Formulario completo del 2016

Transcription

1 Formulario completo del 016 Lista de medicamentos cubiertos IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Formulary ID: , Version: 7 Este formulario se actualizó el 08/1/015. Para obtener información más reciente o si tiene preguntas, llame a nuestro departamento de Servicios al miembro de Denver Health Medical Plan, Inc. al Los usuarios de TTY deben llamar al 711. Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la semana, también puede visitar Nota para aquellos que ya son miembros: Este formulario presenta cambios respecto del año pasado. Sírvase revisar este documento para asegurarse de que todavía contenga los medicamentos que usted toma. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario. Esta información está disponible de manera gratuita en otros idiomas. Para obtener más información, llame a nuestro departamento de Servicios al miembro al o al número gratuito Los usuarios de TTY/TDD deben llamar al 711. Nuestro horario de atención es de 8 a. m. a 8 p. m. los siete días de la semana. This information is available for free in other languages. Please contact our Member Services department at or toll free at for more information. TTY/TDD users should call 711. Our hours of operation are from 8 a.m. - 8 p.m. seven days a week. Denver Health Medical Plan, Inc. es un plan HMO aprobado por Medicare. La inscripción en Denver Health Medical Plan, Inc. depende de la renovación del contrato. H5608_1085_CF16_00_SP accepted 1

2 Cuando en esta lista de medicamentos (formulario) figuran los términos nosotros, a nosotros o nuestro, se hace referencia a Denver Health Medical Plan, Inc. Donde dice plan o nuestro plan, significa Medicare Select HMO. Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está en vigencia desde January 1, 016. Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada. En general, usted debe utilizar farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, la lista de medicamentos, la red de farmacias y/o los copagos/coseguro pueden cambiar el January 1, 017 y de vez en cuando durante el año. Qué es el Formulario completo de Denver Health Medical Plan, Inc.? Un formulario es una lista de medicamentos cubiertos seleccionados por nosotros en colaboración con un equipo de proveedores de atención médica, que representa los tratamientos recetados que se consideran parte necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos incluidos en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en una farmacia de la red de Denver Health Medical Plan, Inc. y se sigan otras reglas del plan. Para obtener más información sobre cómo obtener sus medicamentos recetados, revise su Evidencia de cobertura. Puede el Formulario (lista de medicamentos) modificarse? En general, si usted está tomando un medicamento de nuestro formulario del 016 que estaba cubierto a principios del año, no vamos a interrumpir ni a reducir la cobertura del medicamento durante el año de cobertura 016, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o se publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de cambios en el formulario, tales como eliminar un medicamento de nuestro formulario, no afectarán a los miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo compartido durante el resto del año de cobertura para aquellos miembros que lo toman. Consideramos que es importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto por los casos en los que usted pudiera ahorrar dinero adicional o nosotros podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario o añadimos requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada para un medicamento, o movemos un medicamento a un nivel más alto de costo compartido, debemos notificar a los miembros afectados acerca del cambio al menos 60 días antes de que el cambio entre en vigencia o en el momento en que el miembro solicite una renovación del medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no es seguro o si el fabricante del medicamento retira el medicamento del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto tiene vigencia a partir del January 1, 016. Para obtener información actualizada sobre los medicamentos que cubrimos, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada.

3 Los futuros cambios en el formulario se le enviarán con su Explicación mensual de Beneficios de la Parte D. Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no es seguro o el fabricante del medicamento retira el medicamento del mercado, los miembros afectados recibirán una notificación aparte. En nuestro sitio web, encontrará una lista de los futuros cambios que se realizarán en el Formulario. Cómo uso el Formulario? Hay dos maneras de encontrar un medicamento en el formulario: Afección médica El formulario comienza en la página 14. Los medicamentos en este formulario están agrupados en categorías que dependen del tipo de afección médica para la que se usan como tratamiento. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca aparecen bajo la categoría Agentes cardiovasculares. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 14. Luego busque su medicamento en esa categoría. Lista en orden alfabético Si no sabe con certeza en qué categoría buscar, deberá buscar su medicamento en el Índice que comienza en la página I-1. El Índice ofrece una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos aparecen en el Índice. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Vaya a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Nuestro plan cubre tanto medicamentos de marca como genéricos. Un medicamento genérico está aprobado por la FDA porque se considera que tiene los mismos ingredientes activos que el medicamento de marca. En general, los medicamentos genéricos tienen un costo menor que los de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden ser los siguientes: Autorización previa: nuestro plan exige que usted o su médico obtengan una autorización previa para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener nuestra aprobación antes de adquirir sus medicamentos recetados. Si usted no obtiene la aprobación, es posible que no cubramos el medicamento. 3

4 Límites de cantidad: para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos. Por ejemplo, nuestro plan ofrece 90 cápsulas por receta para LYRICA. Esto puede ser además del suministro estándar de un mes o tres meses. Terapia escalonada: en algunos casos, requerimos que para tratar su afección de salud, pruebe ciertos medicamentos primero antes de que aprobemos otro medicamento para tratar esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección de salud, es posible que no cubramos el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento A no funciona para usted, cubriremos el Medicamento B. Para averiguar si su medicamento tiene otros requisitos o límites adicionales, puede consultar el formulario que comienza en la página 14. También puede visitar nuestro sitio web para obtener más información sobre las restricciones que se aplican a un medicamento específico. Hemos publicado en línea documentos que explican nuestras restricciones de autorización previa y de terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada. Puede solicitarnos que hagamos una excepción a esas restricciones o límites o pedirnos una lista de otros medicamentos similares para tratar su afección médica. Consulte la sección Cómo puedo solicitar una excepción respecto del formulario de Denver Health Medical Plan? en la parte inferior de esta página para obtener información sobre cómo solicitar una excepción. Qué pasa si mi medicamento no figura en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), usted debe primero comunicarse con Servicios al miembro y averiguar si su medicamento está cubierto. Si usted se entera de que nuestro plan no cubre su medicamento, usted tiene dos opciones: Puede solicitar a Servicios al miembro una lista de medicamentos similares que cubramos. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan. Puede pedirnos que hagamos una excepción y que cubramos su medicamento. Consulte la información que figura más abajo sobre cómo solicitar una excepción. Cómo puedo solicitar una excepción respecto del formulario de Denver Health Medical Plan, Inc.? Puede pedirnos que hagamos una excepción respecto de nuestras reglas de cobertura. Hay varios tipos de excepciones que usted puede solicitarnos que hagamos. Puede pedirnos que cubramos un medicamento aunque no esté en nuestro formulario. Si aprobamos su pedido, cubriremos este medicamento a un nivel de costo compartido predeterminado, y usted no podrá solicitarnos que le proporcionemos el medicamento a un nivel de costo compartido menor. Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menor si el medicamento no está en el nivel de especialidad. Si esto se aprueba, reduciría el monto que debe pagar por su medicamento. 4

5 Puede pedirnos que anulemos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que anulemos el límite y cubramos una cantidad mayor. Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con costo compartido menor o las restricciones adicionales de utilización no resultaran tan eficaces para tratar su afección o le causaran efectos de salud adversos. Usted debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para obtener una excepción respecto del formulario, el nivel o la restricción de utilización. Cuando usted solicita una excepción respecto del formulario, el nivel o la restricción de utilización, debe presentar una declaración del proveedor o médico, que respalde su solicitud. En general, debemos tomar una decisión dentro de las 7 horas de recibir la declaración de respaldo de su médico. Usted puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera las 7 horas que lleva tomar la decisión. Si se le concede su petición de acelerar la decisión, debemos darle una decisión a más tardar 4 horas después de recibir la declaración de respaldo de su médico u otro proveedor. Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuo en nuestro plan, usted puede tomar medicamentos que no están en nuestro formulario. O bien, puede tomar un medicamento que está en nuestro formulario pero su capacidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes de poder obtener su medicamento con receta. Usted debe hablar con su médico para decidir si debe cambiar por otro medicamento apropiado que cubrimos o solicitar una excepción al formulario de modo que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción correcto para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que usted sea miembro de nuestro plan. Por cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que usted tenga una receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro para 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días. Si usted es residente de un centro de atención a largo plazo, permitiremos la renovación de su medicamento recetado hasta que le hayamos proporcionado un suministro de transición para 91 días, coherente con el incremento de dispensación, (a menos que tenga una receta escrita para menos días). Cubriremos más de una renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia para 31 días de ese medicamento (a menos usted tiene una receta escrita menos días) mientras solicita una excepción al formulario. Si experimenta un cambio en el nivel de atención, por ejemplo, se le interna en un centro de atención a largo plazo o se le da el alta de este, y se encuentra fuera de sus primeros 90 días de cobertura, Denver 5

6 Health Medical Plan, Inc. proporcionará un suministro por única vez un los medicamentos de la Parte D que no están en el formulario, como se describió anteriormente. Para obtener más información Para obtener información más detallada sobre la cobertura de medicamentos recetados que ofrece nuestro plan, consulte su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada. Si tiene preguntas generales sobre la cobertura de Medicare para medicamentos recetados, puede llamar a Medicare al MEDICARE ( ) las 4 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite 6

7 Formulario de Denver Health Medical Plan, Inc. El formulario completo que comienza en la página 14 proporciona información sobre la cobertura de los medicamentos cubiertos por nuestro plan. Si tiene inconvenientes para encontrar su medicamento en la lista, consulte el Índice que comienza en la página I-1. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo, ADVAIR DISKUS) y los medicamentos genéricos aparecen en letra cursiva en minúsculas con un nombre de medicamento de marca de referencia que aparece junto al nombre genérico del fármaco (por ejemplo, amoxicilina (Amoxil)). Los medicamentos genéricos en cursiva con nombres de marca de referencia entre paréntesis indican que sólo el medicamento genérico está en el formulario. La segunda columna le indica en qué nivel de medicamento está su medicamento. Nivel 1 Medicamentos genéricos preferidos Nivel Medicamentos genéricos Nivel 3 Medicamentos de marcas preferidas Nivel 4 Medicamentos de marcas no preferidas Nivel 5 Medicamentos de especialidad Lo que usted paga por su medicamento depende de la etapa de pagos de medicamentos en que se encuentre y del nivel en que su medicamento se encuentra en nuestro formulario. A continuación, se muestra una tabla que le ayudará a entender su copago o coseguro para cada nivel mientras se encuentra en la etapa inicial de cobertura de su beneficio de medicamentos recetados. Consulte su Evidencia de Cobertura para obtener más información acerca de su cobertura de la Parte D de Medicare, incluyendo su costo compartido durante las diferentes etapas de pago de medicamentos. PLAN VENTA HASTA 30 DÍAS ENVÍO POR CORREO HASTA 90 DÍAS Nivel 1 Nivel Nivel 3 Nivel 4 Nivel 5 Nivel 1 Nivel Nivel 3 Nivel 4 Nivel 5 Medicare Select $3 $8 $45 $95 8% $6 $16 $90 $190 8% Su copago y coseguro pueden variar en función del subsidio por bajos ingresos (Low-Income Subsidy, LIS). La información en la columna de Requisitos/Límites le indica si Denver Health Medical Plan, Inc. tiene algún requisito especial para la cobertura de su medicamento. 7

8 Las siguientes abreviaturas pueden encontrarse en el cuerpo de este documento. ABREVIATURAS SOBRE NOTAS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones sobre la Administración de la Utilización de Servicios PA PA BvD PA-HRM PA NSO QL Restricción de autorización previa Restricción de autorización previa para una determinación de Parte B frente a Parte D Restricción de autorización previa para medicamentos de alto riesgo Restricción de autorización previa para nuevos miembros solamente Restricción de límite de cantidad Usted (o su médico) tiene la obligación de obtener autorización previa de Denver Health Medical Plan (DHMP), Inc. antes de obtener el medicamento de su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. Este medicamento puede ser elegible para el pago bajo la Parte B o la Parte D de Medicare. Usted (o su médico) tiene la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. para determinar que este medicamento esté cubierto por la Parte D de Medicare antes de obtener el medicamento indicado en su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. Este medicamento ha sido considerado por CMS como potencialmente perjudicial y, por lo tanto, como medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los miembros de 65 años o más tienen la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. antes de obtener el medicamento de su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. Si usted es un miembro nuevo o si usted no ha tomado este medicamento antes, usted (o su médico) tiene la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. antes de obtener el medicamento que figura en su receta. Sin aprobación previa, DHMP no cubrirá este medicamento. Denver Health Medical Plan, Inc. establece un límite de cobertura respecto de la cantidad de este medicamento por receta, o dentro de un marco de tiempo específico. 8

9 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN ST LA Restricción de terapia escalonada Medicamento de acceso limitado Antes de que Denver Health Medical Plan, Inc. proporcione cobertura para este medicamento, usted debe primero probar otro(s) medicamento(s) para el tratamiento de su afección médica. Este medicamento sólo será cubierto si otro(s) fármaco(s) no funciona(n) para usted. Es posible que este medicamento recetado sólo esté disponible en algunas farmacias. Para obtener más información, consulte su Directorio de farmacias o llame a Servicios al miembro al , de 8 a. m. a 8 p. m. los siete días de la semana. Los usuarios de TTY deben llamar al

10 ABREVIATURAS DE DOSIS Y PRESENTACIÓN ABREVIATURA DESCRIPCIÓN adh. patch parche adhesivo aer br act aerosol, activado por aliento aer pow aerosol, polvo aer pow ba polvo aerosol, activado por aliento aer refill repuesto de aerosol aer w/adap aerosol con adaptador ampul ampolla blkbaginj inyección en bolsas a granel cap dr mp cápsula, multifásica de liberación prolongada cap ds pk cápsula, paquete de dosis cap er 1h cápsula, 1 horas liberación prolongada cap er 4h cápsula, 4 horas liberación prolongada cap er deg cápsula, liberación prolongada degradable cap er pel cápsula, pellets liberación prolongada cap mphase cápsula, multifásica cap.sa 4h cápsula, 4 horas liberación sostenida cap.sr 1h cápsula, 1 horas liberación sostenida cap.sr 4h cápsula, 4 horas liberación sostenida cap4h pct cápsula, 4 horas pellets de inicio controlado cap4h pel cápsula, 4 horas pellets liberación sostenida cap sprink cápsula, esparcir cap sr pel cápsula pellets liberación sostenida cap w/dev cápsula con dispositivo capsule dr cápsula, liberación retardada capsule er cápsula, liberación prolongada capsule sa cápsula, acción sostenida cmb cappad combinación: cápsula, almohadilla cmb ont fm combinación: ungüento, espuma cmb ont lt combinación: ungüento, loción cmb tabpad combinación: comprimido, almohadilla combo. pkg paquete combinado cpmp 1hr cápsula, 1 horas multifásica cpmp 4hr cápsula, 4 horas multifásica cpmp cápsula, multifásica, 30%-70% cpmp cápsula, multifásica, 50%-50% cream(g), cream(gm) crema (gramos) cream(ml) crema (mililitros) cream/appl crema con aplicador cream, er (g) crema, liberación prolongada (gramos) cream pack crema, paquete dehp fr bg bolsa sin di(-etilhexil) ftalato dis needle aguja desechable disk w/dev disco con dispositivo para inhalación disp syrin jeringa desechable drops susp gotas, suspensión

11 ABREVIATURA 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 1h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td4 patch td7 patch tdsw DESCRIPCIÓN gotas, hiperviscosas adhesivo emulsión paquete de emulsión emulsión (gramos) espuma con aplicador accesorio congelado gramo gel con aplicador precargado gel (gramos) gel (mililitros) gel en bomba con dosis medida gel con aplicador gel con bomba paquete de gránulos adaptador para aerosol hfahidrofluoroalcano frasco para infusión pluma de insulina solución intraperitoneal solución de irrigación solución intravenosa jalea jalea con aplicador jalea con aplicador precargado kit: limpiador y crema kit: crema, loción emoliente kit: loción, crema emoliente kit: ungüento, loción emoliente loción, liberación prolongada pastillas con soporte parche de calor con medicamento comprimidos bucales mucoadhesivos microgramo almohadilla con medicamento hisopo con medicamento cinta adhesiva con medicamento miligramo mililitro sistema mucoadhesivo, 1 horas liberación prolongada aguja para inyección suspensión para cubierta de uñas ungüento (gramos) concentrado oral suspensión oral pasta (gramos) parche, 4 horas transdérmico parche, 7 horas transdérmico parche, veces por semana transdérmico

12 ABREVIATURA 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 4h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 1h tab er 4h tab er prt tab er seq tab disper tab ds pk tab er 4 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 1h tab.sr 4h tabergr4hr tablet dr tablet, er tablet eff tablet sa DESCRIPCIÓN parche, 1 vez por semana transdérmico jeringa analgésica controlada por paciente vial analgésico controlado por paciente pellet (cada uno) kit con pluma para inyección pluma para inyección frasco accesorio bolsa plástica paquete de polvo solución con bomba multidosis solución con aplicador solución con aplicador precargado solución, formadora de gel solución, reconstituida solución (gramos) atomizador, suspensión atomizador con bomba varilla (cada una) supositorio, rectal supositorio, vaginal supositorio suspensión, 4 horas liberación prolongada suspensión, reconstituida de liberación prolongada suspensión, microcápsula reconstituida suspensión, paquete de liberación retardada suspensión, reconstituida kit de jeringa comprimido, masticable comprimido, 1 horas liberación prolongada comprimido, 4 horas liberación prolongada comprimido, partículas de liberación prolongada comprimido, efectos de liberación prolongada de liberación prolongada comprimido, dispersable comprimido, paquete de dosis comprimido, 4 horas liberación prolongada comprimido, multifásico comprimido, partículas comprimido, liberación retardada de desintegración rápida comprimido, desintegración rápida comprimido, sublingual comprimido, 1 horas liberación sostenida comprimido, 4 horas liberación sostenida comprimido, 4 horas liberación prolongada gradual comprimido, liberación retardada comprimido, liberación prolongada comprimido, efervescente comprimido, acción sostenida

13 ABREVIATURA tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 1hr tbmp 4hr u vag ring DESCRIPCIÓN comprimido, soluble comprimido, paquete de dosis de liberación prolongada comprimido, paquete de dosis multifásica comprimido, paquete de dosis de desintegración rápida comprimido, paquete de dosis de 3 meses comprimido, 1 horas multifásico comprimido, 4 horas multifásico unidad anillo vaginal

14 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with QL (700 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 (180 per 30 mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral capsule mg (Esgic) PA-HRM; QL (180 per 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) PA-HRM; QL (180 per 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) PA-HRM; QL (180 per 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) PA-HRM; QL (180 per 30 BUTRANS 3 QL (4 per 8 codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral capsule mg (Fiorinal with Codeine #3) PA-HRM; QL (180 per 30 fentanyl (Duragesic) PA; QL (10 per 30 fentanyl citrate (Actiq) 5 PA; QL (10 per 30 hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 30 hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 hydrocodone-acetaminophen oral tablet (Norco) QL (360 per mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen (Ibudone) QL (150 per 30 hydromorphone (pf) injection solution 10 mg/ml (Hydromorphone HCl/PF) 14

15 hydromorphone (pf) injection solution 4 (Dilaudid) mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe mg/ml (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) QL (100 per 30 hydromorphone oral tablet mg, 4 mg (Dilaudid) QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) QL (40 per 30 LAZANDA 5 PA; QL (30 per 30 methadone hcl oral tablet,soluble 40 mg (Diskets) QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Morphine Sulfate) QL (00 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 10 mg/ml, 15 (Morphine Sulfate) mg/ml, 8 mg/ml morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 5 mg/ml, (Morphine Sulfate) 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 morphine oral solution 0 mg/5 ml (Morphine Sulfate) QL (300 per 30 MORPHINE ORAL TABLET 4 QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) QL (10 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 (MS Contin) QL (180 per 30 mg, 00 mg morphine rectal (Morphine Sulfate) NUCYNTA 3 QL (181 per 30 NUCYNTA ER 3 QL (60 per 30 oxycodone hcl-acetaminophen oral (Oxycodone QL (1800 per 30 solution 5-35 mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Xolox) QL (360 per mg,.5-35 mg, 5-35 mg, mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 15

16 oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30 oxycodone oral tablet (Roxicodone) QL (180 per 30 oxycodone-acetaminophen oral tablet 10- (Xolox) QL (360 per mg,.5-35 mg, 5-35 mg, mg oxycodone-acetaminophen oral tablet 10- (Xolox) QL (180 per mg oxycodone-acetaminophen oral tablet 7.5- (Xolox) QL (40 per mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (10 per 30 ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 1 hr 10 mg, 15 mg, 0 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (10 per 30 1 hr 30 mg, 40 mg tramadol oral tablet (Ultram) QL (40 per 30 tramadol-acetaminophen (Ultracet) QL (40 per 30 xylon 10 (Ibudone) QL (150 per 30 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 4 SOLN celecoxib (Celebrex) QL (60 per 30 choline,magnesium salicylate (Choline Sal/Mag Salicylate) diclofenac potassium (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) 5 diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) 16

17 etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR 3 PA flurbiprofen (Flurbiprofen) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) 1 mg indomethacin oral capsule 5 mg (Indomethacin) PA-HRM; QL (40 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (10 per 30 indomethacin oral capsule, extended release (Indomethacin) PA-HRM; QL (60 per 30 indomethacin sodium (Indomethacin Sodium) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 4 (Ketoprofen) hr 00 mg ketorolac oral (Ketorolac QL (0 per 30 Tromethamine) mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) meloxicam oral tablet (Mobic) 1 nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) 1 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 75 mg, 550 (Anaprox) 1 mg piroxicam (Feldene) salsalate (Salsalate) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL 3 Anesthetics Local Anesthetics glydo (Lidocaine HCl) 17

18 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 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 buprenorphine-naloxone (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH BOX 3 QL (56 per 8 CHANTIX CONTINUING MONTH PAK 3 QL (56 per 8 CHANTIX STARTING MONTH BOX 3 QL (53 per 8 disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICOTROL 4 QL (1008 per 90 ZUBSOLV 3 PA; QL (90 per 30 Antianxiety Agents Benzodiazepines 18

19 alprazolam oral tablet (Xanax) QL (10 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (10 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 clonazepam oral tablet mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) QL (10 per 30 clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 mg, 7.5 mg diazepam injection (Diazepam) QL (10 per 8 diazepam intensol (Diazepam) QL (100 per 30 diazepam oral solution (Diazepam) QL (100 per 30 diazepam oral tablet (Valium) QL (10 per 30 diazepam rectal (Diastat) lorazepam oral tablet (Ativan) QL (90 per 30 Antibacterials Aminoglycosides BETHKIS 5 PA BvD gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback Iso-Osm) gentamicin injection solution (Gentamicin Sulfate) 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 5 QL (4 per 8 tobramycin in 0.5 % nacl (Tobi) 5 PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride) tobramycin sulfate injection solution (Tobramycin Sulfate) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) 19

20 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 5 Parenteral) CUBICIN 5 linezolid (Zyvox) 5 methenamine hippurate (Hiprex) methenamine mandelate (Methenamine Mandelate) metronidazole in nacl (iso-os) (Metronidazole/Sodium Chloride) metronidazole oral (Flagyl) nitrofurantoin macrocrystal (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 (10 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 (10 per 30 polymyxin b sulfate (Polymyxin B Sulfate) SYNERCID 5 trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) 0

21 vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) 5 XIFAXAN ORAL TABLET 00 MG 5 PA; QL (9 per 30 ZYVOX ORAL SUSPENSION FOR 5 RECONSTITUTION Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 15 mg/5 ml, 50 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 1 gram/50 ml, gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 100 gram, 300 g, 500 mg cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % 4 CEFEPIME IN DEXTROSE,ISO-OSM 4 INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Cefoxitin Sodium) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime intravenous recon soln 1 (Ceftazidime) gram, gram ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK GRAM/50 ML 1

22 ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef) 1.5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) 1 cephalexin oral suspension for (Cephalexin) 1 reconstitution cephalexin oral tablet (Cephalexin) 1 MEFOXIN IN DEXTROSE (ISO-OSM) 4 SUPRAX ORAL TABLET,CHEWABLE 4 TEFLARO 4 Macrolides azithromycin (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Clarithromycin) release 4 hr DIFICID 5 QL (0 per 10 ERYTHROCIN 4 erythromycin base oral tablet,delayed (Erythromycin Base) release (dr/ec) 50 mg, 500 mg ERYTHROMYCIN BASE ORAL 4 TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral (Eryped 00) suspension for reconstitution erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) erythromycin oral capsule,delayed release(dr/ec) (Erythromycin Base)

23 erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet 50 mg (Erythromycin Stearate) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram (Azactam) CAYSTON 5 LA imipenem-cilastatin (Primaxin) INVANZ 4 meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) 1 amoxicillin oral suspension for (Amoxicillin) 1 reconstitution amoxicillin oral tablet (Amoxicillin) 1 amoxicillin oral tablet,chewable 15 mg, (Amoxicillin) 1 50 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) 1 ampicillin sodium injection recon soln (Ampicillin Sodium) ampicillin sodium intravenous recon soln (Ampicillin Sodium) ampicillin-sulbactam injection recon soln (Unasyn) ampicillin-sulbactam intravenous (Unasyn) BICILLIN C-R 4 BICILLIN L-A 4 dicloxacillin (Dicloxacillin Sodium) nafcillin injection (Nafcillin Sodium) nafcillin intravenous recon soln (Nafcillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- Water) 3

24 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) 1 ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate (Ciprofloxacin Lactate) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral solution (Levaquin) levofloxacin oral tablet (Levaquin) 1 moxifloxacin (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim intravenous ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/Trim ethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 50 (Avidoxy) mg doxycycline hyclate oral tablet 0 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) 4

25 doxycycline monohydrate oral suspension for reconstitution Drug Name Drug Tier Requirements/Limits (Vibramycin) doxycycline monohydrate oral tablet (Avidoxy) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Tetracycline HCl) TYGACIL 5 Anticancer Agents Anticancer Agents ABRAXANE 5 ADCETRIS 5 PA NSO; QL (4 per 1 AFINITOR DISPERZ 5 PA NSO; QL (11 per 8 AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; QL (8 per 8 ALIMTA INTRAVENOUS RECON 5 SOLN anastrozole (Arimidex) AVASTIN INTRAVENOUS SOLUTION 5 PA NSO 5 MG/ML azacitidine (Vidaza) 5 BELEODAQ 5 PA NSO bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) PA BvD BLINCYTO 5 PA NSO; QL (140 per 365 BOSULIF ORAL TABLET 100 MG 5 PA NSO; QL (10 per 30 BOSULIF ORAL TABLET 500 MG 5 PA NSO; QL (30 per 30 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 5 PA NSO; QL (30 per 30 5

26 COMETRIQ 5 PA NSO; QL (11 per 8 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST CYRAMZA INTRAVENOUS 5 PA NSO SOLUTION 10 MG/ML dactinomycin (Dactinomycin) decitabine (Dacogen) 5 doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) PA BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) 5 PA BvD suspension mg/ml doxorubicin, peg-liposomal (Doxil) 5 PA BvD DROXIA 3 ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per 84.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) EMCYT 3 ERIVEDGE 5 PA NSO; QL (30 per 30 ETOPOPHOS 4 etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON 5 FARYDAK 5 PA NSO FASLODEX 5 floxuridine (Floxuridine) PA BvD fluorouracil intravenous solution.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) GAZYVA 5 PA NSO 6

27 GILOTRIF 5 PA NSO; QL (30 per 30 GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 per 30 HERCEPTIN 5 PA NSO HEXALEN 5 hydroxyurea (Hydrea) IBRANCE 5 PA NSO; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna) 5 PA BvD IMBRUVICA 5 PA NSO INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 per 30 IXEMPRA 5 JAKAFI 5 PA NSO; QL (60 per 30 KEYTRUDA 5 PA NSO KYPROLIS 5 PA NSO; QL (6 per 8 LENVIMA 5 PA NSO letrozole (Femara) LEUKERAN 4 leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT 5 LUPRON DEPOT (3 MONTH) 5 QL (1 per 84 LUPRON DEPOT (4 MONTH) 5 QL (1 per 84 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 7

28 LYNPARZA 5 PA NSO; QL (480 per 30 LYSODREN 3 MATULANE 5 megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; QL (90 per 30 MEKINIST ORAL TABLET MG 5 PA NSO; QL (30 per 30 mercaptopurine (Mercaptopurine) 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 mitoxantrone (Mitoxantrone HCl) NEXAVAR 5 PA NSO; QL (10 per 30 NILANDRON 3 ONCASPAR 5 PA NSO OPDIVO INTRAVENOUS SOLUTION 5 PA NSO 40 MG/4 ML POMALYST 5 PA NSO; QL (1 per 8 PROLEUKIN 5 PURIXAN 5 REVLIMID 5 PA NSO; LA RITUXAN 5 PA NSO SOLTAMOX 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; QL (60 per 30 STIVARGA 5 PA NSO; QL (84 per 8 SUTENT 5 PA NSO; QL (30 per 30 8

29 SYLVANT 5 PA NSO SYNRIBO 5 PA NSO; QL (8 per 8 TABLOID 3 TAFINLAR 5 PA NSO; QL (10 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 per 30 TARGRETIN ORAL 5 PA NSO; QL (40 per 30 TARGRETIN TOPICAL 5 PA NSO; QL (60 per 8 TASIGNA 5 PA NSO; QL (11 per 8 TEMODAR INTRAVENOUS 5 PA NSO; (vial only) toposar intravenous (Etoposide) TREANDA 5 TRELSTAR INTRAMUSCULAR 5 QL (1 per 168 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR 5 QL (1 per 84 SYRINGE 11.5 MG/ ML TRELSTAR INTRAMUSCULAR 5 QL (1 per 168 SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR 5 SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) (Tretinoin) 5 (capsule: 10mg) TREXALL 4 PA BvD; ST TYKERB 5 VALSTAR 5 VELCADE 5 PA NSO vinorelbine intravenous solution (Navelbine) VOTRIENT 5 PA NSO; QL (10 per 30 XALKORI 5 PA NSO; QL (60 per 30 9

30 XTANDI 5 PA NSO; QL (10 per 30 YERVOY INTRAVENOUS SOLUTION 5 PA NSO ZELBORAF 5 PA NSO; QL (40 per 30 ZOLADEX SUBCUTANEOUS 4 QL (1 per 84 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG 4 QL (1 per 8 ZOLINZA 5 ZYDELIG 5 PA NSO; QL (60 per 30 ZYKADIA 5 PA NSO; QL (140 per 8 ZYTIGA 5 PA NSO; QL (10 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM 4 ST BANZEL 4 ST carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG 3 DILANTIN 3 divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 4 hr (Depakote ER) 30

31 divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA 4 ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 3 MG LAMICTAL ORAL TABLET, 4 CHEWABLE DISPERSIBLE MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 4hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 5 mg (Lamictal (Blue)) (35) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 4 hr LYRICA ORAL CAPSULE 3 QL (90 per 30 LYRICA ORAL SOLUTION 3 QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR 4 ST PEGANONE 3 phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, 15 mg, (Phenobarbital) QL (90 per mg, 3.4 mg, 60 mg, 64.8 mg, 97. mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (00 per 30 phenobarbital sodium injection solution (Phenobarbital Sodium) QL ( per 30 phenytoin oral suspension 15 mg/5 ml (Dilantin-15) phenytoin oral (Dilantin) 31

32 phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 00 MG, ST ; QL (90 per 30 MG, 400 MG POTIGA ORAL TABLET 50 MG 4 ST ; QL (70 per 30 primidone (Mysoline) SABRIL 5 tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) topiramate oral tablet (Topamax) TROKENDI XR 4 ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 50 mg/5 ml (Depakene) VIMPAT INTRAVENOUS 4 ST ; QL (00 per 5 VIMPAT ORAL SOLUTION 4 ST ; QL (100 per 30 VIMPAT ORAL TABLET 4 ST ; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Donepezil HCl) QL (30 per 30 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per 30 4 hr galantamine oral solution (Galantamine Hbr) QL (00 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 NAMENDA XR ORAL 3 QL (8 per 8 CAP,SPRINKLE,ER 4HR DOSE PACK NAMENDA XR ORAL 3 QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR NAMZARIC 3 rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants 3

33 Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) BRINTELLIX 4 ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) 1 QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Irenka) QL (60 per 30 release(dr/ec) 0 mg, 60 mg duloxetine oral capsule,delayed (Irenka) QL (30 per 30 release(dr/ec) 30 mg, 40 mg EMSAM 4 QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA 4 ST fluoxetine oral capsule (Prozac) 1 fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 0 mg (Fluoxetine HCl) fluvoxamine (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM maprotiline (Maprotiline HCl) MARPLAN 4 mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) 33

34 paroxetine hcl oral tablet extended release (Paxil CR) 4 hr PAXIL ORAL SUSPENSION 4 perphenazine-amitriptyline (Perphenazine/Amitripty PA NSO-HRM line HCl) phenelzine (Nardil) PRISTIQ 4 ST ; QL (30 per 30 protriptyline (Protriptyline HCl) sertraline oral concentrate (Zoloft) sertraline oral tablet (Zoloft) 1 SILENOR 3 QL (30 per 30 SURMONTIL 4 PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) 1 venlafaxine oral capsule,extended release (Effexor XR) 4hr venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 4hr 150 mg, 37.5 mg, 75 mg (Venlafaxine HCl) VIIBRYD 4 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 CYCLOSET 4 QL (180 per 30 GLYXAMBI 3 ST; QL (30 per 30 INVOKAMET ORAL TABLET ST; QL (60 per 30 1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG 3 ST; QL (10 per 30 INVOKANA ORAL TABLET 100 MG 3 ST; QL (60 per 30 INVOKANA ORAL TABLET 300 MG 3 ST; QL (30 per 30 JANUMET 3 QL (60 per 30 JANUMET XR ORAL TABLET, ER 3 QL (30 per 30 MULTIPHASE 4 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 MULTIPHASE 4 HR 50-1,000 MG JANUVIA 3 QL (30 per 30 34

35 JARDIANCE 3 ST; QL (30 per 30 JENTADUETO 3 QL (60 per 30 KORLYM 5 PA; QL (11 per 8 metformin oral tablet 1,000 mg (Glucophage) 1 QL (60 per 30 metformin oral tablet 500 mg (Glucophage) 1 QL (150 per 30 metformin oral tablet 850 mg (Glucophage) 1 QL (90 per 30 metformin oral tablet extended release 4 (Glucophage XR) QL (10 per 30 hr 500 mg metformin oral tablet extended release 4 (Glucophage XR) QL (90 per 30 hr 750 mg metformin oral tablet extended release (Fortamet) QL (60 per 30 4hr 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 3 QL (150 per 30 repaglinide (Prandin) QL (40 per 30 SYMLINPEN 10 4 PA; QL (10.8 per 8 SYMLINPEN 60 4 PA; QL (6 per 8 TRADJENTA 3 QL (30 per 30 TRULICITY 3 ST; QL (4 per 8 VICTOZA 3 ST; QL (9 per 8 Insulins HUMULIN R U QL (40 per 8 "CONCENTRATED" LANTUS 3 QL (40 per 8 LANTUS SOLOSTAR 3 QL (30 per 8 NOVOLIN 70/30 3 QL (40 per 8 NOVOLIN N 3 QL (40 per 8 NOVOLIN R 3 QL (40 per 8 NOVOLOG 3 QL (40 per 8 NOVOLOG FLEXPEN 3 QL (30 per 8 NOVOLOG MIX QL (40 per 8 NOVOLOG MIX FLEXPEN 3 QL (30 per 8 NOVOLOG PENFILL 3 QL (30 per 8 35

36 TOUJEO SOLOSTAR 3 Sulfonylureas glimepiride oral tablet 1 mg, mg (Amaryl) 1 QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) 1 QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) 1 QL (10 per 30 glipizide oral tablet 5 mg (Glucotrol) 1 QL (60 per 30 glipizide oral tablet extended release 4hr (Glucotrol XL) QL (60 per mg glipizide oral tablet extended release 4hr (Glucotrol XL) QL (30 per 30.5 mg, 5 mg glipizide-metformin oral tablet.5-50 mg (Glipizide/Metformin QL (40 per 30 HCl) glipizide-metformin oral tablet (Glipizide/Metformin QL (10 per 30 mg, mg HCl) glyburide micronized oral tablet 1.5 mg (Glynase) PA-HRM; QL (400 per 30 glyburide micronized oral tablet 3 mg (Glynase) PA-HRM; QL (180 per 30 glyburide micronized oral tablet 6 mg (Glynase) PA-HRM; QL (10 per 30 glyburide oral tablet 1.5 mg (Glyburide) PA-HRM; QL (80 per 30 glyburide oral tablet.5 mg (Glyburide) PA-HRM; QL (40 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (10 per 30 glyburide-metformin oral tablet mg (Glucovance) PA-HRM; QL (40 per 30 glyburide-metformin oral tablet mg, mg (Glucovance) PA-HRM; QL (10 per 30 tolazamide oral tablet 50 mg (Tolazamide) QL (10 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (180 per 30 Antifungals Antifungals ABELCET 5 PA BvD AMBISOME 5 PA BvD amphotericin b (Amphotericin B) PA BvD 36

37 CANCIDAS 5 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 400 mg/00 ml Nacl,Iso-Osm) flucytosine (Ancobon) 5 griseofulvin microsize oral tablet (Grifulvin V) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) miconazole nitrate vaginal suppository (Monistat 3) 00 mg NOXAFIL ORAL 5 NYSTATIN (BULK) POWDER 1 BILLION UNIT, 10 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) 5 37

38 Antihistamines Antihistamines cyproheptadine (Cyproheptadine HCl) PA-HRM diphenhydramine hcl injection solution 50 mg/ml (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 3 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 8 dihydroergotamine nasal (Migranal) QL (8 per 8 ERGOMAR 4 QL (40 per 8 naratriptan (Amerge) QL (18 per 8 rizatriptan oral tablet (Maxalt) QL (18 per 8 rizatriptan oral tablet,disintegrating (Maxalt Mlt) QL (18 per 8 sumatriptan nasal spray (Imitrex) QL (1 per 8 sumatriptan oral tablet (Imitrex) QL (18 per 8 sumatriptan succinate subcutaneous (Imitrex) QL (4 per 8 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Sumatriptan Succinate) QL (4 per 8 injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) QL (4 per 8 injector 6 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (4 per 8 solution zolmitriptan oral tablet (Zomig) QL (1 per 8 zolmitriptan oral tablet,disintegrating (Zomig Zmt) QL (1 per 8 Antimycobacterials Antimycobacterials CAPASTAT 4 38

39 dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral solution (Isoniazid) isoniazid oral tablet (Isoniazid) 1 PASER 4 PRIFTIN 4 pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER 4 SIRTURO 5 PA; QL (188 per 168 TRECATOR 4 Antinausea Agents Antinausea Agents dimenhydrinate injection solution (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS 4 QL ( per 8 EMEND ORAL 4 PA BvD granisetron (pf) intravenous solution (Granisetron HCl/PF) granisetron hcl intravenous solution 1 (Granisetron HCl) mg/ml (1 ml) granisetron hcl oral (Granisetron HCl) PA BvD meclizine oral tablet 1.5 mg, 5 mg (Antivert) ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) injection (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection solution (Prochlorperazine Edisylate) prochlorperazine maleate oral (Compazine) 1 promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine HCl) PA-HRM promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP 4 QL (10 per 30 Antiparasite Agents 39

40 Antiparasite Agents ALBENZA 4 ALINIA 4 atovaquone (Mepron) 5 atovaquone-proguanil (Malarone) chloroquine phosphate oral (Chloroquine Phosphate) COARTEM 4 DARAPRIM 4 hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) NEBUPENT 4 PA BvD paromomycin (Paromomycin Sulfate) PENTAM 4 PRIMAQUINE 4 QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (4 per 7 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral (Amantadine HCl) APOKYN 5 QL (60 per 30 AZILECT 3 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 3 ST; QL (30 per 30 pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 4 (Requip XL) hr selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) 40

41 trihexyphenidyl (Trihexyphenidyl HCl) PA-HRM Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL 3 QL (90 per 30 TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA 5 INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA 5 QL (1 per 8 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral tablet 10 mg, 15 mg, 0 (Abilify) QL (30 per 30 mg, 30 mg, 5 mg aripiprazole oral tablet mg (Abilify) QL (60 per 30 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (70 per 30 clozapine oral tablet 00 mg (Clozaril) QL (135 per 30 clozapine oral tablet 5 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating (Fazaclo) ST FANAPT ORAL TABLET 4 ST ; QL (60 per 30 FANAPT ORAL TABLETS,DOSE 4 ST ; QL (8 per 8 PACK fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR 4 QL (6 per 8 haloperidol (Haloperidol) haloperidol decanoate intramuscular (Haloperidol Decanoate) solution 100 mg/ml haloperidol decanoate intramuscular (Haldol Decanoate 50) solution 50 mg/ml haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED 4 ST ; QL (30 per 30 RELEASE 4HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 4HR 6 MG 4 ST ; QL (60 per 30 41

42 INVEGA SUSTENNA 5 QL (0.75 per 8 INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA 5 QL (1 per 8 INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA 5 QL (1.5 per 8 INTRAMUSCULAR SYRINGE 34 MG/1.5 ML INVEGA SUSTENNA 3 QL (0.5 per 8 INTRAMUSCULAR SYRINGE 39 MG/0.5 ML INVEGA SUSTENNA 3 QL (0.5 per 8 INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR 5 QL (0.875 per 84 SYRINGE 73 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR 5 QL (1.315 per 84 SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR 5 QL (1.75 per 84 SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR 5 QL (.65 per 84 SYRINGE 819 MG/.65 ML LATUDA ORAL TABLET 10 MG, 0 4 ST ; QL (30 per 30 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG 4 ST ; QL (60 per 30 loxapine succinate (Loxapine Succinate) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (30 per 30 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) QL (31 per 30 mg ORAP 4 perphenazine (Perphenazine) quetiapine (Seroquel) QL (90 per 30 RISPERDAL CONSTA 4 QL (4 per 8 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 4

43 risperidone oral tablet,disintegrating 0.5 (Risperdal M-Tab) QL (60 per 30 mg, 0.5 mg, 1 mg, mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (10 per 30 mg, 4 mg SAPHRIS (BLACK CHERRY) 4 ST ; QL (60 per 30 thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Thiothixene) trifluoperazine (Trifluoperazine HCl) VERSACLOZ 5 ST ; QL (540 per 30 ziprasidone hcl (Geodon) QL (60 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 405 MG 5 Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) 5 APTIVUS ORAL CAPSULE 5 APTIVUS ORAL SOLUTION 4 ATRIPLA 5 COMPLERA 5 CRIXIVAN ORAL CAPSULE 00 MG, MG didanosine (Videx EC) EDURANT 5 EMTRIVA 3 EPIVIR HBV ORAL SOLUTION 4 EPZICOM 5 EVOTAZ 5 FUZEON SUBCUTANEOUS 5 INTELENCE ORAL TABLET 100 MG, 5 00 MG INTELENCE ORAL TABLET 5 MG 3 INVIRASE 5 ISENTRESS ORAL POWDER IN 3 PACKET ISENTRESS ORAL TABLET 5 43

44 ISENTRESS ORAL 3 TABLET,CHEWABLE KALETRA ORAL SOLUTION 5 KALETRA ORAL TABLET MG 3 KALETRA ORAL TABLET MG 5 lamivudine (Epivir) lamivudine-zidovudine (Combivir) 5 LEXIVA ORAL SUSPENSION 3 LEXIVA ORAL TABLET 5 nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 4 (Viramune XR) hr NORVIR 3 PREZCOBIX 5 PREZISTA ORAL SUSPENSION 4 PREZISTA ORAL TABLET 150 MG, 75 3 MG PREZISTA ORAL TABLET 400 MG, MG, 800 MG RESCRIPTOR 4 RETROVIR INTRAVENOUS 3 REYATAZ ORAL CAPSULE 150 MG, 5 00 MG, 300 MG REYATAZ ORAL POWDER IN 5 PACKET SELZENTRY 5 stavudine (Zerit) STRIBILD 5 SUSTIVA 4 TIVICAY 5 TRIUMEQ 5 TRUVADA 5 VIDEX GRAM PEDIATRIC 3 VIDEX 4 GRAM PEDIATRIC 3 VIRACEPT ORAL TABLET 4 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 4 HR 100 MG 3 44

45 VIREAD 5 VITEKTA 5 ZIAGEN ORAL SOLUTION 4 zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER 4 rimantadine (Flumadine) SYNAGIS 5 TAMIFLU ORAL CAPSULE 30 MG 3 QL (84 per 180 TAMIFLU ORAL CAPSULE 45 MG 3 QL (48 per 180 TAMIFLU ORAL CAPSULE 75 MG 3 QL (4 per 180 TAMIFLU ORAL SUSPENSION FOR 3 QL (540 per 180 RECONSTITUTION Hcv Antivirals HARVONI 5 PA; QL (30 per 30 OLYSIO 5 PA; QL (8 per 8 SOVALDI 5 PA; QL (8 per 8 Interferons INTRON A INJECTION 4 PA NSO PEGASYS 5 PA PEGASYS PROCLICK 5 PA PEGINTRON 5 PA SYLATRON 5 PA NSO; QL (4 per 8 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 00 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous solution (Acyclovir Sodium) PA BvD adefovir (Hepsera) 5 entecavir (Baraclude) 5 famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 00 mg (Rebetol) 45

46 ribavirin oral tablet 00 mg, 400 mg, 600 mg Drug Name Drug Tier Requirements/Limits (Copegus) TYZEKA 5 valacyclovir (Valtrex) valganciclovir (Valcyte) 5 VIRAZOLE 5 PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) 5 ELIQUIS 3 enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 enoxaparin subcutaneous syringe 100 (Lovenox) 5 QL (36 per 30 mg/ml enoxaparin subcutaneous syringe 10 (Lovenox) 5 QL (7. per 30 mg/0.8 ml enoxaparin subcutaneous syringe 150 (Lovenox) 5 QL (34 per 30 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) QL (18 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) QL (13.6 per 30 mg/0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (0.4 per 30 mg/0.6 ml enoxaparin subcutaneous syringe 80 (Lovenox) QL (7. per 30 mg/0.8 ml fondaparinux subcutaneous syringe 10 (Arixtra) QL (4 per 30 mg/0.8 ml fondaparinux subcutaneous syringe.5 (Arixtra) QL (15 per 30 mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) QL (1 per 30 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 (Arixtra) QL (18 per 30 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 1,500 unit/50 ml, 0,000 unit/500 ml (40 unit/ml), 5,000 unit/500 ml (50 unit/ml) (Heparin Sodium,Porcine/D5W) 46

47 heparin (porcine) in 5 % dex intravenous parenteral solution 5,000 unit/50 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin (porcine) injection solution 10,000 unit/ml heparin sodium,porcine-pf intravenous syringe 10 unit/ml heparin, porcine (pf) injection Drug Name Drug Tier Requirements/Limits (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns/PF) (Heparin PA BvD; (PA for ESRD Sodium,Porcine) Only) (Heparin PA BvD Sodium,Porcine) (Monoject Prefill Advanced) (Monoject Prefill PA BvD; (PA for ESRD Advanced) Only) heparin, porcine (pf) intravenous syringe (Monoject Prefill Advanced) heparin-0.45% nacl 5,000 units/50 ml (Heparin Sod,Pork In (100 units/ml) bag latex-free, inner 0.45% NaCl) heparin-d5w 5,000 units/50 ml (100 (Heparin units/ml) bag excel container Sodium,Porcine/D5W) IPRIVASK 5 PA; QL (4 per 8 jantoven (Coumadin) 1 PRADAXA 4 ST; QL (60 per 30 warfarin (Coumadin) 1 XARELTO 3 Blood Formation Modifiers CINRYZE 5 PA EPOGEN INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML 47 3 PA; QL (1 per 8 GRANIX 5 LEUKINE INJECTION RECON SOLN 5 MIRCERA INJECTION SYRINGE PA; QL (0.6 per 8 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL 5 NEULASTA SUBCUTANEOUS 5 SYRINGE NEUMEGA 5

48 NEUPOGEN 5 PROCRIT INJECTION SOLUTION 3 PA; QL (1 per 8 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 5 PA; QL (1 per 8 0,000 UNIT/ML PROCRIT INJECTION SOLUTION 5 PA; QL (6 per 8 40,000 UNIT/ML PROMACTA 5 PA; QL (30 per 30 Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin) 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 4 QL (60 per 30 BRILINTA 3 cilostazol (Pletal) clopidogrel (Plavix) EFFIENT 3 QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-5 4 ALBUKED-5 4 ALBUMIN, HUMAN 5 % 4 ALBUMIN, HUMAN 5 % 4 ALBUMINAR 5 % 4 ALBUMINAR 5 % 4 ALBURX (HUMAN) 5 % 4 ALBUTEIN 5 % 4 ALBUTEIN 5 % 4 BUMINATE 5 % 4 BUMINATE 5 % 4 FLEXBUMIN 5 % 4 48

49 FLEXBUMIN 5 % 4 KEDBUMIN 4 PLASBUMIN 5 % 4 PLASBUMIN 5 % 4 Caloric Agents Caloric Agents AMINO ACIDS 15 % 4 PA BvD AMINOSYN 10 % 4 PA BvD AMINOSYN 3.5 % 4 PA BvD AMINOSYN 7 % 4 PA BvD AMINOSYN 7 % WITH 4 PA BvD ELECTROLYTES AMINOSYN 8.5 % 4 PA BvD AMINOSYN 8.5 %-ELECTROLYTES 4 PA BvD AMINOSYN II 10 % 4 PA BvD AMINOSYN II 15 % 4 PA BvD AMINOSYN II 7 % 4 PA BvD AMINOSYN II 8.5 % 4 PA BvD AMINOSYN II 8.5 %-ELECTROLYTES 4 PA BvD AMINOSYN M 3.5 % 4 PA BvD AMINOSYN-HBC 7% 4 PA BvD AMINOSYN-PF 10 % 4 PA BvD AMINOSYN-PF 7 % (SULFITE-FREE) 4 PA BvD AMINOSYN-RF 5. % 4 PA BvD CLINIMIX 5%/D15W SULFITE FREE 4 PA BvD CLINIMIX 5%/D5W SULFITE-FREE 4 PA BvD CLINIMIX.75%/D5W SULFIT FREE 4 PA BvD CLINIMIX 4.5%/D10W SULF FREE 4 PA BvD CLINIMIX 4.5%/D5W SULFIT FREE 4 PA BvD CLINIMIX 4.5%-D0W SULF-FREE 4 PA BvD CLINIMIX 4.5%-D5W SULF-FREE 4 PA BvD CLINIMIX 5%-D0W(SULFITE-FREE) 4 PA BvD CLINIMIX E.75%/D10W SUL FREE 4 PA BvD CLINIMIX E.75%/D5W SULF FREE 4 PA BvD CLINIMIX E 4.5%/D10W SUL FREE 4 PA BvD CLINIMIX E 4.5%/D5W SUL FREE 4 PA BvD CLINIMIX E 4.5%/D5W SULF FREE 4 PA BvD 49

50 CLINIMIX E 5%/D15W SULFIT FREE 4 PA BvD CLINIMIX E 5%/D0W SULFIT FREE 4 PA BvD CLINIMIX E 5%/D5W SULFIT FREE 4 PA BvD CLINISOL SF 15 % 4 PA BvD cysteine (l-cysteine) intravenous solution (Cysteine HCl) PA BvD d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD intravenous Water) dextrose.5 % in water(d.5w) (Dextrose.5 % in PA BvD Water) dextrose 0 % in water (d0w) (Dextrose 0 % in PA BvD Water) dextrose 5 % in water (d5w) (Dextrose 5 % 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 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) FREAMINE HBC 6.9 % 4 PA BvD FREAMINE III 10 % 4 PA BvD HEPATAMINE 8% 4 PA BvD HEPATASOL 8 % 4 PA BvD INTRALIPID INTRAVENOUS 4 PA BvD EMULSION 0 %, 30 % KABIVEN 4 PA BvD LIPOSYN II 4 PA BvD LIPOSYN III 4 PA BvD NEPHRAMINE 5.4 % 4 PA BvD NUTRILIPID 4 PA BvD PERIKABIVEN 4 PA BvD PREMASOL 10 % 4 PA BvD PREMASOL 6 % 4 PA BvD 50

51 PROCALAMINE 3% 4 PA BvD PROSOL 0 % 4 PA BvD TRAVASOL 10 % 4 PA BvD TROPHAMINE 10 % 4 PA BvD TROPHAMINE 6% 4 PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) 1 clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidone) clonidine transdermal patch weekly 0.1 (Catapres-Tts 1) QL (4 per 8 mg/4 hr, 0. mg/4 hr clonidine transdermal patch weekly 0.3 (Catapres-Tts 1) QL (8 per 8 mg/4 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) NORTHERA 5 PA; QL (180 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) Angiotensin Ii Receptor Antagonists BENICAR 3 ST BENICAR HCT 3 ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) 1 losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR 3 ST valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) 1 51

52 benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) captopril-hydrochlorothiazide (Captopril/Hydrochlorot hiazide) enalapril maleate (Vasotec) 1 enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydrochloro thiazide) lisinopril (Zestril) 1 lisinopril-hydrochlorothiazide (Zestoretic) 1 moexipril (Moexipril HCl) moexipril-hydrochlorothiazide (Moexipril/Hydrochlorot hiazide) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 00 (Cordarone) mg, 400 mg amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Tambocor) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) ml (1 %) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine (Mexiletine HCl) MULTAQ 3 procainamide injection (Procainamide HCl) propafenone oral capsule,extended release (Rythmol SR) 1 hr propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) 5

53 TIKOSYN 3 Beta-Adrenergic Blocking Agents acebutolol oral (Sectral) atenolol (Tenormin) 1 atenolol-chlorthalidone (Tenoretic 50) 1 betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC 3 carvedilol (Coreg) 1 esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Labetalol HCl) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Lopressor) metoprolol tartrate oral (Lopressor) 1 nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 4 hr propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydrochlor othiazid) sotalol hcl oral tablet 10 mg, 160 mg, (Betapace) 40 mg, 80 mg sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) diltiazem hcl oral capsule, extended (Cardizem CD) release 180 mg, 360 mg, 40 mg diltiazem hcl oral capsule,extended release 1 hr (Cardizem CD) 53

54 diltiazem hcl oral capsule,extended (Cardizem CD) release 4hr diltiazem hcl oral tablet (Cardizem CD) 1 diltiazem hcl oral tablet extended release (Cardizem LA) 4 hr dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 4 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 4 (Verelan) hr verapamil oral tablet (Calan) 1 verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous DEMSER 5 digitek oral tablet 15 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (30 per 30 digitek oral tablet 50 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION 3 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 15mcg Per Day); QL (30 per 30 dobutamine in d5w intravenous parenteral (Dobutamine HCl/D5W) PA BvD solution 1,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml (1 mg/ml), 500 mg/50 ml (,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) PA BvD 54

55 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 injection auto-injector (Adrenaclick) epinephrine injection solution (Epinephrine) epinephrine injection syringe 0.1 mg/ml (Epinephrine) (1:10,000) EPIPEN -PAK 3 EPIPEN JR -PAK 3 ethamolin (Ethanolamine Oleate) FIRAZYR 5 hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET MCG, 6.5 MCG 4 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (30 per 30 milrinone (Milrinone Lactate) 5 PA BvD milrinone in 5 % dextrose intravenous (Milrinone 5 PA BvD piggyback 40 mg/00 ml (00 mcg/ml) Lactate/D5W) norepinephrine bitartrate (Levophed Bitartrate) PA BvD papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA 3 Dihydropyridines amlodipine (Norvasc) 1 amlodipine-benazepril (Lotrel) amlodipine-valsartan (Exforge) amlodipine-valsartan-hcthiazid (Exforge HCT) AZOR 3 ST CLEVIPREX INTRAVENOUS 4 EMULSION felodipine (Felodipine) isradipine (Isradipine) nicardipine oral (Nicardipine HCl) 55

56 nifedipine oral tablet extended release (Adalat CC) 4hr 30 mg nifedipine oral tablet extended release (Procardia XL) 4hr 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) 1 chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 5 mg, 50 mg (Chlorthalidone) 1 DYRENIUM 4 furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) 1 hydrochlorothiazide oral capsule (Microzide) 1 hydrochlorothiazide oral tablet (Hydrochlorothiazide) 1 indapamide (Indapamide) 1 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 (Cholestyramine/Asparta packet 4 gram me) colestipol (Colestid) CRESTOR 3 fenofibrate micronized (Lofibra) 56

57 fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) JUXTAPID 5 PA KYNAMRO 5 PA; QL (4 per 8 lovastatin (Mevacor) 1 niacin oral tablet extended release 4 hr (Niaspan) omega-3 acid ethyl esters (Lovaza) pravastatin (Pravachol) 1 simvastatin (Zocor) 1 QL (30 per 30 VASCEPA 3 ZETIA 4 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) 1 isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 4 hr minitran transdermal patch 4 hour 0.1 (Nitro-Dur) QL (30 per 30 mg/hr, 0. mg/hr, 0.6 mg/hr minitran transdermal patch 4 hour 0.4 (Nitro-Dur) QL (60 per 30 mg/hr minoxidil oral (Minoxidil) NITRO-BID 3 nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 4 hour (Nitro-Dur) QL (30 per mg/hr, 0. mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 4 hour (Nitro-Dur) QL (60 per mg/hr NITROSTAT 3 57

58 PROGLYCEM 4 Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA 5 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) 1 hr dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, extended (Dexedrine) QL (10 per 30 release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (30 per 30 capsule,extended release 4hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 30 capsule,extended release 4hr 0 mg, 5 mg, 30 mg flumazenil (Romazicon) guanfacine oral tablet extended release 4 (Intuniv) hr lithium carbonate oral capsule (Lithium Carbonate) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended (Lithobid) release lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic (Metadate Cd) QL (30 per mg, 0 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (30 per mg, 40 mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral solution (Methylin) QL (900 per 30 58

59 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet extended (Methylphenidate HCl) QL (90 per 30 release methylphenidate oral tablet extended (Concerta) QL (30 per 30 release 4hr 18 mg, 7 mg, 54 mg methylphenidate oral tablet extended (Concerta) QL (60 per 30 release 4hr 36 mg NUEDEXTA 3 QL (60 per 30 QUILLIVANT XR 3 riluzole (Rilutek) SAVELLA 3 QL (60 per 30 STRATTERA 3 XENAZINE 5 PA; QL (11 per 8 Contraceptives Contraceptives ashlyna (Seasonique) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet (Desogen) 0.1/.15/.15-5 mg-mcg, mg drospirenone-ethinyl estradiol (Yaz) ELLA 4 QL (6 per 365 ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl Estradiol) gildess 4 fe (Loestrin Fe) junel fe 4 (Loestrin Fe) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 larin 4 fe (Loestrin Fe) levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (1 per 365 levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel-ethin estradiol oral tablet (Amethyst) mg-mcg, mg, (6)/75-40 (5)/15-30(10) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethin QL (91 per 84 tablets,dose pack,3 month mg-mcg Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) 59

60 levonorgestrel-ethinyl estrad oral tablet (Amethyst) QL (91 per mg levonorgestrel-ethinyl estrad oral (Amethyst) QL (91 per 84 tablets,dose pack,3 month l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 8 norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet (Loestrin) 1-0 mg-mcg, mg-mcg norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) 1 mg-0 mcg (1)/75 mg (7), 1 mg-0 mcg (4)/75 mg (4), 1-0(5)/1-30(7) /1mg- 35mcg (9), 1.5 mg-30 mcg (1)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) mg-mcg, mg-mcg, /1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING 3 ST; QL (1 per 8 tarina fe (Loestrin Fe) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous (Peridex) membrane mouthwash 0.1 % pilocarpine hcl oral (Salagen) sodium fluoride oral tablet,chewable 0.5 (Sodium Fluoride) mg fluorid (0.55 mg) triamcinolone acetonide dental (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP 4 acitretin (Soriatane) 5 60

61 acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS 1 ALCOHOL PREP PADS 1 ammonium lactate (Lac-Hydrin) ANACAINE 4 calcipotriene topical cream (Dovonex) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CONDYLOX TOPICAL GEL 4 COSENTYX ( SYRINGES) 5 PA COSENTYX PEN 5 PA COSENTYX PEN ( PENS) 5 PA FLUOROPLEX 4 fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) imiquimod (Aldara) PA NSO; QL (4 per 30 isotretinoin oral capsule 10 mg, 0 mg, 30 (Isotretinoin) mg, 40 mg methoxsalen rapid (Oxsoralen-Ultra) 5 PANRETIN 5 PICATO TOPICAL GEL % 3 QL (3 per 56 PICATO TOPICAL GEL 0.05 % 3 QL ( per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL 4 VALCHLOR 5 ZOVIRAX TOPICAL CREAM 3 QL (15 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) 61

62 erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) erythromycin with ethanol topical swab (Erythromycin Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate applicators (Silver Nitrate Applicator) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone (Alclometasone Dipropionate) betamethasone dipropionate (Betamethasone 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) % 6

63 clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Clobetasol Propionate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) desonide topical cream (Desowen) desonide topical ointment (Desonide) desoximetasone (Topicort) ELIDEL 3 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 1% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera topical gel (Hydrocortisone Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate topical cream (Hydrocortisone Butyrate) hydrocortisone butyrate topical ointment (Locoid) hydrocortisone butyrate topical solution (Locoid) hydrocortisone butyr-emollient (Hydrocortisone Butyrate) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone topical cream 1 %,.5 % (Anusol-HC) hydrocortisone topical lotion %,.5 % (Scalacort) 63

64 hydrocortisone topical ointment 1 %,.5 (Hydrocortisone) % hydrocortisone valerate topical cream (Hydrocortisone Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) ONFI ORAL SUSPENSION 4 PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 0 MG 4 PA NSO; QL (60 per 30 prednicarbate (Dermatop) tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Triamcinolone Acetonide) (Triamcinolone Acetonide) triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 4 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 ECLIPSE LUER-LOK SYRINGE 1 ML 7 X 1/" BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/ ML 31 X 5/16" 64

65 INSULIN PEN NEEDLE NEEDLE 9 GAUGE X 1/ " INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 9, 1 ML 9 X 1/", 1/ ML 8 Drug Name Drug Tier Requirements/Limits VGO 40 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN 5 ALDURAZYME 5 CEREZYME INTRAVENOUS RECON 5 SOLN 400 UNIT CREON 3 ELAPRASE 5 ELITEK INTRAVENOUS RECON 5 SOLN FABRAZYME INTRAVENOUS RECON 5 SOLN KRYSTEXXA 5 KUVAN ORAL TABLET,SOLUBLE 5 lipase-protease-amylase (Zenpep) MYOZYME 5 NAGLAZYME 5 ORFADIN 5 PULMOZYME 5 PA BvD VIMIZIM 5 PA VPRIV 5 ZAVESCA 5 QL (90 per 30 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-68, ,000 UNIT, 5,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, ,000-18,000 UNIT 3 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) 4 65

66 altacaine (Tetcaine) apraclonidine (Iopidine) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) azelastine nasal aerosol,spray (Astepro) QL (30 per 5 azelastine ophthalmic (Azelastine HCl) carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS % cyclopentolate (Cyclogyl) CYSTARAN 5 epinastine (Elestat) homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (30 per % ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (15 per % LACRISERT 3 naphazoline (Naphazoline HCl) 1 phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluorescei n Sod) tetracaine hcl (pf) ophthalmic (Tetracaine HCl/PF) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B Sulfate) CIPRODEX 3 ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S 4 erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) 66

67 gentamicin sulfate ophthalmic ointment (Garamycin) 0.3 % (3 mg/gram) levofloxacin ophthalmic (Levofloxacin) MOXEZA 3 NATACYN 3 neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-polymyxin (Neomycin Su/Bacitra/Polymyxin) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B Sulf/HC) neomycin-polymyxin-hc otic (Neomycin/Polymyxin B drops,suspension Sulf/HC) neomycin-polymyxin-hc otic solution (Cortisporin) neo-polycin (Neomycin Su/Bacitra/Polymyxin) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide-prednisolone (Sulfacetamide/Predniso lone Sp) TOBRADEX ST 3 tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX 3 ZIRGAN 4 ZYLET 3 Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX 3 ST bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) 67

68 DUREZOL 3 flunisolide nasal spray,non-aerosol 5 (Flunisolide) QL (50 per 5 mcg (0.05 %) fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Fluticasone Propionate) 1 QL (16 per 30 ILEVRO 3 ketorolac ophthalmic (Acular) LOTEMAX 3 NEVANAC 3 prednisolone acetate (Omnipred) prednisolone sodium phosphate ophthalmic (Prednisolone Sod Phosphate) PROLENSA 3 RESTASIS 3 QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION 3 cimetidine (Cimetidine) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso- Osm/PF) famotidine intravenous (Famotidine) famotidine oral tablet 0 mg, 40 mg (Pepcid) 1 (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 oral (Protonix) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) 1 (Rx Product Only) sucralfate oral suspension (Sucralfate) 68

69 sucralfate oral tablet (Carafate) Gastrointestinal Agents, Other AMITIZA 3 QL (60 per 30 BUPHENYL ORAL TABLET 5 CARBAGLU 5 cromolyn oral (Gastrocrom) 5 dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) GATTEX 30-VIAL 5 PA GATTEX ONE-VIAL 5 PA glycopyrrolate (Robinul) glycopyrrolate (Robinul) lactulose (Lactulose) LINZESS 3 QL (30 per 30 loperamide oral (Loperamide HCl) LOTRONEX 5 methscopolamine oral (Methscopolamine Bromide) metoclopramide hcl injection (Metoclopramide HCl) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) 1 MOVANTIK 3 QL (30 per 30 NUTRESTORE 4 RAVICTI 5 PA RELISTOR SUBCUTANEOUS 4 PA; QL (8 per 8 RELISTOR SUBCUTANEOUS 4 PA; QL (8 per 8 SYRINGE 8 MG/0.4 ML sodium polystyrene sulfonate oral powder (Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate oral (Sodium Polystyrene suspension 15 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema (Sodium Polystyrene 30 gram/10 ml Sulfonate) ursodiol oral capsule (Actigall) 69

70 ursodiol oral tablet (Urso) Laxatives MOVIPREP 3 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 40 gram Packs) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) PHOSLYRA 4 RENAGEL 3 RENVELA 3 Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ 3 oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended (Ditropan XL) release 4hr tolterodine oral capsule,extended release 4hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ 3 trospium (Trospium Chloride) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) 1 Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS 5 70

71 EXJADE ORAL TABLET, 4 DISPERSIBLE 15 MG EXJADE ORAL TABLET, 5 DISPERSIBLE 50 MG, 500 MG FERRIPROX 5 sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 1.5 gram/50 ml (50 mg/ml) (Sodium Thiosulfate) SYPRINE 5 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM 3 PA; QL (30 per 30 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) 3 PA; QL (150 per 30 ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM), 1.6 % (40.5 MG/.5 GRAM) 3 PA; QL (150 per 30 danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo-Testosterone) PA testosterone enanthate (Delatestryl) PA; QL (5 per 8 testosterone transdermal gel in packet 1 % (5 mg/.5gram) (Androgel) PA; QL (300 per 30 Estrogens And Antiestrogens COMBIPATCH 3 PA-HRM; QL (8 per 8 DUAVEE 3 PA-HRM ESTRACE VAGINAL 3 estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) PA-HRM; QL (8 per 8 estradiol transdermal patch weekly (Climara) PA-HRM; QL (4 per 8 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM 71

72 estropipate (Estropipate) PA-HRM FEMRING 4 QL (1 per 84 MENEST 4 PA-HRM PREMARIN INJECTION 3 PREMARIN ORAL 3 PA-HRM PREMARIN VAGINAL 3 PREMPHASE 3 PA-HRM PREMPRO 3 PA-HRM raloxifene (Evista) VAGIFEM 3 QL (18 per 8 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) 1 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 15 mg, 40 mg methylprednisolone sodium succ (A-Methapred) PA BvD intravenous prednisolone sodium phosphate oral (Pediapred) PA BvD solution prednisone oral solution (Prednisone) PA BvD prednisone oral tablet (Prednisone) 1 PA BvD prednisone oral tablets,dose pack (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION 4 PA BvD RECON SOLN 100 MG/ ML triamcinolone acetonide injection Pituitary (Triamcinolone Acetonide) 7

73 desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (15 per 30 desmopressin nasal (Desmopressin Acetate) QL (15 per 30 desmopressin oral (DDAVP) GENOTROPIN 5 PA GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0. MG/0.5 ML GENOTROPIN MINIQUICK 5 PA SUBCUTANEOUS SYRINGE 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, 1 MG/0.5 ML, 1. MG/0.5 ML, 1.4 MG/0.5 ML, 1.6 MG/0.5 ML, 1.8 MG/0.5 ML, MG/0.5 ML INCRELEX 5 LUPRON DEPOT-PED 5 LUPRON DEPOT-PED (3 MONTH) 5 QL (1 per 84 INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO 5 PA NORDITROPIN NORDIFLEX 5 PA octreotide acetate injection solution 1,000 (Sandostatin) 5 mcg/ml octreotide acetate injection solution 100 (Sandostatin) mcg/ml, 00 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) SAIZEN 5 PA SAIZEN CLICK.EASY 5 PA SANDOSTATIN LAR DEPOT 5 INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON 5 PA SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT 5 QL (1 per 8 SOMAVERT 5 SUPPRELIN LA 5 QL (1 per 360 Progestins 73

74 DEPO-PROVERA INTRAMUSCULAR SOLUTION Drug Name Drug Tier Requirements/Limits 4 QL (10 per 8 medroxyprogesterone intramuscular (Depo-Provera) QL (1 per 84 medroxyprogesterone oral (Provera) MEGACE ES 5 megestrol oral suspension (Megace Es) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) 1 liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST 5 ASTAGRAF XL 4 PA BvD AUBAGIO 5 PA; QL (8 per 8 azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine Sodium) PA BvD CARIMUNE NF NANOFILTERED 5 PA BvD INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS 4 PA BvD CIMZIA 5 PA CIMZIA POWDER FOR RECONST 5 PA cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL 5 PA ENBREL SURECLICK 5 PA FLEBOGAMMA DIF 5 PA BvD GAMASTAN S/D 3 PA BvD GAMMAGARD LIQUID 5 PA BvD GAMMAPLEX 5 PA BvD 74

75 HUMIRA 5 PA HUMIRA CROHN'S DIS START PCK 5 PA HUMIRA PEN 5 PA HYQVIA 5 PA BvD ILARIS (PF) 5 PA IMOGAM RABIES-HT (PF) 4 KINERET 5 PA; QL (18.76 per 8 leflunomide (Arava) mycophenolate mofetil oral capsule (Cellcept) PA BvD mycophenolate mofetil oral suspension for (Cellcept) 5 PA BvD reconstitution mycophenolate mofetil oral tablet (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX 5 PA BvD OCTAGAM 5 PA BvD ORENCIA 5 PA ORENCIA (WITH MALTOSE) 5 PA PRIVIGEN 5 PA BvD PROGRAF INTRAVENOUS 4 PA BvD RAPAMUNE ORAL SOLUTION 5 PA BvD RIDAURA 5 sirolimus oral tablet 0.5 mg, 1 mg (Rapamune) PA BvD sirolimus oral tablet mg (Rapamune) 5 PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI 5 PA; LA; QL (15 per 8 ZORTRESS ORAL TABLET 0.5 MG 4 PA BvD; QL (10 per 30 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 PA BvD; QL (10 per 30 Vaccines ACTHIB (PF) 3 (Vaccine for Haemophilus B ADACEL(TDAP ADOLESN/ADULT)(PF) Conjugate) 3 (Vaccine for Tetanus, Diphtheria, and Pertussis [Tdap]) 75

76 BCG VACCINE, LIVE (PF) 3 PA BvD; (Vaccine for Tuberculosis) BEXSERO (PF) 3 BOOSTRIX TDAP 3 (Vaccine for Tetanus, Diphtheria, and Pertussis [Tdap]) CERVARIX VACCINE (PF) 3 (Vaccine for Human Papillomavirus 16, 18) COMVAX (PF) 3 (Vaccine for Haemophilus B Conjugate/Hepatitis B) DAPTACEL (DTAP PEDIATRIC) (PF) 3 (Vaccine for Pertussis, Diphtheria, and Tetanus [Dtap]) ENGERIX-B (PF) 3 PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 ENGERIX-B PEDIATRIC (PF) 3 PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 GARDASIL (PF) 3 (Vaccine for Human Papillomavirus 6, 11, 16, 18); QL (1.5 per 365 GARDASIL 9 (PF) 3 (Vaccine for Human Papillomavirus 6, 11, 16, 18); QL (1.5 per 365 HAVRIX (PF) INTRAMUSCULAR 3 (Vaccine for Hepatitis A) SUSPENSION HAVRIX (PF) INTRAMUSCULAR 3 (Vaccine for Hepatitis A) SYRINGE IMOVAX RABIES VACCINE (PF) 3 PA BvD; (Vaccine for Rabies) INFANRIX (DTAP) (PF) INTRAMUSCULAR 3 (Vaccine for Tetanus, Diphtheria, and Pertussis [Td/Tdap]) IPOL INJECTION SUSPENSION 3 (Vaccine for Polio) IPOL INJECTION SYRINGE 3 76

77 IXIARO (PF) 3 (Vaccine for Japanese Encephalitis) KINRIX (PF) INTRAMUSCULAR 3 SUSPENSION KINRIX (PF) INTRAMUSCULAR SYRINGE 3 (Vaccine for Diphtheria/Tetanus/Pertu ssis/polio) MENACTRA (PF) INTRAMUSCULAR SOLUTION 3 (Vaccine for Meningococcal Diphtheria) MENHIBRIX (PF) 3 (Vaccine for Haemophilus B/Tetanus Toxoid Conjugate) MENOMUNE - A/C/Y/W-135 (PF) 3 (Vaccine for Meningococcal Polysaccharide) MENVEO A-C-Y-W-135-DIP (PF) 3 (Vaccine for Meningococcal Oligosaccharide/Diphthe ria) MENVEO MENA COMPONENT (PF) 3 (Vaccine for Polio) MENVEO MENCYW-135 COMPNT (PF) 3 (Vaccine for Meningococcal Oligosaccharide/Diphthe ria) M-M-R II (PF) 3 (Vaccine for Measles/Mumps/Rubella ); QL ( per 365 PEDIARIX (PF) 3 PEDVAX HIB (PF) 3 (Vaccine for Haemophilis B Conjugate) PENTACEL (PF) 3 (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) PENTACEL ACTHIB COMPONENT (PF) 3 (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) 77

78 PENTACEL DTAP-IPV COMPNT (PF) 3 (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) PROQUAD (PF) 3 (Vaccine for Measles/Mumps/Rubella /Varicella); QL ( per 365 QUADRACEL (PF) 3 RABAVERT (PF) 3 PA BvD; (Vaccine for Rabies) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 3 PA BvD; (Vaccine for Hepatitis B); QL (3 per PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 ROTARIX 3 ROTATEQ VACCINE 3 (Vaccine for Rotavirus) TENIVAC (PF) INTRAMUSCULAR 3 (Vaccine for Tetanus and Diphtheria [Td]) TETANUS TOXOID,ADSORBED (PF) 3 PA BvD; (Vaccine for Tetanus) TETANUS,DIPHTHERIA TOX PED(PF) 3 (Vaccine for Tetanus and Diphtheria [DT]) TETANUS-DIPHTHERIA TOXOIDS-TD 3 (Vaccine for Tetanus and Diphtheria [Td]) TICE BCG 3 PA BvD; (Vaccine for Tuberculosis) TRUMENBA 3 TWINRIX (PF) 3 (Vaccine for Hepatitis A/Hepatitis B) TYPHIM VI INTRAMUSCULAR 3 (Vaccine for Typhoid VI) VAQTA (PF) 3 (Vaccine for Hepatitis A) VARIVAX (PF) 3 (Vaccine for Varicella); QL ( per 365 YF-VAX (PF) 3 (Vaccine for Yellow Fever) 78

79 ZOSTAVAX (PF) 3 (Vaccine for Shingles); QL (1 per 365 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO 3 ASACOL HD 3 balsalazide (Colazal) budesonide oral (Entocort EC) 5 DELZICOL 3 DIPENTUM 4 ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) LACTATED RINGERS IRRIGATION 3 ringers irrigation (Ringers Solution) sodium chloride irrigation (Sodium Chloride Irrig Solution) 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 8 alendronate oral tablet 10 mg, 40 mg, 5 (Fosamax) 1 mg alendronate oral tablet 35 mg, 70 mg (Fosamax) 1 QL (4 per 8 calcitonin (salmon) (Miacalcin) QL (3.7 per 8 calcitriol intravenous solution 1 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) 79

80 FORTEO 4 PA; QL (.4 per 8 FORTICAL 4 QL (3.7 per 8 ibandronate intravenous solution (Ibandronate Sodium) PA BvD; (PA for ESRD Only); QL (3 per 84 ibandronate oral (Boniva) QL (1 per 8 MIACALCIN INJECTION 3 PA BvD; (PA for ESRD Only) NATPARA 5 PA; QL ( per 8 paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA 3 QL (1 per 180 risedronate oral tablet 150 mg (Actonel) QL (1 per 8 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 8 ZEMPLAR INTRAVENOUS 3 PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS (Zoledronic Acid/Mannitol and Water) (Reclast) QL (100 per PA BvD 5 PA SOLUTION 00 MG/10 ML (0 MG/ML) ACTEMRA SUBCUTANEOUS 5 PA ACTIMMUNE 5 allopurinol (Zyloprim) amifostine crystalline (Ethyol) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVONEX (WITH ALBUMIN) 5 ST AVONEX INTRAMUSCULAR 5 ST AVONEX INTRAMUSCULAR 5 ST 80

81 BENLYSTA INTRAVENOUS RECON 5 PA SOLN BETASERON SUBCUTANEOUS 5 ST bethanechol chloride (Urecholine) buspirone (Buspirone HCl) CERDELGA 5 PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Probenecid) COPAXONE SUBCUTANEOUS 5 SYRINGE CYSTADANE 5 droperidol injection solution (Droperidol) ELMIRON 4 ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS 5 ST finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) 5 FUSILEV 5 GAUZE PAD TOPICAL BANDAGE X 1 " GILENYA 5 PA; QL (8 per 8 GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 4 (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN 3 QL (30 per 30 LEMTRADA 5 PA leucovorin calcium injection recon soln (Leucovorin Calcium) 100 mg, 00 mg, 350 mg leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine (With Sugar)) PA BvD; (PA for ESRD Only) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) 81

82 mesna (Mesnex) MESNEX ORAL 5 MESTINON ORAL SYRUP 4 MESTINON TIMESPAN 4 morrhuate sodium (Sodium Morrhuate) OTEZLA 5 PA; QL (60 per 30 OTEZLA STARTER 5 PA; QL (60 per 30 OTREXUP (PF) 3 PLEGRIDY 5 ST probenecid (Probenecid) PROCYSBI 5 pyridostigmine bromide oral tablet (Mestinon) RASUVO (PF) 3 REBIF (WITH ALBUMIN) 5 REBIF REBIDOSE 5 REBIF TITRATION PACK 5 REMICADE 5 PA SENSIPAR ORAL TABLET 30 MG 3 SENSIPAR ORAL TABLET 60 MG, 90 5 MG SIGNIFOR 5 QL (60 per 30 SIMPONI ARIA 5 PA SIMPONI SUBCUTANEOUS SYRINGE 5 PA STELARA SUBCUTANEOUS 5 PA SYRINGE STERILE PADS TOPICAL BANDAGE 1 X " SYNAREL 5 TECFIDERA ORAL 5 PA; QL (14 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 10 MG TECFIDERA ORAL 5 PA; QL (60 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 10 MG (14)- 40 MG (46), 40 MG THALOMID 5 PA NSO; QL (60 per 30 TYBOST 4 QL (30 per 30 8

83 ULORIC 3 ST; QL (30 per 30 XELJANZ 5 PA; QL (60 per 30 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended (Diamox Sequels) release acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS % AZOPT 3 betaxolol ophthalmic (Betaxolol HCl) brimonidine (Alphagan P) (drops: 0.15%, 0.0%) COMBIGAN 3 dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC DROPS QL (.5 per 5 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE 3 pilocarpine hcl ophthalmic drops 1 %, (Isopto Carpine) %, 4 % SIMBRINZA 3 timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming (Timoptic-Xe) solution TRAVATAN Z 3 QL (.5 per 5 travoprost (benzalkonium) (Travoprost (Benzalkonium)) QL (.5 per 5 Replacement Preparations Replacement Preparations calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD Only) 83

84 citric acid-sodium citrate (Citric Acid/Sodium Citrate) d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % NaCl) d.5 %-0.45 % sodium chloride (Dextrose.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) dextrose 10 % and 0. % nacl (Dextrose 10 % and 0. % NaCl) dextrose 5 %-lactated ringers (Dextrose 5%-Lactated Ringers) dextrose 5%-0. % sod chloride (Dextrose 5 %-0. % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose with sodium chloride (Dextrose 5 %-0. % NaCl) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) HYPERLYTE CR 4 IONOSOL-B IN D5W 4 IONOSOL-MB IN D5W 4 ISOLYTE M IN 5 % DEXTROSE 4 ISOLYTE-H IN 5 % DEXTROSE 4 ISOLYTE-P IN 5 % DEXTROSE 4 ISOLYTE-S 4 klor-con 10 (Potassium Chloride) klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m0 (Potassium Chloride) magnesium chloride injection (Magnesium Chloride) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml (Magnesium Sulfate/D5W) 84

85 magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) Drug Name Drug Tier Requirements/Limits (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) NORMOSOL-M IN 5 % DEXTROSE 4 NORMOSOL-R PH NUTRILYTE 4 NUTRILYTE II 4 phosphorus #1 (K-Phos Neutral) PLASMA-LYTE PLASMA-LYTE A 4 PLASMA-LYTE-56 IN 5 % DEXTROSE 4 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 5 meq potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid (Potassium Chloride) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended (K-Tab ER) release potassium chloride oral tablet,er particles/crystals 10 meq (K-Tab ER) 85

86 potassium chloride oral tablet,er (Potassium Chloride) particles/crystals 0 meq potassium chloride-0.45 % nacl (Potassium Chloride- 0.45% NaCl) potassium chloride-d5-0.%nacl (Potassium Chloride/D5-0.%NaCl) potassium chloride-d5-0.3%nacl (Potassium Chloride/D5- intravenous parenteral solution 0 meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) potassium citrate (Urocit-K) potassium citrate-citric acid oral packet (Potassium Citrate/Citric Acid) potassium phosphate dibasic (Potassium Phos,M- Basic-D-Basic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous solution 1 (Sodium Bicarbonate) meq/ml (8.4 %) sodium bicarbonate intravenous syringe (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) 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 4 TPN ELECTROLYTES II 4 86

87 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 3 QL (60 per 30 ADVAIR HFA 3 QL (1 per 8 BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE 3 QL (60 per 30 DULERA 3 QL (13 per 8 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION 3 QL (60 per 30 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION 3 QL (10 per 30 FLOVENT HFA INHALATION HFA 3 QL (1 per 8 AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (4 per 8 AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (1. per 8 AEROSOL INHALER 44 MCG/ACTUATION QVAR 3 QL (17.4 per 5 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) albuterol sulfate oral tablet extended (Vospire ER) release 1 hr ATROVENT HFA 3 QL (5.8 per 8 COMBIVENT RESPIMAT 3 QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) 87

88 PROAIR HFA 3 QL (17 per 5 PROAIR RESPICLICK 3 QL ( per 30 SEREVENT DISKUS 3 QL (60 per 30 SPIRIVA RESPIMAT 3 QL (4 per 30 SPIRIVA WITH HANDIHALER 3 QL (30 per 30 STRIVERDI RESPIMAT 3 terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet extended release 1 hr 100 mg, 00 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 00 mg/100 ml, 00 mg/50 ml, 400 mg/50 ml, 400 mg/500 ml, 800 mg/50 ml theophylline oral theophylline oral theophylline oral (Theophylline Anhydrous) (Theophylline/D5W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) TUDORZA PRESSAIR 3 QL (1 per 8 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD cromolyn inhalation (Cromolyn Sodium) PA BvD DALIRESP 3 QL (30 per 30 ESBRIET 5 PA; QL (70 per 30 KALYDECO 5 PA; QL (60 per 30 OFEV 5 PA PROLASTIN-C 5 XOLAIR 5 PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (10 per 30 88

89 chlorzoxazone (Parafon Forte DSC) PA-HRM cyclobenzaprine oral tablet 10 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 HETLIOZ 5 PA NUVIGIL 3 PA ROZEREM 3 XYREM 5 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 89

90 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 Vasodilating Agents Vasodilating Agents ADCIRCA 5 PA; QL (60 per 30 ADEMPAS 5 PA; QL (90 per 30 epoprostenol (glycine) intravenous recon (Flolan) PA BvD soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) 5 PA BvD soln 1.5 mg LETAIRIS 5 PA; QL (30 per 30 OPSUMIT 5 PA; QL (30 per 30 ORENITRAM ORAL TABLET 3 PA EXTENDED RELEASE 0.15 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.5 MG, 1 MG,.5 MG 5 PA REMODULIN 5 PA BvD sildenafil intravenous (Revatio) 5 PA; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 TRACLEER 5 PA; LA; QL (60 per 30 TYVASO 5 PA BvD TYVASO REFILL KIT 5 PA BvD TYVASO STARTER KIT 5 PA BvD Vitamins And Minerals Vitamins And Minerals pedi m.vit no.17 with fluoride oral tablet,chewable 0.5 mg prenatal vitamins oral tablet 7 mg iron- 1 mg (Pedi M.Vit No.17 with Fluoride) (Pnv with Ca,No.7/Iron/Fa) 3 (All Rx Prenatal Vitamins Covered) 90

91 sodium fluoride oral tablet (Pedi M.Vit No.17 with Fluoride) 91

92 INDEX 8 8-MOP A abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE... 5 acamprosate acarbose acebutolol acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid... 66, 79 acetylcysteine acitretin ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 45, 61 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 75 ADAGEN adapalene ADCETRIS... 5 ADCIRCA adefovir ADEMPAS ADVAIR DISKUS ADVAIR HFA AFINITOR... 5 AFINITOR DISPERZ... 5 AGGRENOX AKTEN (PF) ALBENZA... 39, 40 ALBUKED ALBUKED ALBUMIN, HUMAN 5 %.. 48 ALBUMIN, HUMAN 5 % ALBUMINAR 5 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 5 % ALBUTEIN 5 % albuterol sulfate alclometasone... 6 ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME alendronate alfuzosin ALIMTA... 5 ALINIA allopurinol ALPHAGAN P alprazolam... 18, 19 ALREX altacaine amantadine hcl AMBISOME amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone... 5 amiodarone hcl... 5 AMITIZA amitriptyline... 3, 33 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 3 amoxicillin-pot clavulanate... 3 amphetamine salt combo amphotericin b ampicillin... 3 ampicillin sodium... 3 ampicillin-sulbactam... 3 AMPYRA ANACAINE anagrelide I-1

93 anastrozole... 5 ANDRODERM ANDROGEL anticoag citrate phos dextrose 80 APOKYN apraclonidine APRISO APTIOM APTIVUS ARCALYST aripiprazole ASACOL HD ashlyna ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 30, 66 ATROVENT HFA AUBAGIO AVASTIN... 5 AVC VAGINAL AVONEX AVONEX (WITH ALBUMIN) azacitidine... 5 azathioprine azathioprine sodium azelastine AZILECT azithromycin... AZOPT AZOR aztreonam... 3 B bacitracin... 19, 66 bacitracin-polymyxin b baclofen balsalazide BANZEL BCG VACCINE, LIVE (PF). 76 BD ECLIPSE LUER-LOK BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BELEODAQ... 5 benazepril benazepril-hydrochlorothiazide... 5 BENICAR BENICAR HCT BENLYSTA benztropine betamethasone acet,sod phos. 7 betamethasone dipropionate.. 6 betamethasone valerate... 6 betamethasone, augmented... 6 BETASERON betaxolol... 53, 83 bethanechol chloride BETHKIS BEXSERO (PF) bicalutamide... 5 BICILLIN C-R... 3 BICILLIN L-A... 3 bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin... 5 BLINCYTO... 5 BOOSTRIX TDAP BOSULIF... 5 BREO ELLIPTA BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine budesonide bumetanide BUMINATE 5 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 14, 18 buprenorphine-naloxone bupropion hcl... 18, 33 buspirone butalb-acetaminophen-caffeine butalbital-acetaminop-caf-cod 14 butalbital-acetaminophen butalbital-acetaminophen-caff 14 butalbital-aspirin-caffeine BUTRANS BYSTOLIC C cabergoline caffeine citrated caffeine-sodium benzoate calcipotriene calcitonin (salmon) calcitriol... 61, 79 calcium acetate calcium carbonate-mag carb-fa calcium chloride calcium gluconate CALDOLOR CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA... 5 captopril... 5 captopril-hydrochlorothiazide 5 CARAFATE CARBAGLU carbamazepine carbidopa I-

94 carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CAYSTON... 3 cefaclor... 1 cefadroxil... 1 cefazolin... 1 cefazolin in dextrose (iso-os). 1 cefdinir... 1 cefditoren pivoxil... 1 cefepime... 1 CEFEPIME IN DEXTROSE 5 %... 1 CEFEPIME IN DEXTROSE,ISO-OSM... 1 cefotaxime... 1 cefoxitin... 1 cefoxitin in dextrose, iso-osm 1 cefpodoxime... 1 cefprozil... 1 ceftazidime... 1 ceftibuten... 1 ceftriaxone... CEFTRIAXONE... ceftriaxone in dextrose,iso-os. 1 CEFTRIAXONE IN DEXTROSE,ISO-OS... 1 cefuroxime axetil... cefuroxime sodium... cefuroxime-dextrose (iso-osm)... celecoxib CELLCEPT INTRAVENOUS CELONTIN cephalexin... CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) 76 cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar).. 56 cholestyramine-aspartame choline,magnesium salicylate 16 ciclopirox ciclopirox-ure-camph-mentheuc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRODEX ciprofloxacin... 4 ciprofloxacin hcl... 4, 66 ciprofloxacin in 5 % dextrose 4 ciprofloxacin lactate... 4 citalopram citric acid-sodium citrate clarithromycin... CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 0 clindamycin palmitate hcl... 0 clindamycin phosphate... 0, 38, 61 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%/D5W SULFIT FREE CLINIMIX 4.5%-D0W SULF-FREE CLINIMIX 4.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE) CLINIMIX E.75%/D10W SUL FREE CLINIMIX E.75%/D5W SULF FREE CLINIMIX E 4.5%/D10W SUL FREE CLINIMIX E 4.5%/D5W SUL FREE CLINIMIX E 4.5%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D0W SULFIT FREE CLINIMIX E 5%/D5W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol propionate... 6 I-3

95 clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 51, 58 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate codeine-butalbital-asa-caffein 14 colchicine colchicine-probenecid colestipol colistin (colistimethate na)... 0 COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ... 6 COMPLERA COMVAX (PF) CONDYLOX COPAXONE cortisone... 7 COSENTYX ( SYRINGES) 61 COSENTYX PEN COSENTYX PEN ( PENS).. 61 CREON CRESTOR CRIXIVAN cromolyn... 66, 69, 88 CUBICIN... 0 cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide... 6 CYCLOPHOSPHAMIDE... 6 CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA... 6 CYSTADANE CYSTARAN cysteine (l-cysteine) D d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride 50 d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 84 dactinomycin... 6 DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM deblitane decitabine... 6 deferoxamine DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA... 73, 74 desipramine desmopressin... 7, 73 desog-e.estradiol/e.estradiol.. 59 desogestrel-ethinyl estradiol.. 59 desonide desoximetasone dexamethasone... 7 dexamethasone sodium phosphate... 67, 7 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl 84 dextrose 10 % in water (d10w) dextrose.5 % in water(d.5w) dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 50 dextrose 5 %-lactated ringers. 84 dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride84 diazepam diazepam intensol diclofenac potassium diclofenac sodium... 16, 67 diclofenac-misoprostol dicloxacillin... 3 dicyclomine didanosine DIFICID... diflunisal digitek digoxin DIGOXIN I-4

96 dihydroergotamine DILANTIN diltiazem hcl... 53, 54 dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine disopyramide phosphate... 5 disulfiram divalproex... 30, 31 dobutamine dobutamine in d5w donepezil... 3 dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin hcl... 6 doxorubicin hcl peg-liposomal... 6 doxorubicin, peg-liposomal... 6 doxycycline hyclate... 4 doxycycline monohydrate 4, 5 dronabinol droperidol drospirenone-ethinyl estradiol 59 DROXIA... 6 DUAVEE DULERA duloxetine DUREZOL DYRENIUM E econazole EDURANT EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD... 6 ELIQUIS ELITEK ELLA ELMIRON EMCYT... 6 EMEND EMSAM EMTRIVA enalapril maleate... 5 enalaprilat... 5 enalapril-hydrochlorothiazide 5 ENBREL ENBREL SURECLICK ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin entacapone entecavir ephedrine sulfate epinastine epinephrine EPIPEN -PAK EPIPEN JR -PAK EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM ergoloid ERGOMAR ERIVEDGE... 6 ERYTHROCIN... erythromycin..., 3, 66 erythromycin base... ERYTHROMYCIN BASE... erythromycin base-ethanol erythromycin ethylsuccinate.. erythromycin stearate... 3 erythromycin with ethanol 61, 6 ESBRIET escitalopram oxalate esmolol esomeprazole sodium ESTRACE estradiol estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet estropipate... 7 ethambutol ethamolin ethinyl estradiol/drospirenone 59 ethosuximide ethynodiol d-ethinyl estradiol 59 etodolac ETOPOPHOS... 6 etoposide... 6 EVOTAZ exemestane... 6 EXJADE EXTAVIA F FABRAZYME famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os). 68 FANAPT FARESTON... 6 FARYDAK... 6 FASLODEX... 6 felbamate felodipine FEMRING... 7 fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen fentanyl I-5

97 fentanyl citrate FERRIPROX FETZIMA finasteride FIRAZYR FLEBOGAMMA DIF flecainide... 5 FLECTOR FLEXBUMIN 5 % FLEXBUMIN 5 % FLOVENT DISKUS FLOVENT HFA floxuridine... 6 fluconazole fluconazole in dextrose(iso-o) 37 fluconazole in nacl (iso-osm). 37 flucytosine fludrocortisone... 7 flumazenil flunisolide fluocinonide fluocinonide-emollient base fluorometholone FLUOROPLEX fluorouracil... 6, 61 fluoxetine fluoxymesterone fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... 6 fluticasone... 63, 68 fluvoxamine fomepizole fondaparinux FORTEO FORTICAL foscarnet fosinopril... 5 fosinopril-hydrochlorothiazide... 5 fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine... 3 GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD GAZYVA... 6 gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK 73 gentamicin... 19, 6, 66 gentamicin in nacl (iso-osm). 19 gentamicin sulfate gentamicin sulfate (ped) (pf). 19 gentamicin sulfate (pf) GEODON gildess 4 fe GILENYA GILOTRIF... 7 GLEEVEC... 7 glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin glycopyrrolate glydo GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guanfacine... 51, 58 guanidine H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heparin (porcine) heparin (porcine) in 5 % dex. 46, 47 heparin (porcine) in nacl (pf). 47 heparin sodium,porcine-pf heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN... 7 HETLIOZ HEXALEN... 7 homatropine hbr HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HUMULIN R U hydralazine hydrochlorothiazide hydrocodone-acetaminophen. 14 hydrocodone-ibuprofen hydrocortisone... 63, 64, 7 I-6

98 hydrocortisone acet-aloe vera. 63 hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate. 7 hydrocortisone valerate hydromorphone hydromorphone (pf)... 14, 15 hydroxychloroquine hydroxyurea... 7 hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYQVIA I ibandronate IBRANCE... 7 ibuprofen ICLUSIG... 7 ifosfamide... 7 ifosfamide-mesna... 7 ILARIS (PF) ILEVRO IMBRUVICA... 7 imipenem-cilastatin... 3 imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF). 75 IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) INLYTA... 7 INSULIN PEN NEEDLE INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ... 3 INVEGA INVEGA SUSTENNA... 4 INVEGA TRINZA... 4 INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide ISENTRESS... 43, 44 ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine itraconazole ivermectin IXEMPRA... 7 IXIARO (PF) J JAKAFI... 7 JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO junel fe JUXTAPID K KABIVEN KALETRA KALYDECO KEDBUMIN ketoconazole ketoprofen ketorolac... 17, 68 KEYTRUDA... 7 KINERET KINRIX (PF) klor-con klor-con m klor-con m klor-con m KORLYM KRYSTEXXA KUVAN KYNAMRO KYPROLIS... 7 L l norgest/e.estradiol-e.estrad.. 59 labetalol LACRISERT LACTATED RINGERS lactulose LAMICTAL lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 4 fe latanoprost LATUDA... 4 LAZANDA leflunomide I-7

99 LEMTRADA LENVIMA... 7 LETAIRIS letrozole... 7 leucovorin calcium LEUKERAN... 7 LEUKINE leuprolide... 7 levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 4, 67 levofloxacin in d5w... 4 levonorgestrel levonorgestrel-ethin estradiol. 59 levonorgestrel-ethinyl estrad. 59, 60 levothyroxine LEXIVA lidocaine lidocaine (pf)... 18, 5 lidocaine hcl lidocaine in 5 % dextrose (pf) 5 lidocaine-prilocaine linezolid... 0 LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III lisinopril... 5 lisinopril-hydrochlorothiazide 5 lithium carbonate lithium citrate l-norgest-eth estr/ethin estra lomustine... 7 loperamide lorazepam oral solution losartan losartan-hydrochlorothiazide.. 51 LOTEMAX LOTRONEX lovastatin loxapine succinate... 4 LUMIGAN LUPRON DEPOT... 7 LUPRON DEPOT (3 MONTH)... 7 LUPRON DEPOT (4 MONTH)... 7 LUPRON DEPOT (6 MONTH)... 7 LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA... 8 LYRICA LYSODREN... 8 M magnesium chloride magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline MARPLAN MATULANE... 8 matzim la meclizine medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM)... MEGACE ES megestrol... 8, 74 MEKINIST... 8 meloxicam MENACTRA (PF) MENEST... 7 MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) mercaptopurine... 8 meropenem... 3 mesna... 8 MESNEX... 8 MESTINON... 8 MESTINON TIMESPAN... 8 metaproterenol metaxalone metformin methadone methadone hcl methazolamide methenamine hippurate... 0 methenamine mandelate... 0 methimazole methocarbamol methotrexate sodium... 8 methotrexate sodium (pf)... 8 methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 58, 59 methylprednisolone... 7 methylprednisolone acetate... 7 methylprednisolone sodium succ... 7 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 0, 38, 6 I-8

100 metronidazole in nacl (iso-os) 0 mexiletine... 5 MIACALCIN miconazole nitrate midodrine milrinone milrinone in 5 % dextrose minitran minocycline... 5 minoxidil MIRCERA mirtazapine misoprostol mitoxantrone... 8 M-M-R II (PF) moexipril... 5 moexipril-hydrochlorothiazide... 5 mometasone montelukast morphine MORPHINE morphine concentrate morrhuate sodium... 8 MOVANTIK MOVIPREP MOXEZA moxifloxacin... 4 MOZOBIL MULTAQ... 5 mupirocin... 6 mupirocin calcium... 6 mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ N nabumetone nadolol nafcillin... 3 NAGLAZYME naloxone naltrexone naltrexone hcl NAMENDA XR... 3 NAMZARIC... 3 naphazoline naproxen naproxen sodium naratriptan NATACYN nateglinide NATPARA NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc. 67 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu... 6 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin NEPHRAMINE 5.4 % NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR... 8 niacin nicardipine NICOTROL nifedipine NILANDRON... 8 NITRO-BID nitrofurantoin macrocrystal... 0 nitrofurantoin monohyd/m-cryst... 0 nitroglycerin nitroglycerin in 5 % dextrose. 57 NITROSTAT NORDITROPIN FLEXPRO.. 73 NORDITROPIN NORDIFLEX norelgestromin/ethin.estradiol 60 norepinephrine bitartrate norethindrone norethindrone (contraceptive) 60 norethindrone acetate norethindrone ac-eth estradiol 60 norethindrone-e.estradiol-iron 60 norethindrone-ethinyl estrad.. 60 norethindrone-mestranol norgestimate-ethinyl estradiol 60 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE I-9

101 NUTRILYTE II NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone O OCTAGAM octreotide acetate OFEV ofloxacin... 4, 67 olanzapine... 4 olanzapine-fluoxetine OLYSIO omega-3 acid ethyl esters omeprazole ONCASPAR... 8 ondansetron ondansetron hcl ondansetron hcl (pf) ONFI OPDIVO... 8 OPSUMIT ORAP... 4 ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN OTEZLA... 8 OTEZLA STARTER... 8 OTREXUP (PF)... 8 oxacillin... 3 oxacillin in dextrose(iso-osm) 3 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone oxycodone hcl-acetaminophen oxycodone hcl-aspirin oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone P PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl... 33, 34 PASER PAXIL pedi m.vit no.17 with fluoride 90 PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl 70 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON penicillin g pot in dextrose... 3 penicillin g potassium... 4 penicillin g procaine... 4 penicillin v potassium... 4 PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline PERIKABIVEN perindopril erbumine... 5 permethrin perphenazine... 4 perphenazine-amitriptyline phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 51, 66 phenytoin phenytoin sodium... 3 phenytoin sodium extended... 3 PHOSLYRA PHOSPHOLINE IODIDE phosphorus # PICATO pilocarpine hcl... 60, 83 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 4 piroxicam PLASBUMIN 5 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY... 8 podofilox podophyllum resin polyethylene glycol polymyxin b sulfate... 0 polymyxin b sulf-trimethoprim POMALYST... 8 potassium acetate potassium bicarb and chloride 85 potassium bicarb-citric acid potassium bicarbonate-cit ac.. 85 potassium chlorid-d5-0.45%nacl potassium chloride... 85, 86 potassium chloride in 0.9%nacl potassium chloride in 5 % dex85 potassium chloride in lr-d I-10

102 potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid potassium hydroxide potassium phosphate dibasic.. 86 POTIGA... 3 PRADAXA pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 68, 7 prednisone... 7 PREMARIN... 7 PREMASOL 10 % PREMASOL 6 % PREMPHASE... 7 PREMPRO... 7 prenatal vitamins PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone... 3 PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid... 8 procainamide... 5 PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI... 8 progesterone progesterone micronized capsules PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN... 8 PROLIA PROMACTA promethazine... 38, 39 promethazine hcl propafenone... 5 propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod. 66 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 0 % protamine protriptyline PULMOZYME PURIXAN... 8 pyrazinamide pyridostigmine bromide... 8 Q QUADRACEL (PF) quetiapine... 4 QUILLIVANT XR quinapril... 5 quinapril-hydrochlorothiazide 5 quinidine gluconate... 5 quinidine sulfate... 5 quinine sulfate QVAR R RABAVERT (PF) raloxifene... 7 ramipril... 5 RANEXA ranitidine hcl RAPAMUNE RASUVO (PF)... 8 RAVICTI REBIF (WITH ALBUMIN).. 8 REBIF REBIDOSE... 8 REBIF TITRATION PACK.. 8 RECOMBIVAX HB (PF) RELENZA DISKHALER RELISTOR REMICADE... 8 REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR RESTASIS RETROVIR REVLIMID... 8 REYATAZ ribavirin... 45, 46 RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringers... 79, 86 risedronate RISPERDAL CONSTA... 4 risperidone... 4, 43 RITUXAN... 8 rivastigmine tartrate... 3 rizatriptan ropinirole ROTARIX I-11

103 ROTATEQ VACCINE ROZEREM S SABRIL... 3 SAIZEN SAIZEN CLICK.EASY salsalate SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA selegiline hcl selenium sulfide... 6 SELZENTRY SENSIPAR... 8 SEREVENT DISKUS SEROSTIM sertraline SIGNIFOR... 8 sildenafil oral tablet 0 mg SILENOR silver nitrate... 6 silver nitrate applicators... 6 silver sulfadiazine... 6 SIMBRINZA SIMPONI... 8 SIMPONI ARIA... 8 simvastatin sirolimus SIRTURO sodium acetate sodium bicarbonate sodium chloride... 79, 86 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... 60, 91 sodium lactate sodium phosphate sodium polystyrene sulfonate 69 sodium thiosulfate sod-pot-k cit-sod cit-cit acid.. 86 SOLTAMOX... 8 SOLU-CORTEF (PF)... 7 SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL... 8 stavudine STELARA... 8 STERILE PADS... 8 STIVARGA... 8 STRATTERA streptomycin STRIBILD STRIVERDI RESPIMAT sucralfate... 68, 69 sulfacetamide sodium sulfacetamide sodium (acne). 6 sulfacetamide-prednisolone sulfadiazine... 4 sulfamethoxazole-trimethoprim... 4 sulfasalazine... 4 sulfatrim... 4 sulfazine... 4 sulfazine ec... 4 sulindac sumatriptan nasal spray sumatriptan succinate SUPPRELIN LA SUPRAX... SURMONTIL SUSTIVA SUTENT... 8 SYLATRON SYLVANT... 9 SYMLINPEN SYMLINPEN SYNAGIS SYNAREL... 8 SYNERCID... 0 SYNRIBO... 9 SYPRINE T TABLOID... 9 tacrolimus... 64, 75 TAFINLAR... 9 TAMIFLU tamoxifen... 9 tamsulosin TARCEVA... 9 TARGRETIN... 9 tarina fe TASIGNA... 9 TAZORAC taztia xt TECFIDERA... 8 TEFLARO... telmisartan telmisartan-hydrochlorothiazid TEMODAR... 9 TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate I-1

104 testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracaine hcl (pf) tetracycline... 5 THALOMID... 8 theophylline theophylline anhydrous theophylline in dextrose 5 %.. 88 thioridazine thiothixene tiagabine... 3 TICE BCG TIKOSYN timolol maleate... 53, 83 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in 0.5 % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide tolbutamide tolmetin tolterodine topiramate... 3 toposar intravenous... 9 torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril... 5 tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA... 9 TRECATOR TRELSTAR... 9 tretinoin tretinoin (chemotherapy)... 9 tretinoin microspheres TREXALL... 9 triamcinolone acetonide.. 60, 64, 7 triamterene-hydrochlorothiazid TRIBENZOR trifluoperazine trifluridine trihexyphenidyl trimethoprim... 0 TRIUMEQ TROKENDI XR... 3 TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX (PF) TYBOST... 8 TYGACIL... 5 TYKERB... 9 TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULORIC ursodiol... 69, 70 V VAGIFEM... 7 valacyclovir VALCHLOR valganciclovir valproate sodium... 3 valproic acid... 3 valproic acid (as sodium salt) 3 valsartan valsartan-hydrochlorothiazide 51 VALSTAR... 9 vancomycin... 0, 1 vancomycin in d5w... 0 VAQTA (PF) VARIVAX (PF) VASCEPA VELCADE... 9 venlafaxine verapamil VERSACLOZ VGO VICTOZA VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMIZIM VIMPAT... 3 vinorelbine... 9 VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VITEKTA VOLTAREN I-13

105 voriconazole VOTRIENT... 9 VPRIV W warfarin water for irrigation, sterile X XALKORI... 9 XARELTO XELJANZ XENAZINE XIFAXAN... 1 XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZAVESCA ZELBORAF ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem... 89, 90 ZOMETA zonisamide... 3 ZORTRESS ZOSTAVAX (PF) ZOVIRAX ZUBSOLV ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX... 1 I-14

106 Este formulario se actualizó el 08/1/015. Para obtener información más reciente o si tiene preguntas, llame a nuestro departamento de Servicios al miembro de Denver Health Medical Plan, Inc. al Los usuarios de TTY deben llamar al 711. Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la semana, o puede visitar