Aetna Better Health Of Virginia Formulary Guide April 2017 · What is the Aetna Better Health of Virginia Formulary? This is a drug list created by Aetna Better Health of Virginia

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health Of Virginia

Formulary Guide April 2017

http://www.aetnabetterhealth.com/Virginia

http://www.aetnabetterhealth.com/Virginia

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What is the Aetna Better Health of Virginia Formulary?

This is a drug list created by Aetna Better Health of Virginia. The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy.

Can the Plan’s Drug List change?

The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers 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 Plan’s 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: shows brand drug for the generic; brand drugs are not covered if generic equivalent is available.

Column #3: tells you if drug has a need for prior authorization or other restrictions

Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug.

What are generic drugs?

The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).

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

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

Are there Medication Copays?

Refer to member handbook for copay information.

Updated: 04/2017

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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, the plan 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, the plan provides 60 pills in 30 days for some drugs.

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

After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan 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.

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

First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:

Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process.

Updated: 04/2017

Aetna Better Health Virginia

Table of Contents

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................3

*AMINOGLYCOSIDES*......................................................................................................................................... 7*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................................ 7*ANALGESICS - NONNARCOTIC*.......................................................................................................................9*ANALGESICS - OPIOID*.................................................................................................................................... 10*ANDROGENS-ANABOLIC*............................................................................................................................... 21*ANORECTAL AGENTS*.....................................................................................................................................21*ANTHELMINTICS*............................................................................................................................................. 22*ANTIANGINAL AGENTS*................................................................................................................................. 22*ANTIANXIETY AGENTS*..................................................................................................................................23*ANTIARRHYTHMICS*....................................................................................................................................... 25*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 25*ANTICOAGULANTS*......................................................................................................................................... 28*ANTICONVULSANTS*.......................................................................................................................................29*ANTIDEPRESSANTS*.........................................................................................................................................31*ANTIDIABETICS*............................................................................................................................................... 33*ANTIDIARRHEALS*...........................................................................................................................................37*ANTIDOTES*....................................................................................................................................................... 37*ANTIEMETICS*................................................................................................................................................... 37*ANTIFUNGALS*..................................................................................................................................................38*ANTIHISTAMINES*............................................................................................................................................ 38*ANTIHYPERLIPIDEMICS*.................................................................................................................................39*ANTIHYPERTENSIVES*.................................................................................................................................... 40*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 43*ANTIMALARIALS*.............................................................................................................................................44*ANTIMYASTHENIC AGENTS*......................................................................................................................... 44*ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 44*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 44*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................45*ANTI-OBESITY AGENT COMBINATIONS**..................................................................................................47*ANTIPARKINSON AGENTS*.............................................................................................................................47*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 48*ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 50*ANTISEPTICS & DISINFECTANTS*.................................................................................................................50*ANTIVIRALS*......................................................................................................................................................51*ASSORTED CLASSES*....................................................................................................................................... 55*BETA BLOCKERS*............................................................................................................................................. 56*CALCIUM CHANNEL BLOCKERS*................................................................................................................. 57*CARDIOTONICS*................................................................................................................................................ 59*CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 59*CEPHALOSPORINS*...........................................................................................................................................60*CHEMICALS*.......................................................................................................................................................61*CONTRACEPTIVES*...........................................................................................................................................61*CORTICOSTEROIDS*......................................................................................................................................... 68

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*COUGH/COLD/ALLERGY*................................................................................................................................69

*DERMATOLOGICALS*...................................................................................................................................... 70*DIAGNOSTIC PRODUCTS*................................................................................................................................78*DIGESTIVE AIDS*...............................................................................................................................................78*DIURETICS*.........................................................................................................................................................78*ENDOCRINE AND METABOLIC AGENTS - MISC.*......................................................................................79*ESTROGENS*.......................................................................................................................................................81*FLUOROQUINOLONES*.................................................................................................................................... 82*GASTROINTESTINAL AGENTS - MISC.*........................................................................................................82*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................................... 83*GOUT AGENTS*..................................................................................................................................................84*HEMATOLOGICAL AGENTS - MISC.*............................................................................................................ 85*HEMATOPOIETIC AGENTS*.............................................................................................................................85*HEPATITIS C AGENT - COMBINATIONS***................................................................................................. 86*HYPNOTICS*....................................................................................................................................................... 86*LAXATIVES*....................................................................................................................................................... 87*MACROLIDES*....................................................................................................................................................88*MEDICAL DEVICES*..........................................................................................................................................89*MIGRAINE PRODUCTS*....................................................................................................................................93*MINERALS & ELECTROLYTES*......................................................................................................................93*MOUTH/THROAT/DENTAL AGENTS*............................................................................................................96*MULTIVITAMINS*..............................................................................................................................................97*MUSCULOSKELETAL THERAPY AGENTS*..................................................................................................99*NASAL AGENTS - SYSTEMIC AND TOPICAL*........................................................................................... 100*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***........................................... 100*NEUROMUSCULAR AGENTS*....................................................................................................................... 100*OPHTHALMIC AGENTS*.................................................................................................................................101*OTIC AGENTS*..................................................................................................................................................104*PASSIVE IMMUNIZING AGENTS*.................................................................................................................105*PENICILLINS*....................................................................................................................................................105*PHARMACEUTICAL ADJUVANTS*.............................................................................................................. 106*POTASSIUM REMOVING AGENTS***..........................................................................................................106*PROGESTINS*....................................................................................................................................................107*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................107*RESPIRATORY AGENTS - MISC.*..................................................................................................................109*SEROTONIN MODULATORS***.................................................................................................................... 109*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***................................... 110*SULFONAMIDES*.............................................................................................................................................110*TETRACYCLINES*........................................................................................................................................... 110*THYROID AGENTS*......................................................................................................................................... 110*ULCER DRUGS*................................................................................................................................................ 111*URINARY ANTI-INFECTIVES*.......................................................................................................................113*URINARY ANTISPASMODICS*......................................................................................................................113*VAGINAL PRODUCTS*....................................................................................................................................114*VASOPRESSORS*............................................................................................................................................. 115*VITAMINS*........................................................................................................................................................ 115

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Aetna Better Health Virginia

CURRENT AS OF 4/2017

Formulary Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Amphetamine Mixtures***

amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 5 mg

Adderall XR

PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days)

amphetamine-dextroamphet er oral capsule extended release 24 hour 30 mg Adderall XR

PA; QLL (30EA per 30 days for members under the age of 12, 60EA per 30 days for members age 12 and older); Additional prior authorization may be required if prescribed with buprenorphine containing products.

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg Adderall


amphetamine-dextroamphetamine oral tablet 30 mg Adderall


*Amphetamines***

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg Dexedrine


dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg Dexedrine


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Formulary Drug Name Reference Restrictions

dextroamphetamine sulfate oral solution 5 mg/5ml ProCentra

PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (1800 ML per 30 days)

dextroamphetamine sulfate oral tablet 10 mg, 5 mg Zenzedi


*Analeptics*** caffeine citrate oral solution 20 mg/ml, 60 mg/3ml caffeine citrated powder

*Anorexiant Combinations*** QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG

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

*Anorexiants Non-Amphetamine***

benzphetamine hcl oral tablet 25 mg Regimex PA; QLL (90 EA per 30 days); AL (Min 12 Years)

benzphetamine hcl oral tablet 50 mg Didrex PA; QLL (90 EA per 30 days); AL (Min 12 Years)

diethylpropion hcl er oral tablet extended release 24 hour 75 mg


diethylpropion hcl oral tablet 25 mg PA; QLL (90 EA per 30 days); AL (Min 17 Years)

phendimetrazine tartrate er oral capsule extended release 24 hour 105 mg


phendimetrazine tartrate oral tablet 35 mg PA; QLL (90 EA per 30 days); AL (Min 17 Years)

phentermine hcl oral capsule 15 mg PA; QLL (60 EA per 30 days); AL (Min 16 Years)

phentermine hcl oral capsule 30 mg PA; QLL (30 EA per 30 days); AL (Min 16 Years)

phentermine hcl oral capsule 37.5 mg Adipex-P PA; QLL (30 EA per 30 days); AL (Min 16 Years)

phentermine hcl oral tablet 37.5 mg Adipex-P PA; QLL (30 EA per 30 days); AL (Min 16 Years)

DIDREX ORAL TABLET 50 MG Benzphetamine HCl PA; QLL (90 EA per 30 days); AL (Min 12 Years)

REGIMEX ORAL TABLET 25 MG Benzphetamine HCl PA; QLL (90 EA per 30 days); AL (Min 12 Years)

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Formulary Drug Name Reference Restrictions *Lipase Inhibitors***

ALLI ORAL CAPSULE 60 MG PA; OTC; QLL (180 EA per 30 days); AL (Min 12 Years)

*Serotonin 2C Receptor Agonists***

BELVIQ ORAL TABLET 10 MG PA; QLL (60 EA per 30 days); AL (Min 18 Years)

*Stimulants - Misc.***

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg

Focalin XR


dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg Focalin XR PA; QLL (30 EA per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg Focalin


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Metadate CD


methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg Ritalin LA


methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg Ritalin LA


methylphenidate hcl er oral tablet extended release 10 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Concerta


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methylphenidate hcl er oral tablet extended release 20 mg Metadate ER


methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg


methylphenidate hcl er oral tablet extended release 24 hour 36 mg


methylphenidate hcl er oral tablet extended release 36 mg Concerta


methylphenidate hcl oral solution 10 mg/5ml Methylin

PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (900 mL per 30 days)

methylphenidate hcl oral solution 5 mg/5ml Methylin

PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (900 ML per 30 days)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Ritalin


methylphenidate hcl oral tablet chewable 10 mg Methylin


methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg Methylin


modafinil oral tablet 100 mg, 200 mg Provigil PA; QLL (30 EA per 30 days)

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Formulary Drug Name Reference Restrictions *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg tobramycin inhalation nebulization solution 300 mg/5ml Tobi PA; QLL (280 mL Max Qty Per

Fill Retail)

*ANALGESICS - ANTI-INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

PA; QLL (1 Kit per 28 days)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PA; QLL (1 Kit per 28 days)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML

PA; QLL (2 Syringes per 28 days)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML PA; QLL (1 Kit per 28 days)

*Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML


HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PA; QLL (1 Kit per 28 days)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML PA; QLL (1 Kit per 28 days)

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Formulary Drug Name Reference Restrictions *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg CeleBREX ST; QLL (30 EA per 30 days)

*Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg 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 fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg

ketorolac tromethamine oral tablet 10 mg Max Limit (Max 2 fills/90 days.); QLL (20 Tablets per 30 days); AL (Min 16 Years)

meclofenamate sodium oral capsule 100 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg Mobic QLL (30 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg QLL (120 EA per 30 days) naproxen dr oral tablet delayed release 375 mg, 500 mg EC-Naprosyn

naproxen oral suspension 125 mg/5ml Naprosyn naproxen oral tablet 250 mg, 500 mg Naprosyn naproxen oral tablet 375 mg naproxen sodium oral tablet 275 mg oxaprozin oral tablet 600 mg Daypro QLL (90 EA per 30 days) piroxicam oral capsule 10 mg, 20 mg Feldene

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Formulary Drug Name Reference Restrictions sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg QLL (90 EA per 30 days) tolmetin sodium oral tablet 200 mg, 600 mg QLL (90 EA per 30 days)

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg Arava QLL (30 EA per 30 days)

*Selective Costimulation Modulators*** ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG PA; QLL (4 Vials per 30 days)

*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

PA; QLL (204 Mgs per 28 days)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

PA; QLL (204 Mgs per 28 days)

*ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 mg Tencon QLL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-300 -40 mg Fioricet

Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325 -40 mg Esgic


butalbital-apap-caffeine oral tablet 50-325-40 mg Esgic


butalbital-aspirin-caffeine oral capsule 50 -325-40 mg Fiorinal


marten-tab oral tablet 50-325 mg Tencon

CAPACET ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine


ESGIC ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days)

TENCON ORAL TABLET 50-325 MG Marten-Tab

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ZEBUTAL ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine


*Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate oral liquid 500 mg/5ml

*Salicylates*** diflunisal oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg Disalcid

*ANALGESICS - OPIOID* *Codeine Combinations***

acetaminophen-codeine #2 oral tablet 300-15 mg

Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg Tylenol with Codeine #3


acetaminophen-codeine #4 oral tablet 300-60 mg Tylenol with Codeine #4


acetaminophen-codeine oral solution 120-12 mg/5ml

Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (4500 ML per 30 days)

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acetaminophen-codeine oral tablet 300-15 mg


acetaminophen-codeine oral tablet 300-60 mg Tylenol with Codeine #4


butalbital-apap-caff-cod oral capsule 50-300 -40-30 mg Fioricet/Codeine

Max Limit (Max 240 tabs or caps/year.); Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days)

butalbital-apap-caff-cod oral capsule 50-325 -40-30 mg


butalbital-asa-caff-codeine oral capsule 50 -325-40-30 mg Ascomp-Codeine


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ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG Butalbital-ASA-Caff-Codeine


*Hydrocodone Combinations***

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

Hycet


hydrocodone-acetaminophen oral tablet 10 -325 mg Lortab


hydrocodone-acetaminophen oral tablet 2.5 -325 mg Verdrocet


hydrocodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg Lortab


hydrocodone-ibuprofen oral tablet 7.5-200 mg


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LORCET HD ORAL TABLET 10-325 MG Hydrocodone-Acetaminophen


LORCET ORAL TABLET 5-325 MG Hydrocodone-Acetaminophen


LORCET PLUS ORAL TABLET 7.5-325 MG Hydrocodone-Acetaminophen


LORTAB ORAL TABLET 10-325 MG Hydrocodone-Acetaminophen


LORTAB ORAL TABLET 5-325 MG, 7.5 -325 MG Hydrocodone-Acetaminophen


*Opioid Agonists***

codeine sulfate oral tablet 15 mg


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fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100

PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days)









hydromorphone hcl oral tablet 2 mg Dilaudid




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hydromorphone hcl rectal suppository 3 mg


methadone hcl oral concentrate 10 mg/ml Methadose PA; QLL (90 ML per 30 days)

methadone hcl oral solution 10 mg/5ml

PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (450 ML per 30 days); AL (Max 1 Years)

methadone hcl oral solution 5 mg/5ml

PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days); AL (Max 1 Years)

methadone hcl oral tablet 10 mg Dolophine


methadone hcl oral tablet 5 mg Dolophine


methadone hcl oral tablet soluble 40 mg Methadose PA; QLL (22 EA per 30 days)

morphine sulfate (concentrate) oral solution 100 mg/5ml


morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg Kadian


15


morphine sulfate er oral capsule extended release 24 hour 100 mg, 50 mg, 60 mg, 80 mg Kadian


morphine sulfate er oral capsule extended release 24 hour 30 mg Kadian


morphine sulfate er oral tablet extended release 100 mg, 200 mg MS Contin


morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg MS Contin


morphine sulfate oral solution 10 mg/5ml


morphine sulfate oral solution 20 mg/5ml


morphine sulfate oral tablet 15 mg


morphine sulfate oral tablet 30 mg


16


morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.

oxycodone hcl oral capsule 5 mg


oxycodone hcl oral concentrate 100 mg/5ml


oxycodone hcl oral solution 5 mg/5ml


oxycodone hcl oral tablet 10 mg


oxycodone hcl oral tablet 15 mg Roxicodone


oxycodone hcl oral tablet 20 mg


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oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg


oxymorphone hcl oral tablet 10 mg Opana


oxymorphone hcl oral tablet 5 mg Opana


tramadol hcl oral tablet 50 mg Ultram

Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years)

METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Methadone HCl PA; QLL (90 ML per 30 days)

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Formulary Drug Name Reference Restrictions *Opioid Combinations***

oxycodone-acetaminophen oral tablet 10-325 mg Percocet


oxycodone-acetaminophen oral tablet 2.5-325 mg Percocet


oxycodone-acetaminophen oral tablet 5-325 mg Endocet


oxycodone-acetaminophen oral tablet 7.5-325 mg Endocet


oxycodone-aspirin oral tablet 4.8355-325 mg


ENDOCET ORAL TABLET 10-325 MG Oxycodone-Acetaminophen


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ENDOCET ORAL TABLET 2.5-325 MG, 5-325 MG Oxycodone-Acetaminophen


ENDOCET ORAL TABLET 7.5-325 MG Oxycodone-Acetaminophen


*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual 2 mg

PA; Two 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (90 EA per 30 days)

buprenorphine hcl sublingual tablet sublingual 8 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


butorphanol tartrate nasal solution 10 mg/ml QLL (1 Bottle per 30 days)

pentazocine-naloxone hcl oral tablet 50-0.5 mg


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BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 5 MCG/HR, 7.5 MCG/HR


BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR, 20 MCG/HR


*Tramadol Combinations***

tramadol-acetaminophen oral tablet 37.5-325 mg Ultracet

Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years)

*ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg methyltestosterone oral capsule 10 mg Android testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml Depo-Testosterone PA

testosterone enanthate intramuscular solution 200 mg/ml PA

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

testosterone transdermal gel 12.5 mg/act (1%) Vogelxo Pump PA; QLL (300 GM per 30 days) testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel PA; QLL (30 pak per 30 days)

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

*ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 mg/60ml Cortenema COLOCORT RECTAL ENEMA 100 MG/60ML Hydrocortisone

CORTIFOAM RECTAL FOAM 10 %

*Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % PA

*Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream 3 -0.5 % LidaZone HC

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Formulary Drug Name Reference Restrictions lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 % LIDAZONE HC RECTAL CREAM 3-0.5 % Lidocaine-Hydrocortisone Ace

PROCTOFOAM HC RECTAL FOAM 1-1 %

*Rectal Steroids*** hydrocortisone acetate rectal suppository 30 mg Proctocort

HEMMOREX-HC RECTAL SUPPOSITORY 30 MG Hydrocortisone Acetate

PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone

PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone

*ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 mg Stromectol reeses pinworm medicine oral tablet 180 mg OTC ALBENZA ORAL TABLET 200 MG

*ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 mg 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 QLL (60 EA per 30 days)

isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg QLL (30 EA per 30 days)

isosorbide mononitrate oral tablet 10 mg, 20 mg nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg Nitro-Time

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Nitrostat

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

22

Formulary Drug Name Reference Restrictions nitroglycerin transdermal patch 24 hour 0.2 mg/hr, 0.6 mg/hr Minitran

nitroglycerin translingual solution 0.4 mg/spray Nitrolingual QLL (12 Grams per 30 days)

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

Nitroglycerin

NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG

Nitroglycerin ER

*ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 5 mg, 7.5 mg QLL (90 EA per 30 days) buspirone hcl oral tablet 15 mg QLL (120 EA per 30 days) hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg Vistaril

meprobamate oral tablet 200 mg, 400 mg

*Benzodiazepines***

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR

Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (60 EA per 30 days); AL (Min 18 Years)

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Xanax


alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg


23


alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR


chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg


clorazepate dipotassium oral tablet 15 mg, 3.75 mg


clorazepate dipotassium oral tablet 7.5 mg Tranxene-T


diazepam oral solution 1 mg/ml

Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (300 ML per 30 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg Valium

Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (120 EA per 30 days)

lorazepam oral concentrate 2 mg/ml LORazepam Intensol


lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Ativan


24


oxazepam oral capsule 10 mg, 15 mg, 30 mg


ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (180 ML per 30 days); AL (Min 18 Years)

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam


*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg Norpace

quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Pacerone

MULTAQ ORAL TABLET 400 MG PA; QLL (60 EA per 30 days) PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG Amiodarone HCl

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution 0.5 -2.5 (3) mg/3ml QLL (180 Nebules per 30 days)

25

Formulary Drug Name Reference Restrictions ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

QLL (1 inhaler per 30 days)

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

QLL (1 EA per 30 days)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT QLL (2 Inhaler per 30 days)

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT QLL (1 Inhaler per 30 days)

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT ST; QLL (1 ea per 30 days)

*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml

*Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg VoSpire ER

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5% QLL (360 Nebules per 30 days)

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml

ST; QLL (360 Nebules per 30 days)

albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg terbutaline sulfate oral tablet 2.5 mg, 5 mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QLL (1 Inhaler per 30 days)

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

QLL (2 Inhaler per 30 days)

*Bronchodilators -Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT QLL (2 Inhaler per 30 days)

26

Formulary Drug Name Reference Restrictions INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

QLL (30 EA per 30 days)

*Leukotriene Receptor Antagonists***

montelukast sodium oral packet 4 mg Singulair PA; QLL (30 EA per 30 days); AL (Max 2 Years)

montelukast sodium oral tablet 10 mg Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4 mg, 5 mg Singulair QLL (30 EA per 30 days)

zafirlukast oral tablet 10 mg Accolate ST; QLL (60 EA per 30 days) zafirlukast oral tablet 20 mg Accolate QLL (60 EA per 30 days)

*Steroid Inhalants*** budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml Pulmicort QLL (120 ML per 30 days); AL

(Max 5 Years) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

QLL (60 Blisters per 30 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

QLL (1 Inhaler per 30 days)

PULMICORT INHALATION SUSPENSION 1 MG/2ML Budesonide QLL (120 ML per 30 days); AL

(Max 5 Years) QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT QLL (1 Inhaler per 30 days)

QVAR INHALATION AEROSOL SOLUTION 80 MCG/ACT QLL (2 Inhaler per 30 days)

*Xanthines*** theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg Theochron

theophylline er oral tablet extended release 12 hour 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Theophylline ER

27

Formulary Drug Name Reference Restrictions *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 5 mg, 7.5 mg Jantoven

warfarin sodium oral tablet 3 mg, 4 mg, 6 mg Coumadin 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*** XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (30 EA per 30 days)

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

*Heparins And Heparinoid-Like Agents*** 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***

enoxaparin sodium injection solution 300 mg/3ml Lovenox

Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization)

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


FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML


*Synthetic Heparinoid-Like Agents***

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Arixtra


28

Formulary Drug Name Reference Restrictions *ANTICONVULSANTS* *Anticonvulsants -Benzodiazepines***

clonazepam oral tablet 0.5 mg, 1 mg KlonoPIN


clonazepam oral tablet 2 mg KlonoPIN


clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet dispersible 2 mg


diazepam rectal gel 10 mg, 20 mg Diastat AcuDial QLL (2 EA per 30 days) diazepam rectal gel 2.5 mg Diastat Pediatric QLL (2 EA per 30 days)

*Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg Carbatrol QLL (120 EA per 30 days)

carbamazepine er oral tablet extended release 12 hour 100 mg TEGretol-XR QLL (300 EA per 30 days); AL

(Min 6 Years) carbamazepine er oral tablet extended release 12 hour 200 mg TEGretol-XR QLL (150 EA per 30 days); AL

(Min 6 Years) carbamazepine er oral tablet extended release 12 hour 400 mg TEGretol-XR QLL (2.5 EA per 1 day); AL

(Min 6 Years) 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 (180 EA per 30 days)

gabapentin oral solution 250 mg/5ml Neurontin gabapentin oral tablet 600 mg Neurontin QLL (180 EA per 30 days) gabapentin oral tablet 800 mg Neurontin QLL (135 EA per 30 days) lamotrigine oral tablet 100 mg, 200 mg LaMICtal QLL (60 EA per 30 days)

29

Formulary Drug Name Reference Restrictions lamotrigine oral tablet 150 mg LaMICtal QLL (90 EA per 30 days) lamotrigine oral tablet 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 5 mg LaMICtal QLL (240 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 500 mg Keppra XR QLL (180 EA per 30 days)

levetiracetam er oral tablet extended release 24 hour 750 mg Keppra XR QLL (120 EA per 30 days)

levetiracetam oral solution 100 mg/ml Keppra levetiracetam oral tablet 1000 mg Keppra QLL (90 EA per 30 days) levetiracetam oral tablet 250 mg Keppra QLL (60 EA per 30 days) levetiracetam oral tablet 500 mg Keppra QLL (180 EA per 30 days) levetiracetam oral tablet 750 mg Keppra QLL (120 EA per 30 days) oxcarbazepine oral suspension 300 mg/5ml Trileptal oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Trileptal

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 Topamax QLL (90 EA per 30 days) topiramate oral tablet 200 mg Topamax QLL (60 EA per 30 days) topiramate oral tablet 25 mg, 50 mg Topamax QLL (120 EA per 30 days) zonisamide oral capsule 100 mg, 25 mg Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 mg QLL (180 EA per 30 days) EPITOL ORAL TABLET 200 MG CarBAMazepine LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

ST

LYRICA ORAL SOLUTION 20 MG/ML ST

*Carbamates*** felbamate oral suspension 600 mg/5ml Felbatol felbamate oral tablet 400 mg, 600 mg Felbatol

*Gaba Modulators*** tiagabine hcl oral tablet 2 mg Gabitril QLL (30 EA per 30 days) tiagabine hcl oral tablet 4 mg Gabitril QLL (120 EA per 30 days) GABITRIL ORAL TABLET 12 MG QLL (120 EA per 30 days) GABITRIL ORAL TABLET 16 MG QLL (90 EA per 30 days)

*Hydantoins*** phenytoin oral suspension 125 mg/5ml Dilantin phenytoin oral tablet chewable 50 mg Phenytoin Infatabs

30

Formulary Drug Name Reference Restrictions phenytoin sodium extended oral capsule 100 mg Dilantin

phenytoin sodium extended oral capsule 200 mg, 300 mg Phenytek

DILANTIN ORAL CAPSULE 30 MG PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG Phenytoin

*Succinimides*** ethosuximide oral capsule 250 mg Zarontin ethosuximide oral solution 250 mg/5ml Zarontin CELONTIN ORAL CAPSULE 300 MG

*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg Depakote ER

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

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

*ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** 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 Remeron 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.*** 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, 200 mg Wellbutrin SR QLL (60 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)

31

Formulary Drug Name Reference Restrictions maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

*Modified Cyclics*** trazodone hcl oral tablet 100 mg, 150 mg, 50 mg

*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg Nardil tranylcypromine sulfate oral tablet 10 mg Parnate MARPLAN ORAL TABLET 10 MG

*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml QLL (600 ML per 30 days)

citalopram hydrobromide oral tablet 10 mg, 20 mg CeleXA QLL (45 EA per 30 days)

citalopram hydrobromide oral tablet 40 mg CeleXA QLL (30 EA per 30 days) escitalopram oxalate oral solution 5 mg/5ml Lexapro QLL (600 ML per 30 days) 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) fluoxetine hcl oral tablet 10 mg QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 100 mg QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 mg, 50 mg QLL (30 EA per 30 days) paroxetine hcl oral tablet 10 mg, 20 mg Paxil QLL (30 EA per 30 days) paroxetine hcl oral tablet 30 mg Paxil QLL (60 EA per 30 days) paroxetine hcl oral tablet 40 mg Paxil QLL (45 EA per 30 days) sertraline hcl oral concentrate 20 mg/ml Zoloft QLL (300 ML per 30 days) sertraline hcl oral tablet 100 mg Zoloft QLL (75 EA per 30 days) sertraline hcl oral tablet 25 mg, 50 mg Zoloft QLL (45 EA per 30 days)

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

duloxetine hcl oral capsule delayed release particles 40 mg QLL (60 EA per 30 days)

32

Formulary Drug Name Reference Restrictions 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 (30 EA per 30 days)

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

*Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 50 mg, 75 mg amitriptyline hcl oral tablet 25 mg Elavil amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg desipramine hcl oral tablet 10 mg, 25 mg Norpramin desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tofranil

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg Pamelor

nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg

*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg Precose QLL (90 EA per 30 days)

*Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg Glucophage XR QLL (120 EA per 30 days)

metformin hcl er oral tablet extended release 24 hour 750 mg Glucophage XR QLL (60 EA per 30 days)

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Glucophage

*Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

QLL (1 Unit Max Qty Per Fill Retail)

GLUCAGON EMERGENCY INJECTION KIT 1 MG

QLL (1 Unit Max Qty Per Fill Retail)

33

Formulary Drug Name Reference Restrictions *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg Nesina QLL (30 EA per 30 Days)

TRADJENTA ORAL TABLET 5 MG ST; QLL (30 EA per 30 days)

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg Kazano QLL (60 EA per 30 Days)

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG ST; QLL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG

ST; QLL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG

ST; QLL (30 EA per 30 days)

*Dpp-4 Inhibitor-Thiazolidinedione Combinations*** 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 QLL (30 EA per 30 Days)

*Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

AL (Max 18 Years)

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

AL (Max 18 Years)

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

AL (Max 18 Years)

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

34

Formulary Drug Name Reference Restrictions HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

OTC; AL (Max 18 Years)

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

OTC; AL (Max 18 Years)

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

AL (Max 18 Years)

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

AL (Max 18 Years)

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

AL (Max 18 Years)

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG ST; QLL (4 EA per 28 days)

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

ST; QLL (4 ea per 28 days)

*Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg Starlix QLL (90 EA per 30 days) repaglinide oral tablet 0.5 mg QLL (120 EA per 30 days) repaglinide oral tablet 1 mg Prandin QLL (120 EA per 30 days) repaglinide oral tablet 2 mg Prandin QLL (240 EA per 30 days)

*Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

35

Formulary Drug Name Reference Restrictions *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; QLL (30 EA per 30 days)

*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg QLL (60 EA per 30 days)

glipizide-metformin hcl oral tablet 5-500 mg QLL (120 EA per 30 days) glyburide-metformin oral tablet 1.25-250 mg QLL (60 EA per 30 days) glyburide-metformin oral tablet 2.5-500 mg Glucovance QLL (60 EA per 30 days) glyburide-metformin oral tablet 5-500 mg Glucovance QLL (120 EA per 30 days)

*Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg Amaryl QLL (30 EA per 30 days) glimepiride oral tablet 4 mg Amaryl QLL (60 EA per 30 days) glipizide er oral tablet extended release 24 hour 10 mg Glucotrol XL QLL (60 EA per 30 days)

glipizide er oral tablet extended release 24 hour 2.5 mg, 5 mg Glucotrol XL QLL (30 EA per 30 days)

glipizide oral tablet 10 mg, 5 mg Glucotrol glipizide xl oral tablet extended release 24 hour 10 mg Glucotrol XL QLL (60 EA per 30 days)

glipizide xl oral tablet extended release 24 hour 2.5 mg, 5 mg Glucotrol XL QLL (30 EA per 30 days)

glyburide micronized oral tablet 1.5 mg, 3 mg Glynase QLL (30 EA per 30 days) glyburide micronized oral tablet 6 mg Glynase QLL (60 EA per 30 days) glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg

*Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg Duetact QLL (30 EA per 30 days)

*Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15 -500 mg, 15-850 mg Actoplus Met QLL (90 EA per 30 days)

36

Formulary Drug Name Reference Restrictions *Thiazolidinediones*** pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Actos QLL (30 EA per 30 days)

AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 EA per 30 days)

*ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg Lomotil

lofene oral tablet 2.5-0.025 mg Lomotil loperamide hcl oral capsule 2 mg Imodium A-D

*ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG

*Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 mg QLL (8 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml Zofran QLL (1 ea per 30 days) ondansetron hcl oral tablet 24 mg QLL (1 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg Zofran QLL (30 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg Zofran ODT QLL (30 EA per 30 days)

*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg meclizine hcl oral tablet 25 mg Wal-Dram II trimethobenzamide hcl oral capsule 300 mg Tigan

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG Aprepitant QLL (3 EA per 30 days)

37

Formulary Drug Name Reference Restrictions *ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Gris-PEG

nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg LamISIL QLL (30 EA per 30 days)

*Imidazoles*** ketoconazole oral tablet 200 mg QLL (30 EA per 30 days)

*Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml Diflucan

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Diflucan QLL (60 EA per 30 days)

itraconazole oral capsule 100 mg Sporanox QLL (120 EA per 30 days)

*ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 mg

*Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 mg Arbinoxa clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral elixir 12.5 mg/5ml QLL (120 mL per 30 days) ARBINOXA ORAL TABLET 4 MG Carbinoxamine Maleate

*Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 mg/ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days) cetirizine hcl oral syrup 1 mg/ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days)

*Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 mg/5ml QLL (180 mL per 30 days) promethazine hcl oral syrup 6.25 mg/5ml QLL (180 mL per 30 days) promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 12.5 mg Phenadoz promethazine hcl rectal suppository 25 mg, 50 mg Phenergan

38

Formulary Drug Name Reference Restrictions PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Promethazine HCl

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl

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

*ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL PACKET 4 GM Cholestyramine Light PREVALITE ORAL POWDER 4 GM/DOSE Cholestyramine Light

*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Lofibra

fenofibrate oral tablet 145 mg, 48 mg Tricor QLL (30 EA per 30 days) fenofibrate oral tablet 160 mg, 54 mg Lofibra fenofibric acid oral capsule delayed release 135 mg, 45 mg Trilipix QLL (30 EA per 30 days)

gemfibrozil oral tablet 600 mg Lopid QLL (60 EA per 30 days)

*Hmg Coa Reductase Inhibitors*** 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 Lescol QLL (30 EA per 30 days) fluvastatin sodium oral capsule 40 mg QLL (30 EA per 30 days) lovastatin oral tablet 10 mg, 20 mg QLL (30 EA per 30 days) lovastatin oral tablet 40 mg Mevacor QLL (60 EA per 30 days) pravastatin sodium oral tablet 10 mg QLL (30 EA per 30 days)

39

Formulary Drug Name Reference Restrictions pravastatin sodium oral tablet 20 mg, 40 mg, 80 mg Pravachol QLL (30 EA per 30 days)

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Crestor PA

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

simvastatin oral tablet 80 mg Zocor ST; QLL (30 EA per 30 days)

*Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 mg Zetia ST; QLL (30 EA per 30 days)

*Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg Niaspan

*ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg Lotrel QLL (30 EA per 30 days)

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-40 mg QLL (30 EA per 30 days)

*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10 -12.5 mg, 20-12.5 mg, 20-25 mg Lotensin HCT QLL (30 EA per 30 days)

benazepril-hydrochlorothiazide oral tablet 5 -6.25 mg QLL (30 EA per 30 days)

captopril-hydrochlorothiazide oral tablet 25 -15 mg, 25-25 mg, 50-15 mg, 50-25 mg QLL (30 EA per 30 days)

enalapril-hydrochlorothiazide oral tablet 10 -25 mg Vaseretic QLL (60 EA per 30 days)

enalapril-hydrochlorothiazide oral tablet 5 -12.5 mg QLL (30 EA per 30 days)

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 Zestoretic QLL (30 EA per 30 days)

lisinopril-hydrochlorothiazide oral tablet 20 -25 mg Zestoretic QLL (60 EA per 30 days)

moexipril-hydrochlorothiazide oral tablet 15 -12.5 mg, 15-25 mg, 7.5-12.5 mg QLL (30 EA per 30 days)

quinapril-hydrochlorothiazide oral tablet 10 -12.5 mg, 20-12.5 mg, 20-25 mg Accuretic QLL (30 EA per 30 days)

40

Formulary Drug Name Reference Restrictions *Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg Lotensin QLL (30 EA per 30 days) benazepril hcl oral tablet 40 mg Lotensin QLL (60 EA per 30 days) benazepril hcl oral tablet 5 mg QLL (30 EA per 30 days) captopril oral tablet 100 mg QLL (90 EA per 30 days) captopril oral tablet 12.5 mg, 25 mg, 50 mg QLL (30 EA per 30 days) enalapril maleate oral tablet 10 mg, 2.5 mg, 5 mg Vasotec QLL (30 EA per 30 days)

enalapril maleate oral tablet 20 mg Vasotec QLL (60 EA per 30 days) fosinopril sodium oral tablet 10 mg, 20 mg QLL (30 EA per 30 days) fosinopril sodium oral tablet 40 mg QLL (60 EA per 30 days) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg Zestril QLL (30 EA per 30 days)

lisinopril oral tablet 40 mg Zestril QLL (60 EA per 30 days) lisinopril oral tablet 5 mg Prinivil QLL (30 EA per 30 days) moexipril hcl oral tablet 15 mg QLL (60 EA per 30 days) moexipril hcl oral tablet 7.5 mg QLL (30 EA per 30 days) perindopril erbumine oral tablet 2 mg QLL (30 EA per 30 days) perindopril erbumine oral tablet 4 mg Aceon QLL (30 EA per 30 days) perindopril erbumine oral tablet 8 mg Aceon QLL (60 EA per 30 days) quinapril hcl oral tablet 10 mg, 20 mg, 5 mg Accupril QLL (30 EA per 30 days) quinapril hcl oral tablet 40 mg Accupril QLL (60 EA per 30 days) ramipril oral capsule 1.25 mg, 2.5 mg, 5 mg Altace QLL (30 EA per 30 days) ramipril oral capsule 10 mg Altace QLL (60 EA per 30 days) trandolapril oral tablet 1 mg, 2 mg Mavik QLL (30 EA per 30 days) trandolapril oral tablet 4 mg Mavik QLL (60 EA per 30 days)

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** 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*** candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg Atacand HCT QLL (30 EA per 30 days)

41

Formulary Drug Name Reference Restrictions irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg Avalide QLL (30 EA per 30 days)

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg Hyzaar QLL (30 EA per 30 days)

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 (30 EA per 30 days)

*Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Atacand QLL (30 EA per 30 days)

irbesartan oral tablet 150 mg, 300 mg, 75 mg Avapro QLL (30 EA per 30 days) losartan potassium oral tablet 100 mg, 25 mg, 50 mg Cozaar QLL (30 EA per 30 days)

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Diovan QLL (30 EA per 30 days)

*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet 10-160 -12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Exforge HCT QLL (30 EA per 30 days)

*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Catapres

clonidine hcl transdermal patch weekly 0.1 mg/24hr Catapres-TTS-1 QLL (4 Patches per 30 days)



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*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg Cardura QLL (30 EA per 30 days)

doxazosin mesylate oral tablet 8 mg Cardura QLL (60 EA per 30 days) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Minipress QLL (120 EA per 30 days) terazosin hcl oral capsule 1 mg, 5 mg QLL (30 EA per 30 days) terazosin hcl oral capsule 10 mg, 2 mg QLL (60 EA per 30 days) 42

Formulary Drug Name Reference Restrictions *Beta Blocker & Diuretic Combinations*** 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 metoprolol-hydrochlorothiazide oral tablet 50-25 mg Lopressor HCT

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg Corzide

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

*Vasodilators*** hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 mg Flagyl metronidazole oral tablet 250 mg, 500 mg Flagyl trimethoprim oral tablet 100 mg vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg vancomycin hcl oral capsule 125 mg Vancocin HCl QLL (56 EA per 30 days) vancomycin hcl oral capsule 250 mg Vancocin HCl QLL (40 EA per 30 days) FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML

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

sulfamethoxazole-trimethoprim oral tablet 400-80 mg Bactrim

sulfamethoxazole-trimethoprim oral tablet 800-160 mg Bactrim DS

43

Formulary Drug Name Reference Restrictions SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML

Sulfamethoxazole-Trimethoprim

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

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

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

*ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine sulfate oral tablet 200 mg Plaquenil mefloquine hcl oral tablet 250 mg DARAPRIM ORAL TABLET 25 MG PA

*ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYASTHENIC/CHOLINER GIC AGENTS* pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg Myambutol 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 Rifadin PRIFTIN ORAL TABLET 150 MG

44

Formulary Drug Name Reference Restrictions *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG

*Antiadrenals*** LYSODREN ORAL TABLET 500 MG

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

*Antiestrogens*** tamoxifen citrate oral tablet 10 mg, 20 mg FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML

*Antimetabolites*** capecitabine oral tablet 150 mg, 500 mg Xeloda PA mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 250 mg/10ml, 50 mg/2ml TABLOID ORAL TABLET 40 MG

*Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA; QLL (30 EA per 30 days)

*Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG PA; QLL (120 EA per 30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA; QLL (30 EA per 30 days)

*Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 100 mg Gleevec PA; QLL (90 EA per 30 days) imatinib mesylate oral tablet 400 mg Gleevec PA; QLL (60 EA per 30 days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; QLL (30 EA per 30 days)

45

Formulary Drug Name Reference Restrictions IMBRUVICA ORAL CAPSULE 140 MG PA; QLL (120 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG PA; QLL (30 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG PA; QLL (120 EA per 30 days)

TYKERB ORAL TABLET 250 MG PA; QLL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG PA; QLL (120 EA per 30 days)

*Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg Hydrea ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML PA

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

PA

MATULANE ORAL CAPSULE 50 MG

*Aromatase Inhibitors*** anastrozole oral tablet 1 mg Arimidex QLL (30 EA per 30 days) exemestane oral tablet 25 mg Aromasin QLL (30 EA per 30 days) letrozole oral tablet 2.5 mg Femara QLL (30 EA per 30 days)

*Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG

*Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

*Imidazotetrazines*** temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg Temodar

*Mitotic Inhibitors*** etoposide oral capsule 50 mg

*Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG LEUKERAN ORAL TABLET 2 MG

*Progestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml Megace Oral

megestrol acetate oral tablet 20 mg, 40 mg

46

Formulary Drug Name Reference Restrictions *Retinoids*** tretinoin oral capsule 10 mg

*Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG

*ANTI-OBESITY AGENT COMBINATIONS** *Anti-Obesity Agent Combinations** CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 8-90 MG


*ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg

*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 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*** selegiline hcl oral capsule 5 mg Eldepryl selegiline hcl oral tablet 5 mg

*Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg Sinemet CR

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg Sinemet

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 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg Stalevo 75 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg Stalevo 100 QLL (270 EA per 30 days)

47

Formulary Drug Name Reference Restrictions carbidopa-levodopa-entacapone oral tablet 31.25-125-200 mg Stalevo 125 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 37.5-150-200 mg Stalevo 150 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg Stalevo 200 QLL (270 EA per 30 days)

*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg Mirapex

ropinirole hcl er oral tablet extended release 24 hour 12 mg Requip XL QLL (60 EA per 30 days)

ropinirole hcl er oral tablet extended release 24 hour 2 mg, 4 mg, 6 mg, 8 mg Requip XL QLL (30 EA per 30 days)

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg Requip QLL (90 EA per 30 days)

*Peripheral Comt Inhibitors*** entacapone oral tablet 200 mg Comtan QLL (120 EA per 30 days)

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 mg Lithobid

lithium carbonate er oral tablet extended release 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml

*Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Geodon QLL (60 EA per 30 days); AL

(Min 18 Years)

*Benzisoxazoles***

risperidone oral solution 1 mg/ml RisperDAL QLL (240 ML per 30 days); AL (Min 18 Years)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg RisperDAL QLL (60 EA per 30 days); AL

(Min 18 Years)

risperidone oral tablet 3 mg RisperDAL QLL (90 EA per 30 days); AL (Min 18 Years)

risperidone oral tablet 4 mg RisperDAL QLL (120 EA per 30 days); AL (Min 18 Years)

48


risperidone oral tablet dispersible 0.25 mg QLL (60 EA per 30 days); AL (Min 18 Years)

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg RisperiDONE M-TAB QLL (60 EA per 30 days); AL

(Min 18 Years)

risperidone oral tablet dispersible 3 mg RisperDAL M-TAB QLL (90 EA per 30 days); AL (Min 18 Years)

risperidone oral tablet dispersible 4 mg RisperDAL M-TAB QLL (120 EA per 30 days); AL (Min 18 Years)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG RisperiDONE QLL (60 EA per 30 days); AL

(Min 18 Years) RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 3 MG RisperiDONE QLL (90 EA per 30 days); AL

(Min 18 Years) RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 4 MG RisperiDONE QLL (120 EA per 30 days); AL

(Min 18 Years)

*Butyrophenones*** haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml Haldol Decanoate AL (Min 3 Years)

haloperidol lactate injection solution 5 mg/ml Haldol AL (Min 3 Years) haloperidol lactate oral concentrate 2 mg/ml AL (Min 3 Years) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg AL (Min 3 Years)

*Dibenzodiazepines***

clozapine oral tablet 100 mg Clozaril QLL (270 EA per 30 days); AL (Min 18 Years)

clozapine oral tablet 200 mg QLL (120 EA per 30 days); AL (Min 18 Years)

clozapine oral tablet 25 mg Clozaril QLL (90 EA per 30 days); AL (Min 18 Years)

clozapine oral tablet 50 mg QLL (90 EA per 30 days); AL (Min 18 Years)

*Dibenzothiazepines*** quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SEROquel QLL (90 EA per 30 days); AL

(Min 18 Years) quetiapine fumarate oral tablet 300 mg, 400 mg SEROquel QLL (60 EA per 30 days); AL

(Min 18 Years)

*Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg AL (Min 5 Years)

*Dihydroindolones*** molindone hcl oral tablet 10 mg, 25 mg, 5 mg

49

Formulary Drug Name Reference Restrictions *Phenothiazines*** chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg AL (Min 5 Years)

fluphenazine decanoate injection solution 25 mg/ml AL (Min 5 Years)

fluphenazine hcl injection solution 2.5 mg/ml AL (Min 5 Years) fluphenazine hcl oral concentrate 5 mg/ml AL (Min 5 Years) fluphenazine hcl oral elixir 2.5 mg/5ml AL (Min 5 Years) fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg AL (Min 5 Years)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg AL (Min 5 Years)

prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg Compro thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg AL (Min 2 Years)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg AL (Min 6 Years)

COMPRO RECTAL SUPPOSITORY 25 MG Prochlorperazine

*Thienbenzodiazepines*** olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg ZyPREXA QLL (30 EA per 30 days); AL

(Min 18 Years) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg ZyPREXA Zydis QLL (30 EA per 30 days); AL

(Min 18 Years)

*Thioxanthenes*** thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg AL (Min 13 Years)

*ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants*** TYBOST ORAL TABLET 150 MG QLL (30 EA per 30 days)

*ANTISEPTICS & DISINFECTANTS* *Chlorine Antiseptics*** chlorhexidine gluconate solution 20 %

50

Formulary Drug Name Reference Restrictions *ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 600 -300 mg Epzicom

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

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

ATRIPLA ORAL TABLET 600-200-300 MG QLL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG DESCOVY ORAL TABLET 200-25 MG QLL (30 EA per 30 days) EVOTAZ ORAL TABLET 300-150 MG GENVOYA ORAL TABLET 150-150-200 -10 MG QLL (30 EA per 30 days)

KALETRA ORAL TABLET 100-25 MG, 200-50 MG PREZCOBIX ORAL TABLET 800-150 MG STRIBILD ORAL TABLET 150-150-200 -300 MG QLL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300 MG QLL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG QLL (30 EA per 30 days)

TRUVADA ORAL TABLET 200-300 MG

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

*Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG QLL (30 EA per 30 days)

51

Formulary Drug Name Reference Restrictions ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG QLL (180 EA per 30 days)

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG QLL (60 EA per 30 days)

*Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML

QLL (2 Bottles Max Qty Per Fill Retail)

PREZISTA ORAL TABLET 150 MG, 75 MG QLL (60 EA per 30 days)

PREZISTA ORAL TABLET 600 MG, 800 MG REYATAZ ORAL CAPSULE 150 MG, 300 MG QLL (30 EA per 30 days)

REYATAZ ORAL CAPSULE 200 MG QLL (60 EA per 30 days) REYATAZ ORAL PACKET 50 MG VIRACEPT ORAL TABLET 250 MG, 625 MG

*Antiretrovirals - Rti-Non-Nucleoside Analogues*** nevirapine er oral tablet extended release 24 hour 100 mg Viramune XR QLL (90 EA per 30 days)

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

nevirapine oral suspension 50 mg/5ml Viramune nevirapine oral tablet 200 mg Viramune EDURANT ORAL TABLET 25 MG INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG QLL (120 EA per 30 days)

52

Formulary Drug Name Reference Restrictions RESCRIPTOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG Nevirapine ER QLL (90 EA per 30 days)

*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** abacavir sulfate oral tablet 300 mg Ziagen didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg Videx EC

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 MG/ML

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** lamivudine oral solution 10 mg/ml Epivir lamivudine oral tablet 150 mg, 300 mg Epivir EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg Zerit

zidovudine oral capsule 100 mg Retrovir zidovudine oral syrup 50 mg/5ml Retrovir zidovudine oral tablet 300 mg RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

*Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG QLL (30 EA per 30 days)

VIREAD ORAL TABLET 300 MG

*Hepatitis B Agents*** entecavir oral tablet 0.5 mg, 1 mg Baraclude QLL (30 EA per 30 days) lamivudine oral tablet 100 mg Epivir HBV QLL (30 EA per 30 days)

53

Formulary Drug Name Reference Restrictions BARACLUDE ORAL SOLUTION 0.05 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/ML QLL (300 mL per 30 days)

*Hepatitis C Agents*** ribavirin oral capsule 200 mg Rebetol PA ribavirin oral tablet 200 mg Moderiba PA MODERIBA ORAL 400 & 600 MG PA MODERIBA ORAL TABLET 200 MG Ribavirin PA PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

PA; QLL (4 Units per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML PA; QLL (4 Units per 28 days)

PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS KIT 120 MCG/0.5ML PA; QLL (4 Units per 28 days)

PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML


PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML


REBETOL ORAL SOLUTION 40 MG/ML PA; QLL (500 mL per 30 days) RIBASPHERE ORAL CAPSULE 200 MG Ribavirin PA RIBASPHERE ORAL TABLET 200 MG Ribavirin PA RIBASPHERE ORAL TABLET 400 MG, 600 MG PA

RIBASPHERE RIBAPAK ORAL TABLET 200 & 400 MG, 400 & 600 MG PA

*Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg Zovirax QLL (60 EA per 30 days) acyclovir oral suspension 200 mg/5ml Zovirax acyclovir oral tablet 400 mg, 800 mg Zovirax QLL (60 EA per 30 days) valacyclovir hcl oral tablet 1 gm Valtrex QLL (21 EA per 30 days) valacyclovir hcl oral tablet 500 mg Valtrex QLL (42 EA per 30 days)

*Herpes Agents - Thymidine Analogues***

famciclovir oral tablet 125 mg, 250 mg QLL (21 EA Max Qty Per Fill Retail)

54


famciclovir oral tablet 500 mg Famvir QLL (21 EA Max Qty Per Fill Retail)

*Influenza Agents***

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

*Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Tamiflu Max Limit (Max 2 Rx/year);

QLL (20 EA per 30 days) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

Max Limit (Max 2 Rx/year); QLL (20 Inhalations per 180 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

Max Limit (Max 2 Rx/year); QLL (3 Bottles Max Qty Per Fill Retail)

*ASSORTED CLASSES* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 50 MG PA; QLL (30 EA per 30 days)

THALOMID ORAL CAPSULE 150 MG, 200 MG PA; QLL (60 EA per 30 days)

*Chelating Agents*** CUPRIMINE ORAL CAPSULE 250 MG

*Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 25 mg Neoral

cyclosporine modified oral capsule 50 mg Gengraf cyclosporine modified oral solution 100 mg/ml Gengraf cyclosporine oral capsule 100 mg, 25 mg SandIMMUNE GENGRAF ORAL CAPSULE 100 MG, 25 MG CycloSPORINE Modified

GENGRAF ORAL SOLUTION 100 MG/ML CycloSPORINE Modified

*Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG PA; QLL (30 EA per 30 days)

*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mg CellCept mycophenolate mofetil oral suspension reconstituted 200 mg/ml CellCept

55

Formulary Drug Name Reference Restrictions mycophenolate mofetil oral tablet 500 mg CellCept

*Irrigation Solutions*** sterile water for irrigation irrigation solution Argyle Sterile Water ARGYLE STERILE WATER IRRIGATION SOLUTION Sterile Water for Irrigation

*Macrolide Immunosuppressants*** sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Rapamune tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Prograf RAPAMUNE ORAL SOLUTION 1 MG/ML

*Potassium Removing Resins*** sodium polystyrene sulfonate oral powder Kayexalate sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml KIONEX ORAL POWDER Sodium Polystyrene Sulfonate KIONEX ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

SPS ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

*Purine Analogs*** azathioprine oral tablet 50 mg Imuran

*BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Coreg QLL (60 EA per 30 days)

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

*Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin betaxolol hcl oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg Zebeta QLL (120 EA per 30 days) bisoprolol fumarate oral tablet 5 mg QLL (30 EA per 30 days) metoprolol succinate er oral tablet extended release 24 hour 100 mg, 50 mg Toprol XL QLL (45 EA per 30 days)

metoprolol succinate er oral tablet extended release 24 hour 200 mg Toprol XL QLL (60 EA per 30 days)

metoprolol succinate er oral tablet extended release 24 hour 25 mg Toprol XL QLL (30 EA per 30 days)

56

Formulary Drug Name Reference Restrictions metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor metoprolol tartrate oral tablet 25 mg

*Beta Blockers Non-Selective*** nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg Inderal LA QLL (30 EA per 30 days)

propranolol hcl er oral capsule extended release 24 hour 80 mg Inderal LA QLL (60 EA per 30 days)

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, 240 mg, 80 mg Sorine

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

*CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg Norvasc QLL (30 EA per 30 days)

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg Cartia XT QLL (30 EA per 30 days)

diltiazem cd oral capsule extended release 24 hour 240 mg Cartia XT QLL (60 EA per 30 days)

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg Taztia XT QLL (30 EA per 30 days)

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 300 mg, 360 mg, 420 mg

Tiazac QLL (30 EA per 30 days)

diltiazem hcl er beads oral capsule extended release 24 hour 240 mg Taztia XT QLL (60 EA per 30 days)

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 300 mg

Cartia XT QLL (30 EA per 30 days)

diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg Cartia XT QLL (60 EA per 30 days)

diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg Cardizem CD QLL (30 EA per 30 days)

57

Formulary Drug Name Reference Restrictions diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg QLL (60 EA per 30 days)

diltiazem hcl er oral capsule extended release 24 hour 120 mg QLL (30 EA per 30 days)

diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg QLL (60 EA per 30 days)

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg Cardizem QLL (120 EA per 30 days) diltiazem hcl oral tablet 90 mg QLL (120 EA per 30 days) dilt-xr oral capsule extended release 24 hour 120 mg QLL (30 EA per 30 days)

dilt-xr oral capsule extended release 24 hour 180 mg, 240 mg QLL (60 EA per 30 days)

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg QLL (30 EA per 30 days)

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, 90 mg Adalat CC QLL (30 EA per 30 days)

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

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

nifedipine oral capsule 10 mg Procardia nifedipine oral capsule 20 mg nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release 24 hour 17 mg, 34 mg, 8.5 mg Sular QLL (30 EA per 30 days)

nisoldipine er oral tablet extended release 24 hour 20 mg, 25.5 mg, 30 mg, 40 mg QLL (30 EA per 30 days)

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg Verelan QLL (30 EA per 30 days)

verapamil hcl er oral capsule extended release 24 hour 240 mg Verelan QLL (60 EA per 30 days)

verapamil hcl er oral capsule extended release 24 hour 300 mg Verelan PM QLL (30 EA per 30 days)

verapamil hcl er oral tablet extended release 120 mg Calan SR QLL (30 EA per 30 days)

verapamil hcl er oral tablet extended release 180 mg Calan SR QLL (60 EA per 30 days)

verapamil hcl er oral tablet extended release 240 mg Isoptin SR QLL (60 EA per 30 days)

verapamil hcl oral tablet 120 mg, 80 mg Calan QLL (120 EA per 30 days)

58

Formulary Drug Name Reference Restrictions verapamil hcl oral tablet 40 mg QLL (120 EA per 30 days) AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG

NIFEdipine ER QLL (30 EA per 30 days)

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 300 MG

Diltiazem HCl ER Coated Beads QLL (30 EA per 30 days)

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG

Diltiazem HCl ER Coated Beads QLL (60 EA per 30 days)

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEdipine ER QLL (30 EA per 30 days)

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG

NIFEdipine ER Osmotic Release QLL (30 EA per 30 days)

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 300 MG, 360 MG

Diltiazem HCl ER Beads QLL (30 EA per 30 days)

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Diltiazem HCl ER Beads QLL (60 EA per 30 days)

*CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution 0.05 mg/ml digoxin oral tablet 125 mcg, 250 mcg Digitek DIGITEK ORAL TABLET 125 MCG, 250 MCG Digoxin

DIGOX ORAL TABLET 125 MCG, 250 MCG Digoxin

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG

*CARDIOVASCULAR AGENTS -MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** 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 QLL (30 EA per 30 days)

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg QLL (30 EA per 30 days)

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg Revatio PA; QLL (90 EA per 30 days)

59

Formulary Drug Name Reference Restrictions *CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250 mg, 500 mg Keflex cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg

*Cephalosporins - 2Nd Generation*** cefaclor er oral tablet extended release 12 hour 500 mg

QLL (14 EA Max Qty Per Fill Retail)

cefaclor oral capsule 250 mg

cefaclor oral capsule 500 mg QLL (14 EA Max Qty Per Fill Retail)

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg Ceftin CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML

*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Suprax QLL (1 Bottle per 30 days)

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg ceftriaxone sodium injection solution reconstituted 1 gm Rocephin QLL (2 Grams Max Qty Per Fill

Retail) ceftriaxone sodium injection solution reconstituted 2 gm, 250 mg, 500 mg

QLL (2 Grams Max Qty Per Fill Retail)

60

Formulary Drug Name Reference Restrictions SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG QLL (20 EA per 30 days)

*CHEMICALS* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder

*Bulk Chemicals - La's*** acidophilus lactobacillus powder 10 bu/gm

*Bulk Chemicals - Le's*** calcium folinate powder leucovorin calcium powder

*Bulk Chemicals - Py's*** pyrimethamine powder

*Bulk Chemicals - St's*** stevia extract powder steviol glycosides powder 95 % stevioside fluid extract 15 %

*Liquids*** benzyl benzoate liquid chlorhexidine gluconate solution glycerine liquid

*CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** desogestrel-ethinyl estradiol oral tablet 0.15 -0.02/0.01 mg (21/5) Mircette

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Mircette AZURETTE ORAL TABLET 0.15 -0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

BEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

NECON 10/11 (28) ORAL TABLET 35 MCG PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

61

Formulary Drug Name Reference Restrictions *Combination Contraceptives -Oral*** alyacen 1/35 oral tablet 1-35 mg-mcg Pirmella 1/35 briellyn oral tablet 0.4-35 mg-mcg Zenchent drospirenone-ethinyl estradiol oral tablet 3 -0.02 mg Vestura

drospirenone-ethinyl estradiol oral tablet 3 -0.03 mg Syeda

levonorgestrel-ethinyl estrad oral tablet 0.1 -20 mg-mcg Orsythia

levonorgestrel-ethinyl estrad oral tablet 0.15 -30 mg-mcg Kurvelo

marlissa oral tablet 0.15-30 mg-mcg Kurvelo norethin ace-eth estrad-fe oral tablet 1-20 mg -mcg Tarina FE 1/20

norethin ace-eth estrad-fe oral tablet 1-20 mg -mcg(24) Blisovi 24 Fe

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg Loestrin 1/20 (21)

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg MonoNessa

ALTAVERA ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

APRI ORAL TABLET 0.15-30 MG-MCG AUBRA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

BALZIVA ORAL TABLET 0.4-35 MG -MCG Briellyn

BLISOVI 24 FE ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

CHATEAL ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35

CYRED ORAL TABLET 0.15-30 MG -MCG 62

Formulary Drug Name Reference Restrictions DASETTA 1/35 ORAL TABLET 1-35 MG -MCG Alyacen 1/35

DELYLA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

ELINEST ORAL TABLET 0.3-30 MG -MCG EMOQUETTE ORAL TABLET 0.15-30 MG-MCG ENSKYCE ORAL TABLET 0.15-30 MG -MCG ESTARYLLA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

FALMINA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

GIANVI ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol GILDAGIA ORAL TABLET 0.4-35 MG -MCG Briellyn

GILDESS FE 1.5/30 ORAL TABLET 1.5 -30 MG-MCG GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

JULEBER ORAL TABLET 0.15-30 MG -MCG JUNEL 1.5/30 ORAL TABLET 1.5-30 MG -MCG JUNEL 1/20 ORAL TABLET 1-20 MG -MCG

Norethindrone Acet-Ethinyl Est

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG -MCG Norethin Ace-Eth Estrad-FE

JUNEL FE 24 ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

KELNOR 1/35 ORAL TABLET 1-35 MG -MCG KURVELO ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

LARIN 1.5/30 ORAL TABLET 1.5-30 MG -MCG LARIN 1/20 ORAL TABLET 1-20 MG -MCG


LARIN 24 FE ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

63

Formulary Drug Name Reference Restrictions LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG LARIN FE 1/20 ORAL TABLET 1-20 MG -MCG Norethin Ace-Eth Estrad-FE

LESSINA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad

LOMEDIA 24 FE ORAL TABLET 1-20 MG-MCG(24) Norethin Ace-Eth Estrad-FE

LORYNA ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG LUTERA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN 1/20 ORAL TABLET 1 -20 MG-MCG


MICROGESTIN 24 FE ORAL TABLET 1 -20 MG-MCG Norethin Ace-Eth Estrad-FE

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

MONONESSA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG NIKKI ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

OCELLA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol

64

Formulary Drug Name Reference Restrictions OGESTREL ORAL TABLET 0.5-50 MG -MCG ORSYTHIA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

PHILITH ORAL TABLET 0.4-35 MG -MCG Briellyn

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35

PORTIA-28 ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

PREVIFEM ORAL TABLET 0.25-35 MG -MCG Norgestimate-Eth Estradiol

RECLIPSEN ORAL TABLET 0.15-30 MG -MCG SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

SRONYX ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

SYEDA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

VESTURA ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol VIENVA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

VYFEMLA ORAL TABLET 0.4-35 MG -MCG Briellyn

WERA ORAL TABLET 0.5-35 MG-MCG ZARAH ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol ZENCHENT ORAL TABLET 0.4-35 MG -MCG Briellyn

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG Ethynodiol Diac-Eth Estradiol

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

*Combination Contraceptives -Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR QLL (1 EA per 30 days)

65

Formulary Drug Name Reference Restrictions *Continuous Contraceptives -Oral*** levonorgestrel-ethinyl estrad oral tablet 90-20 mcg Amethyst

AMETHYST ORAL TABLET 90-20 MCG Levonorgestrel-Ethinyl Estrad

*Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

*Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

*Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg Opcicon One-Step QLL (3 Packages per 1 Year) ELLA ORAL TABLET 30 MG MY WAY ORAL TABLET 1.5 MG Levonorgestrel QLL (3 Packages per 1 Year)

*Extended-Cycle Contraceptives -Oral*** levonorgest-eth estrad 91-day oral tablet 0.15 -0.03 &0.01 mg Camrese

levonorgest-eth estrad 91-day oral tablet 0.15 -0.03 mg Quasense

AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG

Levonorgest-Eth Estrad 91-Day

ASHLYNA ORAL TABLET 0.15-0.03 &0.01 MG


CAMRESE ORAL TABLET 0.15-0.03 &0.01 MG


DAYSEE ORAL TABLET 0.15-0.03 &0.01 MG


INTROVALE ORAL TABLET 0.15-0.03 MG


JOLESSA ORAL TABLET 0.15-0.03 MG Levonorgest-Eth Estrad 91-Day

QUASENSE ORAL TABLET 0.15-0.03 MG


SETLAKIN ORAL TABLET 0.15-0.03 MG Levonorgest-Eth Estrad 91-Day

66

Formulary Drug Name Reference Restrictions *Progestin Contraceptives -Implants*** NEXPLANON SUBCUTANEOUS IMPLANT 68 MG

*Progestin Contraceptives -Injectable*** medroxyprogesterone acetate intramuscular suspension 150 mg/ml Depo-Provera QLL (1 ML per 84 days)

*Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR

*Progestin Contraceptives - Oral*** norethindrone oral tablet 0.35 mg Nora-BE QLL (28 EA per 30 days) CAMILA ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) DEBLITANE ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) ERRIN ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) HEATHER ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) JENCYCLA ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) JOLIVETTE ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) LYZA ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) NORA-BE ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) NORLYROC ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days) SHAROBEL ORAL TABLET 0.35 MG Norethindrone QLL (28 EA per 30 days)

*Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg -mcg Pirmella 7/7/7

levonorg-eth estrad triphasic oral tablet Myzilra norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Estarylla

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

ENPRESSE-28 ORAL TABLET Levonorg-Eth Estrad Triphasic

67

Formulary Drug Name Reference Restrictions LEENA ORAL TABLET 0.5/1/0.5-35 MG -MCG LEVONEST ORAL TABLET Levonorg-Eth Estrad Triphasic MYZILRA ORAL TABLET Levonorg-Eth Estrad Triphasic NECON 7/7/7 ORAL TABLET 0.5/0.75/1 -35 MG-MCG Alyacen 7/7/7

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Norgestim-Eth Estrad Triphasic

TRI-LEGEST FE ORAL TABLET 1-20/1 -30/1-35 MG-MCG TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRIVORA (28) ORAL TABLET Levonorg-Eth Estrad Triphasic VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

*CORTICOSTEROIDS* *Glucocorticosteroids*** cortisone acetate oral tablet 25 mg dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 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

68

Formulary Drug Name Reference Restrictions prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred

prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg, 50 mg prednisone oral tablet 20 mg Deltasone DELTASONE ORAL TABLET 20 MG PredniSONE

*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg Tessalon Perles benzonatate oral capsule 150 mg, 200 mg

*Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 mg/5ml hydrocodone-homatropine oral tablet 5-1.5 mg Tussigon

hydromet oral syrup 5-1.5 mg/5ml TUSSIGON ORAL TABLET 5-1.5 MG Hydrocodone-Homatropine

*Antitussive-Expectorants-Decongestant*** biotuss oral liquid 10-15-300 mg/5ml QLL (120 mL per 30 days)

*Decongestant & Antihistamine*** promethazine vc plain oral syrup 6.25-5 mg/5ml promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % Nebusal

sodium chloride inhalation nebulization solution 7 % HyperSal

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Sodium Chloride

69

Formulary Drug Name Reference Restrictions NEBUSAL INHALATION NEBULIZATION SOLUTION 6 % PULMOSAL INHALATION NEBULIZATION SOLUTION 7 % Sodium Chloride

*Mucolytics*** acetylcysteine inhalation solution 10 %, 20 %

*Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup 6.25-15 mg/5ml QLL (180 mL per 30 days)

*Opioid Antitussive-Antihistamine*** promethazine-codeine oral syrup 6.25-10 mg/5ml QLL (180 mL per 30 days)

*Opioid Antitussive-Decongestant-Antihistamine*** phenyleph-promethazine-cod oral syrup 5 -6.25-10 mg/5ml QLL (180 mL per 30 days)

promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml QLL (180 mL per 30 days)

*DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external gel 1 % Clindagel clindamycin phosphate external lotion 1 % Cleocin-T clindamycin phosphate external solution 1 % Cleocin-T clindamycin phosphate external swab 1 % Clindacin-P ery external pad 2 % erythromycin external gel 2 % Erygel erythromycin external pad 2 % erythromycin external solution 2 % sulfacetamide sodium (acne) external lotion 10 % Klaron

sulfacetamide sodium external suspension 10 % Klaron

CLINDACIN ETZ EXTERNAL SWAB 1 % Clindamycin Phosphate

CLINDACIN-P EXTERNAL SWAB 1 % Clindamycin Phosphate CLINDAMAX EXTERNAL GEL 1 % Clindamycin Phosphate

*Acne Products***

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

70


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

bp foaming wash external liquid 10 % PanOxyl Wash bp wash external liquid 2.5 % PanOxyl

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

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

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

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

AVITA EXTERNAL CREAM 0.025 % Tretinoin QLL (45 GM per 30 days); AL (Max 35 Years)

AVITA EXTERNAL GEL 0.025 % Tretinoin QLL (45 GM per 30 days); AL (Max 35 Years)

BENZIQ WASH EXTERNAL LIQUID 5.25 % CLEARPLEX X EXTERNAL GEL 10 % Acne Medication 10 MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG ST; QLL (60 EA per 30 days)

MYORISAN ORAL CAPSULE 40 MG ST OSCION CLEANSER EXTERNAL LOTION 6 % Benzoyl Peroxide Cleanser

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG ST; QLL (60 EA per 30 days)

ZENATANE ORAL CAPSULE 40 MG ST

*Antibiotics - Topical*** gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate powder mupirocin external ointment 2 % Centany

*Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream 1 -0.05 % Lotrisone

clotrimazole-betamethasone external lotion 1 -0.05 % hydrocortisone-iodoquinol external cream 1-1 % Dermazene

DERMAZENE EXTERNAL CREAM 1-1 % Hydrocortisone-Iodoquinol

71

Formulary Drug Name Reference Restrictions *Antifungals - Topical*** ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % Loprox

ciclopirox external solution 8 % Ciclodan QLL (2 Prescriptions per 1 Year)

ciclopirox olamine external cream 0.77 % Ciclodan ciclopirox olamine external suspension 0.77 % Loprox nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm nystatin external powder 100000 unit/gm Nyamyc CICLODAN EXTERNAL CREAM 0.77 % Ciclopirox Olamine

CICLODAN EXTERNAL SOLUTION 8 % Ciclopirox QLL (2 Prescriptions per 1 Year)

NYAMYC EXTERNAL POWDER 100000 UNIT/GM Nystatin

NYSTOP EXTERNAL POWDER 100000 UNIT/GM Nystatin

*Anti-Inflammatory Agents -Topical*** diclofenac sodium transdermal gel 1 % Voltaren QLL (200 GM per 30 days)

*Antineoplastic Antimetabolites -Topical*** fluorouracil external cream 0.5 % Carac fluorouracil external cream 5 % Efudex fluorouracil external solution 2 %, 5 % FLUOROPLEX EXTERNAL CREAM 1 %

*Antipsoriatics - Systemic*** methoxsalen rapid oral capsule 10 mg Oxsoralen Ultra

*Antipsoriatics*** calcipotriene external ointment 0.005 % Calcitrene calcipotriene external solution 0.005 %

*Antiseborrheic Combinations*** selenium sulfide external shampoo 2.25 % selenium sulf-pyrithione-urea external shampoo 2.25 %

*Antiseborrheic Products*** selenium sulfide external lotion 2.5 % sulfacetamide sodium external liquid 10 % Ovace Wash

72

Formulary Drug Name Reference Restrictions SEB-PREV WASH EXTERNAL LIQUID 10 % Sulfacetamide Sodium

*Antivirals - Topical*** acyclovir external ointment 5 % Zovirax ST; QLL (1 Tube per 30 days)

*Burn Products*** silver sulfadiazine external cream 1 % Thermazene SSD EXTERNAL CREAM 1 % Silver Sulfadiazine THERMAZENE EXTERNAL CREAM 1 % Silver Sulfadiazine

*Cauterizing Agent Combinations*** ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 %

*Corticosteroids - Topical*** ala-cort external cream 1 % Preparation H Hydrocortisone alclometasone dipropionate external cream 0.05 % Aclovate QLL (1 Prescription per 23

days) alclometasone dipropionate external ointment 0.05 %

QLL (1 Prescription per 23 days)

alphatrex external gel 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % betamethasone dipropionate aug external cream 0.05 % Diprolene AF

betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % Diprolene

betamethasone dipropionate aug external ointment 0.05 % Diprolene

betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate e external cream 0.05 % Temovate E

73

Formulary Drug Name Reference Restrictions clobetasol propionate external cream 0.05 % Temovate clobetasol propionate external foam 0.05 % Olux clobetasol propionate external gel 0.05 % Temovate clobetasol propionate external lotion 0.05 % Clobex clobetasol propionate external ointment 0.05 % Temovate

clobetasol propionate external shampoo 0.05 % Clodan

clobetasol propionate external solution 0.05 % Cormax Scalp Application desonide external cream 0.05 % DesOwen desonide external lotion 0.05 % DesOwen desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % Topicort

desoximetasone external gel 0.05 % Topicort desoximetasone external ointment 0.05 %, 0.25 % Topicort

diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream 0.025 % Synalar

fluocinolone acetonide external ointment 0.025 % Synalar

fluocinolone acetonide external solution 0.01 % Synalar

fluocinolone acetonide powder fluocinonide external cream 0.05 % fluocinonide external cream 0.1 % Vanos fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 %

fluticasone propionate external cream 0.05 % Cutivate QLL (1 Prescription per 23 days)

fluticasone propionate external ointment 0.005 %

QLL (1 Prescription per 23 days)

halobetasol propionate external cream 0.05 % Ultravate halobetasol propionate external ointment 0.05 % Ultravate

hydrocortisone acetate powder

74

Formulary Drug Name Reference Restrictions hydrocortisone butyr lipo base external cream 0.1 % Locoid Lipocream

hydrocortisone butyrate external cream 0.1 % Locoid hydrocortisone butyrate external ointment 0.1 % Locoid

hydrocortisone butyrate external solution 0.1 % Locoid

hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 % Cortizone-10 hydrocortisone external ointment 2.5 % hydrocortisone micronized powder hydrocortisone powder hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % Westcort

mometasone furoate external cream 0.1 % Elocon mometasone furoate external ointment 0.1 % Elocon mometasone furoate external solution 0.1 % Elocon prednicarbate external cream 0.1 % Dermatop prednicarbate external ointment 0.1 % Dermatop scalacort external lotion 2 % Ala Scalp triamcinolone acetonide external cream 0.025 %, 0.5 % triamcinolone acetonide external cream 0.1 % Triderm triamcinolone acetonide external lotion 0.025 %, 0.1 % triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide powder CLODAN EXTERNAL SHAMPOO 0.05 % Clobetasol Propionate CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 % Clobetasol Propionate

LOKARA EXTERNAL LOTION 0.05 % Desonide TRIDERM EXTERNAL CREAM 0.1 % Triamcinolone Acetonide

*Emollients*** NEOSALUS EXTERNAL LOTION CVS Extra Moisturizing

*Enzymes - Topical*** SANTYL EXTERNAL OINTMENT 250 UNIT/GM

75

Formulary Drug Name Reference Restrictions *Imidazole-Related Antifungals -Topical*** clotrimazole external cream 1 % Lotrimin AF Jock Itch

clotrimazole external solution 1 % FungiCure Intensive/NailGuard

econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % Nizoral kp clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC

*Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external cream 5 % Aldara QLL (12 Packets per 30 days)

*Insect Repellents***

OFF DEEP WOODS DRY EXTERNAL AEROSOL CVS Total Home Insect Repel

QLL (Quantity limit of 1 bottle per fill with a maximum of 2 fills per month); OTC; AL (Min 14 Years and Max 44 Years)

OFF DEEP WOODS EXTERNAL AEROSOL CVS Total Home Insect Repel


OFF DEEP WOODS SPORTSMEN EXTERNAL AEROSOL 30 % CVS Total Home Insect Repel


OFF FAMILYCARE CLEAN FEEL EXTERNAL LIQUID 5 %


OFF SMOOTH & DRY EXTERNAL AEROSOL 15 % CVS Total Home Insect Repel


SAWYER INSECT REPELLENT EXTERNAL LIQUID 20 %


ULTRATHON INSECT REPELLENT 8 EXTERNAL AEROSOL 25 % CVS Total Home Insect Repel


*Keratolytic/Antimitotic Agents*** podofilox external solution 0.5 % Condylox

76

Formulary Drug Name Reference Restrictions salicylic acid external cream 6 % Salacyn salicylic acid external lotion 6 % Salacyn salicylic acid external shampoo 6 % Salex CONDYLOX EXTERNAL GEL 0.5 % SALACYN EXTERNAL CREAM 6 % Salicylic Acid SALACYN EXTERNAL LOTION 6 % Salicylic Acid

*Local Anesthetics - Topical*** lidocaine external ointment 5 % QLL (90 GM per 30 days) lidocaine external patch 5 % Lidoderm QLL (90 EA per 30 days) lidocaine hcl external cream 3 % CidalEaze lidocaine hcl external gel 2 % Regenecare HA lidocaine hcl external solution 4 % Xylocaine lidopin external cream 3 % CidalEaze premium lidocaine external ointment 5 % QLL (90 GM per 30 days) CIDALEAZE EXTERNAL CREAM 3 % Lidopin GLYDO EXTERNAL GEL 2 % Lidocaine HCl

*Macrolide Immunosuppressants -Topical*** tacrolimus external ointment 0.03 % Protopic ST; QLL (30 GM per 30 days)

tacrolimus external ointment 0.1 % Protopic ST; QLL (30 GM per 30 days); AL (Min 2 Years)

ELIDEL EXTERNAL CREAM 1 % ST; QLL (30 GM per 30 days)

*Rosacea Agents*** metronidazole external cream 0.75 % Rosadan metronidazole external gel 0.75 % Rosadan metronidazole external gel 1 % Metrogel metronidazole external lotion 0.75 % MetroLotion ROSADAN EXTERNAL CREAM 0.75 % MetroNIDAZOLE ROSADAN EXTERNAL GEL 0.75 % MetroNIDAZOLE

*Scabicides & Pediculicides*** lindane external shampoo 1 % QLL (60 mL per 30 days) malathion external lotion 0.5 % Ovide QLL (1 Pack per 180 days) permethrin external cream 5 % Elimite QLL (1 Pack per 180 days) ULESFIA EXTERNAL LOTION 5 % QLL (2 Packs per 180 days)

*Skin Cleansers*** essentra wipes 9x9" external 70 % Pharmacist Choice Alcohol

77

Formulary Drug Name Reference Restrictions *Steroid-Local Anesthetic Combinations*** CORTANE-B EXTERNAL LOTION 10 -10-1 MG/ML

*Topical Anesthetic Combinations*** lidocaine-prilocaine external cream 2.5-2.5 % QLL (240 GM per 30 days) lidocaine-prilocaine external kit 2.5-2.5 % Relador Pak Plus LIVIXIL PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR LP LITE PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR RELADOR PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 % Lidopril XR

*Topical Selective Retinoid X Receptor Agonists*** TARGRETIN EXTERNAL GEL 1 %

*DIAGNOSTIC PRODUCTS* *Diagnostic Tests*** ONETOUCH ULTRA BLUE IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30

days)

ONETOUCH VERIO IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30 days)

*DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT

*DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour 500 mg Diamox Sequels

acetazolamide oral tablet 125 mg, 250 mg methazolamide oral tablet 25 mg, 50 mg Neptazane 78

Formulary Drug Name Reference Restrictions *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5 -50 mg spironolactone-hctz oral tablet 25-25 mg Aldactazide triamterene-hctz oral capsule 37.5-25 mg Dyazide triamterene-hctz oral capsule 50-25 mg triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 triamterene-hctz oral tablet 75-50 mg Maxzide

*Loop Diuretics*** bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex furosemide oral solution 10 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix torsemide oral tablet 10 mg, 20 mg Demadex torsemide oral tablet 100 mg, 5 mg

*Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg Aldactone

*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 12.5 mg Microzide hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral solution 70 mg/75ml QLL (4 Bottles per 30 days) alendronate sodium oral tablet 10 mg, 40 mg, 5 mg QLL (30 EA per 30 days)

alendronate sodium oral tablet 35 mg QLL (4 EA per 30 days) alendronate sodium oral tablet 70 mg Fosamax QLL (4 EA per 30 days) etidronate disodium oral tablet 200 mg QLL (90 EA per 30 days) etidronate disodium oral tablet 400 mg QLL (150 EA per 30 days)

79

Formulary Drug Name Reference Restrictions ibandronate sodium intravenous solution 3 mg/3ml Boniva

ibandronate sodium oral tablet 150 mg Boniva QLL (1 EA per 30 days) pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act Miacalcin QLL (1 Bottle per 30 days)

*Carnitine Replenisher - Agents*** levocarnitine oral solution 1 gm/10ml Carnitor SF levocarnitine oral tablet 330 mg Carnitor

*Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg QLL (16 EA per 30 days)

*Growth Hormones*** OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG PA

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol calcitriol oral solution 1 mcg/ml Rocaltrol paricalcitol oral capsule 1 mcg, 2 mcg Zemplar ST; QLL (30 EA per 30 days) paricalcitol oral capsule 4 mcg ST; QLL (30 EA per 30 days)

*Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl oral tablet 60 mg Evista QLL (30 EA per 30 days)

*Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

SandoSTATIN PA

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

PA

*Vasopressin*** desmopressin ace rhinal tube nasal solution 0.01 % DDAVP Rhinal Tube QLL (1 Bottle per 30 days)

desmopressin ace spray refrig nasal solution 0.01 % QLL (1 Bottle per 30 days)

desmopressin acetate oral tablet 0.1 mg, 0.2 mg DDAVP QLL (90 EA per 30 days)

80

Formulary Drug Name Reference Restrictions desmopressin acetate spray nasal solution 0.01 % DDAVP QLL (1 Bottle per 30 days)

*ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 0.5 -0.1 mg Mimvey Lo QLL (30 EA per 30 days)

estradiol-norethindrone acet oral tablet 1-0.5 mg Mimvey QLL (30 EA per 30 days)

jevantique lo oral tablet 0.5-2.5 mg-mcg Fyavolv norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg Fyavolv

norethindrone-eth estradiol oral tablet 1-5 mg-mcg Fyavolv QLL (30 EA per 30 days)

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY QLL (4 Patches per 30 days)

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

QLL (8 Patches per 30 days)

FYAVOLV ORAL TABLET 0.5-2.5 MG -MCG Norethindrone-Eth Estradiol

FYAVOLV ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol QLL (30 EA per 30 days) JINTELI ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol QLL (30 EA per 30 days) MIMVEY LO ORAL TABLET 0.5-0.1 MG Estradiol-Norethindrone Acet QLL (30 EA per 30 days) MIMVEY ORAL TABLET 1-0.5 MG Estradiol-Norethindrone Acet QLL (30 EA per 30 days) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) QLL (30 EA per 30 days)

PREMPHASE ORAL TABLET 0.625-5 MG QLL (30 EA per 30 days)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG QLL (30 EA per 30 days)

*Estrogens*** estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace QLL (30 EA per 30 days) estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.075 mg/24hr Vivelle-Dot QLL (8 Patches per 30 days)

estradiol transdermal patch twice weekly 0.0375 mg/24hr, 0.1 mg/24hr Minivelle QLL (8 Patches per 30 days)

estradiol transdermal patch twice weekly 0.05 mg/24hr Alora QLL (8 Patches 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 EA per 30 days)

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg QLL (30 EA per 30 days)

81

Formulary Drug Name Reference Restrictions MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG QLL (30 EA per 30 days)

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG QLL (30 EA per 30 days)

*FLUOROQUINOLONES* *Fluoroquinolones*** 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) ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%) Cipro

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg Cipro XR QLL (14 EA per 30 days)

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 mg Cipro XR QLL (3 EA per 30 days)

levofloxacin oral solution 25 mg/ml QLL (280 mL Max Qty Per Fill Retail)

levofloxacin oral tablet 250 mg, 500 mg, 750 mg Levaquin QLL (14 EA Max Qty Per Fill

Retail) ofloxacin oral tablet 400 mg QLL (28 EA per 30 days)

*GASTROINTESTINAL AGENTS -MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule 300 mg Actigall ursodiol oral tablet 250 mg Urso 250 ursodiol oral tablet 500 mg Urso Forte

*Gastrointestinal Stimulants*** metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg Reglan

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG QLL (30 EA per 30 days)

*Inflammatory Bowel Agents*** balsalazide disodium oral capsule 750 mg Colazal mesalamine oral tablet delayed release 800 mg Asacol HD

mesalamine rectal enema 4 gm sulfasalazine oral tablet 500 mg Azulfidine

82

Formulary Drug Name Reference Restrictions sulfasalazine oral tablet delayed release 500 mg Azulfidine EN-tabs

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM CANASA RECTAL SUPPOSITORY 1000 MG QLL (42 EA per 30 days)

*Intestinal Acidifiers*** enulose oral solution 10 gm/15ml generlac oral solution 10 gm/15ml lactulose encephalopathy oral solution 10 gm/15ml

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

*Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule 667 mg PhosLo

calcium acetate (phos binder) oral tablet 667 mg Eliphos

AURYXIA ORAL TABLET 1 GM 210 MG(FE) ST

PHOSLYRA ORAL SOLUTION 667 MG/5ML

*GENITOURINARY AGENTS -MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** finasteride oral tablet 5 mg Proscar QLL (30 EA per 30 days)

*Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hour 10 mg Uroxatral QLL (30 EA per 30 days)

tamsulosin hcl oral capsule 0.4 mg Flomax QLL (60 EA per 30 days)

*Citrates*** citric acid-sodium citrate oral solution 334 -500 mg/5ml Shohls Modified

cytra k crystals oral packet 3300-1002 mg Taron-Crystals 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

83

Formulary Drug Name Reference Restrictions potassium citrate er oral tablet extended release 5 meq (540 mg) Urocit-K 5

potassium citrate-citric acid oral packet 3300 -1002 mg Taron-Crystals

potassium citrate-citric acid oral solution 1100-334 mg/5ml tricitrates oral solution 550-500-334 mg/5ml virtrate-2 oral solution 500-334 mg/5ml Shohls Modified virtrate-3 oral solution 550-500-334 mg/5ml virtrate-k oral solution 1100-334 mg/5ml TARON-CRYSTALS ORAL PACKET 3300-1002 MG Potassium Citrate-Citric Acid

*Genitourinary Irrigants*** sodium chloride irrigation solution 0.9 % Curity Sterile Saline ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 % Sodium Chloride

CURITY STERILE SALINE IRRIGATION SOLUTION 0.9 % Sodium Chloride

*Interstitial Cystitis Agents*** ELMIRON ORAL CAPSULE 100 MG

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

*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg Pyridium

PHENAZO ORAL TABLET 200 MG Phenazopyridine HCl

*GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 mg

*Gout Agents*** allopurinol oral tablet 100 mg, 300 mg Zyloprim colchicine oral tablet 0.6 mg Colcrys QLL (9 EA per 30 days) ULORIC ORAL TABLET 40 MG, 80 MG ST; QLL (30 EA per 30 days)

*Uricosurics*** probenecid oral tablet 500 mg

84

Formulary Drug Name Reference Restrictions *HEMATOLOGICAL AGENTS -MISC.* *Complement Inhibitors*** SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML

*Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 mg

*Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100 mg, 50 mg

*Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25 mg, 50 mg, 75 mg

*Quinazoline Agents*** anagrelide hcl oral capsule 0.5 mg Agrylin anagrelide hcl oral capsule 1 mg

*Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 300 mg Plavix QLL (1 EA per 30 days) clopidogrel bisulfate oral tablet 75 mg Plavix QLL (30 EA per 30 days)

*HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml

*Cxcr4 Receptor Antagonist*** MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML

*Cytotoxic Agents*** DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

*Erythropoiesis-Stimulating Agents (Esas)*** EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PA

*Erythropoietins*** EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PA

85

Formulary Drug Name Reference Restrictions *Folic Acid/Folate Combinations*** fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25 -0.5 mg folplex 2.2 oral tablet 2.2-25-0.5 mg

*Folic Acid/Folates*** folic acid oral tablet 1 mg

*Granulocyte Colony-Stimulating Factors (G-Csf)*** GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG PA

*Iron Combinations*** ICAR-C PLUS ORAL TABLET 100-250 -0.025-1 MG Iron 100 Plus

*Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG PA; QLL (30 EA per 30 days)

*HEPATITIS C AGENT -COMBINATIONS*** *Hepatitis C Agent -Combinations*** ZEPATIER ORAL TABLET 50-100 MG PA; QLL (30 EA per 30 days)

*HYPNOTICS* *Barbiturate Hypnotics*** phenobarbital oral elixir 20 mg/5ml phenobarbital oral solution 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

86

Formulary Drug Name Reference Restrictions *Benzodiazepine Hypnotics***

estazolam oral tablet 1 mg, 2 mg


flurazepam hcl oral capsule 15 mg, 30 mg


temazepam oral capsule 15 mg, 30 mg Restoril


triazolam oral tablet 0.125 mg


triazolam oral tablet 0.25 mg Halcion


*Non-Benzodiazepine - Gaba-Receptor Modulators***

zaleplon oral capsule 10 mg, 5 mg Sonata QLL (30 EA per 30 days); AL (Min 18 Years)

zolpidem tartrate oral tablet 10 mg, 5 mg Ambien QLL (30 EA per 30 days); AL (Min 18 Years)

*Selective Melatonin Receptor Agonists*** ROZEREM ORAL TABLET 8 MG ST; QLL (30 EA per 30 days)

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted 240 gm Colyte with Flavor Packs QLL (1 Unit per 30 days)

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm Nulytely with Flavor Packs

87

Formulary Drug Name Reference Restrictions peg-3350/electrolytes oral solution reconstituted 236 gm Golytely QLL (1 Unit per 30 days)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM PEG 3350/Electrolytes QLL (1 Unit per 30 days)

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM PEG-3350/Electrolytes QLL (1 Unit per 30 days)

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

*Laxatives - Miscellaneous*** constulose oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml, 20 gm/30ml polyethylene glycol 3350 oral packet MiraLax QLL (30 EA per 30 days)

*Lubricant Laxatives*** mineral oil heavy oil mineral oil light oil Muri-Lube

*MACROLIDES* *Azithromycin*** azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Zithromax QLL (30 mL Max Qty Per Fill

Retail) azithromycin oral tablet 250 mg Zithromax Z-Pak QLL (12 EA per 30 days) azithromycin oral tablet 500 mg Zithromax QLL (3 EA per 30 days) azithromycin oral tablet 600 mg Zithromax QLL (8 EA per 30 days)

*Clarithromycin*** clarithromycin er oral tablet extended release 24 hour 500 mg Biaxin XL Pac QLL (14 EA per 30 days)

clarithromycin oral suspension reconstituted 125 mg/5ml

QLL (150 mL Max Qty Per Fill Retail)

clarithromycin oral suspension reconstituted 250 mg/5ml Biaxin QLL (150 mL Max Qty Per Fill

Retail) clarithromycin oral tablet 250 mg, 500 mg Biaxin QLL (28 EA per 30 days)

*Erythromycins*** erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml EryPed 200

88

Formulary Drug Name Reference Restrictions erythromycin ethylsuccinate oral tablet 400 mg E.E.S. 400

E.E.S. 400 ORAL TABLET 400 MG Erythromycin Ethylsuccinate ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG Erythromycin Stearate

*MEDICAL DEVICES* *Applicators,Cotton Balls,Etc***

alcohol wipes pad BD Swabs Single Use Butterfly

ALCOH-GLOVE CONTOURED WIPE PAD QC Alcohol Swabs

*Cervical Caps*** FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM PRENTIF CAVITY-RIM CERV CAP VAGINAL DEVICE 22 MM, 25 MM, 28 MM, 31 MM PRENTIF FITTING SET VAGINAL

*Diaphragms*** 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 %

89

Formulary Drug Name Reference Restrictions *Misc. Devices***

mucosal atomization device Ameda Dual HygieniKit System OTC

*Nebulizers*** nebulizer compressor Pari LC Plus nebulizer updraft-style Pari LC Plus

*Needles & Syringes*** ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML Leader Insulin Syringe

BD ECLIPSE SYRINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Leader Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Elite-Thin Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 1 ML

Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML Leader Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE U-100 1 ML

Kmart Valu Insulin Syringe 30G

MONOJECT LIFESHIELD SYRINGE 18G X 1" 12 ML Syringe/Hypodermic Safety

MONOJECT MAGELLAN SYRINGE 18G X 1" 12 ML Syringe/Hypodermic Safety

MONOJECT MAGELLAN SYRINGE 20G X 1-1/2" 12 ML, 20G X 1-1/2" 6 ML, 21G X 1" 12 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML

Syringe

MONOJECT MAGELLAN SYRINGE 23G X 1" 1 ML, 25G X 5/8" 1 ML Anti-Stick Immun Syringe

MONOJECT MAGELLAN SYRINGE 25G X 1" 1 ML MONOJECT SAFETY SYRINGE/SHIELD 20G X 1-1/2" 12 ML, 20G X 1-1/2" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 6 ML

Syringe

90

Formulary Drug Name Reference Restrictions MONOJECT SYRINGE 20G X 1-1/2" 6 ML, 21G X 1" 6 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 6 ML

Syringe

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Elite-Thin Insulin Syringe QLL (100 EA per 30 days)

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe QLL (100 EA per 30 days)

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML Leader Insulin Syringe

*Peak Flow Meters*** TRUZONE PEAK FLOW METER DEVICE

Peak Flow Meter Universal Rang QLL (2 EA per 1 Year)

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device Pocket Chamber QLL (2 EA per 1 year) AEROCHAMBER MINI CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER MV Valved Holding Chamber QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU Valved Holding Chamber QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU LARGE Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU MEDIUM Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU SMALL Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU W/MASK Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLOW VU Valved Holding Chamber QLL (2 EA per 1 year) AEROCHAMBER W/FLOWSIGNAL Valved Holding Chamber QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS Valved Holding Chamber QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS CHAMBR Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/LARGE Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/MEDIUM Valved Holding Chamber QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/SMALL Valved Holding Chamber QLL (2 EA per 1 year)

AEROVENT PLUS DEVICE Valved Holding Chamber QLL (2 EA per 1 Year)

91

Formulary Drug Name Reference Restrictions BREATHERITE Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE COLL SPACER ADULT Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE COLL SPACER CHILD Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE COLL SPACER INFANT Valved Holding Chamber QLL (2 EA per 1 Year)

BREATHERITE RIGID SPACER/MASK Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE SPACER NEONATE Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE SPACER SMALL CHILD Valved Holding Chamber QLL (2 EA per 1 Year)

BREATHERITE/LARGE MASK Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE/MEDIUM MASK Valved Holding Chamber QLL (2 EA per 1 Year) BREATHERITE/SMALL MASK Valved Holding Chamber QLL (2 EA per 1 Year) EASIVENT Valved Holding Chamber QLL (2 EA per 1 Year) EASIVENT MASK LARGE Valved Holding Chamber QLL (2 EA per 1 Year) EASIVENT MASK MEDIUM Valved Holding Chamber QLL (2 EA per 1 Year) EASIVENT MASK SMALL Valved Holding Chamber QLL (2 EA per 1 Year) E-Z SPACER DEVICE Valved Holding Chamber QLL (2 EA per 1 Year) E-Z SPACER THE BODY GUARDS PK DEVICE Valved Holding Chamber QLL (2 EA per 1 Year)

FLEXICHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 1 year) INSPIRACHAMBER/MEDIUM DEVICE Valved Holding Chamber QLL (2 EA per 1 year) INSPIRACHAMBER/MOUTHPIECE DEVICE Valved Holding Chamber QLL (2 EA per 1 year)

INSPIRACHAMBER/SMALL DEVICE Valved Holding Chamber QLL (2 EA per 1 year) INSPIREASE Valved Holding Chamber QLL (2 EA per 1 Year) LITEAIRE DEVICE Valved Holding Chamber QLL (2 EA per 1 Year) MICROCHAMBER Valved Holding Chamber QLL (2 EA per 1 year) MICROSPACER Valved Holding Chamber QLL (2 EA per 1 year) OPTICHAMBER ADVANTAGE Valved Holding Chamber QLL (2 EA per 1 year) OPTICHAMBER ADVANTAGE-LG MASK Valved Holding Chamber QLL (2 EA per 1 year)

OPTICHAMBER ADVANTAGE-MED MASK Valved Holding Chamber QLL (2 EA per 1 year)

OPTICHAMBER ADVANTAGE-SM MASK Valved Holding Chamber QLL (2 EA per 1 year)

OPTICHAMBER DIAMOND Valved Holding Chamber QLL (2 EA per 1 year) OPTICHAMBER DIAMOND DEVICE Valved Holding Chamber QLL (2 EA per 1 year) OPTICHAMBER DIAMOND-LG MASK DEVICE Valved Holding Chamber QLL (2 EA per 1 year)

OPTICHAMBER DIAMOND-MD MASK Valved Holding Chamber QLL (2 EA per 1 year)

92

Formulary Drug Name Reference Restrictions OPTICHAMBER DIAMOND-SM MASK Valved Holding Chamber QLL (2 EA per 1 year) OPTIHALER Valved Holding Chamber QLL (2 EA per 1 Year) OPTIHALER DEVICE Valved Holding Chamber QLL (2 EA per 1 Year) POCKET CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 1 year) POCKET SPACER DEVICE Valved Holding Chamber QLL (2 EA per 1 year) RITEFLO DEVICE Valved Holding Chamber QLL (2 EA per 1 Year) VORTEX VALVED HOLDING CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 1 year)

WATCHHALER DEVICE Valved Holding Chamber QLL (2 EA per 1 Year)

*MIGRAINE PRODUCTS* *Ergot Combinations*** MIGERGOT RECTAL SUPPOSITORY 2 -100 MG

*Migraine Products*** dihydroergotamine mesylate nasal solution 4 mg/ml Migranal QLL (8 ML per 30 days)

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

*Selective Serotonin Agonists 5-Ht(1)*** naratriptan hcl oral tablet 1 mg, 2.5 mg Amerge QLL (9 EA per 30 days) rizatriptan benzoate oral tablet 10 mg, 5 mg Maxalt QLL (9 EA per 30 days) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg Maxalt-MLT QLL (9 EA per 30 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act Imitrex QLL (6 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Imitrex QLL (9 EA 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 Imitrex QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose System QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml QLL (4 Vials per 30 days)

*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium bicarbonate intravenous solution 8.4 %

93

Formulary Drug Name Reference Restrictions *Fluoride Combinations*** FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 1 (F) -236.79 MG

*Fluoride*** fluoritab oral solution 0.275 (0.125 f) mg/drop Fluor-a-day fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg Ludent

fluoritab oral tablet chewable 2.2 (1 f) mg NaFrinse sodium fluoride oral solution 1.1 (0.5 f) mg/ml Luride 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 Ludent

sodium fluoride oral tablet chewable 2.2 (1 f) mg NaFrinse

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML FLUOR-A-DAY ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

FLURA-DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP KARIDIUM ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

LUDENT ORAL TABLET CHEWABLE 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG

Sodium Fluoride

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

NAFRINSE ORAL TABLET CHEWABLE 2.2 (1 F) MG Sodium Fluoride

*Phosphate*** av-phos 250 neutral oral tablet 155-852-130 mg Phospho-Trin 250 Neutral

virt-phos 250 neutral oral tablet 155-852-130 mg Phospho-Trin 250 Neutral

K-PHOS ORAL TABLET 500 MG PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG Virt-Phos 250 Neutral

94

Formulary Drug Name Reference Restrictions *Potassium Combinations*** effervescent pot chloride oral tablet effervescent 25 meq pot bicarb-pot chloride oral tablet effervescent 25 meq

*Potassium*** k-effervescent oral tablet effervescent 25 meq K-Prime k-vescent oral tablet effervescent 25 meq K-Prime potassium bicarbonate oral tablet effervescent 25 meq K-Prime

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 Micro-K

potassium chloride er oral tablet extended release 10 meq, 20 meq K-Tab

potassium chloride er oral tablet extended release 8 meq Klor-Con

potassium chloride oral packet 20 meq Klor-Con potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ K-Effervescent

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ Potassium Chloride ER

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ Potassium Chloride Crys ER

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ Potassium Chloride Crys ER

KLOR-CON ORAL PACKET 20 MEQ Potassium Chloride KLOR-CON ORAL PACKET 25 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ Potassium Chloride ER

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ

Potassium Chloride ER

KLOR-CON/EF ORAL TABLET EFFERVESCENT 25 MEQ K-Effervescent

95

Formulary Drug Name Reference Restrictions K-PRIME ORAL TABLET EFFERVESCENT 25 MEQ K-Effervescent

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine hcl mouth/throat solution 4 % lidocaine viscous mouth/throat solution 2 %

*Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge 10 mg clotrimazole mouth/throat troche 10 mg nystatin mouth/throat suspension 100000 unit/ml

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution 0.12 % Paroex

PAROEX MOUTH/THROAT SOLUTION 0.12 % Chlorhexidine Gluconate

PERIOGARD MOUTH/THROAT SOLUTION 0.12 % Chlorhexidine Gluconate

*Fluoride Dental Products*** neutral sodium fluoride mouth/throat solution 0.2 % PreviDent

sf 5000 plus dental cream 1.1 % PreviDent 5000 Plus sf dental gel 1.1 % Karigel CAVAREST DENTAL GEL 1.1 % SF DENTA 5000 PLUS DENTAL CREAM 1.1 % SF 5000 Plus

DENTAGEL DENTAL GEL 1.1 % SF KARIGEL DENTAL GEL 1.1 % SF KARIGEL-N DENTAL GEL 1.1 % SF NEUTRAGARD ADVANCED DENTAL GEL 1.1 % SF

PHOS-FLUR DENTAL GEL 1.1 % SF

*Saliva Stimulants*** pilocarpine hcl oral tablet 5 mg, 7.5 mg Salagen

*Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste 0.1 % Oralone

ORALONE MOUTH/THROAT PASTE 0.1 % Triamcinolone Acetonide

96

Formulary Drug Name Reference Restrictions *MULTIVITAMINS* *Multiple Vitamins W/ Minerals*** biocel oral tablet Bacmin b-plex plus oral tablet Bacmin

v-c forte oral capsule PreserVision AREDS 2+Multi Vit

vit b3-azelac-turm-fa-b6-zn-cu oral tablet Bacmin CORVITE FREE ORAL TABLET GNP Century LYSIPLEX PLUS ORAL TABLET GNP Century NUTRIFAC ZX ORAL TABLET GNP Century VIC-FORTE ORAL CAPSULE Cellular Security VITA S FORTE ORAL TABLET GNP Century VITACEL ORAL TABLET GNP Century

*Ped Multi Vitamins W/Fl & Fe*** multi-vit/fluoride/iron oral solution 0.25-10 mg/ml

*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml Quflora Pediatric

multi-vitamin/fluoride oral solution 0.25 mg/ml Quflora Pediatric

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

multivitamins/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML Polyvitamin/Fluoride

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multivitamins/Fluoride

QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML Polyvitamin/Fluoride

QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML Poly-Vitamin/Fluoride

*Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution 0.25-10 mg/ml

*Ped Vitamins Acd W/ Fluoride*** tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

97

Formulary Drug Name Reference Restrictions tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml vitamins acd-fluoride oral solution 0.25 mg/ml

*Prenatal Mv & Min W/Fe-Fa*** bp multinatal plus oral tablet 30-1 mg QLL (100 EA per 90 days) bp multinatal plus oral tablet chewable 40-1 mg Vinate Care QLL (100 EA per 90 days)

completenate oral tablet chewable 29-1 mg QLL (100 EA per 90 days) dothelle dha oral capsule 53.5-38-1 mg Taron-C DHA QLL (100 EA per 90 days) mynatal plus oral tablet Vitafol-OB QLL (100 EA per 90 days) mynatal-z oral tablet Vitafol-OB QLL (100 EA per 90 days) pnv folic acid + iron oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days) pnv prenatal plus multivitamin oral tablet 27 -1 mg Prenatal/Folic Acid QLL (100 EA per 90 days)

pnv-select oral tablet 27-0.6-0.4 mg QLL (100 EA per 90 days) pnv-vp-u oral capsule 106.5-1 mg Prenatal-U QLL (100 EA per 90 days) prenatal 19 oral tablet QLL (100 EA per 90 days) prenatal 19 oral tablet chewable , 29-1 mg QLL (100 EA per 90 days) prenatal oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days) prenatal plus oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days) prenatal vitamin plus low iron oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days)

preplus oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days) se-natal 19 oral tablet chewable 29-1 mg QLL (100 EA per 90 days) triadvance oral tablet 90-1 mg Inatal GT QLL (100 EA per 90 days) trinatal rx 1 oral tablet 60-1 mg Vinate One QLL (100 EA per 90 days) virt-c dha oral capsule 53.5-38-1 mg Taron-C DHA QLL (100 EA per 90 days) vol-plus oral tablet 27-1 mg Prenatal/Folic Acid QLL (100 EA per 90 days) CONCEPT DHA ORAL CAPSULE 53.5 -38-1 MG Virt-C DHA QLL (100 EA per 90 days)

INATAL ADVANCE ORAL TABLET TriAdvance QLL (100 EA per 90 days) INATAL GT ORAL TABLET TriAdvance QLL (100 EA per 90 days) INATAL ULTRA ORAL TABLET TriAdvance QLL (100 EA per 90 days) M-VIT ORAL TABLET Prenatal Plus/Iron QLL (100 EA per 90 days) NIVA-PLUS ORAL TABLET 27-1 MG Prenatal Plus/Iron QLL (100 EA per 90 days) O-CAL FA ORAL TABLET 27-1 MG Prenatal Plus/Iron QLL (100 EA per 90 days) PRENATABS RX ORAL TABLET 29-1 MG Prenatal Plus Iron QLL (100 EA per 90 days)

PRENATAL-U ORAL CAPSULE 106.5-1 MG PNV-VP-U QLL (100 EA per 90 days)

98

Formulary Drug Name Reference Restrictions SELECT-OB ORAL TABLET CHEWABLE 29-1 MG QLL (100 EA per 90 days)

TARON-C DHA ORAL CAPSULE 53.5 -38-1 MG Virt-C DHA QLL (100 EA per 90 days)

TRICARE ORAL TABLET Prenatal Plus/Iron QLL (100 EA per 90 days) TRINATE ORAL TABLET Vol-Nate QLL (100 EA per 90 days) VINATE II ORAL TABLET 29-1 MG QLL (100 EA per 90 days) VINATE M ORAL TABLET 27-1 MG QLL (100 EA per 90 days) VINATE ONE ORAL TABLET 60-1 MG Trinatal Rx 1 QLL (100 EA per 90 days) VITAFOL-OB ORAL TABLET Mynatal-Z QLL (100 EA per 90 days)

*Prenatal Mv & Min W/Fe-Fa-Dha*** folcal dha oral capsule 27-1.25-300 mg VemaVite-PRx 2 QLL (100 EA per 90 days) pnv-dha oral capsule 27-0.6-0.4-300 mg Zatean-Pn DHA QLL (100 EA per 90 days) pnv-dha+docusate oral capsule 27-1.25-300 mg VemaVite-PRx 2 QLL (100 EA per 90 days)

SELECT-OB+DHA ORAL 29-1 & 250 MG QLL (100 EA per 90 days) VEMAVITE-PRX 2 ORAL CAPSULE 27 -1.25-300 MG Folcal DHA QLL (100 EA per 90 days)

*Prenatal Vitamins*** bp folinatal plus b oral tablet 1 mg QLL (100 EA per 90 days)

*Specialty Vitamins Products*** urosex oral tablet Brain

*MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg QLL (120 EA per 30 days)

carisoprodol oral tablet 350 mg Soma

Prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days)

chlorzoxazone oral tablet 500 mg Parafon Forte DSC QLL (120 EA per 30 days) cyclobenzaprine hcl oral tablet 10 mg QLL (90 EA per 30 days)

cyclobenzaprine hcl oral tablet 5 mg Max Limit (Max 21 DS in 90 days.); QLL (90 EA per 30 days)

methocarbamol oral tablet 500 mg Robaxin QLL (120 EA per 30 days) methocarbamol oral tablet 750 mg Robaxin-750 QLL (120 EA per 30 days)

99

Formulary Drug Name Reference Restrictions orphenadrine citrate er oral tablet extended release 12 hour 100 mg tizanidine hcl oral tablet 2 mg QLL (270 EA per 30 days) tizanidine hcl oral tablet 4 mg Zanaflex QLL (270 EA per 30 days)

*Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg QLL (120 EA per 30 days) dantrolene sodium oral capsule 25 mg, 50 mg Dantrium QLL (120 EA per 30 days)

*Muscle Relaxant Combinations*** carisoprodol-aspirin oral tablet 200-325 mg QLL (120 EA per 30 days) carisoprodol-aspirin-codeine oral tablet 200-325-16 mg QLL (120 EA per 30 days)

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 %, 0.06 % QLL (1 Bottle per 30 days)

*Nasal Antihistamines*** azelastine hcl nasal solution 0.1 % QLL (1 Bottle per 30 days) azelastine hcl nasal solution 0.15 % Astepro QLL (1 Bottle per 30 days)

*Nasal Steroids*** flunisolide nasal solution 25 mcg/act (0.025%) ST; QLL (2 Bottles per 30 days)

fluticasone propionate nasal suspension 50 mcg/act Flonase

ST; Step Therapy applies to Rx product only; QLL (1 bottle per 30 days)

mometasone furoate nasal suspension 50 mcg/act Nasonex ST; QLL (1 ea per 30 days)

triamcinolone acetonide nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC; QLL (1 Bottle per 30

days) RHINOCORT ALLERGY NASAL SUSPENSION 32 MCG/ACT Budesonide OTC; QLL (1 bottle per 30

Days)

*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG PA; QLL (60 EA per 30 days)

*NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet 50 mg Rilutek 100

Formulary Drug Name Reference Restrictions *OPHTHALMIC AGENTS* *Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml Cosopt QLL (10 mL per 30 days)

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % QLL (5 mL per 30 days)

*Beta-Blockers - Ophthalmic*** betaxolol hcl ophthalmic solution 0.5 % carteolol hcl ophthalmic solution 1 % levobunolol hcl ophthalmic solution 0.5 % Betagan metipranolol ophthalmic solution 0.3 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % Timoptic-XE QLL (5 mL per 30 days)

timolol maleate ophthalmic solution 0.25 %, 0.5 % Timoptic QLL (5 mL per 30 days)

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % QLL (10 mL per 30 days)

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl QLL (3 mL per 30 days)

homatropine hbr ophthalmic solution 5 % Homatropaire tropicamide ophthalmic solution 0.5 % QLL (15 mL per 30 days) tropicamide ophthalmic solution 1 % Mydriacyl QLL (15 mL per 30 days) HOMATROPAIRE OPHTHALMIC SOLUTION 5 % Homatropine HBr

*Miotics - Cholinesterase Inhibitors*** PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

*Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % Isopto Carpine QLL (15 mL per 30 days)

*Ophthalmic Antiallergic*** azelastine hcl ophthalmic solution 0.05 % ST cromolyn sodium ophthalmic solution 4 % QLL (10 mL per 30 days) epinastine hcl ophthalmic solution 0.05 % Elestat ST; QLL (5 mL per 30 days) olopatadine hcl ophthalmic solution 0.1 % Patanol ST; QLL (1 Bottle per 25 days)

101

Formulary Drug Name Reference Restrictions *Ophthalmic Antibiotics*** bacitracin ophthalmic ointment 500 unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % Ciloxan QLL (5 mL per 30 days) erythromycin ophthalmic ointment 5 mg/gm gatifloxacin ophthalmic solution 0.5 % Zymaxid QLL (2.5 mL per 30 days) gentamicin sulfate ophthalmic ointment 0.3 % Gentak gentamicin sulfate ophthalmic solution 0.3 % QLL (5 mL per 30 days) levofloxacin ophthalmic solution 0.5 % ofloxacin ophthalmic solution 0.3 % Ocuflox QLL (5 mL per 30 days) tobramycin ophthalmic solution 0.3 % Tobrex QLL (5 mL per 30 days) CILOXAN OPHTHALMIC OINTMENT 0.3 % GENTAK OPHTHALMIC OINTMENT 0.3 % Gentamicin Sulfate

TOBREX OPHTHALMIC OINTMENT 0.3 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % QLL (3 mL per 30 days)

*Ophthalmic Antifungal*** NATACYN OPHTHALMIC SUSPENSION 5 %

*Ophthalmic Anti-Infective Combinations*** ak-poly-bac ophthalmic ointment 500-10000 unit/gm Polycin

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Polycin

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 Neo-Polycin QLL (5 mL per 30 days)

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 Neosporin QLL (10 mL per 30 days)

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% Polytrim QLL (10 mL per 30 days)

NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000

Neomycin-Bacitracin Zn-Polymyx QLL (5 mL per 30 days)

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM Bacitracin-Polymyxin B

*Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 % Viroptic QLL (10 mL per 30 days)

102

Formulary Drug Name Reference Restrictions *Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution 2 % Trusopt QLL (10 mL per 30 days) AZOPT OPHTHALMIC SUSPENSION 1 % ST; QLL (15 mL per 30 days)

*Ophthalmic Decongestants*** phenylephrine hcl ophthalmic solution 10 %, 2.5 % Altafrin

ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 % Phenylephrine HCl

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution 0.1 % QLL (5 mL per 30 days) flurbiprofen sodium ophthalmic solution 0.03 % Ocufen

ketorolac tromethamine ophthalmic solution 0.4 % Acular LS QLL (5 mL per 30 days)

ketorolac tromethamine ophthalmic solution 0.5 % Acular

*Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic solution 0.15 % Alphagan P QLL (5 mL per 30 days)

brimonidine tartrate ophthalmic solution 0.2 % QLL (5 mL per 30 days)

*Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % Neo-Polycin HC

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 Maxitrol

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 Maxitrol QLL (5 mL per 30 days)

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 QLL (10 mL per 30 days)

sulfacetamide-prednisolone ophthalmic solution 10-0.23 % QLL (5 mL per 30 days)

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % TobraDex QLL (5 mL per 30 days)

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 %

Bacitra-Neomycin-Polymyxin-HC

103

Formulary Drug Name Reference Restrictions TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

*Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution 0.1 % QLL (5 mL per 30 days)

fluorometholone ophthalmic suspension 0.1 % FML Liquifilm QLL (10 mL per 30 days) prednisolone acetate ophthalmic suspension 1 % Omnipred QLL (10 mL per 30 days)

prednisolone sodium phosphate ophthalmic solution 1 % QLL (10 mL per 30 days)

FML FORTE OPHTHALMIC SUSPENSION 0.25 % QLL (10 mL per 30 days)

PRED MILD OPHTHALMIC SUSPENSION 0.12 % QLL (5 mL per 30 days)

*Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % Bleph-10 QLL (15 mL per 30 days)

*Prostaglandins - Ophthalmic*** latanoprost ophthalmic solution 0.005 % Xalatan QLL (2.5 ML per 25 days)

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % acetic acid-aluminum acetate otic solution 2 %

*Otic Analgesic Combinations*** exotic-hc otic solution 10-10-1 mg/ml Cortane-B otomax-hc otic solution 10-10-1 mg/ml Cortane-B CORTIC-ND OTIC SOLUTION 10-10-1 MG/ML Exotic-HC

CYOTIC OTIC SOLUTION 10-10-1 MG/ML Exotic-HC

*Otic Anti-Infectives*** ciprofloxacin hcl otic solution 0.2 % Cetraxal ofloxacin otic solution 0.3 % Floxin Otic

*Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution 1 %, 3.5 -10000-1 Cortisporin

104

Formulary Drug Name Reference Restrictions neomycin-polymyxin-hc otic suspension 3.5 -10000-1

*Otic Steroids*** hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC ACETASOL HC OTIC SOLUTION 2-1 % Hydrocortisone-Acetic Acid

*PASSIVE IMMUNIZING AGENTS* *Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML PA; QLL (1 Vial per 26 days)

*Immune Serums*** HEPAGAM B INJECTION SOLUTION HYPERHEP B S/D INTRAMUSCULAR SOLUTION 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 RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML QLL (2 mL per 1 Year)

*PENICILLINS* *Aminopenicillins*** 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 250 mg, 500 mg ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

*Natural Penicillins*** penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

105

Formulary Drug Name Reference Restrictions penicillin v potassium oral tablet 250 mg, 500 mg

*Penicillin Combinations*** amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg Augmentin XR QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml Augmentin

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml Augmentin ES-600

amoxicillin-pot clavulanate oral tablet 250 -125 mg QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet 500 -125 mg, 875-125 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)

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg

*PHARMACEUTICAL ADJUVANTS* *Oral Vehicles*** distilled water oral liquid RA Crystal Lake Dist Water OTC purified water oral liquid RA Crystal Lake Dist Water

*POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder Kayexalate sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml KIONEX ORAL POWDER Sodium Polystyrene Sulfonate KIONEX ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

SPS ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

106

Formulary Drug Name Reference Restrictions *PROGESTINS* *Progestins*** medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg Provera

megestrol acetate oral suspension 625 mg/5ml Megace ES norethindrone acetate oral tablet 5 mg Aygestin progesterone micronized oral capsule 100 mg, 200 mg Prometrium QLL (60 EA per 30 days)

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents*** acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg Antabuse

*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10 -25 mg, 5-12.5 mg

*Cholinomimetics - Ache Inhibitors***

donepezil hcl oral tablet 10 mg, 5 mg Aricept QLL (30 EA per 30 days); AL (Min 40 Years)

donepezil hcl oral tablet dispersible 10 mg, 5 mg

QLL (30 EA per 30 days); AL (Min 40 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 40 Years) galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg Razadyne QLL (60 EA per 30 days); AL

(Min 40 Years) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

QLL (60 EA per 30 days); AL (Min 40 Years)

*Fibromyalgia Agent - Snris*** 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)

*Ms Agents - Pyrimidine Synthesis Inhibitors*** AUBAGIO ORAL TABLET 14 MG, 7 MG PA; QLL (30 EA per 30 days)

107

Formulary Drug Name Reference Restrictions *Multiple Sclerosis Agents -Interferons*** EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA; QLL (15 Vials per 30 days) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

PA; QLL (12 Injectors per 30 days)

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


*Multiple Sclerosis Agents - Nrf2 Pathway Activators***

TECFIDERA ORAL 120 & 240 MG PA; QLL (1 STARTER PACK per 90 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG PA; QLL (60 EA per 30 days)

*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML


GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

PA; QLL (30 EA per 30 days)

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution 2 mg/ml Namenda AL (Min 40 Years) memantine hcl oral tablet 10 mg, 5 mg Namenda AL (Min 40 Years) memantine hcl oral tablet 5 (28)-10 (21) mg Namenda Titration Pak AL (Min 40 Years)

*Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

108

Formulary Drug Name Reference Restrictions *Smoking Deterrents***

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg Zyban

Max Limit (Limited to a 180 day supply every 365 days); QLL (60 EA per 30 days)

nicotine mini mouth/throat lozenge 4 mg Nicorette

Max Limit (Limited to a 180 day supply every 365 days); OTC; QLL (200 EA per 30 days); AL (Min 18 Years)

nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette Starter Kit


nicotine polacrilex mouth/throat lozenge 2 mg Commit


nicotine polacrilex mouth/throat lozenge 4 mg Nicorette


nicotine transdermal kit 21-14-7 mg/24hr Max Limit (Limited to a 180 day supply every 365 days); OTC; QLL (30 EA per 30 days)

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ

Max Limit (Limited to a 180 day supply every 365 days); QLL (30 EA per 30 days); AL (Min 18 Years)

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE 0.5 MG PA; QLL (30 EA per 30 days)

*Thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg Symbyax QLL (30 EA per 30 days)

*RESPIRATORY AGENTS -MISC.* *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML PA; QLL (150 mL per 30 days)

*SEROTONIN MODULATORS*** *Serotonin Modulators*** trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

109

Formulary Drug Name Reference Restrictions *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG ST; QLL (60 EA per 30 days)

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet 500 mg

*TETRACYCLINES* *Tetracyclines*** avidoxy oral tablet 100 mg Adoxa demeclocycline hcl oral tablet 150 mg, 300 mg doxycycline hyclate oral tablet 20 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg doxycycline monohydrate oral capsule 100 mg Monodox doxycycline monohydrate oral capsule 50 mg Mondoxyne NL doxycycline monohydrate oral suspension reconstituted 25 mg/5ml Vibramycin

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg Adoxa

doxycycline monohydrate oral tablet 150 mg Adoxa Pak 1/150 minocycline hcl oral capsule 100 mg, 50 mg, 75 mg Minocin

tetracycline hcl oral capsule 250 mg, 500 mg MONDOXYNE NL ORAL CAPSULE 100 MG, 50 MG Doxycycline Monohydrate

*THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg Tapazole propylthiouracil oral tablet 50 mg

*Thyroid Hormones*** levothyroxine sodium oral tablet 100 mcg, 137 mcg, 150 mcg, 175 mcg, 25 mcg Levoxyl QLL (30 EA per 30 days)

levothyroxine sodium oral tablet 112 mcg, 300 mcg, 75 mcg Unithroid Direct QLL (30 EA per 30 days)

levothyroxine sodium oral tablet 125 mcg, 200 mcg, 50 mcg, 88 mcg Unithroid QLL (30 EA per 30 days)

110

Formulary Drug Name Reference Restrictions liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Cytomel

np thyroid oral tablet 30 mg, 60 mg, 90 mg Armour Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 180 MG, 240 MG, 300 MG ARMOUR THYROID ORAL TABLET 15 MG NP Thyroid

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Levothyroxine Sodium QLL (30 EA per 30 days)

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


NATURE-THROID ORAL TABLET 130 MG UNITHROID DIRECT ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


WESTHROID ORAL TABLET 130 MG WP THYROID ORAL TABLET 130 MG

*ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg Bentyl dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 20 mg Bentyl

*Belladonna Alkaloids*** 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 solution 0.125 mg/ml hyoscyamine sulfate oral tablet 0.125 mg Levsin hyoscyamine sulfate oral tablet dispersible 0.125 mg NuLev

111

Formulary Drug Name Reference Restrictions hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Symax-SL

hyosyne oral elixir 0.125 mg/5ml hyosyne oral solution 0.125 mg/ml oscimin oral tablet 0.125 mg Levsin oscimin oral tablet dispersible 0.125 mg NuLev oscimin sr oral tablet extended release 12 hour 0.375 mg Levbid

oscimin sublingual tablet sublingual 0.125 mg Symax-SL NULEV ORAL TABLET DISPERSIBLE 0.125 MG Oscimin

SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG Oscimin

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG Hyoscyamine Sulfate ER

*H-2 Antagonists*** cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 300 mg, 400 mg, 800 mg QLL (60 EA per 30 days) famotidine oral suspension reconstituted 40 mg/5ml Pepcid

famotidine oral tablet 20 mg Pepcid famotidine oral tablet 40 mg Pepcid QLL (60 EA per 30 days) nizatidine oral capsule 150 mg QLL (60 EA per 30 days) nizatidine oral capsule 300 mg QLL (30 EA per 30 days) nizatidine oral solution 15 mg/ml ranitidine hcl oral capsule 150 mg, 300 mg QLL (60 EA per 30 days) ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml ranitidine hcl oral tablet 150 mg Zantac ranitidine hcl oral tablet 300 mg Zantac QLL (60 EA per 30 days)

*Misc. Anti-Ulcer*** sucralfate oral tablet 1 gm Carafate

*Proton Pump Inhibitors*** lansoprazole oral capsule delayed release 15 mg Prevacid QLL (60 EA per 30 days)

lansoprazole oral capsule delayed release 30 mg Prevacid QLL (30 EA per 30 days)

omeprazole oral capsule delayed release 20 mg PriLOSEC QLL (60 EA per 30 days)

112

Formulary Drug Name Reference Restrictions omeprazole oral capsule delayed release 40 mg QLL (30 EA per 30 days)

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg Protonix QLL (30 EA per 30 days)

rabeprazole sodium oral tablet delayed release 20 mg Aciphex QLL (30 EA per 30 days)

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML

*Quaternary Anticholinergics*** glycopyrrolate oral tablet 1 mg Robinul glycopyrrolate oral tablet 2 mg Robinul-Forte propantheline bromide oral tablet 15 mg

*Ulcer Drugs - Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg Cytotec

*URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine hippurate oral tablet 1 gm Hiprex 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 Furadantin

*URINARY ANTISPASMODICS* *Urinary Antispasmodic -Antimuscarinic (Anticholinergic)*** oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg Ditropan XL QLL (30 EA per 30 days)

oxybutynin chloride oral syrup 5 mg/5ml QLL (450 mL per 30 days) oxybutynin chloride oral tablet 5 mg QLL (90 EA per 30 days) tolterodine tartrate oral tablet 1 mg, 2 mg Detrol QLL (60 EA per 30 days) trospium chloride oral tablet 20 mg QLL (60 EA per 30 days) OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 MG/24HR QLL (8 Patches per 28 days)

113

Formulary Drug Name Reference Restrictions *Urinary Antispasmodic -Antimuscarinics (Antichol)***(New) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg Ditropan XL QLL (30 EA per 30 days)

oxybutynin chloride oral syrup 5 mg/5ml QLL (450 mL per 30 days) oxybutynin chloride oral tablet 5 mg QLL (90 EA per 30 days) tolterodine tartrate oral tablet 1 mg, 2 mg Detrol QLL (60 EA per 30 days) trospium chloride oral tablet 20 mg QLL (60 EA per 30 days) OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 MG/24HR QLL (8 Patches per 28 days)

*Urinary Antispasmodics -Cholinergic Agonists*** bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Urecholine

*Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Urecholine

*Urinary Antispasmodics - Direct Muscle Relaxants*** flavoxate hcl oral tablet 100 mg QLL (240 EA per 30 days)

*Urinary Antispasmodics - Direct Muscle Relaxants*** (New) flavoxate hcl oral tablet 100 mg QLL (240 EA per 30 days)

*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** miconazole 3 vaginal suppository 200 mg terconazole vaginal cream 0.4 % Terazol 7 terconazole vaginal cream 0.8 % Zazole terconazole vaginal suppository 80 mg Zazole ZAZOLE VAGINAL CREAM 0.8 % Terconazole ZAZOLE VAGINAL SUPPOSITORY 80 MG Terconazole

*Vaginal Anti-Infectives*** clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % Vandazole CLEOCIN VAGINAL SUPPOSITORY 100 MG VANDAZOLE VAGINAL GEL 0.75 % MetroNIDAZOLE

114

Formulary Drug Name Reference Restrictions *Vaginal Estrogens*** ESTRACE VAGINAL CREAM 0.1 MG/GM ESTRING VAGINAL RING 2 MG QLL (1 EA per 90 days) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR QLL (1 EA per 90 days)

PREMARIN VAGINAL CREAM 0.625 MG/GM YUVAFEM VAGINAL TABLET 10 MCG

*VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector 0.15 mg/0.15ml Adrenaclick QLL (2 Units Max Qty Per Fill

Retail) epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml EpiPen Jr 2-Pak QLL (4 PENS per 365 days)

epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml Adrenaclick QLL (4 PENS per 365 days)

*Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

*VITAMINS* *Vitamin D*** ergocalciferol oral capsule 50000 unit Drisdol vitamin d (ergocalciferol) oral capsule 50000 unit Drisdol

vitamin d3 oral tablet dispersible 5000 unit OTC

*Vitamin K*** MEPHYTON ORAL TABLET 5 MG

115

116

Index Header

abacavir sulfate 53

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abacavir sulfate-lamivudine 51abacavir-lamivudine-zidovudine 51acamprosate calcium 107acarbose 33acebutolol hcl 56acetaminophen-codeine 10, 11acetaminophen-codeine #2 10acetaminophen-codeine #3 10acetaminophen-codeine #4 10ACETASOL HC 105acetazolamide 78acetazolamide er 78acetic acid 104acetic acid-aluminum acetate 104acetylcysteine 70acidophilus lactobacillus 61ACTIMMUNE 46acyclovir 54, 73adapalene 70, 71AEROCHAMBER MINI CHAMBER 91AEROCHAMBER MV 91AEROCHAMBER PLUS FLO-VU 91AEROCHAMBER PLUS FLO-VU LARGE .....................

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91AEROCHAMBER PLUS FLO-VU MEDIUM 91AEROCHAMBER PLUS FLO-VU SMALL 91AEROCHAMBER PLUS FLO-VU W/MASK 91AEROCHAMBER PLUS FLOW VU 91AEROCHAMBER W/FLOWSIGNAL 91AEROCHAMBER Z-STAT PLUS 91AEROCHAMBER Z-STAT PLUS CHAMBR 91AEROCHAMBER Z-STAT PLUS/LARGE 91AEROCHAMBER Z-STAT PLUS/MEDIUM 91AEROCHAMBER Z-STAT PLUS/SMALL 91AEROVENT PLUS 91AFEDITAB CR 59AFINITOR 45

ak-poly-bac 102

ala-cort 73ALBENZA 22albuterol sulfate 26albuterol sulfate er 26alclometasone dipropionate 73ALCOH-GLOVE CONTOURED WIPE 89alcohol wipes 89alendronate sodium 79alfuzosin hcl er 83ALKERAN 46ALLI 5allopurinol 84alogliptin benzoate 34alogliptin-metformin hcl 34alogliptin-pioglitazone 34alphatrex 73alprazolam 23alprazolam er .............................

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23ALPRAZOLAM INTENSOL . 25alprazolam xr 24ALTAFRIN 103ALTAVERA 62alyacen 1/35 62alyacen 7/7/7 67amantadine hcl 47amcinonide 73AMETHIA 66AMETHYST 66amiloride hcl 79amiloride-hydrochlorothiazide 79amiodarone hcl 25amitriptyline hcl 33amlodipine besy-benazepril hcl 40amlodipine besylate 57amlodipine besylate-valsartan 41amlodipine-atorvastatin 59amlodipine-valsartan-hctz 42amoxapine 33amoxicillin 105amoxicillin-pot clavulanate 106amoxicillin-pot clavulanate er 106amphetamine-dextroamphet er 3amphetamine-dextroamphetamine 3ampicillin 105anagrelide hcl 85anastrozole 46ANORO ELLIPTA 26

APRI 62

APRISO 83APTIVUS 52ARANELLE 67ARBINOXA 38ARCAPTA NEOHALER 26ARGYLE STERILE SALINE .84ARGYLE STERILE WATER 56ARMOUR THYROID 111ARZOL SILVER NITAPPLICATORS 73ASCOMP-CODEINE 12ASHLYNA 66ASSURE ID INSULIN SAFETY SYR 90atenolol 56atenolol-chlorthalidone 43atorvastatin calcium 39ATRIPLA 51atropine sulfate 101ATROVENT HFA 26AUBAGIO 107AUBRA 62AURYXIA 83AVANDIA 37AVIANE 62avidoxy 110AVITA 71av-phos 250 neutral 94azathioprine 56azelastine hcl 100, 101azithromycin 88AZOPT 103AZURETTE 61bacitracin 102bacitracin-polymyxin b 102bacitra-neomycin-polymyxin-hc

103baclofen 99balsalazide disodium 82BALZIVA 62BARACLUDE 54BASAGLAR KWIKPEN 34BD ECLIPSE SYRINGE 90BEKYREE 61BELVIQ 5benazepril hcl 41benazepril-hydrochlorothiazide . 40BENZIQ WASH 71benzonatate 69

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117

benzphetamine hcl 4

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benztropine mesylate 47benzyl benzoate 61betamethasone dipropionate 73betamethasone dipropionate aug73betamethasone valerate 73betaxolol hcl 56, 101bethanechol chloride 114BETOPTIC-S 101bicalutamide 45biocel 97bio-statin 38biotuss 69bisoprolol fumarate 56bisoprolol-hydrochlorothiazide 43BLISOVI 24 FE 62BLISOVI FE 1.5/30 62BLISOVI FE 1/20 62bp foaming wash 71bp folinatal plus b 99bp multinatal plus 98bp wash 71b-plex plus 97BREATHERITE 92BREATHERITE COLL SPACER ADULT 92BREATHERITE COLL SPACER CHILD 92BREATHERITE COLL SPACER INFANT 92BREATHERITE RIGID SPACER/MASK 92BREATHERITE SPACER NEONATE 92BREATHERITE SPACER SMALL CHILD 92BREATHERITE/LARGE MASK 92BREATHERITE/MEDIUM MASK 92BREATHERITE/SMALL MASK 92BREO ELLIPTA 26briellyn 62brimonidine tartrate 103bromocriptine mesylate 47brompheniramine tannate 38budesonide 27bumetanide 79buprenorphine hcl 20buprenorphine hcl-naloxone hcl .20bupropion hcl .............................

31

bupropion hcl er (smoking det) 109bupropion hcl er (sr) 31bupropion hcl er (xl) 31buspirone hcl 23butalbital-acetaminophen 9butalbital-apap-caff-cod 11butalbital-apap-caffeine 9butalbital-asa-caff-codeine 11butalbital-aspirin-caffeine 9butorphanol tartrate 20BUTRANS 21cabergoline 80CABOMETYX 45caffeine citrate 4caffeine citrated 4calcipotriene 72calcitonin (salmon) 80calcitriol 80calcium acetate (phos binder) 83calcium folinate 61CAMILA 67CAMRESE 66CANASA 83candesartan cilexetil 42candesartan cilexetil-hctz 41CAPACET 9capecitabine 45captopril 41captopril-hydrochlorothiazide 40carbamazepine 29carbamazepine er 29carbidopa-levodopa 47carbidopa-levodopa er 47carbidopa-levodopa-entacapone

47, 48carbinoxamine maleate 38carisoprodol 99carisoprodol-aspirin 100carisoprodol-aspirin-codeine 100carteolol hcl 101CARTIA XT 59carvedilol 56CAVAREST 96CAZIANT 67cefaclor 60cefaclor er 60cefadroxil 60cefdinir 60cefixime 60cefpodoxime proxetil 60cefprozil 60CEFTIN 60

ceftriaxone sodium ......................

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60cefuroxime axetil 60celecoxib 8CELONTIN 31cephalexin 60cetirizine hcl 38CHATEAL 62CHEMET 37chlordiazepoxide hcl 24chlordiazepoxide-amitriptyline .107chlorhexidine gluconate . 50, 61, 96chloroquine phosphate 44chlorothiazide 79chlorpromazine hcl 50chlorpropamide 36chlorthalidone 79chlorzoxazone 99cholestyramine 39cholestyramine light 39choline & mag trisalicylate 10choline-mag trisalicylate 10CICLODAN 72ciclopirox 72ciclopirox olamine 72CIDALEAZE 77cilostazol 85CILOXAN 102cimetidine 112cimetidine hcl ............................

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112ciprofloxacin 82ciprofloxacin hcl 82, 102, 104ciprofloxacin-ciproflox hcl er 82citalopram hydrobromide 32citric acid-sodium citrate 83clarithromycin 88clarithromycin er 88CLEARPLEX X 71clemastine fumarate 38CLEOCIN 114CLIMARA PRO 81CLINDACIN ETZ 70CLINDACIN-P 70CLINDAMAX 70clindamycin hcl 44clindamycin palmitate hcl ...........44clindamycin phosphate 70, 114clobetasol propionate 74clobetasol propionate e 73CLODAN 75clonazepam 29clonidine hcl 42clopidogrel bisulfate 85

118

clorazepate dipotassium 24

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clotrimazole 76, 96clotrimazole-betamethasone 71clozapine 49codeine sulfate 13, 14colchicine 84colchicine-probenecid 84colestipol hcl 39COLOCORT 21COMBIGAN 101COMBIPATCH 81COMBIVENT RESPIMAT 26COMPLERA 51completenate 98COMPRO 50CONCEPT DHA 98CONDYLOX 77constulose 88CONTRAVE 47COPAXONE 108CORMAX SCALP APPLICATION 75CORTANE-B 78CORTIC-ND 104CORTIFOAM 21cortisone acetate 68CORVITE FREE 97CREON 78CRIXIVAN 52cromolyn sodium 26, 101CRYSELLE-28 62CUPRIMINE 55CURITY STERILE SALINE 84cyanocobalamin 85CYCLAFEM 1/35 62CYCLAFEM 7/7/7 67cyclobenzaprine hcl 99cyclopentolate hcl 101cyclosporine 55cyclosporine modified 55CYOTIC 104cyproheptadine hcl 39CYRED 62cytra k crystals 83danazol 21dantrolene sodium 100dapsone 44DARAPRIM 44DASETTA 1/35 63DASETTA 7/7/7 67DAYSEE 66DEBLITANE 67

DELTASONE 69DELYLA 63demeclocycline hcl 110DENTA 5000 PLUS 96DENTAGEL 96DERMAZENE 71DESCOVY ................................

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51desipramine hcl 33desmopressin ace rhinal tube 80desmopressin ace spray refrig 80desmopressin acetate 80desmopressin acetate spray 81desogestrel-ethinyl estradiol 61desonide 74desoximetasone 74dexamethasone 68dexamethasone sodium phosphate 104dexmethylphenidate hcl 5dexmethylphenidate hcl er 5dextroamphetamine sulfate 4dextroamphetamine sulfate er 3diazepam 24, 29diclofenac potassium 8diclofenac sodium 8, 72, 103diclofenac sodium er 8dicloxacillin sodium .................

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106dicyclomine hcl 111didanosine 53DIDREX 4diethylpropion hcl 4diethylpropion hcl er 4diflorasone diacetate 74diflunisal 10DIGITEK 59DIGOX 59digoxin 59dihydroergotamine mesylate 93DILANTIN 31diltiazem cd 57diltiazem hcl ...............................

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58diltiazem hcl er 58diltiazem hcl er beads 57diltiazem hcl er coated beads 57dilt-xr 58diphenhydramine hcl 38diphenoxylate-atropine 37dipyridamole 85disopyramide phosphate 25distilled water 106disulfiram 107divalproex sodium 31

divalproex sodium er 31donepezil hcl 107dorzolamide hcl 103dorzolamide hcl-timolol mal 101dothelle dha 98doxazosin mesylate 42doxepin hcl ..................................

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33doxycycline hyclate 110doxycycline monohydrate 110drospirenone-ethinyl estradiol 62DROXIA 85DULERA 26duloxetine hcl 32E.E.S. 400 89EASIVENT 92EASIVENT MASK LARGE 92EASIVENT MASK MEDIUM 92EASIVENT MASK SMALL 92econazole nitrate 76ed-spaz 111EDURANT 52EFFER-K 95effervescent pot chloride 95ELIDEL 77ELINEST 63ELLA 66ELMIRON 84EMCYT 46EMEND 37EMOQUETTE 63EMTRIVA 53enalapril maleate 41enalapril-hydrochlorothiazide 40ENBREL 9ENBREL SURECLICK 9ENDOCET 19, 20enoxaparin sodium 28ENPRESSE-28 67ENSKYCE 63entacapone 48entecavir 53ENTRESTO 100enulose 83epinastine hcl 101epinephrine 115EPITOL 30EPIVIR HBV 54EPOGEN 85ergocalciferol 115ERGOMAR 93ERRIN 67ery 70

119

ERYPED 400 89

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ERY-TAB 89ERYTHROCIN STEARATE 89erythromycin 70, 102erythromycin base 88erythromycin ethylsuccinate .88, 89escitalopram oxalate 32ESGIC 9essentra wipes 9x9" 77ESTARYLLA 63estazolam 87ESTRACE 115estradiol 81estradiol-norethindrone acet 81ESTRING 115estropipate 81ethambutol hcl 44ethosuximide 31etidronate disodium 79etodolac 8etodolac er 8etoposide 46EVOTAZ 51exemestane 46exotic-hc 104EXTAVIA 108E-Z SPACER 92E-Z SPACER THE BODY GUARDS PK 92ezetimibe 40FALMINA 63famciclovir 54, 55famotidine 112FARESTON 45fa-vitamin b-6-vitamin b-12 86felbamate 30felodipine er 58FEMCAP 89FEMRING 115fenofibrate .................................. 39fenofibrate micronized 39fenofibric acid 39fenoprofen calcium 8fentanyl 14finasteride 83FIRST-LANSOPRAZOLE 113FIRST-OMEPRAZOLE 113FIRST-VANCOMYCIN 25 43FIRST-VANCOMYCIN 50 43flavoxate hcl 114flecainide acetate 25FLEXICHAMBER 92

FLORIVA PLUS 97FLOVENT DISKUS 27fluconazole 38fludrocortisone acetate 69flunisolide 100fluocinolone acetonide 74fluocinonide 74fluocinonide-e 74FLUORABON ..........................

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94FLUOR-A-DAY 94fluoritab 94fluorometholone 104FLUOROPLEX 72fluorouracil 72fluoxetine hcl 32fluoxetine hcl (pmdd) 108fluphenazine decanoate 50fluphenazine hcl 50FLURA-DROPS 94flurazepam hcl 87flurbiprofen 8flurbiprofen sodium 103flutamide 45fluticasone propionate 74, 100fluvastatin sodium 39fluvastatin sodium er 39fluvoxamine maleate 32FML FORTE 104folcal dha 99folic acid 86folplex 2.2 86fondaparinux sodium 28fosinopril sodium 41fosinopril sodium-hctz 40FRAGMIN 28furosemide 79FUZEON 51FYAVOLV 81gabapentin 29GABITRIL 30galantamine hydrobromide 107galantamine hydrobromide er 107gatifloxacin 102GAVILYTE-C 88GAVILYTE-G 88GAVILYTE-N WITH FLAVOR PACK 88gemfibrozil 39generlac 83GENGRAF 55GENTAK 102gentamicin sulfate 71, 102

GENVOYA 51GIANVI 63GILDAGIA 63GILDESS FE 1.5/30 63GILDESS FE 1/20 63GILENYA 109GLATIRAMER ACETATE 108glimepiride 36glipizide 36glipizide er 36glipizide xl 36glipizide-metformin hcl 36GLUCAGEN HYPOKIT 33GLUCAGON EMERGENCY . 33glyburide 36glyburide micronized 36glyburide-metformin 36glycerine 61glycopyrrolate ...........................113GLYDO 77granisetron hcl 37GRANIX 86griseofulvin microsize 38griseofulvin ultramicrosize 38guanfacine hcl 42halobetasol propionate 74haloperidol 49haloperidol decanoate 49haloperidol lactate 49HEATHER 67HEMMOREX-HC 22HEPAGAM B 105heparin sodium (porcine) 28heparin sodium (porcine) pf 28HEXALEN 45HOMATROPAIRE 101homatropine hbr 101HUMALOG 34HUMALOG KWIKPEN 34HUMALOG MIX 50/50 34HUMALOG MIX 50/50 KWIKPEN 34HUMALOG MIX 75/25 34HUMALOG MIX 75/25 KWIKPEN 34HUMIRA 7HUMIRA PEDIATRIC CROHNS START 7HUMIRA PEN 7HUMIRA PEN-CROHNS STARTER 7

120

HUMIRA PEN-PSORIASIS STARTER 7

HUMULIN 70/30 KWIKPEN . 35HUMULIN N KWIKPEN 35HUMULIN R U-500 (CONCENTRATED) 35HUMULIN R U-500 KWIKPEN 35hydralazine hcl 43hydrochlorothiazide 79hydrocodone-acetaminophen 12hydrocodone-homatropine 69hydrocodone-ibuprofen 12hydrocortisone 21, 68, 75hydrocortisone acetate 22, 74hydrocortisone butyr lipo base 75hydrocortisone butyrate 75hydrocortisone micronized 75hydrocortisone valerate 75hydrocortisone-acetic acid 105hydrocortisone-iodoquinol 71hydromet 69hydromorphone hcl 14, 15hydroxychloroquine sulfate 44hydroxyprogesterone caproate 61hydroxyurea 46hydroxyzine hcl 23hydroxyzine pamoate 23hyoscyamine sulfate 111, 112hyoscyamine sulfate er 111hyosyne 112HYPERHEP B S/D 105HYPERRHO S/D 105HYPERSAL 69ibandronate sodium 80ibuprofen ......................................

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8ICAR-C PLUS 86imatinib mesylate 45IMBRUVICA 46imipramine hcl 33imiquimod 76INATAL ADVANCE 98INATAL GT 98INATAL ULTRA 98INCRUSE ELLIPTA 27indapamide 79indomethacin 8indomethacin er 8INSPIRACHAMBER/MEDIUM 92INSPIRACHAMBER/MOUTHPIECE 92

INSPIRACHAMBER/SMALL92

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INSPIREASE 92INTELENCE 52INTRON A 46INTROVALE 66INVIRASE ................................

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INVOKAMET 110INVOKANA 36ipratropium bromide 26, 100ipratropium-albuterol 25irbesartan 42irbesartan-hydrochlorothiazide ..42ISENTRESS 51, 52isoniazid 44isosorbide dinitrate 22isosorbide dinitrate er 22isosorbide mononitrate 22isosorbide mononitrate er .......... 22isradipine 58itraconazole 38ivermectin 22JANTOVEN 28JENCYCLA 67JENTADUETO 34JENTADUETO XR 34jevantique lo 81JINTELI 81JOLESSA 66JOLIVETTE 67JULEBER 63JUNEL 1.5/30 63JUNEL 1/20 63JUNEL FE 1.5/30 63JUNEL FE 1/20 63JUNEL FE 24 63KALETRA 51KARIDIUM 94KARIGEL 96KARIGEL-N 96KARIVA 61k-effervescent 95KELNOR 1/35 63ketoconazole 38, 76ketoprofen 8ketorolac tromethamine 8, 103KIMIDESS 61KIONEX 56, 106KLOR-CON 95KLOR-CON 10 95KLOR-CON M10 95KLOR-CON M15 95KLOR-CON M20 95

KLOR-CON SPRINKLE 95

KLOR-CON/EF 95kp clotrimazole 76K-PHOS 94K-PHOS NO 2 84K-PRIME 96KURVELO 63k-vescent 95KYLEENA 67labetalol hcl 56lactulose 88lactulose encephalopathy 83lamivudine 53lamivudine-zidovudine 51lamotrigine 29, 30LANOXIN 59lansoprazole 112LANTUS 35LANTUS SOLOSTAR 35LARIN 1.5/30 63LARIN 1/20 63LARIN 24 FE 63LARIN FE 1.5/30 64LARIN FE 1/20 64latanoprost 104LEENA 68leflunomide 9LESSINA 64letrozole 46leucovorin calcium 46, 61LEUKERAN 46LEUKINE 86levetiracetam 30levetiracetam er 30levobunolol hcl 101levocarnitine 80levofloxacin .........................82, 102LEVONEST 68levonorgest-eth estrad 91-day 66levonorgestrel 66levonorgestrel-ethinyl estrad 62, 66levonorg-eth estrad triphasic 67LEVORA 0.15/30 (28) 64LEVO-T 111levothyroxine sodium 110LEVOXYL 111LEXIVA 52LIDAZONE HC 22lidocaine 77lidocaine hcl 77, 96lidocaine viscous 96

121

lidocaine-hydrocortisone ace 21, 22

lidocaine-prilocaine 78lidopin 77lindane 77LINZESS 82liothyronine sodium 111lisinopril 41lisinopril-hydrochlorothiazide 40LITEAIRE 92lithium 48lithium carbonate .......................

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48lithium carbonate er 48LIVIXIL PAK 78lofene 37LOKARA 75LOMEDIA 24 FE 64loperamide hcl 37lopinavir-ritonavir 51lorazepam 24LORAZEPAM INTENSOL 25LORCET 13LORCET HD 13LORCET PLUS 13LORTAB 13LORYNA 64losartan potassium 42losartan potassium-hctz 42lovastatin 39LOW-OGESTREL 64loxapine succinate 49LP LITE PAK 78LUDENT 94LUTERA 64LYRICA 30LYSIPLEX PLUS 97LYSODREN 45LYZA 67MAGELLAN INSULIN SAFETY SYR 90malathion 77maprotiline hcl 32marlissa 62MARPLAN 32marten-tab 9MATULANE 46meclizine hcl 37meclofenamate sodium 8medroxyprogesterone acetate

67, 107mefloquine hcl 44megestrol acetate 46, 107

meloxicam 8

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memantine hcl 108MENEST 82MEPHYTON .......................... 115meprobamate 23mercaptopurine 45mesalamine 82MESNEX 47metaproterenol sulfate 26metformin hcl 33metformin hcl er 33methadone hcl 15METHADONE HCL INTENSOL 18methazolamide 78methenamine hippurate 113methenamine mandelate 113methimazole 110methocarbamol 99methotrexate 45methotrexate sodium (pf) 45methoxsalen rapid 72methyclothiazide 79methyldopa 42methyldopa-hydrochlorothiazide 41methylphenidate hcl 6methylphenidate hcl er 5, 6methylphenidate hcl er (cd) 5methylphenidate hcl er (la) 5methylprednisolone 68methyltestosterone 21metipranolol 101metoclopramide hcl 82metolazone 79metoprolol succinate er 56metoprolol tartrate 57metoprolol-hydrochlorothiazide .43metronidazole 43, 77, 114mexiletine hcl 25miconazole 3 114MICRHOGAM ULTRA-FILTERED PLUS 105MICROCHAMBER 92MICROGESTIN 1.5/30 64MICROGESTIN 1/20 64MICROGESTIN 24 FE 64MICROGESTIN FE 1.5/30 64MICROGESTIN FE 1/20 64MICROSPACER 92midodrine hcl 115MIGERGOT 93MIMVEY 81

MIMVEY LO 81

mineral oil heavy 88mineral oil light 88MINITRAN 23minocycline hcl 110minoxidil 43MIRENA (52 MG) 67mirtazapine 31misoprostol 113modafinil 6MODERIBA 54moexipril hcl 41moexipril-hydrochlorothiazide ...40molindone hcl 49mometasone furoate ............75, 100MONDOXYNE NL 110MONOJECT INSULIN SYRINGE 90MONOJECT LIFESHIELD SYRINGE 90MONOJECT MAGELLAN SYRINGE 90MONOJECT SAFETY SYRINGE/SHIELD 90MONOJECT SYRINGE 91MONOJECT ULTRA COMFORT SYRINGE 91MONO-LINYAH 64MONONESSA 64montelukast sodium 27morphine sulfate 16, 17morphine sulfate (concentrate) 15morphine sulfate er 15, 16MOVANTIK 83MOZOBIL 85mucosal atomization device 90MULTAQ 25multi-vit/fluoride 97multi-vit/fluoride/iron 97multivitamin/fluoride 97multi-vitamin/fluoride 97multivitamins/fluoride 97mupirocin 71MVC-FLUORIDE 97M-VIT 98MY WAY 66mycophenolate mofetil 55, 56MYLERAN 45mynatal plus 98mynatal-z 98MYORISAN 71MYZILRA 68

122

NABI-HB 105

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nabumetone 8nadolol 57nadolol-bendroflumethiazide 43NAFRINSE 94NAFRINSE DROPS 94naloxone hcl 37naltrexone hcl 37naproxen 8naproxen dr 8naproxen sodium 8naratriptan hcl 93NARCAN 37NATACYN 102nateglinide 35NATURE-THROID 111nebulizer compressor 90nebulizer updraft-style 90NEBUSAL 69, 70NECON 0.5/35 (28) 64NECON 1/35 (28) 64NECON 1/50 (28) 64NECON 10/11 (28) 61NECON 7/7/7 68neomycin sulfate 7neomycin-bacitracin zn-polymyx

102neomycin-polymyxin-dexameth 103neomycin-polymyxin-gramicidin

102neomycin-polymyxin-hc

103, 104, 105NEO-POLYCIN 102NEO-POLYCIN HC 103NEOSALUS 75NEUTRAGARD ADVANCED96neutral sodium fluoride 96nevirapine 52nevirapine er 52NEXAVAR 45NEXPLANON 67niacin er (antihyperlipidemic) 40nicardipine hcl 58nicotine 109nicotine mini 109nicotine polacrilex 109NIFEDIAC CC 59NIFEDICAL XL 59nifedipine 58nifedipine er 58nifedipine er osmotic release 58NIKKI 64

nilutamide 45nimodipine 58nisoldipine er 58NITRO-BID ..............................

............. ................ ................

23nitrofurantoin 113nitrofurantoin macrocrystal 113nitrofurantoin monohyd macro 113nitroglycerin 22, 23nitroglycerin er 22NITRO-TIME 23NIVA-PLUS 98nizatidine 112NORA-BE 67norethin ace-eth estrad-fe 62norethindrone 67norethindrone acetate 107norethindrone acet-ethinyl est 62norethindrone-eth estradiol 81norgestimate-eth estradiol 62norgestim-eth estrad triphasic 67NORLYROC 67NORTREL 0.5/35 (28) 64NORTREL 1/35 (21) 64NORTREL 1/35 (28) 64NORTREL 7/7/7 68nortriptyline hcl 33NORVIR 52NOVOLOG 35NOVOLOG FLEXPEN 35NOVOLOG MIX 70/30 35NOVOLOG MIX 70/30 FLEXPEN 35np thyroid .................................

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111NULEV 112NUTRIFAC ZX 97NUVARING 65NYAMYC 72nystatin 38, 72, 96NYSTOP 72O-CAL FA 98OCELLA 64octreotide acetate 80OFF DEEP WOODS 76OFF DEEP WOODS DRY 76OFF DEEP WOODS SPORTSMEN 76OFF FAMILYCARE CLEAN FEEL 76OFF SMOOTH & DRY 76ofloxacin 82, 102, 104OGESTREL 65olanzapine 50

olanzapine-fluoxetine hcl ..........109olopatadine hcl 101omeprazole 112, 113OMEPRAZOLE+SYRSPEND SF ALKA 113OMNIFLEX DIAPHRAGM ....

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89OMNITROPE 80ondansetron 37ondansetron hcl 37ONETOUCH ULTRA BLUE 78ONETOUCH VERIO 78OPTICHAMBER ADVANTAGE 92OPTICHAMBER ADVANTAGE-LG MASK 92OPTICHAMBER ADVANTAGE-MED MASK 92OPTICHAMBER ADVANTAGE-SM MASK 92OPTICHAMBER DIAMOND 92OPTICHAMBER DIAMOND-LG MASK 92OPTICHAMBER DIAMOND-MD MASK 92OPTICHAMBER DIAMOND-SM MASK 93OPTIHALER 93ORALONE 96ORENCIA 9orphenadrine citrate er 100ORSYTHIA 65oscimin 112oscimin sr 112OSCION CLEANSER 71oseltamivir phosphate 55otomax-hc 104oxaprozin 8oxazepam 25oxcarbazepine 30oxybutynin chloride 113, 114oxybutynin chloride er 113, 114oxycodone hcl 17, 18oxycodone-acetaminophen 19oxycodone-aspirin 19oxymorphone hcl 18oxymorphone hcl er 18OXYTROL 113, 114PACERONE 25pamidronate disodium 80pantoprazole sodium 113PARAGARD INTRAUTERINE COPPER 66

123

paricalcitol 80

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PAROEX 96paromomycin sulfate 7paroxetine hcl 32peg 3350/electrolytes 87peg 3350-kcl-na bicarb-nacl 87peg-3350/electrolytes 88PEGASYS 54PEGASYS PROCLICK 54PEGINTRON 54PEG-INTRON REDIPEN .......

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54PEG-INTRON REDIPEN PAK 4 54penicillin v potassium 105, 106pentazocine-naloxone hcl 20pentoxifylline er 85perindopril erbumine 41PERIOGARD 96permethrin 77perphenazine 50perphenazine-amitriptyline 108PHENADOZ 39PHENAZO 84phenazopyridine hcl 84phendimetrazine tartrate 4phendimetrazine tartrate er 4phenelzine sulfate 32PHENERGAN 39phenobarbital 86phentermine hcl 4phenyleph-promethazine-cod 70phenylephrine hcl 103phenytoin 30PHENYTOIN INFATABS 31phenytoin sodium extended 31PHILITH 65PHOS-FLUR 96PHOSLYRA 83PHOSPHA 250 NEUTRAL 94PHOSPHOLINE IODIDE 101pilocarpine hcl 96, 101PIMTREA 61pindolol 57pioglitazone hcl 37pioglitazone hcl-glimepiride 36pioglitazone hcl-metformin hcl 36PIRMELLA 1/35 65PIRMELLA 7/7/7 68piroxicam 8pnv folic acid + iron 98pnv prenatal plus multivitamin 98pnv-dha 99

pnv-dha+docusate 99pnv-select 98pnv-vp-u 98POCKET CHAMBER 93POCKET SPACER 93podofilox 76POLYCIN 102polyethylene glycol 3350 88polymyxin b-trimethoprim 102PORTIA-28 65pot bicarb-pot chloride 95potassium bicarbonate ...............

..................... 95

potassium chloride 95potassium chloride crys er 95potassium chloride er 95potassium citrate er 83, 84potassium citrate-citric acid 84pramipexole dihydrochloride 48pravastatin sodium 39, 40prazosin hcl 42PRED MILD 104prednicarbate 75prednisolone 68prednisolone acetate 104prednisolone sodium phosphate

68, 69, 104prednisone 69PREFEST 81PREMARIN 82, 115premium lidocaine 77PREMPHASE 81PREMPRO 81PRENATABS RX 98prenatal ......................................

................................. 98

prenatal 19 98prenatal plus 98prenatal vitamin plus low iron 98PRENATAL-U 98PRENTIF CAVITY-RIM CERV CAP 89PRENTIF FITTING SET 89preplus 98PREVALITE 39PREVIFEM 65PREZCOBIX 51PREZISTA 52PRIFTIN 44primidone 30probenecid 84prochlorperazine 50prochlorperazine maleate 50PROCTOFOAM HC 22

PROCTO-PAK 22PROCTOSOL HC 22PROCTOZONE-HC 22progesterone micronized 107PROMACTA .............................

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86promethazine hcl 38promethazine vc plain 69promethazine vc/codeine 70promethazine-codeine 70promethazine-dm 70promethazine-phenylephrine 69PROMETHEGAN 39propafenone hcl 25propantheline bromide 113propranolol hcl 57propranolol hcl er 57propranolol-hctz 43propylthiouracil 110protriptyline hcl 33PULMICORT 27PULMICORT FLEXHALER . 27PULMOSAL 70PULMOZYME 109purified water 106pyrazinamide 44pyridostigmine bromide 44pyrimethamine 61QSYMIA 4QUASENSE 66quetiapine fumarate 49QUFLORA PEDIATRIC 97quinapril hcl 41quinapril-hydrochlorothiazide 40quinidine gluconate er 25quinidine sulfate 25QVAR 27rabeprazole sodium 113raloxifene hcl 80ramipril 41ranitidine hcl 112RAPAMUNE 56REBETOL 54REBIF 108REBIF REBIDOSE 108REBIF REBIDOSE TITRATION PACK 108REBIF TITRATION PACK 108RECLIPSEN 65RECTIV 21reeses pinworm medicine 22REGIMEX 4RELADOR PAK 78

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RELADOR PAK PLUS 78

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RELENZA DISKHALER 55repaglinide 35repaglinide-metformin hcl 35RESCRIPTOR 53RETROVIR ..............................

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53REVLIMID 55REYATAZ 52RHINOCORT ALLERGY 100RHOGAM ULTRA-FILTERED PLUS 105RHOPHYLAC 105RIBASPHERE 54RIBASPHERE RIBAPAK 54ribavirin 54RIDAURA 8rifabutin 44rifampin 44riluzole 100rimantadine hcl 55risperidone 48, 49RISPERIDONE M-TAB 49RITEFLO 93rivastigmine tartrate 107rizatriptan benzoate 93ropinirole hcl 48ropinirole hcl er 48ROSADAN 77rosuvastatin calcium 40ROZEREM 87SALACYN 77salicylic acid 77salsalate 10SANDOSTATIN LAR DEPOT 80SANTYL 75SAVELLA 107SAVELLA TITRATION PACK 107SAWYER INSECT REPELLENT 76scalacort 75SEB-PREV WASH 73SELECT-OB 99SELECT-OB+DHA 99selegiline hcl 47selenium sulfide 72selenium sulf-pyrithione-urea 72SELZENTRY 51se-natal 19 98sertraline hcl 32SETLAKIN 66

sf 96sf 5000 plus 96SHAROBEL 67sildenafil citrate 59silver sulfadiazine 73simvastatin 40sirolimus 56sodium bicarbonate 93sodium chloride 69, 84sodium fluoride 94sodium polystyrene sulfonate

56, 106SOLIRIS 85SOLTAMOX 45sotalol hcl 57sotalol hcl (af) ............................

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57spironolactone 79spironolactone-hctz 79SPRINTEC 28 65SPS 56, 106SRONYX 65SSD 73stavudine 53sterile water for irrigation 56stevia extract 61steviol glycosides 61stevioside 61STIOLTO RESPIMAT 26STRIBILD 51STRIVERDI RESPIMAT 26sucralfate 112sulfacetamide sodium 70, 72, 104sulfacetamide sodium (acne) 70sulfacetamide-prednisolone 103sulfadiazine 110sulfamethoxazole-trimethoprim ..43sulfasalazine 82, 83SULFATRIM PEDIATRIC 44sulindac 9sumatriptan 93sumatriptan succinate 93sumatriptan succinate refill 93SUPRAX 61SUSTIVA 53SUTENT 45SYEDA 65SYMAX-SL 112SYMAX-SR 112SYNAGIS 105TABLOID 45tacrolimus 56, 77TAMIFLU 55

tamoxifen citrate 45tamsulosin hcl 83TANZEUM 35TARCEVA 46TARGRETIN 78TARINA FE 1/20 65TARON-C DHA ........................99TARON-CRYSTALS 84TASIGNA 46TAZTIA XT 59TECFIDERA 108temazepam 87temozolomide 46TENCON 9terazosin hcl 42terbinafine hcl 38terbutaline sulfate 26terconazole 114testosterone 21testosterone cypionate 21testosterone enanthate 21tetracycline hcl 110THALOMID 55THEOCHRON 27theophylline 27theophylline er 27THERMAZENE 73thioridazine hcl 50thiothixene 50tiagabine hcl 30TILIA FE 68timolol maleate 57, 101TIVICAY 52tizanidine hcl 100TOBRADEX 104tobramycin 7, 102tobramycin-dexamethasone 103TOBREX 102tolazamide 36tolbutamide 36tolmetin sodium 9tolterodine tartrate 113, 114topiramate 30torsemide 79TRADJENTA 34tramadol hcl 18tramadol-acetaminophen 21trandolapril 41tranylcypromine sulfate 32trazodone hcl 32, 109tretinoin 47, 71triadvance 98

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triamcinolone acetonide 75, 96, 100

triamterene-hctz 79triazolam 87TRICARE 99tricitrates 84TRIDERM 75TRI-ESTARYLLA 68trifluoperazine hcl 50trifluridine 102trihexyphenidyl hcl 47TRI-LEGEST FE 68TRI-LINYAH 68TRILYTE 88trimethobenzamide hcl 37trimethoprim 43trinatal rx 1 98TRINATE 99TRINESSA (28) 68TRI-PREVIFEM 68TRI-SPRINTEC 68TRIUMEQ ................................

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51tri-vit/fluoride 97tri-vit/fluoride/iron 97tri-vitamin/fluoride 98TRIVORA (28) 68tropicamide 101trospium chloride 113, 114TRULICITY 35TRUVADA 51TRUZONE PEAK FLOW METER 91TUSSIGON 69TYBOST 50TYKERB 46ULESFIA 77ULORIC 84ULTICARE INSULIN SAFETY SYR 91ULTRATHON INSECT REPELLENT 8 76UNITHROID ..........................

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111UNITHROID DIRECT 111urosex 99ursodiol 82valacyclovir hcl 54valproic acid 31valsartan 42valsartan-hydrochlorothiazide 42valved holding chamber 91vancomycin hcl 43VANDAZOLE 114

v-c forte 97

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VELIVET 68VEMAVITE-PRX 2 99venlafaxine hcl 33venlafaxine hcl er 33VENTOLIN HFA 26verapamil hcl 58, 59verapamil hcl er 58VESTURA 65VIC-FORTE 97VIDEX 53VIENVA 65VIGAMOX 102VINATE II 99VINATE M 99VINATE ONE 99VIOKACE 78viorele 61VIRACEPT 52VIRAMUNE XR 53VIREAD 53virt-c dha 98virt-phos 250 neutral 94virtrate-2 84virtrate-3 84virtrate-k 84vit b3-azelac-turm-fa-b6-zn-cu 97VITA S FORTE 97VITACEL 97VITAFOL-OB 99vitamin d (ergocalciferol) 115vitamin d3 115vitamins acd-fluoride 98VIVITROL 37vol-plus 98VORTEX VALVED HOLDING CHAMBER 93VOTRIENT 46VYFEMLA 65warfarin sodium 28WATCHHALER 93WERA 65WESTHROID 111WIDE-SEAL DIAPHRAGM 60 89WIDE-SEAL DIAPHRAGM 65 89WIDE-SEAL DIAPHRAGM 70 89WIDE-SEAL DIAPHRAGM 75 89

WIDE-SEAL DIAPHRAGM 80 89WIDE-SEAL DIAPHRAGM 85 89WIDE-SEAL DIAPHRAGM 90 89WIDE-SEAL DIAPHRAGM 95 89WP THYROID 111XARELTO 28XARELTO STARTER PACK 28XULANE 65YUVAFEM 115zafirlukast 27zaleplon 87ZARAH 65ZARXIO 86ZAZOLE 114ZEBUTAL 10ZENATANE 71ZENCHENT 65ZENPEP 78ZEPATIER 86ZIAGEN 53zidovudine 53ziprasidone hcl 48zolpidem tartrate 87zonisamide 30ZOVIA 1/35E (28) 65ZOVIA 1/50E (28) 65

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Aetna Better Health® of Virginia

2017 FORMULARY UPDATES

JANUARY 2017

Added Oloptadine ophthalmic (step therapy added) to formulary

FEBRUARY 2017

Removed Procrit from formulary

Removed Aranesp from formulary

Removed Lidocaine 3% lotion from formulary

Removed nystatin/triamcinolone cream/ointment from formulary

Removed mupirocin cream from formulary

Removed Buspirone 30 mg from formulary

Removed fluoxetine 20 mg tablets from formulary

Removed fluoxetine 60 mg tablets from formulary

Removed Ciprodex from formulary

Removed Cipro HC from formulary

Removed doxycycline hyclate immediate release from formulary

Removed naproxen 550 mg from formulary

Albuterol 0.021% (added step therapy for members 18 years and older)

Albuterol 0.042% (added step therapy for members 18 years and older)

Montelukast granules (added prior authorization for members 2 years and older)

Zafirlukast (added step therapy)



FEBRUARY 2017

Removed diltiazem ER/LA tablets from formulary

Removed clomipramine from formulary

Removed imipramine capsules from formulary

Removed trazodone 300 mg from formulary

Removed carisoprodol 250 mg from formulary

Removed clindamycin aerosol from formulary

Removed clindamycin/benzoyl peroxide combo from formulary

Removed erythromycin/benzoyl peroxide combo from formulary

Removed sulfacetamide/sulfur from formulary

Removed salicylic acid gel 6% from formulary

Removed benzoyl peroxide 7 % liquid from formulary

Removed benzoyl peroxide 4 % kit from formulary

Removed Claravis from formulary

Removed Amitiza from formulary

Removed Copaxone 20 mg from formulary

Removed Farxiga from formulary

Removed Renvela from formulary

Removed Renagel from formulary

Removed Delzicol from formulary

Removed Dipentum from formulary



FEBRUARY 2017

Removed Pentasa from formulary

Removed Pancreaze from formulary

Removed Advair from formulary

Removed Symbicort from formulary

Removed Spiriva from formulary

Removed Tudorza from formulary

Removed Neupogen from formulary

Removed step therapy from Linzess

Added step therapy to adapalene cream/gel RX version

Added step therapy to tretinoin cream/gel

Added Apriso to formulary

Added Viokace to formulary

Added Breo Ellipta to formulary

Added Myorisan (step therapy required) to formulary

Added Zenatane (step therapy required) to formulary

Added Auryxia (step therapy required) to formulary

Added Xarelto (prior authorization required) to formulary

Added Zepatier (prior authorization required) to formulary

Added Gilenya (prior authorization required) to formulary

Added Tecfidera (prior authorization required) to formulary



FEBRUARY 2017

Added Imbruvica (prior authorization required) to formulary

Added Epogen (prior authorization required) to formulary

Added Kyleena to formulary

Added orphenadrine to formulary

Added orlistat OTC (prior authorization required) to formulary

Added benzphetamine (prior authorization required) to formulary

Added phentermine (prior authorization required) to formulary

Added phendimetrazine (prior authorization required) to formulary

Added diethylpropion (prior authorization required) to formulary

Added Belviq (prior authorization required) to formulary

Added Qsymia (prior authorization required) to formulary

Added Contrave (prior authorization required) to formulary

MARCH 2017

Added dexmethylphenidate 25 mg SR and 35 mg SR (prior authorization required) to formulary

APRIL 2017

Added Selzentry 25 mg and 75 mg to formulary

Added levetiracetam solution 100 mg/mL to formulary

Added Linzess 72 mg to formulary

Added pyrantel pamoate tablets to formulary

Added Jentadueto XR (step therapy required) to formulary



APRIL 2017

Added Vitamin D3 Chew 5000 units to formulary

Documents

Aetna Better Health Of Virginia Formulary Guide April 2017 · What is the Aetna Better Health of Virginia Formulary? This is a drug list created by Aetna Better Health of Virginia