2016 FORMULARY OF COVERED PRESCRIPTION DRUGS

Transcription

1 A Medicare Advantage Plan 206 FORMULARY OF COVERED PRESCRIPTION DRUGS Approved Formulary Submission ID Number: , Version 7 H5549_206 Formulary_085_DSB_rv_Accepted Preferred (HMO SNP) VNSNY CHOICE Total (HMO SNP) Maximum (HMO SNP) Classic (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit

2 and VNSNY CHOICE Total 206 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Includes members enrolled in Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Approved Formulary Submission ID Number: , Version: 7 This formulary was updated on August 29, 205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means VNSNY CHOICE Medicare. When it refers to plan or our plan, it means our VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). This document includes a list of the drugs (formulary) for our plan, which is current as of August 29, 205. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January, 207, and from time to time during the year. is an HMO plan with a Medicare contract. Enrollment in depends on contract renewal. H5549_206 Formulary_085_DSB Last updated: 08/29/205

3 What is the Formulary? A formulary is a list of covered drugs selected by in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. VNSNY CHOICE Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 206 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 29, 205. To get updated information about the drugs covered by, please contact us. Our contact information appears on the front cover and back cover pages. If we update our printed formulary with non-maintenance formulary changes, we will send you a notice that includes this information. 2

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 49. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 49. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on I-. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from before you fill your prescriptions. If you don t get approval, may not cover the drug. Quantity Limits: For certain drugs, limits the amount of the drug that will cover. For example, provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, requires you to first try certain drugs to treat 3

5 cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, may not cover Drug B unless you try Drug A first. If Drug A does not work for you, will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 49. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You can ask to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the s formulary? on page 5 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. pays for certain OTC drugs. COVERED OVER-THE-COUNTER (OTC) DRUGS DRUG Generic Name cetirizine hydrochloride cetirizine hydrochloride/ pseudoephedrine hydrochloride (Reference Brand Name) (Zyrtec) (Zyrtec-D) Dosage Form Chewable Tablets, Solution, Tablets 2 Hour Tablets loratadine (Claritin) Solution, Tablets loratadine/ 2 Hour Tablets (Claritin-D) pseudoephedrine sulfate 24 Hour Tablets ketotifen fumarate (Zaditor) Drops will provide these OTC drugs at no cost to you. The cost to of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) 4

6 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by. You can ask to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Formulary? You can ask to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower costsharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. 5

7 When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. A transition fill is provided to current members that are in need of a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change. 6

8 For more information For more detailed information about your prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit This information is available for free in other languages. Please call Member Services at for additional information. (TTY users should call 7 Toll-free) Monday through Friday from 8:00 AM to 8:00 PM. Member Services also has free language interpreter services available for non-english speakers. is an HMO with a Medicare contract. Enrollment in depends on contract renewal. 7

9 s Formulary The formulary that begins on page 49 provides coverage information about the drugs covered by. If you have trouble finding your drug in the list, turn to the Index that begins on page I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., naproxen). The information in the Requirements/Limits column tells you if VNSNY CHOICE Medicare has any special requirements for coverage of your drug. The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. PA BvD Prior Authorization Restriction for Part B vs Part D Determination This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug. 8

10 ABBREVIATION DESCRIPTION EXPLANATION PA-HRM PA NSO QL ST Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug If you are a new member, you (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. limits the amount of this drug that is covered per prescription, or within a specific time frame. Before will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. 9

11 The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , Monday through Friday from 8:00 am to 8:00 pm. TTY/TDD users should call 7. You may be able to receive greater than a -month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. 0

12 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 2h capsule, 2 hour extended release cap er 24h capsule, 24 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 24h capsule, 24 hour sustained action cap.sr 2h capsule, 2 hour sustained release cap.sr 24h capsule, 24 hour sustained release cap24h pct capsule, 24 hour controlled-onset pellets cap24h pel capsule, 24 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 2hr capsule, 2 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70%

13 ABBREVIATION DESCRIPTION cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution jel jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleanser and cream kt crm le kit: cream, lotion emollient 2

14 ABBREVIATION 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 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 DESCRIPTION kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted 3

15 ABBREVIATION 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 tablet sol tb er dspk tb mp dspk DESCRIPTION solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 2 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 2 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack 4

16 ABBREVIATION tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPTION tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 2 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring 5

17 y VNSNY CHOICE Total Formulario de Medicamentos 20 (Listado de Medicamentos Cubiertos) Incluye miembros inscritos en Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Aprobado Formulario Número de la petición: , Versión Este formulario de medicamentos fue actualizado 08/29/205. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al o, para aquellos que utilizan TTY, al 7, de lunes a viernes, de 8:00 AM a 8:00 PM o visite Aviso para miembros existentes: Este formulario de medicamentos ha cambiado desde el año pasado. Por favor, revise este documento para asegurar que aún contiene los medicamentos que usted toma. Cuando esta relación de medicamentos (formulario de medicamentos) hace referencia a nos, nosotros, o nuestro, se refiere a. Cuando hace referencia al plan o nuestro plan, se refiere a nuestro VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). Este documento incluye una relación de los medicamentos (formulario de medicamentos) para nuestro plan, que se encuentra actualizado a partir del 08/29/205. Para recibir un formulario de medicamentos actualizado, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Por lo general, debe utilizar las farmacias dentro de la red para poder utilizar su beneficio de medicamentos con receta. Los beneficios, el formulario de medicamentos, la red de farmacias, las primas y/o copagos/coaseguro pueden cambiar el de enero de 207. es un plan de HMO con contrato de Medicare. La inscripción en depende de la renovación del contrato. 6

18 Qué es el formulario de medicamentos de VNSNY CHOICE Medicare? Un formulario de medicamentos es una relación de medicamentos cubiertos seleccionados por en consulta con un equipo de proveedores de servicios médicos, que representan los tratamientos con receta que se piensan ser una parte necesaria de un programa de tratamiento de calidad. VNSNY CHOICE Medicare, por lo general, cubrirá los medicamentos que aparecen en nuestro formulario de medicamentos siempre que dicho medicamento es médicamente necesario, la receta se llena en una farmacia de la red de, y se siguen otros reglamentos del plan. Para más información sobre cómo llenar sus recetas, sírvase revisar su Evidencia de Cobertura. Puede cambiar el formulario de medicamentos (relación de medicamentos)? Generalmente, si está tomando un medicamento que se encuentra en nuestro formulario de medicamentos de 206 que fue cubierto al comienzo del año, no descontinuaremos ni reduciremos la cobertura de ese medicamento durante el año de cobertura de 206 con la excepción de que se haga disponible un medicamento genérico nuevo y más económico o si se difunde nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario de medicamentos, tal como eliminar un medicamento del mismo, no afectará a los miembros que están tomando el medicamento actualmente. Permanecerá disponible al mismo costo compartido para aquellos miembros que lo toman durante lo que resta del año de cobertura. Pensamos que es importante que usted tenga acceso continuado a los medicamentos del formulario de medicamentos que tenía disponible cuando escogió nuestro plan, para lo que resta del año de cobertura, con excepción de los casos en los cuales puede ahorrar dinero adicional o podemos asegurar su seguridad. Si eliminamos medicamentos de nuestro formulario de medicamentos, o añadimos restricciones de autorización previa, límites de cantidad y/o terapias escalonadas para un medicamento o si cambiamos un medicamento a un nivel de costo compartido más alto, debemos notificar a los miembros afectados de dicho cambio un mínimo de 60 días antes de que tome vigencia, o cuando el miembro pide una reposición del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días de dicho medicamento. Si el Organismo para el Control de Alimentos y Fármacos (FDA, por sus siglas en inglés) considera que un medicamento que se encuentra en nuestro formulario de medicamentos no es seguro o el fabricante del medicamento lo retira del mercado, nosotros eliminaremos el mismo de nuestro formulario de medicamentos de inmediato y le daremos aviso a aquellos miembros que toman ese medicamento. El formulario de medicamentos adjunto se encuentra actualizado a partir 08/29/205. Para recibir información actualizada sobre los 7

19 medicamentos cubiertos por, sírvase comunicarse con nosotros. Nuestra información de contacto aparece en la portada y contraportada. Si actualizamos nuestro formulario de medicamentos impreso con cambios que no son de mantenimiento, le enviaremos una notificación que contiene esta información. Cómo utilizo el formulario de medicamentos? Existen dos formas de encontrar su medicamento dentro del formulario de medicamentos: Condición médica El formulario de medicamentos comienza en la página 49. Los medicamentos en este formulario de medicamentos están agrupados en categorías de acuerdo a los tipos de condiciones médicas para los cuales son utilizados. Por ejemplo, los medicamentos utilizados para tratar una condición cardíaca se encuentran bajo la categoría, Cardiovascular Agents. Si sabe para qué se utiliza el medicamento, busque el nombre de la categoría en la relación que comienza en la página 49. Luego, mire bajo el nombre de categoría para buscar ese medicamento. Relación alfabética Si no está seguro en qué categoría buscar, debe buscar el medicamento en el Índice que comienza en la página I-. El Índice ofrece una relación alfabética de todos los medicamentos incluidos en este documento. Los medicamentos de marca, al igual que los medicamentos genéricos, se encuentran en el Índice. Busque en el Índice y encuentre el medicamento. Al lado del medicamento, verá el número de la página en la cual puede encontrar la información de cobertura. Vaya a la página mencionada en el Índice y encuentre el nombre del medicamento en la primera columna de la relación. Qué son los medicamentos genéricos? cubre los medicamentos de marca al igual que los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA como teniendo el mismo ingrediente activo que el de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca. 8

20 Existe alguna restricción sobre mi cobertura? Algunos medicamentos cubiertos pueden tener requerimientos o limitaciones adicionales sobre su cobertura. Estos requerimientos y limitaciones pueden incluir: Autorización previa: exige que usted o su médico reciba autorización previa para ciertos medicamentos. Esto implica que deberá recibir aprobación de antes de llenar sus recetas. Si no consigue aprobación, es posible que VNSNY CHOICE Medicare no cubra el medicamento. Limitaciones de cantidad: Para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad del medicamento que cubrirá. Por ejemplo, suministra 60 cápsulas por cada receta para el medicamento Celebrex. Esto puede ser además de un suministro estándar de un mes o tres meses. Tratamiento escalonado: En algunos casos, exige que pruebe ciertos medicamentos primero, para tratar su condición médica, antes que cubriremos otro medicamento para tratar esa condición. Por ejemplo, si Medicamento A y Medicamento B pueden tratar su condición médica, es posible que no cubra el Medicamento B al menos que primero pruebe con el Medicamento A. Si no le funciona el Medicamento A, entonces cubrirá el medicamento B. Usted puede determinar si su medicamento tiene algún requerimiento adicional o limitación con buscar en el formulario de medicamentos que comienza en la página 49. También puede recibir más información sobre las restricciones que aplican a ciertos medicamentos cubiertos con visitar nuestro sitio Web. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Puede pedirle a para hacer una excepción a estas restricciones o limitaciones o para una relación de otros medicamentos similares que pueden tratar su condición de salud. Véase la sección, Cómo pido una excepción al formulario de medicamentos de? que se encuentra en la página 20 para obtener más información sobre cómo solicitar una excepción. 9

21 MEDICAMENTOS DE VENTA LIBRE (OTC) CON COBERTURA MEDICAMENTOS Nombre genérico (Nombre de marca de referencia) Presentación hidrocloruro de Tabletas masticables, (Zyrtec) cetirizina solución, tabletas hidrocloruro de cetirizina/ hidrocloruro de (Zyrtec-D) Tabletas de 2 horas pseudoefedrina loratadina (Claritin) Solución, tabletas loratadina/ Tabletas de 2 horas sulfato de (Claritin-D) Tabletas de 24 horas pseudoefedrina fumarato de cetotifeno (Zaditor) Gotas Y Si mi medicamento no se encuentra en el formulario de medicamentos? Si su medicamento no se incluye en este formulario de medicamentos (relación de medicamentos cubiertos), debe primero comunicarse con Servicios para Miembros para consultar si su medicamento se encuentra cubierto. Si descubre que no cubre su medicamento, usted tiene dos opciones: Puede pedirle a Servicios para Miembros para una relación de medicamentos similares que están cubiertos por. Cuando recibe la relación, muéstrela a su médico y pídale que recete un medicamento similar que sea cubierto por. Puede pedirle a para que haga una excepción y cubra su medicamento. Véase a continuación para obtener información sobre cómo solicitar una excepción. 20

22 Cómo pido una excepción al Vademécum de VNSNY CHOICE Medicare? Puede pedirle a de hacer una excepción a los reglamentos de cobertura. Existen varios tipos de excepciones que nos puede pedir. Nos puede pedir cubrir un medicamento, aunque no se encuentra en nuestro formulario de medicamentos. Si es aprobado, este medicamento será cubierto en un nivel de costo compartido predeterminado, y no podrá pedirnos ofrecer el medicamento a un nivel de costo compartido inferior. Nos puede pedir cubrir un medicamento que se encuentra en el formulario de medicamentos a un nivel de costo compartido inferior si el medicamento no se encuentra en el nivel especializado. Si es aprobado, esto reduciría el monto que debe pagar para su medicamento. Nos puede pedir eliminar las restricciones o limitaciones de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, nos puede pedir eliminar ese límite y cubrir una cantidad mayor. Por lo general, solamente aprobará su solicitud para una excepción si los medicamentos alternativos incluidos en el formulario de medicamentos del plan, el medicamento de costo compartido inferior o las restricciones de utilización adicionales no serían tan eficaces en tratar su condición y/o le causaría tener efectos médicos adversos. Debe comunicarse con nosotros para pedirnos una decisión de cobertura inicial para una excepción de restricción al formulario de medicamentos, escalonamiento o utilización. Cuando solicita una excepción de restricción al formulario de medicamentos, escalonamiento o utilización, debe presentar una declaración del prescriptor o médico apoyando su petición. Por lo general, debemos tomar nuestra decisión dentro de 72 horas de recibir la declaración de apoyo de su prescriptor. Puede pedir una excepción acelerada (rápida) si usted o su médico piensa que su salud puede ser seriamente perjudicada si espera hasta 72 horas para recibir una decisión. Si se le otorga su petición para acelerar, le debemos dar una decisión no menos de 24 horas después de recibir la declaración de apoyo de su médico u otro prescriptor. 2

23 Qué debo hacer antes de hablar con mi médico sobre cambiar mis medicamentos o pedir una excepción? Como un miembro nuevo o continuado de nuestro plan, es posible que usted está tomando medicamentos que no se encuentran en nuestro formulario de medicamentos. También es posible que esté tomando un medicamento que se encuentra en nuestro formulario de medicamentos pero su habilidad de conseguirlo es limitada. Por ejemplo, usted puede necesitar una autorización previa de nosotros antes de poder llenar su receta. Debe consultar con su médico para determinar si debe cambiar a un medicamento apropiado que cubrimos o pedir una excepción al formulario de medicamentos para poder cubrirle el medicamento que toma. Mientras consulta con su médico para determinar el curso apropiado para usted, es posible que cubriremos su medicamentos en ciertos casos durante los primeros 90 días que usted es un miembro de nuestro plan. Por cada uno de los medicamentos que no se encuentran en nuestro formulario de medicamentos o si tiene habilidad limitada de conseguir sus medicamentos, cubriremos un suministro provisional de 30 días (al menos que tiene una receta escrita para menos días) cuando vaya a una farmacia dentro de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aunque ha sido un miembro del plan menos de 90 días. Si es residente de una centro de atención a largo plazo, le permitiremos reposicionar su receta hasta que le hayamos proveído con un suministro de 9 días, consistente con el incremento de dispensación (al menos que tiene una receta escrita por menos días). Cubriremos más de una reposición de estos medicamentos para los primeros 90 días si es un miembro de nuestro plan. Si necesita de un medicamento que no se encuentra en nuestro formulario de medicamentos o si tiene habilidad limitada en conseguir sus medicamentos, pero se encuentran pasados los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 3 días para ese medicamento (al menos que tiene una receta para menos días) mientras solicita una excepción al formulario de medicamentos. Un resurtido de transición sera proporcionado, por una vez, a los miembros actuales que están en necesidad de un resurtido de emergencia o que han sido recetado un medicamento fuera del formulario debido a un cambio de nivel de atención. 22

24 Para más información Para obtener más información sobre su cobertura de medicamentos con receta de, sírvase revisar la Evidencia de Cobertura y demás materiales del plan. Si tiene alguna duda sobre, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Si tiene alguna duda en general sobre la cobertura de medicamentos con receta de Medicare sírvase llamar al -800-MEDICARE ( ) las 24 horas del día/7 días a la semana. Los usuarios de TTY deben llamar al O, visite Esta información está disponible gratis en otros idiomas. Comuníquese con nuestros Servicios al miembro al número para obtener información adicional. (Los usuarios de TTY deben llamar al 7.) Horario de atención de lunes a viernes de 8:00 a.m. a 8:00 p.m. Los Servicios al miembro también tienen disponibles servicios gratis de intérpretes de idiomas para personas que no hablan ingles es un plan de HMO con contrato de Medicare. La inscripción en depende de la renovación del contrato. 23

25 Formulario de Medicamentos de El formulario de medicamentos que comienza en la página 49 ofrece información de cobertura sobre los medicamentos cubiertos por. Si tiene dificultad en encontrar su medicamento en esta relación, sírvase consultar el Índice que comienza en la página I-. En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca aparecen con letras mayúsculas (por ejemplo, CELEBREX) y los medicamentos genéricos aparecen con letras minúsculas y en bastardilla (por ejemplo, naproxen). La información que se encuentra en la columna de Requerimientos/Limitaciones le informa si tiene algún requerimiento especial para la cobertura de su medicamento. 24

26 Las siguientes abreviaturas de Gestión de Uso se pueden encontrar en el cuerpo de este documento ABREVIATURAS DE LOS AVISOS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones en la Gestión de Uso PA PA BvD PA-HRM Restricciones de la Autorización previa Restricciones de Autorización previa para determinación de la Parte B frente a la Parte D Restricciones de autorización previa para Medicamentos de alto riesgo 25 Se requiere que usted (o su médico) obtenga autorización previa de para poder surtir este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. Es posible que este medicamento sea elegible para pago según la Parte B o la Parte D de Medicare. Usted (o su médico) deben obtener autorización previa de para determinar si este medicamento está cubierto por la Parte D de Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que no cubra este medicamento. CMS considera que este medicamento es potencialmente dañino y, por consiguiente, se clasifica como medicamento de alto riesgo para los beneficiarios de Medicare de 65 años de edad o mayores. Se requiere que los afiliados de 65 años de edad o mayores obtengan autorización previa de antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento.

27 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA NSO QL ST Restricciones de autorización previa para nuevos afiliados únicamente Restricciones para los límites de cantidad Restricción en la terapia de pasos Si es un afiliado nuevo, se requiere que usted (o su médico) obtenga autorización previa de VNSNY CHOICE Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. limita la cantidad de este medicamentos que es cubierto por receta médica, o dentro de un marco de tiempo específico. Antes de que VNSNY CHOICE Medicare le proporcione cobertura para este medicamento, primero debe intentar usar otro medicamento o medicamentos para tratar su condición médica. Este medicamente se cubrirá únicamente si los otros medicamentos no funcionan para usted. 26

28 Las siguientes abreviaturas de aviso de cobertura adicional se pueden encontrar en el cuerpo de este documento OTROS REQUERIMIENTOS ESPECIALES PARA LA COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN LA NM Medicamentos de acceso limitado Medicamentos que no se pueden enviar por correo Estos medicamentos con receta médica podrían estar disponibles únicamente en ciertas farmacias. Para obtener más información, consulte con el Directorio de proveedores y farmacias o llame a Servicios al afiliado al , de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al 7. Es posible que pueda recibir por correo más de un mes de suministros para la mayoría de los medicamentos en su formulario, con un costo compartido reducido. Los medicamentos que no están disponibles mediante el beneficio de pedido por correo, se identifican con las iniciales «NM» en la columna de Requerimientos/Límites de su formulario. 27

29 ABREVIATURAS DE POTENCIA Y PRESENTACIÓN ABREVIATURA adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 2hr cpmp 24hr DESCRIPCIÓN parche adhesivo aerosol, activado por la respiración aerosol, polvo aerosol en polvo, activado por la respiración recarga de aerosol aerosol con adaptador ampolleta inyecciones de bolsa a granel cápsula, liberación retardada multifásica cápsula, paquete de dosis cápsula, 2 horas de acción prolongada cápsula, 24 horas de acción prolongada cápsula, liberación prolongada degradable cápsula, gránulos de liberación prolongada cápsula, multifásica cápsula, 24 horas de acción sostenida cápsula, 2 horas de liberación sostenida cápsula, 24 horas de liberación sostenida cápsula, gránulos de 24 horas de acción local controlada cápsula, gránulos de 24 horas de liberación sostenida cápsula, dispersable cápsula de gránulos de liberación sostenida cápsula con dispositivo cápsula de liberación prolongada cápsula de liberación extendida cápsula de acción sostenida combinación: cápsula, almohadilla combinación: ungüento, espuma combinación: ungüento, loción combinación: tableta, almohadilla paquete combinado cápsula, 2 horas multifásica cápsula, 24 horas multifásica 28

30 ABREVIATURA DESCRIPCIÓN cpmp cápsula, multifásicas, 30%-70% cpmp cápsula, multifásicas, 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 di(2-etilhexil)ftalato bolsa libre dis needle aguja desechable disk w/dev disco con dispositivo de inhalación disp syrin jeringa desechable drops susp gotas, suspensión drps hpvis gotas, hiperviscosas emul adhes emulsión adhesiva emul packt emulsión en paquete emulsn(g) emulsión (gramos) foam/appl. espuma con aplicador froz.piggy solución premezclada congelada g gramo gel/pf app gel con aplicador llenado previamente gel (gm) gel (gramos) gel (ml) gel (mililitros) gel md pmp gel en bomba de dosis medida gel w/appl gel con aplicador gel w/pump gel con bomba gran pack paquete de gránulos hfa aer ad adaptador de aerosoles hfa infus. btl frasco de infusión insuln pen pluma de insulina ip soln solución intraperitoneal irrig soln solución de irrigación iv soln. solución intravenosa jel gel jelly/app gel con aplicador jel/pf app gel con aplicador llenado previamente kit cl&crm kit: limpiador y crema 29

31 ABREVIATURA 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 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 DESCRIPCIÓN kit: crema, loción emoliente kit: loción, crema emoliente kit: ungüento, loción emoliente loción, liberación prolongada controlador de comprimidos parche de calor medicado tableta bucal mucoadhesiva microgramo almohadilla medicada hisopo medicado cinta adhesiva medicada miligramo mililitro sistema mucoadhesivo, 2 horas de liberación prolongada aguja para inyección suspensión en película para uñas ungüento (gramos) concentrado oral suspensión oral pasta (gramos) parche, 24 horas transdérmico parche, 72 horas transdérmico parche, transdérmico quincenal parche, transdérmico semanal jeringa de analgésico controlado por el paciente vial de analgésico controlado por el paciente gránulos (cada uno) kit de pluma de inyección pluma de inyección frasco de solución premezclada bolsa de plástico paquete de polvo solución con bomba multidosificadora solución con aplicador solución con aplicador llenado previamente 30

32 ABREVIATURA 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 tablet sol DESCRIPCIÓN solución formadora de gel solución, reconstituida solución (gramos) atomizador, suspensión atomizador con bomba barra (cada una) supositorio, rectal supositorio, vaginal supositorio suspensión, 24 horas de liberación prolongada suspensión, liberación prolongada reconstituida suspensión, microcápsula reconstituida suspensión, paquete de liberación prolongada suspensión, reconstituida kit de jeringas tableta, masticable tableta, 2 horas liberación prolongada tableta, 24 horas liberación prolongada tableta, partículas de liberación prolongada tableta, hora liberación prolongada tableta, dispersable tableta, paquete de dosis tableta, 24 horas liberación prolongada tableta, multifásica tableta, partículas tableta, liberación prolongada de desintegración rápida tableta, desintegración rápida tableta, sublingual tableta, 2 horas liberación sostenida tableta, 24 horas liberación sostenida tableta, 24 horas liberación prolongada gradual tableta, liberación prolongada tableta, liberación prolongada tableta, efervescente tableta, acción sostenida tableta, soluble 3

33 ABREVIATURA tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring DESCRIPCIÓN tableta, paquete de dosis de liberación prolongada tableta, paquete de dosis multifásica tableta, paquete de dosis de desintegración rápida tableta, paquete de dosis para 3 meses tableta, 2 horas multifásica tableta, 24 horas multifásica unidad anillo vaginal 32

34 VNSNY CHOICE Total 206 Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) ID , VNSNY CHOICE Medicare TTY 7 8:00 8:00 VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) / / 207 Medicare HMO VNSNY CHOICE Medicare 08/29/205 33

35 /

36 49 49 I- (Index) FDA VNSNY CHOICE Medicare 60 Celebrex A B A B A B 35

37 49 5 VNSNY CHOICE Medicare (OTC) OTC Medicare OTC (OTC) ( ) (cetirizine hydrochloride) (Zyrtec) (cetirizine hydrochloride)/ (Zyrtec-D) 2 (pseudoephedrine hydrochloride) (loratadine) (Claritin) (loratadine)/ (pseudoephedrine sulfate) (ketotifen fumarate) (Claritin-D) (Zaditor) 2 24 OTC OTC Part D 36

38 37

39 ,

40 Medicare -800-MEDICARE ( ) Medicare 24 TTY (TTY 7 ) 8 8 Medicare HMO VNSNY CHOICE Medicare 39

41 49 I- CELEBREX naproxen (Requirements/Limits) PA PA BvD Part B Part D ( ) Medicare Part B Part D ( ) Medicare Part D 40

42 PA-HRM PA NSO QL ST CMS 65 Medicare 65 VNSNY CHOICE Medicare VNSNY CHOICE Medicare ( ) 4

43 LA NM :00 8:00 TTY/TDD 7 / (Requirements/Limits) "NM" 42

44 adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt

45 cmb tabpad combo. pkg cpmp 2hr cpmp 24hr cpmp cpmp cream(g), cream(gm) cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump %-70% 50%-50% ( ) ( ) ( ) (2- ) (di(2- ethylhexyl)phthalate) ( ) ( ) ( ) 44

46 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 hfa 2 ( ) 45

47 paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon ( ) ( ) ( ) ( ) 24 46

48 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 tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr u vag ring

49 48

50 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 EMBEDA ORAL CAPSULE,ORAL QL (60 per 30 ONLY,EXT.REL PELL 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) Formulary ID: , Version: 7 49 Effective: January 0, 206

51 Formulary ID: , Version: 7 50 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 oxycodone oral concentrate (Oxycodone HCl) QL (80 per 30 Effective: January 0, 206

52 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 XARTEMIS XR QL (360 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) etodolac (Etodolac) Formulary ID: , Version: 7 5 Effective: January 0, 206

53 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 injection cartridge 5 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection cartridge 30 mg/ml (Ketorolac QL (20 per 30 Tromethamine) ketorolac injection solution 5 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection solution 30 mg/ml ( (Ketorolac QL (20 per 30 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 Tromethamine) ketorolac oral (Ketorolac QL (20 per 30 Tromethamine) mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) meloxicam oral tablet (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) Formulary ID: , Version: 7 52 Effective: January 0, 206

54 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) lidocaine (pf) intravenous syringe 00 (Lidocaine HCl/PF) mg/5 ml (2 %) lidocaine hcl injection solution (Xylocaine) PA BvD; (PA for ESRD Only) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive (Lidoderm) PA patch,medicated lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Lidocaine/Prilocaine) PA BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 buprenorphine-naloxone (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) bupropion hcl sr 50 mg tablet f/c (Zyban) CHANTIX QL (68 per 84 CHANTIX CONTINUING MONTH QL (56 per 28 BOX CHANTIX CONTINUING MONTH PAK QL (56 per 28 CHANTIX STARTING MONTH BOX QL (53 per 28 Formulary ID: , Version: 7 53 Effective: January 0, 206

55 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 alprazolam oral tablet extended release 24 (Xanax XR) QL (20 per 30 hr 0.5 mg, mg, 2 mg alprazolam oral tablet extended release 24 (Xanax XR) QL (90 per 30 hr 3 mg chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (20 per 30 clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating 2 (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 5 mg (Tranxene T-Tab) QL (20 per 30 clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 mg, 7.5 mg 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) estazolam oral tablet mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 Formulary ID: , Version: 7 54 Effective: January 0, 206

56 estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 flurazepam oral capsule 5 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (0 per 30 temazepam oral capsule 5 mg, 22.5 mg, 30 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 Formulary ID: , Version: 7 55 Effective: January 0, 206

57 temazepam oral capsule 7.5 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (20 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (20 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 Antibacterials 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 Formulary ID: , Version: 7 56 Effective: January 0, 206

58 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) 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 oral capsule 00 mg (Macrodantin/Macrobid) PA-HRM; QL (20 per 30 nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 Formulary ID: , Version: 7 57 Effective: January 0, 206

59 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 (Vancomycin mg HCl/D5W) 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 Formulary ID: , Version: 7 58 Effective: January 0, 206

60 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) 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 SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) Formulary ID: , Version: 7 59 Effective: January 0, 206

61 Formulary ID: , Version: 7 60 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) 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) Effective: January 0, 206

62 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) 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 solution (Levaquin) levofloxacin oral tablet (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) Formulary ID: , Version: 7 6 Effective: January 0, 206

63 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 (Vibramycin) for reconstitution doxycycline monohydrate oral tablet (Avidoxy) MINOCIN INTRAVENOUS 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 25 MG/ML PA NSO Formulary ID: , Version: 7 62 Effective: January 0, 206

64 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) Formulary ID: , Version: 7 63 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 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST CYRAMZA INTRAVENOUS PA NSO SOLUTION 0 MG/ML dactinomycin (Dactinomycin) DAUNOXOME decitabine (Dacogen) docetaxel intravenous solution 60 mg/6 ml (0 mg/ml), 20 mg/2 ml (final), 80 mg/4 (Taxotere) ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) Effective: January 0, 206

65 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 gemcitabine intravenous recon soln (Gemzar) gram GILOTRIF PA NSO; QL (30 per 30 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 Formulary ID: , Version: 7 64 Effective: January 0, 206

66 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 30 LYSODREN MARQIBO PA NSO; QL (4 per 28 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 melphalan hcl intravenous (Alkeran) 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 Formulary ID: , Version: 7 65 Effective: January 0, 206

67 NILANDRON ONCASPAR PA NSO OPDIVO INTRAVENOUS SOLUTION PA NSO 40 MG/4 ML oxaliplatin intravenous solution 00 (Eloxatin) mg/20 ml PERJETA PA NSO 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 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 Formulary ID: , Version: 7 66 Effective: January 0, 206

68 TEMODAR INTRAVENOUS PA NSO; (vial only) teniposide (Teniposide) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 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 VECTIBIX INTRAVENOUS PA NSO SOLUTION VELCADE PA NSO vincristine (Vincristine Sulfate) PA BvD vincristine sulfate (Vincristine Sulfate) PA BvD vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; QL (20 per 30 XALKORI PA NSO; QL (60 per 30 XTANDI PA NSO; QL (20 per 30 YERVOY INTRAVENOUS SOLUTION PA NSO ZALTRAP 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 Formulary ID: , Version: 7 67 Effective: January 0, 206

69 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 0. mg/ml syringe luer-jet syr (Atropine Sulfate) atropine injection solution (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0. (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM BANZEL 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 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) Formulary ID: , Version: 7 68 Effective: January 0, 206

70 GABITRIL ORAL TABLET 2 MG, 6 MG GRALISE ST; QL (90 per 30 GRALISE 30-DAY STARTER PACK ST; QL (78 per 30 LAMICTAL ODT STARTER (BLUE) LAMICTAL ODT STARTER (GREEN) LAMICTAL ODT STARTER (ORANGE) 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 in nacl (iso-os) (Levetiracetam In Nacl (Iso-Os)) 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 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) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) Formulary ID: , Version: 7 69 Effective: January 0, 206

71 Formulary ID: , Version: 7 70 POTIGA ORAL TABLET 200 MG, 300 QL (90 per 30 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 primidone (Mysoline) SABRIL TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) topiramate oral tablet (Topamax) TROKENDI XR valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral (Depakene) solution 250 mg/5 ml VIMPAT INTRAVENOUS QL (200 per 5 VIMPAT ORAL SOLUTION QL (200 per 30 VIMPAT ORAL TABLET 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 Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) Effective: January 0, 206

72 Formulary ID: , Version: 7 7 BRINTELLIX 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) DESVENLAFAXINE FUMARATE QL (30 per 30 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 fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine (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) paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION Effective: January 0, 206

73 Formulary ID: , Version: 7 72 perphenazine-amitriptyline (Perphenazine/Amitripty PA NSO-HRM line HCl) phenelzine (Nardil) PRISTIQ QL (30 per 30 protriptyline (Protriptyline HCl) sertraline oral concentrate (Zoloft) sertraline oral tablet (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 (Venlafaxine HCl) 24hr 50 mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 24hr 225 mg VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 ACTOPLUS MET XR QL (60 per 30 CYCLOSET QL (80 per 30 GLYSET QL (90 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 ST; QL (20 per 30 MG 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 QL (30 per 30 MULTIPHASE 24 HR 00-,000 MG, MG JANUMET XR ORAL TABLET, ER QL (60 per 30 MULTIPHASE 24 HR 50-,000 MG JANUVIA QL (30 per 30 Effective: January 0, 206

74 JARDIANCE ST; QL (30 per 30 JENTADUETO QL (60 per 30 KAZANO 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 NESINA QL (30 per 30 OSENI QL (30 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 QL (0.8 per 28 SYMLINPEN 60 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 "CONCENTRATED" QL (40 per 28 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 Formulary ID: , Version: 7 73 Effective: January 0, 206

75 Formulary ID: , Version: 7 74 NOVOLOG MIX FLEXPEN QL (30 per 28 NOVOLOG PENFILL QL (30 per 28 TOUJEO SOLOSTAR 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 Effective: January 0, 206

76 Formulary ID: , Version: 7 75 amphotericin b (Amphotericin B) PA BvD CANCIDAS ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole 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) EXELDERM 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 NYSTATIN (BULK) POWDER BILLION UNIT, 0 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin) SPORANOX ORAL SOLUTION terbinafine hcl oral (Lamisil) voriconazole intravenous (Vfend IV) Effective: January 0, 206

77 Formulary ID: , Version: 7 76 voriconazole oral (Vfend) Antihistamines Antihistamines carbinoxamine maleate (Carbinoxamine PA-HRM Maleate) clemastine oral tablet 2.68 mg (Clemastine Fumarate) PA-HRM cyproheptadine (Cyproheptadine HCl) PA-HRM diphenhydramine hcl injection solution 50 (Diphenhydramine HCl) mg/ml diphenhydramine hcl injection syringe (Diphenhydramine HCl) levocetirizine (Xyzal) promethazine oral syrup (Promethazine HCl) PA-HRM Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL 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 Effective: January 0, 206

78 Formulary ID: , Version: 7 77 zolmitriptan oral tablet,disintegrating (Zomig Zmt) QL (2 per 28 Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral solution (Isoniazid) isoniazid oral tablet (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 (Prochlorperazine solution Edisylate) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine HCl) PA-HRM Effective: January 0, 206

79 Formulary ID: , Version: 7 78 promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (0 per 30 Antiparasite Agents Antiparasite Agents ALBENZA 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 (Requip XL) hr Effective: January 0, 206

80 selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) PA-HRM Antipsychotic Agents 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 RELEASE 24HR.5 MG, 3 MG, 9 MG ST; QL (30 per 30 Formulary ID: , Version: 7 79 Effective: January 0, 206

81 Formulary ID: , Version: 7 80 INVEGA ORAL TABLET EXTENDED ST; QL (60 per 30 RELEASE 24HR 6 MG INVEGA SUSTENNA QL (0.75 per 28 INTRAMUSCULAR SYRINGE 7 MG/0.75 ML 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 Effective: January 0, 206

82 Formulary ID: , Version: 7 8 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) QL (60 per 30 mg, 0.5 mg, mg, 2 mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (20 per 30 mg, 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 SEROQUEL XR ORAL TABLET ST; QL (60 per 30 EXTENDED RELEASE 24 HR 50 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET ST; QL (30 per 30 EXTENDED RELEASE 24 HR 200 MG 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 ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS INTELENCE ORAL TABLET 00 MG, 200 MG Effective: January 0, 206

83 INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine (Epivir) lamivudine-zidovudine (Combivir) LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr NORVIR PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 400 MG, 600 MG, 800 MG 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 Formulary ID: , Version: 7 82 Effective: January 0, 206

84 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 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) BARACLUDE ORAL SOLUTION cidofovir (Vistide) entecavir (Baraclude) famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD Formulary ID: , Version: 7 83 Effective: January 0, 206

85 ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 (Copegus) mg ribavirin oral tablets,dose pack 200 mg (Ribatab) (7)- 400 mg (7), mg (28)-mg (28), mg (28)-mg (28) TYZEKA valacyclovir (Valtrex) VALCYTE ORAL RECON SOLN 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 enoxaparin subcutaneous syringe 20 (Lovenox) QL (27.2 per 30 mg/0.8 ml enoxaparin subcutaneous syringe 50 (Lovenox) QL (34 per 30 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) QL (8 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) QL (3.6 per 30 mg/0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (20.4 per 30 mg/0.6 ml enoxaparin subcutaneous syringe 80 (Lovenox) QL (27.2 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 0 (Arixtra) QL (24 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) QL (5 per 30 mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) QL (2 per 30 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Arixtra) QL (8 per 30 Formulary ID: , Version: 7 84 Effective: January 0, 206

86 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 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 Formulary ID: , Version: 7 (Heparin Sodium,Porcine/D5W) (Heparin Sod,Pork In 0.45% NaCl) 85 (Heparin Sodium,Porcine/Ns/PF) (Heparin PA BvD; (PA for ESRD Sodium,Porcine) Only) (Heparin PA BvD Sodium,Porcine) (Monoject Prefill Advanced) (Monoject Prefill PA BvD; (PA for ESRD Advanced) Only) heparin, porcine (pf) intravenous syringe (Monoject Prefill Advanced) heparin-0.45% nacl 25,000 units/250 ml (Heparin Sod,Pork In (00 units/ml) bag latex-free, inner 0.45% NaCl) 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 SAVAYSA ST warfarin (Coumadin) XARELTO Blood Formation Modifiers CINRYZE PA EPOGEN INJECTION SOLUTION 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 PA; QL (2 per 28 Effective: January 0, 206

87 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, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION PA; QL (2 per 28 20,000 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 30 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 % Formulary ID: , Version: 7 86 Effective: January 0, 206

88 Formulary ID: , Version: 7 87 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 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 Effective: January 0, 206

89 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 PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) FREAMINE HBC 6.9 % PA BvD FREAMINE III 0 % PA BvD HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD PERIKABIVEN PA BvD Formulary ID: , Version: 7 88 Effective: January 0, 206

90 Formulary ID: , Version: 7 89 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) 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) EDARBI ST EDARBYCLOR ST irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TEVETEN HCT ST TRIBENZOR ST Effective: January 0, 206

91 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) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 00 mg, 200 mg, 400 mg (Cordarone) amiodarone intravenous (Amiodarone HCl) 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) Formulary ID: , Version: 7 90 Effective: January 0, 206

92 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) 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) Formulary ID: , Version: 7 9 Effective: January 0, 206

93 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 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 Formulary ID: , Version: 7 92 Effective: January 0, 206

94 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) LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG 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 Formulary ID: , Version: 7 93 Effective: January 0, 206

95 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) 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 ALTOPREV amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral powder 4 gram (Cholestyramine/Asparta me) Formulary ID: , Version: 7 94 Effective: January 0, 206

96 cholestyramine-aspartame oral powder in (Cholestyramine/Asparta packet 4 gram me) colestipol (Colestid) CRESTOR ST fenofibrate micronized (Lofibra) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) JUXTAPID ORAL CAPSULE 0 MG, 30 PA; QL (30 per 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG PA; QL (90 per 30 JUXTAPID ORAL CAPSULE 5 MG PA; QL (45 per 30 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 VYTORIN 0-0 VYTORIN 0-20 VYTORIN 0-40 VYTORIN 0-80 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. mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) QL (30 per 30 Formulary ID: , Version: 7 95 Effective: January 0, 206

97 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 30 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) Formulary ID: , Version: 7 96 Effective: January 0, 206

98 Formulary ID: , Version: 7 97 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 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) Effective: January 0, 206

99 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 (Loestrin) -20 mg-mcg,.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) mg-20 mcg (2)/75 mg (7), mg-20 mcg (24)/75 mg (4), -20(5)/-30(7) /mg- 35mcg (9),.5 mg-30 mcg (2)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) mg-mcg, mg-mcg, /- 35 mg-mcg/mg-mcg, 0.5/0.75/ mg- 35 mcg, 0.5// mg-mcg, -35 mg-mcg norethindrone-mestranol (Norinyl +50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING QL ( per 28 tarina fe (Loestrin Fe) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) Formulary ID: , Version: 7 98 Effective: January 0, 206

100 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 COSENTYX PEN PA COSENTYX PEN (2 PENS) PA DENAVIR 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) Formulary ID: , Version: 7 99 Effective: January 0, 206

101 Formulary ID: , Version: 7 00 REGRANEX PA; QL (30 per 30 SANTYL VALCHLOR VEREGEN 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) erythromycin-benzoyl peroxide (Benzamycin) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate applicators (Silver Nitrate Applicator) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone (Alclometasone Dipropionate) betamethasone dipropionate (Betamethasone Dipropionate) betamethasone valerate topical cream (Betamethasone Valerate) Effective: January 0, 206

102 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) 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) Formulary ID: , Version: 7 0 Effective: January 0, 206

103 permethrin topical cream (Elimite) Formulary ID: , Version: 7 02 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) tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Triamcinolone Acetonide) triamcinolone acetonide topical ointment %, 0. %, 0.5 % (Triamcinolone 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 EURAX malathion (Ovide) Effective: January 0, 206

104 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 CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN ORAL TABLET,SOLUBLE lipase-protease-amylase (Zenpep) MYOZYME NAGLAZYME ORFADIN PERTZYE PULMOZYME PA BvD VIMIZIM PA VPRIV Formulary ID: , Version: 7 03 Effective: January 0, 206

105 Formulary ID: , Version: 7 04 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) BEPREVE ST carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN 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) TYZINE NASAL DROPS 0. % Effective: January 0, 206

106 TYZINE NASAL SPRAY,NON- AEROSOL Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B Sulfate) BLEPHAMIDE BLEPHAMIDE S.O.P. CILOXAN OPHTHALMIC OINTMENT CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S CORTISPORIN-TC 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) 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) Formulary ID: , Version: 7 05 Effective: January 0, 206

107 Formulary ID: , Version: 7 06 ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide-prednisolone (Sulfacetamide/Predniso lone Sp) TOBRADEX OPHTHALMIC OINTMENT 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) prednisolone sodium phosphate (Prednisolone Sod ophthalmic Phosphate) PROLENSA RESTASIS QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION Effective: January 0, 206

108 cimetidine (Cimetidine) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) DEXILANT ST 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) nizatidine (Nizatidine) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) pantoprazole oral (Protonix) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral capsule (Ranitidine HCl) (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) diphenoxylate-atropine oral tablet (Lomotil) GATTEX 30-VIAL PA GATTEX ONE-VIAL PA glycopyrrolate (Robinul) glycopyrrolate (Robinul) lactulose (Lactulose) Formulary ID: , Version: 7 07 Effective: January 0, 206

109 calcium acetate oral capsule (Phoslo) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) Formulary ID: , Version: 7 08 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 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) VELPHORO 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) PREPOPIK sodium chloride-nahco3-kcl-peg oral (Nulytely with Flavor recon soln 420 gram Packs) Phosphate Binders AURYXIA Effective: January 0, 206

110 FOSRENOL 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 (Detrol LA) 24hr tolterodine oral tablet (Detrol) TOVIAZ trospium (Trospium Chloride) VESICARE 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 ORAL TABLET, DISPERSIBLE 25 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG FERRIPROX sodium thiosulfate intravenous solution (Sodium Thiosulfate) gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM PA; QL (30 per 30 Formulary ID: , Version: 7 09 Effective: January 0, 206

111 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 Formulary ID: , Version: 7 0 PA; QL (50 per 30 PA; QL (50 per 30 GRAM),.62 % (40.5 MG/2.5 GRAM) AXIRON PA; QL (80 per 28 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 ESTRING QL ( per 84 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 Effective: January 0, 206

112 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone Sod PA BvD injection Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone Sod PA BvD Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ injection (A-Methapred) PA BvD recon soln 25 mg, 40 mg methylprednisolone sodium succ (A-Methapred) PA BvD intravenous prednisolone sodium phosphate oral (Pediapred) PA BvD solution PREDNISONE INTENSOL PA BvD prednisone oral solution (Prednisone) PA BvD prednisone oral tablet (Prednisone) PA BvD prednisone oral tablets,dose pack (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 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 SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML PA Formulary ID: , Version: 7 Effective: January 0, 206

113 GENOTROPIN MINIQUICK PA SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML INCRELEX LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) QL ( per 84 INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO PA NORDITROPIN NORDIFLEX PA octreotide acetate injection solution,000 (Sandostatin) mcg/ml octreotide acetate injection solution 00 (Sandostatin) mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) 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 STIMATE SUPPRELIN LA QL ( per 360 Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION QL (0 per 28 medroxyprogesterone intramuscular (Depo-Provera) QL ( per 84 medroxyprogesterone oral (Provera) MEGACE ES megestrol oral suspension (Megace Es) norethindrone acetate (Aygestin) progesterone (Progesterone) Formulary ID: , Version: 7 2 Effective: January 0, 206

114 Formulary ID: , Version: 7 3 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 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 GAMUNEX-C INJECTION SOLUTION 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 Effective: January 0, 206

115 Formulary ID: , Version: 7 4 leflunomide (Arava) mycophenolate mofetil oral capsule (Cellcept) PA BvD mycophenolate mofetil oral suspension for (Cellcept) PA BvD reconstitution mycophenolate mofetil oral tablet (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 oral tablet 0.5 mg, mg (Rapamune) PA BvD sirolimus oral tablet 2 mg (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; LA; QL (5 per 28 ZORTRESS ORAL TABLET 0.25 MG PA BvD; QL (20 per 30 ZORTRESS ORAL TABLET 0.5 MG, PA BvD; QL (20 per MG Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD; QL (3 per 365 ENGERIX-B PEDIATRIC (PF) PA BvD; QL (3 per 365 GARDASIL (PF) QL (.5 per 365 GARDASIL 9 (PF) QL (.5 per 365 Effective: January 0, 206

116 Formulary ID: , Version: 7 5 HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) PA BvD INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION 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) M-M-R II (PF) QL (2 per 365 PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PROQUAD (PF) QL (2 per 365 QUADRACEL (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 PA BvD; QL (3 per 365 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE PA BvD; QL (3 per 365 ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) PA BvD TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD Effective: January 0, 206

117 TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR VAQTA (PF) VARIVAX (PF) QL (2 per 365 YF-VAX (PF) ZOSTAVAX (PF) 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) Metabolic Bone Disease Agents Metabolic Bone Disease Agents ACTONEL ORAL TABLET 35 MG QL (4 per 28 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 Formulary ID: , Version: 7 6 Effective: January 0, 206

118 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 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 pamidronate intravenous (Pamidronate Disodium) PA BvD; (PA for ESRD Only) 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 XGEVA PA ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback (Zoledronic Acid/Mannitol and Water) zoledronic acid-mannitol-water (Reclast) QL (00 per 300 intravenous solution ZOMETA INTRAVENOUS SOLUTION PA BvD 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/0 ML (20 MG/ML) PA Formulary ID: , Version: 7 7 Effective: January 0, 206

119 Formulary ID: , Version: 7 8 ACTEMRA SUBCUTANEOUS PA ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Ethyol) ammonium chloride (Ammonium Chloride) 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) BOTOX INJECTION RECON SOLN 00 PA; QL (4 per 90 UNIT BOTOX INJECTION RECON SOLN 200 PA; QL ( per 90 UNIT buspirone (Buspirone HCl) CERDELGA PA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Probenecid) COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML CYSTADANE dexrazoxane hcl intravenous recon soln (Totect) 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 GLUCAGON EMERGENCY KIT (HUMAN) Effective: January 0, 206

120 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 methylergonovine injection (Methylergonovine Maleate) morrhuate sodium (Sodium Morrhuate) MYOBLOC INTRAMUSCULAR QL ( per 90 SOLUTION 5,000 UNIT/ML NPLATE SUBCUTANEOUS RECON PA; QL (8 per 28 SOLN 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 ORAL TABLET 30 MG Formulary ID: , Version: 7 9 Effective: January 0, 206

121 SENSIPAR ORAL TABLET 60 MG, 90 MG SIGNIFOR QL (60 per 30 SIMPONI ARIA PA SIMPONI SUBCUTANEOUS SYRINGE PA 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 PA; QL (60 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG THALOMID PA NSO; QL (60 per 30 TYBOST QL (30 per 30 ULORIC ST; QL (30 per 30 XELJANZ PA; QL (60 per 30 Non-Frf Non-Frf ibandronate intravenous syringe (Ibandronate Sodium) PA BvD; QL (3 per 84 megestrol oral suspension 625 mg/5 ml (Megestrol Acetate) 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) BETOPTIC S Formulary ID: , Version: 7 20 Effective: January 0, 206

122 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 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 QL (2.5 per 25 (Benzalkonium)) ZIOPTAN (PF) QL (30 per 30 Replacement Preparations Replacement Preparations calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD Only) 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) Formulary ID: , Version: 7 2 Effective: January 0, 206

123 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 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 (Magnesium piggyback gram/00 ml Sulfate/D5W) magnesium sulfate in water intravenous (Magnesium Sulfate in piggyback 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) 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) Formulary ID: , Version: 7 22 Effective: January 0, 206

124 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 lr-d5 intravenous parenteral solution (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid (Potassium Chloride) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended (K-Tab ER) release potassium chloride oral tablet,er (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) Formulary ID: , Version: 7 23 Effective: January 0, 206

125 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 %) 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 AEROSOL INHALER 0 MCG/ACTUATION QL (2 per 28 Formulary ID: , Version: 7 24 Effective: January 0, 206

126 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 QL (24 per 28 QL (2.2 per 28 MCG/ACTUATION QVAR QL (7.4 per 25 Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization (Albuterol Sulfate) PA BvD 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 FORADIL AEROLIZER QL (60 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 QL (4 per 28 terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral elixir 80 mg/5 ml theophylline anhydrous oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline/D5W) Formulary ID: , Version: 7 25 Effective: January 0, 206

127 theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL ( per 28 VENTOLIN HFA QL (36 per 25 Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD cromolyn inhalation (Cromolyn Sodium) PA BvD DALIRESP QL (30 per 30 ESBRIET PA; QL (270 per 30 KALYDECO PA; QL (60 per 30 OFEV PA; QL (60 per 30 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; QL (30 per 30 NUVIGIL PA ROZEREM XYREM LA Formulary ID: , Version: 7 26 Effective: January 0, 206

128 zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 zolpidem oral tablet (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 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 CIALIS ORAL TABLET 2.5 MG, 5 MG PA; QL (30 per 30 epoprostenol (glycine) intravenous recon (Flolan) PA BvD soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) PA BvD soln.5 mg LETAIRIS PA; QL (30 per 30 OPSUMIT PA; QL (30 per 30 ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG PA Formulary ID: , Version: 7 27 Effective: January 0, 206

129 ORENITRAM ORAL TABLET PA EXTENDED RELEASE 0.25 MG, MG, 2.5 MG 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 (Pedi M.Vit No.7 with tablet,chewable 0.5 mg Fluoride) prenatal vitamins oral tablet 27 mg iron- (Pnv with (All Rx Prenatal mg sodium fluoride oral tablet Ca,No.72/Iron/Fa) (Pedi M.Vit No.7 with Fluoride) Vitamins Covered) Formulary ID: , Version: 7 28 Effective: January 0, 206

130 INDEX 8 8-MOP A abacavir... 8 abacavir-lamivudine-zidovudine... 8 ABELCET ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE acamprosate acarbose acebutolol... 9 acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid... 05, 6 acetylcysteine acitretin ACTEMRA... 7, 8 ACTHIB (PF)... 4 ACTIMMUNE... 8 ACTONEL... 6 ACTOPLUS MET XR acyclovir... 83, 99 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 4 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS ADVAIR DISKUS ADVAIR HFA AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 %.. 86 ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME alendronate... 6 alfuzosin ALIMTA ALINIA allopurinol... 8 ALPHAGAN P alprazolam ALREX altacaine ALTOPREV amantadine hcl AMBISOME amifostine crystalline... 8 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 amiodarone hcl AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium chloride... 8 ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphetamine salt combo Formulary ID: , Version: 7 I- Effective: January 0, 206

131 amphotericin b ampicillin ampicillin sodium... 60, 6 ampicillin-sulbactam... 6 AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL... 0 anticoag citrate phos dextrose... 8 APOKYN apraclonidine APRISO... 6 APTIOM APTIVUS... 8 ARCALYST... 3 aripiprazole ASACOL HD... 6 ashlyna ASSURE ID INSULIN SAFETY ASTAGRAF XL... 3 atenolol... 9 atenolol-chlorthalidone... 9 atorvastatin atovaquone atovaquone-proguanil ATRIPLA... 8 atropine... 68, 04 ATROVENT HFA AUBAGIO... 3 AURYXIA AVASTIN AVC VAGINAL AVONEX... 8 AVONEX (WITH ALBUMIN)... 8 AXIRON... 0 azacitidine azathioprine... 3 azathioprine sodium... 3 azelastine AZILECT azithromycin AZOPT AZOR aztreonam B bacitracin... 57, 05 bacitracin-polymyxin b baclofen balsalazide... 6 BANZEL BARACLUDE BCG VACCINE, LIVE (PF) 4 BD ECLIPSE LUER-LOK.. 03 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BELEODAQ benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA... 8 benztropine BEPREVE betamethasone acet,sod phos betamethasone dipropionate 00 betamethasone valerate 00, 0 betamethasone, augmented.. 0 BETASERON... 8 betaxolol... 9, 20 bethanechol chloride... 8 BETHKIS BETOPTIC S BEXSERO (PF)... 4 bicalutamide BICILLIN C-R... 6 BICILLIN L-A... 6 bisoprolol fumarate... 9 bisoprolol-hydrochlorothiazide... 9 bleomycin BLEPHAMIDE BLEPHAMIDE S.O.P BLINCYTO BOOSTRIX TDAP... 4 BOSULIF BOTOX... 8 BREO ELLIPTA BRILINTA brimonidine... 2 BRINTELLIX... 7 bromfenac bromocriptine budesonide... 6 bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 49, 53 buprenorphine-naloxone bupropion hcl... 53, 7 buspirone... 8 butalb-acetaminophen-caffeine butalbital-acetaminop-caf-cod 49 butalbital-acetaminophen butalbital-acetaminophen-caff 49 butalbital-aspirin-caffeine BUTRANS BYSTOLIC... 9 C cabergoline caffeine citrated caffeine-sodium benzoate calcipotriene calcitonin (salmon)... 6 calcitriol... 99, 7 calcium acetate Formulary ID: , Version: 7 I-2 Effective: January 0, 206

132 calcium carbonate-mag carb-fa calcium chloride... 2 calcium gluconate... 2 CALDOLOR... 5 CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 90 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate CARIMUNE NF NANOFILTERED... 3 carisoprodol carteolol cartia xt... 9 carvedilol... 9 CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 58 cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 59 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os 59 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... 5 CELLCEPT INTRAVENOUS... 3 CELONTIN cephalexin CEPROTIN (BLUE BAR) CERDELGA... 8 CEREZYME CERVARIX VACCINE (PF)... 4 cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar).. 94 cholestyramine-aspartame 94, 95 choline,magnesium salicylate 5 CIALIS ciclopirox ciclopirox-ure-camph-mentheuc cidofovir cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA... 3 CIMZIA POWDER FOR RECONST... 3 CINRYZE CIPRODEX ciprofloxacin... 6 ciprofloxacin hcl... 6, 05 ciprofloxacin in 5 % dextrose 6 ciprofloxacin lactate... 6 citalopram... 7 citric acid-sodium citrate... 2 clarithromycin... 59, 60 clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 57 clindamycin palmitate hcl clindamycin phosphate... 57, 76, 00 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 Formulary ID: , Version: 7 I-3 Effective: January 0, 206

133 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... 0 clobetasol propionate... 0 clobetasol-emollient... 0 clocortolone pivalate... 0 clomipramine... 7 clonazepam clonidine clonidine hcl... 89, 96 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate codeine-butalbital-asa-caffein 49 colchicine... 8 colchicine-probenecid... 8 colestipol colistin (colistimethate na) COLY-MYCIN S COMBIGAN... 2 COMBIPATCH... 0 COMBIVENT RESPIMAT. 25 COMETRIQ COMPLERA... 8 COMVAX (PF)... 4 CONDYLOX COPAXONE... 8 cortisone... CORTISPORIN-TC COSENTYX (2 SYRINGES) 99 COSENTYX PEN COSENTYX PEN (2 PENS). 99 CREON CRESTOR CRIXIVAN... 8 cromolyn... 04, 07, 26 CUBICIN cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine... 3 cyclosporine modified... 3 cyclosporine, modified... 3 cyproheptadine CYRAMZA CYSTADANE... 8 CYSTARAN cysteine (l-cysteine) D d0 % & 0.45 % sodium chloride... 2 d0 %-0.9 % sodium chloride 88 d2.5 %-0.45 % sodium chloride... 2 d5 % and 0.9 % sodium chloride... 2 d5 %-0.45 % sodium chloride... 2 dactinomycin DALIRESP danazol... 0 dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF)... 4 DARAPRIM DAUNOXOME deblitane decitabine deferoxamine DELZICOL... 6 DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA... 2 desipramine... 7 desmopressin... desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol.. 97 desonide... 0 desoximetasone... 0 DESVENLAFAXINE FUMARATE... 7 dexamethasone... dexamethasone sodium phosphate... 06, DEXILANT dexmethylphenidate dexrazoxane hcl... 8 dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl... 2 dextrose 0 % in water (d0w) Formulary ID: , Version: 7 I-4 Effective: January 0, 206

134 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).. 88 dextrose 5 %-lactated ringers 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 chloride diazepam diazepam intensol diclofenac potassium... 5 diclofenac sodium... 5, 06 diclofenac-misoprostol... 5 dicloxacillin... 6 dicyclomine didanosine... 8 DIFICID diflunisal... 5 digitek digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl... 9, 92 dilt-xr dimenhydrinate DIPENTUM... 6 diphenhydramine hcl diphenoxylate-atropine disopyramide phosphate disulfiram divalproex dobutamine dobutamine in d5w docetaxel donepezil dopamine dopamine in 5 % dextrose dorzolamide... 2 dorzolamide-timolol... 2 doxazosin doxepin... 7 doxercalciferol... 7 doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate doxycycline monohydrate dronabinol droperidol... 8 drospirenone-ethinyl estradiol 97 DROXIA DUAVEE... 0 DULERA duloxetine... 7 DUREZOL DYRENIUM E econazole EDARBI EDARBYCLOR EDURANT... 8 EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL... 0 ELIGARD... 63, 64 ELIQUIS ELITEK ELLA ELMIRON... 8 EMBEDA EMCYT EMEND EMSAM... 7 EMTRIVA... 8 enalapril maleate enalaprilat enalapril-hydrochlorothiazide 90 ENBREL... 3 ENBREL SURECLICK... 3 ENGERIX-B (PF)... 4 ENGERIX-B PEDIATRIC (PF)... 4 enoxaparin entacapone entecavir ephedrine sulfate epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK EPIVIR HBV... 8 eplerenone EPOGEN epoprostenol (glycine) EPZICOM... 8 ergoloid... 8 ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 60, 05 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate.. 60 erythromycin stearate erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET Formulary ID: , Version: 7 I-5 Effective: January 0, 206

135 escitalopram oxalate... 7 esmolol... 9 esomeprazole sodium estazolam... 54, 55 ESTRACE... 0 estradiol... 0 estradiol valerate... 0 estradiol/norethindrone acet. 0 estradiol-norethindrone acet. 0 ESTRING... 0 estropipate... 0 ethambutol ethamolin ethinyl estradiol/drospirenone 97 ethosuximide ethynodiol d-ethinyl estradiol. 97 etodolac... 5 ETOPOPHOS etoposide EURAX EVOTAZ... 8 EXELDERM exemestane EXJADE EXTAVIA... 8 F FABRAZYME famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os)07 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine FEMRING... 0 fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate FERRIPROX FETZIMA... 7 finasteride... 8 FIRAZYR FLEBOGAMMA DIF... 3 flecainide FLECTOR FLEXBUMIN 25 % FLEXBUMIN 5 % FLOVENT DISKUS FLOVENT HFA... 24, 25 floxuridine fluconazole fluconazole in dextrose(iso-o) 75 fluconazole in nacl (iso-osm) 75 flucytosine fludrocortisone... flumazenil flunisolide fluocinonide... 0 fluocinonide-emollient base 0 fluorometholone FLUOROPLEX fluorouracil... 64, 99 fluoxetine... 7 FLUOXETINE... 7 fluoxymesterone... 0 fluphenazine decanoate fluphenazine hcl flurazepam flurbiprofen flurbiprofen sodium flutamide fluticasone... 0, 06 fluvoxamine... 7 fomepizole... 8 fondaparinux FORADIL AEROLIZER FORTEO... 7 FORTICAL... 7 foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FREAMINE HBC 6.9 % FREAMINE III 0 % furosemide FUSILEV... 8 FUZEON... 8 FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D... 3 GAMMAGARD LIQUID... 3 GAMMAPLEX... 3 GAMUNEX-C... 3 ganciclovir sodium GARDASIL (PF)... 4 GARDASIL 9 (PF)... 4 gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD... 8 GAZYVA gemcitabine gemfibrozil GENOTROPIN... GENOTROPIN MINIQUICK..., 2 gentamicin... 56, 00, 05 gentamicin in nacl (iso-osm).. 56 gentamicin sulfate gentamicin sulfate (ped) (pf).. 56 gentamicin sulfate (pf) GEODON gildess 24 fe Formulary ID: , Version: 7 I-6 Effective: January 0, 206

136 GILENYA... 8 GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT... 8 GLUCAGON EMERGENCY KIT (HUMAN)... 8 glyburide glyburide micronized glyburide-metformin glycopyrrolate glydo GLYSET GLYXAMBI GRALISE GRALISE 30-DAY STARTER PACK granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guanfacine... 89, 96 guanidine... 9 H halobetasol propionate... 0 haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF)... 5 heparin (porcine) heparin (porcine) in 5 % dex.. 85 heparin (porcine) in nacl (pf). 85 heparin sodium,porcine-pf heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN homatropine hbr HUMIRA... 3 HUMIRA CROHN'S DIS START PCK... 3 HUMIRA PEN... 3 HUMULIN R U hydralazine hydrochlorothiazide hydrocodone-acetaminophen. 49 hydrocodone-ibuprofen hydrocortisone... 0, 02, hydrocortisone acet-aloe vera... 0 hydrocortisone acetate-urea. 0 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate hydrocortisone valerate hydromorphone hydromorphone (pf)... 49, 50 hydroxychloroquine hydroxyurea hydroxyzine hcl... 9 hydroxyzine pamoate... 9 HYPERLYTE CR HYQVIA... 3 I ibandronate... 7, 20 IBRANCE ibuprofen ICLUSIG ifosfamide ifosfamide-mesna ILARIS (PF)... 3 ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl... 7 imipramine pamoate... 7 imiquimod IMOGAM RABIES-HT (PF)... 3 IMOVAX RABIES VACCINE (PF)... 5 INCRELEX... 2 indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF)... 5 INLYTA... 64, 65 INSULIN PEN NEEDLE INSULIN SYRINGE-NEEDLE U INTELENCE... 8, 82 INTRALIPID INTRON A INVANZ INVEGA... 79, 80 INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL... 5 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 Formulary ID: , Version: 7 I-7 Effective: January 0, 206

137 isosorbide mononitrate isotretinoin isradipine itraconazole ivermectin IXEMPRA IXIARO (PF)... 5 J JAKAFI JALYN... 9 jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO junel fe JUXTAPID K KABIVEN KALETRA KALYDECO KAZANO KEDBUMIN ketoconazole ketoprofen ketorolac... 52, 06 KEYTRUDA KINERET... 3 KINRIX (PF)... 5 klor-con klor-con m klor-con m klor-con m KORLYM KRYSTEXXA KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad labetalol... 9 LACRISERT LACTATED RINGERS... 6 lactulose LAMICTAL LAMICTAL ODT STARTER (BLUE) LAMICTAL ODT STARTER (GREEN) LAMICTAL ODT STARTER (ORANGE) lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost... 2 LATUDA LAZANDA leflunomide... 4 LEMTRADA... 9 LENVIMA LETAIRIS letrozole leucovorin calcium... 9 LEUKERAN LEUKINE leuprolide levetiracetam levetiracetam in nacl (iso-os). 69 levobunolol... 2 levocarnitine... 9 levocarnitine (with sugar)... 9 levocetirizine levofloxacin... 6, 05 levofloxacin in d5w... 6 levonorgestrel levonorgestrel-ethin estradiol 98 levonorgestrel-ethinyl estrad. 98 levothyroxine... 3 LEXIVA lidocaine lidocaine (pf)... 53, 90 lidocaine hcl lidocaine in 5 % dextrose (pf) 90 lidocaine-prilocaine linezolid LINZESS liothyronine... 3 lipase-protease-amylase LIPOSYN II LIPOSYN III lisinopril lisinopril-hydrochlorothiazide 90 lithium carbonate... 96, 97 lithium citrate l-norgest-eth estr/ethin estra lomustine loperamide lorazepam oral solution losartan losartan-hydrochlorothiazide. 89 LOTEMAX LOTRONEX lovastatin loxapine succinate LUMIGAN... 2 LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED... 2 LUPRON DEPOT-PED (3 MONTH)... 2 LYNPARZA LYRICA LYSODREN M magnesium chloride Formulary ID: , Version: 7 I-8 Effective: January 0, 206

138 magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water.. 22 malathion maprotiline... 7 MARPLAN... 7 MARQIBO MATULANE matzim la meclizine medroxyprogesterone... 2 mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) MEGACE ES... 2 megestrol... 65, 2, 20 MEKINIST meloxicam melphalan hcl intravenous MENACTRA (PF)... 5 MENEST... 0 MENHIBRIX (PF)... 5 MENOMUNE - A/C/Y/W-35 (PF)... 5 MENVEO A-C-Y-W-35-DIP (PF)... 5 MENVEO MENA COMPONENT (PF)... 5 MENVEO MENCYW-35 COMPNT (PF)... 5 mercaptopurine meropenem mesna... 9 MESNEX... 9 MESTINON... 9 MESTINON TIMESPAN... 9 metaproterenol metaxalone metformin methadone methadone hcl methazolamide... 2 methenamine hippurate methenamine mandelate methimazole... 3 methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylergonovine... 9 methylphenidate methylprednisolone... methylprednisolone acetate. methylprednisolone sodium succ... metipranolol... 2 metoclopramide hcl metolazone metoprolol succinate... 9 metoprolol ta-hydrochlorothiaz... 9 metoprolol tartrate... 9 metronidazole... 57, 76, 00 metronidazole in nacl (iso-os) 57 mexiletine MIACALCIN... 7 miconazole nitrate midazolam midodrine milrinone milrinone in 5 % dextrose minitran... 95, 96 MINOCIN minocycline minoxidil MIRCERA mirtazapine... 7 misoprostol mitoxantrone M-M-R II (PF)... 5 moexipril moexipril-hydrochlorothiazide mometasone montelukast morphine MORPHINE morphine concentrate morrhuate sodium... 9 MOVANTIK MOVIPREP MOXEZA moxifloxacin... 6 MOZOBIL MULTAQ mupirocin mupirocin calcium mycophenolate mofetil... 4 mycophenolate sodium... 4 MYOBLOC... 9 MYOZYME MYRBETRIQ N nabumetone nadolol... 9 nafcillin... 6 NAGLAZYME naloxone naltrexone naltrexone hcl NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NATACYN nateglinide NATPARA... 7 NEBUPENT nefazodone... 7 neomy sulf-bacitrac zn-poly-hc Formulary ID: , Version: 7 I-9 Effective: January 0, 206

139 neomycin neomycin-bacitracin-poly-hc 05 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin NEPHRAMINE 5.4 % NESINA NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine NICOTROL nifedipine NILANDRON NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose. 96 NITROSTAT nizatidine NORDITROPIN FLEXPRO 2 NORDITROPIN NORDIFLEX... 2 norelgestromin/ethin.estradiol 98 norepinephrine bitartrate norethindrone norethindrone (contraceptive) 98 norethindrone acetate... 2 norethindrone ac-eth estradiol 98 norethindrone-e.estradiol-iron 98 norethindrone-ethinyl estrad.. 98 norethindrone-mestranol norgestimate-ethinyl estradiol 98 norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortriptyline... 7 NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NPLATE... 9 NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX... 4 NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone O OCTAGAM... 4 octreotide acetate... 2 OFEV ofloxacin... 6, 05, 06 olanzapine olanzapine-fluoxetine... 7 OLYSIO omega-3 acid ethyl esters omeprazole ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI OPDIVO OPSUMIT ORAP ORENCIA... 4 ORENCIA (WITH MALTOSE)... 4 ORENITRAM... 27, 28 ORFADIN OSENI OTEZLA... 9 OTEZLA STARTER... 9 OTREXUP (PF)... 9 oxacillin... 6 oxacillin in dextrose(iso-osm) 6 oxaliplatin oxandrolone... 0 oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 50, 5 oxycodone hcl-acetaminophen oxycodone hcl-aspirin oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 OXYCONTIN... 5 oxymorphone... 5 P pamidronate... 7 PANRETIN pantoprazole papaverine paricalcitol... 7 paromomycin Formulary ID: , Version: 7 I-0 Effective: January 0, 206

140 paroxetine hcl... 7 PASER PAXIL... 7 pedi m.vit no.7 with fluoride PEDIARIX (PF)... 5 PEDVAX HIB (PF)... 5 peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON penicillin g pot in dextrose... 6 penicillin g potassium... 6 penicillin g procaine... 6 penicillin v potassium... 6 PENTACEL (PF)... 5 PENTACEL ACTHIB COMPONENT (PF)... 5 PENTACEL DTAP-IPV COMPNT (PF)... 5 PENTAM pentoxifylline PERIKABIVEN perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline PERTZYE phenelzine phenobarbital phenobarbital sodium phenylephrine hcl... 89, 04 phenytoin phenytoin sodium phenytoin sodium extended PHOSLYRA PHOSPHOLINE IODIDE... 2 phosphorus # PICATO pilocarpine hcl... 99, 2 pindolol... 9 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 6 piroxicam PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY... 9 podofilox podophyllum resin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid. 23 potassium bicarbonate-cit ac 23 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid. 23 potassium hydroxide potassium phosphate dibasic 23 POTIGA PRADAXA pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 06, prednisone... PREDNISONE INTENSOL PREMARIN... 0 PREMASOL 0 % PREMASOL 6 % PREMPHASE... 0 PREMPRO... 0 prenatal vitamins PREPOPIK PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRISTIQ PRIVIGEN... 4 PROAIR HFA PROAIR RESPICLICK probenecid... 9 procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate Formulary ID: , Version: 7 I- Effective: January 0, 206

141 PROCRIT PROCYSBI... 9 progesterone... 2 progesterone micronized capsules... 3 PROGLYCEM PROGRAF... 4 PROLASTIN-C PROLENSA PROLEUKIN PROLIA... 7 PROMACTA promethazine... 76, 77, 78 promethazine hcl propafenone... 9 propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod 04 propranolol... 9 propranolol-hydrochlorothiazid... 9 propylthiouracil... 3 PROQUAD (PF)... 5 PROSOL 20 % protamine protriptyline PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide... 9 Q QUADRACEL (PF)... 5 quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide 90 quinidine gluconate... 9 quinidine sulfate... 9 quinine sulfate QVAR R RABAVERT (PF)... 5 raloxifene... 0 ramipril RANEXA ranitidine hcl RAPAMUNE... 4 RASUVO (PF)... 9 RAVICTI REBIF (WITH ALBUMIN) 9 REBIF REBIDOSE... 9 REBIF TITRATION PACK 9 RECOMBIVAX HB (PF)... 5 REGRANEX RELENZA DISKHALER RELISTOR REMICADE... 9 REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR RESTASIS RETROVIR REVLIMID REYATAZ ribavirin RIDAURA... 4 rifabutin rifampin RIFATER riluzole rimantadine ringers... 6, 23 risedronate... 7 RISPERDAL CONSTA risperidone... 80, 8 RITUXAN rivastigmine tartrate rizatriptan ropinirole ROTARIX... 5 ROTATEQ VACCINE... 5 ROZEREM S SABRIL SAIZEN... 2 SAIZEN CLICK.EASY... 2 salsalate SANDOSTATIN LAR DEPOT... 2 SANTYL SAPHRIS (BLACK CHERRY)... 8 SAVAYSA SAVELLA selegiline hcl selenium sulfide SELZENTRY SENSIPAR... 9, 20 SEREVENT DISKUS SEROQUEL XR... 8 SEROSTIM... 2 sertraline SIGNIFOR sildenafil oral tablet 20 mg.. 28 SILENOR silver nitrate silver nitrate applicators silver sulfadiazine SIMBRINZA... 2 SIMPONI SIMPONI ARIA simvastatin sirolimus... 4 SIRTURO sodium acetate sodium bicarbonate sodium chloride... 6, 24 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % Formulary ID: , Version: 7 I-2 Effective: January 0, 206

142 sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride... 99, 28 sodium lactate sodium phosphate sodium polystyrene sulfonate sodium thiosulfate sod-pot-k cit-sod cit-cit acid. 24 SOLTAMOX SOLU-CORTEF (PF)... SOMATULINE DEPOT... 2 SOMAVERT... 2 sorbitol... 6 sorbitol-mannitol... 6 sotalol... 9 sotalol hcl... 9 SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX SPRYCEL stavudine STELARA STERILE PADS STIMATE... 2 STIVARGA STRATTERA streptomycin STRIBILD STRIVERDI RESPIMAT sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 00 sulfacetamide-prednisolone.. 06 sulfadiazine... 6 sulfamethoxazole-trimethoprim... 6 sulfasalazine... 6 sulfatrim sulfazine sulfazine ec sulindac sumatriptan nasal spray sumatriptan succinate SUPPRELIN LA... 2 SUPRAX SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE T TABLOID tacrolimus... 02, 4 TAFINLAR TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe TASIGNA TAZORAC taztia xt TECFIDERA TEFLARO TEGRETOL XR telmisartan telmisartan-hydrochlorothiazid temazepam... 55, 56 TEMODAR teniposide TENIVAC (PF)... 5 terazosin terbinafine hcl terbutaline terconazole testosterone... 0 testosterone cypionate... 0 testosterone enanthate... 0 TETANUS TOXOID,ADSORBED (PF)... 5 TETANUS,DIPHTHERIA TOX PED(PF)... 5 TETANUS-DIPHTHERIA TOXOIDS-TD... 5 tetracaine hcl (pf) tetracycline TEVETEN HCT THALOMID theophylline theophylline anhydrous theophylline in dextrose 5 % 25 thioridazine... 8 thiothixene... 8 tiagabine TICE BCG... 6 TIKOSYN... 9 timolol maleate... 9, 2 TIVICAY tizanidine TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide tolbutamide Formulary ID: , Version: 7 I-3 Effective: January 0, 206

143 tolmetin tolterodine topiramate toposar intravenous topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z... 2 travoprost (benzalkonium)... 2 trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide 99, 02, triamterene-hydrochlorothiazid triazolam TRIBENZOR trifluoperazine... 8 trifluridine trihexyphenidyl trimethoprim TRIUMEQ TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA... 6 TRUVADA TUDORZA PRESSAIR TWINRIX (PF)... 6 TYBOST TYGACIL TYKERB TYPHIM VI... 6 TYSABRI... 4 TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA TYZINE... 04, 05 U ULORIC ursodiol V VAGIFEM... 0 valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 70 valsartan valsartan-hydrochlorothiazide 90 VALSTAR vancomycin vancomycin in d5w VAQTA (PF)... 6 VARIVAX (PF)... 6 VASCEPA VECTIBIX VELCADE VELPHORO venlafaxine VENTOLIN HFA verapamil VEREGEN VERSACLOZ... 8 VESICARE VGO VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMIZIM VIMPAT vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VITEKTA VOLTAREN voriconazole... 75, 76 VOTRIENT VPRIV VYTORIN VYTORIN VYTORIN VYTORIN W warfarin water for irrigation, sterile... 6 X XALKORI XARELTO XARTEMIS XR... 5 XELJANZ XENAZINE XGEVA... 7 XIFAXAN Formulary ID: , Version: 7 I-4 Effective: January 0, 206

144 XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF)... 6 Z zafirlukast zaleplon ZALTRAP ZAVESCA ZELBORAF ZEMPLAR... 7 ZENPEP ZETIA ZIAGEN zidovudine ZIOPTAN (PF)... 2 ziprasidone hcl... 8 ZIRGAN ZOLADEX zoledronic acid... 7 zoledronic acid-mannitol-water... 7 ZOLINZA zolmitriptan... 76, 77 zolpidem ZOMETA... 7 zonisamide ZORTRESS... 4 ZOSTAVAX (PF)... 6 ZOVIRAX ZUBSOLV ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV... 8 ZYTIGA ZYVOX Formulary ID: , Version: 7 I-5 Effective: January 0, 206

145 tolmetin tolterodine... topiramate toposar intravenous topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ... TPN ELECTROLYTES TPN ELECTROLYTES II.. 26 TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril... 9 tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travoprost (benzalkonium).. 23 trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide... 00, 04, 3 triamterene-hydrochlorothiazid triazolam TRIBENZOR... 9 trifluoperazine trifluridine trihexyphenidyl trimethoprim TRIUMEQ TROKENDI XR TROPHAMINE 0 %...90 TROPHAMINE 6%...90 trospium... TRULICITY...74 TRUMENBA... 7 TRUVADA...84 TUDORZA PRESSAIR TWINRIX (PF)... 7 TYBOST TYGACIL...62 TYKERB...68 TYPHIM VI... 8 TYSABRI... 6 TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA...85 TYZINE U ULORIC ursodiol... 0 V VAGIFEM... 2 valacyclovir...85 VALCHLOR... 0 VALCYTE...85 valganciclovir...85 valproate sodium...70 valproic acid...70 valproic acid (as sodium salt).7 valsartan...9 valsartan-hydrochlorothiazide 9 VALSTAR...68 vancomycin...58 vancomycin in d5w...58 VAQTA (PF)... 8 VARIVAX (PF)... 8 VASCEPA...96 VECTIBIX...68 VELCADE...68 VELPHORO... 0 venlafaxine...73 VENTOLIN HFA verapamil VEREGEN... 0 VERSACLOZ VESICARE... VGO VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIGAMOX VIIBRYD VIMIZIM VIMPAT... 7 vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VITEKTA VOLTAREN voriconazole VOTRIENT VPRIV VYTORIN VYTORIN VYTORIN VYTORIN W warfarin water for irrigation, sterile... 8 X XALKORI XARELTO XARTEMIS XR... 5 XELJANZ XENAZINE XGEVA... 9 XIFAXAN VNS Choice Medicare Formulary ID: , Version: 7 I-4 Effective: January 0, 206

146 XOLAIR XTANDI xylon XYREM Y YERVOY YF-VAX (PF)... 8 Z zafirlukast zaleplon ZALTRAP ZAVESCA ZELBORAF ZEMPLAR... 9 ZENPEP ZETIA...96 ZIAGEN...84 zidovudine...84 ZIOPTAN (PF) ziprasidone hcl...82 ZIRGAN ZOLADEX...68 zoledronic acid... 9 zoledronic acid-mannitol-water... 9 ZOLINZA...68 zolmitriptan...77 zolpidem ZOMETA... 9 zonisamide... 7 ZORTRESS... 6 ZOSTAVAX (PF)... 8 ZOVIRAX... 0 ZUBSOLV ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX VNS Choice Medicare Formulary ID: , Version: 7 I-5 Effective: January 0, 206

147 This formulary was updated on 08/29/205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit Este formulario de medicamentos fue actualizado 08/29/205. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al o, para aquellos que utilizan TTY, al 7, de lunes a viernes, de 8:00 AM a 8:00 PM o visite VNSNY CHOICE Medicare TTY 7 8:00 8:00

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150 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit Any questions? Call toll free (TTY for the hearing impaired 7) 8 am 8 pm, Monday Friday 250 Broadway, th floor, New York, NY 000