Aetna Better Health Kids Formulary Guide

AETNA BETTER HEALTH® KIDS Formulary Guide – 2022

Aetna Better Health Kids Formulary

Guide April 2022


What is the Aetna Better Health Kids Formulary?

This is a drug list created by Aetna Better Health Kids. We will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, we will cover the drug. Drugs must also be filled at an in-network pharmacy.

This list is for drugs covered under your prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own.

Are there any exclusions from the formulary?

Yes, some drugs are excluded from coverage by direction of the Pennsylvania Department of Human Services (DHS). Examples include:

• Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA

• Drugs and devices not approved by the FDA or whose use is not approved by the FDA • Drugs and other items prescribed for obesity or appetite control • Drugs designated as a DESI (Drug Efficacy Study Implementation). A DESI drug is one

that was approved by the FDA solely on the basis of their safety prior to 1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs.

• Durable Medical Equipment (DME) items (with the exception of preferred diabetic supplies, syringes, lancets, alcohol wipes and condoms)

• Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program

• Pharmaceutical services provided to a hospitalized person • Placebos

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Can our drug list change?

We may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review at least 30 days before the change is made. Utilizing members will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use the formulary?

• Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).

• Column #2: lists the brand name of the drug when a generic is covered • Column #3: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “OTIC.” If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.

What are generic drugs?

Generic drugs are copies of brand-name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use.

When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from Aetna Better Health Kids before the brand will be covered.

Are Over‐The‐Counter (OTC) drugs covered?

We will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the we will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the Aetna Better Health Kids.




How much will I pay for covered drugs?

No Copays There are no copays for: • Children under 21 years of age • Members in a nursing home or other facility (Intermediate Care Facility for Mental

Retardation) • Family planning drugs • Emergency situation (condition in which emergency medical care is needed to

prevent death or serious injury of a member) • Certain drug groups listed below do not have copays. For those drug groups

that will not require a copay the drug group will be marked with a “no copay” on the formulary.

o Anti‐glaucoma drugs o Anti‐Parkinson drugs o Antipsychotic drugs (except for those anti‐anxiety drugs that are

controlled substances, like alprazolam or diazepam) o Cancer drugs o Diabetes drugs o Drugs used only to treat HIV/AIDS o Epilepsy drugs o Heart disease drugs o High blood pressure drugs o Naloxone injection/nasal spray for drug overdose o Preventative vaccines




What are some types of coverage rules?

• Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, We will not cover the drug.

• Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, we provide 60 pills in 30 days for some drugs. Your doctor will need to get approval from Aetna Better Health Kids first before the drug can be filled for more than your benefit limits.

• Step Therapy (ST): This means you may need to try certain drugs first to treat your condition.

o After the first drug is tried, we will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. We may not cover Drug B unless you try Drug A first. If Drug A does not work for you or you cannot take Drug A, then Drug B will be covered.

What if my drug is not on the plan’s Formulary?

First, please call your doctor and ask if your drug is on the formulary. If the drug is not listed on the formulary then:

• Ask your doctor for a similar drug that is on the formulary, or • Your doctor can ask the us to cover your drug through the prior approval process.

Where can I fill my prescriptions?

You can fill your prescriptions at any network pharmacy. You can find the location of an in‐network pharmacy by visiting the CVS Caremark pharmacy locator. http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy This allows you to search for a pharmacy by zip code so you can find a location close to you.



http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy


Definition of Symbols F Formulary

AL

Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which the medication is being used to treat.

OR FDA-approved age limitations. Click this symbol on the online search tool for more information.

Name s in

Italics

Generic Drug - We cover both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

PA This means your doctor will need to get approval from us first before the drug can be filled at the pharmacy. If it is not approved, we will not cover the drug.

QLL This means there is a limit on the amount of drug we will cover. For example, we provide 60 pills in 30 days for some drugs.

ST

This means you may need to try certain drugs first to treat your condition. After the first drug is tried, we will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. We may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. For a complete list of all drugs requiring step therapy; click on the following -https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf



http://client.formularynavigator.com/Search.aspx?siteCode=3385538457

https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf

http://client.formularynavigator.com/Search.aspx?siteCode=3385538457



Nondiscrimination Notice

Aetna Better Health Kids complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna Better Health Kids does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Aetna Better Health Kids provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters; and • Written information in other formats (large print, audio, accessible electronic formats).

Aetna Better Health Kids provides free language services to people whose primary language is not English, such as: • Qualified interpreters; and • information written in other languages.

If you need these services, contact Aetna Better Health Kids at 1-800-822-2447.

If you believe that Aetna Better Health Kids has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

The Bureau of Equal Opportunity, Room 223, Health and Welfare Building,P.O. Box 2675, Harrisburg, PA 17105-2675,

Phone: (717) 787-1127, TTY (800) 654-5484, Fax: (717) 772-4366, orEmail: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Bureau of Equal Opportunity is available to help you.

You can also file a civil rights complaint electronically through the Office for Civil Rights Complaint Portal, available at https://ocmortal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone with the U.S. Department of Health and Human Services, Office for Civil Rights at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW.,Room 509F, HHH Building, Washington, DC 20201,

1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http:// www.hhs.gov/ocr/office/file/index.htm.l


http://www.hhs.gov/ocr/office/file/index.htm.l

https://ocmortal.hhs.gov/ocr/portal/lobby.jsf

mailto:[email protected]


Multi-Language Interpreter Services

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call: 1-800-822-2447 (TTY: 1-800-628-3323).

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PA-19-08-01


Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System.......................................... 3 *Alternative Medicines* - Vitamins And Minerals................................................................................................... 4 *Aminoglycosides* - Drugs For Infections............................................................................................................... 4 *Analgesics - Anti-Inflammatory* - Drugs For Pain And Fever...............................................................................5 *Analgesics - Nonnarcotic* - Drugs For Pain And Fever......................................................................................... 6 *Analgesics - Opioid* - Drugs For Pain And Fever.................................................................................................. 6 *Androgens-Anabolic* - Hormones.......................................................................................................................... 9 *Anorectal And Related Products* - Rectal Preparations....................................................................................... 10 *Antacids* - Drugs For The Stomach......................................................................................................................10 *Anthelmintics* - Drugs For Infections...................................................................................................................10 *Antianginal Agents* - Drugs For The Heart..........................................................................................................11 *Antianxiety Agents* - Drugs For The Nervous System........................................................................................ 11 *Antiarrhythmics* - Drugs For The Heart...............................................................................................................12 *Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs.................................................................... 13 *Anticoagulants* - Drugs For The Blood................................................................................................................15 *Anticonvulsants* - Drugs For The Nervous System..............................................................................................16 *Antidepressants* - Drugs For The Nervous System.............................................................................................. 18 *Antidiabetics* - Hormones.....................................................................................................................................20 *Antidiarrheal/Probiotic Agents* - Drugs For The Stomach...................................................................................24 *Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning.......................................................... 24 *Antiemetics* - Drugs For The Stomach.................................................................................................................25 *Antifungals* - Drugs For Infections...................................................................................................................... 25 *Antihistamines* - Drugs For The Lungs................................................................................................................25 *Antihyperlipidemics* - Drugs For The Heart........................................................................................................ 26 *Antihypertensives* - Drugs For The Heart............................................................................................................ 28 *Anti-Infective Agents - Misc.* - Drugs For Infections..........................................................................................30 *Antimalarials* - Drugs For Infections................................................................................................................... 31 *Antimycobacterial Agents* - Drugs For Infections............................................................................................... 32 *Antineoplastics And Adjunctive Therapies* - Drugs For Cancer..........................................................................32 *Antiparkinson And Related Therapy Agents* - Drugs For The Nervous System................................................. 37 *Antipsychotics/Antimanic Agents* - Drugs For The Nervous System................................................................. 38 *Antiseptics & Disinfectants* - Antiseptics And Disinfectants.............................................................................. 42 *Antivirals* - Drugs For Infections......................................................................................................................... 42 *Beta Blockers* - Drugs For The Heart...................................................................................................................46 *Calcium Channel Blockers* - Drugs For The Heart.............................................................................................. 47 *Cardiotonics* - Drugs For The Heart.....................................................................................................................48 *Cardiovascular Agents - Misc.* - Drugs For The Heart........................................................................................ 49 *Cephalosporins* - Drugs For Infections................................................................................................................ 50 *Contraceptives* - Drugs For Women.....................................................................................................................50 *Corticosteroids* - Hormones................................................................................................................................. 55 *Cough/Cold/Allergy* - Drugs For The Lungs....................................................................................................... 56 *Dermatologicals* - Drugs For The Skin................................................................................................................ 57 *Diagnostic Products*..............................................................................................................................................64 *Digestive Aids* - Drugs For The Stomach............................................................................................................ 64 *Diuretics* - Drugs For The Heart.......................................................................................................................... 65 *Endocrine And Metabolic Agents - Misc.* - Hormones........................................................................................66 *Estrogens* - Hormones.......................................................................................................................................... 68 *Fluoroquinolones* - Drugs For Infections.............................................................................................................68

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*Gastrointestinal Agents - Misc.* - Drugs For The Stomach..................................................................................68 *Genitourinary Agents - Miscellaneous* - Drugs For The Urinary System............................................................70 *Gout Agents* - Drugs For Pain And Fever............................................................................................................71 *Hematological Agents - Misc.* - Drugs For The Blood........................................................................................71 *Hematopoietic Agents* - Drugs For Nutrition.......................................................................................................72 *Hypnotics/Sedatives/Sleep Disorder Agents* - Drugs For The Nervous System................................................. 72 *Laxatives* - Drugs For The Stomach.................................................................................................................... 73 *Macrolides* - Drugs For Infections....................................................................................................................... 74 *Medical Devices And Supplies* - Medical Supplies And Durable Medical Equipment.......................................74 *Migraine Products* - Drugs For The Nervous System..........................................................................................82 *Minerals & Electrolytes* - Drugs For Nutrition.................................................................................................... 83 *Miscellaneous Therapeutic Classes* - Vitamins And Minerals.............................................................................84 *Mouth/Throat/Dental Agents* - Drugs For The Mouth And Throat..................................................................... 84 *Multivitamins* - Drugs For Nutrition....................................................................................................................85 *Musculoskeletal Therapy Agents* - Drugs For Muscles, Ligaments, Tendons, And Bones................................ 88 *Nasal Agents - Systemic And Topical* - Drugs For The Nose............................................................................. 89 *Neuromuscular Agents* - Drugs For Nerves And Muscles...................................................................................90 *Nutrients* - Drugs For Nutrition............................................................................................................................90 *Ophthalmic Agents* - Drugs For The Eye.............................................................................................................90 *Otic Agents* - Drugs For The Ear......................................................................................................................... 93 *Passive Immunizing And Treatment Agents* - Biological Agents....................................................................... 94 *Penicillins* - Drugs For Infections........................................................................................................................ 95 *Pharmaceutical Adjuvants*....................................................................................................................................96 *Progestins* - Hormones......................................................................................................................................... 96 *Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System....................................96 *Respiratory Agents - Misc.* - Drugs For The Lungs.............................................................................................99 *Sulfonamides* - Drugs For Infections................................................................................................................. 100 *Tetracyclines* - Drugs For Infections..................................................................................................................100 *Thyroid Agents* - Hormones...............................................................................................................................100 *Toxoids* - Biological Agents.............................................................................................................................. 101 *Ulcer Drugs/Antispasmodics/Anticholinergics* - Drugs For The Stomach........................................................101 *Vaccines* - Biological Agents.............................................................................................................................103 *Vaginal And Related Products* - Drugs For Women..........................................................................................104 *Vasopressors* - Drugs For The Heart..................................................................................................................104 *Vitamins* - Drugs For Nutrition..........................................................................................................................105

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Formulary Drug Name Reference Restrictions *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System *Adhd Agent - Selective Alpha Adrenergic Agonists*** - Drugs For Attention Deficit Disorder guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg Intuniv QLL (30 Tablets per 30 days);

AL (Min 6 Years)

*Amphetamine Mixtures*** - Drugs For Attention Deficit Disorder amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Adderall XR QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg Adderall QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) amphetamine-dextroamphetamine oral tablet 30 mg Adderall QLL (2 EA per 1 day); AL (Min

6 Years and Max 17 Years)

*Amphetamines*** - Drugs For Attention Deficit Disorder dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg Dexedrine QLL (4 EA per 1 day); AL (Min

6 Years and Max 17 Years) dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg Dexedrine QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) dextroamphetamine sulfate oral tablet 10 mg, 5 mg Zenzedi QLL (6 EA per 1 day); AL (Min


ZENZEDI ORAL TABLET 10 MG, 5 MG dextroamphetamine sulfate QLL (6 EA per 1 day); AL (Min 6 Years and Max 17 Years)

*Analeptics*** - Drugs For The Nervous System caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

*Stimulants - Misc.*** - Drugs For Attention Deficit Disorder armodafinil oral tablet 150 mg, 200 mg, 250 mg Nuvigil PA; QLL (1 EA per 1 day)

armodafinil oral tablet 50 mg Nuvigil PA; QLL (2 EA per 1 day) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

Focalin XR QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg Focalin QLL (2 EA per 1 day); AL (Min


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Formulary Drug Name Reference Restrictions methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg Ritalin LA QLL (1 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg Ritalin LA QLL (2 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Concerta QLL (1 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg


methylphenidate hcl er oral tablet extended release 24 hour 54 mg


methylphenidate hcl er oral tablet extended release 36 mg Concerta QLL (2 EA per 1 day); AL (Min


methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml Methylin

QLL (30 ML per 1 day); AL (Min 6 Years and Max 17 Years)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Ritalin QLL (3 EA per 1 day); AL (Min


methylphenidate hcl oral tablet chewable 5 mg QLL (5 EA per 1 day); AL (Min 6 Years and Max 17 Years)

*Alternative Medicines* - Vitamins And Minerals *Alternative Medicine - Me's*** -Vitamins And Minerals melatonin maximum strength oral tablet 5 mg OTC melatonin oral tablet 1 mg, 3 mg, 5 mg OTC sm melatonin oral tablet 3 mg OTC

*Alternative Medicine Combinations - Two Ingredients*** - Vitamins And Minerals melatonin-pyridoxine oral tablet 1-10 mg OTC

*Aminoglycosides* - Drugs For Infections *Aminoglycosides*** - Antibiotics neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg Humatin 4

Formulary Drug Name Reference Restrictions tobramycin inhalation nebulization solution 300 mg/5ml Kitabis Pak

*Analgesics - Anti-Inflammatory* -Drugs For Pain And Fever *Cyclooxygenase 2 (Cox-2) Inhibitors*** - Arthritis And Pain Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg CeleBREX ST

*Gold Compounds*** - Arthritis And Pain Drugs RIDAURA ORAL CAPSULE 3 MG

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** - Arthritis And Pain Drugs diclofenac potassium oral tablet 50 mg Cataflam diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg Lodine etodolac oral tablet 500 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg IBU indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketorolac tromethamine oral tablet 10 mg QLL (20 Tablets per 30 days) meloxicam oral tablet 15 mg, 7.5 mg Mobic nabumetone oral tablet 500 mg, 750 mg Relafen naproxen oral suspension 125 mg/5ml Naprosyn ST naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg Naprosyn piroxicam oral capsule 10 mg, 20 mg Feldene sulindac oral tablet 150 mg, 200 mg

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Formulary Drug Name Reference Restrictions *Pyrimidine Synthesis Inhibitors*** -Arthritis And Pain Drugs leflunomide oral tablet 10 mg, 20 mg Arava

*Soluble Tumor Necrosis Factor Receptor Agents*** - Arthritis And Pain Drugs ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML PA

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PA; QLL (3.92 ML per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

PA

*Analgesics - Nonnarcotic* - Drugs For Pain And Fever *Analgesics-Sedatives*** - Arthritis And Pain Drugs butalbital-acetaminophen oral tablet 50-325 mg Tencon QLL (60 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-300-40 mg Fioricet QLL (60 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg Esgic QLL (60 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg Bac QLL (60 EA per 30 days)

butalbital-asa-caffeine oral capsule 50-325-40 mg QLL (60 EA per 30 days)

*Salicylates*** - Arthritis And Pain Drugs diflunisal oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg

*Analgesics - Opioid* - Drugs For Pain And Fever *Codeine Combinations*** -Arthritis And Pain Drugs acetaminophen-codeine #2 oral tablet 300-15 mg QLL (13 EA per 1 day)

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Formulary Drug Name Reference Restrictions acetaminophen-codeine #3 oral tablet 300-30 mg QLL (11 EA per 1 day)

acetaminophen-codeine #4 oral tablet 300-60 mg QLL (5 EA per 1 day)

acetaminophen-codeine oral solution 120-12 mg/5ml PA; QLL (137.5 ML per 1 day)

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg Fioricet/Codeine QLL (6 EA per 1 day)

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg QLL (6 EA per 1 day)

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg Ascomp-Codeine QLL (6 EA per 1 day)

*Hydrocodone Combinations*** -Arthritis And Pain Drugs hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml QLL (100 ML per 1 day)

hydrocodone-acetaminophen oral tablet 10-325 mg QLL (5 EA per 1 day)

hydrocodone-acetaminophen oral tablet 5-325 mg QLL (8 EA per 1 day)

hydrocodone-acetaminophen oral tablet 7.5-325 mg QLL (6 EA per 1 day)

hydrocodone-ibuprofen oral tablet 10-200 mg PA hydrocodone-ibuprofen oral tablet 5-200 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg QLL (5 EA per 1 day)

*Opioid Agonists*** - Arthritis And Pain Drugs codeine sulfate oral tablet 15 mg QLL (22 EA per 1 day) codeine sulfate oral tablet 30 mg QLL (11 EA per 1 day) codeine sulfate oral tablet 60 mg QLL (5 EA per 1 day) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

Actiq QLL (4 EA per 1 day)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

PA; QLL (10 EA per 30 days)

hydromorphone hcl injection solution 2 mg/ml Dilaudid hydromorphone hcl oral tablet 2 mg Dilaudid QLL (6 EA per 1 day) hydromorphone hcl oral tablet 4 mg Dilaudid QLL (3 EA per 1 day) hydromorphone hcl oral tablet 8 mg Dilaudid QLL (1 EA per 1 day) hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml, 500 mg/50ml

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Formulary Drug Name Reference Restrictions hydromorphone hcl rectal suppository 3 mg QLL (4 EA per 1 day) methadone hcl oral concentrate 10 mg/ml Methadone HCl Intensol PA; QLL (1.25 EA per 1 day) methadone hcl oral solution 10 mg/5ml PA; QLL (6.25 ML per 1 day) methadone hcl oral solution 5 mg/5ml PA; QLL (12.5 ML per 1 day) methadone hcl oral tablet 10 mg PA; QLL (1 EA per 1 day) methadone hcl oral tablet 5 mg PA; QLL (2 EA per 1 day) methadone hcl oral tablet soluble 40 mg Methadose PA; QLL (1 EA per 1 day) morphine sulfate (concentrate) oral solution 10 mg/0.5ml QLL (2.5 ML per 1 day)

morphine sulfate er oral tablet extended release 100 mg, 200 mg, 30 mg MS Contin PA; QLL (1 EA per 1 day)

morphine sulfate er oral tablet extended release 15 mg MS Contin PA; QLL (3 EA per 1 day)

morphine sulfate er oral tablet extended release 60 mg MS Contin PA; QLL (2 EA per 1 day)

morphine sulfate oral solution 10 mg/5ml QLL (15 ML per 1 day) morphine sulfate oral solution 20 mg/5ml QLL (12.5 ML per 1 day) morphine sulfate oral tablet 15 mg QLL (3 EA per 1 day) morphine sulfate oral tablet 30 mg QLL (1 EA per 1 day) morphine sulfate rectal suppository 10 mg QLL (4 EA per 1 day) morphine sulfate rectal suppository 20 mg QLL (2 EA per 1 day) morphine sulfate rectal suppository 30 mg QLL (1 EA per 1 day) morphine sulfate rectal suppository 5 mg QLL (5 EA per 1 day) oxycodone hcl oral solution 5 mg/5ml QLL (30 ML per 1 day) oxycodone hcl oral tablet 10 mg QLL (3 EA per 1 day) oxycodone hcl oral tablet 15 mg Roxicodone QLL (4 EA per 1 day) oxycodone hcl oral tablet 20 mg QLL (1 EA per 1 day) oxycodone hcl oral tablet 30 mg Roxicodone QLL (1 EA per 1 day) oxycodone hcl oral tablet 5 mg Oxaydo QLL (6 EA per 1 day) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg

PA; ST; QLL (1 EA per 1 day)

oxymorphone hcl er oral tablet extended release 12 hour 5 mg PA; ST; QLL (3 EA per 1 day)

oxymorphone hcl er oral tablet extended release 12 hour 7.5 mg PA; ST; QLL (2 EA per 1 day)

tramadol hcl oral tablet 100 mg QLL (4 EA per 1 day) tramadol hcl oral tablet 50 mg Ultram QLL (8 EA per 1 day)

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Formulary Drug Name Reference Restrictions *Opioid Combinations*** - Arthritis And Pain Drugs oxycodone-acetaminophen oral tablet 10-325 mg Endocet QLL (3 EA per 1 day)

oxycodone-acetaminophen oral tablet 2.5-325 mg Endocet QLL (12 EA per 1 day)

oxycodone-acetaminophen oral tablet 5-325 mg Endocet QLL (6 EA per 1 day)

oxycodone-acetaminophen oral tablet 7.5-325 mg Endocet QLL (4 EA per 1 day)

*Opioid Partial Agonists*** -Arthritis And Pain Drugs buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

PA; QLL (60 EA per 30 days); AL (Min 18 Years)

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg Suboxone QLL (2 EA per 1 day)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg QLL (3 EA per 1 day)

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr

Butrans PA; QLL (4 EA per 28 days)

pentazocine-naloxone hcl oral tablet 50-0.5 mg QLL (2 EA per 1 day)

*Tramadol Combinations*** -Arthritis And Pain Drugs tramadol-acetaminophen oral tablet 37.5-325 mg Ultracet QLL (8 EA per 1 day)

*Androgens-Anabolic* - Hormones *Androgens*** - Drugs For Men danazol oral capsule 100 mg, 200 mg, 50 mg testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml Depo-Testosterone PA; QLL (1 ML per 28 days)

testosterone enanthate intramuscular solution 200 mg/ml PA; QLL (5 ML per 30 days)

testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act (1%) Vogelxo Pump PA; QLL (300 GM per 30 days)

testosterone gel 20.25 mg/act (1.62%) transdermal 20.25 mg/act (1.62%) AndroGel Pump PA; QLL (5 GM per 1 day)

testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) AndroGel PA; QLL (300 GM per 30 days)

testosterone transdermal gel 10 mg/act (2%) Fortesta PA; QLL (2 canisters per 30 days)

9

Formulary Drug Name Reference Restrictions testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel PA

testosterone transdermal solution 30 mg/act PA; QLL (6 ML per 1 day)

*Anorectal And Related Products* -Rectal Preparations *Intrarectal Steroids*** - Rectal Preparations hydrocortisone rectal enema 100 mg/60ml Cortenema

*Nitrate Vasodilating Agents*** -Rectal Preparations RECTIV RECTAL OINTMENT 0.4 % PA; QLL (30 gm per 30 days)

*Rectal Anesthetic Combinations*** - Rectal Preparations hemorrhoidal external cream 1-0.25-14.4-15 %

Avedana Hemorrhoid Pain Relief OTC

hemorrhoidal max st/aloe external cream 1-0.25-14.4-15 %

Avedana Hemorrhoid Pain Relief OTC

*Rectal Anesthetic/Steroids*** -Rectal Preparations PROCTOFOAM HC EXTERNAL FOAM 1-1 %

*Rectal Steroids*** - Rectal Preparations hydrocortisone (perianal) external cream 1 % Procto-Pak hydrocortisone (perianal) external cream 2.5 % Procto-Med HC

PROCTO-MED HC EXTERNAL CREAM 2.5 % hydrocortisone (perianal)

PROCTO-PAK EXTERNAL CREAM 1 % hydrocortisone (perianal)

*Antacids* - Drugs For The Stomach *Antacid Combinations*** - Drugs For Ulcers And Stomach Acid sm foaming antacid oral tablet chewable 80-20 mg OTC

*Anthelmintics* - Drugs For Infections *Anthelmintics*** - Drugs For Parasites albendazole oral tablet 200 mg Albenza ST ivermectin oral tablet 3 mg Stromectol

10

Formulary Drug Name Reference Restrictions praziquantel oral tablet 600 mg Biltricide PA reeses pinworm medicine oral suspension 144 (50 base) mg/ml OTC

*Antianginal Agents* - Drugs For The Heart *Nitrates*** - Drugs For Angina isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Nitrostat

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Nitro-Dur

NITRO-BID TRANSDERMAL OINTMENT 2 %

*Antianxiety Agents* - Drugs For The Nervous System *Antianxiety Agents - Misc.*** -Drugs For Anxiety buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg

QLL (2 EA per 1 day); AL (Min 6 Years)

hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg QLL (4 EA per 1 day) hydroxyzine hcl oral tablet 50 mg QLL (8 EA per 1 day) hydroxyzine pamoate oral capsule 100 mg QLL (4 EA per 1 day) hydroxyzine pamoate oral capsule 25 mg, 50 mg Vistaril QLL (4 EA per 1 day)

*Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR AL (Min 18 Years)

alprazolam oral tablet 0.25 mg, 0.5 mg Xanax QLL (4 EA per 1 day) alprazolam oral tablet 1 mg Xanax QLL (6 EA per 1 day) alprazolam oral tablet 2 mg Xanax QLL (5 EA per 1 day) alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR AL (Min 18 Years)

11

Formulary Drug Name Reference Restrictions chlordiazepoxide hcl oral capsule 10 mg, 5 mg QLL (4 EA per 1 day) chlordiazepoxide hcl oral capsule 25 mg QLL (12 EA per 1 day) diazepam oral solution 5 mg/5ml QLL (10 ML per 1 day) diazepam oral tablet 10 mg, 2 mg, 5 mg Valium QLL (4 EA per 1 day) lorazepam oral tablet 0.5 mg Ativan QLL (4 EA per 1 day) lorazepam oral tablet 1 mg Ativan QLL (6 EA per 1 day) lorazepam oral tablet 2 mg Ativan QLL (5 EA per 1 day) oxazepam oral capsule 10 mg, 15 mg, 30 mg QLL (4 EA per 1 day) LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam QLL (2 ML per 1 day); AL

(Min 12 Years)

*Antiarrhythmics* - Drugs For The Heart *Antiarrhythmics Type I-A*** -Drugs For Abnormal Heart Rhythms disopyramide phosphate oral capsule 100 mg, 150 mg Norpace

procainamide hcl injection solution 100 mg/ml quinidine sulfate oral tablet 200 mg, 300 mg

*Antiarrhythmics Type I-B*** -Drugs For Abnormal Heart Rhythms mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

*Antiarrhythmics Type I-C*** -Drugs For Abnormal Heart Rhythms flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg Rythmol SR

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

*Antiarrhythmics Type Iii*** -Drugs For Abnormal Heart Rhythms amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Pacerone

MULTAQ ORAL TABLET 400 MG PA; QLL (2 EA per 1 day)

12

Formulary Drug Name Reference Restrictions *Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs *Adrenergic Combinations*** -Drugs For Asthma/Copd budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg/act, 80-4.5 mcg/act Symbicort QLL (10.2 GM per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose Advair Diskus QLL (2 EA per 1 day); AL (Min

4 Years and Max 11 Years) fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act AirDuo RespiClick 113/14 QLL (1 Inhaler per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 232-14 mcg/act AirDuo RespiClick 232/14 QLL (1 Inhaler per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 55-14 mcg/act AirDuo RespiClick 55/14 QLL (1 Inhaler per 30 days)

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT ST; QLL (1 inhaler per 30 days)

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 MCG/INH

ST; QLL (2 EA per 1 day)

*Anti-Ige Monoclonal Antibodies*** - Drugs For Asthma/Copd XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

PA

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG PA

*Anti-Inflammatory Agents*** -Drugs For Asthma/Copd cromolyn sodium inhalation nebulization solution 20 mg/2ml

*Beta Adrenergics*** - Drugs For Asthma/Copd albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act ProAir HFA QLL (6 Fills per 365 days)

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

QLL (15 ML per 1 day)

albuterol sulfate oral syrup 2 mg/5ml 13

Formulary Drug Name Reference Restrictions levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QLL (1 Respimat per 30 days)

*Bronchodilators -Anticholinergics*** - Drugs For Asthma/Copd ipratropium bromide inhalation solution 0.02 % INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

QLL (1 Inhaler per 30 days)

*Leukotriene Receptor Antagonists*** - Drugs For Asthma/Copd montelukast sodium oral packet 4 mg Singulair AL (Max 1 Years) montelukast sodium oral tablet 10 mg Singulair montelukast sodium oral tablet chewable 4 mg, 5 mg Singulair

zafirlukast oral tablet 10 mg, 20 mg Accolate ST

*Steroid Inhalants*** - Drugs For Asthma/Copd budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml Pulmicort QLL (120 ML per 30 days)

budesonide inhalation suspension 1 mg/2ml Pulmicort QLL (4 ML per 1 day) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

QLL (1 EA per 1 day)

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

QLL (0.4 GM per 1 day); AL (Max 12 Years)

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

QLL (0.3534 GM per 1 day); AL (Max 12 Years)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT

QLL (10.6 GM per 30 days)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT

QLL (21.2 GM per 30 days)

*Xanthines*** - Drugs For Asthma/Copd theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 14

Formulary Drug Name Reference Restrictions theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml

*Anticoagulants* - Drugs For The Blood *Coumarin Anticoagulants*** -Drugs To Prevent Blood Clots warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Jantoven

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

warfarin sodium

*Direct Factor Xa Inhibitors*** -Drugs To Prevent Blood Clots ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG QLL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG QLL (1 EA per 1 day)

XARELTO ORAL TABLET 2.5 MG PA; QLL (2 EA per 1 day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG QLL (1 FILL per 90 days)

*Heparins And Heparinoid-Like Agents*** - Drugs To Prevent Blood Clots heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

*Low Molecular Weight Heparins*** - Drugs To Prevent Blood Clots enoxaparin sodium injection solution 300 mg/3ml Lovenox QLL (21 days per 180 days)

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Lovenox QLL (21 days per 180 days)

15

Formulary Drug Name Reference Restrictions *Anticonvulsants* - Drugs For The Nervous System *Anticonvulsants -Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KlonoPIN clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg diazepam rectal gel 10 mg, 20 mg Diastat AcuDial QLL (2 EA per 1 Fill) diazepam rectal gel 2.5 mg Diastat Pediatric QLL (2 EA per 1 Fill) NAYZILAM NASAL SOLUTION 5 MG/0.1ML

PA; QLL (2 EA Max Qty Per Fill Retail)

VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML QLL (2 EA per 30 days)

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK 7.5 MG/0.1ML QLL (2 EA per 30 days)

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK 10 MG/0.1ML QLL (2 EA per 30 days)

VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML QLL (2 EA per 30 days)

*Anticonvulsants - Misc.*** - Drugs For Seizures /Personality Disorder/Nerve Pain carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg Carbatrol

carbamazepine er oral tablet extended release 12 hour 100 mg TEGretol-XR

carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg TEGretol-XR QLL (120 EA per 30 days)

carbamazepine oral suspension 100 mg/5ml TEGretol carbamazepine oral tablet 200 mg Epitol carbamazepine oral tablet chewable 100 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg Neurontin QLL (3600 MG (cumulative)

per 1 day)

gabapentin oral solution 250 mg/5ml Neurontin QLL (3600 MG (cumulative) per 1 day)

gabapentin oral tablet 600 mg, 800 mg Neurontin QLL (3600 MG (cumulative) per 1 day)

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg LaMICtal

lamotrigine oral tablet chewable 25 mg, 5 mg LaMICtal 16

Formulary Drug Name Reference Restrictions levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg Keppra XR

levetiracetam oral solution 100 mg/ml Keppra levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg Keppra

oxcarbazepine oral suspension 300 mg/5ml Trileptal oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Trileptal

pregabalin oral capsule 100 mg, 150 mg, 25 mg, 50 mg, 75 mg Lyrica PA; QLL (3 EA per 1 day)

pregabalin oral capsule 225 mg, 300 mg Lyrica PA; QLL (2 EA per 1 day) primidone oral tablet 250 mg, 50 mg Mysoline topiramate oral capsule sprinkle 15 mg, 25 mg Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Topamax QLL (120 EA per 30 days)

zonisamide oral capsule 100 mg, 25 mg Zonegran zonisamide oral capsule 50 mg QLL (6 EA per 1 day)

*Gaba Modulators*** - Drugs For Seizures /Personality Disorder/Nerve Pain tiagabine hcl oral tablet 2 mg Gabitril tiagabine hcl oral tablet 4 mg Gabitril QLL (60 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl

*Hydantoins*** - Drugs For Seizures /Personality Disorder/Nerve Pain phenytoin oral suspension 125 mg/5ml Dilantin phenytoin oral tablet chewable 50 mg Dilantin Infatabs phenytoin sodium extended oral capsule 100 mg Dilantin

phenytoin sodium extended oral capsule 200 mg, 300 mg Phenytek

DILANTIN ORAL CAPSULE 100 MG phenytoin sodium extended

*Succinimides*** - Drugs For Seizures /Personality Disorder/Nerve Pain ethosuximide oral capsule 250 mg Zarontin ethosuximide oral solution 250 mg/5ml Zarontin

17

Formulary Drug Name Reference Restrictions *Valproic Acid*** - Drugs For Seizures /Personality Disorder/Nerve Pain divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg Depakote ER PA

divalproex sodium oral capsule delayed release sprinkle 125 mg Depakote Sprinkles

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg Depakote

valproic acid oral capsule 250 mg valproic acid oral solution 250 mg/5ml

*Antidepressants* - Drugs For The Nervous System *Alpha-2 Receptor Antagonists (Tetracyclics)*** - Drugs For Depression mirtazapine oral tablet 15 mg Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 30 mg Remeron QLL (60 EA per 30 days) mirtazapine oral tablet 45 mg QLL (45 EA per 30 days) mirtazapine oral tablet 7.5 mg QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15 mg, 45 mg Remeron SolTab QLL (30 EA per 30 days)

mirtazapine oral tablet dispersible 30 mg Remeron SolTab QLL (60 EA per 30 days)

*Antidepressants - Misc.*** - Drugs For Depression bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg Wellbutrin SR QLL (120 EA per 30 days)

bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg Wellbutrin SR QLL (2 EA per 1 day)

bupropion hcl er (sr) oral tablet extended release 12 hour 200 mg Wellbutrin SR QLL (30 EA per 30 days)

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg Wellbutrin XL QLL (90 EA per 30 days)

bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg Wellbutrin XL QLL (30 EA per 30 days)

bupropion hcl oral tablet 100 mg QLL (135 EA per 30 days) bupropion hcl oral tablet 75 mg QLL (180 EA per 30 days)

*Monoamine Oxidase Inhibitors (Maois)*** - Drugs For Depression phenelzine sulfate oral tablet 15 mg Nardil QLL (6 EA per 1 day)

18

Formulary Drug Name Reference Restrictions *Selective Serotonin Reuptake Inhibitors (Ssris)*** - Drugs For Depression citalopram hydrobromide oral solution 10 mg/5ml

QLL (600 ML per 30 days); AL (Max 10 Years)

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg CeleXA QLL (30 EA per 30 days)

escitalopram oxalate oral solution 5 mg/5ml QLL (600 ML per 30 days); AL (Max 10 Years)

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Lexapro QLL (30 EA per 30 days)

fluoxetine hcl oral capsule 10 mg PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20 mg PROzac QLL (120 EA per 30 days) fluoxetine hcl oral capsule 40 mg PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution 20 mg/5ml QLL (600 ML per 30 days) fluvoxamine maleate oral tablet 100 mg QLL (3 EA per 1 day) fluvoxamine maleate oral tablet 25 mg QLL (1 EA per 1 day) fluvoxamine maleate oral tablet 50 mg QLL (2 EA per 1 day) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Paxil QLL (1 EA per 1 day)

sertraline hcl oral concentrate 20 mg/ml Zoloft QLL (300 ML per 30 days); AL (Max 12 Years)

sertraline hcl oral tablet 100 mg Zoloft QLL (75 EA per 30 days) sertraline hcl oral tablet 25 mg Zoloft QLL (30 Tablet per 30 days) sertraline hcl oral tablet 50 mg Zoloft QLL (60 Tablet per 30 days)

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** - Drugs For Depression duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg Cymbalta QLL (30 EA per 30 days)

duloxetine hcl oral capsule delayed release particles 40 mg QLL (30 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour 150 mg Effexor XR QLL (60 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg Effexor XR QLL (1 EA per 1 day)

venlafaxine hcl oral tablet 100 mg QLL (3 EA per 1 day) venlafaxine hcl oral tablet 25 mg QLL (9 EA per 1 day) venlafaxine hcl oral tablet 37.5 mg QLL (10 EA per 1 day) venlafaxine hcl oral tablet 50 mg QLL (7 EA per 1 day) venlafaxine hcl oral tablet 75 mg QLL (5 EA per 1 day)

19

Formulary Drug Name Reference Restrictions *Tricyclic Agents*** - Drugs For Depression amitriptyline hcl oral tablet 10 mg QLL (30 Tablets per 1 day) amitriptyline hcl oral tablet 100 mg QLL (3 Tablets per 1 day) amitriptyline hcl oral tablet 150 mg, 75 mg QLL (2 Tablets per 1 day) amitriptyline hcl oral tablet 25 mg QLL (12 Tablets per 1 day) amitriptyline hcl oral tablet 50 mg QLL (6 Tablets per 1 day) amoxapine oral tablet 100 mg QLL (6 EA per 1 day) amoxapine oral tablet 150 mg QLL (4 EA per 1 day) amoxapine oral tablet 25 mg QLL (24 EA per 1 day) amoxapine oral tablet 50 mg QLL (12 EA per 1 day) doxepin hcl oral capsule 10 mg QLL (30 EA per 1 day) doxepin hcl oral capsule 100 mg QLL (3 EA per 1 day) doxepin hcl oral capsule 150 mg QLL (2 EA per 1 day) doxepin hcl oral capsule 25 mg QLL (12 EA per 1 day) doxepin hcl oral capsule 50 mg QLL (6 EA per 1 day) doxepin hcl oral capsule 75 mg QLL (4 EA per 1 day) doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg imipramine hcl oral tablet 50 mg QLL (180 EA per 30 days) nortriptyline hcl oral capsule 10 mg Pamelor nortriptyline hcl oral capsule 25 mg Pamelor QLL (180 EA per 30 days) nortriptyline hcl oral capsule 50 mg Pamelor QLL (90 EA per 30 days) nortriptyline hcl oral capsule 75 mg Pamelor QLL (60 EA per 30 days) nortriptyline hcl oral solution 10 mg/5ml AL (Max 10 Years)

*Antidiabetics* - Hormones *Alpha-Glucosidase Inhibitors*** -Drugs For Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg Precose

*Biguanides*** - Drugs For Diabetes metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

*Diabetic Other*** - Drugs For Diabetes glucagon emergency injection kit 1 mg BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE QLL (2 EA per 30 days)

20

Formulary Drug Name Reference Restrictions BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE QLL (2 EA per 30 days)

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML

QLL (0.4 ML Max Qty Per Fill Retail)

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1 MG/0.2ML


GVOKE KIT SUBCUTANEOUS SOLUTION 1 MG/0.2ML


GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML


*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** - Drugs For Diabetes alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg Nesina

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** - Drugs For Diabetes alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg Kazano

*Dpp-4 Inhibitor-Thiazolidinedione Combinations*** - Drugs For Diabetes alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg

Oseni

*Human Insulin*** - Drugs For Diabetes insulin glargine-yfgn subcutaneous solution 100 unit/ml Semglee (yfgn)

insulin glargine-yfgn subcutaneous solution pen-injector 100 unit/ml Semglee (yfgn)

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

insulin lispro (1 unit dial)

ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML insulin lispro

21

Formulary Drug Name Reference Restrictions BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

insulin lispro prot & lispro

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

OTC

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

OTC

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

OTC

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML OTC

NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

OTC

NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

OTC

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML OTC

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML OTC

NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML

OTC

NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML

OTC

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML OTC

22

Formulary Drug Name Reference Restrictions NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML OTC

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

insulin asp prot & asp flexpen

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML insulin aspart prot & aspart

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** - Drugs For Diabetes OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

ST; QLL (0.05 ML per 1 day)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 MG/3ML

ST; QLL (0.1071 ML per 1 day)

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML

ST; QLL (4 Pens per 28 days)

*Meglitinide Analogues*** - Drugs For Diabetes nateglinide oral tablet 120 mg, 60 mg repaglinide oral tablet 0.5 mg, 1 mg, 2 mg

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** - Drugs For Diabetes JARDIANCE ORAL TABLET 10 MG, 25 MG PA; QLL (1 EA per 1 day)

STEGLATRO ORAL TABLET 15 MG, 5 MG ST; QLL (1 EA per 1 day)

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** -Drugs For Diabetes SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG

ST; QLL (2 EA per 1 day)

*Sulfonylurea-Biguanide Combinations*** - Drugs For Diabetes glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

23

Formulary Drug Name Reference Restrictions glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

*Sulfonylureas*** - Drugs For Diabetes glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg Glucotrol XL

glipizide oral tablet 10 mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Glynase

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

*Thiazolidinediones*** - Drugs For Diabetes pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Actos

*Antidiarrheal/Probiotic Agents* -Drugs For The Stomach *Antiperistaltic Agents*** - Drugs For Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg Lomotil

loperamide hcl oral capsule 2 mg Imodium A-D

*Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning *Antidotes - Chelating Agents*** -Drugs For Overdose Or Poisoning CHEMET ORAL CAPSULE 100 MG

*Opioid Antagonists*** - Drugs For Overdose Or Poisoning

naloxone hcl injection solution 0.4 mg/ml QLL (2 ML Max Qty Per Fill Retail)

naloxone hcl nasal liquid 4 mg/0.1ml Narcan naltrexone hcl oral tablet 50 mg QLL (3 EA per 1 day) NARCAN NASAL LIQUID 4 MG/0.1ML naloxone hcl VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

24

Formulary Drug Name Reference Restrictions *Antiemetics* - Drugs For The Stomach *5-Ht3 Receptor Antagonists*** -Drugs For Vomiting And Nausea granisetron hcl oral tablet 1 mg ST ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg QLL (3 EA per 1 day) ondansetron oral tablet dispersible 4 mg, 8 mg QLL (3 EA per 1 day)

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** - Drugs For Vomiting And Nausea EMEND ORAL CAPSULE 80 MG aprepitant

*Antifungals* - Drugs For Infections *Antifungals*** - Drugs For Fungus griseofulvin microsize oral suspension 125 mg/5ml ST

griseofulvin microsize oral tablet 500 mg ST griseofulvin ultramicrosize oral tablet 125 mg, 250 mg ST

nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg QLL (84 EA per 365 days)

*Imidazoles*** - Drugs For Fungus ketoconazole oral tablet 200 mg

*Triazoles*** - Drugs For Fungus fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml Diflucan

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Diflucan

itraconazole oral capsule 100 mg Sporanox itraconazole oral solution 10 mg/ml Sporanox

*Antihistamines* - Drugs For The Lungs *Antihistamines - Ethanolamines*** - Drugs For Allergies allergy relief childrens oral liquid 12.5 mg/5ml Banophen OTC; QLL (20 ML per 1 day)

carbinoxamine maleate oral tablet 4 mg clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral capsule 50 mg Banophen

25

Formulary Drug Name Reference Restrictions diphenhydramine hcl oral liquid 12.5 mg/5ml Banophen OTC; QLL (20 ML per 1 day) diphenhydramine hcl oral liquid 6.25 mg/ml OTC eq allergy relief childrens oral liquid 12.5 mg/5ml Banophen OTC; QLL (20 ML per 1 day)

BANOPHEN ORAL LIQUID 12.5 MG/5ML allergy relief childrens OTC; QLL (20 ML per 1 day)

*Antihistamines - Non-Sedating*** -Drugs For Allergies cetirizine hcl oral solution 1 mg/ml KLS Aller-Tec Childrens QLL (10 ML per 1 day) cetirizine hcl oral tablet 10 mg KLS Aller-Tec OTC; QLL (2 EA per 1 day) cetirizine hcl oral tablet 5 mg OTC levocetirizine dihydrochloride oral tablet 5 mg Xyzal Allergy 24HR QLL (1 EA per 1 day) loradamed oral tablet 10 mg Claritin OTC; QLL (1 EA per 1 day)

*Antihistamines - Phenothiazines*** - Drugs For Allergies promethazine hcl oral solution 6.25 mg/5ml QLL (80 ML per 1 day) promethazine hcl oral syrup 6.25 mg/5ml QLL (80 ML per 1 day) promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 12.5 mg, 25 mg Promethegan

*Antihistamines - Piperidines*** -Drugs For Allergies cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg

*Antihyperlipidemics* - Drugs For The Heart *Antihyperlipidemics - Misc.*** -Drugs For Cholesterol icosapent ethyl oral capsule 1 gm Vascepa PA; QLL (4 EA per 1 day) omega-3-acid ethyl esters oral capsule 1 gm Lovaza ST; QLL (4 EA per 1 day)

*Bile Acid Sequestrants*** - Drugs For Cholesterol cholestyramine light oral packet 4 gm Prevalite cholestyramine oral packet 4 gm Questran colesevelam hcl oral packet 3.75 gm Welchol colestipol hcl oral tablet 1 gm Colestid

26

Formulary Drug Name Reference Restrictions *Fibric Acid Derivatives*** - Drugs For Cholesterol fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral tablet 600 mg Lopid QLL (60 EA per 30 days)

*Hmg Coa Reductase Inhibitors*** -Drugs For Cholesterol atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg Lipitor QLL (30 EA per 30 days)

fluvastatin sodium er oral tablet extended release 24 hour 80 mg Lescol XL QLL (30 EA per 30 days)

fluvastatin sodium oral capsule 20 mg, 40 mg ST; QLL (2 EA per 1 day) lovastatin oral tablet 10 mg, 20 mg QLL (1 EA per 1 day) lovastatin oral tablet 40 mg QLL (2 EA per 1 day) pravastatin sodium oral tablet 10 mg QLL (60 EA per 30 days) pravastatin sodium oral tablet 20 mg, 40 mg, 80 mg QLL (1 EA per 1 day)

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Crestor ST; QLL (1 EA per 1 day)

simvastatin oral tablet 10 mg, 20 mg, 40 mg Zocor QLL (1 EA per 1 day) simvastatin oral tablet 5 mg QLL (1 EA per 1 day) simvastatin oral tablet 80 mg Zocor QLL (30 EA per 30 days)

*Intestinal Cholesterol Absorption Inhibitors*** - Drugs For Cholesterol ezetimibe oral tablet 10 mg Zetia ST

*Pcsk9 Inhibitors*** - Drugs For Cholesterol REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

PA

27

Formulary Drug Name Reference Restrictions *Antihypertensives* - Drugs For The Heart *Ace Inhibitor & Calcium Channel Blocker Combinations*** - Drugs For High Blood Pressure amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg Lotrel

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-40 mg

*Ace Inhibitors & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Lotensin HCT

benazepril-hydrochlorothiazide oral tablet 5-6.25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg Vaseretic

enalapril-hydrochlorothiazide oral tablet 5-12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Zestoretic

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Accuretic

*Ace Inhibitors*** - Drugs For High Blood Pressure benazepril hcl oral tablet 10 mg, 20 mg Lotensin QLL (2 EA per 1 day) benazepril hcl oral tablet 40 mg Lotensin benazepril hcl oral tablet 5 mg QLL (2 EA per 1 day) enalapril maleate oral tablet 10 mg, 2.5 mg, 5 mg Vasotec QLL (2 EA per 1 day)

enalapril maleate oral tablet 20 mg Vasotec fosinopril sodium oral tablet 10 mg, 20 mg QLL (2 EA per 1 day) fosinopril sodium oral tablet 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg Zestril QLL (2 EA per 1 day)

lisinopril oral tablet 40 mg Zestril QLL (60 EA per 30 days) perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

28

Formulary Drug Name Reference Restrictions quinapril hcl oral tablet 10 mg, 20 mg, 5 mg Accupril QLL (2 EA per 1 day) quinapril hcl oral tablet 40 mg Accupril ramipril oral capsule 1.25 mg, 2.5 mg, 5 mg Altace QLL (2 EA per 1 day) ramipril oral capsule 10 mg Altace trandolapril oral tablet 1 mg, 2 mg trandolapril oral tablet 4 mg Mavik

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** - Drugs For High Blood Pressure amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg Exforge QLL (30 EA per 30 Days)

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg Atacand HCT ST

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg Avalide

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg Hyzaar

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Diovan HCT QLL (1 EA per 1 day)

*Angiotensin Ii Receptor Antagonists*** - Drugs For High Blood Pressure candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Atacand ST

irbesartan oral tablet 150 mg, 300 mg, 75 mg Avapro losartan potassium oral tablet 100 mg Cozaar losartan potassium oral tablet 25 mg, 50 mg Cozaar QLL (2 EA per 1 day) telmisartan oral tablet 20 mg, 40 mg, 80 mg Micardis QLL (1 EA per 1 day) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Diovan QLL (60 EA per 30 days)

*Antiadrenergics - Centrally Acting*** - Drugs For High Blood Pressure clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24hr Catapres-TTS-1 ST

29

Formulary Drug Name Reference Restrictions clonidine transdermal patch weekly 0.2 mg/24hr Catapres-TTS-2 ST

clonidine transdermal patch weekly 0.3 mg/24hr Catapres-TTS-3 ST

guanfacine hcl oral tablet 1 mg QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 mg QLL (120 EA per 30 days) methyldopa oral tablet 250 mg, 500 mg

*Antiadrenergics - Peripherally Acting*** - Drugs For High Blood Pressure doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg Cardura QLL (1 EA per 1 day)

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Minipress terazosin hcl oral capsule 1 mg, 2 mg, 5 mg QLL (1 EA per 1 day) terazosin hcl oral capsule 10 mg QLL (2 EA per 1 day)

*Beta Blocker & Diuretic Combinations*** - Drugs For High Blood Pressure atenolol-chlorthalidone oral tablet 100-25 mg Tenoretic 100 atenolol-chlorthalidone oral tablet 50-25 mg Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg Ziac

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

*Vasodilators*** - Drugs For High Blood Pressure hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg

*Anti-Infective Agents - Misc.* -Drugs For Infections *Anti-Infective Agents - Misc.*** -Drugs For Infections metronidazole oral capsule 375 mg Flagyl metronidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg

*Anti-Infective Misc. -Combinations*** - Antibiotics sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Sulfatrim Pediatric

30

Formulary Drug Name Reference Restrictions sulfamethoxazole-trimethoprim oral tablet 400-80 mg Bactrim

*Glycopeptides*** - Antibiotics FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML FIRVANQ ORAL SOLUTION RECONSTITUTED 50 MG/ML vancomycin hcl

*Leprostatics*** - Antibiotics dapsone oral tablet 100 mg, 25 mg

*Lincosamides*** - Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Cleocin

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml Cleocin

*Oxazolidinones*** - Antibiotics linezolid oral tablet 600 mg Zyvox PA

*Urinary Anti-Infectives*** -Antibiotics methenamine hippurate oral tablet 1 gm methenamine mandelate oral tablet 0.5 gm, 1 gm nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg Macrodantin

nitrofurantoin monohyd macro oral capsule 100 mg Macrobid

nitrofurantoin oral suspension 25 mg/5ml AL (Max 10 Years)

*Antimalarials* - Drugs For Infections *Antimalarial Combinations*** -Drugs For Parasites atovaquone-proguanil hcl oral tablet 250-100 mg Malarone QLL (1 EA per 1 day)

atovaquone-proguanil hcl oral tablet 62.5-25 mg Malarone QLL (3 EA per 1 day)

*Antimalarials*** - Drugs For Parasites chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine sulfate oral tablet 200 mg Plaquenil mefloquine hcl oral tablet 250 mg

31

Formulary Drug Name Reference Restrictions primaquine phosphate oral tablet 26.3 (15 base) mg QLL (2 EA per 1 day)

pyrimethamine oral tablet 25 mg Daraprim PA

*Antimycobacterial Agents* - Drugs For Infections *Antimycobacterial Agents*** -Antibiotics ethambutol hcl oral tablet 100 mg ethambutol hcl oral tablet 400 mg Myambutol isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg Mycobutin rifampin oral capsule 150 mg, 300 mg PRIFTIN ORAL TABLET 150 MG

*Antineoplastics And Adjunctive Therapies* - Drugs For Cancer *Alkylating Agents*** - Drugs For Cancer MYLERAN ORAL TABLET 2 MG

*Androgen Biosynthesis Inhibitors*** - Drugs For Cancer abiraterone acetate oral tablet 250 mg Zytiga PA

*Antiandrogens*** - Drugs For Cancer bicalutamide oral tablet 50 mg Casodex flutamide oral capsule 125 mg Eulexin nilutamide oral tablet 150 mg Nilandron QLL (60 EA per 30 days)

*Antiestrogens*** - Drugs For Cancer tamoxifen citrate oral tablet 10 mg, 20 mg toremifene citrate oral tablet 60 mg Fareston SOLTAMOX ORAL SOLUTION 10 MG/5ML

*Antimetabolites*** - Drugs For Cancer capecitabine oral tablet 150 mg Xeloda PA capecitabine oral tablet 500 mg Xeloda PA; QLL (154 EA per 21 days) 32

Formulary Drug Name Reference Restrictions floxuridine injection solution reconstituted 0.5 gm mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg TABLOID ORAL TABLET 40 MG

*Antineoplastic - Alk Inhibitors*** -Drugs For Cancer ALECENSA ORAL CAPSULE 150 MG PA

*Antineoplastic - Anti-Her2 Agents*** - Drugs For Cancer TUKYSA ORAL TABLET 150 MG, 50 MG PA

*Antineoplastic - Bcl-2 Inhibitors*** - Drugs For Cancer VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

PA

*Antineoplastic - Bcr-Abl Kinase Inhibitors*** - Drugs For Cancer imatinib mesylate oral tablet 100 mg, 400 mg Gleevec PA SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA; QLL (30 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG PA; QLL (2 EA per 1 day)

TASIGNA ORAL CAPSULE 50 MG PA; QLL (4 EA per 1 day)

*Antineoplastic - Braf Kinase Inhibitors*** - Drugs For Cancer TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA

*Antineoplastic - Btk Inhibitors*** -Drugs For Cancer IMBRUVICA ORAL CAPSULE 140 MG PA; QLL (120 EA per 30 days) IMBRUVICA ORAL CAPSULE 70 MG PA; QLL (1 EA per 1 day)

*Antineoplastic - Egfr Inhibitors*** -Drugs For Cancer erlotinib hcl oral tablet 150 mg Tarceva PA GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA

33

Formulary Drug Name Reference Restrictions *Antineoplastic - Hedgehog Pathway Inhibitors*** - Drugs For Cancer ERIVEDGE ORAL CAPSULE 150 MG PA

*Antineoplastic - Mek Inhibitors*** -Drugs For Cancer MEKINIST ORAL TABLET 0.5 MG, 2 MG PA

*Antineoplastic - Mtor Kinase Inhibitors*** - Drugs For Cancer everolimus oral tablet 10 mg Afinitor PA

*Antineoplastic - Multikinase Inhibitors*** - Drugs For Cancer sunitinib malate oral capsule 12.5 mg, 25 mg, 37.5 mg Sutent PA; QLL (1 EA per 1 day)

sunitinib malate oral capsule 50 mg Sutent PA; QLL (28 EA per 42 days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; QLL (30 EA per 30 days)

CAPRELSA ORAL TABLET 100 MG, 300 MG PA

RYDAPT ORAL CAPSULE 25 MG PA TYKERB ORAL TABLET 250 MG lapatinib ditosylate PA; QLL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG PA; QLL (120 EA per 30 days)

*Antineoplastics Misc.*** - Drugs For Cancer hydroxyurea oral capsule 500 mg Hydrea MATULANE ORAL CAPSULE 50 MG

*Aromatase Inhibitors*** - Drugs For Cancer anastrozole oral tablet 1 mg Arimidex exemestane oral tablet 25 mg Aromasin letrozole oral tablet 2.5 mg Femara

*Cyclin-Dependent Kinases (Cdk) Inhibitors*** - Drugs For Cancer IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; QLL (1 EA per 1 day)

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; QLL (2 EA per 1 day)

34

Formulary Drug Name Reference Restrictions *Folic Acid Antagonists Rescue Agents*** - Drugs For Cancer leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

*Gonadotropin Releasing Hormone (Gnrh) Antagonists*** - Drugs For Cancer FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

*Imidazotetrazines*** - Drugs For Cancer temozolomide oral capsule 100 mg, 140 mg, 180 mg, 250 mg Temodar

temozolomide oral capsule 20 mg, 5 mg

*Janus Associated Kinase (Jak) Inhibitors*** - Drugs For Cancer JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA

*Lhrh Analogs*** - Drugs For Cancer leuprolide acetate injection kit 1 mg/0.2ml PA ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG PA

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG

PA

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG PA

*Mitotic Inhibitors*** - Drugs For Cancer etoposide oral capsule 50 mg PA

*Nitrogen Mustards And Related Analogues*** - Drugs For Cancer cyclophosphamide oral capsule 25 mg, 50 mg melphalan oral tablet 2 mg Alkeran LEUKERAN ORAL TABLET 2 MG

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors*** - Drugs For Cancer LYNPARZA ORAL TABLET 100 MG, 150 MG PA; QLL (4 EA per 1 day)

35

Formulary Drug Name Reference Restrictions *Progestins-Antineoplastic*** -Drugs For Cancer hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml megestrol acetate oral tablet 20 mg, 40 mg

*Retinoids*** - Drugs For Cancer tretinoin oral capsule 10 mg PA

*Selective Retinoid X Receptor Agonists*** - Drugs For Cancer bexarotene oral capsule 75 mg Targretin PA

*Topoisomerase I Inhibitors*** -Drugs For Cancer HYCAMTIN ORAL CAPSULE 1 MG PA

*Urinary Tract Protective Agents*** - Drugs For Cancer MESNEX ORAL TABLET 400 MG

*Vascular Endothelial Growth Factor (Vegf) Inhibitors*** - Drugs For Cancer INLYTA ORAL TABLET 1 MG, 5 MG PA; QLL (4 EA per 1 day) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG PA

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3 X 4 MG PA

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 & 4 MG PA

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 MG

PA


LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10 MG & 4 MG

PA

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4 MG PA


36

Formulary Drug Name Reference Restrictions *Antiparkinson And Related Therapy Agents* - Drugs For The Nervous System *Antiparkinson Anticholinergics*** -Drugs For Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl hcl oral solution 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg

*Antiparkinson Dopaminergics*** -Drugs For Parkinson amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5ml amantadine hcl oral tablet 100 mg bromocriptine mesylate oral capsule 5 mg Parlodel bromocriptine mesylate oral tablet 2.5 mg Parlodel

*Antiparkinson Monoamine Oxidase Inhibitors*** - Drugs For Parkinson selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg

*Levodopa Combinations*** - Drugs For Parkinson carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg Sinemet carbidopa-levodopa oral tablet 25-100 mg Dhivy carbidopa-levodopa oral tablet 25-250 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg Stalevo 50

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg Stalevo 75

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg Stalevo 100



37

Formulary Drug Name Reference Restrictions carbidopa-levodopa-entacapone oral tablet 50-200-200 mg Stalevo 200

*Nonergoline Dopamine Receptor Agonists*** - Drugs For Parkinson pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg ST

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg QLL (3 EA per 1 day)

*Peripheral Comt Inhibitors*** -Drugs For Parkinson entacapone oral tablet 200 mg Comtan QLL (4 EA per 1 day)

*Antipsychotics/Antimanic Agents* -Drugs For The Nervous System *Antimanic Agents*** - Drugs For Severe Mental Disorders lithium carbonate er oral tablet extended release 300 mg Lithobid QLL (8 EA per 1 day)

lithium carbonate er oral tablet extended release 450 mg QLL (6 EA per 1 day)

lithium carbonate oral capsule 150 mg QLL (16 EA per 1 day) lithium carbonate oral capsule 300 mg QLL (8 EA per 1 day) lithium carbonate oral capsule 600 mg QLL (4 EA per 1 day) lithium carbonate oral tablet 300 mg QLL (8 EA per 1 day)

*Antipsychotics - Misc.*** - Drugs For Severe Mental Disorders ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Geodon QLL (2 EA per 1 day); AL (Min

18 Years)

*Benzisoxazoles*** - Drugs For Severe Mental Disorders

risperidone oral solution 1 mg/ml RisperDAL QLL (16 ML per 1 day); AL (Min 5 Years)

risperidone oral tablet 0.25 mg QLL (2 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet 0.5 mg, 1 mg, 2 mg RisperDAL QLL (2 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet 3 mg RisperDAL QLL (3 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet 4 mg RisperDAL QLL (4 EA per 1 day); AL (Min 5 Years)

38

Formulary Drug Name Reference Restrictions risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg


risperidone oral tablet dispersible 3 mg QLL (3 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet dispersible 4 mg QLL (4 EA per 1 day); AL (Min 5 Years)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML

PA; QLL (0.75 ML per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML

PA; QLL (1 ML per 28 days)







INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.88ML








RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG


*Butyrophenones*** - Drugs For Severe Mental Disorders haloperidol decanoate intramuscular solution 100 mg/ml Haldol Decanoate QLL (5 ML per 28 days); AL

(Min 18 Years) haloperidol decanoate intramuscular solution 50 mg/ml Haldol Decanoate QLL (9 ML per 28 days); AL

(Min 18 Years)

haloperidol lactate injection solution 5 mg/ml QLL (4 ML per 1 day); AL (Min 18 Years)

39

Formulary Drug Name Reference Restrictions

haloperidol lactate oral concentrate 2 mg/ml QLL (50 ML per 1 day); AL (Min 18 Years)

haloperidol oral tablet 0.5 mg, 20 mg, 5 mg QLL (5 EA per 1 day); AL (Min 18 Years)

haloperidol oral tablet 1 mg, 10 mg, 2 mg QLL (10 EA per 1 day); AL (Min 18 Years)

*Dibenzodiazepines*** - Drugs For Severe Mental Disorders

clozapine oral tablet 100 mg Clozaril QLL (9 EA per 1 day); AL (Min 18 Years)

clozapine oral tablet 200 mg, 50 mg Clozaril QLL (4 EA per 1 day); AL (Min 18 Years)

clozapine oral tablet 25 mg Clozaril QLL (3 EA per 1 day); AL (Min 18 Years)

*Dibenzothiazepines*** - Drugs For Severe Mental Disorders quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SEROquel QLL (3 EA per 1 day); AL (Min

10 Years) quetiapine fumarate oral tablet 300 mg, 400 mg SEROquel QLL (2 EA per 1 day); AL (Min

10 Years)

*Dibenzoxazepines*** - Drugs For Severe Mental Disorders loxapine succinate oral capsule 10 mg, 5 mg, 50 mg


loxapine succinate oral capsule 25 mg QLL (10 EA per 1 day); AL (Min 18 Years)

*Phenothiazines*** - Drugs For Severe Mental Disorders fluphenazine decanoate injection solution 25 mg/ml

QLL (8 ML per 28 days); AL (Min 18 Years)

fluphenazine hcl oral concentrate 5 mg/ml QLL (8 ML per 1 day); AL (Min 18 Years)

perphenazine oral tablet 16 mg QLL (4 EA per 1 day); AL (Min 18 Years)

perphenazine oral tablet 2 mg, 4 mg QLL (6 EA per 1 day); AL (Min 18 Years)

perphenazine oral tablet 8 mg QLL (5 EA per 1 day); AL (Min 18 Years)

prochlorperazine maleate oral tablet 10 mg QLL (4 EA per 1 day); AL (Min 18 Years)

prochlorperazine maleate oral tablet 5 mg QLL (8 EA per 1 day); AL (Min 18 Years)

40


prochlorperazine rectal suppository 25 mg Compro QLL (2 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 10 mg QLL (6 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 100 mg QLL (8 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 25 mg, 50 mg QLL (3 EA per 1 day); AL (Min 18 Years)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg


trifluoperazine hcl oral tablet 5 mg QLL (3 EA per 1 day); AL (Min 18 Years)

COMPRO RECTAL SUPPOSITORY 25 MG prochlorperazine QLL (2 EA per 1 day); AL (Min

18 Years)

*Quinolinone Derivatives*** - Drugs For Severe Mental Disorders aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg Abilify QLL (1 EA per 1 day); AL (Min

6 Years) ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG


ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML PA; QLL (3.9 ML per 56 days)




*Thienbenzodiazepines*** - Drugs For Severe Mental Disorders olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg ZyPREXA QLL (1 EA per 1 day); AL (Min

13 Years) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg ZyPREXA Zydis QLL (1 EA per 1 day); AL (Min

13 Years)

olanzapine oral tablet dispersible 5 mg ZyPREXA Zydis QLL (1 EA per 1 day); AL (Min 18 Years)

41

Formulary Drug Name Reference Restrictions *Thioxanthenes*** - Drugs For Severe Mental Disorders thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg


*Antiseptics & Disinfectants* -Antiseptics And Disinfectants *Chlorine Antiseptics*** -Antiseptics And Disinfectants chlorhexidine gluconate solution 20 %

*Antivirals* - Drugs For Infections *Antiretroviral Combinations*** -Drugs For Viral Infections abacavir sulfate-lamivudine oral tablet 600-300 mg Epzicom DIAGNOSIS REQUIRED

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg Trizivir DIAGNOSIS REQUIRED

efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg Symfi Lo QLL (1 EA per 1 day)

efavirenz-lamivudine-tenofovir oral tablet 600-300-300 mg Symfi QLL (1 EA per 1 day)

lamivudine-zidovudine oral tablet 150-300 mg Combivir DIAGNOSIS REQUIRED lopinavir-ritonavir oral solution 400-100 mg/5ml Kaletra DIAGNOSIS REQUIRED

lopinavir-ritonavir oral tablet 100-25 mg Kaletra DIAGNOSIS REQUIRED ATRIPLA ORAL TABLET 600-200-300 MG efavirenz-emtricitab-tenofovir DIAGNOSIS REQUIRED

BIKTARVY ORAL TABLET 50-200-25 MG

DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

COMPLERA ORAL TABLET 200-25-300 MG DIAGNOSIS REQUIRED

DESCOVY ORAL TABLET 120-15 MG PA; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

DESCOVY ORAL TABLET 200-25 MG PA; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

DOVATO ORAL TABLET 50-300 MG DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

EVOTAZ ORAL TABLET 300-150 MG DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

GENVOYA ORAL TABLET 150-150-200-10 MG


JULUCA ORAL TABLET 50-25 MG PA; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

42

Formulary Drug Name Reference Restrictions STRIBILD ORAL TABLET 150-150-200-300 MG


SYMTUZA ORAL TABLET 800-150-200-10 MG


TEMIXYS ORAL TABLET 300-300 MG DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

TRIUMEQ ORAL TABLET 600-50-300 MG DIAGNOSIS REQUIRED

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG emtricitabine-tenofovir df QLL (1 EA per 1 day)

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** - Drugs For Viral Infections maraviroc oral tablet 150 mg, 300 mg Selzentry SELZENTRY ORAL TABLET 25 MG, 75 MG DIAGNOSIS REQUIRED

*Antiretrovirals - Fusion Inhibitors*** - Drugs For Viral Infections FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG DIAGNOSIS REQUIRED

*Antiretrovirals - Integrase Inhibitors*** - Drugs For Viral Infections

ISENTRESS HD ORAL TABLET 600 MG DIAGNOSIS REQUIRED; QLL (2 EA per 1 day)

ISENTRESS ORAL PACKET 100 MG DIAGNOSIS REQUIRED ISENTRESS ORAL TABLET 400 MG DIAGNOSIS REQUIRED ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG DIAGNOSIS REQUIRED

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


TIVICAY PD ORAL TABLET SOLUBLE 5 MG

DIAGNOSIS REQUIRED; AL (Max 12 Years)

*Antiretrovirals - Protease Inhibitors*** - Drugs For Viral Infections atazanavir sulfate oral capsule 150 mg DIAGNOSIS REQUIRED atazanavir sulfate oral capsule 200 mg, 300 mg Reyataz DIAGNOSIS REQUIRED

fosamprenavir calcium oral tablet 700 mg Lexiva DIAGNOSIS REQUIRED ritonavir oral tablet 100 mg Norvir DIAGNOSIS REQUIRED

43

Formulary Drug Name Reference Restrictions APTIVUS ORAL CAPSULE 250 MG DIAGNOSIS REQUIRED LEXIVA ORAL SUSPENSION 50 MG/ML DIAGNOSIS REQUIRED NORVIR ORAL PACKET 100 MG DIAGNOSIS REQUIRED NORVIR ORAL SOLUTION 80 MG/ML DIAGNOSIS REQUIRED PREZISTA ORAL SUSPENSION 100 MG/ML DIAGNOSIS REQUIRED

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG DIAGNOSIS REQUIRED

REYATAZ ORAL PACKET 50 MG DIAGNOSIS REQUIRED VIRACEPT ORAL TABLET 250 MG, 625 MG DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Non-Nucleoside Analogues*** - Drugs For Viral Infections efavirenz oral capsule 200 mg, 50 mg Sustiva DIAGNOSIS REQUIRED efavirenz oral tablet 600 mg Sustiva DIAGNOSIS REQUIRED etravirine oral tablet 100 mg, 200 mg Intelence PA; DIAGNOSIS REQUIRED nevirapine er oral tablet extended release 24 hour 100 mg DIAGNOSIS REQUIRED

nevirapine er oral tablet extended release 24 hour 400 mg Viramune XR DIAGNOSIS REQUIRED

nevirapine oral suspension 50 mg/5ml PA nevirapine oral tablet 200 mg DIAGNOSIS REQUIRED EDURANT ORAL TABLET 25 MG DIAGNOSIS REQUIRED INTELENCE ORAL TABLET 25 MG DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** - Drugs For Viral Infections abacavir sulfate oral solution 20 mg/ml Ziagen DIAGNOSIS REQUIRED abacavir sulfate oral tablet 300 mg Ziagen DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** - Drugs For Viral Infections emtricitabine oral capsule 200 mg Emtriva PA lamivudine oral solution 10 mg/ml Epivir DIAGNOSIS REQUIRED lamivudine oral tablet 150 mg, 300 mg Epivir DIAGNOSIS REQUIRED EMTRIVA ORAL SOLUTION 10 MG/ML DIAGNOSIS REQUIRED

44

Formulary Drug Name Reference Restrictions *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** - Drugs For Viral Infections stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg DIAGNOSIS REQUIRED

zidovudine oral capsule 100 mg Retrovir DIAGNOSIS REQUIRED zidovudine oral syrup 50 mg/5ml Retrovir DIAGNOSIS REQUIRED zidovudine oral tablet 300 mg DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleotide Analogues*** - Drugs For Viral Infections tenofovir disoproxil fumarate oral tablet 300 mg Viread DIAGNOSIS REQUIRED; QLL

(1 EA per 1 day) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

*Antiretrovirals Adjuvants*** -Drugs For Viral Infections TYBOST ORAL TABLET 150 MG DIAGNOSIS REQUIRED

*Cmv Agents*** - Drugs For Viral Infections valganciclovir hcl oral tablet 450 mg Valcyte QLL (2 EA per 1 day)

*Hepatitis B Agents*** - Drugs For Viral Infections entecavir oral tablet 0.5 mg, 1 mg Baraclude QLL (1 EA per 1 day) lamivudine oral tablet 100 mg Epivir HBV BARACLUDE ORAL SOLUTION 0.05 MG/ML QLL (20 ML per 1 day)

EPIVIR HBV ORAL SOLUTION 5 MG/ML VEMLIDY ORAL TABLET 25 MG QLL (1 EA per 1 day)

*Hepatitis C Agent -Combinations*** - Drugs For Viral Infections sofosbuvir-velpatasvir oral tablet 400-100 mg Epclusa PA; QLL (28 EA per 28 days) MAVYRET ORAL PACKET 50-20 MG PA MAVYRET ORAL TABLET 100-40 MG PA

*Hepatitis C Agents*** - Drugs For Viral Infections ribavirin oral capsule 200 mg ST ribavirin oral tablet 200 mg ST

45

Formulary Drug Name Reference Restrictions PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PA

PEGASYS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 180 MCG/0.5ML PA

*Herpes Agents - Purine Analogues*** - Drugs For Viral Infections acyclovir oral capsule 200 mg QLL (2 EA per 1 day) acyclovir oral suspension 200 mg/5ml Zovirax AL (Max 10 Years) acyclovir oral tablet 400 mg, 800 mg QLL (2 EA per 1 day) valacyclovir hcl oral tablet 1 gm Valtrex QLL (30 EA per 30 days) valacyclovir hcl oral tablet 500 mg Valtrex QLL (60 EA per 30 days)

*Herpes Agents - Thymidine Analogues*** - Drugs For Viral Infections famciclovir oral tablet 125 mg, 250 mg, 500 mg

*Influenza Agents*** - Drugs For Viral Infections

rimantadine hcl oral tablet 100 mg QLL (14 EA Max Qty Per Fill Retail)

*Neuraminidase Inhibitors*** -Drugs For Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Tamiflu QLL (10 EA Max Qty Per Fill

Retail) oseltamivir phosphate oral suspension reconstituted 6 mg/ml Tamiflu QLL (180 ML Max Qty Per Fill

Retail)

*Beta Blockers* - Drugs For The Heart *Alpha-Beta Blockers*** - Drugs For High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Coreg

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg

*Beta Blockers Cardio-Selective*** -Drugs For High Blood Pressure acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin bisoprolol fumarate oral tablet 10 mg, 5 mg

46

Formulary Drug Name Reference Restrictions metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Toprol XL

metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor metoprolol tartrate oral tablet 25 mg TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG

metoprolol succinate er

*Beta Blockers Non-Selective*** -Drugs For High Blood Pressure propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg Inderal LA

propranolol hcl er oral capsule extended release 24 hour 80 mg Inderal LA QLL (1 EA per 1 day)

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Betapace AF

sotalol hcl oral tablet 120 mg, 160 mg, 80 mg Betapace sotalol hcl oral tablet 240 mg Sorine timolol maleate oral tablet 10 mg, 20 mg, 5 mg

*Calcium Channel Blockers* - Drugs For The Heart *Calcium Channel Blockers*** -Drugs For High Blood Pressure amlodipine besylate oral tablet 10 mg Norvasc QLL (1 EA per 1 day) amlodipine besylate oral tablet 2.5 mg, 5 mg Norvasc QLL (2 EA per 1 day) diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 240 mg Taztia XT

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg Taztia XT QLL (3 EA per 1 day)

diltiazem hcl er beads oral capsule extended release 24 hour 300 mg, 360 mg Taztia XT QLL (1 EA per 1 day)

diltiazem hcl er beads oral capsule extended release 24 hour 420 mg Tiadylt ER QLL (1 EA per 1 day)

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 240 mg Cardizem CD

diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg Cardizem CD QLL (3 EA per 1 day)

47

Formulary Drug Name Reference Restrictions diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg Cardizem CD QLL (1 EA per 1 day)

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg QLL (2 EA per 1 day)

diltiazem hcl er oral capsule extended release 24 hour 120 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg Cardizem QLL (4 EA per 1 day) diltiazem hcl oral tablet 90 mg dilt-xr oral capsule extended release 24 hour 120 mg, 240 mg QLL (2 EA per 1 day)

dilt-xr oral capsule extended release 24 hour 180 mg QLL (3 EA per 1 day)

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg Afeditab CR

nifedipine er oral tablet extended release 24 hour 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg Procardia XL QLL (90 EA per 30 days)

nifedipine oral capsule 10 mg, 20 mg verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg Verelan QLL (2 EA per 1 day)

verapamil hcl er oral capsule extended release 24 hour 360 mg Verelan QLL (1 EA per 1 day)

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg Calan SR QLL (2 EA per 1 day)

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg QLL (4 EA per 1 day)

*Cardiotonics* - Drugs For The Heart *Cardiac Glycosides*** - Drugs For The Heart digoxin injection solution 0.25 mg/ml Lanoxin digoxin oral solution 0.05 mg/ml digoxin oral tablet 125 mcg, 250 mcg Digox DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin

LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG digoxin

48

Formulary Drug Name Reference Restrictions *Cardiovascular Agents - Misc.* -Drugs For The Heart *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** -Drugs For Cholesterol amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Caduet

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** - Drugs For High Blood Pressure

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

PA; This drug does not require a copay.; QLL (60 EA per 30 days)

*Prostaglandin Vasodilators*** -Drugs For High Blood Pressure epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg Flolan PA

*Pulmonary Hypertension -Endothelin Receptor Antagonists*** - Drugs For High Blood Pressure ambrisentan oral tablet 10 mg, 5 mg Letairis PA; QLL (1 EA per 1 day) bosentan oral tablet 125 mg, 62.5 mg Tracleer PA; QLL (2 EA per 1 day) OPSUMIT ORAL TABLET 10 MG PA; QLL (30 EA per 30 days) TRACLEER ORAL TABLET SOLUBLE 32 MG PA; QLL (2 EA per 1 day)

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** -Drugs For High Blood Pressure sildenafil citrate oral tablet 20 mg Revatio PA; QLL (3 EA per 1 day) tadalafil (pah) oral tablet 20 mg Adcirca ST; QLL (2 EA per 1 day)

*Sinus Node Inhibitors** - Drugs For High Blood Pressure CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; QLL (60 EA per 30 days)

49

Formulary Drug Name Reference Restrictions *Cephalosporins* - Drugs For Infections *Cephalosporins - 1St Generation*** - Antibiotics cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml AL (Max 12 Years)

cefadroxil oral tablet 1 gm cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml AL (Max 12 Years)

*Cephalosporins - 2Nd Generation*** - Antibiotics cefaclor oral capsule 250 mg, 500 mg cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml AL (Max 12 Years)

cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg

*Cephalosporins - 3Rd Generation*** - Antibiotics cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml AL (Max 12 Years)

cefixime oral capsule 400 mg Suprax QLL (1 EA per 1 Fill) cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml AL (Max 12 Years)

cefpodoxime proxetil oral tablet 100 mg, 200 mg ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg QLL (2 EA per 30 days)

*Contraceptives* - Drugs For Women *Biphasic Contraceptives - Oral*** -Birth Control Pills viorele oral tablet 0.15-0.02/0.01 mg (21/5) Azurette QLL (28 EA per 28 days) AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) viorele QLL (28 EA per 28 days)

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) viorele QLL (28 EA per 28 days)

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) viorele QLL (28 EA per 28 days)

50

Formulary Drug Name Reference Restrictions *Combination Contraceptives -Oral*** - Birth Control Pills alyacen 1/35 oral tablet 1-35 mg-mcg Cyclafem 1/35 QLL (28 EA per 28 days) briellyn oral tablet 0.4-35 mg-mcg Balziva QLL (28 EA per 28 days) drospirenone-ethinyl estradiol oral tablet 3-0.03 mg Ocella QLL (28 EA per 28 days)

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg Aubra QLL (28 EA per 28 days)

levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg Altavera QLL (28 EA per 28 days)

marlissa oral tablet 0.15-30 mg-mcg Altavera QLL (28 EA per 28 days) norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg Estarylla QLL (28 EA per 28 days)

ALTAVERA ORAL TABLET 0.15-30 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

APRI ORAL TABLET 0.15-30 MG-MCG desogestrel-ethinyl estradiol QLL (28 EA per 28 days) AUBRA ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days) AVIANE ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

BALZIVA ORAL TABLET 0.4-35 MG-MCG briellyn QLL (28 EA per 28 days)

CHATEAL ORAL TABLET 0.15-30 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG QLL (28 EA per 28 days)

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG alyacen 1/35 QLL (28 EA per 28 days)

DASETTA 1/35 ORAL TABLET 1-35 MG-MCG alyacen 1/35 QLL (28 EA per 28 days)

ELINEST ORAL TABLET 0.3-30 MG-MCG QLL (28 EA per 28 days)

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG desogestrel-ethinyl estradiol QLL (28 EA per 28 days)

ENSKYCE ORAL TABLET 0.15-30 MG-MCG desogestrel-ethinyl estradiol QLL (28 EA per 28 days)

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG norgestimate-eth estradiol QLL (28 EA per 28 days)

FALMINA ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

51

Formulary Drug Name Reference Restrictions JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG ethynodiol diac-eth estradiol QLL (28 EA per 28 days)

KURVELO ORAL TABLET 0.15-30 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

LARIN 1/20 ORAL TABLET 1-20 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

LESSINA ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

LORYNA ORAL TABLET 3-0.02 MG drospirenone-ethinyl estradiol QLL (28 EA per 28 days) LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG QLL (28 EA per 28 days)

LUTERA ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG norethindrone acet-ethinyl est QLL (21 EA per 28 days)

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG norethin ace-eth estrad-fe QLL (28 EA per 28 days)

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG norgestimate-eth estradiol QLL (28 EA per 28 days)

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG alyacen 1/35 QLL (28 EA per 28 days)

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG alyacen 1/35 QLL (21 EA per 28 days)

OCELLA ORAL TABLET 3-0.03 MG drospirenone-ethinyl estradiol QLL (28 EA per 28 days) ORSYTHIA ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

52

Formulary Drug Name Reference Restrictions PHILITH ORAL TABLET 0.4-35 MG-MCG briellyn QLL (28 EA per 28 days)

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG alyacen 1/35 QLL (28 EA per 28 days)

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

PREVIFEM ORAL TABLET 0.25-35 MG-MCG norgestimate-eth estradiol QLL (28 EA per 28 days)

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG desogestrel-ethinyl estradiol QLL (28 EA per 28 days)

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG norgestimate-eth estradiol QLL (28 EA per 28 days)

SRONYX ORAL TABLET 0.1-20 MG-MCG levonorgestrel-ethinyl estrad QLL (28 EA per 28 days)

SYEDA ORAL TABLET 3-0.03 MG drospirenone-ethinyl estradiol QLL (28 EA per 28 days) VYFEMLA ORAL TABLET 0.4-35 MG-MCG briellyn QLL (28 EA per 28 days)

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ethynodiol diac-eth estradiol QLL (28 EA per 28 days)

*Combination Contraceptives -Transdermal*** - Birth Control Pills XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR QLL (3 Patches per 28 days)

*Combination Contraceptives -Vaginal*** - Birth Control Pills NUVARING VAGINAL RING 0.12-0.015 MG/24HR etonogestrel-ethinyl estradiol QLL (1 EA per 28 days)

*Emergency Contraceptives*** -Birth Control Pills levonorgestrel oral tablet 1.5 mg Option 2 OTC ELLA ORAL TABLET 30 MG OPTION 2 ORAL TABLET 1.5 MG levonorgestrel OTC

*Extended-Cycle Contraceptives -Oral*** - Birth Control Pills levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg Camrese Lo QLL (91 EA per 91 days)

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg Introvale QLL (91 EA per 91 days)

INTROVALE ORAL TABLET 0.15-0.03 MG levonorgest-eth estrad 91-day QLL (91 EA per 91 days)

JOLESSA ORAL TABLET 0.15-0.03 MG levonorgest-eth estrad 91-day QLL (91 EA per 91 days)

53

Formulary Drug Name Reference Restrictions *Progestin Contraceptives -Injectable*** - Birth Control Pills medroxyprogesterone acetate intramuscular suspension 150 mg/ml Depo-Provera QLL (1 ML per 84 days)

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml Depo-Provera QLL (1 ML per 84 days)

*Progestin Contraceptives - Iud*** -Birth Control Pills LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 19.5 MCG/DAY

*Progestin Contraceptives - Oral*** - Birth Control Pills norethindrone oral tablet 0.35 mg Camila QLL (28 EA per 28 days)

*Triphasic Contraceptives - Oral*** - Birth Control Pills alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg Cyclafem 7/7/7 QLL (28 EA per 28 days)

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg Ortho Tri-Cyclen Lo QLL (28 EA per 28 Days)

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Estarylla QLL (28 EA per 28 days)

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG QLL (28 EA per 28 days)

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG QLL (28 EA per 28 days)

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG alyacen 7/7/7 QLL (28 EA per 28 days)

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG alyacen 7/7/7 QLL (28 EA per 28 days)

ENPRESSE-28 ORAL TABLET 50-30/75-40/ 125-30 MCG levonorg-eth estrad triphasic QLL (28 EA per 28 days)

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG QLL (28 EA per 28 days)

LEVONEST ORAL TABLET 50-30/75-40/ 125-30 MCG levonorg-eth estrad triphasic QLL (28 EA per 28 days)

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG alyacen 7/7/7 QLL (28 EA per 28 days)

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG alyacen 7/7/7 QLL (28 EA per 28 days)

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG QLL (28 EA per 28 days)

54

Formulary Drug Name Reference Restrictions TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG norgestim-eth estrad triphasic QLL (28 EA per 28 days)

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG QLL (28 EA per 28 days)

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG norgestim-eth estrad triphasic QLL (28 EA per 28 days)

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG norgestim-eth estrad triphasic QLL (28 EA per 28 days)

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG norgestim-eth estrad triphasic QLL (28 EA per 28 days)

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG norgestim-eth estrad triphasic QLL (28 EA per 28 days)

TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG levonorg-eth estrad triphasic QLL (28 EA per 28 days)

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG QLL (28 EA per 28 days)

*Corticosteroids* - Hormones *Glucocorticosteroids*** - Drugs For Inflammation budesonide oral capsule delayed release particles 3 mg

ST; QLL (90 Days per 365 days)

dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg Decadron

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg dexamethasone sod phosphate pf injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Cortef methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Medrol

prednisolone oral solution 15 mg/5ml prednisolone oral syrup 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg Orapred ODT

55

Formulary Drug Name Reference Restrictions prednisone oral solution 5 mg/5ml AL (Max 10 Years) prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

*Mineralocorticoids*** - Drugs For Inflammation fludrocortisone acetate oral tablet 0.1 mg

*Cough/Cold/Allergy* - Drugs For The Lungs *Antitussive - Nonnarcotic*** -Drugs For Allergies

benzonatate oral capsule 100 mg Tessalon Perles QLL (6 EA per 1 day); AL (Min 10 Years)

benzonatate oral capsule 200 mg QLL (3 EA per 1 day); AL (Min 10 Years)

*Antitussive - Opioid*** - Drugs For Cough And Cold hydrocodone-homatropine oral syrup 5-1.5 mg/5ml Hycodan QLL (30 ML per 1 day); AL

(Min 18 Years) hydrocodone-homatropine oral tablet 5-1.5 mg Hycodan QLL (6 EA per 1 day); AL (Min

18 Years)

hydromet oral syrup 5-1.5 mg/5ml Hycodan QLL (30 ML per 1 day); AL (Min 18 Years)

*Antitussive-Expectorant*** - Drugs For Cough And Cold chest congestion/cough relief oral tablet 20-400 mg SB Tab Tussin DM OTC

dextromethorphan-guaifenesin oral liquid 10-100 mg/5ml Diabetic Tussin DM OTC

gnp mucus relief dm oral tablet 20-400 mg SB Tab Tussin DM OTC gnp tab tussin dm oral tablet 20-400 mg SB Tab Tussin DM OTC hm chest congestion relief dm oral tablet 20-400 mg SB Tab Tussin DM OTC

mucus relief dm cough oral tablet 20-400 mg SB Tab Tussin DM OTC pharbinex-dm oral tablet 20-400 mg SB Tab Tussin DM OTC qc medifin dm oral tablet 20-400 mg SB Tab Tussin DM OTC sb mucus relief dm oral tablet 20-400 mg SB Tab Tussin DM OTC

56

Formulary Drug Name Reference Restrictions sm chest congestion relief dm oral tablet 20-400 mg SB Tab Tussin DM OTC

tussin dm oral liquid 100-10 mg/5ml Diabetic Tussin DM OTC SB TAB TUSSIN DM ORAL TABLET 20-400 MG chest congestion/cough relief OTC

*Decongestant & Antihistamine*** -Drugs For Cough And Cold ALAHIST D ORAL TABLET 17.5-10 MG OTC

*Misc. Respiratory Inhalants*** -Drugs For Allergies sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 7 % HyperSal

*Mucolytics*** - Drugs For The Lungs acetylcysteine inhalation solution 10 %, 20 %

*Non-Narc Antitussive-Antihistamine*** - Drugs For Cough And Cold promethazine-dm oral syrup 6.25-15 mg/5ml

*Opioid Antitussive-Antihistamine*** - Drugs For Cough And Cold promethazine-codeine oral syrup 6.25-10 mg/5ml QLL (30 ML per 1 day)

*Opioid Antitussive-Decongestant-Antihistamine*** - Drugs For Cough And Cold promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml QLL (30 ML per 1 day)

RYDEX ORAL LIQUID 10-1.33-6.33 MG/5ML OTC; QLL (90 ML per 1 day)

*Dermatologicals* - Drugs For The Skin *Acne Antibiotics*** - Drugs For The Skin clindamycin phosphate external gel 1 % Clindagel QLL (1 GM per 1 day) clindamycin phosphate external lotion 1 % Cleocin-T QLL (2 ML per 1 day) clindamycin phosphate external solution 1 % QLL (2 ML per 1 day)

57

Formulary Drug Name Reference Restrictions clindamycin phosphate external swab 1 % Clindacin-P QLL (2 EA per 1 day) ery external pad 2 % QLL (2 EA per 1 day) erythromycin external gel 2 % Erygel QLL (1 GM per 1 day) erythromycin external solution 2 % QLL (2 ML per 1 day) sulfacetamide sodium (acne) external lotion 10 % Klaron QLL (118 ML per 30 days)

CLINDACIN-P EXTERNAL SWAB 1 % clindamycin phosphate QLL (2 EA per 1 day)

*Acne Products*** - Drugs For The Skin acne medication 10 external lotion 10 % OTC

adapalene external cream 0.1 % Differin ST; QLL (45 GM per 30 days); AL (Max 35 Years)

bp wash external liquid 2.5 % PanOxyl OTC isotretinoin oral capsule 10 mg, 20 mg, 30 mg Claravis ST; QLL (2 EA per 1 day)

isotretinoin oral capsule 40 mg Claravis QLL (10 MONTHS per 1 Lifetime)

tretinoin external cream 0.025 % Avita ST; QLL (45 GM per 30 days); AL (Max 35 Years)

tretinoin external cream 0.05 %, 0.1 % Retin-A ST; QLL (45 GM per 30 days); AL (Max 35 Years)

tretinoin external gel 0.01 % Retin-A ST; QLL (45 GM per 30 days); AL (Max 35 Years)

tretinoin external gel 0.025 % Avita ST; QLL (45 GM per 30 days); AL (Max 35 Years)

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG isotretinoin ST; QLL (2 EA per 1 day)

CLARAVIS ORAL CAPSULE 40 MG isotretinoin QLL (10 MONTHS per 1 Lifetime)

DIFFERIN EXTERNAL GEL 0.1 % adapalene QLL (45 GM per 30 days) MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG isotretinoin ST; QLL (2 EA per 1 day)

MYORISAN ORAL CAPSULE 40 MG isotretinoin ST; QLL (10 MONTHS per 1 Lifetime)

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG isotretinoin ST; QLL (2 EA per 1 day)

ZENATANE ORAL CAPSULE 40 MG isotretinoin ST; QLL (10 MONTHS per 1 Lifetime)

*Antibiotics - Topical*** - Drugs For The Skin gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 %

58

Formulary Drug Name Reference Restrictions mupirocin external ointment 2 % Centany QLL (110 GM per 30 days)

*Antifungals - Topical Combinations*** - Drugs For The Skin clotrimazole-betamethasone external cream 1-0.05 % QLL (60 GM per 30 days)

hydrocortisone-iodoquinol external cream 1-1 % Dermazene

*Antifungals - Topical*** - Drugs For The Skin anti-fungal external powder 1 % Lotrimin AF OTC; QLL (45 GM per 30 days) athletes foot powder spray external aerosol powder 1 %

Odor Eaters Foot/Sneaker Spray

OTC; QLL (133 GM per 30 days)

athletes foot spray external aerosol 1 % Tinactin OTC; QLL (133 GM per 30 days)

butenafine hcl external cream 1 % Lotrimin Ultra OTC; QLL (30 GM per 30 days) ciclopirox external shampoo 1 % Loprox ST; QLL (120 ML per 30 days) ciclopirox external solution 8 % Ciclodan QLL (6.6 ML per 30 days) ciclopirox olamine external cream 0.77 % Loprox ST; QLL (60 GM per 30 days) ciclopirox olamine external suspension 0.77 % Loprox ST; QLL (30 ML per 30 days) nystatin external cream 100000 unit/gm QLL (60 GM per 30 days) nystatin external ointment 100000 unit/gm QLL (60 GM per 30 days) nystatin external powder 100000 unit/gm Nyamyc QLL (60 GM per 30 days) terbinafine hcl external cream 1 % LamISIL AT OTC; QLL (60 GM per 30 days) tolnaftate external cream 1 % Tinactin OTC; QLL (90 GM per 30 days) tolnaftate external powder 1 % Lotrimin AF OTC; QLL (45 GM per 30 days)

*Anti-Inflammatory Agents -Topical*** - Drugs For The Skin diclofenac sodium external gel 1 % Aspercreme Arthritis Pain QLL (6.6667 GM per 1 day)

*Antineoplastic Antimetabolites -Topical*** - Drugs For The Skin fluorouracil external cream 5 % Efudex fluorouracil external solution 2 %, 5 %

*Antipsoriatics*** - Drugs For The Skin calcipotriene external cream 0.005 % Dovonex QLL (6.6667 GM per 1 day) calcipotriene external ointment 0.005 % Calcitrene QLL (6.6667 GM per 1 day) calcipotriene external solution 0.005 % QLL (6.6667 ML per 1 day) tazarotene external cream 0.1 % Tazorac ST; QLL (3 GM per 1 day)

59

Formulary Drug Name Reference Restrictions *Antiseborrheic Products*** - Drugs For The Skin selenium sulfide external lotion 2.5 % sulfacetamide sodium external liquid 10 % Ovace Plus Wash

*Antivirals - Topical*** - Drugs For The Skin acyclovir external ointment 5 % Zovirax ST; QLL (15 GM per 30 days) docosanol external cream 10 % Abreva OTC; QLL (1 Tube per 30 days)

*Burn Products*** - Drugs For The Skin silver sulfadiazine external cream 1 % SSD (silver sulfADIAZINE) SSD (SILVER SULFADIAZINE) EXTERNAL CREAM 1 % silver sulfadiazine

*Corticosteroids - Topical*** - Drugs For The Skin alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external ointment 0.1 % betamethasone dipropionate aug external cream 0.05 % QLL (50 GM per 30 days)

betamethasone dipropionate aug external gel 0.05 % QLL (60 GM per 30 days)

betamethasone dipropionate aug external lotion 0.05 % QLL (60 ML per 30 days)

betamethasone dipropionate aug external ointment 0.05 % Diprolene QLL (60 GM per 30 days)

betamethasone dipropionate external cream 0.05 % QLL (60 GM per 30 days)

betamethasone dipropionate external lotion 0.05 % QLL (120 ML per 30 days)

betamethasone dipropionate external ointment 0.05 % QLL (60 GM per 30 days)

betamethasone valerate external cream 0.1 % QLL (60 GM per 30 days) betamethasone valerate external lotion 0.1 % QLL (120 ML per 30 days) betamethasone valerate external ointment 0.1 % QLL (45 GM per 30 days)

clobetasol prop emollient base external cream 0.05 % QLL (60 GM per 30 days)

clobetasol propionate external cream 0.05 % Temovate ST; QLL (60 GM per 30 days)

60

Formulary Drug Name Reference Restrictions clobetasol propionate external gel 0.05 % ST; QLL (60 GM per 30 days) clobetasol propionate external ointment 0.05 % Temovate ST; QLL (60 GM per 30 days)

clobetasol propionate external solution 0.05 % QLL (60 ML per 30 days) fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream 0.025 % Synalar QLL (2 GM per 1 day)

fluocinolone acetonide external ointment 0.025 % Synalar QLL (2 GM per 1 day)

fluocinonide external cream 0.05 % QLL (60 GM per 30 days) fluocinonide external gel 0.05 % QLL (60 GM per 30 days) fluocinonide external ointment 0.05 % QLL (60 GM per 30 days) fluocinonide external solution 0.05 % QLL (60 ML per 30 days) fluticasone propionate external cream 0.05 % fluticasone propionate external ointment 0.005 % halobetasol propionate external cream 0.05 % QLL (50 GM per 30 days) halobetasol propionate external ointment 0.05 % QLL (50 GM per 30 days)

hydrocortisone external cream 0.5 % OTC; QLL (90 GM per 30 days) hydrocortisone external cream 1 % Aveeno Anti-Itch Max St QLL (90 GM per 30 days) hydrocortisone external cream 2.5 % QLL (90 GM per 30 days)

hydrocortisone external lotion 1 % Aquanil HC OTC; QLL (120 GM per 30 days)

hydrocortisone external lotion 2.5 % QLL (120 ML per 30 days) hydrocortisone external ointment 0.5 % OTC; QLL (90 GM per 30 days) hydrocortisone external ointment 1 % Aquaphor Itch Relief Max Str QLL (90 GM per 30 days) hydrocortisone external ointment 2.5 % QLL (90 GM per 30 days) mometasone furoate external cream 0.1 % QLL (45 GM per 30 days) mometasone furoate external ointment 0.1 % QLL (45 GM per 30 days) mometasone furoate external solution 0.1 % QLL (60 ML per 30 days) prednicarbate external ointment 0.1 % QLL (60 GM per 30 days) triamcinolone acetonide external cream 0.025 % QLL (90 GM per 30 days)

triamcinolone acetonide external cream 0.1 %, 0.5 % Triderm QLL (90 GM per 30 days)

triamcinolone acetonide external lotion 0.025 %, 0.1 % QLL (120 ML per 30 days)

triamcinolone acetonide external ointment 0.025 %, 0.5 % QLL (90 GM per 30 days)

61

Formulary Drug Name Reference Restrictions triamcinolone acetonide external ointment 0.05 % Trianex QLL (90 GM per 30 days)

triamcinolone acetonide external ointment 0.1 % SCALPICIN MAXIMUM STRENGTH EXTERNAL SOLUTION 1 % scalp relief maximum strength OTC; QLL (75 ML per 30 days)

*Emollients*** - Drugs For The Skin e-ointment external ointment Aqua-Nu OTC

*Enzymes - Topical*** - Drugs For The Skin SANTYL EXTERNAL OINTMENT 250 UNIT/GM QLL (90 GM per 30 days)

*Imidazole-Related Antifungals -Topical*** - Drugs For The Skin antifungal external powder 2 % Zeasorb-AF OTC; QLL (90 GM per 30 days) athletes foot powder spray external aerosol powder 2 % Cruex Prescription Strength OTC; QLL (133 GM per 30

days) clotrimazole anti-fungal external cream 1 % Desenex QLL (60 GM per 30 days) clotrimazole external cream 1 % Desenex ST; QLL (60 GM per 30 days) clotrimazole external solution 1 % QLL (30 ML per 30 days) ketoconazole external cream 2 % ST; QLL (60 GM per 30 days) ketoconazole external shampoo 2 % QLL (120 ML per 30 days) miconazole antifungal external cream 2 % Cavilon OTC; QLL (90 GM per 30 days) ZEASORB-AF EXTERNAL POWDER 2 % antifungal OTC; QLL (90 GM per 30 days)

*Immunomodulators Imidazoquinolinamines - Topical*** - Drugs For The Skin imiquimod external cream 5 % Aldara

*Insect Repellents*** - Drugs For The Skin OFF DEEP WOODS DRY EXTERNAL AEROSOL cvs insect repellent OTC; QLL (1 bottle per 30

Days) OFF DEEP WOODS EXTERNAL AEROSOL cvs insect repellent OTC; QLL (1 bottle per 30

Days) OFF DEEP WOODS SPORTSMEN EXTERNAL AEROSOL 30 % cvs insect repellent OTC; QLL (1 bottle per 30

Days) OFF FAMILYCARE CLEAN FEEL EXTERNAL LIQUID 5 %

OTC; QLL (1 bottle per 30 Days)

OFF SMOOTH & DRY EXTERNAL AEROSOL 15 % cvs insect repellent OTC; QLL (1 bottle per 30

Days)

62

Formulary Drug Name Reference Restrictions SAWYER INSECT REPELLENT EXTERNAL LIQUID 20 %

OTC; QLL (1 bottle per 30 Days)

ULTRATHON INSECT REPELLENT 8 EXTERNAL AEROSOL 25 % cvs insect repellent OTC; QLL (1 bottle per 30

Days)

*Keratolytic/Antimitotic Agents*** -Drugs For The Skin podofilox external solution 0.5 % salicylic acid external shampoo 6 % Keralyt

*Local Anesthetics - Topical*** -Drugs For The Skin arthritis pain relieving external cream 0.075 % OTC

capsaicin external cream 0.025 % DermacinRx Penetral OTC capsaicin external cream 0.1 % Capzasin-HP OTC capsaicin hp external cream 0.1 % Capzasin-HP OTC gnp lidocaine pain relief external patch 4 % Aspercreme Lidocaine OTC; QLL (1 EA per 1 day) lidocaine external cream 4 % AneCream OTC; QLL (60 GM per 30 days) lidocaine external ointment 5 % PA; QLL (50 GM per 30 days) lidocaine external patch 5 % Lidoderm PA; QLL (90 EA per 30 days) lidocaine hcl external solution 4 % qc lidocaine pain relief external patch 4 % Aspercreme Lidocaine OTC; QLL (1 EA per 1 day)

*Macrolide Immunosuppressants -Topical*** - Drugs For The Skin tacrolimus external ointment 0.03 %, 0.1 % Protopic ST; QLL (30 GM per 30 days)

*Prostaglandins - Topical*** - Drugs For The Skin bimatoprost external solution 0.03 % Latisse ST

*Rosacea Agents*** - Drugs For The Skin metronidazole external cream 0.75 % MetroCream metronidazole external gel 0.75 % Rosadan metronidazole external lotion 0.75 % MetroLotion

*Scabicide Combinations*** - Drugs For The Skin

gnp lice treatment external shampoo 0.33-4 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30 days)

hm lice killing max st external shampoo 0.33-4 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30

days) lice killing external shampoo 0.33-4 %, 4-0.33 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30

days) 63

Formulary Drug Name Reference Restrictions lice killing maximum strength external shampoo 0.33-4 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30

days) sb lice killing max st external shampoo 0.33-4 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30

days) sm lice killing max strength external shampoo 0.33-4 % Rid Lice Killing Shampoo OTC; QLL (240 ML per 30

days)

*Scabicides & Pediculicides*** -Drugs For The Skin

lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

malathion external lotion 0.5 % Ovide ST; QLL (1 pkg per 180 days) permethrin external cream 5 % QLL (60 ML per 30 days)

ra lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

sm lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

spinosad external suspension 0.9 % Natroba

*Topical Anesthetic Combinations*** - Drugs For The Skin lidocaine-prilocaine external cream 2.5-2.5 % QLL (1 GM per 1 day) lidocaine-prilocaine external kit 2.5-2.5 % Lido BDK

*Diagnostic Products* *Diagnostic Tests***

ONETOUCH ULTRA IN VITRO STRIP blood glucose test OTC; QLL (150 EA per 30 days)

ONETOUCH VERIO IN VITRO STRIP blood glucose test OTC; QLL (150 EA per 30 days)

*Digestive Aids* - Drugs For The Stomach *Digestive Enzymes*** - Drugs For The Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 36000-114000 UNIT VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 5000-24000 UNIT 64

Formulary Drug Name Reference Restrictions *Diuretics* - Drugs For The Heart *Carbonic Anhydrase Inhibitors*** -Drugs For High Blood Pressure acetazolamide er oral capsule extended release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg methazolamide oral tablet 25 mg, 50 mg ST

*Diuretic Combinations*** - Drugs For High Blood Pressure amiloride-hydrochlorothiazide oral tablet 5-50 mg spironolactone-hctz oral tablet 25-25 mg Aldactazide triamterene-hctz oral capsule 37.5-25 mg triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 triamterene-hctz oral tablet 75-50 mg Maxzide

*Loop Diuretics*** - Drugs For High Blood Pressure bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg Bumex bumetanide oral tablet 1 mg, 2 mg furosemide injection solution 10 mg/ml furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix torsemide oral tablet 10 mg, 100 mg, 5 mg torsemide oral tablet 20 mg Soaanz

*Potassium Sparing Diuretics*** -Drugs For High Blood Pressure amiloride hcl oral tablet 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg Aldactone

*Thiazides And Thiazide-Like Diuretics*** - Drugs For High Blood Pressure chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 12.5 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg

65

Formulary Drug Name Reference Restrictions *Endocrine And Metabolic Agents -Misc.* - Hormones *Bisphosphonates*** - Drugs For Menopause And Bone Loss alendronate sodium oral solution 70 mg/75ml QLL (4 EA per 30 days) alendronate sodium oral tablet 10 mg, 5 mg QLL (4 EA per 30 days) alendronate sodium oral tablet 35 mg QLL (4 EA per 28 days) alendronate sodium oral tablet 70 mg Fosamax QLL (4 EA per 30 days) ibandronate sodium oral tablet 150 mg Boniva

*Calcimimetic Agents*** - Drugs For Menopause And Bone Loss cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg Sensipar PA

*Calcitonins*** - Drugs For Menopause And Bone Loss calcitonin (salmon) nasal solution 200 unit/act Miacalcin

*Carnitine Replenisher - Agents*** -Drugs For Menopause And Bone Loss levocarnitine oral solution 1 gm/10ml Carnitor levocarnitine oral tablet 330 mg Carnitor

*Dopamine Receptor Agonists*** -Drugs For Women cabergoline oral tablet 0.5 mg

*Growth Hormones*** - Drugs For Growth NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

PA

*Hyperparathyroid Treatment -Vitamin D Analogs*** - Drugs For Menopause And Bone Loss calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol paricalcitol oral capsule 1 mcg, 2 mcg Zemplar ST paricalcitol oral capsule 4 mcg ST

66

Formulary Drug Name Reference Restrictions *Parathyroid Hormone And Derivatives*** - Drugs For Menopause And Bone Loss TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML PA; QLL (0.052 ML per 1 day)

*Rank Ligand (Rankl) Inhibitors*** - Drugs For Menopause And Bone Loss PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60 MG/ML PA; QLL (1 ML per 168 days)

*Selective Estrogen Receptor Modulators (Serms)*** - Drugs For Menopause And Bone Loss raloxifene hcl oral tablet 60 mg Evista

*Somatostatic Agents*** - Drugs For Growth octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml SandoSTATIN PA

octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml PA

octreotide acetate subcutaneous solution prefilled syringe 100 mcg/ml, 50 mcg/ml, 500 mcg/ml

PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML

lanreotide acetate PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 60 MG/0.2ML, 90 MG/0.3ML

PA

*Vasopressin*** - Hormones desmopressin ace spray refrig nasal solution 0.01 % QLL (1 ML per 30 days)

desmopressin acetate injection solution 4 mcg/ml DDAVP

desmopressin acetate oral tablet 0.1 mg, 0.2 mg DDAVP QLL (3 EA per 1 day)

desmopressin acetate pf injection solution 4 mcg/ml DDAVP PF

desmopressin acetate spray nasal solution 0.01 % QLL (1 ML per 30 days)

67

Formulary Drug Name Reference Restrictions *Estrogens* - Hormones *Estrogen & Progestin*** - Drugs For Women estradiol-norethindrone acet oral tablet 0.5-0.1 mg Amabelz

estradiol-norethindrone acet oral tablet 1-0.5 mg Activella

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY FEMHRT ORAL TABLET 0.5-2.5 MG-MCG norethindrone-eth estradiol

JINTELI ORAL TABLET 1-5 MG-MCG norethindrone-eth estradiol PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

*Estrogens*** - Drugs For Women estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.05 mg/24hr Alora QLL (8 EA per 30 days)

estradiol transdermal patch twice weekly 0.0375 mg/24hr Dotti QLL (8 EA per 30 days)

estradiol transdermal patch twice weekly 0.075 mg/24hr, 0.1 mg/24hr Alora QLL (8 EA per 30 days)

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Climara QLL (4 Patches per 30 days)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

*Fluoroquinolones* - Drugs For Infections *Fluoroquinolones*** - Antibiotics ciprofloxacin hcl oral tablet 100 mg, 750 mg QLL (28 EA per 30 days) ciprofloxacin hcl oral tablet 250 mg, 500 mg Cipro QLL (28 EA per 30 days) levofloxacin oral solution 25 mg/ml AL (Max 12 Years) levofloxacin oral tablet 250 mg, 750 mg Levaquin QLL (14 EA per 90 days) levofloxacin oral tablet 500 mg QLL (14 EA per 90 days)

*Gastrointestinal Agents - Misc.* -Drugs For The Stomach *Gallstone Solubilizing Agents*** -Drugs For The Stomach ursodiol oral capsule 300 mg

68

Formulary Drug Name Reference Restrictions ursodiol oral tablet 250 mg Urso 250 ursodiol oral tablet 500 mg Urso Forte

*Gastrointestinal Chloride Channel Activators*** - Drugs For Irritable Bowel Syndrome AMITIZA ORAL CAPSULE 24 MCG, 8 MCG lubiprostone PA; QLL (2 EA per 1 day)

*Gastrointestinal Stimulants*** -Drugs For The Stomach metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg Reglan

*Inflammatory Bowel Agents*** -Drugs For Inflammatory Bowel Disease balsalazide disodium oral capsule 750 mg Colazal mesalamine er oral capsule extended release 24 hour 0.375 gm Apriso

mesalamine oral capsule delayed release 400 mg Delzicol QLL (6 EA per 1 day)

mesalamine oral tablet delayed release 1.2 gm Lialda QLL (120 EA per 30 days) mesalamine oral tablet delayed release 800 mg Asacol HD

mesalamine rectal enema 4 gm mesalamine rectal suppository 1000 mg Canasa sulfasalazine oral tablet 500 mg Azulfidine sulfasalazine oral tablet delayed release 500 mg Azulfidine EN-tabs

*Intestinal Acidifiers*** - Drugs For The Stomach enulose oral solution 10 gm/15ml generlac oral solution 10 gm/15ml lactulose encephalopathy oral solution 10 gm/15ml

*Peripheral Opioid Receptor Antagonists*** - Drugs For The Stomach MOVANTIK ORAL TABLET 12.5 MG, 25 MG PA; QLL (30 EA per 30 days)

69

Formulary Drug Name Reference Restrictions SYMPROIC ORAL TABLET 0.2 MG PA; QLL (1 EA per 1 day)

*Phosphate Binder Agents*** -Drugs For The Stomach calcium acetate (phos binder) oral tablet 667 mg Calphron

sevelamer carbonate oral tablet 800 mg Renvela ST AURYXIA ORAL TABLET 1 GM 210 MG(FE) ST

CALPHRON ORAL TABLET 667 MG calcium acetate (phos binder) OTC

*Genitourinary Agents -Miscellaneous* - Drugs For The Urinary System *5-Alpha Reductase Inhibitors*** -Drugs For The Prostate finasteride oral tablet 5 mg Proscar

*Alpha 1-Adrenoceptor Antagonists*** - Drugs For The Prostate alfuzosin hcl er oral tablet extended release 24 hour 10 mg Uroxatral

tamsulosin hcl oral capsule 0.4 mg Flomax

*Citrates*** - Drugs For Infections cytra k crystals oral packet 3300-1002 mg pot & sod cit-cit ac oral solution 550-500-334 mg/5ml potassium citrate er oral tablet extended release 10 meq (1080 mg) Urocit-K 10

potassium citrate er oral tablet extended release 15 meq (1620 mg) Urocit-K 15

potassium citrate er oral tablet extended release 5 meq (540 mg) Urocit-K 5

sod citrate-citric acid oral solution 500-334 mg/5ml

*Interstitial Cystitis Agents*** -Drugs For The Urinary System ELMIRON ORAL CAPSULE 100 MG PA

*Phosphates*** - Drugs For Infections K-PHOS NO 2 ORAL TABLET 305-700 MG

70

Formulary Drug Name Reference Restrictions *Urinary Analgesics*** - Drugs For Infections hm urinary pain relief oral tablet 99.5 mg AZO Urinary Pain Relief OTC phenazopyridine hcl oral tablet 100 mg Pyridium phenazopyridine hcl oral tablet 200 mg Phenazo phenazopyridine hcl oral tablet 95 mg AZO Urinary Pain Relief OTC

*Gout Agents* - Drugs For Pain And Fever *Gout Agent Combinations*** -Gout Drugs colchicine-probenecid oral tablet 0.5-500 mg

*Gout Agents*** - Gout Drugs allopurinol oral tablet 100 mg, 300 mg Zyloprim colchicine oral capsule 0.6 mg Mitigare QLL (9 EA per 27 days) colchicine oral tablet 0.6 mg Colcrys QLL (9 EA per 27 days) febuxostat oral tablet 40 mg, 80 mg Uloric ST

*Uricosurics*** - Gout Drugs probenecid oral tablet 500 mg

*Hematological Agents - Misc.* -Drugs For The Blood *Complement Inhibitors*** - Drugs For The Blood SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML PA

*Hematorheologic Agents*** - Drugs For The Blood pentoxifylline er oral tablet extended release 400 mg

*Phosphodiesterase Iii Inhibitors*** - Drugs For The Blood cilostazol oral tablet 100 mg, 50 mg

*Platelet Aggregation Inhibitors*** -Drugs For The Blood dipyridamole oral tablet 25 mg, 50 mg, 75 mg

*Quinazoline Agents*** - Drugs For The Blood anagrelide hcl oral capsule 0.5 mg Agrylin anagrelide hcl oral capsule 1 mg

71

Formulary Drug Name Reference Restrictions *Thienopyridine Derivatives*** -Drugs For The Blood clopidogrel bisulfate oral tablet 300 mg QLL (30 EA per 30 days) clopidogrel bisulfate oral tablet 75 mg Plavix QLL (30 EA per 30 days) prasugrel hcl oral tablet 10 mg, 5 mg Effient QLL (1 EA per 1 day)

*Hematopoietic Agents* - Drugs For Nutrition *Amino Acids*** - Drugs For Nutrition ENDARI ORAL PACKET 5 GM PA

*Cobalamins*** - Drugs For Nutrition cyanocobalamin injection solution 1000 mcg/ml QLL (1 ML per 30 days)

*Erythropoiesis-Stimulating Agents (Esas)*** - Drugs For Nutrition RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

PA

*Granulocyte Colony-Stimulating Factors (G-Csf)*** - Drugs For Nutrition ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

PA

*Thrombopoietin (Tpo) Receptor Agonists*** - Drugs For Nutrition PROMACTA ORAL TABLET 12.5 MG PA

*Hypnotics/Sedatives/Sleep Disorder Agents* - Drugs For The Nervous System *Antihistamine Hypnotics*** - Drugs For Insomnia gnp sleep aid oral tablet 25 mg Unisom SleepTabs OTC

72

Formulary Drug Name Reference Restrictions *Barbiturate Hypnotics*** - Drugs For Insomnia phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

*Benzodiazepine Hypnotics*** -Drugs For Seizures /Personality Disorder/Nerve Pain estazolam oral tablet 1 mg QLL (1 EA per 1 day) estazolam oral tablet 2 mg QLL (30 EA per 30 days) flurazepam hcl oral capsule 15 mg, 30 mg QLL (1 EA per 1 day) temazepam oral capsule 15 mg, 30 mg Restoril QLL (1 EA per 1 day)

*Non-Benzodiazepine - Gaba-Receptor Modulators*** - Drugs For Insomnia zaleplon oral capsule 10 mg, 5 mg QLL (1 EA per 1 day)

zolpidem tartrate oral tablet 10 mg, 5 mg Ambien QLL (30 EA per 30 days); AL (Min 18 Years)

*Selective Melatonin Receptor Agonists*** - Drugs For Insomnia ramelteon oral tablet 8 mg Rozerem ST; QLL (1 EA per 1 day)

*Laxatives* - Drugs For The Stomach *Bowel Evacuant Combinations*** -Drugs To Prevent Constipation peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm GaviLyte-N with Flavor Pack

peg-3350/electrolytes oral solution reconstituted 236 gm GaviLyte-G

*Laxatives - Miscellaneous*** -Drugs To Prevent Constipation constulose oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml, 20 gm/30ml HEALTHYLAX ORAL PACKET 17 GM gavilax OTC; QLL (17 GM per 1 day)

*Saline Laxative Mixtures*** -Drugs To Prevent Constipation FLEET ENEMA RECTAL ENEMA , 7-19 GM/118ML cvs enema disposable OTC

73

Formulary Drug Name Reference Restrictions FLEET PEDIATRIC RECTAL ENEMA 3.5-9.5 GM/59ML enema pediatric OTC

*Surfactant Laxatives*** - Drugs To Prevent Constipation docusate sodium oral capsule 250 mg gnp stool softener oral capsule 250 mg OTC hm stool softener oral capsule 250 mg OTC sm stool softener oral capsule 250 mg OTC stool softener laxative oral capsule 250 mg OTC stool softener oral capsule 250 mg OTC

*Macrolides* - Drugs For Infections *Azithromycin*** - Antibiotics azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Zithromax AL (Max 12 Years)

azithromycin oral tablet 250 mg Zithromax QLL (12 Tablets per 30 days) azithromycin oral tablet 500 mg Zithromax azithromycin oral tablet 600 mg QLL (8 Tablets per 30 days)

*Clarithromycin*** - Antibiotics clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml AL (Max 12 Years)

clarithromycin oral tablet 250 mg, 500 mg QLL (28 EA per 30 days)

*Erythromycins*** - Antibiotics erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml E.E.S. Granules

erythromycin ethylsuccinate oral suspension reconstituted 400 mg/5ml EryPed 400

*Medical Devices And Supplies* -Medical Supplies And Durable Medical Equipment *Applicators,Cotton Balls,Etc*** -Medical Supplies And Durable Medical Equipment

alcohol prep pad BD Swabs Single Use Butterfly OTC

alcohol swabs pad 70 % BD Swabs Single Use Butterfly OTC

alcoh-wipe sheet

hm sterile alcohol prep pad BD Swabs Single Use Butterfly OTC

74


sure comfort alcohol prep pad 70 % BD Swabs Single Use Butterfly OTC

true comfort alcohol prep pads pad 70 % BD Swabs Single Use Butterfly OTC

BD SWABS SINGLE USE BUTTERFLY PAD alcohol prep OTC

*Condoms - Female*** - Medical Supplies And Durable Medical Equipment FC FEMALE CONDOM OTC FC2 FEMALE CONDOM OTC

*Condoms - Male*** - Medical Supplies And Durable Medical Equipment condoms OTC kimono Durex Extra Sensitive OTC maxx Durex Extra Sensitive OTC DUREX EXTRA SENSITIVE DEVICE kimono OTC REALITY LATEX CONDOMS kimono OTC

*Diaphragms*** - Medical Supplies And Durable Medical Equipment OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 %

75

Formulary Drug Name Reference Restrictions *Glucose Monitoring Test Supplies*** - Medical Supplies And Durable Medical Equipment control in vitro solution normal Advance Intuition Control OTC diatrue control level 1 in vitro solution low Advocate Control Solution OTC diatrue control level 2 in vitro solution normal Advance Intuition Control OTC diatrue control level 3 in vitro solution high Advocate Control Solution OTC easy plus ii control in vitro solution high , low Advocate Control Solution OTC easy talk control in vitro solution high , low Advocate Control Solution OTC easy talk control in vitro solution normal Advance Intuition Control OTC easy trak control in vitro solution high , low Advocate Control Solution OTC easy trak control in vitro solution normal Advance Intuition Control OTC element compact control 2 in vitro solution Accu-Chek Aviva OTC element compact control 3 in vitro solution Accu-Chek Aviva OTC ge100 control in vitro solution normal Advance Intuition Control OTC glucose control in vitro solution Accu-Chek Aviva OTC glucose control in vitro solution normal Advance Intuition Control OTC supreme ii high/low control in vitro liquid Accu-Chek Aviva OTC ACCU-CHEK AVIVA IN VITRO SOLUTION element compact control 2 OTC

ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID element compact control 2 OTC

ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION element compact control 2 OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID NORMAL control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID element compact control 2 OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID element compact control 2 OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID HIGH diatrue control level 3 OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID LOW diatrue control level 1 OTC

ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

AGAMATRIX CONTROL IN VITRO SOLUTION element compact control 2 OTC

76

Formulary Drug Name Reference Restrictions AGAMATRIX CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

AGAMATRIX CONTROL IN VITRO SOLUTION NORMAL control OTC

ASSURE 3 CONTROL IN VITRO LIQUID element compact control 2 OTC

ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID element compact control 2 OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION element compact control 2 OTC

ASSURE II CONTROL IN VITRO LIQUID element compact control 2 OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID element compact control 2 OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID element compact control 2 OTC

CARESENS CONTROL A IN VITRO SOLUTION element compact control 2 OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID HIGH diatrue control level 3 OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID LOW diatrue control level 1 OTC

DEXCOM G5 MOB/G4 PLAT SENSOR guardian sensor 3 PA; QLL (4 EA per 28 days) DEXCOM G5 MOBILE RECEIVER DEVICE PA; QLL (1 EA per 365 days)

DEXCOM G5 MOBILE TRANSMITTER PA; QLL (1 EA per 90 days) DEXCOM G5 RECEIVER KIT DEVICE PA; QLL (1 EA per 365 days) DEXCOM G6 RECEIVER DEVICE PA; QLL (1 EA per 365 days) DEXCOM G6 SENSOR guardian sensor 3 PA; QLL (3 EA per 30 days) DEXCOM G6 TRANSMITTER PA; QLL (1 EA per 90 days) DUO-CARE CONTROL SOLUTION IN VITRO LIQUID element compact control 2 OTC

EASY STEP CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

EASY STEP CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

EASY STEP CONTROL IN VITRO SOLUTION NORMAL control OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION element compact control 2 OTC

77

Formulary Drug Name Reference Restrictions EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION element compact control 2 OTC

EASYMAX CONTROL IN VITRO SOLUTION NORMAL control OTC

ELEMENT CONTROL IN VITRO LIQUID HIGH diatrue control level 3 OTC

ELEMENT CONTROL IN VITRO LIQUID LOW diatrue control level 1 OTC

ELEMENT CONTROL IN VITRO LIQUID NORMAL control OTC

EMBRACE CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

EVOLUTION CONTROL IN VITRO SOLUTION NORMAL control OTC

FORA CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

FORA CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

FORA CONTROL IN VITRO SOLUTION NORMAL control OTC

FORACARE GDH CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

FORACARE GDH CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

FORACARE GDH CONTROL IN VITRO SOLUTION NORMAL control OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID element compact control 2 OTC

FREESTYLE LIBRE 14 DAY READER DEVICE PA; QLL (1 EA per 365 days)

FREESTYLE LIBRE 14 DAY SENSOR guardian sensor 3 PA; QLL (4 EA per 28 days) FREESTYLE LIBRE 2 READER DEVICE PA; QLL (1 EA per 365 days)

FREESTYLE LIBRE 2 SENSOR guardian sensor 3 PA; QLL (4 EA per 28 days) FREESTYLE LIBRE READER DEVICE PA; QLL (1 EA per 365 days) GLUCOCARD 01 CONTROL IN VITRO LIQUID element compact control 2 OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION NORMAL control OTC

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION element compact control 2 OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION NORMAL control OTC

78

Formulary Drug Name Reference Restrictions GLUCOCOM CONTROL IN VITRO LIQUID HIGH diatrue control level 3 OTC

GLUCOCOM CONTROL IN VITRO LIQUID NORMAL control OTC

INFINITY CONTROL IN VITRO SOLUTION NORMAL control OTC

LIBERTY GLUCOSE CONTROL IN VITRO LIQUID NORMAL control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION NORMAL control OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION element compact control 2 OTC

MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID element compact control 2 OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID element compact control 2 OTC

MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION element compact control 2 OTC

MYGLUCOHEALTH CONTROL IN VITRO SOLUTION element compact control 2 OTC

NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID element compact control 2 OTC

ONETOUCH ULTRA 2 KIT W/DEVICE blood glucose monitor system OTC; QLL (1 Kit per 1 Year) ONETOUCH ULTRA CONTROL IN VITRO SOLUTION element compact control 2 OTC

ONETOUCH ULTRA MINI KIT W/DEVICE blood glucose monitor system OTC; QLL (1 Kit per 1 Year)

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE blood glucose monitor system OTC; QLL (1 Kit per 1 Year)

ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE blood glucose monitor system OTC; QLL (1 Kit per 1 Year)

ONETOUCH VERIO KIT W/DEVICE blood glucose monitor system OTC; QLL (1 Kit per 1 Year) POCKETCHEM EZ CONTROL IN VITRO SOLUTION element compact control 2 OTC

PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID element compact control 2 OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION HIGH diatrue control level 3 OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION LOW diatrue control level 1 OTC

79

Formulary Drug Name Reference Restrictions QUICKTEK CONTROL SOLUTION IN VITRO LIQUID element compact control 2 OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION element compact control 2 OTC

REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION element compact control 2 OTC

RIGHTEST GC300 CONTROL IN VITRO LIQUID HIGH diatrue control level 3 OTC

RIGHTEST GC300 CONTROL IN VITRO LIQUID NORMAL control OTC

SMARTEST CONTROL MEDIUM IN VITRO SOLUTION element compact control 2 OTC

SOLUS V2 CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

SOLUS V2 CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION element compact control 2 OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID diatrue control level 3 OTC

SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID diatrue control level 1 OTC

SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID control OTC

TAI DOC CONTROL IN VITRO SOLUTION NORMAL control OTC

UNISTRIP CONTROL IN VITRO SOLUTION HIGH diatrue control level 3 OTC

UNISTRIP CONTROL IN VITRO SOLUTION LOW diatrue control level 1 OTC

*Needles & Syringes*** - Medical Supplies And Durable Medical Equipment BD PEN NEEDLE MICRO U/F 32G X 6 MM 1st tier unifine pentips OTC

BD PEN NEEDLE MINI U/F 31G X 5 MM 1st tier unifine pentips OTC BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM 1st tier unifine pentips OTC

BD PEN NEEDLE NANO U/F 32G X 4 MM 1st tier unifine pentips

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM sure comfort pen needles OTC

80

Formulary Drug Name Reference Restrictions BD PEN NEEDLE SHORT U/F 31G X 8 MM 1st tier unifine pentips OTC

*Respiratory Therapy Supplies*** -Medical Supplies And Durable Medical Equipment BREATHERITE VALVED MDI CHAMBER DEVICE adult mask QLL (2 EA per 1 year)

*Spacer/Aerosol-Holding Chambers & Supplies*** - Medical Supplies And Durable Medical Equipment AEROCHAMBER MINI CHAMBER DEVICE breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER MV breathe ease large QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU breathe ease large QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU LARGE breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU MEDIUM breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU SMALL breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU W/MASK breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLOW VU breathe ease large QLL (2 EA per 1 year) AEROCHAMBER W/FLOWSIGNAL breathe ease large QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS breathe ease large QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS CHAMBR breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/LARGE breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/MEDIUM breathe ease large QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/SMALL breathe ease large QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER DEVICE breathe ease large QLL (2 EA per 1 year) COMPACT SPACE CHAMBER/LG MASK DEVICE breathe ease large QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER/MED MASK DEVICE breathe ease large QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER/SM MASK DEVICE breathe ease large QLL (2 EA per 1 year)

FLEXICHAMBER ADULT MASK/SMALL QLL (2 EA per 1 year)

81

Formulary Drug Name Reference Restrictions FLEXICHAMBER CHILD MASK/LARGE QLL (2 EA per 1 year)

FLEXICHAMBER CHILD MASK/SMALL QLL (2 EA per 1 year)

FLEXICHAMBER DEVICE breathe ease large QLL (2 EA per 1 year) INSPIRACHAMBER/LARGE DEVICE breathe ease large QLL (2 EA per 1 year) INSPIRACHAMBER/MEDIUM DEVICE breathe ease large QLL (2 EA per 1 year) INSPIRACHAMBER/MOUTHPIECE DEVICE breathe ease large QLL (2 EA per 1 year)

INSPIRACHAMBER/SMALL DEVICE breathe ease large QLL (2 EA per 1 year) OPTICHAMBER DIAMOND breathe ease large QLL (2 EA per 1 year) OPTICHAMBER DIAMOND-LG MASK DEVICE breathe ease large QLL (2 EA per 1 year)

OPTICHAMBER DIAMOND-MD MASK breathe ease large QLL (2 EA per 1 year) OPTICHAMBER DIAMOND-SM MASK breathe ease large QLL (2 EA per 1 year) POCKET CHAMBER DEVICE breathe ease large QLL (2 EA per 1 year) POCKET SPACER DEVICE breathe ease large QLL (2 EA per 1 year) VORTEX VALVED HOLDING CHAMBER DEVICE breathe ease large QLL (2 EA per 1 year)

*Migraine Products* - Drugs For The Nervous System *Selective Serotonin Agonists 5-Ht(1)*** - Drugs For Migraine Headaches naratriptan hcl oral tablet 1 mg, 2.5 mg Amerge rizatriptan benzoate oral tablet 10 mg Maxalt rizatriptan benzoate oral tablet 5 mg rizatriptan benzoate oral tablet dispersible 10 mg Maxalt-MLT

rizatriptan benzoate oral tablet dispersible 5 mg sumatriptan nasal solution 20 mg/act, 5 mg/act Imitrex QLL (4 Vials per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Imitrex QLL (9 Tablets per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose Refill QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml Imitrex STATdose System QLL (4 Vials per 30 days)

82

Formulary Drug Name Reference Restrictions sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml Imitrex STATdose System

*Minerals & Electrolytes* - Drugs For Nutrition *Calcium Combinations*** - Drugs For Nutrition qc calcium/minerals/vitamin d oral tablet 600-400 mg-unit OTC

*Calcium*** - Drugs For Nutrition ra calcium oral tablet 500 mg OTC

*Electrolytes Oral*** - Drugs For Nutrition

pediatric electrolyte oral solution Advantage Care Electrolyte Ped OTC

*Fluoride*** - Drugs For Nutrition fluoritab oral solution 0.275 (0.125 f) mg/drop NaFrinse Drops AL (Max 13 Years) sodium fluoride oral solution 1.1 (0.5 f) mg/ml AL (Max 13 Years) sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg sodium fluoride oral tablet chewable 2.2 (1 f) mg NaFrinse

*Phosphate*** - Drugs For Nutrition K-PHOS ORAL TABLET 500 MG

*Potassium*** - Drugs For Nutrition potassium chloride crys er oral tablet extended release 10 meq Klor-Con M10

potassium chloride crys er oral tablet extended release 20 meq Klor-Con M20

potassium chloride er oral capsule extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq K-Tab

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ potassium chloride crys er

83

Formulary Drug Name Reference Restrictions *Miscellaneous Therapeutic Classes* - Vitamins And Minerals *Chelating Agents*** - Vitamins And Minerals penicillamine oral tablet 250 mg Depen Titratabs PA; QLL (8 EA per 1 day)

*Cyclosporine Analogs*** - Vitamins And Minerals cyclosporine modified oral capsule 100 mg, 25 mg Gengraf

cyclosporine modified oral capsule 50 mg cyclosporine modified oral solution 100 mg/ml Gengraf cyclosporine oral capsule 100 mg, 25 mg SandIMMUNE

*Inosine Monophosphate Dehydrogenase Inhibitors*** -Vitamins And Minerals mycophenolate mofetil oral capsule 250 mg CellCept mycophenolate mofetil oral tablet 500 mg CellCept

*Macrolide Immunosuppressants*** - Vitamins And Minerals sirolimus oral solution 1 mg/ml Rapamune sirolimus oral tablet 0.5 mg Rapamune tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Prograf

*Purine Analogs*** - Vitamins And Minerals azathioprine oral tablet 50 mg Imuran

*Mouth/Throat/Dental Agents* -Drugs For The Mouth And Throat *Anesthetics Topical Oral*** - Drugs For The Mouth And Throat lidocaine hcl mouth/throat solution 4 %

*Anti-Infectives - Throat*** - Drugs For The Mouth And Throat nystatin mouth/throat suspension 100000 unit/ml

*Antiseptics - Mouth/Throat*** -Drugs For The Mouth And Throat chlorhexidine gluconate mouth/throat solution 0.12 % Paroex

84

Formulary Drug Name Reference Restrictions *Saliva Stimulants*** - Drugs For The Mouth And Throat pilocarpine hcl oral tablet 5 mg, 7.5 mg Salagen

*Multivitamins* - Drugs For Nutrition *Multiple Vitamins W/ Minerals*** -Drugs For Nutrition glucoten oral capsule ICaps OTC gnp healthy eyes supervision oral capsule ICaps OTC i-vite oral tablet Compete OTC thera-m oral tablet Compete OTC v-c forte oral capsule ICaps COMPETE ORAL TABLET i-vite OTC ICAPS LUTEIN & OMEGA-3 ORAL CAPSULE glucoten OTC

ICAPS ORAL CAPSULE glucoten OTC OCUVITE EYE + MULTI ORAL TABLET i-vite OTC

OCUVITE EYE HEALTH FORMULA ORAL CAPSULE glucoten OTC

OCUVITE-LUTEIN ORAL TABLET i-vite OTC SYSTANE ICAPS AREDS2 ORAL CAPSULE glucoten OTC

VIC-FORTE ORAL CAPSULE glucoten

*Ped Multi Vitamins W/Fl & Fe*** -Drugs For Nutrition multi-vit/iron/fluoride oral solution 0.25-10 mg/ml OTC; AL (Max 16 Years)

*Ped Multiple Vitamins W/ Minerals & C*** - Drugs For Nutrition AQUADEKS ORAL LIQUID OTC

*Ped Mv W/ Fluoride*** - Drugs For Nutrition multi-vitamin/fluoride oral solution 0.5 mg/ml Quflora Pediatric AL (Max 16 Years) multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg Multi-Vit-Flor

*Ped Vitamins Acd W/ Fluoride*** -Drugs For Nutrition tri-vitamin/fluoride oral solution 0.25 mg/ml AL (Max 16 Years) vitamins acd-fluoride oral solution 0.25 mg/ml AL (Max 16 Years)

85

Formulary Drug Name Reference Restrictions *Pediatric Multiple Vitamins*** -Drugs For Nutrition POLY-VI-SOL ORAL SOLUTION pc pediatric poly-vitamin drop OTC

*Pediatric Vitamins A & D W/ C*** -Drugs For Nutrition TRI-VI-SOL A/C/D ORAL SOLUTION 250-50-10 OTC

*Prenatal Mv & Min W/Fe-Fa*** -Drugs For Nutrition

classic prenatal oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

completenate oral tablet chewable 29-1 mg QLL (180 EA per 90 days)

eql prenatal formula oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

gnp prenatal oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

kp prenatal multivitamins oral tablet 28-0.8 mg

OTC; QLL (180 EA per 90 days)

m-natal plus oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days)

multi prenatal oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (180 EA per 90 days)

pnv prenatal plus multivitamin oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days)

pnv tabs 29-1 oral tablet 29-1 mg Prenatabs Rx QLL (180 EA per 90 days)

prenatabs fa oral tablet 29-1 mg Co-Natal FA OTC; QLL (180 EA per 90 days)

prenatal (w/iron & fa) oral tablet 27-0.8 mg OTC; QLL (180 EA per 90 days)

prenatal 19 oral tablet OTC; QLL (180 EA per 90 days)

prenatal 19 oral tablet 29-1 mg QLL (180 EA per 90 days) prenatal 19 oral tablet chewable , 29-1 mg QLL (180 EA per 90 days)

prenatal one daily oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (180 EA per 90 days)

prenatal oral tablet 27-0.8 mg NeoNatal Vitamin QLL (180 EA per 90 days) prenatal oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days)

prenatal oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

prenatal plus oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days) prenatal plus/iron oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days)

86

Formulary Drug Name Reference Restrictions prenatal vitamin and mineral oral tablet 28-0.8 mg


prenatal vitamin oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (180 EA per 90 days)

prenatal vitamin plus low iron oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days)

prenatal vitamins oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

prenatal/iron oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

preplus oral tablet 27-1 mg NeoNatal Plus QLL (180 EA per 90 days) pretab oral tablet 29-1 mg Co-Natal FA QLL (180 EA per 90 days) px prenatal multivitamins oral tablet 28-0.8 mg


qc prenatal oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

ra prenatal formula oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

ra prenatal oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

se-natal 19 oral tablet 29-1 mg QLL (180 EA per 90 days) se-natal 19 oral tablet chewable 29-1 mg QLL (180 EA per 90 days)

sm prenatal vitamins oral tablet 28-0.8 mg OTC; QLL (180 EA per 90 days)

thrivite rx oral tablet 29-1 mg Prenatabs Rx QLL (180 EA per 90 days) trinatal rx 1 oral tablet 60-1 mg Vinate One QLL (180 EA per 90 days) CO-NATAL FA ORAL TABLET prenatabs fa QLL (180 EA per 90 days) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG QLL (180 EA per 90 days)

FOLIVANE-OB ORAL CAPSULE 85-1 MG QLL (180 EA per 90 days)

INATAL GT ORAL TABLET QLL (180 EA per 90 days) NEONATAL PLUS ORAL TABLET 27-1 MG m-natal plus QLL (180 EA per 90 days)

NEONATAL VITAMIN ORAL TABLET 27-0.8 MG multi prenatal OTC; QLL (180 EA per 90

days) NIVA-PLUS ORAL TABLET 27-1 MG m-natal plus QLL (180 EA per 90 days) PRENATABS RX ORAL TABLET 29-1 MG pnv tabs 29-1 QLL (180 EA per 90 days)

PRENATAL/FOLIC ACID ORAL TABLET m-natal plus QLL (180 EA per 90 days)

87

Formulary Drug Name Reference Restrictions PRENATAL-U ORAL CAPSULE 106.5-1 MG QLL (180 EA per 90 days)

PROVIDA OB ORAL CAPSULE 20-20-1.25 MG QLL (180 EA per 90 days)

RIGHT STEP PRENATAL ORAL TABLET 27-0.8 MG multi prenatal OTC; QLL (180 EA per 90

days) TARON-C DHA ORAL CAPSULE 35-1 MG QLL (180 EA per 90 days)

THERANATAL CORE NUTRITION ORAL TABLET 27-1 MG m-natal plus OTC; QLL (180 EA per 90

days) TRICARE ORAL TABLET m-natal plus QLL (180 EA per 90 days) TRINATE ORAL TABLET QLL (180 EA per 90 days) VINATE II ORAL TABLET 29-1 MG QLL (180 EA per 90 days) VINATE ONE ORAL TABLET 60-1 MG trinatal rx 1 QLL (180 EA per 90 days)

*Prenatal Mv & Min W/Fe-Fa-Dha*** - Drugs For Nutrition ENFAMIL EXPECTA ORAL 28-0.8 & 200 MG


PRENATAL MULTIVITAMIN + DHA ORAL 28-0.8 & 200 MG


*Specialty Vitamins Products*** -Drugs For Nutrition urosex oral tablet Allerwell Allergy Formula

*Musculoskeletal Therapy Agents* -Drugs For Muscles, Ligaments, Tendons, And Bones *Central Muscle Relaxants*** -Drugs For Muscles, Ligaments, Tendons, And Bones baclofen oral tablet 10 mg, 20 mg baclofen oral tablet 5 mg QLL (4 EA per 1 day) carisoprodol oral tablet 350 mg Soma QLL (120 EA per 30 days) chlorzoxazone oral tablet 500 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg QLL (4 EA per 1 day) methocarbamol oral tablet 500 mg, 750 mg QLL (240 EA per 30 days) orphenadrine citrate er oral tablet extended release 12 hour 100 mg tizanidine hcl oral tablet 2 mg QLL (3 EA per 1 day) tizanidine hcl oral tablet 4 mg Zanaflex QLL (9 EA per 1 day)

88

Formulary Drug Name Reference Restrictions *Direct Muscle Relaxants*** - Drugs For Muscles, Ligaments, Tendons, And Bones dantrolene sodium oral capsule 100 mg, 50 mg dantrolene sodium oral capsule 25 mg Dantrium

*Muscle Relaxant Combinations*** -Drugs For Muscles, Ligaments, Tendons, And Bones carisoprodol-aspirin-codeine oral tablet 200-325-16 mg QLL (8 EA per 1 day)

*Viscosupplements*** - Drugs For Muscles, Ligaments, Tendons, And Bones GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML PA

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

PA

*Nasal Agents - Systemic And Topical* - Drugs For The Nose *Nasal Anticholinergics*** - Allergy ipratropium bromide nasal solution 0.03 %, 0.06 %

*Nasal Antihistamines*** - Allergy azelastine hcl nasal solution 0.1 % QLL (30 ML per 30 days)

*Nasal Steroids*** - Allergy

budesonide nasal suspension 32 mcg/act OTC; QLL (1 bottle per 30 days)

flunisolide nasal solution 25 mcg/act (0.025%) ST; QLL (1.6667 ML per 1 day) fluticasone propionate nasal suspension 50 mcg/act Flonase Allergy Relief QLL (1 bottle per 30 days)

gnp 24 hour nasal allergy nasal aerosol 55 mcg/act KLS Aller-Cort OTC

gnp budesonide nasal spray nasal suspension 32 mcg/act

OTC; QLL (1 bottle per 30 days)

goodsense nasal allergy spray nasal aerosol 55 mcg/act KLS Aller-Cort OTC

triamcinolone acetonide nasal aerosol 55 mcg/act KLS Aller-Cort

89

Formulary Drug Name Reference Restrictions FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 MCG/ACT fluticasone propionate OTC; QLL (1 bottle per 30

days)

*Systemic Decongestants*** - Allergy SUDOGEST ORAL TABLET 60 MG kp pseudoephedrine hcl OTC

*Neuromuscular Agents* - Drugs For Nerves And Muscles *Benzathiazoles*** - Drugs For Nerves And Muscles riluzole oral tablet 50 mg Rilutek

*Nutrients* - Drugs For Nutrition *Misc. Nutritional Substances*** -Drugs For Nutrition sm omega-3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC

*Ophthalmic Agents* - Drugs For The Eye *Artificial Tear And Lubricant Combinations*** - Drugs For The Eye SYSTANE OPHTHALMIC GEL 0.4-0.3 % dry eye relief OTC

*Artificial Tears And Lubricants*** - Drugs For The Eye REFRESH LIQUIGEL OPHTHALMIC GEL 1 %

carboxymethylcellulose sodium OTC

REFRESH TEARS OPHTHALMIC SOLUTION 0.5 %

carboxymethylcellulose sodium OTC

*Beta-Blockers - Ophthalmic Combinations*** - Drugs For Glaucoma brimonidine tartrate-timolol ophthalmic solution 0.2-0.5 % Combigan ST; QLL (10 ML per 30 days)

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml Cosopt ST; QLL (10 ML per 30 days)

*Beta-Blockers - Ophthalmic*** -Drugs For Glaucoma betaxolol hcl ophthalmic solution 0.5 % QLL (10 ML per 30 days) carteolol hcl ophthalmic solution 1 % QLL (10 ML per 30 days) levobunolol hcl ophthalmic solution 0.5 % QLL (10 ML per 30 days) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % Timoptic-XE ST; QLL (5 ML per 30 days)

90

Formulary Drug Name Reference Restrictions timolol maleate ophthalmic solution 0.25 %, 0.5 % Timoptic QLL (10 ML per 30 days)

*Cycloplegic Mydriatics*** - Drugs For The Eye atropine sulfate ophthalmic ointment 1 % QLL (3.5 GM per 1 day) atropine sulfate ophthalmic solution 1 % Isopto Atropine QLL (5 ML per 30 days) cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl

phenylephrine hcl ophthalmic solution 10 % Altafrin phenylephrine hcl ophthalmic solution 2.5 % Altafrin QLL (2 ML per 30 days) tropicamide ophthalmic solution 0.5 % tropicamide ophthalmic solution 1 % Mydriacyl ALTAFRIN OPHTHALMIC SOLUTION 10 % phenylephrine hcl

ALTAFRIN OPHTHALMIC SOLUTION 2.5 % phenylephrine hcl QLL (2 ML per 30 days)

*Miotics - Direct Acting*** - Drugs For Glaucoma pilocarpine hcl ophthalmic solution 1 %, 2 % Isopto Carpine pilocarpine hcl ophthalmic solution 4 %

*Ophthalmic Antiallergic*** - Drugs For Itchy Eye azelastine hcl ophthalmic solution 0.05 % ST; QLL (6 ML per 30 days) cromolyn sodium ophthalmic solution 4 % ketotifen fumarate ophthalmic solution 0.025 % Alaway

olopatadine hcl ophthalmic solution 0.1 % Pataday ST; QLL (5 ML per 25 days) ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION 0.025 % ketotifen fumarate OTC

ALAWAY OPHTHALMIC SOLUTION 0.025 % ketotifen fumarate OTC

*Ophthalmic Antibiotics*** - Anti-Infective/Anti-Inflammatories bacitracin ophthalmic ointment 500 unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % Ciloxan erythromycin ophthalmic ointment 5 mg/gm gentamicin sulfate ophthalmic solution 0.3 % levofloxacin ophthalmic solution 0.5 % QLL (5 ML per 30 days) ofloxacin ophthalmic solution 0.3 % Ocuflox tobramycin ophthalmic solution 0.3 %

91

Formulary Drug Name Reference Restrictions GENTAK OPHTHALMIC OINTMENT 0.3 %

*Ophthalmic Antifungal*** - Drugs For The Eye NATACYN OPHTHALMIC SUSPENSION 5 % QLL (15 ML per 30 days)

*Ophthalmic Anti-Infective Combinations*** - Anti-Infective/Anti-Inflammatories bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Polycin

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 Neo-Polycin

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% Polytrim

NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000

neomycin-bacitracin zn-polymyx

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM bacitracin-polymyxin b

*Ophthalmic Antivirals*** - Anti-Infective/Anti-Inflammatories trifluridine ophthalmic solution 1 % QLL (7.5 ML per 30 days)

*Ophthalmic Carbonic Anhydrase Inhibitors*** - Drugs For Glaucoma brinzolamide ophthalmic suspension 1 % Azopt ST; QLL (10 ML per 30 days) dorzolamide hcl ophthalmic solution 2 % Trusopt

*Ophthalmic Immunomodulators*** - Anti-Infective/Anti-Inflammatories CEQUA OPHTHALMIC SOLUTION 0.09 % PA

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** - Anti-Infective/Anti-Inflammatories diclofenac sodium ophthalmic solution 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ketorolac tromethamine ophthalmic solution 0.4 % Acular LS QLL (1 bottle per 30 days)

92

Formulary Drug Name Reference Restrictions ketorolac tromethamine ophthalmic solution 0.5 % Acular QLL (1 bottle per 30 days)

*Ophthalmic Selective Alpha Adrenergic Agonists*** - Drugs For Glaucoma brimonidine tartrate ophthalmic solution 0.2 % QLL (10 ML per 30 days)

*Ophthalmic Steroid Combinations*** - Anti-Infective/Anti-Inflammatories neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 Maxitrol QLL (3.5 GM per 30 days)

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 Maxitrol

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

*Ophthalmic Steroids*** - Anti-Infective/Anti-Inflammatories dexamethasone sodium phosphate ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 % FML Liquifilm prednisolone acetate ophthalmic suspension 1 % Pred Forte

prednisolone sodium phosphate ophthalmic solution 1 %

*Ophthalmic Sulfonamides*** -Anti-Infective/Anti-Inflammatories sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % Bleph-10

*Prostaglandins - Ophthalmic*** -Drugs For Glaucoma bimatoprost ophthalmic solution 0.03 % ST latanoprost ophthalmic solution 0.005 % Xalatan QLL (2.5 ML per 30 days)

*Otic Agents* - Drugs For The Ear *Otic Agents - Miscellaneous*** -Wax Removal acetic acid otic solution 2 % ear drops earwax aid otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days) ear wax removal drops otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days)

93

Formulary Drug Name Reference Restrictions ear wax removal kit otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days) earwax removal kit otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days) earwax treatment drops otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days) sm ear drops otic solution 6.5 % Clearcanal Earwax Softener OTC; QLL (15 ML per 30 days)

*Otic Anti-Infectives*** - Antibiotics ciprofloxacin hcl otic solution 0.2 % Cetraxal QLL (28 EA per 30 days) ofloxacin otic solution 0.3 % QLL (15 ML per 30 days)

*Otic Steroid-Anti-Infective Combinations*** - Anti-Infective/Anti-Inflammatories neomycin-polymyxin-hc otic solution 3.5-10000-1 QLL (20 ML per 30 days)

neomycin-polymyxin-hc otic suspension 3.5-10000-1 QLL (20 ML per 30 days)

*Otic Steroids*** - Anti-Infective/Anti-Inflammatories hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC QLL (10 ML per 30 days)

*Passive Immunizing And Treatment Agents* - Biological Agents *Immune Serums*** - Biological Agents GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

PA

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

PA

HEPAGAM B INJECTION SOLUTION HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

PA

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML

PA

HYPERHEP B INTRAMUSCULAR SOLUTION 220 UNIT/ML HYPERHEP B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 110 UNIT/0.5ML, 220 UNIT/ML

94

Formulary Drug Name Reference Restrictions HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT NABI-HB INTRAMUSCULAR SOLUTION 312 UNIT/ML PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

PA

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

*Penicillins* - Drugs For Infections *Aminopenicillins*** - Antibiotics amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule 500 mg

*Natural Penicillins*** - Antibiotics penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg

*Penicillin Combinations*** -Antibiotics amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml Augmentin ES-600

amoxicillin-pot clavulanate oral tablet 250-125 mg, 875-125 mg QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet 500-125 mg Augmentin QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg QLL (28 EA per 30 days)

95

Formulary Drug Name Reference Restrictions *Penicillinase-Resistant Penicillins*** - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg

*Pharmaceutical Adjuvants* *Oral Vehicles*** sorbitol solution syrpalta oral syrup 85 %

*Progestins* - Hormones *Progestins*** - Drugs For Women hydroxyprogesterone caproate intramuscular oil 250 mg/ml Makena PA

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg Provera

norethindrone acetate oral tablet 5 mg Aygestin ST progesterone oral capsule 100 mg, 200 mg Prometrium MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML PA

*Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System *Alcohol Deterrents*** - Drugs For The Nervous System disulfiram oral tablet 250 mg, 500 mg QLL (1 EA per 1 day)

*Benzodiazepines & Tricyclic Agents*** - Drugs For Seizures /Personality Disorder/Nerve Pain chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

*Cholinomimetics - Ache Inhibitors*** - Drugs For Alzheimer's Disease

donepezil hcl oral tablet 10 mg, 5 mg Aricept QLL (30 EA per 30 days); AL (Min 18 Years)

donepezil hcl oral tablet dispersible 10 mg, 5 mg

QLL (30 EA per 30 days); AL (Min 18 Years)

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg Razadyne ER QLL (30 EA per 30 days); AL

(Min 18 Years) galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg


96

Formulary Drug Name Reference Restrictions rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg


rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr Exelon QLL (60 EA per 30 days); AL

(Min 18 Years)

*Fibromyalgia Agent - Snris*** -Drugs For Seizures /Personality Disorder/Nerve Pain SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ST; QLL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG ST; QLL (1 FILL per 90 days)

*Movement Disorder Drug Therapy*** - Drugs For The Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PA

*Ms Agents - Pyrimidine Synthesis Inhibitors*** - Drugs For Multiple Sclerosis

AUBAGIO ORAL TABLET 14 MG, 7 MG PA; QLL (30 EA per 30 days); AL (Min 18 Years)

*Multiple Sclerosis Agents -Interferons*** - Drugs For Multiple Sclerosis AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML PA; QLL (4 EA per 28 days)

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML


REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG


97

Formulary Drug Name Reference Restrictions *Multiple Sclerosis Agents -Monoclonal Antibodies*** - Drugs For Multiple Sclerosis OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML PA; QLL (0.12 ML per 1 day)

*Multiple Sclerosis Agents - Nrf2 Pathway Activators*** - Drugs For Multiple Sclerosis dimethyl fumarate oral capsule delayed release 120 mg, 240 mg Tecfidera PA; QLL (60 EA per 30 days)

dimethyl fumarate starter pack oral 120 & 240 mg Tecfidera PA; QLL (1 STARTER PACK

per 90 days)

*Multiple Sclerosis Agents*** -Drugs For Multiple Sclerosis glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml Copaxone PA; QLL (12 ML per 28 days)

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

glatiramer acetate PA; QLL (1 ML per 1 day)

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** - Drugs For Alzheimer's Disease memantine hcl oral solution 2 mg/ml AL (Min 18 Years)

memantine hcl oral tablet 10 mg, 5 mg Namenda QLL (2 EA per 1 day); AL (Min 18 Years)

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg Namenda Titration Pak AL (Min 18 Years)

*Phenothiazines & Tricyclic Agents*** - Drugs For Depression perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg AL (Min 18 Years)

*Smoking Deterrents*** - Drugs For Depression bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg nicotine polacrilex mouth/throat gum 2 mg KLS Quit2 OTC nicotine polacrilex mouth/throat gum 4 mg KLS Quit4 OTC nicotine polacrilex mouth/throat lozenge 2 mg KLS Quit2 OTC nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC nicotine step 1 transdermal patch 24 hour 21 mg/24hr Habitrol OTC

98

Formulary Drug Name Reference Restrictions nicotine step 2 transdermal patch 24 hour 14 mg/24hr Nicoderm CQ OTC

nicotine step 3 transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

nicotine transdermal kit 21-14-7 mg/24hr OTC varenicline tartrate oral tablet 0.5 mg, 1 mg NICOTROL INHALATION INHALER 10 MG QLL (1 Inhaler per 30 days)

NICOTROL NS NASAL SOLUTION 10 MG/ML QLL (10 ML per 30 days)

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** - Drugs For Multiple Sclerosis GILENYA ORAL CAPSULE 0.5 MG PA; QLL (1 EA per 1 day)

*Thienbenzodiazepines & Ssris*** -Drugs For Severe Mental Disorders olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg AL (Min 18 Years)

olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg Symbyax AL (Min 18 Years)

*Respiratory Agents - Misc.* - Drugs For The Lungs *Cftr Potentiators*** - Drugs For Cystic Fibrosis KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG PA

KALYDECO ORAL TABLET 150 MG PA

*Cystic Fibrosis Agent -Combinations*** - Drugs For Cystic Fibrosis ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 MG PA

*Hydrolytic Enzymes*** - Drugs For The Lungs PULMOZYME INHALATION SOLUTION 2.5 MG/2.5ML PA; QLL (5 ML per 1 day)

99

Formulary Drug Name Reference Restrictions *Pulmonary Fibrosis Agents*** -Drugs For The Lungs ESBRIET ORAL CAPSULE 267 MG PA ESBRIET ORAL TABLET 267 MG, 801 MG PA

*Sulfonamides* - Drugs For Infections *Sulfonamides*** - Antibiotics sulfadiazine oral tablet 500 mg

*Tetracyclines* - Drugs For Infections *Tetracyclines*** - Antibiotics doxycycline hyclate oral capsule 100 mg Vibramycin doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg Lymepak doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml Vibramycin AL (Max 12 Years)

minocycline hcl oral capsule 100 mg Minocin minocycline hcl oral capsule 50 mg, 75 mg

*Thyroid Agents* - Hormones *Antithyroid Agents*** - Drugs For Thyroid methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg

*Thyroid Hormones*** - Drugs For Thyroid levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Levoxyl

levothyroxine sodium oral tablet 300 mcg Unithroid liothyronine sodium oral tablet 25 mcg, 50 mcg Cytomel QLL (2 EA per 1 day)

liothyronine sodium oral tablet 5 mcg Cytomel QLL (4 EA per 1 day) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg Armour Thyroid QLL (1 EA per 1 day)

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG QLL (1 EA per 1 day)

100

Formulary Drug Name Reference Restrictions LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

levothyroxine sodium

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

levothyroxine sodium

*Toxoids* - Biological Agents *Toxoid Combinations*** - Vaccines ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5 AL (Min 19 Years)

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU AL (Min 19 Years)

*Ulcer Drugs/Antispasmodics/Anticholinergi cs* - Drugs For The Stomach *Antispasmodics*** - Drugs For Stomach Cramps dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml AL (Max 10 Years) dicyclomine hcl oral tablet 20 mg

*Belladonna Alkaloids*** - Drugs For Stomach Cramps ed-spaz oral tablet dispersible 0.125 mg NuLev hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg Levbid

hyoscyamine sulfate oral elixir 0.125 mg/5ml hyoscyamine sulfate oral tablet 0.125 mg Levsin hyoscyamine sulfate oral tablet dispersible 0.125 mg NuLev

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Levsin/SL

hyosyne oral elixir 0.125 mg/5ml oscimin oral tablet 0.125 mg Levsin oscimin sublingual tablet sublingual 0.125 mg Levsin/SL NULEV ORAL TABLET DISPERSIBLE 0.125 MG ed-spaz

*H-2 Antagonists*** - Drugs For Ulcers And Stomach Acid cimetidine hcl oral solution 300 mg/5ml

101

Formulary Drug Name Reference Restrictions cimetidine oral tablet 300 mg, 400 mg, 800 mg famotidine oral suspension reconstituted 40 mg/5ml AL (Max 10 Years)

famotidine oral tablet 20 mg MM Acid-Pep Maximum Strength

famotidine oral tablet 40 mg Pepcid nizatidine oral capsule 150 mg, 300 mg

*Misc. Anti-Ulcer*** - Drugs For Ulcers And Stomach Acid sucralfate oral suspension 1 gm/10ml Carafate AL (Max 10 Years) sucralfate oral tablet 1 gm Carafate

*Proton Pump Inhibitors*** - Drugs For Ulcers And Stomach Acid esomeprazole magnesium oral capsule delayed release 20 mg GoodSense Esomeprazole QLL (60 EA per 30 days)

esomeprazole magnesium oral tablet delayed release 20 mg NexIUM 24HR OTC

gnp omeprazole oral tablet delayed release dispersible 20 mg OTC; QLL (2 EA per 1 day)

kp omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg OTC; QLL (2 EA per 1 day)

lansoprazole oral capsule delayed release 15 mg Prevacid 24HR QLL (60 EA per 30 days)

lansoprazole oral capsule delayed release 30 mg Prevacid QLL (30 EA per 30 days)

omeprazole magnesium oral tablet delayed release 20 mg PriLOSEC OTC OTC; QLL (2 EA per 1 day)

omeprazole oral capsule delayed release 20 mg QLL (60 EA per 30 Days)

omeprazole oral capsule delayed release 40 mg QLL (30 EA per 30 Days)

omeprazole oral tablet delayed release 20 mg OTC; QLL (60 EA per 30 days) omeprazole oral tablet delayed release dispersible 20 mg OTC; QLL (2 EA per 1 day)

pantoprazole sodium oral tablet delayed release 20 mg Protonix QLL (60 EA per 30 days)

pantoprazole sodium oral tablet delayed release 40 mg Protonix QLL (30 EA per 30 days)

rabeprazole sodium oral tablet delayed release 20 mg Aciphex QLL (2 EA per 1 day)

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML AL (Max 10 Years)

102

Formulary Drug Name Reference Restrictions FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML AL (Max 10 Years)

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML AL (Max 10 Years)

*Quaternary Anticholinergics*** -Drugs For Stomach Cramps glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml glycopyrrolate oral tablet 1 mg Robinul glycopyrrolate oral tablet 2 mg Robinul-Forte

*Ulcer Drugs - Prostaglandins*** -Drugs For Ulcers And Stomach Acid misoprostol oral tablet 100 mcg, 200 mcg Cytotec

*Vaccines* - Biological Agents *Bacterial Vaccines*** - Vaccines MENACTRA INTRAMUSCULAR SOLUTION AL (Min 19 Years)

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED AL (Min 19 Years)

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML AL (Min 19 Years)

*Viral Vaccines*** - Vaccines AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML AL (Min 19 Years)

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML GARDASIL 9 INTRAMUSCULAR SUSPENSION

AL (Min 19 Years and Max 26 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

AL (Min 19 Years and Max 26 Years)

103

Formulary Drug Name Reference Restrictions HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

AL (Min 19 Years)

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML

AL (Min 19 Years)

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

AL (Min 19 Years)

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

AL (Min 19 Years)

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML AL (Min 19 Years)

*Vaginal And Related Products* -Drugs For Women *Imidazole-Related Antifungals*** -Drugs For Infections terconazole vaginal cream 0.4 %, 0.8 %

*Vaginal Anti-Infectives*** - Drugs For Infections clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % Vandazole

*Vaginal Estrogens*** - Drugs For Women ESTRING VAGINAL RING 2 MG QLL (1 EA per 84 days) YUVAFEM VAGINAL TABLET 10 MCG estradiol

*Vasopressors* - Drugs For The Heart *Anaphylaxis Therapy Agents*** -Drugs For Serious Allergic Reaction epinephrine injection solution auto-injector 0.15 mg/0.15ml Auvi-Q QLL (2 PENS per 30 days)

epinephrine injection solution auto-injector 0.15 mg/0.3ml EpiPen Jr 2-Pak QLL (2 PENS per 30 days)

epinephrine injection solution auto-injector 0.3 mg/0.3ml Auvi-Q QLL (2 PENS per 30 days)

*Vasopressors*** - Drugs For Serious Allergic Reaction midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

104

Formulary Drug Name Reference Restrictions *Vitamins* - Drugs For Nutrition *Vitamin B-3*** - Drugs For Nutrition niacin er oral tablet extended release 750 mg Endur-Acin OTC

*Vitamin B-6*** - Drugs For Nutrition pyridoxine hcl injection solution 100 mg/ml

*Vitamin D*** - Drugs For Nutrition ergocal oral capsule 62.5 mcg (2500 ut) QLL (30 EA per 30 days) ergocalciferol oral capsule 1.25 mg (50000 ut) Drisdol vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) Drisdol

vitamin d3 oral tablet dispersible 125 mcg (5000 ut) OTC

*Vitamin K*** - Drugs For Nutrition phytonadione oral tablet 5 mg Mephyton

105

106

Index of Drugs abacavir sulfate 44 abacavir sulfate-lamivudine 42 abacavir-lamivudine-zidovudine 42 ABILIFY MAINTENA 41 abiraterone acetate 32 acarbose 20 ACCU-CHEK AVIVA 76 ACCU-CHEK SMARTVIEW CONTROL 76 ACCUTREND GLUCOSE CONTROL 76 acebutolol hcl 46 acetaminophen-codeine 7 acetaminophen-codeine #2 6 acetaminophen-codeine #3 7 acetaminophen-codeine #4 7 acetazolamide 65 acetazolamide er 65 acetic acid 93 acetylcysteine 57 acne medication 10 58 acyclovir 46, 60 ADACEL 101 adapalene 58 ADMELOG 21 ADMELOG SOLOSTAR 21 ADVANCE INTUITION CONTROL 76 ADVANCE MICRO-DRAW CONTROL 76 ADVANCE MICRO-DRAW NORMAL 76 ADVOCATE CONTROL SOLUTION 76 ADVOCATE REDI-CODE+ CONTROL 76 AEROCHAMBER MINI CHAMBER 81 AEROCHAMBER MV 81 AEROCHAMBER PLUS FLO-VU 81 AEROCHAMBER PLUS FLO-VU LARGE 81 AEROCHAMBER PLUS FLO-VU MEDIUM 81 AEROCHAMBER PLUS FLO-VU SMALL 81 AEROCHAMBER PLUS FLO-VU W/MASK 81 AEROCHAMBER PLUS FLOW VU 81

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AEROCHAMBER W/FLOWSIGNAL 81 AEROCHAMBER Z-STAT PLUS 81 AEROCHAMBER Z-STAT PLUS CHAMBR 81 AEROCHAMBER Z-STAT PLUS/LARGE 81 AEROCHAMBER Z-STAT PLUS/MEDIUM 81 AEROCHAMBER Z-STAT PLUS/SMALL 81 AFLURIA QUADRIVALENT

103 AGAMATRIX CONTROL76, 77 ALAHIST D 57 ALAWAY 91 ALAWAY CHILDRENS ALLERGY 91 albendazole 10 albuterol sulfate 13 albuterol sulfate hfa 13 alclometasone dipropionate 60 alcohol prep 74 alcohol swabs 74 alcoh-wipe 74 ALECENSA 33 alendronate sodium 66 alfuzosin hcl er 70 allergy relief childrens 25 allopurinol 71 alogliptin benzoate 21 alogliptin-metformin hcl 21 alogliptin-pioglitazone 21 alprazolam 11 alprazolam er 11 alprazolam xr 11 ALTAFRIN 91 ALTAVERA 51 alyacen 1/35 51 alyacen 7/7/7 54 amantadine hcl 37 ambrisentan 49 amcinonide 60 amiloride hcl 65 amiloride-hydrochlorothiazide 65 amiodarone hcl 12 AMITIZA 69 amitriptyline hcl 20 amlodipine besy-benazepril hcl 28 amlodipine besylate 47

amlodipine besylate-valsartan 29 amlodipine-atorvastatin 49 amoxapine 20 amoxicillin 95 amoxicillin-pot clavulanate 95 amphetamine-dextroamphet er 3 amphetamine- dextroamphetamine 3 ampicillin 95 anagrelide hcl 71 anastrozole 34 antifungal 62 anti-fungal 59 APRI 51 APTIVUS 44 AQUADEKS 85 ARANELLE 54 aripiprazole 41 ARISTADA 41 armodafinil 3 ARMOUR THYROID 100 ARNUITY ELLIPTA 14 arthritis pain relieving 63 ASSURE 3 CONTROL 77 ASSURE 4 CONTROL LEVEL 1 & 2 77 ASSURE DOSE CONTROL 77 ASSURE DOSE NORM/HIGH CONTROL 77 ASSURE II CONTROL 77 ASSURE II CONTROL LEVEL 1 & 2 77 ASSURE PRO CONTROL LEVEL 1 & 2 77 atazanavir sulfate 43 atenolol 46 atenolol-chlorthalidone 30 athletes foot powder spray 59, 62 athletes foot spray 59 atorvastatin calcium 27 atovaquone-proguanil hcl . 31 ATRIPLA 42 atropine sulfate 91 AUBAGIO 97 AUBRA 51 AURYXIA 70 AUSTEDO 97 AVIANE 51 AVONEX PEN 97 AVONEX PREFILLED 97 azathioprine 84

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89, 91 azithromycin 74 AZURETTE 50 bacitracin 91 bacitracin-polymyxin b 92 baclofen 88 balsalazide disodium 69 BALZIVA 51 BANOPHEN 26 BAQSIMI ONE PACK 20 BAQSIMI TWO PACK 21 BARACLUDE 45 BASAGLAR KWIKPEN 22 BD PEN NEEDLE MICRO U/F 80 BD PEN NEEDLE MINI U/F 80 BD PEN NEEDLE NANO 2ND GEN 80 BD PEN NEEDLE NANO U/F 80 BD PEN NEEDLE ORIGINAL U/F 80 BD PEN NEEDLE SHORT U/F 81 BD SWABS SINGLE USE BUTTERFLY 75 benazepril hcl 28 benazepril-hydrochlorothiazide 28 benzonatate 56 benztropine mesylate 37 betamethasone dipropionate 60 betamethasone dipropionate aug 60 betamethasone valerate 60 betaxolol hcl 90 BEVESPI AEROSPHERE 13 bexarotene 36 bicalutamide 32 BIKTARVY 42 bimatoprost 63, 93 bisoprolol fumarate 46 bisoprolol-hydrochlorothiazide 30 bosentan 49 bp wash 58 BREATHERITE VALVED MDI CHAMBER 81 briellyn 51 brimonidine tartrate 93 brimonidine tartrate-timolol 90 brinzolamide 92 bromocriptine mesylate 37 budesonide 14, 55, 89

budesonide-formoterol fumarate 13 bumetanide ..................................

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65 buprenorphine 9 buprenorphine hcl 9 buprenorphine hcl-naloxone hcl 9 bupropion hcl 18 bupropion hcl er (smoking det) 98 bupropion hcl er (sr) 18 bupropion hcl er (xl) 18 buspirone hcl 11 butalbital-acetaminophen 6 butalbital-apap-caff-cod 7 butalbital-apap-caffeine 6 butalbital-asa-caff-codeine 7 butalbital-asa-caffeine 6 butenafine hcl 59 cabergoline 66 CABOMETYX 34 caffeine citrate 3 calcipotriene 59 calcitonin (salmon) 66 calcitriol 66 calcium acetate (phos binder) 70 CALPHRON 70 candesartan cilexetil 29 candesartan cilexetil-hctz 29 capecitabine 32 CAPRELSA 34 capsaicin 63 capsaicin hp 63 carbamazepine 16 carbamazepine er 16 carbidopa-levodopa 37 carbidopa-levodopa er 37 carbidopa-levodopa-entacapone

37, 38 carbinoxamine maleate 25 CARESENS CONTROL A 77 carisoprodol 88 carisoprodol-aspirin-codeine 89 carteolol hcl 90 carvedilol 46 CAZIANT 54 cefaclor 50 cefadroxil 50 cefdinir 50 cefixime 50 cefpodoxime proxetil 50 cefprozil 50 ceftriaxone sodium 50 cefuroxime axetil 50 celecoxib 5

cephalexin 50 CEQUA 92 cetirizine hcl 26 CHATEAL . 51 CHEMET ... 24 chest congestion/cough relief 56 chlordiazepoxide hcl 12 chlordiazepoxide-amitriptyline 96 chlorhexidine gluconate 42, 84 chloroquine phosphate 31 chlorthalidone 65 chlorzoxazone 88 cholestyramine 26 cholestyramine light 26 ciclopirox 59 ciclopirox olamine 59 cilostazol 71 cimetidine 102 cimetidine hcl 101 cinacalcet hcl 66 ciprofloxacin hcl 68, 91, 94 citalopram hydrobromide 19 CLARAVIS 58 clarithromycin 74 classic prenatal 86 clemastine fumarate 25 CLEVER CHOICE GLUCOSE CONTROL 77 CLINDACIN-P 58 clindamycin hcl 31 clindamycin palmitate hcl 31 clindamycin phosphate . 57, 58, 104 clobetasol prop emollient base 60 clobetasol propionate 60, 61 clonazepam 16 clonidine 29, 30 clonidine hcl 29 clopidogrel bisulfate 72 clotrimazole 62 clotrimazole anti-fungal 62 clotrimazole-betamethasone 59 clozapine 40 codeine sulfate 7 colchicine 71 colchicine-probenecid 71 colesevelam hcl 26 colestipol hcl 26 COMBIPATCH 68 COMPACT SPACE CHAMBER 81 COMPACT SPACE CHAMBER/LG MASK 81

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COMPACT SPACE CHAMBER/MED MASK 81 COMPACT SPACE CHAMBER/SM MASK 81 COMPETE 85 COMPLERA 42 completenate 86 COMPRO 41 CO-NATAL FA 87 CONCEPT OB 87 condoms 75 constulose 73 control 76 CORLANOR 49 CREON 64 cromolyn sodium 13, 91 CRYSELLE-28 51 cyanocobalamin 72 CYCLAFEM 1/35 51 CYCLAFEM 7/7/7 54 cyclobenzaprine hcl 88 cyclopentolate hcl 91 cyclophosphamide 35 cyclosporine 84 cyclosporine modified 84 cyproheptadine hcl 26 cytra k crystals 70 danazol 9 dantrolene sodium 89 dapsone 31 DASETTA 1/35 51 DASETTA 7/7/7 54 DESCOVY 42 desmopressin ace spray refrig 67 desmopressin acetate 67 desmopressin acetate pf 67 desmopressin acetate spray 67 dexamethasone 55 DEXAMETHASONE INTENSOL 56 dexamethasone sod phosphate pf 55 dexamethasone sodium phosphate 55, 93 DEXCOM G5 MOB/G4 PLAT SENSOR 77 DEXCOM G5 MOBILE RECEIVER 77 DEXCOM G5 MOBILE TRANSMITTER 77 DEXCOM G5 RECEIVER KIT 77

DEXCOM G6 RECEIVER 77 DEXCOM G6 SENSOR 77 DEXCOM G6 TRANSMITTER 77 dexmethylphenidate hcl 3 dexmethylphenidate hcl er 3 dextroamphetamine sulfate 3 dextroamphetamine sulfate er 3 dextromethorphan-guaifenesin 56 diatrue control level 1 76 diatrue control level 2 76 diatrue control level 3 76 diazepam 12, 16 diclofenac potassium 5 diclofenac sodium 5, 59, 92 diclofenac sodium er 5 dicloxacillin sodium 96 dicyclomine hcl 101 DIFFERIN 58 diflunisal 6 DIGOX 48 digoxin 48 DILANTIN 17 diltiazem hcl 48 diltiazem hcl er 48 diltiazem hcl er beads 47 diltiazem hcl er coated beads47, 48 dilt-xr 48 dimethyl fumarate 98 dimethyl fumarate starter pack 98 diphenhydramine hcl 25, 26 diphenoxylate-atropine 24 dipyridamole 71 disopyramide phosphate 12 disulfiram 96 divalproex sodium 18 divalproex sodium er 18 docosanol 60 docusate sodium 74 donepezil hcl 96 dorzolamide hcl 92 dorzolamide hcl-timolol mal 90 DOVATO 42 doxazosin mesylate 30 doxepin hcl 20 doxycycline hyclate 100 doxycycline monohydrate 100 drospirenone-ethinyl estradiol 51 duloxetine hcl 19 DUO-CARE CONTROL SOLUTION 77 DUREX EXTRA SENSITIVE 75

ear drops earwax aid 93 ear wax removal drops 93 ear wax removal kit 94 earwax removal kit 94 earwax treatment drops 94 easy plus ii control 76 EASY STEP CONTROL 77 easy talk control 76 EASY TOUCH CONTROL HIGH & LOW 77 easy trak control 76 EASYMAX 15 LEVEL 2 CONTROL 78 EASYMAX CONTROL 78 ed-spaz 101 EDURANT 44 efavirenz 44 efavirenz-lamivudine-tenofovir 42 element compact control 2 76 element compact control 3 76 ELEMENT CONTROL 78 ELIGARD 35 ELINEST 51 ELIQUIS 15 ELIQUIS DVT/PE STARTER PACK 15 ELLA 53 ELMIRON 70 EMBRACE CONTROL 78 EMEND 25 EMOQUETTE 51 emtricitabine 44 EMTRIVA 44 enalapril maleate 28 enalapril-hydrochlorothiazide 28 ENBREL 6 ENBREL MINI 6 ENBREL SURECLICK 6 ENDARI 72 ENFAMIL EXPECTA 88 ENGERIX-B 103 enoxaparin sodium 15 ENPRESSE-28 54 ENSKYCE 51 entacapone 38 entecavir 45 ENTRESTO 49 enulose 69 e-ointment 62 epinephrine 104 EPIVIR HBV 45 epoprostenol sodium 49

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eq allergy relief childrens 26 eql prenatal formula 86 ergocal 105 ergocalciferol 105 ERIVEDGE 34 erlotinib hcl 33 ery 58 erythromycin 58, 91 erythromycin ethylsuccinate 74 ESBRIET 100 escitalopram oxalate 19 esomeprazole magnesium 102 ESTARYLLA 51 estazolam 73 estradiol 68 estradiol-norethindrone acet 68 ESTRING 104 ethambutol hcl 32 ethosuximide 17 etodolac 5 etodolac er 5 etoposide 35 etravirine 44 everolimus 34 EVOLUTION CONTROL 78 EVOTAZ 42 exemestane 34 ezetimibe 27 FALMINA 51 famciclovir 46 famotidine 102 FC FEMALE CONDOM 75 FC2 FEMALE CONDOM 75 febuxostat 71 felodipine er 48 FEMHRT 68 fenofibrate 27 fenofibrate micronized 27 fentanyl 7 fentanyl citrate 7 finasteride 70 FIRMAGON 35 FIRST-LANSOPRAZOLE 102 FIRST-OMEPRAZOLE 103 FIRVANQ 31 flecainide acetate 12 FLEET ENEMA 73 FLEET PEDIATRIC 74 FLEXICHAMBER 82 FLEXICHAMBER ADULT MASK/SMALL 81

FLEXICHAMBER CHILD MASK/LARGE 82 FLEXICHAMBER CHILD MASK/SMALL 82 FLONASE ALLERGY RELIEF 90 FLOVENT HFA 14 floxuridine 33 FLUARIX QUADRIVALENT

103 fluconazole 25 fludrocortisone acetate 56 FLULAVAL QUADRIVALENT 103 flunisolide 89 fluocinolone acetonide 61 fluocinonide 61 fluoritab 83 fluorometholone 93 fluorouracil 59 fluoxetine hcl 19 fluphenazine decanoate 40 fluphenazine hcl 40 flurazepam hcl 73 flurbiprofen 5 flurbiprofen sodium 92 flutamide 32 fluticasone propionate 61, 89 fluticasone-salmeterol 13 fluvastatin sodium 27 fluvastatin sodium er 27 fluvoxamine maleate 19 FLUZONE QUADRIVALENT 103 FOLIVANE-OB 87 FORA CONTROL 78 FORACARE GDH CONTROL 78 fosamprenavir calcium 43 fosinopril sodium 28 fosinopril sodium-hctz 28 FREESTYLE CONTROL SOLUTION 78 FREESTYLE LIBRE 14 DAY READER 78 FREESTYLE LIBRE 14 DAY SENSOR 78 FREESTYLE LIBRE 2 READER 78 FREESTYLE LIBRE 2 SENSOR 78

FREESTYLE LIBRE READER 78 furosemide 65 FUZEON 43 gabapentin 16 GABITRIL 17 galantamine hydrobromide 96 galantamine hydrobromide er 96 GAMMAGARD 94 GAMUNEX-C 94 GARDASIL 9 103 ge100 control 76 GEL-ONE 89 gemfibrozil 27 generlac 69 GENTAK 92 gentamicin sulfate 58, 91 GENVOYA 42 GILENYA 99 GILOTRIF 33 glatiramer acetate 98 GLATOPA 98 glimepiride 24 glipizide 24 glipizide er 24 glipizide-metformin hcl 23 GLUCAGEN HYPOKIT 21 glucagon emergency 20 GLUCOCARD 01 CONTROL 78 GLUCOCARD EXPRESSION CONTROL 78 GLUCOCARD X-SENSOR CONTROL 78 GLUCOCOM CONTROL 79 glucose control 76 glucoten 85 glyburide 24 glyburide micronized 24 glyburide-metformin 24 glycopyrrolate 103 gnp 24 hour nasal allergy 89 gnp budesonide nasal spray 89 gnp healthy eyes supervision 85 gnp lice treatment 63 gnp lidocaine pain relief 63 gnp mucus relief dm 56 gnp omeprazole 102 gnp prenatal 86 gnp sleep aid 72 gnp stool softener 74 gnp tab tussin dm 56

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goodsense nasal allergy spray 89granisetron hcl 25griseofulvin microsize 25griseofulvin ultramicrosize 25guanfacine hcl 30guanfacine hcl er 3GVOKE HYPOPEN 1-PACK 21GVOKE HYPOPEN 2-PACK 21GVOKE KIT 21GVOKE PFS 21halobetasol propionate 61haloperidol 40haloperidol decanoate 39haloperidol lactate 39, 40HAVRIX 104HEALTHYLAX 73hemorrhoidal 10hemorrhoidal max st/aloe 10HEPAGAM B 94heparin sodium (porcine) 15heparin sodium (porcine) pf 15HEPLISAV-B 104HIZENTRA 94hm chest congestion relief dm 56hm lice killing max st 63hm sterile alcohol prep 74hm stool softener 74hm urinary pain relief 71HUMALOG MIX 50/50 22HUMALOG MIX 50/50 KWIKPEN 22HUMALOG MIX 75/25 22HUMALOG MIX 75/25 KWIKPEN 22HUMULIN R U-500 (CONCENTRATED) 22HYCAMTIN 36hydralazine hcl 30hydrochlorothiazide 65hydrocodone-acetaminophen 7hydrocodone-homatropine 56hydrocodone-ibuprofen 7hydrocortisone 10, 55, 61hydrocortisone (perianal) 10hydrocortisone-acetic acid 94hydrocortisone-iodoquinol 59hydromet 56hydromorphone hcl 7, 8hydromorphone hcl pf 7hydroxychloroquine sulfate 31

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hydroxyprogesterone caproate 36, 96

hydroxyurea 34hydroxyzine hcl 11hydroxyzine pamoate 11hyoscyamine sulfate 101hyoscyamine sulfate er 101hyosyne 101HYPERHEP B 94HYPERRHO S/D 95ibandronate sodium 66IBRANCE 34ibuprofen 5ICAPS 85ICAPS LUTEIN & OMEGA-3 85icosapent ethyl 26imatinib mesylate 33IMBRUVICA 33imipramine hcl 20imiquimod 62INATAL GT 87INCRUSE ELLIPTA 14indapamide 65indomethacin 5indomethacin er 5INFINITY CONTROL 79INLYTA 36INSPIRACHAMBER/LARG E 82INSPIRACHAMBER/MEDIU M 82INSPIRACHAMBER/MOUT HPIECE 82INSPIRACHAMBER/SMAL L 82insulin glargine-yfgn 21INTELENCE 44INTROVALE 53INVEGA SUSTENNA 39INVEGA TRINZA 39ipratropium bromide 14, 89ipratropium-albuterol 13irbesartan 29irbesartan-hydrochlorothiazide 29ISENTRESS 43ISENTRESS HD 43isoniazid 32isosorbide dinitrate 11isosorbide mononitrate 11isosorbide mononitrate er 11isotretinoin 58

isradipine 48 itraconazole 25 ivermectin 10 i-vite 85 JAKAFI 35 JANTOVEN 15 JARDIANCE 23 JINTELI 68 JOLESSA 53 JULUCA 42 JUNEL 1.5/30 51 JUNEL 1/20 51 JUNEL FE 1.5/30 52 JUNEL FE 1/20 52 KALYDECO 99 KARIVA 50 KELNOR 1/35 52 ketoconazole 25, 62 ketorolac tromethamine 5, 92, 93 ketotifen fumarate 91 kimono 75 KLOR-CON M15 83 kp omeprazole magnesium 102 kp prenatal multivitamins 86 K-PHOS 83 K-PHOS NO 2 70 KURVELO 52 labetalol hcl 46 lactulose 73 lactulose encephalopathy 69 lamivudine 44, 45 lamivudine-zidovudine 42 lamotrigine 16 LANOXIN 48 lansoprazole 102 LARIN 1.5/30 52 LARIN 1/20 52 LARIN FE 1.5/30 52 LARIN FE 1/20 52 latanoprost 93 LEENA 54 leflunomide 6 LENVIMA (10 MG DAILY DOSE) 36 LENVIMA (12 MG DAILY DOSE) 36 LENVIMA (14 MG DAILY DOSE) 36 LENVIMA (18 MG DAILY DOSE) 36 LENVIMA (20 MG DAILY DOSE) 36

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LENVIMA (24 MG DAILY DOSE) 36 LENVIMA (4 MG DAILY DOSE) 36 LENVIMA (8 MG DAILY DOSE) 36 LESSINA 52 letrozole 34 leucovorin calcium 35 LEUKERAN 35 leuprolide acetate 35 levalbuterol tartrate 14 levetiracetam 17 levetiracetam er 17 levobunolol hcl 90 levocarnitine 66 levocetirizine dihydrochloride 26 levofloxacin 68, 91 LEVONEST 54 levonorgest-eth estrad 91-day 53 levonorgestrel 53 levonorgestrel-ethinyl estrad 51 LEVORA 0.15/30 (28) 52 levothyroxine sodium 100 LEVOXYL 101 LEXIVA 44 LIBERTY GLUCOSE CONTROL 79 LIBERTY GLUCOSE CONTROL MID 79 lice killing 63 lice killing maximum strength 64 lice treatment 64 lidocaine 63 lidocaine hcl 63, 84 lidocaine-prilocaine 64 LILETTA (52 MG) 54 linezolid 31 liothyronine sodium 100 lisinopril 28 lisinopril-hydrochlorothiazide 28 lithium carbonate 38 lithium carbonate er 38 loperamide hcl 24 lopinavir-ritonavir 42 loradamed 26 lorazepam 12 LORAZEPAM INTENSOL 12 LORYNA 52 losartan potassium 29 losartan potassium-hctz 29 lovastatin 27

LOW-OGESTREL 52 loxapine succinate 40 LUTERA 52 LYNPARZA 35 MAKENA 96 malathion 64 maraviroc 43 marlissa 51 MATULANE 34 MAVYRET 45 maxx 75 MEDISENSE GLUCOSE KETONE CONTR 79 MEDISENSE HI/MID/LOW CONTROL 79 medroxyprogesterone acetate

54, 96 mefloquine hcl 31 megestrol acetate 36 MEKINIST 34 melatonin 4 melatonin maximum strength 4 melatonin-pyridoxine 4 meloxicam 5 melphalan 35 memantine hcl 98 MENACTRA 103 MENEST 68 MENVEO 103 mercaptopurine 33 mesalamine 69 mesalamine er 69 MESNEX 36 metformin hcl 20 metformin hcl er 20 methadone hcl 8 methazolamide 65 methenamine hippurate 31 methenamine mandelate 31 methimazole 100 methocarbamol 88 methotrexate 33 methyldopa 30 methylphenidate hcl 4 methylphenidate hcl er 4 methylphenidate hcl er (cd) 4 methylphenidate hcl er (la) 4 methylprednisolone 55 metoclopramide hcl 69 metolazone 65 metoprolol succinate er 47 metoprolol tartrate 47

metoprolol-hydrochlorothiazide . 30 metronidazole ............... 30, 63, 104 mexiletine hcl 12 miconazole antifungal 62 MICRHOGAM ULTRA-FILTERED PLUS 95 MICRODOT CONTROL HIGH/LOW 79 MICROGESTIN 1.5/30 52 MICROGESTIN 1/20 52 MICROGESTIN FE 1.5/30 52 MICROGESTIN FE 1/20 52 midodrine hcl 104 minocycline hcl 100 minoxidil 30 mirtazapine 18 misoprostol 103 m-natal plus 86 mometasone furoate 61 MONO-LINYAH 52 montelukast sodium 14 morphine sulfate 8 morphine sulfate (concentrate) 8 morphine sulfate er 8 MOVANTIK 69 mucus relief dm cough 56 MULTAQ 12 multi prenatal 86 multi-vit/iron/fluoride 85 multivitamin/fluoride 85 multi-vitamin/fluoride 85 mupirocin 59 mycophenolate mofetil 84 MYGLUCOHEALTH CONTROL 79 MYLERAN 32 MYORISAN 58 NABI-HB 95 nabumetone 5 naloxone hcl 24 naltrexone hcl 24 naproxen 5 naratriptan hcl 82 NARCAN 24 NATACYN 92 nateglinide 23 NAYZILAM 16 NECON 1/35 (28) 52 neomycin sulfate 4 neomycin-bacitracin zn-polymyx 92 neomycin-polymyxin-dexameth 93

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neomycin-polymyxin-gramicidin 92 neomycin-polymyxin-hc 94 NEONATAL PLUS 87 NEONATAL VITAMIN 87 NEO-POLYCIN 92 nevirapine 44 nevirapine er 44 niacin er 105 nicardipine hcl 48 nicotine 99 nicotine polacrilex 98 nicotine step 1 98 nicotine step 2 99 nicotine step 3 99 NICOTROL 99 NICOTROL NS 99 nifedipine 48 nifedipine er 48 nifedipine er osmotic release 48 nilutamide 32 NITRO-BID 11 nitrofurantoin 31 nitrofurantoin macrocrystal 31 nitrofurantoin monohyd macro 31 nitroglycerin 11 NIVA-PLUS 87 nizatidine 102 NORDITROPIN FLEXPRO 66 norethindrone 54 norethindrone acetate 96 norgestimate-eth estradiol 51 norgestim-eth estrad triphasic 54 NORTREL 1/35 (21) 52 NORTREL 7/7/7 54 nortriptyline hcl 20 NORVIR 44 NOVA MAX PLUS GLU/KET CONTROL 79 NOVOLIN 70/30 22 NOVOLIN 70/30 FLEXPEN 22 NOVOLIN 70/30 FLEXPEN RELION 22 NOVOLIN 70/30 RELION 22 NOVOLIN N 22 NOVOLIN N FLEXPEN 22 NOVOLIN N FLEXPEN RELION 22 NOVOLIN N RELION 22 NOVOLIN R 22 NOVOLIN R FLEXPEN 22 NOVOLIN R FLEXPEN RELION 22

NOVOLIN R RELION 23 NOVOLOG MIX 70/30 23 NOVOLOG MIX 70/30 FLEXPEN 23 np thyroid 100 NULEV 101 NUVARING 53 nystatin 25, 59, 84 OCELLA 52 OCREVUS 98 octreotide acetate 67 OCUVITE EYE + MULTI 85 OCUVITE EYE HEALTH FORMULA 85 OCUVITE-LUTEIN 85 OFF DEEP WOODS 62 OFF DEEP WOODS DRY 62 OFF DEEP WOODS SPORTSMEN 62 OFF FAMILYCARE CLEAN FEEL 62 OFF SMOOTH & DRY 62 ofloxacin 91, 94 olanzapine 41 olanzapine-fluoxetine hcl 99 olopatadine hcl 91 omega-3-acid ethyl esters 26 omeprazole 102 omeprazole magnesium 102 OMEPRAZOLE+SYRSPEN D SF ALKA 103 OMNIFLEX DIAPHRAGM 75 ondansetron 25 ondansetron hcl 25 ONETOUCH ULTRA 64 ONETOUCH ULTRA 2 79 ONETOUCH ULTRA CONTROL 79 ONETOUCH ULTRA MINI 79 ONETOUCH VERIO 64, 79 ONETOUCH VERIO FLEX SYSTEM 79 ONETOUCH VERIO IQ SYSTEM 79 OPSUMIT 49 OPTICHAMBER DIAMOND .82 OPTICHAMBER DIAMOND-LG MASK 82 OPTICHAMBER DIAMOND-MD MASK 82 OPTICHAMBER DIAMOND-SM MASK 82

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OPTION 2 53 ORKAMBI 99 orphenadrine citrate er 88 ORSYTHIA 52 oscimin 101 oseltamivir phosphate 46 oxazepam 12 oxcarbazepine 17 oxycodone hcl 8 oxycodone-acetaminophen 9 oxymorphone hcl er 8 OZEMPIC (0.25 OR 0.5 MG/DOSE) 23 OZEMPIC (1 MG/DOSE) 23 pantoprazole sodium 102 paricalcitol 66 paromomycin sulfate 4 paroxetine hcl 19 pediatric electrolyte 83 peg 3350-kcl-na bicarb-nacl 73 peg-3350/electrolytes 73 PEGASYS 46 penicillamine 84 penicillin v potassium 95 pentazocine-naloxone hcl 9 pentoxifylline er 71 perindopril erbumine 28 permethrin 64 perphenazine 40 perphenazine-amitriptyline 98 pharbinex-dm 56 phenazopyridine hcl 71 phenelzine sulfate 18 phenobarbital 73 phenylephrine hcl 91 phenytoin 17 phenytoin sodium extended 17 PHILITH 53 phytonadione 105 pilocarpine hcl 85, 91 PIMTREA 50 pioglitazone hcl 24 PIRMELLA 1/35 53 PIRMELLA 7/7/7 54 piroxicam 5 PNEUMOVAX 23 103 pnv prenatal plus multivitamin 86 pnv tabs 29-1 86 POCKET CHAMBER 82 POCKET SPACER 82 POCKETCHEM EZ CONTROL 79

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............................. ................................................ podofilox 63POLYCIN 92polymyxin b-trimethoprim 92POLY-VI-SOL 86PORTIA-28 53pot & sod cit-cit ac 70potassium chloride crys er 83potassium chloride er 83potassium citrate er 70pramipexole dihydrochloride 38prasugrel hcl 72pravastatin sodium 27praziquantel 11prazosin hcl 30PRECISION GLUCOSE KETONE CONTR 79prednicarbate 61prednisolone 55prednisolone acetate 93prednisolone sodium phosphate

55, 93prednisone 56PREFEST 68pregabalin 17prenatabs fa 86PRENATABS RX 87prenatal 86prenatal (w/iron & fa) 86prenatal 19 86PRENATAL MULTIVITAMIN + DHA 88prenatal one daily 86prenatal plus 86prenatal plus/iron 86prenatal vitamin 87prenatal vitamin and mineral 87prenatal vitamin plus low iron 87prenatal vitamins 87PRENATAL/FOLIC ACID 87prenatal/iron 87PRENATAL-U 88preplus 87pretab 87PREVIFEM 53PREZISTA 44PRIFTIN 32primaquine phosphate 32primidone 17PRIVIGEN 95probenecid 71procainamide hcl 12prochlorperazine 41

prochlorperazine maleate 40 PROCTOFOAM HC 10 PROCTO-MED HC 10 PROCTO-PAK 10 PRODIGY CONTROL SOLUTION 79 progesterone 96 PROLIA 67 PROMACTA 72 promethazine hcl 26 promethazine vc/codeine 57 promethazine-codeine 57 promethazine-dm 57 propafenone hcl 12 propafenone hcl er 12 propranolol hcl 47 propranolol hcl er 47 propylthiouracil 100 PROVIDA OB 88 PULMOZYME 99 px prenatal multivitamins 87 pyrazinamide 32 pyridoxine hcl 105 pyrimethamine 32 qc calcium/minerals/vitamin d 83 qc lidocaine pain relief 63 qc medifin dm 56 qc prenatal 87 quetiapine fumarate 40 QUICKTEK CONTROL SOLUTION 80 quinapril hcl 29 quinapril-hydrochlorothiazide 28 quinidine sulfate 12 QUINTET CONTROL HIGH/NORMAL 80 QVAR REDIHALER 14 ra calcium 83 ra lice treatment 64 ra prenatal 87 ra prenatal formula 87 rabeprazole sodium 102 raloxifene hcl 67 ramelteon 73 ramipril 29 REALITY LATEX CONDOMS 75 REBIF 97 REBIF REBIDOSE 97 REBIF REBIDOSE TITRATION PACK 97 REBIF TITRATION PACK 97

RECLIPSEN 53 RECOMBIVAX HB 104 RECTIV 10 reeses pinworm medicine 11 REFRESH LIQUIGEL 90 REFRESH TEARS 90 REFUAH PLUS GLUCOSE CONTROL 80 repaglinide 23 REPATHA 27 REPATHA PUSHTRONEX SYSTEM 27 REPATHA SURECLICK 27 RETACRIT 72 REYATAZ 44 RHOGAM ULTRA-FILTERED PLUS 95 RHOPHYLAC 95 ribavirin 45 RIDAURA 5 rifabutin 32 rifampin 32 RIGHT STEP PRENATAL 88 RIGHTEST GC300 CONTROL 80 riluzole 90 rimantadine hcl 46 RISPERDAL CONSTA 39 risperidone 38, 39 ritonavir 43 rivastigmine 97 rivastigmine tartrate 97 rizatriptan benzoate 82 ropinirole hcl 38 ropinirole hcl er 38 rosuvastatin calcium 27 RYDAPT 34 RYDEX 57 salicylic acid 63 salsalate 6 SANDOSTATIN LAR DEPOT 67 SANTYL 62 SAVELLA 97 SAVELLA TITRATION PACK 97 SAWYER INSECT REPELLENT 63 sb lice killing max st 64 sb mucus relief dm 56 SB TAB TUSSIN DM 57

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SCALPICIN MAXIMUM STRENGTH 62 SEGLUROMET 23 selegiline hcl 37 selenium sulfide 60 SELZENTRY 43 se-natal 19 87 sertraline hcl 19 sevelamer carbonate 70 sildenafil citrate 49 silver sulfadiazine 60 simvastatin 27 sirolimus 84 sm chest congestion relief dm 57 sm ear drops 94 sm foaming antacid 10 sm lice killing max strength 64 sm lice treatment 64 sm melatonin 4 sm omega-3 fish oil 90 sm prenatal vitamins 87 sm stool softener 74 SMARTEST CONTROL MEDIUM 80 sod citrate-citric acid 70 sodium chloride 57 sodium fluoride 83 sofosbuvir-velpatasvir 45 SOLIRIS 71 SOLTAMOX 32 SOLU-CORTEF 56 SOLUS V2 CONTROL 80 SOMATULINE DEPOT 67 sorbitol 96 sotalol hcl 47 sotalol hcl (af) 47 spinosad 64 spironolactone 65 spironolactone-hctz 65 SPRINTEC 28 53 SPRYCEL 33 SRONYX 53 SSD (SILVER SULFADIAZINE) 60 stavudine 45 STEGLATRO 23 STIOLTO RESPIMAT 13 stool softener 74 stool softener laxative 74 STRIBILD 43 STRIVERDI RESPIMAT 14 sucralfate 102

SUDOGEST 90 sulfacetamide sodium 60, 93 sulfacetamide sodium (acne) 58 sulfacetamide-prednisolone 93 sulfadiazine 100 sulfamethoxazole-trimethoprim

30, 31 sulfasalazine 69 sulindac 5 sumatriptan 82 sumatriptan succinate 82, 83 sumatriptan succinate refill 82 sunitinib malate 34 supreme ii high/low control 76 sure comfort alcohol prep 75 SURESTEP GLUCOSE CONTROL 80 SURESTEP PRO HIGH GLUCOSE 80 SURESTEP PRO LOW GLUCOSE 80 SURESTEP PRO NORMAL GLUCOSE 80 SYEDA 53 SYMDEKO 99 SYMPROIC 70 SYMTUZA 43 syrpalta 96 SYSTANE 90 SYSTANE ICAPS AREDS2 85 TABLOID 33 tacrolimus 63, 84 tadalafil (pah) 49 TAFINLAR 33 TAI DOC CONTROL 80 tamoxifen citrate 32 tamsulosin hcl 70 TARON-C DHA 88 TASIGNA 33 tazarotene 59 telmisartan 29 temazepam 73 TEMIXYS 43 temozolomide 35 TENIVAC 101 tenofovir disoproxil fumarate 45 terazosin hcl 30 terbinafine hcl 25, 59 terconazole 104 testosterone 9, 10 testosterone cypionate 9 testosterone enanthate 9

.

theophylline 15 theophylline er 14, 15 thera-m 85 THERANATAL CORE NUTRITION 88 thioridazine hcl 41 thiothixene 42 thrivite rx 87 tiagabine hcl 17 TILIA FE 54 timolol maleate 47, 90, 91 TIVICAY 43 TIVICAY PD 43 tizanidine hcl 88 tobramycin 5, 91 tolnaftate 59 topiramate 17 TOPROL XL 47 toremifene citrate 32 torsemide 65 TRACLEER 49 tramadol hcl 8 tramadol-acetaminophen 9 trandolapril 29 TRELEGY ELLIPTA 13 TRELSTAR MIXJECT 35 tretinoin 36, 58 triamcinolone acetonide 61, 62, 89 triamterene-hctz 65 TRICARE 88 TRI-ESTARYLLA 55 trifluoperazine hcl 41 trifluridine 92 trihexyphenidyl hcl 37 TRI-LEGEST FE 55 TRI-LINYAH 55 trimethoprim 30 trinatal rx 1 87 TRINATE 88 TRINESSA (28) 55 TRI-PREVIFEM 55 TRI-SPRINTEC 55 TRIUMEQ 43 TRI-VI-SOL A/C/D 86 tri-vitamin/fluoride 85 TRIVORA (28) 55 tropicamide 91 true comfort alcohol prep pads 75 TRULICITY 23 TRUVADA 43 TUKYSA 33 tussin dm 57

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................................................ .................................... TYBOST 45

TYKERB 34 TYMLOS 67 ULTRATHON INSECT REPELLENT 8 63 UNISTRIP CONTROL 80 UNITHROID 101 urosex 88 ursodiol 68, 69 valacyclovir hcl 46 valganciclovir hcl 45 valproic acid 18 valsartan 29 valsartan-hydrochlorothiazide 29 VALTOCO 10 MG DOSE 16 VALTOCO 15 MG DOSE 16 VALTOCO 20 MG DOSE 16 VALTOCO 5 MG DOSE 16 VAQTA 104 varenicline tartrate 99 VARIVAX 104 v-c forte 85 VELIVET 55 VEMLIDY 45 VENCLEXTA 33 VENCLEXTA STARTING PACK 33 venlafaxine hcl 19 venlafaxine hcl er 19 verapamil hcl 48 verapamil hcl er 48 VERZENIO 34 VIC-FORTE 85 VINATE II 88 VINATE ONE 88 VIOKACE 64 viorele 50 VIRACEPT 44 VIREAD 45 VISCO-3 89 vitamin d (ergocalciferol) 105 vitamin d3 105 vitamins acd-fluoride 85 VIVITROL 24 VORTEX VALVED HOLDING CHAMBER 82 VOTRIENT 34 VYFEMLA 53 warfarin sodium 15 WIDE-SEAL DIAPHRAGM 60 75

WIDE-SEAL DIAPHRAGM 65 75 WIDE-SEAL DIAPHRAGM 70 75 WIDE-SEAL DIAPHRAGM 75 75 WIDE-SEAL DIAPHRAGM 80 75 WIDE-SEAL DIAPHRAGM 85 75 WIDE-SEAL DIAPHRAGM 90 75 WIDE-SEAL DIAPHRAGM 95 75 XARELTO 15 XARELTO STARTER PACK 15 XOLAIR 13 XULANE 53 YUVAFEM 104 zafirlukast 14 zaleplon 73 ZARXIO 72 ZEASORB-AF 62 ZENATANE 58 ZENPEP 64 ZENZEDI 3 zidovudine 45 ZIEXTENZO 72 ziprasidone hcl 38 ZOLADEX 35 zolpidem tartrate 73 zonisamide 17 ZOVIA 1/35E (28) 53

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Documents

Aetna Better Health Kids Formulary Guide