Formulario completo del 2016

Transcription

1 Formulario completo del 206 Lista de medicamentos cubiertos IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Formulary ID: , Version: 7 Este formulario se actualizó el 08/2/205. Para obtener información más reciente o si tiene preguntas, llame a Servicios al miembro de Denver Health Medical Plan, Inc. al Los usuarios de TTY deben llamar al 7. Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la semana, o puede visitar Nota para aquellos que ya son miembros: Este formulario presenta cambios respecto del año pasado. Sírvase revisar este documento para asegurarse de que todavía contenga los medicamentos que usted toma. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario. Esta información está disponible de manera gratuita en otros idiomas. Para obtener más información, llame a nuestro departamento de Servicios al miembro al o al número gratuito Los usuarios de TTY deben llamar al 7. Nuestro horario de atención es de 8 a. m. a 8 p. m. los siete días de la semana. This information is available for free in other languages. Please contact our Member Services department at or toll free at for more information. TTY users should call 7. Our hours of operation are from 8 a.m. - 8 p.m. seven days a week. Denver Health Medical Plan, Inc. es un plan HMO aprobado por Medicare y tiene un contrato con el Colorado Medicaid Program. La inscripción en Denver Health Medical Plan, Inc. depende de la renovación del contrato. H5608_085 CF6_00_SP accepted

2 Cuando en esta lista de medicamentos (formulario) figuran los términos nosotros, a nosotros o nuestro, se hace referencia a Denver Health Medical Plan, Inc. Donde dice plan o nuestro plan, significa Medicare Choice HMO SNP. Este documento incluye una lista parcial de los medicamentos (formulario) de nuestro plan que está en vigencia desde el January, 206. Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada. En general, usted debe utilizar farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, la lista de medicamentos, la red de farmacias, y/o los copagos/coseguro pueden cambiar el January, 207 y de vez en cuando durante el año. Qué es el Formulario completo de Denver Health Medical Plan, Inc.? Un formulario es una lista de medicamentos cubiertos seleccionados por nosotros en colaboración con un equipo de proveedores de atención médica, que representa los tratamientos recetados que se consideran parte necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos incluidos en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en una farmacia de la red de Denver Health Medical Plan, Inc. y se sigan otras reglas del plan. Para obtener más información sobre cómo obtener sus medicamentos recetados, revise su Evidencia de cobertura. Puede el Formulario (lista de medicamentos) modificarse? En general, si usted está tomando un medicamento de nuestro formulario del 206 que estaba cubierto a principios del año, no vamos a interrumpir ni a reducir la cobertura del medicamento durante el año de cobertura 206, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o se publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de cambios en el formulario, tales como eliminar un medicamento de nuestro formulario, no afectarán a los miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo compartido durante el resto del año de cobertura para aquellos miembros que lo toman. Consideramos que es importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto por los casos en los que usted pudiera ahorrar dinero adicional o nosotros podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario o añadimos requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada para un medicamento, debemos notificar a los miembros afectados acerca del cambio al menos 60 días antes de que el cambio entre en vigencia o en el momento en que el miembro solicite una renovación del medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no es seguro o si el fabricante del medicamento retira el medicamento del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto tiene vigencia a partir del January, 206. Para obtener información actualizada sobre los medicamentos que cubrimos, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada. 2

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

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

5 Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con el nivel más bajo de costo compartido o las restricciones adicionales de utilización no resultaran tan eficaces para tratar su afección o le causaran efectos de salud adversos. Usted debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para obtener una excepción respecto del formulario o de la restricción de utilización. Cuando usted solicita una excepción respecto del formulario o de la restricción de utilización, debe presentar una declaración del proveedor o médico, que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72 horas de recibir la declaración de respaldo de su médico. Usted puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera las 72 horas que lleva tomar la decisión. Si se le concede su petición de acelerar la decisión, debemos darle una decisión a más tardar 24 horas después de recibir la declaración de respaldo de su médico u otro proveedor. Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuo en nuestro plan, usted puede tomar medicamentos que no están en nuestro formulario. O bien, usted puede tomar un medicamento que está en nuestro formulario pero su capacidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes de poder obtener su medicamento con receta. Usted debe hablar con su médico para decidir si debe cambiar por otro medicamento apropiado que cubrimos o solicitar una excepción al formulario de modo que cubramos el medicamento que toma. Mientras hable con su médico para determinar el curso de acción correcto para usted, es posible que cubramos su medicamento en ciertos casos durante los primeros 90 días que usted sea miembro de nuestro plan. Por cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que usted tenga una receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro para 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días. Si usted es residente de un centro de atención a largo plazo, permitiremos la renovación de su medicamento recetado hasta que le hayamos proporcionado un suministro de transición para 9 días, coherente con el incremento de dispensación, (a menos que tenga una receta escrita para menos días). Cubriremos más de una renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia para 3 días de ese medicamento (a menos usted tiene una receta escrita menos días) mientras solicita una excepción al formulario. Si experimenta un cambio en el nivel de atención, por ejemplo, se le interna en un centro de atención a largo plazo o se le da el alta de este, y se encuentra fuera de sus primeros 90 días de cobertura, Denver Health Medical Plan, Inc. proporcionará un suministro por única vez un los medicamentos de la Parte D que no están en el formulario, como se describió anteriormente. 5

6 Para obtener más información Para obtener información más detallada sobre la cobertura de medicamentos recetados que ofrece nuestro plan, consulte su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada. Si tiene preguntas generales sobre la cobertura de Medicare para medicamentos recetados, puede llamar a Medicare al MEDICARE ( ) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite Formulario de Denver Health Medical Plan, Inc. El formulario completo que comienza en la página 3 proporciona información sobre la cobertura de los medicamentos cubiertos por nuestro plan. Si tiene inconvenientes para encontrar su medicamento en la lista, consulte el Índice que comienza en la página I-. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo, ADVAIR DISKUS) y los medicamentos genéricos aparecen en letra cursiva en minúsculas con un nombre de medicamento de marca de referencia que aparece junto al nombre genérico del fármaco (por ejemplo, amoxicilina (Amoxil)). Los medicamentos genéricos en cursiva con nombres de marca de referencia entre paréntesis indican que sólo el medicamento genérico está en el formulario. Durante la etapa inicial de su cobertura, su costo compartido será de 25% cuando obtenga un medicamento recetado de la Parte D en una farmacia de la red. Si usted califica para recibir un subsidio por bajos ingresos, su costo compartido por bajos ingresos dependerá del tipo de medicamento que reciba. Si recibe un medicamento genérico, incluso un medicamento de marca que se considere genérico, usted tendrá que pagar $0, $.20 o $2.95, dependiendo de su nivel de subsidio. Para medicamentos de marca y todos los demás, usted tendrá que pagar $ 0, $3.60 o $7.40, dependiendo de su nivel de subsidio. Para obtener más información sobre sus responsabilidades de costo compartido, consulte el Capítulo 6 de su Evidencia de cobertura. La información en la columna de Requisitos/Límites le indica si Denver Health Medical Plan, Inc. tiene algún requisito especial para la cobertura de su medicamento. 6

7 Las siguientes abreviaturas pueden encontrarse en el cuerpo de este documento. ABREVIATURAS SOBRE NOTAS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones sobre la Administración de la Utilización de Servicios PA Restricción de autorización previa previa Usted (o su médico) tiene la obligación de obtener autorización previa de Denver Health Medical Plan (DHMP), Inc. antes de obtener el medicamento de su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. PA BvD PA-HRM PA NSO QL Restricción de autorización previa para una determinación de Parte B frente a Parte D Restricción de autorización previa para medicamentos de alto riesgo Restricción de autorización previa para nuevos miembros solamente Restricción de límite de cantidad Este medicamento puede ser elegible para el pago bajo la Parte B o la Parte D de Medicare. Usted (o su médico) tiene la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. para determinar que este medicamento esté cubierto por la Parte D de Medicare antes de obtener el medicamento indicado en su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. Este medicamento ha sido considerado por CMS como potencialmente perjudicial y, por lo tanto, como medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los miembros de 65 años o más tienen la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. antes de obtener el medicamento de su receta. Sin autorización previa, Denver Health Medical Plan Inc. no puede cubrir este medicamento. Si usted es un miembro nuevo o si usted no ha tomado este medicamento antes, usted (o su médico) tiene la obligación de obtener una autorización previa de Denver Health Medical Plan, Inc. antes de obtener el medicamento que figura en su receta. Sin aprobación previa, DHMP no cubrirá este medicamento. Denver Health Medical Plan, Inc. establece un límite de cobertura respecto de la cantidad de este medicamento por receta o dentro de un marco de tiempo específico. 7

8 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN ST LA Restricción de terapia escalonada Medicamento de acceso limitado Antes de que Denver Health Medical Plan, Inc. proporcione cobertura para este medicamento, usted debe primero probar otro(s) medicamento(s) para el tratamiento de su afección médica. Este medicamento sólo será cubierto si otro(s) fármaco(s) no funciona(n) para usted. Es posible que este medicamento recetado sólo esté disponible en algunas farmacias. Para obtener más información, consulte su Directorio de farmacias o llame a Servicios al miembro al , de 8 a. m. a 8 p. m. los siete días de la semana. Los usuarios de TTY deben llamar al 7. 8

9 ABREVIATURAS DE DOSIS Y PRESENTACIÓN ABREVIATURA DESCRIPCIÓN adh. patch parche adhesivo aer br act aerosol, activado por aliento aer pow aerosol, polvo aer pow ba polvo aerosol, activado por aliento aer refill repuesto de aerosol aer w/adap aerosol con adaptador ampul ampolla blkbaginj inyección en bolsas a granel cap dr mp cápsula, multifásica de liberación prolongada cap ds pk cápsula, paquete de dosis cap er 2h cápsula, 2 horas liberación prolongada cap er 24h cápsula, 24 horas liberación prolongada cap er deg cápsula, liberación prolongada degradable cap er pel cápsula, pellets liberación prolongada cap mphase cápsula, multifásica cap.sa 24h cápsula, 24 horas liberación sostenida cap.sr 2h cápsula, 2 horas liberación sostenida cap.sr 24h cápsula, 24 horas liberación sostenida cap24h pct cápsula, 24 horas pellets de inicio controlado cap24h pel cápsula, 24 horas pellets liberación sostenida cap sprink cápsula, esparcir cap sr pel cápsula pellets liberación sostenida cap w/dev cápsula con dispositivo capsule dr cápsula, liberación retardada capsule er cápsula, liberación prolongada capsule sa cápsula, acción sostenida cmb cappad combinación: cápsula, almohadilla cmb ont fm combinación: ungüento, espuma cmb ont lt combinación: ungüento, loción cmb tabpad combinación: comprimido, almohadilla combo. pkg paquete combinado cpmp 2hr cápsula, 2 horas multifásica cpmp 24hr cápsula, 24 horas multifásica cpmp cápsula, multifásica, 30%-70% cpmp cápsula, multifásica, 50%-50% cream(g), cream(gm) crema (gramos) cream(ml) crema (mililitros) cream/appl crema con aplicador cream, er (g) crema, liberación prolongada (gramos) cream pack crema, paquete dehp fr bg bolsa sin di(2-etilhexil) ftalato dis needle aguja desechable disk w/dev disco con dispositivo para inhalación disp syrin jeringa desechable drops susp gotas, suspensión 9

10 ABREVIATURA drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw DESCRIPCIÓN gotas, hiperviscosas adhesivo emulsión paquete de emulsión emulsión (gramos) espuma con aplicador accesorio congelado gramo gel con aplicador precargado gel (gramos) gel (mililitros) gel en bomba con dosis medida gel con aplicador gel con bomba paquete de gránulos adaptador para aerosol hfahidrofluoroalcano frasco para infusión pluma de insulina solución intraperitoneal solución de irrigación solución intravenosa jalea jalea con aplicador jalea con aplicador precargado kit: limpiador y crema kit: crema, loción emoliente kit: loción, crema emoliente kit: ungüento, loción emoliente loción, liberación prolongada pastillas con soporte parche de calor con medicamento comprimidos bucales mucoadhesivos microgramo almohadilla con medicamento hisopo con medicamento cinta adhesiva con medicamento miligramo mililitro sistema mucoadhesivo, 2 horas liberación prolongada aguja para inyección suspensión para cubierta de uñas ungüento (gramos) concentrado oral suspensión oral pasta (gramos) parche, 24 horas transdérmico parche, 72 horas transdérmico parche, 2 veces por semana transdérmico 0

11 ABREVIATURA patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa DESCRIPCIÓN parche, vez por semana transdérmico jeringa analgésica controlada por paciente vial analgésico controlado por paciente pellet (cada uno) kit con pluma para inyección pluma para inyección frasco accesorio bolsa plástica paquete de polvo solución con bomba multidosis solución con aplicador solución con aplicador precargado solución, formadora de gel solución, reconstituida solución (gramos) atomizador, suspensión atomizador con bomba varilla (cada una) supositorio, rectal supositorio, vaginal supositorio suspensión, 24 horas liberación prolongada suspensión, reconstituida de liberación prolongada suspensión, microcápsula reconstituida suspensión, paquete de liberación retardada suspensión, reconstituida kit de jeringa comprimido, masticable comprimido, 2 horas liberación prolongada comprimido, 24 horas liberación prolongada comprimido, partículas de liberación prolongada comprimido, efectos de liberación prolongada de liberación prolongada comprimido, dispersable comprimido, paquete de dosis comprimido, 24 horas liberación prolongada comprimido, multifásico comprimido, partículas comprimido, liberación retardada de desintegración rápida comprimido, desintegración rápida comprimido, sublingual comprimido, 2 horas liberación sostenida comprimido, 24 horas liberación sostenida comprimido, 24 horas liberación prolongada gradual comprimido, liberación retardada comprimido, liberación prolongada comprimido, efervescente comprimido, acción sostenida

12 ABREVIATURA tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPCIÓN comprimido, soluble comprimido, paquete de dosis de liberación prolongada comprimido, paquete de dosis multifásica comprimido, paquete de dosis de desintegración rápida comprimido, paquete de dosis de 3 meses comprimido, 2 horas multifásico comprimido, 24 horas multifásico unidad anillo vaginal 2

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with QL (2700 per 30 Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (360 per 30 mg, mg acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (80 per 30 mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral capsule mg (Esgic) PA-HRM; QL (80 per 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) PA-HRM; QL (80 per 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (80 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) PA-HRM; QL (80 per 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) PA-HRM; QL (80 per 30 BUTRANS QL (4 per 28 codeine sulfate oral tablet (Codeine Sulfate) QL (80 per 30 codeine-butalbital-asa-caffein oral capsule mg (Fiorinal with Codeine #3) PA-HRM; QL (80 per 30 fentanyl (Duragesic) PA; QL (0 per 30 fentanyl citrate (Actiq) PA; QL (20 per 30 hydrocodone-acetaminophen oral solution (Hycet) QL (2700 per 30 hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 hydrocodone-acetaminophen oral tablet (Norco) QL (360 per mg, mg, mg, mg hydrocodone-ibuprofen (Ibudone) QL (50 per 30 hydromorphone (pf) injection solution 0 mg/ml (Hydromorphone HCl/PF) 3 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

14 hydromorphone (pf) injection solution 4 (Dilaudid) mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) QL (200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) QL (80 per 30 hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 LAZANDA PA; QL (30 per 30 methadone hcl oral tablet,soluble 40 mg (Diskets) QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Morphine Sulfate) QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 0 mg/ml, 5 (Morphine Sulfate) mg/ml, 8 mg/ml morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral solution 0 mg/5 ml (Morphine Sulfate) QL (700 per 30 morphine oral solution 20 mg/5 ml (Morphine Sulfate) QL (300 per 30 MORPHINE ORAL TABLET QL (80 per 30 morphine oral tablet extended release 00 (MS Contin) QL (20 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 mg, 200 mg morphine rectal (Morphine Sulfate) NUCYNTA QL (8 per 30 NUCYNTA ER QL (60 per 30 oxycodone hcl-acetaminophen oral (Oxycodone QL (800 per 30 solution mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Xolox) QL (360 per mg, mg, mg, mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 4 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

15 oxycodone oral concentrate (Oxycodone HCl) QL (80 per 30 oxycodone oral solution (Oxycodone HCl) QL (300 per 30 oxycodone oral tablet (Roxicodone) QL (80 per 30 oxycodone-acetaminophen oral tablet 0- (Xolox) QL (360 per mg, mg, mg, mg oxycodone-acetaminophen oral tablet 0- (Xolox) QL (80 per mg oxycodone-acetaminophen oral tablet 7.5- (Xolox) QL (240 per mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (20 per 30 ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet (Opana) QL (80 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (20 per 30 2 hr 30 mg, 40 mg tramadol oral tablet (Ultram) QL (240 per 30 tramadol-acetaminophen (Ultracet) QL (240 per 30 xylon 0 (Ibudone) QL (50 per 30 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) QL (60 per 30 choline,magnesium salicylate (Choline Sal/Mag Salicylate) diclofenac potassium (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) 5 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

16 etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR PA flurbiprofen (Flurbiprofen) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) mg indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (20 per 30 indomethacin oral capsule, extended release (Indomethacin) PA-HRM; QL (60 per 30 indomethacin sodium (Indomethacin Sodium) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac oral (Ketorolac QL (20 per 30 Tromethamine) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg, 550 (Anaprox) mg piroxicam (Feldene) salsalate (Salsalate) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) PA BvD; (PA for ESRD Only) 6 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

17 lidocaine hcl injection solution (Xylocaine) PA BvD; (PA for ESRD Only) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) PA lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Lidocaine/Prilocaine) PA BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 buprenorphine-naloxone (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) bupropion hcl sr 50 mg tablet f/c (Zyban) CHANTIX QL (68 per 84 CHANTIX CONTINUING MONTH BOX QL (56 per 28 CHANTIX CONTINUING MONTH PAK QL (56 per 28 CHANTIX STARTING MONTH BOX QL (53 per 28 disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICOTROL QL (008 per 90 ZUBSOLV PA; QL (90 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet (Xanax) QL (20 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (20 per 30 7 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

18 clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating 2 (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 5 mg (Tranxene T-Tab) QL (20 per 30 clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 mg, 7.5 mg diazepam injection (Diazepam) QL (0 per 28 diazepam intensol (Diazepam) QL (200 per 30 diazepam oral solution (Diazepam) QL (200 per 30 diazepam oral tablet (Valium) QL (20 per 30 diazepam rectal (Diastat) lorazepam oral tablet (Ativan) QL (90 per 30 Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback Iso-Osm) gentamicin injection solution (Gentamicin Sulfate) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) solution neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 tobramycin in % nacl (Tobi) PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride) tobramycin sulfate injection solution (Tobramycin Sulfate) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) 8 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

19 clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin Phosphate) solution colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate (Methenamine Mandelate) metronidazole in nacl (iso-os) (Metronidazole/Sodium Chloride) metronidazole oral (Flagyl) nitrofurantoin macrocrystal (Macrodantin/Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 polymyxin b sulfate (Polymyxin B Sulfate) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln,000 (Vancomycin HCl) mg, 0 gram, 750 mg vancomycin intravenous recon soln 500 mg (Vancomycin HCl/D5W) 9 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

20 vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback gram/50 ml, 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln gram, 0 (Cefazolin Sodium) gram, 00 gram, 300 g, 500 mg cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Cefoxitin Sodium) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime intravenous recon soln (Ceftazidime) gram, 2 gram ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone piggyback gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) 20 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

21 ceftriaxone intravenous recon soln gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef).5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for (Cephalexin) reconstitution cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Clarithromycin) release 24 hr DIFICID QL (20 per 0 ERYTHROCIN erythromycin base oral tablet,delayed (Erythromycin Base) release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral (Eryped 200) suspension for reconstitution erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) erythromycin oral tablet (Erythromycin Base) 2 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

22 erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram (Azactam) CAYSTON LA imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for (Amoxicillin) reconstitution amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 25 mg, (Amoxicillin) 250 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Ampicillin Sodium) ampicillin sodium intravenous recon soln (Ampicillin Sodium) ampicillin-sulbactam injection recon soln (Unasyn) ampicillin-sulbactam intravenous (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin injection (Nafcillin Sodium) nafcillin intravenous recon soln (Nafcillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln 0 gram (Oxacillin Sodium) oxacillin intravenous (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- Water) penicillin g potassium (Penicillin G Potassium) 22 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

23 penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam intravenous recon (Zosyn) soln Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate (Ciprofloxacin Lactate) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim intravenous ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/Trim ethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 00 mg (Morgidox) doxycycline hyclate 00 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 00 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 00 mg, 50 (Avidoxy) mg doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension for reconstitution (Vibramycin) 23 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

24 doxycycline monohydrate oral tablet (Avidoxy) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Tetracycline HCl) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS PA NSO; QL (4 per 2 AFINITOR DISPERZ PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; QL (28 per 28 ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) AVASTIN INTRAVENOUS SOLUTION PA NSO 25 MG/ML azacitidine (Vidaza) BELEODAQ PA NSO bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) PA BvD BLINCYTO PA NSO; QL (40 per 365 BOSULIF ORAL TABLET 00 MG PA NSO; QL (20 per 30 BOSULIF ORAL TABLET 500 MG PA NSO; QL (30 per 30 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG PA NSO; QL (30 per 30 COMETRIQ PA NSO; QL (2 per 28 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD 24 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

25 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST CYRAMZA INTRAVENOUS PA NSO SOLUTION 0 MG/ML dactinomycin (Dactinomycin) decitabine (Dacogen) doxorubicin hcl intravenous recon soln 0 (Doxorubicin HCl) PA BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) PA BvD suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD DROXIA ELIGARD SUBCUTANEOUS SYRINGE QL ( per MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL ( per 2 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL ( per MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ERIVEDGE PA NSO; QL (30 per 30 ETOPOPHOS etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON FARYDAK PA NSO FASLODEX floxuridine (Floxuridine) PA BvD fluorouracil intravenous solution 2.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/00 ml, 500 mg/0 ml flutamide (Flutamide) GAZYVA PA NSO GILOTRIF PA NSO; QL (30 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

26 GLEEVEC ORAL TABLET 00 MG PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG PA NSO; QL (60 per 30 HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) IBRANCE PA NSO; QL (2 per 28 ICLUSIG ORAL TABLET 5 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 INLYTA ORAL TABLET MG PA NSO; QL (80 per 30 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IXEMPRA JAKAFI PA NSO; QL (60 per 30 KEYTRUDA PA NSO KYPROLIS PA NSO; QL (6 per 28 LENVIMA PA NSO letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT LUPRON DEPOT (3 MONTH) QL ( per 84 LUPRON DEPOT (4 MONTH) QL ( per 84 LUPRON DEPOT (6 MONTH) QL ( per 68 LYNPARZA PA NSO; QL (480 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

27 LYSODREN MATULANE megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 mercaptopurine (Mercaptopurine) methotrexate sodium (pf) injection recon (Methotrexate PA BvD soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate Sodium) PA BvD solution methotrexate sodium injection (Methotrexate Sodium) PA BvD methotrexate sodium oral (Methotrexate Sodium) PA BvD; ST mitoxantrone (Mitoxantrone HCl) NEXAVAR PA NSO; QL (20 per 30 NILANDRON ONCASPAR PA NSO OPDIVO INTRAVENOUS SOLUTION PA NSO 40 MG/4 ML POMALYST PA NSO; QL (2 per 28 PROLEUKIN PURIXAN REVLIMID PA NSO; LA RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 STIVARGA PA NSO; QL (84 per 28 SUTENT PA NSO; QL (30 per 30 SYLVANT PA NSO 27 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

28 SYNRIBO PA NSO; QL (28 per 28 TABLOID TAFINLAR PA NSO; QL (20 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 00 MG, 25 MG PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 50 MG PA NSO; QL (90 per 30 TARGRETIN ORAL PA NSO; QL (420 per 30 TARGRETIN TOPICAL PA NSO; QL (60 per 28 TASIGNA PA NSO; QL (2 per 28 TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) TREANDA TRELSTAR INTRAMUSCULAR QL ( per 68 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL ( per 84 SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR QL ( per 68 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 0mg) TREXALL PA BvD; ST TYKERB VALSTAR VELCADE PA NSO vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; QL (20 per 30 XALKORI PA NSO; QL (60 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

29 XTANDI PA NSO; QL (20 per 30 YERVOY INTRAVENOUS SOLUTION PA NSO ZELBORAF PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG QL ( per 28 ZOLINZA ZYDELIG PA NSO; QL (60 per 30 ZYKADIA PA NSO; QL (40 per 28 ZYTIGA PA NSO; QL (20 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0. (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ST BANZEL ST carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr (Depakote ER) 29 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

30 divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 2 MG, 6 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 24hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) (35) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 24 hr 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 (500 per 30 phenobarbital oral tablet 00 mg, 5 mg, (Phenobarbital) QL (90 per mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 phenobarbital sodium injection solution (Phenobarbital Sodium) QL (2 per 30 phenytoin oral suspension 25 mg/5 ml (Dilantin-25) phenytoin oral (Dilantin) 30 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

31 phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, 300 ST ; QL (90 per 30 MG, 400 MG POTIGA ORAL TABLET 50 MG ST ; QL (270 per 30 primidone (Mysoline) SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) topiramate oral tablet (Topamax) TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS ST ; QL (200 per 5 VIMPAT ORAL SOLUTION ST ; QL (200 per 30 VIMPAT ORAL TABLET ST ; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Donepezil HCl) QL (30 per 30 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per hr galantamine oral solution (Galantamine Hbr) QL (200 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 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 3 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

32 Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Irenka) QL (60 per 30 release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed (Irenka) QL (30 per 30 release(dr/ec) 30 mg, 40 mg EMSAM QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) fluvoxamine (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM 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) 32 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

33 paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION perphenazine-amitriptyline (Perphenazine/Amitripty PA NSO-HRM line HCl) phenelzine (Nardil) PRISTIQ ST ; QL (30 per 30 protriptyline (Protriptyline HCl) sertraline (Zoloft) SILENOR QL (30 per 30 SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release (Effexor XR) 24hr venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 50 mg, 37.5 mg, 75 mg (Venlafaxine HCl) VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 CYCLOSET QL (80 per 30 GLYXAMBI ST; QL (30 per 30 INVOKAMET ORAL TABLET 50- ST; QL (60 per 30,000 MG, MG, 50-,000 MG INVOKAMET ORAL TABLET MG ST; QL (20 per 30 INVOKANA ORAL TABLET 00 MG ST; QL (60 per 30 INVOKANA ORAL TABLET 300 MG ST; QL (30 per 30 JANUMET QL (60 per 30 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, MG QL (30 per 30 JANUMET XR ORAL TABLET, ER QL (60 per 30 MULTIPHASE 24 HR 50-,000 MG JANUVIA QL (30 per 30 JARDIANCE ST; QL (30 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

34 JENTADUETO QL (60 per 30 KORLYM PA; QL (2 per 28 metformin oral tablet,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (50 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended release 24 (Glucophage XR) QL (20 per 30 hr 500 mg metformin oral tablet extended release 24 (Glucophage XR) QL (90 per 30 hr 750 mg metformin oral tablet extended release (Fortamet) QL (60 per 30 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET QL (50 per 30 repaglinide (Prandin) QL (240 per 30 SYMLINPEN 20 PA; QL (0.8 per 28 SYMLINPEN 60 PA; QL (6 per 28 TRADJENTA QL (30 per 30 TRULICITY ST; QL (4 per 28 VICTOZA ST; QL (9 per 28 Insulins 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 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 34 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

35 Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 0 mg (Glucotrol) QL (20 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 30 0 mg glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per mg, 5 mg glipizide-metformin oral tablet mg (Glipizide/Metformin QL (240 per 30 HCl) glipizide-metformin oral tablet (Glipizide/Metformin QL (20 per 30 mg, mg HCl) glyburide micronized oral tablet.5 mg (Glynase) PA-HRM; QL (400 per 30 glyburide micronized oral tablet 3 mg (Glynase) PA-HRM; QL (80 per 30 glyburide micronized oral tablet 6 mg (Glynase) PA-HRM; QL (20 per 30 glyburide oral tablet.25 mg (Glyburide) PA-HRM; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (20 per 30 glyburide-metformin oral tablet mg (Glucovance) PA-HRM; QL (240 per 30 glyburide-metformin oral tablet mg, mg (Glucovance) PA-HRM; QL (20 per 30 tolazamide oral tablet 250 mg (Tolazamide) QL (20 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (80 per 30 Antifungals Antifungals ABELCET PA BvD AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD CANCIDAS 35 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

36 ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream (Clotrimazole) clotrimazole topical solution (Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth asone Dip) econazole topical (Econazole Nitrate) fluconazole (Diflucan) fluconazole in dextrose(iso-o) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) intravenous (Fluconazole In piggyback 400 mg/200 ml Nacl,Iso-Osm) flucytosine (Ancobon) griseofulvin microsize oral tablet (Grifulvin V) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) miconazole nitrate vaginal suppository (Monistat 3) 200 mg NOXAFIL ORAL NYSTATIN (BULK) POWDER BILLION UNIT, 0 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin) terbinafine hcl oral (Lamisil) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) Antihistamines 36 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

37 Antihistamines cyproheptadine (Cyproheptadine HCl) PA-HRM diphenhydramine hcl injection solution 50 mg/ml (Diphenhydramine HCl) levocetirizine (Xyzal) promethazine oral syrup (Promethazine HCl) PA-HRM Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL 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 (8 per 28 ERGOMAR QL (40 per 28 naratriptan (Amerge) QL (8 per 28 rizatriptan oral tablet (Maxalt) QL (8 per 28 rizatriptan oral tablet,disintegrating (Maxalt Mlt) QL (8 per 28 sumatriptan nasal spray (Imitrex) QL (2 per 28 sumatriptan oral tablet (Imitrex) QL (8 per 28 sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Sumatriptan Succinate) QL (4 per 28 injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) QL (4 per 28 injector 6 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 solution zolmitriptan oral tablet (Zomig) QL (2 per 28 zolmitriptan oral tablet,disintegrating (Zomig Zmt) QL (2 per 28 Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) 37 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

38 ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO PA; QL (88 per 68 TRECATOR Antinausea Agents Antinausea Agents dimenhydrinate injection solution (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS QL (2 per 28 EMEND ORAL PA BvD granisetron (pf) intravenous solution (Granisetron HCl/PF) granisetron hcl intravenous solution (Granisetron HCl) mg/ml ( ml) granisetron hcl oral (Granisetron HCl) PA BvD meclizine oral tablet 2.5 mg, 25 mg (Antivert) ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) injection (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection solution (Prochlorperazine Edisylate) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine HCl) PA-HRM promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (0 per 30 Antiparasite Agents Antiparasite Agents ALBENZA 38 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

39 ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) chloroquine phosphate oral (Chloroquine Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate) PENTAM PRIMAQUINE QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (42 per 7 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral (Amantadine HCl) APOKYN QL (60 per 30 AZILECT benztropine oral (Benztropine Mesylate) PA-HRM bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet extended (Sinemet CR) release carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) NEUPRO ST; QL (30 per 30 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) PA-HRM Antipsychotic Agents 39 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

40 Antipsychotic Agents ABILIFY DISCMELT ORAL QL (90 per 30 TABLET,DISINTEGRATING 0 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA QL ( per 28 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral tablet 0 mg, 5 mg, 20 (Abilify) QL (30 per 30 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 00 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) QL (35 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating (Fazaclo) ST FANAPT ORAL TABLET ST ; QL (60 per 30 FANAPT ORAL TABLETS,DOSE ST ; QL (8 per 28 PACK fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 haloperidol (Haloperidol) haloperidol decanoate intramuscular (Haloperidol Decanoate) solution 00 mg/ml haloperidol decanoate intramuscular (Haldol Decanoate 50) solution 50 mg/ml haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED ST ; QL (30 per 30 RELEASE 24HR.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED ST ; QL (60 per 30 RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML QL (0.75 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

41 INVEGA SUSTENNA QL ( per 28 INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA QL (.5 per 28 INTRAMUSCULAR SYRINGE 234 MG/.5 ML INVEGA SUSTENNA QL (0.25 per 28 INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR QL (0.875 per 84 SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR QL (.35 per 84 SYRINGE 40 MG/.35 ML INVEGA TRINZA INTRAMUSCULAR QL (.75 per 84 SYRINGE 546 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR QL (2.625 per 84 SYRINGE 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 ST ; QL (30 per 30 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST ; QL (60 per 30 loxapine succinate (Loxapine Succinate) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) QL (30 per 30 mg, 5 mg, 5 mg olanzapine oral tablet,disintegrating 20 (Zyprexa Zydis) QL (3 per 30 mg ORAP perphenazine (Perphenazine) quetiapine (Seroquel) QL (90 per 30 RISPERDAL CONSTA QL (4 per 28 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, mg, 2 mg (Risperdal M-Tab) QL (60 per 30 4 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

42 risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (20 per 30 mg, 4 mg SAPHRIS (BLACK CHERRY) ST ; QL (60 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 20 MG, 405 MG Antivirals (Systemic) Antiretrovirals 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) 42 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

43 nevirapine oral tablet extended release 24 (Viramune XR) hr NORVIR PREZCOBIX PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY 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 00 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 MG QL (84 per 80 TAMIFLU ORAL CAPSULE 45 MG QL (48 per 80 TAMIFLU ORAL CAPSULE 75 MG QL (42 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

44 TAMIFLU ORAL SUSPENSION FOR QL (540 per 80 RECONSTITUTION Hcv Antivirals HARVONI PA; QL (30 per 30 OLYSIO PA; QL (28 per 28 SOVALDI PA; QL (28 per 28 Interferons INTRON A INJECTION PA NSO PEGASYS PA PEGASYS PROCLICK PA PEGINTRON 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 solution (Acyclovir Sodium) PA BvD 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 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 00 (Lovenox) QL (36 per 30 mg/ml 44 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

45 enoxaparin subcutaneous syringe 20 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 50 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 0 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 2,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml heparin (porcine) injection solution,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection solution 0,000 unit/ml heparin sodium,porcine-pf intravenous syringe 0 unit/ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe heparin-0.45% nacl 25,000 units/250 ml (00 units/ml) bag latex-free, inner (Lovenox) QL (27.2 per 30 (Lovenox) QL (34 per 30 (Lovenox) QL (8 per 30 (Lovenox) QL (3.6 per 30 (Lovenox) QL (20.4 per 30 (Arixtra) QL (24 per 30 (Arixtra) QL (5 per 30 (Arixtra) QL (2 per 30 (Arixtra) QL (8 per 30 (Heparin Sodium,Porcine/D5W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns/PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) PA BvD; (PA for ESRD Only) PA BvD PA BvD; (PA for ESRD Only) 45 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

46 heparin-d5w 25,000 units/250 ml (00 (Heparin units/ml) bag excel container Sodium,Porcine/D5W) IPRIVASK PA; QL (24 per 28 jantoven (Coumadin) PRADAXA ST; QL (60 per 30 warfarin (Coumadin) XARELTO Blood Formation Modifiers CINRYZE PA EPOGEN INJECTION SOLUTION PA; QL (2 per 28 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA INJECTION SYRINGE 00 PA; QL (0.6 per 28 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION SOLUTION PA; QL (2 per 28 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION PA; QL (6 per 28 40,000 UNIT/ML PROMACTA PA; QL (30 per 30 Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

47 Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 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 5 % PA BvD AMINOSYN 0 % PA BvD AMINOSYN 3.5 % PA BvD AMINOSYN 7 % PA BvD AMINOSYN 7 % WITH PA BvD ELECTROLYTES AMINOSYN 8.5 % PA BvD AMINOSYN 8.5 %-ELECTROLYTES PA BvD AMINOSYN II 0 % PA BvD AMINOSYN II 5 % PA BvD AMINOSYN II 7 % PA BvD 47 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

48 AMINOSYN II 8.5 % PA BvD AMINOSYN II 8.5 %-ELECTROLYTES PA BvD AMINOSYN M 3.5 % PA BvD AMINOSYN-HBC 7% PA BvD AMINOSYN-PF 0 % PA BvD AMINOSYN-PF 7 % (SULFITE-FREE) PA BvD AMINOSYN-RF 5.2 % PA BvD CLINIMIX 5%/D5W SULFITE FREE PA BvD CLINIMIX 5%/D25W SULFITE-FREE PA BvD CLINIMIX 2.75%/D5W SULFIT FREE PA BvD CLINIMIX 4.25%/D0W SULF FREE PA BvD CLINIMIX 4.25%/D5W SULFIT FREE PA BvD CLINIMIX 4.25%-D20W SULF-FREE PA BvD CLINIMIX 4.25%-D25W SULF-FREE PA BvD CLINIMIX 5%-D20W(SULFITE-FREE) PA BvD CLINIMIX E 2.75%/D0W SUL FREE PA BvD CLINIMIX E 2.75%/D5W SULF FREE PA BvD CLINIMIX E 4.25%/D0W SUL FREE PA BvD CLINIMIX E 4.25%/D25W SUL FREE PA BvD CLINIMIX E 4.25%/D5W SULF FREE PA BvD CLINIMIX E 5%/D5W SULFIT FREE PA BvD CLINIMIX E 5%/D20W SULFIT FREE PA BvD CLINIMIX E 5%/D25W SULFIT FREE PA BvD CLINISOL SF 5 % PA BvD cysteine (l-cysteine) intravenous solution (Cysteine HCl) PA BvD d0 %-0.9 % sodium chloride (Dextrose 0 % and 0.9 % NaCl) dextrose 0 % in water (d0w) (Dextrose 0 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in Water) PA BvD 48 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

49 dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) FREAMINE HBC 6.9 % PA BvD FREAMINE III 0 % PA BvD HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % PA BvD KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD PERIKABIVEN PA BvD PREMASOL 0 % PA BvD PREMASOL 6 % PA BvD PROCALAMINE 3% PA BvD PROSOL 20 % PA BvD TRAVASOL 0 % PA BvD TROPHAMINE 0 % PA BvD TROPHAMINE 6% PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidone) clonidine transdermal patch weekly 0. (Catapres-Tts ) QL (4 per 28 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 (Catapres-Tts ) QL (8 per 28 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) 49 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

50 NORTHERA PA; QL (80 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) 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) captopril-hydrochlorothiazide (Captopril/Hydrochlorot hiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydrochloro thiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Moexipril HCl) moexipril-hydrochlorothiazide (Moexipril/Hydrochlorot hiazide) perindopril erbumine (Aceon) quinapril (Accupril) 50 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

51 quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 00 mg, 200 (Cordarone) mg, 400 mg amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Tambocor) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) ml ( %) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine (Mexiletine HCl) MULTAQ procainamide injection (Procainamide HCl) propafenone oral capsule,extended release (Rythmol SR) 2 hr propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol oral (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 (Labetalol HCl) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Lopressor) 5 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

52 metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydrochlor othiazid) sotalol hcl oral tablet 20 mg, 60 mg, (Betapace) 240 mg, 80 mg sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) diltiazem hcl oral capsule, extended (Cardizem CD) release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) release 2 hr diltiazem hcl oral capsule,extended (Cardizem CD) release 24hr diltiazem hcl oral tablet (Cardizem CD) diltiazem hcl oral tablet extended release (Cardizem LA) 24 hr dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 24 (Verelan) hr verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous DEMSER 52 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

53 digitek oral tablet 25 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 dobutamine in d5w intravenous parenteral (Dobutamine HCl/D5W) PA BvD solution,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose intravenous (Dopamine HCl/D5W) PA BvD solution dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine injection auto-injector (Adrenaclick) epinephrine injection solution (Epinephrine) epinephrine injection syringe 0. mg/ml (Epinephrine) (:0,000) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) 53 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

54 LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG Drug Name Drug Tier Requirements/Limits PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose intravenous (Milrinone PA BvD piggyback 40 mg/200 ml (200 mcg/ml) Lactate/D5W) norepinephrine bitartrate (Levophed Bitartrate) PA BvD papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA 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) nifedipine oral tablet extended release (Adalat CC) 24hr 30 mg nifedipine oral tablet extended release (Procardia XL) 24hr 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) mg, 60 mg Diuretics amiloride oral (Midamor) amiloride-hydrochlorothiazide (Amiloride/Hydrochloro thiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 54 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

55 DYRENIUM furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) hydrochlorothiazide oral tablet (Hydrochlorothiazide) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral tablet (Maxzide) Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral powder 4 (Cholestyramine/Asparta gram me) cholestyramine-aspartame oral powder in (Cholestyramine/Asparta packet 4 gram me) colestipol (Colestid) CRESTOR fenofibrate micronized (Lofibra) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) JUXTAPID PA KYNAMRO PA; QL (4 per 28 lovastatin (Mevacor) niacin oral tablet extended release 24 hr (Niaspan) omega-3 acid ethyl esters (Lovaza) pravastatin (Pravachol) simvastatin (Zocor) QL (30 per 30 VASCEPA 55 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

56 ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 24 hr minitran transdermal patch 24 hour 0. (Nitro-Dur) QL (30 per 30 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) QL (60 per 30 mg/hr minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (30 per mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour (Nitro-Dur) QL (60 per mg/hr NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents 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 (Kapvay) 2 hr dexmethylphenidate oral tablet (Focalin) QL (60 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

57 dextroamphetamine oral capsule, extended (Dexedrine) QL (20 per 30 release dextroamphetamine oral tablet (Dexedrine) QL (80 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (30 per 30 capsule,extended release 24hr 0 mg, 5 mg, 5 mg dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 30 capsule,extended release 24hr 20 mg, 25 mg, 30 mg flumazenil (Romazicon) guanfacine oral tablet extended release 24 (Intuniv) hr lithium carbonate oral capsule (Lithium Carbonate) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended (Lithobid) release lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic (Metadate Cd) QL (30 per mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (30 per mg, 40 mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet extended (Methylphenidate HCl) QL (90 per 30 release methylphenidate oral tablet extended (Concerta) QL (30 per 30 release 24hr 8 mg, 27 mg, 54 mg methylphenidate oral tablet extended (Concerta) QL (60 per 30 release 24hr 36 mg NUEDEXTA QL (60 per 30 QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 STRATTERA 57 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

58 XENAZINE PA; QL (2 per 28 Contraceptives Contraceptives ashlyna (Seasonique) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet (Desogen) 0./.25/.5-25 mg-mcg, mg drospirenone-ethinyl estradiol (Yaz) ELLA QL (6 per 365 ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) junel fe 24 (Loestrin Fe) l norgest/e.estradiol-e.estrad (Seasonique) QL (9 per 84 larin 24 fe (Loestrin Fe) levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (2 per 365 levonorgestrel oral tablet.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel-ethin estradiol oral tablet (Amethyst) mg-mcg, mg, (6)/75-40 (5)/25-30(0) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethin QL (9 per 84 tablets,dose pack,3 month mg-mcg Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) levonorgestrel-ethinyl estrad oral tablet (Amethyst) QL (9 per mg levonorgestrel-ethinyl estrad oral (Amethyst) QL (9 per 84 tablets,dose pack,3 month l-norgest-eth estr/ethin estra (Seasonique) QL (9 per 84 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet -20 mg-mcg,.5-30 mg-mcg (Loestrin) 58 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

59 norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) mg-20 mcg (2)/75 mg (7), mg-20 mcg (24)/75 mg (4), -20(5)/-30(7) /mg- 35mcg (9),.5 mg-30 mcg (2)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) mg-mcg, mg-mcg, /- 35 mg-mcg/mg-mcg, 0.5/0.75/ mg- 35 mcg, 0.5// mg-mcg, -35 mg-mcg norethindrone-mestranol (Norinyl +50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL ( per 28 tarina fe (Loestrin Fe) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous (Peridex) membrane mouthwash 0.2 % pilocarpine hcl oral (Salagen) sodium fluoride oral tablet,chewable 0.25 (Sodium Fluoride) mg fluorid (0.55 mg) triamcinolone acetonide dental (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS ALCOHOL PREP PADS ammonium lactate (Lac-Hydrin) ANACAINE calcipotriene topical cream (Dovonex) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) PA 59 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

60 COSENTYX PEN PA COSENTYX PEN (2 PENS) PA FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 0 mg, 20 mg, 30 (Isotretinoin) mg, 40 mg methoxsalen rapid (Oxsoralen-Ultra) PANRETIN PICATO TOPICAL GEL 0.05 % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL VALCHLOR ZOVIRAX TOPICAL CREAM QL (5 per 30 Dermatological Antibacterials clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) erythromycin with ethanol topical swab (Erythromycin Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) 60 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

61 neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate applicators (Silver Nitrate Applicator) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone (Alclometasone Dipropionate) betamethasone dipropionate (Betamethasone Dipropionate) betamethasone valerate topical cream (Betamethasone Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical lotion (Betamethasone Valerate) betamethasone valerate topical ointment (Betamethasone Valerate) betamethasone, augmented topical cream (Diprolene AF) betamethasone, augmented topical gel (Betamethasone Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical (Diprolene) ointment clobetasol propionate topical solution 0.05 (Clobetasol Propionate) % clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Clobetasol Propionate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) desonide topical cream (Desowen) 6 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

62 desonide topical ointment (Desonide) 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) hydrocortisone % ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera topical gel (Hydrocortisone Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate topical cream (Hydrocortisone Butyrate) hydrocortisone butyrate topical ointment (Locoid) hydrocortisone butyrate topical solution (Locoid) hydrocortisone butyr-emollient (Hydrocortisone Butyrate) hydrocortisone rectal cream % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 00 mg/60 ml (Cortenema) hydrocortisone topical cream %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2 %, 2.5 % (Scalacort) hydrocortisone topical ointment %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream (Hydrocortisone Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 ONFI ORAL TABLET 0 MG, 20 MG PA NSO; QL (60 per 30 prednicarbate (Dermatop) 62 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

63 tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Triamcinolone Acetonide) triamcinolone acetonide topical ointment (Triamcinolone %, 0. %, 0.5 % Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0. % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical (Retin-A) PA Scabicides And Pediculicides malathion (Ovide) permethrin topical cream (Elimite) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD ECLIPSE LUER-LOK SYRINGE ML 27 X /2" BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 3 X 5/6", ML 3 X 5/6", /2 ML 3 X 5/6" INSULIN PEN NEEDLE NEEDLE 29 GAUGE X /2 " INSULIN SYRINGE-NEEDLE U-00 SYRINGE 0.3 ML 29, ML 29 X /2", /2 ML 28 VGO 40 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 63 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

64 CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN ORAL TABLET,SOLUBLE lipase-protease-amylase (Zenpep) MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT 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 aerosol,spray (Astepro) QL (30 per 25 azelastine ophthalmic (Azelastine HCl) carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN 64 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

65 epinastine (Elestat) homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (30 per % ipratropium bromide nasal spray,nonaerosol (Atrovent) QL (5 per % LACRISERT naphazoline (Naphazoline HCl) phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluorescei n Sod) tetracaine hcl (pf) ophthalmic (Tetracaine HCl/PF) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment (Garamycin) 0.3 % (3 mg/gram) levofloxacin ophthalmic (Levofloxacin) 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/Polymyxin) neomycin-polymyxin b-dexameth (Maxitrol) 65 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

66 neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B Sulf/HC) neomycin-polymyxin-hc otic (Neomycin/Polymyxin B drops,suspension Sulf/HC) neomycin-polymyxin-hc otic solution (Cortisporin) neo-polycin (Neomycin Su/Bacitra/Polymyxin) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide-prednisolone (Sulfacetamide/Predniso lone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZIRGAN ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX ST bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL flunisolide nasal spray,non-aerosol 25 (Flunisolide) QL (50 per 25 mcg (0.025 %) fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Fluticasone Propionate) QL (6 per 30 ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NEVANAC prednisolone acetate (Omnipred) 66 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

67 prednisolone sodium phosphate ophthalmic Drug Name Drug Tier Requirements/Limits (Prednisolone Sod Phosphate) PROLENSA RESTASIS QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine (Cimetidine) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso- Osm/PF) famotidine intravenous (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole oral capsule,delayed (Prevacid) (Rx Product Only) release(dr/ec) misoprostol (Cytotec) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) pantoprazole oral (Protonix) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 50 mg, 300 mg (Zantac) (Rx Product Only) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) Gastrointestinal Agents, Other AMITIZA QL (60 per 30 BUPHENYL ORAL TABLET CARBAGLU cromolyn oral (Gastrocrom) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) 67 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

68 diphenoxylate-atropine oral tablet (Lomotil) GATTEX 30-VIAL PA GATTEX ONE-VIAL PA glycopyrrolate (Robinul) glycopyrrolate (Robinul) lactulose (Lactulose) LINZESS QL (30 per 30 loperamide oral (Loperamide HCl) LOTRONEX methscopolamine oral (Methscopolamine Bromide) metoclopramide hcl injection (Metoclopramide HCl) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) MOVANTIK QL (30 per 30 NUTRESTORE RAVICTI PA RELISTOR SUBCUTANEOUS PA; QL (28 per 28 RELISTOR SUBCUTANEOUS PA; QL (28 per 28 SYRINGE 8 MG/0.4 ML sodium polystyrene sulfonate oral powder (Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate oral (Sodium Polystyrene suspension 5 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema (Sodium Polystyrene 30 gram/20 ml Sulfonate) ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives MOVIPREP peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) polyethylene glycol 3350 oral (Gavilyte-N) sodium chloride-nahco3-kcl-peg oral recon soln 420 gram (Nulytely with Flavor Packs) 68 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

69 Phosphate Binders calcium acetate oral capsule (Phoslo) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) PHOSLYRA RENAGEL RENVELA Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended (Ditropan XL) release 24hr tolterodine oral capsule,extended release 24hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ trospium (Trospium Chloride) 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 sodium thiosulfate intravenous solution gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) (Sodium Thiosulfate) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM PA; QL (30 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

70 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 Drug Name Drug Tier Requirements/Limits PA; QL (50 per 30 PA; QL (50 per 30 GRAM),.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) testosterone cypionate (Depo-Testosterone) PA testosterone enanthate (Delatestryl) PA; QL (5 per 28 testosterone transdermal gel in packet % (25 mg/2.5gram) (Androgel) PA; QL (300 per 30 Estrogens And Antiestrogens COMBIPATCH PA-HRM; QL (8 per 28 DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) PA-HRM; QL (8 per 28 estradiol transdermal patch weekly (Climara) PA-HRM; QL (4 per 28 estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM estropipate (Estropipate) PA-HRM FEMRING QL ( per 84 MENEST PA-HRM PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (8 per 28 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD 70 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

71 cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone Sod PA BvD injection Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone Sod PA BvD Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ injection (A-Methapred) PA BvD recon soln 25 mg, 40 mg methylprednisolone sodium succ (A-Methapred) PA BvD intravenous prednisolone sodium phosphate oral (Pediapred) PA BvD solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 00 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (5 per 30 desmopressin nasal (Desmopressin Acetate) QL (5 per 30 desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA INCRELEX LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) QL ( per 84 INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO PA NORDITROPIN NORDIFLEX PA 7 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

72 octreotide acetate injection solution,000 (Sandostatin) mcg/ml, 00 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) SAIZEN PA SAIZEN CLICK.EASY PA SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON PA SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT QL ( per 28 SOMAVERT SUPPRELIN LA QL ( per 360 Progestins DEPO-PROVERA INTRAMUSCULAR QL (0 per 28 SOLUTION medroxyprogesterone intramuscular (Depo-Provera) QL ( per 84 medroxyprogesterone oral (Provera) MEGACE ES megestrol oral suspension (Megace Es) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 0 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL PA BvD AUBAGIO PA; QL (28 per 28 azathioprine (Imuran) PA BvD 72 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

73 azathioprine sodium (Azathioprine Sodium) PA BvD CARIMUNE NF NANOFILTERED PA BvD INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD CIMZIA PA CIMZIA POWDER FOR RECONST PA 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 HUMIRA PA HUMIRA CROHN'S DIS START PCK PA HUMIRA PEN PA HYQVIA PA BvD ILARIS (PF) PA IMOGAM RABIES-HT (PF) KINERET PA; QL (8.76 per 28 leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD OCTAGAM PA BvD ORENCIA PA ORENCIA (WITH MALTOSE) PA PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD 73 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

74 TYSABRI PA; LA; QL (5 per 28 ZORTRESS PA BvD; QL (20 per 30 Vaccines ACTHIB (PF) (Vaccine for Haemophilus B Conjugate) ADACEL(TDAP ADOLESN/ADULT)(PF) (Vaccine for Tetanus, Diphtheria, and Pertussis [Tdap]) BCG VACCINE, LIVE (PF) PA BvD; (Vaccine for Tuberculosis) BEXSERO (PF) BOOSTRIX TDAP (Vaccine for Tetanus, Diphtheria, and Pertussis [Tdap]) CERVARIX VACCINE (PF) (Vaccine for Human Papillomavirus 6, 8) COMVAX (PF) (Vaccine for Haemophilus B Conjugate/Hepatitis B) DAPTACEL (DTAP PEDIATRIC) (PF) (Vaccine for Pertussis, Diphtheria, and Tetanus [Dtap]) ENGERIX-B (PF) PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 ENGERIX-B PEDIATRIC (PF) PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 GARDASIL (PF) (Vaccine for Human Papillomavirus 6,, 6, 8); QL (.5 per 365 GARDASIL 9 (PF) (Vaccine for Human Papillomavirus 6,, 6, 8); QL (.5 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

75 HAVRIX (PF) INTRAMUSCULAR (Vaccine for Hepatitis A) SUSPENSION HAVRIX (PF) INTRAMUSCULAR (Vaccine for Hepatitis A) SYRINGE IMOVAX RABIES VACCINE (PF) PA BvD; (Vaccine for Rabies) INFANRIX (DTAP) (PF) INTRAMUSCULAR (Vaccine for Tetanus, Diphtheria, and Pertussis [Td/Tdap]) IPOL INJECTION SUSPENSION (Vaccine for Polio) IPOL INJECTION SYRINGE IXIARO (PF) (Vaccine for Japanese Encephalitis) KINRIX (PF) INTRAMUSCULAR SUSPENSION KINRIX (PF) INTRAMUSCULAR SYRINGE MENACTRA (PF) INTRAMUSCULAR SOLUTION (Vaccine for Diphtheria/Tetanus/Pertu ssis/polio) (Vaccine for Meningococcal Diphtheria) MENHIBRIX (PF) (Vaccine for Haemophilus B/Tetanus Toxoid Conjugate) MENOMUNE - A/C/Y/W-35 (PF) (Vaccine for Meningococcal Polysaccharide) MENVEO A-C-Y-W-35-DIP (PF) (Vaccine for Meningococcal Oligosaccharide/Diphthe ria) MENVEO MENA COMPONENT (PF) (Vaccine for Meningoccal Oligopsaccharide/Dipthe ria) MENVEO MENCYW-35 COMPNT (PF) (Vaccine for Meningococcal Oligosaccharide/Diphthe ria) 75 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

76 M-M-R II (PF) (Vaccine for Measles/Mumps/Rubella ); QL (2 per 365 PEDIARIX (PF) PEDVAX HIB (PF) (Vaccine for Haemophilis B Conjugate) PENTACEL (PF) (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) PENTACEL ACTHIB COMPONENT (PF) (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) PENTACEL DTAP-IPV COMPNT (PF) (Vaccine for Diphtheria/Haemophilis B/Pertussis/Polio/Tetanu s) PROQUAD (PF) (Vaccine for Measles/Mumps/Rubella /Varicella); QL (2 per 365 QUADRACEL (PF) RABAVERT (PF) PA BvD; (Vaccine for Rabies) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 PA BvD; (Vaccine for Hepatitis B); QL (3 per 365 ROTARIX ROTATEQ VACCINE (Vaccine for Rotavirus) TENIVAC (PF) INTRAMUSCULAR (Vaccine for Tetanus and Diphtheria [Td]) TETANUS TOXOID,ADSORBED (PF) PA BvD; (Vaccine for Tetanus) 76 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

77 TETANUS,DIPHTHERIA TOX PED(PF) (Vaccine for Tetanus and Diphtheria [DT]) TETANUS-DIPHTHERIA TOXOIDS-TD (Vaccine for Tetanus and Diphtheria [Td]) TICE BCG PA BvD; (Vaccine for Tuberculosis) TRUMENBA TWINRIX (PF) (Vaccine for Hepatitis A/Hepatitis B) TYPHIM VI INTRAMUSCULAR (Vaccine for Typhoid VI) VAQTA (PF) (Vaccine for Hepatitis A) VARIVAX (PF) (Vaccine for Varicella); QL (2 per 365 YF-VAX (PF) (Vaccine for Yellow Fever) ZOSTAVAX (PF) (Vaccine for Shingles); QL ( per 365 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) LACTATED RINGERS IRRIGATION ringers irrigation (Ringers Solution) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) water for irrigation, sterile (Water For Irrigation,Sterile) 77 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

78 Metabolic Bone Disease Agents Metabolic Bone Disease Agents Drug Name Drug Tier Requirements/Limits alendronate oral solution (Alendronate Sodium) QL (300 per 28 alendronate oral tablet 0 mg, 40 mg, 5 (Fosamax) mg alendronate oral tablet 35 mg, 70 mg (Fosamax) QL (4 per 28 calcitonin (salmon) (Miacalcin) QL (3.7 per 28 calcitriol intravenous solution mcg/ml (Calcitriol) PA BvD; (PA for ESRD Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) FORTEO PA; QL (2.4 per 28 FORTICAL QL (3.7 per 28 ibandronate intravenous solution (Ibandronate Sodium) PA BvD; (PA for ESRD Only); QL (3 per 84 ibandronate oral (Boniva) QL ( per 28 MIACALCIN INJECTION PA BvD; (PA for ESRD Only) NATPARA PA; QL (2 per 28 paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL ( per 80 risedronate oral tablet 50 mg (Actonel) QL ( per 28 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 28 ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution (Zoledronic Acid/Mannitol and Water) (Reclast) QL (00 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

79 ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS Drug Name Drug Tier Requirements/Limits PA BvD PA SOLUTION 200 MG/0 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS PA ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Ethyol) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST BENLYSTA INTRAVENOUS RECON PA SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) buspirone (Buspirone HCl) CERDELGA PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Probenecid) COPAXONE SUBCUTANEOUS SYRINGE CYSTADANE droperidol injection solution (Droperidol) ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS ST finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) FUSILEV GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA PA; QL (28 per 28 GLUCAGEN HYPOKIT 79 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

80 GLUCAGON EMERGENCY KIT (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral solution 0 mg/5 ml (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 LEMTRADA PA leucovorin calcium injection recon soln (Leucovorin Calcium) 00 mg, 200 mg, 350 mg leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine (With Sugar)) PA BvD; (PA for ESRD Only) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) mesna (Mesnex) MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN morrhuate sodium (Sodium Morrhuate) OTEZLA PA; QL (60 per 30 OTEZLA STARTER PA; QL (60 per 30 OTREXUP (PF) PLEGRIDY ST probenecid (Probenecid) PROCYSBI pyridostigmine bromide oral tablet (Mestinon) RASUVO (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIGNIFOR QL (60 per 30 SIMPONI ARIA PA SIMPONI SUBCUTANEOUS SYRINGE PA 80 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

81 STELARA SUBCUTANEOUS PA SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " SYNAREL TECFIDERA ORAL PA; QL (4 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG 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 (Diamox Sequels) release acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 0. % AZOPT betaxolol ophthalmic (Betaxolol HCl) brimonidine (Alphagan P) (drops: 0.5%, 0.20%) COMBIGAN dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC DROPS 0.0 QL (2.5 per 25 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE 8 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

82 pilocarpine hcl ophthalmic drops %, 2 (Isopto Carpine) %, 4 % SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming (Timoptic-Xe) solution TRAVATAN Z QL (2.5 per 25 travoprost (benzalkonium) (Travoprost (Benzalkonium)) QL (2.5 per 25 Replacement Preparations Replacement Preparations calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD citric acid-sodium citrate (Citric Acid/Sodium Citrate) d0 % & 0.45 % sodium chloride (Dextrose 0 % and 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dextrose 0 % and 0.2 % nacl (Dextrose 0 % and 0.2 % NaCl) 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 with sodium chloride (Dextrose 5 %-0.2 % NaCl) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) HYPERLYTE CR IONOSOL-B IN D5W Only) 82 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

83 IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S klor-con 0 (Potassium Chloride) klor-con m0 (Potassium Chloride) klor-con m5 (Potassium Chloride) klor-con m20 (Potassium Chloride) magnesium chloride injection (Magnesium Chloride) magnesium sulfate in d5w intravenous piggyback gram/00 ml (Magnesium Sulfate/D5W) magnesium sulfate in water intravenous piggyback 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II phosphorus # (K-Phos Neutral) PLASMA-LYTE 48 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) potassium bicarbonate-cit ac oral tablet, (Klor-Con-Ef) effervescent 25 meq potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l (Potassium Chloride In 0.9%NaCl) potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride In D5w) 83 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

84 potassium chloride in lr-d5 intravenous (Potassium Chloride In parenteral solution Lr-D5) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid (Potassium Chloride) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended (K-Tab ER) release potassium chloride oral tablet,er (K-Tab ER) particles/crystals 0 meq potassium chloride oral tablet,er (Potassium Chloride) particles/crystals 20 meq potassium chloride-0.45 % nacl (Potassium Chloride- 0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%NaCl) potassium chloride-d5-0.3%nacl (Potassium Chloride/D5- intravenous parenteral solution 20 meq/l 0.3%NaCl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%NaCl) potassium citrate (Urocit-K) potassium citrate-citric acid oral packet (Potassium Citrate/Citric Acid) potassium phosphate dibasic (Potassium Phos,M- Basic-D-Basic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous solution (Sodium Bicarbonate) meq/ml (8.4 %) sodium bicarbonate intravenous syringe (Sodium Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride 0.45 %) sodium chloride 0.9 % injection solution (0.9 % Sodium Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) 84 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

85 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 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS QL (60 per 30 ADVAIR HFA QL (2 per 28 BREO ELLIPTA INHALATION QL (60 per 30 BLISTER WITH DEVICE MCG/DOSE DULERA QL (3 per 28 FLOVENT DISKUS INHALATION QL (60 per 30 BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION QL (20 per 30 BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (2 per 28 AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (24 per 28 AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (2.2 per 28 AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (7.4 per 25 Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) 85 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

86 Bronchodilators albuterol sulfate inhalation solution for (Albuterol Sulfate) PA BvD nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended (Vospire ER) release 2 hr ATROVENT HFA QL (25.8 per 28 COMBIVENT RESPIMAT QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (7 per 25 PROAIR RESPICLICK QL (2 per 30 SEREVENT DISKUS QL (60 per 30 SPIRIVA RESPIMAT QL (4 per 30 SPIRIVA WITH HANDIHALER QL (30 per 30 STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet (Theophylline extended release 2 hr 00 mg, 200 mg, 300 mg Anhydrous) theophylline in dextrose 5 % intravenous (Theophylline/D5W) parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL ( per 28 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD cromolyn inhalation (Cromolyn Sodium) PA BvD DALIRESP QL (30 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

87 ESBRIET PA; QL (270 per 30 KALYDECO PA; QL (60 per 30 OFEV PA PROLASTIN-C XOLAIR PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (20 per 30 chlorzoxazone (Parafon Forte DSC) PA-HRM cyclobenzaprine oral tablet 0 mg, 5 mg (Fexmid) PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents HETLIOZ PA NUVIGIL PA ROZEREM XYREM LA zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

88 zolpidem oral tablet (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 zolpidem oral tablet,ext release multiphase (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 Vasodilating Agents Vasodilating Agents ADCIRCA 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 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 Vitamins And Minerals Vitamins And Minerals pedi m.vit no.7 with fluoride oral tablet,chewable 0.5 mg (Pedi M.Vit No.7 with Fluoride) 88 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

89 prenatal vitamins oral tablet 27 mg iron- mg sodium fluoride oral tablet (Pnv with Ca,No.72/Iron/Fa) (Pedi M.Vit No.7 with Fluoride) (All Rx Prenatal Vitamins Covered) 89 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Effective: January 0, 206 Formulary ID: , Version: 7

90 INDEX 8 8-MOP A abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY DISCMELT... 39, 40 ABILIFY MAINTENA ABRAXANE acamprosate... 7 acarbose acebutolol... 5 acetaminophen-codeine... 3 acetazolamide... 8 acetazolamide sodium... 8 acetic acid... 65, 77 acetylcysteine acitretin ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 44, 59 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 74 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS ADVAIR DISKUS ADVAIR HFA AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 %.. 47 ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone... 6 ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME alendronate alfuzosin ALIMTA ALINIA allopurinol ALPHAGAN P... 8 alprazolam... 7 ALREX altacaine amantadine hcl AMBISOME amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 5 % aminocaproic acid AMINOSYN 0 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone... 5 amiodarone hcl... 5 AMITIZA amitriptyline... 3, 32 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide I- Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

91 anastrozole ANDRODERM ANDROGEL anticoag citrate phos dextrose 79 APOKYN apraclonidine APRISO APTIOM APTIVUS ARCALYST aripiprazole ASACOL HD ashlyna ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol... 5 atenolol-chlorthalidone... 5 atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 29, 64 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVONEX AVONEX (WITH ALBUMIN) azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin... 2 AZOPT... 8 AZOR aztreonam B bacitracin... 8, 65 bacitracin-polymyxin b baclofen balsalazide BANZEL BCG VACCINE, LIVE (PF). 74 BD ECLIPSE LUER-LOK BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BELEODAQ benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benztropine betamethasone acet,sod phos. 70 betamethasone dipropionate.. 6 betamethasone valerate... 6 betamethasone, augmented... 6 BETASERON betaxolol... 5, 8 bethanechol chloride BETHKIS... 8 BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A bisoprolol fumarate... 5 bisoprolol-hydrochlorothiazide... 5 bleomycin BLINCYTO BOOSTRIX TDAP BOSULIF BREO ELLIPTA BRILINTA brimonidine... 8 BRINTELLIX bromfenac bromocriptine budesonide bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 3, 7 buprenorphine-naloxone... 7 bupropion hcl... 7, 32 buspirone butalb-acetaminophen-caffeine... 3 butalbital-acetaminop-caf-cod 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff 3 butalbital-aspirin-caffeine... 3 BUTRANS... 3 BYSTOLIC... 5 C cabergoline caffeine citrated caffeine-sodium benzoate calcipotriene calcitonin (salmon) calcitriol... 59, 78 calcium acetate calcium carbonate-mag carb-fa calcium chloride calcium gluconate CALDOLOR... 5 CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 50 CARAFATE CARBAGLU carbamazepine carbidopa I-2 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

92 carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol... 5 CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 20 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 20 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone... 20, 2 CEFTRIAXONE... 2 ceftriaxone in dextrose,iso-os. 20 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil... 2 cefuroxime sodium... 2 cefuroxime-dextrose (iso-osm)... 2 celecoxib... 5 CELLCEPT INTRAVENOUS CELONTIN cephalexin... 2 CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) 74 cevimeline CHANTIX... 7 CHANTIX CONTINUING MONTH BOX... 7 CHANTIX CONTINUING MONTH PAK... 7 CHANTIX STARTING MONTH BOX... 7 chloramphenicol sod succinate... 8 chlordiazepoxide hcl... 7 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar).. 55 cholestyramine-aspartame choline,magnesium salicylate 5 ciclopirox ciclopirox-ure-camph-mentheuc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 23, 65 ciprofloxacin in 5 % dextrose 23 ciprofloxacin lactate citalopram citric acid-sodium citrate clarithromycin... 2 CLEVIPREX clindamycin hcl... 8 clindamycin in 5 % dextrose.. 8 clindamycin palmitate hcl... 9 clindamycin phosphate... 9, 37, 60 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol... 6 clobetasol propionate... 6 I-3 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

93 clobetasol-emollient... 6 clocortolone pivalate... 6 clomipramine clonazepam... 8 clonidine clonidine hcl... 49, 56 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium... 8 clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 3 codeine-butalbital-asa-caffein 3 colchicine colchicine-probenecid colestipol colistin (colistimethate na)... 9 COLY-MYCIN S COMBIGAN... 8 COMBIPATCH COMBIVENT RESPIMAT COMETRIQ COMPLERA COMVAX (PF) CONDYLOX COPAXONE cortisone... 7 COSENTYX (2 SYRINGES) 59 COSENTYX PEN COSENTYX PEN (2 PENS).. 60 CREON CRESTOR CRIXIVAN cromolyn... 64, 67, 86 CUBICIN... 9 cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide... 24, 25 CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine... 36, 37 CYRAMZA CYSTADANE CYSTARAN cysteine (l-cysteine) D d0 % & 0.45 % sodium chloride d0 %-0.9 % sodium chloride 48 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 82 dactinomycin DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM deblitane decitabine deferoxamine DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA desipramine desmopressin... 7 desog-e.estradiol/e.estradiol.. 58 desogestrel-ethinyl estradiol.. 58 desonide... 6, 62 desoximetasone dexamethasone... 7 dexamethasone sodium phosphate... 66, 7 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl 82 dextrose 0 % in water (d0w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 49 dextrose 5 %-lactated ringers. 82 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride82 diazepam... 8 diazepam intensol... 8 diclofenac potassium... 5 diclofenac sodium... 5, 66 diclofenac-misoprostol... 5 dicloxacillin dicyclomine didanosine DIFICID... 2 diflunisal... 5 digitek digoxin DIGOXIN I-4 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

94 dihydroergotamine DILANTIN diltiazem hcl dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine... 67, 68 disopyramide phosphate... 5 disulfiram... 7 divalproex... 29, 30 dobutamine dobutamine in d5w donepezil... 3 dopamine dopamine in 5 % dextrose dorzolamide... 8 dorzolamide-timolol... 8 doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate doxycycline monohydrate 23, 24 dronabinol droperidol drospirenone-ethinyl estradiol 58 DROXIA DUAVEE DULERA duloxetine DUREZOL DYRENIUM E econazole EDURANT EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ELMIRON EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 50 ENBREL ENBREL SURECLICK ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 44, 45 entacapone entecavir ephedrine sulfate epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM ergoloid ERGOMAR ERIVEDGE ERYTHROCIN... 2 erythromycin... 2, 65 erythromycin base... 2 ERYTHROMYCIN BASE... 2 erythromycin base-ethanol erythromycin ethylsuccinate.. 2 erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol... 5 esomeprazole sodium ESTRACE estradiol estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet estropipate ethambutol ethamolin ethinyl estradiol/drospirenone 58 ethosuximide ethynodiol d-ethinyl estradiol 58 etodolac... 6 ETOPOPHOS etoposide EVOTAZ exemestane EXJADE EXTAVIA F FABRAZYME famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os). 67 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen... 6 fentanyl... 3 I-5 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

95 fentanyl citrate... 3 FERRIPROX FETZIMA finasteride FIRAZYR FLEBOGAMMA DIF flecainide... 5 FLECTOR... 6 FLEXBUMIN 25 % FLEXBUMIN 5 % FLOVENT DISKUS FLOVENT HFA floxuridine fluconazole fluconazole in dextrose(iso-o) 36 fluconazole in nacl (iso-osm). 36 flucytosine fludrocortisone... 7 flumazenil flunisolide fluocinonide fluocinonide-emollient base fluorometholone FLUOROPLEX fluorouracil... 25, 60 fluoxetine fluoxymesterone fluphenazine decanoate fluphenazine hcl flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone... 62, 66 fluvoxamine fomepizole fondaparinux FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 0 % furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine... 3 GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD GAZYVA gemfibrozil GENOTROPIN... 7 GENOTROPIN MINIQUICK 7 gentamicin... 8, 60, 65 gentamicin in nacl (iso-osm). 8 gentamicin sulfate gentamicin sulfate (ped) (pf). 8 gentamicin sulfate (pf)... 8 GEODON gildess 24 fe GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin glycopyrrolate glydo... 6 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guanfacine... 49, 57 guanidine H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heparin (porcine) heparin (porcine) in 5 % dex. 45, 46 heparin (porcine) in nacl (pf). 45 heparin sodium,porcine-pf heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN homatropine hbr HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HUMULIN R U hydralazine hydrochlorothiazide hydrocodone-acetaminophen. 3 hydrocodone-ibuprofen... 3 hydrocortisone... 62, 7 I-6 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

96 hydrocortisone acet-aloe vera. 62 hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate. 7 hydrocortisone valerate hydromorphone... 4 hydromorphone (pf)... 3, 4 hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYQVIA I ibandronate IBRANCE ibuprofen... 6 ICLUSIG ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF). 73 IMOVAX RABIES VACCINE (PF) INCRELEX... 7 indapamide indomethacin... 6 indomethacin sodium... 6 INFANRIX (DTAP) (PF) INLYTA INSULIN PEN NEEDLE INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A INVANZ INVEGA INVEGA SUSTENNA... 40, 4 INVEGA TRINZA... 4 INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO junel fe JUXTAPID K KABIVEN KALETRA KALYDECO KEDBUMIN ketoconazole ketoprofen... 6 ketorolac... 6, 66 KEYTRUDA KINERET KINRIX (PF) klor-con klor-con m klor-con m klor-con m KORLYM KRYSTEXXA KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad.. 58 labetalol... 5 LACRISERT LACTATED RINGERS lactulose LAMICTAL lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost... 8 LATUDA... 4 LAZANDA... 4 leflunomide I-7 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

97 LEMTRADA LENVIMA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol... 8 levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 23, 65 levofloxacin in d5w levonorgestrel levonorgestrel-ethin estradiol. 58 levonorgestrel-ethinyl estrad.. 58 levothyroxine LEXIVA lidocaine... 7 lidocaine (pf)... 6, 5 lidocaine hcl... 7 lidocaine in 5 % dextrose (pf) 5 lidocaine-prilocaine... 7 linezolid... 9 LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III lisinopril lisinopril-hydrochlorothiazide 50 lithium carbonate lithium citrate l-norgest-eth estr/ethin estra lomustine loperamide lorazepam oral solution... 8 losartan losartan-hydrochlorothiazide.. 50 LOTEMAX LOTRONEX lovastatin loxapine succinate... 4 LUMIGAN... 8 LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED... 7 LUPRON DEPOT-PED (3 MONTH)... 7 LYNPARZA LYRICA LYSODREN M magnesium chloride magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline MARPLAN MATULANE matzim la meclizine medroxyprogesterone mefenamic acid... 6 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM)... 2 MEGACE ES megestrol... 27, 72 MEKINIST meloxicam... 6 MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y-W-35-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-35 COMPNT (PF) mercaptopurine meropenem mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxalone metformin methadone... 4 methadone hcl... 4 methazolamide... 8 methenamine hippurate... 9 methenamine mandelate... 9 methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate methylprednisolone... 7 methylprednisolone acetate... 7 methylprednisolone sodium succ... 7 metipranolol... 8 metoclopramide hcl metolazone metoprolol succinate... 5 metoprolol ta-hydrochlorothiaz... 5 metoprolol tartrate... 5, 52 metronidazole... 9, 37, 60 metronidazole in nacl (iso-os) 9 mexiletine... 5 I-8 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

98 MIACALCIN miconazole nitrate midodrine milrinone milrinone in 5 % dextrose minitran minocycline minoxidil MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone montelukast morphine... 4 MORPHINE... 4 morphine concentrate... 4 morrhuate sodium MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL MULTAQ... 5 mupirocin mupirocin calcium mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ N nabumetone... 6 nadolol nafcillin NAGLAZYME naloxone... 7 naltrexone... 7 naltrexone hcl... 7 NAMENDA XR... 3 NAMZARIC... 3 naphazoline naproxen... 6 naproxen sodium... 6 naratriptan NATACYN nateglinide NATPARA NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin... 8 neomycin-bacitracin-poly-hc. 65 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu... 6 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin NEPHRAMINE 5.4 % NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine... 42, 43 NEXAVAR niacin nicardipine NICOTROL... 7 nifedipine NILANDRON NITRO-BID nitrofurantoin macrocrystal... 9 nitrofurantoin monohyd/m-cryst... 9 nitroglycerin nitroglycerin in 5 % dextrose. 56 NITROSTAT NORDITROPIN FLEXPRO.. 7 NORDITROPIN NORDIFLEX... 7 norelgestromin/ethin.estradiol 58 norepinephrine bitartrate norethindrone norethindrone (contraceptive) 58 norethindrone acetate norethindrone ac-eth estradiol 58 norethindrone-e.estradiol-iron 59 norethindrone-ethinyl estrad.. 59 norethindrone-mestranol norgestimate-ethinyl estradiol 59 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCYNTA... 4 NUCYNTA ER... 4 NUEDEXTA NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING NUVIGIL I-9 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

99 nystatin NYSTATIN (BULK) nystatin-triamcinolone O OCTAGAM octreotide acetate OFEV ofloxacin... 23, 66 olanzapine... 4 olanzapine-fluoxetine OLYSIO omega-3 acid ethyl esters omeprazole ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI OPDIVO OPSUMIT ORAP... 4 ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 22 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 5 oxycodone hcl-acetaminophen... 4 oxycodone hcl-aspirin... 4 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 OXYCONTIN... 5 oxymorphone... 5 P PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl... 32, 33 PASER PAXIL pedi m.vit no.7 with fluoride 88 PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl 68 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline PERIKABIVEN perindopril erbumine permethrin perphenazine... 4 perphenazine-amitriptyline phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 50, 65 phenytoin phenytoin sodium... 3 phenytoin sodium extended... 3 PHOSLYRA PHOSPHOLINE IODIDE... 8 phosphorus # PICATO pilocarpine hcl... 59, 82 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam... 6 PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox podophyllum resin polyethylene glycol polymyxin b sulfate... 9 polymyxin b sulf-trimethoprim POMALYST potassium acetate potassium bicarb and chloride 83 potassium bicarb-citric acid potassium bicarbonate-cit ac.. 83 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex83 potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl I-0 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

100 potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid potassium hydroxide potassium phosphate dibasic.. 84 POTIGA... 3 PRADAXA pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 67, 7 prednisone... 7 PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone... 3 PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide... 5 PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized capsules PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 37, 38 promethazine hcl propafenone... 5 propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod. 65 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protamine protriptyline PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QUADRACEL (PF) quetiapine... 4 QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 5 quinidine gluconate... 5 quinidine sulfate... 5 quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril... 5 RANEXA ranitidine hcl RAPAMUNE RASUVO (PF) RAVICTI REBIF (WITH ALBUMIN).. 80 REBIF REBIDOSE REBIF TITRATION PACK.. 80 RECOMBIVAX HB (PF) RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR RESTASIS RETROVIR REVLIMID REYATAZ ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringers... 77, 84 risedronate RISPERDAL CONSTA... 4 risperidone... 4, 42 RITUXAN rivastigmine tartrate... 3 rizatriptan ropinirole ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL... 3 I- Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

101 SAIZEN SAIZEN CLICK.EASY salsalate... 6 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA selegiline hcl selenium sulfide... 6 SELZENTRY SENSIPAR SEREVENT DISKUS SEROSTIM sertraline SIGNIFOR sildenafil oral tablet 20 mg SILENOR silver nitrate... 6 silver nitrate applicators... 6 silver sulfadiazine... 6 SIMBRINZA SIMPONI SIMPONI ARIA simvastatin sirolimus SIRTURO sodium acetate sodium bicarbonate sodium chloride... 77, 85 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... 59, 89 sodium lactate sodium phosphate sodium polystyrene sulfonate. 68 sodium thiosulfate sod-pot-k cit-sod cit-cit acid.. 85 SOLTAMOX SOLU-CORTEF (PF)... 7 SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL stavudine STELARA... 8 STERILE PADS... 8 STIVARGA STRATTERA streptomycin... 8 STRIBILD STRIVERDI RESPIMAT sucralfate sulfacetamide sodium sulfacetamide sodium (acne). 6 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac... 6 sumatriptan nasal spray sumatriptan succinate SUPPRELIN LA SUPRAX... 2 SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL... 8 SYNERCID... 9 SYNRIBO SYPRINE T TABLOID tacrolimus... 63, 73 TAFINLAR TAMIFLU... 43, 44 tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe TASIGNA TAZORAC taztia xt TECFIDERA... 8 TEFLARO... 2 telmisartan telmisartan-hydrochlorothiazid TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) I-2 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

102 TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracaine hcl (pf) tetracycline THALOMID... 8 theophylline theophylline anhydrous theophylline in dextrose 5 %.. 86 thioridazine thiothixene tiagabine... 3 TICE BCG TIKOSYN... 5 timolol maleate... 52, 82 TIVICAY tizanidine TOBI PODHALER... 8 TOBRADEX ST tobramycin tobramycin in % nacl... 8 tobramycin in 0.9 % nacl... 8 tobramycin sulfate... 8 tolazamide tolbutamide tolmetin... 6 tolterodine topiramate... 3 toposar intravenous torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril... 5 tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide.. 59, 63, 7 triamterene-hydrochlorothiazid TRIBENZOR trifluoperazine trifluridine trihexyphenidyl trimethoprim... 9 TRIUMEQ TROKENDI XR... 3 TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX (PF) TYBOST... 8 TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U ULORIC... 8 ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium... 3 valproic acid... 3 valproic acid (as sodium salt) 3 valsartan valsartan-hydrochlorothiazide 50 VALSTAR vancomycin... 9, 20 vancomycin in d5w... 9 VAQTA (PF) VARIVAX (PF) VASCEPA VELCADE venlafaxine verapamil VERSACLOZ VGO VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMIZIM VIMPAT... 3 vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VITEKTA VOLTAREN... 6 voriconazole VOTRIENT VPRIV I-3 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

103 W warfarin water for irrigation, sterile X XALKORI XARELTO XELJANZ... 8 XENAZINE XIFAXAN XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZAVESCA ZELBORAF ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMETA zonisamide... 3 ZORTRESS ZOSTAVAX (PF) ZOVIRAX ZUBSOLV... 7 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX I-4 Denver Health Medical Plan, Inc. 206 Part D Formulary - DSB Formulary ID: , Version: 7 Effective: January 0, 206

104 Este formulario se actualizó el 08/2/205. Para obtener información más reciente o si tiene preguntas, llame a nuestro departamento de Servicios al miembro de Denver Health Medical Plan, Inc. al Los usuarios de TTY deben llamar al 7. Nuestro horario de atención es de 8 a. m. a -8 p. m., los siete días de la semana, o puede visitar