene dificultad para encontrar su medicamento en la lista, consulte el índice que comienza en la página I-. La primera columna de la tabla indica el nombre del medicamento. Los nombres de marca están en mayúsculas (como LIPITOR) y los medicamentos genéricos figuran con cursiva minúscula (como atrovastatina). La información en la columna Requisitos/Límites le comunica si Centers Plan for Healthy Living Advantage Care HMO tiene algún requisito especial para la cobertura de su medicamento. H6988_ENR085_205_SP File and Use

9 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST LA Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from Centers Plan for Healthy Living before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. 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 Centers Plan for Healthy Living to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from Centers Plan for Healthy Living before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Centers Plan for Healthy Living before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. Centers Plan for Healthy Living limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Centers Plan for Healthy Living will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services toll-free at , Monday through Sunday, 8am-8pm EST. TTY/TDD users should call H6988_ENR085_205 File and Use 09/02/204 7

10 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 2h capsule, 2 hour extended release cap er 24h capsule, 24 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 24h capsule, 24 hour sustained action cap.sr 2h capsule, 2 hour sustained release cap.sr 24h capsule, 24 hour sustained release cap24h pct capsule, 24 hour controlled-onset pellets cap24h pel capsule, 24 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 2hr capsule, 2 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle H6988_ENR085_205 File and Use 09/02/204 8

11 ABBREVIATION disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) DESCRIPTION disk with inhalation device disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion packet emulsion (grams) foam with applicator frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) H6988_ENR085_205 File and Use 09/02/204 9

12 ABBREVIATION oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr DESCRIPTION oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 2 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release H6988_ENR085_205 File and Use 09/02/204 0

13 ABBREVIATION tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPTION tablet, rapid disintegrating tablet, sublingual tablet, 2 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 2 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring H6988_ENR085_205 File and Use 09/02/204

14 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with QL (2700 per 30 Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (360 per 30 mg, mg acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (80 per 30 mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral (Esgic) PA-HRM; QL (80 per capsule mg 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) PA-HRM; QL (80 per 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (80 per 30 butalbital-acetaminophen-caff oral tablet (Esgic) PA-HRM; QL (80 per mg 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) PA-HRM; QL (80 per 30 butorphanol tartrate nasal (Butorphanol Tartrate) QL (5 per 28 BUTRANS 2 QL (4 per 28 codeine sulfate oral tablet (Codeine Sulfate) QL (80 per 30 codeine-butalbital-asa-caffein oral (Fiorinal with Codeine PA-HRM; QL (80 per capsule mg #3) 30 DURAMORPH (PF) 3 fentanyl citrate (Actiq) 4 PA; QL (20 per 30 fentanyl transdermal patch 72 hour 00 (Duragesic) PA; QL (20 per 30 mcg/hr fentanyl transdermal patch 72 hour 2 (Duragesic) PA; QL (0 per 30 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution (Hycet) QL (2700 per 30 hydrocodone-acetaminophen oral tablet (Norco) (includes Vicodin, mg, mg, mg Vicodin ES and Vicodin HP); QL (390 per 30 2

15 hydrocodone-acetaminophen oral tablet (Norco) QL (360 per mg, mg, mg, mg hydrocodone-ibuprofen (Ibudone) QL (50 per 30 hydromorphone (pf) injection solution 0 (Hydromorphone mg/ml HCl/PF) hydromorphone (pf) injection solution 4 (Dilaudid) mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) QL (200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) QL (80 per 30 hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 LAZANDA 4 PA; QL (30 per 30 levorphanol tartrate (Levorphanol Tartrate) QL (80 per 30 methadone hcl oral tablet,soluble 40 mg (Diskets) QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Msir) QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 0 mg/ml, 5 (Morphine Sulfate) mg/ml, 8 mg/ml morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral solution 0 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (80 per 30 morphine oral tablet extended release 00 (MS Contin) QL (20 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 mg, 200 mg morphine rectal (Morphine Sulfate) NUCYNTA 2 QL (8 per 30 3

16 NUCYNTA ER 2 QL (60 per 30 oxycodone hcl-acetaminophen oral (Oxycodone QL (800 per 30 solution mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Xolox) QL (360 per mg, mg, mg, mg oxycodone hcl-acetaminophen oral tablet (Xolox) QL (240 per mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 oxycodone oral concentrate (Oxycodone HCl) QL (80 per 30 oxycodone oral solution (Oxycodone HCl) QL (300 per 30 oxycodone oral tablet (Percolone) QL (80 per 30 oxycodone-acetaminophen oral tablet 0- (Xolox) QL (360 per mg, mg, mg, mg oxycodone-acetaminophen oral tablet 0- (Xolox) QL (80 per mg oxycodone-acetaminophen oral tablet 7.5- (Xolox) QL (240 per mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL 2 QL (60 per 30 ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 2 QL (20 per 30 ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet (Opana) QL (80 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (20 per 30 2 hr 30 mg, 40 mg tramadol oral tablet (Ultram) QL (240 per 30 tramadol-acetaminophen (Ultracet) QL (240 per 30 xylon 0 (Ibudone) QL (50 per 30 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 3 SOLN celecoxib (Celebrex) QL (60 per 30 choline,magnesium salicylate (Choline Sal/Mag Salicylate) 4

17 COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) 4 diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR 2 PA flurbiprofen (Ansaid) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) mg indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (20 per 30 indomethacin oral capsule, extended (Indomethacin) PA-HRM; QL (60 per 30 release indomethacin sodium (Indocin I.V.) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac injection cartridge 5 mg/ml (Toradol) QL (40 per 30 ketorolac injection cartridge 30 mg/ml (Toradol) QL (20 per 30 ketorolac injection solution 5 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection solution 30 mg/ml ( (Ketorolac QL (20 per 30 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 Tromethamine) ketorolac oral (Ketorolac QL (20 per 30 Tromethamine) mefenamic acid (Ponstel) 5

18 meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg, 550 (Anaprox) mg piroxicam (Feldene) salsalate (Salsalate) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL 2 Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) PA BvD; (PA for ESRD Only) lidocaine hcl injection solution (Xylocaine) PA BvD; (PA for ESRD Only) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive (Lidoderm) PA patch,medicated lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Lidocaine/Prilocaine) PA BvD LIDODERM 3 PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 6

19 buprenorphine-naloxone (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) bupropion hcl sr 50 mg tablet f/c (Zyban) CHANTIX 2 QL (68 per 84 CHANTIX CONTINUING MONTH 2 QL (56 per 28 BOX CHANTIX CONTINUING MONTH PAK 2 QL (56 per 28 CHANTIX STARTING MONTH BOX 2 QL (53 per 28 disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICOTROL 3 ZUBSOLV SUBLINGUAL TABLET.4-2 PA; QL (90 per MG, MG ZUBSOLV SUBLINGUAL TABLET MG 2 PA; QL (60 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet (Xanax) QL (90 per 30 alprazolam oral tablet extended release 24 (Xanax XR) QL (90 per 30 hr 0.5 mg alprazolam oral tablet extended release 24 (Xanax XR) QL (60 per 30 hr mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating (Alprazolam) QL (90 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (20 per 30 clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating 2 (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 5 mg (Tranxene T-Tab) QL (20 per 30 clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG diazepam injection (Diazepam) QL (0 per 28 diazepam intensol (Diazepam) QL (200 per 30 7

20 diazepam oral solution (Diazepam) QL (200 per 30 diazepam oral tablet (Valium) QL (20 per 30 diazepam rectal (Diastat Acudial) estazolam oral tablet mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 flurazepam oral capsule 5 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 lorazepam oral solution (Ativan) QL (50 per 30 lorazepam injection solution (Ativan) QL (2 per 30 lorazepam injection syringe (Ativan) QL (2 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam HCl/PF) QL (2 per 30 8

21 midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) QL (2 per 30 ml ( mg/ml) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (0 per 30 ONFI ORAL SUSPENSION 3 PA NSO; QL (480 per 30 ONFI ORAL TABLET 0 MG, 20 MG 3 PA NSO; QL (60 per 30 temazepam oral capsule 5 mg, 22.5 mg, 30 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 temazepam oral capsule 7.5 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (20 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (20 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 Antibacterials 9

22 Aminoglycosides BETHKIS 4 PA BvD gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) solution neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION 4 QL (224 per 28 tobramycin in % nacl (Tobi) 4 PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin Phosphate) solution colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN 4 linezolid (Zyvox) 4 methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine gram Mandelate) 20

23 nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 SYNERCID 4 trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln,000 (Vancomycin HCl) mg, 0 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) 4 XIFAXAN ORAL TABLET 200 MG 4 PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 4 ST; QL (60 per 30 ZYVOX ORAL 4 Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) piggyback gram/50 ml cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln (Ancef) 2

24 cefazolin injection recon soln 00 gram, (Cefazolin Sodium) 300 g cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % 3 CEFEPIME IN DEXTROSE,ISO-OSM 3 INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) ceftazidime intravenous recon soln (Ceftazidime) gram, 2 gram ceftibuten (Cedax) ceftriaxone in dextrose,iso-os (Ceftriaxone Na/Dextrose, Iso) ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous (Ceftriaxone Na/Dextrose, Iso) cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef).5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for (Cephalexin) reconstitution cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) 3 SUPRAX ORAL TABLET 3 SUPRAX ORAL TABLET,CHEWABLE 3 TEFLARO 3 22

25 Macrolides azithromycin (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Biaxin XL) release 24 hr DIFICID 4 QL (20 per 0 ERYTHROCIN 3 erythromycin base oral tablet,delayed (Erythromycin Base) release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral (Eryped 200) suspension for reconstitution erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON 4 LA imipenem-cilastatin (Primaxin) INVANZ 3 meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for (Amoxil) reconstitution amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 25 mg, (Amoxicillin) 250 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) 23

26 amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection recon soln (Unasyn) ampicillin-sulbactam intravenous (Unasyn) BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In 3 Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- Water) penicillin g potassium (Penicillin G Potassium) penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam intravenous recon (Zosyn) soln Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution (Cipro I.V.) 400 mg/40 ml levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) 24

27 Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim intravenous ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/Trim ethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 00 mg (Morgidox) doxycycline hyclate 00 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 00 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 00 mg (Adoxa) doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension for reconstitution (Vibramycin) doxycycline monohydrate oral tablet (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL 4 Anticancer Agents Anticancer Agents ABRAXANE 4 ADCETRIS 4 PA NSO; QL (4 per 2 AFINITOR DISPERZ 4 PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG 4 PA NSO; QL (56 per 28 25

28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 4 PA NSO; QL (28 per 28 ALIMTA INTRAVENOUS RECON 4 SOLN anastrozole (Arimidex) ARRANON 4 ARZERRA 4 PA NSO AVASTIN 4 PA NSO azacitidine (Vidaza) 4 BELEODAQ 4 PA NSO bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) PA BvD BLINCYTO 4 PA NSO; QL (40 per 365 BOSULIF ORAL TABLET 00 MG 4 PA NSO; QL (20 per 30 BOSULIF ORAL TABLET 500 MG 4 PA NSO; QL (30 per 30 CAPRELSA ORAL TABLET 00 MG 4 PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 4 PA NSO; QL (30 per 30 carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) COMETRIQ 4 PA NSO; QL (2 per 28 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD CYCLOPHOSPHAMIDE ORAL 3 PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST CYRAMZA 4 PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) decitabine (Dacogen) 4 doxorubicin hcl intravenous recon soln 0 mg (Doxorubicin HCl) PA BvD 26

29 doxorubicin hcl peg-liposomal intravenous (Doxil) 4 PA BvD suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) 4 PA BvD DROXIA 2 ELIGARD SUBCUTANEOUS SYRINGE 3 QL ( per MG ELIGARD SUBCUTANEOUS SYRINGE 3 QL ( per 2 30 MG ELIGARD SUBCUTANEOUS SYRINGE 4 QL ( per MG ELIGARD SUBCUTANEOUS SYRINGE 3 QL ( per MG EMCYT 2 epirubicin intravenous solution 50 mg/25 (Ellence) ml ERBITUX INTRAVENOUS SOLUTION 4 PA NSO ERIVEDGE 4 PA NSO; QL (30 per 30 ETOPOPHOS 3 etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON 4 FARYDAK 4 PA NSO; QL (6 per 2 FASLODEX 4 FIRMAGON KIT W DILUENT 3 SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) fluorouracil intravenous solution 2.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/00 ml, 500 mg/0 ml flutamide (Flutamide) GAZYVA 4 PA NSO; QL (40 per 28 gemcitabine intravenous recon soln (Gemzar) 4 gram GILOTRIF 4 PA NSO; QL (30 per 30 GLEEVEC ORAL TABLET 00 MG 4 PA NSO; QL (90 per 30 27

30 GLEEVEC ORAL TABLET 400 MG 4 PA NSO; QL (60 per 30 HALAVEN 4 PA NSO; QL (24 per 28 HERCEPTIN 4 PA NSO HEXALEN 4 hydroxyurea (Hydrea) IBRANCE 4 PA NSO; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG 4 PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 4 PA NSO; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna) 4 PA BvD IMBRUVICA 4 PA NSO; QL (20 per 30 INLYTA ORAL TABLET MG 4 PA NSO; QL (80 per 30 INLYTA ORAL TABLET 5 MG 4 PA NSO; QL (60 per 30 ISTODAX 4 PA NSO IXEMPRA 4 JAKAFI 4 PA NSO; QL (60 per 30 JEVTANA 4 KADCYLA INTRAVENOUS RECON 4 PA NSO SOLN KEYTRUDA INTRAVENOUS RECON 4 PA NSO SOLN KYPROLIS 4 PA NSO; QL (6 per 28 LENVIMA 4 PA NSO letrozole (Femara) LEUKERAN 3 leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT 4 QL ( per 28 LUPRON DEPOT (3 MONTH) 4 QL ( per 84 28

31 LUPRON DEPOT (4 MONTH) 4 QL ( per 84 LUPRON DEPOT (6 MONTH) 4 QL ( per 68 LUPRON DEPOT-PED 4 QL ( per 28 LUPRON DEPOT-PED (3 MONTH) 4 QL ( per 84 INTRAMUSCULAR SYRINGE KIT LYNPARZA 4 PA NSO; QL (480 per 30 LYSODREN 2 MARQIBO 4 PA NSO; QL (4 per 28 MATULANE 4 MEGACE ES 4 megestrol oral suspension (Megace) megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; QL (90 per 30 MEKINIST ORAL TABLET 2 MG 4 PA NSO; QL (30 per 30 melphalan hcl intravenous (Alkeran) 4 mercaptopurine (Purinethol) methotrexate sodium (pf) injection recon (Methotrexate PA BvD soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate Sodium) PA BvD solution methotrexate sodium injection (Methotrexate Sodium) PA BvD methotrexate sodium oral (Methotrexate Sodium) PA BvD; ST mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Novantrone) MUSTARGEN 2 NEXAVAR 4 PA NSO; QL (20 per 30 NILANDRON 2 ONCASPAR 4 PA NSO OPDIVO INTRAVENOUS SOLUTION 4 PA NSO 40 MG/4 ML oxaliplatin intravenous solution 00 (Eloxatin) 4 mg/20 ml paclitaxel (Paclitaxel) PERJETA 4 PA NSO 29

32 POMALYST 4 PA NSO; QL (2 per 28 PROLEUKIN 4 PURIXAN 4 REVLIMID 4 PA NSO; LA; QL (2 per 28 RITUXAN 4 PA NSO SOLTAMOX 3 SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG 4 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 4 PA NSO; QL (60 per 30 STIVARGA 4 PA NSO; QL (84 per 28 SUTENT 4 PA NSO; QL (30 per 30 SYLVANT 4 PA NSO SYNRIBO 4 PA NSO; QL (28 per 28 TABLOID 2 TAFINLAR 4 PA NSO; QL (20 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 00 MG, 25 MG 4 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 50 MG 4 PA NSO; QL (90 per 30 TARGRETIN ORAL 4 PA NSO; QL (420 per 30 TARGRETIN TOPICAL 4 PA NSO; QL (60 per 28 TASIGNA 4 PA NSO; QL (2 per 28 TEMODAR INTRAVENOUS 4 PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) 4 TORISEL 4 PA BvD; QL (4 per 28 TREANDA INTRAVENOUS RECON 4 SOLN TREANDA INTRAVENOUS SOLUTION 4 30

33 TRELSTAR INTRAMUSCULAR 4 QL ( per 68 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR 4 QL ( per 84 SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR 4 QL ( per 68 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR 4 QL ( per 28 SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) 4 (capsule: 0mg) TREXALL 3 PA BvD; ST TYKERB 4 VALSTAR 4 VECTIBIX INTRAVENOUS 4 PA NSO SOLUTION VELCADE 4 PA NSO vinblastine intravenous (Vinblastine Sulfate) PA BvD vincristine (Vincristine Sulfate) PA BvD vincristine sulfate intravenous solution (Vincristine Sulfate) PA BvD mg/ml vinorelbine intravenous solution (Navelbine) VOTRIENT 4 PA NSO; QL (20 per 30 XALKORI 4 PA NSO; QL (60 per 30 XTANDI 4 PA NSO; QL (20 per 30 YERVOY INTRAVENOUS SOLUTION 4 PA NSO ZALTRAP INTRAVENOUS SOLUTION 4 PA NSO ZELBORAF 4 PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS 3 QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS 3 QL ( per 28 IMPLANT 3.6 MG ZOLINZA 4 ZYDELIG 4 PA NSO; QL (60 per 30 ZYKADIA 4 PA NSO; QL (40 per 28 ZYTIGA 4 PA NSO; QL (20 per 30 3

34 Anticholinergic Agents Antimuscarinics/Antispasmodics Drug Name Drug Tier Requirements/Limits atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0. (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM 3 ST BANZEL 3 ST carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG 2 DILANTIN 2 divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA 3 ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 2 MG, 6 2 MG LAMICTAL ORAL TABLET, 3 CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release 24hr (Lamictal XR) 32

35 lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) (35) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 24 hr LUMINAL 3 QL (2 per 30 LYRICA ORAL CAPSULE 2 QL (90 per 30 LYRICA ORAL SOLUTION 2 QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR 3 ST PEGANONE 2 phenobarbital oral elixir (Phenobarbital) QL (500 per 30 phenobarbital oral tablet 00 mg, 5 mg, (Phenobarbital) QL (90 per mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenobarbital sodium injection solution (Phenobarbital Sodium) QL (2 per 30 phenytoin oral suspension 25 mg/5 ml (Dilantin-25) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, ST; QL (90 per 30 MG, 400 MG POTIGA ORAL TABLET 50 MG 3 ST; QL (270 per 30 primidone (Mysoline) QUDEXY XR 3 ST SABRIL 4 tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) topiramate oral tablet (Topamax) TRILEPTAL ORAL SUSPENSION 3 TROKENDI XR 3 ST 33

36 valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS 3 ST; QL (200 per 5 VIMPAT ORAL SOLUTION 3 ST; QL (200 per 30 VIMPAT ORAL TABLET 3 ST; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 EXELON TRANSDERMAL PATCH 24 QL (30 per 30 HOUR 4.6 MG/24 HR, 9.5 MG/24 HR galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per hr galantamine oral solution (Razadyne) QL (200 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 NAMENDA ORAL SOLUTION 2 QL (360 per 30 NAMENDA ORAL TABLET 2 QL (60 per 30 NAMENDA TITRATION PAK 2 QL (49 per 28 NAMENDA XR ORAL 2 QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL 2 QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) BRINTELLIX 3 ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr citalopram oral solution (Citalopram Hydrobromide) 34

37 citalopram oral tablet (Celexa) QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta) QL (60 per 30 release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed (Cymbalta) QL (30 per 30 release(dr/ec) 30 mg EMSAM 3 QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA 3 ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release (Luvox CR) 24hr fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM KHEDEZLA 3 ST; QL (30 per 30 maprotiline (Maprotiline HCl) MARPLAN 3 mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION 3 perphenazine-amitriptyline (Perphenazine/Amitripty PA NSO-HRM line HCl) phenelzine (Nardil) PRISTIQ 3 ST; QL (30 per 30 35

38 protriptyline (Vivactil) sertraline (Zoloft) SILENOR 2 QL (30 per 30 SURMONTIL 3 PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release (Effexor XR) 24hr venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release (Venlafaxine HCl) 24hr 50 mg, 37.5 mg, 75 mg VIIBRYD 3 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 BYDUREON 2 QL (4 per 28 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML 2 QL (2.4 per 28 BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 QL (.2 per 28 CYCLOSET 3 QL (80 per 30 GLYXAMBI 2 QL (30 per 30 INVOKAMET ORAL TABLET 50-2 ST; QL (60 per 30,000 MG, MG, 50-,000 MG INVOKAMET ORAL TABLET MG 2 ST; QL (20 per 30 INVOKANA ORAL TABLET 00 MG 2 ST; QL (60 per 30 INVOKANA ORAL TABLET 300 MG 2 ST; QL (30 per 30 JANUMET 2 QL (60 per 30 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, MG 2 QL (30 per 30 JANUMET XR ORAL TABLET, ER 2 QL (60 per 30 MULTIPHASE 24 HR 50-,000 MG JANUVIA 2 QL (30 per 30 JARDIANCE 2 ST; QL (30 per 30 JENTADUETO 2 QL (60 per 30 36

39 KORLYM 4 PA; QL (2 per 28 metformin oral tablet,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (20 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended release 24 (Glucophage XR) QL (20 per 30 hr 500 mg metformin oral tablet extended release 24 (Glucophage XR) QL (90 per 30 hr 750 mg metformin oral tablet extended release (Fortamet) QL (60 per 30 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET 2 QL (50 per 30 repaglinide (Prandin) QL (240 per 30 SYMLINPEN 20 3 PA; QL (0.8 per 28 SYMLINPEN 60 3 PA; QL (6 per 28 TRADJENTA 2 QL (30 per 30 TRULICITY 2 QL (4 per 28 VICTOZA 3 PA; QL (9 per 28 Insulins HUMALOG KWIKPEN 2 QL (30 per 28 HUMALOG MIX QL (40 per 28 HUMALOG MIX KWIKPEN 2 QL (30 per 28 HUMALOG MIX QL (40 per 28 HUMALOG MIX KWIKPEN 2 QL (30 per 28 HUMALOG SUBCUTANEOUS 2 QL (40 per 28 HUMULIN 70/30 2 QL (40 per 28 HUMULIN 70/30 KWIKPEN 2 QL (30 per 28 HUMULIN 70/30 PEN 2 QL (30 per 28 HUMULIN N 2 QL (40 per 28 HUMULIN N KWIKPEN 2 QL (30 per 28 HUMULIN N PEN 2 QL (30 per 28 HUMULIN R 2 QL (40 per 28 37

40 HUMULIN R U QL (40 per 28 "CONCENTRATED" LANTUS 2 QL (40 per 28 LANTUS SOLOSTAR 2 QL (30 per 28 NOVOLIN 70/30 2 QL (40 per 28 NOVOLIN N 2 QL (40 per 28 NOVOLIN R 2 QL (40 per 28 NOVOLOG 2 QL (40 per 28 NOVOLOG FLEXPEN 2 QL (30 per 28 NOVOLOG MIX QL (40 per 28 NOVOLOG MIX FLEXPEN 2 QL (30 per 28 TOUJEO SOLOSTAR 2 QL (7.5 per 28 Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 0 mg (Glucotrol) QL (20 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 30 0 mg glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per mg, 5 mg glipizide-metformin oral tablet mg (Glipizide/Metformin QL (60 per 30 HCl) glipizide-metformin oral tablet (Glipizide/Metformin QL (20 per 30 mg, mg HCl) glyburide micronized oral tablet.5 mg (Glynase) PA-HRM; QL (400 per 30 glyburide micronized oral tablet 3 mg (Glynase) PA-HRM; QL (80 per 30 glyburide micronized oral tablet 6 mg (Glynase) PA-HRM; QL (20 per 30 glyburide oral tablet.25 mg (Glyburide) PA-HRM; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (20 per 30 glyburide-metformin oral tablet (Glucovance) PA-HRM; QL (240 per mg 30 38

41 glyburide-metformin oral tablet (Glucovance) PA-HRM; QL (20 per mg, mg 30 tolazamide oral tablet 250 mg (Tolazamide) QL (20 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (80 per 30 Antifungals Antifungals ABELCET 4 PA BvD AMBISOME 4 PA BvD amphotericin b (Amphotericin B) PA BvD CANCIDAS 4 ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream (Clotrimazole) clotrimazole topical solution (Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth asone Dip) econazole topical (Econazole Nitrate) fluconazole (Diflucan) fluconazole in dextrose(iso-o) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) flucytosine (Ancobon) 4 griseofulvin microsize oral tablet (Grifulvin V) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) miconazole nitrate vaginal suppository 200 mg (Monistat 3) 39

42 NOXAFIL ORAL 4 NYSTATIN (BULK) POWDER BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin) terbinafine hcl oral (Lamisil) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) 4 Antihistamines Antihistamines clemastine oral syrup (Clemastine Fumarate) PA-HRM clemastine oral tablet 2.68 mg (Clemastine Fumarate) PA-HRM cyproheptadine (Cyproheptadine HCl) PA-HRM diphenhydramine hcl injection solution 50 mg/ml (Diphenhydramine HCl) diphenhydramine hcl injection syringe (Diphenhydramine HCl) levocetirizine (Xyzal) promethazine oral syrup (Promethazine HCl) PA-HRM Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL 2 clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 dihydroergotamine nasal (Migranal) QL (4 per 28 ERGOMAR 3 QL (40 per 28 naratriptan (Amerge) QL (8 per 28 rizatriptan oral tablet (Maxalt) QL (8 per 28 rizatriptan oral tablet,disintegrating (Maxalt Mlt) QL (8 per 28 sumatriptan nasal spray (Imitrex) QL (2 per 28 40

43 sumatriptan oral tablet (Imitrex) QL (8 per 28 sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) QL (4 per 28 injector sumatriptan succinate subcutaneous solution (Imitrex) QL (4 per 28 zolmitriptan oral tablet (Zomig) QL (2 per 28 zolmitriptan oral tablet,disintegrating (Zomig Zmt) QL (2 per 28 Antimycobacterials Antimycobacterials CAPASTAT 3 dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER 3 PRIFTIN 3 pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER 3 SIRTURO 4 PA; QL (88 per 68 TRECATOR 3 Antinausea Agents Antinausea Agents dimenhydrinate injection solution (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS RECON 3 QL (2 per 28 SOLN EMEND ORAL CAPSULE 25 MG, 40 MG 3 PA BvD; QL ( per day) EMEND ORAL CAPSULE 80 MG 3 PA BvD; QL (2 per day) EMEND ORAL CAPSULE,DOSE PACK 3 PA BvD; QL (3 per day) granisetron (pf) intravenous solution (Granisetron HCl/PF) 4

44 granisetron hcl intravenous solution (Kytril) mg/ml ( ml) granisetron hcl oral (Granisetron HCl) PA BvD meclizine oral tablet 2.5 mg, 25 mg (Antivert) ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) injection (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine edisylate injection solution (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine HCl) PA-HRM promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP 3 QL (0 per 30 Antiparasite Agents Antiparasite Agents ALBENZA 3 ALINIA 3 atovaquone (Mepron) 4 atovaquone-proguanil (Malarone) BILTRICIDE 3 chloroquine phosphate oral (Aralen Phosphate) COARTEM 3 DARAPRIM 3 hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) metronidazole in nacl (iso-os) (Metronidazole/Sodium Chloride) metronidazole oral (Flagyl) NEBUPENT 3 PA BvD paromomycin (Paromomycin Sulfate) PENTAM 3 PRIMAQUINE 3 QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (42 per 7 Antiparkinsonian Agents 42

45 Antiparkinsonian Agents amantadine hcl oral (Amantadine HCl) APOKYN 4 QL (60 per 30 AZILECT 2 benztropine oral (Benztropine Mesylate) PA-HRM bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet extended (Sinemet CR) release carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) NEUPRO 2 ST; QL (30 per 30 pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 (Requip XL) hr selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) PA-HRM Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL 2 QL (90 per 30 TABLET,DISINTEGRATING 0 MG ABILIFY DISCMELT ORAL 2 QL (60 per 30 TABLET,DISINTEGRATING 5 MG ABILIFY INTRAMUSCULAR 2 QL (6.2 per 28 ABILIFY MAINTENA 4 QL ( per 28 ABILIFY ORAL SOLUTION 2 QL (900 per 30 ABILIFY ORAL TABLET 0 MG, 5 2 QL (30 per 30 MG, 20 MG, 30 MG, 5 MG ABILIFY ORAL TABLET 2 MG 2 QL (60 per 30 aripiprazole oral tablet 0 mg, 5 mg, 20 (Abilify) QL (30 per 30 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 00 mg (Clozaril) QL (270 per 30 43

46 clozapine oral tablet 200 mg (Clozaril) QL (35 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating 00 (Fazaclo) ST; QL (90 per 30 mg, 2.5 mg, 25 mg clozapine oral tablet,disintegrating 50 (Fazaclo) ST; QL (80 per 30 mg clozapine oral tablet,disintegrating 200 (Fazaclo) ST; QL (20 per 30 mg FANAPT ORAL TABLET 3 ST; QL (60 per 30 FANAPT ORAL TABLETS,DOSE 3 ST; QL (8 per 28 PACK FAZACLO ORAL TABLET,DISINTEGRATING 50 MG 3 ST; QL (80 per 30 FAZACLO ORAL TABLET,DISINTEGRATING 200 MG 3 ST; QL (20 per 30 fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR 3 QL (6 per 28 haloperidol (Haloperidol) haloperidol decanoate intramuscular (Haloperidol Decanoate) solution 00 mg/ml haloperidol decanoate intramuscular (Haldol Decanoate 50) solution 50 mg/ml haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED 3 ST; QL (30 per 30 RELEASE 24HR.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED 3 ST; QL (60 per 30 RELEASE 24HR 6 MG INVEGA SUSTENNA 4 QL (0.75 per 28 INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA 4 QL ( per 28 INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA 4 QL (.5 per 28 INTRAMUSCULAR SYRINGE 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML 2 QL (0.25 per 28 44

47 INVEGA SUSTENNA 2 QL (0.5 per 28 INTRAMUSCULAR SYRINGE 78 MG/0.5 ML LATUDA ORAL TABLET 20 MG, 20 3 ST; QL (30 per 30 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG 3 ST; QL (60 per 30 loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) QL (30 per 30 mg, 5 mg, 5 mg olanzapine oral tablet,disintegrating 20 (Zyprexa Zydis) QL (3 per 30 mg ORAP 3 perphenazine (Perphenazine) quetiapine (Seroquel) QL (90 per 30 RISPERDAL CONSTA 3 QL (4 per 28 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) QL (60 per 30 mg, 0.5 mg, mg, 2 mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (20 per 30 mg, 4 mg SAPHRIS (BLACK CHERRY) 3 ST; QL (60 per 30 SEROQUEL XR ORAL TABLET 3 ST; QL (60 per 30 EXTENDED RELEASE 24 HR 50 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET 3 ST; QL (30 per 30 EXTENDED RELEASE 24 HR 200 MG thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Navane) trifluoperazine (Trifluoperazine HCl) VERSACLOZ 4 ST; QL (540 per 30 ziprasidone hcl (Geodon) QL (60 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 405 MG 4 QL (2 per 28 Antivirals (Systemic) 45

48 Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) 4 APTIVUS ORAL CAPSULE 4 APTIVUS ORAL SOLUTION 3 ATRIPLA 4 COMPLERA 4 CRIXIVAN ORAL CAPSULE 200 MG, MG didanosine (Videx EC) EDURANT 4 EMTRIVA 2 EPIVIR HBV ORAL SOLUTION 3 EPZICOM 4 EVOTAZ 4 FUZEON SUBCUTANEOUS 4 INTELENCE ORAL TABLET 00 MG, MG INTELENCE ORAL TABLET 25 MG 2 INVIRASE 4 ISENTRESS ORAL POWDER IN 2 PACKET ISENTRESS ORAL TABLET 4 ISENTRESS ORAL 2 TABLET,CHEWABLE KALETRA ORAL SOLUTION 4 KALETRA ORAL TABLET MG 2 KALETRA ORAL TABLET MG 4 lamivudine (Epivir) lamivudine-zidovudine (Combivir) 4 LEXIVA ORAL SUSPENSION 2 LEXIVA ORAL TABLET 4 nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr NORVIR 3 PREZCOBIX 4 46

49 PREZISTA ORAL SUSPENSION 3 PREZISTA ORAL TABLET 50 MG, 75 2 MG PREZISTA ORAL TABLET 400 MG, MG, 800 MG RESCRIPTOR 3 RETROVIR INTRAVENOUS 2 REYATAZ ORAL CAPSULE 50 MG, MG, 300 MG REYATAZ ORAL POWDER IN 4 PACKET SELZENTRY 4 stavudine (Zerit) STRIBILD 4 SUSTIVA 3 TIVICAY 4 TRIUMEQ 4 TRUVADA 4 VIDEX 2 GRAM PEDIATRIC 2 VIDEX 4 GRAM PEDIATRIC 2 VIRACEPT ORAL TABLET 3 VIRAMUNE XR ORAL TABLET 2 EXTENDED RELEASE 24 HR 00 MG VIREAD 4 VITEKTA 4 ZIAGEN ORAL SOLUTION 3 zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER 3 rimantadine (Flumadine) SYNAGIS 4 TAMIFLU ORAL CAPSULE 30 MG 2 QL (84 per 80 TAMIFLU ORAL CAPSULE 45 MG 2 QL (48 per 80 TAMIFLU ORAL CAPSULE 75 MG 2 QL (42 per 80 TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 2 QL (540 per 80 47

50 Hcv Antivirals HARVONI 4 PA; QL (30 per 30 OLYSIO 4 PA; QL (28 per 28 SOVALDI 4 PA; QL (28 per 28 VIEKIRA PAK 4 PA; QL (2 per 28 Interferons INTRON A INJECTION 3 PA NSO PEGASYS 4 PA PEGASYS PROCLICK 4 PA SUBCUTANEOUS PEN INJECTOR PEGINTRON 4 PA PEGINTRON REDIPEN 4 PA SYLATRON 4 PA NSO; QL (4 per 28 SYLATRON 4-PACK SUBCUTANEOUS KIT 200 MCG, 300 MCG 4 PA NSO; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous recon soln (Acyclovir Sodium) PA BvD acyclovir sodium intravenous solution (Acyclovir Sodium) PA BvD adefovir (Hepsera) 4 entecavir (Baraclude) 4 famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA 4 valacyclovir (Valtrex) valganciclovir (Valcyte) 4 VIRAZOLE 4 PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) 4 48

51 ELIQUIS 2 enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 enoxaparin subcutaneous syringe 00 (Lovenox) 4 QL (36 per 30 mg/ml enoxaparin subcutaneous syringe 20 (Lovenox) 4 QL (27.2 per 30 mg/0.8 ml enoxaparin subcutaneous syringe 50 (Lovenox) 4 QL (34 per 30 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) QL (8 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) QL (3.6 per 30 mg/0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (20.4 per 30 mg/0.6 ml enoxaparin subcutaneous syringe 80 (Lovenox) QL (27.2 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 0 (Arixtra) QL (24 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) QL (5 per 30 mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) QL (2 per 30 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 (Arixtra) QL (8 per 30 mg/0.6 ml heparin (porcine) in 5 % dex intravenous (Heparin Sodium in 5% parenteral solution 2,500 unit/250 ml, Dextrose) 20,000 unit/500 ml (40 unit/ml) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(00 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml heparin (porcine) injection heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe 00 unit/ml (Heparin Sodium,Porcine/Ns/PF) (Heparin Sodium,Porcine) (Monoject Prefill Advanced) (Monoject Prefill Advanced) 49 PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only)

52 HEPARIN-0.45% NACL 25,000 UNITS/250 ML (00 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (00 units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 Drug Name Drug Tier Requirements/Limits (Heparin Sodium in 5% Dextrose) (Heparin Sodium in 5% Dextrose) units/ml) bag excel container IPRIVASK 4 PA; QL (24 per 28 jantoven (Coumadin) PRADAXA 3 QL (60 per 30 warfarin (Coumadin) XARELTO 2 Blood Formation Modifiers EPOGEN INJECTION SOLUTION 2 PA; QL (2 per 28 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX 4 LEUKINE INJECTION RECON SOLN 4 MIRCERA 3 PA; QL (0.6 per 28 MOZOBIL 4 NEULASTA SUBCUTANEOUS 4 SYRINGE NEUMEGA 4 NEUPOGEN 4 PROCRIT INJECTION SOLUTION 2 PA; QL (2 per 28 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 4 PA; QL (2 per 28 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 4 PA; QL (6 per 28 40,000 UNIT/ML PROMACTA 4 PA; QL (30 per 30 Hematologic Agents, Miscellaneous aminocaproic acid oral (Amicar) anagrelide (Agrylin) 50

53 protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors AGGRENOX 3 QL (60 per 30 BRILINTA 2 cilostazol (Pletal) clopidogrel (Plavix) EFFIENT 2 QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 3 ALBUKED-5 3 ALBUMIN, HUMAN 25 % 3 ALBUMIN, HUMAN 5 % 3 ALBUMINAR 25 % 3 ALBUMINAR 5 % 3 ALBURX (HUMAN) 5 % 3 ALBUTEIN 25 % 3 ALBUTEIN 5 % 3 BUMINATE 25 % 3 BUMINATE 5 % 3 FLEXBUMIN 25 % 3 FLEXBUMIN 5 % 3 KEDBUMIN 3 PLASBUMIN 25 % 3 PLASBUMIN 5 % 3 Caloric Agents Caloric Agents AMINO ACIDS 5 % 3 PA BvD AMINOSYN 0 % 3 PA BvD AMINOSYN 3.5 % 3 PA BvD AMINOSYN 7 % 3 PA BvD AMINOSYN 7 % WITH 3 PA BvD ELECTROLYTES AMINOSYN 8.5 % 3 PA BvD 5

54 AMINOSYN 8.5 %-ELECTROLYTES 3 PA BvD AMINOSYN II 0 % 3 PA BvD AMINOSYN II 5 % 3 PA BvD AMINOSYN II 7 % 3 PA BvD AMINOSYN II 8.5 % 3 PA BvD AMINOSYN II 8.5 %-ELECTROLYTES 3 PA BvD AMINOSYN M 3.5 % 3 PA BvD AMINOSYN-HBC 7% 3 PA BvD AMINOSYN-PF 0 % 3 PA BvD AMINOSYN-PF 7 % (SULFITE-FREE) 3 PA BvD AMINOSYN-RF 5.2 % 3 PA BvD CLINIMIX 5%/D5W SULFITE FREE 3 PA BvD CLINIMIX 5%/D25W SULFITE-FREE 3 PA BvD CLINIMIX 2.75%/D5W SULFIT FREE 3 PA BvD CLINIMIX 4.25%/D0W SULF FREE 3 PA BvD CLINIMIX 4.25%/D5W SULFIT FREE 3 PA BvD CLINIMIX 4.25%-D20W SULF-FREE 3 PA BvD CLINIMIX 4.25%-D25W SULF-FREE 3 PA BvD CLINIMIX 5%-D20W(SULFITE-FREE) 3 PA BvD CLINIMIX E 2.75%/D0W SUL FREE 3 PA BvD CLINIMIX E 2.75%/D5W SULF FREE 3 PA BvD CLINIMIX E 4.25%/D0W SUL FREE 3 PA BvD CLINIMIX E 4.25%/D25W SUL FREE 3 PA BvD CLINIMIX E 4.25%/D5W SULF FREE 3 PA BvD CLINIMIX E 5%/D5W SULFIT FREE 3 PA BvD CLINIMIX E 5%/D20W SULFIT FREE 3 PA BvD CLINIMIX E 5%/D25W SULFIT FREE 3 PA BvD CLINISOL SF 5 % 3 PA BvD cysteine (l-cysteine) intravenous solution (Cysteine HCl) PA BvD d0 % & 0.45 % sodium chloride (Dextrose 0 % and 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) 52

55 dextrose 0 % and 0.2 % nacl (Dextrose 0 % and 0.2 % NaCl) dextrose 0 % in water (d0w) (Dextrose 0 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) dextrose 5 %-lactated ringers (Dextrose 5%-Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2 % NaCl) FREAMINE HBC 6.9 % 3 PA BvD FREAMINE III 0 % 3 PA BvD glucose oral tablet,chewable (Dextrose) HEPATAMINE 8% 3 PA BvD HEPATASOL 8 % 3 PA BvD INTRALIPID INTRAVENOUS 3 PA BvD EMULSION 20 %, 30 % KABIVEN 3 PA BvD LIPOSYN II 3 PA BvD LIPOSYN III 3 PA BvD NEPHRAMINE 5.4 % 3 PA BvD NUTRILIPID 3 PA BvD PERIKABIVEN 3 PA BvD 53

56 potassium chloride in lr-d5 intravenous parenteral solution Drug Name Drug Tier Requirements/Limits (Potassium Chloride In Lr-D5) PREMASOL 0 % 3 PA BvD PREMASOL 6 % 3 PA BvD PROCALAMINE 3% 3 PA BvD PROSOL 20 % 3 PA BvD TRAVASOL 0 % 3 PA BvD TROPHAMINE 0 % 3 PA BvD TROPHAMINE 6% 3 PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidone) clonidine transdermal patch weekly 0. (Catapres-Tts ) QL (4 per 28 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 (Catapres-Tts ) QL (8 per 28 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) NORTHERA 4 PA; QL (80 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) Angiotensin Ii Receptor Antagonists BENICAR 2 ST BENICAR HCT 2 ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR 2 ST 54

57 valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) captopril-hydrochlorothiazide (Captopril/Hydrochlorot hiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydrochloro thiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 00 mg, 200 (Cordarone) mg, 400 mg amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) ml ( %) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine (Mexiletine HCl) MULTAQ 2 procainamide injection (Procainamide HCl) propafenone oral capsule,extended release (Rythmol SR) 2 hr 55

58 propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN 2 Beta-Adrenergic Blocking Agents acebutolol oral (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC 2 carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydrochlor othiazid) sotalol hcl oral tablet 20 mg, 60 mg, (Betapace) 240 mg, 80 mg sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) 56

59 diltiazem hcl oral capsule, extended (Cardizem CD) release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) release 2 hr diltiazem hcl oral capsule,extended (Cardizem CD) release 24hr diltiazem hcl oral tablet (Cardizem CD) diltiazem hcl oral tablet extended release (Cardizem LA) 24 hr dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 24 (Verelan) hr verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous ADRENALIN MG/ML VIAL SUV adrenalin injection solution mg/ml (Epinephrine) (:,000) (ml) DEMSER 3 digitek oral tablet 25 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION 2 PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 57

60 dobutamine in d5w intravenous parenteral (Dobutamine HCl/D5W) PA BvD solution dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose intravenous (Dopamine HCl/D5W) PA BvD solution dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine mg/ml ampul latex-free (Epinephrine) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0. mg/ml (Epinephrine) (:0,000) EPIPEN 2-PAK 2 EPIPEN JR 2-PAK 2 ethamolin (Ethanolamine Oleate) FIRAZYR 4 hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG 3 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 milrinone (Milrinone Lactate) 4 PA BvD milrinone in 5 % dextrose intravenous (Milrinone 4 PA BvD piggyback 40 mg/200 ml (200 mcg/ml) Lactate/D5W) norepinephrine bitartrate (Levophed Bitartrate) PA BvD papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA 2 Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) AZOR 2 ST CLEVIPREX INTRAVENOUS 3 EMULSION EXFORGE ST EXFORGE HCT ST felodipine (Felodipine) isradipine (Isradipine) 58

61 nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release (Procardia XL) 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) mg, 60 mg Diuretics amiloride oral (Midamor) amiloride-hydrochlorothiazide (Amiloride/Hydrochloro thiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM 3 furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) hydrochlorothiazide oral tablet (Hydrochlorothiazide) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral tablet (Maxzide) Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral powder 4 (Cholestyramine/Asparta gram me) cholestyramine-aspartame oral powder in (Questran) packet 4 gram colestipol (Colestid) CRESTOR 2 fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) 59

62 fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lovastatin (Mevacor) niacin oral tablet extended release 24 hr (Niaspan) omega-3 acid ethyl esters (Lovaza) pravastatin (Pravachol) simvastatin (Zocor) QL (30 per 30 VASCEPA 2 WELCHOL 2 ZETIA 3 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 24 hr minitran transdermal patch 24 hour 0. (Nitro-Dur) QL (30 per 30 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) QL (60 per 30 mg/hr minoxidil oral (Minoxidil) NITRO-BID 2 nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (30 per mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (60 per mg/hr NITROSTAT 2 PROGLYCEM 3 60

63 Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA 4 PA; QL (60 per 30 caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release (Kapvay) 2 hr dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, extended (Dexedrine) QL (20 per 30 release dextroamphetamine oral tablet (Dexedrine) QL (80 per 30 dextroamphetamine-amphetamine oral capsule,extended release 24hr 0 mg, 5 mg, 5 mg (Adderall XR) QL (30 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 30 capsule,extended release 24hr 20 mg, 25 mg, 30 mg flumazenil (Romazicon) guanfacine oral tablet extended release 24 (Intuniv) hr lithium carbonate oral capsule (Eskalith) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended (Lithobid) release lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic mg, 20 mg, 50 mg, 60 mg (Metadate Cd) QL (30 per 30 methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg (Metadate Cd) QL (60 per 30 (Metadate Cd) QL (30 per 30 (Metadate Cd) QL (60 per 30 (Ritalin LA) QL (30 per 30 6

64 methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet extended (Ritalin-SR) QL (90 per 30 release methylphenidate oral tablet extended (Concerta) QL (30 per 30 release 24hr 8 mg, 27 mg, 54 mg methylphenidate oral tablet extended (Concerta) QL (60 per 30 release 24hr 36 mg NUEDEXTA 2 QL (60 per 30 QUILLIVANT XR 2 riluzole (Rilutek) SAVELLA 2 QL (60 per 30 STRATTERA 2 XENAZINE 4 PA; QL (2 per 28 Contraceptives Contraceptives ashlyna (Seasonique) QL (9 per 84 deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet (Desogen) 0./.25/.5-25 mg-mcg drospirenone-ethinyl estradiol (Yaz) ELLA 2 ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) l norgest&e estradiol-e estrad (Seasonique) QL (9 per 84 levonorgestrel (Plan B One-Step) levonorgestrel-ethin estradiol oral tablet (Amethyst) mg-mcg, mg, (6)/75-40 (5)/25-30(0) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethin QL (9 per 84 tablets,dose pack,3 month mg-mcg Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) levonorgestrel-ethinyl estrad oral (Levonorgestrel-Ethin QL (9 per 84 tablets,dose pack,3 month Estradiol) 62

65 l-norgest-eth estr/ethin estra (Seasonique) QL (9 per 84 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet (Loestrin) -20 mg-mcg,.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) mg-20 mcg (2)/75 mg (7), mg-20 mcg (24)/75 mg (4), -20(5)/-30(7) /mg- 35mcg (9),.5 mg-30 mcg (2)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) mg-mcg, mg-mcg, /- 35 mg-mcg/mg-mcg, 0.5/0.75/ mg- 35 mcg, 0.5// mg-mcg, -35 mg-mcg norethindrone-mestranol (Norinyl +50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING 2 ST; QL ( per 28 tarina fe (Loestrin Fe) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous (Peridex) membrane mouthwash 0.2 % pilocarpine hcl oral (Salagen) triamcinolone acetonide dental (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP 3 acitretin (Soriatane) 4 acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Drysol) 63

66 ammonium lactate (Lac-Hydrin) ANACAINE 3 calcipotriene topical cream (Dovonex) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CONDYLOX TOPICAL GEL 3 COSENTYX PEN (2 PENS) 4 PA FLUOROPLEX 3 fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 0 mg, 20 mg, 30 (Isotretinoin) mg, 40 mg mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) 4 PANRETIN 4 PICATO TOPICAL GEL 0.05 % 2 QL (3 per 56 PICATO TOPICAL GEL 0.05 % 2 QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL 3 silver nitrate applicators (Silver Nitrate Applicator) VALCHLOR 4 ZOVIRAX TOPICAL CREAM 2 QL (5 per 30 Dermatological Antibacterials clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) 64

67 erythromycin with ethanol topical swab (Erythromycin Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) alclometasone topical ointment (Alclometasone Dipropionate) betamethasone dipropionate topical cream (Diprosone) betamethasone dipropionate topical lotion (Betamethasone Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical cream (Betamethasone Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical lotion (Betamethasone Valerate) betamethasone valerate topical ointment (Betamethasone Valerate) betamethasone, augmented topical cream (Diprolene AF) betamethasone, augmented topical gel (Betamethasone Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical (Diprolene) ointment clobetasol propionate topical solution 0.05 (Clobetasol Propionate) % clobetasol topical cream (Temovate) 65

68 clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) CORDRAN TOPICAL OINTMENT 3 desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL 2 PA; (PA for Ages fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hydrocortisone acet-aloe vera topical gel (Nuzon) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 00 mg/60 ml (Cortenema) hydrocortisone topical cream %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2 %, 2.5 % (Rederm) hydrocortisone topical ointment %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream (Hydrocortisone Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) 66

69 prednicarbate (Dermatop) tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Kenalog) triamcinolone acetonide topical ointment (Triderm) %, 0.05 %, 0. %, 0.5 % triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0. % (Differin) TAZORAC TOPICAL CREAM 3 tretinoin microspheres (Retin-A Micro) PA tretinoin topical (Retin-A) PA Scabicides And Pediculicides malathion (Ovide) permethrin topical cream (Elimite) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 3 X 5/6", ML 3 X 5/6", /2 ML 3 X 5/6" BD LUER-LOK SYRINGE SYRINGE ML 20 X " INSULIN PEN NEEDLE NEEDLE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U-00 SYRINGE SURE COMFORT INS. SYR. U-00 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN 4 ALDURAZYME 4 67

70 CEREZYME INTRAVENOUS RECON 4 SOLN 400 UNIT CIMZIA 4 PA CIMZIA POWDER FOR RECONST 4 PA CREON 2 ELAPRASE 4 ELITEK INTRAVENOUS RECON 4 SOLN FABRAZYME INTRAVENOUS RECON SOLN 4 KRYSTEXXA 4 KUVAN 4 LINZESS 2 QL (30 per 30 lipase-protease-amylase (Zenpep) LOTRONEX 4 LUMIZYME 4 MYOZYME 4 NAGLAZYME 4 ORFADIN 4 PULMOZYME 4 PA BvD VIMIZIM 4 PA VPRIV 4 ZAVESCA 4 QL (90 per 30 ZENPEP 2 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) 3 altacaine (Tetcaine) apraclonidine (Iopidine) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) azelastine nasal (Astepro) QL (30 per 25 azelastine ophthalmic (Optivar) carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS % cyclopentolate (Cyclogyl) 68

71 CYSTARAN 4 epinastine (Elestat) homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (30 per % ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (5 per % LACRISERT 2 naphazoline (Naphazoline HCl) olopatadine (Patanase) QL (30.5 per 30 PATADAY 2 ST PATANOL 2 ST phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluorescei n Sod) tetracaine hcl (Tetcaine) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Vosol) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B Sulfate) CIPRODEX 2 ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S 3 erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment (Garamycin) 0.3 % (3 mg/gram) levofloxacin ophthalmic (Quixin) MOXEZA 2 NATACYN 2 neomy sulf-bacitrac zn-poly-hc (Neomy Sulf/Bacitrac Zn/Poly/HC) 69

72 neomycin-bacitracin-poly-hc (Neomy Sulf/Bacitrac Zn/Poly/HC) neomycin-bacitracin-polymyxin (Neomy Sulf/Bacitra/Polymyxin B) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide sodium ophthalmic drops 0 (Sulfacetamide Sodium) % sulfacetamide-prednisolone (Sulfacetamide/Predniso lone Sp) TOBRADEX ST 2 tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX 2 ZYLET 2 Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX 2 bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL 2 fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (6 per 30 ILEVRO 2 ketorolac ophthalmic (Acular) LOTEMAX 2 NASONEX 3 QL (34 per 28 NEVANAC 2 prednisolone acetate (Omnipred) 70

73 prednisolone sodium phosphate ophthalmic Drug Name Drug Tier Requirements/Limits (Prednisolone Sod Phosphate) PROLENSA 2 RESTASIS 2 QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION 2 cimetidine (Tagamet) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso- Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole oral capsule,delayed (Prevacid) (Rx Product Only) release(dr/ec) misoprostol (Cytotec) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 50 mg, 300 mg (Zantac) (Rx Product Only) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) Gastrointestinal Agents, Other AMITIZA 2 QL (60 per 30 BUPHENYL ORAL TABLET 4 CHOLBAM 4 cromolyn oral (Gastrocrom) 4 dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) 7

74 diphenoxylate-atropine oral tablet (Lomotil) glycopyrrolate (Robinul) glycopyrrolate (Robinul) lactulose oral solution (Lactulose) loperamide oral (Loperamide HCl) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) MOVANTIK 2 QL (30 per 30 NUTRESTORE 3 RELISTOR SUBCUTANEOUS 3 PA; QL (28 per 28 RELISTOR SUBCUTANEOUS 3 PA; QL (28 per 28 ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives MOVIPREP 2 peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) polyethylene glycol 3350 oral (Gavilyte-N) sodium chloride-nahco3-kcl-peg oral (Nulytely with Flavor recon soln 420 gram Packs) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) PHOSLYRA 3 RENAGEL 2 RENVELA 2 sodium polystyrene sulfonate oral powder (Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate oral (Sodium Polystyrene suspension 5 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema (Sodium Polystyrene 30 gram/20 ml Sulfonate) 72

75 Genitourinary Agents Antispasmodics, Urinary Drug Name Drug Tier Requirements/Limits oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended (Ditropan XL) release 24hr tolterodine oral capsule,extended release (Detrol LA) 24hr tolterodine oral tablet (Detrol) TOVIAZ 2 trospium oral capsule,extended release 24hr (Sanctura XR) trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS 3 EXJADE ORAL TABLET, 3 DISPERSIBLE 25 MG EXJADE ORAL TABLET, 4 DISPERSIBLE 250 MG, 500 MG FERRIPROX 4 sodium thiosulfate intravenous solution gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) (Sodium Thiosulfate) SYPRINE 4 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM 2 PA; QL (30 per 30 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP.25 GRAM/ ACTUATION ( %) 2 PA; QL (300 per 30 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) 2 PA; QL (50 per 30 73

76 ANDROGEL TRANSDERMAL GEL IN PACKET % (25 MG/2.5GRAM), % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 Drug Name Drug Tier Requirements/Limits 2 PA; QL (300 per 30 2 PA; QL (50 per 30 GRAM),.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo-Testosterone) PA testosterone enanthate (Delatestryl) PA; QL (5 per 28 testosterone transdermal gel in packet % (Androgel) PA; QL (50 per 30 (25 mg/2.5gram) Estrogens And Antiestrogens COMBIPATCH 2 PA-HRM; QL (8 per 28 DUAVEE 2 PA-HRM ESTRACE VAGINAL 2 estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) PA-HRM; QL (8 per 28 estradiol transdermal patch weekly (Climara) PA-HRM; QL (4 per 28 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM ESTRASORB 3 PA-HRM; QL (97.44 per 28 estropipate (Ogen) PA-HRM FEMRING 3 QL ( per 84 MENEST 3 PA-HRM norethindrone ac-eth estradiol oral tablet (Femhrt) PA-HRM -5 mg-mcg PREMARIN INJECTION 2 PREMARIN ORAL 2 PA-HRM PREMARIN VAGINAL 2 PREMPHASE 2 PA-HRM PREMPRO 2 PA-HRM raloxifene (Evista) 74

77 VAGIFEM 2 QL (8 per 28 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone Sod PA BvD injection Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone Sod PA BvD Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ injection (A-Methapred) PA BvD recon soln 25 mg, 40 mg methylprednisolone sodium succ (A-Methapred) PA BvD intravenous prednisolone sodium phosphate oral (Orapred) PA BvD solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION 3 PA BvD RECON SOLN 00 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (5 per 30 desmopressin nasal (Desmopressin Acetate) QL (5 per 30 desmopressin oral (DDAVP) GENOTROPIN 4 PA GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML 3 PA 75

78 GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML HUMATROPE 4 PA INCRELEX 4 NORDITROPIN FLEXPRO 4 PA SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) NORDITROPIN NORDIFLEX 4 PA NUTROPIN AQ NUSPIN 4 PA NUTROPIN AQ SUBCUTANEOUS 4 PA NUTROPIN SUBCUTANEOUS RECON 4 PA SOLN 0 MG octreotide acetate injection solution,000 (Sandostatin) 4 mcg/ml octreotide acetate injection solution 00 (Sandostatin) mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE SUBCUTANEOUS 3 PA CARTRIDGE 0 MG/.5 ML (6.7 MG/ML) OMNITROPE SUBCUTANEOUS 4 PA CARTRIDGE 5 MG/.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS 4 PA RECON SOLN PREGNYL 3 SAIZEN 4 PA SAIZEN CLICK.EASY 4 PA SANDOSTATIN LAR DEPOT 4 INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG 4 PA 76

79 SOMATULINE DEPOT 4 QL ( per 28 SOMAVERT 4 SUPPRELIN LA 4 QL ( per 360 TEV-TROPIN 3 PA vasopressin (Pitressin) Progestins DEPO-PROVERA INTRAMUSCULAR 3 QL (0 per 28 SOLUTION medroxyprogesterone intramuscular (Depo-Provera) QL ( per 84 suspension medroxyprogesterone intramuscular syringe (Medroxyprogesterone Acetate) QL ( per 84 medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 0 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST 4 ASTAGRAF XL 3 PA BvD AUBAGIO 4 PA; QL (28 per 28 azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine Sodium) PA BvD CARIMUNE NF NANOFILTERED 4 PA BvD INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS 3 PA BvD cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL 4 PA 77

80 ENBREL SURECLICK 4 PA FLEBOGAMMA DIF 4 PA BvD GAMASTAN S/D 2 PA BvD GAMMAGARD LIQUID 4 PA BvD GAMMAPLEX 4 PA BvD GAMUNEX-C INJECTION SOLUTION 4 PA BvD HUMIRA 4 PA HUMIRA CROHN'S DIS START PCK 4 PA HUMIRA PEN 4 PA HYPERRAB S/D (PF) 3 HYQVIA 4 PA BvD ILARIS (PF) 4 PA IMOGAM RABIES-HT (PF) 3 KINERET 4 PA; QL (8.76 per 28 leflunomide (Arava) mycophenolate mofetil oral capsule (Cellcept) PA BvD mycophenolate mofetil oral suspension for (Cellcept) 4 PA BvD reconstitution mycophenolate mofetil oral tablet (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX 4 PA BvD OCTAGAM 4 PA BvD ORENCIA 4 PA; QL (4 per 28 ORENCIA (WITH MALTOSE) 4 PA PRIVIGEN 4 PA BvD PROGRAF INTRAVENOUS 3 PA BvD RAPAMUNE ORAL SOLUTION 4 PA BvD RAPAMUNE ORAL TABLET MG, 2 4 PA BvD MG RIDAURA 4 sirolimus oral tablet 0.5 mg, mg (Rapamune) PA BvD sirolimus oral tablet 2 mg (Rapamune) 4 PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI 4 PA; LA; QL (5 per 28 ZORTRESS ORAL TABLET 0.25 MG 3 PA BvD; QL (20 per 30 78

81 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 4 PA BvD; QL (20 per 30 Vaccines ACTHIB (PF) 2 ADACEL(TDAP 2 ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) 2 PA BvD BEXSERO (PF) 2 BOOSTRIX TDAP 2 CERVARIX VACCINE (PF) 2 COMVAX (PF) 2 DAPTACEL (DTAP PEDIATRIC) (PF) 2 ENGERIX-B (PF) 2 PA BvD ENGERIX-B PEDIATRIC (PF) 2 PA BvD GARDASIL (PF) 2 GARDASIL 9 (PF) 2 HAVRIX (PF) INTRAMUSCULAR 2 SUSPENSION HAVRIX (PF) INTRAMUSCULAR 2 SYRINGE IMOVAX RABIES VACCINE (PF) 2 PA BvD INFANRIX (DTAP) (PF) 2 INTRAMUSCULAR IPOL 2 IXIARO (PF) 2 KINRIX (PF) 2 MENACTRA (PF) INTRAMUSCULAR 2 SOLUTION MENHIBRIX (PF) 2 MENOMUNE - A/C/Y/W-35 (PF) 2 MENVEO A-C-Y-W-35-DIP (PF) 2 MENVEO MENA COMPONENT (PF) 2 MENVEO MENCYW-35 COMPNT 2 (PF) M-M-R II (PF) 2 PEDIARIX (PF) 2 PEDVAX HIB (PF) 2 PENTACEL (PF) 2 79

82 PENTACEL ACTHIB COMPONENT (PF) Drug Name Drug Tier Requirements/Limits PENTACEL DTAP-IPV COMPNT (PF) 2 PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) 2 PA BvD RECOMBIVAX HB (PF) 2 PA BvD ROTARIX 2 ROTATEQ VACCINE 2 TENIVAC (PF) INTRAMUSCULAR 2 TETANUS TOXOID,ADSORBED (PF) 2 PA BvD TETANUS,DIPHTHERIA TOX PED(PF) 2 TETANUS-DIPHTHERIA TOXOIDS-TD 2 TICE BCG 2 PA BvD TRUMENBA 2 TWINRIX (PF) 2 TYPHIM VI INTRAMUSCULAR 2 VAQTA (PF) 2 VARIVAX (PF) 2 YF-VAX (PF) 2 ZOSTAVAX (PF) 2 QL ( per 365 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO 2 ASACOL HD 2 balsalazide (Colazal) budesonide oral (Entocort EC) 4 DELZICOL 2 DIPENTUM 3 ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION 2 ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) 80 2

83 sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) water for irrigation, sterile (Water For Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution (Alendronate Sodium) QL (300 per 28 alendronate oral tablet 0 mg, 40 mg, 5 (Fosamax) mg alendronate oral tablet 35 mg, 70 mg (Fosamax) QL (4 per 28 calcitonin (salmon) (Miacalcin) QL (3.7 per 28 calcitriol intravenous solution mcg/ml (Calcitriol) PA BvD; (PA for ESRD Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) etidronate disodium (Etidronate Disodium) FORTEO 3 PA; QL (2.4 per 28 FORTICAL 3 QL (3.7 per 28 ibandronate intravenous solution (Ibandronate Sodium) PA BvD; (PA for ESRD Only); QL (3 per 84 ibandronate oral (Boniva) QL ( per 28 MIACALCIN INJECTION 2 PA BvD; (PA for ESRD Only) NATPARA 4 PA; QL (2 per 28 paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA 2 QL ( per 80 risedronate oral tablet 50 mg (Actonel) QL ( per 28 XGEVA 4 PA; QL (.7 per 28 ZEMPLAR INTRAVENOUS 2 PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) 8

84 zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS Drug Name Drug Tier Requirements/Limits (Zoledronic Acid/Mannitol and Water) (Reclast) QL (00 per PA; QL (40 per 30 SOLUTION ACTEMRA SUBCUTANEOUS 4 PA; QL (3.6 per 28 ACTIMMUNE 4 allopurinol (Zyloprim) amifostine crystalline (Ethyol) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART 2 AVONEX (WITH ALBUMIN) 4 ST AVONEX INTRAMUSCULAR 4 ST AVONEX INTRAMUSCULAR 4 ST BENLYSTA INTRAVENOUS RECON 4 PA SOLN BETASERON SUBCUTANEOUS 4 ST bethanechol chloride (Urecholine) BOTOX INJECTION RECON SOLN 00 3 PA; QL (4 per 90 UNIT BOTOX INJECTION RECON SOLN PA; QL ( per 90 UNIT buspirone (Vanspar) CERDELGA 4 PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Probenecid) COLCRYS 2 COPAXONE SUBCUTANEOUS 4 SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE 4 droperidol injection solution (Droperidol)

85 ELMIRON 3 ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS 4 ST finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) 4 FUSILEV 4 GILENYA 4 PA; QL (28 per 28 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 3 (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral syrup 0 mg/5 ml (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN 2 QL (30 per 30 LEMTRADA 4 PA; QL (9.6 per 365 leucovorin calcium injection recon soln (Leucovorin Calcium) 00 mg, 200 mg, 350 mg leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine (With PA BvD; (PA for ESRD Sugar)) Only) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) levoleucovorin calcium (Levoleucovorin 4 Calcium) mesna (Mesnex) MESNEX ORAL 4 MESTINON ORAL SYRUP 3 MESTINON TIMESPAN 3 morrhuate sodium (Sodium Morrhuate) OTEZLA 4 PA; QL (60 per 30 OTEZLA STARTER 4 PA; QL (60 per 30 PLEGRIDY SUBCUTANEOUS PEN 4 ST INJECTOR PLEGRIDY SUBCUTANEOUS 4 ST SYRINGE 25 MCG/0.5 ML probenecid (Probenecid) 83

86 PROCYSBI 4 pyridostigmine bromide (Mestinon) REBIF (WITH ALBUMIN) 4 REBIF REBIDOSE 4 REBIF TITRATION PACK 4 REMICADE 4 PA SENSIPAR ORAL TABLET 30 MG 2 SENSIPAR ORAL TABLET 60 MG, 90 4 MG SIMPONI ARIA 4 PA; QL (2 per 28 SIMPONI SUBCUTANEOUS PEN 4 PA; QL (3 per 28 INJECTOR 00 MG/ML SIMPONI SUBCUTANEOUS PEN 4 PA; QL (0.5 per 28 INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 4 PA; QL (3 per MG/ML SIMPONI SUBCUTANEOUS SYRINGE 4 PA; QL (0.5 per MG/0.5 ML SOLIRIS 4 STELARA SUBCUTANEOUS 4 PA SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " SYNAREL 4 TECFIDERA ORAL 4 PA; QL (4 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG 4 PA; QL (60 per 30 THALOMID 4 PA NSO; QL (60 per 30 TYBOST 3 QL (30 per 30 ULORIC 2 ST; QL (30 per 30 XELJANZ 4 PA; QL (60 per 30 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) 84

87 acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 2 0. % AZOPT 2 betaxolol ophthalmic (Betaxolol HCl) bimatoprost (Bimatoprost) brimonidine (Alphagan P) (drops: 0.5%, 0.20%) COMBIGAN 2 dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC DROPS QL (2.5 per 25 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE 2 pilocarpine hcl ophthalmic drops %, 2 (Isopto Carpine) %, 4 % SIMBRINZA 2 timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming (Timoptic-Xe) solution TRAVATAN Z 2 QL (2.5 per 25 travoprost (benzalkonium) (Travoprost QL (2.5 per 25 (Benzalkonium)) Replacement Preparations Replacement Preparations calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD citric acid-sodium citrate (Citric Acid/Sodium Citrate) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) HYPERLYTE CR 3 IONOSOL-B IN D5W 3 IONOSOL-MB IN D5W 3 Only) 85

88 ISOLYTE M IN 5 % DEXTROSE 3 ISOLYTE-H IN 5 % DEXTROSE 3 ISOLYTE-P IN 5 % DEXTROSE 3 ISOLYTE-S 3 KLOR-CON klor-con 0 (Potassium Chloride) KLOR-CON 8 klor-con m0 (Potassium Chloride) klor-con m5 (Potassium Chloride) klor-con m20 (Potassium Chloride) KLOR-CON/EF magnesium chloride injection (Magnesium Chloride) magnesium sulfate in d5w intravenous (Magnesium piggyback gram/00 ml Sulfate/D5W) magnesium sulfate in water intravenous piggyback 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) NORMOSOL-M IN 5 % DEXTROSE 3 NORMOSOL-R 3 NORMOSOL-R PH NUTRILYTE 3 NUTRILYTE II 3 phosphorus # (K-Phos Neutral) PLASMA-LYTE 48 3 PLASMA-LYTE A 3 PLASMA-LYTE-56 IN 5 % DEXTROSE 3 potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) potassium bicarbonate-cit ac oral tablet, (Klor-Con-Ef) effervescent 25 meq potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl (Potassium Chloride In intravenous parenteral solution 20 meq/l, 0.9%NaCl) 40 meq/l 86

89 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l Drug Name Drug Tier Requirements/Limits (Potassium Chloride In D5w) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended (Klor-Con 8) release potassium chloride oral tablet,er (Klor-Con 8) particles/crystals 0 meq potassium chloride oral tablet,er (Potassium Chloride) particles/crystals 20 meq potassium chloride-0.45 % nacl (Potassium Chloride- 0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%NaCl) potassium chloride-d5-0.3%nacl (Potassium Chloride/D5- intravenous parenteral solution 20 meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) potassium citrate-citric acid oral packet (Potassium Citrate/Citric Acid) potassium citrate-citric acid oral solution (Potassium Citrate/Citric, mg/5 ml Acid) potassium phosphate dibasic (Potassium Phos,M- Basic-D-Basic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride 0.45 %) sodium chloride 0.9 % injection solution (0.9 % Sodium Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) 87

90 sodium citrate-citric acid (Citric Acid/Sodium Citrate) sodium lactate intravenous (Sodium Lactate) sodium phosphate (Sodium Phos,M-Basic- D-Basic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES 3 TPN ELECTROLYTES II 3 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 2 QL (60 per 30 ADVAIR HFA 2 QL (2 per 28 BREO ELLIPTA 2 QL (60 per 30 DULERA 2 QL (3 per 28 FLOVENT DISKUS INHALATION 2 QL (60 per 30 BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION 2 QL (20 per 30 BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA 2 QL (2 per 28 AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA 2 QL (24 per 28 AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA 2 QL (2.2 per 28 AEROSOL INHALER 44 MCG/ACTUATION QVAR 2 QL (7.4 per 25 Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution for (Albuterol Sulfate) PA BvD nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) 88

91 albuterol sulfate oral tablet extended (Vospire ER) release 2 hr ANORO ELLIPTA 2 QL (60 per 30 ATROVENT HFA 2 QL (25.8 per 28 COMBIVENT RESPIMAT 2 QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA 2 QL (7 per 25 SEREVENT DISKUS 2 QL (60 per 30 SPIRIVA RESPIMAT 2 QL (4 per 30 SPIRIVA WITH HANDIHALER 2 QL (30 per 30 terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet (Theophylline extended release 2 hr 00 mg, 200 mg, Anhydrous) 300 mg theophylline in dextrose 5 % intravenous (Theophylline/D5W) parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR 2 QL ( per 28 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD ARALAST NP 4 cromolyn inhalation (Cromolyn Sodium) PA BvD DALIRESP 2 QL (30 per 30 ESBRIET 4 PA; QL (270 per 30 KALYDECO 4 PA; QL (60 per 30 OFEV 4 PA; QL (60 per 30 XOLAIR 4 PA; QL (6 per 28 ZEMAIRA 4 89

92 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (20 per 30 chlorzoxazone (Parafon Forte DSC) PA-HRM COMFORT PAC-CYCLOBENZAPRINE PA-HRM COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 0 mg, 5 mg (Fexmid) PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL 2 PA ROZEREM 2 XYREM 4 LA zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 zolpidem oral tablet (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 90

93 zolpidem oral tablet,ext release multiphase (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents phentolamine injection (Phentolamine Mesylate) PA Vasodilating Agents Vasodilating Agents ADCIRCA 4 PA; QL (60 per 30 ADEMPAS 4 PA; QL (90 per 30 epoprostenol (glycine) intravenous recon (Flolan) PA BvD soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) 4 PA BvD soln.5 mg LETAIRIS 4 PA; QL (30 per 30 OPSUMIT 4 PA; QL (30 per 30 ORENITRAM ORAL TABLET 2 PA EXTENDED RELEASE 0.25 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, MG, 2.5 MG 4 PA REMODULIN 4 PA BvD REVATIO INTRAVENOUS 4 PA; QL (37.5 per day) sildenafil oral tablet 20 mg (Revatio) PA; QL (90 per 30 TRACLEER 4 PA; LA; QL (60 per 30 TYVASO 4 PA BvD TYVASO REFILL KIT 4 PA BvD TYVASO STARTER KIT 4 PA BvD VENTAVIS 4 PA BvD Vitamins And Minerals Vitamins And Minerals 9

94 pedi m.vit no.7 with fluoride oral drops 0.25 mg/ml prenatal vitamins oral tablet 27 mg iron- mg prenatal vitamins with iron sodium fluoride oral tablet Drug Name Drug Tier Requirements/Limits (Pedi Mvi No.82 with Fluoride) (Pnv with Ca,No.72/Iron/Fa) (Pnv9/Iron Fumarate/Fa/Dss) (Pedi Mvi No.82 with Fluoride) 2 (All Rx Prenatal Vitamins Covered) 2 92

95 INDEX 8 8-MOP A abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY DISCMELT... 44, 45 ABILIFY MAINTENA ABRAXANE acamprosate... 7 acarbose acebutolol... 57, 58 acetaminophen-codeine... 2 acetazolamide acetazolamide sodium acetic acid... 7, 83 acetylcysteine acitretin ACTEMRA ACTHIB (PF)... 8 ACTIMMUNE acyclovir... 50, 65 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 8 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adrenalin ADRENALIN ADVAIR DISKUS... 9 ADVAIR HFA... 9 AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 %.. 53 ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate... 9 alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE ALDURAZYME alendronate alfuzosin ALIMTA ALINIA allopurinol ALPHAGAN P alprazolam... 7 ALREX altacaine aluminum chloride amantadine hcl AMBISOME amifostine crystalline amiloride... 6 amiloride-hydrochlorothiazide... 6 AMINO ACIDS 5 % aminocaproic acid AMINOSYN 0 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA... 73, 74 amitriptyline amlodipine amlodipine-atorvastatin... 6 amlodipine-benazepril ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL ANORO ELLIPTA... 9 anticoag citrate phos dextrose 84 APOKYN apraclonidine APRISO APTIOM APTIVUS I-

96 ARALAST NP ARCALYST aripiprazole ARRANON ARZERRA ASACOL HD ashlyna ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin... 6 atovaquone atovaquone-proguanil ATRIPLA atropine... 32, 33, 7 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL... 4 AVODART AVONEX AVONEX (WITH ALBUMIN) azacitidine azathioprine azathioprine sodium azelastine... 7 AZILECT azithromycin AZOPT AZOR aztreonam B bacitracin... 20, 7 bacitracin-polymyxin b... 7 baclofen... 92, 93 balsalazide BANZEL BCG VACCINE, LIVE (PF).. 8 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BD LUER-LOK SYRINGE BELEODAQ benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benztropine betamethasone acet,sod phos. 77 betamethasone dipropionate.. 67 betamethasone valerate betamethasone, augmented... 67, 68 BETASERON betaxolol... 58, 87 bethanechol chloride BETHKIS BEXSERO (PF)... 8 bicalutamide BICILLIN C-R BICILLIN L-A BILTRICIDE bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO BOOSTRIX TDAP... 8 BOSULIF BOTOX BREO ELLIPTA... 9 BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine budesonide bumetanide... 6 BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 2, 7 buprenorphine-naloxone... 7 bupropion hcl... 7, 35 buspirone butalb-acetaminophen-caffeine... 2 butalbital-acetaminop-caf-cod 2 butalbital-acetaminophen... 2 butalbital-acetaminophen-caff 2 butalbital-aspirin-caffeine... 2 butorphanol tartrate... 2 BUTRANS... 2 BYDUREON BYETTA BYSTOLIC C cabergoline caffeine citrated caffeine-sodium benzoate calcipotriene calcitonin (salmon) calcitriol... 66, 83 calcium acetate calcium carbonate-mag carb-fa calcium chloride calcium gluconate CALDOLOR... 4 CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 57 CARAFATE carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol... 7 cartia xt carvedilol CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 22 cefdinir cefditoren pivoxil I-2

97 cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 22 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 22 cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... 4 CELLCEPT INTRAVENOUS CELONTIN cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) 8 cevimeline CHANTIX... 7 CHANTIX CONTINUING MONTH BOX... 7 CHANTIX CONTINUING MONTH PAK... 7 CHANTIX STARTING MONTH BOX... 7 chloramphenicol sod succinate chlordiazepoxide hcl... 7 chlorhexidine gluconate chloroquine phosphate chlorothiazide... 6 chlorothiazide sodium... 6 chlorpromazine chlorthalidone... 6 chlorzoxazone CHOLBAM cholestyramine (with sugar)... 6 cholestyramine-aspartame... 6 choline,magnesium salicylate 5 ciclopirox ciclopirox-ure-camph-mentheuc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX... 7 ciprofloxacin ciprofloxacin hcl... 25, 7 ciprofloxacin in 5 % dextrose 25 ciprofloxacin lactate cisplatin citalopram citric acid-sodium citrate clarithromycin clemastine... 4 CLEVIPREX clindamycin hcl... 2 clindamycin in 5 % dextrose. 2 clindamycin palmitate hcl... 2 clindamycin phosphate... 2, 4, 66 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol clobetasol propionate clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 7 clonidine clonidine hcl... 56, 63 clonidine hcl-chlorthalidone.. 56 clopidogrel clorazepate dipotassium... 7, 8 clotrimazole clotrimazole-betamethasone.. 40 clozapine COARTEM codeine sulfate... 2 codeine-butalbital-asa-caffein 2 colchicine colchicine-probenecid COLCRYS colestipol... 6 colistin (colistimethate na)... 2 COLY-MYCIN S... 7 COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ COMFORT PAC- CYCLOBENZAPRINE COMFORT PAC-IBUPROFEN... 5 COMFORT PAC- MELOXICAM... 5 COMFORT PAC-NAPROXEN... 5 COMFORT PAC-TIZANIDINE I-3

98 COMPLERA COMVAX (PF)... 8 CONDYLOX COPAXONE CORDRAN cortisone COSENTYX PEN (2 PENS).. 66 CREON CRESTOR... 6 CRIXIVAN cromolyn... 7, 74, 92 CUBICIN... 2 CURITY GAUZE cyclobenzaprine CYCLOGYL... 7 cyclopentolate... 7 cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine... 4 CYRAMZA CYSTADANE CYSTARAN... 7 cysteine (l-cysteine) cytarabine cytarabine (pf) D d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 54 dacarbazine dactinomycin DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF)... 8 DARAPRIM deblitane decitabine deferoxamine DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA desipramine desmopressin desog-e.estradiol/e.estradiol.. 64 desogestrel-ethinyl estradiol.. 64 desonide desoximetasone dexamethasone dexamethasone sodium phosphate... 72, 77 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl 54 dextrose 0 % in water (d0w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 55 dextrose 5 %-lactated ringers 55 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride55 DIASTAT ACUDIAL... 8 diazepam... 8 diazepam intensol... 8 diclofenac potassium... 5 diclofenac sodium... 5, 72 diclofenac-misoprostol... 5 dicloxacillin dicyclomine didanosine DIFICID diflunisal... 5 digitek digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl... 58, 59 dilt-xr dimenhydrinate... 42, 43 DIPENTUM diphenhydramine hcl... 4 diphenoxylate-atropine disopyramide phosphate disulfiram... 7 divalproex dobutamine dobutamine in d5w donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate... 25, 26 doxycycline monohydrate dronabinol droperidol drospirenone-ethinyl estradiol 64 DROXIA DUAVEE DULERA... 9 duloxetine DURAMORPH (PF)... 2 DUREZOL DYRENIUM... 6 E econazole EDURANT I-4

99 EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ELMIRON EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 57 ENBREL ENBREL SURECLICK ENGERIX-B (PF)... 8 ENGERIX-B PEDIATRIC (PF)... 8 enoxaparin... 50, 5 entacapone entecavir ephedrine sulfate epinastine... 7 epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM ERBITUX ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 23, 7 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate.. 23 erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium estazolam... 8 ESTRACE estradiol estradiol valerate estradiol/norethindrone acet.. 76 estradiol-norethindrone acet.. 77 ESTRASORB estropipate ethambutol ethamolin ethinyl estradiol/drospirenone 64 ethosuximide ethynodiol d-ethinyl estradiol 64 etidronate disodium etodolac... 5 ETOPOPHOS etoposide EVOTAZ EXELON exemestane EXFORGE EXFORGE HCT EXJADE EXTAVIA F FABRAZYME famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os). 73 FANAPT FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine FEMRING fenofibrate fenofibrate micronized... 6 fenofibrate nanocrystallized.. 6 fenofibric acid fenofibric acid (choline) fenoprofen... 5 fentanyl... 2 fentanyl citrate... 2 FERRIPROX FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLEBOGAMMA DIF flecainide FLECTOR... 5 FLEXBUMIN 25 % FLEXBUMIN 5 % FLOVENT DISKUS... 9 FLOVENT HFA... 9 floxuridine fluconazole fluconazole in dextrose(iso-o) 40 fluconazole in nacl (iso-osm). 4 flucytosine... 4 fludarabine fludrocortisone flumazenil fluocinonide fluocinonide-emollient base fluorometholone FLUOROPLEX fluorouracil... 28, 66 fluoxetine FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam... 8, 9 flurbiprofen... 5 flurbiprofen sodium flutamide fluticasone... 68, 73 fluvoxamine fomepizole fondaparinux... 5 FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % I-5

100 FREAMINE III 0 % furosemide... 6 FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF)... 8 GARDASIL 9 (PF)... 8 gatifloxacin GAZYVA gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK 78 gentamicin... 20, 67, 72 gentamicin in nacl (iso-osm).. 20 gentamicin sulfate gentamicin sulfate (ped) (pf).. 20 gentamicin sulfate (pf) GEODON gildess 24 fe GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glucose glyburide glyburide micronized... 39, 40 glyburide-metformin GLYCINE glycopyrrolate glydo... 6 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize... 4 guanfacine... 56, 63 guanidine H HALAVEN halobetasol propionate haloperidol haloperidol decanoate... 45, 46 haloperidol lactate HARVONI HAVRIX (PF)... 8 heparin (porcine)... 5 heparin (porcine) in 5 % dex. 5 HEPARIN (PORCINE) IN 5 % DEX... 5 heparin (porcine) in nacl (pf). 5 HEPARIN(PORCINE) IN 0.45% NACL... 5 heparin, porcine (pf)... 5 HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HEXALEN homatropine hbr... 7 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HUMULIN 70/ HUMULIN 70/30 KWIKPEN 39 HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N PEN HUMULIN R HUMULIN R U hydralazine hydrochlorothiazide... 6 hydrocodone-acetaminophen 2, 3 hydrocodone-ibuprofen... 3 hydrocortisone... 68, 69, 77 hydrocortisone acet-aloe vera 68 hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate. 77 hydrocortisone valerate hydromorphone... 3 hydromorphone (pf)... 3 hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA I ibandronate IBRANCE ibuprofen... 5 ICLUSIG ifosfamide... 28, 29 ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF) 80 IMOVAX RABIES VACCINE (PF)... 8 INCRELEX indapamide... 6 indomethacin... 5 indomethacin sodium... 5 INFANRIX (DTAP) (PF) INLYTA INSULIN PEN NEEDLE INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS I-6

101 INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 7 IPRIVASK... 5 irbesartan irbesartan-hydrochlorothiazide ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX itraconazole... 4 ivermectin IXEMPRA IXIARO (PF) J JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA K KABIVEN KADCYLA KALETRA KALYDECO KEDBUMIN ketoconazole... 4 ketoprofen... 5 ketorolac... 5, 6, 73 KEYTRUDA KHEDEZLA KINERET KINRIX (PF) KLOR-CON klor-con KLOR-CON klor-con m klor-con m klor-con m KLOR-CON/EF KORLYM KRYSTEXXA KUVAN KYPROLIS L l norgest&e estradiol-e estrad 64 labetalol LACRISERT... 7 LACTATED RINGERS lactulose LAMICTAL lamivudine lamivudine-zidovudine lamotrigine... 33, 34 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR latanoprost LATUDA LAZANDA... 3 leflunomide LEMTRADA LENVIMA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine... 4 levofloxacin... 25, 72 levofloxacin in d5w levoleucovorin calcium levonorgestrel levonorgestrel-ethin estradiol. 64 levonorgestrel-ethinyl estrad. 64, 65 levorphanol tartrate... 3 levothyroxine LEXIVA lidocaine... 6 lidocaine (pf)... 6, 57 lidocaine hcl... 6 lidocaine in 5 % dextrose (pf) 57 lidocaine-prilocaine... 6 LIDODERM... 6 linezolid... 2 LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III lisinopril lisinopril-hydrochlorothiazide 57 lithium carbonate lithium citrate l-norgest-eth estr/ethin estra lomustine loperamide lorazepam oral solution... 9 losartan losartan-hydrochlorothiazide. 56 LOTEMAX LOTRONEX lovastatin loxapine succinate LUMIGAN LUMINAL LUMIZYME LUPRON DEPOT I-7

102 LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA LYSODREN M mafenide acetate magnesium chloride magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline MARPLAN MARQIBO MATULANE matzim la meclizine medroxyprogesterone mefenamic acid... 6 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) MEGACE ES megestrol MEKINIST meloxicam... 6 melphalan hcl intravenous MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y-W-35-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-35 COMPNT (PF) mercaptopurine meropenem mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxalone metformin methadone... 3 methadone hcl... 3 methazolamide methenamine hippurate... 2 methenamine mandelate... 2 methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide... 6 methylphenidate... 63, 64 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone... 6 metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 4, 44, 67 metronidazole in nacl (iso-os) 44 mexiletine MIACALCIN miconazole nitrate... 4 midazolam... 9 midazolam (pf)... 9 midodrine milrinone milrinone in 5 % dextrose minitran minocycline minoxidil MIRCERA mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone montelukast... 9 morphine... 3 MORPHINE... 3 morphine concentrate... 3 morrhuate sodium MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN mycophenolate mofetil mycophenolate sodium MYOZYME N nabumetone... 6 nadolol nafcillin nafcillin in dextrose iso-osm.. 24 NAGLAZYME naloxone... 7 naltrexone... 7 naltrexone hcl... 7 NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline... 7 naproxen... 6 naproxen sodium... 6 naratriptan NASONEX NATACYN nateglinide NATPARA NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc I-8

103 neomycin neomycin-bacitracin-poly-hc. 72 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc NEPHRAMINE 5.4 % NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine NICOTROL... 7 nifedipine... 6 NILANDRON NITRO-BID nitrofurantoin macrocrystal... 2 nitrofurantoin monohyd/m-cryst... 2 nitroglycerin nitroglycerin in 5 % dextrose. 62 NITROSTAT NORDITROPIN FLEXPRO.. 78 NORDITROPIN NORDIFLEX norelgestromin/ethin.estradiol 65 norepinephrine bitartrate noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) 65 norethindrone acetate norethindrone ac-eth estradiol... 65, 77 norethindrone-e.estradiol-iron 65 norethindrone-ethinyl estrad.. 65 norethindrone-mestranol norgestimate-ethinyl estradiol 65 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOXAFIL... 4 NUCYNTA... 4 NUCYNTA ER... 4 NUEDEXTA NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVIGIL nystatin... 4 NYSTATIN (BULK)... 4 nystatin-triamcinolone... 4 O OCTAGAM... 8 octreotide acetate... 78, 79 OFEV ofloxacin... 25, 72 olanzapine olanzapine-fluoxetine olopatadine... 7 OLYSIO omega-3 acid ethyl esters omeprazole OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 9 OPDIVO OPSUMIT ORAP ORENCIA... 8 ORENCIA (WITH MALTOSE)... 8 ORENITRAM ORFADIN OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) 24 oxaliplatin oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 4 oxycodone hcl-acetaminophen... 4 oxycodone hcl-aspirin... 4 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 OXYCONTIN... 4 oxymorphone... 4 P paclitaxel PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PATADAY... 7 PATANOL... 7 PAXIL pedi m.vit no.7 with fluoride... 94, 95 PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl 74 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON I-9

104 PEGINTRON REDIPEN penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline PERIKABIVEN perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline phenelzine phenobarbital phenobarbital sodium phentolamine phenylephrine hcl... 56, 7 phenytoin phenytoin sodium phenytoin sodium extended PHOSLYRA PHOSPHOLINE IODIDE phosphorus # PICATO pilocarpine hcl... 65, 88 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam... 6 PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox podophyllum resin polyethylene glycol polymyxin b sulf-trimethoprim POMALYST potassium acetate potassium bicarb and chloride 89 potassium bicarb-citric acid potassium bicarbonate-cit ac. 89 potassium chlorid-d5-0.45%nacl potassium chloride... 89, 90 potassium chloride in 0.9%nacl potassium chloride in 5 % dex89 potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate-citric acid potassium hydroxide potassium phosphate dibasic. 90 POTIGA PRADAXA pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 73, 77 prednisone PREGNYL PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRISTIQ PRIVIGEN... 8 PROAIR HFA probenecid procainamide PROCALAMINE 3% prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized PROGLYCEM PROGRAF... 8 PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 4, 43 promethazine hcl propafenone propantheline proparacaine... 7 proparacaine hcl... 7 proparacaine-fluorescein sod. 7 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protamine protriptyline PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QUADRACEL (PF) QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 57 quinidine gluconate quinidine sulfate quinine sulfate QVAR... 9 I-0

105 R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE... 8 REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK.. 86 RECOMBIVAX HB (PF) RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR RESTASIS RETROVIR REVATIO REVLIMID REYATAZ ribavirin RIDAURA... 8 rifabutin rifampin RIFATER riluzole rimantadine ringers... 83, 90 risedronate RISPERDAL CONSTA risperidone... 46, 47 RITUXAN rivastigmine tartrate rizatriptan ropinirole ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL SAIZEN SAIZEN CLICK.EASY salsalate... 6 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline sildenafil oral tablet 20 mg SILENOR silver nitrate silver nitrate applicators silver sulfadiazine SIMBRINZA SIMPONI... 86, 87 SIMPONI ARIA simvastatin sirolimus... 8 SIRTURO sodium acetate sodium bicarbonate sodium chloride... 83, 90 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride sodium lactate sodium phosphate sodium polystyrene sulfonate 75 sodium thiosulfate sod-pot-k cit-sod cit-cit acid.. 9 SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL... 30, 3 stavudine STELARA STERILE PADS STIVARGA... 3 STRATTERA streptomycin STRIBILD sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 67 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac... 6 sumatriptan nasal spray sumatriptan succinate SUPPRELIN LA SUPRAX SURE COMFORT INS. SYR. U SURMONTIL SUSTIVA SUTENT... 3 SYLATRON SYLATRON 4-PACK SYLVANT... 3 SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 2 SYNRIBO... 3 SYPRINE I-

106 T TABLOID... 3 tacrolimus... 69, 8 TAFINLAR... 3 TAMIFLU tamoxifen... 3 tamsulosin TARCEVA... 3 TARGRETIN... 3 tarina fe TASIGNA... 3 TAZORAC taztia xt TECFIDERA TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam... 9 TEMODAR... 3 TENIVAC (PF) terazosin terbinafine hcl... 4 terbutaline terconazole... 4, 42 testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracaine hcl... 7 tetracycline TEV-TROPIN THALOMID theophylline theophylline anhydrous theophylline in dextrose 5 %.. 92 thioridazine thiothixene tiagabine TICE BCG TIKOSYN timolol maleate... 58, 88 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide tolbutamide tolmetin... 6 tolterodine topiramate toposar intravenous... 3 topotecan... 3 TORISEL... 3 torsemide... 6 TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES... 9 TPN ELECTROLYTES II... 9 TRACLEER TRADJENTA tramadol... 4 tramadol-acetaminophen... 4 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA... 3 TRECATOR TRELSTAR... 3, 32 tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide.. 65, 69, 78 triamterene-hydrochlorothiazid... 6 triazolam TRIBENZOR triderm trifluoperazine trifluridine trihexyphenidyl TRILEPTAL trimethoprim... 2 TRIUMEQ TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI... 8 TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULORIC ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 35 valsartan valsartan-hydrochlorothiazide 56 VALSTAR vancomycin... 2 vancomycin in d5w... 2 VAQTA (PF) VARIVAX (PF) VASCEPA vasopressin VECTIBIX VELCADE venlafaxine VENTAVIS I-2

107 verapamil VERSACLOZ VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMIZIM VIMPAT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VITEKTA VOLTAREN... 6 voriconazole... 4 VOTRIENT VPRIV W warfarin water for irrigation, sterile WELCHOL X XALKORI XARELTO XELJANZ XENAZINE XGEVA XIFAXAN XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF) Z zafirlukast... 9 zaleplon ZALTRAP ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem... 93, 94 ZOMETA zonisamide ZORTRESS... 8 ZOSTAVAX (PF) ZOVIRAX ZUBSOLV... 7 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX I-3

108 This formulary was updated on 06/9/205. For more recent information or other questions, please contact Advantage Care HMO, at , for TTY users, seven days a week from 8:00 am to 8:00 pm, or visit

109

110 CENTERS PLAN FOR HEALTHY LIVING Para más información o para inscribirse Llamar (gratis) Usuarios TTY Lunes a domingos de 8 a.m. a 8 p.m. ADVANTAGE CARE (HMO) [email protected] CENTERS PLAN CENTERS PLAN