SecureRx PDP Generic Standard Formulary (List of Covered Drugs)

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1 SecureRx PDP Generic Standard SecureRx PDP Option Employer Group Retiree Plan Standard Options 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID v. This formulary was updated on 08/16/017. For more recent information or other questions, please contact SecureRx PDP Customer Service at or, for TTY users, 711, Monday through Friday, 8 a.m. to 8 p.m., or visit AV-8 (11/1/17) S8067_18_00_Accepted 09/0/017

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3 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 Avalon Insurance Company. When it refers to plan or our plan, it means SecureRx PDP. This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 018. 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, 019, and from time to time during the year. What is the SecureRx PDP Formulary? A formulary is a list of covered drugs selected by our Plan 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. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SecureRx PDP 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. 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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 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 60-day supply of the drug. 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. The enclosed formulary is current as of January 1, 018. To get updated information about the drugs covered by SecureRx PDP, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year formulary change, unrelated to a generic becoming available, we will notify you with a written notification of the nonmaintenance formulary change. In addition, the printable formulary will be updated and posted on our website How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page one. 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. If you know what your drug is used for, look for the category name in the list that begins on page one. Then look under the category name for your drug. i

4 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 71. 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? Our Plan 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: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our Plan before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our Plan limits the amount of the drug that we will cover. For example, our Plan provides twelve tablets per prescription for sumatriptan tab 0mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our Plan 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, our Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we 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 one. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction 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 our Plan 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 SecureRx PDP formulary? on page iii for information about how to request an exception. 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 Customer Service and ask if your drug is covered. If you learn that our Plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our Plan. You can ask our Plan to make an exception and cover your drug. See below for information about how to request an exception. ii

5 How do I request an exception to the SecureRx PDP Formulary? You can ask our Plan 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our Plan 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, our Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug 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 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 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 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If 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 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Our Plan also realizes that other situations may arise where you need access to non-formulary drugs. An example of this situation would include when you are discharged from a hospital. In these cases, members should use the exceptions processes described earlier. iii

6 For more information For more detailed information about your SecureRx PDP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SecureRx PDP, 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 MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit SecureRx PDP Formulary The formulary that begins on page one provides coverage information about the drugs covered by our Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 71. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIVALO) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if our Plan has any special requirements for coverage of your drug. iv

7 018 SECURERX PDP MEDICARE FORMULARY Key Drug Tier Levels: Tier 1 Preferred Generic Tier Generic Tier Preferred Brand (includes preferred brand drugs and some generic drugs) Tier Non-Preferred Drug Tier Specialty The symbol B/D next to a drug name indicates that prior authorization for determination of coverage under Part B vs. Part D may apply. The symbol LA next to a drug name indicates the drug has limited access or distribution. The symbol PA next to a drug name indicates that prior authorization may apply. The symbol QL next to a drug name indicates that quantities dispensed may be limited. The symbol ST next to a drug name indicates that Step Therapy may apply. The symbol NM next to a drug name indicates that the drug is not available through mail service. Note: Drugs that are non-formulary and are not listed in this document are not covered unless approval is provided through the Non-Formulary Exception Process. For employer-sponsored plans, please call Customer Service regarding the type of formulary that is offered. Tier Copayments/Coinsurance Up to a 0-Day Supply Up to a 0-Day Supply Up to a 90-Day Supply Up to a 90-Day Supply Preferred Pharmacy Standard Pharmacy Preferred Pharmacy Standard Pharmacy SecureRx PDP Option Tier 1 $ copay $10 copay $1 copay $0 copay Tier $1 copay $0 copay $ copay $60 copay Tier $8 copay $ copay $11 copay $1 copay Tier 0% coinsurance 0% coinsurance 0% coinsurance 0% coinsurance Tier % coinsurance % coinsurance Not Covered Not Covered v

8 Tier Copayments/Coinsurance Up to a 0-Day Supply Up to a 0-Day Supply Up to a 90-Day Supply Up to a 90-Day Supply Preferred Pharmacy Standard Pharmacy Preferred Pharmacy Standard Pharmacy Employer Group Retiree Plan Standard Option Tier 1 $6 copay $1 copay $18 copay $6 copay Tier $1 copay $0 copay $ copay $60 copay Tier $9 copay $7 copay $117 copay $11 copay Tier $90 copay $99 copay $70 copay $97 copay Tier % coinsurance % coinsurance Not Covered Not Covered vi

9 018 GENERIC STANDARD FORMULARY ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) colchicine w/ probenecid COLCRYS QL (10 tabs / 0 days) MITIGARE QL (60 caps / 0 days) probenecid ULORIC ST NSAIDS celecoxib (generic of CELEBREX) CAPS QL (0 caps / 0 days) 0mg celecoxib (generic of CELEBREX) CAPS QL (10 caps / 0 days) 100mg celecoxib (generic of CELEBREX) CAPS QL (60 caps / 0 days) 00mg celecoxib (generic of CELEBREX) CAPS QL (0 caps / 0 days) 00mg diclofenac potassium QL (10 tabs / 0 days) diclofenac sodium TB; TBEC diflunisal etodolac CAPS etodolac (generic of LODINE) TABS 00mg etodolac TABS 00mg etodolac TB flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 00mg, 600mg, 800mg ketoprofen cap 0mg ketoprofen cap 7mg meloxicam (generic of MOBIC) TABS nabumetone TABS naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS mg, 00mg naproxen TABS 7mg naproxen dr (generic of EC-NAPROSYN) naproxen sodium TABS 7mg 1 naproxen sodium (generic of ANAPROX DS) TABS 0mg piroxicam (generic of FELDENE) CAPS sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine SOLN QL (000 ml / 0 days) 1

10 018 GENERIC STANDARD FORMULARY acetaminophen w/ codeine TABS QL (00 tabs / 0 days) acetaminophen w/ codeine (generic of QL (00 tabs / 0 days) TYLENOL/CODEINE #) TABS acetaminophen w/ codeine (generic of QL (00 tabs / 0 days) TYLENOL/CODEINE #) TABS butorphanol tartrate SOLN 1mg/ml, mg/ml nalbuphine hcl SOLN tramadol hcl (generic of ULTRAM) TABS QL (0 tabs / 0 days) tramadol-acetaminophen (generic of QL (0 tabs / 0 days) ULTRACET) OPIOID ANALGESICS, CII endocet (generic of PERCOCET) QL (60 tabs / 0 days) fentanyl citrate (generic of ACTIQ) LPOP QL (10 lozenges / 0 days), PA fentanyl patch 1 mcg/hr (generic of QL (10 patches / 0 DURAGESIC) days) fentanyl patch mcg/hr (generic of QL (10 patches / 0 DURAGESIC) days) fentanyl patch 0 mcg/hr (generic of QL (10 patches / 0 DURAGESIC) days), PA fentanyl patch 7 mcg/hr (generic of QL (10 patches / 0 DURAGESIC) days), PA fentanyl patch 100 mcg/hr (generic of QL (10 patches / 0 DURAGESIC) days), PA FENTORA QL (10 tabs / 0 days), PA hydroco/apap tab -mg (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab 7.- (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab 10-mg (generic of QL (60 tabs / 0 days) NORCO) hydrocodone-acetaminophen 7.- QL (00 ml / 0 days) mg/1ml (generic of HYCET) hydrocodone-ibuprofen tab mg QL (10 tabs / 0 days) hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl SOLN 10mg/ml, B/D 0mg/ml, 00mg/0ml hydromorphone hcl (generic of DILAUDID) QL (70 tabs / 0 days) TABS lorcet hd tab 10-mg (generic of QL (60 tabs / 0 days) NORCO) lorcet plus tab 7.- (generic of NORCO) QL (60 tabs / 0 days) lortab tab -mg (generic of NORCO) QL (60 tabs / 0 days)

11 018 GENERIC STANDARD FORMULARY lortab tab 7.- (generic of NORCO) QL (60 tabs / 0 days) lortab tab 10-mg (generic of NORCO) QL (60 tabs / 0 days) methadone hcl SOLN mg/ml, QL (0 ml / 0 days) 10mg/ml methadone hcl mg (generic of QL (180 tabs / 0 days) DOLOPHINE) methadone hcl 10mg (generic of QL (180 tabs / 0 days) DOLOPHINE) methadone hcl intensol (generic of QL (10 ml / 0 days) METHADOSE) morphine ext-rel tab (generic of MS QL (90 tabs / 0 days) CONTIN) 1mg, 0mg, 60mg, 100mg morphine ext-rel tab (generic of MS QL (60 tabs / 0 days) CONTIN) 00mg morphine sul inj 1mg/ml B/D MORPHINE SUL INJ MG/ML B/D morphine sul inj 10mg/ml (generic of B/D MORPHINE SULFATE) morphine sul inj 1mg/ml B/D MORPHINE SULFATE SOLN mg/ml, B/D 8mg/ml, 10mg/0ml morphine sulfate (generic of MORPHINE B/D SULFATE) SOLN mg/ml, 8mg/ml morphine sulfate TABS QL (180 tabs / 0 days) morphine sulfate oral sol NUCYNTA ER 0mg, 100mg QL (10 tabs / 0 days) NUCYNTA ER 10mg, 00mg, 0mg QL (60 tabs / 0 days) oxycodone hcl CAPS QL (180 caps / 0 days) oxycodone hcl CONC oxycodone hcl SOLN oxycodone hcl (generic of ROXICODONE) QL (180 tabs / 0 days) TABS mg, 1mg, 0mg oxycodone hcl TABS 10mg, 0mg QL (180 tabs / 0 days) oxycodone w/ acetaminophen.-mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen -mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 7.-mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 10-mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen soln QL (1800 ml / 0 days) ANESTHETICS LOCAL ANESTHETICS

12 018 GENERIC STANDARD FORMULARY lidocaine inj 0.% (generic of XYLOCAINE) B/D.% lidocaine inj 0.% (generic of B/D XYLOCAINE-MPF).% lidocaine inj 1% (generic of XYLOCAINE) B/D 1% lidocaine inj 1% (generic of B/D XYLOCAINE-MPF) 1% lidocaine inj 1.% (generic of B/D XYLOCAINE-MPF) lidocaine inj % (generic of XYLOCAINE) B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR SULFADIAZINE TABS tobramycin (generic of KITABIS PAK) NEBU tobramycin inj 1. gm/0ml tobramycin inj 1.gm tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ALINIA atovaquone (generic of MEPRON) SUSP AZACTAM/DEX INJ aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON NM, LA, PA clindamycin cap 7mg (generic of 1 CLEOCIN) clindamycin cap 00 mg (generic of 1 CLEOCIN) clindamycin hcl cap 10 mg (generic of 1 CLEOCIN) clindamycin phosphate in dw (generic of CLEOCIN IN DW) CLINDAMYCIN PHOSPHATE IN NACL

13 018 GENERIC STANDARD FORMULARY clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin soln 7mg/ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR dapsone TABS daptomycin (generic of CUBICIN) EMVERM imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) linezolid in sodium chloride meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal (generic of PA; PA applies if 6 MACRODANTIN) 0mg, 100mg years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro (generic of MACROBID) PENTAM 00 SIVEXTRO sulfamethoxazole-trimethop ds (generic of 1 BACTRIM DS) sulfamethoxazole-trimethoprim SUSP sulfamethoxazole-trimethoprim (generic of 1 BACTRIM) TABS sulfamethoxazole-trimethoprim inj SYNERCID TIGECYCLINE trimethoprim TABS vancomycin hcl (generic of VANCOCIN HCL) CAPS vancomycin hcl SOLR VANCOMYCIN IN NACL PA; PA applies if 6 years and older after a 90 day supply in a calendar year

14 018 GENERIC STANDARD FORMULARY ANTIFUNGALS ABELCET AMBISOME B/D B/D amphotericin b SOLR B/D CANCIDAS fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose FLUCONAZOLE INJ NACL 100 fluconazole inj nacl 00 fluconazole inj nacl 00 flucytosine (generic of ANCOBON) CAPS griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize (generic of GRIS-PEG) itraconazole (generic of SPORANOX) PA CAPS ketoconazole TABS PA MYCAMINE NOXAFIL SUSP QL (60 ml / 0 days) NOXAFIL TBEC QL (9 tabs / 0 days) nystatin TABS terbinafine hcl (generic of LAMISIL) TABS QL (90 tabs / 6 days) voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate (generic of QUALAQUIN) PA CAPS ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) NM APTIVUS CRIXIVAN didanosine (generic of VIDEX EC) NM NM NM EDURANT EMTRIVA FUZEON NM NM NM 6

15 018 GENERIC STANDARD FORMULARY INTELENCE mg NM INTELENCE 100mg, 00mg NM INVIRASE NM ISENTRESS CHEW mg NM ISENTRESS CHEW 100mg NM ISENTRESS PACK NM ISENTRESS TABS NM ISENTRESS HD NM lamivudine (generic of EPIVIR) NM LEXIVA SUSP NM LEXIVA TABS NM nevirapine susp 0 mg/ml (generic of NM VIRAMUNE) nevirapine tab 00mg (generic of VIRAMUNE) NM nevirapine tb (generic of VIRAMUNE XR) NM NORVIR NM PREZISTA SUSP QL (00 ml / 0 days), NM PREZISTA TABS 7mg QL (80 tabs / 0 days), NM PREZISTA TABS 10mg QL (0 tabs / 0 days), NM PREZISTA TABS 600mg QL (60 tabs / 0 days), NM PREZISTA TABS 800mg QL (0 tabs / 0 days), NM RESCRIPTOR NM RETROVIR IV INFUSION NM REYATAZ NM SELZENTRY SOLN NM SELZENTRY TABS mg NM SELZENTRY TABS 7mg, 10mg, 00mg NM stavudine (generic of ZERIT) NM SUSTIVA CAPS 0mg NM SUSTIVA CAPS 00mg NM SUSTIVA TABS NM TIVICAY 10mg NM TIVICAY mg, 0mg NM TYBOST NM VIDEX PEDIATRIC NM VIRACEPT NM VIREAD NM ZERIT SOLR NM 7

16 018 GENERIC STANDARD FORMULARY ZIAGEN SOLN NM zidovudine cap 100mg (generic of NM RETROVIR) zidovudine syp 0mg/ml (generic of NM RETROVIR) zidovudine tab 00mg NM ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of NM EPZICOM) abacavir sulfate-lamivudine-zidovudine NM (generic of TRIZIVIR) ATRIPLA COMPLERA DESCOVY EVOTAZ GENVOYA KALETRA TAB 100-MG KALETRA TAB 00-0MG lamivudine-zidovudine (generic of NM NM NM NM NM NM NM NM COMBIVIR) lopinavir-ritonavir (generic of KALETRA) NM ODEFSEY PREZCOBIX STRIBILD TRIUMEQ NM NM NM NM TRUVADA TAB QL (60 tabs / 0 days), NM TRUVADA TAB 1-00 QL (0 tabs / 0 days), NM TRUVADA TAB QL (0 tabs / 0 days), NM TRUVADA TAB QL (0 tabs / 0 days), NM ANTITUBERCULAR AGENTS CAPASTAT SULFATE cycloserine CAPS ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS 1 isoniazid inj 100 mg/ml isoniazid syp 0mg/ml PASER D/R PRIFTIN pyrazinamide TABS 8

17 018 GENERIC STANDARD FORMULARY rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO LA, PA TRECATOR ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of HEPSERA) NM BARACLUDE SOLN NM DAKLINZA entecavir (generic of BARACLUDE) NM EPIVIR HBV SOLN NM famciclovir TABS 1mg, 0mg famciclovir (generic of FAMVIR) TABS 00mg ganciclovir inj 00mg (generic of CYTOVENE) B/D lamivudine (hbv) (generic of EPIVIR HBV) NM moderiba tab 00mg (generic of NM COPEGUS) oseltamivir phosphate (generic of QL (168 caps / year) TAMIFLU) 0mg oseltamivir phosphate (generic of QL (8 caps / year) TAMIFLU) mg, 7mg PEGASYS PEGASYS PROCLICK REBETOL SOLN NM RELENZA DISKHALER QL (6 inhalers / year) ribasphere (generic of REBETOL) CAPS NM ribasphere (generic of COPEGUS) TABS NM 00mg ribasphere TABS 00mg, 600mg NM ribavirin cap 00mg (generic of REBETOL) NM ribavirin tab 00mg (generic of COPEGUS) NM rimantadine hydrochloride (generic of FLUMADINE) SOVALDI TAMIFLU SUSR QL (1080 ml / year) valacyclovir hcl (generic of VALTREX) TABS 9

18 018 GENERIC STANDARD FORMULARY valganciclovir hcl (generic of VALCYTE) VEMLIDY NM CEPHALOSPORINS cefaclor CAPS cefaclor SUSR CEFACLOR ER TAB 00MG cefadroxil CAPS cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE GM/100ML-% cefazolin inj cefazolin sodium SOLR 1gm, 0gm CEFAZOLIN SODIUM 1 GM/0ML cefdinir CAPS cefdinir SUSR cefepime for inj (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium 1gm, gm, 00mg cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime (generic of FORTAZ) SOLR CEFTAZIDIME/DEXTROSE ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm ceftriaxone sodium SOLR 1gm, gm, 10gm, 0mg, 00mg cefuroxime axetil (generic of CEFTIN) cefuroxime sodium (generic of ZINACEF) cephalexin (generic of KEFLEX) CAPS 1 0mg, 00mg cephalexin SUSR SUPRAX CAPS SUPRAX CHEW SUPRAX SUSR 00mg/ml tazicef (generic of FORTAZ) SOLR TEFLARO ERYTHROMYCINS/MACROLIDES azithromycin PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of ZITHROMAX) 1 TABS clarithromycin (generic of BIAXIN) TABS clarithromycin er (generic of BIAXIN XL) 10

19 018 GENERIC STANDARD FORMULARY clarithromycin for susp 1mg/ml clarithromycin for susp (generic of BIAXIN) 0mg/ml DIFICID e.e.s. 00 ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 0mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES ciprofloxacin (generic of CIPRO) SUSR ciprofloxacin hcl tab 100mg ciprofloxacin hcl tab (generic of CIPRO) 1 0mg, 00mg ciprofloxacin hcl tab 70mg 1 ciprofloxacin in dw ciprofloxacin in dw (generic of CIPRO I.V.-IN DW) ciprofloxacin inj levofloxacin (generic of LEVAQUIN) TABS 1 levofloxacin in dw levofloxacin inj mg/ml levofloxacin oral soln mg/ml PENICILLINS amoxicillin CAPS; SUSR; TABS 1 amoxicillin CHEW amoxicillin & pot clavulanate CHEW amoxicillin & pot clavulanate SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR amoxicillin & pot clavulanate TABS amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB1 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) 11

20 018 GENERIC STANDARD FORMULARY ampicillin cap 1 ampicillin inj ampicillin sodium ampicillin sus BICILLIN L-A dicloxacillin sodium nafcillin sodium for inj 1gm, gm nafcillin sodium for inj 10gm oxacillin sodium 1gm, gm oxacillin sodium 10gm PENICILLIN G POT IN DEXTROSE MU PENICILLIN G POT IN DEXTROSE MU PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium SOLR penicillin v potassium TABS 1 penicilln gk inj mu penicilln gk inj 0mu pfizerpen-g inj mu pfizerpen-g inj 0mu piper/tazoba inj -0.gm (generic of ZOSYN) piper/tazoba inj -0.7gm (generic of ZOSYN) piper/tazoba inj -0.gm (generic of ZOSYN) PIPER/TAZOBA INJ 1-1.GM piper/tazoba inj 6-.gm (generic of ZOSYN) TETRACYCLINES doxy 100 doxycycline (monohydrate) CAPS 0mg doxycycline (monohydrate) (generic of MONODOX) CAPS 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 0mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate 0 mg doxycycline hyclate 100 mg minocycline hcl (generic of MINOCIN) CAPS 0mg, 100mg minocycline hcl CAPS 7mg 1

21 018 GENERIC STANDARD FORMULARY morgidox cap 1x0mg ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA busulfan (generic of BUSULFEX) B/D, NM B/D CYCLOPHOSPHAMIDE CAPS B/D cyclophosphamide SOLR B/D dacarbazine B/D EMCYT GLEOSTINE HEXALEN IFEX INJ GM ifosfamide inj 1gm (generic of IFEX) B/D B/D ifosfamide inj 1gm/0ml B/D IFOSFAMIDE INJ GM B/D ifosfamide inj gm/60ml B/D LEUKERAN melphalan hcl (generic of ALKERAN) B/D MUSTARGEN B/D ANTHRACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj mg/ml B/D (generic of DOXIL) doxorubicin hcl soln mg/ml B/D epirubicin hcl (generic of ELLENCE) B/D ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR B/D ANTIMETABOLITES adrucil B/D adrucil inj B/D ALIMTA B/D azacitidine (generic of VIDAZA) B/D, NM cladribine B/D cytarabine 0mg/ml B/D fludarabine phosphate B/D fluorouracil SOLN B/D gemcitabine inj soln B/D gemcitabine inj solr (generic of GEMZAR) B/D 1gm, 00mg gemcitabine inj solr gm B/D mercaptopurine TABS 1

22 018 GENERIC STANDARD FORMULARY methotrexate sodium inj B/D NIPENT B/D PURIXAN NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE B/D DOCEFREZ B/D docetaxel (generic of TAXOTERE) CONC B/D 0mg/ml, 80mg/ml DOCETAXEL CONC 80mg/ml, B/D 160mg/8ml, 00mg/10ml DOCETAXEL SOLN B/D paclitaxel B/D TAXOTERE 80mg/ml B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar pfs B/D vincristine sulfate B/D vinorelbine tartrate (generic of B/D NAVELBINE) BIOLOGIC RESPONSE MODIFIERS AVASTIN NM, LA, PA BELEODAQ ERIVEDGE NM, LA, PA FARYDAK NM, LA, PA HERCEPTIN IBRANCE NM, LA, PA KADCYLA B/D, NM KEYTRUDA KISQALI KISQALI FEMARA 00 DOSE KISQALI FEMARA 00 DOSE KISQALI FEMARA 600 DOSE LYNPARZA CAPS NM, LA, PA NINLARO ODOMZO NM, LA, PA RITUXAN NM, LA, PA RUBRACA NM, LA, PA TECENTRIQ NM, LA, PA VELCADE VENCLEXTA 10mg, 0mg NM, LA, PA VENCLEXTA 100mg NM, LA, PA VENCLEXTA STARTING PACK NM, LA, PA 1

23 018 GENERIC STANDARD FORMULARY YERVOY ZEJULA ZOLINZA NM, LA, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D exemestane (generic of AROMASIN) FARESTON FASLODEX flutamide B/D hydroxyprogesterone caproate B/D (antineoplastic) letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0. LUPRON DEPOT (1-MONTH).7mg LUPRON DEPOT INJ 11.MG (-MONTH) LYSODREN megestrol ac sus 0mg/ml PA; PA if 6 years and older megestrol ac tab 0mg PA; PA if 6 years and older megestrol ac tab 0mg PA; PA if 6 years and older megestrol sus 6mg/ml (generic of PA MEGACE ES) nilutamide (generic of NILANDRON) SOLTAMOX tamoxifen citrate TABS 1 TRELSTAR DEP INJ.7MG TRELSTAR LA INJ 11.MG XTANDI ZYTIGA NM, LA, PA NM, LA, PA IMMUNOMODULATORS POMALYST NM, LA, PA REVLIMID QL (8 caps / 8 days), NM, LA, PA THALOMID 0mg, 100mg QL (0 caps / 0 days), THALOMID 10mg, 00mg QL (60 caps / 0 days), KINASE INHIBITORS AFINITOR QL (0 tabs / 0 days), 1

24 018 GENERIC STANDARD FORMULARY AFINITOR DISPERZ mg QL (10 tabs / 0 days), AFINITOR DISPERZ mg QL (90 tabs / 0 days), AFINITOR DISPERZ mg QL (60 tabs / 0 days), ALECENSA NM, LA, PA ALUNBRIG NM, LA, PA BOSULIF CABOMETYX QL (0 tabs / 0 days), NM, LA, PA CAPRELSA NM, LA, PA COMETRIQ NM, LA, PA COTELLIC NM, LA, PA GILOTRIF TAB 0MG NM, LA, PA GILOTRIF TAB 0MG NM, LA, PA GILOTRIF TAB 0MG NM, LA, PA ICLUSIG NM, LA, PA imatinib mesylate (generic of GLEEVEC) 100mg QL (90 tabs / 0 days), imatinib mesylate (generic of GLEEVEC) 00mg QL (60 tabs / 0 days), IMBRUVICA CAP 10MG NM, LA, PA INLYTA 1mg QL (180 tabs / 0 days), NM, LA, PA INLYTA mg QL (10 tabs / 0 days), NM, LA, PA IRESSA NM, LA, PA JAKAFI QL (60 tabs / 0 days), NM, LA, PA LENVIMA 8 MG DAILY DOSE NM, LA, PA LENVIMA 10 MG DAILY DOSE NM, LA, PA LENVIMA 1 MG DAILY DOSE NM, LA, PA LENVIMA 18 MG DAILY DOSE NM, LA, PA LENVIMA 0 MG DAILY DOSE NM, LA, PA LENVIMA MG DAILY DOSE NM, LA, PA MEKINIST NM, LA, PA NEXAVAR NM, LA, PA RYDAPT SPRYCEL STIVARGA NM, LA, PA SUTENT TAFINLAR NM, LA, PA TAGRISSO NM, LA, PA 16

25 018 GENERIC STANDARD FORMULARY TARCEVA mg QL (90 tabs / 0 days), NM, LA, PA TARCEVA 100mg, 10mg QL (0 tabs / 0 days), NM, LA, PA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA MISCELLANEOUS bexarotene (generic of TARGRETIN) DROXIA hydroxyurea (generic of HYDREA) CAPS LONSURF MATULANE mitoxantrone hcl LA B/D, NM SYLATRON KIT 00MCG SYLATRON KIT 00MCG SYLATRON KIT 600MCG SYNRIBO tretinoin (chemotherapy) TRISENOX B/D PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin inj 0mg B/D oxaliplatin inj 0mg/10ml B/D oxaliplatin inj 100mg B/D oxaliplatin inj 100mg/0ml B/D PROTECTIVE AGENTS dexrazoxane (generic of ZINECARD) B/D ELITEK B/D leucovorin calcium SOLR B/D leucovorin calcium TABS levoleucovorin calcium 17mg/17.ml B/D, NM LEVOLEUCOVORIN CALCIUM 0mg/ml B/D, NM levoleucovorin calcium 0mg (generic of B/D, NM FUSILEV) LEVOLEUCOVORIN CALCIUM 17MG B/D, NM mesna (generic of MESNEX) B/D MESNEX TABS 17

26 018 GENERIC STANDARD FORMULARY TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl (generic of CAMPTOSAR) B/D 0mg/ml, 100mg/ml irinotecan hcl 00mg/ml B/D toposar B/D topotecan inj mg (generic of HYCAMTIN) B/D TOPOTECAN INJ MG/ML B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 1-10 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 1-0 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 1-0 mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) benazepril & hydrochlorothiazide benazepril & hydrochlorothiazide (generic 1 1 of LOTENSIN HCT) captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide enalapril maleate & hydrochlorothiazide (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide (generic of 1 ZESTORETIC) moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide (generic of 1 1 ACCURETIC) ACE INHIBITORS benazepril hcl TABS mg benazepril hcl (generic of LOTENSIN) 1 1 TABS 10mg, 0mg, 0mg captopril TABS enalapril maleate (generic of VASOTEC) 1 1 TABS fosinopril sodium lisinopril (generic of ZESTRIL) TABS 1 1.mg, 0mg, 0mg 18

27 018 GENERIC STANDARD FORMULARY lisinopril (generic of PRINIVIL) TABS mg, 1 10mg, 0mg moexipril hcl 1 perindopril erbumine mg 1 perindopril erbumine (generic of ACEON) 1 mg, 8mg quinapril hcl (generic of ACCUPRIL) 1 ramipril (generic of ALTACE) 1 trandolapril 1mg, mg 1 trandolapril (generic of MAVIK) mg 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) spironolactone (generic of ALDACTONE) 1 TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) QL (0 tabs / 0 days) 1mg, mg, mg doxazosin mesylate (generic of CARDURA) 8mg prazosin hcl (generic of MINIPRESS) terazosin hcl 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil 1 (generic of AZOR) amlodipine besylate-valsartan tab (generic 1 of EXFORGE) amlodipine-valsartan-hydrochlorothiazide 1 tab (generic of EXFORGE HCT) ENTRESTO irbesartan-hydrochlorothiazide (generic of 1 AVALIDE) losartan-hydrochlorothiazide (generic of 1 HYZAAR) olmesartan 1 medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR) olmesartan medoxomil-hydrochlorothiazide 1 (generic of BENICAR HCT) valsartan-hydrochlorothiazide (generic of 1 DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO) 1 losartan potassium (generic of COZAAR) 1 olmesartan medoxomil (generic of 1 BENICAR) TABS 19

28 018 GENERIC STANDARD FORMULARY valsartan (generic of DIOVAN) 1 ANTIARRHYTHMICS amiodarone hcl SOLN amiodarone hcl TABS 100mg, 00mg amiodarone hcl TABS 00mg disopyramide phosphate (generic of 1 PA; PA if 6 years and NORPACE) older dofetilide (generic of TIKOSYN) NM flecainide acetate mexiletine hcl MULTAQ NORPACE CR PA; PA if 6 years and older pacerone 100mg, 00mg pacerone 00mg propafenone hcl 1 propafenone hcl 1hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETAPACE) 80mg, 10mg, 160mg sorine 0mg sotalol hcl (generic of BETAPACE) 80mg, 10mg, 160mg sotalol hcl 0mg sotalol hcl (afib/afl) (generic of BETAPACE AF) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) 1 TABS lovastatin 10mg, 0mg lovastatin (generic of MEVACOR) 0mg pravastatin sodium 10mg pravastatin sodium (generic of PRAVACHOL) 0mg, 0mg, 80mg rosuvastatin calcium (generic of CRESTOR) 1 QL (0 tabs / 0 days) simvastatin (generic of ZOCOR) TABS 1 mg, 10mg, 0mg, 0mg simvastatin (generic of ZOCOR) TABS 1 QL (0 tabs / 0 days) 80mg ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light PACK 0

29 018 GENERIC STANDARD FORMULARY cholestyramine light (generic of QUESTRAN LIGHT) POWD colestipol hcl 1gm tab (generic of COLESTID) colestipol hcl gran (generic of COLESTID) colestipol hcl pack (generic of COLESTID) ezetimibe (generic of ZETIA) fenofibrate (generic of TRICOR) TABS 8mg, 1mg fenofibrate (generic of LOFIBRA) TABS mg fenofibrate TABS 160mg fenofibrate micronized (generic of LOFIBRA) 67mg, 1mg, 00mg gemfibrozil (generic of LOPID) TABS JUXTAPID KYNAMRO NM, LA, PA niacin er (antihyperlipidemic) (generic of QL (90 tabs / 0 days) NIASPAN) 00mg niacin er (antihyperlipidemic) (generic of NIASPAN) 70mg, 1000mg niacor omega--acid ethyl esters (generic of LOVAZA) PRALUENT prevalite PACK prevalite (generic of QUESTRAN LIGHT) POWD VASCEPA WELCHOL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide (generic of 1 ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol (generic of TENORMIN) TABS 1 mg atenolol TABS 0mg, 100mg bisoprolol fumarate 1 BYSTOLIC.mg, mg, 10mg QL (0 tabs / 0 days) 1

30 018 GENERIC STANDARD FORMULARY BYSTOLIC 0mg QL (60 tabs / 0 days) carvedilol (generic of COREG) labetalol hcl TABS metoprolol succinate (generic of TOPROL 1 XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS mg metoprolol tartrate (generic of 1 1 LOPRESSOR) TABS 0mg, 100mg nadolol (generic of CORGARD) TABS pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl SOLN; TABS propranolol oral sol timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC) amlodipine besylate (generic of NORVASC) 1 TABS cartia xt (generic of CARDIZEM CD) 10mg, 180mg, 0mg cartia xt 00mg dilt-xr cap diltiazem cap 10mg cd (generic of CARDIZEM CD) diltiazem cap 180mg cd (generic of CARDIZEM CD) diltiazem cap 0mg cd (generic of CARDIZEM CD) diltiazem cap 00mg cd diltiazem cap 60mg cd (generic of CARDIZEM CD) diltiazem cap er/1hr diltiazem hcl (generic of CARDIZEM) TABS 0mg, 60mg, 10mg diltiazem hcl TABS 90mg diltiazem hcl cap sr hr diltiazem hcl coated beads cap sr hr (generic of CARDIZEM CD) 10mg, 180mg, 60mg diltiazem hcl coated beads cap sr hr 00mg diltiazem hcl extended release beads cap sr (generic of TIAZAC)

31 018 GENERIC STANDARD FORMULARY diltiazem inj felodipine isradipine nicardipine hcl CAPS nifedical xl (generic of PROCARDIA XL) nifedipine (generic of PROCARDIA XL) TB nifedipine er (generic of ADALAT CC) nimodipine CAPS NYMALIZE taztia xt (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 100mg, 00mg, 00mg verapamil cap er (generic of VERELAN) 10mg, 180mg, 0mg verapamil cap er 60mg verapamil hcl SOLN verapamil hcl TABS 0mg verapamil hcl (generic of CALAN) TABS mg, 10mg verapamil hcl (generic of CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN).mg PA; PA if 6 years and older digitek (generic of LANOXIN).1mg QL (0 tabs / 0 days) digox (generic of LANOXIN) 1mcg QL (0 tabs / 0 days) digox (generic of LANOXIN) 0mcg PA; PA if 6 years and older digoxin (generic of LANOXIN) TABS QL (0 tabs / 0 days) 1mcg digoxin (generic of LANOXIN) TABS PA; PA if 6 years and 0mcg older digoxin inj (generic of LANOXIN) digoxin sol 0mcg/ml PA; PA if 6 years and older DIURETICS acetazolamide (generic of DIAMOX) CP1 acetazolamide TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide inj 0./ml bumetanide tab (generic of BUMEX)

32 018 GENERIC STANDARD FORMULARY chlorothiazide tabs chlorthalidone furosemide SOLN furosemide TABS 0mg, 0mg furosemide (generic of LASIX) TABS mg furosemide inj hydrochlorothiazide (generic of 1 MICROZIDE) CAPS hydrochlorothiazide TABS indapamide methazolamide (generic of NEPTAZANE) 1 TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs mg, 100mg torsemide tabs (generic of DEMADEX) 10mg, 0mg triamterene & hydrochlorothiazide (generic 1 of MAXZIDE) TABS triamterene & hydrochlorothiazide (generic 1 of MAXZIDE-) TABS triamterene & hydrochlorothiazide cap mg (generic of DYAZIDE) MISCELLANEOUS clonidine hcl (generic of CATAPRES-TTS-1) PTWK.1mg/hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/hr clonidine hcl (generic of CATAPRES) TABS 1 CORLANOR DEMSER hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS NORTHERA NM, LA, PA RANEXA NITRATES isosorb mononitrate tab

33 018 GENERIC STANDARD FORMULARY isosorbide dinitrate (generic of ISORDIL TITRADOSE) mg isosorbide dinitrate 10mg, 0mg, 0mg isosorbide dinitrate er isosorbide mononitrate er minitran (generic of NITRO-DUR) NITRO-BID NITRO-DUR DIS 0.MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch.1mg/hr nitroglycerin td patch (generic of NITRO-DUR).mg/hr,.mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION ADCIRCA QL (60 tabs / 0 days), ADEMPAS QL (90 tabs / 0 days), NM, LA, PA LETAIRIS QL (0 tabs / 0 days), NM, LA, PA OPSUMIT QL (0 tabs / 0 days), NM, LA, PA REMODULIN NM, LA, PA sildenafil citrate (pulmonary hypertension) QL (90 tabs / 0 days), (generic of REVATIO) TABS TRACLEER 6.mg QL (10 tabs / 0 days), NM, LA, PA TRACLEER 1mg QL (60 tabs / 0 days), NM, LA, PA VENTAVIS CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.mg (generic of XANAX) 1 QL (0 tabs / 0 days) alprazolam tab 0.mg (generic of XANAX) 1 QL (80 tabs / 0 days) alprazolam tab 1mg (generic of XANAX) 1 QL (10 tabs / 0 days) alprazolam tab mg (generic of XANAX) 1 QL (10 tabs / 0 days) buspirone hcl TABS mg, 7.mg, 10mg, 1mg buspirone hcl TABS 0mg fluvoxamine maleate TABS mg, 0mg QL ( tabs / 0 days) fluvoxamine maleate TABS 100mg lorazepam (generic of ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS 1 QL (10 tabs / 0 days)

34 018 GENERIC STANDARD FORMULARY lorazepam intensol QL (10 ml / 0 days) ANTICONVULSANTS APTIOM 00mg QL (180 tabs / 0 days) APTIOM 00mg QL (90 tabs / 0 days) APTIOM 600mg, 800mg QL (60 tabs / 0 days) BANZEL SUS 0MG/ML PA BANZEL TAB 00MG PA BANZEL TAB 00MG PA BRIVIACT SOLN 10mg/ml PA BRIVIACT SOLN 0mg/ml PA BRIVIACT TABS PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP1 carbamazepine (generic of TEGRETOL) SUSP carbamazepine (generic of TEGRETOL) TABS carbamazepine TB1 100mg carbamazepine (generic of TEGRETOL-XR) TB1 00mg, 00mg CELONTIN clonazepam (generic of KLONOPIN) TABS 1 QL (10 tabs / 0 days) 1mg clonazepam (generic of KLONOPIN) TABS 1 QL (00 tabs / 0 days) mg clonazepam (generic of KLONOPIN) TABS 1 QL (0 tabs / 0 days).mg clonazepam TBDP 1mg QL (10 tabs / 0 days) clonazepam TBDP mg QL (00 tabs / 0 days) clonazepam TBDP.mg QL (0 tabs / 0 days) clonazepam TBDP.mg QL (80 tabs / 0 days) clonazepam TBDP.1mg QL (960 tabs / 0 days) clorazepate dipotassium.7mg QL (10 tabs / 0 days), PA; PA if 6 years and older clorazepate dipotassium (generic of TRANXENE T) 7.mg QL (10 tabs / 0 days), PA; PA if 6 years and older clorazepate dipotassium 1mg QL (180 tabs / 0 days), PA; PA if 6 years and older DIASTAT ACUDIAL DIASTAT PEDIATRIC 6

35 018 GENERIC STANDARD FORMULARY diazepam SOLN 1mg/ml QL (100 ml / 0 days), PA; PA if 6 years and older diazepam SOLN mg/ml diazepam (generic of VALIUM) TABS 1 QL (10 tabs / 0 days), PA; PA if 6 years and older diazepam intensol QL (0 ml / 0 days), PA; PA if 6 years and older DILANTIN DILANTIN-1 SUS 1/ML divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR divalproex sodium (generic of DEPAKOTE ER) TB divalproex sodium (generic of DEPAKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOMPA SUSP QL (70 ml / 0 days), PA FYCOMPA TABS mg QL (180 tabs / 0 days), PA FYCOMPA TABS mg QL (90 tabs / 0 days), PA FYCOMPA TABS 6mg QL (60 tabs / 0 days), PA FYCOMPA TABS 8mg, 10mg, 1mg QL (0 tabs / 0 days), PA gabapentin (generic of NEURONTIN) QL (1080 caps / 0 CAPS 100mg days) gabapentin (generic of NEURONTIN) QL (60 caps / 0 days) CAPS 00mg gabapentin (generic of NEURONTIN) QL (70 caps / 0 days) CAPS 00mg gabapentin (generic of NEURONTIN) QL (160 ml / 0 days) SOLN gabapentin (generic of NEURONTIN) QL (180 tabs / 0 days) TABS 600mg gabapentin (generic of NEURONTIN) QL (10 tabs / 0 days) TABS 800mg GABITRIL 1mg, 16mg 7

36 018 GENERIC STANDARD FORMULARY lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB levetiracetam (generic of KEPPRA) TABS levetiracetam (generic of KEPPRA XR) TB levetiracetam in sodium chloride (generic of LEVETIRACETAM) levetiracetam inj (generic of KEPPRA) levetiracetam oral soln 100 mg/ml (generic of KEPPRA) LYRICA CAPS mg, 0mg, 7mg, QL (10 caps / 0 days) 100mg, 10mg LYRICA CAPS 00mg QL (90 caps / 0 days) LYRICA CAPS mg, 00mg QL (60 caps / 0 days) LYRICA SOLN QL (96 ml / 0 days) ONFI PA oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS PA; PA if 6 years and older PHENOBARBITAL SODIUM SOLN 6mg/ml PA; PA if 6 years and older phenobarbital sodium SOLN 10mg/ml PA; PA if 6 years and older PHENYTEK phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-1) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 100mg phenytoin sodium extended (generic of PHENYTEK) 00mg, 00mg primidone (generic of MYSOLINE) TABS roweepra (generic of KEPPRA) SABRIL PACK QL (180 packets / 0 days), NM, LA, PA 8

37 018 GENERIC STANDARD FORMULARY SABRIL TABS QL (180 tabs / 0 days), NM, LA, PA SPRITAM TEGRETOL TEGRETOL-XR tiagabine hcl (generic of GABITRIL) topiramate (generic of TOPAMAX SPRINKLE) CPSP topiramate (generic of TOPAMAX) TABS valproate sodium oral soln (generic of DEPAKENE) valproate sodium soln 100mg/ml (generic of DEPACON) valproic acid (generic of DEPAKENE) VIMPAT SOLN 10mg/ml QL (100 ml / 0 days) VIMPAT SOLN 00mg/0ml VIMPAT TABS 0mg QL (180 tabs / 0 days) VIMPAT TABS 100mg, 10mg, 00mg QL (60 tabs / 0 days) zonisamide (generic of ZONEGRAN) CAPS mg, 100mg zonisamide CAPS 0mg ANTIDEMENTIA donepezil hydrochloride (generic of QL (60 tabs / 0 days) ARICEPT) TABS mg donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS mg donepezil hydrochloride TBDP mg QL (60 tabs / 0 days) donepezil hydrochloride TBDP 10mg galantamine hydrobromide SOLN galantamine hydrobromide (generic of QL (180 tabs / 0 days) RAZADYNE) TABS mg galantamine hydrobromide (generic of QL (90 tabs / 0 days) RAZADYNE) TABS 8mg galantamine hydrobromide (generic of RAZADYNE) TABS 1mg galantamine hydrobromide er (generic of QL (0 caps / 0 days) RAZADYNE ER) 8mg, 16mg galantamine hydrobromide er (generic of RAZADYNE ER) mg memantine hcl SOLN PA; PA if < 0 yrs memantine hcl (generic of NAMENDA) PA; PA if < 0 yrs TABS NAMENDA XR PA; PA if < 0 yrs 9

38 018 GENERIC STANDARD FORMULARY NAMENDA XR TITRATION PACK PA; PA if < 0 yrs NAMZARIC rivastigmine tartrate rivastigmine td patch hr.6 mg/hr QL (0 patches / 0 (generic of EXELON) days) rivastigmine td patch hr 9. mg/hr QL (0 patches / 0 (generic of EXELON) days) rivastigmine td patch hr 1. mg/hr QL (0 patches / 0 (generic of EXELON) days) ANTIDEPRESSANTS amitriptyline hcl TABS 10mg, 0mg, PA; PA if 6 years and 7mg, 100mg, 10mg older amitriptyline hcl (generic of ELAVIL) TABS PA; PA if 6 years and mg older amoxapine bupropion hcl TABS bupropion hcl (generic of WELLBUTRIN SR) TB1 bupropion hcl (generic of WELLBUTRIN XL) QL (90 tabs / 0 days) TB 10mg bupropion hcl (generic of WELLBUTRIN XL) QL (0 tabs / 0 days) TB 00mg citalopram hydrobromide SOLN citalopram hydrobromide (generic of 1 QL ( tabs / 0 days) CELEXA) TABS 10mg, 0mg citalopram hydrobromide (generic of 1 QL (0 tabs / 0 days) CELEXA) TABS 0mg clomipramine hcl (generic of ANAFRANIL) PA; PA if 6 years and CAPS older desipramine hcl (generic of NORPRAMIN) TABS 10mg, mg desipramine hcl TABS 0mg, 7mg, 100mg, 10mg desvenlafaxine succinate (generic of QL (0 tabs / 0 days) PRISTIQ) doxepin hcl CAPS; CONC PA; PA if 6 years and older duloxetine hcl (generic of CYMBALTA) QL (180 caps / 0 days) CPEP 0mg duloxetine hcl (generic of CYMBALTA) QL (10 caps / 0 days) CPEP 0mg duloxetine hcl (generic of CYMBALTA) QL (60 caps / 0 days) CPEP 60mg EMSAM QL (0 patches / 0 days), PA escitalopram oxalate SOLN QL (600 ml / 0 days) 0

39 018 GENERIC STANDARD FORMULARY escitalopram oxalate (generic of LEXAPRO) QL ( tabs / 0 days) TABS mg, 10mg escitalopram oxalate (generic of LEXAPRO) QL (60 tabs / 0 days) TABS 0mg FETZIMA 0mg QL (180 caps / 0 days) FETZIMA 0mg QL (90 caps / 0 days) FETZIMA 80mg, 10mg QL (0 caps / 0 days) FETZIMA TITRATION PACK fluoxetine cap 10mg (generic of PROZAC) 1 QL (0 caps / 0 days) fluoxetine cap 0mg (generic of PROZAC) 1 QL (10 caps / 0 days) fluoxetine cap 0mg (generic of PROZAC) 1 fluoxetine hcl SOLN imipramine hcl (generic of TOFRANIL) TABS PA; PA if 6 years and older maprotiline hcl MARPLAN TAB 10MG QL (180 tabs / 0 days) mirtazapine TABS 7.mg QL ( tabs / 0 days) mirtazapine (generic of REMERON) TABS QL ( tabs / 0 days) 1mg mirtazapine (generic of REMERON) TABS 0mg, mg mirtazapine (generic of REMERON SOLTAB) QL (0 tabs / 0 days) TBDP 1mg mirtazapine (generic of REMERON SOLTAB) TBDP 0mg, mg nefazodone hcl nortriptyline hcl (generic of PAMELOR) 1 CAPS nortriptyline hcl SOLN paroxetine hcl tabs (generic of PAXIL) 1 QL ( tabs / 0 days) 10mg, 0mg, 0mg paroxetine hcl tabs (generic of PAXIL) 1 QL (60 tabs / 0 days) 0mg PAXIL SUSP QL (900 ml / 0 days) phenelzine sulfate (generic of NARDIL) TABS protriptyline hcl sertraline hcl (generic of ZOLOFT) CONC sertraline hcl (generic of ZOLOFT) TABS 1 QL ( tabs / 0 days) mg, 0mg sertraline hcl (generic of ZOLOFT) TABS 1 100mg tranylcypromine sulfate (generic of PARNATE) 1

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