Partnership HMO SNP 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID: 15303, Version Number: 26 This formulary was updated on 10/1/2015. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit www.carewisc.org. H5209-002_H7475-001_CWHPFC9-22-15_FINAL Populated Template 9/23/2015 DHS Approved 8/27/2014
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Care Wisconsin Health Plan, Inc. When it refers to plan or our plan, it means Partnership. This document includes a list of the drugs (formulary) for our plan which is current as of 10/1/2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2015, and from time to time during the year. Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal. To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin Customer Service at 1-800-963-0035 (TTY/TDD Wisconsin Relay System 711).
What is the Partnership Formulary? A formulary is a list of covered drugs selected by Partnership in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/1/2015. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart i
condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 2. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 43. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Partnership covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Partnership may not cover B unless you try A first. If A does not work for you, Partnership will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. ii
You can ask Partnership to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Partnership formulary? on page iii for information about how to request an exception. What are over-the-counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Plan. Partnership pays for certain OTC drugs. The 2015 Formulary Medicaid Supplement included with this formulary provides the list of OTC drugs covered by Partnership when they are ordered by a physician or nurse practitioner for a medical need and the product has a valid National Code (NDC) that is recognized by Wisconsin Medicaid s claims processing system. Partnership will provide these OTC drugs at no cost to you. The cost to Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap). What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Partnership does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership. You can ask Partnership to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Partnership Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Partnership limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Partnership will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Current members with a change in where they receive care Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include: You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital. iv
You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary. Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of medications that are highly individualized. Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy. For more information For more detailed information about your Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Partnership, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. Partnership s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 43. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the Requirements/Limits column tells you if Partnership has any special requirements for coverage of your drug. v
Formulary: 15303, Version ID: 26 Date generated: September 22, 2015 List of Abbreviations B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. CB: This prescription drug has a capped benefit limit. ED: This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711. MO: Mail Order. This prescription drug is available through a mail-order service. PA: Prior Authorization. Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. QL: Quantity Limit. For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Partnership may not cover drug B unless you try A first. If A does not work for you, Partnership will then cover B. Page 1 of 57
Tier Name Requirements/Limits Analgesics Nonsteroidal Anti-inflammatory s CELEBREX CAPS 100MG 1 ST (Non-Opioid Analgesics #2) celecoxib caps 1 ST (Non-Opioid Analgesics #2) etodolac er 1 PA (Beers-HEDIS Safety PA) etodolac caps, tabs 1 PA (Beers-HEDIS Safety PA) ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg 1 indomethacin caps 1 PA (Beers-HEDIS Safety PA) ketoprofen caps 1 PA (Beers-HEDIS Safety PA) nabumetone 1 PA (Beers-HEDIS Safety PA) naproxen dr 1 naproxen susp, tabs 1 oxycodone/ibuprofen 1 Opioid Analgesics, Long-acting fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr 1 QL (10 EA per 30 days) ST (Opioid Analgesics #3) methadone hcl conc, soln, tabs 1 methadose tabs 10mg 1 morphine sulfate er tbcr 1 morphine sulfate tabs 15mg, 30mg 1 oxycodone hcl er 1 ST (Opioid Analgesics #2) OXYCONTIN T12A 15MG, 30MG, 60MG 1 ST (Opioid Analgesics #2) tramadol hcl er tb24 1 ST (Tramadol #2) Opioid Analgesics, Short-acting acetaminophen/codeine #3 1 acetaminophen/codeine soln 1 acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg 1 CODEINE SULFATE TABS 1 duramorph 1 endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1 fentanyl citrate oral transmucosal 1 ST (Opioid Analgesics #3) PA (Fentanyl Lozenges) hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg 1 hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1 Page 2 of 57 hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 10mg, 500mg; 5mg, 500mg; 7.5mg, 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg, 750mg; 7.5mg hydrocodone/ibuprofen tabs 7.5mg; 200mg 1 hydromorphone hcl liqd, tabs 1 hydromorphone hcl inj 500mg/50ml 1 morphine sulfate inj 0.5mg/ml, 1mg/ml 1 morphine sulfate oral soln 10mg/5ml, 20mg/5ml, 20mg/ml 1 oxycodone hcl tabs 1 oxycodone/acetaminophen 1 roxicet soln 1 ROXICET TABS 325MG; 5MG 1 stagesic 1 tramadol hcl tabs 1 1
tramadol hydrochloride/acetaminophen 1 Anesthetics Local Anesthetics lidocaine hcl jelly 1 lidocaine hcl external soln 1 lidocaine hcl inj 0.5%, 1% 1 lidocaine viscous 1 lidocaine/prilocaine crea 1 lidocaine oint 1 lidocaine ptch 1 QL (90 EA per 30 days) PA (Lidocaine Patch) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 1 disulfiram tabs 1 Opioid Dependence Treatments buprenorphine hcl/naloxone hcl 1 buprenorphine hcl inj 1 buprenorphine hcl subl 1 PA (Buprenorphine) naltrexone hcl tabs 1 Opioid Reversal Agents naloxone hcl inj 1 Smoking Cessation Agents buproban 1 CHANTIX CONTINUING MONTH PAK 1 PA (Varenicline (Chantix)) CHANTIX STARTING MONTH PAK 1 PA (Varenicline (Chantix)) CHANTIX TABS 0.5MG, 1MG 1 PA (Varenicline (Chantix)) NICOTROL INHALER 1 QL (336 EA per 21 days) PA (Nicotine (Nicotrol)) NICOTROL NS 1 QL (168 ML per 30 days) PA (Nicotine (Nicotrol NS)) Anti-inflammatory Agents Nonsteroidal Anti-inflammatory s diclofenac sodium gel 3% 1 PA (Diclofenac (Solaraze)) naproxen sodium tabs 275mg, 550mg 1 oxaprozin 1 PA (Beers-HEDIS Safety PA) Antibacterials Aminoglycosides gentak 1 gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%, 1 1mg/ml; 0.9% gentamicin sulfate crea, inj, external oint, ophthalmic oint, 1 ophthalmic soln isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9% 1 neomycin sulfate 1 neomycin/polymyxin b sulfates 1 paromomycin sulfate 1 streptomycin sulfate inj 1 tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml 1 Page 3 of 57
tobramycin sulfate ophthalmic soln 1 tobramycin sulfate inj 10mg/ml, 80mg/2ml 1 ZYLET 1 Antibacterials, Other ALCOHOL PREP PADS 1 baciim 1 bacitracin/polymyxin b 1 bacitracin oint 1 chloramphenicol sodium succinate 1 clindamycin hcl caps 1 clindamycin phosphate add-vantage 1 clindamycin phosphate crea 2% 1 colistimethate sodium 1 CUBICIN 1 linezolid tabs 1 methenamine hippurate 1 metronidazole in nacl 0.79% 1 metronidazole vaginal 1 metronidazole gel 0.75% 1 ST (Acne Agents #2) metronidazole tabs 1 MONUROL 1 mupirocin oint 1 neomycin/bacitracin/polymyxin 1 neomycin/polymyxin/bacitracin/hydrocortisone 1 neomycin/polymyxin/gramicidin 1 nitrofurantoin macrocrystals caps 50mg 1 QL (28 EA per 30 days) PA (Nitrofurantoin) nitrofurantoin monohydrate 1 QL (28 EA per 30 days) PA (Nitrofurantoin) polymyxin b sulfate/trimethoprim sulfate 1 polymyxin b sulfate inj 1 silver sulfadiazine crea 1 ssd 1 SYNERCID 1 trimethoprim tabs 1 TYGACIL 1 vancomycin hcl caps 1 vancomycin hcl inj 1000mg, 10gm, 500mg 1 vandazole 1 XIFAXAN TABS 550MG 1 ST (Hepatic Encephalopathy #2) ZYVOX 1 Beta-lactam, Cephalosporins cefaclor caps 1 cefadroxil 1 cefazolin sodium inj 10gm, 1gm; 5%, 1gm, 500mg 1 cefdinir 1 cefepime inj 1gm, 2gm 1 cefixime 1 cefpodoxime proxetil 1 Page 4 of 57
cefprozil 1 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg 1 cefuroxime axetil tabs 1 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1 CEFUROXIME/DEXTROSE 1 cephalexin caps 250mg, 500mg 1 cephalexin susr 1 SUPRAX CAPS, TABS 1 SUPRAX SUSR 100MG/5ML, 200MG/5ML 1 TEFLARO INJ 600MG 1 Beta-lactam, Other aztreonam inj 1gm 1 cefotetan 1 imipenem/cilastatin 1 INVANZ 1 meropenem inj 500mg 1 Beta-lactam, Penicillins amoxicillin 1 amoxicillin/clavulanate potassium 1 amoxicillin/clavulanate potassium er 1 ampicillin sodium inj 10gm, 1gm 1 ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm 1 ampicillin caps 1 BICILLIN L-A 1 dicloxacillin sodium 1 nafcillin sodium inj 10gm, 1gm 1 NALLPEN/DEXTROSE INJ 0; 1GM/50ML 1 oxacillin sodium inj 10gm, 2gm 1 penicillin g potassium inj 5000000unit 1 penicillin v potassium 1 piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 1 4gm; 0.5gm ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 1 3GM/50ML; 0.375GM/50ML Macrolides azithromycin susr, tabs 1 azithromycin inj 500mg 1 clarithromycin er 1 clarithromycin susr, tabs 1 DIFICID 1 ST (Clostridum Difficlile Treatment #2) PA (fidaxomicin (Dificid)) e.e.s. 400 1 E.E.S. GRANULES 1 e.s.p. 1 ERY-TAB 1 ERYPED 200 1 ERYPED 400 1 erythrocin lactobionate inj 500mg 1 erythrocin stearate 1 Page 5 of 57
erythromycin base tabs 1 ERYTHROMYCIN ETHYLSUCCINATE TABS 1 erythromycin gel, oint, soln 1 KETEK 1 PA (Telithromycin (Ketek)) Quinolones AVELOX INJ 1 CIPRO HC 1 CIPRODEX 1 ciprofloxacin er 1 ciprofloxacin hcl soln, tabs 1 ciprofloxacin susr 1 ciprofloxacin inj 400mg/40ml 1 gatifloxacin 1 levofloxacin 1 levofloxacin in d5w inj 5%; 500mg/100ml 1 MOXEZA 1 ofloxacin ophthalmic soln, otic soln 1 VIGAMOX 1 Sulfonamides BLEPHAMIDE S.O.P. 1 sodium sulfacetamide soln 1 sulfacetamide sodium/prednisolone sodium phosphate 1 sulfadiazine tabs 1 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 Tetracyclines demeclocycline hcl tabs 1 doxycycline hyclate caps, tabs 1 doxycycline monohydrate tabs 1 minocycline hcl caps 1 Anticonvulsants Anticonvulsants, Other APTIOM 1 FYCOMPA 1 levetiracetam 1 levetiracetam er 1 MAGNESIUM SULFATE IN D5W INJ 5%; 10MG/ML 1 phenobarbital elix, tabs 1 PA (Phenobarbital, new POTIGA 1 Calcium Channel Modifying Agents CELONTIN 1 ethosuximide 1 LYRICA SOLN 1 QL (1400 ML per 31 days) LYRICA CAPS 1 QL (93 EA per 31 days) zonisamide 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt 1 PA (Beers-HEDIS Safety PA, new Page 6 of 57
clonazepam tabs 1 PA (Beers-HEDIS Safety PA, new DIAZEPAM GEL 10MG, 2.5MG, 20MG 1 PA (Beers-HEDIS Safety PA, new divalproex sodium 1 divalproex sodium dr 1 divalproex sodium er 1 gabapentin caps, soln, tabs 1 GABITRIL TABS 12MG, 16MG 1 ONFI TABS 1 PA (clobazam (Onfi), new starts only) ONFI SUSP 1 PA (Clobazam liquid (Onfi), new primidone tabs 1 SABRIL 1 tiagabine hydrochloride 1 valproate sodium inj 1 valproic acid caps, syrp 1 Glutamate Reducing Agents felbamate 1 lamotrigine er 1 lamotrigine chew, tabs 1 QUDEXY XR CS24 50MG 1 ST (Topiramate #2, new topiramate er 1 ST (Topiramate #2, new topiramate tabs 1 topiramate cpsp 1 PA (Topiramate (Topamax sprinkle), new TROKENDI XR 1 ST (Topiramate #2, new Sodium Channel Agents BANZEL 1 carbamazepine er 1 carbamazepine chew, susp, tabs 1 dilantin caps 30mg 1 epitol 1 fosphenytoin sodium inj 100mg pe/2ml 1 oxcarbazepine 1 OXTELLAR XR 1 ST (Oxcarbazepine #2, new starts only) PEGANONE 1 phenytoin sodium extended 1 phenytoin sodium inj 1 phenytoin chew, susp 1 VIMPAT 1 Antidementia Agents Cholinesterase Inhibitors donepezil hcl tbdp 1 donepezil hcl tabs 10mg, 5mg 1 EXELON SOLN 1 galantamine hydrobromide 1 Page 7 of 57
rivastigmine tartrate 1 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl 1 NAMENDA 1 NAMENDA XR 1 NAMENDA XR TITRATION PACK 1 Antidepressants Antidepressants, Other BRINTELLIX 1 ST (Major Depressive Disorder #2, new PA (Vortioxetine (Brintellix), new budeprion sr 1 bupropion hcl sr 1 bupropion hcl xl 1 bupropion hcl tabs 1 maprotiline hcl 1 mirtazapine 1 PA (Beers-HEDIS Safety PA, new mirtazapine odt 1 PA (Beers-HEDIS Safety PA, new nefazodone hcl 1 trazodone hcl tabs 1 Monoamine Oxidase Inhibitors EMSAM 1 PA (Selegiline (Emsam), new starts only) MARPLAN 1 phenelzine sulfate tabs 1 tranylcypromine sulfate 1 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide 1 desvenlafaxine er 1 ST (Desvenlafaxine #2, new starts only) duloxetine hcl cpep 40mg 1 duloxetine hcl cpep 20mg, 30mg, 60mg 1 QL (62 EA per 31 days) FETZIMA 1 ST (Major Depressive Disorder #2, new FETZIMA TITRATION PACK 1 ST (Major Depressive Disorder #2, new fluoxetine dr 1 fluoxetine hcl caps, soln, tabs 1 fluvoxamine maleate 1 KHEDEZLA 1 ST (Desvenlafaxine #2, new starts only) paroxetine hcl 1 PA (Beer's List highly anticholinergic medications, new Page 8 of 57
paroxetine hcl er 1 PA (Beer's List highly anticholinergic medications, new PAXIL SUSP 1 PA (Paroxetine (Paxil), new starts only) sertraline hcl conc, tabs 1 venlafaxine hcl 1 venlafaxine hcl er 1 VIIBRYD 1 Tricyclics amitriptyline hcl tabs 1 PA (Beer's List highly anticholinergic medications, new amoxapine 1 PA (Beer's List highly anticholinergic medications, new clomipramine hcl caps 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new desipramine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new doxepin hcl caps, conc 1 PA (Beer's List highly anticholinergic medications, new imipramine hcl tabs 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new imipramine pamoate 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new nortriptyline hcl soln 1 PA (Beer's List highly anticholinergic medications liquid, new nortriptyline hcl caps 1 PA (Beer's List highly anticholinergic medications, new protriptyline hcl 1 PA (Beer's List highly anticholinergic medications, new SURMONTIL 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new Page 9 of 57
trimipramine maleate caps 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new Antiemetics Antiemetics, Other meclizine hcl tabs 1 PA (Beer's List highly anticholinergic medications) promethazine hcl inj 1 PA (Beers-HEDIS Safety PA) promethazine hcl supp 12.5mg, 25mg 1 PA (Beer's List highly anticholinergic medications) TRANSDERM-SCOP 1 PA (Beer's List highly anticholinergic medications) Emetogenic Therapy Adjuncts ANZEMET TABS 1 QL (9 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D ANZEMET INJ 1 ST (5-HT3 Antagonist Antiemetics #3) dronabinol 1 PA (Dronabinol (Marinol)) EMEND CAPS 0 1 QL (6 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D EMEND CAPS 125MG, 40MG, 80MG 1 QL (9 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D granisetron hcl tabs 1 ST (5-HT3 Antagonist Antiemetics #2) B/D granisetron hcl inj 0.1mg/ml, 1mg/ml 1 ST (5-HT3 Antagonist Antiemetics #2) granisol 1 ST (5-HT3 Antagonist Antiemetics #2) B/D ondansetron hcl oral soln 1 QL (950 ML per 31 days) ST (5- HT3 Antagonist Antiemetics #2) B/D ondansetron hcl inj 4mg/2ml 1 ondansetron hcl tabs 24mg 1 QL (31 EA per 31 days) ST (5-HT3 Antagonist Antiemetics #2) B/D ondansetron hcl tabs 4mg, 8mg 1 QL (62 EA per 31 days) B/D ondansetron odt 1 QL (62 EA per 31 days) B/D Antifungals Antifungals ABELCET 1 AMBISOME 1 amphotericin b 1 CANCIDAS 1 ciclopirox nail lacquer 1 ciclopirox olamine crea 1 ciclopirox sham, susp 1 clotrimazole crea, soln, troc 1 econazole nitrate crea 1 fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1 Page 10 of 57
fluconazole susr, tabs 1 flucytosine 1 griseofulvin microsize susp 1 itraconazole caps 1 ketoconazole crea, sham, tabs 1 miconazole 3 supp 1 MYCAMINE 1 NOXAFIL SUSP 1 NYSTATIN/TRIAMCINOLONE OINT 1 nystatin/triamcinolone crea 1 nystatin crea, oint, powd, susp, tabs 1 SPORANOX SOLN 1 terbinafine hcl tabs 1 terconazole 1 voriconazole inj, susr, tabs 1 zazole supp 1 Antigout Agents Antigout Agents allopurinol tabs 1 colchicine caps, tabs 1 COLCRYS 1 probenecid/colchicine 1 probenecid tabs 1 Antimigraine Agents Ergot Alkaloids CAFERGOT 1 PA (Beers-HEDIS Safety PA) ergomar 1 PA (Beers-HEDIS Safety PA) Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl 1 QL (9 EA per 30 days) rizatriptan benzoate 1 QL (18 EA per 30 days) rizatriptan benzoate odt 1 QL (18 EA per 30 days) sumatriptan succinate inj 1 QL (6 ML per 30 days) ST (Migraine Abortive Agents (5) #2) sumatriptan succinate tabs 1 QL (9 EA per 30 days) zolmitriptan odt 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) zolmitriptan tabs 1 QL (9 EA per 30 days) ST (Migraine Abortive Agents (5) #2) ZOMIG NASAL SPRAY 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) ZOMIG SOLN 2.5MG 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL 1 pyridostigmine bromide tabs 1 Antimycobacterials Antimycobacterials, Other DAPSONE TABS 1 Page 11 of 57
rifabutin 1 Antituberculars CAPASTAT SULFATE 1 ethambutol hcl tabs 1 ISONIAZID INJ 1 isoniazid tabs 1 PASER 1 PRIFTIN 1 pyrazinamide tabs 1 rifampin caps, inj 1 seromycin 1 SIRTURO 1 PA (Bedaquiline (Sirturo)) TRECATOR 1 Antineoplastics Alkylating Agents cyclophosphamide tabs 1 B/D HEXALEN 1 LEUKERAN 1 lomustine 1 MATULANE 1 TREANDA INJ 45MG/0.5ML 1 VALCHLOR 1 Antiandrogens bicalutamide 1 flutamide 1 NILANDRON 1 XTANDI 1 ZYTIGA 1 Antiangiogenic Agents CAPRELSA 1 REVLIMID 1 LA THALOMID 1 Antiestrogens/Modifiers EMCYT 1 FARESTON 1 SOLTAMOX 1 tamoxifen citrate tabs 1 Antimetabolites ADRUCIL INJ 500MG/10ML 1 ALIMTA INJ 500MG 1 hydroxyurea caps 1 mercaptopurine tabs 1 PURIXAN 1 TABLOID 1 Antineoplastics, Other amifostine 1 azacitidine 1 BELEODAQ 1 bleomycin sulfate inj 30unit 1 Page 12 of 57
cisplatin inj 100mg/100ml 1 PA (Beers-HEDIS Safety PA, new COMETRIQ 1 PA (Cabozantinib S-Malate (Cometriq), new daunorubicin hcl inj 5mg/ml 1 DAUNOXOME 1 decitabine 1 DOCEFREZ 1 DOCETAXEL INJ 80MG/4ML, 80MG/8ML 1 doxorubicin hcl inj 2mg/ml 1 ERIVEDGE 1 ERWINAZE 1 GILOTRIF 1 PA (Afatinib (Gilotrif), new starts only) HALAVEN 1 IBRANCE 1 JAKAFI 1 JEVTANA 1 leucovorin calcium tabs 1 leucovorin calcium inj 100mg, 350mg 1 LYNPARZA 1 MEKINIST 1 MENEST 1 mesna 1 MESNEX TABS 1 mitoxantrone hcl 1 ONCASPAR 1 oxaliplatin inj 100mg/20ml 1 POMALYST 1 PROLEUKIN 1 SYLATRON 1 SYNRIBO 1 PA (Omacetaxine Mepesuccinate (Synribo), new TAXOTERE INJ 80MG/4ML 1 TRISENOX 1 VELCADE 1 ZOLINZA 1 Antineoplastics FARYDAK 1 TAFINLAR 1 ZALTRAP INJ 100MG/4ML 1 ZYKADIA 1 Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 exemestane 1 letrozole 1 Enzyme Inhibitors etoposide inj 500mg/25ml 1 topotecan hcl inj 4mg 1 Page 13 of 57
ZYDELIG 1 Molecular Target Inhibitors AFINITOR 1 AFINITOR DISPERZ 1 BOSULIF 1 GLEEVEC 1 ICLUSIG 1 IMBRUVICA 1 INLYTA 1 LENVIMA 10MG DAILY DOSE 1 LENVIMA 14MG DAILY DOSE 1 LENVIMA 20MG DAILY DOSE 1 LENVIMA 24MG DAILY DOSE 1 NEXAVAR 1 SPRYCEL 1 STIVARGA 1 SUTENT 1 TARCEVA 1 TASIGNA 1 TYKERB 1 VOTRIENT 1 XALKORI 1 PA (crizotinib (Xalkori), new starts only) ZELBORAF 1 PA (Vemurafenib (Zelboraf), new Monoclonal Antibodies ARZERRA INJ 100MG/5ML 1 AVASTIN INJ 100MG/4ML 1 CYRAMZA 1 KADCYLA INJ 100MG 1 KEYTRUDA 1 OPDIVO INJ 40MG/4ML 1 PERJETA 1 RITUXAN 1 YERVOY INJ 50MG/10ML 1 Retinoids bexarotene 1 PANRETIN 1 TARGRETIN 1 tretinoin caps 10mg 1 Antiparasitics Anthelmintics ALBENZA 1 BILTRICIDE 1 ivermectin tabs 1 Antiprotozoals ALINIA 1 atovaquone 1 atovaquone/proguanil hcl 1 Page 14 of 57
chloroquine phosphate tabs 1 COARTEM 1 DARAPRIM 1 hydroxychloroquine sulfate tabs 1 mefloquine hcl 1 NEBUPENT 1 PA (Pentamidine) PENTAM 300 1 PA (Pentamidine) primaquine phosphate tabs 1 quinine sulfate 1 Pediculicides/Scabicides EURAX LOTN 1 LINDANE SHAM 1 lindane lotn 1 permethrin crea 1 Antiparkinson Agents Anticholinergics benztropine mesylate tabs 1 PA (Beer's List highly anticholinergic medications) trihexyphenidyl hcl 1 PA (Beer's List highly anticholinergic medications) Antiparkinson Agents, Other entacapone 1 TASMAR 1 tolcapone 1 Dopamine Agonists APOKYN 1 ST (Apomorphine #2) bromocriptine mesylate caps, tabs 1 NEUPRO 1 ST (Rotigotine #2) pramipexole dihydrochloride 1 ropinirole hcl 1 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 1 carbidopa/levodopa er 1 carbidopa/levodopa/entacapone 1 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 1 ST (Monoamine Oxidase B (MOA- B) Inhibitors #2, new selegiline hcl caps, tabs 1 Antipsychotics 1st Generation/Typical chlorpromazine hcl inj, tabs 1 PA (Beer's List highly anticholinergic medications, new compro 1 PA (Beer's List highly anticholinergic medications, new fluphenazine decanoate inj 1 PA (Beer's List highly anticholinergic medications, new Page 15 of 57
fluphenazine hcl conc, elix, inj, tabs 1 PA (Beer's List highly anticholinergic medications, new haloperidol decanoate 1 haloperidol lactate 1 haloperidol conc, tabs 1 loxapine succinate caps 1 PA (Beer's List highly anticholinergic medications, new ORAP 1 PA (Beer's List highly anticholinergic medications, new perphenazine tabs 1 PA (Beer's List highly anticholinergic medications, new prochlorperazine 1 PA (Beer's List highly anticholinergic medications) prochlorperazine edisylate inj 1 PA (Beer's List highly anticholinergic medications, new prochlorperazine maleate tabs 1 PA (Beer's List highly anticholinergic medications, new thioridazine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new thiothixene caps 1 PA (Beer's List highly anticholinergic medications, new trifluoperazine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new 2nd Generation/Atypical ABILIFY DISCMELT 1 PA (Aripiprazole (Abilify), new ABILIFY MAINTENA 1 ABILIFY INJ, TABS 1 ABILIFY ORAL SOLN 1 PA (Aripiprazole (Abilify), new aripiprazole tabs 1 FANAPT 1 ST (Anti-psychotic #3, new starts only) FANAPT TITRATION PACK 1 ST (Anti-psychotic #3, new starts only) GEODON INJ 1 INVEGA 1 ST (Paliperidone #3, new INVEGA SUSTENNA 1 ST (Paliperidone #3, new LATUDA 1 ST (Anti-psychotic #3, new starts only) Page 16 of 57
olanzapine 1 ST (Olanzapine #2, new PA (Beer's List highly anticholinergic medications, new olanzapine odt 1 ST (Olanzapine #2, new PA (Olanzapine (Zyprexa Zydis), new quetiapine fumarate 1 RISPERDAL CONSTA 1 risperidone 1 risperidone odt 1 SAPHRIS 1 SEROQUEL XR 1 ziprasidone hcl 1 ST (Anti-psychotic #2; Paliperidone #2, new ZYPREXA RELPREVV INJ 210MG 1 PA (Olanzapine IM (Zyprexa Relprevv), new Treatment-Resistant clozapine 1 clozapine odt 1 PA (Clozapine, new FAZACLO TBDP 150MG, 200MG 1 PA (Clozapine, new VERSACLOZ 1 PA (Clozapine, new Antispasticity Agents Antispasticity Agents baclofen tabs 1 dantrolene sodium caps 1 tizanidine hcl tabs 1 PA (Beer's List highly anticholinergic medications) Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir 1 ganciclovir inj 1 valganciclovir 1 ZIRGAN 1 Anti-hepatitis B (HBV) Agents adefovir dipivoxil 1 BARACLUDE SOLN 1 entecavir 1 INTRON A W/DILUENT INJ 10MU 1 INTRON A INJ 18MU, 50MU, 6000000UNIT/ML 1 TYZEKA 1 Anti-hepatitis C (HCV) Agents HARVONI 1 QL (28 EA per 28 days) PA (ledipasvir-sofosbuvir (Harvoni)) INCIVEK 1 PA (Telaprevir (Incivek)) MODERIBA 1200 DOSE PACK 1 MODERIBA 800 DOSE PACK 1 moderiba tabs 1 OLYSIO 1 PA (Simeprevir (Olysio)) Page 17 of 57
PEG-INTRON REDIPEN 1 PEG-INTRON INJ 50MCG/0.5ML 1 PEGASYS 1 PEGASYS PROCLICK 1 PEGINTRON INJ 120MCG/0.5ML, 150MCG/0.5ML, 1 80MCG/0.5ML RIBASPHERE RIBAPAK TABS 0 1 ribasphere ribapak tabs 400mg, 600mg 1 ribasphere tabs 1 SOVALDI 1 QL (28 EA per 28 days) PA (Sofosbuvir (Sovaldi)) VICTRELIS 1 PA (boceprivir (Victrelis)) Anti-HIV Agents, Integrase Inhibitors (INSTI) ISENTRESS 1 TIVICAY 1 VITEKTA 1 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 1 EDURANT 1 INTELENCE 1 nevirapine 1 nevirapine er 1 RESCRIPTOR 1 STRIBILD 1 SUSTIVA 1 VIRAMUNE XR TB24 100MG 1 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 1 abacavir sulfate/lamivudine/zidovudine 1 didanosine 1 EMTRIVA 1 EPIVIR HBV SOLN 1 EPIVIR SOLN 1 EPZICOM 1 lamivudine 1 lamivudine/zidovudine 1 RETROVIR IV INFUSION 1 stavudine 1 TRIUMEQ 1 TRUVADA 1 VIDEX PEDIATRIC SOLR 2GM 1 VIREAD 1 ZIAGEN SOLN 1 zidovudine 1 Anti-HIV Agents, Other FUZEON 1 SELZENTRY 1 Page 18 of 57
Anti-HIV Agents, Protease Inhibitors APTIVUS 1 CRIXIVAN 1 EVOTAZ 1 INVIRASE 1 KALETRA 1 LEXIVA 1 NORVIR 1 PREZCOBIX 1 PREZISTA SUSP 1 PREZISTA TABS 150MG, 600MG, 75MG, 800MG 1 REYATAZ PACK 1 REYATAZ CAPS 150MG, 200MG, 300MG 1 VIRACEPT 1 Anti-influenza Agents amantadine hcl caps, tabs 1 RELENZA DISKHALER 1 rimantadine hcl 1 TAMIFLU 1 Antiherpetic Agents acyclovir sodium inj 50mg/ml 1 acyclovir caps, susp, tabs 1 famciclovir tabs 1 trifluridine soln 1 valacyclovir hcl 1 Antivirals ATRIPLA 1 Anxiolytics Anxiolytics, Other buspirone hcl tabs 1 Benzodiazepines alprazolam 1 PA (Beers-HEDIS Safety PA) clorazepate dipotassium 1 PA (Beers-HEDIS Safety PA, new diazepam intensol 1 PA (Beers-HEDIS Safety PA, new diazepam soln 1mg/ml 1 PA (Beers-HEDIS Safety PA, new diazepam tabs 10mg, 2mg, 5mg 1 PA (Beers-HEDIS Safety PA, new estazolam 1 PA (Beers-HEDIS Safety PA) lorazepam intensol 1 PA (Beers-HEDIS Safety PA) lorazepam tabs 1 PA (Beers-HEDIS Safety PA, new oxazepam 1 PA (Beers-HEDIS Safety PA) temazepam 1 PA (Beers-HEDIS Safety PA) triazolam 1 PA (Beers-HEDIS Safety PA) Bipolar Agents Mood Stabilizers Page 19 of 57
lithium 1 lithium carbonate er 1 lithium carbonate caps, tabs 1 Blood Glucose Regulators Antidiabetic Agents acarbose 1 ST (Misc Diabetes Agents #2) AVANDAMET 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) AVANDARYL 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) AVANDIA 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) BYETTA INJ 10MCG/0.04ML 1 ST (Incretin mimetics #2) CYCLOSET 1 ST (Misc Diabetes Agents #2) glimepiride 1 glipizide er 1 glipizide/metformin hcl 1 glipizide tabs 1 GLYSET 1 ST (Misc Diabetes Agents #2) JANUMET 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) JANUVIA 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) JENTADUETO 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) metformin hcl er tb24 500mg, 750mg 1 metformin hcl tabs 1 nateglinide 1 pioglitazone hcl 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) pioglitazone hcl/metformin hcl 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) PRANDIMET 1 ST (Meglitinide #2) repaglinide 1 ST (Meglitinide #2) SYMLINPEN 120 1 ST (Incretin mimetics #2) SYMLINPEN 60 1 ST (Incretin mimetics #2) TRADJENTA 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) Glycemic Agents clinimix 4.25%/dextrose 20% 1 B/D CLINIMIX 5%/DEXTROSE 15% 1 B/D CLINIMIX 5%/DEXTROSE 20% 1 B/D CLINIMIX E 2.75%/DEXTROSE 10% 1 CLINIMIX E 2.75%/DEXTROSE 5% 1 CLINIMIX E 4.25%/DEXTROSE 25% 1 CLINIMIX E 4.25%/DEXTROSE 5% 1 CLINIMIX E 5%/DEXTROSE 15% 1 CLINIMIX E 5%/DEXTROSE 25% 1 DEXTROSE 10%/NACL 0.45% 1 Page 20 of 57
Name Tier dextrose 10% flex container 1 dextrose 10%/nacl 0.2% 1 dextrose 2.5%/sodium chloride 0.45% 1 dextrose 5% 1 dextrose 5%/nacl 0.2% 1 DEXTROSE 5%/NACL 0.225% 1 dextrose 5%/nacl 0.33% 1 dextrose 5%/nacl 0.45% 1 dextrose 5%/nacl 0.9% 1 GLUCAGEN HYPOKIT 1 GLUCAGON EMERGENCY KIT 1 IONOSOL-B/DEXTROSE 5% 1 IONOSOL-MB/DEXTROSE 5% 1 KCL 0.075%/D5W/NACL 0.45% 1 KCL 0.15%/D5W/LR 1 KCL 0.15%/D5W/NACL 0.2% 1 KCL 0.15%/D5W/NACL 0.225% 1 KCL 0.15%/D5W/NACL 0.9% 1 KCL 0.3%/D5W/NACL 0.45% 1 KCL 0.3%/D5W/NACL 0.9% 1 normosol-r in d5w 1 POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% 1 POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% 1 POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 1 PROGLYCEM 1 Insulins APIDRA 1 APIDRA SOLOSTAR 1 HUMALOG 1 HUMALOG KWIKPEN 1 HUMALOG MIX 50/50 1 HUMALOG MIX 50/50 KWIKPEN 1 HUMALOG MIX 75/25 1 HUMALOG MIX 75/25 KWIKPEN 1 HUMULIN 70/30 1 HUMULIN 70/30 KWIKPEN 1 HUMULIN N 1 HUMULIN N KWIKPEN 1 HUMULIN R 1 HUMULIN R U-500 (CONCENTRATED) 1 LANTUS 1 LANTUS SOLOSTAR 1 LEVEMIR 1 LEVEMIR FLEXTOUCH 1 NOVOLIN 70/30 1 NOVOLIN N 1 NOVOLIN R 1 NOVOLOG 1 NOVOLOG FLEXPEN 1 Requirements/Limits Page 21 of 57
NOVOLOG MIX 70/30 1 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 1 NOVOLOG PENFILL 1 Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin sodium 1 fondaparinux sodium 1 ST (injectable anticoagulants #2) FRAGMIN INJ 7500UNIT/0.3ML, 95000UNIT/3.8ML 1 ST (Anticoagulation #2) FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML, 1 ST (injectable anticoagulants #2) 15000UNIT/0.6ML, 18000UNT/0.72ML, 25000UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML heparin sodium/d5w 1 heparin sodium/nacl 0.9% 1 HEPARIN SODIUM INJ 2000UNIT/ML, 2500UNIT/ML 1 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 1 5000unit/ml PRADAXA 1 ST (Anticoagulation #2) PA (Beers- HEDIS Safety PA) warfarin sodium tabs 1 XARELTO 1 ST (Anticoagulation #2) XARELTO STARTER PACK 1 ST (Anticoagulation #2) Blood Formation Modifiers anagrelide hydrochloride 1 ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 1 PA (Darbepoetin alfa (Aranesp)) 100MCG/ML, 10MCG/0.4ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML EPOGEN 1 PA (Epoetin (Epogen/Procrit)) LEUKINE INJ 250MCG 1 PA (Sargramostim (Leukine)) NEUMEGA 1 PA (Oprelvekin (Neumega)) NEUPOGEN 1 PA (Filgrastim (Neupogen)) PROCRIT 1 PA (Epoetin (Epogen/Procrit)) PROMACTA 1 PA (Eltrombopag olamine (Promacta)) Coagulants tranexamic acid inj, tabs 1 Platelet Modifying Agents AGGRENOX 1 aspirin/dipyridamole 1 BRILINTA 1 cilostazol 1 clopidogrel 1 ticlopidine hcl 1 PA (Beers-HEDIS Safety PA) Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl tabs 1 PA (Beers-HEDIS Safety PA) Page 22 of 57
clonidine hcl ptwk 1 PA (clonidine transdermal (Catapres- TTS)) methyldopa tabs 1 PA (Beers-HEDIS Safety PA) methyldopate hcl 1 PA (Beers-HEDIS Safety PA) midodrine hcl 1 Alpha-adrenergic Blocking Agents CARDURA XL 1 PA (Beers-HEDIS Safety PA) prazosin hcl 1 PA (Beers-HEDIS Safety PA) Angiotensin II Receptor Antagonists candesartan cilexetil 1 losartan potassium 1 losartan potassium/hydrochlorothiazide 1 valsartan 1 ST (Angiotensin Receptor Antagonists #2) valsartan/hydrochlorothiazide 1 ST (Angiotensin Receptor Antagonists #2) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide 1 benazepril hcl tabs 1 captopril/hydrochlorothiazide 1 captopril tabs 1 enalapril maleate/hydrochlorothiazide 1 enalapril maleate tabs 1 lisinopril 1 lisinopril/hydrochlorothiazide 1 quinapril hcl 1 quinapril/hydrochlorothiazide 1 ramipril 1 Antiarrhythmics amiodarone hcl inj 50mg/ml 1 PA (Beers-HEDIS Safety PA) amiodarone hcl tabs 200mg, 400mg 1 PA (Beers-HEDIS Safety PA) disopyramide phosphate caps 1 PA (Beers-HEDIS Safety PA) flecainide acetate 1 mexiletine hcl 1 MULTAQ 1 ST (Dronedarone (Multaq) #2) propafenone hcl 1 propafenone hcl er 1 quinidine gluconate cr 1 quinidine sulfate 1 sotalol hcl (af) tabs 120mg 1 PA (Beers-HEDIS Safety PA) sotalol hcl tabs 160mg, 240mg, 80mg 1 PA (Beers-HEDIS Safety PA) TIKOSYN 1 Beta-adrenergic Blocking Agents acebutolol hcl caps 1 atenolol tabs 1 bisoprolol fumarate 1 bisoprolol fumarate/hydrochlorothiazide 1 carvedilol 1 Page 23 of 57
COREG CR 1 ST (Beta Blockers - Extended Release #2) labetalol hcl inj, tabs 1 metoprolol succinate er 1 metoprolol tartrate inj, tabs 1 metoprolol/hydrochlorothiazide 1 nadolol/bendroflumethiazide 1 PINDOLOL 1 propranolol hcl er 1 propranolol hcl inj, tabs 1 propranolol/hydrochlorothiazide 1 Calcium Channel Blocking Agents afeditab cr 1 amlodipine besylate tabs 1 cartia xt 1 dilt-cd cp24 300mg 1 dilt-xr 1 diltiazem cd cp24 240mg 1 diltiazem hcl er cp24 120mg, 180mg, 300mg, 360mg, 420mg 1 diltiazem hcl er cp12 1 diltiazem hcl tabs 1 diltzac 1 matzim la 1 nifedical xl 1 nifedipine er 1 nifedipine caps 1 PA (Beers-HEDIS Safety PA) nimodipine caps 1 taztia xt 1 verapamil hcl er 1 verapamil hcl sr cp24 360mg 1 verapamil hcl inj, tabs 1 Cardiovascular Agents, Other DEMSER 1 digoxin inj 1 PA (Beers-HEDIS Safety PA) digoxin tabs 125mcg 1 digoxin tabs 250mcg 1 PA (Beers-HEDIS Safety PA) pentoxifylline er 1 RANEXA 1 PA (Ranolazine (Ranexa)) TEKTURNA 1 ST (Angiotensin Receptor Antagonists #3) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium 1 acetazolamide tabs 1 Diuretics, Loop bumetanide inj, tabs 1 furosemide inj, tabs 1 furosemide oral soln 10mg/ml 1 torsemide tabs 1 Diuretics, Potassium-sparing Page 24 of 57
amiloride hcl tabs 1 amiloride/hydrochlorothiazide 1 spironolactone/hydrochlorothiazide 1 spironolactone tabs 25mg 1 spironolactone tabs 100mg, 50mg 1 PA (Beers-HEDIS Safety PA) triamterene/hydrochlorothiazide 1 Diuretics, Thiazide candesartan cilexetil/hydrochlorothiazide 1 chlorthalidone tabs 25mg, 50mg 1 hydrochlorothiazide caps, tabs 1 indapamide tabs 1 metolazone 1 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized 1 ST (Fibric Acid Dyslipidemics #2) fenofibrate caps 1 ST (Fibric Acid Dyslipidemics #2) fenofibrate tabs 145mg, 160mg, 48mg, 54mg 1 ST (Fibric Acid Dyslipidemics #2) fenofibric acid dr 1 FIBRICOR 1 ST (Fibric Acid Dyslipidemics #2) gemfibrozil tabs 1 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 1 LIPTRUZET 1 lovastatin 1 pravastatin sodium 1 simvastatin 1 Dyslipidemics, Other cholestyramine light pack 1 cholestyramine powd 1 colestipol hcl 1 JUXTAPID 1 PA (Lomitapide (Juxtapid)) niacin er 1 ST (Niacin #2) niacor 1 omega-3-acid ethyl esters 1 VYTORIN 1 ST (HMGCoA Inhibitors / Cholesterol Absorption Inhibitors #2) WELCHOL TABS 1 ZETIA 1 ST (HMGCoA Inhibitors / Cholesterol Absorption Inhibitors #2) Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate er 1 isosorbide dinitrate tabs 1 isosorbide dinitrate subl 2.5mg 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 nitroglycerin transdermal pt24 0.1mg/hr 1 nitroglycerin inj 1 nitroglycerin pt24 0.2mg/hr, 0.4mg/hr, 0.6mg/hr 1 Page 25 of 57
NITROSTAT 1 Vasodilators, Direct-acting Arterial hydralazine hcl inj, tabs 1 minoxidil tabs 1 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine cp24 1 QL (62 EA per 31 days) ST (Alpha- Adrenergic Agonists #2) PA (Beers- HEDIS Safety PA) amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 1 QL (62 EA per 31 days) PA (Beers- 7.5mg HEDIS Safety PA) amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 1 QL (93 EA per 31 days) PA (Beers- HEDIS Safety PA) 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg dextroamphetamine sulfate er 1 PA (Beers-HEDIS Safety PA) dextroamphetamine sulfate tabs 1 PA (Beers-HEDIS Safety PA) Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines dexmethylphenidate hcl 1 PA (Beers-HEDIS Safety PA) guanfacine er 1 QL (31 EA per 31 days) PA (Guanfacine (Intuniv)) metadate er 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl cd cpcr 10mg, 50mg, 60mg 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl er cp24 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl er tbcr 18mg, 20mg, 27mg, 36mg, 54mg 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl tabs 1 PA (Beers-HEDIS Safety PA) methylphenidate hydrochloride 1 PA (Beers-HEDIS Safety PA) STRATTERA 1 ST (Norepinephrine Reuptake Inhibitors #2) Central Nervous System, Other HORIZANT 1 PA (gabapentin encarbil XR (Horizant)) NUEDEXTA 1 PA (Dextromethorphan Hydrobromide/Quinidine Sulfate (Nuedexta)) riluzole 1 PA (Riluzole (Rilutek)) XENAZINE 1 PA (Tetrabenazine (Xenazine)) Multiple Sclerosis Agents AVONEX 1 BETASERON 1 COPAXONE INJ 20MG/ML 1 GILENYA 1 PA (fingolimod (Gilenya)) GLATOPA 1 REBIF 1 REBIF REBIDOSE 1 REBIF REBIDOSE TITRATION PACK 1 REBIF TITRATION PACK 1 Page 26 of 57
TYSABRI 1 PA (Natalizumab (Tysabri)) Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate oral rinse 1 periogard 1 pilocarpine hcl tabs 7.5mg 1 pilocarpine hydrochloride 1 triamcinolone in orabase 1 Dermatological Agents Dermatological Agents 8-MOP 1 acitretin 1 ST (Psoriasis Agents #3) PA (Acitretin) adapalene gel 0.1% 1 ST (Acne Agents #3) ammonium lactate crea, lotn 1 amnesteem 1 PA (Isotretinoin) calcipotriene oint, soln 1 claravis caps 10mg, 20mg, 40mg 1 PA (Isotretinoin) clindamycin phosphate lotn 1% 1 clindamycin phosphate soln 1% 1 CURITY GAUZE PADS 2"X2" 1 diclofenac sodium transdermal soln 1.5% 1 erythromycin/benzoyl peroxide 1 ST (Acne Agents #2) fluorouracil crea 1 fluorouracil soln 2% 1 imiquimod crea 1 PA (Imiquimod (Aldara), new starts only) methoxsalen caps 1 myorisan 1 PA (Isotretinoin) OXSORALEN 1 podofilox soln 1 PROTOPIC 1 REGRANEX 1 QL (15 GM per 30 days) PA (Becaplermin (Regranex)) SANTYL 1 QL (30 GM per 30 days) PA (Collagenase (Santyl)) selenium sulfide lotn 1 sulfacetamide sodium 1 tacrolimus oint 0.03%, 0.1% 1 TAZORAC GEL 1 QL (100 GM per 30 days) ST (Acne Agents #3; Psoriasis Agents #2) TAZORAC CREA 1 QL (60 GM per 30 days) ST (Acne Agents #3; Psoriasis Agents #2) tretinoin crea 0.025%, 0.05%, 0.1% 1 ST (Acne Agents #2) tretinoin gel 0.01%, 0.025% 1 ST (Acne Agents #2) UVADEX 1 VOLTAREN 1 ST (Topical diclofenac #2) ZENATANE CAPS 30MG 1 PA (Isotretinoin) zenatane caps 10mg, 20mg, 40mg 1 PA (Isotretinoin) Page 27 of 57
Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN 1 ALDURAZYME 1 CARBAGLU 1 PA (Carglumic Acid (Carbaglu)) CEREZYME INJ 400UNIT 1 CREON 1 CYSTADANE 1 CYSTAGON 1 ELAPRASE 1 ELELYSO 1 FABRAZYME INJ 35MG 1 KUVAN TBSO 1 PA (Sapropterin (Kuvan)) KUVAN PACK 500MG 1 PA (Sapropterin (Kuvan)) LUMIZYME 1 NAGLAZYME 1 PANCREAZE 1 sodium phenylbutyrate powd 1 SUCRAID 1 VPRIV 1 ZAVESCA 1 ZENPEP 1 Gastrointestinal Agents Antispasmodics, Gastrointestinal CANTIL 1 dicyclomine hcl caps, tabs 1 PA (Beer's List highly anticholinergic medications) glycopyrrolate tabs 1 glycopyrrolate inj 4mg/20ml 1 Gastrointestinal Agents, Other cromolyn sodium conc 100mg/5ml 1 diphenoxylate/atropine 1 PA (Beer's List highly anticholinergic medications) loperamide hcl caps 1 metoclopramide hcl inj, tabs 1 PA (Beers-HEDIS Safety PA) RELISTOR INJ 12MG/0.6ML 1 ursodiol caps, tabs 1 Histamine2 (H2) Receptor Antagonists famotidine premixed 1 famotidine susr 1 famotidine inj 20mg/2ml 1 famotidine tabs 20mg, 40mg 1 ranitidine hcl caps, syrp 1 ranitidine hcl inj 150mg/6ml 1 ranitidine hcl tabs 150mg, 300mg 1 Irritable Bowel Syndrome Agents alosetron hydrochloride 1 PA (Alosetron (Lotronex)) AMITIZA 1 LOTRONEX 1 PA (Alosetron (Lotronex)) Page 28 of 57
Laxatives constulose 1 enulose 1 gavilyte-c 1 gavilyte-g 1 gavilyte-n/flavor pack 1 generlac 1 lactulose soln 1 peg-3350/electrolytes 1 polyethylene glycol 3350 powd 1 trilyte 1 Protectants CARAFATE SUSP 1 misoprostol 1 sucralfate tabs 1 Proton Pump Inhibitors esomeprazole sodium 1 ST (IV Proton Pump Inhibitors #2) lansoprazole cpdr 1 ST (Proton Pump Inhibitors #2) omeprazole cpdr 1 pantoprazole sodium 1 PROTONIX INJ 1 Genitourinary Agents Antispasmodics, Urinary ENABLEX 1 ST (Urinary Antispasmodics #3) PA (Beers-HEDIS Safety PA) oxybutynin chloride er 1 PA (Beers-HEDIS Safety PA) oxybutynin chloride tabs 1 PA (Beers-HEDIS Safety PA) OXYTROL 1 ST (Urinary Antispasmodics #3) PA (Beers-HEDIS Safety PA) tolterodine tartrate 1 ST (Urinary Antispasmodics #2) PA (Beers-HEDIS Safety PA) tolterodine tartrate er 1 ST (Urinary Antispasmodics #2) PA (Beers-HEDIS Safety PA) trospium chloride 1 ST (Urinary Antispasmodics #3) PA (Beers-HEDIS Safety PA) trospium chloride er 1 ST (Urinary Antispasmodics #3) PA (Beers-HEDIS Safety PA) VESICARE 1 ST (Urinary Antispasmodics #3) PA (Beers-HEDIS Safety PA) Benign Prostatic Hypertrophy Agents AVODART 1 doxazosin mesylate 1 PA (Beers-HEDIS Safety PA) finasteride tabs 5mg 1 tamsulosin hcl 1 terazosin hcl 1 PA (Beers-HEDIS Safety PA) Genitourinary Agents, Other bethanechol chloride 1 ELMIRON 1 phenazopyridine hcl tabs 100mg, 200mg 1 Page 29 of 57
Name Tier THIOLA 1 Phosphate Binders FOSRENOL 1 RENAGEL 1 RENVELA 1 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort 1 augmented betamethasone dipropionate crea, oint 1 betamethasone dipropionate lotn 1 betamethasone valerate crea, lotn, oint 1 budesonide cp24 3mg 1 clobetasol propionate e 1 clobetasol propionate gel, oint, soln 1 clotrimazole/betamethasone dipropionate crea 1 CORMAX SCALP APPLICATION 1 cortisone acetate tabs 1 DEPO-MEDROL INJ 20MG/ML 1 dexamethasone sodium phosphate inj 120mg/30ml 1 dexamethasone elix, tabs 1 fludrocortisone acetate tabs 1 fluocinolone acetonide body 1 fluocinolone acetonide crea, oil, oint 1 fluocinonide-e 1 fluocinonide crea 0.05% 1 fluocinonide gel, oint 1 fluticasone propionate crea 0.05% 1 fluticasone propionate oint 0.005% 1 hydrocortisone butyrate crea, oint, soln 1 hydrocortisone valerate crea 1 hydrocortisone crea 1%, 2.5% 1 hydrocortisone tabs 1 hydrocortisone oint 1%, 2.5% 1 lokara 1 methylprednisolone acetate inj 1 methylprednisolone dose pack 1 methylprednisolone sodiumsuccinate inj 125mg, 1gm, 40mg 1 methylprednisolone tabs 1 mometasone furoate crea, oint, soln 1 prednisolone sodium phosphate oral soln 15mg/5ml, 1 25mg/5ml, 5mg/5ml prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg 1 PROCTOSOL HC 1 proctozone-hc 1 SOLU-CORTEF INJ 250MG 1 triamcinolone acetonide crea 0.025%, 0.1%, 0.5% 1 triamcinolone acetonide lotn 0.025% 1 triamcinolone acetonide oint 0.025%, 0.1%, 0.5% 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Requirements/Limits Page 30 of 57
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate inj, nasal soln, tabs 1 GENOTROPIN 1 PA (Beers-HEDIS Safety PA) GENOTROPIN MINIQUICK 1 PA (Beers-HEDIS Safety PA) HUMATROPE COMBO PACK 1 PA (Beers-HEDIS Safety PA) HUMATROPE INJ 12MG, 24MG, 6MG 1 PA (Beers-HEDIS Safety PA) INCRELEX 1 NORDITROPIN FLEXPRO 1 PA (Beers-HEDIS Safety PA) NUTROPIN AQ NUSPIN 5 1 PA (Beers-HEDIS Safety PA) NUTROPIN AQ PEN 1 PA (Beers-HEDIS Safety PA) NUTROPIN INJ 10MG 1 PA (Beers-HEDIS Safety PA) OMNITROPE 1 PA (Beers-HEDIS Safety PA) pregnyl w/diluent benzyl alcohol/nacl 1 PA (Beers-HEDIS Safety PA) SAIZEN 1 PA (Beers-HEDIS Safety PA) SAIZEN CLICK.EASY 1 PA (Beers-HEDIS Safety PA) SEROSTIM 1 PA (Beers-HEDIS Safety PA) TEV-TROPIN 1 PA (Beers-HEDIS Safety PA) ZOMACTON 1 PA (Beers-HEDIS Safety PA) ZORBTIVE 1 PA (Beers-HEDIS Safety PA) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 1 oxandrolone tabs 1 Androgens ANDRODERM 1 PA (Testosterone (Androderm)) ANDROGEL GEL 50MG/5GM 1 PA (Beers-HEDIS Safety PA) androxy 1 danazol caps 1 TESTIM 1 PA (Beers-HEDIS Safety PA) testosterone cypionate inj 100mg/ml 1 PA (Beers-HEDIS Safety PA) testosterone enanthate inj 1 PA (Beers-HEDIS Safety PA) Estrogens apri 1 aranelle 1 aviane 1 balziva 1 briellyn 1 cesia 1 cryselle-28 1 cyclafem 1/35 1 cyclafem 7/7/7 1 drospirenone/ethinyl estradiol 1 emoquette 1 enpresse-28 1 estrace crea 1 estradiol/norethindrone acetate tabs 0.5mg; 0.1mg 1 estradiol tabs 1 estradiol ptwk 1 PA (estradiol transdermal (Climera)) Page 31 of 57
gildagia 1 introvale 1 junel 1.5/30 1 junel 1/20 1 junel fe 1.5/30 1 junel fe 1/20 1 kariva 1 kelnor 1/35 1 larin 1/20 1 larin fe 1.5/30 1 larin fe 1/20 1 leena 1 lessina 1 levonest 1 levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 1 levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 20mcg; 1 0.1mg levora 0.15/30-28 1 low-ogestrel 1 lutera 1 marlissa 1 microgestin 1.5/30 1 microgestin 1/20 1 microgestin fe 1 microgestin fe 1.5/30 1 mononessa 1 necon 0.5/35-28 1 necon 1/35 1 necon 7/7/7 1 nortrel 0.5/35 (28) 1 nortrel 1/35 1 nortrel 7/7/7 1 orsythia 1 pimtrea 1 pirmella 1/35 1 portia-28 1 PREMARIN CREA, TABS 1 PA (Beers-HEDIS Safety PA) PREMPHASE 1 PA (Beers-HEDIS Safety PA) PREMPRO 1 PA (Beers-HEDIS Safety PA) previfem 1 quasense 1 reclipsen 1 solia 1 sprintec 28 1 sronyx 1 tri-legest fe 1 tri-previfem 1 tri-sprintec 1 trinessa 1 Page 32 of 57
trivora-28 1 velivet 1 vyfemla 1 zenchent 1 zovia 1/35e 1 zovia 1/50e 1 Progestins camila 1 DEPO-PROVERA 1 DEPO-SUBQ PROVERA 104 1 ELLA 1 errin 1 jolivette 1 lyza 1 medroxyprogesterone acetate inj, tabs 1 MEGACE ES 1 PA (megestrol (Megace ES)) megestrol acetate tabs 1 PA (Beers-HEDIS Safety PA, new megestrol acetate susp 40mg/ml 1 PA (Beers-HEDIS Safety PA, new nora-be 1 norethindrone acetate tabs 1 norethindrone tabs 1 progesterone caps 1 Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs 1 liothyronine sodium inj, tabs 1 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN 1 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR 1 Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline 1 ELIGARD 1 firmagon 1 leuprolide acetate inj 1 LUPRON DEPOT 1 LUPRON DEPOT-PED INJ 11.25MG, 15MG 1 octreotide acetate 1 SANDOSTATIN LAR DEPOT 1 SOMATULINE DEPOT INJ 120MG/0.5ML, 90MG/0.3ML 1 SOMAVERT 1 SYNAREL 1 PA (Nafarelin (Synarel)) Page 33 of 57
TRELSTAR MIXJECT 1 Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole tabs 1 propylthiouracil tabs 1 Immunological Agents Angioedema (HAE) Agents CINRYZE 1 PA (Hereditary Angioedema) FIRAZYR 1 PA (Hereditary Angioedema) Immune Suppressants ASTAGRAF XL 1 B/D AZASAN 1 B/D azathioprine tabs 1 B/D CELLCEPT INTRAVENOUS 1 cyclosporine modified caps 100mg, 25mg 1 B/D cyclosporine modified soln 1 B/D cyclosporine caps, inj 1 B/D ENBREL SURECLICK 1 ENBREL INJ 25MG, 50MG/ML 1 gengraf 1 B/D HUMIRA PEN-CROHNS DISEASESTARTER 1 HUMIRA INJ 20MG/0.4ML, 40MG/0.8ML 1 KINERET 1 methotrexate sodium inj 1gm/40ml, 1gm 1 methotrexate tabs 1 mycophenolate mofetil 1 B/D mycophenolic acid dr 1 B/D NULOJIX 1 ORENCIA 1 PROGRAF INJ 1 B/D RAPAMUNE SOLN 1 B/D REMICADE 1 sirolimus tabs 1 B/D tacrolimus caps 0.5mg, 1mg, 5mg 1 B/D TORISEL 1 TREXALL 1 ZORTRESS 1 B/D Immunizing Agents, Passive ATGAM 1 CARIMUNE NANOFILTERED INJ 6GM 1 B/D GAMMAGARD LIQUID INJ 2.5GM/25ML 1 B/D GAMUNEX-C INJ 1GM/10ML 1 B/D HYPERRAB S/D 1 THYMOGLOBULIN 1 Immunomodulators ACTIMMUNE 1 ARCALYST 1 ILARIS 1 PA (Canakinumab (Ilaris)) leflunomide 1 Page 34 of 57
SIMULECT INJ 20MG 1 SYNAGIS INJ 50MG/0.5ML 1 XELJANZ 1 PA (Tofacitinib (Xeljanz)) Vaccines ACTHIB 1 ADACEL 1 bcg vaccine 1 BEXSERO 1 BOOSTRIX 1 CERVARIX 1 COMVAX 1 DAPTACEL 1 DECAVAC 1 DIPHTHERIA/TETANUS TOXOIDS ADSORBED 1 PEDIATRIC ENGERIX-B 1 B/D GARDASIL 1 GARDASIL 9 1 HAVRIX 1 IMOVAX RABIES (H.D.C.V.) 1 INFANRIX 1 IPOL INACTIVATED IPV 1 IXIARO 1 JE-VAX 1 M-M-R II 1 MENACTRA 1 MENOMUNE-A/C/Y/W-135 1 MENVEO 1 PEDVAX HIB 1 PROQUAD 1 QUADRACEL 1 RABAVERT 1 RECOMBIVAX HB 1 B/D ROTARIX 1 ROTATEQ 1 TENIVAC 1 TETANUS TOXOID ADSORBED 1 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 1 TRUMENBA 1 TWINRIX 1 TYPHIM VI 1 VAQTA 1 VARIVAX 1 VARIZIG 1 VIVOTIF BERNA 1 YF-VAX 1 ZOSTAVAX 1 Inflammatory Bowel Disease Agents Aminosalicylates Page 35 of 57
APRISO 1 ASACOL HD 1 balsalazide disodium 1 CANASA 1 ST (Mesalamine #2) delzicol 1 DIPENTUM 1 LIALDA 1 ST (Mesalamine #2) PENTASA 1 Sulfonamides sulfasalazine tabs 1 sulfazine ec 1 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium tabs 1 calcitonin-salmon 1 calcitriol 1 doxercalciferol 1 etidronate disodium 1 FORTEO 1 ST (Osteoporosis #3) fortical 1 ibandronate sodium 1 ST (Osteoporosis #2) MIACALCIN INJ 1 PROLIA 1 ST (Osteoporosis #2) XGEVA 1 zoledronic acid inj 4mg/5ml 1 PA (zoledronic acid (Zometa)) zoledronic acid inj 5mg/100ml 1 ST (Osteoporosis #2) Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 1 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 1 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 1 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 1 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 1 fomepizole 1 intralipid inj 20gm/100ml 1 B/D lactated ringers irrigation 1 LIPOSYN III INJ 2.5%; 30% 1 LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; 1 B/D 10GM/100ML, 1.2GM/100ML; 2.5GM/100ML; 20GM/100ML physiolyte 1 PHYSIOSOL IRRIGATION 1 ringers irrigation 1 SODIUM CHLORIDE 0.9% 1 sterile water irrigation 1 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs latanoprost 1 QL (5 ML per 30 days) LUMIGAN SOLN 0.01% 1 QL (5 ML per 30 days) Page 36 of 57
Ophthalmic Agents, Other atropine sulfate soln 1 LACRISERT 1 mydral 1 RESTASIS 1 QL (60 EA per 30 days) Ophthalmic Anti-allergy Agents azelastine hcl ophthalmic soln 0.05% 1 cromolyn sodium soln 4% 1 PATADAY 1 PATANOL 1 QL (10 ML per 30 days) Ophthalmic Anti-inflammatories ALREX 1 dexamethasone sodium phosphate ophthalmic soln 0.1% 1 diclofenac sodium ophthalmic soln 0.1% 1 fluorometholone 1 flurbiprofen sodium 1 FML 1 ketorolac tromethamine 1 QL (10 ML per 30 days) LOTEMAX SUSP 1 LOTEMAX GEL 1 QL (10 GM per 30 days) neomycin/polymyxin/dexamethasone 1 poly-dex 1 prednisolone acetate 1 prednisolone sodium phosphate ophthalmic soln 1% 1 TOBRADEX OINT 1 tobramycin/dexamethasone 1 VEXOL 1 Ophthalmic Antiglaucoma Agents ALPHAGAN P SOLN 0.1% 1 apraclonidine 1 AZOPT 1 QL (10 ML per 30 days) brimonidine tartrate 1 dorzolamide hcl 1 dorzolamide hcl/timolol maleate 1 QL (10 ML per 30 days) levobunolol hcl 1 methazolamide tabs 1 pilocarpine hcl soln 1%, 2%, 4% 1 PILOPINE HS 1 timolol maleate ophthalmic gel forming 1 timolol maleate soln 1 Otic Agents Otic Agents acetic acid 1 neomycin/polymyxin/hc 1 neomycin/polymyxin/hydrocortisone susp 1 Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 1 QL (60 EA per 30 days) ADVAIR HFA 1 QL (12 GM per 30 days) Page 37 of 57
ASMANEX HFA 1 ASMANEX TWISTHALER 120 METERED DOSES 1 ASMANEX TWISTHALER 30 METERED DOSES 1 ASMANEX TWISTHALER 60 METERED DOSES 1 BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH 1 budesonide inhalation susp 1mg/2ml 1 budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml 1 B/D budesonide nasal susp 32mcg/act 1 FLOVENT HFA AERO 44MCG/ACT 1 QL (21.2 GM per 30 days) FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT 1 QL (24 GM per 30 days) flunisolide soln 0.025% 1 fluticasone propionate susp 50mcg/act 1 NASONEX 1 PULMICORT FLEXHALER 1 PULMICORT SUSP 1MG/2ML 1 B/D QVAR AERS 40MCG/ACT 1 QVAR AERS 80MCG/ACT 1 QL (7.3 GM per 30 days) SYMBICORT 1 triamcinolone acetonide aero 55mcg/act 1 Antihistamines azelastine hcl nasal soln 0.1%, 0.15% 1 cetirizine hcl syrp 1mg/ml 1 hydroxyzine hcl inj 50mg/ml 1 PA (Beers-HEDIS Safety PA) olopatadine hcl 1 Antileukotrienes montelukast sodium 1 zafirlukast 1 ZYFLO 1 ST (Antileukotrienes #2) ZYFLO CR 1 ST (Antileukotrienes #2) Bronchodilators, Anticholinergic ATROVENT HFA 1 COMBIVENT RESPIMAT 1 ipratropium bromide/albuterol sulfate 1 B/D ipratropium bromide nasal soln 1 ipratropium bromide inhalation soln 1 B/D SPIRIVA HANDIHALER 1 ST (Anticholinergic Bronchodilators #2) tudorza pressair 1 ST (Anticholinergic Bronchodilators II #2) Bronchodilators, Sympathomimetic albuterol sulfate nebu 0.083%, 0.5%, 0.63mg/3ml 1 B/D AUVI-Q 1 QL (2 EA per 60 days) EPIPEN 2-PAK 1 QL (2 EA per 60 days) EPIPEN-JR 2-PAK 1 QL (2 EA per 60 days) METAPROTERENOL SULFATE TABS 1 metaproterenol sulfate syrp 1 PROAIR HFA 1 ST (Sympathomimetic Bronchodilators #2) SEREVENT DISKUS 1 QL (60 EA per 30 days) Page 38 of 57
terbutaline sulfate inj, tabs 1 VENTOLIN HFA 1 Cystic Fibrosis Agents CAYSTON 1 PULMOZYME 1 ST (Mucolytics #2) PA (Dornase Alfa (Pulmozyme)) tobramycin 1 PA (Tobramycin (Tobi)) Mast Cell Stabilizers cromolyn sodium nebu 20mg/2ml 1 B/D Phosphodiesterase Inhibitors, Airways Disease aminophylline 1 DALIRESP 1 PA (Roflumilast (Daliresp)) THEO-24 1 theochron 1 theophylline cr tb12 100mg, 200mg 1 theophylline er tb24 1 theophylline er tb12 300mg, 450mg 1 Pulmonary Antihypertensives ADCIRCA 1 PA (Tadalafil (Adcirca)) LETAIRIS 1 ST (Pulmonary Antihypertensives #2) REMODULIN 1 ST (Pulmonary Antihypertensives #2) B/D sildenafil tabs 1 PA (Sildenafil (Revatio)) TRACLEER 1 ST (Pulmonary Antihypertensives #2) LA Respiratory Tract Agents, Other acetylcysteine soln 1 B/D ARALAST NP INJ 400MG 1 GLASSIA 1 PROLASTIN-C 1 TYZINE PEDIATRIC NASAL DROPS 1 XOLAIR 1 ZEMAIRA 1 Skeletal Muscle Relaxants Skeletal Muscle Relaxants cyclobenzaprine hcl tabs 10mg 1 PA (Beer's List highly anticholinergic medications) methocarbamol tabs 1 PA (Beers-HEDIS Safety PA) Sleep Disorder Agents GABA Receptor Modulators zaleplon 1 PA (Beers-HEDIS Safety PA) zolpidem tartrate 1 PA (Beers-HEDIS Safety PA) Sleep Disorders, Other modafinil 1 PA (Modafinal (Provigil)) ROZEREM 1 XYREM 1 LA Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers Page 39 of 57
ammonium chloride 1 CUPRIMINE 1 DEPEN TITRATABS 1 EXJADE 1 SODIUM LACTATE 1 sodium polystyrene sulfonate susp 1 SYPRINE 1 Electrolyte/Mineral Replacement AMINOSYN 1 AMINOSYN 7%/ELECTROLYTES 1 AMINOSYN 8.5%/ELECTROLYTES 1 B/D AMINOSYN II 4.25/DEXTROSE25% 1 AMINOSYN II 5/DEXTROSE 25 1 AMINOSYN II 8.5%/ELECTROLYTES 1 B/D AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 1 B/D 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN M 1 B/D AMINOSYN-HBC 1 B/D AMINOSYN-HF 1 AMINOSYN-PF 1 B/D AMINOSYN-PF 7% 1 B/D calcium acetate caps 1 CLINIMIX 2.75%/DEXTROSE 5% 1 B/D clinimix 4.25%/dextrose 10% 1 B/D clinimix 4.25%/dextrose 25% 1 B/D CLINIMIX 4.25%/DEXTROSE 5% 1 B/D CLINIMIX 5%/DEXTROSE 25% 1 B/D CLINIMIX E 5%/DEXTROSE 20% 1 clinisol sf 15% 1 B/D DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX 1 dextrose 5%/potassium chloride 0.15% 1 Page 40 of 57
FREAMINE HBC 6.9% 1 hepatamine 1 B/D HEPATASOL 1 B/D isolyte-h/dextrose 5% 1 isolyte-m/dextrose 5% 1 ISOLYTE-P/DEXTROSE 5% 1 ISOLYTE-S 1 isolyte-s/dextrose 5% 1 klor-con 10 1 klor-con 8 1 klor-con m15 1 klor-con m20 1 LACTATED RINGERS DEXTROSE 5% VIAFLEX 1 lactated ringers viaflex 1 MAGNESIUM SULFATE INJ 40MG/ML, 80MG/ML 1 magnesium sulfate inj 50% 1 MOZOBIL 1 NEPHRAMINE 1 B/D normosol-m in d5w 1 NORMOSOL-R 1 PLASMA-LYTE A 1 PLASMA-LYTE-148 1 PLASMA-LYTE-56/D5W 1 potassium chloride 0.15% /nacl 0.45% viaflex 1 POTASSIUM CHLORIDE 0.15%/NACL 0.9% 1 potassium chloride 0.3%/d5w 1 potassium chloride er 1 potassium chloride sr tbcr 8meq 1 potassium chloride liqd 1 PA (Potassium Chloride liquid) potassium chloride inj 2meq/ml 1 PREMASOL INJ 52MEQ/L; 1760MG/100ML; 1 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 1 B/D 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROCALAMINE 1 B/D PROSOL 1 B/D ringers injection 1 sodium chloride 0.45% viaflex 1 sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% 1 sodium fluoride tabs 1mg 1 tpn electrolytes 1 Page 41 of 57
TRAVASOL 1 B/D TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1 B/D 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML Vitamins vp-pnv-dha 1 Page 42 of 57
Index Name Page # 8-MOP 27 abacavir 18 abacavir sulfate/lamivudine/zidovudine 18 ABELCET 10 ABILIFY 16 ABILIFY DISCMELT 16 ABILIFY MAINTENA 16 acamprosate calcium dr 3 acarbose 20 acebutolol hcl 23 acetaminophen/codeine 2 acetaminophen/codeine #3 2 acetazolamide 24 acetazolamide sodium 24 acetic acid 37 acetylcysteine 39 acitretin 27 ACTHIB 35 ACTIMMUNE 34 acyclovir 19 acyclovir sodium 19 ADACEL 35 ADAGEN 28 adapalene 27 ADCIRCA 39 adefovir dipivoxil 17 ADRUCIL 12 ADVAIR DISKUS 37 ADVAIR HFA 37 afeditab cr 24 AFINITOR 14 AFINITOR DISPERZ 14 AGGRENOX 22 a-hydrocort 30 ALBENZA 14 albuterol sulfate 38 ALCOHOL PREP PADS 4 ALDURAZYME 28 alendronate sodium 36 ALIMTA 12 ALINIA 14 allopurinol 11 alosetron hydrochloride 28 ALPHAGAN P 37 alprazolam 19 ALREX 37 amantadine hcl 19 Page 43 of 57 Name Page # AMBISOME 10 amifostine 12 amiloride hcl 25 amiloride/hydrochlorothiazide 25 aminophylline 39 AMINOSYN 40 AMINOSYN 7%/ELECTROLYTES 40 AMINOSYN 8.5%/ELECTROLYTES 40 AMINOSYN II 40 AMINOSYN II 4.25/DEXTROSE25% 40 AMINOSYN II 5/DEXTROSE 25 40 AMINOSYN II 8.5%/ELECTROLYTES 40 AMINOSYN M 40 AMINOSYN-HBC 40 AMINOSYN-HF 40 AMINOSYN-PF 40 AMINOSYN-PF 7% 40 amiodarone hcl 23 AMITIZA 28 amitriptyline hcl 9 amlodipine besylate 24 ammonium chloride 40 ammonium lactate 27 amnesteem 27 amoxapine 9 amoxicillin 5 amoxicillin/clavulanate potassium 5 amoxicillin/clavulanate potassium er 5 amphetamine/dextroamphetamine 26 amphotericin b 10 ampicillin 5 ampicillin sodium 5 ampicillin-sulbactam 5 ANADROL-50 31 anagrelide hydrochloride 22 anastrozole 13 ANDRODERM 31 ANDROGEL 31 androxy 31 ANZEMET 10 APIDRA 21 APIDRA SOLOSTAR 21 APOKYN 15 apraclonidine 37 apri 31 APRISO 36 APTIOM 6 APTIVUS 19 ARALAST NP 39 aranelle 31
Page # ARANESP ALBUMIN FREE 22 ARCALYST 34 aripiprazole 16 ARZERRA 14 ASACOL HD 36 ASMANEX HFA 38 ASMANEX TWISTHALER 120 38 METERED DOSES ASMANEX TWISTHALER 30 METERED 38 DOSES ASMANEX TWISTHALER 60 METERED 38 DOSES aspirin/dipyridamole 22 ASTAGRAF XL 34 atenolol 23 ATGAM 34 atorvastatin calcium 25 atovaquone 14 atovaquone/proguanil hcl 14 ATRIPLA 19 atropine sulfate 37 ATROVENT HFA 38 augmented betamethasone dipropionate 30 AUVI-Q 38 AVANDAMET 20 AVANDARYL 20 AVANDIA 20 AVASTIN 14 AVELOX 6 aviane 31 AVODART 29 AVONEX 26 azacitidine 12 AZASAN 34 azathioprine 34 azelastine hcl 37 azelastine hcl 38 AZILECT 15 azithromycin 5 AZOPT 37 aztreonam 5 baciim 4 bacitracin 4 bacitracin/polymyxin b 4 baclofen 17 balsalazide disodium 36 balziva 31 BANZEL 7 BARACLUDE 17 bcg vaccine 35 Name Page # BD INSULIN SYRINGE 36 SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE 36 ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE 36 ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE 36 ULTRAFINE/1ML/31G X 5/16" BD PEN NEEDLE/ULTRAFINE/29G X 36 12.7MM BELEODAQ 12 benazepril hcl 23 benazepril hcl/hydrochlorothiazide 23 benztropine mesylate 15 betamethasone dipropionate 30 betamethasone valerate 30 BETASERON 26 bethanechol chloride 29 bexarotene 14 BEXSERO 35 bicalutamide 12 BICILLIN L-A 5 BILTRICIDE 14 bisoprolol fumarate 23 bisoprolol fumarate/hydrochlorothiazide 23 bleomycin sulfate 12 BLEPHAMIDE S.O.P. 6 BOOSTRIX 35 BOSULIF 14 BREO ELLIPTA 38 briellyn 31 BRILINTA 22 brimonidine tartrate 37 BRINTELLIX 8 bromocriptine mesylate 15 budeprion sr 8 budesonide 30 budesonide 38 bumetanide 24 buprenorphine hcl 3 buprenorphine hcl/naloxone hcl 3 buproban 3 bupropion hcl 8 bupropion hcl sr 8 bupropion hcl xl 8 buspirone hcl 19 BYETTA 20 cabergoline 33 CAFERGOT 11 calcipotriene 27 Page 44 of 57
Page # calcitonin-salmon 36 calcitriol 36 calcium acetate 40 camila 33 CANASA 36 CANCIDAS 10 candesartan cilexetil 23 candesartan cilexetil/hydrochlorothiazide 25 CANTIL 28 CAPASTAT SULFATE 12 CAPRELSA 12 captopril 23 captopril/hydrochlorothiazide 23 CARAFATE 29 CARBAGLU 28 carbamazepine 7 carbamazepine er 7 carbidopa/levodopa 15 carbidopa/levodopa er 15 carbidopa/levodopa/entacapone 15 CARDURA XL 23 CARIMUNE NANOFILTERED 34 cartia xt 24 carvedilol 23 CAYSTON 39 cefaclor 4 cefadroxil 4 cefazolin sodium 4 cefdinir 4 cefepime 4 cefixime 4 cefotetan 5 cefpodoxime proxetil 4 cefprozil 5 ceftriaxone sodium 5 cefuroxime axetil 5 cefuroxime sodium 5 CEFUROXIME/DEXTROSE 5 CELEBREX 2 celecoxib 2 CELLCEPT INTRAVENOUS 34 CELONTIN 6 cephalexin 5 CEREZYME 28 CERVARIX 35 cesia 31 cetirizine hcl 38 CHANTIX 3 CHANTIX CONTINUING MONTH PAK 3 CHANTIX STARTING MONTH PAK 3 Name Page # chloramphenicol sodium succinate 4 chlorhexidine gluconate oral rinse 27 chloroquine phosphate 15 chlorpromazine hcl 15 chlorthalidone 25 cholestyramine 25 cholestyramine light 25 ciclopirox 10 ciclopirox nail lacquer 10 ciclopirox olamine 10 cidofovir 17 cilostazol 22 CINRYZE 34 CIPRO HC 6 CIPRODEX 6 ciprofloxacin 6 ciprofloxacin er 6 ciprofloxacin hcl 6 cisplatin 13 citalopram hydrobromide 8 claravis 27 clarithromycin 5 clarithromycin er 5 clindamycin hcl 4 clindamycin phosphate 4 clindamycin phosphate 27 clindamycin phosphate add-vantage 4 CLINIMIX 2.75%/DEXTROSE 5% 40 clinimix 4.25%/dextrose 10% 40 clinimix 4.25%/dextrose 20% 20 clinimix 4.25%/dextrose 25% 40 CLINIMIX 4.25%/DEXTROSE 5% 40 CLINIMIX 5%/DEXTROSE 15% 20 CLINIMIX 5%/DEXTROSE 20% 20 CLINIMIX 5%/DEXTROSE 25% 40 CLINIMIX E 2.75%/DEXTROSE 10% 20 CLINIMIX E 2.75%/DEXTROSE 5% 20 CLINIMIX E 4.25%/DEXTROSE 25% 20 CLINIMIX E 4.25%/DEXTROSE 5% 20 CLINIMIX E 5%/DEXTROSE 15% 20 CLINIMIX E 5%/DEXTROSE 20% 40 CLINIMIX E 5%/DEXTROSE 25% 20 clinisol sf 15% 40 clobetasol propionate 30 clobetasol propionate e 30 clomipramine hcl 9 clonazepam 7 clonazepam odt 6 clonidine hcl 22 clopidogrel 22 Page 45 of 57
Page # clorazepate dipotassium 19 clotrimazole 10 clotrimazole/betamethasone dipropionate 30 clozapine 17 clozapine odt 17 COARTEM 15 CODEINE SULFATE 2 colchicine 11 COLCRYS 11 colestipol hcl 25 colistimethate sodium 4 COMBIVENT RESPIMAT 38 COMETRIQ 13 COMPLERA 18 compro 15 COMVAX 35 constulose 29 COPAXONE 26 COREG CR 24 CORMAX SCALP APPLICATION 30 cortisone acetate 30 CREON 28 CRIXIVAN 19 cromolyn sodium 28 cromolyn sodium 37 cromolyn sodium 39 cryselle-28 31 CUBICIN 4 CUPRIMINE 40 CURITY GAUZE PADS 2"X2" 27 cyclafem 1/35 31 cyclafem 7/7/7 31 cyclobenzaprine hcl 39 cyclophosphamide 12 CYCLOSET 20 cyclosporine 34 cyclosporine modified 34 CYRAMZA 14 CYSTADANE 28 CYSTAGON 28 DALIRESP 39 danazol 31 dantrolene sodium 17 DAPSONE 11 DAPTACEL 35 DARAPRIM 15 daunorubicin hcl 13 DAUNOXOME 13 DECAVAC 35 decitabine 13 Name Page # delzicol 36 demeclocycline hcl 6 DEMSER 24 DEPEN TITRATABS 40 DEPO-MEDROL 30 DEPO-PROVERA 33 DEPO-SUBQ PROVERA 104 33 desipramine hcl 9 desmopressin acetate 31 desvenlafaxine er 8 dexamethasone 30 dexamethasone sodium phosphate 30 dexamethasone sodium phosphate 37 dexmethylphenidate hcl 26 dextroamphetamine sulfate 26 dextroamphetamine sulfate er 26 DEXTROSE 10%/NACL 0.45% 20 DEXTROSE 5% /ELECTROLYTE #48 40 VIAFLEX dextrose 10% flex container 21 dextrose 10%/nacl 0.2% 21 dextrose 2.5%/sodium chloride 0.45% 21 dextrose 5% 21 dextrose 5%/nacl 0.2% 21 DEXTROSE 5%/NACL 0.225% 21 dextrose 5%/nacl 0.33% 21 dextrose 5%/nacl 0.45% 21 dextrose 5%/nacl 0.9% 21 dextrose 5%/potassium chloride 0.15% 40 DIAZEPAM 7 diazepam 19 diazepam intensol 19 diclofenac sodium 3 diclofenac sodium 27 diclofenac sodium 37 dicloxacillin sodium 5 dicyclomine hcl 28 didanosine 18 DIFICID 5 digoxin 24 dilantin 7 dilt-cd 24 diltiazem cd 24 diltiazem hcl 24 diltiazem hcl er 24 dilt-xr 24 diltzac 24 DIPENTUM 36 diphenoxylate/atropine 28 Page 46 of 57
Page # DIPHTHERIA/TETANUS TOXOIDS 35 ADSORBED PEDIATRIC disopyramide phosphate 23 disulfiram 3 divalproex sodium 7 divalproex sodium dr 7 divalproex sodium er 7 DOCEFREZ 13 DOCETAXEL 13 donepezil hcl 7 dorzolamide hcl 37 dorzolamide hcl/timolol maleate 37 doxazosin mesylate 29 doxepin hcl 9 doxercalciferol 36 doxorubicin hcl 13 doxycycline hyclate 6 doxycycline monohydrate 6 dronabinol 10 drospirenone/ethinyl estradiol 31 duloxetine hcl 8 duramorph 2 e.e.s. 400 5 E.E.S. GRANULES 5 e.s.p. 5 econazole nitrate 10 EDURANT 18 ELAPRASE 28 ELELYSO 28 ELIGARD 33 ELLA 33 ELMIRON 29 EMCYT 12 EMEND 10 emoquette 31 EMSAM 8 EMTRIVA 18 ENABLEX 29 enalapril maleate 23 enalapril maleate/hydrochlorothiazide 23 ENBREL 34 ENBREL SURECLICK 34 endocet 2 ENGERIX-B 35 enoxaparin sodium 22 enpresse-28 31 entacapone 15 entecavir 17 enulose 29 EPIPEN 2-PAK 38 Name Page # EPIPEN-JR 2-PAK 38 epitol 7 EPIVIR 18 EPIVIR HBV 18 EPOGEN 22 EPZICOM 18 ergomar 11 ERIVEDGE 13 errin 33 ERWINAZE 13 ERYPED 200 5 ERYPED 400 5 ERY-TAB 5 erythrocin lactobionate 5 erythrocin stearate 5 erythromycin 6 erythromycin base 6 ERYTHROMYCIN ETHYLSUCCINATE 6 erythromycin/benzoyl peroxide 27 esomeprazole sodium 29 estazolam 19 estrace 31 estradiol 31 estradiol/norethindrone acetate 31 ethambutol hcl 12 ethosuximide 6 etidronate disodium 36 etodolac 2 etodolac er 2 etoposide 13 EURAX 15 EVOTAZ 19 EXELON 7 exemestane 13 EXJADE 40 FABRAZYME 28 famciclovir 19 famotidine 28 famotidine premixed 28 FANAPT 16 FANAPT TITRATION PACK 16 FARESTON 12 FARYDAK 13 FAZACLO 17 felbamate 7 fenofibrate 25 fenofibrate micronized 25 fenofibric acid dr 25 fentanyl 2 fentanyl citrate oral transmucosal 2 Page 47 of 57
Page # FETZIMA 8 FETZIMA TITRATION PACK 8 FIBRICOR 25 finasteride 29 FIRAZYR 34 firmagon 33 flecainide acetate 23 FLOVENT HFA 38 fluconazole 11 fluconazole in dextrose 10 flucytosine 11 fludrocortisone acetate 30 flunisolide 38 fluocinolone acetonide 30 fluocinolone acetonide body 30 fluocinonide 30 fluocinonide-e 30 fluorometholone 37 fluorouracil 27 fluoxetine dr 8 fluoxetine hcl 8 fluphenazine decanoate 15 fluphenazine hcl 16 flurbiprofen sodium 37 flutamide 12 fluticasone propionate 30 fluticasone propionate 38 fluvoxamine maleate 8 FML 37 fomepizole 36 fondaparinux sodium 22 FORTEO 36 fortical 36 fosphenytoin sodium 7 FOSRENOL 30 FRAGMIN 22 FREAMINE HBC 6.9% 41 furosemide 24 FUZEON 18 FYCOMPA 6 gabapentin 7 GABITRIL 7 galantamine hydrobromide 7 GAMMAGARD LIQUID 34 GAMUNEX-C 34 ganciclovir 17 GARDASIL 35 GARDASIL 9 35 gatifloxacin 6 gavilyte-c 29 Name Page # gavilyte-g 29 gavilyte-n/flavor pack 29 gemfibrozil 25 generlac 29 gengraf 34 GENOTROPIN 31 GENOTROPIN MINIQUICK 31 gentak 3 gentamicin sulfate 3 gentamicin sulfate/0.9% sodium chloride 3 GEODON 16 gildagia 32 GILENYA 26 GILOTRIF 13 GLASSIA 39 GLATOPA 26 GLEEVEC 14 glimepiride 20 glipizide 20 glipizide er 20 glipizide/metformin hcl 20 GLUCAGEN HYPOKIT 21 GLUCAGON EMERGENCY KIT 21 glycopyrrolate 28 GLYSET 20 granisetron hcl 10 granisol 10 griseofulvin microsize 11 guanfacine er 26 GUANIDINE HCL 11 HALAVEN 13 haloperidol 16 haloperidol decanoate 16 haloperidol lactate 16 HARVONI 17 HAVRIX 35 HEPARIN SODIUM 22 heparin sodium/d5w 22 heparin sodium/nacl 0.9% 22 hepatamine 41 HEPATASOL 41 HEXALEN 12 HORIZANT 26 HUMALOG 21 HUMALOG KWIKPEN 21 HUMALOG MIX 50/50 21 HUMALOG MIX 50/50 KWIKPEN 21 HUMALOG MIX 75/25 21 HUMALOG MIX 75/25 KWIKPEN 21 HUMATROPE 31 Page 48 of 57
Page # HUMATROPE COMBO PACK 31 HUMIRA 34 HUMIRA PEN-CROHNS 34 DISEASESTARTER HUMULIN 70/30 21 HUMULIN 70/30 KWIKPEN 21 HUMULIN N 21 HUMULIN N KWIKPEN 21 HUMULIN R 21 HUMULIN R U-500 (CONCENTRATED) 21 hydralazine hcl 26 hydrochlorothiazide 25 hydrocodone bitartrate/acetaminophen 2 hydrocodone/acetaminophen 2 hydrocodone/ibuprofen 2 hydrocortisone 30 hydrocortisone butyrate 30 hydrocortisone valerate 30 hydromorphone hcl 2 hydroxychloroquine sulfate 15 hydroxyurea 12 hydroxyzine hcl 38 HYPERRAB S/D 34 ibandronate sodium 36 IBRANCE 13 ibuprofen 2 ICLUSIG 14 ILARIS 34 IMBRUVICA 14 imipenem/cilastatin 5 imipramine hcl 9 imipramine pamoate 9 imiquimod 27 IMOVAX RABIES (H.D.C.V.) 35 INCIVEK 17 INCRELEX 31 indapamide 25 indomethacin 2 INFANRIX 35 INLYTA 14 INTELENCE 18 intralipid 36 INTRON A 17 INTRON A W/DILUENT 17 introvale 32 INVANZ 5 INVEGA 16 INVEGA SUSTENNA 16 INVIRASE 19 IONOSOL-B/DEXTROSE 5% 21 Name Page # IONOSOL-MB/DEXTROSE 5% 21 IPOL INACTIVATED IPV 35 ipratropium bromide 38 ipratropium bromide/albuterol sulfate 38 ISENTRESS 18 isolyte-h/dextrose 5% 41 isolyte-m/dextrose 5% 41 ISOLYTE-P/DEXTROSE 5% 41 ISOLYTE-S 41 isolyte-s/dextrose 5% 41 ISONIAZID 12 isosorbide dinitrate 25 isosorbide dinitrate er 25 isosorbide mononitrate 25 isosorbide mononitrate er 25 isotonic gentamicin 3 itraconazole 11 ivermectin 14 IXIARO 35 JAKAFI 13 JANUMET 20 JANUVIA 20 JENTADUETO 20 JE-VAX 35 JEVTANA 13 jolivette 33 junel 1.5/30 32 junel 1/20 32 junel fe 1.5/30 32 junel fe 1/20 32 JUXTAPID 25 KADCYLA 14 KALETRA 19 kariva 32 KCL 0.075%/D5W/NACL 0.45% 21 KCL 0.15%/D5W/LR 21 KCL 0.15%/D5W/NACL 0.2% 21 KCL 0.15%/D5W/NACL 0.225% 21 KCL 0.15%/D5W/NACL 0.9% 21 KCL 0.3%/D5W/NACL 0.45% 21 KCL 0.3%/D5W/NACL 0.9% 21 kelnor 1/35 32 KETEK 6 ketoconazole 11 ketoprofen 2 ketorolac tromethamine 37 KEYTRUDA 14 KHEDEZLA 8 KINERET 34 klor-con 10 41 Page 49 of 57
Page # klor-con 8 41 klor-con m15 41 klor-con m20 41 KUVAN 28 labetalol hcl 24 LACRISERT 37 LACTATED RINGERS DEXTROSE 5% 41 VIAFLEX lactated ringers irrigation 36 lactated ringers viaflex 41 lactulose 29 lamivudine 18 lamivudine/zidovudine 18 lamotrigine 7 lamotrigine er 7 lansoprazole 29 LANTUS 21 LANTUS SOLOSTAR 21 larin 1/20 32 larin fe 1.5/30 32 larin fe 1/20 32 latanoprost 36 LATUDA 16 leena 32 leflunomide 34 LENVIMA 10MG DAILY DOSE 14 LENVIMA 14MG DAILY DOSE 14 LENVIMA 20MG DAILY DOSE 14 LENVIMA 24MG DAILY DOSE 14 lessina 32 LETAIRIS 39 letrozole 13 leucovorin calcium 13 LEUKERAN 12 LEUKINE 22 leuprolide acetate 33 LEVEMIR 21 LEVEMIR FLEXTOUCH 21 levetiracetam 6 levetiracetam er 6 levobunolol hcl 37 levofloxacin 6 levofloxacin in d5w 6 levonest 32 levonorgestrel and ethinyl estradiol 32 levonorgestrel/ethinyl estradiol 32 levora 0.15/30-28 32 levothyroxine sodium 33 LEXIVA 19 LIALDA 36 Name Page # lidocaine 3 lidocaine hcl 3 lidocaine hcl jelly 3 lidocaine viscous 3 lidocaine/prilocaine 3 LINDANE 15 linezolid 4 liothyronine sodium 33 LIPOSYN III 36 LIPTRUZET 25 lisinopril 23 lisinopril/hydrochlorothiazide 23 lithium 20 lithium carbonate 20 lithium carbonate er 20 lokara 30 lomustine 12 loperamide hcl 28 lorazepam 19 lorazepam intensol 19 losartan potassium 23 losartan potassium/hydrochlorothiazide 23 LOTEMAX 37 LOTRONEX 28 lovastatin 25 low-ogestrel 32 loxapine succinate 16 LUMIGAN 36 LUMIZYME 28 LUPRON DEPOT 33 LUPRON DEPOT-PED 33 lutera 32 LYNPARZA 13 LYRICA 6 LYSODREN 33 lyza 33 MAGNESIUM SULFATE 41 MAGNESIUM SULFATE IN D5W 6 maprotiline hcl 8 marlissa 32 MARPLAN 8 MATULANE 12 matzim la 24 meclizine hcl 10 medroxyprogesterone acetate 33 mefloquine hcl 15 MEGACE ES 33 megestrol acetate 33 MEKINIST 13 memantine hcl 8 Page 50 of 57
Page # MENACTRA 35 MENEST 13 MENOMUNE-A/C/Y/W-135 35 MENVEO 35 mercaptopurine 12 meropenem 5 mesna 13 MESNEX 13 metadate er 26 METAPROTERENOL SULFATE 38 metformin hcl 20 metformin hcl er 20 methadone hcl 2 methadose 2 methazolamide 37 methenamine hippurate 4 methimazole 34 methocarbamol 39 methotrexate 34 methotrexate sodium 34 methoxsalen 27 methyldopa 23 methyldopate hcl 23 methylphenidate hcl 26 methylphenidate hcl cd 26 methylphenidate hcl er 26 methylphenidate hydrochloride 26 methylprednisolone 30 methylprednisolone acetate 30 methylprednisolone dose pack 30 methylprednisolone sodiumsuccinate 30 metoclopramide hcl 28 metolazone 25 metoprolol succinate er 24 metoprolol tartrate 24 metoprolol/hydrochlorothiazide 24 metronidazole 4 metronidazole in nacl 0.79% 4 metronidazole vaginal 4 mexiletine hcl 23 MIACALCIN 36 miconazole 3 11 microgestin 1.5/30 32 microgestin 1/20 32 microgestin fe 32 microgestin fe 1.5/30 32 midodrine hcl 23 minocycline hcl 6 minoxidil 26 mirtazapine 8 Name Page # mirtazapine odt 8 misoprostol 29 mitoxantrone hcl 13 M-M-R II 35 modafinil 39 moderiba 17 MODERIBA 1200 DOSE PACK 17 MODERIBA 800 DOSE PACK 17 mometasone furoate 30 mononessa 32 montelukast sodium 38 MONUROL 4 morphine sulfate 2 morphine sulfate 2 morphine sulfate er 2 MOXEZA 6 MOZOBIL 41 MULTAQ 23 mupirocin 4 MYCAMINE 11 mycophenolate mofetil 34 mycophenolic acid dr 34 mydral 37 myorisan 27 nabumetone 2 nadolol/bendroflumethiazide 24 nafcillin sodium 5 NAGLAZYME 28 NALLPEN/DEXTROSE 5 naloxone hcl 3 naltrexone hcl 3 NAMENDA 8 NAMENDA XR 8 NAMENDA XR TITRATION PACK 8 naproxen 2 naproxen dr 2 naproxen sodium 3 naratriptan hcl 11 NASONEX 38 nateglinide 20 NEBUPENT 15 necon 0.5/35-28 32 necon 1/35 32 necon 7/7/7 32 nefazodone hcl 8 neomycin sulfate 3 neomycin/bacitracin/polymyxin 4 neomycin/polymyxin b sulfates 3 neomycin/polymyxin/bacitracin/hydrocortis 4 one Page 51 of 57
Page # neomycin/polymyxin/dexamethasone 37 neomycin/polymyxin/gramicidin 4 neomycin/polymyxin/hc 37 neomycin/polymyxin/hydrocortisone 37 NEPHRAMINE 41 NEUMEGA 22 NEUPOGEN 22 NEUPRO 15 nevirapine 18 nevirapine er 18 NEXAVAR 14 niacin er 25 niacor 25 NICOTROL INHALER 3 NICOTROL NS 3 nifedical xl 24 nifedipine 24 nifedipine er 24 NILANDRON 12 nimodipine 24 nitrofurantoin macrocrystals 4 nitrofurantoin monohydrate 4 nitroglycerin 25 nitroglycerin transdermal 25 NITROSTAT 26 nora-be 33 NORDITROPIN FLEXPRO 31 norethindrone 33 norethindrone acetate 33 normosol-m in d5w 41 NORMOSOL-R 41 normosol-r in d5w 21 nortrel 0.5/35 (28) 32 nortrel 1/35 32 nortrel 7/7/7 32 nortriptyline hcl 9 NORVIR 19 NOVOLIN 70/30 21 NOVOLIN N 21 NOVOLIN R 21 NOVOLOG 21 NOVOLOG FLEXPEN 21 NOVOLOG MIX 70/30 22 NOVOLOG MIX 70/30 PREFILLED 22 FLEXPEN NOVOLOG PENFILL 22 NOXAFIL 11 NUEDEXTA 26 NULOJIX 34 NUTROPIN 31 Name Page # NUTROPIN AQ NUSPIN 5 31 NUTROPIN AQ PEN 31 nystatin 11 NYSTATIN/TRIAMCINOLONE 11 octreotide acetate 33 ofloxacin 6 olanzapine 17 olanzapine odt 17 olopatadine hcl 38 OLYSIO 17 omega-3-acid ethyl esters 25 omeprazole 29 OMNITROPE 31 ONCASPAR 13 ondansetron hcl 10 ondansetron odt 10 ONFI 7 OPDIVO 14 ORAP 16 ORENCIA 34 orsythia 32 oxacillin sodium 5 oxaliplatin 13 oxandrolone 31 oxaprozin 3 oxazepam 19 oxcarbazepine 7 OXSORALEN 27 OXTELLAR XR 7 oxybutynin chloride 29 oxybutynin chloride er 29 oxycodone hcl 2 oxycodone hcl er 2 oxycodone/acetaminophen 2 oxycodone/ibuprofen 2 OXYCONTIN 2 OXYTROL 29 PANCREAZE 28 PANRETIN 14 pantoprazole sodium 29 paromomycin sulfate 3 paroxetine hcl 8 paroxetine hcl er 9 PASER 12 PATADAY 37 PATANOL 37 PAXIL 9 PEDVAX HIB 35 peg-3350/electrolytes 29 PEGANONE 7 Page 52 of 57
Page # PEGASYS 18 PEGASYS PROCLICK 18 PEGINTRON 18 PEG-INTRON 18 PEG-INTRON REDIPEN 18 penicillin g potassium 5 penicillin v potassium 5 PENTAM 300 15 PENTASA 36 pentoxifylline er 24 periogard 27 PERJETA 14 permethrin 15 perphenazine 16 phenazopyridine hcl 29 phenelzine sulfate 8 phenobarbital 6 phenytoin 7 phenytoin sodium 7 phenytoin sodium extended 7 physiolyte 36 PHYSIOSOL IRRIGATION 36 pilocarpine hcl 27 pilocarpine hcl 37 pilocarpine hydrochloride 27 PILOPINE HS 37 pimtrea 32 PINDOLOL 24 pioglitazone hcl 20 pioglitazone hcl/metformin hcl 20 piperacillin sodium/tazobactam sodium 5 pirmella 1/35 32 PLASMA-LYTE A 41 PLASMA-LYTE-148 41 PLASMA-LYTE-56/D5W 41 podofilox 27 poly-dex 37 polyethylene glycol 3350 29 polymyxin b sulfate 4 polymyxin b sulfate/trimethoprim sulfate 4 POMALYST 13 portia-28 32 potassium chloride 41 potassium chloride 0.15% /nacl 0.45% 41 viaflex POTASSIUM CHLORIDE 0.15% 21 D5W/NACL 0.33% POTASSIUM CHLORIDE 0.15% 21 D5W/NACL 0.45% Name Page # POTASSIUM CHLORIDE 0.15%/NACL 41 0.9% POTASSIUM CHLORIDE 0.22% 21 D5W/NACL 0.45% potassium chloride 0.3%/d5w 41 potassium chloride er 41 potassium chloride sr 41 POTIGA 6 PRADAXA 22 pramipexole dihydrochloride 15 PRANDIMET 20 pravastatin sodium 25 prazosin hcl 23 prednisolone acetate 37 prednisolone sodium phosphate 30 prednisolone sodium phosphate 37 prednisone 30 pregnyl w/diluent benzyl alcohol/nacl 31 PREMARIN 32 PREMASOL 41 PREMPHASE 32 PREMPRO 32 previfem 32 PREZCOBIX 19 PREZISTA 19 PRIFTIN 12 primaquine phosphate 15 primidone 7 PROAIR HFA 38 probenecid 11 probenecid/colchicine 11 PROCALAMINE 41 prochlorperazine 16 prochlorperazine edisylate 16 prochlorperazine maleate 16 PROCRIT 22 PROCTOSOL HC 30 proctozone-hc 30 progesterone 33 PROGLYCEM 21 PROGRAF 34 PROLASTIN-C 39 PROLEUKIN 13 PROLIA 36 PROMACTA 22 promethazine hcl 10 propafenone hcl 23 propafenone hcl er 23 propranolol hcl 24 propranolol hcl er 24 Page 53 of 57
Page # propranolol/hydrochlorothiazide 24 propylthiouracil 34 PROQUAD 35 PROSOL 41 PROTONIX 29 PROTOPIC 27 protriptyline hcl 9 PULMICORT 38 PULMICORT FLEXHALER 38 PULMOZYME 39 PURIXAN 12 pyrazinamide 12 pyridostigmine bromide 11 QUADRACEL 35 quasense 32 QUDEXY XR 7 quetiapine fumarate 17 quinapril hcl 23 quinapril/hydrochlorothiazide 23 quinidine gluconate cr 23 quinidine sulfate 23 quinine sulfate 15 QVAR 38 RABAVERT 35 raloxifene hydrochloride 33 ramipril 23 RANEXA 24 ranitidine hcl 28 RAPAMUNE 34 REBIF 26 REBIF REBIDOSE 26 REBIF REBIDOSE TITRATION PACK 26 REBIF TITRATION PACK 26 reclipsen 32 RECOMBIVAX HB 35 REGRANEX 27 RELENZA DISKHALER 19 RELISTOR 28 REMICADE 34 REMODULIN 39 RENAGEL 30 RENVELA 30 repaglinide 20 RESCRIPTOR 18 RESTASIS 37 RETROVIR IV INFUSION 18 REVLIMID 12 REYATAZ 19 ribasphere 18 RIBASPHERE RIBAPAK 18 Name Page # rifabutin 12 rifampin 12 riluzole 26 rimantadine hcl 19 ringers injection 41 ringers irrigation 36 RISPERDAL CONSTA 17 risperidone 17 risperidone odt 17 RITUXAN 14 rivastigmine tartrate 8 rizatriptan benzoate 11 rizatriptan benzoate odt 11 ropinirole hcl 15 ROTARIX 35 ROTATEQ 35 roxicet 2 ROZEREM 39 SABRIL 7 SAIZEN 31 SAIZEN CLICK.EASY 31 SANDOSTATIN LAR DEPOT 33 SANTYL 27 SAPHRIS 17 selegiline hcl 15 selenium sulfide 27 SELZENTRY 18 SENSIPAR 33 SEREVENT DISKUS 38 seromycin 12 SEROQUEL XR 17 SEROSTIM 31 sertraline hcl 9 sildenafil 39 silver sulfadiazine 4 SIMULECT 35 simvastatin 25 sirolimus 34 SIRTURO 12 sodium chloride 41 sodium chloride 0.45% viaflex 41 SODIUM CHLORIDE 0.9% 36 sodium fluoride 41 SODIUM LACTATE 40 sodium phenylbutyrate 28 sodium polystyrene sulfonate 40 sodium sulfacetamide 6 solia 32 SOLTAMOX 12 SOLU-CORTEF 30 Page 54 of 57
Page # SOMATULINE DEPOT 33 SOMAVERT 33 sotalol hcl 23 sotalol hcl (af) 23 SOVALDI 18 SPIRIVA HANDIHALER 38 spironolactone 25 spironolactone/hydrochlorothiazide 25 SPORANOX 11 sprintec 28 32 SPRYCEL 14 sronyx 32 ssd 4 stagesic 2 stavudine 18 sterile water irrigation 36 STIVARGA 14 STRATTERA 26 streptomycin sulfate 3 STRIBILD 18 SUCRAID 28 sucralfate 29 sulfacetamide sodium 27 sulfacetamide sodium/prednisolone sodium 6 phosphate sulfadiazine 6 sulfamethoxazole/trimethoprim 6 sulfamethoxazole/trimethoprim ds 6 sulfasalazine 36 sulfazine ec 36 sumatriptan succinate 11 SUPRAX 5 SURMONTIL 9 SUSTIVA 18 SUTENT 14 SYLATRON 13 SYMBICORT 38 SYMLINPEN 120 20 SYMLINPEN 60 20 SYNAGIS 35 SYNAREL 33 SYNERCID 4 SYNRIBO 13 SYPRINE 40 TABLOID 12 tacrolimus 27 tacrolimus 34 TAFINLAR 13 TAMIFLU 19 tamoxifen citrate 12 Name Page # tamsulosin hcl 29 TARCEVA 14 TARGRETIN 14 TASIGNA 14 TASMAR 15 TAXOTERE 13 TAZORAC 27 taztia xt 24 TEFLARO 5 TEKTURNA 24 temazepam 19 TENIVAC 35 terazosin hcl 29 terbinafine hcl 11 terbutaline sulfate 39 terconazole 11 TESTIM 31 testosterone cypionate 31 testosterone enanthate 31 TETANUS TOXOID ADSORBED 35 TETANUS/DIPHTHERIA TOXOIDS- 35 ADSORBED ADULT TEV-TROPIN 31 THALOMID 12 THEO-24 39 theochron 39 theophylline cr 39 theophylline er 39 THIOLA 30 thioridazine hcl 16 thiothixene 16 THYMOGLOBULIN 34 tiagabine hydrochloride 7 ticlopidine hcl 22 TIKOSYN 23 timolol maleate 37 timolol maleate ophthalmic gel forming 37 TIVICAY 18 tizanidine hcl 17 TOBRADEX 37 tobramycin 39 tobramycin sulfate 4 tobramycin sulfate/sodium chloride 3 tobramycin/dexamethasone 37 tolcapone 15 tolterodine tartrate 29 tolterodine tartrate er 29 topiramate 7 topiramate er 7 topotecan hcl 13 Page 55 of 57
Page # TORISEL 34 torsemide 24 tpn electrolytes 41 TRACLEER 39 TRADJENTA 20 tramadol hcl 2 tramadol hcl er 2 tramadol hydrochloride/acetaminophen 3 tranexamic acid 22 TRANSDERM-SCOP 10 tranylcypromine sulfate 8 TRAVASOL 42 trazodone hcl 8 TREANDA 12 TRECATOR 12 TRELSTAR MIXJECT 34 tretinoin 14 tretinoin 27 TREXALL 34 triamcinolone acetonide 30 triamcinolone acetonide 38 triamcinolone in orabase 27 triamterene/hydrochlorothiazide 25 triazolam 19 trifluoperazine hcl 16 trifluridine 19 trihexyphenidyl hcl 15 tri-legest fe 32 trilyte 29 trimethoprim 4 trimipramine maleate 10 trinessa 32 tri-previfem 32 TRISENOX 13 tri-sprintec 32 TRIUMEQ 18 trivora-28 33 TROKENDI XR 7 TROPHAMINE 42 trospium chloride 29 trospium chloride er 29 TRUMENBA 35 TRUVADA 18 tudorza pressair 38 TWINRIX 35 TYGACIL 4 TYKERB 14 TYPHIM VI 35 TYSABRI 27 TYZEKA 17 Name Page # TYZINE PEDIATRIC NASAL DROPS 39 ursodiol 28 UVADEX 27 valacyclovir hcl 19 VALCHLOR 12 valganciclovir 17 valproate sodium 7 valproic acid 7 valsartan 23 valsartan/hydrochlorothiazide 23 vancomycin hcl 4 vandazole 4 VAQTA 35 VARIVAX 35 VARIZIG 35 VELCADE 13 velivet 33 venlafaxine hcl 9 venlafaxine hcl er 9 VENTOLIN HFA 39 verapamil hcl 24 verapamil hcl er 24 verapamil hcl sr 24 VERSACLOZ 17 VESICARE 29 VEXOL 37 VICTRELIS 18 VIDEX PEDIATRIC 18 VIGAMOX 6 VIIBRYD 9 VIMPAT 7 VIRACEPT 19 VIRAMUNE XR 18 VIREAD 18 VITEKTA 18 VIVOTIF BERNA 35 VOLTAREN 27 voriconazole 11 VOTRIENT 14 vp-pnv-dha 42 VPRIV 28 vyfemla 33 VYTORIN 25 warfarin sodium 22 WELCHOL 25 XALKORI 14 XARELTO 22 XARELTO STARTER PACK 22 XELJANZ 35 XENAZINE 26 Page 56 of 57
Page 57 of 57 Name Page # XGEVA 36 XIFAXAN 4 XOLAIR 39 XTANDI 12 XYREM 39 YERVOY 14 YF-VAX 35 zafirlukast 38 zaleplon 39 ZALTRAP 13 ZAVESCA 28 zazole 11 ZELBORAF 14 ZEMAIRA 39 ZENATANE 27 zenchent 33 ZENPEP 28 ZETIA 25 ZIAGEN 18 zidovudine 18 ziprasidone hcl 17 ZIRGAN 17 zoledronic acid 36 ZOLINZA 13 zolmitriptan 11 zolmitriptan odt 11 zolpidem tartrate 39 ZOMACTON 31 ZOMIG 11 ZOMIG NASAL SPRAY 11 zonisamide 6 ZORBTIVE 31 ZORTRESS 34 ZOSTAVAX 35 ZOSYN 5 zovia 1/35e 33 zovia 1/50e 33 ZYDELIG 14 ZYFLO 38 ZYFLO CR 38 ZYKADIA 13 ZYLET 4 ZYPREXA RELPREVV 17 ZYTIGA 12 ZYVOX 4
This formulary was updated on 10/1/2015. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit www.carewisc.org. Care Wisconsin Health Plan P.O. Box 14017 Madison, Wisconsin 53708-0017 (608) 245-3075 1-800-963-0035 TTY/TDD Wisconsin Relay System 711 www.carewisc.org 2015 Care Wisconsin Health Plan, Inc.