Aetna Better Health Of Virginia Formulary Guide September 2017 · 2017-09-01 · AETNA BETTER HEALTH® Formulary Guide . What are some types of coverage rules? Prior Approval (PA):

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health Of Virginia

Formulary Guide September 2017

http://www.aetnabetterhealth.com/Virginia

http://www.aetnabetterhealth.com/Virginia


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.

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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.

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Aetna Better Health Virginia

Table of Contents

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* .................................................................................................. 4 *ALTERNATIVE MEDICINES*............................................................................................................................................................. 6 *AMINOGLYCOSIDES*.......................................................................................................................................................................... 6 *ANALGESICS - ANTI-INFLAMMATORY* ....................................................................................................................................... 7 *ANALGESICS - NONNARCOTIC* ...................................................................................................................................................... 9 *ANALGESICS - OPIOID* .................................................................................................................................................................... 10 *ANDROGENS-ANABOLIC*................................................................................................................................................................ 21 *ANORECTAL AGENTS* ..................................................................................................................................................................... 21 *ANTACIDS* ........................................................................................................................................................................................... 22 *ANTHELMINTICS*.............................................................................................................................................................................. 22 *ANTIANGINAL AGENTS* .................................................................................................................................................................. 22 *ANTIANXIETY AGENTS* .................................................................................................................................................................. 23 *ANTIARRHYTHMICS* ....................................................................................................................................................................... 24 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*........................................................................................................... 24 *ANTICOAGULANTS* .......................................................................................................................................................................... 26 *ANTICONVULSANTS* ........................................................................................................................................................................ 28 *ANTIDEPRESSANTS* ......................................................................................................................................................................... 30 *ANTIDIABETICS* ................................................................................................................................................................................ 32 *ANTIDIARRHEALS* ........................................................................................................................................................................... 35 *ANTIDOTES* ........................................................................................................................................................................................ 36 *ANTIEMETICS*.................................................................................................................................................................................... 36 *ANTIFUNGALS* ................................................................................................................................................................................... 36 *ANTIHISTAMINES*............................................................................................................................................................................. 37 *ANTIHYPERLIPIDEMICS* ................................................................................................................................................................ 38 *ANTIHYPERTENSIVES* .................................................................................................................................................................... 39 *ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................................................... 42 *ANTIMALARIALS*.............................................................................................................................................................................. 43 *ANTIMYASTHENIC AGENTS* ......................................................................................................................................................... 43 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* ........................................................................................................................... 43*ANTIMYCOBACTERIAL AGENTS* ................................................................................................................................................ 43 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* ............................................................................................................. 44 *ANTI-OBESITY AGENT COMBINATIONS** ................................................................................................................................. 46 *ANTIPARKINSON AGENTS*............................................................................................................................................................. 46 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* .................................................................................................................................. 47

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*ANTIRETROVIRALS ADJUVANTS*** ............................................................................................................................................ 49 *ANTISEPTICS & DISINFECTANTS* ................................................................................................................................................ 49 *ANTIVIRALS* ....................................................................................................................................................................................... 50 *ASSORTED CLASSES* ........................................................................................................................................................................ 54 *BETA BLOCKERS* .............................................................................................................................................................................. 55 *CALCIUM CHANNEL BLOCKERS*................................................................................................................................................. 56 *CARDIOTONICS*................................................................................................................................................................................. 58 *CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................................................... 58 *CEPHALOSPORINS* ........................................................................................................................................................................... 59 *CHEMICALS* ....................................................................................................................................................................................... 60 *CONTRACEPTIVES*........................................................................................................................................................................... 61 *CORTICOSTEROIDS* ......................................................................................................................................................................... 68 *COUGH/COLD/ALLERGY*................................................................................................................................................................ 69 *DERMATOLOGICALS* ...................................................................................................................................................................... 70 *DIAGNOSTIC PRODUCTS* ............................................................................................................................................................... 80 *DIGESTIVE AIDS* ............................................................................................................................................................................... 80 *DIURETICS* .......................................................................................................................................................................................... 81 *ENDOCRINE AND METABOLIC AGENTS - MISC.* .................................................................................................................... 82 *ESTROGENS*........................................................................................................................................................................................ 83 *FLUOROQUINOLONES* .................................................................................................................................................................... 84 *GASTROINTESTINAL AGENTS - MISC.*....................................................................................................................................... 85 *GENITOURINARY AGENTS - MISCELLANEOUS*...................................................................................................................... 86 *GOUT AGENTS* ................................................................................................................................................................................... 87 *HEMATOLOGICAL AGENTS - MISC.* ........................................................................................................................................... 87 *HEMATOPOIETIC AGENTS*............................................................................................................................................................ 88 *HEPATITIS C AGENT - COMBINATIONS*** ................................................................................................................................ 89 *HYPNOTICS* ........................................................................................................................................................................................ 89 *LAXATIVES*......................................................................................................................................................................................... 89 *MACROLIDES*..................................................................................................................................................................................... 90 *MEDICAL DEVICES* .......................................................................................................................................................................... 91 *MIGRAINE PRODUCTS* .................................................................................................................................................................... 95 *MINERALS & ELECTROLYTES*..................................................................................................................................................... 95 *MOUTH/THROAT/DENTAL AGENTS* ........................................................................................................................................... 97 *MULTIVITAMINS* .............................................................................................................................................................................. 98 *MUSCULOSKELETAL THERAPY AGENTS* ...............................................................................................................................101 *NASAL AGENTS - SYSTEMIC AND TOPICAL* ...........................................................................................................................102*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***.........................................................................102 *NEUROMUSCULAR AGENTS* ........................................................................................................................................................102 *OPHTHALMIC AGENTS*..................................................................................................................................................................103 *OTIC AGENTS* ...................................................................................................................................................................................106 *PASSIVE IMMUNIZING AGENTS* .................................................................................................................................................107 *PENICILLINS* .....................................................................................................................................................................................107 *PHARMACEUTICAL ADJUVANTS* ...............................................................................................................................................108

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*POTASSIUM REMOVING AGENTS*** ..........................................................................................................................................110*PROGESTINS* .....................................................................................................................................................................................111*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*......................................................................................111*RESPIRATORY AGENTS - MISC.* ..................................................................................................................................................114*SEROTONIN MODULATORS*** .....................................................................................................................................................114*SINUS NODE INHIBITORS**............................................................................................................................................................114*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** ................................................................114*SULFONAMIDES* ...............................................................................................................................................................................114*TETRACYCLINES*.............................................................................................................................................................................114*THYROID AGENTS*...........................................................................................................................................................................115*ULCER DRUGS* ..................................................................................................................................................................................115*URINARY ANTI-INFECTIVES*........................................................................................................................................................117*URINARY ANTISPASMODICS* .......................................................................................................................................................118*VAGINAL PRODUCTS* .....................................................................................................................................................................118*VASOPRESSORS* ...............................................................................................................................................................................119*VITAMINS*...........................................................................................................................................................................................119

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Aetna Better Health Virginia

CURRENT AS OF 9/1/2017

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; QLL (30 EA per 30 days)

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

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg Adderall PA; QLL (90 EA per 30 days)

amphetamine-dextroamphetamine oral tablet 30 mg Adderall PA; QLL (60 EA per 30 days)

*Amphetamines***dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg Dexedrine PA; QLL (120 EA per 30 days)

dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg Dexedrine PA; QLL (90 EA per 30 days)

dextroamphetamine sulfate oral solution 5 mg/5ml ProCentra PA; QLL (1800 ML per 30

days) dextroamphetamine sulfate oral tablet 10 mg, 5 mg Zenzedi PA; QLL (180 EA per 30 days)

*Analeptics***caffeine anhydrous powder 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)

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Formulary Drug Name Reference Restrictions *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)

*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, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

Focalin XR PA; QLL (30 EA per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg Focalin PA; QLL (60 EA per 30 days)

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

PA; QLL (30 EA per 30 days)

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Formulary Drug Name Reference Restrictions methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg Ritalin LA PA; QLL (30 EA per 30 days)

methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg Ritalin LA PA; QLL (60 EA per 30 days)

methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg PA; QLL (30 EA per 30 days)

methylphenidate hcl er oral tablet extended release 10 mg PA; QLL (90 EA per 30 days)

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Concerta PA; QLL (30 EA per 30 days)

methylphenidate hcl er oral tablet extended release 20 mg Metadate ER PA; QLL (90 EA per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg PA; QLL (30 EA per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 36 mg PA; QLL (60 EA per 30 days)

methylphenidate hcl er oral tablet extended release 36 mg Concerta PA; QLL (60 EA per 30 days)

methylphenidate hcl oral solution 10 mg/5ml Methylin PA; QLL (900 mL per 30 days) methylphenidate hcl oral solution 5 mg/5ml Methylin PA; QLL (900 ML per 30 days) methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Ritalin PA; QLL (90 EA per 30 days)

methylphenidate hcl oral tablet chewable 10 mg PA; QLL (180 EA per 30 days)

methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg PA; QLL (150 EA per 30 days)

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

*ALTERNATIVE MEDICINES**Alternative Medicine - St's***stevia oral packet 100 mg OTC

*AMINOGLYCOSIDES**Aminoglycosides***neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg tobramycin inhalation nebulization solution 300 mg/5ml Kitabis Pak PA; QLL (280 mL Max Qty Per

Fill Retail) KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

Tobramycin PA; QLL (280 ML Max Qty Per Fill Retail)

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Formulary Drug Name Reference Restrictions *ANALGESICS - ANTI-INFLAMMATORY* *Anti-Tnf-Alpha - MonoclonalAntibodies*** 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 - MonoclonoalAntibodies*** 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)

*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***

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Formulary Drug Name Reference Restrictions RIDAURA ORAL CAPSULE 3 MG

*Nonsteroidal Anti-InflammatoryAgents (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 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)

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Formulary Drug Name Reference Restrictions *Pyrimidine Synthesis Inhibitors***leflunomide oral tablet 10 mg, 20 mg Arava QLL (30 EA per 30 days)

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

*Soluble Tumor Necrosis FactorReceptor 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 QLL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg Esgic QLL (180 EA per 30 days)

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

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

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

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

marten-tab oral tablet 50-325 mg Tencon CAPACET ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days)

ESGIC ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days) TENCON ORAL TABLET 50-325 MG Butalbital-Acetaminophen ZEBUTAL ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days)

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

*Salicylates***

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Formulary Drug Name Reference Restrictions diflunisal oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg

*ANALGESICS - OPIOID**Codeine Combinations***

acetaminophen-codeine #2 oral tablet 300-15 mg

Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 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 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 cumulative morphine equivalents per day.; QLL (4500 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg


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Formulary Drug Name Reference Restrictions

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


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


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


butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg Fiorinal/Codeine #3

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)

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


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hydrocodone-acetaminophen oral tablet 10-325 mg Norco


hydrocodone-acetaminophen oral tablet 2.5-325 mg Verdrocet


hydrocodone-acetaminophen oral tablet 5-325 mg Lorcet


hydrocodone-acetaminophen oral tablet 7.5-325 mg Norco


hydrocodone-ibuprofen oral tablet 7.5-200 mg


LORCET HD ORAL TABLET 10-325 MG Hydrocodone-Acetaminophen


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LORCET ORAL TABLET 5-325 MG Hydrocodone-Acetaminophen


LORCET PLUS ORAL TABLET 7.5-325 MG Hydrocodone-Acetaminophen


ZAMICET ORAL SOLUTION 10-325 MG/15ML

Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 cumulative morphine equivalents per day; QLL (4050 ML per 30 days)

*Opioid Agonists***

codeine sulfate oral tablet 15 mg






13


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






14


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


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


15


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


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

Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 cumulative morphine equivalents per day.

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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 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 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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*Opioid Combinations***


oxycodone-acetaminophen oral tablet 10-325 mg Endocet


oxycodone-acetaminophen oral tablet 2.5-325 mg, 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


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


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ENDOCET ORAL TABLET 7.5-325 MG Oxycodone-Acetaminophen


*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual 2 mg

PA; Three 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


buprenorphine transdermal patch weekly 10 mcg/hr, 5 mcg/hr Butrans PA; QLL (8 EA per 28 days)

buprenorphine transdermal patch weekly 15 mcg/hr, 20 mcg/hr Butrans PA; QLL (4 EA per 28 days)

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 7.5 MCG/HR Buprenorphine


*Tramadol Combinations***

tramadol-acetaminophen oral tablet 37.5-325 mg Ultracet

Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to120 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%) Vogelxo PA; QLL (300 GM per 30 days)

*ANORECTAL AGENTS**Intrarectal Steroids***hydrocortisone rectal enema 100 mg/60ml Colocort 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 % lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %

21

Formulary Drug Name Reference Restrictions PROCTOFOAM HC RECTAL FOAM 1-1 %

*Rectal Steroids***hydrocortisone acetate rectal suppository 30 mg Hemmorex-HC

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

*ANTACIDS**Antacids - Bicarbonate***sodium bicarbonate oral powder

*ANTHELMINTICS**Anthelmintics***ivermectin oral tablet 3 mg Stromectol reeses pinworm medicine oral tablet 180 mg OTC ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG PA

*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

22

Formulary Drug Name Reference Restrictions nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.4 mg/hr Minitran

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

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 QLL (60 EA per 30 days); AL

(Min 18 Years) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Xanax QLL (90 EA per 30 days); AL

(Min 18 Years) alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

QLL (90 EA per 30 days); AL (Min 18 Years)

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR QLL (60 EA per 30 days); AL

(Min 18 Years) 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 QLL (120 EA per 30 days); AL (Min 9 Years)

diazepam oral solution 1 mg/ml QLL (300 ML per 30 days) diazepam oral tablet 10 mg, 2 mg, 5 mg Valium QLL (120 EA per 30 days)

23

Formulary Drug Name Reference Restrictions lorazepam oral concentrate 2 mg/ml LORazepam Intensol QLL (180 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Ativan QLL (90 EA per 30 days)

oxazepam oral capsule 10 mg, 15 mg, 30 mg QLL (120 EA per 30 days); AL (Min 6 Years)

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

QLL (180 ML per 30 days); AL (Min 18 Years)

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam QLL (180 ML per 30 days)

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

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

QLL (1 inhaler per 30 days)

24

Formulary Drug Name Reference Restrictions 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 levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST; QLL (2 INH per 30 days)

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)

25

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

QLL (30 EA per 30 days)

*Leukotriene ReceptorAntagonists***

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, 20 mg Accolate ST; 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

*ANTICOAGULANTS**Coumarin Anticoagulants***

26

Formulary Drug Name Reference Restrictions warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 7.5 mg Jantoven

warfarin sodium oral tablet 3 mg, 4 mg, 5 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-LikeAgents*** 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-LikeAgents***

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

Arixtra


27

Formulary Drug Name Reference Restrictions *ANTICONVULSANTS**Anticonvulsants -Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg KlonoPIN QLL (90 EA per 30 days) clonazepam oral tablet 2 mg KlonoPIN QLL (45 EA per 30 days) clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg QLL (90 EA per 30 days)

clonazepam oral tablet dispersible 2 mg QLL (45 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) 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 Roweepra QLL (180 EA per 30 days)

28

Formulary Drug Name Reference Restrictions 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 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

29

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

*Modified Cyclics***trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

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

30

Formulary Drug Name Reference Restrictions MARPLAN ORAL TABLET 10 MG

*Selective Serotonin ReuptakeInhibitors (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 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) 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 ReuptakeInhibitors (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)

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

31

Formulary Drug Name Reference Restrictions 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)

*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)

32

Formulary Drug Name Reference Restrictions 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-ThiazolidinedioneCombinations*** 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 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)

33

Formulary Drug Name Reference Restrictions 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)

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-1Receptor 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-BiguanideCombinations*** repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

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

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

34

Formulary Drug Name Reference Restrictions 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-ThiazolidinedioneCombinations*** pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg Duetact QLL (30 EA per 30 days)

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

*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

35

Formulary Drug Name Reference Restrictions diphenoxylate-atropine 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 Dramamine Less Drowsy trimethobenzamide hcl oral capsule 300 mg Tigan

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

*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

36

Formulary Drug Name Reference Restrictions 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 clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral elixir 12.5 mg/5ml QLL (120 mL per 30 days)

*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) loratadine allergy relief oral tablet dispersible 10 mg Wal-vert OTC; QLL (30 EA per 30 days)

loratadine oral tablet 10 mg Claritin OTC; QLL (30 EA 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, 50 mg Phenergan

promethazine hcl rectal suppository 25 mg Promethegan 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***

37

Formulary Drug Name Reference Restrictions 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 Triglide fenofibrate oral tablet 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) 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

38

Formulary Drug Name Reference Restrictions 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 AbsorptionInhibitors*** ezetimibe oral tablet 10 mg Zetia ST; QLL (30 EA per 30 days)

*ANTIHYPERTENSIVES**Ace Inhibitor & Calcium ChannelBlocker 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)

*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)

39

Formulary Drug Name Reference Restrictions 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, 5 mg Zestril QLL (30 EA per 30 days)

lisinopril oral tablet 40 mg Zestril QLL (60 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 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 & CaChannel 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)

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)

40

Formulary Drug Name Reference Restrictions 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 ReceptorAntagonists*** 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-CaChannel 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 - CentrallyActing*** 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 - PeripherallyActing*** 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)

41

Formulary Drug Name Reference Restrictions *Beta Blocker & DiureticCombinations*** 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

42

Formulary Drug Name Reference Restrictions sulfamethoxazole-trimethoprim oral tablet 800-160 mg Bactrim DS

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/CholinergicAgents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYASTHENIC/CHOLINERGIC AGENTS* pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYCOBACTERIALAGENTS* *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

43

Formulary Drug Name Reference Restrictions *ANTINEOPLASTICS ANDADJUNCTIVE 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 KinaseInhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA; QLL (30 EA per 30 days)

*Antineoplastic - MultikinaseInhibitors*** 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 KinaseInhibitors*** 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)

44

Formulary Drug Name Reference Restrictions CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; QLL (30 EA per 30 days)

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 RescueAgents*** 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***melphalan oral tablet 2 mg Alkeran LEUKERAN ORAL TABLET 2 MG

*Progestins-Antineoplastic***

45

Formulary Drug Name Reference Restrictions hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml megestrol acetate oral tablet 20 mg, 40 mg

*Retinoids***tretinoin oral capsule 10 mg

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

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


*ANTIPARKINSON AGENTS**Antiparkinson Anticholinergics***benztropine mesylate oral tablet 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 OxidaseInhibitors*** 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

46

Formulary Drug Name Reference Restrictions 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)



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

*Nonergoline Dopamine ReceptorAgonists*** 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/ANTIMANICAGENTS* *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***

47


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)

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

risperidone oral tablet dispersible 0.5 mg RisperDAL M-TAB QLL (60 EA per 30 days); AL (Min 18 Years)

risperidone oral tablet dispersible 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)

48

Formulary Drug Name Reference Restrictions *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)

*Phenothiazines***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) 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)

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

*ANTISEPTICS &DISINFECTANTS*

49

Formulary Drug Name Reference Restrictions *Chlorine Antiseptics***chlorhexidine gluconate solution 20 %

*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 - FusionInhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

50

Formulary Drug Name Reference Restrictions *Antiretrovirals - IntegraseInhibitors*** ISENTRESS HD ORAL TABLET 600 MG QLL (60 EA per 30 days) ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG QLL (30 EA per 30 days) 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 - ProteaseInhibitors*** 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)

51

Formulary Drug Name Reference Restrictions 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) 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-NucleosideAnalogues-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-NucleosideAnalogues-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-NucleosideAnalogues-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

52

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

*Hepatitis C Agents***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)

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

PA; QLL (4 Units per 28 days)

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

*Herpes Agents - PurineAnalogues*** 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 - ThymidineAnalogues***

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

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

53

Formulary Drug Name Reference Restrictions *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 Neoral 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 ForMyelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG PA; QLL (30 EA per 30 days)

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

54

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 Kionex 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 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)

55

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

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 CHANNELBLOCKERS* *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 Cardizem CD 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, 180 mg Taztia XT 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 beads oral capsule extended release 24 hour 300 mg, 360 mg, 420 mg Tiazac QLL (30 EA per 30 days)

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg

Cardizem CD QLL (30 EA per 30 days)

56

Formulary Drug Name Reference Restrictions 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 300 mg Cartia XT QLL (30 EA per 30 days)

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

nifedipine er oral tablet extended release 24 hour 60 mg Afeditab CR QLL (30 EA per 30 days)

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg Procardia 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)

57

Formulary Drug Name Reference Restrictions 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) 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

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)

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG

DilTIAZem HCl ER Coated Beads QLL (30 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 Digitek digoxin oral tablet 250 mcg Lanoxin 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 & HmgCoa Reductase Inhibit Comb***

58

Formulary Drug Name Reference Restrictions 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)

*Prostaglandin Vasodilators***epoprostenol sodium intravenous solution reconstituted 0.5 mg Flolan PA

epoprostenol sodium intravenous solution reconstituted 1.5 mg Veletri PA

*Pulmonary Hypertension -Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG PA; QLL (30 EA per 30 days) TRACLEER ORAL TABLET 125 MG, 62.5 MG PA; QLL (60 EA per 30 days)

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg Revatio PA; QLL (90 EA per 30 days) ADCIRCA ORAL TABLET 20 MG ST; QLL (60 EA per 30 days)

*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 - 2NdGeneration*** 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

59

Formulary Drug Name Reference Restrictions 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 - 3RdGeneration*** 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)

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG QLL (20 EA per 30 days)

*CHEMICALS**Bulk Chemicals - Et's***ethyl oleate liquid

*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

60

Formulary Drug Name Reference Restrictions stevia extract powder 90 % OTC steviol glycosides powder 95 % stevioside fluid extract 15 %

*Fixed Oils***castor oil oil cottonseed oil oil olive oil oil sesame oil oil

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

*Solids***sorbitol powder

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

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Pimtrea AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Viorele

BEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Viorele

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Viorele

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5) Viorele

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Viorele

*Combination Contraceptives -Oral*** alyacen 1/35 oral tablet 1-35 mg-mcg Pirmella 1/35 briellyn oral tablet 0.4-35 mg-mcg Gildagia drospirenone-ethinyl estradiol oral tablet 3-0.02 mg Gianvi

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg Yasmin 28

61

Formulary Drug Name Reference Restrictions levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg Aubra

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

marlissa oral tablet 0.15-30 mg-mcg Lillow 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 Microgestin 1/20

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 Desogestrel-Ethinyl Estradiol 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 Desogestrel-Ethinyl Estradiol

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

62

Formulary Drug Name Reference Restrictions EMOQUETTE ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol

ENSKYCE ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol

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 Desogestrel-Ethinyl Estradiol

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

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

63

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

64

Formulary Drug Name Reference Restrictions 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 Desogestrel-Ethinyl Estradiol

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)

*Continuous Contraceptives -Oral***

65

Formulary Drug Name Reference Restrictions levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

*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 My Way 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

*Progestin Contraceptives -Implants***

66

Formulary Drug Name Reference Restrictions 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 Norlyda 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 Dasetta 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

68

Formulary Drug Name Reference Restrictions prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml 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-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 %

69

Formulary Drug Name Reference Restrictions NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Sodium Chloride

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*** 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 % Cleocin-T clindamycin phosphate external lotion 1 % Cleocin-T clindamycin phosphate external solution 1 % Cleocin-T clindamycin phosphate external swab 1 % Cleocin-T 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

*Acne Products***

70


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

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

bp foaming wash external liquid 10 % Desquam-X Wash bp wash external liquid 2.5 % PanOxyl

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

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

tretinoin external gel 0.01 %, 0.025 % Retin-A ST; 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 QLL (110 GM per 30 days)

*Antifungals - TopicalCombinations*** 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

*Antifungals - Topical***

71

Formulary Drug Name Reference Restrictions 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 Nystop 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 sulf-pyrithione-urea external shampoo 2.25 %

*Antiseborrheic Products***selenium sulfide external lotion 2.5 % selenium sulfide external shampoo 2.25 % 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 (15 GM 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 %

QLL (1 Prescription per 23 days)

alclometasone dipropionate external ointment 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 %

73

Formulary Drug Name Reference Restrictions clobetasol propionate e external cream 0.05 % 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 %

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

fluticasone propionate external ointment 0.005 %


halobetasol propionate external cream 0.05 % Ultravate

74

Formulary Drug Name Reference Restrictions halobetasol propionate external ointment 0.05 % Ultravate

hydrocortisone acetate powder 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 % 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

TRIDERM EXTERNAL CREAM 0.1 % Triamcinolone Acetonide

*Emollient Combinations***

75

Formulary Drug Name Reference Restrictions mineral oil-hydrophil petrolat external ointment OTC

*Emollients***advanced healing/baby external ointment Aquaphor OTC beauty lotion external lotion Eucerin Baby OTC beta care external lotion Eucerin Baby OTC cvs advanced healing external ointment Aquaphor OTC dry skin treatment adv therapy external ointment Aquaphor OTC

dry skin treatment external ointment Aquaphor OTC e-ointment external ointment Aquaphor OTC hydrophor external ointment Aquaphor OTC ointment base external ointment Aquaphor OTC ra hydrating healing external ointment Aquaphor OTC A + D PERSONAL CARE LOTION EXTERNAL LOTION Complete Moisture OTC

ALBOLENE EXTERNAL CREAM CVS Moisturizing OTC ALOE AFTERSUN EXTERNAL LOTION Complete Moisture OTC AMLACTIN CERAPEUTIC EXTERNAL LOTION Complete Moisture OTC

AMLACTIN ULTRA EXTERNAL CREAM CVS Moisturizing OTC

AQUA GLYCOLIC FACE EXTERNAL CREAM CVS Moisturizing OTC

AQUA GLYCOLIC HAND/BODY EXTERNAL LOTION Complete Moisture OTC

AQUA LACTEN EXTERNAL LOTION Complete Moisture OTC AQUADERM EXTERNAL CREAM CVS Moisturizing OTC AQUADERM TREATMENT/MOISTURIZER EXTERNAL LOTION 25-0.03-0.1 %

Complete Moisture OTC

AQUAMED EXTERNAL LOTION Complete Moisture OTC AQUAPHILIC EXTERNAL OINTMENT E-Ointment OTC AQUAPHOR ADVANCED THERAPY EXTERNAL OINTMENT E-Ointment OTC

AQUAPHOR EXTERNAL OINTMENT E-Ointment OTC AVEENO ACTIVE NAT SKIN RELIEF EXTERNAL CREAM CVS Moisturizing OTC

76

Formulary Drug Name Reference Restrictions AVEENO ACTIVE NATURALS DAILY EXTERNAL LOTION Complete Moisture OTC

AVEENO DAILY MOISTURIZING EXTERNAL LOTION Complete Moisture OTC

AVEENO INTENSE RELIEF HAND EXTERNAL CREAM CVS Moisturizing OTC

AVEENO POSITIVELY AGELESS BODY EXTERNAL LOTION Complete Moisture OTC

AVEENO POSITIVELY NOURISHING EXTERNAL CREAM CVS Moisturizing OTC

AVEENO POSITIVELY RADIANT NGHT EXTERNAL CREAM CVS Moisturizing OTC

AVEENO SKIN STRENGTHENING BODY EXTERNAL CREAM CVS Moisturizing OTC

AVEENO SKIN STRENGTHENING HAND EXTERNAL CREAM CVS Moisturizing OTC

AVEENO STRESS RELIEF EXTERNAL LOTION Complete Moisture OTC

BOUDREAUXS BABY BUTT SMOOTH EXTERNAL OINTMENT E-Ointment OTC

CAM EXTERNAL LOTION Complete Moisture OTC CERAVE EXTERNAL LOTION Complete Moisture OTC CERAVE PM EXTERNAL LOTION Complete Moisture OTC CERAVE SA RENEWING EXTERNAL LOTION Complete Moisture OTC

CETAPHIL DAILY ADVANCE EXTERNAL LOTION Complete Moisture OTC

CETAPHIL DAILY FACIAL MOIST EXTERNAL LOTION Complete Moisture OTC

DAILY CONDITIONING TREATMENT EXTERNAL OINTMENT E-Ointment OTC

DERMAPHOR EXTERNAL OINTMENT E-Ointment OTC FLANDERS BUTTOCKS EXTERNAL OINTMENT E-Ointment OTC

GOLD BOND ULTIMATE HEALING EXTERNAL OINTMENT E-Ointment OTC

HYDROLATUM EXTERNAL OINTMENT E-Ointment OTC

LANAPHILIC EXTERNAL OINTMENT E-Ointment OTC NEOSALUS EXTERNAL LOTION Complete Moisture SARATOGA EXTERNAL OINTMENT E-Ointment OTC

77

Formulary Drug Name Reference Restrictions *Enzymes - Topical***SANTYL EXTERNAL OINTMENT 250 UNIT/GM

*Imidazole-Related Antifungals -Topical*** clotrimazole external cream 1 % Clotrimazole GRx

clotrimazole external solution 1 % FungiCure Intensive/NailGuard

ketoconazole external cream 2 % ketoconazole external shampoo 2 % Nizoral kp clotrimazole external cream 1 % Clotrimazole GRx OTC

*ImmunomodulatorsImidazoquinolinamines - 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 %


78


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


*Keratolytic/Antimitotic Agents***podofilox external solution 0.5 % 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***lc-4 lidocaine external cream 4 % Lidocream OTC lidocaine external cream 4 % Lidocream OTC 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) ANECREAM EXTERNAL CREAM 4 % LC-4 Lidocaine OTC ASPERCREME W/LIDOCAINE EXTERNAL CREAM 4 % LC-4 Lidocaine OTC

CIDALEAZE EXTERNAL CREAM 3 % Lidopin GLYDO EXTERNAL GEL 2 % Lidocaine HCl LIDOCREAM EXTERNAL CREAM 4 % LC-4 Lidocaine OTC

*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

79

Formulary Drug Name Reference Restrictions metronidazole external lotion 0.75 % MetroLotion ROSADAN EXTERNAL CREAM 0.75 % MetroNIDAZOLE ROSADAN EXTERNAL GEL 0.75 % MetroNIDAZOLE

*Scabicides & Pediculicides***

cvs permethrin external lotion 1 % OTC; QLL (120 ML per 30 days)

lindane external shampoo 1 % QLL (60 mL per 30 days) malathion external lotion 0.5 % Ovide ST; QLL (1 Pack per 180 days) permethrin external cream 5 % Elimite QLL (1 Pack per 180 days) spinosad external suspension 0.9 % Natroba ST

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

*Steroid-Local AnestheticCombinations*** CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML

*Topical AnestheticCombinations*** lidocaine-prilocaine external cream 2.5-2.5 % QLL (240 GM per 30 days) lidocaine-prilocaine external kit 2.5-2.5 % Priloxx LP LIVIXIL PAK EXTERNAL KIT 2.5-2.5 % Lidocaine-Prilocaine LP LITE PAK EXTERNAL KIT 2.5-2.5 % Lidocaine-Prilocaine RELADOR PAK EXTERNAL KIT 2.5-2.5 % Lidocaine-Prilocaine

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 % Lidocaine-Prilocaine

*Topical Selective Retinoid XReceptor 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***

80

Formulary Drug Name Reference Restrictions CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 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

*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-LikeDiuretics*** chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg

81

Formulary Drug Name Reference Restrictions 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 METABOLICAGENTS - 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) 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 McCarnitine

*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

82

Formulary Drug Name Reference Restrictions 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 ReceptorModulators (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)

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 Femhrt Low Dose norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg Femhrt Low Dose

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 Jevantique Lo

FYAVOLV ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol QLL (30 EA per 30 days)

83

Formulary Drug Name Reference Restrictions 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, 0.0375 mg/24hr, 0.075 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) 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)

84

Formulary Drug Name Reference Restrictions *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 1.2 gm Lialda QLL (120 EA per 30 days) mesalamine oral tablet delayed release 800 mg Asacol HD

mesalamine rectal enema 4 gm sulfasalazine oral tablet 500 mg Azulfidine 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 ReceptorAntagonists*** MOVANTIK ORAL TABLET 12.5 MG, 25 MG PA; QLL (30 EA per 30 days)

*Phosphate Binder Agents***

85

Formulary Drug Name Reference Restrictions 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-AdrenoceptorAntagonists*** 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***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

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 Cytra K Crystals

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

86

Formulary Drug Name Reference Restrictions 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 Pyridium phenazopyridine hcl oral tablet 200 mg Phenazo 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

*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***

87

Formulary Drug Name Reference Restrictions 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

*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-StimulatingFactors (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

88

Formulary Drug Name Reference Restrictions *Iron Combinations***ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG Iron 100 Plus

*Thrombopoietin (Tpo) ReceptorAgonists*** 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

*Benzodiazepine Hypnotics***

estazolam oral tablet 1 mg, 2 mg QLL (30 EA per 30 days); AL (Min 18 Years)

flurazepam hcl oral capsule 15 mg, 30 mg QLL (30 EA per 30 days); AL (Min 15 Years)

temazepam oral capsule 15 mg, 30 mg Restoril QLL (30 EA per 30 days); AL (Min 18 Years)

triazolam oral tablet 0.125 mg QLL (30 EA per 30 days) triazolam oral tablet 0.25 mg Halcion QLL (30 EA per 30 days)

*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 ReceptorAgonists*** ROZEREM ORAL TABLET 8 MG ST; QLL (30 EA per 30 days)

*LAXATIVES**Bowel Evacuant Combinations***

89

Formulary Drug Name Reference Restrictions 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

peg-3350/electrolytes oral solution reconstituted 236 gm GaviLyte-G 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

*Stimulant Laxatives***castor oil oral oil 100 % OTC

*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 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)

90

Formulary Drug Name Reference Restrictions 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 ethylsuccinate oral suspension reconstituted 200 mg/5ml EryPed 200

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

*MEDICAL DEVICES**Cervical Caps***FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

*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 %

*Misc. Devices***mucosal atomization device Flents Ear Stopples OTC

*Nebulizers***nebulizer updraft-style Pari Baby

*Needles & Syringes***ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML Kroger Insulin Syringe

BD ECLIPSE SYRINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe

91

Formulary Drug Name Reference Restrictions MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML Ultra-Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML Ultra-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 20GX 1-1/2" 12 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 20G X 1-1/2" 6 ML, 25G X 1" 1 ML MONOJECT MAGELLAN SYRINGE 23G X 1" 1 ML, 25G X 5/8" 1 ML Anti-Stick Immun Syringe

MONOJECT SYRINGE 20G X 1-1/2" 6 ML MONOJECT SYRINGE 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

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)

92

Formulary Drug Name Reference Restrictions 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 Kroger 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 RiteFlo 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) 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)

93

Formulary Drug Name Reference Restrictions 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) 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)

94

Formulary Drug Name Reference Restrictions 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 %

*Calcium***calcium carbonate extra light powder OTC calcium carbonate light powder calcium carbonate powder

95

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 Flura-Drops fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

sodium fluoride oral solution 1.1 (0.5 f) mg/ml 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, 2.2 (1 f) mg Ludent

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 Sodium Fluoride

LUDENT ORAL TABLET CHEWABLE 2.2 (1 F) MG Fluoritab

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

NAFRINSE ORAL TABLET CHEWABLE 2.2 (1 F) MG Fluoritab

*Phosphate***av-phos 250 neutral oral tablet 155-852-130 mg K-Phos-Neutral

virt-phos 250 neutral oral tablet 155-852-130 mg K-Phos-Neutral

K-PHOS ORAL TABLET 500 MG PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG Virt-Phos 250 Neutral

*Potassium Combinations***

96

Formulary Drug Name Reference Restrictions 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 Effer-K k-vescent oral tablet effervescent 25 meq Effer-K potassium bicarbonate oral tablet effervescent 25 meq Effer-K

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

EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ Potassium Bicarbonate

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 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 Potassium Bicarbonate

K-PRIME ORAL TABLET EFFERVESCENT 25 MEQ Potassium Bicarbonate

*MOUTH/THROAT/DENTALAGENTS* *Anesthetics Topical Oral***

97

Formulary Drug Name Reference Restrictions 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 % Peridex

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 % Denta 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

*MULTIVITAMINS**Multiple Vitamins W/ Minerals***biocel oral tablet One-A-Day Energy

98

Formulary Drug Name Reference Restrictions b-plex plus oral tablet One-A-Day Energy v-c forte oral capsule Theramill Forte vit b3-azelac-turm-fa-b6-zn-cu oral tablet One-A-Day Energy CORVITE FREE ORAL TABLET KP Adults 50+ Daily Formula LYSIPLEX PLUS ORAL TABLET KP Adults 50+ Daily Formula NUTRIFAC ZX ORAL TABLET KP Adults 50+ Daily Formula VIC-FORTE ORAL CAPSULE EQ Vision Formula 50+ VITA S FORTE ORAL TABLET KP Adults 50+ Daily Formula VITACEL ORAL TABLET KP Adults 50+ Daily Formula

*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 Floriva Plus multi-vit/fluoride oral solution 0.5 mg/ml Quflora Pediatric multi-vitamin/fluoride oral solution 0.25 mg/ml Floriva Plus

multivitamin/fluoride oral tablet chewable 0.25 mg Quflora Pediatric

multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg MVC-Fluoride

multivitamins/fluoride oral tablet chewable 0.25 mg Quflora Pediatric

multivitamins/fluoride oral tablet chewable 0.5 mg, 1 mg MVC-Fluoride

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML Multi-Vitamin/Fluoride

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multivitamins/Fluoride

QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML Multi-Vitamin/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***

99

Formulary Drug Name Reference Restrictions tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 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 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 TheraNatal Core Nutrition QLL (100 EA per 90 days) pnv prenatal plus multivitamin oral tablet 27-1 mg TheraNatal Core Nutrition 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 TheraNatal Core Nutrition QLL (100 EA per 90 days) prenatal plus oral tablet 27-1 mg TheraNatal Core Nutrition QLL (100 EA per 90 days) prenatal vitamin plus low iron oral tablet 27-1 mg TheraNatal Core Nutrition QLL (100 EA per 90 days)

preplus oral tablet 27-1 mg TheraNatal Core Nutrition 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 TheraNatal Core Nutrition 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)

100

Formulary Drug Name Reference Restrictions PRENATABS RX ORAL TABLET 29-1 MG Vol-Tab Rx QLL (100 EA per 90 days)

PRENATAL-U ORAL CAPSULE 106.5-1 MG PNV-VP-U QLL (100 EA per 90 days)

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)

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 THERAPYAGENTS* *Central Muscle Relaxants***baclofen oral tablet 10 mg, 20 mg QLL (120 EA per 30 days) carisoprodol oral tablet 350 mg Soma 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)

101

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 - SYSTEMICAND 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)

*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 RA Budesonide OTC; QLL (1 bottle per 30

Days)

*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-AngiotensinIi 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***

102

Formulary Drug Name Reference Restrictions riluzole oral tablet 50 mg Rilutek

*OPHTHALMIC AGENTS**Beta-Blockers - OphthalmicCombinations*** 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 - CholinesteraseInhibitors*** 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

103

Formulary Drug Name Reference Restrictions 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 (5 ML per 25 days) olopatadine hcl ophthalmic solution 0.2 % Pataday ST; QLL (2.5 ML per 25 days)

*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 solution 0.3 % QLL (5 mL per 30 days) levofloxacin ophthalmic solution 0.5 % moxifloxacin hcl ophthalmic solution 0.5 % Vigamox QLL (3 mL per 30 days) 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 % TOBREX OPHTHALMIC OINTMENT 0.3 %

*Ophthalmic Antifungal***NATACYN OPHTHALMIC SUSPENSION 5 %

*Ophthalmic Anti-InfectiveCombinations*** 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 Triple Antibiotic QLL (5 mL per 30 days)

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM AK-Poly-Bac

104

Formulary Drug Name Reference Restrictions *Ophthalmic Antivirals***trifluridine ophthalmic solution 1 % Viroptic QLL (10 mL per 30 days)

*Ophthalmic Carbonic AnhydraseInhibitors*** 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 % ketorolac tromethamine ophthalmic solution 0.4 % Acular LS QLL (5 mL per 30 days)

ketorolac tromethamine ophthalmic solution 0.5 % Acular

*Ophthalmic Selective AlphaAdrenergic 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 SteroidCombinations*** 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)

105

Formulary Drug Name Reference Restrictions 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

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 Oticin HC NR otomax-hc otic solution 10-10-1 mg/ml Oticin HC NR 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

106

Formulary Drug Name Reference Restrictions ofloxacin otic solution 0.3 % Floxin Otic

*Otic Steroid-Anti-InfectiveCombinations*** neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 Cortisporin

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 IMMUNIZINGAGENTS* *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

107

Formulary Drug Name Reference Restrictions amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule 500 mg

*Natural Penicillins***penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml 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-ResistantPenicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg

*PHARMACEUTICALADJUVANTS* *Antimicrobial Agents***benzyl alcohol liquid

*Flavoring Agents***almond oil bitter flavor liquid PCCA Sweetness Enhancer anise extract liquid PCCA Sweetness Enhancer apple flavor liquid PCCA Sweetness Enhancer apricot flavor liquid PCCA Sweetness Enhancer bacon flavor liquid PCCA Sweetness Enhancer banana concentrate liquid PCCA Sweetness Enhancer

108

Formulary Drug Name Reference Restrictions banana cream flavor liquid PCCA Sweetness Enhancer banana creme flavor liquid PCCA Sweetness Enhancer banana flavor liquid PCCA Sweetness Enhancer beef (grilled) flavor oil sol liquid PCCA Sweetness Enhancer OTC beef flavor liquid PCCA Sweetness Enhancer beef type flavor natural liquid PCCA Sweetness Enhancer bitter stop flavor liquid PCCA Sweetness Enhancer bitterness mask flavor liquid PCCA Sweetness Enhancer bitterness suppressor flavor liquid PCCA Sweetness Enhancer blackberry flavor liquid PCCA Sweetness Enhancer blueberry flavor liquid PCCA Sweetness Enhancer bubble gum concentrate liquid PCCA Sweetness Enhancer bubble gum flavor liquid PCCA Sweetness Enhancer

*Gelatin Capsules (Empty)***capsule coni-snap #1 pink capsule DRcaps Size 1 capsule coni-snap #0 blu/white capsule DRcaps Size 1 capsule coni-snap #0 clear capsule DRcaps Size 1 capsule coni-snap #0 dark blue capsule DRcaps Size 1 capsule coni-snap #0 green/clr capsule DRcaps Size 1 capsule coni-snap #0 pink capsule DRcaps Size 1 capsule coni-snap #0 red/white capsule DRcaps Size 1 capsule coni-snap #0 white capsule DRcaps Size 1 capsule coni-snap #00 clear capsule DRcaps Size 1 capsule coni-snap #00 white capsule DRcaps Size 1 capsule coni-snap #000 clear capsule DRcaps Size 1 capsule coni-snap #1 aqua blue capsule DRcaps Size 1 capsule coni-snap #1 blue capsule DRcaps Size 1 capsule coni-snap #1 blue/pink capsule DRcaps Size 1 capsule coni-snap #1 blue/wht capsule DRcaps Size 1 capsule coni-snap #1 brown capsule DRcaps Size 1 capsule coni-snap #1 brwn/ivry capsule DRcaps Size 1 capsule coni-snap #1 clear capsule DRcaps Size 1 capsule coni-snap #1 dk grn/or capsule DRcaps Size 1

*Oral Vehicles***cherry concentrate oral syrup OTC cherry oral syrup

109

Formulary Drug Name Reference Restrictions distilled water oral liquid RA Crystal Lake Dist Water OTC flavor plus oral liquid Ora-Plus oral suspend oral liquid Ora-Plus OTC purified water oral liquid RA Crystal Lake Dist Water raspberry syrup oral syrup simple syrup oral syrup sorbitol solution , 70 % syrpalta oral syrup 85 % GERBER GOOD START WATER ORAL LIQUID OTC

GOOD START STERILE WATER ORAL LIQUID OTC

ORA-PLUS ORAL LIQUID Flavor Plus SIMILAC STERILIZED WATER ORAL LIQUID OTC

SYRSPEND SF ALKA ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF ORAL LIQUID Flavor Plus SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF PH4 ORAL SUSPENSION RECONSTITUTED

*Parenteral Vehicles***sterile water for injection injection solution sterile water for injection intravenous solution

*Pharmaceutical Excipients***lactose monohydrate powder xanthan gum powder PCCA SORBITOL LOLLIPOP BASE FLAKES

*POTASSIUM REMOVINGAGENTS*** *Potassium Removing Agents***sodium polystyrene sulfonate oral powder Kionex sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

110

Formulary Drug Name Reference Restrictions KIONEX ORAL POWDER Sodium Polystyrene Sulfonate KIONEX ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

SPS ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

*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 ANDNEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents***acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg Antabuse

*Benzodiazepines & TricyclicAgents*** chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

*Cholinomimetics - AcheInhibitors***

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


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


*Fibromyalgia Agent - Snris***SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ST; QLL (60 EA per 30 days)

111

Formulary Drug Name Reference Restrictions SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG ST; QLL (1 FILL per 90 days)

*Ms Agents - Pyrimidine SynthesisInhibitors*** AUBAGIO ORAL TABLET 14 MG, 7 MG PA; QLL (30 EA per 30 days)

*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 - Nrf2Pathway 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 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)

112

Formulary Drug Name Reference Restrictions *Phenothiazines & TricyclicAgents*** 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

*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 KLS Quit4

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


nicotine polacrilex mouth/throat lozenge 2 mg Commit


nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4


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)

113

Formulary Drug Name Reference Restrictions *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

*SINUS NODE INHIBITORS***Sinus Node Inhibitors**CORLANOR ORAL TABLET 5 MG PA; QLL (60 EA per 30 days)

*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *Sodium-Glucose Co-Transporter 2Inhibitor-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 demeclocycline hcl oral tablet 150 mg, 300 mg doxycycline hyclate oral tablet 20 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, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg Minocin minocycline hcl oral capsule 75 mg MONDOXYNE NL ORAL CAPSULE 100 MG, 50 MG Doxycycline Monohydrate

114

Formulary Drug Name Reference Restrictions *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, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Unithroid Direct QLL (30 EA per 30 days)

levothyroxine sodium oral tablet 137 mcg Levoxyl QLL (30 EA per 30 days) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Cytomel

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg Armour Thyroid

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG 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

115

Formulary Drug Name Reference Restrictions *Belladonna Alkaloids***ed-spaz oral tablet dispersible 0.125 mg Anaspaz hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg Symax-SR

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 Anaspaz

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Levsin/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 Anaspaz oscimin sr oral tablet extended release 12 hour 0.375 mg Symax-SR

oscimin sublingual tablet sublingual 0.125 mg Levsin/SL NULEV ORAL TABLET DISPERSIBLE 0.125 MG Hyoscyamine Sulfate

SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG Hyoscyamine Sulfate SL

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 AC Maximum Strength 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

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Formulary Drug Name Reference Restrictions 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 24HR 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)

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 NEXIUM 24HR CLEAR MINIS ORAL CAPSULE DELAYED RELEASE 20 MG Esomeprazole Magnesium OTC; QLL (60 EA per 30 days)

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

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Formulary Drug Name Reference Restrictions 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)

*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 - DirectMuscle Relaxants*** flavoxate hcl oral tablet 100 mg QLL (240 EA per 30 days)

*Urinary Antispasmodics - DirectMuscle Relaxants*** (New) flavoxate hcl oral tablet 100 mg QLL (240 EA per 30 days)

*VAGINAL PRODUCTS*

118

Formulary Drug Name Reference Restrictions *Imidazole-Related Antifungals***miconazole 3 vaginal suppository 200 mg terconazole vaginal cream 0.4 % Terazol 7 terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 mg

*Vaginal Anti-Infectives***clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % MetroGel-Vaginal CLEOCIN VAGINAL SUPPOSITORY 100 MG VANDAZOLE VAGINAL GEL 0.75 % MetroNIDAZOLE

*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 Estradiol

*VASOPRESSORS**Anaphylaxis Therapy Agents***epinephrine injection solution auto-injector 0.15 mg/0.15ml Auvi-Q QLL (2 Units Max Qty Per Fill

Retail) epinephrine injection solution auto-injector 0.15 mg/0.3ml EpiPen Jr 2-Pak QLL (4 PENS per 365 days)

epinephrine injection solution auto-injector 0.3 mg/0.3ml Auvi-Q QLL (4 PENS per 365 days)

*Vasopressors***midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

*VITAMINS**Vitamin D***ergocal oral capsule 2500 unit QLL (30 EA per 30 days) ergocalciferol oral capsule 50000 unit Drisdol vitamin d (ergocalciferol) oral capsule 50000 unit Drisdol

vitamin d3 oral tablet dispersible 5000 unit OTC

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Formulary Drug Name Reference Restrictions *Vitamin K***MEPHYTON ORAL TABLET 5 MG

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Index Header

A A + D PERSONAL CARE LOTION 76

abacavir sulfate 52 abacavir sulfate-lamivudine 50 abacavir-lamivudine-zidovudine

50 acamprosate calcium 111 acarbose 32 acebutolol hcl 55 acetaminophen-codeine 10, 11 acetaminophen-codeine #2 10 acetaminophen-codeine #3 10 acetaminophen-codeine #4 10 ACETASOL HC 107 acetazolamide 81 acetazolamide er 81 acetic acid 106 acetic acid-aluminum acetate 106 acetylcysteine 70 acidophilus lactobacillus 60 ACTIMMUNE 45 acyclovir 53, 73 adapalene 71 ADCIRCA 59 advanced healing/baby 76 AEROCHAMBER MINI CHAMBER 93

AEROCHAMBER MV 93 AEROCHAMBER PLUS FLO-VU 93

AEROCHAMBER PLUS FLO-VU LARGE 93

AEROCHAMBER PLUS FLO-VU MEDIUM 93

AEROCHAMBER PLUS FLO-VU SMALL........................93

AEROCHAMBER PLUS FLO-VU W/MASK 93

AEROCHAMBER PLUS FLOW VU 93

AEROCHAMBER W/FLOWSIGNAL 93

AEROCHAMBER Z-STAT PLUS 93

AEROCHAMBER Z-STAT PLUS CHAMBR 93

AEROCHAMBER Z-STAT PLUS/LARGE 93

AEROCHAMBER Z-STAT PLUS/MEDIUM 93

AEROCHAMBER Z-STAT PLUS/SMALL 93

AEROVENT PLUS 93 AFEDITAB CR 58 AFINITOR 44 ak-poly-bac 104 ala-cort 73 ALBENZA 22 ALBOLENE 76 albuterol sulfate 25 albuterol sulfate er 25 alclometasone dipropionate 73 alendronate sodium 82 alfuzosin hcl er 86 ALLI 5 allopurinol 87 almond oil bitter flavor 108 ALOE AFTERSUN 76 alogliptin benzoate 32 alogliptin-metformin hcl 32 alogliptin-pioglitazone 33 alprazolam 23 alprazolam er 23 ALPRAZOLAM INTENSOL 24 alprazolam xr 23 ALTAFRIN 105 ALTAVERA 62 alyacen 1/35 61 alyacen 7/7/7 67 amantadine hcl 46 amcinonide 73 AMETHIA 66 amiloride hcl 81 amiloride-hydrochlorothiazide81 amiodarone hcl 24 amitriptyline hcl 31, 32 AMLACTIN CERAPEUTIC . 76 AMLACTIN ULTRA 76 amlodipine besy-benazepril hcl 39

amlodipine besylate 56 amlodipine besylate-valsartan 40 amlodipine-atorvastatin 59

amlodipine-valsartan-hctz 41

amoxapine 32 amoxicillin 107, 108 amoxicillin-pot clavulanate ..108 amoxicillin-pot clavulanate er 108

amphetamine-dextroamphet er . 4 amphetamine-dextroamphetamine 4

ampicillin 108 anagrelide hcl 87 anastrozole 45 ANECREAM 79 anise extract 108 ANORO ELLIPTA 24 apple flavor 108 APRI 62 apricot flavor 108 APRISO 85 APTIVUS 51 AQUA GLYCOLIC FACE 76 AQUA GLYCOLIC HAND/BODY 76

AQUA LACTEN 76 AQUADERM 76 AQUADERM TREATMENT/MOISTURIZ ER 76

AQUAMED 76 AQUAPHILIC 76 AQUAPHOR 76 AQUAPHOR ADVANCED THERAPY 76

ARANELLE 67 ARCAPTA NEOHALER 25 ARGYLE STERILE SALINE86 ARGYLE STERILE WATER55 ARMOUR THYROID 115 ARZOL SILVER NIT APPLICATORS 73

ASCOMP-CODEINE 11 ASHLYNA 66 ASPERCREME W/LIDOCAINE 79

ASSURE ID INSULIN SAFETY SYR 91

atenolol 55

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atenolol-chlorthalidone 42

atorvastatin calcium 38 ATRIPLA 50 atropine sulfate 103 ATROVENT HFA 25 AUBAGIO 112 AUBRA 62 AURYXIA 86 AVANDIA 35 AVEENO ACTIVE NAT SKIN RELIEF 76

AVEENO ACTIVE NATURALS DAILY 77

AVEENO DAILY MOISTURIZING 77

AVEENO INTENSE RELIEF HAND 77

AVEENO POSITIVELY AGELESS BODY 77

AVEENO POSITIVELY NOURISHING 77

AVEENO POSITIVELY RADIANT NGHT 77

AVEENO SKIN STRENGTHENING BODY 77

AVEENO SKIN STRENGTHENING HAND 77

AVEENO STRESS RELIEF 77 AVIANE 62 avidoxy 114 av-phos 250 neutral 96 azathioprine 55 azelastine hcl 102, 103 azithromycin 90 AZOPT 105 AZURETTE 61 Bbacitracin 104 bacitracin-polymyxin b 104 bacitra-neomycin-polymyxin-hc 105

baclofen 101 bacon flavor 108 balsalazide disodium 85 BALZIVA 62 banana concentrate 108 banana cream flavor 109 banana creme flavor 109

banana flavor 109

BARACLUDE 53 BASAGLAR KWIKPEN 33 BD ECLIPSE SYRINGE 91 beauty lotion 76 beef (grilled) flavor oil sol 109 beef flavor 109 beef type flavor natural 109 BEKYREE 61 BELVIQ 5 benazepril hcl 39 benazepril-hydrochlorothiazide 39

BENZIQ WASH 71 benzonatate 69 benzphetamine hcl 5 benztropine mesylate 46 benzyl alcohol 108 benzyl benzoate 61 beta care 76 betamethasone dipropionate 73 betamethasone dipropionate aug 73

betamethasone valerate 73 betaxolol hcl 55, 103 bethanechol chloride 118 BETOPTIC-S 103 bicalutamide 44 BILTRICIDE 22 biocel 98 bio-statin 36 biotuss 69 bisoprolol fumarate 55 bisoprolol-hydrochlorothiazide 42

bitter stop flavor 109 bitterness mask flavor 109 bitterness suppressor flavor 109 blackberry flavor 109 BLISOVI 24 FE 62 BLISOVI FE 1.5/30 62 BLISOVI FE 1/20 62 blueberry flavor 109 BOUDREAUXS BABY BUTT SMOOTH 77

bp foaming wash 71 bp folinatal plus b 101 bp multinatal plus 100 bp wash 71 b-plex plus 99

BREATHERITE 93

BREATHERITE COLLSPACER ADULT 93

BREATHERITE COLLSPACER CHILD 93

BREATHERITE COLL SPACER INFANT 93

BREATHERITE RIGID SPACER/MASK 93

BREATHERITE SPACER NEONATE 93

BREATHERITE SPACER SMALL CHILD 93

BREATHERITE/LARGE MASK 94

BREATHERITE/MEDIUM MASK 94

BREATHERITE/SMALL MASK 94

BREO ELLIPTA 25 briellyn 61 brimonidine tartrate 105 bromocriptine mesylate 46 brompheniramine tannate 37 bubble gum concentrate 109 bubble gum flavor 109 budesonide 26 bumetanide 81 buprenorphine 20 buprenorphine hcl 20 buprenorphine hcl-naloxone hcl

20 bupropion hcl 30 bupropion hcl er (smoking det)

113 bupropion hcl er (sr) 30 bupropion hcl er (xl) 30 buspirone hcl 23 butalbital-acetaminophen 9 butalbital-apap-caff-cod 11 butalbital-apap-caffeine 9 butalbital-asa-caff-codeine 11 butalbital-aspirin-caffeine 9 butorphanol tartrate 20 BUTRANS 21 C cabergoline 82 CABOMETYX 45 caffeine anhydrous 4 caffeine citrate 4

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calcipotriene 72calcitonin (salmon) 82calcitriol 82calcium acetate (phos binder) . 86calcium carbonate 95calcium carbonate extra light 95calcium carbonate light 95calcium folinate 60CAM 77CAMILA 67CAMRESE 66CANASA 85candesartan cilexetil 41candesartan cilexetil-hctz 40CAPACET 9capecitabine 44capsule coni-snap #1 pink 109capsule coni-snap #0 blu/white

109capsule coni-snap #0 clear 109capsule coni-snap #0 dark blue

109capsule coni-snap #0 green/clr

109capsule coni-snap #0 pink 109capsule coni-snap #0 red/white

109capsule coni-snap #0 white 109capsule coni-snap #00 clear 109capsule coni-snap #00 white 109capsule coni-snap #000 clear109capsule coni-snap #1 aqua blue

109capsule coni-snap #1 blue 109capsule coni-snap #1 blue/pink

109capsule coni-snap #1 blue/wht

109capsule coni-snap #1 brown 109capsule coni-snap #1 brwn/ivry

109capsule coni-snap #1 clear 109capsule coni-snap #1 dk grn/or

109captopril 40captopril-hydrochlorothiazide 39carbamazepine 28carbamazepine er 28carbidopa-levodopa 46

carbidopa-levodopa er 46

carbidopa-levodopa-entacapone 47

carbinoxamine maleate 37carisoprodol 101carisoprodol-aspirin 102carisoprodol-aspirin-codeine 102carteolol hcl 103CARTIA XT 58carvedilol 55castor oil 61, 90CAVAREST 98CAZIANT 67cefaclor 59cefaclor er 59cefadroxil 59cefdinir 60cefixime 60cefpodoxime proxetil 60cefprozil 60CEFTIN 60ceftriaxone sodium 60cefuroxime axetil 60celecoxib .7CELONTIN 30cephalexin 59CERAVE 77CERAVE PM 77CERAVE SA RENEWING 77CETAPHIL DAILY ADVANCE 77

CETAPHIL DAILY FACIAL MOIST 77

cetirizine hcl 37CHATEAL 62CHEMET 36cherry 109cherry concentrate 109chlordiazepoxide hcl 23chlordiazepoxide-amitriptyline

111chlorhexidine gluconate 50, 61,98

chloroquine phosphate 43chlorothiazide 81chlorpropamide 35chlorthalidone 81chlorzoxazone 101cholestyramine 38cholestyramine light 38

choline-mag trisalicylate 9 CICLODAN 72 ciclopirox 72 ciclopirox olamine 72 CIDALEAZE 79 cilostazol 87 CILOXAN 104 cimetidine 116 cimetidine hcl 116 ciprofloxacin 84 ciprofloxacin hcl 84, 104, 106 ciprofloxacin-ciproflox hcl er . 84 citalopram hydrobromide 31 clarithromycin 90, 91 clarithromycin er 90 CLEARPLEX X 71 clemastine fumarate 37 CLEOCIN 119 CLIMARA PRO 83 CLINDACIN ETZ 70 CLINDACIN-P 70 clindamycin hcl 43 clindamycin palmitate hcl 43 clindamycin phosphate 70, 119 clobetasol propionate 74 clobetasol propionate e 74 CLODAN 75 clonazepam 28 clonidine hcl 41 clopidogrel bisulfate 88 clorazepate dipotassium 23 clotrimazole 78, 98 clotrimazole-betamethasone 71 clozapine 48 codeine sulfate 13 colchicine 87 colchicine-probenecid 87 colestipol hcl 38 COLOCORT 21 COMBIGAN 103 COMBIPATCH 83 COMBIVENT RESPIMAT 25 COMPLERA 50 completenate 100 COMPRO 49 CONCEPT DHA 100 CONDYLOX 79 constulose 90 CONTRAVE 46 COPAXONE 112

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CORLANOR 114

CORMAX SCALP APPLICATION 75

CORTANE-B 80 CORTIC-ND 106 CORTIFOAM 21 cortisone acetate 68 CORVITE FREE 99 cottonseed oil 61 CREON 81 CRIXIVAN 51 cromolyn sodium 25, 104 CRYSELLE-28 62 CUPRIMINE 54 CURITY STERILE SALINE . 87 cvs advanced healing 76 cvs permethrin 80 cyanocobalamin 88 CYCLAFEM 1/35 62 CYCLAFEM 7/7/7 67 cyclobenzaprine hcl 101 cyclopentolate hcl 103 cyclosporine 54 cyclosporine modified 54 CYOTIC 106 cyproheptadine hcl 38 CYRED 62 cytra k crystals 86 D DAILY CONDITIONING TREATMENT 77

danazol 21 dantrolene sodium 102 dapsone 43 DARAPRIM 43 DASETTA 1/35 62 DASETTA 7/7/7 67 DAYSEE 66 DEBLITANE 67 DELTASONE 69 DELYLA 62 demeclocycline hcl 114 DENTA 5000 PLUS 98 DENTAGEL 98 DERMAPHOR 77 DERMAZENE 71 DESCOVY 50 desipramine hcl 32 desmopressin ace rhinal tube 83 desmopressin ace spray refrig 83

desmopressin acetate 83

desmopressin acetate spray 83 desogestrel-ethinyl estradiol 61 desonide 74 desoximetasone 74 dexamethasone 68 dexamethasone sodiumphosphate 106

dexmethylphenidate hcl 5 dexmethylphenidate hcl er 5 dextroamphetamine sulfate 4 dextroamphetamine sulfate er 4 diazepam 23 diclofenac potassium 8 diclofenac sodium 8, 72, 105 diclofenac sodium er 8 dicloxacillin sodium 108 dicyclomine hcl 115 didanosine 52 DIDREX 5 diethylpropion hcl 5 diethylpropion hcl er 5 diflorasone diacetate 74 diflunisal 10 DIGITEK 58 DIGOX 58 digoxin 58 dihydroergotamine mesylate 95 DILANTIN 29 diltiazem cd 56 diltiazem hcl 57 diltiazem hcl er 57 diltiazem hcl er beads 56 diltiazem hcl er coated beads . 56, 57

dilt-xr 57 diphenhydramine hcl 37 diphenoxylate-atropine 35, 36 dipyridamole 87 disopyramide phosphate 24 distilled water 110 disulfiram 111 divalproex sodium 30 divalproex sodium er 30 donepezil hcl 111 dorzolamide hcl 105 dorzolamide hcl-timolol mal 103 dothelle dha 100 doxazosin mesylate 41 doxepin hcl 32

doxycycline hyclate 114

doxycycline monohydrate 114 drospirenone-ethinyl estradiol 61 DROXIA 88 dry skin treatment 76 dry skin treatment adv therapy76 DULERA 25 duloxetine hcl 31 E EASIVENT 94 EASIVENT MASK LARGE 94 EASIVENT MASK MEDIUM

94 EASIVENT MASK SMALL . 94 ed-spaz 116 EDURANT 52 EFFER-K 97 effervescent pot chloride 97 ELIDEL 79 ELINEST 62 ELLA 66 ELMIRON 87 EMCYT 45 EMEND 36 EMOQUETTE 63 EMTRIVA 52 enalapril maleate 40 enalapril-hydrochlorothiazide 39 ENBREL 9 ENBREL SURECLICK 9 ENDOCET 19, 20 enoxaparin sodium 27 ENPRESSE-28 67 ENSKYCE 63 entacapone 47 entecavir 53 ENTRESTO 102 enulose 85 e-ointment 76 epinastine hcl 104 epinephrine 119 EPITOL 29 EPIVIR HBV 53 EPOGEN 88 epoprostenol sodium 59 ergocal 119 ergocalciferol 119 ERGOMAR 95 ERRIN 67 ery 70

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ERYPED 400

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91 erythromycin 70, 104 erythromycin ethylsuccinate 91 escitalopram oxalate 31 ESGIC 9 essentra wipes 9x9 80 ESTARYLLA 63 estazolam 89 ESTRACE 119 estradiol 84 estradiol-norethindrone acet 83 ESTRING 119 estropipate 84 ethambutol hcl 43 ethosuximide 29 ethyl oleate 60 etidronate disodium 82 etodolac 8 etodolac er 8 etoposide 45 EVOTAZ 50 exemestane 45 exotic-hc 106 EXTAVIA 112 E-Z SPACER 94 E-Z SPACER THE BODY GUARDS PK 94

ezetimibe 39 FFALMINA 63 famciclovir 53 famotidine 116 FARESTON 44 fa-vitamin b-6-vitamin b-12 88 felbamate 29 felodipine er 57 FEMCAP 91 FEMRING 119 fenofibrate 38 fenofibrate micronized 38 fenofibric acid 38 fenoprofen calcium 8 fentanyl 14 finasteride 86 FIRST-LANSOPRAZOLE 117 FIRST-OMEPRAZOLE 117 FIRST-VANCOMYCIN 25 42 FIRST-VANCOMYCIN 50 42 FLANDERS BUTTOCKS 77 flavor plus 110

flavoxate hcl 118

.. ...........................

flecainide acetate 24 FLEXICHAMBER 94 FLORIVA PLUS 99 FLOVENT DISKUS 26 fluconazole 37 fludrocortisone acetate 69 flunisolide 102 fluocinolone acetonide 74 fluocinonide 74 FLUORABON 96 FLUOR-A-DAY 96 fluoritab 96 fluorometholone 106 FLUOROPLEX 72 fluorouracil 72 fluoxetine hcl 31 fluoxetine hcl (pmdd) 113 fluphenazine decanoate 49 fluphenazine hcl 49 FLURA-DROPS 96 flurazepam hcl 89 flurbiprofen 8 flurbiprofen sodium 105 flutamide 44 fluticasone propionate 74, 102 fluvastatin sodium 38 fluvastatin sodium er 38 fluvoxamine maleate 31 FML FORTE 106 folcal dha 101 folic acid .88 folplex 2.2 88 fondaparinux sodium 27 fosinopril sodium 40 fosinopril sodium-hctz 39 FRAGMIN 27 furosemide 81 FUZEON 50 FYAVOLV 83 G gabapentin 28 GABITRIL 29 galantamine hydrobromide 111 galantamine hydrobromide er

111 gatifloxacin 104 GAVILYTE-C 90 GAVILYTE-G 90

GAVILYTE-N WITH FLAVOR PACK 90

gemfibrozil 38 generlac 85 GENGRAF 54 GENTAK 104 gentamicin sulfate 71, 104 GENVOYA 50 GERBER GOOD START WATER 110

GIANVI 63 GILDAGIA 63 GILDESS FE 1.5/30 63 GILDESS FE 1/20 63 GILENYA 113 GLATIRAMER ACETATE . 112 glimepiride 35 glipizide 35 glipizide er 35 glipizide xl 35 glipizide-metformin hcl 34, 35 GLUCAGEN HYPOKIT 32 GLUCAGON EMERGENCY 32 glyburide 35 glyburide micronized 35 glyburide-metformin. 35 glycerine 61 glycopyrrolate 117 GLYDO 79 GOLD BOND ULTIMATE HEALING 77

GOOD START STERILE WATER 110

granisetron hcl 36 GRANIX 88 griseofulvin microsize 36 griseofulvin ultramicrosize 36 guanfacine hcl 41 Hhalobetasol propionate 74, 75 haloperidol 48 haloperidol decanoate 48 haloperidol lactate 48 HEATHER 67 HEMMOREX-HC 22 HEPAGAM B 107 heparin sodium (porcine) 27 heparin sodium (porcine) pf 27 HEXALEN 44 HOMATROPAIRE 103

125

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homatropine hbr 103HUMALOG 33HUMALOG KWIKPEN 33HUMALOG MIX 50/50 33HUMALOG MIX 50/50KWIKPEN 33

HUMALOG MIX 75/25 33HUMALOG MIX 75/25KWIKPEN 33

HUMIRA 7HUMIRA PEDIATRIC CROHNS START 7

HUMIRA PEN 7HUMIRA PEN-CROHNS STARTER 7

HUMIRA PEN-PSORIASIS STARTER 7

HUMULIN 70/30 KWIKPEN 33HUMULIN N KWIKPEN 33HUMULIN R U-500 (CONCENTRATED) 34

HUMULIN R U-500 KWIKPEN 34

hydralazine hcl 42hydrochlorothiazide 82hydrocodone-acetaminophen 11,12

hydrocodone-homatropine 69hydrocodone-ibuprofen 12hydrocortisone 21, 68, 75hydrocortisone acetate 22, 75hydrocortisone butyr lipo base75hydrocortisone butyrate 75hydrocortisone micronized 75hydrocortisone valerate 75hydrocortisone-acetic acid 107hydrocortisone-iodoquinol 71HYDROLATUM 77hydromet 69hydromorphone hcl 14, 15hydrophor 76hydroxychloroquine sulfate 43hydroxyprogesterone caproate

46, 60hydroxyurea 45hydroxyzine hcl 23hydroxyzine pamoate 23 hyoscyamine sulfate 116 hyoscyamine sulfate er 116 hyosyne 116

HYPERHEP B S/D 107 HYPERRHO S/D 107 HYPERSAL 69 I ibandronate sodium 82 ibuprofen 8 ICAR-C PLUS 89 imatinib mesylate 44 IMBRUVICA 45 imipramine hcl 32 imiquimod 78 INATAL ADVANCE 100 INATAL GT 100 INATAL ULTRA 100 INCRUSE ELLIPTA 26 indapamide 82 indomethacin 8 indomethacin er 8 INSPIRACHAMBER/MEDIU M 94

INSPIRACHAMBER/MOUTH PIECE 94

INSPIRACHAMBER/SMALL 94

INSPIREASE 94 INTELENCE 52 INTRON A 45 INTROVALE 66 INVIRASE 51 INVOKAMET 114 INVOKANA 34 ipratropium bromide 25, 102 ipratropium-albuterol 24 irbesartan 41 irbesartan-hydrochlorothiazide

40 ISENTRESS 51 ISENTRESS HD 51 isoniazid 43 isosorbide dinitrate 22 isosorbide dinitrate er 22 isosorbide mononitrate 22 isosorbide mononitrate er 22 isradipine 57 itraconazole 37 ivermectin 22 JJANTOVEN 27 JENCYCLA 67 JENTADUETO 33

JENTADUETO XR 33 jevantique lo 83 JINTELI 84 JOLESSA 66 JOLIVETTE 67 JULEBER 63 JUNEL 1.5/30 63 JUNEL 1/20 63 JUNEL FE 1.5/30 63 JUNEL FE 1/20 63 JUNEL FE 24 63 K KALETRA 50 KARIDIUM 96 KARIGEL 98 KARIGEL-N 98 KARIVA 61 k-effervescent 97 KELNOR 1/35 63 ketoconazole 37, 78 ketoprofen 8 ketorolac tromethamine 8, 105 KIMIDESS 61 KIONEX 55, 111 KITABIS PAK 6 KLOR-CON 97 KLOR-CON 10 97 KLOR-CON M10 97 KLOR-CON M15 97 KLOR-CON M20 97 KLOR-CON SPRINKLE 97 KLOR-CON/EF 97 kp clotrimazole 78 K-PHOS 96 K-PHOS NO 2 87 K-PRIME 97 KURVELO 63 k-vescent 97 KYLEENA 67 L labetalol hcl 55 lactose monohydrate 110 lactulose 90 lactulose encephalopathy 85 lamivudine 52, 53 lamivudine-zidovudine 50 lamotrigine 28 LANAPHILIC 77 LANOXIN 58 lansoprazole 117

126

LARIN 1.5/30..................................................... .........................

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63

LARIN 1/20 63 LARIN 24 FE 63 LARIN FE 1.5/30 63 LARIN FE 1/20 63 latanoprost 106 lc-4 lidocaine 79 LEENA 68 leflunomide 9 LESSINA 64 LETAIRIS 59 letrozole 45 leucovorin calcium 45, 60 LEUKERAN 45 LEUKINE 88 levalbuterol tartrate 25 levetiracetam 28, 29 levetiracetam er 28 levobunolol hcl 103 levocarnitine 82 levofloxacin 84, 104 LEVONEST 68 levonorgest-eth estrad 91-day 66 levonorgestrel 66 levonorgestrel-ethinyl estrad . 62, 66

levonorg-eth estrad triphasic 67 LEVORA 0.15/30 (28) 64 LEVO-T 115 levothyroxine sodium 115 LEVOXYL 115 LEXIVA 51 lidocaine 79 lidocaine hcl 79, 98 lidocaine viscous 98 lidocaine-hydrocortisone ace 21 lidocaine-prilocaine 80 LIDOCREAM 79 lidopin 79 lindane 80 LINZESS 85 liothyronine sodium 115 lisinopril 40 lisinopril-hydrochlorothiazide 39 LITEAIRE 94 lithium 47 lithium carbonate 47 lithium carbonate er 47 LIVIXIL PAK 80 LOMEDIA 24 FE ... 64

loperamide hcl 36

lopinavir-ritonavir 50 loratadine 37 loratadine allergy relief 37 lorazepam 24 LORAZEPAM INTENSOL 24 LORCET 13 LORCET HD 12 LORCET PLUS 13 LORYNA 64 losartan potassium 41 losartan potassium-hctz 40 lovastatin 38 LOW-OGESTREL 64 loxapine succinate 49 LP LITE PAK 80 LUDENT 96 LUTERA 64 LYRICA 29 LYSIPLEX PLUS 99 LYSODREN 44 LYZA 67 M MAGELLAN INSULIN SAFETY SYR 92

malathion 80 maprotiline hcl 30 marlissa 62 MARPLAN 31 marten-tab 9 MATULANE 45 meclizine hcl 36 meclofenamate sodium 8 medroxyprogesterone acetate 67, 111

mefloquine hcl 43 megestrol acetate 46, 111 meloxicam 8 melphalan 45 memantine hcl 112 MENEST 84 MEPHYTON 120 meprobamate 23 mercaptopurine 44 mesalamine 85 MESNEX 46 metaproterenol sulfate 25 metformin hcl 32 metformin hcl er 32 methadone hcl 15

METHADONE HCL INTENSOL. 18

methazolamide 81 methenamine hippurate 117 methenamine mandelate 117 methimazole 115 methocarbamol 101 methotrexate 44 methotrexate sodium (pf) 44 methoxsalen rapid 72 methyclothiazide 82 methyldopa 41 methyldopa-hydrochlorothiazide

40 methylphenidate hcl 6 methylphenidate hcl er 6 methylphenidate hcl er (cd) 5 methylphenidate hcl er (la) 6 methylprednisolone 68 methyltestosterone 21 metipranolol 103 metoclopramide hcl 85 metolazone 82 metoprolol succinate er 55, 56 metoprolol tartrate 56 metoprolol-hydrochlorothiazide

42 metronidazole 42, 79, 80, 119 mexiletine hcl 24 miconazole 3 119 MICRHOGAM ULTRA-FILTERED PLUS 107

MICROCHAMBER 94 MICROGESTIN 1.5/30 64 MICROGESTIN 1/20 64 MICROGESTIN FE 1.5/30 64 MICROGESTIN FE 1/20 64 MICROSPACER 94 midodrine hcl 119 MIGERGOT 95 MIMVEY 84 MIMVEY LO 84 mineral oil heavy 90 mineral oil light 90 mineral oil-hydrophil petrolat 76 MINITRAN 23 minocycline hcl 114 minoxidil 42 MIRENA (52 MG) 67 mirtazapine 30

127

misoprostol .............................................................

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117

modafinil 6 moexipril hcl 40 moexipril-hydrochlorothiazide

39 mometasone furoate 75, 102 MONDOXYNE NL 114 MONOJECT INSULIN SYRINGE 92

MONOJECT LIFESHIELD SYRINGE 92

MONOJECT MAGELLAN SYRINGE 92

MONOJECT SYRINGE 92 MONOJECT ULTRA COMFORT SYRINGE 92

MONO-LINYAH 64 MONONESSA 64 montelukast sodium 26 morphine sulfate 16 morphine sulfate (concentrate)

15 morphine sulfate er 15, 16 MOVANTIK 85 moxifloxacin hcl 104 MOZOBIL 88 mucosal atomization device 91 MULTAQ 24 multi-vit/fluoride 99 multi-vit/fluoride/iron 99 multivitamin/fluoride 99 multi-vitamin/fluoride 99 multivitamins/fluoride 99 mupirocin 71 MVC-FLUORIDE 99 M-VIT 100 MY WAY 66 mycophenolate mofetil 54, 55 MYLERAN 44 mynatal plus 100 mynatal-z 100 MYORISAN 71 MYZILRA 68 N NABI-HB 107 nabumetone 8 nadolol 56 nadolol-bendroflumethiazide 42 NAFRINSE 96 NAFRINSE DROPS 96

naloxone hcl 36

naltrexone hcl 36 naproxen 8 naproxen dr 8 naproxen sodium 8 naratriptan hcl 95 NARCAN 36 NATACYN 104 nateglinide 34 NATURE-THROID 115 nebulizer updraft-style 91 NEBUSAL 70 NECON 0.5/35 (28) 64 NECON 1/35 (28) 64 NECON 1/50 (28) 64 NECON 7/7/7 68 neomycin sulfate 6 neomycin-bacitracin zn-polymyx 104

neomycin-polymyxin-dexameth 105

neomycin-polymyxin-gramicidin 104

neomycin-polymyxin-hc 105, 107

NEO-POLYCIN 104 NEO-POLYCIN HC 106 NEOSALUS 77 NEUTRAGARD ADVANCED

98 neutral sodium fluoride 98 nevirapine 52 nevirapine er 51, 52 NEXAVAR 44 NEXIUM 24HR CLEAR MINIS 117

NEXPLANON 67 nicardipine hcl 57 nicotine 113 nicotine mini 113 nicotine polacrilex 113 NIFEDIAC CC 58 NIFEDICAL XL 58 nifedipine 57 nifedipine er 57 nifedipine er osmotic release 57 NIKKI 64 nilutamide . 44 nimodipine 57 nisoldipine er 57

NITRO-BID 23 nitrofurantoin 118 nitrofurantoin macrocrystal 117 nitrofurantoin monohyd macro

117 nitroglycerin 22, 23 nitroglycerin er 22 NITRO-TIME 23 NIVA-PLUS 100 nizatidine 116 NORA-BE 67 norethin ace-eth estrad-fe 62 norethindrone 67 norethindrone acetate 111 norethindrone acet-ethinyl est 62 norethindrone-eth estradiol 83 norgestimate-eth estradiol 62 norgestim-eth estrad triphasic . 67 NORLYROC 67 NORTREL 0.5/35 (28) 64 NORTREL 1/35 (21) 64 NORTREL 1/35 (28) 64 NORTREL 7/7/7 68 nortriptyline hcl 32 NORVIR 51 NOVOLOG 34 NOVOLOG FLEXPEN 34 NOVOLOG MIX 70/30 34 NOVOLOG MIX 70/30 FLEXPEN 34

np thyroid 115 NULEV 116 NUTRIFAC ZX 99 NUVARING 65 NYAMYC 72 nystatin . 36, 72, 98 NYSTOP 72 O O-CAL FA 100 OCELLA 64 octreotide acetate 83 OFF DEEP WOODS 78 OFF DEEP WOODS DRY 78 OFF DEEP WOODS SPORTSMEN 78

OFF FAMILYCARE CLEAN FEEL 78

OFF SMOOTH & DRY 78 ofloxacin 84, 104, 107 OGESTREL 64

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76

olanzapine 49 olanzapine-fluoxetine hcl 113 olive oil 61 olopatadine hcl 104 omeprazole 117 OMEPRAZOLE+SYRSPEND SF ALKA 117

OMNIFLEX DIAP HRAGM 91 OMNITROPE 82 ondansetron 36 ondansetron hcl 36 ONETOUCH ULTRA BLUE 80 ONETOUCH VERIO 80 OPTICHAMBER ADVANTAGE 94

OPTICHAMBER ADVANTAGE-LG MASK 94

OPTICHAMBER ADVANTAGE-MED MASK

94 OPTICHAMBER ADVANTAGE-SM MASK94

OPTICHAMBER DIAMOND 94

OPTICHAMBER DIAMOND-LG MASK 94

OPTICHAMBER DIAMOND-MD MASK 94

OPTICHAMBER DIAMOND-SM MASK 94

OPTIHALER 94 oral suspend 110 ORALONE 98 ORA-PLUS 110 ORENCIA 9 orphenadrine citrate er 102 ORSYTHIA 64 oscimin 116 oscimin sr 116 OSCION CLEANSER 71 oseltamivir phosphate 54 otomax-hc 106 oxaprozin 8 oxazepam 24 oxcarbazepine 29 oxybutynin chloride 118 oxybutynin chloride er 118 oxycodone hcl 17, 18 oxycodone-acetaminophen 19

oxycodone-aspirin 19 oxymorphone hcl 18 oxymorphone hcl er 18 OXYTROL 118 P PACERONE 24 pamidronate disodium 82 pantoprazole sodium 117 PARAGARD INTRAUTERINE COPPER 66

paricalcitol 83 PAROEX 98 paromomycin sulfate 6 paroxetine hcl 31 PCCA SORBITOL LOLLIPOP BASE 110

peg 3350/electrolytes 90 peg 3350-kcl-na bicarb-nacl 90 peg-3350/electrolytes 90 PEGASYS 53 PEGASYS PROCLICK 53 PEGINTRON 53 penicillin v potassium 108 pentazocine-naloxone hcl 20 pentoxifylline er 87 perindopril erbumine 40 PERIOGARD 98 permethrin 80 perphenazine 49 perphenazine-amitriptyline 113 PHENADOZ 37 PHENAZO 87 phenazopyridine hcl 87 phendimetrazine tartrate 5 phendimetrazine tartrate er 5 phenelzine sulfate 30 PHENERGAN 37 phenobarbital 89 phentermine hcl 5 phenylephrine hcl 105 phenytoin 29 PHENYTOIN INFATABS 29 phenytoin sodium extended 29 PHILITH 65 PHOS-FLUR 98 PHOSLYRA 86 PHOSPHA 250 NEUTRAL 96 PHOSPHOLINE IODIDE 103 pilocarpine hcl 98, 103 PIMTREA 61

pindolol 56 pioglitazone hcl 35 pioglitazone hcl-glimepiride 35 pioglitazone hcl-metformin hcl

35 PIRMELLA 1/35 65 PIRMELLA 7/7/7 68 piroxicam 8 pnv folic acid + iron 100 pnv prenatal plus multivitamin

100 pnv-dha 101 pnv-dha+docusate 101 pnv-select 100 pnv-vp-u 100 POCKET CHAMBER 94 POCKET SPACER 94 podofilox 79 POLYCIN 104 polyethylene glycol 3350 90 polymyxin b-trimethoprim 104 PORTIA-28 65 pot bicarb-pot chloride 97 potassium bicarbonate 97 potassium chloride crys er . 97 potassium chloride er 97 potassium citrate er 86 potassium citrate-citric acid 86 pramipexole dihydrochloride 47 pravastatin sodium 38 prazosin hcl 41 PRED MILD 106 prednicarbate 75 prednisolone 68 prednisolone acetate 106 prednisolone sodium phosphate

69, 106 prednisone 69 PREFEST 84 PREMARIN 84, 119 premium lidocaine 79 PREMPHASE 84PREMPRO 84PRENATABS RX 101prenatal 100prenatal 19 100 prenatal plus 100 prenatal vitamin plus low iron

100 PRENATAL-U 101

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preplus 100 PREVALITE 38 PREVIFEM 65 PREZCOBIX 50 PREZISTA 51 PRIFTIN 43 primidone 29 probenecid 87 prochlorperazine 49 prochlorperazine maleate 49 PROCTOFOAM HC 22 PROCTO-PAK 22 PROCTOSOL HC 22 PROCTOZONE-HC 22 progesterone micronized 111 PROMACTA 89 promethazine hcl 37 promethazine vc/codeine 70 promethazine-codeine 70 promethazine-dm 70 promethazine-phenylephrine 69 PROMETHEGAN 37 propafenone hcl 24 propantheline bromide 117 propranolol hcl 56 propranolol hcl er 56 propranolol-hctz 42 propylthiouracil 115 protriptyline hcl 32 PULMICORT 26 PULMICORT FLEXHALER 26 PULMOSAL 70 PULMOZYME 114 purified water 110 pyrazinamide 43 pyridostigmine bromide 43 pyrimethamine 60 Q QSYMIA 4 QUASENSE 66 quetiapine fumarate 49 QUFLORA PEDIATRIC 99 quinapril hcl 40 quinapril-hydrochlorothiazide 39 quinidine gluconate er 24 quinidine sulfate 24 QVAR 26 R ra hydrating healing 76 rabeprazole sodium 117

raloxifene hcl .......................... ...................................

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83 ramipril 40 ranitidine hcl 116, 117 RAPAMUNE 55 raspberry syrup 110 REBETOL 53 REBIF 112 REBIF REBIDOSE 112 REBIF REBIDOSETITRATION PACK 112

REBIF TITRATION PACK 112 RECLIPSEN 65 RECTIV 21 reeses pinworm medicine 22 REGIMEX 5 RELADOR PAK 80 RELADOR PAK PLUS 80 RELENZA DISKHALER 54 repaglinide 34 repaglinide-metformin hcl 34 RESCRIPTOR 52 RETROVIR 52 REVLIMID 54 REYATAZ 51 RHINOCORT ALLERGY 102 RHOGAM ULTRA-FILTERED PLUS 107

RHOPHYLAC 107 RIBASPHERE 53 RIDAURA 8 rifabutin 43 rifampin 43 riluzole 103 rimantadine hcl 54 risperidone 48 RISPERIDONE M-TAB 48 RITEFLO 94 rivastigmine tartrate 111 rizatriptan benzoate 95 ropinirole hcl 47 ropinirole hcl er 47 ROSADAN 80 rosuvastatin calcium 38 ROZEREM 89 S SALACYN 79 salicylic acid 79 salsalate 10 SANDOSTATIN LAR DEPOT

83

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78 SARATOGA 77 SAVELLA 111 SAVELLA TITRATION PACK

112 SAWYER INSECT REPELLENT 78

scalacort 75 SEB-PREV WASH 73 SELECT-OB 101 selegiline hcl 46 selenium sulfide 72 selenium sulf-pyrithione-urea . 72 SELZENTRY 50 se-natal 19 100 sertraline hcl 31 sesame oil 61 SETLAKIN 66 sf 98 sf 5000 plus 98 SHAROBEL 67 sildenafil citrate 59 silver sulfadiazine 73 SIMILAC STERILIZED WATER 110

simple syrup 110 simvastatin 39 sirolimus 55 sodium bicarbonate 22, 95 sodium chloride 69, 86 sodium fluoride 96 sodium polystyrene sulfonate 55, 110

SOLIRIS 87 SOLTAMOX 44 sorbitol 61, 110 sotalol hcl 56 sotalol hcl (af) 56 spinosad 80 spironolactone 81 spironolactone-hctz 81 SPRINTEC 28 65 SPS 55, 111 SRONYX 65 SSD 73 stavudine 52 sterile water for injection 110 sterile water for irrigation 55 stevia 6 stevia extract 60, 61

130

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61 stevioside 61 STIOLTO RESPIMAT 25 STRIBILD 50 STRIVERDI RESPIMAT . 25 sucralfate 117 sulfacetamide sodium 70, 72, 106

sulfacetamide sodium (acne) 70 sulfacetamide-prednisolone 105 sulfadiazine 114 sulfamethoxazole-trimethoprim

42, 43 sulfasalazine 85 SULFATRIM PEDIATRIC 43 sulindac 8 sumatriptan 95 sumatriptan succinate 95 sumatriptan succinate refill 95 SUPRAX 60 SUSTIVA 52 SUTENT 44 SYEDA 65 SYMAX-SL 116 SYMAX-SR 116 SYNAGIS 107 syrpalta 110 SYRSPEND SF 110 SYRSPEND SF ALKA 110 SYRSPEND SF PH4 110 T TABLOID 44 tacrolimus 55, 79 TAMIFLU 54 tamoxifen citrate 44 tamsulosin hcl 86 TANZEUM 34 TARCEVA 45 TARGRETIN 80 TARINA FE 1/20 65 TARON-C DHA 101 TARON-CRYSTALS 86 TASIGNA 45 TAZTIA XT 58 TECFIDERA 112 temazepam 89 temozolomide 45 TENCON 9 terazosin hcl 41 terbinafine hcl 37

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terconazole 119 testosterone 21 testosterone cypionate 21 testosterone enanthate . 21 THALOMID 54 THEOCHRON 26 theophylline 26 theophylline er 26 THERMAZENE 73 thioridazine hcl 49 thiothixene 49 tiagabine hcl 29 TILIA FE 68 timolol maleate 56, 103 TIVICAY 51 tizanidine hcl 102 TOBRADEX 106 tobramycin 6, 104 tobramycin-dexamethasone 106 TOBREX 104 tolazamide 35 tolbutamide 35 tolmetin sodium 8 tolterodine tartrate 118 topiramate 29 torsemide 81 TRACLEER 59 TRADJENTA 32 tramadol hcl 18 tramadol-acetaminophen 21 trandolapril 40 tranylcypromine sulfate 30 trazodone hcl 30, 114 tretinoin 46, 71 triadvance 100 triamcinolone acetonide 75, 98, 102

triamterene-hctz 81 triazolam 89 TRICARE 101 tricitrates 86 TRIDERM 75 TRI-ESTARYLLA 68 trifluoperazine hcl 49 trifluridine 105 trihexyphenidyl hcl 46 TRI-LEGEST FE 68 TRI-LINYAH 68 TRILYTE 90

trimethobenzamide hcl ...........

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trimethoprim 42 trinatal rx 1 100 TRINATE 101 TRINESSA (28) 68 TRI-PREVIFEM 68 TRI-SPRINTEC 68 TRIUMEQ 50 tri-vit/fluoride 100 tri-vit/fluoride/iron 99 tri-vitamin/fluoride 100 TRIVORA (28) 68 tropicamide 103 trospium chloride 118 TRULICITY 34 TRUVADA 50 TRUZONE PEAK FLOW METER 93

TUSSIGON 69 TYBOST 49 TYKERB 45 UULORIC 87 ULTICARE INSULIN SAFETY SYR 93

ULTRATHON INSECT REPELLENT 8 79

UNITHROID 115 UNITHROID DIRECT 115 urosex 101 ursodiol 85 Vvalacyclovir hcl 53 valproic acid 30 valsartan 41 valsartan-hydrochlorothiazide 41 valved holding chamber 93 vancomycin hcl 42 VANDAZOLE 119 v-c forte 99 VELIVET 68 VEMAVITE-PRX 2 101 venlafaxine hcl 31 venlafaxine hcl er 31 VENTOLIN HFA 25 verapamil hcl 58 verapamil hcl er 57, 58 VESTURA 65 VIC-FORTE 99 VIDEX 52

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65 VINATE II 101 VINATE M 101 VINATE ONE 101 VIOKACE 81 viorele 61 VIRACEPT 51 VIRAMUNE XR 52 VIREAD 53 virt-c dha 100 virt-phos 250 neutral 96 virtrate-2 86 virtrate-3 86 virtrate-k 86 vit b3-azelac-turm-fa-b6-zn-cu

99 VITA S FORTE 99 VITACEL 99 VITAFOL-OB 101 vitamin d (ergocalciferol) 119 vitamin d3 119 vitamins acd-fluoride 100 VIVITROL 36 vol-plus 100 VORTEX VALVED HOLDING CHAMBER 95

VOTRIENT 45 VYFEMLA 65 W warfarin sodium 27 WATCHHALER 95 WERA 65 WESTHROID 115 WIDE-SEAL DIAPHRAGM 60

91 WIDE-SEAL DIAPHRAGM 65







91 WP THYROID 115 Xxanthan gum 110

XARELTO 27 XARELTO STARTER PACK

27 XULANE 65 YYUVAFEM 119 Zzafirlukast 26 zaleplon 89 ZAMICET 13 ZARAH 65 ZARXIO 88 ZEBUTAL 9 ZENATANE 71 ZENCHENT 65 ZENPEP 81 ZEPATIER 89 ZIAGEN 52 zidovudine 52 ziprasidone hcl 47 zolpidem tartrate 89 zonisamide 29 ZOVIA 1/35E (28) 65 ZOVIA 1/50E (28) 65

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Documents

Aetna Better Health Of Virginia Formulary Guide September 2017 · 2017-09-01 · AETNA BETTER HEALTH® Formulary Guide . What are some types of coverage rules? Prior Approval (PA):