Stanford Health Care Advantage Formulario resumido de 2019 (Lista parcial de medicamentos cubiertos)

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1 Stanford Health Care Advantage Formulario resumido de 019 (Lista parcial de medicamentos cubiertos) LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE ALGUNOS DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN , Ǜ Este formulario resumido fue actualizó en 10/0ǜ/018. Esta no es una lista complete de los medicamentos que cubre nuestro plan. Para consultar un listado completo o si tiene otras preguntas, póngase en contacto con el Departamento de Servicios para los miembros de Stanford Health Care Advantage al o, para los usuarios de TTY, al 711, de 8 am a 8 pm, los 7 días de la semana (excepto el Día de Acción de Gracias y Navidad) desde el 1 de Octubre hasta el 1 de Marzo, y de lunes a viernes (excepto los días feriados) desde el 1 de Abril hasta el 0 de Septiembre., o visite

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13 Table of Contents Analgesics... Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents...5 Antianxiety Agents...5 Antibacterials... 6 Anticancer Agents... 8 Anticholinergic Agents Anticonvulsants...10 Antidementia Agents...11 Antidepressants Antidiabetic Agents... 1 Antifungals...14 Antigout Agents Antihistamines...15 Anti-Infectives (Skin And Mucous Membrane)...15 Antimigraine Agents...15 Antimycobacterials...15 Antinausea Agents...16 Antiparasite Agents...16 Antiparkinsonian Agents...16 Antipsychotic Agents...16 Antivirals (Systemic)...17 Blood Products/Modifiers/Volume Expanders... 0 Caloric Agents...1 Cardiovascular Agents... 1 Central Nervous System Agents... 5 Contraceptives...6 Dental And Oral Agents...8 Dermatological Agents...9 Devices... 0 Enzyme Replacement/Modifiers...1 Eye, Ear, Nose, Throat Agents...1 Gastrointestinal Agents... Genitourinary Agents... Heavy Metal Antagonists... 4 Hormonal Agents, Stimulant/Replacement/Modifying

14 Immunological Agents...7 Inflammatory Bowel Disease Agents...40 Irrigating Solutions...40 Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents...41 Replacement Preparations...41 Respiratory Tract Agents... 4 Skeletal Muscle Relaxants... 4 Sleep Disorder Agents Vasodilating Agents...44 Vitamins And Minerals... 44

15 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml 1 GC; QL (700 per 0 acetaminophen-codeine oral tablet QL (60 per 0 acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) QL (60 per 0 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (180 per 0 endocet oral tablet 10-5 QL (180 per 0 endocet oral tablet 5-5 QL (60 per 0 endocet oral tablet QL (40 per 0 hydrocodone-acetaminophen oral solution (Hycet) QL (700 per /15 ml hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (180 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (40 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (40 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (180 per lorcet (hydrocodone) oral tablet 5-5 QL (40 per 0 lorcet hd oral tablet 10-5 QL (180 per 0 lorcet plus oral tablet QL (180 per 0 oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 40, 60, 80 oxycodone-acetaminophen oral tablet 10- (Endocet) QL (180 per 0 5 oxycodone-acetaminophen oral tablet.5-5, 5-5 (Endocet) QL (60 per 0

16 oxycodone-acetaminophen oral tablet (Endocet) QL (40 per OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG tramadol oral tablet 50 (Ultram) 1 GC; QL (40 per 0 Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % QL (00 per 0 diclofenac sodium topical gel % (Solaraze) PA; QL (100 per 8 ibu oral tablet 600, GC ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, (IBU) 1 GC 800 meloxicam oral tablet 15, 7.5 (Mobic) 1 GC naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly % QL (0 per 0 lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 lidocaine topical ointment 5 % PA; QL (90 per 0 lidocaine viscous mucous membrane solution % 4

17 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) SUBOXONE SUBLINGUAL FILM 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 QL (90 per 0 QL (90 per 0 QL (6 per 65 QL (6 per 65 QL (106 per 65 QL (60 per 0 QL (0 per 0 QL (0 per 0 QL (60 per 0 (Xanax) 1 GC; QL (10 per 0 alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 5

18 lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 Antibacterials Aminoglycosides neomycin oral tablet GC tobramycin in 0.5 % nacl inhalation (Tobi) 5 PA BvD; NM; NDS solution for nebulization 00 /5 ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 150, 00, 75 (Cleocin HCl) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 100, 5, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 0 capsule 100 Cephalosporins cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) 4 azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 1 GC pack), 500 ( pack) azithromycin oral tablet 50, 500 (Zithromax) 1 GC azithromycin oral tablet 600 (Zithromax) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml 6

19 clarithromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION 5 NM; LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML INVANZ INJECTION RECON SOLN 4 1 GRAM Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 1 GC 500 Quinolones ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin hcl oral tablet GC levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 GC levofloxacin oral tablet 500, 750 (Levaquin) 1 GC ofloxacin oral tablet 00, 400 7

20 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 minocycline oral capsule 100, 50 (Minocin) minocycline oral capsule 75 Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 5 PA NSO; NM; NDS; QL (11 per 8 MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 anastrozole oral tablet 1 (Arimidex) 1 GC bicalutamide oral tablet 50 (Casodex) DROXIA ORAL CAPSULE 00 MG, 4 00 MG, 400 MG ELIGARD ( MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) exemestane oral tablet 5 (Aromasin) hydroxyurea oral capsule 500 (Hydrea) 8

21 letrozole oral tablet.5 (Femara) 1 GC LEUKERAN ORAL TABLET MG 5 NM; NDS leuprolide subcutaneous kit 1 /0. ml LUPRON DEPOT ( MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT 5 NM; NDS INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG megestrol oral tablet 0, 40 mercaptopurine oral tablet 50 methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 PURIXAN ORAL SUSPENSION 0 MG/ML 5 NM; NDS REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; LA; NDS; QL (8 per PA NSO; NM; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; NDS; QL (90 per 0 9

22 TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NM; NDS; QL (11 per 8 TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (10 per 0 VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NM; NDS; QL (10 per 0 ZYTIGA ORAL TABLET 50 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics propantheline oral tablet 15 Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 gabapentin oral capsule 100, 00, (Neurontin) 1 GC 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 100, 150, (Lamictal) 1 GC 00, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam oral solution 100 /ml (Keppra) 5 PA NSO; NM; NDS; QL (10 per 0 10

23 levetiracetam oral tablet 1,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG topiramate oral capsule, sprinkle 15, 5 topiramate oral capsule,sprinkle,er 4hr 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 5, 50 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG (Keppra) (Keppra XR) (Topamax) (Qudexy XR) 4 (Topamax) 1 GC QL (90 per 0 QL (900 per 0 4 ST; QL (60 per 0 4 ST; QL (10 per 0 5 ST; NM; NDS; QL (60 per 0 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 (Aricept) 1 GC; QL (0 per 0 donepezil oral tablet,disintegrating 10 QL (0 per 0, 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (0 per 0 4 hr 16, 4, 8 galantamine oral solution 4 /ml QL (00 per 0 galantamine oral tablet 1, 4, 8 (Razadyne) QL (60 per 0 Antidepressants Antidepressants bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 11

24 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 150, 00 citalopram oral solution 10 /5 ml QL (600 per 0 citalopram oral tablet 10, 0, 40 (Celexa) 1 GC; QL (0 per 0 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, (Lexapro) 1 GC 0, 5 fluoxetine oral capsule 10, 0, 40 (Prozac) 1 GC fluoxetine oral solution 0 /5 ml (4 /ml) paroxetine hcl oral tablet 10, 0, (Paxil) 1 GC 0, 40 PAXIL ORAL SUSPENSION 10 4 MG/5 ML sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC trazodone oral tablet 100, 150, 50 1 GC trazodone oral tablet 00 venlafaxine oral capsule,extended release (Effexor XR) QL (0 per 0 4hr 150 venlafaxine oral capsule,extended release (Effexor XR) QL (90 per 0 4hr 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 Antidiabetic Agents Antidiabetic Agents, Miscellaneous JANUMET ORAL TABLET 50-1,000 QL (60 per 0 MG, MG JANUMET XR ORAL TABLET, ER QL (0 per 0 MULTIPHASE 4 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 0 MULTIPHASE 4 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG QL (0 per 0 1

25 metformin oral tablet 1,000 (Glucophage) 6 GC; QL (75 per 0 metformin oral tablet 500 (Glucophage) 6 GC; QL (150 per 0 metformin oral tablet 850 (Glucophage) 6 GC; QL (90 per 0 metformin oral tablet extended release 4 hr 500 (Glucophage XR) 6 GC; QL (10 per 0 metformin oral tablet extended release 4 hr 750 (Glucophage XR) 6 GC; QL (60 per 0 pioglitazone oral tablet 15, 0, 45 (Actos) 6 GC; QL (0 per 0 VICTOZA SUBCUTANEOUS PEN QL (9 per 0 INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) Insulins LANTUS SOLOSTAR U-100 QL (0 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN QL (40 per 8 SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 QL (0 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 U-100 QL (40 per 8 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U- QL (0 per SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG PENFILL U-100 QL (0 per 8 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN QL (40 per 8 ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX U-00 SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) QL (18 per 8 1

26 TOUJEO SOLOSTAR U-00 QL (1.5 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1, (Amaryl) 6 GC; QL (0 per 0 glimepiride oral tablet 4 (Amaryl) 6 GC; QL (60 per 0 glipizide oral tablet 10 (Glucotrol) 6 GC; QL (10 per 0 glipizide oral tablet 5 (Glucotrol) 6 GC; QL (60 per 0 glipizide oral tablet extended release 4hr (Glucotrol XL) QL (60 per 0 10 glipizide oral tablet extended release 4hr (Glucotrol XL) QL (0 per 0.5, 5 Antifungals Antifungals clotrimazole-betamethasone topical (Lotrisone) cream % fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 (Nyamyc) unit/gram nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 1 GC 14

27 Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 1 GC ULORIC ORAL TABLET 40 MG, 80 QL (0 per 0 MG Antihistamines Antihistamines hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 5, 1 GC 50 levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (4HR Allergy Relief) 1 GC Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents rizatriptan oral tablet 10 (Maxalt) QL (18 per 8 rizatriptan oral tablet 5 QL (18 per 8 rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (18 per 8, 5 sumatriptan succinate oral tablet 100, 5, 50 (Imitrex) 1 GC; QL (18 per 8 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (4 per 8 cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose QL (4 per 8 injector 4 /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 8 solution 6 /0.5 ml Antimycobacterials Antimycobacterials dapsone oral tablet 100, 5 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 GC rifampin intravenous recon soln 600 (Rifadin) 15

28 rifampin oral capsule 150, 00 (Rifadin) Antinausea Agents Antinausea Agents meclizine oral tablet 1.5 meclizine oral tablet 5 (Dramamine Less Drowsy) ondansetron oral tablet,disintegrating 4 (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 1.5 promethazine oral tablet 1.5, 5, 1 GC 50 promethazine rectal suppository 1.5, (Phenadoz) 5 promethazine rectal suppository 50 (Phenergan) promethegan rectal suppository 5, 50 Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG 5 NM; NDS atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) hydroxychloroquine oral tablet 00 (Plaquenil) mefloquine oral tablet 50 Antiparkinsonian Agents Antiparkinsonian Agents benztropine oral tablet 0.5, 1, carbidopa-levodopa oral tablet (Sinemet), 5-100, 5-50 carbidopa-levodopa oral tablet extended (Sinemet CR) release 5-100, pramipexole oral tablet 0.15, 0.5 (Mirapex) 1 GC, 0.5, 0.75, 1, 1.5 ropinirole oral tablet 0.5, 0.5, 1 (Requip),,, 4, 5 Antipsychotic Agents Antipsychotic Agents clozapine oral tablet 100 (Clozaril) QL (70 per 0 16

29 clozapine oral tablet 00 QL (15 per 0 clozapine oral tablet 5 (Clozaril) QL (90 per 0 clozapine oral tablet 50 QL (90 per 0 clozapine oral tablet,disintegrating 100 (FazaClo) ST; QL (90 per 0, 1.5, 5 clozapine oral tablet,disintegrating 150 (FazaClo) ST; QL (180 per 0 clozapine oral tablet,disintegrating 00 (FazaClo) ST; QL (10 per 0 haloperidol oral tablet 0.5, 1, 10,, 0, 5 LATUDA ORAL TABLET 10 MG, QL (0 per 0 0 MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 10 (Zyprexa) QL (0 per 0 olanzapine oral tablet 10, 15,.5 (Zyprexa) QL (0 per 0, 0, 5, 7.5 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (0 per 0, 15, 0, 5 perphenazine oral tablet 16,, 4, 8 quetiapine oral tablet 100, 00, 5 (Seroquel) QL (90 per 0, 00, 400, 50 risperidone oral solution 1 /ml (Risperdal) QL (480 per 0 risperidone oral tablet 0.5, 0.5, 1,,, 4 (Risperdal) 1 GC; QL (60 per 0 risperidone oral tablet,disintegrating 0.5 QL (60 per 0, 0.5, 1, risperidone oral tablet,disintegrating QL (10 per 0, 4 VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 ST; NM; NDS; QL (540 per 0 ziprasidone hcl oral capsule 0, 40 (Geodon) QL (60 per 0, 60, 80 Antivirals (Systemic) Antiretrovirals ATRIPLA ORAL TABLET NM; NDS 00 MG COMPLERA ORAL TABLET MG 5 NM; NDS 17

30 EPIVIR HBV ORAL SOLUTION 5 4 MG/5 ML (5 MG/ML) INTELENCE ORAL TABLET NM; NDS MG, 00 MG INTELENCE ORAL TABLET 5 MG 4 ISENTRESS HD ORAL TABLET NM; NDS MG ISENTRESS ORAL POWDER IN 4 PACKET 100 MG ISENTRESS ORAL TABLET 400 MG 5 NM; NDS ISENTRESS ORAL 4 TABLET,CHEWABLE 100 MG, 5 MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG 5 NM; NDS lamivudine oral solution 10 /ml (Epivir) lamivudine oral tablet 100 (Epivir HBV) lamivudine oral tablet 150, 00 (Epivir) lamivudine-zidovudine oral tablet 150- (Combivir) 00 lopinavir-ritonavir oral solution (Kaletra) 5 NM; NDS /5 ml NORVIR ORAL CAPSULE 100 MG 4 NORVIR ORAL POWDER IN 4 PACKET 100 MG NORVIR ORAL SOLUTION 80 4 MG/ML PREZISTA ORAL SUSPENSION NM; NDS MG/ML PREZISTA ORAL TABLET 150 MG, 5 NM; NDS 600 MG, 75 MG, 800 MG ritonavir oral tablet 100 (Norvir) STRIBILD ORAL TABLET NM; NDS MG TRUVADA ORAL TABLET MG, 1-00 MG, MG, MG 5 NM; NDS 18

31 Antivirals, Miscellaneous RELENZA DISKHALER 4 INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 (Flumadine) Hcv Antivirals DAKLINZA ORAL TABLET 0 MG, 60 MG, 90 MG ; QL (8 per 8 EPCLUSA ORAL TABLET MG ; QL (8 per 8 HARVONI ORAL TABLET MG ; QL (0 per 0 MAVYRET ORAL TABLET MG ; QL (84 per 8 SOVALDI ORAL TABLET 400 MG ; QL (8 per 8 TECHNIVIE ORAL TABLET MG ; QL (56 per 8 VIEKIRA PAK ORAL TABLETS,DOSE PACK 1.5 MG-75 MG -50 MG/50 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 4HR 8. MG-50 MG-. MG-00 MG VOSEVI ORAL TABLET MG ZEPATIER ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML ; QL (11 per 8 ; QL (84 per 8 ; QL (8 per 8 ; QL (0 per 0 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 NM; NDS 5 NM; NDS 19

32 PEGASYS SUBCUTANEOUS 5 NM; NDS SYRINGE 180 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 00 (Zovirax) acyclovir oral suspension 00 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) valacyclovir oral tablet 1 gram, 500 (Valtrex) Blood Products/Modifiers/Volume Expanders Anticoagulants jantoven oral tablet 1, 10,, 1 GC.5,, 4, 5, 6, 7.5 warfarin oral tablet 1, 10,, (Coumadin) 1 GC.5,, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (4)- 0 MG (9) Blood Formation Modifiers EPOGEN INJECTION SOLUTION,000 UNIT/ML, 0,000 UNIT/ ML, 4 PA; QL (1 per 8,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 0,000 UNIT/ML ; QL (1 per 8 NEULASTA SUBCUTANEOUS 5 NM; NDS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 00 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 1 PA; QL (1 per 8 ; QL (1 per 8 ; QL (6 per 8 0

33 tranexamic acid oral tablet 650 (Lysteda) QL (0 per 0 Platelet-Aggregation Inhibitors cilostazol oral tablet 100, 50 clopidogrel oral tablet 75 (Plavix) 1 GC Caloric Agents Caloric Agents CLINIMIX 5%-D0W(SULFITE- 4 PA BvD FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.5%/D5W SUL 4 PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX E 5%/D15W SULFIT 4 PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D0W SULFIT 4 PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 5 % in water (d5w) intravenous parenteral solution INTRALIPID INTRAVENOUS 4 PA BvD EMULSION 0 %, 0 % NUTRILIPID INTRAVENOUS 4 PA BvD EMULSION 0 % PROSOL 0 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1, 0., (Catapres) 1 GC 0. doxazosin oral tablet 1,, 4, 8 (Cardura) Angiotensin Ii Receptor Antagonists losartan oral tablet 100, 5, 50 (Cozaar) 6 GC 1

34 losartan-hydrochlorothiazide oral tablet (Hyzaar) 6 GC , 100-5, valsartan-hydrochlorothiazide oral tablet (Diovan HCT) , 160-5, 0-1.5, 0-5, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 0, 40 (Lotensin) 6 GC benazepril oral tablet 5 6 GC lisinopril oral tablet 10, 0, 5 (Prinivil) 6 GC lisinopril oral tablet.5, 0, 40 (Zestril) 6 GC lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 6 GC , 0-1.5, 0-5 Antiarrhythmic Agents amiodarone oral tablet 00 (Pacerone) 1 GC amiodarone oral tablet 400 (Pacerone) flecainide oral tablet 100, 150, 50 pacerone oral tablet 00 1 GC pacerone oral tablet 400 Beta-Adrenergic Blocking Agents atenolol oral tablet 100, 5, 50 (Tenormin) 1 GC carvedilol oral tablet 1.5, 5, (Coreg) 1 GC.15, 6.5 metoprolol succinate oral tablet extended release 4 hr 100, 00, 5, 50 (Toprol XL) metoprolol tartrate oral tablet 100, 50 (Lopressor) 1 GC metoprolol tartrate oral tablet 5 1 GC propranolol oral capsule,extended release (Inderal LA) 4 hr 10, 160, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 10, 0, 40, 60, 80 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 4hr 10, 180, 40, 00

35 diltiazem hcl oral capsule,extended release 1 hr 10, 60, 90 diltiazem hcl oral capsule,extended (Tiazac) release 4 hr 40 diltiazem hcl oral capsule,extended (Cardizem CD) release 4hr 10, 180, 40, 00 diltiazem hcl oral tablet 10, 0, (Cardizem) 60 diltiazem hcl oral tablet 90 dilt-xr oral capsule,ext.rel 4h degradable 10, 180, 40 taztia xt oral capsule,extended release 4 hr 10, 180, 40, 00, 60 verapamil oral capsule, 4 hr er pellet ct (Verelan PM) 100, 00, 00 verapamil oral capsule,ext rel. pellets 4 (Verelan) hr 10, 180, 40 verapamil oral capsule,ext rel. pellets 4 (Verelan) 4 hr 60 verapamil oral tablet 10, 80 (Calan) 1 GC verapamil oral tablet 40 1 GC verapamil oral tablet extended release (Calan SR) 1 GC 10, 180, 40 Cardiovascular Agents, Miscellaneous digitek oral tablet 15 mcg, 50 mcg digox oral tablet 15 mcg, 50 mcg DIGOXIN ORAL SOLUTION 50 4 MCG/ML digoxin oral tablet 15 mcg, 50 mcg (Digitek) hydralazine oral tablet 10, 100, 5, 50 Dihydropyridines amlodipine oral tablet 10,.5, 5 (Norvasc) 1 GC amlodipine-benazepril oral capsule 10-0 (Lotrel), 10-40, 5-10, 5-0, 5-40 amlodipine-benazepril oral capsule.5-10

36 Diuretics furosemide injection solution 10 /ml furosemide injection syringe 10 /ml furosemide oral solution 10 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 (Lasix) 1 GC hydrochlorothiazide oral capsule 1.5 (Microzide) 1 GC hydrochlorothiazide oral tablet 1.5, 1 GC 5, 50 spironolactone oral tablet 100, 5, (Aldactone) 1 GC 50 triamterene-hydrochlorothiazid oral (Dyazide) 1 GC capsule triamterene-hydrochlorothiazid oral (Maxzide-5) 1 GC tablet triamterene-hydrochlorothiazid oral (Maxzide) 1 GC tablet Dyslipidemics atorvastatin oral tablet 10, 0, 40 (Lipitor) 6 GC, 80 fenofibrate oral tablet 160, 54 gemfibrozil oral tablet 600 (Lopid) 1 GC lovastatin oral tablet 10, 0, 40 6 GC pravastatin oral tablet 10 6 GC pravastatin oral tablet 0, 40, 80 (Pravachol) 6 GC simvastatin oral tablet 10, 0, 40 (Zocor) 6 GC simvastatin oral tablet 5 6 GC simvastatin oral tablet 80 (Zocor) 6 GC; QL (0 per 0 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5, 50 (Inspra) TEKTURNA ORAL TABLET 150 ST MG, 00 MG Vasodilators isosorbide dinitrate oral tablet 10, 0, 0 4

37 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide dinitrate oral tablet extended release 40 (ISOCHRON) isosorbide mononitrate oral tablet 10, 1 GC 0 isosorbide mononitrate oral tablet extended release 4 hr 10, 60 isosorbide mononitrate oral tablet 1 GC extended release 4 hr 0 Central Nervous System Agents Central Nervous System Agents AVONEX INTRAMUSCULAR PEN INJECTOR KIT 0 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 0 MCG/0.5 ML dexmethylphenidate oral tablet 10, (Focalin) QL (60 per 0.5, 5 dextroamphetamine-amphetamine oral (Adderall XR) QL (0 per 0 capsule,extended release 4hr 10, 15, 5 dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 0 capsule,extended release 4hr 0, 5, 0 dextroamphetamine-amphetamine oral (Adderall) QL (60 per 0 tablet 10, 1.5, 15, 0, 0, 5, 7.5 lithium carbonate oral capsule 150, 1 GC 00, 600 lithium carbonate oral tablet 00 lithium carbonate oral tablet extended (Lithobid) release 00 lithium carbonate oral tablet extended release 450 methylphenidate hcl oral capsule,er (Ritalin LA) QL (0 per 0 biphasic , 0, 40 methylphenidate hcl oral capsule,er (Ritalin LA) QL (60 per 0 biphasic methylphenidate hcl oral capsule,er biphasic QL (0 per 0 methylphenidate hcl oral solution 10 /5 (Methylin) QL (900 per 0 ml, 5 /5 ml 5

38 methylphenidate hcl oral tablet 10, 0 (Ritalin) QL (90 per 0, 5 SAVELLA ORAL TABLET 100 MG, QL (60 per MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE QL (60 per 0 PACK 1.5 MG (5)-5 MG(8)-50 MG(4) Contraceptives Contraceptives altavera (8) oral tablet apri oral tablet aubra oral tablet mcg aviane oral tablet mcg blisovi 4 fe oral tablet 1-0 mcg (4)/75 (4) blisovi fe 1.5/0 (8) oral tablet mcg (1)/75 (7) blisovi fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) caziant (8) oral tablet 0.1/.15/ mcg delyla (8) oral tablet mcg desogestrel-ethinyl estradiol oral tablet (Apri) emoquette oral tablet enpresse oral tablet 50-0 (6)/75-40 (5)/15-0(10) enskyce oral tablet estarylla oral tablet mcg falmina (8) oral tablet mcg femynor oral tablet mcg introvale oral tablets,dose pack, month QL (91 per mcg isibloom oral tablet juleber oral tablet junel fe 1.5/0 (8) oral tablet mcg (1)/75 (7) junel fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) 6

39 junel fe 4 oral tablet 1-0 mcg (4)/75 (4) kurvelo oral tablet larin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) larin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) larissia oral tablet mcg lessina oral tablet mcg levonest (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (8)) QL (91 per levonorgestrel-ethinyl estrad oral (Introvale) QL (91 per 84 tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet (Enpresse) 50-0 (6)/75-40 (5)/15-0(10) levora-8 oral tablet lutera (8) oral tablet mcg marlissa oral tablet microgestin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) microgestin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) mili oral tablet mcg mononessa (8) oral tablet mcg 4 norethindrone-e.estradiol-iron oral tablet (Blisovi 4 Fe) 1-0 mcg (4)/75 (4) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.15/0.5-5 mcg (8)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (8)) 0.18/0.15/0.5-5 mcg (8) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg orsythia oral tablet mcg portia oral tablet previfem oral tablet mcg 7

40 quasense oral tablets,dose pack, month QL (91 per mcg reclipsen (8) oral tablet setlakin oral tablets,dose pack, month QL (91 per mcg sprintec (8) oral tablet mcg sronyx oral tablet mcg tarina fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) tri-legest fe oral tablet 1-0(5)/1-0(7) /1-5mcg (9) tri-lo-estarylla oral tablet 0.18/0.15/0.5-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5-5 mcg tri-mili oral tablet 0.18/0.15/0.5-5 mcg (8) trinessa (8) oral tablet 0.18/0.15/ mcg (8) tri-previfem (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/0.5-5 mcg (8) trivora (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) tri-vylibra oral tablet 0.18/0.15/0.5-5 mcg (8) velivet triphasic regimen (8) oral tablet 0.1/.15/ mcg vienva oral tablet mcg vylibra oral tablet mcg Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous (Paroex Oral Rinse) 1 GC membrane mouthwash 0.1 % periogard mucous membrane mouthwash 1 GC 0.1 % triamcinolone acetonide dental paste 0.1 % (Oralone) 8

41 Dermatological Agents Dermatological Agents, Other acyclovir topical ointment 5 % (Zovirax) QL (0 per 0 ammonium lactate topical cream 1 % (Geri-Hydrolac) ammonium lactate topical lotion 1 % (AmLactin) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) fluorouracil topical cream 0.5 % (Carac) 5 NM; NDS fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution %, 5 % imiquimod topical cream in packet 5 % (Aldara) PA NSO; QL (4 per 0 TOLAK TOPICAL CREAM 4 % 4 Dermatological Antibacterials clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %,.5 % 1 GC betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone, augmented topical gel 0.05 % clobetasol scalp solution 0.05 % (Cormax) clobetasol topical cream 0.05 % (Temovate) hydrocortisone topical cream 1 %,.5 % (Ala-Cort) 1 GC hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 1 GC hydrocortisone topical ointment.5 % 1 GC mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % 9

42 procto-med hc topical cream with perineal applicator.5 % proctosol hc topical cream with perineal applicator.5 % proctozone-hc topical cream with perineal applicator.5 % triamcinolone acetonide topical cream 1 GC 0.05 % triamcinolone acetonide topical cream 0.1 (Triderm) 1 GC %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tretinoin topical cream 0.05 % (Avita) PA tretinoin topical cream 0.05 %, 0.1 % (Retin-A) PA tretinoin topical gel 0.01 % (Retin-A) PA tretinoin topical gel 0.05 % (Avita) PA tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 9 GAUGE X 1/" BD UF NANO PEN NEEDLE 4MMXG GAUGE X 5/" PEN NEEDLE, DIABETIC NEEDLE (1st Tier Unifine 9 GAUGE X 1/" Pentips) VGO 40 DISPOSABLE DEVICE 0

43 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1,000-8,000-60,000 UNIT, 4,000-76,000-10,000 UNIT,,000-9,500-15,000 UNIT, 6, , ,000 UNIT, 6,000-19,000-0,000 UNIT PULMOZYME INHALATION 5 PA BvD; NM; NDS SOLUTION 1 MG/ML ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-,000-4,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-6,000-84,000 UNIT, 5,000-79, ,000 UNIT, 5,000-85,000-16,000 UNIT,,000-10,000-16,000 UNIT, 40,000-16, ,000 UNIT, 5,000-17,000-7,000 UNIT, 5,000-17,000-4,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous atropine ophthalmic (eye) drops 1 % (Isopto Atropine) 4 azelastine nasal aerosol,spray 17 mcg QL (0 per 5 (0.1 %) azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % Eye, Ear, Nose, Throat Anti-Infectives Agents CIPRODEX OTIC (EAR) DROPS,SUSPENSION % erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gentak ophthalmic (eye) ointment 0. % ( /gram) gentamicin ophthalmic (eye) drops 0. % 1 GC neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension.5/ml-10,000 unit/ml-0.1 % (Maxitrol) 1

44 neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment.5 /g- 10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-10, unit-/ml neomycin-polymyxin-hc otic (ear) drops,suspension.5-10,000-1 /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution.5-10,000-1 /ml-unit/ml-% ofloxacin ophthalmic (eye) drops 0. % (Ocuflox) ofloxacin otic (ear) drops 0. % Eye, Ear, Nose, Throat Anti-Inflammatory Agents fluticasone nasal spray,suspension 50 (4 Hour Allergy 1 GC mcg/actuation Relief) ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) prednisolone acetate ophthalmic (eye) (Omnipred) 4 drops,suspension 1 % RESTASIS OPHTHALMIC (EYE) QL (60 per 0 DROPPERETTE 0.05 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants omeprazole oral capsule,delayed 1 GC release(dr/ec) 10, 0, 40 pantoprazole oral tablet,delayed release (Protonix) 1 GC (dr/ec) 0, 40 Gastrointestinal Agents, Other constulose oral solution 10 gram/15 ml dicyclomine oral capsule 10 1 GC dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 0 1 GC diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet.5- (Lomotil) 0.05 enulose oral solution 10 gram/15 ml generlac oral solution 10 gram/15 ml

45 lactulose oral solution 10 gram/15 ml (Constulose) loperamide oral capsule (Anti-Diarrheal (loperamide)) metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 10, 5 (Reglan) 1 GC ursodiol oral capsule 00 (Actigall) ursodiol oral tablet 50 (URSO 50) ursodiol oral tablet 500 (URSO Forte) Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram peg 50-electrolytes oral recon soln 6- (GaviLyte-G) gram peg 50-electrolytes oral recon soln 40- (Colyte with Flavor gram Packs) SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM Phosphate Binders calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) PHOSLYRA ORAL SOLUTION MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release 4hr 10, 15, 5 TOVIAZ ORAL TABLET EXTENDED RELEASE 4 HR 4 MG, 8 MG Genitourinary Agents, Miscellaneous finasteride oral tablet 5 (Proscar) 1 GC tamsulosin oral capsule 0.4 (Flomax) 1 GC

46 Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 50 MG DEPEN TITRATABS ORAL TABLET 50 MG EXJADE ORAL TABLET, DISPERSIBLE 15 MG, 50 MG, 500 MG JADENU ORAL TABLET 180 MG, 60 MG, 90 MG JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 60 MG, 90 MG Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM), 1.6 % (40.5 MG/.5 GRAM) testosterone cypionate intramuscular oil 100 /ml, 00 /ml testosterone transdermal gel in packet 1 % (5 /.5gram), 1 % (50 /5 gram) Estrogens And Antiestrogens (Depo-Testosterone) PA PA; QL (150 per 0 PA; QL (150 per 0 (AndroGel) PA; QL (00 per 0 estradiol oral tablet 0.5, 1, (Estrace) 1 GC estradiol transdermal patch semiweekly (Alora) QL (8 per /4 hr, 0.05 /4 hr, /4 hr, 0.1 /4 hr estradiol transdermal patch semiweekly (Minivelle) QL (8 per /4 hr estradiol transdermal patch weekly 0.05 (Climara) QL (4 per 8 /4 hr, /4 hr, 0.05 /4 hr, 0.06 /4 hr, /4 hr, 0.1 /4 hr estradiol vaginal cream 0.01 % (0.1 /gram) (Estrace) 4

47 PREMARIN ORAL TABLET 0. MG, 0.45 MG, 0.65 MG, 0.9 MG, 1.5 MG PREMARIN VAGINAL CREAM 0.65 MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (14)/ 0.65MG-5MG(14) PREMPRO ORAL TABLET MG, MG, MG, MG Glucocorticoids/Mineralocorticoids methylprednisolone oral tablet 16, (Medrol), 4, 8 methylprednisolone oral tablets,dose pack 4 (Medrol (Pak)) prednisone oral solution 5 /5 ml PA BvD prednisone oral tablet 1, 10,.5 1 PA BvD; GC, 5, 50 prednisone oral tablet 0 (Deltasone) 1 PA BvD; GC prednisone oral tablets,dose pack 10, 10 (48 pack), 5, 5 (48 pack) Pituitary desmopressin 10 mcg/0.1 ml spr 10 (DDAVP) mcg/spray (0.1 ml) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1, 0. (DDAVP) GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0. MG/0.5 ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, 1 MG/0.5 ML, 1. MG/0.5 ML, 1.4 MG/0.5 ML, 1.6 MG/0.5 ML, 1.8 MG/0.5 ML, MG/0.5 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 1 MG/ML (6 UNIT/ML), 5 MG/ML (15 UNIT/ML) 5

48 HUMATROPE INJECTION CARTRIDGE 1 MG (6 UNIT), 4 MG (7 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 0 MG/ ML (10 MG/ML) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG/1.5 ML (. MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/ ML (5 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/ ML (.5 MG/ML) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (. MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG ZOMACTON SUBCUTANEOUS RECON SOLN 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML medroxyprogesterone intramuscular suspension 150 /ml 4 PA 4 PA 4 QL (10 per 8 (Depo-Provera) QL (1 per 84 6

49 medroxyprogesterone intramuscular (Depo-Provera) 4 QL (1 per 84 syringe 150 /ml medroxyprogesterone oral tablet 10, (Provera) 1 GC.5, 5 progesterone micronized oral capsule 100 (Prometrium), 00 Thyroid And Antithyroid Agents levothyroxine oral tablet 100 mcg, 11 mcg, 15 mcg, 17 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg (Levo-T) 1 GC liothyronine oral tablet 5 mcg, 5 mcg, 50 (Cytomel) mcg Immunological Agents Immunological Agents azathioprine oral tablet 50 (Imuran) PA BvD CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (00 MG X VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/ ML (00 MG/ML X ) cyclosporine modified oral capsule 100 (Gengraf) PA BvD, 5 cyclosporine modified oral capsule 50 PA BvD cyclosporine modified oral solution 100 (Gengraf) PA BvD /ml ENBREL SUBCUTANEOUS RECON SOLN 5 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) gengraf oral capsule 100, 5 PA BvD gengraf oral solution 100 /ml PA BvD 7

50 HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK), 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0. ML, 0 MG/0. ML, 0 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML leflunomide oral tablet 10, 0 (Arava) mycophenolate mofetil oral capsule 50 (CellCept) PA BvD mycophenolate mofetil oral suspension for reconstitution 00 /ml (CellCept) 5 PA BvD; NM; NDS mycophenolate mofetil oral tablet 500 (CellCept) PA BvD tacrolimus oral capsule 0.5, 1, 5 (Prograf) PA BvD Vaccines ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF- ( MCG)-5LF/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML 8

51 ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-15-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT- 0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML PA BvD PA BvD PA BvD PA BvD QL (1 per 65 9

52 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ORAL CAPSULE,EXTENDED RELEASE 4HR 0.75 GRAM CANASA RECTAL SUPPOSITORY 1,000 MG DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1. GRAM mesalamine oral tablet,delayed release (Asacol HD) 4 (dr/ec) 800 sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 Irrigating Solutions Irrigating Solutions sodium chloride irrigation solution 0.9 % (Azulfidine EN-tabs) (Aqua Care Sodium Chloride) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral tablet 10, 5 1 GC alendronate oral tablet 5 1 GC; QL (4 per 8 alendronate oral tablet 70 (Fosamax) 1 GC; QL (4 per 8 calcitriol oral capsule 0.5 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) ibandronate oral tablet 150 (Boniva) QL (1 per 8 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ELMIRON ORAL CAPSULE 100 MG 4 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 5, 50 leucovorin calcium oral tablet 10, 15, 5, 5 levocarnitine (with sugar) oral solution 100 /ml 4 1 GC (Vistaril) 1 GC (Carnitor) 40

53 MESTINON ORAL SYRUP 60 MG/5 ML 5 NM; NDS pyridostigmine bromide oral tablet 60 (Mestinon) Ophthalmic Agents Antiglaucoma Agents ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % brimonidine ophthalmic (eye) drops 0. 1 GC % dorzolamide-timolol ophthalmic (eye) drops.-6.8 /ml (Cosopt) 1 GC latanoprost ophthalmic (eye) drops (Xalatan) 1 GC % timolol maleate ophthalmic (eye) drops (Timoptic) 1 GC 0.5 %, 0.5 % timolol maleate ophthalmic (eye) gel (Timoptic-XE) forming solution 0.5 %, 0.5 % Replacement Preparations Replacement Preparations d5 %-0.45 % sodium chloride intravenous 4 parenteral solution klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq potassium chlorid-d5-0.45%nacl 4 PA BvD intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l, 40 meq/l potassium chloride intravenous solution PA BvD meq/ml, meq/ml (0 ml) potassium chloride oral capsule, extended release 10 meq potassium chloride oral capsule, extended (Klor-Con Sprinkle) release 8 meq potassium chloride oral liquid 0 meq/15 ml, 40 meq/15 ml 41

54 potassium chloride oral tablet extended (K-Tab) release 10 meq, 0 meq, 8 meq potassium chloride oral tablet,er (Klor-Con M10) particles/crystals 10 meq potassium chloride oral tablet,er (Klor-Con M0) particles/crystals 0 meq potassium citrate oral tablet extended (Urocit-K 10) release 10 meq (1,080 ) potassium citrate oral tablet extended (Urocit-K 15) release 15 meq potassium citrate oral tablet extended release 5 meq (540 ) (Urocit-K 5) sodium chloride 0.45 % intravenous 1 GC parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride intravenous parenteral 4 solution.5 meq/ml Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION QL (60 per 0 BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA QL (1 per 8 AEROSOL INHALER MCG/ACTUATION, 0-1 MCG/ACTUATION, 45-1 MCG/ACTUATION QVAR INHALATION AEROSOL 40 QL (17.4 per 5 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION QL (1. per 0 HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral tablet 10 (Singulair) 1 GC montelukast oral tablet,chewable 4, 5 (Singulair) 1 GC 4

55 zafirlukast oral tablet 10, 0 (Accolate) Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.6 / ml, 1.5 / ml,.5 / ml (0.08 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet extended release 1 hr 4, 8 ATROVENT HFA INHALATION QL (5.8 per 8 HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT QL (8 per 0 INHALATION MIST MCG/ACTUATION ipratropium bromide inhalation solution PA BvD 0.0 % PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST 1.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG Respiratory Tract Agents, Other acetylcysteine solution 100 /ml (10 PA BvD %), 00 /ml (0 %) DALIRESP ORAL TABLET 50 QL (8 per 8 MCG DALIRESP ORAL TABLET 500 QL (0 per 0 MCG XOLAIR SUBCUTANEOUS RECON SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants cyclobenzaprine oral tablet 10, 5 4

56 methocarbamol oral tablet 500 (Robaxin) methocarbamol oral tablet 750 (Robaxin-750) Sleep Disorder Agents Sleep Disorder Agents zaleplon oral capsule 10, 5 (Sonata) QL (60 per 0 zolpidem oral tablet 10, 5 (Ambien) 1 GC; QL (0 per 0 Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 0 MG ; QL (60 per 0 sildenafil (antihypertensive) oral tablet 0 Vitamins And Minerals Vitamins And Minerals pnv prenatal plus multivit tab s/f, glutenfree 7 iron- 1 prenatal vitamin plus low iron oral tablet 7 iron- 1 (Revatio) PA; QL (90 per 0 ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 44

57 Index acetaminophen-codeine... acetylcysteine... 4 acyclovir... 0, 9 ADACEL(TDAP ADOLESN/ADULT)(PF)...8 adapalene... 0 ADCIRCA ADVAIR DISKUS...4 ADVAIR HFA...4 AFINITOR... 8 AFINITOR DISPERZ...8 ala-cort...9 ALBENZA albuterol sulfate... 4 alendronate...40 allopurinol ALPHAGAN P alprazolam...5 altavera (8)... 6 amiodarone... amlodipine... amlodipine-benazepril... ammonium lactate...9 amoxicillin...7 amoxicillin-pot clavulanate... 7 anagrelide...0 anastrozole... 8 ANDROGEL... 4 apri...6 APRISO...40 ASSURE ID INSULIN SAFETY...0 atenolol... atorvastatin... 4 atovaquone-proguanil...16 ATRIPLA...17 atropine... 1 ATROVENT HFA...4 INDEX Index aubra... 6 aviane... 6 AVONEX... 5 azathioprine...7 azelastine...1 azithromycin...6 BD ULTRA-FINE NANO PEN NEEDLE... 0 benazepril... benztropine betamethasone dipropionate... 9 betamethasone, augmented...9 bicalutamide... 8 blisovi 4 fe...6 blisovi fe 1.5/0 (8)...6 blisovi fe 1/0 (8)... 6 BOOSTRIX TDAP...8 brimonidine...41 buprenorphine hcl... 5 buprenorphine-naloxone...5 bupropion hcl... 11, 1 calcipotriene... 9 calcitriol calcium acetate... CANASA...40 carbamazepine carbidopa-levodopa cartia xt... carvedilol... CAYSTON...7 caziant (8)... 6 cefdinir... 6 cefprozil... 6 cefuroxime axetil...6 cephalexin... 6 CHANTIX... 5 CHANTIX CONTINUING MONTH BOX...5 Index CHANTIX STARTING MONTH BOX...5 chlorhexidine gluconate...8 cilostazol... 1 CIMZIA... 7 CIMZIA POWDER FOR RECONST... 7 CIPRODEX... 1 ciprofloxacin hcl... 7 citalopram... 1 clarithromycin... 6, 7 clindamycin hcl...6 clindamycin phosphate... 9 CLINIMIX 5%- D0W(SULFITE-FREE)... 1 CLINIMIX E 4.5%/D5W SUL FREE... 1 CLINIMIX E 5%/D15W SULFIT FREE...1 CLINIMIX E 5%/D0W SULFIT FREE...1 clobetasol...9 clonazepam...5 clonidine hcl...1 clopidogrel...1 clotrimazole-betamethasone clozapine...16, 17 COMBIVENT RESPIMAT... 4 COMPLERA...17 constulose... CREON...1 cromolyn...1 CUPRIMINE... 4 cyclobenzaprine... 4 cyclosporine modified...7 d5 %-0.45 % sodium chloride...41 DAKLINZA...19 DALIRESP... 4 I-1