(Plan Medicare o Medicaid) que ofrece Community Health Group

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1 H5172_Comp Formulary_Spanish 2015 v11 Approved A. Plan CommuniCare Advantage Cal MediConnect (Plan Medicare o Medicaid) que ofrece Community Health Group Lista de medicamentos cubiertos para el 2015 (formulario) Este formulario se actualizó el 15/10/2015. Para obtener más información o hacer otras preguntas, comuníquese con el Departamento de Servicios al Afiliado del Plan CommuniCare Advantage Cal MediConnect (plan Medicare, Medicaid) al o, para usuarios de TTY, , las veinticuatro horas del día, los siete días de la semana, o visite Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite i

2 Plan CommuniCare Advantage Cal MediConnect: Lista de medicamentos cubiertos para el año 2015 (formulario) Esta es una lista de medicamentos que los afiliados pueden obtener en el plan CommuniCare Advantage Cal MediConnect. El plan CommuniCare Advantage Cal MediConnect es un plan de salud que tiene contrato con Medicare y Medi-Cal para entregar beneficios de estos dos programas a los afiliados. Los beneficios, la lista de medicamentos cubiertos, las redes de farmacias y proveedores y los copagos pueden cambiar durante el año y el 1 de enero de cada año. Siempre puede revisar la lista actualizada de medicamentos cubiertos del plan CommuniCare Advantage Cal MediConnect en línea a través del sitio web o si llama al Usted puede pedir esta información en otros formatos, como Braille o letra grande. Llame al La llamada es gratuita. Se pueden aplicar limitaciones, copagos y restricciones. Para obtener más información, llame al Departamento de Servicios al Afiliado del plan CommuniCare Advantage Cal MediConnect o lea el Manual del afiliado del plan CommuniCare Advantage Cal MediConnect. Los copagos para los medicamentos de venta con receta médico pueden variar según el nivel de ayuda adicional que usted recibe. Comuníquese con el plan para tener más detalles. Este manual está disponible en otros idiomas en forma gratuita. Llame al Departamento de Servicios al Afiliado al ; atendemos las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al Estas llamadas son gratuitas. Usted puede obtener una copia de este libreto en otros idiomas. Por favor comuníquese al Departamento de Servicios a Participantes, estamos disponibles para ayudarle las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al Las llamadas a estos números de teléfono son gratis ف ي األع ضاء خدمات ب ق سم ات صل.أخرى ب ل غات مجان ا ال ك ت يب هذا ع لى ال ح صول ي م ك نك دعوة TTY ال م س تخدم ين ع لى ي جب.ف تح ل م ساعدت ك األ س بوع ف ي أي ام 7 ال يوم ف ي ساعة 24 ن حن.مجان ية هي ال م كال مات هذه Bạn có thể nhận được cuốn sổ tay này miễn phí bằng các ngôn ngữ khác. Gọi cho Ban Dịch Vụ Hội Viên tại , chúng tôi mở cửa 24 giờ một ngày, 7 ngày một tuần để giúp đỡ. Người dùng TTY nên gọi Các cuộc gọi được miễn phí. Maaari kang makakuha ng manwal na ito nang libre sa iba pang mga wika. Miyembro Serbisyo Department Tumawag sa , bukas kami 24 oras sa isang araw, 7 araw sa isang linggo upang tulungan ka. Dapat tumawag ang mga user ng TTY Ang mga tawag ay libre.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite ii

3 Preguntas frecuentes Aquí puede encontrar las respuestas a las preguntas que tenga sobre esta lista de medicamentos cubiertos. Puede leer todas las preguntas frecuentes para obtener más información o puede buscar una pregunta y su respuesta. 1. Qué medicamentos de venta con receta se encuentran en la lista de medicamentos cubiertos? (Le llamamos "lista de medicamentos a la lista de medicamentos cubiertos). Los medicamentos en la lista de medicamentos son cubiertos por el plan CommuniCare Advantage Cal MediConnect. Los medicamentos están disponibles en farmacias que pertenecen a nuestra red. Una farmacia pertenece a nuestra red si tenemos un acuerdo con esta para que trabaje con nosotros y para que le preste servicios. Nosotros nos referimos a estas farmacias como farmacias de la red. El plan CommuniCare Advantage Cal MediConnect cubrirá todos los medicamentos médicamente necesarios que se encuentren en la lista, si: su médico o la persona autorizada le indica que los necesita para mejorarse o permanecer saludable; y usted surte la receta en una farmacia de la red del plan CommuniCare Advantage Cal MediConnect. En algunos casos, tendrá que hacer algo antes de que pueda obtener el medicamento (consulte la pregunta N. 5 a continuación). También puede ver una lista actualizada de medicamentos que cubrimos en nuestro sitio web o puede llamar al Departamento de Servicios al Afiliado al Puede cambiar la lista de medicamentos? Sí. El plan CommuniCare Advantage Cal MediConnect puede añadir o retirar medicamentos de la lista durante el año. Por lo general, la lista de medicamentos cambiará solo si: aparece un medicamento más barato que funcione igual de bien que el medicamento actual de la lista; o nos enteramos que el medicamento no es seguro. También podemos cambiar nuestras reglas sobre los medicamentos. Por ejemplo, podríamos:? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite iii

4 Decidir si exigir o no aprobación previa para un medicamento (la aprobación previa es el permiso que el plan CommuniCare Advantage Cal MediConnect le da antes de poder obtener un medicamento). Añadir o cambiar la cantidad del medicamento que recibe (denominada límite de cantidad ). Añadir o cambiar las restricciones en terapias escalonadas con respecto a un medicamento (la terapia escalonada se refiere a que usted debe probar un medicamento antes de que cubramos otro). (Para obtener más información sobre estas reglas sobre medicamentos, consulte la página iv y v). Le avisaremos cuando un medicamento que esté tomando se retire de la lista de medicamentos. También le avisaremos cuando cambiemos nuestras reglas para cubrir un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que ocurre cuando la lista de medicamentos cambia. Siempre puede revisar la lista actualizada de medicamentos del plan CommuniCare Advantage Cal MediConnect a través del sitio web También puede llamar al Departamento de Servicios al Afiliado para revisar la lista de medicamentos actual si llama al Qué ocurre cuando aparece un medicamento más barato que funcione igual de bien que el medicamento actual de la lista? Si usted toma un medicamento que es retirado debido a que apareció un medicamento más barato que funciona igual de bien, le avisaremos. Le avisaremos con al menos 60 días de anticipación antes de que retiremos el medicamento de la lista o cuando nos pida una renovación. Luego podrá recibir un suministro para 60 días del medicamento antes de que sea retirado de la lista. Usted recibirá un Aviso de Cambio de Formulario con el Resumen Mensual de Medicamentos de Venta con Receta Médica. El Aviso de Cambio de Formulario le indicará los cambios que se harán dentro de al menos 60 días a partir de la fecha del aviso. 4. Qué ocurre cuando descubrimos que un medicamento no es seguro? Si la Administración de Medicamentos y Alimentos (FDA, Food and Drug Administration) indica que el medicamento que toma no es seguro, lo retiraremos de inmediato de la lista de medicamentos. También le enviaremos una carta para avisarle de esto. Si recibe una carta que le indique que un medicamento que usted toma fue retirado de la lista de medicamentos debido a razones de seguridad por la FDA, deberá comunicarse con su? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite iv

5 médico lo antes posible para analizar otros medicamentos que podría tomar para tratar su enfermedad. 5. Hay alguna restricción o límite sobre la cobertura de medicamentos? O se requiere tomar algunas medidas para poder recibir ciertos medicamentos? Sí, algunos medicamentos tienen reglas de cobertura o límites en la cantidad que usted puede tomar. En algunos casos, usted debe hacer algo antes de recibir el medicamento. Por ejemplo: Aprobación previa (o autorización previa): Para obtener algunos medicamentos, usted, su médico u otra persona autorizada debe recibir la aprobación del plan CommuniCare Advantage Cal MediConnect antes de que pueda surtir su receta médica. Si usted no recibe la aprobación, es posible que el plan CommuniCare Advantage Cal MediConnect no cubra el medicamento. Límites de cantidad: A veces, el plan CommuniCare Advantage Cal MediConnect limita la cantidad del medicamento que usted puede recibir. Terapia escalonada: A veces, el plan CommuniCare Advantage Cal MediConnect exige que se someta a terapia escalonada. Esto significa que usted tendrá que probar medicamentos en cierto orden para tratar su afección. Es posible que deba probar un medicamento antes de que cubramos otro. Si su médico cree que el primer medicamento no funciona, entonces cubriremos el segundo. Usted puede saber si su medicamento tiene cualquier requisito o limites adicionales si observa las tablas que comienzan en la página 1. También puede obtener más información si visita nuestro sitio web Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y de terapia escalonada. También puede solicitarnos que le enviemos una copia. Usted puede solicitar una excepción a estos límites. Consulte la Pregunta 11 para obtener más información sobre las excepciones. Si usted se encuentra en una casa de reposo o en otra instalación de atención a largo plazo y necesita un medicamento que no esté en la lista, o si no puede obtener con facilidad el medicamento que necesita, nosotros podemos ayudar. Nosotros cubriremos un suministro de emergencia por 31 días del medicamento que necesita (a menos que tenga una receta médica por menos días), sea o no afiliado nuevo del plan CommuniCare Advantage Cal MediConnect. Esto le dará tiempo para hablar con su médico u otra persona autorizada. Él o ella puede ayudarlo a decidir si hay un medicamento similar en la lista de medicamentos que usted pueda tomar como alternativa o si necesita solicitar una excepción. Consulte la Pregunta 11 para obtener más información sobre las excepciones.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite v

6 6. Cómo sabrá si el medicamento que desea tiene limitaciones o si se requiere tomar medidas para obtener el medicamento? La lista de medicamentos cubiertos que comienza en la página 1 tiene una columna denominada Medidas necesarias, restricciones o límites de uso. 7. Qué ocurre si cambiamos nuestras reglas sobre cómo cubrimos algunos de los medicamentos? Por ejemplo, si agregamos la autorización previa (aprobación), los límites de cantidad y las restricciones de terapia escalonadas a un medicamento. Le avisaremos si agregamos la aprobación previa, los límites de cantidad y las restricciones de terapia escalonadas a un medicamento. Le avisaremos con al menos 60 días antes de agregar la restricción o la próxima vez que pida una renovación en la farmacia. Luego, podrá obtener un suministro de 60 días del medicamento antes de que se realice el cambio a las reglas de cobertura. Esto le dará tiempo para hablar con su médico u otra persona autorizada sobre lo que deba hacer después. 8. Cómo puede encontrar un medicamento en la lista de medicamentos? Existen dos formas de encontrar un medicamento: Puede buscar por orden alfabético (si sabe cómo deletrear el medicamento), o Puede buscar por afección. Para buscar por orden alfabético, vaya a la sección Lista alfabética. Puede encontrarla en el índice al principio de la página I-1. Para buscar por afección, encuentre la sección denominada Lista de medicamentos por afección al comienzo de la página uno. Luego encuentre su afección. Por ejemplo, si usted tiene una afección cardiaca, deberá buscar en esa categoría. Allí encontrará medicamentos para tratar sus afecciones cardiacas. 9. Qué ocurre si el medicamento que quiere tomar no se encuentra en la lista de medicamentos? Si no encuentra su medicamento en la lista, llame al departamento de Servicios al Afiliado al y pregunte al respecto. Si se entera de que el plan CommuniCare Advantage Cal MediConnect no cubrirá el medicamento, usted puede optar por una de las siguientes acciones:? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite vi

7 Pida al Departamento de Servicios al Afiliado una lista de medicamentos similares al que desea tomar. Luego muéstrele la lista a su médico u otra persona autorizada. Él o ella puede recetar un medicamento de la lista de medicamentos que sea similar al que desea tomar. O Puede pedirle al plan de salud que haga una excepción para cubrir el medicamento. Consulte la pregunta 11 para obtener más información sobre las excepciones. 10. Qué ocurre si usted es un afiliado nuevo al plan CommuniCare Advantage Cal MediConnect y no puede encontrar su medicamento en la lista o tiene problemas para obtenerlo? Nosotros podemos ayudar. Nosotros podemos cubrir un suministro temporal para 31 días de su medicamento durante los primeros 90 días en que usted se convierte en afiliado del plan CommuniCare Advantage Cal MediConnect. Esto le dará tiempo para hablar con su médico u otra persona autorizada. Él o ella puede ayudarlo a decidir si hay un medicamento similar en la lista de medicamentos que usted pueda tomar como alternativa o si necesita solicitar una excepción. Nosotros cubriremos un suministro para 31 días de su medicamento, si: usted toma un medicamento que no forma parte de nuestra lista de medicamentos; las reglas del plan de salud no le permiten obtener la cantidad solicitada por la persona autorizada; El medicamento requiere la aprobación previa del plan CommuniCare Advantage Cal MediConnect, o usted toma un medicamento que forma parte de una restricción de terapia escalonada. Si usted vive en una casa de reposo u otro establecimiento de atención a largo plazo, podrá renovar su receta médica durante 93 días. Usted puede renovar el medicamento varias veces durante los 93 días. Esto le da a la persona autorizada tiempo para cambiar los medicamentos por aquellos que forman parte de la lista de medicamentos o para solicitar una excepción. Para el nivel de las transiciones de la atención, por ejemplo, cuando a usted le dan el alta del hospital a un establecimiento de atención médica a largo plazo o a su hogar: Tomaremos determinaciones de cobertura y volveremos a realizar determinaciones tan pronto como su estado de salud lo requiera. Se le proporcionará un suministro de emergencia de medicamentos que no se encuentran el formulario, lo que incluye los medicamentos que están sujetos a ciertas restricciones, como la autorización previa o la terapia escalonada.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite vii

8 11. Puede pedir una excepción para cubrir un medicamento? Sí. Puede solicitarle al plan CommuniCare Advantage Cal MediConnect que haga una excepción para cubrir un medicamento que no forma parte de la lista de medicamentos. También puede solicitarnos que cambiemos las reglas de su medicamento. Por ejemplo, el plan CommuniCare Advantage Cal MediConnect puede limitar la cantidad del medicamento que nosotros cubramos. Si su medicamento tiene un límite, usted nos puede solicitar que cambiemos este límite y cubramos más. Otros ejemplos: Usted nos puede solicitar que abandonemos las restricciones de terapia escalonada o los requerimientos de aprobación previa. 12. Cuánto tiempo toma obtener una excepción? Primero, debemos recibir una declaración por parte de la persona autorizada que apoye su solicitud de una excepción. Después de que recibamos la declaración, le daremos nuestra decisión sobre la solicitud de excepción dentro de 72 horas. Si usted o la persona autorizada cree que su salud podría verse perjudicada si tiene que esperar 72 horas para conocer la decisión, puede solicitar que se haga una excepción expedita. Esta es una decisión más rápida. Si la persona autorizada apoya su solicitud, le daremos a conocer la decisión dentro de 24 horas tras recibir la declaración de apoyo de la persona autorizada. 13. Cómo puede solicitar una excepción? Para solicitar una excepción, llame al Departamento de Servicios al Afiliado. El Departamento de Servicios al Afiliado trabajará con usted y el proveedor para ayudarlo a solicitar una excepción. 14. Qué son los medicamentos genéricos? Los medicamentos genéricos están hechos de los mismos ingredientes que los medicamentos de marca. Generalmente cuestan menos que los medicamentos de marca y sus nombres son menos conocidos. Los medicamentos genéricos están aprobados por la Administración de Medicamentos y Alimentos (FDA, Food and Drug Administration). El plan CommuniCare Advantage Cal MediConnect cubre tanto los medicamentos de marca como los genéricos. 15. Qué son los medicamentos OTC?? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite viii

9 OTC se refiere a los medicamentos que se venden sin receta médica. El plan CommuniCare Advantage Cal MediConnect cubre algunos medicamentos OTC cuando son escritos como recetas médicas por el proveedor. Usted puede leer la lista de medicamentos del plan CommuniCare Advantage Cal MediConnect para ver cuáles son los medicamentos OTC cubiertos. 16. Son cubiertos los productos OTC no farmacéuticos por el plan CommuniCare Advantage Cal MediConnect? El plan CommuniCare Advantage Cal MediConnect cubre algunos productos OTC no farmacéuticos cuando son escritos como recetas médicas por el proveedor. Usted puede leer la lista de medicamentos del plan CommuniCare Advantage Cal MediConnect para ver cuáles son los productos OTC no farmacéuticos cubiertos. 17. Cuál es su copago? Usted puede leer la lista de medicamentos del plan CommuniCare Advantage Cal MediConnect para obtener información sobre el copago de cada medicamento. Los afiliados del plan CommuniCare Advantage Cal MediConnect que viven en casas de reposo o en otros establecimientos de atención a largo plazo no tendrán copagos. Algunos afiliados que reciben atención a largo plazo en la comunidad no tendrán ningún copago. Los copagos se indican por niveles. Los niveles so grupos de medicamentos con el mismo copago. El nivel 1 incluye medicamentos genéricos. Este es el nivel de menor costo compartido. No hay costo compartido para los medicamentos de este nivel. El nivel 2 incluye medicamentos de marca. Este es el nivel de mayor costo compartido. El copago es de $0 a $6.60, según sus ingresos. El nivel 3 incluye medicamentos de venta con receta médica que no pertenecen a la marca Medicare y medicamentos genéricos. Normalmente, estos medicamentos no son cubiertos por Medicare, pero sí por Medicaid. No hay costo compartido para los medicamentos de este nivel. El nivel 4 incluye medicamentos de venta con receta médica que no pertenecen a la marca Medicare y medicamentos genéricos que se venden sin receta médica. Normalmente, estos medicamentos no son cubiertos por Medicare, pero sí por Medicaid. No hay costo compartido para los medicamentos de este nivel.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite ix

10 Lista de medicamentos cubiertos La lista de medicamentos cubiertos que comienza en la página 1 le brinda información sobre los medicamentos cubiertos por el plan CommuniCare Advantage Cal MediConnect. Si no puede encontrar el medicamento en la lista, vaya al índice que comienza en la página I-1. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca aparecen escritos en mayúsculas (por ejemplo, BYETTA) y los genéricos en cursivas y en minúsculas (por ejemplo, metformina). La información en la columna Medidas necesarias, restricciones o límites de uso le indica si el plan CommuniCare Advantage Cal MediConnect tiene alguna regla para cubrir el medicamento. Usted puede encontrar información sobre qué significan los símbolos y abreviaturas de esta tabla si consulta la tabla a continuación. Nota: El * ubicado al lado de un medicamento significa que este no pertenece a un medicamento de la Parte D. La cantidad que usted paga cuando surte una receta médica para este medicamento no cuenta en el total de costos de medicamentos (es decir, la cantidad que usted paga, no le sirve para calificar para la cobertura de gastos médicos mayores). Estos medicamentos también tienen diferentes reglas para las apelaciones. Una apelación es una manera formal de solicitar que revisemos una decisión que tomamos sobre su cobertura y que la cambiemos, si usted cree que cometimos un error. Por ejemplo, es posible que nosotros decidamos que un medicamento que usted desea no está cubierto o ya no está cubierto por Medicare ni Medi-Cal. Si usted o su médico no están de acuerdo con nuestra decisión, usted puede apelar. Si tiene alguna pregunta, llame al Departamento de Servicios al Afiliado al También puede leer el Manual para el afiliado para obtener más información sobre cómo apelar de una decisión.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite x

11 Las siguientes abreviaturas de Administración de utilización se pueden encontrar al interior del cuerpo de este documento. ABREVIATURAS DE NOTAS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones de la Administración de utilización PA PA BvD PA-HRM PA NSO Restricción de autorización previa (PA) Restricción de autorización previa(pa) para la determinación de la Parte B en comparación con la Parte D (BvD) Restricción de autorización previa (PA) para medicamentos de alto riesgo (HRM) Restricción de autorización previa solo para afiliados nuevos (NSO) Se requiere que usted (o su médico) obtengan la autorización previa por parte de CommuniCare Advantage Cal MediConnect antes de surtir su receta médica para este medicamento. Sin la aprobación previa, es posible que CommuniCare Advantage Cal MediConnect no cubra este medicamento. Es posible que este medicamento sea elegible para el pago a través de la Parte B o la Parte D de Medicare. Se requiere que usted (o su médico) obtengan la autorización previa por parte de CommuniCare Advantage Cal MediConnect para determinar que este medicamento está cubierto por la Parte D de Medicare antes de surtir su receta médica para este medicamento. Sin la aprobación previa, es posible que CommuniCare Advantage Cal MediConnect no cubra este medicamento. Los Centros de Servicios de Medicare consideran que este medicamento es potencialmente nocivo, por lo que es un medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los afiliados de 65 años o más necesitan la autorización previa de CommuniCare Advantage Cal MediConnect antes de surtir su receta médica para este medicamento. Sin la aprobación previa, es posible que CommuniCare Advantage Cal MediConnect no cubra este medicamento. Si usted es un afiliado nuevo, se requerirá que usted (o su médico) obtengan la autorización previa por parte de CommuniCare Advantage Cal MediConnect antes de surtir su receta? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite xi

12 ABREVIATURA DESCRIPCIÓN EXPLICACIÓN médica para este medicamento. Sin la aprobación previa, es posible que CommuniCare Advantage Cal MediConnect no cubra este medicamento. QL ST Restricción de límite de cantidad (QL) Restricción de terapia escalonada (ST) CommuniCare Advantage Cal MediConnect limita la cantidad cubierta de este medicamento por receta médica o dentro de un período de tiempo específico. Antes de que CommuniCare Advantage Cal MediConnect le proporcione cobertura, usted debe probar primero otros medicamentos para tratar su afección. Este medicamento solo se puede cubrir si los otros medicamentos no funcionan para usted. Las siguientes abreviaturas de notas de cobertura adicional se pueden encontrar dentro del cuerpo de este documento. OTROS REQUISITOS ESPECIALES DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN No es un medicamento de Este es un medicamento cubierto por * la Parte D Medicaid que no pertenece a la Parte D. Es posible que esta receta médica solo esté disponible en ciertas farmacias. Para obtener más información, consulte el directorio de farmacias o Medicamento de acceso LA llame a Servicios al Afiliado al limitado (LA) los siete días de la semana, las veinticuatro horas del día. Los usuarios de TTY/TDD deben llamar al NM No es un medicamento para pedido por correo (NM) Usted puede recibir un suministro para más de 1 mes de la mayoría de los medicamentos en su formulario a través de un pedido por correo con una distribución de costo menor. Los medicamentos que no se encuentran disponibles para su beneficio de pedido por correo están marcados con NM en la columna Medidas necesarias, restricciones o límites de uso de su formulario.? Si tiene preguntas, llame al plan CommuniCare Advantage Cal MediConnect al , las 24 horas del día, los siete días de la semana. La llamada es gratuita. Para obtener más información, visite xii

13 Name of Drug What the Analgesics Analgesics, Miscellaneous acetaminophen * oral (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 acetaminophen-codeine oral solution (Acetaminophen with QL (2700 per 30 Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (360 per 30 mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine QL (180 per 30 mg No.3) buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral capsule mg (Esgic) PA-HRM; QL (180 per 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) PA-HRM; QL (180 per 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) PA-HRM; QL (180 per 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) PA-HRM; QL (180 per 30 butorphanol tartrate nasal (Butorphanol QL (5 per 28 Tartrate) BUTRANS QL (4 per 28 children's non-aspirin * oral (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 children's pain & fever relief * oral (Infants' Tylenol) $0 (Tier 4) PA; AGE (Max 21 children's silapap * (Tylenol Sore Throat) $0 (Tier 4) PA; AGE (Max 21 codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral capsule mg (Fiorinal with Codeine #3) PA-HRM; QL (180 per 30 1

14 Name of Drug What the DURAMORPH (PF) fentanyl citrate (Actiq) PA; NM; QL (120 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr (Duragesic) PA; QL (20 per 30 fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) PA; QL (10 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 (150 per 30 hydromorphone (pf) injection solution 10 (Hydromorphone mg/ml HCl/PF) 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 (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 infant acetaminophen * (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 infantaire * (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 2

15 Name of Drug What the infant's pain reliever * (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 LAZANDA PA; NM; QL (30 per 30 levorphanol tartrate (Levorphanol QL (180 per 30 Tartrate) mapap (acetaminophen) * oral elixir (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 mapap (acetaminophen) * oral suspension (Infants' Tylenol) $0 (Tier 4) PA; AGE (Max 21 methadone hcl oral tablet,soluble 40 mg (Diskets) QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Msir) QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) mg/ml morphine injection syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml 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 10 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) QL (120 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 (MS Contin) QL (180 per 30 mg, 200 mg morphine rectal (Morphine Sulfate) 3

16 Name of Drug What the nortemp * oral (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 NUCYNTA QL (181 per 30 NUCYNTA ER QL (60 per 30 oxycodone hcl-acetaminophen oral (Oxycodone QL (1800 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 (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30 oxycodone oral tablet (Percolone) QL (180 per 30 oxycodone-acetaminophen oral tablet (Xolox) QL (360 per mg, mg, mg, mg oxycodone-acetaminophen oral tablet (Xolox) QL (180 per mg oxycodone-acetaminophen oral tablet (Xolox) QL (240 per mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (120 per 30 ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (120 per hr 30 mg, 40 mg pain relief * oral capsule (Acetaminophen) $0 (Tier 4) 4

17 Name of Drug What the q-pap * oral drops (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 q-pap * oral liquid (Tylenol Sore Throat) $0 (Tier 4) PA; AGE (Max 21 silapap * (Acetaminophen) $0 (Tier 4) PA; AGE (Max 21 tramadol oral tablet (Ultram) QL (240 per 30 tramadol-acetaminophen (Ultracet) QL (240 per 30 xylon 10 (Ibudone) QL (150 per 30 Nonsteroidal Anti-Inflammatory Agents aspirin * oral tablet (Ecotrin) $0 (Tier 4) aspirin * oral tablet,chewable (Bayer Chewable $0 (Tier 4) Aspirin) aspirin * oral tablet,delayed release (Ecotrin) $0 (Tier 4) (dr/ec) 325 mg, 650 mg, 81 mg aspir-low * (Ecotrin) $0 (Tier 4) CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) QL (60 per 30 children's advil * (Children'S Motrin) $0 (Tier 4) choline,magnesium salicylate (Choline Sal/Mag Salicylate) COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) 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) NM diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) 5

18 What the Name of Drug e.c. prin * (Ecotrin) $0 (Tier 4) ecotrin * (Ecotrin) $0 (Tier 4) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR flurbiprofen (Ansaid) ibuprofen * 100 mg/5 ml susp children's (Children'S Motrin) $0 (Tier 4) (otc) ibuprofen oral suspension 100 mg/5 ml (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 (120 per 30 indomethacin oral capsule, extended release (Indomethacin) PA-HRM; QL (60 per 30 indomethacin sodium (Indocin I.V.) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac injection cartridge 15 mg/ml (Toradol) QL (40 per 30 ketorolac injection cartridge 30 mg/ml (Toradol) QL (20 per 30 ketorolac injection solution 15 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection solution 30 mg/ml (1 (Ketorolac QL (20 per 30 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 Tromethamine) ketorolac oral (Ketorolac Tromethamine) QL (20 per 30 PA 6

19 What the Name of Drug mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg, 550 (Anaprox) mg piroxicam (Feldene) salsalate (Salsalate) sb aspirin * 325 mg tablet na/f, $0 (Tier 4) caffeine-free st joseph aspirin * (Bayer Chewable $0 (Tier 4) Aspirin) st. joseph aspirin * (Ecotrin) $0 (Tier 4) 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 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) 7

20 Name of Drug What the lidocaine topical adhesive patch,medicated (Lidoderm) PA lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Relador Pak) PA BvD RELADOR PAK PA BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX PA; QL (90 per 30 QL (168 per 84 CHANTIX CONTINUING MONTH QL (56 per 28 BOX CHANTIX CONTINUING MONTH QL (56 per 28 PAK CHANTIX STARTING MONTH BOX QL (53 per 28 disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) nicotine * transdermal patch 24 hour (Nicoderm Cq) $0 (Tier 4) PA; QL (224 per 365 NICOTROL ZUBSOLV SUBLINGUAL TABLET MG PA; QL (120 per 30 8

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

22 Name of Drug What the estazolam oral tablet 1 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 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 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 10

23 Name of Drug What the 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 solution (Ativan) QL (150 per 30 lorazepam injection solution (Ativan) QL (2 per 30 lorazepam injection syringe (Ativan) QL (2 per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam HCl/PF) QL (2 per 30 midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) QL (2 per 30 ml (1 mg/ml) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG PA NSO; QL (60 per 30 temazepam oral capsule 15 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 11

24 Name of Drug What the 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 (120 per 30 triazolam oral tablet mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 Antibacterials Aminoglycosides BETHKIS PA BvD; NM 12

25 What the Name of Drug gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION tobramycin in % nacl (Tobi) PA BvD; NM tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin Phosphate) solution colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN NM linezolid (Zyvox) NM methenamine hippurate (Hiprex) NM; QL (224 per 28 13

26 Name of Drug What the methenamine mandelate oral tablet 1 gram (Methenamine Mandelate) nitrofurantoin macrocrystal oral capsule (Macrodantin) PA-HRM; QL (120 per 100 mg 30 nitrofurantoin macrocrystal oral capsule (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per nitrofurantoin monohyd/m-cryst (Macrobid) 30 PA-HRM; (High Risk SYNERCID Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 NM trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg (Vancomycin HCl/D5W) vancomycin oral capsule (Vancocin HCl) NM XIFAXAN ORAL TABLET 200 MG PA; NM; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG ST; NM; QL (60 per 30 14

27 What the Name of Drug ZYVOX ORAL Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 125 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 Sodium) piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, (Cefazolin Sodium) 300 g cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) NM 15

28 What the Name of Drug cefprozil (Cefprozil) ceftazidime (Fortaz) ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 (Zinacef) gram, 750 mg cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for (Cephalexin) reconstitution cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO 16

29 What the Name of Drug Macrolides azithromycin (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release (Biaxin XL) 24 hr DIFICID 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 200 mg/5 ml erythromycin ethylsuccinate oral tablet (Erythromycin 400 mg 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 (Azactam) CAYSTON imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) NM; QL (20 per 10 NM; LA 17

30 What the Name of Drug Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for (Amoxil) reconstitution amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 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 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassiu tablet,chewable m Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection (Unasyn) ampicillin-sulbactam intravenous recon (Unasyn) soln BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) 18

31 What the Name of Drug oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose-Water) penicillin g potassium (Penicillin G Potassium) penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam (Zosyn) Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution (Cipro I.V.) 400 mg/40 ml levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tr intravenous imethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tr suspension imethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/Tr imethoprim) sulfazine (Azulfidine) 19

32 What the Name of Drug sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 50 (Adoxa) mg doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension (Vibramycin) for reconstitution doxycycline monohydrate oral tablet (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG NM NM PA NSO; NM; QL (4 per 21 PA NSO; NM; QL (112 per 28 PA NSO; NM; QL (56 per 28 PA NSO; NM; QL (28 per 28 20

33 What the Name of Drug ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) ARRANON ARZERRA AVASTIN NM NM PA NSO; NM PA NSO; NM azacitidine (Vidaza) NM BELEODAQ PA NSO; NM bexarotene (Targretin) PA NSO; NM; QL (420 per 30 bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) PA BvD BLINCYTO PA NSO; NM; QL (140 per 365 BOSULIF ORAL TABLET 100 MG PA NSO; NM; QL (120 per 30 BOSULIF ORAL TABLET 500 MG PA NSO; NM; QL (30 per 30 CAPRELSA ORAL TABLET 100 MG PA NSO; NM; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG PA NSO; NM; QL (30 per 30 carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) COMETRIQ PA NSO; NM; QL (112 per 28 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST 21

34 What the Name of Drug CYRAMZA PA NSO; NM cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) decitabine (Dacogen) NM doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) PA BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) PA BvD; NM suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD; NM DROXIA ELIGARD SUBCUTANEOUS QL (1 per 84 SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS QL (1 per 112 SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) NM; QL (1 per 168 ELIGARD SUBCUTANEOUS QL (1 per 28 SYRINGE 7.5 MG (1 MONTH) EMCYT epirubicin intravenous solution 50 mg/25 (Ellence) ml ERBITUX PA NSO; NM ERIVEDGE PA NSO; NM; QL (30 per 30 ETOPOPHOS etoposide intravenous (Etoposide) 22

35 What the Name of Drug exemestane (Aromasin) FARESTON FARYDAK FASLODEX FIRMAGON KIT W DILUENT SYRINGE NM PA NSO; NM; QL (6 per 21 NM floxuridine (FUDR) PA BvD fludarabine (Fludara) fluorouracil intravenous solution 2.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) GAZYVA PA NSO; NM; QL (40 per 28 gemcitabine intravenous recon soln 1 gram (Gemzar) NM GILOTRIF PA NSO; NM; QL (30 per 30 GLEEVEC ORAL TABLET 100 MG PA NSO; NM; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG PA NSO; NM; QL (60 per 30 HALAVEN PA NSO; NM; QL (24 per 28 HERCEPTIN PA NSO; NM HEXALEN NM hydroxyurea (Hydrea) IBRANCE PA NSO; NM; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG PA NSO; NM; QL (60 per 30 23

36 What the Name of Drug ICLUSIG ORAL TABLET 45 MG PA NSO; NM; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna) PA BvD; NM IMBRUVICA PA NSO; NM; QL (120 per 30 INLYTA ORAL TABLET 1 MG PA NSO; NM; QL (180 per 30 INLYTA ORAL TABLET 5 MG PA NSO; NM; QL (60 per 30 IRESSA PA NSO; NM; QL (60 per 30 ISTODAX PA NSO; NM IXEMPRA NM JAKAFI PA NSO; NM; QL (60 per 30 JEVTANA NM KADCYLA PA NSO; NM KEYTRUDA PA NSO; NM KYPROLIS PA NSO; NM; QL (6 per 28 LENVIMA PA NSO; NM letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) 24

37 What the Name of Drug LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT LYNPARZA LYSODREN MARQIBO MATULANE MEGACE ES NM; QL (1 per 28 NM; QL (1 per 84 NM; QL (1 per 84 NM; QL (1 per 168 NM; QL (1 per 28 NM; QL (1 per 84 PA NSO; NM; QL (480 per 30 PA NSO; NM; QL (4 per 28 NM megestrol oral suspension (Megace Es) megestrol oral suspension 625 mg/5 ml (Megace Es) NM megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG PA NSO; NM; QL (90 per 30 MEKINIST ORAL TABLET 2 MG PA NSO; NM; QL (30 per 30 melphalan hcl intravenous (Alkeran) NM mercaptopurine (Purinethol) methotrexate sodium (pf) injection recon soln (Methotrexate Sodium/PF) NM PA BvD 25

38 Name of Drug What the methotrexate sodium (pf) injection (Methotrexate PA BvD solution Sodium) methotrexate sodium injection (Methotrexate PA BvD Sodium) methotrexate sodium oral (Methotrexate PA BvD; ST Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Mitoxantrone HCl) MUSTARGEN NEXAVAR PA NSO; NM; QL (120 per 30 NILANDRON ONCASPAR PA NSO; NM OPDIVO INTRAVENOUS PA NSO; NM SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/20 (Eloxatin) NM ml paclitaxel (Paclitaxel) PERJETA PA NSO; NM POMALYST PA NSO; NM; QL (21 per 28 PROLEUKIN NM PURIXAN NM REVLIMID PA NSO; NM; LA; QL (21 per 28 RITUXAN PA NSO; NM 26

39 What the Name of Drug SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA SUTENT SYLVANT SYNRIBO TABLOID TAFINLAR tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA TEMODAR INTRAVENOUS toposar intravenous (Etoposide) PA NSO; NM; QL (30 per 30 PA NSO; NM; QL (60 per 30 PA NSO; NM; QL (84 per 28 PA NSO; NM; QL (30 per 30 PA NSO; NM PA NSO; NM; QL (28 per 28 PA NSO; NM; QL (120 per 30 PA NSO; NM; QL (60 per 30 PA NSO; NM; QL (90 per 30 PA NSO; NM; QL (60 per 28 PA NSO; NM; QL (112 per 28 PA NSO; NM; (vial only) topotecan intravenous (Hycamtin) NM TORISEL PA BvD; NM; QL (4 per 28 27

40 Name of Drug What the TREANDA INTRAVENOUS RECON NM SOLN TREANDA INTRAVENOUS NM SOLUTION TRELSTAR INTRAMUSCULAR NM; QL (1 per 168 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR NM; QL (1 per 84 SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR NM; QL (1 per 168 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR NM; QL (1 per 28 SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) NM; (capsule: 10mg) TREXALL PA BvD; ST TYKERB NM UNITUXIN PA NSO; NM VALSTAR NM VECTIBIX PA NSO; NM VELCADE PA NSO; NM vinblastine intravenous (Vinblastine Sulfate) PA BvD vincristine (Vincristine Sulfate) PA BvD vincristine sulfate intravenous solution 1 (Vincristine Sulfate) PA BvD mg/ml vinorelbine intravenous solution (Navelbine) VOTRIENT PA NSO; NM; QL (120 per 30 28

41 What the Name of Drug XALKORI XTANDI YERVOY ZALTRAP INTRAVENOUS SOLUTION ZELBORAF ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ZYDELIG ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM PA NSO; NM; QL (60 per 30 PA NSO; NM; QL (120 per 30 PA NSO; NM PA NSO; NM PA NSO; NM; QL (240 per 30 QL (1 per 84 QL (1 per 28 NM PA NSO; NM; QL (60 per 30 PA NSO; NM; QL (140 per 28 PA NSO; NM; QL (120 per 30 ST 29

42 What the Name of Drug BANZEL carbamazepine (Tegretol) carbamazepine oral capsule, er multiphase (Carbatrol) 12 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA ORAL TABLET gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 24hr ST ST 30

43 What the Name of Drug lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) (35) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION oxcarbazepine (Trileptal) OXTELLAR XR PEGANONE QL (90 per 30 QL (900 per 30 phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, 15 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 QL (2 per 30 Sodium) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG ST; QL (90 per 30 POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 ST 31

44 What the Name of Drug primidone (Mysoline) QUDEXY XR SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) TRILEPTAL ORAL SUSPENSION TROKENDI XR valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral (Depakene) solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ST NM ST ST; QL (200 per 5 ST; QL (1200 per 30 ST; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 EXELON TRANSDERMAL QL (30 per 30 galantamine oral capsule,ext rel. pellets 24 (Razadyne ER) QL (30 per 30 hr galantamine oral solution (Razadyne) QL (200 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 memantine oral tablet (Namenda) QL (60 per 30 32

45 Name of Drug What the memantine oral tablets,dose pack (Namenda) QL (49 per 28 NAMENDA ORAL SOLUTION QL (360 per 30 NAMENDA ORAL TABLET QL (60 per 30 NAMENDA TITRATION PAK QL (49 per 28 NAMENDA XR ORAL QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release (Wellbutrin SR), 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM 33

46 Name of Drug What the 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 duloxetine oral capsule,delayed (Irenka) QL (30 per 30 release(dr/ec) 40 mg EMSAM QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release (Luvox CR) 24hr fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM IRENKA QL (30 per 30 KHEDEZLA ST; QL (30 per 30 maprotiline (Maprotiline HCl) MARPLAN mirtazapine (Remeron) nefazodone (Nefazodone HCl) 34

47 What the Name of Drug 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 perphenazine-amitriptyline (Perphenazine/Amitri ptyline HCl) phenelzine (Nardil) PRISTIQ protriptyline (Vivactil) sertraline (Zoloft) SILENOR SURMONTIL 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 150 mg, 37.5 mg, 75 mg VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous PA NSO-HRM ST; QL (30 per 30 QL (30 per 30 PA NSO-HRM acarbose (Precose) QL (90 per 30 BYDUREON QL (4 per 28 35

48 Name of Drug BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML What the CYCLOSET GLYXAMBI INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA JARDIANCE JENTADUETO KORLYM QL (2.4 per 28 QL (1.2 per 28 QL (180 per 30 QL (30 per 30 ST; QL (60 per 30 ST; QL (120 per 30 ST; QL (60 per 30 ST; QL (30 per 30 QL (60 per 30 QL (30 per 30 QL (60 per 30 QL (30 per 30 ST; QL (30 per 30 QL (60 per 30 PA; NM; QL (112 per 28 36

49 Name of Drug What the metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 metformin oral tablet 500 mg (Glucophage) QL (120 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended release 24 (Glucophage XR) QL (120 per 30 hr 500 mg metformin oral tablet extended release 24 (Glucophage XR) QL (90 per 30 hr 750 mg metformin oral tablet extended release (Fortamet) QL (60 per 30 24hr nateglinide (Starlix) QL (90 per 30 pioglitazone (Actos) QL (30 per 30 pioglitazone-glimepiride (Duetact) QL (30 per 30 pioglitazone-metformin (Actoplus Met) QL (90 per 30 PRANDIMET QL (150 per 30 repaglinide (Prandin) QL (240 per 30 SYMLINPEN 120 PA; QL (10.8 per 28 SYMLINPEN 60 PA; QL (6 per 28 TRADJENTA QL (30 per 30 TRULICITY QL (4 per 28 VICTOZA PA; QL (9 per 28 Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) QL (30 per 28 QL (12 per 28 37

50 What the Name of Drug HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) LANTUS LANTUS SOLOSTAR NOVOLIN 70/30 NOVOLIN N NOVOLIN R QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (30 per 28 QL (40 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (40 per 28 QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (40 per 28 QL (40 per 28 38

51 What the Name of Drug NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL TOUJEO SOLOSTAR QL (40 per 28 QL (30 per 28 QL (40 per 28 QL (30 per 28 QL (30 per 28 QL (7.5 per 28 Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per mg glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per mg, 5 mg glipizide-metformin oral tablet mg (Glipizide/Metformin QL (60 per 30 HCl) glipizide-metformin oral tablet (Glipizide/Metformin QL (120 per 30 mg, mg HCl) glyburide micronized oral tablet 1.5 mg (Glynase) PA-HRM; QL (400 per 30 glyburide micronized oral tablet 3 mg (Glynase) PA-HRM; QL (180 per 30 glyburide micronized oral tablet 6 mg (Glynase) PA-HRM; QL (120 per 30 glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 39

52 Name of Drug What the glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 glyburide-metformin oral tablet mg (Glucovance) PA-HRM; QL (240 per 30 glyburide-metformin oral tablet mg, mg (Glucovance) PA-HRM; QL (120 per 30 tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 tolbutamide (Tolbutamide) QL (180 per 30 Antifungals Antifungals ABELCET PA BvD; NM AMBISOME PA BvD; NM amphotericin b (Amphotericin B) PA BvD baza antifungal * (Nuzole) $0 (Tier 4) CANCIDAS NM ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole * 1% cream (otc) (Lotrimin AF) $0 (Tier 4) clotrimazole * 1% solution (otc) (Clotrimazole) $0 (Tier 4) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Lotrimin) clotrimazole * vaginal cream (Gyne-Lotrimin) $0 (Tier 4) 40

53 What the Name of Drug clotrimazole * vaginal tablet (Clotrimazole) $0 (Tier 4) clotrimazole-7 * (Gyne-Lotrimin) $0 (Tier 4) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion (Clotrimazole/Betame thasone Dip) desenex (clotrimazole) * (Lotrimin AF) $0 (Tier 4) econazole topical (Econazole Nitrate) fluconazole (Diflucan) fluconazole in dextrose(iso-o) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) flucytosine (Ancobon) NM fungi cure * (Clotrimazole) $0 (Tier 4) fungoid-d * (Tinactin) $0 (Tier 4) griseofulvin microsize oral tablet (Grifulvin V) inzo antifungal * (Nuzole) $0 (Tier 4) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LOTRIMIN ULTRA * $0 (Tier 4) micatin * (Nuzole) $0 (Tier 4) miconazole 7 * vaginal suppository (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate * topical cream (Nuzole) $0 (Tier 4) miconazole nitrate * vaginal (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate * vaginal (Miconazole Nitrate) $0 (Tier 4) miconazole nitrate * vaginal kit 1,200-2 (Monistat 3) $0 (Tier 4) mg-%, 200 mg- 2 % (9 gram) miconazole nitrate vaginal suppository 200 (Monistat 3) mg miconazole-3 prefil,cream,wipe * (Miconazole/Skin Cleanser No.17) $0 (Tier 4) 41

54 What the Name of Drug MONISTAT 3 * VAGINAL COMB $0 (Tier 4) PACK,PREFILL APPL & CREAM monistat 7 * vaginal (Miconazole Nitrate) $0 (Tier 4) NOXAFIL ORAL NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) nystatin-triamcinolone (Nystatin/Triamcin) terbinafine hcl oral (Lamisil) tolnaftate * topical (Tinactin) $0 (Tier 4) tolnaftate * topical (Tolnaftate) $0 (Tier 4) vagistat-3 * (Monistat 3) $0 (Tier 4) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) NM Antihistamines Antihistamines aller-chlor * oral syrup (Chlorpheniramine Maleate) $0 (Tier 4) PA; AGE (Min 2 aller-chlor * oral tablet (Chlor-Trimeton) $0 (Tier 4) PA; AGE (Min 2 allergy (chlorpheniramine) * (Chlor-Trimeton) $0 (Tier 4) PA; AGE (Min 2 allergy relief (loratadine) * oral (Claritin) $0 (Tier 4) PA; AGE (Min 2 allergy-sinus * oral tablet (Phenylephrine/Diphe nhydramine) $0 (Tier 4) PA; AGE (Min 2 ambi 60pse-4cpm * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 aprodine * (Pseudoephedrine/Tri prolidine) NM $0 (Tier 4) PA; AGE (Min 2 42

55 Name of Drug What the banophen allergy * (Zzzquil) $0 (Tier 4) PA banophen * oral capsule 25 mg (Benadryl) $0 (Tier 4) PA banophen * oral (Diphenhydramine $0 (Tier 4) PA HCl) benadryl allergy * oral tablet (Diphenhydramine $0 (Tier 4) PA HCl) child dometuss-da * (Triaminic Cold-Allergy Pe) $0 (Tier 4) PA; AGE (Min 2 child triaminic cold & allergy * (Dimetapp) $0 (Tier 4) PA; AGE (Min 2 child wal-tap cold-allergy * (Dimetapp) $0 (Tier 4) PA; AGE (Min 2 children's wal-dryl allergy * oral (Zzzquil) $0 (Tier 4) PA child's benadryl-d allergy-sin * (Phenylephrine/Diphe nhydramine) $0 (Tier 4) PA; AGE (Min 2 clemastine oral syrup (Clemastine PA-HRM Fumarate) clemastine oral tablet 2.68 mg (Clemastine PA-HRM Fumarate) cold & cough * oral liquid (Triaminic Cold and Cough) $0 (Tier 4) PA; AGE (Min 2 compoz * (Diphenhydramine $0 (Tier 4) PA HCl) CONEX * ORAL SOLUTION $0 (Tier 4) PA; AGE (Min 2 conex * oral tablet (P-Ephed HCl/D-Bromp Mal) $0 (Tier 4) PA; AGE (Min 2 cyproheptadine (Cyproheptadine PA-HRM HCl) dimaphen (pe) * (Dimetapp) $0 (Tier 4) PA; AGE (Min 2 dimetapp cold-congestion * (Triaminic Cold and Cough) $0 (Tier 4) PA; AGE (Min 2 diphenhist * oral capsule (Benadryl) $0 (Tier 4) PA 43

56 Name of Drug What the diphenhist * oral (Zzzquil) $0 (Tier 4) PA diphenhist * oral tablet 25 mg (Diphenhydramine $0 (Tier 4) PA HCl) diphenhydramine hcl injection solution 50 (Diphenhydramine mg/ml HCl) diphenhydramine hcl injection syringe (Diphenhydramine HCl) diphenhydramine hcl * oral capsule (Benadryl) $0 (Tier 4) PA diphenhydramine hcl * oral tablet 50 mg (Diphenhydramine $0 (Tier 4) PA HCl) diphenhydramine-phenylephrine * (Triaminic Cold and Cough) $0 (Tier 4) PA; AGE (Min 2 ed chlorped jr * (Chlorpheniramine Maleate) $0 (Tier 4) PA; AGE (Min 2 entre-hist pse * (Pseudoephedrine/Tri prolidine) $0 (Tier 4) PA; AGE (Min 2 geri-dryl * oral capsule (Benadryl) $0 (Tier 4) histex pe * (Phenylephrine/Tripr olidine) $0 (Tier 4) PA; AGE (Min 2 levocetirizine (Xyzal) lohist - d * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 lohist-peb * (Brovex Peb) $0 (Tier 4) PA; AGE (Min 2 lohist-psb * (Pseudoephedrine/Br ompheniramin) $0 (Tier 4) PA; AGE (Min 2 loradamed * (Claritin) $0 (Tier 4) PA; AGE (Min 2 loratadine * oral (Claritin) $0 (Tier 4) PA; AGE (Min 2 loratadine * oral (Claritin) $0 (Tier 4) PA; AGE (Min 2 nyt-time sleep * (Diphenhydramine HCl) $0 (Tier 4) PA 44

57 Name of Drug What the pediatex td * (Pseudoephedrine/Tri prolidine) $0 (Tier 4) PA; AGE (Min 2 phenylephrine-brompheniramin * (Phenylephrine/Brom pheniramine) $0 (Tier 4) PA; AGE (Min 2 phenylephrine-chlorpheniramine * oral liquid 4-10 mg/5 ml (Triaminic Cold-Allergy Pe) $0 (Tier 4) PA; AGE (Min 2 phenylephrine-chlorpheniramine * oral tablet 4-10 mg (Phenylephrine/Chlor pheniramine) $0 (Tier 4) PA; AGE (Min 2 promethazine oral syrup (Promethazine HCl) PA-HRM q-dryl * oral liquid (Zzzquil) $0 (Tier 4) PA q-tapp * (Pseudoephedrine/Br ompheniramin) $0 (Tier 4) PA; AGE (Min 2 siladryl sa * (Zzzquil) $0 (Tier 4) PA simply sleep * (Diphenhydramine $0 (Tier 4) PA HCl) sinus & allergy (pseudoephed) * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 sinus nighttime * (Phenylephrine/Tripr olidine) $0 (Tier 4) PA; AGE (Min 2 sleep-tabs * (Diphenhydramine $0 (Tier 4) PA HCl) sudogest cold & allergy * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 triacting orange * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 TRIAMINIC COLD & COUGH NT (PE) * $0 (Tier 4) PA; AGE (Min 2 trymine d * (Pseudoephedrine/Tri prolidine) $0 (Tier 4) PA; AGE (Min 2 unisom sleepgels * (Benadryl) $0 (Tier 4) PA vazobid-pd * (Phenylephrine/Brom pheniramine) $0 (Tier 4) PA; AGE (Min 2 wal-act d cold & allergy * (Pseudoephedrine/Tri prolidine) $0 (Tier 4) PA; AGE (Min 2 45

58 Name of Drug What the wal-dryl allergy * oral (Benadryl) $0 (Tier 4) PA wal-dryl allergy * oral (Diphenhydramine $0 (Tier 4) PA HCl) wal-finate * (Chlor-Trimeton) $0 (Tier 4) PA; AGE (Min 2 wal-finate-d * (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 wal-itin * (Claritin) $0 (Tier 4) PA; AGE (Min 2 wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlorp heniramine) $0 (Tier 4) PA; AGE (Min 2 wal-phed pe sinus & allergy * (Phenylephrine/Chlor pheniramine) $0 (Tier 4) PA; AGE (Min 2 wal-sleep z * oral capsule (Benadryl) $0 (Tier 4) wal-som (diphenhydramine) * oral (Benadryl) $0 (Tier 4) PA capsule wal-som (diphenhydramine) * oral tablet,disintegrating (Unisom Sleepmelts) $0 (Tier 4) wal-tap * (Dimetapp) $0 (Tier 4) PA; AGE (Min 2 z-sleep * oral capsule (Benadryl) $0 (Tier 4) PA Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 dihydroergotamine nasal (Migranal) QL (4 per 28 46

59 What the Name of Drug ERGOMAR QL (40 per 28 naratriptan (Amerge) QL (18 per 28 rizatriptan oral tablet (Maxalt) QL (18 per 28 rizatriptan oral tablet,disintegrating (Maxalt Mlt) QL (18 per 28 sumatriptan nasal spray (Imitrex) QL (12 per 28 sumatriptan oral tablet (Imitrex) QL (18 per 28 sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 cartridge sumatriptan succinate subcutaneous pen (Imitrex) QL (4 per 28 injector sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 solution zolmitriptan oral tablet (Zomig) QL (12 per 28 zolmitriptan oral tablet,disintegrating (Zomig Zmt) QL (12 per 28 Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER 47

60 What the Name of Drug SIRTURO PA; NM; QL (188 per 168 TRECATOR Antinausea Agents Antinausea Agents ambizine * (Meclizine HCl) $0 (Tier 4) PA; AGE (Min 2 dimenhydrinate injection solution (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK granisetron (pf) intravenous solution (Granisetron HCl/PF) granisetron hcl intravenous solution 1 (Kytril) mg/ml (1 ml) QL (2 per 28 PA BvD; QL (1 per 1 day) QL (1 per 1 day) PA BvD; QL (2 per 1 day) PA BvD; QL (3 per 1 day) granisetron hcl oral (Granisetron HCl) PA BvD meclizine * 12.5 mg caplet caplet (otc) (Meclizine HCl) $0 (Tier 4) PA; AGE (Min 2 meclizine * 25 mg tablet (otc) (Meclizine HCl) $0 (Tier 4) PA; AGE (Min 2 meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness (meclizine) * (Meclizine HCl) $0 (Tier 4) PA; AGE (Min 2 ondansetron (Zofran Odt) PA BvD 48

61 Name of Drug What the ondansetron hcl (pf) (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine (Compazine) prochlorperazine edisylate injection (Compazine) solution prochlorperazine maleate (Compazine) prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine HCl) PA-HRM promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (10 per 30 travel sickness (meclizine) * (Bonine) $0 (Tier 4) PA; AGE (Min 2 Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) NM atovaquone-proguanil (Malarone) BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) 49

62 What the Name of Drug metronidazole in nacl (iso-os) (Metronidazole/Sodiu m Chloride) metronidazole oral (Flagyl) NEBUPENT paromomycin (Paromomycin Sulfate) PENTAM pin-x * oral suspension (Pyrantel Pamoate) $0 (Tier 4) PRIMAQUINE PA BvD QL (90 per 30 quinine sulfate (Qualaquin) PA; QL (42 per 7 reese's pinworm medicine * (Pyrantel Pamoate) $0 (Tier 4) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) APOKYN AZILECT benztropine oral (Benztropine Mesylate) 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 NM; QL (60 per 30 PA-HRM ST; QL (30 per 30 50

63 What the Name of Drug pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 (Requip XL) hr selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR ABILIFY MAINTENA ABILIFY ORAL SOLUTION PA-HRM QL (90 per 30 QL (60 per 30 QL (161.2 per 28 NM; QL (1 per 28 QL (900 per 30 aripiprazole oral solution (Abilify) QL (900 per 30 aripiprazole oral tablet 10 mg, 15 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 100 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg (Fazaclo) ST; QL (90 per 30 clozapine oral tablet,disintegrating 150 mg (Fazaclo) ST; QL (180 per 30 51

64 Name of Drug What the clozapine oral tablet,disintegrating 200 mg (Fazaclo) ST; QL (120 per 30 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 solution 100 mg/ml Decanoate) haloperidol decanoate intramuscular (Haldol Decanoate solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, ST; QL (30 per 30 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG ST; QL (60 per 30 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML NM; QL (0.75 per 28 NM; QL (1 per 28 NM; QL (1.5 per 28 QL (0.25 per 28 52

65 Name of Drug INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG What the QL (0.5 per 28 NM; QL (0.875 per 84 NM; QL (1.315 per 84 NM; QL (1.75 per 84 NM; QL (2.625 per 84 ST; QL (30 per 30 LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 olanzapine oral tablet (Zyprexa) QL (30 per 30 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (30 per 30 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 (Zyprexa Zydis) QL (31 per 30 mg ORAP paliperidone oral tablet extended release (Invega) QL (30 per 30 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release (Invega) QL (60 per 30 24hr 6 mg perphenazine (Perphenazine) pimozide (Orap) 53

66 Name of Drug What the quetiapine (Seroquel) QL (90 per 30 REXULTI ORAL TABLET 0.25 MG ST; NM; QL (120 per 30 REXULTI ORAL TABLET 0.5 MG ST; NM; QL (60 per 30 REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG ST; NM; QL (30 per 30 RISPERDAL CONSTA QL (4 per 28 risperidone oral solution (Risperdal) QL (480 per 30 risperidone oral tablet (Risperdal) QL (60 per 30 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) QL (60 per 30 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, (Risperdal M-Tab) QL (120 per 30 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG ST; QL (60 per 30 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG ST; QL (30 per 30 thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Thiothixene) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; NM; QL (540 per 30 ziprasidone hcl (Geodon) QL (60 per 30 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG NM; QL (2 per 28 54

67 What the Name of Drug Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) NM APTIVUS ORAL CAPSULE NM APTIVUS ORAL SOLUTION ATRIPLA NM COMPLERA NM CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT NM EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM NM EVOTAZ NM FUZEON SUBCUTANEOUS NM INTELENCE ORAL TABLET 100 NM MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE NM 55

68 What the Name of Drug 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) NM LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET NM nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr NORVIR PREZCOBIX NM PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 400 MG, NM 600 MG, 800 MG RESCRIPTOR NM NM NM 56

69 What the Name of Drug RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine (Zerit) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION NM NM NM NM NM NM NM NM NM 57

70 Name of Drug What the zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER rimantadine (Flumadine) SYNAGIS NM TAMIFLU ORAL CAPSULE 30 MG QL (84 per 180 TAMIFLU ORAL CAPSULE 45 MG QL (48 per 180 TAMIFLU ORAL CAPSULE 75 MG QL (42 per 180 TAMIFLU ORAL SUSPENSION FOR QL (540 per 180 RECONSTITUTION Hcv Antivirals DAKLINZA PA; NM; QL (28 per 28 HARVONI PA; NM; QL (30 per 30 OLYSIO PA; NM; QL (28 per 28 SOVALDI PA; NM; QL (28 per 28 TECHNIVIE PA; NM; QL (56 per 28 VIEKIRA PAK PA; NM; QL (112 per 28 Interferons INTRON A INJECTION PA NSO 58

71 What the Name of Drug PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN SYLATRON PA; NM PA; NM PA; NM PA; NM PA NSO; NM; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) acyclovir sodium intravenous recon soln (Acyclovir Sodium) PA BvD acyclovir sodium intravenous solution (Acyclovir Sodium) PA BvD adefovir (Hepsera) NM entecavir (Baraclude) NM famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 (Copegus) mg TYZEKA NM valacyclovir (Valtrex) valganciclovir (Valcyte) NM VIRAZOLE PA BvD; NM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) NM 59

72 What the Name of Drug ELIQUIS enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 enoxaparin subcutaneous syringe 100 mg/ml (Lovenox) NM; QL (36 per 30 enoxaparin subcutaneous syringe 120 mg/0.8 ml (Lovenox) NM; QL (27.2 per 30 enoxaparin subcutaneous syringe 150 mg/ml (Lovenox) NM; QL (34 per 30 enoxaparin subcutaneous syringe 30 (Lovenox) QL (18 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) QL (13.6 per 30 mg/0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (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 10 (Arixtra) QL (24 per 30 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) QL (15 per 30 mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) QL (12 per 30 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 (Arixtra) QL (18 per 30 mg/0.6 ml heparin (porcine) in 5 % dex intravenous (Heparin Sodium in parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) 5% Dextrose) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) 60

73 Name of Drug heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection HEPARIN SODIUM,PORCINE-PF * INTRAVENOUS SYRINGE 100 UNIT/ML heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection (Heparin Sodium,Porcine/Ns/P F) (Heparin Sodium,Porcine) What the PA BvD; (PA for ESRD Only) $0 (Tier 3) (Heparin Sodium,Porcine/PF) PA BvD (Monoject Prefill PA BvD; (PA for Advanced) ESRD Only) heparin, porcine (pf) intravenous syringe (Monoject Prefill 100 unit/ml Advanced) HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 (Heparin Sodium in units/ml) bag excel container 5% Dextrose) heparin-d5w 25,000 units/500 ml (50 (Heparin Sodium in units/ml) bag excel container 5% Dextrose) IPRIVASK PA; NM; QL (24 per 28 jantoven (Coumadin) PRADAXA QL (60 per 30 warfarin (Coumadin) XARELTO 61

74 Name of Drug Blood Formation Modifiers EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML What the GRANIX LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ZARXIO Hematologic Agents, Miscellaneous aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet (Amicar) PA; QL (12 per 28 NM NM PA; QL (0.6 per 28 NM NM NM NM PA; QL (12 per 28 PA; NM; QL (12 per 28 PA; NM; QL (6 per 28 PA; NM; QL (30 per 30 ST; NM 62

75 Name of Drug What the 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 aspirin-dipyridamole (Aggrenox) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % 63

76 What the Name of Drug ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % Caloric Agents Caloric Agents AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 64

77 What the Name of Drug AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % boost kid essentials * (Pediatric Nutrition, Iron, Lf) bright beginnings soy * (Ped.Nutrit.,Soy,Iron,Lact Free) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD $0 (Tier 4) PA; AGE (Max 4 $0 (Tier 4) PA; AGE (Max 4 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 65

78 What the Name of Drug CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD cysteine (l-cysteine) intravenous solution (Cysteine HCl) PA BvD d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 % NaCl) d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) 66

79 Name of Drug What the dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) 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 5 %-lactated ringers (Dextrose 5%-Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2% NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2% NaCl) FREAMINE HBC 6.9 % PA BvD FREAMINE III 10 % PA BvD HEPATAMINE 8% PA BvD 67

80 What the Name of Drug HEPATASOL 8 % IMPACT 1 CAL * $0 (Tier 4) impact advanced recovery * (Nut.Tx.Comp. $0 (Tier 4) Immune Systm,Reg) INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN LIPOSYN II LIPOSYN III msud 2 * (Acerflex) $0 (Tier 4) NEPHRAMINE 5.4 % NUTRILIPID NUTRIT SUPP-INULIN-FOS-FIBER $0 (Tier 4) * ORAL LIQUID GRAM-KCAL/ML NUTRITIONAL SUPPLEMENT * $0 (Tier 4) ORAL LIQUID pediasure * oral liquid (Pediatric Nutrition, gram-kcal/ml Iron, Lf) pediatric drink * (Pediatric Nutrition, Iron, Lf) PEPTAMEN JUNIOR WITH $0 (Tier 4) PREBIO1 * PERIKABIVEN PHENYL-FREE 1 * $0 (Tier 4) potassium chloride in lr-d5 intravenous parenteral solution (Potassium Chloride In Lr-D5) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD $0 (Tier 4) PA; AGE (Max 5 $0 (Tier 4) PA; AGE (Max 4 PA BvD 68

81 What the Name of Drug PREMASOL 10 % PREMASOL 6 % PROCALAMINE 3% PROSOL 20 % ra pediatric nutrition drink * (Pediatric Nutrition, Iron, Lf) TRAVASOL 10 % TROPHAMINE 10 % TROPHAMINE 6% twocal hn * (Nut.Sup,Spec.Frm,L $0 (Tier 4) -Fr,Iron/Fos) Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) clonidine hcl-chlorthalidone (Clonidine HCl/Chlorthalidone) clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr PA BvD PA BvD PA BvD PA BvD $0 (Tier 4) PA; AGE (Max 4 PA BvD PA BvD PA BvD (Catapres-Tts 1) QL (4 per 28 (Catapres-Tts 1) QL (8 per 28 doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) nasal decongestant (pe) * oral (Medi-Phenyl) $0 (Tier 4) PA; AGE (Min 2 69

82 What the Name of Drug NORTHERA PA; NM; QL (180 per 30 phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) wal-phed pe * (Medi-Phenyl) $0 (Tier 4) PA; AGE (Min 2 Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) ENTRESTO irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) captopril-hydrochlorothiazide (Captopril/Hydrochlo rothiazide) enalapril maleate (Vasotec) PA; QL (60 per 30 ST 70

83 What the Name of Drug enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) fosinopril-hydrochlorothiazide (Fosinopril/Hydrochl orothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 (Cordarone) mg, 400 mg amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) ml (1%) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 8 mg/ml (0.8 %) HCl/D5w/PF) mexiletine (Mexiletine HCl) MULTAQ procainamide injection (Procainamide HCl) propafenone oral capsule,extended release (Rythmol SR) 12 hr propafenone oral tablet (Rythmol) 71

84 Name of Drug What the quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydroc hlorothiazid) sotalol hcl oral tablet 120 mg, 160 mg, 240 (Betapace) mg, 80 mg 72

85 What the Name of Drug sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Diltiazem HCl) diltiazem hcl oral capsule, extended (Cardizem CD) release 180 mg, 360 mg diltiazem hcl oral capsule, extended (Tiazac) release 420 mg diltiazem hcl oral capsule,extended release (Diltiazem HCl) 12 hr diltiazem hcl oral capsule,extended release (Cardizem CD) 24hr diltiazem hcl oral tablet (Cardizem) diltiazem hcl oral tablet extended release (Cardizem LA) 24 hr dilt-xr (Dilacor XR) matzim la (Cardizem LA) taztia xt (Tiazac) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) verapamil oral capsule,ext rel. pellets 24 (Verelan) hr verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) adrenalin injection solution 1 mg/ml (Epinephrine) (1:1,000)(1ml) CORLANOR ST 73

86 Name of Drug What the DEMSER digitek oral tablet 125 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) PA-HRM; QL (30 per 30 digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) (Dobutamine HCl/D5W) PA BvD dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose intravenous (Dopamine PA BvD solution HCl/D5W) dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine 1 mg/ml ampul latex-free (Epinephrine) epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) 74

87 What the Name of Drug EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET MCG, 62.5 MCG NM PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 milrinone (Milrinone Lactate) PA BvD; NM milrinone in 5 % dextrose intravenous (Milrinone PA BvD; NM piggyback 40 mg/200 ml (200 mcg/ml) Lactate/D5W) norepinephrine bitartrate (Levophed Bitartrate) PA BvD papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) amlodipine-valsartan (Exforge) amlodipine-valsartan-hcthiazid (Exforge HCT) AZOR ST CLEVIPREX INTRAVENOUS EMULSION felodipine (Felodipine) isradipine (Isradipine) 75

88 What the Name of Drug nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release (Procardia XL) 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) mg, 60 mg Diuretics amiloride oral (Midamor) amiloride-hydrochlorothiazide (Amiloride/Hydrochl orothiazide) 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 amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) 76

89 What the Name of Drug cholestyramine-aspartame oral powder 4 (Cholestyramine/Asp gram artame) cholestyramine-aspartame oral powder in (Cholestyramine/Asp packet 4 gram artame) colestipol (Colestid) CRESTOR fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lovastatin (Mevacor) niacin oral tablet extended release 24 hr (Niaspan) omega-3 acid ethyl esters (Lovaza) PRALUENT PEN PRALUENT SYRINGE pravastatin (Pravachol) REPATHA SURECLICK REPATHA SYRINGE PA; NM; QL (2 per 28 PA; NM; QL (2 per 28 PA; NM; QL (3 per 28 PA; NM; QL (3 per 28 simvastatin (Zocor) QL (30 per 30 VASCEPA WELCHOL ZETIA 77

90 What the Name of Drug Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators BIDIL isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet (Imdur) extended release 24 hr minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 mg/hr minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution nitroglycerin intravenous (Nitroglycerin) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT PROGLYCEM (Nitro-Dur) QL (30 per 30 (Nitro-Dur) QL (60 per 30 (Nitro-Dur) QL (30 per 30 (Nitro-Dur) QL (60 per 30 78

91 Name of Drug Central Nervous System Agents Central Nervous System Agents What the amphetamine salt combo (Adderall) QL (60 per 30 AMPYRA PA; NM; 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) 12 hr dexmethylphenidate oral tablet (Focalin) QL (60 per 30 dextroamphetamine oral capsule, extended (Dexedrine) QL (120 per 30 release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (30 per 30 capsule,extended release 24hr 10 mg, 15 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 (Eskalith) lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended (Lithobid) release lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic (Metadate Cd) QL (30 per mg, 20 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg (Metadate Cd) QL (60 per 30 79

92 Name of Drug What the methylphenidate oral capsule,er biphasic (Metadate Cd) QL (30 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) QL (60 per mg methylphenidate oral capsule,er biphasic (Ritalin LA) QL (30 per mg methylphenidate oral solution (Methylin) QL (900 per 30 methylphenidate oral tablet (Ritalin) QL (90 per 30 methylphenidate oral tablet extended (Ritalin-SR) QL (90 per 30 release methylphenidate oral tablet extended (Concerta) QL (30 per 30 release 24hr 18 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 tetrabenazine (Xenazine) PA; NM; QL (112 per 28 XENAZINE PA; NM; QL (112 per 28 Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 cyred (Desogen) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) 80

93 What the Name of Drug desogestrel-ethinyl estradiol oral tablet (Desogen) 0.1/.125/ mg-mcg, mg drospirenone-ethinyl estradiol (Yaz) ELLA ethinyl estradiol/drospirenone (Yaz) ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl Estradiol) fallback solo * (Take Action) $0 (Tier 4) PA; QL (6 per 365 gildess 24 fe (Loestrin Fe) GYNOL II * $0 (Tier 4) junel fe 24 (Loestrin Fe) kimidess (28) (Mircette) l norgest/e.estradiol-e.estrad (Seasonique) QL (91 per 84 larin 24 fe (Loestrin Fe) levonorgestrel * 1.5 mg tablet (otc) (Take Action) $0 (Tier 4) PA; QL (6 per 365 levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 levonorgestrel * oral tablet 1.5 mg (Take Action) $0 (Tier 4) PA; QL (6 per 365 levonorgestrel-ethin estradiol oral tablet (Amethyst) mg-mcg, mg, (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethi QL (91 per 84 tablets,dose pack,3 month mg-mcg n Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) levonorgestrel-ethinyl estrad oral (Levonorgestrel-Ethi QL (91 per 84 tablets,dose pack,3 month n Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 noreth-ethinyl estradiol/iron (Femcon Fe) 81

94 What the Name of Drug norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol oral tablet (Loestrin) 1-20 mg-mcg, mg-mcg norethindrone-e.estradiol-iron (Loestrin Fe) norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet (Modicon) mg-mcg, mg-mcg, /1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 opcicon one-step * (Take Action) $0 (Tier 4) PA; QL (6 per 365 setlakin (Levonorgestrel-Ethi QL (91 per 84 n Estradiol) tarina fe (Loestrin Fe) VAGINAL CONTRACEPTIVE FOAM * $0 (Tier 4) WIDE-SEAL DIAPHRAGM 70 * $0 (Tier 3) Cough And Cold Products Cough And Cold Products adult nasal decongestant * (Pseudoephedrine HCl) cheratussin ac * (M-Clear Wc) $0 (Tier 4) $0 (Tier 4) PA; AGE (Min 2 82

95 Name of Drug What the children's silfedrine * (Pseudoephedrine HCl) $0 (Tier 4) PA; AGE (Min 2 children's sudafed * (Pseudoephedrine HCl) $0 (Tier 4) PA; AGE (Min 2 guaiatussin ac * (M-Clear Wc) $0 (Tier 4) nasal & sinus decongestant * (Sudafed 12-Hour) $0 (Tier 4) PA; AGE (Min 2 phenylhistine dh * (P-Ephed HCl/Cod/Chlorpheni r) (Promethazine HCl/Codeine) (Promethazine/Dextr omethorphan) (Promethazine/Pheny leph/codeine) (Pseudoephedrine HCl) $0 (Tier 4) PA; AGE (Min 2 promethazine-codeine * $0 (Tier 3) PA; AGE (Min 2 promethazine-dm * $0 (Tier 3) PA; AGE (Min 2 promethazine-phenyleph-codeine * $0 (Tier 3) PA; AGE (Min 2 pseudoephedrine hcl * oral $0 (Tier 4) PA; AGE (Min 2 pseudoephedrine hcl * oral (Sudafed 12-Hour) $0 (Tier 4) PA; AGE (Min 2 sudogest * (Sudafed 12-Hour) $0 (Tier 4) PA; AGE (Min 2 suphedrin * oral (Pseudoephedrine HCl) $0 (Tier 4) PA; AGE (Min 2 wal-phed * oral tablet 30 mg (Sudafed 12-Hour) $0 (Tier 4) PA; AGE (Min 2 Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) chlorhexidine gluconate mucous (Peridex) membrane pilocarpine hcl oral (Salagen) triamcinolone acetonide dental (Triamcinolone Acetonide) 83

96 Name of Drug What the Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) NM acne medication * topical gel (Benzoyl Peroxide) $0 (Tier 4) acne-clear * (Benzoyl Peroxide) $0 (Tier 4) acyclovir topical (Zovirax) QL (30 per 30 ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Aluminum Chloride) ammonium lactate (Lac-Hydrin) ANACAINE $0 (Tier 4) benzalkonium chloride * solution 17 % (Benzalkonium Chloride) benzoyl peroxide * 10% gel aqueous (rx) (Benzac Ac) $0 (Tier 4) benzoyl peroxide * topical gel 10 %, 5 % (Benzoyl Peroxide) $0 (Tier 4) calamine * (Calamine) $0 (Tier 4) calcipotriene topical cream (Dovonex) calcipotriene topical ointment (Calcipotriene) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) PA NSO; NM PA NSO; NM PA NSO; NM 84

97 Name of Drug What the DRYSOL DAB-O-MATIC elta tar * (Coal Tar) $0 (Tier 4) FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) ichthammol * (Ichthammol) $0 (Tier 4) imiquimod (Aldara) PA NSO; QL (24 per 30 isotretinoin oral capsule 10 mg, 20 mg, 30 (Isotretinoin) mg, 40 mg mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) NM mg217 psoriasis * (Coal Tar) $0 (Tier 4) PANRETIN NM persa-gel * (Benzoyl Peroxide) $0 (Tier 4) PICATO TOPICAL GEL % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox (Condylox) podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) SANTYL scalp itch-dandruff relief * (Oil-Free Acne Wash) $0 (Tier 4) silver nitrate applicators (Silver Nitrate Applicator) VALCHLOR NM 85

98 What the Name of Drug ZOVIRAX TOPICAL CREAM Dermatological Antibacterials bacitracin * topical (Bacitracin) $0 (Tier 4) bacitracin-polymyxin b * topical (Bacitracin/Polymyxi $0 (Tier 4) n B Sulfate) bacitraycin plus * topical ointment 500 (Bacitracin) $0 (Tier 4) unit/gram clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) erythromycin with ethanol topical swab (Erythromycin Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) polysporin * (Bacitracin/Polymyxi $0 (Tier 4) n B Sulfate) selenium sulfide (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) QL (15 per 30 86

99 What the Name of Drug Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) alclometasone topical ointment (Alclometasone Dipropionate) aquanil hc * (Cortizone-10) $0 (Tier 4) beta-hc * (Cortizone-10) $0 (Tier 4) betamethasone dipropionate topical cream (Diprosone) betamethasone dipropionate topical lotion (Betamethasone Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical cream (Betamethasone Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical lotion (Betamethasone Valerate) betamethasone valerate topical ointment (Betamethasone Valerate) betamethasone, augmented topical cream (Diprolene AF) betamethasone, augmented topical gel (Betamethasone Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical (Diprolene) ointment clobetasol propionate topical solution 0.05 (Clobetasol % Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) 87

100 What the Name of Drug clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) CORDRAN TOPICAL OINTMENT cortaid * topical cream (Hydrocortisone) $0 (Tier 4) cortizone-10 * topical cream (Hydrocortisone) $0 (Tier 4) CORTIZONE-10 * TOPICAL LOTION $0 (Tier 4) cortizone-10 * topical ointment (Hydrocortisone) $0 (Tier 4) dermarest eczema (hydrocort) * (Cortizone-10) $0 (Tier 4) desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hc-1% hemorrhoid * (Hydrocortisone Acetate) hydrocortisone * 1% cream maximum (Hydrocortisone) $0 (Tier 4) strength (otc) hydrocortisone * 1% ointment carton (Hydrocortisone) $0 (Tier 4) (otc) hydrocortisone acet-aloe vera topical gel (Hydrocortisone Acetate/Aloe V) PA; AGE (Min 2 $0 (Tier 4) (OTC cream and ointment only) 88

101 Name of Drug What the hydrocortisone acetate * topical (Hydrocortisone Acetate) $0 (Tier 4) (OTC cream and ointment only) hydrocortisone acetate-aloe * (Hydrocortisone $0 (Tier 4) Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) $0 (Tier 4) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Cortizone-10) $0 (Tier 4) hydrocortisone topical lotion 2 %, 2.5 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) $0 (Tier 4) hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream (Hydrocortisone Valerate) hydrocortisone valerate topical ointment (Westcort) hydroskin * topical lotion (Cortizone-10) $0 (Tier 4) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) $0 (Tier 4) obagi nu-derm tolereen * (Cortizone-10) $0 (Tier 4) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) $0 (Tier 4) recort plus * (Hydrocortisone) $0 (Tier 4) tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Kenalog) 89

102 Name of Drug triamcinolone acetonide topical ointment %, 0.05 %, 0.1 %, 0.5 % triderm topical cream What the (Triderm) (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) PA tretinoin topical cream (Retin-A) PA tretinoin topical gel 0.01 %, % (Retin-A) PA Scabicides And Pediculicides lice cream rinse * (Nix) $0 (Tier 4) lice killing * (Piperonyl $0 (Tier 4) Butoxide/Pyrethrins) lice treatment (permethrin) * (Nix) $0 (Tier 4) lice treatment * topical (Piperonyl $0 (Tier 4) Butoxide/Pyrethrins) lice treatment * topical liquid 1 % (Nix) $0 (Tier 4) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) $0 (Tier 4) Devices Devices AEROCHAMBER PLUS FLOW-VU * $0 (Tier 3) AEROCHAMBER PLUS $0 (Tier 3) FLOW-VU,M MSK * AEROCHAMBER PLUS Z STAT MD $0 (Tier 3) MSK * ASSURE ID INSULIN SAFETY SYRINGE 90

103 What the Name of Drug BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" BD LUER-LOK SYRINGE SYRINGE 1 ML 20 X 1" INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U-100 SYRINGE NESSI SPACER * $0 (Tier 3) OPTICHAMBER ADULT $0 (Tier 3) MASK-LARGE * PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U-100 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA CIMZIA POWDER FOR RECONST CREON ELAPRASE NM NM NM PA; NM PA; NM NM 91

104 What the Name of Drug ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME VIMIZIM VPRIV ZAVESCA ZENPEP NM NM NM NM QL (30 per 30 NM NM NM NM NM PA BvD; NM PA; NM NM NM; QL (90 per 30 92

105 Name of Drug What the Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine (Tetcaine) apraclonidine (Iopidine) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) azelastine nasal (Astepro) QL (30 per 25 azelastine ophthalmic (Optivar) carteolol (Carteolol HCl) cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN NM epinastine (Elestat) homatropine hbr (Isopto Homatropine) ipratropium bromide nasal (Atrovent) QL (30 per 28 spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) QL (15 per 10 spray,non-aerosol 0.06 % LACRISERT muro 128 * (Sodium Chloride) $0 (Tier 4) naphazoline (Naphazoline HCl) olopatadine (Patanase) QL (30.5 per 30 PATADAY ST PATANOL ST 93

106 What the Name of Drug phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod (Proparacaine/Fluore scein Sod) sochlor * ophthalmic (Sodium Chloride) $0 (Tier 4) sodium chloride * ophthalmic (Sodium Chloride) $0 (Tier 4) tetracaine hcl (Tetcaine) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxi n B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment (Garamycin) 0.3 % (3 mg/gram) levofloxacin ophthalmic (Quixin) MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci Zn/Poly/HC) neomycin-bacitracin-poly-hc (Neomycin Su/Baci Zn/Poly/HC) 94

107 neomycin-bacitracin-polymyxin Name of Drug (Neomycin Su/Bacitra/Polymyxin ) What the neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Predn isolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL fluorometholone (FML) 95

108 Name of Drug What the flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (16 per 30 ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX QL (34 per 28 NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate ophthalmic (Prednisolone Sod (Drops) Phosphate) PROLENSA RESTASIS QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) $0 (Tier 4) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine (Tagamet) (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole oral capsule,delayed release(dr/ec) (Prevacid) (Rx Product Only) 96

109 What the Name of Drug misoprostol (Cytotec) omeprazole magnesium * (Omeprazole $0 (Tier 4) Magnesium) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) pub famotidine * 20 mg tablet max (Pepcid Ac) $0 (Tier 4) strength (otc) ranitidine 150 mg tablet maximum (Zantac) $0 (Tier 4) strength (otc) ranitidine hcl injection (Zantac) (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) (Rx Product Only) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) Gastrointestinal Agents, Other almacone * oral suspension (Maalox Maximum $0 (Tier 4) Strength) almacone-2 * (Maalox Maximum $0 (Tier 4) Strength) aluminum hydroxide gel * (Aluminum $0 (Tier 4) Hydroxide) AMITIZA QL (60 per 30 antacid * oral (Tums) $0 (Tier 4) antacid plus anti-gas * oral suspension (Maalox Maximum $0 (Tier 4) Strength) anti-diarrheal * (Pepto-Bismol) $0 (Tier 4) bismatrol * (Pepto-Bismol) $0 (Tier 4) BUPHENYL ORAL TABLET NM 97

110 What the Name of Drug calci-chew * (Tums) $0 (Tier 4) calcium carbonate * oral tablet,chewable (Tums) $0 (Tier 4) 500 mg calcium (1,250 mg) CHOLBAM comfort gel extra strength * (Maalox Maximum $0 (Tier 4) Strength) cromolyn oral (Gastrocrom) NM dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diotame instydose * (Bismuth $0 (Tier 4) Subsalicylate) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Maalox Maximum $0 (Tier 4) Strength) foaming antacid * oral tablet,chewable (Gaviscon) $0 (Tier 4) gelusil antacid & anti-gas * oral (Maalox Maximum $0 (Tier 4) suspension Strength) gelusil antacid & anti-gas * oral (Almacone) $0 (Tier 4) tablet,chewable glycopyrrolate (Robinul) glycopyrrolate (Robinul) kaopectate (bismuth subsalicy) * (Pepto-Bismol) $0 (Tier 4) kaopectate ex str (bismuth ss) * (Pepto-Bismol) $0 (Tier 4) kola-pectin ds * (Pepto-Bismol) $0 (Tier 4) lactulose oral solution (Lactulose) loperamide oral (Loperamide HCl) maalox advanced * oral suspension (Maalox Maximum $0 (Tier 4) Strength) MAALOX MAXIMUM STRENGTH * $0 (Tier 4) NM 98

111 What the Name of Drug masanti double strength * (Maalox Maximum $0 (Tier 4) Strength) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) mi-acid * oral suspension (Maalox Maximum $0 (Tier 4) Strength) mintox * (Maalox Maximum $0 (Tier 4) Strength) mintox maximum strength * (Maalox Maximum $0 (Tier 4) Strength) mintox plus * (Almacone) $0 (Tier 4) MOVANTIK NUTRESTORE pep-t-med * (Pepto-Bismol) $0 (Tier 4) RELISTOR SUBCUTANEOUS RELISTOR SUBCUTANEOUS ri-gel ii * (Maalox Maximum $0 (Tier 4) Strength) ri-mox * (Maalox Maximum $0 (Tier 4) Strength) ri-mox plus * (Maalox Maximum $0 (Tier 4) Strength) soothe (bismuth subsalicylate) * oral (Bismuth $0 (Tier 4) Subsalicylate) soothe regular strength * (Pepto-Bismol) $0 (Tier 4) stomach relief * oral (Bismuth $0 (Tier 4) Subsalicylate) QL (30 per 30 PA; QL (28 per 28 PA; QL (28 per 28 99

112 What the Name of Drug ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives bisac-evac * (Dulcolax) $0 (Tier 4) bisacodyl * rectal (Dulcolax) $0 (Tier 4) biscolax * (Dulcolax) $0 (Tier 4) COLACE CLEAR * $0 (Tier 4) colace * oral capsule 100 mg (Colace Clear) $0 (Tier 4) col-rite * oral capsule (Colace Clear) $0 (Tier 4) doc-q-lace * (Colace Clear) $0 (Tier 4) dok * oral capsule (Colace Clear) $0 (Tier 4) dulcolax stool softener (dss) * (Colace Clear) $0 (Tier 4) MOVIPREP peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) phillips liqui-gels * (Colace Clear) $0 (Tier 4) polyethylene glycol 3350 oral (Polyethylene Glycol 3350) sodium chloride-nahco3-kcl-peg oral recon (Nulytely with Flavor soln 420 gram Packs) stool softener * oral capsule 50 mg (Colace Clear) $0 (Tier 4) the magic bullet * (Dulcolax) $0 (Tier 4) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) CALCIUM ACETATE * ORAL $0 (Tier 4) TABLET 668 MG (169 MG CALCIUM) 100

113 calcium carbonate-mag carb-fa Name of Drug (Calcium Carbonate/Mag Carb/Fa) What the calphron * (Calcium Acetate) $0 (Tier 4) PHOSLYRA RENAGEL RENVELA sodium polystyrene sulfonate oral powder (Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate oral suspension 15 gram/60 ml (Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate rectal enema 30 gram/120 ml Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Sodium Polystyrene Sulfonate) (Oxybutynin Chloride) (Ditropan XL) oxybutynin chloride oral tablet extended release 24hr tolterodine oral capsule,extended release (Detrol LA) 24hr tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended release (Sanctura XR) 24hr trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) 101

114 Name of Drug What the terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS EXJADE ORAL TABLET, DISPERSIBLE 125 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG FERRIPROX JADENU sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate) gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62%) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) NM NM NM NM PA; QL (30 per 30 PA; QL (300 per 30 PA; QL (150 per 30 PA; QL (300 per

115 Name of Drug ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) What the PA; QL (150 per 30 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 1 % (25 mg/2.5gram) (Androgel) PA; QL (150 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 ESTRASORB PA-HRM; QL (97.44 per 28 estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 MENEST PA-HRM 103

116 Name of Drug What the norethindrone ac-eth estradiol oral tablet (Femhrt) PA-HRM 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (18 per 28 Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone 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 125 mg, 40 mg methylprednisolone sodium succ intravenous (A-Methapred) PA BvD 104

117 Name of Drug What the prednisolone sodium phosphate oral (Orapred) PA BvD solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (Desmopressin Acetate) desmopressin nasal (DDAVP) QL (15 per 30 desmopressin nasal (Desmopressin QL (15 per 30 Acetate) desmopressin oral (DDAVP) GENOTROPIN PA; NM GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML PA GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML HUMATROPE INCRELEX NORDITROPIN FLEXPRO NUTROPIN PA; NM PA; NM NM PA; NM PA; NM 105

118 Name of Drug What the NUTROPIN AQ NUSPIN PA; NM NUTROPIN AQ SUBCUTANEOUS PA; NM octreotide acetate injection solution 1,000 (Sandostatin) NM mcg/ml octreotide acetate injection solution 100 (Sandostatin) mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML) OMNITROPE SUBCUTANEOUS CARTRIDGE 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN PREGNYL SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SOMAVERT PA PA; NM PA; NM PA; NM PA; NM NM PA; NM NM; QL (1 per 28 NM 106

119 What the Name of Drug SUPPRELIN LA TEV-TROPIN vasopressin (Pitressin) ZOMACTON Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular suspension medroxyprogesterone intramuscular (Medroxyprogesteron syringe e Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL AUBAGIO NM; QL (1 per 360 PA PA; NM QL (10 per 28 (Depo-Provera) QL (1 per 84 QL (1 per 84 NM PA BvD PA; NM; QL (28 per

120 Name of Drug What the azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF NANOFILTERED PA BvD; NM INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL PA; NM ENBREL SURECLICK PA; NM FLEBOGAMMA DIF PA BvD; NM GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD; NM GAMMAPLEX PA BvD; NM GAMUNEX-C INJECTION PA BvD; NM SOLUTION HUMIRA PA; NM HUMIRA PEN PA; NM HUMIRA PEN CROHN'S-UC-HS PA; NM START HYPERRAB S/D (PF) 108

121 What the Name of Drug HYQVIA ILARIS (PF) IMOGAM RABIES-HT (PF) KINERET leflunomide (Arava) PA BvD; NM PA; NM PA; NM; QL (18.76 per 28 mycophenolate mofetil oral capsule (Cellcept) PA BvD mycophenolate mofetil oral suspension for (Cellcept) PA BvD; NM reconstitution mycophenolate mofetil oral tablet (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD; NM OCTAGAM PA BvD; NM ORENCIA PA; NM; QL (4 per 28 ORENCIA (WITH MALTOSE) PA; NM PRIVIGEN PA BvD; NM PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD; NM RAPAMUNE ORAL TABLET 1 MG, 2 PA BvD; NM MG RIDAURA NM sirolimus oral tablet 0.5 mg, 1 mg (Rapamune) PA BvD sirolimus oral tablet 2 mg (Rapamune) PA BvD; NM 109

122 Name of Drug What the tacrolimus oral (Hecoria) PA BvD TYSABRI PA; NM; LA; QL (15 per 28 ZORTRESS ORAL TABLET 0.25 MG PA BvD; QL (120 per 30 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG PA BvD; NM; QL (120 per 30 Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD ENGERIX-B PEDIATRIC (PF) PA BvD GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION 110

123 What the Name of Drug HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PA BvD 111

124 What the Name of Drug PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) YF-VAX (PF) PA BvD PA BvD PA BvD PA BvD 112

125 What the Name of Drug ZOSTAVAX (PF) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron (Alosetron HCl) NM APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) NM DELZICOL DIPENTUM Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) water for irrigation, sterile (Water For Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution (Alendronate Sodium) QL (1 per 365 ST QL (300 per

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

127 What the Name of Drug XGEVA ZEMPLAR INTRAVENOUS zoledronic acid intravenous (Zometa) zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML PA; NM; QL (1.7 per 28 PA BvD; (PA for ESRD Only) (Zoledronic Acid/Mannitol and Water) (Reclast) QL (100 per 300 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS ACTEMRA SUBCUTANEOUS ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Amifostine Crystalline) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR AVONEX INTRAMUSCULAR NM PA; NM; QL (40 per 30 PA; NM; QL (3.6 per 28 NM ST; NM ST; NM ST; NM 115

128 What the Name of Drug BENLYSTA INTRAVENOUS RECON SOLN BETASERON SUBCUTANEOUS bethanechol chloride (Urecholine) BOTOX INJECTION RECON SOLN 100 UNIT BOTOX INJECTION RECON SOLN 200 UNIT buspirone (Buspirone HCl) CERDELGA colchicine oral tablet (Colcrys) colchicine-probenecid (Colchicine/Probeneci d) COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE droperidol injection solution (Droperidol) ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS finasteride oral tablet 5 mg (Proscar) PA; NM ST; NM PA; QL (4 per 90 PA; QL (1 per 90 PA; NM NM NM ST; NM fomepizole (Fomepizole) NM FUSILEV NM 116

129 What the Name of Drug GILENYA GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) PA; NM; QL (28 per 28 guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 LEMTRADA PA; NM; QL (9.6 per 365 leucovorin calcium injection recon soln 100 (Leucovorin Calcium) 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) levoleucovorin calcium (Levoleucovorin NM Calcium) mesna (Mesnex) MESNEX ORAL NM MESTINON ORAL SYRUP morrhuate sodium (Sodium Morrhuate) OTEZLA PA; NM; QL (60 per 30 OTEZLA STARTER PA; NM; QL (60 per

130 What the Name of Drug PLEGRIDY probenecid (Probenecid) PROCYSBI pyridostigmine bromide (Mestinon) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SIMPONI ARIA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " ST; NM NM NM NM NM PA; NM NM PA; NM; QL (12 per 28 PA; NM; QL (3 per 28 PA; NM; QL (0.5 per 28 PA; NM; QL (3 per 28 PA; NM; QL (0.5 per 28 NM PA; NM 118

131 What the Name of Drug SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID TYBOST ULORIC XELJANZ Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended (Diamox Sequels) release acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) NM PA; NM; QL (14 per 30 PA; NM; QL (60 per 30 PA NSO; NM; QL (60 per 30 QL (30 per 30 ST; QL (30 per 30 PA; NM; QL (60 per 30 ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic (Betaxolol HCl) bimatoprost (Bimatoprost) brimonidine (Alphagan P) (drops: 0.15%, 0.20%) COMBIGAN dorzolamide (Trusopt) 119

132 What the Name of Drug dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, (Isopto Carpine) 4 % SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) timolol maleate ophthalmic gel forming (Timoptic-Xe) solution TRAVATAN Z travoprost (benzalkonium) (Travoprost (Benzalkonium)) Replacement Preparations Replacement Preparations calci-mix * (Calcium Carbonate) $0 (Tier 4) calcium d (d3) * (Os-Cal 500+D) $0 (Tier 4) calcium d * oral tablet 500 (Os-Cal 500+D) $0 (Tier 4) mg(1,250mg) -400 unit calcium 500 with d * (Os-Cal 500+D) $0 (Tier 4) calcium 600 * (Caltrate 600) $0 (Tier 4) calcium d(3) * oral capsule (Calcium $0 (Tier 4) Carbonate/Vitamin D3) calcium d(3) * oral tablet (Os-Cal 500+D) $0 (Tier 4) QL (2.5 per 25 QL (2.5 per 25 QL (2.5 per

133 Name of Drug calcium 600 with vitamin d3 * oral (Calcium Carbonate/Vitamin D3) What the $0 (Tier 4) calcium carbonate * oral (Calcium Carbonate) $0 (Tier 4) calcium carbonate * oral tablet 260 mg (Caltrate 600) $0 (Tier 4) calcium (648 mg) calcium carbonate-vitamin d2 * (Calcium $0 (Tier 4) Carbonate/Vitamin D2) calcium carbonate-vitamin d3 * oral (Calcium $0 (Tier 4) capsule 600 mg(1,500mg) -100 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -500 unit Carbonate/Vitamin D3) calcium carbonate-vitamin d3 * oral tablet (Os-Cal 500+D) $0 (Tier 4) 500 mg(1,250mg) -200 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate-vitamin d3 * oral (Os-Cal 500+D) $0 (Tier 4) tablet,chewable 500 mg(1,250mg) -400 unit calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD Only) calcium gluconate * oral tablet 45 mg (Calcium Gluconate) $0 (Tier 4) (500 mg), 61 mg (648 mg) calcium lactate * oral tablet 84 mg (648 (Calcium Lactate) $0 (Tier 4) mg), 84 mg (650 mg) CALTRATE D * $0 (Tier 4) CALTRATE D VIT D3 (800) * $0 (Tier 4) CENTRUM PRO NUTRIENTS * $0 (Tier 4) citric acid-sodium citrate (Citric Acid/Sodium Citrate) electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) 121

134 What the Name of Drug enfalyte * (Pedialyte) $0 (Tier 4) HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KLOR-CON klor-con 10 (Potassium Chloride) KLOR-CON 8 klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) klor-con sprinkle (Micro-K) KLOR-CON/EF liquid calcium with vitamin d * (Calcium $0 (Tier 4) Carbonate/Vitamin D3) mag 64 * (Magnesium $0 (Tier 4) Chloride) mag-delay * (Magnesium $0 (Tier 4) Chloride) mag-g * (Magonate) $0 (Tier 4) magnesium chloride injection (Magnesium Chloride) 122

135 What the Name of Drug magnesium gluconate * oral tablet (Magonate) $0 (Tier 4) magnesium * oral tablet 200 mg, 250 mg (Magnesium) $0 (Tier 4) magnesium sulf in 0.45% nacl (Magnesium Sulf In 0.45% NaCl) magnesium sulfate in d5w intravenous (Magnesium piggyback 1 gram/100 ml, 4 gram/100 ml Sulfate/D5W) magnesium sulfate in water (Magnesium Sulfate in Water) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Caltrate 600) $0 (Tier 4) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * (Pedialyte) $0 (Tier 4) oysco 500/d * oral tablet (Os-Cal 500+D) $0 (Tier 4) oysco-500 * (Caltrate 600) $0 (Tier 4) oyster shell calcium 500 * (Caltrate 600) $0 (Tier 4) oyster shell calcium-vit d3 * oral tablet (Os-Cal 500+D) $0 (Tier 4) 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit oystercal-d * (Os-Cal 500+D) $0 (Tier 4) PEDIALYTE * ORAL SOLUTION $0 (Tier 4) pediatric electrolyte * oral solution (Pedialyte) $0 (Tier 4) pediatric freezer pops * (Pedialyte) $0 (Tier 4) phosphorus #1 (K-Phos Neutral) 123

136 What the Name of Drug PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) 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 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended (Klor-Con 8) release potassium chloride oral tablet,er (Klor-Con 8) particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq (Potassium Chloride) 124

137 Name of Drug potassium chloride-0.45 % nacl (Potassium Chloride-0.45% NaCl) potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-0.2%Na Cl) potassium chloride-d5-0.3%nacl (Potassium intravenous parenteral solution 20 meq/l Chloride/D5-0.3%Na Cl) potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-0.9%Na Cl) potassium citrate-citric acid oral packet (Potassium 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral solution (Potassium 1, mg/5 ml Citrate/Citric Acid) potassium phosphate m-/d-basic (Potassium Phos,M-Basic-D-Basi c) What the ringers intravenous (Ringers Solution) risacal-d * (Calcium Phosphate $0 (Tier 4) Dibas/Vit D3) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (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 %) 125

138 What the Name of Drug 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-Basi c) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II zinc sulfate * oral (Zinc Sulfate) $0 (Tier 3) Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS ADVAIR HFA BREO ELLIPTA DULERA FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION QL (60 per 30 QL (12 per 28 QL (60 per 30 QL (13 per 28 QL (60 per 30 QL (120 per 30 QL (12 per

139 Name of Drug FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION What the QL (24 per 28 QL (21.2 per 28 QVAR QL (17.4 per 25 Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution for (Albuterol Sulfate) PA BvD nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended (Vospire ER) release 12 hr ANORO ELLIPTA QL (60 per 30 ATROVENT HFA QL (25.8 per 28 COMBIVENT RESPIMAT QL (8 per 30 metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 PROAIR RESPICLICK QL (2 per 25 SEREVENT DISKUS QL (60 per 30 SPIRIVA RESPIMAT QL (4 per

140 What the Name of Drug SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral (Theophylline Anhydrous) (Theophylline/D5W) (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine (Acetadote) PA BvD QL (30 per 30 QL (4 per 28 QL (1 per 28 ARALAST NP NM cromolyn inhalation (Cromolyn Sodium) PA BvD DALIRESP QL (30 per 30 ESBRIET PA; NM; QL (270 per

141 What the Name of Drug KALYDECO OFEV ORKAMBI sodium chloride * inhalation solution for (Pulmosal) $0 (Tier 4) nebulization 0.9 % XOLAIR ZEMAIRA PA; NM; QL (60 per 30 PA; NM; QL (60 per 30 PA; NM; QL (120 per 30 PA; NM; QL (6 per 28 NM Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (120 per 30 chlorzoxazone (Parafon Forte DSC) PA-HRM COMFORT PA-HRM PAC-CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL ROZEREM PA 129

142 What the Name of Drug XYREM NM; LA zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 zolpidem oral tablet (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 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

143 Name of Drug Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents phentolamine injection (Phentolamine Mesylate) What the PA Vasodilating Agents Vasodilating Agents ADCIRCA PA; NM; QL (60 per 30 ADEMPAS PA; NM; QL (90 per 30 epoprostenol (glycine) intravenous recon (Flolan) PA BvD soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) PA BvD; NM soln 1.5 mg LETAIRIS PA; NM; QL (30 per 30 OPSUMIT PA; NM; QL (30 per 30 ORENITRAM ORAL TABLET PA EXTENDED RELEASE MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG PA; NM REMODULIN PA BvD; NM sildenafil intravenous (Revatio) PA; NM; QL (37.5 per 1 day) sildenafil oral (Revatio) PA; QL (90 per 30 TRACLEER PA; NM; LA; QL (60 per 30 TYVASO PA BvD; NM 131

144 What the Name of Drug TYVASO REFILL KIT TYVASO STARTER KIT VENTAVIS Vitamins And Minerals Vitamins And Minerals AQUASOL A * $0 (Tier 3) ascorbic acid * injection (Ascorbic Acid) $0 (Tier 3) b cmplx 4-vit d3-c-fa-zinc ox * (B Cmplx 4/Vit $0 (Tier 3) D3/C/Fa/Zinc Ox) b complex and c no.20-folic acid * oral (B Complex and C $0 (Tier 3) capsule 1 mg No.20/Folic Acid) b-complex with vitamin c * oral tablet (Vita-Bee with C) $0 (Tier 3) b-plex plus * (Multivits,Therap $0 (Tier 3) W-Fe,Hematin) cyanocobalamin (vitamin b-12) * injection (Cyanocobalamin $0 (Tier 3) (Vitamin B-12)) cyanocobalamin-fa-pyridoxine * oral (Foltx) $0 (Tier 3) tablet mg, mg, mg, mg cyanocobalamin-mecobalamin * (Cyanocobalamin/Me $0 (Tier 3) cobalamin) ergocalciferol (vitamin d2) * oral capsule (Drisdol) $0 (Tier 3) ezfe forte * (Pnv No.23-Iron Ps Complex-Fa) fa-vit bcomp and c-se-min aa-zn * (Fa/Vit Bcomp and $0 (Tier 3) C/Se/Min Aa/Zn) fe fumarate-doss-fa-bcomp and c * (Fe $0 (Tier 3) Fumarate/Doss/Fa/B comp and C) fe fumarate-fa-vit bcomp and c * (Fe Fumarate/Fa/Vit $0 (Tier 3) Bcomp and C) $0 (Tier 4) PA PA BvD; NM PA BvD; NM PA BvD; NM 132

145 Name of Drug What the fe fumarate-vit c-b12-if-fa * oral capsule (Fe Fumarate/Vit $0 (Tier 3) mg C/B12-If/Fa) fe fumarate-vit c-b12-stomc * (Fe Fumarate/Vit $0 (Tier 3) C/B12/Stomc) feosol * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) $0 (Tier 4) ferotrinsic * (Fe Fumarate/Vit $0 (Tier 3) C/B12-If/Fa) ferrous fumarate-folic acid * (Hemocyte-F) $0 (Tier 3) ferrous sulfate * oral (Fer-In-Sol) $0 (Tier 4) ferrous sulfate * oral (Ferrous Sulfate) $0 (Tier 4) ferrous sulfate * oral (Ferrous Sulfate) $0 (Tier 4) ferrous sulfate * oral tablet 325 mg (65 (Ferrous Sulfate) $0 (Tier 4) mg iron) folic acid * injection (Folic Acid) $0 (Tier 3) folic acid * oral tablet 1 mg (Folic Acid) $0 (Tier 3) folic acid * oral tablet 400 mcg (Folic Acid) $0 (Tier 4) PA; AGE (Max 46 folic acid-vit b6-vit b12 * oral tablet (Foltx) $0 (Tier 3) folic acid-vitamin b comp w-c * oral tablet mg, 5 mg (Folic Acid/Vitamin B Comp W-C) $0 (Tier 3) folic acid-vitamin b comp w-c * oral tablet mg-mg-mcg-mg folic acid-vitamin b comp w-c * oral tablet mg (Vit B Cplx #11/Fa/C/Biot/Zn Ox) (Folic Acid/Vit Bcomp and C/Cu/Znox) $0 (Tier 3) $0 (Tier 3) hydroxocobalamin * (Hydroxocobalamin) $0 (Tier 3) iron ag and fum-c-fa-mv cmb11-ca-t * (Iron Ag and $0 (Tier 3) Fum/C/Fa/Mv Cmb11/Ca-T) iron ag-c-b12-ca-suc.acid-stom * (Iron Ag/C/B12/Ca/Suc.Aci d/stom) $0 (Tier 3) 133

146 What the Name of Drug iron aspgly and ps-c-b12-fa-ca-suc * (Iron Aspgly and $0 (Tier 3) Ps/C/B12/Fa/Ca/Suc) iron aspgly&ps-c-b12-fa-ca-suc * (Iron Aspgly and $0 (Tier 3) Ps/C/B12/Fa/Ca/Suc) iron aspgly-c-b12-fa-ca-th-suc * (Iron $0 (Tier 3) Aspgly/C/B12/Fa/Ca- Th/Suc) iron bg and ps-vit c-b12-fa-ca thr * oral (Iron Bg and Ps/Vit $0 (Tier 3) capsule mg-mg-mcg-mg C/B12/Fa/Ca Thr) iron fum & ag-c-b12-fa-ca-succ * (Iron Fum and $0 (Tier 3) Ag/C/B12/Fa/Ca/Suc c) iron fum and ag-c-b12-fa-ca-succ * (Iron Fum and $0 (Tier 3) Ag/C/B12/Fa/Ca/Suc c) iron fum and p-fa-vit b and c no.9 * (Integra Plus) $0 (Tier 3) iron fum and polysac#1-fa-mv no.18 * oral (Tandem Plus) $0 (Tier 3) capsule mg iron fum and ps cmp-fa-vit c-b3 * (Integra F) $0 (Tier 3) iron fumarate-vit c-vit b12-fa * (Iron Fumarate/Vit $0 (Tier 3) C/Vit B12/Fa) iron ps cmplx-vit b12-fa * (Niferex-150 Forte) $0 (Tier 3) iron pyrophos-b12-fa-niac-b-6 * (Fe $0 (Tier 3) Fumarate/Cal/E/Fa / Multivit) iron, carbonyl-fa-c-b-6-b12-zn * (Corvite 150) $0 (Tier 3) iron,carb-dss-b12if-fa-mv-mn * (Hemax) $0 (Tier 3) iron-fa-vitamin b comp w-c-min * oral (Iron/Fa/Vitamin B $0 (Tier 3) liquid Comp W-C/Min) iron-fa-vitamin b comp w-c-min * oral (Iron/Liver Ext/Vit $0 (Tier 3) tablet Bcomp and C/Min) iron-fa-vitamin b comp w-c-min * oral (Iron/Fa/Vitamin B $0 (Tier 3) tablet 106 mg iron- 1 mg Comp W-C/Min) 134

147 Name of Drug What the kpn * oral tablet (Prenatal Vit $0 (Tier 4) PA W-Ca,Fe,Fa( Less Than 1 Mg)) levomefolate calcium * oral tablet 7.5 mg (Levomefolate $0 (Tier 3) Calcium) MEPHYTON * $0 (Tier 3) multivit, iron, min #5, fa * (Multivit, Iron, Min $0 (Tier 3) #5, Fa) multivit, iron, min #6, fa * (Multivit, Iron, Min $0 (Tier 3) #6, Fa) multivit, min cmb#20-iron-fa * (Multivit, Min $0 (Tier 3) Cmb#20/Iron/Fa) multivitamins with min no.7-fa * oral (Multivitamins with $0 (Tier 3) capsule 1 mg Min No.7/Fa) multivit-fluor 0.25 mg/ml drop 0.25 mg/ml (Pedi Mvi No.82 with Fluoride) multivits,therap w-fe,hematin * oral tablet (Multivits,Therap $0 (Tier 3) W-Fe,Hematin) NASCOBAL * $0 (Tier 3) om-3-ca carb-d3-fa-mv cmb 13 * (Om-3/Ca $0 (Tier 3) Carb/D3/Fa/Mv Cmb 13) perry prenatal * (Pnv with Ca $0 (Tier 4) PA No.36/Iron/Fa) phytonadione * injection solution 10 (Phytonadione) $0 (Tier 3) mg/ml poly-vita (iron) * (Ped Multivit #46/Iron Sulfate) $0 (Tier 4) PA; AGE (Max 4 poly-vitamin with iron * (Ped Multivit #46/Iron Sulfate) $0 (Tier 4) PA; AGE (Max 4 prenatal formula * oral tablet (Prenatal Vit $0 (Tier 4) PA W-Ca,Fe,Fa( Less Than 1 Mg)) prenatal formula * oral tablet mg (Classic Prenatal) $0 (Tier 4) PA 135

148 Name of Drug What the prenatal gummy * (Pnv62/Fa/Om3/Dha/ $0 (Tier 4) PA Epa/Fish Oil) prenatal multivitamins * (Prenatal) $0 (Tier 4) PA prenatal * oral tablet mg, (Classic Prenatal) $0 (Tier 4) PA mg PRENATAL * ORAL TABLET 28 MG $0 (Tier 4) PA IRON- 800 MCG prenatal vit#96-ferrous fum-fa * (Prenatal $0 (Tier 4) PA Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) $0 (Tier 4) PA prenatal vitamins * oral tablet (Prenatal Vit $0 (Tier 4) PA W-Ca,Fe,Fa( Less Than 1 Mg)) prenatal vitamins oral tablet 27 mg iron- 1 mg (Pnv with Ca,No.72/Iron/Fa) (All Rx Prenatal Vitamins Covered) prenatal vitamins * oral tablet mg (Classic Prenatal) $0 (Tier 4) PA PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG prenatal vit-iron fumarate-fa * (Classic Prenatal) $0 (Tier 4) PA prenatal-1 * (Pnv No.25/Iron $0 (Tier 4) PA Fumarate/Fa/Dha) pyridoxine * injection (Pyridoxine HCl) $0 (Tier 3) right step prenatal vitamins * (Classic Prenatal) $0 (Tier 4) PA sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) sodium fluoride oral tablet 1 mg fluoride (Pedi Mvi No.82 with (2.2 mg) Fluoride) STROVITE ONE * $0 (Tier 3) stuart prenatal * (Classic Prenatal) $0 (Tier 4) PA support-500 * (B Complex with $0 (Tier 3) Vitamin C) therapeutic vitamins/minerals * (Multivitamins with $0 (Tier 3) Min No.7/Fa) thiamine hcl * injection (Thiamine HCl) $0 (Tier 3) 136

149 Name of Drug What the tri-vi-sol * (Vit A Palmitate/Vit C/Vit D3) $0 (Tier 4) PA; AGE (Max 4 tri-vita * (Pedi Multivits A,C, and D3 No.21) $0 (Tier 4) PA; AGE (Max 4 tri-vitamin * (Pedi Multivits A,C, and D3 No.21) $0 (Tier 4) PA; AGE (Max 4 vit b cmplx 3-fa-vit c-biotin * oral tablet (Vit B Cmplx $0 (Tier 3) mg-mg-mcg 3/Fa/Vit C/Biotin) vit b cmplx no3-fa-c-biot-zinc * (Vit B Cmplx $0 (Tier 3) No3/Fa/C/Biot/Zinc) vit b12-lmefolate ca-vit b6-b2 * oral tablet (Cerefolin) $0 (Tier 3) mg vitacel (with lutein) * (Biocel) $0 (Tier 3) vitamin b comp and vit c no.6 * (Vitamin B Comp $0 (Tier 3) and Vit C No.6) vitamin b12-folic acid * sublingual (Cyanocobalamin/Fol $0 (Tier 3) ic Acid) vitamin b-6 * oral tablet 100 mg, 25 mg, (Pyridoxine HCl) $0 (Tier 4) 50 mg vitamins b1,b2,b3,b5, and b6 * injection (Vitamins $0 (Tier 3) solution mg/ml B1,B2,B3,B5, and B6) VITA-RESPA * $0 (Tier 3) 137

150 138

151 8-MOP abacavir abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE acamprosate... 8 acarbose acebutolol acetaminophen... 1 acetaminophen-codeine... 1 acetazolamide acetazolamide sodium acetic acid... 94, 113 acetylcysteine acid reducer (famotidine) acitretin acne medication acne-clear ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 59, 84 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS ADRENALIN adrenalin adult nasal decongestant ADVAIR DISKUS ADVAIR HFA AEROCHAMBER PLUS FLOW-VU INDEX AEROCHAMBER PLUS FLOW-VU,M MSK AEROCHAMBER PLUS Z STAT MD MSK AFINITOR AFINITOR DISPERZ AGGRENOX AKTEN (PF) ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE ALDURAZYME alendronate , 114 alfuzosin ALIMTA ALINIA aller-chlor allergy (chlorpheniramine) allergy relief (loratadine) allergy-sinus allopurinol almacone almacone alosetron ALPHAGAN P alprazolam... 9 ALREX altacaine aluminum chloride aluminum hydroxide gel amantadine hcl ambi 60pse-4cpm AMBISOME ambizine amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA amitriptyline amlodipine...75 amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine I-1

152 amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate...18 amphetamine salt combo amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL , 103 ANORO ELLIPTA antacid antacid plus anti-gas anticoag citrate phos dextrose anti-diarrheal APOKYN apraclonidine APRISO aprodine APTIOM APTIVUS aquanil hc AQUASOL A ARALAST NP ARCALYST aripiprazole ARRANON ARZERRA ASACOL HD ascorbic acid ashlyna aspirin... 5, 7 aspirin-dipyridamole aspir-low... 5 ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 29, 93 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVODART AVONEX AVONEX (WITH ALBUMIN) azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam b cmplx 4-vit d3-c-fa-zinc ox b complex and c no.20-folic acid bacitracin... 13, 86, 94 bacitracin-polymyxin b... 86, 94 bacitraycin plus baclofen balsalazide banophen banophen allergy BANZEL baza antifungal BCG VACCINE, LIVE (PF) b-complex with vitamin c BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE BD LUER-LOK SYRINGE BELEODAQ benadryl allergy benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzalkonium chloride benzoyl peroxide benztropine beta-hc betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 72, 119 bethanechol chloride BETHKIS bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BIDIL BILTRICIDE bimatoprost bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO...21 boost kid essentials BOOSTRIX TDAP BOSULIF BOTOX b-plex plus BREO ELLIPTA bright beginnings soy BRILINTA brimonidine BRINTELLIX I-2

153 bromfenac bromocriptine budesonide bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 1, 8 buprenorphine-naloxone... 8 bupropion hcl... 8, 33 buspirone butalb-acetaminophen-caffeine.. 1 butalbital-acetaminop-caf-cod... 1 butalbital-acetaminophen...1 butalbital-acetaminophen-caff... 1 butalbital-aspirin-caffeine... 1 butorphanol tartrate... 1 BUTRANS... 1 BYDUREON BYETTA BYSTOLIC cabergoline caffeine citrated caffeine-sodium benzoate...79 calamine calci-chew calci-mix calcipotriene calcitonin (salmon) calcitriol... 84, 114 calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) calcium 600 with vitamin d calcium acetate CALCIUM ACETATE calcium carbonate... 98, 121 calcium carbonate-mag carb-fa calcium carbonate-vitamin d calcium carbonate-vitamin d calcium chloride calcium gluconate calcium lactate CALDOLOR... 5 calphron CALTRATE D CALTRATE D VIT D3 (800) CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os) cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil...16 ceftazidime ceftibuten ceftriaxone CEFTRIAXONE ceftriaxone in dextrose,iso-os.. 16 CEFTRIAXONE IN DEXTROSE,ISO-OS cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... 5 CELLCEPT INTRAVENOUS CELONTIN CENTRUM PRO NUTRIENTS cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) cevimeline CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX CONTINUING MONTH PAK... 8 CHANTIX STARTING MONTH BOX... 8 cheratussin ac child dometuss-da child triaminic cold & allergy.. 43 child wal-tap cold-allergy children's advil... 5 children's non-aspirin... 1 children's pain & fever relief...1 children's silapap... 1 children's silfedrine...83 children's sudafed children's wal-dryl allergy child's benadryl-d allergy-sin I-3

154 chloramphenicol sod succinate chlordiazepoxide hcl... 9 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine-aspartame choline,magnesium salicylate... 5 ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX ciprofloxacin ciprofloxacin hcl... 19, 94 ciprofloxacin in 5 % dextrose ciprofloxacin lactate cisplatin citalopram citric acid-sodium citrate clarithromycin clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate... 13, 46, 86 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol... 87, 88 clobetasol propionate clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 9 clonidine clonidine hcl... 69, 79 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium... 9 clotrimazole... 40, 41 clotrimazole clotrimazole-betamethasone clozapine... 51, 52 COARTEM codeine sulfate... 1 codeine-butalbital-asa-caffein... 1 colace COLACE CLEAR colchicine colchicine-probenecid COLCRYS cold & cough colestipol colistin (colistimethate na) col-rite COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ...21 comfort gel extra strength COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-IBUPROFEN... 5 COMFORT PAC-MELOXICAM... 5 COMFORT PAC-NAPROXEN... 5 COMFORT PAC-TIZANIDINE COMPLERA compoz COMVAX (PF) CONDYLOX CONEX conex COPAXONE CORDRAN CORLANOR cortaid cortisone cortizone CORTIZONE COSENTYX (2 SYRINGES) COSENTYX PEN I-4

155 COSENTYX PEN (2 PENS) CREON CRESTOR CRIXIVAN cromolyn... 93, 98, 128 CUBICIN CURITY GAUZE cyanocobalamin (vitamin b-12) cyanocobalamin-fa-pyridoxine cyanocobalamin-mecobalamin cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) cytarabine cytarabine (pf) d10 % & 0.45 % sodium chloride d10 %-0.9 % sodium chloride.. 66 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride.. 66 dacarbazine dactinomycin DAKLINZA DALIRESP danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM deblitane decitabine deferoxamine DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermarest eczema (hydrocort) desenex (clotrimazole) desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone sodium phosphate... 95, 104 dexmethylphenidate dextroamphetamine dextroamphetamine-amphetamine dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) 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 DIASTAT ACUDIAL... 9 diazepam... 9 diazepam intensol... 9 diclofenac potassium... 5 diclofenac sodium... 5, 95 diclofenac-misoprostol... 5 dicloxacillin dicyclomine didanosine DIFICID diflunisal...5 digitek digoxin DIGOXIN dihydroergotamine DILANTIN CAPSULE 30 MG diltiazem hcl dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion diotame instydose DIPENTUM diphenhist... 43, 44 diphenhydramine hcl diphenhydramine-phenylephrine diphenoxylate-atropine disopyramide phosphate disulfiram... 8 divalproex dobutamine dobutamine in d5w doc-q-lace dok donepezil dopamine...74 I-5

156 dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate doxycycline monohydrate dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DRYSOL DAB-O-MATIC DUAVEE dulcolax stool softener (dss) DULERA duloxetine DURAMORPH (PF)... 2 DUREZOL DYRENIUM e.c. prin... 6 econazole ecotrin... 6 ed chlorped jr EDURANT EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ELMIRON elta tar EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide.. 71 ENBREL ENBREL SURECLICK enfalyte ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin entacapone entecavir entre-hist pse ENTRESTO ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 17, 94 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium estazolam ESTRACE estradiol estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet ESTRASORB estropipate ethambutol ethamolin ethinyl estradiol/drospirenone.. 81 ethosuximide ethynodiol d-ethinyl estradiol.. 81 etidronate disodium etodolac... 6 ETOPOPHOS etoposide EVOTAZ EXELON exemestane...23 EXJADE EXTAVIA ezfe forte FABRAZYME fallback solo famciclovir famotidine... 96, 97 famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON FARYDAK FASLODEX fa-vit bcomp and c-se-min aa-zn fe fumarate-doss-fa-bcomp and c fe fumarate-fa-vit bcomp and c fe fumarate-vit c-b12-if-fa fe fumarate-vit c-b12-stomc felbamate felodipine FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) I-6

157 fenoprofen... 6 fentanyl... 2 fentanyl citrate... 2 feosol ferotrinsic FERRIPROX ferrous fumarate-folic acid ferrous sulfate FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flanax antacid FLEBOGAMMA DIF flecainide FLECTOR... 6 FLEXBUMIN 25 %...64 FLEXBUMIN 5 % FLOVENT DISKUS FLOVENT HFA , 127 floxuridine fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) flucytosine fludarabine fludrocortisone flumazenil fluocinonide fluocinonide-emollient base...88 fluorometholone FLUOROPLEX fluorouracil... 23, 85 fluoxetine FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam... 10, 11 flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone... 88, 96 fluvoxamine foaming antacid folic acid folic acid-vit b6-vit b folic acid-vitamin b comp w-c fomepizole fondaparinux FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure fungoid-d furosemide FUSILEV FUZEON FYCOMPA gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GAZYVA gelusil antacid & anti-gas gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentamicin... 13, 86, 94 gentamicin in nacl (iso-osm) gentamicin sulfate gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) GEODON geri-dryl gildess 24 fe GILENYA GILOTRIF GLEEVEC...23 glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide... 39, 40 glyburide micronized glyburide-metformin GLYCINE glycopyrrolate glydo... 7 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaiatussin ac guanfacine... 69, 79 guanidine GYNOL II HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI...58 HAVRIX (PF) , 111 hc-1% hemorrhoid heparin (porcine) heparin (porcine) in 5 % dex... 60, 61 HEPARIN (PORCINE) IN 5 % DEX heparin (porcine) in nacl (pf) HEPARIN SODIUM,PORCINE-PF I-7

158 HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HEXALEN histex pe homatropine hbr HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 2 hydrocodone-ibuprofen... 2 hydrocortisone... 88, 89, 104 hydrocortisone acet-aloe vera. 88 hydrocortisone acetate hydrocortisone acetate-aloe hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate hydrocortisone valerate hydromorphone... 2 hydromorphone (pf)... 2 hydroskin hydroxocobalamin hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA ibandronate IBRANCE ibuprofen... 6 ichthammol ICLUSIG... 23, 24 ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) IMPACT 1 CAL impact advanced recovery INCRELEX indapamide indomethacin... 6 indomethacin sodium... 6 INFANRIX (DTAP) (PF) infant acetaminophen... 2 infantaire... 2 infant's pain reliever... 3 INLYTA INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID...68 INTRON A INVANZ INVEGA INVEGA SUSTENNA... 52, 53 INVEGA TRINZA INVIRASE INVOKAMET INVOKANA inzo antifungal IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRENKA IRESSA iron ag and fum-c-fa-mv cmb11-ca-t iron ag-c-b12-ca-suc.acid-stom iron aspgly and ps-c-b12-fa-ca-suc iron aspgly&ps-c-b12-fa-ca-suc iron aspgly-c-b12-fa-ca-th-suc iron bg and ps-vit c-b12-fa-ca thr iron fum & ag-c-b12-fa-ca-succ iron fum and ag-c-b12-fa-ca-succ iron fum and p-fa-vit b and c no iron fum and polysac#1-fa-mv no iron fum and ps cmp-fa-vit c-b iron fumarate-vit c-vit b12-fa I-8

159 iron ps cmplx-vit b12-fa iron pyrophos-b12-fa-niac-b iron, carbonyl-fa-c-b-6-b12-zn iron,carb-dss-b12if-fa-mv-mn iron-fa-vitamin b comp w-c-min ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX itraconazole ivermectin IXEMPRA IXIARO (PF) JADENU JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA junel fe KABIVEN KADCYLA KALETRA KALYDECO kaopectate (bismuth subsalicy) kaopectate ex str (bismuth ss) KEDBUMIN ketoconazole ketoprofen... 6 ketorolac... 6, 96 KEYTRUDA KHEDEZLA kimidess (28) KINERET KINRIX (PF) KLOR-CON klor-con KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KLOR-CON/EF kola-pectin ds KORLYM kpn KRYSTEXXA KUVAN KYPROLIS l norgest/e.estradiol-e.estrad labetalol LACRISERT LACTATED RINGERS lactulose LAMICTAL lamivudine lamivudine-zidovudine lamotrigine... 30, 31 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 24 fe latanoprost LATUDA LAZANDA... 3 leflunomide LEMTRADA LENVIMA LETAIRIS letrozole...24 leucovorin calcium LEUKERAN...24 LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 19, 94 levofloxacin in d5w levoleucovorin calcium levomefolate calcium levonorgestrel levonorgestrel-ethin estradiol.. 81 levonorgestrel-ethinyl estrad levorphanol tartrate... 3 levothyroxine LEXIVA...56 lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine... 8 lidocaine (pf)... 7, 71 lidocaine hcl... 7 lidocaine in 5 % dextrose (pf) lidocaine-prilocaine... 8 linezolid LINZESS liothyronine lipase-protease-amylase LIPOSYN II LIPOSYN III liquid calcium with vitamin d lisinopril lisinopril-hydrochlorothiazide.. 71 lithium carbonate lithium citrate l-norgest-eth estr/ethin estra lohist - d lohist-peb I-9

160 lohist-psb lomustine loperamide loradamed loratadine lorazepam oral solution losartan losartan-hydrochlorothiazide LOTEMAX LOTRIMIN ULTRA LOTRONEX lovastatin loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT...25 LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA LYSODREN maalox advanced MAALOX MAXIMUM STRENGTH mafenide acetate mag mag-delay mag-g magnesium magnesium chloride magnesium gluconate magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen)... 3 maprotiline MARPLAN MARQIBO masanti double strength MATULANE matzim la meclizine medroxyprogesterone mefenamic acid... 7 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) MEGACE ES megestrol MEKINIST meloxicam... 7 melphalan hcl intravenous memantine... 32, 33 MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesna MESNEX MESTINON metaproterenol metaxalone metformin methadone... 3 methadone hcl... 3 methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf)... 25, 26 methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 79, 80 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 46, 50, 86 metronidazole in nacl (iso-os) mexiletine mg217 psoriasis MIACALCIN mi-acid micatin miconazole miconazole nitrate...41 miconazole-3 prefil,cream,wipe midazolam...11 midazolam (pf) midodrine milrinone milrinone in 5 % dextrose minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitomycin mitoxantrone I-10

161 M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone MONISTAT monistat montelukast morphine... 3 MORPHINE... 3 morphine concentrate... 3 morrhuate sodium motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL msud MULTAQ multivit, iron, min #5, fa multivit, iron, min #6, fa multivit, min cmb#20-iron-fa multivitamins with min no.7-fa multivits,therap w-fe,hematin mupirocin mupirocin calcium muro MUSTARGEN mycophenolate mofetil mycophenolate sodium MYOZYME nabumetone... 7 nadolol nafcillin...18 nafcillin in dextrose iso-osm NAGLAZYME naloxone... 8 naltrexone... 8 naltrexone hcl... 8 NAMENDA NAMENDA TITRATION PAK NAMENDA XR NAMZARIC naphazoline naproxen... 7 naproxen sodium... 7 naratriptan nasal & sinus decongestant nasal decongestant (pe) NASCOBAL NASONEX NATACYN nateglinide NATPARA natural calcium NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc neosporin anti-itch NEPHRAMINE 5.4 % NESSI SPACER NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine nicotine... 8 NICOTROL... 8 nifedipine NILANDRON NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose NITROSTAT NORDITROPIN FLEXPRO norelgestromin/ethin.estradiol norepinephrine bitartrate noreth-ethinyl estradiol/iron...81 norethindrone norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 82, 104 norethindrone-e.estradiol-iron norethindrone-ethinyl estrad norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp... 4 NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL...39 NOXAFIL NUCYNTA... 4 NUCYNTA ER... 4 NUEDEXTA...80 I-11

162 NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUTRIT SUPP-INULIN-FOS-FIBER NUTRITIONAL SUPPLEMENT NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone nyt-time sleep obagi nu-derm tolereen OCTAGAM octreotide acetate OFEV ofloxacin... 19, 95 olanzapine olanzapine-fluoxetine olopatadine OLYSIO om-3-ca carb-d3-fa-mv cmb omega-3 acid ethyl esters...77 omeprazole omeprazole magnesium OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI opcicon one-step OPDIVO OPSUMIT OPTICHAMBER ADULT MASK-LARGE oralyte ORAP ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORKAMBI OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 4 oxycodone hcl-acetaminophen... 4 oxycodone hcl-aspirin... 4 oxycodone-acetaminophen... 4 oxycodone-aspirin... 4 OXYCONTIN... 4 oxymorphone... 4 oysco 500/d oysco oyster shell calcium oyster shell calcium-vit d oystercal-d paclitaxel pain relief... 4 paliperidone PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PATADAY PATANOL PAXIL pedi m.vit no.17 with fluoride PEDIALYTE PEDIARIX (PF) pediasure pediatex td pediatric drink pediatric electrolyte pediatric freezer pops PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM...50 pentoxifylline PEPTAMEN JUNIOR WITH PREBIO pep-t-med PERIKABIVEN perindopril erbumine PERJETA permethrin...90 perphenazine perphenazine-amitriptyline perry prenatal persa-gel phenelzine phenobarbital phenobarbital sodium phentolamine phenylephrine hcl... 70, 94 phenylephrine-brompheniramin I-12

163 phenylephrine-chlorpheniramine PHENYL-FREE phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended phillips liqui-gels PHOSLYRA PHOSPHOLINE IODIDE phosphorus # phytonadione PICATO pilocarpine hcl... 83, 120 pimozide pindolol pin-x pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam... 7 PLASBUMIN 25 % PLASBUMIN 5 %...64 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox podophyllum resin polyethylene glycol polymyxin b sulf-trimethoprim polysporin poly-vita (iron) poly-vitamin with iron POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid potassium bicarbonate-cit ac potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate-citric acid potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 96, 105 prednisone PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal PRENATAL prenatal formula prenatal gummy prenatal multivitamins prenatal vit#96-ferrous fum-fa prenatal vitamin with minerals prenatal vitamins PRENATAL VITAMINS prenatal vit-iron fumarate-fa prenatal preparation h hydrocortisone PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCYSBI progesterone progesterone micronized capsules PROGLYCEM PROGRAF PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 45, 49 promethazine hcl promethazine-codeine...83 promethazine-dm promethazine-phenyleph-codeine propafenone propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod propranolol I-13

164 propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide pyridoxine q-dryl q-pap... 5 q-tapp QUADRACEL (PF) QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR ra pediatric nutrition drink RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECOMBIVAX HB (PF) recort plus reese's pinworm medicine RELADOR PAK... 8 RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR RESTASIS RETROVIR REVLIMID REXULTI REYATAZ ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ii right step prenatal vitamins riluzole rimantadine ri-mox ri-mox plus ringers , 125 risacal-d risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan ropinirole ROTARIX ROTATEQ VACCINE ROZEREM SABRIL SAIZEN SAIZEN CLICK.EASY salsalate... 7 SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scalp itch-dandruff relief selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline setlakin siladryl sa silapap... 5 sildenafil oral tablet 20 mg SILENOR silver nitrate...86 silver nitrate applicators silver sulfadiazine SIMBRINZA simply sleep SIMPONI SIMPONI ARIA simvastatin sinus & allergy (pseudoephed) sinus nighttime sirolimus SIRTURO sleep-tabs sochlor sodium acetate sodium bicarbonate sodium chloride... 94, 113, 126, 129 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride sodium lactate sodium phosphate sodium polystyrene sulfonate I-14

165 sodium thiosulfate sod-pot-k cit-sod cit-cit acid SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe regular strength sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL st joseph aspirin... 7 st. joseph aspirin... 7 stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA streptomycin STRIBILD STRIVERDI RESPIMAT STROVITE ONE stuart prenatal sucralfate sudogest sudogest cold & allergy sulfacetamide sodium sulfacetamide sodium (acne).. 86 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac... 7 sumatriptan nasal spray sumatriptan succinate suphedrin support SUPPRELIN LA SUPRAX SURE COMFORT INS. SYR. U SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE TABLOID tacrolimus... 89, 110 TAFINLAR TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe TASIGNA TAZORAC taztia xt TECFIDERA TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam... 11, 12 TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracaine hcl tetracycline TEV-TROPIN THALOMID the magic bullet theophylline theophylline anhydrous theophylline in dextrose 5 % therapeutic vitamins/minerals thiamine hcl thioridazine thiothixene tiagabine TICE BCG TIKOSYN...72 timolol maleate... 73, 120 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide...40 tolbutamide I-15

166 tolmetin... 7 tolnaftate tolterodine topiramate toposar intravenous...27 topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL...28 triacting orange triamcinolone acetonide... 83, 89, 90, 105 TRIAMINIC COLD & COUGH NT (PE) triamterene-hydrochlorothiazid triazolam TRIBENZOR triderm trifluoperazine trifluridine trihexyphenidyl TRILEPTAL trimethoprim TRIUMEQ tri-vi-sol tri-vita tri-vitamin TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY...37 TRUMENBA TRUVADA trymine d TUDORZA PRESSAIR TWINRIX (PF) twocal hn TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA ULORIC unisom sleepgels UNITUXIN ursodiol VAGIFEM VAGINAL CONTRACEPTIVE FOAM vagistat valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALSTAR vancomycin vancomycin in d5w VAQTA (PF) VARIVAX (PF) VASCEPA vasopressin vazobid-pd VECTIBIX VELCADE venlafaxine VENTAVIS verapamil VERSACLOZ VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD...35 VIMIZIM...92 VIMPAT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD vit b cmplx 3-fa-vit c-biotin vit b cmplx no3-fa-c-biot-zinc vit b12-lmefolate ca-vit b6-b vitacel (with lutein) vitamin b comp and vit c no vitamin b12-folic acid vitamin b vitamins b1,b2,b3,b5, and b VITA-RESPA VITEKTA VOLTAREN... 7 voriconazole VOTRIENT...28 I-16

167 VPRIV wal-act d cold & allergy wal-dryl allergy wal-finate wal-finate-d wal-itin wal-phed... 46, 83 wal-phed pe wal-phed pe sinus & allergy wal-sleep z wal-som (diphenhydramine) wal-tap warfarin water for irrigation, sterile WELCHOL WIDE-SEAL DIAPHRAGM XALKORI XARELTO XELJANZ XENAZINE XGEVA XIFAXAN XOLAIR XTANDI xylon XYREM YERVOY YF-VAX (PF) zafirlukast zaleplon ZALTRAP ZARXIO ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP ZETIA ZIAGEN zidovudine zinc sulfate ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide ZORTRESS ZOSTAVAX (PF) ZOVIRAX z-sleep ZUBSOLV... 8, 9 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX I-17

168 TRANG NÀY ĐÃ BỎ CỐ Ý BLANK

169 Dược liễn này được cập nhật vào ngày 15/10/2015. Để biết thêm thông tin gần đây hơn hoặc những thắc mắc khác, vui lòng liên hệ Dịch Vụ Hội Viên Chương Trình CommuniCare Advantage Cal MediConnect (Chương Trình Medicare-Medicaid), theo số hoặc, đối với những người dùng TTY, , hai mươi tư giờ một ngày, bảy ngày một tuần hoặc truy cập Nếu quý vị có thắc mắc, vui lòng gọi Chương Trình CommuniCare Advantage Cal MediConnect theo số , 24 giờ một ngày, bảy ngày một tuần. Cuộc gọi được miễn phí. Để biết thêm thông tin, vui lòng truy cập H5172_Comp Formulary_Viet 2015 v11 Approved