2015 Comprehensive Formulary

Transcription

1 01 Medicare Plus Blue SM PPO Assure & Prescription Blue SM PDP Option B 01 Comprehensive Formulary List of covered drugs Updated December 1, 01 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS THAT WE COVER IN THIS PLAN This formulary was updated on December 1, 01. For more recent information or other questions, please contact us, Medicare Plus Blue PPO at , Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 711. Or call Prescription Blue PDP Customer Service at , Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 711. From October 1 through February 1, hours are from 8 a.m. to 8 p.m., seven days a week. Or visit Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal. Enrollment DB 18 DEC 1 H97 S8_C_1CompFormAB CMS Accepted Formulary 1, version 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Blue Cross Blue Shield. When it refers to plan or our plan, it means Medicare Plus Blue or Prescription Blue. This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 01. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 016, and from time to time during the year. To request this document in an alternate format, please call Customer Service (phone numbers are printed on the front and back covers of this booklet).

3 What is the Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary? A formulary is a list of covered drugs selected by Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medicare Plus Blue / Prescription Blue will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Plus Blue or Prescription Blue network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 01 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 01 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60 day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 01. To get updated information about the drugs covered by Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid year non maintenance formulary change, we will send out an errata sheet to notify you of this change. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension, Cholesterol. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Medicare Plus Blue / Prescription Blue cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. i

4 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Medicare Plus Blue / Prescription Blue require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Plus Blue or Prescription Blue before you fill your prescriptions. If you don t get approval, Medicare Plus Blue / Prescription Blue may not cover the drug. Quantity Limits: For certain drugs, Medicare Plus Blue / Prescription Blue limit the amount of the drug that Medicare Plus Blue / Prescription Blue will cover. For example, Medicare Plus Blue / Prescription Blue provide two s per day for Celebrex 00 mg. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Medicare Plus Blue / Prescription Blue require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Medicare Plus Blue / Prescription Blue may not cover B unless you try A first. If A does not work for you, Medicare Plus Blue / Prescription Blue will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Medicare Plus Blue / Prescription Blue to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B formulary? on page ii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Medicare Plus Blue / Prescription Blue do not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Medicare Plus Blue / Prescription Blue. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Medicare Plus Blue / Prescription Blue. You can ask Medicare Plus Blue / Prescription Blue to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary? You can ask Medicare Plus Blue / Prescription Blue to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre determined cost sharing level, and you would not be able to ask us to provide the drug at a lower cost sharing level. You can ask us to cover a formulary drug at a lower cost sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medicare Plus Blue / Prescription Blue limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Medicare Plus Blue / Prescription Blue will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. ii

5 You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 1 day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 1 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long term care facility, we will allow you to refill your prescription until we have provided you with a 9 day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1 day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you move into (or out of) a long term care facility, you will continue to have access to your medications during the transition. If needed, limits on early prescription refills will be waived to assure that your medications are available through a new pharmacy provider when you are moving to or from a long term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at forms documents.html. For more information For more detailed information about your Medicare Plus Blue / Prescription Blue prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Medicare Plus Blue / Prescription Blue, please contact us. Our contact information, along with the date we last update the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day / 7 days a week. TTY users should call Or, visit Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Medicare Plus Blue / Prescription Blue. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VYTORIN) and generic drugs are listed in lower case italics (e.g., simvastatin). The information in the column tells you if Medicare Plus Blue / Prescription Blue have any special requirements for coverage of your drug. iii

6 Descriptions Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Costs Up to a 1 day supply Up to a 90 day supply** 1 Description Preferred Generic Non Preferred Generic Preferred Brand Name Non Preferred Brand Name Specialty At long term care, preferred At preferred retail retail At standard cost sharing At out of At the plan s cost sharing retail (in network), network mail order (in network) cost sharing and standard pharmacies* service pharmacies or (in network) retail the plan s mail pharmacies cost sharing order service (in network) pharmacies See your Evidence of Coverage for member cost share details See your Evidence of Coverage for member cost share details 90 day supply is not available *Out of network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details. **Most pharmacies will fill a 90 day supply of medication. Check with your pharmacist. Notes Code Definitions Symbol Definition B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC Gap Coverage. We provide coverage of this prescription drug in Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Medicare Plus Blue Customer Service at , Monday through Friday, 8 a.m. 8 p.m. TTY users should call 711. Or call Prescription Blue PDP Customer Service at , Monday through Friday, 8 a.m. 8 p.m. TTY users should call 711. From October 1 through February 1, hours are from 8 a.m. to 8 p.m., seven days a week. PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don't get approval, we may not cover the drug. QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first. If drug A does not work for you, we will then cover drug B. iv

7 Name ANTI -INFECTIVES AMINOGLYCOSIDES amikacin injection 1,000 mg/ ml, 00 mg/ ml BETHKIS INHALATION FOR NEBULIZATION gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/0 ml, 70 mg/0 ml, 80 mg/100 ml, 80 mg/0 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 100 MG/0 ML, 10 MG/100 ML gentamicin injection gentamicin sulfate (ped) (pf) injection gentamicin sulfate (pf) intravenous 100 mg/10 ml, 80 mg/8 ml GENTAMICIN SULFATE (PF) 60 MG/6 ML B/D PA Name STREPTOMYCIN R TOBI INHALATION FOR NEBULIZATION TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0. % nacl inhalation for nebulization tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection ANTIFUNGALS ABELCET SUSPENSION AMBISOME SUSPENSION FOR RECONSTITUTIO N amphotericin b injection recon soln B/D PA PA PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

8 Name CANCIDAS clotrimazole mucous membrane troche CRESEMBA CRESEMBA ORAL CAPSULE ERAXIS(WATER DILUENT) fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback fluconazole oral suspension for reconstitution fluconazole oral flucytosine oral griseofulvin microsize oral suspension griseofulvin microsize oral griseofulvin ultramicrosize oral B/D PA Name itraconazole oral ketoconazole oral NOXAFIL NOXAFIL ORAL SUSPENSION NOXAFIL ORAL,DELAYE D RELEASE (DR/EC) nystatin oral suspension nystatin oral ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL SPORANOX ORAL terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral ANTIMALARIALS atovaquoneproguanil oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - QL (90 per 90

9 Name chloroquine phosphate oral COARTEM ORAL DARAPRIM ORAL hydroxychloroquine oral mefloquine oral PRIMAQUINE ORAL quinine sulfate oral ANTIPARASITICS/ANTHELMINTIC S ALBENZA ORAL ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL atovaquone oral suspension BILTRICIDE ORAL ivermectin oral MEPRON ORAL SUSPENSION paromomycin oral Name STROMECTOL ORAL tinidazole oral ANTIRETROVIRALS abacavir oral abacavirlamivudinezidovudine oral APTIVUS ORAL CAPSULE APTIVUS ORAL ATRIPLA ORAL COMPLERA ORAL CRIXIVAN ORAL CAPSULE 00 MG, 00 MG didanosine oral,delayed release(dr/ec) EDURANT ORAL EMTRIVA ORAL CAPSULE EMTRIVA ORAL EPIVIR HBV ORAL EPIVIR ORAL EPZICOM ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

10 Name Name EVOTAZ ORAL lamivudine oral FUZEON lamivudinezidovudine oral INTELENCE ORAL 100 MG, 00 MG INTELENCE ORAL MG INVIRASE ORAL CAPSULE INVIRASE ORAL ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL ISENTRESS ORAL,CHEWAB LE 100 MG ISENTRESS ORAL,CHEWAB LE MG KALETRA ORAL KALETRA ORAL 100- MG KALETRA ORAL 00-0 MG lamivudine oral LEXIVA ORAL SUSPENSION LEXIVA ORAL nevirapine oral suspension nevirapine oral nevirapine oral extended release hr NORVIR ORAL CAPSULE NORVIR ORAL NORVIR ORAL PREZCOBIX ORAL PREZISTA ORAL SUSPENSION PREZISTA ORAL 10 MG, 7 MG PREZISTA ORAL 600 MG, 800 MG RESCRIPTOR ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

11 Name Name RESCRIPTOR ORAL, DISPERSIBLE RETROVIR REYATAZ ORAL CAPSULE 10 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY ORAL stavudine oral stavudine oral recon soln STRIBILD ORAL SUSTIVA ORAL CAPSULE SUSTIVA ORAL TIVICAY ORAL TRIUMEQ ORAL TRIZIVIR ORAL TRUVADA ORAL TYBOST ORAL TYZEKA ORAL VIDEX GRAM PEDIATRIC ORAL VIDEX GRAM PEDIATRIC ORAL VIRACEPT ORAL VIRAMUNE XR ORAL EXTENDED RELEASE HR 100 MG VIRAMUNE XR ORAL EXTENDED RELEASE HR 00 MG VIREAD ORAL POWDER VIREAD ORAL VITEKTA ORAL ZIAGEN ORAL zidovudine oral zidovudine oral syrup zidovudine oral ANTITUBERCULARS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

12 Name CAPASTAT CYCLOSERINE ORAL CAPSULE DAPSONE ORAL ethambutol oral isoniazid injection isoniazid oral isoniazid oral MYCOBUTIN ORAL CAPSULE PASER ORAL GRANULES DR FOR SUSP IN PACKET PRIFTIN ORAL pyrazinamide oral rifabutin oral rifampin intravenous recon soln rifampin oral RIFATER ORAL SIRTURO ORAL PA Name TRECATOR ORAL ANTIVIRALS acyclovir oral acyclovir oral suspension 00 mg/ ml acyclovir oral acyclovir sodium intravenous recon soln acyclovir sodium intravenous acyclovir topical ointment adefovir oral amantadine hcl oral amantadine hcl oral amantadine hcl oral BARACLUDE ORAL cidofovir intravenous DAKLINZA ORAL entecavir oral famciclovir oral foscarnet intravenous B/D PA B/D PA PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

13 Name ganciclovir sodium intravenous recon soln HARVONI ORAL HEPSERA ORAL moderiba dose pack oral s,dose pack moderiba oral OLYSIO ORAL CAPSULE REBETOL ORAL RELENZA DISKHALER INHALATION BLISTER WITH DEVICE ribasphere oral ribasphere oral 00 mg, 00 mg ribasphere oral 600 mg ribasphere ribapak oral s,dose pack ribavirin oral ribavirin oral 00 mg rimantadine oral B/D PA PA PA QL (60 per fill) Name SOVALDI ORAL TAMIFLU ORAL CAPSULE 0 MG TAMIFLU ORAL CAPSULE MG, 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N TECHNIVIE ORAL valacyclovir oral VALCYTE ORAL valganciclovir oral VIEKIRA PAK ORAL S,DOSE PACK VIRAZOLE INHALATION CEPHALOSPORINS cefaclor oral cefaclor oral extended release 1 hr cefadroxil oral : 1-Preferred Generic -Specialty s : B/D - Prior Authorization, Part D vs. Part B only Limited Availability PA - Prior Authorization QL - Quantity Limit -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand 7 PA QL (90 per 180 QL (0 per 180 QL (0 per 180 PA PA GC Gap Coverage LA - ST - Step Therapy

14 Name Name cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml CEFOTETAN IN DEXTROSE, ISO- OSM PIGGYBACK cefadroxil oral cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml, gram/0 ml cefotetan injection recon soln cefotetan intravenous recon soln cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 00 g, 00 mg cefazolin intravenous recon soln cefdinir oral cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefdinir oral suspension for reconstitution CEFEPIME IN DEXTROSE % PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefpodoxime oral cefprozil oral suspension for reconstitution cefprozil oral ceftazidime injection recon soln ceftibuten oral cefepime injection recon soln cefixime oral suspension for reconstitution cefotaxime injection recon soln 1 gram, gram, 00 mg ceftibuten oral suspension for reconstitution ceftriaxone in dextrose,iso-os intravenous piggyback : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

15 Name Name ceftriaxone injection recon soln 1 gram, 10 gram, gram, 0 mg, 00 mg ceftriaxone intravenous recon soln cefuroxime axetil oral cefuroxime sodium injection recon soln 1. gram, 70 mg cefuroxime sodium intravenous recon soln cephalexin oral 0 mg, 00 mg cephalexin oral suspension for reconstitution cephalexin oral FORTAZ IN DEXTROSE % PIGGYBACK FORTAZ 1 GRAM, 6 GRAM FORTAZ MAXIPIME MAXIPIME MEFOXIN IN DEXTROSE (ISO- OSM) PIGGYBACK SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N SUPRAX ORAL,CHEWAB LE TAZICEF TAZICEF TEFLARO ZERBAXA ZINACEF IN STERILE WATER PIGGYBACK ZINACEF 1. GRAM, 70 MG MACROLIDES : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

16 Name azithromycin intravenous recon soln azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral clarithromycin oral suspension for reconstitution clarithromycin oral clarithromycin oral extended release hr DIFICID ORAL E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTIO N ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTIO N ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTIO N QL (180 per 90 QL (0 per fill) Name ery-tab oral,delayed release (dr/ec) erythrocin (as stearate) oral 0 mg ERYTHROCIN erythromycin ethylsuccinate oral erythromycin oral KETEK ORAL ZMAX ORAL SUSPENSION,EXT ENDED REL RECON MISCELLANEOUS ANTI- INFECTIVES AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK aztreonam injection recon soln baciim intramuscular recon soln bacitracin intramuscular recon soln QL (0 per 10 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

17 Name CAYSTON INHALATION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln CLEOCIN IN % DEXTROSE PIGGYBACK 900 MG/0 ML clindamycin hcl oral clindamycin in % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection clindamycin phosphate intravenous 600 mg/ ml, 900 mg/6 ml colistin (colistimethate na) injection recon soln CUBICIN PA; QL (8 per 8 Name DALVANCE imipenem-cilastatin intravenous recon soln INVANZ INVANZ linezolid intravenous parenteral linezolid oral linezolid-0.9% sodium chloride intravenous parenteral meropenem intravenous recon soln metro i.v. intravenous piggyback metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral metronidazole oral NEBUPENT INHALATION : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11 B/D PA

18 Name neomycin oral PENTAM polymyxin b sulfate injection recon soln SIVEXTRO SIVEXTRO ORAL SYNERCID TYGACIL VANCOMYCIN IN DW PIGGYBACK VANCOMYCIN IN DEXTROSE ISO- OSM PIGGYBACK vancomycin intravenous recon soln vancomycin oral XIFAXAN ORAL ZYVOX PARENTERAL Name ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N ZYVOX ORAL PENICILLINS amoxicillin oral amoxicillin oral suspension for reconstitution amoxicillin oral amoxicillin oral,chewable 1 mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral amoxicillin-pot clavulanate oral extended release 1 hr amoxicillin-pot clavulanate oral,chewable ampicillin oral ampicillin oral suspension for reconstitution : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

19 Name Name ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous recon soln BICILLIN C-R R SYRINGE BICILLIN L-A R SYRINGE dicloxacillin oral nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln PENICILLIN G POT IN DEXTROSE PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral nafcillin intravenous recon soln pfizerpen-g injection recon soln oxacillin in dextrose(iso-osm) intravenous piggyback piperacillintazobactam intravenous recon soln oxacillin injection recon soln oxacillin intravenous recon soln ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK QUINOLONES : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

20 Name ciprofloxacin (mixture) oral, er multiphase hr ciprofloxacin hcl oral ciprofloxacin in % dextrose intravenous piggyback ciprofloxacin lactate intravenous ciprofloxacin oral suspension,microcap sule recon levofloxacin in dw intravenous piggyback levofloxacin intravenous levofloxacin oral levofloxacin oral moxifloxacin oral ofloxacin oral 00 mg SULFONAMIDES AND COMBINATIONS sulfadiazine oral sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension QL (8 per 8 Name sulfamethoxazoletrimethoprim oral sulfatrim oral suspension TETRACYCLINES ARESTIN DENTAL CARTRIDGE demeclocycline oral doxy-100 intravenous recon soln doxycycline hyclate intravenous recon soln doxycycline hyclate oral doxycycline hyclate oral 100 mg, 0 mg doxycycline hyclate oral,delayed release (dr/ec) 10 mg doxycycline monohydrate oral 100 mg, 0 mg, 7 mg doxycycline monohydrate oral suspension for reconstitution MINOCIN KIT WITH WIPES COMBO PACK : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

21 Name minocycline oral minocycline oral morgidox oral VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate oral methenamine mandelate oral nitrofurantoin macrocrystal oral 100 mg, 0 mg nitrofurantoin monohyd/m-cryst oral nitrofurantoin oral suspension PRIMSOL ORAL trimethoprim oral PA PA PA ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ADJUVANT THERAPY FUSILEV leucovorin calcium injection recon soln Name leucovorin calcium oral LEUKINE levoleucovorin calcium intravenous MESNEX ORAL ALKYLATING AGENTS BICNU BUSULFEX cyclophosphamide intravenous recon soln CYCLOPHOSPHA MIDE ORAL CAPSULE dacarbazine intravenous recon soln LEUKERAN ORAL LOMUSTINE ORAL CAPSULE melphalan hcl intravenous recon soln MUSTARGEN : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1 B/D PA B/D PA

22 Name TREANDA 180 MG/ ML VALCHLOR TOPICAL GEL ZANOSAR ANTIMETABOLITES adrucil intravenous ALIMTA cladribine intravenous cytarabine (pf) injection cytarabine injection DEPOCYT (PF) INTRATHECAL SUSPENSION floxuridine injection recon soln fludarabine intravenous recon soln fludarabine intravenous fluorouracil intravenous. gram/0 ml, gram/100 ml, 00 mg/10 ml PA B/D PA B/D PA B/D PA B/D PA B/D PA Name gemcitabine intravenous recon soln gemcitabine intravenous mercaptopurine oral methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection methotrexate sodium injection methotrexate sodium oral NIPENT PURIXAN ORAL SUSPENSION RHEUMATREX ORAL S,DOSE PACK TABLOID ORAL HORMONAL AGENTS anastrozole oral bicalutamide oral exemestane oral 1 B/D PA; GC B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 16

23 Name FARESTON ORAL FASLODEX R SYRINGE FIRMAGON KIT W DILUENT SYRINGE flutamide oral letrozole oral leuprolide subcutaneous kit LUPRON DEPOT ( MONTH) R SYRINGE KIT. MG LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT (6 MONTH) R SYRINGE KIT LUPRON DEPOT R SYRINGE KIT 7. MG LUPRON DEPOT- PED R KIT 11. MG, 1 MG Name MEGACE ES ORAL SUSPENSION megestrol oral suspension 00 mg/10 ml (10 ml), 00 mg/10 ml (0 mg/ml), 6 mg/ ml PA PA megestrol oral PA NILANDRON ORAL SOLTAMOX ORAL SUPPRELIN LA IMPLANT KIT tamoxifen oral TRELSTAR R SUSPENSION FOR RECONSTITUTIO N VANTAS IMPLANT KIT XTANDI ORAL CAPSULE ZOLADEX IMPLANT ZYTIGA ORAL IMMUNOMODULATORS ARCALYST PA QL (1. per 0 PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 17

24 Name ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR 0. MG, 1 MG ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR MG AZASAN ORAL azathioprine oral CELLCEPT cyclosporine intravenous cyclosporine modified oral cyclosporine modified oral cyclosporine oral GAZYVA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA PA gengraf oral B/D PA gengraf oral B/D PA Name ILARIS (PF) mycophenolate mofetil oral mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral mycophenolate sodium oral,delayed release (dr/ec) NEORAL ORAL CAPSULE NEORAL ORAL NULOJIX POMALYST ORAL CAPSULE PROGRAF RAPAMUNE ORAL REVLIMID ORAL CAPSULE 10 MG, 1 MG, MG, MG REVLIMID ORAL CAPSULE. MG, 0 MG PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA PA B/D PA B/D PA LA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 18

25 Name RITUXAN CONCENTRATE SANDIMMUNE SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SIMULECT PA B/D PA B/D PA B/D PA B/D PA sirolimus oral B/D PA tacrolimus oral 0. mg, 1 mg tacrolimus oral mg TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10 MG (1)- 0 MG (6) TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10 MG, 0 MG THALOMID ORAL CAPSULE B/D PA B/D PA PA PA; QL (6 per 1 PA MISCELLANEOUS ANTINEOPLASTIC AGENTS Name ABRAXANE SUSPENSION FOR RECONSTITUTIO N AFINITOR DISPERZ ORAL FOR SUSPENSION AFINITOR ORAL amifostine crystalline intravenous recon soln ARRANON ARZERRA AVASTIN azacitidine injection recon soln BELEODAQ bexarotene oral bleomycin injection recon soln BLINCYTO KIT PA PA PA PA PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 19

26 Name Name BOSULIF ORAL CAMPTOSAR 00 MG/1 ML CAPRELSA ORAL carboplatin intravenous cisplatin intravenous CLOLAR COMETRIQ ORAL CAPSULE CYRAMZA DACOGEN daunorubicin intravenous DAUNOXOME decitabine intravenous recon soln dexrazoxane hcl intravenous recon soln PA PA DOCEFREZ 0 MG docetaxel intravenous 10 mg/ml, 10 mg/7 ml (0 mg/ml), 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml), 0 mg/ml (1 ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous doxorubicin, pegliposomal intravenous suspension DROXIA ORAL CAPSULE ELLENCE ELOXATIN 100 MG/0 ML EMCYT ORAL CAPSULE epirubicin intravenous recon soln 0 mg B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0

27 Name Name epirubicin intravenous idarubicin intravenous ERBITUX IFEX B/D PA ERIVEDGE ORAL CAPSULE ERWINAZE R PA ifosfamide intravenous recon soln ifosfamide intravenous B/D PA B/D PA ETOPOPHOS ifosfamide-mesna intravenous kit 1-1 gram B/D PA etoposide intravenous IMBRUVICA ORAL CAPSULE PA FARYDAK ORAL CAPSULE PA INLYTA ORAL PA GILOTRIF ORAL PA; QL (1 per 1 IRESSA ORAL GLEEVEC ORAL HALAVEN HERCEPTIN HEXALEN ORAL CAPSULE hydroxyurea oral IBRANCE ORAL CAPSULE ICLUSIG ORAL B/D PA PA PA irinotecan intravenous 100 mg/ ml, 0 mg/ ml irinotecan intravenous 00 mg/ ml ISTODAX IXEMPRA JAKAFI ORAL B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

28 Name Name JEVTANA KADCYLA KEYTRUDA KEYTRUDA LENVIMA ORAL CAPSULE lipodox 0 intravenous suspension lipodox intravenous suspension PA B/D PA PA B/D PA B/D PA NEXAVAR ORAL ONCASPAR OPDIVO oxaliplatin intravenous recon soln oxaliplatin intravenous paclitaxel intravenous concentrate PERJETA PA LYNPARZA ORAL CAPSULE LYSODREN ORAL MATULANE ORAL CAPSULE MEKINIST ORAL mesna intravenous mitomycin intravenous recon soln mitoxantrone intravenous concentrate PA PA B/D PA PROLEUKIN SPRYCEL ORAL STIVARGA ORAL SUTENT ORAL CAPSULE SYNRIBO TAFINLAR ORAL CAPSULE TARCEVA ORAL PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

29 Name Name TARGRETIN ORAL CAPSULE TASIGNA ORAL CAPSULE thiotepa injection recon soln toposar intravenous topotecan intravenous recon soln TORISEL TREANDA TREANDA MG/0. ML TRELSTAR DEPOT R SUSPENSION FOR RECONSTITUTIO N TRELSTAR R SYRINGE TRELSTAR LA R SUSPENSION FOR RECONSTITUTIO N PA PA PA PA tretinoin (chemotherapy) oral TRISENOX TYKERB ORAL UNITUXIN VALSTAR INTRAVESICAL VECTIBIX VELCADE VIDAZA vinblastine intravenous vincasar pfs intravenous vincristine intravenous vinorelbine intravenous VOTRIENT ORAL XALKORI ORAL CAPSULE PA B/D PA B/D PA B/D PA PA PA; QL (6 per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

30 Name XGEVA YERVOY ZALTRAP ZELBORAF ORAL ZINECARD (AS HCL) ZOLINZA ORAL CAPSULE ZORTRESS ORAL 0. MG ZORTRESS ORAL 0. MG, 0.7 MG ZYDELIG ORAL ZYKADIA ORAL CAPSULE CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL ACE-INHIBITORS AND COMBINATIONS benazepril oral PA PA PA; QL (0 per 0 B/D PA B/D PA PA PA Name benazeprilhydrochlorothiazide oral captopril oral captoprilhydrochlorothiazide oral enalapril maleate oral enalaprilat intravenous injectable enalaprilhydrochlorothiazide oral fosinopril oral fosinoprilhydrochlorothiazide oral lisinopril oral lisinoprilhydrochlorothiazide oral moexipril oral moexiprilhydrochlorothiazide oral perindopril erbumine oral quinapril oral quinaprilhydrochlorothiazide oral ramipril oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

31 Name trandolapril oral ALPHA-ADRENERGIC AGENTS CARDURA XL ORAL EXTENDED RELEASE HR clonidine (pf) epidural clonidine hcl oral clonidine transdermal patch weekly doxazosin oral DURACLON (PF) EPIDURAL,000 MCG/10 ML prazosin oral terazosin oral QL (90 per 90 ; QL (1 per 8 ANGIOTENSIN II RECEPTOR BLOCKERS AND COMBINATIONS amlodipinevalsartan oral amlodipinevalsartan-hcthiazid oral BENICAR HCT ORAL BENICAR ORAL Name candesartan oral candesartanhydrochlorothiazid oral EDARBI ORAL EDARBYCLOR ORAL eprosartan oral irbesartan oral irbesartanhydrochlorothiazide oral losartan oral losartanhydrochlorothiazide oral telmisartan oral telmisartanamlodipine oral telmisartanhydrochlorothiazid oral valsartan oral valsartanhydrochlorothiazide oral ANTI-COAGULANTS/HEMOSTASIS AGENTS : 1-Preferred Generic -Specialty s -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

32 Name Name AGGRENOX ORAL CAPSULE, ER MULTIPHASE 1 HR AMICAR ORAL 1,000 MG aminocaproic acid intravenous anagrelide oral enoxaparin subcutaneous syringe 0 mg/0. ml, 0 mg/0. ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, mg/0. ml, 7. mg/0.6 ml aspirin-dipyridamole oral, er multiphase 1 hr BRILINTA ORAL cilostazol oral clopidogrel oral COUMADIN ORAL dipyridamole intravenous EFFIENT ORAL ELIQUIS ORAL enoxaparin subcutaneous enoxaparin subcutaneous syringe 100 mg/ml, 10 mg/0.8 ml, 10 mg/ml fondaparinux subcutaneous syringe. mg/0. ml FRAGMIN FRAGMIN SYRINGE 10,000 ANTI-XA UNIT/ML, 1,00 ANTI-XA UNIT/0. ML, 1,000 ANTI- XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.7 ML, 7,00 ANTI-XA UNIT/0. ML FRAGMIN SYRINGE,00 ANTI-XA UNIT/0. ML,,000 ANTI- XA UNIT/0. ML heparin (porcine) in % dex intravenous parenteral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

33 Name heparin (porcine) in nacl (pf) intravenous parenteral 1,000 unit/00 ml,,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection HEPARIN(PORCIN E) IN 0.% NACL PARENTERAL 1,00 UNIT/0 ML heparin(porcine) in 0.% nacl intravenous parenteral,000 unit/0 ml,,000 unit/00 ml heparin, porcine (pf) injection heparin, porcine (pf) injection syringe INTEGRILIN IPRIVASK jantoven oral pentoxifylline oral extended release PRADAXA ORAL CAPSULE Name REOPRO warfarin oral XARELTO ORAL XARELTO ORAL S,DOSE PACK BETA BLOCKERS AND COMBINATIONS acebutolol oral atenolol oral atenololchlorthalidone oral betaxolol oral bisoprolol fumarate oral bisoprololhydrochlorothiazide oral BREVIBLOC IN NACL (ISO-OSM) PARENTERAL BREVIBLOC 100 MG/10 ML (10 MG/ML) BYSTOLIC ORAL 10 MG ST; QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

34 Name BYSTOLIC ORAL. MG, MG BYSTOLIC ORAL 0 MG ST; QL (90 per 90 ST; QL (180 per 90 carvedilol oral COREG CR ORAL CAPSULE, ER MULTIPHASE HR esmolol intravenous INNOPRAN XL ORAL CAPSULE,EXTEN DED RELEASE HR labetalol intravenous labetalol intravenous syringe 0 mg/ ml ( mg/ml) QL (90 per 90 labetalol oral metoprolol succinate oral extended release hr metoprolol tahydrochlorothiaz oral metoprolol tartrate intravenous metoprolol tartrate intravenous syringe metoprolol tartrate oral ; QL (180 per 90 Name nadolol oral nadololbendroflumethiazide oral pindolol oral propranolol intravenous propranolol oral,extended release hr propranolol oral propranolol oral propranololhydrochlorothiazid oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8 sorine oral sotalol af oral SOTALOL sotalol oral timolol maleate oral CALCIUM CHANNEL BLOCKERS AND COMBINATIONS afeditab cr oral extended release amlodipine oral amlodipineatorvastatin oral ; QL (90 per 90

35 Name Name amlodipinebenazepril oral diltiazem hcl oral,extended release hr AZOR ORAL QL (90 per 90 diltiazem hcl oral CARDENE IV IN DEXTROSE PIGGYBACK CARDENE IV IN SODIUM CHLORIDE PIGGYBACK 0 MG/00 ML CARDIZEM LA ORAL EXTENDED RELEASE HR 10 MG diltiazem hcl oral extended release hr dilt-xr oral,ext release degradable felodipine oral extended release hr isradipine oral matzim la oral extended release hr ; QL (90 per 90 cartia xt oral,extended release hr diltiazem hcl intravenous recon soln diltiazem hcl intravenous diltiazem hcl oral, extended release diltiazem hcl oral,ext release degradable diltiazem hcl oral,extended release 1 hr nicardipine intravenous nicardipine oral nifedical xl oral extended release hr nifedipine oral extended release nifedipine oral extended release hr nisoldipine oral extended release hr ; QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

36 Name TARKA ORAL, IR & ER, BIPHASIC HR taztia xt oral, extended release trandolaprilverapamil oral, ir & er, biphasic hr verapamil intravenous verapamil intravenous syringe verapamil oral, hr er pellet ct verapamil oral,ext rel. pellets hr QL (90 per 90 ; QL (90 per 90 verapamil oral verapamil oral extended release CARBONIC ANHYDRASE INHIBITORS acetazolamide oral, extended release acetazolamide oral acetazolamide sodium injection recon soln methazolamide oral Name CARDIOVASCULAR TREATMENT ADENOCARD SYRINGE adenosine intravenous adenosine intravenous syringe amiodarone intravenous amiodarone intravenous syringe amiodarone oral CORLANOR ORAL CORVERT DIBENZYLINE ORAL CAPSULE digitek oral 1 mcg digitek oral 0 mcg digox oral 1 mcg digox oral 0 mcg digoxin injection digoxin oral 0 mcg/ml digoxin oral 1 mcg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0 QL (180 per 90 ; QL (90 per 90 1 PA; GC ; QL (90 per 90 1 PA; GC ; QL (90 per 90

37 Name digoxin oral 0 mcg dobutamine in dw intravenous parenteral 1,000 mg/0 ml (,000 mcg/ml), 0 mg/0 ml (1 mg/ml), 00 mg/0 ml (,000 mcg/ml) dobutamine intravenous dopamine in % dextrose intravenous dopamine intravenous flecainide oral ibutilide fumarate intravenous ISUPREL LANOXIN LANOXIN ORAL 1 MCG LANOXIN ORAL 187. MCG, 0 MCG LANOXIN ORAL 6. MCG LANOXIN PEDIATRIC 1 PA; GC QL (90 per 90 PA Name LEVOPHED (BITARTRATE) mexiletine oral midodrine oral milrinone in % dextrose intravenous piggyback milrinone intravenous MULTAQ ORAL NATRECOR NEXTERONE NITROPRESS norepinephrine bitartrate intravenous NORPACE CR ORAL CAPSULE, EXTENDED RELEASE NORTHERA ORAL CAPSULE pacerone oral 100 mg, 00 mg, 00 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1 QL (180 per 90

38 Name phenoxybenzamine oral procainamide injection propafenone oral,extended release 1 hr propafenone oral quinidine gluconate injection quinidine gluconate oral extended release quinidine sulfate oral RANEXA ORAL EXTENDED RELEASE 1 HR REMODULIN TIKOSYN ORAL CAPSULE DIURETICS amiloride oral amiloridehydrochlorothiazide oral bumetanide injection bumetanide oral B/D PA Name chlorothiazide oral chlorothiazide sodium intravenous recon soln chlorthalidone oral mg, 0 mg eplerenone oral ethacrynate sodium intravenous recon soln furosemide injection furosemide injection syringe furosemide oral 10 mg/ml, 0 mg/ ml furosemide oral hydrochlorothiazide oral hydrochlorothiazide oral indapamide oral methyclothiazide oral metolazone oral spironolactone oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

39 Name spironolactonhydrochlorothiaz oral torsemide oral triamterenehydrochlorothiazid oral triamterenehydrochlorothiazid oral LIPID LOWERING AGENTS omega- acid ethyl esters oral LIPID-LOWERING AGENTS ADVICOR ORAL, ER MULTIPHASE HR ALTOPREV ORAL EXTENDED RELEASE HR ANTARA ORAL CAPSULE 0 MG, 90 MG atorvastatin oral cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder ST; QL (180 per 90 ST; QL (90 per 90 QL (90 per 90 ; QL (90 per 90 Name cholestyramine light oral powder in packet COLESTID FLAVORED ORAL PACKET colestipol oral granules colestipol oral packet colestipol oral CRESTOR ORAL fenofibrate micronized oral fenofibrate nanocrystallized oral fenofibrate oral 160 mg, mg fenofibric acid (choline) oral,delayed release(dr/ec) 1 mg fenofibric acid (choline) oral,delayed release(dr/ec) mg fenofibric acid oral FENOGLIDE ORAL fluvastatin oral 0 mg ST; QL (90 per 90 QL (90 per 90 QL (90 per 90 QL (90 per 90 QL (70 per 90 QL (90 per 90 ; QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

40 Name fluvastatin oral 0 mg fluvastatin oral extended release hr gemfibrozil oral JUXTAPID ORAL CAPSULE KYNAMRO SYRINGE LESCOL XL ORAL EXTENDED RELEASE HR LIPOFEN ORAL CAPSULE 10 MG LIPOFEN ORAL CAPSULE 0 MG lovastatin oral 10 mg, 0 mg lovastatin oral 0 mg niacin oral extended release hr niacor oral pravastatin oral prevalite oral powder prevalite oral powder in packet ; QL (180 per 90 1 ST; GC; QL (90 per 90 PA PA ST; QL (90 per 90 QL (90 per 90 QL (70 per 90 ; QL (70 per 90 ; QL (180 per 90 ; QL (90 per 90 Name SIMCOR ORAL, ER MULTIPHASE HR simvastatin oral TRIGLIDE ORAL 160 MG VASCEPA ORAL CAPSULE VYTORIN ORAL VYTORIN 10-0 ORAL VYTORIN 10-0 ORAL VYTORIN ORAL WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL ZETIA ORAL MISCELLANEOUS ANTIHYPERTENSIVES CORLOPAM DEMSER ORAL CAPSULE epoprostenol (glycine) intravenous recon soln ST ; QL (90 per 90 QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - ST; QL (90 per 90 ST; QL (90 per 90 ST; QL (90 per 90 ST; QL (90 per 90 QL (90 per 90

41 Name FLOLAN hydralazine injection hydralazine oral minoxidil oral PROGLYCEM ORAL SUSPENSION TEKTURNA HCT ORAL TEKTURNA ORAL VECAMYL ORAL veletri intravenous recon soln VENTAVIS INHALATION FOR NEBULIZATION QL (90 per 90 QL (90 per 90 PA B/D PA NITRATES AND COMBINATIONS BIDIL ORAL DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE ISORDIL ORAL ISORDIL TITRADOSE ORAL MG Name isosorbide dinitrate oral isosorbide dinitrate oral extended release isosorbide mononitrate oral isosorbide mononitrate oral extended release hr nitro-bid transdermal ointment NITRO-DUR TRANSDERMAL PATCH HOUR nitroglycerin in % dextrose intravenous nitroglycerin intravenous nitroglycerin oral, extended release nitroglycerin transdermal patch hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

42 Name NITROSTAT SUBLINGUAL CENTRAL NERVOUS SYSTEM ANTICONVULSANTS APTIOM ORAL BANZEL ORAL SUSPENSION BANZEL ORAL carbamazepine oral, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral carbamazepine oral extended release 1 hr carbamazepine oral,chewable CELONTIN ORAL CAPSULE 00 MG CEREBYX clonazepam oral clonazepam oral,disintegrating diazepam rectal kit Name DILANTIN 0 MG ORAL CAPSULE divalproex oral, sprinkle divalproex oral extended release hr divalproex oral,delayed release (dr/ec) epitol oral ethosuximide oral ethosuximide oral felbamate oral suspension felbamate oral fosphenytoin injection FYCOMPA ORAL MG, MG, 6 MG, 8 MG gabapentin oral gabapentin oral gabapentin oral 600 mg, 800 mg GABITRIL ORAL 1 MG, 16 MG : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

43 Name Name KEPPRA LAMICTAL ODT ORAL,DISINTE GRATING LAMICTAL ODT STARTER (BLUE) ORAL DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL DISINTEGRATING, DOSE PK LAMICTAL STARTER (ORANGE) KIT ORAL S,DOSE PACK lamotrigine oral lamotrigine oral extended release hr lamotrigine oral, chewable dispersible lamotrigine oral,disintegrating lamotrigine oral s,dose pack mg () LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK LAMICTAL STARTER (BLUE) KIT ORAL S,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL S,DOSE PACK levetiracetam intravenous levetiracetam oral levetiracetam oral levetiracetam oral extended release hr LYRICA ORAL CAPSULE LYRICA ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

44 Name ONFI ORAL SUSPENSION ONFI ORAL 10 MG, 0 MG oxcarbazepine oral suspension oxcarbazepine oral OXTELLAR XR ORAL EXTENDED RELEASE HR PEGANONE ORAL phenobarbital oral elixir phenobarbital oral phenytoin oral suspension phenytoin oral,chewable phenytoin sodium extended oral phenytoin sodium intravenous phenytoin sodium intravenous syringe POTIGA ORAL primidone oral QL (80 per 0 QL (180 per 90 ST Name SABRIL ORAL POWDER IN PACKET SABRIL ORAL TEGRETOL XR ORAL EXTENDED RELEASE 1 HR 100 MG tiagabine oral topiramate oral, sprinkle topiramate oral TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE HR valproate sodium intravenous valproic acid (as sodium salt) oral valproic acid oral VIMPAT VIMPAT ORAL VIMPAT ORAL zonisamide oral PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

45 Name ANTIDEPRESSANTS amitriptyline oral amoxapine oral BRINTELLIX ORAL buproban oral extended release bupropion hcl oral bupropion hcl oral extended release bupropion hcl oral extended release hr citalopram oral citalopram oral clomipramine oral CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) desipramine oral DESVENLAFAXIN E FUMARATE ORAL EXTENDED RELEASE HR PA ST PA ST Name DESVENLAFAXIN E ORAL EXTENDED RELEASE HR ST doxepin oral PA doxepin oral concentrate duloxetine oral,delayed release(dr/ec) EMSAM TRANSDERMAL PATCH HOUR escitalopram oxalate oral escitalopram oxalate oral FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE HR fluoxetine oral fluoxetine oral,delayed release(dr/ec) fluoxetine oral fluoxetine oral 10 mg, 0 mg PA ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

46 Name FLUOXETINE ORAL 60 MG fluvoxamine oral,extended release hr fluvoxamine oral imipramine hcl oral imipramine pamoate oral maprotiline oral MARPLAN ORAL mirtazapine oral mirtazapine oral,disintegrating nefazodone oral nortriptyline oral nortriptyline oral OLEPTRO ER ORAL EXTENDED RELEASE HR paroxetine hcl oral paroxetine hcl oral extended release hr PA PA PA Name PAXIL ORAL SUSPENSION PEXEVA ORAL phenelzine oral protriptyline oral sertraline oral concentrate sertraline oral tranylcypromine oral trazodone oral venlafaxine oral,extended release hr venlafaxine oral venlafaxine oral extended release hr 10 mg, 7. mg, 7 mg VIIBRYD ORAL VIIBRYD ORAL S,DOSE PACK ANTIEMETICS droperidol injection ANTIPSYCHOTICS ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0

47 Name Name ABILIFY MAINTENA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA R SUSPENSION,EXT ENDED REL SYRING ABILIFY ORAL CLOZAPINE ORAL,DISINTE GRATING 10 MG, 00 MG ergoloid oral FANAPT ORAL FANAPT ORAL S,DOSE PACK FAZACLO ORAL,DISINTE GRATING 10 MG, 00 MG ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED aripiprazole oral aripiprazole oral chlorpromazine injection chlorpromazine oral clozapine oral fluphenazine decanoate injection fluphenazine hcl injection fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral GEODON R clozapine oral,disintegrating 100 mg, 1. mg, mg haloperidol decanoate intramuscular haloperidol lactate injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

48 Name haloperidol lactate oral concentrate haloperidol oral INVEGA ORAL EXTENDED RELEASE HR INVEGA SUSTENNA R SYRINGE 117 MG/0.7 ML, 16 MG/ML, MG/1. ML INVEGA SUSTENNA R SYRINGE 9 MG/0. ML, 78 MG/0. ML INVEGA TRINZA R SYRINGE LATUDA ORAL loxapine succinate oral olanzapine intramuscular recon soln olanzapine oral olanzapine oral,disintegrating PA ST Name olanzapinefluoxetine oral ORAP ORAL perphenazine oral pimozide oral quetiapine oral REXULTI ORAL RISPERDAL CONSTA R SYRINGE 1. MG/ ML, MG/ ML RISPERDAL CONSTA R SYRINGE 7. MG/ ML, 0 MG/ ML risperidone oral risperidone oral risperidone oral,disintegrating SAPHRIS (BLACK CHERRY) SUBLINGUAL ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

49 Name SEROQUEL XR ORAL EXTENDED RELEASE HR SURMONTIL ORAL CAPSULE thioridazine oral thiothixene oral trifluoperazine oral VERSACLOZ ORAL SUSPENSION ziprasidone hcl oral ZYPREXA RELPREVV R SUSPENSION FOR RECONSTITUTIO N ANXIOLYTICS alprazolam intensol oral concentrate alprazolam oral buspirone oral clorazepate dipotassium oral diazepam intensol oral concentrate PA PA Name diazepam oral concentrate diazepam oral diazepam oral lorazepam intensol oral concentrate lorazepam oral concentrate lorazepam oral CNS STIMULANTS amphetamine salt combo oral CAFCIT caffeine citrated intravenous caffeine citrated oral clonidine hcl oral extended release 1 hr dexedrine oral dextroamphetamine oral DOPRAM guanfacine oral extended release hr ST; QL (60 per 90 ST; QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

50 Name KAPVAY ORAL EXTENDED RELEASE 1 HR methylphenidate oral methylphenidate oral methylphenidate oral,chewable ST; QL (60 per 90 modafinil oral PA; QL (180 per 90 NUVIGIL ORAL 10 MG NUVIGIL ORAL 00 MG, 0 MG, 0 MG STRATTERA ORAL CAPSULE MIGRAINE THERAPY almotriptan malate oral AXERT ORAL butorphanol tartrate nasal spray,nonaerosol D.H.E. dihydroergotamine injection dihydroergotamine nasal spray,nonaerosol PA; QL (1 per 1 PA; QL (90 per 90 ST ST; QL (6 per 90 ST; QL (6 per 90 QL (0 per 90 QL ( per 90 Name ERGOMAR SUBLINGUAL FROVA ORAL migergot rectal suppository naratriptan oral RELPAX ORAL rizatriptan oral rizatriptan oral,disintegrating sumatriptan nasal spray,non-aerosol sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous sumatriptan succinate subcutaneous syringe 6 mg/0. ml ST; QL (18 per 0 QL (7 per 90 ST; QL (18 per 90 ST; QL (18 per 0 ST; QL (18 per 0 QL (18 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

51 Name TREXIMET ORAL ZOMIG NASAL SPRAY,NON- AEROSOL. MG ZOMIG NASAL SPRAY,NON- AEROSOL MG MISCELLANEOUS CNS anectine injection bupivacaine (pf) injection bupivacaine injection bupivacainedextrose-water(pf) injection bupivacaineepinephrine (pf) injection BUPIVACAINE- EPINEPHRINE BITART CARTRIDGE bupivacaineepinephrine injection CARBOCAINE (PF) 10 MG/ML (1 %), 0 MG/ML ( %) carbocaine (pf) injection 1 mg/ml (1. %) QL (9 per fill) ST; QL (18 per 90 Name CARBOCAINE donepezil oral donepezil oral,disintegrating enlon injection ENLON-PLUS EXELON TRANSDERMAL PATCH HOUR galantamine oral,ext rel. pellets hr galantamine oral galantamine oral GRALISE 0-DAY STARTER PACK ORAL EXTENDED RELEASE HR GRALISE ORAL EXTENDED RELEASE HR guanidine oral lidocaine (pf) in d7.w intrathecal : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - QL (90 per 90 PA PA

52 Name Name lidocaine (pf) injection 10 mg/ml (1 %), 0 mg/ml ( %), mg/ml (0. %) lidocaine (pf) intravenous syringe 100 mg/ ml ( %), 0 mg/ ml (1 %) lidocaine hcl injection 10 mg/ml (1 %) lidocaine hcl laryngotracheal lidocaine in % dextrose (pf) intravenous parenteral mg/ml (0. %), 8 mg/ml (0.8 %) lidocaineepinephrine (pf) injection LIDOCAINE- EPINEPHRINE BIT CARTRIDGE %- 1:100,000 lidocaineepinephrine injection lithium carbonate oral lithium carbonate oral lithium carbonate oral extended release lithium citrate oral 8 meq/ ml lta pre-attached laryngotracheal MARCAINE (PF) 0. % (. MG/ML) marcaine (pf) injection 0.7 % (7. mg/ml) MARCAINE MARCAINE SPINAL (PF) MARCAINE- EPINEPHRINE (PF) MARCAINE- EPINEPHRINE memantine oral MEMANTINE ORAL S,DOSE PACK PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

53 Name MEPIVACAINE (PF) CARTRIDGE MESTINON ORAL SYRUP MESTINON TIMESPAN ORAL EXTENDED RELEASE NAMENDA ORAL NAMENDA ORAL NAMENDA TITRATION PAK ORAL S,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,E R HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINK LE,ER HR NAROPIN (PF) NESACAINE NESACAINE-MPF PA PA PA PA PA Name nimodipine oral NUEDEXTA ORAL CAPSULE NYMALIZE ORAL PRIALT INTRATHECAL pyridostigmine bromide oral pyridostigmine bromide oral extended release QUELICIN regonol injection riluzole oral rivastigmine tartrate oral rivastigmine transdermal patch hour ropivacaine (pf) injection 10 mg/ml (1 %), mg/ml (0. %) SAVELLA ORAL SAVELLA ORAL S,DOSE PACK PA; QL (180 per 90 PA; QL (180 per 90 PA; QL (16 per 8 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

54 Name SENSORCAINE 0. % (. MG/ML) sensorcaine injection 0. % ( mg/ml) sensorcaine/epineph rine injection SENSORCAINE- MPF SPINAL SENSORCAINE- MPF/EPINEPHRIN E tetrabenazine oral 1. mg tetrabenazine oral mg XENAZINE ORAL 1. MG XENAZINE ORAL MG XYLOCAINE (CARDIAC) (PF) xylocaine dentalepinephrine injection cartridge XYLOCAINE- EPINEPHRINE PA; QL (8 per 1 PA; QL (1 per 1 PA; QL (8 per 1 PA; QL (1 per 1 Name XYLOCAINE-MPF 1 MG/ML (1. %), 0 MG/ML ( %), 0 MG/ML ( %), MG/ML (0. %) XYLOCAINE- MPF/EPINEPHRIN E NARCOTIC ANTAGONISTS BUPRENEX buprenorphine hcl injection buprenorphine hcl injection syringe buprenorphine hcl sublingual buprenorphinenaloxone sublingual BUTRANS TRANSDERMAL PATCH WEEKLY EVZIO AUTO-INJECTOR naloxone injection naloxone injection syringe naltrexone oral QL (1 per 8 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

55 Name SUBOXONE SUBLINGUAL FILM VIVITROL R SUSPENSION,EXT ENDED REL RECON NARCOTIC MIXED AGONIST/ANTAGONIST butorphanol tartrate injection nalbuphine injection tramadol oral QL (70 per 90 tramadol oral extended release hr tramadol oral, er multiphase hr tramadolacetaminophen oral NARCOTIC/ANALGESIC COMBINATIONS acetaminophencodeine oral 10 mg-1 mg / ml ( ml), 10-1 mg/ ml, 00 mg-0 mg /1. ml acetaminophencodeine oral 00-1 mg QL (90 per 90 QL (90 per 90 QL (1080 per 90 QL (167 per 1 QL (1170 per 90 Name acetaminophencodeine oral 00-0 mg acetaminophencodeine oral mg dihydrocodeacetaminophen-caff oral dihydrocodeineaspirin-caff oral endocet oral 10- mg,.- mg, - mg, 7.- mg QL (1080 per 90 QL (0 per 90 QL (1080 per 90 endodan oral QL (1080 per 90 hydrocodoneacetaminophen oral 10- mg/1 ml(1 ml), - 16 mg/7.ml(7.ml) hydrocodoneacetaminophen oral.-167 mg/ ml hydrocodoneacetaminophen oral 7.- mg/1 ml hydrocodoneacetaminophen oral mg, 10- mg,.- mg, - mg, 7.- mg QL (700 per 1 QL (7 per 1 QL (1080 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

56 Name hydrocodoneacetaminophen oral -00 mg, mg hydrocodoneibuprofen oral IBUDONE ORAL -00 MG ibuprofen-oxycodone oral LAZANDA NASAL SPRAY,NON- AEROSOL lorcet (hydrocodone) oral QL (100 per 90 QL (1080 per 90 QL (70 per 90 PA; QL (0 per 0 QL (1080 per 90 lorcet hd oral QL (1080 per 90 lorcet plus oral 7.- mg lortab 10- oral lortab - oral lortab 7.- oral oxycodoneacetaminophen oral 10- mg,.- mg, - mg, 7.- mg oxycodone-aspirin oral PRIMLEV ORAL reprexain oral QL (1080 per 90 QL (1080 per 90 QL (1080 per 90 QL (1080 per 90 QL (1080 per 90 QL (1080 per 90 QL (1170 per 90 Name tencon oral 0- mg QL (1080 per 90 xylon 10 oral QL (1080 per 90 NARCOTICS ABSTRAL SUBLINGUAL 100 MCG ABSTRAL SUBLINGUAL 00 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG codeine sulfate oral 1 mg codeine sulfate oral 0 mg codeine sulfate oral 60 mg diskets oral,soluble duramorph (pf) injection fentanyl citrate (pf) injection fentanyl citrate (pf) intravenous syringe 100 mcg/ ml (0 mcg/ml) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 600 mcg, 800 mcg PA; QL (60 per 90 PA; QL (1 per 1 QL (160 per 90 QL (1080 per 90 QL (0 per 90 PA; QL (1 per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0

57 Name Name fentanyl citrate buccal lozenge on a handle 00 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr FENTORA BUCCAL, EFFERVESCENT PA; QL (60 per 90 QL ( per 90 PA; QL (1 per 1 methadone injection methadone intensol oral concentrate methadone oral concentrate methadone oral methadone oral hydromorphone (pf) injection methadone oral,soluble hydromorphone injection methadose oral,soluble HYDROMORPHO NE SYRINGE morphine (pf) injection 0. mg/ml, 1 mg/ml hydromorphone oral liquid hydromorphone oral mg hydromorphone oral mg hydromorphone oral 8 mg INFUMORPH P/F KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 00 MG levorphanol tartrate oral QL (10 per 90 QL (70 per 90 QL (60 per 90 QL (180 per 90 morphine (pf) intravenous patient control.analgesia soln morphine concentrate oral morphine injection syringe 10 mg/ml morphine intravenous cartridge 10 mg/ml, 1 mg/ml, mg/ml, mg/ml morphine intravenous 10 mg/ml, 100 mg/ ml, mg/ml, 0 mg/10 ml, 0 mg/ml : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

58 Name MORPHINE SYRINGE 10 MG/ML, 8 MG/ML morphine intravenous syringe mg/ml, mg/ml morphine oral,extend.relea se pellets 10 mg morphine oral,extend.relea se pellets 100 mg, 0 mg, 0 mg, 0 mg, 60 mg, 80 mg morphine oral morphine oral morphine oral extended release morphine rectal suppository NUCYNTA ORAL OPANA ER ORAL,ORAL ONLY,EXT.REL.1 HR OPANA oxycodone oral oxycodone oral concentrate QL (6 per 1 QL (180 per 90 QL (70 per 90 QL (0 per 90 QL (180 per 90 QL (0 per 90 Name oxycodone oral oxycodone oral 10 mg oxycodone oral 1 mg, 0 mg, 0 mg, mg oxymorphone oral oxymorphone oral extended release 1 hr sublimaze (pf) injection SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY NON-STEROIDAL ANTI- INFLAMMATORY celecoxib oral 100 mg, 0 mg celecoxib oral 00 mg, 00 mg diclofenac potassium oral diclofenac sodium oral extended release hr QL (0 per 90 QL (0 per 90 QL (60 per 90 PA QL (60 per 90 QL (180 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

59 Name diclofenac sodium oral,delayed release (dr/ec) diclofenacmisoprostol oral,ir & delay rel,biphasic diflunisal oral etodolac oral etodolac oral etodolac oral extended release hr fenoprofen oral flurbiprofen oral ibuprofen oral suspension ibuprofen oral 00 mg, 600 mg, 800 mg INDOCIN RECTAL SUPPOSITORY indomethacin sodium intravenous recon soln ketoprofen oral ketoprofen oral,ext rel. pellets hr 00 mg meclofenamate oral QL (90 per 90 Name mefenamic acid oral meloxicam oral nabumetone oral naproxen oral suspension naproxen oral naproxen oral,delayed release (dr/ec) naproxen sodium oral 7 mg, 0 mg oxaprozin oral piroxicam oral salsalate oral sulindac oral tolmetin oral tolmetin oral ZIPSOR ORAL CAPSULE PARKINSONS DISEASE AND RELATED DISORDERS APOKYN CARTRIDGE AZILECT ORAL benztropine injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

60 Name benztropine oral bromocriptine oral bromocriptine oral cabergoline oral carbidopa oral carbidopa-levodopa oral carbidopa-levodopa oral extended release carbidopa-levodopa oral,disintegrating carbidopa-levodopaentacapone oral DUOPA J-TUBE INTESTINAL PUMP SUSPENSION entacapone oral HORIZANT ORAL EXTENDED RELEASE NEUPRO TRANSDERMAL PATCH HOUR pramipexole oral PA Name pramipexole oral extended release hr ropinirole oral ropinirole oral extended release hr selegiline hcl oral selegiline hcl oral TASMAR ORAL 100 MG tolcapone oral trihexyphenidyl oral elixir trihexyphenidyl oral ZELAPAR ORAL,DISINTE GRATING SEDATIVE/HYPNOTICS ROZEREM ORAL XYREM ORAL zaleplon oral QL (90 per 90 PA; LA PA; QL (90 per 90 SKELETAL MUSCLE RELAXANTS baclofen oral cyclobenzaprine oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

61 Name Name DANTRIUM dantrolene oral metaxalone oral methocarbamol injection revonto intravenous recon soln tizanidine oral tizanidine oral DERMATOLOGY ACNE TREATMENT adapalene topical cream adapalene topical gel adapalene topical gel with pump amnesteem oral avita topical cream AZELEX TOPICAL CREAM BENZACLIN PUMP TOPICAL GEL BENZACLIN TOPICAL GEL claravis oral 0 mg clindacin etz topical swab clindacin p topical swab CLINDACIN PAC TOPICAL KIT CLINDAGEL TOPICAL GEL clindamycin phosphate intravenous 00 mg/ ml clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel DIFFERIN TOPICAL GEL 0. % claravis oral 10 mg, 0 mg, 0 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

62 Name DIFFERIN TOPICAL GEL WITH PUMP DIFFERIN TOPICAL LOTION DUAC TOPICAL GEL erythromycinbenzoyl peroxide topical gel FINACEA TOPICAL GEL metronidazole topical cream metronidazole topical gel metronidazole topical lotion neuac topical gel NORITATE TOPICAL CREAM RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.0 %, 0.1 % rosadan topical cream rosadan topical gel ROSADAN TOPICAL KIT, CLEANSER & GEL ROSADAN TOPICAL KIT,CLEANSER AND CREAM Name sulfacetamide sodium (acne) topical suspension TAZORAC TOPICAL CREAM TAZORAC TOPICAL GEL tretinoin microspheres topical gel tretinoin microspheres topical gel with pump tretinoin topical cream tretinoin topical gel VELTIN TOPICAL GEL ANTIPSORIATIC/ANTISEBORRHEI C 8-MOP ORAL CAPSULE acitretin oral calcipotriene topical cream calcipotriene topical ointment calcipotriene topical calcipotrienebetamethasone topical ointment calcitrene topical ointment : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

63 Name Name calcitriol topical ointment diclofenac sodium topical gel methoxsalen rapid oral ELIDEL TOPICAL CREAM OXSORALEN TOPICAL LOTION OXSORALEN ULTRA ORAL CAPSULE selenium sulfide topical suspension SORIATANE ORAL CAPSULE 17. MG, MG SORILUX TOPICAL FOAM TACLONEX TOPICAL OINTMENT FLECTOR TRANSDERMAL PATCH 1 HOUR fluorouracil intravenous 1 gram/0 ml FLUOROURACIL TOPICAL CREAM 0. % fluorouracil topical cream % fluorouracil topical imiquimod topical cream in packet PA B/D PA TACLONEX TOPICAL SUSPENSION LEVULAN TOPICAL MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream ammonium lactate topical lotion CARAC TOPICAL CREAM CONDYLOX TOPICAL GEL diclofenac sodium topical drops PANRETIN TOPICAL GEL PICATO TOPICAL GEL 0.01 % PICATO TOPICAL GEL 0.0 % podofilox topical prudoxin topical cream tacrolimus topical ointment QL ( per 1 QL ( per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

64 Name TARGRETIN TOPICAL GEL VEREGEN TOPICAL OINTMENT VOLTAREN GEL TOPICAL GEL 1 % VUSION TOPICAL OINTMENT PA QL (1000 per 1 SCABICIDES/PEDICULICIDES EURAX TOPICAL CREAM EURAX TOPICAL LOTION lindane topical lotion lindane topical shampoo malathion topical lotion permethrin topical cream SKLICE TOPICAL LOTION TOPICAL ANESTHETICS glydo mucous membrane jelly in applicator lidocaine (pf) injection 1 mg/ml (1. %) LIDOCAINE (PF) 0 MG/ML ( %) Name lidocaine (pf) intravenous lidocaine hcl injection 0 mg/ml ( %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane lidocaine hcl urethral gel lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous mucous membrane LIDOCAINE- EPINEPHRINE BIT CARTRIDGE %- 1:0,000 lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit MARCAINE (PF) 0. % ( MG/ML) PA; QL (90 per 0 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

65 Name PLIAGLIS TOPICAL CREAM relador pak plus topical kit relador pak topical kit sensorcaine-mpf injection 0. % ( mg/ml) SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING TOPICAL ANTIBACTERIALS ALTABAX TOPICAL OINTMENT BACTROBAN NASAL NASAL OINTMENT CENTANY TOPICAL OINTMENT CORTISPORIN TOPICAL CREAM CORTISPORIN TOPICAL OINTMENT ery pads topical swab erygel topical gel erythromycin with ethanol topical gel erythromycin with ethanol topical Name erythromycin with ethanol topical swab gentamicin topical cream gentamicin topical ointment METROGEL TOPICAL GEL WITH PUMP metronidazole topical gel with pump mupirocin calcium topical cream mupirocin topical ointment SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS CICLODAN KIT TOPICAL COMBO PACK ciclodan topical cream ciclodan topical ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

66 Name Name ciclopirox topical suspension nystatin topical cream clotrimazole topical cream nystatin topical ointment clotrimazole topical nystatin topical powder clotrimazolebetamethasone topical cream nystatintriamcinolone topical cream clotrimazolebetamethasone topical lotion nystatintriamcinolone topical ointment econazole topical cream nystop topical powder ERTACZO TOPICAL CREAM OXISTAT TOPICAL CREAM EXELDERM TOPICAL CREAM OXISTAT TOPICAL LOTION EXELDERM TOPICAL ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo MENTAX TOPICAL CREAM NAFTIN TOPICAL CREAM NAFTIN TOPICAL GEL nyamyc topical powder XOLEGEL TOPICAL GEL TOPICAL ANTIVIRALS DENAVIR TOPICAL CREAM XERESE TOPICAL CREAM ZOVIRAX TOPICAL CREAM TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone topical cream alclometasone topical ointment : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 60

67 Name Name amcinonide topical cream amcinonide topical lotion amcinonide topical ointment apexicon e topical cream ARISTOSPAN INTRA- ARTICULAR SUSPENSION ARISTOSPAN INTRALESIONAL SUSPENSION betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX TOPICAL SHAMPOO betamethasone dipropionate topical cream betamethasone dipropionate topical lotion betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical foam clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical betamethasone valerate topical lotion clobetasol topical spray,non-aerosol clobetasol-emollient topical cream : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 61

68 Name Name clobetasol-emollient topical foam fluocinolone topical oil CLOBEX TOPICAL SPRAY,NON- AEROSOL clodan topical shampoo CORDRAN TAPE LARGE ROLL TOPICAL TAPE CORDRAN TAPE SMALL ROLL TOPICAL TAPE cormax topical dermasilkrx sds topical kit desonide topical cream desonide topical lotion desonide topical ointment desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment diflorasone topical cream diflorasone topical ointment fluocinolone topical cream fluocinolone topical ointment fluocinolone topical fluocinolone-shower cap topical oil fluocinonide topical cream fluocinonide topical gel fluocinonide topical ointment fluocinonide topical fluocinonide-e topical cream fluticasone topical cream fluticasone topical lotion fluticasone topical ointment halobetasol propionate topical cream halobetasol propionate topical ointment HALOG TOPICAL CREAM HALOG TOPICAL OINTMENT : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

69 Name hydrocortisone butyrate topical cream hydrocortisone butyrate topical ointment hydrocortisone butyrate topical hydrocortisone butyr-emollient topical cream hydrocortisone topical cream 1 %,. % hydrocortisone topical lotion. % hydrocortisone topical ointment 1 %,. % hydrocortisone valerate topical cream hydrocortisone valerate topical ointment hydrocortisone-min oil-wht pet topical ointment KENALOG TOPICAL AEROSOL LOCOID LIPOCREAM TOPICAL CREAM LOCOID TOPICAL LOTION Name mometasone topical cream mometasone topical ointment mometasone topical PANDEL TOPICAL CREAM prednicarbate topical cream prednicarbate topical ointment SYNALAR TS TOPICAL KIT TEXACORT TOPICAL TOPICORT TOPICAL SPRAY,NON- AEROSOL triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.0 %, 0.1 %, 0. % trianex topical ointment : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

70 Name triderm topical cream WOUND AND BURN THERAPY REGRANEX TOPICAL GEL SANTYL TOPICAL OINTMENT silver sulfadiazine topical cream ssd topical cream DIAGNOSTIC AND OTHER MISCELLANEOUS DIAGNOSTIC AND OTHER MISCELLANEOUS acamprosate oral,delayed release (dr/ec) acetylcysteine intravenous ACTHREL AMMONUL ARTISS TOPICAL SYRINGE AURYXIA ORAL BAL IN OIL R PA Name CALCIUM DISODIUM VERSENATE CARBAGLU ORAL, DISPERSIBLE cardioplegic soln perfusion CARNITOR SUGAR-FREE ORAL CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cevimeline oral CHEMET ORAL CAPSULE chlorhexidine gluconate mucous membrane mouthwash CINRYZE deferoxamine injection recon soln DESFERAL LA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

71 Name disulfiram oral EXJADE ORAL, DISPERSIBLE FERRIPROX ORAL FIRAZYR SYRINGE flumazenil intravenous FOSRENOL ORAL POWDER IN PACKET FOSRENOL ORAL,CHEWAB LE gavilyte-c oral recon soln gavilyte-g oral recon soln gavilyte-h and bisacodyl oral kit gavilyte-n oral recon soln glycine irrigation glycine urologic irrigation GOLYTELY ORAL POWDER IN PACKET PA Name HESPAN 6 % IN NS hetastarch 6 % in 0.9 % nacl intravenous HETLIOZ ORAL CAPSULE HEXTEND JADENU ORAL KALBITOR kionex oral powder kionex oral suspension KUVAN ORAL POWDER IN PACKET KUVAN ORAL,SOLUBL E lactated ringers irrigation levocarnitine (with sugar) oral levocarnitine intravenous levocarnitine oral PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

72 Name Name mannitol 10 % intravenous parenteral osmitrol 0 % intravenous parenteral mannitol 0 % intravenous parenteral mannitol % intravenous mannitol % intravenous parenteral MOVIPREP ORAL POWDER IN PACKET neomycin-polymyxin b gu irrigation NEOPROFEN (IBUPROFEN LYSN)(PF) NEOSPORIN GU IRRIGANT IRRIGATION oralone dental paste ORFADIN ORAL CAPSULE OSMITROL 10 % PARENTERAL osmitrol 1 % intravenous parenteral OSMITROL % PARENTERAL OSMOPREP ORAL PANHEMATIN paroex oral rinse mucous membrane mouthwash peg 0- electrolytes oral recon soln peg-0 with flavor packs oral recon soln peg-electrolyte soln oral recon soln peg-prep oral kit periogard mucous membrane mouthwash pilocarpine hcl oral PLEGISOL PERFUSION polyethylene glycol 0 oral powder : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 66

73 Name polyethylene glycol 0 oral powder in packet PREPOPIK ORAL POWDER IN PACKET PROSTIN VR PEDIATRIC protamine intravenous PROTOPAM CHLORIDE RAVICTI ORAL LIQUID RENACIDIN IRRIGATION RENAGEL ORAL RENVELA ORAL POWDER IN PACKET RENVELA ORAL RESECTISOL URETHRAL ringers irrigation RUCONEST PA PA Name SAMSCA ORAL sodium chloride irrigation sodium polystyrene (sorb free) oral suspension sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema SORBITOL IRRIGATION SORBITOL- MANNITOL URETHRAL SOTRADECOL sps oral suspension sps rectal enema SUPREP BOWEL PREP KIT ORAL TEMODAR PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 67

74 Name THAM tranexamic acid intravenous tranexamic acid oral triamcinolone acetonide dental paste trilyte with flavor packets oral recon soln UVADEX water for irrigation, sterile irrigation XIAFLEX ENDOCRINOLOGY QL (90 per 6 PA; QL ( per 90 ADRENOCORTICAL STEROIDS ACTHAR H.P. GEL a-hydrocort injection recon soln betamethasone acet,sod phos injection suspension budesonide oral,delayed,exte nd.release PA Name CELESTONE SOLUSPAN SUSPENSION cortisone oral deltasone oral 0 mg DEPO-MEDROL SUSPENSION dexamethasone intensol oral drops dexamethasone oral elixir dexamethasone oral dexamethasone oral FLO-PRED ORAL SUSPENSION fludrocortisone oral hydrocortisone oral methylprednisolone acetate injection suspension methylprednisolone oral methylprednisolone oral s,dose pack methylprednisolone sodium succ injection recon soln 1 mg, 0 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 68

75 Name methylprednisolone sodium succ intravenous recon soln millipred dp oral s,dose pack MILLIPRED ORAL millipred oral prednisolone oral 1 mg/ ml prednisolone sodium phosphate oral 1 mg/ ml, mg/ ml ( mg/ml), mg base/ ml (6.7 mg/ ml) prednisolone sodium phosphate oral,disintegrating prednisone intensol oral concentrate prednisone oral prednisone oral prednisone oral s,dose pack SOLU-CORTEF SOLU-MEDROL (PF) Name SOLU-MEDROL (PF) SOLU-MEDROL triamcinolone acetonide injection suspension veripred 0 oral ANDROGENS ANDRODERM TRANSDERMAL PATCH HOUR MG/ HOUR ANDRODERM TRANSDERMAL PATCH HOUR MG/ HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP ANDROGEL TRANSDERMAL GEL IN PACKET ANDROID ORAL CAPSULE androxy oral AXIRON TRANSDERMAL IN METERED PUMP W/APP PA; QL (180 per 90 PA; QL (90 per 90 PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 69

76 Name danazol oral METHITEST ORAL oxandrolone oral 10 mg oxandrolone oral. mg STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 1 HR TESTIM TRANSDERMAL GEL TESTOPEL IMPLANT PELLET testosterone cypionate intramuscular oil testosterone enanthate intramuscular oil TESTRED ORAL CAPSULE ANTITHYROID AGENTS methimazole oral 10 mg, mg propylthiouracil oral GLUCOCORTICOIDS dexamethasone sodium phosphate injection mg/ml PA PA PA Name SOLU-CORTEF (PF) GROWTH HORMONE AND RELATED PRODUCTS GENOTROPIN MINIQUICK SYRINGE 0. MG/0. ML GENOTROPIN MINIQUICK SYRINGE 0. MG/0. ML, 0.6 MG/0. ML, 0.8 MG/0. ML, 1 MG/0. ML, 1. MG/0. ML, 1. MG/0. ML, 1.6 MG/0. ML, 1.8 MG/0. ML, MG/0. ML GENOTROPIN CARTRIDGE HUMATROPE CARTRIDGE HUMATROPE NORDITROPIN FLEXPRO PEN INJECTOR PA PA PA PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 70

77 Name Name NUTROPIN AQ NUSPIN CARTRIDGE PA HUMALOG KWIKPEN INSULIN PEN NUTROPIN AQ CARTRIDGE 0 MG/ ML (10 MG/ML) OMNITROPE CARTRIDGE PA PA HUMALOG MIX 0-0 KWIKPEN INSULIN PEN HUMALOG MIX 0-0 SUSPENSION OMNITROPE SAIZEN CLICK.EASY CARTRIDGE SAIZEN SEROSTIM MG, MG, 6 MG PA PA PA PA HUMALOG MIX 7- KWIKPEN INSULIN PEN HUMALOG MIX 7- SUSPENSION HUMALOG CARTRIDGE HUMALOG INSULINS alcohol pads topical pads, medicated APIDRA SOLOSTAR INSULIN PEN APIDRA gauze pads x HUMULIN 70/0 KWIKPEN INSULIN PEN HUMULIN 70/0 SUSPENSION HUMULIN N KWIKPEN INSULIN PEN : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 71

78 Name HUMULIN N SUSPENSION HUMULIN R HUMULIN R U-00 (CONCENTRATED ) insulin pen needle insulin syringe (disp) u ml insulin syringe (disp) u ml syringe insulin syringe (disp) u-100 1/ ml LANTUS SOLOSTAR INSULIN PEN LANTUS LEVEMIR FLEXTOUCH INSULIN PEN LEVEMIR needles, insulin disp.,safety NOVOFINE 0 NEEDLE Name NOVOFINE NEEDLE NOVOFINE PLUS NEEDLE NOVOLIN 70/0 SUSPENSION NOVOLIN N SUSPENSION NOVOLIN R NOVOLOG FLEXPEN INSULIN PEN NOVOLOG MIX 70-0 FLEXPEN INSULIN PEN NOVOLOG MIX 70-0 NOVOLOG PENFILL CARTRIDGE NOVOLOG NOVOTWIST NEEDLE MISCELLANEOUS ENDOCRINE : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

79 Name Name ALDURAZYME BUPHENYL ORAL POWDER BUPHENYL ORAL CERDELGA ORAL CAPSULE CEREZYME 00 UNIT CHORIONIC GONADOTROPIN, HUMAN R CYSTADANE ORAL POWDER desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal PA EGRIFTA MG ELAPRASE ELELYSO ELITEK FABRAZYME GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) KIT INCRELEX PA desmopressin nasal spray,non-aerosol KORLYM ORAL PA desmopressin oral EGRIFTA 1 MG QL (60 per 0 LUMIZYME MYALEPT B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

80 Name MYOZYME NAGLAZYME novarel intramuscular recon soln octreotide acetate injection 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection 100 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe pamidronate intravenous recon soln pamidronate intravenous PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE SANDOSTATIN LAR DEPOT R KIT PA PA Name SANDOSTATIN LAR DEPOT R SUSPENSION,EXT ENDED REL RECON SENSIPAR ORAL 0 MG SENSIPAR ORAL 60 MG, 90 MG SIGNIFOR LAR R SUSPENSION FOR RECONSTITUTIO N SIGNIFOR sodium phenylbutyrate oral powder SOMATULINE DEPOT SYRINGE SOMAVERT STIMATE NASAL SPRAY,NON- AEROSOL SYPRINE ORAL CAPSULE vasopressin injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7 PA

81 Name VIMIZIM VPRIV ZAVESCA ORAL CAPSULE PA NON-INSULIN HYPOGLYCEMIC AGENTS BYDUREON PEN INJECTOR BYDUREON SUSPENSION,EXT ENDED REL RECON BYETTA PEN INJECTOR 10 MCG/DOSE(0 MCG/ML). ML BYETTA PEN INJECTOR MCG/DOSE (0 MCG/ML) 1. ML CYCLOSET ORAL SYMLINPEN 10 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR PA; QL (1 per 8 PA; QL (1 per 8 PA; QL (7. per 8 PA; QL (.6 per 8 QL (0 per 90 Name VICTOZA -PAK PEN INJECTOR VICTOZA -PAK PEN INJECTOR PA PA ORAL HYPOGLYCEMIC AGENTS acarbose oral ACTOPLUS MET XR ORAL, ER MULTIPHASE HR FARXIGA ORAL glimepiride oral QL (90 per 90 ST glipizide oral glipizide oral extended release hr 10 mg glipizide oral extended release hr. mg, mg glipizide-metformin oral GLUMETZA ORAL,ER GAST.RETENTION HR 1,000 MG GLUMETZA ORAL,ER GAST.RETENTION HR 00 MG GLYSET ORAL ; QL (180 per 90 ; QL (70 per 90 QL (180 per 90 QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

82 Name Name INVOKAMET ORAL INVOKANA ORAL JANUMET ORAL JANUMET XR ORAL, ER MULTIPHASE HR 100-1,000 MG JANUMET XR ORAL, ER MULTIPHASE HR 0-1,000 MG, 0-00 MG JANUVIA ORAL JENTADUETO ORAL ST ST QL (180 per 90 QL (90 per 90 QL (180 per 90 QL (90 per 90 QL (180 per 90 metformin oral extended release hr 70 mg metformin oral extended release hr 1,000 mg metformin oral extended release (osm) hr 00 mg nateglinide oral ONGLYZA ORAL pioglitazone oral pioglitazoneglimepiride oral ; QL (180 per 90 ; QL (180 per 90 ; QL (70 per 90 QL (90 per 90 KOMBIGLYZE XR ORAL, ER MULTIPHASE HR.-1,000 MG KOMBIGLYZE XR ORAL, ER MULTIPHASE HR -1,000 MG, -00 MG QL (180 per 90 QL (90 per 90 pioglitazonemetformin oral PRANDIMET ORAL repaglinide oral tolazamide oral metformin oral tolbutamide oral metformin oral extended release hr 00 mg ; QL (60 per 90 TRADJENTA ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 76

83 Name XIGDUO XR ORAL, IR & ER, BIPHASIC HR THYROID HORMONES levothyroxine intravenous recon soln 00 mcg, 00 mcg levothyroxine oral levoxyl oral 100 mcg, 11 mcg, 1 mcg, 17 mcg, 10 mcg, 17 mcg, 00 mcg, mcg, 0 mcg, 7 mcg, 88 mcg liothyronine intravenous liothyronine oral np thyroid oral SYNTHROID ORAL THYROLAR-1 ORAL THYROLAR-1/ ORAL THYROLAR-1/ ORAL THYROLAR- ORAL THYROLAR- ORAL ST Name TRIOSTAT unithroid oral GASTROINTESTINAL AGENTS ANTIDIARRHEALS AND ANTISPASMODICS atropine injection syringe 0.0 mg/ml, 0.1 mg/ml CANTIL ORAL dicyclomine oral dicyclomine oral dicyclomine oral diphenoxylateatropine oral liquid diphenoxylateatropine oral FULYZAQ ORAL,DELAYE D RELEASE (DR/EC) glycopyrrolate injection glycopyrrolate oral loperamide oral methscopolamine oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 77

84 Name propantheline oral ROBINUL ANTIEMETICS AKYNZEO ORAL CAPSULE ALOXI ANZEMET ANZEMET ORAL CESAMET ORAL CAPSULE compro rectal suppository dimenhydrinate injection dronabinol oral EMEND EMEND ORAL CAPSULE EMEND ORAL CAPSULE,DOSE PACK granisetron (pf) intravenous B/D PA B/D PA B/D PA B/D PA Name granisetron hcl intravenous granisetron hcl oral meclizine oral 1. mg, mg ondansetron hcl (pf) injection ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral ondansetron hcl oral ondansetron oral,disintegrating prochlorperazine edisylate injection prochlorperazine maleate oral prochlorperazine rectal suppository SANCUSO TRANSDERMAL PATCH WEEKLY TRANSDERM- SCOP TRANSDERMAL PATCH DAY DIGESTIVE ENZYMES B/D PA B/D PA B/D PA B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 78

85 Name CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) VIOKACE ORAL ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-,000 -,000 UNIT, 1,000-1,000-8,000 UNIT, 0,000-68, ,000 UNIT,,000-8,000-16,000 UNIT,,000-10,000-16,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0,000-16,000-18,000 UNIT H-RECEPTOR ANTAGONISTS famotidine (pf) intravenous Name famotidine (pf)-nacl (iso-os) intravenous piggyback famotidine intravenous famotidine oral suspension famotidine oral 0 mg, 0 mg nizatidine oral nizatidine oral ranitidine hcl injection ranitidine hcl oral ranitidine hcl oral syrup ranitidine hcl oral 10 mg, 00 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 79 MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron oral PA AMITIZA ORAL CAPSULE APRISO ORAL CAPSULE,EXTEN DED RELEASE HR ASACOL HD ORAL,DELAYE D RELEASE (DR/EC) PA

86 Name balsalazide oral CANASA RECTAL SUPPOSITORY CHENODAL ORAL colocort rectal enema constulose oral CORTIFOAM RECTAL FOAM CUVPOSA ORAL DELZICOL ORAL CAPSULE,DELAY ED RELEASE(DR/EC) DIPENTUM ORAL CAPSULE ENTEREG ORAL CAPSULE enulose oral GATTEX 0-VIAL KIT GATTEX ONE- VIAL KIT generlac oral hydrocortisone rectal enema PA; LA PA PA Name KRISTALOSE ORAL PACKET lactulose oral LIALDA ORAL,DELAYE D RELEASE (DR/EC) LINZESS ORAL CAPSULE LOTRONEX ORAL mesalamine rectal enema mesalamine with cleansing wipe rectal enema kit metoclopramide hcl injection metoclopramide hcl injection syringe metoclopramide hcl oral metoclopramide hcl oral metoclopramide hcl oral,disintegrating MOVANTIK ORAL NUTRESTORE ORAL POWDER IN PACKET opium tincture oral tincture PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 80

87 Name pancrelipase 000 oral,delayed release(dr/ec) paregoric oral liquid PENTASA ORAL CAPSULE, EXTENDED RELEASE procto-pak rectal cream proctosol hc rectal cream proctozone-hc rectal cream RELISTOR RELISTOR SYRINGE SUCRAID ORAL sulfasalazine oral sulfasalazine oral,delayed release (dr/ec) sulfazine ec oral,delayed release (dr/ec) sulfazine oral ursodiol oral ursodiol oral PA PA OTHER ULCER THERAPY Name amoxicilclarithromylansopraz oral combo pack CARAFATE ORAL SUSPENSION misoprostol oral OMECLAMOX- PAK ORAL COMBO PACK PYLERA ORAL CAPSULE sucralfate oral PROTON PUMP INHIBITORS esomeprazole magnesium oral,delayed release(dr/ec) esomeprazole sodium intravenous recon soln lansoprazole oral,delayed release(dr/ec) omeprazole oral,delayed release(dr/ec) 10 mg, 0 mg omeprazole oral,delayed release(dr/ec) 0 mg omeprazole-sodium bicarbonate oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 81

88 Name pantoprazole oral,delayed release (dr/ec) rabeprazole oral,delayed release (dr/ec) IMMUNOLOGY AND HEMATOLOGY ANTI-COAGULANTS/HEMOSTASIS AGENTS THROMBATE III 00 (+/-) UNIT COLONY STIMULATING FACTORS ARANESP (IN POLYSORBATE) 100 MCG/ML, 10 MCG/0.7 ML, 00 MCG/ML, 00 MCG/ML ARANESP (IN POLYSORBATE) MCG/ML ARANESP (IN POLYSORBATE) 0 MCG/ML, 60 MCG/ML PA PA; QL (6 per 8 PA Name ARANESP (IN POLYSORBATE) SYRINGE 10 MCG/0. ML, 100 MCG/0. ML, 0 MCG/0. ML, 60 MCG/0. ML ARANESP (IN POLYSORBATE) SYRINGE 10 MCG/0. ML, 00 MCG/0. ML, 00 MCG/0.6 ML, 00 MCG/ML ARANESP (IN POLYSORBATE) SYRINGE MCG/0. ML EPOGEN 10,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML EPOGEN,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML GRANIX SYRINGE NEULASTA SYRINGE PA PA PA; QL (6 per 8 PA PA; QL (6 per 8 QL (1. per 8 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

89 Name NEULASTA SYRINGE, W/ WEARABLE INJECTOR NEUPOGEN NEUPOGEN SYRINGE PROCRIT 10,000 UNIT/ML, 0,000 UNIT/ ML PROCRIT,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML PROCRIT 0,000 UNIT/ML, 0,000 UNIT/ML IMMUNOGLOBULINS ADAGEN R ATGAM INJECTABLE BIVIGAM QL (1. per 8 PA PA; QL (6 per 8 PA PA Name CARIMUNE NF NANOFILTERED 1 GRAM, 6 GRAM CYTOGAM 0 MG/ML FLEBOGAMMA DIF GAMASTAN S/D R GAMMAGARD LIQUID GAMMAGARD S- D (IGA < 1 MCG/ML) GAMMAPLEX GAMUNEX-C HEPAGAM B HIZENTRA PA PA PA PA PA PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

90 Name HYPERHEP B S/D R HYPERHEP B S/D R SYRINGE HYPERHEP B S-D NEONATAL R SYRINGE HYPERRAB S/D (PF) R HYPERRHO S/D R SYRINGE HYPERTET S/D (PF) R SYRINGE HYQVIA IMOGAM RABIES- HT (PF) R MICRHOGAM ULTRA-FILTERED PLUS R SYRINGE NABI-HB R B/D PA B/D PA Name OCTAGAM PRIVIGEN RHOGAM ULTRA- FILTERED PLUS R SYRINGE RHOPHYLAC SYRINGE SYNAGIS R 0 MG/0. ML THYMOGLOBULI N VARIZIG R VARIZIG R WINRHO SDF PA PA INTERFERONS AND MS THERAPY ACTIMMUNE AMPYRA ORAL EXTENDED RELEASE 1 HR PA; QL (6 per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

91 Name Name AUBAGIO ORAL AVONEX (WITH ALBUMIN) R KIT PA INTRON A LEMTRADA PA; QL (6 per 6 AVONEX R PEN INJECTOR KIT PEGASYS PROCLICK PEN INJECTOR QL ( per 8 AVONEX R SYRINGE PEGASYS QL ( per 8 AVONEX R SYRINGE KIT PEGASYS SYRINGE BETASERON KIT COPAXONE SYRINGE EXTAVIA KIT EXTAVIA GILENYA ORAL CAPSULE ST QL (1 per 1 PEGINTRON REDIPEN PEN INJECTOR KIT PEGINTRON KIT 10 MCG/0. ML, 10 MCG/0. ML, 80 MCG/0. ML PEGINTRON KIT 0 MCG/0. ML QL ( per 8 QL ( per 8 glatopa subcutaneous syringe PLEGRIDY PEN INJECTOR INTRON A PLEGRIDY SYRINGE 1 MCG/0. ML : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

92 Name REBIF (WITH ALBUMIN) SYRINGE REBIF REBIDOSE PEN INJECTOR REBIF TITRATION PACK SYRINGE SYLATRON KIT MISCELLANEOUS IMMUNOLOGIC AND HEMATOLOGIC AGENTS ACTEMRA albumin, human % intravenous parenteral albumin, human % intravenous parenteral albuminar % intravenous parenteral albuminar % intravenous parenteral alburx (human) % intravenous parenteral alburx (human) % intravenous parenteral PA Name albutein % intravenous parenteral albutein % intravenous parenteral BENLYSTA buminate % intravenous parenteral buminate % intravenous parenteral CIMZIA POWDER FOR RECONST KIT CIMZIA STARTER KIT SYRINGE KIT CIMZIA SYRINGE KIT COSENTYX ( SYRINGES) SYRINGE COSENTYX PEN ( PENS) PEN INJECTOR COSENTYX PEN PEN INJECTOR PA PA PA PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 86

93 Name Name COSENTYX SYRINGE PA HUMIRA SYRINGE KIT ENBREL QL (8 per 8 KINERET SYRINGE PA; QL (18.8 per 8 ENBREL SYRINGE MOZOBIL PA ENBREL SURECLICK PEN INJECTOR FLEXBUMIN % PARENTERAL FLEXBUMIN % PARENTERAL HUMIRA PEN CROHN'S-UC-HS START PEN INJECTOR KIT HUMIRA PEN PSORIASIS STARTER PEN INJECTOR KIT HUMIRA PEN PEN INJECTOR KIT NEUMEGA NPLATE ORENCIA (WITH MALTOSE) ORENCIA SYRINGE OTEZLA ORAL OTEZLA STARTER ORAL S,DOSE PACK plasbumin % intravenous parenteral plasbumin % intravenous parenteral plasmanate intravenous parenteral PA PA PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 87

94 Name PROMACTA ORAL 1. MG, 7 MG PROMACTA ORAL MG PROMACTA ORAL 0 MG REMICADE SIMPONI PEN INJECTOR SIMPONI SYRINGE SOLIRIS STELARA SYRINGE SYLVANT TYSABRI XELJANZ ORAL PA PA; QL (6 per 1 PA; QL (1 per 1 B/D PA PA PA PA PA PA; LA PA PROTEIN C1 INHIBITORS ARALAST NP PA Name GLASSIA PROLASTIN-C ZEMAIRA VACCINES ACTHIB (PF) R ADACEL(TDAP ADOLESN/ADULT )(PF) R SUSPENSION ADACEL(TDAP ADOLESN/ADULT )(PF) R SYRINGE BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTIO N BEXSERO (PF) R SYRINGE BOOSTRIX TDAP R SUSPENSION BOOSTRIX TDAP R SYRINGE PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 88

95 Name Name CERVARIX VACCINE (PF) R SYRINGE COMVAX (PF) R SUSPENSION DAPTACEL (DTAP PEDIATRIC) (PF) R SUSPENSION ENGERIX-B (PF) R SUSPENSION B/D PA HAVRIX (PF) R SUSPENSION HAVRIX (PF) R SYRINGE IMOVAX RABIES VACCINE (PF) R INFANRIX (DTAP) (PF) R SUSPENSION ENGERIX-B (PF) R SYRINGE ENGERIX-B PEDIATRIC (PF) R SUSPENSION ENGERIX-B PEDIATRIC (PF) R SYRINGE GARDASIL (PF) R SUSPENSION GARDASIL (PF) R SYRINGE GARDASIL 9 (PF) R SUSPENSION GARDASIL 9 (PF) R SYRINGE B/D PA B/D PA B/D PA INFANRIX (DTAP) (PF) R SYRINGE IPOL SUSPENSION IPOL SYRINGE IXIARO (PF) R SYRINGE KINRIX (PF) R SUSPENSION KINRIX (PF) R SYRINGE MENACTRA (PF) R : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 89

96 Name Name MENOMUNE - A/C/Y/W-1 (PF) RECOMBIVAX HB (PF) R SUSPENSION B/D PA MENOMUNE - A/C/Y/W-1 RECOMBIVAX HB (PF) R SYRINGE B/D PA MENVEO A-C-Y- W-1-DIP (PF) R KIT ROTARIX ORAL SUSPENSION FOR RECONSTITUTIO N M-M-R II (PF) ROTATEQ VACCINE ORAL SUSPENSION PEDIARIX (PF) R SYRINGE TENIVAC (PF) R SUSPENSION PEDVAX HIB (PF) R TENIVAC (PF) R SYRINGE PENTACEL (PF) R KIT PROQUAD (PF) SUSPENSION FOR RECONSTITUTIO N QUADRACEL (PF) R SUSPENSION RABAVERT (PF) R SUSPENSION FOR RECONSTITUTIO N TETANUS,DIPHTH ERIA TOX PED(PF) R SUSPENSION TETANUS- DIPHTHERIA TOXOIDS-TD R SUSPENSION THERACYS INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N : 1-Preferred Generic -Specialty s : B/D - Prior Authorization, Part D vs. Part B only Limited Availability PA - Prior Authorization QL - Quantity Limit -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand 90 GC Gap Coverage LA - ST - Step Therapy

97 Name Name TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N ZOSTAVAX (PF) SUSPENSION FOR RECONSTITUTIO N TRUMENBA R SYRINGE TWINRIX (PF) R SUSPENSION TWINRIX (PF) R SYRINGE TYPHIM VI R TYPHIM VI R SYRINGE VAQTA (PF) R SUSPENSION VAQTA (PF) R SYRINGE VARIVAX (PF) SUSPENSION FOR RECONSTITUTIO N YF-VAX (PF) SUSPENSION FOR RECONSTITUTIO N LIFESTYLE MODIFICATION SMOKING CESSATION CHANTIX CONTINUING MONTH BOX ORAL CHANTIX ORAL CHANTIX STARTING MONTH BOX ORAL S,DOSE PACK NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON- AEROSOL OPHTHALMOLOGY MISCELLANEOUS OPHTHALMIC AGENTS AKTEN (PF) OPHTHALMIC GEL ALOCRIL OPHTHALMIC DROPS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 91

98 Name Name ALOMIDE OPHTHALMIC DROPS CYSTARAN OPHTHALMIC DROPS altacaine ophthalmic drops altafluor ophthalmic drops atropine ophthalmic drops azelastine ophthalmic drops balanced salt intraocular BEPREVE OPHTHALMIC DROPS betaxolol ophthalmic drops BETOPTIC S OPHTHALMIC DROPS,SUSPENSI ON bss intraocular BSS PLUS INTRAOCULAR cromolyn ophthalmic drops CYCLOGYL OPHTHALMIC DROPS cyclopentolate ophthalmic drops EMADINE OPHTHALMIC DROPS epinastine ophthalmic drops EYLEA INTRAVITREAL fluoresceinbenoxinate ophthalmic drops fluoresceinproparacaine ophthalmic drops flurox ophthalmic drops LACRISERT OPHTHALMIC INSERT LASTACAFT OPHTHALMIC DROPS LUCENTIS INTRAVITREAL naphazoline ophthalmic drops PATADAY OPHTHALMIC DROPS PATANOL OPHTHALMIC DROPS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

99 Name PAZEO OPHTHALMIC DROPS proparacaine ophthalmic drops RESTASIS OPHTHALMIC DROPPERETTE tetracaine hcl ophthalmic drops tropicamide ophthalmic drops OPHTHALMIC ANTI- INFECTIVE/STEROID COMBINATIONS BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSI ON BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT neomycinbacitracin-poly-hc ophthalmic ointment neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neo-polycin hc ophthalmic ointment Name sulfacetamideprednisolone ophthalmic drops TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST OPHTHALMIC DROPS,SUSPENSI ON tobramycindexamethasone ophthalmic drops,suspension ZYLET OPHTHALMIC DROPS,SUSPENSI ON OPHTHALMIC ANTI-INFECTIVES ak-poly-bac ophthalmic ointment AZASITE OPHTHALMIC DROPS bacitracin ophthalmic ointment bacitracinpolymyxin b ophthalmic ointment BESIVANCE OPHTHALMIC DROPS,SUSPENSI ON BLEPH-10 OPHTHALMIC DROPS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

100 Name Name CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic drops erythromycin ophthalmic ointment erythromycin oral,delayed release(dr/ec) neomycinpolymyxingramicidin ophthalmic drops neo-polycin ophthalmic ointment ofloxacin ophthalmic drops polycin ophthalmic ointment garamycin ophthalmic drops gatifloxacin ophthalmic drops gentak ophthalmic ointment gentamicin ophthalmic drops gentamicin ophthalmic ointment levofloxacin ophthalmic drops polymyxin b sulftrimethoprim ophthalmic drops PRED-G OPHTHALMIC DROPS,SUSPENSI ON PRED-G S.O.P. OPHTHALMIC OINTMENT sulfacetamide sodium ophthalmic drops MOXEZA OPHTHALMIC DROPS, VISCOUS sulfacetamide sodium ophthalmic ointment NATACYN OPHTHALMIC DROPS,SUSPENSI ON neomycinbacitracinpolymyxin ophthalmic ointment tobramycin ophthalmic drops tobramycin sulfate injection recon soln TOBREX OPHTHALMIC OINTMENT trifluridine ophthalmic drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

101 Name VIGAMOX OPHTHALMIC DROPS ZIRGAN OPHTHALMIC GEL OPHTHALMIC ANTI- INFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC DROPPERETTE bromfenac ophthalmic drops diclofenac sodium ophthalmic drops flurbiprofen sodium ophthalmic drops ILEVRO OPHTHALMIC DROPS,SUSPENSI ON ketorolac ophthalmic drops NEVANAC OPHTHALMIC DROPS,SUSPENSI ON OPHTHALMIC BETA BLOCKERS BETIMOL OPHTHALMIC DROPS carteolol ophthalmic drops Name ISTALOL OPHTHALMIC DROPS, ONCE DAILY levobunolol ophthalmic drops 0. % metipranolol ophthalmic drops timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE OPHTHALMIC STEROIDS ALREX OPHTHALMIC DROPS,SUSPENSI ON dexamethasone sodium phos (pf) injection dexamethasone sodium phosphate ophthalmic drops DUREZOL OPHTHALMIC DROPS FLAREX OPHTHALMIC DROPS,SUSPENSI ON : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

102 Name Name fluorometholone ophthalmic drops,suspension RETISERT INTRAVITREAL IMPLANT FML FORTE OPHTHALMIC DROPS,SUSPENSI ON FML S.O.P. OPHTHALMIC OINTMENT TRIESENCE (PF) INTRAOCULAR SUSPENSION VEXOL OPHTHALMIC DROPS,SUSPENSI ON LOTEMAX OPHTHALMIC DROPS,GEL LOTEMAX OPHTHALMIC DROPS,SUSPENSI ON LOTEMAX OPHTHALMIC OINTMENT MAXIDEX OPHTHALMIC DROPS,SUSPENSI ON OZURDEX INTRAVITREAL IMPLANT PRED MILD OPHTHALMIC DROPS,SUSPENSI ON OTHER GLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine ophthalmic drops AZOPT OPHTHALMIC DROPS,SUSPENSI ON bimatoprost ophthalmic drops brimonidine ophthalmic drops COMBIGAN OPHTHALMIC DROPS COSOPT (PF) OPHTHALMIC DROPPERETTE prednisolone acetate ophthalmic drops,suspension prednisolone sodium phosphate ophthalmic drops dorzolamide ophthalmic drops dorzolamide-timolol ophthalmic drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 96

103 Name Name IOPIDINE OPHTHALMIC DROPPERETTE latanoprost ophthalmic drops LUMIGAN OPHTHALMIC DROPS 0.01 % miostat intraocular PHOSPHOLINE IODIDE OPHTHALMIC DROPS BECONASE AQ NASAL SPRAY,NON- AEROSOL budesonide nasal spray,non-aerosol flunisolide nasal spray,non-aerosol mcg (0.0 %) fluticasone nasal spray,suspension NASONEX NASAL SPRAY,NON- AEROSOL pilocarpine hcl ophthalmic drops 1 %, %, % SIMBRINZA OPHTHALMIC DROPS,SUSPENSI ON TRAVATAN Z OPHTHALMIC DROPS travoprost (benzalkonium) ophthalmic drops ZIOPTAN (PF) OPHTHALMIC DROPPERETTE OTIC AND NASAL PREPARATIONS NASAL PREPARATIONS olopatadine nasal spray,non-aerosol OMNARIS NASAL SPRAY,NON- AEROSOL triamcinolone acetonide nasal aerosol,spray VERAMYST NASAL SPRAY,SUSPENSI ON OTIC PREPARATIONS acetasol hc otic drops acetic acid irrigation acetic acid otic acetic acidaluminum acetate otic drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 97

104 Name CIPRO HC OTIC DROPS,SUSPENSI ON CIPRODEX OTIC DROPS,SUSPENSI ON ciprofloxacin hcl otic dropperette COLY-MYCIN S OTIC DROPS,SUSPENSI ON CORTISPORIN-TC OTIC DROPS,SUSPENSI ON fluocinolone acetonide oil otic drops hydrocortisoneacetic acid otic drops neomycinpolymyxin-hc ophthalmic drops,suspension neomycinpolymyxin-hc otic drops,suspension neomycinpolymyxin-hc otic ofloxacin otic drops RESPIRATORY AND ALLERGY ANTIHISTAMINES Name arbinoxa oral liquid arbinoxa oral ASTEPRO NASAL SPRAY,NON- AEROSOL azelastine nasal aerosol,spray azelastine nasal spray,non-aerosol cetirizine oral 1 mg/ml cyproheptadine oral syrup cyproheptadine oral desloratadine oral desloratadine oral,disintegrating diphenhydramine hcl injection 0 mg/ml diphenhydramine hcl injection syringe levocetirizine oral levocetirizine oral EPINEPHRINE ADRENACLICK AUTO- INJECTOR adrenalin injection PA PA QL (90 per 90 QL (90 per 90 PA PA QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 98

105 Name AUVI-Q AUTO- INJECTOR epinephrine injection autoinjector epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN -PAK AUTO- INJECTOR EPIPEN JR -PAK AUTO- INJECTOR INHALED BETA-AGONISTS albuterol sulfate inhalation for nebulization ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE BROVANA INHALATION FOR NEBULIZATION FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE levalbuterol hcl inhalation for nebulization 1 B/D PA; GC QL (90 per 90 B/D PA; QL (60 per 90 B/D PA Name PERFOROMIST INHALATION FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL INHALER PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED PROVENTIL HFA INHALATION HFA AEROSOL INHALER SEREVENT DISKUS INHALATION BLISTER WITH DEVICE STRIVERDI RESPIMAT INHALATION MIST VENTOLIN HFA INHALATION HFA AEROSOL INHALER XOPENEX HFA INHALATION HFA AEROSOL INHALER INHALED STEROIDS B/D PA QL (10 per 90 QL (1 per 90 QL (10 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 99 QL (1 per 0 QL (10 per 90

106 Name AEROSPAN INHALATION HFA AEROSOL INHALER ALVESCO INHALATION HFA AEROSOL INHALER ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED budesonide inhalation suspension for nebulization FLOVENT DISKUS INHALATION BLISTER WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL INHALER PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED B/D PA Name PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/ ML QVAR INHALATION AEROSOL B/D PA MISCELLANEOUS PULMONARY AGENTS acetylcysteine ADCIRCA ORAL ADEMPAS ORAL ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER ATROVENT HFA INHALATION HFA AEROSOL INHALER COMBIVENT RESPIMAT INHALATION MIST cromolyn inhalation for nebulization cromolyn oral concentrate B/D PA PA; QL (6 per 1 PA QL (6 per 90 B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 100

107 Name CUROSURF INTRATRACHEAL SUSPENSION DALIRESP ORAL DULERA INHALATION HFA AEROSOL INHALER ESBRIET ORAL CAPSULE ipratropium bromide inhalation ipratropium bromide nasal spray,nonaerosol ipratropiumalbuterol inhalation for nebulization KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL LETAIRIS ORAL montelukast oral granules in packet montelukast oral montelukast oral,chewable OFEV ORAL CAPSULE QL (9 per 90 PA 1 B/D PA; GC B/D PA PA PA PA PA Name OPSUMIT ORAL ORENITRAM ORAL EXTENDED RELEASE 0.1 MG ORENITRAM ORAL EXTENDED RELEASE 0. MG, 1 MG,. MG ORKAMBI ORAL PULMOZYME INHALATION REVATIO REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N SEMPREX-D ORAL CAPSULE sildenafil intravenous PA PA PA PA B/D PA PA; QL (116 per 1 PA; QL (180 per 0 PA; QL (116 per 1 sildenafil oral PA; QL (70 per 90 SPIRIVA RESPIMAT INHALATION MIST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 101

108 Name SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE SURVANTA INTRATRACHEAL SUSPENSION SYMBICORT INHALATION HFA AEROSOL INHALER terbutaline subcutaneous TRACLEER ORAL TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED TYVASO INHALATION FOR NEBULIZATION TYVASO INSTITUTIONAL START KIT INHALATION FOR NEBULIZATION TYVASO REFILL KIT INHALATION FOR NEBULIZATION QL (90 per 90 QL (0.6 per 90 PA; LA QL ( per 90 B/D PA B/D PA B/D PA Name TYVASO STARTER KIT INHALATION FOR NEBULIZATION TYZINE NASAL DROPS 0.0 % XOLAIR zafirlukast oral ZYFLO CR ORAL, ER MULTIPHASE 1 HR ZYFLO ORAL ORAL BETA-AGONISTS albuterol sulfate oral syrup albuterol sulfate oral albuterol sulfate oral extended release 1 hr metaproterenol oral syrup metaproterenol oral terbutaline oral XANTHINES aminophylline intravenous B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

109 Name elixophyllin oral elixir 80 mg/1 ml theochron oral extended release 1 hr theophylline in dextrose % intravenous parenteral 00 mg/100 ml, 00 mg/0 ml, 00 mg/0 ml, 00 mg/00 ml, 800 mg/0 ml theophylline oral elixir theophylline oral extended release theophylline oral extended release 1 hr RHEUMATOLOGY AND MUSCULOSKELETAL GOUT THERAPY allopurinol oral aloprim intravenous recon soln colchicineprobenecid oral COLCRYS ORAL Name KRYSTEXXA probenecid oral ULORIC ORAL MISCELLANEOUS RHEUMATOLOGIC AGENTS ACTEMRA SYRINGE DEPEN TITRATABS ORAL ibandronate intravenous leflunomide oral OTREXUP (PF) AUTO-INJECTOR RASUVO (PF) AUTO-INJECTOR RIDAURA ORAL CAPSULE OSTEOPOROSIS/BONE RESORPTION ACTONEL ORAL 10 MG ACTONEL ORAL 0 MG, MG ST; QL (90 per 90 PA B/D PA ST; QL ( per 8 ST; QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

110 Name ACTONEL ORAL MG alendronate oral alendronate oral 10 mg, 0 mg, mg alendronate oral mg, 70 mg ATELVIA ORAL,DELAYE D RELEASE (DR/EC) BONIVA SYRINGE calcitonin (salmon) nasal spray,nonaerosol etidronate disodium oral FORTEO PEN INJECTOR FORTICAL NASAL SPRAY,NON- AEROSOL FOSAMAX PLUS D ORAL ibandronate intravenous syringe ibandronate oral MIACALCIN ST; QL (1 per 8 ; QL (1 per 8 ST; QL (1 per 8 B/D PA PA; QL ( per 8 QL (1 per 8 QL ( per 8 Name PROLIA SYRINGE PA raloxifene oral ; QL (90 per 90 risedronate oral 10 mg risedronate oral 0 mg, mg risedronate oral mg, mg (1 pack) risedronate oral,delayed release (dr/ec) zoledronic acid intravenous recon soln zoledronic acid intravenous zoledronic acidmannitol-water intravenous ZOMETA UROLOGY BPH TREATMENT alfuzosin oral extended release hr AVODART ORAL CAPSULE finasteride oral mg QL ( per 8 QL (90 per 90 QL (1 per 8 QL (1 per 8 QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

111 Name RAPAFLO ORAL CAPSULE MG RAPAFLO ORAL CAPSULE 8 MG tamsulosin oral,extended release hr QL (180 per 90 QL (90 per 90 QL (180 per 90 MISCELLANEOUS UROLOGICALS bethanechol chloride oral CYSTAGON ORAL CAPSULE cytra k crystals oral packet cytra-k oral ELMIRON ORAL CAPSULE K-PHOS NO ORAL K-PHOS ORIGINAL ORAL,SOLUBL E potassium citrate oral extended release potassium citratecitric acid oral packet potassium citratecitric acid oral RIMSO-0 INTRAVESICAL Name sodium citrate-citric acid oral URINARY ANTISPASMODICS flavoxate oral MYRBETRIQ ORAL EXTENDED RELEASE HR oxybutynin chloride oral syrup oxybutynin chloride oral oxybutynin chloride oral extended release hr 10 mg, 1 mg oxybutynin chloride oral extended release hr mg tolterodine oral,extended release hr tolterodine oral TOVIAZ ORAL EXTENDED RELEASE HR MG TOVIAZ ORAL EXTENDED RELEASE HR 8 MG trospium oral,extended release hr : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10 ; QL (180 per 90 ; QL (90 per 90 QL (180 per 90 QL (90 per 90 QL (90 per 90

112 Name Name trospium oral VESICARE ORAL VITAMINS AND SUPPLEMENTS ELECTROLYTES AND MISC. NUTRIENTS calcium chloride intravenous calcium chloride intravenous syringe calcium gluconate intravenous cysteine (l-cysteine) intravenous electrolyte-8 in dw intravenous parenteral HYPERLYTE CR IONOSOL-B IN DW PARENTERAL IONOSOL-MB IN DW PARENTERAL ISOLYTE S PH 7. PARENTERAL B/D PA ISOLYTE-P IN % DEXTROSE PARENTERAL ISOLYTE-S PARENTERAL magnesium chloride injection MAGNESIUM SULFATE IN DW PIGGYBACK 1 GRAM/100 ML magnesium sulfate in water intravenous parenteral magnesium sulfate in water intravenous piggyback magnesium sulfate injection magnesium sulfate injection syringe NORMOSOL-R IN % DEXTROSE PARENTERAL NORMOSOL-R PARENTERAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 106

113 Name NORMOSOL-R PH 7. PARENTERAL phospha 0 neutral oral PLASMA-LYTE 18 PARENTERAL PLASMA-LYTE A PARENTERAL PLASMA-LYTE-6 IN % DEXTROSE PARENTERAL sodium acetate intravenous sodium lactate intravenous sodium phosphate intravenous virt-phos 0 neutral oral VOLUVEN 6 % IV FAT EMULSIONS intralipid intravenous emulsion 0 % B/D PA Name INTRALIPID EMULSION 0 % LIPOSYN II EMULSION liposyn iii intravenous emulsion 10 %, 0 % NUTRILIPID EMULSION B/D PA B/D PA B/D PA B/D PA IV S: DEXTROSE AND LACTATED RINGERS dextrose %- lactated ringers intravenous parenteral lactated ringers intravenous parenteral potassium chloride in lr-d intravenous parenteral ringers intravenous parenteral IV S: DEXTROSE- SALINE d10 % & 0. % sodium chloride intravenous parenteral d. %-0. % sodium chloride intravenous parenteral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 107

114 Name d % and 0.9 % sodium chloride intravenous parenteral d %-0. % sodium chloride intravenous parenteral dextrose 10 % and 0. % nacl intravenous parenteral dextrose %-0. % sod chloride intravenous parenteral dextrose %-0. % sod.chloride intravenous parenteral dextrose with sodium chloride intravenous parenteral IV S: DEXTROSE- WATER dextrose 10 % in water (d10w) intravenous parenteral dextrose 0 % in water (d0w) intravenous parenteral dextrose % in water (dw) intravenous syringe B/D PA B/D PA B/D PA Name dextrose 0 % in water (d0w) intravenous parenteral dextrose 0 % in water (d0w) intravenous parenteral dextrose % in ringers intravenous parenteral dextrose % in water (dw) intravenous parenteral dextrose % in water (dw) intravenous piggyback dextrose 0 % in water (d0w) intravenous parenteral dextrose 0 % in water (d0w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral lmd 10 % in 0.9 % sodium chlor intravenous parenteral lmd 10 % in % dextrose intravenous parenteral IV S: SALINE B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA B/D PA B/D PA B/D PA

115 Name sodium chloride 0. % intravenous parenteral sodium chloride 0. % intravenous piggyback sodium chloride 0.9 % intravenous parenteral sodium chloride 0.9 % intravenous piggyback sodium chloride % intravenous parenteral sodium chloride % intravenous parenteral sodium chloride intravenous parenteral POTASSIUM REPLACEMENT dextrose-kcl-nacl intravenous EFFER-K ORAL, EFFERVESCENT 10 MEQ, 0 MEQ effer-k oral, effervescent meq k-effervescent oral, effervescent klor-con 10 oral extended release Name klor-con 8 oral extended release klor-con m10 oral,er particles/crystals klor-con m1 oral,er particles/crystals klor-con m0 oral,er particles/crystals klor-con oral packet KLOR-CON/ ORAL PACKET klor-con/ef oral, effervescent k-sol oral liquid K-TAB ORAL EXTENDED RELEASE 10 MEQ, 0 MEQ k-tab oral extended release 8 meq potassium acetate intravenous meq/ml potassium bicarb and chloride oral, effervescent potassium bicarbcitric acid oral, effervescent : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 109

116 Name Name potassium chloridd-0.%nacl intravenous parenteral potassium chloride in 0.9%nacl intravenous parenteral 0 meq/l, 0 meq/l potassium chloride in % dex intravenous parenteral 0 meq/l, 0 meq/l, 0 meq/l potassium chlorided-0.%nacl intravenous parenteral 0 meq/l potassium chlorided-0.%nacl intravenous parenteral 0 meq/l, 0 meq/l potassium chlorided-0.%nacl intravenous parenteral 0 meq/l potassium chloride intravenous piggyback potassium chloride intravenous potassium chloride oral, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral extended release potassium chloride oral,er particles/crystals potassium chloride- 0. % nacl intravenous parenteral potassium chlorided-0.9%nacl intravenous parenteral potassium phosphate m-/d-basic intravenous PROTEIN REPLACEMENT amino acids 1 % intravenous parenteral AMINOSYN 10 % PARENTERAL AMINOSYN 7 % WITH ELECTROLYTES PARENTERAL B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 110

117 Name AMINOSYN 8. % PARENTERAL AMINOSYN II 10 % PARENTERAL AMINOSYN II 1 % PARENTERAL AMINOSYN II 7 % PARENTERAL AMINOSYN II 8. % PARENTERAL AMINOSYN II 8. %- ELECTROLYTES PARENTERAL AMINOSYN-HBC 7% PARENTERAL AMINOSYN-PF 10 % PARENTERAL B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA Name AMINOSYN-PF 7 % (SULFITE- FREE) PARENTERAL AMINOSYN-RF. % PARENTERAL CLINIMIX %/D1W SULFITE FREE PARENTERAL CLINIMIX %/DW SULFITE-FREE PARENTERAL CLINIMIX.7%/DW SULFIT FREE PARENTERAL CLINIMIX.%/D10W SULF FREE PARENTERAL CLINIMIX.%/DW SULFIT FREE PARENTERAL B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 111

118 Name CLINIMIX.%- D0W SULF-FREE PARENTERAL CLINIMIX.%- DW SULF-FREE PARENTERAL CLINIMIX %- D0W(SULFITE- FREE) PARENTERAL CLINIMIX E.%/D10W SUL FREE PARENTERAL FREAMINE HBC 6.9 % PARENTERAL freamine iii 10 % intravenous parenteral HEPATAMINE 8% PARENTERAL KABIVEN EMULSION B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA Name NEPHRAMINE. % PARENTERAL PERIKABIVEN EMULSION premasol 10 % intravenous parenteral PREMASOL 6 % PARENTERAL travasol 10 % intravenous parenteral TROPHAMINE 10 % PARENTERAL TROPHAMINE 6% PARENTERAL B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA VITAMINS AND MINERALS BERINERT KIT calcitriol intravenous 1 mcg/ml calcitriol oral calcitriol oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11

119 Name Name calcium acetate oral multi-vitamin with fluoride oral drops calcium acetate oral 667 mg CLINPRO 000 DENTAL PASTE denta 000 plus dental cream dentagel dental gel eliphos oral ESCAVITE ORAL,CHEWAB LE multivitamin with fluoride oral,chewable multi-vitamin with fluoride oral,chewable 0. mg multivitamins with fluoride oral,chewable mvc-fluoride oral,chewable fluor-a-day (with xylitol) oral,chewable NEUT FLUOR-A-DAY ORAL DROPS fluoridex daily defense dental gel FLUORIDEX SENSITIVITY RELIEF DENTAL GEL PARICALCITOL HEMODIALYSIS PORT paricalcitol oral perio med dental fluoritab oral,chewable PHOSLYRA ORAL HECTOROL MCG/ML (1 ML) ludent fluoride oral,chewable multi-vit with fluoride & iron oral drops prenatal vitamin oral PREVIDENT 000 BOOSTER PLUS DENTAL PASTE PREVIDENT 000 DRY MOUTH DENTAL GEL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11

120 Name PREVIDENT 000 SENSITIVE DENTAL PASTE sf 000 plus dental cream sf dental gel sodium bicarbonate intravenous sodium bicarbonate intravenous syringe sodium fluoride oral drops sodium fluoride oral sodium fluoride oral,chewable triple vitamin with fluoride oral drops tri-vit with fluoride & iron oral drops tri-vitamin with fluoride oral drops vitamins a,c,d & fluoride oral drops ZEMPLAR WOMEN'S HEALTH CONTRACEPTIVES altavera (8) oral alyacen 1/ (8) oral Name alyacen 7/7/7 (8) oral amethia lo oral s,dose pack, month amethia oral s,dose pack, month amethyst oral apri oral aranelle (8) oral ashlyna oral s,dose pack, month aubra oral aviane oral azurette (8) oral balziva (8) oral BEYAZ ORAL briellyn oral camila oral camrese lo oral s,dose pack, month camrese oral s,dose pack, month caziant (8) oral chateal oral QL (91 per 91 QL (91 per 91 QL (91 per 91 QL (91 per 91 QL (91 per 91 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11

121 Name cryselle (8) oral cyclafem 1/ (8) oral cyclafem 7/7/7 (8) oral cyred oral dasetta 1/ (8) oral dasetta 7/7/7 (8) oral daysee oral s,dose pack, month deblitane oral delyla (8) oral desoge.estradiol/e.estradio l oral desogestrel-ethinyl estradiol oral drospirenone-ethinyl estradiol oral elinest oral ELLA ORAL emoquette oral enpresse oral enskyce oral errin oral estarylla oral QL (91 per 91 QL (6 per 8 Name falmina (8) oral GENERESS FE ORAL,CHEWAB LE gildagia oral gildess fe oral gildess fe oral gildess oral heather oral introvale oral s,dose pack, month jencycla oral jolessa oral s,dose pack, month jolivette oral junel 1./0 (1) oral junel 1/0 (1) oral junel fe 1./0 (8) oral junel fe 1/0 (8) oral kariva (8) oral kelnor 1/ (8) oral kimidess (8) oral QL (91 per 91 QL (91 per 91 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11

122 Name kurvelo oral l norgest/e.estradiole.estrad oral s,dose pack, month 0.10 mg-0 mcg (8)/10 mcg (7) larin 1./0 (1) oral larin fe oral layolis fe oral,chewable lessina oral levonest (8) oral levonorgestrel oral 1. mg levonorgestrelethinyl estrad oral levonorgestrelethinyl estrad oral s,dose pack, month levora-8 oral LO LOESTRIN FE ORAL loryna (8) oral low-ogestrel (8) oral lutera (8) oral marlissa oral QL (91 per 91 QL (91 per 91 Name microgestin 1./0 (1) oral microgestin 1/0 (1) oral microgestin fe 1./0 (8) oral microgestin fe 1/0 (8) oral mono-linyah oral mononessa (8) oral myzilra oral NATAZIA ORAL necon 0./ (8) oral necon 1/ (8) oral necon 10/11 (8) oral necon 7/7/7 (8) oral nikki (8) oral noreth-ethinyl estradiol-iron oral,chewable 0.8mg-mcg() and 7 mg () norethindrone ac-eth estradiol oral 1-0 mg-mcg norethindronee.estradiol-iron oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 116

123 Name norgestimate-ethinyl estradiol oral norlyroc oral nortrel 0./ (8) oral nortrel 1/ (1) oral nortrel 1/ (8) oral nortrel 7/7/7 (8) oral ogestrel (8) oral orsythia oral ORTHO TRI- CYCLEN LO (8) ORAL philith oral pimtrea (8) oral pirmella oral PLAN B ONE- STEP ORAL portia oral previfem oral QUARTETTE ORAL S,DOSE PACK, MONTH quasense oral s,dose pack, month QL (91 per 91 Name reclipsen (8) oral SAFYRAL ORAL setlakin oral s,dose pack, month sharobel oral sprintec (8) oral sronyx oral syeda oral tarina fe oral tilia fe oral tri-estarylla oral tri-legest fe oral tri-linyah oral trinessa (8) oral tri-previfem (8) oral tri-sprintec (8) oral trivora (8) oral velivet triphasic regimen (8) oral viorele (8) oral wera (8) oral QL (91 per 91 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 117

124 Name wymzya fe oral,chewable zarah oral zenchent (8) oral zenchent fe oral,chewable zeosa oral,chewable zovia 1/e (8) oral zovia 1/0e (8) oral ESTROGEN/PROGESTIN COMBINATIONS MENEST ORAL 1. MG,. MG norethindrone ac-eth estradiol oral 1- mg-mcg NUVARING VAGINAL RING ESTROGENS DEPO-ESTRADIOL R OIL DIVIGEL TRANSDERMAL GEL IN PACKET 0. MG (0.1 %), 0. MG (0.1 %) ESTRACE VAGINAL CREAM PA PA QL ( per 8 estradiol oral PA Name estradiol valerate intramuscular oil 0 mg/ml, 0 mg/ml ESTRING VAGINAL RING FEMRING VAGINAL RING PREMARIN VAGINAL CREAM VAGIFEM VAGINAL QL (1 per 90 QL (1 per 90 MISCELLANEOUS WOMEN'S HEALTH AVC VAGINAL VAGINAL CREAM BRISDELLE ORAL CAPSULE CERVIDIL VAGINAL INSERT, EXTENDED RELEASE HEMABATE R LUPRON DEPOT ( MONTH) R SYRINGE KIT 11. MG LUPRON DEPOT R SYRINGE KIT.7 MG : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 118

125 Name LUPRON DEPOT- PED ( MONTH) R SYRINGE KIT LUPRON DEPOT- PED R KIT 7. MG (PED) METHYLERGONO VINE methylergonovine oral oxytocin injection PITOCIN PREPIDIL VAGINAL GEL PROSTIN E VAGINAL SUPPOSITORY SYNAREL NASAL SPRAY,NON- AEROSOL ORAL CONTRACEPTIVES gianvi (8) oral larin 1/0 (1) oral larin fe oral leena 8 oral lyza oral Name nora-be oral norethindrone (contraceptive) oral ocella oral vestura (8) oral xulane transdermal patch weekly PROGESTINS DEPO-PROVERA R DEPO-SUBQ PROVERA 10 SYRINGE MAKENA R OIL medroxyprogesteron e intramuscular suspension medroxyprogesteron e intramuscular syringe medroxyprogesteron e oral norethindrone acetate oral progesterone in oil intramuscular oil progesterone intramuscular oil : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 119

126 Name progesterone micronized oral VAGINAL ANTI-INFECTIVE/ANTI- FUNGAL CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal cream CLINDESSE VAGINAL CREAM,EXTENDE D RELEASE metronidazole vaginal gel miconazole- vaginal suppository terconazole vaginal cream terconazole vaginal suppository vandazole vaginal gel zazole vaginal cream 0. % : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

127 Index 8 8-MOP...6 A abacavir... abacavir-lamivudinezidovudine... ABELCET...1 ABILIFY...1 ABILIFY MAINTENA...1 ABRAXANE...19 ABSTRAL...0 acamprosate...6 acarbose...7 acebutolol...7 acetaminophen-codeine...9 acetasol hc...97 acetazolamide...0 acetazolamide sodium...0 acetic acid...97 acetic acid-aluminum acetate97 acetylcysteine...6, 100 acitretin...6 ACTEMRA...86, 10 ACTHAR H.P ACTHIB (PF)...88 ACTHREL...6 ACTIMMUNE...8 ACTONEL... 10, 10 ACTOPLUS MET XR...7 ACUVAIL (PF)...9 acyclovir...6 acyclovir sodium...6 ADACEL(TDAP ADOLESN/ADULT)(PF) 88 ADAGEN...8 adapalene... ADASUVE...1 ADCIRCA adefovir...6 ADEMPAS ADENOCARD...0 adenosine...0 ADRENACLICK...98 adrenalin...98 adrucil...16 ADVAIR DISKUS ADVAIR HFA ADVICOR... AEROSPAN afeditab cr...8 AFINITOR...19 AFINITOR DISPERZ...19 AGGRENOX...6 a-hydrocort...68 ak-poly-bac...9 AKTEN (PF)...91 AKYNZEO...78 ala-cort...60 ALBENZA... albumin, human %...86 albumin, human %...86 albuminar %...86 albuminar %...86 alburx (human) %...86 alburx (human) %...86 albutein %...86 albutein %...86 albuterol sulfate...99, 10 alclometasone...60 alcohol pads...71 ALDURAZYME...7 alendronate...10 alfuzosin...10 ALIMTA...16 ALINIA... allopurinol...10 almotriptan malate... ALOCRIL...91 ALOMIDE...9 aloprim...10 alosetron...79 ALOXI...78 ALPHAGAN P...96 alprazolam... alprazolam intensol... ALREX...9 ALTABAX...9 altacaine...9 altafluor...9 altavera (8)...11 ALTOPREV... ALVESCO alyacen 1/ (8)...11 alyacen 7/7/7 (8)...11 amantadine hcl...6 AMBISOME...1 Index 1 amcinonide...61 amethia...11 amethia lo...11 amethyst...11 AMICAR...6 amifostine crystalline...19 amikacin...1 amiloride... amiloride-hydrochlorothiazide... amino acids 1 % aminocaproic acid...6 aminophylline...10 AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8. % AMINOSYN II 10 % AMINOSYN II 1 % AMINOSYN II 7 % AMINOSYN II 8. % AMINOSYN II 8. %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF. % amiodarone...0 AMITIZA...79 amitriptyline...9 amlodipine...8 amlodipine-atorvastatin...8 amlodipine-benazepril...9 amlodipine-valsartan... amlodipine-valsartan-hcthiazid... ammonium lactate...7 AMMONUL...6 amnesteem... amoxapine...9 amoxicil-clarithromy-lansopraz...81 amoxicillin...1 amoxicillin-pot clavulanate..1 amphetamine salt combo... amphotericin b...1 ampicillin...1

128 ampicillin sodium...1 ampicillin-sulbactam...1 AMPYRA...8 anagrelide...6 anastrozole...16 ANDRODERM...69 ANDROGEL...69 ANDROID...69 androxy...69 anectine... ANTARA... ANZEMET...78 apexicon e...61 APIDRA...71 APIDRA SOLOSTAR...71 APOKYN... apraclonidine...96 apri...11 APRISO...79 APTIOM...6 APTIVUS... ARALAST NP...88 aranelle (8)...11 ARANESP (IN POLYSORBATE)...8 arbinoxa...98 ARCALYST...17 ARCAPTA NEOHALER...99 ARESTIN...1 aripiprazole...1 ARISTOSPAN INTRA- ARTICULAR...61 ARISTOSPAN INTRALESIONAL...61 ARRANON...19 ARTISS...6 ARZERRA...19 ASACOL HD...79 ashlyna...11 ASMANEX HFA ASMANEX TWISTHALER aspirin-dipyridamole...6 ASTAGRAF XL...18 ASTEPRO...98 ATELVIA...10 atenolol...7 atenolol-chlorthalidone...7 ATGAM...8 atorvastatin... atovaquone... atovaquone-proguanil... ATRIPLA... atropine...77, 9 ATROVENT HFA AUBAGIO...8 aubra...11 AURYXIA...6 AUVI-Q...99 AVASTIN...19 AVC VAGINAL aviane...11 avita... AVODART...10 AVONEX...8 AVONEX (WITH ALBUMIN)...8 AXERT... AXIRON...69 azacitidine...19 AZACTAM IN DEXTROSE (ISO-OSM)...10 AZASAN...18 AZASITE...9 azathioprine...18 azelastine...9, 98 AZELEX... AZILECT... azithromycin...10 AZOPT...96 AZOR...9 aztreonam...10 azurette (8)...11 B baciim...10 bacitracin...10, 9 bacitracin-polymyxin b...9 baclofen... BACTROBAN NASAL...9 BAL IN OIL...6 balanced salt...9 balsalazide...80 balziva (8)...11 BANZEL...6 BARACLUDE...6 BCG VACCINE, LIVE (PF) 88 BECONASE AQ...97 BELEODAQ...19 benazepril... Index benazepril-hydrochlorothiazide... BENICAR... BENICAR HCT... BENLYSTA...86 BENZACLIN... BENZACLIN PUMP... benztropine..., BEPREVE...9 BERINERT...11 BESIVANCE...9 betamethasone acet,sod phos68 betamethasone dipropionate.61 betamethasone valerate...61 betamethasone, augmented...61 BETASERON...8 betaxolol...7, 9 bethanechol chloride...10 BETHKIS...1 BETIMOL...9 BETOPTIC S...9 bexarotene...19 BEXSERO (PF)...88 BEYAZ...11 bicalutamide...16 BICILLIN C-R...1 BICILLIN L-A...1 BICNU...1 BIDIL... BILTRICIDE... bimatoprost...96 bisoprolol fumarate...7 bisoprolol-hydrochlorothiazide...7 BIVIGAM...8 bleomycin...19 BLEPH BLEPHAMIDE...9 BLEPHAMIDE S.O.P....9 BLINCYTO...19 BONIVA...10 BOOSTRIX TDAP...88 BOSULIF...0 BREVIBLOC...7 BREVIBLOC IN NACL (ISO- OSM)...7 briellyn...11 BRILINTA...6 brimonidine...96 BRINTELLIX...9

129 BRISDELLE bromfenac...9 bromocriptine... BROVANA...99 bss...9 BSS PLUS...9 budesonide... 68, 97, 100 bumetanide... buminate %...86 buminate %...86 BUPHENYL...7 bupivacaine... bupivacaine (pf)... bupivacaine-dextrose-water(pf)... bupivacaine-epinephrine... bupivacaine-epinephrine (pf) BUPIVACAINE- EPINEPHRINE BITART. BUPRENEX...8 buprenorphine hcl...8 buprenorphine-naloxone...8 buproban...9 bupropion hcl...9 buspirone... BUSULFEX...1 butorphanol tartrate..., 9 BUTRANS...8 BYDUREON...7 BYETTA...7 BYSTOLIC...7, 8 C cabergoline... CAFCIT... caffeine citrated... calcipotriene...6 calcipotriene-betamethasone 6 calcitonin (salmon)...10 calcitrene...6 calcitriol... 7, 11 calcium acetate...11 calcium chloride CALCIUM DISODIUM VERSENATE...6 calcium gluconate camila...11 CAMPTOSAR...0 camrese...11 camrese lo...11 CANASA...80 CANCIDAS... candesartan... candesartan-hydrochlorothiazid... CANTIL...77 CAPASTAT...6 CAPEX...61 CAPRELSA...0 captopril... captopril-hydrochlorothiazide... CARAC...7 CARAFATE...81 CARBAGLU...6 carbamazepine...6 carbidopa... carbidopa-levodopa... carbidopa-levodopaentacapone... CARBOCAINE... carbocaine (pf)... CARBOCAINE (PF)... carboplatin...0 CARDENE IV IN DEXTROSE...9 CARDENE IV IN SODIUM CHLORIDE...9 cardioplegic soln...6 CARDIZEM LA...9 CARDURA XL... CARIMUNE NF NANOFILTERED...8 CARNITOR SUGAR-FREE 6 carteolol...9 cartia xt...9 carvedilol...8 CAYSTON...11 caziant (8)...11 cefaclor...7 cefadroxil...7, 8 cefazolin...8 cefazolin in dextrose (iso-os).8 cefdinir...8 cefepime...8 CEFEPIME IN DEXTROSE %...8 cefepime in dextrose,iso-osm.8 cefixime...8 cefotaxime...8 cefotetan...8 Index CEFOTETAN IN DEXTROSE, ISO-OSM...8 cefoxitin...8 cefoxitin in dextrose, iso-osm.8 cefpodoxime...8 cefprozil...8 ceftazidime...8 ceftibuten...8 ceftriaxone...9 ceftriaxone in dextrose,iso-os.8 cefuroxime axetil...9 cefuroxime sodium...9 celecoxib... CELESTONE SOLUSPAN..68 CELLCEPT...18 CELONTIN...6 CENTANY...9 cephalexin...9 CEPROTIN (BLUE BAR)...6 CEPROTIN (GREEN BAR) 6 CERDELGA...7 CEREBYX...6 CEREZYME...7 CERVARIX VACCINE (PF)...89 CERVIDIL CESAMET...78 cetirizine...98 cevimeline...6 CHANTIX...91 CHANTIX CONTINUING MONTH BOX...91 CHANTIX STARTING MONTH BOX...91 chateal...11 CHEMET...6 CHENODAL...80 chloramphenicol sod succinate...11 chlorhexidine gluconate...6 chloroquine phosphate... chlorothiazide... chlorothiazide sodium... chlorpromazine...1 chlorthalidone... cholestyramine (with sugar). cholestyramine light...

130 CHORIONIC GONADOTROPIN, HUMAN...7 ciclodan...9 CICLODAN KIT...9 ciclopirox... 9, 60 cidofovir...6 cilostazol...6 CILOXAN...9 CIMZIA...86 CIMZIA POWDER FOR RECONST...86 CIMZIA STARTER KIT...86 CINRYZE...6 CIPRO HC...98 CIPRODEX...98 ciprofloxacin...1 ciprofloxacin (mixture)...1 ciprofloxacin hcl...1, 9, 98 ciprofloxacin in % dextrose...1 ciprofloxacin lactate...1 cisplatin...0 citalopram...9 cladribine...16 claravis... clarithromycin...10 CLEOCIN...10 CLEOCIN IN % DEXTROSE...11 clindacin etz... clindacin p... CLINDACIN PAC... CLINDAGEL... clindamycin hcl...11 clindamycin in % dextrose 11 clindamycin palmitate hcl...11 clindamycin pediatric...11 clindamycin phosphate..11,, 10 clindamycin-benzoyl peroxide... CLINDESSE...10 CLINIMIX %/D1W SULFITE FREE CLINIMIX %/DW SULFITE-FREE CLINIMIX.7%/DW SULFIT FREE CLINIMIX.%/D10W SULF FREE CLINIMIX.%/DW SULFIT FREE CLINIMIX.%-D0W SULF-FREE...11 CLINIMIX.%-DW SULF-FREE...11 CLINIMIX %- D0W(SULFITE-FREE)11 CLINIMIX E.%/D10W SUL FREE...11 CLINPRO clobetasol...61 clobetasol-emollient...61, 6 CLOBEX...6 clodan...6 CLOLAR...0 clomipramine...9 clonazepam...6 clonidine... clonidine (pf)... clonidine hcl..., clopidogrel...6 clorazepate dipotassium... clotrimazole..., 60 clotrimazole-betamethasone.60 clozapine...1 CLOZAPINE...1 COARTEM... codeine sulfate...0 colchicine-probenecid...10 COLCRYS...10 COLESTID FLAVORED... colestipol... colistin (colistimethate na)...11 colocort...80 COLY-MYCIN S...98 COMBIGAN...96 COMBIVENT RESPIMAT100 COMETRIQ...0 COMPLERA... compro...78 COMVAX (PF)...89 CONDYLOX...7 constulose...80 COPAXONE...8 CORDRAN TAPE LARGE ROLL...6 Index CORDRAN TAPE SMALL ROLL...6 COREG CR...8 CORLANOR...0 CORLOPAM... cormax...6 CORTIFOAM...80 cortisone...68 CORTISPORIN...9 CORTISPORIN-TC...98 CORVERT...0 COSENTYX...87 COSENTYX ( SYRINGES)...86 COSENTYX PEN...86 COSENTYX PEN ( PENS)86 COSOPT (PF)...96 COUMADIN...6 CREON...79 CRESEMBA... CRESTOR... CRIXIVAN... cromolyn...9, 100 cryselle (8)...11 CUBICIN...11 CUROSURF CUVPOSA...80 cyclafem 1/ (8)...11 cyclafem 7/7/7 (8)...11 cyclobenzaprine... CYCLOGYL...9 cyclopentolate...9 cyclophosphamide...1 CYCLOPHOSPHAMIDE...1 CYCLOSERINE...6 CYCLOSET...7 cyclosporine...18 cyclosporine modified...18 CYMBALTA...9 cyproheptadine...98 CYRAMZA...0 cyred...11 CYSTADANE...7 CYSTAGON...10 CYSTARAN...9 cysteine (l-cysteine) cytarabine...16 cytarabine (pf)...16 CYTOGAM...8 cytra k crystals...10

131 cytra-k...10 D D.H.E... d10 % & 0. % sodium chloride d. %-0. % sodium chloride d % and 0.9 % sodium chloride d %-0. % sodium chloride dacarbazine...1 DACOGEN...0 DAKLINZA...6 DALIRESP DALVANCE...11 danazol...70 DANTRIUM... dantrolene... DAPSONE...6 DAPTACEL (DTAP PEDIATRIC) (PF)...89 DARAPRIM... dasetta 1/ (8)...11 dasetta 7/7/7 (8)...11 daunorubicin...0 DAUNOXOME...0 daysee...11 deblitane...11 decitabine...0 deferoxamine...6 deltasone...68 delyla (8)...11 DELZICOL...80 demeclocycline...1 DEMSER... DENAVIR...60 denta 000 plus...11 dentagel...11 DEPEN TITRATABS...10 DEPOCYT (PF)...16 DEPO-ESTRADIOL DEPO-MEDROL...68 DEPO-PROVERA DEPO-SUBQ PROVERA dermasilkrx sds...6 DESFERAL...6 desipramine...9 desloratadine...98 desmopressin...7 desog-e.estradiol/e.estradiol...11 desogestrel-ethinyl estradiol...11 desonide...6 desoximetasone...6 DESVENLAFAXINE...9 DESVENLAFAXINE FUMARATE...9 dexamethasone...68 dexamethasone intensol...68 dexamethasone sodium phos (pf)...9 dexamethasone sodium phosphate...70, 9 dexedrine... dexrazoxane hcl...0 dextroamphetamine... dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 0 % in water (d0w) dextrose % in water (dw) dextrose 0 % in water (d0w) dextrose 0 % in water (d0w) dextrose % in ringers dextrose % in water (dw) dextrose %-lactated ringers dextrose %-0. % sod chloride dextrose %-0. % sod.chloride dextrose 0 % in water (d0w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diazepam...6, diazepam intensol... DIBENZYLINE...0 Index diclofenac potassium... diclofenac sodium...,, 7, 9 diclofenac-misoprostol... dicloxacillin...1 dicyclomine...77 didanosine... DIFFERIN..., 6 DIFICID...10 diflorasone...6 diflunisal... digitek...0 digox...0 digoxin...0, 1 dihydrocode-acetaminophencaff...9 dihydrocodeine-aspirin-caff.9 dihydroergotamine... DILANTIN 0 MG...6 DILATRATE-SR... diltiazem hcl...9 dilt-xr...9 dimenhydrinate...78 DIPENTUM...80 diphenhydramine hcl...98 diphenoxylate-atropine...77 dipyridamole...6 diskets...0 disulfiram...6 divalproex...6 DIVIGEL dobutamine...1 dobutamine in dw...1 DOCEFREZ...0 docetaxel...0 donepezil... dopamine...1 dopamine in % dextrose...1 DOPRAM... dorzolamide...96 dorzolamide-timolol...96 doxazosin... doxepin...9 doxorubicin...0 doxorubicin, peg-liposomal..0 doxy doxycycline hyclate...1 doxycycline monohydrate...1 dronabinol...78 droperidol...0

132 drospirenone-ethinyl estradiol...11 DROXIA...0 DUAC...6 DULERA duloxetine...9 DUOPA... DURACLON (PF)... duramorph (pf)...0 DUREZOL...9 E E.E.S. GRANULES...10 econazole...60 EDARBI... EDARBYCLOR... EDURANT... effer-k EFFER-K EFFIENT...6 EGRIFTA...7 ELAPRASE...7 electrolyte-8 in dw ELELYSO...7 ELIDEL...7 elinest...11 eliphos...11 ELIQUIS...6 ELITEK...7 elixophyllin...10 ELLA...11 ELLENCE...0 ELMIRON...10 ELOXATIN...0 EMADINE...9 EMCYT...0 EMEND...78 emoquette...11 EMSAM...9 EMTRIVA... enalapril maleate... enalaprilat... enalapril-hydrochlorothiazide... ENBREL...87 ENBREL SURECLICK...87 endocet...9 endodan...9 ENGERIX-B (PF)...89 ENGERIX-B PEDIATRIC (PF)...89 enlon... ENLON-PLUS... enoxaparin...6 enpresse...11 enskyce...11 entacapone... entecavir...6 ENTEREG...80 enulose...80 epinastine...9 epinephrine...99 EPIPEN -PAK...99 EPIPEN JR -PAK...99 epirubicin...0, 1 epitol...6 EPIVIR... EPIVIR HBV... eplerenone... EPOGEN...8 epoprostenol (glycine)... eprosartan... EPZICOM... ERAXIS(WATER DILUENT)... ERBITUX...1 ergoloid...1 ERGOMAR... ERIVEDGE...1 errin...11 ERTACZO...60 ERWINAZE...1 ery pads...9 erygel...9 ERYPED ERYPED ery-tab...10 ERYTHROCIN...10 erythrocin (as stearate)...10 erythromycin...10, 9 erythromycin ethylsuccinate.10 erythromycin with ethanol...9 erythromycin-benzoyl peroxide...6 ESBRIET ESCAVITE...11 escitalopram oxalate...9 esmolol...8 esomeprazole magnesium...81 esomeprazole sodium...81 estarylla...11 Index 6 ESTRACE estradiol estradiol valerate ESTRING ethacrynate sodium... ethambutol...6 ethosuximide...6 etidronate disodium...10 etodolac... ETOPOPHOS...1 etoposide...1 EURAX...8 EVOTAZ... EVZIO...8 EXELDERM...60 EXELON... exemestane...16 EXJADE...6 EXTAVIA...8 EYLEA...9 F FABRAZYME...7 falmina (8)...11 famciclovir...6 famotidine...79 famotidine (pf)...79 famotidine (pf)-nacl (iso-os)79 FANAPT...1 FARESTON...17 FARXIGA...7 FARYDAK...1 FASLODEX...17 FAZACLO...1 felbamate...6 felodipine...9 FEMRING fenofibrate... fenofibrate micronized... fenofibrate nanocrystallized. fenofibric acid... fenofibric acid (choline)... FENOGLIDE... fenoprofen... fentanyl...1 fentanyl citrate...0, 1 fentanyl citrate (pf)...0 FENTORA...1 FERRIPROX...6 FETZIMA...9 FINACEA...6

133 finasteride...10 FIRAZYR...6 FIRMAGON KIT W DILUENT SYRINGE...17 FLAREX...9 flavoxate...10 FLEBOGAMMA DIF...8 flecainide...1 FLECTOR...7 FLEXBUMIN %...87 FLEXBUMIN %...87 FLOLAN... FLO-PRED...68 FLOVENT DISKUS FLOVENT HFA floxuridine...16 fluconazole... fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm). flucytosine... fludarabine...16 fludrocortisone...68 flumazenil...6 flunisolide...97 fluocinolone...6 fluocinolone acetonide oil...98 fluocinolone-shower cap...6 fluocinonide...6 fluocinonide-e...6 FLUOR-A-DAY...11 fluor-a-day (with xylitol)...11 fluorescein-benoxinate...9 fluorescein-proparacaine...9 fluoridex daily defense...11 FLUORIDEX SENSITIVITY RELIEF...11 fluoritab...11 fluorometholone...96 fluorouracil... 16, 7 FLUOROURACIL...7 fluoxetine...9 FLUOXETINE...0 fluphenazine decanoate...1 fluphenazine hcl...1 flurbiprofen... flurbiprofen sodium...9 flurox...9 flutamide...17 fluticasone... 6, 97 fluvastatin..., fluvoxamine...0 FML FORTE...96 FML S.O.P fondaparinux...6 FORADIL AEROLIZER...99 FORTAZ...9 FORTAZ IN DEXTROSE %...9 FORTEO...10 FORTICAL...10 FOSAMAX PLUS D...10 foscarnet...6 fosinopril... fosinopril-hydrochlorothiazide... fosphenytoin...6 FOSRENOL...6 FRAGMIN...6 FREAMINE HBC 6.9 %...11 freamine iii 10 %...11 FROVA... FULYZAQ...77 furosemide... FUSILEV...1 FUZEON... FYCOMPA...6 G gabapentin...6 GABITRIL...6 galantamine... GAMASTAN S/D...8 GAMMAGARD LIQUID...8 GAMMAGARD S-D (IGA < 1 MCG/ML)...8 GAMMAPLEX...8 GAMUNEX-C...8 ganciclovir sodium...7 garamycin...9 GARDASIL (PF)...89 GARDASIL 9 (PF)...89 gatifloxacin...9 GATTEX 0-VIAL...80 GATTEX ONE-VIAL...80 gauze pads...71 gavilyte-c...6 gavilyte-g...6 gavilyte-h and bisacodyl...6 gavilyte-n...6 GAZYVA...18 gemcitabine...16 Index 7 gemfibrozil... GENERESS FE...11 generlac...80 gengraf...18 GENOTROPIN...70 GENOTROPIN MINIQUICK...70 gentak...9 gentamicin...1, 9, 9 gentamicin in nacl (iso-osm)..1 GENTAMICIN IN NACL (ISO-OSM)...1 gentamicin sulfate (ped) (pf)..1 gentamicin sulfate (pf)...1 GENTAMICIN SULFATE (PF)...1 GEODON...1 gianvi (8) gildagia...11 gildess...11 gildess fe...11 gildess fe...11 GILENYA...8 GILOTRIF...1 GLASSIA...88 glatopa...8 GLEEVEC...1 glimepiride...7 glipizide...7 glipizide-metformin...7 GLUCAGEN HYPOKIT...7 GLUCAGON EMERGENCY KIT (HUMAN)...7 GLUMETZA...7 glycine...6 glycine urologic...6 glycopyrrolate...77 glydo...8 GLYSET...7 GOLYTELY...6 GRALISE... GRALISE 0-DAY STARTER PACK... granisetron (pf)...78 granisetron hcl...78 GRANIX...8 griseofulvin microsize... griseofulvin ultramicrosize... guanfacine... guanidine...

134 H HALAVEN...1 halobetasol propionate...6 HALOG...6 haloperidol... haloperidol decanoate...1 haloperidol lactate...1, HARVONI...7 HAVRIX (PF)...89 heather...11 HECTOROL...11 HEMABATE HEPAGAM B...8 heparin (porcine)...7 heparin (porcine) in % dex 6 heparin (porcine) in nacl (pf)7 heparin(porcine) in 0.% nacl...7 HEPARIN(PORCINE) IN 0.% NACL...7 heparin, porcine (pf)...7 HEPATAMINE 8%...11 HEPSERA...7 HERCEPTIN...1 HESPAN 6 % IN NS...6 hetastarch 6 % in 0.9 % nacl 6 HETLIOZ...6 HEXALEN...1 HEXTEND...6 HIZENTRA...8 HORIZANT... HUMALOG...71 HUMALOG KWIKPEN...71 HUMALOG MIX HUMALOG MIX 0-0 KWIKPEN...71 HUMALOG MIX HUMALOG MIX 7- KWIKPEN...71 HUMATROPE...70 HUMIRA...87 HUMIRA PEN...87 HUMIRA PEN CROHN'S- UC-HS START...87 HUMIRA PEN PSORIASIS STARTER...87 HUMULIN 70/ HUMULIN 70/0 KWIKPEN...71 HUMULIN N...7 HUMULIN N KWIKPEN...71 HUMULIN R...7 HUMULIN R U-00 (CONCENTRATED)...7 hydralazine... hydrochlorothiazide... hydrocodone-acetaminophen...9, 0 hydrocodone-ibuprofen...0 hydrocortisone...6, 68, 80 hydrocortisone butyrate...6 hydrocortisone butyr-emollient...6 hydrocortisone valerate...6 hydrocortisone-acetic acid...98 hydrocortisone-min oil-wht pet...6 hydromorphone...1 HYDROMORPHONE...1 hydromorphone (pf)...1 hydroxychloroquine... hydroxyurea...1 HYPERHEP B S/D...8 HYPERHEP B S-D NEONATAL...8 HYPERLYTE CR HYPERRAB S/D (PF)...8 HYPERRHO S/D...8 HYPERTET S/D (PF)...8 HYQVIA...8 I ibandronate...10, 10 IBRANCE...1 IBUDONE...0 ibuprofen... ibuprofen-oxycodone...0 ibutilide fumarate...1 ICLUSIG...1 idarubicin...1 IFEX...1 ifosfamide...1 ifosfamide-mesna...1 ILARIS (PF)...18 ILEVRO...9 IMBRUVICA...1 imipenem-cilastatin...11 imipramine hcl...0 imipramine pamoate...0 imiquimod...7 Index 8 IMOGAM RABIES-HT (PF)...8 IMOVAX RABIES VACCINE (PF)...89 INCRELEX...7 indapamide... INDOCIN... indomethacin sodium... INFANRIX (DTAP) (PF)...89 INFUMORPH P/F...1 INLYTA...1 INNOPRAN XL...8 insulin pen needle...7 insulin syringe (disp) u ml...7 insulin syringe (disp) u ml...7 insulin syringe (disp) u-100 1/ ml...7 INTEGRILIN...7 INTELENCE... intralipid INTRALIPID INTRON A...8 introvale...11 INVANZ...11 INVEGA... INVEGA SUSTENNA... INVEGA TRINZA... INVIRASE... INVOKAMET...76 INVOKANA...76 IONOSOL-B IN DW IONOSOL-MB IN DW IOPIDINE...97 IPOL...89 ipratropium bromide ipratropium-albuterol IPRIVASK...7 irbesartan... irbesartan-hydrochlorothiazide... IRESSA...1 irinotecan...1 ISENTRESS... ISOLYTE S PH ISOLYTE-P IN % DEXTROSE ISOLYTE-S isoniazid...6

135 ISORDIL... ISORDIL TITRADOSE... isosorbide dinitrate... isosorbide mononitrate... isradipine...9 ISTALOL...9 ISTODAX...1 ISUPREL...1 itraconazole... ivermectin... IXEMPRA...1 IXIARO (PF)...89 J JADENU...6 JAKAFI...1 jantoven...7 JANUMET...76 JANUMET XR...76 JANUVIA...76 jencycla...11 JENTADUETO...76 JEVTANA... jolessa...11 jolivette...11 junel 1./0 (1)...11 junel 1/0 (1)...11 junel fe 1./0 (8)...11 junel fe 1/0 (8)...11 JUXTAPID... K KABIVEN...11 KADCYLA... KADIAN...1 KALBITOR...6 KALETRA... KALYDECO KAPVAY... kariva (8)...11 k-effervescent kelnor 1/ (8)...11 KENALOG...6 KEPPRA...7 KETEK...10 ketoconazole..., 60 ketoprofen... ketorolac...9 KEYTRUDA... kimidess (8)...11 KINERET...87 KINRIX (PF)...89 kionex...6 klor-con klor-con klor-con klor-con m klor-con m klor-con m KLOR-CON/ klor-con/ef KOMBIGLYZE XR...76 KORLYM...7 K-PHOS NO...10 K-PHOS ORIGINAL...10 KRISTALOSE...80 KRYSTEXXA...10 k-sol k-tab K-TAB kurvelo KUVAN...6 KYNAMRO... L l norgest/e.estradiol-e.estrad labetalol...8 LACRISERT...9 lactated ringers...6, 107 lactulose...80 LAMICTAL ODT...7 LAMICTAL ODT STARTER (BLUE)...7 LAMICTAL ODT STARTER (GREEN)...7 LAMICTAL ODT STARTER (ORANGE)...7 LAMICTAL STARTER (BLUE) KIT...7 LAMICTAL STARTER (GREEN) KIT...7 LAMICTAL STARTER (ORANGE) KIT...7 lamivudine... lamivudine-zidovudine... lamotrigine...7 LANOXIN...1 LANOXIN PEDIATRIC...1 lansoprazole...81 LANTUS...7 LANTUS SOLOSTAR...7 larin 1./0 (1) Index 9 larin 1/0 (1) larin fe larin fe LASTACAFT...9 latanoprost...97 LATUDA... layolis fe LAZANDA...0 leena leflunomide...10 LEMTRADA...8 LENVIMA... LESCOL XL... lessina LETAIRIS letrozole...17 leucovorin calcium...1 LEUKERAN...1 LEUKINE...1 leuprolide...17 levalbuterol hcl...99 LEVEMIR...7 LEVEMIR FLEXTOUCH...7 levetiracetam...7 LEVETIRACETAM IN NACL (ISO-OS)...7 levobunolol...9 levocarnitine...6 levocarnitine (with sugar)...6 levocetirizine...98 levofloxacin...1, 9 levofloxacin in dw...1 levoleucovorin calcium...1 levonest (8) levonorgestrel levonorgestrel-ethinyl estrad LEVOPHED (BITARTRATE)...1 levora levorphanol tartrate...1 levothyroxine...77 levoxyl...77 LEVULAN...7 LEXIVA... LIALDA...80 lidocaine...8 lidocaine (pf) in d7.w... lidocaine (pf)...6, 8 LIDOCAINE (PF)...8

136 lidocaine hcl...6, 8 lidocaine in % dextrose (pf)...6 lidocaine viscous...8 lidocaine-epinephrine...6 lidocaine-epinephrine (pf)...6 LIDOCAINE-EPINEPHRINE BIT... 6, 8 lidocaine-prilocaine...8 lindane...8 linezolid...11 linezolid-0.9% sodium chloride...11 LINZESS...80 liothyronine...77 lipodox... lipodox 0... LIPOFEN... LIPOSYN II liposyn iii lisinopril... lisinopril-hydrochlorothiazide... lithium carbonate...6 lithium citrate...6 lmd 10 % in 0.9 % sodium chlor lmd 10 % in % dextrose..108 LO LOESTRIN FE LOCOID...6 LOCOID LIPOCREAM...6 LOMUSTINE...1 loperamide...77 lorazepam... lorazepam intensol... lorcet (hydrocodone)...0 lorcet hd...0 lorcet plus...0 lortab lortab lortab loryna (8) losartan... losartan-hydrochlorothiazide LOTEMAX...96 LOTRONEX...80 lovastatin... low-ogestrel (8) loxapine succinate... lta pre-attached...6 LUCENTIS...9 ludent fluoride...11 LUMIGAN...97 LUMIZYME...7 LUPRON DEPOT...17, 118 LUPRON DEPOT ( MONTH)...17, 118 LUPRON DEPOT ( MONTH)...17 LUPRON DEPOT (6 MONTH)...17 LUPRON DEPOT-PED17, 119 LUPRON DEPOT-PED ( MONTH) lutera (8) LYNPARZA... LYRICA...7 LYSODREN... lyza M magnesium chloride magnesium sulfate MAGNESIUM SULFATE IN DW magnesium sulfate in water 106 MAKENA malathion...8 mannitol 10 %...66 mannitol 0 %...66 mannitol %...66 mannitol %...66 maprotiline...0 MARCAINE...6 marcaine (pf)...6 MARCAINE (PF)...6, 8 MARCAINE SPINAL (PF)..6 MARCAINE-EPINEPHRINE...6 MARCAINE-EPINEPHRINE (PF)...6 marlissa MARPLAN...0 MATULANE... matzim la...9 MAXIDEX...96 MAXIPIME...9 meclizine...78 meclofenamate... medroxyprogesterone mefenamic acid... Index 10 mefloquine... MEFOXIN IN DEXTROSE (ISO-OSM)...9 MEGACE ES...17 megestrol...17 MEKINIST... meloxicam... melphalan hcl...1 memantine...6 MEMANTINE...6 MENACTRA (PF)...89 MENEST MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-1 (PF)...90 MENTAX...60 MENVEO A-C-Y-W-1-DIP (PF)...90 MEPIVACAINE (PF)...7 MEPRON... mercaptopurine...16 meropenem...11 mesalamine...80 mesalamine with cleansing wipe...80 mesna... MESNEX...1 MESTINON...7 MESTINON TIMESPAN...7 metaproterenol...10 metaxalone... metformin...76 methadone...1 methadone intensol...1 methadose...1 methazolamide...0 methenamine hippurate...1 methenamine mandelate...1 methimazole...70 METHITEST...70 methocarbamol... methotrexate sodium...16 methotrexate sodium (pf)...16 methoxsalen rapid...7 methscopolamine...77 methyclothiazide... methylergonovine METHYLERGONOVINE.119 methylphenidate...

137 methylprednisolone...68 methylprednisolone acetate..68 methylprednisolone sodium succ... 68, 69 metipranolol...9 metoclopramide hcl...80 metolazone... metoprolol succinate...8 metoprolol ta-hydrochlorothiaz...8 metoprolol tartrate...8 metro i.v METROGEL...9 metronidazole...11, 6, 9, 10 metronidazole in nacl (iso-os)...11 mexiletine...1 MIACALCIN...10 miconazole MICRHOGAM ULTRA- FILTERED PLUS...8 microgestin 1./0 (1) microgestin 1/0 (1) microgestin fe 1./0 (8)..116 microgestin fe 1/0 (8) midodrine...1 migergot... millipred...69 MILLIPRED...69 millipred dp...69 milrinone...1 milrinone in % dextrose...1 MINOCIN KIT WITH WIPES...1 minocycline...1 minoxidil... miostat...97 mirtazapine...0 misoprostol...81 mitomycin... mitoxantrone... M-M-R II (PF)...90 modafinil... moderiba...7 moderiba dose pack...7 moexipril... moexipril-hydrochlorothiazide... mometasone...6 mono-linyah mononessa (8) montelukast morgidox...1 morphine...1, MORPHINE... morphine (pf)...1 morphine concentrate...1 MOVANTIK...80 MOVIPREP...66 MOXEZA...9 moxifloxacin...1 MOZOBIL...87 MULTAQ...1 multi-vit with fluoride & iron...11 multivitamin with fluoride..11 multi-vitamin with fluoride 11 multi-vitamin with fluoride 11 multivitamins with fluoride 11 mupirocin...9 mupirocin calcium...9 MUSTARGEN...1 mvc-fluoride...11 MYALEPT...7 MYCOBUTIN...6 mycophenolate mofetil...18 mycophenolate sodium...18 MYOZYME...7 MYRBETRIQ...10 myzilra N NABI-HB...8 nabumetone... nadolol...8 nadolol-bendroflumethiazide8 nafcillin...1 nafcillin in dextrose iso-osm 1 NAFTIN...60 NAGLAZYME...7 nalbuphine...9 naloxone...8 naltrexone...8 NAMENDA...7 NAMENDA TITRATION PAK...7 NAMENDA XR...7 naphazoline...9 naproxen... naproxen sodium... naratriptan... Index 11 NAROPIN (PF)...7 NASONEX...97 NATACYN...9 NATAZIA nateglinide...76 NATRECOR...1 NEBUPENT...11 necon 0./ (8) necon 1/ (8) necon 10/11 (8) necon 7/7/7 (8) needles, insulin disp.,safety..7 nefazodone...0 neomycin...1 neomycin-bacitracin-poly-hc9 neomycin-bacitracinpolymyxin...9 neomycin-polymyxin b gu...66 neomycin-polymyxin b- dexameth...9 neomycin-polymyxingramicidin...9 neomycin-polymyxin-hc...98 neo-polycin...9 neo-polycin hc...9 NEOPROFEN (IBUPROFEN LYSN)(PF)...66 NEORAL...18 NEOSPORIN GU IRRIGANT...66 NEPHRAMINE. %...11 NESACAINE...7 NESACAINE-MPF...7 neuac...6 NEULASTA...8, 8 NEUMEGA...87 NEUPOGEN...8 NEUPRO... NEUT...11 NEVANAC...9 nevirapine... NEXAVAR... NEXTERONE...1 niacin... niacor... nicardipine...9 NICOTROL...91 NICOTROL NS...91 nifedical xl...9 nifedipine...9

138 nikki (8) NILANDRON...17 nimodipine...7 NIPENT...16 nisoldipine...9 nitro-bid... NITRO-DUR... nitrofurantoin...1 nitrofurantoin macrocrystal..1 nitrofurantoin monohyd/mcryst...1 nitroglycerin... nitroglycerin in % dextrose NITROPRESS...1 NITROSTAT...6 nizatidine...79 nora-be NORDITROPIN FLEXPRO 70 norepinephrine bitartrate...1 noreth-ethinyl estradiol-iron norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol...116, 118 norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol NORITATE...6 norlyroc NORMOSOL-R NORMOSOL-R IN % DEXTROSE NORMOSOL-R PH NORPACE CR...1 NORTHERA...1 nortrel 0./ (8) nortrel 1/ (1) nortrel 1/ (8) nortrel 7/7/7 (8) nortriptyline...0 NORVIR... novarel...7 NOVOFINE NOVOFINE...7 NOVOFINE PLUS...7 NOVOLIN 70/0...7 NOVOLIN N...7 NOVOLIN R...7 NOVOLOG...7 NOVOLOG FLEXPEN...7 NOVOLOG MIX NOVOLOG MIX 70-0 FLEXPEN...7 NOVOLOG PENFILL...7 NOVOTWIST...7 NOXAFIL... np thyroid...77 NPLATE...87 NUCYNTA... NUEDEXTA...7 NULOJIX...18 NUTRESTORE...80 NUTRILIPID NUTROPIN AQ...71 NUTROPIN AQ NUSPIN...71 NUVARING NUVIGIL... nyamyc...60 NYMALIZE...7 nystatin..., 60 nystatin-triamcinolone...60 nystop...60 O ocella OCTAGAM...8 octreotide acetate...7 OFEV ofloxacin...1, 9, 98 ogestrel (8) olanzapine... olanzapine-fluoxetine... OLEPTRO ER...0 olopatadine...97 OLYSIO...7 OMECLAMOX-PAK...81 omega- acid ethyl esters... omeprazole...81 omeprazole-sodium bicarbonate...81 OMNARIS...97 OMNITROPE...71 ONCASPAR... ondansetron...78 ondansetron hcl...78 ondansetron hcl (pf)...78 ONFI...8 ONGLYZA...76 Index 1 OPANA... OPANA ER... OPDIVO... opium tincture...80 OPSUMIT oralone...66 ORAP... ORAVIG... ORENCIA...87 ORENCIA (WITH MALTOSE)...87 ORENITRAM ORFADIN...66 ORKAMBI orsythia ORTHO TRI-CYCLEN LO (8) OSMITROL 10 %...66 osmitrol 1 %...66 osmitrol 0 %...66 OSMITROL %...66 OSMOPREP...66 OTEZLA...87 OTEZLA STARTER...87 OTREXUP (PF)...10 oxacillin...1 oxacillin in dextrose(iso-osm)...1 oxaliplatin... oxandrolone...70 oxaprozin... oxcarbazepine...8 OXISTAT...60 OXSORALEN...7 OXSORALEN ULTRA...7 OXTELLAR XR...8 oxybutynin chloride...10 oxycodone... oxycodone-acetaminophen...0 oxycodone-aspirin...0 oxymorphone... oxytocin OZURDEX...96 P pacerone...1 paclitaxel... pamidronate...7 PANCREAZE...79 pancrelipase PANDEL...6

139 PANHEMATIN...66 PANRETIN...7 pantoprazole...8 paregoric...81 paricalcitol...11 PARICALCITOL...11 paroex oral rinse...66 paromomycin... paroxetine hcl...0 PASER...6 PATADAY...9 PATANOL...9 PAXIL...0 PAZEO...9 PEDIARIX (PF)...90 PEDVAX HIB (PF)...90 peg 0-electrolytes...66 peg-0 with flavor packs..66 PEGANONE...8 PEGASYS...8 PEGASYS PROCLICK...8 peg-electrolyte soln...66 PEGINTRON...8 PEGINTRON REDIPEN...8 peg-prep...66 PENICILLIN G POT IN DEXTROSE...1 penicillin g potassium...1 penicillin g procaine...1 penicillin g sodium...1 penicillin v potassium...1 PENTACEL (PF)...90 PENTAM...1 PENTASA...81 pentoxifylline...7 PERFOROMIST...99 PERIKABIVEN...11 perindopril erbumine... perio med...11 periogard...66 PERJETA... permethrin...8 perphenazine... PERTZYE...79 PEXEVA...0 pfizerpen-g...1 phenelzine...0 phenobarbital...8 phenoxybenzamine... phenytoin...8 phenytoin sodium...8 phenytoin sodium extended..8 philith PHOSLYRA...11 phospha 0 neutral PHOSPHOLINE IODIDE...97 PICATO...7 pilocarpine hcl...66, 97 pimozide... pimtrea (8) pindolol...8 pioglitazone...76 pioglitazone-glimepiride...76 pioglitazone-metformin...76 piperacillin-tazobactam...1 pirmella piroxicam... PITOCIN PLAN B ONE-STEP plasbumin %...87 plasbumin %...87 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-6 IN % DEXTROSE plasmanate...87 PLEGISOL...66 PLEGRIDY...8 PLIAGLIS...9 podofilox...7 polycin...9 polyethylene glycol 066, 67 polymyxin b sulfate...1 polymyxin b sulf-trimethoprim...9 POMALYST...18 portia potassium acetate potassium bicarb and chloride potassium bicarb-citric acid109 potassium chlorid-d- 0.%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in % dex potassium chloride in lr-d.107 Index 1 potassium chloride-0. % nacl potassium chloride-d- 0.%nacl potassium chloride-d- 0.%nacl potassium chloride-d- 0.9%nacl potassium citrate...10 potassium citrate-citric acid10 potassium phosphate m-/dbasic POTIGA...8 PRADAXA...7 pramipexole... PRANDIMET...76 pravastatin... prazosin... PRED MILD...96 PRED-G...9 PRED-G S.O.P....9 prednicarbate...6 prednisolone...69 prednisolone acetate...96 prednisolone sodium phosphate...69, 96 prednisone...69 prednisone intensol...69 PREMARIN premasol 10 %...11 PREMASOL 6 %...11 prenatal vitamin oral.11 PREPIDIL PREPOPIK...67 prevalite... PREVIDENT 000 BOOSTER PLUS...11 PREVIDENT 000 DRY MOUTH...11 PREVIDENT 000 SENSITIVE...11 previfem PREZCOBIX... PREZISTA... PRIALT...7 PRIFTIN...6 PRIMAQUINE... primidone...8 PRIMLEV...0 PRIMSOL...1

140 PRIVIGEN...8 PROAIR HFA...99 PROAIR RESPICLICK...99 probenecid...10 procainamide... prochlorperazine...78 prochlorperazine edisylate...78 prochlorperazine maleate...78 PROCRIT...8 procto-pak...81 proctosol hc...81 proctozone-hc...81 PROCYSBI...7 progesterone progesterone in oil progesterone micronized...10 PROGLYCEM... PROGRAF...18 PROLASTIN-C...88 PROLEUKIN... PROLIA...10 PROMACTA...88 propafenone... propantheline...78 proparacaine...9 propranolol...8 propranolol-hydrochlorothiazid...8 propylthiouracil...70 PROQUAD (PF)...90 PROSTIN E PROSTIN VR PEDIATRIC.67 protamine...67 PROTOPAM CHLORIDE...67 protriptyline...0 PROVENTIL HFA...99 prudoxin...7 PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN...16 PYLERA...81 pyrazinamide...6 pyridostigmine bromide...7 Q QUADRACEL (PF)...90 QUARTETTE quasense QUELICIN...7 quetiapine... quinapril... quinapril-hydrochlorothiazide... quinidine gluconate... quinidine sulfate... quinine sulfate... QVAR R RABAVERT (PF)...90 rabeprazole...8 raloxifene...10 ramipril... RANEXA... ranitidine hcl...79 RAPAFLO...10 RAPAMUNE...18 RASUVO (PF)...10 RAVICTI...67 REBETOL...7 REBIF (WITH ALBUMIN).86 REBIF REBIDOSE...86 REBIF TITRATION PACK.86 reclipsen (8) RECOMBIVAX HB (PF)...90 regonol...7 REGRANEX...6 relador pak...9 relador pak plus...9 RELENZA DISKHALER...7 RELISTOR...81 RELPAX... REMICADE...88 REMODULIN... RENACIDIN...67 RENAGEL...67 RENVELA...67 REOPRO...7 repaglinide...76 reprexain...0 RESCRIPTOR..., RESECTISOL...67 RESTASIS...9 RETIN-A MICRO PUMP...6 RETISERT...96 RETROVIR... REVATIO REVLIMID...18 revonto... REXULTI... Index 1 REYATAZ... RHEUMATREX...16 RHOGAM ULTRA- FILTERED PLUS...8 RHOPHYLAC...8 ribasphere...7 ribasphere ribapak...7 ribavirin...7 RIDAURA...10 rifabutin...6 rifampin...6 RIFATER...6 riluzole...7 rimantadine...7 RIMSO ringers...67, 107 risedronate...10 RISPERDAL CONSTA... risperidone... RITUXAN...19 rivastigmine...7 rivastigmine tartrate...7 rizatriptan... ROBINUL...78 ropinirole... ropivacaine (pf)...7 rosadan...6 ROSADAN...6 ROTARIX...90 ROTATEQ VACCINE...90 ROZEREM... RUCONEST...67 S SABRIL...8 SAFYRAL SAIZEN...71 SAIZEN CLICK.EASY...71 salsalate... SAMSCA...67 SANCUSO...78 SANDIMMUNE...19 SANDOSTATIN LAR DEPOT...7 SANTYL...6 SAPHRIS (BLACK CHERRY)... SAVELLA...7 selegiline hcl... selenium sulfide...7 SELZENTRY...

141 SEMPREX-D SENSIPAR...7 sensorcaine...8 SENSORCAINE...8 sensorcaine/epinephrine...8 sensorcaine-mpf...9 SENSORCAINE-MPF SPINAL...8 SENSORCAINE- MPF/EPINEPHRINE...8 SEREVENT DISKUS...99 SEROQUEL XR... SEROSTIM...71 sertraline...0 setlakin sf 11 sf 000 plus...11 sharobel SIGNIFOR...7 SIGNIFOR LAR...7 sildenafil silver sulfadiazine...6 SIMBRINZA...97 SIMCOR... SIMPONI...88 SIMULECT...19 simvastatin... sirolimus...19 SIRTURO...6 SIVEXTRO...1 SKLICE...8 sodium acetate sodium bicarbonate...11 sodium chloride...67, 109 sodium chloride 0. % sodium chloride 0.9 % sodium chloride % sodium chloride % sodium citrate-citric acid...10 sodium fluoride...11 sodium lactate sodium phenylbutyrate...7 sodium phosphate sodium polystyrene (sorb free)...67 sodium polystyrene sulfonate...67 SOLIRIS...88 SOLTAMOX...17 SOLU-CORTEF...69 SOLU-CORTEF (PF)...70 SOLU-MEDROL...69 SOLU-MEDROL (PF)...69 SOMATULINE DEPOT...7 SOMAVERT...7 SORBITOL...67 SORBITOL-MANNITOL...67 SORIATANE...7 SORILUX...7 sorine...8 sotalol...8 SOTALOL...8 sotalol af...8 SOTRADECOL...67 SOVALDI...7 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER...10 spironolactone... spironolacton-hydrochlorothiaz... SPORANOX... sprintec (8) SPRYCEL... sps...67 sronyx ssd...6 stavudine... STELARA...88 STIMATE...7 STIVARGA... STRATTERA... STREPTOMYCIN...1 STRIANT...70 STRIBILD... STRIVERDI RESPIMAT...99 STROMECTOL... sublimaze (pf)... SUBOXONE...9 SUBSYS... SUCRAID...81 sucralfate...81 sulfacetamide sodium...9 sulfacetamide sodium (acne) 6 sulfacetamide-prednisolone..9 sulfadiazine...1 sulfamethoxazole-trimethoprim...1 SULFAMYLON...9 sulfasalazine...81 Index 1 sulfatrim...1 sulfazine...81 sulfazine ec...81 sulindac... sumatriptan... sumatriptan succinate... SUPPRELIN LA...17 SUPRAX...9 SUPREP BOWEL PREP KIT...67 SURMONTIL... SURVANTA...10 SUSTIVA... SUTENT... syeda SYLATRON...86 SYLVANT...88 SYMBICORT...10 SYMLINPEN SYMLINPEN SYNAGIS...8 SYNALAR TS...6 SYNAREL SYNERA...9 SYNERCID...1 SYNRIBO... SYNTHROID...77 SYPRINE...7 T TABLOID...16 TACLONEX...7 tacrolimus...19, 7 TAFINLAR... TAMIFLU...7 tamoxifen...17 tamsulosin...10 TARCEVA... TARGRETIN..., 8 tarina fe TARKA...0 TASIGNA... TASMAR... TAZICEF...9 TAZORAC...6 taztia xt...0 TECFIDERA...19 TECHNIVIE...7 TEFLARO...9 TEGRETOL XR...8 TEKTURNA...

142 TEKTURNA HCT... telmisartan... telmisartan-amlodipine... telmisartan-hydrochlorothiazid... TEMODAR...67 tencon...0 TENIVAC (PF)...90 terazosin... terbinafine hcl... terbutaline...10 terconazole...10 TESTIM...70 TESTOPEL...70 testosterone cypionate...70 testosterone enanthate...70 TESTRED...70 TETANUS,DIPHTHERIA TOX PED(PF)...90 TETANUS-DIPHTHERIA TOXOIDS-TD...90 tetrabenazine...8 tetracaine hcl...9 TEXACORT...6 THALOMID...19 THAM...68 theochron...10 theophylline...10 theophylline in dextrose %...10 THERACYS...90 thioridazine... thiotepa... thiothixene... THROMBATE III...8 THYMOGLOBULIN...8 THYROLAR THYROLAR-1/...77 THYROLAR-1/...77 THYROLAR THYROLAR tiagabine...8 TICE BCG...91 TIKOSYN... tilia fe timolol maleate...8, 9 TIMOPTIC OCUDOSE (PF)...9 tinidazole... TIVICAY... tizanidine... TOBI...1 TOBI PODHALER...1 TOBRADEX...9 TOBRADEX ST...9 tobramycin...9 tobramycin in 0. % nacl...1 tobramycin in 0.9 % nacl...1 tobramycin sulfate...1, 9 tobramycin-dexamethasone..9 TOBREX...9 tolazamide...76 tolbutamide...76 tolcapone... tolmetin... tolterodine...10 TOPICORT...6 topiramate...8 toposar... topotecan... TORISEL... torsemide... TOVIAZ...10 TRACLEER...10 TRADJENTA...76 tramadol...9 tramadol-acetaminophen...9 trandolapril... trandolapril-verapamil...0 tranexamic acid...68 TRANSDERM-SCOP...78 tranylcypromine...0 travasol 10 %...11 TRAVATAN Z...97 travoprost (benzalkonium)...97 trazodone...0 TREANDA...16, TRECATOR...6 TRELSTAR...17, TRELSTAR DEPOT... TRELSTAR LA... tretinoin...6 tretinoin (chemotherapy)... tretinoin microspheres...6 TREXIMET... triamcinolone acetonide 6, 68, 69, 97 triamterene-hydrochlorothiazid... trianex...6 Index 16 triderm...6 TRIESENCE (PF)...96 tri-estarylla trifluoperazine... trifluridine...9 TRIGLIDE... trihexyphenidyl... tri-legest fe tri-linyah trilyte with flavor packets...68 trimethoprim...1 trinessa (8) TRIOSTAT...77 triple vitamin with fluoride.11 tri-previfem (8) TRISENOX... tri-sprintec (8) TRIUMEQ... tri-vit with fluoride & iron..11 tri-vitamin with fluoride...11 trivora (8) TRIZIVIR... TROKENDI XR...8 TROPHAMINE 10 %...11 TROPHAMINE 6%...11 tropicamide...9 trospium...10, 106 TRUMENBA...91 TRUVADA... TUDORZA PRESSAIR...10 TWINRIX (PF)...91 TYBOST... TYGACIL...1 TYKERB... TYPHIM VI...91 TYSABRI...88 TYVASO...10 TYVASO INSTITUTIONAL START KIT...10 TYVASO REFILL KIT...10 TYVASO STARTER KIT.10 TYZEKA... TYZINE...10 U ULORIC...10 unithroid...77 UNITUXIN... ursodiol...81 UVADEX...68

143 V VAGIFEM valacyclovir...7 VALCHLOR...16 VALCYTE...7 valganciclovir...7 valproate sodium...8 valproic acid...8 valproic acid (as sodium salt)...8 valsartan... valsartan-hydrochlorothiazide... VALSTAR... vancomycin...1 VANCOMYCIN IN DW...1 VANCOMYCIN IN DEXTROSE ISO-OSM...1 vandazole...10 VANTAS...17 VAQTA (PF)...91 VARIVAX (PF)...91 VARIZIG...8 VASCEPA... vasopressin...7 VECAMYL... VECTIBIX... VELCADE... veletri... velivet triphasic regimen (8) VELTIN...6 venlafaxine...0 VENTAVIS... VENTOLIN HFA...99 VERAMYST...97 verapamil...0 VEREGEN...8 veripred VERSACLOZ... VESICARE vestura (8) VEXOL...96 VIBRAMYCIN...1 VICTOZA -PAK...7 VICTOZA -PAK...7 VIDAZA... VIDEX GRAM PEDIATRIC... VIDEX GRAM PEDIATRIC... VIEKIRA PAK...7 VIGAMOX...9 VIIBRYD...0 VIMIZIM...7 VIMPAT...8 vinblastine... vincasar pfs... vincristine... vinorelbine... VIOKACE...79 viorele (8) VIRACEPT... VIRAMUNE XR... VIRAZOLE...7 VIREAD... virt-phos 0 neutral vitamins a,c,d & fluoride...11 VITEKTA... VIVITROL...9 VOLTAREN GEL...8 VOLUVEN 6 % voriconazole... VOTRIENT... VPRIV...7 VUSION...8 VYTORIN VYTORIN VYTORIN VYTORIN W warfarin...7 water for irrigation, sterile...68 WELCHOL... wera (8) WINRHO SDF...8 wymzya fe X XALKORI... XARELTO...7 XELJANZ...88 XENAZINE...8 XERESE...60 XGEVA... XIAFLEX...68 XIFAXAN...1 XIGDUO XR...77 XOLAIR...10 XOLEGEL...60 Index 17 XOPENEX HFA...99 XTANDI...17 xulane XYLOCAINE (CARDIAC) (PF)...8 xylocaine dental-epinephrine8 XYLOCAINE-EPINEPHRINE...8 XYLOCAINE-MPF...8 XYLOCAINE- MPF/EPINEPHRINE...8 xylon XYREM... Y YERVOY... YF-VAX (PF)...91 Z zafirlukast...10 zaleplon... ZALTRAP... ZANOSAR...16 zarah ZAVESCA...7 zazole...10 ZELAPAR... ZELBORAF... ZEMAIRA...88 ZEMPLAR...11 zenchent (8) zenchent fe ZENPEP...79 zeosa ZERBAXA...9 ZETIA... ZIAGEN... zidovudine... ZINACEF...9 ZINACEF IN STERILE WATER...9 ZINECARD (AS HCL)... ZIOPTAN (PF)...97 ziprasidone hcl... ZIPSOR... ZIRGAN...9 ZMAX...10 ZOLADEX...17 zoledronic acid...10 zoledronic acid-mannitol-water...10 ZOLINZA...

144 ZOMETA...10 ZOMIG... zonisamide...8 ZORTRESS... ZOSTAVAX (PF)...91 ZOSYN IN DEXTROSE (ISO- OSM)...1 zovia 1/e (8) zovia 1/0e (8) ZOVIRAX...60 ZYDELIG... ZYFLO...10 ZYFLO CR...10 ZYKADIA... ZYLET...9 ZYPREXA RELPREVV... ZYTIGA...17 ZYVOX...1 Index 18

145

146 This formulary was updated on December 1, 01. For more recent information or other questions, please contact us, Medicare Plus Blue PPO Customer Service at , or for TTY users, call 711, Monday through Friday, 8 a.m. 8 p.m. Or call Prescription Blue PDP Customer Service at , Monday Through Friday, 8 a.m. 8 p.m. From October 1 through February 1, hours are from 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. Or visit Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal R087