Lista de medicamentos cubiertos

Transcription

1 SANTA CLARA FAMILY HEALTH PLAN CAL MEDICONNECT PLAN (PLAN DE MEDICARE-MEDICAID) Lista de medicamentos cubiertos (Formulario) 2015 Número gratuito: TTY: De 8:00 a. m. a 8:00 p. m., los 7 días de la semana, incluyendo feriados. Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan. La llamada es gratuita. Para obtener más información, visite Formulary ID: Version Number: 16 Last Updated: 11/1/2015 H7890_15103_MMPformulary201409esV1 Approved

2 SCFHP Cal MediConnect Plan (Plan de Medicare-Medicaid) 2015 Lista de medicamentos cubiertos (Formulario) Ésta es una lista de medicamentos que los miembros pueden obtener en Santa Clara Family Health Plan Cal MediConnect Plan (Plan de Medicare-Medicaid). Santa Clara Family Health Plan Cal MediConnect Plan (Plan de Medicare-Medicaid) es un plan de seguro de salud que tiene contratos con Medicare y Medi-Cal para proporcionar los beneficios de los dos programas a los miembros. Los beneficios, la Lista de medicamentos cubiertos y las redes de farmacias y proveedores de Santa Clara Family Health Plan (SCFHP) Cal MediConnect pueden cambiar en cualquier momento durante el año y el 1º de enero de cada año. Usted siempre puede revisar la Lista de medicamentos cubiertos de SCFHP Cal MediConnect en internet en o llamando al SCFHP Servicios al Miembro al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al Usted puede pedir esta información en otros formatos, como Braille o letra grande. Llame al La llamada es gratuita. Se pueden aplicar limitaciones y restricciones. Para obtener más información, llame a SCFHP Servicios al Miembro o lea el Manual del miembro de SCFHP Cal MediConnect. Usted puede obtener esta información gratis en otros idiomas. Llame al Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. You can get this information for free in other languages. Call TTY/TDD users call The call is free. Quý vị có thể nhận thông tin này miễn phí ở các ngôn ngữ khác. Xin gọi số Những người sử dụng TTY/TDD nên gọi số Cuộc gọi được miễn phí. 您 可 免 费 获 得 此 信 息 的 其 他 语 言 版 本 请 拨 打 免 费 电 话 TTY/TDD 使 用 者 應 撥 打 這 是 免 費 電 話 Makukuha mo nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa Ang mga gumagamit ng TTY/TDD ay dapat tumawag sa Libre ang tawag.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite i H7890_15103_MMPformulary201409esV1 Approved SH7006_10066S

3 Preguntas frecuentes Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos cubiertos. Usted puede consultar todas las Preguntas frecuentes o buscar alguna pregunta y su respuesta. 1. Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos? (Llamamos Lista de medicamentos a la Lista de medicamentos cubiertos, para abreviar.) Los medicamentos de la Lista son los medicamentos cubiertos por SCFHP Cal MediConnect. Los medicamentos están disponibles en las farmacias de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ellos, para trabajar con nosotros y proporcionarle servicios a usted. Llamamos a estas farmacias farmacias de la red. SCFHP Cal MediConnect cubrirá cualquiera de los medicamentos necesarios de la Lista, si: su médico u otro proveedor médico dice que usted los necesita para mejorar o para seguir sano y, usted surte la receta en una farmacia de la red de SCFHP. En algunos casos, usted tendrá que hacer algo antes de poder obtener el medicamento (lea la pregunta # 5 de abajo). Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en o llame a Servicio al miembro al La Lista de medicamento cambia alguna vez? Sí. SCFHP podría agregar o quitar medicamentos de la Lista de medicamentos durante el año. De manera general, la Lista de medicamentos sólo cambiará si: Aparece un medicamento más barato, que funcione tan bien como algún medicamento que se encuentre actualmente en la Lista de medicamentos o, Nos enteramos que algún medicamento no es seguro. También podemos cambiar nuestras reglas sobre sobre algunos medicamentos. Por ejemplo, podríamos: Decidir si exigir o no una aprobación previa para algún medicamento. (Aprobación previa es un permiso que damos SCFHP antes que usted pueda obtener un medicamento.) Aumentar o reducir la cantidad de un medicamento que usted puede obtener (llamado límites de cantidad ).? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite ii

4 Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia progresiva significa que usted podría tener que probar un medicamento antes que cubramos otro medicamento.) (Para obtener más información acerca de estas reglas de medicamentos, lea la página iii.) Le avisaremos cuando quitemos de la Lista de medicamentos algún medicamento que usted esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún medicamento. Las preguntas 3, 4 y 7 de abajo tienen más información sobre lo que sucederá cuando cambie la Lista de medicamentos. Usted siempre puede leer la Lista de medicamentos actualizada de SCFHP Cal MediConnect en internet, en También puede llamar a Servicios al miembro para revisar la Lista de medicamentos actual, llamando al Qué sucederá cuando aparezca un medicamento más barato que funcione tan bien como algún medicamento que se encuentre actualmente en la Lista de medicamentos? Le avisaremos si usted toma algún medicamento que hayamos sacado de la lista porque hay un medicamento más barato que funcione tan bien. Le avisaremos por lo menos 60 días antes de sacarlo de la Lista de medicamentos o la próxima vez que pida un resurtido. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de medicamentos. Usted recibirá una carta de SCFHP al menos 60 días antes de que el cambio sea efectivo. Esta información también se publicará en 4. Qué sucederá cuándo averigüemos que algún medicamento no es seguro? Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es seguro, lo quitaremos inmediatamente de la Lista de medicamentos. También le enviaremos una carta avisándole. Póngase en contacto con su proveedor de recetas tras recibir la carta. 5. La cobertura de medicamentos tiene alguna restricción o límite? O hay que hacer algo en particular para poder obtener ciertos medicamentos? Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el medicamento. Por ejemplo:? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite iii

5 Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su médico u otro profesional médico deben obtener una aprobación de SCFHP antes de surtir su receta. Si usted no consigue la aprobación, SCFHP podría no cubrir el medicamento. Límites de cantidad: A veces SCFHP limita la cantidad de un medicamento que usted puede obtener. Tratamiento progresivo: A veces SCFHP exige que usted siga un tratamiento progresivo. Esto significa que usted tendrá que probar los medicamentos para su enfermedad en un cierto orden. Usted podría tener que probar un medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el primer medicamento no funciona para usted, entonces cubriremos el segundo. Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los cuadros empezando en la página 1. Usted también puede obtener más información visitando nuestro sitio web en Tenemos en internet documentos explicando nuestras restricciones de aprobación previa y de tratamiento progresivo. También puede pedirnos que le enviemos una copia. Usted puede pedir una excepción a esos límites. Por favor lea en la Pregunta 11 más información sobre las excepciones. Si usted está en un hogar para personas mayores u otra institución de cuidados a largo plazo y necesita algún medicamento que no esté en la Lista de medicamentos o si no puede obtener el medicamento que necesite fácilmente, podemos ayudarle. Cubriremos un suministro de emergencia de 31 días del medicamento que usted necesite (a menos que tenga una receta para menos días), sin importar que usted sea o no un miembro nuevo de SCFHP. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos, que usted pueda tomar en su lugar o si tiene que pedir una excepción. Por favor lea más información sobre las excepciones en la Pregunta Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer algo para obtenerlo? La Lista de medicamentos cubiertos empezando en la página 1 tiene una columna llamada Medidas necesarias, restricciones o límites de uso.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite iv

6 7. Qué sucederá si cambiamos nuestras reglas sobre cómo cubrimos algunos de los medicamentos? Por ejemplo, si agregamos requisitos de autorización (aprobación) previa, límites de cantidad o restricciones de tratamiento progresivo a algún medicamento. Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidad o restricciones de tratamiento progresivo a un medicamento. Le avisaremos por lo menos 60 días antes de agregar la restricción o la próxima vez que pida un resurtido en la farmacia. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en las reglas de cobertura. Esto le dará tiempo para hablar con su médico u otro profesional médico sobre qué hacer después. 8. Cómo puede encontrar un medicamento en la Lista de medicamentos? Hay dos maneras de encontrar un medicamento: Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del medicamento) o Puede buscar por enfermedad. Para buscar por orden alfabético, vaya a la sección alfabética de la lista. Usted puede encontrarlo en la página I-1. Para buscar por enfermedad, busque la sección titulada Lista de medicamentos por enfermedad de la página 1. Luego, busque su enfermedad. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe buscar en esa categoría. Ahí encontrará los medicamentos que traten enfermedades del corazón. 9. Qué pasará si el medicamento que usted quiere tomar no está en la Lista de medicamentos? Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicio al miembro al y pregunte por él. Si se entera que SCFHP Cal MediConnect no cubrirá el medicamento, usted puede hacer algo de lo siguiente: Pida a Servicios al miembro una lista de medicamentos similar al que usted quiera tomar. Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un medicamento similar al de la Lista de medicamentos que usted quiere tomar. O,? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite v

7 Usted también puede pedir al plan que haga una excepción para cubrir su medicamento. Por favor lea más información sobre las excepciones en la pregunta Qué pasará si usted es un miembro nuevo de SCFHP Cal MediConnect y no puede encontrar su medicamento en la Lista o tiene problemas para obtener su medicamento? Podemos ayudarle. Podríamos cubrir su medicamento temporariamente para un suministro de 30 días durante los primeros 90 días en que usted sea miembro de SCFHP Cal MediConnect. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su lugar o tiene que pedir una excepción. Cubriremos un suministro de 30 días de su medicamento si: Usted está tomando algún medicamento que no esté en nuestra Lista de medicamentos o Las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor médico o El medicamento requiere aprobación previa de SCFHP o Usted toma algún medicamento que forme parte de una restricción de tratamiento progresivo. Si usted vive en un hogar para personas mayores u otra institución de cuidados a largo plazo, usted puede resurtir su receta hasta por 91 días. Usted podrá resurtir el medicamento varias veces durante los 91 días. Esto le dará tiempo a su proveedor médico para cambiar sus medicamentos por los que estén en la Lista de medicamentos o para pedir una excepción. Si está en transición entre distintos niveles de atención (por ejemplo, dentro o fuera de un establecimiento de atención a largo plazo o un hospital), SCFHP cubrirá un nuevo suministro de transición de 31 días del medicamento para que lo consuma en su nuevo escenario. Esto se encargará de cualquier restricción que pudiera existir. 11. Puede pedir al plan que haga una excepción para cubrir su medicamento? Sí. Usted puede pedirle a SCFHP Cal MediConnect que haga una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos. Usted también puede pedirnos un cambio a las reglas de su medicamento. Por ejemplo, SCFHP Cal MediConnect podría limitar la cantidad que cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede pedirnos que quitemos el límite y que cubramos más.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite vi

8 Otros ejemplos: Usted puede pedirnos que quitemos las restricciones de tratamiento progresivo o los requisitos de aprobación previa. 12. Cuánto tiempo toma obtener una excepción? Primero, debemos recibir una declaración de su proveedor médico apoyando su pedido de una excepción. Después de recibir la declaración, le daremos una decisión sobre su pedido de excepción a más tardar en 72 horas. Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72 horas para obtener una decisión, entonces usted puede pedir una excepción rápida. Ésta es una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión a más tardar 24 horas después de recibir la declaración de apoyo de su proveedor médico. 13. Cómo puede pedir una excepción? Para pedir una excepción, llame a Servicios al miembro. Servicios al miembro trabajará con usted y su proveedor para ayudarle a pedir una excepción. 14. Qué son los medicamentos genéricos? Los medicamentos genéricos están compuestos por los mismos ingredientes que los medicamentos de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidas. Los medicamentos genéricos son aprobados por la Administración de alimentos y medicamentos (FDA). SCFHP Cal MediConnect cubre tanto medicamentos de marca como medicamentos genéricos. 15. Qué son los medicamentos de venta libre (OTC)? OTC quiere decir medicamentos de venta libre. Usted puede comprar medicamentos de venta libre con receta de su médico u otro proveedor médico. SCFHP Cal MediConnect cubre algunos medicamentos de venta libre. Usted puede leer la Lista de medicamentos de SCFHP Cal MediConnect para ver qué medicamentos de venta libre están cubiertos.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite vii

9 16. SCFHP Cal MediConnect cubre algún producto de venta libre que no sea un medicamento? SCFHP Cal MediConnect cubre algunos productos de venta libre que no son medicamentos cuando se los receta su médico u otro proveedor médico. Usted puede leer la Lista de medicamentos de SCFHP Cal MediConnect para ver qué productos de venta libre, que no son medicamentos, están cubiertos. 17. Cuál es su copago? Usted puede leer la Lista de medicamentos de SCFHP Cal MediConnect para enterarse de los copagos de cada medicamento. Los miembros de SCFHP Cal MediConnect que vivan en hogares para personas mayores u otras instituciones de cuidados a largo plazo, no tendrán copagos. Tampoco tendrán copagos algunos miembros que reciban cuidados a largo plazo en la comunidad. Los copagos están ordenados por niveles. Los niveles son grupos de medicamentos con los mismos copagos. Los medicamentos de Nivel 1 tienen un copago de $0. Son medicamentos genéricos. Los medicamentos de Nivel 2 tienen un copago de $0. Son medicamentos de marca. Los medicamentos de Nivel 3 tienen un copago de $0. No son medicamentos recetados de Medicare. Los medicamentos de Nivel 4 tienen un copago de $0. No son medicamentos de venta libre de Medicare.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite viii

10 Lista de símbolos y abreviaturas Las siguientes abreviaturas de Gestión de utilización pueden encontrarse dentro del cuerpo de este documento. ABREVIATURAS DE LA NOTA SOBRE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA PA BvD PA-HRM Restricciones de gestión de utilización Autorización previa Autorización previa para determinar Parte B frente a Parte D Restricción de autorización previa para medicamentos de alto riesgo Es necesario que usted (o su médico) obtenga autorización previa de SCFHP Cal MediConnect antes de completar la receta para este medicamento. Sin la autorización previa, es posible que SCFHP Cal MediConnect no cubra este medicamento. Es posible que este medicamento sea elegible para pago conforme a Medicare Parte B o Parte D. Antes de completar la receta para este medicamento, es necesario que usted (o su médico) obtenga autorización previa de SCFHP Cal MediConnect para determinar si este medicamento está cubierto por Medicare Parte D. Sin la autorización previa, es posible que SCFHP Cal MediConnect no cubra este medicamento. El Centro de Servicios de Medicare y Medicaid (Centers for Medicare & Medicaid Services, CMS) ha considerado a este medicamento como potencialmente dañino y, por lo tanto, es un medicamento de alto riesgo para beneficiarios de Medicare de 65 años o más. Es necesario que los miembros de 65 años o más obtengan una autorización previa de SCFHP Cal MediConnect antes de completar la receta para este medicamento. Sin la autorización previa, es posible que SCFHP Cal MediConnect no cubra este medicamento.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite ix

11 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA NSO QL ST Autorización previa para nuevos comienzos solamente Límite de cantidad Terapia escalonada Si usted es un miembro nuevo o si es un miembro que reanuda y no tomó este medicamento antes, es necesario que usted (o su médico) obtenga autorización previa de SCFHP Cal MediConnect antes de completar la receta para este medicamento. Sin la autorización previa, es posible que SCFHP Cal MediConnect no cubra este medicamento. SCFHP Cal MediConnect limita la cantidad de medicamento que se cubre por receta o dentro de un período de tiempo específico. Antes de que SCFHP Cal MediConnect proporcione cobertura para este medicamento, usted debe probar, primero, otro(s) medicamento(s) para tratar su afección médica. Este medicamento solo estará cubierto si los demás medicamentos no le hacen efecto. Las siguientes abreviaturas adicionales de la nota sobre cobertura pueden encontrarse dentro el cuerpo de este documento. OTROS REQUISITOS ESPECIALES PARA LA COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN * LA No es un medicamento Parte D Medicamento de acceso limitado Este medicamento no es un medicamento Parte D cubierto por Medi-Cal. Es posible que este medicamento recetado solo esté disponible en ciertas farmacias. Para obtener más información, consulte con el Directorio de farmacias o llame al Servicio de atención al miembro al , los 7 días de la semana, de 8:00 a.m. a 8:00 p.m., incluso feriados. Los usuarios de TTY/TDD pueden llamar al ? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite x

12 Lista de medicamentos cubiertos La Lista de medicamentos cubiertos que comienza a partir del de la página siguiente le da información sobre los medicamentos cubiertos por SCFHP Cal MediConnect. Si usted tiene problemas para encontrar su medicamento en la lista, pase al Índice que comienza en la página I-1. La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (p.ej.: FLOVENT) y los medicamentos genéricos están escritos en cursivas minúsculas (p.ej.: fluticasone propionate). La información de la columna titulada Medidas necesarias, restricciones o límites de uso, le indica si SCFHP Cal MediConnect tiene alguna regla para cubrir su medicamento. Note: El símbolo asterisco (*) junto a un medicamento significa que el medicamento no es un medicamento Parte D. La cantidad que usted pague cuando surta una receta de este medicamento no cuenta para el costo total de sus medicamentos (o sea, la cantidad que usted pague no le ayudará a ser elegible para la cobertura catastrófica). Estos medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos alguna decisión que hayamos tomado sobre su cobertura y que la cambiemos si le parece que hemos cometido un error. Por ejemplo, podríamos decidir que un medicamento que usted quiere no está cubierto o que ya no está cubierto por Medicare o Medi-Cal. Si usted o su médico no están de acuerdo con nuestra decisión, usted puede apelar. Si en algún momento tiene una pregunta, llame a Servicios al miembro al Usted también puede enterarse sobre cómo apelar una decisión en el Manual del miembro.? Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan al , los 7 días de la semana, de 8 a.m. a 8 p.m., incluyendo días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. Para obtener más información, visite xi

13 Analgesics Analgesics, Miscellaneous acetaminophen * oral (Acetaminophen) PA; AGE (Max 21 acetaminophen-codeine oral (Acetaminophen QL (2700 per 30 solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (360 per mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (180 per mg No.3) buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral PA-HRM; QL (180 per (Esgic) capsule mg 30 butalbital-acetaminop-caf-cod (Fioricet with PA-HRM; QL (180 per Codeine) 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (180 per 30 butalbital-acetaminophen-caff oral PA-HRM; QL (180 per (Esgic) tablet mg 30 butalbital-aspirin-caffeine oral PA-HRM; QL (180 per (Fiorinal) capsule 30 butorphanol tartrate nasal (Butorphanol QL (5 per 28 Tartrate) BUTRANS QL (4 per 28 children's non-aspirin * oral (Acetaminophen) PA; AGE (Max 21 children's pain & fever relief * oral (Infants' Tylenol) PA; AGE (Max 21 children's silapap * (Tylenol Sore PA; AGE (Max 21 Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule mg Codeine #3) 30 DURAMORPH (PF) 1

14 fentanyl citrate (Actiq) fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Duragesic) (Duragesic) (Hycet) (Norco) (Norco) PA; QL (120 per 30 PA; QL (20 per 30 PA; QL (10 per 30 QL (2700 per 30 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 QL (360 per 30 hydrocodone-ibuprofen (Ibudone) QL (150 per 30 hydromorphone (pf) injection (Hydromorphone solution 10 mg/ml HCl/PF) hydromorphone (pf) injection (Dilaudid) solution 4 mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid (Dilaudid) QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 QL (180 per 30 (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 infant acetaminophen * (Acetaminophen) PA; AGE (Max 21 infantaire * (Acetaminophen) PA; AGE (Max 21 2

15 infant's pain reliever * (Acetaminophen) LAZANDA levorphanol tartrate (Levorphanol Tartrate) PA; AGE (Max 21 PA; QL (30 per 30 QL (180 per 30 mapap (acetaminophen) * oral PA; AGE (Max 21 (Acetaminophen) elixir mapap (acetaminophen) * oral PA; AGE (Max 21 (Infants' Tylenol) suspension methadone hcl oral tablet,soluble QL (90 per 30 (Diskets) 40 mg methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Msir) QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml, 2 mg/ml (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (180 per 30 morphine oral tablet extended QL (120 per 30 (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) 3

16 nortemp * oral (Acetaminophen) PA; AGE (Max 21 NUCYNTA QL (181 per 30 NUCYNTA ER QL (60 per 30 oxycodone hcl-acetaminophen oral solution mg/5 ml oxycodone hcl-acetaminophen oral tablet mg, mg, mg, mg (Oxycodone HCl/Acetaminophe n) (Xolox) QL (1800 per 30 QL (360 per 30 oxycodone hcl-aspirin (Percodan) QL (360 per 30 oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30 oxycodone oral tablet (Percolone) QL (180 per 30 oxycodone-acetaminophen oral QL (360 per 30 tablet mg, mg, mg, mg (Xolox) oxycodone-acetaminophen oral QL (180 per 30 (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 (Xolox) tablet mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended QL (60 per 30 release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 (Opana ER) release 12 hr 30 mg, 40 mg 4

17 pain relief * oral capsule (Acetaminophen) q-pap * oral drops (Acetaminophen) q-pap * oral liquid (Tylenol Sore Throat) silapap * (Acetaminophen) PA; AGE (Max 21 PA; AGE (Max 21 PA; AGE (Max 21 tramadol oral tablet (Ultram) QL (240 per 30 tramadol-acetaminophen (Ultracet) QL (240 per 30 xylon 10 (Ibudone) QL (150 per 30 Nonsteroidal Anti-Inflammatory Agents aspirin * oral tablet (Ecotrin) aspirin * oral tablet,chewable (Bayer Chewable Aspirin) aspirin * oral tablet,delayed release (Ecotrin) (dr/ec) 325 mg, 650 mg, 81 mg aspir-low * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) QL (60 per 30 children's advil * (Children'S Motrin) choline,magnesium salicylate (Choline Sal/Mag Salicylate) COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR) diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) Sodium) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) 5

18 e.c. prin * (Ecotrin) ecotrin * (Ecotrin) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR PA flurbiprofen (Ansaid) ibuprofen * 100 mg/5 ml susp (Children'S children's (otc) Motrin) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (120 per 30 indomethacin oral capsule, PA-HRM; QL (60 per (Indomethacin) extended release 30 indomethacin sodium (Indocin I.V.) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac injection cartridge 15 QL (40 per 30 (Toradol) mg/ml ketorolac injection cartridge 30 QL (20 per 30 (Toradol) mg/ml ketorolac injection solution 15 (Ketorolac QL (40 per 30 mg/ml Tromethamine) ketorolac injection solution 30 (Ketorolac QL (20 per 30 mg/ml (1 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 Tromethamine) ketorolac oral (Ketorolac QL (20 per 30 Tromethamine) 6

19 mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (dr/ec) (Ec-Naprosyn) naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam (Feldene) salsalate (Salsalate) sb aspirin * 325 mg tablet na/f, caffeine-free st joseph aspirin * (Bayer Chewable Aspirin) st. joseph aspirin * (Ecotrin) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) lidocaine hcl injection solution (Xylocaine) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA 7

20 lidocaine topical ointment (Lidocaine) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Relador Pak) PA BvD RELADOR PAK PA BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) buprenorphine hcl sublingual (Subutex) buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) PA; QL (90 per 30 PA; QL (90 per 30 CHANTIX QL (168 per 84 CHANTIX CONTINUING QL (56 per 28 MONTH BOX CHANTIX CONTINUING QL (56 per 28 MONTH PAK CHANTIX STARTING MONTH QL (53 per 28 BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) nicotine * transdermal patch 24 PA; QL (224 per 365 (Nicoderm Cq) hour NICOTROL ZUBSOLV SUBLINGUAL PA; QL (120 per 30 TABLET MG ZUBSOLV SUBLINGUAL PA; QL (30 per 30 TABLET MG ZUBSOLV SUBLINGUAL PA; QL (60 per 30 TABLET MG, MG 8

21 ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines Name of Drug PA; QL (90 per 30 alprazolam oral tablet (Xanax) QL (90 per 30 alprazolam oral tablet extended QL (90 per 30 (Xanax XR) release 24 hr 0.5 mg alprazolam oral tablet extended QL (60 per 30 (Xanax XR) release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral QL (90 per 30 (Alprazolam) tablet,disintegrating chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 QL (90 per 30 (Klonopin) mg clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral QL (90 per 30 tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) clonazepam oral QL (300 per 30 (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 (Tranxene T-Tab) 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG diazepam injection (Diazepam) QL (10 per 28 diazepam intensol (Diazepam) QL (1200 per 30 diazepam oral solution (Diazepam) QL (1200 per 30 diazepam oral tablet (Valium) QL (120 per 30 diazepam rectal (Diastat Acudial) 9

22 estazolam oral tablet 1 mg (Estazolam) estazolam oral tablet 2 mg (Estazolam) flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 10

23 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 lorazepam oral solution (Ativan) QL (150 per 30 lorazepam injection solution (Ativan) QL (2 per 30 lorazepam injection syringe (Ativan) QL (2 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam QL (2 per 30 HCl/PF) midazolam (pf) injection syringe 2 (Midazolam QL (2 per 30 mg/2 ml (1 mg/ml) HCl/PF) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Restoril) PA NSO; QL (60 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 11

24 temazepam oral capsule 7.5 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30 triazolam oral tablet mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Garamycin) 12

25 gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 tobramycin in % nacl (Tobi) PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodiu m Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate) nitrofurantoin macrocrystal oral PA-HRM; QL (120 per (Macrodantin) capsule 100 mg 30 13

26 nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA; QL (9 per 30 ST; QL (60 per 30 14

27 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 (Cefazolin Sodium) ml cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, 300 g (Cefazolin Sodium) cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO- OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm (Cefoxitin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os (Ceftriaxone intravenous piggyback 1 gram/50 Na/Dextrose, Iso) ml 15

28 CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln (Ceftriaxone 1 gram Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for reconstitution (Cephalexin) cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO- OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 24 hr (Biaxin XL) DIFICID QL (20 per 10 ERYTHROCIN 16

29 erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml (Erythromycin Base) (Eryped 200) erythromycin ethylsuccinate oral (Erythromycin tablet 400 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin release(dr/ec) Base) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet (Erythromycin 250 mg Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON LA imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for reconstitution (Amoxil) amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 mg, 250 mg (Amoxicillin) amoxicillin-pot clavulanate oral suspension for reconstitution (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet extended release 12 hr (Augmentin XR) 17

30 amoxicillin-pot clavulanate oral (Amoxicillin/Potas tablet,chewable sium Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection (Unasyn) ampicillin-sulbactam intravenous recon soln (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- Water) penicillin g potassium (Penicillin G Potassium) penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam (Zosyn) Quinolones 18

31 ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution 400 mg/40 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension Trimethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/ Trimethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) 19

32 doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet (Adoxa) (Doryx) (Adoxa) (Vibramycin) (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS PA NSO; QL (4 per 21 AFINITOR DISPERZ PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 PA NSO; QL (56 per MG 28 AFINITOR ORAL TABLET 2.5 PA NSO; QL (28 per MG, 5 MG, 7.5 MG 28 ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) ARRANON ARZERRA PA NSO AVASTIN PA NSO azacitidine (Vidaza) BELEODAQ PA NSO bexarotene (Targretin) PA NSO; QL (420 per 30 20

33 bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) COMETRIQ cyclophosphamide intravenous recon soln CYCLOPHOSPHAMIDE ORAL CAPSULE (Cyclophosphamid e) PA BvD PA NSO; QL (140 per 365 PA NSO; QL (120 per 30 PA NSO; QL (30 per 30 PA NSO; QL (60 per 30 PA NSO; QL (30 per 30 PA NSO; QL (112 per 28 PA BvD PA BvD; ST cyclophosphamide oral tablet (Cyclophosphamid e) CYRAMZA PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) decitabine (Dacogen) PA BvD; ST doxorubicin hcl intravenous recon PA BvD (Doxorubicin HCl) soln 10 mg doxorubicin hcl peg-liposomal PA BvD (Doxil) intravenous suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD 21

34 DROXIA ELIGARD SUBCUTANEOUS QL (1 per 84 SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 112 SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 168 SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 28 SYRINGE 7.5 MG (1 MONTH) EMCYT epirubicin intravenous solution 50 mg/25 ml (Ellence) ERBITUX PA NSO ERIVEDGE PA NSO; QL (30 per 30 ETOPOPHOS etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON FARYDAK PA NSO; QL (6 per 21 FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) fluorouracil intravenous solution PA BvD 2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil) mg/10 ml flutamide (Flutamide) GAZYVA PA NSO; QL (40 per 28 gemcitabine intravenous recon soln 1 gram (Gemzar) 22

35 GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG HALAVEN HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) PA NSO; QL (30 per 30 PA NSO; QL (90 per 30 PA NSO; QL (60 per 30 PA NSO; QL (24 per 28 IBRANCE PA NSO; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna PA BvD ) IMBRUVICA PA NSO; QL (120 per 30 INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IRESSA PA NSO; QL (60 per 30 ISTODAX PA NSO IXEMPRA JAKAFI PA NSO; QL (60 per 30 JEVTANA KADCYLA PA NSO 23

36 KEYTRUDA PA NSO KYPROLIS PA NSO; QL (6 per 28 LENVIMA PA NSO letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT QL (1 per 28 LUPRON DEPOT (3 MONTH) QL (1 per 84 LUPRON DEPOT (4 MONTH) QL (1 per 84 LUPRON DEPOT (6 MONTH) QL (1 per 168 LUPRON DEPOT-PED QL (1 per 28 LUPRON DEPOT-PED (3 QL (1 per 84 MONTH) INTRAMUSCULAR SYRINGE KIT LYNPARZA PA NSO; QL (480 per 30 LYSODREN MARQIBO MATULANE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (Megace Es) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG melphalan hcl intravenous (Alkeran) mercaptopurine (Purinethol) PA NSO; QL (4 per 28 PA NSO; QL (90 per 30 PA NSO; QL (30 per 30 24

37 methotrexate sodium (pf) injection (Methotrexate PA BvD recon soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate PA BvD solution Sodium) methotrexate sodium injection (Methotrexate PA BvD Sodium) methotrexate sodium oral (Methotrexate PA BvD; ST Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Mitoxantrone HCl) MUSTARGEN NEXAVAR PA NSO; QL (120 per 30 NILANDRON ONCASPAR PA NSO OPDIVO INTRAVENOUS PA NSO SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel (Paclitaxel) PERJETA PA NSO POMALYST PA NSO; QL (21 per 28 PROLEUKIN PURIXAN REVLIMID PA NSO; LA; QL (21 per 28 RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 PA NSO; QL (30 per 30 MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 25

38 STIVARGA PA NSO; QL (84 per 28 SUTENT PA NSO; QL (30 per 30 SYLVANT PA NSO SYNRIBO PA NSO; QL (28 per 28 TABLOID TAFINLAR PA NSO; QL (120 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 PA NSO; QL (60 per MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA 30 PA NSO; QL (90 per 30 PA NSO; QL (60 per 28 PA NSO; QL (112 per 28 TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR QL (1 per 168 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL (1 per 84 SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 SYRINGE 22.5 MG/2 ML 26

39 TRELSTAR INTRAMUSCULAR QL (1 per 28 SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB UNITUXIN PA NSO VALSTAR VECTIBIX PA NSO VELCADE PA NSO vinblastine intravenous (Vinblastine PA BvD Sulfate) vincristine (Vincristine PA BvD Sulfate) vincristine sulfate intravenous (Vincristine PA BvD solution 1 mg/ml Sulfate) vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; QL (120 per 30 XALKORI PA NSO; QL (60 per 30 XTANDI PA NSO; QL (120 per 30 YERVOY PA NSO ZALTRAP INTRAVENOUS PA NSO SOLUTION ZELBORAF PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS QL (1 per 84 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 28 IMPLANT 3.6 MG ZOLINZA ZYDELIG PA NSO; QL (60 per 30 27

40 ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml (Atropine Sulfate) (Atropine Sulfate) propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ST BANZEL ST carbamazepine (Tegretol) carbamazepine oral capsule, er multiphase 12 hr (Carbatrol) carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended release 12 hr (Tegretol XR) carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr (Depakote ER) divalproex oral tablet,delayed release (dr/ec) (Depakote) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) PA NSO; QL (140 per 28 PA NSO; QL (120 per 30 28

41 FYCOMPA ORAL TABLET ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release 24hr (Lamictal XR) lamotrigine oral tablet, chewable dispersible (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release 24 hr (Keppra XR) LYRICA ORAL CAPSULE QL (90 per 30 LYRICA ORAL SOLUTION QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, QL (90 per mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenobarbital sodium injection (Phenobarbital QL (2 per 30 solution Sodium) 29

42 phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone (Mysoline) QUDEXY XR ST SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er (Qudexy XR) 24hr TRILEPTAL ORAL SUSPENSION TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ST; QL (90 per 30 ST; QL (270 per 30 ST; QL (200 per 5 ST; QL (1200 per 30 ST; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 30

43 EXELON TRANSDERMAL QL (30 per 30 galantamine oral capsule,ext rel. QL (30 per 30 (Razadyne ER) pellets 24 hr galantamine oral solution (Razadyne) QL (200 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 memantine oral tablet (Namenda) QL (60 per 30 memantine oral tablets,dose pack (Namenda) QL (49 per 28 NAMENDA ORAL SOLUTION QL (360 per 30 NAMENDA ORAL TABLET QL (60 per 30 NAMENDA TITRATION PAK QL (49 per 28 NAMENDA XR ORAL QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline PA NSO-HRM HCl) amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release, 150 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr (Wellbutrin XL) citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM 31

44 duloxetine oral capsule,delayed QL (60 per 30 (Irenka) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed QL (30 per 30 (Irenka) release(dr/ec) 30 mg duloxetine oral capsule,delayed QL (30 per 30 (Irenka) release(dr/ec) 40 mg EMSAM QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) (Prozac Weekly) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 24hr (Luvox CR) fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM IRENKA QL (30 per 30 KHEDEZLA ST; QL (30 per 30 maprotiline (Maprotiline HCl) MARPLAN mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) paroxetine hcl oral tablet extended release 24 hr (Paxil CR) 32

45 PAXIL ORAL SUSPENSION perphenazine-amitriptyline (Perphenazine/Ami PA NSO-HRM triptyline HCl) phenelzine (Nardil) PRISTIQ ST; QL (30 per 30 protriptyline (Vivactil) sertraline (Zoloft) SILENOR QL (30 per 30 SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release 24hr (Effexor XR) venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg (Venlafaxine HCl) VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 BYDUREON QL (4 per 28 BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN QL (1.2 per 28 INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET QL (180 per 30 GLYXAMBI QL (30 per 30 INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG ST; QL (60 per 30 33

46 INVOKAMET ORAL TABLET ST; QL (120 per MG INVOKANA ORAL TABLET 100 ST; QL (60 per 30 MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG JANUMET QL (60 per 30 JANUMET XR ORAL TABLET, QL (30 per 30 ER MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, QL (60 per 30 ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA QL (30 per 30 JARDIANCE ST; QL (30 per 30 JENTADUETO QL (60 per 30 KORLYM PA; QL (112 per 28 metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (120 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended QL (120 per 30 (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET QL (150 per 30 repaglinide (Prandin) QL (240 per 30 34

47 SYMLINPEN 120 PA; QL (10.8 per 28 SYMLINPEN 60 PA; QL (6 per 28 TRADJENTA QL (30 per 30 TRULICITY QL (4 per 28 VICTOZA PA; QL (9 per 28 Insulins HUMALOG KWIKPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN QL (12 per 28 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG MIX QL (40 per 28 HUMALOG MIX QL (30 per 28 KWIKPEN HUMALOG MIX QL (40 per 28 HUMALOG MIX QL (30 per 28 KWIKPEN HUMALOG SUBCUTANEOUS QL (30 per 28 CARTRIDGE HUMALOG SUBCUTANEOUS QL (40 per 28 HUMULIN 70/30 QL (40 per 28 HUMULIN 70/30 KWIKPEN QL (30 per 28 HUMULIN N QL (40 per 28 HUMULIN N KWIKPEN QL (30 per 28 HUMULIN R QL (40 per 28 HUMULIN R U-500 QL (40 per 28 (CONCENTRATED) LANTUS QL (40 per 28 LANTUS SOLOSTAR QL (30 per 28 NOVOLIN 70/30 QL (40 per 28 NOVOLIN N QL (40 per 28 NOVOLIN R QL (40 per 28 NOVOLOG QL (40 per 28 35

48 NOVOLOG FLEXPEN QL (30 per 28 NOVOLOG MIX QL (40 per 28 NOVOLOG MIX FLEXPEN QL (30 per 28 NOVOLOG PENFILL QL (30 per 28 TOUJEO SOLOSTAR QL (7.5 per 28 Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended QL (60 per 30 (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (60 per mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (120 per mg, mg in HCl) glyburide micronized oral tablet 1.5 PA-HRM; QL (400 per (Glynase) mg 30 glyburide micronized oral tablet 3 PA-HRM; QL (180 per (Glynase) mg 30 glyburide micronized oral tablet 6 PA-HRM; QL (120 per (Glynase) mg 30 glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 glyburide-metformin oral tablet PA-HRM; QL (240 per (Glucovance) mg 30 glyburide-metformin oral tablet 2.5- PA-HRM; QL (120 per (Glucovance) 500 mg, mg 30 tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 36

49 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (180 per 30 Antifungals Antifungals ABELCET PA BvD AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD baza antifungal * (Nuzole) CANCIDAS ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole * 1% cream (otc) (Lotrimin AF) clotrimazole * 1% solution (otc) (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Lotrimin) clotrimazole * vaginal cream (Gyne-Lotrimin) clotrimazole * vaginal tablet (Clotrimazole) clotrimazole-7 * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion methasone Dip) desenex (clotrimazole) * (Lotrimin AF) econazole topical (Econazole Nitrate) fluconazole (Diflucan) fluconazole in dextrose(iso-o) intravenous piggyback (Fluconazole In Nacl,Iso-Osm) 37

50 fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) flucytosine (Ancobon) fungi cure * (Clotrimazole) fungoid-d * (Tinactin) griseofulvin microsize oral tablet (Grifulvin V) inzo antifungal * (Nuzole) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LOTRIMIN ULTRA * micatin * (Nuzole) miconazole 7 * vaginal suppository (Miconazole Nitrate) miconazole nitrate * topical cream (Nuzole) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal kit 1,200-2 mg-%, 200 mg- 2 % (9 gram) (Monistat 3) miconazole nitrate vaginal suppository 200 mg miconazole-3 prefil,cream,wipe * (Monistat 3) (Miconazole/Skin Cleanser No.17) MONISTAT 3 * VAGINAL COMB PACK,PREFILL APPL & CREAM monistat 7 * vaginal (Miconazole Nitrate) NOXAFIL ORAL NYSTATIN (BULK) POWDER 1 BILLION UNIT 38

51 nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin ) terbinafine hcl oral (Lamisil) tolnaftate * topical (Tinactin) tolnaftate * topical (Tolnaftate) vagistat-3 * (Monistat 3) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) Antihistamines Antihistamines aller-chlor * oral syrup (Chlorpheniramine PA; AGE (Min 2 Maleate) aller-chlor * oral tablet (Chlor-Trimeton) PA; AGE (Min 2 allergy (chlorpheniramine) * (Chlor-Trimeton) PA; AGE (Min 2 allergy relief (loratadine) * oral (Claritin) PA; AGE (Min 2 allergy-sinus * oral tablet (Phenylephrine/Dip PA; AGE (Min 2 henhydramine) ambi 60pse-4cpm * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) aprodine * (Pseudoephedrine/ PA; AGE (Min 2 Triprolidine) banophen allergy * (Zzzquil) PA banophen * oral capsule 25 mg (Benadryl) PA banophen * oral (Diphenhydramine PA HCl) benadryl allergy * oral tablet (Diphenhydramine PA HCl) child dometuss-da * (Triaminic Cold- PA; AGE (Min 2 Allergy Pe) 39

52 child triaminic cold & allergy * (Dimetapp) PA; AGE (Min 2 child wal-tap cold-allergy * (Dimetapp) PA; AGE (Min 2 children's wal-dryl allergy * oral (Zzzquil) PA child's benadryl-d allergy-sin * (Phenylephrine/Dip PA; AGE (Min 2 henhydramine) clemastine oral syrup (Clemastine PA-HRM Fumarate) clemastine oral tablet 2.68 mg (Clemastine PA-HRM Fumarate) cold & cough * oral liquid (Triaminic Cold PA; AGE (Min 2 and Cough) compoz * (Diphenhydramine PA HCl) CONEX * ORAL SOLUTION PA; AGE (Min 2 conex * oral tablet (P-Ephed HCl/D- PA; AGE (Min 2 Bromp Mal) cyproheptadine (Cyproheptadine PA-HRM HCl) dimaphen (pe) * (Dimetapp) PA; AGE (Min 2 dimetapp cold-congestion * (Triaminic Cold PA; AGE (Min 2 and Cough) diphenhist * oral capsule (Benadryl) PA diphenhist * oral (Zzzquil) PA diphenhist * oral tablet 25 mg (Diphenhydramine PA HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) diphenhydramine hcl injection (Diphenhydramine syringe HCl) diphenhydramine hcl * oral capsule (Benadryl) PA diphenhydramine hcl * oral tablet (Diphenhydramine PA 50 mg HCl) 40

53 diphenhydramine-phenylephrine * (Triaminic Cold PA; AGE (Min 2 and Cough) ed chlorped jr * (Chlorpheniramine PA; AGE (Min 2 Maleate) entre-hist pse * (Pseudoephedrine/ PA; AGE (Min 2 Triprolidine) geri-dryl * oral capsule (Benadryl) histex pe * (Phenylephrine/Tri PA; AGE (Min 2 prolidine) levocetirizine (Xyzal) lohist - d * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) lohist-peb * (Brovex Peb) PA; AGE (Min 2 lohist-psb * (Pseudoephedrine/ PA; AGE (Min 2 Brompheniramin) loradamed * (Claritin) PA; AGE (Min 2 loratadine * oral (Claritin) PA; AGE (Min 2 loratadine * oral (Claritin) PA; AGE (Min 2 nyt-time sleep * (Diphenhydramine PA HCl) pediatex td * (Pseudoephedrine/ PA; AGE (Min 2 Triprolidine) phenylephrine-brompheniramin * (Phenylephrine/Bro PA; AGE (Min 2 mpheniramine) phenylephrine-chlorpheniramine * (Triaminic Cold- PA; AGE (Min 2 oral liquid 4-10 mg/5 ml Allergy Pe) phenylephrine-chlorpheniramine * (Phenylephrine/Chl PA; AGE (Min 2 oral tablet 4-10 mg orpheniramine) promethazine oral syrup (Promethazine PA-HRM HCl) q-dryl * oral liquid (Zzzquil) PA 41

54 q-tapp * (Pseudoephedrine/ PA; AGE (Min 2 Brompheniramin) siladryl sa * (Zzzquil) PA simply sleep * (Diphenhydramine PA HCl) sinus & allergy (pseudoephed) * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) sinus nighttime * (Phenylephrine/Tri PA; AGE (Min 2 prolidine) sleep-tabs * (Diphenhydramine PA HCl) sudogest cold & allergy * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) triacting orange * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) TRIAMINIC COLD & COUGH PA; AGE (Min 2 NT (PE) * trymine d * (Pseudoephedrine/ PA; AGE (Min 2 Triprolidine) unisom sleepgels * (Benadryl) PA vazobid-pd * (Phenylephrine/Bro PA; AGE (Min 2 mpheniramine) wal-act d cold & allergy * (Pseudoephedrine/ PA; AGE (Min 2 Triprolidine) wal-dryl allergy * oral (Benadryl) PA wal-dryl allergy * oral (Diphenhydramine PA HCl) wal-finate * (Chlor-Trimeton) PA; AGE (Min 2 wal-finate-d * (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) wal-itin * (Claritin) PA; AGE (Min 2 wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlo PA; AGE (Min 2 rpheniramine) 42

55 wal-phed pe sinus & allergy * (Phenylephrine/Chl orpheniramine) wal-sleep z * oral capsule (Benadryl) wal-som (diphenhydramine) * oral capsule (Benadryl) wal-som (diphenhydramine) * oral (Unisom tablet,disintegrating Sleepmelts) wal-tap * (Dimetapp) PA; AGE (Min 2 PA PA; AGE (Min 2 z-sleep * oral capsule (Benadryl) PA Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 dihydroergotamine nasal (Migranal) QL (4 per 28 ERGOMAR QL (40 per 28 naratriptan (Amerge) QL (18 per 28 rizatriptan oral tablet (Maxalt) QL (18 per 28 rizatriptan oral QL (18 per 28 (Maxalt Mlt) tablet,disintegrating sumatriptan nasal spray (Imitrex) QL (12 per 28 sumatriptan oral tablet (Imitrex) QL (18 per 28 sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) cartridge sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) pen injector sumatriptan succinate subcutaneous QL (4 per 28 (Imitrex) solution 43

56 zolmitriptan oral tablet (Zomig) QL (12 per 28 zolmitriptan oral QL (12 per 28 (Zomig Zmt) tablet,disintegrating Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO PA; QL (188 per 168 TRECATOR Antinausea Agents Antinausea Agents ambizine * (Meclizine HCl) PA; AGE (Min 2 dimenhydrinate injection solution (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS QL (2 per 28 EMEND ORAL CAPSULE 125 PA BvD; QL (1 per 1 MG day) EMEND ORAL CAPSULE 40 MG QL (1 per 1 day) EMEND ORAL CAPSULE 80 MG PA BvD; QL (2 per 1 day) EMEND ORAL CAPSULE,DOSE PA BvD; QL (3 per 1 PACK day) 44

57 granisetron (pf) intravenous (Granisetron solution HCl/PF) granisetron hcl intravenous solution (Kytril) 1 mg/ml (1 ml) granisetron hcl oral (Granisetron HCl) PA BvD meclizine * 12.5 mg caplet caplet PA; AGE (Min 2 (Meclizine HCl) (otc) meclizine * 25 mg tablet (otc) (Meclizine HCl) PA; AGE (Min 2 meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness (meclizine) * (Meclizine HCl) PA; AGE (Min 2 ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection solution (Compazine) prochlorperazine maleate (Compazine) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine PA-HRM HCl) promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (10 per 30 travel sickness (meclizine) * (Bonine) PA; AGE (Min 2 Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) 45

58 BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) metronidazole in nacl (iso-os) (Metronidazole/So dium Chloride) metronidazole oral (Flagyl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate) PENTAM pin-x * oral suspension (Pyrantel Pamoate) PRIMAQUINE QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (42 per 7 reese's pinworm medicine * (Pyrantel Pamoate) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) APOKYN QL (60 per 30 AZILECT benztropine oral (Benztropine Mesylate) bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet extended release (Sinemet CR) carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) PA-HRM 46

59 NEUPRO pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 15 MG ST; QL (30 per 30 PA-HRM QL (90 per 30 QL (60 per 30 ABILIFY INTRAMUSCULAR QL (161.2 per 28 ABILIFY MAINTENA QL (1 per 28 ABILIFY ORAL SOLUTION QL (900 per 30 aripiprazole oral solution (Abilify) QL (900 per 30 aripiprazole oral tablet 10 mg, 15 QL (30 per 30 (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg (Fazaclo) (Fazaclo) ST; QL (90 per 30 ST; QL (180 per 30 47

60 clozapine oral tablet,disintegrating 200 mg (Fazaclo) FANAPT ORAL TABLET FANAPT ORAL TABLETS,DOSE PACK ST; QL (120 per 30 ST; QL (60 per 30 ST; QL (8 per 28 fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 haloperidol (Haloperidol) haloperidol decanoate (Haloperidol intramuscular solution 100 mg/ml Decanoate) haloperidol decanoate (Haldol Decanoate intramuscular solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML ST; QL (30 per 30 ST; QL (60 per 30 QL (0.75 per 28 QL (1 per 28 QL (1.5 per 28 QL (0.25 per 28 48

61 INVEGA SUSTENNA QL (0.5 per 28 INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA QL (0.875 per 84 INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA QL (1.315 per 84 INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA QL (1.75 per 84 INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA QL (2.625 per 84 INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 ST; QL (30 per 30 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral QL (30 per 30 tablet,disintegrating 10 mg, 15 mg, 5 mg (Zyprexa Zydis) olanzapine oral QL (31 per 30 (Zyprexa Zydis) tablet,disintegrating 20 mg ORAP paliperidone oral tablet extended QL (30 per 30 (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 (Invega) release 24hr 6 mg perphenazine (Perphenazine) pimozide (Orap) quetiapine (Seroquel) QL (90 per 30 49

62 REXULTI ORAL TABLET 0.25 ST; QL (120 per 30 MG REXULTI ORAL TABLET 0.5 ST; QL (60 per 30 MG REXULTI ORAL TABLET 1 MG, ST; QL (30 per 30 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral QL (60 per 30 tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) risperidone oral QL (120 per 30 (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG ST; QL (60 per 30 ST; QL (30 per 30 thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Thiothixene) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; QL (540 per 30 ziprasidone hcl (Geodon) QL (60 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG QL (2 per 28 Antivirals (Systemic) Antiretrovirals 50

63 abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir) lamivudine-zidovudine (Combivir) LEXIVA nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 hr (Viramune XR) NORVIR PREZCOBIX PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY 51

64 stavudine (Zerit) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER rimantadine (Flumadine) SYNAGIS TAMIFLU ORAL CAPSULE 30 QL (84 per 180 MG TAMIFLU ORAL CAPSULE 45 QL (48 per 180 MG TAMIFLU ORAL CAPSULE 75 QL (42 per 180 MG TAMIFLU ORAL SUSPENSION QL (540 per 180 FOR RECONSTITUTION Hcv Antivirals DAKLINZA PA; QL (28 per 28 52

65 HARVONI PA; QL (30 per 30 OLYSIO PA; QL (28 per 28 SOVALDI PA; QL (28 per 28 TECHNIVIE PA; QL (56 per 28 VIEKIRA PAK PA; QL (112 per 28 Interferons INTRON A INJECTION PA NSO PEGASYS PA PEGASYS PROCLICK PA PEGINTRON PA PEGINTRON REDIPEN PA SYLATRON PA NSO; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous recon (Acyclovir PA BvD soln Sodium) acyclovir sodium intravenous (Acyclovir PA BvD solution Sodium) adefovir (Hepsera) entecavir (Baraclude) famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA 53

66 valacyclovir (Valtrex) valganciclovir (Valcyte) VIRAZOLE PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 enoxaparin subcutaneous syringe QL (36 per 30 (Lovenox) 100 mg/ml enoxaparin subcutaneous syringe QL (27.2 per 30 (Lovenox) 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe QL (34 per 30 (Lovenox) 150 mg/ml enoxaparin subcutaneous syringe QL (18 per 30 (Lovenox) 30 mg/0.3 ml enoxaparin subcutaneous syringe QL (13.6 per 30 (Lovenox) 40 mg/0.4 ml enoxaparin subcutaneous syringe QL (20.4 per 30 (Lovenox) 60 mg/0.6 ml fondaparinux subcutaneous syringe QL (24 per 30 (Arixtra) 10 mg/0.8 ml fondaparinux subcutaneous syringe QL (15 per 30 (Arixtra) 2.5 mg/0.5 ml fondaparinux subcutaneous syringe QL (12 per 30 (Arixtra) 5 mg/0.4 ml fondaparinux subcutaneous syringe QL (18 per 30 (Arixtra) 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin Sodium 12,500 unit/250 ml, 20,000 unit/500 in 5% Dextrose) ml (40 unit/ml) 54

67 HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection HEPARIN SODIUM,PORCINE-PF * INTRAVENOUS SYRINGE 100 UNIT/ML heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe 100 unit/ml HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 units/ml) bag excel container (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Heparin Sodium in 5% Dextrose) (Heparin Sodium in 5% Dextrose) $0 (Tier 3) PA BvD; (PA for ESRD Only) PA BvD PA BvD; (PA for ESRD Only) PA; QL (24 per 28 IPRIVASK jantoven (Coumadin) PRADAXA QL (60 per 30 warfarin (Coumadin) 55

68 XARELTO Blood Formation Modifiers EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA PA; QL (12 per 28 PA; QL (0.6 per 28 PA; QL (12 per 28 PA; QL (6 per 28 PA; QL (30 per 30 ZARXIO ST Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 56

69 Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 aspirin-dipyridamole (Aggrenox) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % Caloric Agents Caloric Agents AMINO ACIDS 15 % PA BvD AMINOSYN 10 % PA BvD AMINOSYN 3.5 % PA BvD AMINOSYN 7 % PA BvD AMINOSYN 7 % WITH PA BvD ELECTROLYTES AMINOSYN 8.5 % PA BvD 57

70 AMINOSYN 8.5 %- PA BvD ELECTROLYTES AMINOSYN II 10 % PA BvD AMINOSYN II 15 % PA BvD AMINOSYN II 7 % PA BvD AMINOSYN II 8.5 % PA BvD AMINOSYN II 8.5 %- PA BvD ELECTROLYTES AMINOSYN M 3.5 % PA BvD AMINOSYN-HBC 7% PA BvD AMINOSYN-PF 10 % PA BvD AMINOSYN-PF 7 % (SULFITE- PA BvD FREE) AMINOSYN-RF 5.2 % PA BvD boost kid essentials * (Pediatric PA; AGE (Max 4 Nutrition, Iron, Lf) bright beginnings soy * (Ped.Nutrit.,Soy,Ir PA; AGE (Max 4 on,lact Free) CLINIMIX 5%/D15W SULFITE PA BvD FREE CLINIMIX 5%/D25W SULFITE- PA BvD FREE CLINIMIX 2.75%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%/D10W SULF PA BvD FREE CLINIMIX 4.25%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%-D20W SULF- PA BvD FREE CLINIMIX 4.25%-D25W SULF- PA BvD FREE CLINIMIX 5%-D20W(SULFITE- PA BvD FREE) 58

71 CLINIMIX E 2.75%/D10W SUL PA BvD FREE CLINIMIX E 2.75%/D5W SULF PA BvD FREE CLINIMIX E 4.25%/D10W SUL PA BvD FREE CLINIMIX E 4.25%/D25W SUL PA BvD FREE CLINIMIX E 4.25%/D5W SULF PA BvD FREE CLINIMIX E 5%/D15W SULFIT PA BvD FREE CLINIMIX E 5%/D20W SULFIT PA BvD FREE CLINIMIX E 5%/D25W SULFIT PA BvD FREE CLINISOL SF 15 % PA BvD cysteine (l-cysteine) intravenous PA BvD (Cysteine HCl) solution d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % NaCl) d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) 59

72 dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) dextrose 5 %-lactated ringers (Dextrose 5%- Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2 % NaCl) FREAMINE HBC 6.9 % PA BvD FREAMINE III 10 % PA BvD HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD IMPACT 1 CAL * impact advanced recovery * (Nut.Tx.Comp. Immune Systm,Reg) INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD 60

73 msud 2 * (Acerflex) NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD NUTRIT SUPP-INULIN-FOS- FIBER * ORAL LIQUID GRAM-KCAL/ML NUTRITIONAL SUPPLEMENT * ORAL LIQUID pediasure * oral liquid (Pediatric PA; AGE (Max 5 gram-kcal/ml Nutrition, Iron, Lf) pediatric drink * (Pediatric PA; AGE (Max 4 Nutrition, Iron, Lf) PEPTAMEN JUNIOR WITH PREBIO1 * PERIKABIVEN PA BvD PHENYL-FREE 1 * potassium chloride in lr-d5 (Potassium intravenous parenteral solution Chloride In Lr-D5) PREMASOL 10 % PA BvD PREMASOL 6 % PA BvD PROCALAMINE 3% PA BvD PROSOL 20 % PA BvD ra pediatric nutrition drink * (Pediatric PA; AGE (Max 4 Nutrition, Iron, Lf) TRAVASOL 10 % PA BvD TROPHAMINE 10 % PA BvD TROPHAMINE 6% PA BvD twocal hn * (Nut.Sup,Spec.Frm,L-Fr,Iron/Fos) Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidon e) 61

74 clonidine transdermal patch weekly QL (4 per 28 (Catapres-Tts 1) 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly QL (8 per 28 (Catapres-Tts 1) 0.3 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) nasal decongestant (pe) * oral (Medi-Phenyl) PA; AGE (Min 2 NORTHERA PA; QL (180 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) wal-phed pe * (Medi-Phenyl) PA; AGE (Min 2 Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) ENTRESTO PA; QL (60 per 30 irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR ST valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) 62

75 captopril-hydrochlorothiazide (Captopril/Hydroch lorothiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydroc hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg (Cordarone) amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) lidocaine (pf) intravenous syringe (Lidocaine 50 mg/5 ml (1 %) HCl/PF) lidocaine in 5 % dextrose (pf) (Lidocaine intravenous parenteral solution 8 HCl/D5w/PF) mg/ml (0.8 %) mexiletine (Mexiletine HCl) MULTAQ 63

76 procainamide injection (Procainamide HCl) propafenone oral capsule,extended release 12 hr (Rythmol SR) propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release 24 hr (Inderal LA) propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro chlorothiazid) 64

77 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Diltiazem HCl) diltiazem hcl oral capsule, extended release 180 mg, 360 mg (Cardizem CD) diltiazem hcl oral capsule, extended release 420 mg (Tiazac) diltiazem hcl oral capsule,extended release 12 hr (Diltiazem HCl) diltiazem hcl oral capsule,extended release 24hr (Cardizem CD) diltiazem hcl oral tablet (Cardizem) diltiazem hcl oral tablet extended release 24 hr (Cardizem LA) dilt-xr (Dilacor XR) matzim la (Cardizem LA) taztia xt (Tiazac) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 24 hr (Verelan) verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) 65

78 adrenalin injection solution 1 mg/ml (1:1,000) (1ml) (Epinephrine) CORLANOR ST DEMSER digitek oral tablet 125 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 dobutamine in d5w intravenous PA BvD parenteral solution 1,000 mg/250 (Dobutamine ml (4,000 mcg/ml), 250 mg/250 ml HCl/D5W) (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose (Dopamine PA BvD intravenous solution HCl/D5W) dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine 1 mg/ml ampul latexfree (Epinephrine) epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector (Adrenaclick) 66

79 epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET MCG, 62.5 MCG milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose PA BvD (Milrinone intravenous piggyback 40 mg/200 Lactate/D5W) ml (200 mcg/ml) norepinephrine bitartrate (Levophed PA BvD Bitartrate) papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) amlodipine-valsartan (Exforge) amlodipine-valsartan-hcthiazid (Exforge HCT) AZOR ST CLEVIPREX INTRAVENOUS EMULSION felodipine (Felodipine) isradipine (Isradipine) nicardipine oral (Nicardipine HCl) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 67

80 nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 60 mg (Adalat CC) Diuretics amiloride oral (Midamor) amiloride-hydrochlorothiazide (Amiloride/Hydroc hlorothiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 (Chlorthalidone) mg DYRENIUM furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) hydrochlorothiazide oral tablet (Hydrochlorothiazi de) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral (Maxzide) tablet Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral (Cholestyramine/A powder 4 gram spartame) 68

81 cholestyramine-aspartame oral (Cholestyramine/A powder in packet 4 gram spartame) colestipol (Colestid) CRESTOR fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lovastatin (Mevacor) niacin oral tablet extended release 24 hr (Niaspan) omega-3 acid ethyl esters (Lovaza) PRALUENT PEN PA; QL (2 per 28 PRALUENT SYRINGE PA; QL (2 per 28 pravastatin (Pravachol) REPATHA SURECLICK PA; QL (3 per 28 REPATHA SYRINGE PA; QL (3 per 28 simvastatin (Zocor) QL (30 per 30 VASCEPA WELCHOL ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators BIDIL isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) 69

82 isosorbide mononitrate oral tablet extended release 24 hr (Imdur) minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose (Nitroglycerin/D5 intravenous solution W) nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 (Nitro-Dur) mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents QL (30 per 30 QL (60 per 30 QL (30 per 30 QL (60 per 30 amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA PA; QL (60 per 30 caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release 12 hr (Kapvay) dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, QL (120 per 30 (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 70

83 dextroamphetamine-amphetamine QL (30 per 30 oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) dextroamphetamine-amphetamine QL (60 per 30 oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Adderall XR) flumazenil (Romazicon) guanfacine oral tablet extended release 24 hr (Intuniv) lithium carbonate oral capsule (Eskalith) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended release (Lithobid) lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er QL (30 per 30 biphasic mg, 20 mg, 50 mg, 60 mg (Metadate Cd) methylphenidate oral capsule, er QL (60 per 30 (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (60 per 30 (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 (Ritalin LA) biphasic mg methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet QL (90 per 30 (Ritalin-SR) extended release methylphenidate oral tablet QL (30 per 30 extended release 24hr 18 mg, 27 mg, 54 mg (Concerta) methylphenidate oral tablet QL (60 per 30 (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 QUILLIVANT XR 71

84 riluzole (Rilutek) SAVELLA QL (60 per 30 STRATTERA tetrabenazine (Xenazine) PA; QL (112 per 28 XENAZINE PA; QL (112 per 28 Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 cyred (Desogen) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/ mg-mcg, (Desogen) mg drospirenone-ethinyl estradiol (Yaz) ELLA ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D- Ethinyl Estradiol) fallback solo * (Take Action) PA; QL (6 per 365 gildess 24 fe (Loestrin Fe) GYNOL II * junel fe 24 (Loestrin Fe) kimidess (28) (Mircette) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 larin 24 fe (Loestrin Fe) levonorgestrel * 1.5 mg tablet (otc) (Take Action) PA; QL (6 per 365 levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel * oral tablet 1.5 mg (Take Action) PA; QL (6 per

85 levonorgestrel-ethin estradiol oral tablet mg-mcg, mg, (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month mg-mcg levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral (Amethyst) (Levonorgestrel- Ethin Estradiol) (Amethyst) QL (91 per 84 (Levonorgestrel- QL (91 per 84 tablets,dose pack,3 month Ethin Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, mg-mcg (Loestrin) norethindrone-e.estradiol-iron (Loestrin Fe) norethindrone-e.estradiol-iron oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) norethindrone-ethinyl estrad oral tablet mg-mcg, mgmcg, /1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg (Modicon) norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 opcicon one-step * (Take Action) PA; QL (6 per 365 setlakin (Levonorgestrel- QL (91 per 84 Ethin Estradiol) tarina fe (Loestrin Fe) 73

86 VAGINAL CONTRACEPTIVE FOAM * WIDE-SEAL DIAPHRAGM 70 * $0 (Tier 3) Cough And Cold Products Cough And Cold Products adult nasal decongestant * (Pseudoephedrine HCl) cheratussin ac * (M-Clear Wc) children's silfedrine * (Pseudoephedrine HCl) children's sudafed * (Pseudoephedrine HCl) guaiatussin ac * (M-Clear Wc) nasal & sinus decongestant * (Sudafed 12-Hour) phenylhistine dh * promethazine-codeine * promethazine-dm * promethazine-phenyleph-codeine * pseudoephedrine hcl * oral (P-Ephed HCl/Cod/Chlorphe nir) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Promethazine/Phe nyleph/codeine) (Pseudoephedrine HCl) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) pseudoephedrine hcl * oral (Sudafed 12-Hour) sudogest * (Sudafed 12-Hour) suphedrin * oral (Pseudoephedrine HCl) wal-phed * oral tablet 30 mg (Sudafed 12-Hour) Dental And Oral Agents PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 PA; AGE (Min 2 74

87 Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous membrane (Peridex) pilocarpine hcl oral (Salagen) triamcinolone acetonide dental (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) acne medication * topical gel (Benzoyl Peroxide) acne-clear * (Benzoyl Peroxide) acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Aluminum Chloride) ammonium lactate (Lac-Hydrin) ANACAINE benzalkonium chloride * solution (Benzalkonium 17 % Chloride) benzoyl peroxide * 10% gel aqueous (rx) (Benzac Ac) benzoyl peroxide * topical gel 10 %, 5 % (Benzoyl Peroxide) calamine * (Calamine) calcipotriene topical cream (Dovonex) calcipotriene topical ointment (Calcipotriene) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) PA NSO 75

88 COSENTYX PEN PA NSO COSENTYX PEN (2 PENS) PA NSO DRYSOL DAB-O-MATIC elta tar * (Coal Tar) FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) ichthammol * (Ichthammol) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) mg217 psoriasis * (Coal Tar) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL scalp itch-dandruff relief * (Oil-Free Acne Wash) silver nitrate applicators (Silver Nitrate Applicator) VALCHLOR ZOVIRAX TOPICAL CREAM QL (15 per 30 Dermatological Antibacterials bacitracin * topical (Bacitracin) bacitracin-polymyxin b * topical (Bacitracin/Polymy xin B Sulfate) 76

89 bacitraycin plus * topical ointment 500 unit/gram (Bacitracin) clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical (Erythromycin solution Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) polysporin * (Bacitracin/Polymy xin B Sulfate) selenium sulfide (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) 77

90 alclometasone topical ointment (Alclometasone Dipropionate) aquanil hc * (Cortizone-10) beta-hc * (Cortizone-10) betamethasone dipropionate topical cream (Diprosone) betamethasone dipropionate topical (Betamethasone lotion Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical (Betamethasone cream Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical (Betamethasone lotion Valerate) betamethasone valerate topical (Betamethasone ointment Valerate) betamethasone, augmented topical cream (Diprolene AF) betamethasone, augmented topical (Betamethasone gel Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical ointment (Diprolene) clobetasol propionate topical (Clobetasol solution 0.05 % Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) 78

91 clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) CORDRAN TOPICAL OINTMENT cortaid * topical cream (Hydrocortisone) cortizone-10 * topical cream (Hydrocortisone) CORTIZONE-10 * TOPICAL LOTION cortizone-10 * topical ointment (Hydrocortisone) dermarest eczema (hydrocort) * (Cortizone-10) desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hc-1% hemorrhoid * (Hydrocortisone Acetate) hydrocortisone * 1% cream maximum strength (otc) (Hydrocortisone) hydrocortisone * 1% ointment (Hydrocortisone) carton (otc) hydrocortisone acet-aloe vera topical gel (Hydrocortisone Acetate/Aloe V) PA; AGE (Min 2 79

92 hydrocortisone acetate * topical (Hydrocortisone Acetate) hydrocortisone acetate-aloe * (Hydrocortisone Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Cortizone-10) hydrocortisone topical lotion 2 %, 2.5 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream Valerate) hydrocortisone valerate topical ointment (Westcort) hydroskin * topical lotion (Cortizone-10) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) obagi nu-derm tolereen * (Cortizone-10) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) recort plus * (Hydrocortisone) tacrolimus topical (Protopic) 80

93 triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.05 %, 0.1 %, 0.5 % (Triamcinolone Acetonide) (Kenalog) (Triderm) triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical cream (Retin-A) PA tretinoin topical gel 0.01 %, PA (Retin-A) % Scabicides And Pediculicides lice cream rinse * (Nix) lice killing * (Piperonyl Butoxide/Pyrethrin s) lice treatment (permethrin) * (Nix) lice treatment * topical (Piperonyl Butoxide/Pyrethrin s) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) Devices Devices AEROCHAMBER PLUS FLOW- VU * $0 (Tier 3) 81

94 AEROCHAMBER PLUS FLOW- VU,M MSK * $0 (Tier 3) AEROCHAMBER PLUS Z STAT MD MSK * $0 (Tier 3) ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA- FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" BD LUER-LOK SYRINGE SYRINGE 1 ML 20 X 1" INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U- 100 SYRINGE NESSI SPACER * $0 (Tier 3) OPTICHAMBER ADULT MASK- LARGE * $0 (Tier 3) PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U- 100 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA PA CIMZIA POWDER FOR PA RECONST 82

95 CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS QL (30 per 30 lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 ZENPEP Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine (Tetcaine) apraclonidine (Iopidine) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) azelastine nasal (Astepro) QL (30 per 25 azelastine ophthalmic (Optivar) carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % 83

96 cyclopentolate (Cyclogyl) CYSTARAN epinastine (Elestat) homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal (Atrovent) QL (30 per 28 QL (15 per 10 spray,non-aerosol 0.06 % LACRISERT muro 128 * (Sodium Chloride) naphazoline (Naphazoline HCl) olopatadine (Patanase) QL (30.5 per 30 PATADAY ST PATANOL ST phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluo rescein Sod) sochlor * ophthalmic (Sodium Chloride) sodium chloride * ophthalmic (Sodium Chloride) tetracaine hcl (Tetcaine) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy xin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) 84

97 gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic (Quixin) MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-polymyxin (Neomycin Su/Bacitra/Polymy xin) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide drops 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre dnisolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac (Bromfenac Sodium) 85

98 dexamethasone sodium phosphate ophthalmic (Dexasol) diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (16 per 30 ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX QL (34 per 28 NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate (Prednisolone Sod ophthalmic Phosphate) PROLENSA RESTASIS QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine (Tagamet) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) misoprostol (Cytotec) 86

99 omeprazole magnesium * (Omeprazole Magnesium) omeprazole oral capsule,delayed release(dr/ec) (Prilosec) pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) pub famotidine * 20 mg tablet max strength (otc) (Pepcid Ac) ranitidine 150 mg tablet maximum strength (otc) (Zantac) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) Gastrointestinal Agents, Other almacone * oral suspension (Maalox Maximum Strength) almacone-2 * (Maalox Maximum Strength) aluminum hydroxide gel * (Aluminum Hydroxide) AMITIZA QL (60 per 30 antacid * oral (Tums) antacid plus anti-gas * oral (Maalox Maximum suspension Strength) anti-diarrheal * (Pepto-Bismol) bismatrol * (Pepto-Bismol) BUPHENYL ORAL TABLET calci-chew * (Tums) calcium carbonate * oral tablet,chewable 500 mg calcium (1,250 mg) (Tums) 87

100 CHOLBAM comfort gel extra strength * (Maalox Maximum Strength) cromolyn oral (Gastrocrom) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diotame instydose * (Bismuth Subsalicylate) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Maalox Maximum Strength) foaming antacid * oral tablet,chewable (Gaviscon) gelusil antacid & anti-gas * oral (Maalox Maximum suspension Strength) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul) kaopectate (bismuth subsalicy) * (Pepto-Bismol) kaopectate ex str (bismuth ss) * (Pepto-Bismol) kola-pectin ds * (Pepto-Bismol) lactulose oral solution (Lactulose) loperamide oral (Loperamide HCl) maalox advanced * oral suspension (Maalox Maximum Strength) MAALOX MAXIMUM STRENGTH * masanti double strength * (Maalox Maximum Strength) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) 88

101 metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) mi-acid * oral suspension (Maalox Maximum Strength) mintox * (Maalox Maximum Strength) mintox maximum strength * (Maalox Maximum Strength) mintox plus * (Almacone) MOVANTIK QL (30 per 30 NUTRESTORE pep-t-med * (Pepto-Bismol) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 RELISTOR SUBCUTANEOUS PA; QL (28 per 28 ri-gel ii * (Maalox Maximum Strength) ri-mox * (Maalox Maximum Strength) ri-mox plus * (Maalox Maximum Strength) soothe (bismuth subsalicylate) * (Bismuth oral Subsalicylate) soothe regular strength * (Pepto-Bismol) stomach relief * oral (Bismuth Subsalicylate) ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives bisac-evac * (Dulcolax) bisacodyl * rectal (Dulcolax) biscolax * (Dulcolax) COLACE CLEAR * 89

102 colace * oral capsule 100 mg (Colace Clear) col-rite * oral capsule (Colace Clear) doc-q-lace * (Colace Clear) dok * oral capsule (Colace Clear) dulcolax stool softener (dss) * (Colace Clear) MOVIPREP peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) phillips liqui-gels * (Colace Clear) polyethylene glycol 3350 oral (Polyethylene Glycol 3350) sodium chloride-nahco3-kcl-peg (Nulytely with oral recon soln 420 gram Flavor Packs) stool softener * oral capsule 50 mg (Colace Clear) the magic bullet * (Dulcolax) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) CALCIUM ACETATE * ORAL TABLET 668 MG (169 MG CALCIUM) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) calphron * (Calcium Acetate) PHOSLYRA RENAGEL RENVELA sodium polystyrene sulfonate oral powder (Sodium Polystyrene Sulfonate) 90

103 sodium polystyrene sulfonate oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr (Ditropan XL) tolterodine oral capsule,extended release 24hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended release 24hr (Sanctura XR) trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS EXJADE FERRIPROX JADENU sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) (Sodium Thiosulfate) SYPRINE 91

104 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo- Testosterone) PA; QL (30 per 30 PA; QL (300 per 30 PA; QL (150 per 30 PA; QL (300 per 30 PA; QL (150 per 30 testosterone enanthate (Delatestryl) PA; QL (5 per 28 testosterone transdermal gel in PA; QL (150 per 30 (Androgel) packet 1 % (25 mg/2.5gram) Estrogens And Antiestrogens PA-HRM; QL (8 per 28 COMBIPATCH DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) PA PA-HRM; QL (8 per 28 92

105 estradiol transdermal patch weekly (Climara) PA-HRM; QL (4 per 28 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM ESTRASORB PA-HRM; QL (97.44 per 28 estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 MENEST PA-HRM norethindrone ac-eth estradiol oral PA-HRM (Femhrt) tablet 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (18 per 28 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone PA BvD injection Sod Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone PA BvD Sod Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ PA BvD (A-Methapred) injection recon soln 125 mg, 40 mg 93

106 methylprednisolone sodium succ PA BvD (A-Methapred) intravenous prednisolone sodium phosphate PA BvD (Orapred) oral solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (15 per 30 desmopressin nasal (Desmopressin QL (15 per 30 Acetate) desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA HUMATROPE PA INCRELEX NORDITROPIN FLEXPRO PA NUTROPIN PA NUTROPIN AQ NUSPIN PA NUTROPIN AQ PA SUBCUTANEOUS octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 (Sandostatin) mcg/ml, 500 mcg/ml octreotide acetate injection solution (Octreotide 50 mcg/ml Acetate) octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE PA PREGNYL SAIZEN PA 94

107 SAIZEN CLICK.EASY PA SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS PA RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT QL (1 per 28 SOMAVERT SUPPRELIN LA QL (1 per 360 TEV-TROPIN PA vasopressin (Pitressin) ZOMACTON PA Progestins DEPO-PROVERA QL (10 per 28 INTRAMUSCULAR SOLUTION medroxyprogesterone QL (1 per 84 (Depo-Provera) intramuscular suspension medroxyprogesterone (Medroxyprogester QL (1 per 84 intramuscular syringe one Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL PA BvD 95

108 AUBAGIO PA; QL (28 per 28 azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF PA BvD NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL PA ENBREL SURECLICK PA FLEBOGAMMA DIF PA BvD GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD GAMMAPLEX PA BvD GAMUNEX-C INJECTION PA BvD SOLUTION HUMIRA PA HUMIRA PEN PA HUMIRA PEN CROHN'S-UC-HS PA START HYPERRAB S/D (PF) HYQVIA PA BvD ILARIS (PF) PA IMOGAM RABIES-HT (PF) KINERET PA; QL (18.76 per 28 leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD 96

109 OCTAGAM PA BvD ORENCIA PA; QL (4 per 28 ORENCIA (WITH MALTOSE) PA PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RAPAMUNE ORAL TABLET 1 PA BvD MG, 2 MG RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; LA; QL (15 per 28 ZORTRESS PA BvD; QL (120 per 30 Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD ENGERIX-B PEDIATRIC (PF) PA BvD GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 97

110 IMOVAX RABIES VACCINE PA BvD (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) PA BvD ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED PA BvD (PF) TETANUS,DIPHTHERIA TOX PED(PF) 98

111 TETANUS-DIPHTHERIA TOXOIDS-TD Name of Drug TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) QL (1 per 365 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron (Alosetron HCl) APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) water for irrigation, sterile (Water For Irrigation,Sterile) Metabolic Bone Disease Agents 99

112 Metabolic Bone Disease Agents alendronate oral solution (Alendronate QL (300 per 28 Sodium) alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 (Fosamax) mg calcitonin (salmon) (Miacalcin) QL (3.7 per 28 calcitriol intravenous solution 1 PA BvD; (PA for (Calcitriol) mcg/ml ESRD Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) etidronate disodium (Etidronate Disodium) FORTEO PA; QL (2.4 per 28 FORTICAL QL (3.7 per 28 ibandronate intravenous solution PA BvD; (PA for (Ibandronate ESRD Only); QL (3 per Sodium) 84 ibandronate intravenous syringe (Boniva) PA BvD; QL (3 per 84 ibandronate oral (Boniva) QL (1 per 28 MIACALCIN INJECTION PA BvD; (PA for ESRD Only) NATPARA PA; QL (2 per 28 paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL (1 per 180 risedronate oral tablet 150 mg (Actonel) QL (1 per 28 XGEVA PA; QL (1.7 per

113 ZEMPLAR INTRAVENOUS zoledronic acid intravenous (Zometa) (Zoledronic zoledronic acid-mannitol-water Acid/Mannitol and intravenous piggyback Water) zoledronic acid-mannitol-water intravenous solution (Reclast) ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS ACTEMRA SUBCUTANEOUS ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Amifostine Crystalline) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST PA BvD; (PA for ESRD Only) QL (100 per 300 PA; QL (40 per 30 PA; QL (3.6 per 28 BENLYSTA INTRAVENOUS PA RECON SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) BOTOX INJECTION RECON PA; QL (4 per 90 SOLN 100 UNIT BOTOX INJECTION RECON PA; QL (1 per 90 SOLN 200 UNIT buspirone (Buspirone HCl) 101

114 CERDELGA PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Proben ecid) COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE droperidol injection solution (Droperidol) ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS ST finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) FUSILEV GILENYA PA; QL (28 per 28 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral solution 10 PA-HRM (Hydroxyzine HCl) mg/5 ml hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 LEMTRADA PA; QL (9.6 per 365 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg (Leucovorin Calcium) 102

115 leucovorin calcium oral levocarnitine (with sugar) Name of Drug (Leucovorin Calcium) (Levocarnitine (With Sugar)) levocarnitine oral (Carnitor) levoleucovorin calcium (Levoleucovorin Calcium) mesna (Mesnex) MESNEX ORAL MESTINON ORAL SYRUP morrhuate sodium (Sodium Morrhuate) OTEZLA OTEZLA STARTER PLEGRIDY ST probenecid (Probenecid) PROCYSBI pyridostigmine bromide (Mestinon) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIMPONI ARIA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA; QL (60 per 30 PA; QL (60 per 30 PA; QL (12 per 28 PA; QL (3 per 28 PA; QL (0.5 per 28 PA; QL (3 per

116 SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG PA; QL (0.5 per 28 PA PA; QL (14 per 30 PA; QL (60 per 30 THALOMID PA NSO; QL (60 per 30 TYBOST QL (30 per 30 ULORIC ST; QL (30 per 30 XELJANZ PA; QL (60 per 30 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic (Betaxolol HCl) bimatoprost (Bimatoprost) brimonidine (Alphagan P) (drops: 0.15%, 0.20%) 104

117 COMBIGAN dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming solution (Timoptic-Xe) TRAVATAN Z QL (2.5 per 25 travoprost (benzalkonium) (Travoprost QL (2.5 per 25 (Benzalkonium)) Replacement Preparations Replacement Preparations calci-mix * (Calcium Carbonate) calcium d (d3) * (Os-Cal 500+D) calcium d * oral tablet 500 mg(1,250mg) -400 unit (Os-Cal 500+D) calcium 500 with d * (Os-Cal 500+D) calcium 600 * (Caltrate 600) calcium d(3) * oral capsule (Calcium Carbonate/Vitamin D3) calcium d(3) * oral tablet (Os-Cal 500+D) calcium 600 with vitamin d3 * oral (Calcium Carbonate/Vitamin D3) 105

118 calcium carbonate * oral Name of Drug calcium carbonate * oral tablet 260 mg calcium (648 mg) calcium carbonate-vitamin d2 * calcium carbonate-vitamin d3 * oral capsule 600 mg(1,500mg) -100 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * oral tablet 500 mg(1,250mg) -200 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate-vitamin d3 * oral tablet,chewable 500 mg(1,250mg) -400 unit (Calcium Carbonate) (Caltrate 600) (Calcium Carbonate/Vitamin D2) (Calcium Carbonate/Vitamin D3) (Os-Cal 500+D) (Os-Cal 500+D) calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg), 61 mg (648 mg) Gluconate) calcium lactate * oral tablet 84 mg (648 mg), 84 mg (650 mg) (Calcium Lactate) CALTRATE D * CALTRATE D VIT D3 (800) * CENTRUM PRO NUTRIENTS * (Citric citric acid-sodium citrate Acid/Sodium Citrate) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) enfalyte * (Pedialyte) PA BvD; (PA for ESRD Only) 106

119 HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KLOR-CON klor-con 10 (Potassium Chloride) KLOR-CON 8 klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) klor-con sprinkle (Micro-K) KLOR-CON/EF liquid calcium with vitamin d * (Calcium Carbonate/Vitamin D3) mag 64 * (Magnesium Chloride) mag-delay * (Magnesium Chloride) mag-g * (Magonate) magnesium chloride injection (Magnesium Chloride) magnesium gluconate * oral tablet (Magonate) magnesium * oral tablet 200 mg, 250 mg magnesium sulf in 0.45% nacl (Magnesium) (Magnesium Sulf In 0.45% NaCl) 107

120 magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml (Magnesium Sulfate/D5W) magnesium sulfate in water (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Caltrate 600) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * (Pedialyte) oysco 500/d * oral tablet (Os-Cal 500+D) oysco-500 * (Caltrate 600) oyster shell calcium 500 * (Caltrate 600) oyster shell calcium-vit d3 * oral tablet 500 mg(1,250mg) -200 unit, (Os-Cal 500+D) 500 mg(1,250mg) -400 unit oystercal-d * (Os-Cal 500+D) PEDIALYTE * ORAL SOLUTION pediatric electrolyte * oral solution (Pedialyte) pediatric freezer pops * (Pedialyte) phosphorus #1 (K-Phos Neutral) PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) 108

121 potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride intravenous (Klor-Con-Ef) (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride) potassium chloride oral capsule, extended release (Micro-K) potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended release (Klor-Con 8) potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con 8) potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) potassium chloride-0.45 % nacl (Potassium Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%NaCl) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 (Potassium Chloride/D5- meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) 109

122 potassium citrate-citric acid oral (Potassium packet 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium solution 1, mg/5 ml Citrate/Citric Acid) potassium phosphate m-/d-basic (Potassium Phos,M-Basic-D- Basic) ringers intravenous (Ringers Solution) risacal-d * (Calcium Phosphate Dibas/Vit D3) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium solution Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) sodium citrate-citric acid (Citric Acid/Sodium Citrate) sodium lactate intravenous (Sodium Lactate) sodium phosphate (Sodium Phos,M- Basic-D-Basic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II zinc sulfate * oral (Zinc Sulfate) $0 (Tier 3) 110

123 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS QL (60 per 30 ADVAIR HFA QL (12 per 28 BREO ELLIPTA QL (60 per 30 DULERA QL (13 per 28 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION QL (60 per 30 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION QL (120 per 30 FLOVENT HFA INHALATION QL (12 per 28 HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION QL (24 per 28 HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION QL (21.2 per 28 HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (17.4 per 25 Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution PA BvD (Albuterol Sulfate) for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr (Vospire ER) ANORO ELLIPTA QL (60 per 30 ATROVENT HFA QL (25.8 per

124 COMBIVENT RESPIMAT QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 PROAIR RESPICLICK QL (2 per 25 SEREVENT DISKUS QL (60 per 30 SPIRIVA RESPIMAT QL (4 per 30 SPIRIVA WITH HANDIHALER QL (30 per 30 STIOLTO RESPIMAT QL (4 per 28 STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet (Theophylline extended release 12 hr 100 mg, 200 Anhydrous) mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml (Theophylline/D5 W) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL (1 per 28 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine (Acetadote) PA BvD ARALAST NP cromolyn inhalation (Cromolyn PA BvD Sodium) 112

125 DALIRESP QL (30 per 30 ESBRIET PA; QL (270 per 30 KALYDECO PA; QL (60 per 30 OFEV PA; QL (60 per 30 ORKAMBI PA; QL (120 per 30 sodium chloride * inhalation solution for nebulization 0.9 % (Pulmosal) XOLAIR PA; QL (6 per 28 ZEMAIRA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) chlorzoxazone (Parafon Forte DSC) COMFORT PAC- CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM; QL (120 per 30 PA-HRM PA-HRM PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL PA ROZEREM XYREM LA 113

126 zaleplon (Sonata) zolpidem oral tablet (Ambien) zolpidem oral tablet,ext release multiphase Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents (Phentolamine phentolamine injection Mesylate) Vasodilating Agents Vasodilating Agents (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 PA 114

127 ADCIRCA PA; QL (60 per 30 ADEMPAS PA; QL (90 per 30 epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 OPSUMIT PA; QL (30 per 30 ORENITRAM PA REMODULIN PA BvD sildenafil intravenous (Revatio) PA; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 TRACLEER PA; LA; QL (60 per 30 TYVASO PA BvD TYVASO REFILL KIT PA BvD TYVASO STARTER KIT PA BvD VENTAVIS PA BvD Vitamins And Minerals Vitamins And Minerals AQUASOL A * $0 (Tier 3) ascorbic acid * injection (Ascorbic Acid) $0 (Tier 3) b cmplx 4-vit d3-c-fa-zinc ox * (B Cmplx 4/Vit D3/C/Fa/Zinc Ox) $0 (Tier 3) b complex and c no.20-folic acid * (B Complex and C oral capsule 1 mg No.20/Folic Acid) $0 (Tier 3) b-complex with vitamin c * oral tablet (Vita-Bee with C) $0 (Tier 3) b-plex plus * cyanocobalamin (vitamin b-12) * injection (Multivits,Therap W-Fe,Hematin) (Cyanocobalamin (Vitamin B-12)) $0 (Tier 3) $0 (Tier 3) 115

128 cyanocobalamin-fa-pyridoxine * oral tablet mg, mg, mg, mg cyanocobalamin-mecobalamin * ergocalciferol (vitamin d2) * oral capsule ezfe forte * fa-vit bcomp and c-se-min aa-zn * fe fumarate-doss-fa-bcomp and c * fe fumarate-fa-vit bcomp and c * fe fumarate-vit c-b12-if-fa * oral capsule mg fe fumarate-vit c-b12-stomc * (Foltx) $0 (Tier 3) (Cyanocobalamin/ Mecobalamin) $0 (Tier 3) (Drisdol) $0 (Tier 3) (Pnv No.23-Iron Ps Complex-Fa) (Fa/Vit Bcomp and C/Se/Min Aa/Zn) (Fe Fumarate/Doss/Fa/ Bcomp and C) (Fe Fumarate/Fa/Vit Bcomp and C) (Fe Fumarate/Vit C/B12-If/Fa) (Fe Fumarate/Vit C/B12/Stomc) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) feosol * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) $0 (Tier 3) ferrous fumarate-folic acid * (Hemocyte-F) $0 (Tier 3) ferrous sulfate * oral (Fer-In-Sol) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) folic acid * injection (Folic Acid) $0 (Tier 3) folic acid * oral tablet 1 mg (Folic Acid) $0 (Tier 3) folic acid * oral tablet 400 mcg (Folic Acid) PA PA; AGE (Max

129 folic acid-vit b6-vit b12 * oral tablet folic acid-vitamin b comp w-c * oral tablet mg, 5 mg folic acid-vitamin b comp w-c * oral tablet mg-mgmcg-mg folic acid-vitamin b comp w-c * oral tablet mg hydroxocobalamin * iron ag and fum-c-fa-mv cmb11-cat * iron ag-c-b12-ca-suc.acid-stom * iron aspgly and ps-c-b12-fa-ca-suc * iron aspgly&ps-c-b12-fa-ca-suc * iron aspgly-c-b12-fa-ca-th-suc * iron bg and ps-vit c-b12-fa-ca thr * oral capsule mg-mgmcg-mg iron fum & ag-c-b12-fa-ca-succ * (Foltx) $0 (Tier 3) (Folic Acid/Vitamin B Comp W-C) (Vit B Cplx #11/Fa/C/Biot/Zn Ox) (Folic Acid/Vit Bcomp and C/Cu/Znox) (Hydroxocobalami n) (Iron Ag and Fum/C/Fa/Mv Cmb11/Ca-T) (Iron Ag/C/B12/Ca/Suc. Acid/Stom) (Iron Aspgly and Ps/C/B12/Fa/Ca/Su c) (Iron Aspgly and Ps/C/B12/Fa/Ca/Su c) (Iron Aspgly/C/B12/Fa/ Ca-Th/Suc) (Iron Bg and Ps/Vit C/B12/Fa/Ca Thr) (Iron Fum and Ag/C/B12/Fa/Ca/S ucc) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) 117

130 iron fum and ag-c-b12-fa-ca-succ * (Iron Fum and Ag/C/B12/Fa/Ca/S $0 (Tier 3) ucc) iron fum and p-fa-vit b and c no.9 * (Integra Plus) $0 (Tier 3) iron fum and polysac#1-fa-mv no.18 (Tandem Plus) * oral capsule mg $0 (Tier 3) iron fum and ps cmp-fa-vit c-b3 * (Integra F) $0 (Tier 3) iron fumarate-vit c-vit b12-fa * (Iron Fumarate/Vit C/Vit B12/Fa) $0 (Tier 3) iron ps cmplx-vit b12-fa * (Niferex-150 Forte) $0 (Tier 3) iron pyrophos-b12-fa-niac-b-6 * (Fe Fumarate/Cal/E/Fa/ $0 (Tier 3) Multivit) iron, carbonyl-fa-c-b-6-b12-zn * (Corvite 150) $0 (Tier 3) iron,carb-dss-b12if-fa-mv-mn * (Hemax) $0 (Tier 3) iron-fa-vitamin b comp w-c-min * (Iron/Fa/Vitamin B oral liquid Comp W-C/Min) $0 (Tier 3) iron-fa-vitamin b comp w-c-min * (Iron/Liver Ext/Vit oral tablet Bcomp and C/Min) $0 (Tier 3) iron-fa-vitamin b comp w-c-min * (Iron/Fa/Vitamin B oral tablet 106 mg iron- 1 mg Comp W-C/Min) $0 (Tier 3) kpn * oral tablet (Prenatal Vit W- Ca,Fe,Fa( Less Than 1 Mg)) levomefolate calcium * oral tablet (Levomefolate 7.5 mg Calcium) $0 (Tier 3) MEPHYTON * $0 (Tier 3) multivit, iron, min #5, fa * (Multivit, Iron, Min #5, Fa) $0 (Tier 3) multivit, iron, min #6, fa * (Multivit, Iron, Min #6, Fa) $0 (Tier 3) multivit, min cmb#20-iron-fa * (Multivit, Min Cmb#20/Iron/Fa) $0 (Tier 3) multivitamins with min no.7-fa * (Multivitamins oral capsule 1 mg with Min No.7/Fa) $0 (Tier 3) PA 118

131 multivit-fluor 0.25 mg/ml drop 0.25 (Pedi Mvi No.82 mg/ml with Fluoride) multivits,therap w-fe,hematin * oral (Multivits,Therap tablet W-Fe,Hematin) $0 (Tier 3) NASCOBAL * $0 (Tier 3) om-3-ca carb-d3-fa-mv cmb 13 * (Om-3/Ca Carb/D3/Fa/Mv $0 (Tier 3) Cmb 13) perry prenatal * (Pnv with Ca PA No.36/Iron/Fa) phytonadione * injection solution 10 mg/ml (Phytonadione) $0 (Tier 3) poly-vita (iron) * (Ped Multivit PA; AGE (Max 4 #46/Iron Sulfate) poly-vitamin with iron * (Ped Multivit PA; AGE (Max 4 #46/Iron Sulfate) (Prenatal Vit W- PA prenatal formula * oral tablet Ca,Fe,Fa( Less Than 1 Mg)) prenatal formula * oral tablet 28- PA (Classic Prenatal) 0.8 mg prenatal gummy * (Pnv62/Fa/Om3/D PA ha/epa/fish Oil) prenatal multivitamins * (Prenatal) PA prenatal * oral tablet mg, PA (Classic Prenatal) mg PRENATAL * ORAL TABLET 28 PA MG IRON- 800 MCG (Prenatal PA prenatal vit#96-ferrous fum-fa * Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) PA prenatal vitamins * oral tablet (Prenatal Vit W- Ca,Fe,Fa( Less Than 1 Mg)) PA 119

132 prenatal vitamins oral tablet 27 mg (Pnv with (All Rx Prenatal iron- 1 mg Ca,No.72/Iron/Fa) Vitamins Covered) prenatal vitamins * oral tablet 27- PA (Classic Prenatal) 0.8 mg PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG prenatal vit-iron fumarate-fa * (Classic Prenatal) PA prenatal-1 * (Pnv No.25/Iron PA Fumarate/Fa/Dha) pyridoxine * injection (Pyridoxine HCl) $0 (Tier 3) right step prenatal vitamins * (Classic Prenatal) PA sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) sodium fluoride oral tablet 1 mg (Pedi Mvi No.82 fluoride (2.2 mg) with Fluoride) STROVITE ONE * $0 (Tier 3) stuart prenatal * (Classic Prenatal) PA support-500 * (B Complex with Vitamin C) $0 (Tier 3) therapeutic vitamins/minerals * (Multivitamins with Min No.7/Fa) $0 (Tier 3) thiamine hcl * injection (Thiamine HCl) $0 (Tier 3) tri-vi-sol * (Vit A Palmitate/Vit C/Vit D3) PA; AGE (Max 4 tri-vita * tri-vitamin * vit b cmplx 3-fa-vit c-biotin * oral tablet mg-mg-mcg vit b cmplx no3-fa-c-biot-zinc * (Pedi Multivits A,C, and D3 No.21) (Pedi Multivits A,C, and D3 No.21) (Vit B Cmplx 3/Fa/Vit C/Biotin) (Vit B Cmplx No3/Fa/C/Biot/Zin c) $0 (Tier 3) $0 (Tier 3) PA; AGE (Max 4 PA; AGE (Max 4 120

133 vit b12-lmefolate ca-vit b6-b2 * oral (Cerefolin) tablet mg $0 (Tier 3) vitacel (with lutein) * (Biocel) $0 (Tier 3) vitamin b comp and vit c no.6 * (Vitamin B Comp and Vit C No.6) $0 (Tier 3) vitamin b12-folic acid * sublingual (Cyanocobalamin/ Folic Acid) $0 (Tier 3) vitamin b-6 * oral tablet 100 mg, 25 mg, 50 mg (Pyridoxine HCl) vitamins b1,b2,b3,b5, and b6 * injection solution (Vitamins B1,B2,B3,B5, and $0 (Tier 3) mg/ml B6) VITA-RESPA * $0 (Tier 3) 121

134 INDEX 8 8-MOP A abacavir... 50, 51 abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE acamprosate... 8 acarbose acebutolol acetaminophen... 1 acetaminophen-codeine... 1 acetazolamide acetazolamide sodium acetic acid... 84, 99 acetylcysteine acid reducer (famotidine) acitretin acne medication acne-clear ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 53, 75 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 97 ADAGEN adapalene ADCETRIS ADCIRCA , 115 adefovir ADEMPAS adrenalin ADRENALIN adult nasal decongestant ADVAIR DISKUS ADVAIR HFA AEROCHAMBER PLUS FLOW-VU AEROCHAMBER PLUS FLOW-VU,M MSK AEROCHAMBER PLUS Z STAT MD MSK AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone... 77, 78 ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE ALDURAZYME alendronate... 99, 100 alfuzosin ALIMTA ALINIA aller-chlor allergy (chlorpheniramine) allergy relief (loratadine) allergy-sinus allopurinol almacone almacone alosetron ALPHAGAN P alprazolam... 9 ALREX altacaine aluminum chloride aluminum hydroxide gel amantadine hcl ambi 60pse-4cpm AMBISOME ambizine amifostine crystalline amiloride amiloride-hydrochlorothiazide68 AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-1 Effective: November 01, 2015

135 AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate... 17, 18 amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL ANORO ELLIPTA antacid antacid plus anti-gas anticoag citrate phos dextrose anti-diarrheal APOKYN apraclonidine APRISO aprodine APTIOM APTIVUS aquanil hc AQUASOL A ARALAST NP ARCALYST aripiprazole ARRANON ARZERRA ASACOL HD ascorbic acid ashlyna aspirin... 5, 7 aspirin-dipyridamole aspir-low... 5 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 28, 83 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVODART AVONEX AVONEX (WITH ALBUMIN) azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam B b cmplx 4-vit d3-c-fa-zinc ox b complex and c no.20-folic acid bacitracin... 13, 76, 84 bacitracin-polymyxin b... 76, 84 bacitraycin plus baclofen balsalazide banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF).. 97 b-complex with vitamin c BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BD LUER-LOK SYRINGE BELEODAQ benadryl allergy benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzalkonium chloride benzoyl peroxide benztropine beta-hc betamethasone acet,sod phos. 93 betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 64, 104 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-2 Effective: November 01, 2015

136 BICILLIN L-A BIDIL BILTRICIDE bimatoprost bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO boost kid essentials BOOSTRIX TDAP BOSULIF BOTOX b-plex plus BREO ELLIPTA bright beginnings soy BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine budesonide bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 1, 8 buprenorphine-naloxone... 8 bupropion hcl... 8, 31 buspirone butalb-acetaminophen-caffeine 1 butalbital-acetaminop-caf-cod. 1 butalbital-acetaminophen... 1 butalbital-acetaminophen-caff. 1 butalbital-aspirin-caffeine... 1 butorphanol tartrate... 1 BUTRANS... 1 BYDUREON BYETTA BYSTOLIC C cabergoline caffeine citrated caffeine-sodium benzoate calamine calci-chew calci-mix calcipotriene calcitonin (salmon) calcitriol... 75, 100 calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) calcium 600 with vitamin d3 105 calcium acetate CALCIUM ACETATE calcium carbonate... 87, 106 calcium carbonate-mag carb-fa calcium carbonate-vitamin d calcium carbonate-vitamin d calcium chloride calcium gluconate calcium lactate CALDOLOR... 5 calphron CALTRATE D CALTRATE D VIT D3 (800) CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 63 CARAFATE carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CAYSTON cefaclor cefadroxil... 14, 15 cefazolin cefazolin in dextrose (iso-os). 15 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 15 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os. 15 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-3 Effective: November 01, 2015

137 celecoxib... 5 CELLCEPT INTRAVENOUS CELONTIN CENTRUM PRO NUTRIENTS cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) 97 cevimeline... 74, 75 CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX CONTINUING MONTH PAK... 8 CHANTIX STARTING MONTH BOX... 8 cheratussin ac child dometuss-da child triaminic cold & allergy 40 child wal-tap cold-allergy children's advil... 5 children's non-aspirin... 1 children's pain & fever relief... 1 children's silapap... 1 children's silfedrine children's sudafed children's wal-dryl allergy child's benadryl-d allergy-sin. 40 chloramphenicol sod succinate chlordiazepoxide hcl... 9 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine-aspartame 68, 69 choline,magnesium salicylate.. 5 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX ciprofloxacin... 18, 19 ciprofloxacin hcl... 19, 84 ciprofloxacin in 5 % dextrose 19 ciprofloxacin lactate cisplatin citalopram citric acid-sodium citrate clarithromycin clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 13 clindamycin palmitate hcl clindamycin phosphate... 13, 43, 77 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol... 78, 79 clobetasol propionate clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 9 clonidine clonidine hcl... 61, 70 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium... 9 clotrimazole clotrimazole clotrimazole-betamethasone clozapine... 47, 48 COARTEM codeine sulfate... 1 codeine-butalbital-asa-caffein.. 1 colace COLACE CLEAR colchicine colchicine-probenecid COLCRYS SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-4 Effective: November 01, 2015

138 cold & cough colestipol colistin (colistimethate na) col-rite COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 112 COMETRIQ comfort gel extra strength COMFORT PAC- CYCLOBENZAPRINE COMFORT PAC-IBUPROFEN... 5 COMFORT PAC- MELOXICAM... 5 COMFORT PAC-NAPROXEN... 5 COMFORT PAC-TIZANIDINE COMPLERA compoz COMVAX (PF) CONDYLOX conex CONEX COPAXONE CORDRAN CORLANOR cortaid cortisone cortizone CORTIZONE COSENTYX (2 SYRINGES) 75 COSENTYX PEN COSENTYX PEN (2 PENS). 76 CREON CRESTOR CRIXIVAN cromolyn... 83, 88, 112 CUBICIN CURITY GAUZE cyanocobalamin (vitamin b-12) cyanocobalamin-fa-pyridoxine cyanocobalamin-mecobalamin cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) cytarabine cytarabine (pf) D d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride 59 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 59 dacarbazine dactinomycin DAKLINZA DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM deblitane decitabine deferoxamine DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermarest eczema (hydrocort) 79 desenex (clotrimazole) desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone sodium phosphate... 86, 93 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0.2 % nacl 59 dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 60 dextrose 5 %-lactated ringers. 60 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-5 Effective: November 01, 2015

139 dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride 60 DIASTAT ACUDIAL... 9 diazepam... 9 diazepam intensol... 9 diclofenac potassium... 5 diclofenac sodium... 5, 86 diclofenac-misoprostol... 5 dicloxacillin dicyclomine didanosine DIFICID diflunisal... 5 digitek digoxin DIGOXIN dihydroergotamine DILANTIN CAPSULE 30 MG diltiazem hcl dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion diotame instydose DIPENTUM diphenhist diphenhydramine hcl diphenhydramine-phenylephrine diphenoxylate-atropine disopyramide phosphate disulfiram... 8 divalproex dobutamine dobutamine in d5w doc-q-lace dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate... 19, 20 doxycycline monohydrate dronabinol droperidol drospirenone-ethinyl estradiol 72 DROXIA DRYSOL DAB-O-MATIC DUAVEE dulcolax stool softener (dss).. 90 DULERA duloxetine DURAMORPH (PF)... 1 DUREZOL DYRENIUM E e.c. prin... 6 econazole ecotrin... 6 ed chlorped jr EDURANT EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ELMIRON elta tar EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 63 ENBREL ENBREL SURECLICK enfalyte ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin entacapone entecavir entre-hist pse ENTRESTO ephedrine sulfate epinastine epinephrine... 66, 67 epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 17, 84 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate.. 17 erythromycin stearate erythromycin with ethanol SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-6 Effective: November 01, 2015

140 ESBRIET escitalopram oxalate esmolol esomeprazole sodium estazolam ESTRACE estradiol... 92, 93 estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet ESTRASORB estropipate ethambutol ethamolin ethinyl estradiol/drospirenone 72 ethosuximide ethynodiol d-ethinyl estradiol 72 etidronate disodium etodolac... 6 ETOPOPHOS etoposide EVOTAZ EXELON exemestane EXJADE EXTAVIA ezfe forte F FABRAZYME fallback solo famciclovir famotidine... 86, 87 famotidine (pf) famotidine (pf)-nacl (iso-os). 86 FANAPT FARESTON FARYDAK FASLODEX fa-vit bcomp and c-se-min aa-zn fe fumarate-doss-fa-bcomp and c fe fumarate-fa-vit bcomp and c fe fumarate-vit c-b12-if-fa fe fumarate-vit c-b12-stomc. 116 felbamate felodipine FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen... 6 fentanyl... 2 fentanyl citrate... 2 feosol ferotrinsic FERRIPROX ferrous fumarate-folic acid ferrous sulfate FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flanax antacid FLEBOGAMMA DIF flecainide FLECTOR... 6 FLEXBUMIN 25 % FLEXBUMIN 5 % FLOVENT DISKUS FLOVENT HFA floxuridine fluconazole fluconazole in dextrose(iso-o) 37 fluconazole in nacl (iso-osm). 38 flucytosine fludarabine fludrocortisone flumazenil fluocinonide fluocinonide-emollient base fluorometholone FLUOROPLEX fluorouracil... 22, 76 fluoxetine FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam... 10, 11 flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone... 79, 86 fluvoxamine foaming antacid folic acid folic acid-vit b6-vit b folic acid-vitamin b comp w-c fomepizole fondaparinux FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure fungoid-d furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-7 Effective: November 01, 2015

141 GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GAZYVA gelusil antacid & anti-gas gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK 94 gentamicin... 12, 77, 85 gentamicin in nacl (iso-osm).. 12 gentamicin sulfate gentamicin sulfate (ped) (pf).. 13 gentamicin sulfate (pf) GEODON geri-dryl gildess 24 fe GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin GLYCINE glycopyrrolate glydo... 7 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaiatussin ac guanfacine... 62, 71 guanidine GYNOL II H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) hc-1% hemorrhoid heparin (porcine) heparin (porcine) in 5 % dex. 54, 55 HEPARIN (PORCINE) IN 5 % DEX heparin (porcine) in nacl (pf). 55 HEPARIN SODIUM,PORCINE-PF HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HEXALEN histex pe homatropine hbr HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMULIN 70/ HUMULIN 70/30 KWIKPEN 35 HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 2 hydrocodone-ibuprofen... 2 hydrocortisone... 79, 80, 93 hydrocortisone acet-aloe vera 79 hydrocortisone acetate hydrocortisone acetate-aloe hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate. 93 hydrocortisone valerate hydromorphone... 2 hydromorphone (pf)... 2 hydroskin hydroxocobalamin hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA I ibandronate IBRANCE ibuprofen... 6 ichthammol ICLUSIG ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-8 Effective: November 01, 2015

142 IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF) 96 IMOVAX RABIES VACCINE (PF) IMPACT 1 CAL impact advanced recovery INCRELEX indapamide indomethacin... 6 indomethacin sodium... 6 INFANRIX (DTAP) (PF) infant acetaminophen... 2 infantaire... 2 infant's pain reliever... 3 INLYTA INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA... 48, 49 INVEGA TRINZA INVIRASE INVOKAMET... 33, 34 INVOKANA inzo antifungal IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRENKA IRESSA iron ag and fum-c-fa-mv cmb11- ca-t iron ag-c-b12-ca-suc.acid-stom iron aspgly and ps-c-b12-fa-casuc iron aspgly&ps-c-b12-fa-ca-suc iron aspgly-c-b12-fa-ca-th-suc iron bg and ps-vit c-b12-fa-ca thr iron fum & ag-c-b12-fa-ca-succ iron fum and ag-c-b12-fa-casucc iron fum and p-fa-vit b and c no iron fum and polysac#1-fa-mv no iron fum and ps cmp-fa-vit c-b iron fumarate-vit c-vit b12-fa iron ps cmplx-vit b12-fa iron pyrophos-b12-fa-niac-b iron, carbonyl-fa-c-b-6-b12-zn iron,carb-dss-b12if-fa-mv-mn iron-fa-vitamin b comp w-c-min ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate... 69, 70 isotretinoin isradipine ISTODAX itraconazole ivermectin IXEMPRA IXIARO (PF) J JADENU JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA junel fe K KABIVEN KADCYLA KALETRA KALYDECO kaopectate (bismuth subsalicy) kaopectate ex str (bismuth ss) 88 KEDBUMIN ketoconazole ketoprofen... 6 ketorolac... 6, 86 KEYTRUDA KHEDEZLA kimidess (28) KINERET KINRIX (PF) SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-9 Effective: November 01, 2015

143 KLOR-CON klor-con KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KLOR-CON/EF kola-pectin ds KORLYM kpn KRYSTEXXA KUVAN KYPROLIS L l norgest/e.estradiol-e.estrad.. 72 labetalol LACRISERT LACTATED RINGERS lactulose LAMICTAL lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost LATUDA LAZANDA... 3 leflunomide LEMTRADA LENVIMA LETAIRIS letrozole leucovorin calcium , 103 LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 19, 85 levofloxacin in d5w levoleucovorin calcium levomefolate calcium levonorgestrel levonorgestrel-ethin estradiol. 73 levonorgestrel-ethinyl estrad.. 73 levorphanol tartrate... 3 levothyroxine LEXIVA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine... 7, 8 lidocaine (pf)... 7, 63 lidocaine hcl... 7 lidocaine in 5 % dextrose (pf) 63 lidocaine-prilocaine... 8 linezolid LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III liquid calcium with vitamin d lisinopril lisinopril-hydrochlorothiazide 63 lithium carbonate lithium citrate l-norgest-eth estr/ethin estra lohist - d lohist-peb lohist-psb lomustine loperamide loradamed loratadine lorazepam oral solution losartan losartan-hydrochlorothiazide.. 62 LOTEMAX LOTRIMIN ULTRA LOTRONEX lovastatin loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA LYSODREN M maalox advanced MAALOX MAXIMUM STRENGTH mafenide acetate mag mag-delay mag-g magnesium magnesium chloride magnesium gluconate magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen)... 3 SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-10 Effective: November 01, 2015

144 maprotiline MARPLAN MARQIBO masanti double strength MATULANE matzim la meclizine medroxyprogesterone mefenamic acid... 7 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) MEGACE ES megestrol MEKINIST meloxicam... 7 melphalan hcl intravenous memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesna MESNEX MESTINON metaproterenol metaxalone metformin methadone... 3 methadone hcl... 3 methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ... 93, 94 metipranolol metoclopramide hcl... 88, 89 metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 43, 46, 77 metronidazole in nacl (iso-os) 46 mexiletine mg217 psoriasis MIACALCIN mi-acid micatin miconazole miconazole nitrate miconazole-3 prefil,cream,wipe midazolam midazolam (pf) midodrine milrinone milrinone in 5 % dextrose minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone MONISTAT monistat montelukast morphine... 3 MORPHINE... 3 morphine concentrate... 3 morrhuate sodium motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL msud MULTAQ multivit, iron, min #5, fa multivit, iron, min #6, fa multivit, min cmb#20-iron-fa multivitamins with min no.7-fa multivits,therap w-fe,hematin mupirocin mupirocin calcium muro MUSTARGEN mycophenolate mofetil mycophenolate sodium MYOZYME N nabumetone... 7 SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-11 Effective: November 01, 2015

145 nadolol nafcillin nafcillin in dextrose iso-osm.. 18 NAGLAZYME naloxone... 8 naltrexone... 8 naltrexone hcl... 8 NAMENDA NAMENDA TITRATION PAK NAMENDA XR NAMZARIC naphazoline naproxen... 7 naproxen sodium... 7 naratriptan nasal & sinus decongestant nasal decongestant (pe) NASCOBAL NASONEX NATACYN nateglinide NATPARA natural calcium NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc. 85 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neosporin anti-itch NEPHRAMINE 5.4 % NESSI SPACER NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine nicotine... 8 NICOTROL... 8 nifedipine NILANDRON NITRO-BID nitrofurantoin macrocrystal... 13, 14 nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose. 70 NITROSTAT NORDITROPIN FLEXPRO.. 94 norelgestromin/ethin.estradiol 73 norepinephrine bitartrate noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) 73 norethindrone acetate norethindrone ac-eth estradiol... 73, 93 norethindrone-e.estradiol-iron 73 norethindrone-ethinyl estrad.. 73 norethindrone-mestranol norgestimate-ethinyl estradiol 73 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp... 4 NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCYNTA... 4 NUCYNTA ER... 4 NUEDEXTA NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUTRIT SUPP-INULIN-FOS- FIBER NUTRITIONAL SUPPLEMENT NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone nyt-time sleep O obagi nu-derm tolereen OCTAGAM octreotide acetate OFEV ofloxacin... 19, 85 olanzapine olanzapine-fluoxetine olopatadine OLYSIO SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-12 Effective: November 01, 2015

146 om-3-ca carb-d3-fa-mv cmb omega-3 acid ethyl esters omeprazole omeprazole magnesium OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI opcicon one-step OPDIVO OPSUMIT OPTICHAMBER ADULT MASK-LARGE oralyte ORAP ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORKAMBI OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) 18 oxaliplatin oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 4 oxycodone hcl-acetaminophen. 4 oxycodone hcl-aspirin... 4 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 OXYCONTIN... 4 oxymorphone... 4 oysco 500/d oysco oyster shell calcium oyster shell calcium-vit d oystercal-d P paclitaxel pain relief... 5 paliperidone PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PATADAY PATANOL PAXIL pedi m.vit no.17 with fluoride PEDIALYTE PEDIARIX (PF) pediasure pediatex td pediatric drink pediatric electrolyte pediatric freezer pops PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl 90 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentoxifylline PEPTAMEN JUNIOR WITH PREBIO pep-t-med PERIKABIVEN perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline perry prenatal persa-gel phenelzine phenobarbital phenobarbital sodium phentolamine phenylephrine hcl... 62, 84 phenylephrine-brompheniramin phenylephrine-chlorpheniramine PHENYL-FREE phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended phillips liqui-gels PHOSLYRA PHOSPHOLINE IODIDE phosphorus # phytonadione PICATO pilocarpine hcl... 75, 105 pimozide pindolol pin-x pioglitazone pioglitazone-glimepiride pioglitazone-metformin SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-13 Effective: November 01, 2015

147 piperacillin-tazobactam piroxicam... 7 PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox podophyllum resin polyethylene glycol polymyxin b sulf-trimethoprim polysporin poly-vita (iron) poly-vitamin with iron POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 108 potassium bicarbonate-cit ac 109 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate-citric acid. 110 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 86, 94 prednisone PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal PRENATAL prenatal formula prenatal gummy prenatal multivitamins prenatal vit#96-ferrous fum-fa prenatal vitamin with minerals prenatal vitamins , 120 PRENATAL VITAMINS prenatal vit-iron fumarate-fa 120 prenatal preparation h hydrocortisone. 80 PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized capsules PROGLYCEM PROGRAF PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 41, 45 promethazine hcl promethazine-codeine promethazine-dm promethazine-phenylephcodeine propafenone propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod. 84 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME PURIXAN pyrazinamide SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-14 Effective: November 01, 2015

148 pyridostigmine bromide pyridoxine Q q-dryl q-pap... 5 q-tapp QUADRACEL (PF) QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 63 quinidine gluconate quinidine sulfate quinine sulfate QVAR R ra pediatric nutrition drink RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE REBIF (WITH ALBUMIN) 103 REBIF REBIDOSE REBIF TITRATION PACK 103 RECOMBIVAX HB (PF) recort plus reese's pinworm medicine RELADOR PAK... 8 RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR RESTASIS RETROVIR REVLIMID REXULTI REYATAZ ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ii right step prenatal vitamins riluzole rimantadine ri-mox ri-mox plus ringers... 99, 110 risacal-d risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan ropinirole ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL SAIZEN SAIZEN CLICK.EASY salsalate... 7 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scalp itch-dandruff relief selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin siladryl sa silapap... 5 sildenafil oral tablet 20 mg SILENOR silver nitrate silver nitrate applicators silver sulfadiazine SIMBRINZA simply sleep SIMPONI , 104 SIMPONI ARIA simvastatin sinus & allergy (pseudoephed) sinus nighttime sirolimus SIRTURO sleep-tabs sochlor sodium acetate sodium bicarbonate sodium chloride 84, 99, 110, 113 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride sodium lactate sodium phosphate sodium polystyrene sulfonate 90, 91 sodium thiosulfate sod-pot-k cit-sod cit-cit acid. 110 SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-15 Effective: November 01, 2015

149 SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) 89 soothe regular strength sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL st joseph aspirin... 7 st. joseph aspirin... 7 stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA streptomycin STRIBILD STRIVERDI RESPIMAT STROVITE ONE stuart prenatal sucralfate sudogest sudogest cold & allergy sulfacetamide sodium sulfacetamide sodium (acne).. 77 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac... 7 sumatriptan nasal spray sumatriptan succinate suphedrin support SUPPRELIN LA SUPRAX SURE COMFORT INS. SYR. U SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE T TABLOID tacrolimus... 80, 97 TAFINLAR TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe TASIGNA TAZORAC taztia xt TECFIDERA TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam... 11, 12 TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracaine hcl tetracycline TEV-TROPIN THALOMID the magic bullet theophylline theophylline anhydrous theophylline in dextrose 5 % 112 therapeutic vitamins/minerals thiamine hcl thioridazine thiothixene tiagabine TICE BCG TIKOSYN timolol maleate... 65, 105 TIVICAY tizanidine TOBI PODHALER SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-16 Effective: November 01, 2015

150 TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide... 36, 37 tolbutamide tolmetin... 7 tolnaftate tolterodine topiramate toposar intravenous topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR... 26, 27 tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting orange triamcinolone acetonide.. 75, 81, 94 TRIAMINIC COLD & COUGH NT (PE) triamterene-hydrochlorothiazid triazolam TRIBENZOR triderm trifluoperazine trifluridine trihexyphenidyl TRILEPTAL trimethoprim TRIUMEQ tri-vi-sol tri-vita tri-vitamin TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine d TUDORZA PRESSAIR TWINRIX (PF) twocal hn TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULORIC unisom sleepgels UNITUXIN ursodiol V VAGIFEM VAGINAL CONTRACEPTIVE FOAM vagistat valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 30 valsartan valsartan-hydrochlorothiazide 62 VALSTAR vancomycin vancomycin in d5w VAQTA (PF) VARIVAX (PF) VASCEPA vasopressin vazobid-pd VECTIBIX VELCADE venlafaxine VENTAVIS verapamil VERSACLOZ VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMIZIM VIMPAT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-17 Effective: November 01, 2015

151 VIRAMUNE XR VIRAZOLE VIREAD vit b cmplx 3-fa-vit c-biotin. 120 vit b cmplx no3-fa-c-biot-zinc vit b12-lmefolate ca-vit b6-b vitacel (with lutein) vitamin b comp and vit c no vitamin b12-folic acid vitamin b vitamins b1,b2,b3,b5, and b6 121 VITA-RESPA VITEKTA VOLTAREN... 7 voriconazole VOTRIENT VPRIV W wal-act d cold & allergy wal-dryl allergy wal-finate wal-finate-d wal-itin wal-phed... 42, 74 wal-phed pe wal-phed pe sinus & allergy.. 43 wal-sleep z wal-som (diphenhydramine).. 43 wal-tap warfarin water for irrigation, sterile WELCHOL WIDE-SEAL DIAPHRAGM X XALKORI XARELTO XELJANZ XENAZINE XGEVA XIFAXAN XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP ZARXIO ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine zinc sulfate ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide ZORTRESS ZOSTAVAX (PF) ZOVIRAX z-sleep ZUBSOLV... 8, 9 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX SCFHP Cal MediConnect Formulary Formulary ID: , Version: 16 I-18 Effective: November 01, 2015

152 Oficina principal 210 E Hacienda Ave Campbell, CA Número gratuito TTY De 8:00 a. m. a 8:00 p. m., los 7 días de la semana, incluyendo feriados. Si tiene alguna pregunta, por favor llame a Santa Clara Family Health Plan. La llamada es gratuita. Para obtener más información, visite Formulary ID: , Version Number: 16 Last Updated: 11/1/2015 SH7002_10066S 2015, Santa Clara Family Health Plan. All rights reserved. H7890_15103_MMPformulary201409esV1 Approved