Mercy Care Advantage (HMO SNP) · 2019-04-01 · Mercy Care Advantage (HMO SNP) 2019 Formulary...

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Mercy Care Advantage (HMO SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 00019346, Version 9

This formulary was updated on 04/01/2019. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. ‑ 8:00 p.m., 7 days a week, or visit www.MercyCareAdvantage.com.

Mercy Care Advantage (HMO SNP) Formulario 2019 (Lista de medicamentos cubiertos) LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN

Formulario ID 00019346, Versión 9

Este formulario se actualizó el 04/01/2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Departamento de Servicios para miembros de Mercy Care Advantage (HMO SNP), al 602‑586‑1730 o al 1‑877‑436‑5288, los usuarios de TTY deben llamar al 711, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana, o visite la página web www.MercyCareAdvantage.com. AZ‑19‑01‑02

http://www.MercyCareAdvantage.com


Mercy Care Advantage (HMO SNP) 2019 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID 00019346, Version 9

This formulary was updated on 04/01/2019. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services, at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. ‑ 8:00 p.m., 7 days a week, or visit www.MercyCareAdvantage.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Mercy Care. When it refers to “plan” or “our plan,” it means Mercy Care Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of 04/01/2019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

Mercy Care Advantage is an HMO SNP with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in Mercy Care Advantage depends on contract renewal.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 602‑586‑1730 o 1‑877‑436‑5288 (TTY 711).

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What is the Mercy Care Advantage (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Mercy Care Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Mercy Care Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Mercy Care Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost‑sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost‑sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Mercy Care Advantage’s Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost‑sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 31‑day supply of the drug.

The enclosed formulary is current as of 04/01/2019. To get updated information about the drugs covered by Mercy Care Advantage, please contact us. Our contact information appears on the front and back cover pages. If we update the formulary during 2019 due to a non‑maintenance formulary change, an updated version of the formulary and the notice issued to affected members will be posted on our website at www.MercyCareAdvantage.com. Printed formularies will be updated with the changes using an errata notice.

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How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 62. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Mercy Care Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Mercy Care Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t get approval, Mercy Care Advantage may not cover the drug.

• Quantity Limits: For certain drugs, Mercy Care Advantage limits the amount of the drug that Mercy Care Advantage will cover. For example, Mercy Care Advantage provides 30 EA per 30 days per prescription for simvastatin. This may be in addition to a standard one‑month or three‑month supply.

• Step Therapy: In some cases, Mercy Care Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Mercy Care Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Mercy Care Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Mercy Care Advantage’s formulary?” on page IV for information about how to request an exception.

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What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Mercy Care Advantage does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Mercy Care Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Mercy Care Advantage.

• You can ask Mercy Care Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Mercy Care Advantage (HMO SNP) Formulary? You can ask Mercy Care Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre‑determined cost‑sharing level, and you would not be able to ask us to provide the drug at a lower cost‑sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Mercy Care Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Mercy Care Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31‑day supply of medication. After your first 31‑day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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If you are a resident of a long‑term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31‑day emergency supply of that drug while you pursue a formulary exception.

If you are admitted to or discharged from a long‑term care facility, you will be allowed to refill a prescription upon admission or discharge.

For more information For more detailed information about your Mercy Care Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Mercy Care Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day/7 days a week. TTY users should call 1‑877‑486‑2048. Or, visit http://www.medicare.gov.

Mercy Care Advantage’s Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by Mercy Care Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 62.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower‑case italics (e.g., levothyroxine).

The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend on which category the drug is in:

Category Cost‑sharing amount Generic drugs

(including brand drugs treated as generic) $0/$1.25/$3.40 copay

All other drugs $0/$3.80/$8.50 copay

Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will pay for your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phone numbers for Member Services are on the front and back cover pages.

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http://www.medicare.gov

The information in the Requirements/Limits column tells you if Mercy Care Advantage has any special requirements for coverage of your drug.

Abbreviation Requirements/Limits B/D Covered under Medicare Part B or Part D. Most drugs are covered under Part

D, but there are some drugs that can be covered under both Part B or Part D depending on what the drug is used for and how it is administered.

EA Each. Medications listed with EA indicates number of pills dispensed. LA Limited Access. This prescription may be available only at certain pharmacies. For

more information consult the Pharmacy Directory. NM Not available at mail-order. PA Prior Authorization. You or your provider need to get approval from our plan before

we will agree to cover the drug. QL Quantity Limits. The amount per fill or refill is shown. ST Step Therapy. This prescription drug requires that you’ve tried another drug first,

which did not work for you.

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86.03.334.1-AZ

Nondiscrimination Notice

Mercy Care d/b/a Mercy Care Advantage (HMO SNP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Mercy Care d/b/a Mercy Care Advantage (HMO SNP) does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Mercy Care d/b/a Mercy Care Advantage (HMO SNP):

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats,

other formats) • Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe that Mercy Care d/b/a Mercy Care Advantage (HMO SNP) has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Telephone: 1-888-234-7358 (TTY 711) Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal. hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

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

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http://www.hhs.gov/ocr/office/file/index.html

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

mailto:[email protected]


86.03.334.1-AZ

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-436-5288 (TTY: 711).

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Mercy Care Advantage (HMO SNP) Formulario 2019 (Lista de medicamentos cubiertos)

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN

Formulario ID 00019346, Versión 9

Este formulario se actualizó el 1 de abril de 2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Departamento de Servicios para miembros de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 o al 1‑877‑436‑5288, los usuarios de TTY deben llamar al 711, de 8:00 a. m. a 8:00 p. m., los 7 días de la semana, o visite la página web www.MercyCareAdvantage.com.

Nota para los miembros existentes: este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma.

Cuando en esta lista de medicamentos (formulario) se mencionan los términos “nosotros”, “nos” o “nuestro”, se hace referencia a Mercy Care. Cuando se menciona “plan” o “nuestro plan”, se hace referencia a Mercy Care Advantage.

Este documento incluye una lista de medicamentos (formulario) de nuestro plan que está vigente desde el 1 de abril de 2019. Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en las páginas de la portada y la portada posterior.

En general, debe utilizar farmacias de la red para aprovechar su beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos o coseguros pueden cambiar el 1 de enero de 2020, y ocasionalmente durante el año.

Mercy Care Advantage es un plan HMO SNP con un contrato con Medicare y con el programa Medicaid de Arizona. La inscripción en Mercy Care Advantage depende de la renovación del contrato.

El formulario, la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.

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¿Qué es el formulario de Mercy Care Advantage (HMO SNP)? Un formulario es una lista de medicamentos cubiertos seleccionados por Mercy Care Advantage con el asesoramiento de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se consideran necesarios como parte de un programa de tratamiento de calidad. Por lo general, Mercy Care Advantage cubrirá los medicamentos que aparecen en nuestro formulario siempre y cuando el medicamento sea médicamente necesario, se obtenga en una farmacia de la red de Mercy Care Advantage y se sigan otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte su Evidencia de cobertura.

¿Puede cambiar el formulario (la lista de medicamentos)? Por lo general, si toma un medicamento que se encuentra en nuestro formulario 2019 y que estaba cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2019, excepto si aparece un nuevo medicamento genérico menos costoso, si se publica información nueva sobre la seguridad o efectividad de un medicamento o si dicho medicamento se retira del mercado. (Consulte las viñetas que se encuentran debajo para obtener más información sobre los cambios que afectan a los miembros que toman el medicamento en la actualidad). Otros tipos de cambios en el formulario, como la eliminación de un medicamento de nuestro formulario, no afectarán a los miembros que actualmente toman ese medicamento. Continuará estando disponible al mismo costo compartido para aquellos miembros que lo tomen por el resto del año de cobertura. A continuación, se encuentran los cambios a la lista de medicamentos que también afectarán a los miembros que tomen el medicamento en la actualidad:

• Nuevos medicamentos genéricos. Podemos eliminar de inmediato un medicamento de marca de nuestra lista de medicamentos si lo reemplazamos con un medicamento genérico nuevo que aparecerá en el mismo nivel de costo compartido o en un nivel inferior y que tendrá las mismas restricciones o menos. Además, al agregar el medicamento genérico nuevo, podemos decidir conservar el medicamento de marca en nuestra lista de medicamentos, pero moverlo de inmediato a un nivel de costo compartido diferente o agregar nuevas restricciones. Si actualmente toma ese medicamento de marca, es probable que no le informemos el cambio con anticipación. Sin embargo, luego le brindaremos información sobre los cambios específicos que hayamos realizado. o Si efectuamos dicho cambio, usted o la persona autorizada a dar recetas pueden solicitarnos una excepción para que continuemos cubriendo el medicamento de marca para usted. El aviso que le brindamos también incluirá información sobre los pasos que puede seguir para solicitar una excepción. También puede encontrar información en la sección titulada “¿Cómo solicito una excepción al formulario de Mercy Care Advantage?”, que se encuentra a continuación.

• Medicamentos que se retiran del mercado. Si la Administración de Drogas y Alimentos considera que un medicamento de nuestro formulario no es seguro o si el fabricante del medicamento lo retira del mercado, eliminaremos inmediatamente el medicamento de nuestro formulario y proporcionaremos un aviso a los miembros que toman el medicamento.

• Otros cambios. Podemos efectuar otros cambios que afecten a los miembros que consumen el medicamento en la actualidad. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca que se encuentra actualmente en el formulario, agregar restricciones nuevas al medicamento de marca o moverlo a un nivel de costo compartido diferente. O bien, podemos efectuar cambios basados en nuevas pautas clínicas. Si eliminamos medicamentos de nuestro formulario, o agregamos requisitos de autorización previa, límites de cantidad o restricciones de tratamiento escalonado para un medicamento, debemos notificar el cambio a los miembros afectados al menos 30 días antes de que dicho cambio entre en vigencia, o cuando el miembro resurta el medicamento, momento en el cual recibirá un suministro de 31 días del medicamento.

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El formulario adjunto está vigente desde el 1 de abril de 2019. Para obtener información actualizada sobre los medicamentos cubiertos por Mercy Care Advantage, comuníquese con nosotros. Nuestra información de contacto figura en las páginas de la portada y la portada posterior. Si actualizamos el formulario durante el 2019 debido a un cambio no relacionado con el mantenimiento del formulario, se publicará una versión actualizada del formulario y el aviso emitido a los miembros afectados en nuestro sitio web www.MercyCareAdvantage.com. Los formularios impresos se actualizarán con los cambios mediante un aviso de errata.

¿Cómo utilizo el formulario? Hay dos formas de encontrar un medicamento dentro del formulario:

Afección médica El formulario comienza en la página 1. Los medicamentos en este formulario están agrupados en categorías según el tipo de afecciones médicas que traten. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca están incluidos en la categoría “Agentes cardiovasculares”. Si usted sabe para qué se utiliza el medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego, busque su medicamento debajo del nombre de esa categoría.

Listado alfabético Si no sabe en qué categoría buscar su medicamento, hágalo en el Índice que comienza en la página 62. El Índice proporciona un listado alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se encuentran en el Índice. Consulte el Índice y busque su medicamento. Junto al medicamento, verá el número de página en el que puede encontrar la información de cobertura. Vaya a la página que aparece en el Índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Mercy Care Advantage cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir lo siguiente:

• Autorización previa: Mercy Care Advantage exige que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que necesitará contar con la aprobación de Mercy Care Advantage antes de obtener sus medicamentos con receta. Si no obtiene la aprobación, es posible que Mercy Care Advantage no cubra el medicamento.

• Límites de cantidad: para ciertos medicamentos, Mercy Care Advantage limita la cantidad de medicamento que cubrirá. Por ejemplo, Mercy Care Advantage ofrece simvastatina a 30 por receta cada 30 días. Esto puede ser además de un suministro estándar para un mes o tres meses.

• Tratamiento escalonado: en algunos casos, Mercy Care Advantage le exige que primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, es posible que Mercy Care Advantage no cubra el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento A no funciona para su afección, Mercy Care Advantage cubrirá el medicamento B.

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Puede averiguar si su medicamento tiene requisitos o límites adicionales consultando el formulario que comienza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones en tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en las páginas de la portada y la portada posterior.

También puede solicitar que Mercy Care Advantage haga una excepción en cuanto a estas restricciones o límites, o puede pedir una lista de otros medicamentos similares que traten su afección de salud. Para obtener información sobre cómo solicitar una excepción, consulte la sección “¿Cómo solicito una excepción al formulario de Mercy Care Advantage?” que se encuentra en la página XII.

¿Qué sucede si mi medicamento no está incluido en el formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con el Departamento de Servicios para miembros y consultar si su medicamento está cubierto.

Si se le informa que Mercy Care Advantage no cubre su medicamento, tiene dos opciones:

• Puede solicitar al Departamento de Servicios para miembros una lista de medicamentos similares que estén cubiertos por Mercy Care Advantage. Una vez haya recibido la lista, debe mostrársela a su médico y pedirle que le recete un medicamento similar que esté cubierto por Mercy Care Advantage.

• Puede solicitar a Mercy Care Advantage que haga una excepción y cubra su medicamento. Consulte la información sobre cómo solicitar una excepción a continuación.

¿Cómo solicito una excepción al formulario de Mercy Care Advantage (HMO SNP)? Puede solicitar a Mercy Care Advantage que haga una excepción en cuanto a nuestras normas de cobertura. Existen varios tipos de excepciones que puede solicitarnos.

• Puede solicitarnos que cubramos un medicamento aun si este no se encuentra en nuestro formulario. Si se aprueba, el medicamento estará cubierto a un nivel de costo compartido determinado previamente, y usted no podrá solicitar que le proporcionemos el medicamento a un costo compartido menor.

• Puede solicitar que no se apliquen restricciones o límites de cobertura a su medicamento. Por ejemplo, para ciertos medicamentos, Mercy Care Advantage limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos el límite y que cubramos una cantidad mayor.

Por lo general, Mercy Care Advantage solo aprobará su solicitud de una excepción si los medicamentos alternativos incluidos en el formulario del plan, o si las restricciones adicionales de utilización, no son tan efectivos para el tratamiento de su afección o pudieran ocasionar efectos médicos adversos.

Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción al formulario o a una restricción de utilización. Cuando solicite una excepción al formulario o a las restricciones de utilización, debe presentar una declaración de la persona autorizada a dar recetas o de su médico que respalde su solicitud. Por lo general, debemos tomar una decisión en un plazo de 72 horas después de obtener la declaración de respaldo de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que esperar hasta 72 horas para obtener una decisión podría dañar gravemente su salud. Si se le concede la solicitud acelerada, debemos tomar una decisión antes de las 24 horas después de obtener una declaración de respaldo de su médico o de otra persona autorizada a dar recetas.

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¿Qué debo hacer antes de poder hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como un miembro nuevo o continuo de nuestro plan, es posible que tome medicamentos que no se encuentren en nuestro formulario. También puede suceder que el medicamento se encuentre en nuestro formulario, pero su capacidad de obtenerlo sea limitada. Por ejemplo, es posible que necesite nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe comenzar a tomar un medicamento apropiado que cubramos o si debe solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras usted consulta con su médico para determinar la acción más apropiada, podemos cubrir su medicamento en ciertos casos durante sus primeros 90 días como miembro de nuestro plan.

Para cada uno de sus medicamentos que no se encuentren en nuestro formulario, o si su capacidad de obtener sus medicamentos es limitada, cubriremos un suministro temporal de 31 días. Si su receta está indicada para menos días, permitimos obtener los medicamentos hasta alcanzar un suministro máximo de 31 días del medicamento. Luego del primer suministro de 31 días, ya no pagaremos esos medicamentos, incluso si hace menos de 90 días que es miembro del plan.

Si reside en un centro de atención a largo plazo y necesita un medicamento que no se encuentra en nuestro formulario, o si su capacidad de obtener sus medicamentos es limitada, pero ya transcurrieron los primeros 90 días como miembro de nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento mientras usted intenta conseguir una excepción al formulario.

Si usted es ingresado en un centro de atención a largo plazo o si recibe el alta de este centro, le permitiremos obtener un resurtido del medicamento con receta en el momento del ingreso o el alta.

Para obtener más información Para obtener información más detallada sobre su cobertura para medicamentos con receta de Mercy Care Advantage, consulte su Evidencia de cobertura y los otros materiales del plan.

Si tiene preguntas sobre Mercy Care Advantage, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en las páginas de la portada y la portada posterior.

Si tiene alguna pregunta general sobre la cobertura para medicamentos con receta de Medicare, llame a Medicare al 1‑800‑MEDICARE (1‑800‑633‑4227), durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1‑877‑486‑2048. O visite http://www.medicare.gov.

Formulario de Mercy Care Advantage El formulario que comienza en la página 1 proporciona información sobre los medicamentos cubiertos por Mercy Care Advantage. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice que comienza en la página 62.

En la primera columna de esta tabla, se indica el nombre del medicamento. Los medicamentos de marca están escritos en letra mayúscula (p. ej., SYNTHROID) y los medicamentos genéricos están escritos en letra minúscula y cursiva (p. ej., levothyroxine).

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http://www.medicare.gov

La columna “Nivel del medicamento” de la tabla indica la categoría de cada medicamento. Sus montos de costos compartidos dependen de la categoría en la que se encuentre el medicamento:

Categoría Monto de costo compartido Medicamentos genéricos

(incluye medicamentos de marca considerados genéricos)

Copago de $0/$1.25/$3.40

Todos los demás medicamentos Copago de $0/$3.80/$8.50

Sus copagos pueden ser menores, lo cual depende del nivel de “Ayuda adicional” que reciba. La Cláusula adicional a la Evidencia de cobertura para las personas que reciben ayuda adicional para pagar los medicamentos con receta (Cláusula adicional LIS) indica el monto que debe pagar por sus medicamentos con receta. También puede llamar al Departamento de Servicios para miembros para conocer su monto de costo compartido. En las páginas de la portada y la portada posterior, encontrará los números de teléfono del Departamento de Servicios para miembros.

La información en la columna Requisitos/Límites le informa si Mercy Care Advantage establece requisitos especiales de cobertura para su medicamento.

Abreviatura Requisitos/límites B/D Cubiertos por la Parte B o la Parte D de Medicare. La mayoría de los medicamentos

están cubiertos por la Parte D, pero hay algunos medicamentos que pueden estar cubiertos tanto por la Parte B como por la Parte D según para qué se utiliza el medicamento y cómo se administra.

EA Cada uno. Los medicamentos que tienen EA indican la cantidad de píldoras provistas.

LA Acceso limitado. Este medicamento con receta puede estar disponible solo en ciertas farmacias. Para obtener más información, consulte el Directorio de farmacias.

NM No disponible para pedido por correo. PA Autorización previa. Usted o su proveedor deben obtener la autorización de

nuestro plan antes de que aceptemos cubrir el medicamento. QL Límites de cantidad. Se muestra la cantidad por surtido o resurtido. ST Tratamiento escalonado. Este medicamento con receta requiere que usted haya

probado otro medicamento antes, y que no haya funcionado.

XIV

86.03.335.2-AZ

Aviso de no discriminación

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), cumple con las leyes federales de derechos civiles vigentes y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no excluye a las personas ni las trata de manera diferente debido a cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo.

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP):

• Brinda ayuda y servicios gratuitos a personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas calificados o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,

otros formatos) • Brinda servicios de idiomas gratuitos a las personas cuya lengua materna no sea inglés, como

los siguientes: o Intérpretes calificados o Información escrita en otros idiomas

Si necesita un intérprete calificado, información escrita en otros formatos, servicios de traducción u otros servicios, comuníquese con el número que aparece en su tarjeta de identificación.

Si considera que Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no le proporcionó estos servicios o lo discriminó de alguna otra manera por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja ante nuestro Coordinador de Derechos Civiles:

Dirección: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Teléfono: 1-888-234-7358 (TTY 711)Correo electrónico: [email protected]

Puede presentar una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda para presentar una queja, nuestro Coordinador de Derechos Civiles está disponible para ayudarle.

También puede presentar un reclamo de derechos civiles ante el Departamento de Salud y Servicios Sociales de EE. UU., Oficina de Derechos Civiles, de manera electrónica a través del portal de reclamos de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Los formularios de reclamo están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

XV

http://www.hhs.gov/ocr/office/file/index.html


mailto:[email protected]

86.03.335.2-AZ

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-436-5288 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-436-5288 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-436-5288 (TTY: 711)。

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XVI

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-436-5288 (TTY: 711).

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Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-877-436-5288(TTY: 711) まで、お電話にてご連絡ください。

Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-436-5288 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access 04/01/2019 Formulary ID 00019346 v9

1

2019 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits

ANALGESICS ‑ DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT

allopurinol tab GENERIC colchicine w/ probenecid GENERIC COLCRYS OTHER QL (120 tabs / 30 days) MITIGARE OTHER QL (60 caps / 30 days) probenecid GENERIC ULORIC OTHER ST

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg GENERIC QL (240 caps / 30 days) celecoxib CAPS 100mg GENERIC QL (120 caps / 30 days) celecoxib CAPS 200mg GENERIC QL (60 caps / 30 days) celecoxib CAPS 400mg GENERIC QL (30 caps / 30 days) diclofenac potassium GENERIC QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC GENERIC diflunisal GENERIC etodolac GENERIC flurbiprofen TABS GENERIC ibu tab 600mg GENERIC ibu tab 800mg GENERIC ibuprofen SUSP GENERIC ibuprofen TABS 400mg, 600mg, 800mg GENERIC meloxicam TABS GENERIC nabumetone TABS GENERIC naproxen TABS GENERIC naproxen dr GENERIC naproxen sodium TABS 275mg, 550mg GENERIC piroxicam CAPS GENERIC sulindac TABS GENERIC

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg GENERIC QL (400 tabs / 30 days) acetaminophen w/ codeine 300-30mg GENERIC QL (360 tabs / 30 days) acetaminophen w/ codeine 300-60mg GENERIC QL (180 tabs / 30 days) acetaminophen w/ codeine soln GENERIC QL (2700 mL / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access 04/01/2019 Formulary ID 00019346 v9 2


buprenorphine patch GENERIC QL (4 patches / 28 days), PA butorphanol tartrate SOLN 1mg/ml, 2mg/ml GENERIC BUTRANS OTHER QL (4 patches / 28 days), PA nalbuphine hcl SOLN GENERIC tramadol hcl tab 50 mg GENERIC QL (240 tabs / 30 days) tramadol-acetaminophen GENERIC QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet 2.5-325mg GENERIC QL (360 tabs / 30 days) endocet 5-325mg GENERIC QL (360 tabs / 30 days) endocet 7.5-325mg GENERIC QL (240 tabs / 30 days) endocet 10-325mg GENERIC QL (180 tabs / 30 days) fentanyl citrate LPOP GENERIC QL (120 lozenges / 30 days), PA fentanyl patch 12 mcg/hr GENERIC QL (10 patches / 30 days), PA fentanyl patch 25 mcg/hr GENERIC QL (10 patches / 30 days), PA fentanyl patch 50 mcg/hr GENERIC QL (10 patches / 30 days), PA fentanyl patch 75 mcg/hr GENERIC QL (10 patches / 30 days), PA fentanyl patch 100 mcg/hr GENERIC QL (10 patches / 30 days), PA FENTORA OTHER QL (120 tabs / 30 days), PA hydroco/apap tab 5-325mg GENERIC QL (240 tabs / 30 days) hydroco/apap tab 7.5-325 GENERIC QL (180 tabs / 30 days) hydroco/apap tab 10-325mg GENERIC QL (180 tabs / 30 days) hydrocodone-acetaminophen 7.5-325 mg/15ml GENERIC QL (2700 mL / 30 days) hydrocodone-ibuprofen tab 7.5-200 mg GENERIC QL (150 tabs / 30 days) hydromorphone hcl LIQD GENERIC QL (600 mL / 30 days) hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

GENERIC B/D

hydromorphone hcl TABS GENERIC QL (180 tabs / 30 days) HYSINGLA ER OTHER QL (30 tabs / 30 days), PA lorcet hd tab 10-325mg GENERIC QL (180 tabs / 30 days) lorcet plus tab 7.5-325 GENERIC QL (180 tabs / 30 days) lorcet tab 5-325mg GENERIC QL (240 tabs / 30 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml GENERIC QL (450 mL / 30 days), PA methadone hcl 5mg GENERIC QL (90 tabs / 30 days), PA methadone hcl 10mg GENERIC QL (90 tabs / 30 days), PA methadone hcl intensol GENERIC QL (90 mL / 30 days), PA morphine ext-rel tab 15mg, 30mg, 60mg, 100mg GENERIC QL (90 tabs / 30 days), PA morphine ext-rel tab 200mg GENERIC QL (60 tabs / 30 days), PA morphine sul inj 1mg/ml GENERIC B/D


3


MORPHINE SUL INJ 4MG/ML OTHER B/D morphine sul inj 10mg/ml GENERIC B/D MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ ml, 8mg/ml, 10mg/ml, 150mg/30ml

OTHER B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml GENERIC B/D morphine sulfate TABS 15mg GENERIC QL (180 tabs / 30 days) morphine sulfate TABS 30mg GENERIC QL (90 tabs / 30 days) morphine sulfate oral soln 10mg/5ml GENERIC QL (900 mL / 30 days) morphine sulfate oral soln 20mg/5ml GENERIC QL (750 mL / 30 days) morphine sulfate oral soln 100mg/5ml GENERIC QL (180 mL / 30 days) NUCYNTA ER 50mg, 100mg, 200mg, 250mg OTHER QL (60 tabs / 30 days), PA NUCYNTA ER 150mg OTHER QL (90 tabs / 30 days), PA oxycodone hcl CAPS GENERIC QL (180 caps / 30 days) oxycodone hcl CONC GENERIC QL (180 mL / 30 days) oxycodone hcl SOLN GENERIC QL (900 mL / 30 days) oxycodone hcl TABS GENERIC QL (180 tabs / 30 days) oxycodone w/ acetaminophen 2.5-325mg GENERIC QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-325mg GENERIC QL (360 tabs / 30 days) oxycodone w/ acetaminophen 7.5-325mg GENERIC QL (240 tabs / 30 days) oxycodone w/ acetaminophen 10-325mg GENERIC QL (180 tabs / 30 days) OXYCONTIN OTHER QL (60 tabs / 30 days), PA

ANESTHETICS ‑ DRUGS FOR NUMBING LOCAL ANESTHETICS

lidocaine hcl (local anesth.) GENERIC B/D lidocaine inj 0.5% GENERIC B/D lidocaine inj 1% GENERIC B/D lidocaine inj 1.5% preservative free (pf) GENERIC B/D

ANTI‑INFECTIVES ‑ DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN GENERIC gentamicin in saline GENERIC gentamicin sulfate SOLN GENERIC neomycin sulfate TABS GENERIC paromomycin sulfate CAPS GENERIC streptomycin sulfate SOLR GENERIC sulfadiazine TABS GENERIC tobramycin NEBU GENERIC NM, PA tobramycin inj 1.2 gm/30ml GENERIC



tobramycin inj 1.2gm GENERIC tobramycin inj 10mg/ml GENERIC tobramycin inj 40mg/ml GENERIC tobramycin inj 80mg/2ml GENERIC

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS GENERIC ALBENZA OTHER ALINIA OTHER atovaquone SUSP GENERIC AZACTAM IN ISO‑OSMOTIC DE OTHER AZACTAM/DEX INJ OTHER aztreonam GENERIC BILTRICIDE OTHER CAYSTON OTHER NM, LA, PA clindamycin cap 75mg GENERIC clindamycin cap 300 mg GENERIC clindamycin hcl cap 150 mg GENERIC clindamycin phosphate in d5w GENERIC CLINDAMYCIN PHOSPHATE IN NACL OTHER clindamycin phosphate inj GENERIC clindamycin soln 75mg/5ml GENERIC colistimethate sodium SOLR GENERIC dapsone TABS GENERIC DAPTOMYCIN 350mg OTHER daptomycin 500mg GENERIC emverm GENERIC ertapenem sodium GENERIC imipenem-cilastatin GENERIC INVANZ OTHER ivermectin TABS GENERIC linezolid in sodium chloride GENERIC linezolid inj GENERIC linezolid susp GENERIC linezolid tab 600mg GENERIC meropenem GENERIC methenamine hippurate GENERIC metronidazole TABS GENERIC metronidazole in nacl GENERIC


5


NEBUPENT OTHER B/D nitrofurantoin macrocrystal 50mg, 100mg GENERIC PA; PA applies if 70 years and

older after a 90 day supply in a calendar year

nitrofurantoin monohyd macro GENERIC PA; PA applies if 70 years and older after a 90 day supply in a

calendar year PENTAM 300 OTHER praziquantel TABS GENERIC SIVEXTRO OTHER sulfamethoxazole-trimethop ds GENERIC sulfamethoxazole-trimethoprim inj GENERIC sulfamethoxazole-trimethoprim susp GENERIC sulfamethoxazole-trimethoprim tab 400-80mg GENERIC SYNERCID OTHER tigecycline GENERIC trimethoprim TABS GENERIC vancomycin hcl CAPS GENERIC vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

GENERIC

VANCOMYCIN IN NACL OTHER ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET OTHER B/D AMBISOME OTHER B/D amphotericin b SOLR GENERIC B/D caspofungin acetate GENERIC fluconazole SUSR; TABS GENERIC fluconazole in dextrose GENERIC fluconazole inj nacl 200 GENERIC fluconazole inj nacl 400 GENERIC flucytosine CAPS GENERIC griseofulvin microsize GENERIC griseofulvin ultramicrosize GENERIC itraconazole CAPS GENERIC PA ketoconazole TABS GENERIC PA MYCAMINE OTHER NOXAFIL SUSP OTHER QL (630 mL / 30 days) NOXAFIL TBEC OTHER QL (93 tabs / 30 days) nystatin TABS GENERIC



terbinafine hcl TABS GENERIC QL (90 tabs / year) voriconazole SOLR; SUSR; TABS GENERIC

ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl GENERIC chloroquine phosphate TABS GENERIC COARTEM OTHER mefloquine hcl GENERIC primaquine phosphate GENERIC quinine sulfate CAPS GENERIC PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate GENERIC APTIVUS OTHER atazanavir sulfate GENERIC CRIXIVAN OTHER didanosine GENERIC EDURANT OTHER efavirenz GENERIC EMTRIVA OTHER fosamprenavir tab 700 mg GENERIC FUZEON OTHER NM INTELENCE OTHER INVIRASE OTHER ISENTRESS OTHER ISENTRESS HD OTHER lamivudine GENERIC LEXIVA SUSP OTHER nevirapine susp 50 mg/5ml GENERIC nevirapine tab 100mg er GENERIC nevirapine tab 200mg GENERIC nevirapine tab 400mg er GENERIC NORVIR PACK OTHER NORVIR SOLN OTHER PIFELTRO OTHER PREZISTA SUSP OTHER QL (400 mL / 30 days) PREZISTA TABS 75mg OTHER QL (480 tabs / 30 days) PREZISTA TABS 150mg OTHER QL (240 tabs / 30 days) PREZISTA TABS 600mg OTHER QL (60 tabs / 30 days) PREZISTA TABS 800mg OTHER QL (30 tabs / 30 days)


7


RESCRIPTOR OTHER REYATAZ PACK OTHER ritonavir GENERIC SELZENTRY OTHER stavudine GENERIC tenofovir disoproxil fumarate GENERIC TIVICAY OTHER TROGARZO OTHER NM, LA TYBOST OTHER VIDEX EC 125mg OTHER VIDEX PEDIATRIC OTHER VIRACEPT OTHER VIRAMUNE SUSP OTHER VIREAD POWD OTHER VIREAD TABS 150mg, 200mg, 250mg OTHER zidovudine cap 100mg GENERIC zidovudine syp 50mg/5ml GENERIC zidovudine tab 300mg GENERIC

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine GENERIC abacavir sulfate-lamivudine-zidovudine GENERIC ATRIPLA OTHER BIKTARVY OTHER CIMDUO OTHER COMPLERA OTHER DELSTRIGO OTHER DESCOVY OTHER EVOTAZ OTHER GENVOYA OTHER JULUCA OTHER KALETRA TAB 100‑25MG OTHER KALETRA TAB 200‑50MG OTHER lamivudine-zidovudine GENERIC lopinavir-ritonavir GENERIC ODEFSEY OTHER PREZCOBIX OTHER STRIBILD OTHER SYMFI OTHER



SYMFI LO OTHER SYMTUZA OTHER TRIUMEQ OTHER TRUVADA TAB 100‑150 OTHER QL (60 tabs / 30 days) TRUVADA TAB 133‑200 OTHER QL (30 tabs / 30 days) TRUVADA TAB 167‑250 OTHER QL (30 tabs / 30 days) TRUVADA TAB 200‑300 OTHER QL (30 tabs / 30 days)

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS GENERIC ethambutol hcl TABS GENERIC isoniazid TABS GENERIC isoniazid syp 50mg/5ml GENERIC paser d/r GENERIC PRIFTIN OTHER pyrazinamide TABS GENERIC rifabutin GENERIC rifampin CAPS; SOLR GENERIC RIFATER OTHER SIRTURO OTHER LA, PA TRECATOR OTHER

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS GENERIC acyclovir sodium GENERIC B/D adefovir dipivoxil GENERIC BARACLUDE SOLN OTHER entecavir GENERIC EPCLUSA OTHER NM, PA EPIVIR HBV SOLN OTHER famciclovir GENERIC ganciclovir sodium GENERIC B/D HARVONI OTHER NM, PA lamivudine (hbv) GENERIC MAVYRET OTHER NM, PA oseltamivir phosphate CAPS 30mg GENERIC QL (168 caps / year) oseltamivir phosphate CAPS 45mg, 75mg GENERIC QL (84 caps / year) oseltamivir phosphate SUSR GENERIC QL (1080 mL / year) PEGASYS OTHER NM, PA PEGASYS PROCLICK OTHER NM, PA


9


REBETOL SOLN OTHER NM RELENZA DISKHALER OTHER QL (6 inhalers / year) ribasphere GENERIC NM ribavirin cap 200mg GENERIC NM ribavirin tab 200mg GENERIC NM rimantadine hydrochloride GENERIC valacyclovir hcl TABS GENERIC valganciclovir hcl GENERIC VEMLIDY OTHER VOSEVI OTHER NM, PA ZEPATIER OTHER NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor GENERIC cefaclor er tab 500mg GENERIC cefadroxil GENERIC CEFAZOLIN IN DEXTROSE 2GM/100ML‑4% OTHER cefazolin inj GENERIC cefazolin sodium SOLR 1gm, 20gm GENERIC cefazolin sodium 1 gm/50ml GENERIC cefdinir GENERIC cefepime for inj GENERIC cefixime GENERIC cefotaxime sodium GENERIC cefoxitin for inj GENERIC cefpodoxime proxetil GENERIC cefprozil GENERIC ceftazidime SOLR GENERIC CEFTAZIDIME/DEXTROSE OTHER ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

GENERIC

cefuroxime axetil GENERIC cefuroxime sodium GENERIC cephalexin CAPS 250mg, 500mg GENERIC cephalexin SUSR GENERIC SUPRAX CAPS OTHER suprax CHEW GENERIC SUPRAX SUSR 500mg/5ml OTHER tazicef SOLR GENERIC



TEFLARO OTHER ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS

azithromycin PACK; SOLR; SUSR; TABS GENERIC clarithromycin TABS GENERIC clarithromycin er GENERIC clarithromycin for susp GENERIC DIFICID OTHER e.e.s. 400 GENERIC ery-tab GENERIC erythrocin lactobionate GENERIC erythrocin stearate GENERIC erythromycin base GENERIC erythromycin cap 250mg ec GENERIC erythromycin ethylsuccinate TABS GENERIC

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR GENERIC ciprofloxacin hcl tab GENERIC ciprofloxacin in d5w GENERIC levofloxacin TABS GENERIC levofloxacin in d5w GENERIC levofloxacin inj 25mg/ml GENERIC levofloxacin oral soln 25 mg/ml GENERIC moxifloxacin hcl TABS GENERIC

PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin GENERIC amoxicillin & pot clavulanate GENERIC ampicillin & sulbactam sodium GENERIC ampicillin cap 500mg GENERIC ampicillin inj GENERIC ampicillin sodium GENERIC BICILLIN L‑A OTHER dicloxacillin sodium GENERIC nafcillin sodium for inj GENERIC nafcillin sodium for inj 10gm GENERIC oxacillin sodium GENERIC PENICILLIN G POT IN DEXTROSE 2MU OTHER PENICILLIN G POT IN DEXTROSE 3MU OTHER penicillin g procaine GENERIC


11


penicillin g sodium GENERIC penicillin v potassium GENERIC penicilln gk inj 5mu GENERIC penicilln gk inj 20mu GENERIC pfizerpen-g inj 5mu GENERIC pfizerpen-g inj 20mu GENERIC piper/tazoba inj 2-0.25gm GENERIC piper/tazoba inj 3-0.375gm GENERIC piper/tazoba inj 4-0.5gm GENERIC piper/tazoba inj 12-1.5gm GENERIC piper/tazoba inj 36-4.5gm GENERIC

TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 GENERIC doxycycline (monohydrate) CAPS 50mg, 100mg GENERIC doxycycline (monohydrate) TABS GENERIC doxycycline hyclate CAPS; SOLR GENERIC doxycycline hyclate 20 mg GENERIC doxycycline hyclate 100 mg GENERIC minocycline hcl CAPS GENERIC mondoxyne nl cap 100mg GENERIC morgidox cap 1x50mg GENERIC tetracycline hcl CAPS GENERIC

ANTINEOPLASTIC AGENTS ‑ DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA OTHER B/D, NM cyclophosphamide CAPS; SOLR GENERIC B/D dacarbazine 100mg GENERIC B/D EMCYT OTHER GLEOSTINE OTHER IFEX INJ 3GM OTHER B/D ifosfamide inj 1gm/20ml GENERIC B/D IFOSFAMIDE INJ 3GM OTHER B/D ifosfamide inj 3gm/60ml GENERIC B/D LEUKERAN OTHER

ANTHRACYCLINES adriamycin GENERIC B/D doxorubicin hcl GENERIC B/D doxorubicin hcl liposomal GENERIC B/D



epirubicin hcl GENERIC B/D ANTIBIOTICS

bleomycin sulfate GENERIC B/D mitomycin SOLR GENERIC B/D

ANTIMETABOLITES adrucil GENERIC B/D adrucil inj GENERIC B/D ALIMTA OTHER B/D azacitidine GENERIC B/D, NM cytarabine 20mg/ml GENERIC B/D fluorouracil SOLN GENERIC B/D gemcitabine inj soln GENERIC B/D gemcitabine inj solr GENERIC B/D mercaptopurine TABS GENERIC methotrexate sodium inj GENERIC B/D PURIXAN OTHER NM TABLOID OTHER

ANTIMITOTIC, TAXOIDS ABRAXANE OTHER B/D docetaxel CONC 20mg/ml, 80mg/4ml, 200mg/10ml GENERIC B/D DOCETAXEL CONC 80mg/4ml, 160mg/8ml OTHER B/D docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml GENERIC B/D DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

OTHER B/D

paclitaxel GENERIC B/D TAXOTERE 80mg/4ml OTHER B/D

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate GENERIC B/D vincasar pfs GENERIC B/D vincristine sulfate GENERIC B/D vinorelbine tartrate GENERIC B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN OTHER NM, LA, PA BORTEZOMIB OTHER NM, PA DAURISMO OTHER NM, LA, PA ERIVEDGE OTHER NM, LA, PA FARYDAK OTHER NM, LA, PA HERCEPTIN OTHER NM, PA


13


IBRANCE OTHER NM, LA, PA IDHIFA OTHER NM, LA, PA KADCYLA OTHER B/D, NM KEYTRUDA OTHER NM, PA KISQALI OTHER NM, PA KISQALI FEMARA 200 DOSE OTHER NM, PA KISQALI FEMARA 400 DOSE OTHER NM, PA KISQALI FEMARA 600 DOSE OTHER NM, PA LYNPARZA OTHER NM, LA, PA MYLOTARG OTHER NM, LA, PA NINLARO OTHER NM, PA ODOMZO OTHER NM, LA, PA RITUXAN OTHER NM, LA, PA RITUXAN HYCELA OTHER NM, LA, PA RUBRACA OTHER NM, LA, PA TALZENNA OTHER NM, LA, PA TECENTRIQ 1200mg/20ml OTHER NM, LA, PA TIBSOVO OTHER NM, LA, PA VELCADE OTHER NM, PA VENCLEXTA OTHER NM, LA, PA VENCLEXTA STARTING PACK OTHER NM, LA, PA VERZENIO OTHER NM, LA, PA ZEJULA OTHER NM, LA, PA ZOLINZA OTHER NM, PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate GENERIC NM, PA anastrozole TABS GENERIC bicalutamide GENERIC DEPO‑PROVERA INJ 400/ML OTHER B/D ERLEADA OTHER NM, LA, PA exemestane GENERIC FARESTON OTHER FASLODEX OTHER B/D flutamide GENERIC letrozole TABS GENERIC leuprolide inj 1mg/0.2 GENERIC NM, PA LUPRON DEPOT (1‑MONTH) 3.75mg OTHER NM, PA LUPRON DEPOT INJ 11.25MG (3‑MONTH) OTHER NM, PA



LYSODREN OTHER megestrol ac sus 40mg/ml GENERIC megestrol ac tab 20mg GENERIC megestrol ac tab 40mg GENERIC megestrol sus 625mg/5ml GENERIC PA nilutamide GENERIC SOLTAMOX OTHER tamoxifen citrate TABS GENERIC toremifene citrate GENERIC TRELSTAR DEP INJ 3.75MG OTHER NM, PA TRELSTAR LA INJ 11.25MG OTHER NM, PA XTANDI OTHER NM, LA, PA ZYTIGA OTHER NM, LA, PA

IMMUNOMODULATORS POMALYST OTHER NM, LA, PA REVLIMID OTHER QL (28 caps / 28 days), NM, LA,

PA THALOMID 50mg, 100mg OTHER QL (30 caps / 30 days), NM, PA THALOMID 150mg, 200mg OTHER QL (60 caps / 30 days), NM, PA

KINASE INHIBITORS AFINITOR OTHER QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg OTHER QL (150 tabs / 30 days), NM, PA AFINITOR DISPERZ 3mg OTHER QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg OTHER QL (60 tabs / 30 days), NM, PA ALECENSA OTHER NM, LA, PA ALUNBRIG OTHER NM, LA, PA BOSULIF OTHER NM, PA BRAFTOVI OTHER NM, LA, PA CABOMETYX OTHER QL (30 tabs / 30 days), NM, LA,

PA CALQUENCE OTHER NM, LA, PA CAPRELSA OTHER NM, LA, PA COMETRIQ OTHER NM, LA, PA COPIKTRA OTHER NM, LA, PA COTELLIC OTHER NM, LA, PA GILOTRIF TAB 20MG OTHER NM, LA, PA GILOTRIF TAB 30MG OTHER NM, LA, PA GILOTRIF TAB 40MG OTHER NM, LA, PA


15


ICLUSIG OTHER NM, LA, PA imatinib mesylate 100mg GENERIC QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg GENERIC QL (60 tabs / 30 days), NM, PA IMBRUVICA OTHER NM, LA, PA INLYTA 1mg OTHER QL (180 tabs / 30 days), NM, LA,

PA INLYTA 5mg OTHER QL (120 tabs / 30 days), NM, LA,

PA IRESSA OTHER NM, LA, PA JAKAFI OTHER QL (60 tabs / 30 days), NM, LA,

PA LENVIMA 4 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 8 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 10 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 12MG DAILY DOSE OTHER NM, LA, PA LENVIMA 14 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 18 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 20 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 24 MG DAILY DOSE OTHER NM, LA, PA LORBRENA OTHER NM, LA, PA MEKINIST OTHER NM, LA, PA MEKTOVI OTHER NM, LA, PA NERLYNX OTHER NM, LA, PA NEXAVAR OTHER NM, LA, PA RYDAPT OTHER NM, PA SPRYCEL OTHER NM, PA STIVARGA OTHER NM, LA, PA SUTENT OTHER NM, PA TAFINLAR OTHER NM, LA, PA TAGRISSO OTHER NM, LA, PA TARCEVA 25mg OTHER QL (90 tabs / 30 days), NM, LA,

PA TARCEVA 100mg, 150mg OTHER QL (30 tabs / 30 days), NM, LA,

PA TASIGNA OTHER NM, PA TYKERB OTHER NM, LA, PA VITRAKVI OTHER NM, LA, PA VIZIMPRO OTHER NM, LA, PA VOTRIENT OTHER NM, LA, PA



XALKORI OTHER NM, LA, PA XOSPATA OTHER NM, LA, PA ZELBORAF OTHER NM, LA, PA ZYDELIG OTHER NM, LA, PA ZYKADIA OTHER NM, LA, PA

MISCELLANEOUS bexarotene GENERIC NM, PA hydroxyurea CAPS GENERIC LONSURF OTHER NM, PA MATULANE OTHER LA SYLATRON KIT 200MCG OTHER NM, PA SYLATRON KIT 300MCG OTHER NM, PA SYLATRON KIT 600MCG OTHER NM, PA SYNRIBO OTHER NM, PA tretinoin (chemotherapy) GENERIC

PLATINUM-BASED AGENTS carboplatin GENERIC B/D cisplatin GENERIC B/D oxaliplatin inj 50mg GENERIC B/D oxaliplatin inj 50mg/10ml GENERIC B/D oxaliplatin inj 100mg GENERIC B/D oxaliplatin inj 100mg/20ml GENERIC B/D

PROTECTIVE AGENTS dexrazoxane 500mg GENERIC B/D leucovorin calcium SOLR GENERIC B/D leucovorin calcium TABS GENERIC MESNEX TABS OTHER

TOPOISOMERASE INHIBITORS etoposide SOLN GENERIC B/D irinotecan hcl GENERIC B/D toposar GENERIC B/D topotecan hcl GENERIC B/D TOPOTECAN INJ 4MG/4ML OTHER B/D

CARDIOVASCULAR ‑ DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-benazepril hcl cap 2.5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-20 mg GENERIC


17


amlodipine besylate-benazepril hcl cap 5-40 mg GENERIC amlodipine besylate-benazepril hcl cap 10-20 mg GENERIC amlodipine besylate-benazepril hcl cap 10-40 mg GENERIC benazepril & hydrochlorothiazide GENERIC captopril & hydrochlorothiazide GENERIC enalapril maleate & hydrochlorothiazide GENERIC fosinopril sodium & hydrochlorothiazide GENERIC lisinopril & hydrochlorothiazide GENERIC moexipril-hydrochlorothiazide GENERIC quinapril-hydrochlorothiazide GENERIC

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS GENERIC captopril TABS GENERIC enalapril maleate TABS GENERIC fosinopril sodium GENERIC lisinopril TABS GENERIC moexipril hcl GENERIC perindopril erbumine GENERIC quinapril hcl GENERIC ramipril GENERIC trandolapril GENERIC

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone GENERIC spironolactone TABS GENERIC

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate TABS GENERIC prazosin hcl GENERIC terazosin hcl GENERIC

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil GENERIC amlodipine besylate-valsartan tab GENERIC amlodipine-valsartan-hydrochlorothiazide tab GENERIC candesartan cilexetil-hydrochlorothiazide GENERIC ENTRESTO OTHER irbesartan-hydrochlorothiazide GENERIC losartan-hydrochlorothiazide GENERIC olmesartan medoxomil-amlodipine-hydrochlorothiazide GENERIC olmesartan medoxomil-hydrochlorothiazide GENERIC



telmisartan-amlodipine GENERIC telmisartan-hydrochlorothiazide GENERIC valsartan-hydrochlorothiazide GENERIC

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil GENERIC eprosartan mesylate GENERIC irbesartan GENERIC losartan potassium GENERIC olmesartan medoxomil TABS GENERIC telmisartan GENERIC valsartan GENERIC

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln GENERIC amiodarone tab 100mg GENERIC amiodarone tab 200mg GENERIC amiodarone tab 400mg GENERIC disopyramide phosphate GENERIC dofetilide GENERIC NM flecainide acetate GENERIC mexiletine hcl GENERIC MULTAQ OTHER NORPACE CR OTHER pacerone GENERIC propafenone hcl GENERIC propafenone hcl 12hr GENERIC quinidine gluconate GENERIC quinidine sulfate GENERIC sorine GENERIC sotalol hcl GENERIC sotalol hcl (afib/afl) GENERIC

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS GENERIC lovastatin GENERIC pravastatin sodium GENERIC rosuvastatin calcium GENERIC QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg GENERIC simvastatin TABS 80mg GENERIC QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL


19


cholestyramine GENERIC cholestyramine light GENERIC colesevelam hcl GENERIC colestipol hcl gran GENERIC colestipol hcl pack GENERIC colestipol hcl tabs GENERIC ezetimibe GENERIC ezetimibe-simvastatin GENERIC fenofibrate TABS 48mg, 54mg, 145mg, 160mg GENERIC fenofibrate micronized 67mg, 134mg, 200mg GENERIC gemfibrozil TABS GENERIC JUXTAPID OTHER NM, LA, PA KYNAMRO OTHER PA niacin er (antihyperlipidemic) 500mg GENERIC QL (90 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg GENERIC niacor GENERIC PRALUENT OTHER PA prevalite GENERIC VASCEPA OTHER WELCHOL PAK OTHER

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

atenolol & chlorthalidone GENERIC bisoprolol & hydrochlorothiazide GENERIC metoprolol & hydrochlorothiazide GENERIC propranolol & hydrochlorothiazide GENERIC

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS GENERIC atenolol TABS GENERIC betaxolol hcl GENERIC bisoprolol fumarate GENERIC BYSTOLIC 2.5mg, 5mg, 10mg OTHER QL (30 tabs / 30 days) BYSTOLIC 20mg OTHER QL (60 tabs / 30 days) carvedilol GENERIC labetalol hcl TABS GENERIC metoprolol succinate GENERIC metoprolol tartrate SOCT GENERIC metoprolol tartrate SOLN GENERIC

PA - Prior Authorization QL - Quantity Limits ST - Step TherapNM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Acc04/01/2019 Formulary ID 000120

y ess 9346 v9


metoprolol tartrate TABS 25mg, 50mg, 100mg GENERIC nadolol TABS GENERIC pindolol GENERIC propranolol cap er GENERIC propranolol hcl TABS GENERIC propranolol oral sol GENERIC timolol maleate TABS GENERIC

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate TABS GENERIC cartia xt GENERIC dilt-xr cap GENERIC diltiazem cap 120mg cd GENERIC diltiazem cap 180mg cd GENERIC diltiazem cap 240mg cd GENERIC diltiazem cap 360mg cd GENERIC diltiazem cap er/12hr GENERIC diltiazem hcl TABS GENERIC diltiazem hcl cap sr 24hr GENERIC diltiazem hcl coated beads cap sr 24hr GENERIC diltiazem hcl extended release beads cap sr GENERIC diltiazem inj GENERIC felodipine GENERIC isradipine GENERIC nicardipine hcl CAPS GENERIC nifedipine TB24 GENERIC nifedipine er GENERIC nimodipine CAPS GENERIC NYMALIZE OTHER taztia xt GENERIC verapamil cap er GENERIC verapamil hcl SOLN; TABS; TBCR GENERIC verapamil tab er GENERIC

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek .25mg GENERIC PA; PA if 70 years and older digitek .125mg GENERIC QL (30 tabs / 30 days) digox 125mcg GENERIC QL (30 tabs / 30 days) digox 250mcg GENERIC PA; PA if 70 years and older digoxin TABS 125mcg GENERIC QL (30 tabs / 30 days)


21


digoxin TABS 250mcg GENERIC PA; PA if 70 years and older digoxin inj GENERIC digoxin sol 50mcg/ml GENERIC PA; PA if 70 years and older

DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS TEKTURNA OTHER TEKTURNA HCT OTHER

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS GENERIC amiloride & hydrochlorothiazide GENERIC amiloride hcl TABS GENERIC bumetanide inj 0.25/ml GENERIC bumetanide tab GENERIC chlorothiazide tabs GENERIC chlorthalidone GENERIC furosemide SOLN; TABS GENERIC furosemide inj GENERIC hydrochlorothiazide CAPS; TABS GENERIC indapamide GENERIC methazolamide TABS GENERIC methyclothiazide GENERIC metolazone GENERIC spironolactone & hydrochlorothiazide GENERIC torsemide tabs GENERIC triamterene & hydrochlorothiazide cap 37.5-25 mg GENERIC triamterene & hydrochlorothiazide tabs GENERIC

MISCELLANEOUS clonidine hcl TABS GENERIC clonidine hcl ptwk GENERIC CORLANOR OTHER DEMSER OTHER PA hydralazine hcl SOLN; TABS GENERIC midodrine hcl GENERIC minoxidil TABS GENERIC NORTHERA OTHER NM, LA, PA RANEXA OTHER

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab GENERIC isosorbide dinitrate GENERIC



isosorbide dinitrate er GENERIC isosorbide mononitrate er GENERIC minitran GENERIC nitro-bid GENERIC NITRO‑DUR DIS 0.3MG/HR OTHER NITRO‑DUR DIS 0.8MG/HR OTHER nitroglycerin SOLN .4mg/spray GENERIC nitroglycerin SUBL GENERIC nitroglycerin td patch GENERIC

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS OTHER QL (90 tabs / 30 days), NM, LA,

PA LETAIRIS OTHER QL (30 tabs / 30 days), NM, LA,

PA OPSUMIT OTHER QL (30 tabs / 30 days), NM, LA,

PA REMODULIN OTHER NM, LA, PA sildenafil citrate tab 20 mg (pulmonary hypertension) GENERIC QL (90 tabs / 30 days), NM, PA TRACLEER TABS 62.5mg OTHER QL (120 tabs / 30 days), NM, LA,

PA TRACLEER TABS 125mg OTHER QL (60 tabs / 30 days), NM, LA,

PA VENTAVIS OTHER NM, PA

CENTRAL NERVOUS SYSTEM ‑ DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY

alprazolam tab 0.5mg GENERIC QL (150 tabs / 30 days) alprazolam tab 0.25mg GENERIC QL (150 tabs / 30 days) alprazolam tab 1mg GENERIC QL (150 tabs / 30 days) alprazolam tab 2 mg GENERIC QL (150 tabs / 30 days) buspirone hcl TABS GENERIC fluvoxamine maleate TABS GENERIC lorazepam SOLN GENERIC lorazepam TABS GENERIC QL (150 tabs / 30 days) lorazepam intensol GENERIC QL (150 mL / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg OTHER QL (180 tabs / 30 days) APTIOM 400mg OTHER QL (90 tabs / 30 days) APTIOM 600mg, 800mg OTHER QL (60 tabs / 30 days) BANZEL SUS 40MG/ML OTHER PA


23


BANZEL TAB 200MG OTHER PA BANZEL TAB 400MG OTHER PA BRIVIACT INJ 50MG/5ML OTHER PA BRIVIACT SOL 10MG/ML OTHER PA BRIVIACT TAB 10MG OTHER PA BRIVIACT TAB 25MG OTHER PA BRIVIACT TAB 50MG OTHER PA BRIVIACT TAB 75MG OTHER PA BRIVIACT TAB 100MG OTHER PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 GENERIC CELONTIN OTHER clobazam GENERIC PA clonazepam TABS 2mg GENERIC QL (300 tabs / 30 days) clonazepam TABS .5mg, 1mg GENERIC QL (90 tabs / 30 days) clonazepam TBDP 2mg GENERIC QL (300 tabs / 30 days) clonazepam TBDP .125mg, .25mg, .5mg, 1mg GENERIC QL (90 tabs / 30 days) clorazepate dipotassium GENERIC QL (180 tabs / 30 days), PA; PA if

65 years and older DIASTAT ACUDIAL OTHER DIASTAT PEDIATRIC OTHER diazepam TABS GENERIC QL (120 tabs / 30 days), PA; PA if

65 years and older diazepam gel GENERIC diazepam inj GENERIC diazepam intensol GENERIC QL (240 mL / 30 days), PA; PA if

65 years and older diazepam oral soln 1 mg/ml GENERIC QL (1200 mL / 30 days), PA; PA if

65 years and older dilantin cap 30mg GENERIC dilantin cap 100mg GENERIC dilantin chew tab 50mg GENERIC DILANTIN‑125 SUSP OTHER divalproex sodium CSDR; TB24; TBEC GENERIC EPIDIOLEX OTHER QL (600 mL / 30 days), NM, LA,

PA epitol GENERIC ethosuximide CAPS; SOLN GENERIC felbamate GENERIC FYCOMPA SUSP OTHER QL (720 mL / 30 days), PA



FYCOMPA TABS 2mg, 4mg, 6mg OTHER QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg OTHER QL (30 tabs / 30 days), PA gabapentin CAPS 100mg GENERIC QL (1080 caps / 30 days) gabapentin CAPS 300mg GENERIC QL (360 caps / 30 days) gabapentin CAPS 400mg GENERIC QL (270 caps / 30 days) gabapentin SOLN GENERIC QL (2160 mL / 30 days) gabapentin TABS 600mg GENERIC QL (180 tabs / 30 days) gabapentin TABS 800mg GENERIC QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 GENERIC levetiracetam SOLN; TABS; TB24 GENERIC levetiracetam in sodium chloride GENERIC levetiracetam oral soln 100 mg/ml GENERIC LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg OTHER QL (120 caps / 30 days) LYRICA CAPS 200mg OTHER QL (90 caps / 30 days) LYRICA CAPS 225mg, 300mg OTHER QL (60 caps / 30 days) LYRICA SOLN OTHER QL (946 mL / 30 days) ONFI OTHER PA oxcarbazepine GENERIC PEGANONE OTHER phenobarbital ELIX; TABS GENERIC PA; PA if 70 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml OTHER PA; PA if 70 years and older phenobarbital sodium SOLN 130mg/ml GENERIC PA; PA if 70 years and older phenytek GENERIC phenytoin CHEW; SUSP GENERIC phenytoin sodium extended GENERIC phenytoin sodium inj 50mg/ml GENERIC primidone TABS GENERIC roweepra GENERIC roweepra xr GENERIC SABRIL TABS OTHER QL (180 tabs / 30 days), NM, LA,

PA SPRITAM OTHER subvenite tab GENERIC SYMPAZAN OTHER PA tiagabine hcl GENERIC topiramate CPSP; TABS GENERIC valproate sodium SOLN GENERIC valproate sodium oral soln GENERIC


25


valproic acid CAPS GENERIC vigabatrin powd pack 500mg GENERIC QL (180 packets / 30 days), NM,

LA, PA vigabatrin tab 500mg GENERIC QL (180 tabs / 30 days), NM, LA,

PA VIMPAT 50mg OTHER QL (120 tabs / 30 days) VIMPAT 100mg, 150mg, 200mg OTHER QL (60 tabs / 30 days) VIMPAT INJ 200MG/20ML OTHER VIMPAT SOL 10MG/ML OTHER QL (1200 mL / 30 days) zonisamide CAPS GENERIC

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg GENERIC QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg GENERIC donepezil hydrochloride TBDP 5mg GENERIC QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg GENERIC galantamine hydrobromide SOLN GENERIC galantamine hydrobromide TABS GENERIC QL (60 tabs / 30 days) galantamine hydrobromide er GENERIC QL (30 caps / 30 days) memantine hcl cp24 GENERIC PA; PA if < 30 yrs memantine soln GENERIC PA; PA if < 30 yrs memantine tabs GENERIC PA; PA if < 30 yrs memantine titration pak GENERIC PA; PA if < 30 yrs NAMZARIC OTHER rivastigmine tartrate 1.5mg, 3mg GENERIC QL (90 caps / 30 days) rivastigmine tartrate 4.5mg, 6mg GENERIC QL (60 caps / 30 days) rivastigmine td patch 24hr 4.6 mg/24hr GENERIC QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr GENERIC QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr GENERIC QL (30 patches / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS GENERIC amoxapine GENERIC bupropion hcl TABS GENERIC bupropion hcl TB12 GENERIC bupropion hcl TB24 150mg, 300mg GENERIC citalopram hydrobromide GENERIC clomipramine hcl CAPS GENERIC PA desipramine hcl TABS GENERIC desvenlafaxine succinate GENERIC QL (30 tabs / 30 days), PA



doxepin hcl CAPS; CONC GENERIC duloxetine hcl CPEP 20mg GENERIC QL (180 caps / 30 days) duloxetine hcl CPEP 30mg GENERIC QL (120 caps / 30 days) duloxetine hcl CPEP 60mg GENERIC QL (60 caps / 30 days) EMSAM OTHER QL (30 patches / 30 days), PA escitalopram oxalate GENERIC FETZIMA 20mg OTHER QL (180 caps / 30 days), PA FETZIMA 40mg OTHER QL (90 caps / 30 days), PA FETZIMA 80mg, 120mg OTHER QL (30 caps / 30 days), PA FETZIMA TITRATION PACK OTHER PA fluoxetine cap 10mg GENERIC fluoxetine cap 20mg GENERIC fluoxetine cap 40mg GENERIC fluoxetine hcl SOLN GENERIC imipramine hcl TABS GENERIC maprotiline hcl GENERIC MARPLAN TAB 10MG OTHER QL (180 tabs / 30 days) mirtazapine TABS; TBDP GENERIC nefazodone hcl GENERIC nortriptyline hcl CAPS; SOLN GENERIC paroxetine hcl tabs GENERIC PAXIL SUSP OTHER QL (900 mL / 30 days) phenelzine sulfate TABS GENERIC protriptyline hcl GENERIC sertraline hcl CONC; TABS GENERIC tranylcypromine sulfate GENERIC trazodone hcl TABS 50mg, 100mg, 150mg GENERIC trimipramine maleate CAPS 25mg GENERIC QL (240 caps / 30 days) trimipramine maleate CAPS 50mg GENERIC QL (120 caps / 30 days) trimipramine maleate CAPS 100mg GENERIC QL (60 caps / 30 days) TRINTELLIX 5mg OTHER QL (120 tabs / 30 days) TRINTELLIX 10mg OTHER QL (60 tabs / 30 days) TRINTELLIX 20mg OTHER QL (30 tabs / 30 days) venlafaxine hcl CP24; TABS GENERIC VIIBRYD STARTER PACK OTHER VIIBRYD TAB OTHER QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS GENERIC QL (120 caps / 30 days)


27


amantadine hcl SYRP; TABS GENERIC APOKYN OTHER QL (20 cartridges / 30 days),

NM, LA, PA benztropine mesylate inj GENERIC benztropine mesylate tab 0.5mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 1mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 2mg GENERIC PA; PA if 70 years and older bromocriptine mesylate CAPS; TABS GENERIC carbidopa-levodopa GENERIC carbidopa/levodopa/entacapone GENERIC entacapone GENERIC NEUPRO OTHER pramipexole tab 0.5mg GENERIC pramipexole tab 0.25mg GENERIC pramipexole tab 0.75mg GENERIC pramipexole tab 0.125mg GENERIC pramipexole tab 1.5mg GENERIC pramipexole tab 1mg GENERIC rasagiline mesylate TABS GENERIC ropinirole tab 0.5mg GENERIC ropinirole tab 0.25mg GENERIC ropinirole tab 1mg GENERIC ropinirole tab 2mg GENERIC ropinirole tab 3mg GENERIC ropinirole tab 4mg GENERIC ropinirole tab 5mg GENERIC selegiline hcl CAPS; TABS GENERIC trihexyphenidyl hcl GENERIC PA; PA if 70 years and older

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA OTHER QL (1 injection / 28 days) aripiprazole odt GENERIC QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml GENERIC QL (900 mL / 30 days) aripiprazole tab GENERIC QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

OTHER QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml OTHER QL (1 injection / 56 days) ARISTADA INITIO OTHER chlorpromazine hcl TABS GENERIC



chlorpromazine inj GENERIC clozapine odt 12.5mg, 25mg GENERIC PA clozapine odt 100mg GENERIC QL (270 tabs / 30 days), PA clozapine odt 150mg GENERIC QL (180 tabs / 30 days), PA clozapine odt 200mg GENERIC QL (135 tabs / 30 days), PA clozapine tab 25mg GENERIC clozapine tab 50mg GENERIC clozapine tab 100mg GENERIC QL (270 tabs / 30 days) clozapine tab 200mg GENERIC QL (135 tabs / 30 days) FANAPT OTHER QL (60 tabs / 30 days) FANAPT TITRATION PACK OTHER fluphenazine decanoate SOLN GENERIC fluphenazine hcl GENERIC GEODON SOLR OTHER QL (6 mL / 3 days) haloperidol TABS GENERIC haloperidol conc 2mg/ml GENERIC haloperidol decanoate SOLN GENERIC haloperidol lactate inj 5mg/ml GENERIC INVEGA SUST INJ 39 MG/0.25 ML OTHER QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML OTHER QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML OTHER QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML OTHER QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML OTHER QL (1 injection / 28 days) INVEGA TRINZA OTHER QL (1 injection / 90 days) LATUDA 20mg, 60mg, 80mg OTHER QL (60 tabs / 30 days) LATUDA 40mg, 120mg OTHER QL (30 tabs / 30 days) loxapine succinate GENERIC molindone hcl GENERIC NUPLAZID CAPS OTHER QL (30 caps / 30 days), NM, LA,

PA NUPLAZID TABS 10MG OTHER QL (30 tabs / 30 days), NM, LA,

PA NUPLAZID TABS 17MG OTHER QL (60 tabs / 30 days), NM, LA,

PA olanzapine SOLR GENERIC QL (3 vials / 1 day) olanzapine TABS 2.5mg GENERIC QL (240 tabs / 30 days) olanzapine TABS 5mg GENERIC QL (120 tabs / 30 days) olanzapine TABS 7.5mg, 15mg, 20mg GENERIC QL (30 tabs / 30 days) olanzapine TABS 10mg GENERIC QL (60 tabs / 30 days)

28



olanzapine TBDP 5mg, 15mg, 20mg GENERIC QL (30 tabs / 30 days) olanzapine TBDP 10mg GENERIC QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg GENERIC QL (30 tabs / 30 days) paliperidone 6mg GENERIC QL (60 tabs / 30 days) perphenazine TABS GENERIC pimozide GENERIC quetiapine fumarate TABS GENERIC quetiapine fumarate TB24 50mg, 300mg, 400mg GENERIC QL (60 tabs / 30 days) quetiapine fumarate TB24 150mg, 200mg GENERIC QL (30 tabs / 30 days) REXULTI 1mg OTHER QL (90 tabs / 30 days) REXULTI 2mg OTHER QL (60 tabs / 30 days) REXULTI 3mg, 4mg OTHER QL (30 tabs / 30 days) REXULTI .5mg OTHER QL (180 tabs / 30 days) REXULTI .25mg OTHER QL (360 tabs / 30 days) RISPERDAL INJ 12.5MG OTHER QL (2 injections / 28 days) RISPERDAL INJ 25MG OTHER QL (2 injections / 28 days) RISPERDAL INJ 37.5MG OTHER QL (2 injections / 28 days) RISPERDAL INJ 50MG OTHER QL (2 injections / 28 days) risperidone SOLN GENERIC QL (240 mL / 30 days) risperidone TABS GENERIC risperidone TBDP .5mg GENERIC QL (90 tabs / 30 days) risperidone TBDP .25mg, 1mg, 2mg, 3mg, 4mg GENERIC QL (60 tabs / 30 days) SAPHRIS 2.5mg OTHER QL (240 tabs / 30 days) SAPHRIS 5mg OTHER QL (120 tabs / 30 days) SAPHRIS 10mg OTHER QL (60 tabs / 30 days) thioridazine hcl TABS GENERIC thiothixene GENERIC trifluoperazine hcl GENERIC VERSACLOZ OTHER QL (600 mL / 30 days), PA VRAYLAR 1.5mg OTHER QL (60 caps / 30 days), PA VRAYLAR 3mg, 4.5mg, 6mg OTHER QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK OTHER PA ziprasidone hcl GENERIC QL (60 caps / 30 days) ZYPREXA RELPREVV 300mg OTHER QL (2 vials / 28 days), PA ZYPREXA RELPREVV 405mg OTHER QL (1 vial / 28 days), PA ZYPREXA RELPREVV INJ 210MG OTHER QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg GENERIC QL (90 caps / 30 days)

29



amphetamine-dextroamphetamine cap sr 24hr 10 mg GENERIC QL (90 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 15 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 20 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 25 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 30 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine tab 5 mg GENERIC QL (360 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 mg GENERIC QL (240 tabs / 30 days) amphetamine-dextroamphetamine tab 10 mg GENERIC QL (180 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 mg GENERIC QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 15 mg GENERIC QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 20 mg GENERIC QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 30 mg GENERIC QL (60 tabs / 30 days) atomoxetine hcl 10mg, 18mg, 25mg GENERIC QL (120 caps / 30 days) atomoxetine hcl 40mg GENERIC QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 100mg GENERIC QL (30 caps / 30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg GENERIC QL (120 tabs / 30 days) dexmethylphenidate hcl TABS 10mg GENERIC QL (60 tabs / 30 days) guanfacine er (adhd) GENERIC PA; PA if 70 years and older metadate er tab 20mg GENERIC QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg GENERIC QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg GENERIC QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml GENERIC QL (1800 mL / 30 days) methylphenidate hcl oral soln 10mg/5ml GENERIC QL (900 mL / 30 days) methylphenidate tab 10mg er GENERIC QL (90 tabs / 30 days) methylphenidate tab 20mg er GENERIC QL (90 tabs / 30 days)

HYPNOTICS - DRUGS TO TREAT INSOMNIA eszopiclone GENERIC QL (30 tabs / 30 days), PA; PA

applies if 70 years and older after a 90 day supply in a calen

dar year HETLIOZ OTHER NM, LA, PA SILENOR 3mg OTHER QL (60 tabs / 30 days) SILENOR 6mg OTHER QL (30 tabs / 30 days) temazepam 7.5mg GENERIC QL (30 caps / 30 days), PA; PA


dar year


31


temazepam 15mg GENERIC QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calen

dar year zaleplon GENERIC QL (60 caps / 30 days), PA; PA


dar year zolpidem tartrate TABS GENERIC QL (30 tabs / 30 days), PA; PA


dar year MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES

dihydroergotamine mesylate inj 1 mg/ml GENERIC dihydroergotamine mesylate nasal GENERIC QL (8 mL / 30 days) eletriptan hydrobromide GENERIC QL (12 tabs / 30 days) ergotamine w/ caffeine TABS GENERIC naratriptan hcl GENERIC QL (12 tabs / 30 days) rizatriptan benzoate GENERIC QL (18 tabs / 30 days) rizatriptan benzoate odt GENERIC QL (18 tabs / 30 days) sumatriptan SOLN 5mg/act GENERIC QL (24 inhalers / 30 days) sumatriptan SOLN 20mg/act GENERIC QL (12 inhalers / 30 days) sumatriptan inj 4mg/0.5ml GENERIC QL (18 injections / 30 days) sumatriptan inj 6mg/0.5ml GENERIC QL (12 injections / 30 days) sumatriptan succinate TABS GENERIC QL (12 tabs / 30 days) zolmitriptan TABS GENERIC QL (12 tabs / 30 days) zolmitriptan odt GENERIC QL (12 tabs / 30 days)

MISCELLANEOUS AUSTEDO 6mg OTHER QL (60 tabs / 30 days), NM, LA,

PA AUSTEDO 9mg, 12mg OTHER QL (120 tabs / 30 days), NM, LA,

PA lithium carbonate CAPS; TABS GENERIC lithium carbonate er GENERIC LITHIUM SOLN 8MEQ/5ML OTHER LYRICA CR 82.5mg, 165mg OTHER QL (90 tabs / 30 days), PA LYRICA CR 330mg OTHER QL (60 tabs / 30 days), PA NUEDEXTA OTHER QL (60 caps / 30 days), PA pyridostigmine tab 60mg GENERIC riluzole GENERIC



tetrabenazine 12.5mg GENERIC QL (240 tabs / 30 days), NM, PA tetrabenazine 25mg GENERIC QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA OTHER NM, LA, PA BETASERON OTHER QL (14 syringes / 28 days), NM,

PA dalfampridine GENERIC NM, PA GILENYA OTHER QL (28 caps / 28 days), NM, PA glatiramer acetate 20mg/ml GENERIC QL (30 syringes / 30 days), NM,

PA glatiramer acetate 40mg/ml GENERIC QL (12 syringes / 28 days), NM,

PA glatopa 20mg/ml GENERIC QL (30 syringes / 30 days), NM,

PA glatopa 40mg/ml GENERIC QL (12 syringes / 28 days), NM,

PA MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS

baclofen TABS 10mg, 20mg GENERIC carisoprodol TABS 350mg GENERIC QL (120 tabs / 30 days), PA; PA if

70 years and older cyclobenzaprine hcl TABS 5mg, 10mg GENERIC PA; PA if 70 years and older dantrolene sodium CAPS GENERIC methocarbamol TABS GENERIC PA; PA if 70 years and older tizanidine hcl TABS GENERIC

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil 50mg GENERIC QL (90 tabs / 30 days), PA armodafinil 150mg, 200mg, 250mg GENERIC QL (30 tabs / 30 days), PA XYREM OTHER QL (540 mL / 30 days), NM, LA,

PA PSYCHOTHERAPEUTIC-MISC

acamprosate calcium GENERIC buprenorphine hcl SUBL GENERIC QL (90 tabs / 30 days), PA buprenorphine hcl-naloxone hcl sl GENERIC QL (90 tabs / 30 days) bupropion hcl (smoking deterrent) GENERIC CHANTIX OTHER PA CHANTIX CONTINUING MONTH OTHER PA CHANTIX STARTER PACK OTHER PA disulfiram TABS GENERIC EVZIO OTHER

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA -04/01/2019 Formu

Limited Access lary ID 00019346 v9

33


naloxone inj 0.4mg/ml GENERIC naloxone inj 1mg/ml GENERIC naltrexone hcl TABS GENERIC NARCAN OTHER NICOTROL INHALER OTHER NICOTROL NS OTHER SUBOXONE MIS 2‑0.5MG OTHER QL (90 films / 30 days) SUBOXONE MIS 4‑1MG OTHER QL (90 films / 30 days) SUBOXONE MIS 8‑2MG OTHER QL (90 films / 30 days) SUBOXONE MIS 12‑3MG OTHER QL (60 films / 30 days) VIVITROL OTHER

ENDOCRINE AND METABOLIC ‑ DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL‑50 OTHER PA ANDRODERM OTHER QL (30 patches / 30 days), PA oxandrolone tab 2.5mg GENERIC PA oxandrolone tab 10mg GENERIC PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm GENERIC QL (300 grams / 30 days), PA testosterone cypionate SOLN 100mg/ml, 200mg/ml GENERIC PA testosterone enanthate SOLN GENERIC PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS OTHER BASAGLAR KWIKPEN OTHER BD ULTRAFINE INSULIN SYRINGE OTHER BD ULTRAFINE/NANO PEN NEEDLES OTHER BYDUREON BCISE OTHER QL (4 pens / 28 days) BYDUREON INJ OTHER QL (4 vials / 28 days) BYDUREON PEN OTHER QL (4 pens / 28 days) BYETTA OTHER QL (1 pen / 30 days) FIASP OTHER FIASP FLEXTOUCH OTHER GAUZE PADS 2” X 2” OTHER HUMULIN R INJ U‑500 OTHER B/D HUMULIN R U‑500 KWIKPEN OTHER INSULIN PEN NEEDLE OTHER INSULIN SAFETY NEEDLES OTHER INSULIN SYRINGE OTHER LEVEMIR OTHER



LEVEMIR FLEXTOUCH OTHER NOVOLIN 70/30 OTHER (brand RELION not covered) NOVOLIN 70/30 FLEXPEN OTHER (brand RELION not covered) NOVOLIN N OTHER (brand RELION not covered) NOVOLIN R OTHER (brand RELION not covered) NOVOLOG OTHER NOVOLOG 70/30 FLEXPEN OTHER NOVOLOG FLEXPEN OTHER NOVOLOG MIX 70/30 OTHER NOVOLOG PENFILL OTHER OZEMPIC INJ 0.25 OR 0.5MG/DOSE OTHER QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE OTHER QL (2 pens / 28 days) SOLIQUA 100/33 OTHER QL (10 pens / 30 days) TRESIBA FLEXTOUCH OTHER TRESIBA INJ OTHER TRULICITY OTHER QL (4 pens / 28 days) VICTOZA OTHER QL (3 pens / 30 days) XULTOPHY 100/3.6 OTHER QL (5 pens / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose GENERIC FARXIGA 5mg OTHER QL (60 tabs / 30 days) FARXIGA 10mg OTHER QL (30 tabs / 30 days) glimepiride 1mg GENERIC QL (240 tabs / 30 days) glimepiride 2mg GENERIC QL (120 tabs / 30 days) glimepiride 4mg GENERIC QL (60 tabs / 30 days) glip/metform tab 2.5-250mg GENERIC QL (240 tabs / 30 days) glip/metform tab 2.5-500mg GENERIC QL (120 tabs / 30 days) glip/metform tab 5-500mg GENERIC QL (120 tabs / 30 days) glipizide TABS 5mg GENERIC QL (240 tabs / 30 days) glipizide TABS 10mg GENERIC QL (120 tabs / 30 days) glipizide TB24 2.5mg GENERIC QL (240 tabs / 30 days) glipizide TB24 5mg GENERIC QL (120 tabs / 30 days) glipizide TB24 10mg GENERIC QL (60 tabs / 30 days) glipizide xl 2.5mg GENERIC QL (240 tabs / 30 days) glipizide xl 5mg GENERIC QL (120 tabs / 30 days) glipizide xl 10mg GENERIC QL (60 tabs / 30 days) glyburide TABS 1.25mg GENERIC QL (480 tabs / 30 days), PA; PA if

70 years and older


35


glyburide TABS 2.5mg GENERIC QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide TABS 5mg GENERIC QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 1.5mg GENERIC QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 3mg GENERIC QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 6mg GENERIC QL (60 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 1.25-250 mg GENERIC QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 2.5-500 mg GENERIC QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 5-500mg GENERIC QL (120 tabs / 30 days), PA; PA if 70 years and older

JANUMET OTHER QL (60 tabs / 30 days) JANUMET XR TAB 50‑500MG OTHER QL (60 tabs / 30 days) JANUMET XR TAB 50‑1000 OTHER QL (60 tabs / 30 days) JANUMET XR TAB 100‑1000 OTHER QL (30 tabs / 30 days) JANUVIA OTHER QL (30 tabs / 30 days) JARDIANCE 10mg OTHER QL (60 tabs / 30 days) JARDIANCE 25mg OTHER QL (30 tabs / 30 days) JENTADUETO OTHER QL (60 tabs / 30 days) JENTADUETO TAB XR 2.5‑1000 MG OTHER QL (60 tabs / 30 days) JENTADUETO TAB XR 5‑1000 MG OTHER QL (30 tabs / 30 days) metformin er 500mg GENERIC QL (120 tabs / 30 days); (generic

of GLUCOPHAGE XR) metformin er 750mg GENERIC QL (60 tabs / 30 days); (generic

of GLUCOPHAGE XR) metformin hcl TABS 500mg GENERIC QL (150 tabs / 30 days) metformin hcl TABS 850mg GENERIC QL (90 tabs / 30 days) metformin hcl TABS 1000mg GENERIC QL (75 tabs / 30 days) nateglinide GENERIC QL (90 tabs / 30 days) pioglitazone hcl GENERIC QL (30 tabs / 30 days) repaglinide 2mg GENERIC QL (240 tabs / 30 days) repaglinide .5mg, 1mg GENERIC QL (120 tabs / 30 days) SYNJARDY TAB 5‑500MG OTHER QL (120 tabs / 30 days) SYNJARDY TAB 5‑1000MG OTHER QL (60 tabs / 30 days) SYNJARDY TAB 12.5‑500MG OTHER QL (60 tabs / 30 days)



SYNJARDY TAB 12.5‑1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 5‑1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 10‑1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5‑1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 25‑1000MG OTHER QL (30 tabs / 30 days) TRADJENTA OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 2.5‑1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5‑500MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5‑1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 10‑500MG OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 10‑1000MG OTHER QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium GENERIC ibandronate sodium TABS GENERIC B/D pamidronate disodium GENERIC B/D pamidronate inj 30mg GENERIC B/D pamidronate inj 90mg GENERIC B/D risedronate sodium TABS 5mg, 35mg, 150mg GENERIC risedronate sodium TBEC GENERIC zoledronic acid inj 5mg/100ml GENERIC B/D, NM zoledronic inj 4mg/5ml GENERIC B/D, NM

CALCIUM RECEPTOR AGONISTS cinacalcet hcl 30mg, 90mg GENERIC B/D, QL (120 tabs / 30 days),

NM cinacalcet hcl 60mg GENERIC B/D, QL (60 tabs / 30 days), NM SENSIPAR 30mg, 90mg OTHER B/D, QL (120 tabs / 30 days),

NM SENSIPAR 60mg OTHER B/D, QL (60 tabs / 30 days), NM

CHELATING AGENTS CHEMET OTHER DEPEN TITRATABS OTHER JADENU OTHER NM, LA, PA JADENU SPRINKLE OTHER NM, LA, PA kionex sus 15gm/60ml GENERIC sodium polystyrene sulfonate powder GENERIC sodium polystyrene sulfonate susp GENERIC sps susp 15gm/60ml GENERIC trientine hcl GENERIC PA



CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab GENERIC alyacen 1/35 GENERIC amethia GENERIC amethia lo GENERIC apri GENERIC aranelle GENERIC ashlyna GENERIC aubra GENERIC aviane GENERIC balziva GENERIC bekyree GENERIC blisovi 24 fe GENERIC blisovi fe 1.5/30 GENERIC blisovi fe 1/20 GENERIC briellyn GENERIC camila GENERIC camrese lo GENERIC caziant pak GENERIC cryselle-28 GENERIC cyclafem 1/35 GENERIC cyclafem 7/7/7 GENERIC cyred tab GENERIC dasetta 1/35 GENERIC dasetta 7/7/7 GENERIC deblitane GENERIC delyla GENERIC desogestrel & ethinyl estradiol GENERIC desogestrel-ethinyl estradiol (biphasic) GENERIC drospirenone-ethinyl estradiol GENERIC drospirenone-ethinyl estradiol-levomefolate calcium GENERIC ELLA OTHER emoquette GENERIC enpresse-28 GENERIC enskyce GENERIC errin GENERIC estarylla tab 0.25-35 GENERIC ethynodiol diacet & eth estrad GENERIC

37



ethynodiol tab 1-50 GENERIC falmina GENERIC fayosim GENERIC femynor GENERIC gianvi tab 3-0.02mg GENERIC hailey 24 fe GENERIC heather GENERIC incassia GENERIC introvale GENERIC isibloom GENERIC jolessa tab 0.15-0.03 mg GENERIC jolivette GENERIC juleber GENERIC junel 1.5/30 GENERIC junel 1/20 GENERIC junel fe 1.5/30 GENERIC junel fe 1/20 GENERIC junel fe 24 GENERIC kaitlib fe GENERIC kariva GENERIC kelnor 1/35 GENERIC kelnor 1/50 GENERIC kurvelo GENERIC larin 1.5/30 GENERIC larin 1/20 GENERIC larin fe 1.5/30 GENERIC larin fe 1/20 GENERIC larissia tab GENERIC layolis fe GENERIC leena tab GENERIC lessina GENERIC levonest GENERIC levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg

GENERIC

levonor/ethi tab GENERIC levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

GENERIC

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

GENERIC


39


levonorgestrel & eth estradiol GENERIC levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) GENERIC levora 0.15/30-28 GENERIC lomedia 24 fe GENERIC loryna GENERIC low-ogestrel GENERIC lutera GENERIC lyza GENERIC marlissa GENERIC medroxyprogesterone acetate (contraceptive) GENERIC melodetta 24 fe GENERIC mibelas 24 fe GENERIC microgestin 1.5/30 GENERIC microgestin 1/20 GENERIC microgestin fe 1.5/30 GENERIC microgestin fe 1/20 GENERIC mili GENERIC mono-linyah tab 0.25-35 GENERIC mononessa GENERIC myzilra GENERIC necon 0.5/35-28 GENERIC necon 1/50-28 GENERIC necon 7/7/7 GENERIC nikki GENERIC nora-be tab 0.35mg GENERIC norethin acet & estrad-fe GENERIC norethindrone & ethinyl estradiol-fe GENERIC norethindrone (contraceptive) GENERIC norethindrone acet & eth estra GENERIC norgest/ethi tab 0.25/35 GENERIC norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

GENERIC

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

GENERIC

norlyroc GENERIC nortrel 0.5/35 (28) GENERIC nortrel 1/35 GENERIC nortrel 7/7/7 GENERIC NUVARING OTHER



ocella tab 3-0.03mg GENERIC orsythia GENERIC philith GENERIC pimtrea GENERIC pirmella 1/35 GENERIC portia-28 GENERIC previfem GENERIC quasense GENERIC reclipsen GENERIC rivelsa GENERIC setlakin tab GENERIC sharobel GENERIC sprintec 28 GENERIC sronyx GENERIC syeda GENERIC tarina fe 1/20 GENERIC tilia fe GENERIC tri-estarylla GENERIC tri-legest fe GENERIC tri-linyah GENERIC tri-lo marzia GENERIC tri-lo-estarylla GENERIC tri-lo-sprintec GENERIC tri-mili GENERIC tri-previfem GENERIC tri-sprintec GENERIC tri-vylibra GENERIC tri-vylibra lo GENERIC trinessa GENERIC trinessa lo GENERIC trivora-28 GENERIC tulana GENERIC tydemy GENERIC velivet GENERIC vienva GENERIC viorele GENERIC vyfemla GENERIC vylibra GENERIC


41


wymzya fe GENERIC xulane dis 150-35 GENERIC zarah GENERIC zovia 1/35e GENERIC zovia 1/50e GENERIC

ENDOMETRIOSIS danazol CAPS GENERIC SYNAREL OTHER

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN OTHER NM, LA, PA ALDURAZYME OTHER NM, LA, PA CARBAGLU OTHER NM, LA, PA CERDELGA OTHER NM, PA CEREZYME OTHER NM, LA, PA CYSTADANE OTHER NM, LA CYSTAGON OTHER NM, LA, PA FABRAZYME OTHER NM, LA, PA KUVAN OTHER NM, LA, PA levocarnitine (metabolic modifiers) GENERIC B/D LUMIZYME OTHER NM, LA, PA miglustat GENERIC NM, PA NAGLAZYME OTHER NM, LA, PA NITYR OTHER NM, LA, PA ORFADIN OTHER NM, LA, PA sodium phenylbutyrate GENERIC NM, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml OTHER estradiol PTWK; TABS GENERIC estradiol vaginal cream GENERIC estradiol vaginal tab GENERIC estradiol valerate inj GENERIC fyavolv GENERIC jinteli GENERIC norethindrone acetate-ethinyl estradiol GENERIC yuvafem vaginal tablet 10 mcg GENERIC

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS GENERIC dexamethasone CONC; ELIX; SOLN; TABS GENERIC



dexamethasone sodium phosphate GENERIC fludrocortisone acetate TABS GENERIC hydrocortisone TABS GENERIC methylpr ss inj GENERIC B/D methylpred pak 4mg GENERIC methylpred tab 4mg GENERIC B/D methylpred tab 8mg GENERIC B/D methylpred tab 16mg GENERIC B/D methylpred tab 32mg GENERIC B/D methylprednisolone acetate GENERIC B/D pred sod pho sol 5mg/5ml GENERIC B/D prednisolone sodium phosphate SOLN 15mg/5ml GENERIC B/D prednisolone sol 15mg/5ml GENERIC B/D prednisolone sol 25mg/5ml GENERIC B/D prednisone con 5mg/ml GENERIC B/D prednisone pak 5mg GENERIC prednisone pak 10mg GENERIC prednisone sol 5mg/5ml GENERIC B/D prednisone tab 1mg GENERIC B/D prednisone tab 2.5mg GENERIC B/D prednisone tab 5mg GENERIC B/D prednisone tab 10mg GENERIC B/D prednisone tab 20mg GENERIC B/D prednisone tab 50mg GENERIC B/D SOLU‑CORTEF OTHER

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN HYPOKIT OTHER GLUCAGON EMERGENCY KIT OTHER PROGLYCEM SUS 50MG/ML OTHER

MISCELLANEOUS cabergoline GENERIC calcitonin (salmon) GENERIC B/D FORTEO OTHER NM, PA GENOTROPIN OTHER NM, PA GENOTROPIN MINIQUICK OTHER NM, PA INCRELEX OTHER NM, LA, PA KORLYM OTHER NM, LA, PA LUPRON DEP‑PED INJ 7.5MG OTHER NM, PA


43


LUPRON DEP‑PED INJ 11.25MG (3‑MONTH) OTHER NM, PA LUPRON DEPOT‑PED (1‑MONTH OTHER NM, PA LUPRON DEPOT‑PED (3‑MONTH OTHER NM, PA NATPARA OTHER NM, PA octreotide acetate GENERIC NM, PA PROLIA OTHER QL (1 injection / 180 days), NM raloxifene tab 60mg GENERIC SIGNIFOR OTHER NM, LA, PA SOMATULINE DEPOT OTHER NM, PA SOMAVERT OTHER NM, LA, PA TYMLOS OTHER NM, PA XGEVA OTHER NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA OTHER QL (360 tabs / 30 days), PA calcium acetate (phosphate binder) CAPS GENERIC QL (360 caps / 30 days) calcium acetate (phosphate binder) TABS GENERIC QL (360 tabs / 30 days) sevelamer carbonate PACK 2.4gm GENERIC QL (180 packets / 30 days) sevelamer carbonate PACK .8gm GENERIC QL (540 packets / 30 days) sevelamer carbonate TABS GENERIC QL (540 tabs / 30 days)

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab GENERIC norethindrone acetate TABS GENERIC

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levo-t GENERIC levothyroxine sodium TABS GENERIC levoxyl GENERIC liothyronine sodium TABS GENERIC methimazole TABS GENERIC propylthiouracil TABS GENERIC SYNTHROID OTHER unithroid GENERIC

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray GENERIC desmopressin acetate spray refrigerated GENERIC desmopressin acetate tabs GENERIC desmopressin inj 4mcg/ml GENERIC STIMATE OTHER NM

GASTROINTESTINAL ‑ DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS



ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant GENERIC B/D aprepitant pak 80mg & 125mg GENERIC B/D compro supp GENERIC dronabinol GENERIC B/D, QL (60 caps / 30 days) EMEND SUSR OTHER B/D granisetron hcl SOLN GENERIC granisetron hcl TABS GENERIC B/D meclizine hcl TABS GENERIC metoclopramide hcl SOLN; TABS GENERIC metoclopramide hcl inj GENERIC ondansetron hcl TABS GENERIC B/D ondansetron hcl inj GENERIC ondansetron hcl oral soln GENERIC B/D ondansetron odt GENERIC B/D prochlorperazine inj GENERIC prochlorperazine maleate TABS GENERIC prochlorperazine supp GENERIC promethazine hcl SYRP; TABS GENERIC PA; PA if 70 years and older promethazine hcl inj GENERIC PA; PA if 70 years and older scopolamine patch GENERIC QL (10 patches / 30 days), PA;

PA if 70 years and older TRANSDERM‑SCOP OTHER QL (10 patches / 30 days), PA;

PA if 70 years and older ANTISPASMODICS - DRUGS FOR STOMACH SPASMS

dicyclomine hcl cap 10mg GENERIC dicyclomine hcl soln 10mg/5ml GENERIC dicyclomine hcl tab 20mg GENERIC glycopyrrolate tab 1mg GENERIC glycopyrrolate tab 2mg GENERIC

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID famotidine SUSR GENERIC famotidine TABS 20mg, 40mg GENERIC famotidine in nacl GENERIC famotidine inj GENERIC ranitidine hcl TABS 150mg, 300mg GENERIC ranitidine hcl inj GENERIC ranitidine inj GENERIC



ranitidine syrup GENERIC INFLAMMATORY BOWEL DISEASE

APRISO OTHER QL (120 caps / 30 days) balsalazide disodium GENERIC budesonide ec GENERIC CANASA OTHER colocort GENERIC DELZICOL OTHER hydrocortisone (enema) GENERIC mesalamine ENEM GENERIC mesalamine SUPP GENERIC mesalamine TBEC 800mg GENERIC mesalamine w/ cleanser GENERIC sulfasalazine TABS GENERIC sulfasalazine ec GENERIC

LAXATIVES constulose GENERIC enulose GENERIC gavilyte-c GENERIC gavilyte-g GENERIC gavilyte-n/flavor pack GENERIC generlac GENERIC GOLYTELY OTHER lactulose SOLN GENERIC lactulose (encephalopathy) GENERIC MOVIPREP OTHER NULYTELY/FLAVOR PACKS OTHER peg 3350-kcl-sod bicarb-sod chloride-sod sulfate GENERIC peg 3350-potassium chloride-sod bicarbonate-sod chloride

GENERIC

peg 3350/electrolytes GENERIC SUPREP BOWEL PREP KIT OTHER trilyte GENERIC

MISCELLANEOUS alosetron hcl GENERIC PA AMITIZA CAP 8MCG OTHER QL (180 caps / 30 days) AMITIZA CAP 24MCG OTHER QL (60 caps / 30 days) cromolyn sodium (mastocytosis) GENERIC

45



diphenoxylate w/ atropine GENERIC GATTEX OTHER NM, LA, PA LINZESS OTHER QL (30 caps / 30 days) loperamide hcl CAPS GENERIC misoprostol TABS GENERIC MOVANTIK 12.5mg OTHER QL (60 tabs / 30 days) MOVANTIK 25mg OTHER QL (30 tabs / 30 days) RELISTOR SOLN OTHER PA sucralfate TABS GENERIC SYMPROIC OTHER ursodiol CAPS; TABS GENERIC XIFAXAN 550mg OTHER PA

PANCREATIC ENZYMES CREON OTHER ZENPEP OTHER

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT OTHER QL (30 caps / 30 days) esomeprazole magnesium GENERIC QL (30 caps / 30 days) esomeprazole sodium inj GENERIC lansoprazole CPDR GENERIC QL (30 caps / 30 days) omeprazole cap 10mg GENERIC omeprazole cap 20mg GENERIC omeprazole cap 40mg GENERIC pantoprazole sodium SOLR GENERIC pantoprazole sodium tbec GENERIC rabeprazole sodium GENERIC QL (30 tabs / 30 days)

GENITOURINARY ‑ DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE

alfuzosin hcl GENERIC QL (30 tabs / 30 days) dutasteride CAPS GENERIC QL (30 caps / 30 days) dutasteride-tamsulosin hcl GENERIC QL (30 caps / 30 days) finasteride TABS 5mg GENERIC tamsulosin hcl GENERIC

MISCELLANEOUS bethanechol chloride TABS GENERIC potassium citrate (alkalinizer) er tabs GENERIC

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ 25mg OTHER QL (60 tabs / 30 days)


47


MYRBETRIQ 50mg OTHER QL (30 tabs / 30 days) oxybutynin chloride SYRP GENERIC oxybutynin chloride TABS GENERIC oxybutynin chloride TB24 5mg GENERIC QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg GENERIC QL (60 tabs / 30 days) tolterodine tartrate CP24 GENERIC QL (30 caps / 30 days), ST tolterodine tartrate TABS GENERIC ST TOVIAZ OTHER QL (30 tabs / 30 days) trospium chloride TABS GENERIC QL (60 tabs / 30 days) VESICARE OTHER QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal GENERIC metronidazole vaginal GENERIC terconazole vaginal GENERIC vandazole GENERIC

HEMATOLOGIC ‑ DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN OTHER ELIQUIS OTHER ELIQUIS STARTER PACK OTHER enoxaparin sodium GENERIC fondaparinux sodium GENERIC heparin sod (porcine) in d5w GENERIC heparin sod inj 1000/ml GENERIC B/D heparin sod inj 5000/ml GENERIC B/D heparin sod inj 10000/ml GENERIC B/D heparin sod inj 20000/ml GENERIC B/D HEPARIN SODIUM/NACL 0.45% OTHER jantoven GENERIC PRADAXA OTHER warfarin sodium GENERIC XARELTO OTHER XARELTO STARTER PACK OTHER

HEMATOPOIETIC GROWTH FACTORS GRANIX OTHER NM, PA NEUPOGEN OTHER NM, PA PROCRIT OTHER NM, PA

MISCELLANEOUS



anagrelide hcl GENERIC BERINERT OTHER QL (24 boxes / 30 days), NM, LA,

PA cilostazol GENERIC DROXIA OTHER ENDARI OTHER NM, LA, PA FIRAZYR OTHER QL (9 syringes / 30 days), NM,

PA HAEGARDA 2000unit OTHER QL (30 vials / 30 days), NM, LA,

PA HAEGARDA 3000unit OTHER QL (20 vials / 30 days), NM, LA,

PA pentoxifylline TBCR GENERIC PROMACTA PACK OTHER QL (360 packets / 30 days), NM,

LA, PA PROMACTA TABS 12.5mg OTHER QL (360 tabs / 30 days), NM, LA,

PA PROMACTA TABS 25mg OTHER QL (180 tabs / 30 days), NM, LA,



PA tranexamic acid SOLN; TABS GENERIC

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole GENERIC BRILINTA OTHER clopidogrel tab 75mg GENERIC prasugrel hcl GENERIC ZONTIVITY OTHER

IMMUNOLOGIC AGENTS ‑ DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRI-TIS HUMIRA 10mg/0.1ml, 20mg/0.2ml OTHER QL (2 injections / 28 days), NM,

PA HUMIRA 40mg/0.4ml OTHER QL (6 injections / 28 days), NM,

PA HUMIRA INJ 10MG/0.2ML OTHER QL (2 syringes / 28 days), NM,

PA


49


HUMIRA KIT 20MG/0.4ML OTHER QL (2 syringes / 28 days), NM, PA

HUMIRA KIT 40MG/0.8ML OTHER QL (6 syringes / 28 days), NM, PA

HUMIRA PEDIATRIC CROHNS DISEASE OTHER NM, PA HUMIRA PEN OTHER QL (6 pens / 28 days), NM, PA HUMIRA PEN CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ PS/UV STARTER OTHER NM, PA HUMIRA PEN‑PS/UV STARTER OTHER NM, PA hydroxychloroquine sulfate GENERIC leflunomide TABS GENERIC methotrexate sodium tabs GENERIC REMICADE OTHER NM, PA XATMEP OTHER B/D XELJANZ OTHER QL (60 tabs / 30 days), NM, PA XELJANZ XR OTHER QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINS BIVIGAM OTHER NM, PA CARIMUNE NANOFILTERED OTHER NM, PA FLEBOGAMMA DIF OTHER NM, PA GAMASTAN S/D OTHER B/D, NM GAMMAGARD LIQUID OTHER NM, PA GAMMAGARD S/D OTHER NM, PA GAMMAKED OTHER NM, PA GAMMAPLEX OTHER NM, PA GAMMAPLEX 10GM/100ML OTHER NM, PA GAMUNEX‑C OTHER NM, PA OCTAGAM OTHER NM, PA PANZYGA OTHER NM, PA PRIVIGEN OTHER NM, PA

IMMUNOMODULATORS ACTIMMUNE OTHER NM, LA, PA ARCALYST OTHER NM, PA INTRON‑A INJ 10MU OTHER B/D, NM INTRON‑A INJ 18MU OTHER B/D, NM INTRON‑A INJ 25MU OTHER B/D, NM INTRON‑A INJ 50MU OTHER B/D, NM



IMMUNOSUPPRESSANTS azathioprine TABS GENERIC B/D BENLYSTA OTHER NM, PA cyclosporine CAPS; SOLN GENERIC B/D cyclosporine modified (for microemulsion) GENERIC B/D gengraf GENERIC B/D mycophenolate mofetil CAPS; SUSR; TABS GENERIC B/D mycophenolate sodium tbec GENERIC B/D NULOJIX OTHER B/D RAPAMUNE SOLN OTHER B/D SANDIMMUNE SOLN 100mg/ml OTHER B/D sirolimus SOLN; TABS GENERIC B/D tacrolimus CAPS GENERIC B/D ZORTRESS TAB 0.5MG OTHER B/D ZORTRESS TAB 0.25MG OTHER B/D ZORTRESS TAB 0.75MG OTHER B/D ZORTRESS TAB 1MG OTHER B/D

VACCINES ACTHIB OTHER ADACEL OTHER BCG VACCINE OTHER BEXSERO OTHER BOOSTRIX OTHER DAPTACEL OTHER DIPHTHERIA/TETANUS TOXOID OTHER B/D ENGERIX‑B SUSP OTHER B/D GARDASIL 9 OTHER HAVRIX OTHER HIBERIX OTHER IMOVAX RABIES (H.D.C.V.) OTHER B/D INFANRIX OTHER IPOL INACTIVATED IPV OTHER IXIARO OTHER KINRIX OTHER M‑M‑R II OTHER MENACTRA OTHER MENVEO OTHER PEDIARIX OTHER


51


PEDVAX HIB OTHER PENTACEL OTHER PROQUAD OTHER QUADRACEL OTHER RABAVERT OTHER B/D RECOMBIVAX HB OTHER B/D ROTARIX OTHER ROTATEQ OTHER SHINGRIX OTHER QL (2 vials per lifetime) TDVAX OTHER B/D TENIVAC OTHER B/D TRUMENBA OTHER TWINRIX INJ OTHER TYPHIM VI OTHER VAQTA OTHER VARIVAX OTHER YF‑VAX OTHER ZOSTAVAX OTHER QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES

klor-con 8 GENERIC klor-con 10 GENERIC klor-con m10 GENERIC klor-con m15 GENERIC klor-con m20 GENERIC klor-con pak 20meq GENERIC klor-con spr cap 8meq GENERIC klor-con spr cap 10meq GENERIC MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

OTHER

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

GENERIC

MAGNESIUM SULFATE IN D5W OTHER magnesium sulfate in dextrose GENERIC magnesium sulfate inj 50% GENERIC potassium chloride CPCR GENERIC potassium chloride PACK GENERIC potassium chloride SOLN 10%, 20% GENERIC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

Formulary ID 00019346 v9 04/01/2019 52


potassium chloride TBCR GENERIC potassium chloride microencapsulated crystals er GENERIC potassium chloride tab cr 10 meq GENERIC sodium chloride SOLN 2.5meq/ml GENERIC sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln GENERIC tpn electrolytes OTHER B/D

IV NUTRITION AMINOSYN OTHER B/D AMINOSYN 7%/ELECTROLYTES OTHER B/D aminosyn 8.5%/electrolyte GENERIC B/D aminosyn ii 8.5%/electrol GENERIC B/D AMINOSYN II INJ 8.5% OTHER B/D AMINOSYN II INJ 10% OTHER B/D AMINOSYN M OTHER B/D AMINOSYN‑HBC OTHER B/D AMINOSYN‑PF 7% OTHER B/D AMINOSYN‑PF INJ 10% OTHER B/D AMINOSYN‑RF OTHER B/D CLINIMIX 4.25%/DEXTROSE 5% OTHER B/D CLINIMIX 4.25%/DEXTROSE 25% OTHER B/D CLINIMIX 5%/DEXTROSE 15% OTHER B/D CLINIMIX 5%/DEXTROSE 20% OTHER B/D CLINIMIX 5%/DEXTROSE 25% OTHER B/D CLINIMIX INJ 4.25/D10 OTHER B/D FREAMINE HBC 6.9% OTHER B/D FREAMINE III OTHER B/D hepatamine GENERIC B/D INTRALIPID 30% OTHER B/D intralipid inj 20% GENERIC B/D NEPHRAMINE OTHER B/D nutrilipid inj 20% GENERIC B/D premasol 6% GENERIC B/D premasol 10% GENERIC B/D PROCALAMINE OTHER B/D PROSOL OTHER B/D TRAVASOL OTHER B/D TROPHAMINE INJ 10% OTHER B/D

IV REPLACEMENT SOLUTIONS


53


dextrose 2.5%/nacl 0.45% GENERIC dextrose 5% GENERIC DEXTROSE 5% /ELECTROLYTE OTHER dextrose 5%/nacl 0.2% GENERIC DEXTROSE 5%/NACL 0.3% OTHER dextrose 5%/nacl 0.9% GENERIC dextrose 5%/nacl 0.33% GENERIC dextrose 5%/nacl 0.45% GENERIC dextrose 5%/nacl 0.225% GENERIC dextrose 5%/potassium chl GENERIC dextrose 10% flex contain GENERIC DEXTROSE 10%/NACL 0.2% OTHER dextrose 10%/nacl 0.45% GENERIC dextrose 50% GENERIC dextrose in lactated ringers GENERIC dextrose inj 70% GENERIC IONOSOL‑MB/DEXTROSE 5% OTHER ISOLYTE P OTHER ISOLYTE S OTHER kcl0.15%/d5w/nacl0.2% GENERIC KCL 0.3%/D5W/NACL 0.9% OTHER kcl 0.3%/d5w/nacl 0.45% GENERIC kcl 0.15%/d5w/nacl 0.9% GENERIC KCL 0.15%/D5W/NACL 0.225% OTHER kcl 0.075%/d5w/nacl 0.45% GENERIC kcl/d5w inj 0.3% GENERIC kcl/d5w/nacl inj 0.22%/0.45% GENERIC kcl/d5w/nacl inj .15/.33% GENERIC kcl/d5w/nacl inj .15/.45% GENERIC kcl/nacl inj 0.3-0.9 GENERIC kcl/nacl inj 0.15%-0.9% GENERIC lactated ringer’s GENERIC NORMOSOL‑M IN D5W OTHER NORMOSOL‑R OTHER NORMOSOL‑R IN D5W OTHER PLASMA‑LYTE A OTHER PLASMA‑LYTE‑148 OTHER pot chloride inj 2meq/ml GENERIC



potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

GENERIC

potassium chloride in nacl GENERIC sodium chloride SOLN 3%, 5% GENERIC sodium chloride 0.45% GENERIC sodium chloride inj 0.9% GENERIC

VITAMINS calcitriol CAPS GENERIC B/D calcitriol inj GENERIC B/D calcitriol oral soln 1 mcg/ml GENERIC B/D M‑NATAL PLUS OTHER NIVA‑PLUS OTHER O‑CAL FA OTHER paricalcitol CAPS GENERIC B/D PNV FOLIC ACID + IRON MUL OTHER PNV PRENATAL PLUS OTHER PNV PRENATAL TAB PLUS OTHER PRENATAL OTHER PRENATAL PLUS OTHER PRENATAL PLUS LOW IRON OTHER PREPLUS OTHER RAYALDEE OTHER TRICARE OTHER VOL‑PLUS OTHER

OPHTHALMIC ‑ DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc GENERIC blephamide OINT GENERIC neomycin-polymy-dexameth GENERIC neomycin-polymyxin-hc (ophth) GENERIC sulfacetamide sod-prednisolone GENERIC TOBRADEX OINT OTHER TOBRADEX ST OTHER tobramycin-dexamethasone GENERIC ZYLET OTHER

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE OTHER


55


bacitracin (ophthalmic) GENERIC bacitracin-polymyxin b (ophth) GENERIC BESIVANCE OTHER CILOXAN OINT OTHER ciprofloxacin hcl (ophth) GENERIC erythromycin (ophth) GENERIC gatifloxacin (ophth) GENERIC gentak GENERIC gentamicin sulfate soln (ophth) GENERIC MOXEZA OTHER moxifloxacin hcl (ophth) GENERIC NATACYN OTHER neomycin-bacitracin zn-polymyxin GENERIC neomycin-polymyxin-gramicidin GENERIC ofloxacin (ophth) GENERIC polymyxin b-trimethoprim GENERIC sulfacetamide sodium (ophth) GENERIC tobramycin (ophth) GENERIC trifluridine GENERIC ZIRGAN OTHER

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX OTHER bromfenac sodium (ophth) GENERIC BROMSITE OTHER dexamethasone sodium phosphate (ophth) GENERIC diclofenac sodium (ophth) GENERIC DUREZOL OTHER fluorometholone GENERIC flurbiprofen sodium GENERIC ILEVRO OTHER ketorolac tromethamine (ophth) GENERIC LOTEMAX OTHER prednisolone acetate (ophth) GENERIC prednisolone sodium phosphate (ophth) GENERIC PROLENSA OTHER

ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine drop 0.05% GENERIC BEPREVE OTHER



cromolyn sodium (ophth) GENERIC LASTACAFT OTHER olopatadine hcl 0.2% GENERIC PAZEO OTHER

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% OTHER AZOPT OTHER betaxolol hcl (ophth) GENERIC BETOPTIC‑S OTHER brimonidine sol 0.2% GENERIC brimonidine sol 0.15% GENERIC carteolol hcl (ophth) GENERIC COMBIGAN OTHER dorzolamide hcl GENERIC dorzolamide hcl-timolol maleate GENERIC latanoprost SOLN GENERIC levobunolol hcl GENERIC LUMIGAN OTHER PHOSPHOLINE IODIDE OTHER pilocarpine hcl SOLN GENERIC SIMBRINZA OTHER timolol maleate (ophth) soln GENERIC timolol maleate gel GENERIC timolol maleate ophth soln 0.5% (once-daily) GENERIC TRAVATAN Z OTHER

MISCELLANEOUS CYSTARAN OTHER NM, LA, PA proparacaine hcl SOLN GENERIC RESTASIS OTHER QL (60 single use vials / 30 days) RESTASIS MULTIDOSE OTHER QL (1 bottle / 30 days)

RESPIRATORY ‑ DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPTA OTHER QL (60 blisters / 30 days) BEVESPI AEROSPHERE OTHER QL (1 inhaler / 30 days) COMBIVENT RESPIMAT OTHER QL (2 inhalers / 30 days) ipratropium-albuterol nebu GENERIC B/D TRELEGY ELLIPTA OTHER QL (60 blisters / 30 days)

ANTICHOLINERGICS - DRUGS TO TREAT COPD


57


ATROVENT HFA OTHER QL (2 inhalers / 30 days) INCRUSE ELLIPTA OTHER QL (30 blisters / 30 days) ipratropium bromide SOLN GENERIC B/D ipratropium bromide (nasal) GENERIC

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine spr 0.1% GENERIC azelastine spr 0.15% GENERIC cetirizine syrup GENERIC cyproheptadine hcl SYRP; TABS GENERIC PA; PA if 70 years and older diphenhydramine hcl inj 50mg/ml GENERIC hydroxyzine hcl SYRP; TABS GENERIC PA; PA if 70 years and older hydroxyzine hcl inj GENERIC PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg GENERIC PA; PA if 70 years and older levocetirizine dihydrochloride GENERIC

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers / 30 days); (ge

neric of Proair HFA) albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers / 30 days); (ge

neric of Ventolin HFA) albuterol sulfate NEBU GENERIC B/D albuterol sulfate SYRP GENERIC albuterol sulfate TABS GENERIC albuterol sulfate TB12 GENERIC levalbuterol hcl NEBU GENERIC B/D levalbuterol hcl soln nebu conc 1.25 mg/0.5ml GENERIC B/D levalbuterol tartrate hfa GENERIC QL (2 inhalers / 30 days) SEREVENT DISKUS OTHER QL (60 inhalations / 30 days) terbutaline sulfate TABS GENERIC VENTOLIN HFA OTHER QL (2 inhalers / 30 days)

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS GENERIC zafirlukast GENERIC

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sod neb 20mg/2ml GENERIC B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20% GENERIC B/D ARALAST NP OTHER NM, LA, PA DALIRESP OTHER



epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml GENERIC (generic of Adrenaclick) ESBRIET OTHER NM, PA KALYDECO OTHER NM, PA OFEV OTHER NM, PA ORKAMBI OTHER NM, PA PROLASTIN‑C OTHER NM, LA, PA PULMOZYME OTHER NM, PA SYMDEKO OTHER NM, LA, PA theo-24 GENERIC theophylline GENERIC XOLAIR OTHER NM, LA, PA ZEMAIRA OTHER NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide (nasal) GENERIC QL (3 bottles / 30 days) fluticasone propionate (nasal) GENERIC QL (1 bottle / 30 days)

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA OTHER QL (30 inhalations / 30 days) budesonide (inhalation) .25mg/2ml, .5mg/2ml GENERIC B/D FLOVENT DISKUS 50mcg/blist, 100mcg/blist OTHER QL (120 inhalations / 30 days) FLOVENT DISKUS 250mcg/blist OTHER QL (240 inhalations / 30 days) FLOVENT HFA OTHER QL (2 inhalers / 30 days) PULMICORT FLEXHALER OTHER QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS OTHER QL (60 inhalations / 30 days) ADVAIR HFA OTHER QL (1 inhaler / 30 days) BREO ELLIPTA OTHER QL (60 blisters / 30 days) SYMBICORT OTHER QL (1 inhaler / 30 days)

TOPICAL ‑ DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE

amnesteem GENERIC PA avita GENERIC PA benzoyl peroxide-erythromycin GENERIC claravis GENERIC PA clindacin-p GENERIC clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB

GENERIC

ery pad 2% GENERIC erythromycin (acne aid) GENERIC


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isotretinoin CAPS GENERIC PA myorisan GENERIC PA sulfacetamide sodium (acne) GENERIC tretinoin CREA GENERIC PA tretinoin GEL .01%, .025% GENERIC PA zenatane GENERIC PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) GENERIC mupirocin OINT GENERIC silver sulfadiazine CREA GENERIC ssd GENERIC SULFAMYLON CREA OTHER

DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; GEL; SUSP GENERIC ciclopirox shampoo 1% GENERIC clotrimazole (topical) GENERIC clotrimazole w/ betamethasone CREA GENERIC ketoconazole cream GENERIC nyamyc GENERIC nystatin (topical) GENERIC nystop GENERIC

DERMATOLOGY, ANTIPSORIATICS acitretin GENERIC PA calcipotriene CREA; OINT GENERIC QL (120 gm / 30 days), PA calcipotriene SOLN GENERIC QL (120 mL / 30 days), PA calcitrene GENERIC QL (120 gm / 30 days), PA tazarotene CREA GENERIC PA TAZORAC CREA .05% OTHER PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo GENERIC selenium sulfide LOTN GENERIC

DERMATOLOGY, CORTICOSTEROIDS ala-cort GENERIC alclometasone dipropionate GENERIC betamethasone dipropionate (topical) GENERIC betamethasone dipropionate augmented GENERIC betamethasone valerate CREA; LOTN; OINT GENERIC ENSTILAR OTHER PA



fluocinolone acetonide CREA; OIL; OINT; SOLN GENERIC fluocinolone acetonide oil body GENERIC fluocinonide CREA .05% GENERIC fluocinonide GEL GENERIC fluocinonide SOLN GENERIC fluocinonide emulsified base GENERIC fluticasone propionate CREA; OINT GENERIC halobetasol propionate CREA; OINT GENERIC hydrocortisone (topical) CREA GENERIC hydrocortisone (topical) LOTN GENERIC hydrocortisone (topical) OINT 2.5% GENERIC hydrocortisone butyrate cream 0.1% GENERIC hydrocortisone butyrate oint 0.1% GENERIC hydrocortisone valerate GENERIC mometasone furoate CREA; OINT; SOLN GENERIC texacort soln 2.5% GENERIC triamcinolone acetonide (topical) CREA; LOTN; OINT GENERIC

DERMATOLOGY, LOCAL ANESTHETICS glydo GENERIC QL (30 mL / 30 days), PA lidocaine PTCH GENERIC QL (3 patches / 1 day), PA lidocaine hcl GEL GENERIC QL (30 mL / 30 days), PA lidocaine hcl SOLN 4% GENERIC QL (50 mL / 30 days), PA lidocaine oint 5% GENERIC QL (50 grams / 30 days), PA lidocaine-prilocaine GENERIC QL (30 grams / 30 days), PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN GENERIC diclofenac sodium (topical) 1% gel GENERIC PA fluorouracil (topical) CREA 5% GENERIC fluorouracil (topical) SOLN GENERIC imiquimod CREA 5% GENERIC metronidazole (topical) CREA; LOTN GENERIC metronidazole gel 0.75% GENERIC PANRETIN OTHER PICATO .05% OTHER QL (2 tubes / 30 days) PICATO .015% OTHER QL (3 tubes / 30 days) podofilox SOLN GENERIC procto-med hc GENERIC procto-pak GENERIC


proctosol hc cre 2.5% GENERIC proctozone-hc GENERIC rosadan cre 0.75% GENERIC tacrolimus (topical) GENERIC TARGRETIN GEL OTHER NM, PA VALCHLOR OTHER NM, LA, PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion GENERIC permethrin cre 5% GENERIC

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% GENERIC REGRANEX OTHER PA SANTYL OTHER sodium chlor sol 0.9% irr GENERIC water for irrigation, sterile GENERIC

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl GENERIC chlorhexidine gluconate (mouth-throat) GENERIC clotrimazole LOZG GENERIC lidocaine hcl (mouth-throat) GENERIC nystatin (mouth-throat) GENERIC paroex sol 0.12% GENERIC periogard GENERIC pilocarpine hcl (oral) GENERIC triamcinolone acetonide (mouth) GENERIC

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) GENERIC CIPRODEX OTHER flac GENERIC fluocinolone acetonide (otic) GENERIC neomycin-polymyxin-hc (otic) GENERIC ofloxacin (otic) GENERIC


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Index of drugs Drug Name Page Number

abacavir sulfate 6 abacavir sulfate-lamivudine 7 abacavir sulfate-lamivudine-zidovudine 7 ABELCET 5 ABILIFY MAINTENA 27 abiraterone acetate 13 ABRAXANE 12 acamprosate calcium 32 acarbose 34 acebutolol hcl CAPS 19 acetaminophen w/ codeine 300-15mg 1 acetaminophen w/ codeine 300-30mg 1 acetaminophen w/ codeine 300-60mg 1 acetaminophen w/ codeine soln 1 acetazolamide CP12; TABS 21 acetic acid .25% 61 acetic acid (otic) 61 acetylcysteine SOLN 10%, 20% 57 acitretin 59 ACTHIB 50 ACTIMMUNE 49 acyclovir CAPS; SUSP; TABS 8 acyclovir sodium 8 ADACEL 50 ADAGEN 41 adefovir dipivoxil 8 ADEMPAS 22 adriamycin 11 adrucil 12 adrucil inj 12 ADVAIR DISKUS 58 ADVAIR HFA 58 AFINITOR 14 AFINITOR DISPERZ 2mg 14 AFINITOR DISPERZ 3mg 14 AFINITOR DISPERZ 5mg 14 ala-cort 59 albendazole TABS 4 ALBENZA 4 albuterol sulfate AERS 108mcg/act 57 albuterol sulfate AERS 108mcg/act 57 albuterol sulfate NEBU 57 albuterol sulfate SYRP 57 albuterol sulfate TABS 57

Drug Name Page Number

albuterol sulfate TB12 57 alclometasone dipropionate 59 ALCOHOL SWABS 33 ALDURAZYME 41 ALECENSA 14 alendronate sodium 36 alfuzosin hcl 46 ALIMTA 12 ALINIA 4 allopurinol tab 1 alosetron hcl 45 ALPHAGAN P SOL 0.1% 56 alprazolam tab 0.5mg 22 alprazolam tab 0.25mg 22 alprazolam tab 1mg 22 alprazolam tab 2 mg 22 ALREX 55 altavera tab 37 ALUNBRIG 14 alyacen 1/35 37 amantadine hcl CAPS 26 amantadine hcl SYRP; TABS 27 AMBISOME 5 amethia 37 amethia lo 37 amikacin sulfate SOLN 3 amiloride hcl TABS 21 amiloride & hydrochlorothiazide 21 AMINOSYN 52 AMINOSYN 7%/ELECTROLYTES 52 aminosyn 8.5%/electrolyte 52 AMINOSYN‑HBC 52 aminosyn ii 8.5%/electrol 52 AMINOSYN II INJ 8.5% 52 AMINOSYN II INJ 10% 52 AMINOSYN M 52 AMINOSYN‑PF 7% 52 AMINOSYN‑PF INJ 10% 52 AMINOSYN‑RF 52 amiodarone hcl soln 18 amiodarone tab 100mg 18 amiodarone tab 200mg 18 amiodarone tab 400mg 18 AMITIZA CAP 8MCG 45

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Drug Name Page Number AMITIZA CAP 24MCG 45 amitriptyline hcl TABS 25 amlodipine besylate-benazepril hcl cap 2.5-10 mg .16 amlodipine besylate-benazepril hcl cap 5-10 mg 16 amlodipine besylate-benazepril hcl cap 5-20 mg 16 amlodipine besylate-benazepril hcl cap 5-40 mg 17 amlodipine besylate-benazepril hcl cap 10-20 mg 17 amlodipine besylate-benazepril hcl cap 10-40 mg 17 amlodipine besylate-olmesartan medoxomil 17 amlodipine besylate TABS 20 amlodipine besylate-valsartan tab 17 amlodipine-valsartan-hydrochlorothiazide tab 17 ammonium lactate CREA; LOTN 60 amnesteem 58 amoxapine 25 amoxicillin 10 amoxicillin & pot clavulanate 10 amphetamine-dextroamphetamine cap sr 24hr 5 mg 29 amphetamine-dextroamphetamine cap sr 24hr 10 mg 30 amphetamine-dextroamphetamine cap sr 24hr 15 mg 30 amphetamine-dextroamphetamine cap sr 24hr 20 mg 30 amphetamine-dextroamphetamine cap sr 24hr 25 mg 30 amphetamine-dextroamphetamine cap sr 24hr 30 mg 30 amphetamine-dextroamphetamine tab 5 mg 30 amphetamine-dextroamphetamine tab 7.5 mg 30 amphetamine-dextroamphetamine tab 10 mg 30 amphetamine-dextroamphetamine tab 12.5 mg 30 amphetamine-dextroamphetamine tab 15 mg 30 amphetamine-dextroamphetamine tab 20 mg 30 amphetamine-dextroamphetamine tab 30 mg 30 amphotericin b SOLR 5 ampicillin cap 500mg 10 ampicillin inj 10 ampicillin sodium 10 ampicillin & sulbactam sodium 10 AMPYRA 32 ANADROL‑50 33 anagrelide hcl 48 anastrozole TABS 13 ANDRODERM 33 ANORO ELLIPTA 56

Drug Name Page Number APOKYN 27 aprepitant 44 aprepitant pak 80mg & 125mg 44 apri 37 APRISO 45 APTIOM 200mg 22 APTIOM 400mg 22 APTIOM 600mg, 800mg 22 APTIVUS 6 ARALAST NP 57 aranelle 37 ARCALYST 49 aripiprazole odt 27 aripiprazole oral solution 1 mg/ml 27 aripiprazole tab 27 ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml 27 ARISTADA 1064mg/3.9ml 27 ARISTADA INITIO 27 armodafinil 50mg 32 armodafinil 150mg, 200mg, 250mg 32 ARNUITY ELLIPTA 58 ashlyna 37 aspirin-dipyridamole 48 atazanavir sulfate 6 atenolol & chlorthalidone 19 atenolol TABS 19 atomoxetine hcl 10mg, 18mg, 25mg 30 atomoxetine hcl 40mg 30 atomoxetine hcl 60mg, 80mg, 100mg 30 atorvastatin calcium TABS 18 atovaquone-proguanil hcl 6 atovaquone SUSP 4 ATRIPLA 7 ATROVENT HFA 57 aubra 37 AURYXIA 43 AUSTEDO 6mg 31 AUSTEDO 9mg, 12mg 31 AVASTIN 12 aviane 37 avita 58 azacitidine 12 AZACTAM/DEX INJ 4 AZACTAM IN ISO‑OSMOTIC DE 4 AZASITE 54 azathioprine TABS 50

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Drug Name Page Number azelastine drop 0.05% 55 azelastine spr 0.1% 57 azelastine spr 0.15% 57 azithromycin PACK; SOLR; SUSR; TABS 10 AZOPT 56 aztreonam 4 bacitracin (ophthalmic) 55 bacitracin-polymyxin b (ophth) 55 bacitracin-poly-neomycin-hc 54 baclofen TABS 10mg, 20mg 32 balsalazide disodium 45 balziva 37 BANZEL SUS 40MG/ML 22 BANZEL TAB 200MG 23 BANZEL TAB 400MG 23 BARACLUDE SOLN 8 BASAGLAR KWIKPEN 33 BCG VACCINE 50 BD ULTRAFINE INSULIN SYRINGE 33 BD ULTRAFINE/NANO PEN NEEDLES 33 bekyree 37 benazepril hcl TABS 17 benazepril & hydrochlorothiazide 17 BENDEKA 11 BENLYSTA 50 benzoyl peroxide-erythromycin 58 benztropine mesylate inj 27 benztropine mesylate tab 0.5mg 27 benztropine mesylate tab 1mg 27 benztropine mesylate tab 2mg 27 BEPREVE 55 BERINERT 48 BESIVANCE 55 betamethasone dipropionate augmented 59 betamethasone dipropionate (topical) 59 betamethasone valerate CREA; LOTN; OINT 59 BETASERON 32 betaxolol hcl 19 betaxolol hcl (ophth) 56 bethanechol chloride TABS 46 BETOPTIC‑S 56 BEVESPI AEROSPHERE 56 bexarotene 16 BEXSERO 50 bicalutamide 13 BICILLIN L‑A 10 BIKTARVY 7

Drug Name Page Number BILTRICIDE 4 bisoprolol fumarate 19 bisoprolol & hydrochlorothiazide 19 BIVIGAM 49 bleomycin sulfate 12 blephamide OINT 54 blisovi 24 fe 37 blisovi fe 1.5/30 37 blisovi fe 1/20 37 BOOSTRIX 50 BORTEZOMIB 12 BOSULIF 14 BRAFTOVI 14 BREO ELLIPTA 58 briellyn 37 BRILINTA 48 brimonidine sol 0.2% 56 brimonidine sol 0.15% 56 BRIVIACT INJ 50MG/5ML 23 BRIVIACT SOL 10MG/ML 23 BRIVIACT TAB 10MG 23 BRIVIACT TAB 25MG 23 BRIVIACT TAB 50MG 23 BRIVIACT TAB 75MG 23 BRIVIACT TAB 100MG 23 bromfenac sodium (ophth) 55 bromocriptine mesylate CAPS; TABS 27 BROMSITE 55 budesonide ec 45 budesonide (inhalation) .25mg/2ml, .5mg/2ml 58 bumetanide inj 0.25/ml 21 bumetanide tab 21 buprenorphine hcl-naloxone hcl sl 32 buprenorphine hcl SUBL 32 buprenorphine patch 2 bupropion hcl (smoking deterrent) 32 bupropion hcl TABS 25 bupropion hcl TB12 25 bupropion hcl TB24 150mg, 300mg 25 buspirone hcl TABS 22 butorphanol tartrate SOLN 1mg/ml, 2mg/ml 2 BUTRANS 2 BYDUREON BCISE 33 BYDUREON INJ 33 BYDUREON PEN 33 BYETTA 33 BYSTOLIC 2.5mg, 5mg, 10mg 19

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Drug Name Page Number BYSTOLIC 20mg 19 cabergoline 42 CABOMETYX 14 calcipotriene CREA; OINT 59 calcipotriene SOLN 59 calcitonin (salmon) 42 calcitrene 59 calcitriol CAPS 54 calcitriol inj 54 calcitriol oral soln 1 mcg/ml 54 calcium acetate (phosphate binder) CAPS 43 calcium acetate (phosphate binder) TABS 43 CALQUENCE 14 camila 37 camrese lo 37 CANASA 45 candesartan cilexetil 18 candesartan cilexetil-hydrochlorothiazide 17 CAPRELSA 14 captopril & hydrochlorothiazide 17 captopril TABS 17 CARBAGLU 41 carbamazepine CHEW; CP12; SUSP; TABS; TB12 23 carbidopa-levodopa 27 carbidopa/levodopa/entacapone 27 carboplatin 16 CARIMUNE NANOFILTERED 49 carisoprodol TABS 350mg 32 carteolol hcl (ophth) 56 cartia xt 20 carvedilol 19 caspofungin acetate 5 CAYSTON 4 caziant pak 37 cefaclor 9 cefaclor er tab 500mg 9 cefadroxil 9 CEFAZOLIN IN DEXTROSE 2GM/100ML‑4% 9 cefazolin inj 9 cefazolin sodium 1 gm/50ml 9 cefazolin sodium SOLR 1gm, 20gm 9 cefdinir 9 cefepime for inj 9 cefixime 9 cefotaxime sodium 9 cefoxitin for inj 9 cefpodoxime proxetil 9

Drug Name Page Number cefprozil 9 CEFTAZIDIME/DEXTROSE 9 ceftazidime SOLR 9 ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg 9 cefuroxime axetil 9 cefuroxime sodium 9 celecoxib CAPS 50mg 1 celecoxib CAPS 100mg 1 celecoxib CAPS 200mg 1 celecoxib CAPS 400mg 1 CELONTIN 23 cephalexin CAPS 250mg, 500mg 9 cephalexin SUSR 9 CERDELGA 41 CEREZYME 41 cetirizine syrup 57 cevimeline hcl 61 CHANTIX 32 CHANTIX CONTINUING MONTH 32 CHANTIX STARTER PACK 32 CHEMET 36 chlorhexidine gluconate (mouth-throat) 61 chloroquine phosphate TABS 6 chlorothiazide tabs 21 chlorpromazine hcl TABS 27 chlorpromazine inj 28 chlorthalidone 21 cholestyramine 19 cholestyramine light 19 ciclopirox CREA; GEL; SUSP 59 ciclopirox shampoo 1% 59 cilostazol 48 CILOXAN OINT 55 CIMDUO 7 cinacalcet hcl 30mg, 90mg 36 cinacalcet hcl 60mg 36 CIPRODEX 61 ciprofloxacin hcl (ophth) 55 ciprofloxacin hcl tab 10 ciprofloxacin in d5w 10 ciprofloxacin SUSR 10 cisplatin 16 citalopram hydrobromide 25 claravis 58 clarithromycin er 10 clarithromycin for susp 10

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Drug Name Page Number clarithromycin TABS 10 clindacin-p 58 clindamycin cap 75mg 4 clindamycin cap 300 mg 4 clindamycin hcl cap 150 mg 4 clindamycin phosphate in d5w 4 clindamycin phosphate inj 4 CLINDAMYCIN PHOSPHATE IN NACL 4 clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB 58 clindamycin phosphate vaginal 47 clindamycin soln 75mg/5ml 4 CLINIMIX 4.25%/DEXTROSE 5% 52 CLINIMIX 4.25%/DEXTROSE 25% 52 CLINIMIX 5%/DEXTROSE 15% 52 CLINIMIX 5%/DEXTROSE 20% 52 CLINIMIX 5%/DEXTROSE 25% 52 CLINIMIX INJ 4.25/D10 52 clobazam 23 clomipramine hcl CAPS 25 clonazepam TABS 2mg 23 clonazepam TABS .5mg, 1mg 23 clonazepam TBDP 2mg 23 clonazepam TBDP .125mg, .25mg, .5mg, 1mg 23 clonidine hcl ptwk 21 clonidine hcl TABS 21 clopidogrel tab 75mg 48 clorazepate dipotassium 23 clotrimazole LOZG 61 clotrimazole (topical) 59 clotrimazole w/ betamethasone CREA 59 clozapine odt 12.5mg, 25mg 28 clozapine odt 100mg 28 clozapine odt 150mg 28 clozapine odt 200mg 28 clozapine tab 25mg 28 clozapine tab 50mg 28 clozapine tab 100mg 28 clozapine tab 200mg 28 COARTEM 6 colchicine w/ probenecid 1 COLCRYS 1 colesevelam hcl 19 colestipol hcl gran 19 colestipol hcl pack 19 colestipol hcl tabs 19 colistimethate sodium SOLR 4

Drug Name Page Number colocort 45 COMBIGAN 56 COMBIVENT RESPIMAT 56 COMETRIQ 14 COMPLERA 7 compro supp 44 constulose 45 COPIKTRA 14 CORLANOR 21 cortisone acetate TABS 41 COTELLIC 14 COUMADIN 47 CREON 46 CRIXIVAN 6 cromolyn sodium (mastocytosis) 45 cromolyn sodium (ophth) 56 cromolyn sod neb 20mg/2ml 57 cryselle-28 37 cyclafem 1/35 37 cyclafem 7/7/7 37 cyclobenzaprine hcl TABS 5mg, 10mg 32 cyclophosphamide CAPS; SOLR 11 cycloserine CAPS 8 cyclosporine CAPS; SOLN 50 cyclosporine modified (for microemulsion) 50 cyproheptadine hcl SYRP; TABS 57 cyred tab 37 CYSTADANE 41 CYSTAGON 41 CYSTARAN 56 cytarabine 20mg/ml 12 dacarbazine 100mg 11 dalfampridine 32 DALIRESP 57 danazol CAPS 41 dantrolene sodium CAPS 32 dapsone TABS 4 DAPTACEL 50 DAPTOMYCIN 350mg 4 daptomycin 500mg 4 dasetta 1/35 37 dasetta 7/7/7 37 DAURISMO 12 deblitane 37 DELESTROGEN 10mg/ml 41 DELSTRIGO 7 delyla 37

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Drug Name Page Number DELZICOL 45 DEMSER 21 DEPEN TITRATABS 36 DEPO‑PROVERA INJ 400/ML 13 DESCOVY 7 desipramine hcl TABS 25 desmopressin acetate spray 43 desmopressin acetate spray refrigerated 43 desmopressin acetate tabs 43 desmopressin inj 4mcg/ml 43 desogestrel & ethinyl estradiol 37 desogestrel-ethinyl estradiol (biphasic) 37 desvenlafaxine succinate 25 dexamethasone CONC; ELIX; SOLN; TABS 41 dexamethasone sodium phosphate 42 dexamethasone sodium phosphate (ophth) 55 DEXILANT 46 dexmethylphenidate hcl TABS 2.5mg, 5mg 30 dexmethylphenidate hcl TABS 10mg 30 dexrazoxane 500mg 16 dextrose 2.5%/nacl 0.45% 53 dextrose 5% 53 DEXTROSE 5% /ELECTROLYTE 53 dextrose 5%/nacl 0.2% 53 DEXTROSE 5%/NACL 0.3% 53 dextrose 5%/nacl 0.9% 53 dextrose 5%/nacl 0.33% 53 dextrose 5%/nacl 0.45% 53 dextrose 5%/nacl 0.225% 53 dextrose 5%/potassium chl 53 dextrose 10% flex contain 53 DEXTROSE 10%/NACL 0.2% 53 dextrose 10%/nacl 0.45% 53 dextrose 50% 53 dextrose inj 70% 53 dextrose in lactated ringers 53 DIASTAT ACUDIAL 23 DIASTAT PEDIATRIC 23 diazepam gel 23 diazepam inj 23 diazepam intensol 23 diazepam oral soln 1 mg/ml 23 diazepam TABS 23 diclofenac potassium 1 diclofenac sodium (ophth) 55 diclofenac sodium TB24; TBEC 1 diclofenac sodium (topical) 1% gel 60

Drug Name Page Number dicloxacillin sodium 10 dicyclomine hcl cap 10mg 44 dicyclomine hcl soln 10mg/5ml 44 dicyclomine hcl tab 20mg 44 didanosine 6 DIFICID 10 diflunisal 1 digitek .25mg 20 digitek .125mg 20 digox 125mcg 20 digox 250mcg 20 digoxin inj 21 digoxin sol 50mcg/ml 21 digoxin TABS 125mcg 20 digoxin TABS 250mcg 21 dihydroergotamine mesylate inj 1 mg/ml 31 dihydroergotamine mesylate nasal 31 DILANTIN‑125 SUSP 23 dilantin cap 30mg 23 dilantin cap 100mg 23 dilantin chew tab 50mg 23 diltiazem cap 120mg cd 20 diltiazem cap 180mg cd 20 diltiazem cap 240mg cd 20 diltiazem cap 360mg cd 20 diltiazem cap er/12hr 20 diltiazem hcl cap sr 24hr 20 diltiazem hcl coated beads cap sr 24hr 20 diltiazem hcl extended release beads cap sr 20 diltiazem hcl TABS 20 diltiazem inj 20 dilt-xr cap 20 diphenhydramine hcl inj 50mg/ml 57 diphenoxylate w/ atropine 46 DIPHTHERIA/TETANUS TOXOID 50 disopyramide phosphate 18 disulfiram TABS 32 divalproex sodium CSDR; TB24; TBEC 23 docetaxel CONC 20mg/ml, 80mg/4ml, 200mg/10ml . 12 DOCETAXEL CONC 80mg/4ml, 160mg/8ml 12 docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml 12 DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml 12 dofetilide 18 donepezil hydrochloride TABS 5mg 25

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Drug Name Page Number donepezil hydrochloride TABS 10mg 25donepezil hydrochloride TBDP 5mg 25donepezil hydrochloride TBDP 10mg 25dorzolamide hcl 56dorzolamide hcl-timolol maleate 56doxazosin mesylate TABS 17doxepin hcl CAPS; CONC 26doxorubicin hcl 11doxorubicin hcl liposomal 11doxy 100 11doxycycline hyclate 20 mg 11doxycycline hyclate 100 mg 11doxycycline hyclate CAPS; SOLR 11doxycycline (monohydrate) CAPS 50mg, 100mg 11doxycycline (monohydrate) TABS 11dronabinol 44drospirenone-ethinyl estradiol 37drospirenone-ethinyl estradiol-levomefolate calcium . 37 DROXIA 48Drug Name 1duloxetine hcl CPEP 20mg 26duloxetine hcl CPEP 30mg 26duloxetine hcl CPEP 60mg 26DUREZOL 55dutasteride CAPS 46dutasteride-tamsulosin hcl 46EDURANT 6e.e.s. 400 10efavirenz 6eletriptan hydrobromide 31ELIQUIS 47ELIQUIS STARTER PACK 47ELLA 37EMCYT 11EMEND SUSR 44emoquette 37EMSAM 26EMTRIVA 6emverm 4enalapril maleate & hydrochlorothiazide 17enalapril maleate TABS 17ENDARI 48endocet 2.5-325mg 2endocet 5-325mg 2endocet 7.5-325mg 2endocet 10-325mg 2

Drug Name Page Number ENGERIX‑B SUSP 50 enoxaparin sodium 47 enpresse-28 37 enskyce 37 ENSTILAR 59 entacapone 27 entecavir 8 ENTRESTO 17 enulose 45 EPCLUSA 8 EPIDIOLEX 23 epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml 58 epirubicin hcl 12 epitol 23 EPIVIR HBV SOLN 8 eplerenone 17 eprosartan mesylate 18 ergotamine w/ caffeine TABS 31 ERIVEDGE 12 ERLEADA 13 errin 37 ertapenem sodium 4 ery pad 2% 58 ery-tab 10 erythrocin lactobionate 10 erythrocin stearate 10 erythromycin (acne aid) 58 erythromycin base 10 erythromycin cap 250mg ec 10 erythromycin ethylsuccinate TABS 10 erythromycin (ophth) 55 ESBRIET 58 escitalopram oxalate 26 esomeprazole magnesium 46 esomeprazole sodium inj 46 estarylla tab 0.25-35 37 estradiol PTWK; TABS 41 estradiol vaginal cream 41 estradiol vaginal tab 41 estradiol valerate inj 41 eszopiclone 30 ethambutol hcl TABS 8 ethosuximide CAPS; SOLN 23 ethynodiol diacet & eth estrad 37 ethynodiol tab 1-50 38 etodolac 1

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Drug Name Page Number etoposide SOLN 16EVOTAZ 7EVZIO 32exemestane 13ezetimibe 19ezetimibe-simvastatin 19FABRAZYME 41falmina 38famciclovir 8famotidine inj 44famotidine in nacl 44famotidine SUSR 44famotidine TABS 20mg, 40mg 44FANAPT 28FANAPT TITRATION PACK 28FARESTON 13FARXIGA 5mg 34FARXIGA 10mg 34FARYDAK 12FASLODEX 13fayosim 38felbamate 23felodipine 20femynor 38fenofibrate micronized 67mg, 134mg, 200mg 19fenofibrate TABS 48mg, 54mg, 145mg, 160mg 19fentanyl citrate LPOP 2fentanyl patch 12 mcg/hr 2fentanyl patch 25 mcg/hr 2fentanyl patch 50 mcg/hr 2fentanyl patch 75 mcg/hr 2fentanyl patch 100 mcg/hr 2FENTORA 2FETZIMA 20mg 26FETZIMA 40mg 26FETZIMA 80mg, 120mg 26FETZIMA TITRATION PACK 26FIASP 33FIASP FLEXTOUCH 33finasteride TABS 5mg 46FIRAZYR 48flac 61FLEBOGAMMA DIF 49flecainide acetate 18FLOVENT DISKUS 50mcg/blist, 100mcg/blist 58FLOVENT DISKUS 250mcg/blist 58FLOVENT HFA 58

Drug Name Page Numberfluconazole in dextrose 5 fluconazole inj nacl 200 5 fluconazole inj nacl 400 5 fluconazole SUSR; TABS 5 flucytosine CAPS 5 fludrocortisone acetate TABS 42 flunisolide (nasal) 58 fluocinolone acetonide CREA; OIL; OINT; SOLN 60 fluocinolone acetonide oil body 60 fluocinolone acetonide (otic) 61 fluocinonide CREA .05% 60 fluocinonide emulsified base 60 fluocinonide GEL 60 fluocinonide SOLN 60 fluorometholone 55 fluorouracil SOLN 12 fluorouracil (topical) CREA 5% 60 fluorouracil (topical) SOLN 60 fluoxetine cap 10mg 26 fluoxetine cap 20mg 26 fluoxetine cap 40mg 26 fluoxetine hcl SOLN 26 fluphenazine decanoate SOLN 28 fluphenazine hcl 28 flurbiprofen sodium 55 flurbiprofen TABS 1 flutamide 13 fluticasone propionate CREA; OINT 60 fluticasone propionate (nasal) 58 fluvoxamine maleate TABS 22 fondaparinux sodium 47 FORTEO 42 fosamprenavir tab 700 mg 6 fosinopril sodium 17 fosinopril sodium & hydrochlorothiazide 17 FREAMINE HBC 6.9% 52 FREAMINE III 52 furosemide inj 21 furosemide SOLN; TABS 21 FUZEON 6 fyavolv 41 FYCOMPA SUSP 23 FYCOMPA TABS 2mg, 4mg, 6mg 24 FYCOMPA TABS 8mg, 10mg, 12mg 24 gabapentin CAPS 100mg 24 gabapentin CAPS 300mg 24 gabapentin CAPS 400mg 24

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Drug Name Page Numbergabapentin SOLN 24 gabapentin TABS 600mg 24 gabapentin TABS 800mg 24 galantamine hydrobromide er 25 galantamine hydrobromide SOLN 25 galantamine hydrobromide TABS 25 GAMASTAN S/D 49 GAMMAGARD LIQUID 49 GAMMAGARD S/D 49 GAMMAKED 49 GAMMAPLEX 49 GAMMAPLEX 10GM/100ML 49 GAMUNEX‑C 49 ganciclovir sodium 8 GARDASIL 9 50 gatifloxacin (ophth) 55 GATTEX 46 GAUZE PADS 2” X 2” 33 gavilyte-c 45 gavilyte-g 45 gavilyte-n/flavor pack 45 gemcitabine inj soln 12 gemcitabine inj solr 12 gemfibrozil TABS 19 generlac 45 gengraf 50 GENOTROPIN 42 GENOTROPIN MINIQUICK 42 gentak 55 gentamicin in saline 3 gentamicin sulfate SOLN 3 gentamicin sulfate soln (ophth) 55 gentamicin sulfate (topical) 59 GENVOYA 7 GEODON SOLR 28 gianvi tab 3-0.02mg 38 GILENYA 32 GILOTRIF TAB 20MG 14 GILOTRIF TAB 30MG 14 GILOTRIF TAB 40MG 14 glatiramer acetate 20mg/ml 32 glatiramer acetate 40mg/ml 32 glatopa 20mg/ml 32 glatopa 40mg/ml 32 GLEOSTINE 11 glimepiride 1mg 34 glimepiride 2mg 34

Drug Name Page Numberglimepiride 4mg .......................................................

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34 glipizide TABS 5mg 34 glipizide TABS 10mg 34 glipizide TB24 2.5mg 34 glipizide TB24 5mg 34 glipizide TB24 10mg 34 glipizide xl 2.5mg 34 glipizide xl 5mg 34 glipizide xl 10mg 34 glip/metform tab 2.5-250mg 34 glip/metform tab 2.5-500mg 34 glip/metform tab 5-500mg 34 GLUCAGEN HYPOKIT 42 GLUCAGON EMERGENCY KIT 42 glyburide-metformin tab 1.25-250 mg 35 glyburide-metformin tab 2.5-500 mg 35 glyburide-metformin tab 5-500mg 35 glyburide micronized 1.5mg 35 glyburide micronized 3mg 35 glyburide micronized 6mg 35 glyburide TABS 1.25mg 34 glyburide TABS 2.5mg 35 glyburide TABS 5mg 35 glycopyrrolate tab 1mg 44 glycopyrrolate tab 2mg 44 glydo 60 GOLYTELY 45 granisetron hcl SOLN 44 granisetron hcl TABS 44 GRANIX 47 griseofulvin microsize 5 griseofulvin ultramicrosize 5 guanfacine er (adhd) 30 HAEGARDA 2000unit 48 HAEGARDA 3000unit 48 hailey 24 fe 38 halobetasol propionate CREA; OINT 60 haloperidol conc 2mg/ml 28 haloperidol decanoate SOLN 28 haloperidol lactate inj 5mg/ml 28 haloperidol TABS 28 HARVONI 8 HAVRIX 50 heather 38 heparin sod inj 1000/ml 47 heparin sod inj 5000/ml 47 heparin sod inj 10000/ml 47

Drug Name Page Number heparin sod inj 20000/ml 47 HEPARIN SODIUM/NACL 0.45% 47 heparin sod (porcine) in d5w 47 hepatamine 52 HERCEPTIN 12 HETLIOZ 30 HIBERIX 50 HUMIRA 10mg/0.1ml, 20mg/0.2ml 48 HUMIRA 40mg/0.4ml 48 HUMIRA INJ 10MG/0.2ML 48 HUMIRA KIT 20MG/0.4ML 49 HUMIRA KIT 40MG/0.8ML 49 HUMIRA PEDIATRIC CROHNS DISEASE 49 HUMIRA PEN 49 HUMIRA PEN CD/UC/HS STARTER 49 HUMIRA PEN INJ CD/UC/HS STARTER 49 HUMIRA PEN INJ PS/UV STARTER 49 HUMIRA PEN‑PS/UV STARTER 49 HUMULIN R INJ U‑500 33 HUMULIN R U‑500 KWIKPEN 33 hydralazine hcl SOLN; TABS 21 hydrochlorothiazide CAPS; TABS 21 hydroco/apap tab 5-325mg 2 hydroco/apap tab 7.5-325 2 hydroco/apap tab 10-325mg 2 hydrocodone-acetaminophen 7.5-325 mg/15ml 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocortisone butyrate cream 0.1% 60 hydrocortisone butyrate oint 0.1% 60 hydrocortisone (enema) 45 hydrocortisone TABS 42 hydrocortisone (topical) CREA 60 hydrocortisone (topical) LOTN 60 hydrocortisone (topical) OINT 2.5% 60 hydrocortisone valerate 60 hydromorphone hcl LIQD 2 hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml 2 hydromorphone hcl TABS 2 hydroxychloroquine sulfate 49 hydroxyurea CAPS 16 hydroxyzine hcl inj 57 hydroxyzine hcl SYRP; TABS 57 hydroxyzine pamoate CAPS 25mg, 50mg 57 HYSINGLA ER 2 ibandronate sodium TABS 36 IBRANCE 13

Drug Name Page Numberibuprofen SUSP 1 ibuprofen TABS 400mg, 600mg, 800mg 1 ibu tab 600mg 1 ibu tab 800mg 1 ICLUSIG 15 IDHIFA 13 IFEX INJ 3GM 11 ifosfamide inj 1gm/20ml 11 IFOSFAMIDE INJ 3GM 11 ifosfamide inj 3gm/60ml 11 ILEVRO 55 imatinib mesylate 100mg 15 imatinib mesylate 400mg 15 IMBRUVICA 15 imipenem-cilastatin 4 imipramine hcl TABS 26 imiquimod CREA 5% 60 IMOVAX RABIES (H.D.C.V.) 50 incassia 38 INCRELEX 42 INCRUSE ELLIPTA 57 indapamide 21 INFANRIX 50 INLYTA 1mg 15 INLYTA 5mg 15 INSULIN PEN NEEDLE 33 INSULIN SAFETY NEEDLES 33 INSULIN SYRINGE 33 INTELENCE 6 INTRALIPID 30% 52 intralipid inj 20% 52 INTRON‑A INJ 10MU 49 INTRON‑A INJ 18MU 49 INTRON‑A INJ 25MU 49 INTRON‑A INJ 50MU 49 introvale 38 INVANZ 4 INVEGA SUST INJ 39 MG/0.25 ML 28 INVEGA SUST INJ 78 MG/0.5 ML 28 INVEGA SUST INJ 117 MG/0.75 ML 28 INVEGA SUST INJ 156MG/ML 28 INVEGA SUST INJ 234 MG/1.5 ML 28 INVEGA TRINZA 28 INVIRASE 6 IONOSOL‑MB/DEXTROSE 5% 53 IPOL INACTIVATED IPV 50 ipratropium-albuterol nebu 56

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Drug Name Page Numberipratropium bromide (nasal) 57 ipratropium bromide SOLN 57 irbesartan 18 irbesartan-hydrochlorothiazide 17 IRESSA 15 irinotecan hcl 16 ISENTRESS 6 ISENTRESS HD 6 isibloom 38 ISOLYTE P 53 ISOLYTE S 53 isoniazid syp 50mg/5ml 8 isoniazid TABS 8 isosorbide dinitrate 21 isosorbide dinitrate er 22 isosorbide mononitrate er 22 isosorb mononitrate tab 21 isotretinoin CAPS 59 isradipine 20 itraconazole CAPS 5 ivermectin TABS 4 IXIARO 50 JADENU 36 JADENU SPRINKLE 36 JAKAFI 15 jantoven 47 JANUMET 35 JANUMET XR TAB 50‑500MG 35 JANUMET XR TAB 50‑1000 35 JANUMET XR TAB 100‑1000 35 JANUVIA 35 JARDIANCE 10mg 35 JARDIANCE 25mg 35 JENTADUETO 35 JENTADUETO TAB XR 2.5‑1000 MG 35 JENTADUETO TAB XR 5‑1000 MG 35 jinteli 41 jolessa tab 0.15-0.03 mg 38 jolivette 38 juleber 38 JULUCA 7 junel 1.5/30 38 junel 1/20 38 junel fe 1.5/30 38 junel fe 1/20 38 junel fe 24 38 JUXTAPID 19

Drug Name Page Number KADCYLA 13 kaitlib fe 38 KALETRA TAB 100‑25MG 7 KALETRA TAB 200‑50MG 7 KALYDECO 58 kariva 38 KCL 0.3%/D5W/NACL 0.9% 53 kcl 0.3%/d5w/nacl 0.45% 53 kcl0.15%/d5w/nacl0.2% 53 kcl 0.15%/d5w/nacl 0.9% 53 KCL 0.15%/D5W/NACL 0.225% 53 kcl 0.075%/d5w/nacl 0.45% 53 kcl/d5w inj 0.3% 53 kcl/d5w/nacl inj 0.22%/0.45% 53 kcl/d5w/nacl inj .15/.33% 53 kcl/d5w/nacl inj .15/.45% 53 kcl/nacl inj 0.3-0.9 53 kcl/nacl inj 0.15%-0.9% 53 kelnor 1/35 38 kelnor 1/50 38 ketoconazole cream 59 ketoconazole shampoo 59 ketoconazole TABS 5 ketorolac tromethamine (ophth) 55 KEYTRUDA 13 KINRIX 50 kionex sus 15gm/60ml 36 KISQALI 13 KISQALI FEMARA 200 DOSE 13 KISQALI FEMARA 400 DOSE 13 KISQALI FEMARA 600 DOSE 13 klor-con 8 51 klor-con 10 51 klor-con m10 51 klor-con m15 51 klor-con m20 51 klor-con pak 20meq 51 klor-con spr cap 8meq 51 klor-con spr cap 10meq 51 KORLYM 42 kurvelo 38 KUVAN 41 KYNAMRO 19 labetalol hcl TABS 19 lactated ringer’s 53 lactulose (encephalopathy) 45 lactulose SOLN 45

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Drug Name Page Number lamivudine 6lamivudine (hbv) 8lamivudine-zidovudine 7lamotrigine CHEW; TABS; TB24 24lansoprazole CPDR 46larin 1.5/30 38larin 1/20 38larin fe 1.5/30 38larin fe 1/20 38larissia tab 38LASTACAFT 56latanoprost SOLN 56LATUDA 20mg, 60mg, 80mg 28LATUDA 40mg, 120mg 28layolis fe 38leena tab 38leflunomide TABS 49LENVIMA 4 MG DAILY DOSE 15LENVIMA 8 MG DAILY DOSE 15LENVIMA 10 MG DAILY DOSE 15LENVIMA 12MG DAILY DOSE 15LENVIMA 14 MG DAILY DOSE 15LENVIMA 18 MG DAILY DOSE 15LENVIMA 20 MG DAILY DOSE 15LENVIMA 24 MG DAILY DOSE 15lessina 38LETAIRIS 22letrozole TABS 13leucovorin calcium SOLR 16leucovorin calcium TABS 16LEUKERAN 11leuprolide inj 1mg/0.2 13levalbuterol hcl NEBU 57levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 57levalbuterol tartrate hfa 57LEVEMIR 33LEVEMIR FLEXTOUCH 34levetiracetam in sodium chloride 24levetiracetam oral soln 100 mg/ml 24levetiracetam SOLN; TABS; TB24 24levobunolol hcl 56levocarnitine (metabolic modifiers) 41levocetirizine dihydrochloride 57levofloxacin in d5w 10levofloxacin inj 25mg/ml 10levofloxacin oral soln 25 mg/ml 10levofloxacin TABS 10

Drug Name Page Number levonest 38 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg 38 levonor/ethi tab 38 levonorgestrel & eth estradiol 39 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) 39 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 38 levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7) 38 levora 0.15/30-28 39 levo-t 43 levothyroxine sodium TABS 43 levoxyl 43 LEXIVA SUSP 6 lidocaine hcl GEL 60 lidocaine hcl (local anesth.) 3 lidocaine hcl (mouth-throat) 61 lidocaine hcl SOLN 4% 60 lidocaine inj 0.5% 3 lidocaine inj 1% 3 lidocaine inj 1.5% preservative free (pf) 3 lidocaine oint 5% 60 lidocaine-prilocaine 60 lidocaine PTCH 60 linezolid inj 4 linezolid in sodium chloride 4 linezolid susp 4 linezolid tab 600mg 4 LINZESS 46 liothyronine sodium TABS 43 lisinopril & hydrochlorothiazide 17 lisinopril TABS 17 lithium carbonate CAPS; TABS 31 lithium carbonate er 31 LITHIUM SOLN 8MEQ/5ML 31 lomedia 24 fe 39 LONSURF 16 loperamide hcl CAPS 46 lopinavir-ritonavir 7 lorazepam intensol 22 lorazepam SOLN 22 lorazepam TABS 22 LORBRENA 15 lorcet hd tab 10-325mg 2 lorcet plus tab 7.5-325 2

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Drug Name Page Number lorcet tab 5-325mg 2 loryna 39 losartan-hydrochlorothiazide 17 losartan potassium 18 LOTEMAX 55 lovastatin 18 low-ogestrel 39 loxapine succinate 28 LUMIGAN 56 LUMIZYME 41 LUPRON DEPOT (1‑MONTH) 3.75mg 13 LUPRON DEPOT INJ 11.25MG (3‑MONTH) 13 LUPRON DEPOT‑PED (1‑MONTH 43 LUPRON DEPOT‑PED (3‑MONTH 43 LUPRON DEP‑PED INJ 7.5MG 42 LUPRON DEP‑PED INJ 11.25MG (3‑MONTH) 43 lutera 39 LYNPARZA 13 LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg .24 LYRICA CAPS 200mg 24 LYRICA CAPS 225mg, 300mg 24 LYRICA CR 82.5mg, 165mg 31 LYRICA CR 330mg 31 LYRICA SOLN 24 LYSODREN 14 lyza 39 MAGNESIUM SULFATE IN D5W 51 magnesium sulfate in dextrose 51 magnesium sulfate inj 50% 51 MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml 51 magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50% 51 malathion 61 maprotiline hcl 26 marlissa 39 MARPLAN TAB 10MG 26 MATULANE 16 MAVYRET 8 meclizine hcl TABS 44 medroxyprogesterone acetate (contraceptive) 39 medroxyprogesterone acetate tab 43 mefloquine hcl 6 megestrol ac sus 40mg/ml 14 megestrol ac tab 20mg 14 megestrol ac tab 40mg 14 megestrol sus 625mg/5ml 14

Drug Name Page Number MEKINIST 15 MEKTOVI 15 melodetta 24 fe 39 meloxicam TABS 1 memantine hcl cp24 25 memantine soln 25 memantine tabs 25 memantine titration pak 25 MENACTRA 50 MENVEO 50 mercaptopurine TABS 12 meropenem 4 mesalamine ENEM 45 mesalamine SUPP 45 mesalamine TBEC 800mg 45 mesalamine w/ cleanser 45 MESNEX TABS 16 metadate er tab 20mg 30 metformin er 500mg 35 metformin er 750mg 35 metformin hcl TABS 500mg 35 metformin hcl TABS 850mg 35 metformin hcl TABS 1000mg 35 methadone hcl 5mg 2 methadone hcl 10mg 2 methadone hcl intensol 2 methadone hcl SOLN 5mg/5ml, 10mg/5ml 2 methazolamide TABS 21 methenamine hippurate 4 methimazole TABS 43 methocarbamol TABS 32 methotrexate sodium inj 12 methotrexate sodium tabs 49 methyclothiazide 21 methylphenidate hcl oral soln 5mg/5ml 30 methylphenidate hcl oral soln 10mg/5ml 30 methylphenidate hcl TABS 5mg, 10mg 30 methylphenidate hcl TABS 20mg 30 methylphenidate tab 10mg er 30 methylphenidate tab 20mg er 30 methylprednisolone acetate 42 methylpred pak 4mg 42 methylpred tab 4mg 42 methylpred tab 8mg 42 methylpred tab 16mg 42 methylpred tab 32mg 42 methylpr ss inj 42

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Drug Name Page Number metoclopramide hcl inj 44 metoclopramide hcl SOLN; TABS 44 metolazone 21 metoprolol & hydrochlorothiazide 19 metoprolol succinate 19 metoprolol tartrate SOCT 19 metoprolol tartrate SOLN 19 metoprolol tartrate TABS 25mg, 50mg, 100mg 20 metronidazole gel 0.75% 60 metronidazole in nacl 4 metronidazole TABS 4 metronidazole (topical) CREA; LOTN 60 metronidazole vaginal 47 mexiletine hcl 18 mibelas 24 fe 39 microgestin 1.5/30 39 microgestin 1/20 39 microgestin fe 1.5/30 39 microgestin fe 1/20 39 midodrine hcl 21 miglustat 41 mili 39 minitran 22 minocycline hcl CAPS 11 minoxidil TABS 21 mirtazapine TABS; TBDP 26 misoprostol TABS 46 MITIGARE 1 mitomycin SOLR 12 M‑M‑R II 50 M‑NATAL PLUS 54 moexipril hcl 17 moexipril-hydrochlorothiazide 17 molindone hcl 28 mometasone furoate CREA; OINT; SOLN 60 mondoxyne nl cap 100mg 11 mono-linyah tab 0.25-35 39 mononessa 39 montelukast sodium CHEW; PACK; TABS 57 morgidox cap 1x50mg 11 morphine ext-rel tab 15mg, 30mg, 60mg, 100mg 2 morphine ext-rel tab 200mg 2 morphine sulfate oral soln 10mg/5ml 3 morphine sulfate oral soln 20mg/5ml 3 morphine sulfate oral soln 100mg/5ml 3 MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ ml, 8mg/ml, 10mg/ml, 150mg/30ml 3

Drug Name Page Number morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml .3 morphine sulfate TABS 15mg 3 morphine sulfate TABS 30mg 3 morphine sul inj 1mg/ml 2 MORPHINE SUL INJ 4MG/ML 3 morphine sul inj 10mg/ml 3 MOVANTIK 12.5mg 46 MOVANTIK 25mg 46 MOVIPREP 45 MOXEZA 55 moxifloxacin hcl (ophth) 55 moxifloxacin hcl TABS 10 MULTAQ 18 mupirocin OINT 59 MYCAMINE 5 mycophenolate mofetil CAPS; SUSR; TABS 50 mycophenolate sodium tbec 50 MYLOTARG 13 myorisan 59 MYRBETRIQ 25mg 46 MYRBETRIQ 50mg 47 myzilra 39 nabumetone TABS 1 nadolol TABS 20 nafcillin sodium for inj 10 nafcillin sodium for inj 10gm 10 NAGLAZYME 41 nalbuphine hcl SOLN 2 naloxone inj 0.4mg/ml 33 naloxone inj 1mg/ml 33 naltrexone hcl TABS 33 NAMZARIC 25 naproxen dr 1 naproxen sodium TABS 275mg, 550mg 1 naproxen TABS 1 naratriptan hcl 31 NARCAN 33 NATACYN 55 nateglinide 35 NATPARA 43 NEBUPENT 5 necon 0.5/35-28 39 necon 1/50-28 39 necon 7/7/7 39 nefazodone hcl 26 neomycin-bacitracin zn-polymyxin 55 neomycin-polymy-dexameth 54

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Drug Name Page Number neomycin-polymyxin-gramicidin 55 neomycin-polymyxin-hc (ophth) 54 neomycin-polymyxin-hc (otic) 61 neomycin sulfate TABS 3 NEPHRAMINE 52 NERLYNX 15 NEUPOGEN 47 NEUPRO 27 nevirapine susp 50 mg/5ml 6 nevirapine tab 100mg er 6 nevirapine tab 200mg 6 nevirapine tab 400mg er 6 NEXAVAR 15 niacin er (antihyperlipidemic) 500mg 19 niacin er (antihyperlipidemic) 750mg, 1000mg 19 niacor 19 nicardipine hcl CAPS 20 NICOTROL INHALER 33 NICOTROL NS 33 nifedipine er 20 nifedipine TB24 20 nikki 39 nilutamide 14 nimodipine CAPS 20 NINLARO 13 nitro-bid 22 NITRO‑DUR DIS 0.3MG/HR 22 NITRO‑DUR DIS 0.8MG/HR 22 nitrofurantoin macrocrystal 50mg, 100mg 5 nitrofurantoin monohyd macro 5 nitroglycerin SOLN .4mg/spray 22 nitroglycerin SUBL 22 nitroglycerin td patch 22 NITYR 41 NIVA‑PLUS 54 nora-be tab 0.35mg 39 norethin acet & estrad-fe 39 norethindrone acetate-ethinyl estradiol 41 norethindrone acetate TABS 43 norethindrone acet & eth estra 39 norethindrone (contraceptive) 39 norethindrone & ethinyl estradiol-fe 39 norgest/ethi tab 0.25/35 39 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg 39 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg 39

Drug Name Page Number norlyroc 39 NORMOSOL‑M IN D5W 53 NORMOSOL‑R 53 NORMOSOL‑R IN D5W 53 NORPACE CR 18 NORTHERA 21 nortrel 0.5/35 (28) 39 nortrel 1/35 39 nortrel 7/7/7 39 nortriptyline hcl CAPS; SOLN 26 NORVIR PACK 6 NORVIR SOLN 6 NOVOLIN 70/30 34 NOVOLIN 70/30 FLEXPEN 34 NOVOLIN N 34 NOVOLIN R 34 NOVOLOG 34 NOVOLOG 70/30 FLEXPEN 34 NOVOLOG FLEXPEN 34 NOVOLOG MIX 70/30 34 NOVOLOG PENFILL 34 NOXAFIL SUSP 5 NOXAFIL TBEC 5 NUCYNTA ER 50mg, 100mg, 200mg, 250mg 3 NUCYNTA ER 150mg 3 NUEDEXTA 31 NULOJIX 50 NULYTELY/FLAVOR PACKS 45 NUPLAZID CAPS 28 NUPLAZID TABS 10MG 28 NUPLAZID TABS 17MG 28 nutrilipid inj 20% 52 NUVARING 39 nyamyc 59 NYMALIZE 20 nystatin (mouth-throat) 61 nystatin TABS 5 nystatin (topical) 59 nystop 59 O‑CAL FA 54 ocella tab 3-0.03mg 40 OCTAGAM 49 octreotide acetate 43 ODEFSEY 7 ODOMZO 13 OFEV 58 ofloxacin (ophth) 55

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Drug Name Page Number ofloxacin (otic) 61 olanzapine SOLR 28 olanzapine TABS 2.5mg 28 olanzapine TABS 5mg 28 olanzapine TABS 7.5mg, 15mg, 20mg 28 olanzapine TABS 10mg 28 olanzapine TBDP 5mg, 15mg, 20mg 29 olanzapine TBDP 10mg 29 olmesartan medoxomil-amlodipine-hydrochlorothiazide 17 olmesartan medoxomil-hydrochlorothiazide 17 olmesartan medoxomil TABS 18 olopatadine hcl 0.2% 56 omeprazole cap 10mg 46 omeprazole cap 20mg 46 omeprazole cap 40mg 46 ondansetron hcl inj 44 ondansetron hcl oral soln 44 ondansetron hcl TABS 44 ondansetron odt 44 ONFI 24 OPSUMIT 22 ORFADIN 41 ORKAMBI 58 orsythia 40 oseltamivir phosphate CAPS 30mg 8 oseltamivir phosphate CAPS 45mg, 75mg 8 oseltamivir phosphate SUSR 8 oxacillin sodium 10 oxaliplatin inj 50mg 16 oxaliplatin inj 50mg/10ml 16 oxaliplatin inj 100mg 16 oxaliplatin inj 100mg/20ml 16 oxandrolone tab 2.5mg 33 oxandrolone tab 10mg 33 oxcarbazepine 24 oxybutynin chloride SYRP 47 oxybutynin chloride TABS 47 oxybutynin chloride TB24 5mg 47 oxybutynin chloride TB24 10mg, 15mg 47 oxycodone hcl CAPS 3 oxycodone hcl CONC 3 oxycodone hcl SOLN 3 oxycodone hcl TABS 3 oxycodone w/ acetaminophen 2.5-325mg 3 oxycodone w/ acetaminophen 5-325mg 3 oxycodone w/ acetaminophen 7.5-325mg 3

Drug Name Page Number oxycodone w/ acetaminophen 10-325mg 3 OXYCONTIN 3 OZEMPIC INJ 0.25 OR 0.5MG/DOSE 34 OZEMPIC INJ 1MG/DOSE 34 pacerone 18 paclitaxel 12 paliperidone 1.5mg, 3mg, 9mg 29 paliperidone 6mg 29 pamidronate disodium 36 pamidronate inj 30mg 36 pamidronate inj 90mg 36 PANRETIN 60 pantoprazole sodium SOLR 46 pantoprazole sodium tbec 46 PANZYGA 49 paricalcitol CAPS 54 paroex sol 0.12% 61 paromomycin sulfate CAPS 3 paroxetine hcl tabs 26 paser d/r 8 PAXIL SUSP 26 PAZEO 56 PEDIARIX 50 PEDVAX HIB 51 peg 3350/electrolytes 45 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 45 peg 3350-potassium chloride-sod bicarbonate-sod chloride 45 PEGANONE 24 PEGASYS 8 PEGASYS PROCLICK 8 PENICILLIN G POT IN DEXTROSE 2MU 10 PENICILLIN G POT IN DEXTROSE 3MU 10 penicillin g procaine 10 penicillin g sodium 11 penicillin v potassium 11 penicilln gk inj 5mu 11 penicilln gk inj 20mu 11 PENTACEL 51 PENTAM 300 5 pentoxifylline TBCR 48 perindopril erbumine 17 periogard 61 permethrin cre 5% 61 perphenazine TABS 29 pfizerpen-g inj 5mu 11 pfizerpen-g inj 20mu 11

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Drug Name Page Number phenelzine sulfate TABS 26phenobarbital ELIX; TABS 24PHENOBARBITAL SODIUM SOLN 65mg/ml 24phenobarbital sodium SOLN 130mg/ml 24phenytek 24phenytoin CHEW; SUSP 24phenytoin sodium extended 24phenytoin sodium inj 50mg/ml 24philith 40PHOSPHOLINE IODIDE 56PICATO .05% 60PICATO .015% 60PIFELTRO 6pilocarpine hcl (oral) 61pilocarpine hcl SOLN 56pimozide 29pimtrea 40pindolol 20pioglitazone hcl 35piper/tazoba inj 2-0.25gm 11piper/tazoba inj 3-0.375gm 11piper/tazoba inj 4-0.5gm 11piper/tazoba inj 12-1.5gm 11piper/tazoba inj 36-4.5gm 11pirmella 1/35 40piroxicam CAPS 1PLASMA‑LYTE‑148 53PLASMA‑LYTE A 53PNV FOLIC ACID + IRON MUL 54PNV PRENATAL PLUS 54PNV PRENATAL TAB PLUS 54podofilox SOLN 60polymyxin b-trimethoprim 55POMALYST 14portia-28 40potassium chloride CPCR 51potassium chloride in nacl 54potassium chloride microencapsulated crystals er .52potassium chloride PACK 51potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml 54potassium chloride SOLN 10%, 20% 51potassium chloride tab cr 10 meq 52potassium chloride TBCR 52potassium citrate (alkalinizer) er tabs 46pot chloride inj 2meq/ml 53

Drug Name Page Number PRADAXA 47 PRALUENT 19 pramipexole tab 0.5mg 27 pramipexole tab 0.25mg 27 pramipexole tab 0.75mg 27 pramipexole tab 0.125mg 27 pramipexole tab 1.5mg 27 pramipexole tab 1mg 27 prasugrel hcl 48 pravastatin sodium 18 praziquantel TABS 5 prazosin hcl 17 prednisolone acetate (ophth) 55 prednisolone sodium phosphate (ophth) 55 prednisolone sodium phosphate SOLN 15mg/5ml 42 prednisolone sol 15mg/5ml 42 prednisolone sol 25mg/5ml 42 prednisone con 5mg/ml 42 prednisone pak 5mg 42 prednisone pak 10mg 42 prednisone sol 5mg/5ml 42 prednisone tab 1mg 42 prednisone tab 2.5mg 42 prednisone tab 5mg 42 prednisone tab 10mg 42 prednisone tab 20mg 42 prednisone tab 50mg 42 pred sod pho sol 5mg/5ml 42 premasol 6% 52 premasol 10% 52 PRENATAL 54 PRENATAL PLUS 54 PRENATAL PLUS LOW IRON 54 PREPLUS 54 prevalite 19 previfem 40 PREZCOBIX 7 PREZISTA SUSP 6 PREZISTA TABS 75mg 6 PREZISTA TABS 150mg 6 PREZISTA TABS 600mg 6 PREZISTA TABS 800mg 6 PRIFTIN 8 primaquine phosphate 6 primidone TABS 24 PRIVIGEN 49 probenecid 1

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Drug Name Page Number PROCALAMINE 52 prochlorperazine inj 44 prochlorperazine maleate TABS 44 prochlorperazine supp 44 PROCRIT 47 procto-med hc 60 procto-pak 60 proctosol hc cre 2.5% 61 proctozone-hc 61 PROGLYCEM SUS 50MG/ML 42 PROLASTIN‑C 58 PROLENSA 55 PROLIA 43 PROMACTA PACK 48 PROMACTA TABS 12.5mg 48 PROMACTA TABS 25mg 48 PROMACTA TABS 50mg 48 PROMACTA TABS 75mg 48 promethazine hcl inj 44 promethazine hcl SYRP; TABS 44 propafenone hcl 18 propafenone hcl 12hr 18 proparacaine hcl SOLN 56 propranolol cap er 20 propranolol hcl TABS 20 propranolol & hydrochlorothiazide 19 propranolol oral sol 20 propylthiouracil TABS 43 PROQUAD 51 PROSOL 52 protriptyline hcl 26 PULMICORT FLEXHALER 58 PULMOZYME 58 PURIXAN 12 pyrazinamide TABS 8 pyridostigmine tab 60mg 31 QUADRACEL 51 quasense 40 quetiapine fumarate TABS 29 quetiapine fumarate TB24 50mg, 300mg, 400mg 29 quetiapine fumarate TB24 150mg, 200mg 29 quinapril hcl 17 quinapril-hydrochlorothiazide 17 quinidine gluconate 18 quinidine sulfate 18 quinine sulfate CAPS 6 RABAVERT 51

Drug Name Page Numberrabeprazole sodium 46 raloxifene tab 60mg 43 ramipril 17 RANEXA 21 ranitidine hcl inj 44 ranitidine hcl TABS 150mg, 300mg 44 ranitidine inj 44 ranitidine syrup 45 RAPAMUNE SOLN 50 rasagiline mesylate TABS 27 RAYALDEE 54 REBETOL SOLN 9 reclipsen 40 RECOMBIVAX HB 51 REGRANEX 61 RELENZA DISKHALER 9 RELISTOR SOLN 46 REMICADE 49 REMODULIN 22 repaglinide 2mg 35 repaglinide .5mg, 1mg 35 RESCRIPTOR 7 RESTASIS 56 RESTASIS MULTIDOSE 56 REVLIMID 14 REXULTI 1mg 29 REXULTI 2mg 29 REXULTI 3mg, 4mg 29 REXULTI .5mg 29 REXULTI .25mg 29 REYATAZ PACK 7 ribasphere 9 ribavirin cap 200mg 9 ribavirin tab 200mg 9 rifabutin 8 rifampin CAPS; SOLR 8 RIFATER 8 riluzole 31 rimantadine hydrochloride 9 risedronate sodium TABS 5mg, 35mg, 150mg 36 risedronate sodium TBEC 36 RISPERDAL INJ 12.5MG 29 RISPERDAL INJ 25MG 29 RISPERDAL INJ 37.5MG 29 RISPERDAL INJ 50MG 29 risperidone SOLN 29 risperidone TABS 29

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Drug Name Page Number risperidone TBDP .5mg 29 risperidone TBDP .25mg, 1mg, 2mg, 3mg, 4mg 29 ritonavir 7 RITUXAN 13 RITUXAN HYCELA 13 rivastigmine tartrate 1.5mg, 3mg 25 rivastigmine tartrate 4.5mg, 6mg 25 rivastigmine td patch 24hr 4.6 mg/24hr 25 rivastigmine td patch 24hr 9.5 mg/24hr 25 rivastigmine td patch 24hr 13.3 mg/24hr 25 rivelsa 40 rizatriptan benzoate 31 rizatriptan benzoate odt 31 ropinirole tab 0.5mg 27 ropinirole tab 0.25mg 27 ropinirole tab 1mg 27 ropinirole tab 2mg 27 ropinirole tab 3mg 27 ropinirole tab 4mg 27 ropinirole tab 5mg 27 rosadan cre 0.75% 61 rosuvastatin calcium 18 ROTARIX 51 ROTATEQ 51 roweepra 24 roweepra xr 24 RUBRACA 13 RYDAPT 15 SABRIL TABS 24 SANDIMMUNE SOLN 100mg/ml 50 SANTYL 61 SAPHRIS 2.5mg 29 SAPHRIS 5mg 29 SAPHRIS 10mg 29 scopolamine patch 44 selegiline hcl CAPS; TABS 27 selenium sulfide LOTN 59 SELZENTRY 7 SENSIPAR 30mg, 90mg 36 SENSIPAR 60mg 36 SEREVENT DISKUS 57 sertraline hcl CONC; TABS 26 setlakin tab 40 sevelamer carbonate PACK 2.4gm 43 sevelamer carbonate PACK .8gm 43 sevelamer carbonate TABS 43 sharobel 40

Drug Name Page Number SHINGRIX 51 SIGNIFOR 43 sildenafil citrate tab 20 mg (pulmonary hypertension) 22 SILENOR 3mg 30 SILENOR 6mg 30 silver sulfadiazine CREA 59 SIMBRINZA 56 simvastatin TABS 5mg, 10mg, 20mg, 40mg 18 simvastatin TABS 80mg 18 sirolimus SOLN; TABS 50 SIRTURO 8 SIVEXTRO 5 sodium chloride 0.45% 54 sodium chloride inj 0.9% 54 sodium chloride SOLN 2.5meq/ml 52 sodium chloride SOLN 3%, 5% 54 sodium chlor sol 0.9% irr 61 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln 52 sodium phenylbutyrate 41 sodium polystyrene sulfonate powder 36 sodium polystyrene sulfonate susp 36 SOLIQUA 100/33 34 SOLTAMOX 14 SOLU‑CORTEF 42 SOMATULINE DEPOT 43 SOMAVERT 43 sorine 18 sotalol hcl 18 sotalol hcl (afib/afl) 18 spironolactone & hydrochlorothiazide 21 spironolactone TABS 17 sprintec 28 40 SPRITAM 24 SPRYCEL 15 sps susp 15gm/60ml 36 sronyx 40 ssd 59 stavudine 7 STIMATE 43 STIVARGA 15 streptomycin sulfate SOLR 3 STRIBILD 7 SUBOXONE MIS 2‑0.5MG 33 SUBOXONE MIS 4‑1MG 33 SUBOXONE MIS 8‑2MG 33 SUBOXONE MIS 12‑3MG 33

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Drug Name Page Number subvenite tab 24 sucralfate TABS 46 sulfacetamide sodium (acne) 59 sulfacetamide sodium (ophth) 55 sulfacetamide sod-prednisolone 54 sulfadiazine TABS 3 sulfamethoxazole-trimethop ds 5 sulfamethoxazole-trimethoprim inj 5 sulfamethoxazole-trimethoprim susp 5 sulfamethoxazole-trimethoprim tab 400-80mg 5 SULFAMYLON CREA 59 sulfasalazine ec 45 sulfasalazine TABS 45 sulindac TABS 1 sumatriptan inj 4mg/0.5ml 31 sumatriptan inj 6mg/0.5ml 31 sumatriptan SOLN 5mg/act 31 sumatriptan SOLN 20mg/act 31 sumatriptan succinate TABS 31 SUPRAX CAPS 9 suprax CHEW 9 SUPRAX SUSR 500mg/5ml 9 SUPREP BOWEL PREP KIT 45 SUTENT 15 syeda 40 SYLATRON KIT 200MCG 16 SYLATRON KIT 300MCG 16 SYLATRON KIT 600MCG 16 SYMBICORT 58 SYMDEKO 58 SYMFI 7 SYMFI LO 8 SYMPAZAN 24 SYMPROIC 46 SYMTUZA 8 SYNAREL 41 SYNERCID 5 SYNJARDY TAB 5‑500MG 35 SYNJARDY TAB 5‑1000MG 35 SYNJARDY TAB 12.5‑500MG 35 SYNJARDY TAB 12.5‑1000MG 36 SYNJARDY XR TAB 5‑1000MG 36 SYNJARDY XR TAB 10‑1000MG 36 SYNJARDY XR TAB 12.5‑1000MG 36 SYNJARDY XR TAB 25‑1000MG 36 SYNRIBO 16 SYNTHROID 43

Drug Name Page Number

TABLOID 12 tacrolimus CAPS 50 tacrolimus (topical) 61 TAFINLAR 15 TAGRISSO 15 TALZENNA 13 tamoxifen citrate TABS 14 tamsulosin hcl 46 TARCEVA 25mg 15 TARCEVA 100mg, 150mg 15 TARGRETIN GEL 61 tarina fe 1/20 40 TASIGNA 15 TAXOTERE 80mg/4ml 12 tazarotene CREA 59 tazicef SOLR 9 TAZORAC CREA .05% 59 taztia xt 20 TDVAX 51 TECENTRIQ 1200mg/20ml 13 TEFLARO 10 TEKTURNA 21 TEKTURNA HCT 21 telmisartan 18 telmisartan-amlodipine 18 telmisartan-hydrochlorothiazide 18 temazepam 7.5mg 30 temazepam 15mg 31 TENIVAC 51 tenofovir disoproxil fumarate 7 terazosin hcl 17 terbinafine hcl TABS 6 terbutaline sulfate TABS 57 terconazole vaginal 47 testosterone cypionate SOLN 100mg/ml, 200mg/ml 33 testosterone enanthate SOLN 33 testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm 33 tetrabenazine 12.5mg 32 tetrabenazine 25mg 32 tetracycline hcl CAPS 11 texacort soln 2.5% 60 THALOMID 50mg, 100mg 14 THALOMID 150mg, 200mg 14 theo-24 58 theophylline 58 thioridazine hcl TABS 29 thiothixene 29

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Drug Name Page Number tiagabine hcl 24 TIBSOVO 13 tigecycline 5 tilia fe 40 timolol maleate gel 56 timolol maleate (ophth) soln 56 timolol maleate ophth soln 0.5% (once-daily) 56 timolol maleate TABS 20 TIVICAY 7 tizanidine hcl TABS 32 TOBRADEX OINT 54 TOBRADEX ST 54 tobramycin-dexamethasone 54 tobramycin inj 1.2gm 4 tobramycin inj 1.2 gm/30ml 3 tobramycin inj 10mg/ml 4 tobramycin inj 40mg/ml 4 tobramycin inj 80mg/2ml 4 tobramycin NEBU 3 tobramycin (ophth) 55 tolterodine tartrate CP24 47 tolterodine tartrate TABS 47 topiramate CPSP; TABS 24 toposar 16 topotecan hcl 16 TOPOTECAN INJ 4MG/4ML 16 toremifene citrate 14 torsemide tabs 21 TOVIAZ 47 tpn electrolytes 52 TRACLEER TABS 62.5mg 22 TRACLEER TABS 125mg 22 TRADJENTA 36 tramadol-acetaminophen 2 tramadol hcl tab 50 mg 2 trandolapril 17 tranexamic acid SOLN; TABS 48 TRANSDERM‑SCOP 44 tranylcypromine sulfate 26 TRAVASOL 52 TRAVATAN Z 56 trazodone hcl TABS 50mg, 100mg, 150mg 26 TRECATOR 8 TRELEGY ELLIPTA 56 TRELSTAR DEP INJ 3.75MG 14 TRELSTAR LA INJ 11.25MG 14 TRESIBA FLEXTOUCH 34

Drug Name Page Number TRESIBA INJ 34 tretinoin (chemotherapy) 16 tretinoin CREA 59 tretinoin GEL .01%, .025% 59 triamcinolone acetonide (mouth) 61 triamcinolone acetonide (topical) CREA; LOTN; OINT 60 triamterene & hydrochlorothiazide cap 37.5-25 mg ... 21 triamterene & hydrochlorothiazide tabs 21 TRICARE 54 trientine hcl 36 tri-estarylla 40 trifluoperazine hcl 29 trifluridine 55 trihexyphenidyl hcl 27 tri-legest fe 40 tri-linyah 40 tri-lo-estarylla 40 tri-lo marzia 40 tri-lo-sprintec 40 trilyte 45 trimethoprim TABS 5 tri-mili 40 trimipramine maleate CAPS 25mg 26 trimipramine maleate CAPS 50mg 26 trimipramine maleate CAPS 100mg 26 trinessa 40 trinessa lo 40 TRINTELLIX 5mg 26 TRINTELLIX 10mg 26 TRINTELLIX 20mg 26 tri-previfem 40 tri-sprintec 40 TRIUMEQ 8 trivora-28 40 tri-vylibra 40 tri-vylibra lo 40 TROGARZO 7 TROPHAMINE INJ 10% 52 trospium chloride TABS 47 TRULICITY 34 TRUMENBA 51 TRUVADA TAB 100‑150 8 TRUVADA TAB 133‑200 8 TRUVADA TAB 167‑250 8 TRUVADA TAB 200‑300 8 tulana 40

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Drug Name Page Number TWINRIX INJ 51TYBOST 7tydemy 40TYKERB 15TYMLOS 43TYPHIM VI 51ULORIC 1unithroid 43ursodiol CAPS; TABS 46valacyclovir hcl TABS 9VALCHLOR 61valganciclovir hcl 9valproate sodium oral soln 24valproate sodium SOLN 24valproic acid CAPS 25valsartan 18valsartan-hydrochlorothiazide 18vancomycin hcl CAPS 5vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg 5VANCOMYCIN IN NACL 5vandazole 47VAQTA 51VARIVAX 51VASCEPA 19VELCADE 13velivet 40VEMLIDY 9VENCLEXTA 13VENCLEXTA STARTING PACK 13venlafaxine hcl CP24; TABS 26VENTAVIS 22VENTOLIN HFA 57verapamil cap er 20verapamil hcl SOLN; TABS; TBCR 20verapamil tab er 20VERSACLOZ 29VERZENIO 13VESICARE 47VICTOZA 34VIDEX EC 125mg 7VIDEX PEDIATRIC 7vienva 40vigabatrin powd pack 500mg 25vigabatrin tab 500mg 25VIIBRYD STARTER PACK 26VIIBRYD TAB 26

Drug Name Page Number VIMPAT 50mg 25 VIMPAT 100mg, 150mg, 200mg 25 VIMPAT INJ 200MG/20ML 25 VIMPAT SOL 10MG/ML 25 vinblastine sulfate 12 vincasar pfs 12 vincristine sulfate 12 vinorelbine tartrate 12 viorele 40 VIRACEPT 7 VIRAMUNE SUSP 7 VIREAD POWD 7 VIREAD TABS 150mg, 200mg, 250mg 7 VITRAKVI 15 VIVITROL 33 VIZIMPRO 15 VOL‑PLUS 54 voriconazole SOLR; SUSR; TABS 6 VOSEVI 9 VOTRIENT 15 VRAYLAR 1.5mg 29 VRAYLAR 3mg, 4.5mg, 6mg 29 VRAYLAR THERAPY PACK 29 vyfemla 40 vylibra 40 warfarin sodium 47 water for irrigation, sterile 61 WELCHOL PAK 19 wymzya fe 41 XALKORI 16 XARELTO 47 XARELTO STARTER PACK 47 XATMEP 49 XELJANZ 49 XELJANZ XR 49 XGEVA 43 XIFAXAN 550mg 46 XIGDUO XR TAB 2.5‑1000MG 36 XIGDUO XR TAB 5‑500MG 36 XIGDUO XR TAB 5‑1000MG 36 XIGDUO XR TAB 10‑500MG 36 XIGDUO XR TAB 10‑1000MG 36 XOLAIR 58 XOSPATA 16 XTANDI 14 xulane dis 150-35 41 XULTOPHY 100/3.6 34

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Drug Name Page Number XYREM 32 YF‑VAX 51 yuvafem vaginal tablet 10 mcg 41 zafirlukast 57 zaleplon 31 zarah 41 ZEJULA 13 ZELBORAF 16 ZEMAIRA 58 zenatane 59 ZENPEP 46 ZEPATIER 9 zidovudine cap 100mg 7 zidovudine syp 50mg/5ml 7 zidovudine tab 300mg 7 ziprasidone hcl 29 ZIRGAN 55 zoledronic acid inj 5mg/100ml 36 zoledronic inj 4mg/5ml 36 ZOLINZA 13

Drug Name Page Number zolmitriptan odt 31 zolmitriptan TABS 31 zolpidem tartrate TABS 31 zonisamide CAPS 25 ZONTIVITY 48 ZORTRESS TAB 0.5MG 50 ZORTRESS TAB 0.25MG 50 ZORTRESS TAB 0.75MG 50 ZORTRESS TAB 1MG 50 ZOSTAVAX 51 zovia 1/35e 41 zovia 1/50e 41 ZYDELIG 16 ZYKADIA 16 ZYLET 54 ZYPREXA RELPREVV 300mg 29 ZYPREXA RELPREVV 405mg 29 ZYPREXA RELPREVV INJ 210MG 29 ZYTIGA 14

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Mercy Care Advantage (HMO SNP) Member Services Call 602‑586‑1730 or 1‑877‑436‑5288

Calls to these numbers are free. 8:00 a.m. ‑ 8:00 p.m., 7 days a week.

Member Services also has free language interpreter services available for non‑English speakers.

TTY 711 Calls to this number are free. 8:00 a.m. ‑ 8:00 p.m., 7 days a week.

Write Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Website www.MercyCareAdvantage.com

This formulary was updated on 04/01/2019. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. ‑ 8:00 p.m., 7 days a week, or visit www.MercyCareAdvantage.com.

Servicios al Miembro de Mercy Care Advantage (HMO SNP) Llame 602‑586‑1730 ó 1‑877‑436‑5288

Las llamadas a estos números son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Servicios al Miembro también tiene servicios gratuitos de interpretación de idiomas disponibles para personas que no hablan inglés.

TTY 711 Las llamadas a este número son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Escriba Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Sitio Web www.MercyCareAdvantage.com

Este formulario se actualizó el 04/01/2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Departamento de Servicios para miembros de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 o al 1‑877‑436‑5288, los usuarios de TTY deben llamar al 711, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana, o visite la página web www.MercyCareAdvantage.com.





Mercy Care Advantage (HMO SNP) · 2019-04-01 · Mercy Care Advantage (HMO SNP) 2019 Formulary...

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